Appendix H - New Listings

The following items have been added to the NIHB Drug Benefit List since it was last published. Some of these items may have specific criteria for use. Please consult Appendix A for criteria.

56:00 GASTROINTESTINAL DRUGS

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HYDROCHLORIDE

Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST8MG Tablet 02478935 ACCEL-ONDANSETRON ACP 2020-05-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:32.28 SELECTIVE SEROTONIN AGONISTS

RIZATRIPTAN BENZOATE

Table: RIZATRIPTAN BENZOATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5MG Tablet (Orally Disintegrating) 02483270 ACCEL-RIZATRIPTAN ODT ACP 2020-05-01

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN

Table: ACETAMINOPHEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST325MG Tablet 01977415 ACETAMINOPHEN TLI 2020-04-09
ST500MG Tablet 02362368 ACETAMINOPHEN APX 2020-04-09
ST160MG Tablet (Chewable) 02237562 ACETAMINOPHEN TLI 2020-04-08

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

PRAVASTATIN SODIUM

Table: PRAVASTATIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST10MG Tablet 02440644 ACH-PRAVASTATIN ACC 2020-05-01
ST40MG Tablet 02440660 ACH-PRAVASTATIN ACC 2020-05-01
ST20MG Tablet 02440652 ACH-PRAVASTATIN ACC 2020-05-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST40MG Drop 02328445 ADVIL PEDIATRIC DROPS FEVER FROM COLDS OR FLU PFI 2020-04-15

08:00 ANTI-INFECTIVE AGENTS

08:18.08 ANTIRETROVIRALS

DARUNAVIR

Table: DARUNAVIR
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
600MG Tablet 02487241 APO-DARUNAVIR APX 2020-05-27
800MG Tablet 02487268 APO-DARUNAVIR APX 2020-03-31

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:32.00 PROGESTINS

DIENOGEST

Table: DIENOGEST
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST2MG Tablet 02493055 ASPEN-DIENOGEST UNK 2020-06-01

08:00 ANTI-INFECTIVE AGENTS

08:18.08 ANTIRETROVIRALS

DARUNAVIR (DARUNAVIR PROPYLENE GLYCOLATE)

Table: DARUNAVIR (DARUNAVIR PROPYLENE GLYCOLATE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
600MG Tablet 02486121 AURO-DARUNAVIR AUR 2020-05-27

94:00 DEVICES

94:01.00 DEVICES (DIABETIC)

INSULIN PUMP SUPPLIES

Table: INSULIN PUMP SUPPLIES
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
43110IN/CM Device 97799201 AUTOSOFT 30 13MM UNK 2020-04-15
2360IN/CM Device 97799202 AUTOSOFT 30 13MM UNK 2020-04-15
43110IN/CM Device 97799197 AUTOSOFT 90 6MM UNK 2020-04-15
2360IN/CM Device 97799200 AUTOSOFT 90 6MM UNK 2020-04-15
2360IN/CM Device 97799199 AUTOSOFT 90 6MM UNK 2020-04-15
2360IN/CM Device 97799198 AUTOSOFT 90 6MM UNK 2020-04-15
2360IN/CM Device 97799194 AUTOSOFT 90 9MM UNK 2020-04-15
2360IN/CM Device 97799195 AUTOSOFT 90 9MM UNK 2020-04-06
2360IN/CM Device 97799196 AUTOSOFT 90 9MM UNK 2020-04-15
43110IN/CM Device 97799193 AUTOSOFT 90 9MM UNK 2020-04-14

PEN NEEDLE

Table: PEN NEEDLE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST Needle 09991391 BD PRECISIONGLIDE 23GX1 1/4 BTD 2020-03-01

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM

Table: ATORVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Tablet 02481219 BIO-ATORVASTATIN BMI 2020-04-07
10MG Tablet 02481189 BIO-ATORVASTATIN BMI 2020-04-07
40MG Tablet 02481200 BIO-ATORVASTATIN BMI 2020-04-07
20MG Tablet 02481197 BIO-ATORVASTATIN BMI 2020-04-07

88:00 VITAMINS

88:16.00 VITAMIN D

CALCITRIOL

Table: CALCITRIOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.25MCG Capsule 02495899 CALCITRIOL STS 2020-05-27
0.5MCG Capsule 02495902 CALCITRIOL STS 2020-05-27

