Ontario Drug Benefit Formulary/ Comparative Drug Index Edition 42 Summary of Changes – April 2014 Effective April 30, 2014
Ministry of Health and Long-Term Care
Table of Contents Additions to Formulary ............................................................................ 3 New Single Source Drugs ......................................................................... 4 New Multi-Source Products....................................................................... 5 Off-Formulary Interchangeable (OFI) Products ....................................... 15 New Product Identification Number (PIN) ............................................... 17 Changes to Current Formulary Products .............................................. 19 Drug Benefit Price (DBP) Changes ......................................................... 20 Exceptional Access Program (EAP) Product Price Changes .................. 30 OFI Product Price Changes .................................................................... 31 PIN/DIN Changes ................................................................................... 32 Product Brand and Manufacturer Name Changes................................... 33 Change to Therapeutic Note ................................................................... 34 Discontinued Products ............................................................................ 35 Status Change from Discontinued Drug to Not-A-Benefit........................ 36 Removals from Formulary...................................................................... 37 Discontinued Drugs (Removed From Payment & Listing) ....................... 38 Manufacturer Requested Delistings ........................................................ 39
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Additions to Formulary
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New Single Source Drugs DIN 02299844
PRODUCT Celsentri 150mg Tab
GENERIC NAME MARAVIROC
MFR VIH
DBP 16.5000
02299852
Celsentri 300mg Tab
MARAVIROC
VIH
16.5000
Therapeutic Note For use in combination with an optimized regimen for the treatment of HIV-1 infection in treatment experienced adult patients with: • CCR5 tropic virus only; AND who have one of the following: - Documented resistance to at least one drug in each of the major classes of antiretrovirals: protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and nucleoside reverse transcriptase inhibitors (NRTIs); OR - Documented class resistance to ONE of the major classes of anti-retrovirals: PIs, NNRTIs and NRTIs precluding treatment with that antiretroviral class; OR - Experienced serious class-effect intolerance to at least one major class of antiretrovirals: PIs, NNRTIs or NRTIs precluding treatment with that antiretroviral class. NOTE: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Celsentri is not considered for funding in treatment naïve adult patients.
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New Multi-Source Products DIN
BRAND NAME
STRENGTH
02419726
Apo-Exemestane
25mg
DOSAGE MFR FORM Tab APX
DBP 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.
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New Multi-Source Products (Cont’d...) DIN
BRAND NAME
STRENGTH 3.125mg
DOSAGE MFR FORM Tab AUR
02418495
Auro-Carvedilol
02418509
DBP 0.3377
Auro-Carvedilol
6.25mg
Tab
AUR
0.3377
02418517
Auro-Carvedilol
12.5mg
Tab
AUR
0.3377
02418525
Auro-Carvedilol
25mg
Tab
AUR
0.3377
(Interchangeable with Coreg)
Reason for Use Code & Clinical Criteria Code 183 For patients with: a) NYHA Class II or III Congestive Heart Failure (CHF); and b) Currently being treated with an angiotensin converting enzyme (ACE) inhibitor, diuretics with or without digoxin, or previously treated, and failed these agents; and c) An ejection fraction less than or equal to 35%; and d) At least one episode of symptomatic CHF within a 12 month period while receiving optimal management. LU Authorization Period: Indefinite.
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New Multi-Source Products (Cont’d...) DIN
BRAND NAME
STRENGTH
02416387
Auro-Clopidogrel
75mg
DOSAGE MFR FORM Tab AUR
DBP 0.6576
(Interchangeable with Plavix)
DIN
BRAND NAME
STRENGTH
02420198
Jamp-Omeprazole DR
20mg
DOSAGE MFR FORM DR Tab JPC
DBP 0.4117
(Interchangeable with Losec DR (DIN 02190915)) Reason for Use Code & Clinical Criteria Code 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy. Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or step-down therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year.
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Code 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year.
Code 401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings LU Authorization Period: 1 year.
Code 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a fourweek period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. LU Authorization Period: 1 year.
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PIN
BRAND NAME
STRENGTH
09857464
Jamp-Omeprazole DR
20mg
DOSAGE MFR FORM DR Tab JPC
DBP 0.4117
(Interchangeable with Losec DR (PIN 09857195)) Reason for Use Code & Clinical Criteria Code 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pylori-positive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 year.
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New Multi-Source Products (Cont’d...) DIN
BRAND NAME
STRENGTH
02417448
Mint-Pantoprazole
40mg
DOSAGE MFR FORM Ent Tab MIN
DBP 0.3628
(Interchangeable with Pantoloc) Reason For Use Code & Clinical Criteria Code 293 Gastroesophageal Reflux Disease (GERD) For the treatment of erosive GERD or upper GI malignancy; OR For the treatment of non-erosive GERD after failure of H2-receptor antagonist therapy. Patients with GERD should be reassessed within 6 months after initial treatment with a PPI. The reassessment could include confirmation of need for PPI with endoscopy, a trial of PPI withdrawal, or step-down therapy to H2-receptor antagonist therapy. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year. Code 295 H. pylori-positive Peptic Ulcers For the treatment of H. pylori-positive peptic ulcers where H. pylori is documented, by serology, urea breath test or endoscopy, for a one-week course in combination with antimicrobial therapy. Retreatment of H. pylori-positive peptic ulcers must be documented by persistent H. pylori infection on urea breath test or endoscopy. Maximum duration: 7 days (for retreatment, a four-week period must elapse since the end of the previous treatment). LU Authorization Period: 1 year.
