UPDATE AG Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 24, 2012 SUMMARY OF CHANGES

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1 UPDATE AG Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective April 24, 2012 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 4 Off Formulary Interchangeable Product(s) 7 Manufacturer Requested Discontinued Drug(s) 8 New Drug Identification Number(s) 9 Drug Benefit Price(s) 10 New Manufacturer Name(s) 21 Therapeutic Note Change(s) 22 Trade Name Change(s) 23 Index 24 Page 1

2 New Single Source Drug(s) DIN PRODUCT GENERIC NAME MFR DBP Pradax 110mg Cap DABIGATRAN ETEXILATE BOE Pradax 150mg Cap DABIGATRAN ETEXILATE BOE Reason for Use Code Clinical Criteria 431 For the prevention of stroke and systemic embolism in at risk patients with non-valvular atrial fibrillation (AF), AND in whom: 1) Anticoagulation is inadequate following a reasonable trial on warfarin; OR 2) Anticoagulation with warfarin is contraindicated or not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy, and at home). Exclusion Criteria: Impaired renal function (creatinine clearance or estimated glomerular filtration rate less than 30mL/min); OR greater than or equal to 75 years of age without documented stable renal function; OR hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis; OR prosthetic heart valves. Note: (a) Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate maintained for at least 3 months (i.e., 30-49mL/min for 110mg twice daily dosing and, greater than or equal to 50mL/min for 150mg twice daily dosing for at least 3 months). (b) At risk patients with atrial fibrillation are defined as those with a CHADS2 score of greater than or equal to 1. (c) Inadequate anticoagulation is defined as INR testing results that are outside of the desired INR range for at least 35% of the tests during the monitoring period (i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period). Continued on the next page: Page 2

3 DIN PRODUCT GENERIC NAME MFR DBP Reason for Use Code Continued from the previous page Clinical Criteria Note: (d) A reasonable trial on warfarin is defined as at least 2 months of therapy. (e) Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see product monograph). (f) Patients starting dabigatran should have ready access to appropriate medical services to manage a major bleeding event. (g) There are currently no data to support that dabigatran provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart valves; dabigatran is not recommended in these populations. LU Authorization Period: Indefinite Vimpat 50mg Tab LACOSAMIDE UCB Vimpat 100mg Tab LACOSAMIDE UCB Vimpat 150mg Tab LACOSAMIDE UCB Vimpat 200mg Tab LACOSAMIDE UCB Reason for Use Code Clinical Criteria 430 As adjunctive therapy in the treatment of adult patients with partial onset seizures who have had an inadequate response or have significant intolerance to at least 3 less costly anticonvulsant therapies; AND Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc. LU Authorization Period: Indefinite. Page 3

4 New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Auro-Cefprozil 250mg Tab AUR Auro-Cefprozil (Interchangeable with Cefzil) 500mg Tab AUR Co Mycophenolate (Interchangeable with Cellcept) 500mg Tab COB Reason for Use Code Clinical Criteria 190 For the prophylaxis of organ rejection in patients receiving allogeneic renal, cardiac or hepatic transplants. LU Authorization Period: Indefinite Mylan-Candesartan 4mg Tab MYL Mylan-Candesartan 8mg Tab MYL Mylan-Candesartan 16mg Tab MYL Mylan-Candesartan 32mg Tab MYL (Interchangeable with Atacand) Mylan-Montelukast (Interchangeable with Singulair) Reason for Use Code Clinical Criteria 4mg Chew Tab MYL For the treatment of asthma in patients aged 2-5 years old. LU Authorization Period: 1 Year. Page 4

5 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Mylan-Telmisartan HCTZ 80mg & 12.5mg Tab MYL Mylan-Telmisartan HCTZ 80mg & 25mg Tab MYL (Interchangeable with Micardis Plus) Ran-Venlafaxine XR 37.5mg ER Cap RAN Ran-Venlafaxine XR 75mg ER Cap RAN Ran-Venlafaxine XR (Interchangeable with Effexor XR) 150mg ER Cap RAN Teva-Galantamine ER 8mg ER Cap TEV Teva-Galantamine ER 16mg ER Cap TEV Teva-Galantamine ER (Interchangeable with Reminyl ER) 24mg ER Cap TEV Reason for Use Code Clinical Criteria 347 Initial Trial: For patients with mild to moderate Alzheimer's Disease (Mini-Mental State Exam [MMSE] 10-26). Patients will be reimbursed for a period of up to 3 months after which continued treatment must be reassessed. Network note: Maximum duration 3 months. LU Authorization Period: 1 year. 348 Continuation: Further reimbursement will be made available to those patients whose disease has not progressed/deteriorated while on this drug. Patients must continue to have a MMSE score of LU Authorization Period: 1 year. Page 5

