P.E.I. Pharmacare Formulary PEI Pharmacare Formulary …………………………………………………Page - 1 -

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P.E.I. Pharmacare Formulary
PEI Pharmacare Formulary …………………………………………………Page - 1 -
Inquiries should be directed to:
PEI Pharmacare
Health PEI
P.O. Box 2000, 20 Fitzroy St.
Charlottetown, PEI
C1A 7N8
Telephone inquiries should be directed to:
Client Eligibility
Prescriber Eligibility
Medication Eligibility
Pharmacy Eligibility
Pharmacist Eligibility
Claim Inquiries
Special Authorization Drug Status
Formulary Inquiries
1-902-368-4947 Charlottetown
1-877-577-3737 Toll Free in PEI
1-902-368-4905 Fax
Pharmacy Information Program (PhIP)
Inquiries and Technical Support Help Desk
628-3772 Charlottetown
1-877-201-6771 Toll Free in PEI
7:00 am to 12:00 midnight
7 days per week
Published by the authority of the Minister of Health and Wellness, Province of Prince Edward
Island for the exclusive use of PEI Pharmacare
Updated: May 2014
PEI Pharmacare Formulary …………………………………………………Page - 2 -
THE FORMULARY
The Prince Edward Island Pharmacare Formulary is a listing of therapeutically effective
medications approved for coverage including those considered therapeutically interchangeable
under the:
AIDS/HIV Program
Catastrophic Drug Program (Oct 1, 2013)
Community Mental Health Program
Children in Care Program
Cystic Fibrosis Progarm
Diabetes Control Program
Erythropoietin Program
Family Health Benefit Program
Financial Assistance Program
Growth Hormone Program
Hepatitis Program
High Cost Drug Program
Immunization Program
Institutional Pharmacy Program
Intron A Program
Meningitis Program
Nursing Home Program
Nutrition Services Program
Phenylketonuria (PKU) Program
Quit Smoking Program
Rabies Program
Rheumatic Fever Program
Seniors Drug Cost Assistance Program
Sexually Transmitted Diseases Program
Transplant Drug Program
Tuberculosis Program
It is compiled on behalf of the Minister of Health and Wellness based upon recommendations
from either the Atlantic or Canadian Expert Drug Advisory Committees, or the Joint Oncology
Drug Review Committee.
Medications in the Formulary are listed by Therapeutic Categories developed by the American
Society of Hospital Pharmacists.
The PEI Pharmacare Formulary may be downloaded from the Health PEI website at –
www.healthpei.ca/pharmacare
PEI Pharmacare Formulary …………………………………………………Page - 3 -
PRINCE EDWARD ISLAND DRUG PROGRAMS
Program
(Formulary Code)
Beneficiaries
Benefits
(Note: A
prescription is
required for all
benefits)
Fee
Programs Delivered Through Community Retail Pharmacies
Children-In-Care
Program
(W)
Persons in temporary
or permanent
custody of the
Director of Child
Welfare
All prescription
medications.
Non-prescription
medications
approved under the
Financial Assistance
Program
No fee.
Diabetes Control
Program
(D)
Persons eligible for
PEI Medicare,
diagnosed with
diabetes, and
registered with the
program.
Approved insulin
products
$10.00 per 10 mL vial
of insulin.
$20.00 per box of
insulin cartridges.
Approved oral
diabetes
medications
$11.00 per
prescription
Approved urine
testing materials
(Diastix and
Ketostix)
$11.00 per
prescription
Approved high cost
diabetes
medications.
Patients must apply
for coverage on an
annual basis and
provide income
information to the
program.
An income-based
portion of the
medication cost plus
the pharmacy
professional fee for
each prescription
obtained.
Blood Glucose test
strips. Patients must
have used insulin
within 150 days.
$11 per dispense.
Maximum of 100
strips per 30 days.
Financial
Assistance
Program
(W)
Persons eligible
under the Social
Assistance Act and
Regulations.
Approved
prescription and
non-prescription
medications.
No fee.
Family Health
Benefit Program
Families (parents,
guardians, and
Approved
prescription
The pharmacy
professional fee for
PEI Pharmacare Formulary …………………………………………………Page - 4 -
Program
(Formulary Code)
Beneficiaries
Benefits
(Note: A
prescription is
required for all
benefits)
medications.
Fee
(F)
children under 25
years of age) eligible
for PEI Medicare,
with at least one
child under 25 years
of age who is still
attending school full
time, and a total
annual net family
income less than
$24,800, plus $3,000
for each additional
child. Families must
apply for coverage
on an annual basis
and provide income
information to the
program.
High Cost Drugs
Program
(M)
Persons eligible for
PEI Medicare and
approved for
coverage for one or
more of the
medications included
in the program.
Patients must apply
for coverage on an
annual basis and
provide income
information to the
program.
Approved high cost
medications.
An income-based
portion of the
medication cost plus
the pharmacy
professional fee for
each prescription
obtained.
Nursing Home
Program
(N)
Residents in private
nursing homes
eligible for coverage
under the Social
Assistance Act.
Approved
prescription and
non-prescription
medications.
No fee.
Quit Smoking
Program
(Z)
Persons eligible for
PEI Medicare and
who have registered
with the program by
phone at
1-877-513-5333
Approved
prescription and
non-prescription
medications.
The program will pay
for the first $75.00 of
prescriptions for
approved medications
per year. Patients are
responsible for all
additional medication
each prescription
obtained.
PEI Pharmacare Formulary …………………………………………………Page - 5 -
Program
(Formulary Code)
Beneficiaries
Benefits
(Note: A
prescription is
required for all
benefits)
Fee
costs.
Seniors Drug Cost
Assistance Plan
(S)
Catastrophic Drug
Program
(Q)
Effective Oct 1,
2013
Persons eligible for
PEI Medicare and 65
years of age or older.
Eligibility is effective
upon a person
becoming 65 years
of age.
Approved
prescription
medications.
First $8.25 of the
medication cost plus
the pharmacy
professional fee for
each prescription
obtained.
PEI permanent
residents with a
PEI Health card
whose household
members have up
to date tax filings
and are
experiencing out
of pocket eligible
drug expenses
that exceed their
annual household
limit.
Out of pocket
costs for eligible
drug expenses
This is an income
based program.
Once an
applicant’s out of
pocket eligible
drug expenses
exceed the annual
household limit the
program will cover
any further eligible
drug expenses in
the program year.
Approved antibiotics
No fee.
Eligible drug
expenses are
expenses
incurred for drugs
designated as
having coverage
under the
Catastrophic
Program- (Q)
listed on the PEI
formulary.
Sexually
Transmitted
Diseases (STD)
Program/ Opiod
Replacement
Therapy Program
Persons diagnosed
with a sexually
transmitted disease
or identified contacts
of a person
diagnosed with a
sexually transmitted
PEI Pharmacare Formulary …………………………………………………Page - 6 -
Program
(Formulary Code)
Beneficiaries
(V)
disease
Benefits
(Note: A
prescription is
required for all
benefits)
Fee
Programs Delivered Through the Provincial Pharmacy
Note: Beneficiaries are responsible for arranging for and paying for delivery of
medications obtained through the Provincial Pharmacy.
AIDS/HIV Program
(A)
Persons diagnosed
as HIV positive,
diagnosed with
AIDS, or with a non
work related needlestick injury and no
private insurance;
and registered with
the program through
the Chief Health
Officer.
Approved
antiretroviral agents
and adjunctive
therapies
No fee.
Community Mental
Health Program
(B)
Approved long-term
psychiatric patients
living in the
community.
Approved longacting injectable
antipsychotic
medications
provided through
out-patient
psychiatric
programs.
No fee.
Cystic Fibrosis
Program
(C)
Persons eligible for
PEI Medicare,
diagnosed with cystic
fibrosis, and who are
registered with the
program.
Approved
prescription and
non-prescription
medications.
No fee.
Growth Hormone
Program
(G)
Children eligible for
PEI Medicare, with a
proven growth
hormone deficiency
or Turners
Syndrome, and who
are registered with
the program.
Approved growth
hormone
supplements.
No fee.
Hepatitis Program
(H)
Persons diagnosed
with hepatitis C
Intron A (Interferon
alfa-2b) injections.
No fee
Pegatron (peg
Interferon alfa-2b
PEI Pharmacare Formulary …………………………………………………Page - 7 -
Program
(Formulary Code)
Beneficiaries
Benefits
(Note: A
prescription is
required for all
benefits)
and Ribavirin)
Fee
Persons who have
been in close contact
with a person
diagnosed with
hepatitis or are at
risk of infection.
Hepatitis A vaccine
No fee
Persons with an
occupational risk of
infection.
Hepatitis A vaccine
Hepatitis B vaccine
Hepatitis A & B
vaccine
Vaccine may be
purchased at cost.
Hepatitis B vaccine
Hepatitis A & B
vaccine
Immunization
Program
(I)
Children and persons
at risk for exposure
to various
communicable
diseases.
Vaccines for various
communicable
diseases.
Please contact the
local Public Health
Nursing office.
Institutional
Pharmacy Program
(N)
Residents in
government manors.
Approved
prescription and
non-prescription
medications.
No fee.
Intron A (Interferon
alfa-2b) Program
(J)
Persons eligible for
PEI Medicare; have
been diagnosed with
with Hairy Cell
Leukemia, AIDSrelated Kaposis
Sarcoma, and Basal
Cell Carcinoma; who
cannot afford the
costs, or who do not
have third party
coverage; and have
been registered with
the program through
the Chief Health
Officer.
Intron A (Interferon
alfa-2b) injections
No fee.
Meningitis Program
(K)
Persons who have
been in close contact
with a person
diagnosed with
Approved anibiotics
The copay is
reimbursed for
persons with private
drug insurance.
No fee.
PEI Pharmacare Formulary …………………………………………………Page - 8 -
Program
(Formulary Code)
Beneficiaries
Benefits
(Note: A
prescription is
required for all
benefits)
Fee
meningitis or are at
risk of infection.
Nutrition Services
Program
(O)
High-risk pregnant
women diagnosed
with a nutritional
deficiency.
Approved vitamin
and mineral
supplement
provided through
Community
Nutritionists.
No fee.
Phenylketonuria
(PKU) Program
(P)
Persons eligible for
PEI Medicare,
diagnosed with
phenylketonuria, and
who are registered
with the program.
Special low protein
formulae.
No fee.
Rheumatic Fever
Program
(U)
Persons eligible for
PEI Medicare and
who have a
well-documented
history of rheumatic
fever or rheumatic
heart disease, and
are registered with
the program.
Approved
prophylactic
antibiotics
No fee.
Transplant Drugs
Program
(T)
Persons eligible for
PEI Medicare, who
received a bone
marrow or solid
organ transplant, and
are registered with
the program.
Approved
immunosuppressant
medications
No fee.
Tuberculosis (TB)
Drug Program
(X)
Persons diagnosed
with tuberculosis or
who have been in
close contact with a
person diagnosed
with tuberculosis,
and who have
registered with the
program through the
Chief Health Officer.
Approved antibiotics
No fee.
Programs Delivered Through Hospitals
PEI Pharmacare Formulary …………………………………………………Page - 9 -
Program
(Formulary Code)
Beneficiaries
Erythropoietin
Program
(E)
Persons eligible for
PEI Medicare, have
been diagnosed with
chronic renal failure
or are receiving
kidney dialysis.
Rabies Program
(R)
Persons with
exposure to or at risk
for exposure to
rabies through an
animal bite.
Benefits
(Note: A
prescription is
required for all
benefits)
Approved
erythropoietin
injections
Fee
Rabies vaccine and
immunoglobulin
No fee.
No fee.
FORMULARY REVIEW PROCESS
The coverage of new pharmaceutical products, new dosage forms and new strengths of existing
products, and new uses for existing products must be approved on the authority of the Minister of
Health and Wellness. The approval is based, in part, upon review by and recommendations received
from either the Canadian Expert Drug Advisory Committee (CEDAC), the Atlantic Expert Advisory
Committee (AEAC) or the Pan Canadian Oncology Drug Review ( P-CODR).
The membership of these committees includes practicing physicians, pharmacists, and experts in drug
evaluation. They review and evaluate scientific and economic information on new pharmaceutical
products and make a recommendation to participating federal, provincial, and territorial government
drug programs on whether a drug should be listed as a program benefit, including any conditions
and/or criteria for coverage.
PEI Pharmacare Formulary …………………………………………………Page - 10 -
National Common Drug Review
PEI Pharmacare is a participant in the national Common Drug Review (CDR). The CDR provides
participating federal, provincial and territorial drug benefit programs 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 Expert Drug Advisory Committee (CEDAC).
Submissions for new chemical entities, new combination products, and resubmissions related to these
products should be filed with the CDR Directorate. Information on the CDR requirements and
procedures are posted at: www.cadth.ca.
Atlantic Common Drug Review
PEI Pharmacare is a participant in the Atlantic Common Drug Review (ACDR). The ACDR provides
the provincial drug benefit programs in New Brunswick, Newfoundland and Labrador, Nova Scotia, and
Prince Edward Island with a systematic review of the best available clinical evidence and a formulary
listing recommendation made by the Atlantic Expert Advisory Committee (AEAC).
Submissions for new single source products that do not contain new chemical entities, line extensions,
new indications for products released prior to CEDAC, and resubmissions for products reviewed prior
to CEDAC should be sent to the drug programs within each of the four Atlantic provinces. The Prince
Edward Island copy should be sent to:
PEI Pharmacare
Health PEI
P.O. Box 2000, 20 Fitzroy St.
Charlottetown, PE C1A 7N8
Products are normally reviewed in the order of receipt of complete submissions. However, there can
be exceptions to this. There is no fast tracking of products or pre-NOC reviews.
Information on the ACDR requirements and procedures are posted at:
www.gov.ns.ca/health/pharmacare/acdr.htm
Pan Canadian Oncology Drug Review
PEI is a participant in the Pan Canadian Oncology Drug Review ( P-CODR) Process. This process
provides participating federal, provincial and territotial drug benefit programs with a systematic review
of the best available clinical evidence and a formulary listing recommendation for oncology medications
by an Expert Advisory Committee.
Submissions for new oncology medications and re-submissions related to these products should be
directed through this process. More information on P-CODR please reference the following web site:
http://www.pcodr.ca
PEI Pharmacare Formulary …………………………………………………Page - 11 -
INTERCHANGEABLE PRODUCTS
The process for adding medications to the PEI Pharmacare Interchangeable/Maximum Reimbursable
Price (MRP) list has been revised effective July 1, 2012.
Submission Process
All submissions for the addition of products to the PEI Pharmacare Interchangeable/ Maximum
Reimbursable Price (MRP) list must be made electronically by email only. Fax, paper, or CD
(compact disk) submissions will not be accepted.
All documents must be in an Adobe Acrobat PDF format.
Submissions must not be made until there is product ready for sale and shipment to PEI pharmacies.
Pre-Notice of Compliance (NOC) submissions will not be accepted.
Complete submissions must be received by 4:00 pm Atlantic Standard Time on the last business day of
the previous month and be at a price of no more than 25% of the reference brand price in order to be
considered for the next monthly update.
If the price is more than 25% of the reference brand price then the manufacturer must submit, in detail,
the reasons and this will be considered. The time frame required to determine eligibility of price
exceptions cannot be guaranteed.
Submissions must be sent to: PEI Pharmacare( MRP Submissions)
Health PEI
P.O. Box 2000, 20 Fitzroy St.
Charlottetown, PE C1A 7N8
email: [email protected]
The subject of all email submissions must be “MRP List Submission”.
Email submissions must not exceed 5 megabytes in size. Submissions may be sent as compressed
“zip” files.
An email confirmation will be sent to manufacturers to notify them that submissions are considered to
be complete and to confirm availability and pricing. Questions regarding the submission will also be
sent to manufacturers by email.
PEI Pharmacare will not be responsible for any errors in submissions noted by manufacturers after the
submission cut-off date (i.e. 4:00 pm on the last business day of the month immediately prior to the
update).
Submissions will be reviewed by drug program staff.
PEI Pharmacare Formulary …………………………………………………Page - 12 -
Submission Requirements
The following information must be contained in the submission and should be compiled in the following
order:
1. Cover Letter or Executive Summary.
2. The name, phone number, and email address of a person that may be contacted regarding the
submission.
3. Copy of the Notice of Compliance (NOC) issued by Health Canada or, for drug products without
a Notice of Compliance, the Drug Notification Form.
4. At least one of the following types of evidence that each dosage form and strength of the
submitted product is interchangeable with the same dosage forms and strengths of the original
product:
a.
The dosage form, strength, formula, manufacturing process, and testing standards
of the submitted drug product are identical to those of the original drug product to which
it is compared (i.e. the new product is an “ultra-generic” of the original drug product).
OR
b. The drug product is designated by Health Canada as being equivalent to the original
product the drug product is being compared with, through designation of the original
drug product as the Canadian Reference Product under the Food and Drug
Regulations (Canada).
5. Copy of the Health Canada approved Product Monograph.
6. Current price for all dosage forms and strengths.
7. A signed letter stating that the manufacturer is able to supply the drug product in quantities
sufficient to meet the anticipated demand in the province.
8. A signed letter authorizing unrestricted communication regarding the drug product between PEI
Pharmacare 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)
PEI Pharmacare Formulary …………………………………………………Page - 13 -
Determination of Interchangeability
Products may be designated as being interchangeable with products already covered by PEI
Pharmacare if:
1. The new product contains the same amounts of the same active ingredients in a similar dosage
form as the listed products.
AND
2. The new product is currently available to all PEI Pharmacies in quantities sufficient to meet
anticipated demand.
AND
3. The manufacturer provides the following evidence of interchangeability with the listed products:
a) The dosage form, strength, formula, manufacturing process, and testing standards of the
submitted drug product are identical to those of the original drug product to which it is
compared (i.e. the new product is an “ultra-generic” of the original drug product).
OR
b) The drug product is designated by Health Canada as being equivalent to the original
product the drug product is being compared with, through designation of the original
drug product as the Canadian Reference Product under the Food and Drug Regulations
(Canada).
If;
a) The drug product that Health Canada identifies in the Notice of Compliance as
the Canadian Reference Product is not listed as interchangeable in the PEI
Pharmacare Formulary.
OR
b) The drug product has a Health Canada designated DIN however no Notice of
Compliance has been issued by Health Canada (neither the brand nor the
generic have a Notice of Compliance).
OR
c) The generic product has a Health Canada designated Notice of Compliance of
the New Drug Submission (NDS) type. This Notice of Compliance submission
type does not explicitly state any reference, Canadian or otherwise.
OR
d) The generic product has a non-Canadian Reference Product.
OR
e) Line extensions.
THEN:
The drug product being submitted for interchangeability must be listed as
interchangeable in three or more Canadian jurisdictions and at least one of those
jurisdictions must be an Atlantic province.
PEI Pharmacare Formulary …………………………………………………Page - 14 -
PEI Pharmacare may refuse to designate a product as being interchangeable, although it meets the
above conditions, if drug program staff considers it advisable in the public interest to do so.
Products that have not been designated as being interchangeable may still be listed in the Formulary
along with a note specifically indicating they are not interchangeable with other similar products listed in
the Formulary.
PEI Pharmacare Formulary …………………………………………………Page - 15 -
SUBMISSION REQUIREMENTS FOR BRAND PRODUCTS
All submissions should be made electronically by email only. All documents must be in an Adobe
Acrobat PDF format. Due to technical limitations individual email submissions must not exceed 5
megabytes in size. Submissions may be sent as compressed “zip” files.
Submission Requirements
The following information must be contained in the submission and should be compiled in the following
order:
1.
Cover Letter or Executive Summary.
2.
The name, phone number, and email address of a person that may be contacted regarding the
submission.
3.
Copy of the Notice of Compliance (NOC) issued by Health Canada.
4.
Copy of the Health Canada approved Product Monograph.
5.
Current price for all dosage forms and strengths.
6.
A signed letter stating that the manufacturer is able to supply the drug product in quantities
sufficient to meet the anticipated demand in the province.
7.
A signed letter authorizing unrestricted communication regarding the drug product between PEI
Pharmacare and
a.
b.
c.
d.
e.
8.
Other federal, provincial, and territorial (F/P/T) drug programs
F/P/T health authorities and related facilities
Health Canada
Patented Medicine Prices Review Board (PMPRB)
Canadian Agency for Drugs and Technologies in Health (CADTH)
A Budget Impact Analysis (BIA).
For More Information
For more information on the submission process, please contact:
B. Roy Cairns
Pharmacy Consultant
Department of Health and Wellness
P.O. Box 2000, 20 Fitzroy St.
Charlottetown, PE C1A 7N8
phone: 902-368-4907
fax:
902-368-4905
email: [email protected]
PEI Pharmacare Formulary …………………………………………………Page - 16 -
PRODUCT DELETIONS
Except where the manufacture of a product is discontinued or approval for sale of a product in Canada
is withdrawn, the deletion of products from the Formulary must be approved on the authority of the
Minister of Health and Wellness.
SPECIAL AUTHORIZATION DRUG STATUS
Under the AIDS/HIV, Diabetes Control, Family Health Benefit, Financial Assistance, High Cost Drugs,
Institutional Pharmacy, Nursing Home, Seniors , and Transplant Drugs Programs certain drug products
may be considered for Special Authorization (SA) coverage under the following circumstances:
1.
Therapeutic alternatives listed in the Formulary are contraindicated or have been found
to be ineffective; or
2.
Drugs for which there is no alternative listed in the Formulary.
SA coverage will not be considered for medications that have not yet been reviewed for coverage by
the Atlantic Expert Advisory Committee (AEAC), the Canadian Expert Drug Advisory Committee
(CEDAC), the Pan Canadian Oncology Drug Review (P-CODR) or that have received a negative
recommendation from one of these expert advisory committees.
SA coverage will normally only be approved for the treatment of indications and in dosages listed in the
official product monograph approved by Health Canada and published in the most recent edition of the
Compendium of Pharmaceuticals and Specialities (CPS).
See Appendix A for further detail regarding the SA process.
"NO-SUBSTITUTION" PRESCRIPTIONS
Both generic and brand name products are manufactured under the same standards of good
manufacturing practice, and only those brands which meet accepted standards of equivalence are
accepted as interchangeable in Prince Edward Island.
Unless special authorization is granted, clients must pay the pharmacy the standard co-pay, plus any
cost difference between the brand name requested and the price paid by government for the least
expensive interchangeable product.
In cases where a patient experiences problems with a specific brand of medication (e.g. a documented
allergy) and has tried all interchangeable products, a prescriber may apply to PEI Pharmacare for
exemption from the cost of the higher cost brand by submitting a completed Special Authorization
Request form.
PEI Pharmacare Formulary …………………………………………………Page - 17 -
EXTEMPORANEOUS PREPARATIONS
Extemporaneous preparations are defined as a drug or mixture of drugs prepared or compounded in a
pharmacy according to the orders of a prescriber.
To be eligible as a benefit, extemporaneous preparations must:
1.
Be for external use;
2.
Be specifically tailored to a prescription;
3.
Contain one or more medications presently listed as a benefit under the Program for
which the person is eligible and all of which are considered a therapeutic benefit in the
concentrations and manner used (subject to the review procedure for SA coverage, if
deemed appropriate); and
Not duplicate the formulation of a manufactured drug product, dilute or alter its
formulation, as to result in a product of equivalent therapeutic advantage or one which
offers no clear therapeutic advantage relative to a listed benefit.
4.
Claims for extemporaneous preparations are to be submitted electronically using the major ingredient
DIN and the appropriate CPhA compound type code.
Claims for extemporaneous preparations intended for internal use will be considered under Special
Authorization Status.
EXCLUSIONS
The following are excluded as benefits under PEI Pharmacare:
$
$
All benefits a person is entitled to under any other provincial or federal program (e.g. Workers
Compensation, Department of Veterans Affairs, Indian Affairs, etc.) or legislation.
The following classes of products, except for those specifically listed in the Formulary:
$
Over-the-counter (OTC) or non-prescription medications (some programs)
$
Dietary and nutritional supplements (e.g. Ensure, Boost)
$
Weight loss products
$
Soaps, cleansers, and shampoos
$
Oral ergoloid mesylates (i.e. Hydergine)
$
Peripheral vasodilators (e.g. Arlidin)
$
Combination anti-spasmodic/sedative products (e.g. Donnatal, Librax, Stelabid)
$
Combination sedative/analgesic products (e.g. Fiorinal, Tecnal)
$
Allergy serums
$
Products for the treatment of impotence or infertility.
$
Diagnostic agents (except diabetes)
$
Prostheses, medical devices and appliances, and medical supplies, including first aid
supplies and syringes
PEI Pharmacare Formulary …………………………………………………Page - 18 -
PRESCRIPTION QUANTITIES
Based on the negotiated Pharmacy Services Contract between the Province and the PEI Pharmacists’
Association and due to possible wastage as well as the potential danger of storing large quantities of
potent drugs in the home, all PEI Pharmacare programs have limits on the maximum days supply of
drugs that will be paid for at one time. These limits are:
Program
Maximum Allowable Days Supply
Private Nursing Home Program
35
Institutional Pharmacy Program ( Gov’t
Manors)
35
AIDS/HIV Program
Catastrophic Drug Program
(effective October 1, 2013)
60
Children-In-Care Program
30 - regular drugs, 90 - maintenance drugs
30 - drugs under SA coverage
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
30 - regular drugs, 90 - maintenance drugs
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
Community Mental Health Program
not applicable
Cystic Fibrosis Program
60
Diabetes Control Program
30 – insulin and test strips 90 - oral medications;
30 - drugs under SA coverage
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
not applicable
Erythropoietin Program
Family Health Benefit Program
Growth Hormone Program
30 - regular drugs, 90 - maintenance drugs
30 - drugs under SA coverage
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
30 - regular drugs, 90 - maintenance drugs
30 - drugs under SA coverage
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
30
Hepatitis Program
30
Financial Assistance Program
PEI Pharmacare Formulary …………………………………………………Page - 19 -
Program
High Cost Drugs Program
Maximum Allowable Days Supply
30, unless otherwise specified in criteria for
drug(s).
Immunization Program
not applicable
Intron A Program
30
Nutrition Services Program
not applicable
Phenylkentonuria Program
60
Rheumatic Fever Program
60
Seniors Drug Cost Assistance Plan
30 - regular drugs, 90 - maintenance drugs
30 - drugs under SA coverage
Note: Prescriptions introducing a new
medication, strength, dosage, or dosage form
shall be filled for a maximum 30 days for the
first two prescriptions or refills.
not applicable
7 days – OTC Drugs ; 14 days – Prescription
drugs
Sexually Transmitted Diseases Program
Smoke Program
Transplant Drugs Program
60
Tuberculosis Drug Program
60
Rabies Program
not applicable
Maintenance drugs under the Children-In-Care, Family Health Benefit, Financial Assistance, and
Seniors Programs include:
a.
Antilipemic agents, including statins, fibrates, and bile acid sequestrants.
b.
Oral nonsteroidal anti-inflammatory agents (NSAIDS), as well as Acetaminophen 325
mg & 500mg tablets.
c.
Gastrointestinal agents, including digestants, histamine H2 antagonists, prostaglandins,
protectants, and proton pump inhibitors.
d.
Cardiovascular Drugs, including beta blockers, calcium channel blockers, ACE
inhibitors, angiotensin receptor blockers. Nitroglycerin transdermal patches are not
included.
e.
Antihypertensives, including beta blockers, calcium channel blockers, ACE inhibitors,
angiotensin receptor blockers.
f.
Anticonvulsants, except for Lamotrigine, Topiramate, and Vigabatrin.
g.
Anti-Coagulants
h.
Diuretics
PEI Pharmacare Formulary …………………………………………………Page - 20 -
i.
Estrogens/Progestogens, including oral contraceptives and products for the prevention
of menopause symptoms.
j.
Tamsulosin for use in benign prostatic hyperplasia (BPH).
k.
Thyroid preparations
l.
Other therapeutic classifications or specific drugs which may be listed following
negotiations with the P.E.I. Pharmacists’ Association.
Maintenance drugs are identified in the formulary by an asterix (*) preceding the non-proprietary or
generic name.
PEI Pharmacare Formulary …………………………………………………Page - 21 -
LEGEND
08:00 ANTI-INFECTIVE AGENTS
1
08:12.16 ANTIBIOTICS PENICILLINS
*AMOXICILLIN
250MG CAPSULE
00406724
2
3
4
5
00628115
00865567
02041294
02181487
02238171
NOVAMOXIN
6
NOP
APO-AMOXI
NU-AMOXI
AMOXIL
LIN-AMOX
GEN-AMOXICILLIN
7
FSW
APX
NXP
WAY
LIN
GPM
FSW
FSW
FSW
FSW
FSW
GLA
FSW
BETALOC DURULES
LOPRESOR SR
AZE
NVR
FSW
FSW
TOPAMAX
JAN
FSW
8
CEFUROXIME AXETIL
SEE APPENDIX A FOR SA CRITERIA
9
250MG TABLET
02212277
CEFTIN (SA)
9
*METOPROLOL TARTRATE
200MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
00497827
00534560
10
TOPIRAMATE
200MG TABLET
02230896
Note: Limited to a maximum 30-day supply of medication.
11
PEI Pharmacare Formulary …………………………………………………Page - 22 -
Legend Key:
1. Pharmacological-Therapeutic classification
2. Pharmacological-Therapeutic sub-classification
3. Non-proprietary or generic name of the drug. Maintenance drugs are identified by an asterix (*)
preceding the generic name.
4. Drug strength and dosage form
5. Drug Identification Number (DIN) assigned by Health Canada or an Identification Number
assigned by PEI Pharmacare for billing purposes only.
6. Brand name of the drug
7. Three letter identification code is assigned to each manufacturer. The codes are listed in the
Formulary.
8. Drug programs for which the product is considered to be a benefit:
A
AIDS/HIV Program
B
Community Mental Health Program
C
Cystic Fibrosis Program
P
Phenylkentonuria (PKU)
Program
Q
Catastrophic Drug Program
(Oct1/13)
D
Diabetes Control Program
R
Rabies Program
E
Erythropoietin Program
S
Seniors Drug Cost
F
Family Health Benefit Program
G
Growth Hormone Program
T
Transplant Drug Program
H
Hepatitis Program
U
Rheumatic Fever Program
I
Immunization Program
V
Sexually Transmitted
J
Intron A Program
K
Meningitis Program
M
High Cost Drugs Program
N
Nursing Home/Institutional
X
Tuberculosis (TB) Program
Pharmacy Programs
Z
Quit Smoke Program
O
Assistance Plan
Diseases (STD) Program
W
Financial Assistance/
Children-In-Care Programs
Nutrition Services Program
9. This product requires Special Authorization Status (SA) approval (see Appendix A for SA
criteria).
10. The products listed are not interchangeable.
11. Special note regarding the product(s) listed in this section.
PEI Pharmacare Formulary …………………………………………………Page - 23 -
04:00.00 ANTIHISTAMINES
CETIRIZINE
10MG TABLET
02223554
02231603
02315955
REACTINE
APO-CETIRIZINE
EXTRA STRENGTH ALLERGY RELIEF
PFI NW
APX NW
PMS NW
DIPHENHYDRAMINE HCL
25MG CAPSULE
00757683
PMS-DIPHENHYDRAMINE
PMS NW
50MG CAPSULE
00757691
PMS NW
PMS-DIPHENHYDRAMINE
12.5MG/5ML ELIXIR
02019736
BENADRYL
MCL NW
50MG/ML INTRAMUSCULAR INJECTION
00596612
DIPHENHYDRAMINE
SDZ
LORATADINE
10MG TABLET
00782696
02243880
SCH W
APX W
CLARITIN
APO-LORATADINE
N
04:04.16 PIPERAZINE DERIVATIVES
FLUNARIZINE HCL
5MG CAPSULE
02246082
APO-FLUNARIZINE
AAA
FNQSW
JAN
FNQW
08:08.00 ANTHELMINTICS
MEBENDAZOLE
100MG TABLET
00556734
VERMOX
PEI Pharmacare Formulary …………………………………………………Page - 24 -
PYRANTEL PAMOATE
125MG TABLET
01944363
COMBANTRIN
PFI
NW
50MG/ML ORAL SUSPENSION
01944355
COMBANTRIN
PFI
NW
GENTAMICIN SULFATE
80MG/2ML INJECTION SOLUTION (2ML)
02242652
GENTAMICIN
SDZ
FNQSW
TOBRAMYCIN
80MG/2ML INJECTION SOLUTION
02241210
TOBRAMYCIN
02382814
TOBRAMYCIN INJECTION USP
SDZ
JPC
CFNQSW
CFNQSW
08:12.02 ANTIBIOTICS AMINOGLYCOSIDES
08:12.04 ANTIBIOTICS ANTIFUNGALS
FLUCONAZOLE
SEE APPENDIX A FOR SA CRITERIA (AIDS/HIV PROGRAM DOES NOT REQUIRE AN SA
REQUEST)
50MG TABLET
02236978
NOVO-FLUCONAZOLE (SA)
NOP AFNQSW
02237370
APO-FLUCONAZOLE (SA)
APX AFNQSW
02245292
MYLAN-FLUCONAZOLE (SA)
MYL AFNQSW
02245643
PMS-FLUCONAZOLE (SA)
PMS AFNQSW
02281260
CO-FLUCONAZOLE (SA)
COB AFNQSW
100MG TABLET
02236979
02237371
02245293
02245644
02281279
NOVO-FLUCONAZOLE (SA)
APO-FLUCONAZOLE (SA)
MYLAN-FLUCONAZOLE (SA)
PMS-FLUCONAZOLE (SA)
CO-FLUCONAZOLE (SA)
NOP
APX
MYL
PMS
COB
150MG TABLET
02141442
02241895
02282348
DIFLUCAN (SA)
APO-FLUCONAZOLE (SA)
PMS-FLUCONAZOLE (SA)
PFI AFNQSW
APX AFNQSW
PMS AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 25 -
ITRACONAZOLE
SEE APPENDIX A FOR SA CRITERIA
100MG CAPSULE
02047454
SPORANOX (SA)
JAN
FNQSW
KETOCONAZOLE
SEE APPENDIX A FOR SA CRITERIA (AIDS/HIV PROGRAM DOES NOT REQUIRE AN SA
REQUEST)
200MG TABLET
02231061
NOVO-KETOCONAZOLE (SA)
NOP AFNQSW
02237235
APO-KETOCONAZOLE (SA)
APX AFNQSW
08:12.06 ANTIBIOTICS CEPHALOSPORINS
CEFIXIME
400MG TABLET
00868981
SUPRAX
AVN V
CEFPROZIL
SEE APPENDIX A FOR SA CRITERIA
250MG TABLET
02163659
CEFZIL (SA)
02292998
APO-CEFPROZIL (SA)
02293528
RAN-CEFPROZIL (SA)
02302179
SANDOZ-CEFPROZIL (SA)
02347245
AURO-CEFPROZIL (SA)
BMS
APX
RAN
SDZ
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
500MG TABLET
02163667
02293005
02293536
02302187
02347253
BMS
APX
RAN
SDZ
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CEFZIL (SA)
APO-CEFPROZIL (SA)
RAN-CEFPROZIL (SA)
SANDOZ-CEFPROZIL (SA)
AURO-CEFPROZIL (SA)
25MG/ML ORAL SUSPENSION
02163675
CEFZIL (SA)
02293943
APO-CEFPROZIL (SA)
02303426
SANDOZ-CEFPROZIL (SA)
BMS FNQSW
APX FNQSW
SDZ FNQSW
50MG/ML ORAL SUSPENSION
02163683
CEFZIL (SA)
02293951
APO-CEFPROZIL (SA)
02303434
SANDOZ-CEFPROZIL (SA)
BMS FNQSW
APX FNQSW
SDZ FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 26 -
125MG/5ML SUSPENSION
02329204
RAN-CEFPROZIL (SA)
RBX FNQSW
CEFTRIAXONE
1.0G/VIAL INTRAMUSCULAR INJECTION
00657417
ROCEPHIN
02287633
CEFTRIAXONE FOR INJECTION
02292270
CEFTRIAXONE FOR INJECTION
02292874
CEFTRIAXONE FOR INJECTION
02325616
CEFTRIAXONE FOR INJECTION
HLR
NOP
SDZ
HOS
STE
NQ
NQ
NQ
NQ
NQ
CEFUROXIME AXETIL
SEE APPENDIX A FOR SA CRITERIA (CYSTIC FIBROSIS AND NURSING HOME
PROGRAMS DO NOT REQUIRE AN SA REQUEST)
250MG TABLET
02212277
CEFTIN (SA)
GSK CFNQSW
02242656
RATIO-CEFUROXIME (SA)
RPH CFNQSW
02244393
APO-CEFUROXIME (SA)
APX CFNQSW
02344823
AURO-CEFUROXIME (SA)
ARO CFNQSW
500MG TABLET
02212285
02242657
02244394
02344831
CEFTIN (SA)
RATIO-CEFUROXIME (SA)
APO-CEFUROXIME (SA)
AURO-CEFUROXIME (SA)
GSK
RPH
APX
ARO
CFNQSW
CFNQSW
CFNQSW
CFNQSW
25MG/ML ORAL SUSPENSION
02212307
CEFTIN (SA)
GSK CFNQSW
CEPHALEXIN MONOHYDRATE
250MG CAPSULE
00342084
NOVO LEXIN
NOP FNQSW
500MG CAPSULE
00342114
NOVO LEXIN
NOP FNQSW
250MG TABLET
00583413
00768723
NOVO-LEXIN
APO-CEPHALEX
NOP CFNQSW
APX CFNQSW
500MG TABLET
00583421
00768715
NOVO-LEXIN
APO-CEPHALEX
NOP CFNQSW
APX CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 27 -
25MG/ML ORAL SUSPENSION
00342106
NOVO-LEXIN
NOP CFNQSW
50MG/ML ORAL SUSPENSION
00342092
NOVO-LEXIN
NOP CFNQSW
08:12.12 ANTIBIOTICS ERYTHROMYCINS
AZITHROMYCIN
SEE APPENDIX A for SA criteria (AIDS/HIV, Cystic Fibrosis, Sexually Transmitted Diseases
and Tuberculosis do not require a SA request)
100MG/5ML
02332388
SANDOZ-AZITHROMYCIN (SA)
SDZ
ACFNQSWVX
200MG/5ML
02332396
SANDOZ-AZITHROMYCIN (SA)
SDZ
ACFNQSWVX
250MG TABLET
02212021
02247423
02255340
02261634
02265826
02274531
02275287
