Ontario Drug Benefit Formulary/ Comparative Drug Index

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1 Ontario Drug Benefit Formulary/ Comparative Drug Index Edition 42 Summary of Changes January 2014 Effective January 30, 2014 Ministry of Health and Long-Term Care

2 Table of Contents Additions to Formulary... 3 New Multi-Source Products... 4 Off-Formulary Interchangeable (OFI) Products... 9 Changes to Current Formulary Products Drug Benefit Price (DBP) Changes OFI Product Price Changes Exceptional Access Program (EAP) Product Price Changes Status Change from Not-A-Benefit to General Benefit Status Change from Discontinued Drug to Not-A-Benefit DIN/PIN Change Product Manufacturer Name Change Removals from Formulary Manufacturer Requested Delisting Discontinued Drug (Removed From Payment & Listing)

3 Additions to Formulary 3

4 New Multi-Source Products DIN BRAND NAME STRENGTH DOSAGE MFR DBP Apo-Azithromycin Z 250mg Tab APX (Interchangeable with Zithromax) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Gd-Azithromycin 100mg/5mL O/L-15mL Pk GEM Gd-Azithromycin 200mg/5mL O/L-15mL Pk GEM Gd-Azithromycin 200mg/5mL O/L-22.5mL Pk GEM (Interchangeable with Zithromax) 4

5 New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Med-Exemestane 25mg Tab GMP (Interchangeable with Aromasin) Reason for Use Code & Clinical Criteria Code 180 For the hormonal treatment of metastatic breast cancer in hormone receptor positive post-menopausal women who have disease progression following tamoxifen therapy. LU Authorization Period: Indefinite. Code 407 For the sequential treatment of postmenopausal women with estrogen receptor-positive early breast cancer who have received 2-3 years of initial adjuvant tamoxifen therapy. LU Authorization Period: Treatment period required to complete a total of 5 years of adjuvant therapy. Code 450 In combination with everolimus, for the treatment of hormone-receptor positive HER2 negative advanced breast cancer, in postmenopausal women with ECOG performance status less than or equal to 2 after recurrence or progression following a non-steroidal aromatase inhibitor (NSAI). LU Authorization Period: 1 year. 5

6 New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Med-Rivastigmine 1.5mg Cap GMP Med-Rivastigmine 3mg Cap GMP Med-Rivastigmine 4.5mg Cap GMP Med-Rivastigmine 6mg Cap GMP (Interchangeable with Exelon) Reason for Use Code & 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. 6

7 New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Med-Rosuvastatin 5mg Tab GMP Med-Rosuvastatin 10mg Tab GMP Med-Rosuvastatin 20mg Tab GMP Med-Rosuvastatin 40mg Tab GMP (Interchangeable with Crestor) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Mirvala mg & 0.03mg Tab-21 Pk APX (Interchangeable with Marvelon 21) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Mirvala mg & 0.03mg Tab-28 Pk APX (Interchangeable with Marvelon 28) 7

8 New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP Sandoz Tacrolimus 1mg Cap SDZ Sandoz Tacrolimus 5mg Cap SDZ (Interchangeable with Prograf) Reason For Use Code Clinical Criteria Code 173 For solid organ transplant and bone marrow transplant. LU Authorization Period: Indefinite. 8

9 Off-Formulary Interchangeable (OFI) Products DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST Apo-Imiquimod 5% Top Cr 250mg-UD Pk APX (Interchangeable with Aldara) DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST Mylan-Atovaquone/Proguanil 250mg & 100mg Tab MYL (Interchangeable with Malarone) 9

10 Changes to Current Formulary Products 10

11 Drug Benefit Price (DBP) Changes DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Adalat XL 20mg ER Tab BAY Adderall XR 5mg ER Cap SHI Adderall XR 10mg ER Cap SHI Adderall XR 15mg ER Cap SHI Adderall XR 20mg ER Cap SHI Adderall XR 25mg ER Cap SHI Adderall XR 30mg ER Cap SHI Aldactazide-25 25mg & 25mg Tab PFI Aldactazide-50 50mg & 50mg Tab PFI Aldactone 25mg Tab PFI Aldactone 100mg Tab PFI Aricept 5mg Tab PFI Aricept 10mg Tab PFI Atacand 4mg Tab AZC Atacand 8mg Tab AZC Atacand 16mg Tab AZC Atacand 32mg Tab AZC Atacand Plus 16mg & 12.5mg Tab AZC Atacand Plus 32mg & 12.5mg Tab AZC Atacand Plus 32mg & 25mg Tab AZC Ativan 0.5mg Tab PFI Ativan 1mg Tab PFI Ativan 2mg Tab PFI Avelox 400mg Tab BAY Bonefos 400mg Cap BAY Brevicon 0.035mg & 0.5mg Tab-21 Pk PFI Brevicon 0.035mg & 0.5mg Tab-28 Pk PFI Brevicon 1/ mg & 1mg Tab-21 Pk PFI Brevicon 1/ mg & 1mg Tab-28 Pk PFI

