BULLETIN # 70. Manitoba Drug Benefits and Interchangeability Formulary Amendments. The following amendments will take effect on January 21, 2013
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1 BULLETIN # 70 Manitoba Drug Benefits and Interchangeability Formulary Amendments The following amendments will take effect on January 21, 2013 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 21, 2013 Bulletin 70 is currently available for download: Inside This Issue Part 1 Additions Page 1-3 Part 2 Additions Page 4-5 Part 3 Additions Page 6-8 New Interchangeable Categories Page 8-9 New Interchangeable Products Page Product Deletions Page Category Deletions Page 18 Interchangeable Product Price Changes Page Discontinued Products Page 25 Manufacturer Updates Page 25
2 Part 1 Additions DIN TRADE NAME GENERIC STRENGTH FORM MFR* Accu-Chek Fastclix - - Lancet RCH Alysena 21 Alysena 28 levonorgestrel/ ethinyl estradiol 100/20 mcg APX Apo-Amlodipine amlodipine 5 mg APX Apo-Candesartan/HCTZ candesartan/hctz 16/12.5 mg APX Apo-Hydromorphone hydromorphone 1 mg 2 mg 4 mg 8 mg APX Apo-Irbesartan irbesartan 75 mg 150 mg 300 mg APX Apo-Irbesartan/HCTZ irbesartan/hctz 150/12.5 mg 300/12.5 mg 300/25 mg APX Apo-Lamivudine HBV lamivudine 100 mg APX Apo-Ropinirole ropinirole 0.25 mg 1 mg 2 mg 5 mg APX Apo-Rosuvastatin rosuvastatin 20 mg 40 mg APX Apo-Valsartan/HCTZ valsartan/hctz 80/12.5 mg 160/12.5 mg 160/25 mg 320/12.5 mg 320/25 mg APX Atorvastatin atorvastatin 20 mg 40 mg 80 mg APX CO Amlodipine amlodipine 5 mg COB CO Candesartan/HCT candesartan/hctz 16/12.5 mg COB CO Exemestane exemestane 25 mg COB CO Latanoprost latanoprost 0.005% Ophthalmic COB 1 of 25
3 CO Losartan/HCT losartan/hctz 50/12.5 mg 100/12.5 mg 100/25 mg COB CO Nabilone nabilone 0.5 mg 1 mg Capsule COB CO Telmisartan CO Telmisartan/HCTZ CO Temozolamide ESME 21 ESME 28 Jamp-Amlodipine Jamp-Atenolol telmisartan telmisartan/hctz temozolamide levonorgestrel/ ethinyl estradiol amlodipine atenolol 40 mg 80 mg 80/12.5 mg 80/25 mg 20 mg 100 mg 140 mg 250 mg Capsule COB COB COB 100/20 mcg MYL 5 mg 25 mg 50 mg 100 mg Jamp-Bicalutamide bicalutamide 50 mg JPC JPC JPC Jamp-Candesartan candesartan 4 mg 8 mg 16 mg 32 mg JPC Jamp-Fluoxetine fluoxetine 20 mg Capsule JPC Jamp-Letrozole letrozole 2.5 mg JPC Jamp-Risperidone Jamp-Simvastatin risperidone simvastatin 0.25 mg 0.5 mg 1 mg 2 mg 3 mg 4 mg 5 mg 20 mg 40 mg 80 mg Levocarb CR levodopa/carbidopa 200/50 mg AAA Mezavant mesalazine 1.2 G SHI JPC JPC Mylan-Amlodipine amlodipine 5 mg MYL 2 of 25
4 Mylan-Anastrozole anastrozole 1 mg MYL Mylan-Atorvastatin atorvastatin 20 mg 40 mg 80 mg Mylan-Candesartan HCTZ candesartan/hctz 16/12.5 mg MYL Mylan-Entacapone entacapone 200 mg MYL Mylan-Nevirapine nevirapine 200 mg MYL Mylan-Olanzapine ODT Mylan-Rosuvastatin Mylan-Valsartan olanzapine rosuvastatin valsartan 5 mg 15 mg 20 mg 40 mg 40 mg 80 mg 160 mg 320 mg pms-candesartan-hctz candesartan/hctz 16/12.5 mg PMS MYL MYL MYL MYL Sandoz Candesartan Plus Sandoz Fluorometholone Sandoz Polytrimethoprim Teva-Amlodipine candesartan/hctz 16/12.5 mg SDZ fluorometholone 0.1% Ophthalmic polymyxin B/trimethoprim amlodipine 10,000 U/1 mg 5 mg Ophthalmic SDZ SDZ TEV Teva-Candesartan/HCTZ candesartan/hctz 16/12.5 mg TEV Teva-Rosuvastatin rosuvastatin 20 mg 40 mg TEV Tobramycin tobramycin 40 mg/ml Injection JPC *Abbreviation of Manufacturers' Names 3 of 25
5 Part 2 Additions Bulletin # mg/5 ml Accel-Clarithromycin clarithromycin Suspension ACC 250 mg/5 ml For the treatment of patients: (a) Not responding to or intolerant of alternative antibiotics (eg. amoxicillin and erythromycin); (b) With Mycobacterial infections due to mycobacterium intracellulare; (c) In combination therapy in the treatment of H.pylori; (d) Pneumonia; (e) Infections requiring a macrolide (including CAP in patients 65 and older) with documented intolerance to erythromycin Apo-Montelukast montelukast APX (a) Indicated as adjunctive therapy for asthma in cases where: (i) maximum doses inhaled corticosteroids have not effectively controlled