BULLETIN # 91. Manitoba Drug Benefits and Interchangeability Formulary Amendments. The following amendments will take effect on April 20, 2017

Transcription

1 BULLETIN # 91 Manitoba Drug Benefits and Interchangeability Formulary Amendments The following amendments will take effect on April 20, 2017 The amended Manitoba Specified Drug Regulation and Drug Interchangeability Formulary Regulation will be available on the Manitoba Health website on the effective date of April 20, 2017 Bulletin 91 is currently available for download: Inside This Issue Part 1 Additions Page 1-2 Part 2 Additions Page 2 Part 3 Additions Page 2-4 New Interchangeable Categories Page 5-6 New Interchangeable Products Page 6-8 Product Deletions Page 8 Categor Deletions Page 8 Interchangeable Product Price Changes Page 8-13 pan-canadian Price Changes Page Discontinued Products Page 14

2 Part 1 Additions Bulletin #91 DIN TRADE NAME GENERIC STRENGTH FORM MFR* Auro- Abacavir/Lamivudine abacavir/lamivudine 600/300 mg AUP Auro-Candesartan HCT candesartan/hctz 16 mg/12.5 mg AUP Auro-Losartan HCT losartan/hctz 50 mg/12.5 mg 100 mg/12.5 mg 100 mg/25 mg AUP Auro-Telmisartan telmisartan 40 mg 80 mg AUP Auro-Telmisartan HCTZ telmisartan/hctz 80 mg/12.5 mg 80 mg/25 mg AUP Cholestyramine-Odan cholestyramine 4 g/sachet Powder ODN Creon Minimicrospheres Micro lipase/amylase/protease - Granules MYL Euro-Hydrocortisone hydrocortisone 1% Cream SDZ Mar-Topiramate topiramate 25 mg 100 mg 200 mg MAR Metadol-D methadone hydrochloride 10 mg/ml Oral Concentrate PAL Mint-Gliclazide MR gliclazide 60 mg MPH Mint-Levocarb levodopa/carbidopa 100/10 mg 100/25 mg 250/25 mg MPH Mylan-Buprenorphine/ Naloxone (moved from Part 3) buprenorphine/naloxone 2/0.5 mg 8/2 mg MYL Odan-Erythromycin erythromycin 5 mg/g Ointment ODN Sandoz Diclofenac Optha diclofenac 0.1% Ophthalmic SDZ Suboxone (moved from Part 3) buprenorphine/naloxone 2/0.5 mg 8/2 mg RBP Teva-Buprenorphine/ Naloxone (moved from Part 3) buprenorphine/naloxone 2/0.5 mg 8/2 mg TEV 1 of 14

3 Part 2 Additions Auro-Pramipexole pramipexole 0.25 mg 0.5 mg 1 mg 1.5 mg AUP For the treatment of idiopathic Parkinson's Disease Auro-Rizatriptan rizatriptan 10 mg AUP For the treatment of ACUTE migraine attacks in patients where standard therapy has failed Med-Moxifloxacin moxifloxacin 400 mg GMP (a) Step-down care following hospital separation in patients treated with parenteral antibiotics (b) Treatment of resistant gram-positive or gram-negative infections; (c) Treatment of infections in persons allergic to alternative agents (eg. penicillins, cephalosporins and sulfonamides); (d) Treatment of infections in patients failing or likely to fail or intolerant of penicillins, cephalosporins and/or macrolides NAT-Zolmitriptan zolmitriptan 2.5 mg NAT For the treatment of ACUTE migraine attacks in patients where standard therapy has failed. Part 3 Additions The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis Apo-Sildenafil R sildenafil 20 mg APX When prescribed by a specialist in the treatment of Pulmonary Arterial Hypertension (PAH) for the following indications noted in WHO Group 1 PAH: 1. Idiopathic Pulmonary Arterial Hypertension (IPAH) in WHO functional class II or III, OR 2. PAH secondary to connective tissue disease in patients with WHO functional class II or III 3. Indications associated with pulmonary arterial hypertension secondary to congenital heart disease (CHD) in patients who have not responded to conventional therapy or tolerated other treatments. Note: Diagnosis of PAH should be confirmed by right heart catheterization. The maximum daily dosage allowed for coverage of sildenafil is 20mg three times daily. On written request by PAH specialist only. 2 of 14

