BULLETIN # 102. Manitoba Drug Benefits and Interchangeability Formulary Amendments. The following amendments will take effect on January 24, 2019

Transcription

1 BULLETIN # 102 Manitoba Drug Benefits and Interchangeability Formulary Amendments The following amendments will take effect on January 24, 2019 The amended Manitoba Specified Drug Regulation and Drug Interchangeability Formulary Regulation will be available on the Manitoba Health website on the effective date of January 24, 2019 Bulletin 102 is currently available for download: Inside This Issue Part 1 Additions Page 1-2 Part 2 Additions Page 2 Part 3 Additions Page 2-8 New Interchangeable Categories Page 8-10 New Interchangeable Products Page Product Deletions Page Category Deletions Page 14 Interchangeable Product Price Changes Page Discontinued Products Page 24-26

2 Part 1 Additions Bulletin #102 DIN TRADE NAME GENERIC STRENGTH FORM MFR* ACH-Ezetimibe ezetimibe 10 mg ACH Actikerall fluiriuracil/salicylic acid 0.5/10% Topical Solution CPH Apo-HYDROmorphone CR hydromorphone HCL 3 mg 4.5 mg 6 mg 9 mg 18 mg 24 mg 30 mg Apo-Pinaverium pinaverium 50 mg 100 mg Apo-Solifenacin solifenacin 5 mg 10 mg Auro-Cephalexin cephalexin 250 mg 500 mg Auro-Pravastatin Auro-Trandolapril pravastatin trandolapril 10 mg 20 mg 40 mg 0.5 mg 1 mg 2 mg 4 mg Jamp-Ursodiol ursodiol 250 mg 500 mg Capsule Capsules Kyleena levonorgestrol 19.5 mg IUD BAY Mar-Methimazole thiamazole 5 mg MAR APX APX APX AUP AUP AUP JPC Mar-Midodrine midodrine 2.5 mg 5 mg Mint-Furosemide furosemide 20 mg 40 mg Pharma-Amlodipine amlodipine 5 mg 10 mg Pharma-Escitalopram escitalopram 10 mg 20 mg Pharma-Ramipril ramipril 1.25 mg 2.5 mg 5 mg 10 mg Capsule MAR MPH PMS PMS PMS 1 of 26

3 Quetiapine XR quetiapine Bulletin # mg 150 mg 200 mg 300 mg 400 mg Ran-Esomeprazole esomeprazole 40 mg RAN Sandoz Esomeperazole esomeprazole 40 mg SDZ SIP Teva-Aripiprazole Teva-Trandolapril aripiprazole trandolapril 2 mg 5 mg 10 mg 15 mg 20 mg 30 mg 0.5 mg 1 mg 2 mg 4 mg Capsule TEV TEV Part 2 Additions Auro-Dutasteride dutasteride 0.5 mg Capsules AUP For the treatment of symptomatic benign prostatic hyperplasia. Part 3 Additions The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis Apo-Lansoprazole- Amoxicillin- Clarithromycin lansoprazole/amoxicillin/ clarithromycin 30/500/500 mg Capsule/Capsul e/ APX For H. pylori eradication Apo-Efavirenz- Emtricitabine-Tenofovir efavirenz/emtricitabine/ tenofovir 600/200/300 mg APX For the treament of HIV-1 infection for patients where the virus is susceptible to each of efavirenz, emtricitabine and tenofovir Auro-Lacosamide Pharma-Lacosamide lacosamide lacosamide 50 mg 100 mg 150 mg 200 mg 50 mg 100 mg 150 mg 200 mg AUP PMS 2 of 26

4 Bulletin #102 Sandoz Lacosamide lacosamide 50 mg 100 mg 150 mg 200 mg SDZ 50 mg Teva-Lacosamide lacosamide 100 mg 150 mg TEV 200 mg For use as an adjunctive therapy in patients with refractory partial-onset seizures who meet all the following criteria: - Are under the care of a physician experienced in the treatment of epilepsy, and - Are currently receiving two or more antiepileptic drugs, and - In whom all other antiepileptic drugs are ineffective or not appropriate Dysport Therapeutic 300 U abobotulinumtoxina Injection (new indication) 500 U For the symptomatic treatment of lower limb spasticity (LLS) in patients two years of age and older. IPL Jamp-Fosfomycin fosfomycin 3 G Powder JPC For the treatment of uncomplicated urinary tract infections in adult female patients where: - the infecting organism is resistant to other oral antimicrobials; or - other conventional antimicrobials are not tolerated due to adverse effects or allergic reaction mg Lancora ivabradine hydrochloride SEV 7.5 mg For the treatment of stable chronic heart failure with reduced left ventricular ejection fraction (LVEF) (<35%) in adult patients with New York Heart Association (NYHA) classes II or III who are in sinus rhythm with a resting heart rate > 77 beats per minute, to reduce the incidence of cardiovascular mortality and hospitalizations for worsening heart failure, administered in combination with standard chronic heart failure therapies, if the following clinical criteria are met: - Patients with NYHA class II to III symptoms despite at least four weeks of treatment with a stable dose of an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) in combination with a beta blocker and, if tolerated, a mineralocorticoid receptor antagonist (MRA) - Patients with at least one hospitatilization due to heart failure in the last year. - Resting heart rate must be documented as > 77 bpm on average using either an ECG on at least three separate visits or by continuous monitoring. Initiation and up-titration should be conducted by or under the direct guidance of a physician experienced with the treatment of heart failure to respect the referral process Revestive teduglutide 5 mg Vial SHI For the treatment of short bowel syndrome. Complete criteria may be obtained from the EDS office at Manitoba Health Spinraza nusinersen 2.4 mg/ml For the treatment of Spinal Muscular Atrophy (SMA) Type 1. Complete criteria may be obtained from the EDS office at Manitoba Health. Intrathecal Solution BIG 3 of 26

