UPDATE AT Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 30, 2013 SUMMARY OF CHANGES

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1 UPDATE AT Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 30, 2013 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 6 Off Formulary Interchangeable Product(s) 9 Manufacturer Requested Discontinued Drug(s) 11 Drug Benefit Price(s) 12 New Manufacturer Name(s) 22 Not-A-Benefit Drug(s) 23 Status Change(s) from Not-A-Benefit to General Benefit 24 Trade Name Change(s) 25 Page 1

2 New Single Source Drug(s) DIN PRODUCT GENERIC NAME MFR DBP Acuvail 0.45% Oph Sol-0.4mL Vial Pk KETOROLAC TROMETHAMINE ALL Brilinta 90mg Tab TICAGRELOR AZC Reason for Use Code 441 Clinical Criteria In combination with ASA 75mg 150mg (See Note a) below) daily for patients with acute coronary syndrome (i.e., ST elevation myocardial infarction [STEMI], non-st elevation myocardial infarction [NSTEMI], or unstable angina [UA] with ONE of the following: 1. Failure on optimal clopidogrel and ASA therapy as defined by definite stent thrombosis (See Note b) below), or recurrent STEMI, or NSTEMI or UA after prior revascularization via percutaneous coronary intervention (PCI) OR 2. STEMI and undergoing revascularization via PCI OR 3. NSTEMI or UA with high risk angiographic features and undergoing revascularization via PCI Treatment must be initiated in hospital. Funding approval is for up to 1 year. Notes: a) Co-administration of ticagrelor with high maintenance dose ASA (greater than 150mg daily) is not recommended. b) Definite stent thrombosis, according to the Academic Research Consortium, is a total occlusion originating in or within 5mm of the stent, or is a visible thrombus within the stent, or is within 5mm of the stent in the presence of an acute ischemic clinical syndrome within 48 hours. Definite stent thrombosis must be confirmed by angiography or by pathologic confirmation of acute thrombosis. c) Ticagrelor is contraindicated in patients with active pathological bleeding, in those with a history of intracranial hemorrhage and moderate to severe hepatic impairment. LU Authorization Period: 1 year Page 2

3 DIN PRODUCT GENERIC NAME MFR DBP Lyrica 25mg Cap PREGABALIN PFI Lyrica 50mg Cap PREGABALIN PFI Lyrica 75mg Cap PREGABALIN PFI Lyrica 150mg Cap PREGABALIN PFI Lyrica 300mg Cap PREGABALIN PFI Onbrez Breezhaler 75mcg Inh Pd- Cap INDACATEROL NOV Reason for Use Code 443 Clinical Criteria For patients with moderate to severe COPD with persistent respiratory symptoms despite an adequate trial of, or an intolerance to, a regularly scheduled short-acting bronchodilator AND a long-acting anticholinergic. Note: The dose of Onbrez Breezhaler should not exceed 75mcg per day. LU Authorization Period: Indefinite. Page 3

4 DIN PRODUCT GENERIC NAME MFR DBP Alitretinoin should only be prescribed by physicians knowledgeable in the use of retinoids systemically, who understand the riskof teratogenicity in females of child bearing potential. Alitretinoin is contraindicated in pregnancy and females must not become pregnant while taking alitretinoin and for at least one month after its discontinuation. Please refer to the Toctino product monograph for details on use in women of child bearing potential Toctino 10mg Cap ALITRETINOIN GSK Toctino 30mg Cap ALITRETINOIN GSK Reason for Use Code 442 Clinical Criteria For adult patients with severe (see note 1 below) chronic (see note 2 below) hand eczema AND unresponsive to an 8 week course of high potency topical corticosteroids. 1. Severe defined based on the Physician Global Assessment (PGA), including: At least one of the following cardinal features present at baseline as moderate or severe: erythema, scaling, hyperkeratosis/lichenification; and one of the following features present as severe: vesiculation, edema, fissures, pruritus/pain; and with an area of greater than 30% of affected hand surface 2. Chronic defined as: persists for greater than 3 months; OR reoccurs greater than or equal to 2 times within 12 months LU Authorization Period: 1 Year. Page 4

