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 2015 Effective January 28, 2015 Ministry of Health and Long-Term Care
2 Table of Contents New Multi-Source Products... 3 New Off-Formulary Interchangeable (OFI) Products... 8 Drug Benefit Price (DBP) Changes Product Formulation Change New Package Size Discontinued Products Delisted Products
3 New Multi-Source Products Amlodipine 5mg Tab JPC Amlodipine 10mg Tab JPC (Interchangeable with Norvasc) 3
4 New Multi-Source Products (Cont d...) Apo-Celecoxib 100mg Cap APX Co Celecoxib 100mg Cap ACV Gd-Celecoxib 100mg Cap GEM Jamp-Celecoxib 100mg Cap JPC Mar-Celecoxib 100mg Cap MAR Mint-Celecoxib 100mg Cap MIN Mylan-Celecoxib 100mg Cap MYL PMS-Celecoxib 100mg Cap PMS Ran-Celecoxib 100mg Cap RAN Sandoz Celecoxib 100mg Cap SDZ Teva-Celecoxib 100mg Cap TEV (Interchangeable with Celebrex) Reason For Use Code and Clinical Criteria Osteoarthritis Code 316 For patients who have failed an adequate trial of acetaminophen (e.g. acetaminophen 1g QID for several weeks) and have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of osteoarthritis is 200mg. LU Authorization Period: 1 year. Rheumatoid arthritis Code 317 For patients who have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of rheumatoid arthritis is 400mg. LU Authorization Period: 1 year. 4
5 New Multi-Source Products (Cont d...) Apo-Celecoxib 200mg Cap APX Co Celecoxib 200mg Cap ACV Gd-Celecoxib 200mg Cap GEM Jamp-Celecoxib 200mg Cap JPC Mar-Celecoxib 200mg Cap MAR Mint-Celecoxib 200mg Cap MIN Mylan-Celecoxib 200mg Cap MYL PMS-Celecoxib 200mg Cap PMS Ran-Celecoxib 200mg Cap RAN Sandoz Celecoxib 200mg Cap SDZ Teva-Celecoxib 200mg Cap TEV (Interchangeable with Celebrex) Reason For Use Code and Clinical Criteria Osteoarthritis Code 316 For patients who have failed an adequate trial of acetaminophen (e.g. acetaminophen 1g QID for several weeks) and have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of osteoarthritis is 200mg. LU Authorization Period: 1 year. Rheumatoid arthritis Code 317 For patients who have had: History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS. NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of rheumatoid arthritis is 400mg. LU Authorization Period: 1 year. 5
6 New Multi-Source Products (Cont d...) Citalopram 20mg Tab JPC Citalopram 40mg Tab JPC (Interchangeable with Celexa) Abbott-Olanzapine ODT 5mg Rapid Dissolve Tab ABB Abbott-Olanzapine ODT 10mg Rapid Dissolve Tab ABB Abbott-Olanzapine ODT 15mg Rapid Dissolve Tab ABB (Interchangeable with Zyprexa Zydis) Sandoz Paroxetine Tablets 20mg Tab SDZ Sandoz Paroxetine Tablets 30mg Tab SDZ (Interchangeable with Paxil) Abbott-Rabeprazole 10mg Tab ABB (Interchangeable with Pariet) 6
7 New Multi-Source Products (Cont d...) Sandoz Tacrolimus 0.5mg Cap SDZ (Interchangeable with Prograf) Reason For Use Code and Clinical Criteria Code 173 For solid organ transplant and bone marrow transplant. LU Authorization Period: Indefinite Sandoz Topiramate Tablets 25mg Tab SDZ Sandoz Topiramate Tablets 100mg Tab SDZ Sandoz Topiramate Tablets 200mg Tab SDZ (Interchangeable with Topamax) Teva-Valganciclovir 450mg Tab TEV (Interchangeable with Valcyte) Reason For Use Code and Clinical Criteria Code 374 For the treatment of CMV retinitis in patients with AIDS. LU Authorization Period: 1 Year. 7