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Reason For Use Code & Clinical Criteria Code 297 Confirmed Peptic Ulcers or NSAID-induced Ulcer Prophylaxis: For the treatment of confirmed peptic ulcers and NSAID-induced ulcers; OR For the prophylaxis of NSAID-induced ulcers for patients at increased risk of GI bleeding. Note: There is a lack of published evidence to support double-dose PPI therapy in this setting. LU Authorization Period: 1 year. Code 401 Other Gastrointestinal Disorders For the treatment of gastroduodenal Crohns disease, short-gut syndrome, scleroderma, or pancreatitis. Note: There is a lack of published evidence to support double-dose PPI therapy in these settings LU Authorization Period: 1 year. Code 402 Severe Conditions: For the treatment of severe esophagitis, Zollinger-Ellison syndrome, esophageal stricture, persistent symptoms of GERD or persistent erosive esophagitis, or upon hospital discharge following a gastrointestinal bleed. For patients receiving double-dose therapy, the need to continue treatment at higher doses should be reassessed after eight weeks. For re-treatment at higher doses, a fourweek period should have elapsed from the end of the previous treatment. Reassessment could include a procedural assessment of the condition or step-down therapy to lower-dose proton pump inhibitor (PPI) therapy. LU Authorization Period: 1 year.
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New Multi-Source Products (Cont’d...) DIN
BRAND NAME
STRENGTH 18mg
DOSAGE MFR FORM SR Tab PMS
02413728
PMS-Methylphenidate ER
02413736
DBP 1.0197
PMS-Methylphenidate ER
27mg
SR Tab
PMS
1.1768
02413744
PMS-Methylphenidate ER
36mg
SR Tab
PMS
1.3339
02413752
PMS-Methylphenidate ER
54mg
SR Tab
PMS
1.6480
(Interchangeable with Concerta)
Therapeutic Note: Patients greater than or equal to 6 years of age diagnosed with ADHD according to DSM-IV criteria and where symptoms are not due to other medical conditions which affect concentration, and who require 12-hour continuous coverage due to academic and/or psychosocial needs, and who meet the following: 1) Patients who demonstrate significant and problematic disruptive behaviour or who have problems with inattention that interfere with learning; AND 2) Prescribed by or in consultation with a specialist in pediatric psychiatry, pediatrics or a general practitioner with expertise in ADHD; AND 3) Have been tried on methylphenidate immediate release (IR) or methylphenidate slow release (SR) or Dexedrine IR or Dexedrine SR (Spansules), and have experienced unsatisfactory results due to poor symptom control, side effects, administrative barriers, or societal barriers.
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Administrative barriers include: . inability of a school to dose the child at lunch; . the school lunch hour does not coincide with the dosing schedule; . poor compliance with noon or afternoon doses; . the patient is unable to swallow tablets. Societal barriers include: . the patient or patient's caregiver(s) has(have) a history of substance abuse or diversion of listed immediate-release alternatives; . the patient or patient's caregiver(s) is/are at risk of substance abuse or diversion of listed immediate-release alternatives.
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New Multi-Source Products (Cont’d...) DIN 02408082
BRAND NAME STRENGTH DOSAGE FORM Zoledronic Acid Injection 5mg/100mL Inj Sol-100mL Pk
MFR TEV
DBP 335.4000
(Interchangeable with Aclasta)
Reason For Use Code & Clinical Criteria Code 319 For the treatment of Paget’s disease. LU Authorization Period: Indefinite.
Code 436 For the treatment of osteoprosis in postmenopausal women who would otherwise be eligible for funding for oral bisphosphonates, but for whom bisphosphonates are contraindicated due to abnormalities of the esophagus (e.g., esopahgeal stricture or achalasia), AND have at leaset two of the following: . Age greater than 75 years old . A prior fragility fracture . A bone mineral density (BMD) T-Score less than or equal to -2.5 Note: Patients receiving Zoledronic Acid should not be receiving cocomitant biphosphonate therapy. The recommended dose of Zoledronic Acid is a single IV injection of 5mg, once yearly. LU Authorization Period: Indefinite.
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Off-Formulary Interchangeable (OFI) Products DIN
BRAND NAME
STRENGTH DOSAGE FORM
MFR
UNIT COST
02420333
Apo-Adefovir
10mg
APX
18.0353
Tab
(Interchangeable with Hepsera)
DIN
BRAND NAME
STRENGTH DOSAGE FORM
MFR
UNIT COST
02408414
Jamp-Pantoprazole
20mg
JPC
0.3246
Ent Tab
(Interchangeable with Pantoloc)
DIN
BRAND NAME
STRENGTH DOSAGE FORM
MFR
UNIT COST
02330210
PMS-Betahistine
16mg
Tab
PMS
0.3557
02330237
PMS-Betahistine
24mg
Tab
PMS
0.4983
(Interchangeable with Serc)
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Off-Formulary Interchangeable (OFI) Products (Cont’d...) DIN
BRAND NAME
STRENGTH DOSAGE FORM
MFR
UNIT COST
02295407
Teva-Omeprazole
10mg
TEV
0.8167
DR Tab
(Interchangeable with Losec DR Tab (DIN 02230737))
DIN
BRAND NAME
STRENGTH DOSAGE FORM
MFR
UNIT COST
02401606
Zoledronic Acid-Z
4mg/5mL
SDZ
415.5600
(Interchangeable with Zometa Concentrate)
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Inj Sol-5mL Vial Pk
New Product Identification Number (PIN) PIN PRODUCT 09857463* Eliquis 2.5mg Tab
GENERIC NAME APIXABAN
MFR BQU
DBP 1.6000
*For Reason For Use (RFU) Code 448 only. Existing Eliquis 2.5mg Tab DIN 02377233 will no longer apply to RFU Code 448.
