Dynamic Therapeutic Formulary (DTF) Prescription Drug Listing for Plan Members www.esi-canada.com Your drug plan provides coverage based on two lists of eligible drugs. Tier 1 - Dynamic Therapeutic Formulary (DTF) Tier 2 - Base Plan (a formulary of drugs selected by your employer) *Note: Some benefit plans only have the DTF. The drugs listed in this document is intended as a guide to help you and your physician determine if a drug is covered under the DTF. When a drug is prescribed from the DTF list, you will be reimbursed at a higher percentage compared to a drug from your base plan list. Your base plan drugs are not listed in this document. The DTF is a GENERIC formulary, so where there is a GENERIC that is considered interchangeable with the BRAND, only the cost of the GENERIC will be reimbursed. • BRAND drugs appear in BLACK • GENERIC drugs appear in GREEN HOW TO SEARCH To help you determine the coverage of a particular drug. Click on the corresponding link listed below, then you can search the listing by using these quick steps: 1) Click Ctrl+F on the keyboard OR Go to Edit –> Find 2) A Find box will open. Here you can enter either the DIN # or the Drug Name. Press enter when finished. Click the links to find: • DIN listing of DTF drugs • Drugs NOT covered on the DTF • Drugs that require Prior Authorization This list is subject to change upon review of new products or information. ® 1 05/2012
Transcript
Dynamic Therapeutic Formulary (DTF) Prescription Drug Listing for Plan Members
www.esi-canada.com
Your drug plan provides coverage based on two lists of eligible drugs. Tier 1 - Dynamic Therapeutic Formulary (DTF) Tier 2 - Base Plan (a formulary of drugs selected by your employer) *Note: Some benefit plans only have the DTF. The drugs listed in this document is intended as a guide to help you and your physician determine if a drug is covered under the DTF. When a drug is prescribed from the DTF list, you will be reimbursed at a higher percentage compared to a drug from your base plan list. Your base plan drugs are not listed in this document. The DTF is a GENERIC formulary, so where there is a GENERIC that is considered interchangeable with the BRAND, only the cost of the GENERIC will be reimbursed.
• BRAND drugs appear in BLACK • GENERIC drugs appear in GREEN
HOW TO SEARCH To help you determine the coverage of a particular drug. Click on the corresponding link listed below, then you can search the listing by using these quick steps: 1) Click Ctrl+F on the keyboard OR Go to Edit –> Find 2) A Find box will open. Here you can enter either the DIN # or the Drug Name. Press
enter when finished.
Click the links to find: • DIN listing of DTF drugs • Drugs NOT covered on the DTF • Drugs that require Prior Authorization
This list is subject to change upon review of new products or information.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
2 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA080800 ANTHELMINTICS080800 02230897 BILTRICIDE 600MG TAB PRAZIQUANTEL 600MG TAB080800 02169967 HETRAZAN TAB 50MG DIETHYLCARBAMAZINE CITRATE 50MG TAB080800 00556734 VERMOX 100MG CHEWABLE TAB MEBENDAZOLE 100MG TAB080800 00333395 VERMOX 100MG TAB MEBENDAZOLE 100MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
7 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081207 MISCELLANEOUS ΒETA-LACTAM 081207 02329840 CAYSTON 75MG/VIAL INH AZTREONAM 75MG/VIAL INH081207 02247437 INVANZ 1G/VIAL INJ ERTAPENEM SODIUM 1G/VIAL INJ081207 00717274 PRIMAXIN 250 IV INJ IMIPENEM/CILASTATIN SODIUM 250 MG INJ081207 00717282 PRIMAXIN 500 IV INJ IMIPENEM/CILASTATIN SODIUM 500 MG INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
17 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081224 TETRACYCLINES081224 00740713 APO‐DOXY 100MG CAP DOXYCYCLINE 100MG CAP081224 00874256 APO‐DOXY TABS 100MG DOXYCYCLINE 100MG TAB081224 02084104 APO‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02084090 APO‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 00580929 APO‐TETRA 250MG CAP TETRACYCLINE 250MG CAP081224 02363593 AVA‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02363585 AVA‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02259478 CO MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02099721 DERMYCIN 100 MG CAP DOXYCYCLINE 100MG CAP081224 02099713 DERMYCIN 100 MGTAB DOXYCYCLINE 100 MG TAB081224 02289598 DOM‐DOXYCYCLINE 100MG CAP DOXYCYCLINE HYCLATE 100MG CAP081224 02289547 DOM‐DOXYCYCLINE 100MG TAB DOXYCYCLINE HYCLATE 100MG TAB081224 02239668 DOM‐MINOCYCLINE 100MG CAP MINOCYCLINE 100MG CAP081224 02239667 DOM‐MINOCYCLINE 50MG CAP MINOCYCLINE 50MG CAP081224 00817120 DOXYCIN CAP 100MG DOXYCYCLINE 100MG CAP081224 00860751 DOXYCIN TAB 100MG DOXYCYCLINE 100MG TAB081224 02351234 DOXYCYCLINE 100MG CAP DOXYCYCLINE HYCLATE 100MG CAP081224 02351242 DOXYCYCLINE 100MG TAB DOXYCYCLINE HYCLATE 100MG TAB081224 02231037 DOXYCYCLINE M‐RATIOP DOXYCYCLINE MONOHYDRATE 100MG TAB081224 02231039 DOXYCYCLINE M‐RATIOP DOXYCYCLINE MONOHYDRATE 200MG TAB081224 02248209 ENCA 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02248208 ENCA 50MG CAP MINOCYCLINE HYDROCHLORIDE 50MG CAP081224 02237876 MED‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02237875 MED‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02173506 MINOCIN CAP 100MG MINOCYCLINE HCL 100MG CAP081224 02230945 MINOCYCLINE 100MG CAP MINOCYCLINE 100MG CAP081224 02287234 MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02230944 MINOCYCLINE 50MG CAP MINOCYCLINE 50MG CAP081224 02287226 MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02238607 MINOCYCLINE‐RATIOPHARM 100MG MINOCYCLINE 100MG CAP081224 02230736 MYLAN‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02230735 MYLAN‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02158574 NOVO‐DOXYLIN 100MG TAB DOXYCYCLINE 100MG TAB081224 00725250 NOVO‐DOXYLIN CAP 100MG DOXYCYCLINE 100MG CAP081224 02108151 NOVO‐MINOCYCLINE 100MG MINOCYCLINE HCL 100MG CAP081224 02108143 NOVO‐MINOCYCLINE 50MG MINOCYCLINE HCL 50MG CAP081224 00021806 NOVOTETRA 250MG TETRACYCLINE 250MG TAB081224 02347687 NTP‐DOXYCYCLINE 100MG CAP DOXYCYCLINE HYCLATE J01AA02 CAP081224 02347679 NTP‐DOXYCYCLINE 100MG TAB DOXYCYCLINE HYCLATE 100MG TAB081224 02044668 NU‐DOXYCYCLINE 100 MG CAP DOXYCYCLINE 100MG CAP081224 02044676 NU‐DOXYCYCLINE 100MG TAB DOXYCYCLINE 100MG TAB081224 02335336 NU‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02335328 NU‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 00717606 NU‐TETRA CAP 250MG TETRACYCLINE 250MG CAP081224 00742562 PDL‐DOXYCYCLINE CAP 100MG USP DOXYCYCLINE 100MG CAP081224 00887064 PDL‐DOXYTAB 100MG DOXYCYCLINE 100MG TAB081224 02154366 PDL‐MINOCYCLINE 100M MINOCYCLINE 100MG CAP081224 02153394 PDL‐MINOCYCLINE 50MG MINOCYCLINE 50MG CAP081224 00156744 PDL‐TETRACYCLINE CAP 250MG TETRACYCLINE 250MG CAP081224 02289431 PHL‐DOXYCYCLINE 100MG CAP DOXYCYCLINE HYCLATE 100MG CAP081224 02289458 PHL‐DOXYCYCLINE 100MG TAB DOXYCYCLINE HYCLATE 100MG TAB081224 02294141 PHL‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02294133 PHL‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02239239 PMS‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02294427 PMS‐MINOCYCLINE 100MG CAP MINOCYCLINE 100MG CAP081224 02239238 PMS‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02294419 PMS‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02372789 Q‐MINOCYCLINE 100MG CAP MINOCYCLINE 100MG CAP081224 02372770 Q‐MINOCYCLINE 50MG CAP MINOCYCLINE 50MG CAP081224 01914146 RATIO‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 01914138 RATIO‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02242081 RIVA‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02242080 RIVA‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02237314 SANDOZ‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 02237313 SANDOZ‐MINOCYCLINE 50MG CAP MINOCYCLINE HCL 50MG CAP081224 02239982 SCHEIN‐MINOCYCLINE 100MG CAP MINOCYCLINE HCL 100MG CAP081224 00024368 VIBRAMYCIN CAP 100MG DOXYCYCLINE 100MG CAP081224 00578452 VIBRA‐TABS 100MG DOXYCYCLINE 100MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
21 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081428 POLYENES081428 02125145 DOM‐NYSTATIN 100,000U/ML O/L NYSTATIN 100000U/ML O/L081428 00792667 PMS‐NYSTATIN 100 000U/ML SUSP NYSTATIN 100,000/ML O/L081428 02194198 RATIO NYSTATIN 500000U TAB NYSTATIN 500000U TAB081428 02194201 RATIO‐NYSTATIN 100000U/ML O/L NYSTATIN 100000U/ML O/L
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
22 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081492 MISCELLANEOUS ANTIFUNGALS081492 00513229 FULVICIN PG TAB 165MG GRISEOFULVIN 165MG TAB081492 00028266 FULVICIN U/F TAB 125MG GRISEOFULVIN 125MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
24 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081692 MISCELLANEOUS ANTIMYCOBACTERIALS081692 02041510 DAPSONE 100MG TAB DAPSONE 100MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
25 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081804 ADAMANTANES081804 02343398 AMANTADINE 100MG CAP AMANTADINE HCL 100MG CAP081804 02130963 DOM‐AMANTADINE 100MG CAP AMANTADINE HCL 100MG CAP081804 02130971 DOM‐AMANTADINE 10MG/ML O/L AMANTADINE HCL 10MG/ML O/L081804 02139200 MYLAN‐AMANTADINE 100MG TAB AMANTADINE HCL 100MG CAP081804 02238306 PHL‐AMANTADINE 100MG CAP AMANTADINE HCL 100MG CAP081804 02262649 PHL‐AMANTADINE SYRUP 10MG/ML AMANTADINE HCL 10MG/ML O/L081804 02022826 PMS‐AMANTADINE 10MG/ML SYRUP AMANTADINE HCL 10MG/ML O/L081804 01990403 PMS‐AMANTADINE CAP 100MG AMANTADINE HCL 100MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
27 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081808 02240358 ZIAGEN 20MG/ML O/L ABACAVIR SULFATE 20MG/ML O/L081808 02240357 ZIAGEN 300MG TAB ABACAVIR SULFATE 300MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
29 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081828 NEURAMINIDASE INHIBITORS081828 02240863 RELENZA PWD FOR INHALATION 5MG ZANAMIVIR 5MG/DS PDR081828 02381842 TAMIFLU 6MG/ML O/L OSELTAMIVIR PHOSPHATE 6MG/ML O/L081828 02241472 TAMIFLU 75MG CAP OSELTAMIVIR PHOSPHATE 75MG CAP081828 02245549 TAMIFLU PEDIATRIC OSELTAMIVIR PHOSPHATE 12MG/ML O/L
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
32 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA081892 MISCELLANEOUS ANTIVIRALS081892 02240713 IMUNOVIR 500MG TAB INOSIPLEX 500MG TAB081892 02371553 INCIVEK 375MG TAB TELAPREVIR 375MG TAB081892 02370816 VICTRELIS 200MG CAP BOCEPREVIR 200MG CAP081892 02371456 VICTRELIS TRIPLE 200/100/200 BOCEPREVIR/PEGINTERFERON/RIBAV KIT081892 02371464 VICTRELIS TRIPLE 200/120/200 BOCEPREVIR/PEGINTERFERON/RIBAV KIT081892 02371472 VICTRELIS TRIPLE 200/150/200 BOCEPREVIR/PEGINTERFERON/RIBAV KIT081892 02371448 VICTRELIS TRIPLE 200/80/200 BOCEPREVIR/PEGINTERFERON/RIBAV 200/80/200 KIT
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
33 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA083004 AMEBICIDES083004 01997769 DIODOQUIN TAB 210MG IODOQUINOL 210MG TAB083004 01997750 DIODOQUIN TAB 650MG IODOQUINOL 650MG TAB083004 02078759 HUMATIN 250 MG CAP PAROMOMYCIN SULFATE 250MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
35 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA083092 MISCELLANEOUS ANTIPROTOZOALS083092 00545066 APO‐METRONIDAZOLE 250MG TAB METRONIDAZOLE 250MG TAB083092 02248562 APO‐METRONIDAZOLE 500MG CAP METRONIDAZOLE 500MG CAP083092 01926853 FLAGYL 500MG CAP METRONIDAZOLE 500MG CAP083092 02244405 FLORAZOLE ER 750MG TAB METRONIDAZOLE 750MG TAB083092 02217422 MEPRON 750MG/5ML ORAL SUSP ATOVAQUONE 750MG/5ML O/L083092 00870420 METRONIDAZOLE 5MG/ML INJ METRONIDAZOLE 5MG/ML INJ083092 00649074 METRONIDAZOLE INJ USP 5MG/ML METRONIDAZOLE 5MG/ML INJ083092 00420409 PDL‐METRONIDAZOLE TAB 250MG METRONIDAZOLE 250MG TAB083092 02183072 PENTAMIDINE ISETHION PENTAMIDINE ISETHIONATE 200MG INJ083092 02183080 PENTAMIDINE ISETHIONATE INJ PENTAMIDINE ISETHIONATE 200MG/VIAL INJ083092 00783137 PMS‐METRONIDAZOLE 500MG CAP METRONIDAZOLE 500MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
40 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA100000 02241800 PROCYTOX 2000MG/VIAL INJ CYCLOPHOSPHAMIDE 2000MG/VIA INJ100000 02241797 PROCYTOX 200MG/VIAL INJ CYCLOPHOSPHAMIDE 200MG/VIAL INJ100000 02241795 PROCYTOX 25MG TAB CYCLOPHOSPHAMIDE 25MG TAB100000 02241798 PROCYTOX 500MG/VIAL INJ CYCLOPHOSPHAMIDE 500MG/VIAL INJ100000 02241796 PROCYTOX 50MG TAB CYCLOPHOSPHAMIDE 50MG TAB100000 00004723 PURINETHOL 50MG TAB MERCAPTOPURINE 50MG TAB100000 02371324 RAN‐BICALUTAMIDE 50MG TAB BICALUTAMIDE 50MG TAB100000 02372282 RAN‐LETROZOLE 2.5MG TAB LETROZOLE 2.5MG TAB100000 02277700 RATIO‐BICALUTAMIDE 50MG TAB BICALUTAMIDE 50MG TAB100000 02244798 RATIO‐METHOTREXATE 2.5MG TAB METHOTREXATE SODIUM 2.5MG TAB100000 02304902 REVLIMID 10MG CAP LENALIDOMIDE 10MG CAP PA (N)100000 02317699 REVLIMID 15MG CAP LENALIDOMIDE 15MG CAP PA (N)100000 02317710 REVLIMID 25MG CAP LENALIDOMIDE 25MG CAP PA (N)100000 02304899 REVLIMID 5MG CAP LENALIDOMIDE 5MG CAP PA (N)100000 02241927 RITUXAN 10MG/ML LIQ RITUXIMAB 10MG/ML INJ PA (N)100000 02276089 SANDOZ BICALUTAMIDE 50MG TAB BICALUTAMIDE 50MG TAB100000 02344815 SANDOZ LETROZOLE 2.5MG TAB LETROZOLE 2.5MG TAB100000 02320193 SPRYCEL 100MG TAB DASATINIB MONOHYDRATE 100MG TAB PA (N)100000 02360829 SPRYCEL 140MG TAB DASATINIB MONOHYDRATE 140MG TAB PA (N)100000 02293129 SPRYCEL 20MG TAB DASATINIB MONOHYDRATE 20MG TAB PA (N)100000 02293137 SPRYCEL 50MG TAB DASATINIB MONOHYDRATE 50MG TAB PA (N)100000 02293145 SPRYCEL 70MG TAB DASATINIB MONOHYDRATE 70MG TAB PA (N)100000 02360810 SPRYCEL 80MG TAB DASATINIB MONOHYDRATE 80MG TAB PA (N)100000 02131692 STERILE BLEOMYCIN SULFATE USP BLEOMYCIN SULFATE 15IU/VIAL INJ100000 02228955 SUPREFACT DEPOT 2 MONTHS IMPL BUSERELIN ACETATE 6.3MG IMPLANT100000 02240749 SUPREFACT DEPOT 3MON 9.45MG BUSERELIN ACETATE 9.45MG IMPLANT100000 02225166 SUPREFACT INJ 1MG/ML BUSERELIN ACETATE 1MG/ML INJ100000 02225158 SUPREFACT NASAL SOL 1MG/ML BUSERELIN ACETATE 1MG/ML NAS SOL100000 02280795 SUTENT 12.5MG CAP SUNITINIB MALATE 12.5MG CAP PA (N)100000 02280809 SUTENT 25MG CAP SUNITINIB MALATE 25MG CAP PA (N)100000 02328607 SUTENT 37.5MG CAP SUNITINIB MALATE 37.5MG CAP PA (N)100000 02280817 SUTENT 50MG CAP SUNITINIB MALATE 50MG CAP PA (N)100000 01926624 TAMOFEN 10MG TAB TAMOXIFEN CITRATE 10MG TAB100000 01926632 TAMOFEN 20MG TAB TAMOXIFEN CITRATE 20MG TAB100000 00657360 TAMOFEN TAB 10MG TAMOXIFEN CITRATE 10MG TAB100000 00657379 TAMOFEN TAB 20MG TAMOXIFEN CITRATE 20MG TAB100000 02163778 TAMONE 10MG TAB TAMOXIFEN CITRATE 10MG TAB100000 02220652 TAMOPLEX 10MG TAB TAMOXIFEN CITRATE 10 MG TAB100000 02220660 TAMOPLEX 20MG TAB TAMOXIFEN CITRATE 20 MG TAB100000 02230042 TAMOXIFEN 10MG TAB TAMOXIFEN CITRATE 10MG TAB100000 02237596 TAMOXIFEN 10MG TAB TAMOXIFEN CITRATE 10MG TAB100000 02230043 TAMOXIFEN 20MG TAB TAMOXIFEN CITRATE 20MG TAB100000 02237597 TAMOXIFEN 20MG TAB TAMOXIFEN CITRATE 20MG TAB100000 02296721 TAMOXIFENE 10MG TAB TAMOXIFENE CITRATE 10MG TAB100000 02269015 TARCEVA 100MG TAB ERLOTINIB HCL 100MG TAB PA (N)100000 02269023 TARCEVA 150MG TAB ERLOTINIB HCL 150MG TAB PA (N)100000 02269007 TARCEVA 25MG TAB ERLOTINIB HCL 25MG TAB PA (N)100000 02368250 TASIGNA 150MG CAP NILOTINIB HCL 150MG CAP PA (N)100000 02315874 TASIGNA 200MG CAP NILOTINIB HCL 200MG CAP PA (N)100000 02241095 TEMODAL 100MG CAP TEMOZOLOMIDE 100MG CAP PA (N)100000 02312794 TEMODAL 140MG CAP TEMOZOLOMIDE 140MG CAP PA (N)100000 02312816 TEMODAL 180MG CAP TEMOZOLOMIDE 180MG CAP PA (N)100000 02241094 TEMODAL 20MG CAP TEMOZOLOMIDE 20MG CAP PA (N)100000 02241096 TEMODAL 250MG CAP TEMOZOLOMIDE 250MG CAP PA (N)100000 02241093 TEMODAL 5MG CAP TEMOZOLOMIDE 5MG CAP PA (N)100000 02230089 TEVA‐FLUTAMIDE TAB 250MG FLUTAMIDE 250MG TAB100000 02355205 THALOMID 100MG CAP THALIDOMIDE 100MG CAP PA (N)100000 02355213 THALOMID 150MG CAP THALIDOMIDE 150MG CAP PA (N)100000 02355221 THALOMID 200MG CAP THALIDOMIDE 200MG CAP PA (N)100000 02355191 THALOMID 50MG CAP THALIDOMIDE 50MG CAP PA (N)100000 02229566 TOMUDEX 2MG VIAL INJ RALTITREXED 2MG INJ100000 02333880 TOPOTECAN 4MG/VIAL INJ TOPOTECAN HCL 4MG/VIAL INJ100000 02379422 TOPOTECAN HCL 1MG/ML INJ TOPOTECAN HCL 1MG/ML INJ100000 02379422 TOPOTECAN HCL 1MG/ML INJ TOPOTECAN HCL 1MG/ML INJ100000 02344009 TOPOTECAN HCL 4MG/VIAL INJ TOPOTECAN HCL 4MG/VIAL INJ100000 02346656 TOPOTECAN HCL 4MG/VIAL INJ TOPOTECAN HCL 4MG/VIAL INJ100000 02243856 TRELSTAR 11.25MG/VIAL INJ TRIPTORELIN PAMOATE 11.25MG/VL INJ100000 02240000 TRELSTAR 3.75MG/VIAL INJ TRIPTORELIN PAMOATE 3.75MG/VL INJ100000 02326442 TYKERB 250MG TAB LAPATINIB DITOSYLATE MONOHYDRA 250MG TAB PA (N)100000 02308487 VECTIBIX 100MG/5ML IV INJ PANITUMUMAB 100MG/5ML INJ PA (N)100000 02308495 VECTIBIX 200MG/10ML IV INJ PANITUMUMAB 200MG/10ML INJ PA (N)100000 02308509 VECTIBIX 400MG/20ML IV INJ PANITUMUMAB 400MG/20ML INJ PA (N)100000 00616192 VEPESID CAP 50MG ETOPOSIDE 50MG CAP100000 02145839 VESANOID 10MG CAP TRETINOIN 10 MG CAP100000 02336707 VIDAZA 100MG/VIAL INJ AZACITIDINE 100MG/VIAL INJ PA (N)100000 02183064 VINBLASTINE SULFATE 10MG/VIAL VINBLASTINE SULPHATE 10MG/VIAL INJ100000 02183056 VINBLASTINE SULFATE 1MG/ML INJ VINBLASTINE SULPHATE 1MG/ML INJ100000 02183013 VINCRISTINE SULFATE 1MG/ML INJ VINCRISTINE SULFATE 1MG/ML INJ100000 02324148 VINCRISTINE SULFATE 1MG/ML INJ VINCRISTINE SULFATE 1MG/ML INJ100000 02333198 VINCRISTINE SULFATE 1MG/ML INJ VINCRISTINE SULFATE 1MG/ML INJ100000 02183021 VINCRISTINE SULFATE 1MG/VIAL VINCRISTINE SULPHATE 1MG/VIAL INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
43 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA120400 02266717 REMINYL ER 8MG CAP GALANTAMINE HBR 8MG CAP LA120400 02312492 RIVASTIGMINE 1.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 1.5MG CAP120400 02375729 RIVASTIGMINE 1.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 1.5MG CAP120400 02312506 RIVASTIGMINE 3MG CAP RIVASTIGMINE HYDROGEN TARTRATE 3MG CAP120400 02375737 RIVASTIGMINE 3MG CAP RIVASTIGMINE HYDROGEN TARTRATE 3MG CAP120400 02312514 RIVASTIGMINE 4.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 4.5MG CAP120400 02375745 RIVASTIGMINE 4.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 4.5MG CAP120400 02312522 RIVASTIGMINE 6MG CAP RIVASTIGMINE HYDROGEN TARTRATE 6MG CAP120400 02375753 RIVASTIGMINE 6MG CAP RIVASTIGMINE HYDROGEN TARTRATE 6MG CAP120400 02216345 SALAGEN 5MG TAB PILOCARPINE HCL 5MG TAB120400 02324563 SANDOZ RIVASTIGMINE 1.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 1.5MG CAP120400 02324571 SANDOZ RIVASTIGMINE 3MG CAP RIVASTIGMINE HYDROGEN TARTRATE 3MG CAP120400 02324598 SANDOZ RIVASTIGMINE 4.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 4.5MG CAP120400 02324601 SANDOZ RIVASTIGMINE 6MG CAP RIVASTIGMINE HYDROGEN TARTRATE 6MG CAP120400 02377969 TEVA‐GALANTAMINE ER 16MG CAP GALANTAMINE HYDROBROMIDE 16MG CAP LA120400 02377977 TEVA‐GALANTAMINE ER 24MG CAP GALANTAMINE HYDROBROMIDE 24MG CAP LA120400 02377950 TEVA‐GALANTAMINE ER 8MG CAP GALANTAMINE HYDROBROMIDE 8MG CAP LA120400 02308622 ZYM‐RIVASTIGMINE 1.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 1.5MG CAP120400 02308630 ZYM‐RIVASTIGMINE 3MG CAP RIVASTIGMINE HYDROGEN TARTRATE 3MG CAP120400 02308649 ZYM‐RIVASTIGMINE 4.5MG CAP RIVASTIGMINE HYDROGEN TARTRATE 4.5MG CAP120400 02308657 ZYM‐RIVASTIGMINE 6MG CAP RIVASTIGMINE HYDROGEN TARTRATE 6MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
45 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA121200 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
46 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA121204 ALPHA-ADRENERGICAGONISTS121204 02349590 AA‐MIDODRINE 2.5MG TAB MIDODRINE HCL 2.5MG TAB121204 02349604 AA‐MIDODRINE 5MG TAB MIDODRINE HCL 5MG TAB121204 02247148 AMATINE 10MG TAB MIDODRINE HCL 10MG TAB121204 02278677 MIDODRINE 2.5MG TAB MIDODRINE HCL 2.5MG TAB121204 02278685 MIDODRINE 5MG TAB MIDODRINE HCL 5MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
48 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA121208 02361744 ZENHALE 5/50MCG INH FORMOTEROL/MOMETASONE 5/50MCG INH
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