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST100MG Suspension 02328437 CHILDREN'S ADVIL FEVER FROM COLDS OR FLU PFI 2020-04-15
ST100MG Suspension 02280175 CHILDREN'S IBUPROFEN PER 2020-03-27

36:00 DIAGNOSTIC AGENTS (DX)

36:00.00 DIAGNOSTIC AGENTS (DX)

COAGULATION MONITORS

Table: COAGULATION MONITORS
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Device 97499983 COAGUCHEK INRANGE METER ROD 2020-04-06

LANCET

Table: LANCET
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Lancet 97499991 COAGUCHEK LANCETS ROD 2020-04-06

COAGULATION MONITORS

Table: COAGULATION MONITORS
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Device 97499986 COAGUCHEK XS KIT ROD 2020-04-06

COAGULATION TEST

Table: COAGULATION TEST
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Strip 97499988 COAGUCHEK XS PT STRIPS 24 ROD 2020-04-06
 Strip 97499987 COAGUCHEK XS PT STRIPS 48 ROD 2020-04-06
 Strip 97499989 COAGUCHEK XS PT STRIPS 6 ROD 2020-04-06

08:00 ANTI-INFECTIVE AGENTS

08:14.08 AZOLES

ISAVUCONAZOLE (ISAVUCONAZONIUM SULFATE)

Table: ISAVUCONAZOLE (ISAVUCONAZONIUM SULFATE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
200MG Powder For Solution 02483998 CRESEMBA UNK 2020-02-11
100MG Capsule 02483971 CRESEMBA UNK 2020-02-11

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:02.00 EENT - ANTIALLERGIC AGENTS

DICLOFENAC SODIUM

Table: DICLOFENAC SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.1% Solution 02475065 DICLOFENAC UNK 2020-03-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS

ACETAMINOPHEN

Table: ACETAMINOPHEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST500MG Tablet 02285797 EXTRA STRENGTH ACETAMINOPHEN VTH 2020-04-09

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:16.00 HEMATOPOIETIC AGENTS

PEGFILGRASTIM

Table: PEGFILGRASTIM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Solution 02484153 FULPHILA BGP 2020-04-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

IBUPROFEN

Table: IBUPROFEN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST400MG Tablet 02439735 IBUPROFEN APX 2020-04-15
ST200MG Tablet 02439727 IBUPROFEN APX 2020-04-15

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE

Table: CANDESARTAN CILEXETIL, HYDROCHLOROTHIAZIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST32MG & 12.5MG Tablet 02473259 JAMP CANDESARTAN-HCT JMP 2020-03-16

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:16.00 ANTIGOUT AGENTS

FEBUXOSTAT

Table: FEBUXOSTAT
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST80MG Tablet 02490870 JAMP FEBUXOSTAT JMP 2020-06-01

08:00 ANTI-INFECTIVE AGENTS

08:30.08 ANTIMALARIALS

HYDROXYCHLOROQUINE SULFATE

Table: HYDROXYCHLOROQUINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
200MG Tablet 02491427 JAMP HYDROXYCHLOROQUINE SULFATE JMP 2020-04-07

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:40.28 EENT - PROSTAGLANDIN AGENTS

LATANOPROST

Table: LATANOPROST
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MCG Solution 02453355 JAMP LATANOPROST JMP 2020-04-30

56:00 GASTROINTESTINAL DRUGS

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HYDROCHLORIDE

Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
4MG Solution 02490617 JAMP ONDANSETRON JMP 2020-05-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:32.28 SELECTIVE SEROTONIN AGONISTS

ZOLMITRIPTAN

Table: ZOLMITRIPTAN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2.5MG Tablet 02477106 JAMP ZOLMITRIPTAN JMP 2020-04-01

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:40.28 EENT - PROSTAGLANDIN AGENTS

LATANOPROST, TIMOLOL MALEATE

Table: LATANOPROST, TIMOLOL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MCG & 5MG Solution 02453770 JAMP-LATANOPROST/TIMOLOL JMP 2020-05-15

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

ADULT

Table: ADULT
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Oral Liquid 95900217 JEVITY 1.5 CAL ABB 2020-03-12

08:00 ANTI-INFECTIVE AGENTS

08:12.28 MISCELLANEOUS ANTIBIOTICS

LINEZOLID

Table: LINEZOLID
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2MG Solution 02481278 LINEZOLID JMP 2020-04-01

94:00 DEVICES

94:01.00 DEVICES (DIABETIC)

ISOPROPYL ALCOHOL

Table: ISOPROPYL ALCOHOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
70% Pad 02248362 LORIS ALCOHOL SWABS UNK 2020-04-03