02267845
02278359
02278588
02330881
02415542
ZITHROMAX (SA)
APO-ZITHROMYCIN (SA)
CO-ZITHROMYCIN (SA)
PMS-AZITHROMYCIN (SA)
SANDOZ AZITHROMYCIN (SA)
GD-AZITHROMYCIN (SA)
RATIO-AZITHROMYCIN (SA)
NOVO-AZITHROMYCIN (SA)
MYLAN-AZITHROMYCIN (SA)
PHL-AZITHROMYCIN (SA)
AZITHROMYCIN (SA)
APO-AZITHROMYCIN Z (SA)
PFI
APX
COB
PMS
SDZ
GMD
RPH
NOP
MYL
PHL
SNS
APX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
ACFNQSWVX
600MG TABLET
02231143
02256088
02261642
02330911
ZITHROMYCIN (SA)
CO-AZITHROMYCIN (SA)
PMS-AZITHROMYCIN (SA)
AZITHROMYCIN (SA)
PFI
COB
PMS
SNS
ACFNQSWX
ACFNQSWX
ACFNQSWX
ACFNQSWX
20MG/ML ORAL SUSPENSION
02223716
ZITHROMAX (SA)
02274388
PMS-AZITHROMYCIN (SA)
02274566
GMD-AZITHROMYCIN (SA)
02315157
NOVO-AZITHROMYCIN (SA)
02332388
SANDOZ-AZITHROMYCIN (SA)
PFI
PMS
PMS
NOP
SDZ
ACFNQSWX
ACFNQSWX
ACFNQSWX
ACFNQSWX
ACFNQSWX
PEI Pharmacare Formulary …………………………………………………Page - 28 -
40MG/ML ORAL SUSPENSION
02223724
ZITHROMAX (SA)
02274396
PMS-AZITHROMYCIN (SA)
02274574
GMD-AZITHROMYCIN (SA)
02315165
NOVO-AZITHROMYCIN (SA)
02332396
SANDOZ-AZITHROMYCIN (SA)
PFI
PMS
PMS
NOP
SDZ
ACFNQSWX
ACFNQSWX
ACFNQSWX
ACFNQSWX
ACFNQSWX
CLARITHROMYCIN
SEE APPENDIX A FOR SA CRITERIA (AIDS/HIV, CYSTIC FIBROSIS, AND NURSING
HOME PROGRAMS DO NOT REQUIRE AN SA REQUEST)
250MG TABLET
01984853
BIAXIN (SA)
ABB AFCNQSWX
02247573
PMS-CLARITHROMYCIN (SA)
PMS AFCNQSWX
02247818
RATIO-CLARITHROMYCIN (SA)
RPH AFCNQSWX
02248804
TEVA-CLARITHROMYCIN (SA)
TEV AFCNQSWX
02248856
MYLAN-CLARITHROMYCIN (SA)
MYL AFCNQSWX
02266539
SANDOZ CLARITHROMYCIN (SA)
SDZ AFCNQSWX
02274744
APO-CLARITHROMYCIN (SA)
APX AFCNQSWX
02361426
RAN-CLARITHROMYCIN (SA)
RAN AFCNQSWX
500MG TABLET
02126710
02247574
02247819
02248805
02248857
02266547
02274752
02361434
ABB
PMS
RPH
TEV
MYL
SDZ
APX
RAN
AFCNQSWX
AFCNQSWX
AFCNQSWX
AFCNQSWX
AFCNQSWX
AFCNQSWX
AFCNQSWX
AFCNQSWX
500MG EXTENDED-RELEASE TABLET
02244756
BIAXIN XL (SA)
ABB
CFNQSW
25MG/ML ORAL SUSPENSION
02146908
BIAXIN (SA)
02390442
ACCEL-CLARITHROMYCIN (SA)
02408988
CLARITHTROMYCIN (SA)
ABB CFNQSWX
ACC CFNQSWX
SNS CFNQSWX
50MG/ML ORAL SUSPENSION
02244641
BIAXIN (SA)
02390450
ACCEL-CLARITHROMYCIN (SA)
02408996
CLARITHTROMYCIN (SA)
ABB CFNQSWX
ACC CFNQSWX
SNS CFNQSWX
BIAXIN (SA)
PMS-CLARITHROMYCIN (SA)
RATIO-CLARITHROMYCIN (SA)
TEVA-CLARITHROMYCIN (SA)
MYLAN-CLARITHROMYCIN (SA)
SANDOZ-CLARITHROMYCIN (SA)
APO-CLARITHROMYCIN (SA)
RAN-CLARITHROMYCIN (SA)
PEI Pharmacare Formulary …………………………………………………Page - 29 -
ERYTHROMYCIN BASE
250MG CAPSULE (ENTERIC COATED PELLETS)
00607142
ERYC
00726672
APO-ERYTHRO E C
PFI
AAA
CFNQSW
CFNQSW
333MG CAPSULE (ENTERIC COATED PELLETS)
00873454
ERYC
01925938
APO-ERYTHRO E-C
PFI
AAA
CFNQSW
CFNQSW
250MG TABLET
00682020
AAA
CFNQSVW
APO-ERYTHRO
ERYTHROMYCIN ESTOLATE
50MG/ML ORAL SUSPENSION
00262595
NOVO-RYTHRO ESTOLATE
NOP CFNQSW
ERYTHROMYCIN ETHYLSUCCINATE
600MG TABLET
00637416
APO-ERYTHRO ES
AAA
40MG/ML ORAL SUSPENSION
00605859
NOVO-RYTHRO-EES
NOP CFNQSW
80MG/ML ORAL SUSPENSION
00652318
NOVO-RYTHRO EES
NOP CFNQSW
CFNQSW
08:12.16 ANTIBIOTICS PENICILLINS
AMOXICILLIN
250MG CAPSULE
00406724
00628115
02230243
02238171
02352710
02388073
02401495
NOVAMOXIN
APO-AMOXI
PMS-AMOXICILLIN
MYLAN-AMOXICILLIN
AMOXICILLIN
AURO-AMOXICILLIN
AMOXICILLIN
500MG CAPSULE
00406716
NOVAMOXIN
00628123
APO-AMOXI
NOP
APX
PMS
MYL
SNS
ARO
SIV
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSVW
NOP CFNQSVW
APX CFNQSVW
PEI Pharmacare Formulary …………………………………………………Page - 30 -
PMS
MYL
SNS
ARO
SIV
CFNQSVW
CFNQSVW
CFNQSVW
CFNQSVW
CFNQSVW
25MG/ML ORAL SUSPENSION
00452149
NOVAMOXIN
00628131
APO-AMOXI
02230245
PMS-AMOXICILLIN
02352761
AMOXICILLIN SUGAR REDUCED
02352745
AMOXICILLIN
NOP
APX
PMS
SNS
SNS
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
50MG/ML ORAL SUSPENSION
00452130
NOVAMOXIN
00628158
APO-AMOXI
02230246
PMS-AMOXICILLIN
02352788
AMOXICILLIN SUGAR REDUCED
02352753
AMOXICILLIN
02401541
AMOXICILLIN
NOP
APX
PMS
SNS
SNS
SIV
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
AMOXICILLIN & CLAVULANIC ACID
250MG & 125MG TABLET
02243350
APO-AMOXI CLAV
APX
CFNQSW
500MG & 125MG TABLET
01916858
CLAVULIN
02243351
APO-AMOXI CLAV
02243771
RATIO-AMOXI CLAV
GSK CFNQSW
APX CFNQSW
RPH CFNQSW
875MG & 125MG TABLET
02238829
CLAVULIN
02245623
APO-AMOXI CLAV
02247021
RATIO-ACLAVULANATE
02248138
NOVO-CLAVAMOXIN
GSK
APX
RPH
NOP
25MG & 6.25MG/ML ORAL SUSPENSION
01916882
CLAVULIN
02243986
APO-AMOXI CLAV
02244646
RATIO-AMOXI CLAV
GSK CFNQSW
APX CFNQSW
RPH CFNQSW
50MG & 12.5MG/ML ORAL SUSPENSION
01916874
CLAVULIN
02244647
RATIO-AMOXI CLAV
GSK CFNQSW
RPH CFNQSW
02230244
02238172
02352729
02388081
02401509
PMS-AMOXICILLIN
MYLAN-AMOXICILLIN
AMOXICILLIN
AURO-AMOXICILLIN
AMOXICILLIN
CFNQSW
CFNQSW
CFNQSW
CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 31 -
80MG & 11.4MG/ML ORAL SUSPENSION
02238830
CLAVULIN
02288559
APO-AMOXI CLAV
GSK CFNQSW
APX CFNQSW
AMPICILLIN
250MG CAPSULE
00020877
NOVO-AMPICILLIN
NOP CFNQSW
500MG CAPSULE
00020885
NOVO-AMPICILLIN
NOP CFNQSW
500MG INJECTION POWDER
00872652
AMPICILLIN SODIUM FOR INJECTION
NOP NQ
CLOXACILLIN
250MG CAPSULE
00337765
NOVO-CLOXIN
NOP CFNQSW
500MG CAPSULE
00337773
NOVO-CLOXIN
NOP CFNQSW
25MG/ML ORAL LIQUID
00337757
NOVO-CLOXIN
NOP CFNQSW
500MG INJECTION POWDER
01912429
CLOXACILLIN SODIUM
NOP NQ
PENICILLIN V (POTASSIUM)
300MG TABLET
00642215
APO-PEN VK
APX
CFNQSUW
25MG/ML ORAL SOLUTION
00642223
APO-PEN VK
APX
FQW
60MG/ML ORAL SOLUTION
00391603
NOVO-PEN VK
00642231
APO-PEN VK
NOP CFNQSW
APX CFNQSW
8:12.18 QUINOLONES
CIPROFLOXACIN
SEE APPENDIX A FOR SA CRITERIA (CYSTIC FIBROSIS, NURSING HOME, AND
TUBERCULOSIS PROGRAMS DO NOT REQUIRE AN SA REQUEST)
PEI Pharmacare Formulary …………………………………………………Page - 32 -
250MG TABLET
02155958
02161737
02229521
02245647
02247339
02248437
02248756
02303728
02317427
02353318
02379627
02379686
02380358
02381907
02386119
CIPRO (SA)
NOVO-CIPROFLOXACIN (SA)
APO-CIPROFLOX (SA)
MYLAN-CIPROFLOXACIN (SA)
CO-CIPROFLOXACIN (SA)
PMS-CIPROFLOXACIN (SA)
SANDOZ CIPROFLOXACIN (SA)
RAN-CIPROFLOXACIN (SA)
MINT-CIPROFLOXACIN (SA)
CIPROFLOXACIN (SA)
SEPTA-CIPROFLOXACIN (SA)
MAR-CIPROFLOXACIN (SA)
JAMP-CIPROFLOXACIN (SA)
AURO-CIPROFLOXACIN (SA)
CIPROFLOXACIN (SA)
BAY
NOP
APX
MYL
COB
PMS
SDZ
RAN
MNT
SNS
SPT
MAR
JPC
ARO
SIV
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
500MG TABLET
02155966
02161745
02229522
02245648
02247340
02248438
02248757
02303736
02317435
02353326
02379635
02379694
02380366
02381923
02386127
CIPRO (SA)
NOVO-CIPROFLOXACIN (SA)
APO-CIPROFLOX (SA)
MYLAN-CIPROFLOXACIN (SA)
CO-CIPROFLOXACIN (SA)
PMS-CIPROFLOXACIN (SA)
SANDOZ CIPROFLOXACIN (SA)
RAN-CIPROFLOXACIN (SA)
MINT-CIPROFLOXACIN (SA)
CIPROFLOXACIN (SA)
SEPTA-CIPROFLOXACIN (SA)
MAR-CIPROFLOXACIN (SA)
JAMP-CIPROFLOXACIN (SA)
AURO-CIPROFLOXACIN (SA)
CIPROFLOXACIN (SA)
BAY
NOP
APX
MYL
COB
PMS
SDZ
RAN
MNT
SNS
SPT
MAR
JPC
ARO
SIV
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
CFNQSWX
750MG TABLET
02155974
02161753
02229523
02245649
02247341
02248439
02248758
02303744
02317443
02353334
CIPRO (SA)
NOVO-CIPROFLOXACIN (SA)
APO-CIPROFLOX (SA)
MYLAN-CIPROFLOXACIN (SA)
CO-CIPROFLOXACIN (SA)
PMS-CIPROFLOXACIN (SA)
SANDOZ-CIPROFLOXACIN (SA)
RAN-CIPROFLOXACIN (SA)
MINT-CIPROFLOXACIN (SA)
CIPROFLOXACIN (SA)
BAY
NOP
APX
MYL
COB
PMS
SDZ
RAN
MNT
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 33 -
SPT
MAR
JPC
ARO
FNQSW
FNQSW
FNQSW
FNQSW
100MG/ML ORAL SUSPENSION
02237514
CIPRO (SA)
BAY
FNQSW
1000MG EXTENDED-RELEASE TABLET
02251787
CIPRO XL (SA)
BAY
FNQSW
02379643
02379708
02380374
02381931
SEPTA-CIPROFLOXACIN (SA)
MAR-CIPROFLOXACIN (SA)
JAMP-CIPROFLOXACIN (SA)
AURO-CIPROFLOXACIN (SA)
LEVOFLOXACIN
SEE APPENDIX A FOR SA CRITERIA (CYSTIC FIBROSIS AND NURSING HOME
PROGRAMS DO NOT REQUIRE AN SA REQUEST)
250MG TABLET
02236841
LEVAQUIN (SA)
JAN CFNQSW
02248262
NOVO-LEVOFLOXACIN (SA)
NOP CFNQSW
02284677
PMS-LEVOFLOXACIN (SA)
PMS CFNQSW
02284707
APO-LEVOFLOX (SA)
APX CFNQSW
02298635
SANDOZ-LEVOFLOXACIN (SA)
SDZ CFNQSW
02313979
MYLAN-LEVOFLOXACIN (SA)
MYL CFNQSW
02315424
CO-LEVOFLOXACIN (SA)
COB CFNQSW
500MG TABLET
02236842
02248263
02284685
02284715
02298643
02313987
02315432
LEVAQUIN (SA)
NOVO-LEVOFLOXACIN (SA)
PMS-LEVOFLOXACIN (SA)
APO-LEVOFLOX (SA)
SANDOZ-LEVOFLOXACIN (SA)
MYLAN-LEVOFLOXACIN (SA)
CO-LEVOFLOXACIN (SA)
JAN
NOP
PMS
APX
SDZ
MYL
COB
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
750MG TABLET
02246804
02285649
02298651
02305585
02315440
02325942
LEVAQUIN (SA)
NOVO-LEVOFLOXACIN (SA)
SANDOZ-LEVOFLOXACIN (SA)
PMS-LEVOFLOXACIN (SA)
CO-LEVOFLOXACIN (SA)
APO-LEVOFLOX (SA)
JAN
NOP
SDZ
PMS
COB
APX
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CFNQSW
MOXIFLOXACIN HCL
SEE APPENDIX A FOR SA CRITERIA (CYSTIC FIBROSIS AND NURSING HOME
PROGRAMS DO NOT REQUIRE AN SA REQUEST)
400MG TABLET
02242965
AVELOX (SA)
BAY FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 34 -
NORFLOXACIN
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
400MG TABLET
02229524
APO-NORFLOX (SA)
APX FNQSW
02237682
NOVO-NORFLOXACIN (SA)
NOP FNQSW
02246596
PMS-NORFLOXACIN (SA)
PMS FNQSW
02269627
CO-NORFLOXACIN (SA)
COB FNQSW
OFLOXACIN
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
200MG TABLET
02231529
APO-OFLOX (SA)
AAA FNQSW
300MG TABLET
02231531
APO-OFLOX (SA)
AAA
FNQSW
400MG TABLET
02231532
APO-OFLOX (SA)
AAA
FNQSW
08:12.20 SULFONAMIDES
SULFAMETHOXAZOLE & TRIMETHOPRIM
400MG & 80MG TABLET
00445274
APO-SULFATRIM
00510637
NOVO-TRIMEL
APX AFCNQSWX
NOP AFCNQSWX
800MG & 160MG TABLET
00445282
APO-SULFATRIM DS
00510645
NOVO-TRIMEL DS
APX AFCNQSWX
NOP AFCNQSWX
40MG & 8MG/ML ORAL SUSPENSION
00726540
NOVO-TRIMEL
NOP AFCNQSWX
08:12.24 ANTIBIOTICS TETRACYCLINES
DOXYCYCLINE
100MG CAPSULE
00024368
VIBRAMYCIN
00725250
NOVO-DOXYLIN
PFI CFNQSVWX
NOP CFNQSVWX
PEI Pharmacare Formulary …………………………………………………Page - 35 -
00740713
00817120
02351234
APO-DOXY
DOXYCIN
DOXYCYCLINE
APX CFNQSVWX
RIV CFNQSVWX
SNS CFNQSVWX
100 MG TABLET
00860751
00874256
02158574
02351242
DOXYCIN
APO-DOXY
NOVO-DOXYLIN
DOXYCYCLINE
RIV
APX
NOP
SNS
FNQSVW
FNQSVW
FNQSVW
FNQSVW
MINOCYCLINE HCL
SEE APPENDIX A FOR SA CRITERIA
50MG CAPSULE
02084090
APO-MINOCYCLINE (SA)
02108143
NOVO-MINOCYCLINE (SA)
02173514
MINOCIN (SA)
02230735
MYLAN-MINOCYCLINE (SA)
02237313
SANDOZ-MINOCYCLINE (SA)
02239238
PMS-MINOCYCLINE (SA)
02294419
PMS-MINOCYCLINE (SA)
02287226
MINOCYCLINE (SA)
APX
NOP
GSK
MYL
SDZ
PMS
PMS
SNS
FQW
FQW
FQW
FQW
FQW
FQW
FQW
FQW
100 MG CAPSULE
02084104
02108151
02230736
02237314
02239239
02294427
02287234
APX
NOP
MYL
SDZ
PMS
PMS
SNS
FQW
FQW
FQW
FQW
FQW
FQW
FQW
AAA
CFNQSW
PFI
NOP
APX
MYL
CFNQSW
CFNQSW
CFNQSW
CFNQSW
APO-MINOCYCLINE (SA)
NOVO-MINOCYCLINE (SA)
MYLAN-MINOCYCLINE (SA)
SANDOZ-MINOCYCLINE (SA)
PMS-MINOCYCLINE (SA)
PMS-MINOCYCLINE (SA)
MINOCYCLINE (SA)
TETRACYCLINE
250MG CAPSULE
00580929
APO-TETRA
8:12.28 ANTIBIOTICS OTHER ANTIBIOTICS
CLINDAMYCIN HCL
150MG CAPSULE
00030570
DALACIN C
02241709
TEVA-CLINDAMYCIN
02245232
APO-CLINDAMYCIN
02258331
MYLAN-CLINDAMYCIN
PEI Pharmacare Formulary …………………………………………………Page - 36 -
300MG CAPSULE
02182866
02241710
02245233
02258358
PFI
NOP
APX
MYL
CFNQSW
CFNQSW
CFNQSW
CFNQSW
CLINDAMYCIN PALMITATE HCL
15MG/ML ORAL SOLUTION
00225851
DALACIN C
PFI
FNQSW
LINEZOLID
SEE APPENDIX A FOR SA CRITERIA
600MG TABLET
02243684
ZYVOXAM (SA)
PFI
FNQSW
VANCOMYCIN HCL
SEE APPENDIX A FOR SA CRITERIA
125MG CAPSULE
00800430
VANCOCIN (SA)
02377470
VANCOMYCIN HYDROCHLORIDE (SA)
02407744
VANCOMYCIN (SA)
MRS FNQSW
PPC FNQSW
JPC FNQSW
250MG CAPSULE
00788716
VANCOCIN (SA)
02377489
VANCOMYCIN HYDROCHLORIDE (SA)
02407752
VANCOMYCIN (SA)
MRS FNQSW
PPC FNQSW
JPC FNQSW
DALACIN C
NOVO-CLINDAMYCIN
APO-CLINDAMYCIN
MYLAN-CLINDAMYCIN
08:14.00 ANTIFUNGALS
NYSTATIN
500,000U TABLET
02194198
RATIO-NYSTATIN
RPH AFNQSW
100,000U/ML ORAL SUSPENSION
00792667
PMS-NYSTATIN
02194201
RATIO-NYSTATIN
PMS AFNQSW
RPH AFNQSW
TERBINAFINE
SEE APPENDIX A FOR SA CRITERIA
250MG TABLET
02239893
APO-TERBINAFINE (SA)
02240807
PMS-TERBINAFINE (SA)
02242503
MYLAN-TERBINAFINE (SA)
02240346
NOVO-TERBINAFINE (SA)
APX
PMS
MYL
NOP
AFNQSW
AFNQSW
AFNQSW
AFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 37 -
COB
SDZ
PMS
ARO
SNS
JPC
SIV
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
VORICONAZOLE
SEE APPENDIX A FOR SA CRITERIA
50MG TABLET
02256460
VFEND (SA)
02396866
TEVA-VORICONAZOLE (SA)
02399245
SANDOZ-VORICONAZOLE (SA)
02409674
APO-VORICONAZOLE (SA)
PFI
TEV
SDZ
APX
Q
Q
Q
Q
200MG TABLET
02256479
02396874
02399253
02409682
PFI
TEV
SDZ
APX
Q
Q
Q
Q
02254727
02262177
02294273
02320134
02353121
02357070
02385279
CO-TERBINAFINE (SA)
SANDOZ-TERBINAFINE (SA)
PMS-TERBINAFINE (SA)
AURO-TERBINAFINE (SA)
TERBINAFINE (SA)
JAMP-TERBINAFINE (SA)
TERBINAFINE (SA)
VFEND (SA)
TEVA-VORICONAZOLE (SA)
SANDOZ-VORICONAZOLE (SA)
APO-VORICONAZOLE (SA)
08:16.00 ANTITUBERCULOSIS AGENTS
ETHAMBUTOL
100MG TABLET
00247960
ETIBI
VAL
AX
400MG TABLET
00247979
ETIBI
VAL
AX
ISONIAZID
300MG TABLET
00577804
PMS-ISONIAZID
PMS AX
PYRAZINAMIDE
500MG TABLET
00618810
PMS-PYRAZINAMIDE
PMS X
RIFABUTIN
150MG CAPSULE
02063786
MYCOBUTIN
PFI
AX
PEI Pharmacare Formulary …………………………………………………Page - 38 -
RIFAMPIN
150MG CAPSULE
00393444
ROFACT
02091887
RIFADIN
VAL AKQX
AVN AKQX
300MG CAPSULE
00343617
ROFACT
02092808
RIFADIN
VAL AKQX
AVN AKQX
8:16.92 MISCELLANEOUS ANTIMYCOBACTERIALS
DAPSONE
100MG TABLET
02041510
AVLOSULFON
JAC
A
8:18.00 ANTIVIRALS
ACYCLOVIR
200MG TABLET
00634506
02078627
02207621
02242784
02285959
02286556
ZOVIRAX
RATIO-AVIRAX
APO-ACYCLOVIR
MYLAN-ACYCLOVIR
NOVO-ACYCLOVIR
ACYCLOVIR
GSK
RPH
APX
MYL
NOP
SNS
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
400MG TABLET
01911627
02207648
02242463
02285967
02286564
ZOVIRAX
APO-ACYCLOVIR
MYLAN-ACYCLOVIR
NOVO-ACYCLOVIR
ACYCLOVIR
GSK
APX
MYL
NOP
SNS
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
800MG TABLET
01911635
02078651
02207656
02242464
02285975
02286572
ZOSTAB PAC
RATIO-AVIRAX
APO-ACYCLOVIR
MYLAN-ACYCLOVIR
NOVO-ACYCLOVIR
ACYCLOVIR
GSK
RPH
APX
MYL
NOP
SNS
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 39 -
FAMCICLOVIR
125MG TABLET
02229110
02278081
02278634
02292025
02305682
FAMVIR
PMS-FAMICICLOVIR
SANDOZ-FAMCICLOVIR
APO-FAMCICLOVIR
CO-FAMCICLOVIR
NVR
PMS
SDZ
APX
COB
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
250MG TABLET
02229129
02278103
02278642
02292041
02305690
FAMVIR
PMS-FAMICICLOVIR
SANDOZ-FAMCICLOVIR
APO-FAMCICLOVIR
CO-FAMCICLOVIR
NVR
PMS
SDZ
APX
COB
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
500MG TABLET
02177102
02278111
02278650
02292068
02305704
FAMVIR
PMS-FAMICICLOVIR
SANDOZ-FAMCICLOVIR
APO-FAMCICLOVIR
CO-FAMCICLOVIR
NVR
PMS
SDZ
APX
COB
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
VALACYCLOVIR
500MG TABLET
02219492
02295822
02298457
02331748
02351579
02357534
02405040
VALTREX
APO-VALACYCLOVIR
PMS-VALACYCLOVIR
CO-VALACYCLOVIR
MYLAN-VALACYCLOVIR
TEVA-VALACYCLOVIR
AURO-VALACYCLOVIR
GSK
APX
PMS
COB
MYL
TEV
ARO
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
AFNQSW
HLR
APX
AT
AT
VALGANCICLOVIR
SEE APPENDIX A FOR SA CRITERIA
450MG TABLET
02245777
VALCYTE (SA)
02393824
APO-VALGANCICLOVIR (SA)
8:18.04 ADAMANTANES
AMANTADINE HCL
10MG/ML SYRUP
02022826
PMS-AMANTADINE
PMS FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 40 -
100MG CAPSULE
01990403
PMS-AMANTADINE
02139200
MYLAN-AMANTADINE
PMS FNQSW
MYL FNQSW
08:18.08.04 ANTIRETROVIRAL AGENTS (HIV ENTRY AND FUSION
INHIBITORS)
ENFUVIRTIDE
SEE APPENDIX A FOR SA CRITERIA
90MG/ML INJECTION KIT
02247725
FUZEON (SA)
HLR
A
MARAVIROX
150MG TABLET
02299844
CELSENTRI
VII
A
300MG TABLET
02299852
CELSENTRI
VII
A
08:18.08.08 ANTIRETROVIRAL AGENTS (PROTEASE INHIBITORS)
ATAZANAVIR
150MG CAPSULE
02248610
REYATAZ
BMS A
200MG CAPSULE
02248611
REYATAZ
BMS A
300MG CAPSULE
02294176
REYATAZ
BMS A
DARUNAVIR
75MG TABLET
02338432
PREZISTA
JAN
A
150MG TABLET
02369753
PREZISTA
JAN
A
PEI Pharmacare Formulary …………………………………………………Page - 41 -
400MG TABLET
02324016
PREZISTA
JAN
A
600MG TABLET
02324024
PREZISTA
JAN
A
FOSAMPRENAVIR
700MG TABLET
02261545
TELZIR
VII A
INDINAVIR SULFATE
200MG CAPSULE
02229161
CRIXIVAN
MSD A
400MG CAPSULE
02229196
CRIXIVAN
MSD A
LOPINAVIR & RITONAVIR
200MG & 50MG TABLET
02285533
KALETRA
ABB
A
NELFINAVIR MESYLATE
250MG TABLET
02238617
VIRACEPT
PFI
A
625MG TABLET
02248761
VIRACEPT
PFI
A
RITONAVIR
100MG TABLET
02241480
NORVIR SEC
ABB
A
100MG FILM COATED TABLET
02357593
NORVIR
ABB
A
SAQUINAVIR
200MG CAPSULE
02216965
INVIRASE
HLR
A
500MG TABLET
02279320
HLR
A
INVIRASE
PEI Pharmacare Formulary …………………………………………………Page - 42 -
8:18.08.12 ANTIRETROVIRAL AGENTS (INTEGRASE INHIBITORS)
RALTEGRAVIR
400MG TABLET
02301881
ISENTRESS
MSD A
8:18.08.16 ANTIRETROVIRAL AGENTS (NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)
EFAVIRENZ
50MG CAPSULE
02239886
SUSTIVA
BMS A
200MG CAPSULE
02239888
SUSTIVA
BMS A
600MG TABLET
02246045
02381524
02389762
BMS A
MYL A
TEV A
SUSTIVA
MYLAN-EFAVIRENZ
TEVA-EFAVIRENZ
EMTRICITABINE/RILPIVIRINE/TENOFOVIR
200MG/25MG/300MG TABLET
02374129
COMPLERA
GIL
A
ETRAVIRINE
100MG TABLET
02306778
INTELENCE
JAN
A
NEVIRAPINE
200MG TABLET
02238748
02352893
02387727
02405776
VIRAMUNE
TEVA-NEVIRAPINE
MYLAN-NEVIRAPINE
PMS-NEVIRAPINE
BOE
TEV
MYL
PMS
A
A
A
A
NEVIRAPINE
400MG EXTENDED RELEASE TABLET
02367289
VIRAMUNE XR
BOE A
RILPIVIRINE
25MG TABLET
02370603
JAN
EDURANT
A
PEI Pharmacare Formulary …………………………………………………Page - 43 -
08:18.08.20 ANTIRETROVIRAL AGENTS (NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS)
ABACAVIR SULFATE
300MG TABLET
02240357
ZIAGEN
VII
A
ABACAVIR & LAMIVUDINE
600MG & 300MG TABLET
02269341
KIVEXA
VII
A
ABACAVIR & LAMIVUDINE & ZIDOVUDINE
300MG & 150MG TABLET & 300MG
02244757
TRIZIVIR
VII
A
DIDANOSINE
125MG CAPSULE (ENTERIC COATED BEADLET)
02244596
VIDEX EC
BMS A
200MG CAPSULE (ENTERIC COATED BEADLET)
02244597
VIDEX EC
BMS A
250MG CAPSULE (ENTERIC COATED BEADLET)
02244598
VIDEX EC
BMS A
400MG CAPSULE (ENTERIC COATED BEADLET)
02244599
VIDEX EC
BMS A
EFAVIRENZ & EMBRICITABINE & TENOFOVIR
600MG & 200MG & 300MG TABLET
02300699
ATRIPLA
BMS A
LAMIVUDINE
150MG TABLET
02192683
3TC
VII
A
300MG TABLET
02247825
3TC
VII
A
VII
A
LAMIVUDINE & ZIDOVUDINE
150MG & 300MG TABLET
02239213
COMBIVIR
PEI Pharmacare Formulary …………………………………………………Page - 44 -
A
A
02375540
02387247
APO-LAMIVUDINE/ZIDOVUDINE
TEVA-LAMIVUDINE/ZIDOVUDINE
APX
TEV
STAVUDINE
15MG CAPSULE
02216086
20MG CAPSULE
02216094
ZERIT
BMS A
ZERIT
BMS A
30MG CAPSULE
02216108
ZERIT
BMS A
40MG CAPSULE
02216116
ZERIT
BMS A
TENOFOVIR
300MG TABLET
02247128
VIREAD
GIL
A
TENOFOVIR & EMTRICITABINE
300MG & 200MG TABLET
02274906
TRUVADA
GIL
AH
ZIDOVUDINE (AZT)
100MG CAPSULE
01902660
RETROVIR
01946323
APO-ZIDOVUDINE
VII
APX
A
A
8:18:20 INTERFERONS
INTERFERON ALFA-2B
SEE APPENDIX A FOR SA CRITERIA
6 MILLION IU/ML PREMIXED SOLUTION (ALBUMIN (HUMAN) FREE)
02238674
INTRON A (SA)
MSD HJ
10 MILLION IU/ML PREMIXED SOLUTION (ALBUMIN (HUMAN) FREE)
02238675
INTRON A (SA)
MSD HJ
15 MILLION IU/ML MULTI DOSE PEN (ALBUMIN (HUMAN) FREE)
02240693
INTRON A (SA)
MSD HJ
25 MILLION IU/ML MULTI DOSE PEN (ALBUMIN (HUMAN) FREE)
02240694
INTRON A (SA)
MSD HJ
PEI Pharmacare Formulary …………………………………………………Page - 45 -
50 MILLION IU/ML MULTI DOSE PEN (ALBUMIN (HUMAN) FREE)
02240695
INTRON A (SA)
MSD HJ
PEGINTERFERON ALFA-2A
SEE APPENDIX A FOR SA CRITERIA
180UG/ML INJECTION (VIAL)
02248078
PEGASYS (SA)
HLR H
180UG/0.5ML PRE-FILLED SYRINGE
02248077
PEGASYS (SA)
HLR
H
PEGINTERFERON ALFA-2A & RIBAVIRIN
SEE APPENDIX A FOR SA CRITERIA
180UG/0.5ML VIAL & 200 MG TABLET
02253410
PEGASYS RBV (SA)
HLR
H
180UG/0.5ML PRE-FILLED SYRINGE & 200 MG TABLET
02253429
PEGASYS RBV(SA)
HLR
H
PEGINTERFERON ALFA-2B & RIBAVIRIN
SEE APPENDIX A FOR SA CRITERIA
80UG/0.5ML PEN & 200MG CAPSULE
02254581
PEGETRON REDIPEN (SA)
MSD H
100UG/0.5ML PEN & 200MG CAPSULE
02254603
PEGETRON REDIPEN (SA)
MSD H
120UG/0.5ML PEN & 200MG CAPSULE
02254638
PEGETRON REDIPEN (SA)
MSD H
150UG/0.5ML PEN & 200MG CAPSULE
02254646
PEGETRON REDIPEN (SA)
MSD H
08:18.32 NUCLEOSIDES AND NUCLEOTIDES
ADEFOVIR DIPIVOXIL
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02247823
HEPSERA (SA)
GIL
H
PEI Pharmacare Formulary …………………………………………………Page - 46 -
ENTECAVIR
SEE APPENDIX A FOR SA CRITERIA
0.5MG TABLET
02282224
BARACLUDE (SA)
02396955
APO-ENTECAVIR (SA)
BMS H
APX H
08:18.40 HCV PROTEASE INHIBITORS
BOCEPREVIR
SEE APPENDIX A FOR SA CRITERIA
200MG CAPSULE
02370816
VICTRELIS (SA)
MSD H
BOCEPREVIR/RIBAVIRIN/0-ALFA-2B
SEE APPENDIX A FOR SA CRITERIA
200MG/80MCG INJECTOR KIT
02371448
VICTRELIS TRIPLE (SA)
MSD H
200MG/100MCG INJECTOR KIT
02371456
VICTRELIS TRIPLE (SA)
MSD H
200MG/120 MCG INJECTOR KIT
02371464
VICTRELIS TRIPLE (SA)
MSD H
200MG/150 MCG INJECTOR KIT
02371472
VICTRELIS TRIPLE (SA)
MSD H
TELAPREVIR
SEE APPENDIX A FOR SA CRITERIA
375MG TABLET
02371553
INCIVEK (SA)
VER H
08:30.08 ANTIMALARIALS
CHLOROQUINE PHOSPHATE
250 MG TABLET
00021261
TEVA-CHLOROQUINE
TEV
FNQSW
HYDROXYCHLOROQUINE SULFATE
200MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 47 -
02017709
PLAQUENIL
AVN FNQSW
02246691
02252600
APO-HYDROXYQUINE
MYLAN-HYDROXYCHLOROQUINE
APX FNQSW
MYL FNQSW
QUININE SULFATE
200MG CAPSULE
00021008
NOVO-QUININE
00695440
QUININE-ODAN
02254514
APO-QUININE
NOP FNQSW
ODN FNQSW
APX FNQSW
300MG CAPSULE
00021016
NOVO-QUININE
00695459
QUININE-ODAN
02254522
APO-QUININE
NOP FNQSW
ODN FNQSW
APX FNQSW
08:30.92 MISCELLANEOUS ANTIPROTOZOALS
METRONIDAZOLE
250MG TABLET
00545066
APO-METRONIDAZOLE
AAA
CFNQSW
08:36.00 URINARY ANTI INFECTIVES
NITROFURANTOIN
50MG CAPSULE (MACROCRYSTALS)
02231015
NOVO-FURANTOIN
NOP FNQSW
100MG CAPSULE (MACROCRYSTALS)
02231016
NOVO-FURANTOIN
NOP FNQSW
50MG TABLET
00319511
APO-NITROFURANTOIN
AAA
FNQSW
100MG TABLET
00312738
APO-NITROFURANTOIN
AAA
FNQSW
TRIMETHOPRIM
100MG TABLET
02243116
APO-TRIMETHOPRIM
AAA
FNQSW
200MG TABLET
02243117
APO-TRIMETHOPRIM
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 48 -
10:00.00 ANTINEOPLASTIC AGENTS
ANASTROZOLE
1MG TABLET
02224135
02313049
02320738
02328690
02338467
02339080
02351218
02361418
02365650
02374420
02379104
02394898
02379562
02393573
02404990
ARIMIDEX
TEVA-ANASTROZOLE
PMS-ANASTROZOLE
RAN-ANASTROZOLE
SANDOZ-ANASTROZOLE
JAMP-ANASTROZOLE
ANASTROZOLE
MYLAN-ANASTROZOLE
TARO-ANASTROZOLE
APO-ANASTROZOLE
MED-ANASTROZOLE
CO-ANASTROZOLE
MAR-ANASTROZOLE
MINT-ANASTROZOLE
AURO-ANASTROZOLE
AZE
TEV
PMS
RAN
SDZ
JPC
ACH
MYL
TAR
APX
GMP
COB
MAR
MNT
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
BICALUTAMIDE
50MG TABLET
02184478
02270226
02274337
02275589
02276089
02277700
02296063
02302403
02325985
02357216
02371324
02382423
CASODEX
NOVO-BICALUTAMIDE
CO-BICALUTAMIDE
PMS-BICALUTAMIDE
SANDOZ-BICALUTAMIDE
RATIO-BICALUTAMIDE
APO-BICALUTAMIDE
MYLAN-BICALUTAMIDE
BICALUTAMIDE
JAMP-BICALUTAMIDE
RAN-BICALUTAMIDE
BICALUTAMIDE
AZE
NOP
COB
PMS
SDZ
RPH
APX
MYL
ACH
JPC
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
BUSULFAN
2MG TABLET
00004618
MYLERAN
TRI
FNQSW
HLR
TEV
MQ
MQ
CAPECITABINE
SEE APPENDIX A FOR SA CRITERIA
150MG TABLET
02238453
XELODA (SA)
02400022
TEVA-CAPECITABINE
PEI Pharmacare Formulary …………………………………………………Page - 49 -
500MG TABLET
02238454
02400030
HLR
TEV
MQ
MQ
TRI
FNQSW
PFI
MQ
PFI
MQ
CYCLOPHOSPHAMIDE
25MG TABLET
02241795
PROCYTOX
BAX
FNQSW
50MG TABLET
02241796
BAX
FNQSW
XELODA (SA)
TEVA-CAPECITABINE
CHLORAMBUCIL
2MG TABLET
00004626
LEUKERAN
CRIZOTINIB
SEE APPENDIX A FOR SA CRITERIA
200MG CAPSULE
02384256
XALKORI (SA)
250MG CAPSULE
02384264
XALKORI (SA)
PROCYTOX
CYPROTERONE ACETATE
50MG TABLET
00704431
ANDROCUR
02245898
APO-CYPROTERONE
02390760
MED-CYPROTERONE
BAY FNQSW
AAA FNQSW
GMP FNQSW
DASATINIB
SEE APPENDIX A FOR SA CRITERIA
20 MG TABLET
02293129
SPRYCEL (SA)
BMS MQ
50 MG TABLET
02293137
SPRYCEL (SA)
BMS MQ
70 MG TABLET
02293145
SPRYCEL (SA)
BMS MQ
DEGARELIX
80MG/VIAL POWDER FOR INJECTION
02337029
FIRMAGON
FEI
FNQSW
120MG/VIAL POWDER FOR INJECTION
02337037
FIRMAGON
FEI
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 50 -
ERLOTINIB
SEE APPENDIX A FOR SA CRITERIA
25 MG TABLET
02269007
TARCEVA (SA)
HLR
MQ
100 MG TABLET
02269015
TARCEVA (SA)
HLR
MQ
150 MG TABLET
02269023
TARCEVA (SA)
HLR
MQ
EXEMESTANE
25MG TABLET
02242705
02390183
02407841
02408473
AROMASIN
CO-EXEMESTANE
MED-EXEMESTANE
TEVA-EXEMESTANE
PFI
COB
GMP
TEV
FNQSW
FNQSW
FNQSW
FNQSW
FLUDARABINE PHOSPHATE
SEE APPENDIX A FOR SA CRITERIA
10 MG TABLET
02246226
FLUDARA (SA)
AVN MQ
FLUTAMIDE
250MG TABLET
00637726
EUFLEX
MSD FNQSW
02230089
02238560
NOVO-FLUTAMIDE
APO-FLUTAMIDE
NOP FNQSW
APX FNQSW
HYDROXYUREA
500MG CAPSULE
00465283
HYDREA
02242920
MYLAN-HYDROXYUREA
02343096
HYDROXYUREA
BMS FNQSW
MYL FNQSW
SNS FNQSW
IMATINIB
SEE APPENDIX A FOR SA CRITERIA
100MG TABLET
02253275
GLEEVEC (SA)
02355337
APO-IMATINIB (SA)
02399806
TEVA-IMATINIB (SA)
NVR MQ
APX MQ
TEV MQ
400MG TABLET
02253283
NVR MQ
GLEEVEC (SA)
PEI Pharmacare Formulary …………………………………………………Page - 51 -
02355345
02399814
APO-IMATINIB (SA)
TEVA-IMATINIB (SA)
APX
TEV
MQ
MQ
LETROZOLE
2.5MG TABLET
02231384
02309114
02322315
02338459
02343657
02344815
02347997
02348969
02358514
02372169
02372282
02373009
02373424
02414400
FEMARA
PMS-LETROZOLE
MED-LETROZOLE
LETROZOLE USP
NOVO-LETROZOLE
SANDOZ-LETROZOLE
LETROZOLE
LETROZOLE
APO-LETROZOLE
MYL-LETROZOLE
RAN-LETROZOLE
JAMP-LETROZOLE
MAR-LETROZOLE
AURO-LETROZOLE
NVR
PMS
GMP
ACH
NOP
SDZ
TEV
COB
APX
MYL
RAN
JPC
MAR
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
LEUPROLIDE ACETATE
3.75MG/ML DEPOT INJECTION
00884502
LUPRON DEPOT
ABB
G
7.5MG/ML DEPOT INJECTION (NOT INTERCHANGEABLE)
00836273
LUPRON DEPOT
02248239
ELIGARD
ABB FGNQSW
AVN FGNQSW
11.25MG DEPOT INJECTION
02239834
LUPRON DEPOT
ABB
22.5MG/ML DEPOT INJECTION (NOT INTERCHANGEABLE)
02230248
LUPRON DEPOT
02248240
ELIGARD
ABB FNQSW
AVN FNQSW
45MG DEPOT INJECTION
02268892
ELIGARD
AVN FNQSW
MEDROXYPROGESTERONE ACETATE
100MG TABLET
00030945
PROVERA
02267640
APO-MEDROXY
PFI
APX
FNQSW
FNQSW
FNQSW
MEGESTROL ACETATE
SEE APENDIX A FOR SA CRITERIA (AIDS/HIV PROGRAM DOES NOT REQUIRE AN SA
PEI Pharmacare Formulary …………………………………………………Page - 52 -
REQUEST)
40MG TABLET
02195917
MEGESTROL (SA)
AAA
AFNQSW
160MG TABLET
02195925
APO-MEGESTROL (SA)
AAA
FNQSW
40MG/ML ORAL SUSPENSION
02168979
MEGACE OS (SA)
BMS FNQSW
MELPHALAN
2MG TABLET
00004715
TRI
ALKERAN
FNQSW
MERCAPTOPURINE
50MG TABLET
00004723
PURINETHOL
02415275
MERCAPTOPURINE
NOP FNQSW
STE FNQSW
METHOTREXATE
2.5MG TABLET
02170698
METHOTREXATE
02182963
METHOTREXATE
02244798
RATIO-METHOTREXATE SODIUM
WAY FNQSW
HOS FNQSW
RPH FNQSW
10MG TABLET
02182750
HOS FNQSW
METHOTREXATE
25MG/ML INJECTION SOLUTION
02182777
METHOTREXATE
02182955
METHOTREXATE/PF
HOS FNQSW
HOS FNQSW
NILOTINIB
SEE APPENDIX A FOR SA CRITERIA
150MG CAPSULE
02368250
TASIGNA (SA)
NVR MQ
200MG CAPSULE
02315874
TASIGNA (SA)
NVR MQ
NILUTAMIDE
SEE APPENDIX A FOR SA CRITERIA
50 MG TABLET
02221861
ANANDRON (SA)
AVN FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 53 -
PAZOPANIB
SEE APPENDIX A FOR SA CRITERIA
200MG TABLET
02352303
VOTRIENT (SA)
GSK MQ
RITUXIMAB
SEE APPENDIX A FOR SA CRITERIA
10MG/ML VIAL
02241927
RITUXAN (SA)
HLR
MQ
SUNITINIB MALATE
SEE APPENDIX A FOR SA CRITERIA
12.5 MG CAPSULE
02280795
SUTENT (SA)
PFI
MQ
25 MG CAPSULE
02280809
SUTENT (SA)
PFI
MQ
50 MG CAPSULE
02280817
SUTENT (SA)
PFI
MQ
TAMOXIFEN CITRATE
10MG TABLET
00812404
APO-TAMOX
00851965
NOVO-TAMOXIFEN
02088428
MYLAN-TAMOXIFEN
APX FNQSW
NOP FNQSW
MYL FNQSW
20MG TABLET
00812390
00851973
02048485
02089858
APX
NOP
AZE
MYL
APO-TAMOX
NOVO-TAMOXIFEN
NOLVADEX D
MYLAN-TAMOXIFEN
FNQSW
FNQSW
FNQSW
FNQSW
TEMOZOLOMIDE
SEE APPENDIX A FOR HIGH COST PROGRAM CRITERIA
5MG TABLET
02241093
TEMODAL
MSD FMNQSW
20MG TABLET
02241094
TEMODAL
MSD FMNQSW
100MG TABLET
02241095
TEMODAL
MSD FMNQSW
PEI Pharmacare Formulary …………………………………………………Page - 54 -
140MG TABLET
02312794
TEMODAL
MSD FMNQSW
250MG TABLET
02241096
TEMODAL
MSD FMNQSW
THIOGUANINE
40MG TABLET
00282081
LANVIS
TRI
FNQSW
TRETINOIN
SEE APPENDIX A FOR SA CRITERIA
10MG CAPSULE
02145839
VESANOID (SA)
ROC MQ
TRIPTORELIN
3.75MG INTRAMUSCULAR INJECTION
02240000
TRELSTAR
PAL
FNQSW
11.25MG INTRAMUSCULAR INJECTION
02243856
TRELSTAR LA
PAL
FNQSW
12:04.00 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
BETHANECHOL CHLORIDE
10MG TABLET
01947958
DUVOID
SHR FNQSW
25MG TABLET
01947931
DUVOID
SHR FNQSW
50MG TABLET
01947923
DUVOID
SHR FNQSW
DONEPEZIL
SEE CHOLINESTERASE INHIBITORS IN APPENDIX A FOR SA CRITERIA
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02232043
ARICEPT (SA)
PFI
02322331
PMS-DONEPEZIL (SA)
PMS
02328666
SANDOZ-DONEPEZIL (SA)
SDZ
02340607
TEVA-DONEPEZIL (SA)
TEV
02359472
MYLAN-DONEPEZIL (SA)
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 55 -
02362260
02381508
02397595
02400560
02402092
02404419
02420597
APO-DONEPEZIL (SA)
RAN-DONEPEZIL (SA)
CO-DONEPEZIL (SA)
AURO-DONEPEZIL (SA)
MAR-DONEPEZIL (SA)
JAMP-DONEPEZIL (SA)
DONEPEZIL (SA)
APX
RAN
COB
ARO
MAR
JPC
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
02232044
02322358
02328682
02340615
02359480
02362279
02381516
02397609
02400588
02402106
02404427
02420600
ARICEPT (SA)
PMS-DONEPEZIL (SA)
SANDOZ-DONEPEZIL (SA)
TEVA-DONEPEZIL (SA)
MYLAN-DONEPEZIL (SA)
APO-DONEPEZIL (SA)
RAN-DONEPEZIL (SA)
CO-DONEPEZIL (SA)
AURO-DONEPEZIL (SA)
MAR-DONEPEZIL (SA)
JAMP-DONEPEZIL (SA)
DONEPEZIL (SA)
PFI
PMS
SDZ
TEV
MYL
APX
RAN
COB
ARO
MAR
JPC
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
GALANTAMINE
SEE CHOLINESTERASE INHIBITORS IN APPENDIX A FOR SA CRITERIA
SEE APPENDIX A FOR SA CRITERIA
8MG EXTENDED RELEASE CAPSULE
02266717
REMINYL ER (SA)
JAN
02316943
PAT-GALANTAMINE ER (SA)
PAT
02339439
MYLAN-GALANTAMINE (SA)
MYL
02377950
TEVA-GALANTAMINE ER (SA)
TEV
02398370
PMS-GALANTAMINE ER (SA)
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
16MG EXTENDED RELEASE CAPSULE
02266725
REMINYL ER (SA)
02316951
PAT-GALANTAMINE ER (SA)
02339447
MYLAN-GALANTAMINE (SA)
02377969
TEVA-GALANTAMINE ER (SA)
02398389
PMS-GALANTAMINE ER (SA)
JAN
PAT
MYL
TEV
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
24MG EXTENDED RELEASE CAPSULE
02266733
REMINYL ER (SA)
02316978
PAT-GALANTAMINE ER (SA)
02339455
MYLAN-GALANTAMINE (SA)
02377977
TEVA-GALANTAMINE ER (SA)
02398397
PMS-GALANTAMINE ER (SA)
JAN
PAT
MYL
TEV
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 56 -
NEOSTIGMINE BROMIDE
15MG TABLET
00869945
PROSTIGMINE
VAL
FNQSW
PILOCARPINE
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02216345
SALAGEN (SA)
02402483
PILOCARPINE HYDROCHLORIDE (SA)
PFI
STE
FNQSW
FNQSW
PYRIDOSTIGMINE BROMIDE
60MG TABLET
00869961
MESTINON
VAL
FNQSW
180MG LONG ACTING TABLET
00869953
MESTINON
VAL
FNQSW
RIVASTIGMINE
SEE CHOLINESTERASE INHIBITORS FOR SA CRITERIA
SEE APPENDIX A FOR SA CRITERIA
1.5MG CAPSULE
02242115
EXELON (SA)
02306034
PMS-RIVASTIGMINE (SA)
02324563
SANDOZ-RIVASTIGMINE (SA)
02305984
NOVO-RIVASTIGMINE (SA)
02311283
RATIO-RIVASTIGMINE (SA)
02336715
APO-RIVASTIGMINE (SA)
02401614
MED-RIVASTIGMINE (SA)
02406985
MINT-RIVASTIGMINE (SA)
NVR
PMS
SDZ
NOP
RPH
APX
MED
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
3.0MG CAPSULE
02242116
02306042
02324571
02305992
02311291
02336723
02401622
02406993
EXELON (SA)
PMS-RIVASTIGMINE (SA)
SANDOZ-RIVASTIGMINE (SA)
NOVO-RIVASTIGMINE (SA)
RATIO-RIVASTIGMINE (SA)
APO-RIVASTIGMINE (SA)
MED-RIVASTIGMINE (SA)
MINT-RIVASTIGMINE (SA)
NVR
PMS
SDZ
NOP
RPH
APX
GMP
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
4.5MG CAPSULE
02242117
02306050
02324598
02306018
EXELON (SA)
PMS-RIVASTIGMINE (SA)
SANDOZ-RIVASTIGMINE (SA)
NOVO-RIVASTIGMINE (SA)
NVR
PMS
SDZ
NOP
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 57 -
02311305
02336731
02401630
02407000
RATIO-RIVASTIGMINE (SA)
APO-RIVASTIGMINE (SA)
MED-RIVASTIGMINE (SA)
MINT-RIVASTIGMINE (SA)
RPH
APX
GMP
MNT
FNQSW
FNQSW
FNQSW
FNQSW
6.0MG CAPSULE
02242118
02324601
02306026
02311313
02336758
02401649
02407019
EXELON (SA)
SANDOZ-RIVASTIGMINE (SA)
NOVO-RIVASTIGMINE (SA)
RATIO-RIVASTIGMINE (SA)
APO-RIVASTIGMINE (SA)
MED-RIVASTIGMINE (SA)
MINT-RIVASTIGMINE (SA)
NVR
SDZ
NOP
RPH
APX
GMP
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
ATROPINE SULFATE
0.6MG/ML INJECTION SOLUTION (1ML)
00392693
ATROPINE SULFATE
SDZ
N
DICYCLOMINE HCL
2MG/ML SYRUP
02102978
BENTYLOL
AXC FNQSW
10MG TABLET
02103087
BENTYLOL
AXC FNQSW
20MG TABLET
02103095
BENTYLOL
AXC FNQSW
12:08.08 ANTIMUSCARINICS/ANTISPASMODICS
GLYCOPYRRONIUM BROMIDE
50MCG INHALATION CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02394936
SEEBRI BREEZHALER (SA)
NVR FNQSW
HYOSCINE BUTYLBROMIDE
10MG TABLET
00363812
BUSCOPAN
BOE FNQSW
IPRATROPIUM BROMIDE
200UG/DOSE INHALER AEROSOL (200 DOSE)
02247686
ATROVENT HFA
BOE CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 58 -
0.25MG/ML INHALATION SOLUTION (20ML)
02126222
APO-IPRAVENT
02210479
NOVO-IPRAMIDE
02231136
PMS-IPRATROPIUM
02239131
MYLAN-IPRATROPIUM
APX
NOP
PMS
MYL
0.0125% INHALATION SOLUTION NEBULE (2ML)
02097176
RATIO-IPRATROPIUM UDV
02231135
PMS-IPRATROPIUM
RPH FNQSW
PMS FNQSW
0.025% INHALATION SOLUTION NEBULE (2ML)
02097168
RATIO-IPRATROPIUM UDV
02216221
TEVA-IPRATROPIUM
02231245
PMS-IPRATROPIUM
RPH FNQSW
TEV FNQSW
PMS FNQSW
0.03% NASAL SPRAY - 345 DOSES
02163705
ATROVENT NASAL SPRAY
02239627
PMS-IPRATROPIUM
BOE CFNQSW
PMS CFNQSW
IPRATROPIUM & SALBUTAMOL
1.0MG & 0.2MG PER ML INHALATION SOLUTION NEBULE (2.5ML)
02231675
COMBIVENT
02243789
RATIO-IPRA SAL UDV
02272695
TEVA-COMBO STERINEBS
BOE FNQSW
RPH FNQSW
TEV FNQSW
PINAVERIUM BROMIDE
50MG TABLET
01950592
DICETEL
SLV
FNQSW
100MG TABLET
02230684
SLV
FNQSW
DICETEL
CFNQSW
CFNQSW
CFNQSW
CFNQSW
SCOPOLAMINE HYDROBROMIDE
0.4MG/ML INJECTION SOLUTION (1ML)
00541869
SCOPOLAMINE
HOS N
TIOTROPIUM BROMIDE
SEE APPENDIX A FOR SA CRITERIA
18UG/INHALATION POWDER CAPSULE
02246793
SPIRIVA (SA)
BOE FNQSW
12:12.00 SYMPATHOMIMETIC (ADRENERGIC) AGENTS
PEI Pharmacare Formulary …………………………………………………Page - 59 -
EPINEPHRINE HCL
1MG/ML INJECTION SOLUTION (1ML)
00721891
EPINEPHRINE INJECTION USP
00155357
ADRENALINE CHLORIDE
HOS INQ
ERF INQ
0.15MG PER DOSE AUTO-INJECTOR (NOT INTERCHANGEABLE)
SEE APPENDIX A FOR SA CRITERIA
00578657
EPIPEN JR. (SA)
02268205
TWINJECT (SA)
02382059
ALLERJECT (SA)
ALX FQW
PAL FQW
AVN FQW
0.3MG PER DOSE AUTO-INJECTOR (NOT INTERCHANGEABLE)
SEE APPENDIX A FOR SA CRITERIA
00509558
EPIPEN (SA)
02247310
TWINJECT (SA)
02382067
ALLERJECT (SA)
ALX FQW
PAL FQW
AVN FQW
FORMOTEROL FUMARATE
SEE APPENDIX A FOR SA CRITERIA
12UG/DOSE AEROSOL POWDER CAPSULE
02230898
FORADIL (SA)
NVR FNQSW
6UG/DOSE INHALER POWDER
02237225
OXEZE TURBUHALER (SA)
AZE
FNQSW
12UG/DOSE INHALER POWDER
02237224
OXEZE TURBUHALER (SA)
AZE
FNQSW
FORMOTEROL & BUDESONIDE
SEE APPENDIX A FOR SA CRITERIA
6UG & 100UG PER DOSE INHALER POWDER
02245385
SYMBICORT TURBUHALER (SA)
AZE
FNQSW
6UG & 200UG PER DOSE INHALER POWDER
02245386
SYMBICORT TURBUHALER (SA)
AZE
FNQSW
INDACATEROL
SEE APPENDIX A FOR SA CRITERIA
75MCG INHALATION POWDER CAPSULE
02376938
ONBREZ (SA)
NVR FNQSW
MIDODRINE HCL
SEE APPENDIX A FOR SA CRITERIA
2.5MG TABLET
02278677
APO-MIDODRINE (SA)
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 60 -
5MG TABLET
02278685
APO-MIDODRINE (SA)
AAA
FNQSW
MOMETASONE FUROATE/FORMOTEROL FUMARATE DIHYDRATE
SEE APPENDIX A FOR SA CRITERIA
50MCG/5MCG INHALER
02361744
ZENHALE (SA)
MSD FNQSW
100MCG/5MCG INHALER
02361752
ZENHALE (SA)
MSD FNQSW
200MCG/5MCG INHALER
02361760
ZENHALE (SA)
MSD FNQSW
ORCIPRENALINE SULFATE
2MG/ML SYRUP
02236783
APO-ORCIPRENALINE
APX
PSEUDOEPHEDRINE HCL
6MG/ML SYRUP
00815993
PMS-PSEUDOEPHEDRINE
PMS N
FNQSW
SALBUTAMOL
100UG/DOSE INHALER AEROSOL HYDROFLUOROALKANE (HFA) (200 DOSE)
02232570
AIROMIR HFA
VAL CFNQSW
02241497
VENTOLIN HFA
GSK CFNQSW
02245669
APO-SALVENT CFC FREE
APX CFNQSW
02326450
NOVO-SALBUTAMOL HFA
NOP CFNQSW
200UG/DOSE INHALER POWDER
02243115
VENTOLIN DISKUS
GSK CFNQSW
5MG/ML INHALATION SOLUTION (10ML)
00860808
RATIO-SALBUTAMOL
02069571
PMS-SALBUTAMOL
02154412
SANDOZ-SALBUTAMOL
02213486
VENTOLIN
RPH
PMS
SDZ
GSK
CFNQSW
CFNQSW
CFNQSW
CFNQSW
0.5MG/ML INHALATION SOLUTION PRESERVATIVE FREE NEBULE (2.5ML)
02208245
PMS-SALBUTAMOL
PMS CFNQSW
02239365
RATIO-SALBUTAMOL
RPH CFNQSW
1MG/ML INHALATION SOLUTION PRESERVATIVE FREE NEBULE (2.5ML)
01926934
TEVA-SALBUTAMOL STERINEB
TEV
CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 61 -
01986864
02208229
02213419
RATIO-SALBUTAMOL
PMS-SALBUTAMOL
VENTOLIN NEBULES P.F.
RPH CFNQSW
PMS CFNQSW
GSK CFNQSW
2MG/ML INHALATION SOLUTION PRESERVATIVE FREE NEBULE (2.5ML)
02213427
VENTOLIN NEBULES P.F.
GSK
02173360
TEVA-SALBUTAMOL STERINEB
TEV
02208237
PMS-SALBUTAMOL
PMS
02239366
RATIO-SALBUTAMOL
RPH
CFNQSW
CFNQSW
CFNQSW
CFNQSW
2MG TABLET
02146843
APO-SALVENT
APX
CFNQSW
4MG TABLET
02146851
APO-SALVENT
APX
CFNQSW
SALMETEROL XINAFOATE
SEE APPENDIX A FOR SA CRITERIA
50UG/DOSE INHALED POWDER DISK (60)
02231129
SEREVENT DISKUS (SA)
GSK FNQSW
50UG/DOSE AEROSOL POWDER DISK
02214261
SEREVENT DISKHALER (SA)
GSK FNQSW
SALMETEROL & FLUTICASONE
SEE APPENDIX A FOR SA CRITERIA
25UG & 125UG/DOSE INHALER AEROSOL
02245126
ADVAIR (SA)
GSK FNQSW
25UG & 250UG/DOSE INHALER AEROSOL
02245127
ADVAIR (SA)
GSK FNQSW
50UG & 100UG/DOSE INHALER POWDER DISK
02240835
ADVAIR DISKUS (SA)
GSK FNQSW
50UG & 250UG/DOSE INHALER POWDER DISK
02240836
ADVAIR DISKUS (SA)
GSK FNQSW
50UG & 500UG/DOSE INHALER POWDER DISK
02240837
ADAVAIR DISKUS (SA)
GSK FNQSW
TERBUTALINE SULFATE
0.5MG/DOSE INHALER POWDER
00786616
BRICANYL TURBUHALER
AZE
CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 62 -
12:16.00 SYMPATHOLYTIC AGENTS (ANTIMIGRAINE DRUGS)
DIHYDROERGOTAMINE MESYLATE
SEE APPENDIX A FOR SA CRITERIA
4MG/ML NASAL SPRAY
02228947
MIGRANAL (SA)
Note: Coverage is limited to 6 bottles per 30 day period.
