NON-INSURED HEALTH BENEFITS First Nations and Inuit Health Branch
DRUG BENEFIT LIST
2014
The Non-Insured Health Benefits (NIHB) program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First Nations and recognized Inuit throughout Canada.
Visit our Web site at: www.healthcanada.gc.ca/nihb
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Table of Contents 1. Background on NIHB Program .............................................................................................. iii 2. Purpose of the NIHB Drug Benefit List .................................................................................. iii 3. Drug Review Process ............................................................................................................. iii 4. Benefit Criteria ....................................................................................................................... v
A. Drug Benefit Listings .................................................................................................. v B. Deletion Criteria ........................................................................................................ .vi C. Open Benefits……………….………………………………………………………………..vii D. Limited Use Benefits ................................................................................................. vii E. Exception Criteria ...................................................................................................... vii F. Exclusions ................................................................................................................ viii
5. Policies ................................................................................................................................ viii A. Best Price Alternative and Interchangeability ........................................................... viii B. “No Substitution” Claims .......................................................................................... viii C. Prescription Quantities .............................................................................................. ix D. Short Term Dispensing ……………………………………………………………………...ix
6. Special Formulary for Chronic Renal Failure Patients ............................................................. x 7. Palliative Care Formulary ........................................................................................................ x 8. Drug Utilization Evaluation ...................................................................................................... x 9. General Information ............................................................................................................... xi
10. NIHB Privacy Code ................................................................................................................ xi 11. Pharmacologic-Therapeutic Classification of Drugs ............................................................... xi
Legend ................................................................................................................................. xii Drug Benefit List
04:00 Antihistamine Drugs ............................................................................................... 1 08:00 Anti-Infective Agents .............................................................................................. 2 10:00 Antineoplastic Agents .......................................................................................... 13 12:00 Autonomic Drugs ................................................................................................. 16 20:00 Blood Formation and Coagulation ........................................................................ 23 24:00 Cardiovascular Drugs .......................................................................................... 27 28:00 Central Nervous System Agents .......................................................................... 50 32:00 Contraceptives (Non-Oral) ................................................................................... 83 36:00 Diagnostic Agents ................................................................................................ 84 40:00 Electrolytic, Caloric and Water Balance ............................................................... 85 48:00 Respiratory Tract Agents ..................................................................................... 88 52:00 Eye, Ear, Nose and Throat Preparations ............................................................. 89 56:00 Gastrointestinal Drugs ......................................................................................... 95 60:00 Gold Compounds ............................................................................................... 103 64:00 Heavy Metal Antagonists ................................................................................... 104 68:00 Hormones and Synthetic Substitutes ................................................................. 105 80:00 Serums, Toxoids and Vaccines.......................................................................... 114 84:00 Skin and Mucous Membrane Agents ................................................................. 115 86:00 Smooth Muscle Relaxants ................................................................................. 123 88:00 Vitamins ............................................................................................................. 125 92:00 Unclassified Therapeutic Agents........................................................................ 128 94:00 Devices .............................................................................................................. 134 96:00 Pharmaceutical Aids .......................................................................................... 138
Appendix A (Limited Use Benefits and Criteria)....................................................................... A-1 Appendix B (Special Formulary for Chronic Renal Failure Patients) ........................................ B-1 Appendix C (Palliative Care Formulary) .................................................................................. C-1 Appendix D (List of Drug Manufacturers) ................................................................................ D-1 Appendix E (List of Exclusions) .............................................................................................. E-1 Alphabetical Index of drug products ......................................................................................... I-1
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1. BACKGROUND ON NON-INSURED HEALTH BENEFITS (NIHB) PROGRAM The Non-Insured Health Benefits (NIHB) Program of Health Canada provides coverage for approximately 808,686 (decrease attributed to the transfer of clients to the First Nations Health Authority (FNHA) in British Columbia) eligible registered First Nations and recognized Inuit with a limited range of medically necessary health-related goods and services not provided through private or provincial/territorial health insurance plans. These benefits complement provincial and territorial health care programs, such as physician and hospital care, as well as other First Nations and Inuit community-based programs and services. Benefits include drugs, medical transportation, dental care, medical supplies and equipment, crisis intervention counselling and vision care. The authority for the NIHB Program is based on the 1979 Indian Health Policy which describes the responsibility for the health of First Nations as shared amongst various levels of government, the private sector and First Nations communities. As a result of this shared responsibility, when a benefit is covered under another plan, the federal government requires the coordination of benefits to ensure that the other plan meets its obligations. 2. PURPOSE OF THE NIHB DRUG BENEFIT LIST (DBL) The Drug Benefit List (DBL) is a listing of the drugs provided as benefits by the NIHB Program. The DBL is updated regularly and published annually. The listed drugs are those primarily used in a home or ambulatory setting. A prescription from a licensed practitioner is required for any listed drug to be processed as a benefit. Practitioners are health professionals authorized to prescribe drugs within the scope of practice in their province or territory. The DBL is a tool for prescribers and pharmacists that encourages the selection of optimal, cost-effective drug therapy. 3. DRUG REVIEW PROCESS
The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted.
3.1 New Chemical Entities / New Combination Drug Products/ Existing Chemical Entities with New Indication Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Drug Expert Committee (CDEC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB Program, for consideration. The NIHB Program and other drug plans make listing decisions based on CDEC recommendations and other specific relevant factors, such as mandate, priorities and resources. Please refer to CADTH for a list of requirements for manufacturers’ submissions and a summary of procedures for the Common Drug Review Process. Inquiries should be directed to:
Common Drug Review (CDR) Canadian Agency for Drugs and Technologies in Health 865 Carling Avenue, Suite 600 Ottawa, Ontario K1S 5S8 Telephone: (613) 226-2553 Website: www.cadth.ca
Please ensure a copy of the complete CDR submission is also sent to NIHB either electronically to [email protected] or on CD ROM to the mailing address indicated in section 3.2.2.4. Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program. 3.2 Line Extensions, Generics and All Other Submissions Submissions for line extensions, generics and all other submissions are reviewed internally or by the NIHB Drugs and Therapeutics Advisory Committee (DTAC). Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.
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3.2.1 Drugs and Therapeutics Advisory Committee (DTAC) The DTAC provides formulary listing recommendations for drug products to the NIHB Program. The NIHB Program makes listing decisions based on DTAC recommendations and other specific relevant factors, such as mandate, priorities and resources. The DTAC is an advisory body of highly qualified health professionals who bring impartial and practical expert medical and pharmaceutical advice to the NIHB Program to promote improvement in the health outcomes of First Nations and Inuit clients through effective use of pharmaceuticals. The approach is evidence-based and the advice reflects medical and scientific knowledge, current utilization trends, current clinical practice, health care delivery and specific departmental client healthcare needs.
3.2.2 Submission Requirements All submissions for drug products that are line extensions, generics and all other types of submissions must be submitted to the NIHB Program. Only drug products with a Health Canada Notice of Compliance (NOC) will be considered for provision as a benefit.
3.2.2.1 Letter of Authorization The manufacturer will provide a letter authorizing the NIHB Program to gain access to all information with respect to the product in the possession of Health Canada or of the government of any provinces or territory in Canada, Patented Medicine Prices Review Board (PMPRB) or CADTH. 3.2.2.2 Justification for Consideration of Listing The manufacturer will provide a statement indicating the rationale and evidence to justify the provision of the new product. 3.2.2.3 General Information Additional information should include: Evidence of approval by Health Canada, such as a Notice of Compliance (NOC) and Drug
Identification Number (DIN).and Two therapeutic Classifications:
- American Hospital Formulary Service (AHFS) Pharmacologic Therapeutic Classification and;
- The World Health Organization’s Anatomical Therapeutic Chemical (ATC) Classification 3.2.2.4 Pricing and Marketing Information The manufacturer must submit current price information for the drug product. Manufacturers are required to notify the NIHB Program of any significant change to listed drug products. Significant changes include changes in DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or discontinuation of a product. Notification of changes should be provided electronically to the NIHB Program.
All submissions for drug products, to be reviewed for inclusion on the NIHB DBL, must be sent to the NIHB Program electronically. Please send all drug submissions to the following email address: [email protected]. Submissions will also be accepted on CD ROM when mailed to the following address:
C/o Manager of Policy Development - Pharmacy Non-Insured Health Benefits First Nations and Inuit Health Branch, Health Canada 200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture Ottawa, Ontario K1A 0K9
Only ONE copy of the submission is required. Receipt of submission will be acknowledged
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electronically with a confirmatory email message. Paper (binder) versions of drug submissions are no longer accepted by the NIHB Program.
4. BENEFIT CRITERIA The following criteria are the framework for the NIHB Program DBL. The criteria provide the basis for decisions about drugs on the formulary relating to:
A. Drug Benefit Listings B. Deletions C. Open Benefit D. Limited Use E. Exceptions F. Exclusions
All drugs that are to be either considered for listing or currently listed as Program benefits must, as a minimum:
1. be legally available for sale in Canada with an NOC;
2. be sold in Canada (proof may include a copy of the completed notification form issued under the Food and Drug Regulations or listing on a provincial drug benefit formulary);
3. be administered in a home setting or in other ambulatory care settings;
4. not be provided in a provincially/territorially covered setting (hospital/institution) or provided through provincially/territorial covered programs or clinics according to provincial/territorial legislation; and
5. be in accordance with NIHB Program mandate and policies.
A. Drug Benefit Listings The NIHB Program, with assistance from the CDEC and the NIHB DTAC, balances a number of factors in making listing decisions about changes to the Drug Benefit List, such as:
• The needs of First Nations and Inuit clients;
• Accumulated scientific and clinical research on currently-listed drugs;
• Cost-benefit analysis;
• Availability of alternatives;
• Current health practices; and • Policies and listings in provincial drug formularies.
New formulations and new strengths of listed products may be added or may replace previously approved products. Generic products are added according to provincial/territorial interchangeability lists and other relevant factors. Combination products are considered for listing if:
1. each component of the combination makes a contribution to the claimed effect;
2. a pharmacological or pharmaceutical rationale exists for the combination;
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3. the dosage of each component (amount, frequency, duration) is safe and effective for a significant proportion of the patient population requiring such concurrent therapy as defined in the labeling of the drug; and
4. the cost is reduced, or scientific evidence indicates that the advantages outweigh any additional cost; or
5. an improvement in compliance, resulting in an increase in clinical effectiveness, is demonstrated.
Sustained Release Products may be listed when:
1. clinical studies have demonstrated the safety and efficacy of the active ingredient when administered in the sustained released form; and
2. a therapeutic advantage is demonstrated in the treatment of the disease entity for which the product is indicated (therapeutic advantage is defined as: improved efficacy relative to the conventional dosage with no increase in toxicity; or less toxicity with improved or similar efficacy); or
3. there is demonstrated improvement in compliance resulting in an increase in clinical effectiveness, or
4. there is evidence that the sustained release product is at least as cost-effective as the best price alternative in the conventional form that is currently covered; or
5. there is no suitable conventional dosage form(s) of the drug listed that is readily available.
Injectable Drug Products will be considered if they are:
1. self-administered in a home or other ambulatory setting;
2. not part of a physician’s standard office supply; 3. not provided in a provincially/territorially covered hospital or institution; or 4. not provided through provincially/territorial covered programs or clinics according to
provincial/territorial legislation. B. Deletion Criteria The following deletion criteria guide the removal or delisting of a drug product from the NIHB drug benefit list. Drugs are deleted:
1. when a product is discontinued from the Canadian market;
2. when new products possessing clearly demonstrated therapeutic and safety advantages or improvements have been listed;
3. when new toxicity data shift the risk/benefit ratio to make the continued listing of the product inappropriate;
4. when new information demonstrates that the product does not have the anticipated therapeutic benefit;
5. when the purchase cost is disproportionate to the benefits provided; or
6. when the drug has a high potential for misuse or abuse.
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NOTE: Drugs may also be removed at the discretion of the Director General, NIHB Program when there are undesirable financial, supply or administrative implications to the continued listing of a product. C. Open Benefits Open benefits are the drugs listed in the NIHB DBL which do not have established criteria or prior approval requirements. D. Limited Use Benefits Limited use drugs are drug products listed on the NIHB DBL that may be inappropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB Program. A product will be designated for limited use when:
1. it has the potential for widespread use outside the indications for which benefit has been demonstrated;
2. it has proven effectiveness, but is associated with predictable severe adverse effects;
3. it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative; or
4. it is very costly and a therapeutically effective alternative is available as a benefit.
There are three types of limited use benefits:
1. Limited use benefits which do not require prior approval. These include: Multivitamins (which are benefits for children up to 6 years of age); and Prenatal and postnatal vitamins (which are benefits for women of childbearing
age (12 to 50 years). 2. Benefits which have a quantity and frequency limit. A maximum quantity of drug is
allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drug within the specified period. An example of a category of drugs with a quantity and frequency limit is smoking cessation products. Recipients are eligible to receive up to three treatment courses of nicotine replacement therapy (NRT) within a 12-month period with quantity limits, which include 2 courses of NRT patches and 1 course of NRT products used PRN (i.e. gums, lozenges, inhalers).
3. Limited use benefits which require prior approval (using the “Limited Use Drugs Request Form”). Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List and also in Appendix A. The criteria are also listed on the forms faxed to prescribers for completion.
E. Exceptions Exception drugs are drug products which are not listed in the DBL. These drug products may be approved in special circumstances upon receipt of a completed “Exception Drugs Request Form” from the attending licensed practitioner.
when the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion; and
when there is significant evidence that the requested drug is superior to drugs already listed as program benefits; or
when a patient has experienced an adverse reaction with a best- price alternative drug, and a higher cost alternative is requested by the prescriber; or
when there is supporting evidence that available alternatives are ineffective, toxic, or contraindicated (personal preference alone does not justify an exception).
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F. Exclusions Exclusions are items not listed as benefits on the DBL and are not available through the exception or appeal processes. These include certain drug therapies for particular conditions which fall outside of the NIHB mandate and are not provided as benefits under the NIHB Program. Examples of categories of drugs or drug products* that are not considered for coverage under the NIHB Program under any circumstances are listed in Appendix E
Anti-obesity drugs; Household products (e.g. regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccines Medications for travel Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations.
*Note: List of excluded drugs or drug products is not exhaustive and may be modified as necessary 5. POLICIES
A. Best Price Alternative and Interchangeability The NIHB program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial/territorial pharmacy legislation/policies to identify interchangeable products and to select the lowest-priced brand. (NIHB may not necessarily reimburse at the cost listed in the provincial drug plan formulary). B. “No Substitution” Claims NIHB will consider reimbursement for a higher-cost interchangeable product when a patient has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide the NIHB Program with: 1. a completed and signed Canada Vigilance Adverse Reaction Reporting Form: ‘Report of
suspected adverse reactions to health products in Canada’ and, 2. the prescription with “No Substitution” or “No Sub” handwritten. Upon receipt, the pharmacist will forward a copy of the prescription to NIHB for review. The prescriber is responsible for sending a copy of the form to the Canada Vigilance Program. Forms can be obtained by calling the Canada Vigilance Program at 1-866-234-2345 or by downloading a copy from Health Canada website at: http://www.hc-sc.gc.ca/dhp-mps/medeff/report-declaration/ar-ei_form-eng.php or by photocopying a copy from the Compendium of Pharmaceuticals and Specialties. NOTE: The Canada Vigilance Adverse Reaction Reporting Form will not need to be resubmitted for renewals or new prescriptions of the same drug for the patient, although “No Sub” will still have to be written on the prescription. C. Prescription Quantities The normal quantity dispensed shall be the entire quantity of the drug prescribed. A maximum 100-day supply should be considered for those circumstances where the patient has been stabilized on a
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medication and the prescriber feels that further adjustment during the prescribed period is unlikely. Prescriptions for opioids have a maximum 30–day supply. The physician may continue to prescribe a smaller quantity with repeats at certain intervals when it is in the patient’s best interest. D. Short Term Dispensing Policy It is the Program’s expectation that certain medications required for long-term maintenance therapy should be prescribed and dispensed in up to 100 days supplies. For refills for medications requiring short-term dispensing for a shorter time than 28 days due to compliance concerns, the Program will only reimburse a total of one dispensing fee per 28 days up to the regional maximum of the Program, These medications include (but are not limited to) drugs in the following categories: Alpha-adrenoreceptor Antagonists Anti-dementia Drugs Anti-gout Drugs Anti-Parkinsonian Drugs Anti-platelet aggregation Drugs BPH Drugs Cardiovascular Drugs Enzyme Preparations Drugs for Diabetes Drugs for Treatment of Bone Diseases GI Anti-inflammatory Drugs Thyroid Therapy Proton Pump Inhibitors Urinary Anti-Spasmotics NSAIDs H2-Receptor Antagonists OTCs (including vitamins) Other Drugs for Peptic Ulcer and Gastro-esophageal Reflux Disease (GERD)
Note: This list may be amended as required and changes will be communicated through the quarterly on-line updates to the DBL. Medications on the Short term Dispensing list are identified in the DBL using the symbol ST beside the medication strength and dosage form. The following are exceptions to the STD policy: • Refills for intermittent treatment of a chronic disorder or refills of a medication which is prescribed to be taken on an “as needed” (PRN) basis. Note: Medications prescribed to be taken on an “as needed” (PRN) basis and dispensed chronically may be subject to audit and recovery. • Prescriptions for dose changes. • The following drug categories: opioids, methadone. • The following dosage forms: injectable and suppository. • Refills or new prescriptions when prescribed/dispensed in accordance with a court order. • Others as identified by the NIHB Program Compensation The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to audit and recover in instances where quantity reduction occurs. Less than 28 Day Supply For the medications listed below in which short-term dispensing is deemed medically necessary, the Program will compensate up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7th of this fee: • Anticonvulsants; • Antidepressants; • Antipsychotics; • Benzodiazepines; • Stimulants; and • Nicotine Replacement Therapy. Implementation When filling a new prescription for a chronic use drug, the Program will pay a full dispensing fee regardless of the days supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber. When refilling a prescription for a chronic use drug that is for less than a 28 day supply or when a need for compliance packaging is identified by the prescriber, the Program will pay no more than one full
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dispensing fee per 28 day period. For the medications listed above the Program will pay no more than full dispensing fee per 7 day period. A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug.
6. FORMULARY FOR CHRONIC RENAL FAILURE PATIENTS Clients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the NIHB DBL but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB clients are eligible to receive darbepoetin alfa through the provincial programs), calcium products, multivitamins formulated for renal patients and select nutritional supplements formulated for renal patients. New clients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the client is confirmed as eligible, coverage will automatically be extended to all drugs in the special formulary for as long as needed. 7. PALLIATIVE CARE FORMULARY Clients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. Requests for any of the DINs on the Palliative Care Formulary will generate a Palliative Care Application Form, faxed to the prescriber. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met: The client: 1. is not receiving care in a provincially covered hospital or provincially covered long-term care
facility; and 2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause
of death within six months or less Once approved, the client will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months will be granted upon receipt of another completed Palliative Care Application Form. 8. DRUG UTILIZATION EVALUATION A drug utilization evaluation, which is part of the point-of-service or on-line adjudication system, provides an analysis of both previous claims data and current claims data to identify potential drug-related problems. Messages are returned to pharmacists to alert them of the potential problems. These messages are intended to enhance pharmacy practice with additional information. Currently, the system monitors for:
- potential drug/drug interactions - duplicate drugs - duplicate therapy
The DTAC is an important component of the NIHB Drug Use Evaluation (DUE) Program which provides advice to the NIHB Program, to promote effective, efficient and optimal drug therapy to First Nations and Inuit recipients. 9. GENERAL INFORMATION Sources of information about the NIHB Program include:
The NIHB section of the Health Canada website which provides background information on the program and a copy of the DBL. This can be found at: www.healthcanada.gc.ca/nihb
NIHB DBL Updates are available to pharmacists and to prescribers via the Health Canada website. These updates can be found at: http://www.hc-sc.gc.ca/fniah-spnia/pubs/nihb-ssna/index-
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eng.php#drug-med Information about the NIHB Program can also be obtained by contacting: Non-Insured Health Benefits First Nations and Inuit Health Branch
200 Eglantine Driveway, 2nd Floor Postal Locator 1902A Tunney's Pasture
Ottawa, Ontario K1A 0K9
10. NIHB PRIVACY CODE The NIHB Program of Health Canada is committed to protecting an individual’s privacy and safeguarding the personal information in its possession. When a benefit request is received, the NIHB Program collects, uses, discloses and retains an individual’s personal information according to the applicable federal privacy legislation. The information collected is limited to only that information required for the NIHB Program to administer and verify benefits. As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, the Treasury Board of Canada Privacy and Data Protection Policies, the Government Security Policy, and Health Canada’s Security Policy. 11. PHARMACOLOGIC-THERAPEUTIC CLASSIFICATION OF DRUGS The drugs in the NIHB DBL are classified according to the AHFS Pharmacologic-Therapeutic classification developed by the American Society of Health-System Pharmacists for the purposes of the AHFS Drug Information. Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions from the original context. Drugs are listed alphabetically within each therapeutic classification according to their chemical names. Under each drug, acceptable products are listed.
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LEGEND
1. Pharmacologic-Therapeutic classification
2. Pharmacologic-Therapeutic sub-classification 3. Nonproprietary or generic name of the drug 4. Drug strength and dosage form. ST indicates the drug is identified as a
chronic medication under the Short-Term Dispensing Policy. 5. Drug Identification Number (DIN), assigned by the Therapeutic Products
Directorate of Health Canada, to uniquely identify the drug product as to its manufacturer, name and strength of active ingredients, route of administration and pharmaceutical dosage form
6. Brand name of the drug 7. List of all active ingredients in a combination product 8. Strengths of active ingredients in a combination product, listed in the same
order as the ingredients 9. List of available brands of drugs. Provincial or territorial drug plan
formularies should be consulted to determine interchangeable products and to identify best price (lowest cost) alternatives
10. Three letter identification code assigned to manufacturer
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1 04:00 ANTIHISTAMINE DRUGS
2 04.00.00 ANTIHISTAMINE DRUGS
3 CETIRIZINE HCL
4 ST 10mg Tablet
5 02231603 APO-CETIRIZINE APX
6
7 28:08.08 ACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE
8 300mg & 15mg & 15mg Tablet
00706515 PMS-ACET 2 PMS
00653241 RATIO-LENOLTEC NO.2 RPH
02163934 TYLENOL WITH CODEINE NO.2 JNO
9
300mg & 15mg & 30mg Tablet
00653276 RATIO-LENOLTEC NO.3 RPH
02163926 TYLENOL WITH CODEINE NO.3 JNO
10
Non-Insured Health BenefitsHealth Canada
04:00 ANTIHISTAMINE DRUGS
04:00.00 ANTIHISTAMINE DRUGS
CETIRIZINE HCL
1MG/ML SyrupST
02238337 REACTINE JNO10MG Tablet
ST
02315955 ALLERGY RELIEF ES PMS02231603 APO-CETIRIZINE APX02223554 REACTINE JNO
20MG TabletST
02315963 PMS-CETIRIZINE PMS01900978 REACTINE JNO
CHLORPHENIRAMINE MALEATE
12MG Sustained Release TabletST
00738964 CHLOR-TRIPOLON SCH4MG Tablet
ST
00738972 CHLOR-TRIPOLON SCH00021288 NOVOPHENIRAM TEV
DESLORATADINE
0.5MG/ML SyrupST
02247193 AERIUS KIDS SCH5MG Tablet
ST
02243919 AERIUS SCH02369656 ALLERNIX MULTI SYMPTOM TEP02338424 DESLORATADINE APX02298155 DESLORATADINE ALLERGY
CONTROLPMS
DIPHENHYDRAMINE HCL
25MG Capsule
00757683 PMS-DIPHENHYDRAMINE PMS50MG Capsule
02019671 BENADRYL WLA00757691 PMS-DIPHENHYDRAMINE PMS
2.5MG/ML Elixir
00804193 ALLERNIX RPH02019736 BENADRYL WLA00833266 DIPHENHYDRAMINE HCL TAN02298503 JAMP-DIPHENHYDRAMINE JAP00792705 PMS-DIPHENHYDRAMINE PMS
50MG/ML Injection
00596612 DIPHENHYDRAMINE SDZ00878200 PMS-DIPHENHYDRAMINE PMS
1.25MG/ML Liquid
02019698 BENADRYL CHILD WLA25MG Tablet
02176483 ALLER-AIDE RPH01949454 ALLERGY TAN02229492 ALLERGY FORMULA SDR02097583 ALLERNIX RPH02017849 BENADRYL WLA02257548 DIPHENHYDRAMINE JAP
04:00.00 ANTIHISTAMINE DRUGS
DIPHENHYDRAMINE HCL
50MG Tablet
02097575 ALLERNIX PLUS RPH02257556 DIPHENHYDRAMINE JAP02230398 DIPHENHYDRAMINE HCL TAN
FEXOFENADINE HCL
60MG TabletST
02231462 ALLEGRA AVT120MG Tablet
ST
02242819 ALLEGRA 24HR SAC
KETOTIFEN FUMARATE
0.2MG/ML SyrupST
02221330 APO-KETOTIFEN APX02176084 NOVO-KETOTIFEN TEV02231679 PMS-KETOTIFEN PMS
1MG TabletST
02230730 NOVO-KETOTIFEN TEV02231680 PMS-KETOTIFEN PMS00577308 ZADITEN NVR
LORATADINE
1MG/ML SyrupST
02019973 CLARITIN SCH02241523 CLARITIN KIDS SCH
10MG TabletST
02243880 APO-LORATADINE APX00782696 CLARITIN SCH02244692 LORATADINE VTH02280159 LORATADINE VTH *
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Non-Insured Health BenefitsHealth Canada
08:00 ANTI-INFECTIVE AGENTS
08:08.00 ANTHELMINTICS
MEBENDAZOLE
100MG Tablet
00556734 VERMOX JNO
PYRANTEL PAMOATE
50MG/ML Suspension
01944355 COMBANTRIN PFI125MG Tablet
01944363 COMBANTRIN PFI
08:12.06 CEPHALOSPORINS
CEFACLOR
250MG Capsule
02230263 APO-CEFACLOR APX00465186 CECLOR PHH02237729 SCHEIN-CEFACLOR SCN
500MG Capsule
02230264 APO-CEFACLOR APX00465194 CECLOR PHH02237730 SCHEIN-CEFACLOR SCN
25MG/ML Suspension
00465208 CECLOR PHH50MG/ML Suspension
00465216 CECLOR PHH75MG/ML Suspension
02237502 APO-CEFACLOR APX00832804 CECLOR BID PHH
CEFADROXIL
500MG Capsule
02240774 APO-CEFADROXIL APX02235134 NOVO-CEFADROXIL TEV02311062 PRO-CEFADROXIL PDL
CEFIXIME
20MG/ML Suspension
00868965 SUPRAX SAC400MG Tablet
00868981 SUPRAX SAC
CEFPROZIL
25MG/ML Suspension
02293943 APO-CEFPROZIL APX02347261 AURO-CEFPROZIL AUR02163675 CEFZIL BMS02329204 RAN-CEFPROZIL RBY02303426 SANDOZ CEFPROZIL SDZ
50MG/ML Suspension
02293951 APO-CEFPROZIL APX02347288 AURO-CEFPROZIL AUR02163683 CEFZIL BMS02293579 RAN-CEFPROZIL RBY02303434 SANDOZ CEFPROZIL SDZ
08:12.06 CEPHALOSPORINS
CEFPROZIL
250MG Tablet
02292998 APO-CEFPROZIL APX02347245 AURO-CEFPROZIL AUR02163659 CEFZIL BMS02293528 RAN-CEFPROZIL RBY02302179 SANDOZ CEFPROZIL SDZ
500MG Tablet
02293005 APO-CEFPROZIL APX02347253 AURO-CEFPROZIL AUR02163667 CEFZIL BMS02293536 RAN-CEFPROZIL RBY02302187 SANDOZ CEFPROZIL SDZ
CEFUROXIME AXETIL
25MG/ML Suspension
02212307 CEFTIN GSK250MG Tablet
02244393 APO-CEFUROXIME APX02344823 AURO-CEFUROXIME APL02212277 CEFTIN GSK02242656 RATIO-CEFUROXIME RPH
500MG Tablet
02244394 APO-CEFUROXIME APX02344831 AURO-CEFUROXIME APL02212285 CEFTIN GSK02311453 PRO-CEFUROXIME PDL02242657 RATIO-CEFUROXIME RPH
CEPHALEXIN
250MG Capsule
00342084 NOVO-LEXIN TEV500MG Capsule
00342114 NOVO-LEXIN TEV25MG/ML Suspension
02177862 DOM-CEPHALEXIN DPC00342106 NOVO-LEXIN TEV
50MG/ML Suspension
02177870 DOM-CEPHALEXIN DPC00342092 NOVO-LEXIN TEV
250MG Tablet
00768723 APO-CEPHALEX APX02177846 DOM-CEPHALEXIN DPC00583413 NOVO-LEXIN TEV00828858 PDL-CEPHALEXIN PDL02177781 PMS-CEPHALEXIN PMS
500MG Tablet
00768715 APO-CEPHALEX APX02177854 DOM-CEPHALEXIN DPC00583421 NOVO-LEXIN TEV00828866 PDL-CEPHALEXIN PDL02177803 PMS-CEPHALEXIN PMS
Page 2 of 1382014
Non-Insured Health BenefitsHealth Canada
08:12.12 MACROLIDES
AZITHROMYCIN
20MG/ML Suspension
02315157 NOVO-AZITHROMYCIN TEV02274388 PMS-AZITHROMYCIN PMS02332388 SANDOZ-AZITHROMYCIN SDZ02223716 ZITHROMAX PFI
40MG/ML Suspension
02315165 NOVO-AZITHROMYCIN TEV02274396 PMS-AZITHROMYCIN PMS02332396 SANDOZ-AZITHROMYCIN SDZ02223724 ZITHROMAX PFI
250MG Tablet
02247423 APO-AZITHROMYCIN APX02330881 AZITHROMYCIN SAN02255340 CO-AZITHROMYCIN ACT02278499 DOM-AZITHROMYCIN DOM02278359 GEN-AZITHROMYCIN GEN02267845 NOVO-AZITHROMYCIN TEV02278588 PHL-AZITHROMYCIN PMI02261634 PMS-AZITHROMYCIN PMS02310600 PRO-AZITHROMYCINE PDL02275287 RATIO-AZITHROMYCIN RPH02265826 SANDOZ-AZITHROMYCIN SDZ02212021 ZITHROMAX PFI
600MG Tablet
02256088 CO-AZITHROMYCIN ACT02261642 PMS-AZITHROMYCIN PMS02231143 ZITHROMAX PFI
CLARITHROMYCIN
500MG Extended Release Tablet
02244756 BIAXIN XL ABB250MG Film Coated Tablet
02274744 APO-CLARITHROMYCIN APX01984853 BIAXIN ABB02248856 GEN-CLARITHROMYCIN GEN02247573 PMS-CLARITHROMYCIN PMS02324482 PRO-CLARITHROMYCIN PDL02361426 RAN-CLARITHROMYCIN RBY02247818 RATIO-CLARITHROMYCIN RPH02248804 TEVA-CLARITHROMYCIN TEV
500MG Film Coated Tablet
02274752 APO-CLARITHROMYCIN APX02126710 BIAXIN ABB02351005 DOM-CLARITHROMYCIN SEV02248857 GEN-CLARITHROMYCIN GEN02247574 PMS-CLARITHROMYCIN PMS02324490 PRO-CLARITHROMYCIN PDL02361434 RAN-CLARITHROMYCIN RBY02247819 RATIO-CLARITHROMYCIN RPH02346532 RIVA-CLARITHROMYCIN RIV02248805 TEVA-CLARITHROMYCIN TEP
25MG/ML Suspension
02390442 ACCEL-CLARITHROMYCIN ACP02146908 BIAXIN ABB02408988 CLARITHROMYCIN SAN
08:12.12 MACROLIDES
CLARITHROMYCIN
50MG/ML Suspension
02390450 ACCEL-CLARITHROMYCIN ACP02244641 BIAXIN ABB02408996 CLARITHROMYCIN SAN
ERYTHROMYCIN
250MG Enteric Coated Capsule
00726672 APO-ERYTHRO APX00607142 ERYC PFI
333MG Enteric Coated Capsule
01925938 APO-ERYTHRO APX333MG Enteric Coated Tablet
00873454 ERYC PFI00769991 P.C.E. ABB
250MG Tablet
00682020 APO-ERYTHRO BASE APX
ERYTHROMYCIN ESTOLATE
50MG/ML Suspension
00262595 NOVO-RYTHRO ESTOLATE TEV
ERYTHROMYCIN ETHYLSUCCINATE
600MG Tablet
00637416 APO-ERYTHRO-S APX00583782 EES-600 ABB00704377 ERYTHRO-ES PDL
ERYTHROMYCIN ETHYLSUCCINATE &
SULFISOXAZOLE ACETYL
40MG & 120MG/ML Suspension
00583405 PEDIAZOLE ABB
ERYTHROMYCIN STEARATE
250MG Tablet
00545678 APO-ERYTHRO-S APX00563854 ERYTHROMYCIN PDL
500MG Tablet
00688568 APO-ERYTHRO S APX00704393 ERYTHRO PDL
08:12.16 PENICILLINS
AMOXICILLIN
250MG Capsule
02352710 AMOXICILLIN SAN02401495 AMOXICILLIN SIV00628115 APO-AMOXI APX02388073 AURO-AMOXICILLIN AUR02238171 GEN-AMOXICILLIN GEN00406724 NOVAMOXIN TEV02230243 PMS-AMOXICILLIN PMS
Page 3 of 1382014
Non-Insured Health BenefitsHealth Canada
08:12.16 PENICILLINS
AMOXICILLIN
500MG Capsule
02352729 AMOXICILLIN SAN02401509 AMOXICILLIN SIV00628123 APO-AMOXI APX02388081 AURO-AMOXICILLIN AUR02238172 GEN-AMOXICILLIN GEN00406716 NOVAMOXIN TEV02230244 PMS-AMOXICILLIN PMS00644315 PRO-AMOX PDL
125MG Chewable Tablet
02036347 NOVAMOXIN TEV250MG Chewable Tablet
02036355 NOVAMOXIN TEV25MG/ML Suspension
02352745 AMOXICILLIN SAN02352761 AMOXICILLIN SUGAR
REDUCEDSAN
00628131 APO-AMOXI APX00452149 NOVAMOXIN TEV01934171 NOVAMOXIN SUGAR
REDUCEDTEV
02230245 PMS-AMOXICILLIN PMS50MG/ML Suspension
02352753 AMOXICILLIN SAN02401541 AMOXICILLIN SIV02352788 AMOXICILLIN SUGAR
REDUCEDSAN
00628158 APO-AMOXI APX02230880 APO-AMOXI SUGAR FREE APX00452130 NOVAMOXIN TEV01934163 NOVAMOXIN SUGAR
REDUCEDTEV
02230246 PMS-AMOXICILLIN PMS00644331 PRO-AMOX PDL
AMOXICILLIN, CLAVULANIC ACID
25MG & 6.25MG/ML Suspension
02243986 APO-AMOXI CLAV APX01916882 CLAVULIN-F 125 GSK
40MG & 5.7MG/ML Suspension
02288559 APO-AMOXI CLAV APX02238831 CLAVULIN 200 GSK
50MG & 12.5MG/ML Suspension
02243987 APO-AMOXI CLAV APX01916874 CLAVULIN-F 250 GSK
80MG & 11.4MG/ML Suspension
02238830 CLAVULIN 400 GSK250MG & 125MG Tablet
02243350 APO-AMOXI CLAV APX500MG & 125MG Tablet
02326515 AMOXI-CLAV PDL02243351 APO-AMOXI CLAV APX01916858 CLAVULIN-F GSK02243771 RATIO-ACLAVULANATE RPH
08:12.16 PENICILLINS
AMOXICILLIN, CLAVULANIC ACID
875MG & 125MG Tablet
02326523 AMOXI-CLAV PDL02245623 APO-AMOXI CLAV APX02238829 CLAVULIN GSK02248138 NOVO-CLAVAMOXIN TEV02247021 RATIO-ACLAVULANATE RPH
AMPICILLIN
250MG Capsule
00020877 NOVO-AMPICILLIN TEV500MG Capsule
00020885 NOVO-AMPICILLIN TEV50MG/ML Suspension
00603287 APO-AMPICILLIN APX
CLOXACILLIN
250MG Capsule
02069660 CLOXACILLINE PRO00337765 NOVO-CLOXIN TEV
500MG Capsule
02069679 CLOXACILLINE PRO00337773 NOVO-CLOXIN TEV
25MG/ML Suspension
00337757 NOVO-CLOXIN TEV
PENICILLIN V POTASSIUM
25MG/ML Suspension
00642223 APO-PEN VK APX60MG/ML Suspension
00642231 APO-PEN VK APX00391603 NOVO-PEN VK TEV
300MG Tablet
00642215 APO-PEN VK APX00717568 NU-PEN VK NXP00468029 PENICILLINE V PDL
PIVMECILLINAM HCL
200MG Tablet
00657212 SELEXID LEO
Page 4 of 1382014
Non-Insured Health BenefitsHealth Canada
08:12.18 QUINOLONES
CIPROFLOXACIN HCL
250MG Tablet
02229521 APO-CIPROFLOX APX02381907 AURO-CIPROFLOXACIN AUR02155958 CIPRO BAY02353318 CIPROFLOXACIN SAN02386119 CIPROFLOXACIN SIV02247339 CO-CIPROFLOXACIN ACT02245647 GEN-CIPROFLOXACIN GEN02380358 JAMP-CIPROFLOXACIN JAP02379686 MAR-CIPROFLOXACIN MAR02317427 MINT-CIPROFLOXACIN MIN02161737 NOVO-CIPROFLOXACIN TEV02251310 PHL-CIPROFLOXACIN PHH02248437 PMS-CIPROFLOXACIN PMS02317796 PRO-CIPROFLOXACIN PDL02303728 RAN-CIPROFLOX RBY02246825 RATIO-CIPROFLOXACIN RPH02251221 RIVA-CIPROFLOXACIN RIV02248756 SANDOZ-CIPROFLOXACIN SDZ02379627 SEPTA-CIPROFLOXACIN SPT02266962 TARO-CIPROFLOXACIN TAR
500MG Tablet
02229522 APO-CIPROFLOX APX02381923 AURO-CIPROFLOXACIN AUR02155966 CIPRO BAY02353326 CIPROFLOXACIN SAN02386127 CIPROFLOXACIN SIV02247340 CO-CIPROFLOXACIN ACT02251280 DOM-CIPROFLOXACIN DPC02245648 GEN-CIPROFLOXACIN GEN02380366 JAMP-CIPROFLOXACIN JAP02379694 MAR-CIPROFLOXACIN MAR02317435 MINT-CIPROFLOXACIN MIN02161745 NOVO-CIPROFLOXACIN TEV02251329 PHL-CIPROFLOXACIN PHH02248438 PMS-CIPROFLOXACIN PMS02317818 PRO-CIPROFLOXACIN PDL02303736 RAN-CIPROFLOX RBY02246826 RATIO-CIPROFLOXACIN RPH02248757 RHOXAL-CIPROFLOXACIN RHO02251248 RIVA-CIPROFLOXACIN RIV02379635 SEPTA-CIPROFLOXACIN SPT02266970 TARO-CIPROFLOXACIN TAR
08:12.18 QUINOLONES
CIPROFLOXACIN HCL
750MG Tablet
02229523 APO-CIPROFLOX APX02381931 AURO-CIPROFLOXACIN AUR02155974 CIPRO BAY02353334 CIPROFLOXACIN SAN02247341 CO-CIPROFLOXACIN ACT02245649 GEN-CIPROFLOXACIN GEN02380374 JAMP-CIPROFLOXACIN JAP02379708 MAR-CIPROFLOXACIN MAR02317443 MINT-CIPROFLOXACIN MIN02161753 NOVO-CIPROFLOXACIN TEV02251337 PHL-CIPROFLOXACIN PHH02248439 PMS-CIPROFLOXACIN PMS02303744 RAN-CIPROFLOX RBY02246827 RATIO-CIPROFLOXACIN RPH02248758 RHOXAL-CIPROFLOXACIN RHO02251256 RIVA-CIPROFLOXACIN RIV02379643 SEPTA-CIPROFLOXACIN SPT
LEVOFLOXACIN
Limited use benefit (prior approval not required).
Coverage will be limited to a maximum of 30 days.250MG Tablet
02284707 APO-LEVOFLOXACIN APX02315424 CO-LEVOFLOXACIN ACT02236841 LEVAQUIN JNO02313979 MYLAN-LEVOFLOXACIN MYL02248262 NOVO-LEVOFLOXACIN TEV02284677 PMS-LEVOFLOXACIN PMS02298635 SANDOZ LEVOFLOXACIN SDZ
500MG Tablet
02284715 APO-LEVOFLOXACIN APX02315432 CO-LEVOFLOXACIN ACT02236842 LEVAQUIN JNO02313987 MYLAN-LEVOFLOXACIN MYL02248263 NOVO-LEVOFLOXACIN TEV02284685 PMS-LEVOFLOXACIN PMS02298643 SANDOZ LEVOFLOXACIN SDZ
750MG Tablet
02325942 APO-LEVOFLOXACIN APX02315440 CO-LEVOFLOXACIN ACT02246804 LEVAQUIN JNO02285649 NOVO-LEVOFLOXACIN TEV02305585 PMS-LEVOFLOXACIN PMS02298651 SANDOZ LEVOFLOXACIN SDZ
NORFLOXACIN
400MG Tablet
02229524 APO-NORFLOX APX02269627 CO-NORFLOXACIN ACT02237682 NOVO-NORFLOXACIN TEV02246596 PMS-NORFLOXACIN PMS
OFLOXACIN
200MG Tablet
02231529 APO-OFLOX APX
Page 5 of 1382014
Non-Insured Health BenefitsHealth Canada
08:12.18 QUINOLONES
OFLOXACIN
300MG Tablet
02231531 APO-OFLOX APX02243475 NOVO-OFLOXACIN TEV
400MG Tablet
02231532 APO-OFLOX APX
08:12.20 SULFONAMIDES
SULFAMETHOXAZOLE
500MG Tablet
00421480 APO-SULFAMETHOXAZOLE APX
SULFAMETHOXAZOLE, TRIMETHOPRIM
40MG & 8MG/ML Suspension
00726540 NOVO-TRIMEL TEV100MG & 20MG Tablet
00445266 APO-SULFATRIM PED APX400MG & 80MG Tablet
00445274 APO-SULFATRIM APX00510637 NOVO-TRIMEL TEV
800MG & 160MG Tablet
00445282 APO-SULFATRIM DS APX00510645 NOVO-TRIMEL DS TEV00512524 PROTRIN DF PRO
SULFASALAZINE
500MG Enteric Coated Tablet
00598488 PMS-SULFASALAZINE PMS02064472 SALAZOPYRIN PFI
500MG Tablet
00598461 PMS-SULFASALAZINE PMS02064480 SALAZOPYRIN PFI
08:12.24 TETRACYCLINES
DOXYCYCLINE
100MG Capsule
00740713 APO-DOXY APX00817120 DOXYCIN RIV02351234 DOXYCYCLINE SAN00725250 NOVO-DOXYLIN TEV
100MG Tablet
00874256 APO-DOXY APX00860751 DOXYCIN RIV02351242 DOXYCYCLINE SAN00887064 DOXYTAB PDL02158574 NOVO-DOXYLIN TEV
08:12.24 TETRACYCLINES
MINOCYCLINE HCL
Limited use benefit (prior approval required).
For:a. - patients who cannot tolerate other tetracyclines.b. - patients with severe widespread acne who have failed on tetracycline.
50MG Capsule
02084090 APO-MINOCYCLINE APX02239667 DOM-MINOCYCLINE DPC02287226 MINOCYCLINE SAN02108143 NOVO-MINOCYCLINE TEV02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS02294419 PMS-MINOCYCLINE PMS01914138 RATIO-MINOCYCLINE RPH02242080 RIVA-MINOCYCLINE RIV02237313 SANDOZ-MINOCYCLINE SDZ
100MG Capsule
02084104 APO-MINOCYCLINE APX02239668 DOM-MINOCYCLINE DPC02173506 MINOCIN STI02239982 MINOCYCLINE IVX02287234 MINOCYCLINE SAN02108151 NOVO-MINOCYCLINE TEV02154366 PDL-MINOCYCLINE PDL02294427 PMS-MINOCYCLINE PMS02239239 PMS-MONOCYCLINE PMS01914146 RATIO-MINOCYCLINE RPH02242081 RIVA-MINOCYCLINE RIV02237314 SANDOZ-MINOCYCLINE SDZ
TETRACYCLINE HCL
250MG Capsule
00580929 APO-TETRA APX00156744 TETRACYCLINE PRO
08:12.28 MISCELLANEOUS ANTIBIOTICS
CLINDAMYCIN HCL
150MG Capsule
02245232 APO-CLINDAMYCIN APX02400529 CLINDAMYCIN SAN02248525 CLINDAMYCINE PDL00030570 DALACIN C PFI02258331 GEN-CLINDAMYCIN GEN02241709 NOVO-CLINDAMYCIN TEV
300MG Capsule
02245233 APO-CLINDAMYCIN APX02400537 CLINDAMYCIN SAN02248526 CLINDAMYCINE PDL02182866 DALACIN C PFI02258358 GEN-CLINDAMYCIN GEN02241710 NOVO-CLINDAMYCIN TEV
CLINDAMYCIN PALMITATE HCL
15MG/ML Solution
00225851 DALACIN C PFI
Page 6 of 1382014
Non-Insured Health BenefitsHealth Canada
08:12.28 MISCELLANEOUS ANTIBIOTICS
LINEZOLID
Limited use benefit (prior approval required).
Tablets:
For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.
I.V. solution:
When linezolid cannot be administered orally in the above mentioned situations.
2MG/ML Injection
02243685 ZYVOXAM PFI600MG Tablet
02243684 ZYVOXAM PFI
08:14.04 ALLYLAMINES
TERBINAFINE HCL
250MG Tablet
02320134 AURO-TERBINAFINE AUR02299275 DOM-TERBINAFINE DOM02357070 JAMP-TERBINAFINE JAP02294273 PMS-TERBINAFINE PMS02353121 TERBINAFINE SAN02385279 TERBINAFINE SIV02242735 TERBINAFINE-250 PDL
250MG Tablet
02239893 APO-TERBINAFINE APX02254727 CO-TERBINAFINE ACT02242503 GEN-TERBINAFINE GEN02031116 LAMISIL NVR02240346 NOVO-TERBINAFINE TEV02240807 PMS-TERBINAFINE PMS02262177 SANDOZ-TERBINAFINE SDZ
08:14.08 AZOLES
FLUCONAZOLE
150MG Capsule
02241895 APO-FLUCONAZOLE APX02311690 CANESORAL BAY02323419 CO FLUCONAZOLE ACT02141442 DIFLUCAN PFI02243645 NOVO-FLUCONAZOLE TEV02246620 PMS-FLUCONAZOLE PMS02282348 PMS-FLUCONAZOLE PMS02255510 RIVA-FLUCONAZOLE RIV
10MG/ML Suspension
02024152 DIFLUCAN PFI
08:14.08 AZOLES
FLUCONAZOLE
50MG Tablet
02237370 APO-FLUCONAZOLE APX02281260 CO FLUCONAZOLE ACT00891800 DIFLUCAN PFI02245292 GEN-FLUCONAZOLE GEN02236978 NOVO-FLUCONAZOLE TEV02245643 PMS-FLUCONAZOLE PMS02249294 TARO-FLUCONAZOLE TAR
100MG Tablet
02237371 APO-FLUCONAZOLE APX02281279 CO FLUCONAZOLE ACT02246109 DOM-FLUCONAZOLE PMS02245293 GEN-FLUCONAZOLE GEN02236979 NOVO-FLUCONAZOLE TEV02245644 PMS-FLUCONAZOLE PMS02310686 PRO-FLUCONAZOLE PDL02249308 TAR0-FLUCONAZOLE TAR
ITRACONAZOLE
100MG Capsule
02047454 SPORANOX JNO10MG/ML Solution
02231347 SPORANOX JNO
KETOCONAZOLE
200MG Tablet
02237235 APO-KETOCONAZOLE APX02231061 NOVO-KETOCONAZOLE TEV
VORICONAZOLE
Limited use benefit (prior approval required).
For the treatment of:a. - patients with invasive aspergillosis.b. - culture proven invasive candidiasis with documented resistance to fluconazole.
50MG Tablet
02256460 VFEND PFI200MG Tablet
02256479 VFEND PFI
08:14.28 POLYENES
NYSTATIN
100,000U/ML Suspension
02125145 DOM-NYSTATIN DPC00792667 PMS-NYSTATIN PMS02194201 RATIO-NYSTATIN RPH
500,000U Tablet
02194198 RATIO-NYSTATIN RPH
08:16.04 ANTITUBERCULOSIS AGENTS
ETHAMBUTOL HCL
100MG Tablet
00247960 ETIBI VAE400MG Tablet
00247979 ETIBI VAE
Page 7 of 1382014
Non-Insured Health BenefitsHealth Canada
08:16.04 ANTITUBERCULOSIS AGENTS
ISONIAZID
10MG/ML Syrup
00265500 ISOTAMINE VAE00577812 PMS-ISONIAZID PMS
300MG Tablet
00272655 ISOTAMINE VAE00577804 PMS-ISONIAZID PMS
PYRAZINAMIDE
500MG Tablet
00618810 PMS-PYRAZINAMIDE PMS00283991 TEBRAZID VAE
RIFABUTIN
150MG Capsule
02063786 MYCOBUTIN PFI
RIFAMPIN
150MG Capsule
02091887 RIFADIN SAC00393444 ROFACT VAE
300MG Capsule
02092808 RIFADIN SAC00343617 ROFACT VAE
08:18.04 ADAMANTANES
AMANTADINE HCL
100MG Capsule
02130963 DOM-AMANTADINE DPC02139200 GEN-AMANTADINE GEN01990403 PMS-AMANTADINE PMS
10MG/ML Syrup
02022826 PMS-AMANTADINE PMS
08:18.08 ANTIRETROVIRALS
ABACAVIR
20MG/ML Oral Liquid
02240358 ZIAGEN GSK300MG Tablet
02240357 ZIAGEN GSK
ABACAVIR, LAMIVUDINE
600MG & 300MG Tablet
02269341 KIVEXA GSK
ABACAVIR, LAMIVUDINE, ZIDOVUDINE
300MG & 150MG & 300MG Tablet
02244757 TRIZIVIR GSK
ATAZANAVIR SULFATE
150MG Capsule
02248610 REYATAZ BMS200MG Capsule
02248611 REYATAZ BMS300MG Capsule
02294176 REYATAZ BMS
08:18.08 ANTIRETROVIRALS
COBICISTAT, EMTRICITABINE,
ELVITEGRAVIR, TENOFOVIR
150MG & 200MG & 150MG & 300MG Tablet
02397137 STRIBILD GIL
DARUNAVIR ETHANOLATE
75MG Tablet
02338432 PREZISTA JNO150MG Tablet
02369753 PREZISTA JNO400MG Tablet
02324016 PREZISTA JNO600MG Tablet
02324024 PREZISTA JNO800MG Tablet
02393050 PREZISTA KEG
DIDANOSINE
125MG Capsule
02244596 VIDEX EC BMS200MG Capsule
02244597 VIDEX EC BMS250MG Capsule
02244598 VIDEX EC BMS400MG Capsule
02244599 VIDEX EC BMS
EFAVIRENZ
50MG Capsule
02239886 SUSTIVA BMS200MG Capsule
02239888 SUSTIVA BMS600MG Tablet
02381524 MYLAN-EFAVIRENZ MYL02246045 SUSTIVA BMS02389762 TEVA-EFAVIRENZ TEP
EFAVIRENZ, TENOFOVIR, EMTRICITABINE
600MG & 300MG & 200MG Tablet
02300699 ATRIPLA BMS
EMTRICITABINE, RILPIVIRINE, TENOFOVIR
DISOPROXIL FUMARATE
200MG & 25MG & 300MG Tablet
02374129 COMPLERA GIL
EMTRICITABINE, TENOFOVIR DISOPROXIL
FUMARATE
200MG& 300MG Tablet
02274906 TRUVADA GIL
Page 8 of 1382014
Non-Insured Health BenefitsHealth Canada
08:18.08 ANTIRETROVIRALS
ETRAVIRINE
Limited use benefit (prior approval required).
For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:a.- have failed prior antiretroviral therapy; andb. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs
100MG Tablet
02306778 INTELENCE JNO200MG Tablet
02375931 INTELENCE KEG
FOSAMPRENAVIR CALCIUM
50MG/ML Oral Suspension
02261553 TELZIR GSK700MG Tablet
02261545 TELZIR GSK
INDINAVIR SULFATE
200MG Capsule
02229161 CRIXIVAN FRS400MG Capsule
02229196 CRIXIVAN FRS
LAMIVUDINE
10MG/ML Solution
02192691 3TC GSK100MG Tablet
02393239 APO-LAMIVUDINE HBV APX02239193 HEPTOVIR GSK
150MG Tablet
02192683 3TC GSK02369052 APO-LAMIVUDINE APX
300MG Tablet
02247825 3TC GSK02369060 APO-LAMIVUDINE APX
LAMIVUDINE, ZIDOVUDINE
150MG & 300MG Tablet
02375540 APO-LAMIVUDINE-ZIDOVUDINE APX02239213 COMBIVIR GSK02387247 TEVA-
LAMIVUDINE/ZIDOVUDINETEP
LOPINAVIR, RITONAVIR
133.3MG & 33.3MG Capsule
02243643 KALETRA ABB80MG & 20MG/ML Oral Solution
02243644 KALETRA ABB100MG & 25MG Tablet
02312301 KALETRA ABV200MG & 50MG Tablet
02285533 KALETRA ABB
08:18.08 ANTIRETROVIRALS
MARAVIROC
Limited use benefit (prior approval required).
For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:a. - CR5 tropic viruses; andb. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)
150MG Tablet
02299844 CELSENTRI VII300MG Tablet
02299852 CELSENTRI VII
NELFINAVIR MESYLATE
50MG/G Powder for Suspension
02238618 VIRACEPT PFI250MG Tablet
02238617 VIRACEPT PFI625MG Tablet
02248761 VIRACEPT PFI
NEVIRAPINE
200MG Tablet
02318601 AURO-NEVIRAPINE AUR02387727 MYLAN-NEVIRAPINE MYL02405776 PMS-NEVIRAPINE PMS02352893 TEVA-NEVIRAPINE TEP02238748 VIRAMUNE BOE
RALTEGRAVIR
Limited use benefit (prior approval required).
For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.
400MG Tablet
02301881 ISENTRESS FRS
RILPIVIRINE HYDROCHLORIDE
25MG Tablet
02370603 EDURANT KEG
RITONAVIR
100MG Capsule
02241480 NORVIR SEC ABB80MG/ML Liquid
02229145 NORVIR ABB100MG Tablet
02357593 NORVIR ABV
SAQUINAVIR MESYLATE
200MG Capsule
02216965 INVIRASE HLR500MG Tablet
02279320 INVIRASE HLR
Page 9 of 1382014
Non-Insured Health BenefitsHealth Canada
08:18.08 ANTIRETROVIRALS
STAVUDINE
15MG Capsule
02216086 ZERIT BMS20MG Capsule
02216094 ZERIT BMS30MG Capsule
02216108 ZERIT BMS40MG Capsule
02216116 ZERIT BMS
TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required).
For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.
245MG Tablet
02247128 VIREAD GIL
TIPRANAVIR
Limited use benefit (prior approval required).
For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitorsb. - intolerant to all currently listed protease inhibitors
250MG Capsule
02273322 APTIVUS BOE
ZIDOVUDINE
100MG Capsule
01946323 APO-ZIDOVUDINE APX01902660 RETROVIR GSK
10MG/ML Syrup
01902652 RETROVIR GSK
08:18.20 INTERFERONS
PEGINTERFERON ALFA-2A
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
180MCG/0.5ML Injection
02248077 PEGASYS HLR180MCG/1ML Injection
02248078 PEGASYS HLR
08:18.20 INTERFERONS
PEGINTERFERON ALFA-2A, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
180MCG/0.5ML & 200MG Injection & Tablet
02253429 PEGASYS RBV HLR180MCG/1ML & 200MG Injection & Tablet
02253410 PEGASYS RBV HLR
PEGINTERFERON ALFA-2B, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
50MCG/0.5ML & 200MG Injection & Capsule
02246026 PEGETRON SCH02254573 PEGETRON REDIPEN SCH
80MCG/0.5ML & 200MG Injection & Capsule
02254581 PEGETRON REDIPEN SCH100MCG/0.5ML & 200MG Injection & Capsule
02254603 PEGETRON REDIPEN SCH120MCG/0.5ML & 200MG Injection & Capsule
02254638 PEGETRON REDIPEN SCH150MCG/0.5ML & 200MG Injection & Capsule
02246030 PEGETRON SCH02254646 PEGETRON REDIPEN SCH
08:18.32 NUCLEOSIDES AND
NUCLEOTIDES
ACYCLOVIR
40MG/ML Suspension
00886157 ZOVIRAX GSK200MG Tablet
02286556 ACYCLOVIR SAN02207621 APO-ACYCLOVIR APX02242784 GEN-ACYCLOVIR GEN02285959 NOVO-ACYCLOVIR TEV02078627 RATIO-ACYCLOVIR RPH00634506 ZOVIRAX GSK
Page 10 of 1382014
Non-Insured Health BenefitsHealth Canada
08:18.32 NUCLEOSIDES AND
NUCLEOTIDES
ACYCLOVIR
400MG Tablet
02286564 ACYCLOVIR SAN02207648 APO-ACYCLOVIR APX02242463 GEN-ACYCLOVIR GEN02285967 NOVO-ACYCLOVIR TEV02078635 RATIO-ACYCLOVIR RPH01911627 ZOVIRAX GSK
800MG Tablet
02286572 ACYCLOVIR SAN02207656 APO-ACYCLOVIR APX02242464 GEN-ACYCLOVIR GEN02285975 NOVO-ACYCLOVIR TEV02078651 RATIO-ACYCLOVIR RPH
ENTECAVIR
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.
0.5MG Tablet
02396955 APO-ENTECAVIR APX
FAMCICLOVIR
125MG Tablet
02292025 APO-FAMCICLOVIR APX02305682 CO FAMCICLOVIR ACT02324865 FAMCICLOVIR PDL02229110 FAMVIR NVR02278081 PMS-FAMCICLOVIR PMS02278634 SANDOZ-FAMCICLOVIR SDZ
250MG Tablet
02292041 APO-FAMCICLOVIR APX02305690 CO FAMCICLOVIR ACT02229129 FAMVIR NVR02278103 PMS-FAMCICLOVIR PMS02278642 SANDOZ-FAMCICLOVIR SDZ
500MG Tablet
02292068 APO-FAMCICLOVIR APX02305704 CO FAMCICLOVIR ACT02177102 FAMVIR NVR02278111 PMS-FAMCICLOVIR PMS02278650 SANDOZ-FAMCICLOVIR SDZ
GANCICLOVIR SODIUM
500MG Injection
02162695 CYTOVENE HLR
08:18.32 NUCLEOSIDES AND
NUCLEOTIDES
VALACYCLOVIR HCL
500MG Tablet
02331748 CO VALACYCLOVIR ACT02307936 DOM-VALACYCLOVIR DOM02351579 MYLAN-VALACYCLOVIR MYL02357534 NOVO-VALACYCLOVIR TEP02315173 PRO-VALACYCLOVIR PDL02316447 RIVA-VALACYCLOVIR RIV02219492 VALTREX GSK
VALGANCICLOVIR HCL
450MG Tablet
02393824 APO-VALGANCICLOVIR APX02245777 VALCYTE HLR
08:18.40
BOCEPREVIR
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria:
-detectable levels of hepatitis C virus RNA in the last six months;- fibrosis stage of F2, F3 or F4;-one course of treatment only (maximum of 44 weeks, based on response).
200MG Capsule
02370816 VICTRELIS FRS
BOCEPREVIR, PEGINTERFERON, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b) + ribavirin), and the following criteria:
-detectable levels of hepatitis C virus RNA in the last six months;- fibrosis stage of F2, F3 or F4;-one course of treatment only (maximum of 44 weeks, based on response).
200MG & 100 MCG & 200MG Kit
02371456 VICTRELIS TRIPLE FRS200MG & 120 MCG & 200MG Kit
02371464 VICTRELIS TRIPLE FRS200MG & 150 MCG & 200MG Kit
02371472 VICTRELIS TRIPLE FRS200MG & 80 MCG & 200MG Kit
02371448 VICTRELIS TRIPLE FRS
Page 11 of 1382014
Non-Insured Health BenefitsHealth Canada
08:18.92 MISCELLANEOUS ANTIVIRALS
TELAPREVIR
Limited use benefit (prior approval required).
For the treatment of chronic Hepatitis C in treatment-naïve and treatment experienced patients who meet all the following criteria before consideration:- HCV genotype 1 - Detectable levels of hepatitis C virus HCV RNA in the last six months.- Fibrosis stage F2 or greater (Metavir scale or equivalent). Copy of report is required - No diagnosis of cirrhosis OR compensated liver disease (cirrhosis with a Child Pugh Score = A (5-6))
375MG Tablet
02371553 INCIVEK VPC
08:30.04 AMEBICIDES
DIIODOHYDROXYQUIN
210MG Tablet
01997769 DIODOQUIN GLE650MG Tablet
01997750 DIODOQUIN GLE
PAROMOMYCIN SULFATE
250MG Capsule
02078759 HUMATIN ERF
08:30.08 ANTIMALARIALS
CHLOROQUINE PHOSPHATE
250MG Tablet
00021261 NOVO-CHLOROQUINE TEV
HYDROXYCHLOROQUINE SULFATE
200MG Tablet
02246691 APO-HYDROXYQUINE APX02252600 GEN-HYDROXYCHLOROQUINE GEN02017709 PLAQUENIL SAC
PRIMAQUINE PHOSPHATE
26.3MG Tablet
02017776 PRIMAQUINE SAC
PYRIMETHAMINE
25MG Tablet
00004774 DARAPRIM GSK
08:30.92 MISCELLANEOUS
ANTIPROTOZOALS
ATOVAQUONE
150MG/ML Suspension
02217422 MEPRON GSK
METRONIDAZOLE
500MG Capsule
02248562 APO-METRONIDAZOLE APX00783137 TRIKACIDE PMS
250MG Tablet
00545066 APO-METRONIDAZOLE APX00420409 METRONIDAZOLE PDL
08:36.00 URINARY ANTI-INFECTIVES
NITROFURANTOIN
50MG Capsule
02231015 NOVO-FURANTOIN TEV100MG Capsule
02063662 MACROBID PGP02231016 NOVO-FURANTOIN TEV
50MG Tablet
00319511 APO-NITROFURANTOIN APX100MG Tablet
00312738 APO-NITROFURANTOIN APX
TRIMETHOPRIM
100MG Tablet
02243116 APO-TRIMETHOPRIM APX200MG Tablet
02243117 APO-TRIMETHOPRIM APX
Page 12 of 1382014
Non-Insured Health BenefitsHealth Canada
10:00 ANTINEOPLASTIC AGENTS
10:00.00 ANTINEOPLASTIC AGENTS
ALTRETAMINE
50MG Capsule
02126230 HEXALEN LIL
ANASTROZOLE
1MG Tablet
02374420 APO-ANASTROZOLE APX02224135 ARIMIDEX AZC02394898 CO-ANASTROZOLE ACT02339080 JAMP-ANASTROZOLE JAP02379562 MAR-ANASTROZOLE MAR02379104 MED-ANASTROZOLE GMP02393573 MINT-ANASTROZOLE MIN02361418 MYLAN-ANASTROZOLE MYL02320738 PMS-ANASTROZOLE PMS02328690 RAN-ANASTROZOLE RBY02392259 RIVA-ANASTROZOLE RIV02338467 SANDOZ ANASTROZOLE SDZ02365650 TARO-ANASTROZOLE TAR02313049 TEVA-ANASTROZOLE TEP
BICALUTAMIDE
50MG Tablet
02296063 APO-BICALUTAMIDE APX02325985 BICALUTAMIDE ACC02382423 BICALUTAMIDE SIV02184478 CASODEX AZC02274337 CO-BICALUTAMIDE ACT02302403 GEN-BICALUTAMIDE GEN02357216 JAMP-BICALUTAMIDE JAP02270226 NOVO-BICALUTAMIDE TEV02275589 PMS-BICALUTAMIDE PMS02311038 PRO-BICALUTAMIDE PDL02371324 RAN-BICALUTAMIDE RBY02276089 SANDOZ-BICALUTAMIDE SDZ
BUSERELIN ACETATE
1MG/ML Injection
02225166 SUPREFACT SAC1MG/ML Nasal Solution
02225158 SUPREFACT SAC6.3MG/IMPLANT Subcutaneous Injection
02228955 SUPREFACT DEPOT 2 MONTHS
SAC
9.45MG/IMPLANT Subcutaneous Injection
02240749 SUPREFACT DEPOT 3 MONTHS
SAC
BUSULFAN
2MG Tablet
00004618 MYLERAN GSK
CAPECITABINE
150MG Tablet
02400022 TEVA-CAPECITABINE TEP02238453 XELODA HLR
10:00.00 ANTINEOPLASTIC AGENTS
CAPECITABINE
500MG Tablet
02400030 TEVA-CAPECITABINE TEP02238454 XELODA HLR
CHLORAMBUCIL
2MG Tablet
00004626 LEUKERAN GSK
CYCLOPHOSPHAMIDE
25MG Tablet
02241795 PROCYTOX BAT50MG Tablet
02241796 PROCYTOX BAT
CYPROTERONE ACETATE
50MG Tablet
00704431 ANDROCUR BEX02245898 APO-CYPROTERONE APX02390760 MED-CYPROTERONE GMP02395797 RIVA-CYPROTERONE RIV
DEGARELIX ACETATE
80MG/VIAL Injection
02337029 FIRMAGON FEI120MG/VIAL Injection
02337037 FIRMAGON FEI
ERLOTINIB HYDROCLORIDE
Limited use benefit (prior approval required).
Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown.
100MG Tablet
02269015 TARCEVA HLR150MG Tablet
02269023 TARCEVA HLR
ETOPOSIDE
50MG Capsule
00616192 VEPESID BMS
EXEMESTANE
25MG Tablet
02242705 AROMASIN PFI02390183 CO EXEMESTANE ACT
FLUDARABINE PHOSPHATE
10MG Tablet
02246226 FLUDARA BEX
FLUTAMIDE
250MG Tablet
02238560 APO-FLUTAMIDE APX00637726 EUFLEX SCH02230089 NOVO-FLUTAMIDE TEV02230104 PMS-FLUTAMIDE PMS
Page 13 of 1382014
Non-Insured Health BenefitsHealth Canada
10:00.00 ANTINEOPLASTIC AGENTS
GOSERELIN ACETATE
3.6MG/DEPOT Injection
02049325 ZOLADEX AZC10.8MG/DEPOT Injection
02225905 ZOLADEX LA AZC
HYDROXYUREA
500MG Capsule
02247937 APO-HYDROXYUREA APX02242920 GEN-HYDROXYUREA GEN00465283 HYDREA BMS02343096 HYDROXYUREA SAN
IMATINIB MESYLATE
Limited use benefit (prior approval required).
a.- For the treatment of patients with chronic myeloid leukemia (CML) in blast crisis, accelerated phase, or in chronic phase.b.- For the treatment of patients with gastrointestinal stromal tumour.c.- For newly diagnosed adult patients with Philadelphia chromosome-positive (CML).
100MG Tablet
02355337 APO-IMATINIB APX02253275 GLEEVEC NVR02399806 TEVA-IMATINIB TEP
400MG Tablet
02355345 APO-IMATINIB APX02253283 GLEEVEC NOV02399814 TEVA-IMATINIB TEP
INTERFERON ALFA-2B
6,000,000IU/ML Injection
02238674 INTRON A SCH10,000,000IU/ML Injection
02238675 INTRON A SCH10,000,000IU/VIAL Injection
02223406 INTRON A SCH15,000,000IU/ML Injection
02240693 INTRON A SCH25,000,000IU/ML Injection
02240694 INTRON A SCH50,000,000IU/ML Injection
02240695 INTRON A SCH
10:00.00 ANTINEOPLASTIC AGENTS
LETROZOLE
2.5MG Tablet
02358514 APO-LETROZOLE APX02231384 FEMARA NVR02373009 JAMP-LETROZOLE JAP02338459 LETROZOLE ACC02347997 LETROZOLE TEP02348969 LETROZOLE ACT02402025 LETROZOLE PDL02373424 MAR-LETROZOLE MAR02322315 MED-LETROZOLE GMP02372169 MYL-LETROZOLE MYL02309114 PMS-LETROZOLE PMS02372282 RAN-LETROZOLE RBY02344815 SANDOZ LETROZOLE SDZ02343657 TEVA-LETROZOLE TEP
LEUPROLIDE ACETATE
3.75MG/VIAL Injection
00884502 LUPRON DEPOT ABB7.5MG/VIAL Injection
00836273 LUPRON DEPOT ABB11.25MG/VIAL Injection
02239834 LUPRON DEPOT ABB22.5MG/VIAL Injection
02248240 ELIGARD SAC02230248 LUPRON DEPOT ABB
30MG/VIAL Injection
02248999 ELIGARD SAC02239833 LUPRON DEPOT ABB
45MG/VIAL Injection
02268892 ELIGARD SAC
LOMUSTINE
10MG Capsule
00360430 CEENU BMS40MG Capsule
00360422 CEENU BMS100MG Capsule
00360414 CEENU BMS
MEGESTROL ACETATE
40MG/ML Suspension
02168979 MEGACE BMS40MG Tablet
02195917 APO-MEGESTROL APX160MG Tablet
02195925 APO-MEGESTROL APX
MELPHALAN
2MG Tablet
00004715 ALKERAN GSK
MERCAPTOPURINE
50MG Tablet
00004723 PURINETHOL TEV
Page 14 of 1382014
Non-Insured Health BenefitsHealth Canada
10:00.00 ANTINEOPLASTIC AGENTS
METHOTREXATE SODIUM
10MG/ML Injection
02182947 METHOTREXATE MAY25MG/ML Injection
02182777 METHOTREXATE MAY02182955 METHOTREXATE MAY02398427 METHOTREXATE SDZ02099705 NOVO-METHOTREXATE TEV
2.5MG Tablet
02182963 APO-METHOTREXATE APX02170698 METHOTREXATE WAY02244798 RATIO-METHOTREXATE RPH
10MG Tablet
02182750 METHOTREXATE MAY
MITOTANE
500MG Tablet
00463221 LYSODREN BMS
NILUTAMIDE
50MG Tablet
02221861 ANANDRON SAC
PROCARBAZINE HCL
50MG Capsule
00012750 NATULAN SIG
RITUXIMAB
Limited use benefit (prior approval required).
Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents.
Treatment beyond six months will only be considered for patients who have achieved a response. (Please refer to Appendix A).
10MG/ML Injection
02241927 RITUXAN HLR
SUNITINIB MALATE
Limited use benefit (Prior approval required)
Criteria for initial six month coverage of Sutent:For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.
Criteria for assessment at every six months:There is no objective evidence of disease progression.
12.5MG Capsule
02280795 SUTENT PFI25MG Capsule
02280809 SUTENT PFI50MG Capsule
02280817 SUTENT PFI
10:00.00 ANTINEOPLASTIC AGENTS
TAMOXIFEN CITRATE
10MG Tablet
00812404 APO-TAMOX APX02088428 GEN-TAMOXIFEN GEN00851965 NOVO-TAMOXIFEN TEV02237459 PMS-TAMOXIFEN PMS
20MG Tablet
00812390 APO-TAMOX APX02089858 GEN-TAMOXIFEN GEN02048485 NOLVADEX D AZC00851973 NOVO-TAMOXIFEN TEV02237460 PMS-TAMOXIFEN PMS
TEMOZOLOMIDE
Limited use benefit (prior approval required).
For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.
5MG Capsule
02241093 TEMODAL SCH20MG Capsule
02395274 CO TEMOZOLOMIDE ACT02241094 TEMODAL SCH
100MG Capsule
02395282 CO TEMOZOLOMIDE ACT02241095 TEMODAL SCH
140MG Capsule
02395290 CO TEMOZOLOMIDE ACT02312794 TEMODAL FRS
250MG Capsule
02395312 CO TEMOZOLOMIDE ACT02241096 TEMODAL SCH
THIOGUANINE
40MG Tablet
00282081 LANVIS GSK
TRETINOIN
10MG Capsule
02145839 VESANOID HLR
TRIPTORELIN PAMOATE
3.75MG/VIAL Injection
02240000 TRELSTAR WAT11.25MG/VIAL Injection
02243856 TRELSTAR LA WAT
VINCRISTINE SULFATE
1MG/ML Injection
02143305 VINCRISTINE SULFATE TEV02183013 VINCRISTINE SULFATE MAY
Page 15 of 1382014
Non-Insured Health BenefitsHealth Canada
12:00 AUTONOMIC DRUGS
12:04.00 PARASYMPATHOMIMETIC
AGENTS
BETHANECHOL CHLORIDE
10MG Tablet
01947958 DUVOID SHI25MG Tablet
01947931 DUVOID SHI50MG Tablet
01947923 DUVOID SHI
GALANTAMINE HYDROBROMIDE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer‟s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer‟s disease; AND•MMSE score > 10; OR•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
8MG Extended Release Capsule
02339439 MYLAN-GALANTAMINE ER MYL02316943 PAT-GALANTAMINE ER JNO02398370 PMS-GALANTAMINE ER PMS02377950 TEVA-GALANTAMINE ER TEP
16MG Extended Release Capsule
02339447 MYLAN-GALANTAMINE ER MYL02316951 PAT-GALANTAMINE ER JNO02398389 PMS-GALANTAMINE ER PMS02377969 TEVA-GALANTAMINE ER TEP
24MG Extended Release Capsule
02339455 MYLAN-GALANTAMINE ER MYL02316978 PAT-GALANTAMINE ER JNO02398397 PMS-GALANTAMINE ER PMS02377977 TEVA-GALANTAMINE ER TEP
NEOSTIGMINE BROMIDE
15MG Tablet
00869945 PROSTIGMIN VAE
12:04.00 PARASYMPATHOMIMETIC
AGENTS
PILOCARPINE HCL
5MG Tablet
02402483 PILOCARPINE STE02216345 SALAGEN PFI
PYRIDOSTIGMINE BROMIDE
180MG Sustained Release Tablet
00869953 MESTINON-SR VAE60MG Tablet
00869961 MESTINON VAE
RIVASTIGMINE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer‟s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer‟s disease; AND•MMSE score > 10; OU•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
1.5MG Capsule
02336715 APO-RIVASTIGMINE APX02242115 EXELON NOV02406985 MINT-RIVASTIGMINE MIN02332809 MYLAN-RIVASTIGMINE MYL02305984 NOVO-RIVASTIGMINE TEV02306034 PMS-RIVASTIGMINE PMS02311283 RATIO-RIVASTIGMINE TEP02324563 SANDOZ RIVASTIGMINE SDZ
3MG Capsule
02336723 APO-RIVASTIGMINE APX02242116 EXELON NOV02406993 MINT-RIVASTIGMINE MIN02332817 MYLAN-RIVASTIGMINE MYL02305992 NOVO-RIVASTIGMINE TEV02306042 PMS-RIVASTIGMINE PMS02311291 RATIO-RIVASTIGMINE TEP02324571 SANDOZ RIVASTIGMINE SDZ
Page 16 of 1382014
Non-Insured Health BenefitsHealth Canada
12:04.00 PARASYMPATHOMIMETIC
AGENTS
RIVASTIGMINE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer‟s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer‟s disease; AND•MMSE score > 10; OU•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
4.5MG Capsule
02336731 APO-RIVASTIGMINE APX02242117 EXELON NOV02407000 MINT-RIVASTIGMINE MIN02332825 MYLAN-RIVASTIGMINE MYL02306018 NOVO-RIVASTIGMINE TEV02306050 PMS-RIVASTIGMINE PMS02311305 RATIO-RIVASTIGMINE TEP02324598 SANDOZ RIVASTIGMINE SDZ
6MG Capsule
02336758 APO-RIVASTIGMINE APX02242118 EXELON NOV02407019 MINT-RIVASTIGMINE MIN02332833 MYLAN-RIVASTIGMINE MYL02306026 NOVO-RIVASTIGMINE TEV02306069 PMS-RIVASTIGMINE PMS02311313 RATIO-RIVASTIGMINE TEP02324601 SANDOZ RIVASTIGMINE SDZ
2MG/ML O/L
02245240 EXELON NOV
12:08.04 ANTIPARKINSONIAN AGENTS
BENZTROPINE MESYLATE
1MG/ML Injection
02238903 BENZTROPINE OMEGA OMG1MG Tablet
00706531 PMS-BENZTROPINE PMS2MG Tablet
00426857 APO-BENZTROPINE APX00587265 PMS-BENZTROPINE PMS
12:08.04 ANTIPARKINSONIAN AGENTS
ETHOPROPAZINE HCL
50MG Tablet
01927744 PARSITAN ERF
PROCYCLIDINE HCL
0.5MG/ML Elixir
00587362 PMS-PROCYCLIDINE PMS2.5MG Tablet
00649392 PMS-PROCYCLIDINE PMS5MG Tablet
00587354 PMS-PROCYCLIDINE PMS
ROPINIROLE HCL
0.25MG Tablet
02232565 REQUIP GSK1MG Tablet
02232567 REQUIP GSK2MG Tablet
02232568 REQUIP GSK5MG Tablet
02232569 REQUIP GSK
TRIHEXYPHENIDYL HCL
0.4MG/ML Liquid
00885398 PMS-TRIHEXYPHENIDYL PMS2MG Tablet
00545058 APO-TRIHEX APX5MG Tablet
00545074 APO-TRIHEX APX
12:08.08 ANTIMUSCARINICS /
ANTISPASMODICS
IPRATROPIUM BROMIDE
250MCG/ML Inhalation Solution (Multi-Dose)
02126222 APO-IPRAVENT APX02239131 GEN-IPRATROPIUM GEN02210479 NOVO-IPRAMIDE TEV02231136 PMS-IPRATROPIUM PMS
125MCG/ML Inhalation Solution (Unit Dose)
02231135 PMS-IPRATROPIUM UDV PMS02097176 RATIO-IPRATROPIUM UDV RPH
250MCG/ML Inhalation Solution (Unit Dose)
02216221 GEN-IPRATROPIUM UDV GEN02231244 PMS-IPRATROPIUM UDV PMS02231245 PMS-IPRATROPIUM UDV PMS02097168 RATIO-IPRATROPIUM UDV RPH99001446 RATIO-IPRATROPIUM UDV RPH *
20MCG/INHALATION Inhaler HFA
02247686 ATROVENT HFA BOE0.03% Nasal Spray
02246083 APO-IPRAVENT APX02240508 DOM-IPRATROPIUM DPC02239627 PMS-IPRATROPIUM PMS
0.06% Nasal Spray
02246084 APO-IPRAVENT APX
Page 17 of 1382014
Non-Insured Health BenefitsHealth Canada
12:08.08 ANTIMUSCARINICS /
ANTISPASMODICS
IPRATROPIUM BROMIDE, SALBUTAMOL
0.2MG & 1MG/ML Inhalation Solution (Unit Dose)
02231675 COMBIVENT BOE02272695 GEN-COMBO GEN
SCOPOLAMINE BUTYLBROMIDE
10MG Tablet
00363812 BUSCOPAN BOE
TIOTROPIUM BROMIDE MONOHYDRATE
Limited use benefit (prior approval required).
For patients with chronic obstructive pulmonary disease (COPD) and who:
-did not respond to a trial of ipratropium (Atrovent); OR-did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5.
18MCG Powder for Inhalation (Capsule)
02246793 SPIRIVA BOE
12:12.04 ALPHA ADRENERGIC AGONISTS
MIDODRINE HCL
2.5MG Tablet
02278677 APO-MIDODRINE APX5MG Tablet
02278685 APO-MIDODRINE APX
12:12.08 BETA ADRENERGIC AGONISTS
FORMOTEROL FUMARATE
Limited use benefit (prior approval required).•For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid-onset, short-duration bronchodilator.
OR
•For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.
12MCG/CAP Powder for Inhalation
02230898 FORADIL NVR
FORMOTEROL FUMARATE DIHYDRATE
Limited use benefit (prior approval required).
For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, short duration bronchodilator
6MCG/DOSE Dry Powder Inhaler
02237225 OXEZE TURBUHALER AZC12MCG/DOSE Dry Powder Inhaler
02237224 OXEZE TURBUHALER AZC
12:12.08 BETA ADRENERGIC AGONISTS
FORMOTEROL FUMARATE DIHYDRATE,
BUDESONIDE
Limited use benefit (prior approval required).
•For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
OR ONE OF THE FOLLOWING
•For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.
•For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist.
6MCG & 100MCG/INHALATION Inhaler
02245385 SYMBICORT 100 TURBUHALER AZC6MCG & 200MCG/INHALATION Inhaler
02245386 SYMBICORT 200 TURBUHALER AZC
FORMOTEROL FUMARATE DIHYDRATE,
MOMETASONE FUROATE
Limited use benefit (prior approval required).
For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 200-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
5MCG & 100MCG Inhaler
02361752 ZENHALE FRS5MCG & 200MCG Inhaler
02361760 ZENHALE FRS5MCG & 50MCG Inhaler
02361744 ZENHALE FRS
INDACATEROL MALEATE
Limited use benefit (prior approval required).
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.
75MCG Capsule
02376938 ONBREZ NOV
IPRATROPIUM BROMIDE, SALBUTAMOL
0.2MG & 1MG/ML Inhalation Solution (Unit Dose)
02243789 RATIO-IPRA SAL RPH
ORCIPRENALINE SULFATE
2MG/ML Syrup
02236783 APO-ORCIPRENALINE APX
Page 18 of 1382014
Non-Insured Health BenefitsHealth Canada
12:12.08 BETA ADRENERGIC AGONISTS
SALBUTAMOL
5MG/ML Inhalation Solution (Multi-Dose)
02139324 DOM-SALBUTAMOL DPC02069571 PMS-SALBUTAMOL PMS00860808 RATIO-SALBUTAMOL RPH02154412 SANDOZ-SALBUTAMOL SDZ02213486 VENTOLIN GSK
0.5MG/ML Inhalation Solution (Unit Dose)
02208245 PMS-SALBUTAMOL PMS02239365 RATIO-SALBUTAMOL RPH
1MG/ML Inhalation Solution (Unit Dose)
02216949 DOM-SALBUTAMOL DPC02208229 PMS-SALBUTAMOL PMS01986864 RATIO-SALBUTAMOL RPH02213419 VENTOLIN PF GSK
2MG/ML Inhalation Solution (Unit Dose)
02208237 PMS-SALBUTAMOL PMS02213427 VENTOLIN PF GSK
100MCG/INHALATION Inhaler CFC-Free
02232570 AIROMIR MMH02245669 APO-SALVENT CFC FREE APX
100MCG/INHALATION Inhaler HFA
02326450 NOVO-SALBUTAMOL TEV02241497 VENTOLIN HFA GSK
2MG Tablet
02146843 APO-SALVENT APX4MG Tablet
02146851 APO-SALVENT APX
SALMETEROL XINAFOATE
Limited use benefit (prior approval required).
a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium, tiotropium or a short acting beta-agonist.
50MCG/DOSE Powder Diskus
02231129 SEREVENT DISKUS GSK50MCG/INHALATION Powder for Inhalation
02214261 SEREVENT DISKHALER GSK
12:12.08 BETA ADRENERGIC AGONISTS
SALMETEROL XINAFOATE, FLUTICASONE
PROPIONATE
Limited use benefit (prior approval required).
•For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
OR ONE OF THE FOLLOWING
•For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.
•For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonist.
25MCG & 125MCG INHALATION Inhaler
02245126 ADVAIR GSK25MCG & 250MCG INHALATION Inhaler
02245127 ADVAIR GSK50MCG & 100MCG Inhaler
02240835 ADVAIR DISKUS 100 GSK50MCG & 250MCG Inhaler
02240836 ADVAIR DISKUS 250 GSK50MCG & 500MCG Inhaler
02240837 ADVAIR DISKUS 500 GSK
TERBUTALINE SULFATE
500MCG/INHALATION Powder for Inhalation
00786616 BRICANYL TURBUHALER AZC
12:12.12 ALPHA AND BETA ADRENERGIC
AGONISTS
EPINEPHRINE
0.15MG/0.15ML Injection
02382059 ALLERJECT SAC02268205 TWINJECT PAL
0.3MG/0.3ML Injection
02382067 ALLERJECT SAC0.5MG/ML Injection
00578657 EPIPEN JR AXL1MG/ML Injection
00155357 ADRENALIN ERF00721891 EPINEPHRINE ABB00509558 EPIPEN AXL02247310 TWINJECT PAL
1MG/ML Topical Solution
00155365 ADRENALIN ERF
Page 19 of 1382014
Non-Insured Health BenefitsHealth Canada
12:16.00 SYMPATHOLYTIC AGENTS
DIHYDROERGOTAMINE MESYLATE
1MG/ML Injection
00027243 DIHYDROERGOTAMINE STE02241163 DIHYDROERGOTAMINE SDZ
4MG/ML Nasal Spray
02228947 MIGRANAL STE
12:16.04 ALPHA-ADRENERGIC BLOCKING
AGENTS
ALFUZOSIN HYDROCHLORIDE
10MG Sustained Release TabletST
02315866 APO-ALFUZOSIN ER APX02304678 SANDOZ ALFUZOSIN SDZ02314282 TEVA-ALFUZOSIN PR TEP02245565 XATRAL SAC
TAMSULOSIN HCL
0.4MG Long Acting CapsuleST
02298570 MYLAN-TAMSULOSIN MYL02281392 NOVO-TAMSULOSIN TEV02294265 RATIO-TAMSULOSIN RPH09857334 RATIO-TAMSULOSIN RAT02295121 SANDOZ TAMSULOSIN SDZ
0.4MG Long Acting TabletST
02362406 APO-TAMSULOSIN CR APX02270102 FLOMAX CR BOE02340208 SANDOZ TAMSULOSIN SDZ
12:20.04 CENTRALL ACTING SKELETAL
MUSCLE RELAXANTS
CYCLOBENZAPRINE HCL
Limited use benefit (prior approval is not required).
For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks renewable every two (2) months.
10MG Tablet
02177145 APO-CYCLOBENZAPRINE APX02348853 AURO-CYCLOBENZAPRINE AUR02220644 CYCLOBENZAPRINE PDL02287064 CYCLOBENZAPRINE SAN02238633 DOM-CYCLOBENZAPRINE DPC02231353 GEN-CYCLOPRINE GEN02357127 JAMP-CYCLOBENZAPRINE JAP02080052 NOVO-CYCLOPRINE TEV02249359 PHL-CYCLOBENZAPRINE PMI02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH02242079 RIVA-CYCLOBENZAPRINE RIV
12:20.04 CENTRALL ACTING SKELETAL
MUSCLE RELAXANTS
TIZANIDINE HCL
Limited use benefit (prior approval required).
For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.
4MG Tablet
02259893 APO-TIZANIDINE APX02272059 GEN-TIZANIDINE GEN02239170 ZANAFLEX ELN
12:20.08 DIRECT-ACTING SKELETAL
MUSCLE RELAXANTS
DANTROLENE SODIUM
25MG Capsule
01997602 DANTRIUM PGP100MG Capsule
01997653 DANTRIUM PGP
12:20.12 GABA-DERIVATIVE SKELETAL
MUSCLE RELAXANTS
BACLOFEN
10MG Tablet
02139332 APO-BACLOFEN APX02152584 BACLOFEN PDL02287021 BACLOFEN SAN02138271 DOM-BACLOFEN DPC02088398 GEN-BACLOFEN GEN00455881 LIORESAL NVR02236963 PHL-BACLOFEN PHH02063735 PMS-BACLOFEN PMS02236507 RATIO-BACLOFEN RPH02242150 RIVA-BACLOFEN RIV
20MG Tablet
02139391 APO-BACLOFEN APX02152592 BACLOFEN PDL02287048 BACLOFEN SAN02138298 DOM-BACLOFEN DPC02088401 GEN-BACLOFEN GEN00636576 LIORESAL DS NVR02236964 PHL-BACLOFEN PHH02063743 PMS-BACLOFEN PMS02236508 RATIO-BACLOFEN RPH02242151 RIVA-BACLOFEN RIV
Page 20 of 1382014
Non-Insured Health BenefitsHealth Canada
12:92.00 MISCELLANEOUS AUTONOMIC
DRUGS
NICOTINE (GUM)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.
2MG GumST
02091933 NICORETTE JNO80000396 THRIVE NOV
4MG GumST
02091941 NICORETTE PLUS PMJ80000118 NICOTINE PER80000402 THRIVE NOV94799972 THRIVE NOV
NICOTINE (INHALER)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 945 during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.
10MG InhalerST
02241742 NICORETTE JNO
NICOTINE (LOZENGES)
1MG Lozenges
80007461 THRIVE NOV94799970 THRIVE NOV
2MG LozengesST
02247347 NICORETTE JNO80007464 THRIVE NOV94799968 THRIVE NOV
4MG LozengesST
02247348 NICORETTE JNO
12:92.00 MISCELLANEOUS AUTONOMIC
DRUGS
NICOTINE (PATCH)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches
Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.
5MG PatchST
02028697 NICOTROL TRANSDERMAL 5MG
WAR
10MG PatchST
02029405 NICOTROL TRANSDERMAL 10MG
WAR
15MG PatchST
02029413 NICOTROL TRANSDERMAL 15MG
WAR
17.5MG PatchST
02241227 TRANSDERMAL NICOTINE NVC35MG Patch
ST
02241226 TRANSDERMAL NICOTINE NVC52.5MG Patch
ST
02241228 TRANSDERMAL NICOTINE NVC7MG Patch (Habitrol)
ST
01943057 HABITROL NVC14MG Patch (Habitrol)
ST
01943065 HABITROL NVC21MG Patch (Habitrol)
ST
01943073 HABITROL NVC36MG Patch (Nicoderm)
ST
02093111 NICODERM PMJ78MG Patch (Nicoderm)
ST
02093138 NICODERM PMJ114MG Patch (Nicoderm)
ST
02093146 NICODERM PMJ8.3MG/10CM2 Patch (Nicotrol)
ST
02065738 NICOTROL TRANSDERMAL JNO16.6MG/20CM2 Patch (Nicotrol)
ST
02065754 NICOTROL TRANSDERMAL JNO24.9MG/30CM2 Patch (Nicotrol)
ST
02065762 NICOTROL TRANSDERMAL JNO
Page 21 of 1382014
Non-Insured Health BenefitsHealth Canada
12:92.00 MISCELLANEOUS AUTONOMIC
DRUGS
VARENICLINE
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix®) when one year has elapsed from the day the initial prescription was filled.
0.5MG Tablet
02291177 CHAMPIX PFI1MG Tablet
02291185 CHAMPIX PFI0.5MG & 1MG Tablets
02298309 CHAMPIX STARTER PACK PFI
Page 22 of 1382014
Non-Insured Health BenefitsHealth Canada
20:00 BLOOD FORMATION
COAGULATION AND
THROMBOSIS
20:04.04 IRON PREPARATIONS
FERROUS FUMARATE
300MG CapsuleST
02237556 EURO-FER EUR00482064 NEO FER NEO01923420 PALAFER GSK
300MG/5ML Oral LiquidST
02246590 FERRATE O/L EUO20MG Suspension
ST
80029822 JAMP FERROUS FUMARATE JAP60MG/ML Suspension
ST
01923439 PALAFER GSK300MG Tablet
ST
00031089 FERROUS FUMARATE PED
FERROUS GLUCONATE
300MG TabletST
00545031 APO-FERROUS GLUCONATE APX00031097 FERROUS GLUCONATE PED00041157 FERROUS GLUCONATE PMS80009681 FERROUS GLUCONATE WAM80000435 NOVO-FERROGLUC TEV
324MG TabletST
00582727 FERROUS GLUCONATE VTH *
FERROUS SULFATE
15MG/ML DropST
02237385 FERODAN ODN02232202 PEDIAFER EUR02222574 PMS-FERROUS SULFATE PMS
75MG/ML DropST
00762954 FER-IN-SOL MJO30MG/ML Oral Liquid
80008295 JAMP FERROUS SULPHATE LIQUID
JAP
75MG/ML Oral Liquid
80008309 JAMP FERROUS SULPHATE INFANT
JAP
6MG/ML SyrupST
00017884 FER-IN-SOL MJO02242863 PEDIAFER EUR
30MG/ML SyrupST
00758469 FERODAN ODN00792675 PMS-FERROUS SULFATE PMS
300MG TabletST
01912518 APO-FERROUS SULFATE FC APX02246733 EURO-FERROUS SULFATE EUR02248699 FERODAN ODN00031100 FERROUS SULFATE PED00346918 FERROUS SULFATE PMT00782114 FERROUS SULFATE VTH *00586323 PMS-FERROUS SULFATE PMS
20:04.04 IRON PREPARATIONS
IRON
100MG CapsuleST
80024232 JAMP-FER JAP
IRON DEXTRAN
50MG/ML Injection
02205963 DEXIRON GEN02221780 INFUFER SDZ
IRON SUCROSE
20MG/ML Injection
02243716 VENOFER LUI
20:12.04 ANTICOAGULANTS
APIXABAN
Limited use benefit (prior approval required)
For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
* At risk patients with atrial fibrillation are defined as those 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.
2.5MG Tablet
02377233 ELIQUIS BMS5MG Tablet
02397714 ELIQUIS BMS
DABIGATRAN ETEXILATE MESILATE
Limited use benefit (prior approval required).
For at risk patients* with non-valvular atrial fibrillation who require dabigatran for the prevention of stroke and systemic embolism AND in whom: of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
110MG Capsule
02312441 PRADAXA BOE150MG Capsule
02358808 PRADAXA BOE
Page 23 of 1382014
Non-Insured Health BenefitsHealth Canada
20:12.04 ANTICOAGULANTS
DALTEPARIN SODIUM
10,000IU/ML Injection
02132664 FRAGMIN PMJ25,000IU/ML Injection (Multi-Dose)
02231171 FRAGMIN PMJ2,500IU/0.2ML Injection (Pre-filled Syringe)
02132621 FRAGMIN PMJ5,000IU/0.2ML Injection (Pre-filled Syringe)
02132648 FRAGMIN PMJ7500IU/0.3ML Injection (Pre-filled Syringe)
02352648 FRAGMIN PFI10000IU/0.4ML Injection (Pre-filled Syringe)
02352656 FRAGMIN PFI12500IU/0.5ML Injection (Pre-filled Syringe)
02352664 FRAGMIN PFI15000IU/0.6ML Injection (Pre-filled Syringe)
02352672 FRAGMIN PFI18000IU/0.72ML Injection (Pre-filled Syringe)
02352680 FRAGMIN PFI
ENOXAPARIN SODIUM
30MG/0.3ML Injection
02012472 LOVENOX SAC40MG/0.4ML Injection
02236883 LOVENOX SAC60MG/0.6ML Injection
02378426 LOVENOX SAC80MG/0.8ML Injection
02378434 LOVENOX SAC100MG/1ML Injection
02378442 LOVENOX SAC150MG/1.0ML Injection
02242692 LOVONEX HP SAC150MG/1ML Injection
02378469 LOVONEX HP SAC300MG/3ML Injection
02236564 LOVENOX SAC
HEPARIN SODIUM
1,000U/ML Injection
00453811 HEPARIN LEO LEO02303086 HEPARIN SODIUM SDZ
5,000U/ML Injection
02382334 HEPARIN SODIUM PFI10,000U/ML Injection
00579718 HEPARIN LEO LEO02303094 HEPARIN SODIUM SDZ02303108 HEPARIN SODIUM SDZ
25,000U/ML Injection
00453781 HEPARIN LEO LEO10U/ML Lock Flush
00725323 HEPARIN LOCK FLUSH ABB
20:12.04 ANTICOAGULANTS
HEPARIN SODIUM
100U/ML Lock Flush
00727520 HEPARIN LEO LEO00725315 HEPARIN LOCK FLUSH HOS
NADROPARIN CALCIUM
9,500IU/ML Injection
02236913 FRAXIPARINE GSK19,000IU/ML Injection
02240114 FRAXIPARINE FORTE GSK
NICOUMALONE
1MG Tablet
00010383 SINTROM PED4MG Tablet
00010391 SINTROM PED
RIVAROXABAN
Limited use benefit (prior approval required).
Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF)For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: •Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR•Anticoagulation with warfarin is contraindicated; ;OR•Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home) Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT)
•For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months.
15MG Tablet
02378604 XARELTO BAY20MG Tablet
02378612 XARELTO B A
RIVAROXABAN (10)
Limited use benefit (prior approval not required).
