12:00 Autonomic Drugs 12:00. Autonomic Drugs
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1 Autonomic Drugs Autonomic Drugs
2 12:04 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS PILOCARPINE HCL 5 MG ORAL TABLET SALAGEN PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABLET MESTINON 180 MG ORAL SUSTAINED-RELEASE TABLET MESTINON-SR :08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) ACLIDINIUM BROMIDE 400 MCG / DOSE INHALATION METERED INHALATION POWDER TUDORZA GENUAIR ATROPINE SULFATE 0.4 MG / ML INJECTION ATROPINE SULFATE 0.6 MG / ML INJECTION ATROPINE SULFATE SDZ SDZ BELLADONNA/ ERGOTAMINE TARTRATE/ PHENOBARBITAL 0.2 MG * 0.6 MG * 40 MG ORAL SUSTAINED-RELEASE TABLET BELLERGAL SPACETABS PAL GLYCOPYRROLATE 0.2 MG / ML INJECTION GLYCOPYRROLATE SDZ HYOSCINE BUTYLBROMIDE 10 MG ORAL TABLET BUSCOPAN 20 MG / ML INJECTION BUSCOPAN SAV SAV IPRATROPIUM BROMIDE 20 MCG / DOSE INHALATION METERED DOSE AEROSOL ATROVENT HFA 250 MCG / ML INHALATION SOLUTION APO-IPRAVENT MYLAN-IPRATROPIUM IPRATROPIUM 0.03 % NASAL SPRAY IPRATROPIUM ATROVENT SAV IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE 0.2 MG / ML * 1 MG / ML (BASE) INHALATION SOLUTION A-COMBO STERINEBS COMBIVENT UDV UNIT OF ISSUE - REFER TO PRICE POLICY 27 EFFECTIVE APRIL 1, 2018
3 12:08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG / DOSE INHALATION SOLUTION SPIRIVA RESPIMAT 18 MCG INHALATION CAPSULE SPIRIVA UMECLIDINIUM BROMIDE 62.5 MCG / DOSE INHALATION METERED INHALATION POWDER INCRUSE ELLIPTA :12.04 (ALPHA-ADRENERGIC AGONISTS) MIDODRINE HCL 2.5 MG ORAL TABLET MIDODRINE 5 MG ORAL TABLET MIDODRINE : BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) FORMOTEROL FUMARATE 12 MCG INHALATION CAPSULE FORADIL FORMOTEROL FUMARATE DIHYDRATE 6 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER 12 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER INDACATEROL MALEATE 75 MCG (BASE) INHALATION CAPSULE ONBREZ BREEZHALER ORCIPRENALINE SULFATE 2 MG / ML ORAL SYRUP ORCIPRENALINE SALBUTAMOL 100 MCG / DOSE INHALATION METERED DOSE AEROSOL SALBUTAMOL HFA AIROMIR CFC-FREE APO-SALVENT CFC FREE VENTOLIN HFA PRODUCT IS NOT INTERCHANGEABLE 28 EFFECTIVE APRIL 1, 2018
4 12:08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG / DOSE INHALATION SOLUTION SPIRIVA RESPIMAT 18 MCG INHALATION CAPSULE SPIRIVA UMECLIDINIUM BROMIDE 62.5 MCG / DOSE INHALATION METERED INHALATION POWDER INCRUSE ELLIPTA :12.04 (ALPHA-ADRENERGIC AGONISTS) MIDODRINE HCL 2.5 MG ORAL TABLET MIDODRINE 5 MG ORAL TABLET MIDODRINE : BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) FORMOTEROL FUMARATE 12 MCG INHALATION CAPSULE FORADIL FORMOTEROL FUMARATE DIHYDRATE 6 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER 12 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER INDACATEROL MALEATE 75 MCG (BASE) INHALATION CAPSULE ONBREZ BREEZHALER ORCIPRENALINE SULFATE 2 MG / ML ORAL SYRUP ORCIPRENALINE SALBUTAMOL 100 MCG / DOSE INHALATION METERED DOSE AEROSOL SALBUTAMOL HFA AIROMIR CFC-FREE APO-SALVENT CFC FREE VENTOLIN HFA PRODUCT IS NOT INTERCHANGEABLE 28 EFFECTIVE APRIL 1, 2018
