Ontario Drug Benefit Formulary/ Comparative Drug Index Edition 42 Summary of Changes January 2014 Effective January 30, 2014 Ministry of Health and Long-Term Care
Table of Contents Additions to Formulary... 3 New Multi-Source Products... 4 Off-Formulary Interchangeable (OFI) Products... 9 Changes to Current Formulary Products... 10 Drug Benefit Price (DBP) Changes... 11 OFI Product Price Changes... 20 Exceptional Access Program (EAP) Product Price Changes... 21 Status Change from Not-A-Benefit to General Benefit... 22 Status Change from Discontinued Drug to Not-A-Benefit... 23 DIN/PIN Change... 24 Product Manufacturer Name Change... 25 Removals from Formulary... 26 Manufacturer Requested Delisting... 27 Discontinued Drug (Removed From Payment & Listing)... 28 2
Additions to Formulary 3
New Multi-Source Products DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02415542 Apo-Azithromycin Z 250mg Tab APX 1.3070 (Interchangeable with Zithromax) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02274566 Gd-Azithromycin 100mg/5mL O/L-15mL Pk GEM 5.9347 02274574 Gd-Azithromycin 200mg/5mL O/L-15mL Pk GEM 8.4062 09857455 Gd-Azithromycin 200mg/5mL O/L-22.5mL Pk GEM 12.6093 (Interchangeable with Zithromax) 4
New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02407841 Med-Exemestane 25mg Tab GMP 1.3263 (Interchangeable with Aromasin) Reason for Use Code & Clinical Criteria Code 180 For the hormonal treatment of metastatic breast cancer in hormone receptor positive post-menopausal women who have disease progression following tamoxifen therapy. LU Authorization Period: Indefinite. Code 407 For the sequential treatment of postmenopausal women with estrogen receptor-positive early breast cancer who have received 2-3 years of initial adjuvant tamoxifen therapy. LU Authorization Period: Treatment period required to complete a total of 5 years of adjuvant therapy. Code 450 In combination with everolimus, for the treatment of hormone-receptor positive HER2 negative advanced breast cancer, in postmenopausal women with ECOG performance status less than or equal to 2 after recurrence or progression following a non-steroidal aromatase inhibitor (NSAI). LU Authorization Period: 1 year. 5
New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02401614 Med-Rivastigmine 1.5mg Cap GMP 0.6514 02401622 Med-Rivastigmine 3mg Cap GMP 0.6514 02401630 Med-Rivastigmine 4.5mg Cap GMP 0.6514 02401649 Med-Rivastigmine 6mg Cap GMP 0.6514 (Interchangeable with Exelon) Reason for Use Code & Clinical Criteria Code 347 Initial Trial: For patients with mild to moderate Alzheimer's Disease (Mini-Mental State Exam [MMSE] 10-26). Patients will be reimbursed for a period of up to 3 months after which continued treatment must be reassessed. Network note: Maximum duration 3 months. LU Authorization Period: 1 year. Code 348 Continuation: Further reimbursement will be made available to those patients whose disease has not progressed/deteriorated while on this drug. Patients must continue to have a MMSE score of 10-26. LU Authorization Period: 1 year. 6
