NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY

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

NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY Copyright - 2014 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

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

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 Email Announcements. February 2014 I

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

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

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

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

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: www.cadth.ca. 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: www.pcodr.ca 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: http://novascotia.ca/dhw/pharmacare/atlantic-common-drug-review.asp 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) 453-8266 Department of Health Fax: (506) 453-3983 520 King Street, 6 th Floor HSBC Place info@nbpdp-pmnob.ca 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 e-mail. Please include a contact e- mail address in the submission. February 2014 VI

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: http://www.gov.ns.ca/health/pharmacare/committees/acdr.asp February 2014 VII

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

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) 453-3983 February 2014 IX

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 00782882 MLA EF-18G Liq CORTICOSTEROIDS FOR LOCAL ORAL TREATMENT CORTICOSTÉROÏDES POUR TRAITEMENT BUCCAL LOCALISÉ TRIAMCINOLONE TRIAMCINOLONE Pst Den 0.1% Oracort 01964054 TAR AEFGVW Pst OTHER AGENTS FOR LOCAL ORAL TREATMENT AUTRES MÉDICAMENTS POUR TRAITEMENT BUCCAL LOCALISÉ BENZYDAMINE BENZYDAMINE Liq Buc 0.15% Pharixia 02229777 PMS AEFGVW Liq Apo-Benzydamine (Disc/non disp Mar 30/14) 02239044 APX AEFGVW Novo-Benzydamine (Disc/non disp Feb 15/15) 02310422 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 01966529 CHU G Susp Sus Orl 120mg/60mg Diovol EX 00491217 CHU G Susp February 2014 / février 2014 Page 1

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 00584215 APX f ABEFGVW Tab Orl 300mg Apo-Cimetidine 00487872 APX f ABEFGVW Mylan-Cimetidine 02227444 MYL f ABEFGVW Tab Orl 400mg Apo-Cimetidine 00600059 APX f ABEFGVW Mylan-Cimetidine 02227452 MYL f ABEFGVW A02BA02 Tab Orl 600mg Apo-Cimetidine 00600067 APX f ABEFGVW Mylan-Cimetidine 02227460 MYL f ABEFGVW Tab Orl 800mg Apo-Cimetidine 00749494 APX f ABEFGVW RANITIDINE RANITIDINE Liq Inj 25mg Zantac 02212366 GSK W Liq Liq Orl 15mg Teva-Ranidine 02242940 TEV f EFGVW Liq Apo-Ranitidine 02280833 APX f EFGVW Tab Orl 150mg Apo-Ranitidine 00733059 APX f ABEFGVW Teva-Ranidine 00828564 TEV f ABEFGVW ratio-ranitidine (Disc/non disp Jun 29/14) 00828823 RPH f ABEFGVW Mylan-Ranitidine 02207761 MYL f ABEFGVW Zantac 02212331 GSK f ABEFGVW pms-ranitidine 02242453 PMS f ABEFGVW Sandoz Ranitidine 02243229 SDZ f ABEFGVW Co Ranitidine 02248570 COB f ABEFGVW Ran-Ranitidine 02336480 RAN f ABEFGVW Ranitidine 02353016 SAS f ABEFGVW Myl-Ranitidine 02367378 MYL f ABEFGVW Tab Orl 300mg Apo-Ranitidine 00733067 APX f ABEFGVW Teva-Ranidine 00828556 TEV f ABEFGVW Mylan-Ranitidine 02207788 MYL f ABEFGVW Zantac 02212358 GSK f ABEFGVW pms-ranitidine 02242454 PMS f ABEFGVW Sandoz Ranitidine 02243230 SDZ f ABEFGVW Co Ranitidine 02248571 COB f ABEFGVW Ran-Ranitidine 02336502 RAN f ABEFGVW Ranitidine 02353024 SAS f ABEFGVW Myl-Ranitidine 02367386 MYL f ABEFGVW February 2014 / février 2014 Page 2

A02BB A02BB01 A02BC A02BC01 A02BC02 A02BC04 PROSTAGLANDINS PROSTAGLANDINES MISOPROSTOL MISOPROSTOL Tab Orl 100mcg Misoprostol 02244022 AAP f AEFGVW Tab Orl 200mcg Misoprostol 02244023 AAP f AEFGVW PROTON PUMP INHIBITORS INHIBITEURS DE LA POMPE À PROTONS OMEPRAZOLE OMÉPRAZOLE SRC Orl 20mg Losec 1 00846503 AZE f ABEFGVW Caps.L.L Apo-Omeprazole 1 02245058 APX f ABEFGVW Sandoz Omeprazole 1 02296446 SDZ f ABEFGVW pms-omeprazole 1 02320851 PMS f ABEFGVW Mylan-Omeprazole 1 02329433 MYL f ABEFGVW Omeprazole 1 02348691 SAS f ABEFGVW Ran-Omeprazole 1 02403617 RAN f ABEFGVW SRT Orl 20mg Losec 1 02190915 AZE f ABEFGVW L.L. ratio-omeprazole(disc/non disp July 24/15) 1 02260867 TEV f ABEFGVW Teva-Omeprazole 1 02295415 TEV f ABEFGVW pms-omeprazole DR 1 02310260 PMS f ABEFGVW Ran-Omeprazole 1 02374870 RAN f ABEFGVW PANTOPRAZOLE PANTOPRAZOLE Tab Orl 40mg Tecta 02267233 TAK ABEFGVW RABEPRAZOLE RABÉPRAZOLE ECT Orl 10mg Pariet 02243796 JAN f ABEFGVW Ent Teva-Rabeprazole EC 02296632 TEV f ABEFGVW Ran-Rabeprazole 02298074 RAN f ABEFGVW pms-rabeprazole EC 02310805 PMS f ABEFGVW Sandoz Rabeprazole 02314177 SDZ f ABEFGVW Apo-Rabeprazole 02345579 APX f ABEFGVW Rabeprazole EC 02356511 SAS f ABEFGVW Pat-Rabeprazole 02381737 PAT f ABEFGVW Mylan-Rabeprazole 02408392 MYL f ABEFGVW ECT Orl 20mg Pariet 02243797 JAN f ABEFGVW Ent. Teva-Rabeprazole EC 02296640 TEV f ABEFGVW Ran-Rabeprazole 02298082 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

A02BC04 A02BX A03 A03A A02BX02 A03AA A03AA05 A03AA07 RABEPRAZOLE RABÉPRAZOLE ECT Orl 20mg pms-rabeprazole EC 02310813 PMS f ABEFGVW Ent. Sandoz Rabeprazole 02314185 SDZ f ABEFGVW Apo-Rabeprazole 02345587 APX f ABEFGVW Rabeprazole EC 02356538 SAS f ABEFGVW Pat-Rabeprazole 02381745 PAT f ABEFGVW Mylan-Rabeprazole 02408406 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 02103567 AXC AEFGVW Susp. Tab Orl 1gm Teva-Sulcralfate 02045702 TEV f AEFGVW Sulcrate 02100622 AXC f AEFGVW Apo-Sucralfate 02125250 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 02245663 AAP f AEFGVW Tab Orl 200mg Modulon 00803499 AXC f AEFGVW Trimebutine 02245664 AAP f AEFGVW DICYCLOVERINE (DICYCLOMINE) DICYCLOVERINE (DICYCLOMINE) Cap Orl 10mg Protylol 00287709 PDL AEFGVW Caps Syr Orl 2mg Bentylol 02102978 AXC AEFGVW Sir. Tab Orl 10mg Bentylol 02103087 AXC AEFGVW Tab Orl 20mg Protylol-20 00513059 PDL AEFGVW Bentylol 02103095 AXC AEFGVW February 2014 / février 2014 Page 4

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 02039508 SDZ AEFVW Liq OTHER DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS AUTRES MÉDICAMENTS POUR LES TROUBLES FONCTIONNELS DE L'INTESTIN PINAVERIUM PINAVERIUM Tab Orl 50mg Dicetel 01950592 ABB AEFGVW Tab Tab Orl 100mg Dicetel 02230684 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 00115630 VLN AEFGVW Caps Apo-Chlorax 00618454 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 00176141 TRI AEFGVW L.L. PROPULSIVES PROPULSIFS PROPULSIVES PROPULSIVES METOCLOPRAMIDE MÉTOCLOPRAMIDE Liq Inj 5mg Metoclopramide HCL 02185431 SDZ W Liq Syr Orl 1mg Metonia 02230433 PDP f AEFGVW Sir. February 2014 / février 2014 Page 5

A04 A04A A03FA01 A03FA03 A04AA A04AA01 METOCLOPRAMIDE MÉTOCLOPRAMIDE Tab Orl 5mg Apo-Metoclop (Disc/non disp Mar 30/14) 00842826 APX f AEFGVW Metonia 02230431 PDP f AEFGVW Tab Orl 10mg Apo-Metoclop (Disc/non disp Mar 30/14) 00842834 APX f AEFGVW Metonia 02230432 PDP f AEFGVW DOMPERIDONE DOMPÉRIDONE Tab Orl 10mg ratio-domperidone 01912070 RPH f AEFGVW Apo-Domperidone 02103613 APX f AEFGVW Teva-Domperidone 02157195 TEV f AEFGVW pms-domperidone 02236466 PMS f AEFGVW Ran-Domperidone 02268078 RAN f AEFGVW Mylan-Domperidone 02278669 MYL f AEFGVW Domperidone 02350440 SAS f AEFGVW Jamp-Domperidone 02369206 JPC f AEFGVW Mar-Domperidone 02403870 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 02213745 GSK f W Liq Ondansetron preservative free 02265524 TEV f W Ondansetron with preservative 02265532 TEV f W AJ-Ondansetron 02390019 AJP f W Tab Orl 4mg Zofran 2 02213567 GSK f AEFGV Zofran 02213567 GSK f W pms-ondansetron 2 02258188 PMS f AEFGV pms-ondansetron 02258188 PMS f W Teva-Ondansetron 02264056 TEV f W Teva-Ondansetron 2 02264056 TEV f AEFGV Sandoz Ondansetron 02274310 SDZ f W Sandoz Ondansetron 2 02274310 SDZ f AEFGV Ratio-Ondansetron 2 02278529 RPH f AEFGV Ratio-Ondansetron 02278529 RPH f W Phl-Ondansetron 2 02278618 PHL f AEFGV Phl-Ondansetron 02278618 PHL f W Apo-Ondansetron 2 02288184 APX f AEFGV Apo-Ondansetron 02288184 APX f W Co Ondansetron 02296349 COB f W Co Ondansetron 2 02296349 COB f AEFGV Mylan-Ondansetron 2 02297868 MYL f AEFGV Mylan-Ondansetron 02297868 MYL f W Mint-Ondansetron 2 02305259 MNT f AEFGV February 2014 / février 2014 Page 6

A04AA01 ONDANSETRON ONDANSÉTRON Tab Orl 4mg Mint-Ondansetron 02305259 MNT f W Ondansetron-Odan 2 02306212 ODN f AEFGV Ondansetron-Odan 02306212 ODN f W Ran-Ondansetron 2 02312247 RAN f AEFGV Ran-Ondansetron 02312247 RAN f W Jamp-Ondansetron 02313685 JPC f W Jamp-Ondansetron 2 02313685 JPC f AEFGV Mar-Ondansetron 02371731 MAR f W Mar-Ondansetron 2 02371731 MAR f AEFGV Septa-Ondansetron 02376091 SPT f W Septa-Ondansetron 2 02376091 SPT f AEFGV Tab Orl 8mg Zofran 2 02213575 GSK f AEFGV Zofran 02213575 GSK f W pms-ondansetron 02258196 PMS f W pms-ondansetron 2 02258196 PMS f AEFGV Teva-Ondansetron 2 02264064 TEV f AEFGV Teva-Ondansetron 02264064 TEV f W Sandoz Ondansetron 2 02274329 SDZ f AEFGV Sandoz Ondansetron 02274329 SDZ f W ratio-ondansetron 02278537 RPH f W ratio-ondansetron 2 02278537 RPH f AEFGV Phl-Ondansetron 2 02278626 PHL f AEFGV Phl-Ondansetron 02278626 PHL f W Apo-Ondansetron 02288192 APX f W Apo-Ondansetron 2 02288192 APX f AEFGV Co Ondansetron 2 02296357 COB f AEFGV Co Ondansetron 02296357 COB f W Mylan-Ondansetron 02297876 MYL f W Mylan-Ondansetron 2 02297876 MYL f AEFGV Mint-Ondansetron 02305267 MNT f W Mint-Ondansetron 2 02305267 MNT f AEFGV Ondansetron-Odan 2 02306220 ODN f AEFGV Ondansetron-Odan 02306220 ODN f W Ran-Ondansetron 2 02312255 RAN f AEFGV Ran-Ondansetron 02312255 RAN f W Jamp-Ondansetron 02313693 JPC f W Jamp-Ondansetron 2 02313693 JPC f AEFGV Mar-Ondansetron 2 02371758 MAR f AEFGV Mar-Ondansetron 02371758 MAR f W Septa-Ondansetron 02376105 SPT f W Septa-Ondansetron 2 02376105 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

A04AA02 A04AA04 A04AD A04AD01 GRANISETRON GRANISÉTRON Tab Orl 1mg Kytril 3 02185881 HLR f AEFGV Kytril 02185881 HLR f W Granisetron 3 02308894 AAP f AEFGV Granisetron 02308894 AAP f W DOLASETRON DOLASETRON Tab Orl 100mg Anzemet 4 02231379 SAV AEFGV Anzemet 02231379 SAV W OTHER ANTIEMETICS AUTRES ANTIEMÉTIQUES SCOPOLAMINE SCOPOLAMINE Liq Inj 20mg Buscopan 00363839 BOE W Liq Hyoscine Butylbromide 02229868 SDZ VW Tab Orl 10mg Buscopan 00363812 BOE AEFGVW Liq Inj 0.4mg Scopolamine Hydrobromide 00541869 HOS AEFVW Liq Liq Inj 0.6mg Scopolamine Hydrobromide 00541877 HOS AEFVW Liq A04AD12 Srd Trd 1.5mg Transderm-V 80024336 NVR AEFGVW Srd APREPITANT APRÉPITANT Cap Orl 80mg Emend 5 02298791 FRS AEFGV Caps Emend 02298791 FRS W Cap Orl 125mg Emend 02298805 FRS W Caps Emend 5 02298805 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

A04AD12 APREPITANT APRÉPITANT Cap Orl 85mg Emend-Tri-Pack Cap 02298813 FRS W Caps Emend-Tri-Pack Cap 5 02298813 FRS AEFGV A04AD99 DIMENHYDRINATE DIMENHYDRINATE Liq Inj 50mg Gravol 00013579 CHU W Liq Syr Orl 3mg Gravol 00230197 CHU G Sir. A07 A07A A07AA A07D Tab Orl 15mg Gravol 00511196 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 100000IU pms-nystatin Oral 00792667 PMS ABEFGVW Susp. Ratio-Nystatin 02194201 RPH ABEFGVW A07DA A07DA01 Tab Orl 500000IU ratio-nystatin (Disc/non disp Jan. 21/15) 02194198 RPH ABEFGVW ANTIPROPULSIVES ANTIPROPULSIFS ANTIPROPULSIVES ANTIPROPULSIFS DIPHENOXYLATE DIPHÉNOXYLATE DIPHENOXYLATE / ATROPINE DIPHÉNOXYLATE / ATROPINE Tab Orl 2.5mg/0.025mg Lomotil 00036323 PFI AEFGVW A07DA03 LOPERAMIDE LOPÉRAMIDE Liq Orl 0.2mg/mL pms-loperamide Hydrochloride 02016095 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

A07DA03 LOPERAMIDE LOPÉRAMIDE Tab Orl 2mg Novo-Loperamide 02132591 TEV f AEFGVW Imodium (Disc/non disp Aug 01/15) 02183862 JNJ f AEFGVW Apo-Loperamide 02212005 APX f AEFGVW pms-loperamide 02228351 PMS f AEFGVW Sandoz-Loperamide (Disc/non disp Nov 15/15) 02257564 SDZ f AEFGVW Loperamide 02256452 JPC AEFGVW A07E A07EA INTESTINAL ANTIINFLAMMATORY AGENTS AGENTS ANTI-INFLAMMATOIRES INTESTINAUX CORTICOSTEROIDS ACTING LOCALLY CORTICOSTÉROÏDES AGISSANT LOCALEMENT A07EA02 HYDROCORTISONE HYDROCORTISONE Aer Rt 10% Cortifoam 00579335 PAL AEFGVW Aér Enm Rt 1.66666mg Hycort 00230316 VLN AEFGVW Lav. Cortenema 02112736 AXC AEFGVW A07EA04 BETAMETHASONE BÉTAMÉTHASONE Enm Rt 0.05mg Betnesol 02060884 PAL AEFGVW Lav. A07EA06 BUDESONIDE BUDÉSONIDE Cap Orl 3mg Entocort 02229293 AZE AEFGVW Caps A07EB ANTIALLERGIC AGENTS, EXCL. CORTICOSTEROIDS AGENTS ANTIALLERGIQUES, À L EXCLUSION DES CORTICOSTÉROÏDES A07EB01 CROMOGLICIC ACID CROMOGLYCATE DISODIQUE Cap Orl 100mg Nalcrom 00500895 SAV AEFGVW Caps A07EC AMINOSALICYLIC ACID AND SIMILAR AGENTS ACIDE AMINOSALICYLIQUE ET AGENTS SEMBLABLES A07EC01 SULFASALAZINE SULFASALAZINE ECT Orl 500mg Salazopyrin EN 02064472 PFI f AEFGVW Ent pms-sulfasalazine EC 00598488 PMS AEFGVW Tab Orl 500mg Salazopyrin 02064480 PFI f AEFGVW pms-sulfasalazine 00598461 PMS AEFGVW February 2014 / février 2014 Page 10

A07EC02 MESALAZINE MÉSALAZINE ECT Orl 500mg Mesasal 01914030 GSK AEFGVW Ent Salofalk 02112787 AXC AEFGVW SRT Orl 500mg Pentasa 02099683 FEI AEFGVW L.L. Sup Rt 1gm Pentasa 02153564 FEI AEFGVW Supp. Salofalk 02242146 AXC AEFGVW Sup Rt 500mg Salofalk 02112760 AXC AEFGVW Supp. Sus Rt 1gm Pentasa 02153521 FEI AEFGVW Susp Sus Rt 2gm Salofalk 02112795 AXC AEFGVW Susp. Sus Rt 4gm Pentasa 02153556 FEI AEFGVW Susp. Sus Rt 66.66666mg Salofalk 02112809 AXC AEFGVW Susp. ECT Orl 400mg Asacol 01997580 WNC AEFGVW Ent ECT Orl 800mg Asacol 02267217 WNC AEFGVW Ent. Tab Orl 1.2gm Mezavant 02297558 SHI AEFGVW A07EC03 OLSALAZINE OLSALAZINE Cap Orl 250mg Dipentum 02063808 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 80017987 ERF AEFGVW Caps February 2014 / février 2014 Page 11

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 4 02203324 AXC BEFG Caps. Cap Orl 8000IU/30000IU/30000IU Cotazym 00263818 FRS BEFG Caps. Cap Orl 12000U/39000U/39000U Ultrase MT 12 02045834 AXC BEFG Caps. Cap Orl 20000U/ 65000U/65000U Ultrase MT 20 02045869 AXC BEFG Caps. ECC Orl 4000U/12000U/12000U Pancrease MT 4 00789445 JAN BEFG Caps.Ent. ECC Orl 5000U/16600U/18750U Creon 5 Minimicrospheres 02239007 ABB BEFG Caps.Ent. ECC Orl 6000U/30000U/19000U Creon 6 Minimicrospheres 02415194 ABB BEFG Caps.Ent. ECC Orl 8000U/30000U/30000U Cotazym ECS 8 00502790 SCH BEFG Caps.Ent. ECC Orl 10000U/33200U/37500U Creon10 Minimicrospheres 02200104 ABB BEFG Caps.Ent. ECC Orl 1000U/30000U/30000U Pancrease MT 10 00789437 JAN BEFG Caps.Ent. ECC Orl 16000U/48000U/48000U Pancrease MT 16 00789429 JAN BEFG Caps.Ent. ECC Orl 20000U/55000U/55000U Cotazym ECS 20 00821373 SCH BEFG Caps.Ent. ECC Orl25000U/ 74000U/62500U Creon25 Minimicrospheres 01985205 ABB BEFG Caps.Ent. Tab Orl 8000U/ 30000U/30000U Viokase 8 02230019 AXC BEFG Tab Orl 16000U/ 60000U/60000U Viokase 16 02241933 AXC BEFG February 2014 / février 2014 Page 12

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* 00586714 LIL AEFGVW Liq Humulin R (cartridge)* 01959220 LIL AEFGVW Novolin GE Toronto* 02024233 NNO AEFGVW Novolin GE Toronto(penfill) (3ml)* 02024284 NNO AEFGVW INSULIN LISPRO; FAST-ACTING INSULINE LISPRO; ACTION RAPIDE Liq Inj 100IU Humalog* 6 02229704 LIL AEFGV Liq Humalog (cartridge)* 6 02229705 LIL AEFGV Humalog (kwikpen)* 6 02403412 LIL AEFGV INSULIN ASPART INSULINE ASPART Liq Inj 100IU Novorapid (penfill) (3ml)* 6 02244353 NNO AEFGV Liq Novorapid* 6 02245397 NNO AEFGV INSULIN GLULISINE INSULINE GLULISINE Liq Inj 3mL Apidra (cartridge) 6 02279479 SAV AVW Liq Apidra (cartridge) 02279479 SAV EFG-18 Apidra Solostar 6 02294346 SAV AVW Apidra Solostar 02294346 SAV EFG-18 Liq Inj 10mL Apidra 02279460 SAV EFG-18 Liq Apidra 6 02279460 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 * 00587737 LIL AEFGVW Susp. Humulin N (cartridge) * 01959239 LIL AEFGVW Humulin N (kwikpen) * 02403447 LIL AEFGVW Novolin GE NPH* 02024225 NNO AEFGVW Novolin GE NPH (penfill) (3ml) * 02024268 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

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* 00795879 LIL AEFGVW Susp. Humulin 30/70 (cartridge) * 01959212 LIL AEFGVW Novolin GE 30/70* 02024217 NNO AEFGVW Novolin GE 30/70 (penfill) (3ml) * 02025248 NNO AEFGVW Sus Inj 40 IU/60IU Novolin GE 40/60 (Penfill) * 02024314 NNO AEFGVW Susp. A10B A10BA A10BA02 Sus Inj 50 IU/50IU Novolin GE 50/50 (Penfill) * 02024322 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 * 02045710 TEV f AEFGVW Glucophage * 02099233 SAV f AEFGVW Mylan-Metformin * 02148765 MYL f AEFGVW Apo-Metformin * 02167786 APX f AEFGVW pms-metformin * 02223562 PMS f AEFGVW Metformin * 02242794 MEL f AEFGVW ratio-metformin * 02242974 RPH f AEFGVW Sandoz Metformin FC * 02246820 SDZ f AEFGVW Co-Metformin * 02257726 COB f AEFGVW Ran-Metformin * 02269031 RAN f AEFGVW Metformin * 02353377 SAS f AEFGVW Metformin* 02378841 MAR f AEFGVW Mar-Metformin* 02378620 MAR f AEFGVW Jamp-Metformin* 02380196 JPC f AEFGVW Jamp-Metformin Blackberry* 02380722 JPC f AEFGVW Septa-Metformin* 02379767 SPT f AEFGVW Mint-Metformin* 02388766 MNT f AEFGVW Tab Orl 850mg Glucophage * 02162849 SAV f AEFGVW Mylan-Metformin * 02229656 MYL f AEFGVW Apo-Metformin * 02229785 APX f AEFGVW Teva-Metformin * 02230475 TEV f AEFGVW pms-metformin * 02242589 PMS f AEFGVW ratio-metformin * 02242931 RPH f AEFGVW Sandoz Metformin FC * 02246821 SDZ f AEFGVW Co-Metformin * 02257734 COB f AEFGVW Ran-Metformin * 02269058 RAN f AEFGVW Metformin * 02353385 SAS f AEFGVW Metformin* 02378868 MAR f AEFGVW Mar-Metformin* 02378639 MAR f AEFGVW February 2014 / février 2014 Page 14

A10BA02 A10BB A10BB01 A10BB02 METFORMIN METFORMINE Tab Orl 850mg Jamp-Metformin* 02380218 JPC f AEFGVW Jamp-Metformin Blackberry* 02380730 JPC f AEFGVW Septa-Metformin* 02379775 SPT f AEFGVW Mint-Metformin* 02388774 MNT f AEFGVW SULFONAMIDES, UREA DERIVATIVES SULFONAMIDES, DÉRIVÉS DE L URÉE GLIBENCLAMIDE (GLYBURIDE) GLIBENCLAMIDE (GLYBURIDE) Tab Orl 2.5mg Mylan-Glybe * 00808733 MYL f AEFGVW ratio-glyburide * 01900927 RPH f AEFGVW Apo-Glyburide * 01913654 APX f AEFGVW Teva-Glyburide * 01913670 TEV f AEFGVW Diabeta * 02224550 SAV f AEFGVW Sandoz Glyburide * 02248008 SDZ f AEFGVW Glyburide * 02350459 SAS f AEFGVW Tab Orl 5mg Mylan-Glybe * 00808741 MYL f AEFGVW ratio-glyburide * 01900935 RPH f AEFGVW Apo-Glyburide * 01913662 APX f AEFGVW Teva-Glyburide * 01913689 TEV f AEFGVW Diabeta * 02224569 SAV f AEFGVW Sandoz Glyburide * 02248009 SDZ f AEFGVW Glyburide * 02350467 SAS f AEFGVW CHLORPROPAMIDE CHLORPROPAMIDE Tab Orl 100mg Apo-Chlorpropamide * 00399302 APX f AEFGVW Tab Orl 250mg Apo-Chlorpropamide * 00312711 APX f AEFGVW A10BB03 TOLBUTAMIDE TOLBUTAMIDE Tab Orl 500mg Tolbutamide * 00312762 AAP f AEFGVW A10BB09 GLICLAZIDE GLICLAZIDE ECT Orl 30mg Diamicron MR * 02242987 SEV f ABEFGVW Ent. Gliclazide MR * 02297795 AAP f ABEFGVW ECT Orl 60mg Diamicron MR 02356422 SEV ABEFGVW Ent. Tab Orl 80mg Diamicron * 00765996 SEV f ABEFGVW Mylan-Gliclazide * 02229519 MYL f ABEFGVW Novo-Gliclazide * 02238103 TEV f ABEFGVW Apo-Gliclazide * 02245247 APX f ABEFGVW Gliclazide * 02287072 SAS f ABEFGVW February 2014 / février 2014 Page 15

A10BB12 GLIMEPIRIDE GLIMÉPIRIDE Tab Orl 1mg Amaryl * 02245272 SAV f ABEFGVW Sandoz Glimepiride * 02269589 SDZ f ABEFGVW Ratio-Glimepiride * 02273101 TEV f ABEFGVW Novo-Glimepiride * 02273756 TEV f ABEFGVW Apo-Glimepiride * 02295377 APX f ABEFGVW Tab Orl 2mg Amaryl * 02245273 SAV f ABEFGVW Sandoz Glimepiride * 02269597 SDZ f ABEFGVW Ratio-Glimepiride * 02273128 TEV f ABEFGVW Novo-Glimepiride * 02273764 TEV f ABEFGVW Apo-Glimepiride * 02295385 APX f ABEFGVW A11 A11A A11AA A11C A11AA03 A11CC A11CC01 Tab Orl 4mg Amaryl * 02245274 SAV f ABEFGVW Sandoz Glimepiride * 02269619 SDZ f ABEFGVW Ratio-Glimepiride * 02273136 TEV f ABEFGVW Novo-Glimepiride * 02273772 TEV f ABEFGVW Apo-Glimepiride * 02295393 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 02246236 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 02237450 EUR AEFGVW Caps Osto-D2 02301911 TRI AEFGVW Dps Orl 8288IU Drisdol (Disc/non disp Feb. 4/15) 02017598 SAV f AEFGVW Gttes Erdol (Drisodan) 80003615 ODN f AEFGVW A11CC03 Tab Orl 1000IU Vitamin D 80000436 JAM EF-18G ALFACALCIDOL ALFACALCIDOL Cap Orl 0.25mcg One-Alpha 00474517 LEO AEFGVW Caps February 2014 / février 2014 Page 16

A11H A11CC03 A11CC04 A11HA ALFACALCIDOL ALFACALCIDOL Cap Orl 1mcg One-Alpha 00474525 LEO AEFGVW Caps CALCITRIOL CALCITRIOL Cap Orl 0.25mcg Rocaltrol 00481823 HLR AEFGVW Caps Cap Orl 0.5mcg Rocaltrol 00481815 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 00463469 KRI W Liq A11HA03 TOCOPHEROL (VIT E) TOCOPHÉROL (VIT E) Cap Orl 200IU Vitamin E 02041073 VTH BEF-18G Caps Dps Orl 50IU Aquasol E 02162075 CLC BEF-18G Gttes Cap Orl 100IU Vitamin E Natural 00122823 JAM BEF-18G Caps Vitamin E 00189227 JAM BEF-18G Cap Orl 200IU Vitamin E Natural 00122831 JAM BEF-18G Caps Vitamin E 00189235 SWS BEF-18G Cap Orl 400IU Vitamin E Natural 00122858 JAM BEF-18G Caps Vitamin E Natural 00201995 JPC BEF-18G Vitamin E 00266108 PMT BEF-18G Vitamin E Synthetic 00274259 WAM BEF-18G Vitamin E 02040816 PMT BEF-18G Vitamin E 02247190 HHC BEF-18G A11J A11JA OTHER VITAMIN PRODUCTS, COMBINATIONS AUTRES PRODUITS VITAMINIQUES, EN COMBINAISON COMBINATIONS OF VITAMINS COMBINAISONS DE VITAMINES Liq Orl Infantol 00558079 CHU BEFG Liq February 2014 / février 2014 Page 17

A12 A12B A12BA A12BA01 MINERAL SUPPLEMENTS SUPPLÉMENTS DE MINÉRAUX POTASSIUM POTASSIUM POTASSIUM POTASSIUM POTASSIUM CHLORIDE CHLORURE DE POTASSIUM Liq Orl 100mg pms-potassium 02238604 PMS f AEFGVW Liq K-10(Disc/non disp Jul 31/14) 01918303 GSK AEFGVW K-10 80024360 GSK AEFGVW SRC Orl 600mg Micro-K 02042304 PAL AEFGVW Caps.L.L. SRT Orl 600mg Slow-K 80040226 NVR AEFGVW L.L. Apo-K 00602884 APX AEFGVW Jamp-K8 80013005 JPC AEFGVW SRT Orl 1500mg Odan K-20 80004415 ODN AEFGVW L.L. K-Dur 20(Disc/non disp Dec 1/14) 00713376 FRS AEFGVW Jamp-K20 80013007 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 00610100 PDP EF-18G Gttes Tab Orl 2.21mg Fluor-a-Day 00575569 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 01918311 BRI f AEFGVW Taro-Warfarin 02242680 TAR f AEFGVW Apo-Warfarin 02242924 APX f AEFGVW Mylan-Warfarin 02244462 MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) 02265273 TEV f AEFGVW Warfarin 02344025 SAS f AEFGVW February 2014 / février 2014 Page 18

B01AA03 WARFARIN WARFARINE Tab Orl 2mg Coumadin 01918338 BRI f AEFGVW Taro-Warfarin 02242681 TAR f AEFGVW Apo-Warfarin 02242925 APX f AEFGVW Mylan-Warfarin 02244463 MYL f AEFGVW Novo-Warfarin 02265281 TEV f AEFGVW Warfarin 02344033 SAS f AEFGVW Tab Orl 2.5mg Coumadin 01918346 BRI f AEFGVW Taro-Warfarin 02242682 TAR f AEFGVW Apo-Warfarin 02242926 APX f AEFGVW Mylan-Warfarin 02244464 MYL f AEFGVW Novo-Warfarin 02265303 TEV f AEFGVW Warfarin 02344041 SAS f AEFGVW Tab Orl 3mg Coumadin 02240205 BRI f AEFGVW Taro-Warfarin 02242683 TAR f AEFGVW Apo-Warfarin 02245618 APX f AEFGVW Mylan-Warfarin 02287498 MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) 02265311 TEV f AEFGVW Warfarin 02344068 SAS f AEFGVW Tab Orl 4mg Coumadin 02007959 BRI f AEFGVW Taro-Warfarin 02242684 TAR f AEFGVW Apo-Warfarin 02242927 APX f AEFGVW Mylan-Warfarin 02244465 MYL f AEFGVW Novo-Warfarin (Disc/non disp Jun 4/15) 02265338 TEV f AEFGVW Warfarin 02344076 SAS f AEFGVW Tab Orl 5mg Coumadin 01918354 BRI f AEFGVW Taro-Warfarin 02242685 TAR f AEFGVW Apo-Warfarin 02242928 APX f AEFGVW Mylan-Warfarin 02244466 MYL f AEFGVW Novo-Warfarin 02265346 TEV f AEFGVW Warfarin 02344084 SAS f AEFGVW Tab Orl 6mg Coumadin 02240206 BRI f AEFGVW Taro-Warfarin 02242686 TAR f AEFGVW Mylan-Warfarin 02287501 MYL f AEFGVW Warfarin (Disc/non disp Jan 1/15) 02344092 SAS f AEFGVW B01AA07 Tab Orl 10mg Coumadin 01918362 BRI f AEFGVW Taro-Warfarin 02242687 TAR f AEFGVW Apo-Warfarin 02242929 APX f AEFGVW Mylan-Warfarin 02244467 MYL f AEFGVW Warfarin 02344114 SAS f AEFGVW ACENOCOUMAROL (NICOUMALONE) ACENOCOUMAROL (NICOUMALONE) Tab Orl 1mg Sintrom 00010383 PAL AEFGVW February 2014 / février 2014 Page 19

B01AA07 B01AB B01AB01 B01AB04 ACENOCOUMAROL (NICOUMALONE) ACENOCOUMAROL (NICOUMALONE) Tab Orl 4mg Sintrom 00010391 PAL AEFGVW HEPARIN GROUP GROUPE DE L HÉPARINE HEPARIN HÉPARINE Liq Inj 100IU Heparin 00727520 LEO W Liq Liq Inj 10,000IU Heparin * 00579718 LEO AEFGV Liq DALTEPARIN DALTÉPARINE Liq Inj 5,000IU Fragmin (prefilled syringe) 02132648 PFI W Liq Liq Inj 7,500IU Fragmin (prefilled syringe) 02352648 PFI W Liq Liq Inj 10,000IU Fragmin (prefilled syringe) * 7 02352656 PFI AEF18+V Liq Fragmin (prefilled syringe) 02352656 PFI W Liq Inj 12,500IU Fragmin (prefilled syringe)* 7 02352664 PFI AEF18+V Liq Fragmin (prefilled syringe) 02352664 PFI W Liq Inj 15,000IU Fragmin (prefilled syringe) 02352672 PFI W Liq Fragmin (prefilled syringe) * 7 02352672 PFI AEF18+V Liq Inj 18,000IU Fragmin (prefilled syringe) 02352680 PFI W Liq Fragmin (prefilled syringe) * 7 02352680 PFI AEF18+V B01AB05 Liq Inj 25,000IU Fragmin * 7 02231171 PFI AEF18+V Liq Fragmin 02231171 PFI W ENOXAPARIN ÉNOXAPARINE Liq Inj 30mg/0.3mL Lovenox (prefilled syringe) 02012472 SAV W Liq Liq Inj 40mg/0.4mL Lovenox (prefilled syringe) 02236883 SAV W Liq Liq Inj 60mg/0.6mL Lovenox (prefilled syringe) 02378426 SAV W Liq Liq Inj 80mg/0.8mL Lovenox (prefilled syringe) 02378434 SAV W Liq February 2014 / février 2014 Page 20

B01AB05 ENOXAPARIN ÉNOXAPARINE Liq Inj 100mg/mL Lovenox (prefilled syringe) 02378442 SAV W Liq Liq Inj 300mg/3mL Lovenox 02236564 SAV W Liq Lovenox * 7 02236564 SAV AEF18+V Liq Inj 120mg/0.8mL Lovenox HP (prefilled syringe) 02242692 SAV W Liq Lovenox HP (prefilled syringe) * 7 02242692 SAV AEF18+V B01AB06 B01AB10 B01AC B01AC04 B01AC05 Liq Inj 150mg/mL Lovenox HP (prefilled syringe) 02378469 SAV W Liq Lovenox HP (prefilled syringe) * 7 02378469 SAV AEF18+V NADROPARIN NADROPARINE Liq Inj 19000IU Fraxiparin Forte (prefilled syringe) * 7 02240114 GSK AEF18+V Liq Fraxiparin Forte (prefilled syringe) 02240114 GSK W TINZAPARIN TINZAPARINE Liq Inj 10000IU/mL Innohep * 7 02167840 LEO AEF18+V Liq Innohep 02167840 LEO W Innohep (prefilled syringe) 02229755 LEO W Liq Inj 20000IU/mL Innohep * 7 02229515 LEO AEF18+V Liq Innohep 02229515 LEO W Innohep (prefilled syringe) 02231478 LEO W Innohep (prefilled syringe) * 7 02231478 LEO AEF18+V PLATELET AGGREGATION INHIBITORS EXCLUDING HEPARIN INHIBITEURS D AGRÉGATION PLAQUETTAIRE, À L EXCLUSION DE HÉPARINE CLOPIDOGREL CLOPIDOGREL Tab Orl 75mg Plavix 02238682 SAV f W Apo-Clopidogrel 02252767 APX f W Teva-Clopidogrel 02293161 TEV f W Co-Clopidogrel 02303027 COB f W pms-clopidogrel 02348004 PMS f W Mylan-Clopidogrel 02351536 MYL f W Sandoz Clopidogrel 02359316 SDZ f W Ran-Clopidogrel 02379813 RAN f W Clopidogrel 02400553 SAS f W Mint-Clopidogrel 02408910 MNT f W TICLOPIDINE TICLOPIDINE Tab Orl 250mg Teva-Ticlopidine 02236848 TEV f AEFVW Apo-Ticlopidine 02237701 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

B01AC05 B01AC07 B01AX B02 B02A B01AX06 B02AA B02AA02 B02AA03 TICLOPIDINE TICLOPIDINE Tab Orl 250mg Mylan-Ticlopidine 02239744 MYL f AEFVW Ticlopidine 02343045 SAS f AEFVW DIPYRIDAMOLE DIPYRIDAMOLE Tab Orl 25mg Apo-Dipyridamole FC/FE 00895644 APX f AEFGVW Tab Orl 50mg Apo-Dipyridamole FC/FE 00895652 APX f AEFGVW Tab Orl 75mg Apo-Dipyridamole FC/FE 00895660 APX f AEFGVW OTHER ANTITHROMBOTIC AGENTS AUTRES AGENTS ANTITHROMBOTIQUES RIVAROXABAN RIVAROXABAN Tab Orl 10mg Xarelto 8 02316986 BAY AEFVW ANTIHAEMORRHAGICS ANTIHÉMORRAGIQUES ANTIFIBRINOLYTICS ANTIFIBRINOLYTIQUES AMINO ACIDS ACIDES AMINÉS TRANEXAMIC ACID ACIDE TRANEXAMIQUE Tab Orl 500mg Cyklokapron 02064405 PFI f AEFGVW Tranexamic Acid 02401231 STR f AEFGVW AMINOMETHYLBENZOIC ACID ACIDE AMINOMETHYLBENZOIQUE Cap Orl 500mg Potaba 00611271 GLE AEFGVW Caps Pwr Orl 2000mg Potaba (Disc/non disp Jul 24/14) 00611298 GLE AEFGVW Pd. Tab Orl 500mg Potaba 00550175 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

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 00808954 BIF AEFGVW Caps Cap Orl 300mg Neo-Fer 00482064 NEO AEFGVW Caps Palafer 01923420 MVL AEFGVW Sus Orl 60mg Palafer 01923439 MVL AEFGVW Susp. B03AA03 Tab Orl 300mg Ferrous Fumarate 00031089 JPC AEFGVW FERROUS GLUCONATE GLUCONATE FERREUX Tab Orl 37.5mg Chelated Iron 00633666 RHG AEFGVW Tab Orl 50mg Fer 00832677 NSE AEFGVW B03AA07 Tab Orl 300mg Ferrous Gluconate 00031097 JPC AEFGVW Apo-ferrous Gluconate 00545031 APX AEFGVW Ferrous Gluconate 00582727 VTH AEFGVW pms-ferrous Gluconate 00743976 PVR AEFGVW Novo-Ferrogluc 80000435 TEV AEFGVW FERROUS SULPHATE SULFATE FERREUX Cap Orl 45mg Mega SR Iron 00362727 KRI AEFGVW Caps Iron Formula 00647454 GNC AEFGVW Dps Orl 75mg pms-ferrous Sulfate 02222574 PMS AEFGVW Gttes ECT Orl 300mg Apo-Ferrous Sulfate-FC 01912518 APX AEFGVW Ent. Liq Orl 15mg Fer-In-Sol 00762954 MJO f AEFGVW Liq Ferodan 02237385 ODN f AEFGVW Jamp Ferrous Sulfate 80008309 JPC AEFGVW Liq Orl 30mg Jamp Ferrous Sulfate 80008295 JPC AEFGVW Liq February 2014 / février 2014 Page 23

B03AA07 B03AC B03B B03AC01 B03BA B03BA01 B03BB B03X B03BA01 B03XA B03XA01 FERROUS SULPHATE SULFATE FERREUX SRT Orl 160mg Slow-Fe 00623520 NNC G L.L Syr Orl 30mg Fer-In-Sol 00017884 MJO AEFGVW Sir. Ferodan 00758469 ODN AEFGVW pms-ferrous Sulfate 00792675 PMS AEFGVW Tab Orl 300mg Ferrous Sulfate 00031100 JPC AEFGVW Ferrous Sulfate 00346918 PMT AEFGVW pms-ferrous Sulfate 00586323 PMS AEFGVW IRON TRIVALENT, PARENTERAL PREPARATIONS FER TRIVALENT, PRÉPARATIONS PARENTÉRALES FERRIC OXIDE POLYMALTOSE COMPLEXES FERRIC OXIDE POLYMALTOSE COMPLEXES Liq Inj 50mg Dexiron * 02205963 MYL AEFGVW Liq Infufer * 02221780 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 * 00521515 SDZ f AEFGVW Liq Cyanocobalamin * 01987003 CYI f AEFGVW FOLIC ACID AND DERIVATIVES ACIDE FOLIQUE ET DÉRIVÉS FOLIC ACID ACIDE FOLIQUE Tab Orl 5mg Apo-Folic Acid 00426849 APX AEFGVW Euro-Folic 02285673 EUR AEFGVW Jamp-Folic 02366061 JPC AEFGVW OTHER ANTIANEMIC PREPARATIONS AUTRES PRÉPARATIONS ANTIANÉMIQUES OTHER ANTIANEMIC PREPARATIONS AUTRES PRÉPARATIONS ANTIANÉMIQUES ERYTHROPOIETIN ÉRYTHROPOIETINE Liq Inj 1000IU Eprex 02231583 JAN W Liq Liq Inj 2000IU Eprex 02231584 JAN W Liq Liq Inj 3000IU Eprex 02231585 JAN W Liq February 2014 / février 2014 Page 24

B03XA01 ERYTHROPOIETIN ÉRYTHROPOIETINE Liq Inj 4000IU Eprex 02231586 JAN W Liq Liq Inj 6000IU Eprex 02243401 JAN W Liq Liq Inj 8000IU Eprex 02243403 JAN W Liq Liq Inj 100000IU Eprex 02231587 JAN W Liq B03XA02 Liq Inj 40000IU Eprex 02240722 JAN W Liq DARBEPOETIN ALFA DARBÉPOÉTINE ALFA Liq Inj 10mcg/0.4mL Aranesp 02392313 AGA W Liq Liq Inj 20mcg/0.5mL Aranesp 02246355 AGA W Liq Liq Inj 30mcg Aranesp 02246357 AGA W Liq Liq Inj 40mcg Aranesp 02391740 AGA W Liq Liq Inj 50mcg Aranesp 02246357 AGA W Liq Liq Inj 60mcg Aranesp 02246358 AGA W Liq Liq Inj 80mcg Aranesp 02246358 AGA W Liq Liq Inj 100mcg Aranesp 02246358 AGA W Liq Liq Inj 130mcg Aranesp 02246358 AGA W Liq Liq Inj 150mcg Aranesp (Disc/non disp Nov. 04/15) 02391821 AGA W Liq February 2014 / février 2014 Page 25

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 200000IU/40mg Neosporin Irrigating Sol. 00666157 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 02242320 PDP AEFGVW Liq Tab Orl 0.0625mg Toloxin 02335700 PDP AEFGVW Tab Orl 0.125mg Toloxin 02335719 PDP AEFGVW Tab Orl 0.25mg Toloxin 02335727 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 00638692 ERF AEFGVW L.L. SRT Orl 500mg Procan SR 00638676 ERF AEFGVW L.L. SRT Orl 750mg Procan SR 00638684 ERF AEFGVW L.L. February 2014 / février 2014 Page 26

C01BA03 C01BB C01BB02 C01BC C01BC03 DISOPYRAMIDE DISOPYRAMIDE Cap Orl 100mg Rythmodan 02224801 SAV AEFGVW Caps Cap Orl 150mg Rythmodan (Disc/non disp July 1/14) 02224828 SAV AEFGVW Caps ANTIARRHYTHMICS, CLASS IB ANTIARHYTHMIQUES, CATÉGORIE IB MEXILETINE MEXILÉTINE Cap Orl 100mg Novo-Mexiletine 02230359 TEV f AEFGVW Caps Cap Orl 200mg Novo-Mexiletine 02230360 TEV f AEFGVW Caps ANTIARRHYTHMICS, CLASS IC ANTIARHYTHMIQUES, CATÉGORIE IC PROPAFENONE PROPAFÉNONE Tab Orl 150mg Rythmol 00603708 ABB f AEFGVW Apo-Propafenone 02243324 APX f AEFGVW Mylan-Propafenone 02245372 MYL f AEFGVW pms-propafenone 02294559 PMS f AEFGVW Propafenone 02343053 SAS f AEFGVW Tab Orl 300mg Rythmol 00603716 ABB f AEFGVW Apo-Propafenone 02243325 APX f AEFGVW Mylan-Propafenone 02245373 MYL f AEFGVW pms-propafenone 02294575 PMS f AEFGVW Propafenone 02343061 SAS f AEFGVW C01BC04 C01BD C01BD01 FLECAINIDE FLÉCAÏNIDE Tab Orl 50mg Tambocor (Disc/non disp Sep 1/14) 01966197 VLN f AEFGVW Flecainide 02275538 AAP f AEFGVW Tab Orl 100mg Tambocor (Disc/non disp Nov 1/14) 01966200 VLN f AEFGVW Flecainide 02275546 AAP f AEFGVW ANTIARRHYTHMICS, CLASS III ANTIARHYTHMIQUES, CATÉGORIE III AMIODARONE AMIODARONE Tab Orl 100mg pms-amiodarone 02292173 PMS AEFGVW February 2014 / février 2014 Page 27

C01C C01BD01 C01CA C01CA24 AMIODARONE AMIODARONE Tab Orl 200mg Cordarone 02036282 PFI f AEFGVW Teva-Amiodarone 02239835 TEV f AEFGVW ratio-amiodarone (Disc/non disp Jun 29/14) 02240071 RPH f AEFGVW Mylan-Amiodarone 02240604 MYL f AEFGVW pms-amiodarone 02242472 PMS f AEFGVW Sandoz Amiodarone 02243836 SDZ f AEFGVW Phl-Amiodarone 02245781 PHL f AEFGVW Apo-Amiodarone 02246194 APX f AEFGVW Amiodarone 02364336 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 * 02268205 PAL AEFGVW Liq Allerject 02382059 SAV AEFGVW Liq Inj 0.3mg Twinject * 02247310 PAL AEFGVW Liq Allerject 02382067 SAV AEFGVW Liq Inj 0.5mg Epi Pen Jr * 00578657 KNG AEFGVW Liq C01D C01DA C01DA02 Liq Inj 1mg Epi Pen * 00509558 KNG AEFGVW Liq Liq Inj 1mg Adrenalin * 00155357 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 02231441 SAV f AEFGVW Aém Rho-Nitro 02238998 SDZ f AEFGVW Mylan-Nitro SL 02243588 MYL f AEFGVW Apo-Nitroglycerin 02393433 APX f AEFGVW Ont Top 2% Nitrol 01926454 PAL AEFGVW Ont Pth Trd 0.2mg/hr Nitro-Dur 01911910 FRS f AEFVW Pth Mylan-Nitro Patch 02407442 MYL f AEFVW Minitran 02162806 VLN AEFVW Trinipatch 02230732 PAL AEFV February 2014 / février 2014 Page 28