For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days.
10MG Tablet
02316986 XARELTO BAY
TINZAPARIN SODIUM
10,000IU/ML (2ML) Injection
02167840 INNOHEP LEO20,000IU/ML (2ML) Injection
02229515 INNOHEP LEO20,000IU/ML Injection (Graduated Syringe)
02231478 INNOHEP LEO
Page 24 of 1382014
Non-Insured Health BenefitsHealth Canada
20:12.04 ANTICOAGULANTS
TINZAPARIN SODIUM
10,000IU/ML Injection (Pre-filled Syringe)
02229755 INNOHEP LEO3500U SYG
02358158 INNOHEP LEO4500U SYG
02358166 INNOHEP LEO14000U SYG
02358174 INNOHEP LEO18000U SYG
02358182 INNOHEP LEO
WARFARIN SODIUM
1MG Tablet
02242924 APO-WARFARIN APX01918311 COUMADIN BMS02244462 GEN-WARFARIN GEN02265273 NOVO-WARFARIN TEV02242680 TARO-WARFARIN TAR02344025 WARFARIN SAN
2MG Tablet
02242925 APO-WARFARIN APX01918338 COUMADIN BMS02244463 GEN-WARFARIN GEN02265281 NOVO-WARFARIN TEV02242681 TARO-WARFARIN TAR02344033 WARFARIN SAN
2.5MG Tablet
02242926 APO-WARFARIN APX01918346 COUMADIN BMS02244464 GEN-WARFARIN GEN02265303 NOVO-WARFARIN TEV02242682 TARO-WARFARIN TAR02344041 WARFARIN SAN
3MG Tablet
02245618 APO-WARFARIN APX02240205 COUMADIN BMS02287498 GEN-WARFARIN GEN02265311 NOVO-WARFARIN TEV02242683 TARO-WARFARIN TAR02344068 WARFARIN SAN
4MG Tablet
02242927 APO-WARFARIN APX02007959 COUMADIN BMS02244465 GEN-WARFARIN GEN02265338 NOVO-WARFARIN TEV02242684 TARO-WARFARIN TAR02344076 WARFARIN SAN
5MG Tablet
02242928 APO-WARFARIN APX01918354 COUMADIN BMS02244466 GEN-WARFARIN GEN02265346 NOVO-WARFARIN TEV02242685 TARO-WARFARIN TAR02344084 WARFARIN SAN
20:12.04 ANTICOAGULANTS
WARFARIN SODIUM
6MG Tablet
02240206 COUMADIN BMS02287501 GEN-WARFARIN GEN02242686 TARO-WARFARIN TAR02344092 WARFARIN SAN
7.5MG Tablet
02287528 GEN-WARFARIN GEN02242697 TARO-WARFARIN TAR02344106 WARFARIN SAN
10MG Tablet
02242929 APO-WARFARIN APX01918362 COUMADIN BMS02244467 GEN-WARFARIN GEN02242687 TARO-WARFARIN TAR02344114 WARFARIN SAN
20:12.18 PLATELET AGGREGATION
INHIBITORS
ANAGRELIDE HCL
0.5MG CapsuleST
02236859 AGRYLIN SHI02253054 GEN-ANAGRELIDE GEN02274949 PMS-ANAGRELIDE PMS02260107 RHOXAL-ANAGRELIDE RHO
CLOPIDOGREL BISULFATE
Limited use benefit (prior approval not required).
Limit of 12 months following a client‟s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician.
75MG TabletST
02252767 APO-CLOPIDOGREL APX02385813 CLOPIDOGREL SIV02394820 CLOPIDOGREL PDL02400553 CLOPIDOGREL SAN02303027 CO CLOPIDOGREL ACT02378507 DOM-CLOPIDOGREL DOM02408910 MINT-CLOPIDOGREL MIN02351536 MYLAN-CLOPIDOGREL MYL02238682 PLAVIX SAC02348004 PMS CLOPIDOGREL PMS02379813 RAN-CLOPIDOGREL RBY02388529 RIVA CLOPIDOGREL RIV02359316 SANDOZ CLOPIDOGREL SDZ02293161 TEVA-CLOPIDOGREL TEP
TICLOPIDINE HCL
250MG TabletST
02237701 APO-TICLOPIDINE APX02239744 GEN-TICLOPIDINE GEN02236848 NOVO-TICLOPIDINE TEV02343045 TICLOPIDINE SAN
Page 25 of 1382014
Non-Insured Health BenefitsHealth Canada
20:16.00 HEMATOPOIETIC AGENTS
FILGRASTIM
300MCG/ML Injection
01968017 NEUPOGEN AMG
PEGFILGRASTIM
Limited use benefit (prior approval required).
a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.andb. - Where access to a health care facility is problematic.
10MG/ML Injection
02249790 NEULASTA AMG
20:24.00 HEMORRHEOLOGIC AGENTS
PENTOXIFYLLINE
400MG Sustained Release TabletST
02230090 APO-PENTOXIFYL APX
20:28.16 HEMOSTATICS
TRANEXAMIC ACID
500MG Tablet
02064405 CYKLOKAPRON PFI02401231 TRANEXAMIC ACID STE
Page 26 of 1382014
Non-Insured Health BenefitsHealth Canada
24:00 CARDIOVASCULAR DRUGS
24:04.04 ANTIARRHYTHMIC AGENTS
AMIODARONE HCL
100MG TabletST
02292173 PMS-AMIODARONE PMS200MG Tablet
ST
02364336 AMIODARONE SAN02385465 AMIODARONE SIV02246194 APO-AMIODARONE APX02036282 CORDARONE WAY02246331 DOM-AMIODARONE PMS02240604 GEN-AMIODARONE GEN02239835 NOVO-AMIODARONE TEV02242472 PMS-AMIODARONE PMS02309661 PRO-AMIODARONE-200 PDL02240071 RATIO-AMIODARONE RPH02245781 RIVA-AMIODARONE PHH02247217 RIVA-AMIODARONE RIV02243836 SANDOZ-AMIODARONE SDZ
DISOPYRAMIDE
100MG CapsuleST
02224801 RYTHMODAN SAC
FLECAINIDE ACETATE
50MG TabletST
02275538 APO-FLECAINIDE APX01966197 TAMBOCOR MMH
100MG TabletST
02275546 APO-FLECAINIDE APX01966200 TAMBOCOR MMH
MEXILETINE HCL
100MG CapsuleST
02230359 NOVO-MEXILETINE TEV200MG Capsule
ST
02230360 NOVO-MEXILETINE TEV
PROCAINAMIDE HCL
250MG CapsuleST
00713325 APO-PROCAINAMIDE APX375MG Capsule
ST
00713333 APO-PROCAINAMIDE APX500MG Capsule
ST
00713341 APO-PROCAINAMIDE APX250MG Sustained Release Tablet
ST
00638692 PROCAN SR PFI500MG Sustained Release Tablet
ST
00638676 PROCAN SR PFI750MG Sustained Release Tablet
ST
00638684 PROCAN SR PFI
24:04.04 ANTIARRHYTHMIC AGENTS
PROPAFENONE HYDROCHLORIDE
150MG TabletST
02243324 APO-PROPAFENONE APX02245372 GEN-PROPAFENONE GEN02243727 PMS-PROPAFENONE PMS02294559 PMS-PROPAFENONE PMS02243783 PROPAFENONE PDL02343053 PROPAFENONE SAN00603708 RYTHMOL ABB
300MG TabletST
02243325 APO-PROPAFENONE APX02245373 GEN-PROPAFENONE GEN02243728 PMS-PROPAFENONE PMS02294575 PMS-PROPAFENONE PMS02243784 PROPAFENONE PDL02343061 PROPAFENONE SAN00603716 RYTHMOL ABB
24:04.08 CARDIOTONIC AGENTS
DIGOXIN
0.05MG/ML ElixirST
02242320 LANOXIN VIR0.0625MG Tablet
ST
02335700 TOLOXIN PED0.125MG Tablet
ST
02335719 TOLOXIN PED0.25MG Tablet
ST
02335727 TOLOXIN PED
24:06.04 BILE ACID SEQUESTRANTS
CHOLESTYRAMINE RESIN
4G PowderST
00890960 PMS-CHOLESTYRAMINE LIGHT PMS02210320 PMS-CHOLESTYRAMINE
REGULARPMS
COLESTIPOL HCL
5G GranulesST
00642975 COLESTID PFI02132699 COLESTID ORANGE PFI
1G TabletST
02132680 COLESTID PFI
Page 27 of 1382014
Non-Insured Health BenefitsHealth Canada
24:06.05 CHOLESTEROL ABSORPTION
INHIBITORS
EZETIMIBE
Limited use benefit (prior approval required).
a.- For use in combination with a HMG-CoA reductase inhibitor („statin‟) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated “statin” doses.
b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.
10MG TabletST
02247521 EZETROL MSP
24:06.06 FIBRIC ACID DERIVATIVES
BEZAFIBRATE
400MG Sustained Release TabletST
02083523 BEZALIP SR HLR200MG Tablet
ST
02240331 PMS-BEZAFIBRATE PMS
FENOFIBRATE
67MG CapsuleST
02243180 APO-FENO-MICRO APX02243551 NOVO-FENOFIBRATE TEV
100MG CapsuleST
02225980 APO-FENOFIBRATE APX160MG Capsule
ST
02250004 FENOMAX CIP200MG Capsule
ST
02239864 APO-FENO-MICRO APX02286092 FENOFIBRATE MICRO SAN02240360 FENO-MICRO PDL02240210 GEN-FENOFIBRATE GEN02146959 LIPIDIL MICRO FOU02243552 NOVO-FENOFIBRATE TEV02250039 RATIO-FENOFIBRATE RPH02247306 RIVA-FENOFIBRATE MICRO RIV
48MG TabletST
02269074 LIPIDIL EZ FOU02390698 SANDOZ FENOFIBRATE E SDZ
100MG TabletST
02246859 APO-FENO-SUPER APX02356570 FENOFIBRATE-S SAN02241601 LIPIDIL SUPRA FOU02289083 NOVO-FENOFIBRATE-S TEV02310228 PRO-FENO-SUPER PDL02288044 SANDOZ FENOFIBRATE S SDZ
145MG TabletST
02269082 LIPIDIL EZ FOU02390701 SANDOZ FENOFIBRATE E SDZ
24:06.06 FIBRIC ACID DERIVATIVES
FENOFIBRATE
160MG TabletST
02246860 APO-FENO-SUPER APX02356589 FENOFIBRATE-S SAN02241602 LIPIDIL SUPRA FOU02289091 NOVO-FENOFIBRATE-S TEV02310236 PRO-FENO-SUPER PDL02288052 SANDOZ FENOFIBRATE S SDZ
GEMFIBROZIL
300MG CapsuleST
01979574 APO-GEMFIBROZIL APX02241608 DOM-GEMFIBROZIL DPC02185407 GEN-FIBRO GEN02241704 NOVO-GEMFIBROZIL TEV02239951 PMS-GEMFIBROZIL PMS
600MG TabletST
01979582 APO-GEMFIBROZIL APX02230580 DOM-GEMFIBROZIL DPC02136058 GEMFIBROZIL PDL02230476 GEN-GEMFIBROZIL GEN02142074 NOVO-GEMFIBROZIL TEV02242126 RIVA-GEMFIBROZIL RIV
24:06.08 HMG-COA REDUCTASE
INHIBITORS
ATORVASTATIN CALCIUM
10MG TabletST
02295261 APO-ATORVASTATIN APX02346486 ATORVASTATIN PDL02348624 ATORVASTATIN RPH02348705 ATORVASTATIN SAN02387891 ATORVASTATIN SIV02396424 ATORVASTATIN APX02411350 ATORVASTATIN-10 SIV02310899 CO ATORVASTATIN ACT02355612 DOM-ATORVASTATIN DOM02288346 GD-ATORVASTATIN PFI02391058 JAMP-ATORVASTATIN JAP02230711 LIPITOR PFI02373203 MYLAN-ATORVASTATIN MYL02302675 NOVO-ATORVASTATIN TEV02313448 PMS-ATORVASTATIN PMS02399377 PMS-ATORVASTATIN PMS02313707 RAN-ATORVASTATIN RBY02350297 RATIO-ATORVASTATIN RPH02324946 SANDOZ ATORVASTATIN SDZ
Page 28 of 1382014
Non-Insured Health BenefitsHealth Canada
24:06.08 HMG-COA REDUCTASE
INHIBITORS
ATORVASTATIN CALCIUM
20MG TabletST
02295288 APO-ATORVASTATIN APX02346494 ATORVASTATIN PDL02348632 ATORVASTATIN RPH02348713 ATORVASTATIN SAN02387905 ATORVASTATIN SIV02396432 ATORVASTATIN APX02411369 ATORVASTATIN-20 SIV02310902 CO ATORVASTATIN ACT02355620 DOM-ATORVASTATIN DOM02288354 GD-ATORVASTATIN PFI02391066 JAMP-ATORVASTATIN JAP02230713 LIPITOR PFI02373211 MYLAN-ATORVASTATIN MYL02302683 NOVO-ATORVASTATIN TEV02313456 PMS-ATORVASTATIN PMS02399385 PMS-ATORVASTATIN PMS02313715 RAN-ATORVASTATIN RBY02350319 RATIO-ATORVASTATIN RPH02324954 SANDOZ ATORVASTATIN SDZ
40MG TabletST
02295296 APO-ATORVASTATIN APX02346508 ATORVASTATIN PDL02348640 ATORVASTATIN RPH02348721 ATORVASTATIN SAN02387913 ATORVASTATIN SIV02396440 ATORVASTATIN APX02411377 ATORVASTATIN-40 SIV02310910 CO ATORVASTATIN ACT02355639 DOM-ATORVASTATIN DOM02288362 GD-ATORVASTATIN PFI02391074 JAMP-ATORVASTATIN JAP02230714 LIPITOR PFI02373238 MYLAN-ATORVASTATIN MYL02302691 NOVO-ATORVASTATIN TEV02313464 PMS-ATORVASTATIN PMS02399393 PMS-ATORVASTATIN PMS02313723 RAN-ATORVASTATIN RBY02350327 RATIO-ATORVASTATIN RPH02324962 SANDOZ ATORVASTATIN SDZ
24:06.08 HMG-COA REDUCTASE
INHIBITORS
ATORVASTATIN CALCIUM
80MG TabletST
02295318 APO-ATORVASTATIN APX02346516 ATORVASTATIN PDL02348659 ATORVASTATIN RPH02348748 ATORVASTATIN SAN02387921 ATORVASTATIN SIV02396459 ATORVASTATIN APX02411385 ATORVASTATIN-80 SIV02310929 CO ATORVASTATIN ACT02288370 GD-ATORVASTATIN PFI02390182 JAMP-ATORVASTATIN JAP02243097 LIPITOR PFI02373246 MYLAN-ATORVASTATIN MYL02302713 NOVO-ATORVASTATIN TEV02313472 PMS-ATORVASTATIN PMS02399407 PMS-ATORVASTATIN PMS02313758 RAN-ATORVASTATIN RBY02350335 RATIO-ATORVASTATIN RPH02324970 SANDOZ ATORVASTATIN SDZ
FLUVASTATIN SODIUM
20MG CapsuleST
02061562 LESCOL NVR02400235 SANDOZ FLUVASTATIN SDZ02299224 TEVA-FLUVASTATIN TEP
40MG CapsuleST
02061570 LESCOL NVR02400243 SANDOZ FLUVASTATIN SDZ02299232 TEVA-FLUVASTATIN TEP
80MG Extended Release TabletST
02250527 LESCOL XL NOV
LOVASTATIN
20MG TabletST
02220172 APO-LOVASTATIN APX02248572 CO-LOVASTATIN ACT02243127 GEN-LOVASTATIN GEN02353229 LOVASTATIN SAN00795860 MEVACOR FRS02246542 NOVO-LOVASTATIN TEV02246013 PMS-LOVASTATIN PMS02312670 PRO-LOVASTATIN PDL02272288 RIVA-LOVASTATIN RIV02247056 SANDOZ-LOVASTATIN SDZ
40MG TabletST
02220180 APO-LOVASTATIN APX02248573 CO-LOVASTATIN ACT02243129 GEN-LOVASTATIN GEN02353237 LOVASTATIN SAN00795852 MEVACOR FRS02246543 NOVO-LOVASTATIN TEV02246014 PMS-LOVASTATIN PMS02312689 PRO-LOVASTATIN PDL02272296 RIVA-LOVASTATIN RIV02247057 SANDOZ-LOVASTATIN SDZ
Page 29 of 1382014
Non-Insured Health BenefitsHealth Canada
24:06.08 HMG-COA REDUCTASE
INHIBITORS
PRAVASTATIN SODIUM
10MG TabletST
02243506 APO-PRAVASTATIN APX02248182 CO PRAVASTATIN 10MG TAB ACT02249723 DOM-PRAVASTATIN DPC02257092 GEN-PRAVASTATIN GEN02330954 JAMP-PRAVASTATIN JAP02317451 MINT-PRAVASTATIN MIN02247008 NOVO-PRAVASTATIN TEV02249766 PHL-PRAVASTATIN PMI02247655 PMS-PRAVASTATIN PMS00893749 PRAVACHOL BMS02356546 PRAVASTATIN SAN02389703 PRAVASTATIN SIV02243824 PRAVASTATIN-10 PDL02284421 RAN-PRAVASTATIN RBY02246930 RATIO-PRAVASTATIN RPH02247856 RHOXAL-PRAVASTATIN RHO02270234 RIVA-PRAVASTATIN RIV02301792 ZYM-PRAVASTATIN SOR
20MG TabletST
02243507 APO-PRAVASTATIN APX02248183 CO PRAVASTATIN 20MG TAB ACT02249731 DOM-PRAVASTATIN DPC02257106 GEN-PRAVASTATIN GEN02330962 JAMP-PRAVASTATIN JAP02317478 MINT-PRAVASTATIN MIN02247009 NOVO-PRAVASTATIN TEV02249774 PHL-PRAVASTATIN PMI02247656 PMS-PRAVASTATIN PMS00893757 PRAVACHOL BMS02356554 PRAVASTATIN SAN02389738 PRAVASTATIN SIV02243825 PRAVASTATIN-20 PDL02284448 RAN-PRAVASTATIN RBY02246931 RATIO-PRAVASTATIN RPH02247857 RHOXAL-PRAVASTATIN RHO02270242 RIVA-PRAVASTATIN RIV02301806 ZYM-PRAVASTATIN SOR
24:06.08 HMG-COA REDUCTASE
INHIBITORS
PRAVASTATIN SODIUM
40MG TabletST
02243508 APO-PRAVASTATIN APX02248184 CO PRAVASTATIN 40MG TAB ACT02249758 DOM-PRAVASTATIN DPC02257114 GEN-PRAVASTATIN GEN02330970 JAMP-PRAVASTATIN JAP02317486 MINT-PRAVASTATIN MIN02247010 NOVO-PRAVASTATIN TEV02249782 PHL-PRAVASTATIN PMI02247657 PMS-PRAVASTATIN PMS02222051 PRAVACHOL BMS02356562 PRAVASTATIN SAN02389746 PRAVASTATIN SIV02243826 PRAVASTATIN-40 PDL02284456 RAN-PRAVASTATIN RBY02246932 RATIO-PRAVASTATIN RPH02247858 RHOXAL-PRAVASTATIN RHO02270250 RIVA-PRAVASTATIN RIV02301814 ZYM-PRAVASTATIN SOR
ROSUVASTATIN CALCIUM
5MG TabletST
02337975 APO-ROSUVASTATIN APX02339765 CO ROSUVASTATIN ACT02265540 CRESTOR AZC02386704 DOM-ROSUVASTATIN DOM02391252 JAMP-ROSUVASTATIN JAP02397781 MINT-ROSUVASTATIN MIN02381265 MYLAN-ROSUVASTATIN MYL02378523 PMS-ROSUVASTATIN PMS02382644 RAN-ROSUVASTATIN RBY02380013 RIVA-ROSUVASTATIN RIV02381176 ROSUVASTATIN PDL02389037 ROSUVASTATIN SIV02405628 ROSUVASTATIN SAN02411628 ROSUVASTATIN-5 SIV02338726 SANDOZ ROSUVASTATIN SDZ02354608 TEVA-ROSUVASTATIN TEP
10MG TabletST
02337983 APO-ROSUVASTATIN APX02339773 CO ROSUVASTATIN ACT02247162 CRESTOR AZC02386712 DOM-ROSUVASTATIN DOM02391260 JAMP-ROSUVASTATIN JAP02397803 MINT-ROSUVASTATIN MIN02381273 MYLAN-ROSUVASTATIN MYL02378531 PMS-ROSUVASTATIN PMS02382652 RAN-ROSUVASTATIN RBY02380056 RIVA-ROSUVASTATIN RIV02381184 ROSUVASTATIN PDL02389045 ROSUVASTATIN SIV02405636 ROSUVASTATIN SAN02411636 ROSUVASTATIN-10 SIV02338734 SANDOZ ROSUVASTATIN SDZ02354616 TEVA-ROSUVASTATIN TEP
Page 30 of 1382014
Non-Insured Health BenefitsHealth Canada
24:06.08 HMG-COA REDUCTASE
INHIBITORS
ROSUVASTATIN CALCIUM
20MG TabletST
02337991 APO-ROSUVASTATIN APX02339781 CO ROSUVASTATIN ACT02247163 CRESTOR AZC02386720 DOM-ROSUVASTATIN DOM02391279 JAMP-ROSUVASTATIN JAP02397811 MINT-ROSUVASTATIN MIN02381281 MYLAN-ROSUVASTATIN MYL02378558 PMS-ROSUVASTATIN PMS02382660 RAN-ROSUVASTATIN RBY02380064 RIVA-ROSUVASTATIN RIV02381192 ROSUVASTATIN PDL02389053 ROSUVASTATIN SIV02405644 ROSUVASTATIN SAN02411644 ROSUVASTATIN-20 SIV02338742 SANDOZ ROSUVASTATIN SDZ02354624 TEVA-ROSUVASTATIN TEP
40MG TabletST
02338009 APO-ROSUVASTATIN APX02339803 CO ROSUVASTATIN ACT02247164 CRESTOR AZC02391287 JAMP-ROSUVASTATIN JAP02397838 MINT-ROSUVASTATIN MIN02381303 MYLAN-ROSUVASTATIN MYL02378566 PMS-ROSUVASTATIN PMS02382679 RAN-ROSUVASTATIN RBY02380102 RIVA-ROSUVASTATIN RIV02381206 ROSUVASTATIN PDL02389061 ROSUVASTATIN SIV02405652 ROSUVASTATIN SAN02411652 ROSUVASTATIN-40 SIV02338750 SANDOZ ROSUVASTATIN SDZ02354632 TEVA-ROSUVASTATIN TEP
24:06.08 HMG-COA REDUCTASE
INHIBITORS
SIMVASTATIN
5MG TabletST
02247011 APO-SIMVASTATIN APX02248103 CO-SIMVASTATIN ACT02253747 DOM-SIMVASTATIN DPC02281619 DOM-SIMVASTATIN PMS02246582 GEN-SIMVASTATIN GEN02331020 JAMP-SIMVASTATIN JAP02375591 JAMP-SIMVASTATIN JAP02375036 MAR-SIMVASTATIN MAR02372932 MINT-SIMVASTATIN MIN02250144 NOVO-SIMVASTATIN TEV02281546 PHL-SIMVASTATIN PMI02252619 PMS-SIMVASTATIN PMS02269252 PMS-SIMVASTATIN PMS02329131 RAN-SIMVASTATIN RBY02247067 RATIO-SIMVASTATIN RPH02247827 RHOXAL-SIMVASTATIN RHO02247297 RIVA-SIMVASTATIN RIV02284723 SIMVASTATIN SAN02386291 SIMVASTATIN SIV02378884 SIMVASTATIN-ODAN ODN00884324 ZOCOR FRS02300907 ZYM-SIMVASTATIN ZYM
10MG TabletST
02247012 APO-SIMVASTATIN APX02248104 CO-SIMVASTATIN ACT02253755 DOM-SIMVASTATIN DPC02281627 DOM-SIMVASTATIN PMS02246583 GEN-SIMVASTATIN GEN02331039 JAMP-SIMVASTATIN JAP02375605 JAMP-SIMVASTATIN JAP02375044 MAR-SIMVASTATIN MAR02372940 MINT-SIMVASTATIN MIN02250152 NOVO-SIMVASTATIN TEV02281554 PHL-SIMVASTATIN PMI02252635 PMS-SIMVASTATIN PMS02269260 PMS-SIMVASTATIN PMS02329158 RAN-SIMVASTATIN RBY02247068 RATIO-SIMVASTATIN RPH02247298 RIVA-SIMVASTATIN RIV02247828 SANDOZ-SIMVASTATIN SDZ02284731 SIMVASTATIN SAN02386305 SIMVASTATIN SIV02247221 SIMVASTATIN-10 PDL02378892 SIMVASTATIN-ODAN ODN02265885 TARO-SIMVASTATIN TAR00884332 ZOCOR FRS02300915 ZYM-SIMVASTATIN ZYM
Page 31 of 1382014
Non-Insured Health BenefitsHealth Canada
24:06.08 HMG-COA REDUCTASE
INHIBITORS
SIMVASTATIN
20MG TabletST
02247013 APO-SIMVASTATIN APX02248105 CO-SIMVASTATIN ACT02253763 DOM-SIMVASTATIN DPC02281635 DOM-SIMVASTATIN PMS02246737 GEN-SIMVASTATIN GEN02331047 JAMP-SIMVASTATIN JAP02375613 JAMP-SIMVASTATIN JAP02375052 MAR-SIMVASTATIN MAR02372959 MINT-SIMVASTATIN MIN02250160 NOVO-SIMVASTATIN TEV02281562 PHL-SIMVASTATIN PMI02252643 PMS-SIMVASTATIN PMS02269279 PMS-SIMVASTATIN PMS02329166 RAN-SIMVASTATIN RBY02247299 RIVA-SIMVASTATIN RIV02247830 SANDOZ-SIMVASTATIN SDZ02284758 SIMVASTATIN SAN02386313 SIMVASTATIN SIV02247222 SIMVASTATIN-20 PDL02378906 SIMVASTATIN-ODAN ODN02265893 TARO-SIMVASTATIN TAR00884340 ZOCOR FRS02300923 ZYM-SIMVASTATIN ZYM
40MG TabletST
02247014 APO-SIMVASTATIN APX02248106 CO-SIMVASTATIN ACT02253771 DOM-SIMVASTATIN DPC02281643 DOM-SIMVASTATIN PMS02246584 GEN-SIMVASTATIN GEN02331055 JAMP-SIMVASTATIN JAP02375621 JAMP-SIMVASTATIN JAP02375060 MAR-SIMVASTATIN MAR02372967 MINT-SIMVASTATIN MIN02250179 NOVO-SIMVASTATIN TEV02281570 PHL-SIMVASTATIN PMI02252651 PMS-SIMVASTATIN PMS02269287 PMS-SIMVASTATIN PMS02329174 RAN-SIMVASTATIN RBY02247300 RIVA-SIMVASTATIN RIV02247831 SANDOZ-SIMVASTATIN SDZ02284766 SIMVASTATIN SAN02386321 SIMVASTATIN SIV02247223 SIMVASTATIN-40 PDL02378914 SIMVASTATIN-ODAN ODN02265907 TARO-SIMVASTATIN TAR00884359 ZOCOR FRS02300931 ZYM-SIMVASTATIN ZYM
24:06.08 HMG-COA REDUCTASE
INHIBITORS
SIMVASTATIN
80MG TabletST
02247015 APO-SIMVASTATIN APX02248107 CO-SIMVASTATIN ACT02253798 DOM-SIMVASTATIN DPC02281651 DOM-SIMVASTATIN PMS02246585 GEN-SIMVASTATIN GEN02331063 JAMP-SIMVASTATIN JAP02375648 JAMP-SIMVASTATIN JAP02375079 MAR-SIMVASTATIN MAR02372975 MINT-SIMVASTATIN MIN02250187 NOVO-SIMVASTATIN TEV02281589 PHL-SIMVASTATIN PMI02252678 PMS-SIMVASTATIN PMS02269295 PMS-SIMVASTATIN PMS02329182 RAN-SIMVASTATIN RBY02247071 RATIO-SIMVASTATIN RPH02247301 RIVA-SIMVASTATIN RIV02247833 SANDOZ-SIMVASTATIN SDZ02247224 SIMVASTATIN PDL02284774 SIMVASTATIN SAN02386348 SIMVASTATIN SIV02378922 SIMVASTATIN-ODAN ODN02240332 ZOCOR FRS02300974 ZYM-SIMVASTATIN ZYM
24:08.16 CENTRAL ALPHA-AGONISTS
CLONIDINE HCL
0.025MG TabletST
00519251 DIXARIT BOE02304163 NOVO-CLONIDINE TEV
0.1MG TabletST
00259527 CATAPRES BOE01910396 CLONIDINE PRO02046121 NOVO-CLONIDINE TEV
0.2MG TabletST
00868957 APO-CLONIDINE APX00291889 CATAPRES BOE01908162 CLONIDINE PRO02046148 NOVO-CLONIDINE TEV
METHYLDOPA
125MG TabletST
00360252 APO-METHYLDOPA APX250MG Tablet
ST
00360260 APO-METHYLDOPA APX500MG Tablet
ST
00426830 APO-METHYLDOPA APX
METHYLDOPA, HYDROCHLOROTHIAZIDE
250MG & 15MG TabletST
00441708 APO-METHAZIDE-15 APX250MG & 25MG Tablet
ST
00441716 APO-METHAZIDE-25 APX
Page 32 of 1382014
Non-Insured Health BenefitsHealth Canada
24:08.20 DIRECT VASODILATORS
DIAZOXIDE
100MG CapsuleST
00503347 PROGLYCEM SCH
HYDRALAZINE HCL
10MG TabletST
00441619 APO-HYDRALAZINE APX01913638 HYDRALAZINE PDL
25MG TabletST
00441627 APO-HYDRALAZINE APX50MG Tablet
ST
00441635 APO-HYDRALAZINE APX00759481 NOVO-HYLAZIN TEV
MINOXIDIL
2.5MG TabletST
00514497 LONITEN PFI10MG Tablet
ST
00514500 LONITEN PFI
24:12.08 NITRATES AND NITRITES
ISOSORBIDE DINITRATE
5MG Sublingual TabletST
00670944 APO-ISDN APX10MG Tablet
ST
00441686 APO-ISDN APX00786667 PMS-ISOSORBIDE PMS
30MG TabletST
00441694 APO-ISDN APX
ISOSORBIDE-5-MONONITRATE
60MG Extended Release TabletST
02272830 APO-ISMN APX02126559 IMDUR AZE02301288 PMS-ISMN PMS02311321 PRO-ISMN PDL
NITROGLYCERIN
2% Ointment
01926454 NITROL SQU0.2 Patch
ST
02407442 MYLAN-NITRO MYL0.2MG Patch
ST
02162806 MINITRAN MMH01911910 NITRO-DUR KEY00584223 TRANSDERM-NITRO NVR02230732 TRINIPATCH TRT
0.4 PatchST
02407450 MYLAN-NITRO MYL0.4MG Patch
ST
02163527 MINITRAN MMH01911902 NITRO-DUR KEY00852384 TRANSDERM-NITRO NVR02230733 TRINIPATCH TRT
0.6 PatchST
02407469 MYLAN-NITRO MYL
24:12.08 NITRATES AND NITRITES
NITROGLYCERIN
0.6MG PatchST
02163535 MINITRAN MMH01911929 NITRO-DUR KEY02046156 TRANSDERM-NITRO NVR02230734 TRINIPATCH TRT
0.8 PatchST
02407477 MYLAN-NITRO MYL0.8MG Patch
ST
02011271 NITRO-DUR KEY0.4MG Spray
ST
02393433 APO-NITROGLYCERIN APX02243588 GEN-NITRO GEN02238998 RHO-NITRO PUMPSPRAY SAC
0.4MG/DOSE Spray
02231441 NITROLINGUAL PUMPSPRAY SAC0.3MG Sublingual Tablet
00037613 NITROSTAT PFI0.6MG Sublingual Tablet
00037621 NITROSTAT PFI
24:12.12 PHOSPHODIESTERASE
INHIBITORS
SILDENAFIL CITRATE
Limited use benefit (prior approval required).
Maximum dose covered is 20 mg three times a day
Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents.
20MG TabletST
02319500 RATIO-SILDENAFIL R TEP02279401 REVATIO PFI
TADALAFIL
Limited use benefit (prior approval required).
Maximum dose covered is 40 mg daily
Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents
20MG TabletST
02338327 ADCIRCA LIL
Page 33 of 1382014
Non-Insured Health BenefitsHealth Canada
24:12.92 MISCELLANEOUS
VASODILATING AGENTS
AMBRISENTAN
Limited use benefit (prior approval required).
Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.
5MG TabletST
02307065 VOLIBRIS GSK10MG Tablet
ST
02307073 VOLIBRIS GSK
BOSENTAN
Limited use benefit (prior approval required). Maximum dose covered is 125 mg twice daily
-Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.
62.5MG TabletST
02386194 CO BOSENTAN ACT02383497 MYLAN-BOSENTAN MYL02383012 PMS-BOSENTAN PMS02386275 SANDOZ BOSENTAN SDZ02244981 TRACLEER ACN
125MG TabletST
02386208 CO BOSENTAN ACT02383500 MYLAN-BOSENTAN MYL02383020 PMS-BOSENTAN PMS02386283 SANDOZ BOSENTAN SDZ02244982 TRACLEER ACN
DIPYRIDAMOLE
25MG TabletST
00895644 APO-DIPYRIDAMOLE APX50MG Tablet
ST
00895652 APO-DIPYRIDAMOLE APX00571245 APO-DIPYRIDAMOLE SC APX
75MG TabletST
00895660 APO-DIPYRIDAMOLE APX00601845 APO-DIPYRIDAMOLE SC APX
DIPYRIDAMOLE, ACETYLSALICYLIC ACID
Limited use benefit (prior approval required).
For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.
200MG & 25MG CapsuleST
02242119 AGGRENOX BOE
24:20.00 ALPHA ADRENERGIC BLOCKING
AGENTS
DOXAZOSIN MESYLATE
1MG TabletST
02240588 APO-DOXAZOSIN APX01958100 CARDURA 1 PFI02240978 DOXAZOSIN PDL02240498 GEN-DOXAZOSIN GEN02242728 NOVO-DOXAZOSIN TEV02244527 PMS-DOXAZOSIN PMS
2MG TabletST
02240589 APO-DOXAZOSIN APX01958097 CARDURA 2 PFI02240979 DOXAZOSIN PDL02240499 GEN-DOXAZOSIN GEN02242729 NOVO-DOXAZOSIN TEV02244528 PMS-DOXAZOSIN PMS
4MG TabletST
02240590 APO-DOXAZOSIN APX01958119 CARDURA 4 PFI02240980 DOXAZOSIN PDL02240500 GEN-DOXAZOSIN GEN02242730 NOVO-DOXAZOSIN TEV02244529 PMS-DOXAZOSIN PMS
PRAZOSIN HCL
1MG TabletST
00882801 APO-PRAZO APX00560952 MINIPRESS ERF01934198 NOVO-PRAZIN TEV
2MG TabletST
00882828 APO-PRAZO APX00560960 MINIPRESS ERF01934201 NOVO-PRAZIN TEV
5MG TabletST
00882836 APO-PRAZO APX00560979 MINIPRESS ERF01934228 NOVO-PRAZIN TEV
TERAZOSIN HCL
1MG TabletST
02234502 APO-TERAZOSIN APX02243746 DOM-TERAZOSIN DPC00818658 HYTRIN ABB02396289 MYLAN-TERAZOSIN MYL02230805 NOVO-TERAZOSIN TEV02237476 PDL-TERAZOSIN PDL02243518 PMS-TERAZOSIN PMS02218941 RATIO-TERAZOSIN RPH02350475 TERAZOSIN SAN
Page 34 of 1382014
Non-Insured Health BenefitsHealth Canada
24:20.00 ALPHA ADRENERGIC BLOCKING
AGENTS
TERAZOSIN HCL
2MG TabletST
02234503 APO-TERAZOSIN APX02243747 DOM-TERAZOSIN DPC00818682 HYTRIN ABB02396297 MYLAN-TERAZOSIN MYL02230806 NOVO-TERAZOSIN TEV02237477 PDL-TERAZOSIN PDL02243519 PMS-TERAZOSIN PMS02218968 RATIO-TERAZOSIN RPH02350483 TERAZOSIN SAN
5MG TabletST
02234504 APO-TERAZOSIN APX02243748 DOM-TERAZOSIN DPC00818666 HYTRIN ABB02396300 MYLAN-TERAZOSIN MYL02230807 NOVO-TERAZOSIN TEV02237478 PDL-TERAZOSIN PDL02243520 PMS-TERAZOSIN PMS02218976 RATIO-TERAZOSIN RPH02350491 TERAZOSIN SAN
10MG TabletST
02234505 APO-TERAZOSIN APX02243749 DOM-TERAZOSIN DPC00818674 HYTRIN ABB02396319 MYLAN-TERAZOSIN MYL02230808 NOVO-TERAZOSIN TEV02237479 PDL-TERAZOSIN PDL02243521 PMS-TERAZOSIN PMS02218984 RATIO-TERAZOSIN RPH02350505 TERAZOSIN SAN
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
ACEBUTOLOL HCL
100MG TabletST
02164396 ACEBUTOLOL PDL02286246 ACEBUTOLOL SAN02147602 APO-ACEBUTOLOL APX02237721 GEN-ACEBUTOLOL GEN02237885 GEN-ACEBUTOLOL (TYPE S) GEN02204517 NOVO-ACEBUTOLOL TEV02257599 SANDOZ-ACEBUTOLOL SDZ01926543 SECTRAL SAC
200MG TabletST
02164418 ACEBUTOLOL PDL02286254 ACEBUTOLOL SAN02147610 APO-ACEBUTOLOL APX02237722 GEN-ACEBUTOLOL GEN02237886 GEN-ACEBUTOLOL (TYPE S) GEN02204525 NOVO-ACEBUTOLOL TEV02257602 SANDOZ-ACEBUTOLOL SDZ01926551 SECTRAL SAC
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
ACEBUTOLOL HCL
400MG TabletST
02164426 ACEBUTOLOL PDL02286262 ACEBUTOLOL SAN02147629 APO-ACEBUTOLOL APX02237723 GEN-ACEBUTOLOL GEN02237887 GEN-ACEBUTOLOL (TYPE S) GEN02204533 NOVO-ACEBUTOLOL TEV02257610 SANDOZ-ACEBUTOLOL SDZ01926578 SECTRAL SAC
ATENOLOL
25MG TabletST
02303647 GEN-ATENOLOL GEN02367556 JAMP-ATENOLOL JAP02371979 MAR-ATENOLOL MAR02368013 MINT-ATENOLOL MIN02266660 NOVO-ATENOL TEV02247182 PHL-ATENOLOL SIV02246581 PMS-ATENOLOL PMS02326701 PRO-ATENOLOL PDL02373963 RAN-ATENOLOL RBY02277379 RIVA-ATENOLOL RIV02368633 SEPTA-ATENOLOL SPT
50MG TabletST
00773689 APO-ATENOL APX00828807 ATENOLOL PDL02255545 CO-ATENOLOL ACT02229467 DOM-ATENOLOL DPC02146894 GEN-ATENOLOL GEN02367564 JAMP-ATENOLOL JAP02371987 MAR-ATENOLOL MAR02368021 MINT-ATENOLOL MIN01912062 NOVO-ATENOL TEV02238316 PHL-ATENOLOL PHH02237600 PMS-ATENOLOL PMS02267985 RAN-ATENOLOL RBY02171791 RATIO-ATENOLOL RPH02242094 RIVA-ATENOLOL RIV02231731 SANDOZ-ATENOLOL SDZ02368641 SEPTA-ATENOLOL SPT02039532 TENORMIN AZC
Page 35 of 1382014
Non-Insured Health BenefitsHealth Canada
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
ATENOLOL
100MG TabletST
00773697 APO-ATENOL APX00828793 ATENOLOL PDL02255553 CO-ATENOLOL ACT02229468 DOM-ATENOLOL DPC02147432 GEN-ATENOLOL GEN02367572 JAMP-ATENOLOL JAP02371995 MAR-ATENOLOL MAR02368048 MINT-ATENOLOL MIN01912054 NOVO-ATENOL TEV02238318 PHL-ATENOLOL PHH02237601 PMS-ATENOLOL PMS02267993 RAN-ATENOLOL RBY02171805 RATIO-ATENOLOL RPH02242093 RIVA-ATENOLOL RIV02368668 SEPTA-ATENOLOL SPT02039540 TENORMIN AZC
ATENOLOL, CHLORTHALIDONE
50MG & 25MG TabletST
02248763 APO-ATENIDONE APX02302918 NOVO-ATENOLTHALIDONE TEV02049961 TENORETIC AZC
100MG & 25MG TabletST
02248764 APO-ATENIDONE APX02302926 NOVO-ATENOLTHALIDONE TEV02049988 TENORETIC AZC
BISOPROLOL FUMARATE
5MG TabletST
02256134 APO-BISOPROLOL APX02321556 BISOPROLOL SOR02383055 BISOPROLOL SIV02391589 BISOPROLOL SAN02384418 MYLAN-BISOPROLOL MYL02267470 NOVO-BIPOPROLOL TEV02302632 PMS-BISOPROLOL PMS02306999 PRO-BISOPROLOL-5 PDL02247439 SANDOZ-BISOPROLOL SDZ
10MG TabletST
02256177 APO-BISOPROLOL APX02321572 BISOPROLOL SOR02383063 BISOPROLOL SIV02391597 BISOPROLOL SAN02384426 MYLAN-BISOPROLOL MYL02267489 NOVO-BIPOPROLOL TEV02302640 PMS-BISOPROLOL PMS02307006 PRO-BISOPROLOL-10 PDL02247440 SANDOZ-BISOPROLOL SDZ
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
CARVEDILOL
3.125MG TabletST
02247933 APO-CARVEDILOL APX02248752 CARVEDILOL SIV02364913 CARVEDILOL SAN02248748 DOM-CARVEDILOL DPC02368897 JAMP-CARVEDILOL JAP02347512 MYLAN-CARVEDILOL MYL02245914 PMS-CARVEDILOL PMS02324504 PRO-CARVEDILOL PDL02268027 RAN-CARVEDILOL RBY02252309 RATIO-CARVEDILOL RPH02338068 ZYM-CARVEDILOL ZYM
6.25MG TabletST
02247934 APO-CARVEDILOL APX02248753 CARVEDILOL SIV02364921 CARVEDILOL SAN02248749 DOM-CARVEDILOL DPC02368900 JAMP-CARVEDILOL JAP02347520 MYLAN-CARVEDILOL MYL02245915 PMS-CARVEDILOL PMS02324512 PRO-CARVEDILOL PDL02268035 RAN-CARVEDILOL RBY02252317 RATIO-CARVEDILOL RPH02338092 ZYM-CARVEDILOL ZYM
12.5MG TabletST
02247935 APO-CARVEDILOL APX02248754 CARVEDILOL SIV02364948 CARVEDILOL SAN02248750 DOM-CARVEDILOL DPC02368919 JAMP-CARVEDILOL JAP02347555 MYLAN-CARVEDILOL MYL02245916 PMS-CARVEDILOL PMS02324520 PRO-CARVEDILOL PDL02268043 RAN-CARVEDILOL RBY02252325 RATIO-CARVEDILOL RPH02338106 ZYM-CARVEDILOL ZYM
25MG TabletST
02247936 APO-CARVEDILOL APX02248755 CARVEDILOL SIV02364956 CARVEDILOL SAN02248751 DOM-CARVEDILOL DPC02368927 JAMP-CARVEDILOL JAP02347571 MYLAN-CARVEDILOL MYL02245917 PMS-CARVEDILOL PMS02324539 PRO-CARVEDILOL PDL02268051 RAN-CARVEDILOL RBY02252333 RATIO-CARVEDILOL RPH02338114 ZYM-CARVEDILOL ZYM
LABETALOL HCL
100MG TabletST
02106272 TRANDATE SHI200MG Tablet
ST
02106280 TRANDATE SHI
Page 36 of 1382014
Non-Insured Health BenefitsHealth Canada
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
METOPROLOL TARTRATE
100MG Sustained Release TabletST
02285169 APO-METOPROLOL SR APX00658855 LOPRESOR SR NVR02351404 METOPROLOL SR PDL02303396 SANDOZ-METOPROLOL SR SDZ
200MG Sustained Release TabletST
02285177 APO-METOPROLOL SR APX00534560 LOPRESOR SR NVR02351412 METOPROLOL SR PDL02303418 SANDOZ-METOPROLOL SR SDZ
25MG TabletST
02246010 APO-METOPROLOL APX02252252 DOM-METOPROLOL-L DPC02302055 GEN-METOPROLOL (TYPE L) GEN02356813 JAMP-METOPROLOL-L JAP02296713 METOPROLOL-25 PDL02315106 METOPROLOL-L SOR02261898 NOVO-METOPROL CT TEV02248855 PMS-METOPROLOL-L PMS02315300 RIVA-METOPROLOL L RIV
50MG TabletST
00618632 APO-METOPROLOL APX00749354 APO-METOPROLOL-L APX02172550 DOM-METOPROLOL-B DPC02231121 DOM-METOPROLOL-L DPC02174545 GEN-METOPROLOL-L GEN02356821 JAMP-METOPROLOL-L JAP00397423 LOPRESOR NVR00648019 METOPROLOL PDL02350394 METOPROLOL SAN02315114 METOPROLOL-L SOR00648035 NOVO-METOPROL TEV00842648 NOVO-METOPROL TEV02145413 PMS-METOPROLOL-B PMS02230803 PMS-METOPROLOL-L PMS02315319 RIVA-METOPROLOL L RIV02354187 SANDOZ METOPROLOL (L) SDZ
100MG TabletST
00618640 APO-METOPROLOL APX00751170 APO-METOPROLOL-L APX02172569 DOM-METOPROLOL-B DPC02231122 DOM-METOPROLOL-L DPC02174553 GEN-METOPROLOL-L GEN02356848 JAMP-METOPROLOL-L JAP00397431 LOPRESOR NVR00648027 METOPROLOL PDL02350408 METOPROLOL SAN02315122 METOPROLOL-L SOR00648043 NOVO-METOPROL TEV00842656 NOVO-METOPROL-B TEV02145421 PMS-METOPROLOL-B PMS02230804 PMS-METOPROLOL-L PMS02315327 RIVA-METOPROLOL L RIV02354195 SANDOZ METOPROLOL (L) SDZ
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
NADOLOL
40MG TabletST
00782505 APO-NADOL APX00828815 NADOLOL PDL
80MG TabletST
00782467 APO-NADOL APX00818704 NADOLOL PDL
160MG TabletST
00782475 APO-NADOL APX
PINDOLOL
5MG TabletST
00755877 APO-PINDOL APX02231650 DOM-PINDOLOL DPC00869007 NOVO-PINDOL TEV00828416 PINDOLOL PDL02231536 PMS-PINDOLOL PMS02261782 SANDOZ-PINDOLOL SDZ00417270 VISKEN NVR
10MG TabletST
00755885 APO-PINDOL APX02238046 DOM-PINDOLOL DPC00869015 NOVO-PINDOL TEV00828424 PINDOLOL PDL02231537 PMS-PINDOLOL PMS02261790 SANDOZ-PINDOLOL SDZ00443174 VISKEN NVR
15MG TabletST
00755893 APO-PINDOL APX02238047 DOM-PINDOLOL DPC00869023 NOVO-PINDOL TEV00828432 PINDOLOL PDL02231539 PMS-PINDOLOL PMS02261804 SANDOZ-PINDOLOL SDZ00417289 VISKEN NVR
PINDOLOL, HYDROCHLOROTHIAZIDE
10MG & 25MG TabletST
00568627 VISKAZIDE NVR10MG & 50MG Tablet
ST
00568635 VISKAZIDE NVR
PROPRANOLOL HCL
60MG Long Acting CapsuleST
02042231 INDERAL LA WAY80MG Long Acting Capsule
ST
02042258 INDERAL LA WAY120MG Long Acting Capsule
ST
02042266 INDERAL LA WAY160MG Long Acting Capsule
ST
02042274 INDERAL LA WAY10MG Tablet
ST
02137313 DOM-PROPRANOLOL DPC00496480 NOVO-PRANOL TEV
Page 37 of 1382014
Non-Insured Health BenefitsHealth Canada
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
PROPRANOLOL HCL
20MG TabletST
00740675 NOVO-PRANOL TEV40MG Tablet
ST
02137321 DOM-PROPRANOLOL DPC00496499 NOVO-PRANOL TEV
80MG TabletST
02137348 DOM-PROPRANOLOL DPC00496502 NOVO-PRANOL TEV00582271 PMS-PROPRANOLOL PMS
120MG TabletST
00504335 APO-PROPRANOLOL APX00582298 PMS-PROPRANOLOL PMS
SOTALOL HCL
80MG TabletST
02210428 APO-SOTALOL APX02270625 CO-SOTALOL ACT02238634 DOM-SOTALOL DPC02229778 GEN-SOTALOL GEN02368617 JAMP-SOTALOL JAP02231181 NOVO-SOTALOL TEV02238768 PHL-SOTALOL PHH02238326 PMS-SOTALOL PMS02316528 PRO-SOTALOL PDL02084228 RATIO-SOTALOL RPH02242156 RIVA-SOTALOL RIV02257831 SANDOZ-SOTALOL SDZ02385988 SOTALOL SIV
160MG TabletST
02167794 APO-SOTALOL APX02270633 CO-SOTALOL ACT02238635 DOM-SOTALOL DPC02229779 GEN-SOTALOL GEN02368625 JAMP-SOTALOL JAP02231182 NOVO-SOTALOL TEV02238769 PHL-SOTALOL PHH02238327 PMS-SOTALOL PMS02316536 PRO-SOTALOL PDL02084236 RATIO-SOTALOL RPH02257858 RHOXAL-SOTALOL RHO02242157 RIVA-SOTALOL RIV02385996 SOTALOL SIV
TIMOLOL MALEATE
5MG TabletST
00755842 APO-TIMOL APX01947796 NOVO-TIMOL TEV00812455 TIMOLOL PDL
10MG TabletST
00755850 APO-TIMOL APX01947818 NOVO-TIMOL TEV00812447 TIMOLOL PDL
24:24.00 BETA ADRENERGIC BLOCKING
AGENTS
TIMOLOL MALEATE
20MG TabletST
00755869 APO-TIMOL APX01947826 NOVO-TIMOL TEV
24:28.08 DIHYDROPYRIDINES
AMLODIPINE
2.5MG TabletST
02326795 AMLODIPINE PDL02385783 AMLODIPINE SIV02378744 AMLODIPINE-ODAN ODN02326825 DOM-AMLODIPINE DOM02280124 GD-AMLODIPINE PFI02357186 JAMP-AMLODIPINE JAP02371707 MAR-AMLODIPINE MAR02326760 PHL-AMLODIPINE PMI02295148 PMS-AMLODIPINE PMS02398877 RAN-AMLODIPINE RBY02331489 RIVA-AMLODIPINE RIV02330474 SANDOZ-AMLODIPINE SDZ02357704 SEPTA-AMLODIPINE SPT
5MG TabletST
02341093 ACCEL-AMLODIPINE ACP02331284 AMLODIPINE SAN02385791 AMLODIPINE SIV02378760 AMLODIPINE-ODAN ODN02273373 APO-AMLODIPINE APX02397072 AURO-AMLODIPINE AUR02297485 CO AMLODIPINE ACT02326833 DOM-AMLODIPINE DOM02280132 GD-AMLODIPINE PFI02357194 JAMP-AMLODIPINE JAP02371715 MAR-AMLODIPINE MAR02362651 MINT-AMLODIPINE MIN02272113 MYLAN-AMLODIPINE MYL00878928 NORVASC PFI02326779 PHL-AMLODIPINE PMI02284065 PMS-AMLODIPINE PMS02321858 RAN-AMLODIPINE RBY02259605 RATIO-AMLODIPINE RPH02331497 RIVA-AMLODIPINE RIV02284383 SANDOZ-AMLODIPINE SDZ02357712 SEPTA-AMLODIPINE SPT02250497 TEVA-AMLODIPINE TEP02326809 ZYM-AMLODIPINE ZYM02342790 ZYM-AMLODIPINE ZYM
Page 38 of 1382014
Non-Insured Health BenefitsHealth Canada
24:28.08 DIHYDROPYRIDINES
AMLODIPINE
10MG TabletST
02341107 ACCEL-AMLODIPINE ACP02331292 AMLODIPINE SAN02385805 AMLODIPINE SIV02378779 AMLODIPINE-ODAN ODN02273381 APO-AMLODIPINE APX02397080 AURO-AMLODIPINE AUR02297493 CO AMLODIPINE ACT02326841 DOM-AMLODIPINE DOM02280140 GD-AMLODIPINE PFI02357208 JAMP-AMLODIPINE JAP02371723 MAR-AMLODIPINE MAR02362678 MINT-AMLODIPINE MIN02272121 MYLAN-AMLODIPINE MYL00878936 NORVASC PFI02326787 PHL-AMLODIPINE PMI02284073 PMS-AMLODIPINE PMS02321866 RAN-AMLODIPINE RBY02259613 RATIO-AMLODIPINE RPH02331500 RIVA-AMLODIPINE RIV02284391 SANDOZ-AMLODIPINE SDZ02357720 SEPTA-AMLODIPINE SPT02250500 TEVA-AMLODIPINE TEP02326817 ZYM-AMLODIPINE ZYM02342804 ZYM-AMLODIPINE ZYM
AMLODIPINE, ATORVASTATIN
5MG & 10MG TabletST
02273233 CADUET PFI02362759 GD-
AMLODIPINE/ATORVASTATINPFI
02404222 PMS-AMLODIPINE/ATORVASTATIN
PMS
5MG & 20MG TabletST
02273241 CADUET PFI02362767 GD-
AMLODIPINE/ATORVASTATINPFI
02404230 PMS-AMLODIPINE/ATORVASTATIN
PMS
5MG & 40MG TabletST
02273268 CADUET PFI02362775 GD-
AMLODIPINE/ATORVASTATINPFI
5MG & 80MG TabletST
02273276 CADUET PFI02362783 GD-
AMLODIPINE/ATORVASTATINPFI
10MG & 10MG TabletST
02273284 CADUET PFI02362791 GD-
AMLODIPINE/ATORVASTATINPFI
02404249 PMS-AMLODIPINE/ATORVASTATIN
PMS
24:28.08 DIHYDROPYRIDINES
AMLODIPINE, ATORVASTATIN
10MG & 20MG TabletST
02273292 CADUET PFI02362805 GD-
AMLODIPINE/ATORVASTATINPFI
02404257 PMS-AMLODIPINE/ATORVASTATIN
PMS
10MG & 40MG TabletST
02273306 CADUET PFI02362813 GD-
AMLODIPINE/ATORVASTATINPFI
10MG & 80MG TabletST
02273314 CADUET PFI02362821 GD-
AMLODIPINE/ATORVASTATINPFI
AMLODIPINE, TELMISARTAN
5MG & 40MG TabletST
02371022 TWYNSTA BOE5MG & 80MG Tablet
ST
02371049 TWYNSTA BOE10MG & 40MG Tablet
ST
02371030 TWYNSTA BOE10MG & 80MG Tablet
ST
02371057 TWYNSTA BOE
FELODIPINE
2.5MG Extended Release TabletST
02057778 PLENDIL AZC5MG Extended Release Tablet
ST
00851779 PLENDIL AZC02280264 SANDOZ-FELODIPINE SDZ09857203 SANDOZ-FELODIPINE SDZ *
10MG Extended Release TabletST
00851787 PLENDIL AZC02280272 SANDOZ-FELODIPINE SDZ09857204 SANDOZ-FELODIPINE SDZ *
NIFEDIPINE
5MG CapsuleST
00725110 APO-NIFED APX02235897 PMS-NIFEDIPINE PMS
10MG CapsuleST
00755907 APO-NIFED APX02235898 PMS-NIFEDIPINE PMS
20MG Extended Release TabletST
02237618 ADALAT XL BAY30MG Extended Release Tablet
ST
02155907 ADALAT XL BAY02349167 MYLAN-NIFEDIPINE ER MYL
60MG Extended Release TabletST
02155990 ADALAT XL BAY02321149 MYLAN-NIFEDIPINE ER MYL
10MG Sustained Release TabletST
02197448 APO-NIFED PA APX
Page 39 of 1382014
Non-Insured Health BenefitsHealth Canada
24:28.08 DIHYDROPYRIDINES
NIFEDIPINE
20MG Sustained Release TabletST
02181525 APO-NIFED PA APX
NIMODIPINE
30MG TabletST
02325926 NIMOTOP BAY
24:28.92 MISCELLANEOUS CALCIUM-
CHANNEL BLOCKING AGENTS
DILTIAZEM HCL
120MG Controlled Delivery CapsuleST
02230997 APO-DILTIAZ CD APX02097249 CARDIZEM CD BPC02231472 DILTIAZEM CD PDL02400421 DILTIAZEM CD SAN02242538 NOVO-DILTAZEM CD TEV02355752 PMS-DILTIAZEM CD PMS02229781 RATIO-DILTIAZEM CD RPH02243338 SANDOZ-DILTIAZEM CD SDZ
180MG Controlled Delivery CapsuleST
02230998 APO-DILTIAZ CD APX02097257 CARDIZEM CD BPC02231474 DILTIAZEM CD PDL02400448 DILTIAZEM CD SAN02242539 NOVO-DILTAZEM CD TEV02355760 PMS-DILTIAZEM CD PMS02229782 RATIO-DILTIAZEM CD RPH02243339 SANDOZ-DILTIAZEM CD SDZ
240MG Controlled Delivery CapsuleST
02230999 APO-DILTIAZ CD APX02097265 CARDIZEM CD BPC02231475 DILTIAZEM CD PDL02400456 DILTIAZEM CD SAN02242540 NOVO-DILTAZEM CD TEV02355779 PMS-DILTIAZEM CD PMS02229783 RATIO-DILTIAZEM CD RPH02243340 SANDOZ-DILTIAZEM CD SDZ
300MG Controlled Delivery CapsuleST
02229526 APO-DILTIAZ CD APX02097273 CARDIZEM CD BPC02231057 DILTIAZEM CD PDL02400464 DILTIAZEM CD SAN02242541 NOVO-DILTAZEM CD TEV02355787 PMS-DILTIAZEM CD PMS02229784 RATIO-DILTIAZEM CD RPH02243341 SANDOZ-DILTIAZEM CD SDZ
120MG Extended Release CapsuleST
02291037 APO-DILTIAZ TZ APX02370611 CO DILTIAZEM CD ACT02370441 CO DILTIAZEM T ACT02231150 TIAZAC BPC
24:28.92 MISCELLANEOUS CALCIUM-
CHANNEL BLOCKING AGENTS
DILTIAZEM HCL
180MG Extended Release CapsuleST
02291045 APO-DILTIAZ TZ APX02370638 CO DILTIAZEM CD ACT02370492 CO DILTIAZEM T ACT02231151 TIAZAC BPC
240MG Extended Release CapsuleST
02291053 APO-DILTIAZ TZ APX02370646 CO DILTIAZEM CD ACT02370506 CO DILTIAZEM T ACT02231152 TIAZAC BPC
300MG Extended Release CapsuleST
02291061 APO-DILTIAZ TZ APX02370654 CO DILTIAZEM CD ACT02370514 CO DILTIAZEM T ACT02231154 TIAZAC BPC
360MG Extended Release CapsuleST
02291088 APO-DILTIAZ TZ APX02370522 CO DILTIAZEM T ACT02231155 TIAZAC BPC
120MG Extended Release TabletST
02256738 TIAZAC XC BPC180MG Extended Release Tablet
ST
02256746 TIAZAC XC BPC240MG Extended Release Tablet
ST
02256754 TIAZAC XC BPC300MG Extended Release Tablet
ST
02256762 TIAZAC XC BPC360MG Extended Release Tablet
ST
02256770 TIAZAC XC BPC60MG Sustained Release Capsule
ST
02222957 APO-DILTIAZ SR APX90MG Sustained Release Capsule
ST
02222965 APO-DILTIAZ SR APX120MG Sustained Release Capsule
ST
02222973 APO-DILTIAZ SR APX02271605 NOVO-DILTIAZEM HCL ER BOV02245918 SANDOZ-DILTIAZEM T SDZ
180MG Sustained Release CapsuleST
02271613 NOVO-DILTIAZEM HCL ER BOV02245919 SANDOZ-DILTIAZEM T SDZ
240MG Sustained Release CapsuleST
02271621 NOVO-DILTIAZEM HCL ER BOV02245920 SANDOZ-DILTIAZEM T SDZ
300MG Sustained Release CapsuleST
02271648 NOVO-DILTIAZEM HCL ER BOV02245921 SANDOZ-DILTIAZEM T SDZ
360MG Sustained Release CapsuleST
02271656 NOVO-DILTIAZEM HCL ER BOV02245922 SANDOZ-DILTIAZEM T SDZ
Page 40 of 1382014
Non-Insured Health BenefitsHealth Canada
24:28.92 MISCELLANEOUS CALCIUM-
CHANNEL BLOCKING AGENTS
DILTIAZEM HCL
30MG TabletST
00771376 APO-DILTIAZ APX00828785 DILTIAZEM PDL00862924 NOVO-DILTIAZEM TEV
60MG TabletST
00771384 APO-DILTIAZ APX00828777 DILTIAZEM PDL00862932 NOVO-DILTIAZEM TEV
VERAPAMIL HCL
180MG Extended Release TabletST
02231676 COVERA-HS PFI240MG Extended Release Tablet
ST
02231677 COVERA-HS PFI120MG Sustained Release Tablet
ST
02246893 APO-VERAP SR APX02210347 GEN-VERAPAMIL SR GEN01907123 ISOPTIN SR ABB02324156 PRO-VERAPAMIL SR PDL
180MG Sustained Release TabletST
02246894 APO-VERAP SR APX02210355 GEN-VERAPAMIL SR GEN01934317 ISOPTIN SR ABB
240MG Sustained Release TabletST
02246895 APO-VERAP SR APX02240321 DOM-VERAPAMIL SR DPC02210363 GEN-VERAPAMIL SR GEN00742554 ISOPTIN SR ABB02211920 NOVO-VERAMIL SR TEV02238276 PHL-VERAPAMIL PHH02237791 PMS-VERAPAMIL SR PMS02312697 PRO-VERAPAMIL SR PDL02248082 RIVA-VERAPAMIL SR RIV
80MG TabletST
00782483 APO-VERAP APX02237921 GEN-VERAPAMIL GEN00812331 NOVO-VERAMIL TEV00871028 VERAPAMIL PDL
120MG TabletST
00782491 APO-VERAP APX02237922 GEN-VERAPAMIL GEN00812358 NOVO-VERAMIL TEV
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
BENAZEPRIL HCL
5MG TabletST
02290332 APO-BENAZEPRIL APX00885835 LOTENSIN NVR
10MG TabletST
02290340 APO-BENAZEPRIL APX
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
BENAZEPRIL HCL
20MG TabletST
02273918 APO-BENAZEPRIL APX00885851 LOTENSIN NVR
CAPTOPRIL
6.25MG TabletST
01999559 APO-CAPTO APX12.5MG Tablet
ST
00893595 APO-CAPTO APX02242788 CAPTOPRIL ZYM02238551 DOM-CAPTOPRIL DPC02163551 GEN-CAPTOPRIL GEN01942964 NOVO-CAPTORIL TEV
25MG TabletST
00893609 APO-CAPTO APX01910337 CAPTOPRIL PDL02242789 CAPTOPRIL ZYM02238552 DOM-CAPTOPRIL DPC02163578 GEN-CAPTOPRIL GEN01942972 NOVO-CAPTORIL TEV
50MG TabletST
00893617 APO-CAPTO APX02242790 CAPTOPRIL ZYM02238553 DOM-CAPTOPRIL DPC02163586 GEN-CAPTOPRIL GEN01942980 NOVO-CAPTORIL TEV
100MG TabletST
00893625 APO-CAPTO APX02242791 CAPTOPRIL ZYM02238554 DOM-CAPTOPRIL DPC02163594 GEN-CAPTOPRIL GEN01942999 NOVO-CAPTORIL TEV02230206 PMS-CAPTOPRIL PMS
CILAZAPRIL
1MG TabletST
02291134 APO-CILAZAPRIL APX02350963 CILAZAPRIL SAN02283778 GEN-CILAZAPRIL GEN02266350 NOVO-CILAZAPRIL TEV02280442 PMS-CILAZAPRIL PMS
2.5MG TabletST
02291142 APO-CILAZAPRIL APX02350971 CILAZAPRIL SAN02285215 CO CILAZAPRIL ACT02283786 GEN-CILAZAPRIL GEN01911473 INHIBACE HLR02266369 NOVO-CILAZAPRIL TEV02280450 PMS-CILAZAPRIL PMS
Page 41 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
CILAZAPRIL
5MG TabletST
02291150 APO-CILAZAPRIL APX02350998 CILAZAPRIL SAN02285223 CO CILAZAPRIL ACT02283794 GEN-CILAZAPRIL GEN01911481 INHIBACE HLR02266377 NOVO-CILAZAPRIL TEV02280469 PMS-CILAZAPRIL PMS
CILAZAPRIL, HYDROCHLOROTHIAZIDE
5MG & 12.5MG TabletST
02284987 APO-CILAZAPRIL HCTZ APX02181479 INHIBACE PLUS HLR02313731 NOVO-CILAZAPRIL /HCTZ TEV
ENALAPRIL MALEATE
2.5MG TabletST
02020025 APO ENALAPRIL APX02291878 CO ENALAPRIL ACT02400650 ENALAPRIL SAN02300036 GEN-ENALAPRIL GEN02300680 NOVO-ENALAPRIL TEV02300079 PMS-ENALAPRIL PMS02311402 PRO-ENALAPRIL PDL02352230 RAN-ENALAPRIL RBY02299984 RATIO-ENALAPRIL RPH02300796 RIVA-ENALAPRIL RIV02299933 SANDOZ ENALAPRIL SDZ02323478 SIG-ENALAPRIL SIG02300117 TARO-ENALAPRIL TAR00851795 VASOTEC FRS
5MG TabletST
02019884 APO ENALAPRIL APX02291886 CO ENALAPRIL ACT02400669 ENALAPRIL SAN02300044 GEN-ENALAPRIL GEN02233005 NOVO-ENALAPRIL TEV02300087 PMS-ENALAPRIL PMS02311410 PRO-ENALAPRIL PDL02352249 RAN-ENALAPRIL RBY02299992 RATIO-ENALAPRIL RPH02300818 RIVA-ENALAPRIL RIV02299941 SANDOZ ENALAPRIL SDZ02323486 SIG-ENALAPRIL SIG02300125 TARO-ENALAPRIL TAR00708879 VASOTEC FRS
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
ENALAPRIL MALEATE
10MG TabletST
02019892 APO ENALAPRIL APX02291894 CO ENALAPRIL ACT02400677 ENALAPRIL SAN02300052 GEN-ENALAPRIL GEN02233006 NOVO-ENALAPRIL TEV02300095 PMS-ENALAPRIL PMS02311429 PRO-ENALAPRIL PDL02352257 RAN-ENALAPRIL RBY02300001 RATIO-ENALAPRIL RPH02300826 RIVA-ENALAPRIL RIV02299968 SANDOZ ENALAPRIL SDZ02323494 SIG-ENALAPRIL SIG02300133 TARO-ENALAPRIL TAR00670901 VASOTEC FRS
20MG TabletST
02019906 APO ENALAPRIL APX02291908 CO ENALAPRIL ACT02400685 ENALAPRIL SAN02300060 GEN-ENALAPRIL GEN02233007 NOVO-ENALAPRIL TEV02300109 PMS-ENALAPRIL PMS02311437 PRO-ENALAPRIL PDL02352265 RAN-ENALAPRIL RBY02300028 RATIO-ENALAPRIL RPH02300834 RIVA-ENALAPRIL RIV02299976 SANDOZ ENALAPRIL SDZ02323508 SIG-ENALAPRIL SIG02300141 TARO-ENALAPRIL TAR00670928 VASOTEC FRS
ENALAPRIL MALEATE,
HYDROCHLOROTHIAZIDE
5MG & 12.5MG TabletST
02352923 APO-ENALAPRIL MALEATE/HCTZ
APX
02300222 NOVO-ENALAPRIL/HCTZ TEV10MG & 25MG Tablet
ST
02352931 APO-ENALAPRIL MALEATE/HCTZ
APX
02300230 NOVO-ENALAPRIL/HCTZ TEV00657298 VASERETIC FRS
FOSINOPRIL SODIUM
10MG TabletST
02266008 APO-FOSINOPRIL APX02332566 FOSINOPRIL RBY02303000 FOSINOPRIL-10 PDL02262401 GEN-FOSINOPRIL GEN02331004 JAMP-FOSINOPRIL JAP01907107 MONOPRIL BMS02247802 NOVO-FOSINOPRIL TEV02255944 PMS-FOSINOPRIL PMS02294524 RAN-FOSINOPRIL RBY02265923 RIVA-FOSINOPRIL RIV
Page 42 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
FOSINOPRIL SODIUM
20MG TabletST
02266016 APO-FOSINOPRIL APX02332574 FOSINOPRIL RBY02303019 FOSINOPRIL-20 PDL02262428 GEN-FOSINOPRIL GEN02331012 JAMP-FOSINOPRIL JAP01907115 MONOPRIL BMS02247803 NOVO-FOSINOPRIL TEV02255952 PMS-FOSINOPRIL PMS02294532 RAN-FOSINOPRIL RBY02265931 RIVA-FOSINOPRIL RIV
LISINOPRIL
5MG TabletST
09853685 APO-LISINOPRIL APX *02217481 APO-LISINOPRIL (TYPE Z) APX02394472 AURO-LISINOPRIL AUR02271443 CO LISINOPRIL ACT02274833 GEN-LISINOPRIL GEN02361531 JAMP-LISINOPRIL JAP02386232 LISINOPRIL SIV02285061 NOVO-LISINOPRIL (TYPE P) TEV02285118 NOVO-LISINOPRIL (TYPE Z) TEV02292203 PMS-LISINOPRIL PMS00839388 PRINIVIL FRS02310961 PRO-LISINOPRIL PDL02294230 RAN-LISINOPRIL RBY02256797 RATIO-LISINOPRIL P RPH02299879 RATIO-LISINOPRIL Z RPH02300958 RIVA-LISINOPRIL RIV02289199 SANDOZ LISINOPRIL SDZ02049333 ZESTRIL AZC
10MG TabletST
09853960 APO-LISINOPRIL APX *02217503 APO-LISINOPRIL (TYPE Z) APX02394480 AURO-LISINOPRIL AUR02271451 CO LISINOPRIL ACT02274841 GEN-LISINOPRIL GEN02361558 JAMP-LISINOPRIL JAP02386240 LISINOPRIL SIV02285088 NOVO-LISINOPRIL (TYPE P) TEV02285126 NOVO-LISINOPRIL (TYPE Z) TEV02292211 PMS-LISINOPRIL PMS00839396 PRINIVIL FRS02310988 PRO-LISINOPRIL PDL02294249 RAN-LISINOPRIL RBY02256800 RATIO-LISINOPRIL P RPH02299887 RATIO-LISINOPRIL Z RPH02300982 RIVA-LISINOPRIL RIV02289202 SANDOZ-LISINOPRIL SDZ02049376 ZESTRIL AZC
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
LISINOPRIL
20MG TabletST
09854010 APO-LISINOPRIL APX *02217511 APO-LISINOPRIL (TYPE Z) APX02394499 AURO-LISINOPRIL AUR02271478 CO LISINOPRIL ACT02274868 GEN-LISINOPRIL GEN02361566 JAMP-LISINOPRIL JAP02386259 LISINOPRIL SIV02285096 NOVO-LISINOPRIL (TYPE P) TEV02285134 NOVO-LISINOPRIL (TYPE Z) TEV02292238 PMS-LISINOPRIL PMS00839418 PRINIVIL FRS02310996 PRO-LISINOPRIL PDL02294257 RAN-LISINOPRIL RBY02256819 RATIO-LISINOPRIL P RPH02299895 RATIO-LISINOPRIL Z RPH02300990 RIVA-LISINOPRIL RIV02289229 SANDOZ LISINOPRIL SDZ02049384 ZESTRIL AZC
LISINOPRIL, HYDROCHLOROTHIAZIDE
10MG & 12.5MG TabletST
02261979 APO-LISINOPRIL/HCTZ APX02297736 GEN-LISINOPRIL HCTZ GEN02362945 LISINOPRIL/HCTZ (TYPE Z) SAN02302136 NOVO-LISINOPRIL/HCTZ
(TYPE P)TEV
02301768 NOVO-LISINOPRIL/HCTZ (TYPE Z)
TEV
02302365 SANDOZ LISINOPRIL HCT SDZ02103729 ZESTORETIC AZC
20MG & 12.5MG TabletST
02261987 APO-LISINOPRIL/HCTZ APX02297744 GEN-LISINOPRIL HCTZ GEN02362953 LISINOPRIL/HCTZ (TYPE Z) SAN02302144 NOVO-LISINOPRIL (TYPE P) TEV02301776 NOVO-LISINOPRIL/HCTZ
(TYPE Z)TEV
00884413 PRINZIDE FRS02302373 SANDOZ LISINOPRIL HCT SDZ02045737 ZESTORETIC AZC
20MG & 25MG TabletST
02261995 APO-LISINOPRIL/HCTZ APX02297752 GEN-LISINOPRIL HCTZ GEN02362961 LISINOPRIL/HCTZ (TYPE Z) SAN02302152 NOVO-LISINOPRIL/HCTZ
(TYPE P)TEV
02301784 NOVO-LISINOPRIL/HCTZ (TYPE Z)
TEV
02302381 SANDOZ LISINOPRIL HCT SDZ02045729 ZESTORETIC AZC
PERINDOPRIL ERBUMINE
2MG TabletST
02123274 COVERSYL SEV
Page 43 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
PERINDOPRIL ERBUMINE
4MG TabletST
02123282 COVERSYL SEV8MG Tablet
ST
02246624 COVERSYL SEV
PERINDOPRIL ERBUMINE, INDAPAMIDE
4MG & 1.25MG TabletST
02246569 COVERSYL PLUS SEV8MG/2.5MG Tablet
ST
02321653 COVERSYL PLUS HD SEV
QUINAPRIL HCL
5MG TabletST
01947664 ACCUPRIL PFI02248499 APO-QUINAPRIL APX
10MG TabletST
01947672 ACCUPRIL PFI02248500 APO-QUINAPRIL APX
20MG TabletST
01947680 ACCUPRIL PFI02248501 APO-QUINAPRIL APX
40MG TabletST
01947699 ACCUPRIL PFI02248502 APO-QUINAPRIL APX
QUINAPRIL HCL, HYDROCHLOROTHIAZIDE
10MG & 12.5MG TabletST
02237367 ACCURETIC PFI02408767 APO-QUINAPRIL/HCTZ APX
20MG & 12.5MG TabletST
02237368 ACCURETIC PFI02408775 APO-QUINAPRIL/HCTZ APX
20MG & 25MG TabletST
02237369 ACCURETIC PFI02408783 APO-QUINAPRIL/HCTZ APX
RAMIPRIL
1.25MG CapsuleST
02221829 ALTACE SAC02251515 APO-RAMIPRIL APX02387387 AURO-RAMIPRIL AUR02295482 CO RAMIPRIL ACT02308371 DOM-RAMIPRIL DOM02331101 JAMP-RAMIPRIL JAP02301148 MYLAN-RAMIPRIL MYL02295369 PMS-RAMIPRIL PMS02310023 PRO-RAMIPRIL PDL02299372 RAMIPRIL RIV02308363 RAMIPRIL SIV02310503 RAN-RAMIPRIL RBY02287692 RATIO-RAMIPRIL RPH
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
RAMIPRIL
2.5MG CapsuleST
02221837 ALTACE SAC02251531 APO-RAMIPRIL APX02387395 AURO-RAMIPRIL AUR02295490 CO RAMIPRIL ACT02287951 DOM-RAMIPRIL DOM02331128 JAMP-RAMIPRIL JAP02301156 MYLAN-RAMIPRIL MYL02247945 NOVO-RAMIPRIL TEV02247917 PMS-RAMIPRIL PMS02310066 PRO-RAMIPRIL PDL02255316 RAMIPRIL PMS02287927 RAMIPRIL SIV02374846 RAMIPRIL SAN02411563 RAMIPRIL-2.5 SIV02310511 RAN-RAMIPRIL RBY02287706 RATIO-RAMIPRIL RPH
5MG CapsuleST
02221845 ALTACE SAC02251574 APO-RAMIPRIL APX02387409 AURO-RAMIPRIL AUR02295504 CO RAMIPRIL ACT02287978 DOM-RAMIPRIL DOM02331136 JAMP-RAMIPRIL JAP02301164 MYLAN-RAMIPRIL MYL02247946 NOVO-RAMIPRIL TEV02247918 PMS-RAMIPRIL PMS02310074 PRO-RAMIPRIL PDL02255324 RAMIPRIL PMS02287935 RAMIPRIL SIV02374854 RAMIPRIL SAN02411571 RAMIPRIL-5 SIV02310538 RAN-RAMIPRIL RBY
10MG CapsuleST
02221853 ALTACE SAC02251582 APO-RAMIPRIL APX02387417 AURO-RAMIPRIL AUR02295512 CO RAMIPRIL ACT02287986 DOM-RAMIPRIL DOM02331144 JAMP-RAMIPRIL JAP02301172 MYLAN-RAMIPRIL MYL02247947 NOVO-RAMIPRIL TEV02247919 PMS-RAMIPRIL PMS02310104 PRO-RAMIPRIL PDL02255332 RAMIPRIL PMS02287943 RAMIPRIL SIV02374862 RAMIPRIL SAN02411598 RAMIPRIL-10 SIV02310546 RAN-RAMIPRIL RBY
15MG CapsuleST
02325381 APO-RAMIPRIL APX02343932 PMS-RAMIPRIL PMS
1.25MG TabletST
02291398 SANDOZ RAMIPRIL SDZ
Page 44 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.04 ANGIOTENSIN-CONVERTING
ENZYME INHIBITORS
RAMIPRIL
2.5MG TabletST
02291401 SANDOZ RAMIPRIL SDZ5MG Tablet
ST
02291428 SANDOZ RAMIPRIL SDZ10MG Tablet
ST
02291436 SANDOZ RAMIPRIL SDZ
RAMIPRIL, HYDROCHLOROTHIAZIDE
2.5MG & 12.5MG TabletST
02283131 ALTACE HCT SAC02354004 APO-RAMIPRIL/HCTZ APX02342138 PMS-RAMIPRIL-HCTZ PMS02388332 TEVA-RAMIPRIL/HCTZ TEP
5MG & 12.5MG TabletST
02283158 ALTACE HCT SAC02354012 APO-RAMIPRIL/HCTZ APX02342146 PMS-RAMIPRIL-HCTZ PMS02388340 TEVA-RAMIPRIL/HCTZ TEP
5MG & 25MG TabletST
02283174 ALTACE HCT SAC02354020 APO-RAMIPRIL/HCTZ APX02342162 PMS-RAMIPRIL-HCTZ PMS02388367 TEVA-RAMIPRIL/HCTZ TEP
10MG & 12.5MG TabletST
02283166 ALTACE HCT SAC02342154 PMS-RAMIPRIL-HCTZ PMS02388359 TEVA-RAMIPRIL/HCTZ TEP
10MG & 25MG TabletST
02283182 ALTACE HCT SAC02354039 APO-RAMIPRIL/HCTZ APX02342170 PMS-RAMIPRIL-HCTZ PMS02388375 TEVA-RAMIPRIL/HCTZ TEP
TRANDOLAPRIL
0.5MG CapsuleST
02231457 MAVIK ABB1MG Capsule
ST
02231459 MAVIK ABB2MG Capsule
ST
02231460 MAVIK ABB4MG Capsule
ST
02239267 MAVIK ABB
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
CANDESARTAN CILEXETIL
4MG TabletST
02365340 APO-CANDESARTAN APX02239090 ATACAND AZE02388693 CANDESARTAN SIV02388901 CANDESARTAN SAN02376520 CO-CANDESARTAN ACT02386496 JAMP-CANDESARTAN JAP02379120 MYLAN-CANDESARTAN MYL02391171 PMS-CANDESARTAN PMS02380684 RAN-CANDESARTAN RBY02326957 SANDOZ CANDESARTAN SDZ
8MG TabletST
02365359 APO-CANDESARTAN APX02239091 ATACAND AZC02377934 CANDESARTAN PDL02388707 CANDESARTAN SIV02388928 CANDESARTAN SAN02376539 CO-CANDESARTAN ACT02395762 DOM-CANDESARTAN DOM02386518 JAMP-CANDESARTAN JAP02379139 MYLAN-CANDESARTAN MYL02391198 PMS-CANDESARTAN PMS02380692 RAN-CANDESARTAN RBY02326965 SANDOZ CANDESARTAN SDZ02366312 TEVA-CANDESARTAN TEP
16MG TabletST
02365367 APO-CANDESARTAN APX02239092 ATACAND AZC02377942 CANDESARTAN PDL02388715 CANDESARTAN SIV02388936 CANDESARTAN SAN02376547 CO-CANDESARTAN ACT02386526 JAMP-CANDESARTAN JAP02379147 MYLAN-CANDESARTAN MYL02391201 PMS-CANDESARTAN PMS02380706 RAN-CANDESARTAN RBY02326973 SANDOZ CANDESARTAN SDZ02366320 TEVA-CANDESARTAN TEP
32MG TabletST
02399105 APO-CANDESARTAN APX02311658 ATACAND AZE02376555 CO-CANDESARTAN ACT02386534 JAMP-CANDESARTAN JAP02379155 MYLAN-CANDESARTAN MYL02391228 PMS-CANDESARTAN PMS02380714 RAN-CANDESARTAN RBY02392267 SANDOZ CANDESARTAN SDZ02366339 TEVA-CANDESARTAN TEP
Page 45 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
CANDESARTAN CILEXETIL,
HYDROCHLOROTHIAZIDE
16MG & 12.5MG TabletST
02367866 APO-CANDESARTAN/HCTZ APX02244021 ATACAND PLUS AZC02394812 CANDESARTAN HCT SIV02394804 CANDESARTAN/HCTZ SAN02388650 CO CANDESARTAN/HCTZ ACT02374897 MYLAN-CANDESART/HCTZ MYL02391295 PMS-CANDESARTAN/HCTZ ACT02327902 SANDOZ CANDESARTAN PLUS SDZ02395541 TEVA-CANDESARTAN/HCTZ TEP
32MG & 12.5MG TabletST
02395126 APO-CANDESARTAN/HCTZ APX02332922 ATACAND PLUS AZE02395568 TEVA-CANDESARTAN/HCTZ TEP
32MG & 25MG TabletST
02395134 APO-CANDESARTAN/HCTZ APX02332957 ATACAND PLUS AZE02395576 TEVA-CANDESARTAN/HCTZ TEP
EPOSARTAN MESYLATE
400MG TabletST
02240432 TEVETEN SPH600MG Tablet
ST
02243942 TEVETEN SPH
EPOSARTAN MESYLATE,
HYDROCHLOROTHIAZIDE
600MG/12.5MG TabletST
02253631 TEVETEN PLUS SPH
IRBESARTAN
150MG TabletST
02328089 CO IRBESARTAN ACT02372193 DOM-IRBESARTAN DOM02365200 IRBESARTAN PDL02372371 IRBESARTAN SAN02385295 IRBESARTAN SIV02347318 MYLAN-IRBESARTAN MYL02317079 PMS-IRBESARTAN PMS02406829 RAN-IRBESARTAN RBY02316404 RATIO-IRBESARTAN RTP02328488 SANDOZ IRBESARTAN SDZ02315998 TEVA-IRBESARTAN TEP
300MG TabletST
02328100 CO IRBESARTAN ACT02365219 IRBESARTAN PDL02372398 IRBESARTAN SAN02385309 IRBESARTAN SIV02347326 MYLAN-IRBESARTAN MYL02317087 PMS-IRBESARTAN PMS02406837 RAN-IRBESARTAN RBY02316412 RATIO-IRBESARTAN RTP02328496 SANDOZ IRBESARTAN SDZ02316005 TEVA-IRBESARTAN TEP
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
IRBESARTAN
75MG TabletST
02328070 CO IRBESARTAN ACT02365197 IRBESARTAN PDL02372347 IRBESARTAN SAN02385287 IRBESARTAN SIV02347296 MYLAN-IRBESARTAN MYL02317060 PMS-IRBESARTAN PMS02406810 RAN-IRBESARTAN RBY02316390 RATIO-IRBESARTAN RTP02328461 SANDOZ IRBESARTAN SDZ02315971 TEVA-IRBESARTAN TEP
75MG TabletST
02386968 APO-IRBESARTAN APX02237923 AVAPRO SAC
150MG TabletST
02386976 APO-IRBESARTAN APX02237924 AVAPRO SAC
300MG TabletST
02386984 APO-IRBESARTAN APX02237925 AVAPRO SAC
IRBESARTAN, HYDROCHLOROTHIAZIDE
150MG & 12.5MG TabletST
02387646 APO-IRBESARTAN/HCTZ APX02241818 AVALIDE SAC02357399 CO IRBESARTAN/HCT ACT02385317 IRBESARTAN HCT SIV02365162 IRBESARTAN/HCTZ PDL02372886 IRBESARTAN/HCTZ SAN02392992 MINT-IRBESARTAN/HCTZ MIN02328518 PMS-IRBESARTAN/HCT PMS02363208 RAN-IRBESARTAN HCTZ RBY02330512 RATIO-IRBESARTAN HCTZ RTP02337428 SANDOZ IRBESARTAN HCTZ SDZ02316013 TEVA-IRBESARTAN/HCTZ TEP
300MG & 12.5MG TabletST
02387654 APO-IRBESARTAN/HCTZ APX02241819 AVALIDE SAC02357402 CO IRBESARTAN/HCT ACT02385325 IRBESARTAN HCT SIV02365170 IRBESARTAN/HCTZ PDL02372894 IRBESARTAN/HCTZ SAN02393018 MINT-IRBESARTAN/HCTZ MIN02328526 PMS-IRBESARTAN/HCT PMS02363216 RAN-IRBESARTAN HCTZ RBY02330520 RATIO-IRBESARTAN HCTZ RTP02337436 SANDOZ IRBESARTAN HCTZ SDZ02316021 TEVA-IRBESARTAN/HCTZ TEP
Page 46 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
IRBESARTAN, HYDROCHLOROTHIAZIDE
300MG & 25MG TabletST
02387662 APO-IRBESARTAN/HCTZ APX02280213 AVALIDE SAC02357410 CO IRBESARTAN/HCT ACT02385333 IRBESARTAN HCT SIV02365189 IRBESARTAN/HCTZ PDL02372908 IRBESARTAN/HCTZ SAN02393026 MINT-IRBESARTAN/HCTZ MIN02328534 PMS-IRBESARTAN/HCT PMS02363224 RAN-IRBESARTAN HCTZ RBY02330539 RATIO-IRBESARTAN HCTZ RTP02337444 SANDOZ IRBESARTAN HCTZ SDZ02316048 TEVA-IRBESARTAN/HCTZ TEP
LOSARTAN POTASSIUM
25MG TabletST
02379058 APO-LOSARTAN APX02354829 CO LOSARTAN ACT02182815 COZAAR FRS02398834 JAMP-LOSARTAN JAP02388790 LOSARTAN SIV02388863 LOSARTAN SAN02368277 MYLAN-LOSARTAN MYL02309750 PMS-LOSARTAN PMS02313332 SANDOZ LOSARTAN SDZ02380838 TEVA-LOSARTAN TEP
50MG TabletST
02353504 APO-LOSARTAN APX02354837 CO LOSARTAN ACT02182874 COZAAR FRS02398842 JAMP-LOSARTAN JAP02388804 LOSARTAN SIV02388871 LOSARTAN SAN02368285 MYLAN-LOSARTAN MYL02309769 PMS-LOSARTAN PMS02404478 RAN-LOSARTAN RBY02313340 SANDOZ LOSARTAN SDZ02357968 TEVA-LOSARTAN TEP
100MG TabletST
02353512 APO-LOSARTAN APX02354845 CO LOSARTAN ACT02182882 COZAAR FRS02398850 JAMP-LOSARTAN JAP02388812 LOSARTAN SIV02388898 LOSARTAN SAN02368293 MYLAN-LOSARTAN MYL02309777 PMS-LOSARTAN PMS02404486 RAN-LOSARTAN RBY02313359 SANDOZ LOSARTAN SDZ02357976 TEVA-LOSARTAN TEP
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
LOSARTAN POTASSIUM,
HYDROCHLOROTHIAZIDE
50MG & 12.5MG TabletST
02371235 APO-LOSARTAN/HCTZ APX02388251 CO LOSARTAN/HCT ACT02230047 HYZAAR FRS02408244 JAMP-LOSARTAN HCTZ JAP02388960 LOSARTAN/HCT SIV02389657 MINT-LOSARTAN/HCTZ MIN02378078 MYLAN-LOSARTAN/HCTZ MYL02392224 PMS-LOSARTAN-HCTZ PMS02313375 SANDOZ LOSARTAN HCT SDZ02358263 TEVA-LOSARTAN HCTZ TEP
100MG & 12.5MG TabletST
02371243 APO-LOSARTAN/HCTZ APX02388278 CO LOSARTAN/HCT ACT02297841 HYZAAR FRS02388979 LOSARTAN/HCT SIV02389665 MINT-LOSARTAN/HCTZ MIN02378086 MYLAN-LOSARTAN/HCTZ MYL02392232 PMS-LOSARTAN-HCTZ PMS02362449 SANDOZ LOSARTAN HCT SDZ02377144 TEVA-LOSARTAN HCTZ TEP
100MG & 25MG TabletST
02371251 APO-LOSARTAN/HCTZ APX02388286 CO LOSARTAN/HCT ACT02241007 HYZAAR DS FRS02408252 JAMP-LOSARTAN HCTZ JAP02388987 LOSARTAN/HCT SIV02389673 MINT-LOSARTAN/HCTZ MIN02378094 MYLAN-LOSARTAN/HCTZ MYL02392240 PMS-LOSARTAN-HCTZ PMS02313383 SANDOZ LOSARTAN HCT SDZ02377152 TEVA-LOSARTAN HCTZ TEP
OLMESARTAN MEDOXOMIL
20MG TabletST
02318660 OLMETEC FRS40MG Tablet
ST
02318679 OLMETEC FRS
OLMESARTAN MEDOXOMIL,
HYDROCHLOROTHIAZIDE
20MG & 12.5MG TabletST
02319616 OLMETEC PLUS FRS40MG & 12.5MG Tablet
ST
02319624 OLMETEC PLUS FRS40MG & 25MG Tablet
ST
02319632 OLMETEC PLUS FRS
Page 47 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
TELMISARTAN
40MG TabletST
02393247 CO TELMISARTAN ACT02240769 MICARDIS BOE02376717 MYLAN-TELMISARTAN MYL02391236 PMS-TELMISARTAN PMS02375958 SANDOZ TELMISARTAN SDZ02388944 TELMISARTAN SAN02390345 TELMISARTAN SIV02395223 TELMISARTAN PDL02320177 TEVA-TELMISARTAN TEP
80MG TabletST
02393255 CO TELMISARTAN ACT02240770 MICARDIS BOE02376725 MYLAN-TELMISARTAN MYL02391244 PMS-TELMISARTAN PMS02375966 SANDOZ TELMISARTAN SDZ02388952 TELMISARTAN SAN02390353 TELMISARTAN SIV02395231 TELMISARTAN PDL02320185 TEVA-TELMISARTAN TEP
TELMISARTAN, HYDROCHLOROTHIAZIDE
80MG & 12.5MG TabletST
02393263 CO TELMISARTAN/HCT ACT02244344 MICARDIS PLUS BOE02373564 MYLAN-TELMISARTAN HCTZ MYL02401665 PMS-TELMISARTAN-HCTZ PMS02393557 SANDOZ TELMISARTAN HCT SDZ02390302 TELMISARTAN HCTZ SIV02395355 TELMISARTAN/HCTZ SAN02395525 TELMISARTAN/HCTZ PDL02330288 TEVA-TELMISARTAN HCTZ TEP
80MG & 25MG TabletST
02393271 CO TELMISARTAN/HCT ACT02318709 MICARDIS PLUS BOE02373572 MYLAN-TELMISARTAN HCTZ MYL02393565 SANDOZ TELMISARTAN HCT SDZ02390310 TELMISARTAN HCTZ SIV02395363 TELMISARTAN/HCTZ SAN02395533 TELMISARTAN/HCTZ PDL02379252 TEVA-TELMISARTAN HCTZ TEP
VALSARTAN
80MG CapsuleST
02236808 DIOVAN 80MG CAP NOV
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
VALSARTAN
40MG TabletST
02371510 APO-VALSARTAN APX02337487 CO VALSARTAN ACT02270528 DIOVAN NVR02383527 MYLAN-VALSARTAN MYL02312999 PMS-VALSARTAN PMS02363062 RAN-VALSARTAN RBY02356740 SANDOZ VALSARTAN SDZ02356643 TEVA-VALSARTAN TEP02366940 VALSARTAN SAN02367726 VALSARTAN PDL02384523 VALSARTAN SIV
80MG TabletST
02371529 APO-VALSARTAN APX02337495 CO VALSARTAN ACT02244781 DIOVAN NVR02383535 MYLAN-VALSARTAN MYL02313006 PMS-VALSARTAN PMS02363100 RAN-VALSARTAN RBY02356759 SANDOZ VALSARTAN SDZ02356651 TEVA-VALSARTAN TEP02366959 VALSARTAN SAN02367734 VALSARTAN PDL02384531 VALSARTAN SIV
160MG TabletST
02371537 APO-VALSARTAN APX02337509 CO VALSARTAN ACT02244782 DIOVAN NVR02383543 MYLAN-VALSARTAN MYL02313014 PMS-VALSARTAN PMS02363119 RAN-VALSARTAN RBY02356767 SANDOZ VALSARTAN SDZ02356678 TEVA-VALSARTAN TEP02366967 VALSARTAN SAN02367742 VALSARTAN PDL02384558 VALSARTAN SIV
320MG TabletST
02371545 APO-VALSARTAN APX02337517 CO VALSARTAN ACT02289504 DIOVAN NVR02383551 MYLAN-VALSARTAN MYL02344564 PMS-VALSARTAN PMS02356775 SANDOZ VALSARTAN SDZ02356686 TEVA-VALSARTAN TEP02366975 VALSARTAN SAN02367750 VALSARTAN PDL02384566 VALSARTAN SIV
Page 48 of 1382014
Non-Insured Health BenefitsHealth Canada
24:32.08 ANGIOTENSIN II RECEPTOR
ANTAGONISTS
VALSARTAN, HYDROCHLOROTHIAZIDE
80MG & 12.5MG TabletST
02382547 APO-VALSARTAN/HCTZ APX02241900 DIOVAN-HCT NVR02373734 MYLAN-VALSARTAN HCTZ MYL02356694 SANDOZ VALSARTAN HCT SDZ02356996 TEVA-VALSARTAN/HCTZ TEP02384736 VALSARTAN HCT SIV02367769 VALSARTAN-HCTZ PDL
160MG & 12.5MG TabletST
02382555 APO-VALSARTAN/HCTZ APX02241901 DIOVAN-HCT NVR02373742 MYLAN-VALSARTAN HCTZ MYL02356708 SANDOZ VALSARTAN HCT SDZ02357003 TEVA-VALSARTAN/HCTZ TEP02367017 VALSARTAN HCT SAN02384744 VALSARTAN HCT SIV02367777 VALSARTAN-HCTZ PDL
160MG & 25MG TabletST
02382563 APO-VALSARTAN/HCTZ APX02246955 DIOVAN-HCT NVR02373750 MYLAN-VALSARTAN HCTZ MYL02356716 SANDOZ VALSARTAN HCT SDZ02357011 TEVA-VALSARTAN/HCTZ TEP02367025 VALSARTAN HCT SAN02384752 VALSARTAN HCT SIV02367785 VALSARTAN-HCTZ PDL
320MG & 12.5MG TabletST
02382571 APO-VALSARTAN/HCTZ APX02308908 DIOVAN-HCT NOV02373769 MYLAN-VALSARTAN HCTZ MYL02356724 SANDOZ VALSARTAN HCT SDZ02357038 TEVA-VALSARTAN/HCTZ TEP02367033 VALSARTAN HCT SAN02384760 VALSARTAN HCT SIV
320MG & 25MG TabletST
02382598 APO-VALSARTAN/HCTZ APX02308916 DIOVAN-HCT NOV02373777 MYLAN-VALSARTAN HCTZ MYL02356732 SANDOZ VALSARTAN HCT SDZ02357046 TEVA-VALSARTAN/HCTZ TEP02367009 VALSARTAN HCT SAN02367041 VALSARTAN HCT SAN02384779 VALSARTAN HCT SIV
24:32.20 MINERALOCORTICOIDE
(ALDOSTERONE) RECEPTOR
ANTAGONISTS
SPIRONOLACTONE
25MG TabletST
00028606 ALDACTONE PFI00613215 NOVO-SPIROTON TEV
24:32.20 MINERALOCORTICOIDE
(ALDOSTERONE) RECEPTOR
ANTAGONISTS
SPIRONOLACTONE
100MG TabletST
00285455 ALDACTONE PFI00613223 NOVO-SPIROTON TEV
Page 49 of 1382014
Non-Insured Health BenefitsHealth Canada
28:00 CENTRAL NERVOUS SYSTEM
AGENTS
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
Limited use benefit (prior approval is not required).
ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome).
80MG Chewable TabletST
02269139 ACETYLSALICYLIC ACID JAP02321750 ASA ZYM02009013 ASAPHEN PMS02280167 ASATAB ODN02296004 LOWPRIN EUR02311518 PRO-ASA PRO02202352 RIVASA RIV
80MG Delayed Release TabletST
02283905 ACETYLSALICYLIC ACID JAP02321769 ASA EC SOR02238545 ASAPHEN EC PMS02311496 PRO-ASA EC PRO
81MG Delayed Release TabletST
02372177 ASA 81MG VTH02283700 PRAXIS ASA EC PMS
162MG Delayed Release TabletST
02247550 ASAPHEN EC PMS325MG Delayed Release Tablet
ST
02352427 ASATAB EC ODN02284529 PMS-ASA EC PMS
650MG Delayed Release TabletST
02352435 ASATAB EC ODN02284537 PMS-ASA EC PMS
81MG Enteric Coated TabletST
02243101 ASA PMS02244993 ASA PMS02243896 ASA EC PMS02237726 ASPIRIN BCD02242281 ENTROPHEN EC PED02243801 EQUATE DAILY LOW-DOSE PMS
325MG Enteric Coated TabletST
00510696 APO-ASEN ECT APX02010526 ASA VTH02150417 ASPIRIN BCD02050161 ENTROPHEN WAM00010332 ENTROPHEN-5 WAM00216666 NOVASEN TEV02285371 PMS-ASA EC PMS
650MG Enteric Coated TabletST
00794244 ASA WSB02046261 ASA FRS00472476 ENTERIC COATED ASA APX00010340 ENTROPHEN ECT FRS01905392 ENTROPHEN-10 FRS00229296 NOVASEN TEV
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
ACETYLSALICYLIC ACID
Limited use benefit (prior approval is not required).
ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome).
150MG SuppositoryST
00785547 PMS-ASA PMS650MG Suppository
ST
00582867 ASA JNO80MG Tablet
ST
02150352 ASPIRIN BCD02250675 EURO-ASA EUR02295563 LOWPRIN EUR02202360 RIVASA RIV
325MG TabletST
00472468 APO-ASA APX00036145 ASA PED00230324 ASA TEV00530336 ASA VTH *02150328 ASPIRIN BCD
CELECOXIB
Limited use benefit (prior approval required).
For patients who have:
¨A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation);
OR
¨Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).
100MG Capsule
02239941 CELEBREX PFI200MG Capsule
02239942 CELEBREX PFI
DICLOFENAC SODIUM
25MG Enteric Coated Tablet
00839175 APO-DICLO APX02231662 DOM-DICLOFENAC DPC00808539 NOVO-DIFENAC TEV02231502 PMS-DICLOFENAC PMS
50MG Enteric Coated Tablet
00839183 APO-DICLO APX02352397 DICLOFENAC EC SAN00870978 DICLOFENAC-50 PDL02231663 DOM-DICLOFENAC DPC00808547 NOVO-DIFENAC TEV02231503 PMS-DICLOFENAC PMS00514012 VOLTAREN NVR
75MG Extended Release Tablet
02352400 DICLOFENAC SR SAN02261901 SANDOZ-DICLOFENAC SR SDZ
Page 50 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
DICLOFENAC SODIUM
100MG Extended Release Tablet
02261944 SANDOZ-DICLOFENAC SR SDZ50MG Suppository
02231506 PMS-DICLOFENAC PMS00632724 VOLTAREN NVR
100MG Suppository
02231508 PMS-DICLOFENAC PMS00632732 VOLTAREN NVR
75MG Sustained Release Tablet
02162814 APO-DICLO SR APX02224119 DICLOFENAC-SR PDL02231664 DOM-DICLOFENAC SR DPC02158582 NOVO-DIFENAC SR TEV02231504 PMS-DICLOFENAC SR PMS00782459 VOLTAREN SR NVR
100MG Sustained Release Tablet
02091194 APO-DICLO SR APX02224127 DICLOFENAC-SR PDL02048698 NOVO-DIFENAC SR TEV02231505 PMS-DICLOFENAC SR PMS00590827 VOLTAREN SR NVR
25MG Tablet
02261952 SANDOZ-DICLOFENAC SDZ50MG Tablet
02261960 SANDOZ-DICLOFENAC SDZ
DICLOFENAC SODIUM, MISOPROSTOL
50MG & 200MCG Tablet
01917056 ARTHROTEC PFI02397145 CO DICLO-MISO ACT02400596 SANDOZ DICLO/MISOPROS SDZ
75MG & 200MCG Tablet
02229837 ARTHROTEC PFI02397153 CO DICLO-MISO ACT02400618 SANDOZ DICLO/MISOPROS SDZ
DIFLUNISAL
250MG Tablet
02039486 APO-DIFLUNISAL APX02048493 NOVO-DIFLUNISAL TEV
500MG Tablet
02039494 APO-DIFLUNISAL APX
FLURBIPROFEN
50MG Tablet
01912046 APO-FLURBIPROFEN APX02100509 NOVO-FLURPROFEN TEV
100MG Tablet
01912038 APO-FLURBIPROFEN APX02100517 NOVO-FLURPROFEN TEV
IBUPROFEN
100MG Chewable Tablet
02246403 ADVIL JUNIOR STRENGTH WRI
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
IBUPROFEN
40MG/ML Drop
02242522 ADVIL PEDIATRIC WRI02238626 CHILDREN'S MOTRIN MCL
20MG/ML Oral Liquid
02232297 CHILDREN'S ADVIL WRI02242365 CHILDREN'S MOTRIN JNO
100MG Tablet
02240527 MOTRIN JUNIOR STRENGTH MCL200MG Tablet
01933558 ADVIL WRI00441643 APO-IBUPROFEN APX02257912 IBUPROFEN PMT02272849 IBUPROFEN JAP02314754 IBUPROFEN PMS02314762 IBUPROFEN PMS02186934 MOTRIN MCL
300MG Tablet
00441651 APO-IBUPROFEN APX400MG Tablet
00506052 APO-IBUPROFEN APX00636533 IBUPROFEN PDL02314770 IBUPROFEN PMS02317338 JAMP IBUPROFEN JAP02401290 JAMP IBUPROFEN JAP
600MG Tablet
00585114 APO-IBUPROFEN APX00658804 IBUPROFEN PDL00629359 NOVO-PROFEN TEV
INDOMETHACIN
25MG Capsule
00611158 APO-INDOMETHACIN APX00337420 NOVO-METHACIN TEV00646261 PRO-INDO PDL
50MG Capsule
00611166 APO-INDOMETHACIN APX00337439 NOVO-METHACIN TEV00646288 PRO-INDO PDL
50MG Suppository
02231799 SAB-INDOMETHACIN SIL100MG Suppository
01934139 RATIO-INDOMETHACIN RPH02231800 SAB-INDOMETHACIN SIL
KETOPROFEN
50MG Capsule
00790427 APO-KETO APX02150808 PMS-KETOPROFEN PMS
50MG Enteric Coated Tablet
00790435 APO KETO-E APX02150816 PMS-KETOPROFEN PMS
Page 51 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
KETOPROFEN
100MG Enteric Coated Tablet
00842664 APO-KETO-E APX02150824 PMS-KETOPROFEN PMS
100MG Suppository
02015951 PMS-KETOPROFEN PMS200MG Sustained Release Tablet
02172577 APO-KETO SR APX
MEFENAMIC ACID
250MG Capsule
02229452 APO-MEFENAMIC APX02237826 DOM-MEFENAMIC ACID DPC
MELOXICAM
7.5MG Tablet
02248973 APO-MELOXICAM APX02390884 AURO-MELOXICAM AUR02250012 CO-MELOXICAM ACT02248605 DOM-MELOXICAM DPC02255987 GEN-MELOXICAM GEN02324326 MELOXICAM PDL02353148 MELOXICAM SAN02242785 MOBICOX BOE02258315 NOVO-MELOXICAM TEV02248607 PHL-MELOXICAM PHH02248267 PMS-MELOXICAM PMS02247889 RATIO-MELOXICAM RPH
15MG Tablet
02248974 APO-MELOXICAM APX02390892 AURO-MELOXICAM AUR02250020 CO-MELOXICAM ACT02248606 DOM-MELOXICAM DPC02255995 GEN-MELOXICAM GEN02353156 MELOXICAM SAN02242786 MOBICOX BOE02258323 NOVO-MELOXICAM TEV02248608 PHL-MELOXICAM PHH02248268 PMS-MELOXICAM PMS02248031 RATIO-MELOXICAM RPH
NAPROXEN
250MG Enteric Coated Tablet
02246699 APO-NAPROXEN EC APX02350785 NAPROXEN EC SAN02243312 NOVO-NAPROX TEV
375MG Enteric Coated Tablet
02246700 APO-NAPROXEN EC APX02162415 NAPROSYN E HLR02350793 NAPROXEN EC SAN02243313 NOVO-NAPROX TEV02294702 PMS-NAPROXEN EC PMS02310945 PRO-NAPROXEN EC PDL
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
NAPROXEN
500MG Enteric Coated Tablet
02246701 APO-NAPROXEN EC APX02241024 GEN-NAPROXEN EC GEN02162423 NAPROSYN E HLR02350807 NAPROXEN EC SAN02243314 NOVO-NAPROX TEV02294710 PMS-NAPROXEN EC PMS02310953 PRO-NAPROXEN EC PDL
25MG/ML Suspension
02162431 NAPROSYN HLR750MG Sustained Release Tablet
02162466 NAPROSYN SR HLR125MG Tablet
00522678 APO-NAPROXEN APX250MG Tablet
00522651 APO-NAPROXEN APX00590762 NAPROXEN PDL02350750 NAPROXEN SAN00565350 NOVO-NAPROX TEV02240786 RIVA-NAPROXEN RIV
375MG Tablet
00600806 APO-NAPROXEN APX02243432 GEN-NAPROXEN GEN00655686 NAPROXEN PDL02350769 NAPROXEN SAN00627097 NOVO-NAPROX TEV02240787 RIVA-NAPROXEN RIV
500MG Tablet
00592277 APO-NAPROXEN APX00618721 NAPROXEN PDL02350777 NAPROXEN SAN00589861 NOVO-NAPROX TEV02240788 RIVA-NAPROXEN RIV
NAPROXEN SODIUM
220MG Tablet
02362430 NAPROXEN PMS275MG Tablet
02162725 ANAPROX HLR00784354 APO-NAPRO NA APX00887056 NAPROXEN NA PDL02351013 NAPROXEN SODIUM SAN00778389 NOVO-NAPROX SODIUM TEV
550MG Tablet
02162717 ANAPROX DS HLR01940309 APO-NAPRO NA DS APX02351021 NAPROXEN SODIUM DS SAN02153386 NAPROXEN-NA DF PDL02026600 NOVO-NAPROX SODIUM DS TEV02240828 RIVA-NAPROXEN SODIUM RIV
Page 52 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.04 NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
PIROXICAM
10MG Capsule
00642886 APO-PIROXICAM APX00836249 PMS-PIROXICAM PMS
20MG Capsule
00642894 APO-PIROXICAM APX02239536 DOM-PIROXICAM DPC00836230 PMS-PIROXICAM PMS
10MG Suppository
02154420 PMS-PIROXICAM PMS20MG Suppository
02154463 PMS-PIROXICAM PMS10MG Tablet
00695718 NOVO-PIROCAM TEV20MG Tablet
00695696 NOVO-PIROCAM TEV
SULINDAC
150MG Tablet
00778354 APO-SULIN APX00745588 NOVO-SUNDAC TEV
200MG Tablet
00778362 APO-SULIN APX00745596 NOVO-SUNDAC TEV
TIAPROFENIC ACID
200MG Tablet
02179679 NOVO-TIAPROFENIC TEV02230827 PMS-TIAPROFENIC PMS
300MG Tablet
02231060 DOM-TIAPROFENIC DPC02179687 NOVO-TIAPROFENIC TEV
28:08.08 OPIATE AGONISTS
ACETAMINOPHEN, CAFFEINE CITRATE,
CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
300MG & 30MG & 15MG Tablet
00293504 ATASOL-15 HOR02232388 EXDOL-15 PED
300MG & 30MG & 30MG Tablet
00293512 ATASOL-30 HOR02232389 EXDOL-30 PED
28:08.08 OPIATE AGONISTS
ACETAMINOPHEN, CAFFEINE, CODEINE
PHOSPHATE
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
300MG & 15MG & 15MG Tablet
00653241 RATIO-LENOLTEC NO.2 RPH02163934 TYLENOL WITH CODEINE NO.2 JNO
300MG & 15MG & 30MG Tablet
00653276 RATIO-LENOLTEC NO.3 RPH02163926 TYLENOL WITH CODEINE NO.3 JNO
ACETAMINOPHEN, CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
32MG & 1.6MG/ML Elixir
00816027 PMS-ACETAMINOPHEN WITH CODEINE
PMS
300MG & 30MG Tablet
01999648 ACET CODEINE 30 PMS02232658 PROCET-30 PDL00608882 RATIO-EMTEC-30 RPH00789828 TRIATEC-30 TRI
ACETAMINOPHEN, OXYCODONE HCL
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
325MG & 2.5MG Tablet
01916491 PERCOCET DEMI BMS325MG & 5MG Tablet
02324628 APO-OXYCODONE/ACET APX01916548 ENDOCET EDM02361361 OXYCODONE/ACET SAN01916475 PERCOCET BMS02327171 PRO-OXYCOD ACET PDL00608165 RATIO-OXYCOCET RPH02242468 RIVACOCET RIV02307898 SANDOZ OXYCOD ACET SDZ
Page 53 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.08 OPIATE AGONISTS
ACETYLSALICYLIC ACID, CAFFEINE CITRATE,
CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
375MG & 30MG & 15MG Tablet
02234510 282 PED375MG & 30MG & 30MG Tablet
02238645 292 PED
ACETYLSALICYLIC ACID, OXYCODONE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
325MG & 5MG Tablet
00608157 RATIO-OXYCODAN RPH
CODEINE MONOHYDRATE, CODEINE
SULFATE TRIHYDRATE
Limited use benefit (prior approval required).For treatment of:a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, orb. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
50MG Long Acting Tablet
02230302 CODEINE CONTIN CR PFR100MG Long Acting Tablet
02163748 CODEINE CONTIN CR PFR150MG Long Acting Tablet
02163780 CODEINE CONTIN CR PFR200MG Long Acting Tablet
02163799 CODEINE CONTIN CR PFR
28:08.08 OPIATE AGONISTS
CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
2MG/ML Liquid
00380571 LINCTUS CODEINE ATL5MG/ML Syrup
00050024 CODEINE PHOSPHATE ATL00779474 RATIO-CODEINE RPH
15MG Tablet
00779458 CODEINE RPH02009889 CODEINE TRI00593435 RATIO-CODEINE RPH
30MG Tablet
00593451 CODEINE PHOSPHATE RPH02009757 CODEINE PHOSPHATE TRI02243979 PMS-CODEINE PMS
FENTANYL
Limited use benefit (prior approval required).For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dosetitration and adjunctive therapy including laxatives and antiemetics.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
12MCG Patch
02311925 TEVA-FENTANYL TEP12MCG/H Patch
02386844 CO FENTANYL ACT02395657 FENTANYL PDL02396696 MYLAN-FENTANYL MYL02341379 PMS-FENTANYL PMS02330105 RAN-FENTANYL RBY02327112 SANDOZ FENTANYL SDZ
25MCG/H Patch
02314630 APO-FENTANYL APX02386852 CO FENTANYL ACT02275813 DURAGESIC MAT JNO02395665 FENTANYL PDL02396718 MYLAN-FENTANYL MYL02341387 PMS-FENTANYL PMS02330113 RAN-FENTANYL RBY02327120 SANDOZ FENTANYL SDZ02282941 TEVA-FENTANYL RPH
Page 54 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.08 OPIATE AGONISTS
FENTANYL
Limited use benefit (prior approval required).For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dosetitration and adjunctive therapy including laxatives and antiemetics.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
50MCG/H Patch
02314649 APO-FENTANYL APX02386879 CO FENTANYL ACT02275821 DURAGESIC MAT JNO02395673 FENTANYL PDL02396726 MYLAN-FENTANYL MYL02341395 PMS-FENTANYL PMS02330121 RAN-FENTANYL RBY02327147 SANDOZ FENTANYL SDZ02282968 TEVA-FENTANYL RPH
75MCG/H Patch
02314657 APO-FENTANYL APX02386887 CO FENTANYL ACT02275848 DURAGESIC MAT JNO02395681 FENTANYL PDL02396734 MYLAN-FENTANYL MYL02341409 PMS-FENTANYL PMS02330148 RAN-FENTANYL RBY02327155 SANDOZ FENTANYL SDZ02282976 TEVA-FENTANYL RPH
100MCG/H Patch
02314665 APO-FENTANYL APX02386895 CO FENTANYL ACT02275856 DURAGESIC MAT JNO02395703 FENTANYL PDL02396742 MYLAN-FENTANYL MYL02341417 PMS-FENTANYL PMS02330156 RAN-FENTANYL RBY02327163 SANDOZ FENTANYL SDZ02282984 TEVA-FENTANYL RPH
28:08.08 OPIATE AGONISTS
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
3MG Controlled Release Capsule
02125323 HYDROMORPH CONTIN PFR4.5MG Controlled Release Capsule
02359502 HYDROMORPH CONTIN PFR6MG Controlled Release Capsule
02125331 HYDROMORPH CONTIN PFR9MG Controlled Release Capsule
02359510 HYDROMORPH CONTIN PFR12MG Controlled Release Capsule
02125366 HYDROMORPH CONTIN PFR18MG Controlled Release Capsule
02243562 HYDROMORPH CONTIN PFR24MG Controlled Release Capsule
02125382 HYDROMORPH CONTIN PFR30MG Controlled Release Capsule
02125390 HYDROMORPH CONTIN PFR1MG/ML Oral Liquid
00786535 DILAUDID ABB01916386 PMS-HYDROMORPHONE PMS
3MG Suppository
01916394 PMS-HYDROMORPHONE PMS1MG Tablet
02364115 APO-HYDROMORPHONE APX00705438 DILAUDID ABB02192101 PHL-HYDROMORPHONE PHH00885444 PMS-HYDROMORPHONE PMS02319403 TEVA-HYDROMORPHONE TEP
2MG Tablet
02364123 APO-HYDROMORPHONE APX00125083 DILAUDID ABB02249928 PHL-HYDROMORPHONE PHH00885436 PMS-HYDROMORPHONE PMS02319411 TEVA-HYDROMORPHONE TEP
4MG Tablet
02364131 APO-HYDROMORPHONE APX00125121 DILAUDID ABB02249936 PHL-HYDROMORPHONE PHH00885401 PMS-HYDROMORPHONE PMS02319438 TEVA-HYDROMORPHONE TEP
Page 55 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.08 OPIATE AGONISTS
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
8MG Tablet
02364158 APO-HYDROMORPHONE APX00786543 DILAUDID ABB02192144 PHL-HYDROMORPHONE PHH00885428 PMS-HYDROMORPHONE PMS02319446 TEVA-HYDROMORPHONE TEP
METHADONE HCL
10mg/mL Liquid
02394596 METHADOSE MAT02394618 METHADOSE SUGARFREE MAT
METHADONE HCL (PA)
limited use benefit (prior approval required) with the following criteria:
Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.
Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.
1MG/ML Liquid
02247694 METADOL PAL10MG/ML Liquid
02241377 METADOL PAL1MG Tablet
02247698 METADOL PAL5MG Tablet
02247699 METADOL PAL10MG Tablet
02247700 METADOL PAL25MG Tablet
02247701 METADOL PAL
28:08.08 OPIATE AGONISTS
MORPHINE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
30MG Sustained Release Tablet
00776181 M.O.S. SR VAE60MG Sustained Release Tablet
00776203 M.O.S. SR VAE1MG/ML Syrup
00614491 DOLORAL 1 ATL00607762 RATIO-MORPHINE RPH
5MG/ML Syrup
00614505 DOLORAL 5 ATL00514217 M.O.S. VAE00607770 RATIO-MORPHINE RPH
10MG/ML Syrup
00632503 M.O.S. 10 VAE00690783 RATIO-MORPHINE RPH
20MG/ML Syrup
00690791 RATIO-MORPHINE RPH50MG/ML Syrup
00690236 M.O.S. 50 VAE10MG Tablet
00690198 M.O.S. 10 VAE20MG Tablet
00690201 M.O.S. 20 VAE40MG Tablet
00690228 M.O.S. 40 VAE60MG Tablet
00690244 M.O.S. 60 VAE
MORPHINE SULFATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
50MG/ML Drop
00705799 STATEX PMS5MG Suppository
00632228 STATEX PMS10MG Suppository
00632201 STATEX PMS20MG Suppository
00596965 STATEX PMS10MG Sustained Release Capsule
02242163 KADIAN MAY02019930 M-ESLON SAC
Page 56 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.08 OPIATE AGONISTS
MORPHINE SULFATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
15MG Sustained Release Capsule
02177749 M-ESLON SAC20MG Sustained Release Capsule
02184435 KADIAN SR MAY30MG Sustained Release Capsule
02019949 M-ESLON SR SAC50MG Sustained Release Capsule
02184443 KADIAN SR MAY60MG Sustained Release Capsule
02019957 M-ESLON SR SAC100MG Sustained Release Capsule
02184451 KADIAN SR MAY02019965 M-ESLON SR SAC
200MG Sustained Release Capsule
02177757 M-ESLON SR SAC15MG Sustained Release Tablet
02350815 MORPHINE SR SAN02015439 MS CONTIN SR PFR02244790 RATIO-MORPHINE SULFATE
SRRPH
02302764 TEVA-MORPHINE SR 15MG TAB
TEP
30MG Sustained Release Tablet
02350890 MORPHINE SR SAN02014297 MS CONTIN SR PFR02244791 RATIO-MORPHINE SULFATE
SRRPH
02302772 TEVA-MORPHINE SR 30MG TAB
TEP
60MG Sustained Release Tablet
02350912 MORPHINE SR SAN02014300 MS CONTIN SR PFR02244792 RATIO-MORPHINE SULFATE
SRRPH
02302780 TEVA-MORPHINE SR 60MG TAB
TEP
100MG Sustained Release Tablet
02350920 MORPHINE SR SAN02014319 MS CONTIN SR PFR02302799 TEVA-MORPHINE SR 100MG
TABTEP
200MG Sustained Release Tablet
02350947 MORPHINE SR SAN02014327 MS CONTIN SR PFR02302802 TEVA-MORPHINE SR 200MG
TABTEP
1MG/ML Syrup
00591467 STATEX PMS
28:08.08 OPIATE AGONISTS
MORPHINE SULFATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
5MG/ML Syrup
00591475 STATEX PMS10MG/ML Syrup
00647217 STATEX PMS5MG Tablet
02009773 M.O.S. SULFATE VAE02014203 MS IR PFR00594652 STATEX PMS
10MG Tablet
02009765 M.O.S. SULFATE VAE02014211 MS IR PFR00594644 STATEX PMS
20MG Tablet
02014238 MS IR PFR25MG Tablet
02009749 M.O.S. SULFATE VAE00594636 STATEX PMS
30MG Tablet
02014254 MS IR PFR50MG Tablet
02009706 M.O.S. SULFATE VAE00675962 STATEX PMS
OXYCODONE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
10MG Suppository
00392480 SUPEUDOL SIL20MG Suppository
00392472 SUPEUDOL SIL5MG Tablet
02325950 OXYCODONE PDL02231934 OXY-IR PFR02319977 PMS-OXYCODONE PMS00789739 SUPEUDOL SDZ
10MG Tablet
02240131 OXY-IR PFR02319985 PMS-OXYCODONE PMS00443948 SUPEUDOL SDZ
Page 57 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.08 OPIATE AGONISTS
OXYCODONE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
20MG Tablet
02240132 OXY-IR PFR02319993 PMS-OXYCODONE PMS02262983 SUPEUDOL SDZ
28:08.12 OPIATE PARTIAL AGONISTS
BUPRENORPHINE, NALOXONE
Limited use benefit (prior approval required).
For the treatment of opioid dependence in patients who have a contraindication to methadone due to:• Evidence of (or high risk for) QT interval prolongation; and• Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.
8MG & 2MG Tablet
02295709 SUBOXONE RBP09991204 SUBOXONE MAINTENANCE UNK
28:08.92 MISCELLANEOUS ANALGESICS
AND ANTIPYRETICS
ACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
80MG Chewable TabletST
02129957 ACETAMIN CHILD WTR01905856 ACETAMINOPHEN TRI02017458 ACETAMINOPHEN RIV02015676 CHILDREN'S ACETAMINOPHEN TAN
160MG Chewable TabletST
02017431 ACETAMINOPHEN RIV02231011 FEVERHALT PED02230934 TANTAPHEN GRAPE TAN
80MG/ML DropST
01904140 ACETAMINOPHEN TAN01905864 ACETAMINOPHEN TRI00631353 ATASOL HOR02230787 FEVERHALT PED02263793 PEDIAPHEN EUR02027801 PEDIATRIX RPH00887587 PMS-ACETAMINOPHEN PMS00875988 TEMPRA MJO02046059 TYLENOL GRAPE MCL
28:08.92 MISCELLANEOUS ANALGESICS
AND ANTIPYRETICS
ACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
16MG/ML LiquidST
01905848 ACETAMINOPHEN TRI02263807 PEDIAPHEN EUR00792713 PMS-ACETAMINOPHEN PMS00884553 TEMPRA MJO
32MG/ML LiquidST
01901389 ACETAMINOPHEN JAP01958836 ACETAMINOPHEN TRI02263831 PEDIAPHEN EUR02027798 PEDIATRIX RPH00792691 PMS-ACETAMINOPHEN PMS00875996 TEMPRA DOUBLE STRENGTH MJO02046040 TYLENOL MCL
120MG Suppository
00553328 ABENOL GSK01919385 ABENOL PED02230434 ACET 120 PMS02046660 PMS-ACETAMINOPHEN PMS
160MG Suppository
02230435 ACET PMS325MG Suppository
01919393 ABENOL PED02230436 ACET 325 PMS02046687 PMS-ACETAMINOPHEN PMS
650MG Suppository
01919407 ABENOL PED02230437 ACET 650 PMS02046695 PMS-ACETAMINOPHEN PMS
80MG/ML SuspensionST
02237390 ACETAMINOPHEN PER80MG Tablet
ST
02238295 CHILDREN'S TYLENOL SOFT CHEWS
JNO
02263815 PEDIAPHEN CHEWABLE TAB 80MG
EUO
160MG TabletST
02142805 ACETAMINOPHEN WTR02263823 PEDIAPHEN CHEWABLE TAB
160MGEUO
02347792 TYLENOL JR STRENGTH FASTMELTS
JNO
02241361 TYLENOL JUNIOR STRENGTH JNO
Page 58 of 1382014
Non-Insured Health BenefitsHealth Canada
28:08.92 MISCELLANEOUS ANALGESICS
AND ANTIPYRETICS
ACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
325MG TabletST
00374148 ACETAMINOPHEN WAM00382752 ACETAMINOPHEN PRO00589241 ACETAMINOPHEN PMS00605751 ACETAMINOPHEN VTH *00743542 ACETAMINOPHEN PMT00789801 ACETAMINOPHEN TRI01938088 ACETAMINOPHEN JAP02022214 ACETAMINOPHEN RIV00544981 APO-ACETAMINOPHEN APX02229873 APO-ACETAMINOPHEN APX00293482 ATASOL HOR00389218 NOVO-GESIC TEV00559393 TYLENOL MCL00723894 TYLENOL MCL
500MG TabletST
00386626 ACETAMINOPHEN PDL00549703 ACETAMINOPHEN PMT00567663 ACETAMINOPHEN PED00589233 ACETAMINOPHEN PMS00605778 ACETAMINOPHEN VTH00789798 ACETAMINOPHEN TRI01939122 ACETAMINOPHEN JAP02022222 ACETAMINOPHEN RIV02252813 ACETAMINOPHEN PMT02255251 ACETAMINOPHEN PMT00545007 APO-ACETAMINOPHEN APX02229977 APO-ACETAMINOPHEN APX00013668 ATASOL FORTE HOR02355299 JAMP-ACETAMINOPHEN JAP00482323 NOVO-GESIC TEV00892505 PMS-ACETAMINOPHEN PMS01962353 TANTAPHEN TAN00559407 TYLENOL EXTRA STRENGTH MCL00723908 TYLENOL EXTRA STRENGTH MCL
FLOCTAFENINE
200MG Tablet
02244680 APO-FLOCTAFENINE APX400MG Tablet
02244681 APO-FLOCTAFENINE APX
28:12.04 ANTICONVULSANTS -
BARBITURATES
PRIMIDONE
125MG TabletST
00399310 APO-PRIMIDONE APX250MG Tablet
ST
00396761 APO-PRIMIDONE APX
28:12.08 ANTICONVULSANTS -
BENZODIAZEPINES
CLONAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.25MG TabletST
02179660 PMS-CLONAZEPAM PMS0.5MG Tablet
ST
02177889 APO-CLONAZEPAM APX02230366 CLONAPAM VAE02270641 CO-CLONAZEPAM ACT02130998 DOM-CLONAZEPAM DPC02224100 DOM-CLONAZEPAM-R DPC02230950 GEN-CLONAZEPAM GEN02239024 NOVO-CLONAZEPAM TEV02145227 PHL-CLONAZEPAM PHH02236948 PHL-CLONAZEPAM-R PMI02048701 PMS-CLONAZEPAM PMS02207818 PMS-CLONAZEPAM R PMS02311593 PRO-CLONAZEPAM PDL02242077 RIVA-CLONAZEPAM RIV00382825 RIVOTRIL HLR02233960 SANDOZ-CLONAZEPAM SDZ02345676 ZYM-CLONAZEPAM ZYM
1MG TabletST
02230368 CLONAPAM VAE02270668 CO-CLONAZEPAM ACT02145235 PHL-CLONAZEPAM PHH02048728 PMS-CLONAZEPAM PMS02311607 PRO-CLONAZEPAM PDL02233982 SANDOZ-CLONAZEPAM SDZ02303329 ZYM-CLONAZEPAM ZYM
Page 59 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.08 ANTICONVULSANTS -
BENZODIAZEPINES
CLONAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
2MG TabletST
02177897 APO-CLONAZEPAM APX02230369 CLONAPAM VAE02270676 CO-CLONAZEPAM ACT02131013 DOM-CLONAZEPAM DPC02230951 GEN-CLONAZEPAM GEN02239025 NOVO-CLONAZEPAM TEV02145243 PHL-CLONAZEPAM PHH02048736 PMS-CLONAZEPAM PMS02311615 PRO-CLONAZEPAM PDL02242078 RIVA-CLONAZEPAM RIV00382841 RIVOTRIL HLR02233985 SANDOZ-CLONAZEPAM SDZ02303337 ZYM-CLONAZEPAM ZYM
28:12.12 ANTICONVULSANTS -
HYDANTOINS
PHENYTOIN
30MG CapsuleST
00022772 DILANTIN PFI100MG Capsule
ST
00022780 DILANTIN PFI50MG Chewable Tablet
ST
00023698 DILANTIN INFATABS PFI6MG/ML Suspension
00023442 DILANTIN 30 PFI25MG/ML Suspension
00023450 DILANTIN 125 PFI02250896 TARO-PHENYTOIN TAR
28:12.20 ANTICONVULSANTS-
SUCCINIMIDES
ETHOSUXIMIDE
250MG CapsuleST
00022799 ZARONTIN ERF50MG/ML Syrup
00023485 ZARONTIN ERF
METHSUXIMIDE
300MG CapsuleST
00022802 CELONTIN ERF
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
CARBAMAZEPINE
100MG Chewable TabletST
02231542 PMS-CARBAMAZEPINE PMS02261855 SANDOZ-CARBAMAZEPINE SDZ02244403 TARO-CARBAMAZEPINE TAR00369810 TEGRETOL NVR
200MG Chewable TabletST
02231540 PMS-CARBAMAZEPINE PMS02261863 SANDOZ-CARBAMAZEPINE SDZ02244404 TARO-CARBAMAZEPINE TAR00665088 TEGRETOL NVR
200MG Extended Release TabletST
02261839 SANDOZ-CARBAMAZEPINE SDZ400MG Extended Release Tablet
ST
02261847 SANDOZ-CARBAMAZEPINE SDZ20MG/ML Suspension
02367394 TARO-CARBAMAZEPINE TAR02194333 TEGRETOL NVR
200MG Sustained Release TabletST
02238222 DOM-CARBAMAZEPINE CR DPC02241882 GEN-CARBAMAZEPINE CR GEN02231543 PMS-CARBAMAZEPINE SRT PMS02237907 TARO-CARBAMAZEPINE CR TAR00773611 TEGRETOL CR NVR
400MG Sustained Release TabletST
02238223 DOM-CARBAMAZEPINE CR DPC02241883 GEN-CARBAMAZEPINE CR GEN02231544 PMS-CARBAMAZEPINE SRT PMS02237908 TARO-CARBAMAZEPINE CR TAR00755583 TEGRETOL CR NVR
200MG TabletST
00402699 APO-CARBAMAZEPINE APX00578460 CARBAMAZEPINE PDL00782718 NOVO-CARBAMAZ TEV00010405 TEGRETOL NVR
DIVALPROEX SODIUM
125MG Enteric Coated TabletST
02239698 APO-DIVALPROEX APX02400499 DIVALPROEX SAN00596418 EPIVAL ABB02239701 NOVO-DIVALPROEX TEV02244138 PMS-DIVALPROEX PMS
250MG Enteric Coated TabletST
02239699 APO-DIVALPROEX APX02240342 DIVALPROEX PDL02400502 DIVALPROEX SAN00596426 EPIVAL ABB02239702 NOVO-DIVALPROEX TEV02244139 PMS-DIVALPROEX PMS
Page 60 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
DIVALPROEX SODIUM
500MG Enteric Coated TabletST
02239700 APO-DIVALPROEX APX02400510 DIVALPROEX SAN02240343 DIVALPROEX EC PDL00596434 EPIVAL ABB02239703 NOVO-DIVALPROEX TEV02244140 PMS-DIVALPROEX PMS
GABAPENTIN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.
100MG CapsuleST
02244304 APO-GABAPENTIN APX02321203 AURO-GABAPENTIN AUR02256142 CO-GABAPENTIN ACT02243743 DOM-GABAPENTIN DPC02246314 GABAPENTIN SIV02304775 GABAPENTIN SOR02353245 GABAPENTIN SAN02248259 GEN-GABAPENTIN GEN02361469 JAMP-GABAPENTIN JAP02084260 NEURONTIN PFI02244513 NOVO-GABAPENTIN TEV02243446 PMS-GABAPENTIN PMS02310449 PRO-GABAPENTIN PDL02319055 RAN-GABAPENTIN RBY02251167 RIVA-GABAPENTIN RIV
300MG CapsuleST
02244305 APO-GABAPENTIN APX02321211 AURO-GABAPENTIN AUR02256150 CO-GABAPENTIN ACT02243744 DOM-GABAPENTIN DPC02246315 GABAPENTIN SIV02304783 GABAPENTIN SOR02353253 GABAPENTIN SAN02248260 GEN-GABAPENTIN GEN02361485 JAMP-GABAPENTIN JAP02084279 NEURONTIN PFI02244514 NOVO-GABAPENTIN TEV02243447 PMS-GABAPENTIN PMS02310457 PRO-GABAPENTIN PDL02319063 RAN-GABAPENTIN RBY02251175 RIVA-GABAPENTIN RIV
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
GABAPENTIN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.
400MG CapsuleST
02244306 APO-GABAPENTIN APX02321238 AURO-GABAPENTIN AUR02256169 CO-GABAPENTIN ACT02243745 DOM-GABAPENTIN DPC02246316 GABAPENTIN SIV02304791 GABAPENTIN SOR02353261 GABAPENTIN SAN02248261 GEN-GABAPENTIN GEN02361493 JAMP-GABAPENTIN JAP02084287 NEURONTIN PFI02244515 NOVO-GABAPENTIN TEV02243448 PMS-GABAPENTIN PMS02310465 PRO-GABAPENTIN PDL02319071 RAN-GABAPENTIN RBY02260905 RATIO-GABAPENTIN RPH02251183 RIVA-GABAPENTIN RIV
600MG TabletST
02293358 APO-GABAPENTIN APX02388200 GABAPENTIN SIV02285843 GD-GABAPENTIN PFI02402289 JAMP-GABAPENTIN JAP02397471 MYLAN-GABAPENTIN MYL02239717 NEURONTIN PFI02248457 NOVO-GABAPENTIN TEV02255898 PMS-GABAPENTIN PMS02310473 PRO-GABAPENTIN PDL02260913 RATIO-GABAPENTIN RPH02259796 RIVA-GABAPENTIN RIV
800MG TabletST
02293366 APO-GABAPENTIN APX02388219 GABAPENTIN SIV02402297 JAMP-GABAPENTIN JAP02397498 MYLAN-GABAPENTIN MYL02239718 NEURONTIN PFI02247346 NOVO-GABAPENTIN TEV02255901 PMS-GABAPENTIN PMS02310481 PRO-GABAPENTIN PDL02260921 RATIO-GABAPENTIN RPH02259818 RIVA-GABAPENTIN RIV
Page 61 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
LACOSAMIDE
Limited use benefit (prior approval required).For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria:a- Are under the care of a physician experienced in the treatment of epilepsy, ANDb- Are currently receiving two or more antiepileptic medications, ANDc- Have failed or demonstrated intolerance to at least two other antiepileptic medications.
50MG TabletST
02357615 VIMPAT UCB100MG Tablet
ST
02357623 VIMPAT UCB150MG Tablet
ST
02357631 VIMPAT UCB200MG Tablet
ST
02357658 VIMPAT UCB
LAMOTRIGINE
2MG Chewable TabletST
02243803 LAMICTAL GSK5MG Chewable Tablet
ST
02240115 LAMICTAL GSK25MG Tablet
ST
02245208 APO-LAMOTRIGINE APX02381354 AURO-LAMOTRIGINE AUR02265494 GEN-LAMOTRIGINE GEN02142082 LAMICTAL GSK02302969 LAMOTRIGINE PDL02343010 LAMOTRIGINE SAN02248232 NOVO-LAMOTRIGINE TEV02246897 PMS-LAMOTRIGINE PMS
100MG TabletST
02245209 APO-LAMOTRIGINE APX02381362 AURO-LAMOTRIGINE AUR02265508 GEN-LAMOTRIGINE GEN02142104 LAMICTAL GSK02302985 LAMOTRIGINE PDL02343029 LAMOTRIGINE SAN02248233 NOVO-LAMOTRIGINE TEV02246898 PMS-LAMOTRIGINE PMS
150MG TabletST
02245210 APO-LAMOTRIGINE APX02381370 AURO-LAMOTRIGINE AUR02265516 GEN-LAMOTRIGINE GEN02142112 LAMICTAL GSK02302993 LAMOTRIGINE PDL02343037 LAMOTRIGINE SAN02248234 NOVO-LAMOTRIGINE TEV02246899 PMS-LAMOTRIGINE PMS
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
LEVETIRACETAM
Limited use benefit (prior approval required).
For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two anti-epileptic medications used either as monotherapy or in combination.
250MG TabletST
02285924 APO-LEVETIRACETAM APX02375249 AURO-LEVETIRACETAM AUR02274183 CO-LEVETIRACETAM ACT02403005 JAMP-LEVETIRACETAM JAP02247027 KEPPRA UCB02353342 LEVETIRACETAM SAN02296101 PMS-LEVETIRACETAM PMS02396106 RAN-LEVETIRACETAM RBY
500MG TabletST
02285932 APO-LEVETIRACETAM APX02375257 AURO-LEVETIRACETAM AUR02274191 CO-LEVETIRACETAM ACT02297418 DOM-LEVETIRACETAM DOM02403021 JAMP-LEVETIRACETAM JAP02247028 KEPPRA UCB02353350 LEVETIRACETAM SAN02296128 PMS-LEVETIRACETAM PMS02311380 PRO-LEVETIRACETAM PDL02396114 RAN-LEVETIRACETAM RBY
750MG TabletST
02285940 APO-LEVETIRACETAM APX02375265 AURO-LEVETIRACETAM AUR02274205 CO-LEVETIRACETAM ACT02403048 JAMP-LEVETIRACETAM JAP02247029 KEPPRA UCB02353369 LEVETIRACETAM SAN02296136 PMS-LEVETIRACETAM PMS02311399 PRO-LEVETIRACETAM PDL02396122 RAN-LEVETIRACETAM RBY
Page 62 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
PREGABALIN
Limited use benefit (prior approval required).
For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)
OR
For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA.
The dose of pregabalin is limited to a maximum of 600 mg per day
25MG CapsuleST
02394235 APO-PREGABALIN APX02402912 CO PREGABALIN ACT02402556 DOM-PREGABALIN DOM02360136 GD-PREGABALIN PFI02268418 LYRICA PFI02359596 PMS-PREGABALIN PMS02396483 PREGABALIN PDL02403692 PREGABALIN SIV02405539 PREGABALIN SAN02411725 PREGABALIN-25 SIV02392801 RAN-PREGABALIN RBY02377039 RIVA-PREGABALIN RIV02390817 SANDOZ PREGABALIN SDZ02361159 TEVA-PREGABALIN TEP
50MG CapsuleST
02394243 APO-PREGABALIN APX02402920 CO PREGABALIN ACT02402564 DOM-PREGABALIN DOM02360144 GD-PREGABALIN PFI02268426 LYRICA PFI02359618 PMS-PREGABALIN PMS02396505 PREGABALIN PDL02403706 PREGABALIN SIV02405547 PREGABALIN SAN02392828 RAN-PREGABALIN RBY02377047 RIVA-PREGABALIN RIV02390825 SANDOZ PREGABALIN SDZ02361175 TEVA-PREGABALIN TEP
50MG CapsuleST
02411733 PREGABALIN-50 SIV
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
PREGABALIN
Limited use benefit (prior approval required).
For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)
OR
For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA.
The dose of pregabalin is limited to a maximum of 600 mg per day
75MG CapsuleST
02394251 APO-PREGABALIN APX02402939 CO PREGABALIN ACT02402572 DOM-PREGABALIN DOM02360152 GD-PREGABALIN PFI02268434 LYRICA PFI02359626 PMS-PREGABALIN PMS02396513 PREGABALIN PDL02403714 PREGABALIN SIV02405555 PREGABALIN SAN02411741 PREGABALIN-75 SIV02392836 RAN-PREGABALIN RBY02377055 RIVA-PREGABALIN RIV02390833 SANDOZ PREGABALIN SDZ02361183 TEVA-PREGABALIN TEP
150MG CapsuleST
02394278 APO-PREGABALIN APX02402955 CO PREGABALIN ACT02402580 DOM-PREGABALIN DOM02360179 GD-PREGABALIN PFI02268450 LYRICA PFI02359634 PMS-PREGABALIN PMS02396521 PREGABALIN PDL02403722 PREGABALIN SIV02405563 PREGABALIN SAN02411768 PREGABALIN-150 SIV02392844 RAN-PREGABALIN RBY02377063 RIVA-PREGABALIN RIV02390841 SANDOZ PREGABALIN SDZ02361205 TEVA-PREGABALIN TEP
300MG CapsuleST
02394294 APO-PREGABALIN APX02402998 CO PREGABALIN ACT02360209 GD-PREGABALIN PFI02268485 LYRICA PFI02359642 PMS-PREGABALIN PMS02396548 PREGABALIN PDL02403730 PREGABALIN SIV02405598 PREGABALIN SAN02392860 RAN-PREGABALIN RBY02377071 RIVA-PREGABALIN RIV02390868 SANDOZ PREGABALIN SDZ02361248 TEVA-PREGABALIN TEP
Page 63 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
RUFINAMIDE
Limited use benefit (prior approval required).
-For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist-Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs
100MG TabletST
02369613 BANZEL 100MG TAB EIS200MG Tablet
ST
02369621 BANZEL 200MG TAB EIS400MG Tablet
ST
02369648 BANZEL 400MG TAB EIS
TOPIRAMATE
15MG Sprinkle CapsuleST
02239907 TOPAMAX SPRINKLE JNO25MG Sprinkle Capsule
ST
02239908 TOPAMAX SPRINKLE JNO25MG Tablet
ST
02351307 ACCEL-TOPIRAMATE ACP02279614 APO-TOPIRAMATE APX02345803 AURO-TOPIRAMATE APL02287765 CO TOPIRAMATE ACT02271141 DOM-TOPIRAMATE DPC *02263351 GEN-TOPIRAMATE GEN02315645 MINT-TOPIRAMATE MIN02248860 NOVO-TOPIRAMATE TEV02271184 PHL-TOPIRAMATE PMI02262991 PMS-TOPIRAMATE PMS02313650 PRO-TOPIRAMATE PDL02396076 RAN-TOPIRAMATE RBY02260050 SANDOZ-TOPIRAMATE SDZ02230893 TOPAMAX JNO02356856 TOPIRAMATE SAN02389460 TOPIRAMATE SIV02325136 ZYM-TOPIRAMATE ZYM
50MG TabletST
02312085 PMS-TOPIRAMATE PMS
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
TOPIRAMATE
100MG TabletST
02351315 ACCEL-TOPIRAMATE ACP02279630 APO-TOPIRAMATE APX02345838 AURO-TOPIRAMATE APL02287773 CO TOPIRAMATE ACT02271168 DOM-TOPIRAMATE DPC *02263378 GEN-TOPIRAMATE GEN02315653 MINT-TOPIRAMATE MIN02248861 NOVO-TOPIRAMATE TEV02271192 PHL-TOPIRAMATE PMI02263009 PMS-TOPIRAMATE PMS02313669 PRO-TOPIRAMATE PDL02396084 RAN-TOPIRAMATE RBY02260069 SANDOZ-TOPIRAMATE SDZ02230894 TOPAMAX JNO02356864 TOPIRAMATE SAN02389487 TOPIRAMATE SIV02325144 ZYM-TOPIRAMATE ZYM
200MG TabletST
02351323 ACCEL-TOPIRAMATE ACP02279649 APO-TOPIRAMATE APX02345846 AURO-TOPIRAMATE APL02287781 CO TOPIRAMATE ACT02271176 DOM-TOPIRAMATE DPC *02263386 GEN-TOPIRAMATE GEN02315661 MINT-TOPIRAMATE MIN02248862 NOVO-TOPIRAMATE TEV02313677 PDL-TOPIRAMATE PDL02271206 PHL-TOPIRAMATE PMI02263017 PMS-TOPIRAMATE PMS02396092 RAN-TOPIRAMATE RBY02267837 SANDOZ-TOPIRAMATE SDZ02230896 TOPAMAX JNO02356872 TOPIRAMATE SAN02325152 ZYM-TOPIRAMATE ZYM
VALPROATE, SODIUM
50MG/ML Syrup
02238370 APO-VALPROIC APX00443832 DEPAKENE ABB02238817 DOM-VALPROIC ACID DPC02236807 PMS-VALPROIC ACID PMS
VALPROIC ACID
250MG CapsuleST
02238048 APO-VALPROIC APX00443840 DEPAKENE ABB02231030 DOM-VALPROIC ACID DPC02184648 GEN-VALPROIC GEN02100630 NOVO-VALPROIC TEV02238546 PDL-VALPROIC PDL02230768 PMS-VALPROIC ACID PMS02239714 SANDOZ-VALPROIC SDZ
Page 64 of 1382014
Non-Insured Health BenefitsHealth Canada
28:12.92 MISCELLANEOUS
ANTICONVULSANTS
VALPROIC ACID
500MG Enteric Coated CapsuleST
02231031 DOM-VALPROIC ACID DPC02218321 NOVO-VALPROIC TEV02260662 PHL-VALPROIC ACID PHH02229628 PMS-VALPROIC ACID PMS
VIGABATRIN
500MG Powder
02068036 SABRIL OVA500MG Tablet
ST
02065819 SABRIL OVA
28:16.04 ANTIDEPRESSANTS
AMITRIPTYLINE HCL
10MG TabletST
00370991 AMITRIPTYLINE PRO00335053 APO-AMITRIPTYLINE APX02403137 APO-AMITRIPTYLINE APX02248131 DOM-AMITRIPTYLINE DPC00654523 PMS-AMITRIPTYLINE PMS
25MG TabletST
00371009 AMITRIPTYLINE PRO00335061 APO-AMITRIPTYLINE APX02403145 APO-AMITRIPTYLINE APX02248132 DOM-AMITRIPTYLINE DPC00654515 PMS-AMITRIPTYLINE PMS02247303 PMS-AMITRIPTYLINE PMS
50MG TabletST
00456349 AMITRIPTYLINE PDL00335088 APO-AMITRIPTYLINE APX02403153 APO-AMITRIPTYLINE APX02248133 DOM-AMITRIPTYLINE DPC00271152 LEVATE ICN02247304 PMS-AMITRIPTYLINE PMS
75MG TabletST
00754129 APO-AMITRIPTYLINE APX02403161 APO-AMITRIPTYLINE APX00405612 LEVATE VAE
BUPROPION HCL (WELLBUTRIN)
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).
150MG Extended Release TabletST
02382075 MYLAN-BUPROPION XL MYL02275090 WELLBUTRIN XL FRS
300MG Extended Release TabletST
02382083 MYLAN-BUPROPION XL MYL02275104 WELLBUTRIN XL FRS
28:16.04 ANTIDEPRESSANTS
BUPROPION HCL (WELLBUTRIN)
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).
100MG Sustained Release TabletST
02331616 BUPROPION SR PDL02391562 BUPROPION SR SAN02325373 PMS-BUPROPION SR PMS02285657 RATIO-BUPROPION RPH02275074 SANDOZ-BUPROPION SR SDZ
150MG Sustained Release TabletST
02391570 BUPROPION SR SAN02313421 PMS-BUPROPION SR PMS02325357 PRO-BUPROPION SR PDL02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ02237825 WELLBUTRIN SR BPC
BUPROPION HCL (ZYBAN)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.
150MG Sustained Release TabletST
02238441 ZYBAN BPC
CITALOPRAM
10MG TabletST
02355248 ACCEL-CITALOPRAM ACP02301822 CITALOPRAM MEL02387948 CITALOPRAM SIV02273055 DOM-CITALOPRAM PMS02370085 JAMP-CITALOPRAM JAP02371871 MAR-CITALOPRAM MAR02370077 MINT-CITALOPRAM MIN02273543 PHL-CITALOPRAM PMI02270609 PMS-CITALOPRAM PMS02325047 PRO-CITALOPRAM PDL02312336 TEVA-CITALOPRAM TEV
Page 65 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.04 ANTIDEPRESSANTS
CITALOPRAM
20MG TabletST
02355256 ACCEL-CITALOPRAM ACP02246056 APO-CITALOPRAM APX02275562 AURO-CITALOPRAM AUR02239607 CELEXA LUD02301830 CITALOPRAM MEL02353660 CITALOPRAM SAN02387956 CITALOPRAM SIV02257513 CITALOPRAM-20 PDL02306239 CITALOPRAM-ODAN ODN02248050 CO-CITALOPRAM ACT02248942 DOM-CITALOPRAM DPC02246594 GEN-CITALOPRAM GEN02371898 MAR-CITALOPRAM MAR02293218 NOVO-CITALOPRAM TEV02248944 PHL-CITALOPRAM PHH02248010 PMS-CITALOPRAM PMS02285622 RAN-CITALO RBY02303264 RIVA-CITALOPRAM RIV02248170 SANDOZ-CITALOPRAM SDZ02355272 SEPTA-CITALOPRAM SPT
40MG TabletST
02355264 ACCEL-CITALOPRAM ACP02246057 APO-CITALOPRAM APX02275570 AURO-CITALOPRAM AUR02239608 CELEXA LUD02301849 CITALOPRAM MEL02353679 CITALOPRAM SAN02387964 CITALOPRAM SIV02306247 CITALOPRAM-ODAN ODN02248051 CO-CITALOPRAM ACT02248943 DOM-CITALOPRAM DPC02246595 GEN-CITALOPRAM GEN02371901 MAR-CITALOPRAM MAR02293226 NOVO-CITALOPRAM TEV02248945 PHL-CITALOPRAM PHH02248011 PMS-CITALOPRAM PMS02285630 RAN-CITALO RBY02249286 RIVA-CITALOPRAM RIV02303272 RIVA-CITALOPRAM RIV02248171 SANDOZ-CITALOPRAM SDZ02355280 SEPTA-CITALOPRAM SPT
CLOMIPRAMINE HCL
10MG TabletST
00330566 ANAFRANIL ORY02040786 APO-CLOMIPRAMINE APX02244816 CO-CLOMIPRAMINE ACT02230256 NOVO-CLOPAMINE TEV
25MG TabletST
00324019 ANAFRANIL ORY02040778 APO-CLOMIPRAMINE APX02244817 CO-CLOMIPRAMINE ACT02130165 NOVO-CLOPAMINE TEV
28:16.04 ANTIDEPRESSANTS
CLOMIPRAMINE HCL
50MG TabletST
00402591 ANAFRANIL ORY02040751 APO-CLOMIPRAMINE APX02244818 CO-CLOMIPRAMINE ACT02130173 NOVO-CLOPAMINE TEV
DESIPRAMINE HCL
10MG TabletST
02216248 APO-DESIPRAMINE APX02223341 NOVO-DESIPRAMINE TEV
25MG TabletST
02216256 APO-DESIPRAMINE APX02130092 DOM-DESIPRAMINE DPC02223325 NOVO-DESIPRAMINE TEV
50MG TabletST
02216264 APO-DESIPRAMINE APX02130106 DOM-DESIPRAMINE DPC02223333 NOVO-DESIPRAMINE TEV01946277 PMS-DESIPRAMINE PMS
75MG TabletST
02216272 APO-DESIPRAMINE APX02223368 NOVO-DESIPRAMINE TEV01946242 PMS-DESIPRAMINE PMS
100MG TabletST
02216280 APO-DESIPRAMINE APX
DOXEPIN HCL
10MG CapsuleST
02049996 APO-DOXEPIN APX00024325 SINEQUAN ERF
25MG CapsuleST
02050005 APO-DOXEPIN APX01913425 NOVO-DOXEPIN TEV00024333 SINEQUAN ERF
50MG CapsuleST
02050013 APO-DOXEPIN APX01913433 NOVO-DOXEPIN TEV00024341 SINEQUAN ERF
75MG CapsuleST
02050021 APO-DOXEPIN APX01913441 NOVO-DOXEPIN TEV00400750 SINEQUAN ERF
100MG CapsuleST
02050048 APO-DOXEPIN APX01913468 NOVO-DOXEPIN TEV00326925 SINEQUAN ERF
150MG CapsuleST
01913476 NOVO-DOXEPIN TEV
DULOXETINE
30MG Delayed Release CapsuleST
02301482 CYMBALTA LIL60MG Delayed Release Capsule
ST
02301490 CYMBALTA LIL
Page 66 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.04 ANTIDEPRESSANTS
ESCITALOPRAM
10MG TabletST
02263238 CIPRALEX LUK02391449 CIPRALEX MELTZ LUK
20MG TabletST
02263254 CIPRALEX LUK02391457 CIPRALEX MELTZ LUK
FLUOXETINE HCL
10MG CapsuleST
02216353 APO-FLUOXETINE APX02242177 CO-FLUOXETINE SCN02177617 DOM-FLUOXETINE DPC02286068 FLUOXETINE SAN02374447 FLUOXETINE SIV02237813 GEN-FLUOXETINE GEN02401894 JAMP-FLUOXETINE JAP02392909 MAR-FLUOXETINE MAR02380560 MINT-FLUOXETINE MIN02216582 NOVO-FLUOXETINE TEV02223481 PHL-FLUOXETINE PHH02177579 PMS-FLUOXETINE PMS02314991 PRO-FLUOXETINE PDL02018985 PROZAC LIL02405695 RAN-FLUOXETINE RBY02242123 RIVA-FLUOXETINE RIV02243486 SANDOZ-FLUOXETINE SDZ02302659 ZYM-FLUOXETINE ZYM
20MG CapsuleST
02216361 APO-FLUOXETINE APX02242178 CO-FLUOXETINE SCN02177625 DOM-FLUOXETINE DPC02286076 FLUOXETINE SAN02374455 FLUOXETINE SIV02237814 GEN-FLUOXETINE GEN02386402 JAMP-FLUOXETINE JAP02392917 MAR-FLUOXETINE MAR02380579 MINT-FLUOXETINE MIN02216590 NOVO-FLUOXETINE TEV02223503 PHL-FLUOXETINE PHH02177587 PMS-FLUOXETINE PMS02315009 PRO-FLUOXETINE PDL00636622 PROZAC LIL02405709 RAN-FLUOXETINE RBY02242124 RIVA-FLUOXETINE RIV02243487 SANDOZ-FLUOXETINE SDZ02302667 ZYM-FLUOXETINE ZYM
4MG/ML Liquid
02231328 APO-FLUOXETINE APX
28:16.04 ANTIDEPRESSANTS
FLUVOXAMINE MALEATE
50MG TabletST
02231329 APO-FLUVOXAMINE APX02255529 CO-FLUVOXAMINE ACT02241347 DOM-FLUVOXAMINE DPC02236753 FLUVOXAMINE PDL01919342 LUVOX SPH02239953 NOVO-FLUVOXAMINE TEV02218453 RATIO-FLUVOXAMINE RPH02303345 RIVA-FLUVOX RIV02247054 SANDOZ-FLUVOXAMINE SDZ
100MG TabletST
02231330 APO-FLUVOXAMINE APX02255537 CO-FLUVOXAMINE ACT02241348 DOM-FLUVOXAMINE DPC02236754 FLUVOXAMINE PDL01919369 LUVOX SPH02239954 NOVO-FLUVOXAMINE TEV02218461 RATIO-FLUVOXAMINE RPH02247055 SANDOZ-FLUVOXAMINE SDZ
IMIPRAMINE HCL
10MG TabletST
00360201 APO-IMIPRAMINE APX00021504 NOVO-PRAMINE TEV
25MG TabletST
00312797 APO-IMIPRAMINE APX50MG Tablet
ST
00326852 APO-IMIPRAMINE APX00021520 NOVO-PRAMINE TEV
75MG TabletST
00644579 APO-IMIPRAMINE APX
MAPROTILINE HCL
25MG TabletST
02158612 NOVO-MAPROTILINE TEV50MG Tablet
ST
02158620 NOVO-MAPROTILINE TEV75MG Tablet
ST
02158639 NOVO-MAPROTILINE TEV
MIRTAZAPINE
15MG Orally Disintegrating TabletST
02299801 AURO-MIRTAZAPINE OD AUR02279894 NOVO-MIRTAZAPINE OD TEV02248542 REMERON RD ORG
30MG Orally Disintegrating TabletST
02299828 AURO-MIRTAZAPINE OD AUR02279908 NOVO-MIRTAZAPINE OD TEV02248543 REMERON RD ORG
45MG Orally Disintegrating TabletST
02299836 AURO-MIRTAZAPINE OD AUR02279916 NOVO-MIRTAZAPINE OD TEV02248544 REMERON RD ORG
Page 67 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.04 ANTIDEPRESSANTS
MIRTAZAPINE
15MG TabletST
02286610 APO-MIRTAZAPINE APX02256096 GEN-MIRTAZAPINE GEN02281732 MIRTAZAPINE MEL02273942 PMS-MIRTAZAPINE PMS02312778 PRO-MIRTAZAPINE PDL02250594 RHOXAL-MIRTAZAPINE RHO02325179 ZYM-MIRTAZAPINE ZYM
30MG TabletST
02286629 APO-MIRTAZAPINE APX02274361 CO-MIRTAZAPINE ACT02252287 DOM-MIRTAZAPINE DPC02256118 GEN-MIRTAZAPINE GEN02370689 MIRTAZAPINE SAN02259354 NOVO-MIRTAZAPINE TEV02252279 PHL-MIRTAZAPINE PHH02248762 PMS-MIRTAZAPINE PMS02312786 PRO-MIRTAZAPINE PDL02270927 RATIO-MIRTAZAPINE RPH02243910 REMERON ORG02265265 RIVA-MIRTAZAPINE RIV02250608 SANDOZ-MIRTAZAPINE SDZ02325187 ZYM-MIRTAZAPINE ZYM
45MG TabletST
02286637 APO-MIRTAZAPINE APX02256126 GEN-MIRTAZAPINE GEN
MOCLOBEMIDE
100MG TabletST
02232148 APO-MOCLOBEMIDE APX02239746 NOVO-MOCLOBEMIDE TEV
150MG TabletST
02232150 APO-MOCLOBEMIDE APX00899356 MANERIX HLR02239747 NOVO-MOCLOBEMIDE TEV02243218 PMS-MOCLOBEMIDE PMS
300MG TabletST
02240456 APO-MOCLOBEMIDE APX02166747 MANERIX HLR02239748 NOVO-MOCLOBEMIDE TEV02243219 PMS-MOCLOBEMIDE PMS
NORTRIPTYLINE HCL
10MG CapsuleST
02223511 APO-NORTRIPTYLINE APX00015229 AVENTYL PHH02178729 DOM-NORTRIPTYLINE DPC02231781 NOVO-NORTRIPTYLINE TEV02177692 PMS-NORTRIPTYLINE PMS
25MG CapsuleST
02223538 APO-NORTRIPTYLINE APX00015237 AVENTYL PHH02178737 DOM-NORTRIPTYLINE DPC02231782 NOVO-NORTRIPTYLINE TEV02177706 PMS-NORTRIPTYLINE PMS
28:16.04 ANTIDEPRESSANTS
PAROXETINE HCL
10MG TabletST
02240907 APO-PAROXETINE APX02383276 AURO-PAROXETINE AUR02262746 CO-PAROXETINE ACT02248447 DOM-PAROXETINE DPC02248012 GEN-PAROXETINE GEN02368862 JAMP-PAROXETINE JAP02248556 NOVO-PAROXETINE TEV02248913 PAROXETINE PDL02282844 PAROXETINE SAN02302012 PAROXETINE SOR02388227 PAROXETINE SIV02027887 PAXIL GSK02248450 PHL-PAROXETINE PHH02247750 PMS-PAROXETINE PMS02248559 RIVA-PAROXETINE RIV
20MG TabletST
02240908 APO-PAROXETINE APX02262754 CO-PAROXETINE ACT02248448 DOM-PAROXETINE DPC02248013 GEN-PAROXETINE GEN02368870 JAMP-PAROXETINE JAP02248557 NOVO-PAROXETINE TEV02248914 PAROXETINE PDL02282852 PAROXETINE SAN02302020 PAROXETINE SOR02388235 PAROXETINE SIV01940481 PAXIL GSK02248451 PHL-PAROXETINE PHH02247751 PMS-PAROXETINE PMS02248560 RIVA-PAROXETINE RIV02254751 SANDOZ-PAROXETINE SDZ
20MG TabletST
02383284 AURO-PAROXETINE AUR30MG Tablet
ST
02240909 APO-PAROXETINE APX02383292 AURO-PAROXETINE AUR02262762 CO-PAROXETINE ACT02248449 DOM-PAROXETINE DPC02248014 GEN-PAROXETINE GEN02368889 JAMP-PAROXETINE JAP02248558 NOVO-PAROXETINE TEV02248915 PAROXETINE PDL02282860 PAROXETINE SAN02302039 PAROXETINE SOR02388243 PAROXETINE SIV01940473 PAXIL GSK02248452 PHL-PAROXETINE PHH02247752 PMS-PAROXETINE PMS02248561 RIVA-PAROXETINE RIV02254778 SANDOZ-PAROXETINE SDZ
40MG TabletST
02293749 PMS-PAROXETINE PMS
Page 68 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.04 ANTIDEPRESSANTS
PHENELZINE SULFATE
15MG TabletST
00476552 NARDIL PFI
SERTRALINE
25MG CapsuleST
02238280 APO-SERTRALINE APX02390906 AURO-SERTRALINE AUR02287390 CO SERTRALINE ACT02245748 DOM-SERTRALINE DPC02242519 GEN-SERTRALINE GEN02357143 JAMP-SERTRALINE JAP02402378 MINT-SERTRALINE MIN02240485 NOVO-SERTRALINE TEV02245824 PHL-SERTRALINE PHH02244838 PMS-SERTRALINE PMS02374552 RAN-SERTRALINE RBY02248496 RIVA-SERTRALINE RIV02245159 SANDOZ-SERTRALINE SDZ02303779 SERTRALINE MEL02353520 SERTRALINE SAN02386070 SERTRALINE SIV02241302 SERTRALINE-25 PDL02132702 ZOLOFT PFI
50MG CapsuleST
02238281 APO-SERTRALINE APX02390914 AURO-SERTRALINE AUR02287404 CO SERTRALINE ACT02245749 DOM-SERTRALINE DPC02242520 GEN-SERTRALINE GEN02357151 JAMP-SERTRALINE JAP02402394 MINT-SERTRALINE MIN02240484 NOVO-SERTRALINE TEV02245825 PHL-SERTRALINE PHH02244839 PMS-SERTRALINE PMS02374560 RAN-SERTRALINE RBY02248497 RIVA-SERTRALINE RIV02245160 SANDOZ-SERTRALINE SDZ02303809 SERTRALINE MEL02353539 SERTRALINE SAN02386089 SERTRALINE SIV02241303 SERTRALINE-50 PDL01962817 ZOLOFT PFI
28:16.04 ANTIDEPRESSANTS
SERTRALINE
100MG CapsuleST
02238282 APO-SERTRALINE APX02390922 AURO-SERTRALINE AUR02287412 CO SERTRALINE ACT02245750 DOM-SERTRALINE DPC02242521 GEN-SERTRALINE GEN02357178 JAMP-SERTRALINE JAP02402408 MINT-SERTRALINE MIN02240481 NOVO-SERTRALINE TEV02245826 PHL-SERTRALINE PHH02244840 PMS-SERTRALINE PMS02374579 RAN-SERTRALINE RBY02248498 RIVA-SERTRALINE RIV02245161 SANDOZ-SERTRALINE SDZ02303817 SERTRALINE MEL02353547 SERTRALINE SAN02386097 SERTRALINE SIV02241304 SERTRALINE-100 PDL01962779 ZOLOFT PFI
TRANYLCYPROMINE SULFATE
10MG TabletST
01919598 PARNATE GSK
TRAZODONE HCL
50MG TabletST
02147637 APO-TRAZODONE APX02128950 DOM-TRAZODONE DPC02231683 GEN-TRAZODONE GEN02144263 NOVO-TRAZODONE TEV02236941 PHL-TRAZODONE PHH01937227 PMS-TRAZODONE PMS02277344 RATIO-TRAZODONE RPH02164353 TRAZODONE PDL02348772 TRAZODONE SAN02230284 TRAZOREL VAE
75MG TabletST
02237339 PMS-TRAZODONE PMS100MG Tablet
ST
02147645 APO-TRAZODONE APX02128969 DOM-TRAZODONE DPC02231684 GEN-TRAZODONE GEN02144271 NOVO-TRAZODONE TEV02236942 PHL-TRAZODONE PHH01937235 PMS-TRAZODONE PMS02277352 RATIO-TRAZODONE RPH02164361 TRAZODONE PDL02348780 TRAZODONE SAN02230285 TRAZOREL VAE
150MG TabletST
02147653 APO-TRAZODONE D APX02144298 NOVO-TRAZODONE TEV02165406 NU-TRAZODONE D NXP02277360 RATIO-TRAZODONE RPH02164388 TRAZODONE PDL02348799 TRAZODONE SAN
Page 69 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.04 ANTIDEPRESSANTS
TRIMIPRAMINE MALEATE
75MG CapsuleST
02070987 APO-TRIMIP APX12.5MG Tablet
ST
00740799 APO-TRIMIPRAMINE APX25MG Tablet
ST
00740802 APO-TRIMIPRAMINE APX01940430 NOVO-TRIPRAMINE TEV
50MG TabletST
00740810 APO-TRIMIPRAMINE APX01940449 NOVO-TRIPRAMINE TEV
100MG TabletST
00740829 APO-TRIMIPRAMINE APX01940457 NOVO-TRIPRAMINE TEV
VENLAFAXINE HCL
37.5MG Sustained Release CapsuleST
02331683 APO-VENLAFAXINE XR APX02237279 EFFEXOR XR WAY02275023 NOVO-VENLAFAXINE XR TEV02278545 PMS-VENLAFAXINE XR PMS02380072 RAN-VENLAFAXINE XR RBY02339242 VENLAFAXINE XR PDL02354713 VENLAFAXINE XR SAN02385929 VENLAFAXINE XR SIV
75MG Sustained Release CapsuleST
02331691 APO-VENLAFAXINE XR APX02299305 DOM-VENLAFAXINE XR DOM02237280 EFFEXOR XR WAY02275031 NOVO-VENLAFAXINE XR TEV02278553 PMS-VENLAFAXINE XR PMS02380080 RAN-VENLAFAXINE XR RBY02339250 VENLAFAXINE XR PDL02354721 VENLAFAXINE XR SAN02385937 VENLAFAXINE XR SIV
150MG Sustained Release CapsuleST
02331705 APO-VENLAFAXINE XR APX02237282 EFFEXOR XR WAY02275058 NOVO-VENLAFAXINE XR TEV02278561 PMS-VENLAFAXINE XR PMS02380099 RAN-VENLAFAXINE XR RBY02339269 VENLAFAXINE XR PDL02354748 VENLAFAXINE XR SAN02385945 VENLAFAXINE XR SIV
28:16.08 ANTIPSYCHOTIC AGENTS
ARIPIPRAZOLE
Limited use benefit (prior approval required). For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent
2MG TabletST
02322374 ABILIFY BMS
28:16.08 ANTIPSYCHOTIC AGENTS
ARIPIPRAZOLE
Limited use benefit (prior approval required). For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent
5MG TabletST
02322382 ABILIFY BMS10MG Tablet
ST
02322390 ABILIFY BMS15MG Tablet
ST
02322404 ABILIFY BMS20MG Tablet
ST
02322412 ABILIFY BMS30MG Tablet
ST
02322455 ABILIFY BMS
ASENAPINE
Limited use benefit (prior approval required). For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:
- Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response
OR
- Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response.
5MG Sublingual TabletST
02374803 SAPHRIS FRS10MG Sublingual Tablet
ST
02374811 SAPHRIS FRS
CHLORPROMAZINE
25MG/ML Injection
00743518 CHLORPROMAZINE HCL SDZ25MG Tablet
ST
00232823 NOVO-CHLORPROMAZINE TEV50MG Tablet
ST
00232807 NOVO-CHLORPROMAZINE TEV100MG Tablet
ST
00232831 NOVO-CHLORPROMAZINE TEV
CLOZAPINE
25MG TabletST
02248034 APO-CLOZAPINE APX00894737 CLOZARIL NVR02247243 GEN-CLOZAPINE GEN
100MG TabletST
02248035 APO-CLOZAPINE APX00894745 CLOZARIL NVR02247244 GEN-CLOZAPINE GEN
Page 70 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.08 ANTIPSYCHOTIC AGENTS
FLUPENTHIXOL DECANOATE
20MG/ML Injection
02156032 FLUANXOL DEPOT LUD100MG/ML Injection
02156040 FLUANXOL DEPOT LUD
FLUPENTHIXOL DIHYDROCHLORIDE
0.5MG TabletST
02156008 FLUANXOL LUD3MG Tablet
ST
02156016 FLUANXOL LUD
FLUPHENAZINE DECANOATE
25MG/ML Injection
02091275 PMS-FLUPHENAZINE PMS100MG/ML Injection
00755575 MODECATE BMS02241928 PMS-FLUPHENAZINE PMS
FLUPHENAZINE HCL
1MG TabletST
00405345 APO-FLUPHENAZINE APX2MG Tablet
ST
00410632 APO-FLUPHENAZINE APX5MG Tablet
ST
00405361 APO-FLUPHENAZINE APX
HALOPERIDOL
5MG/ML InjectionST
00808652 HALOPERIDOL SDZ02366010 HALOPERIDOL OMG
2MG/ML Solution
00759503 PMS-HALOPERIDOL PMS0.5MG Tablet
ST
00396796 APO-HALOPERIDOL APX00363685 NOVO-PERIDOL TEV
1MG TabletST
00396818 APO-HALOPERIDOL APX00363677 NOVO-PERIDOL TEV
2MG TabletST
00363669 NOVO-PERIDOL TEV5MG Tablet
ST
00363650 NOVO-PERIDOL TEV10MG Tablet
ST
00463698 APO-HALOPERIDOL APX00713449 NOVO-PERIDOL TEV
20MG TabletST
00768820 NOVO-PERIDOL TEV
HALOPERIDOL DECANOATE
50MG/ML Injection
02130297 HALOPERIDOL LA SDZ02230707 PMS-HALOPERIDOL LA PMS
28:16.08 ANTIPSYCHOTIC AGENTS
HALOPERIDOL DECANOATE
100MG/ML Injection
02130300 HALOPERIDOL LA SDZ02239640 HALOPERIDOL LA OMG02230708 PMS-HALOPERIDOL LA PMS
LOXAPINE HCL
25MG/ML Oral Liquid
02239101 PMS-LOXAPINE PMS
LOXAPINE SUCCINATE
2.5MG TabletST
02242868 PMS-LOXAPINE PMS5MG Tablet
ST
02239918 DOM-LOXAPINE DPC02236943 PHL-LOXAPINE PHH02230837 PMS-LOXAPINE PMS
10MG TabletST
02239919 DOM-LOXAPINE DPC02236944 PHL-LOXAPINE PHH02230838 PMS-LOXAPINE PMS
25MG TabletST
02239920 DOM-LOXAPINE DPC02236945 PDL-LOXAPINE PHH02230839 PMS-LOXAPINE PMS
50MG TabletST
02239921 DOM-LOXAPINE DPC02236946 PDL-LOXAPINE PHH02230840 PMS-LOXAPINE PMS
METHOTRIMEPRAZINE
2MG TabletST
02238403 APO-METHOPRAZINE APX5MG Tablet
ST
02238404 APO-METHOPRAZINE APX02232903 PMS-METHOTRIMEPRAZINE PMS
25MG TabletST
02238405 APO-METHOPRAZINE APX01964925 NOVO-MEPRAZINE TEV
50MG TabletST
02238406 APO-METHOPRAZINE APX
OLANZAPINE
5MG Orally Disintegrating TabletST
02360616 APO-OLANZAPINE ODT APX02327562 CO OLANZAPINE ODT ACT02389088 MAR-OLANZAPINE ODT MAR02382709 MYLAN-OLANZAPINE ODT MYL02338645 OLANZAPINE ODT PDL02343665 OLANZAPINE ODT SIV02352974 OLANZAPINE ODT SAN02303191 PMS-OLANZAPINE ODT PMS02327775 SANDOZ OLANZAPINE ODT SDZ02321343 TEVA-OLANZAPINE OD TEP02243086 ZYPREXA ZYDIS LIL
Page 71 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.08 ANTIPSYCHOTIC AGENTS
OLANZAPINE
10MG Orally Disintegrating TabletST
02360624 APO-OLANZAPINE ODT APX02327570 CO OLANZAPINE ODT ACT02389096 MAR-OLANZAPINE ODT MAR02382717 MYLAN-OLANZAPINE ODT MYL02338653 OLANZAPINE ODT PDL02343673 OLANZAPINE ODT SIV02352982 OLANZAPINE ODT SAN02303205 PMS-OLANZAPINE ODT PMS02327783 SANDOZ OLANZAPINE ODT SDZ02321351 TEVA-OLANZAPINE OD TEP02243087 ZYPREXA ZYDIS LIL
15MG Orally Disintegrating TabletST
02360632 APO-OLANZAPINE ODT APX02327589 CO OLANZAPINE ODT ACT02389118 MAR-OLANZAPINE ODT MAR02382725 MYLAN-OLANZAPINE ODT MYL02338661 OLANZAPINE ODT PDL02343681 OLANZAPINE ODT SIV02352990 OLANZAPINE ODT SAN02303213 PMS-OLANZAPINE ODT PMS02327791 SANDOZ OLANZAPINE ODT SDZ02321378 TEVA-OLANZAPINE OD TEP02243088 ZYPREXA ZYDIS LIL
2.5MG TabletST
02281791 APO-OLANZAPINE APX02325659 CO OLANZAPINE ACT02337878 MYLAN-OLANZAPINE MYL02276712 NOVO-OLANZAPINE TEV02311968 OLANZAPINE PDL02372819 OLANZAPINE SAN02385864 OLANZAPINE SIV02403064 RAN-OLANZAPINE RBY02337126 RIVA-OLANZAPINE RIV02310341 SANDOZ-OLANZAPINE PDL02229250 ZYPREXA LIL
5MG TabletST
02281805 APO-OLANZAPINE APX02325667 CO OLANZAPINE ACT02337886 MYLAN-OLANZAPINE MYL02276720 NOVO-OLANZAPINE TEV02311976 OLANZAPINE PDL02372827 OLANZAPINE SAN02385872 OLANZAPINE SIV02403072 RAN-OLANZAPINE RBY02337134 RIVA-OLANZAPINE RIV02310368 SANDOZ-OLANZAPINE PDL02229269 ZYPREXA LIL
28:16.08 ANTIPSYCHOTIC AGENTS
OLANZAPINE
7.5MG TabletST
02281813 APO-OLANZAPINE APX02325675 CO OLANZAPINE ACT02337894 MYLAN-OLANZAPINE MYL02276739 NOVO-OLANZAPINE TEV02311984 OLANZAPINE PDL02372835 OLANZAPINE SAN02385880 OLANZAPINE SIV02403080 RAN-OLANZAPINE RBY02337142 RIVA-OLANZAPINE RIV02310376 SANDOZ-OLANZAPINE PDL02229277 ZYPREXA LIL
10MG TabletST
02281821 APO-OLANZAPINE APX02325683 CO OLANZAPINE ACT02337908 MYLAN-OLANZAPINE MYL02276747 NOVO-OLANZAPINE TEV02311992 OLANZAPINE PDL02372843 OLANZAPINE SAN02385899 OLANZAPINE SIV02403099 RAN-OLANZAPINE RBY02337150 RIVA-OLANZAPINE RIV02310384 SANDOZ-OLANZAPINE PDL02229285 ZYPREXA LIL
15MG TabletST
02281848 APO-OLANZAPINE APX02325691 CO OLANZAPINE ACT02337916 MYLAN-OLANZAPINE MYL02276755 NOVO-OLANZAPINE TEV02312018 OLANZAPINE PDL02372851 OLANZAPINE SAN02385902 OLANZAPINE SIV02403102 RAN-OLANZAPINE RBY02337169 RIVA-OLANZAPINE RIV02310392 SANDOZ-OLANZAPINE PDL02238850 ZYPREXA LIL
PERICYAZINE
5MG CapsuleST
01926780 NEULEPTIL ERF10MG Capsule
ST
01926772 NEULEPTIL ERF20MG Capsule
ST
01926764 NEULEPTIL ERF10MG/ML Drop
01926756 NEULEPTIL ERF
PERPHENAZINE
3.2MG/ML Liquid
00751898 PMS-PERPHENAZINE PMS2MG Tablet
ST
00335134 APO-PERPHENAZINE APX4MG Tablet
ST
00335126 APO-PERPHENAZINE APX
Page 72 of 1382014
Non-Insured Health BenefitsHealth Canada
28:16.08 ANTIPSYCHOTIC AGENTS
PERPHENAZINE
8MG TabletST
00335118 APO-PERPHENAZINE APX16MG Tablet
ST
00335096 APO-PERPHENAZINE APX
PIMOZIDE
2MG TabletST
02245432 APO-PIMOZIDE APX00313815 ORAP PHH
4MG TabletST
02245433 APO-PIMOZIDE APX00313823 ORAP PHH
PIPOTIAZINE PALMITATE
25MG/ML Injection
01926667 PIPORTIL L4 SAC50MG/ML Injection
00894672 PIPORTIL L4 RHO *
PROCHLORPERAZINE
5MG/ML InjectionST
00789747 PROCHLORPERAZINE SDZ10MG Suppository
ST
00753688 PMS-PROCHLORPERAZINE PMS00789720 PROCHLORPERAZINE SIL
5MG TabletST
00886440 APO-PROCHLORAZINE APX00753661 PMS-PROCHLORPERAZINE PMS
10MG TabletST
00886432 APO-PROCHLORAZINE APX00753637 PMS-PROCHLORPERAZINE PMS
QUETIAPINE FUMARATE
50MG Extended Release TabletST
02407671 SANDOZ QUETIAPINE XRT SDZ02300184 SEROQUEL XR AZE02395444 TEVA-QUETIAPINE XR TEP
150MG Extended Release TabletST
02407698 SANDOZ QUETIAPINE XRT SDZ02321513 SEROQUEL XR AZE02395452 TEVA-QUETIAPINE XR TEP
200MG Extended Release TabletST
02407701 SANDOZ QUETIAPINE XRT SDZ02300192 SEROQUEL XR AZE02395460 TEVA-QUETIAPINE XR TEP
300MG Extended Release TabletST
02407728 SANDOZ QUETIAPINE XRT SDZ02300206 SEROQUEL XR AZE02395479 TEVA-QUETIAPINE XR TEP
400MG Extended Release TabletST
02407736 SANDOZ QUETIAPINE XRT SDZ02300214 SEROQUEL XR AZE02395487 TEVA-QUETIAPINE XR TEP
28:16.08 ANTIPSYCHOTIC AGENTS
QUETIAPINE FUMARATE
25MG TabletST
02390205 AURO-QUETIAPINE AUR02298996 DOM-QUETIAPINE DOM02330415 JAMP-QUETIAPINE JAP02299054 PHL-QUETIAPINE PMI02317346 PRO-QUETIAPINE PDL02317893 QUETIAPINE SIV02353164 QUETIAPINE SAN02397099 RAN-QUETIAPINE RBY02316692 RIVA-QUETIAPINE RIV02236951 SEROQUEL AZC
50MG TabletST
02361892 PMS-QUETIAPINE VTH100MG Tablet
ST
02390213 AURO-QUETIAPINE AUR02299003 DOM-QUETIAPINE DOM02330423 JAMP-QUETIAPINE JAP02299062 PHL-QUETIAPINE PMI02317354 PRO-QUETIAPINE PDL02317907 QUETIAPINE MEL02353172 QUETIAPINE SAN02397102 RAN-QUETIAPINE RBY02316706 RIVA-QUETIAPINE RIV02236952 SEROQUEL AZC
200MG TabletST
02390248 AURO-QUETIAPINE AUR02299038 DOM-QUETIAPINE DOM02330458 JAMP-QUETIAPINE JAP02299089 PHL-QUETIAPINE PMI02317362 PRO-QUETIAPINE PDL02317923 QUETIAPINE SIV02353199 QUETIAPINE SAN02397110 RAN-QUETIAPINE RBY02316722 RIVA-QUETIAPINE RIV02236953 SEROQUEL AZC
300MG TabletST
02390256 AURO-QUETIAPINE AUR02299046 DOM-QUETIAPINE DOM02330466 JAMP-QUETIAPINE JAP02299097 PHL-QUETIAPINE PMI02317370 PRO-QUETIAPINE PDL02317931 QUETIAPINE SIV02353202 QUETIAPINE SAN02397129 RAN-QUETIAPINE RBY02316730 RIVA-QUETIAPINE RIV02244107 SEROQUEL AZC
RISPERIDONE
0.5MG Orally Disintegrating TabletST
02247704 RISPERDAL-M JNO1MG Orally Disintegrating Tablet
ST
02291789 PMS-RISPERIDONE ODT PMS02247705 RISPERDAL-M JNO
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28:16.08 ANTIPSYCHOTIC AGENTS
RISPERIDONE
2MG Orally Disintegrating TabletST
02291797 PMS-RISPERIDONE ODT PMS02247706 RISPERDAL-M JNO
3MG Orally Disintegrating TabletST
02370697 PMS-RISPERIDONE ODT PMS02268086 RISPERDAL-M JNO
4MG Orally Disintegrating TabletST
02370700 PMS-RISPERIDONE ODT PMS02268094 RISPERDAL-M JNO
1MG/ML SolutionST
02280396 APO-RISPERIDONE APX02279266 PMS-RISPERIDONE PMS02236950 RISPERDAL JNO
0.25MG TabletST
02282119 APO-RISPERIDONE APX02282585 CO-RISPERIDONE ACT02282240 GEN-RISPERIDONE GEN02359529 JAMP-RISPERIDONE JAP02371766 MAR-RISPERIDONE MAR02359790 MINT-RISPERIDONE MIN02282690 NOVO-RISPERIDONE TEV02258439 PHL-RISPERIDONE PMI02252007 PMS-RISPERIDONE PMS02312700 PRO-RISPERIDONE PDL02328305 RAN-RISPERIDONE RBY02264757 RATIO-RISPERIDONE RPH02240551 RISPERDAL JNO02303485 RISPERIDONE MEL02356880 RISPERIDONE SAN02283565 RIVA-RISPERIDONE RIV
0.5MG TabletST
02282127 APO-RISPERIDONE APX02282593 CO-RISPERIDONE ACT02278448 DOM-RISPERIDONE DOM02282259 GEN-RISPERIDONE GEN02359537 JAMP-RISPERIDONE JAP02371774 MAR-RISPERIDONE MAR02359804 MINT-RISPERIDONE MIN02264188 NOVO-RISPERIDONE TEV02258447 PHL-RISPERIDONE PMI02252015 PMS-RISPERIDONE PMS02312719 PRO-RISPERIDONE PDL02328313 RAN-RISPERIDONE RBY02264765 RATIO-RISPERIDONE RPH02240552 RISPERDAL JNO02303493 RISPERIDONE MEL02356899 RISPERIDONE SAN02283573 RIVA-RISPERIDONE RIV
28:16.08 ANTIPSYCHOTIC AGENTS
RISPERIDONE
1MG TabletST
02282135 APO-RISPERIDONE APX02282607 CO-RISPERIDONE ACT02278456 DOM-RISPERIDONE DOM02282267 GEN-RISPERIDONE GEN02359545 JAMP-RISPERIDONE JAP02371782 MAR-RISPERIDONE MAR02359812 MINT-RISPERIDONE MIN02264196 NOVO-RISPERIDONE TEV02258455 PHL-RISPERIDONE PMI02252023 PMS-RISPERIDONE PMS02312727 PRO-RISPERIDONE PDL02328321 RAN-RISPERIDONE RBY02264773 RATIO-RISPERIDONE RPH02025280 RISPERDAL JNO02303507 RISPERIDONE MEL02356902 RISPERIDONE SAN02283581 RIVA-RISPERIDONE RIV02279800 SANDOZ-RISPERIDONE SDZ
2MG TabletST
02359820 MINT-RISPERIDONE MIN2MG Tablet
ST
02282143 APO-RISPERIDONE APX02282615 CO-RISPERIDONE ACT02278464 DOM-RISPERIDONE DOM02282275 GEN-RISPERIDONE GEN02359553 JAMP-RISPERIDONE JAP02371790 MAR-RISPERIDONE MAR02264218 NOVO-RISPERIDONE TEV02258463 PHL-RISPERIDONE PMI02252031 PMS-RISPERIDONE PMS02312735 PRO-RISPERIDONE PDL02328348 RAN-RISPERIDONE RBY02264781 RATIO-RISPERIDONE RPH02025299 RISPERDAL JNO02303515 RISPERIDONE MEL02356910 RISPERIDONE SAN02283603 RIVA-RISPERIDONE RIV02279819 SANDOZ-RISPERIDONE SDZ
Page 74 of 1382014
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28:16.08 ANTIPSYCHOTIC AGENTS
RISPERIDONE
3MG TabletST
02282151 APO-RISPERIDONE APX02282623 CO-RISPERIDONE ACT02278472 DOM-RISPERIDONE DOM02282283 GEN-RISPERIDONE GEN02359561 JAMP-RISPERIDONE JAP02371804 MAR-RISPERIDONE MAR02359839 MINT-RISPERIDONE MIN02264226 NOVO-RISPERIDONE TEV02258471 PHL-RISPERIDONE PMI02252058 PMS-RISPERIDONE PMS02312743 PRO-RISPERIDONE PDL02328364 RAN-RISPERIDONE RBY02264803 RATIO-RISPERIDONE RPH02025302 RISPERDAL JNO02303523 RISPERIDONE MEL02356929 RISPERIDONE SAN02283611 RIVA-RISPERIDONE RIV02279827 SANDOZ-RISPERIDONE SDZ
4MG TabletST
02282178 APO-RISPERIDONE APX02282631 CO-RISPERIDONE ACT02282291 GEN-RISPERIDONE GEN02359588 JAMP-RISPERIDONE JAP02371812 MAR-RISPERIDONE MAR02359847 MINT-RISPERIDONE MIN02264234 NOVO-RISPERIDONE TEV02258498 PHL-RISPERIDONE PMI02252066 PMS-RISPERIDONE PMS02312751 PRO-RISPERIDONE PDL02328372 RAN-RISPERIDONE RBY02264811 RATIO-RISPERIDONE RPH02025310 RISPERDAL JNO02303531 RISPERIDONE MEL02356937 RISPERIDONE SAN02283638 RIVA-RISPERIDONE RIV02279835 SANDOZ-RISPERIDONE SDZ
THIOPROPERAZINE MESYLATE
10MG TabletST
01927639 MAJEPTIL ERF
THIOTHIXENE
2MG CapsuleST
00024430 NAVANE ERF5MG Capsule
ST
00024449 NAVANE ERF10MG Capsule
ST
00024457 NAVANE ERF
TRIFLUOPERAZINE HCL
10MG/ML Liquid
00751871 PMS-TRIFLUOPERAZINE PMS1MG Tablet
ST
00345539 APO-TRIFLUOPERAZINE APX
28:16.08 ANTIPSYCHOTIC AGENTS
TRIFLUOPERAZINE HCL
2MG TabletST
00312754 APO-TRIFLUOPERAZINE APX5MG Tablet
ST
00312746 APO-TRIFLUOPERAZINE APX10MG Tablet
ST
00326836 APO-TRIFLUOPERAZINE APX20MG Tablet
ST
00595942 APO-TRIFLUOPERAZINE APX
ZIPRASIDONE
Limited use benefit (prior approval required).
