UPDATE AG: Ontario Drug Benefit … Page 1 UPDATE AG Ontario Drug Benefit Formulary/Comparative Drug...

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Page 1

UPDATE AG

Ontario Drug Benefit

Formulary/Comparative Drug Index

No. 41

Effective April 24, 2012

SUMMARY OF CHANGES

TABLE OF CONTENTS

New Single Source Drug(s) 2 New Multi-Source Drug(s) 4 Off Formulary Interchangeable Product(s) 7 Manufacturer Requested Discontinued Drug(s) 8 New Drug Identification Number(s) 9 Drug Benefit Price(s) 10 New Manufacturer Name(s) 21 Therapeutic Note Change(s) 22 Trade Name Change(s) 23 Index 24

Continued on the next page:

Page 2

New Single Source Drug(s)

DIN PRODUCT GENERIC NAME MFR DBP

02312441 Pradax 110mg Cap DABIGATRAN ETEXILATE BOE 1.6000

02358808 Pradax 150mg Cap

Reason for Use Code Clinical Criteria

431 For the prevention of stroke and systemic embolism in at risk patients with non-valvular atrial fibrillation (AF), AND in whom:

1) Anticoagulation is inadequate following a reasonable trial on warfarin; OR

2) Anticoagulation with warfarin is contraindicated or not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy, and at home).

Exclusion Criteria: Impaired renal function (creatinine clearance or estimated glomerular filtration rate less than 30mL/min); OR greater than or equal to 75 years of age without documented stable renal function; OR hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis; OR prosthetic heart valves.

Note:

(a) Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate maintained for at least 3 months (i.e., 30-49mL/min for 110mg twice daily dosing and, greater than or equal to 50mL/min for 150mg twice daily dosing for at least 3 months).

(b) At risk patients with atrial fibrillation are defined as those with a CHADS2 score of greater than or equal to 1.

(c) Inadequate anticoagulation is defined as INR testing results that are outside of the desired INR range for at least 35% of the tests during the monitoring period (i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period).

DABIGATRAN ETEXILATE BOE 1.6000

DIN PRODUCT GENERIC NAME MFR DBP

Continued from the previous page Reason for Use Code

Clinical Criteria

Note:

Page 3

(d) A reasonable trial on warfarin is defined as at least 2 months of therapy.

(e) Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see product monograph).

(f) Patients starting dabigatran should have ready access to appropriate medical services to manage a major bleeding event.

(g) There are currently no data to support that dabigatran provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart valves; dabigatran is not recommended in these populations.

LU Authorization Period: Indefinite

02357615 Vimpat 50mg Tab LACOSAMIDE UCB 2.3200



02357658 Vimpat 200mg Tab

Reason for Use Code

Clinical Criteria

430 As adjunctive therapy in the treatment of adult patients with partial onset seizures who have had an inadequate response or have significant intolerance to at least 3 less costly anticonvulsant therapies; AND Patients are under the care of a physician experienced in the treatment of epilepsy.

Note: Less costly anticonvulsant therapies may include the following: Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc.

LU Authorization Period: Indefinite.

LACOSAMIDE UCB 5.3200

Page 4

New Multi-Source Drug(s)

DIN BRAND STRENGTH DOSAGE FORM MFR DBP

02347245 Auro-Cefprozil 250mg Tab AUR 0.4332

02347253 Auro-Cefprozil

(Interchangeable with Cefzil)

500mg Tab AUR 0.8494

02379996 Co Mycophenolate

(Interchangeable with Cellcept)

Reason for Use Code

Clinical Criteria

190 For the prophylaxis of organ rejection in patients receiving allogeneic renal, cardiac or hepatic transplants.

LU Authorization Period: Indefinite.

500mg Tab COB 1.0310

02379120 Mylan-Candesartan 4mg Tab MYL 0.1700



02379155 Mylan-Candesartan

(Interchangeable with Atacand)

32mg Tab MYL 0.2932

02380749 Mylan-Montelukast

(Interchangeable with Singulair)

Reason for Use Code

Clinical Criteria

382 For the treatment of asthma in patients aged 2-5 years old.

LU Authorization Period: 1 Year.

4mg Chew Tab MYL 0.3646


Page 5

02373564 Mylan-Telmisartan HCTZ 80mg & 12.5mg Tab MYL 0.2824

02373572 Mylan-Telmisartan HCTZ

(Interchangeable with Micardis Plus)

80mg & 25mg Tab MYL 0.2824

02380072 Ran-Venlafaxine XR 37.5mg ER Cap RAN 0.2206

02380080 Ran-Venlafaxine XR 75mg ER Cap RAN 0.4412

02380099 Ran-Venlafaxine XR

(Interchangeable with Effexor XR)

150mg ER Cap RAN 0.4658

02377950 Teva-Galantamine ER 8mg ER Cap TEV 1.2465

02377969 Teva-Galantamine ER 16mg ER Cap TEV 1.2465

02377977 Teva-Galantamine ER

(Interchangeable with Reminyl ER)

Reason for Use Code Clinical Criteria

347 Initial Trial: For patients with mild to moderate Alzheimer's Disease (Mini-Mental State Exam [MMSE] 10-26). Patients will be reimbursed for a period of up to 3 months after which continued treatment must be reassessed.