12 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Cardura-1 1mg Tab AZC Cardura-2 2mg Tab AZC Cardura-4 4mg Tab AZC Casodex 50mg Tab AZC Celebrex 100mg Cap PFI Celebrex 200mg Cap PFI Champix 0.5mg Tab PFI Champix 1.0mg Tab PFI Champix 0.5mg & 1.0mg Tabs (Starter Pack) PFI Cipralex MELTZ 10mg Orally VLH Disintegrating Tab Cipralex MELTZ 20mg Orally Disintegrating Tab VLH Cipro 250mg Tab BAY Cipro 500mg Tab BAY Cipro 750mg Tab BAY Cipro 10g/100mL Oral Susp BAY Cipro XL 500mg ER Tab BAY Cipro XL 1000mg ER Tab BAY Colestid Orange Gran-7.5g Pk PFI Cortef 10mg Tab PFI Cortef 20mg Tab PFI Cosopt 2% & 0.5% Oph Sol MFC Cosopt 2% & 0.5% Oph Sol-0.2mL MFC Preservative free Pk Cotazym 8000 & & Cap ORG USP Unit Cotazym ECS & & USP Unit Ent Microsph Cap ORG Cotazym ECS & & USP Unit Ent Microsph Cap ORG

13 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Cozaar 25mg Tab MFC Cozaar 50mg Tab MFC Cozaar 100mg Tab MFC Crestor 10mg Tab AZC Crestor 20mg Tab AZC Crestor 40mg Tab AZC Crestor 5mg Tab AZC Cyclen 0.25mg & 0.035mg Tab-21 Pk JAN Cyclen 0.25mg & 0.035mg Tab-28 Pk JAN Dalacin C 150mg Cap PFI Dalacin C 300mg Cap PFI Dalacin C 15mg/mL Pd for Oral Susp PFI Flavoured Granules Demulen mg & 2mg Tab-21 Pk PFI Demulen mg & 2mg Tab-28 Pk PFI Depo-Medrol 40mg/mL Inj Susp-1mL Pk PFI Depo-Medrol 80mg/mL Inj Susp-1mL Pk PFI Depo-Medrol 100mg/5mL Inj Susp-5mL Pk PFI Depo-Testosterone 100mg/mL Oily Inj Sol-10mL Pk PFI Detrol 2mg Tab PFI Detrol LA 2mg SR Cap PFI Detrol LA 4mg SR Cap PFI Diflucan P.O.S. 10mg/mL O/L PFI Dilantin 30mg Cap PFI Dilantin 100mg Cap PFI Dilantin 6mg/mL O/L PFI Dilantin 25mg/mL O/L PFI Dilantin 50mg Tab PFI

14 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Edurant 25mg Tab JAN Emcyt 140mg Cap PFI Eprex 20,000IU/0.5mL Pref Syr-0.5mL Pk JAN Eprex 40,000IU/mL Pref Syr - 1mL Pk JAN Fragmin 2500IU/0.2mL Inj Pref Syr PFI Fragmin 5000IU/0.2mL Inj Pref Syr PFI Fragmin 10000IU/mL Inj Sol-1mL Pk PFI Fragmin 25000IU/mL Multidose 3.8mL Pk PFI Fragmin 7500IU/0.3mL Inj Pref Syr PFI Fragmin 10000IU/0.4mL Inj Pref Syr PFI Fragmin 12500IU/0.5mL Inj Pref Syr PFI Fragmin 15000IU/0.6mL Inj Pref Syr PFI Fragmin 18000IU/0.72mL Inj Pref Syr PFI Glucobay 50mg Tab BAY Glucobay 100mg Tab BAY Hyzaar 50mg & 12.5mg Tab MFC Hyzaar 100mg & 12.5mg Tab MFC Hyzaar DS 100mg & 25mg Tab MFC Intelence 100mg Tab JAN Intelence 200mg Tab JAN Invega Sustenna 50mg Inj Pref Syr JAN Invega Sustenna 75mg Inj Pref Syr JAN Invega Sustenna 100mg Inj Pref Syr JAN Invega Sustenna 150mg Inj Pref Syr JAN Leucovorin Calcium 5mg Tab WAY Lomotil 2.5mg & 0.025mg Tab PFI Loniten 2.5mg Tab PFI Loniten 10mg Tab PFI