5 Entyvio vedolizumab 300 mg/vl Injection Crohn's Disease: For treatment of moderate to severely active Crohn's Disease in patients with inadequate response, intolerance or contraindications to an adequate course of corticosteroids AND an immunosuppressive agent. Fistulizing Crohn's Disease: For the treatment of Fistulizing Crohn's Disease in patients with actively draining perianal or enterocutaneous fistula who meet the following criteria: Presence of fistula that has persisted despite a course of antibiotic therapy (e.g. ciprofloxacin and/or metronidazole) AND Have had inadequate response, intolerance or contraindications to an immunosuppressive agent (e.g. azathioprine or 6 mercaptopurine). Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids Humira adalimumab 40 mg/0.8 ml Injection Crohn's Disease: For treatment of moderate to severely active Crohn's Disease in patients with inadequate response, intolerance or contraindications to an adequate course of corticosteroids AND an immunosuppressive agent. Fistulizing Crohn's Disease: For the treatment of Fistulizing Crohn's Disease in patients with actively draining perianal or enterocutaneous fistula who meet the following criteria: Presence of fistula that has persisted despite a course of antibiotic therapy (e.g. ciprofloxacin and/or metronidazole) AND Have had inadequate response, intolerance or contraindications to an immunosuppressive agent (e.g. azathioprine or 6 mercaptopurine). Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids. 4 of 26

6 Inflectra infliximab 100 mg/vl Injection Crohn's Disease: For treatment of moderate to severely active Crohn's Disease in patients with inadequate response, intolerance or contraindications to an adequate course of corticosteroids AND an immunosuppressive agent. For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Crohn's Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Crohn's Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Fistulizing Crohn's Disease: For the treatment of Fistulizing Crohn's Disease in patients with actively draining perianal or enterocutaneous fistula who meet the following criteria: Presence of fistula that has persisted despite a course of antibiotic therapy (e.g. ciprofloxacin and/or metronidazole) AND Have had inadequate response, intolerance or contraindications to an immunosuppressive agent (e.g. azathioprine or 6 mercaptopurine). For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Fistulizing Crohn s Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Fistulizing Crohn s Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids. For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Ulcerative Colitis. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Ulcerative Colitis. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve 5 of 26

7 patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab Remicade infliximab 100 mg/10 ml Injection Crohn's Disease: For treatment of moderate to severely active Crohn's Disease in patients with inadequate response, intolerance or contraindications to an adequate course of corticosteroids AND an immunosuppressive agent. For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Crohn's Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Crohn's Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Fistulizing Crohn's Disease: For the treatment of Fistulizing Crohn's Disease in patients with actively draining perianal or enterocutaneous fistula who meet the following criteria: Presence of fistula that has persisted despite a course of antibiotic therapy (e.g. ciprofloxacin and/or metronidazole) AND Have had inadequate response, intolerance or contraindications to an immunosuppressive agent (e.g. azathioprine or 6 mercaptopurine). For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Fistulizing Crohn s Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Fistulizing Crohn s Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids. For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Ulcerative Colitis. 6 of 26

8 For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Ulcerative Colitis. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab Renflexis infliximab 100 mg Injection Crohn's Disease: For treatment of moderate to severely active Crohn's Disease in patients with inadequate response, intolerance or contraindications to an adequate course of corticosteroids AND an immunosuppressive agent. For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Crohn's Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Crohn's Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Fistulizing Crohn's Disease: For the treatment of Fistulizing Crohn's Disease in patients with actively draining perianal or enterocutaneous fistula who meet the following criteria: Presence of fistula that has persisted despite a course of antibiotic therapy (e.g. ciprofloxacin and/or metronidazole) AND Have had inadequate response, intolerance or contraindications to an immunosuppressive agent (e.g. azathioprine or 6 mercaptopurine). For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Fistulizing Crohn s Disease. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Fistulizing Crohn s Disease. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab. Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids. 7 of 26

9 Bulletin #102 For Adults: Renflexis or Inflectra will be the preferred* infliximab option for all infliximab-naïve adult patients prescribed an infliximab product for Ulcerative Colitis. For Pediatrics: Renflexis will be the preferred* infliximab option for all infliximab-naïve pediatric patients prescribed an infliximab product for Ulcerative Colitis. *Preferred means the first infliximab product to be considered for reimbursement for infliximab-naïve patients. Patients will not be permitted to switch from Remicade, Renflexis or Inflectra to another infliximab product or vice versa, if: Previously trialed and deemed unresponsive to infliximab Simponi golimumab 50 mcg/0.5 ml 50 mcg/0.5 ml Injection Ulcerative Colitis: For the treatment of patients over 18 years of age with moderate to severely active ulcerative colitis who have had inadequate response, intolerance or contraindications to conventional therapy including 5-aminosalicylate compounds AND corticosteroids. New Interchangeable Categories Doxylamine/Pyridoxine - 10/10 mg - $ Diclectin DUI pms-doxylamine-pyridoxine PMS Apo-Doxylamine/B6 APX Fosfomycin - 3G - Oral Powder Monurol PAL Jamp-Fosfomycin JPC $ per G Hydromorphone HCL - 3 mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Hydromorphone HCL mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Hydromorphone HCL - 6 mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Hydromorphone HCL - 9 mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Hydromorphone HCL - 18 mg - Extended Release Capsule $ Hydromorph Contin PUR of 26