Reason For Use Code and Clinical Criteria Code 448 INCLUSION CRITERIA: At risk patients with non-valvular atrial fibrillation, for the prevention of stroke and systemic embolism AND in whom: 1. Anticoagulation is inadequate following at least a 2-month trial on warfarin; OR 2. Anticoagulation using warfarin is contraindicated or not possible due to inability to regularly monitor the patient via International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home) EXCLUSION CRITERIA: 1. Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate less than 25mL per min); OR 2. Patients who are greater than or equal to 75 years of age and who do not have documented stable renal function; OR 3. Patients who have hemodynamically significant rheumatoid valvular heart disease (especially mitral stenosis); OR 4. Patients who have prosthetic heart valves.
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NOTES: At-risk patients with atrial fibrillation are defined as those with a CHADS2 score of greater than or equal to 1. Prescribers may consider an antiplatelet regimen or oral anticoagulation for patients with a CHADS2 score of 1. Inadequate anticoagulation is defined as INR testing results that are outside the desired INR range for at least 35% of the tests during the monitoring period (i.e., adequate anticoagulation is defined as INR test results that are within the desired INR range for at least 65% of the tests during the monitoring period). Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate maintained for at least 3 months. DOSING: the usual recommended dose is 5mg twice daily; a reduced dose of apixaban 2.5mg twice daily is recommended for patients with at least two (2) of the following: age greater than or equal to 80 years old, body weight less than or equal to 60kg, or serum creatinine greater than or equal to 133 micromole per litre. Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see apixaban product monograph). Patients starting apixaban should have ready access to appropriate medical services to manage a major bleeding event. There is currently no data to support that apixaban provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart valves. As a result, apixaban is not recommended for these patient populations. LU Authorization Period: Indefinite.
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Changes to Current Formulary Products
19
Drug Benefit Price (DBP) Changes DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02322374 02322382 02322404 02322412 02322455 02269198 02232570 00004715 02382059* 02382067* 00893560 02236876 02248151 02221829 02221837 02221845 02221853 02221861 02279460 02279479
Abilify Abilify Abilify Abilify Abilify Aclasta Airomir HFA Alkeran Allerject Allerject Alomide Alphagan Alphagan P Altace Cap Altace Cap Altace Cap Altace Cap Anandron Apidra Apidra
2mg 5mg 15mg 20mg 30mg 5mg/100mL
Tab Tab Tab Tab Tab Inj Sol-100mL Pk Inh-200 dose Pk Tab Pref Autoinjector Pref Autoinjector Oph Sol Oph Sol Oph Sol Cap Cap Cap Cap Tab Inj Sol-10mL Vial
BQU BQU BQU BQU BQU NOV GRA TRT SAC SAC ALC ALL ALL SAV SAV SAV SAV SAV SAV SAV
3.1267 3.5216 4.8784 5.5934 6.9284 690.9200 5.1500 1.6468 82.6200 82.6200 1.1170 3.4420 2.4260 0.7240 0.8310 0.8320 1.0553 2.2383 25.0500 49.5500
02294346
Apidra
100U/mL
SAV
50.1000
09857185 02391821 (09857186) 02392364** (09857187) 02300699 02331624 02238873 02248472 00637661 02060884
Aranesp Aranesp
200mcg/0.4mL 300mcg/0.6mL
Pref Syr-0.4mL Pk Pref Syr-0.6mL Pk
AMG AMG
593.0800 916.1600
Aranesp
500mcg/1.0mL
Pref Syr-1.0mL Pk
AMG
1,526.9400
Atripla Azarga Azopt BenzaClin Topical Gel Betagan Betnesol
600mg/300mg/200mg
Tab
1% & 0.5% 1% 1% & 5% 0.5% 5mg/100mL
Oph Susp-5mL Pk
BQU ALC ALC VAL ALL PAL
43.2478 22.4100 3.4120 0.9458 3.3560 10.1457
100mcg/Metered Dose
2mg 0.15mg/0.15mL 0.3mg/0.3mL 0.1% 0.2% 0.2% 1.25mg 2.5mg 5mg 10mg 50mg 100U/mL 100U/mL
*Allergen Program Product. **New DIN. See PIN/DIN Change section for details.