C01DA02 NITROGLYCERIN (GLYCERYL TRINITRATE) NITROGLYCERINE (TRINITRATE DE GLYCERYLE) Pth Trd 0.4mg/hr Nitro-Dur 01911902 FRS f AEFVW Pth Mylan-Nitro Patch 02407450 MYL f AEFVW Minitran 02163527 VLN AEFVW Trinipatch 02230733 PAL AEFV Pth Trd 0.6mg/hr Nitro-Dur 01911929 FRS f AEFVW Pth Mylan-Nitro Patch 02407469 MYL f AEFVW Minitran 02163535 VLN AEFVW Trinipatch 02230734 PAL AEFV Pth Trd 0.8mg/hr Nitro-Dur 02011271 FRS f AEFVW Pth Mylan-Nitro Patch 02407477 MYL f AEFVW Slt Slg 0.3mg Nitrostat 00037613 PFI AEFGVW S.L. Slt Slg 0.6mg Nitrostat 00037621 PFI AEFGVW S.L. Srd Trd 0.2mg Transderm-Nitro 00584223 NVR AEFVW Srd Srd Trd 0.4mg Transderm-Nitro 00852384 NVR AEFVW Srd C01DA08 Srd Trd 0.6mg Transderm-Nitro 02046156 NVR AEFVW Srd ISOSORBIDE DINITRATE DINITRATE D ISOSORBIDE Slt Slg 5mg ISDN S/L 00670944 AAP f AEFGVW S.L. Tab Orl 10mg ISDN 00441686 AAP f AEFGVW C01DA14 Tab Orl 30mg ISDN 00441694 AAP f AEFGVW ISOSORBIDE MONONITRATE MONONITRATE D ISOSORBIDE SRT Orl 60mg Imdur 02126559 AZE f AEFGVW L.L. Apo-ISMN 02272830 APX f AEFGVW pms-ismn 02301288 PMS f AEFGVW February 2014 / février 2014 Page 29

C02 C02A C02AB C02AB02 ANTIHYPERTENSIVES ANTIHYPERTENSEURS ANTIADRENERGIC AGENTS, CENTRALLY ACTING AGENTS ANTIADRÉNERGIQUES, AGISSANT CENTRALEMENT METHYLDOPA METHYLDOPA METHYLDOPA (RACEMIC) METHYLDOPA (RACEMIQUE) Tab Orl 125mg Methyldopa 00360252 AAP f AEFGVW Tab Orl 250mg Methyldopa 00360260 AAP f AEFGVW C02AC C02AC01 Tab Orl 500mg Methyldopa 00426830 AAP f AEFGVW IMIDAZOLINE RECEPTOR AGONISTS AGONISTES DU RÉCEPTEUR IMIDAZOLINE CLONIDINE CLONIDINE Tab Orl 0.025mg Dixarit 00519251 BOE f AEFGVW Novo-Clonidine 02304163 TEV f AEFGVW Tab Orl 0.1mg Catapres 00259527 BOE f AEFGVW Novo-Clonidine 02046121 TEV f AEFGVW C02C C02CA C02CA01 Tab Orl 0.2mg Catapres 00291889 BOE f AEFGVW Apo-Clonidine (Disc/non disp Mar 30/14) 00868957 APX f AEFGVW Novo-Clonidine 02046148 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 00882801 APX f AEFGVW Teva-Prazin 01934198 TEV f AEFGVW Tab Orl 2mg Apo-Prazo 00882828 APX f AEFGVW Teva-Prazin 01934201 TEV f AEFGVW C02CA04 Tab Orl 5mg Apo-Prazo 00882836 APX f AEFGVW Teva-Prazin 01934228 TEV f AEFGVW DOXAZOSIN DOXAZOSIN Tab Orl 1mg Cardura-1 01958100 PFI f AEF18+V Mylan-Doxazosin 02240498 MYL f AEF18+V Apo-Doxazosin 02240588 APX f AEF18+V February 2014 / février 2014 Page 30

C02CA04 DOXAZOSIN DOXAZOSIN Tab Orl 1mg Novo-Doxazosin 02242728 TEV f AEF18+V pms-doxazosin 02244527 PMS f AEF18+V Tab Orl 2mg Cardura-2 01958097 PFI f AEF18+V Mylan-Doxazosin 02240499 MYL f AEF18+V Apo-Doxazosin 02240589 APX f AEF18+V Novo-Doxazosin 02242729 TEV f AEF18+V pms-doxazosin 02244528 PMS f AEF18+V Tab Orl 4mg Cardura-4 01958119 PFI f AEF18+V Mylan-Doxazosin 02240500 MYL f AEF18+V Apo-Doxazosin 02240590 APX f AEF18+V Novo-Doxazosin 02242730 TEV f AEF18+V pms-doxazosin 02244529 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 00441619 AAP f AEFGVW Tab Orl 25mg Hydralazine 00441627 AAP f AEFGVW Tab Orl 50mg Hydralazine 00441635 AAP f AEFGVW C02DC PYRIMIDINE DERIVATIVES DÉRIVÉS DU PYRIMIDINE C02DC01 MINOXIDIL MINOXIDIL Tab Orl 2.5mg Loniten 00514497 PFI AEFGVW Tab Orl 10mg Loniten 00514500 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 02274086 PMS f AEFGVW Apo-Hydro 02327856 APX f AEFGVW February 2014 / février 2014 Page 31

C03AA03 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE Tab Orl 25mg Teva-Hydrochlorothiazide 00021474 TEV f AEFGVW Apo-Hydro 00326844 APX f AEFGVW pms-hydrochlorothiazide 02247386 PMS f AEFGVW Tab Orl 50mg Teva-Hydrazide 00021482 TEV f AEFGVW Apo-Hydro 00312800 APX f AEFGVW pms-hydrochlorothiazide 02247387 PMS f AEFGVW Hydrochlorothiazide 02360608 SAS f AEFGVW C03B C03BA C03C C03BA04 C03BA08 C03BA11 C03CA C03CA01 Tab Orl 100mg Apo-Hydro 00644552 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 00360279 AAP f AEFGVW METOLAZONE MÉTOLAZONE Tab Orl 2.5mg Zaroxolyn 00888400 SAV AEFGVW INDAPAMIDE INDAPAMIDE Tab Orl 1.25mg Lozide 02179709 SEV f AEFGVW Mylan-Indapamide 02240067 MYL f AEFGVW Apo-Indapamide 02245246 APX f AEFGVW pms-indapamide 02239619 PMS f AEFGVW Jamp-Indapamide 02373904 JPC f AEFGVW Tab Orl 2.5mg Lozide 00564966 SEV f AEFGVW Mylan-Indapamide 02153483 MYL f AEFGVW Apo-Indapamide 02223678 APX f AEFGVW Novo-Indapamide 02231184 TEV f AEFGVW pms-indapamide 02239620 PMS f AEFGVW Jamp-Indapamide 02373912 JPC f AEFGVW HIGH-CEILING DIURETICS DIURÉTIQUES À PLAFOND ÉLEVÉ SULFONAMIDES, PLAIN SULFONAMIDES, ORDINAIRES FUROSEMIDE FUROSEMIDE Liq Inj 10mg Furosemide 00527033 SDZ VW Liq Furosemide 02382539 SDZ f VW February 2014 / février 2014 Page 32

C03CA01 FUROSEMIDE FUROSEMIDE Liq Orl 10mg Lasix 02224720 SAV AEFGVW Liq Tab Orl 20mg Teva-Furosemide 00337730 TEV f AEFGVW Apo-Furosemide 00396788 APX f AEFGVW Lasix (Disc/non disp Jun 30/14) 02224690 SAV f AEFGVW pms-furosemide 02247493 PMS f AEFGVW Furosemide 02351420 SAS f AEFGVW Tab Orl 40mg Lasix (Disc/non disp Apr 1/14) 02224704 SAV f AEFGVW pms-furosemide 02247494 PMS f AEFGVW Furosemide 02351439 SAS f AEFGVW Tab Orl 80mg Apo-Furosemide 00707570 APX f AEFGVW Teva-Furosemide 00765953 TEV f AEFGVW Furosemide 02351447 SAS f AEFGVW C03CC C03CC01 Tab Orl 500mg Lasix Special 02224755 SAV AEFGVW ARYLOXYACETIC ACID DERIVATIVES DÉRIVÉS DE L ACIDE ARYLOXYACÉTIQUE ETHACRYNIC ACID ACIDE ETHACRYNIQUE Tab Orl 25mg Edecrin 02258528 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 00028606 PFI f AEFGVW Teva-Spiroton 00613215 TEV f AEFGVW Tab Orl 100mg Aldactone 00285455 PFI f AEFGVW Teva-Spiroton 00613223 TEV f AEFGVW OTHER POTASSIUM-SPARING AGENTS AUTRES MÉDICAMENTS D ÉPARGNE DE POTASSIUM AMILORIDE AMILORIDE Tab Orl 5mg Midamor 02249510 AAP f AEFGVW February 2014 / février 2014 Page 33

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 00784400 APX f AEFGVW Novamilor 01937219 TEV f AEFGVW Mylan-Amilazide (Disc/non disp Jun 5/14) 02257378 MYL f AEFGVW HYDROCHLOROTHIAZIDE / SPIRONOLACTONE HYDROCHLOROTHIAZIDE / SPIRONOLACTONE Tab Orl 25mg/25mg Aldactazide-25 00180408 PFI f AEFGVW Teva-Spirozine-25 00613231 TEV f AEFGVW Tab Orl 50mg/50mg Aldactazide-50 00594377 PFI f AEFGVW Teva-Spirozine-50 00657182 TEV f AEFGVW TRIAMTERENE / HYDROCHLOROTHIAZIDE TRIAMTERENE / HYDROCHLOROTHIAZIDE Tab Orl 50mg/25mg Apo-Triazide 00441775 APX f AEFGVW Teva-Triamterene/HCTZ 00532657 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 01926713 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 00505773 JNJ f AEFGVW Ont Anodan HC 02128446 ODN f AEFGVW Sandoz Anuzinc HC 02247691 SDZ f AEFGVW Ratio-Hemcort HC 00607789 RPH AEFGVW February 2014 / février 2014 Page 34

C05AA01 HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE / ZINC HYDROCORTISONE / ZINC Sup Rt 0.5%/0.5% Anusol-HC 00476285 JNJ f AEFGVW Supp. Anodan HC 02236399 ODN f AEFGVW Sab-Anuzinc HC 02242798 SDZ f AEFGVW Ratio-Hemcort HC 00607797 RPH AEFGVW Aer Rt 1%/1% Proctofoam HC 00363014 DUI AEFGVW Aér FRAMYCETIN / ESCULIN / DIBUCAINE / HYDROCORTISONE FRAMYCÉTINE / ESCULINE / DIBUCAINE / HYDROCORTISONE Ont Rt 10mg/10mg/5mg/5mg Proctosedyl 02223252 AXC f AEFGVW Ont. Sandoz Proctomyxin HC 02242527 SDZ f AEFGVW Proctol Ointment 02247322 ODN f AEFGVW Sup Rt 10mg/10mg/5mg/5mg Proctosedyl 02223260 AXC f AEFGVW Supp. Sandoz Proctomyxin HC Supp 02242528 SDZ f AEFGVW Proctol Suppositories 02247882 ODN f AEFGVW HYDROCORTISONE / PRAMOXINE / ZINC HYDROCORTISONE / PRAMOXINE / ZINC Ont Rt 0.5%/1%/0.5% Anugesic-HC 00505781 JNJ f AEFGVW Ont Proctodan-HC Suppositories 02234466 ODN f AEFGVW Sandoz-Anuzinc HC Plus (Disc/non disp Mar 21/14) 02247692 SDZ f AEFGVW C07 C07A C07AA C07AA03 Sup Rt 10mg/20mg/10mg Anugesic-HC 00476242 JNJ f AEFGVW Supp. Proctodan-HC Suppositories 02240851 ODN f AEFGVW Sab-Anuzinc HC Plus 02242797 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 00417270 NVR f AEFGVW Apo-Pindol 00755877 APX f AEFGVW Teva-Pindol 00869007 TEV f AEFGVW pms-pindolol 02231536 PMS f AEFGVW Sandoz Pindolol 02261782 SDZ f AEFGVW Tab Orl 10mg Visken 00443174 NVR f AEFGVW Apo-Pindol 00755885 APX f AEFGVW Teva-Pindol 00869015 TEV f AEFGVW pms-pindolol 02231537 PMS f AEFGVW Sandoz Pindolol 02261790 SDZ f AEFGVW February 2014 / février 2014 Page 35

C07AA03 C07AA05 PINDOLOL PINDOLOL Tab Orl 15mg Visken 00417289 NVR f AEFGVW Apo-Pindol 00755893 APX f AEFGVW Teva-Pindol 00869023 TEV f AEFGVW pms-pindolol 02231539 PMS f AEFGVW Sandoz Pindolol 02261804 SDZ f AEFGVW PROPRANOLOL PROPRANOLOL Tab Orl 10mg Apo-Propranolol (Disc/non disp Apr 10/15) 00402788 APX f AEFGVW Novo-Pranol 00496480 TEV f AEFGVW Tab Orl 20mg Apo-Propranolol (Disc/non disp Oct 22/15) 00663719 APX f AEFGVW Novo-Pranol 00740675 TEV f AEFGVW Tab Orl 40mg Apo-Propranolol (Disc/non disp Apr 10/15) 00402753 APX f AEFGVW Novo-Pranol 00496499 TEV f AEFGVW Tab Orl 80mg Apo-Propranolol (Disc/non disp Apr 10/15) 00402761 APX f AEFGVW Novo-Pranol 00496502 TEV f AEFGVW C07AA06 Tab Orl 120mg Apo-Propranolol 00504335 APX f AEFGVW TIMOLOL TIMOLOL Tab Orl 5mg Apo-Timol 00755842 APX f AEFGVW Teva-Timol 01947796 TEV f AEFGVW Tab Orl 10mg Apo-Timol 00755850 APX f AEFGVW Teva-Timol 01947818 TEV f AEFGVW C07AA07 Tab Orl 20mg Apo-Timol 00755869 APX f AEFGVW Teva-Timol 01947826 TEV f AEFGVW SOTALOL SOTALOL Tab Orl 80mg Apo-Sotalol 02210428 APX f AEFGVW Mylan-Sotalol 02229778 MYL f AEFGVW Novo-Sotalol 02231181 TEV f AEFGVW pms-sotalol 02238326 PMS f AEFGVW Sandoz Sotalol 02257831 SDZ f AEFGVW Co-Sotalol (Disc/non disp Dec 12/14) 02270625 COB f AEFGVW Jamp-Sotalol 02368617 JPC f AEFGVW ratio-sotalol 02084228 TEV f AEFGVW Tab Orl 160mg ratio-sotalol 02084236 TEV f AEFGVW Apo-Sotalol 02167794 APX f AEFGVW Mylan-Sotalol 02229779 MYL f AEFGVW Novo-Sotalol 02231182 TEV f AEFGVW pms-sotalol 02238327 PMS f AEFGVW Sandoz Sotalol 02257858 SDZ f AEFGVW February 2014 / février 2014 Page 36

C07AA07 C07AA12 SOTALOL SOTALOL Tab Orl 160mg Co-Sotalol (Disc/non disp Dec 12/14) 02270633 COB f AEFGVW Jamp-Sotalol 02368625 JPC f AEFGVW NADOLOL NADOLOL Tab Orl 40mg Apo-Nadol 00782505 APX f AEFGVW Teva-Nadolol (Disc/non disp Oct 25/14) 02126753 TEV f AEFGVW Tab Orl 80mg Apo-Nadol 00782467 APX f AEFGVW Teva- Nadolol (Disc/non disp Oct 25/14) 02126761 TEV f AEFGVW C07AB C07AB02 Tab Orl 160mg Apo-Nadol 00782475 APX f AEFGVW BETA BLOCKING AGENTS, SELECTIVE BETA-BLOQUANTS, SÉLECTIFS METOPROLOL MÉTOPROLOL SRT Orl 100mg Lopresor SR 00658855 NVR f AEFGVW L.L. Apo-Metoprolol SR 02285169 APX f AEFGVW Sandoz Metoprolol SR 02303396 SDZ f AEFGVW SRT Orl 200mg Lopresor SR 00534560 NVR f AEFGVW L.L. Apo-Metoprolol SR 02285177 APX f AEFGVW Sandoz Metoprolol SR 02303418 SDZ f AEFGVW Tab Orl 25mg Apo-Metoprolol 02246010 APX f AEFGVW pms-metoprolol-l 02248855 PMS f AEFGVW Mylan-Metoprolol (type L) 02302055 MYL f AEFGVW Jamp-Metoprolol-L 02356813 JPC f AEFGVW Tab Orl 50mg Lopresor (coated) 00397423 NVR f AEFGVW Apo-Metoprolol (uncoated) 00618632 APX f AEFGVW Teva-Metoprolol (coated) 00648035 TEV f AEFGVW Apo-Metoprolol type L 00749354 APX f AEFGVW Teva-Metoprolol (uncoated) 00842648 TEV f AEFGVW Mylan-Metoprolol (type L) 02174545 MYL f AEFGVW pms-metoprolol-l 02230803 PMS f AEFGVW Sandoz Metoprolol (type L) (Disc/non disp Feb 22/14) 02247875 SDZ f AEFGVW Metoprolol 02350394 SAS f AEFGVW Sandoz Metoprolol 02354187 SDZ f AEFGVW Jamp-Metoprolol-L 02356821 JPC f AEFGVW Tab Orl 100mg Lopresor (coated) 00397431 NVR f AEFGVW Apo-Metoprolol (uncoated) 00618640 APX f AEFGVW Teva-Metoprolol (coated) 00648043 TEV f AEFGVW Apo-Metoprolol type L 00751170 APX f AEFGVW Teva-Metoprolol (uncoated) 00842656 TEV f AEFGVW Mylan-Metoprolol (type L) 02174553 MYL f AEFGVW pms-metoprolol-l 02230804 PMS f AEFGVW Sandoz Metoprolol (type L) (Disc/non disp Feb 22/14) 02247876 SDZ f AEFGVW February 2014 / février 2014 Page 37

C07AB02 C07AB03 METOPROLOL MÉTOPROLOL Tab Orl 100mg Metoprolol 02350408 SAS f AEFGVW Sandoz Metoprolol 02354195 SDZ f AEFGVW Jamp-Metoprolol-L 02356848 JPC f AEFGVW ATENOLOL ATÉNOLOL Tab Orl 25mg pms-atenolol 02246581 PMS f AEFGVW Atenolol 02247182 SIV f AEFGVW Teva-Atenolol 02266660 TEV f AEFGVW Mylan-Atenolol 02303647 MYL f AEFGVW Jamp-Atenolol 02367556 JPC f AEFGVW Mint-Atenolol 02368013 MNT f AEFGVW Mar-Atenolol 02371979 MAR f AEFGVW Ran-Atenolol 02373963 RAN f AEFGVW Tab Orl 50mg Apo-Atenol 00773689 APX f AEFGVW Tenormin 02039532 AZE f AEFGVW Mylan-Atenolol-50 02146894 MYL f AEFGVW ratio-atenolol 02171791 TEV f AEFGVW Sandoz Atenolol 02231731 SDZ f AEFGVW pms-atenolol 02237600 PMS f AEFGVW Atenolol 02238316 SIV f AEFGVW Co Atenolol 02255545 COB f AEFGVW Ran-Atenolol 02267985 RAN f AEFGVW Jamp-Atenolol 02367564 JPC f AEFGVW Mint-Atenolol 02368021 MNT f AEFGVW Septa-Atenolol 02368641 SPT f AEFGVW Mar-Atenolol 02371987 MAR f AEFGVW C07AB04 Tab Orl 100mg Apo-Atenol 00773697 APX f AEFGVW Teva-Atenolol 01912054 TEV f AEFGVW Tenormin 02039540 AZE f AEFGVW Mylan-Atenolol-100 02147432 MYL f AEFGVW ratio-atenolol 02171805 TEV f AEFGVW Sandoz Atenolol 02231733 SDZ f AEFGVW pms-atenolol 02237601 PMS f AEFGVW Atenolol 02238318 SIV f AEFGVW Co Atenolol 02255553 COB f AEFGVW Ran-Atenolol 02267993 RAN f AEFGVW Jamp-Atenolol 02367572 JPC f AEFGVW Mint-Atenolol 02368048 MNT f AEFGVW Septa-Atenolol 02368668 SPT f AEFGVW Mar-Atenolol 02371995 MAR f AEFGVW ACEBUTOLOL ACÉBUTOLOL Tab Orl 100mg Sectral (Disc/non disp Jun 30/14) 01926543 SAV f AEFGVW Apo-Acebutolol 02147602 APX f AEFGVW Teva-Acebutolol 02204517 TEV f AEFGVW Mylan-Acebutolol 02237721 MYL f AEFGVW Mylan-Acebutolol Type S 02237885 MYL f AEFGVW Acebutolol 02286246 SAS f AEFGVW February 2014 / février 2014 Page 38

C07AB04 ACEBUTOLOL ACÉBUTOLOL Tab Orl 200mg Sectral 01926551 SAV f AEFGVW Apo-Acebutolol 02147610 APX f AEFGVW Teva-Acebutolol 02204525 TEV f AEFGVW Mylan-Acebutolol 02237722 MYL f AEFGVW Mylan-Acebutolol Type S 02237886 MYL f AEFGVW Acebutolol 02286254 SAS f AEFGVW Tab Orl 400mg Sectral 01926578 SAV f AEFGVW Apo-Acebutolol 02147629 APX f AEFGVW Teva-Acebutolol 02204533 TEV f AEFGVW Mylan-Acebutolol 02237723 MYL f AEFGVW Mylan-Acebutolol Type S 02237887 MYL f AEFGVW Acebutolol 02286262 SAS f AEFGVW C07AB07 BISOPROLOL BISOPROLOL Tab Orl 5mg Sandoz Bisoprolol 02247439 SDZ f AEFVW Apo-Bisoprolol 02256134 APX f AEFVW Novo-Bisoprolol 02267470 TEV f AEFVW pms-bisoprolol 02302632 PMS f AEFVW Mylan-Bisoprolol 02384418 MYL f AEFVW Bisoprolol 02391589 SAS f AEFVW Tab Orl 10mg Sandoz Bisoprolol 02247440 SDZ f AEFVW Apo-Bisoprolol 02256177 APX f AEFVW Novo-Bisoprolol 02267489 TEV f AEFVW pms-bisoprolol 02302640 PMS f AEFVW Mylan-Bisoprolol 02384426 MYL f AEFVW Bisoprolol 02391597 SAS f AEFVW C07AG ALPHA AND BETA BLOCKING AGENTS ALPHA-BLOQUANTS ET BETA-BLOQUANTS C07AG01 LABETALOL LABÉTALOL Tab Orl 100mg Trandate 02106272 PAL f AEFGVW Tab Orl 200mg Trandate 02106280 PAL f AEFGVW C07AG01 CARVEDILOL CARVÉDILOL Tab Orl 3.125mg pms-carvedilol 9 02245914 PMS f AEFV Apo-Carvedilol 9 02247933 APX f AEFV Carvedilol 9 02248752 SIV f AEFV ratio-carvedilol 9 02252309 TEV f AEFV Ran-Carvedilol 9 02268027 RAN f AEFV Zym-Carvedilol 9 02338068 ZYM f AEFV Mylan-Carvedilol 9 02347512 MYL f AEFV Carvidilol 9 02364913 SAS f AEFV Jamp-Carvedilol 9 02368897 JPC f AEFV February 2014 / février 2014 Page 39

C07AG01 CARVEDILOL CARVÉDILOL Tab Orl 6.25mg pms-carvedilol 9 02245915 PMS f AEFV Apo-Carvedilol 9 02247934 APX f AEFV Carvedilol 9 02248753 SIV f AEFV ratio-carvedilol 9 02252317 TEV f AEFV Ran-Carvedilol 9 02268035 RAN f AEFV Zym-Carvedilol 9 02338092 ZYM f AEFV Mylan-Carvedilol 9 02347520 MYL f AEFV Carvidilol 9 02364921 SAS f AEFV Jamp-Carvedilol 9 02368900 JPC f AEFV Tab Orl 12.5mg pms-carvedilol 9 02245916 PMS f AEFV Apo-Carvedilol 9 02247935 APX f AEFV Carvedilol 9 02248754 SIV f AEFV ratio-carvedilol 9 02252325 TEV f AEFV Ran-Carvedilol 9 02268043 RAN f AEFV Zym-Carvedilol 9 02338106 ZYM f AEFV Mylan-Carvedilol 9 02347555 MYL f AEFV Carvidilol 9 02364948 SAS f AEFV Jamp-Carvedilol 9 02368919 JPC f AEFV C07C C07CA C07CA03 Tab Orl 25mg pms-carvedilol 9 02245917 PMS f AEFV Apo-Carvedilol 9 02247936 APX f AEFV Carvedilol 9 02248755 SIV f AEFV ratio-carvedilol 9 02252333 TEV f AEFV Ran-Carvedilol 9 02268051 RAN f AEFV Zym-Carvedilol 9 02338114 ZYM f AEFV Mylan-Carvedilol 9 02347571 MYL f AEFV Carvedilol 9 02364956 SAS f AEFV Jamp-Carvedilol 9 02368927 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 00568627 NVR AEFGVW Tab Orl 10mg/50mg Viskazide 00568635 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

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 02049961 AZE f AEFGVW Apo-Atenidone 02248763 APX f AEFGVW Teva-Atenolol/Chlorthalidone 02302918 TEV f AEFGVW Tab Orl 100mg/25mg Tenoretic 02049988 AZE f AEFGVW Apo-Atenidone 02248764 APX f AEFGVW Teva-Atenolol/Chlorthalidone 02302926 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 02295148 PMS f AEFVW Co Amlodipine 02297477 COB f AEFVW Amlodipine 02326795 PDL f AEFVW Sandoz Amlodipine 02330474 SDZ f AEFVW Jamp-Amlodipine 02357186 JPC f AEFVW Mar-Amlodipine 02371707 MAR f AEFVW Septa-Amlodipine 02357704 SPT f AEFVW Ran-Amlodipine 02398877 RAN f AEFVW Tab Orl 5mg Norvasc 00878928 PFI f AEFVW Teva-Amlodipine 02250497 TEV f AEFVW ratio-amlodipine 02259605 RPH f AEFVW Mylan-Amlodipine 02272113 MYL f AEFVW Apo-Amlodipine 02273373 APX f AEFVW GD-Amlodipine 02280132 GMD f AEFVW pms-amlodipine 02284065 PMS f AEFVW Sandoz Amlodipine 02284383 SDZ f AEFVW Co Amlodipine 02297485 COB f AEFVW Ran-Amlodipine 02321858 RAN f AEFVW Phl-Amlodipine 02326779 PHL f AEFVW Amlodipine 02326809 PDL f AEFVW Jamp-Amlodipine 02331071 JPC f AEFVW Amlodipine 02331284 SAS f AEFVW Jamp-Amlodipine (new formulation) 02357194 JPC f AEFVW Septa-Amlodipine 02357712 SPT f AEFVW Mint-Amlodipine 02362651 MNT f AEFVW Mar-Amlodipine 02371715 MAR f AEFVW Amlodipine-Odan 02378760 ODN f AEFVW Auro-Amlodipine 02397072 ARO f AEFVW February 2014 / février 2014 Page 41

C08CA01 C08CA02 AMLODIPINE AMLODIPINE Tab Orl 10mg Norvasc 00878936 PFI f AEFVW Teva-Amlodipine 02250500 TEV f AEFVW ratio-amlodipine 02259613 RPH f AEFVW Mylan-Amlodipine 02272121 MYL f AEFVW Apo-Amlodipine 02273381 APX f AEFVW GD-Amlodipine 02280140 GMD f AEFVW pms-amlodipine 02284073 PMS f AEFVW Sandoz Amlodipine 02284391 SDZ f AEFVW Co Amlodipine 02297493 COB f AEFVW Ran-Amlodipine 02321866 RAN f AEFVW Phl-Amlodipine 02326787 PHL f AEFVW Amlodipine 02326817 PDL f AEFVW Jamp-Amlodipine 02331098 JPC f AEFVW Amlodipine 02331292 SAS f AEFVW Jamp-Amlodipine (new formulation) 02357208 JPC f AEFVW Septa-Amlodipine 02357720 SPT f AEFVW Mar-Amlodipine 02371723 MAR f AEFVW Amlodipine-Odan 02378779 ODN f AEFVW Auro-Amlodipine 02397080 ARO f AEFVW Mint-Amlodipine 02362678 MNT f AEFVW FELODIPINE FÉLODIPINE SRT Orl 2.5mg Plendil 02057778 AZE f AEFVW L.L. Renedil (Disc/non disp Sep 18/15) 02221985 SAV f AEFVW SRT Orl 5mg Plendil 00851779 AZE f AEFVW L.L. Renedil (Disc/non disp Aug 6/15) 02221993 SAV f AEFVW Sandoz Felodipine 02280264 SDZ f AEFVW C08CA05 SRT Orl 10mg Plendil 00851787 AZE f AEFVW L.L. Renedil (Disc/non disp Apr 29/15) 02222000 SAV f AEFVW Sandoz Felodipine 02280272 SDZ f AEFVW NIFEDIPINE NIFÉDIPINE Cap Orl 5mg Nifedipine 00725110 AAP f AEFGVW Caps Cap Orl 10mg Nifedipine 00755907 AAP f AEFGVW Caps ERT Orl 20mg Adalat XL 02237618 BAY f AEFGVW L.P. ERT Orl 30mg Adalat XL 02155907 BAY f AEFGVW L.P. Mylan-Nifedipine Extended Release 02349167 MYL f AEFGVW ERT Orl 60mg Adalat XL 02155990 BAY f AEFGVW L.P. Mylan-Nifedipine Extended Release 02321149 MYL f AEFGVW February 2014 / février 2014 Page 42

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 01934317 ABB f AEFGVW L.L. Mylan-Verapamil 02210355 MYL f AEFGVW Apo-Verap SR 02246894 APX f AEFGVW Covera-HS 02231676 PFI AEFVW SRT Orl 240mg Isoptin SR 00742554 ABB f AEFGVW L.L. Mylan-Verapamil 02210363 MYL f AEFGVW pms-verapamil SR 02237791 PMS f AEFGVW Apo-Verap SR 02246895 APX f AEFGVW Novo-Veramil SR 02211920 TEV AEFGVW Covera-HS 02231677 PFI AEFGV Tab Orl 80mg Apo-Verap 00782483 APX f AEFGVW Mylan-Verapamil 02237921 MYL f AEFGVW C08DB C08DB01 Tab Orl 120mg Apo-Verap 00782491 APX f AEFGVW Mylan-Verapamil 02237922 MYL f AEFGVW BENZOTHIAZEPINE DERIVATIVES DÉRIVÉS DU BENZOTHIAZÉPINE DILTIAZEM DILTIAZEM CD Orl 120mg Cardizem CD 02097249 VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD 02230997 APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) 02229781 RPH f AEFGVW Teva-Diltazem CD 02242538 TEV f AEFGVW Sandoz Diltiazem CD 02243338 SDZ f AEFGVW pms-diltiazem CD 02355752 PMS f AEFGVW Co Diltiazem CD 02370611 COB f AEFGVW Diltiazem CD 02400421 SAS f AEFGVW CD Orl 180mg Cardizem CD 02097257 VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD 02230998 APX f AEFGVW ratio-diltiazem CD (Disc/non disp June 29/14) 02229782 RPH f AEFGVW Teva-Diltazem CD 02242539 TEV f AEFGVW Sandoz Diltiazem CD 02243339 SDZ f AEFGVW pms-diltiazem CD 02355760 PMS f AEFGVW Co Diltiazem CD 02370638 COB f AEFGVW Diltiazem CD 02400448 SAS f AEFGVW CD Orl 240mg Cardizem CD 02097265 VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD 02230999 APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) 02229783 RPH f AEFGVW Teva-Diltazem CD 02242540 TEV f AEFGVW Sandoz Diltiazem CD 02243340 SDZ f AEFGVW February 2014 / février 2014 Page 43

C08DB01 DILTIAZEM DILTIAZEM CD Orl 240mg pms-diltiazem CD 02355779 PMS f AEFGVW Caps.L.C. Co Diltiazem CD 02370646 COB f AEFGVW Diltiazem CD 02400456 SAS f AEFGVW CD Orl 300mg Cardizem CD 02097273 VLN f AEFGVW Caps.L.C. Apo-Diltiaz CD 02229526 APX f AEFGVW ratio-diltiazem CD (Disc/non disp Jun 29/14) 02229784 RPH f AEFGVW Teva-Diltazem CD 02242541 TEV f AEFGVW Sandoz Diltiazem CD 02243341 SDZ f AEFGVW pms-diltiazem CD 02355787 PMS f AEFGVW Co Diltiazem CD 02370654 COB f AEFGVW Diltiazem CD 02400464 SAS f AEFGVW ERC Orl 120mg Tiazac 02231150 VLN f AEFVW Caps.L.P Sandoz Diltiazem T 02245918 SDZ f AEFVW Teva-Diltiazem ER 02271605 TEV f AEFVW Apo-Diltiaz TZ 02291037 APX f AEFVW Co Diltiazem T 02370441 COB f AEFVW ERC Orl 180mg Tiazac 02231151 VLN f AEFVW Caps.L.P Sandoz Diltiazem T 02245919 SDZ f AEFVW Teva-Diltiazem ER 02271613 TEV f AEFVW Apo-Diltiaz TZ 02291045 APX f AEFVW Co Diltiazem T 02370492 COB f AEFVW ERC Orl 240mg Tiazac 02231152 VLN f AEFVW Caps.L.P Sandoz Diltiazem T 02245920 SDZ f AEFVW Teva-Diltiazem ER 02271621 TEV f AEFVW Apo-Diltiaz TZ 02291053 APX f AEFVW Co Diltiazem T 02370506 COB f AEFVW ERC Orl 300mg Tiazac 02231154 VLN f AEFVW Caps.L.P Sandoz Diltiazem T 02245921 SDZ f AEFVW Teva-Diltiazem ER 02271648 TEV f AEFVW Apo-Diltiaz TZ 02291061 APX f AEFVW Co Diltiazem T 02370514 COB f AEFVW ERC Orl 360mg Tiazac 02231155 VLN f AEFVW Caps.L.P Sandoz Diltiazem T 02245922 SDZ f AEFVW Teva-Diltiazem ER 02271656 TEV f AEFVW Apo-Diltiaz TZ 02291088 APX f AEFVW Co Diltiazem T 02370522 COB f AEFVW ERT Orl 120mg Tiazac XC 02256738 VLN AEFGVW L.P. ERT Orl 180mg Tiazac XC 02256746 VLN AEFGVW L.P. ERT Orl 240mg Tiazac XC 02256754 VLN AEFGVW L.P. February 2014 / février 2014 Page 44

C08DB01 DILTIAZEM DILTIAZEM ERT Orl 300mg Tiazac XC 02256762 VLN AEFGVW L.P. ERT Orl 360mg Tiazac XC 02256770 VLN AEFGVW L.P. Tab Orl 30mg Apo-Diltiaz 00771376 APX f AEFGVW Teva-Diltiazem 00862924 TEV f AEFGVW Tab Orl 60mg Apo-Diltiaz 00771384 APX f AEFGVW Teva-Diltiazem 00862932 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 00893595 APX f AEFGVW Teva-Captoril 01942964 TEV f AEFGVW Mylan-Captopril 02163551 MYL f AEFGVW Tab Orl 25mg Apo-Capto 00893609 APX f AEFGVW Teva-Captoril 01942972 TEV f AEFGVW Mylan-Captopril 02163578 MYL f AEFGVW Tab Orl 50mg Apo-Capto 00893617 APX f AEFGVW Teva-Captoril 01942980 TEV f AEFGVW Mylan-Captopril 02163586 MYL f AEFGVW Tab Orl 100mg Apo-Capto 00893625 APX f AEFGVW Teva-Captoril 01942999 TEV f AEFGVW Mylan-Captopril 02163594 MYL f AEFGVW C09AA02 ENALAPRIL ÉNALAPRIL Tab Orl 2.5mg Vasotec 10 00851795 FRS f AEFGVW Apo-Enalapril 10 02020025 APX f AEFGVW Co Enalapril 10 02291878 COB f AEFGVW Sandoz Enalapril 10 02299933 SDZ f AEFGVW Mylan-Enalapril 10 02300036 MYL f AEFGVW Teva-Enalapril 10 02300680 TEV f AEFGVW Ran-Enalapril 10 02352230 RAN f AEFGVW pms-enalapril 10 02300079 PMS f AEFGVW Enalapril 10 02400650 SAS f AEFGVW February 2014 / février 2014 Page 45

C09AA02 ENALAPRIL ÉNALAPRIL Tab Orl 5mg Vasotec 10 00708879 FRS f AEFGVW Apo-Enalapril 10 02019884 APX f AEFGVW Co Enalapril 10 02291886 COB f AEFGVW Sandoz Enalapril 10 02299941 SDZ f AEFGVW Mylan-Enalapril 10 02300044 MYL f AEFGVW Teva-Enalapril 10 02233005 TEV f AEFGVW Ran-Enalapril 10 02352249 RAN f AEFGVW pms-enalapril 10 02300087 PMS f AEFGVW Enalapril 10 02400669 SAS f AEFGVW Tab Orl 10mg Vasotec 10 00670901 FRS f AEFGVW Apo-Enalapril 10 02019892 APX f AEFGVW Co Enalapril 10 02291894 COB f AEFGVW Sandoz Enalapril 10 02299968 SDZ f AEFGVW Mylan-Enalapril 10 02300052 MYL f AEFGVW Teva-Enalapril 10 02233006 TEV f AEFGVW Ran-Enalapril 10 02352257 RAN f AEFGVW pms-enalapril 10 02300095 PMS f AEFGVW Enalapril 10 02400677 SAS f AEFGVW Tab Orl 20mg Vasotec 10 00670928 FRS f AEFGVW Apo-Enalapril 10 02019906 APX f AEFGVW Co Enalapril 10 02291908 COB f AEFGVW Sandoz Enalapril 10 02299976 SDZ f AEFGVW Mylan-Enalapril 10 02300060 MYL f AEFGVW Teva-Enalapril 10 02233007 TEV f AEFGVW Ran-Enalapril 10 02352265 RAN f AEFGVW pms-enalapril 10 02300109 PMS f AEFGVW Enalapril 10 02400685 SAS f AEFGVW C09AA03 LISINOPRIL LISINOPRIL Tab Orl 5mg Prinivil 00839388 FRS f AEFGVW Zestril 02049333 AZE f AEFGVW Apo-Lisinopril 02217481 APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) 02256797 RPH f AEFGVW Co Lisinopril 02271443 COB f AEFGVW Mylan-Lisinopril 02274833 MYL f AEFGVW Teva-Lisinopril P 02285061 TEV f AEFGVW Teva-Lisinopril Z 02285118 TEV f AEFGVW Sandoz Lisinopril 02289199 SDZ f AEFGVW pms-lisinopril 02292203 PMS f AEFGVW Ran-Lisinopril 02294230 RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) 02299879 RPH f AEFGVW Jamp-Lisinopril 02361531 JPC f AEFGVW Auro-Lisinopril 02394472 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

C09AA03 LISINOPRIL LISINOPRIL Tab Orl 10mg Prinivil 00839396 FRS f AEFGVW Zestril 02049376 AZE f AEFGVW Apo-Lisinopril 02217503 APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) 02256800 RPH f AEFGVW Co Lisinopril 02271451 COB f AEFGVW Mylan-Lisinopril 02274841 MYL f AEFGVW Teva-Lisinopril P 02285088 TEV f AEFGVW Teva-Lisinopril Z 02285126 TEV f AEFGVW Sandoz Lisinopril 02289202 SDZ f AEFGVW pms-lisinopril 02292211 PMS f AEFGVW Ran-Lisinopril 02294249 RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) 02299887 RPH f AEFGVW Jamp-Lisinopril 02361558 JPC f AEFGVW Auro-Lisinopril 02394480 ARO f AEFGVW Tab Orl 20mg Prinivil 00839418 FRS f AEFGVW Zestril 02049384 AZE f AEFGVW Apo-Lisinopril 02217511 APX f AEFGVW ratio-lisinopril P (Disc/non disp Jun 29/14) 02256819 RPH f AEFGVW Co Lisinopril 02271478 COB f AEFGVW Mylan-Lisinopril 02274868 MYL f AEFGVW Teva-Lisinopril P 02285096 TEV f AEFGVW Teva-Lisinopril Z 02285134 TEV f AEFGVW Sandoz Lisinopril 02289229 SDZ f AEFGVW pms-lisinopril 02292238 PMS f AEFGVW Ran-Lisinopril 02294257 RAN f AEFGVW ratio-lisinopril Z (Disc/non disp Jun 29/14) 02299895 RPH f AEFGVW Jamp-Lisinopril 02361566 JPC f AEFGVW Auro-Lisinopril 02394499 ARO f AEFGVW C09AA04 PERINDOPRIL PERINDOPRIL Tab Orl 2mg Coversyl 02123274 SEV AEFGVW Tab Orl 4mg Coversyl 02123282 SEV AEFGVW Tab Orl 8mg Coversyl 02246624 SEV f AEFGVW C09AA05 RAMIPRIL RAMIPRIL Cap Orl 1.25mg Altace 02221829 SAV f AEFGVW Caps Apo-Ramipril 02251515 APX f AEFGVW ratio-ramipril 02287692 RPH f AEFGVW pms-ramipril 02295369 PMS f AEFGVW Co Ramipril 02295482 COB f AEFGVW Mylan-Ramipril 02301148 MYL f AEFGVW February 2014 / février 2014 Page 47

C09AA05 RAMIPRIL RAMIPRIL Cap Orl 1.25mg Ran-Ramipril 02310503 RAN f AEFGVW Caps Jamp-Ramipril 02331101 JPC f AEFGVW Auro-Ramipril 02387387 ARO f AEFGVW Cap Orl 2.5mg Altace 02221837 SAV f AEFGVW Caps pms-ramipril 02247917 PMS f AEFGVW Teva-Ramipril 02247945 TEV f AEFGVW Apo-Ramipril 02251531 APX f AEFGVW ratio-ramipril 02287706 RPH f AEFGVW Co Ramipril 2295490 COB f AEFGVW Mylan-Ramipril 02301156 MYL f AEFGVW Ran-Ramipril 02310511 RAN f AEFGVW Jamp-Ramipril 02331128 JPC f AEFGVW Ramipril 02374846 SAS f AEFGVW Auro-Ramipril 02387395 ARO f AEFGVW Cap Orl 5mg Altace 02221845 SAV f AEFGVW Caps pms-ramipril 02247918 PMS f AEFGVW Teva-Ramipril 02247946 TEV f AEFGVW Apo-Ramipril 02251574 APX f AEFGVW Co Ramipril 02295504 COB f AEFGVW Mylan-Ramipril 02301164 MYL f AEFGVW Ran-Ramipril 02310538 RAN f AEFGVW Jamp-Ramipril 02331136 JPC f AEFGVW Ramipril 02374854 SAS f AEFGVW Auro-Ramipril 02387409 ARO f AEFGVW Cap Orl 10mg Altace 02221853 SAV f AEFGVW Caps pms-ramipril 02247919 PMS f AEFGVW Teva-Ramipril 02247947 TEV f AEFGVW Apo-Ramipril 02251582 APX f AEFGVW Co Ramipril 02295512 COB f AEFGVW Mylan-Ramipril 02301172 MYL f AEFGVW Ran-Ramipril 02310546 RAN f AEFGVW Jamp-Ramipril 02331144 JPC f AEFGVW Ramipril 02374862 SAS f AEFGVW Auro-Ramipril 02387417 ARO f AEFGVW Cap Orl 15mg Altace 02281112 SAV f AEFGVW Caps Apo-Ramipril 02325381 APX f AEFGVW Tab Orl 1.25mg Sandoz Ramipril 02291398 SDZ AEFGVW Tab Orl 2.5mg Sandoz Ramipril 02291401 SDZ AEFGVW Tab Orl 5mg Sandoz Ramipril 02291428 SDZ AEFGVW Tab Orl 10mg Sandoz Ramipril 02291436 SDZ AEFGVW February 2014 / février 2014 Page 48

C09AA06 QUINAPRIL QUINAPRIL Tab Orl 5mg Accupril 01947664 PFI f AEFGVW Apo-Quinapril 02248499 APX f AEFGVW Tab Orl 10mg Accupril 01947672 PFI f AEFGVW Apo-Quinapril 02248500 APX f AEFGVW C09AA07 Tab Orl 20mg Accupril 01947680 PFI f AEFGVW Apo-Quinapril 02248501 APX f AEFGVW Tab Orl 40mg Accupril 01947699 PFI f AEFGVW Apo-Quinapril 02248502 APX f AEFGVW BENAZEPRIL BÉNAZÉPRIL Tab Orl 5mg Lotensin 00885835 NVR f AEFGVW Benazapril 02290332 AAP f AEFGVW Tab Orl 10mg Lotensin (Disc/non disp Apr 3/14) 00885843 NVR f AEFGVW Benazapril 02290340 AAP f AEFGVW C09AA08 Tab Orl 20mg Lotensin 00885851 NVR f AEFGVW Benazapril 02273918 AAP f AEFGVW CILAZAPRIL CILAZAPRIL Tab Orl 1mg Novo-Cilazapril 02266350 TEV f AEFGVW pms-cilazapril 02280442 PMS f AEFGVW Mylan-Cilazapril 02283778 MYL f AEFGVW Apo-Cilazapril 02291134 APX f AEFGVW Cilazapril (Disc/non disp Jan 1/15) 02350963 SAS f AEFGVW Tab Orl 2.5mg Inhibace 01911473 HLR f AEFGVW Novo-Cilazapril 02266369 TEV f AEFGVW pms-cilazapril 02280450 PMS f AEFGVW Mylan-Cilazapril 02283786 MYL f AEFGVW Co-Cilazapril 02285215 COB f AEFGVW Apo-Cilazapril 02291142 APX f AEFGVW Cilazapril 02350971 SAS f AEFGVW Tab Orl 5mg Inhibace 01911481 HLR f AEFGVW Novo-Cilazapril 02266377 TEV f AEFGVW pms-cilazapril 02280469 PMS f AEFGVW Mylan-Cilazapril 02283794 MYL f AEFGVW Co-Cilazapril 02285223 COB f AEFGVW Apo-Cilazapril 02291150 APX f AEFGVW Cilazapril 02350998 SAS f AEFGVW C09AA09 FOSINOPRIL FOSINOPRIL Tab Orl 10mg Monopril (Disc/non disp Jun 17/15) 01907107 BRI f AEFGVW Teva-Fosinopril 02247802 TEV f AEFGVW February 2014 / février 2014 Page 49

C09AA09 C09AA09 FOSINOPRIL FOSINOPRIL Tab Orl 10mg Mylan-Fosinopril 02262401 MYL f AEFGVW Apo-Fosinopril 02266008 APX f AEFGVW Ran-Fosinopril 02294524 RAN f AEFGVW Jamp-Fosinopril 02331004 JPC f AEFGVW Tab Orl 20mg Monopril (Disc/non disp Jun 17/15) 01907115 BRI f AEFGVW Teva-Fosinopril 02247803 TEV f AEFGVW Mylan-Fosinopril 02262428 MYL f AEFGVW Apo-Fosinopril 02266016 APX f AEFGVW Ran-Fosinopril 02294532 RAN f AEFGVW Jamp-Fosinopril 02331012 JPC f AEFGVW TRANDOLAPRIL TRANDOLAPRIL Cap Orl 1mg Mavik 02231459 ABB AEFGVW Caps Cap Orl 2mg Mavik 02231460 ABB AEFGVW Caps C09B C09BA C09BA02 Cap Orl 4mg Mavik 02239267 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 11 02300222 TEV f AEFGVW Apo-Enalapril/HCTZ 11 02352923 APX f AEFGVW Tab Orl 10mg/25mg Vaseretic 11 00657298 FRS f AEFGVW Novo-Enalapril/HCT 11 02300230 TEV f AEFGVW Apo-Enalapril/HCTZ 11 02352931 APX f AEFGVW C09BA03 LISINOPRIL AND DIURETICS LISINOPRIL ET DIURÉTIQUES LISINOPRIL / HYDROCHLOROTHIAZIDE LISINOPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Zestoretic 02103729 AZE f AEFGVW Apo-Lisinopril/HCTZ 02261979 APX f AEFGVW Mylan-Lisinopril HCTZ 02297736 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

C09BA03 LISINOPRIL AND DIURETICS LISINOPRIL ET DIURÉTIQUES LISINOPRIL / HYDROCHLOROTHIAZIDE LISINOPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Teva-Lisinopril HCTZ (Type Z) 02301768 TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) 02302136 TEV f AEFGVW Sandoz Lisinopril HCT 02302365 SDZ f AEFGVW Lisinopril HCTZ (Type Z) 02362945 SAS f AEFGVW Tab Orl 20mg/12.5mg Zestoretic 02045737 AZE f AEFGVW Prinzide 00884413 FRS f AEFGVW Apo-Lisinopril/HCTZ 02261987 APX f AEFGVW Mylan-Lisinopril HCTZ 02297744 MYL f AEFGVW Teva-Lisinopril HCTZ (Type Z) 02301776 TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) 02302144 TEV f AEFGVW Sandoz Lisinopril HCT 02302373 SDZ f AEFGVW Lisinopril HCTZ (Type Z) 02362953 SAS f AEFGVW C09BA04 C09BA05 Tab Orl 20mg/25mg Zestoretic 02045729 AZE f AEFGVW Apo-Lisinopril/HCTZ 02261995 APX f AEFGVW Mylan-Lisinopril HCTZ 02297752 MYL f AEFGVW Teva-Lisinopril HCTZ (Type Z) 02301784 TEV f AEFGVW Teva-Lisinopril HCTZ (Type P) 02302152 TEV f AEFGVW Sandoz Lisinopril HCT 02302381 SDZ f AEFGVW Lisinopril HCTZ (Type Z) 02362961 SAS f AEFGVW PERINDOPRIL AND DIURETICS PERINDOPRIL ET DIURÉTIQUES PERINDOPRIL / INDAPAMIDE PERINDOPRIL / INDAPAMIDE Tab Orl 4mg/1.25mg Coversyl Plus 02246569 SEV AEFGVW Tab Orl 8mg/2.5mg Coversyl Plus HD 02321653 SEV AEFGVW RAMIPRIL AND DIURETICS RAMIPRIL ET DIURÉTIQUES RAMIPRIL / HYDROCHLOROTHIAZIDE RAMIPRIL / HYDROCHLOROTHIAZIDE Tab Orl 2.5mg/12.5mg Altace HCT 02283131 SAV f AEFGVW pms Ramipril-HCTZ 02342138 PMS f AEFGVW Teva-Ramipril/HCTZ 02388332 TEV f AEFGVW Tab Orl 5mg/12.5mg Altace HCT 02283158 SAV f AEFGVW pms Ramipril-HCTZ 02342146 PMS f AEFGVW Teva-Ramipril/HCTZ 02388340 TEV f AEFGVW Tab Orl 5mg/25mg Altace HCT 02283174 SAV f AEFGVW pms Ramipril-HCTZ 02342162 PMS f AEFGVW Teva-Ramipril/HCTZ 02388367 TEV f AEFGVW February 2014 / février 2014 Page 51