6 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Teva-Losartan (Interchangeable with Cozaar) 25mg Tab TEV Teva-Telmisartan HCTZ 80mg & 12.5mg Tab TEV Teva-Telmisartan HCTZ 80mg & 25mg Tab TEV (Interchangeable with Micardis Plus) Page 6

7 Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST Auro-Levetiracetam 250mg Tab AUR Auro-Levetiracetam 500mg Tab AUR Auro-Levetiracetam (Interchangeable with Keppra) 750mg Tab AUR Cefoxitin for Injection USP 1g/Vial Inj Pd-Vial Pk NOP Cefoxitin for Injection USP 2g/Vial Inj Pd-Vial Pk NOP (Interchangeable with Mefoxin) Mylan-Montelukast (Interchangeable with Singulair) 5mg Chew Tab MYL Teva-Atovaquone Proguanil 250mg & 100mg Tab TEV (Interchangeable with Malarone) Page 7

8 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 Celestoderm-V/2 0.05% Cr SCH Celestoderm-V 0.1% Cr SCH Celestoderm-V/2 0.05% Oint SCH Celestoderm-V 0.1% Oint SCH Ratio-Gabapentin 100mg Cap RPH Ratio-Gabapentin 300mg Cap RPH Ratio-Pantoprazole 20mg Tab RPH Ratio-Pantoprazole 40mg Tab RPH Ratio-Ramipril Cap 5mg Cap RPH Ratio-Ramipril Cap 10mg Cap RPH Ratio-Ramipril Cap 15mg Cap RPH Ratio-Sertraline 25mg Cap RPH Ratio-Sertraline 50mg Cap RPH Ratio-Sertraline 100mg Cap RPH Ratio-Simvastatin 20mg Tab RPH Ratio-Valproic 250mg Cap RPH Page 8

9 New Drug Identification Number(s) DIN BRAND STRENGTH DOSAGE FORM MFR Celestoderm-V/2 0.05% Cr SCH Celestoderm-V 0.1% Cr SCH Celestoderm-V/2 0.05% Oint SCH Celestoderm-V 0.1% Oint SCH Page 9

10 Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Accupril 5mg Tab PFI Accupril 10mg Tab PFI Accupril 20mg Tab PFI Accupril 40mg Tab PFI Accuretic 10mg & 12.5mg Tab PFI Accuretic 20mg & 12.5mg Tab PFI Actonel 5mg Tab WAR Actonel 30mg Tab WAR Actos 15mg Tab TAK Actos 30mg Tab TAK Actos 45mg Tab TAK Alesse 20mcg & 100mcg Tab-21 Pk WAY Alesse 20mcg & 100mcg Tab-28 Pk WAY Alkeran 2mg Tab TRT Alomide 0.1% Oph Sol ALC Altace Cap 1.25mg SAV Altace Cap 2.5mg SAV Altace Cap 5mg SAV Altace Cap 10mg SAV Altace HCT 10mg & 12.5mg Tab SAV Altace HCT 10mg & 25mg Tab SAV Alvesco 100mcg/Actuation Inh-120 Dose Pk NYC Alvesco 200mcg/Actuation Inh-120 Dose Pk NYC Anandron 50mg Tab SAV Androderm 12.2mg Transdermal Patch PAL Anzemet 100mg Tab SAV Apidra 100U/mL Inj Sol-5x3mL SAV SoloSTAR Pref Pen Apidra 100U/mL Inj Sol-10mL Vial SAV Apidra 100U/mL Inj 5x3mL Cart SAV ClickStar Pen Apo-Bromocriptine 2.5mg Tab APX Apo-Bromocriptine 5mg Cap APX Apo-Flurazepam 15mg Cap APX Apo-Flurazepam 30mg Cap APX Apo-Medroxy 100mg Tab APX Apri mg & 0.03mg Tab-21 Pk APX Apri mg & 0.03mg Tab-28 Pk APX Aranesp 200mcg/0.4mL Pref Syr-0.4mL Pk AMG Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk AMG Aranesp 500mcg/1.0mL Pref Syr-1.0mL Pk AMG Arava 10mg Tab SAV Arava 20mg Tab SAV Arixtra 2.5mg Inj-0.5mL Pk GSK Aromasin 25mg Tab PFI Page 10