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Inj 5x3mL Cart ClickStar Pen Inj Sol-5x3mL SoloSTAR Pref Pen
Oph Susp Top Gel Oph Sol Enema-100mL Pk
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
01908448 01926691 00461733 00236683 02097249 02097257 02097265 02097273 00360430 00360422 00360414 02163675 09857358 02163683 09857359 02163659 02163667 02239607 02239608 02256193 00548375 02230302 02163748 02163780 02163799 09857298 02374129 02243763 02112736 00579335 01918311 01918338 01918346
Betoptic S Calcimar Carbolith Carbolith Cardizem CD Cardizem CD Cardizem CD Cardizem CD CeeNU CeeNU CeeNU Cefzil Cefzil Cefzil Cefzil Cefzil Cefzil Celexa Celexa Cesamet Cesamet Codeine Contin Codeine Contin Codeine Contin Codeine Contin Combigan Complera Comtan Cortenema Cortifoam Coumadin Coumadin Coumadin
0.3% 400IU/2mL 150mg 300mg 120mg 180mg 240mg 300mg 10mg 40mg 100mg 125mg/5mL 125mg/5mL 250mg/5mL 250mg/5mL 250mg 500mg 20mg 40mg 0.5mg 1mg 50mg 100mg 150mg 200mg 0.2% & 0.5%
Oph Susp Inj Sol-2mL Pk Cap Cap LA Cap LA Cap LA Cap LA Cap Cap Cap Cap
200mg & 25mg & 300mg
Tab Tab
ALC SAV VAL VAL VAL VAL VAL VAL BQU BQU BQU BQU BQU BQU BQU BQU BQU VLH VLH VAL VAL PFP PFP PFP PFP ALL GIL NOV BFI PAL BQU BQU BQU
2.3940 56.5700 0.1229 0.0955 1.6100 2.1373 2.8349 3.5437 7.0825 12.2101 20.1575 14.1000 18.8000 28.2200 37.6200 1.9265 3.7770 1.3717 1.3717 3.2914 6.5826 0.3280 0.6560 0.9840 1.3120 41.8900 42.5305 1.6491 7.1286 88.9200 0.3600 0.3810 0.3045
Oral Susp-75mL Pk Oral Susp-100mL Pk Oral Susp-75mL Pk Oral Susp-100mL Pk
Tab Tab Tab Tab Cap Cap CR Tab CR Tab CR Tab CR Tab Oph Sol-10mL Pk
200mg 100mg/60mL 10% 1mg 2mg 2.5mg
Enema-60mL Pk Rect Aero-15g Pk
Tab Tab Tab
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Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02240205 02007959 01918354 01918362 00016055 02018144 02018152 02018160 02301482 02301490 00029246 02138018 01924516 01924559 01924567 02224550 02224569 02238162 09853340 09853430 02278251 09857333 01947958 01947931 01947923 02349124 02247238 02213192 02213206 02213214 02213222 02242903 02274728 09857394
Coumadin Coumadin Coumadin Coumadin Cuprimine Cyclomen Cyclomen Cyclomen Cymbalta Cymbalta Delatestryl Demerol Dexedrine
3mg 4mg 5mg 10mg 250mg 50mg 100mg 200mg 30mg 60mg 1000mg/5mL Oily 50mg 5mg 10mg 15mg 2.5mg 5mg 5mg/mL 5mg/mL 5mg/mL 0.5% & 0.004% 0.5% & 0.004% 10mg 25mg 50mg 10mg 1% 0.05mg 0.1mg 0.15mg 0.2mg 25mg/Vial 50mg/mL 50mg/mL
Tab Tab Tab Tab Cap Cap Cap Cap DR Cap DR Cap Inj Sol-5mL Pk Tab Tab SR Cap SR Cap Tab Tab Rect Gel-2x 5mg Pk Rect Gel-2x10mg Pk Rect Gel-2x15mg Pk Oph Sol-2.5mL Pk Oph Sol-5mL Pk Tab Tab Tab Tab Cr Tab Tab Tab Tab Inj Pd-Vial Pk Inj Pref Syr Pref AutoInj
BQU BQU BQU BQU ATO SAV SAV SAV LIL LIL VAL SAV PAL PAL PAL SAV SAV VAL VAL VAL ALC ALC PAL PAL PAL LIL VAL TRT TRT TRT TRT IMU IMU IMU
0.4720 0.4720 0.3050 0.5480 3.4971 0.9264 1.3748 2.1969 1.9254 3.8575 50.6500 0.1538 0.6577 0.9433 1.1533 0.1367 0.2447 153.5800 153.5800 153.5800 32.6600 65.3200 0.2974 0.4818 0.6346 2.7133 2.2767 0.0295 0.0362 0.0402 0.0425 195.3125 390.7425 390.7425
Dexedrine Spansules Dexedrine Spansules
Diabeta Diabeta Diastat Diastat Diastat DuoTrav DuoTrav Duvoid Duvoid Duvoid Effient Elidel Eltroxin Eltroxin Eltroxin Eltroxin Enbrel Enbrel Enbrel SureClick
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Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02168898 00247960 00247979 02231384 01926861 01926853 01926829 01926845 00756784 02086026 02156008 02156016 02156032 02156040 02246226 00247855 00029149 02099233 02229704 09853715 02403412 02240294 09857353 02240297 02403439* (09857355) 00795879 09853855 09853804 00587737 09853766 00586714 01916580 00230316