15 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Losec DR Tab 20mg AZC Losec DR Tab 20mg AZC Lyrica 150mg Cap PFI Lyrica 300mg Cap PFI Marvelon mg & 0.03mg Tab-21 Pk ORG Marvelon mg & 0.03mg Tab-28 Pk ORG Medrol 4mg Tab PFI Methotrexate 2.5mg Tab PFI Mezavant 1.2g Delayed & ER Tab SHI Micronor 0.35mg Tab-28 Pk JAN Min-Ovral mg & 0.15mg Tab-21 Pk PFI Min-Ovral mg & 0.15mg Tab-28 Pk PFI Mirena 52mg Insert BAY Mycobutin 150mg Cap PFI Neurontin 100mg Cap PFI Neurontin 300mg Cap PFI Neurontin 400mg Cap PFI Nimotop 30mg Tab BAH Nitro-Dur 0.4mg/Hr Transdermal Patch SCH Nitro-Dur 0.6mg/Hr Transdermal Patch SCH Nitrostat 0.3mg SL Tab PFI Nitrostat 0.6mg SL Tab PFI Olmetec 20mg Tab SCP Olmetec 40mg Tab SCP Olmetec Plus 20mg & 12.5mg Tab SCP Olmetec Plus 40mg & 12.5mg Tab SCP Olmetec Plus 40mg & 25mg Tab SCP

16 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Ortho 0.5/ mg & 0.5mg Tab-21 Pk JAN Ortho 0.5/ mg & 0.5mg Tab-28 Pk JAN Ortho 1/ mg & 1mg Tab-28 Pk JAN Ortho 1/ mg & 1mg Tab-21 Pk JAN Ortho 7/7/7 3 Phase Tab-21 Pk JAN Ortho 7/7/7 3 Phase Tab-28 Pk JAN Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk JAN Pancrease MT & & USP Unit Ent Microsph Cap JAN Premarin 0.625mg Tab PFI Premarin 0.625mg/g Vag Cr PFI Vaginal Cream Prinivil 10mg Tab MFC Prinivil 20mg Tab MFC Prinzide 20mg & 12.5mg Tab MFC Proscar 5mg Tab MFC Provera 5mg Tab PFI Provera 2.5mg Tab PFI Provera 10mg Tab PFI Pulmicort 400mcg/Metered Pd Inh-200 AZC Turbuhaler Dose Dose Pk Rapamune 1mg/mL O/L WAY Rapamune 1mg Tab WAY Remeron 30mg Tab ORG Remeron RD 15mg Orally ORG Remeron RD 30mg Orally Disintegrating Tab Disintegrating Tab Remeron RD 45mg Orally Disintegrating Tab ORG ORG

17 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Rhinocort Aqua 64mcg/Metered Nas Sp-120 AZC Dose Dose Pk Rhinocort 100mcg/Metered Nas Aero 200 AZC Turbuhaler Dose Dose Risperdal 1mg Tab JAN Risperdal 2mg Tab JAN Risperdal 3mg Tab JAN Risperdal 4mg Tab JAN Risperdal 0.25mg Tab JAN Risperdal 0.5mg Tab JAN Risperdal Consta 25mg Pd for Inj-Vial Pk JAN Risperdal Consta 37.5mg Pd for Inj-Vial Pk JAN Risperdal Consta 50mg Pd for Inj-Vial Pk JAN Salazopyrin 500mg Ent Tab PFI Salazopyrin 500mg Tab PFI Sinemet 250mg & 25mg Tab MFC Sinemet 100mg & 10mg Tab MFC Sinemet 100mg & 25mg Tab MFC Sinemet CR 200mg & 50mg Tab MFC Sinemet CR 100mg & 25mg Tab MFC Symbicort mcg/6mcg Pd Inh-120 AZC Turbuhaler Dose Pk Symbicort mcg/6mcg Pd Inh-120 AZC Turbuhaler Dose Pk Synphasic 3 Phase Tab-21 Pk PFI Synphasic 3 Phase Tab-28 Pk PFI Tenoretic 100/ & 25mg Tab AZC Tenoretic 50/25 50 & 25mg Tab AZC Tenormin 50mg Tab AZC Tenormin 100mg Tab AZC Terazol % Vag Cr JAN

