BULLETIN # 72 Manitoba Drug Benefits and Interchangeability Formulary Amendments The following amendments will take effect on April 18, 2013 The amended Manitoba Specified Drug Regulation and Drug Interchangeability Formulary Regulation will be available on the Manitoba Health website http://www.gov.mb.ca/health/mdbif on the effective date of April 18, 2013 Bulletin 72 is currently available for download: http://www.gov.mb.ca/health/mdbif/bulletin72.pdf Inside This Issue Part 1 Additions Page 1-2 Part 2 Additions Page 3 Part 3 Additions Page 4 New Interchangeable Categories Page 4-5 New Interchangeable Products Page 5-9 Product Deletions Page 9 Category Deletions Page 9 Interchangeable Product Price Changes Page 10-17 Discontinued Products Page 17 Manufacturer Updates Page 18
Part 1 Additions DIN TRADE NAME GENERIC STRENGTH FORM MFR* 02357844 Celestoderm V betamethasone 0.1% Cream VPI 02357852 Celestoderm V betamethasone 0.1% Ointment VPI 02357860 Celestoderm V/2 betamethasone 0.05% Cream VPI 02357879 Celestoderm V/2 betamethasone 0.05% Ointment VPI 02370611 02370638 02370646 02370654 CO Diltiazem CD diltiazem 120 mg 180 mg 240 mg 300 mg Capsule COB 02370441 02370492 02370506 02370514 02370522 CO Diltiazem T diltiazem 120 mg 180 mg 240 mg 300 mg 360 mg Capsule COB 02368897 02358900 02368919 02368927 Jamp-Carvedilol carvedilol 3.125 mg 6.25 mg 12.5 mg 25 mg 02370085 Jamp-Citalopram citalopram 10 mg 02369206 Jamp-Domperidone domperidone 10 mg 02331004 02331012 Jamp-Fosinopril fosinopril 10 mg 20 mg 02361469 02361485 02361493 Jamp-Gabapentin gabapentin 100 mg 300 mg 400 mg Capsule 80013007 Jamp-K20 potassium chloride 1500 mg 02361531 02361558 02361566 Jamp-Lisinopril lisinopril 5 mg 10 mg 20 mg 02380722 02380730 Jamp-Metformin (Blackberry) metformin 500 mg 850 mg 02380196 02380218 Jamp-Metformin metformin 500 mg 850 mg 02368862 02368870 02368889 Jamp-Paroxetine paroxetine 10 mg 20 mg 30 mg 1 of 18
02330954 02330962 02330970 Jamp-Pravastatin pravastatin 10 mg 20 mg 40 mg 02352338 02352346 02352354 02352362 Jamp-Ropinirole ropinirole 0.25 mg 1 mg 2 mg 5 mg 02357143 02357151 02357178 Jamp-Sertraline sertraline 25 mg 50 mg 100 mg 02368617 02368625 Jamp-Sotalol sotalol 80 mg 160 mg 02357070 Jamp-Terbinafine terbinafine 250 mg 02396327 02396335 02396343 02392992 02393018 02393026 02389657 02389665 02389673 02388766 02388774 02396289 02396297 02396300 02396319 Mar-Allopurinol Mint-Irbesartan/HCTZ Mint-Losartan/HCTZ Mint-Metformin Mylan-Terazosin allopurinol irbesartan/hctz losartan/hctz metformin terazosin 100 mg 200 mg 300 mg 150/12.5 mg 300/12.5 mg 300/25 mg 50/12.5 mg 100/12.5 mg 100/25 mg 500 mg 850 mg 1 mg 2 mg 5 mg 10 mg MAR MPH MPH MPH MYL 02369753 02393050 Prezista darunavir 150 mg 800 mg JAN 02312247 02312255 Ran-Ondansetron ondansetron 4 mg 8 mg RBX 02299224 02299232 Teva-Fluvastatin fluvastatin 20 mg 40 mg TEV *Abbreviation of Manufacturers' Names 2 of 18
Part 2 Additions Bulletin #72 02357127 Jamp-Cyclobenzaprine cyclobenzaprine 10 mg As an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions not responding to alternative therapy. 02389878 Mint-Finasteride finasteride 5 mg MPH For the treatment of symptomatic benign prostatic hyperplasia. 02376393 Nutropin AQ NuSpin somatropin 10 mg/2 ml Injection RCH (a) For the long term management of children who have growth failure due to an inadequate secretion of normal endogenous growth hormone; (b) For the treatment of children who have growth failure associated with chronic renal failure insufficiency up to the time of renal transplant; (c) For treatment of short stature associated with Turner Syndrome in patients whose epiphyses are not closed. 