50 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA121600 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS121604 02322900 ACCEL‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02315866 APO‐ALFUZOSIN ER 10MG TAB ALFUZOSIN HCL 10MG TAB LA121604 02362406 APO‐TAMSULOSIN CR 0.4MG TAB TAMSULOSIN HYDROCHLORIDE 0.4MG TAB LA121604 02364395 AVA‐ALFUZOSIN 10MG TAB ALFUZOSIN HCL 10MG TAB121604 02366231 AVA‐TAMSULOSIN CR 0.4MG TAB TAMSULOSIN HYDROCHLORIDE 0.4MG TAB LA121604 00176141 BELLERGAL SPACETABS BELLADONNA/ERGOTAMINE/PHENOBAR0.2/0.6/40 TAB121604 00176095 CAFERGOT TAB CAFFEINE/ERGOTAMINE TARTRATE TAB121604 00027243 DIHYDROERGOTAMINE 1MG/ML INJ DIHYDROERGOTAMINE MESYLATE 1MG/ML INJ121604 02241163 DIHYDROERGOTAMINE 1MG/ML INJ DIHYDROERGOTAMINE MESYLATE 1MG/ML INJ121604 00156086 ERGODRYL CAP ERGOTAMINE COMPOUND HF 100MG CAP121604 02270102 FLOMAX CR 0.4MG TAB TAMSULOSIN HCL 0.4MG TAB LA121604 00116858 GRAVERGOL CAP ERGOTAMINE COMPOUND CAP121604 00176176 HYDERGINE 1MG TAB ERGOLOID MESYLATES 1MG TAB121604 02352419 JAMP‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02228947 MIGRANAL 4MG/ML NASAL SPRAY DIHYDROERGOTAMINE MESYLATE 4MG/ML NAS SPR121604 02317494 MINT‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02298570 MYLAN‐TAMSULOSIN 0.4MG CAP TAMSULOSIN HYDROCHLORIDE 0.4MG CAP LA121604 02243737 PHENTOLAMINE MESYLATE 5MG/ML I PHENTOLAMINE MESYLATE 5MG/ML INJ121604 02242411 PMS‐DIHYDROERGOTAMINE 4MG/ML DIHYDROERGOTAMINE MESYLATE 4MG/ML NAS SOL121604 02294885 RAN‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02294265 RATIO‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 09857334 RATIO‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02242979 ROGITINE 10MG/ML INJ PHENTOLAMINE MESYLATE 10MG/ML INJ121604 02304678 SANDOZ ALFUZOSIN 10MG TAB ALFUZOSIN HCL 10MG TAB LA121604 02319217 SANDOZ TAMSULOSIN 0.4MG CAP TAMSULOSIN HCL 0.4MG CAP121604 02340208 SANDOZ TAMSULOSIN 0.4MG CR TAMSULOSIN HCL 0.4MG TAB LA121604 02295121 SANDOZ TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02331780 TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02349450 TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02314282 TEVA‐ALFUZOSIN PR 10MG TAB ALFUZOSIN HCL 10MG TAB121604 02281392 TEVA‐TAMSULOSIN 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02368242 TEVA‐TAMSULOSIN CR 0.4MG TAB TAMSULOSIN HCL 0.4MG TAB LA121604 02333333 UFLO 0.4MG ER CAP TAMSULOSIN HCL 0.4MG CAP LA121604 02245565 XATRAL PR 10MG TAB ALFUZOSIN HCL 10MG TAB LA
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
52 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA122008 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS122008 01997653 DANTRIUM CAP 100MG DANTROLENE SODIUM 100MG CAP122008 01997602 DANTRIUM CAP 25MG DANTROLENE SODIUM 25MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
54 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA200404 IRON PREPARATIONS200404 02205963 DEXIRON 50MG/ML INJ IRON DEXTRAN 50MG/ML INJ200404 02221780 INFUFER 50MG/ML INJ IRON DEXTRAN 50MG/ML INJ200404 00391867 TRINSICON CAP IRON/B12 CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
55 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA200408 LIVER AND STOMACH PREPARATIONS200408 00504572 LIVER EXTRACT INJ CRUDE 2MG/ML LIVER INJECTION 2MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
58 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA201214 PLATELET-REDUCING AGENTS201214 02236859 AGRYLIN 0.5MG CAP ANAGRELIDE HCL 0.5MG CAP201214 02236860 AGRYLIN 1MG CAP ANAGRELIDE HCL 1MG CAP201214 02283344 ANAGRYD 0.5MG CAP ANAGRELIDE HCL MONOHYDRATE 0.5MG CAP201214 02281287 DOM‐ANAGRELIDE 0.5MG CAP ANAGRELIDE HCL MONOHYDRATE 0.5MG CAP201214 02253054 MYLAN‐ANAGRELIDE 0.5MG CAP ANAGRELIDE HCL 0.5MG CAP201214 02281155 PHL‐ANAGRELIDE 0.5MG CAP ANAGRELIDE HCL MONOHYDRATE 0.5MG CAP201214 02274949 PMS‐ANAGRELIDE 0.5MG CAP ANAGRELIDE HCL MONOHYDRATE 0.5MG CAP201214 02260107 SANDOZ‐ANAGRELIDE 0.5MG CAP ANAGRELIDE HCL 0.5MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
61 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA202400 HEMORRHEOLOGIC AGENTS202400 02230090 APO‐PENTOXIFYLLINE SR 400MG TA PENTOXIFYLLINE 400MG TAB LA202400 02230401 NU‐PENTOXIFYLLINE SR 400MG TAB PENTOXIFYLLINE 400MG TAB LA202400 02243879 PENTOXIFYLLINE 400MG ER TAB PENTOXIFYLLINE 400MG TAB LA202400 02221977 TRENTAL 400MG SR TAB PENTOXIFYLLINE 400MG TAB LA
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
62 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA202816 HEMOSTATICS202816 02064405 CYKLOKAPRON 500MG TAB TRANEXAMIC ACID 500MG TAB202816 02010372 CYKLOKAPRON TAB 500MG TRANEXAMIC ACID 500MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
64 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA240408 CARDIOTONIC AGENTS240408 02335700 TOLOXIN 0.0625MG TAB DIGOXIN 0.0625MG TAB240408 02335719 TOLOXIN 0.125MG TAB DIGOXIN 0.125MG TAB240408 02335727 TOLOXIN 0.25MG TAB DIGOXIN 0.250MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
66 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA240605 CHOLESTEROL ABSORPTION INHIBITORS240605 02247521 EZETROL 10MG TAB EZETIMIBE 10MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
74 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA240692 MISCELLANEOUS ANTILIPEMIC AGENTS240692 02091909 LORELCO 250MG TAB PROBUCOL 250MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
77 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA240832 PERIPHERAL ADRENERGIC INHIBITORS240832 00396745 APO‐GUANETHIDINE 10MG TAB GUANETHIDINE SULFATE 10MG TAB240832 00396753 APO‐GUANETHIDINE 25MG TAB GUANETHIDINE MONOSULFATE 25MG TAB240832 00005509 ISMELIN 10MG TAB GUANETHIDINE MONOSULFATE 10MG TAB240832 00074365 ISMELIN ESIDRIX GUANETHIDINE MONOSULFATE/HCTZ 10MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
78 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA240892 MISCELLANEOUS HYPOTENSIVE AGENTS
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
80 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA241212 PHOSPHODIESTERASE INHIBITORS 241212 02338327 ADCIRCA 20MG TAB TADALAFIL 20MG TAB PA (N)241212 02319500 RATIO‐SILDENAFIL R 20MG TAB SILDENAFIL CITRATE 20MG TAB PA (N)241212 02279401 REVATIO 20MG TAB SILDENAFIL CITRATE 20MG TAB PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
92 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA242808 02342804 ZYM‐AMLODIPINE 10MG TAB AMLODIPINE BESYLATE 10MG TAB242808 02342782 ZYM‐AMLODIPINE 2.5MG TAB AMLODIPINE BESYLATE 2.5MG TAB242808 02342790 ZYM‐AMLODIPINE 5MG TAB AMLODIPINE BESYLATE 5MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
93 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA242892 MISC. CALCIUM-CHANNEL BLOCKING AGENTS242892 02229815 ALBERT‐DILTIAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02229816 ALBERT‐DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02229817 ALBERT‐DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02229818 ALBERT‐DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 00771376 APO‐DILTIAZ 30MG TAB DILTIAZEM HCL 30MG TAB242892 00771384 APO‐DILTIAZ 60MG TAB DILTIAZEM HCL 60MG TAB242892 02230997 APO‐DILTIAZ CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02230998 APO‐DILTIAZ CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02230999 APO‐DILTIAZ CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02229526 APO‐DILTIAZ CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02222973 APO‐DILTIAZ SR 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02222957 APO‐DILTIAZ SR 60MG CAP DILTIAZEM HCL 60MG CAP LA242892 02222965 APO‐DILTIAZ SR 90MG CAP DILTIAZEM HCL 90MG CAP LA242892 02291037 APO‐DILTIAZ TZ 120MG ER CAP DILTIAZEM HCL 120MG CAP LA242892 02291045 APO‐DILTIAZ TZ 180MG ER CAP DILTIAZEM HCL 180MG CAP LA242892 02291053 APO‐DILTIAZ TZ 240MG ER CAP DILTIAZEM HCL 240MG CAP LA242892 02291061 APO‐DILTIAZ TZ 300MG ER CAP DILTIAZEM HCL 300MG CAP LA242892 02291088 APO‐DILTIAZ TZ 360MG ER CAP DILTIAZEM HCL 360MG CAP LA242892 00782491 APO‐VERAP 120MG TAB VERAPAMIL HCL 120MG TAB242892 00782483 APO‐VERAP 80MG TAB VERAPAMIL HCL 80MG TAB242892 02246893 APO‐VERAP SR 120MG TAB VERAPAMIL HCL 120MG TAB LA242892 02246894 APO‐VERAP SR 180MG TAB VERAPAMIL HCL 180MG TAB LA242892 02246895 APO‐VERAP SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02343304 APX‐DILTIAZ CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02343312 APX‐DILTIAZ CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02343320 APX‐DILTIAZ CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02343339 APX‐DILTIAZ CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02363984 AVA‐DILTIAZEM 30MG TAB DILTIAZEM HCL 30MG TAB242892 02363992 AVA‐DILTIAZEM 60MG TAB DILTIAZEM HCL 60MG TAB242892 02365804 AVA‐VERAPAMIL 120MG TAB VERAPAMIL HCL 120MG TAB242892 02365790 AVA‐VERAPAMIL 80MG TAB VERAPAMIL HCL 80MG TAB242892 01917072 CARDIZEM CD 120MG CAP DILTIAZEM HCL 300MG CAP LA242892 02009323 CARDIZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02097249 CARDIZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02009315 CARDIZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02097257 CARDIZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 01917064 CARDIZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02097265 CARDIZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02097273 CARDIZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 00587753 CARDIZEM TAB 30MG DILTIAZEM HCL 30MG TAB242892 00587761 CARDIZEM TAB 60MG DILTIAZEM HCL 60MG TAB242892 02370611 CO DILTIAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02370638 CO DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02370646 CO DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02370654 CO DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02370441 CO DILTIAZEM T 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02370492 CO DILTIAZEM T 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02370506 CO DILTIAZEM T 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02370514 CO DILTIAZEM T 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02370522 CO DILTIAZEM T 360MG CAP DILTIAZEM HCL 360MG CAP LA242892 02231472 DILTIAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02231474 DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02231475 DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP242892 02240321 DOM‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB242892 02254824 GEN‐DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02254832 GEN‐DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 01907123 ISOPTIN SR TAB 120MG VERAPAMIL HCL 120MG TAB LA242892 01934317 ISOPTIN SR TAB 180MG VERAPAMIL HCL 180MG TAB LA242892 00742554 ISOPTIN SR TAB 240MG VERAPAMIL HCL 240MG TAB LA242892 02237304 MED‐DILTIAZEM SR 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02237302 MED‐DILTIAZEM SR 60MG CAP DILTIAZEM HCL 60MG CAP LA242892 02237303 MED‐DILTIAZEM SR 90MG CAP DILTIAZEM HCL 90MG CAP LA242892 02237922 MYLAN‐VERAPAMIL 120MG TAB VERAPAMIL HCL 120MG TAB242892 02237921 MYLAN‐VERAPAMIL 80MG TAB VERAPAMIL HCL 80MG TAB242892 02210347 MYLAN‐VERAPAMIL SR 120MG TAB VERAPAMIL HCL 120MG TAB LA242892 02210355 MYLAN‐VERAPAMIL SR 180MG TAB VERAPAMIL HCL 180MG TAB LA242892 02210363 MYLAN‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02271605 NOVO‐DILTIAZEM HCL ER 120MG DILTIAZEM HCL 120MG CAP LA242892 02271613 NOVO‐DILTIAZEM HCL ER 180MG DILTIAZEM HCL 180MG CAP LA242892 02271621 NOVO‐DILTIAZEM HCL ER 240MG DILTIAZEM HCL 240MG CAP LA242892 02271648 NOVO‐DILTIAZEM HCL ER 300MG DILTIAZEM HCL 300MG CAP LA242892 02271656 NOVO‐DILTIAZEM HCL ER 360MG DILTIAZEM HCL 360MG CAP LA242892 02211920 NOVO‐VERAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 00812358 NOVO‐VERAMIL TAB 120MG VERAPAMIL HCL 120MG TAB242892 00812331 NOVO‐VERAMIL TAB 80MG VERAPAMIL HCL 80MG TAB242892 02231052 NU‐DILTIAZ CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02231053 NU‐DILTIAZ CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02231054 NU‐DILTIAZ CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 00886068 NU‐DILTIAZ TAB 30MG DILTIAZEM HCL 30MG TAB242892 00886076 NU‐DILTIAZ TAB 60MG DILTIAZEM HCL 60MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
94 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA242892 02336367 NU‐VERAP SR 120MG TAB LA VERAPAMIL HYDROCHLORIDE 120MG TAB LA242892 02336375 NU‐VERAP SR 180MG TAB LA VERAPAMIL HYDROCHLORIDE 180MG TAB LA242892 02249812 NU‐VERAP SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 00886041 NU‐VERAP TAB 120MG VERAPAMIL HCL 120MG TAB242892 00886033 NU‐VERAP TAB 80MG VERAPAMIL HCL 80MG TAB242892 02231057 PDL‐DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 00828785 PDL‐DILTIAZEM‐30 TAB 30MG DILTIAZEM HCL 30MG TAB242892 00828777 PDL‐DILTIAZEM‐60 TAB 60MG DILTIAZEM HCL 60MG TAB242892 00871028 PDL‐VERAPAMIL TAB 80MG VERAPAMIL HCL 80MG TAB242892 02229593 PENTA‐DILTIAZEM 30MG TAB DILTIAZEM HCL 30MG TAB242892 02229594 PENTA‐DILTIAZEM 60MG TAB DILTIAZEM HCL 60MG TAB242892 02237248 PHARMA‐DILTIAZ 30MG TAB DILTIAZEM HCL 30MG TAB242892 02237249 PHARMA‐DILTIAZ 60MG TAB DILTIAZEM HCL 60MG TAB242892 02238276 PHL‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02355787 PMS‐DILTIAZEM CD DILTIAZEM HCL 300MG CAP242892 02355752 PMS‐DILTIAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP242892 02355760 PMS‐DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP242892 02355779 PMS‐DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP242892 02237791 PMS‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02325306 PRO‐DILTIAZEM TZ 120MG ER CAP DILTIAZEM HCL 120MG CAP LA242892 02325314 PRO‐DILTIAZEM TZ 180MG ER CAP DILTIAZEM HCL 180MG CAP LA242892 02325322 PRO‐DILTIAZEM TZ 240MG ER CAP DILTIAZEM HCL 240MG CAP LA242892 02325330 PRO‐DILTIAZEM TZ 300MG ER CAP DILTIAZEM HCL 300MG CAP LA242892 02325349 PRO‐DILTIAZEM TZ 360MG ER CAP DILTIAZEM 360MG CAP LA242892 02324156 PRO‐VERAPAMIL SR 120MG TAB VERAPAMIL HCL 120MG TAB242892 02324164 PRO‐VERAPAMIL SR 180MG TAB VERAPAMIL HCL 180MG TAB LA242892 02312697 PRO‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02229781 RATIO‐DILTIAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02229782 RATIO‐DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02229783 RATIO‐DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02229784 RATIO‐DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02248082 RIVA‐VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02243338 SANDOZ DILTIAZEM 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02243339 SANDOZ DILTIAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02243340 SANDOZ DILTIAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02243341 SANDOZ DILTIAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 02245918 SANDOZ‐DILTIAZEM T 120MG ER CA DILTIAZEM HCL 120MG CAP LA242892 02245919 SANDOZ‐DILTIAZEM T 180MG ER CA DILTIAZEM HCL 180MG CAP LA242892 02245920 SANDOZ‐DILTIAZEM T 240MG ER CA DILTIAZEM HCL 240MG CAP LA242892 02245921 SANDOZ‐DILTIAZEM T 300MG ER CA DILTIAZEM HCL 300MG CAP LA242892 02245922 SANDOZ‐DILTIAZEM T 360MG ER CA DILTIAZEM HCL 360MG CAP LA242892 02242538 TEVA‐DILTAZEM CD 120MG CAP DILTIAZEM HCL 120MG CAP LA242892 02242539 TEVA‐DILTAZEM CD 180MG CAP DILTIAZEM HCL 180MG CAP LA242892 02242540 TEVA‐DILTAZEM CD 240MG CAP DILTIAZEM HCL 240MG CAP LA242892 02242541 TEVA‐DILTAZEM CD 300MG CAP DILTIAZEM HCL 300MG CAP LA242892 00862924 TEVA‐DILTAZEM TAB 30MG DILTIAZEM HCL 30MG TAB242892 00862932 TEVA‐DILTAZEM TAB 60MG DILTIAZEM HCL 60MG TAB242892 02231150 TIAZAC 120MG SR CAP DILTIAZEM HCL 120MG CAP LA242892 02231151 TIAZAC 180MG SR CAP DILTIAZEM HCL 180MG CAP LA242892 02231152 TIAZAC 240MG SR CAP DILTIAZEM HCL 240MG CAP LA242892 02231154 TIAZAC 300MG SR CAP DILTIAZEM HCL 300MG CAP LA242892 02231155 TIAZAC 360MG SR CAP DILTIAZEM HCL 360MG CAP LA242892 02256738 TIAZAC XC 120MG TAB DILTIAZEM HCL 120MG TAB LA242892 02256746 TIAZAC XC 180MG TAB DILTIAZEM HCL 180MG TAB LA242892 02256754 TIAZAC XC 240MG TAB DILTIAZEM HCL 240MG TAB LA242892 02256762 TIAZAC XC 300MG TAB DILTIAZEM HCL 300MG TAB LA242892 02256770 TIAZAC XC 360MG TAB DILTIAZEM HCL 360MG TAB LA242892 02340682 VERAPAMIL HCL 120MG SR TAB VERAPAMIL HCL 120MG TAB LA242892 02178753 VERAPAMIL HCL 120MG TAB VERAPAMIL HCL 120MG TAB242892 02340941 VERAPAMIL HCL 120MG TAB VERAPAMIL HCL 120MG TAB242892 02340690 VERAPAMIL HCL 180MG SR TAB VERAPAMIL HCL 180MG TAB LA242892 02340704 VERAPAMIL HCL 240MG SR TAB VERAPAMIL HCL 240MG TAB LA242892 02178745 VERAPAMIL HCL 80MG TAB VERAPAMIL HCL 80MG TAB242892 02340933 VERAPAMIL HCL 80MG TAB VERAPAMIL HCL 80MG TAB242892 02303558 VERAPAMIL SR 240MG TAB VERAPAMIL HCL 240MG TAB LA242892 02100479 VERELAN 120MG SR CAP VERAPAMIL HCL 120MG CAP LA242892 02100487 VERELAN 180MG SR CAP VERAPAMIL HCL 180MG CAP LA242892 02100495 VERELAN 240MG SR CAP VERAPAMIL HCL 240MG CAP LA
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
106 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA243220 MINERALOCORTICOID (ALDOSTERONE) RECEPTOR ANTAGONISTS243220 00028606 ALDACTONE 25MG TAB SPIRONOLACTONE 25MG TAB243220 00285455 ALDACTONE TAB 100MG SPIRONOLACTONE 100MG TAB243220 02323052 INSPRA 25MG TAB EPLERENONE 25MG TAB PA (N)243220 02323060 INSPRA 50MG TAB EPLERENONE 50MG TAB PA (N)243220 02347628 NTP‐SPIRONOLACTONE 100MG TAB SPIRONOLACTONE 100MG TAB243220 02347601 NTP‐SPIRONOLACTONE 25MG TAB SPIRONOLACTONE 25MG TAB243220 00613223 TEVA‐SPIROTON TAB 100MG SPIRONOLACTONE 100MG TAB243220 00613215 TEVA‐SPIROTON TAB 25MG SPIRONOLACTONE 25MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
107 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA243240 RENIN INHIBITORS243240 02302063 RASILEZ 150MG TAB ALISKIREN FUMARATE 150MG TAB243240 02302071 RASILEZ 300MG TAB ALISKIREN FUMARATE 300MG TAB243240 02332728 RASILEZ HCT 150MG/12.5MG TAB ALISKIREN FUMARATE/HCTZ 150/12.5MG TAB243240 02332736 RASILEZ HCT 150MG/25MG TAB ALISKIREN FUMARATE/HCTZ 150/25MG TAB243240 02332744 RASILEZ HCT 300MG/12.5MG TAB ALISKIREN FUMARATE/HCTZ 300/12.5MG TAB243240 02332752 RASILEZ HCT 300MG/25MG TAB ALISKIREN FUMARATE/HCTZ 300/25MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