For the treatment of schizophrenia and schizoaffective disorders in patients who have:a.- intolerance or lack of response to an adequate trial of another antipsychotic agent orb.- a contraindication to another antipsychotic agent
20MG CapsuleST
02298597 ZELDOX PFI40MG Capsule
ST
02298600 ZELDOX PFI60MG Capsule
ST
02298619 ZELDOX PFI80MG Capsule
ST
02298627 ZELDOX PFI
28:20.04 AMPHETAMINES
DEXTROAMPHETAMINE SULFATE
10MG Sustained Release CapsuleST
01924559 DEXEDRINE SPANSULE GSK15MG Sustained Release Capsule
ST
01924567 DEXEDRINE SPANSULE GSK5MG Tablet
ST
01924516 DEXEDRINE GSK
LISDEXAMFETAMINE DIMESYLATE
20MG CapsuleST
02347156 VYVANSE 20MG CAP BCM30MG Capsule
ST
02322951 VYVANSE 30MG CAP BCM40MG Capsule
ST
02347164 VYVANSE 40MG CAP BCM50MG Capsule
ST
02322978 VYVANSE 50MG CAP BCM60MG Capsule
ST
02347172 VYVANSE 60MG CAP BCM
28:20.32
METHYLPHENIDATE HCL
18MG Extended Release TabletST
02247732 CONCERTA 18MG TAB JNO02315068 TEVA-METHYLPHENIDATE ER
18MGTEP
Page 75 of 1382014
Non-Insured Health BenefitsHealth Canada
28:20.32
METHYLPHENIDATE HCL
20MG Extended Release TabletST
02320312 SANDOZ-METHYLPHENIDATE SR 20MG
SDZ
27MG Extended Release TabletST
02250241 CONCERTA 27MG TAB JNO02315076 TEVA-METHYLPHENIDATE ER
27MGTEP
36MG Extended Release TabletST
02247733 CONCERTA 36MG TAB JNO02315084 TEVA-METHYLPHENIDATE ER
36MGTEP
54MG Extended Release TabletST
02330377 APO-METHYLPHENIDATE 54MG ER
APX
02247734 CONCERTA 54MG TAB JNO02315092 TEVA-METHYLPHENIDATE ER
54MGTEP
5MG TabletST
02326221 METHYLPHENIDATE 5MG TAB PDL10MG Tablet
ST
02326248 METHYLPHENIDATE 10MG TAB PDL20MG Tablet
ST
02326256 METHYLPHENIDATE 20MG TAB PDL
28:20.92 MISC ANOREXIGENIC AGENTS &
RESPIRATORY & CEREBRAL
STIMULANT
METHYLPHENIDATE HCL
20MG Extended Release TabletST
02266687 APO-METHYLPHENIDATE SR APX5MG Tablet
ST
02273950 APO-METHYLPHENIDATE APX02234749 PMS-METHYLPHENIDATE PMS
10MG TabletST
02249324 APO-METHYLPHENIDATE APX00584991 PMS-METHYLPHENIDATE PMS
20MG TabletST
02249332 APO-METHYLPHENIDATE APX00585009 PMS-METHYLPHENIDATE PMS
MODAFINIL
100MG TabletST
02239665 ALERTEC DPY
28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
ALPRAZOLAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.25MG TabletST
01908189 ALPRAZOLAM PDL02349191 ALPRAZOLAM SAN00865397 APO-ALPRAZ APX02137534 GEN-ALPRAZOLAM GEN02400111 JAMP-ALPRAZOLAM JAP01913484 NOVO-ALPRAZOL TEV00548359 XANAX PFI
0.5MG TabletST
01908170 ALPRAZOLAM PDL02349205 ALPRAZOLAM SAN00865400 APO-ALPRAZ APX02137542 GEN-ALPRAZOLAM GEN02400138 JAMP-ALPRAZOLAM JAP01913492 NOVO-ALPRAZOL TEV00548367 XANAX PFI
1MG TabletST
02248706 ALPRAZOLAM PDL02243611 APO-ALPRAZ APX02229813 GEN-ALPRAZOLAM GEN02400146 JAMP-ALPRAZOLAM JAP00723770 XANAX PFI
2MG TabletST
02243612 APO-ALPRAZ APX02229814 GEN-ALPRAZOLAM GEN02400154 JAMP-ALPRAZOLAM JAP00813958 XANAX TS PFI
BROMAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
1.5MG TabletST
02177153 APO-BROMAZEPAM APX
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28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
BROMAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
3MG TabletST
02177161 APO-BROMAZEPAM APX02220520 BROMAZEPAM PDL00518123 LECTOPAM HLR02230584 NOVO-BROMAZEPAM TEV
6MG TabletST
02177188 APO-BROMAZEPAM APX02220539 BROMAZEPAM PDL00518131 LECTOPAM HLR02230585 NOVO-BROMAZEPAM TEV
CLOBAZAM
10MG TabletST
02244638 APO-CLOBAZAM APX02248454 CLOBAZAM PDL02247230 DOM-CLOBAZAM DPC02221799 FRISIUM PED02238334 NOVO-CLOBAZAM TEV02244474 PMS-CLOBAZAM PMS
DIAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
1MG/ML Oral SolutionST
00891797 PMS-DIAZEPAM PMS2MG Tablet
ST
00405329 APO-DIAZEPAM APX00434396 DIAZEPAM PDL02247490 PMS-DIAZEPAM PMS
5MG TabletST
00362158 APO-DIAZEPAM APX00313580 DIAZEPAM PRO02247491 PMS-DIAZEPAM PMS00013285 VALIUM HLR
28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
DIAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
10MG TabletST
00405337 APO-DIAZEPAM APX00434388 DIAZEPAM PDL02247492 PMS-DIAZEPAM PMS
LORAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.5MG TabletST
00655740 APO-LORAZEPAM APX02410745 APO-LORAZEPAM
SUBLINGUALAPX
02041413 ATIVAN WAY02041456 ATIVAN SUBLINGUAL WAY02245784 DOM-LORAZEPAM DPC02351072 LORAZEPAM SAN00711101 NOVO-LORAZEM TEV00728187 PMS-LORAZEPAM PMS00655643 PRO-LORAZEPAM PDL
1MG TabletST
00655759 APO-LORAZEPAM APX02410753 APO-LORAZEPAM
SUBLINGUALAPX
02041421 ATIVAN WAY02041464 ATIVAN SUBLINGUAL WAY02245785 DOM-LORAZEPAM DPC02351080 LORAZEPAM SAN00637742 NOVO-LORAZEM TEV00728195 PMS-LORAZEPAM PMS00655651 PRO-LORAZEPAM PDL
Page 77 of 1382014
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28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
LORAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
2MG TabletST
00655767 APO-LORAZEPAM APX02410761 APO-LORAZEPAM
SUBLINGUALAPX
02041448 ATIVAN WAY02041472 ATIVAN SUBLINGUAL WAY02245786 DOM-LORAZEPAM DPC02351099 LORAZEPAM SAN00637750 NOVO-LORAZEM TEV00728209 PMS-LORAZEPAM PMS00655678 PRO-LORAZEPAM PDL
NITRAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
5MG TabletST
02245230 APO-NITRAZEPAM APX00511528 MOGADON ICN02229654 NITRAZADON VAE02234003 SANDOZ-NITRAZEPAM SDZ
10MG TabletST
02245231 APO-NITRAZEPAM APX00511536 MOGADON ICN02229655 NITRAZADON VAE02234007 SANDOZ-NITRAZEPAM SDZ
28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
OXAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
10MG TabletST
00402680 APO-OXAZEPAM APX00497754 OXAZEPAM PDL00414247 OXPAM VAE00568392 ZAPEX RIV
15MG TabletST
00402745 APO-OXAZEPAM APX00497762 OXAZEPAM PDL00568406 ZAPEX RIV
30MG TabletST
00402737 APO-OXAZEPAM APX00497770 OXAZEPAM PDL00414263 OXPAM VAE00568414 ZAPEX RIV
TEMAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
15MG CapsuleST
02225964 APO-TEMAZEPAM APX02244814 CO-TEMAZEPAM ACT02229756 DOM-TEMAZEPAM DPC02230095 NOVO-TEMAZEPAM TEV02243023 RATIO-TEMAZEPAM RPH00604453 RESTORIL ORY02229760 TEMAZEPAM PDL
30MG CapsuleST
02225972 APO-TEMAZEPAM APX02244815 CO-TEMAZEPAM ACT02229758 DOM-TEMAZEPAM DPC02230102 NOVO-TEMAZEPAM TEV02243024 RATIO-TEMAZEPAM RPH00604461 RESTORIL ORY02229761 TEMAZEPAM PDL
Page 78 of 1382014
Non-Insured Health BenefitsHealth Canada
28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
TRIAZOLAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.125MG TabletST
00808563 APO-TRIAZO APX0.25MG Tablet
ST
00808571 APO-TRIAZO APX
28:24.92 MISCELLANEOUS ANXIOLYTICS,
SEDATIVES, AND HYPNOTICS
HYDROXYZINE HCL
10MG Capsule
00739618 HYDROXYZINE PDL00738824 NOVO-HYDROXYZIN TEV02241192 RIVA-HYDROXYZIN RIV
25MG Capsule
00739626 HYDROXYZINE PDL00738832 NOVO-HYDROXYZIN TEV02241193 RIVA-HYDROXYZIN RIV
50MG Capsule
00739634 HYDROXYZINE PDL00738840 NOVO-HYDROXYZIN TEV02241194 RIVA-HYDROXYZIN RIV
2MG/ML Syrup
00024694 ATARAX ERF00741817 PMS-HYDROXYZINE PMS
10MG Tablet
00646059 APO-HYDROXYZINE APX25MG Tablet
00646024 APO-HYDROXYZINE APX50MG Tablet
00646016 APO-HYDROXYZINE APX
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE
150MG Capsule
02242837 APO-LITHIUM CARB APX09857532 APO-LITHIUM CARBONATE APX02013231 LITHANE ERF02216132 PMS-LITHIUM CARBONATE PMS
300MG Capsule
02242838 APO-LITHIUM CARB APX09857540 APO-LITHIUM CARBONATE APX00236683 CARBOLITH VAE00406775 LITHANE ERF02216140 PMS-LITHIUM CARBONATE PMS
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE
600MG Capsule
02011239 CARBOLITH VAE02216159 PMS-LITHIUM CARBONATE PMS
300MG Sustained Release Tablet
02266695 APO-LITHIUM CARBONATE APX
LITHIUM CITRATE
60MG/ML Syrup
02074834 PMS-LITHIUM CITRATE PMS
28:32.28 SELECTIVE SEROTONIN
AGONISTS
ALMOTRIPTAN MALATE
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
6.25MG Tablet
02405792 APO-ALMOTRIPTAN APX02248128 AXERT MCL02398435 MYLAN-ALMOTRIPTAN MYL
12.5MG Tablet
02405806 APO-ALMOTRIPTAN APX02248129 AXERT MCL02398443 MYLAN-ALMOTRIPTAN MYL02405334 SANDOZ ALMOTRIPTAN SDZ
NARATRIPTAN HCL
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
1MG Tablet
02237820 AMERGE GSK02314290 TEVA-NARATRIPTAN TEP
2.5MG Tablet
02237821 AMERGE GSK02322323 SANDOZ NARATRIPTAN SDZ02314304 TEVA-NARATRIPTAN TEP
RIZATRIPTAN
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
5MG Orally Disintegrating Tablet
02393484 APO-RIZATRIPTAN RPD APX02374730 CO-RIZATRIPTAN ODT ACT02240518 MAXALT RPD FRS02379198 MYLAN-RIZATRIPTAN ODT MYL02393360 PMS-RIZATRIPTAN RDT PMS02351870 SANDOZ RIZATRIPTAN ODT SDZ
Page 79 of 1382014
Non-Insured Health BenefitsHealth Canada
28:32.28 SELECTIVE SEROTONIN
AGONISTS
RIZATRIPTAN
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
10MG Orally Disintegrating Tablet
02393492 APO-RIZATRIPTAN RPD APX02374749 CO-RIZATRIPTAN ODT ACT02396203 DOM-RIZATRIPTAN RDT DOM02240519 MAXALT RPD FRS02379201 MYLAN-RIZATRIPTAN ODT MYL02393379 PMS-RIZATRIPTAN RDT PMS02351889 SANDOZ RIZATRIPTAN ODT SDZ
5MG Tablet
02393468 APO-RIZATRIPTAN APX02380455 JAMP-RIZATRIPTAN JAP02379651 MAR-RIZATRIPTAN MAR
10MG Tablet
02393476 APO-RIZATRIPTAN APX02381702 CO RIZATRIPTAN ACT02380463 JAMP-RIZATRIPTAN JAP02379678 MAR-RIZATRIPTAN MAR02240521 MAXALT FRS
SUMATRIPTAN HEMISULFATE
5MG Nasal Spray
02230418 IMITREX GSK20MG Nasal Spray
02230420 IMITREX GSK
SUMATRIPTAN SUCCINATE
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
12MG/ML Injection
02212188 IMITREX GSK99000598 IMITREX GSK *02361698 TARO-SUMATRIPTAN TAR
25MG Tablet
02257882 CO-SUMATRIPTAN ACT02270749 DOM-SUMATRIPTAN DPC02268906 GEN-SUMATRIPTAN GEN02286815 NOVO-SUMATRIPTAN DF TEV02256428 PMS-SUMATRIPTAN PMS02286513 SUMATRIPTAN SAN
28:32.28 SELECTIVE SEROTONIN
AGONISTS
SUMATRIPTAN SUCCINATE
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
50MG Tablet
02268388 APO-SUMATRIPTAN APX02257890 CO-SUMATRIPTAN ACT02270757 DOM-SUMATRIPTAN DPC02268914 GEN-SUMATRIPTAN GEN02212153 IMITREX DF GSK02286823 NOVO-SUMATRIPTAN DF TEV02256436 PMS-SUMATRIPTAN PMS02324652 PRO-SUMATRIPTAN PDL02263025 SANDOZ-SUMATRIPTAN SDZ02286521 SUMATRIPTAN SAN02385570 SUMATRIPTAN DF SIV
100MG Tablet
02268396 APO-SUMATRIPTAN APX02257904 CO-SUMATRIPTAN ACT02270765 DOM-SUMATRIPTAN DPC02268922 GEN-SUMATRIPTAN GEN02212161 IMITREX DF GSK02239367 NOVO-SUMATRIPTAN TEV02286831 NOVO-SUMATRIPTAN DF TEV02256444 PMS-SUMATRIPTAN PMS02324660 PRO-SUMATRIPTAN PDL02263033 SANDOZ-SUMATRIPTAN SDZ02286548 SUMATRIPTAN SAN02385589 SUMATRIPTAN DF SIV
ZOLMITRIPTAN
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
2.5MG Orally Disintegrating Tablet
02381575 APO-ZOLMITRIPTAN RAPID APX02387158 MYLAN ZOLMITRIPTAN ODT MYL02324768 PMS-ZOLMITRIPTAN ODT PMS02362996 SANDOZ ZOLMITRIPTAN ODT SDZ02342545 TEVA-ZOLMITRIPTAN OD TEP02379988 ZOLMITRIPTAN ODT PDL02243045 ZOMIG RAPIMELT AZC
2.5MG Tablet
02380951 APO-ZOLMITRIPTAN APX02389525 DOM-ZOLMITRIPTAN DOM02369036 MYLAN ZOLMITRIPTAN MYL02324229 PMS-ZOLMITRIPTAN PMS02401304 RIVA-ZOLMITRIPTAN RIV02362988 SANDOZ ZOLMITRIPTAN SDZ02313960 TEVA-ZOLMITRIPTAN TEP02379929 ZOLMITRIPTAN PDL02238660 ZOMIG AZC
Page 80 of 1382014
Non-Insured Health BenefitsHealth Canada
28:32.92 MISCELLANEOUS ANTIMIGRANE
AGENTS
FLUNARIZINE HCL
5MG Capsule
02246082 APO-FLUNARIZINE APX
PIZOTYLINE HYDROGEN MALATE
0.5MG Tablet
00329320 SANDOMIGRAN PED1MG Tablet
00511552 SANDOMIGRAN DS PED
28:36.12 ANTIPARKINSONIAN AGENTS -
CATECHOL-O-
METHYLTRANSFERASE (COMT)
INHIBITORS
ENTACAPONE
200MG TabletST
02243763 COMTAN NVR02390337 MYLAN-ENTACAPONE MYL02380005 SANDOZ ENTACAPONE SDZ02375559 TEVA-ENTACAPONE TEP
28:36.16 ANTIPARKINSONIAN AGENTS -
DOPAMINE PRECURSORS
LEVODOPA, BENZERAZIDE
50MG & 12.5MG CapsuleST
00522597 PROLOPA HLR100MG & 25MG Capsule
ST
00386464 PROLOPA HLR200MG & 50MG Capsule
ST
00386472 PROLOPA HLR
LEVODOPA, CARBIDOPA
100MG & 25MG Controlled Release TabletST
02272873 APO-LEVOCARB CR AAP02028786 SINEMET CR BMS
200MG & 50MG Controlled Release TabletST
02245211 APO-LEVOCARB CR APX00870935 SINEMET CR BMS
100MG & 10MG TabletST
02195933 APO-LEVOCARB APX02244494 NOVO-LEVOCARBIDOPA TEV00355658 SINEMET BMS
100MG & 25MG TabletST
02195941 APO-LEVOCARB APX02244495 NOVO-LEVOCARBIDOPA TEV02311178 PRO-LEVOCARB PDL00513997 SINEMET BMS
250MG & 25MG TabletST
02195968 APO-LEVOCARB APX02244496 NOVO-LEVOCARBIDOPA TEV00328219 SINEMET BMS
28:36.16 ANTIPARKINSONIAN AGENTS -
DOPAMINE PRECURSORS
LEVODOPA, CARBIDOPA, ENTACAPONE
50MG & 12.5MG & 200MG TabletST
02305933 STALEVO NOV75MG & 18.75MG & 200MG Tablet
ST
02337827 STALEVO NOV100MG & 25MG & 200MG Tablet
ST
02305941 STALEVO NOV125MG & 31.25MG & 200MG Tablet
ST
02337835 STALEVO NOV150MG & 37.5MG & 200MG Tablet
ST
02305968 STALEVO NOV
28:36.20 ANTIPARKINSONIAN AGENTS -
DOPAMINE RECEPTOR
AGONISTS
BROMOCRIPTINE MESYLATE
5MG Capsule
02230454 APO-BROMOCRIPTINE APX02238637 DOM-BROMOCRIPTINE DPC02236949 PMS-BROMOCRIPTINE PMS
2.5MG Tablet
02087324 APO-BROMOCRIPTINE APX02238636 DOM-BROMOCRIPTINE DPC02231702 PMS-BROMOCRIPTINE PMS
CABERGOLINE
Limited use benefit (prior approval required).
For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.
0.5MG Tablet
02301407 CO CABERGOLINE ACT02242471 DOSTINEX PFI
PRAMIPEXOLE DIHYDROCHLORIDE
0.25MG TabletST
02292378 APO-PRAMIPEXOLE APX02297302 CO PRAMIPEXOLE ACT02309017 DOM-PRAMIPEXOLE DOM02237145 MIRAPEX BOE09857268 MIRAPEX (ONT) BOE *02376350 MYLAN-PRAMIPEXOLE MYL02269309 NOVO-PRAMIPEXOLE TEV02290111 PMS-PRAMIPREXOLE PMS02309122 PRAMIPEXOLE SIV02367602 PRAMIPEXOLE SAN02325802 PRO-PRAMIPEXOLE PDL02315262 SANDOZ-PRAMIPEXOLE SDZ
Page 81 of 1382014
Non-Insured Health BenefitsHealth Canada
28:36.20 ANTIPARKINSONIAN AGENTS -
DOPAMINE RECEPTOR
AGONISTS
PRAMIPEXOLE DIHYDROCHLORIDE
0.5MG TabletST
02292386 APO-PRAMIPEXOLE APX02297310 CO PRAMIPEXOLE ACT02241594 MIRAPEX BOE02376369 MYLAN-PRAMIPEXOLE MYL02269317 NOVO-PRAMIPEXOLE TEV02290138 PMS-PRAMIPREXOLE PMS02309130 PRAMIPEXOLE SIV02367610 PRAMIPEXOLE SAN02325810 PRO-PRAMIPEXOLE PDL02315270 SANDOZ-PRAMIPEXOLE SDZ
1MG TabletST
02292394 APO-PRAMIPEXOLE APX02297329 CO PRAMIPEXOLE ACT02237146 MIRAPEX BOE09857269 MIRAPEX (ONT) BOE *02376377 MYLAN-PRAMIPEXOLE MYL02269325 NOVO-PRAMIPEXOLE TEV02290146 PMS-PRAMIPREXOLE PMS02309149 PRAMIPEXOLE SIV02325829 PRO-PRAMIPEXOLE PDL02315289 SANDOZ-PRAMIPEXOLE SDZ
1.5MG TabletST
02292408 APO-PRAMIPEXOLE APX02297337 CO PRAMIPEXOLE ACT02237147 MIRAPEX BOE09857270 MIRAPEX (ONT) BOE *02376385 MYLAN-PRAMIPEXOLE MYL02269333 NOVO-PRAMIPEXOLE TEV02290154 PMS-PRAMIPREXOLE PMS02309157 PRAMIPEXOLE SIV02325837 PRO-PRAMIPEXOLE PDL02315297 SANDOZ-PRAMIPEXOLE SDZ
ROPINIROLE HCL
0.25MG TabletST
02337746 APO-ROPINIROLE APX02316846 CO-ROPINIROLE ACT02352338 JAMP-ROPINIROLE JAP02326590 PMS-ROPINIROLE PMS02314037 RAN-ROPINIROLE RBY02353040 ROPINIROLE SAN
1MG TabletST
02337762 APO-ROPINIROLE APX02316854 CO-ROPINIROLE ACT02352346 JAMP-ROPINIROLE JAP02326612 PMS-ROPINIROLE PMS02314053 RAN-ROPINIROLE RBY02353059 ROPINIROLE SAN
28:36.20 ANTIPARKINSONIAN AGENTS -
DOPAMINE RECEPTOR
AGONISTS
ROPINIROLE HCL
2MG TabletST
02337770 APO-ROPINIROLE APX02316862 CO-ROPINIROLE ACT02352354 JAMP-ROPINIROLE JAP02326620 PMS-ROPINIROLE PMS02314061 RAN-ROPINIROLE RBY02353067 ROPINIROLE SAN
5MG TabletST
02337800 APO-ROPINIROLE APX02316870 CO-ROPINIROLE ACT02352362 JAMP-ROPINIROLE JAP02326639 PMS-ROPINIROLE PMS02314088 RAN-ROPINIROLE RBY02353075 ROPINIROLE SAN
28:36.32 ANTIPARKINSONIAN AGENTS -
MONOAMINE OXIDASE B
INHIBITORS
SELEGILINE HCL
5MG TabletST
02230641 APO-SELEGILINE APX02238340 DOM-SELEGILINE DPC02231036 GEN-SELEGILINE GEN02068087 NOVO-SELEGILINE TEV
28:92.00 MISCELLANEOUS CENTRAL
NERVOUS SYSTEM AGENTS
ACAMPROSATE CALCIUM
Limited use benefit (prior approval required).
For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program
333MG Delayed Release Tablet
02293269 CAMPRAL MYL
BETAHISTINE HCL
8MG Tablet
02280183 NOVO-BETAHISTINE TEV16MG Tablet
02374757 CO BETAHISTINE ACT02280191 NOVO-BETAHISTINE TEV02243878 SERC SPH
24MG Tablet
02374765 CO BETAHISTINE ACT02280205 NOVO-BETAHISTINE TEV02247998 SERC SPH
TETRABENAZINE
25MG Tablet
02407590 APO-TETRABENAZINE APX02199270 NITOMAN LHL02402424 PMS-TETRABENAZINE PMS
Page 82 of 1382014
Non-Insured Health BenefitsHealth Canada
32:00 CONTRACEPTIVES (NON-ORAL)
32:00.00 CONTRACEPTIVES (NON-ORAL)
CONDOM, MALE
Device
99400527 CONDOM, LATEX, LUBRICATED
99400485 CONDOM, LATEX, LUBRICATED, NONOXYNOL
99400486 CONDOM, LATEX, NON-LUBRICATED
99400786 CONDOM, NON-LATEX, LUBRICATED
INTRAUTERINE DEVICE
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 device every 12 months.Device
98099999 FLEXI-T IUD PRN99401085 LIBERTE UT380 SHORT MSC99401086 LIBERTE UT380 STANDARD MSC99400482 NOVA-T IUD BEX
Page 83 of 1382014
Non-Insured Health BenefitsHealth Canada
36:00 DIAGNOSTIC AGENTS (DX)
36:00.00 DIAGNOSTIC AGENTS (DX)
THYROTROPIN ALFA
0.9MG/ML Powder for Solution
02246016 THYROGEN GEE
36:26.00 DX - DIABETES MELLITUS
GLUCOSE OXIDASE, PEROXIDASE
Accu-Chek Advantage Strip
97799824 ACCU-CHEK ADVANTAGE ROCAccu-Chek Aviva Strip
97799814 ACCU-CHEK AVIVA ROD09857178 ACCU-CHEK AVIVA (ON) ROC
Accu-Chek Compact Strip
97799962 ACCU-CHEK COMPACT ROD09854282 ACCU-CHEK COMPACT (ON) ROD *
Accu-Chek Mobile Strip
97799497 ACCU-CHEK MOBILE ROC09857452 ACCU-CHEK MOBILE (ON) ROC
Accutrend Strip
09853162 ACCUTREND (ON) ROD97799959 ACCUTREND GLUCOSE ROC
Ascensia Breeze 2 Strip
97799748 ASCENSIA BREEZE 2 BAY09857293 ASCENSIA BREEZE 2 (ON) BAY
Ascensia Contour Strip
97799702 ASCENSIA CONTOUR BAY09857127 ASCENSIA CONTOUR (ON) BAY
BG Star Strip
97799465 BG STAR SAC09857422 BG STAR (ON) SAC
Contour Next Strip
97799459 CONTOUR NEXT BAY09857453 CONTOUR NEXT (ON) BAY
EZ Health Oracle Strip
97799564 EZ HEALTH ORACLE TRE09857357 EZ HEALTH ORACLE (ON) TRE
Freestyle Strip
97799829 FREESTYLE THS09857141 FREESTYLE (ON) THS
Freestyle Lite Strip
09857297 FREESTYLE LITE (ON) ABBiTest Strip
97799692 ITEST AUC09857348 ITEST (ON) AUC
Medi+Sure Strip
97799403 MEDI+SURE MSD09857432 MEDI+SURE (ON) MSD
One Touch Ultra Strip
97799985 ONE TOUCH ULTRA JAJ09854290 ONE TOUCH ULTRA (ON) JAJ *
One Touch Verio Strip
09857392 ONE TOUCH VERIO (ON) JAJ97799475 ONETOUCH VERIO JAJ
36:26.00 DX - DIABETES MELLITUS
GLUCOSE OXIDASE, PEROXIDASE
Precision Xtra Strip
97799840 PRECISION XTRA AUC09854070 PRECISION XTRA (ON) AUC
True Test Strip
97799532 TRUETEST HODTrue Track Strip
09857283 TRUETRACK (ON) AUC
36:88.00 DX - URINE AND FECES
CONTENTS
GLUCOSE OXIDASE, PEROXIDASE
Diastix Strip
97799914 DIASTIX BAY
SODIUM NITROPRUSSIDE
Strip
00035092 KETOSTIX BAY00977322 KETOSTIX BAY *00980595 KETOSTIX BAY99067074 KETOSTIX (MB) BAY *09853286 KETOSTIX (ON) BAY *
Page 84 of 1382014
Non-Insured Health BenefitsHealth Canada
40:00 ELECTROLYTIC, CALORIC, AND
WATER BALANCE
40:08.00 ALKALINIZING AGENTS
CITRIC ACID, SODIUM CITRATE
66.8MG & 100MG/ML Solution
00721344 DICITRATE PMS
SODIUM BICARBONATE
300MG Tablet
00481912 SODIUM BICARBONATE XEN
40:10.00 AMMONIA DETOXICANTS
LACTULOSE
667MG/ML Oral LiquidST
02242814 APO-LACTULOSE APX02247383 EURO-LAC EUR02295881 JAMP-LACTULOSE JAP00703486 PMS-LACTULOSE PMS00854409 RATIO-LACTULOSE RPH02331551 TEVA-LACTULOSE TEP
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM
100MG Oral LiquidST
80002626 SOLUCAL JAP80025527 SOLUCAL GREEN APPLE JAP80025523 SOLUCAL RASPBERRY JAP80006877 WAMPOLE MINERAL CALCIUM JAP
500MG TabletST
80003773 CALCIUM TRI
CALCIUM & VITAMIN D
500MG & 400IU Chewable Tablet
80009628 CALODAN D ODN80009412 M-CAL D MAN
500MG & 400IU Oral LiquidST
80008126 SOLUCAL D JAP80025543 SOLUCAL D CITRUS JAP80025541 SOLUCAL D RASPBERRY JAP
250MG & 200IU TabletST
80013612 CI-CAL D EUR500MG & 1000IU Tablet
ST
80019536 M-CAL D MAN500MG & 125IU Tablet
ST
80017196 CAL-500 D PRO80004966 CALCITE D RIV80004968 CALCIUM D TRI80004281 PHARMA-CAL D PMS
500MG & 400IU Tablet
80003919 BIOCAL-D FORTE BMI80004963 CALCITE 500 D RIV80004969 CALCIUM + D TRI80017190 CAL-D 400 PDL80002703 NU-CAL D ODN80015351 PRIVA CAL D FORTE PHA
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM & VITAMIN D
500MG & 800IU TabletST
80019533 M-CAL D MAN
CALCIUM CARBONATE
500MG TabletST
00682039 APO-CAL 500 APX02240240 CALCIUM PMT80003658 CALCIUM WNP80017732 CALCIUM PRO02246040 CALCIUM CARBONATE JAP02237352 EURO-CAL EUR00618098 NU-CAL ODN00622443 O-CALCIUM 500 VTH80001408 OYSTER SHELL CALCIUM NUR
CALCIUM CARBONATE, CHOLECALCIFEROL
500MG & 125IU TabletST
00730599 CALCIUM CARBONATE WITH VIT D
PMT
02237351 EURO-CAL D EUR00720798 NEO CAL-D-500 NEO
CALCIUM CARBONATE, VITAMIN D
500MG & 400IU Chewable Tablet
80002901 CARBOCAL D EUR500MG & 125IU Tablet
ST
02246041 JAMP CALCIUM + VITAMIN D JAP500MG & 400IU Tablet
80002623 CALCIUM WITH VITAMIN D JAP02245511 CARBOCAL D EUR80002122 J CAL-D JAP99100832 JAMP-CALCIUM + VIT D JAP80013329 M-CAL D MAN
ELECTROLYTE & DEXTROSE
Miscellaneous
80023410 HYDRALYTE ELECTROLYTE POPS
HPP
Powder
80026860 HYDRALYTE ELECTROLYTE PWD
HPP
3.56G & 300MG & 470MG & 530MG Powder
01931563 GASTROLYTE REG SAC5.1 G /SAC Powder
80027403 JAMP REHYDRALYTE JAPSolution
80026861 HYDRALYTE ELECTROLYTE SOL
HPP
25MG & 2.2MG & 2.2MG & 0.9MG/ML Solution
00630365 PEDIALYTE ABB02219883 PEDIATRIC ELECTROLYTE PMS
MAGNESIUM
100MG/ML Oral Liquid
00026697 RATIO-MAGNESIUM RPH
Page 85 of 1382014
Non-Insured Health BenefitsHealth Canada
40:12.00 REPLACEMENT PREPARATIONS
POTASSIUM CHLORIDE
25MEQ Effervescent TabletST
02085992 K LYTE WPC8MMOL Long Acting Capsule
ST
02042304 MICRO-K EXTENCAPS WAY02244068 RIVA-K RIV
8MMOL Long Acting TabletST
00602884 APO-K APX02246734 EURO-K 600 EUR80035346 MK 8 MAN00613274 PRO-600K PDL
10MMOL Long Acting TabletST
80026332 MK 10 MAN20MMOL Long Acting Tablet
ST
02242261 EURO-K 20 EUR02243975 RIVA-K 20 RIV
1.33MEQ/ML Oral LiquidST
02238604 PMS-POTASSIUM PMS20MEQ Oral Liquid
ST
80024835 JAMP-POTASSIUM CHLORIDE JAP8MMOL Tablet
ST
80013005 JAMP-K 8 JAP20MMOL Tablet
ST
80013007 JAMP-K 20 JAP80025624 MK 20 MAN
600MG TabletST
80040226 SLOW-K NOV
SODIUM CHLORIDE
0.9% Inhalation Diluent
02094657 BACTERIOSTATIC NACL BIO00801267 SODIUM CHLORIDE UNK *02058235 SODIUM CHLORIDE BDH
0.9% Injection
00060208 SODIUM CHLORIDE BAT00402249 SODIUM CHLORIDE ABB02150204 SODIUM CHLORIDE OMG99002329 SODIUM CHLORIDE AUT *
40:17.00 CALCIUM-REMOVING RESINS
CALCIUM POLYSTYRENE SULFONATE
1G binds with approx 1.6mmol K Powder
02017741 RESONIUM CALCIUM SAC
40:18.00 ION-REMOVING AGENTS
SODIUM POLYSTYRENE SULFONATE
1G binds with approx 1mmol K Powder
02026961 KAYEXALATE SAC00765252 K-EXIT OMG00755338 PMS-SOD POLYSTYRENE
SULFONAPMS
250MG/ML Oral Suspension
00769541 PMS-SOD POLYSTYRENE SULF
PMS
40:18.00 ION-REMOVING AGENTS
SODIUM POLYSTYRENE SULFONATE
250MG/ML Retention Enema
00769533 PMS-SOD POLYSTYRENE SULF
PMS
40:20.00 CALORIC AGENTS
LEVOCARNITINE
Limited use benefit (prior approval required).
• For treatment of carnitine deficiency100MG/ML Oral Liquid
02144336 CARNITOR SIG200MG/ML Solution
02144344 CARNITOR IV SIG330MG Tablet
02144328 CARNITOR SIG
40:28.08 LOOP DIURETICS
ETHACRYNIC ACID
25MG TabletST
02258528 EDECRIN FRS
FUROSEMIDE
10MG/ML SolutionST
02224720 LASIX SAC20MG Tablet
ST
00396788 APO-FUROSEMIDE APX02247371 BIO-FUROSEMIDE BMI02248124 DOM-FUROSEMIDE BMI00496723 FUROSEMIDE PDL02351420 FUROSEMIDE SAN02224690 LASIX SAC00337730 NOVO-SEMIDE TEV02247493 PMS-FUROSEMIDE PMS
40MG TabletST
00362166 APO-FUROSEMIDE APX02247372 BIO-FUROSEMIDE BMI02248125 DOM-FUROSEMIDE BMI00397792 FUROSEMIDE PDL02351439 FUROSEMIDE SAN02224704 LASIX SAC00337749 NOVO-SEMIDE TEV02247494 PMS-FUROSEMIDE PMS
80MG TabletST
00707570 APO-FUROSEMIDE APX00667080 FUROSEMIDE PDL02351447 FUROSEMIDE SAN00765953 NOVO-SEMIDE TEV
500MG TabletST
02224755 LASIX SAC
40:28.16 POTASSIUM SPARING DIURETICS
AMILORIDE HCL
5MG TabletST
02249510 APO-AMILORIDE APX
Page 86 of 1382014
Non-Insured Health BenefitsHealth Canada
40:28.16 POTASSIUM SPARING DIURETICS
AMILORIDE HCL, HYDROCHLOROTHIAZIDE
5MG & 50MG TabletST
00870943 AMI-HYDRO PDL00784400 APO-AMILZIDE APX01937219 NOVAMILOR TEV
TRIAMTERENE, HYDROCHLOROTHIAZIDE
50MG & 25MG TabletST
00441775 APO-TRIAZIDE APX00532657 NOVO-TRIAMZIDE TEV00519367 PRO-TRIAZIDE PRO02240846 RIVA-ZIDE RIV
40:28.20 TIAZIDE DIURETICS
HYDROCHLOROTHIAZIDE
12.5MG TabletST
02327856 APO-HYDRO APX02274086 PMS-HYDROCHLOROTHIAZIDE PMS
25MG TabletST
00326844 APO-HYDROCLOROTHIAZIDE APX02247170 BIO-HYDROCHLOROTHIAZIDE BMI02248134 DOM-HYDROCHLOROTHIAZIDE DPC00341975 HYDROCHLOROTHIAZIDE PDL02360594 HYDROCHLOROTHIAZIDE SAN00021474 NOVO-HYDRAZIDE TEV02247386 PMS-HYDROCHLOROTHIAZIDE PMS
50MG TabletST
02360608 HYDROCHLOROTHIAZIDE SAN50MG Tablet
ST
00312800 APO-HYDRO APX02247171 BIO-HYDROCHLOROTHIAZIDE BMI02248135 DOM-HYDROCHLOROTHIAZIDE DPC00021482 NOVO-HYDRAZIDE TEV02247387 PMS-HYDROCHLOROTHIAZIDE PMS
100MG TabletST
00644552 APO-HYDRO APX00532088 HYDROCHLOROTHIAZIDE PDL
SPIRONOLACTONE, HYDROCHLOROTHIAZIDE
25MG & 25MG TabletST
00180408 ALDACTAZIDE-25 PFI00613231 NOVO-SPIROZINE-25 TEV
50MG & 50MG TabletST
00594377 ALDACTAZIDE-50 PFI00657182 NOVO-SPIROZINE-50 TEV
40:28.24 THIAZIDE LIKE DIURETICS
CHLORTHALIDONE
50MG TabletST
00360279 APO-CHLORTHALIDONE APX100MG Tablet
ST
00360287 APO-CHLORTHALIDONE APX
40:28.24 THIAZIDE LIKE DIURETICS
INDAPAMIDE
1.25MG TabletST
02245246 APO-INDAPAMIDE APX02239913 DOM-INDAPAMIDE DPC02240067 GEN-INDAPAMIDE GEN02373904 JAMP-INDAPAMIDE JAP02179709 LOZIDE SEV02240349 PHL-INDAPAMIDE PHH02239619 PMS-INDAPAMIDE PMS02312530 PRO-INDAPAMIDE PDL02247245 RIVA-INDAPAMIDE RIV
2.5MG TabletST
02223678 APO-INDAPAMIDE APX02239917 DOM-INDAPAMIDE DPC02153483 GEN-INDAPAMIDE GEN02373912 JAMP-INDAPAMIDE JAP00564966 LOZIDE SEV02231184 NOVO-INDAPAMIDE TEV02239620 PMS-INDAPAMIDE PMS02312549 PRO-INDAPAMIDE PDL02242125 RIVA-INDAPAMIDE RIV
METOLAZONE
2.5MG TabletST
00888400 ZAROXOLYN AVT
40:36.00 IRRIGATING SOLUTIONS
WATER
Injection
00402257 STERILE WATER FOR INJ OMG02142546 STERILE WATER FOR INJ HOS
40:40.00 URICOSURIC AGENTS
SULFINPYRAZONE
200MG Tablet
00441767 APO-SULFINPYRAZONE APX
Page 87 of 1382014
Non-Insured Health BenefitsHealth Canada
48:00 RESPIRATORY TRACT AGENTS
48:10.24 LEUKOTRIENE MODIFIERS
MONTELUKAST
Limited use benefit (prior approval required).
For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
4MG Chewable Tablet
02377608 APO-MONTELUKAST APX02399865 MAR-MONTELUKAST MAR02379317 MONTELUKAST SAN02379821 MONTELUKAST PDL02382458 MONTELUKAST SIV02380749 MYLAN-MONTELUKAST MYL02354977 PMS-MONTELUKAST PMS02402793 RAN-MONTELUKAST RBY02330385 SANDOZ MONTELUKAST TEP02243602 SINGULAIR FRS02355507 TEVA- MONTELUKAST TEP
5MG Chewable Tablet
02377616 APO-MONTELUKAST APX02399873 MAR-MONTELUKAST MAR02379325 MONTELUKAST SAN02379848 MONTELUKAST PDL02382466 MONTELUKAST SIV02380757 MYLAN-MONTELUKAST MYL02354985 PMS-MONTELUKAST PMS02402807 RAN-MONTELUKAST RBY02330393 SANDOZ MONTELUKAST TEP02238216 SINGULAIR FRS02355515 TEVA- MONTELUKAST TEP
4MG Granules
02358611 SANDOZ MONTELUKAST SDZ02247997 SINGULAIR FRS
10MG Tablet
02374609 APO-MONTELUKAST APX02376695 DOM-MONTELUKAST DOM02391422 JAMP-MONTELUKAST JAP02399997 MAR-MONTELUKAST MAR02379333 MONTELUKAST SAN02379856 MONTELUKAST PDL02382474 MONTELUKAST SIV02368226 MYLAN-MONTELUKAST MYL02373947 PMS-MONTELUKAST PMS02389517 RAN-MONTELUKAST RBY02328593 SANDOZ MONTELUKAST SDZ02238217 SINGULAIR FRS02355523 TEVA- MONTELUKAST TEP
48:10.24 LEUKOTRIENE MODIFIERS
ZAFIRLUKAST
Limited use benefit (prior approval required).
For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
20MG Tablet
02236606 ACCOLATE AZC
48:10.32 MAST CELL STABILIZERS
SODIUM CROMOGLYCATE
100MG Capsule
00500895 NALCROM AVT10MG/ML Inhalation Solution (Unit Dose)
02046113 PMS-SOD CROMOGLYCATE PMS2% Nasal Solution
01950541 CROMOLYN PMS2% Ophth Solution
02009277 CROMOLYN PMS02230621 OPTICROM ALL
Page 88 of 1382014
Non-Insured Health BenefitsHealth Canada
52:00 EYE, EAR, NOSE AND THROAT
(EENT) PREPARATIONS
52:02.00 EENT - ANTIALLERGIC AGENTS
LEVOCABASTINE HCL
0.05% Nasal Spray
02020017 LIVOSTIN JNO
NEDOCROMIL SODIUM
2% Ophth Solution
02241407 ALOCRIL ALL
OLOPATADINE HCL
0.1% Ophth Solution
02305054 APO-OLOPATADINE APX02233143 PATANOL ALC02358913 SANDOZ OLOPATADINE SDZ
SODIUM CROMOGLYCATE
2% Nasal Solution
02231390 APO-CROMOLYN APX
52:04.04 EENT - ANTIBACTERIALS
BACITRACIN ZINC, POLYMYXIN B SULFATE
500IU & 10,000IU/G Ophth Ointment
02160889 OPTIMYXIN SDZ02239157 POLYSPORIN PFI
CHLORAMPHENICOL
1% Ophth Ointment
02026260 DIOCHLORAM DKT0.5% Ophth Solution
02023857 DIOCHLORAM DKT
CIPROFLOXACIN HCL
0.3% Ophth Ointment
02200864 CILOXAN ALC0.3% Ophth Solution
02263130 APO-CIPROFLOX APX01945270 CILOXAN ALC02387131 SANDOZ CIPROFLOXACIN SDZ
CIPROFLOXACIN HCL, DEXAMETHASONE
0.3%/0.1% Otic Solution
02252716 CIPRODEX ALC
ERYTHROMYCIN
5MG/G Ophth Ointment
02326663 ERYTHROMYCIN STG01912755 PMS-ERYTHROMYCIN PMS
FRAMYCETIN SULFATE
0.5% Ophth Ointment
02224895 SOFRAMYCIN STERILE EYE ERF0.5% Ophth Solution
02224887 SOFRAMYCIN ERF
GENTAMICIN SULFATE
0.3% Ophth Ointment
02023776 DIOGENT DKT
52:04.04 EENT - ANTIBACTERIALS
GENTAMICIN SULFATE
0.3% Solution
02023822 DIOGENT DKT02219581 GENTAMICIN SPH00776521 PMS-GENTAMICIN PMS
GRAMICIDIN, POLYMYXIN B SULFATE
0.025MG & 10,000U/ML Solution
00701785 OPTIMYXIN EYE/EAR SDZ02239156 POLYSPORIN EYE/EAR WLA
OFLOXACIN
0.3% Ophth Solution
02248398 APO-OFLOXACIN APX02143291 OCUFLOX ALL02247189 SANDOZ OFLOXACIN SDZ
POLYMYXIN B SULFATE, TRIMETHOPRIM
SULFATE
10,000U & 1MG/ML Ophth Solution
02240363 PMS-POLYTRIMETHOPRIM PMS02011956 POLYTRIM ALL02239234 SANDOZ POLYTRIMETHOPRIM SDZ
SULFACETAMIDE SODIUM
10% Ophth Solution
02023830 DIOSULF DKT
TOBRAMYCIN
0.3% Ophth Ointment
00614254 TOBREX ALC0.3% Ophth Solution
02241755 SANDOZ-TOBRAMYCIN SDZ00513962 TOBREX ALC
52:04.20 EENT - ANTIVIRALS
TRIFLURIDINE
1% Ophth Solution
00687456 VIROPTIC GSK
52:08.08 EENT - CORTICOSTEROIDS
BECLOMETHASONE DIPROPIONATE
50MCG/DOSE Nasal Spray
02238796 APO-BECLOMETHASONE APX02172712 GEN-BECLO AQ GEN02228300 RIVANASE AQ RIV
BETAMETHASONE SODIUM PHOSPHATE,
GENTAMICIN SULFATE
0.1% & 0.3% Ophth Ointment
00586706 GARASONE SCH
BUDESONIDE
64MCG/DOSE Nasal Spray
02241003 GEN-BUDESONIDE AQ GEN02231923 RHINOCORT AQ AZC
100MCG/DOSE Nasal Spray
02230648 GEN-BUDESONIDE AQ GEN
Page 89 of 1382014
Non-Insured Health BenefitsHealth Canada
52:08.08 EENT - CORTICOSTEROIDS
BUDESONIDE
100MCG/DOSE Powder
02035324 RHINOCORT TURBUHALER AZC
DEXAMETHASONE
0.1% Ophth Ointment
00042579 MAXIDEX ALC0.1% Ophth Solution
02023865 DIODEX DKT00785261 PMS-DEXAMETHASONE PMS00739839 SANDOZ-DEXAMETHASONE SDZ
0.1% Ophth Suspension
00042560 MAXIDEX ALC
DEXAMETHASONE, TOBRAMYCIN
0.1% & 0.3% Ophth Ointment
00778915 TOBRADEX ALC0.1% & 0.3% Ophth Suspension
00778907 TOBRADEX ALC
FLUMETHASONE PIVALATE, CLIOQUINOL
0.02% & 1% Otic Solution
00074454 LOCACORTEN VIOFORM PAL
FLUOROMETHOLONE
0.1% Ophth Solution
02238568 PMS-FLUOROMETHOLONE PMS00432814 SANDOZ FLUOROMETHOLONE SDZ
0.1% Ophth Suspension
00247855 FML ALL0.25% Ophth Suspension
00707511 FML FORTE ALL
FLUOROMETHOLONE ACETATE
0.1% Ophth Solution
00756784 FLAREX ALC
FLUTICASONE PROPIONATE
50MCG/DOSE Nasal Spray
02294745 APO-FLUTICASONE APX02213672 FLONASE GSK02296071 RATIO-FLUTICASONE RPH
FRAMYCETIN SULFATE, GRAMICIDIN,
DEXAMETHASONE
5MG & 0.05MG/ML & 0.5MG Ophth/Otic Solution
02224623 SOFRACORT EYE/EAR SAC
MOMETASONE FUROATE
50MCG Nasal Spray
02403587 APO-MOMETASONE APX02238465 NASONEX SCH
PREDNISOLONE ACETATE
0.12% Ophth Suspension
00299405 PRED MILD ALL
52:08.08 EENT - CORTICOSTEROIDS
PREDNISOLONE ACETATE
1% Ophth Suspension
00301175 PRED FORTE ALL00700401 RATIO-PREDNISOLONE RPH01916203 SANDOZ-PREDNISOLONE SDZ
PREDNISOLONE ACETATE, SULFACETAMIDE
SODIUM
0.2% & 10% Ophth Ointment
00307246 BLEPHAMIDE ALL0.5% & 10% Ophth Solution
02023814 DIOPTIMYD DKT0.2% & 10% Ophth Suspension
00807788 BLEPHAMIDE ALL
PREDNISOLONE SODIUM PHOSPHATE
0.5% Ophth Solution
02148498 PREDNISOLONE CUV
TRIAMCINOLONE ACETONIDE
55MCG/DOSE Nasal Spray
02213834 NASACORT AQ SAC
52:08.20 EENT - NONSTEROIDAL ANTI-
INFLAMMATORY AGENTS
DICLOFENAC SODIUM
0.1% Ophth Solution
01940414 VOLTAREN NVR
KETOROLAC TROMETHAMINE
0.5% Ophth Solution
01968300 ACULAR ALL02245821 APO-KETOROLAC APX
52:12.00 EENT - CONTACT LENS
SOLUTION
HYPROMELLOSE
3MG Ophth Solution
02231289 GENTEAL ARTIFICIAL TEARS NVC
52:20.00 EENT - MIOTICS
CARBACHOL
1.5% Ophth Solution
00000655 ISOPTO CARBACHOL ALC
52:24.00 EENT - MYDRIATICS
ATROPINE SULFATE
1% Ophth Solution
02023695 ATROPINE DKT02148358 ATROPINE SULPHATE MINIMS NVR00035017 ISOPTO ATROPINE ALC
CYCLOPENTOLATE HCL
0.5% Ophth Solution
02148331 CYCLOPENTOLATE NVR
Page 90 of 1382014
Non-Insured Health BenefitsHealth Canada
52:24.00 EENT - MYDRIATICS
CYCLOPENTOLATE HCL
1% Ophth Solution
00252506 CYCLOGYL ALC02148382 CYCLOPENTOLATE MINIMS NVR02023644 DIOPENTOLATE DKT
DIPIVEFRIN HCL
0.1% Ophth Solution
02242232 APO-DIPIVEFRIN APX02237868 PMS-DIPIVEFRIN PMS
HOMATROPINE HBR
2% Ophth Solution
00000779 ISOPTO HOMATROPINE ALC5% Ophth Solution
00000787 ISOPTO HOMATROPINE ALC
52:28.00 EENT - MOUTHWASHES AND
GARGLES
BENZYDAMINE HCL
Limited use benefit (prior approval required).
For:a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.b. - use in immunocompromised patients who are at risk of mucosal breakdown.
0.15% Rinse
02239044 APO-BENZYDAMINE APX02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE TEV02229777 PMS-BENZYDAMINE PMS
CHLORHEXIDINE GLUCONATE
0.12% Rinse
02240433 PERICHLOR PMS02237452 PERIDEX MMH02207796 PERIOGARD COP
52:32.00 EENT - VASOCONSTRICTORS
ANTAZOLINE PHOSPHATE, NAPHAZOLINE HCL
0.5% & 0.05% Ophth Solution
00433519 ALBALON A ALL
NAPHAZOLINE HCL
0.1% Ophth Solution
00001147 ALBALON ALL00390283 NAPHCON FORTE ALC
PHENYLEPHRINE HCL
0.12% Ophth Solution
00395161 PREFRIN LIQUIFILM ALL2.5% Ophth Solution
02027100 DIONEPHRINE DKT00465763 MYDFRIN ALC02148447 PHENYLEPHRINE MINIMS NVR
10% Ophth Solution
02148455 PHENYLEPHRINE NVR
52:40.04 EENT - ALPHA-ADRENERGIC
AGONISTS
BRIMONIDINE TARTRATE
0.2% Ophth Solution
02236876 ALPHAGAN ALL02260077 APO-BRIMONIDINE APX02246284 PMS-BRIMONIDINE PMS02243026 RATIO-BRIMONIDINE RPH02305429 SANDOZ BRIMONIDINE 0.2%
OP SOLSDZ
BRIMONIDINE TARTRATE (ALPHAGAN P)
Limited use benefit (prior approval required).
For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.
0.15% Ophth Solution
02248151 ALPHAGAN P ALL
BRIMONIDINE TARTRATE, TIMOLOL MALEATE
0.2% & 0.5% Ophth Solution
02248347 COMBIGAN ALL
52:40.08 EENT - BETA-ADRENERGIC
BLOCKING AGENTS
BETAXOLOL HCL
0.5% Ophth Solution
02235971 SANDOZ-BETAXOLOL SDZ0.25% Ophth Suspension
01908448 BETOPTIC S ALC
LEVOBUNOLOL HCL
0.25% Ophth Solution
02241575 APO-LEVOBUNOLOL APX00751286 BETAGAN ALL02031159 RATIO-LEVOBUNOLOL RPH
0.5% Ophth Solution
00637661 BETAGAN ALL02237991 PMS-LEVOBUNOLOL PMS02031167 RATIO-LEVOBUNOLOL RPH02241716 SANDOZ-LEVOBUNOLOL SDZ
TIMOLOL MALEATE
0.25% Long Acting Ophth Solution
02171880 TIMOPTIC-XE FRS0.5% Long Acting Ophth Solution
02171899 TIMOPTIC-XE FRS0.25% Ophth Gel Solution
02242275 TIMOLOL MALEATE-EX PMS0.5% Ophth Gel Solution
02242276 TIMOLOL MALEATE-EX PMS0.25% Ophth Solution
00755826 APO-TIMOP APX02048523 NOVO-TIMOL TEV02083353 PMS-TIMOLOL PMS
Page 91 of 1382014
Non-Insured Health BenefitsHealth Canada
52:40.08 EENT - BETA-ADRENERGIC
BLOCKING AGENTS
TIMOLOL MALEATE
0.5% Ophth Solution
00755834 APO-TIMOP APX02083345 PMS-TIMOLOL PMS00451207 TIMOPTIC FRS
52:40.12 EENT - CARBONIC ANHYDRASE
INHIBITORS
ACETAZOLAMIDE
250MG Tablet
00545015 APO-ACETAZOLAMIDE APX
BRINZOLAMIDE
1% Ophth Suspension
02238873 AZOPT ALC
BRINZOLAMIDE, TIMOLOL MALEATE
1% & 0.5% Ophth Suspension
02331624 AZARGA ALC
DORZOLAMIDE HCL
2% Ophth Solution
02316307 SANDOZ DORZOLAMIDE SDZ02216205 TRUSOPT FRS
DORZOLAMIDE HCL, TIMOLOL MALEATE
20MG & 5MG/ML Ophth Solution
02299615 APO-DORZO-TIMOP APX02404389 CO DORZOTIMOLOL ACT02240113 COSOPT FRS02344351 SANDOZ
DORZOLAMIDE/TIMOLOLSDZ
02320525 TEVA-DORZOTIMOL TEP
METHAZOLAMIDE
50MG Tablet
02245882 APO-METHAZOLAMIDE APX
52:40.20 EENT - MIOTICS
CARBACHOL
0.01% Ophth Solution
00042544 MIOSTAT ALC3% Ophth Solution
00000663 ISOPTO CARBACHOL ALC
PILOCARPINE HCL
4% Ophth Gel
00575240 PILOPINE HS ALC1% Ophth Solution
00000841 ISOPTO CARPINE ALC02229556 PILOCARPINE SCN
2% Ophth Solution
00000868 ISOPTO CARPINE ALC4% Ophth Solution
02023733 DIOCARPINE DKT00000884 ISOPTO CARPINE ALC
52:40.20 EENT - MIOTICS
PILOCARPINE NITRATE
2% Ophth Solution
02148463 PILOCARPINE NITRATE MINIMS
NVR
52:40.28 EENT - PROSTAGLANDIN AGENTS
BIMATOPROST
0.01% Ophth Solution
02324997 LUMIGAN RC ALL
LATANOPROST
0.005% Ophth Solution
02296527 APO-LATANOPROST APX02254786 CO LATANOPROST ACT02373041 GD-LATANOPROST PFI02367335 SANDOZ LATANOPROST SDZ02231493 XALATAN PFI
LATANOPROST, TIMOLOL MALEATE
0.005% & 0.5% Ophth Solution
02373068 GD-LATANOPROST/TIMOLOL PFI02404591 PMS-LATANOPROST-TIMOLOL PMS02394685 SANDOZ
LATANOPROST/TIMOLOLSDZ
02393921 TEVA-LATANOPROST/TIMOLOL TEP02246619 XALACOM PFI
TIMOLOL MALEATE, TRAVOPROST
0.5% & 0.004% Ophth Solution
02278251 DUO TRAV ALC
TRAVOPROST
0.004% Ophth Solution
02318008 TRAVATAN Z ALC
52:92.00 MISCELLANEOUS EENT DRUGS
APRACLONIDINE HCL
0.5% Ophth Solution
02076306 IOPIDINE ALC
DEXTRAN 70,
HYDROXYPROPYLMETHYLCELLULOSE
0.1% & 0.3% Ophth Solution
00390291 TEARS NATURALE ALC01943308 TEARS NATURALE FREE ALC00743445 TEARS NATURALE II ALC
DIPIVEFRIN HCL, LEVOBUNOLOL HCL
0.1% & 0.5% Ophth Solution
02209071 PROBETA ALL
HYDROXYPROPYLMETHYLCELLULOSE
0.5% Ophth Solution
00000809 ISOPTO TEARS ALC1% Ophth Solution
00000817 ISOPTO TEARS ALC
Page 92 of 1382014
Non-Insured Health BenefitsHealth Canada
52:92.00 MISCELLANEOUS EENT DRUGS
HYPROLOSE
5MG Ophth Solution
02250624 LACRISERT FRS
IPRATROPIUM BROMIDE
0.03% Nasal Spray
02163705 ATROVENT BOE0.06% Nasal Spray
02163713 ATROVENT BOE
LODOXAMIDE TROMETHAMINE
0.1% Ophth Solution
00893560 ALOMIDE ALC
MACROGOL, PROPYLENE GLYCOL
15% & 20% Nasal Gel
02220806 PMS-RHINARIS PMS00551805 SECARIS PMS
15% & 20% Nasal Spray
00732230 RHINARIS PMS
MINERAL OIL, PETROLATUM
80% & 20% Ophth Ointment
02125706 DUOLUBE BSH
MINERAL OIL, WHITE PETROLATUM
55.5% & 42.5% Ophth Ointment
00210889 LACRI LUBE ALL
PETROLATUM, LANOLIN, MINERAL OIL
94% & 3% & 3% Ophth Ointment
02082519 TEARS NATURALE P.M. ALC
PETROLATUM, PETROLATUM LIQUID
85% & 15% Ophth Ointment
02133288 HYPOTEARS NVR
POLYVINYL ALCOHOL
1% Ophth Solution
02133253 HYPOTEARS NVR1.4% Ophth Solution
02229570 ARTIFICIAL TEARS PMS00579408 TEARS PLUS ALL
POLYVINYL ALCOHOL, POVIDONE
1.4% & 0.6% Ophth Solution
02229632 ARTIFICIAL TEARS EXTRA PMS
52:92.00 MISCELLANEOUS EENT DRUGS
RANIBIZUMAB
Limited use benefit (prior approval required).
For the treatment of:a. Diabetic Macular Edema (DME)b. Wet Age-Related Macular Degeneration (w-AMD)Criteria for coverage of ranibizumab (Lucentis) for DME and w-AMD:• Administered by a qualified ophthalmologist experienced in intravitreal injections• Interval between doses not shorter than 1 monthNote: Coverage will be limited to a maximum of 1 vial of Lucentis per eye treated every 30 daysFor the treatment of diabetic macular edema (DME) for patients who meet the following:• Clinically significant diabetic macular edema for whom laser photocoagulation is also indicated; AND• Have a hemoglobin A1c of less than 11%Initial Coverage for the treatment of neovascular wet age-related macular degeneration (wAMD) where all of the following apply to the eye to be treated:• Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96• The lesion size is less than or equal to 12 disc areas in greatest linear dimension• There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or optical coherence tomography (OCT))Note: Coverage will not be approved for patients:• With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines.• Receiving concurrent treatment with verteporfinContinued Coverage:Treatment with Lucentis for wAMD should be continued only in people who maintain adequate response to therapyTreatment with Lucentis should be permanently discontinued if any one of the following occurs:• Reduction in BCVA in the treated eye to less than 15 letters (absolute) on two (2) consecutive visits in the treated eye, attributed toAMD in the absence of other pathology• Reductions in BCVA of 30 letters or more compared to eitherbaseline and/or best recorded level since baseline as this mayindicate either poor treatment effect, adverse events or both.• There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits.
10MG/ML Injection
02296810 LUCENTIS NOV
SODIUM CARBOXYMETHYL CELLULOSE
0.5% Ophth Solution
02049260 REFRESH PLUS ALL1% Ophth Solution
00870153 CELLUVISC ALL10MG/ML Ophth Solution
02244650 REFRESH LIQUIGEL ALL0.5% Ophth Solution (Multi-Dose)
02231008 REFRESH TEARS ALL
SODIUM CHLORIDE
0.7% Nasal Solution
00857777 OTRIVIN SALINE NVC
Page 93 of 1382014
Non-Insured Health BenefitsHealth Canada
52:92.00 MISCELLANEOUS EENT DRUGS
SODIUM CHLORIDE
0.7% Nasal Spray
00810436 OTRIVIN SALINE NVC9MG/ML Nasal Spray
80024381 SALINEX SDZ80024901 SALINEX DROPS SDZ
5% Ophth Ointment
00750816 MURO-128 BSH5% Ophth Solution
00750824 MURO-128 BSH
TIMOLOL MALEATE
0.25% Ophth Solution
02238770 DOM-TIMOLOL DPC0.5% Ophth Solution
02238771 DOM-TIMOLOL DPC
VERTEPORFIN
Limited use benefit (prior approval required).
For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.
15MG/VIAL Injection
02242367 VISUDYNE QLT
Page 94 of 1382014
Non-Insured Health BenefitsHealth Canada
56:00 GASTROINTESTINAL DRUGS
56:04.00 ANTACIDS AND ADSORBENTS
BISMUTH SUBSALICYLATE
17.6MG/ML Liquid
02097079 PEPTO BISMOL PGI262MG Tablet
02177994 PEPTO BISMOL PGI
MAG OXIDE
420MG Tablet
00299448 MAGNESIUM OXIDE SWS
56:08.00 ANTIDIARRHEA AGENTS
LOPERAMIDE HCL
0.2MG/ML Liquid
02192667 DIARR-EZE PMS02016095 PMS-LOPERAMIDE PMS
2MG/15ML Oral Solution
02291800 IMODIUM JNO2MG Tablet
02170272 ANTI-DIARRHEAL STA02212005 APO-LOPERAMIDE APX02229552 DIARR-EZE PMS02256452 DIARRHEA RELIEF VTH02239535 DOM-LOPERAMIDE DPC02183862 IMODIUM MCL02225182 LOPERAMIDE PDL02132591 NOVO-LOPERAMIDE TEV02228351 PMS-LOPERAMIDE PMS02238211 RIVA-LOPERAMIDE RIV02257564 SANDOZ-LOPERAMIDE SDZ
56:12.00 CATHARTICS AND LAXATIVES
BISACODYL
5MG Delayed Release Tablet
02273411 BISACODYL-ODAN ODN5MG Enteric Coated Tablet
00545023 APO-BISACODYL APX00714488 BISACOLAX ICN00254142 DULCOLAX BOE00587273 PMS-BISACODYL PMS
5MG Suppository
00003867 DULCOLAX BOE10MG Suppository
00261327 BISACOLAX ICN00003875 DULCOLAX BOE00582883 PMS-BISACODYL PMS00404802 RATIO-BISACODYL RPH02229743 SOFLAX EX PMS
5MG Tablet
02246039 JAMP-BISACODYL JAP
BISACODYL (POLYETHYLENE GLYCOL BASE)
10MG Suppository
02241091 MAGIC BULLET DCM
56:12.00 CATHARTICS AND LAXATIVES
CITRIC ACID, MAGNESIUM OXIDE, SODIUM
PICOSULFATE
Powder
02254794 PICO-SALAX FEI02317966 PURG-ODAN ODN
DIOCTYL CALCIUM SULFOSUCCINATE
240MG CapsuleST
02245080 APO-DOCUSATE CALCIUM APX00830275 DOCUSATE CALCIUM TAR00842044 NOVO-DOCUSATE CALCIUM TEV00664553 PMS-DOCUSATE CALCIUM PMS00809055 RATIO-DOCUSATE CALCIUM RPH
DIOCTYL SODIUM SULFOSUCCINATE
100MG CapsuleST
02245079 APO-DOCUSATE SODIUM APX02106256 COLACE WPC00716731 DOCUSATE SODIUM TAR00794406 DOCUSATE SODIUM SDR00830267 DOCUSATE SODIUM TRI02246036 DOCUSATE SODIUM RPH02239658 DOM-DOCUSATE SODIUM DPC02247385 EURO-DOCUSATE EUO02020084 NOVO-DOCUSATE TEV00703494 PMS-DOCUSATE SODIUM PMS00870196 RATIO-DOCUSATE SODIUM RPH00514888 SELAX ODN01994344 SOFLAX PMS
200MG CapsuleST
02029529 SOFLAX PMS250MG Capsule
ST
02006596 SELAX ODN10MG/ML Drop
ST
02090163 COLACE WPC00870218 DOCUSATE SODIUM RPH00880140 PMS-SODIUM DOCUSATE PMS02006723 SOFLAX PMS
4MG/ML SyrupST
02086018 COLACE WPC00703508 PMS-DOCUSATE SODIUM PMS00870226 RATIO-DOCUSATE SODIUM RPH02006758 SOFLAX SYRUP PMS
50MG/ML SyrupST
00848417 PMS-DOCUSATE SODIUM PMS
DIOCTYL SODIUM SULFOSUCCINATE, SENNA
50MG & 187MG TabletST
00026123 SENOKOT S PFR
DIOCTYL SODIUM SULFOSUCCINATE,
SENNOSIDES
50MG & 8.6MG TabletST
02247390 EURO-SENNA S EUR
Page 95 of 1382014
Non-Insured Health BenefitsHealth Canada
56:12.00 CATHARTICS AND LAXATIVES
DOCUSATE CALCIUM
240MG CapsuleST
02283255 JAMP-DOCUSATE CALCIUM JAP
DOCUSATE SODIUM
100MG CapsuleST
02245946 DOCUSATE SODIUM JAP02326086 DOCUSATE SODIUM PDL02303825 EURO-DOCUSATE C EUR02281031 STOOL SOFTENER PMS02357305 STOOL SOFTENER VTH
4MG/ML SyrupST
02238283 DOCUSATE SODIUM ATL02283239 DOCUSATE SODIUM JAP00695033 SELAX ODN
50MG/ML SyrupST
02283220 DOCUSATE SODIUM JAP
GLYCERIN
Adult Suppository
02020394 GLYCERIN TCH80029765 JAMP GLYCERIN JAP
GLYCERINE
Adult Suppository
00873462 GLYCERIN RPH *01926039 GLYCERIN WLA
Pediatric Suppository
02020815 GLYCERIN INFANT RPH01926047 GLYCERIN INFANT & CHILD PFI
MACROGOL, POTASSIUM CHLORIDE, SODIUM
BICARBONATE, SODIUM CHLORIDE, SODIUM
SULFATE
60G & 750MG & 1.68G & 1.46G & 5.68G/L Powder
00677442 COLYTE ZYM00652512 GOLYTELY BAX00777838 PEGLYTE PMS
MAGNESIUM CITRATE
50MG/ML Oral Liquid
00262609 CITRO MAG TCH
MAGNESIUM HYDROXIDE
80MG/ML Liquid
02150646 MILK OF MAGNESIA PLAIN/SUGARFREE
BCD
80MG/ML Oral Liquid
02245289 MILK OF MAGNESIA PMS311MG Tablet
02150638 MILK OF MAGNESIA BCD
MINERAL OIL
78% Jelly
00608734 LANSOYL GEL AXC02186926 LANSOYL GEL SUGARFREE AXC
56:12.00 CATHARTICS AND LAXATIVES
MINERAL OIL
Liquid
01935348 MINERAL OIL (HEAVY) 100% USP
RWP
PLANTAGO SEED
50% Powder
00599875 MUCILLIUM PMS
POLYETHYLENE GLYCOL & ELECTROL
Oral Liquid
02326302 BI-PEGLYTE TROUSSE PEI
POLYETHYLENE GLYCOL 3350
1G/G Powder
02317680 LAX-A-DAY 1G/G PDR PED02358034 PEG 3350 PDR MDS
POLYETHYLENE GLYCOL, POTASSIUM
CHLORIDE, SODIUM BICARBONATE, SODIUM
CHLORIDE, SODIUM SULFATE
Oral Liquid
02147793 KLEAN-PREP RVX
PSYLLIUM HYDROPHILIC MUCILLOID
680MG/G Powder
02174812 METAMUCIL ORIGINAL TEXTURE
PGI
02174790 METAMUCIL SM TEXT ORANGE PGI02174782 METAMUCIL SM TEXT
ORANGE S/FPGI
02174804 METAMUCIL SM TEXT UNFLAV PGI
SENNOSIDES
1.7MG/ML LiquidST
02144379 SENNALAX PMS02084651 SENNAPREP PMS00367729 SENOKOT PFR
1.7MG/ML Oral LiquidST
80024394 JAMP-SENNAQUIL JAP8.6MG Tablet
ST
02247389 EURO-SENNA EUR80009595 JAMP-SENNA JAP80043280 M-SENNOSIDES MAN00896411 PMS-SENNOSIDES PMS01949292 RIVA-SENNA RIV02237105 SENNA LAXATIVE SDR02068109 SENNATAB PMS00026158 SENOKOT PFR
12MG TabletST
00896403 PMS-SENNOSIDES PMS
SODIUM CITRATE, SODIUM LAURYL
SULFOACETATE, SORBITOL
90MG & 9MG & 625MG Enema
02063905 MICROLAX PMS
Page 96 of 1382014
Non-Insured Health BenefitsHealth Canada
56:12.00 CATHARTICS AND LAXATIVES
SODIUM PHOSPHATE DIBASIC, SODIUM
PHOSPHATE MONOBASIC
180MG & 480MG/ML Oral Liquid
02230399 PMS-PHOSPHATES SOLUTION PMS60MG & 160MG/ML Rectal Liquid
02096900 ENEMOL DPC00009911 FLEET ENEMA FRS
60MG & 160MG/ML PED Rectal Liquid
00108065 FLEET ENEMA PEDIATRIC JAJ
56:14.00 CHOLELITHOLYTIC AGENTS
URSODIOL
250MG TabletST
02281317 PHL-URSODIOL C PMI02273497 PMS-URSODIOL PMS02238984 URSO AXC
500MG TabletST
02281325 PHL-URSODIOL C PMI02273500 PMS-URSODIOL PMS02245894 URSO DS AXC
56:16.00 DIGESTANTS
ANETHOLE
25MG Tablet
02240344 SIALOR PAL
LACTASE
Oral Liquid
99100157 LACTEEZE DROPS AUT3,000U Tablet
02200384 DAIRY DIGESTIVE PER02239139 DAIRY DIGESTIVE SDR02017512 DAIRY FREE KIN01951637 DAIRYAID TAN02230653 LACTAID JNO
4,500U Tablet
02239140 DAIRY DIGESTIVE EXTRA STRENGTH
SDR
02224909 DAIRY FREE EXTRA STRENGTH
KIN
02230654 LACTAID EXTRA STRENGTH JNO
LIPASE, AMYLASE, PROTEASE
5,000U & 16,600U & 18,750U CapsuleST
02239007 CREON 5 MINIMICROSPHERES SPH8,000U & 30,000U & 30,000U Capsule
ST
00263818 COTAZYM ORG20,000U & 66,400U & 75,000U Capsule
ST
02239008 CREON 20 MINIMICROSPHERES
SPH
4,000U & 12,000U & 12,000U Capsule (Enteric Coated
Particles)
ST
00789445 PANCREASE MT 4 JNO4,500U & 20,000U & 25,000U Capsule (Enteric Coated
Particles)
ST
02203324 ULTRASE MS 4 AXC
56:16.00 DIGESTANTS
LIPASE, AMYLASE, PROTEASE
8,000U & 30,000U & 30,000U Capsule (Enteric Coated
Particles)
ST
00502790 COTAZYM ECS 8 ORG10,000U & 30,000U & 30,000U Capsule (Enteric Coated
Particles)
ST
00789437 PANCREASE MT 10 JNO10,000U & 33,200U & 37,500U Capsule (Enteric Coated
Particles)
ST
02200104 CREON 10 MINIMICROSPHERES
SPH
12,000U & 39,000U & 39,000U Capsule (Enteric Coated
Particles)
ST
02045834 ULTRASE MT 12 AXC16,000U & 48,000U & 48,000U Capsule (Enteric Coated
Particles)
ST
00789429 PANCREASE MT 16 JNO20,000U & 55,000U & 55,000U Capsule (Enteric Coated
Particles)
ST
00821373 COTAZYM ECS 20 ORG20,000U & 65,000 & 65,000U Capsule (Enteric Coated
Particles)
ST
02045869 ULTRASE MT 20 AXC25,000U & 74,000U & 62,500U Capsule (Enteric Coated
Particles)
ST
01985205 CREON 25 MINIMICROSPHERES
SPH
8,000U & 30,000U & 30,000U TabletST
02230019 VIOKASE AXC16,000U & 60,000U & 60,000U Tablet
ST
02241933 VIOKASE AXC
56:20.00 EMETICS
IPECAC
14MG/ML Syrup
00378801 IPECAC XEN
56:22.08 ANTIHISTAMINES
DIMENHYDRINATE
50MG/ML Injection
00392537 DIMENHYDRINATE SDZ00013579 GRAVOL HOR
3MG/ML Liquid
00230197 GRAVOL HOR25MG Suppository
00783595 GRAVOL HOR50MG Suppository
00392553 DIMENHYDRINATE SIL100MG Suppository
00013609 GRAVOL ADULT HOR15MG Tablet
00511196 GRAVOL HOR
Page 97 of 1382014
Non-Insured Health BenefitsHealth Canada
56:22.08 ANTIHISTAMINES
DIMENHYDRINATE
50MG Tablet
00363766 APO-DIMENHYDRINATE APX00013803 GRAVOL HOR02245416 JAMP-DIMENHYDRINATE JAP00399779 NAUSEATOL SIL00021423 NOVODIMENATE TEV00586331 PMS-DIMENHYDRINATE PMS00605786 TRAVEL AID VTH
DOXYLAMINE SUCCINATE, PYRIDOXINE HCL
10MG & 10MG Tablet
00609129 DICLECTIN DUI
56:22.20 5-HT3 RECEPTOR ANTAGONISTS
DOLASETRON MESYLATE
100MG Tablet
02231379 ANZEMET SAC
GRANISETRON
1MG Tablet
02308894 GRANISETRON AAP02185881 KYTRIL HLR
ONDANSETRON HCL DIHYDRATE
4MG/CM Film
02389983 ONDISSOLVE ODF TAK8MG/CM Film
02389991 ONDISSOLVE ODF TAK0.8MG/ML Liquid
02229639 ZOFRAN GSK4MG Tablet
02288184 APO-ONDANSETRON APX02296349 CO-ONDANSETRON ACT02313685 JAMP-ONDANSETRON JAP02371731 MAR-ONDANSETRON MAR02297868 MYLAN-ONDANSETRON MYL02264056 NOVO-ONDANSETRON TEV02306212 ONDANSETRON-ODAN ODN02278618 PHL-ONDANSETRON PMI02258188 PMS-ONDANSETRON PMS02278529 RATIO-ONDANSETRON RPH02274310 SANDOZ-ONDANSETRON SDZ02376091 SEPTA-ONDANSETRON SPT02213567 ZOFRAN GSK02239372 ZOFRAN ODT GSK02344440 ZYM-ONDANSETRON ZYM
56:22.20 5-HT3 RECEPTOR ANTAGONISTS
ONDANSETRON HCL DIHYDRATE
8MG Tablet
02288192 APO-ONDANSETRON APX02296357 CO-ONDANSETRON ACT02313693 JAMP-ONDANSETRON JAP02371758 MAR-ONDANSETRON MAR02297876 MYLAN-ONDANSETRON MYL02264064 NOVO-ONDANSETRON TEV02325160 ONDANSETRON PDL02306220 ONDANSETRON-ODAN ODN02278626 PHL-ONDANSETRON PMI02258196 PMS-ONDANSETRON PMS02278537 RATIO-ONDANSETRON RPH02274329 SANDOZ-ONDANSETRON SDZ02376105 SEPTA-ONDANSETRON SPT02213575 ZOFRAN GSK02239373 ZOFRAN ODT GSK02344459 ZYM-ONDANSETRON ZYM
56:22.92 MISCELLANEOUS ANTIEMETICS
NABILONE
Limited use benefit (prior approval required).
• For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation;
OR
• patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
0.25MG Capsule
02312263 CESAMET VAE02358077 RAN-NABILONE RBY02392925 TEVA-NABILONE TEP
0.5MG Capsule
02256193 CESAMET VAE02393581 CO NABILONE ACT02380900 PMS-NABILONE PMS02358085 RAN-NABILONE RBY02384884 TEVA-NABILONE TEP
1MG Capsule
00548375 CESAMET VAE02393603 CO NABILONE ACT02380919 PMS-NABILONE PMS02358093 RAN-NABILONE RBY02384892 TEVA-NABILONE TEP
56:28.12 HISTAMINE H2-ANTAGONISTS
CIMETIDINE
200MG TabletST
00584215 APO-CIMETIDINE APX00582409 NOVO-CIMETINE TEV02229717 PMS-CIMETIDINE PMS
Page 98 of 1382014
Non-Insured Health BenefitsHealth Canada
56:28.12 HISTAMINE H2-ANTAGONISTS
CIMETIDINE
300MG TabletST
00487872 APO-CIMETIDINE APX02231287 DOM-CIMETIDINE DPC02227444 GEN-CIMETIDINE GEN00582417 NOVO-CIMETINE TEV02229718 PMS-CIMETIDINE PMS
400MG TabletST
00600059 APO-CIMETIDINE APX02231288 DOM-CIMETIDINE DPC02227452 GEN-CIMETIDINE GEN00603678 NOVO-CIMETINE TEV02229719 PMS-CIMETIDINE PMS
600MG TabletST
00600067 APO-CIMETIDINE APX00618705 CIMETIDINE PDL02231290 DOM-CIMETIDINE DPC02227460 GEN-CIMETIDINE GEN00603686 NOVO-CIMETINE TEV02229720 PMS-CIMETIDINE PMS
800MG TabletST
00749494 APO-CIMETIDINE APX02227479 GEN-CIMETIDINE GEN00663727 NOVO-CIMETINE TEV02229721 PMS-CIMETIDINE PMS
FAMOTIDINE
20MG TabletST
01953842 APO-FAMOTIDINE APX02351102 FAMOTIDINE SAN02196018 GEN-FAMOTIDINE GEN02022133 NOVO-FAMOTIDINE TEV02237148 ULCIDINE VAE
40MG TabletST
01953834 APO-FAMOTIDINE APX02351110 FAMOTIDINE SAN02196026 GEN-FAMOTIDINE GEN02022141 NOVO-FAMOTIDINE TEV02237149 ULCIDINE VAE
NIZATIDINE
150MG CapsuleST
02220156 APO-NIZATIDINE APX00778338 AXID PHH02185814 DOM-NIZATIDINE DPC02240457 NOVO-NIZATIDINE TEV02177714 PMS-NIZATIDINE PMS
300MG CapsuleST
02220164 APO-NIZATIDINE APX00778346 AXID PHH02238195 NIZATIDINE PHH02240458 NOVO-NIZATIDINE TEV02177722 PMS-NIZATIDINE PMS
56:28.12 HISTAMINE H2-ANTAGONISTS
RANITIDINE HCL
15MG/ML Oral SolutionST
02280833 APO-RANITIDINE APX02242940 NOVO-RANITIDINE TEV
150MG TabletST
00733059 APO-RANITIDINE APX02248570 CO-RANITIDINE ACT02207761 GEN-RANITIDINE GEN02293471 MAXIMUM STRENGTH ACID
REDUCERPMS
02367378 MYL-RANITIDINE MYL00828564 NOVO-RANIDINE TEV02242453 PMS-RANITIDINE PMS00740748 RANITIDINE PDL02353016 RANITIDINE SAN02385953 RANITIDINE SIV02336480 RAN-RANITIDINE RBY00828823 RATIO-RANITIDINE RPH02245782 RIVA-RANITIDINE PHH02247814 RIVA-RANTIDINE RIV02243229 SANDOZ-RANITIDINE SDZ02212331 ZANTAC GSK
300MG TabletST
00733067 APO-RANITIDINE APX02248571 CO-RANITIDINE ACT02207788 GEN-RANITIDINE GEN02367386 MYL-RANITIDINE MYL02242454 PMS-RANITIDINE PMS00740756 RANITIDINE PDL02353024 RANITIDINE SAN02385961 RANITIDINE SIV02336502 RAN-RANITIDINE RBY00828688 RATIO-RANITIDINE RPH02245783 RIVA-RANITIDINE PHH02247815 RIVA-RANITIDINE RIV02243230 SANDOZ-RANITIDINE SDZ02212358 ZANTAC GSK
56:28.28 PROSTAGLANDINS
MISOPROSTOL
100MCG TabletST
02244022 APO-MISOPROSTOL APX200MCG Tablet
ST
02244023 APO-MISOPROSTOL APX02244125 PMS-MISOPROSTOL PMS
56:28.32 PROTECTANTS
SUCRALFATE
200MG/ML SuspensionST
02103567 SULCRATE PLUS AXC1G Tablet
ST
02125250 APO-SUCRALFATE APX02045702 NOVO-SUCRALATE TEV02130939 SUCRALFATE-1 PDL02100622 SULCRATE AXC
Page 99 of 1382014
Non-Insured Health BenefitsHealth Canada
56:28.36 PROTON-PUMP INHIBITORS
AMOXICILLIN, CLARITHROMYCIN,
LANSOPRAZOLE
500MG & 500MG & 30MG Kit
02238525 HP-PAC ABB
LANSOPRAZOLE
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
15MG Sustained Release CapsuleST
02293811 APO-LANSOPRAZOLE APX02357682 LANSOPRAZOLE SAN02385767 LANSOPRAZOLE SIV02353830 MYLAN-LANSOPRAZOLE MYL02395258 PMS-LANSOPRAZOLE PMS02165503 PREVACID ABB02402610 RAN-LANSOPRAZOLE RBY02385643 SANDOZ LANSOPRAZOLE SDZ02280515 TEVA-LANSOPRAZOLE TEP
30MG Sustained Release CapsuleST
02293838 APO-LANSOPRAZOLE APX02357690 LANSOPRAZOLE SAN02366282 LANSOPRAZOLE PDL02385775 LANSOPRAZOLE SIV02410389 LANSOPRAZOLE SIV02353849 MYLAN-LANSOPRAZOLE MYL02395266 PMS-LANSOPRAZOLE PMS02165511 PREVACID ABB02402629 RAN-LANSOPRAZOLE RBY02385651 SANDOZ LANSOPRAZOLE SDZ02280523 TEVA-LANSOPRAZOLE TEP
LANSOPRAZOLE ODT
(Please refer to Appendix A).
Limited use benefit (prior approval required).
Coverage will be limited to 400 tablets/capsules every 180 days.•For children 12 years of age or under who are unable to swallow the capsule formulation•For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.
15MG Delayed Release TabletST
02249464 PREVACID FASTAB TAK30MG Delayed Release Tablet
ST
02249472 PREVACID FASTAB TAK
56:28.36 PROTON-PUMP INHIBITORS
OMEPRAZOLE
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Delayed Release CapsuleST
02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ
20MG Delayed Release CapsuleST
02245058 APO-OMEPRAZOLE APX00846503 LOSEC AZC02329433 MYLAN-OMEPRAZOLE GEN02339927 OMEPRAZOLE PDL02348691 OMEPRAZOLE SAN02385384 OMEPRAZOLE SIV02411857 OMEPRAZOLE SIV02320851 PMS-OMEPRAZOLE PMS02403617 RAN-OMEPRAZOLE RBY02296446 SANDOZ OMEPRAZOLE SDZ
20MG Delayed Release TabletST
02333430 DOM-OMEPRAZOLE DR DOM02190915 LOSEC AZC02310260 PMS-OMEPRAZOLE DR PMS02374870 RAN-OMEPRAZOLE RBU02260867 RATIO-OMEPRAZOLE RPH02295415 TEVA-OMEPRAZOLE TEP
OMEPRAZOLE (PA)
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Delayed Release TabletST
02230737 LOSEC AZC02260859 RATIO-OMEPRAZOLE RPH
Page 100 of 1382014
Non-Insured Health BenefitsHealth Canada
56:28.36 PROTON-PUMP INHIBITORS
PANTOPRAZOLE
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
40MG Delayed Release TabletST
02300486 ACT PANTOPRAZOLE ACT02292920 APO-PANTOPRAZOLE APX02310007 DOM-PANTOPRAZOLE DOM02299585 MYLAN-PANTOPRAZOLE MYL02309866 PANTOPRAZOLE MEL02310201 PANTOPRAZOLE SOR02318695 PANTOPRAZOLE PDL02370808 PANTOPRAZOLE SAN02385759 PANTOPRAZOLE SIV02307871 PMS-PANTOPRAZOLE PMS02316463 RIVA-PANTOPRAZOLE RIV02301083 SANDOZ-PANTOPRAZOLE SDZ02285487 TEVA-PANTOPRAZOLE TEP
40MG Enteric Coated TabletST
02229453 PANTOLOC NCC02305046 RAN-PANTOPRAZOLE RBL
PANTOPRAZOLE MAGNESIUM
40MG Tablet
02267233 TECTA TAK
RABEPRAZOLE SODIUM
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Enteric Coated TabletST
02345579 APO-RABEPRAZOLE APX02408392 MYLAN-RABEPRAZOLE MYL02296632 NOVO-RABEPRAZOLE TEV02243796 PARIET EC JNO02381737 PAT-RABEPRAZOLE EC KLA02310805 PMS-RABEPRAZOLE EC PMS02315181 PRO-RABEPRAZOLE PDL02356511 RABEPRAZOLE SAN02385449 RABEPRAZOLE SIV02298074 RAN-RABEPRAZOLE RBY02330083 RIVA-RABEPRAZOLE EC RIV02314177 SANDOZ-RABEPRAZOLE SDZ
56:28.36 PROTON-PUMP INHIBITORS
RABEPRAZOLE SODIUM
(Please refer to Appendix A).
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
20MG Enteric Coated TabletST
02345587 APO-RABEPRAZOLE APX02320460 DOM-RABEPRAZOLE DOM02408406 MYLAN-RABEPRAZOLE MYL02296640 NOVO-RABEPRAZOLE TEV02243797 PARIET EC JNO02381745 PAT-RABEPRAZOLE EC KLA02310813 PMS-RABEPRAZOLE EC PMS02315203 PRO-RABEPRAZOLE PDL02356538 RABEPRAZOLE SAN02385457 RABEPRAZOLE SIV02298082 RAN-RABEPRAZOLE RBY02330091 RIVA-RABEPRAZOLE EC RIV02314185 SANDOZ-RABEPRAZOLE SDZ
56:32.00 PROKINETIC AGENTS
DOMPERIDONE MALEATE
10MG Tablet
02103613 APO-DOMPERIDONE APX02238315 DOM-DOMPERIDONE DPC02236857 DOMPERIDONE PDL02238341 DOMPERIDONE SIV02350440 DOMPERIDONE SAN02278669 GEN-DOMPERIDONE GEN02369206 JAMP-DOMPERIDONE JAP02157195 NOVO-DOMPERIDONE TEV02236466 PMS-DOMPERIDONE PMS02268078 RAN-DOMPERIDONE RBY01912070 RATIO-DOMPERIDONE RPH
METOCLOPRAMIDE HCL
1MG/ML Oral Liquid
02230433 PMS-METOCLOPRAMIDE PMS5MG Tablet
00842826 APO-METOCLOP APX02230431 PMS-METOCLOPRAMIDE PMS
10MG Tablet
00842834 APO-METOCLOP APX02230432 PMS-METOCLOPRAMIDE PMS
56:36.00 ANTI-INFLAMMATORY AGENTS
5-AMINOSALICYLIC ACID
500MG Delayed Release TabletST
02099683 PENTASA FEI800MG Delayed Release Tablet
ST
02267217 ASACOL WAC2G/60G Enema
02112795 SALOFALK AXC4G/60G Enema
02112809 SALOFALK AXC
Page 101 of 1382014
Non-Insured Health BenefitsHealth Canada
56:36.00 ANTI-INFLAMMATORY AGENTS
5-AMINOSALICYLIC ACID
400MG Enteric Coated TabletST
01997580 ASACOL WAC500MG Enteric Coated Tablet
ST
02112787 SALOFALK AXC500MG Suppository
ST
02112760 SALOFALK AXC
MESALAZINE
1G/100ML Enema
02153521 PENTASA FEI4G/100ML Enema
02153556 PENTASA FEI400MG Enteric Coated Tablet
ST
02171929 NOVO 5-ASA TEV500MG Enteric Coated Tablet
ST
01914030 MESASAL GSK1.2G Extended Release Tablet
ST
02297558 MEZAVANT BCM1G Suppository
ST
02153564 PENTASA FEI1000MG Suppository
ST
02242146 SALOFALK AXC
OLSALAZINE SODIUM
250MG CapsuleST
02063808 DIPENTUM LUD
Page 102 of 1382014
Non-Insured Health BenefitsHealth Canada
60:00 GOLD COMPOUNDS
60:00.00 GOLD COMPOUNDS
AURANOFIN
3MG Capsule
01916823 RIDAURA SQU
SODIUM AUROTHIOMALATE
10MG/ML Injection
01927620 MYOCHRYSINE SAC02245456 SODIUM AUROTHIOMALATE SDZ
25MG/ML Injection
01927612 MYOCHRYSINE SAC50MG/ML Injection
02245458 SODIUM AUROTHIOMALATE SDZ
Page 103 of 1382014
Non-Insured Health BenefitsHealth Canada
64:00 HEAVY METAL ANTAGONISTS
64:00.00 HEAVY METAL ANTAGONISTS
PENICILLAMINE
250MG Capsule
00016055 CUPRIMINE FRS
Page 104 of 1382014
Non-Insured Health BenefitsHealth Canada
68:00 HORMONES AND SYNTHETIC
SUBSTITUTES
68:04.00 ADRENALS
BECLOMETHASONE DIPROPIONATE
50MCG Inhaler CFC-Free
02242029 QVAR MMH100MCG Inhaler CFC-Free
02242030 QVAR MMH
BUDESONIDE
0.125MG/ML Inhalation Solution
02229099 PULMICORT NEBUAMP AZC0.25MG/ML Inhalation Solution
01978918 PULMICORT NEBUAMP AZC0.5MG/ML Inhalation Solution
01978926 PULMICORT NEBUAMP AZC100MCG Powder for Inhalation
00852074 PULMICORT TURBUHALER AZC200MCG Powder for Inhalation
00851752 PULMICORT TURBUHALER AZC400MCG Powder for Inhalation
00851760 PULMICORT TURBUHALER AZC
CICLESONIDE
100MG/ACT Inhaler
02285606 ALVESCO NCC200MG/ACT Inhaler
02285614 ALVESCO NCC
CORTISONE ACETATE
25MG Tablet
00280437 CORTISONE VAE
DEXAMETHASONE
0.1MG/ML Elixir
01946897 PMS-DEXAMETHASONE PMS0.5MG Tablet
02261081 APO-DEXAMETHASONE APX00295094 DEXASONE VAE02237044 PHL-DEXAMETHASONE PHH01964976 PMS-DEXAMETHASONE PMS02240684 RATIO-DEXAMETHASONE RPH
0.75MG Tablet
00285471 DEXASONE VAE01964968 PMS-DEXAMETHASONE PMS
2MG Tablet
02279363 PMS-DEXAMETHASONE PMS4MG Tablet
02250055 APO-DEXAMETHASONE APX00489158 DEXASONE VAE02237046 PHL-DEXAMETHASONE PHH01964070 PMS-DEXAMETHASONE PMS02311267 PRO-DEXAMETHASONE PRO02240687 RATIO-DEXAMETHASONE RPH
68:04.00 ADRENALS
DEXAMETHASONE PHOSPHATE
4MG/ML Injection
00664227 DEXAMETHASONE SDZ01977547 DEXAMETHASONE CYX02204266 DEXAMETHASONE-OMEGA OMG
10MG/ML Injection
00874582 DEXAMETHASONE SDZ02204274 DEXAMETHASONE-OMEGA OMG00783900 PMS-DEXAMETHASONE PMS
FLUDROCORTISONE ACETATE
0.1MG Tablet
02086026 FLORINEF SHI
FLUTICASONE PROPIONATE
50MCG/INHALATION Inhaler HFA
02244291 FLOVENT HFA 50 GSK125MCG/INHALATION Inhaler HFA
02244292 FLOVENT HFA 125 GSK250MCG/INHALATION Inhaler HFA
02244293 FLOVENT HFA 250 GSK50MCG/DOSE Powder Diskus
02237244 FLOVENT DISKUS GSK100MCG/DOSE Powder Diskus
02237245 FLOVENT DISKUS GSK250MCG/DOSE Powder Diskus
02237246 FLOVENT DISKUS GSK500MCG/DOSE Powder Diskus
02237247 FLOVENT DISKUS GSK
HYDROCORTISONE
10MG Tablet
00030910 CORTEF PFI20MG Tablet
00030929 CORTEF PFI
METHYLPREDNISOLONE
4MG Tablet
00030988 MEDROL PFI16MG Tablet
00036129 MEDROL PFI
METHYLPREDNISOLONE ACETATE
40MG/ML Suspension for Injection
00030759 DEPO-MEDROL PMJ02245400 METHYLPREDNISOLONE
ACETATESDZ
02245407 METHYLPREDNISOLONE ACETATE
SDZ
80MG/ML Suspension for Injection
00030767 DEPO-MEDROL PMJ02245406 METHYLPREDNISOLONE
ACETATESDZ
02245408 METHYLPREDNISOLONE ACETATE
SDZ
20MG/ML Suspension for Injection (Multi-Dose)
01934325 DEPO-MEDROL PMJ
Page 105 of 1382014
Non-Insured Health BenefitsHealth Canada
68:04.00 ADRENALS
METHYLPREDNISOLONE ACETATE
40MG/ML Suspension for Injection (Multi-Dose)
01934333 DEPO-MEDROL PMJ80MG/ML Suspension for Injection (Multi-Dose)
01934341 DEPO-MEDROL PMJ
MOMETASONE FUROATE
200MCG Powder for Inhalation
02243595 ASMANEX TWISTHALER FRS400MCG Powder for Inhalation
02243596 ASMANEX TWISTHALER FRS
PREDNISOLONE SODIUM PHOSPHATE
1MG/ML Oral Liquid
02230619 PEDIAPRED AVT02245532 PMS-PREDNISOLONE PMS
PREDNISONE
1MG Tablet
00598194 APO-PREDNISONE APX00271373 WINPRED VAE
5MG Tablet
00312770 APO-PREDNISONE APX00156876 PREDNISONE PRO
50MG Tablet
00550957 APO-PREDNISONE APX00232378 NOVO-PREDNISONE TEV00607517 PREDNISONE PRO
TRIAMCINOLONE ACETONIDE
10MG/ML Suspension for Injection
01999761 KENALOG-10 WSB02229540 TRIAMCINOLONE SDZ
40MG/ML Suspension for Injection
01999869 KENALOG-40 WSB02229550 TRIAMCINOLONE SDZ09857128 TRIAMCINOLONE ACETONIDE
(5ML)SIL
TRIAMCINOLONE DIACETATE
40MG/ML Suspension for Injection
01977555 STERILE TRIAMCINOLONE CYX
TRIAMCINOLONE HEXACETONIDE
20MG/ML Suspension for Injection
02194155 ARISTOSPAN VAO
68:08.00 ANDROGENS
DANAZOL
50MG Capsule
02018144 CYCLOMEN SAC100MG Capsule
02018152 CYCLOMEN SAC200MG Capsule
02018160 CYCLOMEN SAC
68:08.00 ANDROGENS
TESTOSTERONE CYPIONATE
100MG/ML Injection
00030783 DEPO-TESTOSTERONE PFI02246063 TESTOSTERONE CYPIONATE SDZ
TESTOSTERONE ENANTHATE
200MG/ML Injection
00029246 DELATESTRYL BMS00739944 PMS-TESTOSTERONE PMS
TESTOSTERONE UNDECANOATE
40MG Capsule
00782327 ANDRIOL ORG02322498 PMS-TESTOSTERONE PMS
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL, DESOGESTREL
25MCG & 150MCG (21) Tablet
02272903 LINESSA (21) ORG25MCG & 150MCG (28) Tablet
02257238 LINESSA (28) ORG30MCG & 150MCG (21) Tablet
02317192 APRI (21) TEP02396491 FREYA (21) FAM02042487 MARVELON (21) ORG02410249 MIRVALA (21) APX
30MCG & 150MCG (28) Tablet
02317206 APRI (28) TEP02396610 FREYA (28) FAM02042479 MARVELON (28) ORG02410257 MIRVALA (28) APX02042533 ORTHO CEPT (28) JNO
ETHINYL ESTRADIOL, DROSPIRENONE
30MCG & 2MG (28) Tablet
02321157 YAZ BAY30MCG & 3MG (21) Tablet
02261723 YASMIN (21) BEX02410788 ZAMINE (21) APX02385058 ZARAH (21) ACT
30MCG & 3MG (28) Tablet
02261731 YASMIN (28) BEX02410796 ZAMINE (28) APX02385066 ZARAH (28) ACT
ETHINYL ESTRADIOL, ETHYNODIOL
DIACETATE
30MCG & 2MG (21) Tablet
00469327 DEMULEN 30 (21) PFI30MCG & 2MG (28) Tablet
00471526 DEMULEN 30 (28) PFI
ETHINYL ESTRADIOL, ETONOGESTREL
11.4MG & 2.6MG Device
02253186 NUVARING ORG
Page 106 of 1382014
Non-Insured Health BenefitsHealth Canada
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL, LEVONORGESTREL
20MCG & 100MCG (21) Tablet
02236974 ALESSE (21) WAY02387875 ALYSENA (21) APX02298538 AVIANE (21) BAR02388138 ESME (21) FAM02401185 LUTERA (21) ACT
20MCG & 100MCG (28) Tablet
02236975 ALESSE (28) WAY02387883 ALYSENA (28) APX02298546 AVIANE (28) BAR02388146 ESME (28) FAM02401207 LUTERA (28) ACT
10MCG & 30MCG & 150MCG Tablet
02346176 SEASONIQUE TEV30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG &
0.125MG (10) (21) Tablet
00707600 TRIQUILAR (21) BEX30MCG & 0.05MG (6), 40MCG & 0.075MG (5), 30MCG &
0.125MG (10), (28) Tablet
00707503 TRIQUILAR (28) BEX30MCG & 150MCG Tablet
02296659 SEASONALE TEP30MCG & 150MCG (21) Tablet
02042320 MIN OVRAL (21) WAY02387085 OVIMA (21) APX02295946 PORTIA (21) BAR
30MCG & 150MCG (28) Tablet
02042339 MIN OVRAL (28) WAY02387093 OVIMA (28) APX02295954 PORTIA (28) BAR
ETHINYL ESTRADIOL, NORELGESTROMIN
0.6MG & 6MG PATCH
02248297 EVRA JNO
ETHINYL ESTRADIOL, NORETHINDRONE
35MCG & 0.5MG (21) Tablet
02187086 BREVICON 0.5/35 (21) PFI00317047 ORTHO 0.5/35 (21) JNO
35MCG & 0.5MG (28) Tablet
02187094 BREVICON 0.5/35 (28) PFI00340731 ORTHO 0.5/35 (28) JNO
35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG
(5) (21) Tablet
02187108 SYNPHASIC (21) PFI35MCG & 0.5MG (7), 35MCG & 1MG (9), 35MCG & 0.5MG
(5) (28) Tablet
02187116 SYNPHASIC (28) PFI35MCG & 1MG (21) Tablet
02189054 BREVICON 1/35 (21) PFI00372846 ORTHO 1/35 (21) JNO02197502 SELECT 1/35 (21) DSP
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL, NORETHINDRONE
35MCG & 1MG (28) Tablet
02189062 BREVICON 1/35 (28) PFI00372838 ORTHO 1/35 (28) JNO02199297 SELECT 1/35 (28) DSP
35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG &
1MG (7) (21) Tablet
00602957 ORTHO 7/7/7 (21) JNO35MCG & 500MCG (7), 35MCG & 750MCG (7), 35MCG &
1MG (7), (28) Tablet
00602965 ORTHO 7/7/7 (28) JNO
ETHINYL ESTRADIOL, NORETHINDRONE
ACETATE
20MCG & 1MG (21) Tablet
00315966 MINESTRIN 1/20 (21) GCL20MCG & 1MG (28) Tablet
00343838 MINESTRIN 1/20 (28) GCL30MCG & 1.5MG (21) Tablet
00297143 LOESTRIN 1.5/30 (21) GCL30MCG & 1.5MG (28) Tablet
00353027 LOESTRIN 1.5/30 (28) GCL
ETHINYL ESTRADIOL, NORGESTIMATE
25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG &
0.25MG (7) (21) Tablet
02258560 TRI-CYCLEN LO (21) JNO25MCG & 0.180MG (7), 25MCG & 0.215MG (7), 25MCG &
0.25MG (7), (28) Tablet
02258587 TRI-CYCLEN LO (28) JNO35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG &
0.25MG (7) (21) Tablet
02028700 TRI-CYCLEN (21) JNO35MCG & 0.180MG (7), 35MCG & 0.215MG (7), 35MCG &
0.25MG (7), (28) Tablet
02029421 TRI-CYCLEN (28) JNO35MCG & 0.25MG (21) Tablet
01968440 CYCLEN (21) JNO35MCG & 0.25MG (28) Tablet
01992872 CYCLEN (28) JNO
LEVONORGESTREL
0.75MG Tablet
02364905 NEXT CHOICE ACT02285576 NORLEVO LAP02371189 OPTION 2 PER02241674 PLAN B BAR
LEVONORGESTREL INTRAUTERINE INSERT
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 device every 2 years.52MG Intrauterine Insert
02243005 MIRENA BAY
Page 107 of 1382014
Non-Insured Health BenefitsHealth Canada
68:12.00 CONTRACEPTIVES
NORETHINDRONE
0.35MG (28) Tablet
00037605 MICRONOR (28) JNO
68:16.04 ESTROGENS
CONJUGATED ESTROGENS
0.3MG Tablet
02043394 PREMARIN WAY0.625MG Tablet
02043408 PREMARIN WAY1.25MG Tablet
02043424 PREMARIN WAY0.625MG/G Vaginal Cream
02043440 PREMARIN WAY
CONJUGATED ESTROGENS,
MEDROXYPROGESTERONE ACETATE
0.625MG & 2.5MG Kit
02242878 PREMPLUS WAY0.625MG & 5MG Kit
02242879 PREMPLUS WAY
ESTRADIOL
0.06% Gel
02238704 ESTROGEL SCH0.39MG Patch
02245676 ESTRADOT 25 NVR0.585MG Patch
02243999 ESTRADOT 37.5 NVR0.78MG Patch
02244000 ESTRADOT 50 NVR1.17MG Patch
02244001 ESTRADOT 75 NVR1.56MG Patch
02244002 ESTRADOT 100 NVR5MG Patch
02243722 OESCLIM PAL10MG Patch
02243724 OESCLIM PAL50MCG Patch
02246967 SANDOZ-ESTRADIOL DERM SDZ75MCG Patch
02246968 SANDOZ-ESTRADIOL DERM SDZ100MCG Patch
00756792 ESTRADERM NVR02246969 SANDOZ-ESTRADIOL DERM SDZ
0.5MG Tablet
02225190 ESTRACE SHI1MG Tablet
02148587 ESTRACE SHI2MG Tablet
02148595 ESTRACE SHI
68:16.04 ESTROGENS
ESTRADIOL
2MG Vaginal Ring
02168898 ESTRING PMJ
ESTRADIOL (ESTRADIOL HEMIHYDRATE)
25MCG Patch
02247499 CLIMARA 25 BEX50MCG Patch
02231509 CLIMARA 50 BEX75MCG Patch
02247500 CLIMARA 75 BEX100MCG Patch
02231510 CLIMARA 100 BEX10MCG Tablet
02325462 VAGIFEM NOO
ESTRADIOL, NORETHINDRONE ACETATE
0.51MG & 4.8MG Patch
02241837 ESTALIS 250/50 NVR0.62MG & 2.7MG Patch
02241835 ESTALIS 140/50 NVR
ESTRONE
1MG/G Vaginal Cream
00727369 NEO-ESTRONE NEO
ESTROPIPATE
0.625MG Tablet
02089793 OGEN PFI
68:16.12 ESTROGEN AGONISTS-
ANTAGONISTS
RALOXIFENE HCL
Limited use benefit (prior approval required).
