UPDATE F Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective 30 January, 2009 SUMMARY OF CHANGES
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1 UPDATE F Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective 30 January, 2009 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 3 Manufacturer Requested Discontinued Drug(s) 5 Delisted Drug(s) 6 Drug Benefit Price(s) 7 Off Formulary Interchangeable Product(s) 10 Discontinued Drug(s) (Removed From Payment & Listing) 11 Index 12 Page 1
2 New Single Source Drug(s) DIN PRODUCT GENERIC NAME MFR DBP DuoTrav 0.5% & 0.004% Oph Sol- 2.5mL Pk TIMOLOL MALEATE & TRAVOPROST ALC Reason for Use Code Clinical Criteria 310 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 Intelence 100mg Tab ETRAVIRINE JNO Note: For use in combination with an optimized regimen, for the treatment of HIV-1 infection in treatmentexperienced adult patients who have failed prior anti-retroviral therapies and have HIV-1 strains resistant to multiple antiretroviral agents, including protease inhibitors (PIs) and other non-nucleoside reverse transcriptase inhibitors (NNRTIs). Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism Niaspan 500mg ER Tab NIACIN SEP Niaspan 750mg ER Tab NIACIN SEP Niaspan 1000mg ER Tab NIACIN SEP Note: For the treatment of dyslipidemia in patients who, after an adequate trial of crystalline niacin (defined as at least 1 month duration during which time appropriate dose titration, use of ASA and patient counseling have occurred), are unable to continue taking crystalline niacin because of intractable and intolerable side effects Telzir 50mg/mL Oral Susp FOSAMPRENAVIR CALCIUM GSK Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Page 2
3 New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Apo-Cyclosporine Oral Solution (Interchangeable with Neoral) 100mg/mL O/L APX Reason for Use Code Clinical Criteria 177 For the treatment of psoriasis in patients who have failed, or are intolerant to, other systemic therapies, including methotrexate, Acitretin or PUVA LU Authorization Period: Indefinite. 178 For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, other systemic therapies, including Disease- Modifying Antirheumatic Drugs (DMARDs). LU Authorization Period: Indefinite Apo-Diltiaz TZ 120mg SR Cap APX Apo-Diltiaz TZ 180mg SR Cap APX Apo-Diltiaz TZ 240mg SR Cap APX Apo-Diltiaz TZ 300mg SR Cap APX Apo-Diltiaz TZ 360mg SR Cap APX (Interchangeable with Tiazac) Gen-Leflunomide 10mg Tab GEN Gen-Leflunomide 20mg Tab GEN (Interchangeable with Arava) Reason for Use Code Clinical Criteria 331 For the treatment of rheumatoid arthritis in patients who have failed,or are intolerant to, one or more of the listed Disease-Modifying Anti- Rheumatic Drugs (DMARDA). LU Authorization Period: Indefinite. Page 3