02350122 02350130 02350149 Saizen somatropin 6 mg 12 mg 20 mg Injection SRO (a) For the long term management of children who have growth failure due to an inadequate secretion of normal endogenous growth hormone; (b) For the treatment of children who have growth failure associated with chronic renal failure insufficiency up to the time of renal transplant; (c) For treatment of short stature associated with Turner Syndrome in patients whose epiphyses are not closed. 02381842 Tamiflu oseltamivir 6 mg/ml Suspension HLR Please refer to Part 2 of the Specified Drug Regulation for the eligible criteria. 3 of 18
Part 3 Additions The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis. 02365529 02365537 Jamp-Pioglitazone pioglitazone 30 mg 45 mg As per Actos criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf). 02368552 Jamp-Risedronate risedronate 35 mg As per Actonel criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf). 02394863 02394871 Mint-Alendronate alendronate 10 mg 70 mg MPH As per Alendronate criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf). New Interchangeable Categories The following new interchangeable categories and products were added: Generic Name - Strength - Form DIN Trade Name Manufacturer Price in Dollars Allopurinol - 100 mg - s $ 00402818 Zyloprim AAA 0.0858 02396327 Mar-Allopurinol MAR 0.0780 Allopurinol - 200 mg - s $ 00479799 Zyloprim AAA 0.1502 02396335 Mar-Allopurinol MAR 0.1300 Allopurinol - 300 mg - s $ 00402796 Zyloprim AAA 0.2125 02396343 Mar-Allopurinol MAR 0.2155 Betamethasone-17-Valerate - 0.05% - Ointment 00716642 Betaderm TAR 02357879 Celestoderm V/2 VPI Betamethasone-17-Valerate - 0.1% - Ointment 00716650 Betaderm TAR 02357852 Celestoderm V VPI $ per gram 0.0667 0.0596 $ per gram 0.0998 0.0889 4 of 18
Betamethasone-17-Valerate - 0.05% - Cream 00535427 ratio-ectosone RPH 00716618 Betaderm TAR 02357860 Celestoderm V/2 VPI $ per gram 0.0612 0.0605 0.0596 Citalopram - 10 mg - s $ 02270609 pms-citalopram PMS 0.4464 02370085 Jamp-Citalopram 0.2493 Fluconazole - 150 mg - Capsules $ 02241895 Apo-Fluconazole APX 9.1900 02282348 pms-fluconazole PMS 9.1900 Fluticasone - 120 dose - 50 mcg - Nasal Spray 02213672 Flonase GSK 02294745 Apo-Fluticasone APX $ per dose 0.2807 0.1831 Fluvastatin - 20 mg - Capsules $ 02061562 Lescol NVT 0.9691 02299224 Teva-Fluvastatin TEV 0.7048 Fluvastatin - 40 mg - Capsules $ 02061570 Lescol NVT 1.3607 02299232 Teva-Fluvastatin TEV 0.9896 New Interchangeable Products The following products have been added to existing interchangeable drug categories: Alendronate - 10 mg - s $ 02394863 Mint-Alendronate MPH **0.4987 Alendronate - 70 mg - s $ 02394871 Mint-Alendronate MPH **2.5144 Betamethasone-17-Valerate - 0.1% - Cream 02357844 Celestoderm V VPI $ per gram **0.0889 Carvedilol - 3.125 mg - s $ 02368897 Jamp-Carvedilol **0.4728 Carvedilol - 6.25 mg - s $ 02358900 Jamp-Carvedilol **0.4728 Carvedilol - 12.5 mg - s $ 02368919 Jamp-Carvedilol **0.4728 5 of 18