STE
FNQSW
12:20.00 SKELETAL MUSCLE RELAXANTS
BACLOFEN
10MG TABLET
00455881
02063735
02088398
02139332
02236507
02236963
02287021
LIORESAL
PMS-BACLOFEN
MYLAN BACLOFEN
APO-BACLOFEN
RATIO-BACLOFEN
PHL-BACLOFEN
BACLOFEN
NVR
PMS
MYL
APX
RPH
PHL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
00636576
02063743
02088401
02139391
02236508
02236964
02287048
LIORESAL DS
PMS-BACLOFEN
MYLAN BACLOFEN
APO-BACLOFEN
RATIO-BACLOFEN
PHL-BACLOFEN
BACLOFEN
NVR
PMS
MYL
APX
RPH
PHL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NOP
APX
PMS
MYL
PHL
SNS
ARO
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CYCLOBENZAPRINE HCL
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02080052
NOVO-CYCLOPRINE (SA)
02177145
APO-CYCLOBENZAPRINE (SA)
02212048
PMS-CYCLOBENZAPRINE (SA)
02231353
MYLAN-CYCLOPRINE (SA)
02249359
PHL-CYCLOBENZAPRINE (SA)
02287064
CYCLOBENZAPRINE (SA)
02348853
AURO-CLOBENZAPRINE (SA)
02357127
JAMP-CLOBENZAPRINE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 63 -
DANTROLENE SODIUM
25MG CAPSULE
01997602
DANTRIUM
MPA FNQSW
100MG CAPSULE
01997653
DANTRIUM
MPA FNQSW
METHOCARBAMOL
500MG TABLET
01930990
ROBAXIN
PFI
METHOCARBAMOL & ACETAMINOPHEN
400MG & 325MG CAPLET
02026805
ROBAXACET
02230521
METHOXACET
PFI W
ROG W
METHOCARBAMOL & ACETYLSALICYLIC ACID
400MG & 325MG CAPLET
00868868
METHOXISAL
02026783
ROBAXISAL
ROG W
WAY W
METHOCARBAMOL & ACETYLSALICYLIC ACID & CODEINE
400MG & 325MG & 16.2MG CAPLET
01934783
ROBAXISAL C-1/4
01966367
METHOXISAL C-1/4
PFI FQW
ROG FQW
400MG & 325MG & 32.4MG CAPLET
01934791
ROBAXISAL C-1/2
01966375
METHOXISAL C-1/2
PFI FQW
ROG FQW
TIZANIDINE HCL
SEE APPENDIX A FOR SA CRITERIA
4MG TABLET
02239170
ZANAFLEX (SA)
02259893
APO-TIZANIDINE (SA)
02272059
MYLAN-TIZANIDINE (SA)
PAL FNQSW
APX FNQSW
MYL FNQSW
NW
12:92.00 MISCELLANEOUS AUTONOMIC DRUGS
BUPROPION
SEE APPENDIX A FOR SA CRITERIA. (QUIT SMOKE PROGRAM DOES NOT REQUIRE A
SA REQUEST)
PEI Pharmacare Formulary …………………………………………………Page - 64 -
150 MG SUSTAINED RELEASE TABLET
02238441
ZYBAN (SA)
BVL
NICOTINE
7MG/24HOUR TRANSDERMAL PATCH
01943057
HABITROL
02093111
NICODERM
NVR Z
MCL Z
14MG/24HOUR TRANSDERMAL PATCH
01943065
HABITROL
02093138
NICODERM
NVR Z
MCL Z
21MG/24HOUR TRANSDERMAL PATCH
01943073
HABITROL
02093146
NICODERM
NVR Z
MCL Z
NICOTINE POLACRILEX
2MG GUM
02091933
NICORETTE
MCL Z
4MG GUM
02091941
MCL Z
NICORETTE PLUS
FQWZ
20:04.04 IRON PREPARATIONS
FERROUS GLUCONATE
300MG (35MG IRON) TABLET
00031097
FERROUS GLUCONATE
00021458
FERROUS GLUCONATE
JPC
TEV
FERROUS SULFATE
30MG (6MG IRON)/ML SYRUP
00792675
PMS-FERROUS SULFATE
PMS CNW
75MG (15MG IRON)/ML ORAL DROPS
02222574
PMS-FERROUS SULFATE
PMS W
300MG (60MG IRON) TABLET
00031100
FERROUS SULFATE
JPC
160MG (50MG IRON) SUSTAINED-RELEASE TABLET
00623520
SLOW-FE
NVR NOW
CNOW
CNOW
CNOW
PEI Pharmacare Formulary …………………………………………………Page - 65 -
IRON DEXTRAN COMPLEX
SEE APPENDIX A FOR SA CRITERIA
50MG/ML INTRAMUSCULAR INJECTION
02205963
DEXIRON (SA)
02221780
INFUFER (SA)
BHC FNQSW
SDZ FNQSW
20:12.04 ANTI COAGULANTS
APIXABAN
SEE APPENDIX A FOR SA CRITERIA
2.5MG TABLET
02377233
ELIQUIS (SA)
BMS FNQSW
5MG TABLET
02397714
BMS FNQSW
ELIQUIS (SA)
DABIGATRAN
SEE APPENDIX A FOR SA CRITERIA
110MG CAPSULE
02312441
PRADAXA (SA)
BOE FNQSW
150MG CAPSULE
02358808
PRADAXA (SA)
BOE FNQSW
DALTEPARIN
SEE APPENDIX A FOR SA CRITERA
PRE-FILLED SYRINGE 2,500 UNITS/0.2ML
02132621
FRAGMIN (SA)
PFI
FNQSW
PRE-FILLED SYRINGE 5,000 UNITS/0.2ML
02132648
FRAGMIN (SA)
PFI
FNQSW
PRE-FILLED SYRINGE 7500 UNITS/0.3ML
02352648
FRAGMIN (SA)
PFI
FNQSW
PRE-FILLED SYRINGE 10,000 UNITS/0.4ML
02352656
FRAGMIN (SA)
PFI
FNQSW
PRE-FILLED SYRINGE 12,500 UNITS/0.5ML
02352664
FRAGMIN (SA)
PFI
FNQSW
PRE-FILLED SYRINGE 15,000 UNITS/0.6ML
02352672
FRAGMIN (SA)
PFI
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 66 -
PRE-FILLED SYRINGE 18,000 UNITS/0.72ML
02352680
FRAGMIN (SA)
PFI
FNQSW
AMP 10,000 UNITS/ML (1ML)
02132664
FRAGMIN (SA)
PFI
FNQSW
MULTIDOSE VIAL 25,000 UNITS/ML (3.8ML)
02231171
FRAGMIN (SA)
PFI
FNQSW
ENOXAPARIN
SEE APPENDIX A FOR SA CRITERA
PRE-FILLED SYRINGE 30MG/0.3ML
02012472
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 40MG/0.4ML
02236883
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 120MG/0.8ML
02242692
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 60MG/0.6ML
02378426
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 80MG/0.8ML
02378434
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 100MG/1.0ML
02378442
LOVENOX (SA)
AVN FNQSW
PRE-FILLED SYRINGE 150MG/1.0ML
02378469
LOVENOX (SA)
AVN FNQSW
MULIDOSE VIAL
02236564
AVN FNQSW
LOVENOX (SA)
HEPARIN
100U/ML LOCK FLUSH SOLUTION
00727520
HEPARIN
LEO NQ
10,000U/ML INJECTION SOLUTION
00579718
HEPARIN
LEO NQ
PEI Pharmacare Formulary …………………………………………………Page - 67 -
TINZAPARIN
SEE APPENDIX A FOR SA CRITERIA
2500 UNIT/0.25ML SYRINGE
02229755
INNOHEP (SA)
LEO FNQSW
3500 UNIT/0.35ML SYRINGE
02358158
INNOHEP (SA)
LEO FNQSW
4500 UNIT/0.45ML SYRINGE
02358166
INNOHEP (SA)
LEO FNQSW
10000 UNIT/0.5ML SYRINGE
02231478
INNOHEP (SA)
LEO FNQSW
14000 UNIT/0.7ML SYRINGE
02358174
INNOHEP (SA)
LEO FNQSW
18000 UNIT/0.9ML SYRINGE
02358182
INNOHEP (SA)
LEO FNQSW
10000 UNIT/ML MULTIDOSE VIAL
02167840
INNOHEP (SA)
LEO FNQSW
20000 UNIT/ML MULTIDOSE VIAL
02229515
INNOHEP (SA)
LEO FNQSW
*WARFARIN
1MG TABLET
01918311
02242680
02242924
02244462
02344025
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2MG TABLET
01918338
02242681
02242925
02244463
02265281
02344033
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
NOVO-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2.5MG TABLET
01918346
02242682
COUMADIN
TARO-WARFARIN
BMS FNQSW
TAR FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 68 -
02242926
02244464
02344041
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
APX FNQSW
MYL FNQSW
SNS FNQSW
3MG TABLET
02240205
02242683
02245618
02287498
02344068
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
4MG TABLET
02007959
02242684
02242927
02244465
02344076
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
01918354
02242685
02242928
02244466
02344084
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
6MG TABLET
02240206
02287501
COUMADIN
MYLAN-WARFARIN
BMS FNQSW
MYL FNQSW
10MG TABLET
01918362
02242687
02242929
02244467
02344114
COUMADIN
TARO-WARFARIN
APO-WARFARIN
MYLAN-WARFARIN
WARFARIN
BMS
TAR
APX
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
RIVAROXABAN
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02316986
XARELTO (SA)
BAY
FNQSW
15MG TABLET
02378604
BAY
FNQSW
XARELTO (SA)
PEI Pharmacare Formulary …………………………………………………Page - 69 -
20MG TABLET
02378612
BAY
FNQSW
SHR
MYL
SDZ
PMS
FNQSW
FNQSW
FNQSW
FNQSW
CLOPIDOGREL BISULFATE
SEE APPENDIX A FOR REVISED SA CRITERIA
75MG TABLET
02238682
PLAVIX (SA)
02293161
TEVA-CLOPIDOGREL (SA)
02359316
SANDOZ-CLOPIDOGREL (SA)
02252767
APO-CLOPIDOGREL (SA)
02303027
CO-CLOPIDOGREL (SA)
02348004
PMS-CLOPIDOGREL (SA)
02351536
MYLAN-CLOPIDOGREL (SA)
02379813
RAN-CLOPIDOGREL (SA)
02385813
CLOPIDOGREL (SA)
02400553
CLOPIDOGREL (SA)
02408910
MINT-CLOPIDOGREL (SA)
AVN
TEV
SDZ
APX
COB
PMS
MYL
RAN
SIV
SNS
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
TICAGRELOR
SEE APPENDIX A FOR SA CRITERIA
90MG TABLET
02368544
BRILINTA (SA)
AZE
FNQSW
TICLOPIDINE HCL
SEE APPENDIX A FOR SA CRITERIA
250MG TABLET
02236848
NOVO-TICLOPIDINE (SA)
02237701
APO-TICLOPIDINE (SA)
02239744
MYLAN-TICLOPIDINE (SA)
NOP FNQSW
APX FNQSW
MYL FNQSW
XARELTO (SA)
20:12.14 PLATELET REDUCING AGENTS
ANAGRELIDE HCL
SEE APPENDIX A FOR SA CRITERIA
0.5MG Capsule
02236859
AGRYLIN (SA)
02253054
MYLAN-ANAGRELIDE (SA)
02260107
SANDOZ ANAGRELIDE (SA)
02274949
PMS-ANAGRELIDE (SA)
20:12.18 PLATELET AGGREGATION INHIBITORS
PEI Pharmacare Formulary …………………………………………………Page - 70 -
02243327
02243587
02343045
PMS-TICLOPIDINE (SA)
SANDOZ-TICLOPIDINE (SA)
TICLOPIDINE (SA)
PMS FNQSW
SDZ FNQSW
SNS FNQSW
20:16.00 HEMATOPOIETIC AGENTS
DARBEPOETIN ALFA
SEE APPENDIX A FOR SA CRITERIA
25UG/ML PRE-FILLED SYRINGE
02246354
ARANESP (SA)
AMG E
40UG/ML PRE-FILLED SYRINGE
02246355
ARANESP (SA)
AMG E
100UG/ML PRE-FILLED SYRINGE
02246357
ARANESP (SA)
AMG E
200UG/ML PRE-FILLED SYRINGE
02246358
ARANESP (SA)
AMG E
EPOETIN ALFA
SEE APPENDIX A FOR SA CRITERIA
4000IU/0.4ML PRE-FILLED SYRINGE
02231586
EPREX (SA)
JAN
E
6000IU/0.6ML PRE-FILLED SYRINGE
02243401
EPREX (SA)
JAN
E
8000IU/0.8ML PRE-FILLED SYRINGE
02243403
EPREX (SA)
JAN
E
10,000IU/1.0ML PRE-FILLED SYRINGE
02231587
EPREX (SA)
JAN
E
FILGRASTIM
SEE APPENDIX A FOR SA CRITERA
300 MCG/ML INJECTION
01968017
NEUPOGEN (SA)
AMG MQ
20:24.00 HEMORRHEOLOGIC AGENTS
PENTOXIFYLLINE
400MG SUSTAINED RELEASE TABLET
PEI Pharmacare Formulary …………………………………………………Page - 71 -
AAA
FNQSW
*ACEBUTOLOL HCL
100MG TABLET
01910140
RHOTRAL
01926543
SECTRAL
02147602
APO-ACEBUTOLOL
02204517
NOVO-ACEBUTOLOL
02237721
MYLAN-ACEBUTOLOL
02237885
MYLAN-ACEBUTOLOL (TYPE S)
02257599
SANDOZ-ACEBUTOLOL
02286246
ACEBUTOLOL
AVN
AVN
APX
NOP
MYL
MYL
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
200MG TABLET
01910159
01926551
02147610
02204525
02237722
02237886
02257602
02286254
RHOTRAL
SECTRAL
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
MYLAN-ACEBUTOLOL
MYLAN-ACEBUTOLOL (TYPE S)
SANDOZ-ACEBUTOLOL
ACEBUTOLOL
AVN
AVN
APX
NOP
MYL
MYL
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
400MG TABLET
01910167
01926578
02147629
02204533
02237723
02237887
02257610
02286262
RHOTRAL
SECTRAL
APO-ACEBUTOLOL
NOVO-ACEBUTOLOL
MYLAN-ACEBUTOLOL
MYLAN-ACEBUTOLOL (TYPE S)
SANDOZ-ACEBUTOLOL
ACEBUTOLOL
AVN
AVN
APX
NOP
MYL
MYL
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*AMIODARONE
100MG TABLET
02292173
PMS-AMIODARONE
PMS FNQSW
200MG TABLET
02036282
02239835
02240071
02240604
CORDARONE
TEVA-AMIODARONE
RATIO-AMIODARONE
MYLAN-AMIODARONE
PFI
TEV
RPH
MYL
02230090
PENTOXIFYLLINE SR
24:00.00 CARDIAC DRUGS
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 72 -
02242472
02243836
02246194
02245781
02364336
02385465
PMS
SDZ
APX
PHL
SNS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
COB
PMS
SDZ
JPC
SPT
MAR
ODN
SIV
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NORVASC
TEVA-AMLODIPINE
RATIO-AMLODIPINE
MYLAN-AMLODIPINE
APO-AMLODIPINE
PMS-AMLODIPINE
SANDOZ-AMLODIPINE
CO-AMLODIPINE
RAN-AMLODIPINE
GD-AMLODIPINE BESYLATE
PHL-AMLODIPINE
JAMP-AMLODIPINE
SANIS-AMLODIPINE
JAMP-AMLODIPINE
SEPTA-AMLODIPINE
AMLODIPINE
MINT-AMLODIPINE
MAR-AMLODIPINE
AMLODIPINE-ODAN
AURO-AMOLDIPINE
PFI
TEV
RPH
MYL
APX
PMS
SDZ
COB
RAN
GMD
PHL
JPC
SNS
JPC
SPT
SIV
MNT
MAR
ODN
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NORVASC
TEVA-AMLODIPINE
RATIO-AMLODIPINE
MYLAN-AMLODIPINE
PFI
TEV
RPH
MYL
FNQSW
FNQSW
FNQSW
FNQSW
PMS-AMIODARONE
SANDOZ-AMIODARONE
APO-AMIODARONE
PHL-AMIODARONE
SANIS-AMIODARONE
AMIODARONE
*AMLODIPINE BESYLATE
2.5MG TABLET
02297477
CO-AMLODIPINE
02295148
PMS-AMLODIPINE
02330474
SANDOZ-AMLODIPINE
02357186
JAMP-AMLODIPINE
02357704
SEPTA-AMLODIPINE
02371707
MAR-AMLODIPINE
02378744
AMLODIPINE-ODAN
02385783
AMLODIPINE
02398877
RAN-AMLODIPINE
5MG TABLET
00878928
02250497
02259605
02272113
02273373
02284065
02284383
02297485
02321858
02280132
02326779
02331071
02331284
02357194
02357712
02385791
02362651
02371715
02378760
02397072
10MG TABLET
00878936
02250500
02259613
02272121
PEI Pharmacare Formulary …………………………………………………Page - 73 -
02273381
02284073
02284391
02280140
02297493
02321866
02326787
02331098
02331292
02357208
02357720
02362678
02371723
02378779
02385805
02397080
APO-AMLODIPINE
PMS-AMLODIPINE
SANDOZ-AMLODIPINE
GD-AMLODIPINE BESYLATE
CO-AMLODIPINE
RAN-AMLODIPINE
PHL-AMLODIPINE
JAMP-AMLODIPINE
SANIS-AMLODIPINE
JAMP-AMLODIPINE
SEPTA-AMLODIPINE
MINT-AMLODIPINE
MAR-AMLODIPINE
AMLODIPINE-ODAN
AMLODIPINE
AURO-AMLODIPINE
APX
PMS
SDZ
GMD
COB
RAN
PHL
JPC
SNS
JPC
SPT
MNT
MAR
ODN
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*ATENOLOL
25MG TABLET
02246581
02247182
02266660
02303647
02367556
02373963
PMS-ATENOLOL
ATENOLOL
TEVA-ATENOL
MYLAN-ATENOLOL
JAMP-ATENOLOL
RAN-ATENOLOL
PMS
SIV
TEV
MYL
JPC
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
APO-ATENOL
TENORMIN
MYLAN-ATENOLOL
RATIO-ATENOLOL
SANDOZ-ATENOLOL
PMS-ATENOLOL
ATENOLOL
CO ATENOLOL
RAN-ATENOLOL
JAMP-ATENOLOL
MINT-ATENOL
SEPTA-ATENOLOL
MAR-ATENOLOL
APX
AZE
MYL
RPH
SDZ
PMS
SIV
COB
RAN
JPC
MNT
SPT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
APO-ATENOL
TENORMIN
MYLAN-ATENOLOL
RATIO-ATENOLOL
APX
AZE
MYL
RPH
FNQSW
FNQSW
FNQSW
FNQSW
50MG TABLET
00773689
02039532
02146894
02171791
02231731
02237600
02238316
02255545
02267985
02367564
02368021
02368641
02371987
100MG TABLET
00773697
02039540
02147432
02171805
PEI Pharmacare Formulary …………………………………………………Page - 74 -
02231733
02237601
02238318
02255553
02267993
02367572
02368048
02368668
02371995
SANDOZ-ATENOLOL
PMS-ATENOLOL
ATENOLOL
CO ATENOLOL
RAN-ATENOLOL
JAMP-ATENOLOL
MINT-ATENOL
SEPTA-ATENOLOL
MAR-ATENOL
SDZ
PMS
SIV
COB
RAN
JPC
MNT
SPT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*ATENOLOL & CHLORTHALIDONE
50MG & 25MG TABLET
02049961
TENORETIC
02248763
APO-ATENIDONE
02302918
TEVA-ATENOLOL/CHLORTHALIDONE
AZE FNQSW
APX FNQSW
NOP FNQSW
100MG & 25MG TABLET
02049988
TENORETIC
02248764
APO-ATENIDONE
02302926
TEVA-ATENOLOL/CHOLRTHALIDONE
AZE FNQSW
APX FNQSW
NOP FNQSW
*BISOPROLOL
5MG TABLET
02247439
02256134
02267470
02302632
02383055
02384418
02391589
SANDOZ-BISOPROLOL
APO-BISOPROLOL
NOVO-BISOPROLOL
PMS-BISOPROLOL
BISOPROLOL
MYLAN-BISOPROLOL
BISOPROLOL
SDZ
APX
NOP
PMS
SIV
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
02247440
02256177
02267489
02302640
02383063
02384426
02391597
SANDOZ-BISOPROLOL
APO-BISOPROLOL
NOVO-BISOPROLOL
PMS-BISOPROLOL
BISOPROLOL
MYLAN-BISOPROLOL
BISOPROLOL
SDZ
APX
NOP
PMS
SIV
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CARVEDILOL
SEE APPENDIX A FOR SA CRITERIA
3.125MG TABLET
02245914
PMS-CARVEDILOL (SA)
02247933
APO-CARVEDILOL (SA)
PMS FNQSW
APX FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 75 -
02248752
02252309
02268027
02347512
02364913
02368897
CARVEDILOL (SA)
RATIO-CARVEDILOL (SA)
RAN-CARVEDILOL (SA)
MYLAN-CARVEDIOLOL (SA)
CARVEDILOL (SA)
JAMP-CARVEDILOL (SA)
SIV
RPH
RAN
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
6.25MG TABLET
02245915
02247934
02248753
02252317
02268035
02347520
02364921
02368900
PMS-CARVEDILOL (SA)
APO-CARVEDILOL (SA)
CARVEDILOL (SA)
RATIO-CARVEDILOL (SA)
RAN-CARVEDILOL (SA)
MYLAN-CARVEDIOLOL (SA)
CARVEDILOL (SA)
JAMP-CARVEDILOL (SA)
PMS
APX
SIV
RPH
RAN
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
12.5MG TABLET
02245916
02247935
02248754
02252325
02268043
02347555
02364948
02368919
PMS-CARVEDILOL (SA)
APO-CARVEDILOL (SA)
CARVEDILOL (SA)
RATIO-CARVEDILOL (SA)
RAN-CARVEDILOL (SA)
MYLAN-CARVEDIOLOL (SA)
CARVEDILOL (SA)
JAMP-CARVEDILOL (SA)
PMS
APX
SIV
RPH
RAN
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
25MG TABLET
02245917
02247936
02248755
02252333
02268051
02347571
02364956
02368927
PMS-CARVEDILOL (SA)
APO-CARVEDILOL (SA)
CARVEDILOL (SA)
RATIO-CARVEDILOL (SA)
RAN-CARVEDILOL (SA)
MYLAN-CARVEDIOLOL (SA)
CARVEDILOL (SA)
JAMP-CARVEDILOL (SA)
PMS
APX
SIV
RPH
RAN
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*DIGOXIN
0.05MG/ML ELIXIR
02242320
TOLOXIN
0.0625MG TABLET
02335700
TOLOXIN
0.125MG TABLET
02335719
TOLOXIN
PEN FNQSW
PEN FNQSW
PEN FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 76 -
0.25MG TABLET
02335727
TOLOXIN
PEN FNQSW
0.25 MG/ML INJECTION SOLUTION
02048264
DIGOXIN
SDZ
NQ
*DILTIAZEM
120MG EXTENDED RELEASE CAPSULE
02231150
TIAZAC
02245918
SANDOZ-DILTIAZEM T
02271605
NOVO-DILTIAZEM ER
02291037
APO-DILTIAZ TZ
02370441
CO-DILTIAZEM
02400421
DILTIAZEM CD
BVL
SDZ
BVL
APX
COB
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
180MG EXTENDED RELEASE CAPSULE
02231151
TIAZAC
02245919
SANDOZ-DILTIAZEM T
02271613
NOVO-DILTIAZEM ER
02291045
APO-DILTIAZ TZ
02370492
CO-DILTIAZEM
02400448
DILTIAZEM CD
BVL
SDZ
BVL
APX
COB
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
240MG EXTENDED RELEASE CAPSULE
02231152
TIAZAC
02245920
SANDOZ-DILTIAZEM T
02271621
NOVO-DILTIAZEM ER
02291053
APO-DILTIAZ TZ
02370506
CO-DILTIAZEM
02400456
DILTIAZEM CD
BVL
SDZ
BVL
APX
COB
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG EXTENDED RELEASE CAPSULE
02231154
TIAZAC
02245921
SANDOZ-DILTIAZEM T
02271648
NOVO-DILTIAZEM ER
02291061
APO-DILTIAZ TZ
02370514
CO-DILTIAZEM
02400464
DILTIAZEM CD
BVL
SDZ
BVL
APX
COB
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
360MG EXTENDED RELEASE CAPSULE
02231155
TIAZAC
02245922
SANDOZ-DILTIAZEM T
02271656
NOVO-DILTIAZEM ER
02291088
APO-DILTIAZ TZ
BVL
SDZ
BVL
APX
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 77 -
02370522
CO-DILTIAZEM
COB FNQSW
120MG EXTENDED RELEASE TABLET
02256738
TIAZAC XC
BVL
FNQSW
180MG EXTENDED RELEASE TABLET
02256746
TIAZAC XC
BVL
FNQSW
240MG EXTENDED RELEASE TABLET
02256754
TIAZAC XC
BVL
FNQSW
300MG EXTENDED RELEASE TABLET
02256762
TIAXAC XC
BVL
FNQSW
360MG EXTENDED RELEASE TABLET
02256770
TIAXAC XC
BVL
FNQSW
120MG CONTROLLED DELIVERY CAPSULE
02097249
CARDIZEM CD
02229781
RATIO-DILTIAZEM CD
02230997
APO-DILTIAZ CD
02242538
NOVO-DILTAZEM CD
02243338
SANDOZ-DILTIAZEM CD
02355752
PMS-DILTIAZEM CD
02370611
CO-DILTIAZEM
BVL
RPH
APX
NOP
SDZ
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
180MG CONTROLLED DELIVERY CAPSULE
02097257
CARDIZEM CD
02229782
RATIO-DILTIAZEM CD
02230998
APO-DILTIAZ CD
02242539
NOVO-DILTAZEM CD
02243339
SANDOZ-DILTIAZEM CD
02355760
PMS-DILTIAZEM CD
02370638
CO-DILTIAZEM
BVL
RPH
APX
NOP
SDZ
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
240MG CONTROLLED DELIVERY CAPSULE
02097265
CARDIZEM CD
02229783
RATIO-DILTIAZEM CD
02230999
APO-DILTIAZ CD
02242540
NOVO-DILTAZEM CD
02243340
SANDOZ-DILTIAZEM CD
02355779
PMS-DILTIAZEM CD
02370646
CO-DILTIAZEM
BVL
RPH
APX
NOP
SDZ
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG CONTROLLED DELIVERY CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 78 -
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02097273
02229526
02229784
02242541
02243341
02355787
02370654
CARDIZEM CD
APO-DILTIAZ CD
RATIO-DILTIAZEM CD
NOVO-DILTAZEM CD
SANDOZ-DILTIAZEM CD
PMS-DILTIAZEM CD
CO-DILTIAZEM
BVL
APX
RPH
NOP
SDZ
PMS
COB
30MG TABLET
00771376
00862924
APO-DILTIAZ
NOVO-DILTAZEM
APX FNQSW
NOP FNQSW
60MG TABLET
00771384
00862932
APO-DILTIAZ
NOVO-DILTAZEM
APX FNQSW
NOP FNQSW
*DISOPYRAMIDE
100MG CAPSULE
02224801
RYTHMODAN
AVN FNQSW
*FLECAINIDE ACETATE
50MG TABLET
02275538
APO-FLECAINIDE
AAA
FNQSW
100MG TABLET
02275546
AAA
FNQSW
*LABETALOL HCL
100MG TABLET
02106272
TRANDATE
PAL
FNQSW
200MG TABLET
02106280
PAL
FNQSW
APO-FLECAINIDE
TRANDATE
*METOPROLOL TARTRATE
100MG SUSTAINED RELEASE TABLET
00658855
LOPRESOR SR
02285169
APO-METOPROLOL SR
02303396
SANDOZ-METOPROLOL SR
NVR FNQSW
APX FNQSW
SDZ FNQSW
200MG SUSTAINED RELEASE TABLET
00534560
LOPRESOR SR
02285177
APO-METOPROLOL SR
02303418
SANDOZ-METOPROLOL SR
NVR FNQSW
APX FNQSW
SDZ FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 79 -
25MG TABLET
02246010
02248855
02302055
02356813
APO-METOPROLOL
PMS-METOPROLOL-L
MYLAN-METOPROLOL (TYPE L)
JAMP-METOPROLOL-L
APX
PMS
MYL
JPC
FNQSW
FNQSW
FNQSW
FNQSW
50 MG TABLET
00397423
00618632
00648035
00749354
00842648
02145413
02174545
02230803
02247875
02350394
02354187
02356821
LOPRESOR
APO-METOPROLOL
TEVA-METOPROL
APO-METOPROLOL (TYPE L)
NOVO-METOPROL (UNCOATED)
PMS-METOPROLOL-B
MYLAN-METOPROLOL (TYPE L)
PMS-METOPROLOL-L
SANDOZ-METOPROLOL (TYPE L)
METOPROLOL
SANDOZ-METOPROLOL
JAMP-METOPROLOL-L
NVR
APX
NOP
APX
NOP
PMS
MYL
PMS
SDZ
SNS
SDZ
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
00397431
00618640
00648043
00751170
00842656
LOPRESOR
APO-METOPROLOL
TEVA-METOPROL
APO-METOPROLOL (TYPE L)
NOVO-METOPROL (UNCOATED)
NVR
APX
NOP
APX
NOP
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02145421
02174553
02230804
02247876
02350408
02354195
02356848
PMS-METOPROLOL-B
MYLAN-METOPROLOL (TYPE L)
PMS-METOPROLOL-L
SANDOZ-METOPROLOL (TYPE L)
METOPROLOL
SANDOZ-METOPROLOL
JAMP-METOPROLOL-L
PMS
MYL
PMS
SDZ
SNS
SDZ
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*MEXILETINE HCL
100MG CAPSULE
02230359
NOVO-MEXILETINE
NOP FNQSW
200MG CAPSULE
02230360
NOVO-MEXILETINE
NOP FNQSW
*NADOLOL
40MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 80 -
00782505
APO-NADOL
APX
FNQSW
80MG TABLET
00782467
APO-NADOL
APX
FNQSW
160MG TABLET
00782475
APO-NADOL
APX
FNQSW
*NIFEDIPINE
5MG CAPSULE
00725110
NIFEDIPINE
AAA
FNQSW
10MG CAPSULE
00755907
NIFEDIPINE
AAA
FNQSW
20MG EXTENDED RELEASE TABLET
02237618
ADALAT XL
BAY
FNQSW
30MG EXTENDED RELEASE TABLET
02155907
ADALAT XL
02349167
MYLAN-NIFEDIPINE ER
BAY FNQSW
MYL FNQSW
60MG EXTENDED RELEASE TABLET
02155990
ADALAT XL
02321149
MYLAN-NIFEDIPINE ER
BAY FNQSW
MYL FNQSW
*PINDOLOL
5MG TABLET
00417270
00755877
00869007
02231536
02261782
VISKEN
APO-PINDOL
NOVO-PINDOL
PMS-PINDOLOL
SANDOZ-PINDOLOL
NVR
APX
NOP
PMS
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
VISKEN
APO-PINDOL
NOVO-PINDOL
PMS-PINDOLOL
SANDOZ-PINDOLOL
NVR
APX
NOP
PMS
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
VISKEN
APO-PINDOL
NOVO-PINDOL
PMS-PINDOLOL
NVR
APX
NOP
PMS
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
00443174
00755885
00869015
02231537
02261790
15MG TABLET
00417289
00755893
00869023
02231539
PEI Pharmacare Formulary …………………………………………………Page - 81 -
SDZ
FNQSW
*PROCAINAMIDE HCL
250MG SUSTAINED RELEASE TABLET
00638692
PROCAN SR
ERF
FNQSW
500MG SUSTAINED RELEASE TABLET
00638676
PROCAN SR
ERF
FNQSW
750MG SUSTAINED RELEASE TABLET
00638684
PROCAN SR
ERF
FNQSW
*PROPAFENONE HCL
150MG TABLET
00603708
RYTHMOL
02243324
APO-PROPAFENONE
02245372
MYLAN-PROPAFENONE
02294559
PMS-PROPAFENONE
02343053
PROPAFENONE
ABB
APX
MYL
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG TABLET
00603716
02243325
02245373
02294575
02343061
ABB
APX
MYL
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02261804
SANDOZ-PINDOLOL
RYTHMOL
APO-PROPAFENONE
MYLAN-PROPAFENONE
PMS-PROPAFENONE
PROPAFENONE
*PROPRANOLOL
10MG TABLET
00496480
NOVO-PRANOL
NOP FNQSW
20MG TABLET
00663719
00740675
APO-PROPRANOLOL
NOVO-PRANOL
APX FNQSW
NOP FNQSW
40MG TABLET
00496499
NOVO-PRANOL
NOP FNQSW
80MG TABLET
00496502
NOVO-PRANOL
NOP FNQSW
120MG TABLET
00504335
APO-PROPRANOLOL
APX
FNQSW
60MG LONG ACTING CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 82 -
INDERAL L.A.
PFI
FNQSW
80MG LONG ACTING CAPSULE
02042258
INDERAL L.A.
PFI
FNQSW
120MG LONG ACTING CAPSULE
02042266
INDERAL L.A.
PFI
FNQSW
160MG LONG ACTING CAPSULE
02042274
INDERAL L.A.
PFI
FNQSW
*SOTALOL HCL
80MG TABLET
02084228
02210428
02229778
02231181
02257831
02368617
02238326
02385988
RATIO-SOTALOL
APO-SOTALOL
MYLAN-SOTALOL
NOVO-SOTALOL
SANDOZ-SOTALOL
JAMP-SOTALOL
PMS-SOTALOL
SOTALOL
RPH
APX
MYL
NOP
SDZ
JPC
PMS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
160MG TABLET
02084236
02167794
02229779
02231182
02238327
02368625
02385996
RATIO-SOTALOL
APO-SOTALOL
MYLAN-SOTALOL
NOVO-SOTALOL
PMS-SOTALOL
JAMP-SOTALOL
SOTALOL
RPH
APX
MYL
NOP
PMS
JPC
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02042231
*TIMOLOL MALEATE
5MG TABLET
00755842
APO-TIMOL
01947796
NOVO-TIMOL
APX FNQSW
NOP FNQSW
10MG TABLET
00755850
01947818
APO-TIMOL
NOVO-TIMOL
APX FNQSW
NOP FNQSW
20MG TABLET
00755869
01947826
APO-TIMOL
NOVO-TIMOL
APX FNQSW
NOP FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 83 -
*VERAPAMIL HCL
80MG TABLET
00782483
APO-VERAP
02237921
MYLAN-VERAPAMIL
APX FNQSW
MYL FNQSW
120MG TABLET
00782491
02237922
APX FNQSW
MYL FNQSW
APO-VERAP
MYLAN-VERAPAMIL
120MG SUSTAINED RELEASE TABLET
01907123
ISOPTIN SR
02210347
MYLAN-VERAPAMIL SR
02246893
APO-VERAP SR
ABB FNQSW
MYL FNQSW
APX FNQSW
180MG SUSTAINED RELEASE TABLET
01934317
ISOPTIN SR
02210355
MYLAN-VERAPAMIL SR
02246894
APO-VERAP SR
ABB FNQSW
MYL FNQSW
APX FNQSW
240MG SUSTAINED RELEASE TABLET
00742554
ISOPTIN SR
02210363
MYLAN-VERAPAMIL SR
02211920
NOVO-VERAMIL SR
02237791
PMS-VERAPAMIL SR
02246895
APO-VERAP SR
ABB
MYL
NOP
PMS
APX
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
180MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET
02231676
COVERA-HS
PFI
FNQSW
240MG CONTROLLED-ONSET EXTENDED-RELEASE TABLET
02231677
COVERA-HS
PFI
FNQSW
PFI
GMD
APX
PMS
RPH
COB
RBX
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
24:06.00 ANTILIPEMIC DRUGS
*ATORVASTATIN CALCIUM
10MG TABLET
02230711
LIPITOR
02288346
GD-ATOROVASTATIN
02295261
APO-ATORVASTATIN
02313448
PMS-ATORVASTATIN
02350297
RATIO-ATORVASTATIN
02310899
CO-ATORVASTATIN
02313707
RAN-ATORVASTATIN
02324946
SANDOZ-ATORVASTATIN
PEI Pharmacare Formulary …………………………………………………Page - 84 -
02302675
02348705
02373203
02391058
02399377
02411350
NOVO-ATORVASTATIN
ATORVASTATIN
MYLAN-ATORVASTATIN
JAMP-ATORVASTATIN
PMS-ATORVASTATIN
ATORVASTATIN
NOP
SNS
MYL
JPC
PMS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
02230713
02288354
02295288
02313456
02350319
02310902
02313715
02324954
02302683
02348713
02373211
02391066
02399385
02411369
LIPITOR
GD-ATROVASTATIN
APO-ATORVASTATIN
PMS-ATORVASTATIN
RATIO-ATORVASTATIN
CO-ATORVASTATIN
RAN-ATORVASTATIN
SANDOZ-ATORVASTATIN
NOVO-ATORVASTATIN
ATORVASTATIN
MYLAN-ATORVASTATIN
JAMP-ATORVASTATIN
PMS-ATORVASTATIN
ATORVASTATIN
PFI
GMD
APX
PMS
RPH
COB
RAN
SDZ
NOP
SNS
MYL
JPC
PMS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
02230714
02288362
02295296
02313464
02350327
02310910
02313723
02324962
02302691
02348721
02373238
02391074
02399393
02411377
LIPITOR
GD-ATROVASTATIN
APO-ATORVASTATIN
PMS-ATORVASTATIN
RATIO-ATORVASTATIN
CO-ATORVASTATIN
RAN-ATORVASTATIN
SANDOZ-ATORVASTATIN
NOVO-ATORVASTATIN
ATORVASTATIN
MYLAN-ATORVASTATIN
JAMP-ATORVASTATIN
PMS-ATORVASTATIN
ATORVASTATIN
PFI
GMD
APX
PMS
RPH
COB
RAN
SDZ
NOP
SNS
MYL
JPC
PMS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
80MG TABLET
02243097
02288370
02295318
02313472
LIPITOR
GD-ATROVASTATIN
APO-ATORVASTATIN
PMS-ATORVASTATIN
PFI
GMD
APX
PMS
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 85 -
02350335
02310929
02313758
02324970
02302713
02348748
02373246
02391082
02399407
02411385
RATIO-ATORVASTATIN
CO-ATORVASTATIN
RAN-ATORVASTATIN
SANDOZ-ATORVASTATIN
NOVO-ATORVASTATIN
ATORVASTATIN
MYLAN-ATORVASTATIN
JAMP-ATORVASTATIN
PMS-ATORVASTATIN
ATORVASTATIN
RPH
COB
RAN
SDZ
NOP
SNS
MYL
JPC
PMS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*CHOLESTYRAMINE
REGULAR - 4G/POUCH X 30 POUCHES - 120G/PK ORAL POWDER (POUCHES)
02210320
OLESTYR
PEN FNQSW
* price per gram for cholestyramine powder pouches
LIGHT - 4G/POUCH X 30 POUCHES- 120G/PK
00890960
OLESTYR
PEN FNQSW
EZETIMIBE
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02247521
EZETROL (SA)
MSD FNQSW
*FENOFIBRATE
100MG CAPSULE
02225980
APO-FENOFIBRATE
APX
FNQSW
100MG TABLET
02241601
02246859
02288044
02289083
02356570
LIPIDIL SUPRA
APO-FENO-SUPER
SANDOZ-FENOFIBRATE S
NOVO-FENOFIBRATE-S
FENOFIBRATE-S
FFR
APX
SDZ
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
160MG TABLET
02241602
02246860
02288052
LIPIDIL SUPRA
APO-FENO-SUPRA
SANDOZ-FENOFIBRATE S
FFR
APX
SDZ
FNQSW
FNQSW
FNQSW
02289091
02356589
NOVO-FENOFIBRATE-S
FENOFIBRATE-S
NOP FNQSW
SNS FNQSW
200MG CAPSULE
02146959
LIPIDIL MICRO
FFR
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 86 -
02239864
02240210
02243552
02250039
02273551
02286092
APO-FENO-MICRO
MYLAN-FENOFIBRATE MICRO
NOVO-FENOFIBRATE MICRO
RATIO-FENOFIBRATE MC
PMS-FENOFIBRATE MICRO
FENOFIBRATE MICRO
APX
MYL
NOP
RPH
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*FLUVASTATIN
80MG SUSTAINED RELEASE TABLET
02250527
LESCOL XL
NVR FNQSW
*FLUVASTATIN SODIUM
20MG CAPSULE
02061562
LESCOL
02299224
TEVA-FLUVASTATIN
02400235
SANDOZ-FLUVASTATIN
NVR FNQSW
TEV FNQSW
SDZ FNQSW
40MG CAPSULE
02061570
02299232
02400243
LESCOL
TEVA-FLUVASTATIN
SANDOZ-FLUVASTATIN
NVR FNQSW
TEV FNQSW
SDZ FNQSW
*GEMFIBROZIL
300MG CAPSULE
00599026
01979574
02185407
02239951
02241704
LOPID
APO-GEMFIBROZIL
MYLAN-GEMFIBROZIL
PMS-GEMFIBROZIL
NOVO-GEMFIBROZIL
PFI
APX
MYL
PMS
NOP
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
600MG TABLET
00659606
01979582
02142074
02230183
02230476
LOPID
APO-GEMFIBROZIL
NOVO-GEMFIBROZIL
PMS-GEMFIBROZIL
MYLAN-GEMFIBROZIL
PFI
APX
NOP
PMS
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*LOVASTATIN
20MG TABLET
00795860
02220172
02243127
02245822
02246013
02246542
MEVACOR
APO-LOVASTATIN
MYLAN-LOVASTATIN
RATIO-LOVASTATIN
PMS-LOVASTATIN
NOVO-LOVASTATIN
MSD
APX
MYL
RPH
PMS
NOP
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 87 -
02248572
02353229
CO-LOVASTATIN
LOVASTATIN
COB FNQSW
SNS FNQSW
40MG TABLET
00795852
02220180
02243129
02245823
02246014
02246543
02248573
02353237
MEVACOR
APO-LOVASTATIN
MYLAN-LOVASTATIN
RATIO-LOVASTATIN
PMS-LOVASTATIN
NOVO-LOVASTATIN
CO-LOVASTATIN
LOVASTATIN
MSD
APX
MYL
RPH
PMS
NOP
COB
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*LOVASTATIN & NIACIN
20MG & 500MG EXTENDED-RELEASE TABLET
02270439
ADVICOR
ORX FNQSW
20MG & 1000MG EXTENDED-RELEASE TABLET
02270447
ADVICOR
ORX FNQSW
40MG & 1000MG EXTENDED-RELEASE TABLET
02293501
ADVICOR
ORX FNQSW
*PRAVASTATIN
10MG TABLET
00893749
02243506
02247008
02247655
02247856
02248182
02257092
02284421
02317451
02330954
02356546
02389703
PRAVACHOL
APO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
SANDOZ-PRAVASTATIN
CO-PRAVASTATIN
MYLAN-PRAVASTATIN
RAN-PRAVASTATIN
MINT-PRAVASTATIN
JAMP PRAVASTATIN
PRAVASTATIN
PRAVASTATIN
BMS
APX
NOP
PMS
SDZ
COB
MYL
RAN
MNT
JPC
SNS
SVI
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
00893757
02243507
02247009
02247656
02248183
02257106
PRAVACHOL
APO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
CO-PRAVASTATIN
MYLAN-PRAVASTATIN
BMS
APX
NOP
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 88 -
02284448
02317478
02330962
02356554
02389738
RAN-PRAVASTATIN
MINT-PRAVASTATIN
JAMP PRAVASTATIN
PRAVASTATIN
PRAVASTATIN
RAN
MNT
JPC
SNS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
02222051
02243508
02247010
02247657
02248184
02257114
02284456
02317486
02330970
02356562
02389746
PRAVACHOL
APO-PRAVASTATIN
NOVO-PRAVASTATIN
PMS-PRAVASTATIN
CO-PRAVASTATIN
MYLAN-PRAVASTATIN
RAN-PRAVASTATIN
MINT-PRAVASTATIN
JAMP PRAVASTATIN
PRAVASTATIN
PRAVASTATIN
BMS
APX
NOP
PMS
COB
MYL
RAN
MNT
JPC
SNS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*ROSUVASTATIN
NOTE: 5MG STRENGTH REQUIRES A SA.
5MG TABLET
02265540
CRESTOR (SA)
02337975
APO-ROSUVASTATIN (SA)
02338726
SANDOZ-ROSUVASTATIN (SA)
02339765
CO-ROSUVASTATIN (SA)
02354608
TEVA-ROSUVASTATIN (SA)
02378523
PMS-ROSUVASTATIN (SA)
02381265
MYLAN-ROSUVASTATIN (SA)
02382644
RAN-ROSUVASTATIN (SA)
02391252
JAMP-ROSUVASTATIN (SA)
02405628
ROSUVASTATIN (SA)
02397781
MINT-ROSUVASTATIN (SA)
02399164
MED-ROSUVASTATIN (SA)
02411628
ROSUVASTATIN-5 (SA)
AZE
APX
SDZ
COB
TEV
PMS
MYL
RAN
JPC
SNS
MNT
GMP
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
02247162
02337983
02338734
02339773
02354616
02378531
02381273
02382652
AZE
APX
SDZ
COB
TEV
PMS
MYL
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CRESTOR
APO-ROSUVASTATIN
SANDOZ-ROSUVASTATIN
CO-ROSUVASTATIN
TEVA-ROSUVASTATIN
PMS-ROSUVASTATIN
MYLAN-ROSUVASTATIN
RAN-ROSUVASTATIN
PEI Pharmacare Formulary …………………………………………………Page - 89 -
02391260
02405636
02397803
02399172
02411636
JAMP-ROSUVASTATIN
ROSUVASTATIN
MINT-ROSUVASTATIN
MED-ROSUVASTATIN
ROSUVASTATIN-10
JPC
SNS
MNT
GMP
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
02247163
02337991
02338742
02339781
02354624
02378558
02381281
02382660
02391279
02405644
02397811
02399180
02411644
CRESTOR
APO-ROSUVASTATIN
SANDOZ-ROSUVASTATIN
CO-ROSUVASTATIN
TEVA-ROSUVASTATIN
PMS-ROSUVASTATIN
MYLAN-ROSUVASTATIN
RAN-ROSUVASTATIN
JAMP-ROSUVASTATIN
ROSUVASTATIN
MINT-ROSUVASTATIN
MED-ROSUVASTATIN
ROSUVASTATIN-20
AZE
APX
SDZ
COB
TEV
PMS
MYL
RAN
JPC
SNS
MNT
GMP
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
02247164
02338009
02338750
02339803
02354632
02378566
02381303
02382679
02391287
02405652
02397838
02399199
02411652
CRESTOR
APO-ROSUVASTATIN
SANDOZ-ROSUVASTATIN
CO-ROSUVASTATIN
TEVA-ROSUVASTATIN
PMS-ROSUVASTATIN
MYLAN-ROSUVASTATIN
RAN-ROSUVASTATIN
JAMP-ROSUVASTATIN
ROSUVASTATIN
MINT-ROSUVASTATIN
MED-ROSUVASTATIN
ROSUVASTATIN-40
AZE
APX
SDZ
COB
TEV
PMS
MYL
RAN
JPC
SNS
MNT
GMP
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*SIMVASTATIN
5MG TABLET
00884324
02246582
02247011
02247827
02248103
02250144
02252619
ZOCOR
MYLAN-SIMVASTATIN
APO-SIMVASTATIN
SANDOZ-SIMVASTATIN
CO-SIMVASTATIN
TEVA-SIMVASTATIN
PMS-SIMVASTATIN
MSD
MYL
APX
SDZ
COB
TEV
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 90 -
02269252
02281546
02329131
02331020
02284723
02372932
02375036
02375591
02378884
02386291
PMS-SIMVASTATIN
PHL-SIMVASTATIN
RAN-SIMVASTATIN
JAMP-SIMVASTATIN
SIMVASTATIN
MINT-SIMVASTATIN
MAR-SIMVISTATIN
JAMP-SIMVASTATIN
SIMVASTATIN-ODAN
SIMVASTATIN
PMS
PHL
RAN
JPC
SNS
MNT
MAR
JPC
ODN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
00884332
02246583
02247012
02247828
02248104
02250152
02252635
02269260
02281554
02329158
02331039
02284731
02372940
02375044
02375605
02378892
02386305
ZOCOR
MYLAN-SIMVASTATIN
APO-SIMVASTATIN
SANDOZ-SIMVASTATIN
CO-SIMVASTATIN
TEVA-SIMVASTATIN
PMS-SIMVASTATIN
PMS-SIMVASTATIN
PHL-SIMVASTATIN
RAN-SIMVASTATIN
JAMP-SIMVASTATIN
SIMVASTATIN
MINT-SIMVASTATIN
MAR-SIMVISTATIN
JAMP-SIMVASTATIN
SIMVASTATIN-ODAN
SIMVASTATIN
MSD
MYL
APX
SDZ
COB
TEV
PMS
PMS
JPC
RAN
JPC
SNS
MNT
MAR
JPC
ODN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
00884340
02246737
02247013
02247830
02248105
02250160
02252643
02269279
02281562
02329166
02331047
02284758
02372959
02375052
ZOCOR
MYLAN-SIMVASTATIN
APO-SIMVASTATIN
SANDOZ-SIMVASTATIN
CO-SIMVASTATIN
TEVA-SIMVASTATIN
PMS-SIMVASTATIN
PMS-SIMVASTATIN
PHL-SIMVASTATIN
RAN-SIMVASTATIN
JAMP-SIMVASTATIN
SIMVASTATIN
MINT-SIMVASTATIN
MAR-SIMVISTATIN
MSD
MYL
APX
SDZ
COB
TEV
PMS
PMS
PHL
RAN
JPC
SNS
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 91 -
02375613
02378906
02386313
JAMP-SIMVASTATIN
SIMVASTATIN-ODAN
SIMVASTATIN
JPC FNQSW
ODN FNQSW
SIV FNQSW
40MG TABLET
00884359
02246584
02247014
02247831
02248106
02250179
02252651
02269287
02281570
02329174
02331055
02284766
02372967
02375060
02375621
02378914
02386321
ZOCOR
MYLAN-SIMVASTATIN
APO-SIMVASTATIN
SANDOZ-SIMVASTATIN
CO-SIMVASTATIN
TEVA-SIMVASTATIN
PMS-SIMVASTATIN
PMS-SIMVASTATIN
PHL-SIMVASTATIN
RAN-SIMVASTATIN
JAMP-SIMVASTATIN
SIMVASTATIN
MINT-SIMVASTATIN
MAR-SIMVISTATIN
JAMP-SIMVASTATIN
SIMVASTATIN-ODAN
SIMVASTATIN
MSD
MYL
APX
SDZ
COB
TEV
PMS
PMS
PHL
RAN
JPC
SNS
MNT
MAR
JPC
ODN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
80MG TABLET
02240332
02246585
02247015
02247833
02248107
02250187
02252678
02269295
02281589
02329182
02331063
02284774
02372975
02375079
02375648
ZOCOR
MYLAN-SIMVASTATIN
APO-SIMVASTATIN
SANDOZ-SIMVASTATIN
CO-SIMVASTATIN
TEVA-SIMVASTATIN
PMS-SIMVASTATIN
PMS-SIMVASTATIN
PHL-SIMVASTATIN
RAN-SIMVASTATIN
JAMP-SIMVASTATIN
SIMVASTATIN
MINT-SIMVASTATIN
MAR-SIMVISTATIN
JAMP-SIMVASTATIN
MSD
MYL
APX
SDZ
COB
TEV
PMS
PMS
PHL
RAN
JPC
SNS
MNT
MAR
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02378922
02386348
SIMVASTATIN-ODAN
SIMVASTATIN
ODN FNQSW
SIV FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 92 -
24:08.00 HYPOTENSIVE DRUGS
*HYDRALAZINE HCL
10MG TABLET
00441619
APO-HYDRALAZINE
APX
FNQSW
25MG TABLET
00441627
APO-HYDRALAZINE
APX
FNQSW
50MG TABLET
00441635
APO-HYDRALAZINE
APX
FNQSW
*PERINDOPRIL
2MG TABLET
02123274
COVERSYL
SEV
FNQSW
4MG TABLET
02123282
COVERSYL
SEV
FNQSW
8MG TABLET
02246624
COVERSYL
SEV
FNQSW
*PERINDOPRIL & INDAPAMIDE
4MG & 1.25MGMG TABLET
02246569
COVERSYL PLUS
SEV
FNQSW
*PERINDOPRIL ERBUMIN/INDAPAMIDE
8MG & 2.5MG TABLET
02321653
COVERSYL PLUS HD
SEV FNQSW
24:08.16 CENTRAL ALPHA AGONISTS
*CLONIDINE HCL
0.025MG TABLET
00519251
DIXARIT
02304163
NOVO-CLONIDINE
BOE FNQSW
NOP FNQSW
0.1MG TABLET
00259527
02046121
BOE FNQSW
NOP FNQSW
CATAPRES
NOVO-CLONIDINE
PEI Pharmacare Formulary …………………………………………………Page - 93 -
0.2MG TABLET
00291889
02046148
CATAPRES
NOVO-CLONIDINE
BOE FNQSW
NOP FNQSW
*METHYLDOPA
125MG TABLET
00360252
APO-METHYLDOPA
AAA
FNQSW
250MG TABLET
00360260
APO-METHYLDOPA
AAA
FNQSW
500MG TABLET
00426830
APO-METHYLDOPA
AAA
FNQSW
24:12.00 MISCELLANEOUS VASODILATING AGENTS
AMBRISENTAN
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02307065
VOLIBRIS (SA)
GSK MQ
10MG TABLET
02307073
GSK MQ
VOLIBRIS (SA)
BETAHISTINE HCL
SEE APPENDIX A FOR SA CRITERIA (EXCEPT NURSING HOME PROGRAM)
16MG TABLET
02243878
SERC (SA)
ABB FNQSW
02280191
NOVO-BETAHISTINE (SA)
NOP FNQSW
02330219
PMS-BETAHISTINE (SA)
PMS FNQSW
02374757
CO-BETAHISTINE (SA)
COB FNQSW
24MG TABLET
02247998
02280205
02330237
02374765
SERC (SA)
NOVO-BETAHISTINE (SA)
PMS-BETAHISTINE (SA)
CO-BETAHISTINE (SA)
*DIPYRIDAMOLE
25MG TABLET
00895644
APO-DIPYRIDAMOLE-FC
ABB
NOP
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
APX
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 94 -
50MG TABLET
00067393
00895652
PERSANTINE
APO-DIPYRIDAMOLE-FC
BOE FNQSW
APX FNQSW
75MG TABLET
00895660
APO-DIPYRIDAMOLE-FC
APX
FNQSW
EPOPROSTENOL SODIUM
SEE APPENDIX A FOR SA CRITERIA
0.5 MG INJECTION
02230845
FLOLAN (SA)
GSK MQ
1.5 MG INJECTION
02230848
FLOLAN (SA)
GSK MQ
FLOLAN DILUENT
02230857
FLOLAN DILUENT (SA)
GSK MQ
SEE APPENDIX A FOR SA CRITERIA
0.5MG INJECTION
02397447
CARIPUL (SA)
ACT
MQ
1.5MG INJECTION
02397455
CARIPUL (SA)
ACT
MQ
*ISOSORBIDE DINITRATE
5MG SUBLINGUAL TABLET
00670944
APO-ISDN
AAA
FNQSW
10MG TABLET
00441686
APO-ISDN
AAA
FNQSW
30MG TABLET
00441694
APO-ISDN
AAA
FNQSW
*ISOSORBIDE MONONITRATE
60MG TABLET
02126559
IMDUR
02272830
APO-ISMM
02301288
PMS-ISMN
AST FNQSW
APX FNQSW
PMS FNQSW
NITROGLYCERIN
NOTES:
1. To prevent development of tolerance, patches should be removed after 12-14 hours to
PEI Pharmacare Formulary …………………………………………………Page - 95 -
provide daily NITRATE-FREE periods of 10-12 hours. The NITRATE-FREE period
should be timed to coincide with the period in which angina is least likely to occur
(USUALLY AT NIGHT).
