REIMBURSEMENT STATUS OF HIV MEDICATIONS IN ONTARIO
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1 REIMBURSEMENT STATUS OF HIV MEDICATIONS IN ONTARIO Ont. Drug Distr. Ontario Drug Benefit/Trillium: Other Formulary (F/A) Limited Use (Section 16) Antiretrovirals AZT 100 mg capsules NRTIs (single): Abacavir, 3TC, d4t, ddi EC, tenofovir NRTIs (combination): AZT/3TC (Combivir ), AZT, 3TC, abacavir (Trizivir ), abacavir/3tc (Kivexa ), tenofovir/ftc (Truvada ), emtricitabine/tenof ovir/ efavirenz (Atripla ) NNRTIs: delavirdine, efavirenz, etravirine, nevirapine PIs: Darunavir, fosamprenavir, indinavir, lopinavir/ritonavir nelfinavir, ritonavir, saquinavir Antivirals Acyclovir Ganciclovir IV, Famciclovir, Valacyclovir, Integrase Inhibitors: raltegravir PIs: tipranavir (Aptivus ) Entry inhibitors: enfuvirtide, maraviroc Didanosine pediatric powder (SAP), d4t oral liquid (SAP) Foscarnet, Cidofovir (SAP)
2 Ont. Drug Distr. Ontario Drug Benefit/Trillium: Other Formulary (F/A) Limited Use (Section 16) Acyclovir 800 mg tablets and IV, Valganciclovir Antifungals Clotrimazole vag tabs, Nystatin, Ketoconazole, IV Ampho B Itraconazole capsules and solution Fluconazole Liposomal amphotericin (Ambisome), voriconazole Ampho B lozenges, Ampho B oral solution, Clotrimazole troches, Flucytosine (SAP) PCP/Toxo Agents TMP/SMX, TMP, Clindamycin, Folinic Acid, Dapsone Atovaquone liquid, Pyrimethamine Primaquine Aerosolized Pentamidine, Sulfadiazine, Trimetrexate (SAP) Mycobacterials Isoniazid, Rifampin, Pyrazinamide, Ethambutol, B 6, Clarithromycin tabs and liquid, Azithromycin 250 mg tabs or liquid Azithromycin 600 mg tablets Rifabutin, Ciprofloxacin Amikacin Clofazimine, streptomycin (SAP); INH, RIF, ETM, PZA, B 6 (CDCNU); 2nd line TB drugs (Toronto Public Health) Misc. Megace, nabilone, most NSAIDs, codeine, morphine, hydromorphone, oxycodone + AAS or acetaminophen Doxycycline, paramomycin, nutritional products, pneumococcal vaccine, potassium supplements Fentanyl patch, gabapentin, ondansetron, pancreatic enzyme (Cotazyme ECS 20), interferon α-2a, interferon α-2b, diphenoxylate / atropine, loperamide, dronabinol, oxycodone, testosterone patch (Androderm), testosterone gel (Androgel) Ketorolac, G-CSF (Neupogen), octreotide, somatropin (Serostim), imiquimod (Aldara) Albendazole, aldesleukin, GM-CSF, Thalidomide (SAP); oxandrolone (SAP - but need to pay in advance: call (613) ); Altiretinoin (Panretin ) - SAP Prepared by: Alice Tseng, Pharm.D., FCSHP, Toronto General Hospital January 2009
3 OBTAINING ANTIRETROVIRALS IN ONTARIO Drug Status Patient Criteria MD Criteria Paperwork/Pharmacy Cost/Month Combination products: AZT 300 mg/3tc 150 mg tablets (Combivir ) AZT 300 mg/ 3TC 150 mg/abacavir 300 mg tablets (Trizivir ) abacavir 600 mg/ 3TC 300 mg tablets (Kivexa ) Emtricitabine 200 mg/ tenofovir 300 mg tablets (Truvada ) Emtricitabine 200 mg/ tenofovir 300 mg/ efavirenz 600 mg tablets (Atripla ) /Trillium plan /Trillium plan /Trillium plan /Trillium plan /Trillium plan Nucleoside Reverse Transcriptase Inhibitors: abacavir (Ziagen ) /Trillium plan AZT, zidovudine 100 mg capsules (Retrovir ) Ont. Drug Distribution/ Ontario Health Card CD 4 <500 MD on List MD on List MD on List MD on List MD on List MD on List Antiretroviral Registration Form to Ont. Drug Distribution/ follow-up info q3months Pick up Rx at designated hospital pharmacy $ $ $ $ $ $ $314.26
4 Drug Status Patient Criteria MD Criteria Paperwork/Pharmacy Cost/Month ddi pediatric oral solution (Videx ) Ont. Drug Distribution/, Ontario Health Card CD 4 <200 Antiretroviral Registration Form to Ont. Drug Distribution/ ; follow-up info q3months Pick up Rx at designated hospital pharmacy ddi + cost of Maalox disp. Fee Individual Clinical Review (ICR) application (incl. cost of Maalox & extemporaneous compounding) made to Director of Drug s Branch, fax ddi enteric coated tablets 3TC, lamivudine d4t, stavudine (Zerit ) tenofovir (Viread ) Integrase Inhibitor: raltegravir (Isentress ) /Trillium plan /Trillium plan /Trillium plan /Trillium plan Non-Nucleoside Reverse Transcriptase Inhibitors: Delavirdine (Rescriptor ) /Trillium plan efavirenz (Sustiva ) etravirine (Intelence ) MD on List MD on List MD on List MD on List (416) /Trillium plan Individual Clinical Review (ICR) s Branch, fax (416) /Trillium plan /Trillium plan MD on List MD on List MD on List $ $ $ $ $ $ $ $654.00
5 Drug Status Patient Criteria MD Criteria Paperwork/Pharmacy Cost/Month nevirapine /Trillium plan MD on $ (Viramune ) List Protease Inhibitors: atazanavir (Reyataz ) darunavir (Prezista ) fosamprenavir (Telzir ) indinavir (Crixivan ) lopinavir/ ritonavir (Kaletra ) nelfinavir (Viracept ) ritonavir liquid or capsules (Norvir ) Saquinavir 500 mg tablet (Invirase ) Tipranavir (Aptivus ) /Trillium plan /Trillium plan /Trillium plan /Trillium plan /Trillium plan /Trillium plan /Trillium plan /Trillium plan MD on List MD on List MD on List MD on List MD on List MD on List MD on List MD on List /Trillium plan Individual Clinical Review (ICR) s Branch, fax (416) $624.06; $ $ $950.40; $ $484.80; $ $ $ $ (booster doses) $ $
6 Drug Status Patient Criteria MD Criteria Paperwork/Pharmacy Cost/Month Fusion Inhibitors Enfuvirtide (Fuzeon ) /Trillium plan 6 months therapy with each ARV class and documented resistance mutations to 2 drugs in each class virologic failure (RNA>50 copies/ml after 6 months and <1 log drop after 12 weeks on most recent regimen) use in combination with 1 other sensitive ARV Individual Clinical Review (ICR) s Branch, fax (416) $ CCR5 Inhibitor: maraviroc (Selzentry ) /Trillium plan Individual Clinical Review (ICR) s Branch, fax (416) $ Alice Tseng, ACPR, Pharm.D.,FSCHP, Toronto General Hospital, Toronto, ON Updated June 18, 2009
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