8 New Off-Formulary Interchangeable (OFI) Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST PMS-Diclofenac 1.5% W/W Top Sol PMS (Interchangeable with Pennsaid) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST PMS-Eletriptan 20mg Tab PMS PMS-Eletriptan 40mg Tab PMS (Interchangeable with Relpax) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Mar-Modafinil 100mg Tab MAR (Interchangeable with Alertec) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Sandoz Paroxetine Tablets 10mg Tab SDZ (Interchangeable with Paxil) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Auro-Repaglinide 0.5mg Tab AUR Auro-Repaglinide 1mg Tab AUR Auro-Repaglinide 2mg Tab AUR (Interchangeable with GlucoNorm) 8
9 New Off-Formulary Interchangeable (OFI) Products (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Jamp-Rizatriptan IR 5mg Tab JPC Jamp-Rizatriptan IR 10mg Tab JPC (Interchangeable with Maxalt) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST PMS-Sildenafil R 20mg Tab PMS (Interchangeable with Revatio) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST Jamp-Zolmitriptan ODT 2.5mg Orally Disintegrating Tab JPC (Interchangeable with Zomig Rapimelt) 9
10 Drug Benefit Price (DBP) Changes Accupril 5mg Tab PFI Accupril 10mg Tab PFI Accupril 20mg Tab PFI Accupril 40mg Tab PFI Accuretic 20mg & 25mg Tab PFI Aldactazide-25 25mg & 25mg Tab PFI Aldactazide-50 50mg & 50mg Tab PFI Aldactone 25mg Tab PFI Aldactone 100mg Tab PFI Apo-Doxepin 10mg Cap APX Apo-Doxepin 25mg Cap APX Apo-Doxepin 50mg Cap APX Apo-Salvent CFC Free 100mcg/Metered Dose Inh-200 Dose Pk APX Apo-Travoprost Z 0.004% Oph Sol-5mL Pk APX Arthrotec 50 50mg & 200mcg Tab PFI Arthrotec 75 75mg & 200mcg Tab PFI Benztropine 2mg Tab PMS 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 Cardura-1 1mg Tab AZC Cardura-2 2mg Tab AZC Cardura-4 4mg Tab AZC Colestid Orange Gran-7.5g Pk PFI Colestid Regular Gran-5g Pk PFI Cordarone 200mg Tab PFI Cortef 10mg Tab PFI Cortef 20mg Tab PFI Cosopt 2% & 0.5% Oph Sol MFC Cosopt Preservative Free 2% & 0.5% Oph Sol-0.2mL Pk MFC Cotazym 8000 & & USP Units Cap ORG Cotazym ECS & & USP Units Ent Microsph Cap ORG Cotazym ECS & & USP Units Ent Microsph Cap ORG Cozaar 25mg Tab MFC Cozaar 50mg Tab MFC Cozaar 100mg Tab MFC Dalacin C 150mg Cap PFI Dalacin C 300mg Cap PFI Dalacin C Flavoured Granules 15mg/mL Pd For Oral Susp PFI
11 Drug Benefit Price (DBP) Changes (Cont d...) 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 1mg Tab 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 50mg Tab PFI Dilantin 100mg Cap PFI Dilantin 6mg/mL O/L PFI Dilantin 25mg/mL O/L PFI Edurant 25mg Tab JAN Effexor XR 37.5mg ER Cap WAY Effexor XR 75mg ER Cap WAY Effexor XR 150mg ER Cap WAY Emcyt 140mg Cap PFI Eprex 20,000 IU/0.5mL Pref Syr-0.5mL Pk JAN Eprex 40,000 IU/mL Pref Syr-1mL Pk JAN * Esbriet 267mg Cap INT Hyzaar 50mg & 12.5mg Tab MFC Hyzaar 100mg/12.5mg Tab MFC Hyzaar DS 100mg/25mg Tab MFC * Inlyta 1mg Tab PFI * Inlyta 5mg Tab PFI Intelence 100mg Tab JAN Intelence 200mg Tab JAN Lomotil 2.5mg & 0.025mg Tab PFI Loniten 2.5mg Tab PFI Loniten 10mg Tab 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 *Exceptional Access Program product 11