Network note: Maximum duration 3 months.

LU Authorization Period: 1 year.

348 Continuation: Further reimbursement will be made available to those patients whose disease has not progressed/deteriorated while on this drug. Patients must continue to have a MMSE score of 10-26.

LU Authorization Period: 1 year.

24mg ER Cap TEV 1.2465


Page 6

02380838 Teva-Losartan

(Interchangeable with Cozaar)

25mg Tab TEV 0.3148

02330288 Teva-Telmisartan HCTZ 80mg & 12.5mg Tab TEV 0.2824

02379252 Teva-Telmisartan HCTZ

(Interchangeable with Micardis Plus)

80mg & 25mg Tab TEV 0.2824

Page 7

Off Formulary Interchangeable Product(s)

DIN BRAND STRENGTH

DOSAGE

FORM MFR UNIT COST

02375249 Auro-Levetiracetam 250mg Tab AUR 0.8000

02375257 Auro-Levetiracetam 500mg Tab AUR 0.9750

02375265 Auro-Levetiracetam

(Interchangeable with Keppra)

750mg Tab AUR 1.3500

02128187 Cefoxitin for Injection USP 1g/Vial Inj Pd-Vial Pk NOP 10.6000

02128195 Cefoxitin for Injection USP

(Interchangeable with Mefoxin)

2g/Vial Inj Pd-Vial Pk NOP 21.2500

02380757 Mylan-Montelukast

(Interchangeable with Singulair)

5mg Chew Tab MYL 1.2075

02380927 Teva-Atovaquone Proguanil

(Interchangeable with Malarone)

250mg & 100mg Tab TEV 4.0462

Page 8

Manufacturer Requested Discontinued Drug(s) Please note that these discontinued products will remain on the formulary until the current stock is

depleted.

DIN BRAND STRENGTH DOSAGE FORM MFR

00027898 Celestoderm-V/2 0.05% Cr SCH

00027901 Celestoderm-V 0.1% Cr SCH

00028355 Celestoderm-V/2 0.05% Oint SCH

00028363 Celestoderm-V 0.1% Oint SCH

02260883 Ratio-Gabapentin 100mg Cap RPH

02260891 Ratio-Gabapentin 300mg Cap RPH

02308681 Ratio-Pantoprazole 20mg Tab RPH

02308703 Ratio-Pantoprazole 40mg Tab RPH

02287714 Ratio-Ramipril Cap 5mg Cap RPH



02245787 Ratio-Sertraline 25mg Cap RPH



02247069 Ratio-Simvastatin 20mg Tab RPH

02140047 Ratio-Valproic 250mg Cap RPH

Page 9

New Drug Identification Number(s)


02357860 Celestoderm-V/2 0.05% Cr SCH

02357844 Celestoderm-V 0.1% Cr SCH

02357879 Celestoderm-V/2 0.05% Oint SCH

02357852 Celestoderm-V 0.1% Oint SCH

Page 10

Drug Benefit Price(s)

