NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY

Transcription

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 [email protected] 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

22 A07DA03 LOPERAMIDE LOPÉRAMIDE Tab Orl 2mg Novo-Loperamide TEV f AEFGVW Imodium (Disc/non disp Aug 01/15) JNJ f AEFGVW Apo-Loperamide APX f AEFGVW pms-loperamide PMS f AEFGVW Sandoz-Loperamide (Disc/non disp Nov 15/15) SDZ f AEFGVW Loperamide JPC AEFGVW A07E A07EA INTESTINAL ANTIINFLAMMATORY AGENTS AGENTS ANTI-INFLAMMATOIRES INTESTINAUX CORTICOSTEROIDS ACTING LOCALLY CORTICOSTÉROÏDES AGISSANT LOCALEMENT A07EA02 HYDROCORTISONE HYDROCORTISONE Aer Rt 10% Cortifoam PAL AEFGVW Aér Enm Rt mg Hycort VLN AEFGVW Lav. Cortenema AXC AEFGVW A07EA04 BETAMETHASONE BÉTAMÉTHASONE Enm Rt 0.05mg Betnesol PAL AEFGVW Lav. A07EA06 BUDESONIDE BUDÉSONIDE Cap Orl 3mg Entocort AZE AEFGVW Caps A07EB ANTIALLERGIC AGENTS, EXCL. CORTICOSTEROIDS AGENTS ANTIALLERGIQUES, À L EXCLUSION DES CORTICOSTÉROÏDES A07EB01 CROMOGLICIC ACID CROMOGLYCATE DISODIQUE Cap Orl 100mg Nalcrom SAV AEFGVW Caps A07EC AMINOSALICYLIC ACID AND SIMILAR AGENTS ACIDE AMINOSALICYLIQUE ET AGENTS SEMBLABLES A07EC01 SULFASALAZINE SULFASALAZINE ECT Orl 500mg Salazopyrin EN PFI f AEFGVW Ent pms-sulfasalazine EC PMS AEFGVW Tab Orl 500mg Salazopyrin PFI f AEFGVW pms-sulfasalazine PMS AEFGVW February 2014 / février 2014 Page 10

23 A07EC02 MESALAZINE MÉSALAZINE ECT Orl 500mg Mesasal GSK AEFGVW Ent Salofalk AXC AEFGVW SRT Orl 500mg Pentasa FEI AEFGVW L.L. Sup Rt 1gm Pentasa FEI AEFGVW Supp. Salofalk AXC AEFGVW Sup Rt 500mg Salofalk AXC AEFGVW Supp. Sus Rt 1gm Pentasa FEI AEFGVW Susp Sus Rt 2gm Salofalk AXC AEFGVW Susp. Sus Rt 4gm Pentasa FEI AEFGVW Susp. Sus Rt mg Salofalk AXC AEFGVW Susp. ECT Orl 400mg Asacol WNC AEFGVW Ent ECT Orl 800mg Asacol WNC AEFGVW Ent. Tab Orl 1.2gm Mezavant SHI AEFGVW A07EC03 OLSALAZINE OLSALAZINE Cap Orl 250mg Dipentum UCB AEFGVW Caps A07F A07FA ANTIDIARRHEAL MICROORGANISMS MICRO-ORGANISMES ANTIDIARRHÉIQUES ANTIDIARRHEAL MICROORGANISMS MICRO-ORGANISMES ANTIDIARRHÉIQUES A07FA01 LACTIC ACID PRODUCING ORGANISMS ORGANISMES PRODUISANT DE L ACIDE LACTIQUE Cap Orl 1b Bacid ERF AEFGVW Caps February 2014 / février 2014 Page 11

24 A09 A09A A09AA A09AA02 DIGESTIVES, INCLUDING ENZYMES AGENTS DIGESTIFS, Y COMPRIS LES ENZYMES DIGESTIVES, INCLUDING ENZYMES AGENTS DIGESTIFS, Y COMPRIS LES ENZYMES ENZYME PREPARATIONS PRÉPARATIONS D ENZYMES MULTIENZYMES (LIPASE, PROTEASE ETC) MULTIENZYMES (LIPASE, PROTÉASE ETC) Cap Orl 4500U/ 20000U/20000U Ultrase MS AXC BEFG Caps. Cap Orl 8000IU/30000IU/30000IU Cotazym FRS BEFG Caps. Cap Orl 12000U/39000U/39000U Ultrase MT AXC BEFG Caps. Cap Orl 20000U/ 65000U/65000U Ultrase MT AXC BEFG Caps. ECC Orl 4000U/12000U/12000U Pancrease MT JAN BEFG Caps.Ent. ECC Orl 5000U/16600U/18750U Creon 5 Minimicrospheres ABB BEFG Caps.Ent. ECC Orl 6000U/30000U/19000U Creon 6 Minimicrospheres ABB BEFG Caps.Ent. ECC Orl 8000U/30000U/30000U Cotazym ECS SCH BEFG Caps.Ent. ECC Orl 10000U/33200U/37500U Creon10 Minimicrospheres ABB BEFG Caps.Ent. ECC Orl 1000U/30000U/30000U Pancrease MT JAN BEFG Caps.Ent. ECC Orl 16000U/48000U/48000U Pancrease MT JAN BEFG Caps.Ent. ECC Orl 20000U/55000U/55000U Cotazym ECS SCH BEFG Caps.Ent. ECC Orl25000U/ 74000U/62500U Creon25 Minimicrospheres ABB BEFG Caps.Ent. Tab Orl 8000U/ 30000U/30000U Viokase AXC BEFG Tab Orl 16000U/ 60000U/60000U Viokase AXC BEFG February 2014 / février 2014 Page 12

25 A10 A10A A10AB A10AB01 A10AB04 A10AB05 A10AB06 A10AC DRUGS USED IN DIABETES MÉDICAMENTS UTILISÉS CHEZ LES DIABÉTIQUES INSULINS AND ANALOGUES INSULINES ET ANALOGUES INSULINS & ANALOGUES FOR INJECTION, FAST-ACTING INSULINES ET ANALOGUES POUR L INJECTION, À ACTION RAPIDE INSULIN (HUMAN); FAST-ACTING INSULINE (HUMAINE); ACTION RAPIDE Liq Inj 100IU Humulin R* LIL AEFGVW Liq Humulin R (cartridge)* LIL AEFGVW Novolin GE Toronto* NNO AEFGVW Novolin GE Toronto(penfill) (3ml)* NNO AEFGVW INSULIN LISPRO; FAST-ACTING INSULINE LISPRO; ACTION RAPIDE Liq Inj 100IU Humalog* LIL AEFGV Liq Humalog (cartridge)* LIL AEFGV Humalog (kwikpen)* LIL AEFGV INSULIN ASPART INSULINE ASPART Liq Inj 100IU Novorapid (penfill) (3ml)* NNO AEFGV Liq Novorapid* NNO AEFGV INSULIN GLULISINE INSULINE GLULISINE Liq Inj 3mL Apidra (cartridge) SAV AVW Liq Apidra (cartridge) SAV EFG-18 Apidra Solostar SAV AVW Apidra Solostar SAV EFG-18 Liq Inj 10mL Apidra SAV EFG-18 Liq Apidra SAV AVW INSULINS & ANALOGUES FOR INJECTION, INTERMEDIATE-ACTING INSULINES ET ANALOGUES POUR INJECTION, ACTION INTERMÉDIAIRE A10AC01 INSULIN (HUMAN); INTERMEDIATE-ACTING INSULINE (HUMAINE); ACTION INTERMÉDIAIRE Sus Inj 100IU Humulin N * LIL AEFGVW Susp. Humulin N (cartridge) * LIL AEFGVW Humulin N (kwikpen) * LIL AEFGVW Novolin GE NPH* NNO AEFGVW Novolin GE NPH (penfill) (3ml) * NNO AEFGVW 6 Prescriptions written by New Brunswick endocrinologists and internists do not require special authorization. Subsequent refills by other practitioners will not require special authorization. Les ordonnances rédigées par des endocrinologues et des internists du Nouveau-Brunswick ne requièrent pas d autorisation spéciale. Les renouvellements prescrits par d autres practiciens ne nécessiteront pas d autorisation spéciale. February 2014 / février 2014 Page 13

26 A10AD A10AD01 INSULINS & ANALOGUES FOR INJECTION INTERMEDIATE-ACTING, FAST-ACTING INSULINES ET ANALOGUES POUR INJECTION, ACTION INTERMÉDIAIRE, À ACTION RAPIDE INSULIN (HUMAN), INTERMEDIATE-ACTING IN COMBINATION INSULINE (HUMAINE); ACTION INTERMÉDIAIRE, COMBINASON Sus Inj 30 IU/70IU Humulin 30/70* LIL AEFGVW Susp. Humulin 30/70 (cartridge) * LIL AEFGVW Novolin GE 30/70* NNO AEFGVW Novolin GE 30/70 (penfill) (3ml) * NNO AEFGVW Sus Inj 40 IU/60IU Novolin GE 40/60 (Penfill) * NNO AEFGVW Susp. A10B A10BA A10BA02 Sus Inj 50 IU/50IU Novolin GE 50/50 (Penfill) * NNO AEFGVW Susp. BLOOD GLUCOSE LOWERING DRUGS, EXCLUDING INSULINS MÉDICAMENTS HYPOGLYCÉMIANTS, À L EXCLUSION DES INSULINES BIGUANIDES BIGUANIDES METFORMIN METFORMINE Tab Orl 500mg Teva-Metformin * TEV f AEFGVW Glucophage * SAV f AEFGVW Mylan-Metformin * MYL f AEFGVW Apo-Metformin * APX f AEFGVW pms-metformin * PMS f AEFGVW Metformin * MEL f AEFGVW ratio-metformin * RPH f AEFGVW Sandoz Metformin FC * SDZ f AEFGVW Co-Metformin * COB f AEFGVW Ran-Metformin * RAN f AEFGVW Metformin * SAS f AEFGVW Metformin* MAR f AEFGVW Mar-Metformin* MAR f AEFGVW Jamp-Metformin* JPC f AEFGVW Jamp-Metformin Blackberry* JPC f AEFGVW Septa-Metformin* SPT f AEFGVW Mint-Metformin* MNT f AEFGVW Tab Orl 850mg Glucophage * SAV f AEFGVW Mylan-Metformin * MYL f AEFGVW Apo-Metformin * APX f AEFGVW Teva-Metformin * TEV f AEFGVW pms-metformin * PMS f AEFGVW ratio-metformin * RPH f AEFGVW Sandoz Metformin FC * SDZ f AEFGVW Co-Metformin * COB f AEFGVW Ran-Metformin * RAN f AEFGVW Metformin * SAS f AEFGVW Metformin* MAR f AEFGVW Mar-Metformin* MAR f AEFGVW February 2014 / février 2014 Page 14

27 A10BA02 A10BB A10BB01 A10BB02 METFORMIN METFORMINE Tab Orl 850mg Jamp-Metformin* JPC f AEFGVW Jamp-Metformin Blackberry* JPC f AEFGVW Septa-Metformin* SPT f AEFGVW Mint-Metformin* MNT f AEFGVW SULFONAMIDES, UREA DERIVATIVES SULFONAMIDES, DÉRIVÉS DE L URÉE GLIBENCLAMIDE (GLYBURIDE) GLIBENCLAMIDE (GLYBURIDE) Tab Orl 2.5mg Mylan-Glybe * MYL f AEFGVW ratio-glyburide * RPH f AEFGVW Apo-Glyburide * APX f AEFGVW Teva-Glyburide * TEV f AEFGVW Diabeta * SAV f AEFGVW Sandoz Glyburide * SDZ f AEFGVW Glyburide * SAS f AEFGVW Tab Orl 5mg Mylan-Glybe * MYL f AEFGVW ratio-glyburide * RPH f AEFGVW Apo-Glyburide * APX f AEFGVW Teva-Glyburide * TEV f AEFGVW Diabeta * SAV f AEFGVW Sandoz Glyburide * SDZ f AEFGVW Glyburide * SAS f AEFGVW CHLORPROPAMIDE CHLORPROPAMIDE Tab Orl 100mg Apo-Chlorpropamide * APX f AEFGVW Tab Orl 250mg Apo-Chlorpropamide * APX f AEFGVW A10BB03 TOLBUTAMIDE TOLBUTAMIDE Tab Orl 500mg Tolbutamide * AAP f AEFGVW A10BB09 GLICLAZIDE GLICLAZIDE ECT Orl 30mg Diamicron MR * SEV f ABEFGVW Ent. Gliclazide MR * AAP f ABEFGVW ECT Orl 60mg Diamicron MR SEV ABEFGVW Ent. Tab Orl 80mg Diamicron * SEV f ABEFGVW Mylan-Gliclazide * MYL f ABEFGVW Novo-Gliclazide * TEV f ABEFGVW Apo-Gliclazide * APX f ABEFGVW Gliclazide * SAS f ABEFGVW February 2014 / février 2014 Page 15

28 A10BB12 GLIMEPIRIDE GLIMÉPIRIDE Tab Orl 1mg Amaryl * SAV f ABEFGVW Sandoz Glimepiride * SDZ f ABEFGVW Ratio-Glimepiride * TEV f ABEFGVW Novo-Glimepiride * TEV f ABEFGVW Apo-Glimepiride * APX f ABEFGVW Tab Orl 2mg Amaryl * SAV f ABEFGVW Sandoz Glimepiride * SDZ f ABEFGVW Ratio-Glimepiride * TEV f ABEFGVW Novo-Glimepiride * TEV f ABEFGVW Apo-Glimepiride * APX f ABEFGVW A11 A11A A11AA A11C A11AA03 A11CC A11CC01 Tab Orl 4mg Amaryl * SAV f ABEFGVW Sandoz Glimepiride * SDZ f ABEFGVW Ratio-Glimepiride * TEV f ABEFGVW Novo-Glimepiride * TEV f ABEFGVW Apo-Glimepiride * APX f ABEFGVW VITAMINS VITAMINES MULTIVITAMINS, COMBINATIONS MULTIVITAMINES, EN COMBINAISON MULTIVITAMINS WITH MINERALS MULTIVITAMINES ET MINÉRAUX MULTIVITAMIN AND OTHER MINERALS, INCLUDING COMBINATIONS MULTIVITAMINE ET AUTRES MINÉRAUX, Y COMPRIS LES COMBINAISONS Tab Orl Centrum Junior WCH G VITAMIN A AND D, INCLUDING COMBINATIONS OF THE TWO VITAMINE A ET D, Y COMPRIS LES COMBINAISONS DES DEUX VITAMIN D AND ANALOGUES VITAMINE D ET ANALOGUES ERGOCALCIFEROL ERGOCALCIFEROL Cap Orl 50000IU D-Forte EUR AEFGVW Caps Osto-D TRI AEFGVW Dps Orl 8288IU Drisdol (Disc/non disp Feb. 4/15) SAV f AEFGVW Gttes Erdol (Drisodan) ODN f AEFGVW A11CC03 Tab Orl 1000IU Vitamin D JAM EF-18G ALFACALCIDOL ALFACALCIDOL Cap Orl 0.25mcg One-Alpha LEO AEFGVW Caps February 2014 / février 2014 Page 16

29 A11H A11CC03 A11CC04 A11HA ALFACALCIDOL ALFACALCIDOL Cap Orl 1mcg One-Alpha LEO AEFGVW Caps CALCITRIOL CALCITRIOL Cap Orl 0.25mcg Rocaltrol HLR AEFGVW Caps Cap Orl 0.5mcg Rocaltrol HLR AEFGVW Caps OTHER PLAIN VITAMIN PREPARATIONS AUTRES PRÉPARATIONS VITAMINIQUES ORDINAIRES OTHER PLAIN VITAMIN PREPARATIONS AUTRES PRÉPARATIONS VITAMINIQUES ORDINAIRES A11HA02 PYRIDOXINE (VIT B6) PYRIDOXINE (VIT B6) Liq Inj 100mg Pyridoxine KRI W Liq A11HA03 TOCOPHEROL (VIT E) TOCOPHÉROL (VIT E) Cap Orl 200IU Vitamin E VTH BEF-18G Caps Dps Orl 50IU Aquasol E CLC BEF-18G Gttes Cap Orl 100IU Vitamin E Natural JAM BEF-18G Caps Vitamin E JAM BEF-18G Cap Orl 200IU Vitamin E Natural JAM BEF-18G Caps Vitamin E SWS BEF-18G Cap Orl 400IU Vitamin E Natural JAM BEF-18G Caps Vitamin E Natural JPC BEF-18G Vitamin E PMT BEF-18G Vitamin E Synthetic WAM BEF-18G Vitamin E PMT BEF-18G Vitamin E HHC BEF-18G A11J A11JA OTHER VITAMIN PRODUCTS, COMBINATIONS AUTRES PRODUITS VITAMINIQUES, EN COMBINAISON COMBINATIONS OF VITAMINS COMBINAISONS DE VITAMINES Liq Orl Infantol CHU BEFG Liq February 2014 / février 2014 Page 17

30 A12 A12B A12BA A12BA01 MINERAL SUPPLEMENTS SUPPLÉMENTS DE MINÉRAUX POTASSIUM POTASSIUM POTASSIUM POTASSIUM POTASSIUM CHLORIDE CHLORURE DE POTASSIUM Liq Orl 100mg pms-potassium PMS f AEFGVW Liq K-10(Disc/non disp Jul 31/14) GSK AEFGVW K GSK AEFGVW SRC Orl 600mg Micro-K PAL AEFGVW Caps.L.L. SRT Orl 600mg Slow-K NVR AEFGVW L.L. Apo-K APX AEFGVW Jamp-K JPC AEFGVW SRT Orl 1500mg Odan K ODN AEFGVW L.L. K-Dur 20(Disc/non disp Dec 1/14) FRS AEFGVW Jamp-K JPC AEFGVW A12C A12CD B01 B01A A12CD01 B01AA OTHER MINERAL SUPPLEMENTS AUTRES SUPPLÉMENTS MINÉRAUX FLUORIDE FLUORURE SODIUM FLUORIDE FLUORURE DE SODIUM Dps Orl 5.56mg Fluor-a-Day PDP EF-18G Gttes Tab Orl 2.21mg Fluor-a-Day PDP EF-18G ANTITHROMBOTIC AGENTS AGENTS ANTITHROMBOTIQUES ANTITHROMBOTIC AGENTS AGENTS ANTITHROMBOTIQUES VITAMIN K ANTAGONISTS ANTAGONISTES DE LA VITAMINE K B01AA03 WARFARIN WARFARINE Tab Orl 1mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) TEV f AEFGVW Warfarin SAS f AEFGVW February 2014 / février 2014 Page 18

31 B01AA03 WARFARIN WARFARINE Tab Orl 2mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin TEV f AEFGVW Warfarin SAS f AEFGVW Tab Orl 2.5mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin TEV f AEFGVW Warfarin SAS f AEFGVW Tab Orl 3mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) TEV f AEFGVW Warfarin SAS f AEFGVW Tab Orl 4mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) TEV f AEFGVW Warfarin SAS f AEFGVW Tab Orl 5mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Novo-Warfarin TEV f AEFGVW Warfarin SAS f AEFGVW Tab Orl 6mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Mylan-Warfarin MYL f AEFGVW Warfarin (Disc/non disp Jan 1/15) SAS f AEFGVW B01AA07 Tab Orl 10mg Coumadin BRI f AEFGVW Taro-Warfarin TAR f AEFGVW Apo-Warfarin APX f AEFGVW Mylan-Warfarin MYL f AEFGVW Warfarin SAS f AEFGVW ACENOCOUMAROL (NICOUMALONE) ACENOCOUMAROL (NICOUMALONE) Tab Orl 1mg Sintrom PAL AEFGVW February 2014 / février 2014 Page 19

32 B01AA07 B01AB B01AB01 B01AB04 ACENOCOUMAROL (NICOUMALONE) ACENOCOUMAROL (NICOUMALONE) Tab Orl 4mg Sintrom PAL AEFGVW HEPARIN GROUP GROUPE DE L HÉPARINE HEPARIN HÉPARINE Liq Inj 100IU Heparin LEO W Liq Liq Inj 10,000IU Heparin * LEO AEFGV Liq DALTEPARIN DALTÉPARINE Liq Inj 5,000IU Fragmin (prefilled syringe) PFI W Liq Liq Inj 7,500IU Fragmin (prefilled syringe) PFI W Liq Liq Inj 10,000IU Fragmin (prefilled syringe) * PFI AEF18+V Liq Fragmin (prefilled syringe) PFI W Liq Inj 12,500IU Fragmin (prefilled syringe)* PFI AEF18+V Liq Fragmin (prefilled syringe) PFI W Liq Inj 15,000IU Fragmin (prefilled syringe) PFI W Liq Fragmin (prefilled syringe) * PFI AEF18+V Liq Inj 18,000IU Fragmin (prefilled syringe) PFI W Liq Fragmin (prefilled syringe) * PFI AEF18+V B01AB05 Liq Inj 25,000IU Fragmin * PFI AEF18+V Liq Fragmin PFI W ENOXAPARIN ÉNOXAPARINE Liq Inj 30mg/0.3mL Lovenox (prefilled syringe) SAV W Liq Liq Inj 40mg/0.4mL Lovenox (prefilled syringe) SAV W Liq Liq Inj 60mg/0.6mL Lovenox (prefilled syringe) SAV W Liq Liq Inj 80mg/0.8mL Lovenox (prefilled syringe) SAV W Liq February 2014 / février 2014 Page 20

33 B01AB05 ENOXAPARIN ÉNOXAPARINE Liq Inj 100mg/mL Lovenox (prefilled syringe) SAV W Liq Liq Inj 300mg/3mL Lovenox SAV W Liq Lovenox * SAV AEF18+V Liq Inj 120mg/0.8mL Lovenox HP (prefilled syringe) SAV W Liq Lovenox HP (prefilled syringe) * SAV AEF18+V B01AB06 B01AB10 B01AC B01AC04 B01AC05 Liq Inj 150mg/mL Lovenox HP (prefilled syringe) SAV W Liq Lovenox HP (prefilled syringe) * SAV AEF18+V NADROPARIN NADROPARINE Liq Inj 19000IU Fraxiparin Forte (prefilled syringe) * GSK AEF18+V Liq Fraxiparin Forte (prefilled syringe) GSK W TINZAPARIN TINZAPARINE Liq Inj 10000IU/mL Innohep * LEO AEF18+V Liq Innohep LEO W Innohep (prefilled syringe) LEO W Liq Inj 20000IU/mL Innohep * LEO AEF18+V Liq Innohep LEO W Innohep (prefilled syringe) LEO W Innohep (prefilled syringe) * LEO AEF18+V PLATELET AGGREGATION INHIBITORS EXCLUDING HEPARIN INHIBITEURS D AGRÉGATION PLAQUETTAIRE, À L EXCLUSION DE HÉPARINE CLOPIDOGREL CLOPIDOGREL Tab Orl 75mg Plavix SAV f W Apo-Clopidogrel APX f W Teva-Clopidogrel TEV f W Co-Clopidogrel COB f W pms-clopidogrel PMS f W Mylan-Clopidogrel MYL f W Sandoz Clopidogrel SDZ f W Ran-Clopidogrel RAN f W Clopidogrel SAS f W Mint-Clopidogrel MNT f W TICLOPIDINE TICLOPIDINE Tab Orl 250mg Teva-Ticlopidine TEV f AEFVW Apo-Ticlopidine APX f AEFVW 7 For the treatment of DVT. Annual quantity limits applied. Pour le traitment initial de la thrombose veineuse profonde. Des limites quantitatives annuelles s appliquent. February 2014 / février 2014 Page 21

34 B01AC05 B01AC07 B01AX B02 B02A B01AX06 B02AA B02AA02 B02AA03 TICLOPIDINE TICLOPIDINE Tab Orl 250mg Mylan-Ticlopidine MYL f AEFVW Ticlopidine SAS f AEFVW DIPYRIDAMOLE DIPYRIDAMOLE Tab Orl 25mg Apo-Dipyridamole FC/FE APX f AEFGVW Tab Orl 50mg Apo-Dipyridamole FC/FE APX f AEFGVW Tab Orl 75mg Apo-Dipyridamole FC/FE APX f AEFGVW OTHER ANTITHROMBOTIC AGENTS AUTRES AGENTS ANTITHROMBOTIQUES RIVAROXABAN RIVAROXABAN Tab Orl 10mg Xarelto BAY AEFVW ANTIHAEMORRHAGICS ANTIHÉMORRAGIQUES ANTIFIBRINOLYTICS ANTIFIBRINOLYTIQUES AMINO ACIDS ACIDES AMINÉS TRANEXAMIC ACID ACIDE TRANEXAMIQUE Tab Orl 500mg Cyklokapron PFI f AEFGVW Tranexamic Acid STR f AEFGVW AMINOMETHYLBENZOIC ACID ACIDE AMINOMETHYLBENZOIQUE Cap Orl 500mg Potaba GLE AEFGVW Caps Pwr Orl 2000mg Potaba (Disc/non disp Jul 24/14) GLE AEFGVW Pd. Tab Orl 500mg Potaba GLE AEFGVW 8 For prophylaxis of VTE following total knee replacement surgery. A bi-annual quiantity limit has been establisted. Please refer to Appendix IV for the criteria. Pour la prévention des ETEV chez les patients qui ont subi une arthroplastic totale de la hauche ou du genou. Une quantité limite semestrielle a été établie. Veuillez consulter l annexe IV pour les critères. February 2014 / février 2014 Page 22

35 B03 B03A B03AA B03AA02 ANTIANAEMIC PREPARATIONS PRÉPARATIONS ANTIANÉMIQUES IRON PREPARATIONS PRÉPARATIONS DE FER IRON BIVALENT, ORAL PREPARATIONS FER BIVALENT, PRÉPARATIONS ORALES FERROUS FUMARATE FUMARATE FERREUX Cap Orl 18mg Iron BIF AEFGVW Caps Cap Orl 300mg Neo-Fer NEO AEFGVW Caps Palafer MVL AEFGVW Sus Orl 60mg Palafer MVL AEFGVW Susp. B03AA03 Tab Orl 300mg Ferrous Fumarate JPC AEFGVW FERROUS GLUCONATE GLUCONATE FERREUX Tab Orl 37.5mg Chelated Iron RHG AEFGVW Tab Orl 50mg Fer NSE AEFGVW B03AA07 Tab Orl 300mg Ferrous Gluconate JPC AEFGVW Apo-ferrous Gluconate APX AEFGVW Ferrous Gluconate VTH AEFGVW pms-ferrous Gluconate PVR AEFGVW Novo-Ferrogluc TEV AEFGVW FERROUS SULPHATE SULFATE FERREUX Cap Orl 45mg Mega SR Iron KRI AEFGVW Caps Iron Formula GNC AEFGVW Dps Orl 75mg pms-ferrous Sulfate PMS AEFGVW Gttes ECT Orl 300mg Apo-Ferrous Sulfate-FC APX AEFGVW Ent. Liq Orl 15mg Fer-In-Sol MJO f AEFGVW Liq Ferodan ODN f AEFGVW Jamp Ferrous Sulfate JPC AEFGVW Liq Orl 30mg Jamp Ferrous Sulfate JPC AEFGVW Liq February 2014 / février 2014 Page 23

36 B03AA07 B03AC B03B B03AC01 B03BA B03BA01 B03BB B03X B03BA01 B03XA B03XA01 FERROUS SULPHATE SULFATE FERREUX SRT Orl 160mg Slow-Fe NNC G L.L Syr Orl 30mg Fer-In-Sol MJO AEFGVW Sir. Ferodan ODN AEFGVW pms-ferrous Sulfate PMS AEFGVW Tab Orl 300mg Ferrous Sulfate JPC AEFGVW Ferrous Sulfate PMT AEFGVW pms-ferrous Sulfate PMS AEFGVW IRON TRIVALENT, PARENTERAL PREPARATIONS FER TRIVALENT, PRÉPARATIONS PARENTÉRALES FERRIC OXIDE POLYMALTOSE COMPLEXES FERRIC OXIDE POLYMALTOSE COMPLEXES Liq Inj 50mg Dexiron * MYL AEFGVW Liq Infufer * SDZ AEFGVW VITAMIN B12 AND FOLIC ACID VITAMINE B12 ET ACIDE FOLIQUE VITAMIN B12 (CYANOCOBALAMIN AND DERIVATIVES) VITAMINE B12 (CYANOCOBALAMINE ET DÉRIVÉS) CYANOCOBALAMIN CYANOCOBALAMINE Liq Inj 1000mcg Vitamin B12 * SDZ f AEFGVW Liq Cyanocobalamin * CYI f AEFGVW FOLIC ACID AND DERIVATIVES ACIDE FOLIQUE ET DÉRIVÉS FOLIC ACID ACIDE FOLIQUE Tab Orl 5mg Apo-Folic Acid APX AEFGVW Euro-Folic EUR AEFGVW Jamp-Folic JPC AEFGVW OTHER ANTIANEMIC PREPARATIONS AUTRES PRÉPARATIONS ANTIANÉMIQUES OTHER ANTIANEMIC PREPARATIONS AUTRES PRÉPARATIONS ANTIANÉMIQUES ERYTHROPOIETIN ÉRYTHROPOIETINE Liq Inj 1000IU Eprex JAN W Liq Liq Inj 2000IU Eprex JAN W Liq Liq Inj 3000IU Eprex JAN W Liq February 2014 / février 2014 Page 24

37 B03XA01 ERYTHROPOIETIN ÉRYTHROPOIETINE Liq Inj 4000IU Eprex JAN W Liq Liq Inj 6000IU Eprex JAN W Liq Liq Inj 8000IU Eprex JAN W Liq Liq Inj IU Eprex JAN W Liq B03XA02 Liq Inj 40000IU Eprex JAN W Liq DARBEPOETIN ALFA DARBÉPOÉTINE ALFA Liq Inj 10mcg/0.4mL Aranesp AGA W Liq Liq Inj 20mcg/0.5mL Aranesp AGA W Liq Liq Inj 30mcg Aranesp AGA W Liq Liq Inj 40mcg Aranesp AGA W Liq Liq Inj 50mcg Aranesp AGA W Liq Liq Inj 60mcg Aranesp AGA W Liq Liq Inj 80mcg Aranesp AGA W Liq Liq Inj 100mcg Aranesp AGA W Liq Liq Inj 130mcg Aranesp AGA W Liq Liq Inj 150mcg Aranesp (Disc/non disp Nov. 04/15) AGA W Liq February 2014 / février 2014 Page 25

38 B05 B05C B05CA BLOOD SUBSTITUTES AND PERFUSION SOLUTIONS PRODUITS DE REMPLACEMENT DU SANG ET SOLUTIONS POUR PERFUSION IRRIGATING SOLUTIONS SOLUTIONS POUR IRRIGATION ANTIINFECTIVES ANTI-INFECTIEUX B05CA10 COMBINATIONS COMBINAISONS POLYMYXIN B / NEOMYCIN POLYMYXINE B / NÉOMYCINE Liq Urh IU/40mg Neosporin Irrigating Sol GSK AEFGVW Liq C01 C01A C01AA CARDIAC THERAPY CARDIOTHÉRAPIE CARDIAC GLYCOSIDES GLUCOSIDES CARDIOTONIQUES DIGITALIS GLYCOSIDES GLUCOSIDES DIGITALIQUE C01AA05 DIGOXIN DIGITOXINE Liq Orl 0.05mg Toloxin PDP AEFGVW Liq Tab Orl mg Toloxin PDP AEFGVW Tab Orl 0.125mg Toloxin PDP AEFGVW Tab Orl 0.25mg Toloxin PDP AEFGVW C01B C01BA ANTIARRHYTHMICS, CLASS I AND III ANTIARHYTHMIQUES, CATÉGORIES I ET III ANTIARRHYTHMICS, CLASS IA ANTIARHYTHMIQUES, CATÉGORIE IA C01BA02 PROCAINAMIDE PROCAINAMIDE SRT Orl 250mg Procan SR ERF AEFGVW L.L. SRT Orl 500mg Procan SR ERF AEFGVW L.L. SRT Orl 750mg Procan SR ERF AEFGVW L.L. February 2014 / février 2014 Page 26

39 C01BA03 C01BB C01BB02 C01BC C01BC03 DISOPYRAMIDE DISOPYRAMIDE Cap Orl 100mg Rythmodan SAV AEFGVW Caps Cap Orl 150mg Rythmodan (Disc/non disp July 1/14) SAV AEFGVW Caps ANTIARRHYTHMICS, CLASS IB ANTIARHYTHMIQUES, CATÉGORIE IB MEXILETINE MEXILÉTINE Cap Orl 100mg Novo-Mexiletine TEV f AEFGVW Caps Cap Orl 200mg Novo-Mexiletine TEV f AEFGVW Caps ANTIARRHYTHMICS, CLASS IC ANTIARHYTHMIQUES, CATÉGORIE IC PROPAFENONE PROPAFÉNONE Tab Orl 150mg Rythmol ABB f AEFGVW Apo-Propafenone APX f AEFGVW Mylan-Propafenone MYL f AEFGVW pms-propafenone PMS f AEFGVW Propafenone SAS f AEFGVW Tab Orl 300mg Rythmol ABB f AEFGVW Apo-Propafenone APX f AEFGVW Mylan-Propafenone MYL f AEFGVW pms-propafenone PMS f AEFGVW Propafenone SAS f AEFGVW C01BC04 C01BD C01BD01 FLECAINIDE FLÉCAÏNIDE Tab Orl 50mg Tambocor (Disc/non disp Sep 1/14) VLN f AEFGVW Flecainide AAP f AEFGVW Tab Orl 100mg Tambocor (Disc/non disp Nov 1/14) VLN f AEFGVW Flecainide AAP f AEFGVW ANTIARRHYTHMICS, CLASS III ANTIARHYTHMIQUES, CATÉGORIE III AMIODARONE AMIODARONE Tab Orl 100mg pms-amiodarone PMS AEFGVW February 2014 / février 2014 Page 27

40 C01C C01BD01 C01CA C01CA24 AMIODARONE AMIODARONE Tab Orl 200mg Cordarone PFI f AEFGVW Teva-Amiodarone TEV f AEFGVW ratio-amiodarone (Disc/non disp Jun 29/14) RPH f AEFGVW Mylan-Amiodarone MYL f AEFGVW pms-amiodarone PMS f AEFGVW Sandoz Amiodarone SDZ f AEFGVW Phl-Amiodarone PHL f AEFGVW Apo-Amiodarone APX f AEFGVW Amiodarone SAS f AEFGVW CARDIAC STIMULANTS EXCLUDING CARDIAC GLYCOSIDES CARDIOTONIQUES À L EXCLUSION DES GLYCOSIDES CARDIOTONIQUES ADRENERGIC AND DOPAMINERGIC AGENTS AGENTS ADRÉNERGIQUES ET DOPAMINERGIQUES EPINEPHRINE (CARDIAC STIMULANTS) ÉPINEPHRINE (STIMULANTS CARDIAQUES) Liq Inj 0.15mg Twinject * PAL AEFGVW Liq Allerject SAV AEFGVW Liq Inj 0.3mg Twinject * PAL AEFGVW Liq Allerject SAV AEFGVW Liq Inj 0.5mg Epi Pen Jr * KNG AEFGVW Liq C01D C01DA C01DA02 Liq Inj 1mg Epi Pen * KNG AEFGVW Liq Liq Inj 1mg Adrenalin * ERF AEFGVW Liq VASODILATORS USED IN CARDIAC DISEASES VASODILATATEURS UTILISÉS POUR LES MALADIES CARDIAQUES ORGANIC NITRATES NITRATES ORGANIQUES NITROGLYCERIN (GLYCERYL TRINITRATE) NITROGLYCERINE (TRINITRATE DE GLYCERYLE) Aem Slg 0.4mg Nitrolingual SAV f AEFGVW Aém Rho-Nitro SDZ f AEFGVW Mylan-Nitro SL MYL f AEFGVW Apo-Nitroglycerin APX f AEFGVW Ont Top 2% Nitrol PAL AEFGVW Ont Pth Trd 0.2mg/hr Nitro-Dur FRS f AEFVW Pth Mylan-Nitro Patch MYL f AEFVW Minitran VLN AEFVW Trinipatch PAL AEFV February 2014 / février 2014 Page 28

41 C01DA02 NITROGLYCERIN (GLYCERYL TRINITRATE) NITROGLYCERINE (TRINITRATE DE GLYCERYLE) Pth Trd 0.4mg/hr Nitro-Dur FRS f AEFVW Pth Mylan-Nitro Patch MYL f AEFVW Minitran VLN AEFVW Trinipatch PAL AEFV Pth Trd 0.6mg/hr Nitro-Dur FRS f AEFVW Pth Mylan-Nitro Patch MYL f AEFVW Minitran VLN AEFVW Trinipatch PAL AEFV Pth Trd 0.8mg/hr Nitro-Dur FRS f AEFVW Pth Mylan-Nitro Patch MYL f AEFVW Slt Slg 0.3mg Nitrostat PFI AEFGVW S.L. Slt Slg 0.6mg Nitrostat PFI AEFGVW S.L. Srd Trd 0.2mg Transderm-Nitro NVR AEFVW Srd Srd Trd 0.4mg Transderm-Nitro NVR AEFVW Srd C01DA08 Srd Trd 0.6mg Transderm-Nitro NVR AEFVW Srd ISOSORBIDE DINITRATE DINITRATE D ISOSORBIDE Slt Slg 5mg ISDN S/L AAP f AEFGVW S.L. Tab Orl 10mg ISDN AAP f AEFGVW C01DA14 Tab Orl 30mg ISDN AAP f AEFGVW ISOSORBIDE MONONITRATE MONONITRATE D ISOSORBIDE SRT Orl 60mg Imdur AZE f AEFGVW L.L. Apo-ISMN APX f AEFGVW pms-ismn PMS f AEFGVW February 2014 / février 2014 Page 29

42 C02 C02A C02AB C02AB02 ANTIHYPERTENSIVES ANTIHYPERTENSEURS ANTIADRENERGIC AGENTS, CENTRALLY ACTING AGENTS ANTIADRÉNERGIQUES, AGISSANT CENTRALEMENT METHYLDOPA METHYLDOPA METHYLDOPA (RACEMIC) METHYLDOPA (RACEMIQUE) Tab Orl 125mg Methyldopa AAP f AEFGVW Tab Orl 250mg Methyldopa AAP f AEFGVW C02AC C02AC01 Tab Orl 500mg Methyldopa AAP f AEFGVW IMIDAZOLINE RECEPTOR AGONISTS AGONISTES DU RÉCEPTEUR IMIDAZOLINE CLONIDINE CLONIDINE Tab Orl 0.025mg Dixarit BOE f AEFGVW Novo-Clonidine TEV f AEFGVW Tab Orl 0.1mg Catapres BOE f AEFGVW Novo-Clonidine TEV f AEFGVW C02C C02CA C02CA01 Tab Orl 0.2mg Catapres BOE f AEFGVW Apo-Clonidine (Disc/non disp Mar 30/14) APX f AEFGVW Novo-Clonidine TEV f AEFGVW ANTIADRENERGIC AGENTS, PERIPHERALLY ACTING AGENTS ANTIADRÉNERGIQUES, AGISSANT EN PÉRIPHÉRIE ALPHA-ADRENOCEPTOR ANTAGONISTS ALPHABLOQUANT DE L ADRÉNOCEPTEUR PRAZOSIN PRAZOSIN Tab Orl 1mg Apo-Prazo APX f AEFGVW Teva-Prazin TEV f AEFGVW Tab Orl 2mg Apo-Prazo APX f AEFGVW Teva-Prazin TEV f AEFGVW C02CA04 Tab Orl 5mg Apo-Prazo APX f AEFGVW Teva-Prazin TEV f AEFGVW DOXAZOSIN DOXAZOSIN Tab Orl 1mg Cardura PFI f AEF18+V Mylan-Doxazosin MYL f AEF18+V Apo-Doxazosin APX f AEF18+V February 2014 / février 2014 Page 30

43 C02CA04 DOXAZOSIN DOXAZOSIN Tab Orl 1mg Novo-Doxazosin TEV f AEF18+V pms-doxazosin PMS f AEF18+V Tab Orl 2mg Cardura PFI f AEF18+V Mylan-Doxazosin MYL f AEF18+V Apo-Doxazosin APX f AEF18+V Novo-Doxazosin TEV f AEF18+V pms-doxazosin PMS f AEF18+V Tab Orl 4mg Cardura PFI f AEF18+V Mylan-Doxazosin MYL f AEF18+V Apo-Doxazosin APX f AEF18+V Novo-Doxazosin TEV f AEF18+V pms-doxazosin PMS f AEF18+V C02D C02DB ARTERIOLAR SMOOTH MUSCLE, AGENTS ACTING ON MUSCLES LISSES ARTÉRIOLAIRES, AGENTS AGISSANT SUR LES HYDRAZINOPHTHALAZINE DERIVATIVES DÉRIVÉS DU HYDRAZINOPHTHALAZINE C02DB02 HYDRALAZINE HYDRALAZINE Tab Orl 10mg Hydralazine AAP f AEFGVW Tab Orl 25mg Hydralazine AAP f AEFGVW Tab Orl 50mg Hydralazine AAP f AEFGVW C02DC PYRIMIDINE DERIVATIVES DÉRIVÉS DU PYRIMIDINE C02DC01 MINOXIDIL MINOXIDIL Tab Orl 2.5mg Loniten PFI AEFGVW Tab Orl 10mg Loniten PFI AEFGVW C03 C03A C03AA DIURETICS DIURÉTIQUES LOW-CEILING DIURETICS, THIAZIDES DIURÉTIQUES DE PLAFOND BAS, THIAZIDES THIAZIDES, PLAIN THIAZIDES, ORDINAIRE C03AA03 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE Tab Orl 12.5mg pms-hydrochlorothiazide PMS f AEFGVW Apo-Hydro APX f AEFGVW February 2014 / février 2014 Page 31

44 C03AA03 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE Tab Orl 25mg Teva-Hydrochlorothiazide TEV f AEFGVW Apo-Hydro APX f AEFGVW pms-hydrochlorothiazide PMS f AEFGVW Tab Orl 50mg Teva-Hydrazide TEV f AEFGVW Apo-Hydro APX f AEFGVW pms-hydrochlorothiazide PMS f AEFGVW Hydrochlorothiazide SAS f AEFGVW C03B C03BA C03C C03BA04 C03BA08 C03BA11 C03CA C03CA01 Tab Orl 100mg Apo-Hydro APX AEFGVW LOW-CEILING DIURETICS, EXCLUDING THIAZIDES DIURÉTIQUES DE PLAFOND BAS, À L EXCLUSION DES THIAZIDES SULFONAMIDES, PLAIN SULFONAMIDES, ORDINAIRES CHLORTHALIDONE CHLORTHALIDONE Tab Orl 50mg Chlorthalidone AAP f AEFGVW METOLAZONE MÉTOLAZONE Tab Orl 2.5mg Zaroxolyn SAV AEFGVW INDAPAMIDE INDAPAMIDE Tab Orl 1.25mg Lozide SEV f AEFGVW Mylan-Indapamide MYL f AEFGVW Apo-Indapamide APX f AEFGVW pms-indapamide PMS f AEFGVW Jamp-Indapamide JPC f AEFGVW Tab Orl 2.5mg Lozide SEV f AEFGVW Mylan-Indapamide MYL f AEFGVW Apo-Indapamide APX f AEFGVW Novo-Indapamide TEV f AEFGVW pms-indapamide PMS f AEFGVW Jamp-Indapamide JPC f AEFGVW HIGH-CEILING DIURETICS DIURÉTIQUES À PLAFOND ÉLEVÉ SULFONAMIDES, PLAIN SULFONAMIDES, ORDINAIRES FUROSEMIDE FUROSEMIDE Liq Inj 10mg Furosemide SDZ VW Liq Furosemide SDZ f VW February 2014 / février 2014 Page 32

45 C03CA01 FUROSEMIDE FUROSEMIDE Liq Orl 10mg Lasix SAV AEFGVW Liq Tab Orl 20mg Teva-Furosemide TEV f AEFGVW Apo-Furosemide APX f AEFGVW Lasix (Disc/non disp Jun 30/14) SAV f AEFGVW pms-furosemide PMS f AEFGVW Furosemide SAS f AEFGVW Tab Orl 40mg Lasix (Disc/non disp Apr 1/14) SAV f AEFGVW pms-furosemide PMS f AEFGVW Furosemide SAS f AEFGVW Tab Orl 80mg Apo-Furosemide APX f AEFGVW Teva-Furosemide TEV f AEFGVW Furosemide SAS f AEFGVW C03CC C03CC01 Tab Orl 500mg Lasix Special SAV AEFGVW ARYLOXYACETIC ACID DERIVATIVES DÉRIVÉS DE L ACIDE ARYLOXYACÉTIQUE ETHACRYNIC ACID ACIDE ETHACRYNIQUE Tab Orl 25mg Edecrin VLN AEFGVW C03D C03DA C03DA01 C03DB C03DB01 POTASSIUM-SPARING DRUGS MÉDICAMENTS D ÉPARGNE DE POTASSIUM ALDOSTERONE ANTAGONISTS ANTAGONISTES DE L ALDOSTÉRONE SPIRONOLACTONE SPIRONOLACTONE Tab Orl 25mg Aldactone PFI f AEFGVW Teva-Spiroton TEV f AEFGVW Tab Orl 100mg Aldactone PFI f AEFGVW Teva-Spiroton TEV f AEFGVW OTHER POTASSIUM-SPARING AGENTS AUTRES MÉDICAMENTS D ÉPARGNE DE POTASSIUM AMILORIDE AMILORIDE Tab Orl 5mg Midamor AAP f AEFGVW February 2014 / février 2014 Page 33

46 C03E C03EA C03EA01 DIURETICS AND POTASSIUM-SPARING AGENTS IN COMBINATION DIURÉTIQUES ET MÉDICAMENTS D ÉPARGNE DE POTASSIUM EN COMBINAISON LOW-CEILING DIURETICS AND POTASSIUM-SPARING AGENTS DIURÉTIQUES DE PLAFOND BAS ET MÉDICAMENTS D ÉPARGNE DE POTASSIUM EN COMBINAISON HYDROCHLOROTHIAZIDE AND POTASSIUM-SPARING DRUGS HYDROCHLOROTHIAZIDE ET MÉDICAMENTS D ÉPARGNE DE POTASSIUM HYDROCHLOROTHIAZIDE / AMILORIDE HYDROCHLOROTHIAZIDE / AMILORIDE Tab Orl 50mg/5mg Apo-Amilzide APX f AEFGVW Novamilor TEV f AEFGVW Mylan-Amilazide (Disc/non disp Jun 5/14) MYL f AEFGVW HYDROCHLOROTHIAZIDE / SPIRONOLACTONE HYDROCHLOROTHIAZIDE / SPIRONOLACTONE Tab Orl 25mg/25mg Aldactazide PFI f AEFGVW Teva-Spirozine TEV f AEFGVW Tab Orl 50mg/50mg Aldactazide PFI f AEFGVW Teva-Spirozine TEV f AEFGVW TRIAMTERENE / HYDROCHLOROTHIAZIDE TRIAMTERENE / HYDROCHLOROTHIAZIDE Tab Orl 50mg/25mg Apo-Triazide APX f AEFGVW Teva-Triamterene/HCTZ TEV f AEFGVW C04 C04A C04AA C05 C05A C04AA02 C05AA C05AA01 PERIPHERAL VASODILATORS VASODILATATEURS PÉRIPHÉRIQUES PERIPHERAL VASODILATORS VASODILATATEURS PÉRIPHÉRIQUES 2-AMINO-1-PHENYLETHANOL DERIVATIVES DÉRIVÉS DU 2-AMINO-1 PHÉNYLÉTHANOL BUPHENINE (HYLIDRIN) BUPHENINE (HYLIDRINE) Tab Orl 6mg Arlidin ERF AEFGVW VASOPROTECTIVES VASOPROTECTEURS AGENTS FOR TREATMENT OF HEMORRHOIDS & ANAL FISSURES FOR TOPICAL USE AGENTS POUR LE TRAITEMENT DES HÉMORROÏDES ET FISSURES ANALES / USAGE TOPIQUE CORTICOSTEROIDS CORTICOSTÉROÏDES HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE / ZINC HYDROCORTISONE / ZINC Ont Rt 0.5%/0.5% Anusol-HC JNJ f AEFGVW Ont Anodan HC ODN f AEFGVW Sandoz Anuzinc HC SDZ f AEFGVW Ratio-Hemcort HC RPH AEFGVW February 2014 / février 2014 Page 34

47 C05AA01 HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE / ZINC HYDROCORTISONE / ZINC Sup Rt 0.5%/0.5% Anusol-HC JNJ f AEFGVW Supp. Anodan HC ODN f AEFGVW Sab-Anuzinc HC SDZ f AEFGVW Ratio-Hemcort HC RPH AEFGVW Aer Rt 1%/1% Proctofoam HC DUI AEFGVW Aér FRAMYCETIN / ESCULIN / DIBUCAINE / HYDROCORTISONE FRAMYCÉTINE / ESCULINE / DIBUCAINE / HYDROCORTISONE Ont Rt 10mg/10mg/5mg/5mg Proctosedyl AXC f AEFGVW Ont. Sandoz Proctomyxin HC SDZ f AEFGVW Proctol Ointment ODN f AEFGVW Sup Rt 10mg/10mg/5mg/5mg Proctosedyl AXC f AEFGVW Supp. Sandoz Proctomyxin HC Supp SDZ f AEFGVW Proctol Suppositories ODN f AEFGVW HYDROCORTISONE / PRAMOXINE / ZINC HYDROCORTISONE / PRAMOXINE / ZINC Ont Rt 0.5%/1%/0.5% Anugesic-HC JNJ f AEFGVW Ont Proctodan-HC Suppositories ODN f AEFGVW Sandoz-Anuzinc HC Plus (Disc/non disp Mar 21/14) SDZ f AEFGVW C07 C07A C07AA C07AA03 Sup Rt 10mg/20mg/10mg Anugesic-HC JNJ f AEFGVW Supp. Proctodan-HC Suppositories ODN f AEFGVW Sab-Anuzinc HC Plus SDZ f AEFGVW BETA BLOCKING AGENTS BETA-BLOQUANTS BETA BLOCKING AGENTS, PLAIN BETA-BLOQUANTS, ORDINAIRES BETA BLOCKING AGENTS, NON-SELECTIVE BETA-BLOQUANTS, NON SÉLECTIFS PINDOLOL PINDOLOL Tab Orl 5mg Visken NVR f AEFGVW Apo-Pindol APX f AEFGVW Teva-Pindol TEV f AEFGVW pms-pindolol PMS f AEFGVW Sandoz Pindolol SDZ f AEFGVW Tab Orl 10mg Visken NVR f AEFGVW Apo-Pindol APX f AEFGVW Teva-Pindol TEV f AEFGVW pms-pindolol PMS f AEFGVW Sandoz Pindolol SDZ f AEFGVW February 2014 / février 2014 Page 35

48 C07AA03 C07AA05 PINDOLOL PINDOLOL Tab Orl 15mg Visken NVR f AEFGVW Apo-Pindol APX f AEFGVW Teva-Pindol TEV f AEFGVW pms-pindolol PMS f AEFGVW Sandoz Pindolol SDZ f AEFGVW PROPRANOLOL PROPRANOLOL Tab Orl 10mg Apo-Propranolol (Disc/non disp Apr 10/15) APX f AEFGVW Novo-Pranol TEV f AEFGVW Tab Orl 20mg Apo-Propranolol (Disc/non disp Oct 22/15) APX f AEFGVW Novo-Pranol TEV f AEFGVW Tab Orl 40mg Apo-Propranolol (Disc/non disp Apr 10/15) APX f AEFGVW Novo-Pranol TEV f AEFGVW Tab Orl 80mg Apo-Propranolol (Disc/non disp Apr 10/15) APX f AEFGVW Novo-Pranol TEV f AEFGVW C07AA06 Tab Orl 120mg Apo-Propranolol APX f AEFGVW TIMOLOL TIMOLOL Tab Orl 5mg Apo-Timol APX f AEFGVW Teva-Timol TEV f AEFGVW Tab Orl 10mg Apo-Timol APX f AEFGVW Teva-Timol TEV f AEFGVW C07AA07 Tab Orl 20mg Apo-Timol APX f AEFGVW Teva-Timol TEV f AEFGVW SOTALOL SOTALOL Tab Orl 80mg Apo-Sotalol APX f AEFGVW Mylan-Sotalol MYL f AEFGVW Novo-Sotalol TEV f AEFGVW pms-sotalol PMS f AEFGVW Sandoz Sotalol SDZ f AEFGVW Co-Sotalol (Disc/non disp Dec 12/14) COB f AEFGVW Jamp-Sotalol JPC f AEFGVW ratio-sotalol TEV f AEFGVW Tab Orl 160mg ratio-sotalol TEV f AEFGVW Apo-Sotalol APX f AEFGVW Mylan-Sotalol MYL f AEFGVW Novo-Sotalol TEV f AEFGVW pms-sotalol PMS f AEFGVW Sandoz Sotalol SDZ f AEFGVW February 2014 / février 2014 Page 36

49 C07AA07 C07AA12 SOTALOL SOTALOL Tab Orl 160mg Co-Sotalol (Disc/non disp Dec 12/14) COB f AEFGVW Jamp-Sotalol JPC f AEFGVW NADOLOL NADOLOL Tab Orl 40mg Apo-Nadol APX f AEFGVW Teva-Nadolol (Disc/non disp Oct 25/14) TEV f AEFGVW Tab Orl 80mg Apo-Nadol APX f AEFGVW Teva- Nadolol (Disc/non disp Oct 25/14) TEV f AEFGVW C07AB C07AB02 Tab Orl 160mg Apo-Nadol APX f AEFGVW BETA BLOCKING AGENTS, SELECTIVE BETA-BLOQUANTS, SÉLECTIFS METOPROLOL MÉTOPROLOL SRT Orl 100mg Lopresor SR NVR f AEFGVW L.L. Apo-Metoprolol SR APX f AEFGVW Sandoz Metoprolol SR SDZ f AEFGVW SRT Orl 200mg Lopresor SR NVR f AEFGVW L.L. Apo-Metoprolol SR APX f AEFGVW Sandoz Metoprolol SR SDZ f AEFGVW Tab Orl 25mg Apo-Metoprolol APX f AEFGVW pms-metoprolol-l PMS f AEFGVW Mylan-Metoprolol (type L) MYL f AEFGVW Jamp-Metoprolol-L JPC f AEFGVW Tab Orl 50mg Lopresor (coated) NVR f AEFGVW Apo-Metoprolol (uncoated) APX f AEFGVW Teva-Metoprolol (coated) TEV f AEFGVW Apo-Metoprolol type L APX f AEFGVW Teva-Metoprolol (uncoated) TEV f AEFGVW Mylan-Metoprolol (type L) MYL f AEFGVW pms-metoprolol-l PMS f AEFGVW Sandoz Metoprolol (type L) (Disc/non disp Feb 22/14) SDZ f AEFGVW Metoprolol SAS f AEFGVW Sandoz Metoprolol SDZ f AEFGVW Jamp-Metoprolol-L JPC f AEFGVW Tab Orl 100mg Lopresor (coated) NVR f AEFGVW Apo-Metoprolol (uncoated) APX f AEFGVW Teva-Metoprolol (coated) TEV f AEFGVW Apo-Metoprolol type L APX f AEFGVW Teva-Metoprolol (uncoated) TEV f AEFGVW Mylan-Metoprolol (type L) MYL f AEFGVW pms-metoprolol-l PMS f AEFGVW Sandoz Metoprolol (type L) (Disc/non disp Feb 22/14) SDZ f AEFGVW February 2014 / février 2014 Page 37

50 C07AB02 C07AB03 METOPROLOL MÉTOPROLOL Tab Orl 100mg Metoprolol SAS f AEFGVW Sandoz Metoprolol SDZ f AEFGVW Jamp-Metoprolol-L JPC f AEFGVW ATENOLOL ATÉNOLOL Tab Orl 25mg pms-atenolol PMS f AEFGVW Atenolol SIV f AEFGVW Teva-Atenolol TEV f AEFGVW Mylan-Atenolol MYL f AEFGVW Jamp-Atenolol JPC f AEFGVW Mint-Atenolol MNT f AEFGVW Mar-Atenolol MAR f AEFGVW Ran-Atenolol RAN f AEFGVW Tab Orl 50mg Apo-Atenol APX f AEFGVW Tenormin AZE f AEFGVW Mylan-Atenolol MYL f AEFGVW ratio-atenolol TEV f AEFGVW Sandoz Atenolol SDZ f AEFGVW pms-atenolol PMS f AEFGVW Atenolol SIV f AEFGVW Co Atenolol COB f AEFGVW Ran-Atenolol RAN f AEFGVW Jamp-Atenolol JPC f AEFGVW Mint-Atenolol MNT f AEFGVW Septa-Atenolol SPT f AEFGVW Mar-Atenolol MAR f AEFGVW C07AB04 Tab Orl 100mg Apo-Atenol APX f AEFGVW Teva-Atenolol TEV f AEFGVW Tenormin AZE f AEFGVW Mylan-Atenolol MYL f AEFGVW ratio-atenolol TEV f AEFGVW Sandoz Atenolol SDZ f AEFGVW pms-atenolol PMS f AEFGVW Atenolol SIV f AEFGVW Co Atenolol COB f AEFGVW Ran-Atenolol RAN f AEFGVW Jamp-Atenolol JPC f AEFGVW Mint-Atenolol MNT f AEFGVW Septa-Atenolol SPT f AEFGVW Mar-Atenolol MAR f AEFGVW ACEBUTOLOL ACÉBUTOLOL Tab Orl 100mg Sectral (Disc/non disp Jun 30/14) SAV f AEFGVW Apo-Acebutolol APX f AEFGVW Teva-Acebutolol TEV f AEFGVW Mylan-Acebutolol MYL f AEFGVW Mylan-Acebutolol Type S MYL f AEFGVW Acebutolol SAS f AEFGVW February 2014 / février 2014 Page 38

51 C07AB04 ACEBUTOLOL ACÉBUTOLOL Tab Orl 200mg Sectral SAV f AEFGVW Apo-Acebutolol APX f AEFGVW Teva-Acebutolol TEV f AEFGVW Mylan-Acebutolol MYL f AEFGVW Mylan-Acebutolol Type S MYL f AEFGVW Acebutolol SAS f AEFGVW Tab Orl 400mg Sectral SAV f AEFGVW Apo-Acebutolol APX f AEFGVW Teva-Acebutolol TEV f AEFGVW Mylan-Acebutolol MYL f AEFGVW Mylan-Acebutolol Type S MYL f AEFGVW Acebutolol SAS f AEFGVW C07AB07 BISOPROLOL BISOPROLOL Tab Orl 5mg Sandoz Bisoprolol SDZ f AEFVW Apo-Bisoprolol APX f AEFVW Novo-Bisoprolol TEV f AEFVW pms-bisoprolol PMS f AEFVW Mylan-Bisoprolol MYL f AEFVW Bisoprolol SAS f AEFVW Tab Orl 10mg Sandoz Bisoprolol SDZ f AEFVW Apo-Bisoprolol APX f AEFVW Novo-Bisoprolol TEV f AEFVW pms-bisoprolol PMS f AEFVW Mylan-Bisoprolol MYL f AEFVW Bisoprolol SAS f AEFVW C07AG ALPHA AND BETA BLOCKING AGENTS ALPHA-BLOQUANTS ET BETA-BLOQUANTS C07AG01 LABETALOL LABÉTALOL Tab Orl 100mg Trandate PAL f AEFGVW Tab Orl 200mg Trandate PAL f AEFGVW C07AG01 CARVEDILOL CARVÉDILOL Tab Orl 3.125mg pms-carvedilol PMS f AEFV Apo-Carvedilol APX f AEFV Carvedilol SIV f AEFV ratio-carvedilol TEV f AEFV Ran-Carvedilol RAN f AEFV Zym-Carvedilol ZYM f AEFV Mylan-Carvedilol MYL f AEFV Carvidilol SAS f AEFV Jamp-Carvedilol JPC f AEFV February 2014 / février 2014 Page 39

52 C07AG01 CARVEDILOL CARVÉDILOL Tab Orl 6.25mg pms-carvedilol PMS f AEFV Apo-Carvedilol APX f AEFV Carvedilol SIV f AEFV ratio-carvedilol TEV f AEFV Ran-Carvedilol RAN f AEFV Zym-Carvedilol ZYM f AEFV Mylan-Carvedilol MYL f AEFV Carvidilol SAS f AEFV Jamp-Carvedilol JPC f AEFV Tab Orl 12.5mg pms-carvedilol PMS f AEFV Apo-Carvedilol APX f AEFV Carvedilol SIV f AEFV ratio-carvedilol TEV f AEFV Ran-Carvedilol RAN f AEFV Zym-Carvedilol ZYM f AEFV Mylan-Carvedilol MYL f AEFV Carvidilol SAS f AEFV Jamp-Carvedilol JPC f AEFV C07C C07CA C07CA03 Tab Orl 25mg pms-carvedilol PMS f AEFV Apo-Carvedilol APX f AEFV Carvedilol SIV f AEFV ratio-carvedilol TEV f AEFV Ran-Carvedilol RAN f AEFV Zym-Carvedilol ZYM f AEFV Mylan-Carvedilol MYL f AEFV Carvedilol SAS f AEFV Jamp-Carvedilol JPC f AEFV BETA BLOCKING AGENTS AND OTHER DIURETICS BETA-BLOQUANTS ET AUTRES DIURÉTIQUES BETA BLOCKING AGENTS, NON-SELECTIVE, OTHER DIURETICS BETA-BLOQUANTS, NON SÉLECTIFS, AUTRES DIURÉTIQUES PINDOLOL AND OTHER DIURETICS PINDOLOL ET AUTRE DIURÉTIQUES PINDOLOL / HYDROCHLOROTHIAZIDE PINDOLOL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/25mg Viskazide NVR AEFGVW Tab Orl 10mg/50mg Viskazide NVR AEFGVW 9 Requests for coverage of Carvedilol will be considered under special authorization. Please refer to Appendix IV. Prescriptions written by cardiologists or internists do not require special authorization. Subsequent refills by other practitioners will not require special authorization. Les demandes de protection pour le Carvedilol seront examinées sur autorisation spéciale. Veuillez consulter l'annexe IV. Les ordonnances des cardiologistes ou des internistes ne nécessitent pas une autorisation spéciale. Les renouvellements prescrits par d'autres practiciens ne nécessiteront pas d'autorisation spéciale. February 2014 / février 2014 Page 40

53 C07CB C08 C08C C07CB03 C08CA C08CA01 BETA BLOCKING AGENTS, SELECTIVE, AND OTHER DIURETICS BETA-BLOQUANTS, SÉLECTIFS, ET AUTRES DIURÉTIQUES ATENOLOL AND OTHER DIURETICS ATÉNOLOL ET AUTRE DIURÉTIQUES ATENOLOL / CHLORTHALIDONE ATÉNOLOL / CHLORTHALIDONE Tab Orl 50mg/25mg Tenoretic AZE f AEFGVW Apo-Atenidone APX f AEFGVW Teva-Atenolol/Chlorthalidone TEV f AEFGVW Tab Orl 100mg/25mg Tenoretic AZE f AEFGVW Apo-Atenidone APX f AEFGVW Teva-Atenolol/Chlorthalidone TEV f AEFGVW CALCIUM CHANNEL BLOCKERS ANTAGONISTES DU CALCIUM SELECTIVE CALCIUM CHANNEL BLOCKERS WITH MAINLY VASCULAR EFFECTS ANTAGONISTES DU CALCIUM SÉLECTIFS AVEC PRINCIPALEMENT DES EFFETS VASCULAIRES DIHYDROPYRIDINE DERIVATIVES DÉRIVÉS DU DIHYDROPYRIDINE AMLODIPINE AMLODIPINE Tab Orl 2.5mg pms-amlodipine PMS f AEFVW Co Amlodipine COB f AEFVW Amlodipine PDL f AEFVW Sandoz Amlodipine SDZ f AEFVW Jamp-Amlodipine JPC f AEFVW Mar-Amlodipine MAR f AEFVW Septa-Amlodipine SPT f AEFVW Ran-Amlodipine RAN f AEFVW Tab Orl 5mg Norvasc PFI f AEFVW Teva-Amlodipine TEV f AEFVW ratio-amlodipine RPH f AEFVW Mylan-Amlodipine MYL f AEFVW Apo-Amlodipine APX f AEFVW GD-Amlodipine GMD f AEFVW pms-amlodipine PMS f AEFVW Sandoz Amlodipine SDZ f AEFVW Co Amlodipine COB f AEFVW Ran-Amlodipine RAN f AEFVW Phl-Amlodipine PHL f AEFVW Amlodipine PDL f AEFVW Jamp-Amlodipine JPC f AEFVW Amlodipine SAS f AEFVW Jamp-Amlodipine (new formulation) JPC f AEFVW Septa-Amlodipine SPT f AEFVW Mint-Amlodipine MNT f AEFVW Mar-Amlodipine MAR f AEFVW Amlodipine-Odan ODN f AEFVW Auro-Amlodipine ARO f AEFVW February 2014 / février 2014 Page 41

54 C08CA01 C08CA02 AMLODIPINE AMLODIPINE Tab Orl 10mg Norvasc PFI f AEFVW Teva-Amlodipine TEV f AEFVW ratio-amlodipine RPH f AEFVW Mylan-Amlodipine MYL f AEFVW Apo-Amlodipine APX f AEFVW GD-Amlodipine GMD f AEFVW pms-amlodipine PMS f AEFVW Sandoz Amlodipine SDZ f AEFVW Co Amlodipine COB f AEFVW Ran-Amlodipine RAN f AEFVW Phl-Amlodipine PHL f AEFVW Amlodipine PDL f AEFVW Jamp-Amlodipine JPC f AEFVW Amlodipine SAS f AEFVW Jamp-Amlodipine (new formulation) JPC f AEFVW Septa-Amlodipine SPT f AEFVW Mar-Amlodipine MAR f AEFVW Amlodipine-Odan ODN f AEFVW Auro-Amlodipine ARO f AEFVW Mint-Amlodipine MNT f AEFVW FELODIPINE FÉLODIPINE SRT Orl 2.5mg Plendil AZE f AEFVW L.L. Renedil (Disc/non disp Sep 18/15) SAV f AEFVW SRT Orl 5mg Plendil AZE f AEFVW L.L. Renedil (Disc/non disp Aug 6/15) SAV f AEFVW Sandoz Felodipine SDZ f AEFVW C08CA05 SRT Orl 10mg Plendil AZE f AEFVW L.L. Renedil (Disc/non disp Apr 29/15) SAV f AEFVW Sandoz Felodipine SDZ f AEFVW NIFEDIPINE NIFÉDIPINE Cap Orl 5mg Nifedipine AAP f AEFGVW Caps Cap Orl 10mg Nifedipine AAP f AEFGVW Caps ERT Orl 20mg Adalat XL BAY f AEFGVW L.P. ERT Orl 30mg Adalat XL BAY f AEFGVW L.P. Mylan-Nifedipine Extended Release MYL f AEFGVW ERT Orl 60mg Adalat XL BAY f AEFGVW L.P. Mylan-Nifedipine Extended Release MYL f AEFGVW February 2014 / février 2014 Page 42

