NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY

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1 NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY FORMULAIRE DU PLAN DE MÉDICAMENTS SUR ORDONNANCE DU NOUVEAU-BRUNSWICK FEBRUARY 2014 FÉVRIER 2014

2 NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY Copyright HM The Queen in Right of The Province of New Brunswick as represented by The Honourable Hugh J. Flemming, Q.C. Minister of Health ADMINISTERED BY MEDAVIE BLUE CROSS ON BEHALF OF THE GOVERNMENT OF NEW BRUNSWICK

3 TABLE OF CONTENTS Page Introduction New Brunswick Prescription Drug Program Plans Exclusions Drug Review Process ACDR Drug Requirements Legend Comment Sheet I II - III IV - V VI VII VIII IX Anatomical Therapeutic Chemical Classification of Drugs A Alimentary Tract and Metabolism 1 B Blood and Blood Forming Organs 18 C Cardiovascular System 26 D Dermatologicals 67 G Genito Urinary System and Sex Hormones 79 H Systemic Hormonal Preparations, Excluding Sex Hormones 88 J Antiinfectives for Systemic Use 94 L Antineoplastic and Immunomodulating Agents 118 M Musculo-Skeletal System 126 N Nervous System 135 P Antiparasitic Products, Insecticides and Repellants 182 R Respiratory System 184 S Sensory Organs 192 V Various 201 Appendices I-A Abbreviations of Dosage Forms A-1 - A-4 I-B Abbreviations of Routes A-5 - A-6 I-C Abbreviations of Units A-7 - A-8 I-D Abbreviations of Manufacturers' Names A-9 - A-10 II Placebos A-11 III Extemporaneous Preparations A-12 IV Special Authorization A-13 - A-14 IV Special Authorization Drug Criteria A-15

4 NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY Introduction The New Brunswick Prescription Drug Program (NBPDP) provides prescription drug coverage to eligible New Brunswick residents (see pages II and III). The New Brunswick Prescription Drug Program (NBPDP) Formulary is a list of the drugs which are eligible benefits under the Program. All drugs considered for listing as benefits must be reviewed according to the drug review process. Most drugs listed in the NBPDP Formulary are regular benefits which are reimbursed with no criteria or prior approval requirements. Some drugs require special authorization in order to be reimbursed. Certain drug products are not eligible benefits and are identified on the exclusion list (see Formulary pages IV and V). An electronic copy of the Formulary is updated monthly on the NBPDP web page. To have your name added to the e- mail mailing list to receive notification of monthly updates and Formulary Update Bulletins, please sign up online at NBPDP Announcements. February 2014 I

5 New Brunswick Prescription Drug Program Plans Plans Fees Participating Beneficiaries Legislative Authority A $9.05 per prescription up to an annual copay ceiling of $500 for GIS recipients. $15.00 per prescription with no annual ceiling for non-gis recipients Eligible residents of the province who are sixty-five years of age or older Prescription Drug Payment Act and Regulations B $50 per year registration fee (1) ; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit Persons with cystic fibrosis who are eligible residents and registered with the Department of Health Prescription Drug Payment Act and Regulations E $4 per prescription; up to an annual copay ceiling of $250 per person (2) Persons in licensed residential facilities who are in receipt of financial assistance from the Department of Social Development and hold a valid health card issued by the Department of Social Development Health Services Act and Regulations F $4 per prescription for adults (18 years and over) $2 per prescription for children (under 18 years); up to an annual copay ceiling of $250 per family unit (2) Department of Social Development clients Health Services Act and Regulations G None Children in care of the Minister of the Department of Social Development and special needs children Health Services Act and Regulations H $50 per year premium; copay ranges from zero to 100 per cent for each prescription Persons with multiple sclerosis who are eligible residents and registered with the Department of Health Prescription Drug Payment Act and Regulations R $50 per year registration fee (1) ; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit T $50 per year registration fee (1) ; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit U $50 per year registration fee (1) ; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit Solid organ transplant recipients who are eligible residents and registered with the Department of Health Persons with growth hormone deficiency who are eligible residents and registered with the Department of Health HIV-infected persons who are eligible residents and registered with the Department of Health Prescription Drug Payment Act and Regulations Prescription Drug Payment Act and Regulations Prescription Drug Payment Act and Regulations February 2014 II