2. Only Nitro-Dur brand (or generic interchangeable(s)) of transdermal patches are
covered by the Nursing Homes Program.
0.2MG/HR TRANSDERMAL PATCH
01911910
NITRO-DUR 0.2
02407442
MYLAN-NITRO PATCH
MSD FNQSW
MYL FNQSW
0.2MG/HR TRANSDERMAL PATCH (NOT INTERCHANGEABLE)
00584223
TRANSDERM - NITRO 0.2
01911910
NITRO-DUR 0.2
02162806
MINITRAN 0.2
02230732
TRINIPATCH 0.2
NVR
MSD
VAL
PAL
0.4 MG/HR TRANSDERMAL PATCH
01911902
NITRO-DUR 0.4
02407450
MYLAN-NITRO PATCH
MSD FNQSW
MYL FNQSW
0.4 MG/HR TRANSDERMAL PATCH (NOT INTERCHANGEABLE)
00852384
TRANSDERM - NITRO 0.4
01911902
NITRO-DUR 0.4
02163527
MINITRAN 0.4
02230733
TRINIPATCH 0.4
NVR
MSD
VAL
PAL
0.6 MG/HR TRANSDERMAL PATCH
01911929
NITRO-DUR 0.6
02407469
MYLAN-NITRO PATCH
MSD FNQSW
MYL FNQSW
0.6 MG/HR TRANSDERMAL PATCH (NOT INTERCHANGEABLE)
01911929
NITRO-DUR 0.6
02046156
TRANSDERM - NITRO 0.6
02163535
MINITRAN 0.6
02230734
TRINIPATCH 0.6
MSD
NVR
VAL
PAL
0.8MG/HR TRANSDERMAL PATCH
02011271
NITRO-DUR 0.8
02407477
MYLAN-NITRO PATCH
MSD FNQSW
MYL FNQSW
0.3MG SUBLINGUAL TABLET
00037613
NITROSTAT
PFI
NQW
0.6MG SUBLINGUAL TABLET
00037621
NITROSTAT
PFI
NQW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 96 -
0.4MG/DOSE METERED DOSE LINGUAL SPRAY
02231441
NITROLINGUAL PUMPSPRAY
02238998
RHO-NITRO PUMPSPRAY
02243588
MYLAN-NITRO SL SPRAY
02393433
APO-NITROGLYCERIN
AVN
SDZ
MYL
APX
NQW
NQW
NQW
NQW
2% TOPICAL OINTMENT
01926454
NITROL
PAL
FNQSW
SILDENAFIL CITRATE
SEE APPENDIX A FOR SA CRITERIA
20 MG TABLET
02279401
REVATIO (SA)
02319500
RATIO-SILDENAFIL R (SA)
02418118
APO-SILDENAFIL (SA)
PFI MQ
RPH MQ
APX MQ
24:20.00 ALPHA ADRENERGIC BLOCKING AGENTS
*DOXAZOSIN
1MG TABLET
01958100
02240498
02240588
02242728
02244527
CARDURA
MYLAN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
PMS-DOXAZOSIN
PFI
MYL
APX
NOP
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2MG TABLET
01958097
02240499
02240589
02242729
02244528
CARDURA
MYLAN-DOXAZOSIN
APO-DOXAZOSIN
NOVO-DOXAZOSIN
PMS-DOXAZOSIN
PFI
MYL
APX
NOP
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
4MG TABLET
01958119
02240500
02240590
CARDURA
MYLAN-DOXAZOSIN
APO-DOXAZOSIN
PFI FNQSW
MYL FNQSW
APX FNQSW
02242730
02244529
NOVO-DOXAZOSIN
PMS-DOXAZOSIN
NOP FNQSW
PMS FNQSW
*PRAZOSIN HCL
1MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 97 -
00882801
01934198
APO-PRAZO
NOVO-PRAZIN
APX FNQSW
NOP FNQSW
2MG TABLET
00882828
01934201
APO-PRAZO
NOVO-PRAZIN
APX FNQSW
NOP FNQSW
5MG TABLET
00882836
01934228
APO-PRAZO
NOVO-PRAZIN
APX FNQSW
NOP FNQSW
*TERAZOSIN HCL
1MG TABLET
00818658
02218941
02230805
02234502
02243518
02350475
02396289
HYTRIN
RATIO-TERAZOSIN
TEVA-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
TERAZOSIN
MYLAN-TERAZOSIN
ABB
RPH
TEV
APX
PMS
SNS
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2MG TABLET
00818682
02218968
02230806
02234503
02243519
02350483
02396297
HYTRIN
RATIO-TERAZOSIN
TEVA-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
TERAZOSIN
MYLAN-TERAZOSIN
ABB
RPH
TEV
APX
PMS
SNS
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
00818666
02218976
02230807
02234504
02243520
02350491
02396300
HYTRIN
RATIO-TERAZOSIN
TEVA-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
TERAZOSIN
MYLAN-TERAZOSIN
ABB
RPH
TEV
APX
PMS
SNS
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
00818674
02218984
02230808
02234505
02243521
HYTRIN
RATIO-TERAZOSIN
TEVA-TERAZOSIN
APO-TERAZOSIN
PMS-TERAZOSIN
ABB
RPH
TEV
APX
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 98 -
02350505
02396319
TERAZOSIN
MYLAN-TERAZOSIN
SNS FNQSW
MYL FNQSW
24:28.08 DIHYDROPYRIDINES (CALCIUM CHANNEL BLOCKERS)
*FELODIPINE
2.5MG SUSTAINED RELEASE TABLET
02057778
PLENDIL
AZE
FNQSW
5MG SUSTAINED RELEASE TABLET
00851779
PLENDIL
02280264
SANDOZ FELODIPINE
AZE
SDZ
FNQSW
FNQSW
10MG SUSTAINED RELEASE TABLET
00851787
PLENDIL
02280272
SANDOZ FELODIPINE
AZE
SDZ
FNQSW
FNQSW
24:32.04 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
*BENAZEPRIL HCL
5MG TABLET
00885835
LOTENSIN
02290332
APO-BENAZEPRIL
NVR FNQSW
AAA FNQSW
10MG TABLET
02290340
APO-BENAZEPRIL
AAA
20MG TABLET
00885851
02273918
LOTENSIN
APO-BENAZEPRIL
NVR FNQSW
AAA FNQSW
*CAPTOPRIL
12.5MG TABLET
00893595
01942964
02163551
02230203
APO-CAPTO
NOVO-CAPTORIL
MYLAN-CAPTOPRIL
PMS-CAPTOPRIL
APX
NOP
MYL
PMS
FNQSW
FNQSW
FNQSW
FNQSW
25MG TABLET
00893609
APO-CAPTO
APX
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 99 -
02163578
MYLAN-CAPTOPRIL
MYL FNQSW
50MG TABLET
00893617
02163586
APO-CAPTO
MYLAN-CAPTOPRIL
APX FNQSW
MYL FNQSW
100MG TABLET
00893625
01942999
02163594
APO-CAPTO
NOVO-CAPTORIL
MYLAN-CAPTOPRIL
APX FNQSW
NOP FNQSW
MYL FNQSW
*CILAZAPRIL
1MG TABLET
02266350
02280442
02283778
02291134
02350963
NOVO-CILAZAPRIL
PMS-CILAZAPRIL
MYLAN-CILAZAPRIL
APO-CILAZAPRIL
CILZAPRIL
NOP
PMS
MYL
APX
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2.5MG TABLET
01911473
02266369
02280450
02283786
02291142
02350971
INHIBACE
NOVO-CILAZAPRIL
PMS-CILAZAPRIL
MYLAN-CILAZAPRIL
APO-CILAZAPRIL
CILAZAPRIL
HLR
NOP
PMS
MYL
APX
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
01911481
02266377
02280469
02283794
02291150
02350998
INHIBACE
NOVO-CILAZAPRIL
PMS-CILAZAPRIL
MYLAN-CILAZAPRIL
APO-CILAZAPRIL
CILAZAPRIL
HLR
NOP
PMS
MYL
APX
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*CILAZAPRIL & HYDROCHLOROTHIAZIDE
5MG & 12.5MG TABLET
02181479
INHIBACE PLUS
HLR
FNQSW
02284987
02313731
APX FNQSW
NOP FNQSW
APO-CILAZAPRIL/HCTZ
NOVO-CILAZAPRIL/HCTZ
*ENALAPRIL MALEATE
2.5MG TABLET
00851795
VASOTEC
MSD FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 100 -
02020025
02291878
02299933
02300036
02300079
02300680
02352230
02400650
APO-ENALAPRIL
CO-ENALAPRIL
SANDOZ-ENALAPRIL
MYLAN-ENALAPRIL
PMS-ENALAPRIL
NOVO-ENALAPRIL
RAN-ENALAPRIL
ENALAPRIL
APX
COB
SDZ
MYL
PMS
NOP
RAN
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
00708879
02019884
02233005
02291886
02299941
02300044
02300087
02300087
02352249
02400669
VASOTEC
APO-ENALAPRIL
NOVO- ENALAPRIL
CO-ENALAPRIL
SANDOZ-ENALAPRIL
MYLAN-ENALAPRIL
PMS-ENALAPRIL
PMS-ENALAPRIL
RAN-ENALAPRIL
ENALAPRIL
MSD
APX
NOP
COB
SDZ
MYL
PMS
PMS
RAN
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
00670901
02019892
02233006
02291894
02299968
02300052
02300095
02352257
02400677
VASOTEC
APO-ENALAPRIL
NOVO- ENALAPRIL
CO-ENALAPRIL
SANDOZ-ENALAPRIL
MYLAN-ENALAPRIL
PMS-ENALAPRIL
RAN-ENALAPRIL
ENALAPRIL
MSD
APX
NOP
COB
SDZ
MYL
PMS
RAN
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
00670928
02019906
02233007
02291908
02299976
02300060
02300109
02352265
02400685
VASOTEC
APO-ENALAPRIL
NOVO- ENALAPRIL
CO-ENALAPRIL
SANDOZ-ENALAPRIL
MYLAN-ENALAPRIL
PMS-ENALAPRIL
RAN-ENALAPRIL
ENALAPRIL
MSD
APX
NOP
COB
SDZ
MYL
PMS
RAN
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*ENALAPRIL & HYDROCHLOROTHIAZIDE
5MG & 12.5MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 101 -
VASERETIC
NOVO-ENALAPRIL/HCTZ
APO-ENALAPRIL MALEATE/HCTZ
MSD FNQSW
NOP FNQSW
APX FNQSW
10MG & 25MG TABLET
00657298
VASERETIC
02300230
NOVO-ENALAPRIL/HCTZ
02352931
APO-ENALAPRIL MALEATE/HCTZ
MSD FNQSW
NOP FNQSW
APX FNQSW
*EPROSARTAN MESYLATE
400MG TABLET
02240432
TEVETEN
ABB
FNQSW
600MG TABLET
02243942
ABB
FNQSW
*EPROSARTAN & HYDROCHLOROTHIAZIDE
600MG & 12.5MG TABLET
02253631
TEVETEN PLUS
ABB
FNQSW
*LISINOPRIL
5MG TABLET
00839388
02049333
02217481
02256797
02271443
02274833
02285061
02285118
02292203
02294230
02299879
02361531
02386232
02394472
PRINIVIL
ZESTRIL
APO-LISINOPRIL
RATIO-LISINOPRIL P
CO-LISINOPRIL
MYLAN-LISINOPRIL
NOVO-LISINOPRIL (TYPE P)
NOVO-LISINOPRIL (TYPE Z)
PMS-LISINOPRIL
RAN-LISINOPRIL
RATIO-LISINOPRIL Z
JAMP-LISINOPRIL
LISINOPRIL
AURO-LISINOPRIL
MSD
AZE
APX
RPH
COB
MYL
NOP
NOP
PMS
RAN
RPH
JPC
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
00839396
02049376
02217503
02256800
02271451
02274841
02285088
PRINIVIL
ZESTRIL
APO-LISINOPRIL
RATIO-LISINOPRIL P
CO-LISINOPRIL
MYLAN-LISINOPRIL
TEVA-LISINOPRIL (TYPE P)
MSD
AZE
APX
RPH
COB
MYL
NOP
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02242826
02300222
02352923
TEVETEN
PEI Pharmacare Formulary …………………………………………………Page - 102 -
02285126
02289202
02292211
02294249
02299887
02361558
02386240
02394480
NOVO-LISINOPRIL (TYPE Z)
SANDOZ-LISINOPRIL
PMS-LISINOPRIL
RAN-LISINOPRIL
RATIO-LISINOPRIL Z
JAMP-LISINOPRIL
LISINOPRIL
AURO-LISINOPRIL
NOP
SDZ
PMS
RAN
RPH
JPC
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
00839418
02049384
02217511
02256819
02271478
02274868
02285096
02285134
02289229
02292238
02294257
02299895
02361566
02386259
02394499
PRINIVIL
ZESTRIL
APO-LISINOPRIL
RATIO-LISINOPRIL P
CO-LISINOPRIL
MYLAN-LISINOPRIL
TEVA-LISINOPRIL (TYPE P)
NOVO-LISINOPRIL (TYPE Z)
SANDOZ-LISINOPRIL
PMS-LISINOPRIL
RAN-LISINOPRIL
RATIO-LISINOPRIL Z
JAMP-LISINOPRIL
LISINOPRIL
AURO-LISINOPRIL
MSD
AZE
APX
RPH
COB
MYL
NOP
NOP
SDZ
PMS
RAN
RPH
JPC
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*LISINOPRIL & HYDROCHLOROTHIAZIDE
10MG & 12.5MG TABLET
02103729
ZESTORESTIC
02108194
PRINZIDE
02261979
APO-LISINOPRIL/HCTZ
02297736
MYLAN-LISINOPRIL/HCTZ
02301768
NOVO-LISINOPRIL/HCTZ (TYPE Z)
02302136
NOVO-LISINOPRIL/HCTZ (TYPE P)
02302365
SANDOZ LISINOPRIL/HCT
02362945
LISINOPRIL
AZE
MSD
APX
MYL
NOP
NOP
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG & 12.5MG TABLET
00884413
PRINZIDE
02045737
ZESTORESTIC
02261987
APO-LISINOPRIL/HCTZ
02297744
MYLAN-LISINOPRIL/HCTZ
02301776
TEVA-LISINOPRIL/HCTZ (TYPE Z)
02302144
NOVO-LISINOPRIL/HCTZ (TYPE P)
02302373
SANDOZ LISINOPRIL/HCT
MSD
AZE
APX
MYL
NOP
NOP
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 103 -
02362953
LISINOPRIL
SNS FNQSW
20MG & 25MG TABLET
02045729
ZESTORESTIC
02261995
APO-LISINOPRIL/HCTZ
02297752
MYLAN-LISINOPRIL/HCTZ
02301784
NOVO-LISINOPRIL/HCTZ (TYPE Z)
02302152
NOVO-LISINOPRIL/HCTZ (TYPE P)
02302381
SANDOZ-LISINOPRIL/HCT
02362961
LISINOPRIL
AZE
APX
MYL
NOP
NOP
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*QUINAPRIL HCL
5MG TABLET
01947664
ACCUPRIL
02248499
APO-QUINAPRIL
PFI
APX
FNQSW
FNQSW
10MG TABLET
01947672
02248500
ACCUPRIL
APO-QUINAPRIL
PFI
APX
FNQSW
FNQSW
20MG TABLET
01947680
02248501
ACCUPRIL
APO-QUINAPRIL
PFI
APX
FNQSW
FNQSW
40MG TABLET
01947699
02248502
ACCUPRIL
APO-QUINAPRIL
PFI
APX
FNQSW
FNQSW
*QUINAPRIL HCL & HYDROCHLOROTHIAZIDE
10MG & 12.5MG TABLET
02237367
ACCURETIC
02408767
APO-QUINAPRIL HCTZ
PFI
APX
FNQSW
FNQSW
20MG & 12.5MG TABLET
02237368
ACCURETIC
02408775
APO-QUINAPRIL HCTZ
PFI
APX
FNQSW
FNQSW
20MG & 25MG TABLET
02237369
ACCURETIC
02408783
APO-QUINAPRIL HCTZ
PFI
APX
FNQSW
FNQSW
*RAMIPRIL
1.25MG CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 104 -
02221829
02251515
02291398
02295482
02295369
02301148
02310503
02331101
02387387
ALTACE
APO-RAMIPRIL
SANDOZ RAMIPRIL
CO-RAMIPRIL
PMS-RAMIPRIL
MYLAN-RAMIPRIL
RAN-RAMIPRIL
JAMP RAMIPRIL
AURO-RAMIPRIL
AVN
APX
SDZ
COB
PMS
MYL
RAN
JPC
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2.5MG CAPSULE
02221837
02247917
02247945
02251531
02291401
02295490
02301156
02310511
02331128
02374846
02387395
02411563
ALTACE
PMS-RAMIPRIL
TEVA-RAMIPRIL
APO-RAMIPRIL
SANDOZ RAMIPRIL
CO-RAMIPRIL
MYLAN-RAMIPRIL
RAN-RAMIPRIL
JAMP-RAMIPRIL
RAMIPRIL
AURO-RAMIPRIL
RAMIPRIL-2.5
AVN
PMS
TEV
APX
SDZ
COB
MYL
RAN
JPC
SNS
ARO
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG CAPSULE
02221845
02247918
02247946
02251574
02295504
02301164
02310538
02331136
02374854
02387409
02411571
ALTACE
PMS-RAMIPRIL
TEVA-RAMIPRIL
APO-RAMIPRIL
CO-RAMIPRIL
MYLAN-RAMIPRIL
RAN-RAMIPRIL
JAMP-RAMIPRIL
RAMIPRIL
AURO-RAMIPRIL
RAMIPRIL-5
AVN
PMS
TEV
APX
COB
MYL
RAN
JPC
SNS
ARO
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG CAPSULE
02221853
02247919
02247947
02251582
02291436
02295512
02301172
ALTACE
PMS-RAMIPRIL
TEVA-RAMIPRIL
APO-RAMIPRIL
SANDOZ-RAMIPRIL
CO-RAMIPRIL
MYLAN-RAMIPRIL
AVN
PMS
TEV
APX
SDZ
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 105 -
02310546
02331144
02374862
02387417
02411598
RAN-RAMIPRIL
JAMP-RAMIPRIL
RAMIPRIL
AURO-RAMIPRIL
RAMIPRIL-10
RAN
JPC
SNS
ARO
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*RAMIPRIL & HYDROCHLOROTHIAZIDE
2.5MG & 12.5MG TABLET
02283131
ALTACE HCT
02342138
PMS-RAMIPRIL HCTZ
02388332
TEVA-RAMIPRIL HCTZ
SAN FNQSW
PMS FNQSW
TEV FNQSW
5MG & 12.5MG TABLET
02283158
ALTACE HCT
02342146
PMS-RAMIPRIL HCTZ
02388340
TEVA-RAMIPRIL HCTZ
02412640
RAMIPRIL HCTZ
SAN
PMS
TEV
SNS
FNQSW
FNQSW
FNQSW
FNQSW
10MG & 12.5MG TABLET
02283166
ALTACE HCT
02342154
PMS-RAMIPRIL-HCTZ
02388359
TEVA-RAMIPRIL HCTZ
02412659
RAMIPRIL HCTZ
AVN
PMS
TEV
SNS
FNQSW
FNQSW
FNQSW
FNQSW
5MG & 25MG TABLET
02283174
ALTACE HCT
02342162
PMS-RAMIPRIL-HCTZ
02388367
TEVA-RAMIPRIL HCTZ
02412667
RAMIPRIL HCTZ
AVN
PMS
TEV
SNS
FNQSW
FNQSW
FNQSW
FNQSW
10MG & 25MG TABLET
02283182
ALTACE HCT
02342170
PMS-RAMIPRIL-HCTZ
AVN FNQSW
PMS FNQSW
02388375
02412675
TEV FNQSW
SNS FNQSW
TEVA-RAMIPRIL HCTZ
RAMIPRIL HCTZ
*TRANDOLAPRIL
0.5MG CAPSULE
02231457
MAVIK
ABB
FNQSW
1MG CAPSULE
02231459
ABB
FNQSW
MAVIK
2MG CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 106 -
02231460
MAVIK
ABB
FNQSW
4MG CAPSULE
02239267
MAVIK
ABB
FNQSW
*CANDESARTAN CILEXETIL
4MG TABLET
02239090
ATACAND
02326957
SANDOZ-CANDESARTAN
02365340
APO-CANDESARTAN
02376520
CO-CANDESARTAN
02379120
MYLAN-CANDESARTAN
02379260
CANDESARTAN CILEXETIL
02380684
RAN-CANDESARTAN
02386496
JAMP-CANDESARTAN
02388693
CANDESARTAN
02388901
CANDESARTAN
02391171
PMS-CANDESARTAN
AZE
SDZ
APX
COB
MYL
ACH
RAN
JPC
SIV
SNS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
8MG TABLET
02239091
02326965
02365359
02366312
02376539
02379139
02379279
02380692
02386518
02388707
02388928
02391198
ATACAND
SANDOZ-CANDESARTAN
APO-CANDESARTAN
TEVA-CANDESARTAN
CO-CANDESARTAN
MYLAN-CANDESARTAN
CANDESARTAN CILEXETIL
RAN-CANDESARTAN
JAMP-CANDESARTAN
CANDESARTAN
CANDESARTAN
PMS-CANDESARTAN
AZE
SDZ
APX
TEV
COB
MYL
ACH
RAN
JPC
SIV
SNS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
16MG TABLET
02239092
02326973
02365367
02366320
02376547
02379147
02379287
ATACAND
SANDOZ-CANDESARTAN
APO-CANDESARTAN
TEVA-CANDESARTAN
CO-CANDESARTAN
MYLAN-CANDESARTAN
CANDESARTAN CILEXETIL
AZE
SDZ
APX
TEV
COB
MYL
ACH
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
24:32.08 ANGIOTENSIN II RECEPTOR ANTAGONISTS
PEI Pharmacare Formulary …………………………………………………Page - 107 -
02380706
02386526
02388715
02388936
02391201
RAN-CANDESARTAN
JAMP-CANDESARTAN
CANDESARTAN
CANDESARTAN
PMS-CANDESARTAN
RAN
JPC
SIV
SNS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
32MG TABLET
02311658
02366339
02376555
02379155
02379295
02380714
02386534
02391228
02392267
02399105
ATACAND
TEVA-CANDESARTAN
CO-CANDESARTAN
MYLAN-CANDESARTAN
CANDESARTAN CILEXETIL
RAN-CANDESARTAN
JAMP-CANDESARTAN
PMS-CANDESARTAN
SANDOZ-CANDESARTAN
APO-CANDESARTAN
AZE
TEV
COB
MYL
ACH
RAN
JPC
PMS
SDZ
APX
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*CANDESARTAN CILEXETIL & HYDROCHLOROTHIAZIDE
16MG & 12.5MG TABLET
02244021
ATACAND PLUS
02367866
APO-CANDESARTAN HCTZ
02374897
MYLAN-CANDSARTAN HCTZ
02388650
CO-CANDESARTAN HCT
02391295
PMS-CANDESARTAN HCTZ
02394804
CANDESARTAN/HCTZ
02394812
CANDESARTAN/HCTZ
02395541
TEVA-CANDESARTAN HCTZ
AZE
APX
MYL
COB
PMS
SNS
SIV
TEV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
32MG & 12.5MG TABLET
02332922
ATACAND PLUS
02395126
APO-CANDESARTAN HCTZ
02395568
TEVA-CANDESARTAN HCTZ
AZE
APX
TEV
FNQSW
FNQSW
FNQSW
32MG & 25MG TABLET
02332957
ATACAND PLUS
02395134
APO-CANDESARTAN HCTZ
AZE
APX
FNQSW
FNQSW
*FOSINOPRIL
10MG TABLET
01907107
02247802
02262401
02266008
02331004
BMS
TEV
MYL
APX
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
MONOPRIL
TEVA-FOSINOPRIL
MYLAN-FOSINOPRIL
APO-FOSINOPRIL
JAMP-FOSINOPRIL
PEI Pharmacare Formulary …………………………………………………Page - 108 -
02294524
RAN-FOSINOPRIL
RAN FNQSW
20MG TABLET
01907115
02247803
02255952
02262428
02266016
02331012
02294532
MONOPRIL
TEVA-FOSINOPRIL
PMS-FOSINOPRIL
MYLAN-FOSINOPRIL
APO-FOSINOPRIL
JAMP-FOSINOPRIL
RAN-FOSINOPRIL
BMS
TEV
PMS
MYL
APX
JPC
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*IRBESARTAN
75MG TABLET
02237923
02315971
02316390
02317060
02328070
02328461
02347296
02372347
02385287
02386968
02406098
02406810
02418193
AVAPRO
TEVA-IRBESARTAN
RATIO-IRBESARTAN
PMS-IRBESARTAN
CO-IRBESARTAN
SANDOZ-IRBESARTAN
MYLAN-IRBESARTAN
IRBESARTAN
IRBESARTAN
APO-IRBESARTAN
AURO-IRBESARTAN
RAN-IRBESARTAN
JAMP-IRBESARTAN
AVN
TEV
RPH
PMS
COB
SDZ
MYL
SNS
SIV
APX
ARO
RAN
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
150MG TABLET
02237924
02315998
02316404
02317079
02328089
02328488
02347318
02372371
02385295
02386976
02406101
02406829
02418207
AVAPRO
TEVA-IRBESARTAN
RATIO-IRBESARTAN
PMS-IRBESARTAN
CO-IRBESARTAN
SANDOZ-IRBESARTAN
MYLAN-IRBESARTAN
IRBESARTAN
IRBESARTAN
APO-IRBESARTAN
AURO-IRBESARTAN
RAN-IRBESARTAN
JAMP-IRBESARTAN
AVN
TEV
RPH
PMS
COB
SDZ
MYL
SNS
SIV
APX
ARO
RAN
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG TABLET
02237925
02316005
AVAPRO
TEVA-IRBESARTAN
AVN FNQSW
TEV FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 109 -
RPH
PMS
COB
SDZ
MYL
SNS
SIV
APX
ARO
RAN
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*IRBESARTAN & HYDROCHLOROTHIAZIDE
150MG & 12.5MG TABLET
02241818
AVALIDE
02316013
TEVA-IRBESARTAN HCTZ
02328518
PMS-IRBESARTAN HCTZ
02330512
RATIO-IRBESARTAN HCTZ
02337428
SANDOZ-IRBESARTAN HCT
02357399
CO-IRBESARTAN HCT
02363208
RAN-IRBESARTAN HCTZ
02372886
IRBESARTAN HCTZ
02385317
IRBESARTAN HCT
02387646
APO-IRBESARTAN HCTZ
02392992
MINT-IRBESARTAN HCTZ
02418223
JAMP-IRBESARTAN/HCTZ
AVN
TEV
PMS
RPH
SDZ
COB
RAN
SNS
SIV
APX
MNT
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG & 12.5MG TABLET
02241819
AVALIDE
02316021
TEVA-IRBESARTAN HCTZ
02328526
PMS-IRBESARTAN HCTZ
02330520
RATIO-IRBESARTAN HCTZ
02337436
SANDOZ-IRBESARTAN HCT
02357402
CO-IRBESARTAN HCT
02363216
RAN-IRBESARTAN HCTZ
02372894
IRBESARTAN HCTZ
02385325
IRBESARTAN HCT
02387654
APO-IRBESARTAN HCTZ
02393018
MINT-IRBESARTAN HCTZ
02418231
JAMP-IRBESARTAN HCTZ
AVN
TEV
PMS
RPH
SDZ
COB
RAN
SNS
SIV
APX
MNT
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG & 25MG TABLET
02316048
TEVA-IRBESARTAN HCTZ
02328534
PMS-IRBESARTAN HCTZ
02330539
RATIO-IRBESARTAN HCTZ
TEV FNQSW
PMS FNQSW
RPH FNQSW
02316412
02317087
02328100
02328496
02347326
02372398
02385309
02386984
02406128
02406837
02418215
RATIO-IRBESARTAN
PMS-IRBESARTAN
CO-IRBESARTAN
SANDOZ-IRBESARTAN
MYLAN-IRBESARTAN
IRBESARTAN
IRBESARTAN
APO-IRBESARTAN
AURO-IRBESARTAN
RAN-IRBESARTAN
JAMP-IRBESARTAN
PEI Pharmacare Formulary …………………………………………………Page - 110 -
SDZ
COB
RAN
SNS
SIV
APX
MNT
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*LOSARTAN POTASSIUM
25MG TABLET
02182815
COZAAR
02313332
SANDOZ-LOSARTAN
02309750
PMS-LOSARTAN
02354829
CO-LOSARTAN
02368277
MYLAN-LOSARTAN
02379058
APO-LOSARTAN
02380838
TEVA-LOSARTAN
02388790
LOSARTAN
02388863
LOSARTAN
02398834
JAMP-LOSARTAN
02403323
AURO-LOSARTAN
02404451
RAN-LOSARTAN
02405733
MINT-LOSARTAN
MSD
SDZ
PMS
COB
MYL
APX
TEV
SIV
SNS
JPC
ARO
RAN
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
50MG TABLET
02182874
02309769
02353504
02354837
02357968
02368285
02388804
02388871
02398842
02403331
02404478
02405741
COZAAR
PMS-LOSARTAN
APO-LOSARTAN
CO-LOSARTAN
TEVA-LOSARTAN
MYLAN-LOSARTAN
LOSARTAN
LOSARTAN
JAMP-LOSARTAN
AURO-LOSARTAN
RAN-LOSARTAN
MINT-LOSARTAN
MSD
PMS
APX
COB
TEV
MYL
SIV
SNS
JPC
ARO
RAN
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
02182882
02309777
02313359
02353512
02354845
COZAAR
PMS-LOSARTAN
SANDOZ-LOSARTAN
APO-LOSARTAN
CO-LOSARTAN
MSD
PMS
SDZ
APX
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02337444
02357410
02363224
02372908
02385333
02387662
02393026
02418258
SANDOZ-IRBESARTAN HCT
CO-IRBESARTAN HCT
RAN-IRBESARTAN HCTZ
IRBESARTAN HCTZ
IRBESARTAN HCT
APO-IRBESARTAN HCTZ
MINT-IRBESARTAN HCTZ
JAMP-IRBESRTAN HCTZ
PEI Pharmacare Formulary …………………………………………………Page - 111 -
TEV
MYL
SIV
SNS
JPC
ARO
RAN
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE
50MG & 12.5MG TABLET
02230047
HYZAAR
02313375
SANDOZ-LOSARTAN HCT
02358263
TEVA-LOSARTAN HCTZ
02371235
APO-LOSARTAN HCTZ
02378078
MYLAN-LOSARTAN HCTZ
02388251
CO-LOSARTAN HCT
02388960
LOSARTAN HCTZ
02389657
MINT-LOSARTAN HCTZ
02392224
PMS-LOSARTAN HCTZ
02408244
JAMP-LOSARTAN HCTZ
MSD
SDZ
TEV
APX
MYL
COB
SIV
MNT
PMS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG & 12.5MG TABLET
02297841
HYZAAR
02362449
SANDOZ-LOSARTAN HCT
02371243
APO-LOSARTAN HCTZ
02377144
TEVA-LOSARTAN HCTZ
02378086
MYLAN-LOSARTAN HCTZ
02388278
CO-LOSARTAN HCT
02388979
LOSARTAN HCTZ
02389665
MINT-LOSARTAN HCTZ
02392232
PMS-LOSARTAN HCTZ
MSD
SDZ
APX
TEV
MYL
COB
SIV
MNT
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG & 25MG TABLET
02241007
HYZAAR DS
02313383
SANDOZ-LOSARTAN HCT
02371251
APO-LOSARTAN HCTZ
02377152
TEVA-LOSARTAN HCTZ
02378094
MYLAN-LOSARTAN HCTZ
02388286
CO-LOSARTAN HCT
02388987
LOSARTAN HCTZ
02389673
MINT-LOSARTAN HCTZ
02392240
PMS-LOSARTAN HCTZ
02408252
JAMP-LOSARTAN HCTZ
MSD
SDZ
APX
TEV
MYL
COB
SIV
MNT
PMS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02357976
02368293
02388812
02388898
02398850
02403358
02404486
02405768
TEVA-LOSARTAN
MYLAN-LOSARTAN
LOSARTAN
LOSARTAN
JAMP-LOSARTAN
AURO-LOSARTAN
RAN-LOSARTAN
MINT-LOSARTAN
PEI Pharmacare Formulary …………………………………………………Page - 112 -
*OLMESARTAN
20MG TABLET
02318660
OLMETEC
MSD FNQSW
40MG TABLET
02318679
OLEMETEC
MSD FNQSW
*OLMESARTAN & HYDROCHLOROTHIAZIDE
20/12.5 TABLET
02319616
OLMETEC PLUS
MSD FNQSW
40/12.5MG TABLET
02319624
OLMETEC PLUS
MSD FNQSW
40/25MG TABLET
02319632
OLMETEC PLUS
MSD FNQSW
*TELMISARTAN
40MG TABLET
02240769
02320177
02375966
02388944
02390345
02391236
02393247
MICARDIS
TEVA-TELMISARTAN
SANDOZ-TELMISARTAN
TELMISARTAN
TELMISARTAN
PMS-TELMISARTAN
CO-TELMISARTAN
BOE
TEV
SDZ
SNS
SIV
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
80MG TABLET
02240770
02320185
02375958
02388952
02390353
02391244
02393255
MICARDIS
TEVA-TELMISARTAN
SANDOZ-TELMISARTAN
TELMISARTAN
TELMISARTAN
PMS-TELMISARTAN
CO-TELMISARTAN
BOE
TEV
SDZ
SNS
SIV
PMS
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*TELMISARTAN & AMLODIPINE
40/5MG TABLET
02371022
TWYNSTA
BOE FNQSW
40/10MG TABLET
02371030
TWYNSTA
02376717
MYLAN-TELMISARTAN
BOE FNQSW
MYL FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 113 -
80/5MG TABLET
02371049
TWYNSTA
02376725
MYLAN-TELMISARTAN
BOE FNQSW
MYL FNQSW
80/10MG TABLET
02371057
TWYNSTA
BOE FNQSW
*TELMISARTAN & HYDROCHLOROTHIAZIDE
80MG & 12.5MG TABLET
02244344
MICARDIS PLUS
02330288
TEVA-TELMISARTAN HCTZ
02373564
MYLAN-TELMISARTAN HCTZ
02390302
TELMISARTAN-HCTZ
02393263
CO-TELMISARTAN HCT
02393557
SANDOZ-TELMISARTAN HCT
02395355
TELMISARTAN HCTZ
02401665
PMS-TELMISARTAN HCTZ
BOE
TEV
MYL
SIV
COB
SDZ
SNS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
80MG & 25 MG TABLET
02318709
MICARDIS PLUS
02379252
TEVA-TELMISARTAN HCTZ
02373572
MYLAN-TELMISARTAN HCTZ
02390310
TELMISARTAN-HCTZ
02393271
CO-TELMISARTAN HCT
02393565
SANDOZ-TELMISARTAN HCT
02395363
TELMISARTAN HCTZ
02401673
PMS-TELMISARTAN HCTZ
BOE
TEV
MYL
SIV
COB
SDZ
SNS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*VALSARTAN
40MG TABLET
02270528
02312999
02337487
02356740
02356643
02363062
02366940
02371510
02383527
02384523
DIOVAN
PMS-VALSARTAN
CO-VALSARTAN
SANDOZ-VALSARTAN
TEVA-VALSARTAN
RAN-VALSARTAN
VALSARTAN
APO-VALSARTAN
MYLAN-VALSARTAN
VALSARTAN
NVR
PMS
COB
SDZ
TEV
RBX
SNS
APX
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
80MG TABLET
02244781
02313006
02337495
DIOVAN
PMS-VALSARTAN
CO-VALSARTAN
NVR FNQSW
PMS FNQSW
COB FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 114 -
02356759
02356651
02363100
02366959
02371529
02383535
02384531
SANDOZ-VALSARTAN
TEVA-VALSARTAN
RAN-VALSARTAN
VALSARTAN
APO-VALSARTAN
MYLAN-VALSARTAN
VALSARTAN
SDZ
TEV
RBX
SNS
APX
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
160MG TABLET
02244782
02313014
02337509
02356767
02356678
02363119
02366967
02371537
02383543
02384558
DIOVAN
PMS-VALSARTAN
CO-VALSARTAN
SANDOZ-VALSARTAN
TEVA-VALSARTAN
RAN-VALSARTAN
VALSARTAN
APO-VALSARTAN
MYLAN-VALSARTAN
VALSARTAN
NVR
PMS
COB
SDZ
TEV
RBX
SNS
APX
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
320MG TABLET
02289504
02337517
02344564
02356775
02356686
02366975
02371545
02383551
02384566
DIOVAN
CO-VALSARTAN
PMS-VALSARTAN
SANDOZ-VALSARTAN
TEVA-VALSARTAN
VALSARTAN
APO-VALSARTAN
MYLAN-VALSARTAN
VALSARTAN
NVR
COB
PMS
SDZ
TEV
SNS
APX
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*VALSARTAN & HYDROCHLORTHIAZIDE
80MG & 12.5MG TABLET
02241900
DIOVAN-HCT
02356694
SANDOZ-VALSARTAN HCT
02356996
TEVA-VALSARTAN HCTZ
02367009
VALSARTAN HCTZ
02373734
MYLAN-VALSARTAN HCTZ
02382547
APO-VALSARTAN HCTZ
02384736
VALSARTAN HCT
02408112
AURO-VALSARTAN HCT
NVR
SDZ
TEV
SNS
MYL
APX
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
160MG & 12.5MG TABLET
02241901
DIOVAN-HCT
02356708
SANDOZ-VALSARTAN HCT
NVR FNQSW
SDZ FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 115 -
TEVA-VALSARTAN HCTZ
VALSARTAN HCTZ
MYLAN-VALSARTAN HCTZ
APO-VALSARTAN HCTZ
VALSARTAN HCT
AURO-VALSARTAN HCT
TEV
SNS
MYL
APX
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
160MG & 25MG TABLET
02246955
DIOVAN-HCT
02356716
SANDOZ-VALSARTAN HCT
02357011
TEVA-VALSARTAN HCTZ
02367025
VALSARTAN HCTZ
02373750
MYLAN-VALSARTAN HCTZ
02382563
APO-VALSARTAN HCTZ
02384752
VALSARTAN HCT
02408139
AURO-VALSARTAN HCT
NVR
SDZ
TEV
SNS
MYL
APX
SIV
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
320MG & 12.5MG TABLET
02308908
DIOVAN-HCT
02356724
SANDOZ-VALSARTAN HCT
02357038
TEVA-VALSARTAN HCTZ
02367033
VALSARTAN HCTZ
02373769
MYLAN-VALSARTAN HCTZ
02382571
APO-VALSARTAN HCTZ
02408147
AURO-VALSARTAN HCT
NVR
SDZ
TEV
SNS
MYL
APX
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
320MG & 25MG TABLET
02308916
DIOVAN-HCT
02356732
SANDOZ-VALSARTAN HCT
02357046
TEVA-VALSARTAN HCTZ
02367041
VALSARTAN HCTZ
02373777
MYLAN-VALSARTAN HCTZ
02382598
APO-VALSARTAN HCTZ
02408155
AURO-VALSARTAN HCT
NVR
SDZ
TEV
SNS
MYL
APX
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02357003
02367017
02373742
02382555
02384744
02408120
28:08.04 NONSTEROIDAL ANTI INFLAMMATORY AGENTS
*ACETYLSALICYLIC ACID
325MG TABLET
00999963
ASA (DIN for billing purposes only)
81MG ENTERIC COATED TABLET
02237726
COATED ASPIRIN DAILY LOW DOSE
02242281
ENTROPHEN
NW
BAY NW
PEN NW
PEI Pharmacare Formulary …………………………………………………Page - 116 -
325MG ENTERIC COATED TABLET
00010332
ENTROPHEN
00216666
NOVASEN
02284529
PMS-ASA EC
PMS NW
NOP NW
PMS NW
650MG ENTERIC COATED TABLET
00229296
NOVASEN
NOP NW
*DICLOFENAC SODIUM
25MG ENTERIC COATED TABLET
00839175
APO-DICLO
02261952
SANDOZ-DICLOFENAC
02302616
PMS-DICLOFENAC
APX FNQSW
SDZ FNQSW
PMS FNQSW
50MG ENTERIC COATED TABLET
00514012
VOLTAREN
00808547
TEVA DIFENAC
00839183
APO-DICLO
02261960
SANDOZ-DICLOFENAC
02302624
PMS-DICLOFENAC
02352397
DICLOFENAC EC
NVR
TEV
APX
SDZ
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
75MG SUSTAINED RELEASE TABLET
00782459
VOLTAREN SR
02158582
TEVA DIFENAC SR
02162814
APO-DICLO SR
02231504
PMS-DICLOFENAC SR
02261901
SANDOZ-DICLOFENAC
02352400
DICLOFENAC SR
NVR
TEV
APX
PMS
SDZ
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG SUSTAINED RELEASE TABLET
00590827
VOLTAREN SR
02048698
TEVA DIFENAC SR
02091194
APO-DICLO SR
02231505
PMS-DICLOFENAC SR
02261944
SANDOZ-DICLOFENAC
NVR
TEV
APX
PMS
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
50MG SUPPOSITORY
00632724
VOLTAREN
02231506
PMS-DICLOFENAC
02261928
SANDOZ-DICLOFENAC
100MG SUPPOSITORY
00632732
VOLTAREN
02231508
PMS-DICLOFENAC
02261936
SANDOZ-DICLOFENAC
NVR FNQSW
PMS FNQSW
SDZ FNQSW
NVR FNQSW
PMS FNQSW
SDZ FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 117 -
Note: Suppository formulation limited to a maximum one-month supply of medication.
*DIFLUNISAL
250MG TABLET
02039486
02048493
APO-DIFLUNISAL
NOVO-DIFLUNISAL
APX FNQSW
NOP FNQSW
500MG TABLET
02039494
APO-DIFLUNISAL
APX
FNQSW
*FLURBIPROFEN
50MG TABLET
00647942
ANSAID
01912046
APO-FLURBIPROFEN
02100509
NOVO-FLURPROFEN
PFI FNQSW
APX FNQSW
NOP FNQSW
100MG TABLET
00600792
01912038
02100517
ANSAID
APO-FLURBIPROFEN
NOVO-FLURPROFEN
PFI FNQSW
APX FNQSW
NOP FNQSW
*IBUPROFEN
300MG TABLET
00441651
02242632
APO-IBUPROFEN
MOTRIN IB EXTRA STRENGTH
APX NW
MCL NW
400MG TABLET
00629340
02242658
02317338
NOVO-PROFEN
MOTRIN IB SUPER STRENGTH
IBUPROFEN
NOP NW
MCL NW
JPC NW
600MG TABLET
00585114
00629359
APO-IBUPROFEN
NOVO-PROFEN
APX FNQSW
NOP FNQSW
*INDOMETHACIN
25MG CAPSULE
00337420
NOVO-METHACIN
NOP FNQSW
50MG CAPSULE
00337439
NOP FNQSW
NOVO-METHACIN
50MG RECTAL SUPPOSITORY
02231799
SAB-INDOMETHACIN
SDZ
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 118 -
100MG RECTAL SUPPOSITORY
01934139
RATIO-INDOMETHACIN
RPH FNQSW
02231800
SAB-INDOMETHACIN
SDZ FNQSW
Note: Suppository formulation limited to a maximum one-month supply of medication.
*KETOPROFEN
50MG CAPSULE
00790427
AAA
FNQSW
50MG ENTERIC COATED TABLET
00790435
APO-KETO E
AAA
FNQSW
100MG ENTERIC COATED TABLET
00842664
APO-KETO E
AAA
FNQSW
APO-KETO
100MG RECTAL SUPPOSITORY
02015951
PMS-KETOPROFEN
PMS FNQSW
Note: Suppository formulation limited to a maximum one-month supply of medication.
*MEFENAMIC ACID
250MG CAPSULE
02229452
APO-MEFENAMIC
AAA
FQW
NABUMETONE
SEE APPENDIX A FOR CRITERIA
500MG TABLET
02238639
APO-NABUMETONE (SA)
02240867
NOVO-NABUMETONE (SA)
02244563
MYLAN-NABUMETONE (SA)
02343282
NABUMETONE (SA)
APX
NOP
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
*NAPROXEN
125MG TABLET
00522678
APO-NAPROXEN
APX
FNQSW
250MG TABLET
00522651
00565350
02350750
APO-NAPROXEN
TEVA-NAPROX
NAPROXEN
APX FNQSW
TEV FNQSW
SNS FNQSW
375MG TABLET
00600806
00627097
02350769
APO-NAPROXEN
TEVA NAPROX
NAPROXEN
APX FNQSW
TEV FNQSW
SNS FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 119 -
500MG TABLET
00589861
00592277
02350777
TEVA-NAPROX
APO-NAPROXEN
NAPROXEN
NOP FNQSW
APX FNQSW
SNS FNQSW
250MG ENTERIC COATED TABLET
02162792
NAPROSYN-E
02243312
TEVA-NAPROXEN EC
02246699
APO-NAPROXEN EC
02350785
NAPROXEN EC
HLR
TEV
APX
SNS
FNQSW
FNQSW
FNQSW
FNQSW
375MG ENTERIC COATED TABLET
02162415
NAPROSYN-E
02243313
TEVA-NAPROXEN EC
02243432
MYLAN-NAPROXEN EC
02246700
APO-NAPROXEN EC
02294702
PMS-NAPROXEN EC
02350793
NAPROXEN EC
HLR
TEV
MYL
APX
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
500MG ENTERIC COATED TABLET
02162423
NAPROSYN-E
02241024
MYLAN-NAPROXEN EC
02243314
TEVA-NAPROXEN EC
02246701
APO-NAPROXEN EC
02294710
PMS-NAPROXEN EC
02350807
NAPROXEN EC
HLR
MYL
TEV
APX
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
750MG SUSTAINED RELEASE TABLET
02162466
NAPROSYN SR
02177072
APO-NAPROXEN SR
HLR
APX
FNQSW
FNQSW
500MG RECTAL SUPPOSITORY
02017237
PMS-NAPROXEN
PMS FNQSW
Note: Suppository formulation limited to a maximum one-month supply of medication.