Carvedilol - 25 mg - s $ 02368927 Jamp-Carvedilol **0.4728 Cyclobenzaprine - 10 mg - s $ 02357127 Jamp-Cyclobenzaprine **0.3765 Diltiazem HCL - 120 mg- Controlled Delivery Capsules $ 02370611 CO Diltiazem CD COB **0.4940 Diltiazem HCL - 180 mg- Controlled Delivery Capsules $ 02370638 CO Diltiazem CD COB **0.6557 Diltiazem HCL - 240 mg- Controlled Delivery Capsules $ 02380646 CO Diltiazem CD COB **0.8698 Diltiazem HCL - 300 mg- Controlled Delivery Capsules $ 02380654 CO Diltiazem CD COB **1.0872 Diltiazem HCL - 120 mg- Extended Release Capsules $ 02370411 CO Diltiazem T COB **0.2987 Diltiazem HCL - 180 mg- Extended Release Capsules $ 02370492 CO Diltiazem T COB **0.4045 Diltiazem HCL - 240 mg- Extended Release Capsules $ 02370506 CO Diltiazem T COB **0.5365 Diltiazem HCL - 300 mg- Extended Release Capsules $ 02370514 CO Diltiazem T COB **0.6607 Diltiazem HCL - 360 mg- Extended Release Capsules $ 02370522 CO Diltiazem T COB **0.8089 Domperidone - 10 mg - s $ 02369206 Jamp-Domperidone **0.1446 Finasteride - 5 mg - s $ 02389878 Mint-Finasteride MPH **0.4633 Fosinopril - 10 mg - s $ 02331004 Jamp-Fosinopril **0.4390 Fosinopril - 20 mg - s $ 02331012 Jamp-Fosinopril **0.5279 Gabapentin - 100 mg - Capsules $ 02361469 Jamp-Gabapentin **0.1926 Gabapentin - 300 mg - Capsules $ 02361485 Jamp-Gabapentin **0.4687 6 of 18
Gabapentin - 400 mg - Capsules $ 02361493 Jamp-Gabapentin **0.5585 Irbesartan/HCTZ - 150/12.5 mg - s $ 02392992 Mint-Irbesartan/HCTZ MPH **0.3073 Irbesartan/HCTZ - 300/12.5 mg - s $ 02393018 Mint-Irbesartan/HCTZ MPH **0.3073 Irbesartan/HCTZ - 300/25 mg - s $ 02393026 Mint-Irbesartan/HCTZ MPH **0.3052 Lisinopril - 5 mg - s $ 02361531 Jamp-Lisinopril **0.4849 Lisinopril - 10 mg - s $ 02361558 Jamp-Lisinopril **0.5827 Lisinopril - 20 mg - s $ 02361566 Jamp-Lisinopril **0.7001 Losartan/HCTZ - 50/12.5 mg - s $ 02389657 Mint-Losartan/HCTZ MPH **0.3148 Losartan/HCTZ - 100/12.5 mg - s $ 02389665 Mint-Losartan/HCTZ MPH **0.3082 Losartan/HCTZ - 100/25 mg - s $ 02389673 Mint-Losartan/HCTZ MPH **0.3148 Metformin - 500 mg - s $ 02380722 Jamp-Metformin Blackberry **0.0936 02380196 Jamp-Metformin **0.0936 02388766 Mint-Metformin MPH **0.0936 Metformin - 850 mg - s $ 02380730 Jamp-Metformin Blackberry **0.1186 02380217 Jamp-Metformin **0.1186 02388774 Mint-Metformin MPH **0.1186 Ondansetron - 4 mg - s $ 02312247 Ran-Ondansetron RBX **5.3390 Ondansetron - 8 mg - s $ 02312255 Ran-Ondansetron RBX **8.1576 Paroxetine - 10 mg - s $ 02368862 Jamp-Paroxetine **0.9387 7 of 18
Paroxetine - 20 mg - s $ 02368870 Jamp-Paroxetine **0.6320 Paroxetine - 30 mg - s $ 02368889 Jamp-Paroxetine **0.6714 Pioglitazone - 30 mg - s $ 02365529 Jamp-Pioglitazone **1.0824 Pioglitazone - 45 mg - s $ 02365537 Jamp-Pioglitazone **1.6275 Pravastatin - 10 mg - s $ 02330954 Jamp-Pravastatin **0.5103 Pravastatin - 20 mg - s $ 02330962 Jamp-Pravastatin **0.6020 Pravastatin - 40 mg - s $ 02330970 Jamp-Pravastatin **0.7251 Risedronate - 35 mg - s $ 02368552 Jamp-Risedronate **2.4875 Ropinirole - 0.25 mg - s $ 02352338 Jamp-Ropinirole **0.0894 Ropinirole - 1 mg - s $ 02352346 Jamp-Ropinirole **0.3577 Ropinirole - 2 mg - s $ 02352354 Jamp-Ropinirole **0.3934 Ropinirole - 5 mg - s $ 02352362 Jamp-Ropinirole **1.0831 Sertraline - 25 mg - s 02357143 Jamp-Sertraline **0.2806 Sertraline - 50 mg - s $ 02357151 Jamp-Sertraline **0.5611 Sertraline - 100 mg - s $ 02357178 Jamp-Sertraline **0.5880 Sotalol - 80 mg - s $ 02368617 Jamp-Sotalol **0.5932 Sotalol - 160 mg - s $ 02368625 Jamp-Sotalol **0.1623 8 of 18