6 New Brunswick Prescription Drug Program Plans Plans Fees Participating Beneficiaries Legislative Authority V None Eligible residents of Nursing Homes as defined in the Nursing Home Act operated by a licensee under the Act Prescription Drug Payment Act and Regulations Special Authorization Plan dependent (3) Persons approved to have payment made for certain drugs following medical consultation Prescription Drug Payment Act Non-NBPDP Plan Fees Participating Beneficiaries Legislative Authority W $9.05 per prescription Extra Mural Hospital patients who are in possession of a Prescription Drug Authorization Form Hospital Services Act (1) Family and Community Services clients are exempted from these fees. (2) Exempted from these fees for contraceptives. (3) See Appendix IV. February 2014 III

7 Exclusions Exclusions are items that are not eligible benefits under the New Brunswick Prescription Drug Program. These items fall outside of the program s mandate or are excluded based on the recommendation of an expert advisory committee and are not considered for coverage. 1. Patent medicines such as Jack and Jill Cough Syrup, Extract of Wild Strawberry, etc. 2. Non-prescription acetylsalicylic acid (ASA) preparations except enteric coated ASA products designated as benefits. 3. Non-prescription mouth, throat and nasal preparations, including decongestants. 4. Prescription and non-prescription, cough and cold products (e.g. antitussives, expectorants and decongestants) except those listed as benefits for children in care (Plan G). 5. (a) Non-prescription adult vitamins with or without iron supplements (Plans A, E, F [over 18 years of age]) as a dietary supplement. (b) Multivitamins (prescription and non-prescription) as a dietary supplement. 6. Non-prescription tonics and compounded iron preparations (except single entity iron preparations designated as benefits). 7. Dietary/nutritional supplements and food products. 8. Artificial sweetening agents. 9. Weight loss products (prescription and non-prescription). 10. Calcium preparations (prescription and non-prescription) as a dietary supplement. 11. Laxatives (Plans A, E,F and G). 12. Antacids (Plans A only). 13. Smoking cessation products. 14. Ergoloid mesylates, oral, (Hydergine). 15. Potassium supplements, oral, when supplied as K-Lyte effervescent tablets, lime or orange flavoured. 16. Retinoic acid (eg. Tretinoin) topical and oral preparations (Plan A only). 17. Cosmetic, health, dental and beauty aids, and cosmetic drugs. 18. Soaps, cleansers and shampoos, medicated or otherwise. 19. Appliances, devices and medical supplies including prostheses, first aid supplies and syringes. 20. Diagnostic agents and point-of-care testing kits. 21. Household remedies e.g. calamine lotion, iodine, hydrogen peroxide, antiseptics and disinfectants. 22. Injectables or other products normally administered in a hospital setting or requiring a health care professional for administration and/or monitoring to ensure the appropriate standard of patient care is provided. 23. Any insured service for which the resident is entitled to benefit under Department of Veterans Affairs, Workplace Health & Safety Compensation Commission or other legislation. 24. Delivery, postal or C.O.D. charges. 25. Refills in excess of the number specified by the physician or any refill of a prescription older than one year unless approved for refill by the prescriber. February 2014 IV

8 26. Antihistamines (Plans A, E, F, and V) 27. Benzoyl Peroxide preparations in strengths of 5% or less. 28. Lactase Enzyme products. 29. All drug products used for the treatment of infertility. 30. Products for the treatment of impotence and sexual dysfunction. 31. Butorphanol nasal spray. 32. Drugs excluded as eligible benefits further to the expert advisory committee s review and recommendation that they not be listed. 33. Medications for the prevention of travel acquired diseases (eg. malaria, gastrointestinal illnesses and other potential conditions) February 2014 V