New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02399164 Med-Rosuvastatin 5mg Tab GMP 0.3225 02399172 Med-Rosuvastatin 10mg Tab GMP 0.3400 02399180 Med-Rosuvastatin 20mg Tab GMP 0.4250 02399199 Med-Rosuvastatin 40mg Tab GMP 0.4975 (Interchangeable with Crestor) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02410249 Mirvala 21 0.15mg & 0.03mg Tab-21 Pk APX 7.7700 (Interchangeable with Marvelon 21) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02410257 Mirvala 28 0.15mg & 0.03mg Tab-28 Pk APX 7.7700 (Interchangeable with Marvelon 28) 7
New Multi-Source Products (Cont d...) DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02416824 Sandoz Tacrolimus 1mg Cap SDZ 1.8900 02416832 Sandoz Tacrolimus 5mg Cap SDZ 9.4650 (Interchangeable with Prograf) Reason For Use Code Clinical Criteria Code 173 For solid organ transplant and bone marrow transplant. LU Authorization Period: Indefinite. 8
Off-Formulary Interchangeable (OFI) Products DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST 02407825 Apo-Imiquimod 5% Top Cr 250mg-UD Pk APX 11.0300 (Interchangeable with Aldara) DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST 02402165 Mylan-Atovaquone/Proguanil 250mg & 100mg Tab MYL 4.1308 (Interchangeable with Malarone) 9
Changes to Current Formulary Products 10
Drug Benefit Price (DBP) Changes DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02237618 Adalat XL 20mg ER Tab BAY 1.2725 02248808 Adderall XR 5mg ER Cap SHI 2.1489 02248809 Adderall XR 10mg ER Cap SHI 2.4421 02248810 Adderall XR 15mg ER Cap SHI 2.7353 02248811 Adderall XR 20mg ER Cap SHI 3.0286 02248812 Adderall XR 25mg ER Cap SHI 3.3218 02248813 Adderall XR 30mg ER Cap SHI 3.6152 00180408 Aldactazide-25 25mg & 25mg Tab PFI 0.1358 00594377 Aldactazide-50 50mg & 50mg Tab PFI 0.2879 00028606 Aldactone 25mg Tab PFI 0.1358 00285455 Aldactone 100mg Tab PFI 0.3201 02232043 Aricept 5mg Tab PFI 5.0346 02232044 Aricept 10mg Tab PFI 5.0346 02239090 Atacand 4mg Tab AZC 0.7233 02239091 Atacand 8mg Tab AZC 1.2033 02239092 Atacand 16mg Tab AZC 1.2033 02311658 Atacand 32mg Tab AZC 1.2033 02244021 Atacand Plus 16mg & 12.5mg Tab AZC 1.2033 02332922 Atacand Plus 32mg & 12.5mg Tab AZC 1.2033 02332957 Atacand Plus 32mg & 25mg Tab AZC 1.2033 02041413 Ativan 0.5mg Tab PFI 0.0373 02041421 Ativan 1mg Tab PFI 0.0465 02041448 Ativan 2mg Tab PFI 0.0727 02242965 Avelox 400mg Tab BAY 6.0920 01984845 Bonefos 400mg Cap BAY 1.9582 02187086 Brevicon 0.035mg & 0.5mg Tab-21 Pk PFI 11.8000 02187094 Brevicon 0.035mg & 0.5mg Tab-28 Pk PFI 11.8000 02189054 Brevicon 1/35 0.035mg & 1mg Tab-21 Pk PFI 11.8000 02189062 Brevicon 1/35 0.035mg & 1mg Tab-28 Pk PFI 11.8000 11