10 Apo-HYDROmorph CR APX Bulletin #102 Hydromorphone HCL - 24 mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Hydromorphone HCL - 30 mg - Extended Release Capsule $ Hydromorph Contin PUR Apo-HYDROmorph CR APX Lacosamide - 50 mg - $ Vimpat Auro-Lacosamide AUP Pharma-Lacosamide PMS Sandoz Lacosamide SDZ Teva-Lacosamide TEV Lacosamide mg - $ Vimpat Auro-Lacosamide AUP Pharma-Lacosamide PMS Sandoz Lacosamide SDZ Teva-Lacosamide TEV Lacosamide mg - $ Vimpat Auro-Lacosamide AUP Pharma-Lacosamide PMS Sandoz Lacosamide SDZ Teva-Lacosamide TEV Lacosamide mg - $ Vimpat Auro-Lacosamide AUP Pharma-Lacosamide PMS Sandoz Lacosamide SDZ Teva-Lacosamide TEV Lansoprazole/Amoxicillin/Clarithromycin - 30 mg/500 mg/500 mg - Kit $ HP-Pac ABB Apo- Lansoprazole/Amoxicillin /Clarithromycin Midodrine mg - $ Midodrine AAA Mar-Midodrine MAR Midodrine - 5 mg - $ Midodrine AAA Mar-Midodrine MAR APX of 26

11 Phenytoin Sodium mg - Capsules $ Dilantin PFI Apo-Phenytoin Sodium APX Pinaverium - 50 mg - s $ Dicetel ABB Apo-Pinaverium APX Pinaverium mg - $ Dicetel ABB Apo-Pinaverium APX Spironolactone - 25 mg - $ Aldactone PFI Novo-Spiroton TEV Spironolactone mg - $ Aldactone PFI Novo-Spiroton TEV Thiamazole - 5 mg - $ Tapazole PAL Mar-Methimazole MAR New Interchangeable Products The following products have been added to existing interchangeable drug categories: Amlodipine - 5 mg - $ Pharma-Amlodipine PMS ** Amlodipine - 10 mg - $ Pharma-Amlodipine PMS ** Aripiprazole - 2 mg - $ Teva-Aripiprazole TEV Aripiprazole - 5 mg - $ Teva-Aripiprazole TEV Aripiprazole - 10 mg - $ Teva-Aripiprazole TEV Aripiprazole - 15 mg - $ Teva-Aripiprazole TEV Aripiprazole - 20 mg - $ Teva-Aripiprazole TEV of 26

12 Aripiprazole - 30 mg - $ Teva-Aripiprazole TEV Atorvastatin - 20 mg - $ pms-atorvastatin PMS Atorvastatin - 40 mg - $ pms-atorvastatin PMS Cephalexin mg - $ Auro-Cephalexin AUP ** Cephalexin mg - $ Auro-Cephalexin AUP ** Dutasteride mg - Capsules $ Auro-Dutasteride AUP Efavirenz/Emtricitabine/Tenofovir mg/200 mg/300 mg - $ Apo-Efavirenz/Emtricitabine/ Tenofovir APX Escitalopram - 10 mg - $ Pharma-Escitalopram PMS Escitalopram - 20 mg - $ Pharma-Escitalopram PMS ** Esomeprazole - 40 mg - $ Ran-Esomeprazole RAN Sandoz Esomeprazole SDZ Ezetimibe - 10 mg - $ ACH-Ezetimibe ACH ** Furosemide - 20 mg - $ Mint-Furosemide MPH ** Furosemide - 40 mg - $ Mint-Furosemide MPH ** Pravastatin - 10 mg - $ Auro-Pravastatin AUP ** Pravastatin - 20 mg - $ Auro-Pravastatin AUP ** Pravastatin - 40 mg - $ 11 of 26

13 Auro-Pravastatin AUP Bulletin #102 ** Quetiapine - 50 mg - Extended Release $ Quetiapine XR SIP Quetiapine mg - Extended Release $ Quetiapine XR SIP Quetiapine mg - Extended Release $ Quetiapine XR SIP Quetiapine mg - Extended Release $ Quetiapine XR SIP Quetiapine mg - Extended Release $ Quetiapine XR SIP Ramipril mg - Capsule $ Pharma-Ramipril PMS ** Ramipril mg - Capsule $ Pharma-Ramipril PMS ** Ramipril - 5 mg - Capsule $ Pharma-Ramipril PMS ** Ramipril - 10 mg - Capsule $ Pharma-Ramipril PMS ** Solifenacin - 5 mg - $ Apo-Solifenacin APX ** Solifenacin - 10 mg - $ Apo-Solifenacin APX ** Trandolapril mg - Capsule $ Auro-Trandolapril AUP ** Teva-Trandolapril TEV ** Trandolapril - 1 mg - Capsule $ Auro-Trandolapril AUP ** Teva-Trandolapril TEV ** Trandolapril - 2 mg - Capsule $ Auro-Trandolapril AUP ** Teva-Trandolapril TEV ** Trandolapril - 4 mg - Capsule $ Auro-Trandolapril AUP ** of 26