Terazosin - 1 mg - s $ 02396289 Mylan-Terazosin MYL **0.2447 Terazosin - 2 mg - s $ 02396297 Mylan-Terazosin MYL **0.3111 Terazosin - 5 mg - s $ 02396300 Mylan-Terazosin MYL **0.4225 Terazosin - 10 mg - s $ 02396319 Mylan-Terazosin MYL **0.6183 Terbinafine - 250 mg - s $ 02357070 Jamp-Terbinafine **1.8545 ** The price has resulted in a change to the lowest price in the category. The following products have been deleted. 02258538 Aviane 21 Product Deletions ethinyl estradiol/ levonorgestrel 20 mcg/100 mcg 02298546 Aviane 28 ethinyl estradiol/ levonorgestrel 20 mcg/100 mcg 02242738 Capex fluocinolone 0.01% Shampoo 00756849 Estraderm estradiol-17b 25 mcg Patch 02231508 pms-diclofenac diclofenac sodium 100 mg Suppository 00587966 Stevia-A tretinoin 0.025% Gel 00641863 Stevia-A tretinoin 0.05% Gel - Diclofenac Sodium - 100 mg - Suppositories - Tretinoin - 0.05% - Topical Cream - Tretinoin - 0.01% - Topical Cream - Tretinoin - 0.01% - Topical Gel - Tretinoin - 0.025% - Topical Gel - Tretinoin - 0.05% - Topical Gel Category Deletions 9 of 18
Interchangeable Product Price Changes Bulletin #72 The following changes in prices have occurred: ($) 02303442 Accel-Pioglitazone pioglitazone 15 mg s 0.8133 02303469 Accel-Pioglitazone pioglitazone 30 mg s 1.1394 02303450 Accel-Pioglitazone pioglitazone 45 mg s 1.7132 02242572 Actos pioglitazone 15 mg s 2.7577 02242573 Actos pioglitazone 30 mg s 3.8637 02242574 Actos pioglitazone 45 mg s 5.7981 02221829 Altace ramipril 1.25 mg Capsules 0.7895 02221837 Altace ramipril 2.5 mg Capsules 0.9061 02221845 Altace ramipril 5 mg Capsules 0.9072 02221853 Altace ramipril 10 mg Capsules 1.1506 02281112 Altace ramipril 15 mg Capsules 1.2778 02245272 Amaryl glimepiride 1 mg s 0.9843 02245273 Amaryl glimepiride 2 mg s 1.0712 02245274 Amaryl glimepiride 4 mg s 1.1467 02162725 Anaprox naproxen 275 mg s 0.6969 02162717 Anaprox DS naproxen 550 mg s 1.3418 02243987 Apo-Amoxi-Clav amoxicillin/clavulanic acid 50/12.5 mg Oral Liquid 0.1830 00362166 Apo-Furosemide furosemide 40 mg s 0.0746 00396826 Apo-Haloperidol haloperidol 2 mg s 0.2748 00396834 Apo-Haloperidol haloperidol 5 mg s 0.4385 02229080 Apo-Ketorolac ketorolac 10 mg s 0.5192 02245821 Apo-Ketorolac ketorolac 0.5% Ophthalmic Solution 2.5960 00782505 Apo-Nadol nadolol 40 mg s 0.4512 00642215 Apo-Pen VK penicillin 300 mg s 0.1873 02325381 Apo-Ramipril ramipril 15 mg Capsules 0.8550 02280833 Apo-Ranitidine ranitidine 15 mg/ml Solution 0.1480 01946323 Apo-Zidovudine zidovudine 100 mg Capsules 1.3977 00015229 Aventyl nortriptyline 10 mg Capsules 0.2389 00015237 Aventyl nortriptyline 25 mg Capsules 0.4804 02241888 Arava leflunomide 10 mg s 12.1745 02241889 Arava leflunomide 20 mg s 12.1745 00778338 Axid nizatidine 150 mg Capsules 0.9358 02146908 Biaxin clarithromycin 125 mg/5 ml Suspension 0.3280 02244641 Biaxin clarithromycin 250 mg/5 ml Suspension 0.6347 00028096 Celestone Soluspan bethamethasone 6 mg/ml Suspension 12.4568 02239607 Celexa citalopram 20 mg s 1.4649 02239608 Celexa citalopram 40 mg s 1.4649 02256193 Cesamet nabilone 0.5 mg Capsules 3.5152 00548375 Cesamet nabilone 1 mg Capsules 7.0301 10 of 18
01945270 Ciloxan ciprofloxacin 0.3% Ophthalmic Solution 2.2880 02091879 Clomid clomiphene 50 mg s 6.2087 02240113 Cosopt dorzolamide/timolol 2/0.5% Ophthalmic Solution 6.5846 01918311 Coumadin warfarin 1 mg s 0.3847 01918338 Coumadin warfarin 2 mg s 0.4069 01918346 Coumadin warfarin 2.5 mg s 0.3254 02240205 Coumadin warfarin 3 mg s 0.5044 02007959 Coumadin warfarin 4 mg s 0.5044 01918354 Coumadin warfarin 5 mg s 0.3260 01918362 Coumadin warfarin 10 mg s 0.5852 02182815 Cozaar losartan 25 mg s 1.4267 02182874 Cozaar losartan 50 mg s 1.4267 02182882 Cozaar losartan 100 mg s 1.4267 00836362 DDAVP desmopressin 10 mcg Nasal Spray 21.3928 02224550 Diabeta glyburide 2.5 mg s 0.1493 02224569 Diabeta glyburide 5 mg s 0.2670 00578428 Diprosalic betamethasone/ salicyclic acid 0.5 mg/20 