DIN BRAND STRENGTH DOSAGE

FORM

MFR DBP

01947664 Accupril 5mg Tab PFI 0.8977




02237367 Accuretic 10mg & 12.5mg Tab PFI 0.8975

02237368 Accuretic 20mg & 12.5mg Tab PFI 0.8975

02242518 Actonel 5mg Tab WAR 1.8800

02239146 Actonel 30mg Tab WAR 12.1800

02242572 Actos 15mg Tab TAK 2.4532

02242573 Actos 30mg Tab TAK 3.4369

02242574 Actos 45mg Tab TAK 5.1677

02236974 Alesse 20mcg & 100mcg Tab-21 Pk WAY 14.7600

02236975 Alesse 20mcg & 100mcg Tab-28 Pk WAY 14.7600

00004715 Alkeran 2mg Tab TRT 1.6002

00893560 Alomide 0.1% Oph Sol ALC 1.0727

02221829 Altace Cap 1.25mg SAV 0.7077

02221837 Altace Cap 2.5mg SAV 0.8167

02221845 Altace Cap 5mg SAV 0.8167

02221853 Altace Cap 10mg SAV 1.0343

02283166 Altace HCT 10mg & 12.5mg Tab SAV 0.4875

02283182 Altace HCT 10mg & 25mg Tab SAV 0.4875

02285606 Alvesco 100mcg/Actuation Inh-120 Dose Pk NYC 44.5600

02285614 Alvesco 200mcg/Actuation Inh-120 Dose Pk NYC 73.6600

02221861 Anandron 50mg Tab SAV 2.0716

02239653 Androderm 12.2mg Transdermal Patch PAL 2.0320

02231379 Anzemet 100mg Tab SAV 29.1580

02294346 Apidra 100U/mL Inj Sol-5x3mL

SoloSTAR Pref Pen

SAV 49.0000

02279460 Apidra 100U/mL Inj Sol-10mL Vial SAV 24.5000

02279479 Apidra 100U/mL Inj 5x3mL Cart

ClickStar Pen

SAV 48.4500

02087324 Apo-Bromocriptine 2.5mg Tab APX 0.9782

02230454 Apo-Bromocriptine 5mg Cap APX 1.4644

00521698 Apo-Flurazepam 15mg Cap APX 0.1166

00521701 Apo-Flurazepam 30mg Cap APX 0.1364

02267640 Apo-Medroxy 100mg Tab APX 1.2057

02317192 Apri 21 0.15mg & 0.03mg Tab-21 Pk APX 11.4200

02317206 Apri 28 0.15mg & 0.03mg Tab-28 Pk APX 11.4200

09857185 Aranesp 200mcg/0.4mL Pref Syr-0.4mL Pk AMG 560.9300



02241888 Arava 10mg Tab SAV 10.9043

02241889 Arava 20mg Tab SAV 10.9093

02245531 Arixtra 2.5mg Inj-0.5mL Pk GSK 15.7561

02242705 Aromasin 25mg Tab PFI 5.2010


FORM

MFR DBP

Page 11

01917056 Arthrotec 50 50mg & 200mcg Tab PFI 0.6054

02229837 Arthrotec 75 75mg & 200mcg Tab PFI 0.8239

01997580 Asacol 400mg Tab WAR 0.5440

02267217 Asacol 800mg Tab WAR 1.0410

02239090 Atacand 4mg Tab AZC 0.7120




02244021 Atacand Plus 16mg/12.5mg Tab AZC 1.1980

02332922 Atacand Plus 32mg & 12.5mg Tab AZC 1.1980

02332957 Atacand Plus 32mg & 25mg Tab AZC 1.1980

02300699 Atripla 600mg/300mg/200mg Tab BQU 41.4000

02241818 Avalide 150 & 12.5mg Tab SAV 1.2671

02241819 Avalide 300 & 12.5mg Tab SAV 1.2671

02237923 Avapro 75mg Tab SAV 1.2671

02237924 Avapro 150mg Tab SAV 1.2671

02237925 Avapro 300mg Tab SAV 1.2671

00294926 Benuryl 500mg Tab VAL 0.5280

02248472 BenzaClin 1% & 5% Top Gel SAV 0.8918

02060884 Betnesol 5mg/100mL Enema-100mL Pk PAL 9.7514

01908448 Betoptic S 0.25% Oph Susp ALC 2.3000

02277166 Biphentin 10mg ER Cap PFP 0.6850








00786616 Bricanyl Turbuhaler 0.5mg/Dose Inh-200 Dose Pk AZC 15.2800

00265470 C.E.S. 0.625mg Tab VAL 0.0807

00176095 Cafergot 1mg & 100mg Tab NOV 0.8930

01926691 Calcimar 400IU/2mL Inj Sol-2mL Pk SAV 55.2500

00461733 Carbolith 150mg Cap VAL 0.1171

00236683 Carbolith 300mg Cap VAL 0.0924

02097249 Cardizem CD 120mg LA Cap BIO 1.5177




02184478 Casodex 50mg Tab AZC 6.7700

00360430 CeeNU 10mg Cap BQU 6.6758

00360422 CeeNU 40mg Cap BQU 11.5092

00360414 CeeNU 100mg Cap BQU 19.0026

02212277 Ceftin 250mg Tab GSK 1.6527

02212285 Ceftin 500mg Tab GSK 3.2740

02163675 Cefzil 125mg/5mL Oral Susp-75mL Pk BQU 13.3100





FORM

MFR DBP

Page 12

02163659 Cefzil 250mg Tab BQU 1.8159

02163667 Cefzil 500mg Tab BQU 3.5604

02239941 Celebrex 100mg Cap PFI 0.6829

