Ontario Drug Benefit Formulary/Comparative Drug Index Edition 42 Summary of Changes - February 2015 Effective February 26, 2015 Ministry of Health and Long-Term Care
Table of Contents New Multi-Source Products... 3 New Off-Formulary Interchangeable (OFI) Products... 7 Drug Benefit Price (DBP) Changes... 9 OFI Product Price Changes... 11 Product Brand and Manufacturer Name Changes... 12 Discontinued Products... 13 Delisted Products... 14 2
New Multi-Source Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02408090 Mylan-Buprenorphine/Naloxone 2mg & 0.5mg SL Tab MYL 1.3350 02408104 Mylan-Buprenorphine/Naloxone 8mg & 2mg SL Tab MYL 2.3650 02424851 Teva-Buprenorphine/Naloxone 2mg & 0.5mg SL Tab TEV 1.3350 02424878 Teva-Buprenorphine/Naloxone 8mg & 2mg SL Tab TEV 2.3650 (Interchangeable with Suboxone) Reason For Use Code and Clinical Criteria Code 437 For the treatment of opioid dependence in patients who have failed, have significant intolerance, have a contraindication to, or who are at high risk for toxicity with methadone. NOTE: High risk for toxicity with methadone defined as: use of benzodiazepines, alcohol abuse or dependence, elderly, patients who are dependent on codeine or abuse opioids on a less than daily basis, on medications that interfere with methadone metabolism, at high risk for prolonged QT interval. NOTE: Physicians should complete an accredited course on opioid addiction and buprenorphine treatment before prescribing Suboxone. LU Authorization Period: 1 year. Code 438 For the treatment of opioid dependence when a methadone maintenance program is not available or accessible (i.e. No methadone maintenance programs available in the area, or waiting list is 3 months or longer). NOTE: Physicians should complete an accredited course on opioid addiction and buprenorphine treatment before prescribing Suboxone. LU Authorization Period: 1 year. 3
New Multi-Source Products (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02426757 Ach-Capecitabine 150mg Tab ACH 0.4575 02426765 Ach-Capecitabine 500mg Tab ACH 1.5250 (Interchangeable with Xeloda) Reason For Use Code and Clinical Criteria Code 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. Code 360 For the treatment of metastatic breast cancer where patients have progressed after prior chemotherapy. LU Authorization Period: Indefinite. Code 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. Code 409 As part of the CAPOX regimen for the first-line and second-line treatment of metastatic colorectal cancer LU Authorization Period: Indefinite. Continued on next page. 4
. Continued from previous page Code 426 In combination with trastuzumab and cisplatin for the treatment of patients with HER2- positive metastatic adenocarcinoma of the stomach or gastro-esophageal junction who have not received prior anti-cancer treatment for their metastatic disease. LU Authorization Period: Indefinite. Code 427 For the neo-adjuvant treatment of rectal cancer. LU Authorization Period: Indefinite. 5