mg/g Lotion 0.5423 00637726 Euflex flutamide 637726 s 1.6097 00596418 Epival divalproex 125 mg s 0.3404 00596426 Epival divalproex 250 mg s 0.6119 00596434 Epival divalproex 500 mg s 1.2241 02099233 Glucophage metformin 500 mg s 0.2735 02162849 Glucophage metformin 850 mg s 0.3951 00818658 Hytrin terazosin 1 mg s 0.8629 00818682 Hytrin terazosin 2 mg s 1.0966 00818666 Hytrin terazosin 5 mg s 1.4893 00818674 Hytrin terazosin 10 mg s 2.1802 02230047 Hyzaar 02297841 Hyzaar losartan/ hydrochlorothiazide losartan/ hydrochlorothiazide 50/12.5 mg s 1.4267 100/12.5 mg s 1.3967 02241007 Hyzaar DS losartan/ hydrochlorothiazide 100/25 mg s 1.4267 02216167 Imovane zopiclone 5 mg s 1.1545 01926799 Imovane zopiclone 7.5 mg s 1.4577 11 of 18
00004596 Imuran azathioprine 50 mg s 1.1000 01911473 Inhibace cilazapril 2.5 mg s 0.8180 01911481 Inhibace cilazapril 5 mg s 0.9503 01907123 Ispotin SR verapamil 120 mg s 1.5844 01934317 Ispotin SR verapamil 180 mg s 1.7891 00742554 Ispotin SR verapamil 240 mg s 2.3858 02142082 Lamictal lamotrigine 25 mg s 0.4266 02142112 Lamictal lamotrigine 150 mg s 2.5100 02142104 Lamictal lamotrigine 100 mg s 1.7032 02347997 Letrozole letrozole 2.5 mg s 2.0044 01919342 Luvox fluvoxamine 50 mg s 0.9820 01919369 Luvox fluvoxamine 100 mg s 1.7648 02379651 Mar-Rizatriptan rizatriptan 5 mg s 4.8933 02379678 Mar-Rizatriptan rizatriptan 10 mg s 4.8933 02042487 Marvelon 21 desogestrel/ethinyl estradiol 0.15/0.03 mg s 0.8751 02042479 Marvelon 28 desogestrel/ethinyl estradiol 0.15/0.03 mg s 0.6563 02240521 Maxalt rizatriptan 10 mg s 17.1435 02240518 Maxalt RPD rizatriptan 5 mg s 17.1435 02240519 Maxalt RPD rizatriptan 10 mg s 17.1435 01907107 Monopril fosinopril 10 mg s 1.0525 01907115 Monopril fosinopril 20 mg s 1.2665 02015439 MS Contin morphine sulfate 15 mg s 0.7590 02014297 MS Contin morphine sulfate 30 mg s 1.1484 02014300 MS Contin morphine sulfate 60 mg s 2.0240 02014319 MS Contin morphine sulfate 100 mg s 3.0855 02014327 MS Contin morphine sulfate 200 mg s 5.7376 02286335 Mylan-Alendronate alendronate 70 mg s 3.5201 02303647 Mylan-Atenolol atenolol 25 mg s 0.0946 02146894 Mylan-Atenolol atenolol 50 mg s 0.1911 02147432 Mylan-Atenolol atenolol 100 mg s 0.3141 02278359 Mylan-Azithromycin azithromycin 250 mg s 2.5346 02302403 Mylan-Bicalutamide bicalutamide 50 mg s 3.8870 02384418 Mylan-Bisoprolol bisoprolol 5 mg s **0.0994 02384426 Mylan-Bisoprolol bisoprolol 10 mg s **0.1450 02379120 Mylan-Candesartan candesartan 4 mg s 0.2308 02379139 Mylan-Candesartan candesartan 8 mg s **0.2932 02379147 Mylan-Candesartan candesartan 16 mg s **0.2932 02379155 Mylan-Candesartan candesartan 32 mg s **0.2995 02245647 Mylan-Ciprofloxacin ciprofloxacin 250 mg s 0.8400 02245648 Mylan-Ciprofloxacin ciprofloxacin 500 mg s 0.9477 02245649 Mylan-Ciprofloxacin ciprofloxacin 750 mg s 1.7354 02351536 Mylan-Clopidogrel clopidogrel 75 mg s **0.6576 02300044 Mylan-Enalapril enalapril 5 mg s 0.6318 12 of 18
02390337 Mylan-Entacapone entacapone 200 mg s **0.4062 02356058 Mylan-Finasteride finasteride 5 mg s **0.4633 02237813 Mylan-Fluoxetine finasteride 10 mg s 0.8650 02237814 Mylan-Fluoxetine finasteride 20 mg s 0.6116 02347296 Mylan-Irbesartan irbesartan 75 mg s **0.3073 02347318 Mylan-Irbesartan irbesartan 150 mg s **0.3073 02347326 Mylan-Irbesartan irbesartan 300 mg s **0.3073 02248259 Mylan-Gabapentin gabapentin 100 mg Capsules 0.2140 02248260 Mylan-Gabapentin gabapentin 300 mg Capsules 0.5208 02248261 Mylan-Gabapentin gabapentin 400 mg Capsules 0.6206 02353830 