02239942 Celebrex 200mg Cap PFI 1.3659

01926683 Cerubidine Inj Pd-20mg Pk ERF 90.2000

02291177 Champix 0.5mg Tab PFI 1.7205

02291185 Champix 1.0mg Tab PFI 1.7204

02298309 Champix 0.5mg & 1.0mg Tabs (Starter Pack) PFI 43.0200

02263238 Cipralex 10mg Tab VLH 1.6933

02263254 Cipralex 20mg Tab VLH 1.8027

02243158 Clindoxyl 1% & 5% Gel STI 0.9064

02285215 Co Cilazapril 2.5mg Tab COB 0.1795

02285223 Co Cilazapril 5mg Tab COB 0.2085

02270641 Co Clonazepam 0.5mg Tab COB 0.0495

02270676 Co Clonazepam 2mg Tab COB 0.0854

02270633 Co Sotalol 160mg Tab COB 0.1623

02244814 Co Temazepam 15mg Cap COB 0.0438

02244815 Co Temazepam 30mg Cap COB 0.0526

02230302 Codeine Contin 50mg CR Tab PFP 0.3175




02132699 Colestid Orange Gran-7.5g Pk PFI 0.9093

02243763 Comtan 200mg Tab NOV 1.6248

00579335 Cortifoam 10% Rect Aero-15g Pk PAL 85.4700

01912828 Cortisporin 10000U & 5mg &

10mg/mL

Ot Sol GSK 1.3079

01918311 Coumadin 1mg Tab BQU 0.3395


01918346 Coumadin 2.5mg Tab BQU 0.2872





02192284 Cyclocort 0.1% Cr STI 0.4234

02192276 Cyclocort 0.1% Lot STI 0.3516

02192268 Cyclocort 0.1% Oint STI 0.4234

02018144 Cyclomen 50mg Cap SAV 0.9047



02301482 Cymbalta 30mg DR Cap LIL 1.8768

02301490 Cymbalta 60mg DR Cap LIL 3.7536

02162695 Cytovene 500mg/Vial Pd Inj-10mL Pk HLR 42.0380

02138018 Demerol 50mg Tab SAV 0.1503

00030848 Depo-Provera 50mg/mL Inj Sol-5mL Pk PFI 26.6900

00585092 Depo-Provera 150mg/mL Inj PFI 27.5420

02239064 Detrol 1mg Tab PFI 0.9542

02239065 Detrol 2mg Tab PFI 0.9542

02244612 Detrol LA 2mg SR Cap PFI 1.9083


FORM

MFR DBP

Page 13

02244613 Detrol LA 4mg SR Cap PFI 1.9083

01924516 Dexedrine 5mg Tab PAL 0.6379

02224550 Diabeta 2.5mg Tab SAV 0.1337

02224569 Diabeta 5mg Tab SAV 0.2393

02238162 Diastat 5mg/mL Rect Gel-2x 5mg Pk VAL 146.4500

09853340 Diastat 5mg/mL Rect Gel-2x10mg Pk VAL 146.4500

09853430 Diastat 5mg/mL Rect Gel-2x15mg Pk VAL 146.4500

00609129 Diclectin 10mg & 10mg SR Tab DUI 1.2471

02176017 Didrocal 400mg/500mg Tab-90 Tablets Kit WAR 44.4800

01947958 Duvoid 10mg Tab PAL 0.2858



00330582 Efudex 5% Cr VAL 0.8350

02213192 Eltroxin 0.05mg Tab TRT 0.0288




00192597 Emo-Cort 1% Cr STI 0.1713

00192600 Emo-Cort 1% Lot STI 0.1583

00595799 Emo-Cort 2.5% Cr STI 0.1990

00595802 Emo-Cort 2.5% Lot STI 0.2093

02242903 Enbrel 25mg/Vial Inj Pd-Vial Pk IMU 189.4150

02274728 Enbrel 50mg/mL Inj Pref Syr IMU 378.9425

09857394 Enbrel SureClick 50mg/mL Pref AutoInj IMU 378.9425

02168898 Estring 2mg Vag Ring PFI 64.6200

00247960 Etibi 100mg Tab VAL 0.1015

00247979 Etibi 400mg Tab VAL 0.2830

02239028 Evista 60mg Tab LIL 1.8804

02287420 Exjade 125mg Tab for Susp NOV 10.4233



02177102 Famvir 500mg Tab NOV 6.9661

02231384 Femara 2.5mg Tab NOV 6.0747

01926853 Flagyl 500mg Cap SAV 0.9942

01926861 Flagyl 10% Vag Cr-App SAV 0.2322

01926829 Flagystatin 500mg & 100000U Vag Sup SAV 3.1230

01926845 Flagystatin 500mg & 100000U/g Vag Cr-App SAV 0.5678

00756784 Flarex 0.1% Oph Susp ALC 1.8209

02086026 Florinef 0.1mg Tab PAL 0.2530

02230898 Foradil 12mcg/Cap Inh Pd-Device Pk NOV 50.5300

02287145 Fosrenol 250mg Chew Tab SHI 1.0748




00029149 Fungizone Inj Pd-50mg Pk BQU 75.0893

02099233 Glucophage 500mg Tab SAV 0.2450

02240297 Humalog Mix50 50% & 50% Inj Susp-5x3mL Pk LIL 54.4500

09857355 Humalog Mix50 Kwikpen 50% & 50% Inj Susp-5x3mL Pk LIL 54.4500

09853855 Humulin 30/70 100U/mL Inj Susp-5x3mL Pk LIL 42.5200


FORM

MFR DBP

Page 14

00795879 Humulin 30/70 1000U/10mL Inj Susp-10mL Pk LIL 21.6700