4 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Jamp-Citalopram 20mg Tab JPC Jamp-Citalopram 40mg Tab JPC (Interchangeable with Celexa) Jamp-Ondansetron (Interchangeable with Zofran) 4mg Tab JPC Reason for Use Code Clinical Criteria 215 For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. LU Authorization Period: 1 year. 216 For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. LU Authorization Period: 1 year. 217 For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics. LU Authorization Period: 1 year. 218 For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Zofran more than 24 hours after the last dose of chemotherapy is unproven. LU Authorization Period: 1 year. Page 4
5 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 Combigan 0.2% & 0.5% Oph Sol-5mL Pk ALL Cytoxan 50mg Tab BQU Pondocillin 500mg Tab LEO Sandoz Ramipril Tab 1.25mg SDZ Sandoz Ramipril Tab 2.5mg SDZ Sandoz Ramipril Tab 5mg SDZ Sandoz Ramipril Tab 10mg SDZ Symmetrel 10mg/mL O/L BQU Page 5
6 Delisted Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR Benzagel 5% Gel NOV Anthranol 0.1% Cr MEI Anthranol 0.2% Cr MEI Anthranol 0.4% Cr MEI Anthraforte 1 1% Oint MEI Anthraforte 2 2% Oint MEI Ratio-Fosinopril 10mg Tab RPH Ratio-Fosinopril 20mg Tab RPH Page 6
7 Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Adalat XL 20mg ER Tab BAY Adalat XL 30mg ER Tab BAY Adalat XL 60mg ER Tab BAY Adrenalin 30mg/30mL Inj Sol-30mL Pk ERF Apo-Diclo 25mg Ent Tab APX Apo-Feno-Super 160mg Tab APX Avelox 400mg Tab BAY Betnesol 5mg/100mL Enema-100mL Pk SQI Bonefos 400mg Cap BAY Choledyl 20mg/mL O/L ERF Cipro XL 500mg ER Tab BAY Cipro XL 1000mg ER Tab BAY Cortifoam 10% Rect Aero-15g Pk SQI Cosopt 2% & 0.5% Oph Sol MFC Cozaar 25mg Tab MFC Cozaar 50mg Tab MFC Cozaar 100mg Tab MFC Cyclen 0.25mg & 0.035mg Tab-21 Pk JNO Cyclen 0.25mg & 0.035mg Tab-28 Pk JNO Duragesic 25 25mcg/hr Trans Patch JNO Duragesic 50 50mcg/hr Trans Patch JNO Duragesic 75 75mcg/hr Trans Patch JNO Duragesic mcg/hr Trans Patch JNO Duvoid 10mg Tab SQI Duvoid 25mg Tab SQI Duvoid 50mg Tab SQI Elocom 0.1% Cr SCH Ezetrol 10mg Tab MFS Florinef 0.1mg Tab SQI Fludara 10mg Tab BAY Fosamax 10mg Tab MFC Fosamax 70mg Tab MFC Glucobay 50mg Tab BAY Glucobay 100mg Tab BAY Hyzaar 50mg/12.5mg Tab MFC Hyzaar DS 100mg/25mg Tab MFC Intron A 15mu/mL 18mu MD Pen Kit SCH Intron A 25mu/mL 30mu MD Pen Kit SCH Intron A 50mu/mL 60mu MD Pen Kit SCH Leustatin 1mg/mL Inj JNO Locacorten-Vioform 0.02% & 1% Ot Sol SQI Loestrin 1.5/ mg & 1.5mg Tab-21 Pk SQI Loestrin 1.5/ mg & 1.5mg Tab-28 Pk SQI Marvelon mg & 0.03mg Tab-21 Pk ORG Marvelon mg & 0.03mg Tab-28 Pk ORG Page 7
8 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Mevacor 20mg Tab MFC Mevacor 40mg Tab MFC Micronor 0.35mg Tab-28 Pk JNO Minestrin 1/ mg & 1mg Tab-21 Pk SQI Minestrin 1/ mg & 1mg Tab-28 Pk SQI Mirena 52mg Insert BAY Navane 2mg Cap ERF Navane 5mg Cap ERF Neuleptil 10mg Cap ERF Nitrol 2% Oint SQI Novo-Fenofibrate-S 160mg Tab NOP Ortho 0.5/ mg & 0.5mg Tab-21 Pk JNO Ortho 0.5/ mg & 0.5mg Tab-28 Pk JNO Ortho 1/ mg & 1mg Tab-21 Pk JNO Ortho 1/ mg & 1mg Tab-28 Pk JNO Ortho 7/7/7 3 Phase Tab-21 Pk JNO Ortho 7/7/7 3 Phase Tab-28 