New Exception Status Benefits

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1 OCTOBER 2017 Nova Scotia Formulary Updates Mifegymiso New Exception Status Benefits Prozac (fluoxetine syr) Brenzys (etanercept) Neupro (rotigotine) Criteria Updates Tarceva (erlotinib) Metadol Tab (Methadone) OAB Medications New Products Changes in Benefit Status Non Insured Products Delisted Products Notification of Delisting of Butalbital- Containing Products Administration of Publicly-Funded Influenza Vaccine by Pharmacists for the Influenza Season Nova Scotia Formulary Updates Mifegymiso Effective November 1, 2017 coverage is available for Mifegymiso for women in Nova Scotia with a valid health card number. Any other sources of insurance, such as a private plan, must be billed first. The method for claims submission is outlined below, should you have any questions please contact the Pharmacare Office. CPHA CLAIM STANDARD FIELD CPHA CLAIM STANDARD FIELD NAME CONTENT D56.03 DIN/GP#/PIN D Quantity (one) D Prescriber ID Prescriber ID D Drug Cost/Product Value DDDDD (MLP dollar value) D Cost Upcharge DDDDD (usual Pharmacare upcharge) D Professional Fee DDDDD (usual Pharmacare dispensing fee) New Exception Status Benefits The following product has been listed with the following criteria, effective immediately. Prozac (fluoxetine) 20mg/5mL Syr Various DNP VAR Criteria For use in patients for whom oral capsules are not an option

2 PAGE 2 OF 9 New Exception Status Benefits Continued The following products were reviewed by the Canadian Drug Expert Committee (CDEC) and were listed with the following criteria effective immediately. Brenzys (etanercept) 50 mg/ml Prefilled Pen 50 mg/ml Prefilled Syringe DNP DNP FRS FRS For etanercept-naïve patients whose etanercept therapy is initiated after November 1, 2017, the biosimilar will be the product that is approved for the following indications. Criteria Ankylosing Spondylitis For the treatment of patients with moderate to severe ankylosing spondylitis (Bath AS Disease Activity Index (BASDAI) score 4 on 10 point scale) who: o have axial symptoms and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation, or in whom NSAIDs are contraindicated; OR o have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate response to an optimal dose or maximal tolerated dose of a DMARD Notes: Must be prescribed by a rheumatologist or prescriber with a specialty in rheumatology. Requests for renewal must include information showing the beneficial effects of the treatment, specifically: o a decrease of at least 2 points on the BASDAI scale, compared with the pretreatment score; OR o patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement (measured by outcomes such as HAQ or "ability to return to work") Initial coverage period 6 months, maximum dose 50mg per week and not in combination with other anti-tnf agents Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication of axial disease, do not require a trial of 2 NSAIDs Rheumatoid Arthritis For the treatment of severely active rheumatoid arthritis, in combination with methotrexate or other disease modifying antirheumatic drugs (DMARDs), in adult patients who are refractory or intolerant to: o methotrexate (oral or parenteral) at a dose of 20 mg weekly ( 15mg if patient is 65 years of age), or o use in combination with another DMARD, for a minimum of 12 weeks AND

3 PAGE 3 OF 9 New Exception Status Benefits Continued Brenzys 50 mg/ml Prefilled Pen DNP (etanercept) 50 mg/ml Prefilled Syringe DNP FRS FRS Criteria o methotrexate in combination with at least two other DMARDs, such as hydroxychloroquine and sulfasalazine, for a minimum of 12 weeks Clinical Notes: For patients who do not demonstrate a clinical response to oral methotrexate, or who experience gastrointestinal intolerance, a trial of parenteral methotrexate must be considered Optimal treatment response to DMARDs may take up to 24 weeks, however coverage of a biologic therapy can be considered if no improvement is seen after 12 weeks of triple DMARD use If patient factors (e.g. intolerance) prevent the use of triple DMARD therapy, these must be described and dual therapy with DMARDs must be tried Refractory is defined as lack of effect at the recommended doses and for duration of treatments specified above Intolerant is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs. The nature of intolerance(s) must be clearly documented Claim Notes: Must be prescribed by a rheumatologist Combined use of more than one biologic DMARD will not be reimbursed Initial Approval: 6 months Renewal Approval: 1 year. Confirmation of continued response is required Maximum Dosage Approved: 50mg once per week with no dose escalation permitted Neupro 2mg/24hr Patch DNP (rotigotine) 4mg/24hr Patch DNP 6mg/24hr Patch DNP 8mg/24hr Patch DNP UCB UCB UCB UCB Criteria For adjunctive therapy to levodopa for the treatment of patients with advanced stage Parkinson s disease (APD)