4 Levetiracetam levetiracetam 250 mg 500 mg 750 mg As per Keppra criteria ( SIP mg Daklinza daclatasvir BMS 30 mg For use as combination therapy with sofosbuvir (Sovaldi) for treatment-naïve or treatment-experienced adult patients with chronic hepatitis C genotype 3 infection. Complete criteria may be obtained from the EDS office at Manitoba Health. Request for coverage must be made by a hepatologist, gastroenterologist or an infectious disease specialist Epclusa sofosbuvir/velpatasvir 400/100 mg GIL For treatment-naive or treatment-experienced adult patients with chronic hepatitis C genotype 1, 2,3,4,5,6 or mixed genotypes infection. Complete criteria may be obtained from the EDS office at Manitoba Health. Request for coverage must be made by a hepatologist, gastroenterologist or an infectious disease specialist NAT-Levetiracetam levetiracetam 250 mg 500 mg 750 mg As per Keppra criteria ( NAT pms-sildenafil R sildenafil 20 mg PMS When prescribed by a specialist in the treatment of Pulmonary Arterial Hypertension (PAH) for the following indications noted in WHO Group 1 PAH: 1. Idiopathic Pulmonary Arterial Hypertension (IPAH) in WHO functional class II or III, OR 2. PAH secondary to connective tissue disease in patients with WHO functional class II or III 3. Indications associated with pulmonary arterial hypertension secondary to congenital heart disease (CHD) in patients who have not responded to conventional therapy or tolerated other treatments. Note: Diagnosis of PAH should be confirmed by right heart catheterization. The maximum daily dosage allowed for coverage of sildenafil is 20mg three times daily. On written request by PAH specialist only ratio-sildenafil R sildenafil 20 mg TEV When prescribed by a specialist in the treatment of Pulmonary Arterial Hypertension (PAH) for the following indications noted in WHO Group 1 PAH: 1. Idiopathic Pulmonary Arterial Hypertension (IPAH) in WHO functional class II or III, OR 2. PAH secondary to connective tissue disease in patients with WHO functional class II or III 3. Indications associated with pulmonary arterial hypertension secondary to congenital heart disease (CHD) in patients who have not responded to conventional therapy or tolerated other treatments. Note: Diagnosis of PAH should be confirmed by right heart catheterization. The maximum daily dosage allowed for coverage of sildenafil is 20mg three times daily. On written request by PAH specialist only. 3 of 14

5 Revlimid (New Indication) lenalidomide 5 mg 10 mg 15 mg 20 mg 25 mg Capsule As an option for first line treatment of patients with multiple myeloma who are not eligible for autologous stem cell transplantation (TNE). Treatment should be in combination with dexamethasone for patients with an ECOG performance status less than or equal to 2 and until disease progression. CEL Simponi (New Indication and New Strength) golimumab 50 mg/0.5 ml 50 mg/0.5 ml 100 mg/1 ml 100 mg/1 ml Injection For the treatment of patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy including 5-aminosalicylate compounds, corticosteroids and immunomodulators. Request for coverage must be made by a specialist in gastroenterology. JAN mg Solifenacin solifenacin 10 mg As per Vesicare criteria ( s SAH Xolair omalizumab 150 mg/vl Powder NVT For the treatment of adults and adolescents (12 years of age or older) with moderate to severe chronic idiopathic urticaria (CIU) who remain symptomatic (presence of hives and/or associated itching) despite optimum management with available oral therapies. Complete criteria may be obtained from the EDS office at Manitoba Health. Request for coverage must be made by a specialist in allergy, immunology or dermatology with knowledge of CIU treatment Zepatier elbasvir/grazoprevir 50/100 mcg MFX For treatment-naive or treatment-experienced adult patients with chronic hepatitis C genotype 1 or 4 infection. Complete criteria may be obtained from the EDS office at Manitoba Health. Request for coverage must be made by a hepatologist, gastroenterologist or an infectious disease specialist Zytiga (New abraterone acetate 500 mg JAN Strength) For the treatment of metastatic castrate-resistant prostate cancer. Please refer to Bulletin 77 for complete criteria. 4 of 14

