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Ontario Drug Benefit Formulary/Comparative Drug Index

Edition 43

Summary of Changes – June 2020Effective June 30, 2020

Drug Programs Policy and Strategy BranchDrugs and Devices DivisionMinistry of Health

Visit Formulary Downloads: Edition 43

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Table of ContentsNew Single Source Products ........................................................................................... 3

New Multi-Source Products ............................................................................................. 5

New Off-Formulary Interchangeable (OFI) Products ..................................................... 19

New Nutrition Products .................................................................................................. 24

Temporary Benefits ....................................................................................................... 25

Drug Benefit Price (DBP) Changes ............................................................................... 26

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New Single Source Products DIN/PIN Brand Name Strength Dosage

Form Generic Name Mfr DBP

02344327 Clinoleic 20% 16% & 4% w/w

Inj Emuls-250mL Pk

OLIVE OIL & SOYBEAN OIL

BAX 25.0000/Bag

09858109 Clinoleic 20% 16% & 4% w/w

Inj Emuls-500mL Pk

OLIVE OIL & SOYBEAN OIL

BAX 30.0000/Bag

Reason For Use Code and Clinical Criteria

Code 579

As part of a parenteral nutrition regimen for adult patients when oral or enteral nutrition is not possible, insufficient, or contraindicated.

LU Authorization Period: Indefinite

New Single Source Products (Continued)

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DIN/PIN Brand Name Strength Dosage Form

Generic Name Mfr DBP

02470632 Triamcinolone Hexacetonide Injectable Suspension

20mg/mL 1mL-Amp Pk

TRIAMCINOLONEHEXACETONIDE

MDX 18.0000/Amp

Reason For Use Code and Clinical Criteria

Code 580

For intra-articular, intrasynovial, or periarticular use in adults and adolescents for the symptomatic treatment of subacute and chronic inflammatory joint diseases including:

o Rheumatoid arthritis o Juvenile Idiopathic Arthritis (JIA)* o Osteoarthritis and post-traumatic arthritis o Synovitis, tendinitis, bursitis and epicondylitis

*Note: triamcinolone hexacetonide injectable suspension may also be used as an intra-articular injection in children aged 3-12 years with Juvenile Idiopathic Arthritis.

LU Authorization Period: Indefinite

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New Multi-Source Products Where applicable, please consult the respective brand reference product’s drug profile on the ODB e-Formulary for the details of the Limited Use (LU) code and criteria, and/or any associated Therapeutic Notes (TN).

DIN/PIN Product Name Strength Dosage Form Mfr DBP 09857644 Apo-Travoprost-

Timop PQ 0.5% & 0.004% Oph Sol-5mL Pk APX 44.2125

(Interchangeable with DuoTrav PQ PIN 09857513 – LU. Apo-Travoprost-Timop is discontinued.)

New Therapeutic Note: This product is stable for 120 days after opening. Please refer to the product monograph for more information.

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02493055 Aspen-Dienogest 2mg Tab ASI 1.5346

(Interchangeable with Visanne – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02490617 Jamp Ondansetron 4mg/5mL Oral Sol (with

Preservative) JPC 1.1360/mL

(Interchangeable with Zofran – LU)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02489937 Jamp-Doxazosin 1mg Tab JPC 0.1719

(Interchangeable with Cardura-1 – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02489945 Jamp-Doxazosin 2mg Tab JPC 0.2062

(Interchangeable with Cardura-2 – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02489953 Jamp-Doxazosin 4mg Tab JPC 0.2681

(Interchangeable with Cardura-4 – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02447800 Jamp-Timolol 5mg/mL Oph Sol (with

Preservative) JPC 1.2145/mL

(Interchangeable with Timoptic – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02483556 Mint-Aripiprazole 2mg Tab MIN 0.8092 02483564 Mint-Aripiprazole 5mg Tab MIN 0.9046 02483572 Mint-Aripiprazole 10mg Tab MIN 1.0754 02483580 Mint-Aripiprazole 15mg Tab MIN 1.2692 02483599 Mint-Aripiprazole 20mg Tab MIN 1.0017 02483602 Mint-Aripiprazole 30mg Tab MIN 1.0017

(Interchangeable with Abilify – GB with TN)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02479680 NRA-Azithromycin 250mg Tab NRA 0.9410

(Interchangeable with Zithromax – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02479737 NRA-Celecoxib 100mg Cap NRA 0.1279 02479745 NRA-Celecoxib 200mg Cap NRA 0.2558