114 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA280808 02232389 EXDOL‐30 TAB ACETAMINOPHEN/CAFFEINE/CODEINE 30MG TAB280808 02349914 FENTANYL 100MCG/HR PATCH FENTANYL 100MCG/HR PATCH280808 02349876 FENTANYL 12MCG/HR PATCH FENTANYL 12MCG/HR PATCH280808 02349884 FENTANYL 25MCG/HR PATCH FENTANYL 25MCG/HR PATCH280808 02349892 FENTANYL 50MCG/HR PATCH FENTANYL 50MCG/HR PATCH280808 02349906 FENTANYL 75MCG/HR PATCH FENTANYL 75MCG/HR PATCH280808 00965715 FENTANYL CITRATE 50MCG/ML INJ FENTANYL CITRATE 50MCG/ML INJ280808 02384124 FENTANYL CITRATE 50MCG/ML INJ FENTANYL CITRATE 50MCG/ML INJ280808 00176206 FIORINAL C1/2 CAP ASA/CAFFEINE/CODEINE/BUTALBITA CAP280808 00176192 FIORINAL C1/4 CAP ASA/CAFFEINE/CODEINE/BUTALBITA CAP280808 02125358 HYDROMORPH CONTIN 10MG HYDROMORPHONE HCL 10MG CAP LA280808 02125366 HYDROMORPH CONTIN 12MG SR CAP HYDROMORPHONE HCL 12MG CAP LA280808 02125374 HYDROMORPH CONTIN 20MG HYDROMORPHONE HCL 20MG CAP LA280808 02125382 HYDROMORPH CONTIN 24MG SR CAP HYDROMORPHONE HCL 24MG CAP LA280808 02125323 HYDROMORPH CONTIN 3MG CR CAP HYDROMORPHONE HCL 3MG CAP LA280808 02359502 HYDROMORPH CONTIN 4.5MG CAP HYDROMORPHONE HCL 4.5MG CAP280808 02125331 HYDROMORPH CONTIN 6MG CR CAP HYDROMORPHONE HCL 6MG CAP LA280808 02359510 HYDROMORPH CONTIN 9MG CAP HYDROMORPHONE HCL 9MG CAP280808 02243562 HYDROMORPH CONTIN SR 18MG CAP HYDROMORPHONE HCL 18MG CAP LA280808 02225220 HYDROMORPH IR 1MG CAP HYDROMORPHONE HCL 1MG CAP280808 02225239 HYDROMORPH IR 2MG CAP HYDROMORPHONE HCL 2MG CAP280808 02225247 HYDROMORPH IR 4MG CAP HYDROMORPHONE HCL 4MG CAP280808 02225255 HYDROMORPH IR 8MG CAP HYDROMORPHONE HCL 8MG CAP280808 02125390 HYDROMORPHON CONTIN 30MG CRCAP HYDROMORPHONE HCL 30MG CAP LA280808 02382636 HYDROMORPHONE 10MG/ML INJ HYDROMORPHONE HCL 10MG/ML INJ280808 02145901 HYDROMORPHONE 2MG/ML INJ HYDROMORPHONE HCL 2 MG/ML INJ280808 02244797 HYDROMORPHONE HP 100MG/ML INJ HYDROMORPHONE HCL 100MG/ML INJ280808 02145928 HYDROMORPHONE HP 10MG/ML INJ HYDROMORPHONE HCL 10MG/ML INJ280808 02145936 HYDROMORPHONE HP 20MG/ML INJ HYDROMORPHONE HCL 20MG/ML INJ280808 02146126 HYDROMORPHONE HP 50MG/ML INJ HYDROMORPHONE HCL 50MG/ML INJ280808 02242018 IBUCODONE 7.5MG/200MG TAB HYDROCODONE BITART/IBUPROFEN TAB280808 02184451 KADIAN 100MG SR CAP MORPHINE SULFATE 100MG CAP LA280808 02242163 KADIAN 10MG CAP (SUSTAINED REL MORPHINE SULFATE 10MG CAP LA280808 02184435 KADIAN 20MG SR CAP MORPHINE SULFATE 20MG CAP LA280808 02184443 KADIAN 50MG SR CAP MORPHINE SULFATE 50MG CAP LA280808 00380571 LINCTUS CODEINE BLANC CODEINE PHOSPHATE 10MG O/L280808 00486582 M O S SYR 1.0MG/ML MORPHINE HCL 1MG/ML O/L280808 00632503 M.O.S. 10 SYRUP 10MG/ML MORPHINE HCL 10MG/ML O/L280808 00690198 M.O.S. 10 TAB 10MG MORPHINE HCL 10MG TAB280808 00632481 M.O.S. 20 CONC 20MG/ML MORPHINE HCL 20MG/ML O/L280808 00690201 M.O.S. 20 TAB 20MG MORPHINE HCL 20MG TAB280808 00690228 M.O.S. 40 TAB 40MG MORPHINE HCL 40MG TAB280808 00776181 M.O.S. SR TAB 30MG MORPHINE HCL 30MG TAB LA280808 00776203 M.O.S. SR TAB 60MG MORPHINE HCL 60MG TAB LA280808 02009765 M.O.S. SULFATE 10MG TAB MORPHINE SULFATE 10MG TAB280808 02009749 M.O.S. SULFATE 25MG TAB MORPHINE SULFATE 25MG TAB280808 02009706 M.O.S. SULFATE 50MG TAB MORPHINE HCL 50MG TAB280808 02009773 M.O.S. SULFATE 5MG TAB MORPHINE HCL 5MG TAB280808 00514217 M.O.S. SYRUP 5MG/ML MORPHINE HCL 5MG/ML O/L280808 00392650 MEPERIDINE 100MG INJ MEPERIDINE HCL 100MG INJ280808 00725757 MEPERIDINE 75MG/ML INJ MEPERIDINE HCL 75MG/ML INJ280808 00497479 MEPERIDINE HCL 100MG/ML INJ MEPERIDINE HCL 100MG/ML INJ280808 00725749 MEPERIDINE HCL 100MG/ML INJ MEPERIDINE HCL 100MG/ML INJ280808 00497452 MEPERIDINE HCL 50MG/ML INJ MEPERIDINE HCL 50MG/ML INJ280808 00725765 MEPERIDINE HCL 50MG/ML INJ MEPERIDINE HCL 50MG/ML INJ280808 00497436 MEPERIDINE HCL INJ 10MG/ML MEPERIDINE HCL 10MG/ML INJ280808 00497444 MEPERIDINE HCL INJ 25MG/ML MEPERIDINE HCL 25MG/ML INJ280808 00497460 MEPERIDINE HCL INJ 75MG/ML MEPERIDINE HCL 75MG/ML INJ280808 02019965 M‐ESLON 100MG SR CAP MORPHINE SULFATE 100MG CAP LA280808 02019930 M‐ESLON 10MG SR CAP MORPHINE SULFATE 10MG CAP LA280808 02177749 M‐ESLON 15MG SR CAP MORPHINE SULFATE 15MG CAP LA280808 02177757 M‐ESLON 200MG SR CAP MORPHINE SULFATE 200MG CAP LA280808 02019949 M‐ESLON 30MG SR CAP MORPHINE SULFATE 30MG CAP LA280808 02019957 M‐ESLON 60MG SR CAP MORPHINE SULFATE 60MG CAP LA280808 02247700 METADOL 10MG TAB METHADONE HCL 10MG TAB280808 02241377 METADOL 10MG/ML LIQ METHADONE HCL 10MG/ML O/L280808 02247698 METADOL 1MG TAB METHADONE HCL 1MG TAB280808 02247694 METADOL 1MG/ML O/L METHADONE HCL 1MG/ML O/L280808 02247701 METADOL 25MG TAB METHADONE HCL 25MG TAB280808 02247699 METADOL 5MG TAB METHADONE HCL 5MG TAB280808 02247696 METADOL‐D 10MG TAB METHADONE HCL 10MG TAB280808 02244290 METADOL‐D 10MG/ML O/L METHADONE HCL 10MG/ML O/L280808 02247693 METADOL‐D 1MG TAB METHADONE HCL 1MG TAB280808 02247697 METADOL‐D 25MG TAB METHADONE HCL 25MG TAB280808 02247695 METADOL‐D 5MG TAB METHADONE HCL 5MG TAB280808 01966367 METHOXISAL C1/4 CAPLET ASA/CODEINE/METHOCARBAMOL 325/16.2MG CAPL280808 01980696 MORPHINE 1MG/ML INJ MORPHINE SULFATE 1MG/ML INJ280808 02137232 MORPHINE 1MG/ML INJ MORPHINE SULFATE 1 MG/ML INJ280808 02137240 MORPHINE 2MG/ML INJ MORPHINE SULFATE 2 MG/ML INJ280808 00869325 MORPHINE EXTRA FORTE 50MG/ML MORPHINE SULFATE 50MG/ML INJ280808 00869317 MORPHINE FORTE INJ 25MG/ML MORPHINE SULFATE 25MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
115 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA280808 00617288 MORPHINE HP 50 INJ 50MG/ML USP MORPHINE SULFATE 50MG/ML INJ280808 00676411 MORPHINE HP INJ 25MG/ML MORPHINE SULFATE 25MG/ML INJ280808 00029971 MORPHINE INJ AMP 15MG/ML MORPHINE SULFATE 15MG/ML INJ280808 00854581 MORPHINE LP 0.5 INJ 0.5MG/ML MORPHINE 0.5MG/ML INJ280808 00854573 MORPHINE LP 1.0 INJ 1MG/ML MORPHINE 1MG/ML INJ280808 02021048 MORPHINE LP 1MG/ML MORPHINE SULFATE 1MG/ML INJ280808 01949047 MORPHINE SANS P 0.5MG INJ MORPHINE SULFATE 0.5MG/ML INJ280808 01949055 MORPHINE SANS P 1.0MG INJ MORPHINE SULFATE 1MG/ML INJ280808 02350920 MORPHINE SR 100MG TAB MORPHINE SULFATE 100MG TAB LA280808 02350246 MORPHINE SR 15MG TAB MORPHINE SULFATE 15MG TAB LA280808 02350815 MORPHINE SR 15MG TAB MORPHINE SULFATE 15MG TAB LA280808 02350947 MORPHINE SR 200MG TAB MORPHINE SULFATE 200MG TAB LA280808 02350254 MORPHINE SR 30MG TAB MORPHINE SULFATE 30MG TAB LA280808 02350890 MORPHINE SR 30MG TAB MORPHINE SULFATE 30MG TAB LA280808 02350262 MORPHINE SR 60MG TAB MORPHINE SULFATE 60MG TAB LA280808 02350912 MORPHINE SR 60MG TAB MORPHINE SULFATE 60MG TAB LA280808 00392588 MORPHINE SULFATE 10MG/ML INJ MORPHINE SULFATE 10MG/ML INJ280808 00850322 MORPHINE SULFATE 10MG/ML INJ MORPHINE SULFATE 10MG/ML INJ280808 00392561 MORPHINE SULFATE 15MG/ML INJ MORPHINE SULFATE 15MG/ML INJ280808 00884081 MORPHINE SULFATE 25MG/ML MORPHINE SULFATE 25MG/ML INJ280808 00850314 MORPHINE SULFATE 2MG/ML INJ MORPHINE SULFATE 2MG/ML INJ280808 01964437 MORPHINE SULFATE 2MG/ML INJ MORPHINE SULFATE 2 MG/ML INJ280808 02242484 MORPHINE SULFATE 2MG/ML INJ MORPHINE SULFATE 2MG/ML INJ280808 00884111 MORPHINE SULFATE 50MG/ML MORPHINE SULFATE 50MG/ML INJ280808 02137267 MORPHINE SULFATE 50MG/ML INJ MORPHINE SULFATE 50MG/ML INJ280808 00497355 MORPHINE SULFATE INJ 10MG/ML MORPHINE SULFATE 10MG/ML INJ280808 00497363 MORPHINE SULFATE INJ 15MG/ML MORPHINE SULFATE 15MG/ML INJ280808 01964429 MORPHINE SULFATE INJ 5MG/ML MORPHINE SULFATE 5MG/ML INJ280808 00335398 MORPHINE SULPHATE INJ 10MG/ML MORPHINE SULFATE 10MG/ML INJ280808 00690236 MOS‐50 CONCENTRATE LIQ 50MG/ML MORPHINE HCL 50MG/ML O/L280808 00690244 MOS‐60 TAB 60MG MORPHINE HCL 60MG TAB280808 00665134 MS CONTIN 15MG L.A. TAB MORPHINE SULFATE 15MG TAB LA280808 02145979 MS CONTIN 200MG L.A. SUPP MORPHINE SULFATE 200MG SUPP LA280808 01907131 MS CONTIN 200MG L.A. TAB MORPHINE SULFATE 200MG TAB LA280808 00665142 MS CONTIN 30MG L.A. TAB MORPHINE SULFATE 30MG TAB LA280808 00665150 MS CONTIN 60MG L.A. TAB MORPHINE SULFATE 60MG TAB LA280808 02014319 MS CONTIN SRT 100MG MORPHINE SULFATE 100MG TAB LA280808 02015439 MS CONTIN SRT 15MG MORPHINE SULFATE 15MG TAB LA280808 02014327 MS CONTIN SRT 200MG MORPHINE SULFATE 200MG TAB LA280808 02014297 MS CONTIN SRT 30MG MORPHINE SULFATE 30MG TAB LA280808 02014300 MS CONTIN SRT 60MG MORPHINE SULFATE 60MG TAB LA280808 02242830 MS CONTIN XL SR 120MG CAP MORPHINE SULFATE 120MG CAP LA280808 02242831 MS CONTIN XL SR 150MG CAP MORPHINE SULFATE 150MG CAP LA280808 02242832 MS CONTIN XL SR 200MG CAP MORPHINE SULFATE 200MG CAP LA280808 02242827 MS CONTIN XL SR 30MG CAP MORPHINE SULFATE 30MG CAP LA280808 02242828 MS CONTIN XL SR 60MG CAP MORPHINE SULFATE 60MG CAP LA280808 02242829 MS CONTIN XL SR 90MG CAP MORPHINE SULFATE 90MG CAP LA280808 01909401 MS IR 5MG MORPHINE SULFATE 5MG TAB280808 01909444 MS IR SUPP 10MG MORPHINE SULFATE 10MG SUPP280808 01909452 MS IR SUPP 20MG MORPHINE SULFATE 20MG SUPP280808 01909460 MS IR SUPP 30MG MORPHINE SULFATE 30MG SUPP280808 01909398 MS IR TAB 10MG MORPHINE SULFATE 10MG TAB280808 02014211 MS IR TAB 10MG MORPHINE SULFATE 10MG TAB280808 01909371 MS IR TAB 20MG MORPHINE SULFATE 20MG TAB280808 02014238 MS IR TAB 20MG MORPHINE SULFATE 20MG TAB280808 01909428 MS IR TAB 30MG MORPHINE SULFATE 30MG TAB280808 02014254 MS IR TAB 30MG MORPHINE SULFATE 30MG TAB280808 02014203 MS IR TAB 5MG MORPHINE SULFATE 5MG TAB280808 02314665 NOVO‐FENTANYL 100MCG PATCH FENTANYL 100MCG PATCH280808 02314630 NOVO‐FENTANYL 25MCG PATCH FENTANYL 25MCG PATCH280808 02314649 NOVO‐FENTANYL 50MCG PATCH FENTANYL 50MCG PATCH280808 02314657 NOVO‐FENTANYL 75MCG PATCH FENTANYL 75MCG PATCH280808 02302799 NOVO‐MORPHINE SR 100MG TAB MORPHINE SULFATE 100MG TAB LA280808 02302764 NOVO‐MORPHINE SR 15MG TAB MORPHINE SULFATE 15MG TAB LA280808 02307898 NOVO‐OXYCOD ACET 5/325MG TAB OXYCODONE HCL/ACETAMINOPHEN 5/325MG TAB280808 02346397 NTP‐MORPHINE SR 100MG TAB MORPHINE SULFATE 100MG TAB280808 02346362 NTP‐MORPHINE SR 15MG TAB MORPHINE SULFATE 15MG TAB280808 02346400 NTP‐MORPHINE SR 200MG TAB MORPHINE SULFATE 200MG TAB280808 02346370 NTP‐MORPHINE SR 30MG TAB MORPHINE SULFATE 30MG TAB280808 02346389 NTP‐MORPHINE SR 60MG TAB MORPHINE SULFATE 60MG TAB280808 02325969 OXYCODONE 10MG TAB OXYCODONE HCL 10MG TAB280808 02325977 OXYCODONE 20MG TAB OXYCODONE HCL 20MG TAB280808 02336855 OXYCODONE 20MG TAB OXYCODONE HCL 20MG TAB280808 02325950 OXYCODONE 5MG TAB OXYCODONE HCL 5MG TAB280808 02361361 OXYCODONE/ACET 5MG/325MG TAB OXYCODONE/ACETAMINOPHEN 5MG/325MG TAB280808 02327171 OXYCODONE‐ACET TAB ACETAMINOPHEN/OXYCODONE 325/5MG TAB280808 02202441 OXYCONTIN 10MG CR TAB OXYCODONE 10MG TAB LA280808 02323222 OXYCONTIN 120MG CR TAB OXYCODONE HCL 120MG TAB LA280808 02323192 OXYCONTIN 15MG CR TAB OXYCODONE HCL 15MG TAB LA280808 02246902 OXYCONTIN 160MG SR TAB OXYCODONE HCL 160MG TAB LA280808 02202468 OXYCONTIN 20MG CR TAB OXYCODONE 20MG TAB LA
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
118 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA280812 OPIATE PARTIAL AGONISTS280812 02242504 APO‐BUTORPHANOL 10MG/ML NAS SO BUTORPHANOL TARTRATE 10MG/ML NAS SOL280812 02341212 BUTRANS 10MCG/HOUR PATCH BUPRENORPHINE 10MCG/HOUR PATCH280812 02341220 BUTRANS 20MCG/HOUR PATCH BUPRENORPHINE 20MCG/HOUR PATCH280812 02341174 BUTRANS 5MCG/HOUR PATCH BUPRENORPHINE 5MCG/HOUR PATCH280812 02242921 LIN‐BUTORPHANOL 10MG/ML NS BUTORPHANOL TARTRATE 10MG/ML NAS SPR280812 01913980 NUBAIN 10MG/ML INJ NALBUPHINE HYDROCHLORIDE 10MG/ML INJ280812 01913972 NUBAIN 20MG/ML INJ NALBUPHINE 20MG/ML INJ280812 02244508 PMS‐BUTORPHANOL 10MG/ML NAS SP BUTORPHANOL TARTRATE 10MG/ML NAS SPR280812 02295695 SUBOXONE 2MG/0.5MG SL TAB BUPRENORPHINE HCL/NALOXONE HCL 2MG/0.5MG TAB280812 02295709 SUBOXONE 8MG/2MG SL TAB BUPRENORPHINE HCL/NALOXONE HCL 8MG/2MG TAB280812 02241976 TALWIN 30MG/ML INJ PENTAZOCINE 30MG/ML INJ280812 01904965 TALWIN 50MG TAB PENTAZOCINE 50MG TAB280812 02137984 TALWIN 50MG TAB PENTAZOCINE HCL 50MG TAB280812 00229210 TALWIN COMPOUND‐50 PENTAZOCINE 50MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
119 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA280892 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS280892 02244680 FLOCTAFENINE 200MG TAB FLOCTAFENINE 200MG TAB280892 02244681 FLOCTAFENINE 400MG TAB FLOCTAFENINE 400MG TAB280892 02360160 GD‐PREGABALIN 100MG CAP PREGABALIN 100MG CAP280892 02360179 GD‐PREGABALIN 150MG CAP PREGABALIN 150MG CAP280892 02360187 GD‐PREGABALIN 200MG CAP PREGABALIN 200MG CAP280892 02360195 GD‐PREGABALIN 225MG CAP PREGABALIN 225MG CAP280892 02360136 GD‐PREGABALIN 25MG CAP PREGABALIN 25MG CAP280892 02360209 GD‐PREGABALIN 300MG CAP PREGABALIN 300MG CAP280892 02360144 GD‐PREGABALIN 50MG CAP PREGABALIN 50MG CAP280892 02360152 GD‐PREGABALIN 75MG CAP PREGABALIN 75MG CAP280892 00638668 IDARAC 200MG TAB FLUOCTAFENIN 200MG TAB280892 00754153 IDARAC 400MG TAB FLOCTAFENINE 400MG TAB280892 02268442 LYRICA 100MG CAP PREGABALIN 100MG CAP280892 02268450 LYRICA 150MG CAP PREGABALIN 150MG CAP280892 02268469 LYRICA 200MG CAP PREGABALIN 200MG CAP280892 02268477 LYRICA 225MG CAP PREGABALIN 225MG CAP280892 02268418 LYRICA 25MG CAP PREGABALIN 25MG CAP280892 02268485 LYRICA 300MG CAP PREGABALIN 300MG CAP280892 02268426 LYRICA 50MG CAP PREGABALIN 50MG CAP280892 02268434 LYRICA 75MG CAP PREGABALIN 75MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
120 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA281000 OPIATE ANTAGONISTS281000 02148706 NALOXONE 0.4MG/ML INJ NALOXONE HCL 0.4MG/ML INJ281000 02382482 NALOXONE 0.4MG/ML INJ NALOXONE HCL 0.4MG/ML INJ281000 02382601 NALOXONE 0.4MG/ML INJ NALOXONE HCL INJ281000 02148714 NALOXONE HCL 1MG/ML INJ NALOXONE HCL 1MG/ML INJ281000 02213826 REVIA 50MG TAB NALTREXONE HCL 50MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
121 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA281204 BARBITURATES281204 00399310 APO‐PRIMIDONE 125MG TAB PRIMIDONE 125MG TAB281204 00396761 APO‐PRIMIDONE 250MG TAB PRIMIDONE 250MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
123 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA281212 HYDANTOINS281212 00023450 DILANTIN 125MG/5ML SUSP PHENYTOIN 125MG/5ML O/L281212 00023442 DILANTIN 30MG/5ML SUSP PHENYTOIN 30MG/5ML O/L281212 00022780 DILANTIN CAP 100MG PHENYTOIN 100MG CAP281212 00022772 DILANTIN CAP 30MG PHENYTOIN 30MG CAP281212 00023698 DILANTIN INFATABS 50MG PHENYTOIN 50MG TAB281212 00497304 PHENYTOIN SODIUM 50MG/ML INJ PHENYTOIN SODIUM 50MG/ML INJ281212 02250896 TARO‐PHENYTOIN 125MG/5ML O/L PHENYTOIN 125MG/5ML O/L281212 00498335 TREMYTOINE INJ 50MG/ML PHENYTOIN SODIUM 50MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
124 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA281220 SUCCINIMIDES281220 00022802 CELONTIN CAP 300MG METHSUXIMIDE 300MG CAP281220 00022799 ZARONTIN CAP 250MG ETHOSUXIMIDE 250MG CAP281220 00023485 ZARONTIN SYR 250MG/5ML ETHOSUXIMIDE 250MG/5ML O/L
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
140 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA281604 02287013 TRAZODONE 150MG TAB TRAZODONE HCL 150MG TAB281604 02348799 TRAZODONE 150MG TAB TRAZODONE HCL 150MG TAB281604 02286998 TRAZODONE 50MG TAB TRAZODONE HCL 50MG TAB281604 02348772 TRAZODONE 50MG TAB TRAZODONE HCL 50MG TAB281604 02230285 TRAZOREL 100MG TAB TRAZODONE HCL 100MG TAB281604 02230284 TRAZOREL 50MG TAB TRAZODONE HCL 50MG TAB281604 00629316 TRIADAPIN 150MG CAP DOXEPIN HCL 150MG CAP281604 00740829 TRIMIPRAMINE 100MG TAB TRIMIPRAMINE MALEATE 100MG TAB281604 00740799 TRIMIPRAMINE 12.5MG TAB TRIMIPRAMINE MALEATE 12.5MG TAB281604 00740802 TRIMIPRAMINE 25MG TAB TRIMIPRAMINE MALEATE 25MG TAB281604 00740810 TRIMIPRAMINE 50MG TAB TRIMIPRAMINE MALEATE 50MG TAB281604 02070987 TRIMIPRAMINE 75MG CAP TRIMIPRAMINE MALEATE 75MG CAP281604 00761702 TRIMIPRAMINE TAB 12.5MG TRIMIPRAMINE MALEATE 12.5M TAB281604 02239326 TRYPTAN 250MG TAB L‐TRYPTOPHAN 250MG TAB281604 02029456 TRYPTAN 500MG TAB L‐TRYPTOPHAN 500MG TAB281604 02239327 TRYPTAN 750MG TAB L‐TRYPTOPHAN 750MG TAB281604 00718149 TRYPTAN CAP 500MG L‐TRYPTOPHAN 500MG CAP281604 00654531 TRYPTAN TAB 1000MG L‐TRYPTOPHAN 1G TAB281604 02373874 VENLAFAXINE ER 150MG CAP VENLAFAXINE HCL 150MG CAP LA281604 02373858 VENLAFAXINE ER 37.5MG CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02373866 VENLAFAXINE ER 75MG CAP VENLAFAXINE HCL 75MG CAP LA281604 02289075 VENLAFAXINE XR 150MG CAP VENLAFAXINE HCL 150MG CAP LA281604 02339269 VENLAFAXINE XR 150MG CAP VENLAFAXINE HCL 150MG CAP LA281604 02340070 VENLAFAXINE XR 150MG CAP VENLAFAXINE HCL 150MG CAP LA281604 02354748 VENLAFAXINE XR 150MG CAP VENLAFAXINE HCL 150MG CAP LA281604 02334739 VENLAFAXINE XR 150MG ER CAP VENLAFAXINE HCL 150MG CAP LA281604 02344769 VENLAFAXINE XR 150MG ER CAP VENLAFAXINE HCL 150MG CAP LA281604 02289059 VENLAFAXINE XR 37.5MG CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02339242 VENLAFAXINE XR 37.5MG CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02340054 VENLAFAXINE XR 37.5MG CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02354713 VENLAFAXINE XR 37.5MG CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02334704 VENLAFAXINE XR 37.5MG ER CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02344742 VENLAFAXINE XR 37.5MG ER CAP VENLAFAXINE HCL 37.5MG CAP LA281604 02289067 VENLAFAXINE XR 75MG CAP VENLAFAXINE HCL 75MG CAP LA281604 02339250 VENLAFAXINE XR 75MG CAP VENLAFAXINE HCL 75MG CAP LA281604 02340062 VENLAFAXINE XR 75MG CAP VENLAFAXINE HCL 75MG CAP LA281604 02354721 VENLAFAXINE XR 75MG CAP VENLAFAXINE HCL 75MG CAP LA281604 02334712 VENLAFAXINE XR 75MG ER CAP VENLAFAXINE HCL 75MG CAP LA281604 02344750 VENLAFAXINE XR 75MG ER CAP VENLAFAXINE HCL 75MG CAP LA281604 02237825 WELLBUTRIN SR 150MG TAB BUPROPION HCL 150MG TAB LA281604 02237823 WELLBUTRIN SR 50MG TAB BUPROPION HCL 50MG TAB LA281604 02275090 WELLBUTRIN XL 150MG TAB BUPROPION HCL 150MG TAB LA281604 02275104 WELLBUTRIN XL 300MG TAB BUPROPION HCL 300MG TAB LA281604 01962779 ZOLOFT 100 MG CAP SERTRALINE HCL 100MG CAP281604 01962787 ZOLOFT 150MG CAP SERTRALINE 150MG CAP281604 01962795 ZOLOFT 200MG CAP SERTRALINE 200MG CAP281604 02132702 ZOLOFT 25MG CAP SERTRALINE HCL 25MG CAP281604 01962817 ZOLOFT 50MG CAP SERTRALINE HCL 50MG CAP281604 02331799 ZYM‐BUPROPION SR 100MG TAB BUPROPION HCL 100MG TAB LA281604 02331802 ZYM‐BUPROPION SR 150MG TAB BUPROPION HCL 150MG TAB LA281604 02302659 ZYM‐FLUOXETINE 10MG CAP FLUOXETINE HCL 10MG CAP281604 02302667 ZYM‐FLUOXETINE 20MG CAP FLUOXETINE HCL 20MG CAP281604 02325179 ZYM‐MIRTAZAPINE 15MG TAB MIRTAZAPINE 15MG TAB281604 02325187 ZYM‐MIRTAZAPINE 30MG TAB MIRTAZAPINE 30MG TAB281604 02325128 ZYM‐TRAZODONE 100MG TAB TRAZODONE HCL 100MG TAB281604 02325101 ZYM‐TRAZODONE 50MG TAB TRAZODONE HCL 50MG TAB281604 02249804 ZYM‐TRAZODONE 75MG TAB TRAZODONE HCL 75MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
150 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA282004 AMPHETAMINES282004 02248809 ADDERALL XR 10MG CAPS MIXED SALTS AMPHETAMINE 10MG CAP LA282004 02248810 ADDERALL XR 15MG CAPS MIXED SALTS AMPHETAMINE 15MG CAP LA282004 02248811 ADDERALL XR 20MG CAPS MIXED SALTS AMPHETAMINE 20MG CAP LA282004 02248812 ADDERALL XR 25MG CAPS MIXED SALTS AMPHETAMINE 25MG CAP LA282004 02248813 ADDERALL XR 30MG CAPS MIXED SALTS AMPHETAMINE 30MG CAP LA282004 02248808 ADDERALL XR 5MG CAPS MIXED SALTS AMPHETAMINE 5MG CAP LA282004 01924516 DEXEDRINE 5MG TAB DEXTROAMPHETAMINE SULFATE 5MG TAB282004 00181439 DEXEDRINE SPANSULE 10MG DEXTROAMPHETAMINE SULFATE 10MG CAP282004 00181447 DEXEDRINE SPANSULE 15MG DEXTROAMPHETAMINE SULFATE 15MG CAP282004 01924559 DEXEDRINE SPANSULE SRC 10MG DEXTROAMPHETAMINE SULFATE 10MG CAP LA282004 01924567 DEXEDRINE SPANSULE SRC 15MG DEXTROAMPHETAMINE SULFATE 15MG CAP LA
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
157 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA282800 ANTIMANIC AGENTS282800 02242837 APO‐LITHIUM CARB 150MG CAP LITHIUM CARBONATE 150MG CAP282800 02242838 APO‐LITHIUM CARB 300MG CAP LITHIUM CARBONATE 300MG CAP282800 05550001 APO‐LITHIUM CARBONATE 150MG NT LITHIUM CARBONATE 150MG CAP282800 05550002 APO‐LITHIUM CARBONATE 300MG NT LITHIUM CARBONATE 300MG CAP282800 00461733 CARBOLITH CAP 150MG LITHIUM CARBONATE 150MG CAP282800 00236683 CARBOLITH CAP 300MG LITHIUM CARBONATE 300MG CAP282800 02011239 CARBOLITH CAP 600MG LITHIUM CARBONATE 600MG CAP282800 02304511 EURO LITHIUM 150MG CAP LITHIUM CARBONATE 150MG CAP282800 02304538 EURO LITHIUM 300MG CAP LITHIUM CARBONATE 300MG CAP282800 02013231 LITHANE 150MG CAP LITHIUM CARBONATE 150MG CAP282800 00406775 LITHANE CAP 300MG LITHIUM CARBONATE 300MG CAP282800 00024406 LITHANE TABS 300 MG LITHIUM CARBONATE 300MG TAB282800 02266695 LITHMAX SR 300MG LITHIUM CARBONATE 300MG TAB LA282800 02237006 PHL‐LITHIUM CARBONATE150MG CAP LITHIUM CARBONATE 150MG CAP282800 02237007 PHL‐LITHIUM CARBONATE300MG CAP LITHIUM CARBONATE 300MG CAP282800 02237008 PHL‐LITHIUM CARBONATE600MG CAP LITHIUM CARBONATE 600MG CAP282800 02216132 PMS‐LITHIUM CARBONATE 150MG LITHIUM CARBONATE 150MG CAP282800 02216140 PMS‐LITHIUM CARBONATE 300MG LITHIUM CARBONATE 300MG CAP282800 02216159 PMS‐LITHIUM CARBONATE 600MG LITHIUM CARBONATE 600MG CAP282800 02074834 PMS‐LITHIUM CITRATE 300MG LIQ LITHIUM CITRATE 300MG O/L282800 02311356 PRO‐LITHIUM CARBONATE 150MG CA LITHIUM CARBONATE 150MG CAP282800 02311364 PRO‐LITHIUM CARBONATE 300MG CA LITHIUM CARBONATE 300MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
160 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA283292 MISC. ANTIMIGRAINE AGENTS283292 00511552 SANDOMIGRAN DS 1MG TAB PIZOTIFEN MALATE 1MG TAB283292 00329320 SANDOMIGRAN TAB 0.5MG PIZOTIFEN MALATE 0.5MG TAB283292 00027499 SANSERT TAB 2MG METHYSERGIDE BIMALEATE 2MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
162 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA283612 CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS283612 02321459 APO‐ENTACAPONE 200MG TAB ENTACAPONE 200MG TAB283612 02243763 COMTAN 200MG TAB ENTACAPONE 200MG TAB283612 02380005 SANDOZ ENTACAPONE 200MG TAB ENTACAPONE 200MG TAB283612 02375559 TEVA‐ENTACAPONE 200MG TAB ENTACAPONE 200MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
166 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA283620 02331349 ZYM‐ROPINIROLE 5MG TAB ROPINIROLE HCL 5MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