Mylan-Lansoprazole lansoprazole 15 mg s 0.7000 02353849 Mylan-Lansoprazole lansoprazole 30 mg s 0.7000 02372169 MYL-Letrozole letrozole 2.5 mg s 2.0042 02368277 Mylan-Losartan losartan 25 mg s **0.3148 02368285 Mylan-Losartan losartan 50 mg s **0.3148 02368293 Mylan-Losartan losartan 100 mg s **0.3148 02378078 Mylan-Losartan HCTZ losartan/hctz 50/12.5 mg s **0.3148 02378086 Mylan-Losartan HCTZ losartan/hctz 100/12.5 mg s **0.3082 02378094 Mylan-Losartan HCTZ losartan/hctz 100/25 mg s **0.3148 02371154 Mylan-Mycophenolate mycophenolate 250 mg s 0.6856 02370549 Mylan-Mycophenolate mycophenolate 500 mg s 1.3712 02337878 Mylan-Olanzapine olanzapine 2.5 mg s **0.4493 02337886 Mylan-Olanzapine olanzapine 5 mg s **0.8986 02337894 Mylan-Olanzapine olanzapine 7.5 mg s **1.3479 02337908 Mylan-Olanzapine olanzapine 10 mg s **1.7972 02337916 Mylan-Olanzapine olanzapine 15 mg s **2.6958 02382709 Mylan-Olanzapine ODT olanzapine 5 mg s **0.8937 02382717 Mylan-Olanzapine ODT olanzapine 10 mg s **1.7857 02382725 Mylan-Olanzapine ODT olanzapine 15 mg s **2.6777 02297876 Mylan-Ondansetron ondansetron 8 mg s 8.1776 02298279 Mylan-Pioglitazone pioglitazone 15 mg s 0.8133 02298287 Mylan-Pioglitazone pioglitazone 30 mg s 1.1394 02298295 Mylan-Pioglitazone pioglitazone 45 mg s 1.7132 02257092 Mylan-Pravastatin pravastatin 10 mg s 0.5670 02257106 Mylan-Pravastatin pravastatin 20 mg s 0.6689 02257114 Mylan-Pravastatin pravastatin 40 mg s 0.8057 02282240 Mylan-Risperidone risperidone 0.25 mg s 0.1425 02282259 Mylan-Risperidone risperidone 0.5 mg s 0.2395 02282267 Mylan-Risperidone risperidone 1 mg s 0.3310 02282275 Mylan-Risperidone risperidone 2 mg s 0.6607 02282283 Mylan-Risperidone risperidone 3 mg s 0.9910 02282291 Mylan-Risperidone risperidone 4 mg s 1.3215 02242519 Mylan-Sertraline sertraline 25 mg s 0.4245 13 of 18
02242520 Mylan-Sertraline sertraline 50 mg s 0.8490 02242521 Mylan-Sertraline sertraline 100 mg s 0.8895 02246582 Mylan-Simvastatin simvastatin 5 mg s **0.3305 02246583 Mylan-Simvastatin simvastatin 10 mg s **0.6631 02246737 Mylan-Simvastatin simvastatin 20 mg s **0.8218 02246584 Mylan-Simvastatin simvastatin 40 mg s **0.8218 02246585 Mylan-Simvastatin simvastatin 80 mg s **0.8218 02376717 Mylan-Telmisartan telmisartan 40 mg s **0.2824 02376725 Mylan-Telmisartan telmisartan 80 mg s **0.2824 02373564 Mylan-Telmisartan HCTZ telmisartan/hctz 80/12.5 mg s **0.2824 02373572 Mylan-Telmisartan HCTZ telmisartan/hctz 80/25 mg s **0.2824 02242503 Mylan-Terbinafine terbinafine 250 mg s 2.1240 02263351 Mylan-Topiramate topiramate 25 mg s 0.6444 02263378 Mylan-Topiramate topiramate 100 mg s 1.2215 02263386 Mylan-Topiramate topiramate 200 mg s 1.8239 02351579 Mylan-Valacyclovir valacyclovir 500 mg s **0.8481 02383535 Mylan-Valsartan valsartan 80 mg s **0.2999 02383543 Mylan-Valsartan valsartan 160 mg s **0.2998 02383551 Mylan-Valsartan valsartan 320 mg s **0.2914 02373734 Mylan-Valsartan HCTZ valsartan/hctz 80/12.5 mg s **0.2985 02373742 Mylan-Valsartan HCTZ valsartan/hctz 160/12.5 mg s **0.2993 02373750 Mylan-Valsartan HCTZ valsartan/hctz 160/25 mg s **0.3003 02373769 Mylan-Valsartan HCTZ valsartan/hctz 320/12.5 mg s **0.2985 02373777 Mylan-Valsartan HCTZ valsartan/hctz 320/25 mg s **0.2985 02238596 Mylan-Zopiclone zopiclone 7.5 mg s 0.4685 02162415 Naprosyn E naproxen 375 mg s 0.6120 02231441 Nitrolingual nitroglycerin 0.4 mg/dose Spray 0.0815 02364883 Novo-Mycophenolate mycophenolate 250 mg s 0.6856 02348675 Novo-Mycophenolate mycophenolate 500 mg s 1.3712 02230619 Pediapred