symptoms, or (ii) evidence of serious adverse effects associated with corticosteroids exists, eg. adrenal suppression, increased lung infections; (b) Indicated as first line therapy for exercise induced asthma mg Apo-Rizatriptan rizatriptan For the treatment of ACUTE migraine attacks in patients where standard therapy has failed. APX CO Fentanyl fentanyl 12 mcg 25 mcg 50 mcg 75 mcg 100 mcg Patch COB For the treatment of pain in patients unable to tolerate analgesics or when there is failure to adequately control pain with oral analgesics or in patients for whom oral analgesics are deemed inappropiate CO Rizatriptan rizatriptan COB For the treatment of ACUTE migraine attacks in patients where standard therapy has failed mg Jamp-Ciprofloxacin ciprofloxacin 500 mg 750 mg (a) Step down care following hospital separation in patients treated with parenteral antibiotics; (b) Treatment of Pseudomonal infections or resistant gram negative infections; (c) Treatment of resistant Gonococcal infections; (d) Treatment of infections in persons allergic to alternative agents (eg. penicillins, cephalosporins and sulfonamides); (e) Treatment of infections in immunocompromised patients; (f) Treatment of diabetic foot infections and complications of orthopedic surgery; (g) Treatment of chronic bacterial prostatitis. JPC Jamp-Finasteride finasteride 5 mg JPC For the treatment of symptomatic benign prostatic hyperplasia. 4 of 25
6 Jamp-Montelukast montelukast JPC (a) Indicated as adjunctive therapy for asthma in cases where: (i) maximum doses inhaled corticosteroids have not effectively controlled symptoms, or (ii) evidence of serious adverse effects associated with corticosteroids exists, eg. adrenal suppression, increased lung infections; (b) Indicated as first line therapy for exercise induced asthma mg Jamp-Rizatriptan rizatriptan For the treatment of ACUTE migraine attacks in patients where standard therapy has failed. JPC Mylan-Fentanyl Matrix fentanyl 12 mcg 25 mcg 50 mcg 75 mcg 100 mcg Patch MYL For the treatment of pain in patients unable to tolerate analgesics or when there is failure to adequately control pain with oral analgesics or in patients for whom oral analgesics are deemed inappropiate Mylan-Montelukast montelukast 4 mg 5 mg (a) Indicated as adjunctive therapy for asthma in cases where: (i) maximum doses inhaled corticosteroids have not effectively controlled symptoms, or (ii) evidence of serious adverse effects associated with corticosteroids exists, eg. adrenal suppression, increased lung infections; (b) Indicated as first line therapy for exercise induced asthma. MYL Mylan-Zolmitriptan ODT zolmitriptan 2.5 mg MYL For the treatment of ACUTE migraine attacks in patients where standard therapy has failed mg/1.5 ml Omnitrope somatropin Injection /1.5 ml For the long term management of children who have growth failure due to inadequate secretion of normal endogenous growth hormone; SDZ Sandoz Ciprofloxacin ciprofloxacin 0.3% Ophthalmic SDZ For the treatment of ophthalmic infections caused by gram-negative oraganisms or those not responding to alternative agents Sandoz Ofloxacin ofloxacin 0.3% Ophthalmic SDZ For the treatment of ophthalmic infections caused by gram-negative oraganisms or those not responding to alternative agents. 5 of 25
7 Part 3 Additions The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis Banzel rufinamide 100 mg 200 mg 400 mg EIS For the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome for patients who meet all of the following criteria: - Are under the care of a physician experienced in treating Lennox-Gastaut syndrome associated seizures, a - Are currently receiving two or more antiepileptic drugs, and - In whom less costly antiepileptic drugs are ineffective or not appropriate. Note: BANZEL is not indicated for the treatment of any other type of seizure disorder Brilinta ticagrelor 90 mg AZC For the treatment of: 1. Failure on optimal clopidogrel and ASA therapy as defined by definite stent thrombosis, or recurrent STEMI, or NSTEMI or UA after prior revascularization via percutaneous coronary intervention (PCI); OR 2. STEMI and undergoing revascularization via PCI; OR 3. NSTEMI or UA and high risk angiographic anatomy and undergoing revascularization via PCI. emtricitabine/rilpivirine/ Complera 200/25/300 mg GIL tenofovir For the treatment of human immunodeficiency virus type 1 (HIV-1) in antiretroviral treatment-naive patients, or to replace the three components given as dual or triple therapy for patients stabilized on appropriate dose CO Raloxifene raloxifene 60 mg COB As per Evista criteria ( 6 of 25