169 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA360000 DIAGNOSTIC AGENTS360000 00980722 DIMERCAPTOSUCCINIC ACID POWDER DIMERCAPTOSUCCINIC ACID PDR360000 02246016 THYROGEN 0.9MG/ML INJ THYROTROPIN ALFA 0.9MG/ML INJ PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
170 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA362600 DIABETES MELLITUS 362600 00907731 ACCUCHECK ADVANTAGE EASY TEST BLOOD GLUCOSE TEST STRIP STRIP362600 00905348 ACCU‐CHECK ADVANTAGE STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00950883 ACCU‐CHECK ADVANTAGE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123021 ACCU‐CHECK ADVANTAGE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99002884 ACCU‐CHECK ADVANTAGE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123033 ACCUCHECK AVIVA BG TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 44123007 ACCUCHECK EASY BG TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99146753 ACCUCHECK EASY TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 09853081 ACCUCHECK EASY TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977060 ACCUCHECK TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799938 ACCU‐CHEK 1, 11, 111 REFLOULUX CONTROL SOLUTION SOL362600 97799823 ACCU‐CHEK ADV STRIP 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799824 ACCU‐CHEK ADV TEST 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 09853626 ACCU‐CHEK ADVANTAGE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09854002 ACCU‐CHEK ADVANTAGE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09899671 ACCUCHEK ADVANTAGE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00977124 ACCU‐CHEK AVIVA BG TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99100214 ACCU‐CHEK AVIVA STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 97799814 ACCU‐CHEK AVIVA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00950949 ACCU‐CHEK AVIVA TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 97799815 ACCU‐CHEK AVIVA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00964646 ACCU‐CHEK AVIVA TEST STRIPS PQ BLOOD GLUCOSE TEST STRIPS STRIP362600 99888750 ACCUCHEK BG TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00969079 ACCU‐CHEK C.SOL/PARAFFIN (PQ) CONT SOL/PARAFFIN (PQ) MISC362600 00977062 ACCUCHEK COMFORT STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799963 ACCU‐CHEK COMP TEST 51 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799941 ACCU‐CHEK COMPACT CONTROL SOLUTION SOL362600 09854282 ACCU‐CHEK COMPACT TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 90312254 ACCU‐CHEK COMPACT TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00901370 ACCUCHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00965960 ACCUCHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00965979 ACCUCHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977070 ACCUCHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99004364 ACCUCHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950900 ACCU‐CHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123026 ACCU‐CHEK COMPACT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00907227 ACCUCHEK CONTROL SOLN CONTROL SOLUTION SOL362600 00967386 ACCU‐CHEK MOBILE STRIP CASSETT BLOOD GLUCOSE TEST STRIP STRIP362600 97799496 ACCU‐CHEK MOBILE STRIP CASSETT BLOOD GLUCOSE TEST STRIP STRIP362600 97799497 ACCU‐CHEK MOBILE STRIP CASSETT BLOOD GLUCOSE TEST STRIP STRIP362600 99100791 ACCU‐CHEK MOBILE STRIP CASSETT BLOOD GLUCOSE TEST STRIP STRIP362600 00909459 ACCUSOFT TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799939 ACCUTREND G CONTROL SOLUTION SOL362600 97799959 ACCUTREND GC TEST 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00908924 ACCUTREND GC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99698373 ACCUTREND GLUCOSE STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00906697 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908193 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977031 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 01284860 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853162 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123006 ACCUTREND GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799961 ADVANTAGE COMF TEST 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00909556 ADVANTAGE CONTROL SOLN CONTROL SOLUTION SOL362600 00977061 ADVANTAGE GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908290 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908312 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908479 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00921076 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00924061 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950661 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00989967 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123008 ADVANTAGE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799940 ADVANTAGE,ACCUSOFT,ACCUSOFT MG CONTROL SOLUTION SOL362600 09991086 ASCENCIA CONTOUR TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 99100096 ASCENCIA CONTOUR TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799869 ASCENSIA AUTODISC CONTROL SOLN CONTROL SOLUTION SOL362600 97799868 ASCENSIA AUTODISC NORMAL CONT CONTROL SOLUTION SOL362600 97799927 ASCENSIA AUTODISC TEST 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00904945 ASCENSIA AUTODISC TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00950878 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00960217 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967157 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977471 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853693 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123019 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 95000147 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99002604 ASCENSIA AUTODISC TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123038 ASCENSIA BREEZE 2 BG TEST STRI BLOOD GLUCOSE TEST STRIPS STRIP362600 09857293 ASCENSIA BREEZE 2 STRIP BLOOD GLUCOSE TEST STRIP STRIP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
171 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA362600 97799748 ASCENSIA BREEZE 2 STRIP 100 BLOOD GLUCOSE TEST STRIP STRIP362600 97799749 ASCENSIA BREEZE 2 STRIP 50 BLOOD GLUCOSE TEST STRIP STRIP362600 00964816 ASCENSIA BREEZE 2 STRIPS (PQ) BLOOD GLUCOSE TEST STRIP STRIP362600 00950960 ASCENSIA BREEZE 2 TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99100388 ASCENSIA BREEZE 2 TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 09991084 ASCENSIA BREEZE 2 TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977119 ASCENSIA CONTOUR BG TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 44123037 ASCENSIA CONTOUR BG TEST STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 00950924 ASCENSIA CONTOUR STRIP (100) BLOOD GLUCOSE TEST STRIP STRIP362600 97799702 ASCENSIA CONTOUR STRIP (100) BLOOD GLUCOSE TEST STRIP STRIP362600 97799877 ASCENSIA CONTOUR STRIP (100) BLOOD GLUCOSE TEST STRIP STRIP362600 00964476 ASCENSIA CONTOUR STRIP (50) BLOOD GLUCOSE TEST STRIP STRIP362600 97799878 ASCENSIA CONTOUR STRIP (50) BLOOD GLUCOSE TEST STRIP STRIP362600 97799867 ASCENSIA ELITE CONTROL SOLN CONTROL SOLUTION SOL362600 97799866 ASCENSIA ELITE NORMAL CONTROL CONTROL SOLUTION SOL362600 97799925 ASCENSIA ELITE TEST 25 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799924 ASCENSIA ELITE TEST 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00907685 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950572 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977308 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00980100 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00987727 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123002 ASCENSIA ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123032 ASCENSIA MICROFILL BG TEST STR BLOOD GLUCOSE TEST STRIPS STRIP362600 97799871 ASCENSIA MICROFILL CONTROL SOL CONTROL SOLUTION SOL362600 97799870 ASCENSIA MICROFILL NORMAL CONT CONTROL SOLUTION SOL362600 97799900 BD LATITUDE TEST (100) NS BLOOD GLUCOSE TEST STRIP STRIP362600 97799901 BD LATITUDE TEST 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00977107 BD LATITUDE TEST STRIP (NF) BLOOD GLUCOSE TEST STRIP STRIP362600 00900142 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00901411 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00950911 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00963720 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123030 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 99100002 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99401067 BD LATITUDE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799465 BG STAR TEST STRIPS (100) BLOOD GLUCOSE TEST STRIP STRIP362600 97799464 BG STAR TEST STRIPS (50) BLOOD GLUCOSE TEST STRIP STRIP362600 99100827 BGSTAR TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799478 BIONIME RIGHTEST GS100 STRIP BLOOD GLUCOSE TEST STRIP 100 STRIPS STRIP362600 97799479 BIONIME RIGHTEST GS100 STRIP BLOOD GLUCOSE TEST STRIPS 50 STRIPS STRIP362600 00999955 BLOOD GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 44123022 CHECKMATE PLUS BG TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00960055 CHEMSTRIP GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 02423464 CHEMSTRIP GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00990906 CHEMSTRIP‐BG STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00977411 CHEMSTRIP‐BG STRIP (ACCUCHEK) BLOOD GLUCOSE TEST STRIP STRIP362600 00990027 CHEMSTRIP‐BG STRIP (ACCUCHEK) BLOOD GLUCOSE TEST STRIP STRIP362600 44123009 CHEMSTRIP‐BG STRIP (ACCU‐CHEK) BLOOD GLUCOSE TEST STRIP STRIP362600 09853189 CHEMSTRIP‐BG STRIPS (ACCUCHEK) BLOOD GLUCOSE TEST STRIP STRIP362600 00909379 DEX CONTROL SOLUTION CONTROL SOLUTION SOL362600 95000146 DEX CONTROL SOLUTION CONTROL SOLUTION SOL362600 00977944 DEX CONTROL SOLUTION HIGH CONTROL SOLUTION SOL362600 00977942 DEX CONTROL SOLUTION LOW CONTROL SOLUTION SOL362600 00977943 DEX CONTROL SOLUTION NORMAL CONTROL SOLUTION SOL362600 00930002 ELITE CONTROL SOLUTION CONTROL SOLUTION SOL362600 00999121 ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09941401 ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09949401 ELITE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799865 ENCORE NORMAL CONTROL CONTROL SOLUTION SOL362600 00920371 ENCORE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977033 ENCORE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00980200 ENCORE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853103 ENCORE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123003 ENCORE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799922 ENCORE TEST STRIPS 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 44123014 EXACTECH BG TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00906859 EXACTECH CONTROL SOL CONTROL SOLUTION SOL362600 00977810 EXACTECH CONTROL SOL CONTROL SOLUTION SOL362600 09857357 EZ HEALTH ORACLE STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799564 EZ HEALTH ORACLE STRIP (100) BLOOD GLUCOSE TEST STRIP STRIP362600 97799565 EZ HEALTH ORACLE STRIP (50) BLOOD GLUCOSE TEST STRIP STRIP362600 00909200 EZ HEALTH ORACLE STRIP(MB) BLOOD GLUCOSE TEST STRIP STRIP362600 00964085 FAST TAKE TEST STRIP (PQ ONLY) BLOOD GLUCOSE TEST STRIP STRIP362600 03921021 FAST TAKE TEST STRIP (PQ ONLY) BLOOD GLUCOSE TEST STRIP STRIP362600 00909378 FASTTAKE CONTROL SOLUTION CONTROL SOLUTION SOL362600 00920143 FASTTAKE CONTROL SOLUTION CONTROL SOLUTION SOL362600 00903531 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00909246 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00920142 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950882 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
172 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA362600 00967084 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967092 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967106 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09854029 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 44123017 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 95000210 FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09857297 FREESTYLE LITE STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00905502 FREESTYLE LITE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799597 FREESTYLE LITE TEST STRIP 100 BLOOD GLUCOSE TEST STRIP STRIP362600 97799596 FREESTYLE LITE TEST STRIP 50 BLOOD GLUCOSE TEST STRIP STRIP362600 99100478 FREESTYLE LITE TEST STRIPS (PQ BLOOD GLUCOSE TEST STRIP STRIP362600 00901388 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00905500 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00950907 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977838 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 09857141 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123028 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 99401062 FREESTYLE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99004704 FREESTYLE TEST STRIPS (PQ) BLOOD GLUCOSE TEST STRIP STRIP362600 97799829 FREESTYLE TEST STRIPS 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799827 FREESTYLE TEST STRIPS 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00757710 GLUCODEX TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00906646 GLUCOFILM CONTROL SOLN CONTROL SOLUTION SOL362600 99463968 GLUCOFILM CONTROL SOLN CONTROL SOLUTION SOL362600 00907669 GLUCOFILM TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99084566 HEMASTIX 50 HEMASTIX STRIP362600 09857348 ITEST 2.71IU BG STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 44123034 ITEST BLOOD GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 97799770 ITEST BLOOD GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99100332 ITEST BLOOD GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00950956 ITEST TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799593 LIFEBRAND GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799594 LIFEBRAND GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00906867 MEDISENSE CONTROL SOL MEDISENSE CONTROL SOL SOL362600 97799839 MS GLUCOSE/KETONE CONTROL SOLN CONTROL SOLUTION SOL362600 99100497 NOVA MAX TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00905504 NOVAMAX TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799583 NOVAMAX TEST STRIP 100 BLOOD GLUCOSE TEST STRIP STRIP362600 97799584 NOVAMAX TEST STRIP 50 BLOOD GLUCOSE TEST STRIP STRIP362600 09853480 NOVO‐GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09857340 ON CALL PLUS STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799582 ON‐CALL PLUS TEST STRIP 100 BLOOD GLUCOSE TEST STRIP STRIP362600 97799580 ON‐CALL PLUS TEST STRIP 25 (NS BLOOD GLUCOSE TEST STRIP STRIP362600 97799581 ON‐CALL PLUS TEST STRIP 50 (NS BLOOD GLUCOSE TEST STRIP STRIP362600 99100479 ON‐CALL PLUS TEST STRIPS (PQ) BLOOD GLUCOSE TEST STRIP STRIP362600 00977845 ONE TOUCH CONTROL SOLN CONTROL SOLUTION SOL362600 99480004 ONE TOUCH CONTROL SOLN CONTROL SOLUTION SOL362600 99925768 ONE TOUCH CONTROL SOLN CONTROL SOLUTION SOL362600 00977995 ONE TOUCH FASTTAKE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00010198 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00897655 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00905399 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950459 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977837 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00981087 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00984787 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853243 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123011 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99295972 ONE TOUCH TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853138 ONE TOUCH ULTRA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 09854290 ONE TOUCH ULTRA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 44123025 ONE TOUCH ULTRA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99004240 ONE TOUCH ULTRA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99401057 ONE TOUCH ULTRA TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00901353 ONE TOUCH ULTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00907000 ONE TOUCH ULTRA TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00950893 ONE TOUCH ULTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977936 ONE TOUCH ULTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799976 ONETOUCH 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799977 ONETOUCH 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799973 ONETOUCH FASTTAKE CONTROL SOLUTION SOL362600 97799982 ONETOUCH FASTTAKE 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799983 ONETOUCH FASTTAKE 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799971 ONETOUCH NORMAL CONTROL SOLUTION SOL362600 97799979 ONETOUCH SURE STEP 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799972 ONETOUCH SURESTEP CONTROL SOLUTION SOL362600 97799980 ONETOUCH SURESTEP 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799974 ONETOUCH ULTRA CONTROL SOLUTION SOL362600 97799985 ONETOUCH ULTRA 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799986 ONETOUCH ULTRA 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 99100787 ONETOUCH VERIO BG TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
173 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA362600 09857392 ONETOUCH VERIO TEST STRIP (ON) BLOOD GLUCOSE TEST STRIP STRIP362600 97799476 ONETOUCH VERIO TEST STRIPS (50 BLOOD GLUCOSE TEST STRIPS STRIP362600 97799475 ONETOUCH VERIO TEST STRIPS 100 BLOOD GLUCOSE TEST STRIP STRIP362600 99100516 ORACLE TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00906300 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00950912 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00977110 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 09857508 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123031 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 99100013 PRECISION EASY TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 44123024 PRECISION EXTRA BG TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00986763 PRECISION EXTRA GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 97799844 PRECISION PLUS ELECTRO 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 44123015 PRECISION PLUS ELECTRODES BLOOD GLUCOSE TEST STRIP STRIP362600 00801135 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00906298 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00906670 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908339 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950300 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967904 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977057 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977059 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977087 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853146 PRECISION PLUS TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09854070 PRECISION XTRA GLUC TEST STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 99004879 PRECISION XTRA STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 97799840 PRECISION XTRA STRIPS 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799841 PRECISION XTRA STRIPS 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00908437 PRECISION XTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00909300 PRECISION XTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950894 PRECISION XTRA TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00977100 PRECISION XTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99004119 PRECISION XTRA TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853677 PRESTIGE STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00977037 PRESTIGE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 44123029 PRESTIGE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 99001977 PRESTIGE TEST STRPS BLOOD GLUCOSE TEST STRIP STRIP362600 99100834 RIGHTEST GS100 TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123035 SIDEKICK BG TEST STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 97799601 SIDEKICK BG TESTING SYSTEM BG TEST SYSTEM WITH 50 STRIPS STRIP362600 99100412 SIDEKICK TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00950948 SIDEKICK TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00990009 SMART STRIP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 95000209 SMART STRIP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99004577 SOF‐TACT BLOOD GLUCOSE TEST STRIP STRIP362600 44123027 SOF‐TACT GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 97799838 SOFTACT STRIPS 100 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799830 SOFTACT STRIPS 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 00901383 SOFTACT TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00950902 SOF‐TACT TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 00977103 SOF‐TACT TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 09854304 SOF‐TACT TEST STRIPS BLOOD GLUCOSE TEST STRIPS STRIP362600 95000053 SURE STEP BG TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00909629 SURE STEP CONTROL SOLUTION CONTROL SOLUTION SOL362600 00963461 SURE STEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00999482 SURE STEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 09853634 SURE STEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 44123012 SURE STEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00908843 SURESTEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00950734 SURESTEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967513 SURESTEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00967521 SURESTEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 99000318 SURESTEP TEST STRIPS BLOOD GLUCOSE TEST STRIP STRIP362600 00977141 TRUE TRACK BG TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 44123036 TRUE TRACK BG TEST STRIP BLOOD GLUCOSE TEST STRIPS STRIP362600 09857283 TRUE TRACK SMART SYSTEM STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99100714 TRUETEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 00905506 TRUETEST TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799532 TRUETEST TEST STRIP (100) BLOOD GLUCOSE TEST STRIP STRIP362600 97799531 TRUETEST TEST STRIP (50) BLOOD GLUCOSE TEST STRIP STRIP362600 44123045 TRUETEST TEST STRIP (BC) BLOOD GLUCOSE TEST STRIP STRIP362600 00950957 TRUETRACK TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 99100413 TRUETRACK TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP362600 97799603 TRUETRACK TEST STRIP ‐ 50 (NS) BLOOD GLUCOSE TEST STRIP STRIP362600 97799602 TRUETRACK TEST STRIP ‐100 (NS) BLOOD GLUCOSE TEST STRIP STRIP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