55 C08D C08DA C08DA01 SELECTIVE CALCIUM CHANNEL BLOCKERS WITH DIRECT CARDIAC EFFECTS ANTAGONISTES DU CALCIUM SÉLECTIFS AVEC EFFETS CARDIAQUES DIRECTS PHENYLALKYLAMINE DERIVATIVES DÉRIVÉS DU PHÉNYLALKYLAMINE VERAPAMIL VÉRAPAMIL SRT Orl 180mg Isoptin SR ABB f AEFGVW L.L. Mylan-Verapamil MYL f AEFGVW Apo-Verap SR APX f AEFGVW Covera-HS PFI AEFVW SRT Orl 240mg Isoptin SR ABB f AEFGVW L.L. Mylan-Verapamil MYL f AEFGVW pms-verapamil SR PMS f AEFGVW Apo-Verap SR APX f AEFGVW Novo-Veramil SR TEV AEFGVW Covera-HS PFI AEFGV Tab Orl 80mg Apo-Verap APX f AEFGVW Mylan-Verapamil MYL f AEFGVW C08DB C08DB01 Tab Orl 120mg Apo-Verap APX f AEFGVW Mylan-Verapamil MYL f AEFGVW BENZOTHIAZEPINE DERIVATIVES DÉRIVÉS DU BENZOTHIAZÉPINE DILTIAZEM DILTIAZEM CD Orl 120mg Cardizem CD VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) RPH f AEFGVW Teva-Diltazem CD TEV f AEFGVW Sandoz Diltiazem CD SDZ f AEFGVW pms-diltiazem CD PMS f AEFGVW Co Diltiazem CD COB f AEFGVW Diltiazem CD SAS f AEFGVW CD Orl 180mg Cardizem CD VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD APX f AEFGVW ratio-diltiazem CD (Disc/non disp June 29/14) RPH f AEFGVW Teva-Diltazem CD TEV f AEFGVW Sandoz Diltiazem CD SDZ f AEFGVW pms-diltiazem CD PMS f AEFGVW Co Diltiazem CD COB f AEFGVW Diltiazem CD SAS f AEFGVW CD Orl 240mg Cardizem CD VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) RPH f AEFGVW Teva-Diltazem CD TEV f AEFGVW Sandoz Diltiazem CD SDZ f AEFGVW February 2014 / février 2014 Page 43

56 C08DB01 DILTIAZEM DILTIAZEM CD Orl 240mg pms-diltiazem CD PMS f AEFGVW Caps.L.C. Co Diltiazem CD COB f AEFGVW Diltiazem CD SAS f AEFGVW CD Orl 300mg Cardizem CD VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) RPH f AEFGVW Teva-Diltazem CD TEV f AEFGVW Sandoz Diltiazem CD SDZ f AEFGVW pms-diltiazem CD PMS f AEFGVW Co Diltiazem CD COB f AEFGVW Diltiazem CD SAS f AEFGVW ERC Orl 120mg Tiazac VLN f AEFVW Caps.L.P Sandoz Diltiazem T SDZ f AEFVW Teva-Diltiazem ER TEV f AEFVW Apo-Diltiaz TZ APX f AEFVW Co Diltiazem T COB f AEFVW ERC Orl 180mg Tiazac VLN f AEFVW Caps.L.P Sandoz Diltiazem T SDZ f AEFVW Teva-Diltiazem ER TEV f AEFVW Apo-Diltiaz TZ APX f AEFVW Co Diltiazem T COB f AEFVW ERC Orl 240mg Tiazac VLN f AEFVW Caps.L.P Sandoz Diltiazem T SDZ f AEFVW Teva-Diltiazem ER TEV f AEFVW Apo-Diltiaz TZ APX f AEFVW Co Diltiazem T COB f AEFVW ERC Orl 300mg Tiazac VLN f AEFVW Caps.L.P Sandoz Diltiazem T SDZ f AEFVW Teva-Diltiazem ER TEV f AEFVW Apo-Diltiaz TZ APX f AEFVW Co Diltiazem T COB f AEFVW ERC Orl 360mg Tiazac VLN f AEFVW Caps.L.P Sandoz Diltiazem T SDZ f AEFVW Teva-Diltiazem ER TEV f AEFVW Apo-Diltiaz TZ APX f AEFVW Co Diltiazem T COB f AEFVW ERT Orl 120mg Tiazac XC VLN AEFGVW L.P. ERT Orl 180mg Tiazac XC VLN AEFGVW L.P. ERT Orl 240mg Tiazac XC VLN AEFGVW L.P. February 2014 / février 2014 Page 44

57 C08DB01 DILTIAZEM DILTIAZEM ERT Orl 300mg Tiazac XC VLN AEFGVW L.P. ERT Orl 360mg Tiazac XC VLN AEFGVW L.P. Tab Orl 30mg Apo-Diltiaz APX f AEFGVW Teva-Diltiazem TEV f AEFGVW Tab Orl 60mg Apo-Diltiaz APX f AEFGVW Teva-Diltiazem TEV f AEFGVW C09 C09A C09AA C09AA01 AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM AGENTS AGISSANT SUR LE SYSTÈME RÉNINE-ANGIOTENSINE ACE INHIBITORS, PLAIN INHIBITEUR DE L ENZYME CONVERTISSANT L ANGIOTENSINE, ORDINAIRE ACE INHIBITORS, PLAIN INHIBITEUR DE L ENZYME CONVERTISSANT L ANGIOTENSINE, ORDINAIRE CAPTOPRIL CAPTOPRIL Tab Orl 12.5mg Apo-Capto APX f AEFGVW Teva-Captoril TEV f AEFGVW Mylan-Captopril MYL f AEFGVW Tab Orl 25mg Apo-Capto APX f AEFGVW Teva-Captoril TEV f AEFGVW Mylan-Captopril MYL f AEFGVW Tab Orl 50mg Apo-Capto APX f AEFGVW Teva-Captoril TEV f AEFGVW Mylan-Captopril MYL f AEFGVW Tab Orl 100mg Apo-Capto APX f AEFGVW Teva-Captoril TEV f AEFGVW Mylan-Captopril MYL f AEFGVW C09AA02 ENALAPRIL ÉNALAPRIL Tab Orl 2.5mg Vasotec FRS f AEFGVW Apo-Enalapril APX f AEFGVW Co Enalapril COB f AEFGVW Sandoz Enalapril SDZ f AEFGVW Mylan-Enalapril MYL f AEFGVW Teva-Enalapril TEV f AEFGVW Ran-Enalapril RAN f AEFGVW pms-enalapril PMS f AEFGVW Enalapril SAS f AEFGVW February 2014 / février 2014 Page 45

58 C09AA02 ENALAPRIL ÉNALAPRIL Tab Orl 5mg Vasotec FRS f AEFGVW Apo-Enalapril APX f AEFGVW Co Enalapril COB f AEFGVW Sandoz Enalapril SDZ f AEFGVW Mylan-Enalapril MYL f AEFGVW Teva-Enalapril TEV f AEFGVW Ran-Enalapril RAN f AEFGVW pms-enalapril PMS f AEFGVW Enalapril SAS f AEFGVW Tab Orl 10mg Vasotec FRS f AEFGVW Apo-Enalapril APX f AEFGVW Co Enalapril COB f AEFGVW Sandoz Enalapril SDZ f AEFGVW Mylan-Enalapril MYL f AEFGVW Teva-Enalapril TEV f AEFGVW Ran-Enalapril RAN f AEFGVW pms-enalapril PMS f AEFGVW Enalapril SAS f AEFGVW Tab Orl 20mg Vasotec FRS f AEFGVW Apo-Enalapril APX f AEFGVW Co Enalapril COB f AEFGVW Sandoz Enalapril SDZ f AEFGVW Mylan-Enalapril MYL f AEFGVW Teva-Enalapril TEV f AEFGVW Ran-Enalapril RAN f AEFGVW pms-enalapril PMS f AEFGVW Enalapril SAS f AEFGVW C09AA03 LISINOPRIL LISINOPRIL Tab Orl 5mg Prinivil FRS f AEFGVW Zestril AZE f AEFGVW Apo-Lisinopril APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) RPH f AEFGVW Co Lisinopril COB f AEFGVW Mylan-Lisinopril MYL f AEFGVW Teva-Lisinopril P TEV f AEFGVW Teva-Lisinopril Z TEV f AEFGVW Sandoz Lisinopril SDZ f AEFGVW pms-lisinopril PMS f AEFGVW Ran-Lisinopril RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) RPH f AEFGVW Jamp-Lisinopril JPC f AEFGVW Auro-Lisinopril ARO f AEFGVW 10 Each tablet is made with 2.5mg, 5mg, 10mg or 20mg of enalapril maleate that appears as 2mg, 4mg, 8mg, 16mg of enalapril sodium, respectively, in the finished tablets. Chaque comprimé est compose de 2,5mg, 5mg, 10mg ou 20mg de maleate d énalapril contenant respectivement 2mg, 4mg, 8mg ou 16mg de sodium d énalapril, dans les comprimés en version finale. February 2014 / février 2014 Page 46

59 C09AA03 LISINOPRIL LISINOPRIL Tab Orl 10mg Prinivil FRS f AEFGVW Zestril AZE f AEFGVW Apo-Lisinopril APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) RPH f AEFGVW Co Lisinopril COB f AEFGVW Mylan-Lisinopril MYL f AEFGVW Teva-Lisinopril P TEV f AEFGVW Teva-Lisinopril Z TEV f AEFGVW Sandoz Lisinopril SDZ f AEFGVW pms-lisinopril PMS f AEFGVW Ran-Lisinopril RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) RPH f AEFGVW Jamp-Lisinopril JPC f AEFGVW Auro-Lisinopril ARO f AEFGVW Tab Orl 20mg Prinivil FRS f AEFGVW Zestril AZE f AEFGVW Apo-Lisinopril APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) RPH f AEFGVW Co Lisinopril COB f AEFGVW Mylan-Lisinopril MYL f AEFGVW Teva-Lisinopril P TEV f AEFGVW Teva-Lisinopril Z TEV f AEFGVW Sandoz Lisinopril SDZ f AEFGVW pms-lisinopril PMS f AEFGVW Ran-Lisinopril RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) RPH f AEFGVW Jamp-Lisinopril JPC f AEFGVW Auro-Lisinopril ARO f AEFGVW C09AA04 PERINDOPRIL PERINDOPRIL Tab Orl 2mg Coversyl SEV AEFGVW Tab Orl 4mg Coversyl SEV AEFGVW Tab Orl 8mg Coversyl SEV f AEFGVW C09AA05 RAMIPRIL RAMIPRIL Cap Orl 1.25mg Altace SAV f AEFGVW Caps Apo-Ramipril APX f AEFGVW ratio-ramipril RPH f AEFGVW pms-ramipril PMS f AEFGVW Co Ramipril COB f AEFGVW Mylan-Ramipril MYL f AEFGVW February 2014 / février 2014 Page 47

60 C09AA05 RAMIPRIL RAMIPRIL Cap Orl 1.25mg Ran-Ramipril RAN f AEFGVW Caps Jamp-Ramipril JPC f AEFGVW Auro-Ramipril ARO f AEFGVW Cap Orl 2.5mg Altace SAV f AEFGVW Caps pms-ramipril PMS f AEFGVW Teva-Ramipril TEV f AEFGVW Apo-Ramipril APX f AEFGVW ratio-ramipril RPH f AEFGVW Co Ramipril COB f AEFGVW Mylan-Ramipril MYL f AEFGVW Ran-Ramipril RAN f AEFGVW Jamp-Ramipril JPC f AEFGVW Ramipril SAS f AEFGVW Auro-Ramipril ARO f AEFGVW Cap Orl 5mg Altace SAV f AEFGVW Caps pms-ramipril PMS f AEFGVW Teva-Ramipril TEV f AEFGVW Apo-Ramipril APX f AEFGVW Co Ramipril COB f AEFGVW Mylan-Ramipril MYL f AEFGVW Ran-Ramipril RAN f AEFGVW Jamp-Ramipril JPC f AEFGVW Ramipril SAS f AEFGVW Auro-Ramipril ARO f AEFGVW Cap Orl 10mg Altace SAV f AEFGVW Caps pms-ramipril PMS f AEFGVW Teva-Ramipril TEV f AEFGVW Apo-Ramipril APX f AEFGVW Co Ramipril COB f AEFGVW Mylan-Ramipril MYL f AEFGVW Ran-Ramipril RAN f AEFGVW Jamp-Ramipril JPC f AEFGVW Ramipril SAS f AEFGVW Auro-Ramipril ARO f AEFGVW Cap Orl 15mg Altace SAV f AEFGVW Caps Apo-Ramipril APX f AEFGVW Tab Orl 1.25mg Sandoz Ramipril SDZ AEFGVW Tab Orl 2.5mg Sandoz Ramipril SDZ AEFGVW Tab Orl 5mg Sandoz Ramipril SDZ AEFGVW Tab Orl 10mg Sandoz Ramipril SDZ AEFGVW February 2014 / février 2014 Page 48

61 C09AA06 QUINAPRIL QUINAPRIL Tab Orl 5mg Accupril PFI f AEFGVW Apo-Quinapril APX f AEFGVW Tab Orl 10mg Accupril PFI f AEFGVW Apo-Quinapril APX f AEFGVW C09AA07 Tab Orl 20mg Accupril PFI f AEFGVW Apo-Quinapril APX f AEFGVW Tab Orl 40mg Accupril PFI f AEFGVW Apo-Quinapril APX f AEFGVW BENAZEPRIL BÉNAZÉPRIL Tab Orl 5mg Lotensin NVR f AEFGVW Benazapril AAP f AEFGVW Tab Orl 10mg Lotensin (Disc/non disp Apr 3/14) NVR f AEFGVW Benazapril AAP f AEFGVW C09AA08 Tab Orl 20mg Lotensin NVR f AEFGVW Benazapril AAP f AEFGVW CILAZAPRIL CILAZAPRIL Tab Orl 1mg Novo-Cilazapril TEV f AEFGVW pms-cilazapril PMS f AEFGVW Mylan-Cilazapril MYL f AEFGVW Apo-Cilazapril APX f AEFGVW Cilazapril (Disc/non disp Jan 1/15) SAS f AEFGVW Tab Orl 2.5mg Inhibace HLR f AEFGVW Novo-Cilazapril TEV f AEFGVW pms-cilazapril PMS f AEFGVW Mylan-Cilazapril MYL f AEFGVW Co-Cilazapril COB f AEFGVW Apo-Cilazapril APX f AEFGVW Cilazapril SAS f AEFGVW Tab Orl 5mg Inhibace HLR f AEFGVW Novo-Cilazapril TEV f AEFGVW pms-cilazapril PMS f AEFGVW Mylan-Cilazapril MYL f AEFGVW Co-Cilazapril COB f AEFGVW Apo-Cilazapril APX f AEFGVW Cilazapril SAS f AEFGVW C09AA09 FOSINOPRIL FOSINOPRIL Tab Orl 10mg Monopril (Disc/non disp Jun 17/15) BRI f AEFGVW Teva-Fosinopril TEV f AEFGVW February 2014 / février 2014 Page 49

62 C09AA09 C09AA09 FOSINOPRIL FOSINOPRIL Tab Orl 10mg Mylan-Fosinopril MYL f AEFGVW Apo-Fosinopril APX f AEFGVW Ran-Fosinopril RAN f AEFGVW Jamp-Fosinopril JPC f AEFGVW Tab Orl 20mg Monopril (Disc/non disp Jun 17/15) BRI f AEFGVW Teva-Fosinopril TEV f AEFGVW Mylan-Fosinopril MYL f AEFGVW Apo-Fosinopril APX f AEFGVW Ran-Fosinopril RAN f AEFGVW Jamp-Fosinopril JPC f AEFGVW TRANDOLAPRIL TRANDOLAPRIL Cap Orl 1mg Mavik ABB AEFGVW Caps Cap Orl 2mg Mavik ABB AEFGVW Caps C09B C09BA C09BA02 Cap Orl 4mg Mavik ABB AEFGVW Caps ACE-INHIBITORS, COMBINATIONS INHIBITEUR DE L ENZYME CONVERTISSANT L ANGIOTENSINE, COMBINAISONS ACE-INHIBITORS AND DIURETICS INHIBITEUR DE L ENZYME CONVERTISSANT L ANGIOTENSINE, ET DIURÉTIQUES ENALAPRIL AND DIURETICS ÉNALAPRIL ET DIURÉTIQUES ENALAPRIL / HYDROCHLOROTHIAZIDE ÉNALAPRIL / HYDROCHLOROTHIAZIDE Tab Orl 5mg/12.5mg Novo-Enalapril/HCT TEV f AEFGVW Apo-Enalapril/HCTZ APX f AEFGVW Tab Orl 10mg/25mg Vaseretic FRS f AEFGVW Novo-Enalapril/HCT TEV f AEFGVW Apo-Enalapril/HCTZ APX f AEFGVW C09BA03 LISINOPRIL AND DIURETICS LISINOPRIL ET DIURÉTIQUES LISINOPRIL / HYDROCHLOROTHIAZIDE LISINOPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Zestoretic AZE f AEFGVW Apo-Lisinopril/HCTZ APX f AEFGVW Mylan-Lisinopril HCTZ MYL f AEFGVW 11 Each tablet is made with 5mg or 10mg of enalapril maleate that appears as 4mg or 8mg of enalapril sodium, respectively, in the finished tablets. Chaque comprimé est compose de 5mg ou 10mg de maleate d énalapril contenant respectivement 4mg ou 8mg de sodium d énalapril, dans les comprimés en version finale. February 2014 / février 2014 Page 50

63 C09BA03 LISINOPRIL AND DIURETICS LISINOPRIL ET DIURÉTIQUES LISINOPRIL / HYDROCHLOROTHIAZIDE LISINOPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Teva-Lisinopril HCTZ (Type Z) TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) TEV f AEFGVW Sandoz Lisinopril HCT SDZ f AEFGVW Lisinopril HCTZ (Type Z) SAS f AEFGVW Tab Orl 20mg/12.5mg Zestoretic AZE f AEFGVW Prinzide FRS f AEFGVW Apo-Lisinopril/HCTZ APX f AEFGVW Mylan-Lisinopril HCTZ MYL f AEFGVW Teva-Lisinopril HCTZ (Type Z) TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) TEV f AEFGVW Sandoz Lisinopril HCT SDZ f AEFGVW Lisinopril HCTZ (Type Z) SAS f AEFGVW C09BA04 C09BA05 Tab Orl 20mg/25mg Zestoretic AZE f AEFGVW Apo-Lisinopril/HCTZ APX f AEFGVW Mylan-Lisinopril HCTZ MYL f AEFGVW Teva-Lisinopril HCTZ (Type Z) TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) TEV f AEFGVW Sandoz Lisinopril HCT SDZ f AEFGVW Lisinopril HCTZ (Type Z) SAS f AEFGVW PERINDOPRIL AND DIURETICS PERINDOPRIL ET DIURÉTIQUES PERINDOPRIL / INDAPAMIDE PERINDOPRIL / INDAPAMIDE Tab Orl 4mg/1.25mg Coversyl Plus SEV AEFGVW Tab Orl 8mg/2.5mg Coversyl Plus HD SEV AEFGVW RAMIPRIL AND DIURETICS RAMIPRIL ET DIURÉTIQUES RAMIPRIL / HYDROCHLOROTHIAZIDE RAMIPRIL / HYDROCHLOROTHIAZIDE Tab Orl 2.5mg/12.5mg Altace HCT SAV f AEFGVW pms Ramipril-HCTZ PMS f AEFGVW Teva-Ramipril/HCTZ TEV f AEFGVW Tab Orl 5mg/12.5mg Altace HCT SAV f AEFGVW pms Ramipril-HCTZ PMS f AEFGVW Teva-Ramipril/HCTZ TEV f AEFGVW Tab Orl 5mg/25mg Altace HCT SAV f AEFGVW pms Ramipril-HCTZ PMS f AEFGVW Teva-Ramipril/HCTZ TEV f AEFGVW February 2014 / février 2014 Page 51

64 C09BA05 RAMIPRIL AND DIURETICS RAMIPRIL ET DIURÉTIQUES RAMIPRIL / HYDROCHLOROTHIAZIDE RAMIPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Altace HCT SAV f AEFGVW pms Ramipril-HCTZ PMS f AEFGVW Teva-Ramipril/HCTZ TEV f AEFGVW C09BA06 Tab Orl 10mg/25mg Altace HCT SAV f AEFGVW pms Ramipril-HCTZ PMS f AEFGVW Teva-Ramipril/HCTZ TEV f AEFGVW QUINAPRIL AND DIURETICS QUINAPRIL ET DIURÉTIQUES QUINAPRIL / HYDROCHLOROTHIAZIDE QUINAPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Accuretic PFI f AEFGVW Apo-Quinapril/HCTZ APX f AEFGVW Tab Orl 20mg/12.5mg Accuretic PFI f AEFGVW Apo-Quinapril/HCTZ APX f AEFGVW C09C C09BA08 C09CA C09CA01 Tab Orl 20mg/25mg Accuretic PFI f AEFGVW Apo-Quinapril/HCTZ APX f AEFGVW CILAZAPRIL AND DIURETICS CILAZAPRIL ET DIURÉTIQUES CILAZAPRIL / HYDROCHLOROTHIAZIDE CILAZAPRIL / HYDROCHLOROTHIAZIDE Tab Orl 5mg/12.5mg Inhibace Plus HLR f AEFGVW Apo-Cilazapril/HCTZ APX f AEFGVW Novo-Cilazapril/HCTZ TEV f AEFGVW ANGIOTENSIN II ANTAGONISTS, PLAIN ANTAGONISTES DE L ANGIOTENSINE II, ORDINAIRE ANGIOTENSIN II ANTAGONISTS, PLAIN ANTAGONISTES DE L ANGIOTENSINE II, ORDINAIRE LOSARTAN LOSARTAN Tab Orl 25mg Cozaar FRS f AEFGVW pms-losartan PMS f AEFGVW Sandoz Losartan SDZ f AEFGVW Co Losartan COB f AEFGVW Mylan-Losartan MYL f AEFGVW Apo-Losartan APX f AEFGVW Teva-Losartan TEV f AEFGVW Losartan SAS f AEFGVW Jamp-Losartan JPC f AEFGVW Auro-Losartan ARO f AEFGVW Ran-Losartan RAN f AEFGVW February 2014 / février 2014 Page 52

65 C09CA01 C09CA02 C09CA03 LOSARTAN LOSARTAN Tab Orl 50mg Cozaar FRS f AEFGVW pms-losartan PMS f AEFGVW Sandoz Losartan SDZ f AEFGVW Co Losartan COB f AEFGVW Mylan-Losartan MYL f AEFGVW Apo-Losartan APX f AEFGVW Teva-Losartan TEV f AEFGVW Losartan SAS f AEFGVW Jamp-Losartan JPC f AEFGVW Auro-Losartan ARO f AEFGVW Ran-Losartan RAN f AEFGVW Tab Orl 100mg Cozaar FRS f AEFGVW pms-losartan PMS f AEFGVW Sandoz Losartan SDZ f AEFGVW Co Losartan COB f AEFGVW Mylan-Losartan MYL f AEFGVW Apo-Losartan APX f AEFGVW Teva-Losartan TEV f AEFGVW Losartan SAS f AEFGVW Jamp-Losartan JPC f AEFGVW Auro-Losartan ARO f AEFGVW Ran-Losartan RAN f AEFGVW EPROSARTAN ÉPROSARTAN Tab Orl 400mg Teveten ABB AEFGVW Tab Orl 600mg Teveten ABB AEFGVW VALSARTAN VALSARTAN Tab Orl 40mg Diovan NVR f AEFGVW pms-valsartan PMS f AEFGVW Co Valsartan COB f AEFGVW Teva-Valsartan TEV f AEFGVW Sandoz Valsartan SDZ f AEFGVW Ran-Valsartan RAN f AEFGVW Mylan- Valsartan MYL f AEFGVW Apo-Valsartan APX f AEFGVW Valsartan SAS f AEFGVW Tab Orl 80mg Diovan NVR f AEFGVW pms-valsartan PMS f AEFGVW Co Valsartan COB f AEFGVW Teva-Valsartan TEV f AEFGVW Sandoz Valsartan SDZ f AEFGVW Ran-Valsartan RAN f AEFGVW February 2014 / février 2014 Page 53

66 C09CA03 VALSARTAN VALSARTAN Tab Orl 80mg Mylan- Valsartan MYL f AEFGVW Apo-Valsartan APX f AEFGVW Valsartan SAS f AEFGVW Tab Orl 160mg Diovan NVR f AEFGVW pms-valsartan PMS f AEFGVW Co Valsartan COB f AEFGVW Teva-Valsartan TEV f AEFGVW Sandoz Valsartan SDZ f AEFGVW Ran-Valsartan RAN f AEFGVW Mylan- Valsartan MYL f AEFGVW Apo-Valsartan APX f AEFGVW Valsartan SAS f AEFGVW C09CA04 Tab Orl 320mg Diovan NVR f AEFGVW pms-valsartan PMS f AEFGVW Co Valsartan COB f AEFGVW Teva-Valsartan TEV f AEFGVW Sandoz Valsartan SDZ f AEFGVW Mylan- Valsartan MYL f AEFGVW Apo-Valsartan APX f AEFGVW Valsartan SAS f AEFGVW IRBESARTAN IRBESARTAN Tab Orl 75mg Avapro SAV f AEFGVW Teva-Irbesartan TEV f AEFGVW ratio-irbesartan TEV f AEFGVW pms-irbesartan PMS f AEFGVW Co Irbesartan COB f AEFGVW Sandoz Irbesartan SDZ f AEFGVW Mylan-Irbesartan MYL f AEFGVW Irbesartan SAS f AEFGVW Apo-Irbesartan APX f AEFGVW Auro-Irbesartan ARO f AEFGVW Ran-Irbesartan RAN f AEFGVW Tab Orl 150mg Avapro SAV f AEFGVW Teva-Irbesartan TEV f AEFGVW ratio-irbesartan TEV f AEFGVW pms-irbesartan PMS f AEFGVW Co Irbesartan COB f AEFGVW Sandoz Irbesartan SDZ f AEFGVW Mylan-Irbesartan MYL f AEFGVW Irbesartan SAS f AEFGVW Apo-Irbesartan APX f AEFGVW Auro-Irbesartan ARO f AEFGVW Ran-Irbesartan RAN f AEFGVW Tab Orl 300mg Avapro SAV f AEFGVW Teva-Irbesartan TEV f AEFGVW ratio-irbesartan TEV f AEFGVW February 2014 / février 2014 Page 54

67 C09CA04 C09CA06 IRBESARTAN IRBESARTAN Tab Orl 300mg pms-irbesartan PMS f AEFGVW Co Irbesartan COB f AEFGVW Sandoz Irbesartan SDZ f AEFGVW Mylan-Irbesartan MYL f AEFGVW Irbesartan SAS f AEFGVW Apo-Irbesartan APX f AEFGVW Auro-Irbesartan ARO f AEFGVW Ran-Irbesartan RAN f AEFGVW CANDESARTAN CANDÉSARTAN Tab Orl 4mg Atacand AZE f AEFGVW Sandoz Candesartan SDZ f AEFGVW Apo-Candesartan APX f AEFGVW Co Candesartan COB f AEFGVW Mylan-Candesartan MYL f AEFGVW pms-candesartan PMS f AEFGVW Jamp-Candesartan JPC f AEFGVW Candesartan Cilexetil AHI f AEFGVW Candesartan SAS f AEFGVW Ran-Candesartan RAN f AEFGVW Tab Orl 8mg Atacand AZE f AEFGVW Sandoz Candesartan SDZ f AEFGVW Apo-Candesartan APX f AEFGVW Teva-Candesartan TEV f AEFGVW Co Candesartan COB f AEFGVW Mylan-Candesartan MYL f AEFGVW pms-candesartan PMS f AEFGVW Candesartan SAS f AEFGVW Jamp-Candesartan JPC f AEFGVW Candesartan Cilexetil AHI f AEFGVW Ran-Candesartan RAN f AEFGVW Tab Orl 16mg Atacand AZE f AEFGVW Sandoz Candesartan SDZ f AEFGVW Apo-Candesartan APX f AEFGVW Teva-Candesartan TEV f AEFGVW Co Candesartan COB f AEFGVW Mylan-Candesartan MYL f AEFGVW pms-candesartan PMS f AEFGVW Candesartan SAS f AEFGVW Jamp-Candesartan JPC f AEFGVW Candesartan Cilexetil AHI f AEFGVW Ran-Candesartan RAN f AEFGVW Tab Orl 32mg Atacand AZE f AEFGVW Teva-Candesartan TEV f AEFGVW Co Candesartan COB f AEFGVW Mylan-Candesartan MYL f AEFGVW pms-candesartan PMS f AEFGVW Sandoz Candesartan SDZ f AEFGVW February 2014 / février 2014 Page 55

68 C09D C09CA06 C09CA07 C09CA08 C09DA C09DA01 CANDESARTAN CANDÉSARTAN Tab Orl 32mg Jamp-Candesartan JPC f AEFGVW Candesartan Cilexetil AHI f AEFGVW Apo-Candesartan APX f AEFGVW Ran-Candesartan RAN f AEFGVW TELMISARTAN TELMISARTAN Tab Orl 40mg Micardis BOE f AEFGVW Teva-Telmisartan TEV f AEFGVW Sandoz Telmisartan SDZ f AEFGVW Mylan-Telmisartan MYL f AEFGVW pms-telmisartan PMS f AEFGVW Telmisartan SAS f AEFGVW Co-Telmisartan COB f AEFGVW Tab Orl 80mg Micardis BOE f AEFGVW Teva-Telmisartan TEV f AEFGVW Sandoz Telmisartan SDZ f AEFGVW Mylan-Telmisartan MYL f AEFGVW pms-telmisartan PMS f AEFGVW Telmisartan SAS f AEFGVW Co-Telmisartan COB f AEFGVW OLMESARTAN MEDOXOMIL OLMÉSARTAN MÉDOXOMIL Tab Orl 20mg Olmetec FRS AEFGVW Tab Orl 40mg Olmetec FRS AEFGVW ANGIOTENSIN II ANTAGONISTS, COMBINATIONS ANTAGONISTES DE L ANGIOTENSINE II, EN COMBINAISON ANGIOTENSIN II ANTAGONISTS AND DIURETICS ANTAGONISTES DE L ANGIOTENSINE II ET DIURÉTIQUES LOSARTAN AND DIURETICS LOSARTAN ET DIURÉTIQUES LOSARTAN / HYDROCHLOROTHIAZIDE LOSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 50mg/12.5mg Hyzaar FRS f AEFGVW Sandoz Losartan HCT SDZ f AEFGVW Teva-Losartan HCTZ TEV f AEFGVW Apo-Losartan HCTZ APX f AEFGVW Mylan-Losartan HCTZ MYL f AEFGVW pms-losartan-hctz PMS f AEFGVW Co-Losartan/HCT COB f AEFGVW Mint-Losartan/HCTZ MNT f AEFGVW February 2014 / février 2014 Page 56

69 C09DA01 LOSARTAN AND DIURETICS LOSARTAN ET DIURÉTIQUES LOSARTAN / HYDROCHLOROTHIAZIDE LOSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 100mg/12.5mg Hyzaar FRS f AEFGVW Sandoz Losartan HCT SDZ f AEFGVW Teva-Losartan HCTZ TEV f AEFGVW Apo-Losartan HCTZ APX f AEFGVW Mylan-Losartan HCTZ MYL f AEFGVW pms-losartan-hctz PMS f AEFGVW Co-Losartan/HCT COB f AEFGVW Mint-Losartan/HCTZ MNT f AEFGVW Tab Orl 100mg/25mg Hyzaar DS FRS f AEFGVW Sandoz Losartan HCT SDZ f AEFGVW Teva-Losartan HCTZ TEV f AEFGVW Apo-Losartan HCTZ APX f AEFGVW Mylan-Losartan HCTZ MYL f AEFGVW pms-losartan-hctz PMS f AEFGVW Co-Losartan/HCT COB f AEFGVW Mint-Losartan/HCTZ DS MNT f AEFGVW C09DA02 EPROSARTAN AND DIURETICS ÉPROSARTAN ET DIURÉTIQUES EPROSARTAN / HYDROCHLOROTHIAZIDE ÉPROSARTAN / HYDROCHLOROTHIAZIDE C09DA03 Tab Orl 600mg/12.5mg Teveten Plus ABB AEFGVW VALSARTAN AND DIURETICS VALSARTAN ET DIURÉTIQUES VALSARTAN / HYDROCHLOROTHIAZIDE VALSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 80mg/12.5mg Diovan HCT NVR f AEFGVW Sandoz Valsartan HCT SDZ f AEFGVW Teva-Valsartan/ HCTZ TEV f AEFGVW Mylan-Valsartan HCTZ MYL f AEFGVW Apo-Valsartan/HCTZ APX f AEFGVW Valsartan/HCTZ SAS f AEFGVW Tab Orl 160mg/12.5mg Diovan HCT NVR f AEFGVW Sandoz Valsartan HCT SDZ f AEFGVW Teva-Valsartan/ HCTZ TEV f AEFGVW Mylan-Valsartan HCTZ MYL f AEFGVW Apo-Valsartan/HCTZ APX f AEFGVW Valsartan/HCTZ SAS f AEFGVW Diovan HCT NVR f AEFGVW Sandoz Valsartan HCT SDZ f AEFGVW Teva-Valsartan/ HCTZ TEV f AEFGVW Mylan-Valsartan HCTZ MYL f AEFGVW Apo-Valsartan/HCTZ APX f AEFGVW Valsartan/HCTZ SAS f AEFGVW February 2014 / février 2014 Page 57

70 C09DA03 C09DA04 VALSARTAN AND DIURETICS VALSARTAN ET DIURÉTIQUES VALSARTAN / HYDROCHLOROTHIAZIDE VALSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 320mg/12.5mg Diovan HCT NVR f AEFGVW Sandoz Valsartan HCT SDZ f AEFGVW Teva-Valsartan/ HCTZ TEV f AEFGVW Mylan-Valsartan HCTZ MYL f AEFGVW Apo-Valsartan/HCTZ APX f AEFGVW Valsartan/HCTZ SAS f AEFGVW Tab Orl 320mg/25mg Diovan HCT NVR f AEFGVW Sandoz Valsartan HCT SDZ f AEFGVW Teva-Valsartan/ HCTZ TEV f AEFGVW Mylan-Valsartan HCTZ MYL f AEFGVW Apo-Valsartan/HCTZ APX f AEFGVW Valsartan/HCTZ SAS f AEFGVW IRBESARTAN AND DIURETICS IRBESARTAN ET DIURÉTIQUES IRBESARTAN / HYDROCHLOROTHIAZIDE IRBESARTAN / HYDROCHLOROTHIAZIDE Tab Orl 150mg/12.5mg Avalide SAV f AEFGVW Teva-Irbesartan HCTZ TEV f AEFGVW pms-irbesartan HCTZ PMS f AEFGVW ratio-irbesartan HCTZ TEV f AEFGVW Sandoz Irbesartan HCT SDZ f AEFGVW Co Irbesartan HCT COB f AEFGVW Ran-Irbesartan HCTZ RAN f AEFGVW Irbesartan/HCTZ SAS f AEFGVW Apo-Irbesartan/HCTZ APX f AEFGVW Mint-Irbesartan/HCTZ MNT f AEFGVW Tab Orl 300mg/12.5mg Avalide SAV f AEFGVW Teva-Irbesartan HCTZ TEV f AEFGVW pms-irbesartan HCTZ PMS f AEFGVW ratio-irbesartan HCTZ TEV f AEFGVW Sandoz Irbesartan HCT SDZ f AEFGVW Co Irbesartan HCT COB f AEFGVW Ran-Irbesartan HCTZ RAN f AEFGVW Irbesartan/HCTZ SAS f AEFGVW Apo-Irbesartan/HCTZ APX f AEFGVW Mint-Irbesartan/HCTZ MNT f AEFGVW Tab Orl 300mg/25mg Teva-Irbesartan HCTZ TEV f AEFGVW pms-irbesartan HCTZ PMS f AEFGVW ratio-irbesartan HCTZ TEV f AEFGVW Sandoz Irbesartan HCT SDZ f AEFGVW Co Irbesartan HCT COB f AEFGVW Ran-Irbesartan HCTZ RAN f AEFGVW Irbesartan/HCTZ SAS f AEFGVW Apo-Irbesartan/HCTZ APX f AEFGVW Mint-Irbesartan/HCTZ MNT f AEFGVW February 2014 / février 2014 Page 58

71 C09DA06 CANDESARTAN AND DIURETICS CANDÉSARTAN ET DIURÉTIQUES CANDESARTAN / HYDROCHLOROTHIAZIDE CANDÉSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 16mg/12.5mg Atacand Plus AZE f AEFGVW Apo-Candesartan/HCTZ APX f AEFGVW Co-Candesartan/HCT COB f AEFGVW Mylan-Candesartan HCTZ MYL f AEFGVW pms-candesartan-hctz PMS f AEFGVW Sandoz Candesartan Plus SDZ f AEFGVW Candesartan/HCTZ SAS f AEFGVW Teva-Candesartan/HCTZ TEV f AEFGVW Tab Orl 32mg/12.5mg Atacand Plus AZE f AEFGVW Apo-Candesartan/HCTZ APX f AEFGVW Teva-Candesartan/HCTZ TEV f AEFGVW C09DA07 Tab Orl 32mg/25mg Atacand Plus AZE f AEFGVW Apo-Candesartan/HCTZ APX f AEFGVW TELMISARTAN AND DIURETICS TELMISARTAN ET DIURÉTIQUES TELMISARTAN / HYDROCHLOROTHIAZIDE TELMISARTAN / HYDROCHLOROTHIAZIDE Tab Orl 80mg/12.5mg Micardis Plus BOE f AEFGVW Teva-telmisartan HCTZ TEV f AEFGVW Mylan-telmisartan HCTZ MYL f AEFGVW Sandoz Telmisartan HCT SDZ f AEFGVW Telmisartan/HCTZ SAS f AEFGVW Co-Telmisartan/HCT COB f AEFGVW pms-telmisartan/hctz PMS f AEFGVW Tab Orl 80mg/25mg Micardis Plus BOE f AEFGVW Teva-telmisartan HCTZ TEV f AEFGVW Mylan-telmisartan HCTZ MYL f AEFGVW Sandoz Telmisartan HCT SDZ f AEFGVW Telmisartan/HCTZ SAS f AEFGVW Co-Telmisartan/HCT COB f AEFGVW pms-telmisartan/hctz PMS f AEFGVW C09DA08 OLMESARTAN AND DIURETICS OLMÉSARTAN ET DIURÉTIQUES OLMESARTAN / HYDROCHLOROTHIAZIDE OLMÉSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 20mg/12.5mg Olmetec Plus FRS f AEFGVW Tab Orl 40mg/12.5mg Olmetec Plus FRS f AEFGVW Tab Orl 40mg/25mg Olmetec Plus FRS f AEFGVW February 2014 / février 2014 Page 59

72 C09DB C09DB04 ANGIOTENSIN II ANTAGONISTS AND CALCIUM CHANNEL BLOCKERS ANTAGONISTES DE L ANGIOTENSINE II ET ANTAGONISTES DU CALCIUM TELMISARTAN AND AMLODIPINE TELMISARTAN ET AMLODIPINE Tab Orl 40mg/5mg Twynsta BOE AEFGVW Tab Orl 40mg/10mg Twynsta BOE AEFGVW C10 C10A C10AA C10AA01 Tab Orl 80mg/5mg Twynsta BOE AEFGVW Tab Orl 80mg/10mg Twynsta BOE AEFGVW LIPID MODIFYING AGENTS AGENTS RÉDUISANT LES LIPIDES SÉRIQUES LIPID MODIFYING AGENTS, PLAIN AGENTS RÉDUISANT LES LIPIDES SÉRIQUES, ORDINAIRES HMG COA REDUCTASE INHIBITORS INHIBITEURS DU HMG COA-REDUCTASE SIMVASTATIN SIMVASTATINE Tab Orl 5mg Zocor FRS f AEFGVW Mylan-Simvastatin MYL f AEFGVW Apo-Simvastatin APX f AEFGVW Co Simvastatin COB f AEFGVW Teva-Simvastatin TEV f AEFGVW pms-simvastatin PMS f AEFGVW Phl-Simvastatin PHL f AEFGVW Simvastatin SAS f AEFGVW Ran-Simvastatin RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) JPC f AEFGVW Mint-Simvastatin MNT f AEFGVW Mar-Simvastatin MAR f AEFGVW Jamp-Simvastatin JPC f AEFGVW Simvastatin-Odan ODN f AEFGVW Tab Orl 10mg Zocor FRS f AEFGVW Mylan-Simvastatin MYL f AEFGVW Apo-Simvastatin APX f AEFGVW Sandoz Simvastatin SDZ f AEFGVW Co Simvastatin COB f AEFGVW Teva-Simvastatin TEV f AEFGVW pms-simvastatin PMS f AEFGVW Phl-Simvastatin PHL f AEFGVW Simvastatin SAS f AEFGVW Ran-Simvastatin RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) JPC f AEFGVW Mint-Simvastatin MNT f AEFGVW Mar-Simvastatin MAR f AEFGVW February 2014 / février 2014 Page 60

73 C10AA01 SIMVASTATIN SIMVASTATINE Tab Orl 10mg Jamp-Simvastatin JPC f AEFGVW Simvastatin-Odan ODN f AEFGVW Tab Orl 20mg Zocor FRS f AEFGVW Mylan-Simvastatin MYL f AEFGVW Apo-Simvastatin APX f AEFGVW Sandoz Simvastatin SDZ f AEFGVW Co Simvastatin COB f AEFGVW Teva-Simvastatin TEV f AEFGVW pms-simvastatin PMS f AEFGVW Phl-Simvastatin PHL f AEFGVW Simvastatin SAS f AEFGVW Ran-Simvastatin RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) JPC f AEFGVW Mint-Simvastatin MNT f AEFGVW Mar-Simvastatin MAR f AEFGVW Jamp-Simvastatin JPC f AEFGVW Simvastatin-Odan ODN f AEFGVW Tab Orl 40mg Zocor FRS f AEFGVW Mylan-Simvastatin MYL f AEFGVW Apo-Simvastatin APX f AEFGVW Sandoz Simvastatin SDZ f AEFGVW Co Simvastatin COB f AEFGVW Teva-Simvastatin TEV f AEFGVW pms-simvastatin PMS f AEFGVW Phl-Simvastatin PHL f AEFGVW Simvastatin SAS f AEFGVW Ran-Simvastatin RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) JPC f AEFGVW Mint-Simvastatin MNT f AEFGVW Mar-Simvastatin MAR f AEFGVW Jamp-Simvastatin JPC f AEFGVW Simvastatin-Odan ODN f AEFGVW Tab Orl 80mg Zocor FRS f AEFGVW Mylan-Simvastatin MYL f AEFGVW Apo-Simvastatin APX f AEFGVW Sandoz Simvastatin SDZ f AEFGVW Co Simvastatin COB f AEFGVW Teva-Simvastatin TEV f AEFGVW pms-simvastatin PMS f AEFGVW Phl-Simvastatin PHL f AEFGVW Simvastatin SAS f AEFGVW Ran-Simvastatin RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) JPC f AEFGVW Mint-Simvastatin MNT f AEFGVW Mar-Simvastatin MAR f AEFGVW Jamp-Simvastatin JPC f AEFGVW Simvastatin-Odan ODN f AEFGVW February 2014 / février 2014 Page 61

74 C10AA02 LOVASTATIN LOVASTATINE Tab Orl 20mg Mevacor FRS f AEFGVW Apo-Lovastatin APX f AEFGVW Mylan-Lovastatin MYL f AEFGVW ratio-lovastatin (Disc/non disp Jun 29/14) RPH f AEFGVW pms-lovastatin PMS f AEFGVW Teva-Lovastatin TEV f AEFGVW Sandoz Lovastatin (Disc/non disp Nov 15/15) SDZ f AEFGVW Co Lovastatin COB f AEFGVW Lovastatin SAS f AEFGVW Tab Orl 40mg Mevacor FRS f AEFGVW Apo-Lovastatin APX f AEFGVW Mylan-Lovastatin MYL f AEFGVW ratio-lovastatin (Disc/non disp Jun 29/14) RPH f AEFGVW pms-lovastatin PMS f AEFGVW Teva-Lovastatin TEV f AEFGVW Sandoz Lovastatin (Disc/non disp Nov 15/15) SDZ f AEFGVW Co Lovastatin COB f AEFGVW Lovastatin SAS f AEFGVW C10AA03 PRAVASTATIN PRAVASTATINE Tab Orl 10mg Pravachol (Disc/non disp Sep 14/14) BRI f AEFGVW Apo-Pravastatin APX f AEFGVW Teva-Pravastatin TEV f AEFGVW pms-pravastatin PMS f AEFGVW Sandoz Pravastatin SDZ f AEFGVW Co Pravastatin COB f AEFGVW Mylan-Pravastatin MYL f AEFGVW Ran-Pravastatin RAN f AEFGVW Mint-Pravastatin MNT f AEFGVW Jamp-Pravastatin JPC f AEFGVW Pravastatin SAS f AEFGVW Tab Orl 20mg Pravachol BRI f AEFGVW Apo-Pravastatin APX f AEFGVW Teva-Pravastatin TEV f AEFGVW pms-pravastatin PMS f AEFGVW Sandoz Pravastatin SDZ f AEFGVW Co Pravastatin COB f AEFGVW Mylan-Pravastatin MYL f AEFGVW Ran-Pravastatin RAN f AEFGVW Mint-Pravastatin MNT f AEFGVW Jamp-Pravastatin JPC f AEFGVW Pravastatin SAS f AEFGVW Tab Orl 40mg Pravachol BRI f AEFGVW Apo-Pravastatin APX f AEFGVW Teva-Pravastatin TEV f AEFGVW pms-pravastatin PMS f AEFGVW Sandoz Pravastatin SDZ f AEFGVW February 2014 / février 2014 Page 62

75 C10AA03 C10AA04 PRAVASTATIN PRAVASTATINE Tab Orl 40mg Co Pravastatin COB f AEFGVW Mylan-Pravastatin MYL f AEFGVW Ran-Pravastatin RAN f AEFGVW Mint-Pravastatin MNT f AEFGVW Jamp-Pravastatin JPC f AEFGVW Pravastatin SAS f AEFGVW FLUVASTATIN FLUVASTATINE Cap Orl 20mg Lescol NVR f AEFGVW Caps Teva-Fluvastatin TEV f AEFGVW Sandoz Fluvastatin SDZ f AEFGVW Cap Orl 40mg Lescol NVR f AEFGVW Caps Teva-Fluvastatin TEV f AEFGVW Sandoz Fluvastatin SDZ f AEFGVW C10AA05 SRT Orl 80mg Lescol XL NVR AEFGVW L.L ATORVASTATIN ATORVASTATINE Tab Orl 10mg Lipitor PFI f AEFGVW GD-Atorvastatin GMD f AEFGVW Apo-Atorvastatin APX f AEFGVW Novo-Atorvastatin TEV f AEFGVW Co Atorvastatin COB f AEFGVW pms-atorvastatin PMS f AEFGVW Ran-Atorvastatin RAN f AEFGVW Sandoz Atorvastatin SDZ f AEFGVW Atorvastatin SAS f AEFGVW ratio-atorvastatin TEV f AEFGVW Mylan-Atorvastatin MYL f AEFGVW pms-atorvastatin PMS f AEFGVW Tab Orl 20mg Lipitor PFI f AEFGVW GD-Atorvastatin GMD f AEFGVW Apo-Atorvastatin APX f AEFGVW Novo-Atorvastatin TEV f AEFGVW Co Atorvastatin COB f AEFGVW pms-atorvastatin PMS f AEFGVW Ran-Atorvastatin RAN f AEFGVW Sandoz Atorvastatin SDZ f AEFGVW Atorvastatin SAS f AEFGVW ratio-atorvastatin TEV f AEFGVW Mylan-Atorvastatin MYL f AEFGVW pms-atorvastatin PMS f AEFGVW Tab Orl 40mg Lipitor PFI f AEFGVW GD-Atorvastatin GMD f AEFGVW Apo-Atorvastatin APX f AEFGVW February 2014 / février 2014 Page 63

76 C10AA05 C10AA07 ATORVASTATIN ATORVASTATINE Tab Orl 40mg Novo-Atorvastatin TEV f AEFGVW Co Atorvastatin COB f AEFGVW pms-atorvastatin PMS f AEFGVW Ran-Atorvastatin RAN f AEFGVW Sandoz Atorvastatin SDZ f AEFGVW Atorvastatin SAS f AEFGVW ratio-atorvastatin TEV f AEFGVW Mylan-Atorvastatin MYL f AEFGVW pms-atorvastatin PMS f AEFGVW Tab Orl 80mg Lipitor PFI f AEFGVW GD-Atorvastatin GMD f AEFGVW Apo-Atorvastatin APX f AEFGVW Novo-Atorvastatin TEV f AEFGVW Co Atorvastatin COB f AEFGVW pms-atorvastatin PMS f AEFGVW Ran-Atorvastatin RAN f AEFGVW Sandoz Atorvastatin SDZ f AEFGVW Atorvastatin SAS f AEFGVW ratio-atorvastatin TEV f AEFGVW Mylan-Atorvastatin MYL f AEFGVW pms-atorvastatin PMS f AEFGVW ROSUVASTATIN ROSUVASTATINE Tab Orl 5mg Crestor AZE f AEFGVW Apo-Rosuvastatin APX f AEFGVW Sandoz Rosuvastatin SDZ f AEFGVW Co Rosuvastatin COB f AEFGVW Teva-Rosuvastatin TEV f AEFGVW pms-rosuvastatin PMS f AEFGVW Mylan-Rosuvastatin MYL f AEFGVW Ran-Rosuvastatin RAN f AEFGVW Rosuvastatin SAS f AEFGVW Mint-Rosuvastatin MNT f AEFGVW Jamp-Rosuvastatin JPC f AEFGVW Tab Orl 10mg Crestor AZE f AEFGVW Apo-Rosuvastatin APX f AEFGVW Sandoz Rosuvastatin SDZ f AEFGVW Co Rosuvastatin COB f AEFGVW Teva-Rosuvastatin TEV f AEFGVW pms-rosuvastatin PMS f AEFGVW Mylan-Rosuvastatin MYL f AEFGVW Ran-Rosuvastatin RAN f AEFGVW Jamp-Rosuvastatin JPC f AEFGVW Rosuvastatin SAS f AEFGVW Mint-Rosuvastatin MNT f AEFGVW Tab Orl 20mg Crestor AZE f AEFGVW Apo-Rosuvastatin APX f AEFGVW Sandoz Rosuvastatin SDZ f AEFGVW February 2014 / février 2014 Page 64

77 C10AA07 C10AB C10AB04 C10AB05 ROSUVASTATIN ROSUVASTATINE Tab Orl 20mg Co Rosuvastatin COB f AEFGVW Teva-Rosuvastatin TEV f AEFGVW pms-rosuvastatin PMS f AEFGVW Mylan-Rosuvastatin MYL f AEFGVW Ran-Rosuvastatin RAN f AEFGVW Jamp-Rosuvastatin JPC f AEFGVW Rosuvastatin SAS f AEFGVW Mint-Rosuvastatin MNT f AEFGVW Tab Orl 40mg Crestor AZE f AEFGVW Apo-Rosuvastatin APX f AEFGVW Sandoz Rosuvastatin SDZ f AEFGVW Co Rosuvastatin COB f AEFGVW Teva-Rosuvastatin TEV f AEFGVW pms-rosuvastatin PMS f AEFGVW Mylan-Rosuvastatin MYL f AEFGVW Ran-Rosuvastatin RAN f AEFGVW Jamp-Rosuvastatin JPC f AEFGVW Rosuvastatin SAS f AEFGVW Mint-Rosuvastatin MNT f AEFGVW FIBRATES FIBRATES GEMFIBROZIL GEMFIBROZIL Tab Orl 300mg Apo-Gemfibrozil APX f AEFGVW Mylan-Gemfibrozil MYL f AEFGVW pms-gemfibrozil PMS f AEFGVW Novo-Gemfibrozil TEV f AEFGVW Tab Orl 600mg Apo-Gemfibrozil APX f AEFGVW Mylan-Gemfibrozil MYL f AEFGVW pms-gemfibrozil (Disc/non disp Jan 31/16) PMS f AEFGVW Novo-Gemfibrozil TEV f AEFGVW FENOFIBRATE FÉNOFIBRATE Cap Orl 100mg Apo-Fenofibrate APX f AEFGVW Caps Cap Orl 200mg Lipidil Micro ABB f AEFGVW Caps Apo-Feno-Micro APX f AEFGVW Mylan-Fenofibrate Micro MYL f AEFGVW Novo-Fenofibrate Micro TEV f AEFGVW ratio-fenofibrate MC TEV f AEFGVW pms-fenofibrate Micro (Disc/non disp Apr 1/16) PMS f AEFGVW Fenofibrate Micro SAS f AEFGVW Tab Orl 100mg Lipidil Supra ABB f AEFGVW Apo-Feno-Super APX f AEFGVW February 2014 / février 2014 Page 65

78 C10AB05 C10AC C10AC01 C10AC02 FENOFIBRATE FÉNOFIBRATE Tab Orl 100mg Sandoz Fenofibrate S SDZ f AEFGVW Teva-Fenofibrate-S TEV f AEFGVW Fenofibrate S SAS f AEFGVW Tab Orl 160mg Lipidil Supra ABB f AEFGVW Apo-Feno-Super APX f AEFGVW Sandoz Fenofibrate S SDZ f AEFGVW Teva-Fenofibrate-S TEV f AEFGVW Fenofibrate S SAS f AEFGVW BILE ACID SEQUESTRANTS SEQUESTRANTS DE L ACIDE BILIAIRE COLESTYRAMINE COLESTYRAMINE Pws Orl 4g Packets/sachets Olestyr PDP f AEFGVW Pds. Pws Orl 4g Packets/sachets Olestyr PDP f AEFGVW Pds. COLESTIPOL COLESTIPOL Tab Orl 1g Colestid PFI AEFGVW Pws Orl 5g Colestid PFI AEFGVW Pds. C10B C10BA C10BA01 C10BX C10BX03 Pws Orl 7.5g Colestid (Orange) PFI AEFGVW Pds. LIPID MODIFYING AGENTS, COMBINATIONS AGENTS RÉDUISANT LES LIPIDES SÉRIQUES, EN COMBINAISON HMG COA REDUCTASE INHIBITORS IN COMBINATION WITH OTHER LIPID MODIFYING AGENTS INHIBITEURS DE LA HMG COA RÉDUCTASE EN COMBINAISON AVEC D AUTRES AGENTS DE MODIFICATION DES LIPIDES LOVASTATIN AND NICOTINIC ACID LOVASTATINE ET ACIDE NICOTINIQUE SRT Orl 20mg/500mg Advicor (Disc/non disp Jun 27/14) SNV AEFGVW L.L. SRT Orl 20mg/1000mg Advicor (Disc/non disp Jun 27/14) SNV AEFGVW L.L. HMG COA REDUCTASE INHIBITORS, OTHER COMBINATIONS INHIBITEURS DE LA HMG COA RÉDUCTASE, AUTRES COMBINAISONS ATORVASTATIN AND AMLODIPINE ATORVASTATINE ET AMLODIPINE Tab Orl 5mg/10mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV February 2014 / février 2014 Page 66

79 C10BX03 ATORVASTATIN AND AMLODIPINE ATORVASTATINE ET AMLODIPINE Tab Orl 5mg/10mg pms-amlodipine/atorvastatin PMS f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 5mg/20mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV pms-amlodipine/atorvastatin PMS f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 5mg/40mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 5mg/80mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 10mg/10mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV pms-amlodipine/atorvastatin PMS f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 10mg/20mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV pms-amlodipine/atorvastatin PMS f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV Tab Orl 10mg/40mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV D01 D01A D01AA D01AA01 Tab Orl 10mg/80mg Caduet PFI f AEFV GD-Amlodipine/Atorvastatin GMD f AEFV Apo-Amlodipine-Atorvastatin APX f AEFV ANTIFUNGALS FOR DERMATOLOGICAL USE ANTIFONGIQUES À USAGE DERMATOLOGIQUE ANTIFUNGALS FOR TOPICAL USE ANTIFONGIQUES POUR USAGE TOPIQUE ANTIBIOTICS ANTIBIOTIQUES NYSTATIN NYSTATINE Crm Top IU Nyaderm TAR AEFGVW Cr. Ratio-Nystatin RPH AEFGVW Ont Top IU Ratio-Nystatin RPH AEFGVW Ont 12 If the beneficiary has had a claim for both amlodipine and atorvastatin reimbursed by NBPDP in the previous 6 months, the claim for Caduet will automatically be reimbursed without requiring special authorization. Si le bénéficiaire a fait une demande de remboursement au PMONB pour l amlodipine et l atorvastatine au cours des six derniers mois, la demande pour Caduet sera automatiquement remboursée sans autorisation spéciale. February 2014 / février 2014 Page 67

80 D01AC D01AC01 D01AC02 D01AC08 D01AC20 IMIDAZOLE AND TRIAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE ET TRIAZOLE CLOTRIMAZOLE CLOTRIMAZOLE Crm Top 1% Canesten YNO f AEFGVW Cr. Clotrimaderm TAR AEFGVW MICONAZOLE MICONAZOLE Crm Top 2% Micatin WLS AEFGVW Cr. Monistat Derm JNJ AEFGVW KETOCONAZOLE KÉTOCONAZOLE Crm Top 2% Ketoderm TPH f AEFGVW Cr. COMBINATION, TOPICAL ANTIFUNGALS (IMIDAZOLE DERVATIVES) COMBINAISON, ANTIFONGIQUES TOPIQUES (DÉRIVÉS DE L IMIDAZOLE) CLOTRIMAZOLE / BETAMETHASONE CLOTRIMAZOLE / BETAMETHASONE Crm Top 1%/0.05% Lotriderm FRS AEFGVW Cr. D01AE D05 D05A D01AE14 D01AE15 D05AA D05AA99 OTHER ANTIFUNGALS FOR TOPICAL USE AUTRES ANTIFONGIQUES POUR USAGE TOPIQUE CICLOPIROX CICLOPIROX Crm Top 1% Loprox VLN AEFGVW Cr. Lot Top 1% Loprox VLN AEFGVW Lot TERBINAFINE TERBINAFINE Crm Top 1% Lamisil NVR AEFGVW Cr. ANTIPSORIATICS TRAITEMENT DU PSORIASIS ANTIPSORIATICS FOR TOPICAL USE TRAITEMENT DU PSORIASIS, POUR USAGE TOPIQUE TARS GOUDRONS TARS GOUDRONS Liq Top 20% Odans LCD ODN AEFGV Liq February 2014 / février 2014 Page 68

81 D05AX D05AX02 OTHER ANTISPORIATICS FOR TOPICAL USE AUTRES TRAITEMENTS DU PSORIASIS POUR USAGE TOPIQUE CALCIPOTRIOL CALCIPOTRIOL Crm Top 50mcg Dovonex LEO AEFV Cr. Ont Top 50mcg Dovonex LEO AEFV Ont D05B D05BA D05BA02 D05BB D05BB02 Liq Top 50mcg Dovonex Scalp Solution LEO AEFV Liq ANTIPSORIATICS FOR SYSTEMIC USE TRAITEMENT DU PSORIASIS, POUR USAGE SYSTÉMIQUE PSORALENS FOR SYSTEMIC USE PSORALENES, POUR USAGE SYSTÉMIQUE METHOXSALEN MÉTHOXSALENE Cap Orl 10mg Oxsoralen VLN AEFGVW Caps RETINOIDS FOR TREATMENT OF PSORIASIS RÉTINOÏDES POUR LE TRAITEMENT DU PSORIASIS ACITRETIN ACITRÉTINE Cap Orl 10mg Soriatane TRB AEFGVW Caps Cap Orl 25mg Soriatane TRB AEFGVW Caps D06 D06A D05AX D06AX01 D06AX07 ANTIBIOTICS AND CHEMOTHERAPEUTICS FOR DERMATOLOGICAL USE ANTIBIOTIQUES ET AGENTS CHIMIOTHÉRAPEUTIQUES ET DERMATOLOGIQUES ANTIBIOTICS FOR TOPICAL USE ANTIBIOTIQUES POUR USAGE TOPIQUE OTHER ANTIBIOTICS FOR TOPICAL USE AUTRES ANTIBIOTIQUES POUR USAGE TOPIQUE FUSIDIC ACID ACIDE FUSIDIQUE Ont Top 2% Fucidin LEO AEFGVW Ont Crm Top 2% Fucidin LEO AEFGVW Cr. GENTAMICIN GENTAMICINE Crm Top 0.1% ratio-gentamicin Sulfate RPH AEFGVW Cr. February 2014 / février 2014 Page 69

82 D06B D06AX07 D06AX09 D06BA D06BA01 D06BB D06BB01 D06BB03 D06BB04 D06BX D06BX01 GENTAMICIN GENTAMICINE Ont Top 0.1% ratio-gentamicin Sulfate RPH AEFGVW Ont MUPROCIN MUPROCINE Ont Top 2% Bactroban GCH f AEFGVW Ont Taro-Mupirocin TAR f AEFGVW CHEMOTHERAPEUTICS FOR TOPICAL USE AGENTS CHIMIOTHÉRAPEUTIQUES POUR USAGE TOPIQUE SULFONAMIDES SULFONAMIDES SILVER SULFADIAZINE SULFADIAZINE D ARGENT Crm Top 1% Flamazine SNE AEFGVW Cr. ANTIVIRALS ANTIVIRAUX IDOXURIDINE IDOXURIDINE Liq Top 0.1% Sandoz Idoxuridine(Disc/non disp Mar 21/14) SDZ f AEFGVW Liq ACYCLOVIR ACYCLOVIR Ont Top 5% Zovirax VLN AEFGVW Ont PODOPHYLLOTOXIN PODOPHYLLOTOXINE Liq Top 250mg Podofilm PAL AEFGV Liq OTHER CHEMOTHERAPEUTICS AUTRES AGENTS DE CHIMOTHÉRAPIE METRONIDAZOLE MÉTRONIDAZOLE Crm Top 0.75% Metrocream GAC AEFV Cr. Crm Top 1% Noritate VLN AEFV Cr. Rosasol cream GSK AEFV Gel Top 1% Metrogel GAC AEFGVW Gel Lot Top 0.75% Metrolotion GAC AEFGVW Lot February 2014 / février 2014 Page 70

83 D07 CORTICOSTEROIDS, DERMATOLOGICAL PREPARATIONS CORTICOSTÉROÏDES, PRÉPARATIONS DERMATOLOGIQUES D07A CORTICOSTEROIDS, PLAIN CORTICOSTÉROÏDES, ORDINAIRES D07AA CORTICOSTEROIDS, WEAK (GROUP I) CORTICOSTÉROÏDES, FAIBLES (GROUPE I) D07AA02 HYDROCORTISONE HYDROCORTISONE Crm Top 0.5% Hydrosone ROG AEFGVW Cr. Cortate SCO AEFGVW Hyderm TAR AEFGVW Crm Top 1% Emo-Cort GSK AEFGVW Cr. Prevex HC GSK AEFGVW Hyderm TAR AEFGVW Crm Top 2.5% Emo-Cort GSK AEFGVW Cr. Lot Top 1% Emo-Cort GSK AEFGVW Lot Sarna HC GSK AEFGVW Lot Top 2.5% Emo-Cort GSK AEFGVW Lot Sarna HC GSK AEFGVW Ont Top 1% Cortoderm TAR AEFGVW Ont Crm Top 0.2% Hydroval TPH f AEFGVW Cr. Ont Top 0.2% Hydroval TPH f AEFGVW Ont D07AB CORTICOSTEROIDS, MODERATELY POTENT (GROUP II) CORTICOSTÉROÏDES, MOYENNEMENT PUISSANT (GROUPE II) D07AB01 CLOBETASONE CLOBÉTASONE D07AB08 Crm Top 0.05% Spectro Eczemacare GCH AEFGVW Cr. DESONIDE DÉSONIDE Crm Top 0.05% pms-desonide PMS f AEFGVW Cr. Ont Top 0.05% pms-desonide PMS f AEFGVW Ont Desocort (Disc/non disp Apr 30/14) GAC AEFGVW February 2014 / février 2014 Page 71

84 D07AB09 TRIAMCINOLONE TRIAMCINOLONE Crm Top 0.1% Aristocort R VAL AEFGVW Cr. Crm Top 0.5% Aristocort C VAL AEFGVW Cr. Ont Top 0.1% Aristocort R VAL AEFGVW Ont D07AC CORTICOSTEROIDS, POTENT (GROUP III) CORTICOSTÉROÏDES, PUISSANT (GROUPE III) D07AC01 BETAMETHASONE BÉTAMÉTHASONE Crm Top 0.05% ratio-ectosone Mild RPH AEFGVW Cr. Betaderm TAR f AEFGVW Celestoderm V/ VAL f AEFGVW Crm Top 0.1% ratio-ectosone RPH AEFGVW Cr. Betaderm TAR f AEFGVW Celestoderm V VAL f AEFGVW Lot Top 0.05% ratio-ectosone Mild RPH AEFGVW Lot Lot Top 0.1% Valisone VAL AEFGVW Lot ratio-ectosone Scalp RPH AEFGVW Betaderm TAR AEFGVW ratio-ectosone RPH AEFGVW Ont Top 0.05% Betaderm TAR f AEFGVW Ont Celestoderm V/ VAL f AEFGVW Ont Top 0.1% Betaderm TAR f AEFGVW Ont Celestoderm V VAL f AEFGVW Crm Top 0.05% Diprosone FRS AEFGVW Cr. Diprolene Glycol FRS AEFGVW ratio-topisone RPH AEFGVW ratio-topilene RPH AEFGVW Lot Top 0.05% Diprosone FRS AEFGVW Lot Diprolene Glycol FRS AEFGVW ratio-topisone RPH AEFGVW ratio-topilene Glycol RPH AEFGVW Ont Top 0.05% Diprosone FRS AEFGVW Ont Diprolene Glycol FRS f AEFGVW ratio-topilene Glycol RPH f AEFGVW ratio-topisone RPH AEFGVW February 2014 / février 2014 Page 72

85 D07AC03 DESOXIMETASONE DÉSOXIMÉTASONE Crm Top 0.05% Topicort Mild VLN f AEFGVW Cr. Crm Top 0.25% Topicort VLN f AEFGVW Cr. Gel Top 0.05% Topicort VLN f AEFGVW Gel D07AC06 DIFLUCORTOLONE DIFLUCORTOLONE Crm Top 0.1% Nerisone Oily GSK AEFGVW Cr. Nerisone GSK AEFGVW Ont Top 0.1% Nerisone (Disc/non disp Mar 15/14) GSK AEFGVW Ont D07AC08 FLUOCINONIDE FLUOCINONIDE Crm Top 0.05% Lyderm TPH AEFGVW Cr. Lidemol VAL AEFGVW Gel Top 0.05% Lidex Gel VAL f AEFGVW Gel Lyderm TPH f AEFGVW Ont Top 0.05% Lidex VAL f AEFGVW Ont Lyderm TPH f AEFGVW D07AC11 AMCINONIDE AMCINONIDE Crm Top 0.1% Cyclocort GSK f AEFGVW Cr. Taro-Amcinonide TAR f AEFGVW ratio-amcinonide TEV f AEFGVW Lot Top 0.1% Cyclocort GSK f AEFGVW Lot ratio-amcinonide TEV f AEFGVW Ont Top 0.1% Cyclocort GSK f AEFGVW Ont ratio-amcinonide TEV f AEFGVW D07AC13 MOMETASONE MOMÉTASONE Crm Top 0.1% Elocom FRS f ABEFGVW Cr. Taro-Mometasone TAR f ABEFGVW Lot Top 0.1% Elocom FRS f ABEFGVW Lot Taro-Mometasone TAR f ABEFGVW Ont Top 0.1% Elocom FRS f ABEFGVW Ont ratio-mometasone TEV f ABEFGVW February 2014 / février 2014 Page 73