5 12: BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) SALBUTAMOL SULFATE 2 MG (BASE) ORAL TABLET APO-SALVENT 4 MG (BASE) ORAL TABLET APO-SALVENT 0.5 MG / ML (BASE) INHALATION SOLUTION SALBUTAMOL 1 MG / ML (BASE) INHALATION SOLUTION SALBUTAMOL A-SALBUTAMOL STERINEBS P.F VENTOLIN NEBULES P.F. 5 MG / ML (BASE) INHALATION SOLUTION VENTOLIN 2 MG / ML (BASE) INHALATION UNIT DOSE SOLUTION SALBUTAMOL POLYNEB A-SALBUTAMOL STERINEBS P.F. VENTOLIN NEBULES P.F SALMETEROL XINAFOATE 50 MCG / DOSE (BASE) INHALATION METERED INHALATION POWDER SEREVENT DISKUS TERBUTALINE SULFATE 0.5 MG / DOSE INHALATION METERED INHALATION POWDER BRICANYL TURBUHALER :12.12 (ALPHA- AND BETA-ADRENERGIC AGONISTS) EPINEPHRINE 0.15 MG / SYR INJECTION SYRINGE EPIPEN JR MYS 0.3 MG / SYR INJECTION SYRINGE EPIPEN MYS EPINEPHRINE HCL 1 MG / ML INJECTION ADRENALIN ERF 12:16 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS DIHYDROERGOTAMINE MESYLATE 4 MG / ML NASAL SPRAY MIGRANAL 1 MG / ML INJECTION DIHYDROERGOTAMINE (DHE) UNIT OF ISSUE - REFER TO PRICE POLICY 29 EFFECTIVE APRIL 1, 2018
6 12:16 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS ERGOLOID MESYLATES 1 MG ORAL TABLET HYDERGINE 12:20.04 SKELETAL MUSCLE RELAXANTS (CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS) CYCLOBENZAPRINE HCL RESTRICTED BENEFIT - Coverage is limited to 126 tablets per plan participant per year as an adjunct to rest and physical therapy for the treatment of acute muscle spasm. 10 MG ORAL TABLET :20.08 APO-CYCLOBENZAPRINE AURO-CYCLOBENZAPRINE CYCLOBENZAPRINE JAMP-CYCLOBENZAPRINE MYLAN-CYCLOBENZAPRINE -CYCLOBENZAPRINE A-CYCLOBENZAPRINE SKELETAL MUSCLE RELAXANTS AUR JPC (DIRECT-ACTING SKELETAL MUSCLE RELAXANTS) DANTROLENE SODIUM 25 MG ORAL CAPSULE DANTRIUM PAL 12:20.12 SKELETAL MUSCLE RELAXANTS (GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS) BACLOFEN 10 MG ORAL TABLET APO-BACLOFEN BACLOFEN MYLAN-BACLOFEN BACLOFEN LIORESAL 20 MG ORAL TABLET APO-BACLOFEN BACLOFEN MYLAN-BACLOFEN BACLOFEN LIORESAL D.S MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL 0.5 MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL PRODUCT IS NOT INTERCHANGEABLE 30 EFFECTIVE APRIL 1, 2018
7 12:20.12 SKELETAL MUSCLE RELAXANTS (GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS) BACLOFEN 2 MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL :92 MISCELLANEOUS VARENICLINE TARTRATE RESTRICTED BENEFIT - This product is a benefit in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Coverage will be granted for a total of 12 weeks." 0.5 MG (BASE) ORAL TABLET CHAMPIX 1 MG (BASE) ORAL TABLET CHAMPIX VARENICLINE TARTRATE/ VARENICLINE TARTRATE RESTRICTED BENEFIT - This product is a benefit in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Coverage will be granted for a total of 12 weeks." MG * 1 MG ORAL TABLET CHAMPIX (STARTER PACK) UNIT OF ISSUE - REFER TO PRICE POLICY 31 EFFECTIVE APRIL 1, 2018
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