Estring Etibi Etibi Femara Flagyl Flagyl Flagystatin Flagystatin Flarex Florinef Fluanxol Fluanxol Fluanxol Depot Fluanxol Depot Fludara FML Fungizone Glucophage Humalog Humalog Humalog Kwikpen Humalog Mix25 Humalog Mix25 Kwikpen Humalog Mix50 Humalog Mix50 Kwikpen
2mg 100mg 400mg 2.5mg 10% 500mg
500mg 100U/mL 100U/mL 100U/mL 25% & 75% 25% & 75% 50% & 50% 50% & 50%
Vag Ring Tab Tab Tab Vag Cr-App Cap Vag Sup Vag Cr-App Oph Susp Tab Tab Tab Inj Sol-1mL Amp Pk Inj Sol-1mL Amp Pk Tab Oph Susp Inj Pd-50mg Pk Tab Inj Sol-10mL Pk Inj Sol-5x1.5mL Pk Inj Sol-5x3mL Pk Inj Susp-5x3mL Pk Inj Susp-5x3mL Pk Inj Susp-5x3mL Pk Inj Susp-5x3mL Pk
PFI VAL VAL NOV SAV SAV SAV SAV ALC PAL VLH VLH VLH VLH GZM ALL BQU SAV LIL LIL LIL LIL LIL LIL LIL
67.2300 0.2000 0.6000 6.5700 0.2375 1.0742 3.1970 0.5813 1.8960 0.2632 0.2557 0.5523 7.4016 37.0079 40.0760 3.2120 79.6500 0.2508 27.6100 55.2700 55.2700 55.9200 55.9200 54.9900 54.9900
Humulin 30/70 Humulin 30/70 Humulin N Humulin NPH Humulin R Humulin Regular Hycodan Hycort
1000U/10mL 100U/mL 100U/mL 1000U/10mL 100U/mL 1000U/10mL 1mg/mL 100mg/60mL
Inj Susp-10mL Pk Inj Susp-5x3mL Pk Inj Susp-5x3mL Pk Inj Susp-10mL Pk Inj Sol-5x3mL Pk Inj Sol-10mL Pk O/L Enema-60mL Pk
LIL LIL LIL LIL LIL LIL BQU VAL
22.5400 44.2400 44.2400 22.5400 44.2400 22.5400 0.1251 5.5986
500mg & 100000U 500mg & 100000U/g
0.1% 0.1mg 0.5mg 3mg 20mg/mL 100mg/mL 10mg 0.1%
*New DIN. See PIN/DIN change section
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Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02125323 02359502 02125331 02359510 02125366 02243562 02125382 02125390 00004596 00035017 00000841 00000868 00000884 02026961 01999761 00990876 01999869 02294338 02251930 02245689 00282081 02224720 02224755 02061562 02061570 02250527 00004626 00455881 00636576 00074454 00297143 00353027
Hydromorph Contin Hydromorph Contin Hydromorph Contin Hydromorph Contin Hydromorph Contin Hydromorph Contin Hydromorph Contin Hydromorph Contin Imuran Isopto Atropine Isopto Carpine Isopto Carpine Isopto Carpine Kayexalate Kenalog-10 Kenalog-40 Kenalog-40 Lantus Solostar Lantus-(Cartridge) Lantus-(Vial) Lanvis Lasix Lasix Special Lescol Lescol Lescol XL Leukeran Lioresal Lioresal DS Locacorten-Vioform Loestrin 1.5/30 Loestrin 1.5/30
3mg 4.5mg 6mg 9mg 12mg 18mg 24mg 30mg 50mg 1% 1% 2% 4% 1mEq/g 50mg/5mL 40mg/mL 200mg/5mL 100U/mL 100U/mL 100U/mL 40mg 10mg/mL 500mg 20mg 40mg 80mg 2mg 10mg 20mg 0.02% & 1% 0.03mg & 1.5mg 0.03mg & 1.5mg
CR Cap CR Cap CR Cap CR Cap CR Cap CR Cap CR Cap CR Cap Tab Oph Sol Oph Sol Oph Sol Oph Sol Oral Pd-454g Pk Inj Susp-5mL Pk Inj Susp-1mL Pk Inj Susp-5mL Pk Inj Sol-5x3mL Pk Inj Sol-5x3mL Pk
PFP PFP PFP PFP PFP PFP PFP PFP TRT ALC ALC ALC ALC SAV BQU BQU BQU SAV SAV SAV GSK SAV SAV NOV NOV NOV TRT NOV NOV PAL PAL PAL
0.6890 0.8320 1.0330 1.3640 1.7900 2.5830 3.3060 3.9600 1.0136 0.6540 0.2227 0.2567 0.2913 84.0500 17.8000 8.2000 28.9500 92.2000 92.2000 61.0600 4.4360 0.2822 3.0875 0.9104 1.2793 1.5392 1.4348 0.7651 1.4892 1.5773 13.8900 13.8900
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Inj Sol-10mL Vial Pk
Tab O/L Tab Cap Cap ER Tab Tab Tab Tab Ot Sol Tab-21 Pk Tab-28 Pk
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
00397423 00397431 00658855 00534560 00885835 00885851 02324997 09857368 09857398 00899356 02166747 00042579 00042560 00869961 00869953 02297809 00315966 00343838 02163527 02163535 02014319 02015439 02014327 02014297 02014300 00004618 01927620 01927612 01927604 01968017 09853464 01926454 02231441 02156091