86 D07AD CORTICOSTEROIDS, VERY POTENT (GROUP IV) CORTICOSTÉROÏDES, TRÈS PUISSANT (GROUPE IV) D07AD01 CLOBETASOL CLOBÉTASOL Crm Top 0.05% ratio-clobetasol TEV f AEFGVW Cr. Dermovate TPH f AEFGVW Taro-Clobetasol Cream TAR f AEFGVW Mylan-Clobetasol MYL AEFGVW Novo-Clobetasol TEV AEFGVW Lot Top 0.05% ratio-clobetasol TEV f AEFGVW Lot Dermovate TPH f AEFGVW Taro-Clobetasol Topical Sol n TAR f AEFGVW Mylan-Clobetasol Propionate MYL AEFGVW Ont Top 0.05% ratio-clobetasol TEV f AEFGVW Ont Dermovate TPH f AEFGVW Taro-Clobetasol Ointment TAR f AEFGVW Mylan-Clobetasol MYL AEFGVW Novo-Clobetasol TEV AEFGVW D07C D07CA CORTICOSTEROIDS, COMBINATIONS WITH ANTIBIOTICS CORTICOSTÉROÏDES, EN COMBINAISON AVEC DES ANTIBIOTIQUES CORTICOSTEROIDS, WEAK, COMBINATIONS WITH ANTIBIOTICS CORTICOSTÉROÏDES, FAIBLES, EN COMBINAISON AVEC DES ANTIBIOTIQUES D07CA02 HYDROCORTISONE AND ANTIBIOTICS HYDROCORTISONE ET ANTIBIOTIQUES IODOCHLORHYDROXYQUINE / HYDROCORTISONE IODOCHLORHYDROXYQUINE / HYDROCORTISONE Crm Top 3%/1% Vioform HC PAL AEFGVW Cr. POLYMYXIN B SULFATE / BACITRACIN ZINC / HYDROCORTISONE / NEOMYCIN POLYMYXINE B (SULFATE DE) / BACITRACINE / HYDROCORTISONE / NÉOMYCINE Ont Top 5000IU/400IU/10mg/5mg Cortisporin GSK AEFGVW Ont FUSIDIC ACID / HYDROCORTISONE ACIDE FUSIDIQUE / HYDROCORTISONE Crm Top 2%/1% Fucidin H LEO AEFGVW Cr. D07CB CORTICOSTEROIDS, MODERATELY POTENT, COMBINATIONS WITH ANTIBIOTICS CORTICOSTÉROÏDES, MOYENNEMENT PUISSANTS, EN COMBINAISON AVEC DES ANTIBIOTIQUES D07CB01 TRIAMCINOLONE AND ANTIBIOTICS TRIAMCINOLONE ET ANTIBIOTIQUES TRIAMCINOLONE / NEOMYCIN / NYSTATIN / GRAMICIDIN TRIAMCINOLONE / NÉOMYCINE / NYSTATINE / GRAMICIDINE Crm Top IU/2.5mg/1mg/0.25mg Viaderm K-C TAR AEFGVW Cr. February 2014 / février 2014 Page 74

87 D07CB01 D07CB05 D07CC D07X D07CC01 D07XA D07XA01 TRIAMCINOLONE AND ANTIBIOTICS TRIAMCINOLONE ET ANTIBIOTIQUES TRIAMCINOLONE / NEOMYCIN / NYSTATIN / GRAMICIDIN TRIAMCINOLONE / NÉOMYCINE / NYSTATINE / GRAMICIDINE Ont Top IU/2.5mg/1mg/0.25mg Viaderm K-C TAR AEFGVW Ont FLUMETASONE AND ANTIBIOTICS FLUMETASONE ET ANTIBIOTIQUES CLIOQUINO/FLUMETHASONE CLIOQUINO/FLUMÉTHASONE Crm Top 3%/0.02% Locacorten-Vioform PAL AEFGVW Cr. CORTICOSTEROIDS, POTENT, COMBINATIONS WITH ANTIBIOTICS CORTICOSTÉROÏDES, PUISSANT, EN COMBINAISON AVEC DES ANTIBIOTIQUES BETAMETHASONE AND ANTIBIOTICS BÉTAMETHASONE ET ANTIBIOTIQUES BETAMETHASONE / GENTAMICIN BÉTAMETHASONE / GENTAMICINE Ont Top 0.1%/0/1% Valisone G VAL AEFGVW Ont Crm Top 0.1%/0.1% Valisone G VAL AEFGVW Cr. CORTICOSTEROIDS, OTHER COMBINATIONS CORTICOSTÉROÏDES, AUTRES COMBINAISONS CORTICOSTEROIDS, WEAK, OTHER COMBINATIONS CORTICOSTÉROÏDES, FAIBLES, AUTRES COMBINAISONS HYDROCORTISONE, OTHER COMBINATIONS HYDROCORTISONE, AUTRES COMBINAISONS HYDROCORTISONE / PRAMOXINE HYDROCORTISONE / PRAMOXINE Crm Top 1%/1% Pramox HC DPT AEFGVW Cr. HYDROCORTISONE / UREA HYDROCORTISONE / URÉA Crm Top 10%/1% Uremol HC GSK AEFGVW Cr. Lot Top 10%/1% Uremol HC GSK AEFGVW Lot February 2014 / février 2014 Page 75

88 D07XC D08 D08A D08AJ D07XC01 D07XC04 D08AJ58 CORTICOSTEROIDS, POTENT, OTHER COMBINATIONS CORTICOSTÉROÏDES, PUISSANTS, AUTRES COMBINAISONS BETAMETHASONE, OTHER COMBINATIONS BETAMETHASONE, AUTRES COMBINAISONS BETAMETHASONE / SALICYLIC ACID BETAMETHASONE / ACIDE SALICYLIQUE Lot Top 20mg/0.5mg Diprosalic FRS f AEFGVW Lot ratio-topisalic TEV f AEFGVW Ont Top 30mg/0.5mg Diprosalic FRS AEFGVW Ont DIFLUCORTOLONE, OTHER COMBINATIONS DIFLUCORTOLONE, AUTRES COMBINAISONS DIFLUCORTOLONE / SALICYLIC ACID DIFLUCORTOLONE / ACIDE SALICYLIQUE Crm Top 3%/0.02% Nerisalic Oily (Disc/non disp Feb 21/14) GSK f AEFGV Cr. ANTISEPTICS AND DISINFECTANTS ANTISEPTIQUES ET AGENTS STÉRILISANTS ANTISEPTICS AND DISINFECTANTS ANTISEPTIQUES ET AGENTS STÉRILISANTS QUATERNARY AMMONIUM COMPOUNDS COMPOSÉS D AMMONIUM QUATERNAIRE BENZETHONIUM CHLORIDE, COMBINATIONS COMBINATION DE BENZETHONIUM CHLORIDE ALUMINUM ACETATE / BENZETHONIUM CHLORIDE ACÉTATE D ALUMINIUM / CHLORURE DE BENZÉTHONIUM Pwr Top 0.35% Buro Sol TCD AEFGVW Pds. D09 MEDICATED DRESSINGS PANSEMENTS MÉDICAMENTEUX D09A MEDICATED DRESSINGS PANSEMENTS MÉDICAMENTEUX D09AA MEDICATED DRESSINGS WITH ANTIINFECTIVES PANSEMENTS MÉDICAMENTEUX ET ANTI-INFECTIEUX D09AA01 FRAMYCETIN FRAMYCÉTINE Dre Top 1% Sofra-Tulle (10cm x 30cm) ERF AEFGVW Dre Sofra-Tulle (10cm x 10cm) ERF AEFGVW February 2014 / février 2014 Page 76

89 D10 D10A D10AA D10AA02 D10AB D10AB02 D10AD D10AD01 ANTI-ACNE PREPARATIONS PRÉPARATIONS CONTRE L ACNÉ ANTI-ACNE PREPARATIONS FOR TOPICAL USE PRÉPARATIONS TOPIQUES CONTRE L ACNÉ CORTICOSTEROIDS, COMBINATIONS FOR TREATMENT OF ACNE CORTICOSTÉROÏDES, COMBINAISON CONTRE L ACNÉ METHYLPREDNISONE, COMBINATION METHYLPREDNISONE, COMBINAISON ALUMINUM CHLORHYDROXIDE / SULPHUR / METHYLPREDNISOLONE / NEOMYCIN ALUMINUM (CHLORHYDROXIDE D ) / SOUFRE / MÉTHYLPREDNISOLONE / NÉOMYCINE Lot Top 100mg/50mg/2.5mg/2.5mg Neo-Medrol Acne PFI EFGW Lot PREPARATIONS CONTAINING SULPHUR PRÉPARATIONS CONTENANT DU SOUFRE SULPHUR SOUFRE SULFACETAMIDE SODIUM/SULPHUR SULFACÉTAMIDE SODIQUE/SOUFRE Lot Top 10%/5% Sulfacet R VLN AEFGVW Lot RETINOIDS FOR TOPICAL USE IN ACNE RÉTINOÏDES POUR USAGE TOPIQUE CONTRE L ACNÉ TRETINOIN TRÉTINOINE Crm Top 0.01% Stieva-A GSK EFG Cr. Crm Top 0.025% Stieva-A GSK EFG Cr. Crm Top 0.05% Retin-A VLN EFG Cr. Stieva-A GSK EFG Crm Top 0.1% Retin-A (Disc/non disp Jun 1/14) VLN EFG Cr. Stieva-A Forte GSK EFG Gel Top 0.01% Vitamin A Acid VLN EFG Gel Gel Top 0.025% Stieva-A (Disc/non Disp Jul 3/14) GSK EFG Gel Vitamin A Acid VLN EFG Gel Top 0.05% Vitamin A Acid VLN EFG Gel February 2014 / février 2014 Page 77

90 D10AE D10AE01 D10AF D10AF01 D10AF52 D10AX D10B D10AX03 D10BA D10BA01 PEROXIDES PEROXIDES BENZOYL PEROXIDE PEROXYDE DE BENZOYLE BENZOYL PEROXIDE / POLYOXYETHYLENE LAURYL ETHER PEROXYDE DE BENZOYLE / LAURYL ETHER DE POLYOXYÉTHYLÈNE Gel Top 10%/6% Panoxyl GSK AEFGVW Gel Gel Top 20%/6% Panoxyl GSK AEFGVW Gel ANTIINFECTIVES FOR TREATMENT OF ACNE ANTI-INFECTIEUX POUR LE TRAITEMENT DE L ACNEÉ CLINDAMYCIN CLINDAMYCINE Liq Top 1% Dalacin T PFI f AEFGV Liq Taro-Clindamycin TAR f AEFGV ERYTHROMYCIN COMBINATIONS ÉRYTHROMYCINE, EN COMBINAISON ERYTHROMYCIN BASE / TRETINOIN ÉRYTHROMYCINE BASE / TRÉTINOÏNE Gel Top 4%/0.025% Stievamycin GSK EFG Gel OTHER ANTI ACNE PREPARATIONS FOR TOPICAL USE AUTRES PRÉPARATIONS CONTRE L ACNÉ POUR USAGE TOPIQUE AZELAIC ACID ACIDE AZÉLAIQUE Gel Top 15% Finacea BAY AEFGVW Gel ANTI ACNE PREPARATIONS FOR SYSTEMIC USE PRÉPARATIONS CONTRE L ACNÉ POUR USAGE SYSTÉMIQUE RETINOIDS FOR TREATMENT OF ACNE RÉTINOÏDES POUR LE TRAITEMENT DE L ACNÉ ISOTRETINOIN ISOTRÉTINOINE Cap Orl 10mg Accutane Roche HLR f EFG Cap Clarus MYL f EFG Cap Orl 40mg Accutane Roche HLR f EFG Cap Clarus MYL f EFG February 2014 / février 2014 Page 78

91 G01 G01A G01AA G01AA01 G01AA51 G01AC G01AC01 G01AF G01AF01 G01AF02 GYNECOLOGICAL ANTIINFECTIVES AND ANTISEPTICS ANTI-INFECTIEUX ET ANTISEPTIQUES GYNÉCOLOGIQUES ANTIINFECTIVES AND ANTISEPTICS, EXCLUDING COMBINATIONS WITH CORTICOSTEROIDS ANTI-INFECTIEUX ET ANTISEPTIQUES, SAUF LES ASSOCIATIONS AVEC DES CORTICOSTÉROÏDES ANTIBIOTICS ANTIBIOTIQUES NYSTATIN NYSTATINE Crm Vag 25000IU Nyaderm TAR AEFGVW Cr. Crm Vag IU Ratio-Nystatin RPH AEFGVW Cr. NYSTATIN, COMBINATIONS COMBINATION NYSTATINE NYSTATIN / METRONIDAZOLE NYSTATINE / METRONIDAZOLE Sup Vag IU/500mg Flagystatin SAV AEFGVW Supp. QUINOLINE DERIVATIVES DÉRIVÉS DE LA QUINOLEINE DIIODOHYDROXYQUINOLINE QUINOLEINE DIIODOHYDROXYLE Tab Orl 650mg Diodoquin GLE AEFGVW IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE METRONIDAZOLE MÉTRONIDAZOLE Crm Vag 10% Flagyl AVE AEFGVW Cr. CLOTRIMAZOLE CLOTRIMAZOLE Crm Vag 1% Canesten YNO AEFGVW Cr. Crm Vag 2% Canesten YNO AEFGVW Cr. G01AF04 Crm Vag 500mg/1% Canesten 3 Comfortab Combi-Pak YNO AEFGVW Cr. Canesten 1 Comfortab YNO AEFGVW MICONAZOLE MICONAZOLE Crm Vag 2% Monistat JNJ f AEFGVW Cr. Micozole Vaginal 2% TAR f AEFGVW February 2014 / février 2014 Page 79

92 G01AF04 MICONAZOLE MICONAZOLE Sup Vag 400mg Monistat JNJ AEFGVW Supp. Crm Vag 1200mg/2% Monistat 3 Dual Pak JNJ AEFGVW Cr. G01AG TRIAZOLE DERIVATIVES DÉRIVÉS DU TRIAZOLE G01AG02 TERCONAZOLE TERCONAZOLE Crm Vag 0.4% Terazol JAN f AEFGVW Cr. Taro-Terconazole TAR f AEFGVW G02 G02B G02BA OTHER GYNECOLOGICALS AUTRES AGENTS GYNÉCOLOGIQUES CONTRACEPTIVES FOR TOPICAL USE CONTRACEPTIFS TOPIQUES INTRAUTERINE CONTRACEPTIVES CONTRACEPTIFS INTRA-UTÉRINS G02BA03 PLASTIC IUD WITH PROGESTERONE AND LEVONORGESTREL DIU EN PLASTIQUE AVEC LA PROGESTÉRONE ET DE LÉVONORGESTREL Ins Vag 52mg Mirena BAY EFG Ins G02C G02CB OTHER GYNECOLOGICALS AUTRES AGENTS GYNÉCOLOGIQUES PROLACTINE INHIBITORS INHIBITEURS DE LA PROLACTINE G02CB01 BROMOCRIPTINE BROMOCRIPTINE Tab Orl 2.5mg Bromocriptine AAP f AEFGVW pms-bromocriptine (Disc/non disp Feb 16/14) PMS f AEFGVW G03 G03A G03AA Cap Orl 5mg Bromocriptine AAP f AEFGVW Cap pms-bromocriptine (Disc/non disp Feb 16/14) PMS f AEFGVW SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM HORMONES SEXUELLES ET MODULATEURS DE L APPAREIL GÉNITAL HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE CONTRACEPTIFS HORMONAUX, SYSTÉMIQUES PROGESTOGENS AND ESTROGENS, FIXED COMBINATIONS PROGESTOGÈNES ET OESTROGÈNES, COMBINAISONS FIXES G03AA01 ETYNODIOL AND ETHINYLESTRADIOL ETYNODIOL ET ÉTHINYLOESTRADIOL Tab Orl 320mcg/2mg Demulen 30 (21) * PFI EFGV Demulen 30 (28) * PFI EFGV February 2014 / février 2014 Page 80

93 G03AA05 NORETHISTERONE AND ETHINYLESTRADIOL NORÉTHISTERONE ET ÉTHINYLOESTRADIOL Tab Orl 20mcg/1mg Minestrin 1/20 (21) * WNC EFGV Minestrin 1/20 (28) * WNC EFGV Tab Orl 1.5mg/0.03mg Loestrin 1.5/30 (21) * WNC EFGV Loestrin 1.5/30 (28) * WNC EFGV Tab Orl 0.5mg/0.035mg Ortho 0.5/35 (21) * JAN EFGV Ortho 0.5/35 (28) * JAN EFGV Brevicon (21) * PFI EFGV Brevicon (28) * PFI EFGV G03AA07 Tab Orl 1mg/0.035mg Ortho 1/35 (21) * JAN EFGV Ortho 1/35 (28) * JAN EFGV Brevicon 1/35 (21) * PFI EFGV Brevicon 1/35 (28) * PFI EFGV Select 1/35 (21) * PFI EFGV Select 1/35 (28) * PFI EFGV LEVONORGESTREL AND ETHINYLESTRADIOL LÉVONORGESTREL ET ÉTHINYLOESTRADIOL Tab Orl 0.15mg/0.03mg Min-Ovral (21) * PFI f EFGV Min-Ovral (28) * PFI f EFGV Portia 21 * TEV f EFGV Portia 28 * TEV f EFGV Ovima 21 * APX f EFGV Ovima 28 * APX f EFGV Tab Orl 0.1mg/0.02mg Alesse (21) * PFI f EFGV Alesse (28) * PFI f EFGV Aviane 21 * TEV f EFGV Aviane 28 * TEV f EFGV Esme (21) * MYL f EFGV Esme (28) * MYL f EFGV Alysena 21 * APX f EFGV Alysena 28 * APX f EFGV Lutera 21 * COB f EFGV Lutera 28 * COB f EFGV G03AA09 DESORGESTREL AND ETHINYLESTRADIOL DÉSORGESTREL ET ÉTHINYLOESTRADIOL Tab Orl 0.15mg/0.03mg Marvelon (21) * FRS f EFGV Marvelon (28) * FRS f EFGV Apri 21 * TEV f EFGV Apri 28 * TEV f EFGV Freya 21 * TEV f EFGV Freya 28 * TEV f EFGV Linessa 21 * FRS EFGV Linessa 28 * FRS EFGV February 2014 / février 2014 Page 81

94 G03AA12 DROSPIRENONE AND ETHINYLESTRADIOL DROSPIRÉNONE ET ÉTHINYLOESTRADIOL Tab Orl 3mg/0.03mg Yasmin 21 * BAY f EFGV Zarah 21 * COB f EFGV Yasmin 28 * BAY f EFGV Zarah 28 * COB f EFGV G03AB PROGESTOGENS AND ESTROGENS, SEQUENTIAL PREPARATIONS PROGESTOGÈNES ET OESTROGÈNES, PRÉPARATION SÉQUENTIELLE G03AB03 LEVONORGESTREL AND ETHINYLESTRADIOL LÉVONORGESTREL ET ÉTHINYLOESTRADIOL G03AB04 Tab Orl 50mcg/75mcg/125mcg/30mcg/40mcg/30mcg Triquilar (21) * BAY EFGV Triquilar (28) * BAY EFGV NORETHISTERONE AND ETHINYLESTRADIOL NORÉTHISTERONE ET ÉTHINYLOESTRADIOL Tab Orl 1mg/0.5mg/0.035mg Synphasic (21) * PFI EFGV Synphasic (28) * PFI EFGV Tab Orl 1mg/0.75mg/0.5mg/0.035mg Ortho 7/7/7 (21) * JAN EFGV Ortho 7/7/7 (28) * JAN EFGV G03AB11 NORGESTIMATE AND ETHINYLESTRADIOL NORGÉSTIMATE ET ÉTHINYLOESTRADIOL Tab Orl 0.215mg/0.18mg/0.025mg/0.025mg Tri-Cyclen lo (21) * JAN EFGV Tri-Cyclen lo (28) * JAN EFGV Tab Orl 0.25mg/0.215mg/0.18mg/0.035mg Tri-Cyclen (21) * JAN EFGV Tri-Cyclen (28) * JAN EFGV G03AC PROGESTOGENS PROGESTOGÈNES G03AC01 NORGESTIMATE NORGÉSTIMATE Tab Orl 0.35mg Micronor (28) * JAN EFGV G03AC06 MEDROXYPROGESTERONE MÉDROXYPROGESTÉRONE Sus Inj 50mg Depo-Provera PFI W Susp. Sus Inj 150mg/mL Depo-Provera * PFI f EFGV Susp. Medroxyprogesterone Acetate * SDZ f EFGV February 2014 / février 2014 Page 82

95 G03AD G03B G03AD01 G03BA G03C G03BA03 G03CA G03CA03 EMERGENCY CONTRACEPTIVES CONTRACEPTIFS D URGENCE LEVONORGESTREL (EMERGENCY CONTRACEPTIVE) LÉVONORGESTREL (CONTRACEPTIF D URGENCE) Tab Orl 0.75mg Plan B * PAL f EFG Next Choice * COB f EFG ANDROGENS ANDROGÈNES 3-OXOANDROSTEN (4) DERIVATIVES DÉRIVÉS DU 3-OXOANDROSTENE (4) TESTOSTERONE TESTOSTÉRONE Liq Inj 100mg Depo-Testosterone PFI W Liq Liq Inj 200mg Delatestryl VLN W Liq ESTROGENS OESTROGÈNES NATURAL AND SEMISYNTHETIC ESTROGENS, PLAIN OESTROGÈNES NATURELS ET SEMI-SYNTHÉTIQUES, ORDINAIRES ESTRADIOL ESTRADIOL Tab Vag 10mcg Vagifem NNO AEFGVW Gel Trd 0.06% Estrogel FRS AEFV Gel Ins Vag 2mg Estring PAL AEFV Ins Pth Trd 25mcg Climara BAY AEFVW Pth Pth Trd 50mcg Climara BAY AEFV Pth Pth Trd 75mcg Climara BAY AEFVW Pth Pth Trd 100mcg Climara BAY AEFV Pth Srd Trd 25mcg Estraderm-25 (Disc/non disp Nov 7/14) NVR AEFGVW Srd Srd Trd 100mcg Estraderm-100(Disc/non disp Jan 8/15) NVR AEFGVW Srd February 2014 / février 2014 Page 83

96 G03CA03 G03CA57 ESTRADIOL ESTRADIOL Tab Orl 0.5mg Estrace SHI AEFGVW Tab Orl 1mg Estrace SHI AEFGVW Tab Orl 2mg Estrace SHI AEFGVW CONJUGATED ESTROGENS OESTROGÈNES CONJUGUÉS Crm Vag 0.625mg Premarin PFI AEFGVW Cr. Tab Orl 0.3g Premarin PFI AEFGVW Tab Orl 0.625g Premarin PFI AEFGVW CES (Disc/non disp Jan 4/15) VLN AEFGVW G03D G03DA G03DA02 Tab Orl 1.25mg Premarin PFI AEFGVW PROGESTOGENS PROGESTOGÈNES PREGNEN (4) DERIVATIVES DÉRIVÉS DU PREGNEN (4) MEDROXYPROGESTERONE MÉDROXYPROGESTÉRONE Tab Orl 2.5mg Provera PFI f AEFGVW Teva-Medrone TEV f AEFGVW Apo-Medroxy APX f AEFGVW Tab Orl 5mg Provera PFI f AEFGVW Teva-Medrone TEV f AEFGVW Apo-Medroxy APX f AEFGVW Tab Orl 10mg Provera PFI f AEFGVW Teva-Medrone TEV f AEFGVW Apo-Medroxy APX f AEFGVW Tab Orl 100mg Apo-Medroxy APX f AEFGVW February 2014 / février 2014 Page 84

97 G03H G03HA G03X G03HA01 G03XA G04 G04B G03XA01 G04BD G04BD04 ANTIANDROGENS ANTIANDROGÈNES ANTIANDROGENS, PLAIN ANTIANDROGÈNES, ORDINAIRES CYPROTERONE CYPROTÉRONE Tab Orl 50mg Androcur PMS f AEFVW Cyproterone AAP f AEFVW Med-Cyproterone GMP f AEFVW OTHER SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM AUTRES HORMONES SEXUELLES ET MODULATEURS DE L APPAREIL GÉNITAL ANTIGONADOTROPHINS AND SIMILAR AGENTS ANTIGONADOTROPHINES ET AGENTS SIMILAIRES DANAZOL DANAZOL Cap Orl 100mg Cyclomen SAV AEFVW Caps Cap Orl 200mg Cyclomen SAV AEFVW Caps UROLOGICALS MÉDICAMENTS UROLOGIQUES UROLOGICALS MÉDICAMENTS UROLOGIQUES DRUGS FOR URINARY FREQUENCY AND INCONTINENCE MÉDICAMENTS POUR LA FRÉQUENCE URINAIRE ET INCONTINENCE OXYBUTYNIN OXYBUTYNINE Syr Orl 1mg pms-oxybutynin PMS f AEFGVW Sir. Tab Orl 2.5mg pms-oxybutynin PMS AEFGVW G04BD07 Tab Orl 5mg Apo-Oxybutynin APX f AEFGVW Novo-Oxybutynin TEV f AEFGVW Mylan-Oxybutynin MYL f AEFGVW pms-oxybutynin PMS f AEFGVW Oxybutynin SAS f AEFGVW TOLTERODINE TOLTÉRODINE Tab Orl 1mg Detrol PFI AEFGV Detrol PFI W Tab Orl 2mg Detrol PFI AEFGV Detrol PFI W February 2014 / février 2014 Page 85

98 G04BD07 G04BD09 G04BD10 G04BD11 G04BX SOLIFENACIN SOLIFÉNACINE Tab Orl 5mg Vesicare ASL AEFGV Vesicare ASL W Tab Orl 10mg Vesicare ASL AEFGV Vesicare ASL W TROSPIUM TROSPIUM Tab Orl 20mg Trosec SNV AEFGV Trosec SNV W DARIFENACIN DARIFÉNACINE ERT Orl 7.5mg Enablex MRS AEFGV L.P Enablex MRS W ERT Orl 15mg Enablex MRS AEFGV L.P Enablex MRS W FESOTERODINE FÉSOTÉRODINE ERT Orl 4mg Toviaz PFI AEFGV L.P ERT Orl 8mg Toviaz PFI AEFGV L.P OTHER UROLOGICAL AUTRES MÉDICAMENTS UROLOGIQUES G04BX13 DIMETHYL SULFOXIDE SULFOXYDE DE DIMÉTHYLE Liq Itv 500mg Rimso-50 * BCH f AEFGVW Liq Dimethyl Sulfoxide Irr. * SDZ f AEFGVW 13 Requests for coverage of regular Tolterodine (1mg and 2mg), Darifenacin, Solifenacin, Trospium or Fesoterodine will be considered under special authorization, see Appendix IV. If the beneficiary has had a claim for oxybutynin in the previous 24 months the adjudication system will recognize this information and the claim for regular Tolterodine (1mg and 2mg), Darifenacin, Solifenacin, Trospium or Fesoterodine will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. Les demandes de protection pour du Toltérodine régulier (1mg and 2mg), Darifnacine, Solifénacinr, Trospium ou Fesoterodine seront examinees sur autorisation spéciale. Veuillez consulter l annexe IV. Si le bénéficiare a fait une demande de réglement pour de l oxybutynine dans le précédents 24 mois, le systeme pour la soumission en ligne des a fait une demandes de réglement reconnaîtra cette information et la demande pour du Toltérodine régulier (1mg and 2mg), Darifnacine, Solifénacinr, Trospium ou Fesoterodine sera remboursée automatiquement sans avoir à faire une demande écrite d autorisation spéciale. Les autorisation spéciales écrites continueront d être offertes à titre optionnel pour les bénéficiares qui n ont peut-être pas utilize d agent de premiére ligne en raison des changements à l assurance-médicaments our d autres facteurs. February 2014 / février 2014 Page 86

99 G04C G04CA G04CA02 DRUGS USED IN BENIGN PROSTATIC HYPERTROPHY MÉDICAMENTS UTILISÉS POUR LE TRAITEMENT DE L HYPERTROPHIE BÉNIGNE DE LA PROSTATE ALPHA-ADRENORECEPTOR ANTAGONISTS ANTAGONISTES DE L ALPHA-ADRÉNORÉCEPTEUR TAMSULOSIN TAMSULOSINE ERT Orl 0.4mg Flomax CR BOE f AEFVW L.P Sandoz Tamsulosin CR SDZ f AEFVW Apo-Tamsulosin CR APX f AEFVW Teva-Tamsulosin CR TEV f AEFVW SRC Orl 0.4mg Teva-Tamsulosin TEV f AEFVW Caps.L.L. ratio-tamsulosin TEV f AEFVW Ran-Tamsulosin (Disc/non disp Jun 13/14) RAN f AEFVW Sandoz Tamsulosin SDZ f AEFVW Mylan-Tamsulosin MYL f AEFVW Jamp-Tamsulosin (Disc/non disp Jul 5/14) JPC f AEFVW G04CA03 TERAZOSIN TÉRAZOSINE Tab Orl 1mg Hytrin ABB f AEF18+VW ratio-terazosin RPH f AEF18+VW Teva-Terazosin TEV f AEF18+VW Apo-Terazosin APX f AEF18+VW pms-terazosin PMS f AEF18+VW Terazosin SAS f AEF18+VW Mylan-Terazosin MYL f AEF18+VW Tab Orl 2mg Hytrin ABB f AEF18+VW ratio-terazosin RPH f AEF18+VW Teva-Terazosin TEV f AEF18+VW Apo-Terazosin APX f AEF18+VW pms-terazosin PMS f AEF18+VW Terazosin SAS f AEF18+VW Mylan-Terazosin MYL f AEF18+VW Tab Orl 5mg Hytrin ABB f AEF18+VW ratio-terazosin RPH f AEF18+VW Teva-Terazosin TEV f AEF18+VW Apo-Terazosin APX f AEF18+VW pms-terazosin PMS f AEF18+VW Terazosin SAS f AEF18+VW Mylan-Terazosin MYL f AEF18+VW Tab Orl 10mg Hytrin ABB f AEF18+VW ratio-terazosin RPH f AEF18+VW Teva-Terazosin TEV f AEF18+VW Apo-Terazosin APX f AEF18+VW pms-terazosin PMS f AEF18+VW Terazosin SAS f AEF18+VW Mylan-Terazosin MYL f AEF18+VW February 2014 / février 2014 Page 87

100 H01 H01A H01AC H01AC01 PITUITARY AND HYPOTHALAMIC HORMONES AND ANALOGUES HORMONES HYPOPHYSAIRES ET HYPOTHALAMIQUES ANTERIOR PITUITARY LOBE HORMONES AND ANALOGUES HORMONES DU LOBE ANTEHYPOPHYSAIRE SOMATROPIN AND SOMATROPIN AGONISTS SOMATROPINE ET AGONISTES DE LA SOMATROPINE SOMATROPIN SOMATROPINE Ctg Inj 6mg Humatrope LIL T Cart Ctg Inj 12mg Humatrope LIL T Cart Ctg Inj 24mg Humatrope LIL T Cart Liq Inj 3.33mg Omnitrope SDZ T Liq Liq Inj 6.70mg Omnitrope SDZ T Liq Liq Inj 5mg/mL Nutropin AQ (Disc/non disp Apr 16/15) HLR T Liq Liq Inj 5mg/mL Nutropin AQ NuSpin HLR T Liq Liq Inj 10mg/2mL Nutropin AQ Pen HLR T Liq Liq Inj 6mg Saizen EMD T Liq Liq Inj 12mg Saizen EMD T Liq Liq Inj 20mg Saizen EMD T Liq Pws Inj 1mg Humatrope LIL T Pds. Nutropin (Disc/non disp Dec 02/15) HLR T Pws Inj 3.33mg Saizen EMD T Pds. Pws Inj 5mg Saizen EMD T Pds. Pws Inj 8.8mg Saizen EMD T Pds. February 2014 / février 2014 Page 88

101 H01B H01BA POSTERIOR PITUITARY LOBE HORMONES HORMONES DU LOBE POSTHYPOPHYSAIRE VASOPRESSIN AND ANALOGUES VASOPRESSINE ET ANALOGUES H01BA02 DESMOPRESSIN DESMOPRESSINE Liq Inj 4mg DDAVP* FEI AEFGVW Liq Liq Nas 0.1mg DDAVP FEI AEFGVW Liq ODT Slg 60mg DDAVP Melt FEI EFG-18 D.O. ODT Slg 120mg DDAVP Melt FEI EFG-18 D.O. ODT Slg 240mg DDAVP Melt FEI EFG-18 D.O. Tab Orl 0.1mg DDAVP FEI f EF-18G Apo-Desmopressin APX f EF-18G Novo-Desmopressin TEV f EF-18G pms-desmopressin PMS f EF-18G Tab Orl 0.2mg DDAVP FEI f EF-18G Apo-Desmopressin APX f EF-18G Novo-Desmopressin TEV f EF-18G pms-desmopressin PMS f EF-18G H01C H01CB HYPOTHALAMIC HORMONES HORMONES HYPOTHALAMIQUES SOMATOSTATIN AND ANALOGUES SOMATOSTATINE ET ANALOGUES H01CB02 OCTREOTIDE OCTRÉOTIDE Liq Inj 0.05mg/mL Sandostatin NVR f W Liq Octreotide Acetate Omega OMG f W Liq Inj 0.1mg/mL Sandostatin NVR f W Liq Octreotide Acetate Omega OMG f W Liq Inj 0.2mg/mL Sandostatin (vial) NVR f W Liq Octreotide Acetate Omega OMG f W Liq Inj 0.5mg/mL Sandostatin NVR f W Liq Octreotide Acetate Omega OMG f W Pws Inj 10mg Sandostatin LAR NVR W Pds. February 2014 / février 2014 Page 89

102 H02 H02A H01CB02 H02AA H02AA02 H02AB H02AB01 H02AB02 OCTREOTIDE OCTRÉOTIDE Pws Inj 20mg Sandostatin LAR NVR W Pds. Pws Inj 30mg Sandostatin LAR NVR W Pds. CORTICOSTEROIDS FOR SYSTEMIC USE CORTICOSTÉROÏDES SYSTÉMIQUES CORTICOSTEROIDS FOR SYSTEMIC USE, PLAIN CORTICOSTÉROÏDES SYSTÉMIQUES, ORDINAIRES MINERALOCORTICOIDS MINÉRALOCORTICOÏDES FLUDROCORTISONE FLUDROCORTISONE Tab Orl 0.1mg Florinef PAL AEFGVW GLUCOCORTICOIDS GLUCOCORTICOÏDES BETAMETHASONE BÉTAMÉTHASONE Sus Ia 3mg/3mg Celestone Soluspan FRS AEFGVW Susp. Tab Orl 0.5mg Betnesol SHI AEFGVW DEXAMETHASONE DEXAMÉTHASONE Tab Orl 0.5mg pms-dexamethasone PMS f AEFGVW ratio-dexamethasone RPH f AEFGVW Apo-Dexamethasone APX f AEFGVW Tab Orl 2mg pms-dexamethasone PMS AEFGVW Tab Orl 4mg pms-dexamethasone PMS f AEFGVW ratio-dexamethasone RPH f AEFGVW Apo-Dexamethasone APX f AEFGVW Dexasone VLN AEFGVW H02AB04 Liq Inj 4mg Dexamethasone sodium phosphate SDZ f AEFGVW Liq Dexamethasone sodium phosphate CYI f AEFGVW Dexamethasone-Omega OMG AEFGVW METHYLPREDNISOLONE MÉTHYLPREDNISOLONE Tab Orl 4mg Medrol PFI AEFGVW February 2014 / février 2014 Page 90

103 H02AB04 METHYLPREDNISOLONE MÉTHYLPREDNISOLONE Tab Orl 16mg Medrol PFI AEFGVW Sus Ia 20mg Depo-Medrol * PFI AEFGVW Susp. Sus Ia 80mg Depo-Medrol * PFI AEFGVW Susp. Depo-Medrol * PFI AEFGVW Sus Ibu 40mg Depo-Medrol * PFI AEFGVW Susp. Depo-Medrol * PFI AEFGVW Pws Inj 125mg Solu-Medrol PFI W Pds. Pws Inj 500mg Solu-Medrol PFI W Pds. Pws Inj 1g Solu-Medrol (Disc/non disp Jun 7/14) PFI W Pds. H02AB06 PREDNISOLONE PREDNISOLONE Liq Orl 1mg Pediapred SAV f AEFGVW Liq pms-prednisolone PMS f AEFGVW Tab Orl 1mg Winpred AAP AEFGVW Apo-Prednisone (Disc/non disp Jan 9/16) APX AEFGVW Tab Orl 5mg Novo-Prednisone TEV f ABEFGVW Apo-Prednisone APX f ABEFGVW H02AB09 H02AB10 Tab Orl 50mg Novo-Prednisone TEV f AEFGVW Apo-Prednisone APX f AEFGVW HYDROCORTISONE HYDROCORTISONE Tab Orl 10mg Cortef PFI AEFGVW Tab Orl 20mg Cortef PFI AEFGVW Pws Inj 100mg Solu-Cortef PFI W Pds. CORTISONE CORTISONE Tab Orl 25mg Cortisone VLN f AEFGVW February 2014 / février 2014 Page 91

104 H02B H02BX H03 H03A H02BX01 H03AA H03AA01 CORTICOSTEROIDS FOR SYSTEMIC USE, COMBINATIONS CORTICOSTÉROÏDES SYSTÉMIQUES, EN COMBINAISON CORTICOSTEROIDS FOR SYSTEMIC USE, COMBINATIONS CORTICOSTÉROÏDES SYSTEMIQUES, EN COMBINAISON METHYLPREDNISOLONE, COMBINATIONS MÉTHYLPREDNISOLONE, EN COMBINAISON METHYLPREDNISOLONE / LIDOCAINE MÉTHYLPREDNISOLONE / LIDOCAINE Sus Ia 40mg/10mg Depo-Medrol (Disc/non disp Jun 8/14) * PFI AEFGVW Susp. THYROID THERAPY TRAITEMENT DE LA THYROÏDE THYROID PREPARATIONS PRÉPARATIONS POUR LA THYROÏDE THYROID HORMONES HORMONES POUR LA THYROÏDE LEVOTHYROXINE SODIUM LÉVOTHYROXINE SODIQUE Tab Orl 0.025mg Synthroid ABB AEFGVW Tab Orl 0.05mg Synthroid ABB AEFGVW Eltroxin TRI AEFGVW Tab Orl 0.075mg Synthroid ABB AEFGVW Tab Orl 0.088mg Synthroid ABB AEFGVW Tab Orl 0.1mg Synthroid ABB AEFGVW Eltroxin TRI AEFGVW Tab Orl 0.112mg Synthroid ABB AEFGVW Tab Orl 0.125mg Synthroid ABB AEFGVW Tab Orl 0.137mg Synthroid ABB AEFGVW Tab Orl 0.15mg Synthroid ABB AEFGVW Eltroxin TRI AEFGVW Tab Orl 0.175mg Synthroid ABB AEFGVW Tab Orl 0.2mg Synthroid ABB AEFGVW Eltroxin TRI AEFGVW February 2014 / février 2014 Page 92

105 H03AA02 LIOTHYRONINE SODIUM LIOTHYRONINE SODIQUE Tab Orl 0.3mg Synthroid ABB AEFGVW Eltroxin TRI AEFGVW Tab Orl 5mcg Cytomel PFI AEFGVW Tab Orl 25mcg Cytomel PFI AEFGVW H03AA05 THYROID GLAND PREPARATIONS PRÉPARATIONS POUR LA GLANDE THYROÏDE DESICCATED THYROID EXTRAIT THYROÏDIEN LYOPHILISÉ Tab Orl 30mg Thyroid ERF AEFGVW Tab Orl 60mg Thyroid ERF AEFGVW H03B H03BA H03BA02 H03BB H03BB02 Tab Orl 125mg Thyroid ERF AEFGVW ANTITHYROID PREPARATIONS PRÉPARATIONS ANTI-THYROÏDIENNES THIOURACILS THIOURACILES PROPYLTHIOURACIL PROPYLTHIOURACILE Tab Orl 50mg Propyl-Thyracil PAL AEFGVW Tab Orl 100mg Propyl-Thyracil PAL AEFGVW SULPHUR-CONTAINING IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE CONTENANT DU SOUFRE THIAMAZOLE THIAMAZOLE Tab Orl 5mg Tapazole PAL AEFGVW Tab Orl 10mg Tapazole PAL AEFGVW February 2014 / février 2014 Page 93

106 H04 H04A H04AA PANCREATIC HORMONES HORMONES PANCRÉATIQUES GLYCOGENOLYTIC HORMONES HORMONES GLYCOGÉNOLYTIQUES GLYCOGENOLYTIC HORMONES HORMONES GLYCOGENOLYTIQUES H04AA01 GLUCAGON GLUCAGON Pws Inj 1mg Glucagon * LIL AEFGVW Pds. Glucagen NNO AEFGVW Glucagen Hypokit NNO AEFGVW H05 H05B H05BA CALCIUM HOMEOSTASIS HOMÉOSTASIE DU CALCIUM ANTI-PARATHYROID AGENTS AGENTS ANTI-PARATHYROÏDES CALCITONIN PREPARATIONS PRÉPARATIONS DU CALCITONINE H05BA01 CALCITONIN (SALMON SYNTHETIC) CALCITONINE (SAUMON, SYNTHETIQUE) Liq Inj 100IU Caltine * FEI AEFGVW Liq Liq Inj 200IU Calcimar * SAV f AEFGVW Liq J01 J01A J01AA ANTIBACTERIALS FOR SYSTEMIC USE ANTIBACTÉRIENS POUR USAGE SYSTÉMIQUE TETRACYCLINES TÉTRACYCLINES TETRACYCLINES TÉTRACYCLINES J01AA02 DOXYCYCLINE DOXYCYCLINE Cap Orl 100mg Vibramycin PFI f ABEFGVW Caps Novo-Doxylin TEV f ABEFGVW Apo-Doxy APX f ABEFGVW Doxycycline SAS f ABEFGVW Tab Orl 100mg Apo-Doxy APX f ABEFGVW Novo-Doxylin TEV f ABEFGVW Doxycycline SAS f ABEFGVW J01AA07 TETRACYCLINE TÉTRACYCLINE Cap Orl 250mg Tetra AAP f AEFGVW Caps February 2014 / février 2014 Page 94

107 J01C J01AA08 MINOCYCLINE MINOCYCLINE Cap Orl 50mg Apo-Minocycline APX f ABEFGVW Caps Novo-Minocycline TEV f ABEFGVW Mylan-Minocycline MYL f ABEFGVW Sandoz Minocycline SDZ f ABEFGVW Minocycline SAS f ABEFGVW pms-minocycline PMS f ABEFGVW J01CA J01CA01 Cap Orl 100mg Apo-Minocycline APX f ABEFGVW Caps Novo-Minocycline TEV f ABEFGVW Mylan-Minocycline MYL f ABEFGVW Sandoz Minocycline SDZ f ABEFGVW Minocycline IVX f ABEFGVW Minocycline SAS f ABEFGVW pms-minocycline PMS f ABEFGVW BETA LACTAM ANTIBACTERIALS, PENICILLINS ANTIBACTÉRIEN BETA-LACTAME, PÉNICILLINES PENICILLIN WITH EXTENDED SPECTRUMS PÉNICILLINE AVEC SPECTRUMS ÉTENDUS AMPICILLIN AMPICILLINE Cap Orl 250mg Teva-Ampicillin TEV f AEFGVW Caps Cap Orl 500mg Teva-Ampicillin TEV f AEFGVW Caps Pws Inj 500mg Teva-Ampicillin TEV W Pds. Pws Inj 1g Teva-Ampicillin TEV W Pds. J01CA04 Pws Inj 2g Ampicillin Sodium TEV W Pds. AMOXICILLIN AMOXICILLINE Cap Orl 250mg Novamoxin TEV f ABEFGVW Caps Apo-Amoxi APX f ABEFGVW pms-amoxicillin PMS f ABEFGVW Mylan-Amoxicillin MYL f ABEFGVW Amoxicillin NUM f ABEFGVW Amoxicillin SAS f ABEFGVW Auro-Amoxicillin ARO f ABEFGVW Cap Orl 500mg Novamoxin TEV f ABEFGVW Caps Apo-Amoxi APX f ABEFGVW pms-amoxicillin PMS f ABEFGVW Mylan-Amoxicillin MYL f ABEFGVW February 2014 / février 2014 Page 95

108 J01CA04 AMOXICILLIN AMOXICILLINE Cap Orl 500mg Amoxicillin NUM f ABEFGVW Caps Amoxicillin SAS f ABEFGVW Auro-Amoxicillin ARO f ABEFGVW Pws Orl 25mg Novamoxin TEV f ABEFGVW Pds. Apo-Amoxi APX f ABEFGVW Novamoxin 125 (sugar-reduced) TEV f ABEFGVW pms-amoxicillin PMS f ABEFGVW Amoxicillin SAS f ABEFGVW Amoxicillin (sugar-reduced) SAS f ABEFGVW Pws Orl 50mg Novamoxin TEV f ABEFGVW Pds. Apo-Amoxi APX f ABEFGVW Novamoxin 125 (sugar-reduced) TEV f ABEFGVW pms-amoxicillin PMS f ABEFGVW Amoxicillin SAS f ABEFGVW Amoxicillin (sugar-reduced) SAS f ABEFGVW TabC Orl 125mg Novamoxin chew TEV f ABEFGVW C J01CE J01CA12 TabC Orl 250mg Novamoxin chew TEV f ABEFGVW C PIPERACILLIN PIPÉRACILLINE Pws Inj 3g Piperacillin HOS f W Pds. BETA-LACTAMASE SENSITIVE PENICILLINS PÉNICILLINES SENSIBLES AUX BETA-LACTAMASES J01CE01 BENZYLPENICILLIN (PENICILLIN G) BENZYLPÉNICILLINE (PÉNICILLINE G) Liq Inj IU Penicillin G Sodium TEV W Liq Liq Inj IU Penicillin G Sodium TEV W Liq Liq Inj IU Penicillin G Sodium TEV W Liq Pws Inj IU Crystapen BCH W Pds. Pws Inj IU Crystapen BCH W Pds. February 2014 / février 2014 Page 96

109 J01CE02 PHENOXYMETHYLPENICILLIN (PENICILLIN V) PHENOXYMETHYLPÉNICILLINE (PÉNICILLINE V) Pws Orl 25mg Apo-Pen VK APX AEFGVW Pds. Pws Orl 60mg Novo-Pen-VK (Disc/non disp Feb 26/15) TEV AEFGVW Pds. Apo-Pen VK APX AEFGVW Tab Orl 300mg Novo-Pen-VK (Disc/non disp Feb 26/15) TEV f AEFGVW Apo-Pen VK APX f AEFGVW J01CE08 BENZATHINE BENZYLPENICILLIN (PENICILLIN G BENZATHINE) BENZATHINE BENZYLPÉNICILLINE (PÉNICILLINE G BENZATHINE) Sus Inj IU Bicillin L-A KNG AEFGVW Susp. J01CF BETA-LACTAMASE RESISTANT PENICILLINS PÉNICILLINES RÉSISTANT AUX BETA-LACTAMASE J01CF02 CLOXACILLIN CLOXACILLINE Cap Orl 250mg Novo-Cloxin TEV f ABEFGVW Caps Cap Orl 500mg Novo-Cloxin TEV f ABEFGVW Caps Pws Inj 500mg Cloxacillin Sodium * TEV BEFGW Pds. Pws Inj 1g Cloxacillin Sodium TEV BEFGW Pds. Pws Inj 2g Cloxacillin Sodium TEV BEFGW Pds. Pws Orl 25mg Novo-Cloxin TEV f ABEFGVW Pds. J01CR COMBINATIONS PENICILLINS INCLUDING BETA LACTAMASE INHIBITORS COMBINAISON DE PÉNICILLINES, Y COMPRIS LES INHIBITEURS DE BETA-LACTAMASE J01CR02 AMOXICILLIN AND ENZYME INHIBITOR AMOXICILLINE ET INHIBITEURS D ENZYMES AMOXICILLIN / CLAVULANIC ACID AMOXICILLINE / ACIDE CLAVULANIQUE Pws Orl 25mg/6.25mg Clavulin GSK f ABEFGVW Pds. Apo-Amoxi clav APX f ABEFGVW Ratio-Aclavulanate 125 F TEV f ABEFGVW Pws Orl 50mg/12.5mg Clavulin-250 F GSK f ABEFGVW Pds. Apo-Amoxi clav APX f ABEFGVW Ratio-Aclavulanate 250 F TEV f ABEFGVW February 2014 / février 2014 Page 97

110 J01CR02 AMOXICILLIN AND ENZYME INHIBITOR AMOXICILLINE ET INHIBITEURS D ENZYMES AMOXICILLIN / CLAVULANIC ACID AMOXICILLINE / ACIDE CLAVULANIQUE Pws Orl 200mg/28.5mg/5mL Clavulin GSK ABEFGVW Pds. Pws Orl 400mg/57mg/5mL Clavulin GSK f ABEFGVW Pds. Apo-Amoxi Clav APX f ABEFGVW Tab Orl 250mg/125mg Apo-Amoxi Clav APX f ABEFGVW Tab Orl 500mg/125mg Clavulin-500 F GSK f ABEFGVW Apo-Amoxi Clav APX f ABEFGVW ratio-aclavulanate TEV ABEFGVW Tab Orl 875mg/125mg Clavulin GSK f ABEFGVW Apo-Amoxi Clav APX f ABEFGVW ratio-aclavulanate TEV f ABEFGVW Novo-Clavamoxin TEV f ABEFGVW J01CR03 TICARICILLIN AND ENZYME INHIBITOR TICARICILLINE ET INHIBITEURS D ENZYMES TICARICILLIN / POTASSIUM CLAVULANATE TICARICILLINE / CLAVULANATE DE POTASSIUM Pws Inj 3g Timentin GSK W Pds. J01CR05 PIPERACILLIN AND ENZYME INHIBITOR PIPÉRACILLINE ET INHIBITEURS D ENZYMES PIPERACILLIN / TAZOBACTAM PIPÉRACILLINE / TAZOBACTAM Pws Inj 2g/0.25g Tazocin PFI f W Pds. Piperacillin & Tazobactam APX f W Piperacillin & Tazobactam SDZ W Pws Inj 3g/0.375g Tazocin PFI f W Pds. Piperacillin & Tazobactam APX f W Piperacillin & Tazobactam SDZ W Piperacillin/Tazobactam TEV f W Pws Inj 4g/0.5g Tazocin PFI f W Pds. Piperacillin & Tazobactam APX f W Piperacillin & Tazobactam SDZ W AJ-Pip/Taz AJP f W Piperacillin/Tazobactam TEV f W February 2014 / février 2014 Page 98

111 J01D J01DB J01DB01 OTHER BETA LACTAM ANTIBACTERIALS AUTRES ANTIBACTERIEN BETA-LACTAM FIRST GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE PREMIÈRE GÉNÉRATION CEPHALEXIN CÉPHALEXINE Cap Orl 250mg Novo-Lexin TEV ABEFGVW Caps Cap Orl 500mg Novo-Lexin TEV ABEFGVW Caps Pws Orl 25mg Novo-Lexin TEV f ABEFGVW Pds. Pws Orl 50mg Novo-Lexin TEV f ABEFGVW Pds. Tab Orl 250mg Novo-Lexin TEV f ABEFGVW Apo-Cephalex APX f ABEFGVW J01DB04 J01DB05 Tab Orl 500mg Novo-Lexin TEV f ABEFGVW Apo-Cephalex APX f ABEFGVW CEFAZOLIN CÉFAZOLINE Pws Inj 500mg Cefazolin Sodium TEV f BEFGW Pds. Cefazolin Sodium SDZ f BEFGW Pws Inj 1g Cefazolin Sodium TEV f BEFGW Pds. Cefazolin HOS f BEFGW Cefazolin Sodium SDZ f BEFGW CEFADROXIL CÉFADROXIL Cap Orl 500mg Teva-Cefadroxil TEV f AEFGVW Caps Apo-Cefadroxil APX f AEFGVW J01DC J01DC01 SECOND GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE DEUXIÈME GÉNÉRATION CEFOXITIN CÉFOXITINE Pws Inj 1g Cefoxitin Sodium TEV f W Pds. Cefoxitin for Injection APX f W Pws Inj 2g Cefoxitin Sodium TEV f W Pds. Cefoxitin for Injection APX f W Pws Inj 10g Novo-Cefoxitin TEV W Pds. February 2014 / février 2014 Page 99

112 J01DC02 CEFUROXIME CÉFUROXIME Liq Orl 25mg Ceftin GSK ABEFGVW Liq Tab Orl 250mg Ceftin GSK f ABEFGVW ratio-cefuroxime TEV f ABEFGVW Apo-Cefuroxime APX f ABEFGVW Auro-Cefuroxime ARO f ABEFGVW Tab Orl 500mg Ceftin GSK f ABEFGVW ratio-cefuroxime TEV f ABEFGVW Apo-Cefuroxime APX f ABEFGVW Auro-Cefuroxime ARO f ABEFGVW Pws. Inj 750mg Cefuroxime * PPC f BEFGW Pds. J01DC04 Pws. Inj 1.5g Cefuroxime * PPC f BEFGW Pds. CEFACLOR CÉFACLOR Cap Orl 250mg Ceclor PDP f ABEFGVW Caps Cap Orl 500mg Ceclor PDP f ABEFGVW Caps Pws. Orl 25mg Ceclor PDP f ABEFGVW Pds. Pws. Orl 50mg Ceclor PDP f ABEFGVW Pds. J01DC10 Pws. Orl 75mg Ceclor B.I.D PDP f ABEFGVW Pds. CEFPROZIL CEFPROZIL Tab Orl 250mg Cefzil BRI f AEFGVW Apo-Cefprozil APX f AEFGVW Ran-Cefprozil RAN f AEFGVW Sandoz Cefprozil SDZ f AEFGVW Auro-Cefprozil ARO f AEFGVW Tab Orl 500mg Cefzil BRI f AEFGVW Apo-Cefprozil APX f AEFGVW Ran-Cefprozil RAN f AEFGVW Sandoz Cefprozil SDZ f AEFGVW Auro-Cefprozil ARO f AEFGVW February 2014 / février 2014 Page 100

113 J01DD J01DC10 J01DD01 CEFPROZIL CEFPROZIL Pws. Orl 25mg Cefzil BRI f AEFGVW Pds. Apo-Cefprozil APX f AEFGVW Ran-Cefprozil RAN f AEFGVW Sandoz Cefprozil SDZ f AEFGVW Auro-Cefprozil ARO f AEFGVW Pws. Orl 50mg Cefzil BRI f AEFGVW Pds. Apo-Cefprozil APX f AEFGVW Ran-Cefprozil RAN f AEFGVW Sandoz Cefprozil SDZ f AEFGVW Auro-Cefprozil ARO f AEFGVW THIRD GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE TROISIÈME GÉNÉRATION CEFOTAXIME CÉFOTAXIME Pws Inj 500mg Claforan (Disc/non disp Apr 1/14) SAV W Pds. Pws Inj 1g Claforan SAV W Pds. J01DD02 Pws Inj 2g Claforan SAV W Pds. CEFTAZIDIME CEFTAZIDIME Pws Inj 500mg Fortaz GSK BEFGW Pds. Pws Inj 1g Ceftazidime PPC BEFGW Pds. Fortaz GSK BEFGW J01DD04 Pws Inj 2g Ceftazidime PPC BEFGW Pds. Fortaz GSK BEFGW CEFTRIAXONE CEFTRIAXONE Pws Inj 250mg Rocephin (Disc/non disp Jun 20/14) HLR f BEFGVW Pds. Ceftriaxone APX f BEFGVW Ceftriaxone Sodium STR f BEFGVW Pws Inj 1g Ceftriaxone SDZ f BEFGVW Pds. Ceftriaxone APX f BEFGVW Ceftriaxone Sodium STR f BEFGVW Ceftriaxone Sodium TEV f BEFGVW February 2014 / février 2014 Page 101

114 J01DE J01DH J01DD04 J01DD08 J01DE01 J01DH02 J01DH03 J01DH51 CEFTRIAXONE CEFTRIAXONE Pws Inj 2g Ceftriaxone SDZ f BEFGVW Pds. Ceftriaxone APX f BEFGVW Ceftriaxone Sodium STR f BEFGVW CEFIXIME CÉFIXIME Pws Orl 20mg Suprax SAV ABEFGVW Pds. Tab Orl 400mg Suprax SAV ABEFGVW FOURTH GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE QUATRIÈME GÉNÉRATION CEFEPIME CÉFEPIME Pws Inj 1g Maxipime BRI W Pds. Pws Inj 2g Maxipime BRI f W Pds. Cefepime APX f W CARBAPENEMS CARBAPENEMS MEROPENEM MÉROPÉNEM Pws Inj 500mg Merrem AZE W Pds. Pws Inj 1g Merrem AZE W Pds. ERTAPENEM ERTAPÉNEM Pws Inj 1g Invanz FRS W Pds. IMIPENEM AND ENZYME INHIBITOR IMIPENEM ET INHIBITEURS D ENZYMES IMIPENEM / CILASTATIN IMIPÉNEM / CILASTATINE Pws Inj 250mg Primaxin(Disc/non disp Oct 1/14) FRS W Pds. Ran-Imipenem-Cilastatin OMG W Pws Inj 500mg Primaxin FRS W Pds. Ran-Imipenem-Cilastatin OMG W February 2014 / février 2014 Page 102

115 J01E J01EA SULFONAMIDES AND TRIMETHOPRIM SULFONAMIDES ET TRIMÉTHOPRIME TRIMETHOPRIM AND DERIVATIVES TRIMÉTHOPRIME ET DÉRIVÉS J01EA01 TRIMETHOPRIM TRIMÉTHOPRIME Tab Orl 100mg Trimethoprim AAP f AEFGVW Tab Orl 200mg Trimethoprim AAP f AEFGVW J01EE COMBINATIONS OF SULFONAMIDES AND TRIMETHOPRIM, INCLUDING DERIVATIVES COMBINAISON DE SULFONAMIDES ET DE TRIMÉTHOPRIME, INCLUANT LES DÉRIVÉS J01EE01 SULFAMETHOXASOLE AND TRIMETHOPRIM SULFAMÉTHOXASOLE ET TRIMÉTHOPRIME Sus Orl 8mg/40mg Novo-Trimel TEV f ABEFGVW Susp. Tab Orl 20mg/100mg Apo-Sulfatrim APX ABEFGVW Tab Orl 80mg/400mg Apo-Sulfatrim APX f ABEFGVW Novo-Trimel TEV f ABEFGVW Tab Orl 160mg/800mg Apo-Sulfatrim DS APX f ABEFGVW Novo-Trimel DS TEV f ABEFGVW J01F J01FA MACROLIDES, LINCOSAMIDES AND STREPTOGRAMINS MACROLIDES, LINCOSAMIDES ET STREPTOGRAMINES MACROLIDES MACROLIDES J01FA01 ERYTHROMYCIN ÉRYTHROMYCINE ECC Orl 250mg Eryc PFI f ABEFGVW Caps.Ent. Erythro E-C AAP f ABEFGVW ECC Orl 333mg Eryc PFI f ABEFGVW Caps.Ent. Erythro E-C AAP f ABEFGVW Tab Orl 250mg Erythro AAP f ABEFGVW Liq Orl 50mg Novo-Rythro Estolate TEV f ABEFGVW Liq Pws Orl 40mg Novo-Rythro TEV f ABEFGVW Pds. Pws Orl 80mg Novo-Rythro TEV f ABEFGVW Pds. February 2014 / février 2014 Page 103

116 J01FA01 ERYTHROMYCIN ÉRYTHROMYCINE Tab Orl 600mg Erythro-ES AAP f ABEFGVW Tab Orl 250mg Erythro-S AAP f ABEFGVW Tab Orl 500mg Erythro-S AAP ABEFGVW J01FA02 SPIRAMYCIN SPIRAMYCINE Cap Orl IU Rovamycine ODN AEFGVW Caps J01FA09 Cap Orl IU Rovamycine ODN AEFGVW Caps CLARITHROMYCIN CLARITHROMYCINE ERT Orl 500mg Biaxin XL ABB ABEFGVW L.P. Pws Orl 25mg Biaxin ABB f ABEFGVW Pds. Accel-Clarithromycin ACC f ABEFGVW Clarithromycin SAS f ABEFGVW Pws Orl 50mg Biaxin ABB f ABEFGVW Pds. Accel-Clarithromycin ACC f ABEFGVW Clarithromycin SAS f ABEFGVW Tab Orl 250mg Biaxin BID ABB f ABEFGVW pms-clarithromycin PMS f ABEFGVW ratio-clarithromycin(disc/non disp Apr 12/15) RPH f ABEFGVW Mylan-Clarithromycin MYL f ABEFGVW Sandoz Clarithromycin SDZ f ABEFGVW Apo-Clarithromycin APX f ABEFGVW Ran-Clarithromycin RAN f ABEFGVW Teva-Clarithromycin TEV f ABEFGVW Tab Orl 500mg Biaxin BID ABB f ABEFGVW pms-clarithromycin PMS f ABEFGVW Mylan-Clarithromycin MYL f ABEFGVW ratio-clarithromycin (Disc/non disp Apr 12/15) RPH f ABEFGVW Sandoz Clarithromycin SDZ f ABEFGVW Apo-Clarithromycin APX f ABEFGVW Ran-Clarithromycin RAN f ABEFGVW Teva-Clarithromycin TEV f ABEFGVW February 2014 / février 2014 Page 104

117 J01FA10 AZITHROMYCIN AZITHROMYCINE Pws Inj 500mg Zithromax PFI W Pds. Pws Orl 20mg Zithromax PFI f ABEFGVW Pds. Pms-Azithromycin PMS f ABEFGVW Novo-Azithromycin pediatric TEV f ABEFGVW Sandoz Azithromycin SDZ f ABEFGVW Phl-Azithromycin PHL ABEFGVW GD-Azithromycin GMD f ABEFGVW Pws Orl 40mg Zithromax PFI f ABEFGVW Pds. Pms-Azithromycin PMS f ABEFGVW Novo-Azithromycin pediatric TEV f ABEFGVW Sandoz Azithromycin SDZ f ABEFGVW Phl-Azithromycin PHL ABEFGVW GD-Azithromycin GMD f ABEFGVW Tab Orl 250mg Zithromax PFI f ABEFGVW Apo-Azithromycin APX f ABEFGVW Co Azithromycin COB f ABEFGVW pms-azithromycin PMS f ABEFGVW Sandoz-Azithromycin SDZ f ABEFGVW Novo-Azithromycin TEV f ABEFGVW GD-Azithromycin GMD f ABEFGVW ratio-azithromycin RPH f ABEFGVW Mylan-Azithromycin MYL f ABEFGVW Azithromycin SAS f ABEFGVW Tab Orl 600mg Zithromax PFI f W Co Azithromycin COB f W pms-azithromycin PMS f W Azithromycin SAS f W J01FF LINCOSAMIDES LINCOSAMIDES J01FF01 CLINDAMYCIN CLINDAMYCINE Cap Orl 150mg Dalacin C PFI f ABEFGVW Caps Teva-Clindamycin TEV f ABEFGVW Apo-Clindamycin APX f ABEFGVW Mylan-Clindamycin MYL f ABEFGVW Cap Orl 300mg Dalacin C PFI f ABEFGVW Caps Teva-Clindamycin TEV f ABEFGVW Apo-Clindamycin APX f ABEFGVW Mylan-Clindamycin MYL f ABEFGVW Liq Inj 150mg Dalacin C Phosphate PFI f W Liq Clindamycin (bulk vials) SDZ f W Clindamycin (2ml, 4ml, 6ml vials) SDZ f W February 2014 / février 2014 Page 105

118 J01G J01FF01 J01GB J01M J01GB01 J01GB03 J01GB06 J01MA J01MA01 CLINDAMYCIN CLINDAMYCINE Pws Orl 15mg Dalacin C PFI AEFGVW Pds. AMINOGLYCOSIDE ANTIBACTERIALS ANTIBACTÉRIENS AMINOGLYCOSIDES OTHER AMINOGLYCOSIDES AUTRES AMINOGLYCOSIDES TOBRAMYCIN TOBRAMYCINE Liq Inj 40mg Tobramycin * SDZ f BEFGVW Liq Tobramycin * AJP f BEFGVW GENTAMICIN GENTAMICINE Liq Inj 40mg Gentamicin SDZ f BEFGVW Liq AMIKACIN AMIKACINE Liq Inj 250mg Amikacin SDZ W Liq QUINOLONE ANTIBACTERIALS ANTIBACTÉRIENS QUINOLONES FLOUROQUINOLONES FLOUROQUINOLONES OFLOXACIN OFLOXACINE Tab Orl 200mg Ofloxacin AAP f EF18+ Tab Orl 300mg Ofloxacin AAP f EF18+ Tab Orl 400mg Ofloxacin AAP f EF18+ J01MA02 CIPROFLOXACIN CIPROFLOXACINE ERT Orl 1000mg Cipro XL BAY ABEFGV L.P. 14 The use of Quinolones in children < 18 years of age is generally contraindicated. Les quinolones sont habituellement contre-indiquées pour les enfants. 15 Prescriptions written by New Brunswick urologists, infectious disease specialists and medical microbiologists do not require special authorization. Les ordonnances provenant d urologues, spécialistes en maladies infectieuses, ou microbiologists du Nouveau-Brunswick ne nécessiteront pa une autorisation special. February 2014 / février 2014 Page 106

119 J01MA02 CIPROFLOXACIN CIPROFLOXACINE Liq Inj 2mg Ciprofloxacin I.V TEV f W Liq Liq Inj 10mg Ciprofloxacin PDL W Liq Liq Orl 100mg Cipro Oral Suspension BAY ABEFGV Liq Tab Orl 250mg Cipro BAY f BW Cipro BAY f AEFGV Novo-Ciprofloxacin TEV f BW Novo-Ciprofloxacin TEV f AEFGV Apo-Ciproflox APX f BW Apo-Ciproflox APX f AEFGV Mylan-Ciprofloxacin MYL f BW Mylan-Ciprofloxacin MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Nov.29/15) TEV f BW ratio-ciprofloxacin 16 (Disc/non disp Nov.29/15) TEV f AEFGV Co Ciprofloxacin COB f BW Co Ciprofloxacin COB f AEFGV pms-ciprofloxacin PMS f BW pms-ciprofloxacin PMS f AEFGV Sandoz Ciprofloxacin SDZ f BW Sandoz Ciprofloxacin SDZ f AEFGV Ran-Ciproflox RAN f BW Ran-Ciproflox RAN f AEFGV Mint-Ciprofloxacin MNT f BW Mint-Ciprofloxacin MNT f AEFGV Ciprofloxacin SAS f BW Ciprofloxacin SAS f AEFGV Septa-Ciprofloxacin SPT f BW Septa-Ciprofloxacin SPT f AEFGV Jamp-Ciprofloxacin JPC f BW Jamp-Ciprofloxacin JPC f AEFGV Mar-Ciprofloxacin MAR f BW Mar-Ciprofloxacin MAR f AEFGV Auro-Ciprofloxacin ARO f BW Auro-Ciprofloxacin ARO f AEFGV Tab Orl 500mg Cipro BAY f BW Cipro BAY f AEFGV Novo-Ciprofloxacin TEV f BW Novo-Ciprofloxacin TEV f AEFGV Apo-Ciproflox APX f BW Apo-Ciproflox APX f AEFGV Mylan-Ciprofloxacin MYL f BW Mylan-Ciprofloxacin MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Jul 24/15) TEV f BW ratio-ciprofloxacin (Disc/non disp Jul 24/15) TEV f AEFGV Co Ciprofloxacin COB f BW Co Ciprofloxacin COB f AEFGV February 2014 / février 2014 Page 107