18 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Timoptic 0.50% Oph Sol MFC Timoptic-XE 0.25% Oph Gellan Sol MFC Timoptic-XE 0.50% Oph Gellan Sol MFC Topamax 25mg Tab JNO Topamax 100mg Tab JNO Topamax 200mg Tab JNO Topamax Sprinkle 15mg Sprinkle Cap JNO Topamax Sprinkle 25mg Sprinkle Cap JNO Tri-Cyclen 3 Phase Tab-21 Pk JAN Tri-Cyclen 3 Phase Tab-28 Pk JAN Tri-Cyclen Lo 3 Phase Tab-21 Pk JAN Tri-Cyclen Lo 3 Phase Tab-28 Pk JAN Triquilar 21 3 Phase Tab-21 Pk BAY Triquilar 28 3 Phase Tab-28 Pk BAY Trusopt 2% Oph Sol MFC Vasotec 10mg Tab MFC Vasotec 20mg Tab MFC Vasotec 5mg Tab MFC Vasotec 2.5mg Tab MFC Vermox 100mg Tab JAN Vfend 50mg Tab PFI Vfend 200mg Tab PFI Vyvanse 30mg Cap SHI Vyvanse 50mg Cap SHI Vyvanse 20mg Cap SHI Vyvanse 40mg Cap SHI Vyvanse 60mg Cap SHI

19 Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Xanax 0.25mg Tab PFI Xanax 0.5mg Tab PFI Yasmin mg & 0.03mg Tab-21 Pk BAH Yasmin mg & 0.03mg Tab-28 Pk BAH Yaz 3.0mg & 0.02mg Tab-28 Pk BAH Zeldox 20mg Cap PFI Zeldox 40mg Cap PFI Zeldox 60mg Cap PFI Zeldox 80mg Cap PFI Zestoretic 20mg & 12.5mg Tab AZC Zestoretic 10mg & 12.5mg Tab AZC Zestril 5mg Tab AZC Zestril 10mg Tab AZC Zestril 20mg Tab AZC Zithromax 250mg Tab PFI Zithromax 100mg/5mL O/L-15mL Pk PFI Zithromax 200mg/5mL O/L-15mL Pk PFI Zithromax 200mg/5mL O/L-22.5mL Pk PFI Zocor 5mg Tab MFC Zocor 10mg Tab MFC Zocor 20mg Tab MFC Zocor 40mg Tab MFC Zocor 80mg Tab MFC Zoladex 3.6mg Depot Inj AZC Zoladex LA 10.8mg Depot Inj AZC 1, Zyvoxam 600mg Tab PFI

20 OFI Product Price Changes DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST Mint-Montelukast 5mg Chew Tab MIN Mint-Montelukast 10mg Tab MIN Mint-Pioglitazone 15mg Tab MIN Mint-Pioglitazone 30mg Tab MIN Mint-Pioglitazone 45mg Tab MIN

21 Exceptional Access Program (EAP) Product Price Changes DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP Fosrenol 250mg Chew Tab SHI Fosrenol 500mg Chew Tab SHI Fosrenol 750mg Chew Tab SHI Fosrenol 1000mg Chew Tab SHI Nexavar 200mg Tab BAY Remicade 100mg/10mL Inj. JAN Remicade 100mg/10mL Injection (Compounded) JAN Simponi 50mg/0.5mL Pre-Filled Syringe JAN Simponi 50mg/0.5mL Auto-Injector JAN Sutent 12.5mg Cap PFI Sutent 25mg Cap PFI Sutent 50mg Cap PFI Zytiga 250mg Tab JAN

22 Status Change from Not-A-Benefit to General Benefit DIN BRAND NAME STRENGTH DOSAGE MFR DBP Teva-Risedronate 150mg Tab TEV (Interchangeable with Actonel) 22

23 Status Change from Discontinued Drug to Not-A-Benefit DIN BRAND STRENGTH DOSAGE MFR Apo-Diflunisal 500mg Tab APX (Interchangeable with Dolobid) 23

24 DIN/PIN Change CURRENT DIN/PIN NEW DIN/PIN BRAND NAME STRENGTH DOSAGE MFR Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk AMG 24

25 Product Manufacturer Name Change DIN BRAND NAME STRENGTH DOSAGE Current MFR New MFR Axid 150mg Cap MMT PEN 25

26 Removals from Formulary (Removals from payment and listing) 26

27 Manufacturer Requested Delisting DIN BRAND NAME STRENGTH DOSAGE MFR Novo-Ferrogluc 300mg Tab NOP 27

28 Discontinued Drug (Removed From Payment & Listing) DIN BRAND NAME STRENGTH DOSAGE MFR Kytril* 1mg Tab HLR * Remains in the Formulary as Not-A-Benefit (NAB) as the brand reference product to the generics in the interchangeable group. 28

Ontario Drug Benefit Formulary/Comparative Drug Index

Ontario Drug Benefit Formulary/Comparative Drug Index Edition 42 Summary of Changes - January 2015 Effective January 28, 2015 Ministry of Health and Long-Term Care Table of Contents New Multi-Source Products...