174 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA368800 URINE AND FECES CONTENTS368800 97799916 ACETEST STRIPS 100 (NS) URINE TEST STRIP STRIP368800 00980560 ACETEST TAB URINE TEST TAB TAB368800 00035106 ACETEST TABLETS URINE TEST TAB TAB368800 00977292 ACETEST TABLETS URINE TEST TAB TAB368800 09853294 ACETEST TABLETS URINE TEST TAB TAB368800 99066985 ACETEST TABLETS URINE TEST TAB TAB368800 00963690 ALBUSTIX STRIPS URINE TEST STRIP STRIP368800 00977381 ALBUSTIX STRIPS URINE TEST STRIP STRIP368800 97799851 ALBUSTIX STRIPS 100 (NS) URINE TEST STRIP STRIP368800 97799863 CHEK‐STIX COMBO STRIPS 25 (NS) URINE TEST STRIP STRIP368800 97799864 CHEK‐STIX STRIPS 25 (NS) URINE TEST STRIP STRIP368800 00964387 CHEMSTRIP 10 URINE TEST STRIP STRIP368800 97799954 CHEMSTRIP 10 (100) NS URINE TEST STRIP STRIP368800 97799950 CHEMSTRIP 4 MD 50 (NS) URINE TEST STRIP STRIP368800 97799952 CHEMSTRIP 5L 100 (NS) URINE TEST STRIP STRIP368800 97799953 CHEMSTRIP 9 100 (NS) URINE TEST STRIP STRIP368800 00903671 CHEMSTRIP 9 STRIPS URINE TEST STRIP STRIP368800 00398314 CHEMSTRIP BG URINE TEST STRIP STRIP368800 97799951 CHEMSTRIP GP 100 (NS) URINE TEST STRIP STRIP368800 00903639 CHEMSTRIP STRIPS URINE TEST STRIP STRIP368800 00647659 CHEMSTRIP UG 5000 URINE TEST STRIP STRIP368800 99863043 CHEMSTRIP UG 5000 URINE TEST STRIP STRIP368800 00903612 CHEMSTRIP UG 5000 K URINE TEST STRIP STRIP368800 00977470 CHEMSTRIP UG 5000 K URINE TEST STRIP STRIP368800 00980692 CHEMSTRIP UG 5000 K URINE TEST STRIP STRIP368800 99863050 CHEMSTRIP UG 5000 K URINE TEST STRIP STRIP368800 00647705 CHEMSTRIP UG 5000/K URINE TEST STRIP STRIP368800 00950211 CHEMSTRIP UG STRIPS URINE TEST STRIP STRIP368800 00950238 CHEMSTRIP UG STRIPS URINE TEST STRIP STRIP368800 97799956 CHEMSTRIP UGK STRIPS 50 (NS) URINE TEST STRIP STRIP368800 00905046 CHEMSTRIP‐4 MD STRIPS URINE TEST STRIP STRIP368800 00903604 CHEMSTRIP‐GP STRIPS URINE TEST STRIP STRIP368800 00977918 CHEMSTRIPS #9 URINE TEST STRIP STRIP368800 00977446 CHEMSTRIPS GP URINE TEST STRIP STRIP368800 00977438 CHEMSTRIPS UG 5000 STRIPS URINE TEST STRIP STRIP368800 00980480 CLINISTIX URINE TEST STRIP STRIP368800 97799862 CLINITEK HCG 25 (NS) URINE TEST STRIP STRIP368800 97799860 CLINITEK MICROALBUMIN 25 (NS) URINE TEST STRIP STRIP368800 97799915 CLINITEST 100 (NS) URINE TEST TAB TAB368800 00980420 CLINITEST TAB URINE TEST TAB TAB368800 00035122 CLINITEST TABLETS URINE TEST TAB TAB368800 00977152 CLINITEST TABLETS URINE TEST TAB TAB368800 00977314 CLINITEST TABLETS URINE TEST TAB TAB368800 99067017 CLINITEST TABLETS URINE TEST TAB TAB368800 00903078 DEXTROSTIX URINE TEST STRIP STRIP368800 00035130 DIASTIX URINE TEST STRIP STRIP368800 00977160 DIASTIX URINE TEST STRIP STRIP368800 00980510 DIASTIX URINE TEST STRIP STRIP368800 00980641 DIASTIX URINE TEST STRIP STRIP368800 99159954 DIASTIX 50 URINE TEST STRIP STRIP368800 97799914 DIASTIX 50 (NS) URINE TEST STRIP STRIP368800 97799920 GLUCOSTIX 100 (NS) URINE TEST STRIP STRIP368800 97799849 HEMASTIX 50 (NS) URINE TEST STRIP STRIP368800 97799850 HEMATEST NF 50 (NS) URINE TEST TAB TAB368800 97799848 ICTOTEST NF 100 (NS) URINE TEST TAB TAB368800 00977179 KETO DIASTIX KETONE TEST STRIP STRIP368800 00990647 KETO DIASTIX KETONE TEST STRIP STRIP368800 99067066 KETO DIASTIX KETONE TEST STRIP STRIP368800 00035149 KETODIASTIX URINE KETONE TEST STRIP STRIP368800 00977330 KETO‐DIASTIX KETONE TEST STRIP STRIP368800 97799912 KETO‐DIASTIX 100 (NS) KETONE TEST STRIP STRIP368800 00035092 KETOSTIX KETONE TEST STRIP STRIP368800 00977322 KETOSTIX KETONE TEST STRIP STRIP368800 00980595 KETOSTIX KETONE TEST STRIP STRIP368800 09853286 KETOSTIX KETONE TEST STRIP STRIP368800 99067074 KETOSTIX KETONE TEST STRIP STRIP368800 97799913 KETOSTIX 50 (NS) KETONE TEST STRIP STRIP368800 97799854 LABSTIX 100 (NS) URINE TEST STRIP STRIP368800 97799855 LABSTIX SG 100 (NS) URINE TEST STRIP STRIP368800 00904651 LABSTIX SG STRIP URINE TEST STRIP STRIP368800 00903523 LABSTIX STRIP URINE TEST STRIP STRIP368800 00977357 LABSTIX STRIP URINE TEST STRIP STRIP368800 99160002 LABSTIX STRIPS (100) LABSTIX STRIPS (100) STRIP368800 97799955 MICRAL‐TEST II TEST 30 (NS) URINE TEST STRIP STRIP368800 00904740 MULTISTIX URINE TEST STRIP STRIP368800 00811912 MULTISTIX 10 SG URINE TEST STRIP STRIP368800 00904767 MULTISTIX 10 SG URINE TEST STRIP STRIP368800 00977926 MULTISTIX 10 SG URINE TEST STRIP STRIP368800 97799859 MULTISTIX 10 SG 100 (NS) URINE TEST STRIP STRIP368800 97799853 MULTISTIX 100 (NS) URINE TEST STRIP STRIP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
175 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA368800 97799856 MULTISTIX 5 100 (NS) URINE TEST STRIP STRIP368800 97799858 MULTISTIX 8 SG 100 (NS) URINE TEST STRIP STRIP368800 00904783 MULTISTIX 8 SG STRIPS URINE TEST STRIP STRIP368800 00904759 MULTISTIX SG URINE TEST STRIP STRIP368800 00977586 MULTISTIX STRIPS 2820 URINE TEST STRIP STRIP368800 00951161 NOVAMAX PLUS KETONE TEST STRIP BLOOD GLUCOSE TEST STRIP STRIP368800 97799470 NOVAMAX PLUS KETONE TEST STRIP KETONE TEST STRIP STRIP368800 97799835 PRECISION XTRA BLOOD KET 8(NS) KETONE TEST STRIP STRIP368800 00963755 PRECISION XTRA CETONES KETONE TEST STRIP STRIP368800 00950896 PRECISION XTRA KETONE KETONE TEST STRIP STRIP368800 00909386 PRECISION XTRA KETONE TEST STR KETONE TEST STRIP STRIP368800 00999957 URINE TEST STRIPS (AB DIN) URINE TEST STRIP STRIP368800 97799852 URISTIX 100 (NS) URINE TEST STRIP STRIP368800 00904988 URISTIX 4 URINE TEST STRIP STRIP368800 97799857 URISTIX 4 100 (NS) URINE TEST STRIP STRIP368800 00977365 URISTIX STRIP URINE TEST STRIP STRIP368800 99160028 URISTIX STRIP URINE TEST STRIP STRIP368800 00903159 URISTIX STRIP / GLYCERINE (PQ) URINE TEST STRIP STRIP400800 02353997 UROCIT‐K TAB POTASSIUM CITRATE 1080MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
176 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA401200 REPLACEMENT PREPARATIONS401200 00644684 CALC CARBONATE CALC CARBONATE TAB401200 02244130 CALCITE 500 + D 400 TAB CALCIUM/VITAMIN D3 TAB401200 00722383 CALCIUM 250MG CHEWABLE TAB CALCIUM 250MG TAB401200 02244161 CALCIUM 500 + D 400 TAB CALCIUM AND VITAMIN D TAB401200 00718343 CALCIUM 500MG TAB CALCIUM CARBONATE 500MG TAB401200 02240977 CALCIUM 500MG TAB CALCIUM 500MG TAB401200 02246178 CALCIUM 500MG TAB CALCIUM CARBONATE 500MG TAB401200 02240973 CALCIUM 500MG WITH VITAMIN D CALCIUM/VITAMIN D3 500MG/125U TAB401200 02246180 CALCIUM 500MG WITH VITAMIN D CALCIUM/VITAMIN D3 500MG/125U TAB401200 02238582 CALCIUM 500MG&VIT D 200IU TAB CALCIUM/VITAMIN D3 500MG/200I TAB401200 02239458 CALCIUM 600 + VITAMIN D CALCIUM/VITAMIN D 600MG CAPL401200 02231961 CALCIUM CITRATE 200MG TAB CALCIUM CITRATE 200MG TAB401200 02231833 CALCIUM CITRATE 300MG TAB CALCIUM CITRATE 300MG TAB401200 00722405 CALCIUM LACTATE 648MG TAB CALCIUM LACTATE 648MG TAB401200 02150166 CITRACAL 500MG TAB CALCIUM CITRATE 500MG TAB401200 00208701 ELIXIR KAON 4.68GM POTASSIUM GLUCONATE 1.33MEQ/ML O/L401200 01918303 K‐10 LIQ 20MEQ/15ML POTASSIUM CHLORIDE 10% O/L401200 00704504 KAY CIEL LIQ 1.5GM/15ML POTASSIUM CHLORIDE 1.5G/15ML LIQ401200 00713376 K‐DUR SRT 1500MG POTASSIUM CHLORIDE 1500MG TAB LA401200 00810231 K‐MED 900 TAB 900MG POTASSIUM CHLORIDE 900MG TAB401200 00224227 LMD 10% IN 0.9% SOD CHLOR DEXTRAN/SODIUM CHLORIDE 0.9% INJ401200 00224235 LMD 10% IN DEXTROSE 5% DEXTRAN/DEXTROSE 5% INJ401200 00621919 MEGA‐CAL TAB MEGA CAL TAB401200 00039500 NORMOSOL R INJ ELECTROLYTES INJ401200 00039640 NORMOSOL R W DEXTROSE 5% INJ DEXTROSE/ELECTROLYTES 5% INJ401200 02229437 PHOSLO 667MG TAB CALCIUM ACETATE 667MG TAB401200 00466670 POT CHLOR 0.15%/5% DEX W 0.45% POTASSIUM CHLORIDE/DEXTROSE 50MG/ML SOL401200 00554308 SLO‐POT 600MG TAB POTASSIUM CHLORIDE 600MG TAB LA401200 00074225 SLOW K 600MG TAB POTASSIUM CHLORIDE 600MG TAB401200 02279754 SODIUM CHLORIDE 0.9% INJ SODIUM CHLORIDE 0.9% INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
178 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA401819 PHOSPHATE-REMOVINGAGENTS401819 02244310 RENAGEL 800MG TAB SEVELAMER HCL 800MG TAB401819 02354586 RENVELA 800MG TAB SEVELAMER CARBONATE 800MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
179 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA402000 CALORIC AGENTS402000 02144336 CARNITOR 100MG/ML SY LEVOCARNITINE 100MG/ML O/L402000 02144344 CARNITOR 200MG/ML LEVOCARNITINE 200MG/ML INJ402000 02144328 CARNITOR 330MG TAB LEVOCARNITINE 330MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
184 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA403600 IRRIGATING SOLUTIONS403600 00905224 EAU POUR INJECT EAU POUR INJECT INJ403600 00899569 SOLUTION DE CHLORURE DE SODIUM CHLORIDE 0.90% LIQ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
185 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA404000 URICOSURIC AGENTS404000 00441767 APO‐SULFINPYRAZONE 200MG TAB SULFINPYRAZONE 200MG TAB404000 00294926 BENURYL TAB 500MG PROBENECID 500MG TAB404000 02045699 NU‐SULFINPYRAZONE 200 MG SULFINPYRAZONE 200MG TAB404000 02083434 TARO‐SULFINPYRAZONE 100MG TAB SULFINPYRADONE 100MG TAB404000 02083442 TARO‐SULFINPYRAZONE 200MG TAB SULFINPYRADONE 200MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
186 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA440000 ENZYMES440000 02248966 FABRAZYME 35MG/VIAL INJ AGALSIDASE BETA 35MG/VIAL INJ PA (N)440000 02248965 FABRAZYME 5MG/VIAL INJ AGALSIDASE BETA 5MG/VIAL INJ PA (N)440000 02046733 PULMOZYME 1MG/ML INH DORNASE ALFA RECOMBINANT 1MG/ML INH440000 02249057 REPLAGAL 1MG/ML INJ AGALSIDASE ALFA 1MG/ML INJ PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
188 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA481032 MAST-CELL STABILIZERS481032 02132583 DOM‐SODIUM CROM 2% NAS DISODIUM CROMOGLYCATE 2% NAS SOL481032 02131617 DOM‐SODIUM CROM 2% OPH SOL DISODIUM CROMOGLYCATE 2% OP SOL481032 02145448 DOM‐SODIUM CROMOGLYCATE NEBULI CROMOLYN SODIUM 1% LIQ481032 02237378 MED‐CROMOGLYCATE 1% INH SOL CROMOLYN SODIUM 1% INH SOL481032 00500895 NALCROM 100MG CAP CROMOLYN SODIUM 100MG CAP481032 02231671 NU‐CROMOLYN 10MG/ML INH SOL CROMOLYN SODIUM 10MG/ML INH SOL481032 02237190 PDL‐CROMOLYN 1% STERULES INH CROMOLYN SODIUM 1% INH SOL481032 02046113 PMS‐SOD CROMOGLYCATE 10MG/ML SODIUM CROMOGLYCATE 1% SOL481032 02230288 RYNACROM 2% NASAL SPRAY SODIUM CROMOGLYCATE 2% NAS SPR481032 00328944 RYNACROM ENCAPSULATED PWR SODIUM CROMOGLYCATE 10MG PDR
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
189 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520200 ANTIALLERGIC AGENTS520200 02231390 APO‐CROMOLYN 2% NAS SOL CROMOLYN SODIUM 2% NAS SOL520200 02131625 LIVOSTIN EYE DROPS LEVOCABASTINE HCL 0.5MG/ML OP SOL520200 02020017 LIVOSTIN NASAL SPRAY LEVOCABASTINE 0.5MG/ML NAS SPR520200 02233143 PATANOL 0.1% OPH SOL OLOPATADINE HCL 0.1% OP SOL520200 02242324 ZADITOR 0.25MG/ML OPH SOL KETOTIFEN FUMARATE 0.25MG/ML OP SOL520200 02279223 ZADITOR 0.25MG/ML OPH SOL KETOTIFEN FUMARATE 0.25MG/ML OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
190 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520404 ANTIBIOTICS520404 00622958 AK CHLOR LIQ 0.5% CHLORAMPHENICOL 0.5% OP SOL520404 00622966 AK SULF LIQ 10% SULFACETAMIDE SODIUM 10% OP SOL520404 00627720 AK‐CHLOR 1% OPH OINT CHLORAMPHENICOL 1% OP OINT520404 02023822 AK‐DIOGENT 0.3% OPH SOL GENTAMICIN SULFATE 0.30% OP SOL520404 00635065 AK‐SPOR OPH SOL GRAMICIDIN/NEOMYCIN/POLYMYXIN OP SOL520404 02263130 APO‐CIPROFLOX 0.3% OPH SOL CIPROFLOXACIN HCL 0.3% OP SOL520404 02248398 APO‐OFLOXACIN 0.3% OP SOL OFLOXACIN 0.3% OP SOL520404 02278219 ARESTIN MICROSPHERES 1MG/4MG MINOCYCLINE HCL 1MG/4MG PDR520404 02242473 ATRIDOX 44MG/UNIT DENTAL GEL DOXYCYCLINE 44MG/UNIT GEL520404 02321661 AZASITE 1% OP SOL AZITHROMYCIN 1% OP SOL520404 02345498 AZASITE 1% OPH SOL AZITHROMYCIN 1% OP SOL520404 02336847 BESIVANCE 0.6% OPH SUSP BESIFLOXACIN 0.6% OP SOL520404 02247446 BETAMYCIN OP/OT SOL GENTAMICIN SULPHATE/BETAMETHAS 3MG‐1MG/ML O/O SOL520404 00001287 BLEPH 10 OPH SOL SULFACETAMIDE SODIUM 10% OP SOL520404 02200864 CILOXAN 0.3% OPH OINT CIPROFLOXACIN HCL 0.3% OP OINT520404 01945270 CILOXAN 0.3% OPH SOL CIPROFLOXACIN HCL 0.3% OP SOL520404 02240035 CIPRO HC OTIC SUSP CIPROFLOXACIN/ HYDROCORTISONE 0.2%/1% OT SOL520404 02252716 CIPRODEX OTIC SOL CIPROFLOXACIN HCL/DEXAMETHASON 0.3%/0.1% OT SOL520404 02238710 CROWN AK‐TOBRA 3MG/ML OPH SOL TOBRAMYCIN 3MG/ML OP SOL520404 02023857 DICHLORAM OPH SOL 0.5% CHLORAMPHENICOL 0.50% OP SOL520404 02026260 DIOCHLORAM 1% OPH OINT CHLORAMPHENICOL 1% OP OINT520404 02023776 DIOGENT OPH OINT 0.30% GENTAMICIN SULFATE 0.30% OP OINT520404 02023830 DIOSULF 10% OPH SOL SULFACETAMIDE SODIUM 10% OP SOL520404 02238818 DOM‐GENTAMICIN‐BETAMETHASONE BETAMETHASONE SOD PHOS/GENTAMI 1MG/3MG/ML O/O SOL520404 02326663 ERYTHROMYCIN 0.50% OPTH OINT ERYTHROMYCIN 0.50% OP OINT520404 02237041 ERYTHROMYCIN 5MG OPH OINT ERYTHROMYCIN 5MG OP OINT520404 00001058 FENICOL OINT 1% CHLORAMPHENICOL 1% OP OINT520404 02242360 FLOXIN OTIC 0.3% DROPS OFLOXACIN 0.3% OT SOL520404 02243862 FUCITHALMIC VISCOUS EYE DROPS FUSIDIC ACID 10MG/GM OP SOL520404 00028339 GARAMYCIN OPH OINT GENTAMICIN SULFATE 0.3% OP OINT520404 00512192 GARAMYCIN OPH SOL 3MG/ML GENTAMICIN SULFATE 3MG/ML OP SOL520404 00512184 GARAMYCIN OTIC SOL 3MG/ML GENTAMICIN SULFATE 3MG/ML OT SOL520404 01989073 GENTAC OP OINT GENTAMICIN 0.30% OP OINT520404 00832162 GENT‐AK GENTAMICIN OP SOL520404 00403474 ISOPTO FENICOL OPH SOL 0.5% CHLORAMPHENICOL 0.5% OP SOL520404 02148404 MINIMS GENTAMICIN SULFATE 0.3% GENTAMICIN SULFATE 0.3% OP SOL520404 00601659 NEOSPORIN OPH/OTIC DROPS POLYMYXINE /NEOMYCIN/GRAMICIDI O/O SOL520404 02333228 NU‐CIPROFLOX 0.3% OP SOL CIPROFLOXACIN HCL 0.3% OP SOL520404 02143291 OCUFLOX 0.3% OPH SOL OFLOXACIN 0.30% OP SOL520404 02247189 OFLOXACIN 0.3% OP SOL OFLOXACIN 0.3% OP SOL520404 02243025 OPHTHO‐FLOX 0.3% OPH SOLUTION OFLOXACIN 0.3% OP SOL520404 00807435 OPTIMYXIN PLUS OPH/OT DROPS POLYMYXIN/GRAMICIDIN/NEOMYCIN O/O SOL520404 02164051 PENTAMYCETIN 0.5% OPH SOL CHLORAMPHENICOL 0.50% OP SOL520404 00704571 PENTAMYCETIN OINT 1% CHLORAMPHENICOL 1% OP OINT520404 00704598 PENTAMYCETIN OPH LIQ 2.5MG/ML CHLORAMPHENICOL 2.5MG/ML OP SOL520404 01980564 PENTAMYCETIN OPH OINT 1% CHLORAMPHENICOL 1% OP OINT520404 01980556 PENTAMYCETIN OPH SOL 0.25% CHLORAMPHENICOL 0.25% OP SOL520404 00861383 PMS‐CHLORAMPHENICOL CHLORAMPHENICOL 0.50% OP SOL520404 02253933 PMS‐CIPROFLOXACIN 0.3% OPH SOL CIPROFLOXACIN HCL 0.3% OP SOL520404 01912755 PMS‐ERYTHROMYCIN 0.5% OPH OIN ERYTHROMYCIN HCL 0.50% OP OINT520404 00776521 PMS‐GENTAMICIN 0.3% OPH SOL GENTAMICIN SULFATE 0.30% OP SOL520404 02238819 PMS‐GENTAMICIN‐BETAMETHASONE BETAMETHASONE SOD PHOS/GENTAMI 1MG/3MG/ML O/O SOL520404 02252570 PMS‐OFLOXACIN 0.3% OPH SOL OFLOXACIN 0.3% OP SOL520404 02240363 PMS‐POLYTRIMETHOPRIM OPH SOL TRIMETHOPRIM/POLYMYXIN B SULFA 1MG/10000U OP SOL520404 00838934 PMS‐SULFACETAMIDE 10% OPH SOL SULFACETAMIDE SODIUM 10% OP SOL520404 02239577 PMS‐TOBRAMYCIN 0.3% OPH SOL TOBRAMYCIN 0.3% OP SOL520404 02239156 POLYSPORIN EYE & EAR DROPS POLYMIXIN B SULF/GRAMICIDIN O/O SOL520404 02239157 POLYSPORIN STERILE OPH OINT BACITRACIN/POLYMYXIN B SULFATE OP OINT520404 02011956 POLYTRIM OPH SOL TRIMETHOPRIM SULFATE/POLYMYXIN 1MG/ML OP SOL520404 02229440 SANDOZ GENTAMICIN 0.3% OPH SOL GENTAMICIN SULFATE 0.30% OP SOL520404 02229441 SANDOZ GENTAMICIN 3MG/ML SOL GENTAMICIN SULFATE 0.30% OT SOL520404 02230888 SANDOZ GENTAMICIN SULF OP 0.3% GENTAMICIN SULFATE 0.30% OP OINT520404 02241755 SANDOZ TOBRAMYCIN 3MG/ML SOL TOBRAMYCIN 3MG/ML OP SOL520404 02219581 SCHEIN‐GENTAMICIN OPH 3MG/ML GENTAMICIN SULFATE 0.30% OP SOL520404 02224887 SOFRAMYCIN 0.5% OPH DROPS FRAMYCETIN SULFATE 0.50% OP SOL520404 02224860 SOFRAMYCIN NASAL SPRAY FRAMYCETIN/GRAMICID/PHENYLEPH NAS SPR520404 02224895 SOFRAMYCIN STERILE EYE OINT FRAMYCETIN SULFATE/GRAMICIDIN 0.50% OP OINT520404 00028053 SULAMYD 10% OPH SOL SULFACETAMIDE SODIUM 10% OP SOL520404 00792594 TETRACYCLINE 1% OPH OINT TETRACYCLINE 1% OP OINT520404 00513962 TOBREX 0.3% OPH SOL TOBRAMYCIN 0.3% OP SOL520404 00614254 TOBREX OPH OINT 3MG/G TOBRAMYCIN 3MG/G OP OINT520404 02261243 TOBREXAN 0.3% OPH SOLUTION TOBRAMYCIN 0.3% OP SOL520404 02239234 TRIMETHOPRIM/POLYMYXIN B SULF TRIMETHOPRIM AND POLYMYXIN B 1MG/ML OP SOL520404 02252260 VIGAMOX 0.5% OPH SOL MOXIFLOXACIN HCL 0.5% OP SOL520404 02257270 ZYMAR 3MG/ML OPH SOL GATIFLOXACIN 3MG/ML OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
191 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520420 ANTIVIRALS520420 02248119 APO‐TRIFLURIDINE 1% OPH SOL TRIFLURIDINE 1% OP SOL520420 02248529 SANDOZ TRIFLURIDINE 1% OPH SOL TRIFLURIDINE 1% OP SOL520420 00687456 VIROPTIC 1% OPH SOL TRIFLURIDINE 1% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
192 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520492 MISCELLANEOUS ANTI-INFECTIVES520492 02243861 FUCITHALMIC VISCOUS 1% EYE DRP FUSIDIC ACID 1% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