11 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Arthrotec 50 50mg & 200mcg Tab PFI Arthrotec 75 75mg & 200mcg Tab PFI Asacol 400mg Tab WAR Asacol 800mg Tab WAR Atacand 4mg Tab AZC Atacand 8mg Tab AZC Atacand 16mg Tab AZC Atacand 32mg Tab AZC Atacand Plus 16mg/12.5mg Tab AZC Atacand Plus 32mg & 12.5mg Tab AZC Atacand Plus 32mg & 25mg Tab AZC Atripla 600mg/300mg/200mg Tab BQU Avalide 150 & 12.5mg Tab SAV Avalide 300 & 12.5mg Tab SAV Avapro 75mg Tab SAV Avapro 150mg Tab SAV Avapro 300mg Tab SAV Benuryl 500mg Tab VAL BenzaClin 1% & 5% Top Gel SAV Betnesol 5mg/100mL Enema-100mL Pk PAL Betoptic S 0.25% Oph Susp ALC Biphentin 10mg ER Cap PFP Biphentin 15mg ER Cap PFP Biphentin 20mg ER Cap PFP Biphentin 30mg ER Cap PFP Biphentin 40mg ER Cap PFP Biphentin 50mg ER Cap PFP Biphentin 60mg ER Cap PFP Biphentin 80mg ER Cap PFP Bricanyl Turbuhaler 0.5mg/Dose Inh-200 Dose Pk AZC C.E.S mg Tab VAL Cafergot 1mg & 100mg Tab NOV Calcimar 400IU/2mL Inj Sol-2mL Pk SAV Carbolith 150mg Cap VAL Carbolith 300mg Cap VAL Cardizem CD 120mg LA Cap BIO Cardizem CD 180mg LA Cap BIO Cardizem CD 240mg LA Cap BIO Cardizem CD 300mg LA Cap BIO Casodex 50mg Tab AZC CeeNU 10mg Cap BQU CeeNU 40mg Cap BQU CeeNU 100mg Cap BQU Ceftin 250mg Tab GSK Ceftin 500mg Tab GSK Cefzil 125mg/5mL Oral Susp-75mL Pk BQU Cefzil 125mg/5mL Oral Susp-100mL Pk BQU Cefzil 250mg/5mL Oral Susp-75mL Pk BQU Cefzil 250mg/5mL Oral Susp-100mL Pk BQU Page 11

12 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Cefzil 250mg Tab BQU Cefzil 500mg Tab BQU Celebrex 100mg Cap PFI Celebrex 200mg Cap PFI Cerubidine Inj Pd-20mg Pk ERF Champix 0.5mg Tab PFI Champix 1.0mg Tab PFI Champix 0.5mg & 1.0mg Tabs (Starter Pack) PFI Cipralex 10mg Tab VLH Cipralex 20mg Tab VLH Clindoxyl 1% & 5% Gel STI Co Cilazapril 2.5mg Tab COB Co Cilazapril 5mg Tab COB Co Clonazepam 0.5mg Tab COB Co Clonazepam 2mg Tab COB Co Sotalol 160mg Tab COB Co Temazepam 15mg Cap COB Co Temazepam 30mg Cap COB Codeine Contin 50mg CR Tab PFP Codeine Contin 100mg CR Tab PFP Codeine Contin 150mg CR Tab PFP Codeine Contin 200mg CR Tab PFP Colestid Orange Gran-7.5g Pk PFI Comtan 200mg Tab NOV Cortifoam 10% Rect Aero-15g Pk PAL Cortisporin 10000U & 5mg & Ot Sol GSK mg/mL Coumadin 1mg Tab BQU Coumadin 2mg Tab BQU Coumadin 2.5mg Tab BQU Coumadin 3mg Tab BQU Coumadin 4mg Tab BQU Coumadin 5mg Tab BQU Coumadin 10mg Tab BQU Cyclocort 0.1% Cr STI Cyclocort 0.1% Lot STI Cyclocort 0.1% Oint STI Cyclomen 50mg Cap SAV Cyclomen 100mg Cap SAV Cyclomen 200mg Cap SAV Cymbalta 30mg DR Cap LIL Cymbalta 60mg DR Cap LIL Cytovene 500mg/Vial Pd Inj-10mL Pk HLR Demerol 50mg Tab SAV Depo-Provera 50mg/mL Inj Sol-5mL Pk PFI Depo-Provera 150mg/mL Inj PFI Detrol 1mg Tab PFI Detrol 2mg Tab PFI Detrol LA 2mg SR Cap PFI Page 12