5 DIN PRODUCT GENERIC NAME MFR DBP Toviaz 4mg Tab FESOTERODINE FUMARATE PFI Toviaz 8mg Tab FESOTERODINE FUMARATE PFI Reason for Use Code 290 Clinical Criteria For patients with urinary frequency, urgency or urge incontinence who have: Failed to respond to behavioral techniques AND an adequate trial of oxybutynin with gradual dose escalation has shown to be either ineffective or resulted in unacceptable side effects. NOTE: If after a trial of 2 weeks patients continue to experience similar side effects and no greater efficacy than oxybutynin, continued therapy with this more costly agent should be reassessed. Antimuscarinic agents should be used with caution in the elderly due to potentially serious adverse effects (e.g. confusion, phychosis, acute urinary retention, constipation). Antimuscarinic agents should be avoided in older adults with pre-existing cognitive impairment (e.g. dementia) and those who are already using other drugs with significant anticholinergic effects (e.g. tricyclic antidepressants) in order to avoid a high overall anticholinergic drug burden. LU Authorization Period: Indefinite. Page 5

6 New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Apo-Pregabalin 25mg Cap APX Apo-Pregabalin 50mg Cap APX Apo-Pregabalin 75mg Cap APX Apo-Pregabalin 150mg Cap APX Apo-Pregabalin 300mg Cap APX Auro-Amlodipine 5mg Tab AUR Auro-Amlodipine 10mg Tab AUR (Interchangeable with Norvasc) Auro-Lisinopril 5mg Tab AUR Auro-Lisinopril 10mg Tab AUR Auro-Lisinopril 20mg Tab AUR (Interchangeable with Zestril) Gd-Pregabalin 25mg Cap GEM Gd-Pregabalin 50mg Cap GEM Gd-Pregabalin 75mg Cap GEM Gd-Pregabalin 150mg Cap GEM Gd-Pregabalin 300mg Cap GEM Mar-Montelukast 4mg Chew Tab MAR (Interchangeable with Singulair) Reason for Use Code 382 Clinical Criteria For the treatment of asthma in patients aged 2-5 years old. LU Authorization Period: 1 Year. Page 6

7 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Ran-Candesartan 4mg Tab RAN Ran-Candesartan 8mg Tab RAN Ran-Candesartan 16mg Tab RAN Ran-Candesartan 32mg Tab RAN (Interchangeable with Atacand) Ran-Pregabalin 25mg Cap RAN Ran-Pregabalin 50mg Cap RAN Ran-Pregabalin 75mg Cap RAN Ran-Pregabalin 150mg Cap RAN Ran-Pregabalin 300mg Cap RAN Sandoz Latanoprost/Timolol 50mcg/mL & 5mg/mL Oph Sol-2.5mL Pk SDZ (Interchangeable with Xalacom) Reason for Use Code 310 Clinical Criteria As second-line therapy for patients who do not have an adequate intraocular pressure lowering response to monotherapy with ophthalmic beta-blocking agents. LU Authorization Period: Indefinite. 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 Teva-Pregabalin 25mg Cap TEV Teva-Pregabalin 50mg Cap TEV Teva-Pregabalin 75mg Cap TEV Teva-Pregabalin 150mg Cap TEV Teva-Pregabalin 300mg Cap TEV Page 7

8 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Tobramycin Injection USP 80mg/2mL Inj Sol-2mL Pk AGI (Interchangeable with Nebcin) The prescriber should be aware that tobramycin injection products may be preservative-free or preservativecontaining. If applicable, the prescriber should choose the most appropriate formulation (preservative-free or preservative containing) for use in the specific clinical situation in which the product was prescribed. Page 8

9 Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST Apo-Pregabalin 225mg Cap APX Auro-Montelukast 10mg Tab AUR (Interchangeable with Singulair) Co Pregabalin 225mg Cap COB Gd-Pregabalin 225mg Cap GEM Jamp-Pioglitazone 15mg Tab JPC (Interchangeable with Actos) Mar-Montelukast 5mg Chew Tab MAR (Interchangeable with Singulair) PMS-Pregabalin 225mg Cap PMS PMS-Tetrabenazine 25mg Tab PMS (Interchangeable with Nitoman) Ran-Pregabalin 225mg Cap RAN Sandoz Olopatadine 0.1% Oph Sol SDZ (Interchangeable with Patanol) Septa-Zopiclone 5mg Tab SET Septa-Zopiclone 7.5mg Tab SET (Interchangeable with Imovane) Page 9