6 New Interchangeable Catagories Bulletin #91 Cholestyramine - 4 g - Powder for Suspension $ gram Olestyr PPI Cholestyramine ODN Clobazam - 10 mg - s $ Frisium LUD Apo-Clobazam APX Novo-Clobazam TEV Erythromycin - 5 mg/g - Ointment PDP-Erythromycin PPI Odan-Erythromycin ODN $ gram Ethinyl Estradiol/Drospirenone - 3 mg/0.03 mg - $ Yasmin 21 BAY Zamine 21 APX Zarah 21 ACV Ethinyl Estradiol/Drospirenone - 3 mg/0.03 mg - $ Yasmin 28 BAY Zamine 28 APX Zarah 28 ACV Lorazepam - 1 mg - s $ Ativan PFI Apo-Lorazepam APX Lorazepam SAH Novo-Lorazem TEV pms-lorazepam PMS Sabutamol Sulfate mg/2.5 ml - Unit Dose Nebules $ Ventolin PF GSK Teva-Salbutamol Sterinebs TEV pms-salbutamol PMS Sabutamol Sulfate - 5 mg/2.5 ml - Unit Dose Nebules $ Ventolin PF GSK Teva-Salbutamol Sterinebs TEV pms-salbutamol PMS of 14

7 Sildenafil R - 20 mg - s $ Revatio PFI ratio-sildenafil R TEV pms-sildenafil R PMS Apo-Sildeanfil R APX Tamsulosin mg - Controlled Release s $ Flomax CR BOE Apo-Tamsulosin APX Sandoz Tamsulosin CR SDZ Tamsulosin CR SAH Tamsulosin CR SIP Teva-Tamsulosin CR TEV Valproic Acid - 50 mg/ml - Oral pms-valproic Acid PMS Apo-Valproic APX New Interchangeable Products The following products have been added to existing interchangeable drug categories: Abacavir/Lamivudine - 600/300 mg - s $ Auro-Abacavir/Lamivudine AUP Candesartan/HCTZ - 16/12.5 mg - $ Auro-Candesartan HCT AUP Diclofenac - 0.1% - Ophthalmic $ Sandoz Diclofenac Ophtha SDZ ** Gliclazide MR - 60 mg - $ Mint-Gliclizide MR MPH Levetiracetam mg - $ Levetiracetam SIP NAT-Levetiracetam NAT Levetiracetam mg - $ Levetiracetam SIP NAT-Levetiracetam NAT Levetiracetam mg - $ Levetiracetam SIP NAT-Levetiracetam NAT Levodopa/Carbidopa - 100/10 mg - $ Mint-Levocarb MPH ** of 14

8 Levodopa/Carbidopa - 100/25 mg - $ Mint-Levocarb MPH ** Levodopa/Carbidopa - 250/25 mg - $ Mint-Levocarb MPH ** Losartan/HCTZ - 50/12.5 mg - $ Auro-Losartan HCT AUP Losartan/HCTZ - 100/12.5 mg - $ Auro-Losartan HCT AUP Losartan/HCTZ - 100/25 mg - $ Auro-Losartan HCT AUP Moxifloxacin mg - $ Med-Moxifloxacin GMP Pramipexole mg - $ Auro-Pramipexole AUP ** Pramipexole mg - $ Auro-Pramipexole AUP ** Pramipexole - 1 mg - $ Auro-Pramipexole AUP ** Pramipexole mg - $ Auro-Pramipexole AUP ** Rizatriptan - 10 mg - s $ Auro-Rizatriptan AUP ** Solifenacin - 5 mg - $ Solifenacin SAH Solifenacin - 10 mg - $ Solifenacin SAH Telmisartan - 40 mg - $ Auro-Telmisartan AUP Telmisartan - 80 mg - $ Auro-Telmisartan AUP Telmisartan/HCTZ - 80/12.5 mg - $ Auro-Telmisartan/HCTZ AUP of 14

9 Telmisartan/HCTZ - 80/25 mg - $ Auro-Telmisartan/HCTZ AUP Topiramate - 25 mg - $ Mar-Topiramate MAR Topiramate mg - $ Mar-Topiramate MAR Topiramate mg - $ Mar-Topiramate MAR Zolmitriptan mg - $ NAT-Zolmitriptan NAT ** The price has resulted in a change to the lowest price in the category. The following products have been deleted. Product Deletions Apo-Travoprost Z travoprost 0.004% Ophthalmic Dixarit clonidine mg Metrolotion metronidazole 0.75% Lotion Piportil L4 pipotiazine palmitate 25 mg/ml 50 mg/ml Injection pms-clobazam clobazam 10 mg Zoledronic Acid zoledronic acid 5 mg/100 ml Injection - Risedronate - 30 mg s Category Deletions Interchangeable Product Price Changes The following changes in prices have occurred: ($) TC lamivudine 300 mg Actonel risedronate 5 mg Actonel risedronate 35 mg Acular ketorolac tromethamine 0.5% Ophthalmic of 14