14 Teva-Trandolapril TEV Bulletin #102 ** Ursodiol mg - $ Jamp-Ursodiol JPC ** Ursodiol mg - $ Jamp-Ursodiol JPC ** ** The price has resulted in a change to the lowest price in the category. The following products have been deleted. Product Deletions Cyclocort amcinonide 0.1% Ointment Demerol meperidine 50 mg GD-Gabapentin gabapentin 300 mg Capsule Holkira Pak dasabuvir/ombitasvir/ paritaprevir/ritonavir 250/12.5/ 75/50 mg Lectopam bromazepam 3 mg Lectopam bromazepam 6 mg Lopressor metoprolol 50 mg Lopressor metoprolol 100 mg Meperidine meperidine 10 mg/ml Injection Meperidine meperidine 50 mg/ml Injection Mirapex pramipexole 0.5 mg Mirapex pramipexole 1 mg Mirapex pramipexole 1.5 mg Mylan-Acebutolol acebutolol 100 mg Mylan-Alprazolam alprazolam 0.25 mg Mylan-Atenolol atenolol 25 mg Mylan-Carvedilol carvedilol mg Mylan-Carvedilol carvedilol 6.25 mg Mylan-Carvedilol carvedilol 12.5 mg Mylan-Ciprofloxacin ciprofloxacin 750 mg Mylan-Clonazepam clonazepam 0.5 mg Mylan-Cyclobenzaprine cyclobenzaprine 10 mg Mylan-Donepezil donepezil 5 mg Mylan-Duloxetine duloxetine 30 mg Capsule Mylan-Duloxetine duloxetine 60 mg Capsule Mylan-Famotidine famotidine 40 mg Mylan-Gabapentin gabapentin 400 mg Capsule Mylan-Gliclazide gliclazide 80 mg 13 of 26

15 Mylan-Losartan HCTZ losartan/hctz 100/12.5 mg Mylan-Losartan HCTZ losartan/hctz 100/25 mg Mylan-Losartan HCTZ losartan/hctz 50/12.5 mg Mylan-Meloxicam meloxicam 15 mg Mylan-Meloxicam meloxicam 7.5 mg Mylan-Montelukast montelukast 5 mg Mylan-Montelukast montelukast 10 mg Mylan-Omeprazole omeprazole 20 mg Capsule Mylan-Rabeprazole rabeprazole 10 mg Mylan-Risperidone risperidone 0.25 mg Mylan-Risperidone risperidone 0.5 mg Mylan-Rosuvastatin rosuvastatin 40 mg Mylan-Sertraline sertraline 100 mg Capsule Mylan-Sertraline sertraline 25 mg Capsule Mylan-Venlafaxine XR venlafaxine 37.5 mg Capsule Mylan-Venlafaxine XR venlafaxine 75 mg Capsule Mylan-Zopiclone zopiclone 5 mg Prevex B betamethasone 0.1% Cream Requip ropinirole 1 mg Requip ropinirole 2 mg Requip ropinirole 5 mg - Azithromycin mg - s - Erythromycin - 5 mg/g - Ophthalmic Ointment Category Deletions Interchangeable Product Price Changes The following changes in prices have occurred: ($) Brimonidine brimonidine 0.15 ** Cyproterone cyproterone 50 mg Desmopressin desmopressin 0.1 mg ** Desmopressin desmopressin 0.2 mg ** Dextroamphetamine dextroamphetamine 5 mg ** Enalapril/HCTZ enalapril/hctz 10/25 mg ** Ipravent ipravent 0.06 ** Ketorolac ketorolac 0.50 ** Toradol ketorolac 10 mg Moclobemide moclobemide 150 mg ** of 26

16 Moclobemide moclobemide 300 mg ** Nabumetone nabumetone 500 mg ** Ondansetron ondansetron 4 mg/5 ml ** Baclofen baclofen 10 mg Diclofenac K diclofenac 50 mg Famotidine famotidine 20 mg ** Famotidine famotidine 40 mg ** Furosemide furosemide 80 mg ** Glyburide glyburide 2.5 mg ** Glyburide glyburide 5 mg ** Lansoprazole lansoprazole 15 mg Lansoprazole lansoprazole 30 mg Losartan losartan 25 mg Losartan losartan 50 mg Losartan losartan 100 mg Lovastatin lovastatin 20 mg Lovastatin lovastatin 40 mg Meloxicam meloxicam 7.5 mg Meloxicam meloxicam 15 mg Mirtazapine mirtazapine 30 mg ** Naproxen EC naproxen 250 mg ** Naproxen naproxen 250 mg ** Naproxen naproxen 375 mg ** Naproxen naproxen 500 mg ** Naproxen Sodium naproxen 275 mg ** Naproxen Sodium DS naproxen 550 mg ** Oxybutynin oxybutynin 5 mg ** Trazodone trazodone 50 mg ** Trazodone trazodone 100 mg ** Trazodone trazodone 150 mg ** ACT-Exemestane exemestane 25 mg ACT-Meloxicam meloxicam 7.5 mg ** ACT-Meloxicam meloxicam 15 mg ** ACT-Rizatriptan rizatriptan 10 mg ACT-Ropinirole ropinirole 0.25 mg ACT-Ropinirole ropinirole 1 mg ACT-Ropinirole ropinirole 2 mg ACT-Ropinirole ropinirole 5 mg ACT-Temozolomide temozolomide 20 mg ACT-Temozolomide temozolomide 100 mg ACT-Temozolomide temozolomide 140 mg of 26