120 J01MA02 CIPROFLOXACIN CIPROFLOXACINE Tab Orl 500mg pms-ciprofloxacin PMS f BW pms-ciprofloxacin PMS f AEFGV Sandoz Ciprofloxacin SDZ f BW Sandoz Ciprofloxacin SDZ f AEFGV Ran-Ciproflox RAN f BW Ran-Ciproflox RAN f AEFGV Mint-Ciprofloxacin MNT f BW Mint-Ciprofloxacin MNT f AEFGV Ciprofloxacin SAS f BW Ciprofloxacin SAS f AEFGV Septa-Ciprofloxacin SPT f BW Septa-Ciprofloxacin SPT f AEFGV Jamp-Ciprofloxacin JPC f BW Jamp-Ciprofloxacin JPC f AEFGV Mar-Ciprofloxacin MAR f BW Mar-Ciprofloxacin MAR f AEFGV Auro-Ciprofloxacin ARO f BW Auro-Ciprofloxacin ARO f AEFGV Tab Orl 750mg Cipro BAY f BW Cipro BAY f AEFGV Novo-Ciprofloxacin TEV f BW Novo-Ciprofloxacin TEV f AEFGV Apo-Ciproflox APX f BW Apo-Ciproflox APX f AEFGV Mylan-Ciprofloxacin MYL f BW Mylan-Ciprofloxacin MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Nov.29/15) TEV f BW ratio-ciprofloxacin 16 (Disc/non disp Nov.29/15) TEV f AEFGV Co Ciprofloxacin COB f BW Co Ciprofloxacin COB f AEFGV pms-ciprofloxacin PMS f BW pms-ciprofloxacin PMS f AEFGV Sandoz Ciprofloxacin SDZ f BW Sandoz Ciprofloxacin SDZ f AEFGV Ran-Ciproflox RAN f BW Ran-Ciproflox RAN f AEFGV Mint-Ciprofloxacin MNT f BW Mint-Ciprofloxacin MNT f AEFGV Ciprofloxacin SAS f BW Ciprofloxacin SAS f AEFGV Septa-Ciprofloxacin SPT f BW Septa-Ciprofloxacin SPT f AEFGV Jamp-Ciprofloxacin JPC f BW Jamp-Ciprofloxacin JPC f AEFGV February 2014 / février 2014 Page 108

121 J01MA02 J01MA06 J01MA12 CIPROFLOXACIN CIPROFLOXACINE Tab Orl 750mg Mar-Ciprofloxacin MAR f BW Mar-Ciprofloxacin MAR f AEFGV Auro-Ciprofloxacin ARO f BW Auro-Ciprofloxacin ARO f AEFGV NORFLOXACIN NORFLOXACINE Tab Orl 400mg Apo-Norflox APX f AEFVW Novo-Norfloxacin TEV f AEFVW pms-norfloxacin (Disc/non disp Oct 29/15) PMS f AEFVW Co Norfloxacin COB f AEFVW LEVOFLOXACIN LÉVOFLOXACINE Liq Inj 5mg Levaquin JAN W Liq Tab Orl 250mg Levaquin JAN f VW Levaquin JAN f ABEFG Novo-Levofloxacin TEV f VW Novo-Levofloxacin TEV f ABEFG pms-levofloxacin PMS f VW pms-levofloxacin PMS f ABEFG Apo-Levofloxacin APX f VW Apo-Levofloxacin APX f ABEFG Sandoz Levofloxacin SDZ f VW Sandoz Levofloxacin SDZ f ABEFG Mylan-Levofloxacin MYL f VW Mylan-Levofloxacin MYL f ABEFG Co Levofloxacin COB f VW Co Levofloxacin COB f ABEFG Tab Orl 500mg Levaquin JAN f VW Levaquin JAN f ABEFG Novo-Levofloxacin TEV f VW Novo-Levofloxacin TEV f ABEFG pms-levofloxacin PMS f VW pms-levofloxacin PMS f ABEFG Apo-Levofloxacin APX f VW Apo-Levofloxacin APX f ABEFG Sandoz Levofloxacin SDZ f VW Sandoz Levofloxacin SDZ f ABEFG Mylan-Levofloxacin MYL f VW Mylan-Levofloxacin MYL f ABEFG Co Levofloxacin COB f VW Co Levofloxacin COB f ABEFG 16 Requests for coverage of Cipro (Ciprofloxacin) will be considered under special authorization (see Appendix IV). Prescriptions written by New Brunswick urologists, infectious disease specialists, medical oncologists, hematologists, respiratory medicine specialists or medical microbiologists do not require special authorization. Les demandes de protection pour le Cipro (Ciprofloxacin) seront examinees sur autorisation special. Veuillez consulter l annexe IV. Les ordonnances rédigées par leurologues, spécialistes en maladies infectieuses, oncologues, hématologues, inhalothérapeutes ou microbiologists du Nouveau-Brunswick ne nécessiteront pa une autorisation special. February 2014 / février 2014 Page 109

122 J01MA12 LEVOFLOXACIN LÉVOFLOXACINE Tab Orl 750mg Levaquin JAN f W Novo-Levofloxacin TEV f W Sandoz Levofloxacin SDZ f W pms-levofloxacin PMS f W Co Levofloxacin COB f W Apo-Levofloxacin APX f W J01MA14 MOXIFLOXACIN MOXIFLOXACINE Liq Inj 400mg Avelox I.V BAY W Liq Tab Orl 400mg Avelox BAY VW Avelox BAY ABEFG J01X J01XA OTHER ANTIBACTERIALS AUTRES ANTIBACTÉRIENS GLYCOPEPTIDE ANTIBACTERIALS ANTIBACTÉRIENS GLYCOPEPTIDES J01XA01 VANCOMYCIN VANCOMYCINE Cap Orl 125mg Vancocin MRS f AEFGVW Caps Vancomycin Hydrochloride PPC f AEFGVW Cap Orl 250mg Vancocin MRS f AEFGVW Caps Vancomycin Hydrochloride PPC f AEFGVW Pws Inj 1g pms-vancomycin PMS f ABEFGW Pds. Vancomycin HCL PPC ABEFGW Val-Vancomycin VAL ABEFGW Pws Inj 500mg pms-vancomycin PMS f ABEFGW Pds. Sterile Vancomycin HCL PPC ABEFGW Val-Vancomycin VAL ABEFGW Sterile Vancomycin HOS ABEFGW J01XD IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE J01XD01 METRONIDAZOLE MÉTRONIDAZOLE Liq Inj 0.50% Metronidazole HOS W Liq Metronidazole BAX W Tab Orl 250mg Metronidazole AAP f AEFGVW 17 Prescriptions written by New Brunswick infectious disease specialists, medical microbiologists, medical oncologists, respirologists and internal medicine specialists do not require special authorization. Les ordonnances rédigées par les infectologues, les microbiologistesmédicaux, oncologues, les spécialistes de medicine interne ou le pneumologues du Nouveau-Brunswick ne nécessiteront pa une autorisation special. February 2014 / février 2014 Page 110

123 J01XE J01XE01 NITROFURAN DERIVATIVES DÉRIVÉS DU NITROFURANE NITROFURANTOIN NITROFURANTOÏNE Cap Orl 50mg Teva-Furantoin TEV f AEFGVW Caps Cap Orl 100mg Macrobid WNC AEFGVW Caps J01XX J02 J02A J02AA J02AB J02AC J01XX05 J02AA01 J02AB02 J02AC01 Tab Orl 50mg Nitrofurantoin AAP AEFGVW Tab Orl 100mg Nitrofurantoin AAP AEFGVW OTHER ANTIBACTERIALS AUTRES ANTIBACTÉRIENS METHENAMINE MÉTHÉNAMINE Tab Orl 500mg Mandelamine ERF AEFGVW ANTIMYCOTICS FOR SYSTEMIC USE ANTIMYCOTIQUES POUR USAGE SYSTÉMIQUE ANTIMYCOTICS FOR SYSTEMIC USE ANTIMYCOTIQUES POUR USAGE SYSTÉMIQUE ANTIBIOTICS ANTIBIOTIQUES AMPHOTERICIN B AMPHOTÉRICINE B Pws Inj 50mg Fungizone IV BRI W Pds. IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE KETOCONAZOLE KÉTOCONAZOLE Tab Orl 200mg Novo-Ketoconazole TEV f AEFGVW Apo-Ketoconazole APX f AEFGVW TRIAZOLE DERIVATIVES DÉRIVÉS DE TRIAZOLE FLUCONAZOLE FLUCONAZOLE Cap Orl 150mg Apo-Fluconazole APX f AEFGVW Caps pms-fluconazole PMS f AEFGVW Liq Inj 2mg Diflucan PFI f W Liq Fluconazole (Disc/non disp Jun 4/15) TEV f W February 2014 / février 2014 Page 111

124 J02AX J04 J04A J04AB J04B J02AC01 J02AX04 J04BA J04AB02 J04BA02 FLUCONAZOLE FLUCONAZOLE Tab Orl 50mg Novo-Fluconazole TEV f AEFGVW Apo-Fluconazole APX f AEFGVW Mylan-Fluconazole MYL f AEFGVW pms-fluconazole PMS f AEFGVW Co Fluconazole COB f AEFGVW Tab Orl 100mg Novo-Fluconazole TEV f AEFGVW Apo-Fluconazole APX f AEFGVW Mylan-Fluconazole MYL f AEFGVW pms-fluconazole PMS f AEFGVW Co Fluconazole COB f AEFGVW ANTIMYCOTICS FOR SYSTEMIC USE ANTIMYCOTIQUES POUR USAGE SYSTÉMIQUE CASPOFUNGIN CASPOFUNGIN Pwd Inj 50mg Cancidas IV FRS W Pws. ANTIMYCOBACTERIALS ANTIFONGIQUES BACTÉRIENS DRUGS FOR TREATMENT OF TUBERCULOSIS MÉDICAMENTS POUR LE TRAITEMENT DE LA TUBERCULOSE ANTIBIOTICS ANTIBIOTIQUES RIFAMPICIN RIFAMPICINE Cap Orl 150mg Rofact VLN ABEFGVW Caps Rifadin SAV ABEFGVW Cap Orl 300mg Rofact VLN ABEFGVW Caps Rifadin SAV ABEFGVW DRUGS FOR TREATMENT OF LEPRA MÉDICAMENTS POUR LE TRAITEMENT DE LA LÈPRE DRUGS FOR TREATMENT OF LEPRA MÉDICAMENTS POUR LE TRAITEMENT DE LA LEPRE DAPSONE DAPSONE Tab Orl 100mg Dapsone JCB AEFGVW February 2014 / février 2014 Page 112

125 J05 J05A J05AB J05AB01 ANTIVIRALS FOR SYSTEMIC USE ANTIVIRAUX SYSTÉMIQUES DIRECT ACTING ANTIVIRALS AGENTS AGISSANT DIRECTEMENT SUR LE VIRUS NUCLEOSIDES AND NUCLEOTIDES EXCLUDING REVERSE TRANSCRIPTASE INHIBITORS NUCLÉOSIDES ET NUCLÉOTIDES, À L EXCLUSION DES INHIBITEURS LA TRANSCRIPTASE INVERSÉE ACYCLOVIR ACYCLOVIR Tab Orl 200mg Zovirax GSK f AEFGVW ratio-acyclovir TEV f AEFGVW Apo-Acyclovir APX f AEFGVW Mylan-Acyclovir MYL f AEFGVW Teva-Acyclovir TEV f AEFGVW Acyclovir SAS f AEFGVW Tab Orl 400mg Zovirax GSK f AEFGVW ratio-acyclovir (Disc/non disp Nov.29/15) TEV f AEFGVW Apo-Acyclovir APX f AEFGVW Mylan-Acyclovir MYL f AEFGVW Teva-Acyclovir TEV f AEFGVW Acyclovir SAS f AEFGVW Tab Orl 800mg ratio-acyclovir (Disc/non disp Jul 24/15) TEV f AEFGVW Apo-Acyclovir APX f AEFGVW Mylan-Acyclovir MYL f AEFGVW Teva-Acyclovir TEV f AEFGVW Acyclovir SAS f AEFGVW Liq Inj 25mg Acyclovir Sodium HOS W Liq J05AB06 J05AB09 Liq Inj 50mg Acyclovir Sodium PPC W Liq GANCICLOVIR GANCICLOVIR Pws Inj 500mg Cytovene HLR W Pds. FAMCICLOVIR FAMCICLOVIR Tab Orl 125mg Famvir NVR f AEFGVW pms-famciclovir PMS f AEFGVW Sandoz Famciclovir SDZ f AEFGVW Apo-Famciclovir APX f AEFGVW Co Famciclovir COB f AEFGVW Tab Orl 250mg Famvir NVR f AEFGVW pms-famciclovir PMS f AEFGVW Sandoz Famciclovir SDZ f AEFGVW February 2014 / février 2014 Page 113

126 J05AE J05AB09 J05AB11 J05AE01 J05AE02 J05AE03 J05AE04 FAMCICLOVIR FAMCICLOVIR Tab Orl 250mg Apo-Famciclovir APX f AEFGVW Co Famciclovir COB f AEFGVW Tab Orl 500mg Famvir NVR f AEFGVW pms-famciclovir PMS f AEFGVW Sandoz Famciclovir SDZ f AEFGVW Apo-Famciclovir APX f AEFGVW Co Famciclovir COB f AEFGVW VALACYCLOVIR VALACYCLOVIR Tab Orl 500mg Valtrex GSK f AEFGVW Apo-Valacyclovir APX f AEFGVW pms-valacyclovir PMS f AEFGVW Co Valacyclovir COB f AEFGVW Mylan-Valacyclovir MYL f AEFGVW Auro-Valacyclovir ARO f AEFGVW PROTEASE INHIBITORS INHIBITEURS DE PROTÉASE SAQUINAVIR SAQUINAVIR Cap Orl 200mg Invirase HLR U Caps Tab Orl 300mg Invirase HLR U INDINAVIR INDINAVIR Cap Orl 200mg Crixivan FRS U Caps Cap Orl 400mg Crixivan FRS U Caps RITONAVIR RITONAVIR Tab Orl 100mg Norvir ABV U NELFINAVIR NELFINAVIR Tab Orl 250mg Viracept VIV U Tab Orl 625mg Viracept VIV U February 2014 / février 2014 Page 114

127 J05AE07 J05AE08 J05AE30 FOSAMPRENAVIR FOSAMPRÉNAVIR Sus Orl 50mg Telzir VIV U Susp. Tab Orl 700mg Telzir VIV U ATAZANAVIR ATAZANAVIR Cap Orl 150mg Reyataz BRI U Caps Cap Orl 200mg Reyataz BRI U Caps Cap Orl 300mg Reyataz BRI U Caps COMBINATIONS OF PROTEASE INHIBITORS COMBINAISONS D INHIBITEURS DE PROTÉASE LOPINAVIR / RITONAVIR LOPINAVIR / RITONAVIR Liq Orl 80mg Kaletra Oral Solution ABV U Liq Tab Orl 100mg/25mg Kaletra ABV U J05AF J05AF01 Tab Orl 200mg/50mg Kaletra Tab ABB U NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS INHIBITEURS NUCLÉOSIDIQUES ET NUCLÉOTIDIQUES DE LA TRANSCRIPTASE ZIDOVUDINE ZIDOVUDINE Cap Orl 100mg Retrovir VIV f U Caps Apo-Zidovudine APX f U Liq Inj 100mg Retrovir VIV U Liq J05AF02 Syr Orl 10mg Retrovir VIV U Sir. DIDANOSINE DIDANOSINE ECC Orl 125mg Videx EC BRI U Caps.Ent. ECC Orl 200mg Videx EC BRI U Caps.Ent. February 2014 / février 2014 Page 115

128 J05AF02 J05AF04 DIDANOSINE DIDANOSINE ECC Orl 250mg Videx EC BRI U Caps.Ent. ECC Orl 400mg Videx EC BRI U Caps.Ent. STAVUDINE STAVUDINE Cap Orl 15mg Zerit BRI U Caps Cap Orl 20mg Zerit BRI U Caps Cap Orl 30mg Zerit BRI U Caps J05AF05 Cap Orl 40mg Zerit BRI U Caps LAMIVUDINE LAMIVUDINE Liq Orl 5mg Heptovir GSK AEFV Liq Liq Orl 10mg 3TC VIV U Liq Tab Orl 100mg Heptovir GSK f AEFGVW Apo-Lamivudine HBV APX f AEFGVW Tab Orl 150mg 3TC VIV f U Apo-Lamivudine APX f U J05AF06 Tab Orl 300mg 3TC VIV f U Apo-Lamivudine APX f U ABACAVIR ABACAVIR Liq Orl 20mg Ziagen VIV U Liq Tab Orl 300mg Ziagen VIV U 18 Prescriptions written by certified New Brunswick internal medicine specialists do not require special authorization. Les ordonnances rédigées par les spécialistes en medicine interne du Nouveau-Brunswick ne requiérent pas d autorisation special. February 2014 / février 2014 Page 116

129 J05AG J05AG01 J05AG03 NON-NUCLEOSIDES REVERSE TRANSCRIPTASE INHIBITORS INHIBITEURS NON NUCLÉOSIDIQUES DE LA TRANSCRIPTASE INVERSÉE NEVIRAPINE NÉVIRAPINE ERT Orl 400mg Viramune XR BOE U L.P. Tab Orl 200mg Viramune BOE f U Auro-Nevirapine ARO f U Teva-Nevirapine TEV f U Mylan-Nevirapine MYL f U pms-nevirapine PMS f U EFAVIRENZ ÉFAVIRENZ Cap Orl 20mg Sustiva BRI U Caps Cap Orl 200mg Sustiva BRI U Caps J05AR J05AG05 J05AR02 J05AR02 J05AR03 J05AR04 Tab Orl 600mg Sustiva BRI f U Mylan-Efavirenz MYL f U Teva-Efavirenz TEV f U RILPIVIRINE RILPIVIRINE Tab Orl 25mg Edurant JAN U ANTIVIRALS FOR TREATMENT OF HIV INFECTIONS, COMBINATIONS ANTIVIRAUX POUR LE TRAITEMENT DES INFECTIONS AU VIH, COMBINAISONS LAMIVUDINE AND ZIDOVUDINE LAMIVUDINE ET ZIDOVUDINE Tab Orl 300mg/150mg Combivir VIV f U Apo-Lamivudine/Zidovudine APX f U Teva-Lamivudine/Zidovudine TEV f U LAMIVUDINE AND ABACAVIR LAMIVUDINE ET ABACAVIR Tab Orl 600mg/300mg Kivexa VIV U TENOFOVIR DISOPROXIL AND EMTRICITABINE TENOFOVIR DISOPROXIL ET EMTRICITABINE Tab Orl 300mg/200mg Truvada GIL U ZIDOVUDINE, LAMIVUDINE AND ABACAVIR ZIDOVUDINE, LAMIVUDINE ET ABACAVIR Tab Orl 300mg Trizivir VIV U February 2014 / février 2014 Page 117

130 J05AX L01 L01A J05AR06 J05AR08 J05AX08 L01AA L01AA01 L01AA02 L01AA03 L01AB L01AB01 EMTRICITABINE, TENOFOVIR DISOPROXIL AND EFAVIRENZ EMTRICITABINE, TÉNOFOVIR DISOPROXIL ET ÉFAVIRENZ Tab Orl 600mg/300mg/200mg Atripla GIL U EMTRICITABINE, TENOFOVIR DISOPROXIL AND RILPIVIRINE EMTRICITABINE, TÉNOFOVIR DISOPROXIL ET RILPIVIRINE Tab Orl 25mg/200mg/300mg Complera GIL U OTHER ANTIVIRALS AUTRES ANTIVIRAUX RALTEGRAVIR RALTÉGRAVIR Tab Orl 400mg Isentress FRS U ANTINEOPLASTIC AGENTS AGENTS ANTINÉOPLASIQUES ALKYLATING AGENTS AGENTS ALKYLANTS NITROGEN MUSTARD ANALOGUES ANALOGUES, MOUTARDE AZOTÉE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE Tab Orl 25mg Procytox BAX AEFGVW Tab Orl 50mg Procytox BAX AEFGVW CHLORAMBUCIL CHLORAMBUCIL Tab Orl 2mg Leukeran TRI AEFGVW MELPHALAN MELPHALAN Tab Orl 2mg Alkeran TRI AEFGVW ALKYL SULPHONATES SULFONATES D ALKYLE BUSULFAN BUSULFAN Tab Orl 2mg Myleran TRI AEFGVW February 2014 / février 2014 Page 118

131 L01B L01BA L01BA01 ANTIMETABOLITES ANTIMÉTABOLITES FOLIC ACID ANALOGUES ANALOGUES DE L ACIDE FOLIQUE METHOTREXATE MÉTHOTREXATE Liq Inj 10mg Methotrexate Inj USP * HOS AEFGVW Liq Liq Inj 25mg Methotrexate Inj USP * TEV AEFGVW Liq Methotrexate Inj USP * HOS AEFGVW Methotrexate Inj USP * HOS AEFGVW Tab Orl 2.5mg Methotrexate PFI f AEFGVW Ratio-methotrexate TEV f AEFGVW Methotrexate APX AEFGVW L01BB L01BB02 L01BB03 L01BC L01C L01BC02 L01CB L01CB01 Tab Orl 10mg Methotrexate HOS AEFGVW PURINE ANALOGUES ANALOGUES PURINE MERCAPTOPURINE MERCAPTOPURINE Tab Orl 50mg Purinethol TEV AEFGVW TIOGUANINE TIOGUANINE Tab Orl 40mg Lanvis TRI AEFGVW PYRIMIDINE ANALOGUES ANALOGUES PYRIMIDIQUES FLUOROURACIL FLUOROURACILE Crm Top 5% Efudex VLN AEFGVW Cr. PLANT ALKALOIDS AND OTHER NATURAL PRODUCTS ALCALOIDES DE PLANTES ET AUTRES PRODUITS NATURELS PODOPHYLLOTOXIN DERIVATIVES DÉRIVÉS DE LA PODOPHYLLOTOXINE ETOPOSIDE ÉTOPOSIDE Cap Orl 50mg Vepesid BRI AEFGVW Caps February 2014 / février 2014 Page 119

132 L01X L01XB L01XX L02 L02A L01XB01 L01XX05 L01XX11 L02AB L02AE L02AB01 L02AE01 OTHER ANTINEOPLASTIC AGENTS AUTRES AGENTS ANTINÉOPLASIQUES METHYLHYDRAZINES MÉTHYLHYDRAZINES PROCARBAZINE PROCARBAZINE Cap Orl 50mg Matulane QGT AEFGVW Caps OTHER ANTINEOPLASTIC AGENTS AUTRES AGENTS ANTINÉOPLASIQUES HYDROXYCARBAMIDE (HYDROXYUREA) HYDROXYCARBAMIDE (HYDROXYURÉE) Cap Orl 500mg Hydrea BRI f AEFGVW Caps Mylan-Hydroxyurea MYL f AEFGVW Hydroxyurea SAS f AEFGVW ESTRAMUSTINE ESTRAMUSTINE Cap Orl 140mg Emcyt PFI AEFGVW Caps ENDOCRINE THERAPY TRAITEMENT ENDOCRINIEN HORMONES AND RELATED AGENTS HORMONES ET AGENTS APPARENTÉS PROGESTOGENS PROGESTOGÉNES MEGESTROL MÉGESTROL Tab Orl 40mg Megestrol AAP f AEFGVW Tab Orl 160mg Megestrol AAP f AEFGVW GONADOTROPHIN RELEASING HORMONE ANALOGUES ANALOGUES DE L HORMONE LIBÉRANT DE LA GONADOTROPHINE BUSERELIN BUSÉRÉLINE Asp Nas 1mg Suprefact SAV AVW Asp Imp Inj 6.3mg Suprefact Depot SAV AEF18+VW Imp Imp Inj 9.45mg Suprefact Depot SAV AEF18+VW Imp February 2014 / février 2014 Page 120

133 L02AE02 LEUPRORELIN LEUPRORÉLINE Liq Inj 5mg Lupron * ABV AVW Liq Pws Inj 7.5mg Lupron Depot * ABB AVW Pds. Pws Inj 22.5mg Lupron Depot * ABB AEF18+VW Pds. Pws Inj 30mg Lupron Depot * ABB AEF18+VW Pds. Sus Inj 22.5mg Eligard * SAV AEFVW Susp. L02B L02AE02 L02AE04 L02BA L02BA01 Sus Inj 45mg Eligard * SAV AEFVW Susp. GOSERELIN GOSÉRÉLINE Imp Inj 3.6mg Zoladex AZE AVW Imp Imp Inj 10.8mg Zoladex LA AZE AEF18+VW Imp TRIPTORELIN TRIPTORÉLINE Pws Inj 3.75mg Trelstar * PAL AEFVW Pds. Pws Inj 11.25mg Trelstar * PAL AEFVW Pds. HORMONE ANTAGONISTS AND RELATED AGENTS ANTAGONISTES D HORMONES ET AGENTS CONNEXES ANTI-ESTROGENS ANTI-OESTROGÈNES TAMOXIFEN TAMOXIFÉNE Tab Orl 10mg Apo-Tamox APX f AEFGVW Teva-Tamoxifen TEV f AEFGVW Mylan-Tamoxifen MYL f AEFGVW Tab Orl 20mg Apo-Tamox APX f AEFGVW Teva-Tamoxifen TEV f AEFGVW Mylan-Tamoxifen MYL f AEFGVW Nolvadex-d AZE f AEFGVW February 2014 / février 2014 Page 121

134 L02BB L02BB01 L02BB02 L02BB03 L02BG L02BG03 L02BG04 ANTI-ANDROGENS ANTI-ANDROGÉNES FLUTAMIDE FLUTAMIDE Tab Orl 250mg Euflex FRS f AEFVW Teva-Flutamide TEV f AEFVW pms-flutamide PMS f AEFVW Apo-Flutamide APX f AEFVW NILUTAMIDE NILUTAMIDE Tab Orl 50mg Anandron SAV AEFVW BICALUTAMIDE BICALUTAMIDE Tab Orl 50mg Casodex AZE f AEFVW Novo-Bicalutamide TEV f AEFVW Co Bicalutamide COB f AEFVW pms-bicalutamide PMS f AEFVW Sandoz Bicalutamide SDZ f AEFVW ratio-bicalutamide (Disc/non disp Feb 22/15) RPH f AEFVW Apo-Bicalutamide APX f AEFVW Mylan-Bicalutamide MYL f AEFVW Bicalutamide AHI f AEFVW Jamp-Bicalutamide JPC f AEFVW Ran-Bicalutamide RAN f AEFVW AROMATASE INHIBITORS INHIBITEURS AROMATASES ANASTROZOLE ANASTROZOLE Tab Orl 1mg Arimidex AZE f AEFVW Sandoz Anastrozole SDZ f AEFVW Apo-Anastrozole APX f AEFVW Co-Anastrozole COB f AEFVW Jamp-Anastrozole JPC f AEFVW Mar-Anastrozole MAR f AEFVW Med-Anastrozole GMP f AEFVW Anastrozole AHI f AEFVW Mylan-Anastrozole MYL f AEFVW pms-anastrozole PMS f AEFVW Ran-Anastrozole RAN f AEFVW Taro-Anastrozole TAR f AEFVW Teva-Anastrozole TEV f AEFVW Mint-Anastrozole MNT f AEFVW LETROZOLE LÉTROZOLE Tab Orl 2.5mg Femara NVR f AEFVW pms-letrozole PMS f AEFVW Med-Letrozole GMP f AEFVW February 2014 / février 2014 Page 122

135 L02BX L03 L03A L02BG04 L02BG06 L02BX02 L03AA L03AA02 L03AB L03AB05 LETROZOLE LÉTROZOLE Tab Orl 2.5mg Letrozole tablets usp AHI f AEFVW Sandoz Letrozole SDZ f AEFVW Letrozole (Disc/non disp Jul 24/15) TEV f AEFVW Letrozole COB f AEFVW Apo-Letrozole APX f AEFVW Myl-Letrozole MYL f AEFVW Ran-Letrozole RAN f AEFVW Jamp-Letrozole JPC f AEFVW Mar-Letrozole MAR f AEFVW Teva-Letrozole TEV f AEFVW EXEMESTANE EXÉMESTANE Tab Orl 25mg Aromasin PFI f AEFVW Co-Exemestane COB f AEFVW OTHER HORMONE ANTAGONISTS AND RELATED AGENTS AUTRES ANTAGONISTES D HORMONES ET AGENTS CONNEXES DEGARELIX DEGARELIX Pws Inj 80mg/vial Firmagon FEI AEF+18VW Pds. Pws Inj 120mg/vial Firmagon FEI AEF+18VW Pds. IMMUNOSTIMULANTS IMMUNOSTIMULANTS IMMUNOSTIMULANTS IMMUNOSTIMULANTS COLONY STIMULATING FACTORS FACTEURS DE CROISSANCE DES GLOBULES BLANCS FILGRASTIM FILGRASTIM Liq Inj 0.3mg Neupogen (1.6 ml size only) AGA W Liq Neupogen AGA W INTERFERONS INTERFÉRONS INTERFERON ALFA-2B INTERFÉRON ALFA-2B Liq Inj IU Intron A * SCH AEFGVW Liq Liq Inj IU Intron A * SCH AEFGVW Liq Intron A * SCH AEFGVW Liq Inj IU Intron A * SCH AEFGVW Liq February 2014 / février 2014 Page 123

136 L03AB05 L03AB07 INTERFERON ALFA-2B INTERFÉRON ALFA-2B Liq Inj IU Intron A * FRS AEFGVW Liq Liq Inj IU Intron A * SCH AEFGVW Liq INTERFERON BETA-1A INTERFÉRON BÊTA-1A Liq Inj 22mcg Rebif EMD H Liq Rebif Initiation Pack (Disc/non disp May 1/14) EMD H Rebif Cartridge EMD H Liq Inj 44mcg Rebif EMD H Liq Rebif Cartridge EMD H L03AX L04 L04A L03AB08 L03AX13 L04AA L04AA06 Liq Inj 30mcg Avonex PS BIG H Liq INTERFERON BETA-1B INTERFÉRON BÊTA-1B Liq Inj 0.3mg Betaseron BAY H Liq Extavia NVR H OTHER IMMUNOSTIMULANTS AUTRES IMMUNOSTIMULANTS GLATIRAMER ACETATE GLATIRAMÉRE ACETATE Liq Inj 20mg Copaxone SAV H Liq IMMUNOSUPPRESSANTS AGENTS IMMUNOSUPPRESSEURS IMMUNOSUPPRESSANTS AGENTS IMMUNOSUPPRESSEURS SELECTIVE IMMUNOSUPPRESSANTS IMMUNOSUPPRESSEURS SÉLECTIFS MYCOPHENOLIC ACID ACIDE MYCOPHÉNOLIQUE Cap Orl 250mg Cellcept HLR f R Caps Sandoz Mycophenolate SDZ f R Apo-Mycophenolate APX f R Novo-Mycophenolate TEV f R Mylan-Mycophenolate MYL f R Mycophenolate Mofetil AHI f R Jamp-Mycophenolate JPC f R Tab Orl 500mg Cellcept HLR f R Sandoz Mycophenolate SDZ f R Apo-Mycophenolate APX f R February 2014 / février 2014 Page 124

137 L04AA06 MYCOPHENOLIC ACID ACIDE MYCOPHÉNOLIQUE Tab Orl 500mg Novo-Mycophenolate TEV f R Mylan-Mycophenolate MYL f R Co Mycophenolate COB f R Jamp-Mycophenolate JPC f R Mycophenolate Mofetil AHI f R ECT Orl 180mg Myfortic NVR R Ent. L04AA10 L04AB L04AB01 L04AD L04AD01 ECT Orl 360mg Myfortic NVR R Ent. SIROLIMUS SIROLIMUS Liq Orl 1mg Rapamune PFI R Liq Tab Orl 1mg Rapamune PFI R TUMOR NECROSIS FACTOR ALPHA (TNF-A) INHIBITORS INHIBITEURS DU FACTEUR DE NÉCROSE TUMORALE ALPHA (TNF-A) ETANERCEPT ÉTANERCEPT Pws Inj 25mg Enbrel AGA W Pds. CALCINEURIN INHIBITORS INHIBITEURS DE LA CALCINEURINE CYCLOSPORINE CYCLOSPORINE Cap Orl 10mg Neoral NVR R Caps Cap Orl 25mg Neoral NVR f R Caps Sandoz Cyclosporine SDZ f R Cap Orl 50mg Neoral NVR f R Caps Sandoz Cyclosporine SDZ f R Cap Orl 100mg Neoral NVR f R Caps Sandoz Cyclosporine SDZ f R L04AD02 Liq Orl 100mg Neoral NVR f R Liq Apo-Cyclosporine APX f R TACROLIMUS TACROLIMUS Cap Orl 0.5mg Prograf ASL R Caps February 2014 / février 2014 Page 125

138 L04AD02 TACROLIMUS TACROLIMUS Cap Orl 1mg Prograf ASL f R Caps Sandoz Tacrolimus SDZ f R Cap Orl 5mg Prograf ASL f R Caps Sandoz Tacrolimus SDZ f R ERC Orl 0.5mg Advagraf ASL R Caps.L.P. ERC Orl 1mg Advagraf ASL R Caps.L.P. ERC Orl 3mg Advagraf ASL R Caps.L.P. L04AX M01 M01A L04AX01 M01AB M01AB01 ERC Orl 5mg Advagraf ASL R Caps.L.P. OTHER IMMUNOSUPPRESSANTS AUTRES AGENTS IMMUNOSUPPRESSEURS AZATHIOPRINE AZATHIOPRINE Tab Orl 50mg Imuran TRI f AEFGVW Mylan-Azathioprine MYL f AEFGVW Teva-Azathioprine TEV f AEFGVW Apo-Azathioprine APX f AEFGVW Azathioprine SAS f AEFGVW ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS ANTI-INFLAMMATOIRES ET ANTIRHUMATISMAUX ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS, NON-STEROIDS ANTI-INFLAMMATOIRES ET ANTIRHUMATISMAUX, NON STÉROIDÏENS ACETIC ACID DERIVATIVES AND RELATED SUBSTANCES ACIDE ACÉTIQUE ET SUBSTANCES APPARENTÉES INDOMETHACIN INDOMÉTHACINE Cap Orl 25mg Novo-Methacin TEV f AEFGVW Caps Apo-Indomethacin (Disc/non disp Mar 30/14) APX f AEFGVW Cap Orl 50mg Novo-Methacin TEV f AEFGVW Caps Apo-Indomethacin (Disc/non disp Mar 30/14) APX f AEFGVW Sup Rt 50mg Sab-Indomethacin SDZ f AEFGVW Supp. Sup Rt 100mg Sab-Indomethacin SDZ f AEFGVW Supp. Ratio-Indomethacin TEV f AEFGVW February 2014 / février 2014 Page 126

139 M01AB02 M01AB05 SULINDAC SULINDAC Tab Orl 150mg Teva-Sundac TEV f AEFGVW Apo-Sulin APX f AEFGVW Tab Orl 200mg Teva-Sundac TEV f AEFGVW Apo-Sulin APX f AEFGVW DICLOFENAC DICLOFÉNAC ECT Orl 25mg Teva-Difenac TEV f AEFGVW Ent. Apo-Diclo APX f AEFGVW Sandoz Diclofenac SDZ f AEFGVW pms-diclofenac PMS f AEFGVW ECT Orl 50mg Voltaren NVR f AEFGVW Ent. Teva-Difenac TEV f AEFGVW Apo-Diclo APX f AEFGVW Sandoz Diclofenac SDZ f AEFGVW pms-diclofenac PMS f AEFGVW Diclofenac EC SAS f AEFGVW SRT Orl 75mg Voltaren SR NVR f AEFGVW L.L. Teva-Difenac SR TEV f AEFGVW Apo-Diclo SR APX f AEFGVW Sandoz Diclofenac SR SDZ f AEFGVW pms-diclofenac SR PMS f AEFGVW Diclofenac SR SAS f AEFGVW SRT Orl 100mg Voltaren SR NVR f AEFGVW L.L. Teva-Difenac SR TEV f AEFGVW Apo-Diclo SR APX f AEFGVW Sandoz Diclofenac SR SDZ f AEFGVW pms-diclofenac SR PMS f AEFGVW Sup Rt 50mg Voltaren NVR f AEFGVW Supp. Pms-Difenac PMS f AEFGVW Sandoz Diclofenac SDZ f AEFGVW M01AB15 Sup Rt 100mg Voltaren NVR f AEFGVW Supp. Pms-Difenac PMS f AEFGVW Sandoz Diclofenac SDZ f AEFGVW KETOROLAC KÉTOROLAC Liq Inj 10mg Toradol HLR W Liq Tab Orl 10mg Toradol HLR f W Ketorolac AAP f W Novo-Ketorolac (Disc/non disp Feb 26/15) TEV f W February 2014 / février 2014 Page 127

140 M01AB55 M01AC M01AC01 M01AC06 M01AE M01AE01 DICLOFENAC COMBINATIONS DICLOFENAC, EN COMBINAISON DICLOFENAC / MISOPROSTOL DICLOFÉNAC / MISOPROSTOL Tab Orl 50mg/200mcg Arthrotec PFI AEFGVW Tab Orl 75mg/200mcg Arthrotec PFI AEFGVW OXICAMS OXICAMS PIROXICAM PIROXICAM Cap Orl 10mg Apo-Piroxicam APX f AEFGVW Caps Novo-Pirocam TEV f AEFGVW Cap Orl 20mg Apo-Piroxicam APX f AEFGVW Caps Novo-Pirocam TEV f AEFGVW Sup Rt 20mg pms-piroxicam PMS f AEFGVW Supp. MELOXICAM MELOXICAM Tab Orl 7.5mg Mobicox BOE f AEFGVW pms-meloxicam PMS f AEFGVW Phl-Meloxicam PHL f AEFGVW Apo-Meloxicam APX f AEFGVW Co Meloxicam COB f AEFGVW Mylan-Meloxicam MYL f AEFGVW Teva-Meloxicam TEV f AEFGVW Meloxicam SAS f AEFGVW Auro-Meloxicam ARO f AEFGVW Tab Orl 15mg Mobicox BOE f AEFGVW pms-meloxicam PMS f AEFGVW Phl-Meloxicam PHL f AEFGVW Apo-Meloxicam APX f AEFGVW Co Meloxicam COB f AEFGVW Mylan-Meloxicam MYL f AEFGVW Teva-Meloxicam TEV f AEFGVW Meloxicam SAS f AEFGVW Auro-Meloxicam ARO f AEFGVW PROPIONIC ACID DERIVATIVES DÉRIVÉS DE L ACIDE PROPIONIQUE IBUPROFEN IBUPROFÉNE Tab Orl 300mg Apo-Ibuprofen APX f AEFGVW February 2014 / février 2014 Page 128

141 M01AE01 M01AE02 IBUPROFEN IBUPROFÉNE Tab Orl 400mg Apo-Ibuprofen APX f AEFGVW Novo-Profen TEV f AEFGVW pms-ibuprofen PMS f AEFGVW Motrin IB JNJ f AEFGVW Tab Orl 600mg Apo-Ibuprofen APX f AEFGVW Novo-Profen TEV f AEFGVW NAPROXEN NAPROXÉNE Sup Rt 500mg pms-naproxen PMS f AEFGVW Supp. Sus Orl 25mg Naprosyn HLR AEFGVW Susp. Tab Orl 125mg Apo-Naproxen APX f AEFGVW Tab Orl 250mg Apo-Naproxen APX f AEFGVW Teva-Naproxen TEV f AEFGVW Naproxen SAS f AEFGVW Tab Orl 375mg Apo-Naproxen APX f AEFGVW Teva-Naproxen TEV f AEFGVW Naproxen SAS f AEFGVW Tab Orl 500mg Apo-Naproxen APX f AEFGVW Teva-Naproxen TEV f AEFGVW Naproxen SAS f AEFGVW ECT Orl 250mg Naprosyn E HLR f AEFGVW Ent. Apo-Naproxen EC APX f AEFGVW Naproxen EC SAS f AEFGVW Teva-Naprox EC TEV f AEFGVW ECT Orl 375mg Naprosyn E HLR f AEFGVW Ent. Apo-Naproxen EC APX f AEFGVW Naproxen EC SAS f AEFGVW Teva-Naprox EC TEV f AEFGVW Mylan-Naproxen EC MYL f AEFGVW pms-naproxen EC PMS f AEFGVW ECT Orl 500mg Naprosyn E HLR f AEFGVW Ent. Apo-Naproxen EC APX f AEFGVW Naproxen EC SAS f AEFGVW Teva-Naprox EC TEV f AEFGVW Mylan-Naproxen EC MYL f AEFGVW pms-naproxen EC PMS f AEFGVW February 2014 / février 2014 Page 129

142 M01AE02 M01AE03 NAPROXEN NAPROXÉNE Tab Orl 275mg Anaprox HLR f AEFGVW Apo-Napro-Na APX f AEFGVW Naproxen Sodium SAS f AEFGVW Teva-Naproxen Sodium TEV f AEFGVW Tab Orl 550mg Anaprox DS HLR f AEFGVW Apo-Napro-Na DS APX f AEFGVW Naproxen Sodium DS SAS f AEFGVW Teva-Naproxen Sodium DS TEV f AEFGVW KETOPROFEN KÉTOPROFÉNE Cap Orl 50mg Keto AAP f AEFGVW Caps ECT Orl 50mg Keto-E AAP f AEFGVW Ent. M01AE09 M01AE11 M01AG ECT Orl 100mg Keto-E AAP f AEFGVW Ent. SRT Orl 100mg Keto SR AAP f AEFGVW L.L. Sup Rt 100mg pms-ketoprofen PMS AEFGW Supp. FLURBIPROFEN FLURBIPROFÉNE Tab Orl 50mg Apo-Flurbiprofen APX f AEFGVW Novo-Flurprofen TEV f AEFGVW Tab Orl 100mg Apo-Flurbiprofen APX f AEFGVW Novo-Flurprofen TEV f AEFGVW TIAPROFENIC ACID ACIDE TIAPROFÉNIQUE Tab Orl 200mg Apo-Tiaprofenic (Disc/non disp Apr 10/14) APX f AEFGVW Teva-Tiaprofenic TEV f AEFGVW Tab Orl 300mg Apo-Tiaprofenic (Disc/non disp Apr 10/14) APX f AEFGVW Teva-Tiaprofenic TEV f AEFGVW FENEMATES FENEMATES M01AG01 MEFENAMIC ACID ACIDE MÉFÉNAMIQUE Cap Orl 250mg Mefenamic AAP f AEFGVW Caps February 2014 / février 2014 Page 130

143 M01AH M01C M01AH01 M01CB M01CB01 COXIBS COXIBS CELECOXIB CÉLÉCOXIB Cap Orl 100mg Celebrex PFI AEFVW Caps Cap Orl 200mg Celebrex PFI AEFVW Caps SPECIFIC ANTIRHEUMATIC AGENTS AGENTS ANTIRHUMATISMAUX SPÉCIFIQUES GOLD PREPARATIONS PRÉPARATIONS D OR SODIUM AUROTHIOMALATE AUROTHIOMALATE SODIQUE Liq Inj 10mg Myochrysine * SAV f AEFGVW Liq Sodium Aurothiomalate * SDZ f AEFGVW Liq Inj 25mg Myochrysine * SAV f AEFGVW Liq Sodium Aurothiomalate * SDZ f AEFGVW M01CB03 M01CC M03 M03B Liq Inj 50mg Myochrysine * SAV f AEFGVW Liq Sodium Aurothiomalate * SDZ f AEFGVW AURANOFIN AURANOFINE Cap Orl 3mg Riduara* XPI AEFGVW Caps PENICILLAMINE AND SIMILAR AGENTS PÉNICILLAMINE ET AGENTS SEMBLABLES M01CC01 PENICILLAMINE PÉNICILLAMINE M03BA M03BA03 Cap Orl 250mg Cuprimine VLN AEFGVW Caps MUSCLE RELAXANTS MYORELAXANTS MUSCLE RELAXANTS, CENTRALLY ACTING AGENTS MYORELAXANTS, AGENTS AGISSANT CENTRALEMENT CARBAMIC ACID ESTERS ESTERS DE L ACIDE CARBAMIQUE METHOCARBAMOL MÉTHOCARBAMOL Tab Orl 500mg Robaxin WCH AEFGVW 19 Celecoxib is a regular benefit for beneficiaries age 65 and over. Please refer to Appendix IV. Les Celecoxib est le service assure habituel pour le bénéficiares de 65 ans et plus. Veuillez consulter l annexe IV. February 2014 / février 2014 Page 131

144 M03BA03 M03BA53 M03BC M03BC01 M03BX M03BX01 M03BX08 METHOCARBAMOL MÉTHOCARBAMOL Tab Orl 750mg Robaxin WCH AEFGVW METHOCARBAMOL, COMBINATIONS EXCLUDING PSYCHOLEPTICS MÉTHOCARBAMOL, EN COMBINAISON, A L EXCLUSION DES PSYCHOLEPTIQUES METHOCARBAMOL / ACETYLSALICYLIC ACID / CODEINE PHOSPHATE MÉTHOCARBAMOL / ACIDE ACETYLSALICYLIC / PHOSPHATE DE CODÉINE Tab Orl 400mg/325mg/16.2mg Robaxisal C-1/ WCH W Tab Orl 400mg/325mg/32.4mg Robaxisal C-1/ WCH W ETHERS, CHEMICALLY CLOSE TO ANTIHISTAMINES ÉTHERS, CHIMIQUEMENT PRÈS DES ANTIHISTAMINES ORPHENADRINE ORPHÉNADRINE SRT Orl 100mg Norflex (Disc/non disp Sep 1/14) MDS f AEFGVW L.L. Sandoz Orphenadrine Citrate SDZ f AEFGVW OTHER CENTRALLY ACTING AGENTS AUTRES AGENTS AGISSANT CENTRALEMENT BACLOFEN BACLOFÉNE Tab Orl 10mg Lioresal NVR f AEFGVW pms-baclofen PMS f AEFGVW Mylan-Baclofen MYL f AEFGVW Apo-Baclofen APX f AEFGVW ratio-baclofen TEV f AEFGVW Phl-Baclofen PHL f AEFGVW Baclofen SAS f AEFGVW Tab Orl 20mg Lioresal D.S NVR f AEFGVW pms-baclofen PMS f AEFGVW Mylan-Baclofen MYL f AEFGVW Apo-Baclofen APX f AEFGVW ratio-baclofen TEV f AEFGVW Phl-Baclofen PHL f AEFGVW Baclofen SAS f AEFGVW CYCLOBENZAPRINE CYCLOBENZAPRINE Tab Orl 10mg Novo-Cycloprine TEV f AEFGVW Apo-Cycloprine APX f AEFGVW pms-cyclobenzaprine PMS f AEFGVW Mylan-Cyclobenzaprine MYL f AEFGVW Cyclobenzaprine SAS f AEFGVW Auro-Cyclobenzaprine ARO f AEFGVW Jamp-Cyclobenzaprine JPC f AEFGVW February 2014 / février 2014 Page 132

145 M03C M03CA M04 M04A M03CA01 M04AA M04AA01 MUSCLE RELAXANTS, DIRECTLY ACTING AGENTS MYORELAXANTS, AGENTS AGISSANT DIRECTEMENT DANTROLENE AND DERIVATIVES DANTROLENE ET DÉRIVÉS DANTROLENE DANTROLÉNE Cap Orl 25mg Dantrium MTP AEFGVW Caps Cap Orl 100mg Dantrium MTP AEFGVW Caps ANTIGOUT PREPARATIONS PRÉPARATIONS ANTI-GOUTTE ANTIGOUT PREPARATIONS PRÉPARATIONS ANTI-GOUTTE PREPARATIONS INHIBITING URIC ACID PRODUCTION PRÉPARATIONS INHIBANT LA PRODUCTION D ACIDE URIQUE ALLOPURINOL ALLOPURINOL Tab Orl 100mg Zyloprim AAP f AEFGVW Mar-Allopurinol MAR f AEFGVW Apo-Allopurinol APX f AEFGVW Tab Orl 200mg Zyloprim AAP f AEFGVW Mar-Allopurinol MAR f AEFGVW Apo-Allopurinol APX f AEFGVW M04AB M04AB01 M04AB02 M04AC M04AC01 Tab Orl 300mg Zyloprim AAP f AEFGVW Mar-Allopurinol MAR f AEFGVW Apo-Allopurinol APX f AEFGVW PREPARATIONS INCREASING URIC ACID EXCRETION PRÉPARATIONS AUGMENTANT L EXCRÉTION D ACIDE URIQUE PROBENECID PROBÉNÉCIDE Tab Orl 500mg Benuryl (Disc/non disp Nov 29/14) VLN AEFGVW SULFINPYRAZONE SULFINPYRAZONE Tab Orl 200mg Sulfinpyrazone AAP f AEFGVW PREPARATION WITH NO EFFECT ON URIC ACID METABOLISM PRÉPARATION SANS EFFET SUR LE MÉTABOLISME DE L ACIDE URIQUE COLCHICINE COLCHICINE Tab Orl 0.6mg Colchicine EUR AEFGVW Colchicine ODN AEFGVW February 2014 / février 2014 Page 133

146 M05 M05B M04AC01 M05BA M05BA02 M05BA04 M05BB M05BB03 COLCHICINE COLCHICINE Tab Orl 1mg Colchicine (Disc/non disp Mar 6/15) ODN AEFGVW DRUGS FOR TREATMENT OF BONE DISEASES MÉDICAMENTS POUR LE TRAITEMENT DES MALADIES OSSEUSES DRUGS AFFECTING BONE STRUCTURE AND MINERALIZATION MÉDICAMENTS AGISSANT SUR LA STRUCTURE OSSEUSE ET LA MINÉRALISATION BIPHOSPHONATES BIPHOSPHONATES CLODRONIC ACID ACIDE CLODRONIQUE Cap Orl 400mg Bonefos BAY AEFGVW Caps ALENDRONIC ACID ACIDE ALENDRONIQUE Tab Orl 10mg Teva-Alendronate TEV f W Apo-Alendronate APX f W Mylan-Alendronate MYL f W Sandoz Alendronate SDZ f W Alendronate Sodium AHI f W Ran-Alendronate RAN f W Mint-Alendronate MNT f W Auro-Alendronate ARO f W Tab Orl 40mg Fosamax (Disc/non disp Jun 1/15) FRS f W Co Alendronate COB f W Tab Orl 70mg Fosamax FRS f W Apo-Alendronate APX f W Co Alendronate COB f W Teva-Alendronate TEV f W pms-alendronate FC PMS f W Mylan-Alendronate MYL f W Sandoz Alendronate SDZ f W Alendronate FC SIV f W Alendronate SAS f W Alendronate Sodium AHI f W Ran-Alendronate RAN f W Jamp-Alendronate JPC f W Mint-Alendronate MNT f W Auro-Alendronate ARO f W BIPHOSPHONATES, COMBINATIONS BIPHOSPHONATES EN COMBINAISON ALENDRONIC ACID AND COLECALCIFEROL ACIDE ALENDRONIQUE ET COLÉCALCIFÉROL Tab Orl 70mg/5600mg Fosavance FRS f W Teva-Alendronate/Cholecalciferol TEV f W February 2014 / février 2014 Page 134

147 N01 N01B N01BX N02 N02A N01BX04 N02AA N02AA01 ANAESTHETICS ANESTHÉSIQUES LOCAL ANAESTHETICS ANESTHÉSIQUES LOCAUX OTHER LOCAL ANAESTHETICS AUTRES ANESTHÉSIQUES LOCAUX CAPSAICIN CAPSAÏCINE Crm Top 0.025% Zostrix MDS AEFGVW Cr. Capsaicin VAL AEFGVW Crm Top 0.075% Zostrix H.P MDS AEFGVW Cr. Capsaicin Crm VAL AEFGVW ANALGESICS ANALGÉSIQUES OPIOIDS OPIOÏDES NATURAL OPIUM ALKALOIDS ALKALOÏDES D OPIUM NATUREL MORPHINE MORPHINE SRT Orl 30mg M.O.S.SR VLN AEFGVW L.L. SRT Orl 60mg M.O.S.SR VLN AEFGVW L.L. Syr Orl 1mg ratio-morphine RPH AEFGVW Sir. Syr Orl 5mg ratio-morphine RPH AEFGVW Sir. Syr Orl 10mg ratio-morphine RPH AEFGVW Sir. Syr Orl 20mg ratio-morphine RPH AEFGVW Sir. Dps Orl 20mg Statex PAL AEFGVW Gtts Dps Orl 50mg Statex PAL AEFGVW Gtts Liq Inj 10mg Morphine Sulfate* SDZ AEFGVW Liq Liq Inj 15mg Morphine Sulfate* SDZ AEFGVW Liq February 2014 / février 2014 Page 135

148 N02AA01 MORPHINE MORPHINE Liq Inj 25mg Morphine HP 25* SDZ AEFGVW Liq Liq Inj 50mg Morphine HP 50* SDZ AEFGVW Liq SRC Orl 10mg M-Eslon SAV AEFGVW Caps.L.L. Kadian ABB AEFGVW SRC Orl 15mg M-Eslon SAV AEFGVW Caps.L.L. SRC Orl 20mg Kadian ABB AEFGVW Caps.L.L. SRC Orl 30mg M-Eslon SAV AEFGVW Caps.L.L. SRC Orl 50mg Kadian ABB AEFGVW Caps.L.L. SRC Orl 60mg M-Eslon SAV AEFGVW Caps.L.L. SRC Orl 100mg M-Eslon SAV AEFGVW Caps.L.L. Kadian ABB AEFGVW SRC Orl 200mg Kadian ABB AEFGVW Caps.L.L. SRT Orl 15mg MS Contin PFR f AEFGVW L.L. Sandoz Morphine SR SDZ f AEFGVW Teva-Morphine SR TEV f AEFGVW Morphine SR SAS f AEFGVW SRT Orl 30mg MS Contin PFR f AEFGVW L.L. Sandoz Morphine SR SDZ f AEFGVW Teva-Morphine SR TEV f AEFGVW Morphine SR SAS f AEFGVW SRT Orl 60mg MS Contin PFR f AEFGVW L.L. Sandoz Morphine SR SDZ f AEFGVW Teva-Morphine SR TEV f AEFGVW Morphine SR SAS f AEFGVW SRT Orl 100mg MS Contin PFR f AEFGVW L.L. Teva-Morphine SR TEV f AEFGVW Morphine SR (Disc/non disp Apr 22/15) SAS f AEFGVW February 2014 / février 2014 Page 136

149 N02AA01 MORPHINE MORPHINE SRT Orl 200mg MS Contin PFR f AEFGVW L.L. pms-morphine sulfate (Disc/non disp Apr 1/14) PMS f AEFGVW Teva-Morphine SR TEV f AEFGVW Morphine SR (Disc/non disp Apr 22/15) SAS f AEFGVW Sup Rt 5mg Statex PAL AEFGVW Supp. Sup Rt 10mg Statex PAL AEFGVW Supp. Sup Rt 20mg Statex PAL AEFGVW Supp. Sup Rt 30mg Statex PAL AEFGVW Supp. Syr Orl 1mg Statex PAL AEFGVW Sir. Syr Orl 5mg Statex PAL AEFGVW Sir. Tab Orl 5mg Statex PAL AEFGVW MS IR PFR AEFGVW Tab Orl 10mg Statex PAL AEFGVW MS IR PFR AEFGVW Tab Orl 20mg MS IR PFR AEFGVW Tab Orl 25mg Statex PAL AEFGVW Tab Orl 30mg MS IR PFR AEFGVW Tab Orl 50mg Statex PAL AEFGVW N02AA03 HYDROMORPHONE HYDROMORPHONE Liq Inj 2mg Dilaudid * PFR f AEFGVW Liq Hydromorphone hcl * SDZ f AEFGVW Liq Inj 10mg Dilaudid HP * PFR f AEFGVW Liq Hydromorphone HP * SDZ f AEFGVW Liq Inj 20mg Hydromorphone HP * SDZ f AEFGVW Liq February 2014 / février 2014 Page 137

150 N02AA03 HYDROMORPHONE HYDROMORPHONE Liq Inj 50mg Hydromorphone HP * SDZ f AEFGVW Liq Cap Orl 4.5mg Hydromorph Contin PFR AEFGVW Caps. Cap Orl 9mg Hydromorph Contin PFR AEFGVW Caps. SRC Orl 3mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. SRC Orl 6mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. SRC Orl 12mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. SRC Orl 18mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. SRC Orl 24mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. SRC Orl 30mg Hydromorph Contin SR PFR AEFGVW Caps.L.L. Syr Orl 1mg Dilaudid PFR f AEFGVW Sir. Pms-Hydromorphone PMS f AEFGVW Tab Orl 1mg Dilaudid PFR f AEFGVW pms-hydromorphone PMS f AEFGVW Teva-Hydromorphone TEV f AEFGVW Tab Orl 2mg Dilaudid PFR f AEFGVW pms-hydromorphone PMS f AEFGVW Teva-Hydromorphone TEV f AEFGVW Tab Orl 4mg Dilaudid PFR f AEFGVW pms-hydromorphone PMS f AEFGVW Teva-Hydromorphone TEV f AEFGVW Tab Orl 8mg Dilaudid PFR f AEFGVW pms-hydromorphone PMS f AEFGVW Teva-Hydromorphone TEV f AEFGVW N02AA05 OXYCODONE OXYCODONE ERT Orl 10mg Oxyneo PFR W L.P. February 2014 / février 2014 Page 138

151 N02AA05 OXYCODONE OXYCODONE ERT Orl 15mg Oxyneo PFR W L.P. ERT Orl 20mg Oxyneo PFR W L.P. ERT Orl 30mg Oxyneo PFR W L.P. ERT Orl 40mg Oxyneo PFR W L.P. ERT Orl 60mg Oxyneo PFR W L.P. ERT Orl 80mg Oxyneo PFR W L.P. Sup Rt 10mg Supeudol SDZ AEFGVW Supp. Tab Orl 5mg Oxy-IR PFR f W pms-oxycodone IR PMS f W Tab Orl 10mg Supeudol SDZ f W Oxy-IR PFR f W pms-oxycodone IR PMS f W Tab Orl 20mg Supeudol SDZ f W Oxy-IR PFR f W pms-oxycodone IR PMS f W N02AA59 CODEINE, COMBINATIONS, EXCLUDING PSYCHOLEPTICS CODÉINE, EN COMBINAISON, À L EXCLUSION DES PSYCHOLEPTIQUES ACETAMINOPHEN / CAFFEINE / CODEINE ACÉTAMINOPHÈNE / CAFÉINE / CODÉINE Tab Orl 300mg/30mg/15mg ratio-lenoltec # RPH AEFGVW Tylenol No JAN AEFGVW Tab Orl 300mg/30mg/30mg Atasol CHU AEFGVW ACETAMINOPHEN / CODEINE ACÉTAMINOPHÈNE / CODÉINE Tab Orl 300mg/30mg ratio-emtec RPH AEFGVW Tab Orl 300mg/60mg ratio-lenoltec # RPH AEFGVW Tylenol No JAN AEFGVW February 2014 / février 2014 Page 139

152 N02AA59 N02AB N02AB02 N02AB03 CODEINE, COMBINATIONS, EXCLUDING PSYCHOLEPTICS CODÉINE, EN COMBINAISON, À L EXCLUSION DES PSYCHOLEPTIQUES ACETYLSALICYTIC ACID / CAFFEINE / CODEINE ACETYLSALICYTIC ACIDE / CAFÉINE / CODÉINE Tab Orl 375mg/30mg/30mg PDP AEFGVW PHENYLPIPERIDINE DERIVATIVES DÉRIVÉS DU PHENYLPIPERDINE PETHIDINE (MEPERIDINE) PÉTHIDINE (MÉPÉRIDINE) Tab Orl 50mg Demerol SAV W FENTANYL FENTANYL Pth Trd 12mcg Teva-Fentanyl TEV f W Pth Sandoz Fentanyl patch SDZ f W Ran-Fentanyl Matrix RAN f W Duragesic Mat JAN f W pms-fentanyl MTX PMS f W Mylan-Fentanyl Matrix MYL f W Co-Fentanyl COB f W Pth Trd 25mcg Duragesic Mat JAN f W Pth Teva-Fentanyl TEV f W Apo-Fentanyl APX f W Sandoz Fentanyl SDZ f W Ran-Fentanyl Matrix RAN f W pms-fentanyl MTX PMS f W Mylan-Fentanyl Matrix MYL f W Co-Fentanyl COB f W Pth Trd 37mcg Sandoz Fentanyl SDZ W Pth Pth Trd 50mcg Duragesic Mat JAN f W Pth Teva-Fentanyl TEV f W Apo-Fentanyl APX f W Sandoz Fentanyl SDZ f W Ran-Fentanyl Matrix RAN f W pms-fentanyl MTX PMS f W Mylan-Fentanyl Matrix MYL f W Co-Fentanyl COB f W Pth Trd 75mcg Duragesic Mat JAN f W Pth Teva-Fentanyl TEV f W Apo-Fentanyl APX f W Sandoz Fentanyl SDZ f W Ran-Fentanyl Matrix RAN f W pms-fentanyl MTX PMS f W Mylan-Fentanyl Matrix MYL f W Co-Fentanyl COB f W February 2014 / février 2014 Page 140

153 N02AB03 N02AD N02B N02AD01 N02BA N02BA01 FENTANYL FENTANYL Pth Trd 100mcg Duragesic Mat JAN f W Pth Teva-Fentanyl TEV f W Apo-Fentanyl APX f W Sandoz Fentanyl SDZ f W Ran-Fentanyl Matrix RAN f W pms-fentanyl MTX PMS f W Mylan-Fentanyl Matrix MYL f W Co-Fentanyl COB f W BENZOMORPHAN DERIVATIVES DÉRIVÉS DU BENZOMORPHANE PENTAZOCINE PENTAZOCINE Tab Orl 50mg Talwin SNS W OTHER ANALGESICS AND ANTIPYRETICS AUTRES ANALGÉSIQUES ET ANTIPYRÉTIQUES SALICYLIC ACID AND DERIVATIVES ACIDE SALICYLIQUE ET DÉRIVÉS ACETYLSALICYLIC ACID ACIDE ACÉTYLSALICYLIQUE ECT Orl 81mg ASA daily low dose (Disc/non disp Jun 5/14) PMS V Ent. Equate daily low-dose EC PMS V Rexall Coated low dose ASA PMS V Exact Coated daily low dose ASA PMS V ASA ECT (Disc/non disp Jun 5/14) PMS V Praxis ASA PDP V ECT Orl 325mg Entrophen PDP AEFGVW Ent. Novasen TEV AEFGVW Enteric Coated ASA VTH AEFGVW EC ASA JPC AEFGVW pms-asa EC PMS AEFGVW ASATAB EC ODN AEFGVW N02BA11 ECT Orl 650mg Entrophen PDP AEFGVW Ent. Novasen TEV AEFGVW Jamp-ASA EC JPC AEFGVW DIFLUNISAL DIFLUNISAL Tab Orl 250mg Apo-Diflunisal APX f AEFGVW Novo-Diflunisal TEV f AEFGVW Tab Orl 500mg Apo-Diflunisal APX f AEFGVW February 2014 / février 2014 Page 141

154 N02BA51 N02BA71 ACETYLSALICYLIC ACID, COMBINATIONS EXCLUDING PSYCHOLEPTICS ACIDE ACÉTYLSALICYLIQUE, EN COMBINAISON, À L EXCLUSION DES PSYCHOLEPTIQUES ACETYLSALICYLIC ACID / OXYCODONE ACIDE ACÉTYLSALICYLIQUE / OXYCODONE Tab Orl 325mg/5mg ratio-oxycodan RPH AEFGVW ACETYLSALICYLIC ACID COMBNATIONS WITH PSYCHOLEPTICS ACIDE ACÉTYLSALICYLIQUE, EN COMBINAISON AVEC DES PSYCHOLEPTIQUES BUTALBITAL / ACETYLSALICYLIC ACID / CAFFEINE BUTALBITAL / ACIDE ACÉTYLSALICYLIQUE / CAFÉINE Cap Orl 50mg/330mg/40mg Fiorinal NVR f W Caps ratio-tecnal RPH f W Tab Orl 50mg/330mg/40mg ratio-tecnal RPH W BUTALBITAL / ACETYLSALICYLIC ACID / CAFFEINE / CODEINE BUTALBITAL / ACIDE ACÉTYLSALICYLIQUE / CAFÉINE/ CODÉINE Cap Orl 50mg/330mg/40mg/15mg Fiorinal C ¼ NVR f W Caps ratio-tecnal C ¼ RPH f W N02BE N02BE01 Cap Orl 50mg/330mg/40mg/30mg Fiorinal C ½ NVR f W Caps ratio-tecnal C ½ RPH f W ANILIDES ANILIDES PARACETAMOL (ACETAMINOPHEN) PARACETAMOL (ACÉTAMINOPHÉNE) Sup Rt 120mg Abenol PDP f G Supp. Acet PDP f G Sup Rt 325mg Abenol PDP G Supp. Tab Orl 325mg Novo-Gesic TEV G Apo-Acetaminophen APX G Acetaminophen JPC G Tab Orl 500mg Novo-Gesic TEV G Apo-Acetaminophen APX G Acetaminophen JPC G N02BE51 PARACETAMOL (ACETAMINOPHEN), COMBINATIONS EXCLUDING PSYCHOLEPTICS PARACETAMOL (ACÉTAMINOPHÉNE), EN COMBINAISONS, À L EXCLUSION DES PSYCHOLEPTIQUES ACETAMINOPHEN / CAFFEINE / CODEINE ACÉTAMINOPHÈNE / CAFÉINE / CODÉINE Tab Orl 300mg/30mg/15mg Atasol CHU AEFGVW February 2014 / février 2014 Page 142

155 N02BE51 N02BG N02C N02BG04 N02CA N02CA01 PARACETAMOL (ACETAMINOPHEN), COMBINATIONS EXCLUDING PSYCHOLEPTICS PARACETAMOL (ACÉTAMINOPHÉNE), EN COMBINAISONS, À L EXCLUSION DES PSYCHOLEPTIQUES ACETAMINOPHEN / CAFFEINE / CODEINE ACÉTAMINOPHÈNE / CAFÉINE / CODÉINE Tab Orl 300mg/15mg/15mg ratio-lenoltec # RPH AEFGVW Tylenol No JAN AEFGVW ACETAMINOPHEN / CODEINE ACÉTAMINOPHÈNE / CODÉINE Elx Orl 32mg/1.6mg Tylenol w Codeine (Disc/non JAN AEFGVW Elx disp Jul 2/15) ACETAMINOPHEN / OXYCODONE ACÉTAMINOPHÈNE / OXYCODONE Tab Orl 325mg/2.5mg Percocet Demi BRI AEFGVW Tab Orl 325mg/5mg ratio-oxycocet RPH f AEFGVW Percocet BRI f AEFGVW Endocet BRI f AEFGVW Sandoz Oxycodone/Acetaminophen SDZ f AEFGVW Apo-Oxycodone/Acet APX f AEFGVW Oxycodone/Acet SAS f AEFGVW OTHER ANALGESICS AND ANTIPYRETICS AUTRE ANALGÉSIQUES ET ANTIPYRÉTIQUES FLOCTAFENINE FLOCTAFÉNINE Tab Orl 200mg Floctafenine AAP f AEFGVW Tab Orl 400mg Floctafenine AAP f AEFGVW ANTIMIGRAINE PREPARATIONS PRÉPARATIONS ANTI-MIGRAINES ERGOT ALKALOIDS ALKALOÏDES DE L ERGOT DIHYDROERGOTAMINE DIHYDROERGOTAMINE Liq Inj 1mg Dihydroergotamine * SDZ f AEFGVW Liq Dihydroergotamine * STR f AEFGVW Liq Nas 4mg Migranal STR AEFGVW Liq February 2014 / février 2014 Page 143