New Multi-Source Products (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02422506 Mar-Lisinopril 5mg Tab MAR 0.1347 02422514 Mar-Lisinopril 10mg Tab MAR 0.1619 02422522 Mar-Lisinopril 20mg Tab MAR 0.1945 (Interchangeable with Zestril) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02422468 Mar-Losartan 25mg Tab MAR 0.3147 02422476 Mar-Losartan 50mg Tab MAR 0.3147 02422484 Mar-Losartan 100mg Tab MAR 0.3147 (Interchangeable with Cozaar) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02432099 Mar-Topiramate 25mg Tab MAR 0.3128 02432102 Mar-Topiramate 100mg Tab MAR 0.5929 02432110 Mar-Topiramate 200mg Tab MAR 0.8854 (Interchangeable with Topamax) 6
New Off-Formulary Interchangeable (OFI) Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02377691 Teva-Erlotinib 25mg Tab TEV 11.8666 02377705 Teva-Erlotinib 100mg Tab TEV 47.4666 02377713 Teva-Erlotinib 150mg Tab TEV 71.2000 (Interchangeable with Tarceva) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02428148 Auro-Finasteride 1mg 1mg Tab AUR 1.1455 (Interchangeable with Propecia) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02375532 Sandoz Memantine FCT 10mg Tab SDZ 1.6357 (Interchangeable with Ebixa) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02425548 Ran-Ramipril 15mg Cap RAN 0.8550 (Interchangeable with Altace) 7
New Off-Formulary Interchangeable (OFI) Products (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02403056 PMS-Zoledronic Acid 4mg/5mL Inj Sol-5mL Pk (Preservative-Free) (Interchangeable with Zometa Concentrate) PMS 415.5600 DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02436159 Apo-Zolpidem ODT 5mg SL Tab APX 1.1825 02434946 Apo-Zolpidem ODT 10mg SL Tab APX 1.1884 (Interchangeable with Sublinox) 8
Drug Benefit Price (DBP) Changes DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 02413345 Apo-Clarithromycin XL 500mg ER Tab APX 1.2572 02224135 Arimidex 1mg Tab AZC 5.1863 02244021 Atacand Plus 16mg & 12.5mg Tab AZC 1.2187 02332922 Atacand Plus 32mg & 12.5mg Tab AZC 1.2187 02332957 Atacand Plus 32mg & 25mg Tab AZC 1.2187 00786616 Bricanyl Turbuhaler 0.5mg/dose Inh-100 Dose Pk AZC 7.7300 02368544 Brilinta 90mg Tab AZC 1.4992 02184478 Casodex 50mg Tab AZC 6.9733 02244126 Dovobet 50mcg/g & 0.5mg/g Oint LEO 1.5287 02319012 Dovobet Gel 50mcg/g & 0.5mg/g Top Gel LEO 1.5390 01976133 Dovonex 50mcg/g Oint LEO 0.8110 02150956 Dovonex 50mcg/g Cr LEO 0.8242 00586668 Fucidin 2% Cr LEO 0.7230 00586676 Fucidin 2% Oint LEO 0.7230 02167840 Innohep 10000IU/mL Inj-2mL Pk LEO 38.9530 02229515 Innohep 20000IU/mL Inj-2mL Pk LEO 79.1300 02231478 Innohep 10000IU/0.5mL Inj Pref Syr LEO 20.0430 09857367 Innohep 2500IU/0.25mL Inj Pref Syr LEO 4.9140 02358158 Innohep 3500IU/0.35mL Inj Pref Syr LEO 6.8720 02358166 Innohep 4500IU/0.45mL Inj Pref Syr LEO 8.8380 02358174 Innohep 14000IU/0.7mL Inj Pref Syr LEO 28.0860 02358182 Innohep 18000IU/0.9mL Inj Pref Syr LEO 36.1070 02190915 Losec 20mg DR Tab AZC 2.3370 09857195 Losec 20mg DR Tab AZC 2.3370 02048485 Nolvadex D 20mg Tab AZC 0.3867 00474517 One-Alpha 0.25mcg Cap LEO 0.4890 00474525 One-Alpha 1mcg Cap LEO 1.4637 02375842 Onglyza 2.5 mg Tab AZC 2.3997 02333554 Onglyza 5 mg Tab AZC 2.8753 02057778 Plendil 2.5mg ER Tab AZC 0.5297 01978918 