10 DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST Sumatriptan Sun 6mg/0.5mL Inj Sol-Pref Syr 0.5mL Pk (Interchangeable with Imitrex) SPG Teva-Pregabalin 225mg Cap TEV Tranexamic Acid Tablets 500mg Tab STE (Interchangeable with Cyklokapron) Page 10

11 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 Apo-Haloperidol 2mg Tab APX Apo-Haloperidol 5mg Tab APX Apo-Propranolol 10mg Tab APX Apo-Propranolol 40mg Tab APX Apo-Propranolol 80mg Tab APX Apo-Tiaprofenic 200mg Tab APX Apo-Tiaprofenic 300mg Tab APX PMS-Levobunolol 0.5% Oph Sol PMS Page 11

12 Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Abilify 2mg Tab BQU Abilify 5mg Tab BQU Abilify 10mg Tab BQU Abilify 15mg Tab BQU Abilify 20mg Tab BQU Abilify 30mg Tab BQU Actos 15mg Tab TAK Actos 30mg Tab TAK Actos 45mg Tab TAK Adcirca 20mg Tab LIL Advair /125mcg/Metered Inh-120 Dose Pk GSK Dose Advair /250mcg/Metered Inh-120 Dose Pk GSK Dose Advair Diskus 50/100mcg Inh-60 Dose Pk GSK Advair Diskus 50/250mcg Inh-60 Dose Pk GSK Advair Diskus 50/500mcg Inh-60 Dose Pk GSK Afinitor 5mg Tab NOV Afinitor 10mg Tab NOV Alomide 0.1% Oph Sol ALC Altace Cap 1.25mg SAV Altace Cap 2.5mg SAV Altace Cap 5mg SAV Altace Cap 10mg SAV Alvesco 100mcg/Actuation Inh-120 Dose Pk NYC Alvesco 200mcg/Actuation Inh-120 Dose Pk NYC Anandron 50mg Tab SAV Anzemet 100mg Tab SAV Apidra 100U/mL Inj Sol-5x3mL SoloSTAR Pref Pen SAV Apidra 100U/mL Inj Sol-10mL Vial SAV Apidra 100U/mL Inj 5x3mL Cart SAV ClickStar Pen Apo-Amoxi Clav 50mg & 12.5mg/mL O/L APX Apo-Furosemide 40mg Tab APX Apo-Haloperidol 0.5mg Tab APX Apo-Haloperidol 1mg Tab APX Apo-Haloperidol 2mg Tab APX Apo-Haloperidol 5mg Tab APX Apo-Haloperidol 10mg Tab APX Apo-Ranitidine 15mg/mL Oral Sol APX Aranesp 200mcg/0.4mL Pref Syr-0.4mL Pk AMG Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk AMG Aranesp 500mcg/1.0mL Pref Syr-1.0mL Pk AMG Page 12

13 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Arava 10mg Tab SAV Arava 20mg Tab SAV Arixtra 2.5mg Inj-0.5mL Pk GSK Atripla 600mg/300mg/200mg Tab BQU Avodart 0.5mg Cap GSK Azarga 1% & 0.5% Oph Susp-5mL Pk ALC Azopt 1% Oph Susp ALC Betnesol 5mg/100mL Enema-100mL Pk PAL Betoptic S 0.25% Oph Susp ALC Biphentin 10mg ER Cap PFP Biphentin 15mg ER Cap PFP Biphentin 20mg ER Cap PFP Biphentin 30mg ER Cap PFP Biphentin 40mg ER Cap PFP Biphentin 50mg ER Cap PFP Biphentin 60mg ER Cap PFP Biphentin 80mg ER Cap PFP Calcimar 400IU/2mL Inj Sol-2mL Pk SAV CeeNU 10mg Cap BQU CeeNU 40mg Cap BQU CeeNU 100mg Cap BQU Ceftin 250mg Tab GSK Ceftin 500mg Tab GSK Cefzil 125mg/5mL Oral Susp-75mL Pk BQU Cefzil 125mg/5mL Oral Susp-100mL BQU Pk Cefzil 250mg Tab BQU Cefzil 250mg/5mL Oral Susp-75mL Pk BQU Cefzil 250mg/5mL Oral Susp-100mL BQU Cefzil 500mg Tab BQU Cipralex 10mg Tab VLH Cipralex 20mg Tab VLH Clavulin (BID) 875mg & 125mg Tab GSK Clindoxyl 1% & 5% Gel GSK Codeine Contin 50mg CR Tab PFP Codeine Contin 100mg CR Tab PFP Codeine Contin 150mg CR Tab PFP Codeine Contin 200mg CR Tab PFP Complera 200mg & 25mg & Tab GIL mg Copaxone 20mg/mL Inj Pref Syr-1mLPk TEI Cortenema 100mg/60mL Enema-60mL Pk BFI Cortifoam 10% Rect Aero-15g Pk PAL Cortisporin 10000U & 5mg & Ot Sol GSK mg/mL Coumadin 1mg Tab BQU Page 13