156 N02CA52 ERGOTAMINE, COMBINATIONS EXCLUDING PSYCHOLEPTICS ERGOTAMINE, EN COMBINAISON, À L EXCLUSION DES PSYCHOLEPTIQUES ERGOTAMINE / CAFFEINE ERGOTAMINE / CAFÉINE Tab Orl 1mg/100mg Cafergot NVR AEFGVW ERGOTAMINE / CAFFEINE / DIMENHYDRINATE ERGOTAMINE / CAFÉINE / DIMENHYDRINATE Cap Orl 1mg/100mg/25mg Ergodryl (Disc/non disp ERF AEFGVW Caps Jul 9/15) N02CX OTHER ANTIMIGRAINE PREPARATIONS AUTRES PRÉPARATIONS ANTI-MIGRAINE N02CX01 PIZOTIFEN PIZOTIFÉNE Tab Orl 0.5mg Sandomigran PAL AEFGVW Tab Orl 1mg Sandomigran DS PAL AEFGVW N03 N03A N03AA ANTIEPILEPTICS ANTIÉPILEPTIQUES ANTIEPILEPTICS ANTIÉPILEPTIQUES BARBITURATES AND DERIVATIVES BARBITURIQUES ET DÉRIVÉS N03AA02 PHENOBARBITAL PHÉNOBARBITOL Elx Orl 5mg Phenobarbital PMS AEFGVW Elx Tab Orl 15mg Phenobarbital PDP AEFGVW Tab Orl 30mg Phenobarbital PDP AEFGVW Tab Orl 60mg Phenobarbital PDP AEFGVW Tab Orl 100mg Phenobarbital PDP AEFGVW N03AA03 PRIMIDONE PRIMIDONE Tab Orl 125mg Primidone AAP AEFGVW Tab Orl 150mg Primidone AAP AEFGVW February 2014 / février 2014 Page 144

157 N03AB N03AB02 HYDANTOIN DERIVATIVES DÉRIVÉS DE L HYDANTOÏNE PHENYTOIN PHÉNYTOINE Sus Orl 6mg Dilantin PFI AEFGVW Susp. Sus Orl 25mg Dilantin PFI f AEFGVW Susp. Taro-Phenytoin TAR f AEFGVW Tab Orl 50mg Dilantin infatabs PFI AEFGVW Cap Orl 30mg Dilantin PFI AEFGVW Caps Cap Orl 100mg Dilantin PFI AEFGVW Caps N03AD N03AD01 Liq Orl 50mg Phenytoin Sodium SDZ V Liq SUCCINIMIDE DERIVATIVES DÉRIVÉS DU SUCCINIMIDE ETHOSUXIMIDE ÉTHOSUXIMIDE Cap Orl 250mg Zarontin ERF AEFGVW Caps Syr Orl 50mg Zarontin ERF AEFGVW Sir. N03AD03 N03AE N03AE01 MESUXIMIDE MÉSUXIMIDE Cap Orl 300mg Celontin ERF AEFGVW Caps BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZÉPINES CLONAZEPAM CLONAZÉPAM Tab Orl 0.5mg Rivotril HLR f AEFGVW Apo-Clonazepam APX f AEFGVW pms-clonazepam R PMS f AEFGVW Mylan-Clonazepam MYL f AEFGVW Sandoz Clonazepam SDZ f AEFGVW Phl-Clonazepam PHL f AEFGVW Teva-Clonazepam TEV f AEFGVW Co Clonazepam COB f AEFGVW Zym-Clonazepam ZYM f AEFGVW February 2014 / février 2014 Page 145

158 N03AE01 N03AF N03AF01 CLONAZEPAM CLONAZÉPAM Tab Orl 1mg pms-clonazepam PMS f AEFGVW Sandoz Clonazepam SDZ f AEFGVW Phl-Clonazepam PHL f AEFGVW Co Clonazepam (Disc/non disp Jan 11/15) COB f AEFGVW Zym-Clonazepam ZYM f AEFGVW Tab Orl 2mg Rivotril HLR f AEFGVW Apo-Clonazepam APX f AEFGVW pms-clonazepam PMS f AEFGVW Mylan-Clonazepam MYL f AEFGVW Sandoz Clonazepam SDZ f AEFGVW Phl-Clonazepam PHL f AEFGVW Teva-Clonazepam TEV f AEFGVW Co Clonazepam COB f AEFGVW Zym-Clonazepam ZYM f AEFGVW CARBOXAMIDE DERIVATIVES DÉRIVÉS DU CARBOXAMIDE CARBAMAZEPINE CARBAMAZÉPINE SRT Orl 200mg Tegretol CR NVR f AEFGVW L.L. pms-carbamazepine PMS f AEFGVW Taro-Carbamazepine CR TAR f AEFGVW Mylan-Carbamazepine MYL f AEFGVW Sandoz-Carbamazepine CR SDZ f AEFGVW SRT Orl 400mg Tegretol CR NVR f AEFGVW L.L. pms-carbamazepine PMS f AEFGVW Taro-Carbamazepine CR TAR f AEFGVW Mylan-Carbamazepine MYL f AEFGVW Sandoz-Carbamazepine CR SDZ f AEFGVW Sus Orl 20mg Tegretol NVR f AEFGVW Susp. Taro-Carbamazepine TAR f AEFGVW Tab Orl 200mg Tegretol NVR f AEFGVW Apo-Carbamazepine (Disc/non disp Apr 30/14) APX f AEFGVW Teva-Carbamazepine TEV f AEFGVW TabC Orl 100mg Tegretol Chew NVR f AEFGVW C.. pms-carbamazepine PMS f AEFGVW Sandoz-Carbamazepine Chewtabs SDZ f AEFGVW TabC Orl 200mg Tegretol Chew NVR f AEFGVW C.. pms-carbamazepine PMS f AEFGVW Sandoz-Carbamazepine Chewtabs SDZ f AEFGVW February 2014 / février 2014 Page 146

159 N03AG N03AG01 FATTY ACID DERIVATIVES DÉRIVÉS DES ACIDES GRAS VALPROIC ACID ACIDE VALPROIQUE ECT Orl 125mg Epival ABB f AEFGVW Ent. Apo-Divalproex APX f AEFGVW Novo-Divalproex TEV f AEFGVW Divalproex SAS f AEFGVW ECT Orl 250mg Epival ABB f AEFGVW Ent. Apo-Divalproex APX f AEFGVW Novo-Divalproex TEV f AEFGVW Divalproex SAS f AEFGVW ECT Orl 500mg Epival ABB f AEFGVW Ent. Apo-Divalproex APX f AEFGVW Novo-Divalproex TEV f AEFGVW Divalproex SAS f AEFGVW Cap Orl 250mg Depakene ABB f AEFGVW Caps Novo-Valproic TEV f AEFGVW Mylan-Valproic(Disc/non disp Jul 4/15) MYL f AEFGVW pms-valproic Acid PMS f AEFGVW Apo-Valproic APX f AEFGVW Sandoz Valproic (Disc/non disp Nov 15/15) SDZ f AEFGVW ECC Orl 500mg pms-valproic Acid PMS f AEFGVW Caps.Ent.. N03AX N03AX09 Syr Orl 50mg Depakene ABB f AEFGVW Sir. Ratio-Valproic (Disc/non disp Feb 22/15) RPH f AEFGVW pms-valproic PMS f AEFGVW Apo-Valproic Acid APX f AEFGVW OTHER ANTIEPILEPTICS AUTRE ANTIÉPILEPTIQUES LAMOTRIGINE LAMOTRIGINE Tab Orl 25mg Lamictal GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) TEV f AEFGVW Apo-Lamotrigine APX f AEFGVW pms-lamotrigine PMS f AEFGVW Teva-Lamotrigine TEV f AEFGVW Mylan-Lamotrigine MYL f AEFGVW Lamotrigine SAS f AEFGVW Auro-Lamotrigine ARO f AEFGVW Tab Orl 100mg Lamictal GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) TEV f AEFGVW Apo-Lamotrigine APX f AEFGVW pms-lamotrigine PMS f AEFGVW February 2014 / février 2014 Page 147

160 N03AX09 LAMOTRIGINE LAMOTRIGINE Tab Orl 100mg Teva-Lamotrigine TEV f AEFGVW Mylan-Lamotrigine MYL f AEFGVW Lamotrigine SAS f AEFGVW Auro-Lamotrigine ARO f AEFGVW Tab Orl 150mg Lamictal GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) TEV f AEFGVW Apo-Lamotrigine APX f AEFGVW pms-lamotrigine PMS f AEFGVW Teva-Lamotrigine TEV f AEFGVW Mylan-Lamotrigine MYL f AEFGVW Lamotrigine SAS f AEFGVW Auro-Lamotrigine ARO f AEFGVW TabC Orl 2mg Lamictal Chewtabs GSK AEFGVW C N03AX12 TabC Orl 5mg Lamictal Chewtabs GSK AEFGVW C GABAPENTIN GABAPENTINE Cap Orl 100mg Neurontin PFI f AEFGVW Caps pms-gabapentin PMS f AEFGVW Apo-Gabapentin APX f AEFGVW Teva-Gabapentin TEV f AEFGVW Gabapentin SIV f AEFGVW Mylan-Gabapentin MYL f AEFGVW Co-Gabapentin COB f AEFGVW GD-Gabapentin GMD f AEFGVW Ran-Gabapentin RAN f AEFGVW Auro-Gabapentin ARO f AEFGVW Gabapentin SAS f AEFGVW Jamp-Gabapentin JPC f AEFGVW Mar-Gabapentin MAR f AEFGVW Cap Orl 300mg Neurontin PFI f AEFGVW Caps pms-gabapentin PMS f AEFGVW Apo-Gabapentin APX f AEFGVW Teva-Gabapentin TEV f AEFGVW Gabapentin SIV f AEFGVW Mylan-Gabapentin MYL f AEFGVW Co-Gabapentin COB f AEFGVW GD-Gabapentin GMD f AEFGVW Ran-Gabapentin RAN f AEFGVW Auro-Gabapentin ARO f AEFGVW Gabapentin SAS f AEFGVW Jamp-Gabapentin JPC f AEFGVW Mar-Gabapentin MAR f AEFGVW February 2014 / février 2014 Page 148

161 N03AX12 GABAPENTIN GABAPENTINE Cap Orl 400mg Neurontin PFI f AEFGVW Caps pms-gabapentin PMS f AEFGVW Apo-Gabapentin APX f AEFGVW Teva-Gabapentin TEV f AEFGVW Gabapentin SIV f AEFGVW Mylan-Gabapentin MYL f AEFGVW Co-Gabapentin COB f AEFGVW ratio-gabapentin RPH f AEFGVW GD-Gabapentin GMD f AEFGVW Ran-Gabapentin RAN f AEFGVW Auro-Gabapentin ARO f AEFGVW Gabapentin SAS f AEFGVW Jamp-Gabapentin JPC f AEFGVW Mar-Gabapentin MAR f AEFGVW Tab Orl 600mg Neurontin PFI f AEFGVW pms-gabapentin PMS f AEFGVW Apo-Gabapentin APX f AEFGVW Teva-Gabapentin TEV f AEFGVW GD-Gabapentin GMD f AEFGVW Gabapentin AHI f AEFGVW Mylan-Gabapentin MYL f AEFGVW Jamp-Gabapentin JPC F AEFGVW Tab Orl 800mg Neurontin PFI f AEFGVW pms-gabapentin PMS f AEFGVW Apo-Gabapentin APX f AEFGVW Teva-Gabapentin TEV f AEFGVW GD-Gabapentin GMD f AEFGVW Gabapentin AHI f AEFGVW Mylan-Gabapentin MYL f AEFGVW Jamp-Gabapentin JPC f AEFGVW N03AX16 PREGABALIN PREGABALIN Cap Orl 25mg Lyrica PFI f W Caps Co-Pregabalin COB f W pms-pregabalin PMS f W Ran-Pregabalin RAN f W Sandoz Pregabalin SDZ f W Teva-Pregabalin TEV f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Pregabalin SAS f W Cap Orl 50mg Lyrica PFI f W Caps Co-Pregabalin COB f W pms-pregabalin PMS f W Ran-Pregabalin RAN f W Sandoz Pregabalin SDZ f W Teva-Pregabalin TEV f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Pregabalin SAS f W February 2014 / février 2014 Page 149

162 N03AX16 PREGABALIN PREGABALIN Cap Orl 75mg Lyrica PFI f W Caps Co-Pregabalin COB f W pms-pregabalin PMS f W Ran-Pregabalin RAN f W Sandoz Pregabalin SDZ f W Teva-Pregabalin TEV f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Pregabalin SAS f W Cap Orl 150mg Lyrica PFI f W Caps Co-Pregabalin COB f W pms-pregabalin PMS f W Ran-Pregabalin RAN f W Sandoz Pregabalin SDZ f W Teva-Pregabalin TEV f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Pregabalin SAS f W Cap Orl 225mg Lyrica PFI f W Caps Co-Pregabalin COB f W Teva-Pregabalin TEV f W pms-pregabalin PMS f W Ran-Pregabalin RAN f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Cap Orl 300mg Lyrica PFI f W Caps Co-Pregabalin COB f W pms-pregabalin PMS f W Sandoz Pregabalin SDZ f W Ran-Pregabalin RAN f W Teva-Pregabalin TEV f W Apo-Pregabalin APX f W GD-Pregabalin GMD f W Pregabalin SAS f W N04 ANTI-PARKINSON DRUGS MÉDICAMENTS ANTI-PARKINSON N04A ANTI-CHOLINERGIC AGENTS AGENTS ANTI-CHOLINERGIQUES N04AA TERTIARY AMINES AMINES TERTIAIRES N04AA01 TRIHEXYPHENIDYL TRIHEXYPHÉNIDYLE Tab Orl 2mg Trihex AAP f AEFGVW Tab Orl 5mg Trihex AAP f AEFGVW February 2014 / février 2014 Page 150

163 N04AA04 N04AA05 N04AC N04AC01 PROCYCLIDINE PROCYCLIDINE Elx Orl 0.5mg pms-procyclidine PMS AEFGVW Elx. Tab Orl 2.5mg pms-procyclidine PMS AEFGVW Tab Orl 5mg pms-procyclidine PMS AEFGVW PROFENAMINE (ETHOPROPAZINE) PROFÉNAMINE (ÉTHOPROPAZINE) Tab Orl 50mg Parsitan ERF AEFGVW ETHERS OF TROPINE OR TROPINE DERIVATIVES ÉTHERS DE TROPINE OU DÉRIVÉS DU TROPINE BENZYTROPINE BENZYTROPINE Liq Inj 1mg Benztropine Omega OMG VW Liq Tab Orl 1mg pms-benztropine PMS AEFGVW N04B N04BA N04BA02 Tab Orl 2mg Benztropine PMS f AEFGVW pms-benztropine (Disc/non disp Sep 24/14) PMS AEFGVW DOPAMINERGIC AGENTS AGENTS DOPAMINERGIQUES DOPA AND DOPA DERIVATIVES DOPA ET DÉRIVÉS DU DOPA LEVODOPA AND DECARBOXYLASE INHIBITOR LÉVODOPA ET INHIBITEUR DU DÉCARBOXYLASE LEVODOPA / BENSERAZIDE LÉVODOPA / BÉNSERAZIDE Cap Orl 50mg/12.5mg Prolopa HLR AEFGVW Caps Cap Orl 100mg/25mg Prolopa HLR AEFGVW Caps Cap Orl 200mg/50mg Prolopa HLR AEFGVW Caps LEVODOPA / CARBIDOPA LÉVODOPA / CARBIDOPA SRT Orl 100mg/25mg Sinemet CR FRS f AEFVW L.L. Levocarb CR AAP f AEFVW SRT Orl 200mg/50mg Sinemet CR FRS f AEFVW L.L. Levocarb CR AAP f AEFVW February 2014 / février 2014 Page 151

164 N04BA02 LEVODOPA AND DECARBOXYLASE INHIBITOR LÉVODOPA ET INHIBITEUR DU DÉCARBOXYLASE LEVODOPA / CARBIDOPA LÉVODOPA / CARBIDOPA Tab Orl 100mg/10mg Sinemet FRS f AEFGVW Apo-Levocarb APX f AEFGVW Teva-Levocarbidopa TEV f AEFGVW Tab Orl 100mg/25mg Sinemet FRS f AEFGVW Apo-Levocarb APX f AEFGVW Teva-Levocarbidopa TEV f AEFGVW N04BB N04BB01 Tab Orl 250mg/25mg Sinemet FRS f AEFGVW Apo-Levocarb APX f AEFGVW Teva-Levocarbidopa TEV f AEFGVW ADAMANTINE DERIVATIVES DÉRIVÉS DE L ADAMANTINE AMANTADINE AMANTADINE Cap Orl 100mg pms-amantadine Hydrochloride PMS f AEFGVW Caps Mylan-Amantadine (Disc/non disp Jul 4/15) MYL f AEFGVW N04BC N04BC04 Syr Orl 10mg pms-amantadine PMS f AEFGVW Sir. DOPAMINE AGONISTS AGONISTES DE LA DOPAMINE ROPINIROLE ROPINIROLE Tab Orl 0.25mg Requip GSK f AEFVW Ran-Ropinirole RAN f AEFVW Co Ropinirole COB f AEFVW pms-ropinirole PMS f AEFVW Jamp-Ropinirole JPC f AEFVW Ropinirole SAS f AEFVW Tab Orl 1mg Requip GSK f AEFVW Ran-Ropinirole RAN f AEFVW Co Ropinirole COB f AEFVW pms-ropinirole PMS f AEFVW Jamp-Ropinirole JPC f AEFVW Ropinirole SAS f AEFVW Tab Orl 2mg Requip GSK f AEFVW Ran-Ropinirole RAN f AEFVW Co Ropinirole COB f AEFVW pms-ropinirole PMS f AEFVW Jamp-Ropinirole JPC f AEFVW Ropinirole SAS f AEFVW February 2014 / février 2014 Page 152

165 N04BC04 N04BC05 ROPINIROLE ROPINIROLE Tab Orl 5mg Requip GSK f AEFVW Ran-Ropinirole RAN f AEFVW Co Ropinirole COB f AEFVW pms-ropinirole PMS f AEFVW Jamp-Ropinirole JPC f AEFVW Ropinirole SAS f AEFVW PRAMIPEXOLE PRAMIPEXOLE Tab Orl 0.25mg Mirapex BOE f AEFVW Teva-Pramipexole TEV f AEFVW pms-pramipexole PMS f AEFVW Apo-Pramipexole APX f AEFVW Co Pramipexole COB f AEFVW Sandoz Pramipexole SDZ f AEFVW Mylan-Pramipexole MYL f AEFVW Tab Orl 0.5mg Mirapex BOE f AEFVW Teva-Pramipexole TEV f AEFVW pms-pramipexole PMS f AEFVW Apo-Pramipexole APX f AEFVW Co Pramipexole COB f AEFVW Sandoz Pramipexole SDZ f AEFVW Mylan-Pramipexole MYL f AEFVW Tab Orl 1mg Mirapex BOE f AEFVW Teva-Pramipexole TEV f AEFVW pms-pramipexole PMS f AEFVW Apo-Pramipexole APX f AEFVW Co Pramipexole COB f AEFVW Sandoz Pramipexole SDZ f AEFVW Mylan-Pramipexole MYL f AEFVW N04BD N04BD01 Tab Orl 1.5mg Mirapex BOE f AEFVW Teva-Pramipexole TEV f AEFVW pms-pramipexole PMS f AEFVW Apo-Pramipexole APX f AEFVW Co Pramipexole COB f AEFVW Sandoz Pramipexole SDZ f AEFVW Mylan-Pramipexole MYL f AEFVW MONOAMINE OXIDASE TYPE B INHIBITORS OXIDASE DE MONOAMINE, INHIBITEURS DE TYPE B SELEGILINE SÉLÉGILINE Tab Orl 5mg Novo-Selegiline TEV f AEFVW Apo-Selegiline APX f AEFVW Mylan-Selegiline MYL f AEFVW February 2014 / février 2014 Page 153

166 N05 N05A N05AA N05AA01 PSYCHOLEPTICS PSYCHOLEPTIQUES ANTIPSYCHOTICS ANTIPSYCHOTIQUES PHENOTHIAZINE WITH ALIPHATIC SIDE CHAIN PHÉNOTHIAZINE AVEC CHAÎNE LATÉRALE ALIPHATIQUE CHLORPROMAZINE CHLORPROMAZINE Tab Orl 25mg Teva-Chlorpromazine TEV AEFGVW Tab Orl 50mg Teva-Chlorpromazine TEV AEFGVW N05AA02 Tab Orl 100mg Teva-Chlorpromazine TEV AEFGVW LEVOMEPROMAZINE (METHOTRIMEPRAZINE) LÉVOMÉPROMAZINE (MÉTHOTRIMÉPRAZINE) Liq Inj 25mg Nozinan SAV AEFVW Liq Tab Orl 2mg Methoprazine AAP f AEFGVW Tab Orl 5mg Methoprazine AAP f AEFGVW Tab Orl 25mg Methoprazine AAP f AEFGVW N05AB N05AB02 Tab Orl 50mg Methoprazine AAP f AEFGVW PHENOTHIAZINE WITH PIPERAZINE STRUCTURE PHÉNOTHIAZINE À STRUCTURE DE PIPÉRAZINE FLUPHENAZINE FLUPHÉNAZINE Liq Inj 25mg Fluphenazine (Disc/non disp Nov 20/14) * OMG AEFGVW Liq Liq Inj 100mg Modecate conc * BRI f AEFGVW Liq Fluphenazine (Disc/non disp Nov 20/14) * OMG AEFGVW Tab Orl 1mg Fluphenazine AAP AEFGVW February 2014 / février 2014 Page 154

167 N05AB02 FLUPHENAZINE FLUPHÉNAZINE Tab Orl 2mg Fluphenazine AAP AEFGVW Tab Orl 5mg Fluphenazine AAP AEFGVW N05AB03 PERPHENAZINE PERPHÉNAZINE Tab Orl 2mg Perphenazine AAP f AEFGVW Tab Orl 4mg Perphenazine AAP f AEFGVW Tab Orl 8mg Perphenazine AAP f AEFGVW N05AB04 Tab Orl 16mg Perphenazine AAP f AEFGVW PROCHLORPERAZINE PROCHLORPÉRAZINE Sup Rt 10mg pms-prochlorperazine PMS AEFGVW Supp Tab Orl 5mg Prochlorazine AAP AEFGVW pms-prochlorperazine (Disc/non disp Feb 7/14) PMS AEFGVW Tab Orl 10mg Prochlorazine AAP AEFGVW pms-prochlorperazine (Disc/non disp Feb 7/14) PMS AEFGVW N05AB06 TRIFLUOPERAZINE TRIFLUOPÉRAZINE Tab Orl 1mg Trifluoperazine AAP f AEFGVW Tab Orl 2mg Trifluoperazine AAP f AEFGVW Tab Orl 5mg Trifluoperazine AAP f AEFGVW Tab Orl 10mg Trifluoperazine AAP f AEFGVW N05AC PHENOTHIAZINE WITH PIPERIDINE STRUCTURE PHÉNOTHIAZINES À STRUCTURE DE PIPÉRIDINE N05AC01 PERICYAZINE PÉRICYAZINE Cap Orl 5mg Neuleptil ERF AEFGVW Caps February 2014 / février 2014 Page 155

168 N05AC01 PERICYAZINE PÉRICYAZINE Cap Orl 10mg Neuleptil ERF AEFGVW Caps Cap Orl 20mg Neuleptil ERF AEFGVW Caps Dps Orl 10mg Neuleptil ERF AEFGVW Gttes N05AC04 N05AD N05AD01 PIPOTIAZINE PIPOTIAZINE Liq Inj 25mg Piportil L4 * SAV AEFGVW Liq Liq Inj 50mg Piportil L4 * SAV AEFGVW Liq BUTYROPHENONE DERIVATIVES DÉRIVÉS DU BUTYROPHÉNONE HALOPERIDOL HALOPÉRIDOL Liq Inj 5mg Haloperidol * SDZ AEFGVW Liq Tab Orl 0.5mg Novo-Peridol TEV f AEFGVW Apo-Haloperidol (Disc/non disp Dec 09/15) APX f AEFGVW Tab Orl 1mg Novo-Peridol TEV f AEFGVW Apo-Haloperidol APX f AEFGVW Tab Orl 2mg Novo-Peridol TEV f AEFGVW Apo-Haloperidol (Disc/non disp Apr 10/15) APX f AEFGVW Tab Orl 5mg Novo-Peridol TEV f AEFGVW Apo-Haloperidol (Disc/non disp Apr 10/15) APX f AEFGVW Tab Orl 10mg Novo-Peridol TEV f AEFGVW Apo-Haloperidol APX f AEFGVW Liq Inj 50mg Haloperidol LA * SDZ f AEFGVW Liq Haloperidol (Disc/non disp Nov 20/14)* OMG AEFGVW Liq Inj 100mg Haloperidol LA * SDZ f AEFGVW Liq Haloperidol (Disc/non disp Nov 20/14) * OMG AEFGVW February 2014 / février 2014 Page 156

169 N05AE N05AE04 INDOLE DERIVATIVES DÉRIVÉS DE L INDOLE ZIPRASIDONE ZIPRASIDONE Cap Orl 20mg Zeldox PFI AEFGVW Caps Cap Orl 40mg Zeldox PFI AEFGVW Caps N05AF N05AF01 Cap Orl 60mg Zeldox PFI AEFGVW Caps Cap Orl 80mg Zeldox PFI AEFGVW Caps THIOXANTHENE DERIVATIVES DÉRIVÉS DU THIOXANTHÉNE FLUPENTHIXOL FLUPENTHIXOL Tab Orl 0.5mg Fluanxol VLH AEFGVW Tab Orl 3mg Fluanxol VLH AEFGVW Liq Inj 20mg Fluanxol Depot* VLH AEFGVW Liq Liq Inj 100mg Fluanxol Depot* VLH f AEFGVW Liq N05AF04 THIOTHIXENE THIOTHIXÉNE Cap Orl 2mg Navane ERF AEFGVW Caps Cap Orl 5mg Navane ERF AEFGVW Caps N05AG N05AG02 Cap Orl 10mg Navane ERF AEFGVW Caps DIPHENYLBUTYLPIPERIDINE DERIVATIVES DÉRIVÉS DE LA DIPHÉNYLBUTYLPIPÉRIDINE PIMOZIDE PIMOZIDE Tab Orl 2mg Orap PDP f AEFGVW Apo-Pimozide APX f AEFGVW Tab Orl 4mg Orap PDP f AEFGVW Apo-Pimozide APX f AEFGVW February 2014 / février 2014 Page 157

170 N05AH N05AH01 DIAZEPINES, OXAZEPINES, THIAZEPINES AND OXEPINES DIAZÉPINES, OXAZÉPINES, THIAZÉPINES ET OXÉPINNES LOXAPINE LOXAPINE Tab Orl 2.5mg Xylac PDP AEFGVW Tab Orl 5mg Xylac PDP f AEFGVW Tab Orl 10mg Xylac PDP f AEFGVW Tab Orl 25mg Xylac PDP f AEFGVW N05AH02 Tab Orl 50mg Xylac PDP f AEFGVW CLOZAPINE CLOZAPINE Tab Orl 25mg Clozaril NVR f AEFGV Gen-Clozapine MYL f AEFGV Apo-Clozapine APX f AEFGV Tab Orl 100mg Clozaril NVR f AEFGV Gen-Clozapine MYL f AEFGV Apo-Clozapine APX f AEFGV N05AH03 OLANZAPINE OLANZAPINE ODT Orl 5mg Zyprexa Zydis LIL f AEFGV D.O. Zyprexa Zydis LIL f W pms-olanzapine ODT PMS f AEFGV pms-olanzapine ODT PMS f W Teva-Olanzapine ODT TEV f AEFGV Teva-Olanzapine ODT TEV f W Co Olanzapine ODT COB f AEFGV Co Olanzapine ODT COB f W Sandoz Olanzapine ODT SDZ f AEFGV Sandoz Olanzapine ODT SDZ f W Olanzapine ODT SAS f AEFGV Olanzapine ODT SAS f W Apo-Olanzapine ODT APX f AEFGV Apo-Olanzapine ODT APX f W Mylan-Olanzapine ODT MYL f AEFGV Mylan-Olanzapine ODT MYL f W 20 Requests for coverage of Clozaril (Clozapine) will be considered under special authorization, see Appendix IV. Prescriptions written by Psychiatrists do not require special authorization. Subsequent refills may be ordered by other practitioners. Les demandes de protection pour le Clozaril (Clozapine) seront examinees sur atorisation special. Veuillez consulter l annexe IV. Les ordonnances des psychiatres ne nécessitent pas une autorisation spéciale. Une autorisation special ne sera pas nécessaire pour les renovellements subséquents prescripts pas les autres pratciens. February 2014 / février 2014 Page 158

171 N05AH03 OLANZAPINE OLANZAPINE ODT Orl 5mg Mar-Olanzapine ODT MAR f AEFGV D.O. Mar-Olanzapine ODT MAR f W ODT Orl 10mg Zyprexa Zydis LIL f AEFGV D.O. Zyprexa Zydis LIL f W pms-olanzapine ODT PMS f AEFGV pms-olanzapine ODT PMS f W Teva-Olanzapine ODT TEV f AEFGV Teva-Olanzapine ODT TEV f W Co Olanzapine ODT COB f AEFGV Co Olanzapine ODT COB f W Sandoz Olanzapine ODT SDZ f AEFGV Sandoz Olanzapine ODT SDZ f W Olanzapine ODT SAS f AEFGV Olanzapine ODT SAS f W Apo-Olanzapine ODT APX f AEFGV Apo-Olanzapine ODT APX f W Mylan-Olanzapine ODT MYL f AEFGV Mylan-Olanzapine ODT MYL f W Mar-Olanzapine ODT MAR f AEFGV Mar-Olanzapine ODT MAR f W ODT Orl 15mg Zyprexa Zydis LIL f AEFGV D.O. Zyprexa Zydis LIL f W pms-olanzapine ODT PMS f AEFGV pms-olanzapine ODT PMS f W Teva-Olanzapine ODT TEV f AEFGV Teva-Olanzapine ODT TEV f W Co Olanzapine ODT COB f AEFGV Co Olanzapine ODT COB f W Sandoz Olanzapine ODT SDZ f AEFGV Sandoz Olanzapine ODT SDZ f W Olanzapine ODT SAS f AEFGV Olanzapine ODT SAS f W Apo-Olanzapine ODT APX f AEFGV Apo-Olanzapine ODT APX f W Mylan-Olanzapine ODT MYL f AEFGV Mylan-Olanzapine ODT MYL f W Mar-Olanzapine ODT MAR f AEFGV Mar-Olanzapine ODT MAR f W ODT Orl 20mg Zyprexa Zydis LIL f AEFGV D.O. Zyprexa Zydis LIL f W Teva-Olanzapine ODT TEV f AEFGV Teva-Olanzapine ODT TEV f W Co Olanzapine ODT COB f AEFGV Co Olanzapine ODT COB f W Sandoz Olanzapine ODT SDZ f AEFGV Sandoz Olanzapine ODT SDZ f W Apo-Olanzapine ODT APX f AEFGV Apo-Olanzapine ODT APX f W Mylan-Olanzapine ODT MYL f AEFGV February 2014 / février 2014 Page 159

172 N05AH03 OLANZAPINE OLANZAPINE ODT Orl 20mg Mylan-Olanzapine ODT MYL f W D.O. Mar-Olanzapine ODT MAR f AEFGV Mar-Olanzapine ODT MAR f W Tab Orl 2.5mg Zyprexa LIL f AEFGV Zyprexa LIL f W Teva-Olanzapine TEV f AEFGV Teva-Olanzapine TEV f W Apo-Olanzapine APX f AEFGV Apo-Olanzapine APX f W pms-olanzapine PMS f AEFGV pms-olanzapine PMS f W Sandoz Olanzapine SDZ f AEFGV Sandoz Olanzapine SDZ f W Co Olanzapine COB f AEFGV Co Olanzapine COB f W Mylan-Olanzapine MYL f AEFGV Mylan-Olanzapine MYL f W Olanzapine SAS f AEFGV Olanzapine SAS f W Ran-Olanzapine RAN f AEFGV Ran-Olanzapine RAN f W Tab Orl 5mg Zyprexa LIL f AEFGV Zyprexa LIL f W Teva-Olanzapine TEV f AEFGV Teva-Olanzapine TEV f W Apo-Olanzapine APX f AEFGV Apo-Olanzapine APX f W pms-olanzapine PMS f AEFGV pms-olanzapine PMS f W Sandoz Olanzapine SDZ f AEFGV Sandoz Olanzapine SDZ f W Co Olanzapine COB f AEFGV Co Olanzapine COB f W Mylan-Olanzapine MYL f AEFGV Mylan-Olanzapine MYL f W Olanzapine SAS f AEFGV Olanzapine SAS f W Ran-Olanzapine RAN f AEFGV Ran-Olanzapine RAN f W Tab Orl 7.5mg Zyprexa LIL f AEFGV Zyprexa LIL f W Teva-Olanzapine TEV f AEFGV Teva-Olanzapine TEV f W Apo-Olanzapine APX f AEFGV Apo-Olanzapine APX f W pms-olanzapine PMS f AEFGV pms-olanzapine PMS f W Sandoz Olanzapine SDZ f AEFGV Sandoz Olanzapine SDZ f W February 2014 / février 2014 Page 160

173 N05AH03 OLANZAPINE OLANZAPINE Tab Orl 7.5mg Co Olanzapine COB f AEFGV Co Olanzapine COB f W Mylan-Olanzapine MYL f AEFGV Mylan-Olanzapine MYL f W Olanzapine SAS f AEFGV Olanzapine SAS f W Ran-Olanzapine RAN f AEFGV Ran-Olanzapine RAN f W Tab Orl 10mg Zyprexa LIL f AEFGV Zyprexa LIL f W Teva-Olanzapine TEV f AEFGV Teva-Olanzapine TEV f W Apo-Olanzapine APX f AEFGV Apo-Olanzapine APX f W pms-olanzapine PMS f AEFGV pms-olanzapine PMS f W Sandoz Olanzapine SDZ f AEFGV Sandoz Olanzapine SDZ f W Co Olanzapine COB f AEFGV Co Olanzapine COB f W Mylan-Olanzapine MYL f AEFGV Mylan-Olanzapine MYL f W Olanzapine SAS f AEFGV Olanzapine SAS f W Ran-Olanzapine RAN f AEFGV Ran-Olanzapine RAN f W Tab Orl 15mg Zyprexa LIL f AEFGV Zyprexa LIL f W Teva-Olanzapine TEV f AEFGV Teva-Olanzapine TEV f W Apo-Olanzapine APX f AEFGV Apo-Olanzapine APX f W pms-olanzapine PMS f AEFGV pms-olanzapine PMS f W Sandoz Olanzapine SDZ f AEFGV Sandoz Olanzapine SDZ f W Co Olanzapine COB f AEFGV Co Olanzapine COB f W Mylan-Olanzapine MYL f AEFGV Mylan-Olanzapine MYL f W Ran-Olanzapine RAN f AEFGV Ran-Olanzapine RAN f W February 2014 / février 2014 Page 161

174 N05AH03 N05AH04 OLANZAPINE OLANZAPINE Tab Orl 15mg Olanzapine SAS f AEFGV Olanzapine SAS f W QUETIAPINE QUÉTIAPINE ERT Orl 50mg Seroquel XR AZE f AEFGVW L.P. Teva-Quetiapine XR TEV f AEFGVW Sandoz Quetiapine XR SDZ f AEFGVW ERT Orl 150mg Seroquel XR AZE f AEFGVW L.P. Teva-Quetiapine XR TEV f AEFGVW Sandoz Quetiapine XR SDZ f AEFGVW ERT Orl 200mg Seroquel XR AZE f AEFGVW L.P. Teva-Quetiapine XR TEV f AEFGVW Sandoz Quetiapine XR SDZ f AEFGVW ERT Orl 300mg Seroquel XR AZE f AEFGVW L.P. Teva-Quetiapine XR TEV f AEFGVW Sandoz Quetiapine XR SDZ f AEFGVW ERT Orl 400mg Seroquel XR AZE f AEFGVW L.P. Teva-Quetiapine XR TEV f AEFGVW Sandoz Quetiapine XR SDZ f AEFGVW Tab Orl 25mg Seroquel AZE f AEFGVW Teva-Quetiapine TEV f AEFGVW pms-quetiapine PMS f AEFGVW Phl-Quetiapine PHL f AEFGVW Mylan-Quetiapine MYL f AEFGVW Apo-Quetiapine APX f AEFGVW Sandoz Quetiapine SDZ f AEFGVW Co Quetiapine COB f AEFGVW Jamp-Quetiapine JPC f AEFGVW Quetiapine SAS f AEFGVW Auro-Quetiapine ARO f AEFGVW Quetiapine AHI f AEFGVW Ran-Quetiapine RAN f AEFGVW Mar-Quetiapine MAR f AEFGVW Tab Orl 100mg Seroquel AZE f AEFGVW Teva-Quetiapine TEV f AEFGVW pms-quetiapine PMS f AEFGVW Phl-Quetiapine PHL f AEFGVW Mylan-Quetiapine MYL f AEFGVW 21 Requests for coverage of Zyprexa (Olanzapine) and Zyprexa Zydis (Olanzapine ODT) will be considered under special authorization, see Appendix IV. Prescriptions written by New Brunswick psychiatrists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. Les demandes de protection pour le Zyprexa (Olanzapine) et le Zyprexa Zydis (Olanzapine ODT) seront examineées sur autorisation spéciale. Veuillez consulter l annexe IV. Les ordonnances rédigées par les psychiatres du Nouveau-Brunswick ne requiérent pa d autorisation spéciale. Les renouvellements precrits par d autre praticiens ne nécessiteront pa d autorisation spéciale. February 2014 / février 2014 Page 162

175 N05AH04 QUETIAPINE QUÉTIAPINE Tab Orl 100mg Apo-Quetiapine APX f AEFGVW Sandoz Quetiapine SDZ f AEFGVW Co Quetiapine COB f AEFGVW Jamp-Quetiapine JPC f AEFGVW Quetiapine SAS f AEFGVW Auro-Quetiapine ARO f AEFGVW Quetiapine AHI f AEFGVW Ran-Quetiapine RAN f AEFGVW Mar-Quetiapine MAR f AEFGVW Tab Orl 150mg Teva-Quetiapine TEV f AEFGVW N05AN N05AN01 Tab Orl 200mg Seroquel AZE f AEFGVW Teva-Quetiapine TEV f AEFGVW pms-quetiapine PMS f AEFGVW Phl-Quetiapine PHL f AEFGVW Mylan-Quetiapine MYL f AEFGVW Apo-Quetiapine APX f AEFGVW Sandoz Quetiapine SDZ f AEFGVW Co Quetiapine COB f AEFGVW Jamp-Quetiapine JPC f AEFGVW Quetiapine SAS f AEFGVW Auro-Quetiapine ARO f AEFGVW Quetiapine AHI f AEFGVW Ran-Quetiapine RAN f AEFGVW Mar-Quetiapine MAR f AEFGVW Tab Orl 300mg Seroquel AZE f AEFGVW Teva-Quetiapine TEV f AEFGVW pms-quetiapine PMS f AEFGVW Phl-Quetiapine PHL f AEFGVW Mylan-Quetiapine MYL f AEFGVW Apo-Quetiapine APX f AEFGVW Sandoz Quetiapine SDZ f AEFGVW Co Quetiapine COB f AEFGVW Jamp-Quetiapine JPC f AEFGVW Quetiapine SAS f AEFGVW Auro-Quetiapine ARO f AEFGVW Quetiapine AHI f AEFGVW Ran-Quetiapine RAN f AEFGVW Mar-Quetiapine MAR f AEFGVW LITHIUM LITHIUM LITHIUM LITHIUM Cap Orl 150mg Lithane ERF f AEFGVW Caps Apo-Lithium Carbonate APX f AEFGVW Carbolith VLN f AEFGVW pms-lithium Carbonate PMS f AEFGVW February 2014 / février 2014 Page 163

176 N05AN01 LITHIUM LITHIUM Cap Orl 300mg Lithane ERF f AEFGVW Caps Apo-Lithium Carbonate APX f AEFGVW Carbolith VLN f AEFGVW pms-lithium Carbonate PMS f AEFGVW Cap Orl 600mg Carbolith VLN AEFGVW Caps SRT Orl 300mg Lithmax SR AAP f AEFGVW L.L. N05AX N05AX08 Liq Orl 8mmol/5mL pms-lithium Citrate PMS AEFGVW Liq OTHER ANTIPSYCHOTICS AUTRES ANTIPSYCHOTIQUES RISPERIDONE RISPÉRIDONE Liq Orl 1mg Risperdal JAN f AEFGVW Liq pms-risperidone PMS f AEFGVW Apo-Risperidone APX f AEFGVW ODT Orl 0.5mg Risperdal M JAN W D.O. Risperdal M JAN AEFGV ODT Orl 1mg Risperdal M JAN f W D.O. Risperdal M JAN f AEFGV pms-risperidone ODT PMS f W pms-risperidone ODT PMS f AEFGV ODT Orl 2mg Risperdal M JAN f W D.O. Risperdal M JAN f AEFGV pms-risperidone ODT PMS f W pms-risperidone ODT PMS f AEFGV ODT Orl 3mg Risperdal M JAN f W D.O. Risperdal M JAN f AEFGV pms-risperidone ODT PMS f W pms-risperidone ODT PMS f AEFGV ODT Orl 4mg Risperdal M JAN f W D.O. Risperdal M JAN f AEFGV pms-risperidone ODT PMS f W pms-risperidone ODT PMS f AEFGV 22 Requests for coverage of Risperdal M (Risperidone ODT) will be considered under special authorization, see Appendix IV. Prescriptions written by New Brunswick psychiatrists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. Les demandes de protection pour le Risperdal M (Risperidone ODT) seront examineées sur autorisation spéciale. Veuillez consulter l annexe IV. Les ordonnances rédigées par les psychiatres du Nouveau-Brunswick ne requiérent pa d autorisation spéciale. Les renouvellements precrits par d autre praticiens ne nécessiteront pa d autorisation spéciale February 2014 / février 2014 Page 164

177 N05AX08 RISPERIDONE RISPÉRIDONE Tab Orl 0.25mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone(disc/non disp Jul 2/15) RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) RAN f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Risperidone SAS f AEFGVW Jamp-Risperidone JPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW Tab Orl 0.5mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) RAN f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Risperidone SAS f AEFGVW Jamp-Risperidone JPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW Tab Orl 1mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) RAN f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Risperidone SAS f AEFGVW Jamp-Risperidone JPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW Tab Orl 2mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) RPH f AEFGVW February 2014 / février 2014 Page 165

178 N05B N05AX08 N05BA N05BA01 RISPERIDONE RISPÉRIDONE Tab Orl 2mg Ran-Risperidone (Disc/non disp Jun 13/14) RAN f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Risperidone SAS f AEFGVW Jamp-Risperidone JPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW Tab Orl 3mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) RAN f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Tab Orl 3mg Risperidone SAS f AEFGVW Jamp-Risperidone MPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW Tab Orl 4mg Risperdal JAN f AEFGVW pms-risperidone PMS f AEFGVW Phl-Risperidone PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) RPH f AEFGVW Apo-Risperidone APX f AEFGVW Mylan-Risperidone MYL f AEFGVW Co Risperidone COB f AEFGVW Teva-Risperidone TEV f AEFGVW Sandoz Risperidone SDZ f AEFGVW Ran-Risperidone RAN f AEFGVW Risperidone SAS f AEFGVW Jamp-Risperidone MPC f AEFGVW Mint-Risperidone MNT f AEFGVW Mar-Risperidone MAR f AEFGVW ANXIOLYTICS ANXIOLYTIQUES BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZEPINE DIAZEPAM DIAZÉPAM Liq Inj 5mg Diazepam SDZ VW Liq February 2014 / février 2014 Page 166

179 N05BA01 N05BA02 DIAZEPAM DIAZÉPAM Tab Orl 2mg Apo-Diazepam APX f AEFGVW pms-diazepam PMS f AEFGVW Tab Orl 5mg Valium HLR f AEFGVW Apo-Diazepam APX f AEFGVW pms-diazepam PMS f AEFGVW Tab Orl 10mg Apo-Diazepam APX f AEFGVW pms-diazepam PMS f AEFGVW CHLORDIAZEPOXIDE CHLORDIAZÉPOXIDE Cap Orl 5mg Chlordiazepoxide AAP f AEFGVW Cap Cap Orl 10mg Chlordiazepoxide AAP f AEFGVW Cap N05BA04 Cap Orl 25mg Chlordiazepoxide AAP f AEFGVW Cap OXAZEPAM OXAZÉPAM Tab Orl 10mg Apo-Oxazepam APX f AEFGVW Tab Orl 15mg Apo-Oxazepam APX f AEFGVW N05BA05 Tab Orl 30mg Apo-Oxazepam APX f AEFGVW CLORAZEPATE DIPOTASSIUM CLORAZÉPATE DIPOTASSIQUE Cap Orl 3.75mg Clorazepate AAP f AEFGVW Cap Cap Orl 7.5mg Clorazepate AAP f AEFGVW Cap N05BA06 Cap Orl 15mg Clorazepate AAP f AEFGVW Cap LORAZEPAM LORAZÉPAM Liq Inj 4mg Lorazepam SDZ AEFVW Liq Slt Orl 0.5mg Ativan SL PFI AEFGVW S.L. February 2014 / février 2014 Page 167

180 N05BA06 LORAZEPAM LORAZÉPAM Slt Orl 1mg Ativan SL PFI AEFGVW S.L. Slt Orl 2mg Ativan SL PFI AEFGVW S.L. Tab Orl 0.5mg Ativan PFI f AEFGVW Novo-Lorazepam TEV f AEFGVW pms-lorazepam PMS f AEFGVW Apo-Lorazepam APX f AEFGVW Lorazepam SAS f AEFGVW Tab Orl 1mg Ativan PFI f AEFGVW Novo-Lorazepam TEV f AEFGVW pms-lorazepam PMS f AEFGVW Apo-Lorazepam APX f AEFGVW Lorazepam SAS f AEFGVW N05BA08 N05BA09 N05BA12 Tab Orl 2mg Ativan PFI f AEFGVW Novo-Lorazepam TEV f AEFGVW pms-lorazepam PMS f AEFGVW Apo-Lorazepam APX f AEFGVW Lorazepam SAS f AEFGVW BROMAZEPAM BROMAZÉPAM Tab Orl 1.5mg Apo-Bromazepam APX f AEFGVW Tab Orl 3mg Lectopam HLR f AEFGVW Apo-Bromazepam APX f AEFGVW Novo-Bromazepam TEV f AEFGVW Tab Orl 6mg Lectopam HLR f AEFGVW Apo-Bromazepam APX f AEFGVW Novo-Bromazepam TEV f AEFGVW CLOBAZAM CLOBAZAM Tab Orl 10mg Frisium LBK f AEFGV Novo-Clobazam TEV f AEFGV pms-clobazam PMS f AEFGV Apo-Clobazam APX f AEFGV ALPRAZOLAM ALPRAZOLAM Tab Orl 0.25mg Xanax PFI f AEFGVW Apo-Alpraz APX f AEFGVW Teva-Alprazolam TEV f AEFGVW Mylan-Alprazolam MYL f AEFGVW Alprazolam SAS f AEFGVW February 2014 / février 2014 Page 168

181 N05BA12 N05BB N05BB01 ALPRAZOLAM ALPRAZOLAM Tab Orl 0.5mg Xanax PFI f AEFGVW Apo-Alpraz APX f AEFGVW Teva-Alprazolam TEV f AEFGVW Mylan-Alprazolam MYL f AEFGVW Alprazolam SAS f AEFGVW DIPHENYLMETHANE DERIVATIVES DÉRIVÉS DU DIPHENYLMETHANE HYDROXYZINE HYDROXYZINE Cap Orl 10mg Apo-Hydroxyzine APX f AEFGVW Cap Novo-Hydroxyzine TEV f AEFGVW Cap Orl 25mg Apo-Hydroxyzine APX f AEFGVW Cap Novo-Hydroxyzine TEV f AEFGVW Cap Orl 50mg Apo-Hydroxyzine APX f AEFGVW Cap Novo-Hydroxyzine TEV f AEFGVW N05BE N05C N05BE01 N05CC N05CC01 N05CD N05CD01 Syr Orl 2mg Atarax ERF AEFGVW Sir. pms-hydroxyzine PMS AEFGVW AZASPIRODECANEDIONE DERIVATIVES DÉRIVÉS DE L'AZASPIRODECANEDIONE BUSPIRONE BUSPIRONE Tab Orl 10mg Apo-Buspirone APX f AEFGVW pms-buspirone PMS f AEFGVW Novo-Buspirone TEV f AEFGVW HYPNOTICS AND SEDATIVES HYPNOTIQUES ET SEDATIFS ALDEHYDES AND DERIVATIVES ALDEHYDES ET DÉRIVÉS CHLORAL HYDRATE CHLORAL (HYDRATE DE) Syr Orl 100mg pms-chloral Hydrate PMS AEFGVW Sir. Chloral Hydrate Syrup Odan ODN AEFGVW BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZEPINE FLURAZEPAM FLURAZÉPAM Cap Orl 15mg Apo-Flurazepam APX f AEFGVW Cap Cap Orl 30mg Apo-Flurazepam APX f AEFGVW Cap February 2014 / février 2014 Page 169

182 N05CD02 N05CD05 NITRAZEPAM NITRAZÉPAM Tab Orl 5mg Mogadon AAP f AEFGVW Nitrazadon VLN f AEFGVW Sandoz Nitrazepam SDZ f AEFGVW Apo-Nitrazepam APX f AEFGVW Tab Orl 10mg Mogadon AAP f AEFGVW Nitrazadon VLN f AEFGVW Sandoz Nitrazepam SDZ f AEFGVW Apo-Nitrazepam APX f AEFGVW TRIAZOLAM TRIAZOLAM Tab Orl 0.125mg Triazolam AAP f AEFGVW Tab Orl 0.25mg Triazolam AAP f AEFGVW N05CD07 TEMAZEPAM TÉMAZÉPAM Cap Orl 15mg Restoril SNV f AEFGVW Cap Apo-Temazepam APX f AEFGVW Novo-Temazapam TEV f AEFGVW Co-Temazepam COB f AEFGVW Cap Orl 30mg Restoril SNV f AEFGVW Cap Apo-Temazepam APX f AEFGVW Novo-Temazapam TEV f AEFGVW Co-Temazepam COB f AEFGVW N05CD08 MIDAZOLAM MIDAZOLAM Liq Inj 1mg Midazolam SDZ AEFVW Liq Liq Inj 5mg Midazolam SDZ AEFVW Liq N05CF BENZODIAZEPINE RELATED DRUGS MÉDICAMENTS LIÉS AU BENZODIAZÉPINE N05CF01 ZOPICLONE ZOPICLONE Tab Orl 5mg Imovane SAV f AEFVW pms-zopiclone PMS f AEFVW Apo-Zopiclone APX f AEFVW ratio-zopiclone TEV f AEFVW Novo-Zopiclone TEV f AEFVW Sandoz Zopiclone SDZ f AEFVW Ran-Zopiclone RAN f AEFVW Co Zopiclone COB f AEFVW Phl-Zopiclone PHL f AEFVW February 2014 / février 2014 Page 170

183 N05CF01 ZOPICLONE ZOPICLONE Tab Orl 5mg Mylan-Zopiclone MYL f AEFVW Zopiclone SAS f AEFVW Mar-Zopiclone MAR f AEFVW Mint-Zopiclone MNT f AEFVW Septa-Zopiclone SPT f AEFVW Tab Orl 7.5mg Imovane SAV f AEFVW Rhovane SAV f AEFVW pms-zopiclone PMS f AEFVW Apo-Zopiclone APX f AEFVW ratio-zopiclone TEV f AEFVW Novo-Zopiclone TEV f AEFVW Sandoz Zopiclone SDZ f AEFVW Ran-Zopiclone RAN f AEFVW Co Zopiclone COB f AEFVW Phl-Zopiclone PHL f AEFVW Mylan-Zopiclone MYL f AEFVW Zopiclone SAS f AEFVW Jamp-Zopiclone JPC f AEFVW Mar-Zopiclone MAR f AEFVW Mint-Zopiclone MNT f AEFVW Septa-Zopiclone SPT f AEFVW N06 N06A N06AA PSYCHOANALEPTICS PSYCHOANALEPTIQUES ANTIDEPRESSANTS ANTIDEPRESSIFS NON-SELECTIVE MONOAMINE REUPTAKE INHIBITORS INHIBITEURS DE LA MONOAMINE NON SÉLECTIFS DU RECAPTAGE N06AA01 DESIPRAMINE DÉSIPRAMINE Tab Orl 10mg Desipramine AAP f AEFGVW Tab Orl 25mg Desipramine AAP f AEFGVW Tab Orl 50mg Desipramine AAP f AEFGVW Tab Orl 75mg Desipramine AAP f AEFGVW Tab Orl 100mg Desipramine AAP f AEFGVW N06AA02 IMIPRAMINE IMIPRAMINE Tab Orl 10mg Imipramine AAP f AEFGVW February 2014 / février 2014 Page 171

184 N06AA02 N06AA04 IMIPRAMINE IMIPRAMINE Tab Orl 25mg Imipramine AAP f AEFGVW Tab Orl 50mg Imipramine AAP f AEFGVW Tab Orl 75mg Imipramine AAP f AEFGVW CLOMIPRAMINE CLOMIPRAMINE Tab Orl 10mg Anafranil SNV f AEFGVW Apo-Clomipramine APX f AEFGVW Tab Orl 25mg Anafranil SNV f AEFGVW Apo-Clomipramine APX f AEFGVW Co-Clomipramine COB f AEFGVW N06AA06 Tab Orl 50mg Anafranil SNV f AEFGVW Apo-Clomipramine APX f AEFGVW Co-Clomipramine COB f AEFGVW TRIMIPRAMINE TRIMIPRAMINE Tab Orl 12.5mg Trimipramine AAP f AEFGVW Tab Orl 25mg Trimipramine AAP f AEFGVW Tab Orl 50mg Trimipramine AAP f AEFGVW Cap Orl 75mg Trimipramine AAP f AEFGVW Cap N06AA09 Tab Orl 100mg Trimipramine AAP f AEFGVW AMITRIPTYLINE AMITRIPTYLINE Tab Orl 10mg Elavil AAP f AEFGVW Apo-Amitriptyline APX f AEFGVW Amitriptyline PDL AEFGVW Tab Orl 25mg Elavil AAP f AEFGVW Apo-Amitriptyline APX f AEFGVW Amitriptyline PDL AEFGVW Tab Orl 50mg Elavil AAP f AEFGVW Apo-Amitriptyline APX f AEFGVW February 2014 / février 2014 Page 172

185 N06AA09 AMITRIPTYLINE AMITRIPTYLINE Tab Orl 75mg Elavil AAP f AEFGVW Apo-Amitriptyline APX f AEFGVW N06AA10 NORTRIPTYLINE NORTRIPTYLINE Cap Orl 10mg Aventyl PDP f AEFGVW Cap pms-nortriptyline PMS f AEFGVW Apo-Nortriptyline APX f AEFGVW Teva-Nortriptyline TEV f AEFGVW Cap Orl 25mg Aventyl PDP f AEFGVW Cap pms-nortriptyline PMS f AEFGVW Apo-Nortriptyline APX f AEFGVW Teva-Nortriptyline TEV f AEFGVW N06AA12 DOXEPIN DOXÉPINE Cap Orl 10mg Sinequan ERF f AEFGVW Cap Doxepin AAP f AEFGVW Cap Orl 25mg Sinequan ERF f AEFGVW Cap Doxepin AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) TEV f AEFGVW Cap Orl 50mg Sinequan ERF f AEFGVW Cap Doxepin AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) TEV f AEFGVW Cap Orl 75mg Sinequan ERF f AEFGVW Cap Doxepin AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) TEV f AEFGVW Cap Orl 100mg Sinequan ERF f AEFGVW Cap Doxepin AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) TEV f AEFGVW Cap Orl 150mg Novo-Doxepin (Disc/non disp Oct 18/15) TEV f AEFGVW Cap N06AA21 MAPROTILINE MAPROTILINE Tab Orl 25mg Teva-Maprotiline TEV f AEFGVW Tab Orl 50mg Teva-Maprotiline TEV f AEFGVW Tab Orl 75mg Teva-Maprotiline TEV f AEFGVW February 2014 / février 2014 Page 173

186 N06AB N06AB03 N06AB04 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI'S) INHIBITEURS SPECIFIQUES DU RECAPTAGE DE LA SEROTONINE FLUOXETINE FLUOXÉTINE Cap Orl 10mg Prozac LIL f AEFGVW Cap pms-fluoxetine PMS f AEFGVW Apo-Fluoxetine APX f AEFGVW Teva-Fluoxetine TEV f AEFGVW Phl-Fluoxetine PHL f AEFGVW Mylan-Fluoxetine MYL f AEFGVW ratio-fluoxetine (Disc/non disp Feb 22/15) RPH f AEFGVW Co Fluoxetine COB f AEFGVW Sandoz Fluoxetine SDZ f AEFGVW Fluoxetine SAS f AEFGVW Zym-Fluoxetine ZYM f AEFGVW Mint-Fluoxetine MNT f AEFGVW Auro-Fluoxetine ARO f AEFGVW Fluoxetine AHI f AEFGVW Mar-Fluoxetine MAR f AEFGVW Jamp-Fluoxetine JPC f AEFGVW Ran-Fluoxetine RAN f AEFGVW Cap Orl 20mg Prozac LIL f AEFGVW Cap pms-fluoxetine PMS f AEFGVW Apo-Fluoxetine APX f AEFGVW Teva-Fluoxetine TEV f AEFGVW Phl-Fluoxetine PHL f AEFGVW Mylan-Fluoxetine MYL f AEFGVW ratio-fluoxetine (Disc/non disp Feb 22/15) RPH f AEFGVW Co Fluoxetine COB f AEFGVW Sandoz Fluoxetine SDZ f AEFGVW Fluoxetine SAS f AEFGVW Zym-Fluoxetine ZYM f AEFGVW Mint-Fluoxetine MNT f AEFGVW Fluoxetine AHI f AEFGVW Jamp-Fluoxetine JPC f AEFGVW Auro-Fluoxetine ARO f AEFGVW Mar-Fluoxetine MAR f AEFGVW Ran-Fluoxetine RAN f AEFGVW CITALOPRAM CITALOPRAM Tab Orl 10mg pms-citalopram PMS f AEFGVW Phl-Citalopram PHL f AEFGVW Teva-Citalopram TEV f AEFGVW Mint-Citalopram MNT f AEFGVW Jamp-Citalopram JPC f AEFGVW Mar-Citalopram MAR f AEFGVW Tab Orl 20mg Celexa VLH f AEFGVW Apo-Citalopram APX f AEFGVW Mylan-Citalopram MYL f AEFGVW pms-citalopram PMS f AEFGVW February 2014 / février 2014 Page 174

187 N06AB04 N06AB05 CITALOPRAM CITALOPRAM Tab Orl 20mg Co Citalopram COB f AEFGVW Sandoz Citalopram SDZ f AEFGVW Phl-Citalopram PHL f AEFGVW ratio-citalopram (Disc/non disp Dec 21/14) TEV f AEFGVW Ran-Citalo RAN f AEFGVW Teva-Citalopram TEV f AEFGVW Mint-Citalopram MNT f AEFGVW Citalopram-odan ODN f AEFGVW Jamp-Citalopram JPC f AEFGVW Citalopram SAS f AEFGVW Septa-Citalopram SPT f AEFGVW Mar-Citalopram MAR f AEFGVW Auro-Citalopram ARO f AEFGVW Tab Orl 30mg CTP SNV AEFGVW Tab Orl 40mg Celexa VLH f AEFGVW Apo-Citalopram APX f AEFGVW Mylan-Citalopram MYL f AEFGVW pms-citalopram PMS f AEFGVW Co Citalopram COB f AEFGVW Sandoz Citalopram SDZ f AEFGVW Phl-Citalopram PHL f AEFGVW ratio-citalopram (Disc/non disp Dec 21/14) TEV f AEFGVW Ran-Citalo RAN f AEFGVW Teva-Citalopram TEV f AEFGVW Mint-Citalopram MNT f AEFGVW Citalopram-odan ODN f AEFGVW Auro-Citalopram ARO f AEFGVW Jamp-Citalopram JPC f AEFGVW Citalopram SAS f AEFGVW Septa-Citalopram SPT f AEFGVW Mar-Citalopram MAR f AEFGVW PAROXETINE PAROXÉTINE Tab Orl 20mg Paxil GSK f AEFGVW Apo-Paroxetine APX f AEFGVW pms-paroxetine PMS f AEFGVW ratio-paroxetine (Disc/non disp Feb 22/15) RPH f AEFGVW Mylan-Paroxetine MYL f AEFGVW Teva-Paroxetine TEV f AEFGVW Co Paroxetine COB f AEFGVW Sandoz Paroxetine SDZ f AEFGVW Paroxetine SAS f AEFGVW Jamp-Paroxetine JPC f AEFGVW Auro-Paroxetine ARO f AEFGVW Tab Orl 30mg Paxil GSK f AEFGVW Apo-Paroxetine APX f AEFGVW pms-paroxetine PMS f AEFGVW February 2014 / février 2014 Page 175

188 N06AB05 N06AB06 PAROXETINE PAROXÉTINE Tab Orl 30mg ratio-paroxetine (Disc/non disp Feb 22/15) RPH f AEFGVW Mylan-Paroxetine MYL f AEFGVW Teva-Paroxetine TEV f AEFGVW Co Paroxetine COB f AEFGVW Sandoz Paroxetine SDZ f AEFGVW Paroxetine SAS f AEFGVW Jamp-Paroxetine JPC f AEFGVW Auro-Paroxetine ARO f AEFGVW Tab Orl 40mg pms-paroxetine PMS AEFGVW SERTRALINE SERTRALINE Cap Orl 25mg Zoloft PFI f AEFGVW Caps Apo-Sertraline APX f AEFGVW Teva-Sertraline TEV f AEFGVW Mylan-Sertraline MYL f AEFGVW pms-sertraline PMS f AEFGVW Sandoz Sertraline SDZ f AEFGVW Phl-Sertraline PHL f AEFGVW GD-Sertraline GMD f AEFGVW Co Sertraline COB f AEFGVW Sertraline SAS f AEFGVW Jamp-Sertraline JPC f AEFGVW Ran-Sertraline RAN f AEFGVW Auro-Sertraline ARO f AEFGVW Mar-Sertraline MAR f AEFGVW Mint-Sertraline MNT f AEFGVW Cap Orl 50mg Zoloft PFI f AEFGVW Caps Apo-Sertraline APX f AEFGVW Teva-Sertraline TEV f AEFGVW Mylan-Sertraline MYL f AEFGVW pms-sertraline PMS f AEFGVW Sandoz Sertraline SDZ f AEFGVW Phl-Sertraline PHL f AEFGVW GD-Sertraline GMD f AEFGVW Co Sertraline COB f AEFGVW Sertraline SAS f AEFGVW Jamp-Sertraline JPC f AEFGVW Ran-Sertraline RAN f AEFGVW Auro-Sertraline ARO f AEFGVW Mar-Sertraline MAR f AEFGVW Mint-Sertraline MNT f AEFGVW Cap Orl 100mg Zoloft PFI f AEFGVW Caps Apo-Sertraline APX f AEFGVW Teva-Sertraline TEV f AEFGVW Mylan-Sertraline MYL f AEFGVW pms-sertraline PMS f AEFGVW Sandoz Sertraline SDZ f AEFGVW February 2014 / février 2014 Page 176

189 N06AB06 N06AB06 N06AF N06AF03 N06AF04 N06AG N06AG02 SERTRALINE SERTRALINE Cap Orl 100mg Phl-Sertraline PHL f AEFGVW Caps GD-Sertraline GMD f AEFGVW Co Sertraline COB f AEFGVW Sertraline SAS f AEFGVW Jamp-Sertraline JPC f AEFGVW Ran-Sertraline RAN f AEFGVW Auro-Sertraline ARO f AEFGVW Mar-Sertraline MAR f AEFGVW Mint-Sertraline MNT f AEFGVW FLUVOXAMINE FLUVOXAMINE Tab Orl 50mg Luvox ABB f AEFGVW Ratio-Fluvoxamine TEV f AEFGVW Apo-Fluvoxamine APX f AEFGVW Novo-Fluvoxamine TEV f AEFGVW pms-fluvoxamine (Disc/non disp Sep 13/15) PMS f AEFGVW Co Fluvoxamine COB f AEFGVW Tab Orl 100mg Luvox ABB f AEFGVW Ratio-Fluvoxamine TEV f AEFGVW Apo-Fluvoxamine APX f AEFGVW Novo-Fluvoxamine TEV f AEFGVW pms-fluvoxamine (Disp/non disp Sep 13/15) PMS f AEFGVW Co Fluvoxamine COB f AEFGVW MONOAMINE OXIDASE INHIBITORS, NON-SELECTIVE INHIBITEURS DE LA MONOAMINE OXYDASE, NON SELECTIFS PHENELZINE PHÉNELZINE Tab Orl 15mg Nardil ERF AEFGVW TRANYLCYPROMINE TRANYLCYPROMINE Tab Orl 10mg Parnate GSK AEFGVW MONOAMINE OXIDASE TYPE A INHIBITORS INHIBITEURS DE LA MONOAMINE OXYDASE DE TYPE A MOCLOBEMIDE MOCLOBÉMIDE Tab Orl 100mg Apo-Moclobemide APX f AEFGVW Teva-Moclobemide TEV f AEFGVW Tab Orl 150mg Manerix MVL f AEFGVW Apo-Moclobemide APX f AEFGVW Teva-Moclobemide TEV f AEFGVW February 2014 / février 2014 Page 177

190 N06AG02 N06AX N06AX05 MOCLOBEMIDE MOCLOBÉMIDE Tab Orl 300mg Manerix MVL f AEFGVW Apo-Moclobemide TEV f AEFGVW Teva-Moclobemide APX f AEFGVW OTHER ANTIDEPRESSANTS AUTRES ANTIDEPRESSIFS TRAZODONE TRAZODONE Tab Orl 50mg pms-trazodone PMS f AEFGVW Teva-Trazodone TEV f AEFGVW Apo-Trazodone APX f AEFGVW Mylan-Trazodone MYL f AEFGVW Phl-Trazodone PHL f AEFGVW Trazodone SAS f AEFGVW Tab Orl 100mg pms-trazodone PMS f AEFGVW Teva-Trazodone TEV f AEFGVW Apo-Trazodone APX f AEFGVW Mylan-Trazodone MYL f AEFGVW Phl-Trazodone PHL f AEFGVW Trazodone SAS f AEFGVW N06AX11 Tab Orl 150mg Teva-Trazodone TEV f AEFGVW Apo-Trazodone APX f AEFGVW Trazodone SAS f AEFGVW MIRTAZAPINE MIRTAZAPINE ODT Orl 15mg Remeron RD FRS f AEFGVW D.O. Novo-Mirtazapine OD TEV f AEFGVW Auro-Mirtazapine OD ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) GMD f AEFGVW ODT Orl 30mg Remeron RD FRS f AEFGVW D.O. Novo-Mirtazapine OD TEV f AEFGVW Auro-Mirtazapine OD ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) GMD f AEFGVW ODT Orl 45mg Remeron RD FRS f AEFGVW D.O. Novo-Mirtazapine OD TEV f AEFGVW Auro-Mirtazapine OD ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) GMD f AEFGVW Tab Orl 15mg Sandoz Mirtazapine SDZ f AEFGVW pms-mirtazapine PMS f AEFGVW Mirtazapine MEL f AEFGVW Apo-Mirtazapine APX f AEFGVW Zym-Mirtazapine ZYM f AEFGVW Mylan-Mirtazapine MYL f AEFGVW February 2014 / février 2014 Page 178