8 Incivek telaprevir 375 mg VEP For the treatment of chronic hepatitis C in treatment-naive or treatment-experienced patients with no cirrhosis OR For the treatment of chronic hepatitis C in treatment-naive or treatment-experienced patients with compensated cirrhosis. Compensated cirrhosis is defined as compensation confirmed based on a thorough evaluation by a physician with training in viral hepatology AND In combination with peginterferon alfa and ribavirin who meet 'ALL' of the following criteria: (a) Lab-confirmed Hepatits C 'Genotype 1'; (b) Patient has a quantative HCV RNA value within the last 6 months; (c) Fibrosis stage F2 or greater (confirmed biopsy, Fibroscan, Fibrotest, or clinical or radiological evidence of F2 or greater disease) or ALT level more than 1.5 times the upper limit of normal on two consecutive occasions at least 3 months apart with additional patient-specific information to support therapy; (d) Patient not previously treated with HCV NS3/4A protease inhibitor; (e) Patient not co-infected with HIV; (f) Prescribed by a physician with training in viral hepatology; and (g) One course of treatment only (12 weeks duration) Jamp-Alendronate alendronate 70 mg JPC As per Fosamax criteria ( Jamp-Mycophenolate mycophenolate 250 mg 500 mg Capsule JPC As per Cellcept criteria ( Mylan-Esomeprazole esomeprazole 40 mg MYL As per PPI criteria ( Mylan-Riluzole riluzole 50 mg MYL For the treatment of Amyotrophic Lateral Sclerosis (ALS) % Protopic tacrolimus Ointment ASP 0.003% Second-line therapy for short and long-term intermittent-treatment of moderate to severe atopic dermatitis in non-immunocompromised patients, in whom the use of conventional topical corticosteroid therapies are deemed inadvisable because of potential risks, or who are not adequately responsive to or intolerant of conventional therapies. Note: Both 0.03% and 0.1% for adults and only 0.03% for children aged 2 to 15 years Sandoz Lansoprazole lansoprazole 15 mg 30 mg Capsule SDZ As per PPI criteria ( 7 of 25
9 Trajenta linagliptin 5 mg BOE For the treatment of patients with diabetes who are not adequately controlled on or are intolerant to metformin and a sulfonylurea, and for whom insulin is not an option Uloric febuxostat 80 mg TAK To lower serum uric acid levels in patients with symptomatic gout who have documented hypersensitivity to allopurinol Vimpat lacosamide 50 mg 100 mg 150 mg 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. UCB Visanne dienogest 2 mg BAY The management of pelvic pain associated with endometriosis in patients for whom one or more less costly hormonal options are either ineffective or cannot be used mg Xarelto rivaroxaban BAY 20 mg For treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE). New Interchangeable Categories The following new interchangeable categories and products were added: Generic Name - Strength - Form DIN Trade Name Manufacturer Price in Dollars Anastrozole - 1 mg - s $ Arimidex AZC Mylan-Anastrozole MYL Candesartan/Hydrochlorothiazide - 16 mg/12.5 mg - s $ Atacand Plus AZC Apo-Candesartan/HCTZ APX CO Candesartan/HCT COB Mylan-Candesartan HCTZ MYL pms-candesartan-hctz PMS Sandoz Candesartan Plus SDZ Teva-Candesartan/HCTZ TEV of 25