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:01.28

MULTIVITAMINS (PRENATAL)

Table: MULTIVITAMINS (PRENATAL)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST Capsule 80081007 MATERNA PRENATAL DHA NES 2020-05-01

92:44.00 IMMUNOSUPPRESSIVE AGENTS

CLADRIBINE

Table: CLADRIBINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02470179 MAVENCLAD SRO 2020-02-09

92:01.00 NATURAL HEALTH PRODUCTS

ISOPROPYL ALCOHOL

Table: ISOPROPYL ALCOHOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
70% WIPE, MEDICATED 80074942 MEDISURE ALCOHOL WIPES MDS 2020-04-06

10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

METHOTREXATE SODIUM

Table: METHOTREXATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Solution 02491362 METHOTREXATE SUBCUTANEOUS ACC 2020-06-01

04:00 ANTIHISTAMINE DRUGS

04:08.00 ANTIHISTAMINE DRUGS

CETIRIZINE HYDROCHLORIDE

Table: CETIRIZINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST20MG Tablet 02491125 MINT-CETIRIZINE MIN 2020-02-19

56:00 GASTROINTESTINAL DRUGS

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

ONDANSETRON HYDROCHLORIDE

Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST4MG Tablet (Orally Disintegrating) 02487330 MINT-ONDANSETRON ODT MIN 2020-03-25

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

TELMISARTAN

Table: TELMISARTAN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST40MG Tablet 02486369 MINT-TELMISARTAN MIN 2020-06-01

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:44.00 IMMUNOSUPPRESSIVE AGENTS

MEPOLIZUMAB

Table: MEPOLIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100MG Solution 02492989 NUCALA GSK 2020-05-08
100MG Solution 02492997 NUCALA GSK 2020-05-08

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

ADULT

Table: ADULT
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
 Oral Liquid 95900220 NUTREN 1.5 NES 2020-05-21

08:00 ANTI-INFECTIVE AGENTS

08:14.28 POLYENES

NYSTATIN

Table: NYSTATIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100000U/ML Oral Liquid 99113755 NYSTATIN 100,000U SUSP (QC) UNK 2020-04-01

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

OLMESARTAN MEDOXOMIL

Table: OLMESARTAN MEDOXOMIL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST40MG Tablet 02481065 OLMESARTAN SAN 2020-04-23
ST20MG Tablet 02481057 OLMESARTAN SAN 2020-04-01
40MG Capsule 99113716 OLMESARTAN (QC) UNK 2020-03-01

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:05.00 SERUMS

ALLERGENIC EXTRACTS POLLENS

Table: ALLERGENIC EXTRACTS POLLENS
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
40000U Liquid 02247755 OMEGA ALLERGENIC EXTRACTS POLLENS (SUSPAL) OMG 2020-04-06

12:00 AUTONOMIC DRUGS

12:12.08 BETA ADRENERGIC AGONISTS

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

Table: SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MCG & 100MCG Powder 02494507 PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI PMS 2020-04-30
50MCG & 500MCG Powder 02494523 PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI PMS 2020-04-30
50MCG & 250MCG Powder 02494515 PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI PMS 2020-04-08

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

AMITRIPTYLINE HYDROCHLORIDE

Table: AMITRIPTYLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02490110 PRIVA-AMITRIPTYLINE PHA 2020-05-27
25MG Tablet 02490129 PRIVA-AMITRIPTYLINE PHA 2020-05-27
50MG Tablet 02490137 PRIVA-AMITRIPTYLINE PHA 2020-05-27

24:00 CARDIOVASCULAR DRUGS

24:28.08 DIHYDROPYRIDINES

AMLODIPINE BESYLATE

Table: AMLODIPINE BESYLATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2.5MG Tablet 02444445 PRIVA-AMLODIPINE PHA 2020-04-29
5MG Tablet 02444453 PRIVA-AMLODIPINE PHA 2020-04-29
10MG Tablet 02444461 PRIVA-AMLODIPINE PHA 2020-04-29

24:06.08 HMG-COA REDUCTASE INHIBITORS

ATORVASTATIN CALCIUM

Table: ATORVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Tablet 02482916 PRIVA-ATORVASTATIN PHA 2020-04-29
20MG Tablet 02482894 PRIVA-ATORVASTATIN PHA 2020-04-29
10MG Tablet 02482886 PRIVA-ATORVASTATIN PHA 2020-04-29
40MG Tablet 02482908 PRIVA-ATORVASTATIN PHA 2020-04-29

