Ontario Drug Benefit Formulary/Comparative Drug Index
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1 Ministry of Health and Long-Term Care Ontario Drug Benefit Formulary/Comparative Drug Index Edition 42 Summary of Changes - October 2015 Effective October 29, 2015 Drug Program Services Branch/Ontario Public Drug Programs Division Ministry of Health and Long-Term Care
2 Table of Contents New Single Source Product... 3 New Multi-Source Products... 4 New Off-Formulary Interchangeable (OFI) Products... 9 Addition of Therapeutic Note Drug Benefit Price (DBP) Changes Product Manufacturer Name Changes Discontinued Products Delisted Products
3 New Single Source Product DIN/PIN PRODUCT NAME, STRENGTH & DOSAGE FORM Simbrinza 1.0% & 0.2% Oph Susp-10mL Pk GENERIC NAME MFR DBP BRINZOLAMIDE & BRIMONIDINE TARTRATE ALC Reason For Use Code and Clinical Criteria Code 466 As second-line therapy for patients who do not have an adequate intraocular pressure lowering response to monotherapy with brinzolamide or brimonidine. LU Authorization Period: Indefinite Code 393 For use as initial therapy in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective. LU Authorization Period: Indefinite. 3
4 New Multi-Source Products Nat-Alprazolam 0.25mg Tab NAT Nat-Alprazolam 0.5mg Tab NAT (Interchangeable with Xanax) Act Amphetamine XR 5mg ER Cap ACV Act Amphetamine XR 10mg ER Cap ACV Act Amphetamine XR 15mg ER Cap ACV Act Amphetamine XR 20mg ER Cap ACV Act Amphetamine XR 25mg ER Cap ACV Act Amphetamine XR 30mg ER Cap ACV (Interchangeable with Adderall XR) Therapeutic Note: Notes: Patients greater than 6 years of age diagnosed with ADHD according to DSM-IV criteria and where symptoms are not due to other medical conditions which affect concentration, and who require 12-hour continuous coverage due to academic and/or psychosocial needs, and who meet the following: 1) Patients who demonstrate significant and problematic disruptive behaviour or who have problems with inattention that interfere with learning; AND 2) Prescribed by or in consultation with a specialist in pediatric psychiatry, pediatrics or a general practitioner with expertise in ADHD; AND 3) Have been tried on methylphenidate immediate release (IR) or methylphenidate slow release (SR) or Dexedrine IR, and have experienced unsatisfactory results due to poor symptom control, side effects, administrative barriers, or societal barriers. Administrative barriers include:. inability of a school to dose the child at lunch;. the school lunch hour does not coincide with the dosing schedule;. poor compliance with noon or afternoon doses;. the patient is unable to swallow tablets. Societal barriers include:. the patient or patient's caregiver(s) has(have) a history of substance abuse or diversion of listed immediate-release alternatives;. the patient or patient's caregiver(s) is/are at risk of substance abuse or diversion of listed immediaterelease alternatives. 4
5 New Multi-Source Products (Cont d...) Reddy-Atorvastatin 10mg Tab DRR Reddy-Atorvastatin 20mg Tab DRR Reddy-Atorvastatin 40mg Tab DRR Reddy-Atorvastatin 80mg Tab DRR (Interchangeable with Lipitor) Apo-Diclofenac Ophthalmic 0.1% Oph Sol APX (Interchangeable with Voltaren Ophtha) Nat-Donepezil 5mg Tab NAT Nat-Donepezil 10mg Tab NAT (Interchangeable with Aricept) Reason For Use Code and Clinical Criteria Code 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. Code 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 LU Authorization Period: 1 year. 5