10 Clarithromycin mg/5 ml - Oral Suspension Biaxin ABB Accel-Clarithromycin ACC Clarithromycin mg/5 ml - Oral Suspension Biaxin ABB Accel-Clarithromycin ACC $ per ml $ per ml Exemestane - 25 mg - s $ Aromasin PFI CO Exemestane COB Lamivudine mg - s $ Heptovir GSK Apo-Lamivudine HBV APX Levodopa/Carbidopa mg/50 mg - s $ Sinemet CR MFX Levocarb CR AAA Riluzole - 50 mg - s $ Rilutek SAA Mylan-Riluzole MYL Temozolomide - 20 mg - Capsules $ Temodal SCH CO Temozolomide COB Temozolomide mg - Capsules $ Temodal SCH CO Temozolomide COB Temozolomide mg - Capsules $ Temodal SCH CO Temozolomide COB Temozolomide mg - Capsules $ Temodal SCH CO Temozolomide COB Tobramycin - 40 mg/ml - Injection $ Tobramycin SDZ Tobramycin JPC of 25
11 New Interchangeable Products Bulletin #70 The following products have been added to existing interchangeable drug categories: Alendronate - 70 mg - $ Jamp-Alendronate JPC ** Amlodipine - 5 mg - s $ Apo-Amlodipine APX ** CO Amlodipine COB ** Jamp-Amlodipine JPC ** Mylan-Amlodipine MYL ** Teva-Amlodipine TEV ** Amlodipine - - s $ Apo-Amlodipine APX CO Amlodipine COB Mylan-Amlodipine MYL Teva-Amlodipine TEV Jamp-Amlodipine JPC ** Atenolol - 25 mg - s $ Jamp-Atenolol JPC Atenolol - 50 mg - s $ Jamp-Atenolol JPC Atenolol mg - s $ Jamp-Atenolol JPC Atorvastatin- - s $ Atorvastatin APX Mylan-Atorvastatin MYL Atorvastatin- 20 mg - s $ Atorvastatin APX Mylan-Atorvastatin MYL Atorvastatin- 40 mg - s $ Atorvastatin APX Mylan-Atorvastatin MYL Atorvastatin- 80 mg - s $ Atorvastatin APX Mylan-Atorvastatin MYL Bicalutamide - 50 mg - s $ Jamp-Bicalutamide JPC ** of 25
12 Candesartan - 4 mg - s $ Jamp-Candesartan JPC ** Candesartan - 8 mg - s $ Jamp-Candesartan JPC ** Candesartan - 16 mg - s $ Jamp-Candesartan JPC ** Candesartan - 32 mg - s $ Jamp-Candesartan JPC ** Ciprofloxacin mg - s $ Jamp-Ciprofloxacin JPC ** Ciprofloxacin mg - s $ Jamp-Ciprofloxacin JPC ** Ciprofloxacin mg - s $ Jamp-Ciprofloxacin JPC ** Ciprofloxacin - 0.3% - Ophthalmic $ Sandoz Ciprofloxacin SDZ ** Entacapone mg - s $ Mylan-Entacapone MYL ** Esomeprazole - 40 mg - s $ Mylan-Esomeprazole MYL Ethinyl Estradiol/Levonorgestrel - 20 mcg/100 mcg - $ Alysena 21 APX Esme 21 MYL Ethinyl Estradiol/Levonorgestrel - 20 mcg/100 mcg - $ Alysena 28 APX Esme 28 MYL Fentanyl - 12 mcg - Patch $ CO Fentanyl COB Mylan-Fentanyl Matrix MYL ** Fentanyl - 25 mcg - Patch $ CO Fentanyl COB ** Mylan-Fentanyl Matrix MYL ** Fentanyl - 50 mcg - Patch $ CO Fentanyl COB ** Mylan-Fentanyl Matrix MYL ** of 25
13 Fentanyl - 75 mcg - Patch $ CO Fentanyl COB ** Mylan-Fentanyl Matrix MYL ** Fentanyl mcg - Patch $ CO Fentanyl COB ** Mylan-Fentanyl Matrix MYL ** Finasteride - 5 mg - s $ Jamp-Finasteride JPC ** Fluorometholone - 0.1% - Ophthalmic $ Sandoz Fluorometholone SDZ ** Fluoxetine - 20 mg - Capsules $ Jamp-Fluoxetine JPC ** Hydromorphone - 1 mg - s $ Apo-Hydromorphone APX Hydromorphone - 2 mg - s $ Apo-Hydromorphone APX Hydromorphone - 4 mg - s $ Apo-Hydromorphone APX Hydromorphone - 8 mg - s $ Apo-Hydromorphone APX Irbesartan - 75 mg - s $ Apo-Irbesartan APX Irbesartan mg - s $ Apo-Irbesartan APX Irbesartan mg - s $ Apo-Irbesartan APX IrbesartanHydrochlorothiazide mg/12.5 mg - s $ Apo-Irbesartan/HCTZ APX IrbesartanHydrochlorothiazide mg/12.5 mg - s $ Apo-Irbesartan/HCTZ APX IrbesartanHydrochlorothiazide mg/25 mg - s $ Apo-Irbesartan/HCTZ APX Lansoprazole - 15 mg - Capsules $ Sandoz Lansoprazole SDZ ** of 25
14 Lansoprazole - 30 mg - Capsules $ Sandoz Lansoprazole SDZ ** Latanoprost % - Ophthalmic CO Latanoprost COB $ per ml Letrozole mg - s $ Jamp-Letrozole JPC ** Losartan/Hydrochlorothiazide - 50 mg/12.5 mg - s $ CO Losartan/HCT COB Losartan/Hydrochlorothiazide mg/12.5 mg - s $ CO Losartan/HCT COB Losartan/Hydrochlorothiazide mg/25 mg - s $ CO Losartan/HCT COB Montelukast - 4 mg - s $ Mylan-Montelukast MYL Montelukast - 5 mg - s $ Mylan-Montelukast MYL Montelukast - - s $ Apo-Montelukast APX Jamp-Montelukast JPC Mylan-Montelukast MYL Mycophenolate mg - Capsules $ Jamp-Mycophenolate JPC ** Mycophenolate mg - s $ Jamp-Mycophenolate JPC ** Nabilone mg - Capsule $ CO Nabilone COB Nabilone - 1 mg - Capsule $ CO Nabilone COB Nevirapine mg - s $ Mylan-Nevirapine MYL ** Ofloxacin - 0.3% - Ophthalmic $ Sandoz Ofloxacin SDZ ** Olanzapine - 5 mg - Orally Disintegrating s $ Mylan-Olanzapine ODT MYL ** of 25