prednisolone 5 mg/5 ml Oral Liquid 0.1417 01916475 Percocet oxycodone/acetaminophen 5/325 mg s 0.9036 02017709 Plaquenil hydroxychloroquine 200 mg s 0.6871 02238682 Plavix clopidogrel 75 mg s 2.9578 01990403 pms-amantadine amatadine 100 mg Capsules **0.5868 02229777 pms-benzydamine benzydamine 0.0015 Oral Rinse 0.0299 01964968 pms-dexamethasone dexamethasone 0.75 mg s 0.5099 01916386 pms-hydromorphone hydromorphone 1 mg/ml Syrup **0.0753 00741817 pms-hydroxyzine hydroxyzine 10 mg/5 ml Syrup **0.0449 02239627 pms-ipratropium ipratropium 0.0003 Nasal Spray 0.6624 02245532 pms-prednisolone prednisolone 5 mg/5 ml Liquid **0.0977 02229628 pms-valproic valproic acid 500 mg Capsules 0.5888 14 of 18
02295946 Portia 21 levonorgestrol/ ethinyl estradiol 0.15 mg/0.03 mg s **0.5075 02295954 Portia 21 levonorgestrol/ ethinyl estradiol 0.15 mg/0.03 mg s **0.3806 00839388 Prinivil lisinopril 5 mg s 0.7002 00839396 Prinivil lisinopril 10 mg s 0.8412 00839418 Prinivil lisinopril 20 mg s 1.0114 00884413 Prinzide lisinopril/ hydrochlorothiazide 20/12.5 mg s 1.0416 02010909 Proscar finasteride 5 mg s 2.1417 02275279 ratio-alendronate alendronate 70 mg s 3.5200 02171791 ratio-atenolol atenolol 50 mg s **0.1910 02171805 ratio-atenolol atenolol 100 mg s **0.3140 02277700 ratio-bicalutamide biclautamide 50 mg s 3.8870 02246825 ratio-ciprofloxacin ciprofloxacin 250 mg s 0.8400 02246826 ratio-ciprofloxacin ciprofloxacin 500 mg s 0.9477 02246827 ratio-ciprofloxacin ciprofloxacin 750 mg s 1.7354 02311925 ratio-fentanyl fentanyl 12 mcg Patch 2.2300 02282941 ratio-fentanyl fentanyl 25 mcg Patch **3.6580 02282968 ratio-fentanyl fentanyl 50 mcg Patch 6.8840 02282976 ratio-fentanyl fentanyl 75 mcg Patch 9.6820 02282984 ratio-fentanyl fentanyl 100 mcg Patch 12.0520 02241374 ratio-fluoxetine fluoxetine 20 mg Capsules 0.6116 02243910 Remeron mirtazapine 30 mg s 1.5791 02248542 Remeron RD mirtazapine 15 mg s 0.4598 02248543 Remeron RD mirtazapine 30 mg s 0.9193 02248544 Remeron RD mirtazapine 45 mg s 1.3791 02091887 Rifadin rifampin 150 mg Capsules 0.9235 02092808 Rifadin rifampin 300 mg Capsules 1.4533 02243878 Serc betahistine 16 mg s 0.5151 02247998 Serc betahistine 16 mg s 0.7724 00355658 Simemet levodopa/carbidopa 100/10 mg s 0.5513 00513997 Simemet levodopa/carbidopa 100/25 mg s 0.8231 00328219 Simemet levodopa/carbidopa 250/25 mg s 0.9189 00870935 Simemet CR levodopa/carbidopa 200/50 mg s 1.5653 02247997 Singulair montelukast 4 mg Granules 1.6852 02243602 Singulair montelukast 4 mg s 1.6852 02238216 Singulair montelukast 5 mg s 1.8664 02238217 Singulair montelukast 10 mg s 2.7312 02241094 Temodal temozolomide 20 mg Capsules 34.3200 02241095 Temodal temozolomide 100 mg Capsules 171.6066 02312794 Temodal temozolomide 140 mg Capsules 240.2510 02241096 Temodal temozolomide 250 mg Capsules 429.0044 15 of 18
02261715 Teva-Alendronate alendronate 70 mg s 3.5200 01912062 Teva-Atenolol atenolol 50 mg s 0.1910 01912054 Teva-Atenolol atenolol 100 mg s 0.3140 02270226 Teva-Bicalutamide bicalutamide 50 mg s 3.8870 02366312 Teva-Candesartan candesartan 8 mg s 0.3870 02366320 Teva-Candesartan candesartan 16 mg s 0.3870 02366339 Teva-Candesartan candesartan 32 mg s 0.3870 02161737 Teva-Ciprofloxacin ciprofloxacin 250 mg s 0.8400 02151745 Teva-Ciprofloxacin ciprofloxacin 500 mg s 0.9477 02161753 Teva-Ciprofloxacin ciprofloxacin 750 mg s 1.7354 02375559 Teva-Entacapone entacapone 200 mg s 0.5114 02314630 Teva-Fentanyl fentanyl 25 mcg Patch 3.6580 02314649 Teva-Fentanyl fentanyl 50 mcg Patch 6.8840 02314657 