13 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Detrol LA 4mg SR Cap PFI Dexedrine 5mg Tab PAL Diabeta 2.5mg Tab SAV Diabeta 5mg Tab SAV Diastat 5mg/mL Rect Gel-2x 5mg Pk VAL Diastat 5mg/mL Rect Gel-2x10mg Pk VAL Diastat 5mg/mL Rect Gel-2x15mg Pk VAL Diclectin 10mg & 10mg SR Tab DUI Didrocal 400mg/500mg Tab-90 Tablets Kit WAR Duvoid 10mg Tab PAL Duvoid 25mg Tab PAL Duvoid 50mg Tab PAL Efudex 5% Cr VAL Eltroxin 0.05mg Tab TRT Eltroxin 0.1mg Tab TRT Eltroxin 0.15mg Tab TRT Eltroxin 0.2mg Tab TRT Emo-Cort 1% Cr STI Emo-Cort 1% Lot STI Emo-Cort 2.5% Cr STI Emo-Cort 2.5% Lot STI Enbrel 25mg/Vial Inj Pd-Vial Pk IMU Enbrel 50mg/mL Inj Pref Syr IMU Enbrel SureClick 50mg/mL Pref AutoInj IMU Estring 2mg Vag Ring PFI Etibi 100mg Tab VAL Etibi 400mg Tab VAL Evista 60mg Tab LIL Exjade 125mg Tab for Susp NOV Exjade 250mg Tab for Susp NOV Exjade 500mg Tab for Susp NOV Famvir 500mg Tab NOV Femara 2.5mg Tab NOV Flagyl 500mg Cap SAV Flagyl 10% Vag Cr-App SAV Flagystatin 500mg & U Vag Sup SAV Flagystatin 500mg & U/g Vag Cr-App SAV Flarex 0.1% Oph Susp ALC Florinef 0.1mg Tab PAL Foradil 12mcg/Cap Inh Pd-Device Pk NOV Fosrenol 250mg Chew Tab SHI Fosrenol 500mg Chew Tab SHI Fosrenol 750mg Chew Tab SHI Fosrenol 1000mg Chew Tab SHI Fungizone Inj Pd-50mg Pk BQU Glucophage 500mg Tab SAV Humalog Mix50 50% & 50% Inj Susp-5x3mL Pk LIL Humalog Mix50 Kwikpen 50% & 50% Inj Susp-5x3mL Pk LIL Humulin 30/70 100U/mL Inj Susp-5x3mL Pk LIL Page 13

