UPDATE AF Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective March 26, 2012 SUMMARY OF CHANGES
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1 UPDATE AF Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective March 26, 2012 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Multi-Source Drug(s) 2 Off Formulary Interchangeable Product(s) 6 Manufacturer Requested Discontinued Drug(s) 7 Drug Benefit Price(s) 8 Discontinued Drug(s) (Removed From Payment & Listing) 9 Not-A-Benefit Drug(s) (Removed from Listing) 10 Status Change(s) from Not-A-Benefit to General Benefit 11 Index 12 Page 1
2 New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Apo-Losartan 25mg Tab APX Apo-Losartan 50mg Tab APX Apo-Losartan 100mg Tab APX Apo-Losartan/HCTZ 50mg & 12.5mg Tab APX Apo-Losartan/HCTZ 100mg & 12.5mg Tab APX (Interchangeable with Hyzaar) Apo-Losartan/HCTZ (Interchangeable with Hyzaar DS) 100mg & 25mg Tab APX Auro-Citalopram 20mg Tab AUR Auro-Citalopram 40mg Tab AUR (Interchangeable with Celexa) Co Losartan 25mg Tab COB Co Losartan 50mg Tab COB Co Losartan 100mg Tab COB Erdol (Interchangeable with Drisdol) 8288IU/mL O/L ODN Mylan-Losartan 25mg Tab MYL Mylan-Losartan 50mg Tab MYL Mylan-Losartan 100mg Tab MYL Page 2
3 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Mylan-Losartan HCTZ 50mg & 12.5mg Tab MYL Mylan-Losartan HCTZ 100mg & 12.5mg Tab MYL (Interchangeable with Hyzaar) Mylan-Losartan HCTZ (Interchangeable with Hyzaar DS) 100mg & 25mg Tab MYL Mylan-Telmisartan 40mg Tab MYL Mylan-Telmisartan 80mg Tab MYL (Interchangeable with Micardis) PMS-Clobetasol (Interchangeable with Dermovate) 0.05% Cr PMS PMS-Losartan 25mg Tab PMS PMS-Losartan 50mg Tab PMS PMS-Losartan 100mg Tab PMS Sandoz Losartan 25mg Tab SDZ Sandoz Losartan 50mg Tab SDZ Sandoz Losartan 100mg Tab SDZ Sandoz Losartan HCT 50mg & 12.5mg Tab SDZ Sandoz Losartan HCT 100mg & 12.5mg Tab SDZ (Interchangeable with Hyzaar) Sandoz Losartan HCT DS (Interchangeable with Hyzaar DS) 100mg & 25mg Tab SDZ Septa-Atenolol 50mg Tab SET Septa-Atenolol 100mg Tab SET (Interchangeable with Tenormin) Page 3
4 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Septa-Ondansetron 4mg Tab SET Septa-Ondansetron 8mg Tab SET (Interchangeable with Zofran) 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 Ondansetron Hydrochloride more than 24 hours after the last dose of chemotherapy is unproven. LU Authorization Period: 1 year Taro-Carbamazepine (Interchangeable with Tegretol) 100mg/5mL Oral Susp TAR Teva-Losartan 50mg Tab TEV Teva-Losartan 100mg Tab TEV Page 4
5 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Teva-Losartan HCTZ 50mg & 12.5mg Tab TEV Teva-Losartan/HCTZ 100mg & 12.5mg Tab TEV (Interchangeable with Hyzaar) Teva-Losartan/HCTZ (Interchangeable with Hyzaar DS) 100mg & 25mg Tab TEV Teva-Telmisartan 40mg Tab TEV Teva-Telmisartan 80mg Tab TEV (Interchangeable with Micardis) Page 5