191 N06AX11 N06AX12 MIRTAZAPINE MIRTAZAPINE Tab Orl 30mg Remeron FRS f AEFGVW pms-mirtazapine PMS f AEFGVW Sandoz Mirtazapine SDZ f AEFGVW Mirtazapine MEL f AEFGVW Mylan-Mirtazapine MYL f AEFGVW Novo-Mirtazapine TEV f AEFGVW Apo-Mirtazapine APX f AEFGVW Zym-Mirtazapine ZYM f AEFGVW Mirtazapine SAS f AEFGVW BUPROPION BUPROPION SRT Orl 100mg Sandoz Bupropion SR SDZ f AEFGVW L.L. ratio-bupropion SR TEV f AEFGVW pms-bupropion PMS f AEFGVW Bupropion SR SAS f AEFGVW SRT Orl 150mg Wellbutrin SR VLN f AEFGVW L.L. Sandoz Bupropion SR SDZ f AEFGVW ratio-bupropion SR TEV f AEFGVW pms-bupropion PMS f AEFGVW Bupropion SR SAS f AEFGVW SRT Orl 150mg Wellbutrin XL VLN f AEFGVW L.L. Mylan-Bupropion XL MYL f AEFGVW N06AX16 SRT Orl 300mg Wellbutrin XL VLN f AEFGVW L.L. Mylan-Bupropion XL MYL f AEFGVW VENLAFAXINE VENLAFAXINE SRC Orl 37.5mg Effexor XR PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) TEV f AEFGVW Teva-Venlafaxine XR TEV f AEFGVW pms-venlafaxine XR PMS f AEFGVW Co Venlafaxine XR COB f AEFGVW Mylan-Venlafaxine XR MYL f AEFGVW Sandoz Venlafaxine XR SDZ f AEFGVW Venlafaxine XR SAS f AEFGVW GD-Venlafaxine XR GMD f AEFGVW Ran-Venlafaxine XR RAN f AEFGVW Apo-Venlafaxine XR APX f AEFGVW SRC Orl 75mg Effexor XR PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) TEV f AEFGVW Teva-Venlafaxine XR TEV f AEFGVW pms-venlafaxine XR PMS f AEFGVW Co Venlafaxine XR COB f AEFGVW Mylan-Venlafaxine XR MYL f AEFGVW Sandoz Venlafaxine XR SDZ f AEFGVW Venlafaxine XR SAS f AEFGVW February 2014 / février 2014 Page 179

192 N06B N06AX16 N06BA N06BA02 VENLAFAXINE VENLAFAXINE SRC Orl 75mg GD-Venlafaxine XR GMD f AEFGVW Caps.L.L. Ran-Venlafaxine XR RAN f AEFGVW Apo-Venlafaxine XR APX f AEFGVW SRC Orl 150mg Effexor XR PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) TEV f AEFGVW Teva-Venlafaxine XR TEV f AEFGVW pms-venlafaxine XR PMS f AEFGVW Co Venlafaxine XR COB f AEFGVW Mylan-Venlafaxine XR MYL f AEFGVW Sandoz Venlafaxine XR SDZ f AEFGVW Venlafaxine XR SAS f AEFGVW GD-Venlafaxine XR GMD f AEFGVW Ran-Venlafaxine XR RAN f AEFGVW Apo-Venlafaxine XR APX f AEFGVW PSYCHOSTIMULANTS, AGENTS USED FOR ADHD AND NOOTROPICS PSYCHOSTIMULANTS, AGENTS UTILISÉS POUR ADHD ET NOOTROPIQUES CENTRALLY ACTING SYMPATHOMIMETICS ADRENERGIQUES AGISSANT CENTRALEMENT DEXAMPHETAMINE DEXAMPHÉTAMINE Tab Orl 5mg Dexedrine PAL EF-18G SRC Orl 10mg Dexedrine PAL EF-18G Caps.L.L. N06BA04 SRC Orl 15mg Dexedrine PAL EF-18G Caps.L.L. METHYLPHENIDATE MÉTHYLPHÉNIDATE SRT Orl 20mg Ritalin SR NVR f AEFGVW L.L. Apo-Methylphenidate SR APX f AEFGVW Sandoz Methylphenidate SR SDZ f AEFGVW Tab Orl 5mg Apo-Methylphenidate APX f AEFGVW pms-methylphenidate PMS AEFGVW Tab Orl 10mg Ritalin NVR f AEFGVW pms-methylphenidate PMS f AEFGVW Apo-Methylphenidate APX f AEFGVW Tab Orl 20mg Ritalin NVR f AEFGVW pms-methylphenidate PMS f AEFGVW Apo-Methylphenidate APX f AEFGVW February 2014 / février 2014 Page 180

193 N07 N07A N07AA OTHER NERVOUS SYSTEM DRUGS AUTRES MÉDICAMENTS DU SYSTEME NERVEUX PARASYMPATHOMIMETICS PARAADRENERGIQUES ANTICHOLINESTERASES ANTICHOLINESTERASES N07AA02 PYRIDOSTIGMINE PYRIDOSTIGMINE SRT Orl 180mg Mestinon SR VLN AEFGVW L.L. Tab Orl 60mg Mestinon VLN AEFGVW N07AB CHOLINE ESTERS ESTERS DE CHOLINE N07AB02 BETHANECHOL BÉTHANÉCHOL Tab Orl 10mg Duvoid PAL AEFGVW Tab Orl 25mg Duvoid PAL AEFGVW Tab Orl 50mg Duvoid PAL AEFGVW N07C N07CA ANTIVERTIGO PREPARATIONS PRÉPARATIONS ANTIVERTIGINEUX ANTIVERTIGO PREPARATIONS PRÉPARATIONS ANTIVERTIGINEUX N07CA03 FLUNARIZINE FLUNARIZINE Cap Orl 5mg Flunarizine AAP f EF Caps N07X N07XX OTHER NERVOUS SYSTEM DRUGS AUTRES MÉDICAMENTS DU SYSTEME NERVEUX OTHER NERVOUS SYSTEM DRUGS AUTRES MÉDICAMENTS DU SYSTEME NERVEUX N07XX06 TETRABENAZINE TÉTRABENAZINE Tab Orl 25mg Nitoman VLN f AEFGVW Co pms-tetrabenazine PMS f AEFGVW Apo-Tetrabenazine APX f AEFGVW February 2014 / février 2014 Page 181

194 P01 P01B P01BA P01BA01 P01BA02 P01BC P01BC01 ANTIPROTOZOALS ANTIPROTOZOAIRES ANTIMALARIALS ANTIPALUDIQUES AMINOQUINOLINES AMINOQUINOLINES CHLOROQUINE CHLOROQUINE Tab Orl 250mg Teva-Chloroquine TEV f AEFGVW HYDROXYCHLOROQUINE HYDROXYCHLOROQUINE Tab Orl 200mg Plaquenil SAV f AEFGVW Apo-Hydroxyquine APX f AEFGVW Mylan-Hydroxychloroquine MYL f AEFGVW METHANOLQUINOLINES METHANOLQUINOLINES QUININE QUININE Cap Orl 200mg Apo-Quinine APX f AEFGV Caps Novo-Quinine TEV AEFGVW Quinine Sulfate ODN AEFGV Cap Orl 300mg Apo-Quinine APX f AEFGV Caps Novo-Quinine TEV AEFGVW Quinine Sulfate ODN AEFGV P01BD P02 P02C P01BD01 P02CA P02CA01 Tab Orl 300mg Quinine Sulfate ODN AEFGVW DIAMINOPYRIMIDINES DIAMINOPYRIMIDINES PYRIMETHAMINE PYRIMÉTHAMINE Tab Orl 25mg Daraprim (Disc/non disp Jun 1/15) TRB AEFGVW ANTHELMINTICS ANTHELMINTIQUES ANTINEMATODAL AGENTS AGENTS ANTINEMATODAUX BENZIMIDAZOLE AGENTS AGENTS DU BENZIMIDAZOLE MEBENDAZOLE MÉBENDAZOLE Tab Orl 100mg Vermox JAN AEFGVW February 2014 / février 2014 Page 182

195 P02CC P03 P03A P02CC01 P03AB P03AB02 P03AC P03AC04 TETRAHYDROPIRIMIDINE DERIVATIVES DÉRIVÉS DU TETRAHYDROPIRIMIDINE PYRANTEL PYRANTEL Tab Orl 125mg Combantrin JNJ EF-18G ECTOPARASITICIDES, INCLUDING SCABICIDES, INSECTICIDES & REPELLANTS ECTOPARASITICIDES, Y COMPRIS LES SCABICIDES, LES INSECTICIDES ET REPULSIFS ECTOPARASITICIDES, INCLUDING SCABICIDES ECTOPARASITICIDES, Y COMPRIS LES SCABICIDES CHLORINE CONTAINING PRODUCTS PRODUITS CONTENANT DU CHLORE LINDANE LINDANE Lot Top 1% pms-lindane (Disc/non disp Jun 1/14) PDP EFGV Lot Shp Top 1% Hexit (Disc/non disp Dec 31/14) ODN EFGV Shp pms-lindane (Disc/non disp Jun 1/14) PDP EFGV PYRETHRINES, INCLUDING SYNTHETIC COMPOUNDS PYRETHRINES, Y COMPRIS LES COMPOSÉS SYNTHÉTIQUES PERMETHRIN PERMÉTHRINE Crm Top 1% Nix Creme INP EFGV Cr. Kwellada-P Creme Rinse 1% MDI EFGV Crm Top 5% Nix Dermal GCH EFGV Cr. Lot Top 5% Kwellada-P MDI EFGV Lot P03AC51 PYRETHRUM, COMBINATIONS PYRETHRUM, EN COMBINAISON PYRETHRINS / PIPERONYL BUTOXIDE PYRETHRINS / BUTOXIDE DE PIPÉRONYL Shp Top 3% R & C Shampoo and Conditioner MDI EFGV Shp P03AX OTHER ECTOPARACITICIDES, INCLUDING SCABICIDES AUTRES ECTOPARASITICIDES, Y COMPRIS LES SCABICIDES CROTAMITON CROTAMITON Crm Top 10% Eurax CLC EF-18G Cr. February 2014 / février 2014 Page 183

196 R01 R01A R01AC R01AC01 R01AD R01AD01 R01AD04 R01AD05 ISOPROPYL MYRISTATE MYRISTATE D'ISOPROPYLE Liq Top 50% Resultz MDF EFGV Liq NASAL PREPARATIONS PRÉPARATIONS NASALES DECONGESTANTS AND OTHER NASAL PREPARATIONS FOR TOPICAL USE DÉCONGESTIONNANTS ET AUTRES PRÉPARATIONS NASALES, UTILISATION TOP ANTIALLERGIC AGENTS, EXCLUDING CORTICOSTEROIDS AGENTS ANTI-ALLERGIQUES, A L'EXCLUSION DES CORTICOSTÉROÏDES CROMOGLICIC ACID ACIDE CROMOGLICIQUE Aem Nas 2% Rhinaris-CS Anti-Allergic Nsl PDP AEFGVW Aém CORTICOSTEROIDS CORTICOSTÉROÏDES BECLOMETHASONE BÉCLOMÉTHASONE Aem Nas 50mcg Mylan-Beclo AQ MYL f ABEFGVW Aém Apo-Beclomethasone AQ APX f ABEFGVW FLUNISOLIDE FLUNISOLIDE Asp Nas 0.025% Apo-Flunisolide (Disc/non disp Sep 4/14) APX f AEFGVW Asp BUDESONIDE BUDÉSONIDE Aem Inh 100mcg Rhinocort AZE AEFVW Aém Aem Nas 64mcg Rhinocort Aqua AZE f AEFVW Aém Mylan-Budesonide MYL f AEFVW Aem Nas 100mcg Mylan-Budesonide MYL f AEFGVW Aém R01AD08 R01AD09 FLUTICASONE FLUTICASONE Aem Nas 50mcg Flonase AQ GSK f ABEFGVW Aém Apo-Fluticasone APX f ABEFGVW ratio-fluticasone TEV f ABEFGVW MOMETASONE MOMÉTASONE Asp Nas 0.1% Nasonex Aqueous FRS f EFG-12 Asp Apo-Mometasone APX f EFG-12 February 2014 / février 2014 Page 184

197 R01AX R01B R01AX03 R01BA R03 R03A R01BA52 R03AC R03AC02 OTHER NASAL PREPARATIONS AUTRES PRÉPARATIONS NASALES IPRATROPIUM BROMIDE BROMURE D'IPRATROPIUM Spr Nas 0.03% Atrovent Nasal BOE f AEFGVW Spr pms-ipratropium PMS f AEFGVW NASAL DECONGESTANTS FOR SYSTEMIC USE DÉCONGESTIONNANT NASAL POUR USAGE SYSTEMIQUE SYMPATHOMIMETICS ADRENERGIQUES PSEUDOEPHEDRINE, COMBINATIONS PSEUDOEPHEDRINE, EN COMBINAISON PSEUDOEPHEDRINE /DEXTROMETHORPHAN PSEUDOÉPHÉDRINE /DEXTROMÉTHORPHANE Syr Orl 6mg/3mg Benylin DM-D (Disc/non disp Nov 16/14) JNJ G Sir. DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES OBSTRUCTIVES ADRENERGICS, INHALANTS ADRENERGIQUES, INHALANTS SELECTIVE BETA 2-ADRENOCEPTOR AGONISTS AGONISTES DES RECEPTEURS ADRENERGIQUES BETA 2 SELECTIFS SALBUTAMOL SALBUTAMOL Aem Inh 100mcg Airomir VLN f ABEFGVW Aém Ventolin GSK f ABEFGVW Apo-Salvent CFC Free APX f ABEFGVW Liq Inh 1mg Teva-Salbutamol Sterinebs TEV f BEF-18GVW Liq ratio-salbutamol unit/dose PF TEV f BEF-18GVW pms-salbutamol PMS f BEF-18GVW Ventolin Nebules P.F GSK f BEF-18GVW Med-Salbutamol MED BEF-18GVW Liq Inh 2mg Teva-Salbutamol TEV f G Liq pms-salbutamol PMS f G Ventolin Nebules PF GSK f G ratio-salbutamol (Disc/non disp Aug 26/15) TEV f G Liq Inh 5mg ratio-salbutamol TEV f BEF-18GVW Liq pms-salbutamol PMS f BEF-18GVW Sandoz-Salbutamol SDZ f BEF-18GVW Ventolin GSK f BEF-18GVW Pwr Inh 200mcg Ventolin Diskus GSK AEFGVW Pd. February 2014 / février 2014 Page 185

198 R03AC03 R03AC12 R03AC13 R03AC18 TERBUTALINE TERBUTALINE Aem Inh 0.5mg Bricanyl Turbuhaler AZE AEFGVW Aém SALMETEROL SALMÉTÉROL Pwr Inh 50mcg Serevent Diskus GSK ABEFGV Pd. FORMOTEROL FORMOTÉROL Aem Inh 6mcg Oxeze AZE ABEFGV Aém Aem Inh 12mcg Foradil NVR ABEFGV Aém Oxeze AZE ABEFGV INDACATEROL INDACATÉROL Cap Inh 75mcg Onbrez NVR ABEFGV Cap. R03AK ADRENERGICS AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES ADRÉNERGIQUES ET AUTRES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES R03AK06 SALMETEROL AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES SALMÉTÉROL ET AUTRES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES SALMETEROL/FLUTICASONE SALMÉTÉROL/FLUTICASONE Pwr Inh 25mcg/125mcg Advair GSK W Pd. Pwr Inh 25mcg/250mcg Advair GSK W Pd. Pwr Inh 50mcg/100mcg Advair Diskus GSK W Pd. Pwr Inh 50mcg/250mcg Advair Diskus GSK W Pd. Pwr Inh 50mcg/500mcg Advair Diskus GSK W Pd. 23 Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. Les ordonnances rédigées par les pneumologues diplômés du Nouveau-Brunswick ne requiérent pas d autorisation special. Les renouvellements precrits par d autres praticiens ne nécessiteront pas d autorisation special. February 2014 / février 2014 Page 186

199 R03B R03BA OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES, INHALANTS AUTRES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES OBSTRUCTIVES, INHALANTS GLUCOCORTICOIDS GLUCOCORTICOÏDES R03BA01 BECLOMETHASONE BÉCLOMÉTHASONE Aem Inh 50mcg Qvar VLN ABEFGVW Aém Aem Inh 100mcg Qvar VLN ABEFGVW Aém R03BA02 BUDESONIDE BUDÉSONIDE Aem Inh 100mcg Pulmicort Turbuhaler AZE ABEFGVW Aém Aem Inh 200mcg Pulmicort Turbuhaler AZE ABEFGVW Aém Aem Inh 400mcg Pulmicort Turbuhaler AZE ABEFGVW Aém Sus Inh 0.125mg Pulmicort Nebuamp AZE W Susp. Sus Inh 0.25mg Pulmicort Nebuamp AZE ABEFGVW Susp. Sus Inh 0.5mg Pulmicort Nebuamp AZE ABEFGVW Susp. R03BA05 FLUTICASONE FLUTICASONE Aem Inh 50mcg Flovent Metered Dose HFA GSK ABEFGVW Aém Aem Inh 125mcg Flovent Metered Dose HFA GSK ABEFGVW Aém Aem Inh 250mcg Flovent Metered Dose HFA GSK ABEFGVW Aém Pwr Inh 250mcg Flovent Diskus GSK ABEFGVW Pd. Pwr Inh 500mcg Flovent Diskus GSK ABEFGVW Pd. February 2014 / février 2014 Page 187

200 R03BA07 R03BA08 R03BB R03BB01 MOMETASONE MOMÉTASONE Pwr Inh 200mcg Asmanex Twisthaler MSD AEFGVW Pd. Pwr Inh 400mcg Asmanex Twisthaler MSD AEFGVW Pd. CICLESONIDE CICLÉSONIDE Aem Inh 100mcg Alvesco NYC ABEFGVW Aém Aem Inh 200mcg Alvesco NYC ABEFGVW Aém ANTICHOLINERGICS ANTICHOLINERGIQUES IPRATROPIUM BROMIDE BROMURE D'IPRATROPIUM Aem Inh 20mcg Atrovent HFA BOE ABEFGVW Aém Liq Inh 250mcg Apo-Ipravent APX f BEF-18GVW Liq Novo-Ipramide TEV f BEF-18GVW pms-ipratropium PMS f BEF-18GVW Mylan-Ipratropium Soln MYL f BEF-18GVW R03BC R03BC01 Liq Inh 250mcg ratio-ipratropium UDV TEV f BEF-18GVW Liq Teva-Ipratropium TEV f BEF-18GVW pms-ipratropium (1ml nebules) PMS f BEF-18GVW pms-ipratropium (2ml nebules) PMS f BEF-18GVW ANTIALLERGIC AGENTS, EXCLUDING CORTICOSTEROIDS AGENTS ANTIALLERGIQUES, A L'EXCLUSION DES CORTICOSTÉROÏDES CROMOGLICIC ACID ACIDE CROMOGLICIQUE Liq Inh 10mcg pms-sodium Cromoglycate PMS f ABEFGVW Liq R03BX OTHER DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES, INHALANTS AUTRES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES OBSTRUCTIVES, INHALANTS R03BX99 HYPERTONIC SODIUM CHLORIDE CHLORURE DE SODIUM, HYPERTONIQUE Liq Inh 7% Hyper-Sal KEG BEFG Liq February 2014 / février 2014 Page 188

201 R03C R03CB ADRENERGICS FOR SYSTEMIC USE ADRENERGIQUES, PRÉPARATIONS SYSTEMIQUES NON-SELECTIVE BETA-ADRENOCEPTOR AGONISTS AGONISTES DES RECEPTEURS ADRENERGIQUES BETA NON SELECTIFS R03CB03 ORCIPRENALINE ORCIPRÉNALINE Syr Orl 2mg Apo-Orciprenaline APX f AEFGVW Sir. R03CC SELECTIVE BETA 2-ADRENOCEPTOR AGONISTS AGONISTES DES RECEPTEURS ADRENERGIQUES BETA 2 SELECTIFS R03CC02 SALBUTAMOL SALBUTAMOL Tab Orl 2mg Apo-Salvent APX f AEFGVW R03D R03DA Tab Orl 4mg Apo-Salvent APX f AEFGVW OTHER SYSTEMIC DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES AUTRES MÉDICAMENTS CONTRE LES BRONCHOPNEUMOPATHIES OBSTRUCTIVES XANTHINES XANTHINES R03DA02 CHOLINE THEOPHYLLINATE (OXTRIPHYLLINE) THÉOPHYLLINATE CHOLINE (OXTRIPHYLLINE) Elx Orl 20mg Choledyl ERF AEFGVW Elx R03DA04 THEOPHYLLINE THÉOPHYLLINE Liq Orl mg Theolair VLN AEFGVW Liq SRT Orl 100mg Teva-Theophylline TEV f ABEFGVW L.L. Apo-Theo LA APX ABEFGVW SRT Orl 200mg Teva-Theophylline SR TEV f ABEFGVW L.L. Apo-Theo LA APX ABEFGVW SRT Orl 300mg Teva-Theophylline SR TEV f ABEFGVW L.L. Apo-Theo LA APX ABEFGVW SRT Orl 400mg Uniphyl PFR f ABEFGVW L.L. Theo ER AAP f ABEFGVW SRT Orl 600mg Uniphyl PFR f ABEFGVW L.L. Theo ER AAP f ABEFGVW Tab Orl 125mg Theolair RIK AEFGVW February 2014 / février 2014 Page 189

202 R05 R05C R05CA COUGH AND COLD PREPARATIONS PRÉPARATIONS CONTRE LA TOUX ET LE RHUME EXPECTORANTS, EXCLUDING COMBINATIONS WITH COUGH SUPPRESSANTS EXPECTORANTS, A L'EXCLUSION D'UNE COMBINAISON AVEC UN ANTITUSSIF EXPECTORANTS EXPECTORANTS R05CA03 GUAIFENESIN GUAIFÉNÉSINE Syr Orl 20mg Balminil ROG G Sir Balminil Expect Sans Sucrose ROG G Robitussin WCH G R05CB MUCOLYTICS MUCOLYTIQUES R05CB01 ACETYLCYSTEINE ACÉTYLCYSTÉINE Liq Inh 200mg Mucomyst WLS W Liq Parvolex BCH W Acetylcysteine SDZ W R05D R05DA COUGH SUPPRESSANTS, EXCLUDING COMBINATIONS WITH EXPECTORANTS ANTITUSSIFS, A L'EXCLSION D'UNE COMBINAISON AVEC UN EXPECTORANT OPIUM ALKALOIDS AND DERIVATIVES ALKALOIDES D'OPIUM ET DÉRIVÉS R05DA04 CODEINE CODÉINE Liq Inj 30mg Codeine Phosphate SDZ W Liq Syr Orl mg Codeine Phosphate ATL AEFGVW Sir Syr Orl 5mg ratio-codeine RPH AEFGVW Sir Tab Orl 15mg ratio-codeine RPH AEFGVW Codeine ROG AEFGVW Tab Orl 30mg ratio-codeine RPH AEFGVW SRT Orl 50mg Codeine Contin PFR W L.L. SRT Orl 100mg Codeine Contin PFR W L.L. SRT Orl 150mg Codeine Contin PFR W L.L. SRT Orl 200mg Codeine Contin PFR W L.L. February 2014 / février 2014 Page 190

203 R05F R05DA09 R05FA R06 R06A R05FA02 R06AA R06AA02 DEXTROMETHORPHAN DEXTROMÉTHORPHANE Liq Orl 3mg Koffex Sugar Free Clear ROG G Liq Sus Orl 6mg Delsym NNC G Susp. Syr Orl 3mg Balminil DM ROG G Sir Koffex DM ROG G Benylin DM JNJ G COUGH SUPPRESSANTS AND EXPECTORANTS, COMBINATIONS ANTITUSSIFS ET EXPECTORANTS, EN COMBINAISON OPIUM DERIVATIVES AND EXPECTORANTS DÉRIVÉS DE L'OPIUM ET EXPECTORANTS OPIUM DERIVATIVES AND EXPECTORANTS DÉRIVÉS DE L'OPIUM ET EXPECTORANTS GUAIFENESIN / DEXTROMETHORPHAN GUAIFÉNÉSINE / DEXTROMÉTHORPHANE Liq Orl 20mg/3mg Robitussin DM Exp WCH G Liq GUAIFENESIN / DEXTROMETHORPHAN / PSEUDOEPHEDRINE GUAIFÉNÉSINE / DEXTROMÉTHORPHANE / PSEUDOÉPHÉDRINE Syr Orl 100mg/50mg/30mg Benylin DM-D-E JNJ G Sir ANTIHISTAMINES FOR SYSTEMIC USE ANTIHISTAMINIQUES SYSTEMIQUES ANTIHISTAMINES FOR SYSTEMIC USE ANTIHISTAMINIQUES SYSTEMIQUES AMINOALKYL ETHERS AMINOALKYLETHERS DIPHENHYDRAMINE DIPHENHYDRAMINE Liq Inj 50mg Dimenhydrinate IM SDZ W Liq Tab Orl 25mg Diphenhydramine JPC G Tab Orl 50mg Diphenhydramine JPC G Cap Orl 50mg Benadryl (Disc/non disp Nov 16/14) JNJ G Caps Elx Orl 2.5mg Benadryl JNJ G Elx February 2014 / février 2014 Page 191

204 R06AA02 R06AA09 R06AB R06AB04 R06AE R06AE07 R06AX S01 S01A R06AX13 R06AX17 S01AA S01AA01 DIPHENHYDRAMINE DIPHENHYDRAMINE Tab Orl 25mg Benadryl JNJ G DOXYLAMINE DOXYLAMINE SRT Orl 10mg/10mg Diclectin DUI EF L.L. SUBSTITUTED ALKYL AMINES AMINO-ALKYLES SUBSTITUTES CHLORPHENAMINE CHLORPHÉNAMINE Tab Orl 4mg Novo-Pheniram TEV G Chlor-Tripolon SCO G PIPERAZINE DERIVATIVES DÉRIVÉS DU PIPERAZINE CETIRIZINE CÉTIRIZINE Tab Orl 10mg Reactine JNJ f G Apo-Cetirizine APX f G Extra Strength Allergy Relief PDP f G OTHER ANTIHISTAMINES FOR SYSTEMIC USE DIVERS ANTIHISTAMINIQUES SYSTEMIQUES LORATADINE LORATADINE Tab Orl 10mg Claritin SCO f G Apo-Loratadine APX f G KETOTIFEN KÉTOTIFÉNE Syr Orl 0.2mg Novo-Ketotifen (Disc/non disp Sep 11/15) TEV f EFG Sir Zaditen TEV f EFG Tab Orl 1mg Zaditen TEV f EFG Novo-Ketotifen (Disc/non disp Aug 10/14) TEV f EFG OPHTHALMOLOGICALS AGENTS OPHTHALMOLOGIQUES ANTIINFECTIVES ANTIINFECTIEUX ANTIBIOTICS ANTIBIOTIQUES CHLORAMPHENICOL CHLORAMPHÉNICOL Dps Oph 0.25% Pentamycetin (Disc/non disp Mar 21/14) SDZ AEFGVW Gttes February 2014 / février 2014 Page 192

205 S01AA01 S01AA11 S01AA12 S01AA17 S01AA30 S01AB S01AB04 S01AD S01AD02 CHLORAMPHENICOL CHLORAMPHÉNICOL Dps Oph 0.5% Pentamycetin (Disc/non disp Mar 21/14) SDZ AEFGVW Gttes Ont Oph 1% Pentamycetin (Disc/non disp Mar 21/14) SDZ AEFGVW Ont GENTAMICIN GENTAMICINE Dps Oph 0.3% Garamycin FRS f AEFGVW Gttes Ont Oph 0.3% Sandoz Gentamicin(Disc/non disp Mar21/14) SDZ AEFGVW Ont TOBRAMYCIN TOBRAMYCINE Liq Oph 0.3% Tobrex ALC f AEFGVW Liq pms-tobramycin (Disc/non disp Jun 1/16) PMS f AEFGVW Sandoz Tobramycin SDZ f AEFGVW Ont Oph 0.3% Tobrex ALC AEFGVW Ont ERYTHROMYCIN ÉRYTHROMYCINE Ont Oph 0.5% pms-erythromycin PMS AEFGVW Ont Erythromycin SGQ AEFGVW COMBINATIONS OF DIFFERENT ANTIBIOTICS EN COMBINAISON AVEC DIFFERENTS ANTIBIOTIQUES POLYMYXIN B SULFATE/BACITRACIN ZINC POLYMYXINE B (SULFATE DE)/BACITRACINE Ont Oph 10000IU/500IU Polysporin JNJ G Ont SULFONAMIDES SULFONAMIDES SULFACETAMIDE SULFACETAMIDE Dps Oph 10% Sodium Sulamyd SDZ AEFGVW Gttes ANTIVIRALS ANTIVIRAUX TRIFLURIDINE TRIFLURIDINE Liq Oph 1% Viroptic VLN f AEFGVW Liq Sandoz Trifluridine (Disc/non disp Mar 21/14) SDZ f AEFGVW February 2014 / février 2014 Page 193

206 S01AX S01B S01AX11 S01AX13 S01BA S01BA01 OTHER ANTIINFECTIVES AUTRES ANTIINFECTIEUX OFLOXACIN OFLOXACINE Liq Oph 0.3% Ocuflox ALL f AEFGVW Liq Apo-Ofloxacin APX f AEFGVW pms-ofloxacin (Disc/non disp Jan 8/15) PMS f AEFGVW Sandoz Ofloxacin SDZ f AEFGVW CIPROFLOXACIN CIPROFLOXACINE Liq Oph 0.3% Ciloxan ALC f AEFGVW Liq pms-ciprofloxacin (Disc/non disp Mar 4/15) PMS f AEFGVW Sandoz Ciprofloxacin SDZ f AEFGVW ANTIINFLAMMATORY AGENTS AGENTS ANTIINFLAMMATOIRES CORTICOSTEROIDS, PLAIN CORTICOSTÉROÏDES, ORDINAIRES DEXAMETHASONE DEXAMÉTHASONE Dps Oph 0.1% Maxidex ALC AEFGVW Gttes Ont Oph 0.1% Maxidex ALC AEFGVW Ont S01BA02 S01BA04 HYDROCORTISONE HYDROCORTISONE Ont Oph 2.5% Cortamed (Disc/non disp Mar 21/14) SDZ AEFGVW Ont PREDNISOLONE PREDNISOLONE Liq Oph 0.12% Pred Mild ALL AEFGVW Liq Sus Oph 1% Pred Forte ALL f AEFGVW Susp. ratio-prednisolone RPH f AEFGVW Diopred (Disc/non disp Mar 21/14) SDZ AEFGVW 24 Requests for coverage of Ocuflox (Ofloxacin) will be considered under special authorization. Prescriptions written by ophthalmologists or optometrists do not require special authorization. Les demandes de protection pour le Ocuflox (Ofloxacine) seront examinees sur authorisation spéciale. Les ordonnances des ophtalmologistes ou optometristes ne necessitent pas une authorisation spéciale. 25 Requests for coverage of Ciloxan (Ciprofloxacin) will be considered under special authorization. Prescriptions written by ophthalmologists or optometrists do not require special authorization. Les demandes de protection pour le Ciloxan (ciprofloxacine) seront examinees sur authorisation spéciale. Les ordonnances des ophtalmologistes ou optometrisets ne necessitent pas une authorisation spéciale. February 2014 / février 2014 Page 194

207 S01BA07 S01BC S01C S01BC03 S01BC05 S01CA S01CA01 FLUOROMETHOLONE FLUOROMÉTHOLONE Dps Oph 0.1% FML ALL AEFGVW Gttes pms-fluorometholone PMS AEFGVW Sus Oph 0.25% FML Forte ALL AEFGVW Susp. Sus Oph 0.1% Flarex ALC AEFGVW Susp. ANTIINFLAMMATORY AGENTS, NON STEROIDS AGENTS ANTIINFLAMMATOIRES, NON STEROIDIENS DICLOFENAC DICLOFÉNAC Liq Oph 0.1% Voltaren ALC AEFGVW Liq KETOROLAC KÉTOROLAC Liq Oph 0.5% Acular ALL f AEFGVW Liq Ketorolac AAP f AEFGVW ratio-ketorolac (Disc/non disp Feb 26/15) TEV f AEFGVW ANTIINFLAMMATORY AGENTS & ANTIINFECTIVES IN COMBINATION AGENTS ANTIINFLAMMATOIRES ET ANTIINFECTIEUX EN COMBINAISON CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION CORTICOSTÉROÏDES ET ANTIINFECTIEUX EN COMBINAISON DEXAMETHASONE AND ANTIINFECTIVES DEXAMÉTHASONE ET ANTIINFECTIEUX DEXAMETHASONE / NEOMYCIN / POLYMYXIN B DEXAMÉTHASONE / NÉOMYCINE / POLYMYXINE B Sus Oph 6000IU/3.5mg/1mg Maxitrol ALC AEFGVW Susp. Ont Oph 0.3%/0.1% Tobradex ALC AEFGVW Ont S01CA02 Sus Oph 0.3%/0.1% Tobradex ALC AEFGVW Susp. PREDNISOLONE AND ANTIINFECTIVES PREDNISOLONE ET ANTIINFECTIEUX PREDNISOLONE / SULFACETAMIDE PREDNISOLONE / SULFACÉTAMIDE Dps Oph 10%/0.2% Blephamide ALL AEFGVW Gttes February 2014 / février 2014 Page 195

208 S01E S01CA02 S01EA S01EA03 S01EA05 S01EB S01EB01 PREDNISOLONE AND ANTIINFECTIVES PREDNISOLONE ET ANTIINFECTIEUX PREDNISOLONE / SULFACETAMIDE PREDNISOLONE / SULFACÉTAMIDE Ont Oph 10%/0.2% Blephamide S.O.P ALL AEFGVW Ont ANTIGLAUCOMA PREPARATIONS AND MIOTICS PRÉPARATIONS ANTIGLAUCOME ET MIOTIQUES SYMPATHOMIMETICS IN GLAUCOMA THERAPY ADRENERGIQUES POUR LE TRAITEMENT DU GLAUCOME APRACLONIDINE APRACLONIDINE Liq Oph 0.5% Iopidine ALC AEFVW Liq BRIMONIDINE BRIMONIDINE Liq Oph 0.15% Alphagan P ALL f AEFVW Liq Apo-Brimonidine P APX f AEFVW Liq Oph 0.2% Alphagan ALL f AEFVW Liq ratio-brimonidine TEV f AEFVW pms-brimonidine PMS f AEFVW Apo-Brimonidine APX f AEFVW Sandoz Brimonidine SDZ f AEFVW PARASYMPATHOMIMETICS PARA-ADRENERGIQUES PILOCARPINE PILOCARPINE Dps Oph 1% Isopto Carpine ALC f AEFGVW Gttes Pilocarpine IVX f AEFGVW Dps Oph 2% Isopto Carpine ALC f AEFGVW Gttes Dps Oph 4% Isopto Carpine ALC f AEFGVW Gttes Dps Oph 6% Pilocarpine IVX f AEFGVW Gttes S01EB02 Gel Oph 4% Pilocarpine HS (Disc/non disp Sept. 6/14) ALC AEFGVW Gel CARBACHOL CARBACHOL Liq Oph 1.5% Isopto Carbachol (Disc/non disp Aug 14/14) ALC AEFGVW Liq February 2014 / février 2014 Page 196

209 S01EB02 CARBACHOL CARBACHOL Liq Oph 3% Isopto Carbachol (Disc/non disp Dec 31/14) ALC AEFGVW Liq S01EC S01EC01 S01EC03 S01EC04 S01EC05 S01ED S01ED01 CARBONIC ANHYDRASE INHIBITORS INHIBITEURS DE L'ANHYDRASE CARBONIQUE ACETAZOLAMIDE ACÉTAZOLAMIDE Tab Orl 250mg Acetazolamide AAP f AEFGVW DORZOLAMIDE DORZOLAMIDE Liq Oph 2% Trusopt FRS f AEF18+VW Liq Sandoz Dorzolamide SDZ f AEF18+VW BRINZOLAMIDE BRINZOLAMIDE Liq Oph 1% Azopt ALC AEF18+V Liq METHAZOLAMIDE MÉTHAZOLAMIDE Tab Orl 50mg Methazolamide AAP f AEFGVW BETA BLOCKING AGENTS BETA-BLOQUANTS TIMOLOL TIMOLOL Dps Oph 0.25% Apo-Timop APX f AEFGVW Gttes Sandoz Timolol Maleate SDZ f AEFGVW Mylan-Timolol (Disc/non disp Jun 5/14) MYL f AEFGVW pms-timolol PMS f AEFGVW Dps Oph 0.5% Timoptic Oph FRS f AEFGVW Gttes Apo-Timop APX f AEFGVW Sandoz Timolol Maleate SDZ f AEFGVW Mylan-Timolol (Disc/non disp Jun 5/14) MYL f AEFGVW pms-timolol PMS f AEFGVW Liq Oph 0.25% Timoptic-XE Oph FRS f AEFGVW Liq Timolol Maleate-EX SDZ f AEFGVW Liq Oph 0.5% Timoptic-XE Oph FRS f AEFGVW Liq Timolol Maleate-EX SDZ f AEFGVW Apo-Timop APX f AEFGVW February 2014 / février 2014 Page 197

210 S01ED02 S01ED03 S01ED51 BETAXOLOL BÉTAXOLOL Sus Oph 0.25% Betoptic S ALC AEFVW Susp. LEVOBUNOLOL LÉVOBUNOLOL Liq Oph 0.25% ratio-levobunolol TEV f AEFGVW Liq Liq Oph 0.5% Betagan ALL f AEFGVW Liq ratio-levobunolol TEV f AEFGVW pms-levobunolol PMS f AEFGVW Sandoz Levobunolol SDZ f AEFGVW TIMOLOL COMBINATIONS TIMOLOL EN COMBINAISON TIMOLOL / BRINZOLAMIDE TIMOLOL / BRINZOLAMIDE Sus Oph 0.5%/1% Azarga ALC AEF18+VW Susp. TIMOLOL / DORZOLAMIDE TIMOLOL / DORZOLAMIDE Liq Oph 2%/0.5% Cosopt FRS f AEFVW Liq Apo-Dorzo-Timop APX f AEFVW Sandoz Dorzolamide/Timolol SDZ f AEFVW Teva-Dorzotimol TEV f AEFVW Co-Dorzotimolol COB f AEFVW TIMOLOL / LATANOPROST TIMOLOL / LATANOPROST Liq Oph 0.005%/0.5% Xalacom PFI f AEFGVW Liq GD-Latanoprost/Timolol GMD f AEFGVW Sandoz Latanoprost/Timolol SDZ f AEFGVW TIMOLOL / BRIMONIDINE TIMOLOL / BRIMONIDINE Liq Oph 0.5%/0.2% Combigan ALL AEFGVW Liq TIMOLOL / TRAVOPROST TIMOLOL / TRAVOPROST Liq Oph 0.5%/0.004% Duo Trav ALC AEFVW Liq February 2014 / février 2014 Page 198

211 S01EE S01F S01FA S01G S01EE01 S01EE03 S01EE04 S01FA01 S01FA04 S01FA05 S01GX S01GX01 PROSTAGLANDIN ANALOGUES ANALOGUES DE LA PROSTAGLANDINE LATANOPROST LATANOPROST Liq Oph 0.005% Xalatan PFI f AEFGVW Liq Co Latanoprost COB f AEFGVW Apo-Latanoprost APX f AEFGVW GD-Latanoprost GMD f AEFGVW Sandoz Latanoprost SDZ f AEFGVW BIMATOPROST BIMATOPROST Liq Oph 0.01% Lumigan RC ALL AEFGVW Liq TRAVOPROST TRAVOPROST Liq Oph 0.004% Travatan Z ALC AEFGVW Liq MYDRIATICS AND CYCLOPLEGICS MYDRIATIQUES ET CYCLOPLEGIQUES ANTICHOLINERGICS ANTICHOLINERGIQUES ATROPINE ATROPINE Dps Oph 1% Isopto Atropine ALC AEFGVW Gttes CYCLOPENTOLATE CYCLOPENTOLATE Liq Oph 1% Cyclogyl ALC AEFGVW Liq HOMATROPINE HOMATROPINE Liq Oph 2% Isopto Homatropine ALC AEFGVW Liq Liq Oph 5% Isopto Homatropine ALC AEFGVW Liq DECONGESTANTS AND ANTIALLERGICS DÉCONGESTIONNANTS ET ANTIALLERGIQUES OTHER ANTIALLERGICS AUTRES ANTIALLERGIQUES CROMOGLICIC ACID ACIDE CROMOGLICIQUE Liq Oph 2% Cromolyn Ophthalmic Solution PDP f AEFGVW Liq Opticrom ALL f AEFGVW February 2014 / février 2014 Page 199

212 S01X S01GX09 S01XA S02 S02A S01XA03 S02AA S02C S02AA14 S02AA30 S02CA S02CA02 OLOPATADINE OLOPATADINE Liq Oph 0.2% Pataday ALC AEFGVW Liq OTHER OPTHALMOLOGICALS AUTRES OPTHALMOLOGIQUES OTHER OPTHALMOLOGICALS AUTRES OPTHALMOLOGIQUES SODIUM CHLORIDE, HYPERTONIC CHLORURE DE SODIUM, HYPERTONIQUE Dps Oph 5% Muro BSH f AEFGVW Gttes Ont Oph 5% Muro BSH AEFGVW Ont OTOLOGICALS AGENTS OTOLOGIQUES ANTIINFECTIVES ANTIINFECTIEUX ANTIINFECTIVES ANTIINFECTIEUX GENTAMICIN GENTAMICINE Dps Ot 0.3% Garamycin FRS f AEFGVW Gttes Sandoz Gentamicin SDZ f AEFGVW ANTIINFECTIVES, COMBINATIONS ANTIINFECTIEUX, EN COMBINAISON ALUMINUM ACETATE/BENZETHONIUM CHLORIDE ACÉTATE D'ALUMINIUM/CHLORURE DE BENZÉTHONIUM Liq Ot 0.5%/0.03% Buro-Sol Otic TCD AEFGVW Liq CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION CORTICOSTÉROÏDES ET ANTIINFECTIEUX EN COMBINAISON CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION CORTICOSTÉROÏDES ET ANTIINFECTIEUX EN COMBINAISON FLUMETASONE AND ANTIINFECTIVES FLUMETASONE ET ANTIINFECTIEUX FLUMETASONE / CLIOQUINOL FLUMÉTASONE / CLIOQUINOL Dps Ot 1%/0.02% Locacorten-Vioform PAL AEFGVW Gttes February 2014 / février 2014 Page 200

213 S03 S03C S02CA03 S03CA S03CA01 S03CA04 HYDROCORTISONE AND ANTIINFECTIVES HYDROCORTISONE ET ANTIINFECTIEUX HYDROCORTISONE / NEOMYCIN / POLYMYXIN B HYDROCORTISONE / NÉOMYCINE / POLYMYXIN B Liq Ot 10000unit/10mg/3.5mg Sandoz Cortimyxin SDZ f AEFGVW Liq (Disc/non disp Mar 27/15) Cortisporin (Disc/non disp Dec 10/14) GSK f AEFGVW OPHTHALMOLOGICAL AND OTOLOGICAL PREPARATIONS PRÉPARATIONS OPHTHALMOLOGIQUES ET OTOLOGIQUES CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION CORTICOSTÉROÏDES ET ANTIINFECTIEUX EN COMBINAISON CORTICOSTEROIDS AND ANTIINFECTIVES IN COMBINATION CORTICOSTÉROÏDES ET ANTIINFECTIEUX EN COMBINAISON DEXAMETHASONE AND ANTIINFECTIVES DEXAMÉTHASONE ET ANTIINFECTIEUX DEXAMETHASONE / FRAMYCETIN / GRAMICIDIN DEXAMÉTHASONE / FRAMYCÉTINE / GRAMICIDINE Dps Oph 5mg/0.5mg/0.05mg Sofracort E/E SAV f AEFGV Gttes Sandoz Opticort (Disc/non disp Mar 21/14) SDZ f AEFGV HYDROCORTISONE AND ANTIINFECTIVES HYDROCORTISONE ET ANTIINFECTIEUX HYDROCORTISONE / CHLORAMPHENICOL HYDROCORTISONE / CHLORAMPHÉNICOL Ont Oph 1%/1% Pentamycetin/HC(Disc/non disp Mar 21/14) SDZ AEFGVW Ont Sus Oph 0.2%/1% Pentamycetin/HC(Disc/non disp Mar 21/14) SDZ AEFGVW Susp. V01 V01A S03CA06 V01AA V01AA20 BETAMETHASONE AND ANTIINFECTIVES BÉTAMÉTHASONE ET ANTIINFECTIEUX BETAMETHASONE / GENTAMICIN BÉTAMÉTHASONE / GENTAMICINE Liq Oph 0.3%/0.1% Garasone FRS f AEFGVW Liq Sandoz Pentasone SDZ f AEFGVW ALLERGENS ALLERGENES ALLERGENS ALLERGENES ALLERGEN EXTRACTS EXTRAITS D'ALLERGENES VARIOUS ALLERGEN EXTRACTS DIVERS EXTRAITS D'ALLERGENE Liq Inj Allergy Sera * HJM EF-18G Liq February 2014 / février 2014 Page 201

214 V03 V03A V03AC V03AE V03AF V03AC01 V03AE01 V03AF03 V03AG V03AG99 ALL OTHER THERAPEUTIC PRODUCTS TOUS LES AUTRES PRODUITS THERAPEUTIQUES ALL OTHER THERAPEUTIC PRODUCTS TOUS LES AUTRES PRODUITS THERAPEUTIQUES IRON CHELATING AGENTS AGENTS CHÉLATEURS DE FER DEFEROXAMINE DÉFÉROXAMINE Pws Inj 2g Desferal * NVR f AEFGVW Pds. pms-deferoxamine * PMS f AEFGVW Deferoxamine Mesilate * HOS f AEFGVW Pws Inj 500mg Desferal * NVR f AEFGVW Pds. pms-deferoxamine * PMS f AEFGVW Deferoxamine Mesilate * HOS f AEFGVW FOR TREATMENT OF HYPERKALEMIA AND HYPERPHOSPHATEMIA POUR LE TRAITEMENT DE HYPERKALEMIA ET HYPERPHOSPHATEMIA POLYSTYRENE SULPHONATE POLYSTYRÉNE SULPHONATE Pws Inj 100% pms-sodium Polystyrene PMS f AEFGVW Pds. Kayexalate SAV f AEFGVW Sus Orl 250mg Solystat PDP W Susp. DETOXIFYING AGENTS FOR ANTINEOPLASTIC TREATMENT AGENTS DÉTOXIFIANTS POUR TRAITEMENT ANTINÉOPLASIQUE CALCIUM FOLINATE FOLINATE DE CALCIUM Tab Orl 5mg Leucovorin Calcium PFI AEFGVW DRUGS FOR TREATMENT OF HYPERCALCEMIA MÉDICAMENTS POUR LE TRAITEMENT DE L' HYPERCALCEMIE DRUGS FOR TREATMENT OF HYPERCALCEMIA MÉDICAMENTS POUR LE TRAITEMENT DE L' HYPERCALCEMIE SODIUM ACID PHOSPHATE / SODIUM BICARBONATE / POTASSIUM PHOSPHATE ACIDE DE SODIUM / SODIUM (BICARBONATE DE) / POTASSIUM Evt Orl 356mg/350mg/315mg Phosphate Novartis NVR G Eff. February 2014 / février 2014 Page 202

215 V07 V07A V07AY V07AY90 ALL OTHER NON-THERAPEUTIC PRODUCTS TOUS LES AUTRES PRODUITS NON THERAPEUTIQUES ALL OTHER NON-THERAPEUTIC PRODUCTS TOUS LES AUTRES PRODUITS NON THERAPEUTIQUES OTHER NON-THERAPEUTIC AUXILLIARY PRODUCTS AUTRES PRODUITS AUXILIAIRES NON THERAPEUTIQUES PLACEBO PLACEBO Cap Orl 100mg Placebo ODN AEFGVW Caps February 2014 / février 2014 Page 203

216 APPENDIX I-A / ANNEXE I-A ABBREVIATIONS OF DOSAGE FORMS / ABRÉVIATIONS DES FORMES POSOLOGIQUES FORM CODE FORME Metered-Dose Aerosol AEM/AÉM. Aérosol-dose mesurée Aerosol (with propellants) AER/AÉR. Aérosol (avec agents de propulsion) Aerosol (without propellants) ASP Aérosol (sans agents de propulsion) Blood Collection BCL Sang prélevé Biscuit BIS Biscuit Bulk BLK/VRC En vrac Capsule CAP/CAPS Capsule Chewable Tablets TABC/CO.C. Comprimés à croquer Controlled Delivery Capsules CDC/CAPS.L.C. Capsules à libération contrôlée Cigarette CIG Cigarette Cleanser CLR/NET Nettoyant Cement CMT Ciment Condom CON Condom Cream CRM/CR. Crème Cartridge CTG/CART Cartouche Cube CUB Cube Douche DCH Douche Delayed Action (Injectables) DLA Soluté injectable-retard Drop DPS/GTTES Gouttes Dressing DRE Pansement Enteric Coated Capsule ECC/CAPS.ENT Capsule entérique Each ECH/CH Chacun Enteric Coated Granule ECP Granule entérique Enteric Coated Tablet ECT/CO.ENT. Comprimés entérique Elixir ELX/ÉLIXIR Élixir Emulsion EML/ÉMULS Émulsion Enema ENM/LAV. Lavement Extended Release Capsules ERC/CAPS.L.P. Capsules à libération prolongée Extended Release Tablets ERT/CO.L.P. Comprimés à libération prolongée Effervescent Granule EVG/GEV Granule effervescente February 2014 A - 1

217 APPENDIX I-A / ANNEXE I-A ABBREVIATIONS OF DOSAGE FORMS / ABRÉVIATIONS DES FORMES POSOLOGIQUES FORM CODE FORME Effervescent Powder EVP/PEV Poudre effervescente Effervescent Tablet EVT/CO.EFF. Comprimé effervescent Feed Mix FMX/MÉLF Mélange de fourrage Gas GAS Gaz Jelly GEL Gelée Graft GRT Greffon ` Gum GUM/GOM Gomme Hypodermic Tablet HYT/CO.HYP. Comprimé hypodermique Implant IMP Implant Insert INS Pièce à insérer Jam JAM Confiture Kit KIT Trousse Leaf LEF Feuille Liniment LIN Liniment Liquid LIQ Liquide Lente Suspension LLA/SUSP. Suspension Lotion LOT Lotion Lozenge LOZ Tablette Lubricant LUB Lubrifiant Miscellaneous MIS Divers Mist, Aerosol MST/BAÉR Bruine en aérosol Mouthwash MWH/R.-B. Gargarisme, rnce-bouche, élizir dentifrice Needle NDL/AIG Aiguille Orally Disintegrating Tablet ODT Comprimés à désintégration orale Ointment ONT Onguent, pommade Ostomy OST Ostomie Pad PAD/GAZE Compresse Paper PAP Papier Placebo PCB Placebo Package PCK/EMB. Paquet, emballage February 2014 A - 2

218 APPENDIX I-A / ANNEXE I-A ABBREVIATIONS OF DOSAGE FORMS / ABRÉVIATIONS DES FORMES POSOLOGIQUES FORM CODE FORME Pencil PEN Crayon Plaster PLS Emplâtre Poultice PLT/CAT Cataplasme Paint PNT Badigeon Paste PST Pâte Patch PTH Timbre cutané Powder PWR/PD. Poudre Powder For Solution PWS/PDS. Poudre pour solution Sequential SEQ Séquentiel (le) Shampoo SHP Shampooing Semi-Lente Suspension SLA Suspension semi-lente Sublingual Tablet SLT/CO.S.L. Comprimé sublingual Soap (Bar, Cake) SOP/SAVON Savon (Pain) Sponge SPG Éponge Spray SPR/VAPO Vaporisateur Sustained-Released Capsule SRC/CAPS.L.L. Capsule à liberation lente Sustained-Release Disc SRD Disque à action soutenue Sustained-Release Syrup SRS Sirop à action soutenue Sustained-Release Tablet SRT/CO.L.L. Comprimé à liberation lente Stick STK Bâton Strip STP Bande, plaque, plaquette Suppository SUP/SUPP. Suppositoire Suspension SUS/SUSP. Suspension Suture SUT Suture Swab SWB/TMP Tampon Syrup SYR/SIR. Sirop Tablet TAB/CO. Comprimé Tape TAP/RUBAN Sparadrap, diachylon Tincture TCT Teinture Teat Dilator TDL/DIL Dilatateur de trayon February 2014 A - 3

219 APPENDIX I-A / ANNEXE I-A ABBREVIATIONS OF DOSAGE FORMS / ABRÉVIATIONS DES FORMES POSOLOGIQUES FORM CODE FORME Top Dressing (VET) TDR/PAN Pansement (vét.) Herbal Tea TEA/TIS Tisane Tampon TMP Tampon Tooth Powder TPR Poudre dentifrice Tooth Paste TPT Pâte dentifrice Ultra-Lente Suspension ULA Suspension ultra-lente Wafer WAF Cachet Wire WIR Fil February 2014 A - 4

220 APPENDIX I-B / ANNEXE I-B ABBREVIATIONS OF ROUTES / ABRÉVIATIONS DES VOIES D'AMINISTRATION ROUTE CODE VOIE Block or Infiltration BIN Infiltration Barn BRN/ÉTA Étable Buccal BUC Buccale, orale Caudal Block CAU Anesthésie caudale Dental DEN Dentaire Dialysis DIS Dialyse Epidural EPD Épidural Disinfectant (Food Premises) HOM Désinfectant (locaux alimentaires) Hospital Disinfectant (Area) HOS Désinfectant de locaux hospitaliers Intra Articular IA Intra-articulaire Intra Amniotic IAM Intra-amniotique Intrabursal IBU Intrabursique Intracardiac ICD Intracardiaque Intracranial ICR Intracrânienne Intracavity ICV Intra-cavitaire Intradermal ID Intradermique Intra-Mammary (INF) IMM Intra-mammaire (bébé) Intervertebral IND Intervertébrale Intrafollicular INF Intra-folliculaire Inhalation INH Inhalation Injectable INJ Injectable Instrument(s) INS Instrument(s) Intrathecal INT Intra-thécale Intraocular IO Intraoculaire Intraperitoneal IP Intrapéritonéale Intrapleural IPL Intrapleurale Intrapulmonary IPU Intrapulmonaire Irrigation IR Irrigation Intrasinal ISI Intra-sinusiennne, intra-sinusale Instillation ISL Instillation February 2014 A - 5

221 APPENDIX I-B / ANNEXE I-B ABBREVIATIONS OF ROUTES / ABRÉVIATIONS DES VOIES D'AMINISTRATION ROUTE CODE VOIE Intrasynovial ISY Intra-synoviale Intrathoracic IT Intrathoracique Intubing ITB Intubation Intratracheal ITR Intratrachéal(e) Intratesticular ITS Intratesticulaire Intravesicular ITV Intra-vésiculaire Intrauterine IU Intra-utérin(e) Intraventicular IVR Intraventriculaire Laboratory Test LAB Essai, analyse de laboratoire Miscellaneous MIS Divers Nasal NAS Nasale Nil NIL Néant Ophthalmic OPH Ophtalmique Oral ORL Orale Otic OT Otique Periosteal PRS Périostale Parenteral (Unspecified) PRT Parentérale (non spécifiée) Retrobulbar RB Rétrobulbaire Refer (See Dosage Form) REF Voir forme posologique Rectal RT Rectale Subarachnoidal SAR Sous-arachnoïdienne Sublingual SLG Sublinguale Surgical SUR Chirurgicale Topical TOP Topique Transdermal TRD Transdermique Urethral URH Urétrale Vaginal VAG Vaginale February 2014 A - 6

222 APPENDIX I-C / ANNEXE I-C ABBREVIATIONS OF UNITS / ABRÉVIATIONS DES UNITÉS DE MESURE UNIT CODE UNITE Ampoule AMP Ampoule Billion B Milliard Bottle BOTTL Flacon, bouteille Box BOX Boîte Centesimal Scale C Échelle centésimale Can CAN Boîte métallique Capsule CAP Capsule Cubic Centimetre CC Centimètre cube Dilution - 1/10 Centesimal Scale CH Dilution - 1/10 échelle centésimale Centimetre CM Centimètre Decimal Scale D/M Échelle métrique Disk DISC Disque Dessert Spoon DSP Cuillerée à dessert Fluid Dram FL DR Drachme liquide Fluid Ounce FL OZ Once liquide Gallon GAL Gallon Gram GM Gramme Grain GR Grain Kilogram KG Kilogramme Kit KIT Trousse Litre L Litre Pound LB Livre Limit Flocculation Unit LF Dose LF ou LF Lozenge LOZ Pastille Million M Million Millicurie MC Millicurie Microcurie MCC Microcurie Microgram MCG Microgramme Milliequivalent MEQ Milliéquivalent Milligram MG Milligramme Minim, Drop MIN Goutte February 2014 A - 7

223 APPENDIX I-C / ANNEXE I-C ABBREVIATIONS OF UNITS / ABRÉVIATIONS DES UNITÉS DE MESURE Millitre UNIT CODE UNITE ML Millilitre Millimole MMO Millimole Nil NIL Néant Nanokat NKAT Nanokat Non-standard NS Non normalisé Ounce OZ Once Package PCK Paquet, emballage Percentage % Pourcentage Piece PIECE Pièce Quantity Sufficient QS En quantité suffisante Strip STRIP Bande Square Centimetre SQ CM Centimètre carré Square Inch SQ IN Pouce carré Syringe SYR Seringue Tablet TAB Comprimé Tablespoon TBS Cuillerée à soupe Mother-Tincture TM Teinture-mère Trace TRACE Trace Turbidity Reducing Unit TRU Unité de réduction de la turbidité Teaspoon TSP Cuillerée à thé Tuberculin Unit TUB Unité de tuberculine Tube TUBE Tube International Unit UNIT Unité internationale Protein Nitrogen Unit (PNU) UNIT Unité d'azote protéique TCID 50 Unit UNIT Dict 50 Unit (General Unspecified) UNIT Unité (en général, non précisée) Vial VIAL Fiole Homeopathic Unit X Unité homéopathique February 2014 A - 8

224 APPENDIX I-D / ANNEXE I-D ABBREVIATIONS OF MANUFACTURER'S NAMES/ABRÉVIATIONS DES NOMS DE FABRICANTS AAP ABB AGA AHI AJP ALC ALL APX ARO ASL ATL AVE AXC AXS AZE BAX BAY BCH BIF BIG BOE BRI BSH CDX CHU CLC COB CYI DCL DPT DUI EMD ERF EUR FEI FRS GAC GCH GIL GLE GMD GMP GNC GND GSK HAL HHC HJM HLR HOS INP IVX JAM JAN JCB JNJ JPC KNG KRI LBK LEO LIL MAR AA Pharma Inc. Abbott Laboratories, Ltd. Amgen Canada Inc. Accord Healthcare Inc. Agila-Jamp Canada Inc. Alcon Canada Inc. Allergan Inc. Apotex Inc. Auro Pharma Inc. Astellas Pharma Canada Inc. Laboratoire Atlas Inc. Aventis Pharma Inc. Aptalis Axxess Pharma Inc. Astra Zeneca Pharma Baxter Corporation Bayer Inc., HealthCare Division Bioniche Inc. Bioforce Canada Ltd/Ltee. Biogen Idec Canada, Inc. Boehringer Ingelheim (Canada) Ltd. Bristol-Myers Squibb Canada Inc. Baush & Lomb Canada Inc. Canderm Pharma Inc. Church and Dwight Canada Corp. Columbia Laboratories Canada Inc. Cobalt Pharmaceuticals Company Cytex Pharmaceuticals Inc. D.C. Labs Limited Dermtek Pharmaceuticals Ltd Duchesnay EMD Serono Canada Inc. Erfa Canada Inc. Europharm International Canada Inc. Ferring Inc. Merck Canada Inc. Galderma Canada Inc. GlaxoSmithKline Consumer Healthcare Inc. Gilead Sciences Inc. Glenwood Laboratories Canada Ltd. GenMed, a division of Pfizer Canada Inc. Generic Medical Partners General Nutrition Canada Inc. Golden Neo-Life Diamite International Lt GlaxoSmithKline Hall Laboratories Ltd. Holista Health Corporation Medavie Blue Cross Hoffmann-La Roche Ltd/Ltee. Hospira Healthcare Corporation Insight Pharmaceuticals Corp. Ivax Pharmaceuticals Canada Inc. Jamieson Laboratories Ltd. Janssen Inc. Jacobus Pharmaceutical Company Inc. Johnson & Johnson Consumer Group Jamp Pharma Corporation King Pharmaceuticals Canada Kripps Pharmacy Ltd Lundbeck Inc. Leo Pharma Inc. Eli Lilly Canada Inc. Marcan Pharmaceuticals Inc MDI MDS MED MEL MJO MLA MNT MRS MTP MVL MYL NEO NGP NNC NNO NOP NSE NUM NVO NVR NYC ODN OMG PAL PAT PDL PDP PFI PFR PHL PMS PMT PPC PVR QGT RAN RHG RIK ROG RPH SAS SAV SCH SCO SDZ SEP SEV SHI SIV SNE SNS SNV SPH SPT STR SWS TAR TCD TCH TEV Medtech Products Inc. Medicis Canada LTD./LTEE. Medican Pharma Inc. Meliapharm Inc. Mead Johnson Canada Proctor & Gamble Healthcare Mint Pharmaceuticals Inc. Merus Labs Inc. Methapharm Inc. Meda Valeant Pharma Canada Inc. Mylan Pharmaceuticals ULC Neo Lab Inc. Next Generation Pharma Inc. Novartis Consumer Health Canada Inc. Novo Nordisk Canada Inc. Novopharm Ltd. Nutri Souce Inc Les Aliments Canada Inc. Novartis Ophthalmics Novartis Pharmaceuticals Canada Inc. Nycomed Canada Inc. Odan Laboratories Ltd. Omega Laboratories Limited Paladin Labs Inc. Pathogenesis Canada Ltd Pro Doc Laboratories Ltd PendoPharm, a Division of Pharmascience Inc. Pfizer Canada Inc. Purdue Pharma Pharmel Inc (Div of PMS/Price D.Shipp) Pharmascience Inc. Pharmetics Inc. Pharmaceutical Partners of Canada Pharmavite Corporation Sigma-Tau Ranbaxy Pharmaceuticals Canada Inc. Rheningold Food International Ltd. 3M Pharmaceuticals Rougier Pharma Inc, Div of Ratiopharm Ratiopharm Inc. Sanis Health Inc. Sanofi-Aventis Canada Inc. Schering-Plough Canada Inc. Schering-Plough (Canada) Inc. Sandoz Canada Incorporated Sepracor Pharmaceuticals Inc. Servier Canada Inc. Shire Canada Inc. Sivem Pharmaceuticals Smith & Nephew, Inc. Sanofi-Synthelabo Canada Inc. Sunovion Pharmaceuticals Canada Inc Solvay Pharma Inc. Septa Pharmaceuticals Inc. Sterimax Inc. Swiss Herbal Remedies Ltd Taro Pharmaceuticals Inc. Trans Canaderm Inc. Technilab, Inc. Teva Canada Limited February 2014 A - 9

225 APPENDIX I-D / ANNEXE I-D ABBREVIATIONS OF MANUFACTURER'S NAMES/ABRÉVIATIONS DES NOMS DE FABRICANTS TPH TRB TRI UCB VAL VIV VLH VLN TaroPharma, Divison of Taro Pharmaceuticals Tribute Pharmaceuticals Triton Pharma Inc. UCB Canada Inc. Valeo Pharma Inc. ViiV Healthcare ULC Lundbeck Canada Inc. Valeant Canada Ltd. VTH WAM WCH WLS WNC XPI YNO ZYM Vita Health Company (1985) Ltd Wampole Brands Wyeth Consumer Healthcare Inc. Wellspring Pharmaceutical Cananda Corp. Warner Chilcott Canada Xediton Pharmaceuticals Inc. Bayer Inc. Consumer Care Division Zymcan Pharmaceuticals Inc. February 2014 A - 10

226 APPENDIX II Placebos Placebos, when prescribed as substitutes for benefit products, are normally payable under these programs. This applies particularly to the extemporaneous substitution of inert substances for active ingredients for therapeutic purposes, for example the content of capsules, without the patient's knowledge. In such cases, the pharmacist's claim is to be based on the original product. When a lower-priced manufactured product is substituted which does not require special preparation, the lowerpriced drug becomes the basis for the pharmacist's claim. No claim may be made if the purpose of a prescription is obviously to substitute a dosage or formulation which is not itself covered by the program; such formulations cannot properly be called placebos. Claims for placebos must be submitted for reimbursement on the Special Claim Form using the DIN "999008". The Program also requires the name, quantity and strength of all the ingredients used in the preparation of each placebo. February 2014 A - 11

227 APPENDIX III Extemporaneous Preparations Extemporaneous preparations are defined as a drug or mixture of drugs prepared or compounded in a pharmacy according to the order of a prescriber. To be eligible as a benefit, extemporaneous preparations must be in the list below or: 1. be specifically tailored to a physician's prescription and 2. contain one or more drugs presently considered a benefit and 3. not duplicate the formulation of a manufactured drug product and 4. not contain drugs in the exclusion list Claims for Extemporaneous Preparations listed below are to be submitted electronically using the PIN assigned to the product. Claims for Extemporaneous Preparations not listed below are to be submitted electronically using the DIN of at least one ingredient which is a program benefit. This claim must be identified by entering the appropriate CPhA version 3 code. Note: When there is a shortage or no supply of a commercially available product and the healthcare professional has determined a medical need for this product, the product may be compounded during the period of shortage or no supply only. (Health Products and Food Branch Inspectorate Policy on Manufacturing and Compounding Drug Products in Canada) Regular Benefits Product Name PIN Plans Anthralin Ointment 0.4% AEFGV Anthralin Soft Paste 0.05% AEFGV Anthralin Soft Paste 0.1% AEFGV Anthralin Soft Paste 0.2% AEFGV Anthralin Weak Ointment 0.2% AEFGV Disulfiram powder AEFG Hydrochlorothiazide powders and suspensions for oral use * AEFGV Hydrocortisone powder for topical applications >0.5% * AEFGV LCD (Coal Tar Solution) in compounds for topical applications * AEFGV Meclizine Powder AEFGV Prednisone powders and suspension for oral use * AEFGV Progesterone powder in compounds for topical application * AEFGV Propylene Glycol Liquid in compounds for topical applications * ABEFGV Salicylic Acid in compounds for topical applications * AEFGV Saturated Solution Potassium Iodide * AEFGV Spironolactone powders and suspensions for oral use * AEFGV Sulphur in compounds for topical applications * AEFGV * This PIN must be used to submit claims for any strength of this extemporaneous preparation. February 2014 A - 12