C09BA05 RAMIPRIL AND DIURETICS RAMIPRIL ET DIURÉTIQUES RAMIPRIL / HYDROCHLOROTHIAZIDE RAMIPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Altace HCT 02283166 SAV f AEFGVW pms Ramipril-HCTZ 02342154 PMS f AEFGVW Teva-Ramipril/HCTZ 02388359 TEV f AEFGVW C09BA06 Tab Orl 10mg/25mg Altace HCT 02283182 SAV f AEFGVW pms Ramipril-HCTZ 02342170 PMS f AEFGVW Teva-Ramipril/HCTZ 02388375 TEV f AEFGVW QUINAPRIL AND DIURETICS QUINAPRIL ET DIURÉTIQUES QUINAPRIL / HYDROCHLOROTHIAZIDE QUINAPRIL / HYDROCHLOROTHIAZIDE Tab Orl 10mg/12.5mg Accuretic 02237367 PFI f AEFGVW Apo-Quinapril/HCTZ 02408767 APX f AEFGVW Tab Orl 20mg/12.5mg Accuretic 02237368 PFI f AEFGVW Apo-Quinapril/HCTZ 02408775 APX f AEFGVW C09C C09BA08 C09CA C09CA01 Tab Orl 20mg/25mg Accuretic 02237369 PFI f AEFGVW Apo-Quinapril/HCTZ 02408783 APX f AEFGVW CILAZAPRIL AND DIURETICS CILAZAPRIL ET DIURÉTIQUES CILAZAPRIL / HYDROCHLOROTHIAZIDE CILAZAPRIL / HYDROCHLOROTHIAZIDE Tab Orl 5mg/12.5mg Inhibace Plus 02181479 HLR f AEFGVW Apo-Cilazapril/HCTZ 02284987 APX f AEFGVW Novo-Cilazapril/HCTZ 02313731 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 02182815 FRS f AEFGVW pms-losartan 02309750 PMS f AEFGVW Sandoz Losartan 02313332 SDZ f AEFGVW Co Losartan 02354829 COB f AEFGVW Mylan-Losartan 02368277 MYL f AEFGVW Apo-Losartan 02379058 APX f AEFGVW Teva-Losartan 02380838 TEV f AEFGVW Losartan 02388863 SAS f AEFGVW Jamp-Losartan 02398834 JPC f AEFGVW Auro-Losartan 02403323 ARO f AEFGVW Ran-Losartan 02404451 RAN f AEFGVW February 2014 / février 2014 Page 52

C09CA01 C09CA02 C09CA03 LOSARTAN LOSARTAN Tab Orl 50mg Cozaar 02182874 FRS f AEFGVW pms-losartan 02309769 PMS f AEFGVW Sandoz Losartan 02313340 SDZ f AEFGVW Co Losartan 02354837 COB f AEFGVW Mylan-Losartan 02368285 MYL f AEFGVW Apo-Losartan 02353504 APX f AEFGVW Teva-Losartan 02357968 TEV f AEFGVW Losartan 02388871 SAS f AEFGVW Jamp-Losartan 02398842 JPC f AEFGVW Auro-Losartan 02403331 ARO f AEFGVW Ran-Losartan 02404478 RAN f AEFGVW Tab Orl 100mg Cozaar 02182882 FRS f AEFGVW pms-losartan 02309777 PMS f AEFGVW Sandoz Losartan 02313359 SDZ f AEFGVW Co Losartan 02354845 COB f AEFGVW Mylan-Losartan 02368293 MYL f AEFGVW Apo-Losartan 02353512 APX f AEFGVW Teva-Losartan 02357976 TEV f AEFGVW Losartan 02388898 SAS f AEFGVW Jamp-Losartan 02398850 JPC f AEFGVW Auro-Losartan 02403358 ARO f AEFGVW Ran-Losartan 02404486 RAN f AEFGVW EPROSARTAN ÉPROSARTAN Tab Orl 400mg Teveten 02240432 ABB AEFGVW Tab Orl 600mg Teveten 02243942 ABB AEFGVW VALSARTAN VALSARTAN Tab Orl 40mg Diovan 02270528 NVR f AEFGVW pms-valsartan 02312999 PMS f AEFGVW Co Valsartan 02337487 COB f AEFGVW Teva-Valsartan 02356643 TEV f AEFGVW Sandoz Valsartan 02356740 SDZ f AEFGVW Ran-Valsartan 02363062 RAN f AEFGVW Mylan- Valsartan 02383527 MYL f AEFGVW Apo-Valsartan 02371510 APX f AEFGVW Valsartan 02366940 SAS f AEFGVW Tab Orl 80mg Diovan 02244781 NVR f AEFGVW pms-valsartan 02313006 PMS f AEFGVW Co Valsartan 02337495 COB f AEFGVW Teva-Valsartan 02356651 TEV f AEFGVW Sandoz Valsartan 02356759 SDZ f AEFGVW Ran-Valsartan 02363100 RAN f AEFGVW February 2014 / février 2014 Page 53

C09CA03 VALSARTAN VALSARTAN Tab Orl 80mg Mylan- Valsartan 02383535 MYL f AEFGVW Apo-Valsartan 02371529 APX f AEFGVW Valsartan 02366959 SAS f AEFGVW Tab Orl 160mg Diovan 02244782 NVR f AEFGVW pms-valsartan 02313014 PMS f AEFGVW Co Valsartan 02337509 COB f AEFGVW Teva-Valsartan 02356678 TEV f AEFGVW Sandoz Valsartan 02356767 SDZ f AEFGVW Ran-Valsartan 02363119 RAN f AEFGVW Mylan- Valsartan 02383543 MYL f AEFGVW Apo-Valsartan 02371537 APX f AEFGVW Valsartan 02366967 SAS f AEFGVW C09CA04 Tab Orl 320mg Diovan 02289504 NVR f AEFGVW pms-valsartan 02344564 PMS f AEFGVW Co Valsartan 02337517 COB f AEFGVW Teva-Valsartan 02356686 TEV f AEFGVW Sandoz Valsartan 02356775 SDZ f AEFGVW Mylan- Valsartan 02383551 MYL f AEFGVW Apo-Valsartan 02371545 APX f AEFGVW Valsartan 02366975 SAS f AEFGVW IRBESARTAN IRBESARTAN Tab Orl 75mg Avapro 02237923 SAV f AEFGVW Teva-Irbesartan 02315971 TEV f AEFGVW ratio-irbesartan 02316390 TEV f AEFGVW pms-irbesartan 02317060 PMS f AEFGVW Co Irbesartan 02328070 COB f AEFGVW Sandoz Irbesartan 02328461 SDZ f AEFGVW Mylan-Irbesartan 02347296 MYL f AEFGVW Irbesartan 02372347 SAS f AEFGVW Apo-Irbesartan 02386968 APX f AEFGVW Auro-Irbesartan 02406098 ARO f AEFGVW Ran-Irbesartan 02406810 RAN f AEFGVW Tab Orl 150mg Avapro 02237924 SAV f AEFGVW Teva-Irbesartan 02315998 TEV f AEFGVW ratio-irbesartan 02316404 TEV f AEFGVW pms-irbesartan 02317079 PMS f AEFGVW Co Irbesartan 02328089 COB f AEFGVW Sandoz Irbesartan 02328488 SDZ f AEFGVW Mylan-Irbesartan 02347318 MYL f AEFGVW Irbesartan 02372371 SAS f AEFGVW Apo-Irbesartan 02386976 APX f AEFGVW Auro-Irbesartan 02406101 ARO f AEFGVW Ran-Irbesartan 02406829 RAN f AEFGVW Tab Orl 300mg Avapro 02237925 SAV f AEFGVW Teva-Irbesartan 02316005 TEV f AEFGVW ratio-irbesartan 02316412 TEV f AEFGVW February 2014 / février 2014 Page 54

C09CA04 C09CA06 IRBESARTAN IRBESARTAN Tab Orl 300mg pms-irbesartan 02317087 PMS f AEFGVW Co Irbesartan 02328100 COB f AEFGVW Sandoz Irbesartan 02328496 SDZ f AEFGVW Mylan-Irbesartan 02347326 MYL f AEFGVW Irbesartan 02372398 SAS f AEFGVW Apo-Irbesartan 02386984 APX f AEFGVW Auro-Irbesartan 02406128 ARO f AEFGVW Ran-Irbesartan 02406837 RAN f AEFGVW CANDESARTAN CANDÉSARTAN Tab Orl 4mg Atacand 02239090 AZE f AEFGVW Sandoz Candesartan 02326957 SDZ f AEFGVW Apo-Candesartan 02365340 APX f AEFGVW Co Candesartan 02376520 COB f AEFGVW Mylan-Candesartan 02379120 MYL f AEFGVW pms-candesartan 02391171 PMS f AEFGVW Jamp-Candesartan 02386496 JPC f AEFGVW Candesartan Cilexetil 02379260 AHI f AEFGVW Candesartan 02388901 SAS f AEFGVW Ran-Candesartan 02380684 RAN f AEFGVW Tab Orl 8mg Atacand 02239091 AZE f AEFGVW Sandoz Candesartan 02326965 SDZ f AEFGVW Apo-Candesartan 02365359 APX f AEFGVW Teva-Candesartan 02366312 TEV f AEFGVW Co Candesartan 02376539 COB f AEFGVW Mylan-Candesartan 02379139 MYL f AEFGVW pms-candesartan 02391198 PMS f AEFGVW Candesartan 02388928 SAS f AEFGVW Jamp-Candesartan 02386518 JPC f AEFGVW Candesartan Cilexetil 02379279 AHI f AEFGVW Ran-Candesartan 02380692 RAN f AEFGVW Tab Orl 16mg Atacand 02239092 AZE f AEFGVW Sandoz Candesartan 02326973 SDZ f AEFGVW Apo-Candesartan 02365367 APX f AEFGVW Teva-Candesartan 02366320 TEV f AEFGVW Co Candesartan 02376547 COB f AEFGVW Mylan-Candesartan 02379147 MYL f AEFGVW pms-candesartan 02391201 PMS f AEFGVW Candesartan 02388936 SAS f AEFGVW Jamp-Candesartan 02386526 JPC f AEFGVW Candesartan Cilexetil 02379287 AHI f AEFGVW Ran-Candesartan 02380706 RAN f AEFGVW Tab Orl 32mg Atacand 02311658 AZE f AEFGVW Teva-Candesartan 02366339 TEV f AEFGVW Co Candesartan 02376555 COB f AEFGVW Mylan-Candesartan 02379155 MYL f AEFGVW pms-candesartan 02391228 PMS f AEFGVW Sandoz Candesartan 02392267 SDZ f AEFGVW February 2014 / février 2014 Page 55

C09D C09CA06 C09CA07 C09CA08 C09DA C09DA01 CANDESARTAN CANDÉSARTAN Tab Orl 32mg Jamp-Candesartan 02386534 JPC f AEFGVW Candesartan Cilexetil 02379295 AHI f AEFGVW Apo-Candesartan 02399105 APX f AEFGVW Ran-Candesartan 02380714 RAN f AEFGVW TELMISARTAN TELMISARTAN Tab Orl 40mg Micardis 02240769 BOE f AEFGVW Teva-Telmisartan 02320177 TEV f AEFGVW Sandoz Telmisartan 02375958 SDZ f AEFGVW Mylan-Telmisartan 02376717 MYL f AEFGVW pms-telmisartan 02391236 PMS f AEFGVW Telmisartan 02388944 SAS f AEFGVW Co-Telmisartan 02393247 COB f AEFGVW Tab Orl 80mg Micardis 02240770 BOE f AEFGVW Teva-Telmisartan 02320185 TEV f AEFGVW Sandoz Telmisartan 02375966 SDZ f AEFGVW Mylan-Telmisartan 02376725 MYL f AEFGVW pms-telmisartan 02391244 PMS f AEFGVW Telmisartan 02388952 SAS f AEFGVW Co-Telmisartan 02393255 COB f AEFGVW OLMESARTAN MEDOXOMIL OLMÉSARTAN MÉDOXOMIL Tab Orl 20mg Olmetec 02318660 FRS AEFGVW Tab Orl 40mg Olmetec 02318679 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 02230047 FRS f AEFGVW Sandoz Losartan HCT 02313375 SDZ f AEFGVW Teva-Losartan HCTZ 02358263 TEV f AEFGVW Apo-Losartan HCTZ 02371235 APX f AEFGVW Mylan-Losartan HCTZ 02378078 MYL f AEFGVW pms-losartan-hctz 02392224 PMS f AEFGVW Co-Losartan/HCT 02388251 COB f AEFGVW Mint-Losartan/HCTZ 02389657 MNT f AEFGVW February 2014 / février 2014 Page 56

C09DA01 LOSARTAN AND DIURETICS LOSARTAN ET DIURÉTIQUES LOSARTAN / HYDROCHLOROTHIAZIDE LOSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 100mg/12.5mg Hyzaar 02297841 FRS f AEFGVW Sandoz Losartan HCT 02362449 SDZ f AEFGVW Teva-Losartan HCTZ 02377144 TEV f AEFGVW Apo-Losartan HCTZ 02371243 APX f AEFGVW Mylan-Losartan HCTZ 02378086 MYL f AEFGVW pms-losartan-hctz 02392232 PMS f AEFGVW Co-Losartan/HCT 02388278 COB f AEFGVW Mint-Losartan/HCTZ 02389665 MNT f AEFGVW Tab Orl 100mg/25mg Hyzaar DS 02241007 FRS f AEFGVW Sandoz Losartan HCT 02313383 SDZ f AEFGVW Teva-Losartan HCTZ 02377152 TEV f AEFGVW Apo-Losartan HCTZ 02371251 APX f AEFGVW Mylan-Losartan HCTZ 02378094 MYL f AEFGVW pms-losartan-hctz 02392240 PMS f AEFGVW Co-Losartan/HCT 02388286 COB f AEFGVW Mint-Losartan/HCTZ DS 02389673 MNT f AEFGVW C09DA02 EPROSARTAN AND DIURETICS ÉPROSARTAN ET DIURÉTIQUES EPROSARTAN / HYDROCHLOROTHIAZIDE ÉPROSARTAN / HYDROCHLOROTHIAZIDE C09DA03 Tab Orl 600mg/12.5mg Teveten Plus 02253631 ABB AEFGVW VALSARTAN AND DIURETICS VALSARTAN ET DIURÉTIQUES VALSARTAN / HYDROCHLOROTHIAZIDE VALSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 80mg/12.5mg Diovan HCT 02241900 NVR f AEFGVW Sandoz Valsartan HCT 02356694 SDZ f AEFGVW Teva-Valsartan/ HCTZ 02356996 TEV f AEFGVW Mylan-Valsartan HCTZ 02373734 MYL f AEFGVW Apo-Valsartan/HCTZ 02382547 APX f AEFGVW Valsartan/HCTZ 02367009 SAS f AEFGVW Tab Orl 160mg/12.5mg Diovan HCT 02241901 NVR f AEFGVW Sandoz Valsartan HCT 02356708 SDZ f AEFGVW Teva-Valsartan/ HCTZ 02357003 TEV f AEFGVW Mylan-Valsartan HCTZ 02373742 MYL f AEFGVW Apo-Valsartan/HCTZ 02382555 APX f AEFGVW Valsartan/HCTZ 02367017 SAS f AEFGVW Diovan HCT 02246955 NVR f AEFGVW Sandoz Valsartan HCT 02356716 SDZ f AEFGVW Teva-Valsartan/ HCTZ 02357011 TEV f AEFGVW Mylan-Valsartan HCTZ 02373750 MYL f AEFGVW Apo-Valsartan/HCTZ 02382563 APX f AEFGVW Valsartan/HCTZ 02367025 SAS f AEFGVW February 2014 / février 2014 Page 57

C09DA03 C09DA04 VALSARTAN AND DIURETICS VALSARTAN ET DIURÉTIQUES VALSARTAN / HYDROCHLOROTHIAZIDE VALSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 320mg/12.5mg Diovan HCT 02308908 NVR f AEFGVW Sandoz Valsartan HCT 02356724 SDZ f AEFGVW Teva-Valsartan/ HCTZ 02357038 TEV f AEFGVW Mylan-Valsartan HCTZ 02373769 MYL f AEFGVW Apo-Valsartan/HCTZ 02382571 APX f AEFGVW Valsartan/HCTZ 02367033 SAS f AEFGVW Tab Orl 320mg/25mg Diovan HCT 02308916 NVR f AEFGVW Sandoz Valsartan HCT 02356732 SDZ f AEFGVW Teva-Valsartan/ HCTZ 02357046 TEV f AEFGVW Mylan-Valsartan HCTZ 02373777 MYL f AEFGVW Apo-Valsartan/HCTZ 02382598 APX f AEFGVW Valsartan/HCTZ 02367041 SAS f AEFGVW IRBESARTAN AND DIURETICS IRBESARTAN ET DIURÉTIQUES IRBESARTAN / HYDROCHLOROTHIAZIDE IRBESARTAN / HYDROCHLOROTHIAZIDE Tab Orl 150mg/12.5mg Avalide 02241818 SAV f AEFGVW Teva-Irbesartan HCTZ 02316013 TEV f AEFGVW pms-irbesartan HCTZ 02328518 PMS f AEFGVW ratio-irbesartan HCTZ 02330512 TEV f AEFGVW Sandoz Irbesartan HCT 02337428 SDZ f AEFGVW Co Irbesartan HCT 02357399 COB f AEFGVW Ran-Irbesartan HCTZ 02363208 RAN f AEFGVW Irbesartan/HCTZ 02372886 SAS f AEFGVW Apo-Irbesartan/HCTZ 02387646 APX f AEFGVW Mint-Irbesartan/HCTZ 02392992 MNT f AEFGVW Tab Orl 300mg/12.5mg Avalide 02241819 SAV f AEFGVW Teva-Irbesartan HCTZ 02316021 TEV f AEFGVW pms-irbesartan HCTZ 02328526 PMS f AEFGVW ratio-irbesartan HCTZ 02330520 TEV f AEFGVW Sandoz Irbesartan HCT 02337436 SDZ f AEFGVW Co Irbesartan HCT 02357402 COB f AEFGVW Ran-Irbesartan HCTZ 02363216 RAN f AEFGVW Irbesartan/HCTZ 02372894 SAS f AEFGVW Apo-Irbesartan/HCTZ 02387654 APX f AEFGVW Mint-Irbesartan/HCTZ 02393018 MNT f AEFGVW Tab Orl 300mg/25mg Teva-Irbesartan HCTZ 02316048 TEV f AEFGVW pms-irbesartan HCTZ 02328534 PMS f AEFGVW ratio-irbesartan HCTZ 02330539 TEV f AEFGVW Sandoz Irbesartan HCT 02337444 SDZ f AEFGVW Co Irbesartan HCT 02357410 COB f AEFGVW Ran-Irbesartan HCTZ 02363224 RAN f AEFGVW Irbesartan/HCTZ 02372908 SAS f AEFGVW Apo-Irbesartan/HCTZ 02387662 APX f AEFGVW Mint-Irbesartan/HCTZ 02393026 MNT f AEFGVW February 2014 / février 2014 Page 58

C09DA06 CANDESARTAN AND DIURETICS CANDÉSARTAN ET DIURÉTIQUES CANDESARTAN / HYDROCHLOROTHIAZIDE CANDÉSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 16mg/12.5mg Atacand Plus 02244021 AZE f AEFGVW Apo-Candesartan/HCTZ 02367866 APX f AEFGVW Co-Candesartan/HCT 02388650 COB f AEFGVW Mylan-Candesartan HCTZ 02374897 MYL f AEFGVW pms-candesartan-hctz 02391295 PMS f AEFGVW Sandoz Candesartan Plus 02327902 SDZ f AEFGVW Candesartan/HCTZ 02394804 SAS f AEFGVW Teva-Candesartan/HCTZ 02395541 TEV f AEFGVW Tab Orl 32mg/12.5mg Atacand Plus 02332922 AZE f AEFGVW Apo-Candesartan/HCTZ 02395126 APX f AEFGVW Teva-Candesartan/HCTZ 02395568 TEV f AEFGVW C09DA07 Tab Orl 32mg/25mg Atacand Plus 02332957 AZE f AEFGVW Apo-Candesartan/HCTZ 02395134 APX f AEFGVW TELMISARTAN AND DIURETICS TELMISARTAN ET DIURÉTIQUES TELMISARTAN / HYDROCHLOROTHIAZIDE TELMISARTAN / HYDROCHLOROTHIAZIDE Tab Orl 80mg/12.5mg Micardis Plus 02244344 BOE f AEFGVW Teva-telmisartan HCTZ 02330288 TEV f AEFGVW Mylan-telmisartan HCTZ 02373564 MYL f AEFGVW Sandoz Telmisartan HCT 02393557 SDZ f AEFGVW Telmisartan/HCTZ 02395355 SAS f AEFGVW Co-Telmisartan/HCT 02393263 COB f AEFGVW pms-telmisartan/hctz 02401665 PMS f AEFGVW Tab Orl 80mg/25mg Micardis Plus 02318709 BOE f AEFGVW Teva-telmisartan HCTZ 02379252 TEV f AEFGVW Mylan-telmisartan HCTZ 02373572 MYL f AEFGVW Sandoz Telmisartan HCT 02393565 SDZ f AEFGVW Telmisartan/HCTZ 02395363 SAS f AEFGVW Co-Telmisartan/HCT 02393271 COB f AEFGVW pms-telmisartan/hctz 02401673 PMS f AEFGVW C09DA08 OLMESARTAN AND DIURETICS OLMÉSARTAN ET DIURÉTIQUES OLMESARTAN / HYDROCHLOROTHIAZIDE OLMÉSARTAN / HYDROCHLOROTHIAZIDE Tab Orl 20mg/12.5mg Olmetec Plus 02319616 FRS f AEFGVW Tab Orl 40mg/12.5mg Olmetec Plus 02319624 FRS f AEFGVW Tab Orl 40mg/25mg Olmetec Plus 02319632 FRS f AEFGVW February 2014 / février 2014 Page 59

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 02371022 BOE AEFGVW Tab Orl 40mg/10mg Twynsta 02371030 BOE AEFGVW C10 C10A C10AA C10AA01 Tab Orl 80mg/5mg Twynsta 02371049 BOE AEFGVW Tab Orl 80mg/10mg Twynsta 02371057 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 00884324 FRS f AEFGVW Mylan-Simvastatin 02246582 MYL f AEFGVW Apo-Simvastatin 02247011 APX f AEFGVW Co Simvastatin 02248103 COB f AEFGVW Teva-Simvastatin 02250144 TEV f AEFGVW pms-simvastatin 02269252 PMS f AEFGVW Phl-Simvastatin 02281546 PHL f AEFGVW Simvastatin 02284723 SAS f AEFGVW Ran-Simvastatin 02329131 RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) 02331020 JPC f AEFGVW Mint-Simvastatin 02372932 MNT f AEFGVW Mar-Simvastatin 02375036 MAR f AEFGVW Jamp-Simvastatin 02375591 JPC f AEFGVW Simvastatin-Odan 02378884 ODN f AEFGVW Tab Orl 10mg Zocor 00884332 FRS f AEFGVW Mylan-Simvastatin 02246583 MYL f AEFGVW Apo-Simvastatin 02247012 APX f AEFGVW Sandoz Simvastatin 02247828 SDZ f AEFGVW Co Simvastatin 02248104 COB f AEFGVW Teva-Simvastatin 02250152 TEV f AEFGVW pms-simvastatin 02269260 PMS f AEFGVW Phl-Simvastatin 02281554 PHL f AEFGVW Simvastatin 02284731 SAS f AEFGVW Ran-Simvastatin 02329158 RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) 02331039 JPC f AEFGVW Mint-Simvastatin 02372940 MNT f AEFGVW Mar-Simvastatin 02375044 MAR f AEFGVW February 2014 / février 2014 Page 60

C10AA01 SIMVASTATIN SIMVASTATINE Tab Orl 10mg Jamp-Simvastatin 02375605 JPC f AEFGVW Simvastatin-Odan 02378892 ODN f AEFGVW Tab Orl 20mg Zocor 00884340 FRS f AEFGVW Mylan-Simvastatin 02246737 MYL f AEFGVW Apo-Simvastatin 02247013 APX f AEFGVW Sandoz Simvastatin 02247830 SDZ f AEFGVW Co Simvastatin 02248105 COB f AEFGVW Teva-Simvastatin 02250160 TEV f AEFGVW pms-simvastatin 02269279 PMS f AEFGVW Phl-Simvastatin 02281562 PHL f AEFGVW Simvastatin 02284758 SAS f AEFGVW Ran-Simvastatin 02329166 RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) 02331047 JPC f AEFGVW Mint-Simvastatin 02372959 MNT f AEFGVW Mar-Simvastatin 02375052 MAR f AEFGVW Jamp-Simvastatin 02375613 JPC f AEFGVW Simvastatin-Odan 02378906 ODN f AEFGVW Tab Orl 40mg Zocor 00884359 FRS f AEFGVW Mylan-Simvastatin 02246584 MYL f AEFGVW Apo-Simvastatin 02247014 APX f AEFGVW Sandoz Simvastatin 02247831 SDZ f AEFGVW Co Simvastatin 02248106 COB f AEFGVW Teva-Simvastatin 02250179 TEV f AEFGVW pms-simvastatin 02269287 PMS f AEFGVW Phl-Simvastatin 02281570 PHL f AEFGVW Simvastatin 02284766 SAS f AEFGVW Ran-Simvastatin 02329174 RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) 02331055 JPC f AEFGVW Mint-Simvastatin 02372967 MNT f AEFGVW Mar-Simvastatin 02375060 MAR f AEFGVW Jamp-Simvastatin 02375621 JPC f AEFGVW Simvastatin-Odan 02378914 ODN f AEFGVW Tab Orl 80mg Zocor 02240332 FRS f AEFGVW Mylan-Simvastatin 02246585 MYL f AEFGVW Apo-Simvastatin 02247015 APX f AEFGVW Sandoz Simvastatin 02247833 SDZ f AEFGVW Co Simvastatin 02248107 COB f AEFGVW Teva-Simvastatin 02250187 TEV f AEFGVW pms-simvastatin 02269295 PMS f AEFGVW Phl-Simvastatin 02281589 PHL f AEFGVW Simvastatin 02284774 SAS f AEFGVW Ran-Simvastatin 02329182 RAN f AEFGVW Jamp-Simvastatin (Disc/non disp Jul 8/15) 02331063 JPC f AEFGVW Mint-Simvastatin 02372975 MNT f AEFGVW Mar-Simvastatin 02375079 MAR f AEFGVW Jamp-Simvastatin 02375648 JPC f AEFGVW Simvastatin-Odan 02378922 ODN f AEFGVW February 2014 / février 2014 Page 61

C10AA02 LOVASTATIN LOVASTATINE Tab Orl 20mg Mevacor 00795860 FRS f AEFGVW Apo-Lovastatin 02220172 APX f AEFGVW Mylan-Lovastatin 02243127 MYL f AEFGVW ratio-lovastatin (Disc/non disp Jun 29/14) 02245822 RPH f AEFGVW pms-lovastatin 02246013 PMS f AEFGVW Teva-Lovastatin 02246542 TEV f AEFGVW Sandoz Lovastatin (Disc/non disp Nov 15/15) 02247056 SDZ f AEFGVW Co Lovastatin 02248572 COB f AEFGVW Lovastatin 02353229 SAS f AEFGVW Tab Orl 40mg Mevacor 00795852 FRS f AEFGVW Apo-Lovastatin 02220180 APX f AEFGVW Mylan-Lovastatin 02243129 MYL f AEFGVW ratio-lovastatin (Disc/non disp Jun 29/14) 02245823 RPH f AEFGVW pms-lovastatin 02246014 PMS f AEFGVW Teva-Lovastatin 02246543 TEV f AEFGVW Sandoz Lovastatin (Disc/non disp Nov 15/15) 02247057 SDZ f AEFGVW Co Lovastatin 02248573 COB f AEFGVW Lovastatin 02353237 SAS f AEFGVW C10AA03 PRAVASTATIN PRAVASTATINE Tab Orl 10mg Pravachol (Disc/non disp Sep 14/14) 00893749 BRI f AEFGVW Apo-Pravastatin 02243506 APX f AEFGVW Teva-Pravastatin 02247008 TEV f AEFGVW pms-pravastatin 02247655 PMS f AEFGVW Sandoz Pravastatin 02247856 SDZ f AEFGVW Co Pravastatin 02248182 COB f AEFGVW Mylan-Pravastatin 02257092 MYL f AEFGVW Ran-Pravastatin 02284421 RAN f AEFGVW Mint-Pravastatin 02317451 MNT f AEFGVW Jamp-Pravastatin 02330954 JPC f AEFGVW Pravastatin 02356546 SAS f AEFGVW Tab Orl 20mg Pravachol 00893757 BRI f AEFGVW Apo-Pravastatin 02243507 APX f AEFGVW Teva-Pravastatin 02247009 TEV f AEFGVW pms-pravastatin 02247656 PMS f AEFGVW Sandoz Pravastatin 02247857 SDZ f AEFGVW Co Pravastatin 02248183 COB f AEFGVW Mylan-Pravastatin 02257106 MYL f AEFGVW Ran-Pravastatin 02284448 RAN f AEFGVW Mint-Pravastatin 02317478 MNT f AEFGVW Jamp-Pravastatin 02330962 JPC f AEFGVW Pravastatin 02356554 SAS f AEFGVW Tab Orl 40mg Pravachol 02222051 BRI f AEFGVW Apo-Pravastatin 02243508 APX f AEFGVW Teva-Pravastatin 02247010 TEV f AEFGVW pms-pravastatin 02247657 PMS f AEFGVW Sandoz Pravastatin 02247858 SDZ f AEFGVW February 2014 / février 2014 Page 62

C10AA03 C10AA04 PRAVASTATIN PRAVASTATINE Tab Orl 40mg Co Pravastatin 02248184 COB f AEFGVW Mylan-Pravastatin 02257114 MYL f AEFGVW Ran-Pravastatin 02284456 RAN f AEFGVW Mint-Pravastatin 02317486 MNT f AEFGVW Jamp-Pravastatin 02330970 JPC f AEFGVW Pravastatin 02356562 SAS f AEFGVW FLUVASTATIN FLUVASTATINE Cap Orl 20mg Lescol 02061562 NVR f AEFGVW Caps Teva-Fluvastatin 02299224 TEV f AEFGVW Sandoz Fluvastatin 02400235 SDZ f AEFGVW Cap Orl 40mg Lescol 02061570 NVR f AEFGVW Caps Teva-Fluvastatin 02299232 TEV f AEFGVW Sandoz Fluvastatin 02400243 SDZ f AEFGVW C10AA05 SRT Orl 80mg Lescol XL 02250527 NVR AEFGVW L.L ATORVASTATIN ATORVASTATINE Tab Orl 10mg Lipitor 02230711 PFI f AEFGVW GD-Atorvastatin 02288346 GMD f AEFGVW Apo-Atorvastatin 02295261 APX f AEFGVW Novo-Atorvastatin 02302675 TEV f AEFGVW Co Atorvastatin 02310899 COB f AEFGVW pms-atorvastatin 02313448 PMS f AEFGVW Ran-Atorvastatin 02313707 RAN f AEFGVW Sandoz Atorvastatin 02324946 SDZ f AEFGVW Atorvastatin 02348705 SAS f AEFGVW ratio-atorvastatin 02350297 TEV f AEFGVW Mylan-Atorvastatin 02373203 MYL f AEFGVW pms-atorvastatin 02399377 PMS f AEFGVW Tab Orl 20mg Lipitor 02230713 PFI f AEFGVW GD-Atorvastatin 02288354 GMD f AEFGVW Apo-Atorvastatin 02295288 APX f AEFGVW Novo-Atorvastatin 02302683 TEV f AEFGVW Co Atorvastatin 02310902 COB f AEFGVW pms-atorvastatin 02313456 PMS f AEFGVW Ran-Atorvastatin 02313715 RAN f AEFGVW Sandoz Atorvastatin 02324954 SDZ f AEFGVW Atorvastatin 02348713 SAS f AEFGVW ratio-atorvastatin 02350319 TEV f AEFGVW Mylan-Atorvastatin 02373211 MYL f AEFGVW pms-atorvastatin 02399385 PMS f AEFGVW Tab Orl 40mg Lipitor 02230714 PFI f AEFGVW GD-Atorvastatin 02288362 GMD f AEFGVW Apo-Atorvastatin 02295296 APX f AEFGVW February 2014 / février 2014 Page 63

C10AA05 C10AA07 ATORVASTATIN ATORVASTATINE Tab Orl 40mg Novo-Atorvastatin 02302691 TEV f AEFGVW Co Atorvastatin 02310910 COB f AEFGVW pms-atorvastatin 02313464 PMS f AEFGVW Ran-Atorvastatin 02313723 RAN f AEFGVW Sandoz Atorvastatin 02324962 SDZ f AEFGVW Atorvastatin 02348721 SAS f AEFGVW ratio-atorvastatin 02350327 TEV f AEFGVW Mylan-Atorvastatin 02373238 MYL f AEFGVW pms-atorvastatin 02399393 PMS f AEFGVW Tab Orl 80mg Lipitor 02243097 PFI f AEFGVW GD-Atorvastatin 02288370 GMD f AEFGVW Apo-Atorvastatin 02295318 APX f AEFGVW Novo-Atorvastatin 02302713 TEV f AEFGVW Co Atorvastatin 02310929 COB f AEFGVW pms-atorvastatin 02313472 PMS f AEFGVW Ran-Atorvastatin 02313758 RAN f AEFGVW Sandoz Atorvastatin 02324970 SDZ f AEFGVW Atorvastatin 02348748 SAS f AEFGVW ratio-atorvastatin 02350335 TEV f AEFGVW Mylan-Atorvastatin 02373246 MYL f AEFGVW pms-atorvastatin 02399407 PMS f AEFGVW ROSUVASTATIN ROSUVASTATINE Tab Orl 5mg Crestor 02265540 AZE f AEFGVW Apo-Rosuvastatin 02337975 APX f AEFGVW Sandoz Rosuvastatin 02338726 SDZ f AEFGVW Co Rosuvastatin 02339765 COB f AEFGVW Teva-Rosuvastatin 02354608 TEV f AEFGVW pms-rosuvastatin 02378523 PMS f AEFGVW Mylan-Rosuvastatin 02381265 MYL f AEFGVW Ran-Rosuvastatin 02382644 RAN f AEFGVW Rosuvastatin 02405628 SAS f AEFGVW Mint-Rosuvastatin 02397781 MNT f AEFGVW Jamp-Rosuvastatin 02391252 JPC f AEFGVW Tab Orl 10mg Crestor 02247162 AZE f AEFGVW Apo-Rosuvastatin 02337983 APX f AEFGVW Sandoz Rosuvastatin 02338734 SDZ f AEFGVW Co Rosuvastatin 02339773 COB f AEFGVW Teva-Rosuvastatin 02354616 TEV f AEFGVW pms-rosuvastatin 02378531 PMS f AEFGVW Mylan-Rosuvastatin 02381273 MYL f AEFGVW Ran-Rosuvastatin 02382652 RAN f AEFGVW Jamp-Rosuvastatin 02391260 JPC f AEFGVW Rosuvastatin 02405636 SAS f AEFGVW Mint-Rosuvastatin 02397803 MNT f AEFGVW Tab Orl 20mg Crestor 02247163 AZE f AEFGVW Apo-Rosuvastatin 02337991 APX f AEFGVW Sandoz Rosuvastatin 02338742 SDZ f AEFGVW February 2014 / février 2014 Page 64

C10AA07 C10AB C10AB04 C10AB05 ROSUVASTATIN ROSUVASTATINE Tab Orl 20mg Co Rosuvastatin 02339781 COB f AEFGVW Teva-Rosuvastatin 02354624 TEV f AEFGVW pms-rosuvastatin 02378558 PMS f AEFGVW Mylan-Rosuvastatin 02381281 MYL f AEFGVW Ran-Rosuvastatin 02382660 RAN f AEFGVW Jamp-Rosuvastatin 02391279 JPC f AEFGVW Rosuvastatin 02405644 SAS f AEFGVW Mint-Rosuvastatin 02397811 MNT f AEFGVW Tab Orl 40mg Crestor 02247164 AZE f AEFGVW Apo-Rosuvastatin 02338009 APX f AEFGVW Sandoz Rosuvastatin 02338750 SDZ f AEFGVW Co Rosuvastatin 02339803 COB f AEFGVW Teva-Rosuvastatin 02354632 TEV f AEFGVW pms-rosuvastatin 02378566 PMS f AEFGVW Mylan-Rosuvastatin 02381303 MYL f AEFGVW Ran-Rosuvastatin 02382679 RAN f AEFGVW Jamp-Rosuvastatin 02391287 JPC f AEFGVW Rosuvastatin 02405652 SAS f AEFGVW Mint-Rosuvastatin 02397838 MNT f AEFGVW FIBRATES FIBRATES GEMFIBROZIL GEMFIBROZIL Tab Orl 300mg Apo-Gemfibrozil 01979574 APX f AEFGVW Mylan-Gemfibrozil 02185407 MYL f AEFGVW pms-gemfibrozil 02239951 PMS f AEFGVW Novo-Gemfibrozil 02241704 TEV f AEFGVW Tab Orl 600mg Apo-Gemfibrozil 01979582 APX f AEFGVW Mylan-Gemfibrozil 02230476 MYL f AEFGVW pms-gemfibrozil (Disc/non disp Jan 31/16) 02230183 PMS f AEFGVW Novo-Gemfibrozil 02142074 TEV f AEFGVW FENOFIBRATE FÉNOFIBRATE Cap Orl 100mg Apo-Fenofibrate 02225980 APX f AEFGVW Caps Cap Orl 200mg Lipidil Micro 02146959 ABB f AEFGVW Caps Apo-Feno-Micro 02239864 APX f AEFGVW Mylan-Fenofibrate Micro 02240210 MYL f AEFGVW Novo-Fenofibrate Micro 02243552 TEV f AEFGVW ratio-fenofibrate MC 02250039 TEV f AEFGVW pms-fenofibrate Micro (Disc/non disp Apr 1/16) 02273551 PMS f AEFGVW Fenofibrate Micro 02286092 SAS f AEFGVW Tab Orl 100mg Lipidil Supra 02241601 ABB f AEFGVW Apo-Feno-Super 02246859 APX f AEFGVW February 2014 / février 2014 Page 65

C10AB05 C10AC C10AC01 C10AC02 FENOFIBRATE FÉNOFIBRATE Tab Orl 100mg Sandoz Fenofibrate S 02288044 SDZ f AEFGVW Teva-Fenofibrate-S 02289083 TEV f AEFGVW Fenofibrate S 02356570 SAS f AEFGVW Tab Orl 160mg Lipidil Supra 02241602 ABB f AEFGVW Apo-Feno-Super 02246860 APX f AEFGVW Sandoz Fenofibrate S 02288052 SDZ f AEFGVW Teva-Fenofibrate-S 02289091 TEV f AEFGVW Fenofibrate S 02356589 SAS f AEFGVW BILE ACID SEQUESTRANTS SEQUESTRANTS DE L ACIDE BILIAIRE COLESTYRAMINE COLESTYRAMINE Pws Orl 4g Packets/sachets Olestyr 00890960 PDP f AEFGVW Pds. Pws Orl 4g Packets/sachets Olestyr 02210320 PDP f AEFGVW Pds. COLESTIPOL COLESTIPOL Tab Orl 1g Colestid 02132680 PFI AEFGVW Pws Orl 5g Colestid 00642975 PFI AEFGVW Pds. C10B C10BA C10BA01 C10BX C10BX03 Pws Orl 7.5g Colestid (Orange) 02132699 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) 02270439 SNV AEFGVW L.L. SRT Orl 20mg/1000mg Advicor (Disc/non disp Jun 27/14) 02270447 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 12 02273233 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362759 GMD f AEFV February 2014 / février 2014 Page 66

C10BX03 ATORVASTATIN AND AMLODIPINE ATORVASTATINE ET AMLODIPINE Tab Orl 5mg/10mg pms-amlodipine/atorvastatin 12 02404222 PMS f AEFV Apo-Amlodipine-Atorvastatin 12 02411253 APX f AEFV Tab Orl 5mg/20mg Caduet 12 02273241 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362767 GMD f AEFV pms-amlodipine/atorvastatin 12 02404230 PMS f AEFV Apo-Amlodipine-Atorvastatin 12 02411261 APX f AEFV Tab Orl 5mg/40mg Caduet 12 02273268 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362775 GMD f AEFV Apo-Amlodipine-Atorvastatin 12 02411288 APX f AEFV Tab Orl 5mg/80mg Caduet 12 02273276 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362783 GMD f AEFV Apo-Amlodipine-Atorvastatin 12 02411296 APX f AEFV Tab Orl 10mg/10mg Caduet 12 02273284 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362791 GMD f AEFV pms-amlodipine/atorvastatin 12 02404249 PMS f AEFV Apo-Amlodipine-Atorvastatin 12 02411318 APX f AEFV Tab Orl 10mg/20mg Caduet 12 02273292 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362805 GMD f AEFV pms-amlodipine/atorvastatin 12 02404257 PMS f AEFV Apo-Amlodipine-Atorvastatin 12 02411326 APX f AEFV Tab Orl 10mg/40mg Caduet 12 02273306 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362813 GMD f AEFV Apo-Amlodipine-Atorvastatin 12 02411334 APX f AEFV D01 D01A D01AA D01AA01 Tab Orl 10mg/80mg Caduet 12 02273314 PFI f AEFV GD-Amlodipine/Atorvastatin 12 02362821 GMD f AEFV Apo-Amlodipine-Atorvastatin 12 02411342 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 100000IU Nyaderm 00716871 TAR AEFGVW Cr. Ratio-Nystatin 02194236 RPH AEFGVW Ont Top 100000IU Ratio-Nystatin 02194228 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

D01AC D01AC01 D01AC02 D01AC08 D01AC20 IMIDAZOLE AND TRIAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE ET TRIAZOLE CLOTRIMAZOLE CLOTRIMAZOLE Crm Top 1% Canesten 02150867 YNO f AEFGVW Cr. Clotrimaderm 00812382 TAR AEFGVW MICONAZOLE MICONAZOLE Crm Top 2% Micatin 02085852 WLS AEFGVW Cr. Monistat Derm 02126567 JNJ AEFGVW KETOCONAZOLE KÉTOCONAZOLE Crm Top 2% Ketoderm 02245662 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 00611174 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 02221802 VLN AEFGVW Cr. Lot Top 1% Loprox 02221810 VLN AEFGVW Lot TERBINAFINE TERBINAFINE Crm Top 1% Lamisil 02031094 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 00358495 ODN AEFGV Liq February 2014 / février 2014 Page 68

D05AX D05AX02 OTHER ANTISPORIATICS FOR TOPICAL USE AUTRES TRAITEMENTS DU PSORIASIS POUR USAGE TOPIQUE CALCIPOTRIOL CALCIPOTRIOL Crm Top 50mcg Dovonex 02150956 LEO AEFV Cr. Ont Top 50mcg Dovonex 01976133 LEO AEFV Ont D05B D05BA D05BA02 D05BB D05BB02 Liq Top 50mcg Dovonex Scalp Solution 02194341 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 01946374 VLN AEFGVW Caps RETINOIDS FOR TREATMENT OF PSORIASIS RÉTINOÏDES POUR LE TRAITEMENT DU PSORIASIS ACITRETIN ACITRÉTINE Cap Orl 10mg Soriatane 02070847 TRB AEFGVW Caps Cap Orl 25mg Soriatane 02070863 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 00586676 LEO AEFGVW Ont Crm Top 2% Fucidin 00586668 LEO AEFGVW Cr. GENTAMICIN GENTAMICINE Crm Top 0.1% ratio-gentamicin Sulfate 00805386 RPH AEFGVW Cr. February 2014 / février 2014 Page 69

D06B D06AX07 D06AX09 D06BA D06BA01 D06BB D06BB01 D06BB03 D06BB04 D06BX D06BX01 GENTAMICIN GENTAMICINE Ont Top 0.1% ratio-gentamicin Sulfate 00805025 RPH AEFGVW Ont MUPROCIN MUPROCINE Ont Top 2% Bactroban 01916947 GCH f AEFGVW Ont Taro-Mupirocin 02279983 TAR f AEFGVW CHEMOTHERAPEUTICS FOR TOPICAL USE AGENTS CHIMIOTHÉRAPEUTIQUES POUR USAGE TOPIQUE SULFONAMIDES SULFONAMIDES SILVER SULFADIAZINE SULFADIAZINE D ARGENT Crm Top 1% Flamazine 00323098 SNE AEFGVW Cr. ANTIVIRALS ANTIVIRAUX IDOXURIDINE IDOXURIDINE Liq Top 0.1% Sandoz Idoxuridine(Disc/non disp Mar 21/14) 02237187 SDZ f AEFGVW Liq ACYCLOVIR ACYCLOVIR Ont Top 5% Zovirax 00569771 VLN AEFGVW Ont PODOPHYLLOTOXIN PODOPHYLLOTOXINE Liq Top 250mg Podofilm 00598208 PAL AEFGV Liq OTHER CHEMOTHERAPEUTICS AUTRES AGENTS DE CHIMOTHÉRAPIE METRONIDAZOLE MÉTRONIDAZOLE Crm Top 0.75% Metrocream 02226839 GAC AEFV Cr. Crm Top 1% Noritate 02156091 VLN AEFV Cr. Rosasol cream 02242919 GSK AEFV Gel Top 1% Metrogel 02297809 GAC AEFGVW Gel Lot Top 0.75% Metrolotion 02248206 GAC AEFGVW Lot February 2014 / février 2014 Page 70

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 00564281 ROG AEFGVW Cr. Cortate 80021088 SCO AEFGVW Hyderm 00716820 TAR AEFGVW Crm Top 1% Emo-Cort 00192597 GSK AEFGVW Cr. Prevex HC 00804533 GSK AEFGVW Hyderm 00716839 TAR AEFGVW Crm Top 2.5% Emo-Cort 00595799 GSK AEFGVW Cr. Lot Top 1% Emo-Cort 00192600 GSK AEFGVW Lot Sarna HC 00578541 GSK AEFGVW Lot Top 2.5% Emo-Cort 00595802 GSK AEFGVW Lot Sarna HC 00856711 GSK AEFGVW Ont Top 1% Cortoderm 00716693 TAR AEFGVW Ont Crm Top 0.2% Hydroval 02242984 TPH f AEFGVW Cr. Ont Top 0.2% Hydroval 02242985 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 02214415 GCH AEFGVW Cr. DESONIDE DÉSONIDE Crm Top 0.05% pms-desonide 02229315 PMS f AEFGVW Cr. Ont Top 0.05% pms-desonide 02229323 PMS f AEFGVW Ont Desocort (Disc/non disp Apr 30/14) 02115522 GAC AEFGVW February 2014 / février 2014 Page 71

D07AB09 TRIAMCINOLONE TRIAMCINOLONE Crm Top 0.1% Aristocort R 02194058 VAL AEFGVW Cr. Crm Top 0.5% Aristocort C 02194066 VAL AEFGVW Cr. Ont Top 0.1% Aristocort R 02194031 VAL AEFGVW Ont D07AC CORTICOSTEROIDS, POTENT (GROUP III) CORTICOSTÉROÏDES, PUISSANT (GROUPE III) D07AC01 BETAMETHASONE BÉTAMÉTHASONE Crm Top 0.05% ratio-ectosone Mild 00535427 RPH AEFGVW Cr. Betaderm 00716618 TAR f AEFGVW Celestoderm V/2 02357860 VAL f AEFGVW Crm Top 0.1% ratio-ectosone 00535435 RPH AEFGVW Cr. Betaderm 00716626 TAR f AEFGVW Celestoderm V 02357844 VAL f AEFGVW Lot Top 0.05% ratio-ectosone Mild 00653209 RPH AEFGVW Lot Lot Top 0.1% Valisone 00027944 VAL AEFGVW Lot ratio-ectosone Scalp 00653217 RPH AEFGVW Betaderm 00716634 TAR AEFGVW ratio-ectosone 00750050 RPH AEFGVW Ont Top 0.05% Betaderm 00716642 TAR f AEFGVW Ont Celestoderm V/2 02357879 VAL f AEFGVW Ont Top 0.1% Betaderm 00716650 TAR f AEFGVW Ont Celestoderm V 02357852 VAL f AEFGVW Crm Top 0.05% Diprosone 00323071 FRS AEFGVW Cr. Diprolene Glycol 00688622 FRS AEFGVW ratio-topisone 00804991 RPH AEFGVW ratio-topilene 00849650 RPH AEFGVW Lot Top 0.05% Diprosone 00417246 FRS AEFGVW Lot Diprolene Glycol 00862975 FRS AEFGVW ratio-topisone 00809187 RPH AEFGVW ratio-topilene Glycol 01927914 RPH AEFGVW Ont Top 0.05% Diprosone 00344923 FRS AEFGVW Ont Diprolene Glycol 00629367 FRS f AEFGVW ratio-topilene Glycol 00849669 RPH f AEFGVW ratio-topisone 00805009 RPH AEFGVW February 2014 / février 2014 Page 72