14 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Coumadin 2mg Tab BQU Coumadin 2.5mg Tab BQU Coumadin 3mg Tab BQU Coumadin 4mg Tab BQU Coumadin 5mg Tab BQU Coumadin 10mg Tab BQU Cyclocort 0.1% Cr STI Cyclocort 0.1% Lot STI Cyclocort 0.1% Oint STI Cyclomen 50mg Cap SAV Cyclomen 100mg Cap SAV Cyclomen 200mg Cap SAV Cymbalta 30mg DR Cap LIL Cymbalta 60mg DR Cap LIL Cytovene 500mg/Vial Pd Inj-10mL Pk HLR Demerol 50mg Tab SAV Diabeta 2.5mg Tab SAV Diabeta 5mg Tab SAV Diclectin 10mg & 10mg SR Tab DUI DuoTrav 0.5% & 0.004% Oph Sol-2.5mL Pk ALC DuoTrav 0.5% & 0.004% Oph Sol-5mL Pk ALC Duvoid 10mg Tab PAL Duvoid 25mg Tab PAL Duvoid 50mg Tab PAL Emo-Cort 1% Cr STI Emo-Cort 2.5% Cr STI Emo-Cort 1% Lot STI Emo-Cort 2.5% Lot STI Enbrel 25mg/Vial Inj Pd-Vial Pk IMU Enbrel 50mg/mL Inj Pref Syr IMU Enbrel SureClick 50mg/mL Pref AutoInj IMU Estring 2mg Vag Ring PFI Exjade 125mg Tab for Susp NOV Exjade 250mg Tab for Susp NOV Exjade 500mg Tab for Susp NOV Famvir 500mg Tab NOV Femara 2.5mg Tab NOV Flagyl 500mg Cap SAV Flagyl 10% Vag Cr-App SAV Flagystatin 500mg & U Vag Sup SAV Flagystatin 500mg & U/g Vag Cr-App SAV Flarex 0.1% Oph Susp ALC Florinef 0.1mg Tab PAL Flovent HFA 50mcg/Metered Dose Inh-120 Dose Pk GSK Fungizone Inj Pd-50mg Pk BQU Gleevec 100mg Tab NOV Gleevec 400mg Tab NOV GlucaGen 1mg/Vial Inj Pd-Vial Pk NOO GlucaGen HypoKit 1mg/Vial Inj Pd-Vial Pk NOO Page 14