17 ACT-Temozolomide temozolomide 250 mg Apo-Abacavir/ Lamivudine abacavir/lamivudine 600/300 mg Apo-Acyclovir acyclovir 200 mg Apo-Acyclovir acyclovir 400 mg Apo-Acyclovir acyclovir 800 mg Apo-Alendronate alendronate 5 mg ** Apo-Alfuzosin alfuzosin 10 mg Apo-Alpraz alprazolam 0.25 mg Apo-Alpraz alprazolam 0.5 mg Apo-Alpraz alprazolam 1 mg Apo-Alpraz alprazolam 2 mg Apo-Amoxi Clav amoxicillin/clavulanic acid 500/125 mg ** Apo-Amoxi Clav amoxicillin/clavulanic acid 875/125 mg Apo-Aripiprazole aripiprazole 2 mg Apo-Aripiprazole aripiprazole 5 mg Apo-Aripiprazole aripiprazole 10 mg Apo-Aripiprazole aripiprazole 15 mg Apo-Aripiprazole aripiprazole 20 mg Apo-Aripiprazole aripiprazole 30 mg Apo-Atenidone atenidone 50/25 mg Apo-Atenidone atenidone 100/25 mg Apo-Azathioprine azathioprine 50 mg Apo-Baclofen baclofen 10 mg Apo-Beclomethasone beclomethasone 50 mcg Nasal Spray ** Apo-Buspirone buspirone 10 mg Apo-Capto captopril 12.5 mg ** Apo-Capto captopril 25 mg ** Apo-Capto captopril 50 mg ** Apo-Capto captopril 100 mg ** Apo-Cefuroxime cefuroxime 250 mg Apo-Cefuroxime cefuroxime 500 mg Apo-Clarithromycin clarithromycin 500 mg Apo-Clarithromycin XL clarithromycin 500 mg Apo-Clindamycin clindamycin 150 mg Capsule Apo-Clindamycin clindamycin 300 mg Capsule Apo-Deferasirox deferasirox 125 mg Apo-Deferasirox deferasirox 250 mg Apo-Deferasirox deferasirox 500 mg Apo-Dexamethasone dexamethasone 0.5 mg ** Apo-Dexamethasone dexamethasone 4 mg ** of 26

18 Apo-Diazepam diazepam 5 mg ** Apo-Diazepam diazepam 10 mg ** Apo-Diclo Rapide diclofenac 50 mg Apo-Diclo diclofenac 25 mg Apo-Diclo diclofenac 50 mg Apo-Diclofenac diclofenac 0.10 Opthalmic Sol Apo-Diclo SR diclofenac 75 mg Apo-Diclo SR diclofenac 100 mg Apo-Diltiaz CD diltiazem 120 mg Capsule Apo-Diltiaz CD diltiazem 180 mg Capsule Apo-Diltiaz CD diltiazem 240 mg Capsule Apo-Diltiaz CD diltiazem 300 mg Capsule Apo-Diltiaz diltiazem 30 mg ** Apo-Diltiaz diltiazem 60 mg ** Apo-Divalproex divalproex 125 mg Apo-Divalproex divalproex 250 mg Apo-Divalproex divalproex 500 mg Apo-Dorzo/Timop dorzolamide/timolol 20 mg/5 ml Apo-Doxazosin doxazosin 1 mg ** Apo-Doxazosin doxazosin 2 mg ** Apo-Doxazosin doxazosin 4 mg ** Apo-Doxepin doxepin 10 mg Capsule ** Apo-Doxepin doxepin 25 mg Capsule ** Apo-Doxepin doxepin 50 mg Capsule ** Apo-Doxy doxycycline 100 mg Capsule Apo-Doxy doxycycline 100 mg ** Apo-Entecavir entecavir 0.5 mg Apo-Famotidine famotidine 20 mg Apo-Famotidine famotidine 40 mg Apo-Feno-Micro fenofibrate 200 mg Capsule ** Apo-Feno Super fenofibrate 100 mg Apo-Feno Super fenofibrate 160 mg Apo-Flecainide flecainide 50 mg Apo-Flecainide flecainide 100 mg Apo-Fluconazole fluconazole 50 mg Apo-Fluconazole fluconazole 100 mg Apo-Fluoxetine fluoxetine 20 mg/5 ml Syrup Apo-Flurbiprofen flurbiprofen 50 mg ** Apo-Flurbiprofen flurbiprofen 100 mg ** Apo-Fluvoxamine fluvoxamine 50 mg Apo-Fosinopril fosinopril 10 mg of 26