For:a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.
60MG Tablet
02279215 APO-RALOXIFENE APX02358840 CO RALOXIFENE ACT02239028 EVISTA LIL02358921 PMS-RALOXIFENE PMS02312298 TEVA-RALOXIFENE TEP
68:18.00 GONADOTROPINS
NAFARELIN ACETATE
2MG/ML Nasal Solution
02188783 SYNAREL PFI
68:20.02 ALPHA-GLUCOSIDASE
INHIBITORS
ACARBOSE
50MG TabletST
02190885 GLUCOBAY BAY
Page 108 of 1382014
Non-Insured Health BenefitsHealth Canada
68:20.02 ALPHA-GLUCOSIDASE
INHIBITORS
ACARBOSE
100MG TabletST
02190893 GLUCOBAY BAY
68:20.04 BIGUANIDES
METFORMIN HCL
500MG TabletST
02167786 APO-METFORMIN APX02257726 CO-METFORMIN ACT02229994 DOM-METFORMIN DPC02148765 GEN-METFORMIN GEN02099233 GLUCOPHAGE SAC02229516 GLYCON VAE02380196 JAMP-METFORMIN JAP02380722 JAMP-METFORMIN
BLACKBERRYJAP
02378620 MAR-METFORMIN MAR02242794 METFORMIN ZYM02353377 METFORMIN SAN02378841 METFORMIN MAR02385341 METFORMIN SIV02388766 MINT-METFORMIN MIN02045710 NOVO-METFORMIN TEV02223562 PMS-METFORMIN PMS02314908 PRO-METFORMIN PDL02269031 RAN-METFORMIN RBY02242974 RATIO-METFORMIN RPH02239081 RIVA-METFORMIN RIV02246820 SANDOZ-METFORMIN FC SDZ02379767 SEPTA-METFORMIN SPT
850MG TabletST
02229785 APO-METFORMIN APX02257734 CO-METFORMIN ACT02242726 DOM-METFORMIN DPC02229656 GEN-METFORMIN GEN02162849 GLUCOPHAGE SAC02239214 GLYCON VAE *02380218 JAMP-METFORMIN JAP02380730 JAMP-METFORMIN
BLACKBERRYJAP
02378639 MAR-METFORMIN MAR02242793 METFORMIN ZYM02353385 METFORMIN SAN02378868 METFORMIN MAR02385368 METFORMIN SIV02388774 MINT-METFORMIN MIN02230475 NOVO-METFORMIN TEV02242589 PMS-METFORMIN PMS02314894 PRO-METFORMIN PDL02269058 RAN-METFORMIN RBY02242931 RATIO-METFORMIN RPH02242783 RIVA-METFORMIN RIV02246821 SANDOZ-METFORMIN SDZ02379775 SEPTA-METFORMIN SPT
68:20.04 BIGUANIDES
SITAGLIPTIN, METFORMIN
Limited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
50MG & 1000MG TabletST
02333872 JANUMET FRS50MG & 500MG Tablet
ST
02333856 JANUMET FRS50MG & 850MG Tablet
ST
02333864 JANUMET FRS
68:20.05
LINAGLIPTIN
Limited use benefit (prior approval required).
For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
5MG TabletST
02370921 TRAJENTA BOE
SAXAGLIPTIN HCL
Limited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
2.5MG TabletST
02375842 ONGLYZA BMS5MG Tablet
ST
02333554 ONGLYZA BMS
SITAGLIPTIN
Limited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
25MG TabletST
02388839 JANUVIA MSP50MG Tablet
ST
02388847 JANUVIA MSP100MG Tablet
ST
02303922 JANUVIA FRS
68:20.08 INSULINS
INSULIN (30% NEUTRAL & 70% ISOPHANE)
HUMAN BIOSYNTHETIC
100U/ML (10ML) Injection
02024217 NOVOLIN GE 30/70 NOO100U/ML (3ML) Injection
02025248 NOVOLIN GE 30/70 PENFILL NOO09853812 NOVOLIN GE 30/70 PENFILL NOO
Page 109 of 1382014
Non-Insured Health BenefitsHealth Canada
68:20.08 INSULINS
INSULIN (40% NEUTRAL & 60% ISOPHANE)
HUMAN BIOSYNTHETIC
100U/ML (3ML) Injection
02024314 NOVOLIN GE 40/60 PENFILL NOO
INSULIN (50% NEUTRAL & 50% ISOPHANE)
HUMAN BIOSYNTHETIC
100U/ML (3ML) Injection
02024322 NOVOLIN GE 50/50 PENFILL NOO
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC
100U/ML (10ML) Injection
00587737 HUMULIN N LIL02024225 NOVOLIN GE NPH NOO
100U/ML (3ML) Injection
01959239 HUMULIN N CARTRIDGE LIL09853804 HUMULIN N CARTRIDGE (ON) LIL02403447 HUMULIN N KWIKPEN LIL02024268 NOVOLIN GE NPH PENFILL NOO09853782 NOVOLIN GE NPH PENFILL
(ON)NOO
INSULIN (ZINC CRYSTALLINE) HUMAN
BIOSYNTHETIC (RDNA ORIGIN)
100U/ML (10ML) Injection
00586714 HUMULIN R LIL100U/ML (3ML) Injection
01959220 HUMULIN R CARTRIDGE LIL09853766 HUMULIN R CARTRIDGE (ON) LIL
INSULIN ASPART
100U/ML (10ML) Injection
02245397 NOVORAPID NOO100U/ML (3ML) Injection
02244353 NOVORAPID NOO02377209 NOVORAPID FLEXTOUCH NOO
INSULIN DETEMIR
100U/ML (3ML) Injection
02271842 LEVEMIR PENFILL NOO
INSULIN GLARGINE
100U/ML (10ML) Injection
02245689 LANTUS SAC100U/ML (3ML) Injection
02251930 LANTUS CARTRIDGE SAC02294338 LANTUS SOLOSTAR SAC
INSULIN GLULISINE
100U/ML (10ML) Injection
02279460 APIDRA SAC100U/ML (3ML) Injection
02279479 APIDRA CARTRIDGE SAC02294346 APIDRA SOLOSTAR SAC
INSULIN HUMAN BIOSYNTHETIC
100U/ML (10ML) Injection
02024233 NOVOLIN GE TORONTO NOO
68:20.08 INSULINS
INSULIN HUMAN BIOSYNTHETIC
100U/ML (3ML) Injection
02024284 NOVOLIN GE TORONTO PENFILL
09853774 NOVOLIN GE TORONTO PENFILL (ON)
NOO
INSULIN HUMAN BIOSYNTHETIC 30% &
ISOPHANE 70%
100U/ML (10ML) Injection
00795879 HUMULIN 30/70 LIL100U/ML (3ML) Injection
01959212 HUMULIN 30/70 CARTRIDGE LIL09853855 HUMULIN 30/70 CARTRIDGE
(ON)LIL
INSULIN LISPRO
100U/ML (10ML) Injection
02229704 HUMALOG 10ML LIL100U/ML (3ML) Injection
02229705 HUMALOG CARTRIDGE LIL09853715 HUMALOG CARTRIDGE (ON) LIL *02403412 HUMALOG KWIKPEN LIL
INSULIN LISPRO (25%), INSULIN LISPRO
PROTAMINE SUSPENSION (75%)
100U/ML (3ML) Injection
02240294 HUMALOG MIX 25 LIL02403420 HUMALOG MIX 25 KWIKPEN LIL
INSULIN LISPRO (50%), INSULIN LISPRO
PROTAMINE SUSPENSION (50%)
100U/ML (3ML) Injection
02240297 HUMALOG MIX 50 KWIKPEN LIL02403439 HUMALOG MIX 50 KWIKPEN LIL
68:20.16 MEGLITINIDES
NATEGLINIDE
60MG TabletST
02245438 STARLIX NVR120MG Tablet
ST
02245439 STARLIX NVR
REPAGLINIDE
0.5MG TabletST
02355663 APO-REPAGLINIDE APX02321475 CO-REPAGLINIDE ACT02239924 GLUCONORM NOO02354926 PMS-REPAGLINIDE PMS02357453 SANDOZ REPAGLINIDE SDZ
1MG TabletST
02321483 CO-REPAGLINIDE ACT02239925 GLUCONORM NOO02354934 PMS-REPAGLINIDE PMS02357461 SANDOZ REPAGLINIDE SDZ
Page 110 of 1382014
Non-Insured Health BenefitsHealth Canada
68:20.16 MEGLITINIDES
REPAGLINIDE
2MG TabletST
02321491 CO-REPAGLINIDE ACT02239926 GLUCONORM NOO02354942 PMS-REPAGLINIDE PMS02357488 SANDOZ REPAGLINIDE PFI
68:20.20 ANTIDIABETIC AGENTS -
SULFONYLUREAS
GLICLAZIDE
30MG TabletST
02242987 DIAMICRON MR SEV02297795 GLICLAZIDE MR AAP
60MG TabletST
02356422 DIAMICRON MR SEV80MG Tablet
ST
02245247 APO-GLICLAZIDE APX00765996 DIAMICRON SEV02229519 GEN-GLICLAZIDE GEN02248453 GLICLAZIDE PDL02287072 GLICLAZIDE SAN02238103 TEVA-GLICLAZIDE TEV
GLYBURIDE
2.5MG TabletST
01913654 APO-GLYBURIDE APX02224550 DIABETA SAC00808733 GEN-GLYBE GEN01959352 GLYBURIDE PDL02350459 GLYBURIDE SAN01913670 NOVO-GLYBURIDE TEV01900927 RATIO-GLYBURIDE RPH02248008 SANDOZ-GLYBURIDE SDZ
5MG TabletST
01913662 APO-GLYBURIDE APX02224569 DIABETA SAC02234514 DOM-GLYBURIDE DPC00720941 EUGLUCON PMS00808741 GEN-GLYBE GEN02350467 GLYBURIDE SAN01913689 NOVO-GLYBURIDE TEV02236734 PMS-GLYBURIDE PMS02316544 PRO-GLYBURIDE PDL01900935 RATIO-GLYBURIDE RPH02236548 RIVA-GLYBURIDE PHH02248009 SANDOZ-GLYBURIDE SDZ
TOLBUTAMIDE
500MG TabletST
00312762 APO-TOLBUTAMIDE APX
68:20.28 THIAZOLIDINEDIONES
PIOGLITAZONE HCL
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
15MG TabletST
02303442 ACCEL PIOGLITAZONE ACP02242572 ACTOS LIL02302942 APO-PIOGLITAZONE APX02302861 CO PIOGLITAZONE ACT02307634 DOM-PIOGLITAZONE DOM02298279 GEN-PIOGLITAZONE GEN02326477 JAMP-PIOGLITAZONE MIN02274914 NOVO-PIOGLITAZONE TEV02307669 PHL-PIOGLITAZONE PMI02374013 PIOGLITAZONE SIV02391600 PIOGLITAZONE ACC02303124 PMS-PIOGLITAZONE PMS02312050 PRO-PIOGLITAZONE PDL02375850 RAN-PIOGLITAZONE RBY02301423 RATIO-PIOGLITAZONE RPH02297906 SANDOZ PIOGLITAZONE SDZ02320754 ZYM-PIOGLITAZONE ZYM
30MG TabletST
02303450 ACCEL PIOGLITAZONE ACP02242573 ACTOS LIL02302950 APO-PIOGLITAZONE APX02302888 CO PIOGLITAZONE ACT02307642 DOM-PIOGLITAZONE DOM02298287 GEN-PIOGLITAZONE GEN02326485 JAMP-PIOGLITAZONE MIN02365529 JAMP-PIOGLITAZONE JAP02274922 NOVO-PIOGLITAZONE TEV02307677 PHL-PIOGLITAZONE PMI02339587 PIOGLITAZONE ACC02374021 PIOGLITAZONE SIV02303132 PMS-PIOGLITAZONE PMS02312069 PRO-PIOGLITAZONE PDL02375869 RAN-PIOGLITAZONE RBY02301431 RATIO-PIOGLITAZONE RPH02297914 SANDOZ PIOGLITAZONE SDZ02320762 ZYM-PIOGLITAZONE ZYM
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Non-Insured Health BenefitsHealth Canada
68:20.28 THIAZOLIDINEDIONES
PIOGLITAZONE HCL
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
45MG TabletST
02303469 ACCEL PIOGLITAZONE ACP02242574 ACTOS LIL02302977 APO-PIOGLITAZONE APX02302896 CO PIOGLITAZONE ACT02307650 DOM-PIOGLITAZONE DOM02298295 GEN-PIOGLITAZONE GEN02326493 JAMP-PIOGLITAZONE MIN02365537 JAMP-PIOGLITAZONE JAP02274930 NOVO-PIOGLITAZONE TEV02307723 PHL-PIOGLITAZONE PMI02339595 PIOGLITAZONE ACC02374048 PIOGLITAZONE SIV02303140 PMS-PIOGLITAZONE PMS02312077 PRO-PIOGLITAZONE PDL02375877 RAN-PIOGLITAZONE RBY02301458 RATIO-PIOGLITAZONE RPH02297922 SANDOZ PIOGLITAZONE SDZ02320770 ZYM-PIOGLITAZONE ZYM
ROSIGLITAZONE MALEATE
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
2MG TabletST
02241112 AVANDIA GSK4MG Tablet
ST
02241113 AVANDIA GSK8MG Tablet
ST
02241114 AVANDIA GSK
68:22.12 GLYCOGENOLYTIC AGENTS
GLUCAGON RECOMBINANT DNA ORGIN
1MG/ML Injection
02333619 GLUCAGEN NOO02333627 GLUCAGEN HYPOKIT NOO02243297 GLUCAGON LIL
68:24.00 PARATHYROID
CALCITONIN SALMON (SYNTHETIC)
200IU/ML Injection
01926691 CALCIMAR SAC
68:28.00 PITUITARY
DESMOPRESSIN ACETATE
4MCG/ML Injection
00873993 DDAVP FEI0.1MG/ML Nasal Solution
00402516 DDAVP FEI
68:28.00 PITUITARY
DESMOPRESSIN ACETATE
0.1MG/ML Nasal Spray
02242465 APO-DESMOPRESSIN APX00836362 DDAVP FEI
0.1MG Tablet
02284030 APO-DESMOPRESSIN APX00824305 DDAVP FEI02287730 NOVO-DESMOPRESSIN TEV02304368 PMS-DESMOPRESSIN PMS
0.2MG Tablet
02284049 APO-DESMOPRESSIN APX00824143 DDAVP FEI02287749 NOVO-DESMOPRESSIN TEV02304376 PMS-DESMOPRESSIN PMS
60MCG Tablet
02284995 DDAVP MELT FEI120MCG Tablet
02285002 DDAVP MELT FEI240MCG Tablet
02285010 DDAVP MELT FEI
68:29.04 SOMATOSTATIN AGONISTS
LANREOTIDE
60MG/0.3ML Injection
02283395 SOMATULINE AUTOGEL IPS90MG/0.3ML Injection
02283409 SOMATULINE AUTOGEL IPS120MG/0.5ML Injection
02283417 SOMATULINE AUTOGEL IPS
OCTREOTIDE
10MG/VIAL Injection
02239323 SANDOSTATIN LAR NVR20MG/VIAL Injection
02239324 SANDOSTATIN LAR NVR30MG/VIAL Injection
02239325 SANDOSTATIN LAR NVR50MCG/ML Injection
02248639 OCTREOTIDE ACETATE OMEGA
OMG
00839191 SANDOSTATIN NVR100MCG/ML Injection
02248640 OCTREOTIDE ACETATE OMEGA
OMG
00839205 SANDOSTATIN NVR200MCG/ML Injection
02248642 OCTREOTIDE ACETATE OMEGA
OMG
02049392 SANDOSTATIN NOV500MCG/ML Injection
02248641 OCTREOTIDE ACETATE OMEGA
OMG
00839213 SANDOSTATIN NVR
Page 112 of 1382014
Non-Insured Health BenefitsHealth Canada
68:32.00 PROGESTINS
DIENOGEST
2MG Tablet
02374900 VISANNE BAY
MEDROXYPROGESTERONE ACETATE
50MG/ML Injection
00030848 DEPO-PROVERA PFI150MG/ML Injection
00585092 DEPO-PROVERA PFI02322250 MEDROXYPROGESTERONE SDZ
2.5MG Tablet
02244726 APO-MEDROXY APX02247581 DOM-
MEDROXYPROGESTERONEDPC
02221284 NOVO-MEDRONE TEV02253550 PDL-MEDROXY PDL00708917 PROVERA PFI
5MG Tablet
02244727 APO-MEDROXY APX02247582 DOM-
MEDROXYPROGESTERONEDPC
02221292 NOVO-MEDRONE TEV02253577 PDL-MEDROXY PDL00030937 PROVERA PFI02010739 PROVERA PAK PFI
10MG Tablet
02277298 APO-MEDROXY APX02247583 DOM-
MEDROXYPROGESTERONEDPC
02221306 NOVO-MEDRONE TEV00729973 PROVERA PFI02010933 PROVERA PFI
100MG Tablet
02267640 APO-MEDROXY APX
68:36.04 THYROID AGENTS
LEVOTHYROXINE SODIUM
0.025MG TabletST
02264323 EUTHYROX GEN02172062 SYNTHROID ABB
0.05MG TabletST
02213192 ELTROXIN GSK02264331 EUTHYROX GEN02172070 SYNTHROID ABB
0.075MG TabletST
02264358 EUTHYROX GEN02172089 SYNTHROID ABB
0.088MG TabletST
02172097 SYNTHROID ABB0.1MG Tablet
ST
02213206 ELTROXIN GSK02264374 EUTHYROX GEN02172100 SYNTHROID ABB
68:36.04 THYROID AGENTS
LEVOTHYROXINE SODIUM
0.112MG TabletST
02264390 EUTHYROX GEN02171228 SYNTHROID ABB
0.125MG TabletST
02264404 EUTHYROX GEN02172119 SYNTHROID ABB
0.137MG TabletST
02264412 EUTHYROX GEN02233852 SYNTHROID ABB
0.15MG TabletST
02213214 ELTROXIN GSK02264420 EUTHYROX GEN02172127 SYNTHROID ABB
0.175MG TabletST
02264439 EUTHYROX GEN02172135 SYNTHROID ABB
0.2MG TabletST
02213222 ELTROXIN GSK02264447 EUTHYROX GEN02172143 SYNTHROID ABB
0.3MG TabletST
02213230 ELTROXIN GSK02264455 EUTHYROX GEN02172151 SYNTHROID ABB
THYROID
30MG TabletST
00023949 THYROID ERF60MG Tablet
ST
00023957 THYROID ERF125MG Tablet
ST
00023965 THYROID ERF
68:36.08 ANTITHYROID AGENTS
PROPYLTHIOURACIL
50MG TabletST
00010200 PROPYL THYRACIL SQU100MG Tablet
ST
00010219 PROPYL THYRACIL SQU
THIAMAZOLE
5MG TabletST
00015741 TAPAZOLE PAL10MG Tablet
ST
02296039 TAPAZOLE PAL
Page 113 of 1382014
Non-Insured Health BenefitsHealth Canada
80:00 SERUMS, TOXOIDS, AND
VACCINES
80:04.00 SERUMS
DOLICHOVESPULA ARENARIA VENOM
PROTEIN
120MCG Injection
01948946 YELLOW HORNET VENOM PROTEIN
ALK
DOLICHOVESPULA MACULATA VENOM
PROTEIN EXTRACT
120MCG Injection
01949004 WHITE FACED HORNET VENOM
ALK
HONEY BEE VENOM PROTEIN EXTRACT
1.1MG Injection
01948903 HONEY BEE VENOM ALK120MCG Injection
01948911 HONEY BEE VENOM ALK02226197 VENOMIL HONEY BEE VENOM HOL
550MCG Injection
02220075 HONEY BEE VENOM HOL
NON POLLEN
Injection
00299979 ALLERGENIC EXTRACT NON POLLENS
CEN
00514713 ALLERGENIC EXTRACTS MSL
POLISTES SPP VENOM PROTEIN EXTRACT
1.1MG Injection
01948970 WASP VENOM PROTEIN ALK
POLLEN
Injection
00299987 ALLERGENIC EXTRACT POLLENS
CEN
00464988 POLLINEX R BCA
POLLEN AND NON POLLEN
Injection
00648922 CENTER-AL CEN
VESPULA SPP VENOM PROTEIN EXTRACT
1.1MG Injection
01948954 YELLOW JACKET VENOM PROTEIN
ALG
120MCG Injection
01948962 YELLOW JACKET VENOM PROTEIN
ALK
WASP VENOM PROTEIN
120MCG Injection
02226219 VENOMIL WASP VENOM PROTEIN
HOL
550MCG Injection
02220091 WASP VENOM PROTEIN HOL
80:04.00 SERUMS
WHITE FACED HORNET VENOM PROTEIN
120MCG Injection
02226235 VENOMIL WHITE FACED HORNET VENOM PROTEIN
HOL
WHITE FACED HORNET VENOM PROTEIN,
YELLOW HORNET VENOM PROTEIN, YELLOW
JACKET VENOM PROTEIN
120MCG Injection
01948881 MIXED VESPID VENOM PROTEIN
ALK
02226294 VENOMIL MIXED VESPID VENOM PROTEIN
HOL
550MCG Injection
02221314 MIXED VESPID VENOM PROTEIN
HOL
YELLOW HORNET VENOM PROTEIN
100MCG/ML Injection
02226251 YELLOW JACKET HORNET VENOM PROTEIN
BAY
500MCG Injection
02220083 YELLOW HORNET VENOM PROTEIN
HOL
YELLOW JACKET VENOM PROTEIN
120MCG Injection
02226286 VENOMIL YELLOW JACKET VENOM PROTEIN
HOL
550MCG Injection
02220113 YELLOW JACKET VENOM PROTEIN
BAY
Page 114 of 1382014
Non-Insured Health BenefitsHealth Canada
84:00 SKIN AND MUCOUS
MEMBRANE AGENTS (SMMA)
84:04.04 SMMA - ANTIBIOTICS
BACITRACIN
500IU Ointment
00584908 BACITIN PMS02351714 BACITRACIN JAP
BACITRACIN ZINC, POLYMYXIN B SULFATE
500IU & 10,000IU Ointment
02237227 POLYSPORIN ANTIBIOTIC PFI
CLINDAMYCIN PHOSPHATE
1% Solution
02243659 CLINDA-T VAO00582301 DALACIN T PFI02266938 TARO-CLINDAMYCIN TAR
2% Vaginal Cream
02060604 DALACIN PMJ
ERYTHROMYCIN, TRETINOIN
4% & 0.01% Gel
02015994 STIEVAMYCIN MILD STI4% & 0.025% Gel
01905112 STIEVAMYCIN STI4% & 0.05% Gel
01945262 STIEVAMYCIN FORTE STI
FUSIDATE SODIUM
2% Ointment
00586676 FUCIDIN LEO
FUSIDIC ACID
2% Cream
00586668 FUCIDIN LEO
GRAMICIDIN, POLYMYXIN B SULFATE
0.25MG & 10,000IU Cream
02230844 POLYSPORIN ANTIBIOTIC PFI
MUPIROCIN
2% Cream
02239757 BACTROBAN GSK2% Ointment
01916947 BACTROBAN GSK02279983 TARO-MUPIROCIN 2%
OINTMENTTAR
POLYMYXIN B SULFATE, BACITRACIN
10,000IU & 500IU Ointment
02304473 ANTIBIOTIC OINTMENT PED00876488 BACIMYXIN PMS00621366 BIODERM ODN01942921 POLYTOPIC SDZ
84:04.06 SMMA - ANTIVIRALS
ACYCLOVIR
5% Cream
02039524 ZOVIRAX GSK5% Ointment
00569771 ZOVIRAX GSK
84:04.08 SMMA - ANTIFUNGALS
CLOTRIMAZOLE
1% Cream
02150867 CANESTEN BCD00812382 CLOTRIMADERM TAR
1% & 200MG Cream & Vaginal Suppository
02264099 CANESTEN 3 COMFORT COMBI PAK
BCD
1% & 500MG Cream & Vaginal Suppository
02264102 CANESTEN 1 COMFORT COMBI PAK
BCD
1% Vaginal Cream
02150891 CANESTEN BCD00812366 CLOTRIMADERM TAR
2% Vaginal Cream
02150905 CANESTEN BCD00812374 CLOTRIMADERM TAR
KETOCONAZOLE
2% Cream
02245662 KETODERM TAR2% Shampoo
02182920 NIZORAL MCL
MICONAZOLE NITRATE
2% Cream
02085852 MICATIN MCL02126567 MONISTAT-DERM MCL
2% & 100MG Cream & Vaginal Suppository
02126257 MONISTAT 7 DUAL PAK MCL2% & 400MG Cream & Vaginal Suppository
02126249 MONISTAT 3 DUAL PAK MCL2% Vaginal Cream
02231106 MICOZOLE TAR02084309 MONISTAT 7 MCL
400MG Vaginal Suppository
02171775 MICONAZOLE VTH02126605 MONISTAT 3 MCL
NYSTATIN
100,000IU Cream
00716871 NYADERM TAR02194236 RATIO-NYSTATIN RPH
100,000IU Ointment
02194228 RATIO-NYSTATIN RPH25,000IU Vaginal Cream
00716901 NYADERM TAR100,000IU Vaginal Cream
02194163 RATIO-NYSTATIN RPH
Page 115 of 1382014
Non-Insured Health BenefitsHealth Canada
84:04.08 SMMA - ANTIFUNGALS
TERBINAFINE HCL
1% Cream
02031094 LAMISIL NVR
TERCONAZOLE
0.4% Vaginal Cream
02247651 TARO-TERCONAZOLE TAR00894729 TERAZOL 7 JNO
0.8% & 80MG Vaginal Cream & Vaginal Suppository
02130874 TERAZOL 3 DUAL PAK JNO80MG Vaginal Suppository
00894710 TERAZOL 3 JNO
TOLNAFTATE
1% Cream
00576034 TINACTIN SCH1% Powder
01919245 ATHLETES FOOT SPRAY SCH00576042 TINACTIN SCH02029081 ZEASORB AF STI
1% Spray
00576050 TINACTIN AEROSOL SCH
84:04.12 SMMA - SCABICIDES AND
PEDICULICIDES
CROTAMITON
10% Cream
00623377 EURAX NVC
ISOPROPYL MYRISTATE
50% Solution
02279592 RESULTZ ALN
PERMETHRIN
5% Cream
02219905 NIX DERMAL GSK5% Lotion
02231348 KWELLADA-P GSK1% Rinse
02231480 KWELLADA-P GSK00771368 NIX WLA
PIPERONYL BUTOXIDE, PYRETHRINS
3% & 0.3% Shampoo
02125447 R & C GSK
84:04.92 SMMA - MISCELLANEOUS LOCAL
ANTI-INFECTIVES
BENZOYL PEROXIDE
5% Gel (Alcohol Base)
02162113 BENZAGEL NVC00263702 PANOXYL-5 STI
10% Gel (Alcohol Base)
00263699 PANOXYL-10 STI20% Gel (Alcohol Base)
00373036 PANOXYL-20 STI
84:04.92 SMMA - MISCELLANEOUS LOCAL
ANTI-INFECTIVES
BENZOYL PEROXIDE
2.5% Gel (Water Base)
02214830 PANOXYL AQUAGEL STI4% Gel (Water Base)
01975382 SOLUGEL STI5% Gel (Water Base)
00899453 BENZAC AC GAC01925180 BENZAC W5 GAC *02214849 PANOXYL AQUAGEL STI
8% Gel (Water Base)
02019825 SOLUGEL STI2.5% Lotion
02046539 OXY 5 GSK5% Lotion
02166607 BENZAGEL 5 NVC00374326 OXYDERM VAE
10% Lotion
00370568 BENOXYL STI5% Soap
00483184 PANOXYL-5 STI10% Soap
00527661 PANOXYL-10 STI5% Wash
00896276 BENZAC W GAC02162121 BENZAGEL NVC02214857 PANOXYL STI
10% Wash
01925199 BENZAC W GAC
CHLORHEXIDINE ACETATE
0.5% Dressing
00433497 BACTIGRAS SNE
CHLORHEXIDINE GLUCONATE
2% Liquid
01938991 STANHEXIDINE OMG4% Liquid
01938983 STANHEXIDINE OMG
HYDROGEN PEROXIDE
3% Liquid
00167703 HYDROGEN PEROXIDE 10V RWP00485721 HYDROGEN PEROXIDE 10V RPH *00579297 PEROXIDE D'HYDROGENE ATL
ISOPROPYL ALCOHOL
70% Liquid
00426539 DUONALC VAE
METRONIDAZOLE
0.75% Cream
02226839 METROCREAM GAC1% Cream
02156091 NORITATE SAC02242919 ROSASOL STI
Page 116 of 1382014
Non-Insured Health BenefitsHealth Canada
84:04.92 SMMA - MISCELLANEOUS LOCAL
ANTI-INFECTIVES
METRONIDAZOLE
0.75% Gel
02092832 METROGEL GAC1% Gel
02297809 METROGEL GAC0.75% Lotion
02248206 METROLOTION GAC10% Vaginal Cream
01926861 FLAGYL SAC0.75% Vaginal Gel
02125226 NIDAGEL MMH
METRONIDAZOLE, NYSTATIN
100MG & 20,000U/G Vaginal Cream
01926845 FLAGYSTATIN AVT500MG & 100,000IU Vaginal Suppository
01926829 FLAGYSTATIN AVT
POVIDONE-IODINE
10% Liquid
00158348 BETADINE PFR
SELENIUM SULFIDE
2.5% Lotion
00243000 SELSUN ABB00594601 VERSEL VAO
SILVER SULFADIAZINE
1% Cream
02010917 DERMAZIN PMS00323098 FLAMAZINE SNE09854037 FLAMAZINE 50G SNE *
TRICLOSAN
0.5% Liquid
00266507 ADASEPT ODN00632317 TERSASEPTIC STI
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
AMCINONIDE
0.1% Cream
02192284 CYCLOCORT STI02247098 RATIO-AMCINONIDE RPH02246714 TARO-AMCINONIDE TAR
0.1% Lotion
02192276 CYCLOCORT STI02247097 RATIO-AMCINONIDE RPH
0.1% Ointment
02192268 CYCLOCORT STI02247096 RATIO-AMCINONIDE RPH
BECLOMETHASONE DIPROPIONATE
0.025% Cream
02089602 PROPADERM SHI
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
BETAMETHASONE DIPROPIONATE
0.05% Cream
00323071 DIPROSONE SCH00804991 RATIO-TOPISONE RPH02122049 ROSONE RIV01925350 TARO-SONE TAR
0.05% Lotion
00417246 DIPROSONE SCH00809187 RATIO-TOPISONE RPH02122030 ROSONE RIV
0.05% Ointment
00344923 DIPROSONE SCH00805009 RATIO-TOPISONE RPH02122057 ROSONE RIV
BETAMETHASONE DIPROPIONATE IN
PROPYLENE GLYCOL
0.05% Cream
00688622 DIPROLENE SCH00849650 RATIO-TOPILENE GLYCOL RPH02122073 ROLENE RIV
0.05% Lotion
00862975 DIPROLENE SCH01927914 RATIO-TOPILENE GLYCOL RPH02122065 ROLENE RIV
0.05% Ointment
00629367 DIPROLENE SCH00849669 RATIO-TOPILENE GLYCOL RPH02122081 ROLENE RIV
BETAMETHASONE DIPROPIONATE,
CLOTRIMAZOLE
0.05% & 1% Cream
00611174 LOTRIDERM SCH
BETAMETHASONE DIPROPIONATE,
SALICYLIC ACID
0.05% & 2% Lotion
00578428 DIPROSALIC SCH02245688 RATIO-TOPISALIC RPH
0.05% & 3% Ointment
00578436 DIPROSALIC SCH
BETAMETHASONE DISODIUM PHOSPHATE
0.05MG/ML Enema
02060884 BETNESOL SHI
BETAMETHASONE VALERATE
0.05% Cream
00535427 RATIO-ECTOSONE RPH0.1% Cream
00716626 BETADERM TAR02357844 CELESTODERM V VAO00804541 PREVEX B STI00535435 RATIO-ECTOSONE RPH
Page 117 of 1382014
Non-Insured Health BenefitsHealth Canada
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
BETAMETHASONE VALERATE
0.05% Lotion
00653209 RATIO-ECTOSONE RPH0.1% Lotion
00750050 RATIO-ECTOSONE RPH01940112 RIVASONE RIV
0.05% Ointment
00716642 BETADERM TAR0.1% Ointment
00716650 BETADERM TAR0.1% Scalp Lotion
00716634 BETADERM TAR00027944 VALISONE SCH
BETAMETHASONE, CALCIPOTRIOL
0.5MG & 50MCG Gel
02319012 DOVOBET LEO
BUDESONIDE
0.02MG/ML Enema
02052431 ENTOCORT AZC
CLOBETASOL PROPIONATE
0.05% Cream
02245523 CLOBETASOL PROPIONATE TAR02213265 DERMOVATE TAR02024187 GEN-CLOBETASOL GEN02093162 NOVO-CLOBETASOL TEV02232191 PMS-CLOBETASOL PMS02309521 PMS-CLOBETASOL PMS01910272 RATIO-CLOBETASOL RPH
0.05% Ointment
02245524 CLOBETASOL PROPIONATE TAR02213273 DERMOVATE TAR02026767 GEN-CLOBETASOL GEN02126192 NOVO-CLOBETASOL TEV02309548 PMS-CLOBETASOL PMS01910280 RATIO-CLOBETASOL RPH
0.05% Scalp Lotion
02213281 DERMOVATE TAR02216213 GEN-CLOBETASOL GEN02232195 PMS-CLOBETASOL PMS01910299 RATIO-CLOBETASOL RPH
0.05% Solution
02245522 CLOBETASOL PROPIONATE TAR
CLOBETASONE BUTYRATE
0.05% Cream
02214415 EUMOVATE GSK
DESONIDE
0.05% Cream
02229315 PMS-DESONIDE PMS02154862 TRIDESILON SCN
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
DESONIDE
0.05% Ointment
02115522 DESOCORT GAC02229323 PMS-DESONIDE PMS02154870 TRIDESILON SCN
DESOXIMETASONE
0.05% Cream
02221918 TOPICORT SAC0.25% Cream
02221896 TOPICORT SAC0.05% Gel
02221926 TOPICORT SAC0.25% Ointment
02221934 TOPICORT SAC
DIFLUCORTOLONE VALERATE
0.1% Cream
00587826 NERISONE STI00587818 NERISONE OILY STI
0.1% Ointment
00587834 NERISONE STI
DIFLUCORTOLONE VALERATE, SALICYLIC
ACID
0.1% & 3% Cream
02028719 NERISALIC OILY STI
FLUOCINOLONE ACETONIDE
0.025% Ointment
02162512 SYNALAR MDC0.01% Scalp Lotion
00873292 DERMA-SMOOTHE HIL
FLUOCINONIDE
0.05% Cream
02161923 LIDEX MDC00716863 LYDERM OPT
0.05% Emollient Cream
02163152 LIDEMOL MDC00598933 TIAMOL TAR
0.05% Gel
02236997 LYDERM OPT02161974 TOPSYN HLR
0.05% Ointment
02161966 LIDEX HLR02236996 LYDERM OPT
FLUTICASONE PROPIONATE
0.05% Cream
02089912 CUTIVATE GSK
HALOBETASOL PROPIONATE
0.05% Cream
01962701 ULTRAVATE WSB
Page 118 of 1382014
Non-Insured Health BenefitsHealth Canada
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
HALOBETASOL PROPIONATE
0.05% Ointment
01962728 ULTRAVATE WSB
HYDROCORTISONE
0.5% Cream
80021088 CORTATE SPL00564281 HYDROSONE TCH
1% Cream
02086034 BARRIERE HC SHI00192597 EMO CORT STI00804533 PREVEX HC STI
2.5% Cream
00595799 EMO CORT STI100MG/60ML Enema
02112736 CORTENEMA AXC00230316 HYCORT VAE
0.5% Lotion
80021087 CORTATE SPL1% Lotion
00192600 EMO CORT STI00578541 SARNA HC STI
2.5% Lotion
00595802 EMO CORT STI00641154 EMO CORT SCALP STI00856711 SARNA HC STI
0.5% Ointment
80021085 CORTATE SPL00716685 CORTODERM TAR
1% Ointment
00716693 CORTODERM TAR
HYDROCORTISONE ACETATE
10% Aerosol Foam
00579335 CORTIFOAM SQU0.5% Cream
00716820 HYDERM TAR1% Cream
00716839 HYDERM TAR2% Cream
00749834 NEO-HC NEO1% Lotion
00681997 DERMAFLEX HC NEO
HYDROCORTISONE ACETATE, ZINC SULFATE
0.5% & 0.5% Ointment
02128446 ANODAN-HC ODN00505773 ANUSOL HC PFI02209764 EGOZINC-HC PMS00607789 RATIO-HEMCORT HC RPH02247691 SANDOZ-ANUZINC HC SDZ
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
HYDROCORTISONE ACETATE, ZINC SULFATE
10MG & 10MG Suppository
02236399 ANODAN-HC ODN00476285 ANUSOL HC PFI02210517 EGOZINC HC PMS00607797 RATIO-HEMCORT HC RPH02240112 RIVASOL-HC RIV02242798 SAB-ANUZINC HC SAB
HYDROCORTISONE ACETATE, ZINC SULFATE,
PRAMOXINE HCL
0.5% & 0.5% & 1% Ointment
00505781 ANUGESIC HC PFI02234466 PROCTODAN HC ODN
10MG & 10MG & 20MG Suppository
00476242 ANUGESIC HC PFI02240851 PROCTODAN HC ODN02242797 SAB-ANUZINC HC PLUS SAB
HYDROCORTISONE VALERATE
0.2% Cream
02242984 HYDROVAL TAR0.2% Ointment
02242985 HYDROVAL TAR
HYDROCORTISONE, DIBUCAINE HCL,
ESCULIN, FRAMYCETIN SULFATE
5MG & 5MG & 10MG & 10MG Ointment
02247322 PROCTOL ODN02223252 PROCTOSEDYL AXC02226383 RATIO-PROCTOSONE RPH02242527 SANDOZ-PROCTOMYXIN HC SDZ
5MG & 5MG & 10MG & 10MG Suppository
02247882 PROCTOL ODN02223260 PROCTOSEDYL AXC02226391 RATIO-PROCTOSONE RPH02242528 SAB-PROCTOMYXIN HC SAB
HYDROCORTISONE, UREA
1% Cream
00681989 DERMAFLEX HC NEB1% & 10% Cream
00503134 UREMOL HC STI1% & 10% Lotion
00560022 UREMOL HC STI
HYDROCORTISONE/ZINC
0.5% & 0.5% Ointment
02387239 JAMP ZINC-HC JAP
MOMETASONE FUROATE
0.1% Cream
00851744 ELOCOM SCH02367157 TARO-MOMETASONE TAR
Page 119 of 1382014
Non-Insured Health BenefitsHealth Canada
84:06.00 SMMA - ANTI-INFLAMMATORY
AGENTS
MOMETASONE FUROATE
0.1% Lotion
00871095 ELOCOM SCH02266385 TARO-MOMETASONE TAR
0.1% Ointment
00851736 ELOCOM SCH02244769 PMS-MOMETASONE PMS02270862 PMS-MOMETASONE PMS02248130 RATIO-MOMETASONE RPH02264749 TARO-MOMETASONE TAR
TRIAMCINOLONE ACETONIDE
0.1% Cream
02194058 ARISTOCORT R VAO0.5% Cream
02194066 ARISTOCORT C VAO0.1% Ointment
02194031 ARISTOCORT R VAO0.1% Paste
01964054 ORACORT TAR
84:08.00 SMMA - ANTIPRURITICS AND
LOCAL ANESTHETICS
LIDOCAINE HCL
2% Liquid
01968823 LIDODAN VISCOUS ODN00811874 PMS-LIDOCAINE VISCOUS PMS00001686 XYLOCAINE VISCOUS AZC
LIDOCAINE, PRILOCAINE
2.5% & 2.5% Cream
00886858 EMLA AZC2.5% & 2.5% Patch
02057794 EMLA AZC
84:16.00 SMMA - CELL STIMULANTS AND
PROLIFERANTS
TRETINOIN
0.01% Cream
00897329 RETIN A JAJ00657204 STIEVA-A STI01926497 VITAMIN A ACID SAC
0.025% Cream
00897310 RETIN A JAJ00578576 STIEVA-A STI01926500 VITAMIN A ACID SAC
0.05% Cream
00443794 RETIN A JAJ00518182 STIEVA-A STI
0.1% Cream
00870021 RETIN A JAJ00662348 STIEVA-A FORTE STI01926527 VITAMIN A ACID SAC
84:16.00 SMMA - CELL STIMULANTS AND
PROLIFERANTS
TRETINOIN
0.01% Gel
01926462 VITAMIN A ACID SAC0.025% Gel
00587966 STIEVA-A STI01926470 VITAMIN A ACID SAC
0.05% Gel
00641863 STIEVA-A STI01926489 VITAMIN A ACID SAC
0.025% Solution
00578568 STIEVA-A STI
84:24.12 BASIC OINTMENTS AND
PROTECTANTS
DIMETHICONE
20% Cream
02060841 BARRIERE WPC
PETROLATUM
67% Cream
00635189 PREVEX STI
ZINC OXIDE
15% Cream
02215799 ZINC HJS25% Ointment
00532576 IHLES PASTE RPH00886327 IHLES PASTE ATL
40% Ointment
02239160 ZINCOFAX EXTRA STRENGTH GSK
84:28.00 KERATOLYTIC AGENTS
ADAPALENE
0.1% Cream
02231592 DIFFERIN GAC0.1% Gel
02148749 DIFFERIN GAC
CANTHARIDIN, PODOPHYLLIN, SALICYLIC
ACID
1% & 2% & 30% Liquid
00772011 CANTHARONE PLUS DOR1% & 5% & 30% Liquid
00589500 CANTHACUR PS PMS
DITHRANOL
0.1% Cream
00537594 ANTHRANOL-1 MTI0.2% Cream
00537608 ANTHRANOL-2 MTI0.4% Lotion
00695351 ANTHRASCALP MTI1% Ointment
00566756 ANTHRAFORTE MTI
Page 120 of 1382014
Non-Insured Health BenefitsHealth Canada
84:28.00 KERATOLYTIC AGENTS
DITHRANOL
2% Ointment
00566748 ANTHRAFORTE MTI
FORMALDEHYDE, LACTIC ACID, SALICYLIC
ACID
10% & 5% & 25% Ointment
00513091 DUOPLANT STI
LACTIC ACID, SALICYLIC ACID
17% & 17% Liquid
00370576 DUOFILM STI
PODOFILOX
0.5% Solution
01945149 CONDYLINE CDX
PODOPHYLLIN
25% Liquid
00598208 PODOFILM PMS
SALICYLIC ACID
27% Gel
01939645 DUOFORTE 27 STI170MG/ML Gel
00614246 COMPOUND W GEL WHR20% Liquid
00690333 SOLUVER DER26% Liquid
00754951 OCCLUSAL HP GEN27% Liquid
00837733 SOLUVER PLUS DER40% Plaster
01974335 CLEAR AWAY SCH4% Shampoo
00666106 SEBCUR DER
84:32.00 KERATOPLASTIC AGENTS
COAL TAR
10% Gel
00344508 TARGEL ODN20% Liquid
00358495 ODANS LIQUOR CARBONIS DETERGENT
ODN
0.5% Shampoo
02240645 NEUTROGENA T/GEL JAJ1% Shampoo
00632295 TERSA-TAR MILD STI3% Shampoo
00632309 TERSA-TAR STI4.3% Shampoo
00740314 PENTRAX GEN
COAL TAR, JUNIPER TAR, PINE TAR
1% Shampoo
00249866 POLYTAR STI
84:32.00 KERATOPLASTIC AGENTS
COAL TAR, JUNIPER TAR, PINE TAR, ZINC
PYRITHIONE
0.166% & 0.166% & 0.166% & 1% Shampoo
00628042 MULTI-TAR PLUS MILD VAE *0.33% & 0.33% & 0.33% & 1% Shampoo
02240942 MULTITAR PLUS VAE
COAL TAR, SALICYLIC ACID
8% & 2% Gel
00560448 P&S PLUS BAK *10% & 3% Liquid
00510335 TARGEL SA ODN10% & 4% Shampoo
00666114 SEBCUR-T DER
COAL TAR, SALICYLIC ACID, SULFUR
2% & 2% & 2% Shampoo
00444448 STEREX IDE
84:50.06 PIGMENTING AGENTS
METHOXSALEN
10MG Capsule
00252654 OXSORALEN VAE01946374 OXSORALEN VAE
1% Lotion
01907476 OXSORALEN VAE
84:92.00 MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE AGENTS
ACITRETIN
Open benefit (prior approval not required).
Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug.
10MG Capsule
02070847 SORIATANE HLR25MG Capsule
02070863 SORIATANE HLR
AZELAIC ACID
15% Gel
02270811 FINACEA BAY
BETAMETHASONE, CALCIPOTRIOL
0.5MG & 50MCG Ointment
02244126 DOVOBET LEO
CALCIPOTRIOL
50MCG/G Cream
02150956 DOVONEX LEO50MCG/G Ointment
01976133 DOVONEX LEO50MCG/ML Solution
02194341 DOVONEX LEO
Page 121 of 1382014
Non-Insured Health BenefitsHealth Canada
84:92.00 MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE AGENTS
CAPSAICIN
0.025% Cream
02157101 CAPSAICIN VAO02244952 ZODERM EUO00740306 ZOSTRIX GEN
0.075% Ointment
02157128 CAPSAICIN HP VAO
COLLAGENASE
250U Ointment
02063670 SANTYL KNO
FLUOROURACIL
5% Cream
00330582 EFUDEX VAE
IMIQUIMOD
Limited use benefit (prior approval required).
-For the treatment of condylomata acuminate (genital warts) in patients who have failed:-self-applied podophyllotoxin (podofilox 0.5% solution); OR-provider-applied podophyllum resin (10%-25%)
50MG/G Cream
02239505 ALDARA VAE
ISOTRETINOIN
Open benefit (prior approval not required).
Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.
10MG Capsule
00582344 ACCUTANE HLR02257955 CLARUS PRE
40MG Capsule
00582352 ACCUTANE HLR02257963 CLARUS PRE
PIMECROLIMUS
Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.1% Cream
02247238 ELIDEL NVC
TACROLIMUS (PROTOPIC)
Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.0.03% Ointment
02244149 PROTOPIC AST
84:92.00 MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE AGENTS
TACROLIMUS (PROTOPIC)
Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.0.1% Ointment
02244148 PROTOPIC AST
TAZAROTENE
0.05% Gel
02230784 TAZORAC ALL0.1% Gel
02230785 TAZORAC ALL
VITAMIN E
30IU Ointment
01910787 VITAMIN E JLF
Page 122 of 1382014
Non-Insured Health BenefitsHealth Canada
86:00 SMOOTH MUSCLE RELAXANTS
86:12.00 GENITOURINARY SMOOTH
MUSCLE RELAXANTS
DARIFENACIN HYDROBROMIDE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
7.5MG Extended Release TabletST
02273217 ENABLEX MRL15MG Extended Release Tablet
ST
02273225 ENABLEX MRL
FLAVOXATE HCL
200MG TabletST
00728179 URISPAS PAL
OXYBUTYNIN CHLORIDE
1MG/ML SyrupST
02231089 APO-OXYBUTYNIN APX02223376 PMS-OXYBUTYNIN PMS
2.5MG TabletST
02240549 PMS-OXYBUTYNIN PMS5MG Tablet
ST
02163543 APO-OXYBUTYNIN APX02241285 DOM-OXYBUTYNIN DPC02230800 GEN-OXYBUTYNIN GEN02230394 NOVO-OXYBUTYNIN TEV02220059 OXYBUTYNIN VAE02350238 OXYBUTYNIN SAN02220636 OXYBUTYNINE PDL02240550 PMS-OXYBUTYNIN PMS02299364 RIVA-OXYBUTYNIN RIV
TOLTERODINE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
2MG Extended Release CapsuleST
02244612 DETROL LA PFI4MG Extended Release Capsule
ST
02244613 DETROL LA PFI1MG Tablet
ST
02239064 DETROL PFI2MG Tablet
ST
02239065 DETROL PFI
86:12.00 GENITOURINARY SMOOTH
MUSCLE RELAXANTS
TROSPIUM CHLORIDE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
20MG TabletST
02275066 TROSEC ORY
86:12.04 ANTIMUSCARINICS
SOLIFENACIN SUCCINATE
Limited use benefit (prior approval required).
For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.
5MG TabletST
02277263 VESICARE AST10MG Tablet
ST
02277271 VESICARE AST
86:16.00 RESPIRATORY SMOOTH
MUSCLE RELAXANTS
OXTRIPHYLLINE
20MG/ML Elixir
00476366 CHOLEDYL PFI100MG Tablet
00441724 APO-OXTRIPHYLLINE APX200MG Tablet
00441732 APO-OXTRIPHYLLINE APX300MG Tablet
00511692 APO-OXTRIPHYLLINE APX
THEOPHYLLINE
5.33MG/ML Elixir
00575151 PMS-THEOPHYLLINE PMS00466409 PULMOPHYLLIN RIV00627410 THEOPHYLLINE ATL
5.33MG/ML Solution
01966219 THEOLAIR MMH100MG Sustained Release Tablet
00692689 APO-THEO APX02230085 NOVO-THEOPHYL SR TEV
200MG Sustained Release Tablet
00692697 APO-THEO LA APX02230086 NOVO-THEOPHYL SR TEV
300MG Sustained Release Tablet
00692700 APO-THEO LA APX02230087 NOVO-THEOPHYL SR TEV
400MG Sustained Release Tablet
02360101 THEO ER AAP02014165 UNIPHYL PFR
Page 123 of 1382014
Non-Insured Health BenefitsHealth Canada
86:16.00 RESPIRATORY SMOOTH
MUSCLE RELAXANTS
THEOPHYLLINE
600MG Sustained Release Tablet
02360128 THEO ER AAP02014181 UNIPHYL PFR
Page 124 of 1382014
Non-Insured Health BenefitsHealth Canada
88:00 VITAMINS
88:04.00 VITAMIN A
VITAMIN A
10,000IU CapsuleST
00557447 VIT A VTH *00297720 VITAMIN A JAM
25,000IU CapsuleST
00021067 VITAMIN A TEV50,000IU Capsule
ST
00021075 VITAMIN A TEV
88:08.00 VITAMIN B COMPLEX
CYANOCOBALAMIN
100MCG/ML Injection
00497533 VITAMIN B12 ABB02241500 VITAMIN B12 SDZ
1,000MCG/ML Injection
01987003 CYANOCOBALAMIN CYX02052717 CYANOCOBALAMIN TAR00521515 VIT B12 SDZ00038830 VITAMIN B12 ABB
250MCG TabletST
00335940 VITAMIN B12 JAM1000MCG Tablet
ST
80028902 JAMP-VITAMIN B12 JAP02237736 VITAMIN B12 SWS80003575 VITAMIN B12 PMT
CYANOCOBALAMINE
0.2MG/ML Oral Liquid
80026092 JAMP-VITAMINE JAP100MCG Tablet
ST
80015265 JAMP-VITAMINE JAP250MCG Tablet
ST
80015294 JAMP-VITAMINE JAP
FOLIC ACID
1MG TabletST
00318973 FOLIC ACID JAM00647039 FOLIC ACID VTH02048841 FOLIC ACID PMT02236747 FOLIC ACID PED
5MG TabletST
00426849 APO-FOLIC ACID APX02285673 EURO-FOLIC EUR02366061 JAMP FOLIC ACID JAP
NIACIN
50MG TabletST
00041084 NIACIN PMS100MG Tablet
ST
00268585 NIACIN VAE
88:08.00 VITAMIN B COMPLEX
NIACIN
500MG TabletST
00294950 NIACIN VAE01939130 NIACIN ODN02247004 NIACIN PMT00557412 NIACIN YEAST FREE VTH00309737 VITAMIN B3 JAM
PYRIDOXINE HCL
25MG TabletST
00122645 VITAMIN B6 JAM00232475 VITAMIN B6 PMS01943200 VITAMIN B6 ODN
50MG TabletST
00252689 VITAMIN B6 VAE00305227 VITAMIN B6 JAM00608599 VITAMIN B6 PMS *
100MG TabletST
00263958 VITAMIN B6 VAE00329185 VITAMIN B6 JAM00450677 VITAMIN B6 VTH *02239348 VITAMIN B6 PMT
THIAMINE HCL
100MG/ML Injection
02241983 BETAXIN ABB02243525 THIAMINE CYX00816078 VITAMIN B1 SIL
50MG TabletST
00268631 VITAMIN B1 VAE100MG Tablet
ST
00232467 VITAMIN B1 PMS *00294853 VITAMIN B1 VAE00407011 VITAMIN B1 JAM02239350 VITAMIN B1 PMT
88:12.00 VITAMIN C
ASCORBIC ACID
250MG Chewable TabletST
00266051 VITAMIN C PMT500MG Chewable Tablet
ST
00274240 VITAMIN C PED00322997 VITAMIN C LAL *00784591 VITAMIN C VTH *02243893 VITAMIN C PMT02245721 VITAMIN C PMT
1000MG Sustained Release TabletST
00760587 VITAMIN C PMT250MG Tablet
ST
00221244 VIT C ADA00557811 VIT C VTH *00162515 VITAMIN C PMT
Page 125 of 1382014
Non-Insured Health BenefitsHealth Canada
88:12.00 VITAMIN C
ASCORBIC ACID
500MG TabletST
00266086 ASCORBIC ACID PMT00041114 VIT C ADA00322326 VIT C LAL00036188 VITAMIN C PED00557838 VITAMIN C VTH *01922378 VITAMIN C SWS02163268 VITAMIN C JAM02244469 VITAMIN C PMT
1000MG TabletST
00354376 VITAMIN C PMT
88:16.00 VITAMIN D
ALFACALCIDOL
0.25MCG CapsuleST
00474517 ONE-ALPHA LEO1MCG Capsule
ST
00474525 ONE-ALPHA LEO2MCG/ML Oral Liquid
ST
02240329 ONE-ALPHA LEO
CALCITRIOL
0.25MCG CapsuleST
00481823 ROCALTROL HLR0.5MCG Capsule
ST
00481815 ROCALTROL HLR
CHOLECALCIFEROL
400IU CapsuleST
02242651 EURO D EUR10,000IU Capsule
ST
02253178 EURO D EUR02371499 PHARMA-D PMS
50,000IU CapsuleST
02301911 OSTOFORTE TPH400IU/ML Drop
ST
00762881 D VI SOL MJO02231624 PEDIAVIT D EUR
400IU TabletST
00765384 VITAMIN D LAL02238729 VITAMIN D VTH02240624 VITAMIN D WAM02240858 VITAMIN D PMT
1,000IU TabletST
02245842 VITAMIN D PMT10,000IU Tablet
ST
00821772 D-TABS RIV10,000UI Tablet
ST
02379007 JAMP-VITAMINE D JAP
ERGOCALCIFEROL
50,000IU CapsuleST
02237450 D-FORTE EUR
88:16.00 VITAMIN D
ERGOCALCIFEROL
8,288IU/ML SolutionST
02017598 DRISDOL SAC
VITAMIN D
400IU Capsule
80006629 D-GEL JAP80001145 PHARMA D PED80005560 RIVA-D RIV80008590 VITAMIN D BMI
800IU Capsule
80007769 D-GEL JAP80003010 EURO D EUR80008446 VITAMIN D BMI
1,000 IU CapsuleST
80007766 D-GEL JAP1000IU Capsule
ST
80008496 PHARMA-D PMS400IU Liquid
ST
80019649 D3-DOL JAP400IU/ML Liquid
80003038 VITAMIN D JAP400U/ML Liquid
ST
80038155 DECAXIL ORM8,288 IU/M Liquid
ST
80020776 D2-DOL JAP400IU Tablet
80002452 VITAMIN D WNP80009578 VITAMIN D SWS
1000IU Tablet
80000436 VITAMIN D JAM80002169 VITAMIN D PMS80003663 VITAMIN D WNP80009580 VITAMIN D SWS
88:20.00 VITAMIN E
VITAMIN E
200IU CapsuleST
00122831 VITAMIN E JAM400IU Capsule
ST
00122858 VITAMIN E JAM50IU/ML Liquid
ST
02162075 AQUASOL E NVC
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVATAMINS (PRENATAL)
Tablet
80001842 CENTRUM MATERNA WYA
Page 126 of 1382014
Non-Insured Health BenefitsHealth Canada
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS (PEDIATRIC)
Limited use benefit (prior approval is not required).
Pediatric multivitamins are benefits for children up to 6 years of age.
DropST
00762946 POLY-VI-SOL MJOLiquid
ST
00558079 INFANTOL HORTablet
ST
80020794 CENTRUM JUNIOR COMPLETE TB
PFI
80011134 CENTRUM JUNIOR COMPLETE TAB
WYE
02247975 FLINTSTONES EXTRA C BCD
MULTIVITAMINS (PRENATAL)
Limited use benefit (prior approval is not required.).
Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).
TabletST
02229535 MULTI-PRE AND POST NATAL PED80005770 PRENATAL & POSTPARTUM PMT02241235 PRENATAL AND POSTPARTUM SDR
VITAMIN A, CHOLECALCIFEROL, ASCORBIC
ACID
2,500IU & 666.67IU & 50MG/ML DropST
02229790 PEDIAVIT EUR00762903 TR- VI-SOL MJO
88:32.00
MAGNESIUM OXIDE
100MG TabletST
02068400 MAGNESIUM JAM
Page 127 of 1382014
Non-Insured Health BenefitsHealth Canada
92:00 UNCLASSIFIED THERAPEUTIC
AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC
AGENTS
EXTEMPORANEOUS MIXTURE
Miscellaneous
00999997 EXTEMPORANEOUS MIXTURE (ATL)
*
00990019 EXTEMPORANEOUS MIXTURE (BC) (SK)
*
00999994 EXTEMPORANEOUS MIXTURE (ON)
*
00999999 EXTEMPORANEOUS MIXTURE (QC) (AB)
*
PENTOSAN POLYSULFATE SODIUM
100MG Capsule
02029448 ELMIRON JNO
SEVELAMER HYDROCHLORIDE
Limited Use Benefit ( Prior approval required ).
a. - patients with elevated phosphate levels OR elevated phosphate X calcium product despite dietary restriction of phosphate and use of calcium-based phosphate binders (short term elevations should be managed with aluminium based binders)b. - patients with elevated calcium levels despite discontinuation of calcium binder, and Vitamin D analogue and/or modification of dialysate calciumc. - patients with adynamic bone disease and low PTH levels (<100 pg/ml or <0.9 pmol/L) with normal or elevated calcium levels
800MG Tablet
02244310 RENAGEL GEE *
USTEKINUMAB
Limited use benefit (prior approval required).
For the treatment of moderate to severe psoriasis according to established criteria.
(Please refer to Appendix A).
45MG/0.5ML Injection
02320673 STELARA JNO90MG/ML Injection
02320681 STELARA JNO
WATER
100% Injection
99002264 STERILE WATER AUT *00905178 WATER FOR INJECTION UNK *00038202 WATER STERILE ABB *
92:01.00 NATURAL HEALTH PRODUCTS
SENNOSIDES
8.6MG Tablet
80009182 JAMP-SENNOSIDES JAP12MG Tablet
80009183 JAMP-SENNOSIDES JAP
92:01.40
CALCIUM CARBONATE
500MG Tablet
80001122 PHARMA-CAL PED
92:01.88
ANHYDROUS MAGNESIUM CITRATE
50MG/ML Solution
80001809 CITRODAN ODN
ERGOCALCIFEROL
8,288IU/ML Solution
80003615 ERDOL ODN
MAGNESIUM
25MG Oral Liquid
80009357 JAMP-MAGNESIUM JAP100MG/ML Oral Liquid
80004109 MAGNESIUM-ODAN ODN28MG Tablet
80009539 JAMP-MAGNESIUM GLUCONATE
JAP
MULTIVITAMINS (PEDIATRIC)
Limited use benefit (prior approval is not required).
Pediatric multivitamins are benefits for children up to 6 years of age.
Liquid
80008471 JAMP-MULTIVITAMIN A/D/ C DROPS
JAP
POTASSIUM CHLORIDE
20MMOL Long Acting Tablet
80004415 ODAN K-20 ODN8MEQ Tablet
80008214 ODAN K-8 ODN
PYRIDOXINE HCL
25MG Tablet
80002890 VITAMIN B6 JAP
SODIUM PHOSPHATE
Oral Liquid
80000689 PHOSLAX ODN
THIAMINE
50MG Tablet
02245506 EURO-B1 EUR80009633 JAMP-VITAMIN B1 JAP
100MG Tablet
80009588 JAMP-VITAMIN B1 JAP
Page 128 of 1382014
Non-Insured Health BenefitsHealth Canada
92:08.00
DUTASTERIDE
Limited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
0.5MG Capsule
02247813 AVODART GSK
FINASTERIDE
Limited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker.orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
5MG Tablet
02365383 APO-FINASTERIDE APX02354462 CO FINASTERIDE ACT02376709 DOM-FINASTERIDE DOM02350270 FINASTERIDE PDL02357224 JAMP-FINASTERIDE JAP02389878 MINT-FINASTERIDE MIN02356058 MYLAN-FINASTERIDE MYL02310112 PMS-FINASTERIDE PMS02010909 PROSCAR FRS02371820 RAN-FINASTERIDE RBY02306905 RATIO-FINASTERIDE TEP02322579 SANDOZ FINASTERIDE SDZ02348500 TEVA-FINASTERIDE TEP
92:12.00
LEUCOVORIN CALCIUM
5MG Tablet
02170493 LEUCOVORIN CALCIUM WAY
92:16.00
ALLOPURINOL
100MG TabletST
00449687 ALLOPRIN VAE00555681 ALLOPURINOL PDL02402769 APO-ALLOPURINOL APX02396327 MAR-ALLOPURINOL MAR00402818 ZYLOPRIM AAP
200MG TabletST
00514209 ALLOPRIN VAE02130157 ALLOPURINOL PDL02402777 APO-ALLOPURINOL APX02396335 MAR-ALLOPURINOL MAR00479799 ZYLOPRIM AAP
92:16.00
ALLOPURINOL
300MG TabletST
00454354 ALLOPRIN VAE00294322 ALLOPURINOL APX00555703 ALLOPURINOL PDL02402785 APO-ALLOPURINOL APX02396343 MAR-ALLOPURINOL MAR00402796 ZYLOPRIM AAP
COLCHICINE
0.6MG Tablet
00572349 COLCHICINE ODN02373823 JAMP-COLCHICINE JAP02402181 PMS-COLCHICINE PMS
1MG Tablet
00621374 COLCHICINE ODN
FEBUXOSTAT
Limited use benefit (prior approval required).For patients with symptomatic gout who have documented hypersensitivity to allopurinol
80MG Tablet
02357380 ULORIC TAK
92:24.00
ALENDRONATE SODIUM
Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥ 7.5mg per day for ≥3 months.
5MG TabletST
02248727 APO-ALENDRONATE APX02248251 NOVO-ALENDRONATE TEV02384698 RAN-ALENDRONATE RBY02288079 SANDOZ ALENDRONATE SDZ
10MG TabletST
02248728 APO-ALENDRONATE APX02388545 AURO-ALENDRONATE AUR02270129 GEN-ALENDRONATE GEN02394863 MINT-ALENDRONATE MIN02247373 NOVO-ALENDRONATE TEV02288087 SANDOZ ALENDRONATE SDZ
40MG TabletST
02258102 CO-ALENDRONATE ACT
Page 129 of 1382014
Non-Insured Health BenefitsHealth Canada
92:24.00
ALENDRONATE SODIUM
Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥ 7.5mg per day for ≥3 months.
70MG TabletST
02352966 ALENDRONATE SAN02303078 ALENDRONATE-70 PDL02299712 ALENDRONATE-FC SIV02248730 APO-ALENDRONATE APX02388553 AURO-ALENDRONATE AUR02258110 CO-ALENDRONATE ACT02282763 DOM-ALENDRONATE DOM02245329 FOSAMAX FRS02286335 GEN-ALENDRONATE GEN02385031 JAMP-ALENDRONATE JAP02394871 MINT-ALENDRONATE MIN02261715 NOVO-ALENDRONATE TEV02273179 PMS-ALENDRONATE PMS02284006 PMS-ALENDRONATE FC PMS02275279 RATIO-ALENDRONATE RPH02270889 RIVA-ALENDRONATE RIV02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE FC SOR
ALENDRONATE SODIUM, VITAMIN D3
Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥ 7.5mg per day for ≥3 months.
70MG & 2800U TabletST
02276429 FOSAVANCE FRS02403633 TEVA-ALENDRONATE
CHOLECALCIFEROLTEP
70MG & 5600U TabletST
02314940 FOSAVANCE FRS02403641 TEVA-ALENDRONATE
CHOLECALCIFEROLTEP
92:24.00
DENOSUMAB (P)
Limited use benefit (prior approval required).For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom:- bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); ANDHave at least two of the following:- age >70 years- a prior fragility fracture- a bone mineral density (BMD) T-score ≤ -2.5
60MG/ML Injection (Pre-filled Syringe)
02343541 PROLIA AMG
ETIDRONATE DISODIUM
200MG Tablet
02248686 CO-ETIDRONATE ACT02245330 GEN-ETIDRONATE GEN
ETIDRONATE DISODIUM, CALCIUM
CARBONATE
400MG & 500MG Tablet
02263866 CO-ETIDROCAL ACT02176017 DIDROCAL PGP02353210 ETIDROCAL SAN02247323 MYLAN-ETI-CAL CAREPAC GEN02324199 NOVO-ETIDROCAL TEV
PAMIDRONATE DISODIUM
30MG Injection
02059762 AREDIA IV NVR02244550 PAMIDRONATE DISODIUM MAY02264951 RHOXAL-PAMIDRONATE RHO
60MG Injection
02244551 PAMIDRONATE DISODIUM HOS02264978 RHOXAL-PAMIDRONATE SDZ
90MG Injection
02059789 AREDIA IV NVR02244552 PAMIDRONATE DISODIUM MAY02245999 PMS-PAMIDRONATE PMS02264986 RHOXAL-PAMIDRONATE SDZ
RISEDRONATE SODIUM
Limited use benefit (prior approval required).
For the treatment of:
a. - Osteoporosis in patients who are 60 years of age and over orb. - Osteoporosis in patients who have documented hip, vertebral or other fractures orc. - Paget's Disease ord. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk ore. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months
5MG Tablet
02298376 TEVA-RISEDRONATE TEP
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92:24.00
RISEDRONATE SODIUM
Limited use benefit (prior approval required).
For the treatment of:
a. - Osteoporosis in patients who are 60 years of age and over orb. - Osteoporosis in patients who have documented hip, vertebral or other fractures orc. - Paget's Disease ord. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk ore. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months
5MG Tablet
02242518 ACTONEL PGP30MG Tablet
02239146 ACTONEL PGP02298384 TEVA-RISEDRONATE TEP
35MG Tablet
02246896 ACTONEL PGP02353687 APO-RISEDRONATE APX02309831 DOM-RISEDRONATE DOM02368552 JAMP-RISEDRONATE JAP02357984 MYLAN-RISEDRONATE MYL02302209 PMS-RISEDRONATE PMS02347474 RISEDRONATE PDL02352141 RISEDRONATE SIV02370255 RISEDRONATE SAN02411407 RISEDRONATE-35 SIV02341077 RIVA-RISEDRONATE RIV02327295 SANDOZ RISEDRONATE SDZ02298392 TEVA-RISEDRONATE TEP
ZOLEDRONIC ACID
Limited use benefit (prior approval required).
• For the treatment of Paget‟s disease. Coverage will be granted for one dose per 12 month period. OR.
• For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: • age >70 years • a prior fragility fracture • a bone mineral density (BMD) T-score ≤ - 2.5. • a bone mineral density (BMD) T-score ≤ -2.5.
5MG/100ML Injection
02269198 ACLASTA NOV
92:36.00 DISEASE-MODIFYING
ANTIRHEUMATIC AGENTS
ABATACEPT
Limited use benefit (prior approval required).
For the treatment of:• Rheumatoid Arthritis according to established criteria. • Juvenile Idiopathic Arthritis
(Please refer to Appendix A).250MG/VIAL Injection
02282097 ORENCIA 250MG/VIAL INJ BMS
ADALIMUMAB
Limited use benefit (prior approval required).
For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. • Psoriasis according to established criteria. • Crohn's disease according to established criteria. • Juvenile idiopathic arthritis according to established criteria.(Please refer to Appendix A).
40MG/Vial Injection
02258595 HUMIRA ABB
CERTOLIZUMAB PEGOL
Limited use benefit (prior approval required).
For the treatment of:• Rheumatoid Arthritis according to established criteria.
(Please refer to Appendix A).
200MG/ML Injection
02331675 CIMZIA UCB
ETANERCEPT
Limited use benefit (prior approval required).
For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. • Juvenile Idiopathic Arthritis
(Please refer to Appendix A).25MG/VIAL Injection
02242903 ENBREL IMX50MG/ML Injection
02274728 ENBREL IMX
GOLIMUMAB
Limited use benefit (prior approval required).
For the treatment of:• Rheumatoid Arthritis according to established criteria. • Psoriatic Arthritis according to established criteria. • Ankylosing Spondylitis according to established criteria. (Please refer to Appendix A).
50MG/0.5ML Injection
02324784 SIMPONI KEG02324776 SIMPONI PRE-FILLED KEG
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92:36.00 DISEASE-MODIFYING
ANTIRHEUMATIC AGENTS
INFLIXIMAB
Limited use benefit (prior approval required).
For treatment of:•Fistulizing Crohn‟s disease according to established criteria.•For adult patients with moderately to severely active Crohn‟s Disease who have had an inadequate response to conventional therapy.(Please refer to Appendix A).
or•Rheumatoid Arthritis according to established criteria(Please refer to Appendix A).
100MG/VIAL Injection
02244016 REMICADE CER
LEFLUNOMIDE
10MG Tablet
02256495 APO-LEFLUNOMIDE APX02241888 ARAVA SAC02351668 LEFLUNOMIDE SAN02319225 MYLAN-LEFLUNOMIDE MYL02288265 PMS-LEFLUNOMIDE PMS02283964 SANDOZ LEFLUNOMIDE SDZ02261251 TEVA-LEFLUNOMIDE TEV
20MG Tablet
02256509 APO-LEFLUNOMIDE APX02241889 ARAVA SAC02351676 LEFLUNOMIDE SAN02319233 MYLAN-LEFLUNOMIDE MYL02288273 PMS-LEFLUNOMIDE PMS02283972 SANDOZ LEFLUNOMIDE SDZ02261278 TEVA-LEFLUNOMIDE TEV
TOCILIZUMAB
Limited use benefit (prior approval required).For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-TNF agent.(Please refer to Appendix A).
80MG/4ML Injection
02350092 ACTEMRA HLR200MG/10ML Injection
02350106 ACTEMRA HLR400MG/20ML Injection
02350114 ACTEMRA HLR
92:44.00
AZATHIOPRINE
50MG Tablet
02242907 APO-AZATHIOPRINE APX02243371 AZATHIOPRINE PDL02343002 AZATHIOPRINE SAN00004596 IMURAN GSK
92:44.00
CYCLOSPORINE
Limited use benefit (prior approval required).
For transplant therapy.10MG Capsule
02237671 NEORAL NVR25MG Capsule
02150689 NEORAL NVR02247073 SANDOZ-CYCLOSPORINE SDZ
50MG Capsule
02150662 NEORAL NVR02247074 SANDOZ-CYCLOSPORINE SDZ
100MG Capsule
02150670 NEORAL NVR02242821 SANDOZ-CYCLOSPORINE SDZ
100MG/ML Solution
02150697 NEORAL NVR
MYCOPHENOLATE MOFETIL
Limited use benefit (prior approval required).
For transplant therapy.250MG Capsule
02352559 APO-MYCOPHENOLATE APX02192748 CELLCEPT HLR02386399 JAMP-MYCOPHENOLATE JAP02371154 MYLAN-MYCOPHENOLATE MYL02320630 SANDOZ MYCOPHENOLATE SDZ02364883 TEVA-MYCOPHENOLATE TEP
500MG Tablet
02352567 APO-MYCOPHENOLATE APX02237484 CELLCEPT HLR02379996 CO MYCOPHENOLATE ACT02380382 JAMP-MYCOPHENOLATE JAP02370549 MYLAN-MYCOPHENOLATE MYL02313855 SANDOZ MYCOPHENOLATE SDZ02348675 TEVA-MYCOPHENOLATE TEP
MYCOPHENOLATE SODIUM
Limited use benefit (prior approval required).
For transplant therapy.180MG Enteric Coated Tablet
02264560 MYFORTIC NVR360MG Enteric Coated Tablet
02264579 MYFORTIC NVR
SIROLIMUS
Limited use benefit (prior approval required).
Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.
1MG/ML Oral Liquid
02243237 RAPAMUNE WAY1MG Tablet
02247111 RAPAMUNE WAY
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92:44.00
TACROLIMUS
Limited use benefit (prior approval required).
For transplant therapy.0.5MG Capsule
02243144 PROGRAF AST1MG Capsule
02175991 PROGRAF AST5MG Capsule
02175983 PROGRAF AST0.5MG Extended Release Capsule
02296462 ADVAGRAF AST1MG Extended Release Capsule
02296470 ADVAGRAF AST3MG Extended Release Capsule
02331667 ADVAGRAF AST5MG Extended Release Capsule
02296489 ADVAGRAF AST5MG/ML Injection
02176009 PROGRAF AST
92:92.00
BOTULINUM TOXIN TYPE A
Limited use benefit (prior approval required).
For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis)
50U Injection
09857386 BOTOX ALL100U Injection
01981501 BOTOX ALL200U Injection
09857387 BOTOX ALL
CYPROTERONE ACETATE, ETHINYL
ESTRADIOL
2MG & 35MCG Tablet
02290308 CYESTRA-35 PMS02233542 DIANE-35 BAY02309556 NOVO-
CYPROTERONE/ETHINYL ESTRADIOL
TEV
INCOBOTULINUMTOXINA
Limited use benefit (prior approval required).
-Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older-Treatment of cervical dystonia (spasmodic torticollis)
100U/VIAL Injection
02324032 XEOMIN MEZ
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94:00 DEVICES
94:00.00 DEVICES
NEEDLE (NON-INSULIN)
Needle
99400528 NEEDLES (NON-INSULIN) DISPOSABLE
SPACER DEVICE
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 spacer device every 12 months.Device
96899962 AEROCHAMBER AC BOYZ TRU96899963 AEROCHAMBER AC GIRLZ TRU96899969 AEROCHAMBER PLUS FLOW-
VU LGTRU
96899970 AEROCHAMBER PLUS FLOW-VU MED
TRU
96899968 AEROCHAMBER PLUS FLOW-VU MOUTH
TRU
96899971 AEROCHAMBER PLUS FLOW-VU SM
TRU
99400507 E-Z SPACER WEP99400511 E-Z SPACER (MASK ONLY) WEP99400508 E-Z SPACER WITH SMALL
MASKWEP
99400501 OPTICHAMBER AUC96899961 OPTICHAMBER DIAMOND
(CHAMBER)AUC
96899958 OPTICHAMBER DIAMOND (LARGE M)
AUC
96899959 OPTICHAMBER DIAMOND (MEDIUM M)
AUC
96899960 OPTICHAMBER DIAMOND (MEDIUM M)
AUC
99400504 OPTICHAMBER LARGE MASK AUC99400503 OPTICHAMBER MEDIUM MASK AUC99400502 OPTICHAMBER SMALL MASK AUC99400505 OPTIHALER AUC99400787 POCKET CHAMBER MCA99400791 POCKET CHAMBER WITH
ADULT MASKMCA
99400788 POCKET CHAMBER WITH INFANT MASK
MCA
99400790 POCKET CHAMBER WITH MEDIUM MASK
MCA
99400789 POCKET CHAMBER WITH SMALL MASK
MCA
SYRINGE & NEEDLE (NON-INSULIN)
Syringe & Needle
99400534 NON-INSULIN 1CC99400536 NON-INSULIN 3CC99400537 NON-INSULIN 5CC99400538 NON-INSULIN 10CC
94:00.00 DEVICES
SYRINGE (NON-INSULIN)
Syringe
99400823 LUER LOCK (DISP) 30CC BTD99400549 LUER LOCK (DISP) 60CC99400529 NON-INSULIN (DISP) 1CC99400531 NON-INSULIN (DISP) 3CC99400532 NON-INSULIN (DISP) 5CC99400533 NON-INSULIN (DISP) 10CC
94:01.00 DEVICES (DIABETIC)
INSULIN PUMP SUPPLIES
Device
99401049 ADAPTOR AUC99401052 ADHESIVE PAD WITH COTTON AUC99401053 ADHESIVE PAD WITHOUT
COTTONAUC
99401050 INFUSION SETS AUC99401038 INSULIN PUMP BATTERY AUC99401047 INSULIN PUMP CARTRIDGES AUC99401048 PISTON ROD AUC09991061 RESERVOIR 5XX 1.8ML
SYRINGEMDT
09991062 RESERVOIR 7XX 3.0ML SYRINGE
MDT
99401051 TUBING AUC
ISOPROPYL ALCOHOL
00809357 ALCOHOL SWABS BD BTD70% Swab
00480452 ALCOHOL PREP SWAB PFD02247809 ALCOHOL SWAB TIP02240759 B-D ALCOHOL SWAB BTD99438102 MONOJECT ALCOHOL WIPES SHM00795232 WEBCOL ALCOHOL PREP JAJ
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94:01.00 DEVICES (DIABETIC)
LANCET
Lancet
97799817 ACCU-CHEK MULTICLIX ROD99401068 BD LATITUDE BTD97799466 BG STAR SAC97799541 EZ HEALTH ORACLE TRE00900834 FINGERSTIX BAY00995965 FINGERSTIX BAY00977839 FREESTYLE THS *99401063 FREESTYLE THS97799766 ITEST LANCETS 28G (100) AUC97799767 ITEST LANCETS 33G (100) AUC00901555 LIFESCAN REGULAR JAJ97799388 MEDI+SURE SOFT 30G TWIST MEC97799389 MEDI+SURE SOFT 33G TWIST MEC00906190 MEDISENSE AUC00906239 MICROLET BAY00977493 MICROLET BAY00977543 MONOLET ORIGINAL SHM99401055 MONOLET THIN SHM97799810 MPD THIN (100) MPD97799811 MPD THIN (200) MPD97799807 MPD ULTRA THIN (100) MPD97799808 MPD ULTRA THIN (200) MPD97799431 ONE TOUCH DELICA 30G JAJ00965561 ONE TOUCH DELICA 33G JAJ00901359 ONE TOUCH ULTRA SOFT JAJ97799501 ONETOUCH DELICA 33G JAJ00905917 SOFT TOUCH ROD00000165 SOFTCLIX BOE97799945 SOFTCLIX ROC00902144 SOFTCLIX SELECT BOE00977373 SOFTCLIX SELECT BOE00900141 ULTRA-FINE II BTD00977659 ULTRA-FINE II BTD00977051 UNILET COMFORT TOUCH BAY00977896 UNILET COMFORT TOUCH BAY00984167 UNILET COMFORT TOUCH BAY
MAGNIFIER
Magnifier
99400550 SYRINGE SCALE MAGNIFIER
NEEDLE
Needle
97799526 BD AUTOSHIELD PEN NEEDLE BTD00908452 B-D PEN BTD00977756 NOVOFINE NOO
29G X 12MM Needle
97799566 INSUPEN 29GX12MM NEEDLE DPI30G X 8MM Needle
97799567 INSUPEN 30GX8MM NEEDLE DPI31G X 6MM Needle
97799569 INSUPEN 31GX6MM NEEDLE DPI31G X 8MM Needle
97799568 INSUPEN 31GX8MM NEEDLE DPI
94:01.00 DEVICES (DIABETIC)
NEEDLE
32G X 4MM Needle
97799527 BD ULTRA-FINE NANO PEN NEEDLE
BTD
32G X 6MM Needle
97799571 INSUPEN 32GX6MM NEEDLE DPI32G X 8MM Needle
97799570 INSUPEN 32GX8MM NEEDLE DPI22G Needle
00977616 B-D DISPOSABLE 1 INCH 5155 BTD00977624 B-D DISPOSABLE 1½ INCH
5156BTD
25G Needle
00977071 B-D DISPOSABLE 5/8 INCH 5122
BTD
00977063 B-D DISPOSABLE 1½ INCH 5127
BTD
27G Needle
00977012 B-D DISPOSABLE ½ INCH 5109 BTD28G Needle
99221028 NOVOFINE INSULIN PEN 28G NOO29G Needle
00977101 B-D ULTRA-FINE PEN BTD00900513 OWEN MUMFORD UNIFINE
PENTIPS 1/2 INCHAUC
00908185 ULTRAFINE PEN ULTRA-FINE 29G
BTD
29G X 12.7MM Needle
97799561 SUPER-FINE STANDARD 29G-12.7MM
PMS
29G X 12MM Needle
97799543 ULTI 29GX1/2 INC SHARP CONTAIN
UMI
30G Needle
00921114 NOVOFINE NOO00908169 NOVOFINE 30G NOO99117796 NOVOFINE INSULIN PEN 30G NOO97799467 NOVOTWIST TIP NEEDLE 30G NOO
31G Needle
00909114 BD ULTRA-FINE III PEN NEEDLES
BTD
00977011 B-D ULTRA-FINE PEN III BTD00900511 OWEN MUMFORD UNIFINE
PENTIPS 1/4 INCHAUC
00900512 OWEN MUMFORD UNIFINE PENTIPS 5/16 INCH
AUC
31G X 4.5MM Needle
97799404 CLICKFINE PEN NEEDLE 31G 4.5MM
AUC
31G X 5MM Needle
97799563 SUPER-FINE MICRO 31G-5MM NEEDL
PMS
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94:01.00 DEVICES (DIABETIC)
NEEDLE
31G X 6MM Needle
97799405 CLICKFINE PEN NEEDLE 31G 6MM
AUC
97799545 ULTI 31GX1/4 INC SHARP CONTAIN
UMI
31G X 8MM Needle
97799406 CLICKFINE PEN NEEDLE 31G 8MM
AUC
97799441 LIFE BRAND PEN NEEDLE 31G 8MM
HOD
97799562 SUPER-FINE XTRA 31G-8MM NEEDLE
PMS
97799544 ULTI 31GX5/16 INC SHARP CONTAI
UMI
32G Needle
97799821 NOVOFINE 32G 6MM NOO97799468 NOVOTWIST TIP NEEDLE 32G NOO
32G X 4MM Needle
97799440 ULTICARE PEN NEEDLE 32GX4MM
DPI
SHARPS CONTAINER
Device
99401026 B-D SHARPS CONTAINER 1.4L BTD99401027 B-D SHARPS CONTAINER 3.1L BTD
SYRINGE
Syringe
97799510 ULTICARE LOW DEAD SPACE SYG
UMI
0.3CC Syringe
00977961 B-D MICRO-FINE BTD00977977 B-D ULTRA-FINE / ULTRA-FINE
IIBTD
00977951 MONOJECT SHM99254011 MONOJECT DISP 3/10CC (100) SHM99253047 MONOJECT DISP 3/10CC (30) SHM00920053 SYRN MONOJECT SHM00900506 ULTICARE 29G AUC00964018 ULTICARE 29G AUC00900503 ULTICARE 30G AUC00964174 ULTICARE 30G AUC00920193 ULTRA-FINE BTD
0.5CC Syringe
00977985 B-D ULTRA-FINE II BTD00920177 MICRO-FINE BTD00920355 MONOJECT SHM99432799 MONOJECT (100) SHM99432633 MONOJECT (30) SHM00900505 ULTICARE 29G AUC00963941 ULTICARE 29G AUC00900502 ULTICARE 30G AUC00964115 ULTICARE 30G AUC00920207 ULTRA-FINE BTD
94:01.00 DEVICES (DIABETIC)
SYRINGE
1CC Syringe
99328369 B-D ULTRA-FINE BTD00920045 MONOJECT SHM *99433383 MONOJECT (100) SHM99432914 MONOJECT (30) SHM00900504 ULTICARE 29G AUC00963895 ULTICARE 29G AUC00900501 ULTICARE 30G AUC00964069 ULTICARE 30G AUC00920215 ULTRA-FINE BTD00909238 ULTRA-FINE II 30G BTD
28GX0.5CC Syringe
97799518 ULTICARE 0.5CC 28G SYG 1/2 INC
UMI
28GX1CC Syringe
97799517 ULTICARE 1CC 28G SYG 1/2 INCH
UMI
29GX0.3CC Syringe
97799509 ULTI SYG WITH ULTIG 29G 1/2 IN
UMI
29GX0.5CC Syringe
97799508 ULTI SYG WITH ULTIG 29G 1/2 IN
UMI
29GX1CC Syringe
97799507 ULTI SYG WITH ULTIG 29G 1/2 IN
UMI
97799997 ULTICARE INSULIN SYR 29G 1CC
AUC
97799906 ULTIGUARD INSULIN SYR 29G.1CC
AUC
29GX3CC Syringe
97799999 ULTICARE INSULIN SYR 29G.3CC
AUC
97799908 ULTIGUARD INSULIN SYR 29G.3CC
AUC
29GX5CC Syringe
97799998 ULTICARE INSULIN SYR 29G.5CC
AUC
97799907 ULTIGUARD INSULIN SYR 29G.5CC
AUC
30GX0.3CC Syringe
97799551 ULTI SYG WITH ULTIG 30G 1/2 IN
UMI
97799506 ULTI SYG WITH ULTIG 30G 5/16 I
UMI
30GX0.5CC Syringe
97799550 ULTI SYG WITH ULTIG 30G 1/2 IN
UMI
97799505 ULTI SYG WITH ULTIG 30G 5/16 I
UMI
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94:01.00 DEVICES (DIABETIC)
SYRINGE
30GX1CC Syringe
97799549 ULTI SYG WITH ULTIG 30G 1/2 IN
UMI
97799504 ULTI SYG WITH ULTIG 30G 5/16 I
UMI
97799994 ULTICARE INSULIN SYR 30G.1CC
AUC
97799903 ULTIGUARD INSULIN SYR 30G.1CC
AUC
30GX3CC Syringe
97799996 ULTICARE INSULIN SYR 30G.3CC
AUC
97799905 ULTIGUARD INSULIN SYR 30G.3CC
AUC
30GX5CC Syringe
97799995 ULTICARE INSULIN SYR30G.5CC
AUC
97799904 ULTIGUARD INSULIN SYR 30G.5CC
AUC
31GX0.3CC Syringe
97799548 ULTI SYG WITH ULTIG 31G 5/16 I
UMI
97799513 ULTICARE 0.3CC 31G SYG 5/16 IN
UMI
31GX0.5CC Syringe
97799547 ULTI SYG WITH ULTIG 31G 5/16 I
UMI
97799512 ULTICARE 0.5CC 31G SYG 5/16 IN
UMI
31GX1CC Syringe
97799546 ULTI SYG WITH ULTIG 31G 5/16 I
UMI
97799511 ULTICARE 1CC 31G SYG 5/16 INCH
UMI
SYRINGE & NEEDLE
0.3CC Syringe and Needle
99328419 B-D INSULIN 1/3CC 29G UF 1 BTD99639286 B-D MICRO-FINE 1/3CC BTD00909092 SYRN INS U-II 3/10CC 30G BTD00905690 SYRN INSULIN MICRO 3/10CC
28GBTD
00906786 SYRN INSULIN ULTRA 3/10CC 29G
BTD
0.5CC Syringe and Needle
99328377 B-D INSULIN 50U 29G BTD99221044 B-D MICRO-FINE INSULIN 50U BTD00983004 INSULIN LO DOSE MICRO 28G BTD00909084 SYRN INSULIN U-II 30G BTD00906727 SYRN INSULIN ULTRA 29G BTD
1CC Syringe and Needle
99262295 B-D INJECT-EASE WITH MICRO-FINE
BTD
99767467 B-D MICRO-FINE INSULIN 100U BTD00901911 B-D MICRO-FINE INSULIN 28G BTD00906816 SYRN INSULIN ULTRA 29G BTD
94:01.00 DEVICES (DIABETIC)
SYRINGE CASE
Syringe Case
99400552 MYHEALTH SYRINGE CASE-7 AUC99400551 MYHEALTH SYRINGE CASE-
SINGLEAUC
SYRINGE WITH NEEDLE
3/10CC X 31G Syringe
97799425 BD 0.3ML SYR WITH U/F 6MM NEED
BTD
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96:00 PHARMACEUTICAL AIDS
96:00.00 PHARMACEUTICAL AIDS
METHADONE HCL
Powder
00908835 METHADONE WIL
METHADONE HCL (PA)
limited use benefit (prior approval required) with the following criteria:
Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.
Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.
Powder
09991180 METHADONE POWDER (PAIN) UNK
POLYETHYLENE GLYCOL
Powder
09991007 POLYETHYLENE GLYCOL WIL09991054 POLYETHYLENE GLYCOL 3350
PWDWIL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
08:00 ANTI-INFECTIVE AGENTS08:12.18 QUINOLONES
LEVOFLOXACINLimited use benefit (prior approval not required).
Coverage will be limited to a maximum of 30 days.
250MG Tablet02284707 APO-LEVOFLOXACIN APX
02315424 CO-LEVOFLOXACIN ACT
02236841 LEVAQUIN JNO
02313979 MYLAN-LEVOFLOXACIN MYL
02248262 NOVO-LEVOFLOXACIN TEV
02284677 PMS-LEVOFLOXACIN PMS02298635 SANDOZ LEVOFLOXACIN SDZ
500MG Tablet02284715 APO-LEVOFLOXACIN APX
02315432 CO-LEVOFLOXACIN ACT
02236842 LEVAQUIN JNO
02313987 MYLAN-LEVOFLOXACIN MYL
02248263 NOVO-LEVOFLOXACIN TEV02284685 PMS-LEVOFLOXACIN PMS
02298643 SANDOZ LEVOFLOXACIN SDZ
750MG Tablet02325942 APO-LEVOFLOXACIN APX
02315440 CO-LEVOFLOXACIN ACT02246804 LEVAQUIN JNO
02285649 NOVO-LEVOFLOXACIN TEV02305585 PMS-LEVOFLOXACIN PMS
02298651 SANDOZ LEVOFLOXACIN SDZ
08:12.24 TETRACYCLINESMINOCYCLINE HCL
Limited use benefit (prior approval required).
For:a. - patients who cannot tolerate other tetracyclines.b. - patients with severe widespread acne who have failed on tetracycline.
50MG Capsule02084090 APO-MINOCYCLINE APX
02239667 DOM-MINOCYCLINE DPC02287226 MINOCYCLINE SAN
02108143 NOVO-MINOCYCLINE TEV
02153394 PDL-MINOCYCLINE PDL02239238 PMS-MINOCYCLINE PMS
02294419 PMS-MINOCYCLINE PMS
01914138 RATIO-MINOCYCLINE RPH
02242080 RIVA-MINOCYCLINE RIV
02237313 SANDOZ-MINOCYCLINE SDZ
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
08:12.24 TETRACYCLINESMINOCYCLINE HCL
Limited use benefit (prior approval required).
For:a. - patients who cannot tolerate other tetracyclines.b. - patients with severe widespread acne who have failed on tetracycline.
100MG Capsule02084104 APO-MINOCYCLINE APX
02239668 DOM-MINOCYCLINE DPC
02173506 MINOCIN STI
02239982 MINOCYCLINE IVX
02287234 MINOCYCLINE SAN
02108151 NOVO-MINOCYCLINE TEV02154366 PDL-MINOCYCLINE PDL
02294427 PMS-MINOCYCLINE PMS
02239239 PMS-MONOCYCLINE PMS
01914146 RATIO-MINOCYCLINE RPH
02242081 RIVA-MINOCYCLINE RIV
02237314 SANDOZ-MINOCYCLINE SDZ
08:12.28 MISCELLANEOUS ANTIBIOTICSLINEZOLID
Limited use benefit (prior approval required).
Tablets:
For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.
I.V. solution:
When linezolid cannot be administered orally in the above mentioned situations.
2MG/ML Injection02243685 ZYVOXAM PFI
600MG Tablet02243684 ZYVOXAM PFI
08:14.08 AZOLESVORICONAZOLE
Limited use benefit (prior approval required).
For the treatment of:a. - patients with invasive aspergillosis.b. - culture proven invasive candidiasis with documented resistance to fluconazole.
50MG Tablet02256460 VFEND PFI
200MG Tablet02256479 VFEND PFI
08:18.08 ANTIRETROVIRALSETRAVIRINE
Limited use benefit (prior approval required).
For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:a.- have failed prior antiretroviral therapy; andb. - have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs
100MG Tablet02306778 INTELENCE JNO
200MG Tablet02375931 INTELENCE KEG
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
08:18.08 ANTIRETROVIRALSMARAVIROC
Limited use benefit (prior approval required).
For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:a. - CR5 tropic viruses; andb. - documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)
150MG Tablet02299844 CELSENTRI VII
300MG Tablet02299852 CELSENTRI VII
RALTEGRAVIRLimited use benefit (prior approval required).
For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.
400MG Tablet02301881 ISENTRESS FRS
TENOFOVIR DISOPROXIL FUMARATELimited use benefit (prior approval required).
For the management of HIV disease in patients who have failed or have experienced adverse events to an alternative nucleoside reverse transcriptase inhibitor.
245MG Tablet02247128 VIREAD GIL
TIPRANAVIRLimited use benefit (prior approval required).
For the management of HIV disease in patients a. - who have failed all currently listed protease inhibitorsb. - intolerant to all currently listed protease inhibitors
250MG Capsule02273322 APTIVUS BOE
08:18.20 INTERFERONSPEGINTERFERON ALFA-2A
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
180MCG/0.5ML Injection02248077 PEGASYS HLR
180MCG/1ML Injection02248078 PEGASYS HLR
PEGINTERFERON ALFA-2A, RIBAVIRINLimited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
180MCG/0.5ML & 200MG Injection & Tablet02253429 PEGASYS RBV HLR
180MCG/1ML & 200MG Injection & Tablet02253410 PEGASYS RBV HLR
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
08:18.20 INTERFERONSPEGINTERFERON ALFA-2B, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered
50MCG/0.5ML & 200MG Injection & Capsule02246026 PEGETRON SCH
02254573 PEGETRON REDIPEN SCH
80MCG/0.5ML & 200MG Injection & Capsule02254581 PEGETRON REDIPEN SCH
100MCG/0.5ML & 200MG Injection & Capsule02254603 PEGETRON REDIPEN SCH
120MCG/0.5ML & 200MG Injection & Capsule02254638 PEGETRON REDIPEN SCH
150MCG/0.5ML & 200MG Injection & Capsule02246030 PEGETRON SCH02254646 PEGETRON REDIPEN SCH
08:18.32 NUCLEOSIDES AND NUCLEOTIDESENTECAVIR
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.