15 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Glucophage 500mg Tab SAV Humalog 100U/mL Inj Sol-10mL Pk LIL Humalog Mix25 25% & 75% Inj Susp-5x3mL Pk LIL Humalog Mix25 Kwikpen 25% & 75% Inj Susp-5x3mL Pk LIL Humulin 30/70 100U/mL Inj Susp-5x3mL Pk LIL Humulin 30/ U/10mL Inj Susp-10mL Pk LIL Humulin N 100U/mL Inj Susp-5x3mL Pk LIL Humulin NPH 1000U/10mL Inj Susp-10mL Pk LIL Humulin R 100U/mL Inj Sol-5x3mL Pk LIL Humulin Regular 1000U/10mL Inj Sol-10mL Pk LIL Hycodan 1mg/mL O/L BQU Hydromorph Contin 3mg CR Cap PFP Hydromorph Contin 4.5mg CR Cap PFP Hydromorph Contin 6mg CR Cap PFP Hydromorph Contin 9mg CR Cap PFP Hydromorph Contin 12mg CR Cap PFP Hydromorph Contin 18mg CR Cap PFP Hydromorph Contin 24mg CR Cap PFP Hydromorph Contin 30mg CR Cap PFP Inhibace 2.5mg Tab HLR Inhibace 5mg Tab HLR Inhibace Plus 5mg/12.5mg Tab HLR Invirase 200mg Cap HLR Invirase 500mg Tab HLR Isopto Atropine 1% Oph Sol ALC Isopto Carpine 1% Oph Sol ALC Isopto Carpine 2% Oph Sol ALC Isopto Carpine 4% Oph Sol ALC K mEq/mL O/L GSK Kenalog-10 50mg/5mL Inj Susp-5mL Pk BQU Kenalog-40 40mg/mL Inj Susp-1mL Pk BQU Kenalog mg/5mL Inj Susp-5mL Pk BQU Kivexa 600mg/300mg Tab VIH Lamictal 25mg Tab GSK Lamictal 100mg Tab GSK Lamictal 150mg Tab GSK Lamisil 1% Cr NOV Lantus Solostar 100U/mL Inj Sol-5x3mL Pk SAV Lantus-(Cartridge) 100U/mL Inj Sol-5x3mL Pk SAV Lantus-(Vial) 100U/mL Inj Sol-10mL Vial Pk SAV Lasix 10mg/mL O/L SAV Lasix Special 500mg Tab SAV Lectopam 3mg Tab HLR Lectopam 6mg Tab HLR Lescol 20mg Cap NOV Lescol 40mg Cap NOV Lescol XL 80mg ER Tab NOV Page 15

16 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Levemir Penfill 100U/mL Inj Sol-5x3mL Pk NOO Lioresal 10mg Tab NOV Lioresal DS 20mg Tab NOV Locacorten-Vioform 0.02% & 1% Ot Sol PAL Loestrin 1.5/ mg & 1.5mg Tab-21 Pk PAL Loestrin 1.5/ mg & 1.5mg Tab-28 Pk PAL Lopresor 50mg Tab NOV Lopresor 100mg Tab NOV Lopresor SR 100mg LA Tab NOV Lopresor SR 200mg LA Tab NOV Lotensin 5mg Tab NOV Lotensin 20mg Tab NOV Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk SAV Lovenox 40mg/0.4mL Pref Syr-0.4mL Pk SAV Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk SAV Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk SAV Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox 100mg/mL Pref Syr-1mL Pk SAV Lovenox 100mg/mL Pref Syr-1mL Pk SAV Lovenox 100mg/mL Inj Sol-3mLVial Pk SAV Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox HP 150mg/mL Pref Syr-1mL Pk SAV Lupron Depot PDS 11.25mg Inj-Kit ABB 1, Maxidex 0.1% Oph Oint-3.5g Pk ALC Maxidex 0.1% Oph Susp ALC Mesasal 500mg Ent Tab GSK Metrogel 1% Top Gel GAC Minestrin 1/ mg & 1mg Tab-21 Pk PAL Minestrin 1/ mg & 1mg Tab-28 Pk PAL Monopril 10mg Tab BQU Monopril 20mg Tab BQU MS Contin 15mg SR Tab PFP MS Contin 30mg SR Tab PFP MS Contin 60mg SR Tab PFP MS Contin 100mg SR Tab PFP MS Contin 200mg SR Tab PFP Myochrysine 50mg/mL Inj Sol-1mL Pk SAV Myochrysine 25mg/mL Inj Sol-1mL Pk SAV Myochrysine 10mg/mL Inj Sol-1mL Pk SAV Naprosyn 25mg/mL O/L HLR Neupogen 300mcg/mL 1mL Vial AMG Neupogen 480mcg/1.6mL 1.6mL Vial AMG Niaspan FCT 500mg ER Tab SEP Niaspan FCT 750mg ER Tab SEP Niaspan FCT 1000mg ER Tab SEP Nitrol 2% Oint PAL Page 16