D07AC03 DESOXIMETASONE DÉSOXIMÉTASONE Crm Top 0.05% Topicort Mild 02221918 VLN f AEFGVW Cr. Crm Top 0.25% Topicort 02221896 VLN f AEFGVW Cr. Gel Top 0.05% Topicort 02221926 VLN f AEFGVW Gel D07AC06 DIFLUCORTOLONE DIFLUCORTOLONE Crm Top 0.1% Nerisone Oily 00587818 GSK AEFGVW Cr. Nerisone 00587826 GSK AEFGVW Ont Top 0.1% Nerisone (Disc/non disp Mar 15/14) 00587834 GSK AEFGVW Ont D07AC08 FLUOCINONIDE FLUOCINONIDE Crm Top 0.05% Lyderm 00716863 TPH AEFGVW Cr. Lidemol 02163152 VAL AEFGVW Gel Top 0.05% Lidex Gel 02161974 VAL f AEFGVW Gel Lyderm 02236997 TPH f AEFGVW Ont Top 0.05% Lidex 02161966 VAL f AEFGVW Ont Lyderm 02236996 TPH f AEFGVW D07AC11 AMCINONIDE AMCINONIDE Crm Top 0.1% Cyclocort 02192284 GSK f AEFGVW Cr. Taro-Amcinonide 02246714 TAR f AEFGVW ratio-amcinonide 02247098 TEV f AEFGVW Lot Top 0.1% Cyclocort 02192276 GSK f AEFGVW Lot ratio-amcinonide 02247097 TEV f AEFGVW Ont Top 0.1% Cyclocort 02192268 GSK f AEFGVW Ont ratio-amcinonide 02247096 TEV f AEFGVW D07AC13 MOMETASONE MOMÉTASONE Crm Top 0.1% Elocom 00851744 FRS f ABEFGVW Cr. Taro-Mometasone 02367157 TAR f ABEFGVW Lot Top 0.1% Elocom 00871095 FRS f ABEFGVW Lot Taro-Mometasone 02266385 TAR f ABEFGVW Ont Top 0.1% Elocom 00851736 FRS f ABEFGVW Ont ratio-mometasone 02248130 TEV f ABEFGVW February 2014 / février 2014 Page 73

D07AD CORTICOSTEROIDS, VERY POTENT (GROUP IV) CORTICOSTÉROÏDES, TRÈS PUISSANT (GROUPE IV) D07AD01 CLOBETASOL CLOBÉTASOL Crm Top 0.05% ratio-clobetasol 01910272 TEV f AEFGVW Cr. Dermovate 02213265 TPH f AEFGVW Taro-Clobetasol Cream 02245523 TAR f AEFGVW Mylan-Clobetasol 02024187 MYL AEFGVW Novo-Clobetasol 02093162 TEV AEFGVW Lot Top 0.05% ratio-clobetasol 01910299 TEV f AEFGVW Lot Dermovate 02213281 TPH f AEFGVW Taro-Clobetasol Topical Sol n 02245522 TAR f AEFGVW Mylan-Clobetasol Propionate 02216213 MYL AEFGVW Ont Top 0.05% ratio-clobetasol 01910280 TEV f AEFGVW Ont Dermovate 02213273 TPH f AEFGVW Taro-Clobetasol Ointment 02245524 TAR f AEFGVW Mylan-Clobetasol 02026767 MYL AEFGVW Novo-Clobetasol 02126192 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 00074500 PAL AEFGVW Cr. POLYMYXIN B SULFATE / BACITRACIN ZINC / HYDROCORTISONE / NEOMYCIN POLYMYXINE B (SULFATE DE) / BACITRACINE / HYDROCORTISONE / NÉOMYCINE Ont Top 5000IU/400IU/10mg/5mg Cortisporin 00666246 GSK AEFGVW Ont FUSIDIC ACID / HYDROCORTISONE ACIDE FUSIDIQUE / HYDROCORTISONE Crm Top 2%/1% Fucidin H 02238578 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 100000IU/2.5mg/1mg/0.25mg Viaderm K-C 00717002 TAR AEFGVW Cr. February 2014 / février 2014 Page 74

D07CB01 D07CB05 D07CC D07X D07CC01 D07XA D07XA01 TRIAMCINOLONE AND ANTIBIOTICS TRIAMCINOLONE ET ANTIBIOTIQUES TRIAMCINOLONE / NEOMYCIN / NYSTATIN / GRAMICIDIN TRIAMCINOLONE / NÉOMYCINE / NYSTATINE / GRAMICIDINE Ont Top 100000IU/2.5mg/1mg/0.25mg Viaderm K-C 00717029 TAR AEFGVW Ont FLUMETASONE AND ANTIBIOTICS FLUMETASONE ET ANTIBIOTIQUES CLIOQUINO/FLUMETHASONE CLIOQUINO/FLUMÉTHASONE Crm Top 3%/0.02% Locacorten-Vioform 00074462 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 00232351 VAL AEFGVW Ont Crm Top 0.1%/0.1% Valisone G 00177016 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 00770957 DPT AEFGVW Cr. HYDROCORTISONE / UREA HYDROCORTISONE / URÉA Crm Top 10%/1% Uremol HC 00503134 GSK AEFGVW Cr. Lot Top 10%/1% Uremol HC 00560022 GSK AEFGVW Lot February 2014 / février 2014 Page 75

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 00578428 FRS f AEFGVW Lot ratio-topisalic 02245688 TEV f AEFGVW Ont Top 30mg/0.5mg Diprosalic 00578436 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) 02028719 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 00579947 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) 01987682 ERF AEFGVW Dre Sofra-Tulle (10cm x 10cm) 01988840 ERF AEFGVW February 2014 / février 2014 Page 76

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 00195057 PFI EFGW Lot PREPARATIONS CONTAINING SULPHUR PRÉPARATIONS CONTENANT DU SOUFRE SULPHUR SOUFRE SULFACETAMIDE SODIUM/SULPHUR SULFACÉTAMIDE SODIQUE/SOUFRE Lot Top 10%/5% Sulfacet R 02220407 VLN AEFGVW Lot RETINOIDS FOR TOPICAL USE IN ACNE RÉTINOÏDES POUR USAGE TOPIQUE CONTRE L ACNÉ TRETINOIN TRÉTINOINE Crm Top 0.01% Stieva-A 00657204 GSK EFG Cr. Crm Top 0.025% Stieva-A 00578576 GSK EFG Cr. Crm Top 0.05% Retin-A 00443794 VLN EFG Cr. Stieva-A 00518182 GSK EFG Crm Top 0.1% Retin-A (Disc/non disp Jun 1/14) 00870021 VLN EFG Cr. Stieva-A Forte 00662348 GSK EFG Gel Top 0.01% Vitamin A Acid 01926462 VLN EFG Gel Gel Top 0.025% Stieva-A (Disc/non Disp Jul 3/14) 00587966 GSK EFG Gel Vitamin A Acid 01926470 VLN EFG Gel Top 0.05% Vitamin A Acid 01926489 VLN EFG Gel February 2014 / février 2014 Page 77

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 00263699 GSK AEFGVW Gel Gel Top 20%/6% Panoxyl 00373036 GSK AEFGVW Gel ANTIINFECTIVES FOR TREATMENT OF ACNE ANTI-INFECTIEUX POUR LE TRAITEMENT DE L ACNEÉ CLINDAMYCIN CLINDAMYCINE Liq Top 1% Dalacin T 00582301 PFI f AEFGV Liq Taro-Clindamycin 02266938 TAR f AEFGV ERYTHROMYCIN COMBINATIONS ÉRYTHROMYCINE, EN COMBINAISON ERYTHROMYCIN BASE / TRETINOIN ÉRYTHROMYCINE BASE / TRÉTINOÏNE Gel Top 4%/0.025% Stievamycin 01905112 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 02270811 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 00582344 HLR f EFG Cap Clarus 02257955 MYL f EFG Cap Orl 40mg Accutane Roche 00582352 HLR f EFG Cap Clarus 02257963 MYL f EFG February 2014 / février 2014 Page 78

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 00716901 TAR AEFGVW Cr. Crm Vag 100000IU Ratio-Nystatin 02194163 RPH AEFGVW Cr. NYSTATIN, COMBINATIONS COMBINATION NYSTATINE NYSTATIN / METRONIDAZOLE NYSTATINE / METRONIDAZOLE Sup Vag 100000IU/500mg Flagystatin 01926829 SAV AEFGVW Supp. QUINOLINE DERIVATIVES DÉRIVÉS DE LA QUINOLEINE DIIODOHYDROXYQUINOLINE QUINOLEINE DIIODOHYDROXYLE Tab Orl 650mg Diodoquin 01997750 GLE AEFGVW IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE METRONIDAZOLE MÉTRONIDAZOLE Crm Vag 10% Flagyl 01926861 AVE AEFGVW Cr. CLOTRIMAZOLE CLOTRIMAZOLE Crm Vag 1% Canesten 02150891 YNO AEFGVW Cr. Crm Vag 2% Canesten 3 02150905 YNO AEFGVW Cr. G01AF04 Crm Vag 500mg/1% Canesten 3 Comfortab Combi-Pak 02264099 YNO AEFGVW Cr. Canesten 1 Comfortab 02264102 YNO AEFGVW MICONAZOLE MICONAZOLE Crm Vag 2% Monistat 7 02084309 JNJ f AEFGVW Cr. Micozole Vaginal 2% 02231106 TAR f AEFGVW February 2014 / février 2014 Page 79

G01AF04 MICONAZOLE MICONAZOLE Sup Vag 400mg Monistat-3 02126605 JNJ AEFGVW Supp. Crm Vag 1200mg/2% Monistat 3 Dual Pak 02126249 JNJ AEFGVW Cr. G01AG TRIAZOLE DERIVATIVES DÉRIVÉS DU TRIAZOLE G01AG02 TERCONAZOLE TERCONAZOLE Crm Vag 0.4% Terazol 7 00894729 JAN f AEFGVW Cr. Taro-Terconazole 02247651 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 02243005 BAY EFG Ins G02C G02CB OTHER GYNECOLOGICALS AUTRES AGENTS GYNÉCOLOGIQUES PROLACTINE INHIBITORS INHIBITEURS DE LA PROLACTINE G02CB01 BROMOCRIPTINE BROMOCRIPTINE Tab Orl 2.5mg Bromocriptine 02087324 AAP f AEFGVW pms-bromocriptine (Disc/non disp Feb 16/14) 02231702 PMS f AEFGVW G03 G03A G03AA Cap Orl 5mg Bromocriptine 02230454 AAP f AEFGVW Cap pms-bromocriptine (Disc/non disp Feb 16/14) 02236949 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) * 00469327 PFI EFGV Demulen 30 (28) * 00471526 PFI EFGV February 2014 / février 2014 Page 80

G03AA05 NORETHISTERONE AND ETHINYLESTRADIOL NORÉTHISTERONE ET ÉTHINYLOESTRADIOL Tab Orl 20mcg/1mg Minestrin 1/20 (21) * 00315966 WNC EFGV Minestrin 1/20 (28) * 00343838 WNC EFGV Tab Orl 1.5mg/0.03mg Loestrin 1.5/30 (21) * 00297143 WNC EFGV Loestrin 1.5/30 (28) * 00353027 WNC EFGV Tab Orl 0.5mg/0.035mg Ortho 0.5/35 (21) * 00317047 JAN EFGV Ortho 0.5/35 (28) * 00340731 JAN EFGV Brevicon (21) * 02187086 PFI EFGV Brevicon (28) * 02187094 PFI EFGV G03AA07 Tab Orl 1mg/0.035mg Ortho 1/35 (21) * 00372846 JAN EFGV Ortho 1/35 (28) * 00372838 JAN EFGV Brevicon 1/35 (21) * 02189054 PFI EFGV Brevicon 1/35 (28) * 02189062 PFI EFGV Select 1/35 (21) * 02197502 PFI EFGV Select 1/35 (28) * 02199297 PFI EFGV LEVONORGESTREL AND ETHINYLESTRADIOL LÉVONORGESTREL ET ÉTHINYLOESTRADIOL Tab Orl 0.15mg/0.03mg Min-Ovral (21) * 02042320 PFI f EFGV Min-Ovral (28) * 02042339 PFI f EFGV Portia 21 * 02295946 TEV f EFGV Portia 28 * 02295954 TEV f EFGV Ovima 21 * 02387085 APX f EFGV Ovima 28 * 02387093 APX f EFGV Tab Orl 0.1mg/0.02mg Alesse (21) * 02236974 PFI f EFGV Alesse (28) * 02236975 PFI f EFGV Aviane 21 * 02298538 TEV f EFGV Aviane 28 * 02298546 TEV f EFGV Esme (21) * 02388138 MYL f EFGV Esme (28) * 02388146 MYL f EFGV Alysena 21 * 02387875 APX f EFGV Alysena 28 * 02387883 APX f EFGV Lutera 21 * 02401185 COB f EFGV Lutera 28 * 02401207 COB f EFGV G03AA09 DESORGESTREL AND ETHINYLESTRADIOL DÉSORGESTREL ET ÉTHINYLOESTRADIOL Tab Orl 0.15mg/0.03mg Marvelon (21) * 02042487 FRS f EFGV Marvelon (28) * 02042479 FRS f EFGV Apri 21 * 02317192 TEV f EFGV Apri 28 * 02317206 TEV f EFGV Freya 21 * 02396491 TEV f EFGV Freya 28 * 02396610 TEV f EFGV Linessa 21 * 02272903 FRS EFGV Linessa 28 * 02257238 FRS EFGV February 2014 / février 2014 Page 81

G03AA12 DROSPIRENONE AND ETHINYLESTRADIOL DROSPIRÉNONE ET ÉTHINYLOESTRADIOL Tab Orl 3mg/0.03mg Yasmin 21 * 02261723 BAY f EFGV Zarah 21 * 02385058 COB f EFGV Yasmin 28 * 02261731 BAY f EFGV Zarah 28 * 02385066 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) * 00707600 BAY EFGV Triquilar (28) * 00707503 BAY EFGV NORETHISTERONE AND ETHINYLESTRADIOL NORÉTHISTERONE ET ÉTHINYLOESTRADIOL Tab Orl 1mg/0.5mg/0.035mg Synphasic (21) * 02187108 PFI EFGV Synphasic (28) * 02187116 PFI EFGV Tab Orl 1mg/0.75mg/0.5mg/0.035mg Ortho 7/7/7 (21) * 00602957 JAN EFGV Ortho 7/7/7 (28) * 00602965 JAN EFGV G03AB11 NORGESTIMATE AND ETHINYLESTRADIOL NORGÉSTIMATE ET ÉTHINYLOESTRADIOL Tab Orl 0.215mg/0.18mg/0.025mg/0.025mg Tri-Cyclen lo (21) * 02258560 JAN EFGV Tri-Cyclen lo (28) * 02258587 JAN EFGV Tab Orl 0.25mg/0.215mg/0.18mg/0.035mg Tri-Cyclen (21) * 02028700 JAN EFGV Tri-Cyclen (28) * 02029421 JAN EFGV G03AC PROGESTOGENS PROGESTOGÈNES G03AC01 NORGESTIMATE NORGÉSTIMATE Tab Orl 0.35mg Micronor (28) * 00037605 JAN EFGV G03AC06 MEDROXYPROGESTERONE MÉDROXYPROGESTÉRONE Sus Inj 50mg Depo-Provera 00030848 PFI W Susp. Sus Inj 150mg/mL Depo-Provera * 00585092 PFI f EFGV Susp. Medroxyprogesterone Acetate * 02322250 SDZ f EFGV February 2014 / février 2014 Page 82

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 * 02241674 PAL f EFG Next Choice * 02364905 COB f EFG ANDROGENS ANDROGÈNES 3-OXOANDROSTEN (4) DERIVATIVES DÉRIVÉS DU 3-OXOANDROSTENE (4) TESTOSTERONE TESTOSTÉRONE Liq Inj 100mg Depo-Testosterone 00030783 PFI W Liq Liq Inj 200mg Delatestryl 00029246 VLN W Liq ESTROGENS OESTROGÈNES NATURAL AND SEMISYNTHETIC ESTROGENS, PLAIN OESTROGÈNES NATURELS ET SEMI-SYNTHÉTIQUES, ORDINAIRES ESTRADIOL ESTRADIOL Tab Vag 10mcg Vagifem 10 02325462 NNO AEFGVW Gel Trd 0.06% Estrogel 02238704 FRS AEFV Gel Ins Vag 2mg Estring 02168898 PAL AEFV Ins Pth Trd 25mcg Climara 25 02247499 BAY AEFVW Pth Pth Trd 50mcg Climara 50 02231509 BAY AEFV Pth Pth Trd 75mcg Climara 75 02247500 BAY AEFVW Pth Pth Trd 100mcg Climara 100 02231510 BAY AEFV Pth Srd Trd 25mcg Estraderm-25 (Disc/non disp Nov 7/14) 00756849 NVR AEFGVW Srd Srd Trd 100mcg Estraderm-100(Disc/non disp Jan 8/15) 00756792 NVR AEFGVW Srd February 2014 / février 2014 Page 83

G03CA03 G03CA57 ESTRADIOL ESTRADIOL Tab Orl 0.5mg Estrace 02225190 SHI AEFGVW Tab Orl 1mg Estrace 02148587 SHI AEFGVW Tab Orl 2mg Estrace 02148595 SHI AEFGVW CONJUGATED ESTROGENS OESTROGÈNES CONJUGUÉS Crm Vag 0.625mg Premarin 02043440 PFI AEFGVW Cr. Tab Orl 0.3g Premarin 02043394 PFI AEFGVW Tab Orl 0.625g Premarin 02043408 PFI AEFGVW CES (Disc/non disp Jan 4/15) 00265470 VLN AEFGVW G03D G03DA G03DA02 Tab Orl 1.25mg Premarin 02043424 PFI AEFGVW PROGESTOGENS PROGESTOGÈNES PREGNEN (4) DERIVATIVES DÉRIVÉS DU PREGNEN (4) MEDROXYPROGESTERONE MÉDROXYPROGESTÉRONE Tab Orl 2.5mg Provera 00708917 PFI f AEFGVW Teva-Medrone 02221284 TEV f AEFGVW Apo-Medroxy 02244726 APX f AEFGVW Tab Orl 5mg Provera 00030937 PFI f AEFGVW Teva-Medrone 02221292 TEV f AEFGVW Apo-Medroxy 02244727 APX f AEFGVW Tab Orl 10mg Provera 00729973 PFI f AEFGVW Teva-Medrone 02221306 TEV f AEFGVW Apo-Medroxy 02277298 APX f AEFGVW Tab Orl 100mg Apo-Medroxy 02267640 APX f AEFGVW February 2014 / février 2014 Page 84

G03H G03HA G03X G03HA01 G03XA G04 G04B G03XA01 G04BD G04BD04 ANTIANDROGENS ANTIANDROGÈNES ANTIANDROGENS, PLAIN ANTIANDROGÈNES, ORDINAIRES CYPROTERONE CYPROTÉRONE Tab Orl 50mg Androcur 00704431 PMS f AEFVW Cyproterone 02245898 AAP f AEFVW Med-Cyproterone 02390760 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 02018152 SAV AEFVW Caps Cap Orl 200mg Cyclomen 02018160 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 02223376 PMS f AEFGVW Sir. Tab Orl 2.5mg pms-oxybutynin 02240549 PMS AEFGVW G04BD07 Tab Orl 5mg Apo-Oxybutynin 02163543 APX f AEFGVW Novo-Oxybutynin 02230394 TEV f AEFGVW Mylan-Oxybutynin 02230800 MYL f AEFGVW pms-oxybutynin 02240550 PMS f AEFGVW Oxybutynin 02350238 SAS f AEFGVW TOLTERODINE TOLTÉRODINE Tab Orl 1mg Detrol 13 02239064 PFI AEFGV Detrol 02239064 PFI W Tab Orl 2mg Detrol 13 02239065 PFI AEFGV Detrol 02239065 PFI W February 2014 / février 2014 Page 85

G04BD07 G04BD09 G04BD10 G04BD11 G04BX SOLIFENACIN SOLIFÉNACINE Tab Orl 5mg Vesicare 13 02277263 ASL AEFGV Vesicare 02277263 ASL W Tab Orl 10mg Vesicare 13 02277271 ASL AEFGV Vesicare 02277271 ASL W TROSPIUM TROSPIUM Tab Orl 20mg Trosec 13 02275066 SNV AEFGV Trosec 02275066 SNV W DARIFENACIN DARIFÉNACINE ERT Orl 7.5mg Enablex 13 02273217 MRS AEFGV L.P Enablex 02273217 MRS W ERT Orl 15mg Enablex 13 02273225 MRS AEFGV L.P Enablex 02273225 MRS W FESOTERODINE FÉSOTÉRODINE ERT Orl 4mg Toviaz 13 02380021 PFI AEFGV L.P ERT Orl 8mg Toviaz 13 02380048 PFI AEFGV L.P OTHER UROLOGICAL AUTRES MÉDICAMENTS UROLOGIQUES G04BX13 DIMETHYL SULFOXIDE SULFOXYDE DE DIMÉTHYLE Liq Itv 500mg Rimso-50 * 00493392 BCH f AEFGVW Liq Dimethyl Sulfoxide Irr. * 02243231 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

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 02270102 BOE f AEFVW L.P Sandoz Tamsulosin CR 02340208 SDZ f AEFVW Apo-Tamsulosin CR 02362406 APX f AEFVW Teva-Tamsulosin CR 02368242 TEV f AEFVW SRC Orl 0.4mg Teva-Tamsulosin 02281392 TEV f AEFVW Caps.L.L. ratio-tamsulosin 02294265 TEV f AEFVW Ran-Tamsulosin (Disc/non disp Jun 13/14) 02294885 RAN f AEFVW Sandoz Tamsulosin 02295121 SDZ f AEFVW Mylan-Tamsulosin 02298570 MYL f AEFVW Jamp-Tamsulosin (Disc/non disp Jul 5/14) 02352419 JPC f AEFVW G04CA03 TERAZOSIN TÉRAZOSINE Tab Orl 1mg Hytrin 00818658 ABB f AEF18+VW ratio-terazosin 02218941 RPH f AEF18+VW Teva-Terazosin 02230805 TEV f AEF18+VW Apo-Terazosin 02234502 APX f AEF18+VW pms-terazosin 02243518 PMS f AEF18+VW Terazosin 02350475 SAS f AEF18+VW Mylan-Terazosin 02396289 MYL f AEF18+VW Tab Orl 2mg Hytrin 00818682 ABB f AEF18+VW ratio-terazosin 02218968 RPH f AEF18+VW Teva-Terazosin 02230806 TEV f AEF18+VW Apo-Terazosin 02234503 APX f AEF18+VW pms-terazosin 02243519 PMS f AEF18+VW Terazosin 02350483 SAS f AEF18+VW Mylan-Terazosin 02396297 MYL f AEF18+VW Tab Orl 5mg Hytrin 00818666 ABB f AEF18+VW ratio-terazosin 02218976 RPH f AEF18+VW Teva-Terazosin 02230807 TEV f AEF18+VW Apo-Terazosin 02234504 APX f AEF18+VW pms-terazosin 02243520 PMS f AEF18+VW Terazosin 02350491 SAS f AEF18+VW Mylan-Terazosin 02396300 MYL f AEF18+VW Tab Orl 10mg Hytrin 00818674 ABB f AEF18+VW ratio-terazosin 02218984 RPH f AEF18+VW Teva-Terazosin 02230808 TEV f AEF18+VW Apo-Terazosin 02234505 APX f AEF18+VW pms-terazosin 02243521 PMS f AEF18+VW Terazosin 02350505 SAS f AEF18+VW Mylan-Terazosin 02396319 MYL f AEF18+VW February 2014 / février 2014 Page 87

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 02243077 LIL T Cart Ctg Inj 12mg Humatrope 02243078 LIL T Cart Ctg Inj 24mg Humatrope 02243079 LIL T Cart Liq Inj 3.33mg Omnitrope 02325063 SDZ T Liq Liq Inj 6.70mg Omnitrope 02325071 SDZ T Liq Liq Inj 5mg/mL Nutropin AQ (Disc/non disp Apr 16/15) 02229722 HLR T Liq Liq Inj 5mg/mL Nutropin AQ NuSpin 02376393 HLR T Liq Liq Inj 10mg/2mL Nutropin AQ Pen 02249002 HLR T Liq Liq Inj 6mg Saizen 02350122 EMD T Liq Liq Inj 12mg Saizen 02350130 EMD T Liq Liq Inj 20mg Saizen 02350149 EMD T Liq Pws Inj 1mg Humatrope 00745626 LIL T Pds. Nutropin (Disc/non disp Dec 02/15) 02216191 HLR T Pws Inj 3.33mg Saizen 02215136 EMD T Pds. Pws Inj 5mg Saizen 02237971 EMD T Pds. Pws Inj 8.8mg Saizen 02272083 EMD T Pds. February 2014 / février 2014 Page 88

H01B H01BA POSTERIOR PITUITARY LOBE HORMONES HORMONES DU LOBE POSTHYPOPHYSAIRE VASOPRESSIN AND ANALOGUES VASOPRESSINE ET ANALOGUES H01BA02 DESMOPRESSIN DESMOPRESSINE Liq Inj 4mg DDAVP* 00873993 FEI AEFGVW Liq Liq Nas 0.1mg DDAVP 00402516 FEI AEFGVW Liq ODT Slg 60mg DDAVP Melt 02284995 FEI EFG-18 D.O. ODT Slg 120mg DDAVP Melt 02285002 FEI EFG-18 D.O. ODT Slg 240mg DDAVP Melt 02285010 FEI EFG-18 D.O. Tab Orl 0.1mg DDAVP 00824305 FEI f EF-18G Apo-Desmopressin 02284030 APX f EF-18G Novo-Desmopressin 02287730 TEV f EF-18G pms-desmopressin 02304368 PMS f EF-18G Tab Orl 0.2mg DDAVP 00824143 FEI f EF-18G Apo-Desmopressin 02284049 APX f EF-18G Novo-Desmopressin 02287749 TEV f EF-18G pms-desmopressin 02304376 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 00839191 NVR f W Liq Octreotide Acetate Omega 02248639 OMG f W Liq Inj 0.1mg/mL Sandostatin 00839205 NVR f W Liq Octreotide Acetate Omega 02248640 OMG f W Liq Inj 0.2mg/mL Sandostatin (vial) 02049392 NVR f W Liq Octreotide Acetate Omega 02248642 OMG f W Liq Inj 0.5mg/mL Sandostatin 00839213 NVR f W Liq Octreotide Acetate Omega 02248641 OMG f W Pws Inj 10mg Sandostatin LAR 02239323 NVR W Pds. February 2014 / février 2014 Page 89

H02 H02A H01CB02 H02AA H02AA02 H02AB H02AB01 H02AB02 OCTREOTIDE OCTRÉOTIDE Pws Inj 20mg Sandostatin LAR 02239324 NVR W Pds. Pws Inj 30mg Sandostatin LAR 02239325 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 02086026 PAL AEFGVW GLUCOCORTICOIDS GLUCOCORTICOÏDES BETAMETHASONE BÉTAMÉTHASONE Sus Ia 3mg/3mg Celestone Soluspan 00028096 FRS AEFGVW Susp. Tab Orl 0.5mg Betnesol 02063190 SHI AEFGVW DEXAMETHASONE DEXAMÉTHASONE Tab Orl 0.5mg pms-dexamethasone 01964976 PMS f AEFGVW ratio-dexamethasone 02240684 RPH f AEFGVW Apo-Dexamethasone 02261081 APX f AEFGVW Tab Orl 2mg pms-dexamethasone 02279363 PMS AEFGVW Tab Orl 4mg pms-dexamethasone 01964070 PMS f AEFGVW ratio-dexamethasone 02240687 RPH f AEFGVW Apo-Dexamethasone 02250055 APX f AEFGVW Dexasone 00489158 VLN AEFGVW H02AB04 Liq Inj 4mg Dexamethasone sodium phosphate 00664227 SDZ f AEFGVW Liq Dexamethasone sodium phosphate 01977547 CYI f AEFGVW Dexamethasone-Omega 02204266 OMG AEFGVW METHYLPREDNISOLONE MÉTHYLPREDNISOLONE Tab Orl 4mg Medrol 00030988 PFI AEFGVW February 2014 / février 2014 Page 90

H02AB04 METHYLPREDNISOLONE MÉTHYLPREDNISOLONE Tab Orl 16mg Medrol 00036129 PFI AEFGVW Sus Ia 20mg Depo-Medrol * 01934325 PFI AEFGVW Susp. Sus Ia 80mg Depo-Medrol * 00030767 PFI AEFGVW Susp. Depo-Medrol * 01934341 PFI AEFGVW Sus Ibu 40mg Depo-Medrol * 00030759 PFI AEFGVW Susp. Depo-Medrol * 01934333 PFI AEFGVW Pws Inj 125mg Solu-Medrol 02367955 PFI W Pds. Pws Inj 500mg Solu-Medrol 02367963 PFI W Pds. Pws Inj 1g Solu-Medrol (Disc/non disp Jun 7/14) 02063697 PFI W Pds. H02AB06 PREDNISOLONE PREDNISOLONE Liq Orl 1mg Pediapred 02230619 SAV f AEFGVW Liq pms-prednisolone 02245532 PMS f AEFGVW Tab Orl 1mg Winpred 00271373 AAP AEFGVW Apo-Prednisone (Disc/non disp Jan 9/16) 00598194 APX AEFGVW Tab Orl 5mg Novo-Prednisone 00021695 TEV f ABEFGVW Apo-Prednisone 00312770 APX f ABEFGVW H02AB09 H02AB10 Tab Orl 50mg Novo-Prednisone 00232378 TEV f AEFGVW Apo-Prednisone 00550957 APX f AEFGVW HYDROCORTISONE HYDROCORTISONE Tab Orl 10mg Cortef 00030910 PFI AEFGVW Tab Orl 20mg Cortef 00030929 PFI AEFGVW Pws Inj 100mg Solu-Cortef 00030600 PFI W Pds. CORTISONE CORTISONE Tab Orl 25mg Cortisone 00280437 VLN f AEFGVW February 2014 / février 2014 Page 91

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) * 00260428 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 02172062 ABB AEFGVW Tab Orl 0.05mg Synthroid 02172070 ABB AEFGVW Eltroxin 02213192 TRI AEFGVW Tab Orl 0.075mg Synthroid 02172089 ABB AEFGVW Tab Orl 0.088mg Synthroid 02172097 ABB AEFGVW Tab Orl 0.1mg Synthroid 02172100 ABB AEFGVW Eltroxin 02213206 TRI AEFGVW Tab Orl 0.112mg Synthroid 02171228 ABB AEFGVW Tab Orl 0.125mg Synthroid 02172119 ABB AEFGVW Tab Orl 0.137mg Synthroid 02233852 ABB AEFGVW Tab Orl 0.15mg Synthroid 02172127 ABB AEFGVW Eltroxin 02213214 TRI AEFGVW Tab Orl 0.175mg Synthroid 02172135 ABB AEFGVW Tab Orl 0.2mg Synthroid 02172143 ABB AEFGVW Eltroxin 02213222 TRI AEFGVW February 2014 / février 2014 Page 92

H03AA02 LIOTHYRONINE SODIUM LIOTHYRONINE SODIQUE Tab Orl 0.3mg Synthroid 02172151 ABB AEFGVW Eltroxin 02213230 TRI AEFGVW Tab Orl 5mcg Cytomel 01919458 PFI AEFGVW Tab Orl 25mcg Cytomel 01919466 PFI AEFGVW H03AA05 THYROID GLAND PREPARATIONS PRÉPARATIONS POUR LA GLANDE THYROÏDE DESICCATED THYROID EXTRAIT THYROÏDIEN LYOPHILISÉ Tab Orl 30mg Thyroid 00023949 ERF AEFGVW Tab Orl 60mg Thyroid 00023957 ERF AEFGVW H03B H03BA H03BA02 H03BB H03BB02 Tab Orl 125mg Thyroid 00023965 ERF AEFGVW ANTITHYROID PREPARATIONS PRÉPARATIONS ANTI-THYROÏDIENNES THIOURACILS THIOURACILES PROPYLTHIOURACIL PROPYLTHIOURACILE Tab Orl 50mg Propyl-Thyracil 00010200 PAL AEFGVW Tab Orl 100mg Propyl-Thyracil 00010219 PAL AEFGVW SULPHUR-CONTAINING IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE CONTENANT DU SOUFRE THIAMAZOLE THIAMAZOLE Tab Orl 5mg Tapazole 00015741 PAL AEFGVW Tab Orl 10mg Tapazole 02296039 PAL AEFGVW February 2014 / février 2014 Page 93

H04 H04A H04AA PANCREATIC HORMONES HORMONES PANCRÉATIQUES GLYCOGENOLYTIC HORMONES HORMONES GLYCOGÉNOLYTIQUES GLYCOGENOLYTIC HORMONES HORMONES GLYCOGENOLYTIQUES H04AA01 GLUCAGON GLUCAGON Pws Inj 1mg Glucagon * 02243297 LIL AEFGVW Pds. Glucagen 02333619 NNO AEFGVW Glucagen Hypokit 02333627 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 * 02007134 FEI AEFGVW Liq Liq Inj 200IU Calcimar * 01926691 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 00024368 PFI f ABEFGVW Caps Novo-Doxylin 00725250 TEV f ABEFGVW Apo-Doxy 00740713 APX f ABEFGVW Doxycycline 02351234 SAS f ABEFGVW Tab Orl 100mg Apo-Doxy 00874256 APX f ABEFGVW Novo-Doxylin 02158574 TEV f ABEFGVW Doxycycline 02351242 SAS f ABEFGVW J01AA07 TETRACYCLINE TÉTRACYCLINE Cap Orl 250mg Tetra 00580929 AAP f AEFGVW Caps February 2014 / février 2014 Page 94

J01C J01AA08 MINOCYCLINE MINOCYCLINE Cap Orl 50mg Apo-Minocycline 02084090 APX f ABEFGVW Caps Novo-Minocycline 02108143 TEV f ABEFGVW Mylan-Minocycline 02230735 MYL f ABEFGVW Sandoz Minocycline 02237313 SDZ f ABEFGVW Minocycline 02287226 SAS f ABEFGVW pms-minocycline 02294419 PMS f ABEFGVW J01CA J01CA01 Cap Orl 100mg Apo-Minocycline 02084104 APX f ABEFGVW Caps Novo-Minocycline 02108151 TEV f ABEFGVW Mylan-Minocycline 02230736 MYL f ABEFGVW Sandoz Minocycline 02237314 SDZ f ABEFGVW Minocycline 02239982 IVX f ABEFGVW Minocycline 02287234 SAS f ABEFGVW pms-minocycline 02294427 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 00020877 TEV f AEFGVW Caps Cap Orl 500mg Teva-Ampicillin 00020885 TEV f AEFGVW Caps Pws Inj 500mg Teva-Ampicillin 00872652 TEV W Pds. Pws Inj 1g Teva-Ampicillin 01933345 TEV W Pds. J01CA04 Pws Inj 2g Ampicillin Sodium 01933353 TEV W Pds. AMOXICILLIN AMOXICILLINE Cap Orl 250mg Novamoxin 00406724 TEV f ABEFGVW Caps Apo-Amoxi 00628115 APX f ABEFGVW pms-amoxicillin 02230243 PMS f ABEFGVW Mylan-Amoxicillin 02238171 MYL f ABEFGVW Amoxicillin 02241826 NUM f ABEFGVW Amoxicillin 02352710 SAS f ABEFGVW Auro-Amoxicillin 02388073 ARO f ABEFGVW Cap Orl 500mg Novamoxin 00406716 TEV f ABEFGVW Caps Apo-Amoxi 00628123 APX f ABEFGVW pms-amoxicillin 02230244 PMS f ABEFGVW Mylan-Amoxicillin 02238172 MYL f ABEFGVW February 2014 / février 2014 Page 95

J01CA04 AMOXICILLIN AMOXICILLINE Cap Orl 500mg Amoxicillin 02241827 NUM f ABEFGVW Caps Amoxicillin 02352729 SAS f ABEFGVW Auro-Amoxicillin 02388081 ARO f ABEFGVW Pws Orl 25mg Novamoxin 00452149 TEV f ABEFGVW Pds. Apo-Amoxi 00628131 APX f ABEFGVW Novamoxin 125 (sugar-reduced) 01934171 TEV f ABEFGVW pms-amoxicillin 02230245 PMS f ABEFGVW Amoxicillin 02352745 SAS f ABEFGVW Amoxicillin (sugar-reduced) 02352761 SAS f ABEFGVW Pws Orl 50mg Novamoxin 00452130 TEV f ABEFGVW Pds. Apo-Amoxi 00628158 APX f ABEFGVW Novamoxin 125 (sugar-reduced) 01934163 TEV f ABEFGVW pms-amoxicillin 02230246 PMS f ABEFGVW Amoxicillin 02352753 SAS f ABEFGVW Amoxicillin (sugar-reduced) 02352788 SAS f ABEFGVW TabC Orl 125mg Novamoxin chew 02036347 TEV f ABEFGVW C J01CE J01CA12 TabC Orl 250mg Novamoxin chew 02036355 TEV f ABEFGVW C PIPERACILLIN PIPÉRACILLINE Pws Inj 3g Piperacillin 02246641 HOS f W Pds. BETA-LACTAMASE SENSITIVE PENICILLINS PÉNICILLINES SENSIBLES AUX BETA-LACTAMASES J01CE01 BENZYLPENICILLIN (PENICILLIN G) BENZYLPÉNICILLINE (PÉNICILLINE G) Liq Inj 1000000IU Penicillin G Sodium 01930672 TEV W Liq Liq Inj 5000000IU Penicillin G Sodium 00883751 TEV W Liq Liq Inj 10000000IU Penicillin G Sodium 01930680 TEV W Liq Pws Inj 1000000IU Crystapen 02060086 BCH W Pds. Pws Inj 10000000IU Crystapen 02060108 BCH W Pds. February 2014 / février 2014 Page 96

J01CE02 PHENOXYMETHYLPENICILLIN (PENICILLIN V) PHENOXYMETHYLPÉNICILLINE (PÉNICILLINE V) Pws Orl 25mg Apo-Pen VK 00642223 APX AEFGVW Pds. Pws Orl 60mg Novo-Pen-VK (Disc/non disp Feb 26/15) 00391603 TEV AEFGVW Pds. Apo-Pen VK 00642231 APX AEFGVW Tab Orl 300mg Novo-Pen-VK (Disc/non disp Feb 26/15) 00021202 TEV f AEFGVW Apo-Pen VK 00642215 APX f AEFGVW J01CE08 BENZATHINE BENZYLPENICILLIN (PENICILLIN G BENZATHINE) BENZATHINE BENZYLPÉNICILLINE (PÉNICILLINE G BENZATHINE) Sus Inj 6000000IU Bicillin L-A 02291924 KNG AEFGVW Susp. J01CF BETA-LACTAMASE RESISTANT PENICILLINS PÉNICILLINES RÉSISTANT AUX BETA-LACTAMASE J01CF02 CLOXACILLIN CLOXACILLINE Cap Orl 250mg Novo-Cloxin 00337765 TEV f ABEFGVW Caps Cap Orl 500mg Novo-Cloxin 00337773 TEV f ABEFGVW Caps Pws Inj 500mg Cloxacillin Sodium * 01912429 TEV BEFGW Pds. Pws Inj 1g Cloxacillin Sodium 01975447 TEV BEFGW Pds. Pws Inj 2g Cloxacillin Sodium 01912410 TEV BEFGW Pds. Pws Orl 25mg Novo-Cloxin 00337757 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 01916882 GSK f ABEFGVW Pds. Apo-Amoxi clav 02243986 APX f ABEFGVW Ratio-Aclavulanate 125 F 02244646 TEV f ABEFGVW Pws Orl 50mg/12.5mg Clavulin-250 F 01916874 GSK f ABEFGVW Pds. Apo-Amoxi clav 02243987 APX f ABEFGVW Ratio-Aclavulanate 250 F 02244647 TEV f ABEFGVW February 2014 / février 2014 Page 97

J01CR02 AMOXICILLIN AND ENZYME INHIBITOR AMOXICILLINE ET INHIBITEURS D ENZYMES AMOXICILLIN / CLAVULANIC ACID AMOXICILLINE / ACIDE CLAVULANIQUE Pws Orl 200mg/28.5mg/5mL Clavulin 200 02238831 GSK ABEFGVW Pds. Pws Orl 400mg/57mg/5mL Clavulin 400 02238830 GSK f ABEFGVW Pds. Apo-Amoxi Clav 02288559 APX f ABEFGVW Tab Orl 250mg/125mg Apo-Amoxi Clav 02243350 APX f ABEFGVW Tab Orl 500mg/125mg Clavulin-500 F 01916858 GSK f ABEFGVW Apo-Amoxi Clav 02243351 APX f ABEFGVW ratio-aclavulanate 02243771 TEV ABEFGVW Tab Orl 875mg/125mg Clavulin 02238829 GSK f ABEFGVW Apo-Amoxi Clav 02245623 APX f ABEFGVW ratio-aclavulanate 02247021 TEV f ABEFGVW Novo-Clavamoxin 02248138 TEV f ABEFGVW J01CR03 TICARICILLIN AND ENZYME INHIBITOR TICARICILLINE ET INHIBITEURS D ENZYMES TICARICILLIN / POTASSIUM CLAVULANATE TICARICILLINE / CLAVULANATE DE POTASSIUM Pws Inj 3g Timentin 01916939 GSK W Pds. J01CR05 PIPERACILLIN AND ENZYME INHIBITOR PIPÉRACILLINE ET INHIBITEURS D ENZYMES PIPERACILLIN / TAZOBACTAM PIPÉRACILLINE / TAZOBACTAM Pws Inj 2g/0.25g Tazocin 02170817 PFI f W Pds. Piperacillin & Tazobactam 02308444 APX f W Piperacillin & Tazobactam 02299623 SDZ W Pws Inj 3g/0.375g Tazocin 02170795 PFI f W Pds. Piperacillin & Tazobactam 02308452 APX f W Piperacillin & Tazobactam 02299631 SDZ W Piperacillin/Tazobactam 02370166 TEV f W Pws Inj 4g/0.5g Tazocin 02170809 PFI f W Pds. Piperacillin & Tazobactam 02308460 APX f W Piperacillin & Tazobactam 02299658 SDZ W AJ-Pip/Taz 02391546 AJP f W Piperacillin/Tazobactam 02370174 TEV f W February 2014 / février 2014 Page 98

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 00342084 TEV ABEFGVW Caps Cap Orl 500mg Novo-Lexin 00342114 TEV ABEFGVW Caps Pws Orl 25mg Novo-Lexin 00342106 TEV f ABEFGVW Pds. Pws Orl 50mg Novo-Lexin 00342092 TEV f ABEFGVW Pds. Tab Orl 250mg Novo-Lexin 00583413 TEV f ABEFGVW Apo-Cephalex 00768723 APX f ABEFGVW J01DB04 J01DB05 Tab Orl 500mg Novo-Lexin 00583421 TEV f ABEFGVW Apo-Cephalex 00768715 APX f ABEFGVW CEFAZOLIN CÉFAZOLINE Pws Inj 500mg Cefazolin Sodium 02108119 TEV f BEFGW Pds. Cefazolin Sodium 02308932 SDZ f BEFGW Pws Inj 1g Cefazolin Sodium 02108127 TEV f BEFGW Pds. Cefazolin 02297205 HOS f BEFGW Cefazolin Sodium 02308959 SDZ f BEFGW CEFADROXIL CÉFADROXIL Cap Orl 500mg Teva-Cefadroxil 02235134 TEV f AEFGVW Caps Apo-Cefadroxil 02240774 APX f AEFGVW J01DC J01DC01 SECOND GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE DEUXIÈME GÉNÉRATION CEFOXITIN CÉFOXITINE Pws Inj 1g Cefoxitin Sodium 02128187 TEV f W Pds. Cefoxitin for Injection 02291711 APX f W Pws Inj 2g Cefoxitin Sodium 02128195 TEV f W Pds. Cefoxitin for Injection 02291738 APX f W Pws Inj 10g Novo-Cefoxitin 02240773 TEV W Pds. February 2014 / février 2014 Page 99

J01DC02 CEFUROXIME CÉFUROXIME Liq Orl 25mg Ceftin 02212307 GSK ABEFGVW Liq Tab Orl 250mg Ceftin 02212277 GSK f ABEFGVW ratio-cefuroxime 02242656 TEV f ABEFGVW Apo-Cefuroxime 02244393 APX f ABEFGVW Auro-Cefuroxime 02344823 ARO f ABEFGVW Tab Orl 500mg Ceftin 02212285 GSK f ABEFGVW ratio-cefuroxime 02242657 TEV f ABEFGVW Apo-Cefuroxime 02244394 APX f ABEFGVW Auro-Cefuroxime 02344831 ARO f ABEFGVW Pws. Inj 750mg Cefuroxime * 02241638 PPC f BEFGW Pds. J01DC04 Pws. Inj 1.5g Cefuroxime * 02241639 PPC f BEFGW Pds. CEFACLOR CÉFACLOR Cap Orl 250mg Ceclor 00465186 PDP f ABEFGVW Caps Cap Orl 500mg Ceclor 00465194 PDP f ABEFGVW Caps Pws. Orl 25mg Ceclor 00465208 PDP f ABEFGVW Pds. Pws. Orl 50mg Ceclor 00465216 PDP f ABEFGVW Pds. J01DC10 Pws. Orl 75mg Ceclor B.I.D. 00832804 PDP f ABEFGVW Pds. CEFPROZIL CEFPROZIL Tab Orl 250mg Cefzil 02163659 BRI f AEFGVW Apo-Cefprozil 02292998 APX f AEFGVW Ran-Cefprozil 02293528 RAN f AEFGVW Sandoz Cefprozil 02302179 SDZ f AEFGVW Auro-Cefprozil 02347245 ARO f AEFGVW Tab Orl 500mg Cefzil 02163667 BRI f AEFGVW Apo-Cefprozil 02293005 APX f AEFGVW Ran-Cefprozil 02293536 RAN f AEFGVW Sandoz Cefprozil 02302187 SDZ f AEFGVW Auro-Cefprozil 02347253 ARO f AEFGVW February 2014 / février 2014 Page 100

J01DD J01DC10 J01DD01 CEFPROZIL CEFPROZIL Pws. Orl 25mg Cefzil 02163675 BRI f AEFGVW Pds. Apo-Cefprozil 02293943 APX f AEFGVW Ran-Cefprozil 02329204 RAN f AEFGVW Sandoz Cefprozil 02303426 SDZ f AEFGVW Auro-Cefprozil 02347261 ARO f AEFGVW Pws. Orl 50mg Cefzil 02163683 BRI f AEFGVW Pds. Apo-Cefprozil 02293951 APX f AEFGVW Ran-Cefprozil 02293579 RAN f AEFGVW Sandoz Cefprozil 02303434 SDZ f AEFGVW Auro-Cefprozil 02347288 ARO f AEFGVW THIRD GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE TROISIÈME GÉNÉRATION CEFOTAXIME CÉFOTAXIME Pws Inj 500mg Claforan (Disc/non disp Apr 1/14) 02225085 SAV W Pds. Pws Inj 1g Claforan 02225093 SAV W Pds. J01DD02 Pws Inj 2g Claforan 02225107 SAV W Pds. CEFTAZIDIME CEFTAZIDIME Pws Inj 500mg Fortaz 02212196 GSK BEFGW Pds. Pws Inj 1g Ceftazidime 00886971 PPC BEFGW Pds. Fortaz 02212218 GSK BEFGW J01DD04 Pws Inj 2g Ceftazidime 00886955 PPC BEFGW Pds. Fortaz 02212226 GSK BEFGW CEFTRIAXONE CEFTRIAXONE Pws Inj 250mg Rocephin (Disc/non disp Jun 20/14) 00657387 HLR f BEFGVW Pds. Ceftriaxone 02292866 APX f BEFGVW Ceftriaxone Sodium 02325594 STR f BEFGVW Pws Inj 1g Ceftriaxone 02292270 SDZ f BEFGVW Pds. Ceftriaxone 02292874 APX f BEFGVW Ceftriaxone Sodium 02325616 STR f BEFGVW Ceftriaxone Sodium 2287633 TEV f BEFGVW February 2014 / février 2014 Page 101

J01DE J01DH J01DD04 J01DD08 J01DE01 J01DH02 J01DH03 J01DH51 CEFTRIAXONE CEFTRIAXONE Pws Inj 2g Ceftriaxone 02292289 SDZ f BEFGVW Pds. Ceftriaxone 02292882 APX f BEFGVW Ceftriaxone Sodium 02325624 STR f BEFGVW CEFIXIME CÉFIXIME Pws Orl 20mg Suprax 00868965 SAV ABEFGVW Pds. Tab Orl 400mg Suprax 00868981 SAV ABEFGVW FOURTH GENERATION CEPHALOSPORINS CÉPHALOSPORINES DE QUATRIÈME GÉNÉRATION CEFEPIME CÉFEPIME Pws Inj 1g Maxipime 02163632 BRI W Pds. Pws Inj 2g Maxipime 02163640 BRI f W Pds. Cefepime 02319039 APX f W CARBAPENEMS CARBAPENEMS MEROPENEM MÉROPÉNEM Pws Inj 500mg Merrem 02218488 AZE W Pds. Pws Inj 1g Merrem 02218496 AZE W Pds. ERTAPENEM ERTAPÉNEM Pws Inj 1g Invanz 02247437 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) 00717274 FRS W Pds. Ran-Imipenem-Cilastatin 02351692 OMG W Pws Inj 500mg Primaxin 00717282 FRS W Pds. Ran-Imipenem-Cilastatin 02351706 OMG W February 2014 / février 2014 Page 102