09853804 Humulin N 100U/mL Inj Susp-5x3mL Pk LIL 42.5200

00587737 Humulin NPH 1000U/10mL Inj Susp-10mL Pk LIL 21.6700

09853766 Humulin R 100U/mL Inj Sol-5x3mL Pk LIL 42.5200

00586714 Humulin Regular 1000U/10mL Inj Sol-10mL Pk LIL 21.6700

01916580 Hycodan 1mg/mL O/L BQU 0.1180

00230316 Hycort 100mg/60mL Enema-60mL Pk VAL 5.2786

02125323 Hydromorph Contin 3mg CR Cap PFP 0.6745






02133253 Hypotears 1% Oph-Sol NOV 0.3220

00004596 Imuran 50mg Tab TRT 0.9897

01911473 Inhibace 2.5mg Tab HLR 0.7323

01911481 Inhibace 5mg Tab HLR 0.8508

02181479 Inhibace Plus 5mg/12.5mg Tab HLR 0.8507

02216965 Invirase 200mg Cap HLR 1.8564

02279320 Invirase 500mg Tab HLR 4.2840

00035017 Isopto Atropine 1% Oph-Sol ALC 0.6279

00000655 Isopto Carbachol 1.5% Oph-Sol ALC 0.7047

00000663 Isopto Carbachol 3% Oph-Sol ALC 0.8477

00000841 Isopto Carpine 1% Oph-Sol ALC 0.2142



00000809 Isopto Tears 0.5% Oph-Sol ALC 0.4800

00000817 Isopto Tears 1% Oph-Sol ALC 0.4800

01918303 K-10 1.33mEq/mL O/L GSK 0.0157

02026961 Kayexalate 1mEq/g Oral Pd-454g Pk SAV 83.3100

01999761 Kenalog-10 50mg/5mL Inj Susp-5mL Pk BQU 16.8200

00990876 Kenalog-40 40mg/mL Inj Susp-1mL Pk BQU 7.7625

01999869 Kenalog-40 200mg/5mL Inj Susp-5mL Pk BQU 27.3200

02142082 Lamictal 25mg Tab GSK 0.3821



02031094 Lamisil 1% Cr NOV 0.5197

02251930 Lantus-(Cartridge) 100U/mL Inj Sol-5x3mL Pk SAV 90.0400

02245689 Lantus-(Vial) 100U/mL Inj Sol-10mL Vial Pk SAV 59.8200

02294338 Lantus Solostar 100U/mL Inj Sol-5x3mL Pk SAV 90.0400

00282081 Lanvis 40mg Tab TRT 4.3104

02224720 Lasix 10mg/mL O/L SAV 0.2756

02224690 Lasix 20mg Tab SAV 0.0873

02224755 Lasix Special 500mg Tab SAV 3.0150

00518123 Lectopam 3mg Tab HLR 0.1529

00518131 Lectopam 6mg Tab HLR 0.2234

02061562 Lescol 20mg Cap NOV 0.8810

02061570 Lescol 40mg Cap NOV 1.2370

02250527 Lescol XL 80mg ER Tab NOV 1.4886


FORM

MFR DBP

Page 15

00004626 Leukeran 2mg Tab TRT 1.3940

02271842 Levemir Penfill 100U/mL Inj Sol-5x3mL Pk NOO 100.1800

00455881 Lioresal 10mg Tab NOV 0.7208

00636576 Lioresal DS 20mg Tab NOV 1.4029

02230711 Lipitor 10mg Tab PFI 1.7431




00074454 Locacorten-Vioform 0.02% & 1% Ot Sol PAL 1.5164

00297143 Loestrin 1.5/30 0.03mg & 1.5mg Tab-21 Pk PAL 13.3500

00353027 Loestrin 1.5/30 0.03mg & 1.5mg Tab-28 Pk PAL 13.3500

00397423 Lopresor 50mg Tab NOV 0.2820

00397431 Lopresor 100mg Tab NOV 0.6150

00658855 Lopresor SR 100mg LA Tab NOV 0.3358

00534560 Lopresor SR 200mg LA Tab NOV 0.6093

02190915 Losec DR Tab 20mg AZC 2.3140

09857195 Losec DR Tab 20mg AZC 2.3140

00885835 Lotensin 5mg Tab NOV 0.8404



02236564 Lovenox 100mg/mL Inj Sol-3mLVial Pk SAV 62.7900

02012472 Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk SAV 6.3200




09852484 Lovenox 100mg/mL Pref Syr-1mL Pk SAV 20.9310

09857137 Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk SAV 25.1170

02242692 Lovenox HP 150mg/mL Pref Syr-1mL Pk SAV 31.3960

02019930 M-Eslon 10mg ER Cap ETH 0.2984






00042560 Maxidex 0.1% Oph Susp ALC 1.6116

00042579 Maxidex 0.1% Oph Oint-3.5g Pk ALC 8.7384

00030988 Medrol 4mg Tab PFI 0.3454

01914030 Mesasal 500mg Ent Tab GSK 0.6274

00869961 Mestinon 60mg Tab VAL 0.4484

00869953 Mestinon 180mg LA Tab VAL 0.9807

00315966 Minestrin 1/20 0.02mg & 1mg Tab-21 Pk PAL 13.3500

00343838 Minestrin 1/20 0.02mg & 1mg Tab-28 Pk PAL 13.3500

00511528 Mogadon 5mg Tab VAL 0.1490

00511536 Mogadon 10mg Tab VAL 0.2230

01907107 Monopril 10mg Tab BQU 0.9289

01907115 Monopril 20mg Tab BQU 1.1178

02015439 MS Contin 15mg SR Tab PFP 0.6800




