Appendix B - Special Formulary for Chronic Renal Failure Patients
The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional supplements formulated for renal patients) that are covered for identified eligible Non-Insured Health Benefits (NIHB) clients in chronic renal failure.
These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.
08:00 ANTI-INFECTIVE AGENTS
08:12.02 AMINOGLYCOSIDES
GENTAMICIN SULFATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 10MG/ML Injection | 02225123 | CIDOMYCIN | UNK |
| 10MG Solution | 02470462 | GENTAMICIN | TEL |
| 40MG Solution | 02457008 | GENTAMICIN | TEL |
08:12.06 CEPHALOSPORINS
CEFAZOLIN SODIUM
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 500MG Powder For Solution | 02437104 | CEFAZOLIN | RAX |
| 1G Powder For Solution | 02465469 | CEFAZOLIN | UNK |
| 10G Powder For Solution | 02452162 | CEFAZOLIN | FKD |
| 10G Powder For Solution | 02465477 | CEFAZOLIN | UNK |
| 20G Powder For Solution | 02237141 | CEFAZOLIN | FKD |
| 100G Powder For Solution | 02401029 | CEFAZOLIN | FKD |
20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS
20:16.00 HEMATOPOIETIC AGENTS
DARBEPOETIN ALFA
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 25MCG/ML Solution | 02392313 | ARANESP | AMG |
| 40MCG/ML Solution | 02392321 | ARANESP | AMG |
| 60MCG/ML Solution | 02246348 | ARANESP | AMG |
| 100MCG/ML Solution | 02391740 | ARANESP | AMG |
| 100MCG/ML Solution | 02391759 | ARANESP | AMG |
| 100MCG/ML Solution | 02392348 | ARANESP | AMG |
| 100MCG/ML Solution | 99004917 | ARANESP | AMG |
| 100MCG/ML Solution | 99004925 | ARANESP | AMG |
| 200MCG/ML Solution | 02391767 | ARANESP | AMG |
| 200MCG/ML Solution | 02391775 | ARANESP | AMG |
| 200MCG/ML Solution | 02391783 | ARANESP | AMG |
| 200MCG/ML Solution | 02392356 | ARANESP | AMG |
| 200MCG/ML Solution | 99004909 | ARANESP | AMG |
| 200MCG/ML Solution | 99004933 | ARANESP | AMG |
| 500MCG/ML Solution | 02391791 | ARANESP | AMG |
| 500MCG/ML Solution | 02391805 | ARANESP | AMG |
| 500MCG/ML Solution | 02391821 | ARANESP | AMG |
| 500MCG/ML Solution | 02392364 | ARANESP | AMG |
| 500MCG/ML Solution | 09857185 | ARANESP | AMG |
EPOETIN ALFA
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 1,000U/0.5ML Solution | 02231583 | EPREX | JSO |
| 2,000U/0.5ML Solution | 02231584 | EPREX | JSO |
| 3,000U/0.3ML Solution | 02231585 | EPREX | JSO |
| 4,000U/0.4ML Solution | 02231586 | EPREX | JSO |
| 5000U/0.5ML Solution | 02243400 | EPREX | JSO |
| 6000U/0.6ML Solution | 02243401 | EPREX | JSO |
| 8000U/0.8ML Solution | 02243403 | EPREX | JSO |
| 10,000/ML Solution | 02231587 | EPREX | JSO |
| 20,000U/0.5ML Solution | 02243239 | EPREX | JSO |
| 30,000U/0.75ML Solution | 02288680 | EPREX | JSO |
| 40,000U/ML Solution | 02240722 | EPREX | JSO |
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 250MG Tablet | 00645958 | CALCIUM | NOP |
| 625MG Tablet (Coated) | 00682047 | APOCAL | APX |
CALCIUM CARB-GLUCONOLACTATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 500MG Tablet | 02232482 | CALCIUMSANDOZ FORTE | GSK |
| 1,000MG Tablet | 02232483 | GRAMCAL | GSK |
SODIUM PHOSPHATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 123MG Powder For Solution | 80027202 | PHOSPHATE NOVARTIS | NVR |
| 500MG Tablet | 00225819 | PHOSPHATE-NOVARTIS | NVC |