J01E J01EA SULFONAMIDES AND TRIMETHOPRIM SULFONAMIDES ET TRIMÉTHOPRIME TRIMETHOPRIM AND DERIVATIVES TRIMÉTHOPRIME ET DÉRIVÉS J01EA01 TRIMETHOPRIM TRIMÉTHOPRIME Tab Orl 100mg Trimethoprim 02243116 AAP f AEFGVW Tab Orl 200mg Trimethoprim 02243117 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 00726540 TEV f ABEFGVW Susp. Tab Orl 20mg/100mg Apo-Sulfatrim 00445266 APX ABEFGVW Tab Orl 80mg/400mg Apo-Sulfatrim 00445274 APX f ABEFGVW Novo-Trimel 00510637 TEV f ABEFGVW Tab Orl 160mg/800mg Apo-Sulfatrim DS 00445282 APX f ABEFGVW Novo-Trimel DS 00510645 TEV f ABEFGVW J01F J01FA MACROLIDES, LINCOSAMIDES AND STREPTOGRAMINS MACROLIDES, LINCOSAMIDES ET STREPTOGRAMINES MACROLIDES MACROLIDES J01FA01 ERYTHROMYCIN ÉRYTHROMYCINE ECC Orl 250mg Eryc 00607142 PFI f ABEFGVW Caps.Ent. Erythro E-C 00726672 AAP f ABEFGVW ECC Orl 333mg Eryc 00873454 PFI f ABEFGVW Caps.Ent. Erythro E-C 01925938 AAP f ABEFGVW Tab Orl 250mg Erythro 00682020 AAP f ABEFGVW Liq Orl 50mg Novo-Rythro Estolate 00262595 TEV f ABEFGVW Liq Pws Orl 40mg Novo-Rythro 00605859 TEV f ABEFGVW Pds. Pws Orl 80mg Novo-Rythro 00652318 TEV f ABEFGVW Pds. February 2014 / février 2014 Page 103

J01FA01 ERYTHROMYCIN ÉRYTHROMYCINE Tab Orl 600mg Erythro-ES 00637416 AAP f ABEFGVW Tab Orl 250mg Erythro-S 00545678 AAP f ABEFGVW Tab Orl 500mg Erythro-S 00688568 AAP ABEFGVW J01FA02 SPIRAMYCIN SPIRAMYCINE Cap Orl 750000IU Rovamycine 250 01927825 ODN AEFGVW Caps J01FA09 Cap Orl 1500000IU Rovamycine 500 01927817 ODN AEFGVW Caps CLARITHROMYCIN CLARITHROMYCINE ERT Orl 500mg Biaxin XL 02244756 ABB ABEFGVW L.P. Pws Orl 25mg Biaxin 02146908 ABB f ABEFGVW Pds. Accel-Clarithromycin 02390442 ACC f ABEFGVW Clarithromycin 02408988 SAS f ABEFGVW Pws Orl 50mg Biaxin 02244641 ABB f ABEFGVW Pds. Accel-Clarithromycin 02390450 ACC f ABEFGVW Clarithromycin 02408996 SAS f ABEFGVW Tab Orl 250mg Biaxin BID 01984853 ABB f ABEFGVW pms-clarithromycin 02247573 PMS f ABEFGVW ratio-clarithromycin(disc/non disp Apr 12/15) 02247818 RPH f ABEFGVW Mylan-Clarithromycin 02248856 MYL f ABEFGVW Sandoz Clarithromycin 02266539 SDZ f ABEFGVW Apo-Clarithromycin 02274744 APX f ABEFGVW Ran-Clarithromycin 02361426 RAN f ABEFGVW Teva-Clarithromycin 02248804 TEV f ABEFGVW Tab Orl 500mg Biaxin BID 02126710 ABB f ABEFGVW pms-clarithromycin 02247574 PMS f ABEFGVW Mylan-Clarithromycin 02248857 MYL f ABEFGVW ratio-clarithromycin (Disc/non disp Apr 12/15) 02247819 RPH f ABEFGVW Sandoz Clarithromycin 02266547 SDZ f ABEFGVW Apo-Clarithromycin 02274752 APX f ABEFGVW Ran-Clarithromycin 02361434 RAN f ABEFGVW Teva-Clarithromycin 02248805 TEV f ABEFGVW February 2014 / février 2014 Page 104

J01FA10 AZITHROMYCIN AZITHROMYCINE Pws Inj 500mg Zithromax 02239952 PFI W Pds. Pws Orl 20mg Zithromax 02223716 PFI f ABEFGVW Pds. Pms-Azithromycin 02274388 PMS f ABEFGVW Novo-Azithromycin pediatric 02315157 TEV f ABEFGVW Sandoz Azithromycin 02332388 SDZ f ABEFGVW Phl-Azithromycin 02282380 PHL ABEFGVW GD-Azithromycin 02274566 GMD f ABEFGVW Pws Orl 40mg Zithromax 02223724 PFI f ABEFGVW Pds. Pms-Azithromycin 02274396 PMS f ABEFGVW Novo-Azithromycin pediatric 02315165 TEV f ABEFGVW Sandoz Azithromycin 02332396 SDZ f ABEFGVW Phl-Azithromycin 02282410 PHL ABEFGVW GD-Azithromycin 02274574 GMD f ABEFGVW Tab Orl 250mg Zithromax 02212021 PFI f ABEFGVW Apo-Azithromycin 02247423 APX f ABEFGVW Co Azithromycin 02255340 COB f ABEFGVW pms-azithromycin 02261634 PMS f ABEFGVW Sandoz-Azithromycin 02265826 SDZ f ABEFGVW Novo-Azithromycin 02267845 TEV f ABEFGVW GD-Azithromycin 02274531 GMD f ABEFGVW ratio-azithromycin 02275287 RPH f ABEFGVW Mylan-Azithromycin 02278359 MYL f ABEFGVW Azithromycin 02330881 SAS f ABEFGVW Tab Orl 600mg Zithromax 02231143 PFI f W Co Azithromycin 02256088 COB f W pms-azithromycin 02261642 PMS f W Azithromycin 02330911 SAS f W J01FF LINCOSAMIDES LINCOSAMIDES J01FF01 CLINDAMYCIN CLINDAMYCINE Cap Orl 150mg Dalacin C 00030570 PFI f ABEFGVW Caps Teva-Clindamycin 02241709 TEV f ABEFGVW Apo-Clindamycin 02245232 APX f ABEFGVW Mylan-Clindamycin 02258331 MYL f ABEFGVW Cap Orl 300mg Dalacin C 02182866 PFI f ABEFGVW Caps Teva-Clindamycin 02241710 TEV f ABEFGVW Apo-Clindamycin 02245233 APX f ABEFGVW Mylan-Clindamycin 02258358 MYL f ABEFGVW Liq Inj 150mg Dalacin C Phosphate 00260436 PFI f W Liq Clindamycin (bulk vials) 02230535 SDZ f W Clindamycin (2ml, 4ml, 6ml vials) 02230540 SDZ f W February 2014 / février 2014 Page 105

J01G J01FF01 J01GB J01M J01GB01 J01GB03 J01GB06 J01MA J01MA01 CLINDAMYCIN CLINDAMYCINE Pws Orl 15mg Dalacin C 00225851 PFI AEFGVW Pds. AMINOGLYCOSIDE ANTIBACTERIALS ANTIBACTÉRIENS AMINOGLYCOSIDES OTHER AMINOGLYCOSIDES AUTRES AMINOGLYCOSIDES TOBRAMYCIN TOBRAMYCINE Liq Inj 40mg Tobramycin * 02241210 SDZ f BEFGVW Liq Tobramycin * 02382814 AJP f BEFGVW GENTAMICIN GENTAMICINE Liq Inj 40mg Gentamicin 02242652 SDZ f BEFGVW Liq AMIKACIN AMIKACINE Liq Inj 250mg Amikacin 02242971 SDZ W Liq QUINOLONE ANTIBACTERIALS ANTIBACTÉRIENS QUINOLONES FLOUROQUINOLONES FLOUROQUINOLONES OFLOXACIN OFLOXACINE Tab Orl 200mg Ofloxacin 14 02231529 AAP f EF18+ Tab Orl 300mg Ofloxacin 14 02231531 AAP f EF18+ Tab Orl 400mg Ofloxacin 14 02231532 AAP f EF18+ J01MA02 CIPROFLOXACIN CIPROFLOXACINE ERT Orl 1000mg Cipro XL 15 02251787 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

J01MA02 CIPROFLOXACIN CIPROFLOXACINE Liq Inj 2mg Ciprofloxacin I.V. 02267462 TEV f W Liq Liq Inj 10mg Ciprofloxacin 02204398 PDL W Liq Liq Orl 100mg Cipro Oral Suspension 16 02237514 BAY ABEFGV Liq Tab Orl 250mg Cipro 02155958 BAY f BW Cipro 16 02155958 BAY f AEFGV Novo-Ciprofloxacin 02161737 TEV f BW Novo-Ciprofloxacin 16 02161737 TEV f AEFGV Apo-Ciproflox 02229521 APX f BW Apo-Ciproflox 16 02229521 APX f AEFGV Mylan-Ciprofloxacin 02245647 MYL f BW Mylan-Ciprofloxacin 16 02245647 MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Nov.29/15) 02246825 TEV f BW ratio-ciprofloxacin 16 (Disc/non disp Nov.29/15) 02246825 TEV f AEFGV Co Ciprofloxacin 02247339 COB f BW Co Ciprofloxacin 16 02247339 COB f AEFGV pms-ciprofloxacin 02248437 PMS f BW pms-ciprofloxacin 16 02248437 PMS f AEFGV Sandoz Ciprofloxacin 02248756 SDZ f BW Sandoz Ciprofloxacin 16 02248756 SDZ f AEFGV Ran-Ciproflox 02303728 RAN f BW Ran-Ciproflox 16 02303728 RAN f AEFGV Mint-Ciprofloxacin 02317427 MNT f BW Mint-Ciprofloxacin 16 02317427 MNT f AEFGV Ciprofloxacin 02353318 SAS f BW Ciprofloxacin 16 02353318 SAS f AEFGV Septa-Ciprofloxacin 02379627 SPT f BW Septa-Ciprofloxacin 16 02379627 SPT f AEFGV Jamp-Ciprofloxacin 02380358 JPC f BW Jamp-Ciprofloxacin 16 02380358 JPC f AEFGV Mar-Ciprofloxacin 02379686 MAR f BW Mar-Ciprofloxacin 16 02379686 MAR f AEFGV Auro-Ciprofloxacin 02381907 ARO f BW Auro-Ciprofloxacin 16 02381907 ARO f AEFGV Tab Orl 500mg Cipro 02155966 BAY f BW Cipro 16 02155966 BAY f AEFGV Novo-Ciprofloxacin 02161745 TEV f BW Novo-Ciprofloxacin 16 02161745 TEV f AEFGV Apo-Ciproflox 02229522 APX f BW Apo-Ciproflox 16 02229522 APX f AEFGV Mylan-Ciprofloxacin 02245648 MYL f BW Mylan-Ciprofloxacin 16 02245648 MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Jul 24/15) 02246826 TEV f BW ratio-ciprofloxacin (Disc/non disp Jul 24/15) 16 02246826 TEV f AEFGV Co Ciprofloxacin 02247340 COB f BW Co Ciprofloxacin 16 02247340 COB f AEFGV February 2014 / février 2014 Page 107

J01MA02 CIPROFLOXACIN CIPROFLOXACINE Tab Orl 500mg pms-ciprofloxacin 02248438 PMS f BW pms-ciprofloxacin 16 02248438 PMS f AEFGV Sandoz Ciprofloxacin 02248757 SDZ f BW Sandoz Ciprofloxacin 16 02248757 SDZ f AEFGV Ran-Ciproflox 02303736 RAN f BW Ran-Ciproflox 16 02303736 RAN f AEFGV Mint-Ciprofloxacin 02317435 MNT f BW Mint-Ciprofloxacin 16 02317435 MNT f AEFGV Ciprofloxacin 02353326 SAS f BW Ciprofloxacin 16 02353326 SAS f AEFGV Septa-Ciprofloxacin 02379635 SPT f BW Septa-Ciprofloxacin 16 02379635 SPT f AEFGV Jamp-Ciprofloxacin 02380366 JPC f BW Jamp-Ciprofloxacin 16 02380366 JPC f AEFGV Mar-Ciprofloxacin 02379694 MAR f BW Mar-Ciprofloxacin 16 02379694 MAR f AEFGV Auro-Ciprofloxacin 02381923 ARO f BW Auro-Ciprofloxacin 16 02381923 ARO f AEFGV Tab Orl 750mg Cipro 02155974 BAY f BW Cipro 16 02155974 BAY f AEFGV Novo-Ciprofloxacin 02161753 TEV f BW Novo-Ciprofloxacin 16 02161753 TEV f AEFGV Apo-Ciproflox 02229523 APX f BW Apo-Ciproflox 16 02229523 APX f AEFGV Mylan-Ciprofloxacin 02245649 MYL f BW Mylan-Ciprofloxacin 16 02245649 MYL f AEFGV ratio-ciprofloxacin (Disc/non disp Nov.29/15) 02246827 TEV f BW ratio-ciprofloxacin 16 (Disc/non disp Nov.29/15) 02246827 TEV f AEFGV Co Ciprofloxacin 02247341 COB f BW Co Ciprofloxacin 16 02247341 COB f AEFGV pms-ciprofloxacin 02248439 PMS f BW pms-ciprofloxacin 16 02248439 PMS f AEFGV Sandoz Ciprofloxacin 02248758 SDZ f BW Sandoz Ciprofloxacin 16 02248758 SDZ f AEFGV Ran-Ciproflox 02303744 RAN f BW Ran-Ciproflox 16 02303744 RAN f AEFGV Mint-Ciprofloxacin 02317443 MNT f BW Mint-Ciprofloxacin 16 02317443 MNT f AEFGV Ciprofloxacin 02353334 SAS f BW Ciprofloxacin 16 02353334 SAS f AEFGV Septa-Ciprofloxacin 02379643 SPT f BW Septa-Ciprofloxacin 16 02379643 SPT f AEFGV Jamp-Ciprofloxacin 02380374 JPC f BW Jamp-Ciprofloxacin 16 02380374 JPC f AEFGV February 2014 / février 2014 Page 108

J01MA02 J01MA06 J01MA12 CIPROFLOXACIN CIPROFLOXACINE Tab Orl 750mg Mar-Ciprofloxacin 02379708 MAR f BW Mar-Ciprofloxacin 16 02379708 MAR f AEFGV Auro-Ciprofloxacin 02381931 ARO f BW Auro-Ciprofloxacin 16 02381931 ARO f AEFGV NORFLOXACIN NORFLOXACINE Tab Orl 400mg Apo-Norflox 02229524 APX f AEFVW Novo-Norfloxacin 02237682 TEV f AEFVW pms-norfloxacin (Disc/non disp Oct 29/15) 02246596 PMS f AEFVW Co Norfloxacin 02269627 COB f AEFVW LEVOFLOXACIN LÉVOFLOXACINE Liq Inj 5mg Levaquin 02236839 JAN W Liq Tab Orl 250mg Levaquin 02236841 JAN f VW Levaquin 17 02236841 JAN f ABEFG Novo-Levofloxacin 02248262 TEV f VW Novo-Levofloxacin 17 02248262 TEV f ABEFG pms-levofloxacin 02284677 PMS f VW pms-levofloxacin 17 02284677 PMS f ABEFG Apo-Levofloxacin 02284707 APX f VW Apo-Levofloxacin 17 02284707 APX f ABEFG Sandoz Levofloxacin 02298635 SDZ f VW Sandoz Levofloxacin 17 02298635 SDZ f ABEFG Mylan-Levofloxacin 02313979 MYL f VW Mylan-Levofloxacin 17 02313979 MYL f ABEFG Co Levofloxacin 02315424 COB f VW Co Levofloxacin 17 02315424 COB f ABEFG Tab Orl 500mg Levaquin 02236842 JAN f VW Levaquin 17 02236842 JAN f ABEFG Novo-Levofloxacin 02248263 TEV f VW Novo-Levofloxacin 17 02248263 TEV f ABEFG pms-levofloxacin 02284685 PMS f VW pms-levofloxacin 17 02284685 PMS f ABEFG Apo-Levofloxacin 02284715 APX f VW Apo-Levofloxacin 17 02284715 APX f ABEFG Sandoz Levofloxacin 02298643 SDZ f VW Sandoz Levofloxacin 17 02298643 SDZ f ABEFG Mylan-Levofloxacin 02313987 MYL f VW Mylan-Levofloxacin 17 02313987 MYL f ABEFG Co Levofloxacin 02315432 COB f VW Co Levofloxacin 17 02315432 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

J01MA12 LEVOFLOXACIN LÉVOFLOXACINE Tab Orl 750mg Levaquin 02246804 JAN f W Novo-Levofloxacin 02285649 TEV f W Sandoz Levofloxacin 02298651 SDZ f W pms-levofloxacin 02305585 PMS f W Co Levofloxacin 02315440 COB f W Apo-Levofloxacin 02325942 APX f W J01MA14 MOXIFLOXACIN MOXIFLOXACINE Liq Inj 400mg Avelox I.V. 02246414 BAY W Liq Tab Orl 400mg Avelox 02242965 BAY VW Avelox 17 02242965 BAY ABEFG J01X J01XA OTHER ANTIBACTERIALS AUTRES ANTIBACTÉRIENS GLYCOPEPTIDE ANTIBACTERIALS ANTIBACTÉRIENS GLYCOPEPTIDES J01XA01 VANCOMYCIN VANCOMYCINE Cap Orl 125mg Vancocin 00800430 MRS f AEFGVW Caps Vancomycin Hydrochloride 02377470 PPC f AEFGVW Cap Orl 250mg Vancocin 00788716 MRS f AEFGVW Caps Vancomycin Hydrochloride 02377489 PPC f AEFGVW Pws Inj 1g pms-vancomycin 02241821 PMS f ABEFGW Pds. Vancomycin HCL 02139383 PPC ABEFGW Val-Vancomycin 02342863 VAL ABEFGW Pws Inj 500mg pms-vancomycin 02241820 PMS f ABEFGW Pds. Sterile Vancomycin HCL 02139375 PPC ABEFGW Val-Vancomycin 02342855 VAL ABEFGW Sterile Vancomycin 02230191 HOS ABEFGW J01XD IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE J01XD01 METRONIDAZOLE MÉTRONIDAZOLE Liq Inj 0.50% Metronidazole 00649074 HOS W Liq Metronidazole 00870420 BAX W Tab Orl 250mg Metronidazole 00545066 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

J01XE J01XE01 NITROFURAN DERIVATIVES DÉRIVÉS DU NITROFURANE NITROFURANTOIN NITROFURANTOÏNE Cap Orl 50mg Teva-Furantoin 02231015 TEV f AEFGVW Caps Cap Orl 100mg Macrobid 02063662 WNC AEFGVW Caps J01XX J02 J02A J02AA J02AB J02AC J01XX05 J02AA01 J02AB02 J02AC01 Tab Orl 50mg Nitrofurantoin 00319511 AAP AEFGVW Tab Orl 100mg Nitrofurantoin 00312738 AAP AEFGVW OTHER ANTIBACTERIALS AUTRES ANTIBACTÉRIENS METHENAMINE MÉTHÉNAMINE Tab Orl 500mg Mandelamine 00499013 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 00029149 BRI W Pds. IMIDAZOLE DERIVATIVES DÉRIVÉS DE L IMIDAZOLE KETOCONAZOLE KÉTOCONAZOLE Tab Orl 200mg Novo-Ketoconazole 02231061 TEV f AEFGVW Apo-Ketoconazole 02237235 APX f AEFGVW TRIAZOLE DERIVATIVES DÉRIVÉS DE TRIAZOLE FLUCONAZOLE FLUCONAZOLE Cap Orl 150mg Apo-Fluconazole 02241895 APX f AEFGVW Caps pms-fluconazole 02282348 PMS f AEFGVW Liq Inj 2mg Diflucan 00891835 PFI f W Liq Fluconazole (Disc/non disp Jun 4/15) 02247922 TEV f W February 2014 / février 2014 Page 111

J02AX J04 J04A J04AB J04B J02AC01 J02AX04 J04BA J04AB02 J04BA02 FLUCONAZOLE FLUCONAZOLE Tab Orl 50mg Novo-Fluconazole 02236978 TEV f AEFGVW Apo-Fluconazole 02237370 APX f AEFGVW Mylan-Fluconazole 02245292 MYL f AEFGVW pms-fluconazole 02245643 PMS f AEFGVW Co Fluconazole 02281260 COB f AEFGVW Tab Orl 100mg Novo-Fluconazole 02236979 TEV f AEFGVW Apo-Fluconazole 02237371 APX f AEFGVW Mylan-Fluconazole 02245293 MYL f AEFGVW pms-fluconazole 02245644 PMS f AEFGVW Co Fluconazole 02281279 COB f AEFGVW ANTIMYCOTICS FOR SYSTEMIC USE ANTIMYCOTIQUES POUR USAGE SYSTÉMIQUE CASPOFUNGIN CASPOFUNGIN Pwd Inj 50mg Cancidas IV 02244265 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 00393444 VLN ABEFGVW Caps Rifadin 02091887 SAV ABEFGVW Cap Orl 300mg Rofact 00343617 VLN ABEFGVW Caps Rifadin 02092808 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 02041510 JCB AEFGVW February 2014 / février 2014 Page 112

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 00634506 GSK f AEFGVW ratio-acyclovir 02078627 TEV f AEFGVW Apo-Acyclovir 02207621 APX f AEFGVW Mylan-Acyclovir 02242784 MYL f AEFGVW Teva-Acyclovir 02285959 TEV f AEFGVW Acyclovir 02286556 SAS f AEFGVW Tab Orl 400mg Zovirax 01911627 GSK f AEFGVW ratio-acyclovir (Disc/non disp Nov.29/15) 02078635 TEV f AEFGVW Apo-Acyclovir 02207648 APX f AEFGVW Mylan-Acyclovir 02242463 MYL f AEFGVW Teva-Acyclovir 02285967 TEV f AEFGVW Acyclovir 02286564 SAS f AEFGVW Tab Orl 800mg ratio-acyclovir (Disc/non disp Jul 24/15) 02078651 TEV f AEFGVW Apo-Acyclovir 02207656 APX f AEFGVW Mylan-Acyclovir 02242464 MYL f AEFGVW Teva-Acyclovir 02285975 TEV f AEFGVW Acyclovir 02286572 SAS f AEFGVW Liq Inj 25mg Acyclovir Sodium 02236916 HOS W Liq J05AB06 J05AB09 Liq Inj 50mg Acyclovir Sodium 02236926 PPC W Liq GANCICLOVIR GANCICLOVIR Pws Inj 500mg Cytovene 02162695 HLR W Pds. FAMCICLOVIR FAMCICLOVIR Tab Orl 125mg Famvir 02229110 NVR f AEFGVW pms-famciclovir 02278081 PMS f AEFGVW Sandoz Famciclovir 02278634 SDZ f AEFGVW Apo-Famciclovir 02292025 APX f AEFGVW Co Famciclovir 02305682 COB f AEFGVW Tab Orl 250mg Famvir 02229129 NVR f AEFGVW pms-famciclovir 02278103 PMS f AEFGVW Sandoz Famciclovir 02278642 SDZ f AEFGVW February 2014 / février 2014 Page 113

J05AE J05AB09 J05AB11 J05AE01 J05AE02 J05AE03 J05AE04 FAMCICLOVIR FAMCICLOVIR Tab Orl 250mg Apo-Famciclovir 02292041 APX f AEFGVW Co Famciclovir 02305690 COB f AEFGVW Tab Orl 500mg Famvir 02177102 NVR f AEFGVW pms-famciclovir 02278111 PMS f AEFGVW Sandoz Famciclovir 02278650 SDZ f AEFGVW Apo-Famciclovir 02292068 APX f AEFGVW Co Famciclovir 02305704 COB f AEFGVW VALACYCLOVIR VALACYCLOVIR Tab Orl 500mg Valtrex 02219492 GSK f AEFGVW Apo-Valacyclovir 02295822 APX f AEFGVW pms-valacyclovir 02298457 PMS f AEFGVW Co Valacyclovir 02331748 COB f AEFGVW Mylan-Valacyclovir 02351579 MYL f AEFGVW Auro-Valacyclovir 02405040 ARO f AEFGVW PROTEASE INHIBITORS INHIBITEURS DE PROTÉASE SAQUINAVIR SAQUINAVIR Cap Orl 200mg Invirase 02216965 HLR U Caps Tab Orl 300mg Invirase 02279320 HLR U INDINAVIR INDINAVIR Cap Orl 200mg Crixivan 02229161 FRS U Caps Cap Orl 400mg Crixivan 02229196 FRS U Caps RITONAVIR RITONAVIR Tab Orl 100mg Norvir 02357593 ABV U NELFINAVIR NELFINAVIR Tab Orl 250mg Viracept 02238617 VIV U Tab Orl 625mg Viracept 02248761 VIV U February 2014 / février 2014 Page 114

J05AE07 J05AE08 J05AE30 FOSAMPRENAVIR FOSAMPRÉNAVIR Sus Orl 50mg Telzir 02261553 VIV U Susp. Tab Orl 700mg Telzir 02261545 VIV U ATAZANAVIR ATAZANAVIR Cap Orl 150mg Reyataz 02248610 BRI U Caps Cap Orl 200mg Reyataz 02248611 BRI U Caps Cap Orl 300mg Reyataz 02294176 BRI U Caps COMBINATIONS OF PROTEASE INHIBITORS COMBINAISONS D INHIBITEURS DE PROTÉASE LOPINAVIR / RITONAVIR LOPINAVIR / RITONAVIR Liq Orl 80mg Kaletra Oral Solution 02243644 ABV U Liq Tab Orl 100mg/25mg Kaletra 02312301 ABV U J05AF J05AF01 Tab Orl 200mg/50mg Kaletra Tab 02285533 ABB U NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS INHIBITEURS NUCLÉOSIDIQUES ET NUCLÉOTIDIQUES DE LA TRANSCRIPTASE ZIDOVUDINE ZIDOVUDINE Cap Orl 100mg Retrovir 01902660 VIV f U Caps Apo-Zidovudine 01946323 APX f U Liq Inj 100mg Retrovir 01902644 VIV U Liq J05AF02 Syr Orl 10mg Retrovir 01902652 VIV U Sir. DIDANOSINE DIDANOSINE ECC Orl 125mg Videx EC 02244596 BRI U Caps.Ent. ECC Orl 200mg Videx EC 02244597 BRI U Caps.Ent. February 2014 / février 2014 Page 115

J05AF02 J05AF04 DIDANOSINE DIDANOSINE ECC Orl 250mg Videx EC 02244598 BRI U Caps.Ent. ECC Orl 400mg Videx EC 02244599 BRI U Caps.Ent. STAVUDINE STAVUDINE Cap Orl 15mg Zerit 02216086 BRI U Caps Cap Orl 20mg Zerit 02216094 BRI U Caps Cap Orl 30mg Zerit 02216108 BRI U Caps J05AF05 Cap Orl 40mg Zerit 02216116 BRI U Caps LAMIVUDINE LAMIVUDINE Liq Orl 5mg Heptovir 18 02239194 GSK AEFV Liq Liq Orl 10mg 3TC 02192691 VIV U Liq Tab Orl 100mg Heptovir 02239193 GSK f AEFGVW Apo-Lamivudine HBV 02393239 APX f AEFGVW Tab Orl 150mg 3TC 02192683 VIV f U Apo-Lamivudine 02369052 APX f U J05AF06 Tab Orl 300mg 3TC 02247825 VIV f U Apo-Lamivudine 02369060 APX f U ABACAVIR ABACAVIR Liq Orl 20mg Ziagen 02240358 VIV U Liq Tab Orl 300mg Ziagen 02240357 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

J05AG J05AG01 J05AG03 NON-NUCLEOSIDES REVERSE TRANSCRIPTASE INHIBITORS INHIBITEURS NON NUCLÉOSIDIQUES DE LA TRANSCRIPTASE INVERSÉE NEVIRAPINE NÉVIRAPINE ERT Orl 400mg Viramune XR 02367289 BOE U L.P. Tab Orl 200mg Viramune 02238748 BOE f U Auro-Nevirapine 02318601 ARO f U Teva-Nevirapine 02352893 TEV f U Mylan-Nevirapine 02387727 MYL f U pms-nevirapine 02405776 PMS f U EFAVIRENZ ÉFAVIRENZ Cap Orl 20mg Sustiva 02239886 BRI U Caps Cap Orl 200mg Sustiva 02239888 BRI U Caps J05AR J05AG05 J05AR02 J05AR02 J05AR03 J05AR04 Tab Orl 600mg Sustiva 02246045 BRI f U Mylan-Efavirenz 02381524 MYL f U Teva-Efavirenz 02389762 TEV f U RILPIVIRINE RILPIVIRINE Tab Orl 25mg Edurant 02370603 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 02239213 VIV f U Apo-Lamivudine/Zidovudine 02375540 APX f U Teva-Lamivudine/Zidovudine 02387247 TEV f U LAMIVUDINE AND ABACAVIR LAMIVUDINE ET ABACAVIR Tab Orl 600mg/300mg Kivexa 02269341 VIV U TENOFOVIR DISOPROXIL AND EMTRICITABINE TENOFOVIR DISOPROXIL ET EMTRICITABINE Tab Orl 300mg/200mg Truvada 02274906 GIL U ZIDOVUDINE, LAMIVUDINE AND ABACAVIR ZIDOVUDINE, LAMIVUDINE ET ABACAVIR Tab Orl 300mg Trizivir 02244757 VIV U February 2014 / février 2014 Page 117

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 02300699 GIL U EMTRICITABINE, TENOFOVIR DISOPROXIL AND RILPIVIRINE EMTRICITABINE, TÉNOFOVIR DISOPROXIL ET RILPIVIRINE Tab Orl 25mg/200mg/300mg Complera 02374129 GIL U OTHER ANTIVIRALS AUTRES ANTIVIRAUX RALTEGRAVIR RALTÉGRAVIR Tab Orl 400mg Isentress 02301881 FRS U ANTINEOPLASTIC AGENTS AGENTS ANTINÉOPLASIQUES ALKYLATING AGENTS AGENTS ALKYLANTS NITROGEN MUSTARD ANALOGUES ANALOGUES, MOUTARDE AZOTÉE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE Tab Orl 25mg Procytox 02241795 BAX AEFGVW Tab Orl 50mg Procytox 02241796 BAX AEFGVW CHLORAMBUCIL CHLORAMBUCIL Tab Orl 2mg Leukeran 00004626 TRI AEFGVW MELPHALAN MELPHALAN Tab Orl 2mg Alkeran 00004715 TRI AEFGVW ALKYL SULPHONATES SULFONATES D ALKYLE BUSULFAN BUSULFAN Tab Orl 2mg Myleran 00004618 TRI AEFGVW February 2014 / février 2014 Page 118

L01B L01BA L01BA01 ANTIMETABOLITES ANTIMÉTABOLITES FOLIC ACID ANALOGUES ANALOGUES DE L ACIDE FOLIQUE METHOTREXATE MÉTHOTREXATE Liq Inj 10mg Methotrexate Inj USP * 02182947 HOS AEFGVW Liq Liq Inj 25mg Methotrexate Inj USP * 02099705 TEV AEFGVW Liq Methotrexate Inj USP * 02182777 HOS AEFGVW Methotrexate Inj USP * 02182955 HOS AEFGVW Tab Orl 2.5mg Methotrexate 02170698 PFI f AEFGVW Ratio-methotrexate 02244798 TEV f AEFGVW Methotrexate 02182963 APX AEFGVW L01BB L01BB02 L01BB03 L01BC L01C L01BC02 L01CB L01CB01 Tab Orl 10mg Methotrexate 02182750 HOS AEFGVW PURINE ANALOGUES ANALOGUES PURINE MERCAPTOPURINE MERCAPTOPURINE Tab Orl 50mg Purinethol 00004723 TEV AEFGVW TIOGUANINE TIOGUANINE Tab Orl 40mg Lanvis 00282081 TRI AEFGVW PYRIMIDINE ANALOGUES ANALOGUES PYRIMIDIQUES FLUOROURACIL FLUOROURACILE Crm Top 5% Efudex 00330582 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 00616192 BRI AEFGVW Caps February 2014 / février 2014 Page 119

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 00012750 QGT AEFGVW Caps OTHER ANTINEOPLASTIC AGENTS AUTRES AGENTS ANTINÉOPLASIQUES HYDROXYCARBAMIDE (HYDROXYUREA) HYDROXYCARBAMIDE (HYDROXYURÉE) Cap Orl 500mg Hydrea 00465283 BRI f AEFGVW Caps Mylan-Hydroxyurea 02242920 MYL f AEFGVW Hydroxyurea 02343096 SAS f AEFGVW ESTRAMUSTINE ESTRAMUSTINE Cap Orl 140mg Emcyt 02063794 PFI AEFGVW Caps ENDOCRINE THERAPY TRAITEMENT ENDOCRINIEN HORMONES AND RELATED AGENTS HORMONES ET AGENTS APPARENTÉS PROGESTOGENS PROGESTOGÉNES MEGESTROL MÉGESTROL Tab Orl 40mg Megestrol 02195917 AAP f AEFGVW Tab Orl 160mg Megestrol 02195925 AAP f AEFGVW GONADOTROPHIN RELEASING HORMONE ANALOGUES ANALOGUES DE L HORMONE LIBÉRANT DE LA GONADOTROPHINE BUSERELIN BUSÉRÉLINE Asp Nas 1mg Suprefact 02225158 SAV AVW Asp Imp Inj 6.3mg Suprefact Depot 02228955 SAV AEF18+VW Imp Imp Inj 9.45mg Suprefact Depot 02240749 SAV AEF18+VW Imp February 2014 / février 2014 Page 120

L02AE02 LEUPRORELIN LEUPRORÉLINE Liq Inj 5mg Lupron * 00727695 ABV AVW Liq Pws Inj 7.5mg Lupron Depot * 00836273 ABB AVW Pds. Pws Inj 22.5mg Lupron Depot * 02230248 ABB AEF18+VW Pds. Pws Inj 30mg Lupron Depot * 02239833 ABB AEF18+VW Pds. Sus Inj 22.5mg Eligard * 02248240 SAV AEFVW Susp. L02B L02AE02 L02AE04 L02BA L02BA01 Sus Inj 45mg Eligard * 02268892 SAV AEFVW Susp. GOSERELIN GOSÉRÉLINE Imp Inj 3.6mg Zoladex 02049325 AZE AVW Imp Imp Inj 10.8mg Zoladex LA 02225905 AZE AEF18+VW Imp TRIPTORELIN TRIPTORÉLINE Pws Inj 3.75mg Trelstar * 02240000 PAL AEFVW Pds. Pws Inj 11.25mg Trelstar * 02243856 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 00812404 APX f AEFGVW Teva-Tamoxifen 00851965 TEV f AEFGVW Mylan-Tamoxifen 02088428 MYL f AEFGVW Tab Orl 20mg Apo-Tamox 00812390 APX f AEFGVW Teva-Tamoxifen 00851973 TEV f AEFGVW Mylan-Tamoxifen 02089858 MYL f AEFGVW Nolvadex-d 02048485 AZE f AEFGVW February 2014 / février 2014 Page 121

L02BB L02BB01 L02BB02 L02BB03 L02BG L02BG03 L02BG04 ANTI-ANDROGENS ANTI-ANDROGÉNES FLUTAMIDE FLUTAMIDE Tab Orl 250mg Euflex 00637726 FRS f AEFVW Teva-Flutamide 02230089 TEV f AEFVW pms-flutamide 02230104 PMS f AEFVW Apo-Flutamide 02238560 APX f AEFVW NILUTAMIDE NILUTAMIDE Tab Orl 50mg Anandron 02221861 SAV AEFVW BICALUTAMIDE BICALUTAMIDE Tab Orl 50mg Casodex 02184478 AZE f AEFVW Novo-Bicalutamide 02270226 TEV f AEFVW Co Bicalutamide 02274337 COB f AEFVW pms-bicalutamide 02275589 PMS f AEFVW Sandoz Bicalutamide 02276089 SDZ f AEFVW ratio-bicalutamide (Disc/non disp Feb 22/15) 02277700 RPH f AEFVW Apo-Bicalutamide 02296063 APX f AEFVW Mylan-Bicalutamide 02302403 MYL f AEFVW Bicalutamide 02325985 AHI f AEFVW Jamp-Bicalutamide 02357216 JPC f AEFVW Ran-Bicalutamide 02371324 RAN f AEFVW AROMATASE INHIBITORS INHIBITEURS AROMATASES ANASTROZOLE ANASTROZOLE Tab Orl 1mg Arimidex 02224135 AZE f AEFVW Sandoz Anastrozole 02338467 SDZ f AEFVW Apo-Anastrozole 02374420 APX f AEFVW Co-Anastrozole 02394898 COB f AEFVW Jamp-Anastrozole 02339080 JPC f AEFVW Mar-Anastrozole 02379562 MAR f AEFVW Med-Anastrozole 02379104 GMP f AEFVW Anastrozole 02351218 AHI f AEFVW Mylan-Anastrozole 02361418 MYL f AEFVW pms-anastrozole 02320738 PMS f AEFVW Ran-Anastrozole 02328690 RAN f AEFVW Taro-Anastrozole 02365650 TAR f AEFVW Teva-Anastrozole 02313049 TEV f AEFVW Mint-Anastrozole 02393573 MNT f AEFVW LETROZOLE LÉTROZOLE Tab Orl 2.5mg Femara 02231384 NVR f AEFVW pms-letrozole 02309114 PMS f AEFVW Med-Letrozole 02322315 GMP f AEFVW February 2014 / février 2014 Page 122

L02BX L03 L03A L02BG04 L02BG06 L02BX02 L03AA L03AA02 L03AB L03AB05 LETROZOLE LÉTROZOLE Tab Orl 2.5mg Letrozole tablets usp 02338459 AHI f AEFVW Sandoz Letrozole 02344815 SDZ f AEFVW Letrozole (Disc/non disp Jul 24/15) 02347997 TEV f AEFVW Letrozole 02348969 COB f AEFVW Apo-Letrozole 02358514 APX f AEFVW Myl-Letrozole 02372169 MYL f AEFVW Ran-Letrozole 02372282 RAN f AEFVW Jamp-Letrozole 02373009 JPC f AEFVW Mar-Letrozole 02373424 MAR f AEFVW Teva-Letrozole 02343657 TEV f AEFVW EXEMESTANE EXÉMESTANE Tab Orl 25mg Aromasin 02242705 PFI f AEFVW Co-Exemestane 02390183 COB f AEFVW OTHER HORMONE ANTAGONISTS AND RELATED AGENTS AUTRES ANTAGONISTES D HORMONES ET AGENTS CONNEXES DEGARELIX DEGARELIX Pws Inj 80mg/vial Firmagon 02337029 FEI AEF+18VW Pds. Pws Inj 120mg/vial Firmagon 02337037 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) 00999001 AGA W Liq Neupogen 01968017 AGA W INTERFERONS INTERFÉRONS INTERFERON ALFA-2B INTERFÉRON ALFA-2B Liq Inj 6000000IU Intron A * 02238674 SCH AEFGVW Liq Liq Inj 10000000IU Intron A * 02223406 SCH AEFGVW Liq Intron A * 02238675 SCH AEFGVW Liq Inj 15000000IU Intron A * 02240693 SCH AEFGVW Liq February 2014 / février 2014 Page 123

L03AB05 L03AB07 INTERFERON ALFA-2B INTERFÉRON ALFA-2B Liq Inj 25000000IU Intron A * 02240694 FRS AEFGVW Liq Liq Inj 50000000IU Intron A * 02240695 SCH AEFGVW Liq INTERFERON BETA-1A INTERFÉRON BÊTA-1A Liq Inj 22mcg Rebif 02237319 EMD H Liq Rebif Initiation Pack (Disc/non disp May 1/14) 02281708 EMD H Rebif Cartridge 02318253 EMD H Liq Inj 44mcg Rebif 02237320 EMD H Liq Rebif Cartridge 02318261 EMD H L03AX L04 L04A L03AB08 L03AX13 L04AA L04AA06 Liq Inj 30mcg Avonex PS 02269201 BIG H Liq INTERFERON BETA-1B INTERFÉRON BÊTA-1B Liq Inj 0.3mg Betaseron 02169649 BAY H Liq Extavia 02337819 NVR H OTHER IMMUNOSTIMULANTS AUTRES IMMUNOSTIMULANTS GLATIRAMER ACETATE GLATIRAMÉRE ACETATE Liq Inj 20mg Copaxone 02245619 SAV H Liq IMMUNOSUPPRESSANTS AGENTS IMMUNOSUPPRESSEURS IMMUNOSUPPRESSANTS AGENTS IMMUNOSUPPRESSEURS SELECTIVE IMMUNOSUPPRESSANTS IMMUNOSUPPRESSEURS SÉLECTIFS MYCOPHENOLIC ACID ACIDE MYCOPHÉNOLIQUE Cap Orl 250mg Cellcept 02192748 HLR f R Caps Sandoz Mycophenolate 02320630 SDZ f R Apo-Mycophenolate 02352559 APX f R Novo-Mycophenolate 02364883 TEV f R Mylan-Mycophenolate 02371154 MYL f R Mycophenolate Mofetil 02383780 AHI f R Jamp-Mycophenolate 02386399 JPC f R Tab Orl 500mg Cellcept 02237484 HLR f R Sandoz Mycophenolate 02313855 SDZ f R Apo-Mycophenolate 02348675 APX f R February 2014 / février 2014 Page 124

L04AA06 MYCOPHENOLIC ACID ACIDE MYCOPHÉNOLIQUE Tab Orl 500mg Novo-Mycophenolate 02352567 TEV f R Mylan-Mycophenolate 02370549 MYL f R Co Mycophenolate 02379996 COB f R Jamp-Mycophenolate 02380382 JPC f R Mycophenolate Mofetil 02378574 AHI f R ECT Orl 180mg Myfortic 02264560 NVR R Ent. L04AA10 L04AB L04AB01 L04AD L04AD01 ECT Orl 360mg Myfortic 02264579 NVR R Ent. SIROLIMUS SIROLIMUS Liq Orl 1mg Rapamune 02243237 PFI R Liq Tab Orl 1mg Rapamune 02247111 PFI R TUMOR NECROSIS FACTOR ALPHA (TNF-A) INHIBITORS INHIBITEURS DU FACTEUR DE NÉCROSE TUMORALE ALPHA (TNF-A) ETANERCEPT ÉTANERCEPT Pws Inj 25mg Enbrel 02242903 AGA W Pds. CALCINEURIN INHIBITORS INHIBITEURS DE LA CALCINEURINE CYCLOSPORINE CYCLOSPORINE Cap Orl 10mg Neoral 02237671 NVR R Caps Cap Orl 25mg Neoral 02150689 NVR f R Caps Sandoz Cyclosporine 02247073 SDZ f R Cap Orl 50mg Neoral 02150662 NVR f R Caps Sandoz Cyclosporine 02247074 SDZ f R Cap Orl 100mg Neoral 02150670 NVR f R Caps Sandoz Cyclosporine 02242821 SDZ f R L04AD02 Liq Orl 100mg Neoral 02150697 NVR f R Liq Apo-Cyclosporine 02244324 APX f R TACROLIMUS TACROLIMUS Cap Orl 0.5mg Prograf 02243144 ASL R Caps February 2014 / février 2014 Page 125

L04AD02 TACROLIMUS TACROLIMUS Cap Orl 1mg Prograf 02175991 ASL f R Caps Sandoz Tacrolimus 02416824 SDZ f R Cap Orl 5mg Prograf 02175983 ASL f R Caps Sandoz Tacrolimus 02416832 SDZ f R ERC Orl 0.5mg Advagraf 02296462 ASL R Caps.L.P. ERC Orl 1mg Advagraf 02296470 ASL R Caps.L.P. ERC Orl 3mg Advagraf 02331667 ASL R Caps.L.P. L04AX M01 M01A L04AX01 M01AB M01AB01 ERC Orl 5mg Advagraf 02296489 ASL R Caps.L.P. OTHER IMMUNOSUPPRESSANTS AUTRES AGENTS IMMUNOSUPPRESSEURS AZATHIOPRINE AZATHIOPRINE Tab Orl 50mg Imuran 00004596 TRI f AEFGVW Mylan-Azathioprine 02231491 MYL f AEFGVW Teva-Azathioprine 02236819 TEV f AEFGVW Apo-Azathioprine 02242907 APX f AEFGVW Azathioprine 02343002 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 00337420 TEV f AEFGVW Caps Apo-Indomethacin (Disc/non disp Mar 30/14) 00611158 APX f AEFGVW Cap Orl 50mg Novo-Methacin 00337439 TEV f AEFGVW Caps Apo-Indomethacin (Disc/non disp Mar 30/14) 00611166 APX f AEFGVW Sup Rt 50mg Sab-Indomethacin 02231799 SDZ f AEFGVW Supp. Sup Rt 100mg Sab-Indomethacin 02231800 SDZ f AEFGVW Supp. Ratio-Indomethacin 01934139 TEV f AEFGVW February 2014 / février 2014 Page 126

M01AB02 M01AB05 SULINDAC SULINDAC Tab Orl 150mg Teva-Sundac 00745588 TEV f AEFGVW Apo-Sulin 00778354 APX f AEFGVW Tab Orl 200mg Teva-Sundac 00745596 TEV f AEFGVW Apo-Sulin 00778362 APX f AEFGVW DICLOFENAC DICLOFÉNAC ECT Orl 25mg Teva-Difenac 00808539 TEV f AEFGVW Ent. Apo-Diclo 00839175 APX f AEFGVW Sandoz Diclofenac 02261952 SDZ f AEFGVW pms-diclofenac 02302616 PMS f AEFGVW ECT Orl 50mg Voltaren 00514012 NVR f AEFGVW Ent. Teva-Difenac 00808547 TEV f AEFGVW Apo-Diclo 00839183 APX f AEFGVW Sandoz Diclofenac 02261960 SDZ f AEFGVW pms-diclofenac 02302624 PMS f AEFGVW Diclofenac EC 02352397 SAS f AEFGVW SRT Orl 75mg Voltaren SR 00782459 NVR f AEFGVW L.L. Teva-Difenac SR 02158582 TEV f AEFGVW Apo-Diclo SR 02162814 APX f AEFGVW Sandoz Diclofenac SR 02261901 SDZ f AEFGVW pms-diclofenac SR 02231504 PMS f AEFGVW Diclofenac SR 02352400 SAS f AEFGVW SRT Orl 100mg Voltaren SR 00590827 NVR f AEFGVW L.L. Teva-Difenac SR 02048698 TEV f AEFGVW Apo-Diclo SR 02091194 APX f AEFGVW Sandoz Diclofenac SR 02261944 SDZ f AEFGVW pms-diclofenac SR 02231505 PMS f AEFGVW Sup Rt 50mg Voltaren 00632724 NVR f AEFGVW Supp. Pms-Difenac 02231506 PMS f AEFGVW Sandoz Diclofenac 02261928 SDZ f AEFGVW M01AB15 Sup Rt 100mg Voltaren 00632732 NVR f AEFGVW Supp. Pms-Difenac 02231508 PMS f AEFGVW Sandoz Diclofenac 02261936 SDZ f AEFGVW KETOROLAC KÉTOROLAC Liq Inj 10mg Toradol 02162644 HLR W Liq Tab Orl 10mg Toradol 02162660 HLR f W Ketorolac 02229080 AAP f W Novo-Ketorolac (Disc/non disp Feb 26/15) 02230201 TEV f W February 2014 / février 2014 Page 127

M01AB55 M01AC M01AC01 M01AC06 M01AE M01AE01 DICLOFENAC COMBINATIONS DICLOFENAC, EN COMBINAISON DICLOFENAC / MISOPROSTOL DICLOFÉNAC / MISOPROSTOL Tab Orl 50mg/200mcg Arthrotec 01917056 PFI AEFGVW Tab Orl 75mg/200mcg Arthrotec 02229837 PFI AEFGVW OXICAMS OXICAMS PIROXICAM PIROXICAM Cap Orl 10mg Apo-Piroxicam 00642886 APX f AEFGVW Caps Novo-Pirocam 00695718 TEV f AEFGVW Cap Orl 20mg Apo-Piroxicam 00642894 APX f AEFGVW Caps Novo-Pirocam 00695696 TEV f AEFGVW Sup Rt 20mg pms-piroxicam 02154463 PMS f AEFGVW Supp. MELOXICAM MELOXICAM Tab Orl 7.5mg Mobicox 02242785 BOE f AEFGVW pms-meloxicam 02248267 PMS f AEFGVW Phl-Meloxicam 02248607 PHL f AEFGVW Apo-Meloxicam 02248973 APX f AEFGVW Co Meloxicam 02250012 COB f AEFGVW Mylan-Meloxicam 02255987 MYL f AEFGVW Teva-Meloxicam 02258315 TEV f AEFGVW Meloxicam 02353148 SAS f AEFGVW Auro-Meloxicam 02390884 ARO f AEFGVW Tab Orl 15mg Mobicox 02242786 BOE f AEFGVW pms-meloxicam 02248268 PMS f AEFGVW Phl-Meloxicam 02248608 PHL f AEFGVW Apo-Meloxicam 02248974 APX f AEFGVW Co Meloxicam 02250020 COB f AEFGVW Mylan-Meloxicam 02255995 MYL f AEFGVW Teva-Meloxicam 02258323 TEV f AEFGVW Meloxicam 02353156 SAS f AEFGVW Auro-Meloxicam 02390892 ARO f AEFGVW PROPIONIC ACID DERIVATIVES DÉRIVÉS DE L ACIDE PROPIONIQUE IBUPROFEN IBUPROFÉNE Tab Orl 300mg Apo-Ibuprofen 00441651 APX f AEFGVW February 2014 / février 2014 Page 128