FORM

MFR DBP

Page 16



02014238 MS-IR 20mg Tab PFP 0.3440

02014254 MS-IR 30mg Tab PFP 0.4410

00004618 Myleran 2mg Tab TRT 1.4792

01927620 Myochrysine 10mg/mL Inj Sol-1mL Pk SAV 11.9000



02162431 Naprosyn 25mg/mL O/L HLR 0.0626

00587826 Nerisone 0.1% Cr STI 0.3934

00587818 Nerisone 0.1% Oily Cr STI 0.3934

00587834 Nerisone 0.1% Oint STI 0.3934

01926772 Neuleptil 10mg Cap ERF 0.4051

01926756 Neuleptil 10mg/mL O/L ERF 0.4071

00268585 Niacin-ICN 100mg Tab VAL 0.0303

01926454 Nitrol 2% Oint PAL 0.6548

02231441 Nitrolingual Pump Spray 0.4mg/Metered Dose Spray-200 Dose Pk SAV 14.6000

02048485 Nolvadex D 20mg Tab AZC 0.3683

02156091 Noritate 1% Top Cr SAV 0.5409

00878928 Norvasc 5mg Tab PFI 1.4209

00878936 Norvasc 10mg Tab PFI 2.1091

02024217 Novolin ge 30/70 1000U/10mL Inj Susp-10mL Pk NOO 21.9300

09853812 Novolin ge 30/70 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 42.8300



02024225 Novolin ge NPH 1000U/10mL Inj Susp-10mL Pk NOO 21.9300

09853782 Novolin ge NPH Penfill 100U/mL Inj Susp-5x3mL Pk NOO 42.8700

02024233 Novolin ge Toronto 1000U/10mL Inj Sol-10mL Pk NOO 21.9300

09853774 Novolin ge Toronto Penfill 100U/mL Inj Sol-5x3mL Pk NOO 43.0300

02265435 NovoMix 30 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 54.0700

02244353 NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk NOO 56.6000

01927698 Nozinan 25mg/mL Inj Sol-1mL Pk SAV 3.3370

02322854 Nplate 250mcg/0.5mL Pd for Inj-Vial Pk AMG 924.4300

02322862 Nplate 500mcg/1mL Pd for Inj-Vial Pk AMG 1848.8600

02303671 Omnaris 50mcg/Actuation Metered Dose Nas Sp-

120 Dose Pk

NYC 25.2300

02282097 Orencia 250mg/Vial Inj Pd-Vial Pk BQU 469.1472

01946374 Oxsoralen 10mg Cap VAL 0.5580

02229453 Pantoloc 40mg Ent Tab NYC 2.0803

01919598 Parnate 10mg Tab GSK 0.3759

02230619 Pediapred Oral Liquid 6.7mg/5mL O/L SAV 0.1270

02017733 PhisoHex 3% Top Emuls SAV 0.0532

00575240 Pilopine HS 4% Oph Gel ALC 2.6142

01926667 Piportil L4 25mg/mL Inj Sol-1mL Pk SAV 16.0600

00990507 Piportil L4 50mg/mL Inj Sol-1mL Pk SAV 27.2400

01926675 Piportil L4 100mg/2mL Inj Sol-2mL Pk SAV 51.7800

02017709 Plaquenil 200mg Tab SAV 0.6154

02238682 Plavix 75mg Tab SAV 2.6512

02043440 Premarin 0.625mg/g Vag Cr WAY 0.6379


FORM

MFR DBP

Page 17

00522597 Prolopa 50-12.5 50mg & 12.5mg Cap HLR 0.2787

00386464 Prolopa 100-25 100mg & 25mg Cap HLR 0.4588

00386472 Prolopa 200-50 200mg & 50mg Cap HLR 0.7702

00010200 Propyl-Thyracil 50mg Tab PAL 0.2214

00010219 Propyl-Thyracil 100mg Tab PAL 0.3464

00869945 Prostigmin 15mg Tab VAL 0.4562

02229099 Pulmicort Nebuamp 0.125mg/mL Inh Susp AZC 0.2170



00851752 Pulmicort Turbuhaler 200mcg/Metered Dose Pd Inh-200 Dose Pk AZC 63.8600

02243237 Rapamune 1mg/mL O/L WAY 7.5830

02247111 Rapamune 1mg Tab WAY 7.5829

02302063 Rasilez 150mg Tab NOV 1.2287

02302071 Rasilez 300mg Tab NOV 1.2287

02221985 Renedil 2.5mg SR Tab SAV 0.3170

02221993 Renedil 5mg SR Tab SAV 0.4633

02222000 Renedil 10mg SR Tab SAV 0.6733

02248610 Reyataz 150mg Cap BQU 11.0503

02248611 Reyataz 200mg Cap BQU 11.0880

02231923 Rhinocort Aqua 64mcg/Metered Dose Nas Sp-120 Dose Pk AZC 10.7200

02035324 Rhinocort Turbuhaler 100mcg/Metered Dose Nas Aero 200 Dose AZC 23.8400

02091887 Rifadin 150mg Cap SAV 0.8003

02092808 Rifadin 300mg Cap SAV 1.2594

00005606 Ritalin 10mg Tab NOV 0.3814

00632775 Ritalin SR 20mg ER Tab NOV 0.6691

00393444 Rofact 150mg Cap VAL 0.6198

00343617 Rofact 300mg Cap VAL 0.9755

02242919 Rosasol 1% Cr STI 0.5190

02224828 Rythmodan 150mg Cap SAV 0.3924