14 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Humulin 30/ U/10mL Inj Susp-10mL Pk LIL Humulin N 100U/mL Inj Susp-5x3mL Pk LIL Humulin NPH 1000U/10mL Inj Susp-10mL Pk LIL Humulin R 100U/mL Inj Sol-5x3mL Pk LIL Humulin Regular 1000U/10mL Inj Sol-10mL Pk LIL Hycodan 1mg/mL O/L BQU Hycort 100mg/60mL Enema-60mL Pk VAL Hydromorph Contin 3mg CR Cap PFP Hydromorph Contin 6mg CR Cap PFP Hydromorph Contin 12mg CR Cap PFP Hydromorph Contin 18mg CR Cap PFP Hydromorph Contin 24mg CR Cap PFP Hydromorph Contin 30mg CR Cap PFP Hypotears 1% Oph-Sol NOV Imuran 50mg Tab TRT Inhibace 2.5mg Tab HLR Inhibace 5mg Tab HLR Inhibace Plus 5mg/12.5mg Tab HLR Invirase 200mg Cap HLR Invirase 500mg Tab HLR Isopto Atropine 1% Oph-Sol ALC Isopto Carbachol 1.5% Oph-Sol ALC Isopto Carbachol 3% Oph-Sol ALC Isopto Carpine 1% Oph-Sol ALC Isopto Carpine 2% Oph-Sol ALC Isopto Carpine 4% Oph-Sol ALC Isopto Tears 0.5% Oph-Sol ALC Isopto Tears 1% Oph-Sol ALC K mEq/mL O/L GSK Kayexalate 1mEq/g Oral Pd-454g Pk SAV Kenalog-10 50mg/5mL Inj Susp-5mL Pk BQU Kenalog-40 40mg/mL Inj Susp-1mL Pk BQU Kenalog mg/5mL Inj Susp-5mL Pk BQU Lamictal 25mg Tab GSK Lamictal 100mg Tab GSK Lamictal 150mg Tab GSK Lamisil 1% Cr NOV Lantus-(Cartridge) 100U/mL Inj Sol-5x3mL Pk SAV Lantus-(Vial) 100U/mL Inj Sol-10mL Vial Pk SAV Lantus Solostar 100U/mL Inj Sol-5x3mL Pk SAV Lanvis 40mg Tab TRT Lasix 10mg/mL O/L SAV Lasix 20mg Tab SAV Lasix Special 500mg Tab SAV Lectopam 3mg Tab HLR Lectopam 6mg Tab HLR Lescol 20mg Cap NOV Lescol 40mg Cap NOV Lescol XL 80mg ER Tab NOV Page 14

15 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Leukeran 2mg Tab TRT Levemir Penfill 100U/mL Inj Sol-5x3mL Pk NOO Lioresal 10mg Tab NOV Lioresal DS 20mg Tab NOV Lipitor 10mg Tab PFI Lipitor 20mg Tab PFI Lipitor 40mg Tab PFI Lipitor 80mg Tab PFI Locacorten-Vioform 0.02% & 1% Ot Sol PAL Loestrin 1.5/ mg & 1.5mg Tab-21 Pk PAL Loestrin 1.5/ mg & 1.5mg Tab-28 Pk PAL Lopresor 50mg Tab NOV Lopresor 100mg Tab NOV Lopresor SR 100mg LA Tab NOV Lopresor SR 200mg LA Tab NOV Losec DR Tab 20mg AZC Losec DR Tab 20mg AZC Lotensin 5mg Tab NOV Lotensin 10mg Tab NOV Lotensin 20mg Tab NOV Lovenox 100mg/mL Inj Sol-3mLVial Pk SAV Lovenox 30mg/0.3mL Pref Syr-0.3mL Pk SAV Lovenox 40mg/0.4mL Pref Syr-0.4mL Pk SAV Lovenox 60mg/0.6mL Pref Syr-0.6mL Pk SAV Lovenox 80mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox 100mg/mL Pref Syr-1mL Pk SAV Lovenox HP 120mg/0.8mL Pref Syr-0.8mL Pk SAV Lovenox HP 150mg/mL Pref Syr-1mL Pk SAV M-Eslon 10mg ER Cap ETH M-Eslon 15mg ER Cap ETH M-Eslon 30mg ER Cap ETH M-Eslon 60mg ER Cap ETH M-Eslon 100mg ER Cap ETH M-Eslon 200mg ER Cap ETH Maxidex 0.1% Oph Susp ALC Maxidex 0.1% Oph Oint-3.5g Pk ALC Medrol 4mg Tab PFI Mesasal 500mg Ent Tab GSK Mestinon 60mg Tab VAL Mestinon 180mg LA Tab VAL Minestrin 1/ mg & 1mg Tab-21 Pk PAL Minestrin 1/ mg & 1mg Tab-28 Pk PAL Mogadon 5mg Tab VAL Mogadon 10mg Tab VAL Monopril 10mg Tab BQU Monopril 20mg Tab BQU MS Contin 15mg SR Tab PFP MS Contin 30mg SR Tab PFP MS Contin 60mg SR Tab PFP Page 15