M01AE01 M01AE02 IBUPROFEN IBUPROFÉNE Tab Orl 400mg Apo-Ibuprofen 00506052 APX f AEFGVW Novo-Profen 00629340 TEV f AEFGVW pms-ibuprofen 00836133 PMS f AEFGVW Motrin IB 02242658 JNJ f AEFGVW Tab Orl 600mg Apo-Ibuprofen 00585114 APX f AEFGVW Novo-Profen 00629359 TEV f AEFGVW NAPROXEN NAPROXÉNE Sup Rt 500mg pms-naproxen 02017237 PMS f AEFGVW Supp. Sus Orl 25mg Naprosyn 02162431 HLR AEFGVW Susp. Tab Orl 125mg Apo-Naproxen 00522678 APX f AEFGVW Tab Orl 250mg Apo-Naproxen 00522651 APX f AEFGVW Teva-Naproxen 00565350 TEV f AEFGVW Naproxen 02350750 SAS f AEFGVW Tab Orl 375mg Apo-Naproxen 00600806 APX f AEFGVW Teva-Naproxen 00627097 TEV f AEFGVW Naproxen 02350769 SAS f AEFGVW Tab Orl 500mg Apo-Naproxen 00589861 APX f AEFGVW Teva-Naproxen 00592277 TEV f AEFGVW Naproxen 02350777 SAS f AEFGVW ECT Orl 250mg Naprosyn E 02162792 HLR f AEFGVW Ent. Apo-Naproxen EC 02246699 APX f AEFGVW Naproxen EC 02350785 SAS f AEFGVW Teva-Naprox EC 02243312 TEV f AEFGVW ECT Orl 375mg Naprosyn E 02162415 HLR f AEFGVW Ent. Apo-Naproxen EC 02246700 APX f AEFGVW Naproxen EC 02350793 SAS f AEFGVW Teva-Naprox EC 02243313 TEV f AEFGVW Mylan-Naproxen EC 02243432 MYL f AEFGVW pms-naproxen EC 02294702 PMS f AEFGVW ECT Orl 500mg Naprosyn E 02162423 HLR f AEFGVW Ent. Apo-Naproxen EC 02246701 APX f AEFGVW Naproxen EC 02350807 SAS f AEFGVW Teva-Naprox EC 02243314 TEV f AEFGVW Mylan-Naproxen EC 02241024 MYL f AEFGVW pms-naproxen EC 02294710 PMS f AEFGVW February 2014 / février 2014 Page 129

M01AE02 M01AE03 NAPROXEN NAPROXÉNE Tab Orl 275mg Anaprox 02162725 HLR f AEFGVW Apo-Napro-Na 00784354 APX f AEFGVW Naproxen Sodium 02351013 SAS f AEFGVW Teva-Naproxen Sodium 00778389 TEV f AEFGVW Tab Orl 550mg Anaprox DS 02162717 HLR f AEFGVW Apo-Napro-Na DS 01940309 APX f AEFGVW Naproxen Sodium DS 02351021 SAS f AEFGVW Teva-Naproxen Sodium DS 02026600 TEV f AEFGVW KETOPROFEN KÉTOPROFÉNE Cap Orl 50mg Keto 00790427 AAP f AEFGVW Caps ECT Orl 50mg Keto-E 00790435 AAP f AEFGVW Ent. M01AE09 M01AE11 M01AG ECT Orl 100mg Keto-E 00842664 AAP f AEFGVW Ent. SRT Orl 100mg Keto SR 02172577 AAP f AEFGVW L.L. Sup Rt 100mg pms-ketoprofen 02015951 PMS AEFGW Supp. FLURBIPROFEN FLURBIPROFÉNE Tab Orl 50mg Apo-Flurbiprofen 01912046 APX f AEFGVW Novo-Flurprofen 02100509 TEV f AEFGVW Tab Orl 100mg Apo-Flurbiprofen 01912038 APX f AEFGVW Novo-Flurprofen 02100517 TEV f AEFGVW TIAPROFENIC ACID ACIDE TIAPROFÉNIQUE Tab Orl 200mg Apo-Tiaprofenic (Disc/non disp Apr 10/14) 02136112 APX f AEFGVW Teva-Tiaprofenic 02179679 TEV f AEFGVW Tab Orl 300mg Apo-Tiaprofenic (Disc/non disp Apr 10/14) 02136120 APX f AEFGVW Teva-Tiaprofenic 02179687 TEV f AEFGVW FENEMATES FENEMATES M01AG01 MEFENAMIC ACID ACIDE MÉFÉNAMIQUE Cap Orl 250mg Mefenamic 02229452 AAP f AEFGVW Caps February 2014 / février 2014 Page 130

M01AH M01C M01AH01 M01CB M01CB01 COXIBS COXIBS CELECOXIB CÉLÉCOXIB Cap Orl 100mg Celebrex 19 02239941 PFI AEFVW Caps Cap Orl 200mg Celebrex 19 02239942 PFI AEFVW Caps SPECIFIC ANTIRHEUMATIC AGENTS AGENTS ANTIRHUMATISMAUX SPÉCIFIQUES GOLD PREPARATIONS PRÉPARATIONS D OR SODIUM AUROTHIOMALATE AUROTHIOMALATE SODIQUE Liq Inj 10mg Myochrysine * 01927620 SAV f AEFGVW Liq Sodium Aurothiomalate * 02245456 SDZ f AEFGVW Liq Inj 25mg Myochrysine * 01927612 SAV f AEFGVW Liq Sodium Aurothiomalate * 02245457 SDZ f AEFGVW M01CB03 M01CC M03 M03B Liq Inj 50mg Myochrysine * 01927604 SAV f AEFGVW Liq Sodium Aurothiomalate * 02245458 SDZ f AEFGVW AURANOFIN AURANOFINE Cap Orl 3mg Riduara* 01916823 XPI AEFGVW Caps PENICILLAMINE AND SIMILAR AGENTS PÉNICILLAMINE ET AGENTS SEMBLABLES M01CC01 PENICILLAMINE PÉNICILLAMINE M03BA M03BA03 Cap Orl 250mg Cuprimine 00016055 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 01930990 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

M03BA03 M03BA53 M03BC M03BC01 M03BX M03BX01 M03BX08 METHOCARBAMOL MÉTHOCARBAMOL Tab Orl 750mg Robaxin 01932187 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-1/4 01934783 WCH W Tab Orl 400mg/325mg/32.4mg Robaxisal C-1/2 01934791 WCH W ETHERS, CHEMICALLY CLOSE TO ANTIHISTAMINES ÉTHERS, CHIMIQUEMENT PRÈS DES ANTIHISTAMINES ORPHENADRINE ORPHÉNADRINE SRT Orl 100mg Norflex (Disc/non disp Sep 1/14) 01966154 MDS f AEFGVW L.L. Sandoz Orphenadrine Citrate 02243559 SDZ f AEFGVW OTHER CENTRALLY ACTING AGENTS AUTRES AGENTS AGISSANT CENTRALEMENT BACLOFEN BACLOFÉNE Tab Orl 10mg Lioresal 00455881 NVR f AEFGVW pms-baclofen 02063735 PMS f AEFGVW Mylan-Baclofen 02088398 MYL f AEFGVW Apo-Baclofen 02139332 APX f AEFGVW ratio-baclofen 02236507 TEV f AEFGVW Phl-Baclofen 02236963 PHL f AEFGVW Baclofen 02287021 SAS f AEFGVW Tab Orl 20mg Lioresal D.S. 00636576 NVR f AEFGVW pms-baclofen 02063743 PMS f AEFGVW Mylan-Baclofen 02088401 MYL f AEFGVW Apo-Baclofen 02139391 APX f AEFGVW ratio-baclofen 02236508 TEV f AEFGVW Phl-Baclofen 02236964 PHL f AEFGVW Baclofen 02287048 SAS f AEFGVW CYCLOBENZAPRINE CYCLOBENZAPRINE Tab Orl 10mg Novo-Cycloprine 02080052 TEV f AEFGVW Apo-Cycloprine 02177145 APX f AEFGVW pms-cyclobenzaprine 02212048 PMS f AEFGVW Mylan-Cyclobenzaprine 02231353 MYL f AEFGVW Cyclobenzaprine 02287064 SAS f AEFGVW Auro-Cyclobenzaprine 02348853 ARO f AEFGVW Jamp-Cyclobenzaprine 02357127 JPC f AEFGVW February 2014 / février 2014 Page 132

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 01997602 MTP AEFGVW Caps Cap Orl 100mg Dantrium 01997653 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 00402818 AAP f AEFGVW Mar-Allopurinol 02396327 MAR f AEFGVW Apo-Allopurinol 02402769 APX f AEFGVW Tab Orl 200mg Zyloprim 00479799 AAP f AEFGVW Mar-Allopurinol 02396335 MAR f AEFGVW Apo-Allopurinol 02402777 APX f AEFGVW M04AB M04AB01 M04AB02 M04AC M04AC01 Tab Orl 300mg Zyloprim 00402796 AAP f AEFGVW Mar-Allopurinol 02396343 MAR f AEFGVW Apo-Allopurinol 02402785 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) 00294926 VLN AEFGVW SULFINPYRAZONE SULFINPYRAZONE Tab Orl 200mg Sulfinpyrazone 00441767 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 00287873 EUR AEFGVW Colchicine 00572349 ODN AEFGVW February 2014 / février 2014 Page 133

M05 M05B M04AC01 M05BA M05BA02 M05BA04 M05BB M05BB03 COLCHICINE COLCHICINE Tab Orl 1mg Colchicine (Disc/non disp Mar 6/15) 00621374 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 01984845 BAY AEFGVW Caps ALENDRONIC ACID ACIDE ALENDRONIQUE Tab Orl 10mg Teva-Alendronate 02247373 TEV f W Apo-Alendronate 02248728 APX f W Mylan-Alendronate 02270129 MYL f W Sandoz Alendronate 02288087 SDZ f W Alendronate Sodium 02381486 AHI f W Ran-Alendronate 02384701 RAN f W Mint-Alendronate 02394863 MNT f W Auro-Alendronate 02388545 ARO f W Tab Orl 40mg Fosamax (Disc/non disp Jun 1/15) 02201038 FRS f W Co Alendronate 02258102 COB f W Tab Orl 70mg Fosamax 02245329 FRS f W Apo-Alendronate 02248730 APX f W Co Alendronate 02258110 COB f W Teva-Alendronate 02261715 TEV f W pms-alendronate FC 02284006 PMS f W Mylan-Alendronate 02286335 MYL f W Sandoz Alendronate 02288109 SDZ f W Alendronate FC 02299712 SIV f W Alendronate 02352966 SAS f W Alendronate Sodium 02381494 AHI f W Ran-Alendronate 02384728 RAN f W Jamp-Alendronate 02385031 JPC f W Mint-Alendronate 02394871 MNT f W Auro-Alendronate 02388553 ARO f W BIPHOSPHONATES, COMBINATIONS BIPHOSPHONATES EN COMBINAISON ALENDRONIC ACID AND COLECALCIFEROL ACIDE ALENDRONIQUE ET COLÉCALCIFÉROL Tab Orl 70mg/5600mg Fosavance 02314940 FRS f W Teva-Alendronate/Cholecalciferol 02403641 TEV f W February 2014 / février 2014 Page 134

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 00740306 MDS AEFGVW Cr. Capsaicin 02157101 VAL AEFGVW Crm Top 0.075% Zostrix H.P. 02004240 MDS AEFGVW Cr. Capsaicin Crm 02157128 VAL AEFGVW ANALGESICS ANALGÉSIQUES OPIOIDS OPIOÏDES NATURAL OPIUM ALKALOIDS ALKALOÏDES D OPIUM NATUREL MORPHINE MORPHINE SRT Orl 30mg M.O.S.SR 00776181 VLN AEFGVW L.L. SRT Orl 60mg M.O.S.SR 00776203 VLN AEFGVW L.L. Syr Orl 1mg ratio-morphine 00607762 RPH AEFGVW Sir. Syr Orl 5mg ratio-morphine 00607770 RPH AEFGVW Sir. Syr Orl 10mg ratio-morphine 00690783 RPH AEFGVW Sir. Syr Orl 20mg ratio-morphine 00690791 RPH AEFGVW Sir. Dps Orl 20mg Statex 00621935 PAL AEFGVW Gtts Dps Orl 50mg Statex 00705799 PAL AEFGVW Gtts Liq Inj 10mg Morphine Sulfate* 00392588 SDZ AEFGVW Liq Liq Inj 15mg Morphine Sulfate* 00392561 SDZ AEFGVW Liq February 2014 / février 2014 Page 135

N02AA01 MORPHINE MORPHINE Liq Inj 25mg Morphine HP 25* 00676411 SDZ AEFGVW Liq Liq Inj 50mg Morphine HP 50* 00617288 SDZ AEFGVW Liq SRC Orl 10mg M-Eslon 02019930 SAV AEFGVW Caps.L.L. Kadian 02242163 ABB AEFGVW SRC Orl 15mg M-Eslon 15 02177749 SAV AEFGVW Caps.L.L. SRC Orl 20mg Kadian 02184435 ABB AEFGVW Caps.L.L. SRC Orl 30mg M-Eslon 02019949 SAV AEFGVW Caps.L.L. SRC Orl 50mg Kadian 02184443 ABB AEFGVW Caps.L.L. SRC Orl 60mg M-Eslon 02019957 SAV AEFGVW Caps.L.L. SRC Orl 100mg M-Eslon 02019965 SAV AEFGVW Caps.L.L. Kadian 02184451 ABB AEFGVW SRC Orl 200mg Kadian 02177757 ABB AEFGVW Caps.L.L. SRT Orl 15mg MS Contin 02015439 PFR f AEFGVW L.L. Sandoz Morphine SR 02244790 SDZ f AEFGVW Teva-Morphine SR 02302764 TEV f AEFGVW Morphine SR 02350815 SAS f AEFGVW SRT Orl 30mg MS Contin 02014297 PFR f AEFGVW L.L. Sandoz Morphine SR 02244791 SDZ f AEFGVW Teva-Morphine SR 02302772 TEV f AEFGVW Morphine SR 02350890 SAS f AEFGVW SRT Orl 60mg MS Contin 02014300 PFR f AEFGVW L.L. Sandoz Morphine SR 02244792 SDZ f AEFGVW Teva-Morphine SR 02302780 TEV f AEFGVW Morphine SR 02350912 SAS f AEFGVW SRT Orl 100mg MS Contin 02014319 PFR f AEFGVW L.L. Teva-Morphine SR 02302799 TEV f AEFGVW Morphine SR (Disc/non disp Apr 22/15) 02350920 SAS f AEFGVW February 2014 / février 2014 Page 136

N02AA01 MORPHINE MORPHINE SRT Orl 200mg MS Contin 02014327 PFR f AEFGVW L.L. pms-morphine sulfate (Disc/non disp Apr 1/14) 02245288 PMS f AEFGVW Teva-Morphine SR 02302802 TEV f AEFGVW Morphine SR (Disc/non disp Apr 22/15) 02350947 SAS f AEFGVW Sup Rt 5mg Statex 00632228 PAL AEFGVW Supp. Sup Rt 10mg Statex 00632201 PAL AEFGVW Supp. Sup Rt 20mg Statex 00596965 PAL AEFGVW Supp. Sup Rt 30mg Statex 00639389 PAL AEFGVW Supp. Syr Orl 1mg Statex 00591467 PAL AEFGVW Sir. Syr Orl 5mg Statex 00591475 PAL AEFGVW Sir. Tab Orl 5mg Statex 00594652 PAL AEFGVW MS IR 02014203 PFR AEFGVW Tab Orl 10mg Statex 00594644 PAL AEFGVW MS IR 02014211 PFR AEFGVW Tab Orl 20mg MS IR 02014238 PFR AEFGVW Tab Orl 25mg Statex 00594636 PAL AEFGVW Tab Orl 30mg MS IR 02014254 PFR AEFGVW Tab Orl 50mg Statex 00675962 PAL AEFGVW N02AA03 HYDROMORPHONE HYDROMORPHONE Liq Inj 2mg Dilaudid * 00627100 PFR f AEFGVW Liq Hydromorphone hcl * 02145901 SDZ f AEFGVW Liq Inj 10mg Dilaudid HP * 00622133 PFR f AEFGVW Liq Hydromorphone HP * 02145928 SDZ f AEFGVW Liq Inj 20mg Hydromorphone HP * 02145936 SDZ f AEFGVW Liq February 2014 / février 2014 Page 137

N02AA03 HYDROMORPHONE HYDROMORPHONE Liq Inj 50mg Hydromorphone HP * 02146126 SDZ f AEFGVW Liq Cap Orl 4.5mg Hydromorph Contin 02359502 PFR AEFGVW Caps. Cap Orl 9mg Hydromorph Contin 02359510 PFR AEFGVW Caps. SRC Orl 3mg Hydromorph Contin SR 02125323 PFR AEFGVW Caps.L.L. SRC Orl 6mg Hydromorph Contin SR 02125331 PFR AEFGVW Caps.L.L. SRC Orl 12mg Hydromorph Contin SR 02125366 PFR AEFGVW Caps.L.L. SRC Orl 18mg Hydromorph Contin SR 02243562 PFR AEFGVW Caps.L.L. SRC Orl 24mg Hydromorph Contin SR 02125382 PFR AEFGVW Caps.L.L. SRC Orl 30mg Hydromorph Contin SR 02125390 PFR AEFGVW Caps.L.L. Syr Orl 1mg Dilaudid 00786535 PFR f AEFGVW Sir. Pms-Hydromorphone 01916386 PMS f AEFGVW Tab Orl 1mg Dilaudid 00705438 PFR f AEFGVW pms-hydromorphone 00885444 PMS f AEFGVW Teva-Hydromorphone 02319403 TEV f AEFGVW Tab Orl 2mg Dilaudid 00125083 PFR f AEFGVW pms-hydromorphone 00885436 PMS f AEFGVW Teva-Hydromorphone 02319411 TEV f AEFGVW Tab Orl 4mg Dilaudid 00125121 PFR f AEFGVW pms-hydromorphone 00885401 PMS f AEFGVW Teva-Hydromorphone 02319438 TEV f AEFGVW Tab Orl 8mg Dilaudid 00786543 PFR f AEFGVW pms-hydromorphone 00885428 PMS f AEFGVW Teva-Hydromorphone 02319446 TEV f AEFGVW N02AA05 OXYCODONE OXYCODONE ERT Orl 10mg Oxyneo 02372525 PFR W L.P. February 2014 / février 2014 Page 138

N02AA05 OXYCODONE OXYCODONE ERT Orl 15mg Oxyneo 02372533 PFR W L.P. ERT Orl 20mg Oxyneo 02372797 PFR W L.P. ERT Orl 30mg Oxyneo 02372541 PFR W L.P. ERT Orl 40mg Oxyneo 02372568 PFR W L.P. ERT Orl 60mg Oxyneo 02372576 PFR W L.P. ERT Orl 80mg Oxyneo 02372584 PFR W L.P. Sup Rt 10mg Supeudol 00392480 SDZ AEFGVW Supp. Tab Orl 5mg Oxy-IR 02231934 PFR f W pms-oxycodone IR 02319977 PMS f W Tab Orl 10mg Supeudol 00443948 SDZ f W Oxy-IR 02240131 PFR f W pms-oxycodone IR 02319985 PMS f W Tab Orl 20mg Supeudol 02262983 SDZ f W Oxy-IR 02240132 PFR f W pms-oxycodone IR 02319993 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 #3 00653276 RPH AEFGVW Tylenol No.3 02163926 JAN AEFGVW Tab Orl 300mg/30mg/30mg Atasol-30 00293512 CHU AEFGVW ACETAMINOPHEN / CODEINE ACÉTAMINOPHÈNE / CODÉINE Tab Orl 300mg/30mg ratio-emtec-30 00608882 RPH AEFGVW Tab Orl 300mg/60mg ratio-lenoltec #4 00621463 RPH AEFGVW Tylenol No.4 02163918 JAN AEFGVW February 2014 / février 2014 Page 139

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 292 02238645 PDP AEFGVW PHENYLPIPERIDINE DERIVATIVES DÉRIVÉS DU PHENYLPIPERDINE PETHIDINE (MEPERIDINE) PÉTHIDINE (MÉPÉRIDINE) Tab Orl 50mg Demerol 02138018 SAV W FENTANYL FENTANYL Pth Trd 12mcg Teva-Fentanyl 02311925 TEV f W Pth Sandoz Fentanyl patch 02327112 SDZ f W Ran-Fentanyl Matrix 02330105 RAN f W Duragesic Mat 02334186 JAN f W pms-fentanyl MTX 02341379 PMS f W Mylan-Fentanyl Matrix 02396696 MYL f W Co-Fentanyl 02386844 COB f W Pth Trd 25mcg Duragesic Mat 02275813 JAN f W Pth Teva-Fentanyl 02282941 TEV f W Apo-Fentanyl 02314630 APX f W Sandoz Fentanyl 02327120 SDZ f W Ran-Fentanyl Matrix 02330113 RAN f W pms-fentanyl MTX 02341387 PMS f W Mylan-Fentanyl Matrix 02396718 MYL f W Co-Fentanyl 02386852 COB f W Pth Trd 37mcg Sandoz Fentanyl 02327139 SDZ W Pth Pth Trd 50mcg Duragesic Mat 02275821 JAN f W Pth Teva-Fentanyl 02282968 TEV f W Apo-Fentanyl 02314649 APX f W Sandoz Fentanyl 02327147 SDZ f W Ran-Fentanyl Matrix 02330121 RAN f W pms-fentanyl MTX 02341395 PMS f W Mylan-Fentanyl Matrix 02396726 MYL f W Co-Fentanyl 02386879 COB f W Pth Trd 75mcg Duragesic Mat 02275848 JAN f W Pth Teva-Fentanyl 02282976 TEV f W Apo-Fentanyl 02314657 APX f W Sandoz Fentanyl 02327155 SDZ f W Ran-Fentanyl Matrix 02330148 RAN f W pms-fentanyl MTX 02341409 PMS f W Mylan-Fentanyl Matrix 02396734 MYL f W Co-Fentanyl 02386887 COB f W February 2014 / février 2014 Page 140

N02AB03 N02AD N02B N02AD01 N02BA N02BA01 FENTANYL FENTANYL Pth Trd 100mcg Duragesic Mat 02275856 JAN f W Pth Teva-Fentanyl 02282984 TEV f W Apo-Fentanyl 02314665 APX f W Sandoz Fentanyl 02327163 SDZ f W Ran-Fentanyl Matrix 02330156 RAN f W pms-fentanyl MTX 02341417 PMS f W Mylan-Fentanyl Matrix 02396742 MYL f W Co-Fentanyl 02386895 COB f W BENZOMORPHAN DERIVATIVES DÉRIVÉS DU BENZOMORPHANE PENTAZOCINE PENTAZOCINE Tab Orl 50mg Talwin 02137984 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) 02243101 PMS V Ent. Equate daily low-dose EC 02243801 PMS V Rexall Coated low dose ASA 02243802 PMS V Exact Coated daily low dose ASA 02243896 PMS V ASA ECT (Disc/non disp Jun 5/14) 02244993 PMS V Praxis ASA 02283700 PDP V ECT Orl 325mg Entrophen 00010332 PDP AEFGVW Ent. Novasen 00216666 TEV AEFGVW Enteric Coated ASA 02010526 VTH AEFGVW EC ASA 02245443 JPC AEFGVW pms-asa EC 02284529 PMS AEFGVW ASATAB EC 02352427 ODN AEFGVW N02BA11 ECT Orl 650mg Entrophen 00010340 PDP AEFGVW Ent. Novasen 00229296 TEV AEFGVW Jamp-ASA EC 00794244 JPC AEFGVW DIFLUNISAL DIFLUNISAL Tab Orl 250mg Apo-Diflunisal 02039486 APX f AEFGVW Novo-Diflunisal 02048493 TEV f AEFGVW Tab Orl 500mg Apo-Diflunisal 02039494 APX f AEFGVW February 2014 / février 2014 Page 141

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 00608157 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 00226327 NVR f W Caps ratio-tecnal 00608238 RPH f W Tab Orl 50mg/330mg/40mg ratio-tecnal 00608211 RPH W BUTALBITAL / ACETYLSALICYLIC ACID / CAFFEINE / CODEINE BUTALBITAL / ACIDE ACÉTYLSALICYLIQUE / CAFÉINE/ CODÉINE Cap Orl 50mg/330mg/40mg/15mg Fiorinal C ¼ 00176192 NVR f W Caps ratio-tecnal C ¼ 00608203 RPH f W N02BE N02BE01 Cap Orl 50mg/330mg/40mg/30mg Fiorinal C ½ 00176206 NVR f W Caps ratio-tecnal C ½ 00608181 RPH f W ANILIDES ANILIDES PARACETAMOL (ACETAMINOPHEN) PARACETAMOL (ACÉTAMINOPHÉNE) Sup Rt 120mg Abenol 01919385 PDP f G Supp. Acet 120 02230434 PDP f G Sup Rt 325mg Abenol 01919393 PDP G Supp. Tab Orl 325mg Novo-Gesic 00389218 TEV G Apo-Acetaminophen 00544981 APX G Acetaminophen 01938088 JPC G Tab Orl 500mg Novo-Gesic 00482323 TEV G Apo-Acetaminophen 00545007 APX G Acetaminophen 01939122 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-15 00293504 CHU AEFGVW February 2014 / février 2014 Page 142

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 #2 00653241 RPH AEFGVW Tylenol No.2 02163934 JAN AEFGVW ACETAMINOPHEN / CODEINE ACÉTAMINOPHÈNE / CODÉINE Elx Orl 32mg/1.6mg Tylenol w Codeine (Disc/non 02163942 JAN AEFGVW Elx disp Jul 2/15) ACETAMINOPHEN / OXYCODONE ACÉTAMINOPHÈNE / OXYCODONE Tab Orl 325mg/2.5mg Percocet Demi 01916491 BRI AEFGVW Tab Orl 325mg/5mg ratio-oxycocet 00608165 RPH f AEFGVW Percocet 01916475 BRI f AEFGVW Endocet 01916548 BRI f AEFGVW Sandoz Oxycodone/Acetaminophen 02307898 SDZ f AEFGVW Apo-Oxycodone/Acet 02324628 APX f AEFGVW Oxycodone/Acet 02361361 SAS f AEFGVW OTHER ANALGESICS AND ANTIPYRETICS AUTRE ANALGÉSIQUES ET ANTIPYRÉTIQUES FLOCTAFENINE FLOCTAFÉNINE Tab Orl 200mg Floctafenine 02244680 AAP f AEFGVW Tab Orl 400mg Floctafenine 02244681 AAP f AEFGVW ANTIMIGRAINE PREPARATIONS PRÉPARATIONS ANTI-MIGRAINES ERGOT ALKALOIDS ALKALOÏDES DE L ERGOT DIHYDROERGOTAMINE DIHYDROERGOTAMINE Liq Inj 1mg Dihydroergotamine * 02241163 SDZ f AEFGVW Liq Dihydroergotamine * 00027243 STR f AEFGVW Liq Nas 4mg Migranal 02228947 STR AEFGVW Liq February 2014 / février 2014 Page 143

N02CA52 ERGOTAMINE, COMBINATIONS EXCLUDING PSYCHOLEPTICS ERGOTAMINE, EN COMBINAISON, À L EXCLUSION DES PSYCHOLEPTIQUES ERGOTAMINE / CAFFEINE ERGOTAMINE / CAFÉINE Tab Orl 1mg/100mg Cafergot 00176095 NVR AEFGVW ERGOTAMINE / CAFFEINE / DIMENHYDRINATE ERGOTAMINE / CAFÉINE / DIMENHYDRINATE Cap Orl 1mg/100mg/25mg Ergodryl (Disc/non disp 00156086 ERF AEFGVW Caps Jul 9/15) N02CX OTHER ANTIMIGRAINE PREPARATIONS AUTRES PRÉPARATIONS ANTI-MIGRAINE N02CX01 PIZOTIFEN PIZOTIFÉNE Tab Orl 0.5mg Sandomigran 00329320 PAL AEFGVW Tab Orl 1mg Sandomigran DS 00511552 PAL AEFGVW N03 N03A N03AA ANTIEPILEPTICS ANTIÉPILEPTIQUES ANTIEPILEPTICS ANTIÉPILEPTIQUES BARBITURATES AND DERIVATIVES BARBITURIQUES ET DÉRIVÉS N03AA02 PHENOBARBITAL PHÉNOBARBITOL Elx Orl 5mg Phenobarbital 00645575 PMS AEFGVW Elx Tab Orl 15mg Phenobarbital 00178799 PDP AEFGVW Tab Orl 30mg Phenobarbital 00178802 PDP AEFGVW Tab Orl 60mg Phenobarbital 00178810 PDP AEFGVW Tab Orl 100mg Phenobarbital 00178829 PDP AEFGVW N03AA03 PRIMIDONE PRIMIDONE Tab Orl 125mg Primidone 00399310 AAP AEFGVW Tab Orl 150mg Primidone 00396761 AAP AEFGVW February 2014 / février 2014 Page 144

N03AB N03AB02 HYDANTOIN DERIVATIVES DÉRIVÉS DE L HYDANTOÏNE PHENYTOIN PHÉNYTOINE Sus Orl 6mg Dilantin 30 00023442 PFI AEFGVW Susp. Sus Orl 25mg Dilantin 125 00023450 PFI f AEFGVW Susp. Taro-Phenytoin 02250896 TAR f AEFGVW Tab Orl 50mg Dilantin infatabs 00023698 PFI AEFGVW Cap Orl 30mg Dilantin 00022772 PFI AEFGVW Caps Cap Orl 100mg Dilantin 00022780 PFI AEFGVW Caps N03AD N03AD01 Liq Orl 50mg Phenytoin Sodium 00780626 SDZ V Liq SUCCINIMIDE DERIVATIVES DÉRIVÉS DU SUCCINIMIDE ETHOSUXIMIDE ÉTHOSUXIMIDE Cap Orl 250mg Zarontin 00022799 ERF AEFGVW Caps Syr Orl 50mg Zarontin 00023485 ERF AEFGVW Sir. N03AD03 N03AE N03AE01 MESUXIMIDE MÉSUXIMIDE Cap Orl 300mg Celontin 00022802 ERF AEFGVW Caps BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZÉPINES CLONAZEPAM CLONAZÉPAM Tab Orl 0.5mg Rivotril 00382825 HLR f AEFGVW Apo-Clonazepam 02177889 APX f AEFGVW pms-clonazepam R 02207818 PMS f AEFGVW Mylan-Clonazepam 02230950 MYL f AEFGVW Sandoz Clonazepam 02233960 SDZ f AEFGVW Phl-Clonazepam 02236948 PHL f AEFGVW Teva-Clonazepam 02239024 TEV f AEFGVW Co Clonazepam 02270641 COB f AEFGVW Zym-Clonazepam 02345676 ZYM f AEFGVW February 2014 / février 2014 Page 145

N03AE01 N03AF N03AF01 CLONAZEPAM CLONAZÉPAM Tab Orl 1mg pms-clonazepam 02048728 PMS f AEFGVW Sandoz Clonazepam 02233982 SDZ f AEFGVW Phl-Clonazepam 02145235 PHL f AEFGVW Co Clonazepam (Disc/non disp Jan 11/15) 02270668 COB f AEFGVW Zym-Clonazepam 02303329 ZYM f AEFGVW Tab Orl 2mg Rivotril 00382841 HLR f AEFGVW Apo-Clonazepam 02177897 APX f AEFGVW pms-clonazepam 02048736 PMS f AEFGVW Mylan-Clonazepam 02230951 MYL f AEFGVW Sandoz Clonazepam 02233985 SDZ f AEFGVW Phl-Clonazepam 02145243 PHL f AEFGVW Teva-Clonazepam 02239025 TEV f AEFGVW Co Clonazepam 02270676 COB f AEFGVW Zym-Clonazepam 02303337 ZYM f AEFGVW CARBOXAMIDE DERIVATIVES DÉRIVÉS DU CARBOXAMIDE CARBAMAZEPINE CARBAMAZÉPINE SRT Orl 200mg Tegretol CR 00773611 NVR f AEFGVW L.L. pms-carbamazepine 02231543 PMS f AEFGVW Taro-Carbamazepine CR 02237907 TAR f AEFGVW Mylan-Carbamazepine 02241882 MYL f AEFGVW Sandoz-Carbamazepine CR 02261839 SDZ f AEFGVW SRT Orl 400mg Tegretol CR 00755583 NVR f AEFGVW L.L. pms-carbamazepine 02231544 PMS f AEFGVW Taro-Carbamazepine CR 02237908 TAR f AEFGVW Mylan-Carbamazepine 02241883 MYL f AEFGVW Sandoz-Carbamazepine CR 02261847 SDZ f AEFGVW Sus Orl 20mg Tegretol 02194333 NVR f AEFGVW Susp. Taro-Carbamazepine 02367394 TAR f AEFGVW Tab Orl 200mg Tegretol 00010405 NVR f AEFGVW Apo-Carbamazepine (Disc/non disp Apr 30/14) 00402699 APX f AEFGVW Teva-Carbamazepine 00782718 TEV f AEFGVW TabC Orl 100mg Tegretol Chew 00369810 NVR f AEFGVW C.. pms-carbamazepine 02231542 PMS f AEFGVW Sandoz-Carbamazepine Chewtabs 02261855 SDZ f AEFGVW TabC Orl 200mg Tegretol Chew 00665088 NVR f AEFGVW C.. pms-carbamazepine 02231540 PMS f AEFGVW Sandoz-Carbamazepine Chewtabs 02261863 SDZ f AEFGVW February 2014 / février 2014 Page 146

N03AG N03AG01 FATTY ACID DERIVATIVES DÉRIVÉS DES ACIDES GRAS VALPROIC ACID ACIDE VALPROIQUE ECT Orl 125mg Epival 00596418 ABB f AEFGVW Ent. Apo-Divalproex 02239698 APX f AEFGVW Novo-Divalproex 02239701 TEV f AEFGVW Divalproex 02400499 SAS f AEFGVW ECT Orl 250mg Epival 00596426 ABB f AEFGVW Ent. Apo-Divalproex 02239699 APX f AEFGVW Novo-Divalproex 02239702 TEV f AEFGVW Divalproex 02400502 SAS f AEFGVW ECT Orl 500mg Epival 00596434 ABB f AEFGVW Ent. Apo-Divalproex 02239700 APX f AEFGVW Novo-Divalproex 02239703 TEV f AEFGVW Divalproex 02400510 SAS f AEFGVW Cap Orl 250mg Depakene 00443840 ABB f AEFGVW Caps Novo-Valproic 02100630 TEV f AEFGVW Mylan-Valproic(Disc/non disp Jul 4/15) 02184648 MYL f AEFGVW pms-valproic Acid 02230768 PMS f AEFGVW Apo-Valproic 02238048 APX f AEFGVW Sandoz Valproic (Disc/non disp Nov 15/15) 02239714 SDZ f AEFGVW ECC Orl 500mg pms-valproic Acid 02229628 PMS f AEFGVW Caps.Ent.. N03AX N03AX09 Syr Orl 50mg Depakene 00443832 ABB f AEFGVW Sir. Ratio-Valproic (Disc/non disp Feb 22/15) 02140063 RPH f AEFGVW pms-valproic 02236807 PMS f AEFGVW Apo-Valproic Acid 02238370 APX f AEFGVW OTHER ANTIEPILEPTICS AUTRE ANTIÉPILEPTIQUES LAMOTRIGINE LAMOTRIGINE Tab Orl 25mg Lamictal 02142082 GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) 02243352 TEV f AEFGVW Apo-Lamotrigine 02245208 APX f AEFGVW pms-lamotrigine 02246897 PMS f AEFGVW Teva-Lamotrigine 02248232 TEV f AEFGVW Mylan-Lamotrigine 02265494 MYL f AEFGVW Lamotrigine 02343010 SAS f AEFGVW Auro-Lamotrigine 02381354 ARO f AEFGVW Tab Orl 100mg Lamictal 02142104 GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) 02243353 TEV f AEFGVW Apo-Lamotrigine 02245209 APX f AEFGVW pms-lamotrigine 02246898 PMS f AEFGVW February 2014 / février 2014 Page 147

N03AX09 LAMOTRIGINE LAMOTRIGINE Tab Orl 100mg Teva-Lamotrigine 02248233 TEV f AEFGVW Mylan-Lamotrigine 02265508 MYL f AEFGVW Lamotrigine 02343029 SAS f AEFGVW Auro-Lamotrigine 02381362 ARO f AEFGVW Tab Orl 150mg Lamictal 02142112 GSK f AEFGVW ratio-lamotrigine (Disc/non disp Feb 22/15) 02246963 TEV f AEFGVW Apo-Lamotrigine 02245210 APX f AEFGVW pms-lamotrigine 02246899 PMS f AEFGVW Teva-Lamotrigine 02248234 TEV f AEFGVW Mylan-Lamotrigine 02265516 MYL f AEFGVW Lamotrigine 02343037 SAS f AEFGVW Auro-Lamotrigine 02381370 ARO f AEFGVW TabC Orl 2mg Lamictal Chewtabs 02243803 GSK AEFGVW C N03AX12 TabC Orl 5mg Lamictal Chewtabs 02240115 GSK AEFGVW C GABAPENTIN GABAPENTINE Cap Orl 100mg Neurontin 02084260 PFI f AEFGVW Caps pms-gabapentin 02243446 PMS f AEFGVW Apo-Gabapentin 02244304 APX f AEFGVW Teva-Gabapentin 02244513 TEV f AEFGVW Gabapentin 02246314 SIV f AEFGVW Mylan-Gabapentin 02248259 MYL f AEFGVW Co-Gabapentin 02256142 COB f AEFGVW GD-Gabapentin 02285819 GMD f AEFGVW Ran-Gabapentin 02319055 RAN f AEFGVW Auro-Gabapentin 02321203 ARO f AEFGVW Gabapentin 02353245 SAS f AEFGVW Jamp-Gabapentin 02361469 JPC f AEFGVW Mar-Gabapentin 02391473 MAR f AEFGVW Cap Orl 300mg Neurontin 02084279 PFI f AEFGVW Caps pms-gabapentin 02243447 PMS f AEFGVW Apo-Gabapentin 02244305 APX f AEFGVW Teva-Gabapentin 02244514 TEV f AEFGVW Gabapentin 02246315 SIV f AEFGVW Mylan-Gabapentin 02248260 MYL f AEFGVW Co-Gabapentin 02256150 COB f AEFGVW GD-Gabapentin 02285827 GMD f AEFGVW Ran-Gabapentin 02319063 RAN f AEFGVW Auro-Gabapentin 02321211 ARO f AEFGVW Gabapentin 02353253 SAS f AEFGVW Jamp-Gabapentin 02361485 JPC f AEFGVW Mar-Gabapentin 02391481 MAR f AEFGVW February 2014 / février 2014 Page 148

N03AX12 GABAPENTIN GABAPENTINE Cap Orl 400mg Neurontin 02084287 PFI f AEFGVW Caps pms-gabapentin 02243448 PMS f AEFGVW Apo-Gabapentin 02244306 APX f AEFGVW Teva-Gabapentin 02244515 TEV f AEFGVW Gabapentin 02246316 SIV f AEFGVW Mylan-Gabapentin 02248261 MYL f AEFGVW Co-Gabapentin 02256169 COB f AEFGVW ratio-gabapentin 02260905 RPH f AEFGVW GD-Gabapentin 02285835 GMD f AEFGVW Ran-Gabapentin 02319071 RAN f AEFGVW Auro-Gabapentin 02321238 ARO f AEFGVW Gabapentin 02353261 SAS f AEFGVW Jamp-Gabapentin 02361493 JPC f AEFGVW Mar-Gabapentin 02391503 MAR f AEFGVW Tab Orl 600mg Neurontin 02239717 PFI f AEFGVW pms-gabapentin 02255898 PMS f AEFGVW Apo-Gabapentin 02293358 APX f AEFGVW Teva-Gabapentin 02248457 TEV f AEFGVW GD-Gabapentin 02285843 GMD f AEFGVW Gabapentin 02392526 AHI f AEFGVW Mylan-Gabapentin 02397471 MYL f AEFGVW Jamp-Gabapentin 02402289 JPC F AEFGVW Tab Orl 800mg Neurontin 02239718 PFI f AEFGVW pms-gabapentin 02255901 PMS f AEFGVW Apo-Gabapentin 02293366 APX f AEFGVW Teva-Gabapentin 02247346 TEV f AEFGVW GD-Gabapentin 02285851 GMD f AEFGVW Gabapentin 02392534 AHI f AEFGVW Mylan-Gabapentin 02397498 MYL f AEFGVW Jamp-Gabapentin 02402297 JPC f AEFGVW N03AX16 PREGABALIN PREGABALIN Cap Orl 25mg Lyrica 02268418 PFI f W Caps Co-Pregabalin 02402912 COB f W pms-pregabalin 02359596 PMS f W Ran-Pregabalin 02392801 RAN f W Sandoz Pregabalin 02390817 SDZ f W Teva-Pregabalin 02361159 TEV f W Apo-Pregabalin 02394235 APX f W GD-Pregabalin 02360136 GMD f W Pregabalin 02405539 SAS f W Cap Orl 50mg Lyrica 02268426 PFI f W Caps Co-Pregabalin 02402920 COB f W pms-pregabalin 02359618 PMS f W Ran-Pregabalin 02392828 RAN f W Sandoz Pregabalin 02390825 SDZ f W Teva-Pregabalin 02361175 TEV f W Apo-Pregabalin 02394243 APX f W GD-Pregabalin 02360144 GMD f W Pregabalin 02405547 SAS f W February 2014 / février 2014 Page 149

N03AX16 PREGABALIN PREGABALIN Cap Orl 75mg Lyrica 02268434 PFI f W Caps Co-Pregabalin 02402939 COB f W pms-pregabalin 02359626 PMS f W Ran-Pregabalin 02392836 RAN f W Sandoz Pregabalin 02390833 SDZ f W Teva-Pregabalin 02361183 TEV f W Apo-Pregabalin 02394251 APX f W GD-Pregabalin 02360152 GMD f W Pregabalin 02405555 SAS f W Cap Orl 150mg Lyrica 02268450 PFI f W Caps Co-Pregabalin 02402955 COB f W pms-pregabalin 02359634 PMS f W Ran-Pregabalin 02392844 RAN f W Sandoz Pregabalin 02390841 SDZ f W Teva-Pregabalin 02361205 TEV f W Apo-Pregabalin 02394278 APX f W GD-Pregabalin 02360179 GMD f W Pregabalin 02405563 SAS f W Cap Orl 225mg Lyrica 02268477 PFI f W Caps Co-Pregabalin 02402971 COB f W Teva-Pregabalin 02361221 TEV f W pms-pregabalin 02398079 PMS f W Ran-Pregabalin 02392852 RAN f W Apo-Pregabalin 02394286 APX f W GD-Pregabalin 02360195 GMD f W Cap Orl 300mg Lyrica 02268485 PFI f W Caps Co-Pregabalin 02402998 COB f W pms-pregabalin 02359642 PMS f W Sandoz Pregabalin 02390868 SDZ f W Ran-Pregabalin 02392860 RAN f W Teva-Pregabalin 02361248 TEV f W Apo-Pregabalin 02394294 APX f W GD-Pregabalin 02360209 GMD f W Pregabalin 02405598 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 00545058 AAP f AEFGVW Tab Orl 5mg Trihex 00545074 AAP f AEFGVW February 2014 / février 2014 Page 150

N04AA04 N04AA05 N04AC N04AC01 PROCYCLIDINE PROCYCLIDINE Elx Orl 0.5mg pms-procyclidine 00587362 PMS AEFGVW Elx. Tab Orl 2.5mg pms-procyclidine 00649392 PMS AEFGVW Tab Orl 5mg pms-procyclidine 00587354 PMS AEFGVW PROFENAMINE (ETHOPROPAZINE) PROFÉNAMINE (ÉTHOPROPAZINE) Tab Orl 50mg Parsitan 01927744 ERF AEFGVW ETHERS OF TROPINE OR TROPINE DERIVATIVES ÉTHERS DE TROPINE OU DÉRIVÉS DU TROPINE BENZYTROPINE BENZYTROPINE Liq Inj 1mg Benztropine Omega 02238903 OMG VW Liq Tab Orl 1mg pms-benztropine 00706531 PMS AEFGVW N04B N04BA N04BA02 Tab Orl 2mg Benztropine 00426857 PMS f AEFGVW pms-benztropine (Disc/non disp Sep 24/14) 00587265 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 00522597 HLR AEFGVW Caps Cap Orl 100mg/25mg Prolopa 00386464 HLR AEFGVW Caps Cap Orl 200mg/50mg Prolopa 00386472 HLR AEFGVW Caps LEVODOPA / CARBIDOPA LÉVODOPA / CARBIDOPA SRT Orl 100mg/25mg Sinemet CR 02028786 FRS f AEFVW L.L. Levocarb CR 02272873 AAP f AEFVW SRT Orl 200mg/50mg Sinemet CR 00870935 FRS f AEFVW L.L. Levocarb CR 02245211 AAP f AEFVW February 2014 / février 2014 Page 151

N04BA02 LEVODOPA AND DECARBOXYLASE INHIBITOR LÉVODOPA ET INHIBITEUR DU DÉCARBOXYLASE LEVODOPA / CARBIDOPA LÉVODOPA / CARBIDOPA Tab Orl 100mg/10mg Sinemet 00355658 FRS f AEFGVW Apo-Levocarb 02195933 APX f AEFGVW Teva-Levocarbidopa 02244494 TEV f AEFGVW Tab Orl 100mg/25mg Sinemet 00513997 FRS f AEFGVW Apo-Levocarb 02195941 APX f AEFGVW Teva-Levocarbidopa 02244495 TEV f AEFGVW N04BB N04BB01 Tab Orl 250mg/25mg Sinemet 00328219 FRS f AEFGVW Apo-Levocarb 02195968 APX f AEFGVW Teva-Levocarbidopa 02244496 TEV f AEFGVW ADAMANTINE DERIVATIVES DÉRIVÉS DE L ADAMANTINE AMANTADINE AMANTADINE Cap Orl 100mg pms-amantadine Hydrochloride 01990403 PMS f AEFGVW Caps Mylan-Amantadine (Disc/non disp Jul 4/15) 02139200 MYL f AEFGVW N04BC N04BC04 Syr Orl 10mg pms-amantadine 02022826 PMS f AEFGVW Sir. DOPAMINE AGONISTS AGONISTES DE LA DOPAMINE ROPINIROLE ROPINIROLE Tab Orl 0.25mg Requip 02232565 GSK f AEFVW Ran-Ropinirole 02314037 RAN f AEFVW Co Ropinirole 02316846 COB f AEFVW pms-ropinirole 02326590 PMS f AEFVW Jamp-Ropinirole 02352338 JPC f AEFVW Ropinirole 02353040 SAS f AEFVW Tab Orl 1mg Requip 02232567 GSK f AEFVW Ran-Ropinirole 02314053 RAN f AEFVW Co Ropinirole 02316854 COB f AEFVW pms-ropinirole 02326612 PMS f AEFVW Jamp-Ropinirole 02352346 JPC f AEFVW Ropinirole 02353059 SAS f AEFVW Tab Orl 2mg Requip 02232568 GSK f AEFVW Ran-Ropinirole 02314061 RAN f AEFVW Co Ropinirole 02316862 COB f AEFVW pms-ropinirole 02326620 PMS f AEFVW Jamp-Ropinirole 02352354 JPC f AEFVW Ropinirole 02353067 SAS f AEFVW February 2014 / février 2014 Page 152

N04BC04 N04BC05 ROPINIROLE ROPINIROLE Tab Orl 5mg Requip 02232569 GSK f AEFVW Ran-Ropinirole 02314088 RAN f AEFVW Co Ropinirole 02316870 COB f AEFVW pms-ropinirole 02326639 PMS f AEFVW Jamp-Ropinirole 02352362 JPC f AEFVW Ropinirole 02353075 SAS f AEFVW PRAMIPEXOLE PRAMIPEXOLE Tab Orl 0.25mg Mirapex 02237145 BOE f AEFVW Teva-Pramipexole 02269309 TEV f AEFVW pms-pramipexole 02290111 PMS f AEFVW Apo-Pramipexole 02292378 APX f AEFVW Co Pramipexole 02297302 COB f AEFVW Sandoz Pramipexole 02315262 SDZ f AEFVW Mylan-Pramipexole 02376350 MYL f AEFVW Tab Orl 0.5mg Mirapex 02241594 BOE f AEFVW Teva-Pramipexole 02269317 TEV f AEFVW pms-pramipexole 02290138 PMS f AEFVW Apo-Pramipexole 02292386 APX f AEFVW Co Pramipexole 02297310 COB f AEFVW Sandoz Pramipexole 02315270 SDZ f AEFVW Mylan-Pramipexole 02376369 MYL f AEFVW Tab Orl 1mg Mirapex 02237146 BOE f AEFVW Teva-Pramipexole 02269325 TEV f AEFVW pms-pramipexole 02290146 PMS f AEFVW Apo-Pramipexole 02292394 APX f AEFVW Co Pramipexole 02297329 COB f AEFVW Sandoz Pramipexole 02315289 SDZ f AEFVW Mylan-Pramipexole 02376377 MYL f AEFVW N04BD N04BD01 Tab Orl 1.5mg Mirapex 02237147 BOE f AEFVW Teva-Pramipexole 02269333 TEV f AEFVW pms-pramipexole 02290154 PMS f AEFVW Apo-Pramipexole 02292408 APX f AEFVW Co Pramipexole 02297337 COB f AEFVW Sandoz Pramipexole 02315297 SDZ f AEFVW Mylan-Pramipexole 02376385 MYL f AEFVW MONOAMINE OXIDASE TYPE B INHIBITORS OXIDASE DE MONOAMINE, INHIBITEURS DE TYPE B SELEGILINE SÉLÉGILINE Tab Orl 5mg Novo-Selegiline 02068087 TEV f AEFVW Apo-Selegiline 02230641 APX f AEFVW Mylan-Selegiline 02231036 MYL f AEFVW February 2014 / février 2014 Page 153