00329320 Sandomigran 0.5mg Tab PAL 0.3972

00511552 Sandomigran DS 1mg Tab PAL 0.6594

02239323 Sandostatin LAR 10mg Inj Kit Pk NOV 1320.9300



01926543 Sectral 100mg Tab SAV 0.3450



02236951 Seroquel 25mg Tab AZC 0.5195




02224623 Sofracort 5mg & 50mcg &

0.5mg/mL

Oph/Ot Sol SAV 1.8663

02293129 Sprycel 20mg Tab BQU 36.8940




02305933 Stalevo 50 & 12.5 & 200mg Tab NOV 1.6159



FORM

MFR DBP

Page 18

02305941 Stalevo 100 & 25 & 200mg Tab NOV 1.6159



00657204 Stieva-A 0.01% Cr STI 0.2985

00578576 Stieva-A 0.025% Cr STI 0.2985

00587966 Stieva-A 0.025% Gel STI 0.2985

00518182 Stieva-A 0.05% Cr STI 0.2985

01905112 Stievamycin Gel 0.025% & 4% Top Gel STI 0.8301

00868965 Suprax 20mg/mL Oral Susp SAV 0.4166

00868981 Suprax 400mg Tab SAV 3.5390

02225166 Suprefact 1mg/mL Inj Sol-5.5mL Pk SAV 61.2900

02225158 Suprefact 1mg/mL Nas Sp-10mL Pk SAV 78.2000

02228955 Suprefact Depot 6.3mg Implant Kit SAV 756.8100

02240749 Suprefact Depot 9.45mg Implant Kit SAV 1120.4500

02239886 Sustiva 50mg Cap BQU 1.2309

02239888 Sustiva 200mg Cap BQU 4.9231

02246045 Sustiva 600mg Tab BQU 14.7693

02245385 Symbicort 100 Turbuhaler 100mcg/6mcg Pd Inh-120 Dose Pk AZC 63.2400

02245386 Symbicort 200 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk AZC 82.2000

00253952 Synacthen Depot 1mg/mL Inj Susp-1mL Pk NOV 34.8000

02304848 Tamiflu 30mg Cap HLR 1.9890



00390291 Tears Naturale 0.1%/0.3% Oph-Sol ALC 0.2970

00743445 Tears Naturale II 0.1%/0.3%/0.001% Oph-Sol ALC 0.3087

00369810 Tegretol 100mg Chew Tab NOV 0.1716

00665088 Tegretol 200mg Chew Tab NOV 0.3385

02194333 Tegretol 100mg/5mL Oral Susp NOV 0.0810

00773611 Tegretol CR 200mg LA Tab NOV 0.4202

00755583 Tegretol CR 400mg LA Tab NOV 0.8402

02261553 Telzir 50mg/mL Oral Susp VIH 0.5912

02261545 Telzir 700mg Tab VIH 8.0863

02049961 Tenoretic 50/25 50 & 25mg Tab AZC 0.6713

02049988 Tenoretic 100/25 100 & 25mg Tab AZC 1.1000

02039532 Tenormin 50mg Tab AZC 0.6033

02039540 Tenormin 100mg Tab AZC 0.9920

02280248 Testim 1% Top Gel-5g Pk PAL 3.5197

00023949 Thyroid 30mg Tab ERF 0.0700



02256738 Tiazac XC 120mg ER Tab BIO 0.8194





00778915 TobraDex 0.3% & 0.1% Oph Oint ALC 3.0057

00778907 TobraDex 0.3% & 0.1% Oph Susp ALC 2.0400

00614254 Tobrex 0.3% Oph Oint ALC 2.4728

00513962 Tobrex 0.3% Oph Sol ALC 1.7435


FORM

MFR DBP

Page 19

02106272 Trandate 100mg Tab PAL 0.2933

02106280 Trandate 200mg Tab PAL 0.5185

00852384 Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch NOV 0.8057

02046156 Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch NOV 0.8057

02318008 Travatan Z 0.004% Oph Sol-2.5mL Pk ALC 27.7000

09857332 Travatan Z 0.004% Oph Sol-5mL Pk ALC 55.4000

02240000 Trelstar (1 Month) 3.75mg/Vial Inj Pd-Vial Pk PAL 320.7000

09857199 Trelstar (1 Month) 3.75mg/Vial Inj Pd with Sterile

Water-Vial Pk

PAL 320.7000

02243856 Trelstar LA (3 Month) 11.25mg/Vial Inj Pd-Vial Pk PAL 981.9300

09857200 Trelstar LA (3 Month) 11.25mg/Vial Inj Pd with Sterile

Water-Vial Pk

PAL 981.9300

02221977 Trental 400mg SR Tab SAV 0.8097

02230733 Trinipatch 0.4mg/Hr/14 Sq Cm Patch PAL 0.6528

02230734 Trinipatch 0.6mg/Hr/21 Sq Cm Patch PAL 0.6528

02244757 Trizivir 300mg/150mg/300mg Tab VIH 17.6737

02274906 Truvada 200mg & 300mg Tab GIL 26.6300

00503134 Uremol-HC 1% & 10% Cr STI 0.1661

00560022 Uremol-HC 1% & 10% Lot STI 0.0968

02325462 Vagifem 10 10mcg Vag Tab with Applicator NOO 3.2133

02245777 Valcyte 450mg Tab HLR 22.8582

00616192 Vepesid 50mg Cap BQU 35.1900