*PIROXICAM
10MG CAPSULE
00642886
00695718
APO-PIROXICAM
NOVO-PIROCAM
APX FNQSW
NOP FNQSW
20MG CAPSULE
00642894
00695696
APO-PIROXICAM
NOVO-PIROCAM
APX FNQSW
NOP FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 120 -
*SULINDAC
150MG TABLET
00745588
00778354
NOVO-SUNDAC
APO-SULIN
NOP FNQSW
APX FNQSW
200MG TABLET
00745596
00778362
NOVO-SUNDAC
APO-SULIN
NOP FNQSW
APX FNQSW
*TIAPROFENIC ACID
200MG TABLET
02179679
NOVO-TIAPROFENIC
NOP FNQSW
300MG TABLET
02179687
NOP FNQSW
NOVO-TIAPROFENIC
28:08.08 OPIATE AGONISTS (NARCOTIC ANALGESICS)
ACETAMINOPHEN & CODEINE
300MG & 60MG TABLET
00621463
RATIO-LENOLTEC NO.4
02163918
TYLENOL NO.4
RPH FNQSW
JAN FNQSW
ACETAMINOPHEN COMPOUND WITH CODEINE
15MG CODEINE TABLET
00293504
ATASOL (NOT INTERCHANGEABLE)
00653241
RATIO-LENOLTEC NO.2
02163934
TYLENOL NO.2
CDC FNQSW
RPH FNQSW
JAN FNQSW
30MG CODEINE TABLET
00293512
ATASOL (NOT INTERCHANGEABLE)
00653276
RATIO-LENOLTEC NO.3
02163926
TYLENOL NO.3
CDC FNQSW
RPH FNQSW
JAN FNQSW
ACETYLSALICYLIC ACID COMPOUND WITH CODEINE
30MG CODEINE TABLET
02238645
292
PEN FNQSW
CODEINE
15MG TABLET
00593435
RPH FNQSW
RATIO-CODEINE
PEI Pharmacare Formulary …………………………………………………Page - 121 -
30MG TABLET
00593451
RATIO-CODEINE
RPH FNQSW
50MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02230302
CODEINE CONTIN (SA)
PFR
FNQSW
100MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02163748
CODEINE CONTIN (SA)
PFR
FNQSW
150MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02163780
CODEINE CONTIN (SA)
PFR
FNQSW
200MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02163799
CODEINE CONTIN (SA)
PFR
FNQSW
FENTANYL
SEE APPENDIX A FOR SA CRITERIA
12UG/HR TRANSDERMAL PATCH
02311925
TEVA-FENTANYL (SA)
02327112
SANDOZ-FENTANYL (SA)
02330105
RAN-FENTANYL MTX(SA)
02334186
DURAGESIC MAT (SA)
02341379
PMS-FENTANYL MTX (SA)
02386844
CO-FENTANYL (SA)
02396696
MYLAN-FENTANYL MATRIX (SA)
TEV
SDZ
RBX
JAN
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
25UG/HR TRANSDERMAL PATCH
02275813
DURAGESIC MAT (SA)
02282941
TEVA-FENTANYL (SA)
02314630
APO-FENTANYL (SA)
02327120
SANDOZ-FENTANYL (SA)
02330113
RAN-FENTANYL MTX (SA)
02341387
PMS- FENTANYL MTX (SA)
02386852
CO-FENTANYL (SA)
02396718
MYLAN-FENTANYL MATRIX (SA)
JAN
TEV
APX
SDZ
RBX
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
37UG/HR TRANSDERMAL PATCH
02327139
SANDOZ-FENTANYL (SA)
SDZ
FNQSW
50UG/HR TRANSDERMAL PATCH
PEI Pharmacare Formulary …………………………………………………Page - 122 -
DURAGESIC MAT (SA)
TEVA-FENTANYL (SA)
APO-FENTANYL (SA)
SANDOZ-FENTANYL (SA)
RAN-FENTANYL MTX (SA)
PMS- FENTANYL MTX (SA)
CO-FENTANYL (SA)
MYLAN-FENTANYL MATRIX (SA)
JAN
TEV
APX
SDZ
RBX
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
75UG/HR TRANSDERMAL PATCH
02275848
DURAGESIC MAT (SA)
02282976
TEVA-FENTANYL (SA)
02314657
APO-FENTANYL (SA)
02327155
SANDOZ-FENTANYL (SA)
02330148
RAN-FENTANYL MTX (SA)
02341409
PMS- FENTANYL MTX (SA)
02386887
CO-FENTANYL (SA)
02396734
MYLAN-FENTANYL MATRIX (SA)
JAN
TEV
APX
SDZ
RBX
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100UG/HR TRANSDERMAL PATCH
02275856
DURAGESIC MAT (SA)
02282984
TEVA-FENTANYL (SA)
02314665
APO-FENTANYL (SA)
02327163
SANDOZ-FENTANYL (SA)
02330156
RAN-FENTANYL MTX (SA)
02341417
PMS- FENTANYL MTX (SA)
02386895
CO-FENTANYL (SA)
02396742
MYLAN-FENTANYL MATRIX (SA)
JAN
TEV
APX
SDZ
RBX
PMS
COB
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
HYDROMORPHONE HCL
1MG TABLET
00705438
DILAUDID
00885444
PMS-HYDROMORPHONE
02364115
APO-HYDROMORPHONE
PFR FNQSW
PMS FNQSW
APX FNQSW
2MG TABLET
00125083
DILAUDID
PFR
PMS-HYDROMORPHONE
APO-HYDROMORPHONE
PMS FNQSW
APX FNQSW
DILAUDID
PMS-HYDROMORPHONE
APO-HYDROMORPHONE
PFR FNQSW
PMS FNQSW
APX FNQSW
02275821
02282968
02314649
02327147
02330121
02341395
02386879
02396726
00885436
02364123
4MG TABLET
00125121
00885401
02364131
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 123 -
8MG TABLET
00786543
00885428
02364158
DILAUDID
PMS-HYDROMORPHONE
APO-HYDROMORPHONE
PFR FNQSW
PMS FNQSW
APX FNQSW
3MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02125323
HYDROMORPH CONTIN (SA)
PFR
FNQSW
4.5MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02359502
HYDROMORPH CONTIN (SA)
PFR
FNQSW
6MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02125331
HYDROMORPH CONTIN (SA)
PFR
FNQSW
9MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02359510
HYDROMORPH CONTIN (SA)
PFR
FNQSW
12MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02125366
HYDROMORPH CONTIN (SA)
PFR
FNQSW
18MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02243562
HYDROMORPH CONTIN (SA)
PFR
FNQSW
24MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02125382
HYDROMORPH CONTIN (SA)
PFR
FNQSW
30MG CONTROLLED-RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02125390
HYDROMORPH CONTIN (SA)
PFR
FNQSW
1MG/ML ORAL LIQUID
00786535
DILAUDID
01916386
PMS-HYDROMORPHONE
PFR FNQSW
PMS FNQSW
3MG SUPPOSITORY
01916394
PMS-HYDROMORPHONE
PMS FNQSW
2MG/ML INJECTION SOLUTION (1ML)
02145901
HYDROMORPHONE
SDZ
NQ
PEI Pharmacare Formulary …………………………………………………Page - 124 -
10MG/ML INJECTION SOLUTION (1ML, 5ML, AND 50ML)
SEE APPENDIX A FOR SA CRITERIA. NOTE: SA NOT REQUIRED FOR NURSING HOME
PROGRAM.
02145928
HYDROMORPHONE HP (SA)
SDZ FNQSW
20MG/ML INJECTION
SEE APPENDIX A FOR SA CRITERIA, . NOTE: SA NOT REQUIRED FOR NURSING HOME
PROGRAM.
02145936
HYDROMORPHONE (SA)
SDZ FNQSW
02146118
DILAUDID HP PLUS (SA)
PFR FNQSW
50MG/ML INJECTION SOLUTION (50ML)
SEE APPENDIX A FOR SA CRITERIA. . NOTE: SA NOT REQUIRED FOR NURSING HOME
PROGRAM.
02145863
DILAUDID XP (SA)
PFR FNQSW
02146126
HYDROMORPHONE HP (SA)
SDZ FNQSW
MEPERIDINE HCL
50MG TABLET
02138018
DEMEROL
AVN FNQSW
50MG/ML INJECTION SOLUTION (1ML)
00725765
MEPERIDINE
SDZ
NQ
100MG/ML INJECTION SOLUTION (1ML)
00725749
MEPERIDINE
SDZ
NQ
METHADONE
SEE APPENDIX A FOR SA CRITERIA
1MG TABLET
02247698
METADOL (SA)
PAL
FNQSVW
5MG TABLET
02247699
METADOL (SA)
PAL
FNQSVW
10MG TABLET
02247700
METADOL (SA)
PAL
FNQSVW
25MG TABLET
02247701
METADOL (SA)
PAL
FNQSVW
Tablets Only - For the management of severe chronic or malignant pain as an alternative to
other opiates
PEI Pharmacare Formulary …………………………………………………Page - 125 -
METHADONE SOLUTION
SEE APPENDIX A FOR SA CRITERIA
02394618
10MG/MLMETHADOSE (SA)
NOTE: NOT INTERCHANGEABLE
MAL FNQSVW
MORPHINE
1MG/ML ORAL SOLUTION
00591467
STATEX
00607762
RATIO-MORPHINE
PAL FNQSW
RPH FNQSW
5MG/ML ORAL SOLUTION
00591475
STATEX
00607770
RATIO-MORPHINE
PAL FNQSW
RPH FNQSW
10MG/ML ORAL SOLUTION
00690783
RATIO-MORPHINE
RPH FNQSW
20MG/ML ORAL SOLUTION
00621935
STATEX
00690791
RATIO-MORPHINE
PAL FNQSW
RPH FNQSW
5MG TABLET
00594652
02009773
02014203
STATEX
M.O.S.-SULFATE
MSIR
PAL
VAL
PFR
FNQSW
FNQSW
FNQSW
10MG TABLET
00594644
02009765
02014211
STATEX
M.O.S.-SULFATE
MSIR
PAL
VAL
PFR
FNQSW
FNQSW
FNQSW
25MG TABLET
00594636
02009749
STATEX
M.O.S.-SULFATE
PAL
VAL
FNQSW
FNQSW
30MG TABLET
02014254
MSIR
PFR
FNQSW
40MG TABLET
00690228
M.O.S.
VAL
FNQSW
50MG TABLET
00675962
STATEX
PAL
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 126 -
02009706
M.O.S.-SULFATE
VAL
FNQSW
60MG TABLET
00690244
M.O.S.
VAL
FNQSW
10MG EXTENDED RELEASE CAPSULE
02019930
M-ESLON
ETH
FNQSW
15MG EXTENDED RELEASE CAPSULE
02177749
M-ESLON
ETH
FNQSW
30MG EXTENDED RELEASE CAPSULE
02019949
M-ESLON
ETH
FNQSW
60MG EXTENDED RELEASE CAPSULE
02019957
M-ESLON
ETH
FNQSW
100MG EXTENDED RELEASE CAPSULE
02019965
M-ESLON
ETH
FNQSW
200MG EXTENDED RELEASE CAPSULE
02177757
M-ESLON
ETH
FNQSW
15MG SUSTAINED RELEASE TABLET
02015439
MS CONTIN
02244790
SANDOZ-MORPHINE SR
02302764
NOVO-MORPHINE SR
02350815
MORPHINE SR
PFR
SDZ
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
30MG SUSTAINED RELEASE TABLET
02014297
MS CONTIN
02244791
SANDOZ-MORPHINE SR
02302772
NOVO-MORPHINE SR
02350890
MORPHINE SR
PFR
SDZ
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
30MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
00776181
M.O.S. SR
VAL
FNQSW
60MG SUSTAINED RELEASE TABLET
02014300
MS CONTIN
02244792
SANDOZ-MORPHINE SR
02302780
NOVO-MORPHINE SR
02350912
MORPHINE SR
PFR
SDZ
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
60MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
PEI Pharmacare Formulary …………………………………………………Page - 127 -
00776203
M.O.S. SR
VAL
FNQSW
100MG SUSTAINED RELEASE TABLET
02014319
MS CONTIN
02302799
NOVO-MORPHINE SR
PFR FNQSW
NOP FNQSW
200MG SUSTAINED RELEASE TABLET
02014327
MS CONTIN
02302802
NOVO-MORPHINE SR
PFR FNQSW
NOP FNQSW
10MG/ML INJECTION SOLUTION (1ML)
00392588
MORPHINE SULFATE
SDZ
NQ
15MG/ML INJECTION SOLUTION (1ML)
00392561
MORPHINE SULFATE
SDZ
NQ
50MG/ML INJECTION SOLUTION(5ML AND 10ML)
SEE APPENDIX A FOR SA CRITERIA
00617288
MORPHINE SULFATE (SA)
SDZ
NQ
OXYCODONE
5MG TABLET
00789739
02231934
02319977
SUPEUDOL
OXY-IR
PMS-OXYCODONE
SDZ FNQSW
PFR FNQSW
PMS FNQSW
10MG TABLET
00443948
02240131
02319985
SUPEUDOL
OXY-IR
PMS-OXYCODONE
SDZ FNQSW
PFR FNQSW
PMS FNQSW
20MG TABLET
02240132
02262983
02319993
OXY-IR
SUPEUDOL
PMS-OXYCODONE
PFR FNQSW
SDZ FNQSW
PMS FNQSW
OXYCODONE HCL & ACETAMINOPHEN
5MG & 325MG TABLET
00608165
RATIO-OXYCOCET
01916475
PERCOCET
01916548
ENDOCET
02307898
SANDOZ-OXYCONDONE ACET
02324628
APO-OXYCODONE/ACET
RPH
BMS
BMS
SDZ
APX
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 128 -
OXYCODONE HCL & ACETYLSALICYLIC ACID
5MG & 325MG TAB
00608157
RATIO-OXYCODAN
RPH FQSW
28:08.12 OPIATE PARTIAL AGONISTS
BUPRENORPHINE & NALOXONE
2MG/0.5MG TABLET
SEE APPENDIX A FOR SA CRITERIA
02295695
SUBOXONE (SA)
RBH FNQSVW
8MG/2MG TABLET
SEE APPENDIX A FOR SA CRITERIA
02295709
SUBOXONE (SA)
RBH FNQSVW
PENTAZOCINE
50MG TABLET
02137984
AVN FNQSW
TALWIN
28:08.92 MISCELLANEOUS ANALGESICS AND ANTIPYRETICS
ACETAMINOPHEN
32MG/ML ELIXIR
00999929
ACETAMINOPHEN
NW
Note: The Drug Identification Number listed is for billing purposes only.
80MG/ML DROPS
00999719
ACETAMINOPHEN
Note: The Drug Identification Number listed is for billing purposes only.
W
*325MG TABLET
00999939
ACETAMINOPHEN
Note: The Drug Identification Number listed is for billing purposes only.
NW
*500MG TABLET
00999949
ACETAMINOPHEN
Note: The Drug Identification Number listed is for billing purposes only.
NW
PEI Pharmacare Formulary …………………………………………………Page - 129 -
120MG RECTAL SUPPOSITORY
01919385
ABENOL
02230434
ACET-120
PEN W
PEN W
325MG RECTAL SUPPOSITORY
01919393
ABENOL
02230436
ACET-325
PEN NW
PEN NW
650MG RECTAL SUPPOSITORY
01919407
ABENOL
02230437
ACET-650
PEN NW
PEN NW
FLOCTAFENINE
200MG TABLET
02244680
APO-FLOCTAFENINE
AAA
FNQSW
400MG TABLET
02244681
APO-FLOCTAFENINE
AAA
FNQSW
NALOXONE HCL
0.4MG/ML INJECTION SOLUTION
02148706
NALOXONE
SDZ
NQ
NALTREXONE HCL
SEE APPENDIX A FOR SA CRITERIA
50MG TABLET
02213826
REVIA (SA)
DUR FNQSW
28:10:00 OPIATE ANTAGONISTS
28:12.04 ANTICONVULSANTS (BARBITURATES)
*PHENOBARBITAL
15MG TABLET
00178799
PHENOBARB
30MG TABLET
00178802
PHENOBARB
PEN FNQSW
PEN FNQSW
60MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 130 -
00178810
PHENOBARB
PEN FNQSW
100MG TABLET
00178829
PHENOBARB
PEN FNQSW
5MG/ML ELIXIR
00645575
PHENOBARB
PEN FNQSW
*PRIMIDONE
125MG TABLET
00399310
APO-PRIMIDONE
AAA
FQW
250MG TABLET
00396761
APO-PRIMIDONE
AAA
FNQSW
28:12.08 ANTICONVULSANTS (BENZODIAZEPINES)
*CLONAZEPAM
0.5MG TABLET
00382825
02048701
02103656
02177889
02207818
02230950
02233960
02236948
02239024
02270641
RIVOTRIL
PMS-CLONAZEPAM
RATIO-CLONAZEPAM
APO-CLONAZEPAM
PMS-CLONAZEPAM-R
MYLAN-CLONAZEPAM
SANDOZ-CLONAZEPAM
PFL-CLONAZEPAM
NOVO-CLONAZEPAM
CO-CLONAZEPAM
HLR
PMS
RPH
APX
PMS
MYL
RHP
PHL
NOP
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
1MG TABLET
02048728
02145235
02233982
02270668
PMS-CLONAZEPAM
PFL-CLONAZEPAM
SANDOZ-CLONAZEPAM
CO-CLONAZEPAM
PMS
PHL
SDZ
COB
FNQSW
FNQSW
FNQSW
FNQSW
2MG TABLET
00382841
02048736
02103737
02145243
02177897
02230951
RIVOTRIL
PMS-CLONAZEPAM
RATIO-CLONAZEPAM
PFL-CLONAZEPAM
APO-CLONAZEPAM
MYLAN-CLONAZEPAM
HLR
PMS
RPH
PHL
APX
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 131 -
02233985
02239025
02270676
SANDOZ-CLONAZEPAM
NOVO-CLONAZEPAM
CO-CLONAZEPAM
LORAZEPAM
4MG/ML INJECTION SOLUTION
02243278
LORAZEPAM
RHP FNQSW
NOP FNQSW
COB FNQSW
SDZ
NQ
28:12.12 ANTICONVULSANTS (HYDANTOINS)
*PHENYTOIN
50MG TABLET
00023698
DILANTIN
PFI
FNQSW
30MG CAPSULE
00022772
DILANTIN
PFI
FNQSW
100MG CAPSULE
00022780
DILANTIN
PFI
FNQSW
25MG/ML ORAL SUSPENSION
00023450
DILANTIN
02250896
TARO-PHENYTOIN
PFI
TAR
FNQSW
FNQSW
50MG/ML INJECTION SOLUTION
00780626
PHENYTOIN SODIUM
SDZ
NQ
*ETHOSUXIMIDE
50MG/ML SYRUP
00023485
ZARONTIN
ERF
FNQSW
250MG CAPSULE
00022799
ZARONTIN
ERF
FNQSW
28:12.20 ANTICONVULSANTS (SUCCINIMIDES)
PEI Pharmacare Formulary …………………………………………………Page - 132 -
*METHSUXIMIDE
300MG CAPSULE
00022802
CELONTIN
ERF
FNQSW
28:12.92 ANTICONVULSANTS (MISCELLANEOUS)
*CARBAMAZEPINE
100MG CHEWABLE TABLET
00369810
TEGRETOL CHEWTAB
02231542
PMS-CARBAMAZEPINE
02261855
SANDOZ-CARBAMAZEPINE
NVR FQW
PMS FQW
SDZ FQW
200MG CHEWABLE TABLET
00665088
TEGRETOL CHEWTAB
02231540
PMS-CARBAMAZEPINE
02261863
SANDOZ-CARBAMAZEPINE
NVR FQW
PMS FQW
SDZ FQW
200MG TABLET
00010405
00402699
00782718
NVR FNQSW
APX FNQSW
NOP FNQSW
TEGRETOL
APO-CARBAMAZEPINE
TEVA-CARBAMAZEPINE
200MG CONTROLLED RELEASE TABLET
00773611
TEGRETOL CR
02231543
PMS-CARBAMAZEPINE CR
02241882
MYLAN-CARBAMAZEPINE CR
02261839
SANDOZ-CARBAMAZEPINE CR
NVR
PMS
MYL
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
400MG CONTROLLED RELEASE TABLET
00755583
TEGRETOL CR
02231544
PMS-CARBAMAZEPINE CR
02241883
MYLAN-CARBAMAZEPINE CR
02261847
SANDOZ-CARBAMAZEPINE CR
NVR
PMS
MYL
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
100MG/5ML SUSPENSION
SEE APPENDIX A FOR SA CRITERIA
02194333
TEGRETOL (SA)
02367394
TARO-CARBAMAZEPINE (SA)
NVR FNQSW
TAR FNQSW
*CLOBAZAM
10MG TABLET
02221799
02238334
LUD FNQSW
NOP FNQSW
FRISIUM
NOVO-CLOBAZAM
PEI Pharmacare Formulary …………………………………………………Page - 133 -
02244474
02244638
PMS-CLOBAZAM
APO-CLOBAZAM
PMS FNQSW
APX FNQSW
*DIVALPROEX SODIUM
125MG ENTERIC COATED TABLET
00596418
EPIVAL
02239698
APO-DIVALPROEX
02239701
NOVO-DIVALPROEX
02400499
DIVALPROEX
ABB
APX
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
250MG ENTERIC COATED TABLET
00596426
EPIVAL
02239699
APO-DIVALPROEX
02239702
NOVO-DIVALPROEX
02400502
DIVALPROEX
ABB
APX
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
500MG ENTERIC COATED TABLET
00596434
EPIVAL
02239700
APO-DIVALPROEX
02239703
NOVO-DIVALPROEX
02400510
DIVALPROEX
ABB
APX
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
GABAPENTIN
100MG CAPSULE
02084260
02243446
02244304
02244513
02246314
02248259
02256142
02285819
02319055
02321203
02353245
02361469
02391473
NEURONTIN
PMS-GABAPENTIN
APO-GABAPENTIN
TEVA-GABAPENTIN
GABAPENTIN
MYLAN-GABAPENTIN
CO-GABAPENTIN
GD-GABAPENTIN
RAN-GABAPENTIN
AURO-GABAPENTIN
GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
PFI
PMS
APX
TEV
SIV
MYL
COB
GMD
RAN
ARO
SNS
JPC
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG CAPSULE
02084279
02243447
02244305
02244514
02246315
02248260
NEURONTIN
PMS-GABAPENTIN
APO-GABAPENTIN
TEVA-GABAPENTIN
GABAPENTIN
MYLAN-GABAPENTIN
PFI
PMS
APX
TEV
SIV
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 134 -
02256150
02285827
02321211
02319063
02353253
02361485
02391481
CO-GABAPENTIN
GD-GABAPENTIN
AURO-GABAPENTIN
RAN-GABAPENTIN
GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
COB
GMD
ARO
RAN
SNS
JPC
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
400MG CAPSULE
02084287
02243448
02244306
02244515
02246316
02248261
02256169
02260905
02285835
02319071
02321238
02353261
02361493
02391503
NEURONTIN
PMS-GABAPENTIN
APO-GABAPENTIN
TEVA-GABAPENTIN
GABAPENTIN
MYLAN-GABAPENTIN
CO-GABAPENTIN
RATIO-GABAPENTIN
GD-GABAPENTIN
RAN-GABAPENTIN
AURO-GABAPENTIN
GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
PFI
PMS
APX
TEV
SIV
MYL
COB
RPH
GMD
RAN
ARO
SNS
JPC
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
600MG CAPSULE
02239717
02248457
02255898
02285843
02293358
02388200
02392526
02397471
02402289
NEURONTIN
TEVA-GABAPENTIN
PMS-GABAPENTIN
GD-GABAPENTIN
APO-GABAPENTIN
GABAPENTIN
GABAPENTIN
MYLAN-GABAPENTIN
JAMP-GABAPENTIN
PFI
TEV
PMS
GMD
APX
SIV
ACH
MYL
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
800MG CAPSULE
02239718
02247346
02255901
02285851
02293366
02388219
02392534
02397498
02402297
NEURONTIN
TEVA-GABAPENTIN
PMS-GABAPENTIN
GD-GABAPENTIN
APO-GABAPENTIN
GABAPENTIN
GABAPENTIN
MYLAN-GABAPENTIN
JAMP-GABAPENTIN
PFI
TEV
PMS
GMD
APX
SIV
ACH
MYL
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 135 -
LACOSAMIDE
SEE APPENDIX A FOR CRITERIA
50MG TABLET
02357615
VIMPAT (SA)
UCB FNQSW
100MG TABLET
02357623
VIMPAT (SA)
UCB FNQSW
150MG TABLET
02357631
VIMPAT (SA)
UCB FNQSW
200MG TABLET
02357658
VIMPAT (SA)
UCB FNQSW
LAMOTRIGINE
25MG TABLET
02142082
02243352
02245208
02246897
02248232
02265494
02343010
02381354
LAMICTAL
RATIO-LAMOTRIGINE
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
MYLAN-LAMOTRIGINE
LAMOTRIGINE
AURO-LAMOTRIGINE
GSK
RPH
APX
PMS
NOP
MYL
SNS
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
02142104
02243353
02245209
02246898
02248233
02265508
02343029
02381362
LAMICTAL
RATIO-LAMOTRIGINE
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
MYLAN-LAMOTRIGINE
LAMOTRIGINE
AURO-LAMOTRIGINE
GSK
RPH
APX
PMS
NOP
MYL
SNS
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
150MG TABLET
02142112
02245210
02246899
02248234
02246963
02265516
02343037
02381370
LAMICTAL
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
NOVO-LAMOTRIGINE
RATIO-LAMOTRIGINE
MYLAN-LAMOTRIGINE
LAMOTRIGINE
AURO-LAMOTRIGINE
GSK
APX
PMS
NOP
RPH
MYL
SNS
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 136 -
Note: Limited to a maximum one-month supply of medication.
LEVETIRACETAM
250MG TABLET
02247027
02274183
02285924
02296101
02353342
02375249
02396106
02399776
02403005
KEPPRA
CO-LEVETIRACETAM
APO-LEVETIRACETAM
PMS-LEVETIRACETAM
LEVETIRACETAM
AURO-LEVETIRACETAM
RAN-LEVETIRACETAM
LEVETIRACETAM
JAMP-LEVETIRACETAM
UCB
COB
APX
PMS
SNS
ARO
RAN
ACH
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
500MG TABLET
02247028
02274191
02285932
02296128
02353350
02375257
02396114
02399784
02403021
KEPPRA
CO-LEVETIRACETAM
APO-LEVETIRACETAM
PMS-LEVETIRACETAM
LEVETIRACETAM
AURO-LEVETIRACETAM
RAN-LEVETIRACETAM
LEVETIRACETAM
JAMP-LEVETIRACETAM
UCB
COB
APX
PMS
SNS
ARO
RAN
ACH
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
750MG TABLET
02247029
02274205
02285940
02296136
02353369
02375265
02396122
02399792
02403048
KEPPRA
CO-LEVETIRACETAM
APO-LEVETIRACETAM
PMS-LEVETIRACETAM
LEVETIRACETAM
AURO-LEVETIRACETAM
RAN-LEVETIRACETAM
LEVETIRACETAM
JAMP-LEVETIRACETAM
UCB
COB
APX
PMS
SNS
ARO
RAN
ACH
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
Note: Limited to a maximum one-month supply of medication.
OXCARBAZEPINE
SEE APPENDIX A FOR SA CRITERIA
150MG TABLET
02242067
02284294
TRILEPTAL (SA)
APO-OXCARBAZEPINE (SA)
NVR FNQSW
APX FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 137 -
300MG TABLET
02242068
02284308
TRILEPTAL (SA)
APO-OXCARBAZEPINE (SA)
NVR FNQSW
APX FNQSW
600MG TABLET
02242069
02284316
TRIPEPTAL (SA)
APO-OXCARBAZEPINE (SA)
NVR FNQSW
APX FNQSW
RUFINAMIDE
SEE APPENDIX A FOR SA CRITERIA
100 MG TABLET
02369613
BANZEL (SA)
EIS
Q
200 MG TABLET
02369621
BANZEL (SA)
EIS
Q
400 MG TABLET
02369648
BANZEL (SA)
EIS
Q
TOPIRAMATE
15MG SPRINKLE CAPSULE
02239907
TOPAMAX
JAN
FQW
25MG TABLET
02230893
02248860
02260050
02262991
02263351
02271184
02279614
02287765
02315645
02345803
02356856
02389460
02395738
02396076
TOPAMAX
NOVO-TOPIRAMATE
SANDOZ-TOPIRAMATE
PMS-TOPIRAMATE
MYLAN-TOPIRAMATE
PHL-TOPIRAMATE
APO-TOPIRAMATE
CO-TOPIRAMATE
MINT-TOPIRAMATE
AURO-TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
RAN-TOPIRAMATE
JAN
NOP
SDZ
PMS
MYL
PHL
APX
COB
MNT
ARO
SNS
SIV
ACH
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
50MG TABLET
02312085
PMS-TOPIRAMATE
PMS FNQSW
100MG TABLET
02230894
02248861
TOPAMAX
NOVO-TOPIRAMATE
JAN FNQSW
NOP FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 138 -
02260069
02263009
02263378
02271192
02279630
02287773
02315653
02345838
02356864
02389487
02395746
02396084
SANDOZ-TOPIRAMATE
PMS-TOPIRAMATE
MYLAN-TOPIRAMATE
PHL-TOPIRAMATE
APO-TOPIRAMATE
CO-TOPIRAMATE
MINT-TOPIRAMATE
AURO-TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
RAN-TOPIRAMATE
SDZ
PMS
MYL
PHL
APX
COB
MNT
ARO
SNS
SIV
ACH
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
200MG TABLET
02230896
02248862
02263017
02263386
02267837
02271206
02279649
02287781
02315661
02345846
02356872
02395754
02396092
TOPAMAX
NOVO-TOPIRAMATE
PMS-TOPIRAMATE
MYLAN-TOPIRAMATE
SANDOZ-TOPIRAMATE
PHL-TOPIRAMATE
APO-TOPIRAMATE
CO-TOPIRAMATE
MINT-TOPIRAMATE
AURO-TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
RAN-TOPIRAMATE
JAN
NOP
PMS
MYL
SDZ
PHL
APX
COB
MNT
ARO
SNS
ACH
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
15MG SPRINKLE CAPSULE
02239907
TOPAMAX
JAN
FQW
25MG SPRINKLE CAPSULE
02239908
TOPAMAX
JAN
FQW
Note: Limited to a maximum one-month supply of medication.
*VALPROATE SODIUM
50MG/ML SYRUP
00443832
DEPAKENE
02140063
RATIO-VALPROIC
ABB FNQSW
RPH FNQSW
02236807
02238370
PMS FNQSW
APX FNQSW
PMS-VALPROIC
APO-VALPROIC ACID
PEI Pharmacare Formulary …………………………………………………Page - 139 -
*VALPROIC ACID
250MG CAPSULE
00443840
02100630
02230768
02238048
DEPAKENE
NOVO-VALPROIC
PMS-VALPROIC
APO-VALPROIC
ABB
NOP
PMS
APX
FNQSW
FNQSW
FNQSW
FNQSW
500MG ENTERIC COATED CAPSULE
02218321
NOVO-VALPROIC
02229628
PMS-VALPROIC
NOP FNQSW
PMS FNQSW
VIGABATRIN
500MG TABLET
02065819
LUD
SABRIL
FNQSW
Note: Limited to a maximum one-month supply of medication.
28:16.04 PSYCHOTHERAPEUTIC AGENTS (ANTIDEPRESSANTS)
AMITRIPTYLINE
10MG TABLET
00335053
00654523
02403137
ELAVIL
PMS-AMITRIPTYLINE
AMITRIPTYLINE
AAA FNQSW
PMS FNQSW
APX FNQSW
25MG TABLET
00335061
00654515
02403145
ELAVIL
PMS-AMITRIPTYLINE
AMITRIPTYLINE
AAA FNQSW
PMS FNQSW
APX FNQSW
50MG TABLET
00335088
00654507
02403153
ELAVIL
PMS-AMITRIPTYLINE
AMITRIPTYLINE
AAA FNQSW
PMS FNQSW
APX FNQSW
75MG TABLET
00754129
02403161
ELAVIL
AMITRIPTYLINE
AAA
APX
BUPROPION HCL
SEE APPENDIX A FOR SA CRITERIA
100MG TABLET
02275074
SANDOZ-BUPROPION SR (SA)
FNQSW
FNQSW
SDZ FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 140 -
02285657
02325373
02391562
RATIO-BUPROPION SR (SA)
PMS-BUPROPION SR (SA)
BUPROPION SR (SA)
RPH FNQSW
PMS FNQSW
SNS FNQSW
150MG TABLET
02237825
02275082
02285665
02313421
02391570
WELLBUTRIN SR (SA)
SANDOZ-BUPROPION SR (SA)
RATIO-BUPROPION SR (SA)
PMS-BUPROPION SR (SA)
BUPROPION SR (SA)
BVL
SDZ
RPH
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CITALOPRAM
10MG TABLET
02270609
02273543
02312336
02370077
02370085
02371871
02387948
02409003
PMS-CITALOPRAM
PHL-CITALOPRAM
TEVA-CITALOPRAM
MINT-CITALOPRAM
JAMP-CITALOPRAM
MAR-CITALOPRAM
CITALOPRAM
NAT-CITALOPRAM
PMS
PHL
TEV
MNT
JPC
MAR
SIV
NAT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
02239607
02246056
02246594
02248010
02248050
02248170
02248944
02252112
02285622
02293218
02306239
02304686
02313405
02353660
02355272
02371898
02387956
02409011
CELEXA
APO-CITALOPRAM
MYLAN-CITALOPRAM
PMS-CITALOPRAM
CO-CITALOPRAM
SANDOZ-CITALOPRAM
PHL-CITALOPRAM
RATIO-CITALOPRAM
RAN_CITALOPRAM
NOVO-CITALOPRAM
CITALOPRAM-ODAN
MINT-CITALOPRAM
JAMP-CITALOPRAM
CITALOPRAM
SEPTA-CITALOPRAM
MAR-CITALOPRAM
CITALOPRAM
NAT-CITALOPRAM
LUD
APX
MYL
PMS
COB
SDZ
PHL
RPH
RAN
NOP
ODN
MNT
JPC
SNS
SPT
MAR
SIV
NAT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
02239608
02246057
CELEXA
APO-CITALOPRAM
LUD
APX
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 141 -
02246595
02248011
02248051
02248171
02248945
02252120
02285630
02293226
02306247
02304694
02313413
02353679
02355280
02371901
02387964
02409038
MYLAN-CITALOPRAM
PMS-CITALOPRAM
CO-CITALOPRAM
SANDOZ-CITALOPRAM
PHL-CITALOPRAM
RATIO-CITALOPRAM
RAN-CITALO
TEVA-CITALOPRAM
CITALOPRAM-ODAN
MINT-CITALOPRAM
JAMP-CITALOPRAM
CITALOPRAM
SEPTA-CITALOPRAM
MAR-CITALOPRAM
CITALOPRAM
NAT-CITALOPRAM
MYL
PMS
COB
SDZ
PHL
RPH
RAN
TEV
ODN
MNT
JPC
SNS
SPT
MAR
SIV
NAT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CLOMIPRAMINE HCL
10MG TABLET
00330566
ANAFRANIL
02040786
APO-CLOMIPRAMINE
02244816
CO-CLOPAMINE
ORX FNQSW
APX FNQSW
COB FNQSW
25MG TABLET
00324019
02040778
02244817
ANAFRANIL
APO-CLOMIPRAMINE
CO-CLOMIPRAMINE
ORX FNQSW
APX FNQSW
COB FNQSW
50MG TABLET
00402591
02040751
02244818
ANAFRANIL
APO-CLOMIPRAMINE
CO-CLOMIPRAMINE
ORX FNQSW
APX FNQSW
COB FNQSW
DESIPRAMINE
10MG TABLET
02216248
APO-DESIPRAMINE
APX
FNQSW
25MG TABLET
02216256
APO-DESIPRAMINE
APX
FNQSW
50MG TABLET
02216264
APO-DESIPRAMINE
APX
FNQSW
75MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 142 -
02216272
APO-DESIPRAMINE
APX
FNQSW
100MG TABLET
02216280
APO-DESIPRAMINE
APX
FNQSW
DOXEPIN HCL
10MG CAPSULE
00024325
02049996
SINEQUAN
APO-DOXEPIN
ERF
APX
FNQSW
FNQSW
25MG CAPSULE
00024333
02050005
SINEQUAN
APO-DOXEPIN
ERF
APX
FNQSW
FNQSW
50MG CAPSULE
00024341
02050013
SINEQUAN
APO-DOXEPIN
ERF
APX
FNQSW
FNQSW
75MG CAPSULE
00400750
02050021
SINEQUAN
APO-DOXEPINE
ERF
APX
FNQSW
FNQSW
100MG CAPSULE
00326925
SINEQUAN
02050048
APO-DOXEPIN
ERF
APX
FNQSW
FNQSW
150MG CAPSULE
01913476
NOVO-DOXEPIN
NOP FNQSW
DULOXETINE HYDROCHLORIDE
SEE APPENDIX A FOR SA CRITERIA
30MG DELAYED RELEASE CAPSULE
02301482
CYMBALTA (SA)
LIL
Q
60 MG DELAYED RELEASE CAPSULE
02301490
CYMBALTA (SA)
LIL
Q
FLUOXETINE HCL
10MG CAPSULE
02018985
02177579
02216353
02216582
02223481
02237813
PROZAC
PMS-FLUOXETINE
APO-FLUOXETINE
TEVA-FLUOXETINE
PHL-FLUOXETINE
MYLAN-FLUOXETINE
LIL
PMS
APX
TEV
PHL
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 143 -
02241371
02242177
02286068
02374447
02380560
02385627
02392909
02393441
02401894
02405695
RATIO-FLUOXETINE
CO-FLUOXETINE
FLUOXETINE
FLUOXETINE
MINT-FLUOXETINE
AURO-FLUOXETINE
MAR-FLUOXETINE
FLUOXETINE
JAMP-FLUOXETINE
RAN-FLUOXETINE
RPH
COB
SNS
SIV
MNT
ARO
MAR
ACH
JPC
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG CAPSULE
00636622
02177587
02216361
02216590
02223503
02237814
02241374
02242178
02286076
02374455
02380579
02383241
02385635
02386402
02392917
02405709
PROZAC
PMS-FLUOXETINE
APO-FLUOXETINE
TEVA-FLUOXETINE
PHL-FLUOXETINE
MYLAN-FLUOXETINE
RATIO-FLUOXETINE
CO-FLUOXETINE
FLUOXETINE
FLUOXETINE
MINT-FLUOXETINE
FLUOXETINE
AURO-FLUOXETINE
JAMP-FLUOXETINE
MAR-FLUOXETINE
RAN-FLUOXETINE
LIL
PMS
APX
TEV
PHL
MYL
RPH
COB
SNS
SIV
MNT
ACH
ARO
JPC
MAR
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FLUVOXAMINE MALEATE
50MG TABLET
01919342
LUVOX
02218453
RATIO-FLUVOXAMINE
02231329
APO-FLUVOXAMINE
02239953
TEVA-FLUVOXAMINE
02255529
CO-FLUVOXAMINE
ABB
RPH
APX
TEV
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
01919369
02218461
02231330
LUVOX
RATIO-FLUVOXAMINE
APO-FLUVOXAMINE
ABB FNQSW
RPH FNQSW
APX FNQSW
02239954
02255537
NOVO-FLUVOXAMINE
CO-FLUVOXAMINE
NOP FNQSW
COB FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 144 -
IMIPRAMINE
10MG TABLET
00360201
IMIPRAMINE
AAA
FNQSW
25MG TABLET
00312797
IMIPRAMINE
AAA
FNQSW
50MG TABLET
00010480
00326852
TOFRANIL
IMIPRAMINE
NVR FNQSW
AAA FNQSW
75MG TABLET
00644579
IMIPRAMINE
AAA
L-TRYPTOPHAN
500MG TABLET
02029456
02240333
02248538
TRYPTAN
RATIO-TRYPTOPHAN
APO-TRYPTOPHAN
VAL FNQSW
RPH FNQSW
APX FNQSW
1G TABLET
00654531
02237250
02248539
TRYPTAN
RATIO-TRYPTOPHAN
APO-TRYPTOPHAN
VAL FNQSW
RPH FNQSW
APX FNQSW
MAPROTILINE HCL
25MG TABLET
02158612
NOVO-MAPROTILINE
NOP FNQSW
50MG TABLET
02158620
NOVO-MAPROTILINE
NOP FNQSW
75MG TABLET
02158639
NOVO-MAPROTILINE
NOP FNQSW
MIRTAZAPINE
15 MG TABLET
02250594
02256096
02273942
SANDOZ-MIRTAZAPINE
MYLAN-MIRTAZAPINE
PMS-MIRTAZAPINE
SDZ FNQSW
MYL FNQSW
PMS FNQSW
02286610
02411695
APO-MIRTAZAPINE
AURO-MIRTAZAPINE
APX FNQSW
ARO FNQSW
FNQSW
30MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 145 -
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02243910
02248762
02250608
02256118
02259354
02286629
02370689
02411709
REMERON
PMS-MIRTAZAPINE
SANDOZ-MIRTAZAPINE
MYLAN-MIRTAZAPINE
NOVO-MIRTAZAPINE
APO-MIRTAZAPINE
MIRTAZIPINE
AURO-MIRTAZAPINE
MSD
PMS
SDZ
MYL
NOP
APX
SNS
ARO
45MG TABLET
02286637
02411717
APO-MIRTAZAPINE
MIRTAZAPINE
APX FNQSW
ARO FNQSW
15MG ORALLY DISINTEGRATING TABLET
02248542
REMERON RD
02279894
NOVO-MIRTAZAPINE
02299801
AURO-MIRTAZAPINE
MSD FNQSW
NOP FNQSW
ARO FNQSW
30MG ORALLY DISINTEGRATING TABLET
02248543
REMERON RD
02279908
NOVO-MIRTAZAPINE
02299828
AURO-MIRTAZAPINE
SCH FNQSW
NOP FNQSW
ARO FNQSW
45MG ORALLY DISINTEGRATING TABLET
02248544
REMERON RD
02279916
NOVO-MIRTAZAPINE
02299836
AURO-MIRTAZAPINE
MSD FNQSW
NOP FNQSW
ARO FNQSW
MOCLOBEMIDE
100MG TABLET
02232148
02239746
APO-MOCLOBEMIDE
NOVO-MOCLOBEMIDE
APX FNQSW
NOP FNQSW
150MG TABLET
00899356
02239747
MANERIX
NOVO-MOCLOBEMIDE
HLR FNQSW
NOP FNQSW
300MG TABLET
02166747
02239748
MANERIX
NOVO-MOCLOBEMIDE
HLR FNQSW
NOP FNQSW
NORTRIPTYLINE
10MG CAPSULE
00015229
AVENTYL
02177692
PMS-NORTRIPTYLINE
PEN FNQSW
PMS FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 146 -
02223511
02231781
APO-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
APX FNQSW
NOP FNQSW
25MG CAPSULE
00015237
02177706
02223538
02231782
AVENTYL
PMS-NORTRIPTYLINE
APO-NORTRIPTYLINE
NOVO-NORTRIPTYLINE
PEN
PMS
APX
NOP
FNQSW
FNQSW
FNQSW
FNQSW
PAROXETINE HCL
20MG TABLET
01940481
PAXIL
02240908
APO-PAROXETINE
02247751
PMS-PAROXETINE
02247811
RATIO-PAROXETINE
02248013
MYLAN-PAROXETINE
02368870
JAMP-PAROXETINE
02248557
TEVA-PAROXETINE
02262754
CO-PAROXETINE
02269430
SANDOZ-PAROXETINE
02282852
PAROXETINE
02383284
AURO-PAROXETINE
02388235
PAROXETINE
GSK
APX
PMS
RPH
MYL
JPC
TEV
COB
SDZ
SNS
ARO
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
30MG TABLET
01940473
02240909
02247752
02247812
02248014
02248558
02262762
02368889
02269449
02282860
02383292
02388243
PAXIL
APO-PAROXETINE
PMS-PAROXETINE
RATIO-PAROXETINE
MYLAN-PAROXETINE
TEVA-PAROXETINE
CO-PAROXETINE
JAMP-PAROXETINE
SANDOZ-PAROXETINE
PAROXETINE
AURO-PAROXETINE
PAROXETINE
GSK
APX
PMS
RPH
MYL
TEV
COB
JPC
SDZ
SNS
ARO
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
02293749
PMS-PAROXETINE
PMS FNQSW
PHENELZINE SULFATE
15MG TABLET
00476552
NARDIL
ERF
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 147 -
SERTRALINE HCL
25MG CAPSULE
02132702
ZOLOFT
02238280
APO-SERTRALINE
02240485
TEVA-SERTRALINE
02242519
MYLAN-SERTRALINE
02244838
PMS-SERTRALINE
02245159
SANDOZ-SERTRALINE
02245824
PHL-SERTRALINE
02273683
GD-SERTRALINE
02287390
CO-SERTRALINE
02353520
SERTRALINE
02357143
JAMP-SERTRALINE
02374552
RAN-SERTRALINE
02386070
SERTRALINE
02390906
AURO-SERTRALINE
02399415
MAR-SERTRALINE
02402378
MINT-SERTRALINE
PFI
APX
TEV
MYL
PMS
SDZ
PHL
GMD
COB
SNS
JPC
RAN
SIV
ARO
MAR
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
50MG CAPSULE
01962817
02238281
02240484
02242520
02244839
02245825
02273691
02287404
02353539
02357151
02374560
02386089
02390914
02399423
02402394
ZOLOFT
APO-SERTRALINE
TEVA-SERTRALINE
MYLAN-SERTRALINE
PMS-SERTRALINE
PHL-SERTRALINE
GD-SERTRALINE
CO-SERTRALINE
SERTRALINE
JAMP-SERTRALINE
RAN-SERTRALINE
SERTRALINE
AURO-SERTRALINE
MAR-SERTRALINE
MINT-SERTRALINE
PFI
APX
TEV
MYL
PMS
PHL
GMD
COB
SNS
JPC
RAN
SIV
ARO
MAR
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG CAPSULE
01962779
02238282
02240481
02242521
02244840
02245161
02245826
02273705
ZOLOFT
APO-SERTRALINE
TEVA-SERTRALINE
MYLAN-SERTRALINE
PMS-SERTRALINE
SANDOZ-SERTRALINE
PHL-SERTRALINE
GD-SERTRALINE
PFI
APX
TEV
MYL
PMS
SDZ
PHL
GMD
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 148 -
02287412
02353547
02357178
02374579
02386097
02390922
02399431
02402408
CO-SERTRALINE
SERTRALINE
JAMP-SERTRALINE
RAN-SERTRALINE
SERTRALINE
AURO-SERTRALINE
MAR-SERTRALINE
MINT-SERTRALINE
COB
SNS
JPC
RAN
SIV
ARO
MAR
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
TRANYLCYPROMINE SULFATE
10MG TABLET
01919598
PARNATE
GSK FNQSW
TRAZODONE HCL
50MG TABLET
01937227
02144263
02147637
02236941
02348772
PMS-TRAZODONE
TEVA-TRAZODONE
APO-TRAZODONE
PHL-TRAZODONE
TRAZADONE
PMS
NOP
APX
PHL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
01937235
02144271
02147645
02236942
02348780
PMS-TRAZODONE
TEVA-TRAZODONE
APO-TRAZODONE
PHL-TRAZODONE
TRAZODONE
PMS
NOP
APX
PHL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
150MG TABLET
02144298
02147653
02348799
TEVA-TRAZADONE
APO-TRAZADONE
TRAZADONE
TEV FNQSW
APX FNQSW
SNS FNQSW
TRIMIPRAMINE
AAA
FNQSW
TRIMIPRAMINE
AAA
FNQSW
50MG TABLET
00740810
TRIMIPRAMINE
AAA
FNQSW
100MG TABLET
00740829
TRIMIPRAMINE
AAA
FNQSW
TRIMIPRAMINE
12.5MG TABLET
00740799
25MG TABLET
00740802
PEI Pharmacare Formulary …………………………………………………Page - 149 -
75MG CAPSULE
02070987
AAA
FNQSW
VENLAFAXINE HCL
37.5MG EXTENDED RELEASE CAPSULE
02237279
EFFEXOR XR
02275023
TEVA-VENLAFAXINE XR
02273969
RATIO-VENLAFAXINE XR
02278545
PMS-VENLAFAXINE XR
02304317
CO-VENLAFAXINE XR
02310279
MYLAN-VENLAFAXINE XR
02310317
SANDOZ-VENLAFAXINE XR
02331683
APO-VENLAFAXINE XR
02354713
VENAFAXINE XR
02360020
GD-VENLAFAXINE
02380072
RAN-VENLAFAXINE XR
02385929
VENLAFAXINE XR
PFI
TEV
RPH
PMS
COB
MYL
SDZ
APX
SNS
GMD
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
75MG EXTENDED RELEASE CAPSULE
02237280
EFFEXOR XR
02275031
TEVA-VENLAFAXINE XR
02273977
RATIO-VENLAFAXINE XR
02278553
PMS-VENLAFAXINE XR
02304325
CO-VENLAFAXINE XR
02310287
MYLAN-VENLAFAXINE XR
02310325
SANDOZ VENLAFAXINE XR
02331691
APO-VENLAFAXINE XR
02354721
VENAFAXINE XR
02360039
GD-VENLAFAXINE
02380080
RAN-VENLAFAXINE XR
02385937
VENLAFAXINE XR
PFI
TEV
RPH
PMS
COB
MYL
SDZ
APX
SNS
GMD
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
150MG EXTENDED RELEASE CAPSULE
02237282
EFFEXOR XR
02275058
TEVA-VENLAFAXINE XR
02273985
RATIO-VENLAFAXINE XR
02278561
PMS-VENLAFAXINE XR
02304333
CO-VENLAFAXINE XR
02310295
MYLAN-VENLAFAXINE XR
02310333
SANDOZ-VENLAFAXINE XR
02331705
APO-VENLAFAXINE XR
02354748
VENLAFAXINE XR
02360047
GD-VENLAFAXINE
02380099
RAN-VENLAFAXINE XR
02385945
VENLAFAXINE XR
PFI
TEV
RPH
PMS
COB
MYL
SNS
APX
SNS
GMD
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
TRIMIPRAMINE
PEI Pharmacare Formulary …………………………………………………Page - 150 -
28:16.08 PSYCHOTHERAPEUTIC AGENTS (ANTIPSYCHOTICS)
ARIPIPRAZOLE
SEE APPENDIX A FOR SA CRITERIA
2MG TABLET
02322374
ABILIFY (SA)
BMS Q
5MG TABLET
02322382
ABILIFY (SA)
BMS Q
10MG TABLET
02322390
ABILIFY (SA)
BMS Q
15MG TABLET
02322404
ABILIFY (SA)
BMS Q
20MG TABLET
02322412
ABILIFY (SA)
BMS Q
30MG TABLET
02322455
ABILIFY (SA)
BMS Q
ASENAPINE
SEE APPENDIX A FOR SA CRITERIA
5MG SUBLINGUAL TABLET
02374803
SAPHRIS (SA)
MSD Q
10MG SUBLINGUAL TABLET
02374811
SAPHRIS (SA)
MSD Q
CHLORPROMAZINE
25MG TABLET
00232823
TEVA-CHLORPROMAZINE
TEV
FNQSW
50MG TABLET
00232807
TEVA-CHLORPROMAZINE
TEV
FNQSW
100MG TABLET
00232831
TEVA-CHLORPROMAZINE
TEV
FNQSW
25MG/ML INJECTION SOLUTION (2ML)
PEI Pharmacare Formulary …………………………………………………Page - 151 -
00743518
CHLORPROMAZINE
SDZ
NQ
CLOZAPINE
SEE APPENDIX A FOR SA CRITERIA
25MG TABLET
00894737
CLOZARIL (SA)
02247243
GEN-CLOZAPINE (SA)
02248034
APO-CLOZAPINE (SA)
NVR FNQSW
MYL FNQSW
APX FNQSW
50MG TABLET
02305003
GEN-CLOZAPINE (SA)
MYL FNQSW
100MG TABLET
00894745
02247244
02248035
CLOZARIL (SA)
GEN-CLOZAPINE (SA)
APO-CLOZAPINE (SA)
NVR FNQSW
MYL FNQSW
APX FNQSW
200MG TABLET
02305011
GEN-CLOZAPINE (SA)
MYL FNQSW
Note: Clozapine is only to be dispensed to patients upon receipt of weekly or bi-weekly
hematological test results by the pharmacy.