17 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Nitrolingual Pump Spray 0.4mg/Metered Dose Spray-200 Dose Pk SAV Novolin ge 30/ U/10mL Inj Susp-10mL Pk NOO Novolin ge 30/70 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge 40/60 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge 50/50 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge NPH 100U/mL Inj Susp-10mL Pk NOO Novolin ge NPH Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge Toronto 1000U/10mL Inj Susp-10mL Pk NOO Novolin ge Toronto 100U/mL Inj Sol-5x3mL Pk NOO Penfill NovoMix 30 Penfill 100U/mL Inj Sol-5x3mL Pk NOO NovoRapid 100U/mL Inj Sol-10mL Pk NOO NovoRapid FlexTouch 100U/mL Inj Sol-Prefil 5X3mL NOO Pk Disposable Pen NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk NOO Nozinan 25mg/mL Inj Sol-1mL Pk SAV Nplate 250mcg/0.5mL Pd for Inj-Vial Pk AMG Nplate 500mcg/0.5mL Pd for Inj-Vial Pk AMG Nutropin AQ 10mg/2mL Inj-10mg Pen Cart HLR Pk Nutropin AQ 10mg/2mL Inj Disposable-Pen HLR NuSpin Omnaris 50mcg/Actuation Metered Dose Nas NYC Sp-120 Dose Pk Onglyza 2.5mg Tab BQU Onglyza 5mg Tab BQU Orencia 250mg/Vial Inj Pd-Vial Pk BQU Parnate 10mg Tab GSK Pediapred Oral Liquid 6.7mg/5mL O/L SAV Phisohex 3% Top Emuls SAV Piportil L4 25mg/mL Inj Sol-1mL Pk SAV Piportil L4 50mg/mL Inj Sol-1mL Pk SAV Piportil L4 100mg/2mL Inj Sol-2mL Pk SAV Plaquenil 200mg Tab SAV Plavix 75mg Tab SAV Prolia 60mg/mL Inj Sol-Pref Syr AMG (Preservative Free) Prolopa mg & 12.5mg Cap HLR Prolopa mg & 25mg Cap HLR Prolopa mg & 50mg Cap HLR Propyl-Thyracil 50mg Tab PAL Propyl-Thyracil 100mg Tab PAL Rebif 22mcg Inj-Syr Pk SRO Rebif 44mcg Inj-Syr Pk SRO Rebif 66mcg Inj-Cart Pk SRO Rebif 132mcg Inj-Cart Pk SRO ReQuip 0.25mg Tab GSK ReQuip 1mg Tab GSK Page 17

18 DIN BRAND STRENGTH DOSAGE FORM MFR DBP ReQuip 2mg Tab GSK ReQuip 5mg Tab GSK Rescriptor 100mg Tab PFI Reyataz 150mg Cap BQU Reyataz 200mg Cap BQU Rifadin 150mg Cap SAV Rifadin 300mg Cap SAV Ritalin 10mg Tab NOV Ritalin SR 20mg ER Tab NOV Rivotril 0.5mg Tab HLR Rivotril 2mg Tab HLR Rosasol 1% Cr STI Saizen 3.33mg Inj Pd-3.33mg Vial EMS Pk with diluent Saizen 5mg Inj Pd-5mg vial Pk EMS with Diluent Saizen 8.8mg Inj Pd-8.8mg Vial Pk EMS Saizen 6mg/Cart (5.83mg/mL) Inj Cart EMS Saizen 12mg/Cart (8mg/mL) Inj Cart EMS Saizen 20mg/Cart (8mg/mL) Inj Cart EMS Salofalk 1000mg Sup BFI Salofalk 4g Rect Susp-Pk BFI Salofalk 500mg Ent Tab BFI Salofalk 500mg Sup BFI Sandomigran DS 1mg Tab PAL Sandostatin 50mcg/mL Inj Sol-1mL Amp Pk NOV Sandostatin 100mcg/mL Inj Sol-1mL Amp Pk NOV Sandostatin 500mcg/mL Inj Sol-1mL Amp Pk NOV Sandostatin 200mcg/mL Inj Sol - 5mL Vial Pk NOV Sectral 100mg Tab SAV Sectral 200mg Tab SAV Sectral 400mg Tab SAV Sensipar 30mg Tab AMG Sensipar 60mg Tab AMG Sensipar 90mg Tab AMG Silkis 3mcg/g Oint GAC Sofracort 5mg & 50mcg & Oph/Ot Sol SAV mg/mL Somatuline Autogel 60mg/0.3mL ER Pref Syr-0.3mL IPS Pk Somatuline Autogel 90mg/0.3mL ER Pref Syr-0.3mL IPS Pk Somatuline Autogel 120mg/0.5mL ER Pref Syr-0.5mL IPS Sprycel 20mg Tab BQU Page 18