Pk JNO Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk JNO Pancrease MT & & Ent Microsph Cap JNO USP Units Parsitan 50mg Tab ERF Pentasa 1g Sup FEI Pepcid 20mg Tab MFC Pepcid 40mg Tab MFC Plan B 0.75mg Tab-2 Tabs Pk PAL Pravachol 10mg Tab BQU Pravachol 20mg Tab BQU Pravachol 40mg Tab BQU Prezista 300mg Tab JNO Prinivil 5mg Tab MFC Prinivil 10mg Tab MFC Prinivil 20mg Tab MFC Prinzide 10mg & 12.5mg Tab MFC Prinzide 20mg & 12.5mg Tab MFC Procan SR 250mg LA Tab ERF Procan SR 500mg LA Tab ERF Procan SR 750mg LA Tab ERF Propaderm 0.025% Cr SQI Proscar 5mg Tab MFC Reminyl ER 8mg ER Cap JNO Reminyl ER 16mg ER Cap JNO Reminyl ER 24mg ER Cap JNO Ridaura 3mg Cap SQI Risperdal 1mg/mL O/L JNO Risperdal 0.25mg Tab JNO Risperdal 0.5mg Tab JNO Risperdal 1mg Tab JNO Risperdal 2mg Tab JNO Risperdal 3mg Tab JNO Risperdal 4mg Tab JNO Page 8
9 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Risperdal Consta 25mg Pd for Inj-Vial Pk JNO Risperdal Consta 37.5mg Pd for Inj-Vial Pk JNO Risperdal Consta 50mg Pd for Inj-Vial Pk JNO Risperdal M-Tab 0.5mg Orally Disintegrating Tab JNO Risperdal M-Tab 1mg Orally Disintegrating Tab JNO Risperdal M-Tab 2mg Orally Disintegrating Tab JNO Risperdal M-Tab 3mg Orally Disintegrating Tab JNO Risperdal M-Tab 4mg Orally Disintegrating Tab JNO Sandomigran 0.5mg Tab SQI Sandomigran DS 1mg Tab SQI Singulair 4mg Chew Tab MFC Temodal 5mg Cap SCH Temodal 20mg Cap SCH Temodal 100mg Cap SCH Temodal 250mg Cap SCH Terazol 7 0.4% Cr JNO Thyroid 30mg Tab ERF Thyroid 60mg Tab ERF Thyroid 125mg Tab ERF Timoptic 0.5% Oph Sol MFC Timoptic-XE 0.25% Oph Gellan Sol MFC Timoptic-XE 0.5% 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 Trandate 100mg Tab SQI Trandate 200mg Tab SQI Tri-Cyclen 3 Phase Tab-21 Pk JNO Tri-Cyclen 3 Phase Tab-28 Pk JNO Tri-Cyclen Lo 3 Phase Tab-21 Pk JNO Tri-Cyclen Lo 3 Phase Tab-28 Pk JNO Triquilar 21 3 Phase Tab-21 Pk BAY Triquilar 28 3 Phase Tab-28 Pk BAY Trusopt 2% Oph Sol MFC Vermox 100mg Tab JNO Zocor 5mg Tab MFC Zocor 10mg Tab MFC Zocor 20mg Tab MFC Zocor 40mg Tab MFC Zocor 80mg Tab MFC Page 9
10 Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST PMS-Ciprofloxacin (Interchangeable with Ciloxan) 0.3% Oph Sol-5mL Pk PMS PMS-Oxycodone 5mg Tab PMS PMS-Oxycodone 10mg Tab PMS PMS-Oxycodone (Interchangeable with Oxy.IR) 20mg Tab PMS Page 10
11 Discontinued Drug(s) (Removed From Payment & Listing) DIN BRAND STRENGTH DOSAGE FORM MFR Nutrisure Pudding 113g Pk ABB Percocet 5mg & 325mg Tab BQU Percodan 5mg & 325mg Tab BQU Page 11
UPDATE AF Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective March 26, 2012 SUMMARY OF CHANGES
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UPDATE B Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective October 01, 2008 SUMMARY OF CHANGES
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UPDATE C Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective November 04, 2008 SUMMARY OF CHANGES
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