Teva-Fentanyl fentanyl 75 mcg Patch 9.6820 02314665 Teva-Fentanyl fentanyl 100 mcg Patch 12.0520 02348500 Teva-Finasteride finasteride 5 mg s 0.5677 02216590 Teva-Fluoxetine fluoxetine 20 mg Capsules 0.6116 02280515 Teva-Lansoprazole lansoprazole 15 mg s 0.7000 02280523 Teva-Lansoprazole lansoprazole 30 mg s 0.7000 02352893 Teva-Nevirapine nevirapine 200 mg s 1.7085 02321343 Teva-Olanzapine OD olanzapine 5 mg s 1.2410 02321351 Teva-Olanzapine OD olanzapine 10 mg s 2.4900 02321378 Teva-Olanzapine OD olanzapine 15 mg s 3.7390 02312298 Teva-Raloxifene raloxifene 60 mg s **0.6417 02282690 Teva-Risperidone risperidone 0.25 mg s 0.1425 02264188 Teva-Risperidone risperidone 0.5 mg s 0.2395 02264196 Teva-Risperidone risperidone 1 mg s 0.3310 02264218 Teva-Risperidone risperidone 2 mg s 0.6607 02264226 Teva-Risperidone risperidone 3 mg s 0.9910 02264234 Teva-Risperidone risperidone 4 mg s 1.3215 02250144 Teva-Simvastatin simvastatin 5 mg s 0.3307 02250144 Teva-Simvastatin simvastatin 10 mg s 0.6630 02250160 Teva-Simvastatin simvastatin 20 mg s **0.8217 02250179 Teva-Simvastatin simvastatin 40 mg s **0.8217 02250187 Teva-Simvastatin simvastatin 80 mg s **0.8217 02356643 Teva-Valsartan valsartan 40 mg s 0.3977 02356651 Teva-Valsartan valsartan 80 mg s 0.4040 02356678 Teva-Valsartan valsartan 160 mg s 0.4040 02356686 Teva-Valsartan valsartan 320 mg s 0.3080 02342545 Teva-Zolmitriptan OD zolmitriptan 2.5 mg s 4.6067 00451207 Timoptic timolol 0.5% Ophthalmic Solution 4.4187 16 of 18
02171880 Timoptic XE timolol 0.25% Ophthalmic Solution 00513962 Tobrex tobramycin 0.3% Ophthalmic Solution 02216205 Trusopt dorzolamide 2% Ophthalmic Solution 4.7167 1.9492 4.3296 02163934 Tylenol No.2 acetaminophen/codeine/ caffeine 300/15/15 mg s 0.0976 02163926 Tylenol No.3 acetaminophen/codeine/ caffeine 300/30/15 mg s 0.1075 02163918 Tylenol No.4 acetaminophen/codeine 300/60 mg s 0.2272 00013285 Valium diazepam 5 mg 0.1746 02219492 Valtrex valacyclovir 500 mg 3.7880 00657298 Vaseretic enalapril/ hydrochlorothiazide 10/25 mg 1.3367 00851795 Vasotec enalapril 2.5 mg 0.9308 00708879 Vasotec enalapril 5 mg 1.1010 00670901 Vasotec enalapril 10 mg 1.3229 00670928 Vasotec enalapril 20 mg 1.5963 02213419 Ventolin salbutamol 1 mg/ml Solution 1.1539 02213427 Ventolin salbutamol 2 mg/ml Solution 2.1917 02213486 Ventolin salbutamol 5 mg/ml Solution 1.1198 00884324 Zocor simvastatin 5 mg s 1.2474 00884332 Zocor simvastatin 10 mg s 2.4536 00884340 Zocor simvastatin 20 mg s 3.0324 00884359 Zocor simvastatin 40 mg s 3.0324 02240332 Zocor simvastatin 80 mg s 3.0324 02229639 Zofran ondansetron 4 mg/5 ml Solution 2.2824 02213567 Zofran ondansetron 4 mg 14.9589 02213575 Zofran ondansetron 8 mg 22.8258 00634506 Zovirax acyclovir 200 mg 1.4585 01911627 Zovirax acyclovir 400 mg 2.9387 ** The price change has resulted in a change to the lowest price in the category. Discontinued Products The following products will be deleted with the next Formulary amendments. 00265470 C.E.S conjugated estrogen 0.625 mg VAL 00713376 K-DUR potassium chloride 1500 mg MFX 02310422 Novo-Benzydamine benzydamine 1.5 mg/ml TEV 17 of 18
Manufacturer Updates The following product has had a name change: 01981501 00874167 Botox/Botox Cosmetic onabotulinumtoxina 100 U ALL The following product has had a name change: 02269309 02269317 02269325 02269333 Teva-Pramipexole (was Novo-Pramipexole) pramipexole 0.25 mg 0.5 mg 1 mg 1.5 mg TEV The following product has had a name change: 02324032 Xeomin incobotulinumtoxina 100 U MPG 18 of 18