(Interchangeable with Celebrex – LU with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02482037 NRA-Clopidogrel 75mg Tab NRA 0.2631

(Interchangeable with Plavix – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02476851 NRA-Escitalopram 10mg Tab NRA 0.3109 02476878 NRA-Escitalopram 20mg Tab NRA 0.3310

(Interchangeable with Cipralex – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02481669 NRA-Ezetimibe 10mg Tab NRA 0.1811

(Interchangeable with Ezetrol – LU)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02477149 PMS-Atorvastatin 10mg Tab PMS 0.1743 02477157 PMS-Atorvastatin 20mg Tab PMS 0.2179 02477165 PMS-Atorvastatin 40mg Tab PMS 0.2342 02477173 PMS-Atorvastatin 80mg Tab PMS 0.2342

(Interchangeable with Lipitor – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02492725 Riva-Levofloxacin 250mg Tab RIA 1.2038 02492733 Riva-Levofloxacin 500mg Tab RIA 1.3718

(Interchangeable with Levaquin – GB)

DIN/PIN Product Name Strength Dosage Form

Mfr DBP

02494035 Sandoz Bisoprolol Tablets 5mg Tab SDZ 0.0715 02494043 Sandoz Bisoprolol Tablets 10mg Tab SDZ 0.1044

(Interchangeable with Monocor – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02497506 Taro-Clomipramine 25mg Cap TAR 0.3417 02497514 Taro-Clomipramine 50mg Cap TAR 0.6291

(Interchangeable with Anafranil – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02456753 Teva-Duloxetine 30mg DR Cap TEV 0.4814 02456761 Teva-Duloxetine 60mg DR Cap TEV 0.9769

(Interchangeable with Cymbalta – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02352966 Alendronate 70mg Tab SAI 2.1014 02299712 Alendronate 70mg Tab SIV 2.1014

(Interchangeable with Fosamax – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02467747 Atomoxetine 10mg Cap SAI 0.5106 02445883 Atomoxetine 10mg Cap SIV 0.5106 02467755 Atomoxetine 18mg Cap SAI 0.5748 02445905 Atomoxetine 18mg Cap SIV 0.5748 02467763 Atomoxetine 25mg Cap SAI 0.6420 02445913 Atomoxetine 25mg Cap SIV 0.6420 02467771 Atomoxetine 40mg Cap SAI 0.7369 02445948 Atomoxetine 40mg Cap SIV 0.7369 02467798 Atomoxetine 60mg Cap SAI 0.8092 02445956 Atomoxetine 60mg Cap SIV 0.8092

(Interchangeable with Strattera – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02400553 Clopidogrel 75mg Tab SAI 0.2631 02385813 Clopidogrel 75mg Tab SIV 0.2631

(Interchangeable with Plavix – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02443058 Dutasteride 0.5mg Cap SAI 0.3027 02429012 Dutasteride 0.5mg Cap SIV 0.3027

(Interchangeable with Avodart – LU)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02445077 Finasteride 5mg Tab SAI 0.4138 02447541 Finasteride 5mg Tab SIV 0.4138

(Interchangeable with Proscar DIN 02010909 – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02353164 Quetiapine 25mg Tab SAI 0.0494 02317893 Quetiapine 25mg Tab SIV 0.0494 02353172 Quetiapine 100mg Tab SAI 0.1318 02317907 Quetiapine 100mg Tab SIV 0.1318 02353199 Quetiapine 200mg Tab SAI 0.2647 02317923 Quetiapine 200mg Tab SIV 0.2647 02353202 Quetiapine 300mg Tab SAI 0.3863 02317931 Quetiapine 300mg Tab SIV 0.3863

(Interchangeable with Seroquel – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02354713 Venlafaxine XR 37.5mg ER Cap SAI 0.0913 02385929 Venlafaxine XR 37.5mg ER Cap SIV 0.0913 02354721 Venlafaxine XR 75mg ER Cap SAI 0.1825 02385937 Venlafaxine XR 75mg ER Cap SIV 0.1825 02354748 Venlafaxine XR 150mg ER Cap SAI 0.1927 02385945 Venlafaxine XR 150mg ER Cap SIV 0.1927

(Interchangeable with Effexor XR – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02442736 Anastrozole 1mg Tab SAI 0.9522

(Interchangeable with Arimidex – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02330881 Azithromycin 250mg Tab SAI 0.9410