228 APPENDIX IV Special Authorization Certain drugs are only eligible for coverage under New Brunswick Prescription Drug Program (NBPDP) through special authorization. The criteria are developed by the Atlantic and Canadian Expert Advisory Committees. Drugs eligible for consideration through special authorization: Drugs listed as special authorization benefits have specific criteria which must be met in order to be approved. These drugs are listed alphabetically by generic name in the following section. Under exceptional circumstances, requests for drugs without specific criteria may be reviewed case-by-case and assessed based on the published medical evidence. Drugs not eligible for consideration through special authorization: New drugs not yet reviewed by the expert advisory committee Drugs excluded as eligible benefits further to the expert advisory committee s review and recommendation Drugs not licensed or marketed in Canada (e.g. drugs obtained through Health Canada s Special Access Program) Products specifically excluded as benefits as identified on the exclusion list (Formulary pages IV and V). Reimbursement of brand name products when generics exist When interchangeable generic products are available for a brand name drug, the New Brunswick Prescription Drug Program (NBPDP) will only reimburse pharmacies for the lowest cost generic product. Beneficiaries, who choose to receive a brand name product when a generic product exists, are responsible for paying any difference in price. The NBPDP will consider requests for reimbursement of brand name drugs when a beneficiary has had a hypersensitivity reaction (e.g. edema, respiratory distress, serum sickness, anaphylaxis) to a non-medicinal ingredient contained in the interchangeable generic product. Requests may be made by submitting a completed Special Authorization Request Form and providing details of the hypersensitivity reaction. Information on the safety and effectiveness of generic drugs is available on Health Canada s website at February 2014 A - 13

229 Special authorization requests must be submitted in writing by the prescriber and include the following information: Patient Identification Name of patient NB Medicare number Date of birth Prescriber Identification Name, address, telephone number and FAX number (if applicable) of prescriber Drug Requested Drug name, strength and dosage form Dosage schedule Expected duration of therapy Reason for the Request Diagnosis and/or indication for which the drug is being used Information regarding previous drugs which have been used and the patient s response to therapy where appropriate Any additional information that may assist in making a decision on the request for special authorization. Special authorization requests for beneficiaries of Plans A,B,E,F,G,R,V should be sent by mail or FAX to: Special Authorization Unit New Brunswick Prescription Drug Program P.O. Box 690 Moncton, NB E1C 8M7 Local Fax: Toll Free Fax: NBPDP Inquiry Line: Plan U (HIV - Infected Persons) special authorization requests should be sent by mail or FAX to: Special Authorization Unit Plan U New Brunswick Prescription Drug Program P.O. Box 690 Moncton, NB E1C 8M7 Local fax: Toll Free Fax: Toll Free Telephone: February 2014 A - 14

230 New Brunswick Prescription Drug Program Special Authorization Criteria ABATACEPT (ORENCIA) 250mg vial for intravenous injection For the treatment of Juvenile Rheumatoid Arthritis: o In children (age 6-17) with moderate to severe active polyarticular juvenile idiopathic arthritis/juvenile rheumatoid arthritis who are intolerant to, or who have not had an adequate response from etanercept. o Initial treatment is limited to a maximum of 16 weeks. Retreatment is permitted for children who demonstrated an adequate initial treatment response and who are experiencing a disease flare. o Must be prescribed by a rheumatologist. For patients with moderate to severe active rheumatoid arthritis who: o Have not responded to, or have had intolerable side-effects with, an adequate trial of combination therapy of at least two traditional DMARDs (disease modifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR o Are not candidates for combination DMARD therapy, must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated, AND o Have had an adequate trial of leflunomide unless it is contraindicated or not tolerated. o Must be prescribed by a rheumatologist. Abatacept should not be used in combination with anti-tnf agents or other TNF antagonists. ABIRATERONE (ZYTIGA) 250mg tablets For the treatment of metastatic castration-resistant prostate cancer in patients who have received prior chemotherapy containing docetaxel and who have an ECOG performance status of 0-2*. * Patients who are asymptomatic and those who are symptomatic and in bed less than 50% of the time. ACAMPROSATE CALCIUM (CAMPRAL) 333mg tablets For the maintenance of abstinence from alcohol in patients with alcohol dependence who have been abstinent for at least four days, and who have contraindications to naltrexone (e.g. currently receiving opioids, acute hepatitis or liver failure). Treatment with acamprosate should be part of a comprehensive management plan that includes counseling. ACARBOSE (GLUCOBAY) 50mg and 100mg tablets For non-insulin-dependent diabetes mellitus (NIDDM) patients failing or having contraindications to sulphonylurea and/or biguanide oral hypoglycemics after a reasonable attempt at diet and exercise therapy. ADALIMUMAB (HUMIRA) 40mg/0.8mL (50mg/mL) injection Ankylosing Spondylitis For the treatment of patients with moderate to severe ankylosing spondylitis (e.g. Bath AS Disease Activity Index (BASDAI) score 4 on 10 point scale) who: o Have axial symptoms* and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation or in whom NSAIDs are contraindicated OR o Have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate response to an optimal dose or maximal tolerated dose of a DMARD. * Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication to axial disease, do not require a trial of NSAIDs alone. Must be prescribed by a rheumatologist or internist Approval will be for a maximum of 6 months Requests for renewal must include information showing the beneficial effects of the treatment, specifically: o A decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score February 2014 A - 15

231 OR o Patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement (measured by outcomes such as HAQ or ability to return to work ) Approvals will be for a maximum dose of 40mg every two weeks Adalimumab will not be reimbursed in combination with other anti-tnf agents Crohn s Disease For moderately to severely active Crohn's disease in patients who are refractory or have contraindications to an adequate course of 5-aminosalicylic acid and corticosteroids and other immunosuppressive therapy. o Eligible patients should receive an induction dose of 160mg followed by 80mg two weeks later. o Clinical response should be assessed four weeks after the first induction dose. o Initial requests will be approved for a maximum of 12 weeks. o Ongoing coverage for maintenance therapy will only be reimbursed for responders and for a dose not exceeding 40mg every two weeks. Psoriatic Arthritis For the treatment of active psoriatic arthritis in patients who: o Have at least three active and tender joints, and o Have not responded to an adequate trial of two DMARDs or have an intolerance or contraindication to DMARDs. Must be prescribed by a rheumatologist. The number of doses is limited to twenty-six 40 mg doses per year with no dose escalation permitted. Should not be used in combination with other tumor necrosis factor (TNF) antagonists. Rheumatoid Arthritis For patients with moderate to severe active rheumatoid arthritis who: o Have not responded to, or have had intolerable side-effects with, an adequate trial of combination therapy of at least two traditional DMARDs (disease modifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR o Are not candidates for combination DMARD therapy must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated AND o Have had an adequate trial of leflunomide unless it is contraindicated or not tolerated. Must be prescribed by a rheumatologist. The number of doses is limited to twenty-six 40 mg doses per year with no dose escalation permitted. Should not be used in combination with other tumor necrosis factor (TNF) antagonists Plaque Psoriasis Requests will be considered for treatment of patients with severe, debilitating chronic plaque psoriasis who meet all of the following criteria: o Body surface area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or genital region; o Failure to respond to, contraindications to or intolerance to methotrexate and cyclosporine; o Failure to respond to, intolerance to or unable to access phototherapy Initial approval limited to 16 weeks. Continuation of therapy beyond 16 weeks will be based on response. Patients not responding adequately at these time points should have treatment discontinued with no further treatment with the same agent recommended. An adequate response is defined as either: o 75% reduction in the Psoriasis Area and Severity Index (PASI) score from when treatment started (PASI 75), or o 50% reduction in the PASI score (PASI 50) with a 5 point improvement in the Dermatology Life Quality Index (DLQI) from when treatment started, or o A quantitative reduction in BSA affected with qualitative consideration of specific regions such as face, hands, feet, or genital region. Must be prescribed by a dermatologist Concurrent use of >1 biologic will not be approved Approval limited to a dose of 80 mg administered once followed by 40 mg after 1 week of initial dose, then 40 mg every other week thereafter, up to a year (if response criteria met at 16 weeks). February 2014 A - 16

232 ADEFOVIR DIPIVOXIL (HEPSERA) 10mg tablets For the treatment of Hepatitis B when used in combination with lamivudine, in patients who have failed lamivudine, as defined by an increase in HBV DNA of > 1 log 10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when lamivudine failure is not due to poor adherence to therapy. ALENDRONATE (FOSAMAX and generic brand) 40mg tablets For the treatment of Paget s disease. ALENDRONATE (FOSAMAX and generic brands) 10mg and 70mg tablets See criteria under Osteoporosis Drugs. ALENDRONATE/CHOLECALCIFEROL (FOSAVANCE 70/5600 and generic brand) 70mg/ 140 μg tablets 1. For the treatment of osteoporosis: with documented fragility fracture or; without documented fractures in patients at high 10-year fracture risk 2. For prophylaxis of corticosteroid induced osteoporosis in patients who will be or have been on systemic corticosteroid therapy for 3 months. ALGLUCOSIDASE ALFA (MYOZYME) 50mg vial injection For the treatment of infantile-onset Pompe disease, as demonstrated by onset of symptoms and confirmed cardiomyopathy within the first 12 months of life. Monitoring of therapy The monitoring of markers of disease severity and response to treatment must include at least: 1. Weight, length and head circumference. 2. Need for ventilatory assistance, including supplementary oxygen, CPAP, BiPAP, or endotracheal intubation and ventilation. 3. Left ventricular mass index (LVMI) as determined by echocardiography (not ECG alone). 4. Periodic consultation with cardiology. 5. Periodic consultation with respirology. Withdrawal of therapy 1. Patients to be considered for reimbursement of drug costs for alglucosidase alfa treatment must be willing to participate in the long-term evaluation of the efficacy of treatment by periodic medical assessment. Failure to comply with recommended medical assessment and investigations may result in withdrawal of financial support of drug therapy. 2. The development of the need for continuing invasive ventilatory support after the initiation of ERT should be considered a treatment failure. Funding for ERT should not be continued for infants who fail to achieve ventilatorfree status, or who deteriorate further, within 6 months after the initiation of ventilatory support. 3. Deterioration of cardiac function, as shown by failure of LV hypertrophy (as indicated by LV mass index) to regress by more than Z=1 unit, or persistent clinical or echocardiographic findings of cardiac systolic or diastolic failure without evidence of improvement, in spite of 24 weeks of ERT, should be considered a treatment failure and funding for ERT should be discontinued. ALMOTRIPTAN (AXERT and generic brands) 6.25mg and 12.5mg tablets For the treatment of migraine 1 headache of moderate 2 intensity when other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and naratriptan. For the treatment of migraine 1 headache of severe 2 or ultra severe 2 intensity when patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and/or naratriptan. Coverage limited to 6 doses / 30 days 3 February 2014 A - 17

233 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. AMBRISENTAN (VOLIBRIS) 5mg, 10mg tablets For treatment of patients with pulmonary arterial hypertension (PAH), of at least World Health Organization (WHO) functional class III, which is associated with either idiopathic or connective tissue disease and who have failed to respond to or who have contraindications to, or who are not a candidate for sildenafil. Diagnosis of PAH should be confirmed by cardiac catheterization The maximum dose of ambrisentan that will be reimbursed is 10 mg daily Ambrisentan will not be approved when used concurrently with other endothelin receptor antagonists, epoprostenol, treprostinil or sildenafil. AMLODIPINE BESYLATE / ATORVASTATIN (CADUET and generic brands) 5/10mg, 5/20mg, 5/40mg, 5/80mg, 10/10mg, 10/20mg, 10/40mg and 10/80mg tablets For the treatment of patients who have been titrated to a stable combination of the separate components, amlodipine and atorvastatin. If the beneficiary has had a claim for both amlodipine and atorvastatin reimbursed by NBPDP in the previous 6 months, the claim for Caduet will automatically be reimbursed without requiring special authorization. APREPITANT (EMEND) 80 mg and 125 mg capsule; Tri-Pack For the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (e.g. cisplatin >70 mg/m 2 ) in patients who have experienced emesis despite treatment with a combination of a 5-HT 3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy. Note: Prescription claims for up to a maximum of 2 Tri-packs, or 6 capsules will be automatically reimbursed every 28 days when the prescription is written by an oncologist or an oncology clinical associate/general practitionersoncology. If additional medication is required within a 28 day period subsequent to the initial prescription, a request should be made through special authorization. ARIPIPRAZOLE (ABILIFY) 2mg, 5mg, 10mg, 15mg, 20mg, 30mg tablets For the treatment of schizophrenia and related psychotic disorders (not dementia related) in patients with a history of failure, intolerance, or contraindication to at least one less expensive antipsychotic agent. ASENAPINE (SAPHRIS) 5mg, 10mg sublingual tablets 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, and trials of less expensive atypical antipsychotic agents have failed due to intolerance or lack of response Co-therapy with lithium or divalproex sodium, after trials of less expensive atypical antipsychotic agents have failed due to intolerance or lack of response. February 2014 A - 18

234 ATOVAQUONE (MEPRON) 750mg/5mL suspension For the treatment of mild to moderate Pneumocystis Carinii pneumonia in beneficiaries who are intolerant to trimethoprim-sulfamethoxazole. AZITHROMYCIN (ZITHROMAX and generic brands) 600mg tablets For the prevention of disseminated Mycobacterium Avium Complex (MAC) in HIV positive patients who are severely immunocompromised with CD4 levels <0.1 x 10 9 /L. BETAHISTINE (SERC and generic brands) 8mg, 16mg and 24mg tablets For the symptomatic treatment of the recurrent episodes of vertigo associated with Ménière s disease. BOCEPREVIR (VICTRELIS) 200mg capsule For the treatment of patients with chronic hepatitis C genotype 1 infection (HCV RNA positive) in combination with peginterferon alpha and ribavirin if the following criteria are met: Fibrosis stage of F2, F3 or F4 or on recommendation of an Internal Medicine Specialist Patient is not co-infected with HIV One course of treatment only (for up to 44 weeks duration) will be approved. Notes: 1. Response-guided therapy should be considered in patients for whom this is appropriate. 2. Therapy should be discontinued in all patients with HCV RNA levels 100 IU/mL at treatment week 12, or confirmed HCV RNA positive at treatment week 24. BOCEPREVIR/RIBAVIRIN PLUS PEGINTERFERON ALFA-2B (VICTRELIS TRIPLE) 200mg / 200mg capsules plus 80mcg injection 200mg / 200mg capsules plus 100mcg injection 200mg / 200mg capsules plus 120mcg injection 200mg / 200mg capsules plus 150mcg injection For the treatment of patients with chronic hepatitis C genotype 1 infection (HCV RNA positive) if the following criteria are met: Fibrosis stage of F2, F3 or F4 or on recommendation of an Internal Medicine Specialist Patient is not co-infected with HIV One course of treatment only (for up to 44 weeks duration) will be approved. Notes: 1. Response-guided therapy should be considered in patients for whom this is appropriate. 2. Therapy should be discontinued in all patients with HCV RNA levels 100 IU/mL at treatment week 12, or confirmed HCV RNA positive at treatment week 24. BOSENTAN (TRACLEER and generic brands) 62.5mg and 125mg tablets For treatment of pulmonary arterial hypertension (PAH) in patients with World Health Organization (WHO) functional class III or IV idiopathic pulmonary arterial hypertension (IPAH) in patients who do not demonstrate vasoreactivity on testing or who demonstrate vasoreactivity on testing but fail a trial of, or are intolerant to, calcium channel blockers. pulmonary arterial hypertension associated with connective tissue disease or congenital heart disease or human immunodeficiency virus (HIV) who do not respond adequately to conventional therapy. BUDESONIDE/FORMOTEROL (SYMBICORT) 100mcg/6mcg and 200mcg/6mcg metered dose inhaler Reversible obstructive airway disease: For patients with reversible obstructive airways disease who are - Stabilized on an inhaled corticosteroid and a long-acting beta 2-adrenergic agonist, OR February 2014 A - 19

235 - Using optimal doses of inhaled corticosteroids but are still poorly controlled. Chronic Obstructive Pulmonary Disease: For the treatment of chronic obstructive pulmonary disease (COPD) if: o symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day) Coverage can be provided without a trial of short-acting agent if: o there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms i.e. MRC score of 3-5**. Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms i.e., MRC score of 3-5** AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. BUPRENORPHINE / NALOXONE (SUBOXONE) 2 mg/0.5 mg and 8 mg/2 mg sublingual tablets For the treatment of opioid dependence for patients in whom methadone is contraindicated (e.g. patients at high risk of, or with QT prolongation, or hypersensitivity to methadone). Commonly reported adverse effects associated with methadone therapy (eg. sweating, constipation, insomnia, etc.) will not be considered to be hypersensitivity. Requests from New Brunswick physicians authorized to prescribe methadone or physicians with experience in the treatment of opioid dependence will be considered. BUSERELIN ACETATE (SUPREFACT) 1mg/ml nasal solution Approved for the palliative treatment of stage D 2 carcinoma of the prostate (Plan F beneficiaries). CABERGOLINE (DOSTINEX and generic brand) 0.5mg tablets For the treatment of patients with hyperprolactinemia who have failed or are intolerant to bromocriptine CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE (DOVOBET) 50µg/0.5mg/g gel For the treatment of scalp psoriasis after failure of a topical steroid used alone AND failure of a topical steroid used concomitantly with calcipotriol as single agents. CAPECITABINE (XELODA and generic brand) 150mg and 500mg tablets Colorectal Cancer For single agent therapy of colorectal cancer in patients who are chemotherapy naive or patients who have progressed 6 months after completion of adjuvant 5-FU/ leucovorin therapy. Coverage will be limited to: a) Metastatic colorectal cancer, with an ECOG performance status of 0-2*, when first line combination chemotherapy (5-FU/ leucovorin/irinotecan) is declined or not tolerated. b) Stage III (Dukes C) colon cancer and ECOG status 0-1 as adjuvant therapy. As part of the CAPOX (capecitabine-oxaliplatin) regimen for the first-line and second-line treatment of Metastatic Colorectal Cancer (mcrc) for patients with an ECOG performance status of 0-2*. February 2014 A - 20

236 Metastatic Breast Cancer For treatment of metastatic breast cancer where patients have progressed after prior chemotherapy and who have an ECOG performance status of 0-2*. Requests for capecitabine must be prescribed by a specialist in hematology/oncology. Approvals will be granted for up to 6 months at a time. * Patients who are asymptomatic and those who are symptomatic and in bed less than 50% of the time. CARVEDILOL (COREG and generic brands) 3.125mg, 6.25mg, 12.5mg and 25mg tablets For the treatment of stable symptomatic heart failure in patients with a left ventricular ejection fraction (LVEF) less than or equal to 40%. Prescriptions written by cardiologists or internists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. CELECOXIB (CELEBREX) 100mg and 200mg capsules For the treatment of osteoarthritis and rheumatoid arthritis in patients who have at least one of the following risk factors: Past history of ulcers Concurrent warfarin therapy Concurrent prednisone therapy Failure or intolerance to at least two other NSAIDs (e.g. ibuprofen, diclofenac, naproxen) Recommended maximum daily doses: 200mg for osteoarthritis 400mg for rheumatoid arthritis Note: Celecoxib is a regular benefit for beneficiaries age 65 and over. February 2014 A - 21

237 CHOLINESTERASE INHIBITORS (Donepezil, Galantamine, Rivastigmine) - For the treatment of mild to moderate Alzheimer s disease To initiate therapy: Requests must be submitted on the appropriate NBPDP special authorization form. For a patient being started on a first cholinesterase inhibitor (ChEI): For a patient who has previously taken no more than one other ChEI and is switching: Patients who meet all of the following reimbursement criteria will be approved for an initial 6 months of therapy: a diagnosis of probable Alzheimer s disease or possible Alzheimer s disease with vascular component or Lewy bodies; a Mini Mental Score Exam (MMSE) score of 10 to 30; and a Functional Assessment & Staging Test (FAST) score of 4 to 5 Patients will be approved for an initial 6 months of therapy with a second ChEI when the following information is provided: the reason for discontinuing the first ChEI Requests to switch from one agent in the class to another will not be considered beyond the initial 6 month approval. To continue therapy for 1 year period (once initial 6 month approval has been completed): Patients who meet the following monitoring criteria will be approved for 1 year periods of therapy: MMSE score of 10 to 30 (Note: MMSE score must be provided 6 months after starting a ChEI and then only annually thereafter.); and FAST score of 4 to 5 (Note: FAST score must be provided 6 months after starting a ChEI and then only annually thereafter.) Note: Monitoring of target symptoms will no longer be required; however, physicians will be asked at the initial and subsequent reassessments if, in their opinion, the patient is benefiting from the drug. CIPROFLOXACIN (CILOXAN and generic brand) 0.3% ophthalmic solution For the treatment of corneal ulcers and bacterial conjunctivitis. Prescriptions written by New Brunswick ophthalmologists and optometrists do not require special authorization. CIPROFLOXACIN (CIPRO and generic brands) 250mg, 500mg and 750mg tablets 500mg/5mL Oral Suspension For the treatment of: Complicated urinary tract infections caused by resistant bacteria. Skin, soft tissue, bone and joint infections caused by Gram negative bacteria. Severe ( malignant ) otitis externa. Infections with Pseudomonas aeruginosa (susceptible strains resistance is now common). Prescriptions written by New Brunswick urologists, infectious disease specialists, medical oncologists, hematologists, respiratory medicine specialists or medical microbiologists do not require special authorization. February 2014 A - 22

238 CIPROFLOXACIN (CIPRO XL) 1000mg tablets For the treatment of complicated urinary tract infection and acute uncomplicated pyelonephritis when alternative agents are ineffective, not tolerated or contraindicated. Prescriptions written by New Brunswick urologists, infectious disease specialists and medical microbiologists do not require special authorization. CIPROFLOXACIN HCL / DEXAMETHASONE (CIPRODEX) 0.3% / 0.1% otic suspension For the treatment of acute otitis media with otorrhea through tympanostomy tubes who require treatment. For the treatment of acute otitis externa in the presence of a tympanostomy tube or known perforation of the tympanic membrane. CLOPIDOGREL (PLAVIX and generic brands) 75mg tablets 1. Secondary prevention of vascular ischemic events (myocardial infarction, stroke) in patients with a history of symptomatic atherosclerotic disease (including symptomatic peripheral artery disease) who have had treatment failure or are intolerant or allergic to ASA. 2. For the prevention of thrombosis post stent implantation for a period of up to 6 months for bare-metal stents (BMS) and 12 months for drug- eluting stents (DES). Prescriptions written by invasive (interventional) cardiologists for this procedure do not require special authorization. The claims adjudication system will automatically recognize the NBPDP physician ID number of the cardiologists at the Atlantic Health Sciences Centre. 3. For the prevention of vascular ischemic events in patients who have been hospitalized with acute coronary syndrome (i.e. unstable angina or non-st segment elevation myocardial infarction) in combination with ASA for a period of three months. Longer term combination therapy may be considered for a period of 12 months post NSTE-ACS for patients: with a second acute coronary syndrome within 12 months, or with complex or extensive CAD (i.e. diffuse 3 vessel CAD not amenable to revascularization), or who have had a previous stroke, transient ischemic attack or symptomatic PAD CLOZAPINE (CLOZARIL and generic brands) 25mg and 100mg tablets CLOZAPINE (GEN-CLOZAPINE) 50mg and 200mg tablets Requests will be considered for beneficiaries who are non-responsive to, or intolerant of, conventional or other atypical antipsychotic drugs. o non-responsiveness is defined as a lack of satisfactory clinical response, despite treatment with the appropriate courses of maximum tolerated therapeutic doses of at least two chemically-unrelated antipsychotics. o intolerance is defined as the inability to achieve adequate benefit with conventional antipsychotics because of dose-limiting, intolerable adverse effects such as parkinsonism, dystonia, akathesia and tardive dyskinesia. Clozapine must be prescribed by, or in consultation with, a psychiatrist. Prescriptions written by New Brunswick psychiatrists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. CODEINE (CODEINE CONTIN) 50mg, 100mg, 150mg, and 200mg tablets (controlled release) For the treatment of mild to moderate cancer-related or chronic non-cancer pain. CRIZOTINIB (XALKORI) 200mg, 250mg capsules Second-line therapy for patients with anaplastic lymphoma kinase (ALK) -positive advanced non-small cell lung cancer (NSCLC) with an ECOG performance status of 0-2. February 2014 A - 23

239 CYCLOSPORINE (NEORAL and generic brand) 10mg, 25mg, 50mg, 100mg capsules 100mg/mL oral solution For the treatment of severe psoriasis For the treatment of severe rheumatoid arthritis DABIGATRAN (PRADAXA) 110 mg and 150 mg tablets For the prevention of stroke and systemic embolism in at-risk patients with non-valvular atrial fibrillation for whom: Anticoagulation is inadequate following at least a two month trial of warfarin; or Warfarin is contraindicated or not possible due to inability to regularly monitor through International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy and at home). The following patient groups are excluded from coverage for dabigatran for atrial fibrillation: Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate < 30 ml/min) Patients 75 years of age or older without documented stable renal function Patients with hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis Patients with prosthetic heart valves Notes: 1. At-risk patients with atrial fibrillation are defined as those with a CHADS 2 score of 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). 3. Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see dabigatran Product Monograph). 4. Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate that maintained for at least three months (i.e ml/min for 110 mg twice daily dosing or 50 ml/min for 150 mg twice daily dosing). 5. There is currently no data to support that dabigatran provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart valves, so dabigatran is not recommended in these populations. 6. Patients starting dabigatran should have ready access to appropriate medical services to manage a major bleeding event. DALTEPARIN SODIUM (FRAGMIN) 10,000 IU ampoule, 25,000IU/mL multidose vials 5,000 IU/mL, 7,500 IU/mL, 10,000 IU/mL, 12,500IU/mL, 15,000IU/mL, 18,000IU/mL prefilled syringes See criteria under Low Molecular Weight Heparins. DARBEPOETIN (ARANESP) 10, 20, 30, 40, 50, 60, 80, 100, 130, 150, 200, 300 and 500mcg SingleJect prefilled Syringes For the treatment of anemia associated with chronic renal failure. Note: patients on dialysis (end-stage renal disease) receive darbepoetin through the dialysis units. For the treatment of transfusion dependent patients with hematologic malignancies whose transfusion requirements are 2 units of packed red blood cells per month over 3 months. o Initial approval for 12 weeks. o Approval of further 12 week cycles is dependent on evidence of satisfactory clinical response or reduced treatment requirement to less than 2 units of PRBC monthly. February 2014 A - 24

240 DARIFENACIN HYDROBROMIDE (ENABLEX) 7.5mg and 15mg extended release tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate-release oxybutynin. Requests for the treatment of stress incontinence will not be considered. If the beneficiary has had a claim for oxybutynin in the previous 24 months, the adjudication system will recognize this information and the claim for darifenacin will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. DARUNAVIR (PREZISTA) 75mg, 150mg, 400mg, 600mg and 800mg tablets As part of a HIV treatment regimen for treatment-experienced adult patients (Plan U beneficiaries) who have demonstrated failure to multiple protease inhibitors (PIs), and in whom less expensive PIs are not a treatment option. As part of a HIV treatment regimen for treatment-naïve patients (Plan U beneficiaries) for whom protease inhibitor therapy is indicated. As part of a HIV treatment regimen for treatment-experienced HIV-1 pediatric patients (Plan U beneficiaries). DASATINIB (SPRYCEL) 20mg, 50mg, 70mg, 80mg, 100mg, 140mg tablets Chronic Myeloid Leukemia (CML) For adult patients with chronic phase CML with primary or acquired resistance to imatinib 600mg per day. Dosing recommendation: 100mg per day or 70mg two times daily who progress to accelerated phase on imatinib 600mg per day. Dosing recommendation: 140mg per day who have blast crisis while on imatinib 600mg per day. Dosing recommendation: 140mg per day who have intolerance to imatinib or have experienced grade 3 or higher toxicities to imatinib Initial approval period: 1 year Renewal criteria: Request for renewal must specify how the patient has benefited from therapy and is expected to continue to do so. Renewal period: 1 year Acute Lymphoblastic Leukemia (ALL) For adult patients with Philadelphia chromosome positive acute lymphoblastic leukemia (ALL) whose disease is resistant to imatinib-containing chemotherapy (patient must have tried 600mg/day) or have experienced grade 3 nonhematologic toxicity, or grade 4 hematologic toxicity persisting for more than 7 days as a result of therapy with imatinib. Initial approval period: 1 year. Renewal criteria: Written confirmation that the patient has benefited from therapy and is expected to continue to do so. Renewal period: 1 year. DEFERASIROX (EXJADE) 125mg, 250mg, 500mg dispersable tablets for suspension For patients who require iron chelation but in whom deferoxamine is contraindicated. DELTA-9-TETRAHYDROCANNABINOL (MARINOL) 2.5mg and 5mg capsules Treatment of severe nausea and vomiting associated with cancer chemotherapy in patients who have not been well controlled by standard antiemetic therapy Treatment of anorexia with weight loss associated with acquired immune deficiency syndrome (AIDS). February 2014 A - 25

241 DENOSUMAB (PROLIA) 60mg/mL prefilled syringe For the treatment of osteoporosis in postmenopausal women who would otherwise be eligible for coverage of oral bisphosphonate therapy and who have clinically or radiographically-documented fracture due to osteoporosis AND Contraindication to oral bisphosphonates for one of the following reasons: o immune-mediated hypersensitivity reaction to oral bisphosphonates; OR o abnormalities of the esophagus which delay esophageal emptying such as stricture or achalasia. Please note that commonly reported adverse effects or intolerance to bisphosphonates will not be considered to be hypersensitivity. DENOSUMAB (XGEVA) 120mg/1.7mL single use vial For the prevention of skeletal-related events (SREs) in patients with castrate-resistant prostate cancer (CRPC) with one or more documented bone metastases and an ECOG performance status of 0-2*. * Patients who are asymptomatic and those who are symptomatic and in bed less than 50% of the time. DESMOPRESSIN (DDAVP and generic brands) 0.1mg and 0.2mg tablets DESMOPRESSIN (DDAVP MELT) 60mcg, 120mcg and 240mcg tablets For the management of diabetes insipidus. For the treatment of patients 18 years and older with nocturnal enuresis. Note: Desmopressin oral formulations and solution for injection are regular benefits for Plans EFG-18. DESMOPRESSIN (DDAVP and generic brand) 10µg/metered dose nasal spray and 0.1mg/mL intranasal solution For the treatment of patients with diabetes insipidus. The nasal formulations are no longer indicated for nocturnal enuresis due to the risk of hyponatremia. DIENOGEST (VISANNE) 2mg tablet For the management of pelvic pain associated with endometriosis in patients for whom one or more less costly hormonal options are either ineffective or cannot be used. Note: Continuous combined oral contraceptives and medroxyprogesterone are examples of less costly hormonal options. DIPYRIDAMOLE EXTENDED RELEASE/ASA IMMEDIATE RELEASE (AGGRENOX) 200mg/25mg capsules For the secondary prevention of ischemic stroke/tia in patients who have experienced a recurrent thrombotic event (stroke, symptoms of TIA) while taking ASA. DOLASETRON (ANZEMET) 100 mg tablets For the treatment of emesis in patients who are: receiving moderately or severely emetogenic chemotherapy OR receiving intravenous chemotherapy or radiotherapy and who have not experienced adequate control with other available antiemetics OR receiving any intravenous chemotherapy or radiotherapy and have experienced emesis with a prior cycle of chemotherapy with intolerable side effects to other antiemetics, including steroids and anti-dopaminergic agents. February 2014 A - 26

242 Only requests for the oral dosage forms are eligible for consideration. Usually a single oral dose pre-chemotherapy is sufficient to control symptoms. Some patients may require additional therapy up to 48 hours after the last dose of chemotherapy or last radiation treatment. Benefit beyond 48 hours has not been established. When used in combination with aprepitant, only a single oral dose pre-chemotherapy will be covered. Note: Prescription claims for up to a maximum of 12 tablets of ondansetron or 2 tablets of either granisetron or dolasetron will be automatically reimbursed every 28 days when the prescription is written by an oncologist or an oncology clinical associate/general practitioners-oncology. If additional medication is required within a 28 day period subsequent to the initial prescription, a request should be made through special authorization. DONEPEZIL (ARICEPT and generic brands) 5mg and 10mg tablets See criteria under Cholinesterase Inhibitors. DORNASE ALPHA RECOMBINANT (PULMOZYME) 1 mg/ml solution For cystic fibrosis (Plan B) patients with a FEV 1<70% predicted with clinically significant decline in FEV 1 not responsive to usual treatment. DULOXETINE (CYMBALTA) 30 mg and 60 mg capsules For the treatment of peripheral neuropathic pain in diabetic patients who have failed treatment with at least 2 other less costly agents used for the treatment of neuropathic pain. (i.e. tricyclic antidepressants and/or an anticonvulsant). The maximum allowable dose is 60 mg/day. DUTASTERIDE (AVODART) 0.5mg capsules For the treatment of benign prostatic hyperplasia (BPH) when alpha-blockers are contraindicated, not tolerated or failed. ECULIZUMAB (SOLIRIS) 10mg/mL vial For the treatment of paroxysmal nocturnal hemoglobinuria (PNH). A Request for Coverage including the completed consent and specific special authorization forms must be submitted and the patient must: 1. Satisfy the Clinical Criteria for eculizumab (initial or continued coverage, as appropriate); 2. Not meet any of the criteria specified in Contraindications to Coverage or Discontinuance of Coverage. Please contact the NBPDP at for a packet containing the Clinical Criteria and required forms. ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE (STRIBILD) 150mg/150mg/200mg/300mg tablet As a complete regimen for antiretroviral treatment naïve HIV-1 infected patients in whom efavirenz is not indicated. ENOXAPARIN SODIUM (LOVENOX) Prefilled syringes and 100mg/mL multidose vial ENOXAPARIN SODIUM (LOVENOX HP) Prefilled syringes See criteria under Low Molecular Weight Heparins. ENTACAPONE (COMTAN and generic brand) 200mg tablets Treatment of Parkinson s disease as adjunctive therapy in patients not well controlled and are experiencing significant wearing off symptoms despite optimal therapy with levodopa/decarboxylase or levodopa/benserazide. February 2014 A - 27

243 ENTECAVIR (BARACLUDE and generic brand) 0.5mg tablets For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2,000 lu/ml. ENZALUTAMIDE (XTANDI) 40mg tablet For treatment of patients with metastatic castration resistant prostate cancer, who have progressed on docetaxelbased chemotherapy with an ECOG performance status 2 and no risk factors for seizures and would be an alternative to abiraterone for patients in the post-docetaxel setting but would not be an add-on therapy to abiraterone treatment. EPOETIN ALFA (EPREX) 1000IU/0.5mL, 2000IU/0.5mL, 3000IU/0.3mL, 4000IU/0.4mL, 5000IU/.5mL, 6000IU/.6mL, 8000IU/.8mL, 10000IU/mL, 20000IU/mL, 30,000IU/0.75mL and 40000IU/mL vials and prefilled syringes 1. Treatment of anemia associated with chronic renal failure. Note: patients on dialysis (end-stage renal disease) receive epoetin through the dialysis units. 2. Treatment of transfusion dependent anemia related to therapy with zidovudine in HIV-infected patients. 3. Treatment of transfusion dependent patients with hematologic malignancies whose transfusion requirements are 2 units of packed red blood cells per month over 3 months. Initial approval for 12 weeks. Approval of further 12 week cycles is dependent on evidence of satisfactory clinical response or reduced treatment requirement to less than 2 units of PRBC monthly. EPOPROSTENOL SODIUM (CARIPUL et FLOLAN) 0.5mg and 1.5mg vials for injection 1. For the treatment of World Health Organization (WHO) class III or IV idiopathic pulmonary arterial hypertension in patients who do not demonstrate vasoreactivity on testing or who demonstrate vasoreactivity on testing but fail a trial of, or are intolerant to, calcium channel blockers. 2. For the treatment of WHO class III or IV pulmonary arterial hypertension associated with scleroderma in patients who do not respond adequately to conventional therapy. ERLOTINIB (TARCEVA) 100mg and 150mg tablets Non-small Cell Lung Cancer (NSCLC) For the treatment of patients with locally advanced or metastatic NSCLC after failure of at least one prior platinumbased chemotherapy regimen. Initial approval period: 6 month trial. Renewal criteria: Written confirmation that the patient has responded to treatment and in whom there is no evidence of disease progression. Renewal period: 6 months ESTRADIOL-17β (VIVELLE and ESTRADOT and generic brands) 25 mcg, 37.5mcg, 50mcg, 75mcg and 100mcg transdermal patches For the treatment of menopausal symptoms in women for whom oral forms of HRT are not tolerated or indicated. ETANERCEPT (ENBREL) 25mg liquid injection 50mg/mL pre-filled syringe Ankylosing Spondylitis For the treatment of patients with moderate to severe ankylosing spondylitis (e.g. Bath AS Disease Activity Index (BASDAI) score 4 on 10 point scale) who: o have axial symptoms* and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation or in whom NSAIDs are contraindicated OR o have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate response to an optimal dose or maximal tolerated dose of a DMARD. February 2014 A - 28

244 * Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication to axial disease, do not require a trial of NSAIDs alone. Must be prescribed by a rheumatologist or internist Approval will be for a maximum of 6 months Requests for renewal must include information showing the beneficial effects of the treatment, specifically: o a decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score; OR o patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement (measured by outcomes such as HAQ or ability to return to work ) Approvals will be for a maximum dose of 50mg per week. Etanercept will not be reimbursed in combination with other anti-tnf agents. Juvenile Rheumatoid Arthritis For the treatment of children (age 4-17) with moderately to severely active polyarticular juvenile rheumatoid arthritis who have: o not responded to adequate treatment with one or more disease modifying antirheumatic drug (DMARD) for at least 3 months, OR o intolerance to DMARDs Must be prescribed by a rheumatologist. Psoriatic Arthritis For the treatment of patients with active psoriatic arthritis who have not responded to an adequate trial with two disease modifying antirheumatic drugs (DMARDs) or who have an intolerance or contraindication to DMARDs. Must be prescribed by a rheumatologist. Rheumatoid Arthritis For patients with moderate to severe active rheumatoid arthritis who: o Have not responded to, or have had intolerable side-effects with, an adequate trial of combination therapy of at least two traditional DMARDs (disease modifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR o Are not candidates for combination DMARD therapy must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated AND o Have had an adequate trial of leflunomide unless it is contraindicated or not tolerated. Must be prescribed by a rheumatologist. Plaque Psoriasis Requests will be considered for treatment of patients with severe, debilitating chronic plaque psoriasis who meet all of the following criteria: o Body surface area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or genital region; o Failure to respond to, contraindications to or intolerance to methotrexate and cyclosporine; o Failure to respond to, intolerance to or unable to access phototherapy Initial approval limited to 12 weeks. Continuation of therapy beyond 12 weeks will be based on response. Patients not responding adequately at these time points should have treatment discontinued with no further treatment with the same agent recommended. An adequate response is defined as either: o 75% reduction in the Psoriasis Area and Severity Index (PASI) score from when treatment started (PASI 75), or o 50% reduction in the PASI score (PASI 50) with a 5 point improvement in the Dermatology Life Quality Index (DLQI) from when treatment started, or o A quantitative reduction in BSA affected with qualitative consideration of specific regions such as face, hands, feet, or genital region. Must be prescribed by a dermatologist Concurrent use of >1 biologic will not be approved February 2014 A - 29

245 Approval limited to a dose of 50 mg twice weekly for an initial 12 weeks, then 50 mg weekly, thereafter up to a year (if response criteria met at 12 weeks) ETIDRONATE (DIDRONEL and generic brands) 200mg tablets See criteria under Osteoporosis Drugs. ETIDRONATE AND CALCIUM (DIDROCAL and generic brands) 400mg /500mg See criteria under Osteoporosis Drugs. ETONOGESTREL / ETHINYL ESTRADIOL (NUVARING) 11.4mg /2.6mg vaginal ring For conception control in women who are unable to take oral contraceptives. ETRAVIRINE (INTELENCE) 100mg and 200mg tablets For the treatment of HIV-1 infection in patients (plan U beneficiaries) who are antiretroviral experienced and have virologic failure due to HIV-1 strains resistant to multiple antiretroviral agents, including other non-nucleoside reverse transcriptase inhibitors. EVEROLIMUS (AFINITOR) 2.5mg, 5mg, 10mg tablets 1. For the treatment of metastatic renal cell carcinoma (mrcc) with clear cell morphology, in patients previously treated with a tyrosine kinase inhibitor. 2. In combination with exemestane, for the treatment of hormone-receptor positive, HER2 negative advanced breast cancer, in postmenopausal women with ECOG performance status 2 after recurrence or progression following a non-steroidal aromatase inhibitor (NSAI), if the treating oncologist would consider using exemestane. 3. For the treatment of patients with progressive, unresectable, well or moderately differentiated, locally advanced or metastatic pancreatic neuroendocrine tumours (pnet) with good performance status (ECOG 0-2), until disease progression. Dosing for above indications: maximum 10mg daily EZETIMIBE (EZETROL) 10mg tablets For the treatment of hypercholesterolemia. As adjunctive therapy with a statin, in patients who have not reached treatment goals on maximum tolerated statin therapy alone, OR As monotherapy in patients who are intolerant to statins and, when appropriate, fibrates. FEBUXOSTAT (ULORIC) 80mg tablets For patients with symptomatic gout who have documented hypersensitivity to allopurinol. Hypersensitivity to allopurinol is a rare condition that is characterized by a major skin manifestation, fever, multi-organ involvement, lymphadenopathy and hematological abnormalities (eosinophilia, atypical lymphocytes). Note: Intolerance or lack of response to allopurinol will not be covered by these criteria. FENTANYL (DURAGESIC MAT and generic brands) Transdermal system 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr and 100mcg/hr For the management of malignant or chronic non-malignant pain in adult patients; who were previously receiving continuous opioid administration (i.e. not opioid naive), OR who are unable to take oral therapy. February 2014 A - 30

246 FESOTERODINE FUMARATE (TOVIAZ) 4mg, 8mg extended-release tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate release oxybutynin. Requests for the treatment of stress incontinence will not be considered. If the beneficiary has had a claim for oxybutynin in the previous 24 months, the adjudication system will recognize this information and the claim for fesoterodine fumarate will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. FILGRASTIM (NEUPOGEN - AMGEN) 300mcg/1mL, 480mcg/1.6mL injection GENERAL Filgrastim must be prescribed or requested by a certified hematologist or medical oncologist. 1. USE FOR CHEMOTHERAPY SUPPORT a) Primary prophylaxis: For use in previously untreated patients receiving a moderate to severely myelosuppressive chemotherapy regimen (i.e. 40% incidence of febrile neutropenia). Febrile neutropenia is defined as a temperature C or > 38 0 C three times in a 24 hour period and neutropenia with an absolute neutrophil count (ANC) < 0.5 x 10 9 /L. b) Secondary prophylaxis: For use in patients receiving myelosuppressive chemotherapy who have experienced an episode of febrile neutropenia, neutropenic sepsis or profound neutropenia in a previous cycle of chemotherapy; or For use in patients who have experienced a dose reduction or treatment delay longer than one week, due to neutropenia. c) Dosing for Chemotherapy support: The manufacturer recommends an initial dose of 5mcg/kg/day. When dose scavenging techniques are not available, the following recommendations are suggested: Patients 70 Kg use 1 ml vial (300mcg) DIN Patients > 70 Kg use 1.6 ml vial (480mcg) PIN USE FOR NON-MALIGNANT INDICATIONS a) Treatment of congenital neutropenia, idiopathic neutropenia or cyclic neutropenia in patients with recurrent clinical infections. b) Drug-induced neutropenia (e.g. antiviral therapy in patients with HIV). c) Refer to product monograph for dosing recommendations. 3. USE IN STEM-CELL TRANSPLANTATION a) Mobilization: As an adjunct to progenitor cell transplantation, for mobilization of peripheral blood stem cells (PBSC). The recommended dosage is 10mcg/kg/day. b) Reconstitution/Engraftment: Post bone marrow transplantation (BMT) or PBSC transplantation to speed hematopoietic reconstitution. The recommended dosage is 5mcg/kg/day. 4. UNACCEPTABLE USE Treatment of febrile neutropenia or in the prevention of febrile neutropenia in the palliative setting. FINASTERIDE (PROSCAR and generic brands) 5mg tablets For the treatment of benign prostatic hyperplasia (BPH); when alpha-blockers are contraindicated, not tolerated or failed. in combination with an alpha-blocker when alpha-blocker therapy has been tried as monotherapy and a partial response has been observed. February 2014 A - 31

247 FINGOLIMOD (GILENYA) 0.5 mg capsules For the treatment of patients with Relapsing Remitting Multiple Sclerosis (RRMS) who meet all of the following criteria: Failure to respond to full and adequate courses 1 of at least one interferon OR glatiramer acetate; OR documented intolerance 2 to both therapies Have experienced one or more clinically disabling relapses in the previous year Demonstrate a significant increase in T2 lesion load compared with that from a previous MRI scan (i.e. 3 or more new lesions) OR have at least one gadolinium enhancing lesion Request is being made by and followed by a neurologist experienced in the management of RRMS Patient has a recent Expanded Disability Status Scale (EDSS) score less than or equal to 5.5 (i.e. patients must be able to ambulate at least 100 meters without assistance) 1 Failure to respond to full and adequate courses is defined as a trial of at least 6 months of interferon or glatiramer therapy AND experienced at least one disabling relapse (attack) while on interferon or glatiramer therapy (MRI report does not need to be submitted with the request) 2 Intolerance is defined as documented serious adverse effects or contraindications that are incompatible with further use of that class of drug. (Note that skin reactions at the site of the injection do NOT qualify as a contraindication to interferon or glatiramer therapy.) Dosage: 0.5 mg once daily Approval period: 1 year Exclusion Criteria: Combination therapy of Fingolimod with other disease modifying therapies (e.g. Avonex, Betaseron, Copaxone, Rebif, Extavia, Tysabri) will not be funded. Combination therapy of Fingolimid with Fampyra will not be funded. Patients with EDSS > 5.5 will not be funded Patients who have experienced a heart attack or stroke within the 6 months prior to the funding request will not be considered. Patients with a history of sick sinus syndrome, atrioventricular block, significant QT prolongation, bradycardia, ischemic heart disease, or congestive heart failure will not be considered. Patients younger than 18 years of age will not be considered. Patients with needle phobia or those having a preference for an oral therapy over an injection and who do not have one or more clinical contraindications to interferon or glatiramer therapy will not be funded. Skin reactions at the site of the injection do NOT qualify as a contraindication to interferon or glatiramer therapy. Requirements for Initial Requests: The patient s physician must provide documentation setting out the details of the patient s most recent neurological examination within ninety (90) days of the submitted request. This must include a description of any recent attacks, the dates, and the neurological findings. Renewal requests will be considered. Date and details of the most recent neurological examination and EDSS scores must be provided (exam must have occurred within that last 90 days); AND Patient must be stable or have experienced no more than 1 disabling attack/relapse in the past year; AND The recent Expanded Disability Status Scale (EDSS) score must be less than or equal to 5.5 (i.e. patients must be able to ambulate at least 100 meters without assistance) Dosage: 0.5 mg once daily Renewal period: 2 years FLUDARABINE (FLUDARA) 10mg tablets For the first-line treatment of chronic lymphocytic leukemia (CLL) in combination with rituximab (with or without cyclophosphamide). February 2014 A - 32

248 FORMOTEROL (FORADIL) 12 µg dry powder for inhalation Reversible obstructive airway disease: For the treatment of patients, 12 years of age or older, with reversible obstructive airway disease who are using optimal corticosteroid treatment, but are still poorly controlled. Chronic Obstructive Pulmonary Disease: For the treatment of chronic obstructive pulmonary disease (COPD) with EITHER a long-acting beta 2-adrenergic agonist (LABA) such as formoterol, OR tiotropium if symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day). Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**). Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms (i.e., MRC score of 3-5**) AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. FORMOTEROL (OXEZE) 12 µg turbuhaler For the treatment of patients, 12 years of age or older, with reversible obstructive airway disease who are using optimal corticosteroid treatment, but are still poorly controlled. Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. FORMOTEROL (OXEZE) 6 µg and 12 µg turbuhaler Reversible obstructive airway disease: For the treatment of patients, 12 years of age or older, with reversible obstructive airway disease who are using optimal corticosteroid treatment, but are still poorly controlled. Chronic Obstructive Pulmonary Disease: For the treatment of chronic obstructive pulmonary disease (COPD) with EITHER a long-acting beta 2-adrenergic agonist (LABA) such as formoterol, OR tiotropium if: o symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day) Coverage can be provided without a trial of short-acting agent if: o there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms i.e. MRC score of 3-5**. Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: February 2014 A - 33

249 - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms i.e., MRC score of 3-5** AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. GALANTAMINE (REMINYL ER and generic brands) 8mg, 16mg, and 24mg tablets See criteria under Cholinesterase Inhibitors. GLYCOPYRRONIUM BROMIDE (SEEBRI BREEZHALER) 50mcg capsule For the treatment of chronic obstructive pulmonary disease (COPD) with EITHER glycopyrronium bromide OR a long-acting beta2-adrenergic agonist (LABA) if symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day). Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**). Combination therapy with glycopyrronium bromide AND a long-acting beta2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV1 < 60% and FEV1/FVC ratio < 0.7), and significant symptoms (i.e. MRC score of 3-5**) AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. Note: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. GOLIMUMAB (SIMPONI) 50mg/0.5mL autoinjector/prefilled syringe 1. For the treatment of patients with moderate to severe ankylosing spondylitis (e.g. Bath AS Disease Activity Index (BASDAI) score 4 on 10 point scale) who: Have axial symptoms* and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum dose for a minimum 3 month observation period or in whom NSAIDs are contraindicated OR Have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at least 2 NSAIDs at the optimum dose for a minimum 3 month observation period and have had an inadequate response to an optimal dose or maximal tolerated dose of a DMARD. Must be prescribed by a rheumatologist or internist. February 2014 A - 34

250 Initial approval will be for 4 x 50 mg doses in a 4 month period. Requests for continuation of therapy must include information showing the clinical beneficial effects of the treatment, specifically: a decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score OR patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement (measured by outcomes such as HAQ or ability to return to work ) Approvals for continuation of therapy will be for 12 x 50 mg doses annually with no dose escalation permitted. Golimumab will not be reimbursed in combination with other anti-tnf agents. * Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication to axial disease do not require a trial of NSAIDs alone. 2. For the treatment of moderate to severe psoriatic arthritis in patients who: Have at least three active and tender joints, and Have not responded to an adequate trial of two DMARDs or have an intolerance or contraindication to DMARDs. Must be prescribed by a rheumatologist or internist. Initial approval will be for 4 x 50 mg doses in a 4 month period. Requests for continuation of therapy must include information demonstrating clinical beneficial effects of the treatment. Approvals for continuation of therapy will be for 12 x 50 mg doses annually with no dose escalation permitted. Golimumab will not be reimbursed in combination with other anti-tnf agents. 3. For patients with moderate to severe active rheumatoid arthritis who: Have not responded to, or have had intolerable side-effects with, an adequate trial of combination therapy of at least two traditional DMARDs (disease modifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR Are not candidates for combination DMARD therapy must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated. AND Have had an adequate trial of leflunomide unless it is contraindicated or not tolerated. Must be prescribed by a rheumatologist. Initial approval will be for 4 x 50 mg doses in a 4 month period. Requests for continuation of therapy must include information demonstrating clinical beneficial effects of the treatment. Approvals for continuation of therapy will be for 12 x 50 mg doses annually with no dose escalation permitted. Golimumab will not be reimbursed in combination with other anti-tnf agents. GOSERELIN ACETATE (ZOLADEX) 3.6mg depot 1. Requests will be considered for beneficiaries of Plans E and F for the palliative treatment of stage D 2 carcinoma of the prostate. The value of continued anti-androgen therapy in patients with evidence of disease relapse and progression is questionable. Since the mean time to disease progression after initial hormone management is approximately two years, Special Authorization must be obtained for continuation beyond this period. This should include urologic evaluation detailing physical examination, PSA determinations, and bone scan or acid phosphatase where appropriate. The continued use of this medication would require such authorization every two years if the patient is to remain on the medication. 2. Approved for the hormonal management of endometriosis, including pain relief and reduction of endometriotic lesions. Requests will be considered for women age 18 and older. Approval limits payment to a maximum of 6 months of therapy. GRANISETRON (KYTRIL and generic brand) 1 mg tablets For the treatment of emesis in patients who are: receiving moderately or severely emetogenic chemotherapy OR receiving intravenous chemotherapy or radiotherapy and who have not experienced adequate control with other February 2014 A - 35

251 available antiemetics OR receiving any intravenous chemotherapy or radiotherapy and have experienced emesis with a prior cycle of chemotherapy with intolerable side effects to other antiemetics, including steroids and anti-dopaminergic agents. Only requests for the oral dosage forms are eligible for consideration. Usually a single oral dose pre-chemotherapy is sufficient to control symptoms. Some patients may require additional therapy up to 48 hours after the last dose of chemotherapy or last radiation treatment. Benefit beyond 48 hours has not been established. When used in combination with aprepitant, only a single oral dose pre-chemotherapy will be covered. Note: Prescription claims for up to a maximum of 12 tablets of ondansetron or 2 tablets of either granisetron or dolasetron will be automatically reimbursed every 28 days when the prescription is written by an oncologist or an oncology clinical associate/general practitioners-oncology. If additional medication is required within a 28 day period subsequent to the initial prescription, a request should be made through special authorization. Hp-PAC (Containing LANSOPRAZOLE 30mg Cap, AMOXICILLIN 500mg Cap, CLARITHROMYCIN 500mg Tab) For the treatment of patients with H. pylori infection and active duodenal ulcer disease. Treatment should be limited to a period of 7 days for first-line therapy. Note: In cases of H. pylori treatment failure or re-infection, second-line treatment should be limited to a period of 7-14 days provided at least 4 weeks have elapsed from first-line treatment. In addition, if treatment failure or re-infection occurs within a three month period of first-line treatment, a different antibiotic should be used. IMATINIB (GLEEVEC and generic brands) 100mg and 400mg tablets Requests from specialists in hematology/oncology will be considered for: 1. Patients who have documented evidence of Philadelphia chromosome positive (Ph+) chronic myeloid leukemia (CML), with an ECOG performance status of 0-2*. 2. Patients with C-Kit positive (CD117), metastatic or locally advanced, inoperable gastrointestinal stromal tumours (GIST), who have an ECOG performance status of 0-2*. 3. For the treatment of adult patients with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) when used as a single agent for induction and maintenance phase therapy. *Patients who are asymptomatic and those who are symptomatic and in bed less than 50% of the time. IMIQUIMOD (ALDARA) 5% cream For the treatment of external genital and external perianal/condyloma acuminata warts. For the treatment of actinic keratosis in patients who have failed treatment with 5-Fluorouracil (5-FU) and cryotherapy. For the treatment of biopsy-confirmed primary superficial basal cell carcinoma: - with a tumour diameter of 2 cm AND - located on the trunk, neck or extremities (excluding hands and feet) AND - where surgery or irradiation therapy is not medically indicated - recurrent lesions in previously irradiated area OR - multiple lesions, too numerous to irradiate or remove surgically. - Approval Period: 6 weeks Note: Surgical management should be considered first-line for superficial basal cell carcinoma in most patients, especially for isolated lesions. INCOBOTULINUMTOXIN-A (XEOMIN) 50 LD 50 units/ vial and 100 unit vial for injection For the treatment of blepharospasm in patients 18 years of age and older. For the treatment of cervical dystonia (spasmodic torticollis) in patients 18 years of age or older. February 2014 A - 36

252 INDACATEROL MALEATE (ONBREZ BREEZHALER) 75mcg inhalation powder hard capsules For the treatment of chronic obstructive pulmonary disease (COPD) If symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day) Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**) Combination therapy with tiotropium AND a long-acting beta agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: o there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms (i.e. MRC score of 3-5**) AND o there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. Dose not to exceed 75mcg/day. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. INFLIXIMAB (REMICADE) 100mg liquid injection Ankylosing Spondylitis For the treatment of patients with moderate to severe ankylosing spondylitis (e.g. Bath AS Disease Activity Index (BASDAI) score 4 on 10 point scale) who: o have axial symptoms* and who have failed to respond to the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation or in whom NSAIDs are contraindicated OR o have peripheral symptoms and who have failed to respond to, or have contraindications to, the sequential use of at least 2 NSAIDs at the optimum dose for a minimum period of 3 months observation and have had an inadequate response to an optimal dose or maximal tolerated dose of a DMARD. * Patients with recurrent uveitis (2 or more episodes within 12 months) as a complication to axial disease, do not require a trial of NSAIDs alone. Must be prescribed by a rheumatologist or internist Approval will be for a maximum of 6 months Requests for renewal must include information showing the beneficial effects of the treatment, specifically: o a decrease of at least 2 points on the BASDAI scale, compared with the pre-treatment score; OR o patient and expert opinion of an adequate clinical response as indicated by a significant functional improvement (measured by outcomes such as HAQ or ability to return to work ) Approvals will be for a maximum of 5mg/kg at weeks 0, 2 and 6, then every 6 to 8 weeks thereafter. Infliximab will not be reimbursed in combination with other anti-tnf agents. Crohn s Disease For moderately to severely active Crohn's disease in patients who are refractory or have contraindications to an adequate course of 5-aminosalicylic acid and corticosteroids and other immunosuppressive therapy. Initial approval will consist of 3 doses of 5 mg/kg given at weeks 0, 2 and 6. Ongoing coverage for maintenance therapy will only be reimbursed for responders and for a dose not exceeding 5mg/kg every 8 weeks. Coverage must be reassessed annually and is dependent on evidence of continued response. February 2014 A - 37

253 Must be prescribed by, or in consultation with, a gastroenterologist or physician with a specialty in gastroenterology. Infliximab will not be reimbursed in combination with other anti-tnf agents. Plaque Psoriasis Requests will be considered for treatment of patients with severe, debilitating chronic plaque psoriasis who meet all of the following criteria: o Body surface area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or genital region; o Failure to respond to, contraindications to or intolerance to methotrexate and cyclosporine; o Failure to respond to, intolerance to or unable to access phototherapy Initial approval limited to 12 weeks. Continuation of therapy beyond 12 weeks will be based on response. Patients not responding adequately at these time points should have treatment discontinued with no further treatment with the same agent recommended. An adequate response is defined as either: o 75% reduction in the Psoriasis Area and Severity Index (PASI) score from when treatment started (PASI 75), or o 50% reduction in the PASI score (PASI 50) with a 5 point improvement in the Dermatology Life Quality Index (DLQI) from when treatment started, or o A quantitative reduction in BSA affected with qualitative consideration of specific regions such as face, hands, feet, or genital region. Must be prescribed by a dermatologist Concurrent use of >1 biologic will not be approved Approval limited to a dose of 5 mg/kg administered at 0, 2, and 6 weeks, then every 8 weeks up to a year (if response criteria met at 12 weeks) Rheumatoid Arthritis For patients with moderate to severe active rheumatoid arthritis who: o Have not responded to, or have had intolerable side-effects with, an adequate trial of combination therapy of at least two traditional DMARDs (disease modifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR o Are not candidates for combination DMARD therapy must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated AND o Have had an adequate trial of leflunomide unless it is contraindicated or not tolerated. Must be prescribed by a rheumatologist. INSULIN ASPART (NOVORAPID) 10mL vials and 5x3mL cartridges For patients with type I or II diabetes who have experienced frequent episodes of postprandial hypoglycemia; have unpredictable mealtimes; have insulin resistance; or who are using continuous subcutaneous insulin infusion. Prescriptions written by New Brunswick endocrinologists and internists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. INSULIN DETEMIR (LEVEMIR PENFILL) 100 U/mL cartridge For the treatment of patients who have been diagnosed with Type 1 or Type 2 diabetes requiring insulin and have previously taken insulin NPH and/or pre-mix daily at optimal dosing. AND 1. Have experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management. OR 2. Have documented severe or continuing systemic or local allergic reaction to existing insulin(s). Note: Requests should be submitted on the long-acting insulin analogue special authorization request form. February 2014 A - 38

254 INSULIN GLARGINE (LANTUS) 100U/mL vial, cartridge, & SoloSTAR For the treatment of patients who have been diagnosed with Type 1 or Type 2 diabetes requiring insulin and have previously taken insulin NPH and/or pre-mix daily at optimal dosing. AND 1. Have experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management. OR 2. Have documented severe or continuing systemic or local allergic reaction to existing insulin(s). Note: Requests should be submitted on the long-acting insulin analogue special authorization request form. INSULIN GLULISINE (APIDRA) 100IU/mL vials, cartridges and SoloSTAR pre-filled pens For patients with type I or II diabetes who have experienced frequent episodes of postprandial hypoglycemia; have unpredictable mealtimes; have insulin resistance; or who are using continuous subcutaneous insulin infusion. Prescriptions written by New Brunswick endocrinologists and internists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. Note: Insulin glulisine is a regular benefit for Plans EFG<18 years of age. INSULIN LISPRO (HUMALOG) 10mL vials, 1.5mL and 3mL cartridges, and KwikPen prefilled pen For patients with type I or II diabetes who have experienced frequent episodes of postprandial hypoglycemia; have unpredictable mealtimes; have insulin resistance; or who are using continuous subcutaneous insulin infusion. Prescriptions written by New Brunswick endocrinologists and internists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. INTERFERON ALFA-2B RIBAVIRIN (REBETRON) Injection + 200mg capsules Requests will be considered from internal medicine specialists for the treatment of chronic hepatitis C (HCV RNA positive). Initial coverage of 24 weeks will be approved for all patients. Coverage for an additional 24 weeks will be approved for patients with HCV genotype 1. A positive HCV RNA assay after 24 weeks of therapy is an indication to stop treatment. Interferon monotherapy should be reserved for patients who cannot tolerate ribavirin. ITRACONAZOLE (SPORANOX) 100mg capsules 1. For the treatment of severe systemic fungal infections. 2. For the treatment of severe or resistant fungal infections in immunocompromised patients. 3. For the treatment of severe onychomycosis when used as pulse therapy; Reimbursement for the treatment of fingernail mycosis is limited to 56 x 100mg capsules over an 8 week period. Reimbursement for the treatment of toenail mycosis is limited to 84 x 100mg capsules over a 12 week period. LACOSAMIDE (VIMPAT) 50mg, 100mg, 150mg, 200mg tablets For the adjunctive treatment of refractory partial-onset seizures in patients who meet all of the following criteria: are under the care of a physician experienced in the treatment of epilepsy, and are currently receiving two or more antiepileptic drugs, and in whom all other antiepileptic drugs are ineffective or not appropriate February 2014 A - 39

255 LACTULOSE (various brands) 667 mg/ml For the treatment of hepatic encephalopathy in patients with liver disease. Please note requests for treatment of constipation will not be considered. LAMIVUDINE (HEPTOVIR and generic brand) 5mg/mL solution For the treatment of patients with chronic hepatitis B with evidence of hepatitis B replication, defined as: 1. HBsAg positive for at least 6 months. 2. Evidence of active viral replication (HBeAg positive). 3. ALT level elevated on at least 3 consecutive occasions over a 3 month period. Prescriptions written by New Brunswick internal medicine specialists do not require special authorization. LANREOTIDE ACETATE (SOMATULINE AUTOGEL) 60mg, 90mg and 120mg prefilled syringes For the treatment of acromegaly. LANSOPRAZOLE (PREVACID and generic brands) 15mg and 30mg capsules See criteria under Proton Pump Inhibitors. LANSOPRAZOLE (PREVACID FASTAB) 15mg and 30mg delayed release tablet For patients who meet the special authorization criteria for a proton pump inhibitor and require administration through a feeding tube. LAPATINIB (TYKERB) 250mg tablets For use in combination with capecitabine, for the treatment of HER2-positive patients with advanced or metastatic breast cancer who have progressed on trastuzumab-based treatments (e.g. taxanes, anthracycline, trastuzumab) and who have an ECOG performance status of 0-2. Initial approval period: 6 months Renewal criteria: Written confirmation that the patient has responded to treatment and that there is no evidence of disease progression. Renewal period: 6 months Note: Requests will not be considered for use in combination with trastuzumab for second-line HER2-positive metastatic breast cancer or in the adjuvant setting. LEFLUNOMIDE (ARAVA and generic brands) 10mg and 20mg tablets For the treatment of patients with active rheumatoid arthritis who have not responded to, or have had intolerable toxicity with, an adequate trial of combination traditional DMARD (disease modifying antirheumatic drug) therapy. Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated. Patients who are not candidates for combination DMARD therapy must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated. LENALIDOMIDE (REVLIMID) 5mg, 10mg, 15mg and 25mg capsule 1. For the treatment of Myelodysplastic Syndrome (MDS) in patients with: Demonstrated diagnosis of MDS on bone marrow aspiration Presence of 5-q deletion documented by appropriate genetic testing International Prognostic Scoring System (IPSS) risk category low or intermediate-1 Presence of symptomatic anemia (defined as transfusion dependent)* February 2014 A - 40

256 calculator available on * Requests for patients who are not transfusion-dependent will be considered on a case-by-case basis. The physician should provide clinical evidence of symptomatic anemia affecting the patient s quality of life and the rationale for why transfusions are not being used. Initial approval period: 6 months Renewal criteria: For patients who were transfusion-dependent and have demonstrated a reduction in transfusion requirements of at least 50%. Renewal requests for all other patients will be considered on a case-by-case basis. Information describing the results of serial CBC (pre- and post-lenalidomide) and any other objective evidence of response should be included. Renewal period: 1 year 2. For the treatment of multiple myeloma when used in combination with dexamethasone, in patients who: Are not candidates for autologous stem cell transplant; AND Where the patient is either: o Refractory to or has relapsed after the conclusion of initial or subsequent treatments and who is suitable for further chemotherapy; or o Has completed at least one full treatment regimen as initial therapy and is experiencing intolerance to their current chemotherapy. Note: Due to its structural similarities to thalidomide, lenalidomide (Revlimid) is only available through a controlled distribution program called RevAid SM to minimize the risk of fetal exposure. Only prescribers and pharmacists registered with this program are able to prescribe and dispense lenalidomide (Revlimid). In addition, patients must be registered and meet all the conditions of the program in order to receive the product. For information, call RevAid1 or log onto LEUPROLIDE (LUPRON & LUPRON DEPOT) 5mg injection and 7.5mg depot (1-month slow release) Requests will be considered for beneficiaries of Plans E and F for the palliative treatment of stage D 2 carcinoma of the prostate. 1. (i) The value of continued anti-androgen therapy in patients with evidence of disease relapse and progression is questionable. Since the mean time to disease progression after initial hormone management is approximately two years, Special Authorization must be obtained for continuation beyond this period. This should include urologic evaluation detailing physical examination, PSA determinations, and bone scan or acid phosphatase where appropriate. (ii) The continued use of this medication would require such authorization every two years if the patient is to remain on the medication. 2. For the treatment of central precocious puberty. LEUPROLIDE (LUPRON DEPOT) 3.75mg injection (1-month slow release) 1. For the hormonal management of endometriosis, including pain relief and reduction of endometriotic lesions. Requests will be considered for women age 18 and older. Approval limits payment to a maximum of 6 months of therapy. 2. For the treatment of central precocious puberty. LEUPROLIDE (LUPRON DEPOT) 11.25mg injection (3-month slow release) For the hormonal management of endometriosis, including pain relief and reduction of endometriotic lesions. Requests will be considered for women age 18 and older. Approval limits payment to a maximum of 6 months of therapy. LEVETIRACETAM (KEPPRA and generic brands) 250mg, 500mg, 750mg tablets An adjunctive therapy in the management of patients with epilepsy who are not satisfactorily controlled by conventional therapy. February 2014 A - 41