19 Apo-Fosinopril fosinopril 20 mg Apo-Gliclazide MR gliclazide 30 mg Apo-Gliclazide MR gliclazide 60 mg Apo-Gliclazide gliclazide 80 mg Apo-Glyburide gliclazide 2.5 mg Apo-Glyburide glyburide 5 mg Apo-Granisetron granisetron 1 mg Apo-Hydralazine hydralazine 10 mg Apo-Hydralazine hydralazine 25 mg Apo-Hydralazine hydralazine 50 mg Apo-Hydro hydrochlorothiazide 25 mg Apo-Hydro hydrochlorothiazide 50 mg Apo-Indapamide indapamide 1.25 mg Apo-Indapamide indapamide 2.5 mg Apo-Ipravent ipravent 0.25 mg/ml Sol Inh ** Apo-ISMN isosorbide-5-monohydrate 60 mg Apo-Ketoconazole ketoconazole 200 mg ** Apo-Lactulose lactulose 667 mg/ml O/L Apo-Lamivudine/ Zidovudine lamivudine/zidovudine 150/300 mg Apo-Leflunomide leflunomide 10 mg Apo-Leflunomide leflunomide 20 mg Apo-Levocarb levodopa/carbidopa 100/10 mg Apo-Levocarb levodopa/carbidopa 100/ 25mg Apo-Levocarb levodopa/carbidopa 250/25 mg Apo-Levocarb CR levodopa/carbidopa 200/50 mg Apo-Lisinopril lisinopril 5 mg Apo-Lisinopril lisinopril 10 mg Apo-Lisinopril lisinopril 20 mg Apo-Loperamide loperamide 2 mg ** Apo-Loratadine loratadine 10 mg ** Apo-Lorazepam lorazepam 0.5 mg Apo-Lorazepam lorazepam 1 mg Apo-Lorazepam lorazepam 2 mg Apo-Lorazepam lorazepam 0.5 mg SL ** Apo-Lorazepam lorazepam 1 mg SL ** Apo-Lorazepam lorazepam 2 mg SL ** Apo-Losartan losartan 25 mg Apo-Losartan losartan 50 mg Apo-Losartan losartan 100 mg Apo-Lovastatin lovastatin 20 mg of 26

20 Apo-Lovastatin lovastatin 40 mg Apo-Medroxy medroxyprogesterone 2.5 mg ** Apo-Medroxy medroxyprogesterone 5 mg ** Apo-Medroxy medroxyprogesterone 10 mg Apo-Meloxicam meloxicam 7.5 mg Apo-Meloxicam meloxicam 15 mg Apo-Methotrexate methotrexate 2.5 mg Apo-Methylphenidate methylphenidate 10 mg ** Apo-Methylphenidate methylphenidate 20 mg Apo-Metoprolol metoprolol 25 mg Apo-Metoprolol metoprolol 50 mg Apo-Metoprolol (Type L) metoprolol 50 mg Apo-Metoprolol metoprolol 100 mg Apo-Metoprolol (Type L) metoprolol 100 mg Apo-Mirtazapine mirtazapine 15 mg Apo-Mirtazapine mirtazapine 30 mg Apo-Modafinil modafinil 100 mg Apo-Mometasone mometasone 50 mcg Nasal Spray Apo-Naltrexone naltrexone 50 mg Apo-Naproxen EC naproxen 250 mg Apo-Naproxen EC naproxen 375 mg Apo-Naproxen EC naproxen 500 mg Apo-Naproxen naproxen 250 mg Apo-Naproxen naproxen 375 mg Apo-Naproxen naproxen 500mg Apo-Napro-Na naproxen 275 mg Apo-Napro-Na DS naproxen 550 mg Apo-Ondansetron ondansetron 4 mg Apo-Ondansetron ondansetron 8 mg Apo-Oxcarbazepine oxcarbazepine 300 mg ** Apo-Oxcarbazepine oxcarbazepine 600 mg ** Apo-Oxybutynin oxybutynin 5 mg Apo-Pindol pindolol 5 mg Apo-Pindol pindolol 10 mg ** Apo-Pindol pindolol 15 mg ** Apo-Pioglitazone pioglitazone 15 mg Apo-Pioglitazone pioglitazone 30 mg Apo-Pioglitazone pioglitazone 45 mg Apo-Quinine quinine 200 mg of 26

21 Apo-Quinine quinine 300 mg Apo-Raloxifene raloxifene 60 mg Apo-Repaglinide repaglinide 0.5 mg Apo-Repaglinide repaglinide 1 mg Apo-Repaglinide repaglinide 2 mg Apo-Rizatriptan rizatriptan 10 mg Apo-Salvent CFC Free/ Apo-Salvent sans CFC salbutamol 200 dose Inhaler Apo-Selegiline selegiline 5 mg Apo-Sotalol sotalol 80 mg Apo-Sotalol sotalol 160 mg Apo-Tamox tamoxifen 20 mg ** Apo-Tamox tamoxifen 40 mg Apo-Terazosin terazosin 1 mg Apo-Terazosin terazosin 2 mg Apo-Terazosin terazosin 5 mg Apo-Terazosin terazosin 10 mg Apo-Timop timolol 0.25 Opthalmic Sol Apo-Timop timolol 0.50 Opthalmic Sol Apo-Trazodone trazodone 50 mg Apo-Trazodone trazodone 100 mg Apo-Trazodone-D trazodone 150 mg Apo-Triazide triazide 50/25 mg Apo-Tryptophan tryptophan 500 mg Capsule ** Apo-Tryptophan tryptophan 500 mg ** Apo-Tryptophan tryptophan 1 gm Apo-Verap SR verapamil 120 mg Apo-Verap SR verapamil 240 mg Apo-Verap verapamil 80 mg ** Apo-Verap verapamil 120 mg ** Apo-Warfarin warfarin 1 mg ** Apo-Warfarin warfarin 2 mg ** Apo-Warfarin warfarin 2.5 mg ** Apo-Warfarin warfarin 3 mg ** Apo-Warfarin warfarin 4 mg ** Apo-Warfarin warfarin 5 mg ** Apo-Warfarin warfarin 10 mg ** Baclofen Intrathecal baclofen 0.05 mg/ml Injection Baclofen Intrathecal baclofen 0.5 mg/ml Injection Baclofen Intrathecal baclofen 2 mg/ml Injection Calcitriol-Odan calcitriol 0.25 mg Capsule ** of 26