FLUPENTHIXOL DECANOATE
20MG/ML DEPOT INJECTION SOLUTION (10ML)
02156032
FLUANXOL DEPOT
LUD
B
100MG/ML DEPOT INJECTION SOLUTION (2ML)
02156040
FLUANXOL DEPOT
LUD
B
FLUPENTHIXOL DIHYDROCHLORIDE
0.5MG TABLET
02156008
FLUANXOL
LUD
FNQSW
3MG TABLET
02156016
LUD
FNQSW
FLUANXOL
FLUPHENAZINE DECANOATE
25MG/ML DEPOT INJECTION SOLUTION (5ML)
02091275
PMS-FLUPHENAZINE DECANOATE
PMS B
100MG/ML DEPOT INJECTION SOLUTION (1ML)
00755575
MODECATE CONCENTRATE
02241928
PMS-FLUPHENAZINE
BMS B
PMS B
PEI Pharmacare Formulary …………………………………………………Page - 152 -
FLUPHENAZINE HCL
1MG TABLET
00405345
APO-FLUPHENAZINE
AAA
FNQSW
2MG TABLET
00410632
APO-FLUPHENAZINE
AAA
FNQSW
5MG TABLET
00405361
APO-FLUPHENAZINE
AAA
FNQSW
HALOPERIDOL
0.5MG TABLET
00363685
NOVO-PERIDOL
NOP FNQSW
1MG TABLET
00363677
NOVO-PERIDOL
NOP FNQSW
2MG TABLET
00363669
NOVO-PERIDOL
NOP FNQSW
5 MG TABLET
00363650
NOVO-PERIDOL
NOP FNQSW
10MG TABLET
00713449
NOVO-PERIDOL
NOP FNQSW
20MG TABLET
00768820
NOVO-PERIDOL
NOP FNQSW
5MG/ML INJECTION SOLUTION (1ML)
00808652
HALOPERIDOL
SDZ
NQ
HALOPERIDOL DECANOATE
50MG/ML DEPOT INJECTION SOLUTION (5ML)
02130297
HALOPERIDOL LA
SDZ
B
100MG/ML DEPOT INJECTION SOLUTION (5ML)
02130300
HALOPERIDOL LA
SDZ
B
LOXAPINE SUCCINATE
5MG TABLET
02230837
XYLAC
PEN FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 153 -
10MG TABLET
02230838
XYLAC
PEN FNQSW
25MG TABLET
02230839
XYLAC
PEN FNQSW
50MG TABLET
02230840
XYLAC
PEN FNQSW
METHOTRIMEPRAZINE
2MG TABLET
02238403
APO-METHOPRAZINE
APX
FNQSW
5MG TABLET
02238404
APO-METHOPRAZINE
APX
FNQSW
25MG TABLET
02238405
APO-METHOPRAZINE
APX
FNQSW
50MG TABLET
02238406
APO-METHOPRAZINE
APX
FNQSW
OLANZAPINE
SEE APPENDIX A FOR SA CRITERIA
2.5MG TABLET
02229250
ZYPREXA (SA)
02276712
TEVA-OLANZAPINE (SA)
02281791
APO-OLANZAPINE (SA)
02303116
PMS-OLANZAPINE (SA)
02310341
SANDOZ-OLANZAPINE (SA)
02325659
CO-OLANZAPINE (SA)
02337878
MYLAN-OLANZAPINE (SA)
02372819
OLANZAPINE (SA)
02385864
OLANZAPINE (SA)
02403064
RAN-OLANZAPINE (SA)
LIL
TEV
APX
PMS
SDZ
COB
MYL
SNS
SIV
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
02229269
02276720
02281805
02303159
02310368
02325667
02337886
02372827
LIL
TEV
APX
PMS
SDZ
COB
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
ZYPREXA (SA)
TEVA-OLANZAPINE (SA)
APO-OLANZAPINE (SA)
PMS-OLANZAPINE (SA)
SANDOZ-OLANZAPINE (SA)
CO-OLANZAPINE (SA)
MYLAN-OLANZAPINE (SA)
OLANZAPINE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 154 -
02385872
0240302
OLANZAPINE (SA)
RAN-OLANZAPINE (SA)
SIV FNQSW
RAN FNQSW
7.5MG TABLET
02229277
02276739
02281813
02303167
02310376
02325675
02337894
02372835
02385880
02403080
ZYPREXA (SA)
TEVA-OLANZAPINE (SA)
APO-OLANZAPINE (SA)
PMS-OLANZAPINE (SA)
SANDOZ-OLANZAPINE (SA)
CO-OLANZAPINE (SA)
MYLAN-OLANZAPINE (SA)
OLANZAPINE (SA)
OLANZAPINE (SA)
RAN-OLANZAPINE (SA)
LIL
TEV
APX
PMS
SDZ
COB
MYL
SNS
SIV
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG TABLET
02229285
02276747
02281821
02303175
02310384
02325683
02337908
02372843
02385899
02403099
ZYPREXA (SA)
TEVA-OLANZAPINE (SA)
APO-OLANZAPINE (SA)
PMS-OLANZAPINE (SA)
SANDOZ-OLANZAPINE (SA)
CO-OLANZAPINE (SA)
MYLAN-OLANZAPINE (SA)
OLANZAPINE (SA)
OLANZAPINE (SA)
RAN-OLANZAPINE (SA)
LIL
TEV
APX
PMS
SDZ
COB
MYL
SNS
SIV
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
15MG TABLET
02238850
02276755
02281848
02303183
02310392
02325691
02337916
02372851
02385902
02403102
ZYPREXA (SA)
TEVA-OLANZAPINE (SA)
APO-OLANZAPINE (SA)
PMS-OLANZAPINE (SA)
SANDOZ-OLANZAPINE (SA)
CO-OLANZAPINE (SA)
MYLAN-OLANZAPINE (SA)
OLANZAPINE (SA)
OLANZAPINE (SA)
RAN-OLANZAPINE (SA)
LIL
TEV
APX
PMS
SDZ
COB
MYL
SNS
SIV
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
LIL
PMS
TEV
COB
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG ORALLY DISINTEGRATING TABLET
02243086
ZYPREXA ZYDIS (SA)
02303191
PMS-OLANZAPINE ODT (SA)
02321343
TEVA-OLANZAPINE OD (SA)
02327562
CO-OLANZAPINE ODT (SA)
02327775
SANDOZ-OLANZAPINE ODT (SA)
PEI Pharmacare Formulary …………………………………………………Page - 155 -
SIV
SNS
APX
MYL
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
10MG ORALLY DISINTEGRATING TABLET
02243087
ZYPREXA ZYDIS (SA)
02303205
PMS-OLANZPAINE ODT (SA)
02321351
TEVA-OLANZAPINE OD (SA)
02327570
CO-OLANZAPINE ODT (SA)
02327783
SANDOZ-OLANZAPINE ODT (SA)
02343673
OLANZAPINE ODT (SA)
02352982
OLANZAPINE ODT (SA)
02360624
APO-OLANZAPINE ODT (SA)
02382717
MYLAN-OLANZAPINE ODT (SA)
02389096
MAR-OLANZAPINE ODT(SA)
LIL
PMS
TEV
COB
SDZ
SIV
SNS
APX
MYL
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
15MG ORALLY DISINTEGRATING TABLET
02243088
ZYPREXA ZYDIS (SA)
02303213
PMS-OLANZAPINE ODT (SA)
02321378
TEVA-OLANZAPINE OD (SA)
02327589
CO-OLANZAPINE ODT (SA)
02327791
SANDOZ-OLANZAPINE ODT (SA)
02343681
OLANZAPINE ODT (SA)
02352990
OLANZAPINE ODT (SA)
02360632
APO-OLANZAPINE ODT (SA)
02382725
MYLAN-OLANZAPINE ODT (SA)
02389118
MAR-OLANZAPINE ODT (SA)
LIL
PMS
TEV
COB
SDZ
SIV
SNS
APX
MYL
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG ORALLY DISINTEGRATING TABLET
02243089
ZYPREXA ZYDIS (SA)
02321386
TEVA-OLANZAPINE OD (SA)
02327597
CO-OLANZAPINE ODT (SA)
02327805
SANDOZ-OLANZAPINE ODT (SA)
02343703
OLANZAPINE ODT (SA)
02360640
APO-OLANZAPINE ODT (SA)
02382733
MYLAN-OLANZAPINE ODT (SA)
02389126
MAR-OLANZAPINE ODT(SA)
LIL
TEV
COB
SDZ
SIV
APX
MYL
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PERICYAZINE
5MG CAPSULE
01926780
ERF
FNQSW
02343665
02352974
02360616
02382709
02389088
OLANZAPINE ODT (SA)
OLANZAPINE ODT (SA)
APO-OLANZAPINE ODT (SA)
MYLAN-OLANZAPINE ODT (SA)
MAR-OLANZAPINE ODT (SA)
NEULEPTIL
10MG CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 156 -
01926772
NEULEPTIL
ERF
FNQSW
20MG CAPSULE
01926764
NEULEPTIL
ERF
FNQSW
10MG/ML ORAL DROPS
01926756
NEULEPTIL
ERF
FNQSW
PERPHENAZINE
2MG TABLET
00335134
APO-PERPHENAZINE
AAA
FNQSW
4MG TABLET
00335126
APO-PERPHENAZINE
AAA
FNQSW
8MG TABLET
00335118
APO-PERPHENAZINE
AAA
FNQSW
16MG TABLET
00335096
APO-PERPHENAZINE
AAA
FNQSW
PIMOZIDE
2MG TABLET
00313815
02245432
ORAP
APO-PIMOZIDE
PEN FNQSW
APX FNQSW
4MG TABLET
00313823
02245433
ORAP
APO-PIMOZIDE
PEN FNQSW
APX FNQSW
PIPOTIAZINE PALMITATE
25MG/ML DEPOT INJECTION SOLUTION (1ML)
01926667
PIPORTIL L4
AVN B
50MG/ML DEPOT INJECTION SOLUTION (1ML & 2ML)
01926675
PIPORTIL L4
AVN B
PROCHLORPERAZINE
5MG TABLET
00886440
APO-PROCHLORAZINE
10MG TABLET
00886432
APO-PROCHLORAZINE
APX
FNQSW
APX
FNQSW
10MG RECTAL SUPPOSITORY
00789720
SANDOZ-PROCHLORPERAZINE
SDZ
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 157 -
5MG/ML INJECTION SOLUTION (2ML)
00789747
PROCHLORPERAZINE
SDZ
NQ
QUETIAPINE
SEE APPENDIX A FOR SA CRITERIA
25MG TABLET
02236951
SEROQUEL (SA)
02299054
PHL-QUETIAPINE (SA)
02284235
NOVO-QUETIAPINE (SA)
02296551
PMS-QUETIAPINE (SA)
02307804
MYLAN-QUETIAPINE (SA)
02313901
APO-QUETIAPINE (SA)
02313995
SANDOZ-QUETIAPINE (SA)
02316080
CO-QUETIAPINE (SA)
02317893
QUETIAPINE (SA)
02330415
JAMP-QUETIAPINE (SA)
02353164
QUETIAPINE (SA)
02387794
QUETIAPINE (SA)
02397099
RAN-QUETIAPINE (SA)
02399822
MAR-QUETIAPINE (SA)
02390205
AURO-QUETIAPINE (SA)
AZE
PHL
NOP
PMS
MYL
APX
SDZ
COB
SIV
JPC
SNS
ACH
RAN
MAR
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
02236952
02284243
02296578
02299062
02307812
02313928
02314002
02316099
02317907
02330423
02353172
02387808
02397102
02399830
02390213
SEROQUEL (SA)
NOVO-QUETIAPINE (SA)
PMS-QUETIAPINE (SA)
PHL-QUETIAPINE (SA)
MYLAN-QUETIAPINE (SA)
APO-QUETIAPINE (SA)
SANDOZ QUETIAPINE (SA)
CO-QUETIAPINE (SA)
QUETIAPINE (SA)
JAMP-QUETIAPINE (SA)
QUETIAPINE (SA)
QUETIAPINE (SA)
RAN-QUETIAPINE (SA)
MAR-QUETIAPINE (SA)
AURO-QUETIAPINE (SA)
AZE
NOP
PMS
PHL
MYL
APX
SDZ
COB
SIV
JPC
SNS
ACH
RAN
MAR
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
150MG TABLET
02240862
02284251
SEROQUEL (SA)
TEVA-QUETIAPINE (SA)
AZE
TEV
FNQSW
FNQSW
200MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 158 -
02236953
02284278
02296594
02299089
02307839
02313936
02314010
02316110
02317923
02330458
02353199
02387824
02397110
02399849
02390248
SEROQUEL (SA)
NOVO-QUETIAPINE (SA)
PMS-QUETIAPINE (SA)
PHL-QUETIAPINE (SA)
MYLAN-QUETIAPINE (SA)
APO-QUETIAPINE (SA)
SANDOZ QUETIAPINE (SA)
CO-QUETIAPINE (SA)
QUETIAPINE (SA)
JAMP-QUETIAPINE (SA)
QUETIAPINE (SA)
QUETIAPINE (SA)
RAN-QUETIAPINE (SA)
MAR-QUETIAPINE (SA)
AURO-QUETIAPINE (SA)
AZE
NOP
PMS
SDZ
MYL
APX
SDZ
COB
SIV
JPC
SNS
ACH
RAN
MAR
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG TABLET
02244107
02284286
02296608
02299097
02307847
02313944
02314029
02316129
02317931
02330466
02353202
02387832
02397129
02399857
02390256
SEROQUEL (SA)
TEVA-QUETIAPINE (SA)
PMS-QUETIAPINE (SA)
PHL-QUETIAPINE (SA)
MYLAN-QUETIAPINE (SA)
APO-QUETIAPINE (SA)
SANDOZ QUETIAPINE (SA)
CO-QUETIAPINE (SA)
QUETIAPINE (SA)
JAMP-QUETIAPINE (SA)
QUETIAPINE (SA)
QUETIAPINE (SA)
RAN-QUETIAPINE (SA)
MAR-QUETIAPINE (SA)
AURO-QUETIAPINE (SA)
AZE
TEV
PMS
PHL
MYL
APX
SDZ
COB
SIV
JPC
SNS
ACH
RAN
MAR
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
JAN
PMS
PHL
APX
MYL
COB
NOP
SDZ
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
RISPERIDONE
SEE APPENDIX A FOR SA CRITERIA
0.25MG TABLET
02240551
RISPERDAL (SA)
02252007
PMS-RISPERIDONE (SA)
02258439
PHL-RIPERIDONE (SA)
02282119
APO-RISPERIDONE (SA)
02282240
MYLAN-RISPERIDONE (SA)
02282585
CO-RISPERIDONE (SA)
02282690
NOVO-RISPERIDONE (SA)
02303655
SANDOZ-RISPERIDONE (SA)
02328305
RAN-RISPERIDONE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 159 -
02356880
02359529
02359790
02371766
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
0.5MG TABLET
02240552
02252015
02258447
02264188
02282127
02282259
02282593
02303663
02328313
02356899
02359537
02359804
02371774
RISPERDAL (SA)
PMS-RISPERIDONE (SA)
PHL-RIPERIDONE (SA)
NOVO-RISPERIDONE (SA)
APO-RISPERIDONE (SA)
MYLAN-RISPERIDONE (SA)
CO-RISPERIDONE (SA)
SANDOZ-RISPERIDONE (SA)
RAN-RISPERIODONE (SA)
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
JAN
PMS
PHL
NOP
APX
MYL
COB
SDZ
RAN
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
1MG TABLET
02025280
02252023
02258455
02264196
02279800
02282135
02282267
02282607
02328321
02356902
02359545
02359812
02371782
RISPERDAL (SA)
PMS-RISPERIDONE (SA)
PHL-RIPERIDONE (SA)
NOVO-RISPERIDONE (SA)
SANDOZ-RISPERIDONE (SA)
APO-RISPERIDONE (SA)
MYLAN-RISPERIDONE (SA)
CO-RISPERIDONE (SA)
RAN-RISPERIODONE (SA)
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
JAN
PMS
PHL
NOP
SDZ
APX
MYL
COB
RAN
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
2MG TABLET
02025299
02252031
02258463
02264218
02279819
02282143
02282275
02282615
02328348
RISPERDAL (SA)
PMS-RISPERIDONE (SA)
PHL-RIPERIDONE (SA)
NOVO-RISPERIDONE (SA)
SANDOZ-RISPERIDONE (SA)
APO-RISPERIDONE (SA)
MYLAN-RISPERIDONE (SA)
CO-RISPERIDONE (SA)
RAN-RISPERIODONE (SA)
JAN
PMS
PHL
NOP
SDZ
APX
MYL
COB
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 160 -
02356910
02359553
02359820
02371790
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
3MG TABLET
02025302
02252058
02258471
02264226
02279827
02282151
02282283
02282623
02328364
02356929
02359561
02359839
02371804
RISPERDAL (SA)
PMS-RISPERIDONE (SA)
PHL-RIPERIDONE (SA)
NOVO-RISPERIDONE (SA)
SANDOZ RISPERIDONE (SA)
APO-RISPERIDONE (SA)
MYLAN-RISPERIDONE (SA)
CO-RISPERIDONE (SA)
RAN-RISPERIODONE (SA)
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
JAN
PMS
PHL
NOP
SDZ
APX
MYL
COB
RAN
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
4MG TABLET
02025310
02252066
02258498
02264234
02279835
02282178
02282291
02282631
02328372
02356937
02359588
02359847
02371812
RISPERDAL (SA)
PMS-RISPERIDONE (SA)
PHL-RIPERIDONE (SA)
NOVO-RISPERIDONE (SA)
SANDOZ-RISPERIDONE (SA)
APO-RISPERIDONE (SA)
MYLAN-RISPERIDONE (SA)
CO-RISPERIDONE (SA)
RAN-RISPERIODONE (SA)
RISPERIDONE (SA)
JAMP-RISPERIDONE (SA)
MINT-RISPERIDONE (SA)
MAR-RISPERIDONE (SA)
JAN
PMS
PHL
NOP
SDZ
APX
MYL
COB
RBX
SNS
JPC
MNT
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
0.5MG ORALLY DISINTEGRATING TABLET
02247704
RISPERDAL M-TAB (SA)
02413485
MYLAN-RISPERIDONE ODT (SA)
JAN FNQSW
MYL FNQSW
1MG ORALLY DISINTEGRATING TABLET
02247705
RISPERDAL M-TAB (SA)
02291789
PMS-RISPERIDONE ODT (SA)
02413493
MYLAN-RISPERIDONE ODT (SA)
JAN FNQSW
PMS FNQSW
MYL FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 161 -
2MG ORALLY DISINTEGRATING TABLET
02247706
RISPERDAL M-TAB (SA)
02291797
PMS-RISPERIDONE ODT (SA)
02413507
MYLAN-RISPERIDONE ODT (SA)
JAN FNQSW
PMS FNQSW
MYL FNQSW
1 MG/Ml ORAL SOLUTION
02236950
RISPERDAL (SA)
02279266
PMS-RISPERIDONE (SA)
02280396
APO-RISPERIDONE (SA)
JAN FNQSW
PMS FNQSW
APX FNQSW
12.5MG PROLONGED RELEASE INJECTION
02298465
RISPERDAL CONSTA (SA)
JAN
FNQSW
25MG PROLONGED RELEASE INJECTION
02255707
RISPERDAL CONSTA (SA)
JAN
FNQSW
37.5MG PROLONGED RELEASE INJECTION
02255723
RISPERDAL CONSTA (SA)
JAN
FNQSW
50MG PROLONGED RELEASE INJECTION
02255758
RISPERDAL CONSTA (SA)
JAN
FNQSW
THIOTHIXENE
2MG CAPSULE
00024430
NAVANE
ERF
FNQSW
5MG CAPSULE
00024449
NAVANE
ERF
FNQSW
10MG CAPSULE
00024457
NAVANE
ERF
FNQSW
TRIFLUOPERAZINE
1MG TABLET
00345539
APO-TRIFLUOPERAZINE
AAA
FNQSW
2MG TABLET
00312754
APO-TRIFLUOPERAZINE
AAA
FNQSW
5MG TABLET
00312746
APO-TRIFLUOPERAZINE
AAA
FNQSW
10MG TABLET
00326836
APO-TRIFLUOPERAZINE
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 162 -
ZIPRASIDONE HYDROCHLORIDE
SEE APPENDIX A FOR SA CRITERIA
20MG CAPSULE
02298597
ZELDOX (SA)
PFI
Q
40MG CAPSULE
02298600
ZELDOX (SA)
PFI
Q
60MG CAPSULE
02298619
ZELDOX (SA)
PFI
Q
80MG CAPSULE
02298627
ZELDOX (SA)
PFI
Q
DEXTROAMPHETAMINE SULFATE
5MG TABLET
01924516
DEXEDRINE
PAL
FQW
10MG SUSTAINED RELEASE CAPSULE
01924559
DEXEDRINE
PAL
FQW
15MG SUSTAINED RELEASE CAPSULE
01924567
DEXEDRINE
PAL
FQW
METHYLPHENIDATE HCL
5MG TABLET
02234749
PMS-METHYLPHENIDATE
02273950
APO-METHYLPHENIDATE
PMS FQW
APX FQW
10MG TABLET
00005606
00584991
02230321
02249324
RITALIN
PMS-METHYLPHENIDATE
RATIO-METHYLPHENIDATE
APO-METHYLPHENIDATE
NVR
PMS
RPH
APX
FQW
FQW
FQW
FQW
20MG TABLET
00005614
00585009
02230322
02249332
RITALIN
PMS-METHYLPHENIDATE
RATIO-METHYLPHENIDATE
APO-METHYLPHENIDATE
NVR
PMS
RPH
APX
FQW
FQW
FQW
FQW
28:20.00 RESPIRATORY AND CEREBRAL STIMULANTS
PEI Pharmacare Formulary …………………………………………………Page - 163 -
20MG SUSTAINED RELEASE TABLET
00632775
RITALIN SR
02320312
SANDOZ METHYLPHENIDATE SR
02266687
APO-METHYLPHENIDATE SR
NVR FQW
SDZ FQW
APX FQW
10MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277166
BIPHENTIN (SA)
PFR
FQW
15MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277131
BIPHENTIN (SA)
PFR
FQW
20MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277158
BIPHENTIN (SA)
PFR
FQW
30MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277174
BIPHENTIN (SA)
PFR
FQW
40MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277182
BIPHENTIN (SA)
PFR
FQW
50MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277190
BIPHENTIN (SA)
PFR
FQW
60MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277204
BIPHENTIN (SA)
PFR
FQW
80MG CONTROLLED RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02277212
BIPHENTIN (SA)
PFR
FQW
MODAFINIL
SEE APPENDIX A FOR SA CRITERIA
100MG TABLET
02239665
ALERTEC (SA)
02285398
MODAFINIL (SA)
SHR FNQSW
AAA FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 164 -
28:24.08 ANXIOLYTICS, SEDATIVES, HYPNOTICS (BENZODIAZEPINES)
ALPRAZOLAM
0.25MG TABLET
00548359
00865397
01913484
02137534
02349191
02400111
XANAX
APO-ALPRAZ
TEVA-ALPRAZOLAM
MYLAN-ALPRAZOLAM
ALPRAZOLAM
JAMP-ALPRAZOLAM
PFI
APX
TEV
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
0.5MG TABLET
00548367
00865400
01913492
02137542
02349205
02400138
XANAX
APO-ALPRAZ
TEVA-ALPRAZOLAM
MYLAN-ALPRAZOLAM
ALPRAZOLAM
JAMP-ALPRAZOLAM
PFI
APX
TEV
MYL
SNS
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
BROMAZEPAM
1.5MG TABLET
02177153
APO-BROMAZEPAM
APX
FNQSW
3MG TABLET
00518123
02230584
LECTOPAM
NOVO-BROMAZEPAM
HLR FNQSW
NOP FNQSW
6MG TABLET
00518131
02230585
LECTOPAM
NOVO-BROMAZEPAM
HLR FNQSW
NOP FNQSW
CHLORDIAZEPOXIDE
5MG CAPSULE
00522724
APO-CHLORDIAZEPOXIDE
APX
FNQSW
10MG CAPSULE
00522988
APO-CHLORDIAZEPOXIDE
APX
FNQSW
25MG CAPSULE
00522996
APO-CHLORDIAZEPOXIDE
APX
FNQSW
APX
FNQSW
CLORAZEPATE DIPOTASSIUM
3.75MG CAPSULE
00860689
APO-CLORAZEPATE
PEI Pharmacare Formulary …………………………………………………Page - 165 -
7.5MG CAPSULE
00860700
APO-CLORAZEPATE
APX
FNQSW
15MG CAPSULE
00860697
APO-CLORAZEPATE
APX
FNQSW
DIAZEPAM
2MG TABLET
00405329
02247490
APO-DIAZEPAM
PMS-DIAZEPAM
APX FNQSW
PMS FNQSW
5MG TABLET
00013285
00362158
02247491
VALIUM
APO-DIAZEPAM
PMS-DIAZEPAM
HLR FNQSW
APX FNQSW
PMS FNQSW
10MG TABLET
00405337
02247492
APO-DIAZEPAM
PMS-DIAZEPAM
APX FNQSW
PMS FNQSW
FLURAZEPAM
15MG CAPSULE
00521698
APO-FLURAZEPAM
APX
FNQSW
30MG CAPSULE
00521701
APO-FLURAZEPAM
APX
FNQSW
LORAZEPAM
0.5MG TABLET
00655740
00711101
00728187
02041413
02351072
APO-LORAZEPAM
NOVO-LORAZEM
PMS-LORAZEPAM
ATIVAN
LORAZEPAM
APX
NOP
PMS
PFI
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NOVO-LORAZEM
APO-LORAZEPAM
PMS-LORAZEPM
ATIVAN
LORAZEPAM
NOP
APX
PMS
PFI
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NOVO-LORAZEM
APO-LORAZEPAM
PMS-LORAZEPAM
NOP FNQSW
APX FNQSW
PMS FNQSW
1MG TABLET
00637742
00655759
00728195
02041421
02351080
2MG TABLET
00637750
00655767
00728209
PEI Pharmacare Formulary …………………………………………………Page - 166 -
02041448
02351099
ATIVAN
LORAZEPAM
PFI FNQSW
SNS FNQSW
MIDAZOLAM
5MG/ML INJECTION SOLUTION (2ML)
02240286
MIDAZOLAM
SDZ
NQ
NITRAZEPAM
5MG TABLET
00511528
MOGADON
AAA
FNQSW
10MG TABLET
00511536
MOGADON
AAA
FNQSW
OXAZEPAM
10MG TABLET
00402680
APO-OXAZEPAM
APX
FNQSW
15MG TABLET
00402745
APO-OXAZEPAM
APX
FNQSW
30MG TABLET
00402737
APO-OXAZEPAM
APX
FNQSW
TEMAZEPAM
15MG CAPSULE
00604453
02225964
02230095
02244814
RESTORIL
APO-TEMAZEPAM
NOVO-TEMAZEPAM
CO-TEMAZEPAM
ORX
APX
NOP
COB
FNQSW
FNQSW
FNQSW
FNQSW
30MG CAPSULE
00604461
02225972
02230102
02244815
RESTORIL
APO-TEMAZEPAM
NOVO-TEMAZEPAM
CO-TEMAZEPAM
ORX
APX
NOP
COB
FNQSW
FNQSW
FNQSW
FNQSW
TRIAZOLAM
Note: Treatment with Triazolam should usually not exceed 7 to 10 consecutive days. Use for
more than 2 to 3 consecutive weeks requires a complete re-evaluation of the patient.
0.125MG TABLET
00808563
APO-TRIAZO
APX
FW
0.25MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 167 -
00808571
APO-TRIAZO
APX
FW
28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, HYPNOTICS
BUSPIRONE
10MG TABLET
02211076
02230942
02231492
APO-BUSPIRONE
PMS-BUSPIRONE
NOVO-BUSPIRONE
APX FNQSW
PMS FNQSW
NOP FNQSW
CHLORAL HYDRATE
100MG/ML SYRUP
00792659
PMS-CHLORAL HYDRATE
PMS FNQSW
HYDROXYZINE HCL
10MG CAPSULE
00646059
APO-HYDROXYZINE
00738824
NOVO-HYDROXYZIN
APX FNQSW
NOP FNQSW
25MG CAPSULE
00646024
00738832
APO-HYDROXYZINE
NOVO-HYDROXYZIN
APX FNQSW
NOP FNQSW
50MG CAPSULE
00646016
00738840
APO-HYDROXYZINE
NOVO-HYDROXYZIN
APX FNQSW
NOP FNQSW
2MG/ML SYRUP
00024694
00741817
ATARAX
PMS-HYDROXYZINE
ERF FNQSW
PMS FNQSW
ZOPICLONE
5MG TABLET
02216167
02243426
02245077
02246534
02251450
02257572
02267918
02271931
02294052
02296616
02344122
IMOVANE
PMS-ZOPICLONE
APO-ZOPICLONE
RATIO-ZOPICLONE
NOVO-ZOPICLONE
SANDOZ-ZOPICLONE
RAN-ZOPICLONE
CO-ZOPICLONE
PHL-ZOPICLONE
MYLAN-ZOPICLONE
ZOPICLONE
AVN
PMS
APX
RPH
NOP
SDZ
RAN
COB
PHL
MYL
SNS
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
PEI Pharmacare Formulary …………………………………………………Page - 168 -
02385821
02386771
02386909
02391716
02406969
ZOPICLONE
MAR-ZOPICLONE
SEPTA-ZOPICLONE
MINT-ZOPICLONE
JAMP-ZOPICLONE
SIV
MAR
SPT
MNT
JPC
FNQW
FNQW
FNQW
FNQW
FNQW
7.5MG TABLET
01926799
02008203
02218313
02238596
02240606
02242481
02251469
02267926
02271958
02294060
02282445
02356805
02385848
02386917
02386798
02391724
IMOVANE
RHOVANE
APO-ZOPICLONE
MYLAN-ZOPICLONE
PMS-ZOPICLONE
RATIO-ZOPICLONE
NOVO-ZOPICLONE
RAN-ZOPICLONE
CO-ZOPICLONE
PHL-ZOPICLONE
ZOPICLONE
JAMP-ZOPICLONE
ZOPICLONE
SEPTA-ZOPICLONE
MAR-ZOPICLONE
MINT-ZOPICLONE
AVN
SDZ
APX
MYL
PMS
RPH
NOP
RAN
COB
PHL
SNS
JPC
SIV
SPT
MAR
MNT
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
FNQW
28:28.00 ANTIMANIC AGENTS
LITHIUM CARBONATE
150MG CAPSULE
00461733
CARBOLITH
02216132
PMS-LITHIUM CARBONATE
VAL FNQSW
PMS FNQSW
150MG CAPSULE (NOT INTERCHANGEABLE)
02013231
LITHANE
ERF
300MG CAPSULE
00236683
CARBOLITH
02216140
PMS-LITHIUM CARBONATE
VAL FNQSW
PMS FNQSW
300MG CAPSULE (NOT INTERCHANGEABLE)
00406775
LITHANE
ERF
FNQSW
FNQSW
600MG CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 169 -
02011239
02216159
CARBOLITH
PMS-LITHIUM CARBONATE
300MG SUSTAINED RELEASE TABLET
02266695
LITHMAX
VAL FNQSW
PMS FNQSW
AAA
FNQSW
28:32.00 MISCELLANEOUS ANTIMIGRAINE AGENTS
ALMOTRIPTAN
SEE APPENDIX A FOR SA CRITERIA
6.25MG TABLET
02248128
AXERT (SA)
02398435
MYLAN-ALMOTRIPTAN (SA)
02405792
APO-ALMOTRPTAN (SA)
12.5MG TABLET
02248129
AXERT (SA)
02398435
MYLAN-ALMOTRIPTAN (SA)
02405792
APO-ALMOTRPTAN (SA)
Note: Coverage is limited to 6 tablets per 30 day period
NARATRIPTAN HCL
SEE APPENDIX A FOR SA CRITERIA
1MG TABLET
02237820
AMERGE (SA)
02314290
NOVO-NARATRIPTAN (SA)
2.5MG TABLET
02237821
AMERGE (SA)
02314304
NOVO-NARATRIPTAN (SA)
02322323
SANDOZ-NARATRIPTAN (SA)
Note: Coverage is limited to 6 tablets per 30 day period.
MCL FNQSW
MYL FNQSW
APX FNQSW
MCL FNQSW
MYL FNQSW
APX FNQSW
GSK FNQSW
NOP FNQSW
GSK FNQSW
NOP FNQSW
SDZ FNQSW
PIZOTYLINE
0.5MG TABLET
00329320
SANDOMIGRAN
PEN FNQSW
1MG TABLET
00511552
SANDOMIGRAN DS
PEN FNQSW
SUMATRIPTAN
SEE APPENDIX A FOR SA CRITERIA
25MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 170 -
02239738
02256428
02257882
02268906
02286815
02286513
IMITREX DF (SA)
PMS-SUMATRIPTAN (SA)
CO-SUMATRIPTAN (SA)
MYLAN-SUMATRIPTAN (SA)
NOVO-SUMATRIPTAN (SA)
SUMATRIPTAN (SA)
GSK
PMS
COB
MYL
NOP
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
50MG TABLET
02212153
02256436
02257890
02263025
02268388
02268914
02286823
02286521
02385570
IMITREX DF (SA)
PMS-SUMATRIPTAN (SA)
CO-SUMATRIPTAN (SA)
SANDOZ-SUMATRIPTAN (SA)
APO-SUMATRIPTAN (SA)
MYLAN-SUMATRIPTAN (SA)
NOVO-SUMATRIPTAN (SA)
SUMATRIPTAN (SA)
SUMATRIPTAN (SA)
GSK
PMS
COB
SDZ
APX
MYL
NOP
SNS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
100MG TABLET
02212161
02239367
02256444
02257904
02263033
02268396
02268922
02286831
02286548
02385589
IMITREX DF (SA)
NOVO-SUMATRIPTAN (SA)
PMS-SUMATRIPTAN (SA)
CO-SUMATRIPTAN (SA)
SANDOZ-SUMATRIPTAN (SA)
APO-SUMATRIPTAN (SA)
MYLAN-SUMATRIPTAN (SA)
NOVO-SUMATRIPTAN (SA)
SUMATRIPTAN (SA)
SUMATRIPTAN (SA)
GSK
NOP
PMS
COB
SDZ
APX
MYL
NOP
SNS
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
6MG/0.5ML INJECTION SOLUTION
02212188
IMITREX (SA)
02361698
TARO-SUMATRIPTAN (SA)
GSK FNQSW
TAR FNQSW
5MG NASAL SPRAY
02230418
IMITREX (SA)
GSK FNQSW
20MG NASAL SPRAY
02230420
IMITREX (SA)
GSK FNQSW
Note: Coverage is limited to 6 tablets or 6 sprays or 6 syringes per 30 day period.
ZOLMITRIPTAN
SEE APPENDIX A FOR SA CRITERIA
2.5MG TABLET
02238660
ZOMIG (SA)
AZE
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 171 -
TEV
SDZ
PMS
MYL
FNQSW
FNQSW
FNQSW
FNQSW
BROMOCRIPTINE
2.5MG TABLET
02087324
APO-BROMOCRIPTINE
APX
FNQSW
5MG CAPSULE
02230454
APX
FNQSW
02313960
TEVA-ZOLMITRIPTAN (SA)
02362988
SANDOZ-ZOLMITRIPTAN (SA)
02324229
PMS-ZOLMITRIPTAN (SA)
02369036
MYLAN-ZOLMITRIPTAN (SA)
Note: Coverage is limited to 6 tablets per 30 day period.
28:36.00 ANTI PARKINSONIAN AGENTS
APO-BROMOCRIPTINE
CARBIDOPA & LEVODOPA & ENTACAPONE
SEE APPENDIX A FOR SA CRITERIA
12.5/50/200MG TABLET
02309533
STALEVO 50 (SA)
NVR FNQSW
18.75/75/200MG TABLET
02337827
STALEVO 75 (SA)
NVR FNQSW
25/100/200MG TABLET
02305941
STALEVO 100 (SA)
NVR FNQSW
31.25/125/200MG TABLET
02337835
STALEVO 125 (SA)
NVR FNQSW
37.5/150/200MG TABLET
02305968
STALEVO 150 (SA)
NVR FNQSW
ENTACAPONE
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
200MG TABLET
02243763
COMTAN (SA)
NVR FNQSW
02375559
TEVA-ENTACAPONE (SA)
TEV FNQSW
02380005
02390337
SANDOZ-ENTACAPONE (SA)
MYLAN-ENTACAPONE (SA)
SDZ FNQSW
MYL FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 172 -
LEVODOPA & CARBIDOPA
100MG & 10MG TABLET
00355658
SINEMET
02195933
APO-LEVOCARB
02244494
NOVO-LEVOCARBIDOPA
MSD FNQSW
APX FNQSW
NOP FNQSW
100MG & 25MG TABLET
00513997
SINEMET
02195941
APO-LEVOCARB
02244495
NOVO-LEVOCARBIDOPA
MSD FNQSW
APX FNQSW
NOP FNQSW
250MG & 25MG TABLET
00328219
SINEMET
02195968
APO-LEVOCARB
02244496
NOVO-LEVOCARBIDOPA
MSD FNQSW
APX FNQSW
NOP FNQSW
100MG & 25MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
02028786
SINEMET CR (SA)
MSD FNQSW
02272873
APO-LEVOCARB CR (SA)
AAA FNQSW
02421488
PMS-LEVOCARB CR (SA)
PMS FNQSW
200MG & 50MG CONTROLLED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
00870935
SINEMET CR (SA)
MSD FNQSW
02421496
PMS-LEVOCARB CR (SA)
PMS FNQSW
PRAMIPEXOLE DIHYDROCHLORIDE
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
0.25MG TABLET
02237145
MIRAPEX (SA)
BOE FNQSW
02269309
TEVA-PRMIPEXOLE (SA)
TEV FNQSW
02290111
PMS-PRAMIPEXOLE (SA)
PMS FNQSW
02292378
APO-PRAMIPEXOLE (SA)
APX FNQSW
02297302
CO-PRAMIPEXOLE (SA)
COB FNQSW
02309122
PRAMIPEXOLE (SA)
SIV FNQSW
02315262
SANDOZ PRAMIPEXOLE (SA)
SDZ FNQSW
02376350
MYLAN-PRAMIPEXOLE (SA)
MYL FNQSW
0.5MG TABLET
02241594
02269317
MIRAPEX (SA)
TEVA-PRMIPEXOLE (SA)
BOE FNQSW
TEV FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 173 -
02290138
02292386
02297310
02309130
02315270
02376369
PMS-PRAMIPEXOLE (SA)
APO-PRAMIPEXOLE (SA)
CO-PRAMIPEXOLE (SA)
PRAMIPEXOLE (SA)
SANDOZ-PRAMIPEXOLE (SA)
MYLAN-PRAMIPEXOLE (SA)
PMS
APX
COB
SIV
SDZ
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
1MG TABLET
02237146
02269325
02290146
02292394
02297329
02309149
02315289
02376377
MIRAPEX (SA)
TEVA-PRMIPEXOLE (SA)
PMS-PRAMIPEXOLE (SA)
APO-PRAMIPEXOLE (SA)
CO-PRAMIPEXOLE (SA)
PRAMIPEXOLE (SA)
SANDOZ-PRAMIPEXOLE (SA)
MYLAN-PRAMIPEXOLE (SA)
BOE
TEV
PMS
APX
COB
SIV
SDZ
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
1.5MG TABLET
02237147
02269333
02290154
02292408
02297337
02309157
02315297
02376385
MIRAPEX (SA)
TEVA-PRMIPEXOLE (SA)
PMS-PRAMIPEXOLE (SA)
APO-PRAMIPEXOLE (SA)
CO-PRAMIPEXOLE (SA)
PRAMIPEXOLE (SA)
SANDOZ-PRAMIPEXOLE (SA)
MYLAN-PRAMIPEXOLE (SA)
BOE
TEV
PMS
APX
COB
SIV
SDZ
MYL
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
ROPINIROLE HCL
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
0.25MG TABLET
02232565
REQUIP (SA)
GSK FNQSW
02314037
RAN-ROPINIROLE (SA)
RAN FNQSW
02316846
CO-ROPINIROLE (SA)
COB FNQSW
02326590
PMS-ROPINIROLE (SA)
PMS FNQSW
02352338
JAMP-ROPINIROLE (SA)
JPC FNQSW
02353040
ROPINIROLE (SA)
SNS FNQSW
1MG TABLET
02232567
02314053
02316854
02326612
02352346
02353059
REQUIP (SA)
RAN-ROPINIROLE (SA)
CO-ROPINIROLE (SA)
PMS-ROPINIROLE (SA)
JAMP-ROPINIROLE (SA)
ROPINIROLE (SA)
GSK
RAN
COB
PMS
JPC
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 174 -
2MG TABLET
02232568
02314061
02316862
02326620
02352354
02353067
REQUIP (SA)
RAN-ROPINIROLE (SA)
CO-ROPINIROLE (SA)
PMS-ROPINIROLE (SA)
JAMP-ROPINIROLE (SA)
ROPINIROLE (SA)
GSK
RAN
COB
PMS
JPC
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG TABLET
02232569
02314088
02316870
02326639
02352362
02353075
REQUIP (SA)
RAN-ROPINIROLE (SA)
CO-ROPINIROLE (SA)
PMS-ROPINIROLE (SA)
JAMP-ROPINIROLE (SA)
ROPINIROLE (SA)
GSK
RAN
COB
PMS
JPC
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
SELEGILINE HCL
5MG TABLET
02068087
NOVO-SELEGILINE
02230641
APO-SELEGILINE
02231036
MYLAN-SELEGILINE
NOP FNQSW
APX FNQSW
MYL FNQSW
28:36.08 ANTICHOLINERIC AGENTS
BENZTROPINE MESYLATE
2MG TABLET
00426857
BENZTROPINE
00587265
PMS-BENZTROPINE
PMS FNQSW
PMS FNQSW
1MG/ML INJECTION SOLUTION (2ML)
02238903
BENZTROPINE OMEGA
OMG NQ
PROCYCLIDINE HCL
0.5MG/ML ELIXIR
00587362
PMS-PROCYCLIDINE
PMS FNQSW
5MG TABLET
00587354
PMS FNQSW
PMS-PROCYCLIDINE
TRIHEXYPHENIDYL HCL
2MG TABLET
00545058
APO-TRIHEX
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 175 -
5MG TABLET
00545074
APO-TRIHEX
AAA
FNQSW
28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS
ACAMPROSATE
SEE APPENDIX A FOR SA CRITERIA
333MG DELAYED RELEASE TABLET
02293269
CAMPRAL (SA)
MYL FNQSW
36:26.00 DIABETES MELLITUS
NOTE: THE DRUG IDENTIFICATION NUMBERS LISTED IN THIS SECTION ARE FOR BILLING
PURPOSES ONLY.
BLOOD GLUCOSE TEST STRIP
97799823
ACCU-CHEK ADVANTAGE (50)
97799824
ACCU-CHEK ADVANTAGE (100)
97799815
ACCU-CHEK AVIVA (50)
97799814
ACCU-CHEK AVIVA (100)
97799963
ACCU-CHEK COMPACT (51)
97799962
ACCU-CHEK COMPACT (102)
97799496
ACCU-CHEK MOBILE (50)
97799497
ACCU-CHEK MOBILE (100)
97799959
ACCUTREND GC (50)
97799927
ASCENSIA AUTODISC (50)
97799926
ASCENSIA AUTODISC (100)
97799749
ASCENSIA BREEZE 2 (50)
97799748
ASCENSIA BREEZE 2 (100)
97799703
ASCENSIA CONTOUR (50)
97799702
ASCENSIA CONTOUR (100)
97799925
ASCENSIA ELITE (25)
97799924
ASCENSIA ELITE (50)
97799923
ASCENSIA ELITE (100)
97799901
BD LATIDTUE (50)
97799900
BD LATITUDE (100)
97799465
BG STAR TEST STRIPS (100)
97799460
CONTOUR NEXT (50)
97799459
CONTOUR NEXT (100)
BOE
BOE
BOE
BOE
BOE
BOE
ROC
ROC
BOE
BAY
BAY
BAY
BAY
BAY
BAY
BAY
BAY
BAY
BDC
BDC
AVN
BAY
BAY
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
PEI Pharmacare Formulary …………………………………………………Page - 176 -
THI
THI
ABC
ABC
ABC
ACM
ACM
NBC
NBC
LSN
LSN
LSN
LSN
ABC
ABC
BTN
BIN
BIN
HOM
ABC
HOM
HOM
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
DQ
URINE GLUCOSE TEST STRIP
STRIP
00977160
DIASTIX
BAY
DQW
URINE KETONE TEST STRIP
STRIP
00977322
KETOSTIX
BAY
DQ
97799564
97799565
97799596
97799597
97799829
97799770
97799692
97799584
97799583
97799986
97799976
97799476
97799475
97799841
97799840
97799451
97799479
97799478
97799601
97799838
97799603
97799602
EZ HEALTH ORACLE (50)
EZ HEALTH ORACLE (100)
FREESTYLE LITE (50)
FREESTYLE LITE (100)
FREESTYLE (100)
ITEST (50)
ITEST (100)
NOVAMAX (50)
NOVAMAX (100)
ONE TOUCH ULTRA (50)
ONE TOUCH ULTRA (100)
ONE TOUCH VERIO (50)
ONE TOUCH VERIO (100)
PRECISION FREESTYLE/XTRA (50)
PRECISION FREESTYLE/XTRA (100)
RAPID RESPONSE (50)
RIGHTEST GS100 (50)
RIGHTEST GS100 (100)
SIDEKICK (50)
SOF-TACT(100)
TRUE TRACK (50)
TRUE TRACK (100)
36:60.00 THYROID FUNCTION
THYROTROPIN ALFA
SEE APPENDIX A FOR SA CRITERIA
1.1MG INJECTION
02246016
THYROGEN (SA)
GZY FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 177 -
36:84.00 TUBERCULOSIS
TUBERCULIN PURIFIED PROTEIN DERIVATIVE
5TUB/0.5ML INJECTION SOLUTION
00317268
TUBERSOL
AVN I
40:08.00 ALKALINIZING AGENTS
SODIUM BICARBONATE
500MG TABLET
00392839
SODIUM BICARBONATE
SDZ
50MMOL INJECTION SOLUTION (50ML SYRINGE)
00261998
SODIUM BICARBONATE INJECTION
HOS NQ
N
40:12.00 REPLACEMENT AGENTS
CALCIUM CARBONATE
250MG TABLET
00999910
CALCIUM CARBONATE
Note: The Drug Identification Number listed is for billing purposes only.
500MG TABLET
00999919
CALCIUM CARBONATE
Note: The Drug Identification Number listed is for billing purposes only.