193 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520808 EENT - CORTICOSTEROIDS520808 00630640 AK CIDE OPH SOL SULFACETAMIDE/PREDNISOLONE OP SOL520808 00626597 AK TROL OP SUSP DEXAMETHASONE/NEOMYCIN/POLYMYX OP SOL520808 00395145 BLEPHAMIDE OPH PREDNISOLONE/SULFACETAMIDE OP SOL520808 00807788 BLEPHAMIDE OPH SUSP SULFACETAMIDE/PREDNISOLONE OP SOL520808 00307246 BLEPHAMIDE OPH UNG SOD SULFACETAMIDE OP OINT520808 00575194 CELESTONE S COLLOIDAL EYE DROP BETAMETHASONE SODIUM OP SOL520808 01980661 CORTAMED OPH OINT 2.5% HYDROCORTISONE 2.50% OP OINT520808 00666211 CORTISPORIN OPH SUSP POLYMYXIN B/NEOMYCIN OP SOL520808 00694401 CORTISPORIN OTIC DPS STERILE POLYMYXIN B SULF/NEOMYCIN SULF OP SOL520808 01912828 CORTISPORIN OTIC SOLUTION POLYMYXIN B SULF/NEOMYCIN SULF OT SOL520808 02023865 DIODEX OPH OTIC SOL 0.1% DEXAMETHASONE 0.10% O/O SOL520808 02023768 DIOPRED 1% DROPS PREDNISOLONE ACETATE 1% OP SOL520808 02023814 DIOPTIMYD 100MG‐5MG/ML OPH SOL SULFACETAMIDE/PREDNISOLONE 100MG/5MG OP SOL520808 02023784 DIOPTIMYD OP OINT PREDNISOLONE/SULFACETAMIDE OP OINT520808 02023806 DIOPTROL OPH SUSP DEXAMETHASONE/NEOMYCIN/POLYMYX OP SOL520808 00756784 FLAREX OPH SUSP 0.1% FLUOROMETHOLONE ACETATE 0.1% OP SOL520808 00247855 FML 0.1% OPH SOL FLUOROMETHOLONE 0.1% OP SOL520808 00707511 FML FORTE OPH SUSP 0.25% FLUOROMETHOLONE 0.25% OP SOL520808 00395153 FML‐NEO OP SUSP FLUOROMETHOLONE/NEOMYCIN SULFA0.1/0.5% OP SOL520808 00586706 GARASONE OP UNG BETAMETHASONE/GENTAMICIN 1/3MG/G OP OINT520808 00682217 GARASONE OPH/OT SOL GENTAMICIN/BETAMETHASONE SOD OP SOL520808 00036676 H.M.S. 1% OPH SOL MEDRYSONE 1% OP SOL520808 00062251 HC‐ATROPINE 1% OPH 3G HYDROCORTISONE + ATROPINE SULF 1% OP OINT520808 00074454 LOCACORTEN VIOFORM EARDROPS FLUMETHASONE PIVALATE/CLIOQUIN OT SOL520808 00042579 MAXIDEX OP OINT 0.1% DEXAMETHASONE 0.1% OP OINT520808 00042560 MAXIDEX OPH SUSP 0.1% DEXAMETHASONE 0.1% OP SOL520808 00358177 MAXITROL OP OINT DEXAMETHASONE/NEOMYCIN/POLYMYX OP OINT520808 00042676 MAXITROL OPH SUSP DEXAMETHASONE/NEOMYCIN/POLYMY1MG/ML OP SOL520808 02241031 MED‐BUDESONIDE AQ 100MCG NAS BUDESONIDE 100MCG NAS SPR520808 00177121 METIMYD OPH OINT W NEOMYCIN METIMYD OP OINT520808 02230648 MYLAN‐BUDESONIDE AQ NAS 2MG/ML BUDESONIDE 2MG/ML NAS SPR520808 02241003 MYLAN‐BUDESONIDE AQ NAS SPR BUDESONIDE 64MCG NAS SPR520808 00194921 NEOCORTEF EYE EAR OINT 1.5% HYDROCORTISONE/NEOMYCIN 1.5% O/O OINT520808 00704555 PENTAMYCETIN HC DPS CHLORAMPHENICOL HC OP SOL520808 01980572 PENTAMYCETIN HC EYE/EAR DROPS CHLORAMPHENICOL/HC ACETATE O/O SOL520808 00704563 PENTAMYCETIN HC OINT CHLORAMPHENICOL HC OP OINT520808 01980580 PENTAMYCETIN‐HC CHLORAMPHENICOL/HC ACETATE 1% O/O OINT520808 02242737 PMS‐FLUMETHASONE‐CLIOQUINOL OT FLUMETHASONE PIVALATE OT SOL520808 02238568 PMS‐FLUOROMETHOLONE 0.1% OPH S FLUOROMETHOLONE 0.1% OP SOL520808 00301175 PRED FORTE 1% OPH SOL PREDNISOLONE ACETATE 1% OP SOL520808 00299405 PRED MILD 0.12% OPH SOL PREDNISOLONE ACETATE 0.12% OP SOL520808 02148498 PREDNISOLONE SODIUM PHOS 0.5% PREDNISOLONE SODIUM PHOSPHATE 0.50% OP SOL520808 00700401 RATIO‐PREDNISOLONE 1% OPH SUSP PREDNISOLONE ACETATE 1% OP SOL520808 02231923 RHINOCORT AQ 64MCG/DOSE NAS SP BUDESONIDE 64MCG/DOSE NAS SPR520808 02242485 SANDOZ CORTIMYXIN OPH OINT BACITRACIN/HC/NEOMYCIN/POLYMYX OP OINT520808 02230386 SANDOZ CORTIMYXIN OTIC SOL POLYMYXIN B SULF/NEOMYCIN SULF OT SOL520808 00739839 SANDOZ DEXAMETHASONE 0.1% SOL DEXAMETHASONE 0.10% O/O SOL520808 02247920 SANDOZ OPTICORT OP/OT SOL FRAMYCETIN/GRAMICIDIN/DEXAMETH O/O SOL520808 02244999 SANDOZ PENTASONE OP/OT SOL GENTAMICIN/BETAMETHASONE SOD O/O SOL520808 01916181 SANDOZ PREDNISOLONE 0.12% OP PREDNISOLONE ACETATE 0.12% OP SOL520808 01916203 SANDOZ PREDNISOLONE 1% OP SUSP PREDNISOLONE ACETATE 1% OP SOL520808 02224623 SOFRACORT STERILE OPH/OT DROPS FRAMYCETIN/GRAMICIDIN/DEXAMETH O/O SOL520808 01908839 SPERSADEX DEXAMETHASONE 0.10% O/O SOL520808 00778915 TOBRADEX OPH OINT TOBRAMYCIN/DEXAMETHASONE OP OINT520808 00778907 TOBRADEX OPH SUSP TOBRAMYCIN/DEXAMETHASONE OP SOL520808 00760056 VASOCIDIN OPH SOL PREDNISOLONE/SULFACETAMIDE SOD OP SOL520808 00527998 VASOCIDIN OPH/OTIC SOL PREDNISOLONE PHOSPHATE O/O SOL520808 02163691 VEXOL 1% OPH SOL RIMEXOLONE 1% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
194 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA520820 EENT - NON-STEROIDAL ANTI-INFLAMMATORY AGENTS520820 01968300 ACULAR 0.5% OPH SOL KETOROLAC TROMETHAMINE 0.50% OP SOL520820 02248722 ACULAR LS 0.4% OPH SOLUTION KETOROLAC TROMETHAMINE 0.4% OP SOL520820 02245821 APO‐KETOROLAC 0.5% OPH SOL KETOROLAC TROMETHAMINE 0.5% OP SOL520820 02336693 NU‐KETOROLAC 0.5% OP SOL KETOROLAC TROMETHAMINE 0.5% OP SOL520820 00766046 OCUFEN OPH SOL 0.03% FLURBIPROFEN 0.03% OP SOL520820 02247461 RATIO‐KETOROLAC 0.5% OP SOL KETOROLAC TROMETHAMINE 0.5% OP SOL520820 01940414 VOLTAREN OPHTHA 0.1% OPH SOL DICLOFENAC SODIUM 0.10% OP SOL520892 02355655 RESTASIS 0.05% OPH CYCLOSPORINE 0.05% O/O SOL PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
195 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA521600 LOCAL ANESTHETICS521600 00629707 FLUORACAINE OPH SOL FLUOROCAINE OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
196 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA522400 MYDRIATICS522400 00626627 AK PENTOLATE OPH SOLN 1% CYCLOPENTOLATE HCL 1% OP SOL522400 00626635 AK PENTOLATE OPHTH SOLN 0.5% CYCLOPENTOLATE HCL 0.5% OP SOL522400 02023695 AK‐ATROPINE 1% OPH SOL ATROPINE SULFATE 1% OP SOL522400 02242232 APO‐DIPIVEFRIN 0.1% OPH SOL DIPIVEFRIN HCL 0.1% OP SOL522400 00725498 ATROPINE 1% OPH SOL ATROPINE SULFATE 1% OP SOL522400 02148358 ATROPINE 1% OPH SOL ATROPINE SULFATE 1% OP SOL522400 00622907 ATROPINE AK OPH SOL ATROPINE SULFATE 1% OP SOL522400 00252484 ATROPINE OINT 1% OPH ATROPINE SULFATE 1% OP OINT522400 00252506 CYCLOGYL OPH DPS 1% CYCLOPENTOLATE HCL 1% OP SOL522400 02148331 CYCLOPENTOLATE 0.5% OPH SOL CYCLOPENTOLATE HCL 0.50% OP SOL522400 02023687 DIOPENTOLATE 0.5% OP SOL CYCLOPENTOLATE HCL 0.5% OP SOL522400 02023644 DIOPENTOLATE 1% OPH SOL CYCLOPENTOLATE HCL 1% OP SOL522400 02023717 DIOPHENYL‐T 0.08% PHENYLEPHRINE/TROPICAMIDE 0.08% OP SOL522400 02023660 DIOTROPE 0.5% OPH SOL TROPICAMIDE 0.50% OP SOL522400 02023679 DIOTROPE 1% OPH SOL TROPICAMIDE 1% OP SOL522400 00001090 EPIFRIN 0.5% OPH SOL EPINEPHRINE 0.5% OP SOL522400 00001104 EPIFRIN 1% OPH SOL EPINEPHRINE HCL 1% OP SOL522400 00001112 EPIFRIN 2% OPH SOL EPINEPHRINE HCL 2% OP SOL522400 00035017 ISOPTO ATROPINE 1% OPH SOL ATROPINE SULFATE 1% OP SOL522400 00000779 ISOPTO HOMATROPINE 2% HOMATROPINE HYDROBROMIDE 2% OP SOL522400 00000787 ISOPTO HOMATROPINE 5% HOMATROPINE HYDROBROMIDE 5% OP SOL522400 02148536 MINIMS TROPICAMIDE 1% OPH SOL TROPICAMIDE 1% OP SOL522400 02148382 MINIMS‐CYCLOPENTOLATE 1% OPH CYCLOPENTOLATE HCL 1% OP SOL522400 00000981 MYDRIACYL 0.5% OPH TROPICAMIDE 0.5% OP SOL522400 00001007 MYDRIACYL 1% OPH TROPICAMIDE 1% OP SOL522400 00629693 PHENYLTROPE OPH SOLN PHENYLEPHRINE/TROPICAMIDE 5.0%/0.8% OP SOL522400 00529117 PROPINE LIQ 0.1% OPH SOL DIPIVEFRIN HCL 1MG/ML OP SOL522400 00622885 TROPICACYL OPH DRP 1% TROPICAMIDE 1% OP SOL522400 00528021 VASOSULF OPH DROPS NA SULFACETAMIDE/PHENYLEPHRINE OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
198 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA523200 VASOCONSTRICTORS523200 02148455 PHENYLEPHRINE 10% OP PHENYLEPHRINE HCL 10% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
199 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA524004 EENT - ALPHA-ADRENERGIC AGONISTS524004 02236876 ALPHAGAN 0.2% OPH SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02236877 ALPHAGAN 0.5% OPTH SOL BRIMONIDINE TARTRATE 0.5% OP SOL524004 02248151 ALPHAGAN P 0.15% OPH SOL BRIMONIDINE TARTRATE 0.15% OP SOL524004 02260077 APO‐BRIMONIDINE 0.2% OPH SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02301334 APO‐BRIMONIDINE P 0.15% OP SOL BRIMONIDINE TARTRATE 0.15% OP SOL524004 02350734 APX‐BRIMONIDINE P 0.15% OPTH BRIMONIDINE TARTRATE 0.15% OP SOL524004 02249456 BRIMONIDINE 0.2% OPH SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02246283 BRIMONIDINE OPHTHALMIC SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02245942 BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE 0.2% OP SOL524004 02248347 COMBIGAN OPH SOL BRIMONIDINE TARTRATE/TIMOLOL 0.2%/0.5% OP SOL524004 02246285 DOM‐BRIMONIDINE 0.2% SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02246284 PMS‐BRIMONIDINE 0.2% OPH SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02243026 RATIO‐BRIMONIDINE 0.2% OPH SOL BRIMONIDINE TARTRATE 0.2% OP SOL524004 02305429 SANDOZ BRIMONIDINE 0.2% OP SOL BRIMONIDINE TARTRATE 0.2% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
200 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA524008 EENT - BETA-ADRENERGIC BLOCKING AGENTS524008 02230620 ALTI‐BETAXOLOL 0.5% OPTH SOL BETAXOLOL HCL 0.5% OP SOL524008 02241575 APO‐LEVOBUNOLOL 0.25% OPH SOL LEVOBUNOLOL HCL 0.25% OP SOL524008 02315858 APO‐TIMOP 0.25% OP GEL TIMOLOL MALEATE 0.25% OP GEL524008 00755826 APO‐TIMOP 0.25% OPH SOL TIMOLOL MALEATE 0.25% OP SOL524008 02290812 APO‐TIMOP 0.5% OP GEL TIMOLOL MALEATE 0.5% OP GEL524008 00755834 APO‐TIMOP 0.5% OPH SOL TIMOLOL MALEATE 0.50% OP SOL524008 00637661 BETAGAN 0.5% OPH SOL LEVOBUNOLOL HCL 0.5% OP SOL524008 00751286 BETAGAN OPH SOL 0.25% LEVOBUNOLOL HCL 0.25% OP SOL524008 01908448 BETOPTIC S 0.25% OPH SOL BETAXOLOL HCL 0.25% OP SOL524008 02238539 BETOPTIC/PILO 0.25%/1.75% OPH BETAXOLOL/PILOCARPINE HCL 0.25%/1.75 OP SOL524008 02239300 CROWN‐TIM 2.5MG/ML OPH SOL TIMOLOL MALEATE 2.5MG/ML OP SOL524008 02239301 CROWN‐TIM 5MG/ML OPH SOL TIMOLOL MALEATE 5MG/ML OP SOL524008 02238770 DOM‐TIMOLOL 0.25% OPH SOL TIMOLOL MALEATE 0.25% OP SOL524008 02238771 DOM‐TIMOLOL 0.5% OPH SOL TIMOLOL MALEATE 0.5% OP SOL524008 02200813 GEN‐BUNOLOL 0.25% OPTH LEVOBUNOLOL HCL 0.25% OP SOL524008 02200821 GEN‐BUNOLOL 0.50% OPTH LEVOBUNOLOL HCL 0.50% OP SOL524008 02236792 LEVOBUNOLOL HCL 0.25% OPH SOL LEVOBUNOLOL HCL 0.25% OP SOL524008 02236793 LEVOBUNOLOL HCL 0.5% OPH SOL LEVOBUNOLOL HCL 0.5% OP SOL524008 00893773 MYLAN‐TIMOLOL 0.25% OPH SOL TIMOLOL MALEATE 0.25% OP SOL524008 00893781 MYLAN‐TIMOLOL SOL 0.05% TIMOLOL MALEATE 0.5% OP SOL524008 02240050 NOVO‐BETAXOLOL 0.5% OPH SOL BETAXOLOL HCL 0.5% OP SOL524008 02048523 NOVO‐TIMOL 0.25% OPHTH SOL TIMOLOL MALEATE 0.25% OP SOL524008 02094916 NOVO‐TIMOL 0.25% OPHTH SOL TIMOLOL MALEATE 0.25% OP SOL524008 02094924 NOVO‐TIMOL 0.5% OPH SOL TIMOLOL MALEATE 0.5% OP SOL524008 02094932 NU‐TIMOLOL TIMOLOL MALEATE 2.5MG/ML OP SOL524008 02094940 NU‐TIMOLOL TIMOLOL MALEATE 5MG/ML OP SOL524008 02200848 OPHTHO‐BUNOLOL 0.25% OPH SOL LEVOBUNOLOL HCL 0.25% OP SOL524008 02200856 OPHTHO‐BUNOLOL 0.50% OPTH SOL LEVOBUNOLOL HCL 0.50% OP SOL524008 02237990 PMS‐LEVOBUNOLOL 2.5MG/ML OPTH LEVOBUNOLOL HCL 2.5MG/ML OP SOL524008 02237991 PMS‐LEVOBUNOLOL 5MG/ML OPH SOL LEVOBUNOLOL HCL 0.5% OP SOL524008 02083353 PMS‐TIMOLOL OPH SOL 0.25% TIMOLOL MALEATE 0.25% OP SOL524008 02083345 PMS‐TIMOLOL OPH SOL 0.5% TIMOLOL MALEATE 0.50% OP SOL524008 02209071 PROBETA OPH DROPS LEVOBUNOLOL HCL/DIPIVEFRIN HCL 5MG‐1MG/ML OP SOL524008 02031159 RATIO‐LEVOBUNOLOL 0.25% OP SOL LEVOBUNOLOL HCL 0.25% OP SOL524008 02031167 RATIO‐LEVOBUNOLOL 0.5% OPH SOL LEVOBUNOLOL HCL 0.50% OP SOL524008 02235971 SANDOZ BETAXOLOL 0.5% OPH SOL BETAXOLOL HCL 0.5% OP SOL524008 02241716 SANDOZ LEVOBUNOLOL 0.5% OP SOL LEVOBUNOLOL HCL 0.5% OP SOL524008 02166720 SANDOZ TIMOLOL MALEATE 0.5% TIMOLOL MALEATE 0.50% OP SOL524008 02166712 SANDOZ TIMOLOL OPH SOL 0.25% TIMOLOL MALEATE 0.25% OP SOL524008 02176025 STORZ‐TIMOL 0.25% OPHTH SOL TIMOLOL MALEATE 0.25% OP SOL524008 02176033 STORZ‐TIMOL 0.5% OPHTH SOL TIMOLOL MALEATE 0.5% OP SOL524008 02010240 TIM‐AK LIQ 0.5% OPHT/DROPS TIMOLOL MALEATE 0.5% OP SOL524008 02242276 TIMOLOL MALEATE‐EX 0.5% OP SOL TIMOLOL MALEATE 0.5% OP SOL524008 00451207 TIMOPTIC OPH DPS 0.5% TIMOLOL MALEATE 0.5% OP SOL524008 02171880 TIMOPTIC XE 0.25% OPH DROPS TIMOLOL MALEATE 0.25% OP SOL524008 02171899 TIMOPTIC XE 0.5% OPH DROPS TIMOLOL MALEATE 0.5% OP SOL524008 02202492 T‐LO OPH SOL 0.25% TIMOLOL MALEATE 0.25% OP SOL524008 02202506 T‐LO OPH SOL 0.50% TIMOLOL MALEATE 0.50% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
201 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA524020 EENT - MIOTICS524020 00627747 AKARPINE 2% OPH SOL PILOCARPINE HCL 2% OP SOL524020 00627739 AKARPINE OPH SOL 1% PILOCARPINE HCL 1% OP SOL524020 00627755 AKARPINE OPH SOL 4% PILOCARPINE HCL 4% OP SOL524020 02023733 DIOCARPINE OPH SOL 4% PILOCARPINE HCL 4% OP SOL524020 00000655 ISOPTO CARBACHOL 1.5% CARBACHOL 1.5% OP SOL524020 00000663 ISOPTO CARBACHOL 3% CARBACHOL 3% OP SOL524020 00000841 ISOPTO CARPINE LIQ 1% PILOCARPINE HCL 1% OP SOL524020 00000868 ISOPTO CARPINE LIQ 2% PILOCARPINE HCL 2% OP SOL524020 00000884 ISOPTO CARPINE LIQ 4% PILOCARPINE HCL 4% OP SOL524020 00527548 MIOCARPINE 1% OPH SOL PILOCARPINE 1% OP SOL524020 00527556 MIOCARPINE 2% OPH SOL PILOCARPINE 2% OP SOL524020 00527572 MIOCARPINE 4% OPH SOL PILOCARPINE HCL 4% OP SOL524020 02133326 MIOCHOL E (UNIVIAL) EYE SOL ACETYLCHOLINE CHLORIDE 20MG/VIAL OP SOL524020 00784826 MIOGAN PWS 20MG/VIAL ACETYLCHOLINE CHLORIDE 20MG OP SOL524020 00042544 MIOSTAT OPH SOL 0.01% CARBACHOL 0.01% OP SOL524020 02148463 PILOCARPINE NITRATE PILOCARPINE NITRATE 2% OP SOL524020 00575240 PILOPINE HS 4% OPH GEL PILOCARPINE HCL 4% OP GEL524020 00269115 SCHEIN‐PILOCARPINE OPH 1% PILOCARPINE 1% OP SOL524020 02229556 SCHEIN‐PILOCARPINE OPH SOL 1% PILOCARPINE HCL 1% OP SOL524020 02229555 SCHEIN‐PILOCARPINE OPH SOL 2% PILOCARPINE HCL 2% OP SOL524020 00725420 SPERSACARPINE OPH PILOCARPINE HCL 3% OP SOL524020 00725404 SPERSACARPINE OPH SOLN 10MG/ML PILOCARPINE HCL 1% OP SOL524020 01948571 SPERSACARPINE OPH SOLN 20MG/ML PILOCARPINE HCL 2% OP SOL524020 00725439 SPERSACARPINE OPH SOLN 40MG/ML PILOCARPINE HCL 4% OP SOL524020 01948490 SPERSACARPINE OPTH SOL 4 % PILOCARPINE HCL 4% OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
202 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA524028 EENT - PROSTAGLANDIN ANALOGS524028 02296527 APO‐LATANOPROST 50MCG/ML OPH LATANOPROST 50MCG/ML OP SOL524028 02254786 CO LATANOPROST 50MCG/ML OP SOL LATANOPROST 50MCG/ML OP SOL524028 02278251 DUO TRAV 0.004%/0.5% OPH SOL TRAVOPROST/TIMOLOL MALEATE .004%/0.5% OP SOL524028 09857333 DUOTRAV 0.5%/0.004% OPH SOL TRAVOPROST/TIMOLOL MALEATE 0.5/0.004% OP SOL524028 02373041 GD‐LATANOPROST 50MCG/ML OP SOL LATANOPROST 50MCG/ML OP SOL524028 02373068 GD‐LATANOPROST/TIMOLOL OP SOL LATANOPROST 50MCG/5MG OP SOL524028 02375508 LATANOPROST 50MCG/ML LATANOPROST 50MCG/ML OP SOL524028 02245860 LUMIGAN OPH SOL 0.03% BIMATOPROST 0.03% OP SOL524028 02324997 LUMIGAN RC 0.01% OPH SOL BIMATOPROST 0.01% OP SOL524028 09991181 LUMIGAN RC 0.01% OPH SOL 7.5ML BIMATOPROST 0.01% OP SOL524028 02341085 RIVA‐LATANOPROST 50MCG/ML LATANOPROST 50MCG/ML OP SOL524028 02367335 SANDOZ LATANOPROST 50MCG OPH LATANOPROST 50MCG/ML OP SOL524028 02318008 TRAVATAN Z OP SOL TRAVOPROST 0.004% OP SOL524028 02246619 XALACOM OPTH SOL LATANOPROST/TIMOLOL MALEATE 50UG/5MG OP SOL524028 02231493 XALATAN 50MCG/ML OPH SOL LATANOPROST 50MCG/ML OP SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
203 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA529200 MISCELLANEOUS EENT DRUGS529200 00893560 ALOMIDE OPH SOL LODOXAMIDE 0.10% OP SOL529200 02237355 EMADINE 0.05% OPH SOL EMDASTINE DIFUMARATE 0.05% OP SOL529200 02076306 IOPIDINE 0.5% OPH SOL APRACLONIDINE 0.50% OP SOL529200 00888354 IOPIDINE 1% OPH SOL APRACLONIDINE 1% OP SOL529200 02123363 LIVOSTIN NASAL SPRAY LEVOCABASTINE 0.5MG NAS SPR529200 02296810 LUCENTIS SOL 10MG/ML RANIBIZUMAB 10MG/ML INJ529200 02267225 MACUGEN 0.3MG/90MCL INJ PEGAPTANIB SODIUM .3MG/90MCL INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
204 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA560800 ANTIDIARRHEA AGENTS560800 00172723 DIBAN CAP OPIUM/BELLADONNA ALKALOIDS COM CAP560800 02218348 DIPHENOXYLATE HCL/ATROPINE SUL DIPHENOXYLATE HCL/ATROPINE SUL 2.5/0.025M TAB560800 00633410 DONNAGEL PG KAOLIN/PECTIN/PAREGORIC COMP CAP560800 01914235 DONNAGEL PG KAOLIN/PECTIN/PAREGORIC COMP CAP560800 01909223 DONNAGEL PG LIQ KAOLIN/PECTIN/PAREGORIC O/L560800 00195014 KAOMYCIN KAOLIN/PECTIN/NEOMYCIN O/L560800 00036323 LOMOTIL 2.5 MG TAB DIPHENOXYLATE/ATROPINE SULFATE 2.5MG TAB560800 00399345 LOMOTIL TAB 2.5MG DIPHENOXYLATE/ATROPINE SULFATE 2.5/0.025M TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
205 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA561400 CHOLELITHOLYTIC AGENTS561400 02281295 DOM‐URSODIOL C 250MG TAB URSODIOL 250MG TAB561400 02281309 DOM‐URSODIOL C 500MG TAB URSODIOL 500MG TAB561400 02318091 NOVO‐URSODIOL 250MG TAB URSODIOL 250MG TAB561400 02318105 NOVO‐URSODIOL 500MG TAB URSODIOL 500MG TAB561400 02281317 PHL‐URSODIOL C 250MG TAB URSODIOL 250MG TAB561400 02281325 PHL‐URSODIOL C 500MG TAB URSODIOL 500MG TAB561400 02273497 PMS‐ URSODIOL C 250MG TAB URSODIOL 250MG TAB561400 02262576 PMS‐URSODIOL 250MG TAB URSODIOL 250MG TAB561400 02273500 PMS‐URSODIOL C 500MG TAB URSODIOL 500MG TAB561400 02238984 URSO 250MG TAB URSODIOL 250MG TAB561400 02245894 URSO DS 500MG TAB URSODIOL 500MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
206 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA561600 DIGESTANTS561600 00456233 COTAZYM 65B CAP PANCRELIPASE ENZYME CAP561600 00263818 COTAZYM CAP PANCRELIPASE EQUIVALENT TO LIP 300MG CAP561600 00821373 COTAZYM ECS 20 CAP PANCRELIPASE ENZYME 55000IU CAP561600 00848514 COTAZYM ECS 4 CAP PANCRELIPASE ENZYME CAP561600 00502790 COTAZYM ECS 8 CAP PANCRELIPASE EQUIVALENT TO LIP CAP561600 02181215 COTAZYM ECS4 PANCRELIPASE ENZYME CAP561600 02200104 CREON 10 MINIMICROSPHERES PANCREATIC ENZYME CAP561600 02239008 CREON 20 MINIMICROSPHERES AMYLASE/LIPASE/PROTEASE CAP561600 01985205 CREON 25 MINIMICROSPHERES PANCREATIC ENZYME 74000IU CAP561600 02239007 CREON 5 MINIMICROSPHERES AMYLASE/LIPASE/PROTEASE CAP561600 00789437 PANCREASE MT 10 CAP PANCRELIPASE ENZYME 30000IU CAP561600 00789429 PANCREASE MT 16 CAP PANCRELIPASE ENZYME 48000IU CAP561600 00789445 PANCREASE MT 4 CAP PANCRELIPASE ENZYME 4 CAP561600 02004909 PMS‐PROLACTASE 260MG TAB PROLACTASE 260MG TAB561600 02203324 ULTRASE MS 4 PANCRELIPASE ENZYME CAP561600 02045834 ULTRASE MT12 CAP PANCRELIPASE ENZYME CAP561600 02045869 ULTRASE MT20 CAP PANCRELIPASE ENZYME CAP561600 02241933 VIOKASE 16 TAB AMYLASE/LIPASE/PROTEASE 6000,1,600 TAB561600 02230019 VIOKASE 8 TAB PANCRELIPASE EQUIVALENT TO LIP TAB562200 02367297 ONDANSETRON 2MG/ML INJ ONDANSETRON 2MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
207 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA562208 ANTIHISTAMINES562208 00609129 DICLECTIN TAB DOXYLAMINE SUCCINATE/PYRIDOXIN 10MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
209 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA562220 02239373 ZOFRAN ODT 8MG TAB ONDANSETRON 8MG TAB562220 02213567 ZOFRAN TAB 4MG ONDANSETRON HCL 4MG TAB562220 02213575 ZOFRAN TAB 8MG ONDANSETRON HCL 8MG TAB562220 02344440 ZYM‐ONDANSETRON 4MG TAB ONDANSETRON HCL 4MG TAB562220 02344459 ZYM‐ONDANSETRON 8MG TAB ONDANSETRON HCL 8MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
213 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA562828 PROSTAGLANDINS562828 02349094 AA‐MISOPROSTOL 100MCG TAB MISOPROSTOL 100MCG TAB562828 02349108 AA‐MISOPROSTOL 200MCG TAB MISOPROSTOL 200MCG TAB562828 02185458 MISOPROSTOL 100MCG TAB MISOPROSTOL 100MCG TAB562828 02244022 MISOPROSTOL 100MCG TAB MISOPROSTOL 100MCG TAB562828 02185466 MISOPROSTOL 200MCG TAB MISOPROSTOL 200MCG TAB562828 02244023 MISOPROSTOL 200MCG TAB MISOPROSTOL 200MCG TAB562828 02248846 MISOPROSTOL‐200 200MCG TAB MISOPROSTOL 200MCG TAB562828 02244124 PMS‐MISOPROSTOL 0.1MG TAB MISOPROSTOL 0.1MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
214 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA562832 PROTECTANTS562832 02125250 APO‐SUCRALFATE 1GM TAB SUCRALFATE 1G TAB562832 02140004 CYTOGARD 1G TAB SUCRALFATE 1 GM TAB562832 02239912 DOM‐SUCRALFATE 1G TAB SUCRALFATE 1G TAB562832 02100614 NOVO‐SUCRALATE SUCRALFATE TAB562832 02134829 NU‐SUCRALFATE 1GM TAB SUCRALFATE 1G TAB562832 02130939 PDL‐SUCRALFATE‐1G TAB SUCRALFATE 1 G TAB562832 01924699 SULCRATE 1GM SUCRALFATE 1GM O/L562832 02103567 SULCRATE PLUS 1G/5ML SUSP SUCRALFATE 1G/5ML O/L562832 02100622 SULCRATE TAB 1G SUCRALFATE 1G TAB562832 00506346 SULCRATE TAB 1GM SUCRALFATE 1G TAB562832 02045702 TEVA‐SUCRALATE 1GM TAB SUCRALFATE 1G TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
218 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA569200 MISCELLANEOUS GI DRUGS569200 02246962 PYLERA CAPSULE BISKAL/METRONIDA/TETRACYC 40/125/125 CAP569200 02308215 RELISTOR 20MG/ML METHYLNALTREXONE BROMIDE 20MG/ML INJ PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