Lopresor Lopresor Lopresor SR Lopresor SR Lotensin Lotensin Lumigan RC Lumigan RC Lumigan RC Manerix Manerix Maxidex Maxidex Mestinon Mestinon Metrogel Minestrin 1/20 Minestrin 1/20 Minitran Minitran MS Contin MS Contin MS Contin MS Contin MS Contin Myleran Myochrysine Myochrysine Myochrysine Neupogen Neupogen Nitrol
50mg 100mg 100mg 200mg 5mg 20mg 0.01% 0.01% 0.01% 150mg 300mg 0.1% 0.1% 60mg 180mg 1% 0.02mg & 1mg 0.02mg & 1mg
Nitrolingual Pump Spray
0.4mg/Metered Dose
Noritate
1%
Tab Tab LA Tab LA Tab Tab Tab Oph Sol-3mL Pk Oph Sol-5mL Pk Oph Sol-7.5mL Pk Tab Tab Oph Oint-3.5g Pk Oph Susp Tab LA Tab Top Gel Tab-21 Pk Tab-28 Pk Patch Patch SR Tab SR Tab SR Tab SR Tab SR Tab Tab Inj Sol-1mL Pk Inj Sol-1mL Pk Inj Sol-1mL Pk 1mL Vial 1.6mL Vial Oint Spray-200 Dose Pk Top Cr
NOV NOV NOV NOV NOV NOV ALL ALL ALL MAB MAB ALC ALC VAL VAL GAC PAL PAL GRA GRA PFP PFP PFP PFP PFP TRT SAV SAV SAV AMG AMG PAL SAV VAL
0.2993 0.6529 0.3564 0.6468 0.8921 1.2103 33.8580 56.4300 84.6450 0.6427 1.2618 9.1000 1.6780 0.4756 1.0400 0.6287 13.8900 13.8900 0.7013 0.7017 2.8280 0.6960 5.2580 1.0530 1.8550 1.5224 12.1700 14.8000 23.0100 192.4180 307.8690 0.6813 14.9400 0.5738
0.4mg/Hr/13.3 Sq Cm
0.6mg/Hr/20 Sq Cm 100mg 15mg 200mg 30mg 60mg 2mg 10mg/mL 25mg/mL 50mg/mL 300mcg/mL 480mcg/1.6mL 2%
25
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
01927698 02143291 02230619
Nozinan Ocuflox Pediapred Oral Liquid Piportil L4 Piportil L4 Piportil L4 Plaquenil Plavix
25mg/mL 0.3% 6.7mg/5mL
Inj Sol-1mL Pk Oph Sol O/L
SAV ALL SAV
3.4170 2.4950 0.1299
100mg/2mL 25mg/mL 50mg/mL 200mg 75mg 500mg 20mg 0.12% 60mg/mL 100mg 50mg 15mg 20mg 50mg 100mcg/Metered Dose 50mcg/Metered Dose 10mg 20mg 150mg 300mg 100mg 1000mg 4g 500mg 500mg 1mg 100mg 200mg 400mg
Inj Sol-2mL Pk Inj Sol-1mL Pk Inj Sol-1mL Pk Tab Tab ER Tab Tab Oph Susp Inj Sol-Pref Syr Tab Tab Tab Cap Tab Aero Inh-200 Dose Pk Aero Inh-200 Dose Pk Tab ER Tab Cap Cap Cap Sup Rect Susp-Pk Sup Ent Tab Tab Tab Tab Tab Oph/Ot Sol
SAV SAV SAV SAV SAV PMS BQU ALL AMG PAL PAL VAL LIL NOP GRA GRA NOV NOV VAL VAL SAV BFI BFI BFI BFI PAL SAV SAV SAV SAV
53.0200 16.4400 27.8800 0.6302 2.7125 2.3110 0.8926 1.8320 354.0800 0.3604 0.2304 0.4838 1.8485 2.8610 61.6500 30.9200 0.4049 0.7103 0.6574 1.0348 0.2738 1.8517 6.8971 1.2603 0.5703 0.6861 0.3532 0.5300 1.0548 1.9100
01926675 01926667 00990507 02017709 02238682 02416433 00893757 00299405 02343541 00010219 00010200 00869945 00636622 00004723 02242030 02242029 00005606 00632775 00393444 00343617 02224801 02242146 02112809 02112760 02112787 00511552 01926543 01926551 01926578 02224623
PMS-Ciprofloxacin XL
Pravachol Pred Mild Prolia (Preservative Free) Propyl-Thyracil Propyl-Thyracil Prostigmin Prozac Purinethol QVAR QVAR Ritalin Ritalin SR Rofact Rofact Rythmodan Salofalk Salofalk Salofalk Salofalk Sandomigran DS Sectral Sectral Sectral Sofracort
5mg & 50mcg & 0.5mg/mL
26
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02283395 02283409 02283417 02305933 02337827 02305941 02337835 02305968 00621935 02100622 02103567 00868965 00868981 00253952 00369810 02194333 00665088 00773611 00755583 02280248 01966219
Somatuline Autogel Somatuline Autogel Somatuline Autogel Stalevo Stalevo Stalevo Stalevo Stalevo Statex Sulcrate
60mg/0.3mL 90mg/0.3mL 120mg/0.5mL 50 & 12.5 & 200mg 75 & 18.75 & 200mg 100 & 25 & 200mg
ER Pref Syr-0.3mL Pk ER Pref Syr-0.3mL Pk ER Pref Syr-0.5mL Pk Tab Tab Tab Tab Tab Oral Drops Tab Oral Susp Oral Susp Tab
1,146.4100 1,529.2400 1,914.1500