6 Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST Co Rizatriptan ODT 5mg Orally Co Rizatriptan ODT 10mg Orally (Interchangeable with Maxalt RPD) COB COB Mylan-Atomoxetine 18mg Cap MYL Mylan-Atomoxetine 25mg Cap MYL Mylan-Atomoxetine 40mg Cap MYL Mylan-Atomoxetine (Interchangeable with Strattera) 60mg Cap MYL Mylan-Rizatriptan ODT 5mg Orally Mylan-Rizatriptan ODT 10mg Orally (Interchangeable with Maxalt RPD) MYL MYL Sandoz Rizatriptan ODT 5mg Orally Sandoz Rizatriptan ODT 10mg Orally (Interchangeable with Maxalt RPD) SDZ SDZ Page 6
7 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 Acetaminophen Tab 325mg DPC Novo-Fentanyl 25mcg/hr Trans Patch NOP Novo-Fentanyl 50mcg/hr Trans Patch NOP Novo-Fentanyl 75mcg/hr Trans Patch NOP Novo-Fentanyl 100mcg/hr Trans Patch NOP Novo-Glimepiride 2mg Tab NOP Novo-Glimepiride 4mg Tab NOP Novo-Lamotrigine 25mg Tab NOP Novo-Lamotrigine 100mg Tab NOP Novo-Lamotrigine 150mg Tab NOP Novo-Metformin 500mg Tab NOP Nu-Clonidine 0.1mg Tab NXP Nu-Clonidine 0.2mg Tab NXP PMS-Bromocriptine 2.5mg Tab PMS PMS-Bromocriptine 5mg Cap PMS PMS-Clobetasol 0.05% Cr PMS Ratio-Codeine 5mg/mL O/L RPH Ratio-Meloxicam 7.5mg Tab RPH Ratio-Meloxicam 15mg Tab RPH Ratio-Mirtazapine 30mg Tab RPH Ratio-Quetiapine 25mg Tab RPH Ratio-Quetiapine 100mg Tab RPH Ratio-Quetiapine 200mg Tab RPH Ratio-Quetiapine 300mg Tab RPH Ratio-Ranitidine 300mg Tab RPH Ratio-Simvastatin 10mg Tab RPH Ratio-Simvastatin 40mg Tab RPH Ratio-Simvastatin 80mg Tab RPH Ratio-Temazepam 15mg Cap RPH Ratio-Temazepam 30mg Cap RPH Page 7
8 Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Apo-Prednisone 50mg Tab APX Cosopt 2% & 0.5% Oph Sol MFC Ezetrol 10mg Tab MFS Fosamax 70mg Tab MFC Fosavance 70mg & 70mcg Tab MFC Fosavance 70mg & 140mcg 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 Janumet 500mg & 50mg Tab MEK Janumet 850mg & 50mg Tab MEK Janumet 1000mg & 50mg Tab MEK Januvia 100mg Tab MFC 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 Proscar 5mg Tab MFC Remeron RD 15mg Orally Disintegrating ORG Tab Remeron RD 30mg Orally Disintegrating ORG Tab Remeron RD 45mg Orally Disintegrating ORG Tab Singulair 4mg Chew Tab MFC Temodal 5mg Cap SCH Temodal 20mg Cap SCH Temodal 100mg Cap SCH Temodal 140mg Cap SCH Temodal 250mg Cap SCH Trusopt 2% Oph Sol MFC Page 8
9 Discontinued Drug(s) (Removed From Payment & Listing) DIN BRAND STRENGTH DOSAGE FORM MFR PMS-Cefaclor 250mg Cap PMS PMS-Cefaclor 500mg Cap PMS PMS-Cefaclor 25mg/mL Oral Susp PMS PMS-Cefaclor 50mg/mL Oral Susp PMS PMS-Cefaclor 375mg/5mL Oral Susp PMS Ran-Risperidone 0.25mg Tab RAN Ran-Risperidone 0.5mg Tab RAN Ran-Risperidone 1mg Tab RAN Ran-Risperidone 2mg Tab RAN Ran-Risperidone 3mg Tab RAN Ran-Risperidone 4mg Tab RAN Page 9
10 Not-A-Benefit Drug(s) (Removed From Listing) DIN BRAND STRENGTH DOSAGE FORM MFR Apo-Perindopril 8mg Tab APX Page 10
11 Status Change(s) from Not-A-Benefit to General Benefit DIN BRAND STRENGTH DOSAGE FORM MFR DBP Co Candesartan (Interchangeable with Atacand) 32mg Tab COB Page 11
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