19 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Sprycel 50mg Tab BQU Sprycel 70mg Tab BQU Sprycel 100mg Tab BQU Stalevo 50 & 12.5 & 200mg Tab NOV Stalevo 75 & & 200mg Tab NOV Stalevo 100 & 25 & 200mg Tab NOV Stalevo 125 & & 200mg Tab NOV Stalevo 150 & 37.5 & 200mg Tab NOV Stieva-A 0.01% Cr STI Stieva-A 0.025% Cr STI Stieva-A 0.05% Cr STI Stieva-A 0.025% Gel STI Stievamycin Gel 0.025% & 4% Top Gel STI Sulcrate 1g Tab BFI Sulcrate Suspension 1g/5mL Oral Susp BFI Plus Suprax 20mg/mL Oral Susp SAV Suprax 400mg Tab SAV Suprefact 1mg/mL Inj Sol-5.5mL Pk SAV Suprefact 1mg/mL Nas Sp-10mL Pk SAV Suprefact Depot 6.3mg Implant Kit SAV Suprefact Depot 9.45mg Implant Kit SAV 1, Sustiva 50mg Cap BQU Sustiva 200mg Cap BQU Sustiva 600mg Tab BQU Synacthen Depot 1mg/mL Inj Susp-1mL Pk NOV Tamiflu 30mg Cap HLR Tamiflu 45mg Cap HLR Tamiflu 75mg Cap HLR Tasigna 150mg Cap NOV Tasigna 200mg Cap NOV Tegretol 100mg Chew Tab NOV Tegretol 200mg Chew Tab NOV Tegretol 100mg/5mL Oral Susp NOV Tegretol CR 200mg LA Tab NOV Tegretol CR 400mg LA Tab NOV Telzir 50mg/mL Oral Susp VIH Telzir 700mg Tab VIH Testim 1% Top Gel-5g Pk PAL TOBI 300mg/5mL Inh Sol-5mL Pk NOV TobraDex 0.3% & 0.1% Oph Oint ALC TobraDex 0.3% & 0.1% Oph Susp ALC Tobrex 0.3% Oph Oint ALC Tobrex 0.3% Oph Sol ALC Trandate 100mg Tab PAL Trandate 200mg Tab PAL Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch NOV Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch NOV Travatan Z 0.004% Oph Sol-2.5mL Pk ALC Page 19

20 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Travatan Z 0.004% Oph Sol-5mL Pk ALC Trelstar (1 Month) 3.75mg/Vial Inj Pd-Vial Pk PAL Trelstar (1 Month) 3.75mg/Vial Inj Pd with Sterile PAL Water-Vial Pk Trelstar LA (3 Month) 11.25mg/Vial Inj Pd-Vial Pk PAL Trelstar LA (3 Month) 11.25mg/Vial Inj Pd with Sterile PAL Water-Vial Pk Trinipatch 0.4mg/Hr/14 Sq Cm Patch PAL Trinipatch 0.6mg/Hr/21 Sq Cm Patch PAL Trizivir 300mg/150mg/300mg Tab VIH Trosec 20mg Tab SUO Truvada 200mg & 300mg Tab GIL Uniphyl 400mg SR Tab PFP Uniphyl 400mg SR Tab PFP Uremol-HC 1% & 10% Cr STI Uremol-HC 1% & 10% Lot STI Urso 250mg Tab BFI Urso DS 500mg Tab BFI Vagifem 10 10mcg Vag Tab with NOO Valcyte 450mg Tab Applicator HLR Valtrex 500mg Tab GSK Ventolin 5mg/mL Inh Sol-10mL Pk GSK Ventolin Nebules P.F. 1mg/mL Inh Sol- 2.5mL Pk GSK Ventolin Nebules P.F. 2mg/mL Inh Sol- 2.5mL Pk GSK Vepesid 50mg Cap BQU Videx EC 125mg Enteric Coated Cap BQU Videx EC 200mg Enteric Coated Cap BQU Videx EC 250mg Enteric Coated Cap BQU Videx EC 400mg Enteric Coated Cap BQU Viokase 8000 & & Tab BFI USP Units Viokase & & Pd-114g Pk BFI USP U/0.7g Viokase 16 16mg Tab BFI Viracept 250mg Tab PFI Viracept 625mg Tab PFI Viread 300mg Tab GIL Viskazide 10/25 10mg & 25mg Tab NOV Viskazide 10/50 10mg & 50mg Tab NOV Visken 5mg Tab NOV Visken 10mg Tab NOV Visken 15mg Tab NOV Voltaren 50mg Ent Tab NOV Voltaren 50mg Sup NOV Page 20