(Interchangeable with Zithromax – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02459388 Fosinopril 10mg Tab SAI 0.2178 02459396 Fosinopril 20mg Tab SAI 0.2619

(Interchangeable with Monopril – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02443015 Galantamine ER 8mg ER Cap SAI 1.2465 02443023 Galantamine ER 16mg ER Cap SAI 1.2465 02443031 Galantamine ER 24mg ER Cap SAI 1.2465

(Interchangeable with Reminyl ER – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02287072 Gliclazide 80mg Tab SAI 0.0931

(Interchangeable with Diamicron – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02343010 Lamotrigine 25mg Tab SAI 0.0698 02343029 Lamotrigine 100mg Tab SAI 0.2787 02343037 Lamotrigine 150mg Tab SAI 0.4107

(Interchangeable with Lamictal – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02351668 Leflunomide 10mg Tab SAI 2.6433 02351676 Leflunomide 20mg Tab SAI 2.6433

(Interchangeable with Arava – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02353342 Levetiracetam 250mg Tab SAI 0.3210 02353350 Levetiracetam 500mg Tab SAI 0.3911 02353369 Levetiracetam 750mg Tab SAI 0.5416

(Interchangeable with Keppra – LU)

DIN/PIN Product Name Strength Dosage Form

Mfr DBP

02362945 Lisinopril/HCTZ (Type Z) 10mg & 12.5mg Tab SAI 0.2084 02362953 Lisinopril/HCTZ (Type Z) 20mg & 12.5mg Tab SAI 0.2504

(Interchangeable with Zestoretic – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02370689 Mirtazapine 30mg Tab SAI 0.3100

(Interchangeable with Remeron – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02348691 Omeprazole 20mg DR Cap SAI 0.2287

(Interchangeable with Losec DR Cap DIN 00846503 – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02421402 Ondansetron 4mg Tab SAI 3.2720 02421410 Ondansetron 8mg Tab SAI 4.9930

(Interchangeable with Zofran – LU)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02466147 Pantoprazole T 40mg Ent Coated Tab SAI 0.1875

(Interchangeable with Tecta – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02356511 Rabeprazole EC 10mg Ent Tab SAI 0.0669 02356538 Rabeprazole EC 20mg Ent Tab SAI 0.1338

(Interchangeable with Pariet – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02370255 Risedronate 35mg Tab SAI 1.9787

(Interchangeable with Actonel – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02353040 Ropinirole 0.25mg Tab SAI 0.0710

(Interchangeable with ReQuip – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02427117 Tamsulosin CR 0.4mg ER Tab SAI 0.1500

(Interchangeable with Flomax CR Tab – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02353121 Terbinafine 250mg Tab SAI 0.7714

(Interchangeable with Lamisil – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02356856 Topiramate 25mg Tab SAI 0.2433 02356864 Topiramate 100mg Tab SAI 0.4583 02356872 Topiramate 200mg Tab SAI 0.6748

(Interchangeable with Topamax – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02447576 Alfuzosin 10mg ER Tab SIV 0.2601

(Interchangeable with Xatral – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02385465 Amiodarone 200mg Tab SIV 0.3706

(Interchangeable with Cordarone – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02385791 Amlodipine 5mg Tab SIV 0.1343 02385805 Amlodipine 10mg Tab SIV 0.1993

(Interchangeable with Norvasc – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02411350 Atorvastatin-10 10mg Tab SIV 0.1743 02411369 Atorvastatin-20 20mg Tab SIV 0.2179 02411377 Atorvastatin-40 40mg Tab SIV 0.2342 02411385 Atorvastatin-80 80mg Tab SIV 0.2342

(Interchangeable with Lipitor – GB)

DIN/PIN Product Name Strength Dosage Form

Mfr DBP

02394812 Candesartan HCT 16mg & 12.5mg Tab SIV 0.2156 (Interchangeable with Atacand Plus – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02429675 Celecoxib 100mg Cap SIV 0.1279 02429683 Celecoxib 200mg Cap SIV 0.2558

(Interchangeable with Celebrex – LU with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02386119 Ciprofloxacin 250mg Tab SIV 0.4454 02386127 Ciprofloxacin 500mg Tab SIV 0.5025

(Interchangeable with Cipro – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02442469 Clarithromycin 250mg Tab SIV 0.4122

(Interchangeable with Biaxin BID – GB with TN)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02453630 Duloxetine 30mg DR Cap SIV 0.4814 02453649 Duloxetine 60mg DR Cap SIV 0.9769

