UPDATE C Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective November 04, 2008 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 3 Exceptional Access Product(s) 5 Manufacturer Requested Discontinued Drug(s) 6 Drug Benefit Price(s) 7 Off Formulary Interchangeable Product(s) 9 Palliative Care Drug(s) 10 Status Change(s) from Limited Use to Off Formulary Interchangeable Product(s) 11 Consolidated Index for Update A, B and C 12 Page 1
New Single Source Drug(s) DIN PRODUCT GENERIC NAME MFR DBP 02263238 Cipralex 10mg Tab ESCITALOPRAM VLH 1.5965 02263254 Cipralex 20mg Tab ESCITALOPRAM VLH 1.6997 02297841 Hyzaar 100mg & 12.5mg Tab LOSARTAN & HYDROCHLOROTHIAZIDE MFC 1.1783 02283395 Somatuline Autogel 60mg/0.3mL ER Pref Syr-0.3mL Pk 02283409 Somatuline Autogel 90mg/0.3mL ER Pref Syr-0.3mL Pk 02283417 Somatuline Autogel 120mg/0.5mL ER Pref Syr-0.5mL Pk LANREOTIDE (LANREOTIDE ACETATE) LANREOTIDE (LANREOTIDE ACETATE) LANREOTIDE (LANREOTIDE ACETATE) IPS 1102.0000 IPS 1470.0000 IPS 1840.0000 Page 2
New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02315866 Apo-Alfuzosin (Interchangeable with Xatral) 10mg Prolong-Rel Tab APX 0.4967 Reason for Use Code Clinical Criteria 351 For the management of benign prostatic hyperplasia where six weeks of treatment with other formulary alpha blockers (e.g. doxazosin, terazosin) have been ineffective LU Authorization Period: Indefinite. 352 For the management of benign prostatic hyperplasia where other formulary alpha blockers have produced intolerable side effects. LU Authorization Period: Indefinite. 02250004 Fenomax (Interchangeable with Lipidil Supra) 160mg Tab ORY 0.6231 02310503 Ran-Ramipril Cap 1.25mg RAN 0.3250 02310511 Ran-Ramipril Cap 2.5mg RAN 0.3750 02310538 Ran-Ramipril Cap 5mg RAN 0.3750 02310546 Ran-Ramipril Cap (Interchangeable with Altace) 10mg RAN 0.4750 Page 3
DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02311704 Ratio-Quetiapine 25mg Tab RPH 0.2470 02311712 Ratio-Quetiapine 100mg Tab RPH 0.6590 02311747 Ratio-Quetiapine 200mg Tab RPH 1.3234 02311755 Ratio-Quetiapine (Interchangeable with Seroquel) 300mg Tab RPH 1.9313 02304678 Sandoz Alfuzosin (Interchangeable with Xatral) 10mg Prolong-Rel Tab SDZ 0.4966 Reason for Use Code Clinical Criteria 351 For the management of benign prostatic hyperplasia where six weeks of treatment with other formulary alpha blockers (e.g. doxazosin, terazosin) have been ineffective LU Authorization Period: Indefinite. 352 For the management of benign prostatic hyperplasia where other formulary alpha blockers have produced intolerable side effects. LU Authorization Period: Indefinite. 02315262 Sandoz Pramipexole 0.25mg Tab SDZ 0.4950 (Interchangeable with Mirapex PIN# 09857268) 02315289 Sandoz Pramipexole 1mg Tab SDZ 0.9900 (Interchangeable with Mirapex PIN# 09857269) 02315297 Sandoz Pramipexole 1.5mg Tab SDZ 0.9900 (Interchangeable with Mirapex PIN# 09857270) Note: Mirapex is indicated for both the symptomatic treatment of idiopathic Parkinson's Disease and moderate to severe idiopathic Restless Legs Syndrome under the manufacturer's Drug Indentification Number (DIN). Mirapex has also been assigned a Product Indentification Number (PIN) for the indication of Parkinson's Disease specifically. Apo-Pramipexole, Novo-Pramipexole, PMS-Pramipexole and Sandoz Pramipexole products are interchangeable with Mirapex for the treatment of Parkinson's Disease. Page 4
Exceptional Access Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02269198 Aclasta 5mg/100mL Inj Sol-100mL Pk NOV 645.0000 02293404 Posanol 40mg/mL O/L SCH 9.4100 Page 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 09853570 Nutrisure Pudding 113g Pk ABB Page 6
Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP 00155357 Adrenalin 30mg/30mL Inj Sol-30mL Pk ERF 16.2600 02297795 Apo-Gliclazide MR 30mg SR Tab APX 0.1405 02285169 Apo-Metoprolol SR 100mg LA Tab APX 0.1415 02285177 Apo-Metoprolol SR 200mg LA Tab APX 0.2568 01926683 Cerubidine Inj Pd-20mg Pk ERF 85.8500 00476366 Choledyl 20mg/mL O/L ERF 0.0351 01911465 Inhibace 1mg Tab HLR 0.6229 01911473 Inhibace 2.5mg Tab HLR 0.7179 01911481 Inhibace 5mg Tab HLR 0.8341 02181479 Inhibace Plus 5mg/12.5mg Tab HLR 0.8339 00518123 Lectopam 3mg Tab HLR 0.1499 00518131 Lectopam 6mg Tab HLR 0.2190 02013231 Lithane 150mg Cap ERF 0.1005 00406775 Lithane 300mg Cap ERF 0.1001 00899356 Manerix 150mg Tab HLR 0.6058 02166747 Manerix 300mg Tab HLR 1.1896 02162431 Naprosyn 25mg/mL O/L HLR 0.0614 00024430 Navane 2mg Cap ERF 0.3030 00024449 Navane 5mg Cap ERF 0.3354 00024457 Navane 10mg Cap ERF 0.4318 01926780 Neuleptil 5mg Cap ERF 0.1843 01926772 Neuleptil 10mg Cap ERF 0.2959 01926756 Neuleptil 10mg/mL O/L ERF 0.3636 02024217 Novolin ge 30/70 1000U/10mL Inj Susp-10mL Pk NOO 19.4300 09853812 Novolin ge 30/70 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 37.9400 02024314 Novolin ge 40/60 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 38.8600 02024322 Novolin ge 50/50 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 38.8600 02265435 NovoMix 30 Penfill 100U/mL Inj Susp-5x3mL Pk NOO 50.2600 02245397 NovoRapid 100U/mL Inj Sol-10mL Pk NOO 26.8500 02244353 NovoRapid Penfill 100U/mL Inj Sol-5x3mL Pk NOO 53.7500 09854215 Nutren Junior 1kcal/mL Liq-250mL Pk NES 1.6480 09854223 Nutren Junior Fibre 1kcal/mL Liq-250mL Pk NES 1.6480 01927744 Parsitan 50mg Tab ERF 0.2020 97984779 Peptamen Liq-250mL Pk NES 7.1200 09853588 Peptamen Junior Liq-250mL Pk NES 7.1200 09857101 Peptamen with Prebio 1kcal/mL Liq-250mL Pk NES 7.1200 09857102 Peptamen with Prebio 1kcal/mL Liq-1500mL Pk NES 42.6900 02302624 PMS-Diclofenac 50mg Ent Tab PMS 0.3125 00638692 Procan SR 250mg LA Tab ERF 0.3535 00638676 Procan SR 500mg LA Tab ERF 0.4545 00638684 Procan SR 750mg LA Tab ERF 0.7070 00522597 Prolopa 50-12.5 50mg & 12.5mg Cap HLR 0.2732 00386464 Prolopa 100-25 100mg & 25mg Cap HLR 0.4498 00386472 Prolopa 200-50 200mg & 50mg Cap HLR 0.7551 Page 7
DIN BRAND STRENGTH DOSAGE FORM MFR DBP 00382825 Rivotril 0.5mg Tab HLR 0.1981 00382841 Rivotril 2mg Tab HLR 0.3417 00481823 Rocaltrol 0.25mcg Cap HLR 0.9280 00481815 Rocaltrol 0.5mcg Cap HLR 1.4758 00657387 Rocephin 0.25g/Vial Inj Pd-1 Vial Pk HLR 11.2860 00657417 Rocephin 1g/Vial Inj Pd-1 Vial Pk HLR 35.7000 00024325 Sinequan 10mg Cap ERF 0.2518 00024333 Sinequan 25mg Cap ERF 0.3089 00024341 Sinequan 50mg Cap ERF 0.5730 00400750 Sinequan 75mg Cap ERF 0.8227 00326925 Sinequan 100mg Cap ERF 1.0840 00023949 Thyroid 30mg Tab ERF 0.0449 00023957 Thyroid 60mg Tab ERF 0.0528 00023965 Thyroid 125mg Tab ERF 0.0816 00022799 Zarontin 250mg Cap ERF 0.3131 00023485 Zarontin 50mg/mL O/L ERF 0.0626 Page 8
Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST 02036347 Novamoxin Chewable 125mg Tab NOP 0.4167 02036355 Novamoxin Chewable 250mg Tab NOP 0.6138 (Interchangeable with Amoxil Chewable) 02243551 Novo-Fenofibrate Micronized (Interchangeable with Lipidil Micro) 67mg Cap NOP 0.4325 02289083 Novo-Fenofibrate-S (Interchangeable with Lipidil Supra) 100mg Tab NOP 0.7875 02230201 Novo-Ketorolac (Interchangeable with Toradol) 10mg Tab NOP 0.4550 02230730 Novo-Ketotifen (Interchangeable with Zaditen) 1mg Tab NOP 0.6335 02108143 Novo-Minocycline 50mg Cap NOP 0.5350 02108151 Novo-Minocycline 100mg Cap NOP 1.0332 (Interchangeable with Minocin) 02243312 Novo-Naprox 250mg Ent Tab NOP 0.2835 02243313 Novo-Naprox 375mg Ent Tab NOP 0.3675 02243314 Novo-Naprox (Interchangeable with Naprosyn E) 500mg Ent Tab NOP 0.6894 02305038 Ran-Pantoprazole (Interchangeable with Pantoloc) 20mg Ent Tab RAN 1.3133 02301075 Sandoz Pantoprazole (Interchangeable with Pantoloc) 20mg Ent Tab SDZ 1.2750 Page 9
Palliative Care Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR 09857300 Aredia 3mg/mL Inj Sol-10mL Vial NOV 09857301 Aredia 9mg/mL Inj Sol-10mL Vial NOV 09857302 Pamidronate Disodium 3mg/mL Inj Sol-10mL Vial SDZ 09857304 Pamidronate Disodium 6mg/mL Inj Sol-10mL Vial SDZ 09857305 Pamidronate Disodium 9mg/mL Inj Sol-10mL Vial SDZ 09857306 PMS-Pamidronate 3mg/mL Inj Sol-10mL Vial PMS 09857307 PMS-Pamidronate 9mg/mL Inj Sol-10mL Vial PMS Page 10
Status Change(s) from Limited Use to Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST 02301334 Apo-Brimonidine P (Interchangeable with Alphagan P) 0.15% Oph Sol APX 1.7325 Page 11