15 Olanzapine - - Orally Disintegrating s $ Mylan-Olanzapine ODT MYL ** Olanzapine - 15 mg - Orally Disintegrating s $ Mylan-Olanzapine ODT MYL ** Raloxifene - 60 mg - s $ CO Raloxifene COB ** Risperidone mg - s $ Jamp-Risperidone JPC ** Risperidone mg - s $ Jamp-Risperidone JPC ** Risperidone - 1 mg - s $ Jamp-Risperidone JPC ** Risperidone - 2 mg - s $ Jamp-Risperidone JPC ** Risperidone - 3 mg - s $ Jamp-Risperidone JPC ** Risperidone - 4 mg - s $ Jamp-Risperidone JPC ** Rizatriptan - 5 mg - s $ Apo-Rizatriptan APX Jamp-Rizatriptan JPC ** Rizatriptan - - s $ Apo-Rizatriptan APX CO Rizatriptan COB Jamp-Rizatriptan JPC ** Ropinirole mg - s $ Apo-Ropinirole APX ** Ropinirole - 1 mg - s $ Apo-Ropinirole APX ** Ropinirole - 2 mg - s $ Apo-Ropinirole APX ** Ropinirole - 5 mg - s $ Apo-Ropinirole APX ** of 25
16 Rosuvastatin - - s $ Apo-Rosuvastatin APX ** Mylan-Rosuvastatin MYL ** Teva-Rosuvastatin TEV ** Rosuvastatin - 20 mg - s $ Apo-Rosuvastatin APX ** Mylan-Rosuvastatin MYL ** Teva-Rosuvastatin TEV ** Rosuvastatin - 40 mg - s $ Apo-Rosuvastatin APX ** Mylan-Rosuvastatin MYL ** Teva-Rosuvastatin TEV ** Simvastatin - 5 mg - s $ Jamp-Simvastatin JPC ** Simvastatin - - s $ Jamp-Simvastatin JPC ** Simvastatin - 20 mg - s $ Jamp-Simvastatin JPC ** Simvastatin - 40 mg - s $ Jamp-Simvastatin JPC ** Simvastatin - 80 mg - s $ Jamp-Simvastatin JPC ** Telmisartan - 40 mg - s $ CO Telmisartan COB Telmisartan - 80 mg - s $ CO Telmisartan COB Telmisartan/Hydrochlorothiazide - 80/12.5 mg - s $ CO Telmisartan/HCTZ COB Trimethoprim/Polymyxin B - 1 mg/10,000 U/mL - Ophthalmic $ Sandoz Polytrimethoprim SDZ ** Telmisartan/Hydrochlorothiazide - 80/25 mg - s $ CO Telmisartan/HCTZ COB Valsartan - 40 mg - s $ Mylan-Valsartan MYL ** Valsartan - 80 mg - s $ Mylan-Valsartan MYL ** of 25
17 Valsartan mg - s $ Mylan-Valsartan MYL ** Valsartan mg - s $ Mylan-Valsartan MYL Valsartan/Hydrochlorothiazide - 80 mg/12.5 mg - s $ Apo-Valsartan/HCTZ APX Valsartan/Hydrochlorothiazide mg/12.5 mg - s $ Apo-Valsartan/HCTZ APX Valsartan/Hydrochlorothiazide mg/25 mg - s $ Apo-Valsartan/HCTZ APX Valsartan/Hydrochlorothiazide mg/12.5 mg - s $ Apo-Valsartan/HCTZ APX Valsartan/Hydrochlorothiazide mg/25 mg - s $ Apo-Valsartan/HCTZ APX Zolmitriptan mg - Orally Disintegrating s $ Mylan-Olanzapine ODT MYL ** ** The price has resulted in a change to the lowest price in the category. The following products have been deleted. Product Deletions Apo-Carbamazepine carbamazepine 200 mg Apo-Clonidine clonidine mg Apo-Clonidine clonidine 0.1 mg Apo-Clonidine clonidine 0.2 mg Apo-Indomethacin indomethacin 25 mg Capsules Apo-Indomethacin indomethacin 50 mg Capsules Apo-Metoclop metoclopramide 5 mg Apo-Metoclop metoclopramide Blenoxane bleomycin 15 U Injection Capoten captopril 25 mg Capoten captopril 100 mg Desocort desonide 0.05% Ointment Desocort desonide 0.05% Lotion Doxycycline doxycycline 100 mg Capsules Doxycycline doxycycline 100 mg Lariam melfloquine 250 mg pms-bisacodyl bisacodyl 5 mg 16 of 25
18 pms-captopril captopril 12.5 mg pms-captopril captopril 25 mg pms-captopril captopril 50 mg pms-captopril captopril 100 mg pms-cephalexin cephalexin 250 mg pms-cimetidine cimetidine 800 mg pms-divalproex divalproex 125 mg pms-divalproex divalproex 250 mg pms-divalproex divalproex 500 mg pms-doxycycline doxycycline 100 mg Capsules pms-doxycycline doxycycline 100 mg pms-fluvoxamine fluvoxamine 50 mg pms-fluvoxamine fluvoxamine 100 mg pms-fosinopril fosinopril 20 mg pms-gliclazide gliclazide 80 mg pms-morphine SR morphine 60 mg pms-morphine SR morphine 200 mg pms-oxycodone/ Acetaminophen oxycodone/acetaminophen 5 mg/325 mg pms-pantoprazole pantoprazole 20 mg pms-piroxicam piroxicam 20 mg Capsules pms-rivastigmine rivastigmine 6 mg Capsules pms-selegiline selegiline 5 mg pms-tamoxifen tamoxifen 20 mg pms-temazepam temazepam 15 mg Capsules pms-temazepam temazepam 30 mg Capsules pms-ticlopidine ticlopidine 250 mg pms-tryptophan trryptophan 500 mg Capsules ratio-captopril captopril 12.5 mg ratio-captopril captopril 25 mg ratio-captopril captopril 50 mg ratio-captopril captopril 100 mg ratio-codeine codeine phosphate 5 mg/ml Syrup ratio-gentamicin gentamicin 0.1% Cream ratio-gentamicin gentamicin 0.1% Ointment Rebif interferon beta-1a 8.8 mcg 22 mcg Injection Teva-Fluconazole fluconazole 2 mg/ml Injection 17 of 25
