PEI Drug Programs. Issue October, 2006
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1 PEI Drug Programs Formulary Update Issue October, 2006 The following changes and additions to the July 2006 edition of the PEI Drug Programs Formulary will be effective th October 16, 2006 unless otherwise noted within this update. If there are any questions regarding the information presented in this update please call the Drug Program office at or toll free at Changes and Additions To The Formulary & MAC Pricing ALMOTRIPTAN (new addition) EDS Criteria: For the treatment of migraine headaches where other standard therapies, such as analgesics and/or ergotamine products have failed. Eligibility is restricted to persons over the age of 18 and under 65 years of age. Coverage is limited to 6 tablets per 30 day period. Persons requiring more than 6 doses per 30 day period should be considered for migraine prophylaxis therapy if they are not already receiving such therapy. 6.25mg tablet AXERT (EDS) JAN FW 12.5mg tablet AXERT (EDS) JAN FW DILTIAZEM HYDROCHLORIDE (new addition) 120mg capsule TIAZAC BVL FNSW 180mg capsule TIAZAC BVL FNSW 240mg capsule TIAZAC BVL FNSW 300mg capsule TIAZAC BVL FNSW 360mg capsule TIAZAC BVL FNSW Issue October 2006 Page 1
2 DILTIAZEM HYDROCHLORIDE (new addition) 120mg extended release tablet TIAZAC XC BVL FNSW 180mg extended release tablet TIAZAC XC BVL FNSW 240mg extended release tablet TIAZAC XC BVL FNSW 300mg extended release tablet TIAZAC XC BVL FNSW 360mg extended release tablet TIAZAC XC BVL FNSW ETHINYL ESTRADIOL/DROSPIRENONE (new addition) 3.0mg/0.03mg tablets YASMIN 21 DAY BEX FW YASMIN 28 DAY BEX FW ESPROSARTAN MESYLATE & HYDROCHLOROTHIAZIDE (new addition) 600mg & 12.5mg tablet TEVETEN PLUS SLV FNSW GABAPENTIN (change) There is no longer an EDS restriction on this drug. 100mg capsule NEURONTIN PFI FNSW PMS-GABAPENTIN PMS FNSW APO-GABAPENTIN APX FNSW NOVO-GABAPENTIN NOP FNSW GEN-GABAPENTIN GPM FNSW CO GABAPENTIN COB FNSW RATIO-GABAPENTIN RPH FNSW 300mg capsule NEURONTIN PFI FNSW PMS-GABAPENTIN PMS FNSW APO-GABAPENTIN APX FNSW NOVO-GABAPENTIN NOP FNSW GEN-GABAPENTIN GPM FNSW CO GABAPENTIN COB FNSW RATIO-GABAPENTIN RPH FNSW Issue October 2006 Page 2
3 GABAPENTIN (continued) 400mg capsule NEURONTIN PFI FNSW PMS-GABAPENTIN PMS FNSW APO-GABAPENTIN APX FNSW NOVO-GABAPENTIN NOP FNSW GEN-GABAPENTIN GPM FNSW CO GABAPENTIN COB FNSW RATIO-GABAPENTIN RPH FNSW GABAPENTIN (new addition and MAC pricing) MAC Prices in effect Nov 1, mg capsule NEURONTIN PFI FNSW MAC NOVO-GABAPENTIN NOP FNSW PMS-GABAPENTIN PMS FNSW RATIO-GABAPENTIN RPH FNSW 800mg capsule NEURONTIN PFI FNSW MAC NOVO-GABAPENTIN NOP FNSW PMS-GABAPENTIN PMS FNSW RATIO-GABAPENTIN RPH FNSW GALANTAMINE (new addition) See Appendix A ( Page 210) in the formulary for the criteria for coverage of the cholinesterase inhibitors. 8mg extended release capsule REMINYL ER(EDS) JAN FNSW 16mg extended release capsule REMINYL ER(EDS) JAN FNSW 24mg extended release capsule REMINYL ER(EDS) JAN FNSW GOSERELIN ACETATE (change) Coverage has been approved under the Nursing Home and Institutional Programs. 10.8mg depot injection ZOLADEX LA AZE FNSW IMIQUIMOD (change) There is no longer an EDS restriction on this drug 5% topical cream ALDARA MDA FNSW Issue October 2006 Page 3
4 LEUPROLIDE ACETATE (new addition) 7.5mg depot injection ELIGARD AVN FNSW 22.5mg depot injection ELIGARD AVN FNSW LEUPROLIDE ACETATE (change) Coverage has been approved under the Nursing Home and Institutional Programs. 22.5mg/ml depot injection LUPRON DEPOT ABB FNSW OLANZAPINE (new addition) The EDS criteria for Zyprexa Zydis are the same as for regular olanzapine tablets. See Appendix A (page 230) for the EDS criteria. Family Health Benefit and Financial Assistance Programs do not require an EDS request to be submitted. 5mg orally disintegrating tablet ZYPREXA ZYDIS (EDS) LIL FNSW 10mg orally disintegrating tablet ZYPREXA ZYDIS (EDS) LIL FNSW 15mg orally disintegrating tablet ZYPREXA ZYDIS (EDS) LIL FNSW RISPERIDONE (new addition and MAC Pricing effective November 1, 2006) Due to the significant difference in cost between generic regular risperidone tablets and the oral solution, coverage of the oral solution under all eligible programs will require submission of an Exceptional Drug Request. Coverage will be limited to patients unable to use regular risperidone tablets. 0.25mg tablet See Appendix A( Page 236) for EDS criteria ( Family Health Benefit, Financial Assistance and Nursing Home programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW \ Issue October 2006 Page 4