223 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA680800 ANDROGENS680800 00782327 ANDRIOL 40MG CAP TESTOSTERONE UNDECANOATE 40MG CAP680800 02239653 ANDRODERM 12.2MG TRANSDR PAD TESTOSTERONE 12.2MG PATCH680800 02245972 ANDRODERM 24.3MG TRANSDR PAD TESTOSTERONE 24.3MG PATCH680800 02245345 ANDROGEL 1% GEL TESTOSTERONE 1% GEL680800 02245346 ANDROGEL 1% GEL TESTOSTERONE 1% GEL680800 02249499 ANDROGEL 1% GEL TESTOSTERONE 1% GEL680800 01904817 CYCLOMEN 100 MG DANAZOL 100MG CAP680800 00358754 CYCLOMEN 100MG CAP DANAZOL 100MG CAP680800 02018152 CYCLOMEN 100MG CAP DANAZOL 100MG CAP680800 01908146 CYCLOMEN 200MG DANAZOL 200MG CAP680800 00358762 CYCLOMEN 200MG CAP DANAZOL 200MG CAP680800 02018160 CYCLOMEN 200MG CAP DANAZOL 200MG CAP680800 00491764 CYCLOMEN 50MG CAP DANAZOL 50MG CAP680800 01904809 CYCLOMEN 50MG CAP DANAZOL 50MG CAP680800 02018144 CYCLOMEN 50MG CAP DANAZOL 50MG CAP680800 00270687 DECA DURABOLIN INJ 100MG/ML NANDROLONE DECANOATE 100MG/ML INJ680800 00029246 DELATESTRYL INJ 200MG/ML TESTOSTERONE ENANTHATE 200MG/ML INJ680800 00030783 DEPO‐TESTOSTERONE 100MG/ML INJ TESTOSTERONE CYPIONATE 100MG/ML INJ680800 00177652 MALOGEN AQUEOUS INJ 100MG/ML TESTOSTERONE PROPIONATE 100MG/ML INJ680800 00177636 MALOGEX LA 200 INJ TESTOSTERONE ENANTHATE 200MG INJ680800 00005746 METANDREN 10MG TAB METHYLTESTOSTERONE 10MG TAB680800 00739944 PMS‐TESTOSTERONE 200MG/ML INJ TESTOSTERONE ENANTHATE 200MG/ML INJ680800 02322498 PMS‐TESTOSTERONE 40MG CAP TESTOSTERONE UNDECANOATE 40MG CAP680800 02280248 TESTIM 1% GEL TESTOSTERONE 1% GEL680800 02246063 TESTOSTERONE CYPIONATE INJ 100 TESTOSTERONE CYPIONATE 100MG/ML INJ680800 00211052 TESTOSTERONE PROPIO 10ML TESTOSTERONE PROPIONATE 100MG INJ680800 00298336 TESTOTERONE 10ML TESTOSTERONE PROPIONATE 200MG INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
225 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA681600 ESTROGENS AND ANTIESTROGENS
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
227 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA681612 ESTROGEN AGONISTS-ANTAGONISTS681612 02279215 APO‐RALOXIFENE 60MG TAB RALOXIFENE HCL 60MG TAB681612 02358840 CO RALOXIFENE 60MG TAB RALOXIFENE HCL 60MG TAB681612 02239028 EVISTA 60MG TAB RALOXIFENE HCL 60MG TAB681612 02312298 NOVO‐RALOXIFENE 60MG TAB RALOXIFENE HCL 60MG TAB681612 02358921 PMS‐RALOXIFENE 60MG TAB RALOXIFENE HCL 60MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
228 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA681800 GONADOTROPINS681800 02212145 NAFARELIN ACETATE NAS/SOL NAFARELIN ACETATE 2MG/ML NAS SOL681800 02162709 SYNAREL NAS SOL 2MG/ML NAFARELIN ACETATE 2MG/ML NAS SOL681800 02188783 SYNAREL NAS SOL 2MG/ML NAFARELIN ACETATE 2MG/ML NAS SOL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
229 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682002 ALPHA-GLUCOSIDASE INHIBITORS 682002 02190893 GLUCOBAY 100MG TAB ACARBOSE 100MG TAB682002 02190885 GLUCOBAY 50MG TAB ACARBOSE 50MG TAB682002 02239476 GLYSET TM 100MG TAB MIGLITOL 100MG TAB682002 02239474 GLYSET TM 25MG TAB MIGLITOL 25MG TAB682002 02239475 GLYSET TM 50MG TAB MIGLITOL 50MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
232 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682005 DIPEPTIDYL PEPTIDASE IV (DDP-4) INHIBITORS682005 02303922 JANUVIA 100MG TAB SITAGLIPTIN PHOSPHATE MONOHYDR 100MG TAB682005 02375842 ONGLYZA 2.5MG TAB SAXAGLIPTIN HCL 2.5MG TAB682005 02333554 ONGLYZA 5MG TAB SAXAGLIPTIN HCL 5MG TAB682005 02370921 TRAJENTA 5MG TAB LINAGLIPTIN 5MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
233 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682008 INSULINS682008 02279479 APIDRA 100UNIT/ML CARTRIDGE INSULIN GLULISINE 100UNIT/ML INJ682008 02279460 APIDRA INJ 100UNIT/ML INSULIN GLULISINE 100UNIT/ML INJ682008 02294346 APIDRA SOLOSTAR PREFILLED PEN INSULIN GLULISINE 100U/ML INJ682008 02233562 HUMALOG 100U/ML CARTRIDGE 3ML INSULIN LISPRO 100U INJ682008 02240296 HUMALOG 100U/ML INJ INSULIN LISPRO/PROTAMINE 100U/ML INJ682008 02240299 HUMALOG 100U/ML INJ INSULIN LISPRO/PROTAMINE 50/50 INJ682008 09853715 HUMALOG 100U/ML INJ CARTRIDGE INSULIN 100U/ML INJ682008 02240298 HUMALOG 50/50 PREFILLED PEN INSULIN LISPRO/PROTAMINE 50/50 INJ682008 99002817 HUMALOG INJ 100U/ML INSULIN LISPRO 100U/ML INJ682008 02229705 HUMALOG INSULIN CARTRIDGE INSULIN LISPRO INJ682008 02229704 HUMALOG INSULIN INJ INSULIN LISPRO INJ682008 09857352 HUMALOG KWIKPEN 100U/ML INJ INSULIN LISPRO 100IU/ML INJ682008 00965537 HUMALOG KWIKPEN INJ INSULIN LISPRO/PROTAMINE INJ682008 99100630 HUMALOG KWIKPEN INJ INSULINE LISPRO 100UNIT/ML INJ682008 00965545 HUMALOG MIX 25 KWIKPEN INJ INSULIN LISPRO/PROTAMINE INJ682008 02240294 HUMALOG MIX 25 KWIKPEN INJ INSULIN LISPRO/PROTAMINE 25/75 INJ682008 09857353 HUMALOG MIX 25 KWIKPEN INJ INSULIN LISPRO/PROTAMINE 25/75 INJ682008 99100631 HUMALOG MIX 25 KWIKPEN INJ INSULINE LISPRO/ INSULINE LISP 25/75 INJ682008 00965421 HUMALOG MIX 50 KWIKPEN INSULIN LISPRO/PROTAMINE 50/50 INJ682008 02240297 HUMALOG MIX 50 KWIKPEN INJ INSULIN LISPRO/PROTAMINE 50/50 INJ682008 09857355 HUMALOG MIX 50 KWIKPEN INJ INSULIN LISPRO/PROTAMINE 50/50 INJ682008 09853855 HUMULIN 30/70 CARTRIDGE INJ INSULIN 30/70 INJ682008 00795879 HUMULIN 30/70 INJ INSULIN HUMAN/ISOPHANE 30/70 INJ682008 01959212 HUMULIN 30/70 INJ INSULIN HUMAN/ISOPHANE 30/70 INJ682008 02229750 HUMULIN CARTRIDGES & HUMAJECT INSULIN HUMAN BIOSYNTHETIC 100UNIT/ML SUSP682008 00646148 HUMULIN L LENTE INJ 100UNIT/ML INSULIN ZINC SUSPENSION MEDIUM 100IU/ML INJ682008 00908991 HUMULIN N 100U/ML CARTRIDGE INSULIN BIOSYNTHETIC HUMAN 100U/ML INJ682008 09853804 HUMULIN N 100U/ML INJ CARTRIDG INSULIN BIOSYNTHETIC HUMAN 100U INJ682008 00587737 HUMULIN N INJ 100UNIT/ML INSULIN NPH HUMAN DNA ORIGIN 100IU/ML INJ682008 01959239 HUMULIN N INSULIN INJ INSULIN HUMULIN 100 U INJ682008 99001586 HUMULIN N INSULIN INJ (PQ) INSULIN HUMULIN (PSEUDO IN PQ) 100 U INJ682008 97799500 HUMULIN N KWIKIPEN INSULIN BIOSYNTHETIC HUMAN INJ682008 09853766 HUMULIN R 100U/ML INJ CARTRIDG INSULIN 100U INJ682008 00586714 HUMULIN R INJ INSULIN SEMI SYNTHETIC HUMAN 100IU/ML INJ682008 01959220 HUMULIN R INJ INSULIN HUMULIN 100 U INJ682008 99001594 HUMULIN R INJ (PSEUDO PQ) INSULIN ZINC CRYSTALLINE (PQ) 100U/ML INJ682008 01985981 INITARD INSULIN INSULIN NEUTRAL/ISOPHANE 50/50 INJ682008 00909009 INS HUMULIN 30/70 CART INSULIN BIOSYNTHETIC HUMAN INJ682008 01985949 INSULIN INSULATARD NORDISK INJ INSULIN ISOPHANE NPH PORK 100 U INJ682008 01985957 INSULIN MIXTARD NORDISK INJ INSULIN NEUTRAL/ISOPHANE 30/70 INJ682008 00984299 INSULIN NOVOLIN NPH INSULIN NOVOLIN NPH PENFILL INJ682008 01986791 INSULIN NOVOLIN NPH HUMAN INSULIN HUMAN INJ682008 02294338 LANTUS (3ML SOLOSTAR DISP PEN) INSULIN GLARGINE 100UNIT/ML INJ682008 02245689 LANTUS 100UNIT/ML 10ML VIAL INSULIN GLARGINE 100UNIT/ML INJ682008 02251930 LANTUS 100UNIT/ML CARTRIDGE INSULIN GLARGINE 100IU/ML INJ682008 00773654 MIXTARD 15/85 HUMAN INJ INSULIN NEUTRAL/ISOPHANE 1000U/10ML INJ682008 00632694 MIXTARD 30/70 HUMAN INJ INSULIN NEUTRAL/ISOPHANE 1000U/10ML INJ682008 01986821 MIXTARD 30/70 HUMAN INJ INSULIN NEUTRAL/ISOPHANE 30/70 INJ682008 00632678 MIXTARD 50/50 HUMAN INJ INSULIN NEUTRAL/ISOPHANE 1000U/10ML INJ682008 01985965 MIXTARD 50/50 HUMAN INJ INSULIN NEUTRAL/ISOPHANE 50/50 INJ682008 02024217 NOVOLIN 30/70 INJ 100UNIT/ML INSULIN 30/70 INJ682008 00984434 NOVOLIN 30/70 PENFIL INSULIN INJECTION (30%) + INSU 150U/1.5ML INJ682008 02245179 NOVOLIN GE 10/90 INNOLET INJ INSULIN HUMAN BIOSYNTHETIC INJ682008 02245180 NOVOLIN GE 20/80 INNOLET INJ INSULIN HUMAN BIOSYNTHETIC INJ682008 02247309 NOVOLIN GE 30/70 FLEXPEN INSULIN ISOPHANE HUMAN BIOSYNT 70UNIT/ML INJ682008 02245181 NOVOLIN GE 30/70 INNOLET INJ INSULIN HUMAN BIOSYNTHETIC INJ682008 00908134 NOVOLIN GE 30/70 PEN INSULIN HUMAN/ISOPHANE 150U/1.5ML INJ682008 00920681 NOVOLIN GE 30/70 PENFILL INSULIN INJ682008 02025248 NOVOLIN GE 30/70 PENFILL INSULIN HUMAN/ISOPHANE 30/70 INJ682008 09853812 NOVOLIN GE 30/70 PENFILL INJ INSULIN 30/70 INJ682008 02245182 NOVOLIN GE 40/60 INNOLET INJ INSULIN HUMAN BIOSYNTHETIC INJ682008 02024314 NOVOLIN GE 40/60 PENFILL INSULIN HUMAN/ISOPHANE 40/60 INJ682008 02245183 NOVOLIN GE 50/50 INNOLET INJ INSULIN HUMAN BIOSYNTHETIC INJ682008 02024322 NOVOLIN GE 50/50 PENFILL INSULIN HUMAN/ISOPHANE 50/50 INJ682008 02245177 NOVOLIN GE INNOLET INJ INSULIN HUMAN BIOSYNTHETIC 100U/ML INJ682008 02245178 NOVOLIN GE INNOLET INJ INSULIN HUMAN BIOSYNTHETIC 100U/ML INJ682008 02247308 NOVOLIN GE NPH FLEXPEN INSULIN ISOPHANE HUMAN BIOSYNT 100UNIT/ML INJ682008 02024225 NOVOLIN GE NPH INJ ISOPHANE 100 U INJ682008 99000334 NOVOLIN GE NPH INJ ISOPHANE 1000U/10ML INJ682008 02024268 NOVOLIN GE NPH PENFILL ISOPHANE 100 U INJ682008 09853782 NOVOLIN GE NPH PENFILL 100U/ML INSULIN 100U INJ682008 02247307 NOVOLIN GE TORONTO FLEXPEN INSULIN INJECTION HUMAN BIOSYN 100UNIT/ML INJ682008 00921130 NOVOLIN GE TORONTO INJ INSULIN REGULAR 100U/ML INJ682008 02024233 NOVOLIN GE TORONTO INJ INSULIN HUMAN 100 U INJ682008 02024284 NOVOLIN GE TORONTO PENFILL INSULIN HUMAN BIOSYNTHETIC 100 U INJ682008 09853774 NOVOLIN GE TORONTO PENFILL INSULIN HUMAN BIOSYNTHETIC 100 U INJ682008 02265435 NOVOMIX 30 PENFILL INSULIN ASPART 100UNIT/ML INJ682008 02245397 NOVORAPID 100IU/ML INJ 10ML INSULIN ASPART 100IU/ML INJ682008 02244353 NOVORAPID 100IU/ML INJ 5X3ML INSULIN ASPART 100IU/ML INJ682008 02377209 NOVORAPID FLEXTOUCH 100IU/ML INSULIN ASPART 100IU/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
236 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682020 02248008 SANDOZ GLYBURIDE 2.5MG TAB GLYBURIDE 2.5MG TAB682020 02248009 SANDOZ GLYBURIDE 5MG TAB GLYBURIDE 5MG TAB682020 01913670 TEVA‐GLYBURIDE TAB 2.5MG GLYBURIDE 2.5MG TAB682020 01913689 TEVA‐GLYBURIDE TAB 5MG GLYBURIDE 5MG TAB682020 02228920 TRIA‐GLYBURIDE 2.5MG TAB GLYBURIDE 2.5MG TAB682020 02228939 TRIA‐GLYBURIDE 5MG TAB GLYBURIDE 5 MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
238 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682028 02320762 ZYM‐PIOGLITAZONE 30MG TAB PIOGLITAZONE HCL 30MG TAB682028 02320770 ZYM‐PIOGLITAZONE 45MG TAB PIOGLITAZONE HCL 45MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
239 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682212 GLYCOGENOLYTIC AGENTS682212 02333619 GLUCAGEN 1MG/VIAL INJ GLUCAGON HCL 1MG/ML INJ682212 02333627 GLUCAGEN HYPOKIT 1MG/ML INJ GLUCAGON HCL 1MG/ML INJ682212 02243297 GLUCAGON 1MG/VIAL INJ GLUCAGON/RDNA ORIGIN 1MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
240 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682400 PARATHYROID682400 02247585 APO‐CALCITONIN NASAL SPRAY CALCITONIN (SALMON SYNTHETIC) 200IU/SPR NAS SPR682400 01926691 CALCIMAR 200IU/ML INJ CALCITONIN (SALMON SYNTHETIC) 200IU/ML INJ682400 02007134 CALTINE 100IU/ML INJ CALCITONIN (SALMON SYNTHETIC) 100UI/ML INJ682400 02254689 FORTEO 250MCG/ML TERIPARATIDE 250MCG/ML INJ PA (N)682400 01992880 MIACALCIN 100 UNIT/ML INJ CALCITONIN (SALMON SYNTHETIC) 100UNIT/ML INJ682400 02144301 MIACALCIN 200 UNIT/ML INJ CALCITONIN (SALMON SYNTHETIC) 200UNIT/ML INJ682400 02240775 MIACALCIN NAS SPR 200U/MD CALCITONIN (SALMON SYNTHETIC) 200U NAS SPR682400 02311046 PRO‐CALCITONIN 200IU NAS SPRAY CALCITONIN (SALMON SYNTHETIC) 200U/SPRAY NAS SPR682400 02233022 RHO‐CALCITONIN 200U/ML INJ CALCITONIN (SALMON SYNTHETIC) 200U/ML INJ682400 02261766 SANDOZ‐CALCITONIN NS 200U/SPR CALCITONIN (SALMON SYNTHETIC) 200U/SPRAY NAS SPR
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
241 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA682800 PITUITARY682800 02284030 APO‐DESMOPRESSIN 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 02284049 APO‐DESMOPRESSIN 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 02242465 APO‐DESMOPRESSIN 10MCG NAS SPR DESMOPRESSIN ACETATE 10MCG NAS SPR682800 02348209 APX‐DESMOPRESSIN 10MCG NAS SPR DESMOPRESSIN ACETATE 10MCG NAS SPR682800 02231515 BIO‐TROPIN 1.8MG/VIAL INJ SOMATROPIN 1.8MG/VIAL INJ PA (N)682800 02231516 BIO‐TROPIN 4.8MG/ VIAL INJ SOMATROPIN 4.8MG VIAL INJ PA (N)682800 00824305 DDAVP 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 00402516 DDAVP 0.1MG/ML NASAL SOL DESMOPRESSIN ACETATE 0.1MG/ML NAS SOL682800 00824143 DDAVP 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 00568325 DDAVP 4MCG/ML INJ DESMOPRESSIN ACETATE 4MCG/ML INJ682800 00873993 DDAVP INJ 4MCG/ML DESMOPRESSIN ACETATE 4MCG/ML INJ682800 02285002 DDAVP MELT 120MCG TAB DESMOPRESSIN ACETATE 120MCG TAB682800 02284995 DDAVP MELT 60MCG TAB DESMOPRESSIN ACETATE 60MCG TAB682800 00836362 DDAVP SPRAY NAS SOLUTION DESMOPRESSIN ACETATE 10MCG NAS SPR682800 02257696 DESMOPRESSIN 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 02346788 DESMOPRESSIN 0.1MG TAB DESMOPRESSIN ACETATE TRIHYD 0.1MG TAB682800 02257718 DESMOPRESSIN 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 02346796 DESMOPRESSIN 0.2MG TAB DESMOPRESSIN ACETATE TRIHYD 0.2MG TAB682800 02258706 DESMOPRESSIN NASAL SPRAY DESMOPRESSIN ACETATE 10MCG/ACT NAS SPR682800 02237193 GENTROPIN 1.5MG PWS INJ SOMATROPIN 1.5MG INJ PA (N)682800 02237192 GENTROPIN 13.8MG PWS INJ SOMATROPIN 13.8MG INJ PA (N)682800 02237195 GENTROPIN 13.8MG PWS INJ SOMATROPIN 13.8MG INJ PA (N)682800 02237191 GENTROPIN 5.8MG PWS INJ SOMATROPIN 5.8MG INJ PA (N)682800 02237194 GENTROPIN 5.8MG PWS INJ SOMATROPIN 5.8MG INJ PA (N)682800 02244003 GEREF 0.5MG/VIAL PDR FOR INJ SERMORELIN ACETATE 0.5MG/VIAL INJ PA (N)682800 02244004 GEREF 1MG/VIAL PDR FOR INJ SERMORELIN ACETATE 1MG/VIAL INJ PA (N)682800 02243078 HUMATROPE 12MG SOMATROPIN 12MG INJ PA (N)682800 00745626 HUMATROPE 1MG/ML INJ SOMATROPIN 1MG/ML INJ PA (N)682800 02243077 HUMATROPE 6MG CART SOMATROPIN 6MG INJ PA (N)682800 02243079 HUMATROPE INJ SOMATROPIN 24MG INJ PA (N)682800 02246500 MINIRIN 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 02246505 MINIRIN 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 02334860 NORDITROPIN NORDIFLEX 10MG/1.5 SOMATROPIN 10MG/1.5ML INJ PA (N)682800 02334879 NORDITROPIN NORDIFLEX 15MG/1.5 SOMATROPIN 15MG/1.5ML INJ PA (N)682800 02334852 NORDITROPIN NORDIFLEX 5MG/1.5M SOMATROPIN 5MG/1.5ML INJ PA (N)682800 02334941 NORDITROPIN SIMPLEXX 10MG/1.5M SOMATROPIN 10MG/1.5ML INJ PA (N)682800 02334968 NORDITROPIN SIMPLEXX 15MG/1.5M SOMATROPIN 15MG/1.5ML INJ PA (N)682800 02334925 NORDITROPIN SIMPLEXX 5MG/1.5ML SOMATROPIN 5MG/1.5ML INJ PA (N)682800 02287730 NOVO‐DESMOPRESSIN 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 02287749 NOVO‐DESMOPRESSIN 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 02336154 NU‐DESMOPRESSIN NASAL SPRAY DESMOPRESSIN ACETATE 10MCG NAS SPR682800 02216191 NUTROPIN 10MG/VIAL INJ SOMATROPIN 10MG/VIAL INJ PA (N)682800 02216183 NUTROPIN 5MG/VIAL IN SOMATROPIN 5MG/VIAL INJ PA (N)682800 02229722 NUTROPIN AQ 5MG/ML INJ SOMATROPIN 5MG/ML INJ PA (N)682800 02249002 NUTROPIN AQ PEN CARTRIDGE SOMATROPIN 10MG/2ML INJ PA (N)682800 02024179 OCTOSTIM 15MCG/ML INJ DESMOPRESSIN ACETATE 15MCG/ML INJ682800 02237860 OCTOSTIM NASAL SPRAY 1.5MG/ML DESMOPRESSIN ACETATE 1.5MG/ML NAS SOL682800 02325071 OMNITROPE 10MG/CARTRIDGE INJ SOMATROPIN 10MG/CART INJ PA (N)682800 02325055 OMNITROPE 5.8MG/VIAL PDR INJ SOMATROPIN 5.8MG/VIAL INJ PA (N)682800 02325063 OMNITROPE 5MG/CARTRIDGE INJ SOMATROPIN 5MG/CART INJ PA (N)682800 02304368 PMS‐DESMOPRESSIN 0.1MG TAB DESMOPRESSIN ACETATE 0.1MG TAB682800 02304376 PMS‐DESMOPRESSIN 0.2MG TAB DESMOPRESSIN ACETATE 0.2MG TAB682800 02237970 SAIZEN 1.33MG INJ SOMATROPIN 1.33MG INJ PA (N)682800 02215136 SAIZEN 10U/VIAL INJ SOMATROPIN 10U/VIAL INJ PA (N)682800 02350130 SAIZEN 12MG/CARTRIDGE INJ SOMATROPIN 8MG/ML INJ PA (N)682800 02350149 SAIZEN 20MG/CARTRIDGE INJ SOMATROPIN 8MG/ML INJ PA (N)682800 02283867 SAIZEN 4MG/VIAL INJ SOMATROPIN 4MG/VIAL INJ PA (N)682800 02350122 SAIZEN 6MG/CARTRIDGE INJ SOMATROPIN 5.83MG/ML INJ PA (N)682800 02248168 SAIZEN 8.8MG/VIAL INJ SOMATROPIN 8.8MG/VIAL INJ PA (N)682800 02272083 SAIZEN 8.8MG/VIAL INJ SOMATROPIN 8.8MG/VIAL INJ PA (N)682800 02283875 SAIZEN 8.8MG/VIAL INJ SOMATROPIN 8.8MG/VIAL INJ PA (N)682800 02237971 SAIZEN PWS 5MG INJ SOMATROPIN 5MG INJ PA (N)682800 02244373 SEROSTIM 4MG/VIAL INJ SOMATROPIN 4MG/VIAL INJ PA (N)682800 02239046 SEROSTIM 5MG INJ SOMATROPIN 5MG INJ PA (N)682800 02239047 SEROSTIM 6MG INJ SOMATROPIN 6MG INJ PA (N)682800 02248169 SEROSTIM 8.8MG/VIAL INJ SOMATROPIN 8.8MG/VIAL INJ PA (N)682800 02272075 SEROSTIM 8.8MG/VIAL INJ SOMATROPIN 8.8MG/VIAL INJ PA (N)682800 02271532 SEROSTIM LIQUID 6MG/0.5ML SC SOMATROPIN RDNA ORIGIN 6MG/0.5ML INJ PA (N)682800 00253952 SYNACTHEN DEPOT 1MG/ML INJ COSYNTROPIN ZINC HYDROXIDE 1MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
244 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA683608 ANTITHYROID AGENTS683608 02258935 APO‐METHIMAZOLE 5MG TAB THIAMAZOLE 5MG TAB683608 02265869 DOM‐METHIMAZOLE 5MG TAB THIAMAZOLE 5MG TAB683608 02265850 PHL‐METHIMAZOLE 5MG TAB THIAMAZOLE 5MG TAB683608 00010219 PROPYLTHYRACIL 100MG TAB PROPYLTHIOURACIL 100MG TAB683608 00010200 PROPYLTHYRACIL 50MG TAB PROPYLTHIOURACIL 50MG TAB683608 02296039 TAPAZOLE 10MG TAB THIAMAZOLE 10MG TAB683608 00015741 TAPAZOLE 5MG TAB THIAMAZOLE 5MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
245 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA760000 OXYTOCICS760000 02231593 DURATOCIN 100MCG/ML INJ CARBETOCIN 100MCG/ML INJ760000 02296144 ERGONOVINE 0.25MG/ML ERGONOVINE 0.25MG/ML INJ760000 01996096 ERGONOVINE 0.25MG/ML INJ ERGONOVINE 0.25MG/ML INJ760000 00497312 ERGONOVINE MALEATE INJ 0.25MG/ ERGONOVINE 0.25MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
247 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA800400 02226197 VENOMIL HONEY BEE VENOM INJ ALBUMIN/HONEY BEE VENOM PROTEI 120MCG INJ800400 02226294 VENOMIL MIXED VESPID VENOM INJ ALBMIN/WHTE FACD/YELL HORN/JAC 120MCG INJ800400 02226219 VENOMIL WASP VENOM PROTEIN INJ ALBUMIN/WASP VENOM PROTEIN 120MCG INJ800400 02226235 VENOMIL WHITE FACED HORNET INJ ALBUMIN/WHITE FACED HORNET VEN 120MCG INJ800400 02226286 VENOMIL YELLOW JACKET VNOM INJ ALBUMIN/YELLOW JACKET VENOM 120MCG INJ800400 99100026 VESPIDES COMBINES ALLERGENIC EXTRACT 3.9MG INJ800400 99100269 WASP OF THE EAST(VESPULA) ALLERGENIC EXTRACT 550MCG INJ800400 99100280 WASP OF THE EAST(VESPULA) ALLERGENIC EXTRACT 120MCG INJ800400 01948970 WASP VENOM PROTEIN 1.1MG/VIAL POLISTES SPP VENOM PROTEIN EXT 1.1MG INJ800400 02220091 WASP VENOM PROTEIN 550MCG INJ WASP VENOM PROTEIN 550MCG INJ800400 00541451 WASP VENOM PROTEIN INJ WASP VENOM PROTEIN INJ800400 02230864 WASP VENOM PROTEIN MULTIUSE ALLERGENIC EXTRACT 1300MCG INJ800400 01948997 WHITE FACED HORNET VENOM ALLERGENIC EXTRACT INJ800400 99100016 WHITE FACED HORNET VENOM ALLERGENIC EXTRACT 1.3MG INJ800400 99004607 WHITE HEAD HORNET ALLERGENIC EXTRACT 1.1MG INJ800400 99100266 WHITE HEAD HORNET ALLERGENIC EXTRACT 550MCG INJ800400 99100279 WHITE SPOTTED WASP ALLERGENIC EXTRACT 120MCG INJ800400 02217449 WINRHO SD 1500IU INJ IMMUNE GLOBULIN HUMAN 1500IU INJ800400 02217430 WINRHO SD 600IU INJ IMMUNE GLOBULIN HUMAN 600IU INJ800400 99004593 YELLOW HEAD HORNET ALLERGENIC EXTRACT 1.1MG INJ800400 99100267 YELLOW HEAD HORNET FRELON A TETE JAUNE 550MCG INJ800400 02220083 YELLOW HORNET VENOM 550MCG INJ YELLOW HORNET VENOM PROTEIN 550MCG INJ800400 01948946 YELLOW HORNET VENOM PROTEIN DOLICHOVESPULA ARENARIA PROTEI 120MCG INJ800400 01948938 YELLOW HORNET VENOM PWS 1.1MG ALLERGENIC EXTRACT 1.1MG/VIAL INJ800400 01948954 YELLOW JACKET VENOM PROTEIN YELLOW JACKET VENOM PROTEIN 100MCG/ML INJ800400 01948962 YELLOW JACKET VENOM PROTEIN VESPULA SPP VENOM PROTEIN EXTR 120MCG INJ800400 99100270 YELLOW WASP DOLICHOVESPULA ALLERGENIC EXTRACT 120MCG INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
248 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA800800 TOXOIDS800800 00900664 TETANUS /DEXTROSE PDR (PQ) TETANUS TOXOID INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
249 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840000 SKIN AND MUCOUS MEMBRANE AGENTS
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