9 Drug Review Process All drugs considered for benefit status in the New Brunswick Prescription Drug Program (NBPDP) Formulary are subject to a standard review process. Drugs are reviewed by an expert advisory committee that evaluates the available clinical and cost-effectiveness information and makes a recommendation to drug plans on whether it should be listed as a benefit. The New Brunswick Prescription Drug Program receives formulary listing recommendations from the following three common drug review processes. Formulary listing decisions are based on the expert advisory committee s recommendation, along with other factors, including the budget impact analysis and the program s mandate, priorities and resources. National Common Drug Review The Common Drug Review (CDR) provides participating federal, provincial and territorial drug benefit plans with a systematic review of the best available clinical evidence, a critique of manufacturer-submitted pharmacoeconomic studies and a formulary listing recommendation made by the Canadian Drug Expert Committee (CDEC). Eligible submissions from manufacturers include those for new drugs, new combination products and drugs with new indications. Information on the CDR submission requirements and procedures is posted at: pan-canadian Oncology Drug Review The pan-canadian Oncology Drug Review (pcodr) is an evidence-based cancer drug review process. The pcodr Expert Review Committee (perc) assesses the clinical evidence and cost effectiveness of new cancer drugs and provides a listing recommendation to the participating provinces and territories. Information on the pcodr submission requirements and procedures is posted at: Atlantic Common Drug Review The Atlantic Common Drug Review (ACDR) assesses the clinical and cost effectiveness of drugs that do not fall under the mandates of the national Common Drug Review (CDR) or the pan-canadian Oncology Drug Review (pcodr). Formulary listing recommendations are made by the Atlantic Expert Advisory Committee (AEAC) to the Atlantic provincial drug plans. Information on the ACDR submission requirements and procedures is posted at: Manufacturers' Drug Submissions Drug submission requirements and timelines are outlined in the procedures of the respective common drug review processes. Please send a copy of each submission in the specified format to: Director, NB Prescription Drug Program Phone: (506) Department of Health Fax: (506) King Street, 6 th Floor HSBC Place PO Box 5100 Fredericton, NB E3B 5G8 The NBPDP may charge manufacturers for costs associated with the review of drug submissions and resubmissions; however, this occurs infrequently. ACDR Drug Submission Requirements All documents must be provided to each participating province in electronic format on compact disc accompanied by a cover letter. One complete hard copy submission must be sent to the ACDR coordinator. Receipt of submissions is acknowledged by the ACDR secretariat by . Please include a contact e- mail address in the submission. February 2014 VI

10 New drug products not eligible for review by CDR 1. Executive Summary 2. Notice of Compliance (NOC) 3. Product Monograph 4. Therapeutic classifications: American Hospital Formulary Service, Pharmacologic-Therapeutic Classification (PTC) and World Health Organization's Anatomical Therapeutic Chemical (ATC) classification 5. Clinical evidence on efficacy, effectiveness and safety. Double-blind, randomized, controlled trials (RCTs) published in peer-reviewed journals are given the most weight If unpublished/abstract data is submitted, it must be indicated why it is unpublished List all studies submitted in one table and specify the study name, date, authors and whether it is published or unpublished Published articles supporting the validity of outcome measures in studies (if available) 6. Economic Information a. A pharmacoeconomic evaluation is required for most new chemical entities. Studies should follow current guidelines from the Canadian Agency for Drugs and Technologies in Health (CADTH) b. Budget impact analysis 7. Pricing and availability a. Current price for all strengths and dosage forms b. Method of distribution to pharmacies (wholesale, direct or other arrangements) c. Evidence of ability to supply anticipated demand 8. A letter authorizing unrestricted communication regarding the drug product between the New Brunswick Prescription Drug Program and a. Other federal, provincial and territorial (F/P/T) drug programs b. F/P/T health authorities and related facilities c. Health Canada d. Patented Medicine Prices Review Board (PMPRB) e. Canadian Agency for Drugs and Technologies in Health (CADTH) 9. A letter specifying the current or intended Compendium of Pharmaceuticals and Specialties (CPS) listing status. 10. A copy of the Pharmaceutical Advertising Advisory Board (PAAB) approved promotional materials 11. Manufacturers will be invoiced for any costs associated with the review of a drug submission or re-submission. Drug submission requirements for line extensions and resubmissions are posted at: February 2014 VII

11 Legend 1. ATC-Therapeutic subgroup 2. ATC- Pharmacological subgroups 3. ATC- Chemical Substance 4. Dosage form, route and strength. Strength represents the amount of ingredients present in a solid dose form (Tablet) or in one gram or one millilitre of a preparation (Cream, Liquid, etc.) 5. Brand or manufacturers' product name 6. Drug Identification Number (DIN) 7. Manufacturers' identification code. See Appendix I-D for an explanation of codes 8. Drug program plans for which the product is considered to be a benefit 9. Indicates that the products are interchangeable 10. Manufacturer has discontinued this product it will be deleted from the list as a benefit on the date indicated 11. Indicates that the copay is waived for Plan E and Plan F prescriptions 12. Date of publication February 2014 VIII