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 01958100 Cardura-1 1mg Tab AZC 0.5900 01958097 Cardura-2 2mg Tab AZC 0.7077 01958119 Cardura-4 4mg Tab AZC 0.9202 02184478 Casodex 50mg Tab AZC 6.8700 02239941 Celebrex 100mg Cap PFI 0.7105 02239942 Celebrex 200mg Cap PFI 1.4211 02291177 Champix 0.5mg Tab PFI 1.7901 02291185 Champix 1.0mg Tab PFI 1.7900 02298309 Champix 0.5mg & 1.0mg Tabs (Starter Pack) PFI 44.7600 02391449 Cipralex MELTZ 10mg Orally VLH 1.6933 Disintegrating Tab 02391457 Cipralex MELTZ 20mg Orally Disintegrating Tab VLH 1.8027 02155958 Cipro 250mg Tab BAY 2.4989 02155966 Cipro 500mg Tab BAY 2.8194 02155974 Cipro 750mg Tab BAY 5.1630 02237514 Cipro 10g/100mL Oral Susp BAY 0.5756 02247916 Cipro XL 500mg ER Tab BAY 3.1120 02251787 Cipro XL 1000mg ER Tab BAY 3.1120 02132699 Colestid Orange Gran-7.5g Pk PFI 0.9463 00030910 Cortef 10mg Tab PFI 0.1558 00030929 Cortef 20mg Tab PFI 0.2811 02240113 Cosopt 2% & 0.5% Oph Sol MFC 6.3452 02258692 Cosopt 2% & 0.5% Oph Sol-0.2mL MFC 0.5023 Preservative free Pk 00263818 Cotazym 8000 & 30000 & Cap ORG 0.2018 30000 USP Unit 00821373 Cotazym ECS 20 20000 & 55000 & 55000 USP Unit Ent Microsph Cap ORG 0.9550 00502790 Cotazym ECS 8 8000 & 30000 & 30000 USP Unit Ent Microsph Cap ORG 0.3642 12
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02182815 Cozaar 25mg Tab MFC 1.3748 02182874 Cozaar 50mg Tab MFC 1.3748 02182882 Cozaar 100mg Tab MFC 1.3748 02247162 Crestor 10mg Tab AZC 1.4030 02247163 Crestor 20mg Tab AZC 1.7467 02247164 Crestor 40mg Tab AZC 2.0500 02265540 Crestor 5mg Tab AZC 1.3217 01968440 Cyclen 0.25mg & 0.035mg Tab-21 Pk JAN 21.9800 01992872 Cyclen 0.25mg & 0.035mg Tab-28 Pk JAN 21.9800 00030570 Dalacin C 150mg Cap PFI 0.9553 02182866 Dalacin C 300mg Cap PFI 1.9105 00225851 Dalacin C 15mg/mL Pd for Oral Susp PFI 0.1254 Flavoured Granules 00469327 Demulen 30 0.03mg & 2mg Tab-21 Pk PFI 12.8675 00471526 Demulen 30 0.03mg & 2mg Tab-28 Pk PFI 13.7692 00030759 Depo-Medrol 40mg/mL Inj Susp-1mL Pk PFI 5.2650 00030767 Depo-Medrol 80mg/mL Inj Susp-1mL Pk PFI 10.0980 01934325 Depo-Medrol 100mg/5mL Inj Susp-5mL Pk PFI 11.7900 00030783 Depo-Testosterone 100mg/mL Oily Inj Sol-10mL Pk PFI 28.5900 02239065 Detrol 2mg Tab PFI 0.9733 02244612 Detrol LA 2mg SR Cap PFI 1.9466 02244613 Detrol LA 4mg SR Cap PFI 1.9466 02024152 Diflucan P.O.S. 10mg/mL O/L PFI 1.0725 00022772 Dilantin 30mg Cap PFI 0.0560 00022780 Dilantin 100mg Cap PFI 0.0776 00023442 Dilantin 6mg/mL O/L PFI 0.0422 00023450 Dilantin 25mg/mL O/L PFI 0.0499 00023698 Dilantin 50mg Tab PFI 0.0768 13
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02370603 Edurant 25mg Tab JAN 14.4950 02063794 Emcyt 140mg Cap PFI 3.2476 02243239 Eprex 20,000IU/0.5mL Pref Syr-0.5mL Pk JAN 288.4500 02240722 Eprex 40,000IU/mL Pref Syr - 1mL Pk JAN 432.6700 02132621 Fragmin 2500IU/0.2mL Inj Pref Syr PFI 5.3460 02132648 Fragmin 5000IU/0.2mL Inj Pref Syr PFI 10.6910 02132664 Fragmin 10000IU/mL Inj Sol-1mL Pk PFI 16.8790 02231171 Fragmin 25000IU/mL Multidose 3.8mL Pk PFI 160.3500 02352648 Fragmin 7500IU/0.3mL Inj Pref Syr PFI 16.0340 02352656 Fragmin 10000IU/0.4mL Inj Pref Syr PFI 21.3820 02352664 Fragmin 12500IU/0.5mL Inj Pref Syr PFI 26.7260 02352672 Fragmin 15000IU/0.6mL Inj Pref Syr PFI 32.0700 02352680 Fragmin 18000IU/0.72mL Inj Pref Syr PFI 38.4840 02190885 Glucobay 50mg Tab BAY 0.2695 02190893 Glucobay 