19 Category Deletions Bulletin #70 - Betamethasone disodium phosphate and gentamicin sulfate - 1mg/3 mg/ml - Ophthalmic/Otic - Fluconazole - 2 mg/ml - Injection - Indomethacin - 25 mg - Capsules - Indomethacin - 50 mg - Capsules - Mefloquine HCL mg - s - Triamcinolone - /ml - Injection - Triamcinolone - 40 mg/ml - Injection Interchangeable Product Price Changes The following changes in prices have occurred: ($) Accel-Amlodipine amlodipine 5 mg Accel-Amlodipine amlodipine Acular ketorolac tromethamine 0.5% Ophthalmic Alesse levonorgestrel/ ethinyl estradiol 100/20 mcg Alesse levonorgestrel/ ethinyl estradiol 100/20 mcg Alphagan brimonidine tartrate 0.2% Ophthalmic Atacand candesartan 4 mg Atacand candesartan 8 mg Atacand candesartan 16 mg Atacand candesartan 32 mg Atacand Plus candesartan HCTZ 16/12.5 mg Ativan lorazepam 0.5 mg Ativan lorazepam 1 mg Ativan lorazepam 2 mg Betaject betamethasone 6 mg/ml Injection CO Alendronate alendronate 40 mg CO Cabergoline cabergoline 0.5 mg Crestor rosuvastatin Crestor rosuvastatin 20 mg Crestor rosuvastatin 40 mg Dalacin T clindamycin 1% Depo-Testosterone testosterone 100 mg/ml Injection Diane-35 cyproterone/ ethinyl estradiol 2/0.035 mg Dilantin phenytoin sodium 125 mg/5 ml Oral Suspension Dimenthyl Sulfoxide dimethyl sulfoxide 500 mg/g Injection Duragesic MAT fentanyl 25 mcg Patch Duragesic MAT fentanyl 50 mcg Patch Duragesic MAT fentanyl 75 mcg Patch Duragesic MAT fentanyl 100 mcg Patch of 25
20 Elocom mometasone 0.1% Cream Elocom mometasone 0.1% Lotion Effexor XR venlafaxine 37.5 mg Capsule Effexor XR venlafaxine 75 mg Capsule Effexor XR venlafaxine 150 mg Capsule FML fluorometholone 0.1% Ophthalmic Levaquin levofloxacin 250 mg Levaquin levofloxacin 500 mg Lipitor atorvastatin Lipitor atorvastatin 20 mg Lipitor atorvastatin 40 mg Lipitor atorvastatin 80 mg Opticrom cromolyn sodium 2% Ophthalmic Pamidronate Disodium pamidronate disodium 3 mg/ml Injection Pamidronate Disodium pamidronate disodium 9 mg/ml Injection pms-amantadine amantadine 100 mg pms-atenolol atenolol 25 mg pms-atenolol atenolol 50 mg pms-atenolol atenolol 100 mg pms-azithromycin azithromycin 100 mg/5 ml Suspension pms-azithromycin azithromycin 200 mg/5 ml Suspension pms-azithromycin azithromycin 250 mg pms-azithromycin azithromycin 600 mg pms-biclautamide bicalutamide 50 mg pms-bisacodyl bisacodyl Suppository pms-bisoprolol bisoprolol 5 mg pms-bisoprolol bisoprolol pms-brimonidine brimonidine 0.2% Ophthalmic pms-buspirone buspirone pms-carbamazepine CR carbapazepine 200 mg pms-carbamazepine CR carbapazepine 400 mg pms-cilazapril cilazapril 1 mg pms-cilazapril cilazapril 2.5 mg pms-cilazapril cilazapril 5 mg pms-ciprofloxacin ciprofloxacin 250 mg pms-citalopram citalopram 20 mg pms-citalopram citalopram 40 mg pms-clarithromycin clarithromycin 250 mg pms-clarithromycin clarithromycin 500 mg pms-clobetasol clobetasol Cream pms-clonazepam clonazapam 1 mg pms-deferoxamine deferoxamine 500 mg Injection pms-dexamethasone dexamethasone 4 mg pms-diazepam diazepam 5 mg pms-diazepam diazepam pms-diclofenac-k diclofenac 50 mg pms-diclofenac-sr diclofenac 100 mg of 25
21 pms-famciclovir famciclovir 125 mg pms-famciclovir famciclovir 250 mg pms-famciclovir famciclovir 500 mg pms-finasteride finasteride 5 mg pms-fluconazole fluconazole 50 mg pms-fluconazole fluconazole 100 mg pms-fluoxetine fluoxetine Capsule pms-fluoxetine fluoxetine 20 mg Capsule pms-flutamide flutamide 250 mg pms-gabapentin gabapentin 100 mg Capsule pms-gabapentin gabapentin 300 mg Capsule pms-gabapentin gabapentin 400 mg Capsule pms-hydromorphone hydromorphone 1 mg pms-hydromorphone hydromorphone 2 mg pms-hydromorphone hydromorphone 4 mg pms-hydromorphone hydromorphone 8 mg pms-ipratropium ipratropium