0.5MG Tablet02396955 APO-ENTECAVIR APX
08:18.40BOCEPREVIR
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b+ ribavirin), and the following criteria:
-detectable levels of hepatitis C virus RNA in the last six months;- fibrosis stage of F2, F3 or F4;-one course of treatment only (maximum of 44 weeks, based on response).
200MG Capsule02370816 VICTRELIS FRS
BOCEPREVIR, PEGINTERFERON, RIBAVIRINLimited use benefit (prior approval required).
For the treatment of chronic hepatitis C (CHC) genotype 1 infection in adult patients with compensated liver disease, in combination with peginterferon alpha (a or b+ ribavirin), and the following criteria:
-detectable levels of hepatitis C virus RNA in the last six months;- fibrosis stage of F2, F3 or F4;-one course of treatment only (maximum of 44 weeks, based on response).
200MG & 100 MCG & 200MG Kit02371456 VICTRELIS TRIPLE FRS
200MG & 120 MCG & 200MG Kit02371464 VICTRELIS TRIPLE FRS
200MG & 150 MCG & 200MG Kit02371472 VICTRELIS TRIPLE FRS
200MG & 80 MCG & 200MG Kit02371448 VICTRELIS TRIPLE FRS
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
08:18.92 MISCELLANEOUS ANTIVIRALSTELAPREVIR
Limited use benefit (prior approval required).
For the treatment of chronic Hepatitis C in treatment-naïve and treatment experienced patients who meet all the following criteria before consideration:- HCV genotype 1 - Detectable levels of hepatitis C virus HCV RNA in the last six months.- Fibrosis stage F2 or greater (Metavir scale or equivalent). Copy of report is required - No diagnosis of cirrhosis OR compensated liver disease (cirrhosis with a Child Pugh Score = A (5-6))
375MG Tablet02371553 INCIVEK VPC
10:00 ANTINEOPLASTIC AGENTS10:00.00 ANTINEOPLASTIC AGENTS
ERLOTINIB HYDROCLORIDELimited use benefit (prior approval required).
Treatment of non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive or unknown.
100MG Tablet02269015 TARCEVA HLR
150MG Tablet02269023 TARCEVA HLR
IMATINIB MESYLATELimited use benefit (prior approval required).
a.- For the treatment of patients with chronic myeloid leukemia (CML) in blast crisis, accelerated phase, or in chronic phase.b.- For the treatment of patients with gastrointestinal stromal tumour.c.- For newly diagnosed adult patients with Philadelphia chromosome-positive (CML).
100MG Tablet02355337 APO-IMATINIB APX
02253275 GLEEVEC NVR
02399806 TEVA-IMATINIB TEP
400MG Tablet02355345 APO-IMATINIB APX
02253283 GLEEVEC NOV
02399814 TEVA-IMATINIB TEP
RITUXIMABLimited use benefit (prior approval required).
Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Rituximab should not be used in combination with anti-TNF agents.
For continued coverage for rituximab beyond twenty-four weeks, patient must meet all the following criteria:a. - Initially prescribed by a rheumatologistb. - Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets the response criteria of:c. - a >20% reduction in number of tender and swollen joints d. - a >20% improvement in physician global assessment scale.e. - either a >20% improvement in the patient global assessment scale or a >20% reduction in the acute phase as measured by ESR or CRP.
10MG/ML Injection02241927 RITUXAN HLR
SUNITINIB MALATELimited use benefit (Prior approval required).
Criteria for initial six month coverage of Sutent:For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.
Criteria for assessment at every six months:There is no objective evidence of disease progression.
12.5MG Capsule02280795 SUTENT PFI
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
10:00.00 ANTINEOPLASTIC AGENTSSUNITINIB MALATE
Limited use benefit (Prior approval required).
Criteria for initial six month coverage of Sutent:For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.
Criteria for assessment at every six months:There is no objective evidence of disease progression.
25MG Capsule02280809 SUTENT PFI
50MG Capsule02280817 SUTENT PFI
TEMOZOLOMIDELimited use benefit (prior approval required).
For: a. - treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).b. - treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.
5MG Capsule02241093 TEMODAL SCH
20MG Capsule02395274 CO TEMOZOLOMIDE ACT
02241094 TEMODAL SCH
100MG Capsule02395282 CO TEMOZOLOMIDE ACT
02241095 TEMODAL SCH
140MG Capsule02395290 CO TEMOZOLOMIDE ACT02312794 TEMODAL FRS
250MG Capsule02395312 CO TEMOZOLOMIDE ACT
02241096 TEMODAL SCH
12:00 AUTONOMIC DRUGS12:04.00 PARASYMPATHOMIMETIC AGENTS
GALANTAMINE HYDROBROMIDELimited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer’s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer’s disease; AND•MMSE score > 10; OR•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
8MG Extended Release Capsule02339439 MYLAN-GALANTAMINE ER MYL
02316943 PAT-GALANTAMINE ER JNO
02398370 PMS-GALANTAMINE ER PMS
02377950 TEVA-GALANTAMINE ER TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:04.00 PARASYMPATHOMIMETIC AGENTSGALANTAMINE HYDROBROMIDE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer’s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer’s disease; AND•MMSE score > 10; OR•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
16MG Extended Release Capsule02339447 MYLAN-GALANTAMINE ER MYL
02316951 PAT-GALANTAMINE ER JNO
02398389 PMS-GALANTAMINE ER PMS
02377969 TEVA-GALANTAMINE ER TEP
24MG Extended Release Capsule02339455 MYLAN-GALANTAMINE ER MYL
02316978 PAT-GALANTAMINE ER JNO
02398397 PMS-GALANTAMINE ER PMS
02377977 TEVA-GALANTAMINE ER TEP
RIVASTIGMINELimited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer’s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer’s disease; AND•MMSE score > 10; OR•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
1.5MG Capsule02336715 APO-RIVASTIGMINE APX02242115 EXELON NOV
02406985 MINT-RIVASTIGMINE MIN
02332809 MYLAN-RIVASTIGMINE MYL
02305984 NOVO-RIVASTIGMINE TEV02306034 PMS-RIVASTIGMINE PMS
02311283 RATIO-RIVASTIGMINE TEP
02324563 SANDOZ RIVASTIGMINE SDZ
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:04.00 PARASYMPATHOMIMETIC AGENTSRIVASTIGMINE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:•Diagnosis of mild to moderate Alzheimer’s disease; AND•Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND•Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days•Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every six month interval:•Diagnosis is still mild to moderate Alzheimer’s disease; AND•MMSE score > 10; OR•GDS score between 4 to 6; AND•Improvement or stabilization in at least one of the following domains(please indicate improved, worsened, or no change)1.Memory, reasoning and perception (e.g., names, tasks, MMSE)2.Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)3.Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)4.Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
3MG Capsule02336723 APO-RIVASTIGMINE APX
02242116 EXELON NOV
02406993 MINT-RIVASTIGMINE MIN
02332817 MYLAN-RIVASTIGMINE MYL02305992 NOVO-RIVASTIGMINE TEV02306042 PMS-RIVASTIGMINE PMS
02311291 RATIO-RIVASTIGMINE TEP
02324571 SANDOZ RIVASTIGMINE SDZ
4.5MG Capsule02336731 APO-RIVASTIGMINE APX
02242117 EXELON NOV02407000 MINT-RIVASTIGMINE MIN
02332825 MYLAN-RIVASTIGMINE MYL
02306018 NOVO-RIVASTIGMINE TEV
02306050 PMS-RIVASTIGMINE PMS
02311305 RATIO-RIVASTIGMINE TEP
02324598 SANDOZ RIVASTIGMINE SDZ
6MG Capsule02336758 APO-RIVASTIGMINE APX
02242118 EXELON NOV
02407019 MINT-RIVASTIGMINE MIN
02332833 MYLAN-RIVASTIGMINE MYL
02306026 NOVO-RIVASTIGMINE TEV
02306069 PMS-RIVASTIGMINE PMS
02311313 RATIO-RIVASTIGMINE TEP
02324601 SANDOZ RIVASTIGMINE SDZ
2MG/ML O/L02245240 EXELON NOV
12:08.08 ANTIMUSCARINICS / ANTISPASMODICSTIOTROPIUM BROMIDE MONOHYDRATE
Limited use benefit (prior approval required).
For patients with chronic obstructive pulmonary disease (COPD) and who:
-did not respond to a trial of ipratropium (Atrovent); OR-did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5.
18MCG Powder for Inhalation (Capsule)02246793 SPIRIVA BOE
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:12.08 BETA ADRENERGIC AGONISTSFORMOTEROL FUMARATE
Limited use benefit (prior approval required).•�For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid-onset, short-duration bronchodilator.
OR
•�For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting betagonist.
12MCG/CAP Powder for Inhalation02230898 FORADIL NVR
FORMOTEROL FUMARATE DIHYDRATELimited use benefit (prior approval required).
For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, short duration bronchodilator
6MCG/DOSE Dry Powder Inhaler02237225 OXEZE TURBUHALER AZC
12MCG/DOSE Dry Powder Inhaler02237224 OXEZE TURBUHALER AZC
FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDELimited use benefit (prior approval required).
•�For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
OR ONE OF THE FOLLOWING
•�For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.
•�For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonis
6MCG & 100MCG/INHALATION Inhaler02245385 SYMBICORT 100 TURBUHALER AZC
6MCG & 200MCG/INHALATION Inhaler02245386 SYMBICORT 200 TURBUHALER AZC
FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATELimited use benefit (prior approval required).
For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone200-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
5MCG & 100MCG Inhaler02361752 ZENHALE FRS
5MCG & 200MCG Inhaler02361760 ZENHALE FRS
5MCG & 50MCG Inhaler02361744 ZENHALE FRS
INDACATEROL MALEATELimited use benefit (prior approval required).
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.
75MCG Capsule02376938 ONBREZ NOV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:12.08 BETA ADRENERGIC AGONISTSSALMETEROL XINAFOATE
Limited use benefit (prior approval required).
a. - For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium, tiotropium or a short acting beta-agonist.
50MCG/DOSE Powder Diskus02231129 SEREVENT DISKUS GSK
50MCG/INHALATION Powder for Inhalation02214261 SEREVENT DISKHALER GSK
SALMETEROL XINAFOATE, FLUTICASONE PROPIONATELimited use benefit (prior approval required).
•�For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg daily, or the equivalent) as the sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.
OR ONE OF THE FOLLOWING
•�For the treatment of moderate* COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic AND a long acting beta-agonist.
•�For the treatment of severe** COPD, if a patient continues to be symptomatic after an adequate trial of a long acting anticholinergic OR a long acting beta-agonis
25MCG & 125MCG INHALATION Inhaler02245126 ADVAIR GSK
25MCG & 250MCG INHALATION Inhaler02245127 ADVAIR GSK
50MCG & 100MCG Inhaler02240835 ADVAIR DISKUS 100 GSK
50MCG & 250MCG Inhaler02240836 ADVAIR DISKUS 250 GSK
50MCG & 500MCG Inhaler02240837 ADVAIR DISKUS 500 GSK
12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTSCYCLOBENZAPRINE HCL
Limited use benefit (prior approval is not required).
For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks renewable every two (2) months.
10MG Tablet02177145 APO-CYCLOBENZAPRINE APX
02348853 AURO-CYCLOBENZAPRINE AUR02220644 CYCLOBENZAPRINE PDL
02287064 CYCLOBENZAPRINE SAN
02238633 DOM-CYCLOBENZAPRINE DPC
02231353 GEN-CYCLOPRINE GEN
02357127 JAMP-CYCLOBENZAPRINE JAP
02080052 NOVO-CYCLOPRINE TEV
02249359 PHL-CYCLOBENZAPRINE PMI
02212048 PMS-CYCLOBENZAPRINE PMS02236506 RATIO-CYCLOBENZAPRINE RPH
02242079 RIVA-CYCLOBENZAPRINE RIV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTSTIZANIDINE HCL
Limited use benefit (prior approval required).
For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.
4MG Tablet02259893 APO-TIZANIDINE APX
02272059 GEN-TIZANIDINE GEN
02239170 ZANAFLEX ELN
12:92.00 MISCELLANEOUS AUTONOMIC DRUGSNICOTINE (GUM)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.
2MG Gum02091933 NICORETTE JNO
80000396 THRIVE NOV
4MG Gum02091941 NICORETTE PLUS PMJ80000118 NICOTINE PER
80000402 THRIVE NOV
94799972 THRIVE NOV
NICOTINE (INHALER)Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 945 during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.
10MG Inhaler02241742 NICORETTE JNO
NICOTINE (LOZENGES)1MG Lozenges
80007461 THRIVE NOV94799970 THRIVE NOV
2MG Lozenges02247347 NICORETTE JNO
80007464 THRIVE NOV
94799968 THRIVE NOV
4MG Lozenges02247348 NICORETTE JNO
NICOTINE (PATCH)Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches
Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.
5MG Patch02028697 NICOTROL TRANSDERMAL 5MG WAR
10MG Patch02029405 NICOTROL TRANSDERMAL 10MG WAR
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
12:92.00 MISCELLANEOUS AUTONOMIC DRUGSNICOTINE (PATCH)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation: Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is: Habitrol 168 patches or Nicoderm 140 patches or Nicotrol 140 patches
Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.
15MG Patch02029413 NICOTROL TRANSDERMAL 15MG WAR
17.5MG Patch02241227 TRANSDERMAL NICOTINE NVC
35MG Patch02241226 TRANSDERMAL NICOTINE NVC
52.5MG Patch02241228 TRANSDERMAL NICOTINE NVC
7MG Patch (Habitrol)01943057 HABITROL NVC
14MG Patch (Habitrol)01943065 HABITROL NVC
21MG Patch (Habitrol)01943073 HABITROL NVC
36MG Patch (Nicoderm)02093111 NICODERM PMJ
78MG Patch (Nicoderm)02093138 NICODERM PMJ
114MG Patch (Nicoderm)02093146 NICODERM PMJ
8.3MG/10CM2 Patch (Nicotrol)02065738 NICOTROL TRANSDERMAL JNO
16.6MG/20CM2 Patch (Nicotrol)02065754 NICOTROL TRANSDERMAL JNO
24.9MG/30CM2 Patch (Nicotrol)02065762 NICOTROL TRANSDERMAL JNO
VARENICLINELimited use benefit with quantity and frequency limits (prior approval is not required).
Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, theclient is eligible again for coverage for varenicline (Champix®) when one year has elapsed from the day the initial prescription was filled.
0.5MG Tablet02291177 CHAMPIX PFI
1MG Tablet02291185 CHAMPIX PFI
0.5MG & 1MG Tablets02298309 CHAMPIX STARTER PACK PFI
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS20:12.04 ANTICOAGULANTS
APIXABANLimited use benefit (prior approval required)
For at risk patients* with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism AND in whom: � Anticoagulation is inadequate# with a two-month trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR � Anticoagulation with warfarin is contraindicated.;OR � Anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
* At risk patients with atrial fibrillation are defined as those 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.
2.5MG Tablet02377233 ELIQUIS BMS
5MG Tablet02397714 ELIQUIS BMS
DABIGATRAN ETEXILATE MESILATELimited use benefit (prior approval required).
For at risk patients* with non-valvular atrial fibrillation who require dabigatran for the prevention of stroke and systemic embolism AND in whom: � Anticoagulation is inadequate with a two-month trial of warfarin (please provide a copy of INR records for the last two months of warfarin therapy); OR � Anticoagulation with warfarin is contraindicated. OR � Anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
110MG Capsule02312441 PRADAXA BOE
150MG Capsule02358808 PRADAXA BOE
RIVAROXABANLimited use benefit (prior approval required).
Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Stroke Prevention in Atrial Fibrillation (SPAF)For the prevention of stroke and systemic embolism in at-risk patients* who have non-valvular atrial fibrillation (AF) AND in whom: •�Anticoagulation is inadequate# following a two-month trial on warfarin (please provide copy of INR records for the last two months of warfarin therapy); OR•�Anticoagulation with warfarin is contraindicated; ;OR•�Anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home)
Criteria for Rivaroxaban 15 mg, 20mg tablets (Xarelto) for Deep Vein Thrombosis (DVT)•�For the treatment of deep vein thrombosis (DVT) in patients without symptomatic pulmonary embolism (PE) for a duration of up to six months.
Note: The recommended dose of rivaroxaban for patients initiating DVT treatment is 15 mg twice daily for 3 weeks, followed by 20 mg once daily. NIHB Program coverage for rivaroxaban is an alternative to heparin/warfarin for up to 6 months. When used for greater than 6 months, rivaroxaban is more costly than heparin/warfarin. IF THE INTENDED DURATION OF THERAPY IS GREATER THAN 6 MONTHS, INITIATION OF HEPARIN/WARFARIN SHOULD BE CONSIDERED.
15MG Tablet02378604 XARELTO BAY
20MG Tablet02378612 XARELTO B A
RIVAROXABAN (10)Limited use benefit (prior approval not required).
For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days.
10MG Tablet02316986 XARELTO BAY
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
20:12.18 PLATELET AGGREGATION INHIBITORSCLOPIDOGREL BISULFATE
Limited use benefit (prior approval not required).
Limit of 12 months following a client’s initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent). Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician.
75MG Tablet02252767 APO-CLOPIDOGREL APX
02385813 CLOPIDOGREL SIV
02394820 CLOPIDOGREL PDL
02400553 CLOPIDOGREL SAN
02303027 CO CLOPIDOGREL ACT
02378507 DOM-CLOPIDOGREL DOM02408910 MINT-CLOPIDOGREL MIN
02351536 MYLAN-CLOPIDOGREL MYL
02238682 PLAVIX SAC
02348004 PMS CLOPIDOGREL PMS
02379813 RAN-CLOPIDOGREL RBY
02388529 RIVA CLOPIDOGREL RIV
02359316 SANDOZ CLOPIDOGREL SDZ02293161 TEVA-CLOPIDOGREL TEP
20:16.00 HEMATOPOIETIC AGENTSPEGFILGRASTIM
Limited use benefit (prior approval required).
a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.andb. - Where access to a health care facility is problematic.
10MG/ML Injection02249790 NEULASTA AMG
24:00 CARDIOVASCULAR DRUGS24:06.05 CHOLESTEROL ABSORPTION INHIBITORS
EZETIMIBELimited use benefit (prior approval required).
a.- For use in combination with a HMG-CoA reductase inhibitor (‘statin’) in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated “statin” doses.
b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.
10MG Tablet02247521 EZETROL MSP
24:12.12 PHOSPHODIESTERASE INHIBITORSSILDENAFIL CITRATE
Limited use benefit (prior approval required).
Maximum dose covered is 20 mg three times a day
Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents.
20MG Tablet02319500 RATIO-SILDENAFIL R TEP02279401 REVATIO PFI
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
24:12.12 PHOSPHODIESTERASE INHIBITORSTADALAFIL
Limited use benefit (prior approval required).
Maximum dose covered is 40 mg daily
Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; ANDwho have failed to respond to conventional therapy; ORwho have contraindications to conventional agents
20MG Tablet02338327 ADCIRCA LIL
24:12.92 MISCELLANEOUS VASODILATING AGENTSAMBRISENTAN
Limited use benefit (prior approval required).
Maximum dose covered is 10 mg once daily. Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.
5MG Tablet02307065 VOLIBRIS GSK
10MG Tablet02307073 VOLIBRIS GSK
BOSENTANLimited use benefit (prior approval required). Maximum dose covered is 125 mg twice daily
-Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND-who have failed to respond to sildenafil OR tadalafil; OR-who have contraindications to sildenafil OR tadalafil.
62.5MG Tablet02386194 CO BOSENTAN ACT
02383497 MYLAN-BOSENTAN MYL
02383012 PMS-BOSENTAN PMS02386275 SANDOZ BOSENTAN SDZ
02244981 TRACLEER ACN
125MG Tablet02386208 CO BOSENTAN ACT
02383500 MYLAN-BOSENTAN MYL
02383020 PMS-BOSENTAN PMS02386283 SANDOZ BOSENTAN SDZ02244982 TRACLEER ACN
DIPYRIDAMOLE, ACETYLSALICYLIC ACIDLimited use benefit (prior approval required).
For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.
200MG & 25MG Capsule02242119 AGGRENOX BOE
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:00 CENTRAL NERVOUS SYSTEM AGENTS28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
ACETYLSALICYLIC ACIDLimited use benefit (prior approval is not required).
ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki Syndrome).
80MG Chewable Tablet02269139 ACETYLSALICYLIC ACID JAP
02321750 ASA ZYM
02009013 ASAPHEN PMS
02280167 ASATAB ODN
02296004 LOWPRIN EUR
02311518 PRO-ASA PRO02202352 RIVASA RIV
80MG Delayed Release Tablet02283905 ACETYLSALICYLIC ACID JAP
02321769 ASA EC SOR
02238545 ASAPHEN EC PMS
02311496 PRO-ASA EC PRO
80MG Tablet02150352 ASPIRIN BCD
02250675 EURO-ASA EUR
02295563 LOWPRIN EUR
02202360 RIVASA RIV
CELECOXIBLimited use benefit (prior approval required).
For patients who have:
¨�A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation);
OR
¨�Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).
100MG Capsule02239941 CELEBREX PFI
200MG Capsule02239942 CELEBREX PFI
28:08.08 OPIATE AGONISTSACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
300MG & 30MG & 15MG Tablet00293504 ATASOL-15 HOR
02232388 EXDOL-15 PED
300MG & 30MG & 30MG Tablet00293512 ATASOL-30 HOR02232389 EXDOL-30 PED
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSACETAMINOPHEN, CAFFEINE, CODEINE PHOSPHATE
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
300MG & 15MG & 15MG Tablet00653241 RATIO-LENOLTEC NO.2 RPH
02163934 TYLENOL WITH CODEINE NO.2 JNO
300MG & 15MG & 30MG Tablet00653276 RATIO-LENOLTEC NO.3 RPH
02163926 TYLENOL WITH CODEINE NO.3 JNO
ACETAMINOPHEN, CODEINE PHOSPHATELimited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
32MG & 1.6MG/ML Elixir00816027 PMS-ACETAMINOPHEN WITH CODEINE PMS
300MG & 30MG Tablet01999648 ACET CODEINE 30 PMS
02232658 PROCET-30 PDL
00608882 RATIO-EMTEC-30 RPH
00789828 TRIATEC-30 TRI
ACETAMINOPHEN, OXYCODONE HCLLimited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
325MG & 2.5MG Tablet01916491 PERCOCET DEMI BMS
325MG & 5MG Tablet02324628 APO-OXYCODONE/ACET APX01916548 ENDOCET EDM02361361 OXYCODONE/ACET SAN
01916475 PERCOCET BMS
02327171 PRO-OXYCOD ACET PDL
00608165 RATIO-OXYCOCET RPH
02242468 RIVACOCET RIV
02307898 SANDOZ OXYCOD ACET SDZ
ACETYLSALICYLIC ACID, CAFFEINE CITRATE, CODEINE PHOSPHATELimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
375MG & 30MG & 15MG Tablet02234510 282 PED
375MG & 30MG & 30MG Tablet02238645 292 PED
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSACETYLSALICYLIC ACID, OXYCODONE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
325MG & 5MG Tablet00608157 RATIO-OXYCODAN RPH
CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATELimited use benefit (prior approval required).For treatment of:a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, orb. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
50MG Long Acting Tablet02230302 CODEINE CONTIN CR PFR
100MG Long Acting Tablet02163748 CODEINE CONTIN CR PFR
150MG Long Acting Tablet02163780 CODEINE CONTIN CR PFR
200MG Long Acting Tablet02163799 CODEINE CONTIN CR PFR
CODEINE PHOSPHATELimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
2MG/ML Liquid00380571 LINCTUS CODEINE ATL
5MG/ML Syrup00050024 CODEINE PHOSPHATE ATL00779474 RATIO-CODEINE RPH
15MG Tablet00779458 CODEINE RPH
02009889 CODEINE TRI
00593435 RATIO-CODEINE RPH
30MG Tablet00593451 CODEINE PHOSPHATE RPH
02009757 CODEINE PHOSPHATE TRI02243979 PMS-CODEINE PMS
FENTANYLLimited use benefit (prior approval required).For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dosetitration and adjunctive therapy including laxatives and antiemetics.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
12MCG Patch02311925 TEVA-FENTANYL TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSFENTANYL
Limited use benefit (prior approval required).For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dosetitration and adjunctive therapy including laxatives and antiemetics.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
12MCG/H Patch02386844 CO FENTANYL ACT
02395657 FENTANYL PDL
02396696 MYLAN-FENTANYL MYL02341379 PMS-FENTANYL PMS02330105 RAN-FENTANYL RBY
02327112 SANDOZ FENTANYL SDZ
25MCG/H Patch02314630 APO-FENTANYL APX
02386852 CO FENTANYL ACT
02275813 DURAGESIC MAT JNO
02395665 FENTANYL PDL02396718 MYLAN-FENTANYL MYL
02341387 PMS-FENTANYL PMS
02330113 RAN-FENTANYL RBY
02327120 SANDOZ FENTANYL SDZ02282941 TEVA-FENTANYL RPH
50MCG/H Patch02314649 APO-FENTANYL APX02386879 CO FENTANYL ACT
02275821 DURAGESIC MAT JNO
02395673 FENTANYL PDL
02396726 MYLAN-FENTANYL MYL
02341395 PMS-FENTANYL PMS
02330121 RAN-FENTANYL RBY
02327147 SANDOZ FENTANYL SDZ
02282968 TEVA-FENTANYL RPH
75MCG/H Patch02314657 APO-FENTANYL APX
02386887 CO FENTANYL ACT
02275848 DURAGESIC MAT JNO
02395681 FENTANYL PDL
02396734 MYLAN-FENTANYL MYL
02341409 PMS-FENTANYL PMS02330148 RAN-FENTANYL RBY
02327155 SANDOZ FENTANYL SDZ
02282976 TEVA-FENTANYL RPH
100MCG/H Patch02314665 APO-FENTANYL APX
02386895 CO FENTANYL ACT02275856 DURAGESIC MAT JNO02395703 FENTANYL PDL
02396742 MYLAN-FENTANYL MYL
02341417 PMS-FENTANYL PMS
02330156 RAN-FENTANYL RBY
02327163 SANDOZ FENTANYL SDZ
02282984 TEVA-FENTANYL RPH
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSHYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
3MG Controlled Release Capsule02125323 HYDROMORPH CONTIN PFR
4.5MG Controlled Release Capsule02359502 HYDROMORPH CONTIN PFR
6MG Controlled Release Capsule02125331 HYDROMORPH CONTIN PFR
9MG Controlled Release Capsule02359510 HYDROMORPH CONTIN PFR
12MG Controlled Release Capsule02125366 HYDROMORPH CONTIN PFR
18MG Controlled Release Capsule02243562 HYDROMORPH CONTIN PFR
24MG Controlled Release Capsule02125382 HYDROMORPH CONTIN PFR
30MG Controlled Release Capsule02125390 HYDROMORPH CONTIN PFR
1MG/ML Oral Liquid00786535 DILAUDID ABB01916386 PMS-HYDROMORPHONE PMS
3MG Suppository01916394 PMS-HYDROMORPHONE PMS
1MG Tablet02364115 APO-HYDROMORPHONE APX
00705438 DILAUDID ABB
02192101 PHL-HYDROMORPHONE PHH00885444 PMS-HYDROMORPHONE PMS
02319403 TEVA-HYDROMORPHONE TEP
2MG Tablet02364123 APO-HYDROMORPHONE APX
00125083 DILAUDID ABB
02249928 PHL-HYDROMORPHONE PHH
00885436 PMS-HYDROMORPHONE PMS02319411 TEVA-HYDROMORPHONE TEP
4MG Tablet02364131 APO-HYDROMORPHONE APX
00125121 DILAUDID ABB
02249936 PHL-HYDROMORPHONE PHH
00885401 PMS-HYDROMORPHONE PMS
02319438 TEVA-HYDROMORPHONE TEP
8MG Tablet02364158 APO-HYDROMORPHONE APX
00786543 DILAUDID ABB
02192144 PHL-HYDROMORPHONE PHH
00885428 PMS-HYDROMORPHONE PMS
02319446 TEVA-HYDROMORPHONE TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSMETHADONE HCL
10mg/mL Liquid02394596 METHADOSE MAT
02394618 METHADOSE SUGARFREE MAT
METHADONE HCL (PA)limited use benefit (prior approval required) with the following criteria:
Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.
Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependencyis an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.
1MG/ML Liquid02247694 METADOL PAL
10MG/ML Liquid02241377 METADOL PAL
1MG Tablet02247698 METADOL PAL
5MG Tablet02247699 METADOL PAL
10MG Tablet02247700 METADOL PAL
25MG Tablet02247701 METADOL PAL
MORPHINE HCLLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
30MG Sustained Release Tablet00776181 M.O.S. SR VAE
60MG Sustained Release Tablet00776203 M.O.S. SR VAE
1MG/ML Syrup00614491 DOLORAL 1 ATL
00607762 RATIO-MORPHINE RPH
5MG/ML Syrup00614505 DOLORAL 5 ATL
00514217 M.O.S. VAE00607770 RATIO-MORPHINE RPH
10MG/ML Syrup00632503 M.O.S. 10 VAE
00690783 RATIO-MORPHINE RPH
20MG/ML Syrup00690791 RATIO-MORPHINE RPH
50MG/ML Syrup00690236 M.O.S. 50 VAE
10MG Tablet00690198 M.O.S. 10 VAE
20MG Tablet00690201 M.O.S. 20 VAE
40MG Tablet00690228 M.O.S. 40 VAE
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSMORPHINE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
60MG Tablet00690244 M.O.S. 60 VAE
MORPHINE SULFATELimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
50MG/ML Drop00705799 STATEX PMS
5MG Suppository00632228 STATEX PMS
10MG Suppository00632201 STATEX PMS
20MG Suppository00596965 STATEX PMS
10MG Sustained Release Capsule02242163 KADIAN MAY
02019930 M-ESLON SAC
15MG Sustained Release Capsule02177749 M-ESLON SAC
20MG Sustained Release Capsule02184435 KADIAN SR MAY
30MG Sustained Release Capsule02019949 M-ESLON SR SAC
50MG Sustained Release Capsule02184443 KADIAN SR MAY
60MG Sustained Release Capsule02019957 M-ESLON SR SAC
100MG Sustained Release Capsule02184451 KADIAN SR MAY
02019965 M-ESLON SR SAC
200MG Sustained Release Capsule02177757 M-ESLON SR SAC
15MG Sustained Release Tablet02350815 MORPHINE SR SAN02015439 MS CONTIN SR PFR
02244790 RATIO-MORPHINE SULFATE SR RPH
02302764 TEVA-MORPHINE SR 15MG TAB TEP
30MG Sustained Release Tablet02350890 MORPHINE SR SAN
02014297 MS CONTIN SR PFR02244791 RATIO-MORPHINE SULFATE SR RPH
02302772 TEVA-MORPHINE SR 30MG TAB TEP
60MG Sustained Release Tablet02350912 MORPHINE SR SAN
02014300 MS CONTIN SR PFR
02244792 RATIO-MORPHINE SULFATE SR RPH02302780 TEVA-MORPHINE SR 60MG TAB TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSMORPHINE SULFATE
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-malignant pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000 morphine equivalents over 100 days).
100MG Sustained Release Tablet02350920 MORPHINE SR SAN
02014319 MS CONTIN SR PFR
02302799 TEVA-MORPHINE SR 100MG TAB TEP
200MG Sustained Release Tablet02350947 MORPHINE SR SAN
02014327 MS CONTIN SR PFR02302802 TEVA-MORPHINE SR 200MG TAB TEP
1MG/ML Syrup00591467 STATEX PMS
5MG/ML Syrup00591475 STATEX PMS
10MG/ML Syrup00647217 STATEX PMS
5MG Tablet02009773 M.O.S. SULFATE VAE
02014203 MS IR PFR
00594652 STATEX PMS
10MG Tablet02009765 M.O.S. SULFATE VAE02014211 MS IR PFR
00594644 STATEX PMS
20MG Tablet02014238 MS IR PFR
25MG Tablet02009749 M.O.S. SULFATE VAE
00594636 STATEX PMS
30MG Tablet02014254 MS IR PFR
50MG Tablet02009706 M.O.S. SULFATE VAE00675962 STATEX PMS
OXYCODONE HCLLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
10MG Suppository00392480 SUPEUDOL SIL
20MG Suppository00392472 SUPEUDOL SIL
5MG Tablet02325950 OXYCODONE PDL
02231934 OXY-IR PFR
02319977 PMS-OXYCODONE PMS
00789739 SUPEUDOL SDZ
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.08 OPIATE AGONISTSOXYCODONE HCL
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented an opioid dose limit of 500 mg morphine equivalents per day for non-cancer, non-palliative pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 100-day period (i.e. 50 000morphine equivalents over 100 days).
10MG Tablet02240131 OXY-IR PFR
02319985 PMS-OXYCODONE PMS
00443948 SUPEUDOL SDZ
20MG Tablet02240132 OXY-IR PFR
02319993 PMS-OXYCODONE PMS02262983 SUPEUDOL SDZ
28:08.12 OPIATE PARTIAL AGONISTSBUPRENORPHINE, NALOXONE
Limited use benefit (prior approval required).
For the treatment of opioid dependence in patients who have a contraindication to methadone due to:• Evidence of (or high risk for) QT interval prolongation; and• Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.
8MG & 2MG Tablet02295709 SUBOXONE RBP
09991204 SUBOXONE MAINTENANCE UNK
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICSACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
80MG Chewable Tablet02129957 ACETAMIN CHILD WTR
01905856 ACETAMINOPHEN TRI
02017458 ACETAMINOPHEN RIV02015676 CHILDREN'S ACETAMINOPHEN TAN
160MG Chewable Tablet02017431 ACETAMINOPHEN RIV
02231011 FEVERHALT PED
02230934 TANTAPHEN GRAPE TAN
80MG/ML Drop01904140 ACETAMINOPHEN TAN01905864 ACETAMINOPHEN TRI
00631353 ATASOL HOR
02230787 FEVERHALT PED
02263793 PEDIAPHEN EUR
02027801 PEDIATRIX RPH
00887587 PMS-ACETAMINOPHEN PMS
00875988 TEMPRA MJO
02046059 TYLENOL GRAPE MCL
16MG/ML Liquid01905848 ACETAMINOPHEN TRI
02263807 PEDIAPHEN EUR00792713 PMS-ACETAMINOPHEN PMS
00884553 TEMPRA MJO
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICSACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
32MG/ML Liquid01901389 ACETAMINOPHEN JAP
01958836 ACETAMINOPHEN TRI
02263831 PEDIAPHEN EUR
02027798 PEDIATRIX RPH
00792691 PMS-ACETAMINOPHEN PMS
00875996 TEMPRA DOUBLE STRENGTH MJO02046040 TYLENOL MCL
120MG Suppository02046660 PMS-ACETAMINOPHEN PMS
325MG Suppository02046687 PMS-ACETAMINOPHEN PMS
650MG Suppository02046695 PMS-ACETAMINOPHEN PMS
80MG/ML Suspension02237390 ACETAMINOPHEN PER
80MG Tablet02238295 CHILDREN'S TYLENOL SOFT CHEWS JNO
02263815 PEDIAPHEN CHEWABLE TAB 80MG EUO
160MG Tablet02142805 ACETAMINOPHEN WTR
02263823 PEDIAPHEN CHEWABLE TAB 160MG EUO
02347792 TYLENOL JR STRENGTH FASTMELTS JNO
02241361 TYLENOL JUNIOR STRENGTH JNO
325MG Tablet00374148 ACETAMINOPHEN WAM
00382752 ACETAMINOPHEN PRO
00589241 ACETAMINOPHEN PMS00605751 ACETAMINOPHEN VTH *
00743542 ACETAMINOPHEN PMT
00789801 ACETAMINOPHEN TRI01938088 ACETAMINOPHEN JAP
02022214 ACETAMINOPHEN RIV
00544981 APO-ACETAMINOPHEN APX
02229873 APO-ACETAMINOPHEN APX00293482 ATASOL HOR
00389218 NOVO-GESIC TEV
00559393 TYLENOL MCL
00723894 TYLENOL MCL
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28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICSACETAMINOPHEN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol® #3) or oxycodone (i.e. Percocet®). A total of 360 gramsof acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.
500MG Tablet00386626 ACETAMINOPHEN PDL
00549703 ACETAMINOPHEN PMT
00567663 ACETAMINOPHEN PED
00589233 ACETAMINOPHEN PMS
00605778 ACETAMINOPHEN VTH
00789798 ACETAMINOPHEN TRI01939122 ACETAMINOPHEN JAP
02022222 ACETAMINOPHEN RIV
02252813 ACETAMINOPHEN PMT
02255251 ACETAMINOPHEN PMT
00545007 APO-ACETAMINOPHEN APX
02229977 APO-ACETAMINOPHEN APX
00013668 ATASOL FORTE HOR02355299 JAMP-ACETAMINOPHEN JAP
00482323 NOVO-GESIC TEV
00892505 PMS-ACETAMINOPHEN PMS
01962353 TANTAPHEN TAN
00559407 TYLENOL EXTRA STRENGTH MCL00723908 TYLENOL EXTRA STRENGTH MCL
28:12.08 ANTICONVULSANTS - BENZODIAZEPINESCLONAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.25MG Tablet02179660 PMS-CLONAZEPAM PMS
0.5MG Tablet02177889 APO-CLONAZEPAM APX
02230366 CLONAPAM VAE02270641 CO-CLONAZEPAM ACT
02130998 DOM-CLONAZEPAM DPC
02224100 DOM-CLONAZEPAM-R DPC
02230950 GEN-CLONAZEPAM GEN02239024 NOVO-CLONAZEPAM TEV
02145227 PHL-CLONAZEPAM PHH
02236948 PHL-CLONAZEPAM-R PMI
02048701 PMS-CLONAZEPAM PMS
02207818 PMS-CLONAZEPAM R PMS
02311593 PRO-CLONAZEPAM PDL
02242077 RIVA-CLONAZEPAM RIV00382825 RIVOTRIL HLR02233960 SANDOZ-CLONAZEPAM SDZ
02345676 ZYM-CLONAZEPAM ZYM
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.08 ANTICONVULSANTS - BENZODIAZEPINESCLONAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
1MG Tablet02230368 CLONAPAM VAE
02270668 CO-CLONAZEPAM ACT
02145235 PHL-CLONAZEPAM PHH
02048728 PMS-CLONAZEPAM PMS
02311607 PRO-CLONAZEPAM PDL02233982 SANDOZ-CLONAZEPAM SDZ
02303329 ZYM-CLONAZEPAM ZYM
2MG Tablet02177897 APO-CLONAZEPAM APX
02230369 CLONAPAM VAE
02270676 CO-CLONAZEPAM ACT
02131013 DOM-CLONAZEPAM DPC02230951 GEN-CLONAZEPAM GEN
02239025 NOVO-CLONAZEPAM TEV
02145243 PHL-CLONAZEPAM PHH
02048736 PMS-CLONAZEPAM PMS
02311615 PRO-CLONAZEPAM PDL02242078 RIVA-CLONAZEPAM RIV
00382841 RIVOTRIL HLR
02233985 SANDOZ-CLONAZEPAM SDZ02303337 ZYM-CLONAZEPAM ZYM
28:12.92 MISCELLANEOUS ANTICONVULSANTSGABAPENTIN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.
100MG Capsule02244304 APO-GABAPENTIN APX
02321203 AURO-GABAPENTIN AUR
02256142 CO-GABAPENTIN ACT02243743 DOM-GABAPENTIN DPC
02246314 GABAPENTIN SIV
02304775 GABAPENTIN SOR
02353245 GABAPENTIN SAN02248259 GEN-GABAPENTIN GEN
02361469 JAMP-GABAPENTIN JAP
02084260 NEURONTIN PFI
02244513 NOVO-GABAPENTIN TEV
02243446 PMS-GABAPENTIN PMS
02310449 PRO-GABAPENTIN PDL
02319055 RAN-GABAPENTIN RBY02251167 RIVA-GABAPENTIN RIV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.92 MISCELLANEOUS ANTICONVULSANTSGABAPENTIN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.
300MG Capsule02244305 APO-GABAPENTIN APX
02321211 AURO-GABAPENTIN AUR
02256150 CO-GABAPENTIN ACT
02243744 DOM-GABAPENTIN DPC
02246315 GABAPENTIN SIV
02304783 GABAPENTIN SOR02353253 GABAPENTIN SAN02248260 GEN-GABAPENTIN GEN
02361485 JAMP-GABAPENTIN JAP
02084279 NEURONTIN PFI
02244514 NOVO-GABAPENTIN TEV
02243447 PMS-GABAPENTIN PMS
02310457 PRO-GABAPENTIN PDL
02319063 RAN-GABAPENTIN RBY02251175 RIVA-GABAPENTIN RIV
400MG Capsule02244306 APO-GABAPENTIN APX
02321238 AURO-GABAPENTIN AUR
02256169 CO-GABAPENTIN ACT02243745 DOM-GABAPENTIN DPC
02246316 GABAPENTIN SIV02304791 GABAPENTIN SOR
02353261 GABAPENTIN SAN
02248261 GEN-GABAPENTIN GEN
02361493 JAMP-GABAPENTIN JAP
02084287 NEURONTIN PFI
02244515 NOVO-GABAPENTIN TEV
02243448 PMS-GABAPENTIN PMS
02310465 PRO-GABAPENTIN PDL02319071 RAN-GABAPENTIN RBY
02260905 RATIO-GABAPENTIN RPH02251183 RIVA-GABAPENTIN RIV
600MG Tablet02293358 APO-GABAPENTIN APX
02388200 GABAPENTIN SIV
02285843 GD-GABAPENTIN PFI02402289 JAMP-GABAPENTIN JAP
02397471 MYLAN-GABAPENTIN MYL
02239717 NEURONTIN PFI
02248457 NOVO-GABAPENTIN TEV
02255898 PMS-GABAPENTIN PMS
02310473 PRO-GABAPENTIN PDL
02260913 RATIO-GABAPENTIN RPH02259796 RIVA-GABAPENTIN RIV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.92 MISCELLANEOUS ANTICONVULSANTSGABAPENTIN
Limited use benefit (prior approval is not required).
For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 100-day period, for a total daily dose of 4000mg/day.
800MG Tablet02293366 APO-GABAPENTIN APX
02388219 GABAPENTIN SIV
02402297 JAMP-GABAPENTIN JAP
02397498 MYLAN-GABAPENTIN MYL
02239718 NEURONTIN PFI
02247346 NOVO-GABAPENTIN TEV02255901 PMS-GABAPENTIN PMS02310481 PRO-GABAPENTIN PDL
02260921 RATIO-GABAPENTIN RPH
02259818 RIVA-GABAPENTIN RIV
LACOSAMIDELimited use benefit (prior approval required).For adjunctive therapy in patients with refractory partial-onset seizures who meet all of the following criteria:a- Are under the care of a physician experienced in the treatment of epilepsy, ANDb- Are currently receiving two or more antiepileptic medications, ANDc- Have failed or demonstrated intolerance to at least two other antiepileptic medications.
50MG Tablet02357615 VIMPAT UCB
100MG Tablet02357623 VIMPAT UCB
150MG Tablet02357631 VIMPAT UCB
200MG Tablet02357658 VIMPAT UCB
LEVETIRACETAMLimited use benefit (prior approval required).
For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two anti-epileptic medications used either as monotherapy or in combination.
250MG Tablet02285924 APO-LEVETIRACETAM APX
02375249 AURO-LEVETIRACETAM AUR
02274183 CO-LEVETIRACETAM ACT
02403005 JAMP-LEVETIRACETAM JAP
02247027 KEPPRA UCB
02353342 LEVETIRACETAM SAN
02296101 PMS-LEVETIRACETAM PMS02396106 RAN-LEVETIRACETAM RBY
500MG Tablet02285932 APO-LEVETIRACETAM APX
02375257 AURO-LEVETIRACETAM AUR02274191 CO-LEVETIRACETAM ACT
02297418 DOM-LEVETIRACETAM DOM
02403021 JAMP-LEVETIRACETAM JAP02247028 KEPPRA UCB
02353350 LEVETIRACETAM SAN
02296128 PMS-LEVETIRACETAM PMS
02311380 PRO-LEVETIRACETAM PDL
02396114 RAN-LEVETIRACETAM RBY
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.92 MISCELLANEOUS ANTICONVULSANTSLEVETIRACETAM
Limited use benefit (prior approval required).
For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two anti-epileptic medications used either as monotherapy or in combination.
750MG Tablet02285940 APO-LEVETIRACETAM APX
02375265 AURO-LEVETIRACETAM AUR
02274205 CO-LEVETIRACETAM ACT
02403048 JAMP-LEVETIRACETAM JAP
02247029 KEPPRA UCB
02353369 LEVETIRACETAM SAN02296136 PMS-LEVETIRACETAM PMS02311399 PRO-LEVETIRACETAM PDL
02396122 RAN-LEVETIRACETAM RBY
PREGABALINLimited use benefit (prior approval required).
For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)
OR
For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA.
The dose of pregabalin is limited to a maximum of 600 mg per day
25MG Capsule02394235 APO-PREGABALIN APX
02402912 CO PREGABALIN ACT
02402556 DOM-PREGABALIN DOM02360136 GD-PREGABALIN PFI02268418 LYRICA PFI
02359596 PMS-PREGABALIN PMS
02396483 PREGABALIN PDL
02403692 PREGABALIN SIV
02405539 PREGABALIN SAN
02411725 PREGABALIN-25 SIV
02392801 RAN-PREGABALIN RBY02377039 RIVA-PREGABALIN RIV
02390817 SANDOZ PREGABALIN SDZ
02361159 TEVA-PREGABALIN TEP
50MG Capsule02394243 APO-PREGABALIN APX02402920 CO PREGABALIN ACT
02402564 DOM-PREGABALIN DOM02360144 GD-PREGABALIN PFI
02268426 LYRICA PFI
02359618 PMS-PREGABALIN PMS
02396505 PREGABALIN PDL
02403706 PREGABALIN SIV
02405547 PREGABALIN SAN
02392828 RAN-PREGABALIN RBY02377047 RIVA-PREGABALIN RIV
02390825 SANDOZ PREGABALIN SDZ
02361175 TEVA-PREGABALIN TEP
50MG Capsule02411733 PREGABALIN-50 SIV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.92 MISCELLANEOUS ANTICONVULSANTSPREGABALIN
Limited use benefit (prior approval required).
For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)
OR
For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a TCA.
The dose of pregabalin is limited to a maximum of 600 mg per day
75MG Capsule02394251 APO-PREGABALIN APX
02402939 CO PREGABALIN ACT02402572 DOM-PREGABALIN DOM02360152 GD-PREGABALIN PFI
02268434 LYRICA PFI
02359626 PMS-PREGABALIN PMS
02396513 PREGABALIN PDL
02403714 PREGABALIN SIV
02405555 PREGABALIN SAN
02411741 PREGABALIN-75 SIV02392836 RAN-PREGABALIN RBY
02377055 RIVA-PREGABALIN RIV
02390833 SANDOZ PREGABALIN SDZ
02361183 TEVA-PREGABALIN TEP
150MG Capsule02394278 APO-PREGABALIN APX
02402955 CO PREGABALIN ACT
02402580 DOM-PREGABALIN DOM02360179 GD-PREGABALIN PFI
02268450 LYRICA PFI
02359634 PMS-PREGABALIN PMS
02396521 PREGABALIN PDL
02403722 PREGABALIN SIV
02405563 PREGABALIN SAN
02411768 PREGABALIN-150 SIV02392844 RAN-PREGABALIN RBY02377063 RIVA-PREGABALIN RIV
02390841 SANDOZ PREGABALIN SDZ
02361205 TEVA-PREGABALIN TEP
300MG Capsule02394294 APO-PREGABALIN APX
02402998 CO PREGABALIN ACT02360209 GD-PREGABALIN PFI
02268485 LYRICA PFI
02359642 PMS-PREGABALIN PMS
02396548 PREGABALIN PDL
02403730 PREGABALIN SIV
02405598 PREGABALIN SAN02392860 RAN-PREGABALIN RBY
02377071 RIVA-PREGABALIN RIV02390868 SANDOZ PREGABALIN SDZ
02361248 TEVA-PREGABALIN TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:12.92 MISCELLANEOUS ANTICONVULSANTSRUFINAMIDE
Limited use benefit (prior approval required).
-For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist-Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs
100MG Tablet02369613 BANZEL 100MG TAB EIS
200MG Tablet02369621 BANZEL 200MG TAB EIS
400MG Tablet02369648 BANZEL 400MG TAB EIS
28:16.04 ANTIDEPRESSANTSBUPROPION HCL (WELLBUTRIN)
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).
150MG Extended Release Tablet02382075 MYLAN-BUPROPION XL MYL02275090 WELLBUTRIN XL FRS
300MG Extended Release Tablet02382083 MYLAN-BUPROPION XL MYL
02275104 WELLBUTRIN XL FRS
100MG Sustained Release Tablet02331616 BUPROPION SR PDL
02391562 BUPROPION SR SAN02325373 PMS-BUPROPION SR PMS02285657 RATIO-BUPROPION RPH
02275074 SANDOZ-BUPROPION SR SDZ
150MG Sustained Release Tablet02391570 BUPROPION SR SAN
02313421 PMS-BUPROPION SR PMS
02325357 PRO-BUPROPION SR PDL
02285665 RATIO-BUPROPION RPH02275082 SANDOZ-BUPROPION SR SDZ
02237825 WELLBUTRIN SR BPC
BUPROPION HCL (ZYBAN)Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:Coverage is limited to 180 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached the client is eligible again for coverage for bupropion HCl when one year has elapsed from the day the initial prescription was filled.
150MG Sustained Release Tablet02238441 ZYBAN BPC
28:16.08 ANTIPSYCHOTIC AGENTSARIPIPRAZOLE
Limited use benefit (prior approval required).
For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent
2MG Tablet02322374 ABILIFY BMS
5MG Tablet02322382 ABILIFY BMS
10MG Tablet02322390 ABILIFY BMS
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28:16.08 ANTIPSYCHOTIC AGENTSARIPIPRAZOLE
Limited use benefit (prior approval required).
For the treatment of schizophrenia and schizoaffective disorders in patients who havea. Intolerance or lack of response to an adequate trial of another antipsychotic agent; ORb. A contraindication to another antipsychotic agent
15MG Tablet02322404 ABILIFY BMS
20MG Tablet02322412 ABILIFY BMS
30MG Tablet02322455 ABILIFY BMS
ASENAPINELimited use benefit (prior approval required). For the acute treatment of manic or mixed episodes associated with bipolar I disorder as either:
- Monotherapy, after a trial of lithium or divalproex sodium has failed or is contraindicated, and trials of two atypical antipsychotic agents have failed due to intolerance or lack of response
OR
- Co-therapy with lithium or divalproex sodium, after trials of two atypical antipsychotic agents have failed due to intolerance or lack of response.
5MG Sublingual Tablet02374803 SAPHRIS FRS
10MG Sublingual Tablet02374811 SAPHRIS FRS
ZIPRASIDONELimited use benefit (prior approval required).
For the treatment of schizophrenia and schizoaffective disorders in patients who have:a.- intolerance or lack of response to an adequate trial of another antipsychotic agent orb.- a contraindication to another antipsychotic agent
20MG Capsule02298597 ZELDOX PFI
40MG Capsule02298600 ZELDOX PFI
60MG Capsule02298619 ZELDOX PFI
80MG Capsule02298627 ZELDOX PFI
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESALPRAZOLAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.25MG Tablet01908189 ALPRAZOLAM PDL
02349191 ALPRAZOLAM SAN00865397 APO-ALPRAZ APX
02137534 GEN-ALPRAZOLAM GEN
02400111 JAMP-ALPRAZOLAM JAP
01913484 NOVO-ALPRAZOL TEV
00548359 XANAX PFI
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESALPRAZOLAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.5MG Tablet01908170 ALPRAZOLAM PDL
02349205 ALPRAZOLAM SAN
00865400 APO-ALPRAZ APX
02137542 GEN-ALPRAZOLAM GEN
02400138 JAMP-ALPRAZOLAM JAP01913492 NOVO-ALPRAZOL TEV
00548367 XANAX PFI
1MG Tablet02248706 ALPRAZOLAM PDL
02243611 APO-ALPRAZ APX
02229813 GEN-ALPRAZOLAM GEN
02400146 JAMP-ALPRAZOLAM JAP00723770 XANAX PFI
2MG Tablet02243612 APO-ALPRAZ APX
02229814 GEN-ALPRAZOLAM GEN
02400154 JAMP-ALPRAZOLAM JAP00813958 XANAX TS PFI
BROMAZEPAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
1.5MG Tablet02177153 APO-BROMAZEPAM APX
3MG Tablet02177161 APO-BROMAZEPAM APX
02220520 BROMAZEPAM PDL
00518123 LECTOPAM HLR
02230584 NOVO-BROMAZEPAM TEV
6MG Tablet02177188 APO-BROMAZEPAM APX02220539 BROMAZEPAM PDL00518131 LECTOPAM HLR
02230585 NOVO-BROMAZEPAM TEV
DIAZEPAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
1MG/ML Oral Solution00891797 PMS-DIAZEPAM PMS
2MG Tablet00405329 APO-DIAZEPAM APX
00434396 DIAZEPAM PDL
02247490 PMS-DIAZEPAM PMS
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESDIAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
5MG Tablet00362158 APO-DIAZEPAM APX
00313580 DIAZEPAM PRO
02247491 PMS-DIAZEPAM PMS
00013285 VALIUM HLR
10MG Tablet00405337 APO-DIAZEPAM APX
00434388 DIAZEPAM PDL
02247492 PMS-DIAZEPAM PMS
LORAZEPAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.5MG Tablet00655740 APO-LORAZEPAM APX
02410745 APO-LORAZEPAM SUBLINGUAL APX
02041413 ATIVAN WAY
02041456 ATIVAN SUBLINGUAL WAY
02245784 DOM-LORAZEPAM DPC02351072 LORAZEPAM SAN00711101 NOVO-LORAZEM TEV
00728187 PMS-LORAZEPAM PMS
00655643 PRO-LORAZEPAM PDL
1MG Tablet00655759 APO-LORAZEPAM APX
02410753 APO-LORAZEPAM SUBLINGUAL APX02041421 ATIVAN WAY
02041464 ATIVAN SUBLINGUAL WAY
02245785 DOM-LORAZEPAM DPC
02351080 LORAZEPAM SAN
00637742 NOVO-LORAZEM TEV
00728195 PMS-LORAZEPAM PMS00655651 PRO-LORAZEPAM PDL
2MG Tablet00655767 APO-LORAZEPAM APX
02410761 APO-LORAZEPAM SUBLINGUAL APX
02041448 ATIVAN WAY
02041472 ATIVAN SUBLINGUAL WAY
02245786 DOM-LORAZEPAM DPC
02351099 LORAZEPAM SAN
00637750 NOVO-LORAZEM TEV00728209 PMS-LORAZEPAM PMS
00655678 PRO-LORAZEPAM PDL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESNITRAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
5MG Tablet02245230 APO-NITRAZEPAM APX
00511528 MOGADON ICN
02229654 NITRAZADON VAE
02234003 SANDOZ-NITRAZEPAM SDZ
10MG Tablet02245231 APO-NITRAZEPAM APX
00511536 MOGADON ICN
02229655 NITRAZADON VAE
02234007 SANDOZ-NITRAZEPAM SDZ
OXAZEPAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
10MG Tablet00402680 APO-OXAZEPAM APX
00497754 OXAZEPAM PDL
00414247 OXPAM VAE
00568392 ZAPEX RIV
15MG Tablet00402745 APO-OXAZEPAM APX
00497762 OXAZEPAM PDL
00568406 ZAPEX RIV
30MG Tablet00402737 APO-OXAZEPAM APX
00497770 OXAZEPAM PDL00414263 OXPAM VAE
00568414 ZAPEX RIV
TEMAZEPAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
15MG Capsule02225964 APO-TEMAZEPAM APX02244814 CO-TEMAZEPAM ACT
02229756 DOM-TEMAZEPAM DPC
02230095 NOVO-TEMAZEPAM TEV
02243023 RATIO-TEMAZEPAM RPH00604453 RESTORIL ORY
02229760 TEMAZEPAM PDL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINESTEMAZEPAM
Limited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
30MG Capsule02225972 APO-TEMAZEPAM APX
02244815 CO-TEMAZEPAM ACT
02229758 DOM-TEMAZEPAM DPC
02230102 NOVO-TEMAZEPAM TEV
02243024 RATIO-TEMAZEPAM RPH00604461 RESTORIL ORY
02229761 TEMAZEPAM PDL
TRIAZOLAMLimited use benefit (prior approval is not required).
To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 60 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 6 000 diazepam equivalents over 100 days). This limit will be lowered by 10 mg of diazepam equivalents per day every three months until an acceptable limit is reached. According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.
0.125MG Tablet00808563 APO-TRIAZO APX
0.25MG Tablet00808571 APO-TRIAZO APX
28:32.28 SELECTIVE SEROTONIN AGONISTSALMOTRIPTAN MALATE
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
6.25MG Tablet02405792 APO-ALMOTRIPTAN APX
02248128 AXERT MCL
02398435 MYLAN-ALMOTRIPTAN MYL
12.5MG Tablet02405806 APO-ALMOTRIPTAN APX
02248129 AXERT MCL
02398443 MYLAN-ALMOTRIPTAN MYL
02405334 SANDOZ ALMOTRIPTAN SDZ
NARATRIPTAN HCLLimited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
1MG Tablet02237820 AMERGE GSK
02314290 TEVA-NARATRIPTAN TEP
2.5MG Tablet02237821 AMERGE GSK02322323 SANDOZ NARATRIPTAN SDZ02314304 TEVA-NARATRIPTAN TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:32.28 SELECTIVE SEROTONIN AGONISTSRIZATRIPTAN
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
5MG Orally Disintegrating Tablet02393484 APO-RIZATRIPTAN RPD APX
02374730 CO-RIZATRIPTAN ODT ACT
02240518 MAXALT RPD FRS
02379198 MYLAN-RIZATRIPTAN ODT MYL
02393360 PMS-RIZATRIPTAN RDT PMS
02351870 SANDOZ RIZATRIPTAN ODT SDZ
10MG Orally Disintegrating Tablet02393492 APO-RIZATRIPTAN RPD APX02374749 CO-RIZATRIPTAN ODT ACT
02396203 DOM-RIZATRIPTAN RDT DOM
02240519 MAXALT RPD FRS
02379201 MYLAN-RIZATRIPTAN ODT MYL
02393379 PMS-RIZATRIPTAN RDT PMS
02351889 SANDOZ RIZATRIPTAN ODT SDZ
5MG Tablet02393468 APO-RIZATRIPTAN APX
02380455 JAMP-RIZATRIPTAN JAP
02379651 MAR-RIZATRIPTAN MAR
10MG Tablet02393476 APO-RIZATRIPTAN APX02381702 CO RIZATRIPTAN ACT
02380463 JAMP-RIZATRIPTAN JAP02379678 MAR-RIZATRIPTAN MAR
02240521 MAXALT FRS
SUMATRIPTAN SUCCINATELimited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
12MG/ML Injection02212188 IMITREX GSK
99000598 IMITREX GSK *
02361698 TARO-SUMATRIPTAN TAR
25MG Tablet02257882 CO-SUMATRIPTAN ACT
02270749 DOM-SUMATRIPTAN DPC
02268906 GEN-SUMATRIPTAN GEN02286815 NOVO-SUMATRIPTAN DF TEV02256428 PMS-SUMATRIPTAN PMS
02286513 SUMATRIPTAN SAN
50MG Tablet02268388 APO-SUMATRIPTAN APX
02257890 CO-SUMATRIPTAN ACT
02270757 DOM-SUMATRIPTAN DPC
02268914 GEN-SUMATRIPTAN GEN02212153 IMITREX DF GSK
02286823 NOVO-SUMATRIPTAN DF TEV
02256436 PMS-SUMATRIPTAN PMS
02324652 PRO-SUMATRIPTAN PDL
02263025 SANDOZ-SUMATRIPTAN SDZ02286521 SUMATRIPTAN SAN
02385570 SUMATRIPTAN DF SIV
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
28:32.28 SELECTIVE SEROTONIN AGONISTSSUMATRIPTAN SUCCINATE
Limited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
100MG Tablet02268396 APO-SUMATRIPTAN APX
02257904 CO-SUMATRIPTAN ACT
02270765 DOM-SUMATRIPTAN DPC
02268922 GEN-SUMATRIPTAN GEN
02212161 IMITREX DF GSK
02239367 NOVO-SUMATRIPTAN TEV
02286831 NOVO-SUMATRIPTAN DF TEV02256444 PMS-SUMATRIPTAN PMS02324660 PRO-SUMATRIPTAN PDL
02263033 SANDOZ-SUMATRIPTAN SDZ
02286548 SUMATRIPTAN SAN
02385589 SUMATRIPTAN DF SIV
ZOLMITRIPTANLimited use benefit (prior approval is not required).
A total of 12 tablets (or injections) are permitted in a 30-day period.
2.5MG Orally Disintegrating Tablet02381575 APO-ZOLMITRIPTAN RAPID APX
02387158 MYLAN ZOLMITRIPTAN ODT MYL
02324768 PMS-ZOLMITRIPTAN ODT PMS
02362996 SANDOZ ZOLMITRIPTAN ODT SDZ
02342545 TEVA-ZOLMITRIPTAN OD TEP02379988 ZOLMITRIPTAN ODT PDL
02243045 ZOMIG RAPIMELT AZC
2.5MG Tablet02380951 APO-ZOLMITRIPTAN APX
02389525 DOM-ZOLMITRIPTAN DOM
02369036 MYLAN ZOLMITRIPTAN MYL
02324229 PMS-ZOLMITRIPTAN PMS02401304 RIVA-ZOLMITRIPTAN RIV
02362988 SANDOZ ZOLMITRIPTAN SDZ
02313960 TEVA-ZOLMITRIPTAN TEP
02379929 ZOLMITRIPTAN PDL
02238660 ZOMIG AZC
28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTSCABERGOLINE
Limited use benefit (prior approval required).
For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.
0.5MG Tablet02301407 CO CABERGOLINE ACT
02242471 DOSTINEX PFI
28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTSACAMPROSATE CALCIUM
Limited use benefit (prior approval required).
For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program
333MG Delayed Release Tablet02293269 CAMPRAL MYL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
32:00 CONTRACEPTIVES (NON-ORAL)32:00.00 CONTRACEPTIVES (NON-ORAL)
INTRAUTERINE DEVICELimited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 device every 12 months.
Device98099999 FLEXI-T IUD PRN
99401085 LIBERTE UT380 SHORT MSC
99401086 LIBERTE UT380 STANDARD MSC
99400482 NOVA-T IUD BEX
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE40:20.00 CALORIC AGENTS
LEVOCARNITINELimited use benefit (prior approval required).
• For treatment of carnitine deficiency
100MG/ML Oral Liquid02144336 CARNITOR SIG
200MG/ML Solution02144344 CARNITOR IV SIG
330MG Tablet02144328 CARNITOR SIG
48:00 RESPIRATORY TRACT AGENTS48:10.24 LEUKOTRIENE MODIFIERS
MONTELUKASTLimited use benefit (prior approval required).
For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
4MG Chewable Tablet02377608 APO-MONTELUKAST APX02399865 MAR-MONTELUKAST MAR
02379317 MONTELUKAST SAN
02379821 MONTELUKAST PDL
02382458 MONTELUKAST SIV
02380749 MYLAN-MONTELUKAST MYL
02354977 PMS-MONTELUKAST PMS02402793 RAN-MONTELUKAST RBY02330385 SANDOZ MONTELUKAST TEP
02243602 SINGULAIR FRS
02355507 TEVA- MONTELUKAST TEP
5MG Chewable Tablet02377616 APO-MONTELUKAST APX
02399873 MAR-MONTELUKAST MAR
02379325 MONTELUKAST SAN
02379848 MONTELUKAST PDL02382466 MONTELUKAST SIV
02380757 MYLAN-MONTELUKAST MYL
02354985 PMS-MONTELUKAST PMS02402807 RAN-MONTELUKAST RBY
02330393 SANDOZ MONTELUKAST TEP
02238216 SINGULAIR FRS
02355515 TEVA- MONTELUKAST TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
48:10.24 LEUKOTRIENE MODIFIERSMONTELUKAST
Limited use benefit (prior approval required).
For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
4MG Granules02358611 SANDOZ MONTELUKAST SDZ
02247997 SINGULAIR FRS
10MG Tablet02374609 APO-MONTELUKAST APX
02376695 DOM-MONTELUKAST DOM
02391422 JAMP-MONTELUKAST JAP02399997 MAR-MONTELUKAST MAR
02379333 MONTELUKAST SAN
02379856 MONTELUKAST PDL
02382474 MONTELUKAST SIV
02368226 MYLAN-MONTELUKAST MYL
02373947 PMS-MONTELUKAST PMS
02389517 RAN-MONTELUKAST RBY02328593 SANDOZ MONTELUKAST SDZ
02238217 SINGULAIR FRS
02355523 TEVA- MONTELUKAST TEP
ZAFIRLUKASTLimited use benefit (prior approval required).
For treatment of:a. - asthma when used in patients on concurrent steroid therapy.b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
20MG Tablet02236606 ACCOLATE AZC
52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS52:28.00 EENT - MOUTHWASHES AND GARGLES
BENZYDAMINE HCLLimited use benefit (prior approval required).
For:a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.b. - use in immunocompromised patients who are at risk of mucosal breakdown.
0.15% Rinse02239044 APO-BENZYDAMINE APX
02239537 DOM-BENZYDAMINE DPC02229799 NOVO-BENZYDAMINE TEV02229777 PMS-BENZYDAMINE PMS
52:40.04 EENT - ALPHA-ADRENERGIC AGONISTSBRIMONIDINE TARTRATE (ALPHAGAN P)
Limited use benefit (prior approval required).
For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.
0.15% Ophth Solution02248151 ALPHAGAN P ALL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
52:92.00 MISCELLANEOUS EENT DRUGSRANIBIZUMAB
Limited use benefit (prior approval required).
For the treatment of:a. Diabetic Macular Edema (DME)b. Wet Age-Related Macular Degeneration (w-AMD)Criteria for coverage of ranibizumab (Lucentis) for DME and w-AMD:• Administered by a qualified ophthalmologist experienced in intravitreal injections• Interval between doses not shorter than 1 monthNote: Coverage will be limited to a maximum of 1 vial of Lucentis per eye treated every 30 daysFor the treatment of diabetic macular edema (DME) for patients who meet the following:• Clinically significant diabetic macular edema for whom laser photocoagulation is also indicated; AND• Have a hemoglobin A1c of less than 11%Initial Coverage for the treatment of neovascular wet age-related macular degeneration (wAMD) where all of the following apply to the eye to be treated:• Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96• The lesion size is less than or equal to 12 disc areas in greatest linear dimension• There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or optical coherence tomography (OCT))Note: Coverage will not be approved for patients:• With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines.• Receiving concurrent treatment with verteporfinContinued Coverage:Treatment with Lucentis for wAMD should be continued only in people who maintain adequate response to therapyTreatment with Lucentis should be permanently discontinued if any one of the following occurs:• Reduction in BCVA in the treated eye to less than 15 letters (absolute) on two (2) consecutive visits in the treated eye, attributed toAMD in the absence of other pathology• Reductions in BCVA of 30 letters or more compared to eitherbaseline and/or best recorded level since baseline as this mayindicate either poor treatment effect, adverse events or both.• There is evidence of deterioration of the lesion morphology despite optimum treatment over three (3) consecutive visits.
10MG/ML Injection02296810 LUCENTIS NOV
VERTEPORFINLimited use benefit (prior approval required).
For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.
15MG/VIAL Injection02242367 VISUDYNE QLT
56:00 GASTROINTESTINAL DRUGS56:22.92 MISCELLANEOUS ANTIEMETICS
NABILONELimited use benefit (prior approval required).
• For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation;
OR
• patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
0.25MG Capsule02312263 CESAMET VAE
02358077 RAN-NABILONE RBY
02392925 TEVA-NABILONE TEP
0.5MG Capsule02256193 CESAMET VAE02393581 CO NABILONE ACT
02380900 PMS-NABILONE PMS02358085 RAN-NABILONE RBY
02384884 TEVA-NABILONE TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
56:22.92 MISCELLANEOUS ANTIEMETICSNABILONE
Limited use benefit (prior approval required).
• For patients who are experiencing nausea and vomiting due to cancer chemotherapy or radiation;
OR
• patient is palliative (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
1MG Capsule00548375 CESAMET VAE
02393603 CO NABILONE ACT
02380919 PMS-NABILONE PMS
02358093 RAN-NABILONE RBY02384892 TEVA-NABILONE TEP
56:28.36 PROTON-PUMP INHIBITORSLANSOPRAZOLE
Limited use benefit (prior approval not required).
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Coverage will be limited to 400 tablets/capsules every 180 days.
15MG Sustained Release Capsule02293811 APO-LANSOPRAZOLE APX
02357682 LANSOPRAZOLE SAN02385767 LANSOPRAZOLE SIV
02353830 MYLAN-LANSOPRAZOLE MYL
02395258 PMS-LANSOPRAZOLE PMS
02165503 PREVACID ABB
02402610 RAN-LANSOPRAZOLE RBY
02385643 SANDOZ LANSOPRAZOLE SDZ
02280515 TEVA-LANSOPRAZOLE TEP
30MG Sustained Release Capsule02293838 APO-LANSOPRAZOLE APX
02357690 LANSOPRAZOLE SAN02366282 LANSOPRAZOLE PDL
02385775 LANSOPRAZOLE SIV
02410389 LANSOPRAZOLE SIV
02353849 MYLAN-LANSOPRAZOLE MYL02395266 PMS-LANSOPRAZOLE PMS
02165511 PREVACID ABB
02402629 RAN-LANSOPRAZOLE RBY
02385651 SANDOZ LANSOPRAZOLE SDZ
02280523 TEVA-LANSOPRAZOLE TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
56:28.36 PROTON-PUMP INHIBITORSLANSOPRAZOLE ODT
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
15MG Delayed Release Tablet02249464 PREVACID FASTAB TAK
30MG Delayed Release Tablet02249472 PREVACID FASTAB TAK
OMEPRAZOLEThe following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Delayed Release Capsule02329425 MYLAN-OMEPRAZOLE GEN02296438 SANDOZ OMEPRAZOLE SDZ
20MG Delayed Release Capsule02245058 APO-OMEPRAZOLE APX
00846503 LOSEC AZC
02329433 MYLAN-OMEPRAZOLE GEN
02339927 OMEPRAZOLE PDL
02348691 OMEPRAZOLE SAN
02385384 OMEPRAZOLE SIV02411857 OMEPRAZOLE SIV
02320851 PMS-OMEPRAZOLE PMS
02403617 RAN-OMEPRAZOLE RBY
02296446 SANDOZ OMEPRAZOLE SDZ
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56:28.36 PROTON-PUMP INHIBITORSOMEPRAZOLE
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
20MG Delayed Release Tablet02333430 DOM-OMEPRAZOLE DR DOM02190915 LOSEC AZC
02310260 PMS-OMEPRAZOLE DR PMS
02374870 RAN-OMEPRAZOLE RBU
02260867 RATIO-OMEPRAZOLE RPH
02295415 TEVA-OMEPRAZOLE TEP
OMEPRAZOLE (PA)The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Delayed Release Tablet02230737 LOSEC AZC
02260859 RATIO-OMEPRAZOLE RPH
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
56:28.36 PROTON-PUMP INHIBITORSPANTOPRAZOLE
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
40MG Delayed Release Tablet02300486 ACT PANTOPRAZOLE ACT02292920 APO-PANTOPRAZOLE APX
02310007 DOM-PANTOPRAZOLE DOM
02299585 MYLAN-PANTOPRAZOLE MYL
02309866 PANTOPRAZOLE MEL
02310201 PANTOPRAZOLE SOR
02318695 PANTOPRAZOLE PDL
02370808 PANTOPRAZOLE SAN02385759 PANTOPRAZOLE SIV
02307871 PMS-PANTOPRAZOLE PMS
02316463 RIVA-PANTOPRAZOLE RIV
02301083 SANDOZ-PANTOPRAZOLE SDZ
02285487 TEVA-PANTOPRAZOLE TEP
40MG Enteric Coated Tablet02229453 PANTOLOC NCC
02305046 RAN-PANTOPRAZOLE RBL
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
56:28.36 PROTON-PUMP INHIBITORSRABEPRAZOLE SODIUM
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;•All PPIs are equally efficacious•Double dose PPI is not necessary for initial therapy•Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
All proton pump inhibitors (open benefit and limited use (LU) PPIs) have a maximum quantity limit of 400 tablets/capsules per 180 day period. This quantity limit wilbe in effect for the entire class of PPIs. •For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPtablets/capsules towards the quantity limit. •Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit•Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett’s esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 400 tablets/capsules per 180 days through the prior approval process.
Limited use benefit (prior approval not required).
Coverage will be limited to 400 tablets/capsules every 180 days.
10MG Enteric Coated Tablet02345579 APO-RABEPRAZOLE APX02408392 MYLAN-RABEPRAZOLE MYL
02296632 NOVO-RABEPRAZOLE TEV
02243796 PARIET EC JNO
02381737 PAT-RABEPRAZOLE EC KLA
02310805 PMS-RABEPRAZOLE EC PMS
02315181 PRO-RABEPRAZOLE PDL
02356511 RABEPRAZOLE SAN02385449 RABEPRAZOLE SIV
02298074 RAN-RABEPRAZOLE RBY
02330083 RIVA-RABEPRAZOLE EC RIV
02314177 SANDOZ-RABEPRAZOLE SDZ
20MG Enteric Coated Tablet02345587 APO-RABEPRAZOLE APX
02320460 DOM-RABEPRAZOLE DOM
02408406 MYLAN-RABEPRAZOLE MYL02296640 NOVO-RABEPRAZOLE TEV
02243797 PARIET EC JNO
02381745 PAT-RABEPRAZOLE EC KLA
02310813 PMS-RABEPRAZOLE EC PMS
02315203 PRO-RABEPRAZOLE PDL
02356538 RABEPRAZOLE SAN
02385457 RABEPRAZOLE SIV02298082 RAN-RABEPRAZOLE RBY
02330091 RIVA-RABEPRAZOLE EC RIV02314185 SANDOZ-RABEPRAZOLE SDZ
68:00 HORMONES AND SYNTHETIC SUBSTITUTES68:12.00 CONTRACEPTIVES
LEVONORGESTREL0.75MG Tablet
02364905 NEXT CHOICE ACT
02285576 NORLEVO LAP
02371189 OPTION 2 PER
02241674 PLAN B BAR
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
68:12.00 CONTRACEPTIVESLEVONORGESTREL INTRAUTERINE INSERT
Limited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 device every 2 years.
52MG Intrauterine Insert02243005 MIRENA BAY
68:16.12 ESTROGEN AGONISTS-ANTAGONISTSRALOXIFENE HCL
Limited use benefit (prior approval required).
For:a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.
60MG Tablet02279215 APO-RALOXIFENE APX02358840 CO RALOXIFENE ACT
02239028 EVISTA LIL
02358921 PMS-RALOXIFENE PMS
02312298 TEVA-RALOXIFENE TEP
68:20.04 BIGUANIDESSITAGLIPTIN, METFORMIN
Limited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
50MG & 1000MG Tablet02333872 JANUMET FRS
50MG & 500MG Tablet02333856 JANUMET FRS
50MG & 850MG Tablet02333864 JANUMET FRS
68:20.05LINAGLIPTIN
Limited use benefit (prior approval required).
For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
5MG Tablet02370921 TRAJENTA BOE
SAXAGLIPTIN HCLLimited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
2.5MG Tablet02375842 ONGLYZA BMS
5MG Tablet02333554 ONGLYZA BMS
SITAGLIPTINLimited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
25MG Tablet02388839 JANUVIA MSP
50MG Tablet02388847 JANUVIA MSP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
68:20.05SITAGLIPTIN
Limited use benefit (prior approval required).
• For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.
100MG Tablet02303922 JANUVIA FRS
68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCL
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
15MG Tablet02303442 ACCEL PIOGLITAZONE ACP02242572 ACTOS LIL
02302942 APO-PIOGLITAZONE APX
02302861 CO PIOGLITAZONE ACT
02307634 DOM-PIOGLITAZONE DOM
02298279 GEN-PIOGLITAZONE GEN02326477 JAMP-PIOGLITAZONE MIN
02274914 NOVO-PIOGLITAZONE TEV
02307669 PHL-PIOGLITAZONE PMI
02374013 PIOGLITAZONE SIV
02391600 PIOGLITAZONE ACC
02303124 PMS-PIOGLITAZONE PMS
02312050 PRO-PIOGLITAZONE PDL02375850 RAN-PIOGLITAZONE RBY
02301423 RATIO-PIOGLITAZONE RPH
02297906 SANDOZ PIOGLITAZONE SDZ
02320754 ZYM-PIOGLITAZONE ZYM
30MG Tablet02303450 ACCEL PIOGLITAZONE ACP
02242573 ACTOS LIL
02302950 APO-PIOGLITAZONE APX02302888 CO PIOGLITAZONE ACT
02307642 DOM-PIOGLITAZONE DOM
02298287 GEN-PIOGLITAZONE GEN
02326485 JAMP-PIOGLITAZONE MIN02365529 JAMP-PIOGLITAZONE JAP
02274922 NOVO-PIOGLITAZONE TEV
02307677 PHL-PIOGLITAZONE PMI02339587 PIOGLITAZONE ACC
02374021 PIOGLITAZONE SIV
02303132 PMS-PIOGLITAZONE PMS
02312069 PRO-PIOGLITAZONE PDL
02375869 RAN-PIOGLITAZONE RBY
02301431 RATIO-PIOGLITAZONE RPH
02297914 SANDOZ PIOGLITAZONE SDZ
02320762 ZYM-PIOGLITAZONE ZYM
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
68:20.28 THIAZOLIDINEDIONESPIOGLITAZONE HCL
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
45MG Tablet02303469 ACCEL PIOGLITAZONE ACP
02242574 ACTOS LIL
02302977 APO-PIOGLITAZONE APX
02302896 CO PIOGLITAZONE ACT
02307650 DOM-PIOGLITAZONE DOM
02298295 GEN-PIOGLITAZONE GEN02326493 JAMP-PIOGLITAZONE MIN02365537 JAMP-PIOGLITAZONE JAP
02274930 NOVO-PIOGLITAZONE TEV
02307723 PHL-PIOGLITAZONE PMI
02339595 PIOGLITAZONE ACC
02374048 PIOGLITAZONE SIV
02303140 PMS-PIOGLITAZONE PMS
02312077 PRO-PIOGLITAZONE PDL02375877 RAN-PIOGLITAZONE RBY
02301458 RATIO-PIOGLITAZONE RPH
02297922 SANDOZ PIOGLITAZONE SDZ
02320770 ZYM-PIOGLITAZONE ZYM
ROSIGLITAZONE MALEATELimited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
2MG Tablet02241112 AVANDIA GSK
4MG Tablet02241113 AVANDIA GSK
8MG Tablet02241114 AVANDIA GSK
84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
ACITRETINOpen benefit (prior approval not required).
Soriatane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings, should be consulted prior to prescribing or dispensing this drug.
10MG Capsule02070847 SORIATANE HLR
25MG Capsule02070863 SORIATANE HLR
IMIQUIMODLimited use benefit (prior approval required).
-For the treatment of condylomata acuminate (genital warts) in patients who have failed:-self-applied podophyllotoxin (podofilox 0.5% solution); OR-provider-applied podophyllum resin (10%-25%)
50MG/G Cream02239505 ALDARA VAE
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTSISOTRETINOIN
Open benefit (prior approval not required).
Accutane should be used with caution in women of childbearing potential due to its teratogenicity. Pregnancy must be excluded. Effective contraception must be used. Manufacturer's literature regarding contraindications and warnings should be consulted prior to prescribing or dispensing this drug.
10MG Capsule00582344 ACCUTANE HLR
02257955 CLARUS PRE
40MG Capsule00582352 ACCUTANE HLR
02257963 CLARUS PRE
PIMECROLIMUSLimited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.
1% Cream02247238 ELIDEL NVC
TACROLIMUS (PROTOPIC)Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.
0.03% Ointment02244149 PROTOPIC AST
0.1% Ointment02244148 PROTOPIC AST
86:00 SMOOTH MUSCLE RELAXANTS86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
DARIFENACIN HYDROBROMIDELimited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
7.5MG Extended Release Tablet02273217 ENABLEX MRL
15MG Extended Release Tablet02273225 ENABLEX MRL
TOLTERODINELimited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
2MG Extended Release Capsule02244612 DETROL LA PFI
4MG Extended Release Capsule02244613 DETROL LA PFI
1MG Tablet02239064 DETROL PFI
2MG Tablet02239065 DETROL PFI
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTSTROSPIUM CHLORIDE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.
20MG Tablet02275066 TROSEC ORY
86:12.04 ANTIMUSCARINICSSOLIFENACIN SUCCINATE
Limited use benefit (prior approval required).
For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.
5MG Tablet02277263 VESICARE AST
10MG Tablet02277271 VESICARE AST
88:00 VITAMINS88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVATAMINS (PRENATAL)Tablet
80001842 CENTRUM MATERNA WYA
MULTIVITAMINS (PEDIATRIC)Limited use benefit (prior approval is not required).
Pediatric multivitamins are benefits for children up to 6 years of age.
Drop00762946 POLY-VI-SOL MJO
Liquid00558079 INFANTOL HOR
Tablet80020794 CENTRUM JUNIOR COMPLETE TB PFI80011134 CENTRUM JUNIOR COMPLETE TAB WYE
02247975 FLINTSTONES EXTRA C BCD
MULTIVITAMINS (PRENATAL)Limited use benefit (prior approval is not required.).
Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).
Tablet02229535 MULTI-PRE AND POST NATAL PED80005770 PRENATAL & POSTPARTUM PMT
02241235 PRENATAL AND POSTPARTUM SDR
92:00 UNCLASSIFIED THERAPEUTIC AGENTS92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
SEVELAMER HYDROCHLORIDELimited Use Benefit ( Prior approval required ).
a. - patients with elevated phosphate levels OR elevated phosphate X calcium product despite dietary restriction of phosphate and use of calcium-based phosphatebinders (short term elevations should be managed with aluminium based binders)b. - patients with elevated calcium levels despite discontinuation of calcium binder, and Vitamin D analogue and/or modification of dialysate calciumc. - patients with adynamic bone disease and low PTH levels (<100 pg/ml or <0.9 pmol/L) with normal or elevated calcium levels
800MG Tablet02244310 RENAGEL GEE *
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTSUSTEKINUMAB
Limited use benefit (prior approval required).
For the treatment of moderate to severe psoriasis in patients who meet the following criteria:a. - Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region andb. - Intolerance or lack of response to methotrexate and cyclosporine orc. - A contraindication to methotrexate and/or cyclosporine andd. - Intolerance or lack of response to phototherapy ore. - Inability to access phototherapy
Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI).
45MG/0.5ML Injection02320673 STELARA JNO
90MG/ML Injection02320681 STELARA JNO
92:01.88MULTIVITAMINS (PEDIATRIC)
Limited use benefit (prior approval is not required).
Pediatric multivitamins are benefits for children up to 6 years of age.
Liquid80008471 JAMP-MULTIVITAMIN A/D/ C DROPS JAP
92:08.00DUTASTERIDE
Limited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker. orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
0.5MG Capsule02247813 AVODART GSK
FINASTERIDELimited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker.orb. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
5MG Tablet02365383 APO-FINASTERIDE APX
02354462 CO FINASTERIDE ACT
02376709 DOM-FINASTERIDE DOM
02350270 FINASTERIDE PDL
02357224 JAMP-FINASTERIDE JAP02389878 MINT-FINASTERIDE MIN
02356058 MYLAN-FINASTERIDE MYL02310112 PMS-FINASTERIDE PMS
02010909 PROSCAR FRS
02371820 RAN-FINASTERIDE RBY
02306905 RATIO-FINASTERIDE TEP
02322579 SANDOZ FINASTERIDE SDZ
02348500 TEVA-FINASTERIDE TEP
92:16.00FEBUXOSTAT
Limited use benefit (prior approval required).For patients with symptomatic gout who have documented hypersensitivity to allopurinol
80MG Tablet02357380 ULORIC TAK
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:24.00ALENDRONATE SODIUM
Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥7.5mg per day for ≥3 months.
5MG Tablet02248727 APO-ALENDRONATE APX02248251 NOVO-ALENDRONATE TEV02384698 RAN-ALENDRONATE RBY
02288079 SANDOZ ALENDRONATE SDZ
10MG Tablet02248728 APO-ALENDRONATE APX
02388545 AURO-ALENDRONATE AUR
02270129 GEN-ALENDRONATE GEN
02394863 MINT-ALENDRONATE MIN02247373 NOVO-ALENDRONATE TEV
02288087 SANDOZ ALENDRONATE SDZ
40MG Tablet02258102 CO-ALENDRONATE ACT
70MG Tablet02352966 ALENDRONATE SAN
02303078 ALENDRONATE-70 PDL02299712 ALENDRONATE-FC SIV
02248730 APO-ALENDRONATE APX
02388553 AURO-ALENDRONATE AUR
02258110 CO-ALENDRONATE ACT
02282763 DOM-ALENDRONATE DOM
02245329 FOSAMAX FRS
02286335 GEN-ALENDRONATE GEN
02385031 JAMP-ALENDRONATE JAP02394871 MINT-ALENDRONATE MIN02261715 NOVO-ALENDRONATE TEV
02273179 PMS-ALENDRONATE PMS
02284006 PMS-ALENDRONATE FC PMS
02275279 RATIO-ALENDRONATE RPH
02270889 RIVA-ALENDRONATE RIV
02288109 SANDOZ ALENDRONATE SDZ02302004 ZYM-ALENDRONATE FC SOR
ALENDRONATE SODIUM, VITAMIN D3Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥7.5mg per day for ≥3 months.
70MG & 2800U Tablet02276429 FOSAVANCE FRS
02403633 TEVA-ALENDRONATE CHOLECALCIFEROL TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:24.00ALENDRONATE SODIUM, VITAMIN D3
Limited use benefit (prior approval required).
For the treatment of:
a. - Paget's Disease ORb. - Osteoporosis in patients who are 60 years of age or over ORc. - Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures ORd. - Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk ORe. - Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone ≥7.5mg per day for ≥3 months.
70MG & 5600U Tablet02314940 FOSAVANCE FRS02403641 TEVA-ALENDRONATE CHOLECALCIFEROL TEP
DENOSUMAB (P)Limited use benefit (prior approval required).For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom:- bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); ANDHave at least two of the following:- age >70 years- a prior fragility fracture- a bone mineral density (BMD) T-score ≤ -2.5
60MG/ML Injection (Pre-filled Syringe)02343541 PROLIA AMG
RISEDRONATE SODIUMLimited use benefit (prior approval required).
For the treatment of:
a. - Osteoporosis in patients who are 60 years of age and over orb. - Osteoporosis in patients who have documented hip, vertebral or other fractures orc. - Paget's Disease ord. - Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk ore. - Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months
5MG Tablet02298376 TEVA-RISEDRONATE TEP
5MG Tablet02242518 ACTONEL PGP
30MG Tablet02239146 ACTONEL PGP
02298384 TEVA-RISEDRONATE TEP
35MG Tablet02246896 ACTONEL PGP
02353687 APO-RISEDRONATE APX
02309831 DOM-RISEDRONATE DOM
02368552 JAMP-RISEDRONATE JAP02357984 MYLAN-RISEDRONATE MYL02302209 PMS-RISEDRONATE PMS
02347474 RISEDRONATE PDL
02352141 RISEDRONATE SIV
02370255 RISEDRONATE SAN
02411407 RISEDRONATE-35 SIV
02341077 RIVA-RISEDRONATE RIV
02327295 SANDOZ RISEDRONATE SDZ02298392 TEVA-RISEDRONATE TEP
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:24.00ZOLEDRONIC ACID
Limited use benefit (prior approval required).
• For the treatment of Paget’s disease. Coverage will be granted for one dose per 12 month period. OR.
• For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); ANDwho have at least two of the following: • age >70 years • a prior fragility fracture • a bone mineral density (BMD) T-score ≤ -2.5. • a bone mineral density (BMD) T-score ≤ -2.5.
5MG/100ML Injection02269198 ACLASTA NOV
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSABATACEPT
Limited use benefit (prior approval required).
Coverage is provided for the 2 indications.
1. For the treatment of severely active RHEUMATOID ARTHRITIS:
Criteria for initial for one year coverage:•�Prescribed by a rheumatologist
Coverage is provided for in adult patients ≥ 18 years for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA who has failed:
• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
AND• Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial
OR, if the patient has a contraindication or intolerance to MTX and has failed:• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment.
Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement innumber of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.
2. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years who meet all of the following:
Criteria for initial for one year coverage:•�Prescribed by a rheumatologist
•≥ 5 swollen joints; AND•≥ 3 joints with limited range of motion and/or pain/tenderness;ANDCondition is refractory to an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)
Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire.
Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire.
250MG/VIAL Injection02282097 ORENCIA 250MG/VIAL INJ BMS
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92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSADALIMUMAB
Limited use benefit (prior approval required).
Coverage is provided in adult patients ≥ 18 years for coverage for a MAXIMUM dose of 40mg every 2 weeks the 2 indications.
1. For the treatment of severely active RHEUMATOID ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs andsymptoms of severely active RA in adult patients ≥ 18 years who has failed:
• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patientswho do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
OR, if the patient has a contraindication or intolerance to MTX and has failed:
• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment.
2. For the treatment of moderate to severe PSORIATIC ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Client must have at least two of the following:•5 or more swollen joints•if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle•more than one joint with erosion on imaging study•dactylitis of two or more digits•tenosynovitis refractory to oral NSAIDs and steroid injections•enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)•inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4.•daily use of corticosteroids•use of opioids > 12 hours per day for pain resulting from inflammation
Patient is refractory to:•NSAIDs and•methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks
PLUS a minimum of one of the following:•leflunomide: 20mg daily for 10 weeks OR•gold: weekly injections for 20 weeks OR•cyclosporine: 2-5 mg/kg/day for 12 weeks OR•sulfasalazine at least 2g daily for 3 months
3. For the treatment of ANKYLOSING SPONDYLITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Client who meet the following criteria:
•BASDAI > 4 AND
•patient is refractory to a 4 week trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weeklyparenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.
4. For the treatment of patients with moderate to severe PSORIASIS
Criteria for initial for one year:Prescribed by a dermatologist
Client who meet all of the following criteria:•Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region AND•Intolerance or lack of response to methotrexate AND cyclosporine OR•A contraindication to methotrexate and/or cyclosporine AND•Intolerance or lack of response to phototherapy OR•Inability to access phototherapyCoverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area SeverityIndex (PASI) score and the Dermatology Life Quality Index (DLQI).
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
5. For the treatment of moderately to severely active CROHN'S DISEASE.
Criteria for initial for one year:Prescribed by a gastroenterology specialist
Initial treatment will allow for an induction dose of adalimumab 160mg followed by 80mg 2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks.
Criteria for initial four week coverage are:Patient is an adult with moderate to severely active Crohn's disease refractory to:
•therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks);PLUS•glucorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks; PLUS•azathioprine 2 to 2.5 mg/kg/day for a minimum of 3 months; OR•6-mercaptopurine 50 to 70 mg/day for a minimum of 3 months; OR•MTX (oral or parenteral) 15 to 25 mg, per week for a minimum of 3 months.
6. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years
Criteria for initial for one year:•�Prescribed by a rheumatologist
Client who meet ALL of the following criteria:• 5 swollen joints; AND• 3 joints with limited range of motion and/or pain/tenderness; AND• Condition is refractory an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)
40MG/Vial Injection02258595 HUMIRA ABB
CERTOLIZUMAB PEGOLLimited use benefit (prior approval required).
Coverage is provided in adult patients ≥ 18 years. 1. For the treatment of severely active RHEUMATOID ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Coverage is provided at a dose of 400mg at weeks 0, 2, and 4, followed by 200mg every other week or 400mg every 4 weeks.
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs andsymptoms of severely active RA in adult patients ≥ 18 years who has failed:
• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patientswho do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
OR, if the patient has a contraindication or intolerance to MTX and has failed:
• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment
Note: Criteria will be confirmed against patient‟s medication history. Coverage beyond one year will be based on improvement in number of swollen joints, numberof tender joints, ESR, CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.
200MG/ML Injection02331675 CIMZIA UCB
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSETANERCEPT
Limited use benefit (prior approval required)
The coverage of etanercept in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1.
For the treatment of severely active RHEUMATOID ARTHRITIS
Criteria for initial one year:- Prescribed by a rheumatologist
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients ≥ 18 years who have failed:
- MTX (oral or parenteral a dose ≥ 20mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND- MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment.
OR, if the patient has a contraindication or intolerance to MTX and has failed:
- Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs
2. For the treatment of moderate to severe PSORIATIC ARTHRITIS
Criteria for initial for one year:- Prescribed by a rheumatologist
Client must have at least two of the following:
- 5 or more swollen joints- if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle- more than one joint with erosion on imaging study- dactylitis of two or more digits- tenosynovitis refractory to oral NSAIDs and steroid injections- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4- daily use of corticosteroids- use of opioids > 12 hours per day for pain resulting from imflammation
Patient is refractory to:
- NSAIDs AND- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks
PLUS a minimum of one of the following:- leflunomide: 20mg daily for 10 weeks OR- gold: weekly injections for 20 weeks OR- cyclosporine: 2-5 mg/kg/day for 12 weeks OR- sulfasalazine at least 2g daily for 3 months
3. For the treatment of ANKYLOSING SPONDYLITIS
Criteria for initial one year:- Prescribed by rheumatologist
Client who meet all of the following criteria:- BASDAI > 4 AND- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND- for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks ANDsulfasalazine 2g/day for four months
Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine.
4. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years
Criteria who meet all the following criteria:
- ≥ 5 swollen joints; AND - ≥ 3 joints with limited range of motion and/or pain/tenderness; AND - Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. An adequate trial is defined as at least 3 months of parenteral methotrexate at
10mg/m2 weekly (unless significant toxicity limits the dose tolerated).
25MG/VIAL Injection02242903 ENBREL IMX
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSETANERCEPT
Limited use benefit (prior approval required)
The coverage of etanercept in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg weekly for the four indications.1.
For the treatment of severely active RHEUMATOID ARTHRITIS
Criteria for initial one year:- Prescribed by a rheumatologist
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA in adult patients ≥ 18 years who have failed:
- MTX (oral or parenteral a dose ≥ 20mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND- MTX in combination with at least two other DMARDs, such as sulfasalazine and hydroxycholorquine, for a minimum of 12 weeks of continuous treatment.
OR, if the patient has a contraindication or intolerance to MTX and has failed:
- Combination of at least two DMARDs, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of contiuous treament, or are refractory to a combination of at least 2 DMARDs
2. For the treatment of moderate to severe PSORIATIC ARTHRITIS
Criteria for initial for one year:- Prescribed by a rheumatologist
Client must have at least two of the following:
- 5 or more swollen joints- if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle- more than one joint with erosion on imaging study- dactylitis of two or more digits- tenosynovitis refractory to oral NSAIDs and steroid injections- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4- daily use of corticosteroids- use of opioids > 12 hours per day for pain resulting from imflammation
Patient is refractory to:
- NSAIDs AND- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks
PLUS a minimum of one of the following:- leflunomide: 20mg daily for 10 weeks OR- gold: weekly injections for 20 weeks OR- cyclosporine: 2-5 mg/kg/day for 12 weeks OR- sulfasalazine at least 2g daily for 3 months
3. For the treatment of ANKYLOSING SPONDYLITIS
Criteria for initial one year:- Prescribed by rheumatologist
Client who meet all of the following criteria:
- BASDAI > 4 AND- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND- for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is > 65 years of age) for more than 8 weeks ANDsulfasalazine 2g/day for four months
Note: For axial involvement, patient does not need to be tried on MTX or sulfasalazine.
4. For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years
Criteria who meet all the following criteria: - ≥ 5 swollen joints; AND - ≥ 3 joints with limited range of motion and/or pain/tenderness; AND - Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. An adequate trial is defined as at least 3 months of parenteral methotrexate at
10mg/m2 weekly (unless significant toxicity limits the dose tolerated).
50MG/ML Injection 02274728 ENBREL IMX
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSGOLIMUMAB
Limited use benefit (prior approval required).