100mg Tab BAY 0.3732 02230047 Hyzaar 50mg & 12.5mg Tab MFC 1.3748 02297841 Hyzaar 100mg & 12.5mg Tab MFC 1.3459 02241007 Hyzaar DS 100mg & 25mg Tab MFC 1.3748 02306778 Intelence 100mg Tab JAN 5.8055 02375931 Intelence 200mg Tab JAN 11.3730 02354217 Invega Sustenna 50mg Inj Pref Syr JAN 317.9100 02354225 Invega Sustenna 75mg Inj Pref Syr JAN 476.8700 02354233 Invega Sustenna 100mg Inj Pref Syr JAN 476.8700 02354241 Invega Sustenna 150mg Inj Pref Syr JAN 635.8300 02170493 Leucovorin Calcium 5mg Tab WAY 6.2887 00036323 Lomotil 2.5mg & 0.025mg Tab PFI 0.4622 00514497 Loniten 2.5mg Tab PFI 0.3501 00514500 Loniten 10mg Tab PFI 0.7716 14
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02190915 Losec DR Tab 20mg AZC 2.3367 09857195 Losec DR Tab 20mg AZC 2.3367 02268450 Lyrica 150mg Cap PFI 2.3026 02268485 Lyrica 300mg Cap PFI 2.3026 02042487 Marvelon 21 0.15mg & 0.03mg Tab-21 Pk ORG 17.7074 02042479 Marvelon 28 0.15mg & 0.03mg Tab-28 Pk ORG 17.7074 00030988 Medrol 4mg Tab PFI 0.3523 02170698 Methotrexate 2.5mg Tab PFI 0.6452 02297558 Mezavant 1.2g Delayed & ER Tab SHI 1.6253 00037605 Micronor 0.35mg Tab-28 Pk JAN 21.9800 02042320 Min-Ovral 21 0.03mg & 0.15mg Tab-21 Pk PFI 14.6400 02042339 Min-Ovral 28 0.03mg & 0.15mg Tab-28 Pk PFI 14.6400 02243005 Mirena 52mg Insert BAY 336.2200 02063786 Mycobutin 150mg Cap PFI 4.2198 02084260 Neurontin 100mg Cap PFI 0.4332 02084279 Neurontin 300mg Cap PFI 1.0539 02084287 Neurontin 400mg Cap PFI 1.2559 02325926 Nimotop 30mg Tab BAH 10.0776 01911902 Nitro-Dur 0.4mg/Hr Transdermal Patch SCH 0.7056 01911929 Nitro-Dur 0.6mg/Hr Transdermal Patch SCH 0.7056 00037613 Nitrostat 0.3mg SL Tab PFI 0.1215 00037621 Nitrostat 0.6mg SL Tab PFI 0.1215 02318660 Olmetec 20mg Tab SCP 1.0840 02318679 Olmetec 40mg Tab SCP 1.0840 02319616 Olmetec Plus 20mg & 12.5mg Tab SCP 1.0840 02319624 Olmetec Plus 40mg & 12.5mg Tab SCP 1.0840 02319632 Olmetec Plus 40mg & 25mg Tab SCP 1.0840 15
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 00317047 Ortho 0.5/35 0.035mg & 0.5mg Tab-21 Pk JAN 21.9800 00340731 Ortho 0.5/35 0.035mg & 0.5mg Tab-28 Pk JAN 21.9800 00372838 Ortho 1/35 0.035mg & 1mg Tab-28 Pk JAN 21.9800 00372846 Ortho 1/35 0.035mg & 1mg Tab-21 Pk JAN 21.9800 00602957 Ortho 7/7/7 3 Phase Tab-21 Pk JAN 21.9800 00602965 Ortho 7/7/7 3 Phase Tab-28 Pk JAN 21.9800 02042533 Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk JAN 21.9800 00789445 Pancrease MT4 4000 & 12000 & 12000 USP Unit Ent Microsph Cap JAN 0.5700 02043408 Premarin 0.625mg Tab PFI 0.3162 02043440 Premarin 0.625mg/g Vag Cr PFI 0.6521 Vaginal Cream 00839396 Prinivil 10mg Tab MFC 0.7953 00839418 Prinivil 20mg Tab MFC 0.9562 00884413 Prinzide 20mg & 12.5mg Tab MFC 0.9848 02010909 Proscar 5mg Tab MFC 2.0638 00030937 Provera 5mg Tab PFI 0.3426 00708917 Provera 2.5mg Tab PFI 0.1730 00729973 Provera 10mg Tab PFI 0.6951 00851760 Pulmicort 400mcg/Metered Pd Inh-200 AZC 93.0000 Turbuhaler Dose Dose Pk 02243237 Rapamune 1mg/mL O/L WAY 7.8893 02247111 Rapamune 1mg Tab WAY 7.8893 02243910 Remeron 30mg Tab ORG 1.5073 02248542 Remeron RD 15mg Orally ORG 0.4389 02248543 Remeron RD 30mg Orally Disintegrating Tab Disintegrating Tab 02248544 Remeron RD 45mg Orally Disintegrating Tab ORG 0.8775 ORG 1.3164 16