4 PAGE 4 OF 9 Criteria Updates The following criteria have been updated effective immediately: Tarceva (erlotinib) 100mg Tab 150mg Tab Various Various DNP DNP VAR VAR Criteria For the first-line treatment of patients with EGFR mutation positive locally advanced or metastatic NSCLC with a good performance status For the treatment of patients with locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen and whose EGFR mutation status is positive or unknown Renewal Criteria: Written confirmation that the patient has responded to treatment and there is no evidence of disease progression Claim Notes: Use of erlotinib precludes the use of any other EGFR inhibitor as a subsequent line of therapy Approval period: 6 months In the absence of disease progression and in the event of severe toxicity within the first 12 weeks of therapy, a switch to another approved EGFR inhibitor may be allowed Metadol 1mg Tab DN (methadone) 5mg Tab DN 10mg Tab DN 25mg Tab DN PAL PAL PAL PAL Criteria for the management of severe chronic or malignant pain as an alternative to other opiates written request of a physician authorized to prescribe methadone Clinical note: In the case of comorbid opioid use disorder (past or current), methadone oral liquid would normally be prescribed as per treatment standards. If methadone tablets are requested in this context, a specialist consult may be required.

5 PAGE 5 OF 9 Criteria Updates Continued Enablex 7.5mg Tab DNP (darifenacin) 15mg Tab DNP Toviaz 4mg Tab DNP (fesoterodine) 8mg Tab DNP Trosec (trospium) 20mg Tab DNP MRS MRS PFI PFI SNV Criteria For the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence, and urinary frequency in patients who have an intolerance or insufficient response to an adequate trial of immediate-release oxybutynin, solifenacin or tolterodine Myrbetriq 25mg ER Tab DNP (mirabegron) 50mg ER Tab DNP ASL ASL Criteria For the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence, and urinary frequency in patients who have an intolerance or insufficient response to an adequate trial of immediate-release oxybutynin, solifenacin or tolterodine Note: Not to be used in combination with other pharmacological treatments for OAB. New Products Effective immediately, the following new products have been added to the Nova Scotia Formulary. The benefit status within the Nova Scotia Pharmacare Programs is indicated and any existing criteria will apply. OptiChamber Diamond DNP SFC AUT OptiChamber Diamond with Mask (Sm) DNP SFC AUT OptiChamber Diamond with Mask (Med) DNP SFC AUT OptiChamber Diamond with Mask (Lg) DNP SFC AUT