12 Your comments please... The New Brunswick Prescription Drug Program would like to offer you the opportunity to provide your comments. If you have any concerns and/or suggestions concerning the formulary, product listings, etc., please let us know. Please return to: NB Prescription Drug Program P.O. Box 5100 Fredericton, New Brunswick E3B 5G8 or FAX to: (506) February 2014 IX

13 A01 A01A A01AA A01AA01 A01AC A01AC01 A01AD A02 A02A A01AD02 A02AD A02AD01 STOMATOLOGICAL PREPARATIONS PRODUITS STOMATOLOGIQUES STOMATOLOGICAL PREPARATIONS PRODUITS STOMATOLOGIQUES CARIES PROPHYLACTIC AGENTS AGENTS PROPHYLACTIQUES DES CARIES SODIUM FLUORIDE FLUORURE DE SODIUM Liq Den 0.2% Fluorinse MLA EF-18G Liq CORTICOSTEROIDS FOR LOCAL ORAL TREATMENT CORTICOSTÉROÏDES POUR TRAITEMENT BUCCAL LOCALISÉ TRIAMCINOLONE TRIAMCINOLONE Pst Den 0.1% Oracort TAR AEFGVW Pst OTHER AGENTS FOR LOCAL ORAL TREATMENT AUTRES MÉDICAMENTS POUR TRAITEMENT BUCCAL LOCALISÉ BENZYDAMINE BENZYDAMINE Liq Buc 0.15% Pharixia PMS AEFGVW Liq Apo-Benzydamine (Disc/non disp Mar 30/14) APX AEFGVW Novo-Benzydamine (Disc/non disp Feb 15/15) TEV AEFGVW DRUGS FOR ACID RELATED DISORDERS MÉDICAMENTS CONTRE LES TROUBLES DUS À L'HYPERACIDITÉ ANTACIDS ANTIACIDES COMBINATIONS AND COMPLEXES OF ALUMINIUM, CALCIUM AND MAGNESIUM COMPOUNDS COMBINAISON DE COMPOSÉS DE MAGNÉSIUM, D'ALUMINIUM ET DE CALCIUM ORDINARY SALT COMBINATIONS COMPOSES DE SEL ORDINAIRE ALUMINUM / MAGNESIUM ALUMINUM / MAGNÉSIUM Sus Orl 45.6mg/40mg Diovol CHU G Susp Sus Orl 120mg/60mg Diovol EX CHU G Susp February 2014 / février 2014 Page 1

14 A02B A02BA A02BA01 DRUGS FOR PEPTIC ULCER AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) MÉDICAMENTS CONTRE L'ULCÈRE GASTRODUODÉNAL ET LE REFLUX GASTRO-OESOPHAGIEN H2-RECEPTOR ANTAGONISTS ANTAGONISTES DES RÉCEPTEURS H2 CIMETIDINE CIMETIDINE Tab Orl 200mg Apo-Cimetidine APX f ABEFGVW Tab Orl 300mg Apo-Cimetidine APX f ABEFGVW Mylan-Cimetidine MYL f ABEFGVW Tab Orl 400mg Apo-Cimetidine APX f ABEFGVW Mylan-Cimetidine MYL f ABEFGVW A02BA02 Tab Orl 600mg Apo-Cimetidine APX f ABEFGVW Mylan-Cimetidine MYL f ABEFGVW Tab Orl 800mg Apo-Cimetidine APX f ABEFGVW RANITIDINE RANITIDINE Liq Inj 25mg Zantac GSK W Liq Liq Orl 15mg Teva-Ranidine TEV f EFGVW Liq Apo-Ranitidine APX f EFGVW Tab Orl 150mg Apo-Ranitidine APX f ABEFGVW Teva-Ranidine TEV f ABEFGVW ratio-ranitidine (Disc/non disp Jun 29/14) RPH f ABEFGVW Mylan-Ranitidine MYL f ABEFGVW Zantac GSK f ABEFGVW pms-ranitidine PMS f ABEFGVW Sandoz Ranitidine SDZ f ABEFGVW Co Ranitidine COB f ABEFGVW Ran-Ranitidine RAN f ABEFGVW Ranitidine SAS f ABEFGVW Myl-Ranitidine MYL f ABEFGVW Tab Orl 300mg Apo-Ranitidine APX f ABEFGVW Teva-Ranidine TEV f ABEFGVW Mylan-Ranitidine MYL f ABEFGVW Zantac GSK f ABEFGVW pms-ranitidine PMS f ABEFGVW Sandoz Ranitidine SDZ f ABEFGVW Co Ranitidine COB f ABEFGVW Ran-Ranitidine RAN f ABEFGVW Ranitidine SAS f ABEFGVW Myl-Ranitidine MYL f ABEFGVW February 2014 / février 2014 Page 2