5 RISPERIDONE (continued) 0.5mg tablet See Appendix A (Page 236) for EDS criteria ( Family Health Benefit, Financial Assistance and Nursing Home programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW 1mg tablet See Appendix A (Page 236) for EDS criteria ( Family Health Benefit, Financial Assistance and Nursing Home programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW 2mg tablet See Appendix A (Page 236) for EDS criteria ( Family Health Benefitand Financial Assistance programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW Issue October 2006 Page 5
6 RISPERIDONE (continued) 3mg tablet See Appendix A (Page 236) for EDS criteria ( Family Health Benefit and Financial Assistance programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW 4mg tablet See Appendix A (Page 236) for EDS criteria ( Family Health Benefit and Financial Assistance programs do not require an EDS request to be submitted) RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW CO RISPERIDONE (EDS) COB FNSW GEN-RISPERIDONE (EDS) GPM FNSW NOVO-RISPERIDONE (EDS) NOP FNSW PMS-RISPERIDONE (EDS) PMS FNSW RAN-RISPERIDONE (EDS) RAN FNSW RATIO-RISPERIDONE (EDS) RPH FNSW SANDOZ-RISPERIDONE (EDS) SDZ RNSW 1mg/ml oral solution See Appendix A (page 236) for EDS criteria RISPERDAL (EDS) JAN FNSW MAC APO-RISPERIDONE (EDS) APX FNSW PMS-RISPERIDONE (EDS) PMS FNSW RISPERIDONE - Orally Disintegrating Tablet (change) Due to the recent introduction of generic regular risperidone tablets there is now a significant difference in cost between regular risperidone tablets and the orally disintegrating tablets. As a result, the coverage of Risperdal M-Tabs under all eligible programs will now require submission of an Exceptional Drug Request. See Appendix A (page 236) for EDS criteria. Coverage will be limited to patients unable to use regular risperidone tablets. Coverage for patients already using Risperdal M-Tabs will be automatically approved. 0.5mg orally disintegrating tablet RISPERDAL M-TAB (EDS) JAN FNSW 1mg orally disintegrating tablet RISPERDAL M-TAB (EDS) JAN FNSW Issue October 2006 Page 6
7 RISPERIDONE - Orally Disintegrating Tablet (continued) 2mg orally disintegrating tablet RISPERDAL M-TAB (EDS) JAN FNSW 3mg orally disintegrating tablet RISPERDAL M-TAB (EDS) JAN FNSW 4mg orally disintegrating tablet RISPERDAL M-TAB (EDS) JAN FNSW 2.0 New High Cost Drug Application form for Clients The High Cost Drug Application form has been changed. There has been an area added that allows the client to indicate the appropriate program. A copy of the new form is attached to this update. 3.0 Discontinued Products ALLOPURINOL 100mg tablet ZYLOPRIM GSK FNSW 200mg tablet ZYLOPRIM GSK FNSW 300mg tablet ZYLOPRIM GSK FNSW AMPICILLIN 25mg/ml oral suspension NU-AMPI NXP CFNSW 50mg/ml oral suspension NU-AMPI NXP CFNSW 250mg capsule APO-AMPI APX CFNSW NU-AMPI NXP CFNSW 500mg capsule APO-AMPI APX CFNSW NU-AMPI NXP CFNSW CHOLESTYRAMINE Regular - 440mg/g oral powder (378g can) PMS-CHOLESTYRAMINE PMS FNSW NOVO-CHOLAMINE NOP FNSW Regular - 4g/Pouch X 30 Pouches NOVO-CHOLAMINE NOP FNSW Issue October 2006 Page 7
8 CHOLESTYRAMINE (continued) Light - 440mg/g oral powder (can) PMS-CHOLESTYRAMINE (400G) PMS FNSW NOVO-CHOLAMINE NOP FNSW Light - 4g/pouch X 30 pouches NOVO-CHOLAMINE LIGHT NOP FNSW GALANTIMINE 4mg tablet REMINYL JAN FNSW 8mg tablet REMINYL JAN FNSW 12mg tablet REMINYL JAN FNSW LISINOPRIL 5mg tablet APO-LISINOPRIL APX FNSW 10mg tablet APO-LISINOPRIL APX FNSW 20mg tablet APO-LISINOPRIL APX FNSW METHIMAZOLE 5mg tablet PMS-METHIMAZOLE PMS FNSW APO-METHIMAZOLE APX FNSW METHYLCELLULOSE POWDER PRODIEM BULK FIBRE THERAPY NVR NW QUETIAPINE 150mg tablet SEROQUEL AZE FNSW THIORIDAZINE 10mg tablet APO-THIORIDAZINE APX FW 25mg tablet APO-THIORIDAZINE APX FW 50mg tablet APO-THIORIDAZINE APX FW 100mg tablet APO-THIORIDAZINE APX FW Issue October 2006 Page 8
Manager, PEI Drug Programs Date : December 7, 2009 Tel / Tél : (902) Fax / Téléc : (902)
DRAFT To / Destinataire : All Retail Pharmacists and Staff From / Expéditeur : Faye Campbell Manager, PEI Drug Programs Date : December 7, 2009 Tel / Tél : (902) 368-6338 Fax / Téléc : (902) 368-4905 Subject
Pharmacy Consultant, PEI Drug Programs Date : September 8, 2009 Tel / Tél : (902) Fax / Téléc : (902)
To / Destinataire : All Retail Pharmacists and Staff From / Expéditeur : Patrick Crawford Pharmacy Consultant, PEI Drug Programs Date : September 8, 2009 Tel / Tél : (902) 368-6711 Fax / Téléc : (902)
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