6 New Multi-Source Products (Cont d...) Nat-Escitalopram 10mg Tab NAT Nat-Escitalopram 20mg Tab NAT (Interchangeable with Cipralex) Jamp Olanzapine FC 2.5mg Tab JPC Jamp Olanzapine FC 5mg Tab JPC Jamp Olanzapine FC 7.5mg Tab JPC Jamp Olanzapine FC 10mg Tab JPC Jamp Olanzapine FC 15mg Tab JPC (Interchangeable with Zyprexa) Van-Olanzapine 2.5mg Tab VAN Van-Olanzapine 5mg Tab VAN Van-Olanzapine 7.5mg Tab VAN Van-Olanzapine 10mg Tab VAN Van-Olanzapine 15mg Tab VAN (Interchangeable with Zyprexa) 6
7 New Multi-Source Products (Cont d...) Nat-Omeprazole DR 20mg DR Tab NAT (Interchangeable with Losec DIN ) Reason For Use Code and Clinical Criteria Code 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy. Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or step-down therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year. Code 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year. Code 401 Other Gastrointestinal Disorders: For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings. LU Authorization Period: 1 year. Code 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a four-week period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. LU Authorization Period: 1 year. 7
8 New Multi-Source Products (Cont d...) Nat-Omeprazole DR 20mg DR Tab NAT (Interchangeable with Losec PIN ) Reason For Use Code and Clinical Criteria Code 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pylori-positive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 year Mylan-Pantoprazole T 40mg Ent Coated Tab MYL (Interchangeable with Tecta) Nat-Quetiapine 25mg Tab NAT Nat-Quetiapine 100mg Tab NAT Nat-Quetiapine 200mg Tab NAT Nat-Quetiapine 300mg Tab NAT (Interchangeable with Seroquel) Gd-Quinapril 5mg Tab GEM Gd-Quinapril 10mg Tab GEM Gd-Quinapril 20mg Tab GEM Gd-Quinapril 40mg Tab GEM (Interchangeable with Accupril) Notes: Accupril and Gd-Quinapril contain quinapril HCl. Apo-Quinapril contains quinapril magnesium. 8
9 New Off-Formulary Interchangeable (OFI) Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Nat-Alprazolam 1mg Tab NAT (Interchangeable with Xanax) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Nat-Levetiracetam 250mg Tab NAT Nat-Levetiracetam 500mg Tab NAT Nat-Levetiracetam 750mg Tab NAT (Interchangeable with Keppra) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Jamp-Oxcarbazepine 150mg Tab JPC Jamp-Oxcarbazepine 300mg Tab JPC Jamp-Oxcarbazepine 600mg Tab JPC (Interchangeable with Trileptal) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Nat-Quetiapine 150mg Tab NAT (Interchangeable with Seroquel) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Van-Sildenafil 100mg Tab VAN (Interchangeable with Viagra) 9
10 Addition of Therapeutic Note DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR Spiriva 18mcg Inh Pd-Cap BOE Therapeutic Note: Each Spiriva 18mcg capsule contains 18mcg of tiotropium, equivalent to 22.5mcg of tiotropium bromide monohydrate. 10
11 Drug Benefit Price (DBP) Changes Co Temozolomide 20mg Cap COB Co Temozolomide 100mg Cap COB Co Temozolomide 140mg Cap COB Co Temozolomide 250mg Cap COB Adrenalin 30mg/30mL Inj Sol-30mL Pk ERF Cerubidine Inj Pd-20mg Pk ERF Choledyl 20mg/mL O/L ERF Lithane 150mg Cap ERF Lithane 300mg Cap ERF Nardil 15mg Tab ERF Navane 5mg Cap ERF Neuleptil 5mg Cap ERF Neuleptil 10mg Cap ERF Neuleptil 10mg/mL O/L ERF Parsitan 50mg Tab ERF Sinequan 10mg Cap ERF Sinequan 25mg Cap ERF Sinequan 50mg Cap ERF Thyroid 30mg Tab ERF Thyroid 60mg Tab ERF Thyroid 125mg Tab ERF Zarontin 250mg Tab ERF Zarontin 50mg/mL O/L ERF Dexedrine Spansules 10mg SR Cap PAL Dexedrine Spansules 15mg SR Cap PAL Teva-Solifenacin 5mg Tab TEV Teva-Solifenacin 10mg Tab TEV