NW
NW
DEXTROSE
50% INJECTION SOLUTION (50ML SYRINGE)
00037974
DEXTROSE 50%
HOS NQ
MAGNESIUM GLUCOHEPTONATE
100MG/ML ORAL SOLUTION
00026697
ROUGIER-MAGNESIUM
ROG FNQSW
POTASSIUM CHLORIDE
8MMOL LONG ACTING TABLET
00074225
SLOW-K
00602884
APO-K
NVR NW
APX NW
PEI Pharmacare Formulary …………………………………………………Page - 178 -
1.33MMOL/ML ORAL SOLUTION
01918303
K-10
02238604
PMS-POTASSIUM CHLORIDE
GSK NW
PMS NW
25MMOL EFFERVESCENT TABLET
02085992
K-LYTE
WES NW
2MMOL/ML INJECTION SOLUTION (10ML)
00037869
POTASSIUM CHLORIDE
HOS NQ
SODIUM CHLORIDE
0.9% INJECTION SOLUTION (10ML)
00037796
SODIUM CHLORIDE
HOS NQ
0.9% INJECTION SOLUTION (100ML INTRAVENOUS BAG)
00060208
SODIUM CHLORIDE
BAX
NQ
0.9% IRRIGATION SOLUTION (1000ML)
00786160
SODIUM CHLORIDE
BAX
CNQW
STERILE WATER
INJECTION SOLUTION (10ML)
02142546
STERILE WATER FOR INJECTION
HOS CNQ
40:18.00 POTASSIUM-REMOVING RESINS
SODIUM POLYSTYRENE SULFONATE
ORAL POWDER (1G BINDS WITH APPROXIMATELY 1MMOL K+ IN VIVO)
00755338
PMS-SOD POLYSTYRENE SULF
PMS FNQSW
02026961
KAYEXALATE
AVN FNQSW
40:28.00 DIURETICS
*CHLORTHALIDONE
50MG TABLET
00360279
APO-CHLORTHALIDONE
AAA
*FUROSEMIDE
20MG TABLET
00337730
00396788
NOP FNQSW
APX FNQSW
NOVO-SEMIDE
APO-FUROSEMIDE
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 179 -
02247493
02351420
PMS-FUROSEMIDE
FUROSEMIDE
PMS FNQSW
SNS FNQSW
40MG TABLET
00337749
02247494
02351439
NOVO-SEMIDE
PMS-FUROSEMIDE
FUROSEMIDE
NOP FNQSW
PMS FNQSW
SNS FNQSW
80MG TABLET
00707570
00765953
02351447
APO-FUROSEMIDE
NOVO-SEMIDE
FUROSEMIDE
APX FNQSW
NOP FNQSW
SNS FNQSW
10MG/ML ORAL SOLUTION
02224720
LASIX
AVN FNQSW
10MG/ML INJECTION SOLUTION (2ML)
00527033
FUROSEMIDE
SDZ
*HYDROCHLOROTHIAZIDE
12.5MG TABLET
02274086
PMS-HYDROCHLOROTHIAZIDE
02327856
APO-HYDRO
PMS FNQSW
APX FNQSW
25MG TABLET
00021474
00326844
02247386
TEVA-HYDROCHLOROTHIAZIDE
APO-HYDRO 25
PMS-HYDROCHLOROTHIAZIDE
TEV FNQSW
APX FNQSW
PMS FNQSW
50MG TABLET
00021482
00312800
02247387
NOVO-HYDRAZIDE
APO-HYDRO 50
PMS-HYDROCHLOROTHIAZIDE
NOP FNQSW
APX FNQSW
PMS FNQSW
NQ
*INDAPAMIDE HEMIHYDRATE
1.25MG TABLET
02179709
LOZIDE
02239619
PMS-INDAPAMIDE
02240067
MYLAN-INDAPMAIDE
02245246
APO-INDAPAMIDE
02373904
JAMP-INDAPAMIDE
SEV
PMS
MYL
APX
JPC
2.5MG TABLET
00564966
02153483
SEV FNQSW
MYL FNQSW
LOZIDE
MYLAN-INDAPMAIDE
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 180 -
FNQSW
FNQSW
FNQSW
FNQSW
02223678
02231184
02239620
02373912
APO-INDAPAMIDE
NOVO-INDAPAMIDE
PMS-INDAPAMIDE
JAMP-INDAPAMIDE
APX
NOP
PMS
JPC
*METOLAZONE
2.5MG TABLET
00888400
ZAROXOLYN
AVN FNQSW
40:28.10 DIURETICS (POTASSIUM SPARING)
*AMILORIDE HCL & HYDROCHLOROTHIAZIDE
5MG & 50MG TABLET
00784400
APO-AMILZIDE
01937219
NOVAMILOR
APX FNQSW
NOP FNQSW
*SPIRONOLACTONE
25MG TABLET
00028606
ALDACTONE
00613215
NOVO-SPIROTON
PFI FNQSW
NOP FNQSW
100MG TABLET
00285455
00613223
PFI FNQSW
NOP FNQSW
ALDACTONE
NOVO-SPIROTON
*SPIRONOLACTONE & HYDROCHLOROTHIAZIDE
25MG & 25MG TABLET
00180408
ALDACTAZIDE 25
00613231
NOVO-SPIROZINE 25
PFI FNQSW
NOP FNQSW
50MG & 50MG TABLET
00594377
ALDACTAZIDE 50
00657182
NOVO-SPIROZINE 50
PFI FNQSW
NOP FNQSW
*TRIAMTERENE & HYDROCHLOROTHIAZIDE
50MG & 25MG TABLET
00441775
APO-TRIAZIDE
00532657
NOVO-TRIAMZIDE
APX FNQSW
NOP FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 181 -
40:40.00 URICOSURIC DRUGS
PROBENECID
500MG TABLET
00294926
VAL
FNQSW
AAA
FNQSW
CODEINE & GUAIFENESIN & PHENIRAMINE
2MG & 20MG & 1.5MG PER ML SYRUP
01934740
ROBITUSSIN AC
PFI
W
DEXTROMETHORPHAN HBR
3MG/ML SYRUP
00436895
BALMINIL DM
01928775
BALMINIL DM (SUGAR FREE)
01944738
BENYLIN DM (SUCROSE & ALCOHOL FREE)
ROG NW
ROG NW
MCL NW
HYDROCODONE
1MG/ML SYRUP
01916580
02324253
BMS N
PMS N
BENURYL
SULFINPYRAZONE
200MG TABLET
00441767
APO-SULFINPYRAZONE
48:08.00 ANTITUSSIVES
HYCODAN
PMS-HYDROCODONE
48:16.00 EXPECTORANTS
GUAIFENESIN
20MG/ML ORAL LIQUID
00608920
BALMINIL EXPECTORANT
00609951
BALMINIL EXPECTORANT (SUGAR FREE)
01931032
ROBITUSSIN (SUCROSE & ALCOHOL FREE)
ROG NW
ROG NW
WAY NW
PEI Pharmacare Formulary …………………………………………………Page - 182 -
48:24.00 MUCOLYTIC AGENTS
ACETYLCYSTEINE
20% SOLUTION (30 ML)
02091526
MUCOMYST
02243098
ACETYLCYSTEINE SOLUTION
WEL FNQSW
SDZ FNQSW
52:04.04 ANTI INFECTIVES (ANTIBIOTICS)
CIPROFLOXACIN
SEE APPENDIX A FOR SA CRITERIA
0.3% OPHTHALMIC OINTMENT (3.5G)
02200864
CILOXAN (SA)
ALC
FNQSW
0.3% OPHTHALMIC SOLUTION
01945270
CILOXAN (SA)
02387131
SANDOZ-CIPROFLOXACIN (SA)
ALC
SDZ
FNQSW
FNQSW
0.3% & 0.1% OTIC SUSPENSION
02252716
CIPRODEX (SA)
ALC
FNQSW
ERYTHROMYCIN BASE
0.5% OPHTHALMIC OINTMENT (3.5G)
01912755
PMS-ERYTHROMYCIN
PMS FNQSW
GATIFLOXACIN
SEE APPENDIX A FOR SA CRITERIA
0.3% OPHTHALMIC DROPS
02257270
ZYMAR (SA)
ALL
GENTAMICIN SULFATE
0.3% OPHTHALMIC SOLUTION
00512192
GARAMYCIN
02229440
SANDOZ GENTAMICIN
MSD FNQSW
SDZ FNQSW
0.3% OTIC SOLUTION
00512184
GARAMYCIN
02229441
SANDOZ GENTAMICIN
MSD FNQSW
SDZ FNQSW
CIPROFLOXACIN & DEXAMETHASONE
SEE APPENDIX A FOR SA CRITERIA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 183 -
MOXIFLOXACIN
SEE APPENDIX A FOR SA CRITERIA
0.5% OPHTHALMIC DROPS
02252260
VIGAMOX (SA)
ALC
FNQSW
OFLOXACIN
SEE APPENDIX A FOR SA CRITERIA
0.3% OPHTHALMIC SOLUTION
02143291
OCUFLOX (SA)
02248398
APO-OFLOXACIN (SA))
02247189
SANDOZ-OFLOXACIN (SA)
ALL
APX
SDZ
FNQSW
FNQSW
FNQSW
POLYMYXIN B & BACITRACIN
10,000U & 500U/G OPHTHALMIC OINTMENT
02160889
OPTIMYXIN
02239157
POLYSPORIN
SDZ
JJM
NW
NW
POLYMYXIN B & GRAMICIDIN
10,000U & 0.025MG/ML OPHTHALMIC/OTIC SOLUTION
02239156
POLYSPORIN
JJM
NW
SULFACETAMIDE SODIUM
10% OPHTHALMIC SOLUTION
00028053
SODIUM SULAMYD
SDZ
FNQSW
TOBRAMYCIN
0.3% OPHTHALMIC OINTMENT (3.5G)
00614254
TOBREX
ALC
FNQSW
0.3% OPHTHALMIC SOLUTION
00513962
TOBREX
02239577
PMS-TOBRAMYCIN
02241755
SANDOZ TOBRAMYCIN
ALC FNQSW
PMS FNQSW
SDZ FNQSW
52:04.06 ANTI INFECTIVES (ANTIVIRALS)
TRIFLURIDINE
1% OPHTHALMIC SOLUTION
00687456
VIROPTIC
VAL
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 184 -
52:04.92 MISCELLANEOUS ANTI INFECTIVES
CHLORHEXIDINE
SEE APPENDIX A FOR SA CRITERIA
0.12% ORAL RINSE
02237452
PERIDEX (SA)
02240433
PERICHLOR (SA)
MDA N
PMS N
HEXYLRESORCINOL
2.4MG LOZENGE
00846589
BRADOSOL
CLC
N
52:08.00 ANTI INFLAMMATORY AGENTS
BECLOMETHASONE DIPROPIONATE
50UG/DOSE AQUEOUS NASAL SPRAY
02172712
MYLAN-BECLO AQ.
02238796
APO-BECLOMETHASONE
MYL FNQSW
APX FNQSW
DEXAMETHASONE
0.1% OPHTHALMIC OINTMENT (3.5G)
00042579
MAXIDEX
ALC
FNQSW
0.1% OPHTHALMIC SUSPENSION
00042560
MAXIDEX
ALC
FNQSW
0.1% OPHTHALMIC/OTIC SOLUTION
00739839
SANDOZ-DEXAMETHASONE
SDZ
FNQSW
DICLOFENAC SODIUM
0.1% OPHTHALMIC SOLUTION
01940414
VOLTAREN OPHTHA
ALC
FNQSW
FLUNISOLIDE
0.025% NASAL SPRAY
02162687
RHINALAR
02239288
APO-FLUNISOLIDE
IVX
APX
FNQSW
FNQSW
FLUOROMETHOLONE
0.1% OPHTHALMIC SUSPENSION
00247855
FML 0.1%
00432814
SANDOZ-FLUOROMETHOLONE
ALL
SDZ
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 185 -
FLUOROMETHOLONE ACETATE
0.1% OPHTHALMIC SUSPENSION
00756784
FLAREX
ALC
FNQSW
FLURBIPROFEN SODIUM
0.03% OPHTHALMIC SOLUTION
00766046
OCUFEN
ALL
FNQSW
FLUTICASONE PROPIONATE
50UG/DOSE AQUEOUS NASAL SPRAY
02213672
FLONASE
02294745
APO-FLUTICASONE
02296071
RATIO-FLUTICASONE
GSK FNQSW
APX FNQSW
RPH FNQSW
KETOROLAC TROMETHAMINE
0.5% OPHTHALMIC SOLUTION
01968300
ACULAR
02245821
APO-KETOROLAC
ALL
APX
MOMETASONE
50UG/DOSE NASAL SPRAY
02238465
NASONEX
02403587
APO-MOMETASONE
MSD FNQSW
APX FNQSW
PREDNISOLONE ACETATE
0.12% OPHTHALMIC SUSPENSION
00299405
PRED MILD
ALL
1% OPHTHALMIC SUSPENSION
00301175
PRED FORTE
00700401
RATIO-PREDNISOLONE
01916203
SANDOZ-PREDNISOLONE
ALL FNQSW
RPH FNQSW
SDZ FNQSW
TRIAMCINOLONE
55UG/DOSE NASAL SPRAY
02213834
NASACORT AQ
AVN FNQSW
FNQSW
FNQSW
FNQSW
52:08.08 COMBINATION ANTI-INFECTIVE / ANTI INFLAMMATORY AGENTS
CLIOQUINOL & FLUMETHASONE PIVALATE
1% & 0.02% OTIC SOLUTION
00074454
LOCACORTEN-VIOFORM
PAL
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 186 -
FRAMYCETIN SULFATE & GRAMICIDIN & DEXAMETHASONE
5MG & 50UG & 0.5MG/ML OPHTHALMIC/OPTIC SOLUTION
02224623
SOFRACORT
AVN FNQSW
GENTAMICIN & BETAMETHASONE SODIUM PHOSPHATE
3MG & 1MG/ML OPHTHALMIC/OTIC SOLUTION
02244999
SANDOZ-PENTASONE
SDZ
FNQSW
POLYMYXIN B & NEOMYCIN & HYDROCORTISONE
10000U & 5MG & 10MG/ML OTIC SOLUTION
02230386
SANDOZ-CORTIMYXIN
SDZ
FNQSW
TOBRAMYCIN & DEXAMETHASONE
0.3% & 0.1% OPHTHALMIC OINTMENT
00778915
TOBRADEX
ALC
FNQSW
0.3% & 0.1% OPHTHALMIC SUSPENSION
00778907
TOBRADEX
ALC
FNQSW
ACETAZOLAMIDE
250MG TABLET
00545015
APO-ACETAZOLAMIDE
AAA
FNQSW
BRINZOLAMIDE
02238873
ALC
FNQSW
52:10.00 CARBONIC ANHYDRASE INHIBITORS
AZOPT
DORZOLAMIDE HCL
2% OPHTHALMIC SOLUTION
02216205
TRUSOPT
02316307
SANDOZ-DORZOLAMIDE
MSD FNQSW
SDZ FNQSW
METHAZOLAMIDE
50MG TABLET
02245882
APO-METHAZOLAMIDE
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 187 -
52:24.00 MYDRIATICS
ATROPINE SULFATE
1% OPHTHALMIC SOLUTION
00035017
ISOPTO ATROPINE
ALC
FNQSW
HOMATROPINE HBR
2% OPHTHLAMIC SOLUTION
00000779
ISOPTO HOMATROPINE
ALC
FNQSW
5% OPHTHALMIC SOLUTION
00000787
ISOPTO HOMATROPINE
ALC
FNQSW
PHENYLEPHRINE HCL
2.5% OPHTHALMIC SOLUTION
00465763
MYDFRIN
ALC
FNQSW
52:28.00 MOUTHWASHES AND GARGLES
BENZYDAMINE HCL
SEE APPENDIX A FOR SA CRITERIA
0.15% ORAL RINSE
02226820
SUN-BENZ (SA)
02229777
PMS-BENZYDAMINE (SA)
SUN FNQSW
PMS FNQSW
52:32.00 VASOCONSTRICTORS
XYLOMETAZOLINE
0.1% NASAL SPRAY
00653330
OTRIVIN
01939998
DECONGESTANT NASAL SPRAY
NVR N
ROG N
LATANOPROST & TIMOLOL
50MCG & 5 MG PER ML OPHTHALMIC SOLUTION
02246619
XALACOM
02394685
SANDOZ-LATANOPROST/TIMOLOL
PFI
SDZ
FNQSW
FNQSW
LEVOBUNOLOL HCL
0.25% OPHTHALMIC SOLUTION
PEI Pharmacare Formulary …………………………………………………Page - 188 -
RATIO-LEVOBUNOLOL
SANDOZ-LEVOBUNOLOL
RPH FNQSW
SDZ FNQSW
0.5% OPHTHALMIC SOLUTION
00637661
BETAGAN
02031167
RATIO-LEVOBUNOLOL
02241716
SANDOZ-LEVOBUNOLOL
ALL FNQSW
RPH FNQSW
SDZ FNQSW
02031159
02241715
52:40.00 ALPHA AND BETA ADRENERGIC AGENTS AND PROSTAGLANDIN
ANALOGS
BETAXOLOL HCL
0.25% OPHTHALMIC SUSPENSION
01908448
BETOPTIC S
ALC
FNQSW
BIMATOPROST
0.1 MG/ML OPHTHALMIC SOLUTION
02324997
LUMIGAN
ALL
FNQSW
BRIMONIDINE TARTRATE
0.15% OPHTHALMIC SOLUTION
02248151
ALPHAGAN P
02301334
APO-BRIMONIDINE P
ALL
APX
FNQSW
FNQSW
0.2% OPHTHALMIC SOLUTION
02236876
ALPHAGAN
02243026
RATIO-BRIMONIDINE
02246284
PMS-BRIMONIDINE
02260077
APO-BRIMONIDINE
02305429
SANDOZ BRIMONIDINE
ALL
RPH
PMS
APX
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
BRIMONIDINE & TIMOLOL
0.2% & 0.5% OPHTHALMIC SOLUTION
02248347
COMBIGAN
ALL
FNQSW
BRINZOLAMIDE & TIMOLOL
1% & 0.5% OPHTHALMIC SUSPENSION
02331624
AZARGA
ALC
FNQSW
DOZOLAMIDE & TIMOLOL
2% & 0.5% OPHTHALMIC SOLUTION
02240113
COSOPT
MSD FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 189 -
02299615
02320525
02344351
02404389
APO-DORZO-TIMOP
TEVA-DORZOTIMOL
SANDOZ-DORZOLAMIDE/TIMOLOL
CO-DORZOTIMOLOL
LATANOPROST
50UG/ML OPHTHALMIC SOLUTION
02231493
XALATAN
02254786
CO-LATANOPROST
02296527
APO-LATANOPROST
02367335
SANDOZ-LATANOPROST
02373041
GD-LATANOPROST
APX
TEV
SDZ
COB
FNQSW
FNQSW
FNQSW
FNQSW
PFI
COB
APX
SDZ
GMD
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
Note: The provincial drug programs will only pay for one 2.5 mL bottle of Latanoprost per
client every 30 days. Clients are responsible for the entire prescription cost of any Latanoprost
required beyond this.
TIMOLOL MALEATE
0.25% OPHTHALMIC SOLUTION
00755826
APO-TIMOP
02083353
PMS-TIMOLOL
02166712
SANDOZ-TIMOLOL
APX FNQSW
PMS FNQSW
SDZ FNQSW
0.5% OPHTHALMIC SOLUTION
00451207
TIMOPTIC
00755834
APO-TIMOP
02083345
PMS-TIMOLOL
02166720
SANDOZ-TIMOLOL MALEATE
MSD
APX
PMS
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
TRAVOPROST
0.004% OPHTHALMIC SOLUTION
02318008
TRAVATAN Z
ALC
FNQSW
TRAVAPROST & TIMOLOL
0.004% & 0.5% OPHTHALMIC SOLUTION
02278251
DUOTRAV
ALC
FNQSW
ALC
FNQSW
52:40.20 MIOTICS
CARBACHOL
1.5% OPHTHALMIC SOLUTION
00000655
ISOPTO CARBACHOL
PEI Pharmacare Formulary …………………………………………………Page - 190 -
3% OPHTHALMIC SOLUTION
00000663
ISOPTO CARBACHOL
ALC
FNQSW
PILOCARPINE HCL
4% OPHTHALMIC GEL (5G)
00575240
PILOPINE HS
ALC
FNQSW
1% OPHTHALMIC SOLUTION
00000841
ISOPTO CARPINE
ALC
FNQSW
2% OPHTHALMIC SOLUTION
00000868
ISOPTO CARPINE
ALC
FNQSW
4% OPHTHALMIC SOLUTION
00000884
ISOPTO CARPINE
ALC
FNQSW
52:92.00 EYE, EAR, NOSE, AND THROAT DRUGS, MISCELLANEOUS
APRACLONIDINE HCL
0.5% OPHTHALMIC SOLUTION
02076306
IOPIDINE
ALC
FNQSW
ARTIFICIAL TEARS
0.5% OPHTHALMIC SOLUTION
00000809
ISOPTO TEARS
ALC
NW
1% OPHTHALMIC SOLUTION
00000817
ISOPTO TEARS
ALC
NW
5% OPHTHALMIC OINTMENT
00750816
MURO-128
BLO NW
94% & 3% OPHTHALMIC OINTMENT
02082519
TEARS NATURALE P.M.
ALC
CARBOXYMETHYLCELLUSLOSE & ELECTROLYTES
ORAL SPAY
02238696
MOI-STIR
PMS NW
RANIBIZUMAB
SEE APPENDIX A FOR SA CRITERIA
2.3MG/0.23ML VIAL
02296810
LUCENTIS (SA)
NVR MQ
NW
PEI Pharmacare Formulary …………………………………………………Page - 191 -
CROMOLYN SODIUM
2% OPHTALMIC SOLUTION
02230621
OPTICROM
ALL
FNSW
56:04.00 ANTACIDS AND ADSORBENTS
ALGINIC ACID & ALUMINIUM HYDROXIDE
50MG & 20MG/ML ORAL SUSPENSION
02159775
GAVISCON
GSK NW
ALGINIC ACID & MAGNESIUM CARBONATE
200MG & 40MG TABLET
02159791
GAVISCON HEARTBURN RELIEF
GSK NW
MAGNESIUM HYDROXIDE & ALUMINIUM HYDROXIDE
40MG & 33MG/ML ORAL SUSPENSION
01966529
DIOVOL
CDC NW
MAGNESIUM HYDROXIDE & ALUMINIUM HYDROXIDE & SIMETHICONE
200MG & 200MG & 25MG TABLET
00116882
DIOVOL PLUS
CDC NW
56:08.00 ANTIDIARRHEA AGENTS
DIPHENOXYLATE HCL/ATROPINE SULFATE
SEE APPENDIX A FOR SA CRITERIA
2.5MG/0.025MG TABLET
00036323
LOMOTIL (SA)
PFI
FNQSW
LACTOBACILLUS RHAMNOSUS
CAPSULE
01927906
BACID
ERF
N
LOPERAMIDE
2MG CAPLET
02132591
02183862
02212005
02228351
02229552
NOP
MCL
APX
PMS
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NOVO-LOPERAMIDE
IMODIUM
APO-LOPERAMIDE
PMS-LOPERAMIDE
DIARR-EZE
PEI Pharmacare Formulary …………………………………………………Page - 192 -
0.2MG/ML ORAL SOLUTION
02016095
PMS-LOPERAMIDE HCL
PMS FNQSW
56:10.00 ANTIFLATULENTS
SIMETHICONE
80MG TABLET
00292990
OVOL
CDC NW
56:12.00 CATHARTICS AND LAXATIVES
Note: Cathartics and laxatives should only be used after failure of simpler measures. A high
fiber diet, adequate hydration, and a review of potentially constipating medications is often
effective in relieving constipation.
BISACODYL
5MG ENTERIC COATED TABLET
00254142
DULCOLAX
00545023
APO-BISACODYL
BOE NW
APX NW
5MG RECTAL SUPPOSITORY
00003867
DULCOLAX
BOE W
10MG RECTAL SUPPOSITORY
00003875
DULCOLAX
00404802
RATIO-BISACODYL
00582883
PMS-BISACODYL
BOE NW
RPH NW
PMS NW
10MG RECTAL SUPPOSITORY (NOT INTERCHANGEABLE)
SEE APPENDIX A FOR SA CRITERIA
02241091
MAGIC BULLET (SA)
D&C FNSW
DOCUSATE SODIUM
4MG/ML SYRUP
00703508
PMS-DOCUSATE SODIUM
00870226
RATIO-DOCUSATE SODIUM
02086018
COLACE
PMS NW
RPH NW
WEL NW
100MG CAPSULE
00703494
PMS-DOCUSATE SODIUM
00716731
DOCUSATE SODIUM
00870196
RATIO-DOCUSATE SODIUM
PMS NW
TAR NW
RPH NW
PEI Pharmacare Formulary …………………………………………………Page - 193 -
02106256
02020084
COLACE
NOVO-DOCUSATE
WEL NW
NOP NW
GLYCERIN
90%/2.6G SUPPOSITORY
02020394
GLYCERN
ROG N
LACTULOSE
667MG/ML SYRUP
00703486
00854409
02242814
02295881
02412268
PMS
RPH
APX
JPC
SNS
PMS-LACTULOSE
RATIO-LACTULOSE
APO-LACTULOSE
JAMP-LACTULOSE
LACTULOSE
NW
NW
NW
NW
NW
MAGNESIUM CITRATE
50MG/ML ORAL SOLUTION
00262609
CITRO-MAG
ROG NW
MAGNESIUM CITRATE & BISACODYL
KIT
02122774
ROYVAC BOWEL EVACUANT KIT
WAP APNW
MAGNESIUM HYDROXIDE & MINERAL OIL
60MG & 0.25ML PER ML ORAL EMULSION
00202045
MAGNOLAX
PEN N
PSYLLIUM MUCILLOID
ORAL POWDER
02174782
METAMUCIL SUGAR FREE
02174812
METAMUCIL
PGA NW
PGA NW
SENNOSIDES A&B
8.6MG TABLET
00026158
SENOKOT
00896411
PMS-SENNOSIDES
PFR N
PMS N
1.7MG/ML ORAL LIQUID
00367729
SENOKOT
PFR
N
SODIUM PHOSPHATES
220MG/ML ENEMA (130ML)
00009911
FLEET
JJM
NW
PEI Pharmacare Formulary …………………………………………………Page - 194 -
56:14.00 CHOLELITHOLYTIC AGENTS
URSODIOL
SEE APPENDIX A FOR SA CRITERIA
URSODIOL 250MG TABLET
02238984
URSO (SA)
02273497
PMS-URSODIOL C (SA)
AXC FNQSW
PMS FNQSW
URSODIOL 500MG TABLET
02245894
URSO DS (SA)
02273500
PMS-URSODIOL C (SA)
AXC FNQSW
PMS FNQSW
56:16.00 DIGESTANTS
*PANCRELIPASE EQUIVALENT TO LIPASE & AMYLASE & PROTEASE
8,000 & 30,000 & 30,000USP U CAPSULE
00263818
COTAZYM
MSD CFNQSW
8,000 & 30,000 & 30,000USP U CAPSULE (ENTERIC COATED PARTICLES)
00502790
COTAZYM ECS 8
MSD CFNQSW
20,000 & 55,000 & 55,000USP U CAPSULE (ENTERIC COATED PARTICLES)
00821373
COTAZYM ECS 20
MSD CFNQSW
8,000 & 30,000 & 30,000USP U TABLET
02230019
VIOKASE 8
AXC CFNQSW
16,000 & 60,000 & 60,000USP U TABLET
02241933
VIOKASE 16
AXC CFNQSW
56:22.00 ANTIEMETICS
APREPIRANT
SEE APPENDIX A FOR SA CRITERIA
80MG CAPSULE
02298791
EMEND (SA)
MSD FNQSW
125MG CAPSULE
02298805
EMEND (SA)
MSD FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 195 -
80MG & 80MG & 125MG CAPSULE (PACKAGE)
02298813
EMEND TRI-PACK (SA)
MSD FNQSW
DIMENHYDRINATE
50MG TABLET
00013803
GRAVOL
00021423
NOVO-DIMENATE
00363766
APO-DIMENHYDRINATE
CDC NW
NOP NW
APX NW
50MG RECTAL SUPPOSITORY
00392553
SANDOZ-DIMENHYDRINATE
SDZ
100MG RECTAL SUPPOSITORY
00013609
GRAVOL
00392545
SANDOZ-DIMENHYDRINATE
CDC NW
SDZ NW
50MG/ML INTRAMUSCULAR INJECTION SOLUTION (5ML)
00013579
GRAVOL
00392537
DIMENHYDRINATE IM
CDC NQ
SDZ NQ
10MG/ML INTRAVENOUS INJECTION SOLUTION (5ML)
00392731
DIMENHYDRINATE IV
SDZ
NQ
DOXYLAMINE SUCCINATE & PYRIDOXINE HCL
10MG & 10MG DELAYED RELEASE TABLET
00609129
DICLECTIN
DUI
FQW
DRONABINOL
SEE APPENDIX A FOR SA CRITERIA
2.5MG CAPSULE
00611190
MARINOL (SA)
ABB
FNQSW
5MG CAPSULE
00611204
MARINOL (SA)
SLV
FNQSW
MECLIZINE HCL
25MG TABLET
00220442
BONAMINE
MCL FNQSW
NABILONE
SEE APPENDIX A FOR SA CRITERIA
0.5MG CAPSULE
02256193
CESAMET (SA)
02358085
RAN-NABILONE (SA)
02380900
PMS-NABILONE (SA)
NW
VAL FNQSW
RAN FNQSW
PMS FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 196 -
02384884
02393581
TEVA-NABILONE (SA)
CO-NABILONE (SA)
TEV FNQSW
COB FNQSW
1MG CAPSULE
00548375
02358093
02380919
02384892
02393603
CESAMET (SA)
RAN-NABILONE (SA)
PMS-NABILONE (SA)
TEVA-NABILONE (SA)
CO-NABILONE (SA)
VAL
RAN
PMS
TEV
COB
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
ONDANSETRON HCL
SEE APPENDIX A FOR SA CRITERIA
4MG TABLET
02213567
ZOFRAN (SA)
02258188
PMS-ONDANSETRON (SA)
02264056
NOVO-ONDANSETRON (SA)
02274310
SANDOZ-ONDANSETRON (SA)
02278529
RATIO-ONDANSETRON (SA)
02278618
PHL-ONDANSETRON (SA)
02288184
APO-ONDANSETRON (SA)
02296349
CO-ONDANSETRON (SA)
02297868
MYLAN-ONDANSETRON (SA)
02305259
MINT-ONDANSETRON (SA)
02306212
ONDANSETRON-ODAN (SA)
02312247
RAN-ONDANSETRON (SA)
02313685
JAMP-ONDANSETRON (SA)
02371731
MAR-ONDANSETRON (SA)
02376091
SEPTA-ONDANSETRON (SA)
02421402
ONDANSETRON (SA)
GSK
PMS
NOP
SDZ
RPH
PHL
APX
COB
MYL
MNT
ODN
RAN
JPC
MAR
SPT
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
8MG TABLET
02213575
02258196
02264064
02274329
02278537
02278626
02288192
02296357
02297876
02305267
02306220
02312255
02313693
02371758
GSK
PMS
TEV
SDZ
RPH
PHL
APX
COB
MYL
MNT
ODN
RAN
JPC
MAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
ZOFRAN (SA)
PMS-ONDANSETRON (SA)
TEVA-ONDANSETRON (SA)
SANDOZ-ONDANSETRON (SA)
RATIO-ONDANSETRON (SA)
PHL-ONDANSETRON (SA)
APO-ONDANSETRON (SA)
CO-ONDANSETRON (SA)
MYLAN-ONDANSETRON (SA)
MINT-ONDANSETRON (SA)
ODAN-ONDANSETRON (SA)
RAN-ONDANSETRON (SA)
JAMP-ONDANSETRON (SA)
MAR-ONDANSETRON (SA)
PEI Pharmacare Formulary …………………………………………………Page - 197 -
02376105
02421410
SEPTA-ONDANSETRON (SA)
ONDANSETRON (SA)
0.8MG/ML ORAL SOLUTION
02229639
ZOFRAN (SA)
02291967
APO-ONDANSETRON (SA)
SPT FNQSW
SNS FNQSW
GSK FNQSW
AAA FNQSW
56:28.12 HISTAMINE H2 ANTAGONISTS
*CIMETIDINE
200MG TABLET
00584215
APO-CIMETIDINE
APX
300MG TABLET
02227444
MYLAN-CIMETIDINE
MYL FNQSW
400MG TABLET
02227452
MYLAN-CIMETIDINE
MYL FNQSW
600MG TABLET
02227460
MYLAN-CIMETIDINE
MYL FNQSW
*FAMOTIDINE
20MG TABLET
00710121
01953842
02022133
02196018
02242327
02351102
PEPCID
APO-FAMOTIDINE
NOVO-FAMOTIDINE
MYLAN-FAMOTIDINE
RATIO-FAMOTIDINE
FAMOTIDINE
MSD
APX
NOP
MYL
RPH
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
40MG TABLET
00710113
01953834
02022141
02196026
02242328
02351110
PEPCID
APO-FAMOTIDINE
NOVO-FAMOTIDINE
MYLAN-FAMOTIDINE
RATIO-FAMOTIDINE
FAMOTIDINE
MSD
APX
NOP
MYL
RPH
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*NIZATIDINE
150MG CAPSULE
00778338
AXID
FNQSW
PEN FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 198 -
PMS-NIZATIDINE
NOVO-NIZATIDINE
PMS FNQSW
NOP FNQSW
300MG CAPSULE
00778346
AXID
02177722
PMS-NIZATIDINE
02240458
NOVO-NIZATIDINE
PEN FNQSW
PMS FNQSW
NOP FNQSW
*RANITIDINE HCL
150MG TABLET
00733059
00828564
00828823
02207761
02212331
02242453
02248570
02336480
02353016
02367378
02385953
APO-RANITIDINE
NOVO-RANIDINE
RATIO-RANITIDINE
MYLAN-RANITIDINE
ZANTAC
PMS-RANITIDINE
CO-RANITIDINE
RAN-RANITIDINE
RANITIDINE
MYLAN-RANITIDINE
RANITIDINE
APX
NOP
RPH
MYL
GSK
PMS
COB
RAN
SNS
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
300MG TABLET
00733067
00828556
02207788
02212358
02242454
02243230
02248571
02336502
02353024
02367386
02385961
APO-RANITIDINE
NOVO-RANIDINE
MYLAN-RANITIDINE
ZANTAC
PMS-RANITIDINE
SANDOZ-RANITIDINE
CO-RANITIDINE
RAN-RANITIDINE
RANITIDINE
MYLAN-RANITIDINE
RANITIDINE
APX
NOP
MYL
GSK
PMS
RHP
COB
RAN
SNS
MYL
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02177714
02240457
15MG/ML ORAL SOLUTION
02242940
NOVO-RANIDINE
NOP FNQSW
56:28.28 PROSTAGLANDINS
*MISOPROSTOL
100UG TABLET
02244022
200UG TABLET
MISOPROSTOL
AAA
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 199 -
02244023
MISOPROSTOL
AAA
FNQSW
56:28.32 PROTECTANTS
*SUCRALFATE
1G TABLET
02045702
02100622
02125250
NOVO-SUCRALATE
SULCRATE
APO-SUCRALFATE
200MG/ML ORAL SUSPENSION
02103567
SULCRATE PLUS
NOP FNQSW
AXC FNQSW
APX FNQSW
AVN FNQSW
56:28.36 PROTON PUMP INHIBITORS
LANSOPRAZOLE
SEE PROTON PUMP INHIBITORS IN APPENDIX A FOR SA CRITERIA
15MG DELAYED RELEASE CAPSULE
02165503
PREVACID (SA)
02280515
NOVO-LANSOPRAZOLE (SA)
02293811
APO-LANSOPRAZOLE (SA)
02353830
MYLAN-LANSOPRAZOLE (SA)
02357682
LANSOPRAZOLE (SA)
02385643
SANDOZ-LANSOPRAZOLE (SA)
02395258
PMS-LANSOPRAZOLE (SA)
02402610
RAN-LANSOPRAZOLE (SA)
ABB
NOP
APX
MYL
SNS
SDZ
PMS
RAN
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
30MG DELAYED RELEASE CAPSULE
02165511
PREVACID (SA)
02280523
NOVO-LANSOPRAZOLE (SA)
02293838
APO-LANSOPRAZOLE (SA)
02353849
MYLAN-LANSOPRAZOLE (SA)
02357690
LANSOPRAZOLE (SA)
02385651
SANDOZ-LANSOPRAZOLE (SA)
02395266
PMS-LANSOPRAZOLE (SA)
02402629
RAN-LANSOPRAZOLE (SA)
02410389
LANSOPRAZOLE-30 (SA)
ABB
NOP
APX
MYL
SNS
SDZ
PMS
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
15MG DELAYED RELEASE TABLET
PEI Pharmacare Formulary …………………………………………………Page - 200 -
PREVACID FASTAB (SA)
ABB
FNQSW
30MG DELAYED RELEASE TABLET
02249472
PREVACID FASTAB (SA)
ABB
FNQSW
LANSOPRAZOLE & CLARITHROMYCIN & AMOXICILLIN
SEE APPENDIX A FOR SA CRITERIA
30MG & 500MG & 500MG 7-DAY PACKAGE
02238525
HP-PAC (SA)
ABB
FNQSW
02249464
*OMEPRAZOLE
SEE PROTON PUMP INHIBITORS IN APPENDIX A FOR SA CRITERIA FOR DOSAGES
GREATER THAN 20MG PER DAY.
20MG CAPSULE
00846503
02245058
02296446
02320851
02348691
02403617
02411857
LOSEC
APO-OMEPRAZOLE
SANDOZ-OMEPRAZOLE
PMS-OMEPRAZOLE
OMEPRAZOLE
RAN-OMEPRAZOLE
OMEPRAZOLE-20
20MG DELAYED RELEASE TABLET
02190915
LOSEC
02260867
RATIO-OMEPRAZOLE
02295415
NOVO-OMEPRAZOLE DR
02310260
PMS-OMEPRAZOLE DR
02329433
MYLAN-OMEPRAZOLE
02374870
RAN-OMEPRAZOLE
02420198
JAMP-OMEPRAZOLE
AZE
APX
SDZ
PMS
SNS
RAN
SIV
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
AZE
RPH
TEV
PMS
MYL
RAN
JPC
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*PANTOPRAZOLE MAGNESIUM
SEE PROTON PUMP INHIBITORS IN APPENDIX A FOR SA CRITERIA FOR DOSAGES
GREATER THAN 40 MG/DAY
40MG ENTERIC TABLET (NOT INTERCHANGEABLE)
02267233
TECTA
NYC FNQSW
PANTOPRAZOLE SODIUM
SEE PROTON PUMP INHIBITORS IN APPENDIX A FOR SA CRITERIA FOR DOSAGES
GREATER THAN ONE UNIT/DAY
20MG ENTERIC TABLET
02241804
PANTOLOC
NYC FNQSW
02285479
TEVA-PANTOPRAZOLE
TEV FNQSW
02292912
APO-PANTOPRAZOLE
APX FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 201 -
SANDOZ-PANTOPRAZOLE
RAN-PANTOPRAZOLE
PANTOPRAZOLE
JAMP-PANTOPRAZOLE EC
SDZ
RAN
SIV
JPC
FNQSW
FNQSW
FNQSW
FNQSW
40MG ENTERIC TABLET
02229453
PANTOLOC
02285487
TEVA-PANTOPRAZOLE
02292920
APO-PANTOPRAZOLE
02299585
MYLAN-PANTOPRAZOLE
02300486
CO-PANTOPRAZOLE
02301083
SANDOZ-PANTOPRAZOLE
02305046
RAN-PANTOPRAZOLE
02307871
PMS-PANTOPRAZOLE
02357054
JAMP-PANTOPRAZOLE EC
02370808
PANTOPRAZOLE
02385759
PANTOPRAZOLE
02417448
MINT-PANTOPRAZOLE
NYC
TEV
APX
MYL
COB
SDZ
RAN
PMS
JPC
SNS
SIV
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02301075
02305038
02385740
02408414
*RABEPRAZOLE SODIUM
SEE PROTON PUMP INHIBITORS FOR SA CRITERIA FOR DOSAGES GREATER THAN
20 MG/DAY
10MG ENTERIC COATED TABLET
02243796
PARIET
JAN FNQSW
02296632
TEVA-RABEPRAZOLE EC
TEV FNQSW
02298074
RAN-RABEPRAZOLE
RAN FNQSW
02310805
PMS-RABEPRAZOLE
PMS FNQSW
02314177
SANDOZ-RABEPRAZOLE
SDZ FNQSW
02345579
APO-RABEPRAZOLE
APX FNQSW
02356511
RABEPRAZOLE
SNS FNQSW
02381737
PAT-RABEPRAZOLE
PAT FNQSW
02385449
RABEPRAZOLE
SIV FNQSW
02408392
MYLAN-RABEPRAZOLE
MYL FNQSW
20MG ENTERIC COATED TABLET
02243797
PARIET
02296640
TEVA-RABEPRAZOLE EC
02298082
RAN-RABEPRAZOLE
02310813
PMS-RABEPRAZOLE
02314185
SANDOZ-RABEPRAZOLE
02345587
APO-RABEPRAZOLE
02356538
RABEPRAZOLE
02381745
PAT-RABEPRAZOLE
JAN
TEV
RAN
PMS
SDZ
APX
SNS
PAT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
02385457
SIV
FNQSW
RABEPRAZOLE
PEI Pharmacare Formulary …………………………………………………Page - 202 -
02408406
MYLAN-RABEPRAZOLE
MYL FNQSW
56:32.00 MISCELLANEOUS G.I. DRUGS
DOMPERIDONE MALEATE
10MG TABLET
01912070
RATIO-DOMPERIDONE
02103613
APO-DOMPERIDONE
02236466
PMS-DOMPERIDONE
02238341
DOMPERIDONE
02268078
RAN-DOMPERIDONE
02278669
MYLAN-DOMPERIDONE
02350440
DOMPERIDONE
02369206
JAMP-DOMPERIDONE
02403870
MAR-DOMPERIDONE
RPH
APX
PMS
SIV
RAN
MYL
SNS
JPC
MAR
METOCLOPRAMIDE HCL
5MG TABLET
02230431
METONIA
PMS FNQSW
10MG TABLET
02230432
METONIA
PMS FNQSW
1MG/ML ORAL SOLUTION
02230433
METONIA
PMS FNQSW
5MG/ML INJECTION SOLUTION (2ML)
02185431
METOCLOPRAMIDE
SDZ
SULFASALAZINE
500MG ENTERIC COATED TABLET
00598488
PMS-SULFASALAZINE E.C.