Pulmicort Nebuamp 0.25mg/mL Inh Susp AZC 0.4405 01978926 Pulmicort Nebuamp 0.5mg/mL Inh Susp AZC 0.8795 02229099 Pulmicort Nebuamp 0.125mg/mL Inh Susp AZC 0.2203 02231923 Rhinocort Aqua 64mcg/metered dose Nas Sp-120 Dose Pk AZC 11.0400 02035324 Rhinocort Turbuhaler 100mcg/metered dose Nas Aero 200 Dose AZC 24.4600 02300184 Seroquel XR 50mg ER Tab AZC 1.0003 02321513 Seroquel XR 150mg ER Tab AZC 1.9702 02300192 Seroquel XR 200mg ER Tab AZC 2.6642 02300206 Seroquel XR 300mg ER Tab AZC 3.9102 02300214 Seroquel XR 400mg ER Tab AZC 5.3080 02403390* Stivarga 40mg Tab BAH 72.6200 02245385 Symbicort 100 Turbuhaler 100mcg/6mcg Pd Inh-120 Dose Pk AZC 64.5600 02245386 Symbicort 200 Turbuhaler 200mcg/6mcg Pd Inh-120 Dose Pk AZC 83.8800 * Exceptional Access Program product 9
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR DBP 00001686 Xylocaine Viscous 2% O/L AZC 0.1000 02049325 Zoladex 3.6mg Depot Inj AZC 406.2600 02225905 Zoladex LA 10.8mg Depot Inj AZC 1157.9500 10
OFI Product Price Changes DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR UNIT COST 02352923 Apo-Enalapril Maleate/HCTZ 5mg & 12.5mg Tab APX 0.7493 02352931 Apo-Enalapril Maleate/HCTZ 10mg & 25mg Tab APX 1.0741 02246699 Apo-Naproxen EC 250mg Ent Tab APX 0.2087 02259893 Apo-Tizanidine 4mg Tab APX 0.6884 02319039 Cefepime for Injection 2g Inj Pd-Vial Pk APX 30.1963 02391600 Pioglitazone Hydrochloride Tablets 15mg Tab ACH 1.5716 02339587 Pioglitazone Hydrochloride Tablets 30mg Tab ACH 2.2017 02339595 Pioglitazone Hydrochloride Tablets 45mg Tab ACH 3.3105 02361698 Taro-Sumatriptan 6mg/0.5mL Inj Sol-Pref Syr 0.5mL Pk TAR 33.1750 11
Product Brand and Manufacturer Name Changes DIN CURRENT BRAND NAME CURRENT MFR NEW BRAND NAME NEW MFR STRENGTH DOSAGE FORM 02297795 Gliclazide MR AAP Apo-Gliclazide MR APX 30mg SR Tab 00777838 PegLyte PMS PegLyte Powder PEN Pd-4L Pk 12
Discontinued Products (Some products will remain on Formulary for six months to facilitate depletion of supply) DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR 02272059* Mylan-Tizanidine 4mg Tab MYL 02227452 Mylan-Cimetidine 400mg Tab MYL 02361744 Zenhale 50mcg & 5mcg Metered Dose Inh-120 Dose Pk MEK *Product listed as Not-a-Benefit 13
Delisted Products DIN/PIN BRAND NAME STRENGTH DOSAGE FORM MFR 02223511 Apo-Nortriptyline 10mg Cap APX 02223538 Apo-Nortriptyline 25mg Cap APX 02133253 Hypotears 1% Oph-Sol NOV 02229161 Crixivan 200mg Cap MFC 02229196 Crixivan 400mg Cap MFC 00512192 Garamycin 0.3% Oph Sol SCH 00512184* Garamycin 0.3% Ot Sol SCH 00599026* Lopid 300mg Cap PFI 00795860* Mevacor 20mg Tab MFC 00795852* Mevacor 40mg Tab MFC 00582417 Novo-Cimetine 300mg Tab NOP 00603678 Novo-Cimetine 400mg Tab NOP 00603686 Novo-Cimetine 600mg Tab NOP 01913441 Novo-Doxepin 75mg Cap NOP 01913468 Novo-Doxepin 100mg Cap NOP 01913476 Novo-Doxepin 150mg Cap NOP 02230104 PMS-Flutamide 250mg Tab PMS 00839388* Prinivil 5mg Tab MFC 00884324* Zocor 5mg Tab MFC 02240332* Zocor 80mg Tab MFC *Remain in Formulary as Not-a-Benefit to serve as reference product in interchangeable group. 14
ISSN 1916-2278 (PDF) February 2015 Queen s Printer for Ontario, 2015.