08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES

CIPROFLOXACIN HYDROCHLORIDE

Table: CIPROFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
500MG Tablet 02445344 PRIVA-CIPROFLOXACIN PHA 2020-04-29

56:00 GASTROINTESTINAL DRUGS

56:32.00 PROKINETIC AGENTS

DOMPERIDONE MALEATE

Table: DOMPERIDONE MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02445328 PRIVA-DOMPERIDONE PHA 2020-04-29

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

FLUOXETINE HYDROCHLORIDE

Table: FLUOXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Capsule 02448416 PRIVA-FLUOXETINE PHA 2020-04-29
20MG Capsule 02448408 PRIVA-FLUOXETINE PHA 2020-04-29

28:12.92 MISCELLANEOUS ANTICONVULSANTS

GABAPENTIN

Table: GABAPENTIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
400MG Capsule 02450119 PRIVA-GABAPENTIN PHA 2020-04-29
300MG Capsule 02450100 PRIVA-GABAPENTIN PHA 2020-04-29
100MG Capsule 02450097 PRIVA-GABAPENTIN PHA 2020-04-29

48:00 RESPIRATORY TRACT AGENTS

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST SODIUM

Table: MONTELUKAST SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02440350 PRIVA-MONTELUKAST PHA 2020-04-29

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

PAROXETINE HYDROCHLORIDE

Table: PAROXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
20MG Tablet 02444321 PRIVA-PAROXETINE PHA 2020-04-29
10MG Tablet 02444313 PRIVA-PAROXETINE PHA 2020-04-29
30MG Tablet 02444348 PRIVA-PAROXETINE PHA 2020-04-29

24:00 CARDIOVASCULAR DRUGS

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

PERINDOPRIL ERBUMINE

Table: PERINDOPRIL ERBUMINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2MG Tablet 02483238 PRIVA-PERINDOPRIL ERBUMINE PHA 2020-04-29
8MG Tablet 02483254 PRIVA-PERINDOPRIL ERBUMINE PHA 2020-04-29
4MG Tablet 02483246 PRIVA-PERINDOPRIL ERBUMINE PHA 2020-04-29

24:06.08 HMG-COA REDUCTASE INHIBITORS

PRAVASTATIN SODIUM

Table: PRAVASTATIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02445379 PRIVA-PRAVASTATIN PHA 2020-04-29
20MG Tablet 02445395 PRIVA-PRAVASTATIN PHA 2020-04-29
40MG Tablet 02445409 PRIVA-PRAVASTATIN PHA 2020-04-29

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.08 ANTIPSYCHOTIC AGENTS

QUETIAPINE FUMARATE

Table: QUETIAPINE FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Tablet 02447088 PRIVA-QUETIAPINE PHA 2020-04-29

24:00 CARDIOVASCULAR DRUGS

24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

RAMIPRIL

Table: RAMIPRIL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5MG Capsule 02483424 PRIVA-RAMIPRIL PHA 2020-04-29
10MG Capsule 02483432 PRIVA-RAMIPRIL PHA 2020-04-29
2.5MG Capsule 02483416 PRIVA-RAMIPRIL PHA 2020-04-29

24:06.08 HMG-COA REDUCTASE INHIBITORS

ROSUVASTATIN CALCIUM

Table: ROSUVASTATIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
5MG Tablet 02445417 PRIVA-ROSUVASTATIN PHA 2020-04-29
10MG Tablet 02445425 PRIVA-ROSUVASTATIN PHA 2020-04-29
20MG Tablet 02445433 PRIVA-ROSUVASTATIN PHA 2020-04-29

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

SERTRALINE HYDROCHLORIDE

Table: SERTRALINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
25MG Capsule 02445352 PRIVA-SERTRALINE PHA 2020-04-29
50MG Capsule 02445360 PRIVA-SERTRALINE PHA 2020-04-29
100MG Capsule 02445387 PRIVA-SERTRALINE PHA 2020-04-29

24:00 CARDIOVASCULAR DRUGS

24:06.08 HMG-COA REDUCTASE INHIBITORS

SIMVASTATIN

Table: SIMVASTATIN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02485745 PRIVA-SIMVASTATIN PHA 2020-04-29
40MG Tablet 02485761 PRIVA-SIMVASTATIN PHA 2020-04-29
20MG Tablet 02485753 PRIVA-SIMVASTATIN PHA 2020-04-29