(Interchangeable with Cymbalta – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02429039 Escitalopram 10mg Tab SIV 0.3109 02429047 Escitalopram 20mg Tab SIV 0.3310

(Interchangeable with Cipralex – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02246314 Gabapentin 100mg Cap SIV 0.0416 02246315 Gabapentin 300mg Cap SIV 0.1012 02246316 Gabapentin 400mg Cap SIV 0.1206

(Interchangeable with Neurontin – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02385287 Irbesartan 75mg Tab SIV 0.2281 02385295 Irbesartan 150mg Tab SIV 0.2281 02385309 Irbesartan 300mg Tab SIV 0.2281

(Interchangeable with Avapro – GB)

DIN/PIN Product Name Strength Dosage Form

Mfr DBP

02385317 Irbesartan HCT 150mg & 12.5mg Tab SIV 0.2281 02385325 Irbesartan HCT 300mg & 12.5mg Tab SIV 0.2281 02385333 Irbesartan HCT 300mg & 25mg Tab SIV 0.2184

(Interchangeable with Avalide – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02385767 Lansoprazole 15mg DR Cap SIV 0.5000 02410389 Lansoprazole 30mg DR Cap SIV 0.5000

(Interchangeable with Prevacid – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02388790 Losartan 25mg Tab SIV 0.3147 02388804 Losartan 50mg Tab SIV 0.3147 02388812 Losartan 100mg Tab SIV 0.3147

(Interchangeable with Cozaar – GB)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02382458 Montelukast 4mg Chew Tab SIV 0.2758

(Interchangeable with Singulair – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02385864 Olanzapine 2.5mg Tab SIV 0.1772 02385872 Olanzapine 5mg Tab SIV 0.3544 02385880 Olanzapine 7.5mg Tab SIV 0.5316 02385899 Olanzapine 10mg Tab SIV 0.7088 02385902 Olanzapine 15mg Tab SIV 1.0631

(Interchangeable with Zyprexa – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02428180 Pantoprazole-40 40mg DR Tab SIV 0.2016

(Interchangeable with Pantoloc – LU)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02309122 Pramipexole 0.25mg Tab SIV 0.1950 02309149 Pramipexole 1mg Tab SIV 0.3901 02309157 Pramipexole 1.5mg Tab SIV 0.3901

(Interchangeable with Mirapex – GB with TN. For 0.25mg, interchangeable with Mirapex PIN 09857268.)

New Multi-Source Products (Continued)

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DIN/PIN Product Name Strength Dosage Form Mfr DBP 02417359 Quetiapine XR 50mg ER Tab SIV 0.2501 02417367 Quetiapine XR 150mg ER Tab SIV 0.4926 02417375 Quetiapine XR 200mg ER Tab SIV 0.6661 02417383 Quetiapine XR 300mg ER Tab SIV 0.9776 02417391 Quetiapine XR 400mg ER Tab SIV 1.3270

(Interchangeable with Seroquel XR – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02411628 Rosuvastatin 5mg Tab SIV 0.1284 02411636 Rosuvastatin 10mg Tab SIV 0.1354 02411644 Rosuvastatin 20mg Tab SIV 0.1692 02411652 Rosuvastatin 40mg Tab SIV 0.1990

(Interchangeable with Crestor – GB)

DIN/PIN Product Name Strength Dosage Form Mfr DBP 02386070 Sertraline 25mg Cap SIV 0.1516 02386089 Sertraline 50mg Cap SIV 0.3032 02386097 Sertraline 100mg Cap SIV 0.3303

(Interchangeable with Zoloft – GB with TN)

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New Off-Formulary Interchangeable (OFI) Products DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02479419 Myl-Esomeprazole 20mg DR Tab MYL 1.8690 02479427 Myl-Esomeprazole 40mg DR Tab MYL 1.8690

(Interchangeable with Nexium)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02489821 NRA-Montelukast 10mg Tab NRA 1.7735

(Interchangeable with Singulair)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02495422 Flexeril 10mg Tab ORI 0.3765

(Interchangeable with Flexeril)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02456257 Sandoz Miglustat 100mg Cap SDZ 92.2723

(Interchangeable with Zavesca)

New Off-Formulary Interchangeable (OFI) Products (Continued)

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DIN/PIN Brand Name Strength Dosage Form