The coverage of golimumab in adult patients ≥ 18 years is set at a MAXIMUM dose of 50mg every month for the 3 indications.
1. For the treatment of severely active RHEUMATOID ARTHRITIS.:
Criteria for initial for one year:•�Prescribed by a rheumatologist
Client who meet all of the following criteria:
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs andsymptoms of severely active RA in adult patients ≥ 18 years who has failed:
• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patientswho do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
OR, if the patient has a contraindication or intolerance to MTX and has failed:
• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment.
2. For the treatment of moderate to severe PSORIATIC ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Client who meet all least 2 of the following criteria:
- 5 or more swollen joints- if less than 5 swollen joints, at least one joint proximal to, or including wrist or ankle- more than one joint with erosion on imaging study- dactylitis of two or more digits- tenosynovitis refractory to oral NSAIDs and steroid injections- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4 - daily use of corticosteroids- use of opioids > 12 hours per day for pain resulting from inflammation
Patient is refractory to:- NSAIDs AND
- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following:- leflunomide: 20mg daily for 10 weeks OR- gold: weekly injections for 20 weeks OR- cyclosporine: 2-5 mg/kg/day for 12 weeks OR- sulfasalazine at least 2g daily for 3 months.
3. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:- BASDAI > 4 AND- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weeklyparenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.
NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.
50MG/0.5ML Injection02324784 SIMPONI KEG02324776 SIMPONI PRE-FILLED KEG
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTSINFLIXIMAB
Limited use benefit (prior approval required).
The coverage of etanercept in adult patients ≥ 18 years for 12 weeks for the 4 indications.
1. For the treatment of severely active RHEUMATOID ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
Coverage is provided for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs andsymptoms of severely active RA in adult patients ≥ 18 years who has failed:
• MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
AND• MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
AND• Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial
OR, if the patient has a contraindication or intolerance to MTX and has failed:
• Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks ofcontinuous treatment.
CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS
Patient meets all the following criteria:
• Initially prescribed by a rheumatologist• Previous failure to etanercept or adalimumab• Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following response criteria:
• >20% reduction in number of tender and swollen joints PLUS• >20% improvement in physician global assessment scalePLUS EITHER• >20% improvement in the patient global assessment scale, OR• >20% reduction in the acute phase as measured by ESR or CRP
2. For the treatment of FISTULIZING CROHN‟S DISEASE
Criteria for initial for one year:•�Prescribed by a gastroenterology specialist
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initialdoses.
Patient meets all the following criteria:
•Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite:-a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks)PLUS-immunosuppressive therapy:•azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions.OR•6-mercaptopurine, 50-70mg/day for a minimum of 6 weeks or treatment discontinued before 6 weeks due to severe adverse reactions.OR• OR Other.
3. For the treatment for SEVERE ACTIVE CROHN`S DISEASE
Criteria for initial for one year:•�Prescribed by a gastroenterology specialist
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initialdoses.
Patient meets the following criteria:
Patient is an adult with severe active Crohn‟s disease that has recurred or persisted despite:•Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks).PLUS•Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks.OR •Treatment discontinued due to serious adverse reactions OROR
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92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS•Contraindication to glucocorticoid therapy.PLUS•Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months.OR•6-mercaptopurine 50 to 70mg/day for a minimum of 3 months.OR•Methotrexate 15 to 25mg/week for a minimum of 3 months.
100MG/VIAL Injection02244016 REMICADE CER
TOCILIZUMABLimited use benefit (prior approval required).
The coverage of tocilizumab is for 16 weeks. Patient must had a tuberculin skin test performed. Tocilizumab should not be used in combination with anti-TNF agents.
1. For the treatment of moderate to severely active RHEUMATOID ARTHRITIS
Criteria for initial for one year:•�Prescribed by a rheumatologist
For patients who have failed to respond to an adequate trial of an anti-TNF agent Note: Treatment should be combined with methotrexate or other DMARD.
Coverage is initially provided for 16 weeks at an initial dose of 4 mg/kg/dose every 4 weeks.
2. For the treatment of active SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS Criteria for initial for one year:•�Prescribed by a rheumatologist
Coverage is for patients two years of age and older who have responded inadequately to non-steroidal anti-inflammatory drugs (NSAIDs) and systemic corticosteroids (with or without methotrexate), due to intolerance or lack of efficacy. Coverage is initially provided for 16-week at a dose of 12 mg/kg once every two weeks for children weighing < 30 kg and 8 mg/kg for children weighing > 30 kg.
80MG/4ML Injection02350092 ACTEMRA HLR
200MG/10ML Injection02350106 ACTEMRA HLR
400MG/20ML Injection02350114 ACTEMRA HLR
92:44.00CYCLOSPORINE
Limited use benefit (prior approval required).
For transplant therapy.
10MG Capsule02237671 NEORAL NVR
25MG Capsule02150689 NEORAL NVR
02247073 SANDOZ-CYCLOSPORINE SDZ
50MG Capsule02150662 NEORAL NVR
02247074 SANDOZ-CYCLOSPORINE SDZ
100MG Capsule02150670 NEORAL NVR
02242821 SANDOZ-CYCLOSPORINE SDZ
100MG/ML Solution02150697 NEORAL NVR
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Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:44.00MYCOPHENOLATE MOFETIL
Limited use benefit (prior approval required).
For transplant therapy.
250MG Capsule02352559 APO-MYCOPHENOLATE APX
02192748 CELLCEPT HLR
02386399 JAMP-MYCOPHENOLATE JAP
02371154 MYLAN-MYCOPHENOLATE MYL
02320630 SANDOZ MYCOPHENOLATE SDZ
02364883 TEVA-MYCOPHENOLATE TEP
500MG Tablet02352567 APO-MYCOPHENOLATE APX02237484 CELLCEPT HLR
02379996 CO MYCOPHENOLATE ACT
02380382 JAMP-MYCOPHENOLATE JAP
02370549 MYLAN-MYCOPHENOLATE MYL
02313855 SANDOZ MYCOPHENOLATE SDZ
02348675 TEVA-MYCOPHENOLATE TEP
MYCOPHENOLATE SODIUMLimited use benefit (prior approval required).
For transplant therapy.
180MG Enteric Coated Tablet02264560 MYFORTIC NVR
360MG Enteric Coated Tablet02264579 MYFORTIC NVR
SIROLIMUSLimited use benefit (prior approval required).
Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.
1MG/ML Oral Liquid02243237 RAPAMUNE WAY
1MG Tablet02247111 RAPAMUNE WAY
TACROLIMUSLimited use benefit (prior approval required).
For transplant therapy.
0.5MG Capsule02243144 PROGRAF AST
1MG Capsule02175991 PROGRAF AST
5MG Capsule02175983 PROGRAF AST
0.5MG Extended Release Capsule02296462 ADVAGRAF AST
1MG Extended Release Capsule02296470 ADVAGRAF AST
3MG Extended Release Capsule02331667 ADVAGRAF AST
5MG Extended Release Capsule02296489 ADVAGRAF AST
5MG/ML Injection02176009 PROGRAF AST
Page A-64 de 662014
Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
92:92.00BOTULINUM TOXIN TYPE A
Limited use benefit (prior approval required).
For the treatment of: a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older b. - cervical dystonia (spasmodic torticollis)
50U Injection09857386 BOTOX ALL
100U Injection01981501 BOTOX ALL
200U Injection09857387 BOTOX ALL
INCOBOTULINUMTOXINALimited use benefit (prior approval required).
-Treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older-Treatment of cervical dystonia (spasmodic torticollis)
100U/VIAL Injection02324032 XEOMIN MEZ
94:00 DEVICES94:00.00 DEVICES
SPACER DEVICELimited use benefit with quantity and frequency limits (prior approval is not required).
Coverage is granted for 1 spacer device every 12 months.
Device96899962 AEROCHAMBER AC BOYZ TRU
96899963 AEROCHAMBER AC GIRLZ TRU
96899969 AEROCHAMBER PLUS FLOW-VU LG TRU
96899970 AEROCHAMBER PLUS FLOW-VU MED TRU96899968 AEROCHAMBER PLUS FLOW-VU MOUTH TRU
96899971 AEROCHAMBER PLUS FLOW-VU SM TRU
99400507 E-Z SPACER WEP99400511 E-Z SPACER (MASK ONLY) WEP
99400508 E-Z SPACER WITH SMALL MASK WEP
99400501 OPTICHAMBER AUC
96899961 OPTICHAMBER DIAMOND (CHAMBER) AUC
96899958 OPTICHAMBER DIAMOND (LARGE M) AUC
96899959 OPTICHAMBER DIAMOND (MEDIUM M) AUC
96899960 OPTICHAMBER DIAMOND (MEDIUM M) AUC
99400504 OPTICHAMBER LARGE MASK AUC99400503 OPTICHAMBER MEDIUM MASK AUC99400502 OPTICHAMBER SMALL MASK AUC
99400505 OPTIHALER AUC
99400787 POCKET CHAMBER MCA
99400791 POCKET CHAMBER WITH ADULT MASK MCA
99400788 POCKET CHAMBER WITH INFANT MASK MCA
99400790 POCKET CHAMBER WITH MEDIUM MASK MCA99400789 POCKET CHAMBER WITH SMALL MASK MCA
Page A-65 de 662014
Non-Insured Health BenefitsAppendix A - Limited Use Benefits and Criteria
96:00 PHARMACEUTICAL AIDS96:00.00 PHARMACEUTICAL AIDS
METHADONE HCL (PA)limited use benefit (prior approval required) with the following criteria:
Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.
Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependencyis an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.
Powder09991180 METHADONE POWDER (PAIN) UNK
Page A-66 de 662014
Page
Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria
Page Page1
172821729232ABILIFY49ACCEL PIOGLITAZONE41ACCOLATE51ACCUTANE17ACET CODEINE 3024ACETAMIN CHILD24ACETAMINOPHEN16ACETYLSALICYLIC ACID56ACLASTA46ACT PANTOPRAZOLE63ACTEMRA55ACTONEL49ACTOS15ADCIRCA64ADVAGRAF10ADVAIR10ADVAIR DISKUS 10010ADVAIR DISKUS 25010ADVAIR DISKUS 50065AEROCHAMBER AC BOYZ65AEROCHAMBER AC GIRLZ65AEROCHAMBER PLUS FLOW-VU
LG65AEROCHAMBER PLUS FLOW-VU
MED65AEROCHAMBER PLUS FLOW-VU
MOUTH65AEROCHAMBER PLUS FLOW-VU
SM15AGGRENOX50ALDARA54ALENDRONATE54ALENDRONATE-7054ALENDRONATE-FC41ALPHAGAN P33ALPRAZOLAM37AMERGE25APO-ACETAMINOPHEN54APO-ALENDRONATE37APO-ALMOTRIPTAN33APO-ALPRAZ41APO-BENZYDAMINE34APO-BROMAZEPAM26APO-CLONAZEPAM14APO-CLOPIDOGREL10APO-CYCLOBENZAPRINE34APO-DIAZEPAM4APO-ENTECAVIR
19APO-FENTANYL53APO-FINASTERIDE27APO-GABAPENTIN20APO-HYDROMORPHONE5APO-IMATINIB
43APO-LANSOPRAZOLE29APO-LEVETIRACETAM1APO-LEVOFLOXACIN
35APO-LORAZEPAM35APO-LORAZEPAM SUBLINGUAL1APO-MINOCYCLINE
40APO-MONTELUKAST
64APO-MYCOPHENOLATE36APO-NITRAZEPAM44APO-OMEPRAZOLE36APO-OXAZEPAM17APO-OXYCODONE/ACET46APO-PANTOPRAZOLE49APO-PIOGLITAZONE30APO-PREGABALIN47APO-RABEPRAZOLE48APO-RALOXIFENE55APO-RISEDRONATE7APO-RIVASTIGMINE
38APO-RIZATRIPTAN38APO-RIZATRIPTAN RPD38APO-SUMATRIPTAN36APO-TEMAZEPAM11APO-TIZANIDINE37APO-TRIAZO39APO-ZOLMITRIPTAN39APO-ZOLMITRIPTAN RAPID3APTIVUS
16ASA16ASA EC16ASAPHEN16ASAPHEN EC16ASATAB16ASPIRIN24ATASOL26ATASOL FORTE16ATASOL-1516ATASOL-3035ATIVAN35ATIVAN SUBLINGUAL54AURO-ALENDRONATE10AURO-CYCLOBENZAPRINE27AURO-GABAPENTIN29AURO-LEVETIRACETAM50AVANDIA53AVODART37AXERT32BANZEL 100MG TAB32BANZEL 200MG TAB32BANZEL 400MG TAB65BOTOX34BROMAZEPAM32BUPROPION SR39CAMPRAL40CARNITOR40CARNITOR IV16CELEBREX64CELLCEPT3CELSENTRI
52CENTRUM JUNIOR COMPLETE TB
52CENTRUM JUNIOR COMPLETE TAB
52CENTRUM MATERNA42CESAMET12CHAMPIX12CHAMPIX STARTER PACK24CHILDREN'S ACETAMINOPHEN25CHILDREN'S TYLENOL SOFT
CHEWS
58CIMZIA51CLARUS26CLONAPAM14CLOPIDOGREL15CO BOSENTAN39CO CABERGOLINE14CO CLOPIDOGREL19CO FENTANYL53CO FINASTERIDE64CO MYCOPHENOLATE42CO NABILONE49CO PIOGLITAZONE30CO PREGABALIN48CO RALOXIFENE38CO RIZATRIPTAN6CO TEMOZOLOMIDE
54CO-ALENDRONATE26CO-CLONAZEPAM18CODEINE18CODEINE CONTIN CR18CODEINE PHOSPHATE27CO-GABAPENTIN29CO-LEVETIRACETAM1CO-LEVOFLOXACIN
38CO-RIZATRIPTAN ODT38CO-SUMATRIPTAN36CO-TEMAZEPAM10CYCLOBENZAPRINE51DETROL51DETROL LA34DIAZEPAM20DILAUDID21DOLORAL 121DOLORAL 554DOM-ALENDRONATE41DOM-BENZYDAMINE26DOM-CLONAZEPAM26DOM-CLONAZEPAM-R14DOM-CLOPIDOGREL10DOM-CYCLOBENZAPRINE53DOM-FINASTERIDE27DOM-GABAPENTIN29DOM-LEVETIRACETAM35DOM-LORAZEPAM1DOM-MINOCYCLINE
41DOM-MONTELUKAST45DOM-OMEPRAZOLE DR46DOM-PANTOPRAZOLE49DOM-PIOGLITAZONE30DOM-PREGABALIN47DOM-RABEPRAZOLE55DOM-RISEDRONATE38DOM-RIZATRIPTAN RDT38DOM-SUMATRIPTAN36DOM-TEMAZEPAM39DOM-ZOLMITRIPTAN39DOSTINEX19DURAGESIC MAT51ELIDEL13ELIQUIS51ENABLEX59ENBREL17ENDOCET
Page A-1 of 42014
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Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria
Page Page16EURO-ASA48EVISTA16EXDOL-1516EXDOL-307EXELON
65E-Z SPACER65E-Z SPACER (MASK ONLY)65E-Z SPACER WITH SMALL MASK14EZETROL19FENTANYL24FEVERHALT53FINASTERIDE40FLEXI-T IUD52FLINTSTONES EXTRA C9FORADIL
54FOSAMAX54FOSAVANCE27GABAPENTIN28GD-GABAPENTIN30GD-PREGABALIN54GEN-ALENDRONATE33GEN-ALPRAZOLAM26GEN-CLONAZEPAM10GEN-CYCLOPRINE27GEN-GABAPENTIN49GEN-PIOGLITAZONE38GEN-SUMATRIPTAN11GEN-TIZANIDINE5GLEEVEC
12HABITROL58HUMIRA20HYDROMORPH CONTIN38IMITREX38IMITREX DF5INCIVEK
52INFANTOL2INTELENCE3ISENTRESS
26JAMP-ACETAMINOPHEN54JAMP-ALENDRONATE33JAMP-ALPRAZOLAM10JAMP-CYCLOBENZAPRINE53JAMP-FINASTERIDE27JAMP-GABAPENTIN29JAMP-LEVETIRACETAM41JAMP-MONTELUKAST53JAMP-MULTIVITAMIN A/D/ C
DROPS64JAMP-MYCOPHENOLATE49JAMP-PIOGLITAZONE55JAMP-RISEDRONATE38JAMP-RIZATRIPTAN48JANUMET48JANUVIA22KADIAN22KADIAN SR29KEPPRA43LANSOPRAZOLE34LECTOPAM1LEVAQUIN
29LEVETIRACETAM40LIBERTE UT380 SHORT40LIBERTE UT380 STANDARD
18LINCTUS CODEINE35LORAZEPAM44LOSEC16LOWPRIN42LUCENTIS30LYRICA21M.O.S.21M.O.S. 1021M.O.S. 2021M.O.S. 4021M.O.S. 5022M.O.S. 6021M.O.S. SR23M.O.S. SULFATE40MAR-MONTELUKAST38MAR-RIZATRIPTAN38MAXALT38MAXALT RPD22M-ESLON22M-ESLON SR21METADOL66METHADONE POWDER (PAIN)21METHADOSE21METHADOSE SUGARFREE2MINOCIN1MINOCYCLINE
54MINT-ALENDRONATE14MINT-CLOPIDOGREL53MINT-FINASTERIDE7MINT-RIVASTIGMINE
48MIRENA36MOGADON40MONTELUKAST22MORPHINE SR22MS CONTIN SR23MS IR52MULTI-PRE AND POST NATAL64MYFORTIC39MYLAN ZOLMITRIPTAN39MYLAN ZOLMITRIPTAN ODT37MYLAN-ALMOTRIPTAN15MYLAN-BOSENTAN32MYLAN-BUPROPION XL14MYLAN-CLOPIDOGREL19MYLAN-FENTANYL53MYLAN-FINASTERIDE28MYLAN-GABAPENTIN6MYLAN-GALANTAMINE ER
43MYLAN-LANSOPRAZOLE1MYLAN-LEVOFLOXACIN
40MYLAN-MONTELUKAST64MYLAN-MYCOPHENOLATE44MYLAN-OMEPRAZOLE46MYLAN-PANTOPRAZOLE47MYLAN-RABEPRAZOLE55MYLAN-RISEDRONATE7MYLAN-RIVASTIGMINE
38MYLAN-RIZATRIPTAN ODT63NEORAL14NEULASTA27NEURONTIN47NEXT CHOICE12NICODERM
11NICORETTE11NICORETTE PLUS11NICOTINE12NICOTROL TRANSDERMAL11NICOTROL TRANSDERMAL 10MG12NICOTROL TRANSDERMAL 15MG11NICOTROL TRANSDERMAL 5MG36NITRAZADON47NORLEVO40NOVA-T IUD54NOVO-ALENDRONATE33NOVO-ALPRAZOL41NOVO-BENZYDAMINE34NOVO-BROMAZEPAM26NOVO-CLONAZEPAM10NOVO-CYCLOPRINE27NOVO-GABAPENTIN25NOVO-GESIC1NOVO-LEVOFLOXACIN
35NOVO-LORAZEM1NOVO-MINOCYCLINE
49NOVO-PIOGLITAZONE47NOVO-RABEPRAZOLE7NOVO-RIVASTIGMINE
39NOVO-SUMATRIPTAN38NOVO-SUMATRIPTAN DF36NOVO-TEMAZEPAM44OMEPRAZOLE9ONBREZ
48ONGLYZA65OPTICHAMBER65OPTICHAMBER DIAMOND
(CHAMBER)65OPTICHAMBER DIAMOND
(LARGE M)65OPTICHAMBER DIAMOND
(MEDIUM M)65OPTICHAMBER LARGE MASK65OPTICHAMBER MEDIUM MASK65OPTICHAMBER SMALL MASK65OPTIHALER47OPTION 256ORENCIA 250MG/VIAL INJ36OXAZEPAM9OXEZE TURBUHALER
36OXPAM23OXYCODONE17OXYCODONE/ACET23OXY-IR46PANTOLOC46PANTOPRAZOLE47PARIET EC6PAT-GALANTAMINE ER
47PAT-RABEPRAZOLE EC1PDL-MINOCYCLINE
24PEDIAPHEN25PEDIAPHEN CHEWABLE TAB
160MG25PEDIAPHEN CHEWABLE TAB
80MG24PEDIATRIX3PEGASYS3PEGASYS RBV
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Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria
Page Page4PEGETRON4PEGETRON REDIPEN
17PERCOCET17PERCOCET DEMI26PHL-CLONAZEPAM26PHL-CLONAZEPAM-R10PHL-CYCLOBENZAPRINE20PHL-HYDROMORPHONE49PHL-PIOGLITAZONE49PIOGLITAZONE47PLAN B14PLAVIX14PMS CLOPIDOGREL24PMS-ACETAMINOPHEN17PMS-ACETAMINOPHEN WITH
CODEINE54PMS-ALENDRONATE54PMS-ALENDRONATE FC41PMS-BENZYDAMINE15PMS-BOSENTAN32PMS-BUPROPION SR26PMS-CLONAZEPAM26PMS-CLONAZEPAM R18PMS-CODEINE10PMS-CYCLOBENZAPRINE34PMS-DIAZEPAM19PMS-FENTANYL53PMS-FINASTERIDE27PMS-GABAPENTIN6PMS-GALANTAMINE ER
20PMS-HYDROMORPHONE43PMS-LANSOPRAZOLE29PMS-LEVETIRACETAM1PMS-LEVOFLOXACIN
35PMS-LORAZEPAM1PMS-MINOCYCLINE2PMS-MONOCYCLINE
40PMS-MONTELUKAST42PMS-NABILONE44PMS-OMEPRAZOLE45PMS-OMEPRAZOLE DR23PMS-OXYCODONE46PMS-PANTOPRAZOLE49PMS-PIOGLITAZONE30PMS-PREGABALIN47PMS-RABEPRAZOLE EC48PMS-RALOXIFENE55PMS-RISEDRONATE7PMS-RIVASTIGMINE
38PMS-RIZATRIPTAN RDT38PMS-SUMATRIPTAN39PMS-ZOLMITRIPTAN39PMS-ZOLMITRIPTAN ODT65POCKET CHAMBER65POCKET CHAMBER WITH ADULT
MASK65POCKET CHAMBER WITH INFANT
MASK65POCKET CHAMBER WITH
MEDIUM MASK65POCKET CHAMBER WITH SMALL
MASK52POLY-VI-SOL
13PRADAXA30PREGABALIN31PREGABALIN-15030PREGABALIN-2530PREGABALIN-5031PREGABALIN-7552PRENATAL & POSTPARTUM52PRENATAL AND POSTPARTUM43PREVACID44PREVACID FASTAB16PRO-ASA16PRO-ASA EC32PRO-BUPROPION SR17PROCET-3026PRO-CLONAZEPAM27PRO-GABAPENTIN64PROGRAF29PRO-LEVETIRACETAM55PROLIA35PRO-LORAZEPAM17PRO-OXYCOD ACET49PRO-PIOGLITAZONE47PRO-RABEPRAZOLE53PROSCAR38PRO-SUMATRIPTAN51PROTOPIC47RABEPRAZOLE54RAN-ALENDRONATE14RAN-CLOPIDOGREL19RAN-FENTANYL53RAN-FINASTERIDE27RAN-GABAPENTIN43RAN-LANSOPRAZOLE29RAN-LEVETIRACETAM40RAN-MONTELUKAST42RAN-NABILONE44RAN-OMEPRAZOLE46RAN-PANTOPRAZOLE49RAN-PIOGLITAZONE30RAN-PREGABALIN47RAN-RABEPRAZOLE64RAPAMUNE54RATIO-ALENDRONATE32RATIO-BUPROPION18RATIO-CODEINE10RATIO-CYCLOBENZAPRINE17RATIO-EMTEC-3053RATIO-FINASTERIDE28RATIO-GABAPENTIN17RATIO-LENOLTEC NO.217RATIO-LENOLTEC NO.31RATIO-MINOCYCLINE
21RATIO-MORPHINE22RATIO-MORPHINE SULFATE SR45RATIO-OMEPRAZOLE17RATIO-OXYCOCET18RATIO-OXYCODAN49RATIO-PIOGLITAZONE7RATIO-RIVASTIGMINE
14RATIO-SILDENAFIL R36RATIO-TEMAZEPAM63REMICADE52RENAGEL
36RESTORIL14REVATIO55RISEDRONATE55RISEDRONATE-355RITUXAN
14RIVA CLOPIDOGREL54RIVA-ALENDRONATE26RIVA-CLONAZEPAM17RIVACOCET10RIVA-CYCLOBENZAPRINE27RIVA-GABAPENTIN1RIVA-MINOCYCLINE
46RIVA-PANTOPRAZOLE30RIVA-PREGABALIN47RIVA-RABEPRAZOLE EC55RIVA-RISEDRONATE16RIVASA39RIVA-ZOLMITRIPTAN26RIVOTRIL54SANDOZ ALENDRONATE37SANDOZ ALMOTRIPTAN15SANDOZ BOSENTAN14SANDOZ CLOPIDOGREL19SANDOZ FENTANYL53SANDOZ FINASTERIDE43SANDOZ LANSOPRAZOLE1SANDOZ LEVOFLOXACIN
40SANDOZ MONTELUKAST64SANDOZ MYCOPHENOLATE37SANDOZ NARATRIPTAN44SANDOZ OMEPRAZOLE17SANDOZ OXYCOD ACET49SANDOZ PIOGLITAZONE30SANDOZ PREGABALIN55SANDOZ RISEDRONATE7SANDOZ RIVASTIGMINE
38SANDOZ RIZATRIPTAN ODT39SANDOZ ZOLMITRIPTAN39SANDOZ ZOLMITRIPTAN ODT32SANDOZ-BUPROPION SR26SANDOZ-CLONAZEPAM63SANDOZ-CYCLOSPORINE1SANDOZ-MINOCYCLINE
36SANDOZ-NITRAZEPAM46SANDOZ-PANTOPRAZOLE47SANDOZ-RABEPRAZOLE38SANDOZ-SUMATRIPTAN33SAPHRIS10SEREVENT DISKHALER10SEREVENT DISKUS61SIMPONI61SIMPONI PRE-FILLED40SINGULAIR50SORIATANE8SPIRIVA
22STATEX53STELARA24SUBOXONE24SUBOXONE MAINTENANCE38SUMATRIPTAN38SUMATRIPTAN DF23SUPEUDOL5SUTENT
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Non-Insured Health BenefitsAppendix ALimited Use Benefits and Criteria
Page Page9SYMBICORT 100 TURBUHALER9SYMBICORT 200 TURBUHALER
26TANTAPHEN24TANTAPHEN GRAPE5TARCEVA
38TARO-SUMATRIPTAN36TEMAZEPAM6TEMODAL
24TEMPRA25TEMPRA DOUBLE STRENGTH40TEVA- MONTELUKAST54TEVA-ALENDRONATE
CHOLECALCIFEROL14TEVA-CLOPIDOGREL18TEVA-FENTANYL53TEVA-FINASTERIDE6TEVA-GALANTAMINE ER
20TEVA-HYDROMORPHONE5TEVA-IMATINIB
43TEVA-LANSOPRAZOLE23TEVA-MORPHINE SR 100MG TAB22TEVA-MORPHINE SR 15MG TAB23TEVA-MORPHINE SR 200MG TAB22TEVA-MORPHINE SR 30MG TAB22TEVA-MORPHINE SR 60MG TAB64TEVA-MYCOPHENOLATE42TEVA-NABILONE37TEVA-NARATRIPTAN45TEVA-OMEPRAZOLE46TEVA-PANTOPRAZOLE30TEVA-PREGABALIN48TEVA-RALOXIFENE55TEVA-RISEDRONATE39TEVA-ZOLMITRIPTAN39TEVA-ZOLMITRIPTAN OD11THRIVE15TRACLEER48TRAJENTA12TRANSDERMAL NICOTINE17TRIATEC-3052TROSEC25TYLENOL26TYLENOL EXTRA STRENGTH24TYLENOL GRAPE25TYLENOL JR STRENGTH
FASTMELTS25TYLENOL JUNIOR STRENGTH17TYLENOL WITH CODEINE NO.217TYLENOL WITH CODEINE NO.353ULORIC35VALIUM52VESICARE2VFEND4VICTRELIS4VICTRELIS TRIPLE
29VIMPAT3VIREAD
42VISUDYNE15VOLIBRIS32WELLBUTRIN SR32WELLBUTRIN XL33XANAX34XANAX TS
13XARELTO65XEOMIN11ZANAFLEX36ZAPEX33ZELDOX9ZENHALE
39ZOLMITRIPTAN39ZOLMITRIPTAN ODT39ZOMIG39ZOMIG RAPIMELT32ZYBAN54ZYM-ALENDRONATE FC26ZYM-CLONAZEPAM49ZYM-PIOGLITAZONE2ZYVOXAM
Page A-4 of 42014
Non-Insured Health BenefitsAppendix BSpecial Formulary for Chronic Renal Failure Patients
The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.
20:00 BLOOD FORMATION
COAGULATION AND
THROMBOSIS
20:16.00 HEMATOPOIETIC AGENTS
DARBEPOETIN ALFA
25MCG/ML Injection
02246354 ARANESP AMG40MCG/ML Injection
02246355 ARANESP AMG100MCG/ML Injection
02246357 ARANESP AMG200MCG/ML Injection
02246358 ARANESP AMG500MCG/ML Injection
02246360 ARANESP AMG
EPOETIN ALFA
20,000IU/ML Injection
02206072 EPREX JNO5,000IU/ML Injection
02243400 EPREX JNO1,000IU/0.5ML Prefilled Syringe
02231583 EPREX JNO2,000IU/0.5ML Prefilled Syringe
02231584 EPREX JNO3,000IU/0.3ML Prefilled Syringe
02231585 EPREX JNO4,000IU/0.4ML Prefilled Syringe
02231586 EPREX JNO6,000IU/0.6ML Prefilled Syringe
02243401 EPREX JNO8,000IU/0.8ML Prefilled Syringe
02243403 EPREX JNO10,000IU/ML Prefilled Syringe
02231587 EPREX JNO20,000IU/0.5ML Prefilled Syringe
02243239 EPREX JNO40,000IU/ML Prefilled Syringe
02240722 EPREX JNO
40:00 ELECTROLYTIC, CALORIC, AND
WATER BALANCE
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM (CALCIUM GLUCONOLACTATE,
CALCIUM CARBONATE)
300MG & 2940MG Effervescent Tablet
02232482 CALCIUM SANDOZ NVC1750MG & 2327MG Effervescent Tablet
02232483 GRAMCAL NVC
CALCIUM CARBONATE
500MG Capsule
00648353 CALSAN NVC500MG Chewable Tablet
00705373 CALCIUM WAM00648345 CALSAN NVC
250MG Tablet
00682047 APO-CAL 250 APX00645958 CALCIUM TEV
PHOSPHORUS
500MG Effervescent Tablet
00225819 PHOSPHATE-NOVARTIS NVR
ZINC GLUCONATE
50MG Tablet
00503169 ZINC VTH00505463 ZINC JAM
56:00 GASTROINTESTINAL DRUGS
56:04.00 ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE
500MG Capsule
02135620 BASALJEL AXC60MG/ML Liquid
00572527 ALUGEL ATL64MG/ML Liquid
02125862 AMPHOJEL AXC600MG Tablet
02124971 AMPHOJEL AXC
CALCIUM CARBONATE
500MG Tablet
01970240 TUMS GSK750MG Tablet
01967932 TUMS EXTRA STRENGTH GSK1000MG Tablet
02151138 TUMS ULTRA STRENGTH GSK
Page B-1 of 22014
Non-Insured Health BenefitsAppendix BSpecial Formulary for Chronic Renal Failure Patients
The Special Formulary for Chronic Renal Failure Patients defines selected drugs (for example: darbepoetin alfa, calcium products, water-soluble multivitamin products and selected nutritional products formulated for renal patients) that are covered for identified eligible NIHB clients in chronic renal failure. These drugs are covered in addition to the drugs and products listed in the NIHB Drug Benefit List.
88:00 VITAMINS
88:08.00 VITAMIN B COMPLEX
VITAMIN B COMPLEX
Tablet
00123803 B COMPLEX PLUS C JAM
88:12.00 VITAMIN C
VITAMIN B COMPLEX WITH VITAMIN C
Tablet
02245391 DIAMINE EUO
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS
Tablet
02244872 REPLAVITE WNP00558796 STRESS PLEX C JAM
96:00 PHARMACEUTICAL AIDS
96:00.00 PHARMACEUTICAL AIDS
NUTRITIONAL SUPPLEMENT
Liquid
09853723 NEPRO ABB00907995 NOVASOURCE NVR09853731 SUPLENA ABB
235ML Liquid
99002639 NEPRO ABB99002647 SUPLENA ABB
Powder
09991056 RESOURCE BENEPROTEIN NVR
Page B-2 of 22014
Page
Non-Insured Health BenefitsAppendix BSpecial Formulary for Chronic Renal Failure Patients
1ALUGEL1ALUMINUM HYDROXIDE
1AMPHOJEL1APO-CAL 2501ARANESP2B COMPLEX PLUS C1BASALJEL1CALCIUM1CALCIUM (CALCIUM
GLUCONOLACTATE, CALCIUM
CARBONATE)
1CALCIUM CARBONATE
1CALCIUM SANDOZ1CALSAN1DARBEPOETIN ALFA
2DIAMINE1EPOETIN ALFA
1EPREX1GRAMCAL2MULTIVITAMINS
2NEPRO2NOVASOURCE2NUTRITIONAL SUPPLEMENT
1PHOSPHATE-NOVARTIS1PHOSPHORUS
2REPLAVITE2RESOURCE BENEPROTEIN2STRESS PLEX C2SUPLENA1TUMS1TUMS EXTRA STRENGTH1TUMS ULTRA STRENGTH2VITAMIN B COMPLEX
2VITAMIN B COMPLEX WITH
VITAMIN C
1ZINC1ZINC GLUCONATE
Page B-1 of 12014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
12:00 AUTONOMIC DRUGS
12:08.08 ANTIMUSCARINICS /
ANTISPASMODICS
ATROPINE SULFATE
0.4mg/mL Injection
00392782 ATROPINE SULFATE SDZ
00497231 ATROPINE SULFATE ABB
00960624 ATROPINE SULFATE SDZ
0.6mg/mL Injection
00012076 ATROPINE SULFATE GSK
00392693 ATROPINE SULFATE SDZ
00497258 ATROPINE SULFATE ABB
GLYCOPYRROLATE
0.2mg/mL Injection
02039508 GLYCOPYRROLATE SDZ
HYOSCINE BUTYLBROMIDE
20mg/mL Injection
00363839 BUSCOPAN BOE
02229868 HYOSCINE SDZ
12:08.08 ANTIMUSCARINICS /
ANTISPASMODICS
SCOPOLAMINE HYDROBROMIDE
0.4mg/mL Injection
00541869 SCOPOLAMINE ABB
02242810 SCOPOLAMINE OMG
0.6mg/mL Injection
00541877 SCOPOLAMINE ABB
02242811 SCOPOLAMINE OMG
1.5MG Patch
80024336 TRANSDERM-V NOV
Page C-1 of 62014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
28:00 CENTRAL NERVOUS SYSTEM
AGENTS
28:04.00 GENERAL ANESTHETICS
KETAMINE
10mg/mL Injection
00224391 KETALAR ERF
02246795 KETAMINE SDZ
50mg/mL Injection
00224405 KETALAR ERF
02246796 KETAMINE SDZ
28:08.08 OPIATE AGONISTS
FENTANYL
12mcg Transdermal Patch
02327112 SANDOZ FENTANYL SDZ
02311925 TEVA-FENTANYL TEV
12mcg/h Transdermal Patch
02341379 PMS-FENTANYL MTX PMS
02330105 RAN-FENTANYL MATRIX RBY
28:08.08 OPIATE AGONISTS
FENTANYL
25mcg Transdermal Patch
02330113 RAN-FENTANYL MATRIX RBY
02327120 SANDOZ FENTANYL SDZ
02282941 TEVA-FENTANYL TEV
25mcg/h Transdermal Patch
02275813 DURAGESIC MAT JNO
02314630 NOVO-FENTANYL TEV
02341387 PMS-FENTANYL MTX PMS
50mcg Transdermal Patch
02330121 RAN-FENTANYL MATRIX RBY
02327147 SANDOZ FENTANYL SDZ
02282968 TEVA-FENTANYL TEV
Page C-2 of 62014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
28:08.08 OPIATE AGONISTS
FENTANYL
50mcg/h Transdermal Patch
02275821 DURAGESIC MAT JNO
02314649 NOVO-FENTANYL TEV
02341395 PMS-FENTANYL MTX PMS
75mcg Transdermal Patch
02330148 RAN-FENTANYL MATRIX RBY
02327155 SANDOZ FENTANYL SDZ
02282976 TEVA-FENTANYL TEV
75mcg/h Transdermal Patch
02275848 DURAGESIC MAT JNO
02314657 NOVO-FENTANYL TEV
02341409 PMS-FENTANYL MTX PMS
100mcg Transdermal Patch
02327163 SANDOZ FENTANYL SDZ
02282984 TEVA-FENTANYL TEV
28:08.08 OPIATE AGONISTS
FENTANYL
100mcg/h Transdermal Patch
02275856 DURAGESIC MAT JNO
02314665 NOVO-FENTANYL TEV
02341417 PMS-FENTANYL MTX PMS
02330156 RAN-FENTANYL MATRIX RBY
FENTANYL CITRATE
50mcg/mL Injection
00888346 FENTANYL CITRATE HOS
02126648 FENTANYL CITRATE HOS
02240434 FENTANYL CITRATE SDZ
HYDROMORPHONE HYDROCHLORIDE
2mg/mL Injection
02145901 HYDROMORPHONE SDZ
10mg/mL Injection
02145928 HYDROMORPHONE HP SDZ
20mg/mL Injection
02145936 HYDROMORPHONE HP SDZ
Page C-3 of 62014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
28:08.08 OPIATE AGONISTS
HYDROMORPHONE HYDROCHLORIDE
50mg/mL Injection
02146126 HYDROMORPHONE HP SDZ
METHADONE HYDROCHLORIDE
1mg/mL Liquid
02247694 METADOL PAL
10mg/mL Liquid
02241377 METADOL PAL
1MG Tablet
02247698 METADOL PAL
5MG Tablet
02247699 METADOL PAL
10MG Tablet
02247700 METADOL PAL
25MG Tablet
02247701 METADOL PAL
28:08.08 OPIATE AGONISTS
MORPHINE SULFATE
0.5mg/mL Injection
02021056 MORPHINE LP EPIDURAL SDZ
01949047 MORPHINE-EPD ABB
1mg/mL Injection
01980696 MORPHINE SDZ
02021048 MORPHINE LP EPIDURAL SDZ
01949055 MORPHINE-EPD ABB
2mg/mL Injection
00850314 MORPHINE ABB
01964437 MORPHINE SDZ
02242484 MORPHINE SDZ
5mg/mL Injection
01964429 MORPHINE SDZ
10mg/mL Injection
00850322 MORPHINE ABB
00392588 MORPHINE SULFATE SDZ
Page C-4 of 62014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
28:08.08 OPIATE AGONISTS
MORPHINE SULFATE
15mg/mL Injection
00392561 MORPHINE SULFATE SDZ
25mg/mL Injection
00676411 MORPHINE HP SDZ
50mg/mL Injection
02137267 MORPHINE FAU
00617288 MORPHINE HP SDZ
28:16.08 ANTIPSYCHOTIC AGENTS
METHOTRIMEPRAZINE
25mg/mL Injection
01927698 NOZINAN SAC
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES
DIAZEPAM
5mg/mL Injection
02065614 DIAZEMULS VL ACG
00399728 DIAZEPAM SDZ
28:24.08 ANXIOLYTICS, SEDATIVES AND
HYPNOTICS - BENZODIAZEPINES
LORAZEPAM
4mg/mL Injection
02243278 LORAZEPAM SDZ
MIDAZOLAM
1mg/mL Injection
02240285 MIDAZOLAM SDZ
02242904 MIDAZOLAM PPC
02243934 MIDAZOLAM TEV
5mg/mL Injection
02240286 MIDAZOLAM SDZ
02242905 MIDAZOLAM PPC
02243935 MIDAZOLAM TEV
Page C-5 of 62014
Non-Insured Health BenefitsAppendix CPalliative Care Formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life.
Requests for any of the DINs below will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
The recipient:1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less
Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.
56:00 GASTROINTESTINAL DRUGS
56:22.92 MISCELLANEOUS ANTIEMETICS
NABILONE
0.25MG Capsule
02312263 CESAMET VAE
02358077 RAN-NABILONE RBY
02392925 TEVA-NABILONE TEP
0.5MG Capsule
02256193 CESAMET VAE
02393581 CO NABILONE ACT
02380900 PMS-NABILONE PMS
02358085 RAN-NABILONE RBY
02384884 TEVA-NABILONE TEP
56:22.92 MISCELLANEOUS ANTIEMETICS
NABILONE
1MG Capsule
00548375 CESAMET VAE
02393603 CO NABILONE ACT
02380919 PMS-NABILONE PMS
02358093 RAN-NABILONE RBY
02384892 TEVA-NABILONE TEP
56:32.00 PROKINETIC AGENTS
METOCLOPRAMIDE
5mg/mL Injection
02185431 METOCLOPRAMIDE SDZ
02243563 METOCLOPRAMIDE OMEGA OMG
56:92.00 MISCELLANEOUS GI DRUGS
METHYLNALTREXONE BROMIDE
20mg/mL Injection
02308215 RELISTOR WYE
Page C-6 of 62014
MFR Manufacturer Name MFR Manufacturer Name
Non-Insured Health BenefitsAppendix D
List of Drug Manufacturers
AAP AA PHARMA INC.
ABB ABBOTT LABORATORIES LIMITED
ACG ACTAVIS GROUP PTC EHF
ACN ACTELION PHARMACEUTICALS LTD
ACP ACCEL PHARMA INC
ADA ADAMS LABS LIMITED
ALC ALCON CANADA INCORPORATED
ALG ALLERGOLOGISK LAB A/S
ALK ALK ABELLO A/S
ALL ALLERGAN INCORPORATED
AMG AMGEN CANADA INCORPORATED
APX APOTEX INCORPORATED
AST ASTELLAS PHARMA CANADA INCORPORATED
ATL LABORATORIE ATLAS INCORPORATED
AUC AUTO CONTROL
AUR AURO PHARMA INC
AXC AXCAN PHARMA INCORPORATED
AXL ALLEREX LABORATORY LIMITED
AXX AXXESS PHARMA INCORPORATED
AZC ASTRAZENECA CANADA INCORPORATED
BAK BAKER CUMMINS INCORPORATED.
BAR BARR PHARMACEUTICALS INCORPORATED
BAT BAXTER CORPORATION
BAX BRAINTREE LAB INCORPORATED
BAY BAYER INCORPORATED, HEALTHCARE/DIAGNOSTICS
BCD BAYER INCORPORATED, CONSUMER CARE DIVISION
BDH BDH INCORPORATED
BEN BENCARD ALLERGY LABORATORIES
BEX BERLEX CANADA INCORPORATED
BIO BIONICHE PHARMA (CANADA) LIMITED
BMI BIOMED 2002 INCORPORATED
BMS BRISTOL-MYERS SQUIBB CANADA
BOE BOEHRINGER INGELHEIM (CANADA) LIMITED
BPC BIOVAIL PHARMACEUTICALS CANADA
BSH BAUSCH & LOMB CANADA INCORPORATED
CDX CANDERM PHARMA
CEN CENTOCOR INCORPORATED
CIP CIPHER PHARMACEUTICALS INCORPORATED
COB COBALT PHARMACEUTICALS INCORPORATED
COP COLGATE ORAL PHRAMACEUTICALS INCORPORATED
CUV CHAUVIN PHARMACEUTICALS LIMITED
CYX CYTEX PHARMACEUTICALS INCORPORATED
DCM D & C MOBILITY
DDP THE D DROPS COMPANY INCORPORATED
DER DERMIK LABORATORIES CANADA INCORPORATED
DKT DIOPTIC LABORATORIES INCORPORATED
DOR DORMER LABORATORIES INCORPORATED
DPC DOMINION PHARMACAL
DPI DOMREX PHARMA INC
DPY DRAXIS HEALTH INCORPORATED
DSP DISPENSA PHARM CANADA LIMITED
DUI DUCHESNAY INCORPORATED
EDM ENDO CANADA INCORPORATED
ELN ELAN PHARMACEUTICALS INCORPORATED
ERF ERFA CANADA INCORPORATED
EUR EURO-PHARM INTERNATIONAL CANADA INCORPORATED
Page D-1 of 42014
MFR Manufacturer Name MFR Manufacturer Name
Non-Insured Health BenefitsAppendix D
List of Drug Manufacturers
FEI FERRING INCORPORATED
FOU FOURNIER PHARMA INCORPORATED
FRS MERCK FROSST CANADA LIMITED
GAC GALDERMA CANADA INCORPORATED
GCL GALEN CHEMICALS LIMITED
GEE GENZYME CANADA INCORPORATED
GIL GILEAD SCIENCES INCORPORATED
GLE GLENWOOD LABORATORIES CANADA LIMITED
GMP GENERIC MEDICAL PARTNERS INC
GSC GELDA SCIENTIFIC & INDUSTRIAL DEVELOPMENT CORP
GSK GLAXOSMITHKLINE INCORPORATED
HIL HILL DERMACEUTICALS INCORPORATED
HJS H.J. SUTTON INDUSTRIES LIMITED
HLR HOFFMAN-LAROCHE LIMITED
HOL HOLLISTER LIMITED
HOR CARTER-HORNER CORPORATION
HOS HOSPIRA HEALTHCARE CORPORATION
HPC HEALTHPOINT CANADA ULC
HRA HRA PHARMA
ICN ICN CANADA LIMITED
IDE INTERNATIONAL DERMATOLOGICALS INCORPORATED
IMX IMMUNEX CORPORATION
IPS IPSEN LIMITED
IVX IVAX PHARMACEUTICALS INCORPORATED.
JAJ JOHNSON & JOHNSON
JAM C.E. JAMIESON COMPANY LIMITED
JLF J.L.FREEMAN
JMP JAMP PHARMA CORPORATION
JNO JANSSEN-ORTHO INCORPORATED
KEY KEY PHARMACEUTICALS INCORPORATED
LAL LABORATOIRE LALCO INCORPORATED
LEO LEO PHARMA INCORPORATED
LIL ELI LILLY CANADA INCORPORATED
LUD LUNDBECK CANADA INCORPORATED
MAB MEDA AB
MAN MANTRA PHARMA INC
MAR MARCAN PHARMACEUTICALS INC
MAY MAYNE PHARMA (CANADA) INCORPORATED
MCA MCARTHUR MEDICAL SALES INCORPORATED
MCL MCNEIL CONSUMER PRODUCTS COMPANY
MDC MEDICIS CANADA CORPORATION
MDS MEDISCA PHARMACEUTIQUE INC
MDT MEDTRONIC OF CANADA LIMITED
MEL MELIAPHARM INC
MET MEDICAL TEXTILES MARKETING INCORPORATED
MEZ MERZ PHARMACEUTICALS GMBH
MIN MINT PHARMACEUTICALS INCORPORATED
MJO MEAD JOHNSON CANADA INCORPORATED
MMH 3M PHARMACEUTICALS
MMT MM THERAPEUTICS INC.
MPD MEDICAL PLASTIC DEVICES INCORPORATED
MSL MEDIC SAVOURE LIMITED
MSP MERCK FROSST / SCHERING PHARMA GP
MTH MM THERAPEUTICS INC
MTI MEDICAN TECHNOLOGIES INCORPORATED
MYL MYLAN PHARMACEUTICALS ULC
NCA NOVA DIABETES CARE
NEO NEOLAB INCORPORATED
Page D-2 of 42014
MFR Manufacturer Name MFR Manufacturer Name
Non-Insured Health BenefitsAppendix D
List of Drug Manufacturers
NOO NOVO NORDISK CANADA INCORPORATED
NUR NUTRICORP INTERNATIONAL
NVC NOVARTIS CONSUMER HEALTH CANADA INCORPORATED
NVR NOVARTIS PHARMACEUTICALS CANADA INCORPORATED
NXP NU-PHARM INCORPORATED
ODN ODAN LABORATORIES LIMITED
OMG OMEGA LABORATORIES LIMITED
OPT OPTREX LABS LIMITED
ORG ORGANON CANADA LIMITED
ORY ORYX PHARMACEUTICALS INCORPORATED
OVA OVATION PHARMACEUTICALS INCORPORATED
PAL PALADIN LABS INCORPORATED
PDL PRO DOC LIMITED
PED PENDOPHARM INCORPORATED
PER PERRIGO INTERNATIONAL
PFD PROFESSIONAL DISPOSABLES
PFI PFIZER CANADA INCORPORATED
PFR PURDUE PHARMA
PGI PROCTOR & GAMBLE INCORPORATED
PGP PROCTOR & GAMBLE PHARMACEUTICALS INCORPORATED
PHH PHARMEL INCORPORATED
PMJ PHARMACIA CANADA INCORPORATED
PMS PHARMASCIENCE INCORPORATED
PMT PHARMETICS INCORPORATED
PPC PHARMACEUTICAL PARTNERS OF CANADA,INC
PRO PROVAL PHARMA INCORPORATED
QLT QLT INCORPORATED
RBP RB PHARMACEUTICALS LIMITED
RIV LABORATORIE RIVA INCORPORATED
ROD ROCHE DIAGNOSTICS
RPH RATIOPHARM INCORPORATED
RVX RIVEX PHARMA INCORPORATED
RWP RW PACKAGING LIMITED
SAC SANOFI-AVENTIS CANADA
SAN SANIS HEALTH INC
SCH SCHERING CANADA INCORPORATED
SCN SCHEIN PHARMACEUTICAL CANADA INCORPORATED
SDR STANLEY PHARMACEUTICALS LIMITED
SDZ SANDOZ CANADA INCORPORATED
SEV SERVIER CANADA INCORPORATED
SHI SHIRE CANADA INCORPORATED
SHM SHERWOOD INCORPORATED
SIG SIGMA-TAU PHARMACEUTICALS INCORPORATED
SNE SMITH & NEPHEW INCORPORATED
SOR SORRES PHARMA INC
SPH SOLVAY PHARMA INCORPORATED
SQU SQUIRE PHARMACEUTICALS INCORPORATED
STE STERIMAX INCORPORATED
STG LABORATOIRES STERIGEN INC
STI STIEFEL CANADA INCORPORATED
SUN SUN PHARMA GLOBAL FZE
SWS SWISS HERBAL REMEDIES LIMITED
TAK TAKEDA PHARMACEUTICALS AMERICA INC
TAN TANTA PHARMACEUTICALS INCORPORATED
TAR TARO PHARMACEUTICALS INCORPORATED
TEV TEVA CANADA LIMITED
TIP H & P INDUSTRIES / THE TRIAD-GROUP
TRE TREMBLAY HARRISON INC
Page D-3 of 42014
MFR Manufacturer Name MFR Manufacturer Name
Non-Insured Health BenefitsAppendix D
List of Drug Manufacturers
TRI TRIANON LABORATORIES INCORPORATED
TRT TRITON PHARMA INCORPORATED
TRU TRUDELL MEDICAL INTERNATIONAL
TSN TRIMEDIC SUPPLY NETWORK LTD
UCB UBC PHARMA INCORPORATED
UMI ULTIMED, INCORPORATED
VAE VALEANT CANADA LIMITED
VAO VALEO PHARMA INCORPORATED
VTH VITA HEALTH PRODUCTS INCORPORATED
WAM WAMPOLE INCORPORATED
WAT WATSON LABORATORIES INCORPORATED
WAY WYETH CANADA
WCC WOMEN'S CAPITAL CORPORATION
WCI WARNER CHILCOTT COMPANY INCORPORATED
WEP WE PHARMACEUTICALS
WLA WARNER-LAMBERT CONSUMER HEALTHCARE INCORPORATED
WNP WN PHARMACEUTICALS LIMITED
WPC WELLSPRING PHARMACEUTICAL CANADA CORPORATION
WRI WHITEHALL-ROBINS INCORPORATED
WSB WESTWOOD SQUIBB INCORPORATED
WTR WESTCAN PHARMACEUTICALS LIMITED
XEN XENEX LABS INCORPORATED
ZYM ZYMCAN PHARMACEUTICALS
Page D-4 of 42014
Certain drug products are not within the scope of the program. These products will not be reimbursed as benefits under the NIHB Program:
Anti-obesity drugs; Household products (regular soaps and shampoos); Cosmetics; Alternative therapies, including glucosamine and evening primrose oil; Megavitamins; Drugs with investigational/experimental status; Vaccinations for travel indications; Hair growth stimulants; Fertility agents and impotence drugs; Selected over-the-counter products; Codeine containing cough preparations; Dalmane®, Somnol® and generics (flurazepam);Darvon® and 642® (propoxyphene); Fiorinal®, Fiorinal® C ¼, Fiorinal® C ½ and generics (Butalbital containing analgesics with and without codeine);Librium®, Solium®, Medilium® and generics (chlordiazepoxide);Stadol TM NS and generics (butorphanol tartrate nasal spray);Tranxene® and generics (clorazepate); andImovane® and generics (zopiclone).
The following drugs are excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.Of Note: The Appeal Process and the Emergency Supply Policy will not apply for the following drug products.
Non-Insured Health BenefitsAppendix E
EXCLUSIONS
DIN BRAND NAMEMFR
02248722 ALL ACULAR LS 0.4% OPHTHALMIC SOLUTION02259052 AST AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION02247916 BAY CIPRO XL 500MG TABLET02251787 BAY CIPRO XL 1000MG TABLET02248417 FEI GYNAZOLE-1 VAG CREAM 2%02216167 SAC IMOVANE 5MG TABLET01926799 SAC IMOVANE 7.5MG TABLET02244521 AZC NEXIUM 20MG SR TABLET02244522 AZC NEXIUM 40MG SR TABLET02241804 SPH PANTOLOC 20MG EC TABLET02248503 GSK PAXIL CR 12.5MG EXTENDED RELEASE TABLET02248504 GSK PAXIL CR 25MG EXTENDED RELEASE TABLET02229437 NAB PHOSLO 667MG TABLET02256290 PFI RELPAX 20MG TABLET02256304 PFI RELPAX 40MG TABLET
Page E-1 of 12014
Page
Non-Insured Health BenefitsHealth Canada
Page Page542825429293TC
1015-AMINOSALICYLIC ACID
8ABACAVIR
8ABACAVIR, LAMIVUDINE
8ABACAVIR, LAMIVUDINE,
ZIDOVUDINE
131ABATACEPT
58ABENOL70ABILIFY82ACAMPROSATE CALCIUM
108ACARBOSE
111ACCEL PIOGLITAZONE38ACCEL-AMLODIPINE65ACCEL-CITALOPRAM3ACCEL-CLARITHROMYCIN
64ACCEL-TOPIRAMATE88ACCOLATE84ACCU-CHEK ADVANTAGE84ACCU-CHEK AVIVA84ACCU-CHEK AVIVA (ON)84ACCU-CHEK COMPACT84ACCU-CHEK COMPACT (ON)84ACCU-CHEK MOBILE84ACCU-CHEK MOBILE (ON)
135ACCU-CHEK MULTICLIX44ACCUPRIL44ACCURETIC
122ACCUTANE84ACCUTREND (ON)84ACCUTREND GLUCOSE35ACEBUTOLOL35ACEBUTOLOL HCL
58ACET58ACET 12058ACET 32558ACET 65053ACET CODEINE 3058ACETAMIN CHILD58ACETAMINOPHEN
58ACETAMINOPHEN53ACETAMINOPHEN, CAFFEINE
CITRATE, CODEINE PHOSPHATE
53ACETAMINOPHEN, CAFFEINE,
CODEINE PHOSPHATE
53ACETAMINOPHEN, CODEINE
PHOSPHATE
53ACETAMINOPHEN, OXYCODONE
HCL
92ACETAZOLAMIDE
50ACETYLSALICYLIC ACID50ACETYLSALICYLIC ACID
54ACETYLSALICYLIC ACID,
CAFFEINE CITRATE, CODEINE
PHOSPHATE
54ACETYLSALICYLIC ACID,
OXYCODONE HCL
121ACITRETIN
131ACLASTA101ACT PANTOPRAZOLE132ACTEMRA131ACTONEL111ACTOS90ACULAR
10ACYCLOVIR
10ACYCLOVIR39ADALAT XL
131ADALIMUMAB
120ADAPALENE
134ADAPTOR117ADASEPT33ADCIRCA
134ADHESIVE PAD WITH COTTON134ADHESIVE PAD WITHOUT
COTTON19ADRENALIN
133ADVAGRAF19ADVAIR19ADVAIR DISKUS 10019ADVAIR DISKUS 25019ADVAIR DISKUS 50051ADVIL51ADVIL JUNIOR STRENGTH51ADVIL PEDIATRIC1AERIUS1AERIUS KIDS
134AEROCHAMBER AC BOYZ134AEROCHAMBER AC GIRLZ134AEROCHAMBER PLUS FLOW-VU
LG134AEROCHAMBER PLUS FLOW-VU
MED134AEROCHAMBER PLUS FLOW-VU
MOUTH134AEROCHAMBER PLUS FLOW-VU
SM34AGGRENOX25AGRYLIN19AIROMIR91ALBALON91ALBALON A
134ALCOHOL PREP SWAB134ALCOHOL SWAB134ALCOHOL SWABS BD87ALDACTAZIDE-2587ALDACTAZIDE-5049ALDACTONE
122ALDARA130ALENDRONATE129ALENDRONATE SODIUM
130ALENDRONATE SODIUM,
VITAMIN D3
130ALENDRONATE-70130ALENDRONATE-FC76ALERTEC
107ALESSE (21)107ALESSE (28)126ALFACALCIDOL
20ALFUZOSIN HYDROCHLORIDE
14ALKERAN1ALLEGRA1ALLEGRA 24HR1ALLER-AIDE
114ALLERGENIC EXTRACT NON POLLENS
114ALLERGENIC EXTRACT POLLENS114ALLERGENIC EXTRACTS
1ALLERGY1ALLERGY FORMULA
1ALLERGY RELIEF ES19ALLERJECT1ALLERNIX1ALLERNIX MULTI SYMPTOM1ALLERNIX PLUS
129ALLOPRIN129ALLOPURINOL
129ALLOPURINOL79ALMOTRIPTAN MALATE
89ALOCRIL93ALOMIDE91ALPHAGAN91ALPHAGAN P76ALPRAZOLAM76ALPRAZOLAM
44ALTACE45ALTACE HCT13ALTRETAMINE
105ALVESCO107ALYSENA (21)107ALYSENA (28)
8AMANTADINE HCL
34AMBRISENTAN
117AMCINONIDE
79AMERGE87AMI-HYDRO86AMILORIDE HCL
87AMILORIDE HCL,
HYDROCHLOROTHIAZIDE
27AMIODARONE27AMIODARONE HCL
65AMITRIPTYLINE65AMITRIPTYLINE HCL
38AMLODIPINE
38AMLODIPINE39AMLODIPINE, ATORVASTATIN
39AMLODIPINE, TELMISARTAN
38AMLODIPINE-ODAN3AMOXICILLIN
3AMOXICILLIN4AMOXICILLIN SUGAR REDUCED
100AMOXICILLIN,
CLARITHROMYCIN,
LANSOPRAZOLE
4AMOXICILLIN, CLAVULANIC ACID
4AMOXI-CLAV4AMPICILLIN
66ANAFRANIL25ANAGRELIDE HCL
15ANANDRON52ANAPROX52ANAPROX DS13ANASTROZOLE
106ANDRIOL13ANDROCUR97ANETHOLE
128ANHYDROUS MAGNESIUM
CITRATE
119ANODAN-HC91ANTAZOLINE PHOSPHATE,
NAPHAZOLINE HCL
120ANTHRAFORTE120ANTHRANOL-1120ANTHRANOL-2120ANTHRASCALP
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Non-Insured Health BenefitsHealth Canada
Page Page115ANTIBIOTIC OINTMENT95ANTI-DIARRHEAL
119ANUGESIC HC119ANUSOL HC98ANZEMET
110APIDRA110APIDRA CARTRIDGE110APIDRA SOLOSTAR23APIXABAN
42APO ENALAPRIL51APO KETO-E35APO-ACEBUTOLOL59APO-ACETAMINOPHEN92APO-ACETAZOLAMIDE10APO-ACYCLOVIR
129APO-ALENDRONATE20APO-ALFUZOSIN ER
129APO-ALLOPURINOL79APO-ALMOTRIPTAN76APO-ALPRAZ86APO-AMILORIDE87APO-AMILZIDE27APO-AMIODARONE65APO-AMITRIPTYLINE38APO-AMLODIPINE3APO-AMOXI4APO-AMOXI CLAV4APO-AMOXI SUGAR FREE4APO-AMPICILLIN
13APO-ANASTROZOLE50APO-ASA50APO-ASEN ECT36APO-ATENIDONE35APO-ATENOL28APO-ATORVASTATIN
132APO-AZATHIOPRINE3APO-AZITHROMYCIN
20APO-BACLOFEN89APO-BECLOMETHASONE41APO-BENAZEPRIL17APO-BENZTROPINE91APO-BENZYDAMINE13APO-BICALUTAMIDE95APO-BISACODYL36APO-BISOPROLOL91APO-BRIMONIDINE76APO-BROMAZEPAM81APO-BROMOCRIPTINE85APO-CAL 50045APO-CANDESARTAN46APO-CANDESARTAN/HCTZ41APO-CAPTO60APO-CARBAMAZEPINE36APO-CARVEDILOL2APO-CEFACLOR2APO-CEFADROXIL2APO-CEFPROZIL2APO-CEFUROXIME2APO-CEPHALEX1APO-CETIRIZINE
87APO-CHLORTHALIDONE41APO-CILAZAPRIL42APO-CILAZAPRIL HCTZ98APO-CIMETIDINE
5APO-CIPROFLOX66APO-CITALOPRAM3APO-CLARITHROMYCIN6APO-CLINDAMYCIN
77APO-CLOBAZAM66APO-CLOMIPRAMINE59APO-CLONAZEPAM32APO-CLONIDINE25APO-CLOPIDOGREL70APO-CLOZAPINE89APO-CROMOLYN20APO-CYCLOBENZAPRINE13APO-CYPROTERONE66APO-DESIPRAMINE
112APO-DESMOPRESSIN105APO-DEXAMETHASONE77APO-DIAZEPAM50APO-DICLO51APO-DICLO SR51APO-DIFLUNISAL41APO-DILTIAZ40APO-DILTIAZ CD40APO-DILTIAZ SR40APO-DILTIAZ TZ98APO-DIMENHYDRINATE91APO-DIPIVEFRIN34APO-DIPYRIDAMOLE34APO-DIPYRIDAMOLE SC60APO-DIVALPROEX95APO-DOCUSATE CALCIUM95APO-DOCUSATE SODIUM
101APO-DOMPERIDONE92APO-DORZO-TIMOP34APO-DOXAZOSIN66APO-DOXEPIN6APO-DOXY
42APO-ENALAPRIL MALEATE/HCTZ11APO-ENTECAVIR3APO-ERYTHRO3APO-ERYTHRO BASE3APO-ERYTHRO S3APO-ERYTHRO-S
11APO-FAMCICLOVIR99APO-FAMOTIDINE28APO-FENOFIBRATE28APO-FENO-MICRO28APO-FENO-SUPER54APO-FENTANYL23APO-FERROUS GLUCONATE23APO-FERROUS SULFATE FC
129APO-FINASTERIDE27APO-FLECAINIDE59APO-FLOCTAFENINE7APO-FLUCONAZOLE
81APO-FLUNARIZINE67APO-FLUOXETINE71APO-FLUPHENAZINE51APO-FLURBIPROFEN13APO-FLUTAMIDE90APO-FLUTICASONE67APO-FLUVOXAMINE
125APO-FOLIC ACID42APO-FOSINOPRIL86APO-FUROSEMIDE
61APO-GABAPENTIN28APO-GEMFIBROZIL
111APO-GLICLAZIDE111APO-GLYBURIDE71APO-HALOPERIDOL33APO-HYDRALAZINE87APO-HYDRO87APO-HYDROCLOROTHIAZIDE55APO-HYDROMORPHONE12APO-HYDROXYQUINE14APO-HYDROXYUREA79APO-HYDROXYZINE51APO-IBUPROFEN14APO-IMATINIB67APO-IMIPRAMINE87APO-INDAPAMIDE51APO-INDOMETHACIN17APO-IPRAVENT46APO-IRBESARTAN46APO-IRBESARTAN/HCTZ33APO-ISDN33APO-ISMN86APO-K51APO-KETO52APO-KETO SR7APO-KETOCONAZOLE
52APO-KETO-E90APO-KETOROLAC1APO-KETOTIFEN
85APO-LACTULOSE9APO-LAMIVUDINE9APO-LAMIVUDINE HBV9APO-LAMIVUDINE-ZIDOVUDINE
62APO-LAMOTRIGINE100APO-LANSOPRAZOLE92APO-LATANOPROST
132APO-LEFLUNOMIDE14APO-LETROZOLE62APO-LEVETIRACETAM91APO-LEVOBUNOLOL81APO-LEVOCARB81APO-LEVOCARB CR5APO-LEVOFLOXACIN
43APO-LISINOPRIL43APO-LISINOPRIL (TYPE Z)43APO-LISINOPRIL/HCTZ79APO-LITHIUM CARB79APO-LITHIUM CARBONATE95APO-LOPERAMIDE1APO-LORATADINE
77APO-LORAZEPAM77APO-LORAZEPAM SUBLINGUAL47APO-LOSARTAN47APO-LOSARTAN/HCTZ29APO-LOVASTATIN
113APO-MEDROXY52APO-MEFENAMIC14APO-MEGESTROL52APO-MELOXICAM
109APO-METFORMIN32APO-METHAZIDE-1532APO-METHAZIDE-2592APO-METHAZOLAMIDE71APO-METHOPRAZINE
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Page Page15APO-METHOTREXATE32APO-METHYLDOPA76APO-METHYLPHENIDATE76APO-METHYLPHENIDATE 54MG
ER76APO-METHYLPHENIDATE SR
101APO-METOCLOP37APO-METOPROLOL37APO-METOPROLOL SR37APO-METOPROLOL-L12APO-METRONIDAZOLE18APO-MIDODRINE6APO-MINOCYCLINE
68APO-MIRTAZAPINE99APO-MISOPROSTOL68APO-MOCLOBEMIDE90APO-MOMETASONE88APO-MONTELUKAST
132APO-MYCOPHENOLATE37APO-NADOL52APO-NAPRO NA52APO-NAPRO NA DS52APO-NAPROXEN52APO-NAPROXEN EC39APO-NIFED39APO-NIFED PA78APO-NITRAZEPAM12APO-NITROFURANTOIN33APO-NITROGLYCERIN99APO-NIZATIDINE5APO-NORFLOX
68APO-NORTRIPTYLINE5APO-OFLOX
89APO-OFLOXACIN72APO-OLANZAPINE71APO-OLANZAPINE ODT89APO-OLOPATADINE
100APO-OMEPRAZOLE98APO-ONDANSETRON18APO-ORCIPRENALINE78APO-OXAZEPAM
123APO-OXTRIPHYLLINE123APO-OXYBUTYNIN53APO-OXYCODONE/ACET
101APO-PANTOPRAZOLE68APO-PAROXETINE4APO-PEN VK
26APO-PENTOXIFYL72APO-PERPHENAZINE73APO-PIMOZIDE37APO-PINDOL
111APO-PIOGLITAZONE53APO-PIROXICAM81APO-PRAMIPEXOLE30APO-PRAVASTATIN34APO-PRAZO
106APO-PREDNISONE63APO-PREGABALIN59APO-PRIMIDONE27APO-PROCAINAMIDE73APO-PROCHLORAZINE27APO-PROPAFENONE38APO-PROPRANOLOL44APO-QUINAPRIL
44APO-QUINAPRIL/HCTZ101APO-RABEPRAZOLE108APO-RALOXIFENE44APO-RAMIPRIL45APO-RAMIPRIL/HCTZ99APO-RANITIDINE
110APO-REPAGLINIDE131APO-RISEDRONATE74APO-RISPERIDONE16APO-RIVASTIGMINE80APO-RIZATRIPTAN79APO-RIZATRIPTAN RPD82APO-ROPINIROLE30APO-ROSUVASTATIN19APO-SALVENT19APO-SALVENT CFC FREE82APO-SELEGILINE69APO-SERTRALINE31APO-SIMVASTATIN38APO-SOTALOL99APO-SUCRALFATE6APO-SULFAMETHOXAZOLE6APO-SULFATRIM6APO-SULFATRIM DS6APO-SULFATRIM PED
87APO-SULFINPYRAZONE53APO-SULIN80APO-SUMATRIPTAN15APO-TAMOX20APO-TAMSULOSIN CR78APO-TEMAZEPAM34APO-TERAZOSIN7APO-TERBINAFINE6APO-TETRA
82APO-TETRABENAZINE123APO-THEO123APO-THEO LA25APO-TICLOPIDINE38APO-TIMOL91APO-TIMOP20APO-TIZANIDINE
111APO-TOLBUTAMIDE64APO-TOPIRAMATE69APO-TRAZODONE69APO-TRAZODONE D87APO-TRIAZIDE79APO-TRIAZO75APO-TRIFLUOPERAZINE17APO-TRIHEX12APO-TRIMETHOPRIM70APO-TRIMIP70APO-TRIMIPRAMINE11APO-VALGANCICLOVIR64APO-VALPROIC48APO-VALSARTAN49APO-VALSARTAN/HCTZ70APO-VENLAFAXINE XR41APO-VERAP41APO-VERAP SR25APO-WARFARIN10APO-ZIDOVUDINE80APO-ZOLMITRIPTAN80APO-ZOLMITRIPTAN RAPID92APRACLONIDINE HCL
106APRI (21)106APRI (28)10APTIVUS
126AQUASOL E132ARAVA130AREDIA IV13ARIMIDEX70ARIPIPRAZOLE
120ARISTOCORT C120ARISTOCORT R106ARISTOSPAN13AROMASIN51ARTHROTEC93ARTIFICIAL TEARS93ARTIFICIAL TEARS EXTRA50ASA50ASA 81MG50ASA EC
101ASACOL50ASAPHEN50ASAPHEN EC50ASATAB50ASATAB EC84ASCENSIA BREEZE 284ASCENSIA BREEZE 2 (ON)84ASCENSIA CONTOUR84ASCENSIA CONTOUR (ON)
125ASCORBIC ACID
126ASCORBIC ACID70ASENAPINE
106ASMANEX TWISTHALER50ASPIRIN45ATACAND46ATACAND PLUS79ATARAX58ATASOL59ATASOL FORTE53ATASOL-1553ATASOL-308ATAZANAVIR SULFATE
35ATENOLOL35ATENOLOL
36ATENOLOL, CHLORTHALIDONE
116ATHLETES FOOT SPRAY77ATIVAN77ATIVAN SUBLINGUAL28ATORVASTATIN28ATORVASTATIN CALCIUM
28ATORVASTATIN-1029ATORVASTATIN-2029ATORVASTATIN-4029ATORVASTATIN-8012ATOVAQUONE
8ATRIPLA90ATROPINE90ATROPINE SULFATE
90ATROPINE SULPHATE MINIMS93ATROVENT17ATROVENT HFA
103AURANOFIN
129AURO-ALENDRONATE38AURO-AMLODIPINE3AURO-AMOXICILLIN2AURO-CEFPROZIL
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Non-Insured Health BenefitsHealth Canada
Page Page2AURO-CEFUROXIME5AURO-CIPROFLOXACIN
66AURO-CITALOPRAM20AURO-CYCLOBENZAPRINE61AURO-GABAPENTIN62AURO-LAMOTRIGINE62AURO-LEVETIRACETAM43AURO-LISINOPRIL52AURO-MELOXICAM67AURO-MIRTAZAPINE OD9AURO-NEVIRAPINE
68AURO-PAROXETINE73AURO-QUETIAPINE44AURO-RAMIPRIL69AURO-SERTRALINE7AURO-TERBINAFINE
64AURO-TOPIRAMATE46AVALIDE
112AVANDIA46AVAPRO68AVENTYL
107AVIANE (21)107AVIANE (28)129AVODART79AXERT99AXID92AZARGA
132AZATHIOPRINE132AZATHIOPRINE
121AZELAIC ACID
3AZITHROMYCIN3AZITHROMYCIN
92AZOPT115BACIMYXIN115BACITIN115BACITRACIN115BACITRACIN
89BACITRACIN ZINC, POLYMYXIN B
SULFATE
20BACLOFEN20BACLOFEN
86BACTERIOSTATIC NACL116BACTIGRAS115BACTROBAN64BANZEL 100MG TAB64BANZEL 200MG TAB64BANZEL 400MG TAB
120BARRIERE119BARRIERE HC137BD 0.3ML SYR WITH U/F 6MM
NEED134B-D ALCOHOL SWAB135BD AUTOSHIELD PEN NEEDLE135B-D DISPOSABLE 5/8 INCH 5122135B-D DISPOSABLE ½ INCH 5109135B-D DISPOSABLE 1 INCH 5155135B-D DISPOSABLE 1½ INCH 5127135B-D DISPOSABLE 1½ INCH 5156137B-D INJECT-EASE WITH MICRO-
FINE137B-D INSULIN 1/3CC 29G UF 1137B-D INSULIN 50U 29G135BD LATITUDE136B-D MICRO-FINE137B-D MICRO-FINE 1/3CC
137B-D MICRO-FINE INSULIN 100U137B-D MICRO-FINE INSULIN 28G137B-D MICRO-FINE INSULIN 50U135B-D PEN136B-D SHARPS CONTAINER 1.4L136B-D SHARPS CONTAINER 3.1L136B-D ULTRA-FINE136B-D ULTRA-FINE / ULTRA-FINE II136B-D ULTRA-FINE II135BD ULTRA-FINE III PEN NEEDLES135BD ULTRA-FINE NANO PEN
NEEDLE135B-D ULTRA-FINE PEN135B-D ULTRA-FINE PEN III89BECLOMETHASONE
DIPROPIONATE
1BENADRYL1BENADRYL CHILD
41BENAZEPRIL HCL
116BENOXYL116BENZAC AC116BENZAC W116BENZAC W5116BENZAGEL116BENZAGEL 5116BENZOYL PEROXIDE
17BENZTROPINE MESYLATE
17BENZTROPINE OMEGA91BENZYDAMINE HCL
117BETADERM117BETADINE91BETAGAN82BETAHISTINE HCL
117BETAMETHASONE
DIPROPIONATE
117BETAMETHASONE
DIPROPIONATE IN PROPYLENE
GLYCOL
117BETAMETHASONE
DIPROPIONATE, CLOTRIMAZOLE
117BETAMETHASONE
DIPROPIONATE, SALICYLIC ACID
117BETAMETHASONE DISODIUM
PHOSPHATE
89BETAMETHASONE SODIUM
PHOSPHATE, GENTAMICIN
SULFATE
117BETAMETHASONE VALERATE
118BETAMETHASONE,
CALCIPOTRIOL
125BETAXIN91BETAXOLOL HCL
16BETHANECHOL CHLORIDE
117BETNESOL91BETOPTIC S28BEZAFIBRATE
28BEZALIP SR84BG STAR84BG STAR (ON)3BIAXIN3BIAXIN XL
13BICALUTAMIDE
13BICALUTAMIDE92BIMATOPROST
85BIOCAL-D FORTE115BIODERM
86BIO-FUROSEMIDE87BIO-HYDROCHLOROTHIAZIDE96BI-PEGLYTE TROUSSE95BISACODYL
95BISACODYL (POLYETHYLENE
GLYCOL BASE)
95BISACODYL-ODAN95BISACOLAX95BISMUTH SUBSALICYLATE
36BISOPROLOL36BISOPROLOL FUMARATE
90BLEPHAMIDE11BOCEPREVIR
11BOCEPREVIR, PEGINTERFERON,
RIBAVIRIN
34BOSENTAN
133BOTOX133BOTULINUM TOXIN TYPE A
107BREVICON 0.5/35 (21)107BREVICON 0.5/35 (28)107BREVICON 1/35 (21)107BREVICON 1/35 (28)19BRICANYL TURBUHALER91BRIMONIDINE TARTRATE
91BRIMONIDINE TARTRATE
(ALPHAGAN P)
91BRIMONIDINE TARTRATE,
TIMOLOL MALEATE
92BRINZOLAMIDE
92BRINZOLAMIDE, TIMOLOL
MALEATE
76BROMAZEPAM
77BROMAZEPAM81BROMOCRIPTINE MESYLATE
89BUDESONIDE
58BUPRENORPHINE, NALOXONE
65BUPROPION HCL (WELLBUTRIN)
65BUPROPION HCL (ZYBAN)
65BUPROPION SR18BUSCOPAN13BUSERELIN ACETATE
13BUSULFAN
81CABERGOLINE
39CADUET85CAL-500 D
112CALCIMAR121CALCIPOTRIOL
85CALCITE 500 D85CALCITE D
112CALCITONIN SALMON
(SYNTHETIC)
126CALCITRIOL
85CALCIUM85CALCIUM
85CALCIUM & VITAMIN D
85CALCIUM + D85CALCIUM CARBONATE85CALCIUM CARBONATE
85CALCIUM CARBONATE WITH VIT D
85CALCIUM CARBONATE,
CHOLECALCIFEROL
85CALCIUM CARBONATE, VITAMIN
D
85CALCIUM D
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Non-Insured Health BenefitsHealth Canada
Page Page86CALCIUM POLYSTYRENE
SULFONATE
85CALCIUM WITH VITAMIN D85CAL-D 40085CALODAN D82CAMPRAL45CANDESARTAN45CANDESARTAN CILEXETIL
46CANDESARTAN CILEXETIL,
HYDROCHLOROTHIAZIDE
46CANDESARTAN HCT46CANDESARTAN/HCTZ7CANESORAL
115CANESTEN115CANESTEN 1 COMFORT COMBI
PAK115CANESTEN 3 COMFORT COMBI
PAK120CANTHACUR PS120CANTHARIDIN, PODOPHYLLIN,
SALICYLIC ACID
120CANTHARONE PLUS13CAPECITABINE
122CAPSAICIN
122CAPSAICIN122CAPSAICIN HP41CAPTOPRIL
41CAPTOPRIL90CARBACHOL
60CARBAMAZEPINE60CARBAMAZEPINE
85CARBOCAL D79CARBOLITH40CARDIZEM CD34CARDURA 134CARDURA 234CARDURA 486CARNITOR86CARNITOR IV36CARVEDILOL36CARVEDILOL
13CASODEX32CATAPRES2CECLOR2CECLOR BID
14CEENU2CEFACLOR
2CEFADROXIL
2CEFIXIME
2CEFPROZIL
2CEFTIN2CEFUROXIME AXETIL
2CEFZIL50CELEBREX50CELECOXIB
117CELESTODERM V66CELEXA
132CELLCEPT93CELLUVISC60CELONTIN9CELSENTRI
114CENTER-AL127CENTRUM JUNIOR COMPLETE
TB
127CENTRUM JUNIOR COMPLETE TAB
126CENTRUM MATERNA2CEPHALEXIN
131CERTOLIZUMAB PEGOL
98CESAMET1CETIRIZINE HCL
22CHAMPIX22CHAMPIX STARTER PACK58CHILDREN'S ACETAMINOPHEN51CHILDREN'S ADVIL51CHILDREN'S MOTRIN58CHILDREN'S TYLENOL SOFT
CHEWS13CHLORAMBUCIL
89CHLORAMPHENICOL
116CHLORHEXIDINE ACETATE
91CHLORHEXIDINE GLUCONATE
12CHLOROQUINE PHOSPHATE
1CHLORPHENIRAMINE MALEATE
70CHLORPROMAZINE
70CHLORPROMAZINE HCL87CHLORTHALIDONE
1CHLOR-TRIPOLON126CHOLECALCIFEROL
123CHOLEDYL27CHOLESTYRAMINE RESIN
85CI-CAL D105CICLESONIDE
41CILAZAPRIL41CILAZAPRIL
42CILAZAPRIL,
HYDROCHLOROTHIAZIDE
89CILOXAN98CIMETIDINE
99CIMETIDINE131CIMZIA67CIPRALEX67CIPRALEX MELTZ5CIPRO
89CIPRODEX5CIPROFLOXACIN5CIPROFLOXACIN HCL
89CIPROFLOXACIN HCL,
DEXAMETHASONE
65CITALOPRAM
65CITALOPRAM66CITALOPRAM-2066CITALOPRAM-ODAN95CITRIC ACID, MAGNESIUM
OXIDE, SODIUM PICOSULFATE
85CITRIC ACID, SODIUM CITRATE
96CITRO MAG128CITRODAN
3CLARITHROMYCIN3CLARITHROMYCIN
1CLARITIN1CLARITIN KIDS
122CLARUS4CLAVULIN4CLAVULIN 2004CLAVULIN 4004CLAVULIN-F4CLAVULIN-F 1254CLAVULIN-F 250
121CLEAR AWAY135CLICKFINE PEN NEEDLE 31G
4.5MM136CLICKFINE PEN NEEDLE 31G 6MM136CLICKFINE PEN NEEDLE 31G 8MM108CLIMARA 100108CLIMARA 25108CLIMARA 50108CLIMARA 75
6CLINDAMYCIN6CLINDAMYCIN HCL
6CLINDAMYCIN PALMITATE HCL
115CLINDAMYCIN PHOSPHATE
6CLINDAMYCINE115CLINDA-T77CLOBAZAM
77CLOBAZAM118CLOBETASOL PROPIONATE
118CLOBETASOL PROPIONATE118CLOBETASONE BUTYRATE
66CLOMIPRAMINE HCL
59CLONAPAM59CLONAZEPAM
32CLONIDINE32CLONIDINE HCL
25CLOPIDOGREL25CLOPIDOGREL BISULFATE
115CLOTRIMADERM115CLOTRIMAZOLE
4CLOXACILLIN
4CLOXACILLINE70CLOZAPINE
70CLOZARIL38CO AMLODIPINE28CO ATORVASTATIN82CO BETAHISTINE34CO BOSENTAN81CO CABERGOLINE46CO CANDESARTAN/HCTZ41CO CILAZAPRIL25CO CLOPIDOGREL51CO DICLO-MISO40CO DILTIAZEM CD40CO DILTIAZEM T92CO DORZOTIMOLOL42CO ENALAPRIL13CO EXEMESTANE11CO FAMCICLOVIR54CO FENTANYL
129CO FINASTERIDE7CO FLUCONAZOLE
46CO IRBESARTAN46CO IRBESARTAN/HCT92CO LATANOPROST43CO LISINOPRIL47CO LOSARTAN47CO LOSARTAN/HCT
132CO MYCOPHENOLATE98CO NABILONE72CO OLANZAPINE71CO OLANZAPINE ODT
111CO PIOGLITAZONE81CO PRAMIPEXOLE30CO PRAVASTATIN 10MG TAB
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Non-Insured Health BenefitsHealth Canada
Page Page30CO PRAVASTATIN 20MG TAB30CO PRAVASTATIN 40MG TAB63CO PREGABALIN
108CO RALOXIFENE44CO RAMIPRIL80CO RIZATRIPTAN30CO ROSUVASTATIN69CO SERTRALINE48CO TELMISARTAN48CO TELMISARTAN/HCT15CO TEMOZOLOMIDE64CO TOPIRAMATE11CO VALACYCLOVIR48CO VALSARTAN
121COAL TAR
121COAL TAR, JUNIPER TAR, PINE
TAR
121COAL TAR, JUNIPER TAR, PINE
TAR, ZINC PYRITHIONE
121COAL TAR, SALICYLIC ACID
121COAL TAR, SALICYLIC ACID,
SULFUR
129CO-ALENDRONATE13CO-ANASTROZOLE35CO-ATENOLOL3CO-AZITHROMYCIN
13CO-BICALUTAMIDE8COBICISTAT, EMTRICITABINE,
ELVITEGRAVIR, TENOFOVIR
45CO-CANDESARTAN5CO-CIPROFLOXACIN
66CO-CITALOPRAM66CO-CLOMIPRAMINE59CO-CLONAZEPAM54CODEINE54CODEINE CONTIN CR54CODEINE MONOHYDRATE,
CODEINE SULFATE TRIHYDRATE
54CODEINE PHOSPHATE54CODEINE PHOSPHATE
130CO-ETIDROCAL130CO-ETIDRONATE67CO-FLUOXETINE67CO-FLUVOXAMINE61CO-GABAPENTIN95COLACE
129COLCHICINE
129COLCHICINE27COLESTID27COLESTID ORANGE27COLESTIPOL HCL
62CO-LEVETIRACETAM5CO-LEVOFLOXACIN
122COLLAGENASE
29CO-LOVASTATIN96COLYTE2COMBANTRIN
91COMBIGAN18COMBIVENT9COMBIVIR
52CO-MELOXICAM109CO-METFORMIN68CO-MIRTAZAPINE8COMPLERA
121COMPOUND W GEL
81COMTAN75CONCERTA 18MG TAB76CONCERTA 27MG TAB76CONCERTA 36MG TAB76CONCERTA 54MG TAB83CONDOM, LATEX, LUBRICATED83CONDOM, LATEX, LUBRICATED,
NONOXYNOL83CONDOM, LATEX, NON-
LUBRICATED83CONDOM, MALE
83CONDOM, NON-LATEX, LUBRICATED
121CONDYLINE108CONJUGATED ESTROGENS
108CONJUGATED ESTROGENS,
MEDROXYPROGESTERONE
ACETATE
5CO-NORFLOXACIN84CONTOUR NEXT84CONTOUR NEXT (ON)98CO-ONDANSETRON68CO-PAROXETINE99CO-RANITIDINE27CORDARONE
110CO-REPAGLINIDE74CO-RISPERIDONE79CO-RIZATRIPTAN ODT82CO-ROPINIROLE
119CORTATE105CORTEF119CORTENEMA119CORTIFOAM105CORTISONE105CORTISONE ACETATE
119CORTODERM31CO-SIMVASTATIN92COSOPT38CO-SOTALOL80CO-SUMATRIPTAN97COTAZYM97COTAZYM ECS 897COTAZYM ECS 2078CO-TEMAZEPAM7CO-TERBINAFINE
25COUMADIN41COVERA-HS43COVERSYL44COVERSYL PLUS44COVERSYL PLUS HD47COZAAR97CREON 10 MINIMICROSPHERES97CREON 20 MINIMICROSPHERES97CREON 25 MINIMICROSPHERES97CREON 5 MINIMICROSPHERES30CRESTOR9CRIXIVAN
88CROMOLYN116CROTAMITON
104CUPRIMINE118CUTIVATE125CYANOCOBALAMIN125CYANOCOBALAMIN
125CYANOCOBALAMINE
107CYCLEN (21)
107CYCLEN (28)20CYCLOBENZAPRINE20CYCLOBENZAPRINE HCL
117CYCLOCORT91CYCLOGYL
106CYCLOMEN90CYCLOPENTOLATE90CYCLOPENTOLATE HCL
91CYCLOPENTOLATE MINIMS13CYCLOPHOSPHAMIDE
132CYCLOSPORINE
133CYESTRA-3526CYKLOKAPRON66CYMBALTA13CYPROTERONE ACETATE
133CYPROTERONE ACETATE,
ETHINYL ESTRADIOL
11CYTOVENE126D VI SOL126D2-DOL126D3-DOL23DABIGATRAN ETEXILATE
MESILATE
97DAIRY DIGESTIVE97DAIRY DIGESTIVE EXTRA
STRENGTH97DAIRY FREE97DAIRY FREE EXTRA STRENGTH97DAIRYAID
115DALACIN6DALACIN C
115DALACIN T24DALTEPARIN SODIUM
106DANAZOL
20DANTRIUM20DANTROLENE SODIUM
12DARAPRIM123DARIFENACIN HYDROBROMIDE
8DARUNAVIR ETHANOLATE
112DDAVP112DDAVP MELT126DECAXIL13DEGARELIX ACETATE
106DELATESTRYL106DEMULEN 30 (21)106DEMULEN 30 (28)130DENOSUMAB (P)
64DEPAKENE105DEPO-MEDROL113DEPO-PROVERA106DEPO-TESTOSTERONE119DERMAFLEX HC118DERMA-SMOOTHE117DERMAZIN118DERMOVATE66DESIPRAMINE HCL
1DESLORATADINE1DESLORATADINE
1DESLORATADINE ALLERGY CONTROL
112DESMOPRESSIN ACETATE
118DESOCORT118DESONIDE
118DESOXIMETASONE
123DETROL
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Page Page123DETROL LA90DEXAMETHASONE
105DEXAMETHASONE105DEXAMETHASONE PHOSPHATE
90DEXAMETHASONE, TOBRAMYCIN
105DEXAMETHASONE-OMEGA105DEXASONE75DEXEDRINE75DEXEDRINE SPANSULE23DEXIRON92DEXTRAN 70,