Chew Tab Oral Susp Chew Tab LA Tab LA Tab Top Gel-5g Pk O/L
IPS IPS IPS NOV NOV NOV NOV NOV PAL BFI BFI SAV SAV NOV NOV NOV NOV NOV NOV PAL GRA
SR Cap SR Cap SR Cap SR Cap SR Cap Oph Susp Oph Oint Oph Sol Oph Oint Tab Tab
VAL VAL VAL VAL VAL ALC ALC ALC ALC PAL PAL
0.8877 1.1904 1.5790 1.9640 2.3809 2.1240 3.1314 1.8160 2.5743 0.3294 0.5823
02231150 02231151 02231152 02231154 02231155 00778907 00778915 00513962 00614254 02106272 02106280
Sulcrate Suspension Plus
Suprax Suprax Synacthen Depot Tegretol Tegretol Tegretol Tegretol CR Tegretol CR Testim Theolair Alcohol Free Oral Liquid Tiazac Tiazac Tiazac Tiazac Tiazac TobraDex TobraDex Tobrex Tobrex Trandate Trandate
125 & 31.25 & 200mg
150 & 37.5 & 200mg 20mg/mL 1g 1g/5mL 20mg/mL 400mg 1mg/mL 100mg 100mg/5mL 200mg 200mg 400mg 1% 5.3mg/mL 120mg 180mg 240mg 300mg 360mg 0.3% & 0.1% 0.3% & 0.1% 0.3% 0.3% 100mg 200mg
27
Inj Susp-1mL Pk
1.6810 1.6810 1.6810 1.6810 1.6810 0.3934 0.6057 0.1100 0.4266 3.6229 36.9400 0.1821 0.0860 0.3593 0.4460 0.8919 3.6030 0.0260
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
00852384 02046156 02318008 09857332 02240000 09857199 02243856 09857200 02230733 02230734 02274906 02238984 02245894 00616192 02244596 02244597 02244598 02244599 02247128 00687456 00568627 00568635 00417270 00443174 00417289 01926462 01926489 00514012 00632724 00632732 01940414 02237825
Transderm-Nitro Transderm-Nitro Travatan Z Travatan Z Trelstar (1 Month) Trelstar (1 Month)
0.4mg/Hr/20 Sq Cm 0.6mg/Hr/30 Sq Cm
Patch Patch
0.004% 0.004% 3.75mg/Vial 3.75mg/Vial 11.25mg/Vial 11.25mg/Vial
Oph Sol-2.5mL Pk
0.4mg/Hr/14 Sq Cm 0.6mg/Hr/21 Sq Cm
Patch Patch Tab Tab Tab Cap Enteric Coated Cap Enteric Coated Cap Enteric Coated Cap Enteric Coated Cap Tab Oph Sol Tab Tab Tab Tab Tab Gel Gel Ent Tab Sup Sup Oph Sol Tab
NOV NOV ALC ALC PAL PAL PAL PAL PAL PAL GIL BFI BFI BQU BQU BQU BQU BQU GIL THE NOV NOV NOV NOV NOV VAL VAL NOV NOV NOV NOV VAL
0.8710 0.8710 28.7600 57.5200 340.5200 340.5200 1,021.6000 1,021.6000 0.6852 0.6852 28.0355 1.4535 2.7571 37.3325 3.8550 6.1684 7.6416 12.3617 18.7679 3.2227 1.0005 1.0005 0.6529 1.1147 1.6171 0.3140 0.3140 0.9902 1.4870 2.0016 3.4560 0.9768
Trelstar LA (3 Month) Trelstar LA (3 Month)
Trinipatch Trinipatch Truvada Urso Urso DS Vepesid Videx EC Videx EC Videx EC Videx EC Viread Viroptic Viskazide 10/25 Viskazide 10/50 Visken Visken Visken Vitamin A Acid Vitamin A Acid Voltaren Voltaren Voltaren Voltaren Ophtha Wellbutrin SR
Oph Sol-5mL Pk
Inj Pd-Vial Pk Inj Pd with Sterile Water-Vial Pk Inj Pd-Vial Pk Inj Pd with Sterile Water-Vial Pk
200mg & 300mg 250mg 500mg 50mg 125mg 200mg 250mg 400mg 300mg 1% 10mg & 25mg 10mg & 50mg 5mg 10mg 15mg 0.01% 0.05% 50mg 50mg 100mg 0.1% 150mg
28
Drug Benefit Price (DBP) Changes (Cont’d...) DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
00888400 02216086 02216094 02216108 02216116
Zaroxolyn Zerit Zerit Zerit Zerit
2.5mg 15mg 20mg 30mg 40mg
Tab Cap Cap Cap Cap
SAV BQU BQU BQU BQU
0.1983 4.7000 4.8875 5.0983 5.2850
29
Exceptional Access Program (EAP) Product Price Changes DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
DBP
02338327 02369257 02339501 02339528 09857395 02269201 02322854 02322862 02402475 02302063
Adcirca Afinitor Afinitor Afinitor Avonex Pen Avonex PS Nplate Nplate Orencia Rasilez
20mg 2.5mg 5mg 10mg 30mcg/0.5mL 30mcg/0.5mL 250mcg/0.5mL 500mcg/1mL 125mg/mL 150mg
Tab Tab Tab Tab Pref AutoInj Pen Pref Syr Pd for Inj-Vial Pk Pd for Inj-Vial Pk Tab
LIL NOV NOV NOV BIG BIG AMG AMG BQU NOV
13.4970 195.2200 195.2200 195.2200 405.7575 405.7575 942.4300 1,884.8700 358.8998 1.2528