15 A02BB A02BB01 A02BC A02BC01 A02BC02 A02BC04 PROSTAGLANDINS PROSTAGLANDINES MISOPROSTOL MISOPROSTOL Tab Orl 100mcg Misoprostol AAP f AEFGVW Tab Orl 200mcg Misoprostol AAP f AEFGVW PROTON PUMP INHIBITORS INHIBITEURS DE LA POMPE À PROTONS OMEPRAZOLE OMÉPRAZOLE SRC Orl 20mg Losec AZE f ABEFGVW Caps.L.L Apo-Omeprazole APX f ABEFGVW Sandoz Omeprazole SDZ f ABEFGVW pms-omeprazole PMS f ABEFGVW Mylan-Omeprazole MYL f ABEFGVW Omeprazole SAS f ABEFGVW Ran-Omeprazole RAN f ABEFGVW SRT Orl 20mg Losec AZE f ABEFGVW L.L. ratio-omeprazole(disc/non disp July 24/15) TEV f ABEFGVW Teva-Omeprazole TEV f ABEFGVW pms-omeprazole DR PMS f ABEFGVW Ran-Omeprazole RAN f ABEFGVW PANTOPRAZOLE PANTOPRAZOLE Tab Orl 40mg Tecta TAK ABEFGVW RABEPRAZOLE RABÉPRAZOLE ECT Orl 10mg Pariet JAN f ABEFGVW Ent Teva-Rabeprazole EC TEV f ABEFGVW Ran-Rabeprazole RAN f ABEFGVW pms-rabeprazole EC PMS f ABEFGVW Sandoz Rabeprazole SDZ f ABEFGVW Apo-Rabeprazole APX f ABEFGVW Rabeprazole EC SAS f ABEFGVW Pat-Rabeprazole PAT f ABEFGVW Mylan-Rabeprazole MYL f ABEFGVW ECT Orl 20mg Pariet JAN f ABEFGVW Ent. Teva-Rabeprazole EC TEV f ABEFGVW Ran-Rabeprazole RAN f ABEFGVW 1 Omeprazole prescribed in doses higher than 20mg daily will require special authorization. Please refer to Appendix IV for the criteria. For plans ABEFGV, a bi-annual quantity limit has been established for this drug. La couverture d omeprazole au doses supérieures à 20mg par jour exige une autorisation spéciale. Veuillez consulter l annexe IV pour critéres. Pour les régimes ABEFGV, une quantité limite semestrielle à été établie pour ce médicament. February 2014 / février 2014 Page 3

16 A02BC04 A02BX A03 A03A A02BX02 A03AA A03AA05 A03AA07 RABEPRAZOLE RABÉPRAZOLE ECT Orl 20mg pms-rabeprazole EC PMS f ABEFGVW Ent. Sandoz Rabeprazole SDZ f ABEFGVW Apo-Rabeprazole APX f ABEFGVW Rabeprazole EC SAS f ABEFGVW Pat-Rabeprazole PAT f ABEFGVW Mylan-Rabeprazole MYL f ABEFGVW OTHER DRUGS FOR PEPTIC ULCER AND GASTROESOPHAGEAL REFLUX DISEASE (GORD) AUTRES MÉDICAMENTS CONTRE L'ULCÈRE GASTRODUODÉNAL ET LE REFLUX GASTRO- OESOPHAGIEN SUCRALFATE SUCRALFATE Sus Orl 200mg Sulcrate Plus AXC AEFGVW Susp. Tab Orl 1gm Teva-Sulcralfate TEV f AEFGVW Sulcrate AXC f AEFGVW Apo-Sucralfate APX f AEFGVW DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS MÉDICAMENTS CONTRE LES TROUBLES GASTROINTESTINAUX FONCTIONNELS DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS MÉDICAMENTS CONTRE LES TROUBLES FONCTIONNELS DE L'INTESTIN SYNTHETIC ANTICHOLINERGICS, ESTERS WITH TERTIARY AMINO GROUP ANTICHOLINERGIQUES SYNTHÉTIQUES A ESTERS AVEC GROUPE AMINO TERTIAIRE TRIMEBUTINE TRIMEBUTINE Tab Orl 100mg Trimebutine AAP f AEFGVW Tab Orl 200mg Modulon AXC f AEFGVW Trimebutine AAP f AEFGVW DICYCLOVERINE (DICYCLOMINE) DICYCLOVERINE (DICYCLOMINE) Cap Orl 10mg Protylol PDL AEFGVW Caps Syr Orl 2mg Bentylol AXC AEFGVW Sir. Tab Orl 10mg Bentylol AXC AEFGVW Tab Orl 20mg Protylol PDL AEFGVW Bentylol AXC AEFGVW February 2014 / février 2014 Page 4