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02231923 Rhinocort Aqua 64mcg/Metered Nas Sp-120 AZC 10.9000 Dose Dose Pk 02035324 Rhinocort 100mcg/Metered Nas Aero 200 AZC 24.1500 Turbuhaler Dose Dose 02025280 Risperdal 1mg Tab JAN 1.3315 02025299 Risperdal 2mg Tab JAN 2.6640 02025302 Risperdal 3mg Tab JAN 3.9890 02025310 Risperdal 4mg Tab JAN 5.3190 02240551 Risperdal 0.25mg Tab JAN 0.5755 02240552 Risperdal 0.5mg Tab JAN 0.9641 02255707 Risperdal Consta 25mg Pd for Inj-Vial Pk JAN 163.1700 02255723 Risperdal Consta 37.5mg Pd for Inj-Vial Pk JAN 244.7500 02255758 Risperdal Consta 50mg Pd for Inj-Vial Pk JAN 326.3400 02064472 Salazopyrin 500mg Ent Tab PFI 0.3873 02064480 Salazopyrin 500mg Tab PFI 0.2542 00328219 Sinemet 250mg & 25mg Tab MFC 0.8854 00355658 Sinemet 100mg & 10mg Tab MFC 0.5312 00513997 Sinemet 100mg & 25mg Tab MFC 0.7931 00870935 Sinemet CR 200mg & 50mg Tab MFC 1.5084 02028786 Sinemet CR 100mg & 25mg Tab MFC 0.8176 02245385 Symbicort 100 100mcg/6mcg Pd Inh-120 AZC 63.8000 Turbuhaler Dose Pk 02245386 Symbicort 200 200mcg/6mcg Pd Inh-120 AZC 82.9000 Turbuhaler Dose Pk 02187108 Synphasic 3 Phase Tab-21 Pk PFI 10.8400 02187116 Synphasic 3 Phase Tab-28 Pk PFI 10.8400 02049988 Tenoretic 100/25 100 & 25mg Tab AZC 1.1220 02049961 Tenoretic 50/25 50 & 25mg Tab AZC 0.6845 02039532 Tenormin 50mg Tab AZC 0.6150 02039540 Tenormin 100mg Tab AZC 1.0117 00894729 Terazol 7 0.40% Vag Cr JAN 0.6420 17
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 00451207 Timoptic 0.50% Oph Sol MFC 4.2179 02171880 Timoptic-XE 0.25% Oph Gellan Sol MFC 4.5023 02171899 Timoptic-XE 0.50% Oph Gellan Sol MFC 5.3871 02230893 Topamax 25mg Tab JNO 1.2978 02230894 Topamax 100mg Tab JNO 2.4595 02230896 Topamax 200mg Tab JNO 3.6730 02239907 Topamax Sprinkle 15mg Sprinkle Cap JNO 1.2025 02239908 Topamax Sprinkle 25mg Sprinkle Cap JNO 1.2620 02028700 Tri-Cyclen 3 Phase Tab-21 Pk JAN 21.9800 02029421 Tri-Cyclen 3 Phase Tab-28 Pk JAN 21.9800 02258560 Tri-Cyclen Lo 3 Phase Tab-21 Pk JAN 12.6300 02258587 Tri-Cyclen Lo 3 Phase Tab-28 Pk JAN 12.6300 00707600 Triquilar 21 3 Phase Tab-21 Pk BAY 15.0300 00707503 Triquilar 28 3 Phase Tab-28 Pk BAY 15.0300 02216205 Trusopt 2% Oph Sol MFC 4.0934 00670901 Vasotec 10mg Tab MFC 1.2627 00670928 Vasotec 20mg Tab MFC 1.5237 00708879 Vasotec 5mg Tab MFC 1.0509 00851795 Vasotec 2.5mg Tab MFC 0.8884 00556734 Vermox 100mg Tab JAN 4.7350 02256460 Vfend 50mg Tab PFI 12.9860 02256479 Vfend 200mg Tab PFI 51.9230 02322951 Vyvanse 30mg Cap SHI 3.1415 02322978 Vyvanse 50mg Cap SHI 4.1715 02347156 Vyvanse 20mg Cap SHI 2.6265 02347164 Vyvanse 40mg Cap SHI 3.6565 02347172 Vyvanse 60mg Cap SHI 4.6865 18