10 Agrylin anagrelide 0.5 mg Alertec modafinil 100 mg Alphagan brimonidine 0.2% Ophthalmic Alphagan P brimonidine 0.15% Ophthalmic Altace ramipril 10 mg Capsule Amaryl glimepiride 1 mg Amaryl glimepiride 2 mg Amaryl glimepiride 4 mg Atacand candesartan 4 mg Atacand candesartan 8 mg Atacand candesartan 16 mg Atacand candesartan 32 mg Atacand Plus candesartan/hctz 16/12.5 mg Bentylol dicyclomine 10 mg Bentylol dicyclomine 20 mg Casodex bicalutamide 50 mg Celexa citalopram 20 mg Celexa citalopram 40 mg Ciloxan ciprofloxacin 0.3% Ophthalmic Combivir lamivudine/zidovudine 150/300 mg Cosopt dorzolomide/timolol 2%/0.5% Ophthalmic Cozaar losartan 25 mg Cozaar losartan 50 mg Cozaar losartan 100 mg Dexedrine dextroamphetamine 5 mg Capsule Diabeta glyburide 2.5 mg Diabeta glyburide 5 mg Diane 35 cyproterone/ ethinyl estradiol 2/0.035 mg Diovan valsartan 40 mg Diovan valsartan 80 mg Diovan valsartan 160 mg Diovan valsartan 320 mg Diovan-HCT valsartan/hctz 80/12.5 mg Diovan-HCT valsartan/hctz 160/12.5 mg Diovan-HCT valsartan/hctz 160/25 mg Diovan-HCT valsartan/hctz 320/12.5 mg of 14

11 Diovan-HCT valsartan/hctz 320/25 mg Diprosalic betamethasone/ salicyclic acid 60 ml Lotion Estradot estradiol-17b 50 mcg Patch Estradot estradiol-17b 75 mcg Patch Estradot estradiol-17b 100 mcg Patch Ezetrol ezetimibe 10 mg FML fluoromethalone 0.1% Ophthalmic Fosamax alendronate 70 mg Gluconorm repaglinide 0.5 mg Gluconorm repaglinide 1 mg Gluconorm repaglinide 2 mg Hyzaar losartan/hctz 50/12.5 mg Hyzaar losartan/hctz 100/12.5 mg Hyzaar DS losartan/hctz 100/25 mg Imitrex DF sumatriptan 50 mg Kivexa abacavir/lamivudine 600/300 mg Lamisil terbinafine 250 mg Lioresal baclofen 10 mg Lioresal DS baclofen 20 mg Lioresal Intrathecal baclofen 0.05 mg/ml Injection Lioresal Intrathecal baclofen 0.5 mg/ml Injection Lioresal Intrathecal baclofen 2 mg/ml Injection Lopressor metoprolol 50 mg Lopressor metoprolol 100 mg Lopressor SR metoprolol 100 mg Lopressor SR metoprolol 200 mg Lotensin benazepril 5 mg Lotensin benazepril 20 mg Maxalt rizatriptan 10 mg Maxalt RPD rizatriptan 5 mg Maxalt RPD rizatriptan 10 mg Modulon trimebutine 200 mg MS Contin morphine sulfate 15 mg MS Contin morphine sulfate 30 mg MS Contin morphine sulfate 60 mg MS Contin morphine sulfate 100 mg MS Contin morphine sulfate 200 mg of 14

12 Ocphyl octreotide 500 mcg/ml Injection Oxy IR oxycodone 5 mg Oxy IR oxycodone 10 mg Oxy IR oxycodone 20 mg pms-entecavir entecavir 0.5 mg pms-ipratropium ipratropium 0.03% Nasal Spray pms-lithium Carbonate lithium carbonate 600 mg Capsule pms-sulfasalazine sulfasalazine 500 mg ** Polytrim trimethoprim/polymyxin 0.1% Ophthalmic Prinivil lisinopril 10 mg Prinivil lisinopril 20 mg Proctosedyl hydrocortisone/framycetin/ cinchocaine/aesculin 0.5% Ointment Proctosedyl hydrocortisone/framycetin/ cinchocaine/aesculin 0.5% Suppository Proscar finasteride 5 mg Remeron RD mirtazapine 15 mg Remeron RD mirtazapine 30 mg Remeron RD mirtazapine 45 mg Restoril temazepam 15 mg Capsule Restoril temazepam 30 mg Capsule Retrovir zidovudine 100 mg Capsule Ritalin methylphenidate 10 mg Ritalin methylphenidate 20 mg Ritalin SR methylphenidate 20 mg Sectral acebutolol 100 mg Sectral acebutolol 200 mg Sinemet levodopa/carbidopa 100/10 mg Sinemet levodopa/carbidopa 100/25 mg Sinemet levodopa/carbidopa 250/25 mg Sinemet CR levodopa/carbidopa 100/25 mg Sinemet CR levodopa/carbidopa 200/50 mg Sulcrate sucralfate 1 G Tamiflu oseltamvir 75 mg Capsule Tegretol carbamazepine 200 mg Tegretol Chewable carbamazepine 100 mg Tegretol Chewable carbamazepine 200 mg Tegretol CR carbamazepine 200 mg Tegretol CR carbamazepine 400 mg of 14