02302071 02257130 02257149 02257157 02320193 02293145 02368250 02286386 00800430 00788716 02368153 02260565
Rasilez Sensipar Sensipar Sensipar Sprycel Sprycel Tasigna Tysabri Vancocin Vancocin Xgeva Xolair
300mg 30mg 60mg 90mg 100mg 70mg 150mg 300mg/15mL 125mg 250mg 120mg/1.7mL 150mg
Tab Tab Tab Tab Tab Tab Cap Inj Sol-15mL Vial Cap Cap Inj Sol-Vial Pk Inj Pd-5mL Vial Pk
NOV AMG AMG AMG BQU BQU NOV BIG MEU MEU AMG NOV
1.2528 11.5967 21.1460 30.7710 152.8565 84.2867 28.7160 3,158.6200 5.3485 10.6875 569.3500 612.0000
Pre-Filled Syringe (1mL Syringe)
30
OFI Product Price Changes DIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
UNIT COST
02258102
Co Alendronate
40mg
Tab
COB
3.0832
02301407
Co Cabergoline
0.5mg
Tab
COB
10.6182
31
PIN/DIN Changes CURRENT PIN 09857187
NEW DIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
02392364
Aranesp
500mcg/1mL
Pref Syr-1.0mL Pk
AMG
09857355
02403439
Humalog Mix50 Kwikpen
50% & 50%
Inj Susp-5X3mL Pk
LIL
32
Product Brand and Manufacturer Name Changes DIN
CURRENT BRAND NAME
CURRENT MFR
NEW BRAND NAME
NEW MFR
STRENGTH
DOSAGE FORM
02311925*
Ratio-Fentanyl
RPH
Teva-Fentanyl
TEV
12mcg/hr
Trans Patch
02282941
Ratio-Fentanyl
RPH
Teva-Fentanyl
TEV
25mcg/hr
Trans Patch
02282968
Ratio-Fentanyl
RPH
Teva-Fentanyl
TEV
50mcg/hr
Trans Patch
02282976
Ratio-Fentanyl
RPH
Teva-Fentanyl
TEV
75mcg/hr
Trans Patch
02282984
Ratio-Fentanyl
RPH
Teva-Fentanyl
TEV
100mcg/hr
Trans Patch
*OFI Product
33
Change to Therapeutic Note DIN
BRAND NAME
02301881 Isentress
STRENGTH
DOSAGE FORM
MFR
400mg
Tab
MFC
Updated Therapeutic Note For use as part of an optimized regimen for the treatment of HIV/AIDS in adult patients. Note: The prescriber must be approved for the Facilitated Access mechanism.
34
Discontinued Products (Products will remain on Formulary for six months to facilitate depletion of supply) DIN/PIN
BRAND NAME
STRENGTH
09853723 Nepro
DOSAGE FORM
MFR
Liq-235mL Pk
ABB
01966197 Tambocor
50mg
Tab
GRA
01966200 Tambocor
100mg
Tab
GRA
02244896 Travatan
0.004%
Oph Sol
ALC
35
Status Change from Discontinued Drug to Not-A-Benefit* DIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
02221993 Renedil
5mg
SR Tab
SAV
02222000 Renedil
10mg
SR Tab
SAV
01966065 Tantum
0.15%
Oral Rinse
GRA
*Remain in Formulary as Not-a-Benefit to serve as reference product in interchangeable group.
36
Removals from Formulary (Removals from payment and listing)
37
Discontinued Drugs (Removed From Payment & Listing) DIN/PIN 00642231 00294926 01912828 09857352 02139200 02184648 09853510 00587834 02229799 00391603 00021202 00263702 02214849 02264757
BRAND NAME Apo-Pen V-K Benuryl Cortisporin Humalog Kwikpen Mylan-Amantadine Mylan-Valproic Neocate Nerisone Novo-Benzydamine Novo-Pen-VK-500 Novo-Pen-VK-500 Panoxyl Panoxyl Aquagel Ratio-Risperidone
STRENGTH 60mg/mL 500mg
0.10% 0.15% 60mg/mL 300mg 5% 5% 0.25mg
Cap Cap Pd-400g Pk Oint Oral Rinse O/L Tab Gel Gel Tab
MFR APX VAL GSK LIL MYL MYL SHS STI NOP NOP NOP STI STI RPH
02264765
Ratio-Risperidone
0.5mg
Tab
RPH
02264773
Ratio-Risperidone
1mg
Tab
RPH
02264781
Ratio-Risperidone
2mg
Tab
RPH
02264803
Ratio-Risperidone
3mg
Tab
RPH
02264811
Ratio-Risperidone
4mg
Tab
RPH
02221985
Renedil
2.5mg
SR Tab
SAV
10000U & 5mg & 10mg/mL
100U/mL 100mg 250mg
38
DOSAGE FORM O/L Tab Ot Sol Inj Sol-5x3mL Pk
Manufacturer Requested Delistings DIN/PIN
BRAND NAME
STRENGTH
DOSAGE FORM
MFR
02303426
Sandoz Cefprozil
125mg/5mL
Oral Susp-75mL Pk
SDZ
09857363
Sandoz Cefprozil
125mg/5mL
Oral Susp-100mL Pk
SDZ
02303434
Sandoz Cefprozil
250mg/5mL
Oral Susp-75mL Pk
SDZ
09857364
Sandoz Cefprozil
250mg/5mL
Oral Susp-100mL Pk
SDZ
39