6 PAGE 6 OF 9 New Products Basaglar (insulin glargine - Eli Lilly) is a biosimilar product based on Lantus (insulin glargine - Sanofi-Aventis) as a reference product. Clinical trials have demonstrated that Basaglar has similar efficacy, safety, pharmacodynamics and pharmacokinetics compared to the Lantus brand of insulin glargine. Basaglar was non-inferior in terms of mean change in A1C from baseline at week 24. In addition, the trials studied a group of patients who switched from Lantus to Basaglar, in both studies no statistically significant treatment differences were observed for a mean change in A1C from baseline to week 24 or week 52. The complete Canadian Drug Expert Committee (CDEC) recommendation to fund Basaglar can be accessed at Basaglar is available as a full benefit to Pharmacare clients which provides access to a long acting insulin without the need for prior approval of coverage. Basaglar 100iu/mL Cartridge DNP SF LIL Basaglar 100iu/mL Kwikpen DNP SF LIL Basaglar 100iu/mL Kwikpen DNP SF LIL Change in Benefit Status Effective immediately, the following products have moved to full benefit status. Dalacin Vag Cr 100mg/dose DNP SFC PAL Solifenacin 5mg Tab Various DNP SF VAR Solifenacin 10mg Tab Various DNP SF VAR Tolterodine 1mg Tab Various DNP SF VAR Tolterodine 2mg Tab Various DNP SF VAR Tolterodine 2mg ER Cap Various DNP SF VAR Tolterodine 4mg ER Cap Various DNP SF VAR Non Insured Products The following products will not be insured in the Pharmacare Programs, however, they will be funded through the Exception Drug Fund as per other interferon products in the treatment of Multiple Sclerosis. Plegridy Admin Pack Plegridy Starter Pack 125mcg/0.5mL pre-filled syringe/pen for S/C inj 63mcg/0.5mL and 94mcg/0.5mL pre-filled syringes/pens for S/C inj N/A N/A BIG N/A N/A BIG

7 PAGE 7 OF 9 Delisted Products Effective immediately, the following products have moved to non-benefit status and will no longer be covered under the Nova Scotia Pharmacare Programs. Flagystatin Vag Cr N/A Not Insured SAV Flagystatin Vag Ovules N/A Not Insured SAV Linctus Codeine Blanc 0.2% Liq N/A Not Insured ATL Sufentanil Citrate 50mcg/mL Inj Various N/A Not Insured VAR Notification of Delisting of Butalbital-Containing Products Butalbital-containing capsules will no longer be benefits with the Nova Scotia Pharmacare Programs (i.e., Fiorinal and generics, Fiorinal C1/4 and generics and Fiorinal C1/2 and generics). Butalbital-containing products have a high risk of dependence and abuse, a potential for development of medication overuse headache and the possibility of a withdrawal syndrome and there is a lack of evidence of superiority to standard drugs. Coverage will be continued for Pharmacare beneficiaries who are currently using this therapy. However reassessment of their therapy should be considered. Fiorinal Cap and generics 330mg/50mg/40mg Cap Various N/A Not Insured VAR Fiorinal C1/4 and generics Fiorinal C1/2 and generics 330mg/50mg/40mg/30mg Cap 330mg/50mg/40mg/15mg Cap Various N/A Not Insured VAR Various N/A Not Insured VAR ratio-tecnal 50mg Tab N/A Not Insured TEV Administration of Publicly-Funded Influenza Vaccine by Pharmacists for the Influenza Season Who is eligible to have publicly-funded influenza vaccine administered by a pharmacist? All individuals 5 years of age and over can have publicly-funded influenza vaccine administered by a pharmacist. As publicly-funded influenza vaccine is available free of charge, no individual is to be charged for the vaccine. Who is eligible to have the influenza vaccine administration fee publicly-funded? Only residents with a valid Nova Scotia Health Card Number are eligible to have the influenza vaccine administration fee billed to Pharmacare. There are no copayments or deductibles associated with the administration of the influenza vaccine to residents with a valid Nova Scotia Health Card Number. All other individuals are responsible for paying the applicable administration fee.