bromide 250 mcg/ml Inhalation pms-ipratropium ipratropium bromide 250 mcg/ml Inhalation pms-ipratropium ipratropium bromide 250 mcg/ml Inhalation pms-ipratropium ipratropium bromide 0.03% Nasal Spray pms-irbesartan HCTZ irbesartan/hctz 300/25 mg pms-leflunomide leflunomide pms-leflunomide leflunomide 20 mg pms-letrozole letrozole 2.5 mg pms-levobunolol levobunolol 0.5% Injection pms-lithium Carbonate lithium carbonate 150 mg Capsule pms-lithium Carbonate lithium carbonate 300 mg Capsule pms-loperamide loperamide 2 mg Caplet pms-lorazepam lorazepam 0.5 mg pms-lorazepam lorazepam 1 mg pms-lorazepam lorazepam 2 mg pms-lovastatin lovastatin 20 mg pms-lovastatin lovastatin 40 mg pms-methylphenidate methylphenidate pms-methylphenidate methylphenidate 20 mg pms-metoprolol-l metoprolol 50 mg pms-metoprolol-l metoprolol 100 mg pms-norfloxacin norfloxacin 400 mg pms-nortriptyline nortriptyline Capsule pms-nortriptyline nortriptyline 25 mg Capsule pms-olanzapine olanzapine 2.5 mg pms-olanzapine olanzapine 5 mg pms-olanzapine olanzapine 7.5 mg pms-olanzapine olanzapine pms-olanzapine olanzapine 15 mg pms-olanzapine ODT olanzapine 5 mg pms-olanzapine ODT olanzapine pms-olanzapine ODT olanzapine 15 mg pms-ondansetron ondansetron 4 mg of 25
22 pms-ondansetron ondansetron 8 mg pms-paroxetine paroxetine pms-paroxetine paroxetine 20 mg pms-paroxetine paroxetine 30 mg pms-pioglitazone pioglitazone 15 mg pms-pioglitazone pioglitazone 30 mg pms-pioglitazone pioglitazone 45 mg pms-pramipexole pramipexole 0.25 mg pms-pramipexole pramipexole 0.5 mg pms-pramipexole pramipexole 1 mg pms-pramipexole pramipexole 1.5 mg pms-pravastatin pravastatin pms-pravastatin pravastatin 20 mg pms-pravastatin pravastatin 40 mg pms-rabeprazole EC rabeprazole pms-rabeprazole EC rabeprazole 20 mg pms-ranitidine ranitidine 150 mg pms-ranitidine ranitidine 300 mg pms-risperidone risperidone 0.25 mg pms-risperidone risperidone 0.5 mg pms-risperidone risperidone 1 mg pms-risperidone risperidone 2 mg pms-risperidone risperidone 3 mg pms-risperidone risperidone 4 mg pms-salbutamol salbutamol 0.5 mg/ml pms-salbutamol salbutamol 1 mg/ml pms-salbutamol salbutamol 2 mg/ml pms-salbutamol salbutamol 5 mg/ml pms-sertraline sertraline 25 mg Capsule pms-sertraline sertraline 50 mg Capsule pms-sertraline sertraline 100 mg Capsule pms-simvastatin simvastatin 5 mg pms-simvastatin simvastatin pms-simvastatin simvastatin 20 mg pms-simvastatin simvastatin 40 mg pms-simvastatin simvastatin 80 mg pms-sotalol sotalol 160 mg Caplet pms-sumatriptan sumatriptan 50 mg pms-sumatriptan sumatriptan 100 mg pms-terbinafine terbinafine 250 mg pms-timolol timolol maleate 0.25% pms-topiramate topiramate 25 mg pms-topiramate topiramate 100 mg pms-topiramate topiramate 200 mg pms-trazodone trazodone 50 mg pms-valacyclovir valacyclovir 500 mg Caplet pms-valproic Acid valproic acid 50 mg/ml Syrup pms-venlafaxine XR venlafaxine 37.5 mg Capsule pms-venlafaxine XR venlafaxine 75 mg Capsule pms-venlafaxine XR venlafaxine 150 mg Capsule pms-zopiclone zopiclone 5 mg of 25
23 Polytrim polymyxin b sulfate/ trimethoprim sulfate 1 mg/10,000 U/mL Ophthalmic Provera medroxyprogesterone 2.5 mg Provera medroxyprogesterone 5 mg Ran-Rosuvastatin rosuvastatin Ran-Rosuvastatin rosuvastatin 20 mg Ran-Rosuvastatin rosuvastatin 40 mg Rhinocort Aqua budesonide 64 mcg/dose Nasal Spray Risperdal risperidone 0.25 mg Risperdal risperidone 0.5 mg Risperdal risperidone 1 mg Risperdal risperidone 2 mg Risperdal risperidone 3 mg Risperdal risperidone 4 mg Sandoz Alfuzosin alfuzosin Sandoz Atenolol atenolol 100 mg Sandoz Atenolol atenolol 50 mg Sandoz Azithromycin azithromycin 250 mg Sandoz Bisoprolol bisoprolol Sandoz Bisoprolol bisoprolol 5 mg Sandoz Candesartan candesartan 4 mg Sandoz Candesartan candesartan 8 mg Sandoz Candesartan candesartan 16 mg Sandoz Cefprozil cefprozil 125 mg/5 ml Oral Suspension Sandoz Ciprofloxacin ciprofloxacin 250 mg Sandoz Ciprofloxacin ciprofloxacin 500 mg Sandoz Ciprofloxacin ciprofloxacin 750 mg Sandoz Diclofenac EC diclofenac 25 mg Sandoz Diclofenac