16 DIN BRAND STRENGTH DOSAGE FORM MFR DBP MS Contin 100mg SR Tab PFP MS Contin 200mg SR Tab PFP MS-IR 20mg Tab PFP MS-IR 30mg Tab PFP Myleran 2mg Tab TRT Myochrysine 10mg/mL Inj Sol-1mL Pk SAV Myochrysine 25mg/mL Inj Sol-1mL Pk SAV Myochrysine 50mg/mL Inj Sol-1mL Pk SAV Naprosyn 25mg/mL O/L HLR Nerisone 0.1% Cr STI Nerisone 0.1% Oily Cr STI Nerisone 0.1% Oint STI Neuleptil 10mg Cap ERF Neuleptil 10mg/mL O/L ERF Niacin-ICN 100mg Tab VAL Nitrol 2% Oint PAL Nitrolingual Pump Spray 0.4mg/Metered Dose Spray-200 Dose Pk SAV Nolvadex D 20mg Tab AZC Noritate 1% Top Cr SAV Norvasc 5mg Tab PFI Norvasc 10mg Tab PFI Novolin ge 30/ U/10mL Inj Susp-10mL Pk NOO Novolin ge 30/70 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge 40/60 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge 50/50 Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge NPH 1000U/10mL Inj Susp-10mL Pk NOO Novolin ge NPH Penfill 100U/mL Inj Susp-5x3mL Pk NOO Novolin ge Toronto 1000U/10mL Inj Sol-10mL Pk NOO Novolin ge Toronto Penfill 100U/mL Inj Sol-5x3mL Pk NOO NovoMix 30 Penfill 100U/mL Inj Susp-5x3mL Pk NOO NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk NOO Nozinan 25mg/mL Inj Sol-1mL Pk SAV Nplate 250mcg/0.5mL Pd for Inj-Vial Pk AMG Nplate 500mcg/1mL Pd for Inj-Vial Pk AMG Omnaris 50mcg/Actuation Metered Dose Nas Sp- NYC Dose Pk Orencia 250mg/Vial Inj Pd-Vial Pk BQU Oxsoralen 10mg Cap VAL Pantoloc 40mg Ent Tab NYC Parnate 10mg Tab GSK Pediapred Oral Liquid 6.7mg/5mL O/L SAV PhisoHex 3% Top Emuls SAV Pilopine HS 4% Oph Gel ALC 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 Plaquenil 200mg Tab SAV Plavix 75mg Tab SAV Premarin 0.625mg/g Vag Cr WAY Page 16

17 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Prolopa mg & 12.5mg Cap HLR Prolopa mg & 25mg Cap HLR Prolopa mg & 50mg Cap HLR Propyl-Thyracil 50mg Tab PAL Propyl-Thyracil 100mg Tab PAL Prostigmin 15mg Tab VAL Pulmicort Nebuamp 0.125mg/mL Inh Susp AZC Pulmicort Nebuamp 0.25mg/mL Inh Susp AZC Pulmicort Nebuamp 0.5mg/mL Inh Susp AZC Pulmicort Turbuhaler 200mcg/Metered Dose Pd Inh-200 Dose Pk AZC Rapamune 1mg/mL O/L WAY Rapamune 1mg Tab WAY Rasilez 150mg Tab NOV Rasilez 300mg Tab NOV Renedil 2.5mg SR Tab SAV Renedil 5mg SR Tab SAV Renedil 10mg SR Tab SAV Reyataz 150mg Cap BQU Reyataz 200mg Cap BQU Rhinocort Aqua 64mcg/Metered Dose Nas Sp-120 Dose Pk AZC Rhinocort Turbuhaler 100mcg/Metered Dose Nas Aero 200 Dose AZC Rifadin 150mg Cap SAV Rifadin 300mg Cap SAV Ritalin 10mg Tab NOV Ritalin SR 20mg ER Tab NOV Rofact 150mg Cap VAL Rofact 300mg Cap VAL Rosasol 1% Cr STI Rythmodan 150mg Cap SAV Sandomigran 0.5mg Tab PAL Sandomigran DS 1mg Tab PAL Sandostatin LAR 10mg Inj Kit Pk NOV Sandostatin LAR 20mg Inj Kit Pk NOV Sandostatin LAR 30mg Inj Kit Pk NOV Sectral 100mg Tab SAV Sectral 200mg Tab SAV Sectral 400mg Tab SAV Seroquel 25mg Tab AZC Seroquel 100mg Tab AZC Seroquel 200mg Tab AZC Seroquel 300mg Tab AZC Sofracort 5mg & 50mcg & Oph/Ot Sol SAV mg/mL Sprycel 20mg Tab BQU Sprycel 50mg Tab BQU Sprycel 70mg Tab BQU Sprycel 100mg Tab BQU Stalevo 50 & 12.5 & 200mg Tab NOV Stalevo 75 & & 200mg Tab NOV Page 17