12 Drug Benefit Price (DBP) Changes (Cont d...) Metonia 5mg Tab PEN Metonia 10mg Tab PEN Mycobutin 150mg Cap PFI Neurontin 100mg Cap PFI Neurontin 300mg Cap PFI Neurontin 400mg Cap PFI 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 Pancrease MT & & USP Ent Microsph Cap JAN Units Pariet 10mg Tab JAN Pariet 20mg Tab JAN PMS-Amantadine 10mg/mL O/L PMS PMS-Amantadine HCL 100mg Cap PMS PMS-Desonide 0.05% Cr PMS PMS-Desonide 0.05% Oint PMS PMS-Ketoprofen 100mg Sup PMS PMS-Sodium Cromoglycate 1% Inh Sol-2mL Pk PMS Premarin Vaginal Cream 0.625mg/g Vag Cr PFI Prinivil 5mg Tab MFC Prinivil 10mg Tab MFC Prinivil 20mg Tab MFC Proscar 5mg Tab MFC Provera 2.5mg Tab PFI Provera 5mg Tab PFI Provera 10mg Tab PFI Remeron 30mg Tab ORG Remeron RD 15mg Orally Disintegrating Tab ORG Remeron RD 30mg Orally Disintegrating Tab ORG Remeron RD 45mg Orally Disintegrating Tab ORG Risperdal M-Tab 0.5mg Orally Disintegrating Tab JAN Risperdal M-Tab 1mg Orally Disintegrating Tab JAN Risperdal M-Tab 2mg Orally Disintegrating Tab JAN Risperdal M-Tab 3mg Orally Disintegrating Tab JAN Risperdal M-Tab 4mg Orally Disintegrating Tab JAN
13 Drug Benefit Price (DBP) Changes (Cont d...) Salazopyrin 500mg Ent Tab PFI Salazopyrin 500mg Tab PFI Sandoz Travoprost 0.004% Oph Sol-5mL Pk SDZ Sinemet 100mg & 10mg Tab MFC Sinemet 100mg & 25mg Tab MFC Sinemet 250mg & 25mg Tab MFC Sinemet CR 200mg & 50mg Tab MFC Sinemet CR 100mg & 25mg Tab MFC Synacthen Depot 1mg/mL Inj Susp-1mL Pk QUO Synphasic 3 Phase Tab-21 Pk PFI Synphasic 3 Phase Tab-28 Pk PFI Terazol 7 0.4% Vag Cr JAN Teva-Travoprost Z 0.004% Oph Sol-2.5mL Pk TEV Ophthalmic Solution Teva-Travoprost Z 0.004% Oph Sol-5mL Pk TEV Ophthalmic Solution Timoptic 0.5% Oph Sol MFC Timoptic-XE 0.25% Oph Gellan Sol MFC Timoptic-XE 0.5% Oph Gellan Sol MFC Toloxin 0.05mg/mL O/L PEN Topamax 25mg Tab JNO Topamax 100mg Tab JNO Topamax 200mg Tab JNO Topamax Sprinkle 15mg Sprinkle Cap JNO Topamax Sprinkle 25mg Sprinkle Cap JNO Trusopt 2% Oph Sol MFC Tylenol With Codeine No.2 300mg & 15mg & 15mg Tab JAN Tylenol With Codeine No.3 300mg & 15mg & 30mg Tab JAN Tylenol With Codeine No.4 300mg & 60mg Tab JAN Vasotec 2.5mg Tab MFC Vasotec 5mg Tab MFC Vasotec 10mg Tab MFC Vasotec 20mg Tab MFC Vermox 100mg Tab JAN Xanax 0.25mg Tab PFI Xanax 0.5mg Tab PFI Xylac 5mg Tab PEN Xylac 10mg Tab PEN Xylac 25mg Tab PEN Xylac 50mg Tab PEN
14 Drug Benefit Price (DBP) Changes (Cont d...) Zocor 5mg Tab MFC Zocor 10mg Tab MFC Zocor 20mg Tab MFC Zocor 40mg Tab MFC * Zytiga 250mg Tab JAN *Exceptional Access Program product 14
15 Product Formulation Change CURRENT FORMULATION CURRENT DIN NEW FORMULATION NEW DIN MFR DBP Premarin 0.625mg Tab * Premarin 0.625mg SR Tab PFI *Delisted in this January 2015 Formulary Update. Reason For Use Code Clinical Criteria Code 398 For short-term use in women who are experiencing symptoms of menopause. Note: Recent evidence has demonstrated that use of hormone replacement therapy (HRT) increases the rate of coronary events, breast cancer, dementia, stroke, venous thromboembolism and referrals for abnormal vaginal bleeding. These risks should be discussed with patients and reviewed periodically. LU Authorization Period: 1 year. 15