EC diclofenac 50 mg Sandoz Dorzolamide/ dorzolamide/timolol maleate 2%/0.5% Ophthalmic Timolol Sandoz Felodipine ER felodipine Sandoz Finasteride finasteride 5 mg Sandoz Fluoxetine fluoxetine Capsule Sandoz Fluoxetine fluoxetine 20 mg Capsule Sandoz Glimipiride glimipiride 1 mg Sandoz Glimipiride glimipiride 2 mg Sandoz Glimipiride glimipiride 4 mg Sandoz Latanoprost latanoprost 0.005% Ophthalmic Sandoz Leflunomide leflunomide Sandoz Leflunomide leflunomide 20 mg Sandoz Letrozole letrozole 2.5 mg Sandoz Levofloxacin levofloxacin 250 mg Sandoz Levofloxacin levofloxacin 500 mg Sandoz Loperamide loperamide 2 mg Sandoz Losartan HCT losartan/hctz 100/12.5 mg Sandoz Metoprolol metoprolol 50 mg of 25
24 Sandoz Metoprolol metoprolol 100 mg Sandoz Minocycline minocycline 50 mg Capsule Sandoz Minocycline minocycline 100 mg Capsule Sandoz Morphine SR morphine sulfate 15 mg Sandoz Morphine SR morphine sulfate 30 mg Sandoz Morphine SR morphine sulfate 60 mg Sandoz Nitrazepam nitrazepam Sandoz Nitrazepam nitrazepam 5 mg Sandoz Olanzapine olanzapine 5 mg Sandoz Olanzapine ODT olanzapine 5 mg Sandoz Olanzapine ODT olanzapine Sandoz Olanzapine ODT olanzapine 15 mg Sandoz Omeprazole omeprazole 20 mg Capsule Sandoz Ondansetron ondansetron 4 mg Sandoz Pioglitazone pioglitazone 15 mg Sandoz Pioglitazone pioglitazone 30 mg Sandoz Pioglitazone pioglitazone 45 mg Sandoz Pramipexole pramipexole 0.25 mg Sandoz Pramipexole pramipexole 0.5 mg Sandoz Pramipexole pramipexole 1.5 mg Sandoz Pramipexole pramipexole 1 mg Sandoz Pravastatin pravastatin Sandoz Pravastatin pravastatin 20 mg Sandoz Pravastatin pravastatin 40 mg Sandoz Prednisolone prednisolone 1% Ophthalmic Sandoz Rabeprazole rabeprazole Sandoz Rabeprazole rabeprazole 20 mg Sandoz Ramipril ramipril 1.25 mg Sandoz Ramipril ramipril 2.5 mg Sandoz Ramipril ramipril 5 mg Sandoz Ramipril ramipril Sandoz Ranitidine ranitidine 150 mg Sandoz Ranitidine ranitidine 300 mg Sandoz Repaglinide repaglinide 0.5 mg Sandoz Repaglinide repaglinide 1 mg Sandoz Repaglinide repaglinide 2 mg Sandoz Risperidone risperidone 0.25 mg Sandoz Risperidone risperidone 0.5 mg Sandoz Risperidone risperidone 1 mg Sandoz Risperidone risperidone 2 mg Sandoz Risperidone risperidone 3 mg Sandoz Risperidone risperidone 4 mg Sandoz Sertraline sertraline 25 mg Capsule Sandoz Sertraline sertraline 50 mg Capsule Sandoz Sertraline sertraline 100 mg Capsule Sandoz Simvastatin simvastatin Sandoz Simvastatin simvastatin 20 mg Sandoz Simvastatin simvastatin 40 mg of 25
25 Sandoz Simvastatin simvastatin 80 mg Sandoz Sumatriptan sumatriptan 50 mg Sandoz Sumatriptan sumatriptan 100 mg Sandoz Terbinafine terbinafine 250 mg Sandoz Topiramate topiramate 25 mg Sandoz Topiramate topiramate 100 mg Sandoz Topiramate topiramate 200 mg Sandoz Venlafaxine XR venlafaxine 37.5 mg Capsule Sandoz Venlafaxine XR venlafaxine 75 mg Capsule Sandoz Venlafaxine XR venlafaxine 150 mg Capsule Sandoz Zopiclone zopiclone 7.5 mg Xalatan latanoprost 0.005% Ophthalmic Zoloft sertraline 100 mg Capsule ** The price change has resulted in a change to the lowest price in the category. 24 of 25
26 Discontinued Products The following products will be deleted with the next Formulary amendments Capex fluocinolone 0.01% Shampoo Estraderm estradiol-17b 25 mcg Patch pms-diclofenac diclofenac sodium 100 mg Suppository Manufacturer Updates The following product has had a DIN change: (was DIN ) pms-clobetasol clobetasol 0.05% Cream The following product has had a name change: Benztropine (was Apo-Benztropine) benztropine 2 mg s The following products have had a name change: Freestyle (was Medisense) - - Lancets Freestyle Precision Xtra (was Precision Xtra) - - Blood Glucose Test Strips Freestyle Precision Xtra (was Precision Xtra Ketone) - - Blood Ketone Test Strip The following product is in transition of a name change: Pradaxa (was Pradax) dabigatran 75 mg mg s * Pradaxa will be entering the wholesale in January 2013 and all stock of Pradax should be depleted by April of 25
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