02256460 Vfend 50mg Tab PFI 12.4817

02256479 Vfend 200mg Tab PFI 49.9070

02244596 Videx EC 125mg Enteric Coated Cap BQU 3.6010




02247128 Viread 300mg Tab GIL 17.8300

00568627 Viskazide 10/25 10mg & 25mg Tab NOV 0.9426

00568635 Viskazide 10/50 10mg & 50mg Tab NOV 0.9426

00417270 Visken 5mg Tab NOV 0.6150



01926462 Vitamin A Acid 0.01% Gel SAV 0.2964

01926489 Vitamin A Acid 0.05% Gel SAV 0.2964

00514012 Voltaren 50mg Ent Tab NOV 0.9329

00632724 Voltaren 50mg Sup NOV 1.4010

00632732 Voltaren 100mg Sup NOV 1.8858

01940414 Voltaren Ophtha 0.1% Oph Sol NOV 3.3200

02237825 Wellbutrin SR 150mg Tab BIO 0.9357

02275090 Wellbutrin XL 150mg Tab BIO 0.5573

02275104 Wellbutrin XL 300mg Tab BIO 1.1150

02245565 Xatral 10mg Prolong-Rel Tab SAV 1.0251

00001686 Xylocaine Viscous 2% O/L AZC 0.0950

00888400 Zaroxolyn 2.5mg Tab SAV 0.1937

02298597 Zeldox 20mg Cap PFI 1.6978



FORM

MFR DBP

Page 20



02216086 Zerit 15mg Cap BQU 4.3904

02216094 Zerit 20mg Cap BQU 4.5647

02216108 Zerit 30mg Cap BQU 4.7624

02216116 Zerit 40mg Cap BQU 4.9364

02103729 Zestoretic 10mg & 12.5mg Tab AZC 0.8753

02045737 Zestoretic 20mg & 12.5mg Tab AZC 1.0517

02049333 Zestril 5mg Tab AZC 0.5660



02240358 Ziagen 20mg/mL O/L VIH 0.4568

02049325 Zoladex 3.6mg Depot Inj AZC 390.5000

02225905 Zoladex LA 10.8mg Depot Inj AZC 1113.0000

02132702 Zoloft 25mg Cap PFI 0.8422

01962817 Zoloft 50mg Cap PFI 1.6777

01962779 Zoloft 100mg Cap PFI 1.8350

02238441 Zyban 150mg SR Tab VAL 0.9467

02243684 Zyvoxam 600mg Tab PFI 74.2180

Page 21

New Manufacturer Name(s)


00402818 Apo-Allopurinol 100mg Tab AAP



02297795 Apo-Gliclazide MR 30mg SR Tab AAP

02172577 Apo-Keto SR 200mg LA Tab AAP

02272873 Apo-Levocarb CR 100mg & 25mg Tab AAP

02229452 Apo-Mefenamic 250mg Cap AAP

02357860 Celestoderm-V/2 0.05% Cr VAE

02357844 Celestoderm-V 0.1% Cr VAE

02357879 Celestoderm-V/2 0.05% Oint VAE

02357852 Celestoderm-V 0.1% Oint VAE

02242320 Lanoxin 0.05mg/mL O/L MMT

02008203 Rhovane 7.5mg Tab SDZ

Page 22

Therapeutic Note Change(s)


02253275 Gleevec 100mg Tab NOV

02253283 Gleevec 400mg Tab NOV

These products must be prescribed based on the following criteria:

1) For the treatment of Philadelphia chromosome-positive Chronic Myelogenous

Leukemia (CML) in chronic phase.

The initial dose is 400mg/day. The dose may be increased up to a maximum

of 800 mg/day in patients who do not have an adequate hematologic response

at 3 months or cytogenetic response at 1 year; or if there has been loss of a

previously achieved hematologic and/or cytogenetic response.

Note: The Ministry will only reimburse, in a patient's lifetime, any two (2) of the

oral Tyrosine Kinase Inhibitors (TKIs)* used for chronic phase CML.

* TKIs: Imatinib, Nilotinib, or Dasatinib

2) For the treatment of Philadelphia chromosome-positive Chronic Myelogenous

Leukemia (CML) in blast phase or accelerated phase.

The initial dose is 600mg/day. The dose may be increased to a maximum

of 800 mg/day in patients who do not have an adequate hematologic response

at 3 months or cytogenetic response at 1 year; or loss of a previously achieved

hematologic and/or cytogenetic response.

( )

Page 23

Trade Name Change(s)


02297795 Gliclazide MR 30mg SR Tab APX

02172577 Ketoprofen SR 200mg LA Tab APX

02272873 Levocarb CR 100mg & 25mg Tab APX

02229452 Mefenamic 250mg Cap APX

02242320 Toloxin 0.05mg/mL O/L PMS

00402818 Zyloprim 100mg Tab APX



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