21 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Voltaren 100mg Sup NOV Voltaren Ophtha 0.1% OPH SOL NOV Xatral 10mg Prolong-Rel Tab SAV Xgeva 120mg/1.7mL Inj Sol-Vial Pk AMG Zantac 50mg/2mL Inj Sol-2mL Pk GSK Zaroxolyn 2.5mg Tab SAV Zerit 15mg Cap BQU Zerit 20mg Cap BQU Zerit 30mg Cap BQU Zerit 40mg Cap BQU Zofran 4mg Tab GSK Zofran 8mg Tab GSK Zofran 4mg/5mL O/L GSK Page 21

22 New Manufacturer Name(s) DIN BRAND STRENGTH DOSAGE FORM MFR Cordarone 200mg Tab PFI Min-Ovral 0.03mg & 0.15mg Tab-21 Pk PFI Min-Ovral 0.03mg & 0.15mg Tab-28 Pk PFI Olestyr 4g/5g Pk Oral Pd-Pouch Pk PEN Olestyr 4g/9g Pk Oral Pd-Pouch Pk PEN Phl-Paroxetine 10mg Tab MEL Premarin 0.625mg Tab PFI Premarin 0.625mg/g Vag Cr PFI Zym-Sertraline 25mg Cap MEL Zym-Sertraline 50mg Cap MEL Zym-Sertraline 100mg Cap MEL Page 22

23 Not-A-Benefit Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR Co Pregabalin 25mg Cap COB Co Pregabalin 50mg Cap COB Co Pregabalin 75mg Cap COB Co Pregabalin 150mg Cap COB Co Pregabalin 300mg Cap COB PMS-Pregabalin 25mg Cap PMS PMS-Pregabalin 50mg Cap PMS PMS-Pregabalin 75mg Cap PMS PMS-Pregabalin 150mg Cap PMS PMS-Pregabalin 300mg Cap PMS Sandoz Pregabalin 25mg Cap SDZ Sandoz Pregabalin 50mg Cap SDZ Sandoz Pregabalin 75mg Cap SDZ Sandoz Pregabalin 150mg Cap SDZ Sandoz Pregabalin 300mg Cap SDZ Teva-Quetiapine XR 50mg ER Tab TEV Teva-Quetiapine XR 150mg ER Tab TEV Teva-Quetiapine XR 200mg ER Tab TEV Teva-Quetiapine XR 300mg ER Tab TEV Teva-Quetiapine XR 400mg ER Tab TEV (Interchangeable with Seroquel XR) Page 23

24 Status Change(s) from Not-A-Benefit to General Benefit DIN BRAND STRENGTH DOSAGE FORM MFR DBP PMS-Enalapril 2.5mg Tab PMS PMS-Enalapril 5mg Tab PMS PMS-Enalapril 10mg Tab PMS PMS-Enalapril 20mg Tab PMS (Interchangeable with Vasotec) ** Each tablet is made with 2.5mg, 5mg, 10mg or 20mg enalapril maleate that is equivalent to 2mg, 4mg, 8mg or 16mg of enalapril sodium, respectively, in the finish tablets. Page 24

25 Trade Name Change(s) DIN BRAND STRENGTH DOSAGE FORM MFR Min-Ovral mg & 0.15mg Tab-21 Pk WAY Min-Ovral mg & 0.15mg Tab-28 Pk WAY Paroxetine 10mg Tab PHE Premarin Vaginal Cream 0.625mg/g Vag Cr WAY Sertraline 25mg Cap ZYN Sertraline 50mg Cap ZYN Sertraline 100mg Cap ZYN Page 25

UPDATE AG Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 24, 2012 SUMMARY OF CHANGES

UPDATE AG Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 24, 2012 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 4 Off Formulary