UPDATE E Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective December 23, 2008 SUMMARY OF CHANGES
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1 UPDATE E Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective December 23, 2008 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Multi-Source Drug(s) 2 New Drug Identification Number(s) 4 Manufacturer Requested Discontinued Drug(s) 5 Drug Benefit Price(s) 6 New Manufacturer Name(s) 7 Off Formulary Interchangeable Product(s) 8 Limited Use Change(s) 9 Trade Name Change(s) 10 New DiabeticTesting Agent(s) 11 Index 12 Page 1
2 New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Co Famciclovir (Interchangeable with Famvir) 500mg Tab COB Reason for Use Code Clinical Criteria 147 Herpes zoster in patients 50 years of age or older, up to 72 hours* after appearance of lesions. Dose: 500mg 3 times/day for 7days. *The patient must begin treatment within the time frame specified for the product to be reimbursed. There is no benefit from the therapy begun after this time frame. NETWORK NOTE: Network will limit supply to 7 days and 21 tablets. LU Authorization Period: 1 Year Mint-Ondansetron 4mg Tab MIN Mint-Ondansetron 8mg Tab MIN (Interchangeable with Zofran) Reason for Use Code Clinical Criteria 215 For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. 216 For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. 217 For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other anti-emetics. 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. Page 2
3 DIN BRAND STRENGTH DOSAGE FORM MFR DBP Novo-5-ASA (Interchangeable with Asacol) 400mg Tab NOP PMS-Bupropion SR (Interchangeable with Wellbutrin SR) Reason for Use Code Clinical Criteria 150mg Tab PMS For the treatment of depression. LU Authorization Period: Indefinite Ran-Ondansetron 4mg Tab RAN Ran-Ondansetron 8mg Tab RAN (Interchangeable with Zofran) Reason for Use Code Clinical Criteria 215 For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. 216 For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. 217 For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other anti-emetics. 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. Page 3
4 New Drug Identification Number(s) DIN BRAND STRENGTH DOSAGE FORM MFR Monistat Derm 2% Cr OMC Percocet 5mg & 325mg Tab BQU Percodan 5mg & 325mg Tab BQU 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 Monistat Derm 2% Cr OMC Percocet 5mg & 325mg Tab BQU Percodan 5mg & 325mg Tab BQU Surgam 300mg Tab SAV Vitamin A Acid 0.05% Cr SAV Page 5
6 Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP Apo-Quetiapine 200mg Tab APX Apo-Quetiapine 300mg Tab APX Fenomax 160mg Tab ORY Flovent HFA 50mcg/Metered Dose Inh-120 Dose Pk GSK Fraxiparine 9500IU/mL Pref Syr-0.3mL Pk GSK Fraxiparine 9500IU/mL Pref Syr-0.4mL Pk GSK Fraxiparine 9500IU/mL Pref Syr-0.6mL Pk GSK Fraxiparine 9500IU/mL Pref Syr-0.8mL Pk GSK Fraxiparine 9500IU/mL Pref Syr-1.0mL Pk GSK Fraxiparine Forte 19000IU/mL Pref Syr-0.6mL Pk GSK Fraxiparine Forte 19000IU/mL Pref Syr-0.8mL Pk GSK Fraxiparine Forte 19000IU/mL Pref Syr-1.0mL Pk GSK Novo-Difenac 25mg Ent Tab NOP Telzir 700mg Tab GSK Page 6
7 New Manufacturer Name(s) DIN BRAND STRENGTH DOSAGE FORM MFR Boost 1.0 Standard 1.06kcal/mL Liq-237mL Pk NES Boost 1.5 Plus Calories 1.5kcal/mL Liq-237mL Pk NES Boost Fruit Flavoured Beverage Liq-235mL Pk NES Compleat Modified Liq-250mL Pk NES Compleat Pediatric 1kcal/mL Liq-250mL Pk NES IsoSource 1.5 Cal Liq-250mL Pk NES IsoSource HN Liq-250mL Pk NES IsoSource HN with Fibre Liq-250mL Pk NES IsoSource VHN Liq-250mL Pk NES MCT Oil 7.7kcal/mL Liq-946mL Pk NES NovaSource Renal Liq-237mL Pk NES Resource 2.0 Liq-237mL Pk NES Resource Diabetic 1.06kcal/mL Liq-250mL Pk NES Resource Just for Kids 1.5 Cal 1.5kcal/mL Liq-237mL Pk NES Tolerex Pd-80g Pk NES Vivonex Pediatric Pd-48.7g Pk NES Vivonex Plus Pd-79.5g Pk NES Vivonex T.E.N. Pd-80.4g Pk NES Page 7
8 Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST Co Famciclovir 125mg Tab COB Co Famciclovir 250mg Tab COB (Interchangeable with Famvir) PMS-Cetirizine (Interchangeable with Reactine) 20mg Tab PMS PMS-Pantoprazole (Interchangeable with Pantoloc) 20mg Ent Tab PMS Ratio-Fentanyl (Interchangeable with Duragesic 12) 12mcg/hr Trans Patch RPH Ratio-Tecnal C1/4 (Interchangeable with Fiorinal C1/4) 330mg & 50mg & 40mg & 15mg Cap RPH Ratio-Tecnal C1/2 (Interchangeable with Fiorinal C1/2) 330mg & 50mg & 40mg & 30mg Cap RPH Ratio-Tecnal (Interchangeable with Fiorinal) 330mg & 50mg & 40mg Cap RPH Sandoz Lisinopril HCT (Interchangeable with Zestoretic) 20mg & 25mg Tab SDZ Page 8
9 Limited Use Change(s) DIN BRAND STRENGTH DOSAGE FORM MFR Xeloda 150mg Tab HLR Xeloda 500mg Tab HLR Reason for Use Code Clinical Criteria 346 For the first-line treatment of patients with metastatic colorectal cancer in whom combination chemotherapy is not recommended. NOTE: Not to be used in patients who have failed 5-flurouracil. LU Authorization Period: Indefinite. 360 For the treatment of metastatic breast cancer in combination with docetaxel in women who experience disease progression on or after an anthracycline. LU Authorization Period: Indefinite. 406 For adjuvant treatment of stage 3 or high risk stage 2* colon cancer in patients who have completed surgery (within three months), who would normally be candidates for adjuvant chemotherapy with 5FU/LV. *high risk stage 2 colon cancer is defined as one of the following: - obstruction, - perforation, - poorly differentiated adenocarcinoma, - inadequate lymph node sampling, - T4 tumour. LU Authorization Period: 6 Months. 409 As part of the CAPOX regimen for the first-line and second-line treatment of metastatic colorectal cancer. LU Authorization Period: Indefinite. Page 9
10 Trade Name Change(s) DIN/PIN BRAND STRENGTH DOSAGE FORM MFR Breeze 2 Strip BAH Coversyl Plus LD 2mg & 0.625mg Tab SEV Page 10
11 New Diabetic Testing Agent(s) PIN PRODUCT MFR COST/ UNIT AMT MOH PAYS AMT PATIENT PAYS Nova Max Strip NOB Page 11
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