22 Cholestyramine-Odan cholestyramine 4 gm Powder ** CO Diltiazem T diltiazem 120 mg Capsule CO Diltiazem T diltiazem 180 mg Capsule CO Diltiazem T diltiazem 240 mg Capsule CO Diltiazem T diltiazem 300 mg Capsule CO Diltiazem T diltiazem 360 mg Capsule CO Enalapril enalapril 5 mg CO Enalapril enalapril 20 mg CO Lisinopril lisinopril 5 mg CO Lovastatin lovastatin 20 mg ** CO Lovastatin lovastatin 40 mg ** CO Ondansetron ondansetron 4 mg CO Ondansetron ondansetron 8 mg CO Pioglitazone pioglitazone 15 mg CO Pioglitazone pioglitazone 30 mg CO Pioglitazone pioglitazone 45 mg CO Repaglinide repaglinide 0.5 mg CO Repaglinide repaglinide 1 mg CO Repaglinide repaglinide 2 mg GD-Azithromycin azithromycin 100 mg/5 ml Suspension GD-Azithromycin azithromycin 200 mg/5 ml Suspension Jamp-Bezalip SR bezalip 400 mg ** Jamp-Hydralazine hydralazine 10 mg Jamp-Hydralazine hydralazine 25 mg Jamp-Hydralazine hydralazine 30 mg Jamp-Indapamide indapamide 2.5 mg Losartan losartan 25 mg Losartan losartan 50 mg Losartan losartan 100 mg Mar-Rizatriptan ODT rizatriptan 5 mg Mar-Rizatriptan ODT rizatriptan 10 mg Med-Exemestane exemestane 25 mg Med-Letrozole letrozole 2.5 mg Mint-Gliclazide MR gliclazide 30 mg Mint-Gliclazide MR gliclazide 60 mg Mint-Losartan HCTZ losartan/hctz 50/12.5 mg Mint-Losartan HCTZ losartan/hctz 100/25 mg Mint-Ondansetron ondansetron 8 mg Mint-Tolterodine tolterodine 1 mg Mint-Tolterodine tolterodine 2 mg Mylan-Acyclovir acyclovir 200 mg ** of 26

23 Mylan-Acyclovir acyclovir 400 mg ** Mylan-Acyclovir acyclovir 800 mg ** Mylan-Baclofen baclofen 10 mg Mylan-Bupropion XL bupropion 150 mg Mylan-Bupropion XL bupropion 300 mg Mylan-Clobetasol clobetasol 0.05 Lotion Mylan-Efavirenz efavirenz 600 mg Mylan-Fentanyl Matrix fentanyl 50 mcg Patch Mylan-Fentanyl Matrix fentanyl 75 mcg Patch Mylan-Fentanyl Matrix fentanyl 100 mcg Patch Mylan-Galantamine ER galantamine 8 mg Mylan-Galantamine ER galantamine 16 mg Mylan-Galantamine ER galantamine 24 mg Clarus isotretinoin 40 mg Capsule ** Mylan-Lansoprazole lansoprazole 15 mg Capsule Mylan-Lansoprazole lansoprazole 30 mg Capsule Mylan-Mirtazapine mirtazapine 30 mg Mylan-Nevirapine nevirapine 200 mg Mylan-Nifedipine Extended Release nifedipine 60 mg ** Mylan-Ondansetron ondansetron 4 mg Mylan-Ondansetron ondansetron 8 mg Mylan-Oxybutynin oxybutynin 5 mg Mylan-Rizatriptan OD rizatriptan 5 mg Mylan-Rizatriptan OD rizatriptan 10 mg Mylan-Tolterodine ER tolterodine 2 mg Capsule Mylan-Tolterodine ER tolterodine 4 mg Capsule Mylan-Verapamil verapamil 120 mg ** Novamoxin amoxicillin 250 mg Capsule Odan-Erythromycin erythromycin 5 mg/gm Ointment ** PDP-Erythromycin erythromycin 5 mg Ointment Sandoz Alendronate alendronate 10 mg Sandoz Alfuzosin alfuzosin 10 mg ** Sandoz Anagrelide anagrelide 0.5 mg Capsule ** Sandoz Azithromycin azithromycin 20 mg/ml Suspension Sandoz Azithromycin azithromycin 40 mg/ml Suspension Sandoz Bosentan bosentan 62.5 mg Sandoz Bosentan bosentan 125 mg Sandoz Bupropion SR bupropion 100 mg ** Sandoz Candesartan candesartan 4 mg Sandoz Capecitabine capecitabine 150 mg of 26