17 A03AB A03AB02 A03AX A03C A03AX04 A03CA A03E A03CA02 A03ED A03F A03ED99 A03FA A03FA01 SYNTHETIC ANTICHOLINERGICS, QUATERNARY AMMONIUM COMPOUNDS ANTICHOLINERGIQUES SYNTHÉTIQUES, ESTERS, COMPOSES D'AMMONIUM QUATERNAIRE GLYCOPYRRONIUM (GLYCOPYRROLATE) GLYCOPYRRONIUM (GLYCOPYRROLATE) Liq Inj 0.2mg Glycopyrrolate SDZ AEFVW Liq OTHER DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS AUTRES MÉDICAMENTS POUR LES TROUBLES FONCTIONNELS DE L'INTESTIN PINAVERIUM PINAVERIUM Tab Orl 50mg Dicetel ABB AEFGVW Tab Tab Orl 100mg Dicetel ABB AEFGVW Tab ANTISPASMODICS IN COMBINATION WITH PSYCHOLEPTICS ANTISPASMODIQUES EN COMBINAISON AVEC DES PSYCHOLEPTIQUES SYNTHETIC ANTICHOLINERGIC AGENTS IN COMBINATION WITH PSYCHOLEPTICS AGENTS ANTICHOLINERGIQUES SYNTHÉTIQUES EN COMBINAISON AVEC DES PSYCHOLEPTIQUES CLINIDIUM AND PSYCHOLEPTICS CLINIDIUM ET PSYCHOLEPTIQUES CHLORDIAZEPOXIDE / CLINIDIUM CHLORDIAZEPOXIDE / CLINIDIUM Cap Orl 5mg/2.5mg Librax VLN AEFGVW Caps Apo-Chlorax APX AEFGVW ANTISPASMODICS AND ANTICHOLINERGICS IN COMBINATION WITH OTHER DRUGS ANTISPASMODIQUES ET ANTICHOLINERGIQUES EN COMBINAISON AVEC D'AUTRES MÉDICAMENTS ANTISPASMODICS IN COMBINATION WITH OTHER DRUGS ANTISPASMODIQUES EN COMBINAISON AVEC D'AUTRES MÉDICAMENTS ANTISPASMODICS, COMBINATIONS ANTISPASMODIQUES, COMBINAISONS PHENOBARBITAL / ERGOTAMINE / BELLADONNA PHÉNOBARBITAL / ERGOTAMINE / BELLADONNA SRT Orl 40mg/0/6mg/0.2mg Bellergal spacetabs TRI AEFGVW L.L. PROPULSIVES PROPULSIFS PROPULSIVES PROPULSIVES METOCLOPRAMIDE MÉTOCLOPRAMIDE Liq Inj 5mg Metoclopramide HCL SDZ W Liq Syr Orl 1mg Metonia PDP f AEFGVW Sir. February 2014 / février 2014 Page 5