13 Tegretol carbamazepine 100 mg/5 ml Tenoretic atenolol/chlorthalidone 50/25 mg Tenoretic atenolol/chlorthalidone 100/25 mg Tiazac ER diltiazem 120 mg Capsule Tiazac ER diltiazem 300 mg Capsule Timoptic timolol 0.5% Ophthalmic Timoptic timolol 0.25% Ophthalmic Tobradex tobramycin 0.3% Ophthalmic Trileptal oxcarbazepine 150 mg Trileptal oxcarbazepine 300 mg Trileptal oxcarbazepine 600 mg Trusopt dorzolomide 2% Ophthalmic Urso ursodiol 250 mg Urso DS ursodiol 500 mg Valcyte valgancyclovir 450 mg Xeloda capecitabine 150 mg Xeloda capecitabine 500 mg Vaseretic enalapril/hctz 10/25 mg Vasotec enalapril 5 mg Vasotec enalapril 10 mg Vasotec enalapril 20 mg Voltaren diclofenac 0.1% Ophthalmic Voltaren diclofenac 50 mg Suppository Voltaren diclofenac 50 mg Voltaren Rapide diclofenac 50 mg Voltaren SR diclofenac 75 mg Voltaren SR diclofenac 100 mg Zestoretic lisinopril/hctz 10/12.5 mg Zestoretic lisinopril/hctz 20/12.5 mg Ziagen abacavir 300 mg Zestoretic lisinopril/hctz 20/25 mg Zocor simvastatin 10 mg Zocor simvastatin 20 mg Zocor simvastatin 40 mg of 14

14 Zofran ondansetron 4 mg Zofran ondansetron 8 mg Zofran ODT ondansetron 4 mg Zofran ODT ondansetron 8 mg pan-canadian Price Changes Generic Name - Strength - Form Lowest Generic Price ($) Amlodipine - 5 mg - s ** Amlodipine - 10 mg - s ** Atorvastatin - 10 mg - s ** Atorvastatin - 20 mg - s ** Atorvastatin - 40 mg - s ** Atorvastatin - 80 mg - s ** Clopidogrel - 75 mg - s ** Pantoprazole - 20 mg - s ** Pantoprazole - 40 mg - s ** Ramipril mg - s ** Ramipril mg - s ** Ramipril - 5 mg - s ** Ramipril - 10 mg - s ** Simvastatin - 5 mg - s ** Simvastatin - 10 mg - s ** Simvastatin - 20 mg - s ** of 14

15 Simvastatin - 40 mg - s ** Simvastatin - 80 mg - s ** ** The price change has resulted in a change to the lowest price in the category. The following products will be deleted with the next Formulary amendments Actonel risedronate 30 mg s Bentylol dicyclomine 2 mg/ml Syrup Mylan-Anastrozole anastrozole 1 mg Mylan-Candesartan HCTZ candesartan/hctz 16/12.5 mg Mylan-Finasteride finasteride 5 mg Mylan-Leflunomide Mylan-Gemfibrozil leflunomide gemfibrozil 10 mg 20 mg 600 mg 300 mg Capsule Mylan-Nabumetone nabumetone 500 mg Mylan-Tamoxifen tamoxifen 10 mg 20 mg s Mylan-Tamsulosin tamsulosin 0.4 mg Capsule Mylan-Warfarin Piportil L4 pms-carbamazepine warfarin pipotiazine carbamazepine 1 mg 2 mg 2.5 mg 3 mg 4 mg 5 mg 10 mg 50 mg/ml 100 mg/2ml 100 mg 200 mg s Injection Chewable s pms-fluoxetine fluoxetine 20 mg/5 ml Liquid Reminyl ER Discontinued Products galantamine 8 mg 16 mg 24 mg Capsules Sectral acebutolol 400 mg s 14 of 14