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:92.00 MISCELLANEOUS EENT DRUGS

NATURAL HEALTH PRODUCT

Table: NATURAL HEALTH PRODUCT
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100% Spray 80069578 SALINEX UNK 2020-04-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.08 OPIATE AGONISTS

MORPHINE SULFATE

Table: MORPHINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100MG Tablet (Extended Release) 02478889 SANDOZ MORPHINE SR SDZ 2020-03-01

BUPRENORPHINE (SUBLOCADE)

Table: BUPRENORPHINE (SUBLOCADE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
300MG Solution (Extended Release) 02483092 SUBLOCADE IND 2020-03-18

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE (SUBLOCADE)

Table: BUPRENORPHINE (SUBLOCADE)
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
100MG Solution (Extended Release) 02483084 SUBLOCADE IND 2020-03-18

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:06.00 SMMA - ANTI-INFLAMMATORY AGENTS

BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE

Table: BETAMETHASONE DIPROPIONATE, CLOTRIMAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
0.05% & 1% Cream 02496410 TARO-CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TAR 2020-06-12

24:00 CARDIOVASCULAR DRUGS

24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS

TELMISARTAN

Table: TELMISARTAN
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
80MG Capsule 99113746 TELMISARTAN (QC) UNK 2020-03-26

10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

EVEROLIMUS

Table: EVEROLIMUS
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
10MG Tablet 02463253 TEVA-EVEROLIMUS TEV 2020-03-06
2.5MG Tablet 02463229 TEVA-EVEROLIMUS TEV 2020-03-06
5MG Tablet 02463237 TEVA-EVEROLIMUS TEV 2020-03-06

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:04.00 ADRENALS

TRIAMCINOLONE HEXACETONIDE

Table: TRIAMCINOLONE HEXACETONIDE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
20MG Suspension 02470632 TRIAMCINOLONE HEXACETONIDE INJECTABLE UNK 2020-06-10

68:12.00 CONTRACEPTIVES

NORGESTIMATE, ETHINYL ESTRADIOL

Table: NORGESTIMATE, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST0.25MG & 0.035MG Tablet 02486318 TRI-JORDYNA 28 GLK 2020-04-28

94:00 DEVICES

94:01.00 DEVICES (DIABETIC)

INSULIN PUMP SUPPLIES

Table: INSULIN PUMP SUPPLIES
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
2360IN/CM Device 97799192 TRUSTEEL 6MM UNK 2020-04-15
3280IN/CM Device 97799191 TRUSTEEL 6MM UNK 2020-04-15
2360IN/CM Device 97799190 TRUSTEEL 8MM UNK 2020-04-15
3280IN/CM Device 97799189 TRUSTEEL 8MM UNK 2020-04-15
2360IN/CM Device 97799188 VARISOFT 13MM UNK 2020-04-15
3280IN/CM Device 97799187 VARISOFT 13MM UNK 2020-04-15
43110IN/CM Device 97799186 VARISOFT 13MM UNK 2020-04-15
2360IN/CM Device 97799185 VARISOFT 17MM UNK 2020-04-15
3280IN/CM Device 97799184 VARISOFT 17MM UNK 2020-04-15

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:01.88 VITAMIN B COMPLEX

VITAMIN C

Table: VITAMIN C
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
ST500MG Tablet 80092665 VITAMIN C JAM 2020-06-01

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

DICLOFENAC DIETHYLAMINE

Table: DICLOFENAC DIETHYLAMINE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
1.16% Gel 02290375 VOLTAREN EMULGEL GSK 2020-06-09
2.32% Gel 02393190 VOLTAREN EMULGEL EXTRA STRENGTH GSK 2020-06-09
1.16% Gel 02338580 VOLTAREN EMULGEL JOINT PAIN REGULAR STRENGTH GSK 2020-06-09

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 Coverage start date
ST100MG Oral Liquid 80034595 WAMPOLE CALCIUM FOR CHILDREN PED 2020-04-20

12:00 AUTONOMIC DRUGS

12:12.08 BETA ADRENERGIC AGONISTS

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

Table: SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code Coverage start date
50MCG & 500MCG Powder 02495619 WIXELA INHUB MYL 2020-04-09
50MCG & 250MCG Powder 02495600 WIXELA INHUB MYL 2020-04-09
50MCG & 100MCG Powder 02495597 WIXELA INHUB MYL 2020-04-17
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