Drug Benefit Price (DBP) Changes (Cont d...) DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 00548359 Xanax 0.25mg Tab PFI 0.2583 00548367 Xanax 0.5mg Tab PFI 0.3088 02261723 Yasmin 21 3.0mg & 0.03mg Tab-21 Pk BAH 12.1400 02261731 Yasmin 28 3.0mg & 0.03mg Tab-28 Pk BAH 12.1400 02321157 Yaz 3.0mg & 0.02mg Tab-28 Pk BAH 15.7600 02298597 Zeldox 20mg Cap PFI 1.7665 02298600 Zeldox 40mg Cap PFI 2.0233 02298619 Zeldox 60mg Cap PFI 2.0233 02298627 Zeldox 80mg Cap PFI 2.0233 02045737 Zestoretic 20mg & 12.5mg Tab AZC 1.0725 02103729 Zestoretic 10mg & 12.5mg Tab AZC 0.8925 02049333 Zestril 5mg Tab AZC 0.5770 02049376 Zestril 10mg Tab AZC 0.6935 02049384 Zestril 20mg Tab AZC 0.8330 02212021 Zithromax 250mg Tab PFI 5.2280 02223716 Zithromax 100mg/5mL O/L-15mL Pk PFI 16.9605 02223724 Zithromax 200mg/5mL O/L-15mL Pk PFI 24.0195 09857315 Zithromax 200mg/5mL O/L-22.5mL Pk PFI 36.0293 00884324 Zocor 5mg Tab MFC 1.1907 00884332 Zocor 10mg Tab MFC 2.3420 00884340 Zocor 20mg Tab MFC 2.8945 00884359 Zocor 40mg Tab MFC 2.8945 02240332 Zocor 80mg Tab MFC 2.8945 02049325 Zoladex 3.6mg Depot Inj AZC 398.3000 02225905 Zoladex LA 10.8mg Depot Inj AZC 1,135.2500 02243684 Zyvoxam 600mg Tab PFI 77.2165 19
OFI Product Price Changes DIN BRAND NAME STRENGTH DOSAGE MFR UNIT COST 02408635 Mint-Montelukast 5mg Chew Tab MIN 1.2075 02408643 Mint-Montelukast 10mg Tab MIN 1.7735 02326477 Mint-Pioglitazone 15mg Tab MIN 1.5716 02326485 Mint-Pioglitazone 30mg Tab MIN 2.2017 02326493 Mint-Pioglitazone 45mg Tab MIN 3.3105 20
Exceptional Access Program (EAP) Product Price Changes DIN/PIN BRAND NAME STRENGTH DOSAGE MFR DBP 02287145 Fosrenol 250mg Chew Tab SHI 1.1181 02287153 Fosrenol 500mg Chew Tab SHI 2.2364 02287161 Fosrenol 750mg Chew Tab SHI 3.3654 02287188 Fosrenol 1000mg Chew Tab SHI 4.4619 02284227 Nexavar 200mg Tab BAY 46.4689 02244016 Remicade 100mg/10mL Inj. JAN 987.5600 09852956 Remicade 100mg/10mL Injection (Compounded) JAN 987.5600 02324776 Simponi 50mg/0.5mL Pre-Filled Syringe JAN 1520.2100 02324784 Simponi 50mg/0.5mL Auto-Injector JAN 1520.2100 02280795 Sutent 12.5mg Cap PFI 64.4157 02280809 Sutent 25mg Cap PFI 128.8303 02280817 Sutent 50mg Cap PFI 257.6610 02371065 Zytiga 250mg Tab JAN 29.1833 21
Status Change from Not-A-Benefit to General Benefit DIN BRAND NAME STRENGTH DOSAGE MFR DBP 02413809 Teva-Risedronate 150mg Tab TEV 11.1875 (Interchangeable with Actonel) 22
Status Change from Discontinued Drug to Not-A-Benefit DIN BRAND STRENGTH DOSAGE MFR 02039494 Apo-Diflunisal 500mg Tab APX (Interchangeable with Dolobid) 23
DIN/PIN Change CURRENT DIN/PIN NEW DIN/PIN BRAND NAME STRENGTH DOSAGE MFR 09857186 02391821 Aranesp 300mcg/0.6mL Pref Syr-0.6mL Pk AMG 24
Product Manufacturer Name Change DIN BRAND NAME STRENGTH DOSAGE Current MFR New MFR 00778338 Axid 150mg Cap MMT PEN 25
Removals from Formulary (Removals from payment and listing) 26
Manufacturer Requested Delisting DIN BRAND NAME STRENGTH DOSAGE MFR 00021458 Novo-Ferrogluc 300mg Tab NOP 27
Discontinued Drug (Removed From Payment & Listing) DIN BRAND NAME STRENGTH DOSAGE MFR 02185881 Kytril* 1mg Tab HLR * Remains in the Formulary as Not-A-Benefit (NAB) as the brand reference product to the generics in the interchangeable group. 28