257 LEVODOPA/CARBIDOPA / ENTACAPONE (STALEVO) 50/12.5/200 mg, 75/18.75/200 mg, 100/25/200 mg, 125/31.25/200 mg, and 150/37.5/200 mg tablets For the treatment of patients with Parkinson s disease who are currently receiving immediate-release levodopa/carbidopa and entacapone, or who are not well controlled and are experiencing significant wearing off symptoms despite optimal therapy with levodopa/decarboxylase. LEVOFLOXACIN (LEVAQUIN and generic brands) 250mg, 500mg tablets For the completion of therapy instituted in the hospital setting for the treatment of nosocomial pneumonia, community acquired pneumonia (CAP) or acute exacerbation of chronic bronchitis (AECB). For the treatment of severe pneumonia in nursing home patients (regular benefit for Plan V). For the treatment 1 of CAP in patients; o with co-morbidity 2 upon radiographic confirmation of pneumonia, or o who have failed first line therapies (macrolide, doxycycline, amoxicillin-clavulanate). For the treatment 1 of AECB in complicated patients 3 who have failed treatment with one of the following (amoxicillin, doxycycline, TMP-SMX, cefuroxime, macrolide, ketolide or amoxicillin-clavulanate). Prescriptions written by New Brunswick infectious disease specialists, medical microbiologists, medical oncologists, respirologists and internal medicine specialists will not require special authorization. 1. If treated with an antibiotic within the past 3 months choose an antibiotic from a different class. 2. Co-morbidity includes chronic lung disease, malignancy, diabetes, liver, renal or congestive heart failure, use of antibiotics or steroids in the past 3 months, suspected macroaspiration, hospitalization within last 3 months, HIV/AIDs, smoking, malnutrition or acute weight loss. 3. Complicated AECB defined as increased cough and sputum, sputum purulence and increased dyspnea AND o FEV 1 < 50% predicted OR o FEV % and one of the following: 4 exacerbations per year Ischemic heart disease Chronic oral steroid use Antibiotic use in the past 3 months LINAGLIPTIN (TRAJENTA) 5mg tablets For patients with type 2 diabetes mellitus with inadequate glycemic control while on optimal doses of metformin and a sulfonylurea, and for whom NPH insulin is not an option, when added as a third agent. LINEZOLID (ZYVOXAM) 600mg tablets For treatment of proven vancomycin-resistant enterocci (VRE) infections. For the treatment of proven methicillin-resistant Staphylococcus aureus (MRSA) / methicillin-resistant Staphylococcus epidermidis (MRSE) infections in patients who are unresponsive to, or intolerant of, intravenous vancomycin or in whom intravenous vancomycin is not appropriate. The drug must be prescribed by, or in consultation with, an infectious disease specialist or medical microbiologist. February 2014 A - 42

258 LOW MOLECULAR WEIGHT HEPARINS (Dalteparin Sodium, Enoxaparin Sodium, Nadroparin Calcium, Tinzaparin Sodium). 1. For the treatment of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) for a maximum of 10 days. 2. For the extended treatment of recurrent symptomatic venous thromboembolism (VTE) that has occurred while patients are on therapeutic doses of warfarin. 3. For the prophylaxis of venous thromboembolism (VTE) up to 35 days following elective hip replacement or hip fracture surgery. 4. For the prophylaxis of VTE up to 10 days following elective knee replacement surgery. 5. For the treatment and secondary prevention of symptomatic venous thromboembolism (VTE) or pulmonary embolism (PE) for a period of up to 6 months in patients with cancer for whom warfarin therapy is not an option. Note: One prescription claim annually will be automatically reimbursed, up to the average amount required for one DVT treatment (approximately 10 days of therapy). If additional medication is required subsequent to the initial prescription, a request should be made through special authorization. Dalteparin sodium (Fragmin) Product Name DIN 10 Day Treatment Quantity 10,000IU/mL prefilled syringe 12,500IU/mL prefilled syringe 15,000IU/mL prefilled syringe 18,000IU/mL prefilled syringe 25,000IU/mL multidose vial Enoxaparin sodium (Lovenox) mL x 10 syringes = 4mL 0.5mL x 10 syringes = 5mL 0.6mL x 10 syringes = 6mL 0.72mL x 10 syringes = 8mL 3.8mL x 2 vials = 8mL 100mg/mL multidose vial mL x 5 vials = 15mL Enoxaparin sodium (Lovenox HP) 120mg/0.8mL prefilled syringe 150mg/mL prefilled syringe Nadroparin calcium (Fraxiparin Forte) mL x 10 syringes = 8mL 1mL x 10 syringes = 10mL 19,000IU/mL prefilled syringe mL x 10 syringes = 6mL 0.8mL x 10 syringes = 8mL 1.0mL x 10 syringes = 10mL Tinzaparin sodium (Innohep) 10,000IU/mL multidose vial 20,000IU/mL multidose vial 20,000IU/mL prefilled syringe mL x 8 vials = 16mL 2mL x 4 vials = 8mL 0.5mL x 10 syringes = 5mL 0.7mL x 10 syringes = 7mL 0.9mL x 10 syringes = 9mL February 2014 A - 43

259 MARAVIROC (CELSENTRI) 150 mg and 300 mg tablets For the treatment of HIV-1 infection in patients (Plan U beneficiaries) who have CCR5 tropic viruses and who have documented resistance to at least one agent from each of the three major classes of antiretrovirals (i.e. nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.) Requests for HIV-1 treatment-naïve patients will not be considered. METHADONE Compounded Oral Solution Requests from New Brunswick physicians authorized to prescribe methadone will be considered: 1. For the treatment of severe cancer-related or chronic non-malignant pain as an alternative to other opioids. 2. For the treatment of opioid dependence. All requests must meet requirements set out in the NBPDP methadone reimbursement policies. Pharmacy Claims: Claims submitted by pharmacies must be billed using the applicable PIN. Opioid dependence Chronic pain METHADONE HCL (METHADOSE) 10mg/mL dye-free, sugar-free, unflavored oral concentrate Requests from New Brunswick physicians authorized to prescribe methadone will be considered: 1. For the treatment of opioid dependence. All requests must meet requirements set out in the NBPDP methadone reimbursement policies. Pharmacy Claims: Claims submitted by pharmacies must be billed using DIN METHADONE HCL (METADOL) 1 mg/ml oral solution and 10 mg/ml oral concentrate Requests from New Brunswick physicians authorized to prescribe methadone will be considered: 1. For the treatment of severe cancer-related or chronic non-malignant pain as an alternative to other opioids. 2. For the treatment of opioid dependence. All requests must meet requirements set out in the NBPDP methadone reimbursement policies. Pharmacy Claims: Claims submitted by pharmacies must be billed using the applicable PIN. 1mg/mL oral solution Opioid dependence Chronic pain mg/mL oral concentrate Opioid dependence Chronic pain METHADONE HCL (METADOL) 1mg, 5mg, 10mg, 25mg tablets Requests from New Brunswick physicians authorized to prescribe methadone will be considered: 1. For the treatment of severe cancer-related or chronic non-malignant pain as an alternative to other opioids. Requests will not be considered: 1. For the treatment of opioid dependence. 2. Preparations compounded using Metadol tablets will not be considered. February 2014 A - 44

260 METHYLPHENIDATE (BIPHENTIN) 10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg and 80mg controlled release capsules For the treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children age 6 to 25 years who demonstrate significant symptoms and who have tried immediate release and slow release methylphenidate with unsatisfactory results. Requests will be considered from specialists in pediatric psychiatry, pediatricians or general practitioners with expertise in ADHD. METHYLPHENIDATE-ER (CONCERTA AND TEVA-METHYLPHENIDATE ER-C) 18 mg, 27 mg, 36 mg and 54 mg extended-release tablets For the treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children aged 6 to 25 years who demonstrate significant symptoms and who have tried immediate release or slow release methylphenidate with unsatisfactory results. Requests will be considered from specialists in pediatric psychiatry, pediatricians or general practitioners with expertise in ADHD. MODAFINIL (ALERTEC and generic brands) 100mg tablet For the treatment of narcolepsy confirmed by a sleep study. MOMETASONE FUROATE/FORMOTEROL FUMARATE DIHYDRATE (ZENHALE) 5mcg/50mcg, 5mcg/100mcg, 5mcg/200mcg per actuation metered-dose inhaler For patients with reversible obstructive airways disease who are: Stabilized on an inhaled corticosteroid and a long-acting beta 2-adrenergic agonist OR Using optimal doses of inhaled corticosteroids but are still poorly controlled. MONTELUKAST (SINGULAIR and generic brands) 4mg, 5mg chewable tablets 10mg tablets 4mg oral granules For the treatment of moderate to severe asthma in patients who: Are not adequately controlled with moderate to high dose inhaled corticosteroids despite compliance with treatment AND Require increasing amounts of short-acting beta 2-adrenergic agonists. MOXIFLOXACIN (AVELOX) 400mg tablets For the completion of therapy instituted in the hospital setting for the treatment of nosocomial pneumonia, community acquired pneumonia (CAP) or acute exacerbation of chronic bronchitis (AECB). For the treatment of severe pneumonia in nursing home patients (regular benefit for Plan V). For the treatment 1 of CAP in patients; o with co-morbidity 2 upon radiographic confirmation of pneumonia, or o who have failed first line therapies (macrolide, doxycycline, amoxicillin-clavulanate). For the treatment 1 of AECB in complicated patients 3 who have failed treatment with one of the following (amoxicillin, doxycycline, TMP-SMX, cefuroxime, macrolide, ketolide or amoxicillin-clavulanate). Prescriptions written by New Brunswick infectious disease specialists, medical microbiologists, medical oncologists, respirologists and internal medicine specialists will not require special authorization. 1. If treated with an antibiotic within the past 3 months choose an antibiotic from a different class. 2. Co-morbidity includes chronic lung disease, malignancy, diabetes, liver, renal or congestive heart failure, use of antibiotics or steroids in the past 3 months, suspected macroaspiration, hospitalization within last 3 months, HIV/AIDs, smoking, malnutrition or acute weight loss. 3. Complicated AECB defined as increased cough and sputum, sputum purulence and increased dyspnea AND o FEV 1 < 50% predicted February 2014 A - 45

261 o OR FEV % and one of the following: 4 exacerbations per year Ischemic heart disease Chronic oral steroid use Antibiotic use in the past 3 months NABILONE (CESAMET and generic brands) 0.25mg, 0.5 mg and 1 mg capsules For the management of severe nausea and vomiting associated with cancer chemotherapy. NADROPARIN CALCIUM (FRAXIPARINE) Prefilled syringes NADROPARIN CALCIUM (FRAXIPARIN FORTE) Prefilled syringes See criteria under Low Molecular Weight Heparins. NAFARELIN ACETATE (SYNAREL) 2mg/mL nasal solution Approved for the hormonal management of endometriosis, including pain relief and reduction of endometriotic lesions. Requests will be considered for women age 18 and older. Approval limits payment to a maximum of 6 months of therapy. NALTREXONE (REVIA) 50mg tablets For the treatment of alcohol dependence, as an adjunct to a comprehensive program to support abstinence, and reduce the risk of relapse. For the maintenance of opioid-free state in individuals who were previously opioid-dependent but have successfully completed detoxification. Treatment should not be attempted until the patient has remained opioidfree for 7-10 days. Requests will be considered only when used as an adjunct to psychosocial intervention. In the event that a patient participates in a program other than those offered by New Brunswick Addiction Services, details on the type of counselling/supportive program the patient will be involved in will be requested. Coverage will be approved initially for 12 weeks. Continued coverage will require information on the outcome of therapy as well as patient's compliance with treatment programs. NARATRIPTAN (AMERGE and generic brands) 1mg and 2.5mg tablets For the treatment of migraine 1 headache when: o Migraines are moderate 2 in severity and other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective, or o Migraine attacks are severe 2 or ultra severe 2 Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. February 2014 A - 46

262 NATALIZUMAB (TYSABRI) 300mg/15mL vial Initial Request: For the treatment of Relapsing-Remitting Multiple Sclerosis (RRMS) in patients who meet all the following criteria: The patient s physician is a neurologist experienced in the management of relapsing-remitting multiple sclerosis (RRMS); AND The patient; Has a current EDSS less than or equal to 5.0; AND Has failed to respond to a full and adequate course (see note below) of at least ONE disease modifying therapy OR has contraindications/intolerance to at least TWO disease modifying therapies; AND Has had ONE of the following types of relapses in the past year: - The occurrence of one relapse with partial recovery during the past year AND has at least ONE gadoliniumenhancing lesion on brain MRI, OR significant increase in T2 lesion load compared to a previous MRI; OR - The occurrence of two or more relapses with partial recovery during the past year; OR - The occurrence of two or more relapses with complete recovery during the past year AND has at least ONE gadolinium-enhancing lesion on brain MRI, OR significant increase in T2 lesion load compared to a previous MRI. Approval Period: 1 year Requirements for Initial Requests: The patient s physician provides documentation setting out the details of the patient s most recent neurological examination within ninety (90) days of the submitted request. This must include a description of any recent attacks, the dates, and the neurological findings. MRI reports do NOT need to be submitted with the initial request Renewal: Date and details of the most recent neurological examination and EDSS scores must be provided (exam must have occurred within that last 90 days) AND Patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year; AND Recent Expanded Disability Status Scale (EDSS) score less than or equal to 5.0 Notes: Failure to respond to a full and adequate course: defined as a trial of at least 6 months of interferon or glatiramer therapy AND experienced at least one disabling relapse (attack) while on interferon or glatiramer therapy. Combination therapy of Natalizumab with other disease modifying therapies (e.g. Avonex, Betaseron, Copaxone, Rebif, Extavia, Gilenya) will not be funded. NILOTINIB (TASIGNA) 150mg capsules For the first-line treatment of adult patients with Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) in chronic phase. NILOTINIB (TASIGNA) 200mg capsules For the treatment of chronic phase (CP) and accelerated phase (AP) Philadelphia chromosome positive (Ph+) chronic myeloid leukemia (CML) in adult patients who: are resistant or intolerant to imatinib, or intolerant to dasatinib NORETHINDRONE ACETATE / ESTRADIOL-17β (ESTALIS) 140/50mcg and 250/50mcg transdermal patches For the treatment of menopausal symptoms in women for whom oral forms of HRT are not tolerated or indicated. February 2014 A - 47

263 OCTREOTIDE ACETATE (SANDOSTATIN and generic brand) 50mcg, 100mcg, 500mcg ampoules and 200mcg multi-dose vial For the control of symptoms associated with metastatic carcinoid and vasoactive intestinal peptide-secreting tumors (VIPomas). For the treatment of acromegaly. OCTREOTIDE ACETATE (SANDOSTATIN LAR) 10mg, 20mg and 30mg vials For the treatment of acromegaly. OFLOXACIN (OCUFLOX and generic brands) 0.3% ophthalmic solution For the treatment of bacterial conjunctivitis. Prescriptions written by New Brunswick ophthalmologists and optometrists do not require special authorization. OLANZAPINE (ZYPREXA and generic brands) 2.5mg, 5mg, 7.5mg, 10mg and 15mg tablets OLANZAPINE (ZYPREXA ZYDIS and generic brands) 5mg, 10mg, 15mg and 20mg oral disintegrating tablets For the acute and maintenance treatment of schizophrenia and related psychotic disorders. For the acute treatment of manic or mixed episodes in bipolar l disorder in patients with intolerance or a history of failure to one other atypical antipsychotic. For maintenance treatment in patients with bipolar disorder who are currently stabilized on olanzapine. Advice from a psychiatrist is suggested prior to starting therapy. Prescriptions written by New Brunswick psychiatrists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. OMEPRAZOLE (LOSEC and generic brands) 20mg tablets 20mg capsules See criteria under Proton Pump Inhibitors. ONABOTULINUMTOXINA (BOTOX) 50 Allergan units per vial (PIN ) and 100 Allergan units per vial 1. For the management of focal spasticity following stroke in adults 2. For the treatment of equinus foot deformity in cerebral palsy in patients 2 years of age and older 3. To reduce the subjective symptoms and objective signs of cervical dystonia (spasmodic torticollis) in adults 4. For the treatment of blepharospasm, hemifacial spasm (VII nerve disorder) and strabismus in patients 12 years of age and older ONABOTULINUMTOXINA (BOTOX) 200 Allergan units per vial (PIN ) For the treatment of urinary incontinence due to neurogenic detrusor overactivity resulting from neurogenic bladder associated with multiple sclerosis (MS) or subcervical spinal cord injury (SCI) if the following conditions are met: patient failed to respond to behavioural modification and anticholinergics and/or is intolerant to anticholinergics subsequent treatments are provided at intervals no less than every 36 weeks Patients who fail to respond to initial treatment with onabotulinumtoxina should not be retreated. ONDANSETRON (ZOFRAN and generic brands) 4mg and 8mg tablets 4mg/5mL oral solution For the treatment of emesis in patients who are: receiving moderately or severely emetogenic chemotherapy OR February 2014 A - 48

264 receiving intravenous chemotherapy or radiotherapy and who have not experienced adequate control with other available antiemetics OR receiving any intravenous chemotherapy or radiotherapy and have experienced emesis with a prior cycle of chemotherapy with intolerable side effects to other antiemetics, including steroids and anti-dopaminergic agents. Only requests for the oral dosage forms are eligible for consideration. Usually a single oral dose pre-chemotherapy is sufficient to control symptoms. Some patients may require additional therapy up to 48 hours after the last dose of chemotherapy or last radiation treatment. Benefit beyond 48 hours has not been established. When used in combination with aprepitant, only a single oral dose pre-chemotherapy will be covered. Note: Prescription claims for up to a maximum of 12 tablets of ondansetron or 2 tablets of either granisetron or dolasetron will be automatically reimbursed every 28 days when the prescription is written by an oncologist or an oncology clinical associate/general practitioners-oncology. If additional medication is required within a 28 day period subsequent to the initial prescription, a request should be made through special authorization. ONDANSETRON (ZOFRAN ODT and generic brand) 4mg and 8mg oral disintegrating tablets Requests will be considered for the treatment of emesis in patients who have difficulty swallowing oral tablets and are: receiving moderately or severely emetogenic chemotherapy OR receiving intravenous chemotherapy or radiotherapy and who have not experienced adequate control with other available antiemetics OR receiving any intravenous chemotherapy or radiotherapy and have experienced emesis with a prior cycle of chemotherapy with intolerable side effects to other antiemetics, including steroids and anti-dopaminergic agents. Only requests for the oral dosage forms are eligible for consideration. Usually a single oral dose pre-chemotherapy is sufficient to control symptoms. Some patients may require additional therapy up to 48 hours after the last dose of chemotherapy or last radiation treatment. Benefit beyond 48 hours has not been established. When used in combination with aprepitant, only a single oral dose prechemotherapy will be covered. OSELTAMIVIR (TAMIFLU) 30mg, 45mg and 75mg capsules For beneficiaries residing in long-term care facilities* during an influenza outbreak situation and further to the recommendation of a Medical Officer of Health: For treatment of long-term care residents with clinically suspected or lab confirmed influenza A or B. A clinically suspected case is one in which the patient meets the criteria of influenza-like illness and there is confirmation of influenza A or B circulating within the facility or surrounding community. For prophylaxis of long-term care residents where the facility has an influenza A or B outbreak. Prophylaxis should be continued until the outbreak is over. An outbreak is declared over 7 days after the onset of the last case in the facility. In these criteria, long-term care facility refers to a licensed nursing home and does not include special care homes. February 2014 A - 49

265 OSTEOPOROSIS DRUGS (alendronate, etidronate, raloxifene and risedronate) Requests for osteoporosis drugs for patients without documented fracture should reference the most recent (2010) version of the Canadian Association of Radiologist and Osteoporosis Canada (CAROC) table 1, or the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) when determining whether the patient meets criteria for high (>20%) 10-year fracture risk. Fracture Risk Tables Age (years) Low Risk < 10% Women 10-YEAR RISK Moderate Risk 10% - 20% High Risk > 20% LOWEST T-SCORE femoral neck 50 > to < > to < > to < > to < > to < > to < > to < > to < Age (years) Low Risk < 10% Men 10-YEAR RISK Moderate Risk 10% - 20% High Risk > 20% LOWEST T-SCORE femoral neck 50 > to < > to < > to < > to < > to < > to < > to < > to < Ref: Can Assoc Radiol J, 2011; 62(4): ALENDRONATE (FOSAMAX and generic brands) 10mg and 70mg tablets RISEDRONATE (ACTONEL and generic brands) 5mg and 35mg tablets 1. For the treatment of osteoporosis: with documented fragility fracture; or without documented fractures in patients at high 10-year fracture risk (see fracture risk tables). 2. For prophylaxis of corticosteroid induced osteoporosis in patients who will be or have been on systemic corticosteroid therapy for 3 months. ETIDRONATE (DIDRONEL and generic brands) 200mg tablets ETIDRONATE AND CALCIUM (DIDROCAL KIT and generic brands) 400mg/500mg tablets For the treatment of osteoporosis: with documented fragility fracture when alendronate or risedronate are not tolerated or contraindicated; or without documented fractures in patients at high 10-year fracture risk (see fracture risk tables) when alendronate or risedronate are not tolerated or contraindicated. RALOXIFENE (EVISTA and generic brands) 60mg tablets For the treatment of postmenopausal osteoporosis with documented fragility fracture when bisphosphonates are not tolerated or contraindicated; or without documented fractures in patients at high 10-year fracture risk (see fracture risk tables) when bisphosphonates are not tolerated or contraindicated. February 2014 A - 50

266 OXCARBAZEPINE (TRILEPTAL and generic brand) 150mg, 300mg, 600mg tablets 60mg/mL suspension For the treatment of epilepsy in patients who have had an inadequate response or are intolerant to at least 3 other antileptics including carbamazepine. OXYBUTYNIN (DITROPAN XL) 5mg and 10mg tablets OXYBUTYNIN (UROMAX) 10mg, 15mg controlled release tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate release oxybutynin. Requests for the treatment of stress incontinence will not be considered. OXYCODONE (OXY IR and generic and SUPEUDOL) 5mg, 10mg and 20mg tablets (immediate release) For the treatment of moderate to severe cancer-related or chronic non-malignant pain. PALIPERIDONE (INVEGA SUSTENNA) 50mg/0.5mL, 75mg/0.75mL, 100mg/mL, 150mg/1.5mL prefilled syringes For the treatment of schizophrenia in patients: for whom compliance with an oral antipsychotic presents problems, OR who are currently receiving a typical depot antipsychotic and experiencing significant side effects (EPS or TD) or lack of efficacy. PANTOPRAZOLE SODIUM (PANTOLOC and generic brands) 20mg and 40mg tablets See criteria under Proton Pump Inhibitors. PAZOPANIB (VOTRIENT) 200mg tablets For the treatment of advanced or metastatic renal cell (clear cell) carcinoma (mrcc) in patients who are unable to tolerate sunitinib and who have an ECOG performance status of 0 or 1. Initial approval period: 1 year Renewal criteria: Written confirmation that the patient has benefited from therapy and is expected to continue to do so. Renewal period: 1 year PEGFILGRASTIM (NEULASTA) 6mg prefilled syringe Requests will be considered when prescribed by, or on the advice of, a hematologist or medical oncologist for the following indications: Chemotherapy Support Primary prophylaxis: For use in previously untreated patients receiving a moderate to severely myelosuppressive chemotherapy regimen (i.e. 40% incidence of febrile neutropenia). Febrile neutropenia is defined as a temperature 38.5 C or > 38.0 C three times in a 24 hour period and neutropenia with an absolute neutrophil count (ANC) < 0.5 x 10 9 /L. Secondary prophylaxis: - For use in patients receiving myelosuppressive chemotherapy who have experienced an episode of febrile neutropenia, neutropenic sepsis or profound neutropenia in a previous cycle of chemotherapy; or - For use in patients who have experienced a dose reduction or treatment delay longer than one week, due to neutropenia. Dosing for chemotherapy support: The recommended dosage of pegfilgrastim is a single subcutaneous injection of 6mg, administered once per February 2014 A - 51

267 cycle of chemotherapy. Pegfilgrastim should be administered no sooner than 24 hours after the administration of cytotoxic chemotherapy. Pegfilgrastim is not indicated and requests will not be considered for the following: Myeloid malignancies Pediatric patients with cancer receiving myelosuppressive chemotherapy Non-malignant neutropenias Stem-cell transplantation Treatment of febrile neutropenia or in the prevention of febrile neutropenia in the palliative setting Note: Filgrastim (Neupogen ) dosing is 5 mcg/kg/day. For patients 60 kg who are prescribed filgrastim 300mcg for 9 or fewer days, the cost of filgrastim therapy is less than the cost of pegfilgrastim 6mg. PEGINTERFERON ALFA-2A (PEGASYS) 180mcg/0.5mL pre-filled syringe 180mcg/mL vial injection Requests will be considered from internal medicine specialists for the treatment of: chronic hepatitis C (HCV RNA positive) for patients who cannot tolerate ribavirin. o Initial coverage of 24 weeks will be approved for all patients. Coverage for an additional 24 weeks will be approved for patients with HCV genotype 1. o A positive HCV RNA assay after 24 weeks of therapy is an indication to stop treatment. HBeAg negative chronic hepatitis B patients with compensated liver disease, liver inflammation and evidence of viral replication with demonstrated intolerance or failure to lamivudine therapy. o Maximum duration of coverage will be 48 weeks. PEGINTERFERON ALFA-2A AND RIBAVIRIN (PEGASYS RBV) 180mcg injection and 200mg tablets Requests will be considered from internal medicine specialists: 1. For the treatment of peginterferon and ribavirin treatment-naïve chronic hepatitis C (HCV RNA positive) patients. Note: Initial coverage of 24 weeks will be approved for all patients. Coverage for an additional 24 weeks will be approved for patients with HCV genotypes other than 2 and 3. A positive HCV RNA assay after 24 weeks of therapy is an indication to stop treatment. 2. For the treatment of patients with chronic hepatitis C genotype 1 infection (HCV RNA positive) in combination with boceprevir or telaprevir. Note: Coverage will be approved for up to a total of 48 weeks in combination with boceprevir or telaprevir. PEGINTERFERON ALFA-2B AND RIBAVIRIN (PEGETRON and PEGETRON REDIPEN) 50mcg injection and 200mg capsule, 80mcg injection and 200mg capsule 100mcg injection and 200mg capsule, 120mcg injection and 200mg capsule 150mcg injection and 200mg capsule Requests will be considered from internal medicine specialists: 1. For the treatment of peginterferon and ribavirin treatment-naïve chronic hepatitis C (HCV RNA positive) patients. Note: Initial coverage of 24 weeks will be approved for all patients. Coverage for an additional 24 weeks will be approved for patients with HCV genotypes other than 2 and 3. A positive HCV RNA assay after 24 weeks of therapy is an indication to stop treatment. 2. For the treatment of patients with chronic hepatitis C genotype 1 infection (HCV RNA positive) in combination with boceprevir or telaprevir. Note: Coverage will be approved for up to a total of 48 weeks in combination with boceprevir or telaprevir. PIOGLITAZONE (ACTOS and generic brands) 15mg, 30mg and 45mg tablets For patients with type 2 diabetes who are not adequately controlled by diet, exercise and drug therapy. Drug therapy should include a trial of a sulfonylurea and metformin, alone and in combination, unless one of these agents is not tolerated or is contraindicated. February 2014 A - 52

268 PRASUGREL HYDROCHLORIDE (EFFIENT) 10mg tablet In combination with ASA for patients with: - ST-elevated myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) who have not received antiplatelet therapy prior to arrival in the catheterization lab. Treatment must be initiated in hospital. OR - Acute coronary syndrome who failed on optimal clopidogrel and ASA therapy as defined by definite stent thrombosis1, or recurrent STEMI, or NSTEMI or UA after prior revascularization via PCI. Notes: 1. Definite stent thrombosis, according to the Academic Research Consortium, is a total occlusion originating in or within 5 mm of the stent or is a visible thrombus within the stent or is within 5 mm of the stent in the presence of an acute ischemic clinical syndrome within 48 hours. Definite stent thrombosis must be confirmed by angiography or by pathologic evidence of acute thrombosis. 2. As per the product monograph, prasugrel is contraindicated in patients with a known history of transient ischemic attack or stroke; those with active pathological bleeding such as gastrointestinal bleeding or intracranial hemorrhage; and those with severe hepatic impairment (Child-Pugh Class C). 3. As per the product monograph, prasugrel is not recommended in patients 75 years of age because of the increase risk of fatal and intracranial bleeding; or those with body weight < 60 kg because of increased risk of major bleeding due to an increase in exposure to the active metabolite of prasugrel. Approval will be for a maximum of 12 months. Prescriptions written by invasive (interventional) cardiologists do not require special authorization. PREGABALIN (LYRICA and generic brands) 25mg, 50mg, 75mg, 150mg, 225mg, 300mg tablets For the treatment of neuropathic pain (e.g. diabetic peripheral neuropathy, postherpetic neuralgia) in patients who have failed a trial of a tricyclic antidepressant (e.g. amitriptyline, desipramine, imipramine, nortriptyline). February 2014 A - 53

269 PROTON PUMP INHIBITORS (Lansoprazole, Omeprazole, Pantoprazole Sodium) Omeprazole dose > 20mg daily Requests for omeprazole doses >20mg daily will be considered for indications listed below when beneficiaries remain symptomatic despite an adequate trial of regular benefit PPI (i.e. pantoprazole magnesium*, rabeprazole* OR omeprazole at a dose of 20mg daily) for a minimum of 8 weeks. Lansoprazole 15mg & 30mg capsules and Pantoprazole Sodium 20mg & 40mg tablets Requests for lansoprazole and pantoprazole sodium will be considered for beneficiaries in whom there has been a therapeutic failure with regular benefit PPIs (i.e. pantoprazole magnesium*, rabeprazole*, omeprazole 20mg daily). Approval Periods Requests for lansoprazole, pantoprazole sodium, and doses of omeprazole greater than 20mg per day meeting criteria above will be considered for the following maximum approval periods: Indication and Diagnostic Information Maximum Approval Period 1 2 Symptomatic GERD or other refluxassociated indications (i.e. non-cardiac chest pain) Erosive/ulcerative esophagitis or Barrett s esophagus Considered for short-term (8-12 week) approval Considered for long term approval 3 Zollinger-Ellison Syndrome Considered for long-term approval 4 Gastric/duodenal ulcers in individuals who are H. pylori negative or having uninvestigated peptic ulcer disease (PUD) Considered for up to 12 weeks 5 H. pylori positive patients with PUD 6 Gastro-duodenal protection (ulcer prophylaxis) for high risk patients (e.g. high risk NSAID users) Omeprazole 20mg BID will be reimbursed without a special authorization as part of an H. pylori eradication regimen.* H. pylori regimens containing lansoprazole or pantoprazole sodium will be reimbursed only under special authorization. Considered for one year with reassessment *Pantoprazole Magnesium (Tecta) 40 mg tablets and rabeprazole 10mg and 20mg tablets are regular benefits for Plans ABEFGVW without quantity limit. Note: Omeprazole 20mg tablets and capsules, when prescribed in doses up to 20mg daily, are listed as regular benefits for Plans ABEFGVW. For Plans ABEFGV, a bi-annual quantity limit has been established. QUINAGOLIDE (NORPROLAC) 0.075mg, 0.15mg tablets For the treatment of patients with hyperprolactinemia who have failed or are intolerant to bromocriptine. RALOXIFENE (EVISTA and generic brands) 60mg tablets See criteria under Osteoporosis Drugs. February 2014 A - 54

270 RANIBIZUMAB (LUCENTIS) 2.3 mg / 0.23 ml vial for intravitreal injection Neovascular (wet) age-related macular degeneration (AMD) Initial Coverage: An initial claim of up to two vials of ranibizumab (one vial per eye treated) will be automatically reimbursed when prescribed by an ophthalmologist. If additional medication is required, a request should be made through special authorization. Requests will be considered: For the treatment of patients with neovascular (wet) age-related macular degeneration (AMD) 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) Administration is to be done by a qualified ophthalmologist experienced in intravitreal injections. The interval between doses should not be shorter than 1 month. Coverage will not be approved for patients: With permanent retinal damage as defined by the Royal College of Ophthalmology guidelines Receiving concurrent treatment with verteporfin. Continued Coverage: Treatment with ranibizumab should be continued only in people who maintain adequate response to therapy. Ranibizumab 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 2 consecutive visits in the treated eye, attributed to AMD in the absence of other pathology Reductions in BCVA of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect, adverse events or both. There is evidence of deterioration of the lesion morphology despite optimum treatment over 3 consecutive visits. The NBPDP will limit reimbursement to a maximum of 1 vial of ranibizumab per eye treated every 30 days. Claims submitted for greater than 1 vial, or submitted within 30 days of a previous claim will not be reimbursed. Diabetic macular edema (DME) Initial coverage: For the treatment of visual impairment due to diabetic macular edema (DME) in patients who meet all of the following criteria: clinically significant centre-involving macular edema for whom laser photocoagulation is also indicated hemoglobin A1c test in the past 6 months with a value of less than or equal to 11% best corrected visual acuity of 20/32 to 20/400 central retinal thickness greater than or equal to 250 micrometers Approval Period: 1 year Renewal Criteria: confirm that a hemoglobin A1c test in the past 6 months had a value of less than or equal to 11% date of last visit and results of best corrected visual acuity at that visit date of last OCT and central retinal thickness on that examination if ranibizumab is being administered monthly, please provide details on the rationale Notes : Treatment should be given monthly until maximum visual acuity is achieved (i.e. stable visual acuity for three consecutive months while on ranibizumab). Thereafter, the patient's visual acuity should be monitored monthly. Treatment should be resumed when monitoring indicates a loss of visual acuity due to DME until stable visual acuity is reached again for three consecutive months. Pharmacy Claims: Claims submitted by pharmacies for reimbursement of Lucentis should be billed per vial. This is an exception to the February 2014 A - 55

271 claims submission quantity standards outlined in the April 14, 2009 NBPDP Bulletin #749. Lucentis is supplied by the manufacturer as a 2.3 mg/0.23 ml vial, however CPhA3 messaging for the online submission of pharmacy claims permits transmission of quantities to only one decimal place. Since the 0.23 ml vial cannot be adjudicated to two decimal places, this product should be claimed per vial. REPAGLINIDE (GLUCONORM and generic brands) 0.5mg, 1mg and 2mg tablets For patients with type 2 diabetes who are not adequately controlled by diet and exercise and glyburide and/or metformin or who have frequent or severe hypoglycemic episodes despite dosage adjustment of glyburide. RIFABUTIN (MYCOBUTIN) 150mg capsules Requests will be considered for the prophylaxis of disseminated Mycobacterium avium complex (MAC) disease in the following beneficiaries: HIV infected patients with an AIDS defining diagnosis and CD4+ cell count less than or equal to 200/mm 3. HIV positive patients without an AIDS defining diagnosis and CD4+ cell count less than or equal to 100/mm 3. RILUZOLE (RILUTEK and generic brands) 50mg tablets For the treatment of amyotrophic lateral sclerosis (ALS) or Lou Gehrig s Disease, when initiated by a physician with expertise in the management of ALS in patients who have: A probable or definite diagnosis of ALS as defined by the World Federation of Neurology criteria. ALS symptoms for less than five years. FVC > 60 % predicted upon initiation of therapy. No tracheostomy for invasive ventilation Requests will be approved for a maximum of six months coverage. Coverage cannot be renewed once the patient has a tracheostomy for the purpose of invasive ventilation. RISEDRONATE (ACTONEL and generic brand) 30mg tablets For the treatment of Paget s disease. RISEDRONATE (ACTONEL and generic brands) 5mg tablets and 35mg tablets See criteria under Osteoporosis Drugs. RISPERIDONE (RISPERDAL M and generic brand) 0.5mg, 1mg, 2mg, 3mg and 4mg tablets 1. For the treatment of schizophrenia and related psychotic disorders. 2. For use in severe dementia for the short-term symptomatic management of inappropriate behaviour due to aggression and/or psychosis. 3. For the acute management of manic episodes associated with Bipolar 1 disorder. Requests will be considered for patients who have difficulty swallowing oral tablets. Prescriptions written by New Brunswick psychiatrists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. RISPERIDONE (RISPERDAL CONSTA) Prolonged release suspension for injection 12.5mg, 25mg, 37.5mg and 50mg vials For the treatment of schizophrenia in patients: for whom compliance with an oral antipsychotic presents problems, OR who are currently receiving a typical depot antipsychotic and experiencing significant side effects (EPS or TD) or lack of efficacy February 2014 A - 56

272 RITUXIMAB (RITUXAN) 10mg/mL injection For the treatment of adult patients with severe active rheumatoid arthritis who have failed to respond to an adequate trial with an anti-tnf agent. o Rituximab will not be reimbursed concomitantly with anti-tnf agents. o Approval for re-treatment with rituximab will only be considered for patients who have achieved a response, followed by a subsequent loss of effect and, after an interval of no less than six months from the previous dose. For the induction of remission in patients with severely active granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) who have severe intolerance or other contraindication to cyclophosphamide, or who have failed an adequate trial of cyclophosphamide. RIVAROXABAN (XARELTO) 10mg tablet Venous thromboembolism prophylaxis (following total knee or total hip replacement surgery) For the prophylaxis of venous thromboembolism as an alternative to low molecular weight heparins for total knee replacement (usual duration up to 14 days) OR total hip replacement surgery (usual duration up to 35 days). The maximum dose of rivaroxaban that will be reimbursed is 10 mg daily for up to 30 days during a 6 month period. Note: Subsequent requirements for prophylaxis within a 6 month period (i.e. second joint replacement procedure within the 6 month period) will require Special Authorization. RIVAROXABAN (XARELTO) 15mg and 20mg tablets Stroke and systemic embolism prophylaxis in patients with non-valvular atrial fibrillation For the prevention of stroke and systemic embolism in at-risk patients with non-valvular atrial fibrillation for whom: a. Anticoagulation is inadequate following a at least a two month trial on warfarin; or b. Warfarin is contraindicated or not possible due to inability to regularly monitor through International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home). The following patient groups are excluded from coverage for rivaroxaban for atrial fibrillation: a. Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate <30 ml/min) b. Patients 75 years of age or older without documented stable renal function c. Patients with hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis d. Patients with prosthetic heart valves. Notes: 1. At-risk patients with atrial fibrillation are defined as those with a CHADS 2 score of 1. Although the ROCKET-AF trial included patients with higher CHADS 2 scores ( 2), other landmark studies with the other newer oral anticoagulants demonstrated a therapeutic benefit in patients with a CHADS 2 score of 1. Prescribers may consider an antiplatelet regimen or oral anticoagulation for patients with a CHADS 2 score of 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). 3. Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see rivaroxaban product monograph). 4. Documented stable renal function is defined as creatinine clearance or estimated glomerular filtration rate that is maintained for at least 3 months (i.e ml/min for 15 mg once daily dosing or 50 ml/min for 20 mg once daily dosing). 5. There is currently no data to support that rivaroxaban provides adequate anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart valves, rivaroxaban is not recommended in these populations. 6. Patients starting rivaroxaban should have ready access to appropriate medical services to manage a major bleeding event. February 2014 A - 57

273 RIVAROXABAN (XARELTO) 10mg, 15mg, 20mg film-coated tablets DVT without symptomatic PE For the treatment of deep vein thrombosis (DVT) without symptomatic pulmonary embolism (PE). Approval Period: Up to 6 months Notes: The recommended dose of rivaroxaban for patients initiating DVT treatment is 15mg twice daily for 3 weeks, followed by 20mg once daily. Drug plan 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. As such, patients with an intended duration of therapy greater than 6 months should he considered for initiation on heparin/warfarin. Since renal impairment can increase bleeding risk, it is important to monitor renal function regularly. Other factors that increase bleeding risks should also be assessed and monitored (see product monograph). RIVASTIGMINE (EXELON and generic brands) 1.5mg, 3mg, 4.5mg and 6mg capsules 2mg/mL oral liquid See criteria under Cholinesterase Inhibitors. RIZATRIPTAN (MAXALT, MAXALT RPD and generic brands) 5mg and 10mg tablets For the treatment of migraine 1 headache when: o Migraines are moderate 2 in severity and other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective, or o Migraine attacks are severe 2 or ultra severe 2 Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. RUFINAMIDE (BANZEL) 100mg, 200mg, 400mg tablets For the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome for patients who meet all of the following criteria: are under the care of a physician experienced in treating Lennox-Gastaut syndrome-associated seizures, AND are currently receiving two or more antiepileptic drugs, AND in whom less costly antiepileptic drugs are ineffective or not appropriate. RUXOLITINIB (JAKAVI) 5mg, 15mg, 20mg tablets For patients with intermediate to high risk symptomatic Myelofibrosis (MF) as assessed using the Dynamic International Prognostic Scoring System (DIPSS) Plus or patients with symptomatic splenomegaly. Patients should have ECOG performance status 3 and be either previously untreated or refractory to other treatment. February 2014 A - 58

274 SALMETEROL/FLUTICASONE (ADVAIR) 50/100mcg, 50/250mcg and 50/500mcg discus 25/125mcg and 25/250mcg metered dose inhaler Reversible Obstructive Airway Disease: For patients with reversible obstructive airways disease who are - Stabilized on an inhaled corticosteroid and a long-acting beta 2-adrenergic agonist, OR - Using optimal doses of inhaled corticosteroids but are still poorly controlled. Chronic Obstructive Pulmonary Disease: For the treatment of chronic obstructive pulmonary disease (COPD) if symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day). Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**). Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms (i.e., MRC score of 3-5**) AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. SALMETEROL XINAFOATE (SEREVENT) 25mcg/actuation metered dose inhaler, 50µg diskus Reversible Obstructive Airway Disease: For the treatment of patients, 12 years of age or older, with reversible obstructive airway disease who are using optimal corticosteroid treatment, but are still poorly controlled. Chronic Obstructive Pulmonary Disease: For the treatment of chronic obstructive pulmonary disease (COPD) with EITHER a long-acting beta 2-adrenergic agonist (LABA) such as salmeterol, OR tiotropium if symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day). Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**). Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms (i.e., MRC score of 3-5**) AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. February 2014 A - 59

275 **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. Prescriptions written by certified New Brunswick respirologists do not require special authorization. Subsequent refills ordered by other practitioners will not require special authorization. SEVELAMER (RENAGEL) 400mg and 800mg tablets Treatment of severe renal failure, where a calcium salt is contraindicated or not tolerated or when a phosphate binder is needed in association with a calcium salt, where a calcium salt alone does not produce optimal control of the hyperphosphatemia. The prescription must be initiated by a nephrologist. SILDENAFIL CITRATE (REVATIO and generic brands) 20mg tablets For the treatment of patients with World Health Organization (WHO) functional class III idiopathic pulmonary arterial hypertension (IPAH) who do not demonstrate. vasoreactivity on testing or who do demonstrate vasoreactivity on testing but fail a trial of calcium channel blockers. For the treatment of patients with World Health Organization (WHO) functional class III pulmonary arterial hypertension (PAH) associated with connective tissue disease who do not respond to conventional therapy. Diagnosis of PAH should be confirmed by cardiac catheterization. The maximum dose of sildenafil that will be reimbursed is 20mg three times daily. SITAGLIPTIN (JANUVIA) 100mg tablets SITAGLIPTIN / METFORMIN (JANUMET) 50mg/500mg, 50mg/850mg, 50mg/1000mg tablets For the treatment of Type 2 diabetes mellitus in patients for whom NPH insulin is not an option and: Who have inadequate glycemic control while on optimal doses of metformin and a sulfonylurea when added as a third agent; or In combination with metformin when a sulfonylurea is not suitable due to contraindications or intolerance; or As monotherapy when metformin and sulfonylurea are not suitable due to contraindications or intolerance SOLIFENACIN (VESICARE) 5 mg and 10 mg tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate-release oxybutynin. Requests for the treatment of stress incontinence will not be considered. If the beneficiary has had a claim for oxybutynin in the previous 24 months, the adjudication system will recognize this information and the claim for solifenacin will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. February 2014 A - 60

276 SOMATROPIN (HUMATROPE) 1mg, 6mg, 12mg and 24mg/vial injection SOMATROPIN (NUTROPIN AQ) 5mg/mL Pen Cartridge and NuSpin SOMATROPIN (SAIZEN) 3.33mg, 5mg and 8.8mg/vial injection 6mg, 12mg and 20mg/cartridge For the treatment of short stature associated with Turner Syndrome in patients whose epiphyses are not closed. Must be prescribed by, or in consultation with, an endocrinologist. Note: Somatropin is a regular benefit of Plan T. SORAFENIB (NEXAVAR) 200mg tablets Metastatic Renal Cell Carcinoma (MRCC) As second-line therapy for patients with histologically confirmed metastatic clear cell renal cell carcinoma, who: o have disease progression after prior cytokine therapy (e.g. interferon; aldesleukin) within the previous 8 months; and o have a performance status of 0 or 1 on the basis of the Eastern Cooperative Oncology Group (ECOG) criteria ; and o have a favourable or intermediate risk status, according to the Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic score. Initial approval period: 1 year. Renewal criteria: Written confirmation that the patient has benefited from therapy and is expected to continue to do so. Renewal period: 1 year. Patients who are asymptomatic and those who are symptomatic but completely ambulant. Advanced Hepatocellular Carcinoma (HCC) For patients with Child-Pugh Class A* who have: o A performance status of 0,1, or 2 on the basis of the Eastern Cooperative Oncology Group (ECOG) criteria; and o Either progressed on trans-arterial chemoembolization (TACE) or not suitable for the TACE procedure. o Coverage may be renewed for patients with documentation of radiography and/or scan results indicating no progression Initial approval period: 6 months Approval period for renewal: 1 year Sorafenib will not be reimbursed if used with induction or adjuvant intent along with other curative-intent treatments; for maintenance therapy after trans-arterial chemoembolization; or if patients have Child-Pugh B or Child-Pugh C cirrhosis. *A Child-Pugh score of 5-6 is considered class A (well-compensated disease); 7-9 is class B (significant functional compromise); and is class C (decompensated disease). Patients who are asymptomatic and those who are symptomatic and in bed less than 50% of the time. The Memorial Sloan-Kettering Cancer Center (MSKCC) Prognostic Score categorizes patients into three risk groups according to the number of pre-treatment risk factors present: Favourable = none; Intermediate = one or two; Poor = three or more. Pretreatment risk factors: Low Karnofsky performance status (<80%) Lactate Dehydrogenase level greater than 1.5 times the upper limit of normal Hemoglobin level below the lower limit of normal High corrected serum calcium level (>10 mg/dl or 2.5 mmol/l) Interval of less than 1 year between diagnosis and treatment February 2014 A - 61

277 SUMATRIPTAN (IMITREX AND IMITREX DF and generic brands) 50mg and 100mg tablets For the treatment of migraine 1 headache when: o Migraines are moderate 2 in severity and other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective, or o Migraine attacks are severe 2 or ultra severe 2 Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. SUMATRIPTAN (IMITREX NASAL SPRAY) 5mg and 20mg nasal spray For the treatment of migraine 1 headache of moderate 2 intensity when other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and naratriptan. For the treatment of migraine 1 headache of severe 2 or ultra severe 2 intensity when patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and/or naratriptan. Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. SUMATRIPTAN (IMITREX INJECTION and generic brand) 6mg injection For the treatment of migraine 1 headache of moderate 2 intensity when other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND oral and nasal triptans are not appropriate. For the treatment of migraine 1 headache of severe 2 or ultra severe 2 intensity when oral and nasal triptans are not appropriate. Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping February 2014 A - 62

278 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. SUNITINIB (SUTENT) 12.5mg, 25mg and 50mg capsules 1. For the treatment of patients with progressive, unresectable, well or moderately differentiated, locally advanced or metastatic pancreatic neuroendocrine tumors (pnet) with an ECOG performance status of 0-2, until disease progression. 2. For the treatment of patients with c-kit expressing (CD117+) unresectable or metastatic/recurrent gastrointestinal stromal tumour (GIST) who meet the criteria for imatinib and who have: o Early progression (within 6 months) while on imatinib; o Progression following treatment with optimum (escalated) doses of imatinib; or o Intolerance to imatinib The dose reimbursed will be 50mg per day (4 weeks on, 2 weeks off) Response to sunitinib therapy should be assessed at least every six months and therapy should be discontinued when there is objective evidence of disease progression Sunitinib will not be reimbursed concomitantly with imatinib 3. For patients with histologically confirmed metastatic renal cell carcinoma (MRCC), who require: o First-line therapy for the treatment of MRCC, and the patient is either a favourable or intermediate risk according to the Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic score* or, o Second-line therapy for the treatment of MRCC, provided that disease progression has occurred after prior cytokine therapy (e.g. interferon; aldesleukin). The prescribed dosage is 50mg daily for four weeks, followed by two weeks off. This dosage is repeated in six week cycles. Initial approval period: 1 year Renewal criteria: Written confirmation that the patient has benefited from therapy and is expected to continue to do so. Renewal period: 1 year * The Memorial Sloan-Kettering Cancer Center (MSKCC) Prognostic Score categorizes patients into three risk groups according to the number of pre-treatment risk factors present: Favourable = none; Intermediate = one or two; Poor = three or more. Pretreatment risk factors: Low Karnofsky performance status (<80%) Lactate Dehydrogenase level greater than 1.5 times the upper limit of normal Hemoglobin level below the lower limit of normal High corrected serum calcium level (>10 mg/dl or 2.5 mmol/l) Interval of less than 1 year between diagnosis and treatment Reference: Motzer RJ, Bacik J, Murphy BA et al. Interferon-alfa as a comparative treatment for clinical trials of new therapies against advanced renal cell carcinoma. J Clin Oncol 2002;20; TACROLIMUS (PROTOPIC) 0.03% ointment For children over 2 years of age with refractory atopic dermatitis. Approvals will be given for up to twelve months at a time. TACROLIMUS (PROTOPIC) 0.1% ointment For the treatment of adults with moderate to severe atopic dermatitis who have failed or are intolerant to a site appropriate strength of corticosteroid therapy (i.e. low potency for the face versus intermediate to high potency for the trunk and extremities). TELAPREVIR (INCIVEK) 375mg tablet For the treatment of patients with chronic hepatitis C genotype 1 infection (HCV RNA positive) in combination with peginterferon alpha and ribavirin if the following criteria are met: Fibrosis stage of F2, F3 or F4 or on recommendation of an Internal Medicine Specialist February 2014 A - 63

279 Patient is not co-infected with HIV One course of treatment only (for up to 12 weeks duration) will be approved Notes: 1. Response-guided therapy should be considered in patients for whom this is appropriate. 2. Therapy should be discontinued in all patients with HCV RNA levels greater than 1,000 IU/mL at treatment week 4 or 12, or confirmed HCV RNA positive at treatment week 24. TEMOZOLOMIDE (TEMODAL and generic brand) 5mg, 20mg, 100mg, 140mg, 180mg, 250mg capsules For the treatment of newly diagnosed high grade glioma patients with a good performance status (Karnofsky performance status greater or equal to 60%) when used in combination with radiotherapy or as adjuvant therapy post-radiation up to a maximum of 6 cycles. TENOFOVIR (VIREAD) 300mg tablets For the treatment of adult patients who have experienced adverse events or virologic failure with nucleoside reverse transcriptase inhibitors. For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000 lu/ml. TERBINAFINE HYDROCHLORIDE (LAMISIL and generic brands) 250mg tablets Treatment of onychomycosis o approval limits payment for 6 weeks for the treatment of fingernail mycosis o approval limits payment for 12 weeks for the treatment of toenail mycosis. Treatment of dermatophyte infection unresponsive to other treatments or unlikely to respond to other treatments due to the site or severity of the infection. TESTOSTERONE (ANDRODERM, ANDROGEL, TESTIM) 12.2mg and 24.3mg patches, 2.5g and 5g packets, 1% gel TESTOSTERONE UNDECANDOATE (ANDRIOL and generic brand) 40 mg capsules For the treatment of congenital and acquired primary or secondary hypogonadism in males with a specific diagnosis of: Primary: cryptorchidism, Klinefelter s, orchiectomy, and other established causes Secondary: Pituitary-hypothalamic injury due to tumors, trauma, radiation Testosterone deficiency should be clearly demonstrated by clinical features and confirmed by two separate free testosterone measurements before initiating any replacement therapy Note: Older males with non-specific symptoms of fatigue, malaise, or depression who have low testosterone levels do not satisfy these criteria. THYROTROPIN ALPHA (THYROGEN) 0.9mg/mL injection 1. For on-going evaluation in patients who have documented evidence of thyroid cancer, have undergone appropriate surgical and/or medical management, and require monitoring for recurrence and metastatic disease. This includes: The patient has failed to respond to, or relapsed during: Primary use in patients with inability to raise an endogenous TSH level ( 25 mu/l) with thyroid hormone withdrawal. Primary use in patients with one of the following documented comorbidities in whom severe hypothyroidism could be life threatening: o unstable angina o recent myocardial infarction o class III-IV congestive heart failure o uncontrolled psychiatric illness February 2014 A - 64

280 o other medical condition in which the clinical course could lead to a potential life threatening situation Secondary use in patients with previous thyroid hormone withdrawal resulting in a documented life threatening event. 2. As an adjunctive treatment as pre-therapeutic stimulation for radioiodine ablation of thyroid tissue remnants in patients maintained on thyroid hormone suppression therapy who have undergone near-total or total thyroidectomy for well-differentiated thyroid cancer without evidence of distant metastatic thyroid cancer. TICAGRELOR (BRILINTA) 90mg tablet To be taken in combination with ASA 75mg -150mg daily a for patients with acute coronary syndrome (i.e. ST elevation myocardial infarction (STEMI), non-st elevation myocardial infarction (NSTEMI), or unstable angina (UA), as follows: STEMI b,c STEMI patients undergoing primary PCI NSTEMI or UA b,c Presence of high risk features irrespective of intent to perform revascularization: o High GRACE risk score (>140) o High TIMI risk score (5-7) o Second ACS within 12 months o Complex or extensive coronary artery disease e.g. diffuse three vessel disease o Definite documented cerebrovascular or peripheral vascular disease o Previous CABG OR Undergoing PCI + high risk angiographic anatomy d Notes: (a) Co-administration of ticagrelor with high maintenance dose ASA (>150mg daily) is not recommended. (b) In the PLATO study more patients on ticagrelor experienced non CABG related major bleeding than patients on clopidogrel, however, there was no difference between the rate of overall major bleeding, between patients treated with ticagrelor and those treated with clopidogrel. As with all other antiplatelet treatments the benefit/risk ratio of antithrombotic effect vs. bleeding complications should be evaluated. (c) Ticagrelor is contraindicated in patients with active pathological bleeding, in those with a history of intracranial hemorrhage and moderate to severe hepatic impairment. (d) High risk angiographic anatomy is defined as any of the following: left main stenting, high risk bifurcation stenting (i.e., two-stent techniques), long stents 38 mm or overlapping stents, small stents 2.5 mm in patients with diabetes. Approval will be for a maximum of 12 months. Prescriptions written by invasive (interventional) cardiologists do not require special authorization. TINZAPARIN SODIUM (INNOHEP) 10,000IU/mL multidose vials and prefilled syringes 20,000IU/mL multidose vials and prefilled syringes See criteria under Low Molecular Weight Heparins TIOTROPIUM (SPIRIVA) 18mcg capsule for inhalation For the treatment of chronic obstructive pulmonary disease (COPD) with EITHER tiotropium OR a long-acting beta 2-adrenergic agonist (LABA) if symptoms persist after 2-3 months of short-acting bronchodilator therapy (i.e. salbutamol at a maximum dose of 8 puffs/day or ipratropium at maximum dose of 12 puffs/day). Coverage can be provided without a trial of short-acting agent if there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1 /FVC ratio < 0.7) and significant symptoms (i.e. MRC score of 3-5**). Combination therapy with tiotropium AND a long-acting beta 2-adrenergic agonist/inhaled corticosteroid (LABA/ICS) will only be considered if: - there is spirometric evidence of at least moderate to severe airflow obstruction (FEV 1 < 60% and FEV 1/FVC ratio < 0.7), and significant symptoms (i.e., MRC score of 3-5**) AND - there is evidence of one or more moderate-to-severe exacerbations per year, on average, for 2 consecutive years requiring antibiotics and/or systemic (oral or intravenous) corticosteroids. February 2014 A - 65

281 NOTE: If spirometry cannot be obtained, reasons must be clearly explained and other evidence regarding severity of condition must be provided for consideration (i.e. MRC scale). Spirometry reports from any point in time will be accepted. **Medical Research Council (MRC) Dyspnea Scale COPD Stage Symptoms MODERATE MRC 3 to 4 Shortness of breath from COPD causing the patient to stop after walking about 100 meters (or after a few minutes) on the level. SEVERE MRC 5 Shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure. TIPRANAVIR (APTIVUS) 250mg capsules For the treatment of adult patients with HIV-1 infection (plan U beneficiaries) who are treatment experienced, have demonstrated failure to multiple protease inhibitors and in whom no other protease inhibitor is a treatment option. TIZANIDINE (ZANAFLEX and generic brands) 4mg tablets For the treatment of spasticity caused by traumatic brain injury, multiple sclerosis (MS), spinal cord injury (SCI) or cerebral vascular accident (CVA) in patients in whom baclofen is contraindicated, ineffective or not tolerated. TOBRAMYCIN (TOBI) 300mg/5mL solution for inhalation For the treatment of cystic fibrosis patients who do not tolerate injectable tobramycin when used for inhalation. TOCILIZUMAB (ACTEMRA) 80mg, 200mg, 400mg single dose vials (20mg/mL) Rheumatoid Arthritis For patients with moderate to severe active rheumatoid arthritis who: Have not responded to an adequate trial of combination therapy of at least two traditional DMARDs (diseasemodifying antirheumatic drugs). Combination DMARD therapy must include methotrexate unless contraindicated or not tolerated, OR Are not candidates for combination DMARD therapy, must have had adequate trial of at least three traditional DMARDs in sequence, one of which must have been methotrexate unless contraindicated AND Have had an inadequate response to a tumour necrosis factor (TNF)-alpha antagonist. Must be prescribed by a rheumatologist. Initial approval will be for 16 weeks at a dose of 4 mg/kg. Requests for continuation of therapy must include information demonstrating clinical response. No dose escalation permitted above 8 mg/kg every 4 weeks or a maximum dose of 800 mg per infusion for individuals whose body weight is more than 100 kg. Will not be reimbursed in combination with other biologic agents. Systemic Juvenile Idiopathic Arthritis (sjia) For the treatment of active systemic juvenile idiopathic arthritis (sjia), in patients 2 years of age or 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. Must be prescribed by, or in consultation with, a pediatric rheumatologist. Coverage will be approved for a dose of 12 mg/kg for patients weighing less than 30kg or 8 mg/kg for patients weighing greater than or equal to 30kg to a maximum of 800mg, administered every two weeks. Continued coverage will be dependent on a positive patient response as determined by a pediatric rheumatologist. Initial approval period: 16 weeks Renewal period: 1 year February 2014 A - 66

282 TOLTERODINE (DETROL) 1mg and 2mg tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate release oxybutynin. Requests for the treatment of stress incontinence will not be considered. If the beneficiary has had a claim for oxybutynin in the previous 24 months, the adjudication system will recognize this information and the claim for tolterodine will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. TOLTERODINE (DETROL LA) 2mg, 4mg capsules For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate release oxybutynin. Requests for the treatment of stress incontinence will not be considered. TOPIRAMATE (TOPAMAX and generic brands) 25mg, 50mg, 100mg and 200mg tablets For the treatment of refractory epilepsy not well controlled with conventional therapy. To reduce the frequency of migraine headaches in adult patients who have failed an adequate trial of, or have contraindications to, beta blockers AND tricyclics for prophylaxis. TREPROSTINIL (REMODULIN) 1mg/mL, 2.5mg/mL, 5mg/mL, 10mg/mL solution For the treatment of patients with primary pulmonary hypertension or pulmonary hypertension secondary to collagen vascular disease, with New York Heart Association class III or IV disease who have both: 1. failed to respond to non-prostanoid therapies and 2. who are not candidates for epoprostenol therapy because of: prior recurrent complications with central line access (e.g. infection, thrombosis) or; inability to operate the complicated delivery system of epoprostenol or; they reside in an area without ready access to medical care, which could complicate problems associated with an abrupt interruption of epoprostenol. TRETINOIN (VESANOID) 10mg capsules For the induction of remission in acute promyelocytic leukemia (APL) in previously untreated patients as well as in those who have relapsed after, or were refractory to, standard chemotherapy. TROSPIUM (TROSEC) 20mg tablets For the treatment of overactive bladder with symptoms of urinary frequency, urgency and/or urge incontinence in patients who have not tolerated a reasonable trial of immediate-release oxybutynin. Requests for the treatment of stress incontinence will not be considered. If the beneficiary has had a claim for oxybutynin in the previous 24 months, the adjudication system will recognize this information and the claim for trospium will be automatically reimbursed without the need for a written special authorization request. Written special authorization will continue to be available as an option for beneficiaries who may not have the relevant first line agent on history due to changes in drug coverage or other factors. TRYPTOPHAN (TRYPTAN and generic brands) 500mg capsules, 250mg, 500mg, 750mg and 1g tablets As an adjunctive therapy for drug resistant bipolar affective disorder. February 2014 A - 67

283 URSODIOL (URSO and generic brand) 250mg tablets URSODIOL (URSO DS and generic brand) 500mg tablets For the management of cholestatic liver diseases, such as primary biliary cirrhosis. USTEKINUMAB (STELARA) 45 mg/0.5 ml vial for subcutaneous injection For patients with severe, debilitating chronic plaque psoriasis who meet all of the following criteria: o Body surface area (BSA) involvement of >10% and/or significant involvement of the face, hands, feet or genital region; o Failure to respond to, contraindications to, or intolerant to methotrexate and cyclosporine; o Failure to respond to, intolerant to, or unable to access phototherapy Initial approval limited to 16 weeks. Continuation of therapy beyond 16 weeks will be based on response. Patients not responding adequately at these time points should have treatment discontinued with no further treatment with the same agent recommended. An adequate response is defined as either: o 75% reduction in Psoriasis Area Severity Index (PASI) score from when treatment started, or o 50% reduction in PASI with a 5 point improvement in the Dermatology Life Quality Index (DLQI), or o A quantitative reduction in BSA affected with qualitative consideration of specific regions such as the face, hands, feet or genital region. Must be prescribed by a dermatologist Concurrent use of >1 biologic will not be approved Approval limited to a dose of 45 mg administered initially at weeks 0, 4 and 16, then 45 mg every 12 weeks thereafter, up to a year (if response criteria met at 16 weeks). VALGANCICLOVIR (VALCYTE and generic brand) 450mg tablets For the treatment of cytomegalovirus (CMV) retinitis in HIV positive patients on the advice of an infectious disease specialist. For the prevention of cytomegalovirus (CMV) disease in solid organ transplant patients at high-risk (i.e. donor CMV seropositive / recipient seronegative.) Coverage will be for a maximum of 100 days post transplant. VEMURAFENIB (ZELBORAF) 240mg film-coated tablet For the first line treatment of patients with BRAF V600 mutation-positive unresectable or metastatic melanoma who have an ECOG status performance of 1. For the second line treatment of patients with BRAF V600 mutation-positive unresectable or metastatic melanoma who have an ECOG performance status of 1 and did not receive vemurafenib as first line treatment. VIGABATRIN (SABRIL) 500mg tablets, 500mg sachets 1. Requests will be considered for: the adjunctive management of epilepsy which is not satisfactorily controlled by conventional therapy. initial monotherapy for the management of infantile spasms. 2. The maximum approved dose will be 4g/day VORICONAZOLE (VFEND) 50mg, 200mg tablets For the treatment of invasive aspergillosis. Initial requests will be approved for a maximum of 3 months. For culture proven invasive candidiasis with documented resistance to fluconazole. Must be prescribed in consultation with a specialist in infectious diseases or medical microbiology. February 2014 A - 68

284 ZAFIRLUKAST (ACCOLATE) 20mg tablets For the treatment of moderate to severe asthma in patients who: Are not adequately controlled with moderate to high dose inhaled corticosteroids despite compliance with treatment AND Require increasing amounts of short-acting beta 2-adrenergic agonists. ZANAMIVIR (RELENZA) 5mg powder for inhalation For beneficiaries residing in long-term care facilities meeting the same criteria as for oseltamivir and for whom there is suspected or confirmed oseltamivir resistance, or for whom oseltamivir is contraindicated. ZOLEDRONIC ACID (ACLASTA) 5mg/100mL solution for infusion Osteoporosis For the treatment of osteoporosis in postmenopausal women who were previously approved or would otherwise be eligible for coverage of oral bisphosphonates and who: Have experienced further significant decline in bone mineral density (BMD) after 1 year of continuous oral bisphosphonate therapy. OR Have experienced serious intolerance to oral bisphosphonates. OR Have a contraindication to oral bisphosphonates. Note: Serious intolerance is defined as esophageal ulceration, erosion or stricture, or lower gastrointestinal symptoms severe enough to cause discontinuation of oral bisphosphonates, or swallowing disorders that will increase the risk of esophageal ulceration from oral bisphosphonates. Paget s Disease For the treatment of Paget s disease of bone. ZOLMITRIPTAN (ZOMIG and generic brands) 2.5mg tablets ZOLMITRIPTAN (ZOMIG RAPIMELT and generic brands) 2.5mg tablets For the treatment of migraine 1 headache when: o Migraines are moderate 2 in severity and other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective, or o Migraine attacks are severe 2 or ultra severe 2 Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. ZOLMITRIPTAN (ZOMIG NASAL SPRAY) 2.5mg and 5mg nasal spray For the treatment of migraine 1 headache of moderate 2 intensity when other therapies (e.g. NSAIDs, acetaminophen, DHE spray) are not effective AND patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and naratriptan. February 2014 A - 69

285 For the treatment of migraine 1 headache of severe 2 or ultra severe 2 intensity when patients have not responded to oral sumatriptan, zolmitriptan, rizatriptan and/or naratriptan. Coverage limited to 6 doses / 30 days 3 o patients with >3 migraines/month on average despite prophylactic therapy may be considered for up to a maximum of 12 doses / 30 days 1 As diagnosed based on current Canadian guidelines. 2 Definitions: Moderate - pain is distracting causing need to slow down and limit activities; Severe - pain affects ability to concentrate and very difficult to continue with daily activities; Ultra severe - unable to speak or think clearly; not able to function; likely lying down or sleeping 3 Reimbursement will be available for a maximum quantity of triptan doses as outlined in criteria per 30 days regardless of the agent(s) used within the 30 day period. Special authorization for the products almotriptan 6.25mg and 12.5mg tablets, naratriptan 1mg and 2.5mg tablets, rizatriptan 5mg and 10mg tablets and wafers, sumatriptan 5mg and 20mg nasal spray and zolmitriptan 2.5mg tablets and orally dispersible tablets, 2.5mg and 5mg nasal spray will be considered as a set. Approvals will include all products in this list, however reimbursement will be available for a maximum quantity of one agent per month. February 2014 A - 70