12 Product Manufacturer Name Changes DIN BRAND NAME STRENGTH DOSAGE FORM CURRENT MFR Aristocort R 0.1% Cr VAE VAL Arixtra 2.5mg/0.5mL Inj Sol-Pref Syr 0.5mL Pk (Preservative Free) Arixtra 7.5mg/0.6mL Inj Sol-Pref Syr 0.6mL Pk (Preservative Free) GSK GSK NEW MFR Dexamethasone Sodium 4mg/mL Inj Sol CYI STE Oralair 100IR SL Tab PAL STL Oralair 300IR SL Tab PAL STL ASN ASN 12
13 Discontinued Products (Some products will remain on Formulary for six months to facilitate depletion of supply) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR Apo-Clomipramine 10mg Tab APX Apo-Clomipramine 25mg Tab APX Apo-Clomipramine 50mg Tab APX Ratio-Brimonidine 0.2% Oph Sol RPH Mylan-Alendronate 10mg Tab MYL Mylan-Atorvastatin 10mg Tab MYL Mylan-Atorvastatin 20mg Tab MYL Mylan-Atorvastatin 40mg Tab MYL Mylan-Atorvastatin 80mg Tab MYL Mylan-Bicalutamide 50mg Tab MYL Mylan-Carbamazepine 200mg LA Tab MYL Mylan-Domperidone 10mg Tab MYL Mylan-Doxazosin 1mg Tab MYL Mylan-Doxazosin 2mg Tab MYL Mylan-Doxazosin 4mg Tab MYL Mylan-Glybe 5mg Tab MYL Mylan-Lisinopril HCTZ 10mg & 12.5mg Tab MYL Mylan-Lisinopril HCTZ 20mg & 12.5mg Tab MYL Mylan-Lisinopril HCTZ 20mg & 25mg Tab MYL Mylan-Sotalol 160mg Tab MYL Mylan-Sotalol 80mg Tab MYL Mylan-Terazosin 10mg Tab MYL Mylan-Terazosin 1mg Tab MYL Mylan-Terazosin 2mg Tab MYL Mylan-Terazosin 5mg Tab MYL Mylan-Terbinafine 250mg Tab MYL Mylan-Trazodone 50mg Tab MYL Myl-Ranitidine 150mg Tab MYL Myl-Ranitidine 300mg Tab MYL 13
14 Delisted Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR Ascensia Autodisc Strip BAY Encore Strip BAY Levaquin* 500mg Tab JAN Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk JAN Prezista 400mg Tab JAN Rhotral* 100mg Tab SAV Rhotral* 200mg Tab SAV Rhotral* 400mg Tab SAV Triamcinolone Acetonide 40mg/mL Inj Susp-1mL Pk SDZ Triamcinolone Acetonide 200mg/5mL Inj Susp-5mL Pk SDZ Pentamycetin 0.25% Oph Sol SDZ Sandoz Opticort 5mg & 50mcg & 0.5mg/mL Oph/Ot Sol SDZ Sandoz Pentasone 3mg & 1mg/mL Oph/Ot Drops SDZ Sandoz Gentamicin 0.3% Ot Sol SDZ Diopred 1% Oph Susp SDZ *Remain on Formulary as Not-a-Benefit to serve as reference product in interchangeable group. 14
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UPDATE AX Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective August 29, 2013 SUMMARY OF CHANGES
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UPDATE AB Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective October 25, 2011 SUMMARY OF CHANGES
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UPDATE AJ Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective July 27, 2012 SUMMARY OF CHANGES
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UPDATE C Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective November 04, 2008 SUMMARY OF CHANGES
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UPDATE E Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective December 23, 2008 SUMMARY OF CHANGES
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UPDATE F Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective 30 January, 2009 SUMMARY OF CHANGES
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