18 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Stalevo 100 & 25 & 200mg Tab NOV Stalevo 125 & & 200mg Tab NOV Stalevo 150 & 37.5 & 200mg Tab NOV Stieva-A 0.01% Cr STI Stieva-A 0.025% Cr STI Stieva-A 0.025% Gel STI Stieva-A 0.05% Cr STI Stievamycin Gel 0.025% & 4% Top Gel STI Suprax 20mg/mL Oral Susp SAV Suprax 400mg Tab SAV Suprefact 1mg/mL Inj Sol-5.5mL Pk SAV Suprefact 1mg/mL Nas Sp-10mL Pk SAV Suprefact Depot 6.3mg Implant Kit SAV Suprefact Depot 9.45mg Implant Kit SAV Sustiva 50mg Cap BQU Sustiva 200mg Cap BQU Sustiva 600mg Tab BQU Symbicort 100 Turbuhaler 100mcg/6mcg Pd Inh-120 Dose Pk AZC Symbicort 200 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk AZC Synacthen Depot 1mg/mL Inj Susp-1mL Pk NOV Tamiflu 30mg Cap HLR Tamiflu 45mg Cap HLR Tamiflu 75mg Cap HLR Tears Naturale 0.1%/0.3% Oph-Sol ALC Tears Naturale II 0.1%/0.3%/0.001% Oph-Sol ALC Tegretol 100mg Chew Tab NOV Tegretol 200mg Chew Tab NOV Tegretol 100mg/5mL Oral Susp NOV Tegretol CR 200mg LA Tab NOV Tegretol CR 400mg LA Tab NOV Telzir 50mg/mL Oral Susp VIH Telzir 700mg Tab VIH Tenoretic 50/25 50 & 25mg Tab AZC Tenoretic 100/ & 25mg Tab AZC Tenormin 50mg Tab AZC Tenormin 100mg Tab AZC Testim 1% Top Gel-5g Pk PAL Thyroid 30mg Tab ERF Thyroid 60mg Tab ERF Thyroid 125mg Tab ERF Tiazac XC 120mg ER Tab BIO Tiazac XC 180mg ER Tab BIO Tiazac XC 240mg ER Tab BIO Tiazac XC 300mg ER Tab BIO Tiazac XC 360mg ER Tab BIO TobraDex 0.3% & 0.1% Oph Oint ALC TobraDex 0.3% & 0.1% Oph Susp ALC Tobrex 0.3% Oph Oint ALC Tobrex 0.3% Oph Sol ALC Page 18

19 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Trandate 100mg Tab PAL Trandate 200mg Tab PAL Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch NOV Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch NOV Travatan Z 0.004% Oph Sol-2.5mL Pk ALC Travatan Z 0.004% Oph Sol-5mL Pk ALC Trelstar (1 Month) 3.75mg/Vial Inj Pd-Vial Pk PAL Trelstar (1 Month) 3.75mg/Vial Inj Pd with Sterile PAL Water-Vial Pk Trelstar LA (3 Month) 11.25mg/Vial Inj Pd-Vial Pk PAL Trelstar LA (3 Month) 11.25mg/Vial Inj Pd with Sterile PAL Water-Vial Pk Trental 400mg SR Tab SAV Trinipatch 0.4mg/Hr/14 Sq Cm Patch PAL Trinipatch 0.6mg/Hr/21 Sq Cm Patch PAL Trizivir 300mg/150mg/300mg Tab VIH Truvada 200mg & 300mg Tab GIL Uremol-HC 1% & 10% Cr STI Uremol-HC 1% & 10% Lot STI Vagifem 10 10mcg Vag Tab with Applicator NOO Valcyte 450mg Tab HLR Vepesid 50mg Cap BQU Vfend 50mg Tab PFI Vfend 200mg Tab PFI Videx EC 125mg Enteric Coated Cap BQU Videx EC 200mg Enteric Coated Cap BQU Videx EC 250mg Enteric Coated Cap BQU Videx EC 400mg Enteric Coated Cap BQU Viread 300mg Tab GIL Viskazide 10/25 10mg & 25mg Tab NOV Viskazide 10/50 10mg & 50mg Tab NOV Visken 5mg Tab NOV Visken 10mg Tab NOV Visken 15mg Tab NOV Vitamin A Acid 0.01% Gel SAV Vitamin A Acid 0.05% Gel SAV Voltaren 50mg Ent Tab NOV Voltaren 50mg Sup NOV Voltaren 100mg Sup NOV Voltaren Ophtha 0.1% Oph Sol NOV Wellbutrin SR 150mg Tab BIO Wellbutrin XL 150mg Tab BIO Wellbutrin XL 300mg Tab BIO Xatral 10mg Prolong-Rel Tab SAV Xylocaine Viscous 2% O/L AZC Zaroxolyn 2.5mg Tab SAV Zeldox 20mg Cap PFI Zeldox 40mg Cap PFI Page 19