HYDROXYPROPYLMETHYLCELLU
LOSE
75DEXTROAMPHETAMINE SULFATE
126D-FORTE126D-GEL111DIABETA111DIAMICRON111DIAMICRON MR133DIANE-3595DIARR-EZE95DIARRHEA RELIEF84DIASTIX77DIAZEPAM
77DIAZEPAM33DIAZOXIDE
85DICITRATE98DICLECTIN50DICLOFENAC EC50DICLOFENAC SODIUM
51DICLOFENAC SODIUM,
MISOPROSTOL
50DICLOFENAC SR50DICLOFENAC-5051DICLOFENAC-SR8DIDANOSINE
130DIDROCAL113DIENOGEST
120DIFFERIN7DIFLUCAN
118DIFLUCORTOLONE VALERATE
118DIFLUCORTOLONE VALERATE,
SALICYLIC ACID
51DIFLUNISAL
27DIGOXIN
20DIHYDROERGOTAMINE20DIHYDROERGOTAMINE
MESYLATE
12DIIODOHYDROXYQUIN
60DILANTIN60DILANTIN 3060DILANTIN 12560DILANTIN INFATABS55DILAUDID41DILTIAZEM40DILTIAZEM CD40DILTIAZEM HCL
97DIMENHYDRINATE97DIMENHYDRINATE
120DIMETHICONE
92DIOCARPINE89DIOCHLORAM95DIOCTYL CALCIUM
SULFOSUCCINATE
95DIOCTYL SODIUM
SULFOSUCCINATE
95DIOCTYL SODIUM
SULFOSUCCINATE, SENNA
95DIOCTYL SODIUM
SULFOSUCCINATE, SENNOSIDES
90DIODEX12DIODOQUIN89DIOGENT91DIONEPHRINE91DIOPENTOLATE90DIOPTIMYD89DIOSULF48DIOVAN48DIOVAN 80MG CAP49DIOVAN-HCT
102DIPENTUM1DIPHENHYDRAMINE1DIPHENHYDRAMINE HCL
1DIPHENHYDRAMINE HCL91DIPIVEFRIN HCL
92DIPIVEFRIN HCL, LEVOBUNOLOL
HCL
117DIPROLENE117DIPROSALIC117DIPROSONE34DIPYRIDAMOLE
34DIPYRIDAMOLE,
ACETYLSALICYLIC ACID
27DISOPYRAMIDE
120DITHRANOL
60DIVALPROEX61DIVALPROEX EC60DIVALPROEX SODIUM
32DIXARIT95DOCUSATE CALCIUM96DOCUSATE CALCIUM
95DOCUSATE SODIUM96DOCUSATE SODIUM
98DOLASETRON MESYLATE
114DOLICHOVESPULA ARENARIA
VENOM PROTEIN
114DOLICHOVESPULA MACULATA
VENOM PROTEIN EXTRACT
56DOLORAL 156DOLORAL 5
130DOM-ALENDRONATE8DOM-AMANTADINE
27DOM-AMIODARONE65DOM-AMITRIPTYLINE38DOM-AMLODIPINE35DOM-ATENOLOL28DOM-ATORVASTATIN3DOM-AZITHROMYCIN
20DOM-BACLOFEN91DOM-BENZYDAMINE81DOM-BROMOCRIPTINE45DOM-CANDESARTAN41DOM-CAPTOPRIL60DOM-CARBAMAZEPINE CR36DOM-CARVEDILOL2DOM-CEPHALEXIN
99DOM-CIMETIDINE5DOM-CIPROFLOXACIN
65DOM-CITALOPRAM
3DOM-CLARITHROMYCIN77DOM-CLOBAZAM59DOM-CLONAZEPAM59DOM-CLONAZEPAM-R25DOM-CLOPIDOGREL20DOM-CYCLOBENZAPRINE66DOM-DESIPRAMINE50DOM-DICLOFENAC51DOM-DICLOFENAC SR95DOM-DOCUSATE SODIUM
101DOM-DOMPERIDONE129DOM-FINASTERIDE
7DOM-FLUCONAZOLE67DOM-FLUOXETINE67DOM-FLUVOXAMINE86DOM-FUROSEMIDE61DOM-GABAPENTIN28DOM-GEMFIBROZIL
111DOM-GLYBURIDE87DOM-HYDROCHLOROTHIAZIDE87DOM-INDAPAMIDE17DOM-IPRATROPIUM46DOM-IRBESARTAN62DOM-LEVETIRACETAM95DOM-LOPERAMIDE77DOM-LORAZEPAM71DOM-LOXAPINE
113DOM-MEDROXYPROGESTERONE52DOM-MEFENAMIC ACID52DOM-MELOXICAM
109DOM-METFORMIN37DOM-METOPROLOL-B37DOM-METOPROLOL-L6DOM-MINOCYCLINE
68DOM-MIRTAZAPINE88DOM-MONTELUKAST99DOM-NIZATIDINE68DOM-NORTRIPTYLINE7DOM-NYSTATIN
100DOM-OMEPRAZOLE DR123DOM-OXYBUTYNIN101DOM-PANTOPRAZOLE68DOM-PAROXETINE
101DOMPERIDONE101DOMPERIDONE MALEATE
37DOM-PINDOLOL111DOM-PIOGLITAZONE53DOM-PIROXICAM81DOM-PRAMIPEXOLE30DOM-PRAVASTATIN63DOM-PREGABALIN37DOM-PROPRANOLOL73DOM-QUETIAPINE
101DOM-RABEPRAZOLE44DOM-RAMIPRIL
131DOM-RISEDRONATE74DOM-RISPERIDONE80DOM-RIZATRIPTAN RDT30DOM-ROSUVASTATIN19DOM-SALBUTAMOL82DOM-SELEGILINE69DOM-SERTRALINE31DOM-SIMVASTATIN38DOM-SOTALOL
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Page Page80DOM-SUMATRIPTAN78DOM-TEMAZEPAM34DOM-TERAZOSIN7DOM-TERBINAFINE
53DOM-TIAPROFENIC94DOM-TIMOLOL64DOM-TOPIRAMATE69DOM-TRAZODONE11DOM-VALACYCLOVIR64DOM-VALPROIC ACID70DOM-VENLAFAXINE XR41DOM-VERAPAMIL SR80DOM-ZOLMITRIPTAN92DORZOLAMIDE HCL
92DORZOLAMIDE HCL, TIMOLOL
MALEATE
81DOSTINEX118DOVOBET121DOVONEX34DOXAZOSIN34DOXAZOSIN MESYLATE
66DOXEPIN HCL
6DOXYCIN6DOXYCYCLINE
6DOXYCYCLINE98DOXYLAMINE SUCCINATE,
PYRIDOXINE HCL
6DOXYTAB126DRISDOL126D-TABS95DULCOLAX66DULOXETINE
92DUO TRAV121DUOFILM121DUOFORTE 2793DUOLUBE
116DUONALC121DUOPLANT54DURAGESIC MAT
129DUTASTERIDE
16DUVOID86EDECRIN9EDURANT3EES-6008EFAVIRENZ
8EFAVIRENZ, TENOFOVIR,
EMTRICITABINE
70EFFEXOR XR122EFUDEX119EGOZINC HC119EGOZINC-HC85ELECTROLYTE & DEXTROSE
122ELIDEL14ELIGARD23ELIQUIS
128ELMIRON119ELOCOM113ELTROXIN120EMLA119EMO CORT119EMO CORT SCALP
8EMTRICITABINE, RILPIVIRINE,
TENOFOVIR DISOPROXIL
FUMARATE
8EMTRICITABINE, TENOFOVIR
DISOPROXIL FUMARATE
123ENABLEX42ENALAPRIL42ENALAPRIL MALEATE
42ENALAPRIL MALEATE,
HYDROCHLOROTHIAZIDE
131ENBREL53ENDOCET97ENEMOL24ENOXAPARIN SODIUM
81ENTACAPONE
11ENTECAVIR
50ENTERIC COATED ASA118ENTOCORT50ENTROPHEN50ENTROPHEN EC50ENTROPHEN ECT50ENTROPHEN-1050ENTROPHEN-519EPINEPHRINE
19EPINEPHRINE19EPIPEN19EPIPEN JR60EPIVAL46EPOSARTAN MESYLATE
46EPOSARTAN MESYLATE,
HYDROCHLOROTHIAZIDE
50EQUATE DAILY LOW-DOSE128ERDOL126ERGOCALCIFEROL
13ERLOTINIB HYDROCLORIDE
3ERYC3ERYTHRO3ERYTHRO-ES3ERYTHROMYCIN3ERYTHROMYCIN
3ERYTHROMYCIN ESTOLATE
3ERYTHROMYCIN
ETHYLSUCCINATE
3ERYTHROMYCIN
ETHYLSUCCINATE &
SULFISOXAZOLE ACETYL
3ERYTHROMYCIN STEARATE
115ERYTHROMYCIN, TRETINOIN
67ESCITALOPRAM
107ESME (21)107ESME (28)108ESTALIS 140/50108ESTALIS 250/50108ESTRACE108ESTRADERM108ESTRADIOL
108ESTRADIOL (ESTRADIOL
HEMIHYDRATE)
108ESTRADIOL, NORETHINDRONE
ACETATE
108ESTRADOT 100108ESTRADOT 25108ESTRADOT 37.5108ESTRADOT 50108ESTRADOT 75108ESTRING108ESTROGEL108ESTRONE
108ESTROPIPATE
131ETANERCEPT
86ETHACRYNIC ACID
7ETHAMBUTOL HCL
106ETHINYL ESTRADIOL,
DESOGESTREL
106ETHINYL ESTRADIOL,
DROSPIRENONE
106ETHINYL ESTRADIOL,
ETHYNODIOL DIACETATE
106ETHINYL ESTRADIOL,
ETONOGESTREL
107ETHINYL ESTRADIOL,
LEVONORGESTREL
107ETHINYL ESTRADIOL,
NORELGESTROMIN
107ETHINYL ESTRADIOL,
NORETHINDRONE
107ETHINYL ESTRADIOL,
NORETHINDRONE ACETATE
107ETHINYL ESTRADIOL,
NORGESTIMATE
17ETHOPROPAZINE HCL
60ETHOSUXIMIDE
7ETIBI130ETIDROCAL130ETIDRONATE DISODIUM
130ETIDRONATE DISODIUM,
CALCIUM CARBONATE
13ETOPOSIDE
9ETRAVIRINE
13EUFLEX111EUGLUCON118EUMOVATE116EURAX126EURO D50EURO-ASA
128EURO-B185EURO-CAL85EURO-CAL D95EURO-DOCUSATE96EURO-DOCUSATE C23EURO-FER23EURO-FERROUS SULFATE
125EURO-FOLIC86EURO-K 2086EURO-K 60085EURO-LAC96EURO-SENNA95EURO-SENNA S
113EUTHYROX108EVISTA107EVRA53EXDOL-1553EXDOL-3016EXELON13EXEMESTANE
128EXTEMPORANEOUS MIXTURE
128EXTEMPORANEOUS MIXTURE (ATL)
128EXTEMPORANEOUS MIXTURE (BC) (SK)
128EXTEMPORANEOUS MIXTURE (ON)
128EXTEMPORANEOUS MIXTURE (QC) (AB)
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Non-Insured Health BenefitsHealth Canada
Page Page84EZ HEALTH ORACLE84EZ HEALTH ORACLE (ON)
134E-Z SPACER134E-Z SPACER (MASK ONLY)134E-Z SPACER WITH SMALL MASK28EZETIMIBE
28EZETROL11FAMCICLOVIR
11FAMCICLOVIR99FAMOTIDINE
99FAMOTIDINE11FAMVIR
129FEBUXOSTAT
39FELODIPINE
14FEMARA28FENOFIBRATE
28FENOFIBRATE MICRO28FENOFIBRATE-S28FENOMAX28FENO-MICRO54FENTANYL54FENTANYL
23FER-IN-SOL23FERODAN23FERRATE O/L23FERROUS FUMARATE23FERROUS FUMARATE
23FERROUS GLUCONATE
23FERROUS GLUCONATE23FERROUS SULFATE
23FERROUS SULFATE58FEVERHALT1FEXOFENADINE HCL
26FILGRASTIM
121FINACEA129FINASTERIDE
129FINASTERIDE135FINGERSTIX13FIRMAGON
117FLAGYL117FLAGYSTATIN117FLAMAZINE117FLAMAZINE 50G90FLAREX
123FLAVOXATE HCL
27FLECAINIDE ACETATE
97FLEET ENEMA97FLEET ENEMA PEDIATRIC83FLEXI-T IUD
127FLINTSTONES EXTRA C59FLOCTAFENINE
20FLOMAX CR90FLONASE
105FLORINEF105FLOVENT DISKUS105FLOVENT HFA 125105FLOVENT HFA 250105FLOVENT HFA 5071FLUANXOL71FLUANXOL DEPOT7FLUCONAZOLE
13FLUDARA13FLUDARABINE PHOSPHATE
105FLUDROCORTISONE ACETATE
90FLUMETHASONE PIVALATE,
CLIOQUINOL
81FLUNARIZINE HCL
118FLUOCINOLONE ACETONIDE
118FLUOCINONIDE
90FLUOROMETHOLONE
90FLUOROMETHOLONE ACETATE
122FLUOROURACIL
67FLUOXETINE67FLUOXETINE HCL
71FLUPENTHIXOL DECANOATE
71FLUPENTHIXOL
DIHYDROCHLORIDE
71FLUPHENAZINE DECANOATE
71FLUPHENAZINE HCL
51FLURBIPROFEN
13FLUTAMIDE
90FLUTICASONE PROPIONATE
29FLUVASTATIN SODIUM
67FLUVOXAMINE67FLUVOXAMINE MALEATE
90FML90FML FORTE
125FOLIC ACID125FOLIC ACID
18FORADIL121FORMALDEHYDE, LACTIC ACID,
SALICYLIC ACID
18FORMOTEROL FUMARATE
18FORMOTEROL FUMARATE
DIHYDRATE
18FORMOTEROL FUMARATE
DIHYDRATE, BUDESONIDE
18FORMOTEROL FUMARATE
DIHYDRATE, MOMETASONE
FUROATE
130FOSAMAX9FOSAMPRENAVIR CALCIUM
130FOSAVANCE42FOSINOPRIL42FOSINOPRIL SODIUM
42FOSINOPRIL-1043FOSINOPRIL-2024FRAGMIN89FRAMYCETIN SULFATE
90FRAMYCETIN SULFATE,
GRAMICIDIN, DEXAMETHASONE
24FRAXIPARINE24FRAXIPARINE FORTE84FREESTYLE84FREESTYLE (ON)84FREESTYLE LITE (ON)
106FREYA (21)106FREYA (28)77FRISIUM
115FUCIDIN86FUROSEMIDE86FUROSEMIDE
115FUSIDATE SODIUM
115FUSIDIC ACID
61GABAPENTIN61GABAPENTIN
16GALANTAMINE HYDROBROMIDE
11GANCICLOVIR SODIUM
89GARASONE
85GASTROLYTE REG38GD-AMLODIPINE39GD-AMLODIPINE/ATORVASTATIN28GD-ATORVASTATIN61GD-GABAPENTIN92GD-LATANOPROST92GD-LATANOPROST/TIMOLOL63GD-PREGABALIN28GEMFIBROZIL
28GEMFIBROZIL35GEN-ACEBUTOLOL35GEN-ACEBUTOLOL (TYPE S)10GEN-ACYCLOVIR
129GEN-ALENDRONATE76GEN-ALPRAZOLAM8GEN-AMANTADINE
27GEN-AMIODARONE3GEN-AMOXICILLIN
25GEN-ANAGRELIDE35GEN-ATENOLOL3GEN-AZITHROMYCIN
20GEN-BACLOFEN89GEN-BECLO AQ13GEN-BICALUTAMIDE89GEN-BUDESONIDE AQ41GEN-CAPTOPRIL60GEN-CARBAMAZEPINE CR41GEN-CILAZAPRIL99GEN-CIMETIDINE5GEN-CIPROFLOXACIN
66GEN-CITALOPRAM3GEN-CLARITHROMYCIN6GEN-CLINDAMYCIN
118GEN-CLOBETASOL59GEN-CLONAZEPAM70GEN-CLOZAPINE18GEN-COMBO20GEN-CYCLOPRINE
101GEN-DOMPERIDONE34GEN-DOXAZOSIN42GEN-ENALAPRIL
130GEN-ETIDRONATE99GEN-FAMOTIDINE28GEN-FENOFIBRATE28GEN-FIBRO7GEN-FLUCONAZOLE
67GEN-FLUOXETINE42GEN-FOSINOPRIL61GEN-GABAPENTIN28GEN-GEMFIBROZIL
111GEN-GLICLAZIDE111GEN-GLYBE12GEN-HYDROXYCHLOROQUINE14GEN-HYDROXYUREA87GEN-INDAPAMIDE17GEN-IPRATROPIUM17GEN-IPRATROPIUM UDV62GEN-LAMOTRIGINE43GEN-LISINOPRIL43GEN-LISINOPRIL HCTZ29GEN-LOVASTATIN52GEN-MELOXICAM
109GEN-METFORMIN37GEN-METOPROLOL (TYPE L)
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Page Page37GEN-METOPROLOL-L68GEN-MIRTAZAPINE52GEN-NAPROXEN52GEN-NAPROXEN EC33GEN-NITRO
123GEN-OXYBUTYNIN68GEN-PAROXETINE
111GEN-PIOGLITAZONE30GEN-PRAVASTATIN27GEN-PROPAFENONE99GEN-RANITIDINE74GEN-RISPERIDONE82GEN-SELEGILINE69GEN-SERTRALINE31GEN-SIMVASTATIN38GEN-SOTALOL80GEN-SUMATRIPTAN89GENTAMICIN89GENTAMICIN SULFATE
15GEN-TAMOXIFEN90GENTEAL ARTIFICIAL TEARS7GEN-TERBINAFINE
25GEN-TICLOPIDINE20GEN-TIZANIDINE64GEN-TOPIRAMATE69GEN-TRAZODONE64GEN-VALPROIC41GEN-VERAPAMIL41GEN-VERAPAMIL SR25GEN-WARFARIN14GLEEVEC
111GLICLAZIDE111GLICLAZIDE
111GLICLAZIDE MR112GLUCAGEN112GLUCAGEN HYPOKIT112GLUCAGON112GLUCAGON RECOMBINANT DNA
ORGIN
108GLUCOBAY110GLUCONORM109GLUCOPHAGE84GLUCOSE OXIDASE,
PEROXIDASE
111GLYBURIDE
111GLYBURIDE96GLYCERIN
96GLYCERIN96GLYCERIN INFANT96GLYCERIN INFANT & CHILD96GLYCERINE
109GLYCON131GOLIMUMAB
96GOLYTELY14GOSERELIN ACETATE
89GRAMICIDIN, POLYMYXIN B
SULFATE
98GRANISETRON98GRANISETRON
97GRAVOL97GRAVOL ADULT21HABITROL
118HALOBETASOL PROPIONATE
71HALOPERIDOL
71HALOPERIDOL
71HALOPERIDOL DECANOATE
71HALOPERIDOL LA24HEPARIN LEO24HEPARIN LOCK FLUSH24HEPARIN SODIUM24HEPARIN SODIUM
9HEPTOVIR13HEXALEN91HOMATROPINE HBR
114HONEY BEE VENOM114HONEY BEE VENOM PROTEIN
EXTRACT
100HP-PAC110HUMALOG 10ML110HUMALOG CARTRIDGE110HUMALOG CARTRIDGE (ON)110HUMALOG KWIKPEN110HUMALOG MIX 25110HUMALOG MIX 25 KWIKPEN110HUMALOG MIX 50 KWIKPEN12HUMATIN
131HUMIRA110HUMULIN 30/70110HUMULIN 30/70 CARTRIDGE110HUMULIN 30/70 CARTRIDGE (ON)110HUMULIN N110HUMULIN N CARTRIDGE110HUMULIN N CARTRIDGE (ON)110HUMULIN N KWIKPEN110HUMULIN R110HUMULIN R CARTRIDGE110HUMULIN R CARTRIDGE (ON)119HYCORT119HYDERM33HYDRALAZINE33HYDRALAZINE HCL
85HYDRALYTE ELECTROLYTE POPS
85HYDRALYTE ELECTROLYTE PWD85HYDRALYTE ELECTROLYTE SOL14HYDREA87HYDROCHLOROTHIAZIDE87HYDROCHLOROTHIAZIDE
105HYDROCORTISONE
119HYDROCORTISONE ACETATE
119HYDROCORTISONE ACETATE,
ZINC SULFATE
119HYDROCORTISONE ACETATE,
ZINC SULFATE, PRAMOXINE HCL
119HYDROCORTISONE VALERATE
119HYDROCORTISONE, DIBUCAINE
HCL, ESCULIN, FRAMYCETIN
SULFATE
119HYDROCORTISONE, UREA
119HYDROCORTISONE/ZINC
116HYDROGEN PEROXIDE
116HYDROGEN PEROXIDE 10V55HYDROMORPH CONTIN55HYDROMORPHONE HCL
119HYDROSONE119HYDROVAL12HYDROXYCHLOROQUINE
SULFATE
92HYDROXYPROPYLMETHYLCELLU
LOSE
14HYDROXYUREA14HYDROXYUREA
79HYDROXYZINE79HYDROXYZINE HCL
93HYPOTEARS93HYPROLOSE
90HYPROMELLOSE
34HYTRIN47HYZAAR47HYZAAR DS51IBUPROFEN51IBUPROFEN
120IHLES PASTE14IMATINIB MESYLATE
33IMDUR67IMIPRAMINE HCL
122IMIQUIMOD
80IMITREX80IMITREX DF95IMODIUM
132IMURAN12INCIVEK
133INCOBOTULINUMTOXINA
18INDACATEROL MALEATE
87INDAPAMIDE
37INDERAL LA9INDINAVIR SULFATE
51INDOMETHACIN
127INFANTOL132INFLIXIMAB
23INFUFER134INFUSION SETS41INHIBACE42INHIBACE PLUS24INNOHEP
109INSULIN (30% NEUTRAL & 70%
ISOPHANE) HUMAN
BIOSYNTHETIC
110INSULIN (40% NEUTRAL & 60%
ISOPHANE) HUMAN
BIOSYNTHETIC
110INSULIN (50% NEUTRAL & 50%
ISOPHANE) HUMAN
BIOSYNTHETIC
110INSULIN (ISOPHANE) HUMAN
BIOSYNTHETIC
110INSULIN (ZINC CRYSTALLINE)
HUMAN BIOSYNTHETIC (RDNA
ORIGIN)
110INSULIN ASPART
110INSULIN DETEMIR
110INSULIN GLARGINE
110INSULIN GLULISINE
110INSULIN HUMAN BIOSYNTHETIC
110INSULIN HUMAN BIOSYNTHETIC
30% & ISOPHANE 70%
110INSULIN LISPRO
110INSULIN LISPRO (25%), INSULIN
LISPRO PROTAMINE
SUSPENSION (75%)
110INSULIN LISPRO (50%), INSULIN
LISPRO PROTAMINE
SUSPENSION (50%)
137INSULIN LO DOSE MICRO 28G
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Page Page134INSULIN PUMP BATTERY134INSULIN PUMP CARTRIDGES134INSULIN PUMP SUPPLIES
135INSUPEN 29GX12MM NEEDLE135INSUPEN 30GX8MM NEEDLE135INSUPEN 31GX6MM NEEDLE135INSUPEN 31GX8MM NEEDLE135INSUPEN 32GX6MM NEEDLE135INSUPEN 32GX8MM NEEDLE
9INTELENCE14INTERFERON ALFA-2B
83INTRAUTERINE DEVICE
14INTRON A9INVIRASE
92IOPIDINE97IPECAC97IPECAC
17IPRATROPIUM BROMIDE
18IPRATROPIUM BROMIDE,
SALBUTAMOL
46IRBESARTAN
46IRBESARTAN46IRBESARTAN HCT46IRBESARTAN,
HYDROCHLOROTHIAZIDE
46IRBESARTAN/HCTZ23IRON
23IRON DEXTRAN
23IRON SUCROSE
9ISENTRESS8ISONIAZID
116ISOPROPYL ALCOHOL
116ISOPROPYL MYRISTATE
41ISOPTIN SR90ISOPTO ATROPINE90ISOPTO CARBACHOL92ISOPTO CARPINE91ISOPTO HOMATROPINE92ISOPTO TEARS33ISOSORBIDE DINITRATE
33ISOSORBIDE-5-MONONITRATE
8ISOTAMINE122ISOTRETINOIN
84ITEST84ITEST (ON)
135ITEST LANCETS 28G (100)135ITEST LANCETS 33G (100)
7ITRACONAZOLE
85J CAL-D85JAMP CALCIUM + VITAMIN D23JAMP FERROUS FUMARATE23JAMP FERROUS SULPHATE
INFANT23JAMP FERROUS SULPHATE
LIQUID125JAMP FOLIC ACID96JAMP GLYCERIN51JAMP IBUPROFEN85JAMP REHYDRALYTE
119JAMP ZINC-HC59JAMP-ACETAMINOPHEN
130JAMP-ALENDRONATE76JAMP-ALPRAZOLAM38JAMP-AMLODIPINE13JAMP-ANASTROZOLE
35JAMP-ATENOLOL28JAMP-ATORVASTATIN13JAMP-BICALUTAMIDE95JAMP-BISACODYL85JAMP-CALCIUM + VIT D45JAMP-CANDESARTAN36JAMP-CARVEDILOL5JAMP-CIPROFLOXACIN
65JAMP-CITALOPRAM129JAMP-COLCHICINE20JAMP-CYCLOBENZAPRINE98JAMP-DIMENHYDRINATE1JAMP-DIPHENHYDRAMINE
96JAMP-DOCUSATE CALCIUM101JAMP-DOMPERIDONE23JAMP-FER
129JAMP-FINASTERIDE67JAMP-FLUOXETINE42JAMP-FOSINOPRIL61JAMP-GABAPENTIN87JAMP-INDAPAMIDE86JAMP-K 2086JAMP-K 885JAMP-LACTULOSE14JAMP-LETROZOLE62JAMP-LEVETIRACETAM43JAMP-LISINOPRIL47JAMP-LOSARTAN47JAMP-LOSARTAN HCTZ
128JAMP-MAGNESIUM128JAMP-MAGNESIUM GLUCONATE109JAMP-METFORMIN109JAMP-METFORMIN BLACKBERRY37JAMP-METOPROLOL-L88JAMP-MONTELUKAST
128JAMP-MULTIVITAMIN A/D/ C DROPS
132JAMP-MYCOPHENOLATE98JAMP-ONDANSETRON68JAMP-PAROXETINE
111JAMP-PIOGLITAZONE86JAMP-POTASSIUM CHLORIDE30JAMP-PRAVASTATIN73JAMP-QUETIAPINE44JAMP-RAMIPRIL
131JAMP-RISEDRONATE74JAMP-RISPERIDONE80JAMP-RIZATRIPTAN82JAMP-ROPINIROLE30JAMP-ROSUVASTATIN96JAMP-SENNA96JAMP-SENNAQUIL
128JAMP-SENNOSIDES69JAMP-SERTRALINE31JAMP-SIMVASTATIN38JAMP-SOTALOL7JAMP-TERBINAFINE
128JAMP-VITAMIN B1125JAMP-VITAMIN B12125JAMP-VITAMINE126JAMP-VITAMINE D109JANUMET109JANUVIA86K LYTE
56KADIAN57KADIAN SR9KALETRA
86KAYEXALATE106KENALOG-10106KENALOG-4062KEPPRA7KETOCONAZOLE
115KETODERM51KETOPROFEN
90KETOROLAC TROMETHAMINE
84KETOSTIX84KETOSTIX (MB)84KETOSTIX (ON)1KETOTIFEN FUMARATE
86K-EXIT8KIVEXA
96KLEAN-PREP116KWELLADA-P98KYTRIL36LABETALOL HCL
62LACOSAMIDE
93LACRI LUBE93LACRISERT97LACTAID97LACTAID EXTRA STRENGTH97LACTASE
97LACTEEZE DROPS121LACTIC ACID, SALICYLIC ACID
85LACTULOSE
62LAMICTAL7LAMISIL9LAMIVUDINE
9LAMIVUDINE, ZIDOVUDINE
62LAMOTRIGINE62LAMOTRIGINE
135LANCET
27LANOXIN112LANREOTIDE
100LANSOPRAZOLE
100LANSOPRAZOLE100LANSOPRAZOLE ODT
96LANSOYL GEL96LANSOYL GEL SUGARFREE
110LANTUS110LANTUS CARTRIDGE110LANTUS SOLOSTAR15LANVIS86LASIX92LATANOPROST
92LATANOPROST, TIMOLOL
MALEATE
96LAX-A-DAY 1G/G PDR77LECTOPAM
132LEFLUNOMIDE
132LEFLUNOMIDE29LESCOL29LESCOL XL14LETROZOLE14LETROZOLE
129LEUCOVORIN CALCIUM129LEUCOVORIN CALCIUM
13LEUKERAN14LEUPROLIDE ACETATE
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Non-Insured Health BenefitsHealth Canada
Page Page5LEVAQUIN
65LEVATE110LEVEMIR PENFILL62LEVETIRACETAM
62LEVETIRACETAM91LEVOBUNOLOL HCL
89LEVOCABASTINE HCL
86LEVOCARNITINE
81LEVODOPA, BENZERAZIDE
81LEVODOPA, CARBIDOPA
81LEVODOPA, CARBIDOPA,
ENTACAPONE
5LEVOFLOXACIN
107LEVONORGESTREL
107LEVONORGESTREL
INTRAUTERINE INSERT
113LEVOTHYROXINE SODIUM
83LIBERTE UT380 SHORT83LIBERTE UT380 STANDARD
118LIDEMOL118LIDEX120LIDOCAINE HCL
120LIDOCAINE, PRILOCAINE
120LIDODAN VISCOUS136LIFE BRAND PEN NEEDLE 31G
8MM135LIFESCAN REGULAR109LINAGLIPTIN
54LINCTUS CODEINE106LINESSA (21)106LINESSA (28)
7LINEZOLID
20LIORESAL20LIORESAL DS97LIPASE, AMYLASE, PROTEASE
28LIPIDIL EZ28LIPIDIL MICRO28LIPIDIL SUPRA28LIPITOR75LISDEXAMFETAMINE
DIMESYLATE
43LISINOPRIL43LISINOPRIL
43LISINOPRIL,
HYDROCHLOROTHIAZIDE
43LISINOPRIL/HCTZ (TYPE Z)79LITHANE79LITHIUM CARBONATE
79LITHIUM CITRATE
89LIVOSTIN90LOCACORTEN VIOFORM93LODOXAMIDE TROMETHAMINE
107LOESTRIN 1.5/30 (21)107LOESTRIN 1.5/30 (28)14LOMUSTINE
33LONITEN95LOPERAMIDE95LOPERAMIDE HCL
9LOPINAVIR, RITONAVIR
37LOPRESOR37LOPRESOR SR1LORATADINE
1LORATADINE77LORAZEPAM
77LORAZEPAM
47LOSARTAN47LOSARTAN POTASSIUM
47LOSARTAN POTASSIUM,
HYDROCHLOROTHIAZIDE
47LOSARTAN/HCT100LOSEC41LOTENSIN
117LOTRIDERM29LOVASTATIN29LOVASTATIN
24LOVENOX24LOVONEX HP50LOWPRIN71LOXAPINE HCL
71LOXAPINE SUCCINATE
87LOZIDE93LUCENTIS
134LUER LOCK (DISP) 30CC134LUER LOCK (DISP) 60CC92LUMIGAN RC14LUPRON DEPOT
107LUTERA (21)107LUTERA (28)67LUVOX
118LYDERM63LYRICA15LYSODREN56M.O.S.56M.O.S. 1056M.O.S. 2056M.O.S. 4056M.O.S. 5056M.O.S. 6056M.O.S. SR57M.O.S. SULFATE12MACROBID96MACROGOL, POTASSIUM
CHLORIDE, SODIUM
BICARBONATE, SODIUM
CHLORIDE, SODIUM SULFATE
93MACROGOL, PROPYLENE
GLYCOL
95MAG OXIDE
95MAGIC BULLET85MAGNESIUM
127MAGNESIUM96MAGNESIUM CITRATE
96MAGNESIUM HYDROXIDE
95MAGNESIUM OXIDE127MAGNESIUM OXIDE
128MAGNESIUM-ODAN135MAGNIFIER
75MAJEPTIL68MANERIX67MAPROTILINE HCL
129MAR-ALLOPURINOL38MAR-AMLODIPINE13MAR-ANASTROZOLE35MAR-ATENOLOL9MARAVIROC
5MAR-CIPROFLOXACIN65MAR-CITALOPRAM67MAR-FLUOXETINE14MAR-LETROZOLE
109MAR-METFORMIN
88MAR-MONTELUKAST71MAR-OLANZAPINE ODT98MAR-ONDANSETRON74MAR-RISPERIDONE80MAR-RIZATRIPTAN31MAR-SIMVASTATIN
106MARVELON (21)106MARVELON (28)102MATERNA45MAVIK80MAXALT79MAXALT RPD90MAXIDEX99MAXIMUM STRENGTH ACID
REDUCER85M-CAL D2MEBENDAZOLE
13MED-ANASTROZOLE13MED-CYPROTERONE84MEDI+SURE84MEDI+SURE (ON)
135MEDI+SURE SOFT 30G TWIST135MEDI+SURE SOFT 33G TWIST135MEDISENSE14MED-LETROZOLE
105MEDROL113MEDROXYPROGESTERONE113MEDROXYPROGESTERONE
ACETATE
52MEFENAMIC ACID
14MEGACE14MEGESTROL ACETATE
52MELOXICAM52MELOXICAM
14MELPHALAN
12MEPRON14MERCAPTOPURINE
102MESALAZINE
102MESASAL56M-ESLON57M-ESLON SR16MESTINON16MESTINON-SR56METADOL96METAMUCIL ORIGINAL TEXTURE96METAMUCIL SM TEXT ORANGE96METAMUCIL SM TEXT ORANGE
S/F96METAMUCIL SM TEXT UNFLAV
109METFORMIN109METFORMIN HCL
138METHADONE56METHADONE HCL
56METHADONE HCL (PA)
138METHADONE POWDER (PAIN)56METHADOSE56METHADOSE SUGARFREE92METHAZOLAMIDE
15METHOTREXATE15METHOTREXATE SODIUM
71METHOTRIMEPRAZINE
121METHOXSALEN
60METHSUXIMIDE
32METHYLDOPA
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Non-Insured Health BenefitsHealth Canada
Page Page32METHYLDOPA,
HYDROCHLOROTHIAZIDE
76METHYLPHENIDATE 10MG TAB76METHYLPHENIDATE 20MG TAB76METHYLPHENIDATE 5MG TAB75METHYLPHENIDATE HCL
105METHYLPREDNISOLONE
105METHYLPREDNISOLONE
ACETATE
105METHYLPREDNISOLONE ACETATE
101METOCLOPRAMIDE HCL
87METOLAZONE
37METOPROLOL37METOPROLOL SR37METOPROLOL TARTRATE
37METOPROLOL-2537METOPROLOL-L
116METROCREAM117METROGEL117METROLOTION12METRONIDAZOLE12METRONIDAZOLE
117METRONIDAZOLE, NYSTATIN
29MEVACOR27MEXILETINE HCL
102MEZAVANT48MICARDIS48MICARDIS PLUS
115MICATIN115MICONAZOLE115MICONAZOLE NITRATE
115MICOZOLE136MICRO-FINE86MICRO-K EXTENCAPS96MICROLAX
135MICROLET108MICRONOR (28)18MIDODRINE HCL
20MIGRANAL96MILK OF MAGNESIA96MILK OF MAGNESIA
PLAIN/SUGARFREE107MIN OVRAL (21)107MIN OVRAL (28)96MINERAL OIL
96MINERAL OIL (HEAVY) 100% USP93MINERAL OIL, PETROLATUM
93MINERAL OIL, WHITE
PETROLATUM
107MINESTRIN 1/20 (21)107MINESTRIN 1/20 (28)34MINIPRESS33MINITRAN6MINOCIN6MINOCYCLINE6MINOCYCLINE HCL
33MINOXIDIL
129MINT-ALENDRONATE38MINT-AMLODIPINE13MINT-ANASTROZOLE35MINT-ATENOLOL5MINT-CIPROFLOXACIN
65MINT-CITALOPRAM25MINT-CLOPIDOGREL
129MINT-FINASTERIDE67MINT-FLUOXETINE46MINT-IRBESARTAN/HCTZ47MINT-LOSARTAN/HCTZ
109MINT-METFORMIN30MINT-PRAVASTATIN74MINT-RISPERIDONE16MINT-RIVASTIGMINE30MINT-ROSUVASTATIN69MINT-SERTRALINE31MINT-SIMVASTATIN64MINT-TOPIRAMATE92MIOSTAT81MIRAPEX81MIRAPEX (ONT)
107MIRENA67MIRTAZAPINE
68MIRTAZAPINE106MIRVALA (21)106MIRVALA (28)99MISOPROSTOL
15MITOTANE
114MIXED VESPID VENOM PROTEIN86MK 1086MK 2086MK 852MOBICOX68MOCLOBEMIDE
76MODAFINIL
71MODECATE78MOGADON90MOMETASONE FUROATE
115MONISTAT 3115MONISTAT 3 DUAL PAK115MONISTAT 7115MONISTAT 7 DUAL PAK115MONISTAT-DERM136MONOJECT136MONOJECT (100)136MONOJECT (30)134MONOJECT ALCOHOL WIPES136MONOJECT DISP 3/10CC (100)136MONOJECT DISP 3/10CC (30)135MONOLET ORIGINAL135MONOLET THIN42MONOPRIL88MONTELUKAST
88MONTELUKAST56MORPHINE HCL
57MORPHINE SR56MORPHINE SULFATE
51MOTRIN51MOTRIN JUNIOR STRENGTH
135MPD THIN (100)135MPD THIN (200)135MPD ULTRA THIN (100)135MPD ULTRA THIN (200)57MS CONTIN SR57MS IR96M-SENNOSIDES96MUCILLIUM
127MULTI-PRE AND POST NATAL121MULTITAR PLUS121MULTI-TAR PLUS MILD
126MULTIVATAMINS (PRENATAL)
127MULTIVITAMINS (PEDIATRIC)
127MULTIVITAMINS (PRENATAL)
115MUPIROCIN
94MURO-1288MYCOBUTIN
132MYCOPHENOLATE MOFETIL
132MYCOPHENOLATE SODIUM
91MYDFRIN132MYFORTIC137MYHEALTH SYRINGE CASE-7137MYHEALTH SYRINGE CASE-
SINGLE80MYLAN ZOLMITRIPTAN80MYLAN ZOLMITRIPTAN ODT79MYLAN-ALMOTRIPTAN38MYLAN-AMLODIPINE13MYLAN-ANASTROZOLE28MYLAN-ATORVASTATIN36MYLAN-BISOPROLOL34MYLAN-BOSENTAN65MYLAN-BUPROPION XL46MYLAN-CANDESART/HCTZ45MYLAN-CANDESARTAN36MYLAN-CARVEDILOL25MYLAN-CLOPIDOGREL8MYLAN-EFAVIRENZ
81MYLAN-ENTACAPONE130MYLAN-ETI-CAL CAREPAC54MYLAN-FENTANYL
129MYLAN-FINASTERIDE61MYLAN-GABAPENTIN16MYLAN-GALANTAMINE ER46MYLAN-IRBESARTAN
100MYLAN-LANSOPRAZOLE132MYLAN-LEFLUNOMIDE
5MYLAN-LEVOFLOXACIN47MYLAN-LOSARTAN47MYLAN-LOSARTAN/HCTZ88MYLAN-MONTELUKAST
132MYLAN-MYCOPHENOLATE9MYLAN-NEVIRAPINE
39MYLAN-NIFEDIPINE ER33MYLAN-NITRO72MYLAN-OLANZAPINE71MYLAN-OLANZAPINE ODT
100MYLAN-OMEPRAZOLE98MYLAN-ONDANSETRON
101MYLAN-PANTOPRAZOLE81MYLAN-PRAMIPEXOLE
101MYLAN-RABEPRAZOLE44MYLAN-RAMIPRIL
131MYLAN-RISEDRONATE16MYLAN-RIVASTIGMINE79MYLAN-RIZATRIPTAN ODT30MYLAN-ROSUVASTATIN20MYLAN-TAMSULOSIN48MYLAN-TELMISARTAN48MYLAN-TELMISARTAN HCTZ34MYLAN-TERAZOSIN11MYLAN-VALACYCLOVIR48MYLAN-VALSARTAN49MYLAN-VALSARTAN HCTZ13MYLERAN
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Page Page14MYL-LETROZOLE99MYL-RANITIDINE
103MYOCHRYSINE98NABILONE
37NADOLOL37NADOLOL
24NADROPARIN CALCIUM
108NAFARELIN ACETATE
88NALCROM91NAPHAZOLINE HCL
91NAPHCON FORTE52NAPROSYN52NAPROSYN E52NAPROSYN SR52NAPROXEN52NAPROXEN
52NAPROXEN EC52NAPROXEN NA52NAPROXEN SODIUM52NAPROXEN SODIUM
52NAPROXEN SODIUM DS52NAPROXEN-NA DF79NARATRIPTAN HCL
69NARDIL90NASACORT AQ90NASONEX
110NATEGLINIDE
15NATULAN98NAUSEATOL75NAVANE89NEDOCROMIL SODIUM
135NEEDLE
134NEEDLE (NON-INSULIN)
134NEEDLES (NON-INSULIN) DISPOSABLE
9NELFINAVIR MESYLATE
85NEO CAL-D-50023NEO FER
108NEO-ESTRONE119NEO-HC132NEORAL16NEOSTIGMINE BROMIDE
118NERISALIC OILY118NERISONE118NERISONE OILY26NEULASTA72NEULEPTIL26NEUPOGEN61NEURONTIN
121NEUTROGENA T/GEL9NEVIRAPINE
107NEXT CHOICE125NIACIN125NIACIN
125NIACIN YEAST FREE21NICODERM21NICORETTE21NICORETTE PLUS21NICOTINE21NICOTINE (GUM)
21NICOTINE (INHALER)
21NICOTINE (LOZENGES)
21NICOTINE (PATCH)
21NICOTROL TRANSDERMAL
21NICOTROL TRANSDERMAL 10MG21NICOTROL TRANSDERMAL 15MG21NICOTROL TRANSDERMAL 5MG24NICOUMALONE
117NIDAGEL39NIFEDIPINE
15NILUTAMIDE
40NIMODIPINE
40NIMOTOP82NITOMAN78NITRAZADON78NITRAZEPAM
33NITRO-DUR12NITROFURANTOIN
33NITROGLYCERIN
33NITROL33NITROLINGUAL PUMPSPRAY33NITROSTAT
116NIX116NIX DERMAL99NIZATIDINE99NIZATIDINE
115NIZORAL15NOLVADEX D
114NON POLLEN
134NON-INSULIN 1CC134NON-INSULIN 3CC134NON-INSULIN 5CC134NON-INSULIN (DISP) 1CC134NON-INSULIN (DISP) 3CC134NON-INSULIN (DISP) 5CC134NON-INSULIN (DISP) 10CC134NON-INSULIN 10CC108NORETHINDRONE
5NORFLOXACIN
116NORITATE107NORLEVO68NORTRIPTYLINE HCL
38NORVASC9NORVIR9NORVIR SEC
87NOVAMILOR3NOVAMOXIN4NOVAMOXIN SUGAR REDUCED
50NOVASEN83NOVA-T IUD
102NOVO 5-ASA35NOVO-ACEBUTOLOL10NOVO-ACYCLOVIR
129NOVO-ALENDRONATE76NOVO-ALPRAZOL27NOVO-AMIODARONE4NOVO-AMPICILLIN
35NOVO-ATENOL36NOVO-ATENOLTHALIDONE28NOVO-ATORVASTATIN3NOVO-AZITHROMYCIN
91NOVO-BENZYDAMINE82NOVO-BETAHISTINE13NOVO-BICALUTAMIDE36NOVO-BIPOPROLOL77NOVO-BROMAZEPAM41NOVO-CAPTORIL60NOVO-CARBAMAZ
2NOVO-CEFADROXIL12NOVO-CHLOROQUINE70NOVO-CHLORPROMAZINE41NOVO-CILAZAPRIL42NOVO-CILAZAPRIL /HCTZ98NOVO-CIMETINE5NOVO-CIPROFLOXACIN
66NOVO-CITALOPRAM4NOVO-CLAVAMOXIN6NOVO-CLINDAMYCIN
77NOVO-CLOBAZAM118NOVO-CLOBETASOL59NOVO-CLONAZEPAM32NOVO-CLONIDINE66NOVO-CLOPAMINE4NOVO-CLOXIN
20NOVO-CYCLOPRINE133NOVO-CYPROTERONE/ETHINYL
ESTRADIOL66NOVO-DESIPRAMINE
112NOVO-DESMOPRESSIN50NOVO-DIFENAC51NOVO-DIFENAC SR51NOVO-DIFLUNISAL40NOVO-DILTAZEM CD41NOVO-DILTIAZEM40NOVO-DILTIAZEM HCL ER98NOVODIMENATE60NOVO-DIVALPROEX95NOVO-DOCUSATE95NOVO-DOCUSATE CALCIUM
101NOVO-DOMPERIDONE34NOVO-DOXAZOSIN66NOVO-DOXEPIN6NOVO-DOXYLIN
42NOVO-ENALAPRIL42NOVO-ENALAPRIL/HCTZ
130NOVO-ETIDROCAL99NOVO-FAMOTIDINE28NOVO-FENOFIBRATE28NOVO-FENOFIBRATE-S23NOVO-FERROGLUC
135NOVOFINE135NOVOFINE 30G136NOVOFINE 32G 6MM135NOVOFINE INSULIN PEN 28G135NOVOFINE INSULIN PEN 30G
7NOVO-FLUCONAZOLE67NOVO-FLUOXETINE51NOVO-FLURPROFEN13NOVO-FLUTAMIDE67NOVO-FLUVOXAMINE42NOVO-FOSINOPRIL12NOVO-FURANTOIN61NOVO-GABAPENTIN28NOVO-GEMFIBROZIL59NOVO-GESIC
111NOVO-GLYBURIDE87NOVO-HYDRAZIDE79NOVO-HYDROXYZIN33NOVO-HYLAZIN87NOVO-INDAPAMIDE17NOVO-IPRAMIDE7NOVO-KETOCONAZOLE
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Page Page1NOVO-KETOTIFEN
62NOVO-LAMOTRIGINE81NOVO-LEVOCARBIDOPA5NOVO-LEVOFLOXACIN2NOVO-LEXIN
109NOVOLIN GE 30/70109NOVOLIN GE 30/70 PENFILL110NOVOLIN GE 40/60 PENFILL110NOVOLIN GE 50/50 PENFILL110NOVOLIN GE NPH110NOVOLIN GE NPH PENFILL110NOVOLIN GE NPH PENFILL (ON)110NOVOLIN GE TORONTO110NOVOLIN GE TORONTO PENFILL110NOVOLIN GE TORONTO PENFILL
(ON)43NOVO-LISINOPRIL (TYPE P)43NOVO-LISINOPRIL (TYPE Z)43NOVO-LISINOPRIL/HCTZ (TYPE P)43NOVO-LISINOPRIL/HCTZ (TYPE Z)95NOVO-LOPERAMIDE77NOVO-LORAZEM29NOVO-LOVASTATIN67NOVO-MAPROTILINE
113NOVO-MEDRONE52NOVO-MELOXICAM71NOVO-MEPRAZINE
109NOVO-METFORMIN51NOVO-METHACIN15NOVO-METHOTREXATE37NOVO-METOPROL37NOVO-METOPROL CT37NOVO-METOPROL-B27NOVO-MEXILETINE6NOVO-MINOCYCLINE
68NOVO-MIRTAZAPINE67NOVO-MIRTAZAPINE OD68NOVO-MOCLOBEMIDE52NOVO-NAPROX52NOVO-NAPROX SODIUM52NOVO-NAPROX SODIUM DS99NOVO-NIZATIDINE5NOVO-NORFLOXACIN
68NOVO-NORTRIPTYLINE6NOVO-OFLOXACIN
72NOVO-OLANZAPINE98NOVO-ONDANSETRON
123NOVO-OXYBUTYNIN68NOVO-PAROXETINE4NOVO-PEN VK
71NOVO-PERIDOL1NOVOPHENIRAM
37NOVO-PINDOL111NOVO-PIOGLITAZONE53NOVO-PIROCAM67NOVO-PRAMINE81NOVO-PRAMIPEXOLE37NOVO-PRANOL30NOVO-PRAVASTATIN34NOVO-PRAZIN
106NOVO-PREDNISONE51NOVO-PROFEN
101NOVO-RABEPRAZOLE44NOVO-RAMIPRIL
99NOVO-RANIDINE99NOVO-RANITIDINE
110NOVORAPID110NOVORAPID FLEXTOUCH74NOVO-RISPERIDONE16NOVO-RIVASTIGMINE3NOVO-RYTHRO ESTOLATE
19NOVO-SALBUTAMOL82NOVO-SELEGILINE86NOVO-SEMIDE69NOVO-SERTRALINE31NOVO-SIMVASTATIN38NOVO-SOTALOL49NOVO-SPIROTON87NOVO-SPIROZINE-2587NOVO-SPIROZINE-5099NOVO-SUCRALATE80NOVO-SUMATRIPTAN80NOVO-SUMATRIPTAN DF53NOVO-SUNDAC15NOVO-TAMOXIFEN20NOVO-TAMSULOSIN78NOVO-TEMAZEPAM34NOVO-TERAZOSIN7NOVO-TERBINAFINE
123NOVO-THEOPHYL SR53NOVO-TIAPROFENIC25NOVO-TICLOPIDINE38NOVO-TIMOL64NOVO-TOPIRAMATE69NOVO-TRAZODONE87NOVO-TRIAMZIDE6NOVO-TRIMEL6NOVO-TRIMEL DS
70NOVO-TRIPRAMINE135NOVOTWIST TIP NEEDLE 30G136NOVOTWIST TIP NEEDLE 32G11NOVO-VALACYCLOVIR64NOVO-VALPROIC70NOVO-VENLAFAXINE XR41NOVO-VERAMIL41NOVO-VERAMIL SR25NOVO-WARFARIN85NU-CAL85NU-CAL D4NU-PEN VK
69NU-TRAZODONE D106NUVARING115NYADERM
7NYSTATIN
85O-CALCIUM 500121OCCLUSAL HP112OCTREOTIDE
112OCTREOTIDE ACETATE OMEGA89OCUFLOX
128ODAN K-20128ODAN K-8121ODANS LIQUOR CARBONIS
DETERGENT108OESCLIM
5OFLOXACIN
108OGEN71OLANZAPINE
72OLANZAPINE
71OLANZAPINE ODT47OLMESARTAN MEDOXOMIL
47OLMESARTAN MEDOXOMIL,
HYDROCHLOROTHIAZIDE
47OLMETEC47OLMETEC PLUS89OLOPATADINE HCL
102OLSALAZINE SODIUM
100OMEPRAZOLE100OMEPRAZOLE
100OMEPRAZOLE (PA)
18ONBREZ98ONDANSETRON98ONDANSETRON HCL DIHYDRATE
98ONDANSETRON-ODAN98ONDISSOLVE ODF
135ONE TOUCH DELICA 30G135ONE TOUCH DELICA 33G84ONE TOUCH ULTRA84ONE TOUCH ULTRA (ON)
135ONE TOUCH ULTRA SOFT84ONE TOUCH VERIO (ON)
126ONE-ALPHA135ONETOUCH DELICA 33G84ONETOUCH VERIO
109ONGLYZA134OPTICHAMBER134OPTICHAMBER DIAMOND
(CHAMBER)134OPTICHAMBER DIAMOND
(LARGE M)134OPTICHAMBER DIAMOND
(MEDIUM M)134OPTICHAMBER LARGE MASK134OPTICHAMBER MEDIUM MASK134OPTICHAMBER SMALL MASK88OPTICROM
134OPTIHALER89OPTIMYXIN89OPTIMYXIN EYE/EAR
107OPTION 2120ORACORT73ORAP18ORCIPRENALINE SULFATE
131ORENCIA 250MG/VIAL INJ107ORTHO 0.5/35 (28)107ORTHO 0.5/35 (21)107ORTHO 7/7/7 (21)107ORTHO 7/7/7 (28)107ORTHO 1/35 (21)107ORTHO 1/35 (28)106ORTHO CEPT (28)126OSTOFORTE93OTRIVIN SALINE
107OVIMA (21)107OVIMA (28)135OWEN MUMFORD UNIFINE
PENTIPS 1/2 INCH135OWEN MUMFORD UNIFINE
PENTIPS 1/4 INCH135OWEN MUMFORD UNIFINE
PENTIPS 5/16 INCH78OXAZEPAM
78OXAZEPAM18OXEZE TURBUHALER
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Page Page78OXPAM
121OXSORALEN123OXTRIPHYLLINE
116OXY 5123OXYBUTYNIN123OXYBUTYNIN CHLORIDE
123OXYBUTYNINE57OXYCODONE57OXYCODONE HCL
53OXYCODONE/ACET116OXYDERM57OXY-IR85OYSTER SHELL CALCIUM
121P&S PLUS3P.C.E.
23PALAFER130PAMIDRONATE DISODIUM130PAMIDRONATE DISODIUM
97PANCREASE MT 1097PANCREASE MT 1697PANCREASE MT 4
116PANOXYL116PANOXYL AQUAGEL116PANOXYL-10116PANOXYL-20116PANOXYL-5101PANTOLOC101PANTOPRAZOLE101PANTOPRAZOLE
101PANTOPRAZOLE MAGNESIUM
101PARIET EC69PARNATE12PAROMOMYCIN SULFATE
68PAROXETINE68PAROXETINE HCL
17PARSITAN89PATANOL16PAT-GALANTAMINE ER
101PAT-RABEPRAZOLE EC68PAXIL2PDL-CEPHALEXIN
71PDL-LOXAPINE113PDL-MEDROXY
6PDL-MINOCYCLINE34PDL-TERAZOSIN64PDL-TOPIRAMATE64PDL-VALPROIC23PEDIAFER85PEDIALYTE58PEDIAPHEN58PEDIAPHEN CHEWABLE TAB
160MG58PEDIAPHEN CHEWABLE TAB
80MG106PEDIAPRED85PEDIATRIC ELECTROLYTE58PEDIATRIX
127PEDIAVIT126PEDIAVIT D
3PEDIAZOLE96PEG 3350 PDR10PEGASYS10PEGASYS RBV10PEGETRON
10PEGETRON REDIPEN26PEGFILGRASTIM
10PEGINTERFERON ALFA-2A
10PEGINTERFERON ALFA-2A,
RIBAVIRIN
10PEGINTERFERON ALFA-2B,
RIBAVIRIN
96PEGLYTE104PENICILLAMINE
4PENICILLIN V POTASSIUM
4PENICILLINE V101PENTASA128PENTOSAN POLYSULFATE
SODIUM
26PENTOXIFYLLINE
121PENTRAX95PEPTO BISMOL53PERCOCET53PERCOCET DEMI91PERICHLOR72PERICYAZINE
91PERIDEX43PERINDOPRIL ERBUMINE
44PERINDOPRIL ERBUMINE,
INDAPAMIDE
91PERIOGARD116PERMETHRIN
116PEROXIDE D'HYDROGENE72PERPHENAZINE
120PETROLATUM
93PETROLATUM, LANOLIN,
MINERAL OIL
93PETROLATUM, PETROLATUM
LIQUID
126PHARMA D128PHARMA-CAL85PHARMA-CAL D
126PHARMA-D69PHENELZINE SULFATE
91PHENYLEPHRINE91PHENYLEPHRINE HCL
91PHENYLEPHRINE MINIMS60PHENYTOIN
38PHL-AMLODIPINE35PHL-ATENOLOL3PHL-AZITHROMYCIN
20PHL-BACLOFEN5PHL-CIPROFLOXACIN
65PHL-CITALOPRAM59PHL-CLONAZEPAM59PHL-CLONAZEPAM-R20PHL-CYCLOBENZAPRINE
105PHL-DEXAMETHASONE67PHL-FLUOXETINE55PHL-HYDROMORPHONE87PHL-INDAPAMIDE71PHL-LOXAPINE52PHL-MELOXICAM68PHL-MIRTAZAPINE98PHL-ONDANSETRON68PHL-PAROXETINE
111PHL-PIOGLITAZONE30PHL-PRAVASTATIN73PHL-QUETIAPINE74PHL-RISPERIDONE
69PHL-SERTRALINE31PHL-SIMVASTATIN38PHL-SOTALOL64PHL-TOPIRAMATE69PHL-TRAZODONE97PHL-URSODIOL C65PHL-VALPROIC ACID41PHL-VERAPAMIL
128PHOSLAX95PICO-SALAX16PILOCARPINE16PILOCARPINE HCL
92PILOCARPINE NITRATE
92PILOCARPINE NITRATE MINIMS92PILOPINE HS
122PIMECROLIMUS
73PIMOZIDE
37PINDOLOL
37PINDOLOL37PINDOLOL,
HYDROCHLOROTHIAZIDE
111PIOGLITAZONE111PIOGLITAZONE HCL
116PIPERONYL BUTOXIDE,
PYRETHRINS
73PIPORTIL L473PIPOTIAZINE PALMITATE
53PIROXICAM
134PISTON ROD4PIVMECILLINAM HCL
81PIZOTYLINE HYDROGEN MALATE
107PLAN B96PLANTAGO SEED
12PLAQUENIL25PLAVIX39PLENDIL25PMS CLOPIDOGREL58PMS-ACETAMINOPHEN53PMS-ACETAMINOPHEN WITH
CODEINE130PMS-ALENDRONATE130PMS-ALENDRONATE FC
8PMS-AMANTADINE27PMS-AMIODARONE65PMS-AMITRIPTYLINE38PMS-AMLODIPINE39PMS-
AMLODIPINE/ATORVASTATIN3PMS-AMOXICILLIN
25PMS-ANAGRELIDE13PMS-ANASTROZOLE50PMS-ASA50PMS-ASA EC35PMS-ATENOLOL28PMS-ATORVASTATIN3PMS-AZITHROMYCIN
20PMS-BACLOFEN17PMS-BENZTROPINE91PMS-BENZYDAMINE28PMS-BEZAFIBRATE13PMS-BICALUTAMIDE95PMS-BISACODYL36PMS-BISOPROLOL34PMS-BOSENTAN91PMS-BRIMONIDINE
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Page Page81PMS-BROMOCRIPTINE65PMS-BUPROPION SR45PMS-CANDESARTAN46PMS-CANDESARTAN/HCTZ41PMS-CAPTOPRIL60PMS-CARBAMAZEPINE60PMS-CARBAMAZEPINE SRT36PMS-CARVEDILOL2PMS-CEPHALEXIN1PMS-CETIRIZINE
27PMS-CHOLESTYRAMINE LIGHT27PMS-CHOLESTYRAMINE
REGULAR41PMS-CILAZAPRIL98PMS-CIMETIDINE5PMS-CIPROFLOXACIN
65PMS-CITALOPRAM3PMS-CLARITHROMYCIN
77PMS-CLOBAZAM118PMS-CLOBETASOL59PMS-CLONAZEPAM59PMS-CLONAZEPAM R54PMS-CODEINE
129PMS-COLCHICINE20PMS-CYCLOBENZAPRINE66PMS-DESIPRAMINE
112PMS-DESMOPRESSIN118PMS-DESONIDE90PMS-DEXAMETHASONE77PMS-DIAZEPAM50PMS-DICLOFENAC51PMS-DICLOFENAC SR40PMS-DILTIAZEM CD98PMS-DIMENHYDRINATE1PMS-DIPHENHYDRAMINE
91PMS-DIPIVEFRIN60PMS-DIVALPROEX95PMS-DOCUSATE CALCIUM95PMS-DOCUSATE SODIUM
101PMS-DOMPERIDONE34PMS-DOXAZOSIN42PMS-ENALAPRIL89PMS-ERYTHROMYCIN11PMS-FAMCICLOVIR54PMS-FENTANYL23PMS-FERROUS SULFATE
129PMS-FINASTERIDE7PMS-FLUCONAZOLE
90PMS-FLUOROMETHOLONE67PMS-FLUOXETINE71PMS-FLUPHENAZINE13PMS-FLUTAMIDE42PMS-FOSINOPRIL86PMS-FUROSEMIDE61PMS-GABAPENTIN16PMS-GALANTAMINE ER28PMS-GEMFIBROZIL89PMS-GENTAMICIN
111PMS-GLYBURIDE71PMS-HALOPERIDOL71PMS-HALOPERIDOL LA87PMS-HYDROCHLOROTHIAZIDE55PMS-HYDROMORPHONE79PMS-HYDROXYZINE
87PMS-INDAPAMIDE17PMS-IPRATROPIUM17PMS-IPRATROPIUM UDV46PMS-IRBESARTAN46PMS-IRBESARTAN/HCT33PMS-ISMN8PMS-ISONIAZID
33PMS-ISOSORBIDE51PMS-KETOPROFEN1PMS-KETOTIFEN
85PMS-LACTULOSE62PMS-LAMOTRIGINE
100PMS-LANSOPRAZOLE92PMS-LATANOPROST-TIMOLOL
132PMS-LEFLUNOMIDE14PMS-LETROZOLE62PMS-LEVETIRACETAM91PMS-LEVOBUNOLOL5PMS-LEVOFLOXACIN
120PMS-LIDOCAINE VISCOUS43PMS-LISINOPRIL79PMS-LITHIUM CARBONATE79PMS-LITHIUM CITRATE95PMS-LOPERAMIDE77PMS-LORAZEPAM47PMS-LOSARTAN47PMS-LOSARTAN-HCTZ29PMS-LOVASTATIN71PMS-LOXAPINE52PMS-MELOXICAM
109PMS-METFORMIN71PMS-METHOTRIMEPRAZINE76PMS-METHYLPHENIDATE
101PMS-METOCLOPRAMIDE37PMS-METOPROLOL-B37PMS-METOPROLOL-L6PMS-MINOCYCLINE
68PMS-MIRTAZAPINE99PMS-MISOPROSTOL68PMS-MOCLOBEMIDE
120PMS-MOMETASONE6PMS-MONOCYCLINE
88PMS-MONTELUKAST98PMS-NABILONE52PMS-NAPROXEN EC9PMS-NEVIRAPINE
39PMS-NIFEDIPINE99PMS-NIZATIDINE5PMS-NORFLOXACIN
68PMS-NORTRIPTYLINE7PMS-NYSTATIN
71PMS-OLANZAPINE ODT100PMS-OMEPRAZOLE100PMS-OMEPRAZOLE DR98PMS-ONDANSETRON
123PMS-OXYBUTYNIN57PMS-OXYCODONE
130PMS-PAMIDRONATE101PMS-PANTOPRAZOLE68PMS-PAROXETINE72PMS-PERPHENAZINE97PMS-PHOSPHATES SOLUTION37PMS-PINDOLOL
111PMS-PIOGLITAZONE
53PMS-PIROXICAM89PMS-POLYTRIMETHOPRIM86PMS-POTASSIUM81PMS-PRAMIPREXOLE30PMS-PRAVASTATIN
106PMS-PREDNISOLONE63PMS-PREGABALIN73PMS-PROCHLORPERAZINE17PMS-PROCYCLIDINE27PMS-PROPAFENONE38PMS-PROPRANOLOL8PMS-PYRAZINAMIDE
73PMS-QUETIAPINE101PMS-RABEPRAZOLE EC108PMS-RALOXIFENE44PMS-RAMIPRIL45PMS-RAMIPRIL-HCTZ99PMS-RANITIDINE
110PMS-REPAGLINIDE93PMS-RHINARIS
131PMS-RISEDRONATE74PMS-RISPERIDONE73PMS-RISPERIDONE ODT16PMS-RIVASTIGMINE79PMS-RIZATRIPTAN RDT82PMS-ROPINIROLE30PMS-ROSUVASTATIN19PMS-SALBUTAMOL96PMS-SENNOSIDES69PMS-SERTRALINE31PMS-SIMVASTATIN88PMS-SOD CROMOGLYCATE86PMS-SOD POLYSTYRENE SULF86PMS-SOD POLYSTYRENE
SULFONA95PMS-SODIUM DOCUSATE38PMS-SOTALOL6PMS-SULFASALAZINE
80PMS-SUMATRIPTAN15PMS-TAMOXIFEN48PMS-TELMISARTAN48PMS-TELMISARTAN-HCTZ34PMS-TERAZOSIN7PMS-TERBINAFINE
106PMS-TESTOSTERONE82PMS-TETRABENAZINE
123PMS-THEOPHYLLINE53PMS-TIAPROFENIC91PMS-TIMOLOL64PMS-TOPIRAMATE69PMS-TRAZODONE75PMS-TRIFLUOPERAZINE17PMS-TRIHEXYPHENIDYL97PMS-URSODIOL64PMS-VALPROIC ACID48PMS-VALSARTAN70PMS-VENLAFAXINE XR41PMS-VERAPAMIL SR80PMS-ZOLMITRIPTAN80PMS-ZOLMITRIPTAN ODT
134POCKET CHAMBER134POCKET CHAMBER WITH ADULT
MASK134POCKET CHAMBER WITH INFANT
MASK
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Page Page134POCKET CHAMBER WITH
MEDIUM MASK134POCKET CHAMBER WITH SMALL
MASK121PODOFILM121PODOFILOX
121PODOPHYLLIN
114POLISTES SPP VENOM PROTEIN
EXTRACT
114POLLEN
114POLLEN AND NON POLLEN
114POLLINEX R138POLYETHYLENE GLYCOL138POLYETHYLENE GLYCOL
96POLYETHYLENE GLYCOL &
ELECTROL
96POLYETHYLENE GLYCOL 3350
138POLYETHYLENE GLYCOL 3350 PWD
96POLYETHYLENE GLYCOL,
POTASSIUM CHLORIDE, SODIUM
BICARBONATE, SODIUM
CHLORIDE, SODIUM SULFATE
115POLYMYXIN B SULFATE,
BACITRACIN
89POLYMYXIN B SULFATE,
TRIMETHOPRIM SULFATE
89POLYSPORIN115POLYSPORIN ANTIBIOTIC89POLYSPORIN EYE/EAR
121POLYTAR115POLYTOPIC89POLYTRIM93POLYVINYL ALCOHOL
93POLYVINYL ALCOHOL,
POVIDONE
127POLY-VI-SOL107PORTIA (21)107PORTIA (28)86POTASSIUM CHLORIDE
117POVIDONE-IODINE
23PRADAXA81PRAMIPEXOLE81PRAMIPEXOLE
DIHYDROCHLORIDE
30PRAVACHOL30PRAVASTATIN30PRAVASTATIN SODIUM
30PRAVASTATIN-1030PRAVASTATIN-2030PRAVASTATIN-4050PRAXIS ASA EC34PRAZOSIN HCL
84PRECISION XTRA84PRECISION XTRA (ON)90PRED FORTE90PRED MILD90PREDNISOLONE90PREDNISOLONE ACETATE
90PREDNISOLONE ACETATE,
SULFACETAMIDE SODIUM
90PREDNISOLONE SODIUM
PHOSPHATE
106PREDNISONE
106PREDNISONE91PREFRIN LIQUIFILM
63PREGABALIN
63PREGABALIN63PREGABALIN-15063PREGABALIN-2563PREGABALIN-5063PREGABALIN-75
108PREMARIN108PREMPLUS127PRENATAL & POSTPARTUM127PRENATAL AND POSTPARTUM100PREVACID100PREVACID FASTAB120PREVEX117PREVEX B119PREVEX HC
8PREZISTA12PRIMAQUINE12PRIMAQUINE PHOSPHATE
59PRIMIDONE
43PRINIVIL43PRINZIDE85PRIVA CAL D FORTE86PRO-600K27PRO-AMIODARONE-2004PRO-AMOX
50PRO-ASA50PRO-ASA EC35PRO-ATENOLOL3PRO-AZITHROMYCINE
92PROBETA13PRO-BICALUTAMIDE36PRO-BISOPROLOL-1036PRO-BISOPROLOL-565PRO-BUPROPION SR27PROCAINAMIDE HCL
27PROCAN SR15PROCARBAZINE HCL
36PRO-CARVEDILOL2PRO-CEFADROXIL2PRO-CEFUROXIME
53PROCET-3073PROCHLORPERAZINE73PROCHLORPERAZINE
5PRO-CIPROFLOXACIN65PRO-CITALOPRAM3PRO-CLARITHROMYCIN
59PRO-CLONAZEPAM119PROCTODAN HC119PROCTOL119PROCTOSEDYL17PROCYCLIDINE HCL
13PROCYTOX105PRO-DEXAMETHASONE42PRO-ENALAPRIL28PRO-FENO-SUPER7PRO-FLUCONAZOLE
67PRO-FLUOXETINE61PRO-GABAPENTIN
111PRO-GLYBURIDE33PROGLYCEM
133PROGRAF87PRO-INDAPAMIDE51PRO-INDO33PRO-ISMN
62PRO-LEVETIRACETAM81PRO-LEVOCARB
130PROLIA43PRO-LISINOPRIL81PROLOPA77PRO-LORAZEPAM29PRO-LOVASTATIN
109PRO-METFORMIN68PRO-MIRTAZAPINE52PRO-NAPROXEN EC53PRO-OXYCOD ACET
117PROPADERM27PROPAFENONE27PROPAFENONE
HYDROCHLORIDE
111PRO-PIOGLITAZONE81PRO-PRAMIPEXOLE37PROPRANOLOL HCL
113PROPYL THYRACIL113PROPYLTHIOURACIL
73PRO-QUETIAPINE101PRO-RABEPRAZOLE44PRO-RAMIPRIL74PRO-RISPERIDONE
129PROSCAR38PRO-SOTALOL16PROSTIGMIN80PRO-SUMATRIPTAN
122PROTOPIC64PRO-TOPIRAMATE87PRO-TRIAZIDE6PROTRIN DF
11PRO-VALACYCLOVIR113PROVERA113PROVERA PAK41PRO-VERAPAMIL SR67PROZAC96PSYLLIUM HYDROPHILIC
MUCILLOID
105PULMICORT NEBUAMP105PULMICORT TURBUHALER123PULMOPHYLLIN95PURG-ODAN14PURINETHOL2PYRANTEL PAMOATE
8PYRAZINAMIDE
16PYRIDOSTIGMINE BROMIDE
125PYRIDOXINE HCL
12PYRIMETHAMINE
73QUETIAPINE73QUETIAPINE FUMARATE
44QUINAPRIL HCL
44QUINAPRIL HCL,
HYDROCHLOROTHIAZIDE
105QVAR116R & C101RABEPRAZOLE101RABEPRAZOLE SODIUM
108RALOXIFENE HCL
9RALTEGRAVIR
44RAMIPRIL
44RAMIPRIL45RAMIPRIL,
HYDROCHLOROTHIAZIDE
44RAMIPRIL-10
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Page Page44RAMIPRIL-2.544RAMIPRIL-5
129RAN-ALENDRONATE38RAN-AMLODIPINE13RAN-ANASTROZOLE35RAN-ATENOLOL28RAN-ATORVASTATIN13RAN-BICALUTAMIDE45RAN-CANDESARTAN36RAN-CARVEDILOL2RAN-CEFPROZIL5RAN-CIPROFLOX
66RAN-CITALO3RAN-CLARITHROMYCIN
25RAN-CLOPIDOGREL101RAN-DOMPERIDONE42RAN-ENALAPRIL54RAN-FENTANYL
129RAN-FINASTERIDE67RAN-FLUOXETINE42RAN-FOSINOPRIL61RAN-GABAPENTIN93RANIBIZUMAB
46RAN-IRBESARTAN46RAN-IRBESARTAN HCTZ99RANITIDINE99RANITIDINE HCL
100RAN-LANSOPRAZOLE14RAN-LETROZOLE62RAN-LEVETIRACETAM43RAN-LISINOPRIL47RAN-LOSARTAN
109RAN-METFORMIN88RAN-MONTELUKAST98RAN-NABILONE72RAN-OLANZAPINE
100RAN-OMEPRAZOLE101RAN-PANTOPRAZOLE111RAN-PIOGLITAZONE30RAN-PRAVASTATIN63RAN-PREGABALIN73RAN-QUETIAPINE
101RAN-RABEPRAZOLE44RAN-RAMIPRIL99RAN-RANITIDINE74RAN-RISPERIDONE82RAN-ROPINIROLE30RAN-ROSUVASTATIN69RAN-SERTRALINE31RAN-SIMVASTATIN64RAN-TOPIRAMATE48RAN-VALSARTAN70RAN-VENLAFAXINE XR
132RAPAMUNE4RATIO-ACLAVULANATE
10RATIO-ACYCLOVIR130RATIO-ALENDRONATE117RATIO-AMCINONIDE27RATIO-AMIODARONE38RATIO-AMLODIPINE35RATIO-ATENOLOL28RATIO-ATORVASTATIN3RATIO-AZITHROMYCIN
20RATIO-BACLOFEN
95RATIO-BISACODYL91RATIO-BRIMONIDINE65RATIO-BUPROPION36RATIO-CARVEDILOL2RATIO-CEFUROXIME5RATIO-CIPROFLOXACIN3RATIO-CLARITHROMYCIN
118RATIO-CLOBETASOL54RATIO-CODEINE20RATIO-CYCLOBENZAPRINE
105RATIO-DEXAMETHASONE40RATIO-DILTIAZEM CD95RATIO-DOCUSATE CALCIUM95RATIO-DOCUSATE SODIUM
101RATIO-DOMPERIDONE117RATIO-ECTOSONE53RATIO-EMTEC-3042RATIO-ENALAPRIL28RATIO-FENOFIBRATE
129RATIO-FINASTERIDE90RATIO-FLUTICASONE67RATIO-FLUVOXAMINE61RATIO-GABAPENTIN
111RATIO-GLYBURIDE119RATIO-HEMCORT HC51RATIO-INDOMETHACIN18RATIO-IPRA SAL17RATIO-IPRATROPIUM UDV46RATIO-IRBESARTAN46RATIO-IRBESARTAN HCTZ85RATIO-LACTULOSE53RATIO-LENOLTEC NO.253RATIO-LENOLTEC NO.391RATIO-LEVOBUNOLOL43RATIO-LISINOPRIL P43RATIO-LISINOPRIL Z85RATIO-MAGNESIUM52RATIO-MELOXICAM
109RATIO-METFORMIN15RATIO-METHOTREXATE6RATIO-MINOCYCLINE
68RATIO-MIRTAZAPINE120RATIO-MOMETASONE56RATIO-MORPHINE57RATIO-MORPHINE SULFATE SR7RATIO-NYSTATIN
100RATIO-OMEPRAZOLE98RATIO-ONDANSETRON53RATIO-OXYCOCET54RATIO-OXYCODAN
111RATIO-PIOGLITAZONE30RATIO-PRAVASTATIN90RATIO-PREDNISOLONE
119RATIO-PROCTOSONE44RATIO-RAMIPRIL99RATIO-RANITIDINE74RATIO-RISPERIDONE16RATIO-RIVASTIGMINE19RATIO-SALBUTAMOL33RATIO-SILDENAFIL R31RATIO-SIMVASTATIN38RATIO-SOTALOL20RATIO-TAMSULOSIN78RATIO-TEMAZEPAM
34RATIO-TERAZOSIN117RATIO-TOPILENE GLYCOL117RATIO-TOPISALIC117RATIO-TOPISONE69RATIO-TRAZODONE1REACTINE
93REFRESH LIQUIGEL93REFRESH PLUS93REFRESH TEARS68REMERON67REMERON RD
132REMICADE128RENAGEL110REPAGLINIDE
17REQUIP134RESERVOIR 5XX 1.8ML SYRINGE134RESERVOIR 7XX 3.0ML SYRINGE86RESONIUM CALCIUM78RESTORIL
116RESULTZ120RETIN A10RETROVIR33REVATIO8REYATAZ
93RHINARIS89RHINOCORT AQ90RHINOCORT TURBUHALER33RHO-NITRO PUMPSPRAY25RHOXAL-ANAGRELIDE5RHOXAL-CIPROFLOXACIN
68RHOXAL-MIRTAZAPINE130RHOXAL-PAMIDRONATE30RHOXAL-PRAVASTATIN31RHOXAL-SIMVASTATIN38RHOXAL-SOTALOL
103RIDAURA8RIFABUTIN
8RIFADIN8RIFAMPIN
9RILPIVIRINE HYDROCHLORIDE
131RISEDRONATE130RISEDRONATE SODIUM
131RISEDRONATE-3574RISPERDAL73RISPERDAL-M73RISPERIDONE
74RISPERIDONE9RITONAVIR
15RITUXAN15RITUXIMAB
25RIVA CLOPIDOGREL130RIVA-ALENDRONATE27RIVA-AMIODARONE38RIVA-AMLODIPINE13RIVA-ANASTROZOLE35RIVA-ATENOLOL20RIVA-BACLOFEN5RIVA-CIPROFLOXACIN
66RIVA-CITALOPRAM3RIVA-CLARITHROMYCIN
59RIVA-CLONAZEPAM53RIVACOCET20RIVA-CYCLOBENZAPRINE13RIVA-CYPROTERONE
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Page Page126RIVA-D42RIVA-ENALAPRIL28RIVA-FENOFIBRATE MICRO7RIVA-FLUCONAZOLE
67RIVA-FLUOXETINE67RIVA-FLUVOX42RIVA-FOSINOPRIL61RIVA-GABAPENTIN28RIVA-GEMFIBROZIL
111RIVA-GLYBURIDE79RIVA-HYDROXYZIN87RIVA-INDAPAMIDE86RIVA-K86RIVA-K 2043RIVA-LISINOPRIL95RIVA-LOPERAMIDE29RIVA-LOVASTATIN
109RIVA-METFORMIN37RIVA-METOPROLOL L6RIVA-MINOCYCLINE
68RIVA-MIRTAZAPINE52RIVA-NAPROXEN52RIVA-NAPROXEN SODIUM89RIVANASE AQ72RIVA-OLANZAPINE
123RIVA-OXYBUTYNIN101RIVA-PANTOPRAZOLE68RIVA-PAROXETINE30RIVA-PRAVASTATIN63RIVA-PREGABALIN73RIVA-QUETIAPINE
101RIVA-RABEPRAZOLE EC99RIVA-RANITIDINE99RIVA-RANTIDINE
131RIVA-RISEDRONATE74RIVA-RISPERIDONE30RIVA-ROSUVASTATIN24RIVAROXABAN
24RIVAROXABAN (10)
50RIVASA96RIVA-SENNA69RIVA-SERTRALINE31RIVA-SIMVASTATIN
119RIVASOL-HC118RIVASONE38RIVA-SOTALOL16RIVASTIGMINE
11RIVA-VALACYCLOVIR41RIVA-VERAPAMIL SR87RIVA-ZIDE80RIVA-ZOLMITRIPTAN59RIVOTRIL79RIZATRIPTAN
126ROCALTROL8ROFACT
117ROLENE82ROPINIROLE17ROPINIROLE HCL
116ROSASOL112ROSIGLITAZONE MALEATE
117ROSONE30ROSUVASTATIN30ROSUVASTATIN CALCIUM
30ROSUVASTATIN-10
31ROSUVASTATIN-2031ROSUVASTATIN-4030ROSUVASTATIN-564RUFINAMIDE
27RYTHMODAN27RYTHMOL
119SAB-ANUZINC HC119SAB-ANUZINC HC PLUS51SAB-INDOMETHACIN
119SAB-PROCTOMYXIN HC65SABRIL16SALAGEN6SALAZOPYRIN
19SALBUTAMOL
121SALICYLIC ACID
94SALINEX94SALINEX DROPS19SALMETEROL XINAFOATE
19SALMETEROL XINAFOATE,
FLUTICASONE PROPIONATE
101SALOFALK81SANDOMIGRAN81SANDOMIGRAN DS
112SANDOSTATIN112SANDOSTATIN LAR129SANDOZ ALENDRONATE20SANDOZ ALFUZOSIN79SANDOZ ALMOTRIPTAN13SANDOZ ANASTROZOLE28SANDOZ ATORVASTATIN34SANDOZ BOSENTAN91SANDOZ BRIMONIDINE 0.2% OP
SOL45SANDOZ CANDESARTAN46SANDOZ CANDESARTAN PLUS2SANDOZ CEFPROZIL
89SANDOZ CIPROFLOXACIN25SANDOZ CLOPIDOGREL51SANDOZ DICLO/MISOPROS92SANDOZ DORZOLAMIDE92SANDOZ DORZOLAMIDE/TIMOLOL42SANDOZ ENALAPRIL81SANDOZ ENTACAPONE28SANDOZ FENOFIBRATE E28SANDOZ FENOFIBRATE S54SANDOZ FENTANYL
129SANDOZ FINASTERIDE90SANDOZ FLUOROMETHOLONE29SANDOZ FLUVASTATIN46SANDOZ IRBESARTAN46SANDOZ IRBESARTAN HCTZ
100SANDOZ LANSOPRAZOLE92SANDOZ LATANOPROST92SANDOZ
LATANOPROST/TIMOLOL132SANDOZ LEFLUNOMIDE14SANDOZ LETROZOLE5SANDOZ LEVOFLOXACIN
43SANDOZ LISINOPRIL43SANDOZ LISINOPRIL HCT47SANDOZ LOSARTAN47SANDOZ LOSARTAN HCT37SANDOZ METOPROLOL (L)88SANDOZ MONTELUKAST
132SANDOZ MYCOPHENOLATE
79SANDOZ NARATRIPTAN89SANDOZ OFLOXACIN71SANDOZ OLANZAPINE ODT89SANDOZ OLOPATADINE
100SANDOZ OMEPRAZOLE53SANDOZ OXYCOD ACET
111SANDOZ PIOGLITAZONE89SANDOZ POLYTRIMETHOPRIM63SANDOZ PREGABALIN73SANDOZ QUETIAPINE XRT44SANDOZ RAMIPRIL
110SANDOZ REPAGLINIDE131SANDOZ RISEDRONATE16SANDOZ RIVASTIGMINE79SANDOZ RIZATRIPTAN ODT30SANDOZ ROSUVASTATIN20SANDOZ TAMSULOSIN48SANDOZ TELMISARTAN48SANDOZ TELMISARTAN HCT48SANDOZ VALSARTAN49SANDOZ VALSARTAN HCT80SANDOZ ZOLMITRIPTAN80SANDOZ ZOLMITRIPTAN ODT35SANDOZ-ACEBUTOLOL27SANDOZ-AMIODARONE38SANDOZ-AMLODIPINE
119SANDOZ-ANUZINC HC35SANDOZ-ATENOLOL3SANDOZ-AZITHROMYCIN
91SANDOZ-BETAXOLOL13SANDOZ-BICALUTAMIDE36SANDOZ-BISOPROLOL65SANDOZ-BUPROPION SR60SANDOZ-CARBAMAZEPINE5SANDOZ-CIPROFLOXACIN
66SANDOZ-CITALOPRAM59SANDOZ-CLONAZEPAM
132SANDOZ-CYCLOSPORINE90SANDOZ-DEXAMETHASONE51SANDOZ-DICLOFENAC50SANDOZ-DICLOFENAC SR40SANDOZ-DILTIAZEM CD40SANDOZ-DILTIAZEM T
108SANDOZ-ESTRADIOL DERM11SANDOZ-FAMCICLOVIR39SANDOZ-FELODIPINE67SANDOZ-FLUOXETINE67SANDOZ-FLUVOXAMINE
111SANDOZ-GLYBURIDE91SANDOZ-LEVOBUNOLOL43SANDOZ-LISINOPRIL95SANDOZ-LOPERAMIDE29SANDOZ-LOVASTATIN
109SANDOZ-METFORMIN109SANDOZ-METFORMIN FC76SANDOZ-METHYLPHENIDATE SR
20MG37SANDOZ-METOPROLOL SR6SANDOZ-MINOCYCLINE
68SANDOZ-MIRTAZAPINE78SANDOZ-NITRAZEPAM72SANDOZ-OLANZAPINE98SANDOZ-ONDANSETRON
101SANDOZ-PANTOPRAZOLE
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Non-Insured Health BenefitsHealth Canada
Page Page68SANDOZ-PAROXETINE37SANDOZ-PINDOLOL81SANDOZ-PRAMIPEXOLE90SANDOZ-PREDNISOLONE
119SANDOZ-PROCTOMYXIN HC101SANDOZ-RABEPRAZOLE99SANDOZ-RANITIDINE74SANDOZ-RISPERIDONE19SANDOZ-SALBUTAMOL69SANDOZ-SERTRALINE31SANDOZ-SIMVASTATIN38SANDOZ-SOTALOL80SANDOZ-SUMATRIPTAN7SANDOZ-TERBINAFINE
89SANDOZ-TOBRAMYCIN64SANDOZ-TOPIRAMATE64SANDOZ-VALPROIC
122SANTYL70SAPHRIS9SAQUINAVIR MESYLATE
119SARNA HC109SAXAGLIPTIN HCL
2SCHEIN-CEFACLOR18SCOPOLAMINE BUTYLBROMIDE
107SEASONALE107SEASONIQUE121SEBCUR121SEBCUR-T93SECARIS35SECTRAL95SELAX
107SELECT 1/35 (21)107SELECT 1/35 (28)82SELEGILINE HCL
117SELENIUM SULFIDE
4SELEXID117SELSUN96SENNA LAXATIVE96SENNALAX96SENNAPREP96SENNATAB96SENNOSIDES
96SENOKOT95SENOKOT S38SEPTA-AMLODIPINE35SEPTA-ATENOLOL5SEPTA-CIPROFLOXACIN
66SEPTA-CITALOPRAM109SEPTA-METFORMIN98SEPTA-ONDANSETRON82SERC19SEREVENT DISKHALER19SEREVENT DISKUS73SEROQUEL73SEROQUEL XR69SERTRALINE
69SERTRALINE69SERTRALINE-10069SERTRALINE-2569SERTRALINE-50
128SEVELAMER HYDROCHLORIDE
136SHARPS CONTAINER
97SIALOR42SIG-ENALAPRIL
33SILDENAFIL CITRATE
117SILVER SULFADIAZINE
131SIMPONI131SIMPONI PRE-FILLED31SIMVASTATIN31SIMVASTATIN
31SIMVASTATIN-1032SIMVASTATIN-2032SIMVASTATIN-4031SIMVASTATIN-ODAN81SINEMET81SINEMET CR66SINEQUAN88SINGULAIR24SINTROM
132SIROLIMUS
109SITAGLIPTIN
109SITAGLIPTIN, METFORMIN
86SLOW-K103SODIUM AUROTHIOMALATE
103SODIUM AUROTHIOMALATE85SODIUM BICARBONATE
85SODIUM BICARBONATE93SODIUM CARBOXYMETHYL
CELLULOSE
86SODIUM CHLORIDE86SODIUM CHLORIDE
96SODIUM CITRATE, SODIUM
LAURYL SULFOACETATE,
SORBITOL
88SODIUM CROMOGLYCATE
84SODIUM NITROPRUSSIDE
128SODIUM PHOSPHATE
97SODIUM PHOSPHATE DIBASIC,
SODIUM PHOSPHATE
MONOBASIC
86SODIUM POLYSTYRENE
SULFONATE
95SOFLAX95SOFLAX EX95SOFLAX SYRUP90SOFRACORT EYE/EAR89SOFRAMYCIN89SOFRAMYCIN STERILE EYE
135SOFT TOUCH135SOFTCLIX135SOFTCLIX SELECT123SOLIFENACIN SUCCINATE
85SOLUCAL85SOLUCAL D85SOLUCAL D CITRUS85SOLUCAL D RASPBERRY85SOLUCAL GREEN APPLE85SOLUCAL RASPBERRY
116SOLUGEL121SOLUVER121SOLUVER PLUS112SOMATULINE AUTOGEL121SORIATANE38SOTALOL38SOTALOL HCL
134SPACER DEVICE
18SPIRIVA49SPIRONOLACTONE
87SPIRONOLACTONE,
HYDROCHLOROTHIAZIDE
7SPORANOX81STALEVO
116STANHEXIDINE110STARLIX56STATEX10STAVUDINE
128STELARA121STEREX106STERILE TRIAMCINOLONE128STERILE WATER87STERILE WATER FOR INJ
120STIEVA-A120STIEVA-A FORTE115STIEVAMYCIN115STIEVAMYCIN FORTE115STIEVAMYCIN MILD96STOOL SOFTENER8STRIBILD
58SUBOXONE58SUBOXONE MAINTENANCE99SUCRALFATE
99SUCRALFATE-199SULCRATE99SULCRATE PLUS89SULFACETAMIDE SODIUM
6SULFAMETHOXAZOLE
6SULFAMETHOXAZOLE,
TRIMETHOPRIM
6SULFASALAZINE
87SULFINPYRAZONE
53SULINDAC
80SUMATRIPTAN80SUMATRIPTAN DF80SUMATRIPTAN HEMISULFATE
80SUMATRIPTAN SUCCINATE
15SUNITINIB MALATE
135SUPER-FINE MICRO 31G-5MM NEEDL
135SUPER-FINE STANDARD 29G-12.7MM
136SUPER-FINE XTRA 31G-8MM NEEDLE
57SUPEUDOL2SUPRAX
13SUPREFACT13SUPREFACT DEPOT 2 MONTHS13SUPREFACT DEPOT 3 MONTHS8SUSTIVA
15SUTENT18SYMBICORT 100 TURBUHALER18SYMBICORT 200 TURBUHALER
118SYNALAR108SYNAREL107SYNPHASIC (21)107SYNPHASIC (28)113SYNTHROID136SYRINGE
137SYRINGE & NEEDLE
134SYRINGE & NEEDLE (NON-
INSULIN)
134SYRINGE (NON-INSULIN)
137SYRINGE CASE
135SYRINGE SCALE MAGNIFIER
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Non-Insured Health BenefitsHealth Canada
Page Page137SYRINGE WITH NEEDLE
137SYRN INS U-II 3/10CC 30G137SYRN INSULIN MICRO 3/10CC
28G137SYRN INSULIN U-II 30G137SYRN INSULIN ULTRA 29G137SYRN INSULIN ULTRA 3/10CC 29G136SYRN MONOJECT133TACROLIMUS
122TACROLIMUS (PROTOPIC)
33TADALAFIL
27TAMBOCOR15TAMOXIFEN CITRATE
20TAMSULOSIN HCL
59TANTAPHEN58TANTAPHEN GRAPE
113TAPAZOLE7TAR0-FLUCONAZOLE
13TARCEVA121TARGEL121TARGEL SA117TARO-AMCINONIDE13TARO-ANASTROZOLE60TARO-CARBAMAZEPINE60TARO-CARBAMAZEPINE CR5TARO-CIPROFLOXACIN
115TARO-CLINDAMYCIN42TARO-ENALAPRIL7TARO-FLUCONAZOLE
119TARO-MOMETASONE115TARO-MUPIROCIN 2% OINTMENT60TARO-PHENYTOIN31TARO-SIMVASTATIN
117TARO-SONE80TARO-SUMATRIPTAN
116TARO-TERCONAZOLE25TARO-WARFARIN
122TAZAROTENE
122TAZORAC92TEARS NATURALE92TEARS NATURALE FREE92TEARS NATURALE II93TEARS NATURALE P.M.93TEARS PLUS8TEBRAZID
101TECTA60TEGRETOL60TEGRETOL CR12TELAPREVIR
48TELMISARTAN48TELMISARTAN
48TELMISARTAN HCTZ48TELMISARTAN,
HYDROCHLOROTHIAZIDE
48TELMISARTAN/HCTZ9TELZIR
78TEMAZEPAM78TEMAZEPAM
15TEMODAL15TEMOZOLOMIDE
58TEMPRA58TEMPRA DOUBLE STRENGTH10TENOFOVIR DISOPROXIL
FUMARATE
36TENORETIC
35TENORMIN116TERAZOL 3116TERAZOL 3 DUAL PAK116TERAZOL 734TERAZOSIN34TERAZOSIN HCL
7TERBINAFINE7TERBINAFINE HCL
7TERBINAFINE-25019TERBUTALINE SULFATE
116TERCONAZOLE
117TERSASEPTIC121TERSA-TAR121TERSA-TAR MILD106TESTOSTERONE CYPIONATE106TESTOSTERONE CYPIONATE
106TESTOSTERONE ENANTHATE
106TESTOSTERONE UNDECANOATE
82TETRABENAZINE
6TETRACYCLINE6TETRACYCLINE HCL
88TEVA- MONTELUKAST130TEVA-ALENDRONATE
CHOLECALCIFEROL20TEVA-ALFUZOSIN PR38TEVA-AMLODIPINE13TEVA-ANASTROZOLE45TEVA-CANDESARTAN46TEVA-CANDESARTAN/HCTZ13TEVA-CAPECITABINE65TEVA-CITALOPRAM3TEVA-CLARITHROMYCIN
25TEVA-CLOPIDOGREL92TEVA-DORZOTIMOL8TEVA-EFAVIRENZ
81TEVA-ENTACAPONE54TEVA-FENTANYL
129TEVA-FINASTERIDE29TEVA-FLUVASTATIN16TEVA-GALANTAMINE ER
111TEVA-GLICLAZIDE55TEVA-HYDROMORPHONE14TEVA-IMATINIB46TEVA-IRBESARTAN46TEVA-IRBESARTAN/HCTZ85TEVA-LACTULOSE9TEVA-LAMIVUDINE/ZIDOVUDINE
100TEVA-LANSOPRAZOLE92TEVA-LATANOPROST/TIMOLOL
132TEVA-LEFLUNOMIDE14TEVA-LETROZOLE47TEVA-LOSARTAN47TEVA-LOSARTAN HCTZ75TEVA-METHYLPHENIDATE ER
18MG76TEVA-METHYLPHENIDATE ER
27MG76TEVA-METHYLPHENIDATE ER
36MG76TEVA-METHYLPHENIDATE ER
54MG57TEVA-MORPHINE SR 100MG TAB57TEVA-MORPHINE SR 15MG TAB57TEVA-MORPHINE SR 200MG TAB57TEVA-MORPHINE SR 30MG TAB
57TEVA-MORPHINE SR 60MG TAB132TEVA-MYCOPHENOLATE98TEVA-NABILONE79TEVA-NARATRIPTAN9TEVA-NEVIRAPINE
71TEVA-OLANZAPINE OD100TEVA-OMEPRAZOLE101TEVA-PANTOPRAZOLE63TEVA-PREGABALIN73TEVA-QUETIAPINE XR
108TEVA-RALOXIFENE45TEVA-RAMIPRIL/HCTZ
130TEVA-RISEDRONATE30TEVA-ROSUVASTATIN48TEVA-TELMISARTAN48TEVA-TELMISARTAN HCTZ48TEVA-VALSARTAN49TEVA-VALSARTAN/HCTZ80TEVA-ZOLMITRIPTAN80TEVA-ZOLMITRIPTAN OD46TEVETEN46TEVETEN PLUS
123THEO ER123THEOLAIR123THEOPHYLLINE
123THEOPHYLLINE113THIAMAZOLE
125THIAMINE128THIAMINE
125THIAMINE HCL
15THIOGUANINE
75THIOPROPERAZINE MESYLATE
75THIOTHIXENE
21THRIVE84THYROGEN
113THYROID113THYROID
84THYROTROPIN ALFA
118TIAMOL53TIAPROFENIC ACID
40TIAZAC40TIAZAC XC25TICLOPIDINE25TICLOPIDINE HCL
38TIMOLOL38TIMOLOL MALEATE
92TIMOLOL MALEATE,
TRAVOPROST
91TIMOLOL MALEATE-EX92TIMOPTIC91TIMOPTIC-XE
116TINACTIN116TINACTIN AEROSOL24TINZAPARIN SODIUM
18TIOTROPIUM BROMIDE
MONOHYDRATE
10TIPRANAVIR
20TIZANIDINE HCL
90TOBRADEX89TOBRAMYCIN
89TOBREX132TOCILIZUMAB
111TOLBUTAMIDE
116TOLNAFTATE
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Non-Insured Health BenefitsHealth Canada
Page Page27TOLOXIN
123TOLTERODINE
64TOPAMAX64TOPAMAX SPRINKLE
118TOPICORT64TOPIRAMATE
64TOPIRAMATE118TOPSYN127TR- VI-SOL34TRACLEER
109TRAJENTA36TRANDATE45TRANDOLAPRIL
26TRANEXAMIC ACID
26TRANEXAMIC ACID21TRANSDERMAL NICOTINE33TRANSDERM-NITRO69TRANYLCYPROMINE SULFATE
92TRAVATAN Z98TRAVEL AID92TRAVOPROST
69TRAZODONE69TRAZODONE HCL
69TRAZOREL15TRELSTAR15TRELSTAR LA15TRETINOIN
106TRIAMCINOLONE90TRIAMCINOLONE ACETONIDE
106TRIAMCINOLONE ACETONIDE (5ML)
106TRIAMCINOLONE DIACETATE
106TRIAMCINOLONE
HEXACETONIDE
87TRIAMTERENE,
HYDROCHLOROTHIAZIDE
53TRIATEC-3079TRIAZOLAM
117TRICLOSAN
107TRI-CYCLEN (21)107TRI-CYCLEN (28)107TRI-CYCLEN LO (21)107TRI-CYCLEN LO (28)118TRIDESILON75TRIFLUOPERAZINE HCL
89TRIFLURIDINE
17TRIHEXYPHENIDYL HCL
12TRIKACIDE12TRIMETHOPRIM
70TRIMIPRAMINE MALEATE
33TRINIPATCH15TRIPTORELIN PAMOATE
107TRIQUILAR (21)107TRIQUILAR (28)
8TRIZIVIR123TROSEC123TROSPIUM CHLORIDE
84TRUETEST84TRUETRACK (ON)92TRUSOPT8TRUVADA
134TUBING19TWINJECT39TWYNSTA
58TYLENOL59TYLENOL EXTRA STRENGTH58TYLENOL GRAPE58TYLENOL JR STRENGTH
FASTMELTS58TYLENOL JUNIOR STRENGTH53TYLENOL WITH CODEINE NO.253TYLENOL WITH CODEINE NO.399ULCIDINE
129ULORIC135ULTI 29GX1/2 INC SHARP
CONTAIN136ULTI 31GX1/4 INC SHARP
CONTAIN136ULTI 31GX5/16 INC SHARP
CONTAI136ULTI SYG WITH ULTIG 29G 1/2 IN136ULTI SYG WITH ULTIG 30G 1/2 IN136ULTI SYG WITH ULTIG 30G 5/16 I137ULTI SYG WITH ULTIG 31G 5/16 I137ULTICARE 0.3CC 31G SYG 5/16 IN136ULTICARE 0.5CC 28G SYG 1/2 INC137ULTICARE 0.5CC 31G SYG 5/16 IN136ULTICARE 1CC 28G SYG 1/2 INCH137ULTICARE 1CC 31G SYG 5/16
INCH136ULTICARE 29G136ULTICARE 30G136ULTICARE INSULIN SYR 29G 1CC136ULTICARE INSULIN SYR 29G.3CC136ULTICARE INSULIN SYR 29G.5CC137ULTICARE INSULIN SYR 30G.1CC137ULTICARE INSULIN SYR 30G.3CC137ULTICARE INSULIN SYR30G.5CC136ULTICARE LOW DEAD SPACE
SYG136ULTICARE PEN NEEDLE
32GX4MM136ULTIGUARD INSULIN SYR
29G.1CC136ULTIGUARD INSULIN SYR
29G.3CC136ULTIGUARD INSULIN SYR
29G.5CC137ULTIGUARD INSULIN SYR
30G.1CC137ULTIGUARD INSULIN SYR
30G.3CC137ULTIGUARD INSULIN SYR
30G.5CC136ULTRA-FINE135ULTRA-FINE II136ULTRA-FINE II 30G135ULTRAFINE PEN ULTRA-FINE 29G97ULTRASE MS 497ULTRASE MT 1297ULTRASE MT 20
118ULTRAVATE135UNILET COMFORT TOUCH123UNIPHYL119UREMOL HC123URISPAS97URSO97URSO DS97URSODIOL
128USTEKINUMAB
108VAGIFEM
11VALACYCLOVIR HCL
11VALCYTE11VALGANCICLOVIR HCL
118VALISONE77VALIUM64VALPROATE, SODIUM
64VALPROIC ACID
48VALSARTAN48VALSARTAN
49VALSARTAN HCT49VALSARTAN,
HYDROCHLOROTHIAZIDE
49VALSARTAN-HCTZ11VALTREX22VARENICLINE
42VASERETIC42VASOTEC70VENLAFAXINE HCL
70VENLAFAXINE XR23VENOFER
114VENOMIL HONEY BEE VENOM114VENOMIL MIXED VESPID VENOM
PROTEIN114VENOMIL WASP VENOM PROTEIN114VENOMIL WHITE FACED HORNET
VENOM PROTEIN114VENOMIL YELLOW JACKET
VENOM PROTEIN19VENTOLIN19VENTOLIN HFA19VENTOLIN PF13VEPESID41VERAPAMIL41VERAPAMIL HCL
2VERMOX117VERSEL94VERTEPORFIN
15VESANOID123VESICARE114VESPULA SPP VENOM PROTEIN
EXTRACT
7VFEND11VICTRELIS11VICTRELIS TRIPLE8VIDEX EC
65VIGABATRIN
62VIMPAT15VINCRISTINE SULFATE15VINCRISTINE SULFATE
97VIOKASE9VIRACEPT9VIRAMUNE
10VIREAD89VIROPTIC
113VISANNE37VISKAZIDE37VISKEN94VISUDYNE
125VIT A125VIT B12125VIT C125VITAMIN A125VITAMIN A
120VITAMIN A ACID
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Non-Insured Health BenefitsHealth Canada
Page Page127VITAMIN A, CHOLECALCIFEROL,
ASCORBIC ACID
125VITAMIN B1125VITAMIN B12125VITAMIN B3125VITAMIN B6125VITAMIN C126VITAMIN D126VITAMIN D
122VITAMIN E122VITAMIN E
34VOLIBRIS50VOLTAREN51VOLTAREN SR7VORICONAZOLE
75VYVANSE 20MG CAP75VYVANSE 30MG CAP75VYVANSE 40MG CAP75VYVANSE 50MG CAP75VYVANSE 60MG CAP85WAMPOLE MINERAL CALCIUM25WARFARIN25WARFARIN SODIUM
114WASP VENOM PROTEIN114WASP VENOM PROTEIN
87WATER
128WATER FOR INJECTION128WATER STERILE134WEBCOL ALCOHOL PREP65WELLBUTRIN SR65WELLBUTRIN XL
114WHITE FACED HORNET VENOM114WHITE FACED HORNET VENOM
PROTEIN
114WHITE FACED HORNET VENOM
PROTEIN, YELLOW HORNET
VENOM PROTEIN, YELLOW
JACKET VENOM PROTEIN
106WINPRED92XALACOM92XALATAN76XANAX76XANAX TS24XARELTO20XATRAL13XELODA
133XEOMIN120XYLOCAINE VISCOUS106YASMIN (21)106YASMIN (28)106YAZ114YELLOW HORNET VENOM
PROTEIN114YELLOW HORNET VENOM
PROTEIN
114YELLOW JACKET HORNET VENOM PROTEIN
114YELLOW JACKET VENOM PROTEIN
114YELLOW JACKET VENOM
PROTEIN
1ZADITEN88ZAFIRLUKAST
106ZAMINE (21)106ZAMINE (28)20ZANAFLEX
99ZANTAC78ZAPEX
106ZARAH (21)106ZARAH (28)60ZARONTIN87ZAROXOLYN
116ZEASORB AF75ZELDOX18ZENHALE10ZERIT43ZESTORETIC43ZESTRIL8ZIAGEN
10ZIDOVUDINE
120ZINC120ZINC OXIDE
120ZINCOFAX EXTRA STRENGTH75ZIPRASIDONE
3ZITHROMAX31ZOCOR
122ZODERM98ZOFRAN98ZOFRAN ODT14ZOLADEX14ZOLADEX LA
131ZOLEDRONIC ACID
80ZOLMITRIPTAN
80ZOLMITRIPTAN80ZOLMITRIPTAN ODT69ZOLOFT80ZOMIG80ZOMIG RAPIMELT
122ZOSTRIX10ZOVIRAX65ZYBAN
129ZYLOPRIM130ZYM-ALENDRONATE FC38ZYM-AMLODIPINE36ZYM-CARVEDILOL59ZYM-CLONAZEPAM67ZYM-FLUOXETINE68ZYM-MIRTAZAPINE98ZYM-ONDANSETRON
111ZYM-PIOGLITAZONE30ZYM-PRAVASTATIN31ZYM-SIMVASTATIN64ZYM-TOPIRAMATE72ZYPREXA71ZYPREXA ZYDIS7ZYVOXAM
Page I-24 of 242014