8 PAGE 8 OF 9 Administration of Publicly-Funded Influenza Vaccine by Pharmacists for the Influenza Season Continued Which pharmacies are eligible to bill for the administration of publicly-funded influenza vaccine? Pharmacies set up as providers to bill publicly-funded influenza vaccine administration fees last year are already set up for the influenza season. However, all pharmacies are still required to contact their local Nova Scotia Health Authority public health office to confirm their , dispensary telephone number, and their preferred method for being contacted by public health. Pharmacies that have not yet been set up as a provider to bill publicly-funded influenza vaccine administration must: 1. Comply with the required training and application expectations set out by the Pharmacist Extended Practice Regulations and the NSCP s Standards of Practice: Drug Administration. 2. Sign the Confirmation of Agreement Form for Pharmacist Administered Publicly Funded Seasonal Influenza Vaccine (available in the Pharmacists Guide) and submit it to Medavie Blue Cross. Medavie Blue Cross will confirm by or facsimile that the pharmacy has been set up as a provider to bill influenza vaccine administration fees. 3. Provide their local public health office with their provider confirmation and any other information the public health office requires to issue influenza vaccine to the pharmacy. Where do pharmacies get publicly-funded influenza vaccine? All publicly-funded influenza vaccine must be obtained from the local public health office. All providers are responsible for any transportation costs to obtain publicly-funded vaccine. Pharmacies should contact their local public health office to place their order for vaccine and to arrange pick-up. Review the packing protocol for transporting biologicals in the Nova Scotia Immunization Manual (located at: ) to ensure you have all the required equipment when you pick up your vaccine. Public health can only release vaccine in accordance with this protocol. When can pharmacists begin administering publicly-funded influenza vaccine? Pharmacists may begin administering publicly-funded influenza vaccine as soon as they receive it. How do pharmacies bill Pharmacare for influenza vaccine administration fees? To ensure claims are adjudicated correctly, all influenza claims must be adjudicated using a quantity of 1, as well as the correct DIN and/or PIN. Fees for the administration of publicly-funded influenza vaccine to Nova Scotia residents with a valid Nova Scotia Health Card must be billed to Pharmacare online. The electronic claim must contain the following in the patient s insurance field: Patient ID the patient s Nova Scotia Health Card Number Carrier ID NS If a patient is already set up in the pharmacy system with Pharmacare coverage (e.g., Seniors Pharmacare, Family Pharmacare), a separate patient file does not need to be created. Claims must be submitted using the DIN of the vaccine administered to the patient, unless the patient is pregnant or is a child receiving a second vaccine dose. The following Table provides direction related to submitting claims using a PIN for pregnant women or children receiving a second dose. Claims are submitted with the administration fee in the professional fee field. Providers are not reimbursed for ingredient costs or markups for these claims as they are able to access publicly-funded vaccine at no charge.

9 PAGE 9 OF 9 Administration of Publicly-Funded Influenza Vaccine by Pharmacists for the Influenza Season Continued Claims Submission Field Content for Pharmacist-Administered Publicly Funded Influenza Vaccines CPHA CLAIM STANDARD FIELD # CPHA CLAIM STANDARD FIELD NAME CONTENT D DIN/GP#/PIN DINs - Fluzone Quadrivalent MDV FluLaval Tetra PIN for pregnant women Fluzone Quadrivalent FluLaval Tetra PIN for second dose for children Fluzone Quadrivalent FluLaval Tetra D Quantity (one) D Prescriber ID Pharmacists prescriber ID D Drug Cost/Product Value DDDDD (dollar value - not adjudicated) D Cost Upcharge DDDDD (dollar value - not adjudicated) D Professional Fee $12.00 What documentation does a pharmacy need to retain for audit and other purposes? Pharmacies must retain the signed patient Consent and Disclosure form for each claim reimbursed by Pharmacare. Pharmacies are advised to maintain a record of the quantity of influenza vaccine administered to individuals who do not have a valid Nova Scotia Health Card Number, as this information may be requested by public health. How do I report an adverse event following immunization (AEFI)? It is possible that reactions may occur after administration of influenza vaccine, without a causal association to the vaccine. These reactions must be reported to your local Nova Scotia Health Authority public health office for the appropriate follow-up. Providers should document an AEFI using the Public Health Agency of Canada AEFI form (located at: and forward the form to the local public health office. The local public health office reviews these reports and enters them in their local database before they are forwarded to the Public Health Agency of Canada. What do I do if there is a break in the cold chain? Cold chain refers to the process used to maintain optimal conditions during the transport, storage, and handling of vaccines, starting with the manufacturer and ending with the administration of the vaccine. When vaccines are exposed to temperatures of less than 2 C or more than 8 C, the result is a break in the cold chain. Vaccines affected by a break in the cold chain must be packaged separately, identified with a sticker reading DO NOT USE, and stored in a refrigerator at between 2 C and 8 C separately from vaccines in current use. Contact your local public health office to determine whether they can be used.