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 00232823 TEV AEFGVW Tab Orl 50mg Teva-Chlorpromazine 00232807 TEV AEFGVW N05AA02 Tab Orl 100mg Teva-Chlorpromazine 00232831 TEV AEFGVW LEVOMEPROMAZINE (METHOTRIMEPRAZINE) LÉVOMÉPROMAZINE (MÉTHOTRIMÉPRAZINE) Liq Inj 25mg Nozinan 01927698 SAV AEFVW Liq Tab Orl 2mg Methoprazine 02238403 AAP f AEFGVW Tab Orl 5mg Methoprazine 02238404 AAP f AEFGVW Tab Orl 25mg Methoprazine 02238405 AAP f AEFGVW N05AB N05AB02 Tab Orl 50mg Methoprazine 02238406 AAP f AEFGVW PHENOTHIAZINE WITH PIPERAZINE STRUCTURE PHÉNOTHIAZINE À STRUCTURE DE PIPÉRAZINE FLUPHENAZINE FLUPHÉNAZINE Liq Inj 25mg Fluphenazine (Disc/non disp Nov 20/14) * 02239636 OMG AEFGVW Liq Liq Inj 100mg Modecate conc * 00755575 BRI f AEFGVW Liq Fluphenazine (Disc/non disp Nov 20/14) * 02242570 OMG AEFGVW Tab Orl 1mg Fluphenazine 00405345 AAP AEFGVW February 2014 / février 2014 Page 154

N05AB02 FLUPHENAZINE FLUPHÉNAZINE Tab Orl 2mg Fluphenazine 00410632 AAP AEFGVW Tab Orl 5mg Fluphenazine 00405361 AAP AEFGVW N05AB03 PERPHENAZINE PERPHÉNAZINE Tab Orl 2mg Perphenazine 00335134 AAP f AEFGVW Tab Orl 4mg Perphenazine 00335126 AAP f AEFGVW Tab Orl 8mg Perphenazine 00335118 AAP f AEFGVW N05AB04 Tab Orl 16mg Perphenazine 00335096 AAP f AEFGVW PROCHLORPERAZINE PROCHLORPÉRAZINE Sup Rt 10mg pms-prochlorperazine 00753688 PMS AEFGVW Supp Tab Orl 5mg Prochlorazine 00886440 AAP AEFGVW pms-prochlorperazine (Disc/non disp Feb 7/14) 00753661 PMS AEFGVW Tab Orl 10mg Prochlorazine 00886432 AAP AEFGVW pms-prochlorperazine (Disc/non disp Feb 7/14) 00753637 PMS AEFGVW N05AB06 TRIFLUOPERAZINE TRIFLUOPÉRAZINE Tab Orl 1mg Trifluoperazine 00345539 AAP f AEFGVW Tab Orl 2mg Trifluoperazine 00312754 AAP f AEFGVW Tab Orl 5mg Trifluoperazine 00312746 AAP f AEFGVW Tab Orl 10mg Trifluoperazine 00326836 AAP f AEFGVW N05AC PHENOTHIAZINE WITH PIPERIDINE STRUCTURE PHÉNOTHIAZINES À STRUCTURE DE PIPÉRIDINE N05AC01 PERICYAZINE PÉRICYAZINE Cap Orl 5mg Neuleptil 01926780 ERF AEFGVW Caps February 2014 / février 2014 Page 155

N05AC01 PERICYAZINE PÉRICYAZINE Cap Orl 10mg Neuleptil 01926772 ERF AEFGVW Caps Cap Orl 20mg Neuleptil 01926764 ERF AEFGVW Caps Dps Orl 10mg Neuleptil 01926756 ERF AEFGVW Gttes N05AC04 N05AD N05AD01 PIPOTIAZINE PIPOTIAZINE Liq Inj 25mg Piportil L4 * 01926667 SAV AEFGVW Liq Liq Inj 50mg Piportil L4 * 01926675 SAV AEFGVW Liq BUTYROPHENONE DERIVATIVES DÉRIVÉS DU BUTYROPHÉNONE HALOPERIDOL HALOPÉRIDOL Liq Inj 5mg Haloperidol * 00808652 SDZ AEFGVW Liq Tab Orl 0.5mg Novo-Peridol 00363685 TEV f AEFGVW Apo-Haloperidol (Disc/non disp Dec 09/15) 00396796 APX f AEFGVW Tab Orl 1mg Novo-Peridol 00363677 TEV f AEFGVW Apo-Haloperidol 00396818 APX f AEFGVW Tab Orl 2mg Novo-Peridol 00363669 TEV f AEFGVW Apo-Haloperidol (Disc/non disp Apr 10/15) 00396826 APX f AEFGVW Tab Orl 5mg Novo-Peridol 00363650 TEV f AEFGVW Apo-Haloperidol (Disc/non disp Apr 10/15) 00396834 APX f AEFGVW Tab Orl 10mg Novo-Peridol 00713449 TEV f AEFGVW Apo-Haloperidol 00463698 APX f AEFGVW Liq Inj 50mg Haloperidol LA * 02130297 SDZ f AEFGVW Liq Haloperidol (Disc/non disp Nov 20/14)* 02239639 OMG AEFGVW Liq Inj 100mg Haloperidol LA * 02130300 SDZ f AEFGVW Liq Haloperidol (Disc/non disp Nov 20/14) * 02239640 OMG AEFGVW February 2014 / février 2014 Page 156

N05AE N05AE04 INDOLE DERIVATIVES DÉRIVÉS DE L INDOLE ZIPRASIDONE ZIPRASIDONE Cap Orl 20mg Zeldox 02298597 PFI AEFGVW Caps Cap Orl 40mg Zeldox 02298600 PFI AEFGVW Caps N05AF N05AF01 Cap Orl 60mg Zeldox 02298619 PFI AEFGVW Caps Cap Orl 80mg Zeldox 02298627 PFI AEFGVW Caps THIOXANTHENE DERIVATIVES DÉRIVÉS DU THIOXANTHÉNE FLUPENTHIXOL FLUPENTHIXOL Tab Orl 0.5mg Fluanxol 02156008 VLH AEFGVW Tab Orl 3mg Fluanxol 02156016 VLH AEFGVW Liq Inj 20mg Fluanxol Depot* 02156032 VLH AEFGVW Liq Liq Inj 100mg Fluanxol Depot* 02156040 VLH f AEFGVW Liq N05AF04 THIOTHIXENE THIOTHIXÉNE Cap Orl 2mg Navane 00024430 ERF AEFGVW Caps Cap Orl 5mg Navane 00024449 ERF AEFGVW Caps N05AG N05AG02 Cap Orl 10mg Navane 00024457 ERF AEFGVW Caps DIPHENYLBUTYLPIPERIDINE DERIVATIVES DÉRIVÉS DE LA DIPHÉNYLBUTYLPIPÉRIDINE PIMOZIDE PIMOZIDE Tab Orl 2mg Orap 00313815 PDP f AEFGVW Apo-Pimozide 02245432 APX f AEFGVW Tab Orl 4mg Orap 00313823 PDP f AEFGVW Apo-Pimozide 02245433 APX f AEFGVW February 2014 / février 2014 Page 157

N05AH N05AH01 DIAZEPINES, OXAZEPINES, THIAZEPINES AND OXEPINES DIAZÉPINES, OXAZÉPINES, THIAZÉPINES ET OXÉPINNES LOXAPINE LOXAPINE Tab Orl 2.5mg Xylac 02242868 PDP AEFGVW Tab Orl 5mg Xylac 02230837 PDP f AEFGVW Tab Orl 10mg Xylac 02230838 PDP f AEFGVW Tab Orl 25mg Xylac 02230839 PDP f AEFGVW N05AH02 Tab Orl 50mg Xylac 02230840 PDP f AEFGVW CLOZAPINE CLOZAPINE Tab Orl 25mg Clozaril 20 00894737 NVR f AEFGV Gen-Clozapine 20 02247243 MYL f AEFGV Apo-Clozapine 20 02248034 APX f AEFGV Tab Orl 100mg Clozaril 20 00894745 NVR f AEFGV Gen-Clozapine 20 02247244 MYL f AEFGV Apo-Clozapine 20 02248035 APX f AEFGV N05AH03 OLANZAPINE OLANZAPINE ODT Orl 5mg Zyprexa Zydis 21 02243086 LIL f AEFGV D.O. Zyprexa Zydis 02243086 LIL f W pms-olanzapine ODT 21 02303191 PMS f AEFGV pms-olanzapine ODT 02303191 PMS f W Teva-Olanzapine ODT 21 02321343 TEV f AEFGV Teva-Olanzapine ODT 02321343 TEV f W Co Olanzapine ODT 21 02327562 COB f AEFGV Co Olanzapine ODT 02327562 COB f W Sandoz Olanzapine ODT 21 02327775 SDZ f AEFGV Sandoz Olanzapine ODT 02327775 SDZ f W Olanzapine ODT 21 02352974 SAS f AEFGV Olanzapine ODT 02352974 SAS f W Apo-Olanzapine ODT 21 02360616 APX f AEFGV Apo-Olanzapine ODT 02360616 APX f W Mylan-Olanzapine ODT 21 02382709 MYL f AEFGV Mylan-Olanzapine ODT 02382709 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

N05AH03 OLANZAPINE OLANZAPINE ODT Orl 5mg Mar-Olanzapine ODT 21 02389088 MAR f AEFGV D.O. Mar-Olanzapine ODT 02389088 MAR f W ODT Orl 10mg Zyprexa Zydis 21 02243087 LIL f AEFGV D.O. Zyprexa Zydis 02243087 LIL f W pms-olanzapine ODT 21 02303205 PMS f AEFGV pms-olanzapine ODT 02303205 PMS f W Teva-Olanzapine ODT 21 02321351 TEV f AEFGV Teva-Olanzapine ODT 02321351 TEV f W Co Olanzapine ODT 21 02327570 COB f AEFGV Co Olanzapine ODT 02327570 COB f W Sandoz Olanzapine ODT 21 02327783 SDZ f AEFGV Sandoz Olanzapine ODT 02327783 SDZ f W Olanzapine ODT 21 02352982 SAS f AEFGV Olanzapine ODT 02352982 SAS f W Apo-Olanzapine ODT 21 02360624 APX f AEFGV Apo-Olanzapine ODT 02360624 APX f W Mylan-Olanzapine ODT 21 02382717 MYL f AEFGV Mylan-Olanzapine ODT 02382717 MYL f W Mar-Olanzapine ODT 21 02389096 MAR f AEFGV Mar-Olanzapine ODT 02389096 MAR f W ODT Orl 15mg Zyprexa Zydis 21 02243088 LIL f AEFGV D.O. Zyprexa Zydis 02243088 LIL f W pms-olanzapine ODT 21 02303213 PMS f AEFGV pms-olanzapine ODT 02303213 PMS f W Teva-Olanzapine ODT 21 02321378 TEV f AEFGV Teva-Olanzapine ODT 02321378 TEV f W Co Olanzapine ODT 21 02327589 COB f AEFGV Co Olanzapine ODT 02327589 COB f W Sandoz Olanzapine ODT 21 02327791 SDZ f AEFGV Sandoz Olanzapine ODT 02327791 SDZ f W Olanzapine ODT 21 02352990 SAS f AEFGV Olanzapine ODT 02352990 SAS f W Apo-Olanzapine ODT 21 02360632 APX f AEFGV Apo-Olanzapine ODT 02360632 APX f W Mylan-Olanzapine ODT 21 02382725 MYL f AEFGV Mylan-Olanzapine ODT 02382725 MYL f W Mar-Olanzapine ODT 21 02389118 MAR f AEFGV Mar-Olanzapine ODT 02389118 MAR f W ODT Orl 20mg Zyprexa Zydis 21 02243089 LIL f AEFGV D.O. Zyprexa Zydis 02243089 LIL f W Teva-Olanzapine ODT 21 02321386 TEV f AEFGV Teva-Olanzapine ODT 02321386 TEV f W Co Olanzapine ODT 21 02327597 COB f AEFGV Co Olanzapine ODT 02327597 COB f W Sandoz Olanzapine ODT 21 02327805 SDZ f AEFGV Sandoz Olanzapine ODT 02327805 SDZ f W Apo-Olanzapine ODT 21 02360640 APX f AEFGV Apo-Olanzapine ODT 02360640 APX f W Mylan-Olanzapine ODT 21 02382733 MYL f AEFGV February 2014 / février 2014 Page 159

N05AH03 OLANZAPINE OLANZAPINE ODT Orl 20mg Mylan-Olanzapine ODT 02382733 MYL f W D.O. Mar-Olanzapine ODT 21 02389126 MAR f AEFGV Mar-Olanzapine ODT 02389126 MAR f W Tab Orl 2.5mg Zyprexa 21 02229250 LIL f AEFGV Zyprexa 02229250 LIL f W Teva-Olanzapine 21 02276712 TEV f AEFGV Teva-Olanzapine 02276712 TEV f W Apo-Olanzapine 21 02281791 APX f AEFGV Apo-Olanzapine 02281791 APX f W pms-olanzapine 21 02303116 PMS f AEFGV pms-olanzapine 02303116 PMS f W Sandoz Olanzapine 21 02310341 SDZ f AEFGV Sandoz Olanzapine 02310341 SDZ f W Co Olanzapine 21 02325659 COB f AEFGV Co Olanzapine 02325659 COB f W Mylan-Olanzapine 21 02337878 MYL f AEFGV Mylan-Olanzapine 02337878 MYL f W Olanzapine 21 02372819 SAS f AEFGV Olanzapine 02372819 SAS f W Ran-Olanzapine 21 02403064 RAN f AEFGV Ran-Olanzapine 02403064 RAN f W Tab Orl 5mg Zyprexa 21 02229269 LIL f AEFGV Zyprexa 02229269 LIL f W Teva-Olanzapine 21 02276720 TEV f AEFGV Teva-Olanzapine 02276720 TEV f W Apo-Olanzapine 21 02281805 APX f AEFGV Apo-Olanzapine 02281805 APX f W pms-olanzapine 21 02303159 PMS f AEFGV pms-olanzapine 02303159 PMS f W Sandoz Olanzapine 21 02310368 SDZ f AEFGV Sandoz Olanzapine 02310368 SDZ f W Co Olanzapine 21 02325667 COB f AEFGV Co Olanzapine 02325667 COB f W Mylan-Olanzapine 21 02337886 MYL f AEFGV Mylan-Olanzapine 02337886 MYL f W Olanzapine 21 02372827 SAS f AEFGV Olanzapine 02372827 SAS f W Ran-Olanzapine 21 02403072 RAN f AEFGV Ran-Olanzapine 02403072 RAN f W Tab Orl 7.5mg Zyprexa 21 02229277 LIL f AEFGV Zyprexa 02229277 LIL f W Teva-Olanzapine 21 02276739 TEV f AEFGV Teva-Olanzapine 02276739 TEV f W Apo-Olanzapine 21 02281813 APX f AEFGV Apo-Olanzapine 02281813 APX f W pms-olanzapine 21 02303167 PMS f AEFGV pms-olanzapine 02303167 PMS f W Sandoz Olanzapine 21 02310376 SDZ f AEFGV Sandoz Olanzapine 02310376 SDZ f W February 2014 / février 2014 Page 160

N05AH03 OLANZAPINE OLANZAPINE Tab Orl 7.5mg Co Olanzapine 21 02325675 COB f AEFGV Co Olanzapine 02325675 COB f W Mylan-Olanzapine 21 02337894 MYL f AEFGV Mylan-Olanzapine 02337894 MYL f W Olanzapine 21 02372835 SAS f AEFGV Olanzapine 02372835 SAS f W Ran-Olanzapine 21 02403080 RAN f AEFGV Ran-Olanzapine 02403080 RAN f W Tab Orl 10mg Zyprexa 21 02229285 LIL f AEFGV Zyprexa 02229285 LIL f W Teva-Olanzapine 21 02276747 TEV f AEFGV Teva-Olanzapine 02276747 TEV f W Apo-Olanzapine 21 02281821 APX f AEFGV Apo-Olanzapine 02281821 APX f W pms-olanzapine 21 02303175 PMS f AEFGV pms-olanzapine 02303175 PMS f W Sandoz Olanzapine 21 02310384 SDZ f AEFGV Sandoz Olanzapine 02310384 SDZ f W Co Olanzapine 21 02325683 COB f AEFGV Co Olanzapine 02325683 COB f W Mylan-Olanzapine 21 02337908 MYL f AEFGV Mylan-Olanzapine 02337908 MYL f W Olanzapine 21 02372843 SAS f AEFGV Olanzapine 02372843 SAS f W Ran-Olanzapine 21 02403099 RAN f AEFGV Ran-Olanzapine 02403099 RAN f W Tab Orl 15mg Zyprexa 21 02238850 LIL f AEFGV Zyprexa 02238850 LIL f W Teva-Olanzapine 21 02276755 TEV f AEFGV Teva-Olanzapine 02276755 TEV f W Apo-Olanzapine 21 02281848 APX f AEFGV Apo-Olanzapine 02281848 APX f W pms-olanzapine 21 02303183 PMS f AEFGV pms-olanzapine 02303183 PMS f W Sandoz Olanzapine 21 02310392 SDZ f AEFGV Sandoz Olanzapine 02310392 SDZ f W Co Olanzapine 21 02325691 COB f AEFGV Co Olanzapine 02325691 COB f W Mylan-Olanzapine 21 02337916 MYL f AEFGV Mylan-Olanzapine 02337916 MYL f W Ran-Olanzapine 21 02403102 RAN f AEFGV Ran-Olanzapine 02403102 RAN f W February 2014 / février 2014 Page 161

N05AH03 N05AH04 OLANZAPINE OLANZAPINE Tab Orl 15mg Olanzapine 21 02372851 SAS f AEFGV Olanzapine 02372851 SAS f W QUETIAPINE QUÉTIAPINE ERT Orl 50mg Seroquel XR 02300184 AZE f AEFGVW L.P. Teva-Quetiapine XR 02395444 TEV f AEFGVW Sandoz Quetiapine XR 02407671 SDZ f AEFGVW ERT Orl 150mg Seroquel XR 02321513 AZE f AEFGVW L.P. Teva-Quetiapine XR 02395452 TEV f AEFGVW Sandoz Quetiapine XR 02407698 SDZ f AEFGVW ERT Orl 200mg Seroquel XR 02300192 AZE f AEFGVW L.P. Teva-Quetiapine XR 02395460 TEV f AEFGVW Sandoz Quetiapine XR 02407701 SDZ f AEFGVW ERT Orl 300mg Seroquel XR 02300206 AZE f AEFGVW L.P. Teva-Quetiapine XR 02395479 TEV f AEFGVW Sandoz Quetiapine XR 02407728 SDZ f AEFGVW ERT Orl 400mg Seroquel XR 02300214 AZE f AEFGVW L.P. Teva-Quetiapine XR 02395487 TEV f AEFGVW Sandoz Quetiapine XR 02407736 SDZ f AEFGVW Tab Orl 25mg Seroquel 02236951 AZE f AEFGVW Teva-Quetiapine 02284235 TEV f AEFGVW pms-quetiapine 02296551 PMS f AEFGVW Phl-Quetiapine 02299054 PHL f AEFGVW Mylan-Quetiapine 02307804 MYL f AEFGVW Apo-Quetiapine 02313901 APX f AEFGVW Sandoz Quetiapine 02313995 SDZ f AEFGVW Co Quetiapine 02316080 COB f AEFGVW Jamp-Quetiapine 02330415 JPC f AEFGVW Quetiapine 02353164 SAS f AEFGVW Auro-Quetiapine 02390205 ARO f AEFGVW Quetiapine 02387794 AHI f AEFGVW Ran-Quetiapine 02397099 RAN f AEFGVW Mar-Quetiapine 02399822 MAR f AEFGVW Tab Orl 100mg Seroquel 02236952 AZE f AEFGVW Teva-Quetiapine 02284243 TEV f AEFGVW pms-quetiapine 02296578 PMS f AEFGVW Phl-Quetiapine 02299062 PHL f AEFGVW Mylan-Quetiapine 02307812 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

N05AH04 QUETIAPINE QUÉTIAPINE Tab Orl 100mg Apo-Quetiapine 02313928 APX f AEFGVW Sandoz Quetiapine 02314002 SDZ f AEFGVW Co Quetiapine 02316099 COB f AEFGVW Jamp-Quetiapine 02330423 JPC f AEFGVW Quetiapine 02353172 SAS f AEFGVW Auro-Quetiapine 02390213 ARO f AEFGVW Quetiapine 02387808 AHI f AEFGVW Ran-Quetiapine 02397102 RAN f AEFGVW Mar-Quetiapine 02399830 MAR f AEFGVW Tab Orl 150mg Teva-Quetiapine 02284251 TEV f AEFGVW N05AN N05AN01 Tab Orl 200mg Seroquel 02236953 AZE f AEFGVW Teva-Quetiapine 02284278 TEV f AEFGVW pms-quetiapine 02296594 PMS f AEFGVW Phl-Quetiapine 02299089 PHL f AEFGVW Mylan-Quetiapine 02307839 MYL f AEFGVW Apo-Quetiapine 02313936 APX f AEFGVW Sandoz Quetiapine 02314010 SDZ f AEFGVW Co Quetiapine 02316110 COB f AEFGVW Jamp-Quetiapine 02330458 JPC f AEFGVW Quetiapine 02353199 SAS f AEFGVW Auro-Quetiapine 02390248 ARO f AEFGVW Quetiapine 02387824 AHI f AEFGVW Ran-Quetiapine 02397110 RAN f AEFGVW Mar-Quetiapine 02399849 MAR f AEFGVW Tab Orl 300mg Seroquel 02244107 AZE f AEFGVW Teva-Quetiapine 02284286 TEV f AEFGVW pms-quetiapine 02296608 PMS f AEFGVW Phl-Quetiapine 02299097 PHL f AEFGVW Mylan-Quetiapine 02307847 MYL f AEFGVW Apo-Quetiapine 02313944 APX f AEFGVW Sandoz Quetiapine 02314029 SDZ f AEFGVW Co Quetiapine 02316129 COB f AEFGVW Jamp-Quetiapine 02330466 JPC f AEFGVW Quetiapine 02353202 SAS f AEFGVW Auro-Quetiapine 02390256 ARO f AEFGVW Quetiapine 02387832 AHI f AEFGVW Ran-Quetiapine 02397129 RAN f AEFGVW Mar-Quetiapine 02399857 MAR f AEFGVW LITHIUM LITHIUM LITHIUM LITHIUM Cap Orl 150mg Lithane 02013231 ERF f AEFGVW Caps Apo-Lithium Carbonate 02242837 APX f AEFGVW Carbolith 00461733 VLN f AEFGVW pms-lithium Carbonate 02216132 PMS f AEFGVW February 2014 / février 2014 Page 163

N05AN01 LITHIUM LITHIUM Cap Orl 300mg Lithane 00406775 ERF f AEFGVW Caps Apo-Lithium Carbonate 02242838 APX f AEFGVW Carbolith 00236683 VLN f AEFGVW pms-lithium Carbonate 02216140 PMS f AEFGVW Cap Orl 600mg Carbolith 02011239 VLN AEFGVW Caps SRT Orl 300mg Lithmax SR 02266695 AAP f AEFGVW L.L. N05AX N05AX08 Liq Orl 8mmol/5mL pms-lithium Citrate 02074834 PMS AEFGVW Liq OTHER ANTIPSYCHOTICS AUTRES ANTIPSYCHOTIQUES RISPERIDONE RISPÉRIDONE Liq Orl 1mg Risperdal 02236950 JAN f AEFGVW Liq pms-risperidone 02279266 PMS f AEFGVW Apo-Risperidone 02280396 APX f AEFGVW ODT Orl 0.5mg Risperdal M 02247704 JAN W D.O. Risperdal M 22 02247704 JAN AEFGV ODT Orl 1mg Risperdal M 02247705 JAN f W D.O. Risperdal M 22 02247705 JAN f AEFGV pms-risperidone ODT 02291789 PMS f W pms-risperidone ODT 22 02291789 PMS f AEFGV ODT Orl 2mg Risperdal M 02247706 JAN f W D.O. Risperdal M 22 02247706 JAN f AEFGV pms-risperidone ODT 02291797 PMS f W pms-risperidone ODT 22 02291797 PMS f AEFGV ODT Orl 3mg Risperdal M 02268086 JAN f W D.O. Risperdal M 22 02268086 JAN f AEFGV pms-risperidone ODT 02370697 PMS f W pms-risperidone ODT 22 02370697 PMS f AEFGV ODT Orl 4mg Risperdal M 02268094 JAN f W D.O. Risperdal M 22 02268094 JAN f AEFGV pms-risperidone ODT 02370700 PMS f W pms-risperidone ODT 22 02370700 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

N05AX08 RISPERIDONE RISPÉRIDONE Tab Orl 0.25mg Risperdal 02240551 JAN f AEFGVW pms-risperidone 02252007 PMS f AEFGVW Phl-Risperidone 02258439 PHL f AEFGVW ratio-risperidone(disc/non disp Jul 2/15) 02264757 RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) 02280906 RAN f AEFGVW Apo-Risperidone 02282119 APX f AEFGVW Mylan-Risperidone 02282240 MYL f AEFGVW Co Risperidone 02282585 COB f AEFGVW Teva-Risperidone 02282690 TEV f AEFGVW Sandoz Risperidone 02303655 SDZ f AEFGVW Ran-Risperidone 02328305 RAN f AEFGVW Risperidone 02356880 SAS f AEFGVW Jamp-Risperidone 02359529 JPC f AEFGVW Mint-Risperidone 02359790 MNT f AEFGVW Mar-Risperidone 02371766 MAR f AEFGVW Tab Orl 0.5mg Risperdal 02240552 JAN f AEFGVW pms-risperidone 02252015 PMS f AEFGVW Phl-Risperidone 02258447 PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) 02264765 RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) 02280914 RAN f AEFGVW Apo-Risperidone 02282127 APX f AEFGVW Mylan-Risperidone 02282259 MYL f AEFGVW Co Risperidone 02282593 COB f AEFGVW Teva-Risperidone 02264188 TEV f AEFGVW Sandoz Risperidone 02303663 SDZ f AEFGVW Ran-Risperidone 02328313 RAN f AEFGVW Risperidone 02356899 SAS f AEFGVW Jamp-Risperidone 02359537 JPC f AEFGVW Mint-Risperidone 02359804 MNT f AEFGVW Mar-Risperidone 02371774 MAR f AEFGVW Tab Orl 1mg Risperdal 02025280 JAN f AEFGVW pms-risperidone 02252023 PMS f AEFGVW Phl-Risperidone 02258455 PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) 02264773 RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) 02280922 RAN f AEFGVW Apo-Risperidone 02282135 APX f AEFGVW Mylan-Risperidone 02282267 MYL f AEFGVW Co Risperidone 02282607 COB f AEFGVW Teva-Risperidone 02264196 TEV f AEFGVW Sandoz Risperidone 02279800 SDZ f AEFGVW Ran-Risperidone 02328321 RAN f AEFGVW Risperidone 02356902 SAS f AEFGVW Jamp-Risperidone 02359545 JPC f AEFGVW Mint-Risperidone 02359812 MNT f AEFGVW Mar-Risperidone 02371782 MAR f AEFGVW Tab Orl 2mg Risperdal 02025299 JAN f AEFGVW pms-risperidone 02252031 PMS f AEFGVW Phl-Risperidone 02258463 PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) 02264781 RPH f AEFGVW February 2014 / février 2014 Page 165

N05B N05AX08 N05BA N05BA01 RISPERIDONE RISPÉRIDONE Tab Orl 2mg Ran-Risperidone (Disc/non disp Jun 13/14) 02280930 RAN f AEFGVW Apo-Risperidone 02282143 APX f AEFGVW Mylan-Risperidone 02282275 MYL f AEFGVW Co Risperidone 02282615 COB f AEFGVW Teva-Risperidone 02264218 TEV f AEFGVW Sandoz Risperidone 02279819 SDZ f AEFGVW Ran-Risperidone 02328348 RAN f AEFGVW Risperidone 02356910 SAS f AEFGVW Jamp-Risperidone 02359553 JPC f AEFGVW Mint-Risperidone 02359820 MNT f AEFGVW Mar-Risperidone 02371790 MAR f AEFGVW Tab Orl 3mg Risperdal 02025302 JAN f AEFGVW pms-risperidone 02252058 PMS f AEFGVW Phl-Risperidone 02258471 PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) 02264803 RPH f AEFGVW Ran-Risperidone (Disc/non disp Jun 13/14) 02280949 RAN f AEFGVW Apo-Risperidone 02282151 APX f AEFGVW Mylan-Risperidone 02282283 MYL f AEFGVW Co Risperidone 02282623 COB f AEFGVW Teva-Risperidone 02264226 TEV f AEFGVW Sandoz Risperidone 02279827 SDZ f AEFGVW Ran-Risperidone 02328364 RAN f AEFGVW Tab Orl 3mg Risperidone 02356929 SAS f AEFGVW Jamp-Risperidone 02359561 MPC f AEFGVW Mint-Risperidone 02359839 MNT f AEFGVW Mar-Risperidone 02371804 MAR f AEFGVW Tab Orl 4mg Risperdal 02025310 JAN f AEFGVW pms-risperidone 02252066 PMS f AEFGVW Phl-Risperidone 02258498 PHL f AEFGVW ratio-risperidone (Disc/non disp Jul 2/15) 02264811 RPH f AEFGVW Apo-Risperidone 02282178 APX f AEFGVW Mylan-Risperidone 02282291 MYL f AEFGVW Co Risperidone 02282631 COB f AEFGVW Teva-Risperidone 02264234 TEV f AEFGVW Sandoz Risperidone 02279835 SDZ f AEFGVW Ran-Risperidone 02328372 RAN f AEFGVW Risperidone 02356937 SAS f AEFGVW Jamp-Risperidone 02359588 MPC f AEFGVW Mint-Risperidone 02359847 MNT f AEFGVW Mar-Risperidone 02371812 MAR f AEFGVW ANXIOLYTICS ANXIOLYTIQUES BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZEPINE DIAZEPAM DIAZÉPAM Liq Inj 5mg Diazepam 00399728 SDZ VW Liq February 2014 / février 2014 Page 166

N05BA01 N05BA02 DIAZEPAM DIAZÉPAM Tab Orl 2mg Apo-Diazepam 00405329 APX f AEFGVW pms-diazepam 02247490 PMS f AEFGVW Tab Orl 5mg Valium 00013285 HLR f AEFGVW Apo-Diazepam 00362158 APX f AEFGVW pms-diazepam 02247491 PMS f AEFGVW Tab Orl 10mg Apo-Diazepam 00405337 APX f AEFGVW pms-diazepam 02247492 PMS f AEFGVW CHLORDIAZEPOXIDE CHLORDIAZÉPOXIDE Cap Orl 5mg Chlordiazepoxide 00522724 AAP f AEFGVW Cap Cap Orl 10mg Chlordiazepoxide 00522988 AAP f AEFGVW Cap N05BA04 Cap Orl 25mg Chlordiazepoxide 00522996 AAP f AEFGVW Cap OXAZEPAM OXAZÉPAM Tab Orl 10mg Apo-Oxazepam 00402680 APX f AEFGVW Tab Orl 15mg Apo-Oxazepam 00402745 APX f AEFGVW N05BA05 Tab Orl 30mg Apo-Oxazepam 00402737 APX f AEFGVW CLORAZEPATE DIPOTASSIUM CLORAZÉPATE DIPOTASSIQUE Cap Orl 3.75mg Clorazepate 00860689 AAP f AEFGVW Cap Cap Orl 7.5mg Clorazepate 00860700 AAP f AEFGVW Cap N05BA06 Cap Orl 15mg Clorazepate 00860697 AAP f AEFGVW Cap LORAZEPAM LORAZÉPAM Liq Inj 4mg Lorazepam 02243278 SDZ AEFVW Liq Slt Orl 0.5mg Ativan SL 02041456 PFI AEFGVW S.L. February 2014 / février 2014 Page 167

N05BA06 LORAZEPAM LORAZÉPAM Slt Orl 1mg Ativan SL 02041464 PFI AEFGVW S.L. Slt Orl 2mg Ativan SL 02041472 PFI AEFGVW S.L. Tab Orl 0.5mg Ativan 02041413 PFI f AEFGVW Novo-Lorazepam 00711101 TEV f AEFGVW pms-lorazepam 00728187 PMS f AEFGVW Apo-Lorazepam 00655740 APX f AEFGVW Lorazepam 02351072 SAS f AEFGVW Tab Orl 1mg Ativan 02041421 PFI f AEFGVW Novo-Lorazepam 00637742 TEV f AEFGVW pms-lorazepam 00728195 PMS f AEFGVW Apo-Lorazepam 00655759 APX f AEFGVW Lorazepam 02351080 SAS f AEFGVW N05BA08 N05BA09 N05BA12 Tab Orl 2mg Ativan 02041448 PFI f AEFGVW Novo-Lorazepam 00637750 TEV f AEFGVW pms-lorazepam 00728209 PMS f AEFGVW Apo-Lorazepam 00655767 APX f AEFGVW Lorazepam 02351099 SAS f AEFGVW BROMAZEPAM BROMAZÉPAM Tab Orl 1.5mg Apo-Bromazepam 02177153 APX f AEFGVW Tab Orl 3mg Lectopam 00518123 HLR f AEFGVW Apo-Bromazepam 02177161 APX f AEFGVW Novo-Bromazepam 02230584 TEV f AEFGVW Tab Orl 6mg Lectopam 00518131 HLR f AEFGVW Apo-Bromazepam 02177188 APX f AEFGVW Novo-Bromazepam 02230585 TEV f AEFGVW CLOBAZAM CLOBAZAM Tab Orl 10mg Frisium 02221799 LBK f AEFGV Novo-Clobazam 02238334 TEV f AEFGV pms-clobazam 02244474 PMS f AEFGV Apo-Clobazam 02244638 APX f AEFGV ALPRAZOLAM ALPRAZOLAM Tab Orl 0.25mg Xanax 00548359 PFI f AEFGVW Apo-Alpraz 00865397 APX f AEFGVW Teva-Alprazolam 01913484 TEV f AEFGVW Mylan-Alprazolam 02137534 MYL f AEFGVW Alprazolam 02349191 SAS f AEFGVW February 2014 / février 2014 Page 168

N05BA12 N05BB N05BB01 ALPRAZOLAM ALPRAZOLAM Tab Orl 0.5mg Xanax 00548367 PFI f AEFGVW Apo-Alpraz 00865400 APX f AEFGVW Teva-Alprazolam 01913492 TEV f AEFGVW Mylan-Alprazolam 02137542 MYL f AEFGVW Alprazolam 02349205 SAS f AEFGVW DIPHENYLMETHANE DERIVATIVES DÉRIVÉS DU DIPHENYLMETHANE HYDROXYZINE HYDROXYZINE Cap Orl 10mg Apo-Hydroxyzine 00646059 APX f AEFGVW Cap Novo-Hydroxyzine 00738824 TEV f AEFGVW Cap Orl 25mg Apo-Hydroxyzine 00646024 APX f AEFGVW Cap Novo-Hydroxyzine 00738832 TEV f AEFGVW Cap Orl 50mg Apo-Hydroxyzine 00646016 APX f AEFGVW Cap Novo-Hydroxyzine 00738840 TEV f AEFGVW N05BE N05C N05BE01 N05CC N05CC01 N05CD N05CD01 Syr Orl 2mg Atarax 00024694 ERF AEFGVW Sir. pms-hydroxyzine 00741817 PMS AEFGVW AZASPIRODECANEDIONE DERIVATIVES DÉRIVÉS DE L'AZASPIRODECANEDIONE BUSPIRONE BUSPIRONE Tab Orl 10mg Apo-Buspirone 02211076 APX f AEFGVW pms-buspirone 02230942 PMS f AEFGVW Novo-Buspirone 02231492 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 00792659 PMS AEFGVW Sir. Chloral Hydrate Syrup Odan 02247621 ODN AEFGVW BENZODIAZEPINE DERIVATIVES DÉRIVÉS DU BENZODIAZEPINE FLURAZEPAM FLURAZÉPAM Cap Orl 15mg Apo-Flurazepam 00521698 APX f AEFGVW Cap Cap Orl 30mg Apo-Flurazepam 00521701 APX f AEFGVW Cap February 2014 / février 2014 Page 169

N05CD02 N05CD05 NITRAZEPAM NITRAZÉPAM Tab Orl 5mg Mogadon 00511528 AAP f AEFGVW Nitrazadon 02229654 VLN f AEFGVW Sandoz Nitrazepam 02234003 SDZ f AEFGVW Apo-Nitrazepam 02245230 APX f AEFGVW Tab Orl 10mg Mogadon 00511536 AAP f AEFGVW Nitrazadon 02229655 VLN f AEFGVW Sandoz Nitrazepam 02234007 SDZ f AEFGVW Apo-Nitrazepam 02245231 APX f AEFGVW TRIAZOLAM TRIAZOLAM Tab Orl 0.125mg Triazolam 00808563 AAP f AEFGVW Tab Orl 0.25mg Triazolam 00808571 AAP f AEFGVW N05CD07 TEMAZEPAM TÉMAZÉPAM Cap Orl 15mg Restoril 00604453 SNV f AEFGVW Cap Apo-Temazepam 02225964 APX f AEFGVW Novo-Temazapam 02230095 TEV f AEFGVW Co-Temazepam 02244814 COB f AEFGVW Cap Orl 30mg Restoril 00604461 SNV f AEFGVW Cap Apo-Temazepam 02225972 APX f AEFGVW Novo-Temazapam 02230102 TEV f AEFGVW Co-Temazepam 02244815 COB f AEFGVW N05CD08 MIDAZOLAM MIDAZOLAM Liq Inj 1mg Midazolam 02240285 SDZ AEFVW Liq Liq Inj 5mg Midazolam 02240286 SDZ AEFVW Liq N05CF BENZODIAZEPINE RELATED DRUGS MÉDICAMENTS LIÉS AU BENZODIAZÉPINE N05CF01 ZOPICLONE ZOPICLONE Tab Orl 5mg Imovane 02216167 SAV f AEFVW pms-zopiclone 02243426 PMS f AEFVW Apo-Zopiclone 02245077 APX f AEFVW ratio-zopiclone 02246534 TEV f AEFVW Novo-Zopiclone 02251450 TEV f AEFVW Sandoz Zopiclone 02257572 SDZ f AEFVW Ran-Zopiclone 02267918 RAN f AEFVW Co Zopiclone 02271931 COB f AEFVW Phl-Zopiclone 02294052 PHL f AEFVW February 2014 / février 2014 Page 170

N05CF01 ZOPICLONE ZOPICLONE Tab Orl 5mg Mylan-Zopiclone 02296616 MYL f AEFVW Zopiclone 02344122 SAS f AEFVW Mar-Zopiclone 02386771 MAR f AEFVW Mint-Zopiclone 02391716 MNT f AEFVW Septa-Zopiclone 02386909 SPT f AEFVW Tab Orl 7.5mg Imovane 01926799 SAV f AEFVW Rhovane 02008203 SAV f AEFVW pms-zopiclone 02240606 PMS f AEFVW Apo-Zopiclone 02218313 APX f AEFVW ratio-zopiclone 02242481 TEV f AEFVW Novo-Zopiclone 02251469 TEV f AEFVW Sandoz Zopiclone 02257580 SDZ f AEFVW Ran-Zopiclone 02267926 RAN f AEFVW Co Zopiclone 02271958 COB f AEFVW Phl-Zopiclone 02294060 PHL f AEFVW Mylan-Zopiclone 02238596 MYL f AEFVW Zopiclone 02282445 SAS f AEFVW Jamp-Zopiclone 02356805 JPC f AEFVW Mar-Zopiclone 02386798 MAR f AEFVW Mint-Zopiclone 02391724 MNT f AEFVW Septa-Zopiclone 02386917 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 02216248 AAP f AEFGVW Tab Orl 25mg Desipramine 02216256 AAP f AEFGVW Tab Orl 50mg Desipramine 02216264 AAP f AEFGVW Tab Orl 75mg Desipramine 02216272 AAP f AEFGVW Tab Orl 100mg Desipramine 02216280 AAP f AEFGVW N06AA02 IMIPRAMINE IMIPRAMINE Tab Orl 10mg Imipramine 00360201 AAP f AEFGVW February 2014 / février 2014 Page 171

N06AA02 N06AA04 IMIPRAMINE IMIPRAMINE Tab Orl 25mg Imipramine 00312797 AAP f AEFGVW Tab Orl 50mg Imipramine 00326852 AAP f AEFGVW Tab Orl 75mg Imipramine 00644579 AAP f AEFGVW CLOMIPRAMINE CLOMIPRAMINE Tab Orl 10mg Anafranil 00330566 SNV f AEFGVW Apo-Clomipramine 02040786 APX f AEFGVW Tab Orl 25mg Anafranil 00324019 SNV f AEFGVW Apo-Clomipramine 02040778 APX f AEFGVW Co-Clomipramine 02244817 COB f AEFGVW N06AA06 Tab Orl 50mg Anafranil 00402591 SNV f AEFGVW Apo-Clomipramine 02040751 APX f AEFGVW Co-Clomipramine 02244818 COB f AEFGVW TRIMIPRAMINE TRIMIPRAMINE Tab Orl 12.5mg Trimipramine 00740799 AAP f AEFGVW Tab Orl 25mg Trimipramine 00740802 AAP f AEFGVW Tab Orl 50mg Trimipramine 00740810 AAP f AEFGVW Cap Orl 75mg Trimipramine 02070987 AAP f AEFGVW Cap N06AA09 Tab Orl 100mg Trimipramine 00740829 AAP f AEFGVW AMITRIPTYLINE AMITRIPTYLINE Tab Orl 10mg Elavil 00335053 AAP f AEFGVW Apo-Amitriptyline 02403137 APX f AEFGVW Amitriptyline 00370991 PDL AEFGVW Tab Orl 25mg Elavil 00335061 AAP f AEFGVW Apo-Amitriptyline 02403145 APX f AEFGVW Amitriptyline 00371009 PDL AEFGVW Tab Orl 50mg Elavil 00335088 AAP f AEFGVW Apo-Amitriptyline 02403153 APX f AEFGVW February 2014 / février 2014 Page 172

N06AA09 AMITRIPTYLINE AMITRIPTYLINE Tab Orl 75mg Elavil 00754129 AAP f AEFGVW Apo-Amitriptyline 02403161 APX f AEFGVW N06AA10 NORTRIPTYLINE NORTRIPTYLINE Cap Orl 10mg Aventyl 00015229 PDP f AEFGVW Cap pms-nortriptyline 02177692 PMS f AEFGVW Apo-Nortriptyline 02223511 APX f AEFGVW Teva-Nortriptyline 02231781 TEV f AEFGVW Cap Orl 25mg Aventyl 00015237 PDP f AEFGVW Cap pms-nortriptyline 02177706 PMS f AEFGVW Apo-Nortriptyline 02223538 APX f AEFGVW Teva-Nortriptyline 02231782 TEV f AEFGVW N06AA12 DOXEPIN DOXÉPINE Cap Orl 10mg Sinequan 00024325 ERF f AEFGVW Cap Doxepin 02049996 AAP f AEFGVW Cap Orl 25mg Sinequan 00024333 ERF f AEFGVW Cap Doxepin 02050005 AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) 01913425 TEV f AEFGVW Cap Orl 50mg Sinequan 00024341 ERF f AEFGVW Cap Doxepin 02050013 AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) 01913433 TEV f AEFGVW Cap Orl 75mg Sinequan 00400750 ERF f AEFGVW Cap Doxepin 02050021 AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) 01913441 TEV f AEFGVW Cap Orl 100mg Sinequan 00326925 ERF f AEFGVW Cap Doxepin 02050048 AAP f AEFGVW Novo-Doxepin (Disc/non disp Oct 18/15) 01913468 TEV f AEFGVW Cap Orl 150mg Novo-Doxepin (Disc/non disp Oct 18/15) 01913476 TEV f AEFGVW Cap N06AA21 MAPROTILINE MAPROTILINE Tab Orl 25mg Teva-Maprotiline 02158612 TEV f AEFGVW Tab Orl 50mg Teva-Maprotiline 02158620 TEV f AEFGVW Tab Orl 75mg Teva-Maprotiline 02158639 TEV f AEFGVW February 2014 / février 2014 Page 173

N06AB N06AB03 N06AB04 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI'S) INHIBITEURS SPECIFIQUES DU RECAPTAGE DE LA SEROTONINE FLUOXETINE FLUOXÉTINE Cap Orl 10mg Prozac 02018985 LIL f AEFGVW Cap pms-fluoxetine 02177579 PMS f AEFGVW Apo-Fluoxetine 02216353 APX f AEFGVW Teva-Fluoxetine 02216582 TEV f AEFGVW Phl-Fluoxetine 02223481 PHL f AEFGVW Mylan-Fluoxetine 02237813 MYL f AEFGVW ratio-fluoxetine (Disc/non disp Feb 22/15) 02241371 RPH f AEFGVW Co Fluoxetine 02242177 COB f AEFGVW Sandoz Fluoxetine 02243486 SDZ f AEFGVW Fluoxetine 02286068 SAS f AEFGVW Zym-Fluoxetine 02302659 ZYM f AEFGVW Mint-Fluoxetine 02380560 MNT f AEFGVW Auro-Fluoxetine 02385627 ARO f AEFGVW Fluoxetine 02393441 AHI f AEFGVW Mar-Fluoxetine 02392909 MAR f AEFGVW Jamp-Fluoxetine 02401894 JPC f AEFGVW Ran-Fluoxetine 02405695 RAN f AEFGVW Cap Orl 20mg Prozac 00636622 LIL f AEFGVW Cap pms-fluoxetine 02177587 PMS f AEFGVW Apo-Fluoxetine 02216361 APX f AEFGVW Teva-Fluoxetine 02216590 TEV f AEFGVW Phl-Fluoxetine 02223503 PHL f AEFGVW Mylan-Fluoxetine 02237814 MYL f AEFGVW ratio-fluoxetine (Disc/non disp Feb 22/15) 02241374 RPH f AEFGVW Co Fluoxetine 02242178 COB f AEFGVW Sandoz Fluoxetine 02243487 SDZ f AEFGVW Fluoxetine 02286076 SAS f AEFGVW Zym-Fluoxetine 02302667 ZYM f AEFGVW Mint-Fluoxetine 02380579 MNT f AEFGVW Fluoxetine 02383241 AHI f AEFGVW Jamp-Fluoxetine 02386402 JPC f AEFGVW Auro-Fluoxetine 02385635 ARO f AEFGVW Mar-Fluoxetine 02392917 MAR f AEFGVW Ran-Fluoxetine 02405709 RAN f AEFGVW CITALOPRAM CITALOPRAM Tab Orl 10mg pms-citalopram 02270609 PMS f AEFGVW Phl-Citalopram 02273543 PHL f AEFGVW Teva-Citalopram 02312336 TEV f AEFGVW Mint-Citalopram 02370077 MNT f AEFGVW Jamp-Citalopram 02370085 JPC f AEFGVW Mar-Citalopram 02371871 MAR f AEFGVW Tab Orl 20mg Celexa 02239607 VLH f AEFGVW Apo-Citalopram 02246056 APX f AEFGVW Mylan-Citalopram 02246594 MYL f AEFGVW pms-citalopram 02248010 PMS f AEFGVW February 2014 / février 2014 Page 174

N06AB04 N06AB05 CITALOPRAM CITALOPRAM Tab Orl 20mg Co Citalopram 02248050 COB f AEFGVW Sandoz Citalopram 02248170 SDZ f AEFGVW Phl-Citalopram 02248944 PHL f AEFGVW ratio-citalopram (Disc/non disp Dec 21/14) 02252112 TEV f AEFGVW Ran-Citalo 02285622 RAN f AEFGVW Teva-Citalopram 02293218 TEV f AEFGVW Mint-Citalopram 02304686 MNT f AEFGVW Citalopram-odan 02306239 ODN f AEFGVW Jamp-Citalopram 02313405 JPC f AEFGVW Citalopram 02353660 SAS f AEFGVW Septa-Citalopram 02355272 SPT f AEFGVW Mar-Citalopram 02371898 MAR f AEFGVW Auro-Citalopram 02275562 ARO f AEFGVW Tab Orl 30mg CTP 30 02296152 SNV AEFGVW Tab Orl 40mg Celexa 02239608 VLH f AEFGVW Apo-Citalopram 02246057 APX f AEFGVW Mylan-Citalopram 02246595 MYL f AEFGVW pms-citalopram 02248011 PMS f AEFGVW Co Citalopram 02248051 COB f AEFGVW Sandoz Citalopram 02248171 SDZ f AEFGVW Phl-Citalopram 02248945 PHL f AEFGVW ratio-citalopram (Disc/non disp Dec 21/14) 02252120 TEV f AEFGVW Ran-Citalo 02285630 RAN f AEFGVW Teva-Citalopram 02293226 TEV f AEFGVW Mint-Citalopram 02304694 MNT f AEFGVW Citalopram-odan 02306247 ODN f AEFGVW Auro-Citalopram 02275570 ARO f AEFGVW Jamp-Citalopram 02313413 JPC f AEFGVW Citalopram 02353679 SAS f AEFGVW Septa-Citalopram 02355280 SPT f AEFGVW Mar-Citalopram 02371901 MAR f AEFGVW PAROXETINE PAROXÉTINE Tab Orl 20mg Paxil 01940481 GSK f AEFGVW Apo-Paroxetine 02240908 APX f AEFGVW pms-paroxetine 02247751 PMS f AEFGVW ratio-paroxetine (Disc/non disp Feb 22/15) 02247811 RPH f AEFGVW Mylan-Paroxetine 02248013 MYL f AEFGVW Teva-Paroxetine 02248557 TEV f AEFGVW Co Paroxetine 02262754 COB f AEFGVW Sandoz Paroxetine 02269430 SDZ f AEFGVW Paroxetine 02282852 SAS f AEFGVW Jamp-Paroxetine 02368870 JPC f AEFGVW Auro-Paroxetine 02383284 ARO f AEFGVW Tab Orl 30mg Paxil 01940473 GSK f AEFGVW Apo-Paroxetine 02240909 APX f AEFGVW pms-paroxetine 02247752 PMS f AEFGVW February 2014 / février 2014 Page 175