18 A04 A04A A03FA01 A03FA03 A04AA A04AA01 METOCLOPRAMIDE MÉTOCLOPRAMIDE Tab Orl 5mg Apo-Metoclop (Disc/non disp Mar 30/14) APX f AEFGVW Metonia PDP f AEFGVW Tab Orl 10mg Apo-Metoclop (Disc/non disp Mar 30/14) APX f AEFGVW Metonia PDP f AEFGVW DOMPERIDONE DOMPÉRIDONE Tab Orl 10mg ratio-domperidone RPH f AEFGVW Apo-Domperidone APX f AEFGVW Teva-Domperidone TEV f AEFGVW pms-domperidone PMS f AEFGVW Ran-Domperidone RAN f AEFGVW Mylan-Domperidone MYL f AEFGVW Domperidone SAS f AEFGVW Jamp-Domperidone JPC f AEFGVW Mar-Domperidone MAR f AEFGVW ANTIEMETICS AND ANTINAUSEANTS ANTIEMÉTIQUES ET ANTINAUSÉEUX ANTIEMETICS AND ANTINAUSEANTS ANTIEMÉTIQUES ET ANTINAUSÉEUX SEROTONIN (5HT3) ANTAGONISTS ANTAGONISTES DE LA SÉROTONINE (5HT3) ONDANSETRON ONDANSÉTRON Liq Inj 2mg Zofran GSK f W Liq Ondansetron preservative free TEV f W Ondansetron with preservative TEV f W AJ-Ondansetron AJP f W Tab Orl 4mg Zofran GSK f AEFGV Zofran GSK f W pms-ondansetron PMS f AEFGV pms-ondansetron PMS f W Teva-Ondansetron TEV f W Teva-Ondansetron TEV f AEFGV Sandoz Ondansetron SDZ f W Sandoz Ondansetron SDZ f AEFGV Ratio-Ondansetron RPH f AEFGV Ratio-Ondansetron RPH f W Phl-Ondansetron PHL f AEFGV Phl-Ondansetron PHL f W Apo-Ondansetron APX f AEFGV Apo-Ondansetron APX f W Co Ondansetron COB f W Co Ondansetron COB f AEFGV Mylan-Ondansetron MYL f AEFGV Mylan-Ondansetron MYL f W Mint-Ondansetron MNT f AEFGV February 2014 / février 2014 Page 6

19 A04AA01 ONDANSETRON ONDANSÉTRON Tab Orl 4mg Mint-Ondansetron MNT f W Ondansetron-Odan ODN f AEFGV Ondansetron-Odan ODN f W Ran-Ondansetron RAN f AEFGV Ran-Ondansetron RAN f W Jamp-Ondansetron JPC f W Jamp-Ondansetron JPC f AEFGV Mar-Ondansetron MAR f W Mar-Ondansetron MAR f AEFGV Septa-Ondansetron SPT f W Septa-Ondansetron SPT f AEFGV Tab Orl 8mg Zofran GSK f AEFGV Zofran GSK f W pms-ondansetron PMS f W pms-ondansetron PMS f AEFGV Teva-Ondansetron TEV f AEFGV Teva-Ondansetron TEV f W Sandoz Ondansetron SDZ f AEFGV Sandoz Ondansetron SDZ f W ratio-ondansetron RPH f W ratio-ondansetron RPH f AEFGV Phl-Ondansetron PHL f AEFGV Phl-Ondansetron PHL f W Apo-Ondansetron APX f W Apo-Ondansetron APX f AEFGV Co Ondansetron COB f AEFGV Co Ondansetron COB f W Mylan-Ondansetron MYL f W Mylan-Ondansetron MYL f AEFGV Mint-Ondansetron MNT f W Mint-Ondansetron MNT f AEFGV Ondansetron-Odan ODN f AEFGV Ondansetron-Odan ODN f W Ran-Ondansetron RAN f AEFGV Ran-Ondansetron RAN f W Jamp-Ondansetron JPC f W Jamp-Ondansetron JPC f AEFGV Mar-Ondansetron MAR f AEFGV Mar-Ondansetron MAR f W Septa-Ondansetron SPT f W Septa-Ondansetron SPT f AEFGV 2 Requests for coverage of ondansetron (Zofran and generics) will be considered under special authorization, see Appendix IV. Prescriptions written by oncologists or oncology clinical associates/general practitioners-oncology for a maximum of 12 tablets every 28 days do not require special authorization. Les demandes de protection pour l'ondansétron (Zofran et génériques) seront examinées sur autorisation spéciale. Veuillez consulter l'annexe IV. Les ordonnances des oncologues ou des cliniciens adjoint/omnipraticiens en oncologie pour un maximum de 12 comprimées chaque 28 jours ne nécessitent pas une authorisation spéciale. February 2014 / février 2014 Page 7

