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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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
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