N06AB05 N06AB06 PAROXETINE PAROXÉTINE Tab Orl 30mg ratio-paroxetine (Disc/non disp Feb 22/15) 02247812 RPH f AEFGVW Mylan-Paroxetine 02248014 MYL f AEFGVW Teva-Paroxetine 02248558 TEV f AEFGVW Co Paroxetine 02262762 COB f AEFGVW Sandoz Paroxetine 02269449 SDZ f AEFGVW Paroxetine 02282860 SAS f AEFGVW Jamp-Paroxetine 02368889 JPC f AEFGVW Auro-Paroxetine 02383292 ARO f AEFGVW Tab Orl 40mg pms-paroxetine 02293749 PMS AEFGVW SERTRALINE SERTRALINE Cap Orl 25mg Zoloft 02132702 PFI f AEFGVW Caps Apo-Sertraline 02238280 APX f AEFGVW Teva-Sertraline 02240485 TEV f AEFGVW Mylan-Sertraline 02242519 MYL f AEFGVW pms-sertraline 02244838 PMS f AEFGVW Sandoz Sertraline 02245159 SDZ f AEFGVW Phl-Sertraline 02245824 PHL f AEFGVW GD-Sertraline 02273683 GMD f AEFGVW Co Sertraline 02287390 COB f AEFGVW Sertraline 02353520 SAS f AEFGVW Jamp-Sertraline 02357143 JPC f AEFGVW Ran-Sertraline 02374552 RAN f AEFGVW Auro-Sertraline 02390906 ARO f AEFGVW Mar-Sertraline 02399415 MAR f AEFGVW Mint-Sertraline 02402378 MNT f AEFGVW Cap Orl 50mg Zoloft 01962817 PFI f AEFGVW Caps Apo-Sertraline 02238281 APX f AEFGVW Teva-Sertraline 02240484 TEV f AEFGVW Mylan-Sertraline 02242520 MYL f AEFGVW pms-sertraline 02244839 PMS f AEFGVW Sandoz Sertraline 02245160 SDZ f AEFGVW Phl-Sertraline 02245825 PHL f AEFGVW GD-Sertraline 02273691 GMD f AEFGVW Co Sertraline 02287404 COB f AEFGVW Sertraline 02353539 SAS f AEFGVW Jamp-Sertraline 02357151 JPC f AEFGVW Ran-Sertraline 02374560 RAN f AEFGVW Auro-Sertraline 02390914 ARO f AEFGVW Mar-Sertraline 02399423 MAR f AEFGVW Mint-Sertraline 02402394 MNT f AEFGVW Cap Orl 100mg Zoloft 01962779 PFI f AEFGVW Caps Apo-Sertraline 02238282 APX f AEFGVW Teva-Sertraline 02240481 TEV f AEFGVW Mylan-Sertraline 02242521 MYL f AEFGVW pms-sertraline 02244840 PMS f AEFGVW Sandoz Sertraline 02245161 SDZ f AEFGVW February 2014 / février 2014 Page 176

N06AB06 N06AB06 N06AF N06AF03 N06AF04 N06AG N06AG02 SERTRALINE SERTRALINE Cap Orl 100mg Phl-Sertraline 02245826 PHL f AEFGVW Caps GD-Sertraline 02273705 GMD f AEFGVW Co Sertraline 02287412 COB f AEFGVW Sertraline 02353547 SAS f AEFGVW Jamp-Sertraline 02357178 JPC f AEFGVW Ran-Sertraline 02374579 RAN f AEFGVW Auro-Sertraline 02390922 ARO f AEFGVW Mar-Sertraline 02399431 MAR f AEFGVW Mint-Sertraline 02402408 MNT f AEFGVW FLUVOXAMINE FLUVOXAMINE Tab Orl 50mg Luvox 01919342 ABB f AEFGVW Ratio-Fluvoxamine 02218453 TEV f AEFGVW Apo-Fluvoxamine 02231329 APX f AEFGVW Novo-Fluvoxamine 02239953 TEV f AEFGVW pms-fluvoxamine (Disc/non disp Sep 13/15) 02240682 PMS f AEFGVW Co Fluvoxamine 02255529 COB f AEFGVW Tab Orl 100mg Luvox 01919369 ABB f AEFGVW Ratio-Fluvoxamine 02218461 TEV f AEFGVW Apo-Fluvoxamine 02231330 APX f AEFGVW Novo-Fluvoxamine 02239954 TEV f AEFGVW pms-fluvoxamine (Disp/non disp Sep 13/15) 02240683 PMS f AEFGVW Co Fluvoxamine 02255537 COB f AEFGVW MONOAMINE OXIDASE INHIBITORS, NON-SELECTIVE INHIBITEURS DE LA MONOAMINE OXYDASE, NON SELECTIFS PHENELZINE PHÉNELZINE Tab Orl 15mg Nardil 00476552 ERF AEFGVW TRANYLCYPROMINE TRANYLCYPROMINE Tab Orl 10mg Parnate 01919598 GSK AEFGVW MONOAMINE OXIDASE TYPE A INHIBITORS INHIBITEURS DE LA MONOAMINE OXYDASE DE TYPE A MOCLOBEMIDE MOCLOBÉMIDE Tab Orl 100mg Apo-Moclobemide 02232148 APX f AEFGVW Teva-Moclobemide 02239746 TEV f AEFGVW Tab Orl 150mg Manerix 00899356 MVL f AEFGVW Apo-Moclobemide 02232150 APX f AEFGVW Teva-Moclobemide 02239747 TEV f AEFGVW February 2014 / février 2014 Page 177

N06AG02 N06AX N06AX05 MOCLOBEMIDE MOCLOBÉMIDE Tab Orl 300mg Manerix 02166747 MVL f AEFGVW Apo-Moclobemide 02240456 TEV f AEFGVW Teva-Moclobemide 02239748 APX f AEFGVW OTHER ANTIDEPRESSANTS AUTRES ANTIDEPRESSIFS TRAZODONE TRAZODONE Tab Orl 50mg pms-trazodone 01937227 PMS f AEFGVW Teva-Trazodone 02144263 TEV f AEFGVW Apo-Trazodone 02147637 APX f AEFGVW Mylan-Trazodone 02231683 MYL f AEFGVW Phl-Trazodone 02236941 PHL f AEFGVW Trazodone 02348772 SAS f AEFGVW Tab Orl 100mg pms-trazodone 01937235 PMS f AEFGVW Teva-Trazodone 02144271 TEV f AEFGVW Apo-Trazodone 02147645 APX f AEFGVW Mylan-Trazodone 02231684 MYL f AEFGVW Phl-Trazodone 02236942 PHL f AEFGVW Trazodone 02348780 SAS f AEFGVW N06AX11 Tab Orl 150mg Teva-Trazodone 02144298 TEV f AEFGVW Apo-Trazodone 02147653 APX f AEFGVW Trazodone 02348799 SAS f AEFGVW MIRTAZAPINE MIRTAZAPINE ODT Orl 15mg Remeron RD 02248542 FRS f AEFGVW D.O. Novo-Mirtazapine OD 02279894 TEV f AEFGVW Auro-Mirtazapine OD 02299801 ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) 02352826 GMD f AEFGVW ODT Orl 30mg Remeron RD 02248543 FRS f AEFGVW D.O. Novo-Mirtazapine OD 02279908 TEV f AEFGVW Auro-Mirtazapine OD 02299828 ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) 02352834 GMD f AEFGVW ODT Orl 45mg Remeron RD 02248544 FRS f AEFGVW D.O. Novo-Mirtazapine OD 02279916 TEV f AEFGVW Auro-Mirtazapine OD 02299836 ARO f AEFGVW GD-Mirtazapine OD (Disc/non disp Nov 30/15) 02352842 GMD f AEFGVW Tab Orl 15mg Sandoz Mirtazapine 02250594 SDZ f AEFGVW pms-mirtazapine 02273942 PMS f AEFGVW Mirtazapine 02281732 MEL f AEFGVW Apo-Mirtazapine 02286610 APX f AEFGVW Zym-Mirtazapine 02325179 ZYM f AEFGVW Mylan-Mirtazapine 02256096 MYL f AEFGVW February 2014 / février 2014 Page 178

N06AX11 N06AX12 MIRTAZAPINE MIRTAZAPINE Tab Orl 30mg Remeron 02243910 FRS f AEFGVW pms-mirtazapine 02248762 PMS f AEFGVW Sandoz Mirtazapine 02250608 SDZ f AEFGVW Mirtazapine 02252279 MEL f AEFGVW Mylan-Mirtazapine 02256118 MYL f AEFGVW Novo-Mirtazapine 02259354 TEV f AEFGVW Apo-Mirtazapine 02286629 APX f AEFGVW Zym-Mirtazapine 02325187 ZYM f AEFGVW Mirtazapine 02370689 SAS f AEFGVW BUPROPION BUPROPION SRT Orl 100mg Sandoz Bupropion SR 02275074 SDZ f AEFGVW L.L. ratio-bupropion SR 02285657 TEV f AEFGVW pms-bupropion 02325373 PMS f AEFGVW Bupropion SR 02391562 SAS f AEFGVW SRT Orl 150mg Wellbutrin SR 02237825 VLN f AEFGVW L.L. Sandoz Bupropion SR 02275082 SDZ f AEFGVW ratio-bupropion SR 02285665 TEV f AEFGVW pms-bupropion 02313421 PMS f AEFGVW Bupropion SR 02391570 SAS f AEFGVW SRT Orl 150mg Wellbutrin XL 02275090 VLN f AEFGVW L.L. Mylan-Bupropion XL 02382075 MYL f AEFGVW N06AX16 SRT Orl 300mg Wellbutrin XL 02275104 VLN f AEFGVW L.L. Mylan-Bupropion XL 02382083 MYL f AEFGVW VENLAFAXINE VENLAFAXINE SRC Orl 37.5mg Effexor XR 02237279 PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) 02273969 TEV f AEFGVW Teva-Venlafaxine XR 02275023 TEV f AEFGVW pms-venlafaxine XR 02278545 PMS f AEFGVW Co Venlafaxine XR 02304317 COB f AEFGVW Mylan-Venlafaxine XR 02310279 MYL f AEFGVW Sandoz Venlafaxine XR 02310317 SDZ f AEFGVW Venlafaxine XR 02354713 SAS f AEFGVW GD-Venlafaxine XR 02360020 GMD f AEFGVW Ran-Venlafaxine XR 02380072 RAN f AEFGVW Apo-Venlafaxine XR 02331683 APX f AEFGVW SRC Orl 75mg Effexor XR 02237280 PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) 02273977 TEV f AEFGVW Teva-Venlafaxine XR 02275031 TEV f AEFGVW pms-venlafaxine XR 02278553 PMS f AEFGVW Co Venlafaxine XR 02304325 COB f AEFGVW Mylan-Venlafaxine XR 02310287 MYL f AEFGVW Sandoz Venlafaxine XR 02310325 SDZ f AEFGVW Venlafaxine XR 02354721 SAS f AEFGVW February 2014 / février 2014 Page 179

N06B N06AX16 N06BA N06BA02 VENLAFAXINE VENLAFAXINE SRC Orl 75mg GD-Venlafaxine XR 02360039 GMD f AEFGVW Caps.L.L. Ran-Venlafaxine XR 02380080 RAN f AEFGVW Apo-Venlafaxine XR 02331691 APX f AEFGVW SRC Orl 150mg Effexor XR 02237282 PFI f AEFGVW Caps.L.L. Venlafaxine XR (Disc/non disp May 6/14) 02273985 TEV f AEFGVW Teva-Venlafaxine XR 02275058 TEV f AEFGVW pms-venlafaxine XR 02278561 PMS f AEFGVW Co Venlafaxine XR 02304333 COB f AEFGVW Mylan-Venlafaxine XR 02310295 MYL f AEFGVW Sandoz Venlafaxine XR 02310333 SDZ f AEFGVW Venlafaxine XR 02354748 SAS f AEFGVW GD-Venlafaxine XR 02360047 GMD f AEFGVW Ran-Venlafaxine XR 02380099 RAN f AEFGVW Apo-Venlafaxine XR 02331705 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 01924516 PAL EF-18G SRC Orl 10mg Dexedrine 01924559 PAL EF-18G Caps.L.L. N06BA04 SRC Orl 15mg Dexedrine 01924567 PAL EF-18G Caps.L.L. METHYLPHENIDATE MÉTHYLPHÉNIDATE SRT Orl 20mg Ritalin SR 00632775 NVR f AEFGVW L.L. Apo-Methylphenidate SR 02266687 APX f AEFGVW Sandoz Methylphenidate SR 02320312 SDZ f AEFGVW Tab Orl 5mg Apo-Methylphenidate 02273950 APX f AEFGVW pms-methylphenidate 02234749 PMS AEFGVW Tab Orl 10mg Ritalin 00005606 NVR f AEFGVW pms-methylphenidate 00584991 PMS f AEFGVW Apo-Methylphenidate 02249324 APX f AEFGVW Tab Orl 20mg Ritalin 00005614 NVR f AEFGVW pms-methylphenidate 00585009 PMS f AEFGVW Apo-Methylphenidate 02249332 APX f AEFGVW February 2014 / février 2014 Page 180

N07 N07A N07AA OTHER NERVOUS SYSTEM DRUGS AUTRES MÉDICAMENTS DU SYSTEME NERVEUX PARASYMPATHOMIMETICS PARAADRENERGIQUES ANTICHOLINESTERASES ANTICHOLINESTERASES N07AA02 PYRIDOSTIGMINE PYRIDOSTIGMINE SRT Orl 180mg Mestinon SR 00869953 VLN AEFGVW L.L. Tab Orl 60mg Mestinon 00869961 VLN AEFGVW N07AB CHOLINE ESTERS ESTERS DE CHOLINE N07AB02 BETHANECHOL BÉTHANÉCHOL Tab Orl 10mg Duvoid 01947958 PAL AEFGVW Tab Orl 25mg Duvoid 01947931 PAL AEFGVW Tab Orl 50mg Duvoid 01947923 PAL AEFGVW N07C N07CA ANTIVERTIGO PREPARATIONS PRÉPARATIONS ANTIVERTIGINEUX ANTIVERTIGO PREPARATIONS PRÉPARATIONS ANTIVERTIGINEUX N07CA03 FLUNARIZINE FLUNARIZINE Cap Orl 5mg Flunarizine 02246082 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 02199270 VLN f AEFGVW Co pms-tetrabenazine 02402424 PMS f AEFGVW Apo-Tetrabenazine 02407590 APX f AEFGVW February 2014 / février 2014 Page 181

P01 P01B P01BA P01BA01 P01BA02 P01BC P01BC01 ANTIPROTOZOALS ANTIPROTOZOAIRES ANTIMALARIALS ANTIPALUDIQUES AMINOQUINOLINES AMINOQUINOLINES CHLOROQUINE CHLOROQUINE Tab Orl 250mg Teva-Chloroquine 00021261 TEV f AEFGVW HYDROXYCHLOROQUINE HYDROXYCHLOROQUINE Tab Orl 200mg Plaquenil 02017709 SAV f AEFGVW Apo-Hydroxyquine 02246691 APX f AEFGVW Mylan-Hydroxychloroquine 02252600 MYL f AEFGVW METHANOLQUINOLINES METHANOLQUINOLINES QUININE QUININE Cap Orl 200mg Apo-Quinine 02254514 APX f AEFGV Caps Novo-Quinine 00021008 TEV AEFGVW Quinine Sulfate 00695440 ODN AEFGV Cap Orl 300mg Apo-Quinine 02254522 APX f AEFGV Caps Novo-Quinine 00021016 TEV AEFGVW Quinine Sulfate 00695459 ODN AEFGV P01BD P02 P02C P01BD01 P02CA P02CA01 Tab Orl 300mg Quinine Sulfate 00695432 ODN AEFGVW DIAMINOPYRIMIDINES DIAMINOPYRIMIDINES PYRIMETHAMINE PYRIMÉTHAMINE Tab Orl 25mg Daraprim (Disc/non disp Jun 1/15) 00004774 TRB AEFGVW ANTHELMINTICS ANTHELMINTIQUES ANTINEMATODAL AGENTS AGENTS ANTINEMATODAUX BENZIMIDAZOLE AGENTS AGENTS DU BENZIMIDAZOLE MEBENDAZOLE MÉBENDAZOLE Tab Orl 100mg Vermox 00556734 JAN AEFGVW February 2014 / février 2014 Page 182

P02CC P03 P03A P02CC01 P03AB P03AB02 P03AC P03AC04 TETRAHYDROPIRIMIDINE DERIVATIVES DÉRIVÉS DU TETRAHYDROPIRIMIDINE PYRANTEL PYRANTEL Tab Orl 125mg Combantrin 01944363 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) 00703591 PDP EFGV Lot Shp Top 1% Hexit (Disc/non disp Dec 31/14) 00430617 ODN EFGV Shp pms-lindane (Disc/non disp Jun 1/14) 00703605 PDP EFGV PYRETHRINES, INCLUDING SYNTHETIC COMPOUNDS PYRETHRINES, Y COMPRIS LES COMPOSÉS SYNTHÉTIQUES PERMETHRIN PERMÉTHRINE Crm Top 1% Nix Creme 00771368 INP EFGV Cr. Kwellada-P Creme Rinse 1% 02231480 MDI EFGV Crm Top 5% Nix Dermal 02219905 GCH EFGV Cr. Lot Top 5% Kwellada-P 02231348 MDI EFGV Lot P03AC51 PYRETHRUM, COMBINATIONS PYRETHRUM, EN COMBINAISON PYRETHRINS / PIPERONYL BUTOXIDE PYRETHRINS / BUTOXIDE DE PIPÉRONYL Shp Top 3% R & C Shampoo and Conditioner 02125447 MDI EFGV Shp P03AX OTHER ECTOPARACITICIDES, INCLUDING SCABICIDES AUTRES ECTOPARASITICIDES, Y COMPRIS LES SCABICIDES CROTAMITON CROTAMITON Crm Top 10% Eurax 00623377 CLC EF-18G Cr. February 2014 / février 2014 Page 183

R01 R01A R01AC R01AC01 R01AD R01AD01 R01AD04 R01AD05 ISOPROPYL MYRISTATE MYRISTATE D'ISOPROPYLE Liq Top 50% Resultz 02279592 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 01950541 PDP AEFGVW Aém CORTICOSTEROIDS CORTICOSTÉROÏDES BECLOMETHASONE BÉCLOMÉTHASONE Aem Nas 50mcg Mylan-Beclo AQ 02172712 MYL f ABEFGVW Aém Apo-Beclomethasone AQ 02238796 APX f ABEFGVW FLUNISOLIDE FLUNISOLIDE Asp Nas 0.025% Apo-Flunisolide (Disc/non disp Sep 4/14) 02239288 APX f AEFGVW Asp BUDESONIDE BUDÉSONIDE Aem Inh 100mcg Rhinocort 02035324 AZE AEFVW Aém Aem Nas 64mcg Rhinocort Aqua 02231923 AZE f AEFVW Aém Mylan-Budesonide 02241003 MYL f AEFVW Aem Nas 100mcg Mylan-Budesonide 02230648 MYL f AEFGVW Aém R01AD08 R01AD09 FLUTICASONE FLUTICASONE Aem Nas 50mcg Flonase AQ 02213672 GSK f ABEFGVW Aém Apo-Fluticasone 02294745 APX f ABEFGVW ratio-fluticasone 02296071 TEV f ABEFGVW MOMETASONE MOMÉTASONE Asp Nas 0.1% Nasonex Aqueous 02238465 FRS f EFG-12 Asp Apo-Mometasone 02403587 APX f EFG-12 February 2014 / février 2014 Page 184

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 02163705 BOE f AEFGVW Spr pms-ipratropium 02239627 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) 01944711 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 02232570 VLN f ABEFGVW Aém Ventolin 02241497 GSK f ABEFGVW Apo-Salvent CFC Free 02245669 APX f ABEFGVW Liq Inh 1mg Teva-Salbutamol Sterinebs 01926934 TEV f BEF-18GVW Liq ratio-salbutamol unit/dose PF 01986864 TEV f BEF-18GVW pms-salbutamol 02208229 PMS f BEF-18GVW Ventolin Nebules P.F. 02213419 GSK f BEF-18GVW Med-Salbutamol 02237414 MED BEF-18GVW Liq Inh 2mg Teva-Salbutamol 02173360 TEV f G Liq pms-salbutamol 02208237 PMS f G Ventolin Nebules PF 02213427 GSK f G ratio-salbutamol (Disc/non disp Aug 26/15) 02239366 TEV f G Liq Inh 5mg ratio-salbutamol 00860808 TEV f BEF-18GVW Liq pms-salbutamol 02069571 PMS f BEF-18GVW Sandoz-Salbutamol 02154412 SDZ f BEF-18GVW Ventolin 02213486 GSK f BEF-18GVW Pwr Inh 200mcg Ventolin Diskus 02243115 GSK AEFGVW Pd. February 2014 / février 2014 Page 185

R03AC03 R03AC12 R03AC13 R03AC18 TERBUTALINE TERBUTALINE Aem Inh 0.5mg Bricanyl Turbuhaler 00786616 AZE AEFGVW Aém SALMETEROL SALMÉTÉROL Pwr Inh 50mcg Serevent Diskus 23 02231129 GSK ABEFGV Pd. FORMOTEROL FORMOTÉROL Aem Inh 6mcg Oxeze 23 02237225 AZE ABEFGV Aém Aem Inh 12mcg Foradil 23 02230898 NVR ABEFGV Aém Oxeze 23 02237224 AZE ABEFGV INDACATEROL INDACATÉROL Cap Inh 75mcg Onbrez 23 02376938 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 125 02245126 GSK W Pd. Pwr Inh 25mcg/250mcg Advair 250 02245127 GSK W Pd. Pwr Inh 50mcg/100mcg Advair Diskus 02240835 GSK W Pd. Pwr Inh 50mcg/250mcg Advair Diskus 02240836 GSK W Pd. Pwr Inh 50mcg/500mcg Advair Diskus 02240837 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

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 02242029 VLN ABEFGVW Aém Aem Inh 100mcg Qvar 02242030 VLN ABEFGVW Aém R03BA02 BUDESONIDE BUDÉSONIDE Aem Inh 100mcg Pulmicort Turbuhaler 00852074 AZE ABEFGVW Aém Aem Inh 200mcg Pulmicort Turbuhaler 00851752 AZE ABEFGVW Aém Aem Inh 400mcg Pulmicort Turbuhaler 00851760 AZE ABEFGVW Aém Sus Inh 0.125mg Pulmicort Nebuamp 02229099 AZE W Susp. Sus Inh 0.25mg Pulmicort Nebuamp 01978918 AZE ABEFGVW Susp. Sus Inh 0.5mg Pulmicort Nebuamp 01978926 AZE ABEFGVW Susp. R03BA05 FLUTICASONE FLUTICASONE Aem Inh 50mcg Flovent Metered Dose HFA 02244291 GSK ABEFGVW Aém Aem Inh 125mcg Flovent Metered Dose HFA 02244292 GSK ABEFGVW Aém Aem Inh 250mcg Flovent Metered Dose HFA 02244293 GSK ABEFGVW Aém Pwr Inh 250mcg Flovent Diskus 02237246 GSK ABEFGVW Pd. Pwr Inh 500mcg Flovent Diskus 02237247 GSK ABEFGVW Pd. February 2014 / février 2014 Page 187

R03BA07 R03BA08 R03BB R03BB01 MOMETASONE MOMÉTASONE Pwr Inh 200mcg Asmanex Twisthaler 02243595 MSD AEFGVW Pd. Pwr Inh 400mcg Asmanex Twisthaler 02243596 MSD AEFGVW Pd. CICLESONIDE CICLÉSONIDE Aem Inh 100mcg Alvesco 02285606 NYC ABEFGVW Aém Aem Inh 200mcg Alvesco 02285614 NYC ABEFGVW Aém ANTICHOLINERGICS ANTICHOLINERGIQUES IPRATROPIUM BROMIDE BROMURE D'IPRATROPIUM Aem Inh 20mcg Atrovent HFA 02247686 BOE ABEFGVW Aém Liq Inh 250mcg Apo-Ipravent 02126222 APX f BEF-18GVW Liq Novo-Ipramide 02210479 TEV f BEF-18GVW pms-ipratropium 02231136 PMS f BEF-18GVW Mylan-Ipratropium Soln 02239131 MYL f BEF-18GVW R03BC R03BC01 Liq Inh 250mcg ratio-ipratropium UDV 02097168 TEV f BEF-18GVW Liq Teva-Ipratropium 02216221 TEV f BEF-18GVW pms-ipratropium (1ml nebules) 02231244 PMS f BEF-18GVW pms-ipratropium (2ml nebules) 02231245 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 02046113 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 80029414 KEG BEFG Liq February 2014 / février 2014 Page 188

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 02236783 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 02146843 APX f AEFGVW R03D R03DA Tab Orl 4mg Apo-Salvent 02146851 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 00476366 ERF AEFGVW Elx R03DA04 THEOPHYLLINE THÉOPHYLLINE Liq Orl 5.33333mg Theolair 01966219 VLN AEFGVW Liq SRT Orl 100mg Teva-Theophylline 02230085 TEV f ABEFGVW L.L. Apo-Theo LA 00692689 APX ABEFGVW SRT Orl 200mg Teva-Theophylline SR 02230086 TEV f ABEFGVW L.L. Apo-Theo LA 00692697 APX ABEFGVW SRT Orl 300mg Teva-Theophylline SR 02230087 TEV f ABEFGVW L.L. Apo-Theo LA 00692700 APX ABEFGVW SRT Orl 400mg Uniphyl 02014165 PFR f ABEFGVW L.L. Theo ER 02360101 AAP f ABEFGVW SRT Orl 600mg Uniphyl 02014181 PFR f ABEFGVW L.L. Theo ER 02360128 AAP f ABEFGVW Tab Orl 125mg Theolair 01966235 RIK AEFGVW February 2014 / février 2014 Page 189

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 00608920 ROG G Sir Balminil Expect Sans Sucrose 00609951 ROG G Robitussin 01931032 WCH G R05CB MUCOLYTICS MUCOLYTIQUES R05CB01 ACETYLCYSTEINE ACÉTYLCYSTÉINE Liq Inh 200mg Mucomyst 02091526 WLS W Liq Parvolex 02181460 BCH W Acetylcysteine 02243098 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 00544884 SDZ W Liq Syr Orl 4.76666mg Codeine Phosphate 00050024 ATL AEFGVW Sir Syr Orl 5mg ratio-codeine 00779474 RPH AEFGVW Sir Tab Orl 15mg ratio-codeine 00593435 RPH AEFGVW Codeine 00779458 ROG AEFGVW Tab Orl 30mg ratio-codeine 00593451 RPH AEFGVW SRT Orl 50mg Codeine Contin 02230302 PFR W L.L. SRT Orl 100mg Codeine Contin 02163748 PFR W L.L. SRT Orl 150mg Codeine Contin 02163780 PFR W L.L. SRT Orl 200mg Codeine Contin 02163799 PFR W L.L. February 2014 / février 2014 Page 190

R05F R05DA09 R05FA R06 R06A R05FA02 R06AA R06AA02 DEXTROMETHORPHAN DEXTROMÉTHORPHANE Liq Orl 3mg Koffex Sugar Free Clear 01928791 ROG G Liq Sus Orl 6mg Delsym 02018403 NNC G Susp. Syr Orl 3mg Balminil DM 00436895 ROG G Sir Koffex DM 01928783 ROG G Benylin DM 01944738 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 01931024 WCH G Liq GUAIFENESIN / DEXTROMETHORPHAN / PSEUDOEPHEDRINE GUAIFÉNÉSINE / DEXTROMÉTHORPHANE / PSEUDOÉPHÉDRINE Syr Orl 100mg/50mg/30mg Benylin DM-D-E 01944673 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 00392537 SDZ W Liq Tab Orl 25mg Diphenhydramine 02257548 JPC G Tab Orl 50mg Diphenhydramine 02257556 JPC G Cap Orl 50mg Benadryl (Disc/non disp Nov 16/14) 02019671 JNJ G Caps Elx Orl 2.5mg Benadryl 02019736 JNJ G Elx February 2014 / février 2014 Page 191

R06AA02 R06AA09 R06AB R06AB04 R06AE R06AE07 R06AX S01 S01A R06AX13 R06AX17 S01AA S01AA01 DIPHENHYDRAMINE DIPHENHYDRAMINE Tab Orl 25mg Benadryl 02017849 JNJ G DOXYLAMINE DOXYLAMINE SRT Orl 10mg/10mg Diclectin 00609129 DUI EF L.L. SUBSTITUTED ALKYL AMINES AMINO-ALKYLES SUBSTITUTES CHLORPHENAMINE CHLORPHÉNAMINE Tab Orl 4mg Novo-Pheniram 00021288 TEV G Chlor-Tripolon 00738972 SCO G PIPERAZINE DERIVATIVES DÉRIVÉS DU PIPERAZINE CETIRIZINE CÉTIRIZINE Tab Orl 10mg Reactine 02223554 JNJ f G Apo-Cetirizine 02231603 APX f G Extra Strength Allergy Relief 02315955 PDP f G OTHER ANTIHISTAMINES FOR SYSTEMIC USE DIVERS ANTIHISTAMINIQUES SYSTEMIQUES LORATADINE LORATADINE Tab Orl 10mg Claritin 00782696 SCO f G Apo-Loratadine 02243880 APX f G KETOTIFEN KÉTOTIFÉNE Syr Orl 0.2mg Novo-Ketotifen (Disc/non disp Sep 11/15) 02176084 TEV f EFG Sir Zaditen 00600784 TEV f EFG Tab Orl 1mg Zaditen 00577308 TEV f EFG Novo-Ketotifen (Disc/non disp Aug 10/14) 02230730 TEV f EFG OPHTHALMOLOGICALS AGENTS OPHTHALMOLOGIQUES ANTIINFECTIVES ANTIINFECTIEUX ANTIBIOTICS ANTIBIOTIQUES CHLORAMPHENICOL CHLORAMPHÉNICOL Dps Oph 0.25% Pentamycetin (Disc/non disp Mar 21/14) 01980556 SDZ AEFGVW Gttes February 2014 / février 2014 Page 192

S01AA01 S01AA11 S01AA12 S01AA17 S01AA30 S01AB S01AB04 S01AD S01AD02 CHLORAMPHENICOL CHLORAMPHÉNICOL Dps Oph 0.5% Pentamycetin (Disc/non disp Mar 21/14) 02164051 SDZ AEFGVW Gttes Ont Oph 1% Pentamycetin (Disc/non disp Mar 21/14) 01980564 SDZ AEFGVW Ont GENTAMICIN GENTAMICINE Dps Oph 0.3% Garamycin 00512192 FRS f AEFGVW Gttes Ont Oph 0.3% Sandoz Gentamicin(Disc/non disp Mar21/14) 02230888 SDZ AEFGVW Ont TOBRAMYCIN TOBRAMYCINE Liq Oph 0.3% Tobrex 00513962 ALC f AEFGVW Liq pms-tobramycin (Disc/non disp Jun 1/16) 02239577 PMS f AEFGVW Sandoz Tobramycin 02241755 SDZ f AEFGVW Ont Oph 0.3% Tobrex 00614254 ALC AEFGVW Ont ERYTHROMYCIN ÉRYTHROMYCINE Ont Oph 0.5% pms-erythromycin 01912755 PMS AEFGVW Ont Erythromycin 02326663 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 02239157 JNJ G Ont SULFONAMIDES SULFONAMIDES SULFACETAMIDE SULFACETAMIDE Dps Oph 10% Sodium Sulamyd 00028053 SDZ AEFGVW Gttes ANTIVIRALS ANTIVIRAUX TRIFLURIDINE TRIFLURIDINE Liq Oph 1% Viroptic 00687456 VLN f AEFGVW Liq Sandoz Trifluridine (Disc/non disp Mar 21/14) 02248529 SDZ f AEFGVW February 2014 / février 2014 Page 193

S01AX S01B S01AX11 S01AX13 S01BA S01BA01 OTHER ANTIINFECTIVES AUTRES ANTIINFECTIEUX OFLOXACIN OFLOXACINE Liq Oph 0.3% Ocuflox 24 02143291 ALL f AEFGVW Liq Apo-Ofloxacin 24 02248398 APX f AEFGVW pms-ofloxacin (Disc/non disp Jan 8/15) 24 02252570 PMS f AEFGVW Sandoz Ofloxacin 24 02247189 SDZ f AEFGVW CIPROFLOXACIN CIPROFLOXACINE Liq Oph 0.3% Ciloxan 25 01945270 ALC f AEFGVW Liq pms-ciprofloxacin (Disc/non disp Mar 4/15) 25 02253933 PMS f AEFGVW Sandoz Ciprofloxacin 25 02387131 SDZ f AEFGVW ANTIINFLAMMATORY AGENTS AGENTS ANTIINFLAMMATOIRES CORTICOSTEROIDS, PLAIN CORTICOSTÉROÏDES, ORDINAIRES DEXAMETHASONE DEXAMÉTHASONE Dps Oph 0.1% Maxidex 00042560 ALC AEFGVW Gttes Ont Oph 0.1% Maxidex 00042579 ALC AEFGVW Ont S01BA02 S01BA04 HYDROCORTISONE HYDROCORTISONE Ont Oph 2.5% Cortamed (Disc/non disp Mar 21/14) 01980661 SDZ AEFGVW Ont PREDNISOLONE PREDNISOLONE Liq Oph 0.12% Pred Mild 00299405 ALL AEFGVW Liq Sus Oph 1% Pred Forte 00301175 ALL f AEFGVW Susp. ratio-prednisolone 00700401 RPH f AEFGVW Diopred (Disc/non disp Mar 21/14) 02023768 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

S01BA07 S01BC S01C S01BC03 S01BC05 S01CA S01CA01 FLUOROMETHOLONE FLUOROMÉTHOLONE Dps Oph 0.1% FML 00247855 ALL AEFGVW Gttes pms-fluorometholone 02238568 PMS AEFGVW Sus Oph 0.25% FML Forte 00707511 ALL AEFGVW Susp. Sus Oph 0.1% Flarex 00756784 ALC AEFGVW Susp. ANTIINFLAMMATORY AGENTS, NON STEROIDS AGENTS ANTIINFLAMMATOIRES, NON STEROIDIENS DICLOFENAC DICLOFÉNAC Liq Oph 0.1% Voltaren 01940414 ALC AEFGVW Liq KETOROLAC KÉTOROLAC Liq Oph 0.5% Acular 01968300 ALL f AEFGVW Liq Ketorolac 02245821 AAP f AEFGVW ratio-ketorolac (Disc/non disp Feb 26/15) 02247461 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 00042676 ALC AEFGVW Susp. Ont Oph 0.3%/0.1% Tobradex 00778915 ALC AEFGVW Ont S01CA02 Sus Oph 0.3%/0.1% Tobradex 00778907 ALC AEFGVW Susp. PREDNISOLONE AND ANTIINFECTIVES PREDNISOLONE ET ANTIINFECTIEUX PREDNISOLONE / SULFACETAMIDE PREDNISOLONE / SULFACÉTAMIDE Dps Oph 10%/0.2% Blephamide 00807788 ALL AEFGVW Gttes February 2014 / février 2014 Page 195

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. 00307246 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 02076306 ALC AEFVW Liq BRIMONIDINE BRIMONIDINE Liq Oph 0.15% Alphagan P 02248151 ALL f AEFVW Liq Apo-Brimonidine P 02301334 APX f AEFVW Liq Oph 0.2% Alphagan 02236876 ALL f AEFVW Liq ratio-brimonidine 02243026 TEV f AEFVW pms-brimonidine 02246284 PMS f AEFVW Apo-Brimonidine 02260077 APX f AEFVW Sandoz Brimonidine 02305429 SDZ f AEFVW PARASYMPATHOMIMETICS PARA-ADRENERGIQUES PILOCARPINE PILOCARPINE Dps Oph 1% Isopto Carpine 00000841 ALC f AEFGVW Gttes Pilocarpine 02229556 IVX f AEFGVW Dps Oph 2% Isopto Carpine 00000868 ALC f AEFGVW Gttes Dps Oph 4% Isopto Carpine 00000884 ALC f AEFGVW Gttes Dps Oph 6% Pilocarpine 02230239 IVX f AEFGVW Gttes S01EB02 Gel Oph 4% Pilocarpine HS (Disc/non disp Sept. 6/14) 00575240 ALC AEFGVW Gel CARBACHOL CARBACHOL Liq Oph 1.5% Isopto Carbachol (Disc/non disp Aug 14/14) 00000655 ALC AEFGVW Liq February 2014 / février 2014 Page 196

S01EB02 CARBACHOL CARBACHOL Liq Oph 3% Isopto Carbachol (Disc/non disp Dec 31/14) 00000663 ALC AEFGVW Liq S01EC S01EC01 S01EC03 S01EC04 S01EC05 S01ED S01ED01 CARBONIC ANHYDRASE INHIBITORS INHIBITEURS DE L'ANHYDRASE CARBONIQUE ACETAZOLAMIDE ACÉTAZOLAMIDE Tab Orl 250mg Acetazolamide 00545015 AAP f AEFGVW DORZOLAMIDE DORZOLAMIDE Liq Oph 2% Trusopt 02216205 FRS f AEF18+VW Liq Sandoz Dorzolamide 02316307 SDZ f AEF18+VW BRINZOLAMIDE BRINZOLAMIDE Liq Oph 1% Azopt 02238873 ALC AEF18+V Liq METHAZOLAMIDE MÉTHAZOLAMIDE Tab Orl 50mg Methazolamide 02245882 AAP f AEFGVW BETA BLOCKING AGENTS BETA-BLOQUANTS TIMOLOL TIMOLOL Dps Oph 0.25% Apo-Timop 00755826 APX f AEFGVW Gttes Sandoz Timolol Maleate 02166712 SDZ f AEFGVW Mylan-Timolol (Disc/non disp Jun 5/14) 00893773 MYL f AEFGVW pms-timolol 02083353 PMS f AEFGVW Dps Oph 0.5% Timoptic Oph 00451207 FRS f AEFGVW Gttes Apo-Timop 00755834 APX f AEFGVW Sandoz Timolol Maleate 02166720 SDZ f AEFGVW Mylan-Timolol (Disc/non disp Jun 5/14) 00893781 MYL f AEFGVW pms-timolol 02083345 PMS f AEFGVW Liq Oph 0.25% Timoptic-XE Oph 02171880 FRS f AEFGVW Liq Timolol Maleate-EX 02242275 SDZ f AEFGVW Liq Oph 0.5% Timoptic-XE Oph 02171899 FRS f AEFGVW Liq Timolol Maleate-EX 02242276 SDZ f AEFGVW Apo-Timop 02290812 APX f AEFGVW February 2014 / février 2014 Page 197

S01ED02 S01ED03 S01ED51 BETAXOLOL BÉTAXOLOL Sus Oph 0.25% Betoptic S 01908448 ALC AEFVW Susp. LEVOBUNOLOL LÉVOBUNOLOL Liq Oph 0.25% ratio-levobunolol 02031159 TEV f AEFGVW Liq Liq Oph 0.5% Betagan 00637661 ALL f AEFGVW Liq ratio-levobunolol 02031167 TEV f AEFGVW pms-levobunolol 02237991 PMS f AEFGVW Sandoz Levobunolol 02241716 SDZ f AEFGVW TIMOLOL COMBINATIONS TIMOLOL EN COMBINAISON TIMOLOL / BRINZOLAMIDE TIMOLOL / BRINZOLAMIDE Sus Oph 0.5%/1% Azarga 02331624 ALC AEF18+VW Susp. TIMOLOL / DORZOLAMIDE TIMOLOL / DORZOLAMIDE Liq Oph 2%/0.5% Cosopt 02240113 FRS f AEFVW Liq Apo-Dorzo-Timop 02299615 APX f AEFVW Sandoz Dorzolamide/Timolol 02344351 SDZ f AEFVW Teva-Dorzotimol 02320525 TEV f AEFVW Co-Dorzotimolol 02404389 COB f AEFVW TIMOLOL / LATANOPROST TIMOLOL / LATANOPROST Liq Oph 0.005%/0.5% Xalacom 02246619 PFI f AEFGVW Liq GD-Latanoprost/Timolol 02373068 GMD f AEFGVW Sandoz Latanoprost/Timolol 02394685 SDZ f AEFGVW TIMOLOL / BRIMONIDINE TIMOLOL / BRIMONIDINE Liq Oph 0.5%/0.2% Combigan 02248347 ALL AEFGVW Liq TIMOLOL / TRAVOPROST TIMOLOL / TRAVOPROST Liq Oph 0.5%/0.004% Duo Trav 02278251 ALC AEFVW Liq February 2014 / février 2014 Page 198

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 02231493 PFI f AEFGVW Liq Co Latanoprost 02254786 COB f AEFGVW Apo-Latanoprost 02296527 APX f AEFGVW GD-Latanoprost 02373041 GMD f AEFGVW Sandoz Latanoprost 02367335 SDZ f AEFGVW BIMATOPROST BIMATOPROST Liq Oph 0.01% Lumigan RC 02324997 ALL AEFGVW Liq TRAVOPROST TRAVOPROST Liq Oph 0.004% Travatan Z 02318008 ALC AEFGVW Liq MYDRIATICS AND CYCLOPLEGICS MYDRIATIQUES ET CYCLOPLEGIQUES ANTICHOLINERGICS ANTICHOLINERGIQUES ATROPINE ATROPINE Dps Oph 1% Isopto Atropine 00035017 ALC AEFGVW Gttes CYCLOPENTOLATE CYCLOPENTOLATE Liq Oph 1% Cyclogyl 00252506 ALC AEFGVW Liq HOMATROPINE HOMATROPINE Liq Oph 2% Isopto Homatropine 00000779 ALC AEFGVW Liq Liq Oph 5% Isopto Homatropine 00000787 ALC AEFGVW Liq DECONGESTANTS AND ANTIALLERGICS DÉCONGESTIONNANTS ET ANTIALLERGIQUES OTHER ANTIALLERGICS AUTRES ANTIALLERGIQUES CROMOGLICIC ACID ACIDE CROMOGLICIQUE Liq Oph 2% Cromolyn Ophthalmic Solution 02009277 PDP f AEFGVW Liq Opticrom 02230621 ALL f AEFGVW February 2014 / février 2014 Page 199

S01X S01GX09 S01XA S02 S02A S01XA03 S02AA S02C S02AA14 S02AA30 S02CA S02CA02 OLOPATADINE OLOPATADINE Liq Oph 0.2% Pataday 02362171 ALC AEFGVW Liq OTHER OPTHALMOLOGICALS AUTRES OPTHALMOLOGIQUES OTHER OPTHALMOLOGICALS AUTRES OPTHALMOLOGIQUES SODIUM CHLORIDE, HYPERTONIC CHLORURE DE SODIUM, HYPERTONIQUE Dps Oph 5% Muro 128 00750824 BSH f AEFGVW Gttes Ont Oph 5% Muro 128 00750816 BSH AEFGVW Ont OTOLOGICALS AGENTS OTOLOGIQUES ANTIINFECTIVES ANTIINFECTIEUX ANTIINFECTIVES ANTIINFECTIEUX GENTAMICIN GENTAMICINE Dps Ot 0.3% Garamycin 00512184 FRS f AEFGVW Gttes Sandoz Gentamicin 02229441 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 00674222 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 00074454 PAL AEFGVW Gttes February 2014 / février 2014 Page 200

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 02230386 SDZ f AEFGVW Liq (Disc/non disp Mar 27/15) Cortisporin (Disc/non disp Dec 10/14) 01912828 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 02224623 SAV f AEFGV Gttes Sandoz Opticort (Disc/non disp Mar 21/14) 02247920 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) 01980580 SDZ AEFGVW Ont Sus Oph 0.2%/1% Pentamycetin/HC(Disc/non disp Mar 21/14) 01980572 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 00682217 FRS f AEFGVW Liq Sandoz Pentasone 02244999 SDZ f AEFGVW ALLERGENS ALLERGENES ALLERGENS ALLERGENES ALLERGEN EXTRACTS EXTRAITS D'ALLERGENES VARIOUS ALLERGEN EXTRACTS DIVERS EXTRAITS D'ALLERGENE Liq Inj Allergy Sera * 00999938 HJM EF-18G Liq February 2014 / février 2014 Page 201

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 * 01981250 NVR f AEFGVW Pds. pms-deferoxamine * 02243450 PMS f AEFGVW Deferoxamine Mesilate * 02247022 HOS f AEFGVW Pws Inj 500mg Desferal * 01981242 NVR f AEFGVW Pds. pms-deferoxamine * 02242055 PMS f AEFGVW Deferoxamine Mesilate * 02241600 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 00755338 PMS f AEFGVW Pds. Kayexalate 02026961 SAV f AEFGVW Sus Orl 250mg Solystat 00769541 PDP W Susp. DETOXIFYING AGENTS FOR ANTINEOPLASTIC TREATMENT AGENTS DÉTOXIFIANTS POUR TRAITEMENT ANTINÉOPLASIQUE CALCIUM FOLINATE FOLINATE DE CALCIUM Tab Orl 5mg Leucovorin Calcium 02170493 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 80027202 NVR G Eff. February 2014 / février 2014 Page 202

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 00501190 ODN AEFGVW Caps February 2014 / février 2014 Page 203

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

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

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

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

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

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

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

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

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 4349121 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

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

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

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% 00901113 AEFGV Anthralin Soft Paste 0.05% 00902063 AEFGV Anthralin Soft Paste 0.1% 00900907 AEFGV Anthralin Soft Paste 0.2% 00900915 AEFGV Anthralin Weak Ointment 0.2% 00901105 AEFGV Disulfiram powder 00999087 AEFG Hydrochlorothiazide powders and suspensions for oral use 00999106* AEFGV Hydrocortisone powder for topical applications >0.5% 00990841* AEFGV LCD (Coal Tar Solution) in compounds for topical applications 00358495* AEFGV Meclizine Powder 00903076 AEFGV Prednisone powders and suspension for oral use 00999108* AEFGV Progesterone powder in compounds for topical application 00990876* AEFGV Propylene Glycol Liquid in compounds for topical applications 00990884* ABEFGV Salicylic Acid in compounds for topical applications 00900788* AEFGV Saturated Solution Potassium Iodide 00999105* AEFGV Spironolactone powders and suspensions for oral use 00999107* AEFGV Sulphur in compounds for topical applications 00900826* AEFGV * This PIN must be used to submit claims for any strength of this extemporaneous preparation. February 2014 A - 12

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 http://www.hcsc.gc.ca/hl-vs/iyh-vsv/med/med-gen-eng.php. February 2014 A - 13

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: 506-867-4872 Toll Free Fax: 1-888-455-8322 NBPDP Inquiry Line: 1-800-332-3691 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: 506-867-4339 Toll Free Fax: 1-866-770-7746 Toll Free Telephone: 1-800-332-3691 February 2014 A - 14

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

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

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

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

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

- 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

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

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. http://www.gnb.ca/0212/alzheimers-e.asp 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

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

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 1. 2. 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. 30-49 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

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

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

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 1-800-332-3691 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

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

* 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

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

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 38.5 0 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 01968017 Patients > 70 Kg use 1.6 ml vial (480mcg) PIN 00999001 2. 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

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

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

- 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

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

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

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

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

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

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

calculator available on www.uptodate.com * 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 1-888- RevAid1 or log onto www.revaid.ca. 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

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 1 50-65% 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

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) 2352656 2352664 2352672 2352680 2231171 0.4mL 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 2236564 3mL x 5 vials = 15mL Enoxaparin sodium (Lovenox HP) 120mg/0.8mL prefilled syringe 150mg/mL prefilled syringe Nadroparin calcium (Fraxiparin Forte) 2242692 2378469 0.8mL x 10 syringes = 8mL 1mL x 10 syringes = 10mL 19,000IU/mL prefilled syringe 2240114 0.6mL 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 2167840 2229515 2231478 2mL 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

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 00999734 Chronic pain 00999801 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 02394618. 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 00903823 Chronic pain 00903825 10mg/mL oral concentrate Opioid dependence 00903824 Chronic pain 00903826 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

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

o OR FEV 1 50-65% 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

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

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 00903741) 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 00999505) 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

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

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) http://www.shef.ac.uk/frax/tool.jsp?lang=en 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 > - 2.5-2.5 to - 3.8 < - 3.8 55 > - 2.5-2.5 to - 3.8 < - 3.8 60 > - 2.3-2.3 to - 3.7 < - 3.7 65 > - 1.9-1.9 to - 3.5 < - 3.5 70 > - 1.7-1.7 to - 3.2 < - 3.2 75 > - 1.2-1.2 to - 2.9 < - 2.9 80 > - 0.5-0.5 to - 2.6 < - 2.6 85 > +0.1 + 0.1 to - 2.2 < - 2.2 Age (years) Low Risk < 10% Men 10-YEAR RISK Moderate Risk 10% - 20% High Risk > 20% LOWEST T-SCORE femoral neck 50 > -2.5-2.5 to - 3.9 < - 3.9 55 > -2.5-2.5 to - 3.9 < - 3.9 60 > -2.5-2.5 to - 3.7 < - 3.7 65 > -2.4-2.4 to - 3.7 < - 3.7 70 > -2.3-2.3 to - 3.7 < - 3.7 75 > -2.3-2.3 to - 3.8 < - 3.8 80 > -2.1-2.1 to - 3.8 < - 3.8 85 > -2.0-2.0 to - 3.8 < - 3.8 1 Ref: Can Assoc Radiol J, 2011; 62(4): 243-50 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

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

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

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

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

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

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

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 1. 2. 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. 30-49 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

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

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

**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

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 10-15 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

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

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;289-96. 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

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

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

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

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

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

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

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