24 Sandoz Capecitabine capecitabine 500 mg Sandoz Carbamazepine CR Sandoz Carbamazepine CR carbamazepine 200 mg ** carbamazepine 400 mg ** Sandoz Clarithromycin clarithromycin 500 mg Sandoz Diclofenac Rapide diclofenac 50 mg ** Sandoz Diclofenac SR diclofenac 75 mg ** Sandoz Diclofenac SR diclofenac 100 mg ** Sandoz Diclofenac diclofenac 50 mg Supp ** Sandoz Diltiazem T diltiazem 120 mg Capsule Sandoz Diltiazem T diltiazem 180 mg Capsule Sandoz Diltiazem T diltiazem 240 mg Capsule Sandoz Diltiazem T diltiazem 300 mg Capsule Sandoz Diltiazem T diltiazem 360 mg Capsule Sandoz Estradiol Derm estradiol 50 mcg Patch Sandoz Estradiol Derm estradiol 75 mcg Patch Sandoz Estradiol Derm estradiol 100 mcg Patch Sandoz Felodipine felodipine 5 mg Sandoz Felodipine felodipine 10 mg Sandoz Fenofibrate E fenofibrate 145 mg Sandoz Fentanyl fentanyl 12 mcg Patch Sandoz Fentanyl fentanyl 25 mcg Patch Sandoz Fentanyl fentanyl 50 mcg Patch Sandoz Fentanyl fentanyl 75 mcg Patch Sandoz Fentanyl fentanyl 100 mcg Patch Haloperidol haloperidol 5 mg/ml Injection Sandoz Letrozole letrozole 2.5 mg Sandoz Losartan losartan 25 mg Sandoz Losartan losartan 50 mg Sandoz Losartan HCTZ losartan/hctz 100/25 mg Sandoz Mirtazapine mirtazapine 15 mg ** Sandoz Mirtazapine mirtazapine 30 mg Rho-Nitro Pumpspray nitroglycerin 0.4 mg Spray Sandoz Ondansetron ondansetron 4 mg Sandoz Quetiapine XRT quetiapine 50 mg Sandoz Quetiapine XRT quetiapine 150 mg Sandoz Quetiapine XRT quetiapine 200 mg Sandoz Quetiapine XRT quetiapine 300 mg Sandoz Quetiapine XRT quetiapine 400 mg of 26

25 Sandoz Repaglinide repaglinide 0.5 mg Sandoz Repaglinide repaglinide 1 mg Sandoz Repaglinide repaglinide 2 mg Sandoz Timolol timolol 0.50 Opthalmic Sol ** Sandoz Voriconazole voriconazole 50 mg Sandoz Voriconazole voriconazole 200 mg Sandoz Zolmitriptan zolmitriptan 2.5 mg ** The price has resulted in a change to the lowest price in the category. The following products will be deleted with the next Formulary amendments Apo-Cefprozil cefprozil 500 mg Apo-Gemfibrozil gemfibrozil 600 mg Apo-Nitroglycerin Pumpspray Discontinued Products nitroglycerin 0.4 mg/dose Spray Apo-Zolmitriptan zolmitriptan 2.5 mg ESME 21 ESME 28 levonorgestrel/ethinyl estradiol 100/20 mcg Mar-Rizatriptan IR rizatriptan 5 mg Mint-Rizatriptan ODT rizatriptan 10 mg Mylan-Acebutolol Mylan-Alprazolam acebutolol alprazolam 100 mg 200 mg 400 mg 0.25 mg 0.5 mg 2 mg Mylan-Amiodarone amiodarone 200 mg Mylan-Amoxicillin amoxicillin 250 mg Capsule Mylan-Anagrelide anagrelide 50 mg Mylan-Atenolol atenolol 50 mg 100 mg Mylan-Bosentan bosentan 62.5 mg Mylan-Candesartan candesartan 4 mg 8 mg 16 mg 32 mg Mylan-Captopril captopril 100 mg Mylan-Carbamazepine 200 mg carbamazepine CR 300 mg Mylan-Celecoxib celecoxib 100 mg Capsule Mylan-Ciprofloxacin ciprofloxacin 250 mg Mylan-Citalopram citalopram 40 mg 24 of 26

26 Mylan-Doxazosin doxazosin 4 mg Mylan-Famotidine famotidine 20 mg Mylan-Fluoxetine fluoxetine 10 mg 20 mg Capsule Mylan-Irbesartan irbesartan 75 mg 150 mg Mylan-Ipratropium ipratropium 200 mcg/ml Mylan-Losartan losartan 25 mg 50 mg 100 mg Mylan-Losartan HCTZ losartan/hctz 50/12.5 mg 100/25 mg Inhalation Solution Mylan-Lovastatin lovastatin 40 mg Mylan-Meloxicam meloxicam 15 mg Mylan-Metformin metformin 500 mg 850 mg Mylan-Naproxen EC naproxen 375 mg 500 mg mg mg Mylan-Olanzapine olanzapine mg mg Mylan-Pantoprazole pantoprazole 40 mg Mylan-Paroxetine paroxetine 10 mg 20 mg 30 mg Mylan-Pioglitazone pioglitazone 30 mg Mylan-Pregabalin pregabalin 25 mg 50 mg 75 mg Capsule mg 300 mg Mylan-Rosuvastatin rosuvastatin 20 mg Mylan-Telmisartan telmisartan 40 mg 80 mg Mylan-Valsartan valsartan 40 mg 80 mg mg Mylan-Venlafaxine XR venlafaxine 150 mg Capsule Mylan-Zopiclone zopiclone 7.5 mg Mylan-Zolmitriptan ODT zolmitriptan 2.5 mg mg mg NAT-Alprazolam alprazolam mg s mg Oxybutyn oxybutynin 5 mg s PDP-Benztropine benztropine 2 mg s PDP-Procyclidine procyclidine 2.5 mg s 5 mg 25 of 26

27 PDP-Procyclidine procyclidine 2.5 mg/5 ml Elixer Sandoz Metoprolol metoprolol 50 mg 100 mg Sandoz Sotalol sotalol 160 mg Scopolamine scopolamine 0.4 mg/ml 0.6 mg/ml Injection Trazorel trazodone 50 mg 100 mg s 26 of 26