250 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840404 ANTIBACTERIALS840404 02281074 ACZONE 5% GEL DAPSONE 5% GEL840404 02053128 ALTI‐CLINDAMYCIN 1% SOL CLINDAMYCIN PHOSPHATE 1% SOL840404 02126737 ALTI‐CLINDAMYCIN 20MG/G VAG CR CLINDAMYCIN PHOSPHATE 20MG/G CR VAG840404 02239757 BACTROBAN CREAM 2% MUPIROCIN CALCIUM 2% CR840404 02236776 BACTROBAN NASAL OINT 2% MUPIROCIN CA 2% OINT840404 01916947 BACTROBAN OINT 2% MUPIROCIN 2% OINT840404 02248472 BENZACLIN TOPICAL GEL CLINDAMYCIN PHOSPHATE/BENZOYL 1%/5% GEL840404 02225271 BENZAMYCIN GEL ERYTHROMYCIN/BENZOYL PEROXIDE 30‐50MG/G GEL840404 02359685 BIACNA 0.025%/1.2% TOPICAL GEL TRETINOIN/CLINDAMYCIN PHOSPHAT 0.025/1.2% GEL840404 00666173 CICATRIN POWDER BACITRACIN/NEOMYCIN/AMINO ACID PDR840404 02242970 CLINDASOL 1% CREAM CLINDAMYCIN PHOSPHATE 10MG/GM CR840404 02243659 CLINDA‐T 1% SOL CLINDAMYCIN PHOSPHATE 1% LIQ840404 02243050 CLINDETS PLEDGETS 1% PAD CLINDAMYCIN PHOSPHATE 1% PAD
840404 02382822 CLINDOXYL ADV 1.0/3.0% GEL CLINDAMYCIN PHOS/BENZOYL PEROX 1.0/3.0% GEL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
251 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840406 ANTIVIRALS840406 02245677 ABREVA 10% CREAM DOCOSANOL 10% CR840406 02238848 DENAVIR 1% CREAM PENCICLOVIR 1% CR840406 02237187 SANDOZ IDOXURIDINE 0.1% SOL IDOXURIDINE 0.1% LIQ840406 02039524 ZOVIRAX CR 5% ACYCLOVIR 5% CR840406 00569771 ZOVIRAX OINT 5% ACYCLOVIR 5% OINT
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
253 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840412 SCABICIDES AND PEDICULICIDES
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
254 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840492 MISCELLANEOUS LOCAL ANTI-INFECTIVES840492 01989499 AVC CREAM SULFANILAMIDE/AMINACRINE HCL CR840492 00370568 BENOXYL LOTION 10% BENZOYL PEROXIDE 10% LOT840492 00187585 BENOXYL LOTION 20% BENZOYL PEROXIDE 20% LOT840492 01912437 BENZAC AC GEL 10% BENZOYL PEROXIDE/ACRYLATES C 10% GEL840492 01925199 BENZAC W WASH GEL 10% BENZOYL PEROXIDE 10% GEL840492 00621056 BENZAC W10 GEL 10% BENZOYL PEROXIDE/WATER‐BASED 10% GEL840492 00426288 BENZAGEL 10 GEL 10% BENZOYL PEROXIDE/ALCOHOL BASE 10% GEL840492 00682055 CHLORHEXIDINE GLUCONATE 20% BP CHLORHEXIDINE GLUCONATE 20% LIQ840492 02053632 CHLORHEXIDINE GLUCONATE SOLN CHLORHEXEDINE GLUCONATE 20% LIQ840492 02010917 DERMAZIN 1% CREAM SILVER SULFADIAZINE 1% CR840492 00542040 DESQUAM X WASH 10% BENZOYL PEROXIDE 10% LIQ840492 00307572 DESQUAM X10 GEL BENZOYL PEROXIDE/WATER‐BASED 10% GEL840492 01908871 DESQUAM‐X GEL 10% BENZOYL PEROXIDE 10% GEL840492 00832030 DEXIDIN 20 SOLN 20MG CHLORHEXIDINE GLUCONATE 20% LIQ840492 00323098 FLAMAZINE CR 1% SILVER SULFADIAZINE 1% CR840492 02247035 NATURE'S CURE ACNE TREATMENT BENZOYL PEROXIDE 5% CR840492 00527661 PANOXYL 10 BAR BENZOYL PEROXIDE 10% BAR840492 00263699 PANOXYL 10 GEL BENZOYL PEROXIDE/ALCOHOL BASE 10% GEL840492 00373036 PANOXYL 20 GEL BENZOYL PEROXIDE/ALCOHOL BASE 20% GEL840492 00205389 PHISOHEX 3% EMULSION HEXACHLOROPHENE 3% EMUL840492 01928341 PHISOHEX 3% EMULSION HEXACHLOROPHENE 3% EMUL840492 02017733 PHISOHEX 3% LIQ HEXACHLOROPHENE 3% LIQ840492 02019825 SOLUGEL #8 BENZOYL PEROXIDE 8% GEL840492 00728799 STANHEXIDINE 2% LIQ CHLORHEXIDINE 2% LIQ840492 02215802 SULFAMYLON 8.5% CR MAFENIDE ACETATE 8.5% CR
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
258 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA840800 ANTIPRURITICS AND LOCAL ANESTHETICS840800 02004062 COCAINE 10% SOL COCAINE HCL 10% SOL840800 00454583 PHENAZO TAB 200MG PHENAZOPYRIDINE HCL 200MG TAB840800 02006308 PMS‐COCAINE 10% TOPICAL SOL COCAINE HCL 10% LIQ840800 02006316 PMS‐COCAINE 4% TOPICAL SOL COCAINE HCL 4% LIQ840800 01954210 PRAMOX HC LOTION PRAMOXINE/HC 1% LOT840800 00662461 RECTOGEL HC BENZOCAINE OINT840800 02142147 ZONALON 5% CR DOXEPIN HCL 5% CR
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
259 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA841600 CELL STIMULANTS AND PROLIFERANTS841600 02243914 RETIN‐A 0.1% MICRO GEL TRETINOIN MICROSPHERE 0.1% GEL841600 00897329 RETIN‐A CR 0.01% TRETINOIN 0.01% CR841600 00897310 RETIN‐A CR 0.025% TRETINOIN 0.025% CR841600 00443794 RETIN‐A CR 0.05% TRETINOIN 0.05% CR841600 00870021 RETIN‐A CR 0.1% TRETINOIN 0.1% CR841600 00532665 RETIN‐A CREAM 0.05% TRETINOIN 0.05% CR841600 00577278 RETIN‐A CRM 0.1% TRETINOIN 0.1% CR841600 00577251 RETIN‐A GEL 0.01% TRETINOIN 0.01% GEL841600 00870013 RETIN‐A GEL 0.01% TRETINOIN 0.01% GEL841600 00443816 RETIN‐A GEL 0.025% TRETINOIN 0.025% GEL841600 00532673 RETIN‐A GEL 0.025% TRETINOIN 0.025% GEL841600 02264633 RETIN‐A MICRO 0.04% GEL TRETINOIN 0.04% GEL841600 02008718 RETISOL A CR 0.05% TRETINOIN 0.05% CR841600 02008726 RETISOL A CR 0.1% FORTE TRETINOIN 2/7.5/0.1% CR841600 02008688 RETISOL‐A CR 0.01% TRETINOIN 0.01% CR841600 02008696 RETISOL‐A CR 0.025% TRETINOIN 0.025% CR841600 00578576 STIEVA A CR 0.025% TRETINOIN 0.025% CR841600 00662348 STIEVA A FORTE CR 0.1% TRETINOIN 0.1% CR841600 00578568 STIEVA A SOLUTION 0.025% TRETINOIN 0.025% LIQ841600 00657204 STIEVA‐A CR 0.01% TRETINOIN 0.01% CR841600 00518182 STIEVA‐A CR 0.05% TRETINOIN 0.05% CR841600 00587966 STIEVA‐A GEL 0.025% TRETINOIN 0.025% GEL841600 00641863 STIEVA‐A GEL 0.05% TRETINOIN 0.05% GEL841600 01926462 VITAMIN A ACID 0.01% GEL TRETINOIN 0.01% GEL841600 01926489 VITAMIN A ACID 0.05% GEL TRETINOIN 0.05% GEL841600 00805505 VITAMIN A ACID CR 0.01% TRETINOIN 0.01% CR841600 01926497 VITAMIN A ACID CR 0.01% TRETINOIN 0.01% CR841600 01926500 VITAMIN A ACID CR 0.025% TRETINOIN 0.025% CR841600 00493333 VITAMIN A ACID CR 0.05% TRETINOIN 0.05% CR841600 01936519 VITAMIN A ACID CR 0.05% TRETINOIN 0.05% CR841600 00673110 VITAMIN A ACID CR 0.1% TRETINOIN 0.1% CR841600 01926527 VITAMIN A ACID CR 0.10% TRETINOIN 0.1% CR841600 00590797 VITAMIN A ACID GEL 0.01% TRETINOIN 0.01% GEL841600 00673102 VITAMIN A ACID GEL 0.025% TRETINOIN 0.025% GEL841600 01926470 VITAMIN A ACID GEL 0.025% TRETINOIN 0.025% GEL841600 00419001 VITAMIN A ACID GEL 0.05% TRETINOIN 0.05% GEL
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
260 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA842800 KERATOLYTIC AGENTS842800 00800708 BICHLORACETIC ACID 1 DICHLOROACETIC ACID O/L842800 00589500 CANTHACUR PS CANTHARIDIN/SAL AC/PODOPHYLLIN LIQ842800 00772011 CANTHARONE PLUS CANTHARIDIN/SAL AC/PODOPHYLLIN LIQ842800 01945149 CONDYLINE 0.5% TOP SOL PODOFILOX 0.50% LIQ842800 02188708 PANOXYL CREAMY WASH 4 BENZOYL PEROXIDE 0.04 LIQ842800 00598208 PODOFILM LIQ 250MG/ML PODOPHYLLUM RESIN 25% LIQ842800 02220407 SULFACET‐R LOTION SULFACETAMIDE/SULFUR 5%‐10% LOT
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
261 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA845006 PIGMENTING AGENTS845006 00007269 OXSORALEN 10MG CAP METHOXSALEN 10MG CAP845006 01946374 OXSORALEN CAPSULES 10MG METHOXSALEN 10MG CAP845006 01907476 OXSORALEN LOTION 1% METHOXSALEN 10MG/ML LOT845006 00252654 OXSORALEN ULTRA CAP 10MG METHOXSALEN 10MG CAP845006 00698059 ULTRA MOP LOTION 1% METHOXSALEN 10MG/ML LOT845006 00646237 ULTRAMOP CAP 10MG METHOXSALEN 10MG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
262 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA849200 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS849200 02239505 ALDARA 50MG/G CREAM IMIQUIMOD 50MG/G CR849200 02259052 AMEVIVE 15MG/0.5ML IM INJ ALEFACEPT 15MG/.5ML INJ PA (N)849200 02258986 AMEVIVE 7.5MG/0.5ML IV INJ ALEFACEPT 7.5MG/.5ML INJ PA (N)849200 02243118 APTHERA 5% TOPICAL PASTE AMLEXANOX 5% MISC849200 02231592 DIFFERIN 0.1% CR ADAPALENE 0.10% CR849200 02148749 DIFFERIN 0.1% GEL ADAPALENE 0.10% GEL849200 02274000 DIFFERIN XP 0.3% GEL ADAPALENE 0.3% GEL849200 02244126 DOVOBET OINTMENT CALCIPOTRIOL/BETAMETHASONE OINT849200 02150956 DOVONEX 50MCG/G CR CALCIPOTRIOL 50MCG CR849200 01976133 DOVONEX 50MCG/G OINT CALCIPOTRIOL 50 MCG/G OINT849200 02194341 DOVONEX 50MCG/ML TOP SOL CALCIPOTRIOL 50MCG LIQ849200 00330582 EFUDEX CR 5% FLUOROURACIL 5% CR849200 02247238 ELIDEL 1% CR PIMECROLIMUS 1% CR849200 02270811 FINACEA 15% TOP GEL AZELAIC ACID 15% GEL849200 02243933 LEVULAN KERASTICK 20% TOP SOL AMINOLEVULINIC ACID HCL 20% LIQ849200 02323273 METVIX 168MG/G CR METHYL AMINOLEVULINATE HCL 168MG/G CR849200 02240328 PANRETIN 0.1% GEL ALITRETINOIN 0.1% GEL849200 02244148 PROTOPIC 1MG/G OINT TACROLIMUS 1MG/G OINT849200 02244149 PROTOPIC OINT (0.03%) TACROLIMUS 0.3MG/G OINT849200 02226383 RATIO‐PROCTOSONE OINT HC/FRAMYCETIN/ESCULIN/DIBUCAIN OINT849200 02070847 SORIATANE 10 MG CAP ACITRETIN 10MG CAP849200 02070863 SORIATANE 25 MG CAP ACITRETIN 25MG CAP849200 02243894 TAZORAC 0.05% CREAM TAZAROTENE 0.05% CR849200 02230784 TAZORAC 0.05% GEL TAZAROTENE 0.05% GEL849200 02243895 TAZORAC 0.1% CREAM TAZAROTENE 0.1% CR849200 02230785 TAZORAC 0.1% GEL TAZAROTENE 0.10% GEL849200 02337630 TOCTINO 10MG CAP ALITRETINOIN 10MG CAP PA (N)849200 02337649 TOCTINO 30MG CAP ALITRETINOIN 30MG CAP PA (N)849200 02178850 TRAVASE OINT SUTILAINS 82,00 OINT849200 02074788 WARTEC 0.5% SOL PODOFILOX (PODOPHYLLOTOXIN) 0.50% LIQ849200 02340445 ZYCLARA 3.75% CREAM IMIQUIMOD 3.75% CR
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
264 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA880400 VITAMIN A880400 00021067 VITAMIN A CAP 25000IU VITAMIN A 25000IU CAP880400 00021075 VITAMIN A CAP 50000IU VITAMIN A 50000IU CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
266 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA881600 VITAMIN D881600 00891738 CALCIJEX INJ 1MCG/ML CALCITRIOL 1MCG INJ881600 00891746 CALCIJEX INJ 2MCG/ML CALCITRIOL 2MCG INJ881600 02245686 CALCITRIOL 1MCG/ML INJ CALCITRIOL 1MCG/ML INJ881600 02237450 D‐FORTE 50000 UNIT CAP VITAMIN D 50000IU CAP881600 01928422 DRISDOL LIQ ERGOCALCIFEROL 8288IU/ML O/L881600 00821772 D‐TABS 10,000IU VITAMIN D 10000 TAB881600 02243790 HECTOROL 2.5MCG CAP DOXERCALCIFEROL 2.5MCG CAP881600 00474517 ONE ALPHA CAPS 0.25MCG ALFACALCIDOL 0.25MCG CAP881600 00474525 ONE ALPHA CAPS 1MCG ALFACALCIDOL 1MCG CAP881600 02239431 ONE‐ALPHA 0.5MCG CAP ALFACALCIDOL 0.5MCG CAP881600 02242502 ONE‐ALPHA 2MCG/ML INJ ALFACALCIDOL 2MCG/ML INJ881600 02240329 ONE‐ALPHA 2MCG/ML ORAL DROPS ALFACALCIDOL 2MCG/ML O/L881600 02301911 OSTOFORTE D2 50000IU CAP VITAMIN D 50000 IU CAP881600 00824291 ROCALTROL 1MCG/ML O/L CALCITRIOL 1UG/ML O/L881600 00481823 ROCALTROL CAP 0.25MCG CALCITRIOL 0.25MCG CAP881600 00481815 ROCALTROL CAP 0.5MCG CALCITRIOL 0.5MCG CAP
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
267 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA882400 VITAMIN K ACTIVITY882400 00804312 VITAMIN K1 INJ 10MG/ML USP PHYTONADIONE 10MG/ML INJ882400 00781878 VITAMIN K1 INJ 1MG/0.5ML USP PHYTONADIONE 2 MG/ML INJ
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
268 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA882800 MULTIVITAMIN PREPARATIONS882800 00556440 CAL MAG PLUS D TAB CALCIUM/MAGNESIUM/VIT D TAB882800 02238085 CALCIUM AND MAGNESIUM VIT D CALCIUM/MAGNESIUM/VITAMIN D CAP882800 02243706 CENTRUM 8390 150MCG TAB MULTI‐MINERAL W/BORON 150MCG TAB882800 02089521 LIQUID CALCIUM‐MAGNESIUM + D CALCIUM/MG OXIDE/VIT D2 O/L882800 00620351 NEO CAL D3 TAB CALCIUM CARBONATE/VITAMIN D3 TAB882800 00687782 O‐CALCIUM 250MG PLUS D CALCIUM/VITAMIN D 250MG TAB882800 02246067 PREGVIT PRENATAL VITAMIN TAB882800 02276194 PREGVIT FOLIC 5 TAB PRENATAL VITAMIN TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
270 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA920000 02320681 STELARA 90MG/ML INJ USTEKINUMAB 90MG/ML INJ PA (N)920000 00616419 TEGISON CAP 25MG ETRETINATE 25MG CAP920000 01949004 WHITE‐FACED HORNET VENOM 120UG DOLICHOVESPULA MACULATA VENOM INJ920000 02324032 XEOMIN 100 UNIT/VIAL INJ CLOSTRIDIUM BOTULINUM NEUROTOX 100UN/VIAL INJ PA (N)920000 00885533 YOHIMBINE 2MG TAB YOHIMBINE HCL 2MG TAB920000 01901885 YOHIMBINE 5.4MG TAB YOHIMBINE HCL 5.4MG TAB920000 01985604 YOHIMBINE 6MG TAB YOHIMBINE HCL 6MG TAB920000 02250519 ZAVESCA 100MG CAP MIGLISTAT 100MG CAP PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
271 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA920100 NATURAL HEALTH PRODUCTS920100 02209764 EGOZINC HC 0.5% OINT HC ACETATE/ZINC SULPHATE 0.50% OINT920113 02074087 PMS‐POTASSIUM GLUCONATE O/L POTASSIUM GLUCONATE 1.33MEQ/ML O/L920188 00575569 FLUOR A DAY 2.21MG TAB SODIUM FLOURIDE 2.21MG TAB920188 01939130 NIACIN 500MG TAB NIACIN 500MG TAB920188 00405264 NIACIN TAB 100MG NICOTINIC ACID 100MG TAB
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
275 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA922000 BIOLOGIC RESPONSE MODIFIERS922000 02237770 AVONEX 30MCG/VIAL IN A KIT INJ INTERFERON BETA 1A 30MCG/VIAL INJ PA (P)922000 09857395 AVONEX PEN 30MCG/0.5ML INTERFERON BETA‐1A 30MCG/0.5M INJ PA (P)922000 02269201 AVONEX PS 30MCG SYR. INTERFERON BETA 1A 30MCG/.5ML INJ PA (P)922000 02169649 BETASERON INJ INTERFERON 0.3MG INJ PA (P)922000 02331675 CIMZIA 200MG/ML INJ CERTOLIZUMAB PEGOL 200MG/ML INJ PA (N)922000 02245619 COPAXONE PREFILLED SYR 20MG/ML GLATIRAMER ACETATE 20MG/ML INJ PA (P)922000 02337819 EXTAVIA 0.3MG/VIAL INJ INTERFERON BETA‐1B 0.3MG/VIAL INJ922000 02338017 FERONA 0.3MG/VIAL INJ INTERFERON BETA‐1B 0.3MG/VIAL INJ922000 02365480 GILENYA 0.5MG CAP FINGOLIMOD HCL 0.5MG CAP PA (N)922000 02344939 ILARIS 150MG/VIAL INJ CANAKINUMAB 150MG INJ PA (N)922000 02318261 REBIF 132MCG/1.5ML INJ INTERFERON BETA‐1A 132MCG/1.5 INJ PA (P)922000 02237319 REBIF 22MCG (6MIU)/0.5ML INJ INTERFERON BETA 1A 22MCG INJ PA (P)922000 02237320 REBIF 44MCG (12MIU)/0.5ML INJ INTERFERON BETA 1A 44MCG INJ PA (P)922000 02237318 REBIF 44MCG (12MIU)/VIAL INJ INTERFERON BETA 1A 44MCG INJ PA (P)922000 02318253 REBIF 66MCG/1.5ML INJ INTERFERON BETA‐1A 66MCG INJ PA (P)922000 02277492 REBIF 8.8MCG/0.2ML INJ INTERFERON BETA‐1A 8.8MCG/0.2 INJ PA (P)922000 02318288 REBIF INIT PK 132MCG/1.5ML INJ INTERFERON BETA‐1A 132MCG/1.5 INJ PA (P)922000 02286386 TYSABRI 300MG/15ML INJ NATALIZUMAB 300MG/15ML INJ PA (N)
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
280 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA925600 PROTECTIVE AGENTS925600 02229691 MESNA 100MG/ML INJ MESNA 100MG/ML INJ925600 02244931 MESNA 100MG/ML INJ MESNA 100MG/ML INJ925600 02371839 UROMITEXAN 100MG/ML IV MESNA 100MG/ML INJ925600 02241411 UROMITEXAN 100MG/ML ORAL PWS MESNA 100MG/ML MISC
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
281 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA940000 DEVICES940000 00904910 NOVOLIN PEN SYRN INSULIN SYRINGE SYG940000 00963658 SAFE‐T‐PRO LANCETS LANCET LANCET940000 00901873 SYRINGE INSU LO DOSE MICRO 100 SYRINGE SYG940000 00895415 VENTOLIN+ROTAHALER SALBUTAMOL 0.4MG DEVICE
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
286 05/2012
DRUGS COVERED ON DTFTherapy Class DIN Drug Name Chemical Name Strength Dosage *PA940100 00963941 ULTICARE SYRINGES 29G 0.5CC SYRINGE 29X0.5CC SYG940100 00963895 ULTICARE SYRINGES 29G 1CC SYRINGE 29X1CC SYG940100 00964174 ULTICARE SYRINGES 30G 0.3CC SYRINGE 30X0.3CC SYG940100 00964115 ULTICARE SYRINGES 30G 0.5CC SYRINGE 30X0.5CC SYG940100 00964069 ULTICARE SYRINGES 30G 1CC SYRINGE 30X1CC SYG940100 00905114 ULTIG W ULTIC PEN NEED 29G NEEDLE NEEDLE940100 00905116 ULTIG W ULTIC PEN NEED 31G NEEDLE NEEDLE940100 00905108 ULTIGUARD INSULIN SYR 29G SYRINGE SYG940100 97799906 ULTIGUARD INSULIN SYR 29G.1CC SYRINGE SYG940100 97799908 ULTIGUARD INSULIN SYR 29G.3CC SYRINGE SYG940100 97799907 ULTIGUARD INSULIN SYR 29G.5CC SYRINGE SYG940100 00905110 ULTIGUARD INSULIN SYR 30G SYRINGE SYG940100 97799903 ULTIGUARD INSULIN SYR 30G.1CC SYRINGE SYG940100 97799905 ULTIGUARD INSULIN SYR 30G.3CC SYRINGE SYG940100 97799904 ULTIGUARD INSULIN SYR 30G.5CC SYRINGE SYG940100 00905112 ULTIGUARD INSULIN SYR 31G SYRINGE SYG940100 97799887 ULTRA 29G. 3/10CC SYRINGE SYG940100 97799888 ULTRA 29G.1/2CC SYRINGE SYG940100 97799889 ULTRA 29G.1CC SYRINGE SYG940100 00964441 ULTRA FINE II SYRINGE SYRINGE SYG940100 00999105 ULTRA‐FINE 0.5CC SYRINGE SYRINGE 0.5CC SYG940100 97799885 ULTRA‐FINE II 30G.1/2CC SYRINGE SYG940100 97799890 ULTRA‐FINE II 30G.1CC SYRINGE SYG940100 97799886 ULTRA‐FINE II 30G.3/10 CC SYRINGE SYG940100 00900141 ULTRA‐FINE II LANCETS LANCET LANCET940100 00977659 ULTRA‐FINE II LANCETS LANCET LANCET940100 00964360 ULTRA‐FINE II SHORT 0.5CC SYR SYRINGE SYG940100 00964301 ULTRA‐FINE II SHORT 1CC SYR SYRINGE SYG940100 00908428 ULTRA‐FINE LANCET/OSMOLITE LANCET LANCET940100 00962473 ULTRA‐FINE LANCETS LANCET LANCET940100 97799883 ULTRAFINE LANCETS 200 (NS) LANCET LANCET940100 97799991 UNFINE 31G.12MM NEEDLE NEEDLE940100 97799993 UNFINE 31G.6MM NEEDLE NEEDLE940100 97799992 UNFINE 31G.8MM NEEDLE NEEDLE940100 00964344 UNIFINE NEEDLES 29G NEEDLE NEEDLE940100 00964220 UNIFINE NEEDLES 31G NEEDLE NEEDLE940100 00964271 UNIFINE NEEDLES 31G NEEDLE NEEDLE940100 00977051 UNILET COMFORT TOUCH LANCETS LANCET LANCET940100 00977896 UNILET COMFORT TOUCH LANCETS LANCET LANCET940100 00984167 UNILET COMFORT TOUCH LANCETS LANCET LANCET940100 00962597 UNILET LANCETS LANCET LANCET940100 00985023 UNILET LANCETS LANCET LANCET940100 97799845 URIN‐TEK TUBE SETS W/O CUPS TUBE SET DEVICE940100 97799846 URIN‐TEK TUBE SETS W/O CUPS TUBE SET DEVICE
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
*Prior Authorization (PA) approval required for these drugs."PA (N)" ‐ PA required for all provinces."PA (P)" ‐ PA required for specific provinces only.Please refer to "Drugs That Require Prior Authorization" page for full listing.
290 05/2012
Drugs NOT on DTF (Tier 1) ALTERNATIVES to drugs not
covered
Alternative drugs that are covered may not be in the same drug class or interchangeable with non-covered drugs. Please note that the lists in this document are not meant to replace the advice of your Health Care Professional, but rather they are meant to provide general information about drug coverage. Drugs not covered on the DTF (Tier 1) may be covered on the secondary plan (Tier 2) as determined by the plan sponsor
This is a GENERIC formulary, so where there is a GENERIC that is considered interchangeable with the BRAND, only the cost of the GENERIC will be reimbursed. The GENERIC name will be listed in brackets beside the BRAND name if available. This list is subject to change upon review of new products or information. Please see plan administrator for specific drug coverage. List of Alternative Drugs is not a complete list. Please see plan administrator for details on specific drug coverage.
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change
TYLENOL WITH CODEINE 2, 3, OR 4 (ACETAMINOPHEN WITH CODEINE 2, 3, OR 4)
VOLTAREN (DICLOFENAC)
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012.
292 05/2012
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
296 05/2012
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
DRUGS NOT COVERED ALTERNATIVE DRUGS COVERED
EYE, EAR, NOSE & THROAT PREPARATIONS (includes solutions, sprays, ointments and gels)
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
297 05/2012
DRUGS NOT COVERED ALTERNATIVE DRUGS COVERED
GASTROINTESTINAL DRUGS (for stomach and intestinal disorders)
Proton Pump Inhibitors (gastric and duodenal ulcer)
Proton Pump Inhibitors (gastric and duodenal ulcer)
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
298 05/2012
DRUGS NOT COVERED ALTERNATIVE DRUGS COVERED
HORMONES AND SYNTHETIC SUBSTITUTES (for hormone replacement, including sex hormones, thyroid hormones, insulin hormones)
ZMAX SR BIAXIN (CLARITHROMYCIN) ERYC (ERYTHROMYCIN) ZITHROMAX (AZITHROMYCIN)
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
302 05/2012
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
303 05/2012
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
Product Document
www.esi-canada.com
®
®
Optimizing the
Value of
Health Benefits
Drugs Not Covered on DTF (Tier 1) with Alternatives
All are excluded except for alternatives listed. THYROGEN
Devices No Alternatives
Herbal Drugs No Alternatives
Vaccines No Alternatives
Antineoplastic Agents Antineoplastic Agents
METOJECT METHOTREXATE VIALS
The information listed in this document was correct at the time of posting. Every effort is made to ensure accuracy, although errors may occur. The information may change without notice. Updated May 30, 2012
304 05/2012
DTF Prior Authorization Drug List The following list indicates the drugs which require Prior Approval from your Employer/Insurance Company. Approval depends on whether specific criteria for using these drugs are met. Please see your plan administrator for details. Drugs requiring Prior Authorization