20 A04AA02 A04AA04 A04AD A04AD01 GRANISETRON GRANISÉTRON Tab Orl 1mg Kytril HLR f AEFGV Kytril HLR f W Granisetron AAP f AEFGV Granisetron AAP f W DOLASETRON DOLASETRON Tab Orl 100mg Anzemet SAV AEFGV Anzemet SAV W OTHER ANTIEMETICS AUTRES ANTIEMÉTIQUES SCOPOLAMINE SCOPOLAMINE Liq Inj 20mg Buscopan BOE W Liq Hyoscine Butylbromide SDZ VW Tab Orl 10mg Buscopan BOE AEFGVW Liq Inj 0.4mg Scopolamine Hydrobromide HOS AEFVW Liq Liq Inj 0.6mg Scopolamine Hydrobromide HOS AEFVW Liq A04AD12 Srd Trd 1.5mg Transderm-V NVR AEFGVW Srd APREPITANT APRÉPITANT Cap Orl 80mg Emend FRS AEFGV Caps Emend FRS W Cap Orl 125mg Emend FRS W Caps Emend FRS AEFGV 3 Requests for coverage of Kytril (Granisetron) will be considered under special authorization. See Appendix IV. Prescriptions written by oncologists or oncology clinical associates/general practitioners-oncology for a maximum of 2 tablets every 28 days do not require special authorization. Les demandes de protection pour le Kytril (Granisétron) seront examinées sur autorisation spéciale. Veuillez consulter l annexe IV. Les ordonnances des oncologues ou des cliniciens adjoint/amnipraticiens en oncologie pour un maximum de 2 comprimées chaque 28 jours ne nécessitent pas d autorisation spéciale. 4 Requests for coverage of Anzemet (Dolasetron) will be considered under special authorization. See Appendix IV. Prescriptions written by oncologists or oncology clinical associates/general practitioners-oncology for a maximum of 2 tablets every 28 days do not require special authorization. Les demandes de protection pour le Anzemet (Dolasetron) seront examinées sur autorisation spéciale. Veuillez consulter l annexe IV. Les ordonnances des oncologues ou des cliniciens adjoint/amnipraticiens en oncologie pour un maximum de 2 comprimées chaque 28 jours ne nécessitent pas d autorisation spéciale. February 2014 / février 2014 Page 8

21 A04AD12 APREPITANT APRÉPITANT Cap Orl 85mg Emend-Tri-Pack Cap FRS W Caps Emend-Tri-Pack Cap FRS AEFGV A04AD99 DIMENHYDRINATE DIMENHYDRINATE Liq Inj 50mg Gravol CHU W Liq Syr Orl 3mg Gravol CHU G Sir. A07 A07A A07AA A07D Tab Orl 15mg Gravol CHU G ANTIDIARRHEALS, INTESTINAL ANTIINFLAMMATORY/ANTIINFECTIVE AGENTS ANTIDIARRHÉIQUES, AGENTS ANTI-INFECTIEUX/ANTI-INFLAMMATOIRES POUR L INTESTIN INTESTINAL ANTIINFECTIVES ANTI-INFECTIEUX INTESTINAUX ANTIBIOTICS ANTIBIOTIQUES A07AA02 NYSTATIN NYSTATINE Susp Orl IU pms-nystatin Oral PMS ABEFGVW Susp. Ratio-Nystatin RPH ABEFGVW A07DA A07DA01 Tab Orl IU ratio-nystatin (Disc/non disp Jan. 21/15) RPH ABEFGVW ANTIPROPULSIVES ANTIPROPULSIFS ANTIPROPULSIVES ANTIPROPULSIFS DIPHENOXYLATE DIPHÉNOXYLATE DIPHENOXYLATE / ATROPINE DIPHÉNOXYLATE / ATROPINE Tab Orl 2.5mg/0.025mg Lomotil PFI AEFGVW A07DA03 LOPERAMIDE LOPÉRAMIDE Liq Orl 0.2mg/mL pms-loperamide Hydrochloride PMS f AEFGVW Liq 5 Requests for coverage of Emend (Aprepitant) will be considered under special authorization. See Appendix IV. Prescriptions written by oncologists or oncology clinical associates/general practitioners-oncology for a maximum of 2 Tripacks or 6 capsules every 28 days do not require special authorization. Les demandes de protection pour le Emend (Aprépitant) seront examinées sur autorisation spéciale. Veuillez consulter l annexe IV. Les ordonnances des oncologues ou des cliniciens adjoint/amnipraticiens en oncologie pour un maximum de 2 emballages de trois ou 6 capsules chaque 28 jours ne nécessitent pas d autorisation spéciale. February 2014 / février 2014 Page 9

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