20 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Zeldox 60mg Cap PFI Zeldox 80mg Cap PFI Zerit 15mg Cap BQU Zerit 20mg Cap BQU Zerit 30mg Cap BQU Zerit 40mg Cap BQU Zestoretic 10mg & 12.5mg Tab AZC Zestoretic 20mg & 12.5mg Tab AZC Zestril 5mg Tab AZC Zestril 10mg Tab AZC Zestril 20mg Tab AZC Ziagen 20mg/mL O/L VIH Zoladex 3.6mg Depot Inj AZC Zoladex LA 10.8mg Depot Inj AZC Zoloft 25mg Cap PFI Zoloft 50mg Cap PFI Zoloft 100mg Cap PFI Zyban 150mg SR Tab VAL Zyvoxam 600mg Tab PFI Page 20

21 New Manufacturer Name(s) DIN BRAND STRENGTH DOSAGE FORM MFR Apo-Allopurinol 100mg Tab AAP Apo-Allopurinol 200mg Tab AAP Apo-Allopurinol 300mg Tab AAP Apo-Gliclazide MR 30mg SR Tab AAP Apo-Keto SR 200mg LA Tab AAP Apo-Levocarb CR 100mg & 25mg Tab AAP Apo-Mefenamic 250mg Cap AAP Celestoderm-V/2 0.05% Cr VAE Celestoderm-V 0.1% Cr VAE Celestoderm-V/2 0.05% Oint VAE Celestoderm-V 0.1% Oint VAE Lanoxin 0.05mg/mL O/L MMT Rhovane 7.5mg Tab SDZ Page 21

22 Therapeutic Note Change(s) DIN BRAND STRENGTH DOSAGE FORM MFR Gleevec 100mg Tab NOV Gleevec 400mg Tab NOV These products must be prescribed based on the following criteria: 1) For the treatment of Philadelphia chromosome-positive Chronic Myelogenous Leukemia (CML) in chronic phase. The initial dose is 400mg/day. The dose may be increased up to a maximum of 800 mg/day in patients who do not have an adequate hematologic response at 3 months or cytogenetic response at 1 year; or if there has been loss of a previously achieved hematologic and/or cytogenetic response. Note: The Ministry will only reimburse, in a patient's lifetime, any two (2) of the oral Tyrosine Kinase Inhibitors (TKIs)* used for chronic phase CML. (* TKIs: Imatinib, Nilotinib, or Dasatinib) 2) For the treatment of Philadelphia chromosome-positive Chronic Myelogenous Leukemia (CML) in blast phase or accelerated phase. The initial dose is 600mg/day. The dose may be increased to a maximum of 800 mg/day in patients who do not have an adequate hematologic response at 3 months or cytogenetic response at 1 year; or loss of a previously achieved hematologic and/or cytogenetic response. Page 22

23 Trade Name Change(s) DIN BRAND STRENGTH DOSAGE FORM MFR Gliclazide MR 30mg SR Tab APX Ketoprofen SR 200mg LA Tab APX Levocarb CR 100mg & 25mg Tab APX Mefenamic 250mg Cap APX Toloxin 0.05mg/mL O/L PMS Zyloprim 100mg Tab APX Zyloprim 200mg Tab APX Zyloprim 300mg Tab APX Page 23