ZINC GLUCONATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| ST50MG Tablet | 00503169 | ZINC | VTH |
| ST50MG Tablet | 00505463 | ZINC | JAM |
40:28.08 LOOP DIURETICS
FUROSEMIDE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 10MG/ML Injection | 01987550 | LASIX SPECIAL | UNK |
| 10MG Liquid | 00527033 | FUROSEMIDE | SDZ |
| 10MG Liquid | 02360365 | FUROSEMIDE | OMG |
| 10MG Solution | 02461404 | FUROSEMIDE | RAX |
| 10MG Solution | 02480530 | FUROSEMIDE | MAR |
| 10MG Solution | 02488868 | FUROSEMIDE | BAX |
| 10MG/ML Solution | 02382539 | FUROSEMIDE | SDZ |
| 10MG/ML Solution | 02384094 | FUROSEMIDE | ALV |
| 250MG Solution | 02466945 | FUROSEMIDE | RAX |
56:00 GASTROINTESTINAL DRUGS
56:04.00 ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 500MG Capsule | 02135620 | BASALJEL | AUP |
| 320MG/ML Suspension | 00572527 | ALUGEL | ATL |
| 325MG/5ML Suspension | 02125862 | AMPHOJEL | AUP |
| 600MG Tablet | 02124971 | AMPHOJEL | AUP |
CALCIUM
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 500MG Tablet | 01970240 | TUMS | GSK |
| 750MG Tablet | 01967932 | TUMS EXTRA STRENGTH | GSK |
| 1,000MG Tablet | 02151138 | TUMS ULTRA STRENGTH | GSK |
SODIUM BICARBONATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 500MG Tablet | 80030520 | JAMP-SODIUM BICARBONATE | JMP |
| 500MG Tablet | 80022194 | SANDOZ SODIUM BICARBONATE | SDZ |
84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)
84:04.04 SMMA - ANTIBIOTICS
GENTAMICIN SULFATE
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| 1MG Ointment | 00872881 | PMS-GENTAMICIN | PMS |
84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
MENTHOL,CAMPHOR
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| ST Ointment | 09991675 | ANTIPRURITIC (PRA) | UNK |
88:00 VITAMINS
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| Tablet/Caplet | 00123803 | B COMPLEX PLUS C | JAM |
| Tablet/Caplet | 80007498 | BC VITAMINS | WNP |
| Tablet/Caplet | 02245391 | DIAMINE | EUR |
| Tablet/Caplet | 80063438 | M-PLAVITE | MAN |
| Tablet/Caplet | 80001432 | RENAVITE | MAC |
| Tablet/Caplet | 00558796 | STRESS PLEX | JAM |
96:00 PHARMACEUTICAL AIDS
96:00.00 PHARMACEUTICAL AIDS
NUTRITIONAL SUPPLEMENT
| Drug strength and dosage form | DIN | Brand name | Manufacturer code |
|---|---|---|---|
| Oral Liquid | 95900049 | BOOST 1.0 STANDARD 237ML LIQ | NES |
| Oral Liquid | 95900053 | BOOST 1.5 | NES |
| Oral Liquid | 95900051 | BOOST FRUIT BEVERAGE 235ML LIQ | NES |
| Oral Liquid | 95900054 | BOOST HIPROTEIN 237ML LIQ | NES |
| Oral Liquid | 95900050 | ENSURE 235ML LIQ | ABB |
| Oral Liquid | 95900061 | BOOST DIABETIC 237ML LIQ | NES |
| Oral Liquid | 95900052 | BOOST PLUS 237ML LIQ | NES |
| Oral Liquid | 95999975 | BOOST PLUS CALORIES 237ML LIQ | NES |
| Oral Liquid | 95900056 | ENSURE HIGH PROTEIN 235ML LIQ | ABB |
| Oral Liquid | 95900057 | ENSURE PLUS 235ML LIQ | ABB |
| Oral Liquid | 95900181 | ENSURE PLUS CALORIES 235ML LIQ | ABB |
| Oral Liquid | 95900204 | ENSURE PROTEIN MAX 235ML LIQ | ABB |
| Oral Liquid | 95900140 | GLUCERNA 237ML LIQ | ABB |
| Oral Liquid | 95900063 | NEPRO 237ML LIQ | ABB |
| Oral Liquid | 95900064 | NOVASOURCE RENAL 237ML LIQ | NVC |
| Oral Liquid | 95900067 | SUPLENA 235ML LIQ | ABB |
| Powder | 95900055 | BOOST JUST PROTEIN 588G PDR | NES |
| Powder | 95900215 | NEPHEA KID 400G PDR | UNK |
| Powder | 95900182 | RESOURCE BENEPROTEIN 227G PDR | NES |