16 New Package Size * Champix 0.5mg & 1.0mg Tab (Starter Pack-53 Tablets) PFI *New PIN issued for this pack size and the DIN remains for the old pack size of 25 Tablets Starter Pack, which is discontinued in this January 2015 Summary of Changes. 16
17 Discontinued Products (Some products will remain on Formulary for six months to facilitate depletion of supply) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR 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 Apo-Lisinopril/HCTZ 10mg & 12.5mg Tab APX Apo-Lisinopril/HCTZ 20mg & 12.5mg Tab APX * Apo-Lisinopril/HCTZ 20mg & 25mg Tab APX ** Champix 0.5mg & 1.0mg Starter Pack PFI Nitrazadon 5mg Tab VAL Nitrazadon 10mg Tab VAL 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 *Product listed as Not-a-Benefit **Product contains 25 Tablets in a pack. 17
18 Delisted Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR Amlodipine-Odan 5mg Tab ODN Amlodipine-Odan 10mg Tab ODN Boost 1.0 Standard 1.06kcal/mL Liq-237mL Pk NES Norvir SEC 100mg Cap ABB Phl-Amiodarone 200mg Tab PHE Phl-Amlodipine 5mg Tab PHE Phl-Amlodipine 10mg Tab PHE Phl-Azithromycin 250mg Tab PHE Phl-Baclofen 10mg Tab PHE Phl-Baclofen 20mg Tab PHE Phl-Citalopram 20mg Tab PHE Phl-Citalopram 40mg Tab PHE Phl-Clonazepam 0.5mg Tab PHE Phl-Clonazepam 2mg Tab PHE Phl-Clonazepam-R 0.5mg Tab PHE * Phl-Cyclobenzaprine 10mg Tab PHE * Phl-Fluoxetine 10mg Cap PHE Phl-Fluoxetine 20mg Cap PHE Phl-Meloxicam 7.5mg Tab PHE Phl-Meloxicam 15mg Tab PHE Phl-Olanzapine 2.5mg Tab PHE Phl-Olanzapine 5mg Tab PHE Phl-Olanzapine 7.5mg Tab PHE Phl-Olanzapine 10mg Tab PHE Phl-Olanzapine 15mg Tab PHE Phl-Olanzapine ODT 5mg Rapid Dissolve Tab PHE Phl-Olanzapine ODT 10mg Rapid Dissolve Tab PHE Phl-Olanzapine ODT 15mg Rapid Dissolve Tab PHE Phl-Ondansetron 4mg Tab PHE Phl-Ondansetron 8mg Tab PHE * Phl-Pioglitazone 15mg Tab PHE * Phl-Pioglitazone 30mg Tab PHE * Phl-Pioglitazone 45mg Tab PHE Phl-Quetiapine 25mg Tab PHE Phl-Quetiapine 100mg Tab PHE Phl-Quetiapine 200mg Tab PHE Phl-Quetiapine 300mg Tab PHE *Product listed as Not-a-Benefit 18
19 Delisted Products (Cont d ) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR Phl-Risperidone 0.25mg Tab PHE Phl-Risperidone 0.5mg Tab PHE Phl-Risperidone 1mg Tab PHE Phl-Risperidone 2mg Tab PHE Phl-Risperidone 3mg Tab PHE Phl-Risperidone 4mg Tab PHE Phl-Sertraline 25mg Cap PHE Phl-Sertraline 50mg Cap PHE Phl-Sertraline 100mg Cap PHE Phl-Simvastatin 5mg Tab PHE Phl-Simvastatin 10mg Tab PHE Phl-Simvastatin 20mg Tab PHE Phl-Simvastatin 40mg Tab PHE Phl-Simvastatin 80mg Tab PHE Phl-Topiramate 25mg Tab PHE Phl-Topiramate 100mg Tab PHE Phl-Topiramate 200mg Tab PHE Phl-Valacyclovir 500mg Tab PHE * Phl-Zopiclone 5mg Tab PHE * Phl-Zopiclone 7.5mg Tab PHE Premarin 0.625mg Tab PFI ** Travatan Z 0.004% Oph Sol-2.5mL ALC *Products listed as Not-a-Benefit. **Remain in Formulary as Not-a-Benefit to serve as reference product in interchangeable group. 19
20 ISSN (PDF) January 2015 Queen s Printer for Ontario, 2015.
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