Mfr DBP

02496410 Taro-Clotrimazole/ Betamethasone Dipropionate

1% w/w & 0.05% w/w

Top Cr TAR 1.0578/g

(Interchangeable with Lotriderm Cream)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02445085 Finasteride 1mg Tab SAI 1.1453 02447568 Finasteride 1mg Tab SIV 1.1455

(Interchangeable with Propecia)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02443082 Memantine 10mg Tab SAI 1.6357 02446049 Memantine 10mg Tab SIV 1.6357

(Interchangeable with Ebixa)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02379333 Montelukast 10mg Tab SAI 1.7735 02382474 Montelukast 10mg Tab SIV 1.7735

(Interchangeable with Singulair)

New Off-Formulary Interchangeable (OFI) Products (Continued)

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DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02466821 Almotriptan 12.5mg Tab SAI 9.7833

(Interchangeable with Axert)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02467801 Atomoxetine 80mg Cap SAI 3.9960 02467828 Atomoxetine 100mg Cap SAI 4.3520

(Interchangeable with Strattera)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02466449 Betahistine 16mg Tab SAI 0.3557 02466457 Betahistine 24mg Tab SAI 0.4983

(Interchangeable with Serc)

DIN/PIN Brand Name Strength Dosage Form

Mfr DBP

02362961 Lisinopril/HCTZ (Type Z) 20mg & 25mg Tab SAI 0.7011 (Interchangeable with Zestoretic)

New Off-Formulary Interchangeable (OFI) Products (Continued)

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DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02353385 Metformin 850mg Tab SAI 0.2090

(Interchangeable with Glucophage)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02286521 Sumatriptan 50mg Tab SAI 9.0650 02286548 Sumatriptan 100mg Tab SAI 9.9867

(Interchangeable with Imitrex)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02442485 Clarithromycin 500mg Tab SIV 2.2009

(Interchangeable with Biaxin BID)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02442493 Esomeprazole 20mg DR Tab SIV 1.8690 02442507 Esomeprazole 40mg DR Tab SIV 1.8690

(Interchangeable with Nexium)

New Off-Formulary Interchangeable (OFI) Products (Continued)

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DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02382466 Montelukast 5mg Chew Tab SIV 1.2075

(Interchangeable with Singulair)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02428172 Pantoprazole-20 20mg DR Tab SIV 1.2750

(Interchangeable with Pantoloc)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02309130 Pramipexole 0.5mg Tab SIV 1.3860

(Interchangeable with Mirapex)

DIN/PIN Brand Name Strength Dosage Form Mfr DBP 02385570 Sumatriptan DF 50mg Tab SIV 9.0650 02385589 Sumatriptan DF 100mg Tab SIV 9.9866

(Interchangeable with Imitrex DF)

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New Nutrition Products H. PEDIATRIC FORMULA, OTHERS MAXIMUM = N/A

Brand Name

Strength, Dosage Form, Package Size

PIN/NPN Mfr Cost ($) Per 1000 Kcal

Cost ($) Per Pkg

Amt ($) MOH Pays

Amt ($) Patient Pays

KetoVie 4:1 1.56kcal/mL, Liq-Chocolate Flavour, 250mL Pk

09858117 CAM 16.78 6.55 6.5451 0.00

KetoVie 4:1 1.44kcal/mL, Liq- Vanilla Flavour, 250mL Pk

09858118 CAM 18.18 6.55 6.5451 0.00

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Temporary Benefits DIN/PIN Brand Name Strength Dosage

Form Generic Name Mfr DBP

09858116 Salbutamol Aldo-Union

100mcg/ Metered Dose

Inh-200 Dose Pk

SALBUTAMOL SULFATE

JPC 8.7500

01964968 PMS-Dexamethasone

0.75mg Tab DEXAMETHASONE PMS 0.6763

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Drug Benefit Price (DBP) Changes DIN/PIN Brand Name Strength Dosage Form Mfr DBP/Unit

Price 02291967 Ondansetron 4mg/5mL O/L AAP 1.1360 02240588 Apo-Doxazosin 1mg Tab APX 0.1719 02240589 Apo-Doxazosin 2mg Tab APX 0.2062 02240590 Apo-Doxazosin 4mg Tab APX 0.2681 02474565 Lapelga 10mg/mL Inj Sol-Pref Syr -

0.6mL Pk (Preservative Free)

APX 1600.0000

02242728 Teva-Doxazosin 1mg Tab TEV 0.1719 02242729 Teva-Doxazosin 2mg Tab TEV 0.2062 02242730 Teva-Doxazosin 4mg Tab TEV 0.2681

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