02064472
SALAZOPYRIN
PMS FNQSW
PFI FNQSW
500MG TABLET
00598461
02064480
PMS FNQSW
PFI FNQSW
PMS-SULFASALAZINE
SALAZOPYRIN
TRIMEBUTINE MALEATE
100MG TABLET
02245663
TRIMEBUTINE
AAA
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
NQ
FNQSW
200MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 203 -
00803499
02245664
MODULON
TRIMEBUTINE
AXC FNQSW
AAA FNQSW
56:36.00 ANTI-INFLAMMATORY AGENTS
5-AMINOSALICYLIC ACID (MESALAMINE)
400MG ENTERIC COATED TABLET
01997580
ASACOL
02171929
NOVO-5-ASA
WCC FNQSW
TEV FNQSW
500MG ENTERIC COATED TABLET (NOT INTERCHANGEABLE)
01914030
MESASAL
02112787
SALOFALK
GSK FNQSW
AXC FNQSW
500MG DELAYED RELEASE TABLET
02099683
PENTASA
FEI
500MG RECTAL SUPPOSITORY
02112760
SALOFALK
AXC FNQSW
4G/60G RETENTION ENEMA (60G)
02112809
SALOFALK
AXC FNQSW
BETAMETHASONE DISODIUM PHOSPHATE
5MG/100ML ENEMA (100ML)
02060884
BETNESOL
PAL
HYDROCORTISONE
100MG/60ML ENEMA (60ML)
02112736
CORTENEMA
AXC FNQSW
OLSALAZINE SODIUM
250MG CAPSULE
02063808
DIPENTUM
UCB FNQSW
FNQSW
FNQSW
60:00.00 GOLD COMPOUNDS
SODIUM AUROTHIOMALATE
10MG/ML INJECTION SOLUTION (1ML)
01927620
MYOCHRYSINE
AVN FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 204 -
02245456
AUROTHIOMALATE
SDZ
FNQSW
25MG/ML INJECTION SOLUTION (1ML)
01927612
MYOCHRYSINE
02245457
AUROTHIOMALATE
AVN FNQSW
SDZ FNQSW
50MG/ML INJECTION SOLUTION (1ML)
01927604
MYOCHRYSINE
02245458
AUROTHIOMALATE
AVN FNQSW
SDZ FNQSW
64:00.00 HEAVY METAL ANTAGONISTS
DEFERASIROX
SEE APPENDIX A FOR SA CRITERIA
125MG DISPERSIBLE TABLETS
00287420
EXJADE (SA)
NVR Q
250MG DISPERSIBLE TABLETS
00287439
EXJADE (SA)
NVR Q
500MG DISPERSIBLE TABLETS
00287447
EXJADE (SA)
NVR Q
PENICILLAMINE
250MG CAPSULE
00016055
CUPRIMINE
VAL
FNQSW
BUDESONIDE
100UG/DOSE INHALER POWDER (200 DOSE)
00852074
PULMICORT TURBUHALER
AZE
FQW
200UG/DOSE INHALER POWDER (200 DOSE)
00851752
PULMICORT TURBUHALER
AZE
CFNQSW
400UG/DOSE INHALER POWDER (200 DOSE)
00851760
PULMICORT TURBUHALER
AZE
CFNQSW
AZE
FQW
68:04.00 CORTICOSTEROIDS
0.125MG/ML INHALATION SOLUTION (2ML)
SEE APPENDIX A FOR SA CRITERIA
02229099
PULMICORT NEBUAMP (SA)
0.25MG/ML INHALATION SOLUTION (2ML)
PEI Pharmacare Formulary …………………………………………………Page - 205 -
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
01978918
PULMICORT NEBUAMP (SA)
AZE CFNQW
0.5MG/ML INHALATION SOLUTION (2ML)
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
AN SA REQUEST)
01978926
PULMICORT NEBUAMP (SA)
AZE CFNQW
3 MG CONTROL ILEAL RELEASE CAPSULE
SEE APPENDIX A FOR SA CRITERIA
02229293
ENTOCORT (SA)
AZE
CICLESONIDE
100UG/DOSE INHALATION AEROSOL
02285606
ALVESCO
NYC FNQSW
200UG/DOSE INHALATION AEROSOL
02285614
ALVESCO
NYC FNQSW
CORTISONE ACETATE
25MG TABLET
00280437
CORTISONE
VAL
DEXAMETHASONE
0.5MG TABLET
01964976
PMS-DEXAMETHASONE
02240684
RATIO-DEXAMETHASONE
02261081
APO-DEXAMETHASONE
PMS CFNQSW
RPH CFNQSW
APX CFNQSW
0.75MG TABLET
01964968
PMS-DEXAMETHASONE
PMS FNQSW
2MG TABLET
02279363
PMS-DEXAMETHASONE
PMS FNQSW
4MG TABLET
00489158
01964070
02240687
02250055
DEXASONE
PMS-DEXAMETHASONE
RATIO-DEXAMETHASONE
APO-DEXAMETHASONE
VAL
PMS
RPH
APX
CFNQSW
CFNQSW
CFNQSW
CFNQSW
SDZ
FNQSW
DEXAMETHASONE 21 PHOSPHATE
4MG/ML INJECTION SOLUTION (5ML)
00664227
DEXAMETHASONE
FNQSW
CFNQSW
PEI Pharmacare Formulary …………………………………………………Page - 206 -
01977547
DEXAMETHASONE
FLUDROCORTISONE ACETATE
0.1MG TABLET
02086026
FLORINEF
CYT
FNQSW
PAL
FNQSW
FLUTICASONE PROPIONATE
50UG/DOSE INHALATION AEROSOL HYDROFLUOROALKANE (HFA)
02244291
FLOVENT HFA
GSK CFNQSW
125UG/DOSE INHALATION AEROSOL HYDROFLUOROALKANE (HFA)
02244292
FLOVENT HFA
GSK CFNQSW
250UG/DOSE INHALATION AEROSOL HYDROFLUOROALKANE (HFA)
02244293
FLOVENT HFA
GSK CFNQSW
50UG/DOSE AEROSOL POWDER DISK (60)
02237244
FLOVENT DISKUS
GSK FQW
100UG/DOSE AEROSOL POWDER DISK (60)
02237245
FLOVENT DISKUS
GSK FNQSW
250UG/DOSE AEROSOL POWDER DISK (60)
02237246
FLOVENT DISKUS
GSK FNQSW
500UG/DOSE AEROSOL POWDER DISK (60)
02237247
FLOVENT DISKUS
GSK FNQSW
HYDROCORTISONE
10MG TABLET
00030910
CORTEF
PFI
CFNQSW
20MG TABLET
00030929
PFI
CFNQSW
HYDROCORTISONE SODIUM SUCCINATE
250MG INJECTION POWDER
00030619
SOLU-CORTEF
PFI
NQ
METHYLPREDNISOLONE
4MG TABLET
00030988
MEDROL
PFI
CFNQSW
16MG TABLET
00036129
PFI
FNQSW
CORTEF
MEDROL
PEI Pharmacare Formulary …………………………………………………Page - 207 -
METHYLPREDNISOLONE ACETATE
40MG/ML INJECTION SUSPENSION (1ML)
00030759
DEPO MEDROL
02245400
METHYLPREDNISOLONE
PFI
SDZ
FNQSW
FNQSW
40MG/ML INJECTION SUSPENSION (2ML)
01934333
DEPO MEDROL
02245407
METHYLPREDNISOLONE
PFI
SDZ
FNQSW
FNQSW
80MG/ML INJECTION SUSPENSION (1ML)
00030767
DEPO MEDROL
02245406
METHYLPREDNISOLONE
PFI
SDZ
FNQSW
FNQSW
MOMETASONE FUROATE
200MCG DRY POWDER INHALER
02243595
ASMANEX
MSD CFNQSW
400MCG DRY POWDER INHALER
02243596
ASMANEX
MSD CFNQSW
PREDNISOLONE SODIUM PHOSPHATE
1MG/ML ORAL LIQUID
02230619
PEDIAPRED
02245532
PMS-PREDNISOLONE
AVN CFNQSW
PMS CFNQSW
PREDNISONE
1MG TABLET
00598194
APO-PREDNISONE
APX
5MG TABLET
00021695
00312770
NOVO-PREDNISONE
APO-PREDNISONE
NOP CFNQSW
APX CFNQSW
50MG TABLET
00232378
00550957
NOVO-PREDNISONE
APO-PREDNISONE
NOP CFNQSW
APX CFNQSW
CFNQSW
68:08.00 ANDROGENS
DANAZOL
50MG CAPSULE
02018144
CYCLOMEN
AVN FQW
100MG CAPSULE
02018152
CYCLOMEN
AVN FQW
PEI Pharmacare Formulary …………………………………………………Page - 208 -
200MG CAPSULE
02018160
CYCLOMEN
AVN FQW
TESTOSTERONE
SEE APPENDIX A FOR SA CRITERIA
25MG/2.5GN TRANSDERMAL GEL
02245345
ANDROGEL (SA)
ABB
FNQSW
SEE APPENDIX A FOR SA CRITERIA
50MG/5GM TRANSDERMAL GEL (NOT INTERCHANGEABLE)
02245346
ANDROGEL (SA)
02280248
TESTIM (SA)
ABB
ABB
FNQSW
FNQSW
TESTOSTERONE ENANTHATE
200MG/ML OILY INJECTION SOLUTION
00029246
DELATESTRYL
VAL
FQW
TESTOSTERONE UNDECANOATE
SEE APPENDIX A FOR SA CRITERIA
40MG CAPSULE
00782327
ANDRIOL (SA)
02322498
PMS-TESTOSTERONE (SA)
MSD FNQSW
PMS FNQSW
68:12.00 CONTRACEPTIVES
ESTRADIOL & ETONOGESTREL
2 MG & 11.4MG VAGINAL INSERT
02253186
NUVARING
SCH FQW
*ETHINYL ESTRADIOL & DESOGESTREL
0.025MG & 0.10MG TABLET (21 DAY)
02272903
LINESSA
MSD FQW
0.025MG & 0.10MG TABLET (28 DAY)
02257238
LINESSA
MSD FQW
0.03MG & 0.15MG TABLET (21 DAY)
02042487
MARVELON
02317192
APRI 21
02396491
FREYA 21
02410249
MIRVALA 21
MSD
TEV
MYL
APX
FQW
FQW
FQW
FQW
PEI Pharmacare Formulary …………………………………………………Page - 209 -
0.03MG & 0.15MG TABLET (28 DAY)
02042479
MARVELON
02317206
APRI 28
02396610
FREYA 21
02410257
MIRVALA 28
MSD
TEV
MYL
APX
FQW
FQW
FQW
FQW
0.03MG & 0.15MG TABLET (28 DAY)
02042533
ORTHO-CEPT
JAN
FQW
*ETHINYL ESTRADIOL & DROSPIRENONE
3.0MG & 0.03MG TABLETS (21 DAY)
02261723
YASMIN
02385058
ZARAH
02410788
ZAMINE
BAY FQW
COB FQW
APX FQW
3.0MG & 0.03MG TABLETS (28 DAY)
02261731
YASMIN
02385066
ZARAH
02410796
ZAMINE
BAY FQW
COB FQW
APX FQW
*ETHINYL ESTRADIOL & ETHYNODIOL DIACETATE
0.03MG & 2MG TABLET (21 DAY)
00469327
DEMULEN 30
PFI
FQW
0.03MG & 2MG TABLET (28 DAY)
00471526
DEMULEN 30
PFI
FQW
*ETHINYL ESTRADIOL & L-NORGESTREL
0.2MG & 0.1MG TABLET (21 DAY)
02236974
ALESSE
02298538
AVIANE 21
02387875
ALYSENA
02388138
ESME 21
02401185
LUTERA 21
PFI
TEV
APX
MYL
COB
FQW
FQW
FQW
FQW
FQW
0.2MG & 0.1MG TABLET (28 DAY)
02236975
ALESSE
02298546
AVIANE 28
02387883
ALYSENA
02388146
ESME 28
02401207
LUTERA 28
PFI
TEV
APX
MYL
COB
FQW
FQW
FQW
FQW
FQW
0.03MG & 0.05MG (6); 0.04MG & 0.075MG (5); 0.03MG & 0.125MG (10) TABLET (21 DAY)
00707600
TRIQUILAR
BAY FQW
PEI Pharmacare Formulary …………………………………………………Page - 210 -
0.03MG & 0.05MG (6); 0.04MG & 0.075MG (5); 0.03MG & 0.125MG (10); INERT TABLETS
(7) TABLET (28 DAY)
00707503
TRIQUILAR
BAY FQW
0.03MG & 0.15MG TABLET (21 DAY)
02042320
MIN-OVRAL
02295946
PORTIA
02387085
OVIMA
PFI
TEV
APX
FQW
FQW
FQW
0.03MG & 0.15MG TABLET (28 DAY)
02042339
MIN-OVRAL
02295954
PORTIA
02387093
OVIMA
PFI
TEV
APX
FQW
FQW
FQW
*ETHINYL ESTRADIOL & NORETHINDRONE
0.035MG & 0.5MG TABLET (21 DAY) (NOT INTERCHANGEABLE)
00317047
ORTHO 0.5/35
02187086
BREVICON
JAN
PFI
FQW
FQW
0.035MG & 0.5MG TABLET (28 DAY) (NOT INTERCHANGEABLE)
00340731
ORTHO 0.5/35
02187094
BREVICON
JAN
PFI
FQW
FQW
0.035MG &0.5MG (7); 0.035MG & 0.75MG (7); 0.035MG & 1.0MG (7) TABLET (21 DAY)
00602957
ORTHO 7/7/7
JAN FQW
0.035MG &0.5MG (7); 0.035MG & 0.75MG (7); 0.035MG & 1.0MG (7); INERT TABLETS (7)
TABLET (28 DAY)
00602965
ORTHO 7/7/7
JAN FQW
0.035MG &0.5MG (7); 0.035MG & 1.0MG (7); 0.035MG & 0.5MG (7) TABLET (21 DAY)
02187108
SYNPHASIC
PFI FQW
0.035MG &0.5MG (7); 0.035MG & 1.0MG (7); 0.035MG & 0.5MG (7); INERT TABLETS (7)
TABLET (28 DAY)
02187116
SYNPHASIC
PFI FQW
0.035MG & 1.0MG TABLET (21 DAY) (NOT INTERCHANGEABLE)
00372846
ORTHO 1/35
02189054
BREVICON 1/35
02197502
SELECT 1/35
JAN
PFI
PFI
FQW
FQW
FQW
0.035MG & 1.0MG TABLET (28DAY) (NOT INTERCHANGEABLE)
00372838
ORTHO 1/35
JAN
FQW
PEI Pharmacare Formulary …………………………………………………Page - 211 -
BREVICON 1/35
SELECT 1/35
PFI
PFI
FQW
FQW
*ETHINYL ESTRADIOL & NORETHINDRONE ACETATE
0.02MG & 1.0MG TABLET (21 DAY)
00315966
MINESTRIN 1/20
PFI
FQW
0.02MG & 1.0MG TABLET (28 DAY)
00343838
MINESTRIN 1/20
PFI
FQW
0.035MG & 1.5MG TABLET (21 DAY)
00297143
LOESTRIN 1.5/30
PFI
FQW
0.035MG & 1.5MG TABLET (28 DAY)
00353027
LOESTRIN 1.5/30
PFI
FQW
02189062
02199297
*ETHINYL ESTRADIOL & NORGESTIMATE
0.025MG & 0.180MG (7); 0.025MG & 0.215MG (7); 0.025MG & 0.250MG (7) TABLET (21
DAY)
02258560
TRI-CYCLEN LO
JAN FQW
0.025MG & 0.180MG (7); 0.025MG & 0.215MG (7); 0.025MG & 0.250MG (7); INERT
TABLETS (7) TABLET (28 DAY)
02258587
TRI-CYCLEN LO
JAN FQW
0.035MG & 0.180MG (7); 0.035MG & 0.215MG (7); 0.035MG & 0.250MG (7) TABLET (21
DAY)
02028700
TRI-CYCLEN
JAN FQW
0.035MG & 0.180MG (7); 0.035MG & 0.215MG (7); 0.035MG & 0.250MG (7); INERT
TABLETS (7) TABLET (28 DAY)
02029421
TRI-CYCLEN
JAN FQW
0.035MG & 0.25MG TABLET (21 DAY)
01968440
CYCLEN
JAN
FQW
0.035MG & 0.25MG TABLET (28 DAY)
01992872
CYCLEN
JAN
FQW
LEVONORGESTROL
0.75MG TABLET
02241674
PLAN B
02364905
NEXT CHOICE
PAL FQW
COB FQW
PEI Pharmacare Formulary …………………………………………………Page - 212 -
52MG INTRAUTERINE SYSTEM
02243005
MIRENA
BAY
FQW
*NORETHINDRONE
0.35MG TABLET (28 DAY)
00037605
MICRONOR
JAN
FQW
*CONJUGATED ESTROGENS
0.3MG TABLET
02043394
PREMARIN
PFI
FNQSW
0.625MG TABLET
02043408
PREMARIN
PFI
FNQSW
1.25MG TABLET
02043424
PREMARIN
PFI
FNQSW
0.625MG/G VAGINAL CREAM
02043440
PREMARIN
PFI
FNQSW
*CONJUGATED ESTROGENS & MEDROXYPROGESTERONE
0.625MG & 2.5MG TABLET
02242878
PREMPLUS
PFI
FNQSW
0.625MG &5MG
02242879
PREMPLUS
PFI
FNQSW
ESTRADIOL
0.5MG TABLET
02225190
ESTRACE
SHR FNQSW
1MG TABLET
02148587
ESTRACE
SHR FNQSW
68:16.00 ESTROGENS
50UG TRANSDERMAL PATCH
SEE APPENDIX A FOR SA CRITERIA
02244000
ESTRADOT (SA)
02246967
SANDOZ-ESTRADIOL DERM (SA)
NVR FNQSW
SDZ FNQSW
75UG TRANSDERMAL PATCH
SEE APPENDIX A FOR SA CRITERIA
PEI Pharmacare Formulary …………………………………………………Page - 213 -
ESTRADOT (SA)
SANDOZ-ESTRADIOL DERM (SA)
NVR FNQSW
SDZ FNQSW
100UG TRANSDERMAL PATCH
SEE APPENDIX A FOR SA CRITERIA
02244002
ESTRADOT (SA)
02246969
SANDOZ-ESTRADIOL DERM (SA)
NVR FNQSW
SDZ FNQSW
10UG VAGINAL TABLET
02325462
VAGIFEM
NNO FNQSW
ESTRADIOL & NORETHINRONE ACETATE
SEE APPENDIX A FOR SA CRITERIA
50UG & 140UG TRANSDERMAL PATCH
02241835
ESTALIS (SA)
NVR FNQSW
50UG & 250UG TRANSDERMAL PATCH
02241837
ESTALIS (SA)
NVR FNQSW
*PIPERAZINE ESTRONE SULFATE
0.625MG TABLET (0.75MG ESTROPIPATE)
02089793
OGEN
PFI
FNQSW
1.25MG TABLET (1.5MG ESTROPIPATE)
02089769
OGEN
PFI
FNQSW
2.5MG TABLET (3MG ESTROPIPATE)
02089777
OGEN
PFI
FNQSW
GOSERELIN ACETATE
3.6MG DEPOT INJECTION
02049325
ZOLADEX
AZE
FNQSW
10.8MG DEPOT INJECTION
02225905
ZOLADEX LA
AZE
FNQSW
BAY
DNQW
02244001
02246968
68:18.00 GONADOTROPINS
68:20.00 ANTIDIABETIC DRUGS (ORAL HYPOGLYCEMICS)
*ACARBOSE
50MG TABLET
02190885
GLUCOBAY
PEI Pharmacare Formulary …………………………………………………Page - 214 -
100MG TABLET
02190893
BAY
DNQW
*CHLORPROPAMIDE
100MG TABLET
00399302
APO-CHLORPROPAMIDE
APX
DNQW
250MG TABLET
00312711
APX
DNQW
*GLICLAZIDE
30MG MODIFIED RELEASE TABLET
02242987
DIAMICRON MR
02297795
GLICLAZIDE MR
SEV
AAA
DNQW
DNQW
80MG TABLET
00765996
02229519
02238103
02245247
02287072
SEV
MYL
NOP
APX
SNS
DNQW
DNQW
DNQW
DNQW
DNQW
60MG EXTENDED RELEASE TABLET
02356422
DIAMICRON MR
SEV
DNQW
*GLIMEPIRIDE
1MG TABLET
02245272
02269589
02273101
02273756
02295377
AMARYL
SANDOZ-GLIMEPIRIDE
RATIO-GLIMEPIRIDE
NOVO-GLIMEPIRIDE
APO-GLIMEPIRIDE
AVN
SDZ
RPH
NOP
APX
DNQW
DNQW
DNQW
DNQW
DNQW
2MG TABLET
02245273
02269597
02273128
02273764
02295385
AMARYL
SANDOZ-GLIMEPIRIDE
RATIO-GLIMEPIRIDE
NOVO-GLIMEPIRIDE
APO-GLIMEPIRIDE
AVN
SDZ
RPH
NOP
APX
DNQW
DNQW
DNQW
DNQW
DNQW
4MG TABLET
02245274
02269619
02273136
AMARYL
SANDOZ-GLIMEPIRIDE
RATIO-GLIMEPIRIDE
AVN DNQW
SDZ DNQW
RPH DNQW
GLUCOBAY
APO-CHLORPROPAMIDE
DIAMICRON
MYLAN-GLICLAZIDE
NOVO-GLICLAZIDE
APO-GLICLAZIDE
GLICLAZIDE
PEI Pharmacare Formulary …………………………………………………Page - 215 -
02273772
02295393
NOVO-GLIMEPIRIDE
APO-GLIMEPIRIDE
NOP DNQW
APX DNQW
*GLYBURIDE
2.5MG TABLET
00808733
01900927
01913654
01913670
02224550
02248008
02350459
MYLAN-GLYBE
RATIO-GLYBURIDE
APO-GLYBURIDE
TEVA-GLYBURIDE
DIABETA
SANDOZ-GLYBURIDE
GLYBURIDE
MYL
RPH
APX
TEV
AVN
SDZ
SNS
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
5MG TABLET
00808741
01900935
01913662
01913689
02224569
02236734
02248009
02350467
MYLAN-GLYBE
RATIO-GLYBURIDE
APO-GLYBURIDE
TEVA-GLYBURIDE
DIABETA
PMS-GLYBURIDE
SANDOZ-GLYBURIDE
GLYBURIDE
MYL
RPH
APX
TEV
AVN
PMS
SDZ
SNS
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
*METFORMIN
500MG TABLET
02045710
02099233
02148765
02167786
02223562
02229516
02242974
02246820
02257726
02269031
02353377
02378620
02378841
02379767
02380196
02380722
02385341
02388766
NOVO-METFORMIN
GLUCOPHAGE
MYLAN-METFORMIN
APO-METFORMIN
PMS-METFORMIN
GLYCON
RATIO-METFORMIN
SANDOZ-METFORMIN FC
CO-METFORMIN
RAN-METFORMIN
METFORMIN
MAR-METFORMIN
METFORMIN
SEPTA-METFORMIN
JAMP-METFORMIN
JAMP-METFORMIN BLACKBERRY
METFORMIN
MINT-METFORMIN
NOP
AVN
MYL
APX
PMS
VAL
RPH
SDZ
COB
RAN
SNS
MAR
MAR
SPT
JPC
JPC
SIV
MNT
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
PEI Pharmacare Formulary …………………………………………………Page - 216 -
850MG TABLET
02162849
02229656
02229785
02230475
02242589
02242931
02246821
02257734
02269058
02353385
02378639
02378868
02379775
02380218
02380730
02385368
02388774
AVN
MYL
APX
NOP
PMS
RPH
SDZ
COB
RAN
SNS
MAR
MAR
SPT
JPC
JPC
SIV
MNT
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
PIOGLITAZONE HCL
SEE APPENDIX A FOR SA CRITERIA
15MG TABLET
02242572
ACTOS (SA)
02274914
NOVO-PIOGLITAZONE (SA)
02297906
SANDOZ-PIOGLITAZONE (SA)
02298279
MYLAN-PIOLGLITAZONE (SA)
02301423
RATIO-PIOGLITZONE (SA)
02302861
CO-PIOGLITAZONE (SA)
02302942
APO-PIOGLITAZONE (SA)
02303124
PMS-PIOGLITAZONE (SA)
02307669
PHL-PIOGLITAZONE (SA)
02326477
MINT-PIOGLICAZONE (SA)
02375850
RAN-PIOGLITAZONE (SA)
02384906
AURO-PIOGLITAZONE (SA)
02391600
PIOGLITAZONE HYDROCHLORIDE (SA)
02397307
JAMP-PIOGLITAZONE (SA)
TAK
NOP
SDZ
MYL
RPH
COB
APX
PMS
PHL
MNT
RAN
ARO
ACH
JPC
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
30MG TABLET
02242573
02274922
02297914
02298287
02301431
02302888
02302950
TAK
NOP
SDZ
MYL
RPH
COB
APX
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
GLUCOPHAGE
MYLAN-METFORMIN
APO-METFORMIN
NOVO-METFORMIN
PMS-METFORMIN
RATIO-METFORMIN
SANDOZ-METFORMIN FC
CO-METFORMIN
RAN-METFORMIN
METFORMIN
MAR-METFORMIN
METFORMIN
SEPTA-METFORMIN
JAMP-METFORMIN
JAMP-METFORMIN-BLACKBERRY
METFORMIN
MINT-METFORMIN
ACTOS (SA)
NOVO-PIOGLITAZONE (SA)
SANDOZ-PIOGLITAZONE (SA)
MYLAN-PIOLGLITAZONE (SA)
RATIO-PIOGLITZONE (SA)
CO-PIOGLITAZONE (SA)
APO-PIOGLITAZONE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 217 -
02303132
02307677
02326485
02339587
02365529
02375869
02384914
PMS-PIOGLITAZONE (SA)
PHL-PIOGLITAZONE (SA)
MINT-PIOGLITAZONE (SA)
PIOGLITAZONE (SA)
JAMP-PIOGLITAZONE (SA)
RAN-PIOGLITAZONE (SA)
AURO-PIOGLITAZONE (SA)
PMS
PHL
MNT
ACH
JPC
RAN
ARO
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
45MG TABLET
02242574
02274930
02297922
02298295
02301458
02302896
02302977
02303140
02307723
02326493
02339595
02365537
02375877
02384922
ACTOS (SA)
NOVO-PIOGLITAZONE (SA)
SANDOZ-PIOGLITAZONE (SA)
MYLAN-PIOLGLITAZONE (SA)
RATIO-PIOGLITZONE (SA)
CO-PIOGLITAZONE (SA)
APO-PIOGLITAZONE (SA)
PMS-PIOGLITAZONE (SA)
PHL-PIOGLITAZONE (SA)
MINT-PIOGLITAZONE (SA)
PIOGLITAZONE (SA)
JAMP-PIOGLITAZONE (SA)
RAN-PIOGLITAZONE (SA)
AURO-PIOGLITAZONE (SA)
TAK
NOP
SDZ
MYL
RPH
COB
APX
PMS
PHL
MNT
ACH
JPC
RAN
ARO
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
DNQW
ROSIGLITAZONE MALEATE
SEE APPENDIX A FOR SA CRITERIA
2MG TABLET
02241112
AVANDIA (SA)
GSK DNQW
4MG TABLET
02241113
AVANDIA (SA)
GSK DNQW
8MG TABLET
02241114
AVANDIA (SA)
GSK DNQW
ROSIGLITAZONE MALEATE & METFORMIN
SEE APPENDIX A FOR SA CRITERIA
1MG & 500MG TABLET
02247085
AVANDAMET (SA)
GSK DNQW
2MG & 500MG TABLET
02247086
AVANDAMET (SA)
GSK DNQW
4MG & 500MG TABLET
02247087
AVANDAMET (SA)
GSK DNQW
PEI Pharmacare Formulary …………………………………………………Page - 218 -
2MG & 1000MG TABLET
02248440
AVANDAMET (SA)
GSK DNQW
4MG & 1000MG TABLET
02248441
AVANDAMET (SA)
GSK DNQW
*TOLBUTAMIDE
500MG TABLET
00312762
AAA
TOLBUTAMIDE
DNQW
68:20.08 ANTIDIABETIC DRUGS (INSULINS-HUMAN BIOSYNTHETIC)
INSULINE (GLULISINE)
100 UNIT/ML CARTRIDGE
02279479
APIDRA
AVN DNQW
100 UNIT/ML VIAL
02279460
APIDRA
AVN DNQW
100 UNIT/ML PREFILLED PEN
02294346
APIDRA
AVN DNQW
INSULIN (REGULAR) ASPART
100IU/ML INJECTION SOLUTION (10ML)
02245397
NOVORAPID
NNO DNQW
100IU/ML INJECTION SOLUTION (CARTRIDGE)
02244353
NOVORAPID
NNO DNQW
INSULIN (ISOPHANE) HUMAN BIOSYNTHETIC
100U/ML INJECTION SUSPENSION (10ML) (NOT INTERCHANGEABLE)
00587737
HUMULIN-N
LIL
DNQW
02024225
NOVOLIN GE NPH
NNO DNQW
100U/ML INJECTION SUSPENSION (CARTRIDGE) (NOT INTERCHANGEABLE)
02403447
HUMULIN-N CARTRIDGE/KWIKPEN
LIL
DNQW
02024268
NOVOLIN GE NPH PENFILL
NNO DNQW
INSULIN (REGULAR) HUMAN BIOSYNTHETIC
100U/ML INJECTION SOLUTION (10ML) (NOT INTERCHANGEABLE)
00586714
HUMULIN-R
02024233
NOVOLIN GE TORONTO
LIL
DNQW
NNO DNQW
PEI Pharmacare Formulary …………………………………………………Page - 219 -
100U/ML INJECTION SOLUTION (CARTRIDGE) (NOT INTERCHANGEABLE)
01959220
HUMULIN-R CARTRIDGE
LIL
DNQW
02024284
NOVOLIN GE TORONTO PENFILL
NNO DNQW
INSULIN (REGULAR/ISOPHANE) HUMAN BIOSYNTHETIC
100U/ML INJECTION SUSPENSION 30%/70% (10ML) (NOT INTERCHANGEABLE)
00795879
HUMULIN 30/70
LIL
DNQW
02024217
NOVOLIN GE 30/70
NNO DNQW
100U/ML INJECTION SUSPENSION 30%/70% (CARTRIDGE) (NOT INTERCHANGEABLE)
01959212
HUMULIN 30/70 CARTRIDGE
LIL
DNQW
02025248
NOVOLIN GE 30/70 PENFILL
NNO DNQW
100U/ML INJECTION SUSPENSION 40%/60% (CARTRIDGE)
02024314
NOVOLIN GE 40/60 PENFILL
NNO DNQW
100U/ML INJECTION SUSPENSION 50%/50% (CARTRIDGE)
02024322
NOVOLIN GE 50/50 PENFILL
NNO DNQW
INSULIN (REGULAR) LISPRO
100U/ML INJECTION SOLUTION (10ML)
02229704
HUMALOG
LIL
DNQW
100U/ML INJECTION SOLUTION (CARTRIDGE)
02403412
HUMALOG CARTRIDGE / KWIKPEN
LIL
DNQW
INSULIN (REGULAR/PROTAMINE) LISPRO
100U/ML INJECTION SUSPENSION 25%/75% (CARTRIDGE)
02403420
HUMALOG MIX 25 CARTRIDGE / KWIKPEN
LIL
DNQW
DESMOPRESSIN
SEE APPENDIX A FOR SA CRITERIA
10U/DOSE INTRANASAL SOLUTION
00402516
D.D.A.V.P. RHINYLE (SA)
FEI
FNQSW
10U/DOSE INTRANASAL SOLUTION (SPRAY PUMP)
00836362
D.D.A.V.P. (SA)
02242465
DEMOSPRESSIN (SA)
FEI
AAA
FNQSW
FNQSW
68:28.00 PITUITARY AGENTS
0.1MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 220 -
00824305
02284030
02287730
02304368
DDAVP (SA)
APO-DESMOPRESSIN (SA)
NOVO-DESMOPRESSIN (SA)
PMS-DESMOPRESSIN (SA)
FEI
APX
NOP
PMS
FNQSW
FNQSW
FNQSW
FNQSW
0.2MG TABLET
00824143
02284049
02287749
02304376
DDAVP (SA)
APO-DESMOPRESSIN (SA)
NOVO-DESMOPRESSIN (SA)
PMS-DESMOPRESSIN (SA)
FEI
APX
NOP
PMS
FNQSW
FNQSW
FNQSW
FNQSW
60UG ORAL DISINTEGRATING TABLET
02284995
DDAVP MELT (SA)
FEI
FNQSW
120UG ORAL DISINTEGRATING TABLET
02285002
DDVAP MELT (SA)
FEI
FNQSW
240UG ORAL DISINTEGRATING TABLET
02285010
DDVAP MELT (SA)
FEI
FNQSW
SOMATROPIN
5MG/1.5ML CARTRIDGE (NOT INTERCHANGEABLE)
02325063
OMNITROPE
SDZ
G
10MG/1.5ML CARTRIDGE (NOT INTERCHANGEABLE)
02325071
OMNITROPE
SDZ
G
SOMATROPIN
5MG INJECTION (VIAL)
00745626
HUMATROPE (NOT INTERCHANGEABLE)
LIL
G
6MG INJECTION (CARTRIDGE)
02243077
HUMATROPE CARTRIDGE
(NOT INTERCHANGEABLE)
LIL
G
12MG INJECTION (CARTRIDGE)
02243078
HUMATROPE CARTRIDGE
(NOT INTERCHANGEABLE)
LIL
G
24MG INJECTION (CARTRIDGE)
02243079
HUMATROPE CARTRIDGE
(NOT INTERCHANGEABLE)
LIL
G
PEI Pharmacare Formulary …………………………………………………Page - 221 -
68:32.00 PROGESTOGENS
DIENOGEST
SEE APPENDIX A FOR SA CRITERIA
2MG TABLET
02374900
VISANNE (SA)
BAY
*MEDROXYPROGESTERONE ACETATE
2.5MG TABLET
00708917
PROVERA
02221284
NOVO-MEDRONE
02244726
APO-MEDROXY
PFI FNQSW
NOP FNQSW
APX FNQSW
5MG TABLET
00030937
02221292
02244727
PROVERA
NOVO-MEDRONE
APO-MEDROXY
PFI FNQSW
NOP FNQSW
APX FNQSW
10MG TABLET
00729973
02221306
02277298
PROVERA
NOVO-MEDRONE
APO-MEDROXY
PFI FNQSW
NOP FNQSW
APX FNQSW
MEDROXYPROGESTERONE ACETATE
150MG/ML INJECTION SUSPENSION (1ML)
00585092
DEPO-PROVERA
02322250
MEDROXYPROGESTERONE ACETATE
FQW
PFI
SDZ
FQW
FQW
*LEVOTHYROXINE SODIUM
0.025MG TABLET
02172062
SYNTHROID
ABB
FNQSW
0.05MG TABLET (NOT INTERCHANGEABLE)
02172070
SYNTHROID
02213192
ELTROXIN
ABB
TRI
FNQSW
FNQSW
0.075MG TABLET
02172089
SYNTHROID
ABB
FNQSW
68:36.04 THYROID AGENTS
0.088MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 222 -
02172097
SYNTHROID
ABB
FNQSW
0.1MG TABLET (NOT INTERCHANGEABLE)
02172100
SYNTHROID
02213206
ELTROXIN
ABB FNQSW
GSK FNQSW
0.112MG TABLET
02171228
SYNTHROID
ABB
FNQSW
0.125MG TABLET
02172119
SYNTHROID
ABB
FNQSW
0.137MG TABLET
02233852
SYNTHROID
ABB
FNQSW
0.15MG TABLET (NOT INTERCHANGEABLE)
02172127
SYNTHROID
02213214
ELTROXIN
ABB FNQSW
GSK FNQSW
0.175MG TABLET
02172135
SYNTHROID
ABB
0.2MG TABLET (NOT INTERCHANGEABLE)
02172143
SYNTHROID
02213222
ELTROXIN
ABB FNQSW
GSK FNQSW
0.3MG TABLET (NOT INTERCHANGEABLE)
02172151
SYNTHROID
02213230
ELTROXIN
ABB FNQSW
GSK FNQSW
FNQSW
68:36.08 ANTI-THYROID AGENTS
*METHIMAZOLE
5MG TABLET
00015741
TAPAZOLE
PAL
FNQSW
10MG TABLET
02296039
TAPAZOLE
PAL
FNQSW
PAL
FNQSW
*PROPYLTHIOURACIL
50MG TABLET
00010200
PROPYL THYRACIL
100MG TABLET
PEI Pharmacare Formulary …………………………………………………Page - 223 -
PAL
FNQSW
LIDOCAINE HCL
1% INJECTION SOLUTION
00001732
XYLOCAINE
AZE
NQ
2% INJECTION SOLUTION
00036641
XYLOCAINE
AZE
NQ
TAL
R
00010219
PROPYL THYRACIL
72:00.00 LOCAL ANESTHETICS
80:04.00 SERUMS
RABIES IMMUNE GLOBULIN (PASTURIZED, HUMAN)
150U/ML INJECTION SOLUTION (2ML)
02230700
HYPERRAB
80:08.00 TOXOIDS
PERTUSIS ANTIGEN AND TOXOID
INJECTION SUSPENSION (0.5ML)
02247600
BOOSTRIX
GSK I
TETANUS - DIPHTHERIA TOXOID (ADSORBED) (DT)
INJECTION SOLUTION (5 X 0.5ML)
00514462
Td ADSORBED
AVP
I
80:12.00 VACCINES
DIPHTHERIA - TETANUS TOXOIDS - POLIOMYLETIS VACCINE (INACTIVATED,
ADSORBED) (TD POLIO)
INJECTION SOLUTION (5 X 0.5ML)
00615358
Td POLIO ADSORBED
AVP I
DIPHTHERIA - TETANUS TOXOIDS - PERTUSSIS (ACELLULAR) - POLIOMYELITIS
VACCINE (INACTIVATED) (DPT POLIO)
INJECTION SOLUTION (5 X 0.5ML)
02230946
QUADRACEL
AVP I
PEI Pharmacare Formulary …………………………………………………Page - 224 -
DIPHTHERIA - TETANUS TOXOIDS - PERTUSSIS (ACELLULAR) VACCINE POLIOMYELITIS VACCINE (INACTIVATED) - HAEMOPHILUS B CONJUGATE
INJECTION SOLUTION (5 X 0.5ML)
02243167
PEDIACEL
AVP I
HAEMOPHILUS B CONJUGATE VACCINE (PRP-T)
INJECTION SOLUTION (5 X 1 DOSE)
01959034
ACT-HIB
AVP
HEPATITIS A VACCINE (INACTIVATED)
720 ELISA UNITS PRE-FILLED SYRINGE (0.5ML)
02231056
HAVRIX JUNIOR
GSK H
1440 ELISA UNITS PRE-FILLED SYRINGE (1.0ML)
02187078
HAVRIX
GSK H
1440 ELISA UNITS (VIAL) (1.0ML)
02187078
HAVRIX
GSK H
50U/1.0ML VIAL (ADULT)I/M SUSPENSION
02229702
VAQTA
MSD H
25U/0.5ML (PED)1/M SUSPENSION
02229702
VAQTA
MSD H
I
HEPATITIS A (INACTIVATED) - HEPATITIS B (RECOMBINANT) VACCINE
360 ELISA UNITS & 10MCG PRE-FILLED SYRINGE (0.5ML)
02237548
TWINRIX JUNIOR
GSK H
720 ELISA UNITS & 20MCG PRE-FILLED SYRINGE (1.0ML)
02230578
TWINRIX
HEPATITIS B VACCINE (RECOMBINANT)
5MCG/0.5ML STERILE SUSPENSION
02243676
RECOMBIVAX HB PEDIATRIC
(PRESERVATIVE FREE)
10MCG/1ML SOLUTION (I/M)
02243676
RECOMBIVAX HB
(PRESERVATIVE FREE)
20MCG/ML STERILE SUSPENSION
01919431
ENGERIX-B
GSK H
MSD HI
MSD HI
GSK HI
PEI Pharmacare Formulary …………………………………………………Page - 225 -
40MCG/ML STERILE SUSPENSION (1ML)
02245977
RECOMBIVAX HB (DIALYSIS)
(PRESERVATIVE FREE)
MSD H
INFLUENZA, ADULT
0.5ML INJECTION SUSPENSION
02015986
FLUVIRAL (ADULT FLU VACCINE)
GSK I
INFLUENZA, PEDIATRIC
0.5ML INJECTION SUSPENSION
02223929
VAXIGRIP (PEDIATRIC FLU VACCINE)
AVP I
MEASLES - MUMPS - RUBELLA VIRUS VACCINE (LIVE, ATTENUATED)
INJECTION SOLUTION (10 X 0.5ML)
00466085
MMR II
MSD I
02239208
PRIORIX
GSK I
INJECTION POWDER FOR SOLUTION
02297884
PRIORIX-TETRA
GSK I
MENINGOCOCCAL VACCINE
INJECTION SOLUTION
01959018
MENOMUNE-A/C/Y/W-135
AVP
I
0.5ML SOLUTION
02279924
MENACTRA
AVP
I
MENINGOCOCCAL “C” VACCINE
25UG/0.5ML POWDER FOR SUSPENSION (I/M)
02243820
MENJUGATE
NVR I
PAPILLOMAVIRUS, QUADRIVALENT (HUMAN RECOMBINANT) VACCINE
INJECTION SOLUTION (0.5 ML)
02283190
GARDASIL
MSD I
PNEUMOCOCCAL -10
0.5ML/DOSE SUSPENSION (I/M)
02335204
PREVNAR
PFI
PNEUMOCOCCAL - 23
25UG/0.5ML SOLUTION (I/M OR SUBCUTANEOUS)
00431648
PNEUMOVAX 23
MSD I
I
PEI Pharmacare Formulary …………………………………………………Page - 226 -
POLIOMYELITIS VACCINE, TRIVALENT (INACTIVATED WHOLE VIRUS) VACCINE
INJECTION SOLUTION (0.5ML)
01959042
IMOVAX POLIO
AVP I
RABIES VACCINE
2.5IU/VIAL INJECTION POWDER
01908286
IMOVAX
AVP
2.5IU/1ML DOSE POWDER FOR SOLUTION (I/M)
02267667
RABAVERT
NVR R
ROTARIX VACCINE, LIVE, ORAL
POWDER FOR SUSPENSION
02300591
ROTARIX
GSK I
VARICELLA VIRUS VACCINE
2000 UNIT/0.5ML POWDER FOR SULTION (SUBCUTANEOUS)
02241047
VARILIX
GSK I
R
84:04.04 ANTI INFECTIVES (ANTIBIOTICS)
CLINDAMYCIN PHOSPHATE
1% TOPICAL SOLUTION
00582301
DALACIN T
02266938
TARO-CLINDAMYCIN
PFI
TAR
FQW
FQW
FRAMYCETIN SULFATE
1% OINTMENT DRESSING (10CM X 10CM)
01988840
SOFRA TULLE
ERF
FNQSW
FUSIDIC ACID
2% TOPICAL CREAM
00586668
FUCIDIN
LEO FNQSW
MUPIROCIN
2% TOPICAL CREAM
02239757
BACTROBAN
GSK FNQSW
2% TOPICAL OINTMENT
01916947
BACTROBAN
02279983
TARO-MUPIROCIN
GCH FNQSW
TAR FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 227 -
POLYMYXIN B & BACITRACIN
10,000U & 500U/G TOPICAL OINTMENT
02237227
POLYSPORIN
JJM
N
POLYMYXIN B & GRAMICIDIN
10,000U & 250U/G TOPICAL CREAM
02230844
POLYSPORIN
JJM
N
POLYMYXIN B & NEOMYCIN & BACITRACIN
5,000U & 5MG & 400U/G TOPICAL OINTMENT
00666122
NEOSPORIN
GSK FNQSW
SODIUM FUSIDATE
2% TOPICAL OINTMENT
00586676
FUCIDIN
LEO FNQSW
84:04.06 ANTI INFECTIVES (ANTIVIRALS)
ACYCLOVIR
5% TOPICAL CREAM
02039524
ZOVIRAX
VAL
FNQSW
5% TOPICAL OINTMENT
00569771
ZOVIRAX
VAL
FNQSW
IDOXURIDINE
0.1% TOPICAL SOLUTION
02237187
SANDOZ IDOXURIDINE
SDZ
FNQSW
CICLOPIROX OLAMINE
1% TOPICAL CREAM
02221802
LOPROX
VAL
FNQSW
1% TOPICAL LOTION
02221810
LOPROX
VAL
FNSQW
CLOTRIMAZOLE
1% TOPICAL CREAM
00812382
CLOTRIMADERM
02150867
CANESTEN
TAR
BAY
NSW
NSW
84:04.08 ANTI INFECTIVES (FUNGICIDES)
PEI Pharmacare Formulary …………………………………………………Page - 228 -
1% VAGINAL CREAM
00812366
CLOTRIMADERM
02150891
CANESTEN 6
TAR
BAY
NSW
NSW
2% VAGINAL CREAM
00812374
CLOTRIMADERM
02150905
CANESTEN 3
TAR
BAY
NSW
NSW
KETOCONAZOLE
2% TOPICAL CREAM
02245662
KETODERM
TAR
FNQSW
2% SHAMPOO
02182920
JJM
N
NIZORAL
MICONAZOLE NITRATE
2% TOPICAL CREAM
02085852
MICATIN
02126567
MONISTAT DERM
WES NSW
JJM NSW
2% VAGINAL CREAM
02084309
MONISTAT-7
02231106
MICOZOLE
JJM
TAR
NSW
NSW
400MG VAGINAL OVULE
02126605
MONISTAT-3
JJM
NSW
100MG VAGINAL SUPPOSITORY & 2% TOPICAL CREAM (COMBINATION PACKAGE)
02126257
MONISTAT-7
JJM NSW
400MG VAGINAL OVULE & 2% TOPICAL CREAM (COMBINATION PACKAGE)
02126249
MONISTAT-3 COMBINATION
JJM NSW
NYSTATIN
100,000U/G TOPICAL CREAM
00716871
NYDERM
02194236
RATIO-NYSTATIN
TAR NSW
RPH NSW
100,000U/G TOPICAL OINTMENT
02194228
RATIO-NYSTATIN
RPH NSW
25,000U/G VAGINAL CREAM
00716901
NYADERM
TAR
NSW
PEI Pharmacare Formulary …………………………………………………Page - 229 -
100,000U/G VAGINAL CREAM
02194163
RATIO-NYSTATIN
RPH NSW
TERBINAFINE HCL
SEE APPENDIX A FOR SA CRITERIA
1% TOPICAL CREAM
02031094
LAMISIL (SA)
NVR FNQSW
TOLNAFTATE
1% TOPICAL CREAM
00576034
TINACTIN
SCH NW
1% TOPICAL POWDER
00576042
TINACTIN
SCH N
84:04.12 ANTI-INFECTIVES, SCABICIDES, AND PEDICULICIDES
ISOPROPYL MYRISTATE
50% TOPICAL LIQUID
02279592
RESULTZ
MFI
PERMETHRIN
1% CREME RINSE
00771368
NIX CREME RINSE
02231480
KWELLADA-P CREME RINSE
GSK NW
GSK NW
5% TOPICAL CREAM
02219905
NIX DERMAL CREAM
GSK NW
5% TOPICAL LOTION
02231348
KWELLADA-P LOTION
GSK NW
CNW
84:04.16 ANTI INFECTIVES, OTHER ANTI INFECTIVES
HEXACHLOROPHENE
3% TOPICAL EMULSION
02017733
PHISOHEX
AVN FQW
METRONIDAZOLE
1% TOPICAL GEL
02297809
METROGEL
GAC FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 230 -
0.75% TOPICAL CREAM
02226839
METROCREAM
GAC FNQSW
0.75% TOPICAL LOTION
02248206
METROLOTION
GAC FNQSW
10% VAGINAL CREAM
01926861
FLAGYL
AVN FNQSW
METRONIDAZOLE & NYSTATIN
500MG & 100,000U/APPLICATORFUL VAGINAL CREAM
01926845
FLAGYSTATIN
AVN FNQSW
SILVER SULFADIAZINE
1% TOPICAL CREAM
00323098
FLAMAZINE
SNE FNQSW
TRICLOSAN
0.5% TOPICAL LIQUID
00632317
TERSASEPTIC
GSK NW
PEI Pharmacare Formulary …………………………………………………Page - 231 -
84:06.00 ANTI INFLAMMATORY AGENTS
APPROXIMATE RELATIVE POTENCIES OF TOPICAL STEROID PREPARATIONS
ULTRA HIGH POTENCY
GROUP N
Betamethasone dipropionate 0.05% glycol cream, ointment, lotion
Betamethasone dipropionate 0.05% & Salicylic Acid 3%, ointment
Clobetasol propionate 0.05% cream, ointment, scalp lotion
HIGH POTENCY
GROUP II
Amcinonide 0.1% ointment
Betamethasone dipropionate 0.05% ointment
Clobetasone butyrate 0.05% cream, ointment
Desoximetasone 0.25% cream, ointment
Desoximetasone 0.05% gel
Fluocinonide 0.05% cream, ointment, gel
GROUP III
Betamethasone dipropionate 0.05% cream, lotion
Betamethasone valerate 0.1% ointment
Diflucortolone valerate 0.1% oily cream
Triamcinolone acetonide 0.1% ointment
MID POTENCY
GROUP IV
Amcinonide 0.1% cream, lotion
Beclomethasone dipropionate 0.025% cream, lotion (lotion d/c=d)
Flucinolone acetonide 0.025% ointment
Desoximetasone 0.05% cream
Mometasone furoate 0.1% cream, ointment
Triamcinolone acetonide 0.1% cream
GROUP V
Betamethasone valerate 0.1% cream, lotion, scalp lotion
Betamethasone valerate 0.05% cream, ointment, lotion
Flucinolone acetonide 0.025% cream
Flucinolone acetonide 0.01% cream
Triamcinolone acetonide 0.25% cream
LOW POTENCY
GROUP VI
Desonide 0.05% cream, ointment
PEI Pharmacare Formulary …………………………………………………Page - 232 -
GROUP VII
Hydrocortisone 0.05% cream, ointment, lotion
Hydrocortisone 1% cream, ointment, lotion
Hydrocortison 1% & Urea 10% cream, lotion
The classification of products in this table is based upon the >WHO Model Prescribing
Information: Drugs Used in Dermatology (1995).=
In general, ointments, as a result of their more occlusive property, tend to exhibit higher
potency than creams containing the same concentration of the same anti-inflammatory agent.
Cream formulations, in turn, appear to be more potent than lotions of the same strength.
AMCINONIDE
0.1% TOPICAL CREAM
02246714
TARO-AMCINONIDE
02247098
RATIO-AMCINONIDE
TAR FNQSW
RPH FNQSW
0.1% TOPICAL LOTION
02192276
CYCLOCORT
02247097
RATIO-AMCINONIDE
GSK FNQSW
RPH FNQSW
0.1% TOPICAL OINTMENT
02247096
RATIO-AMCINONIDE
RPH FNQSW
BECLOMETHASONE DIPROPIONATE
0.025% TOPICAL CREAM
02089602
PROPADERM
PAL
BETAMETHASONE DIPROPIONATE
0.05% TOPICAL CREAM
00323071
DIPROSONE
01925350
TARO-SONE
MSD FNQSW
TAR FNQSW
0.05% TOPICAL LOTION
00417246
DIPROSONE
00809187
RATIO-TOPISONE
MSD FNQSW
RPH FNQSW
0.05% TOPICAL OINTMENT
00344923
DIPROSONE
00805009
RATIO-TOPISONE
MSD FNQSW
RPH FNQSW
0.05% TOPICAL GLYCOL BASE CREAM
00688622
DIPROLENE
00849650
RATIO-TOPILENE GLYCOL
MSD FNQSW
RPH FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 233 -
0.05% TOPICAL GLYCOL BASE OINTMENT
00629367
DIPROLENE
00849669
RATIO-TOPILENE GLYCOL
MSD FNQSW
RPH FNQSW
0.05% TOPICAL GLYCOL LOTION
00862975
DIPROLENE
01927914
RATIO-TOPILENE
MSD FNQSW
RPH FNQSW
BETAMETHASONE DIPROPIONATE & CALCIPOTRIOL
50MCG/0.5MG/GM TOPICAL GEL
SEE APPENDIX A FOR SA CRITERIA
02319012
DOVOBET (SA)
LEO FNQSW
BETAMETHASONE DIPROPIONATE & SALICYLIC ACID
0.05% & 2% TOPICAL LOTION
00578428
DIPROSALIC
02245688
RATIO-TOPISALIC
MSD FNQSW
RPH FNQSW
0.05% & 3% TOPICAL OINTMENT
00578436
DIPROSALIC
MSD FNQSW
BETAMETHASONE VALERATE
0.05% TOPICAL CREAM
00535427
RATIO-ECTOSONE
00716618
BETADERM
RPH FNQSW
TAR FNQSW
0.1% TOPICAL CREAM
00535435
RATIO-ECTOSONE
00716626
BETADERM
RPH FNQSW
TAR FNQSW
0.05% TOPICAL OINTMENT
00716642
BETADERM
TAR
FNQSW
0.1% TOPICAL OINTMENT
00716650
BETADERM
TAR
FNQSW
0.05% TOPICAL LOTION
00653209
RATIO-ECTOSONE
RPH FNQSW
0.1% TOPICAL LOTION
00750050
RATIO-ECTOSONE
RPH FNQSW
0.1% SCALP LOTION
00653217
RATIO-ECTOSONE
00716634
BETADERM
RPH FNQSW
TAR FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 234 -
CLOBETASOL 17 PROPIONATE
0.05% TOPICAL CREAM
01910272
RATIO-CLOBETASOL
02024187
MYLAN-CLOBETASOL
02093162
NOVO-CLOBETASOL
02213265
DERMOVATE
02245523
TARO-CLOBETASOL
02309521
PMS-CLOBETASOL
RPH
MYL
NOP
TAR
TAR
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
0.05% TOPICAL OINTMENT
01910280
RATIO-CLOBETASOL
02026767
MYLAN-CLOBETASOL
02126192
NOVO-CLOBETASOL
02213273
DERMOVATE
02232193
PMS-CLOBETASOL
02245524
TARO-CLOBETASOL
02309548
PMS-CLOBETASOL
RPH
MYL
NOP
TAR
PMS
TAR
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
0.05% SCALP LOTION
01910299
RATIO-CLOBETASOL
02213281
DERMOVATE
02216213
MYLAN-CLOBETASOL
02232195
PMS-CLOBETASOL
02245522
TARO-CLOBETASOL
RPH
TAR
MYL
PMS
TAR
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
CLOBETASONE BUTYRATE
0.05% TOPICAL CREAM
02214415
SPECTRO ECZEMA CARE
GSK FNQSW
DESONIDE
0.05% TOPICAL CREAM
02229315
PMS-DESONIDE
PMS FNQSW
0.05% TOPICAL OINTMENT
02229323
PMS-DESONIDE
PMS FNQSW
DESOXIMETASONE
0.05% TOPICAL EMOLLIENT CREAM
02221918
TOPICORT MILD
VAL
FNQSW
0.25% TOPICAL EMOLLIENT CREAM
02221896
TOPICORT
VAL
FNQSW
0.05% TOPICAL GEL
02221926
TOPICORT
VAL
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 235 -
0.25% TOPICAL OINTMENT
02221934
TOPICORT
VAL
DIFLUCORTOLONE VALERATE
0.1% TOPICAL OILY CREAM
00587818
NERISONE OILY
GSK FNQSW
FLUOCINONIDE
0.05% TOPICAL CREAM
00716863
LYDERM
02161923
LIDEX
TAR FNQSW
VLO FNQSW
0.05% TOPICAL GEL
02161974
LIDEX
02236997
LYDERM
VLO FNQSW
TAR FNQSW
0.05% TOPICAL OINTMENT
02161966
LIDEX
02236996
LYDERM
VLO FNQSW
TAR FNQSW
HYDROCORTISONE
0.5% TOPICAL CREAM
00716820
HYDERM
TAR
NW
1% TOPICAL CREAM
00716839
HYDERM
TAR
FNQSW
1% TOPICAL OINTMENT
00716693
CORTODERM
TAR
FNQSW
HYDROCORTISONE & UREA
1% & 10% TOPICAL CREAM
00503134
UREMOL HC
GSK FNQSW
1% & 10% TOPICAL LOTION
00560022
UREMOL HC
GSK FNQSW
HYDROCORTISONE & ZINC SULFATE
0.5% & 0.5% RECTAL OINTMENT
00505773
ANUSOL-HC
00607789
RATIO-HEMCORT-HC
MCL FNQSW
RPH FNQSW
0.5% & 0.5% RECTAL SUPPOSITORY
00476285
ANUSOL-HC
00607797
RATIO-HEMCORT-HC
MCL FNQSW
RPH FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 236 -
MOMETASONE FUROATE
0.1% TOPICAL CREAM
00851744
ELOCOM
02367157
TARO-MOMETASONE
MSD FNQSW
TAR FNQSW
0.1% TOPICAL OINTMENT
00851736
ELOCOM
02248130
RATIO-MOMETASONE
MSD FNQSW
RPH FNQSW
TRIAMCINOLONE ACETONIDE
0.1% TOPICAL CREAM
00716960
TRIADERM
02194058
ARISTOCORT R
TAR FNQSW
VLO FNQSW
0.1% TOPICAL OINTMENT
02194031
ARISTOCORT R
VLO FNQSW
0.1% ORAL TOPICAL OINTMENT
01964054
ORACORT
TAR
FNQSW
CLIOQUINOL & HYDROCORTISONE
3% & 1% TOPICAL CREAM
00074500
VIOFORM HYDROCORTISONE
PAL
FNQSW
HYDROCORTISONE & FRAMYCETIN & CINCHOCAINE HCL
1% & 0.5% RECTAL OINTMENT
02226383
RATIO-PROCTOSONE
02223252
PROCTOSEDYL
02242527
SANDOZ-PROCTOMYXINHC
02247322
PROCTOL
RPH
AXC
SDZ
ODN
FNQSW
FNQSW
FNQSW
FNQSW
1% & 0.5% RECTAL SUPPOSITORY
02223260
PROCTOSEDYL
02226391
RATIO-PROCTOSONE
02242528
SANDOZ-PROCTOMYXINHC
02247882
PROCTOL
AXC
RPH
SDZ
ODN
FNQSW
FNQSW
FNQSW
FNQSW
TRIAMCINOLONE & NYSTATIN & NEOMYCIN & GRAMICIDIN
2.5MG & 0.25MG & 100,000U & 1MG/G TOPICAL CREAM
00717002
VIADERM K C
TAR
FNQSW
2.5MG & 0.25MG & 100,000U & 1MG/G TOPICAL OINTMENT
00717029
VIADERM K C
TAR
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 237 -
84:08.00 ANTIPRURITICS AND TOPICAL ANESTHETICS
CALAMINE
TOPICAL LOTION
00999829
CALAMINE LOTION
Note: The Drug Identification Number listed is for billing purposes only.
N
LIDOCAINE HCL
2% TOPICAL GEL
00001694
XYLOCAINE
AZE
FNQSW
2% TOPICAL SOLUTION
00001686
XYLOCAINE VISCOUS
AZE
FNQSW
2% TOPICAL JELLY (SYRINGE)
00385484
XYLOCAINE
AZE
NQ
84:16.00 CELL STIMULANTS AND PROLIFERANTS
TRETINOIN
0.01% TOPICAL CREAM
00657204
STIEVA-A
GSK FQW
0.025% TOPICAL CREAM
00578576
STIEVA-A
GSK FQW
0.05% TOPICAL CREAM
00443794
RETIN A
00518182
STIEVA-A
VAL FQW
GSK FQW
0.1% TOPICAL CREAM
00662348
STIEVA-A FORTE
00870021
RETIN A
GSK FQW
VAL FQW
0.01% TOPICAL GEL
00870013
RETIN A
VAL
0.025% TOPICAL GEL
00443816
RETIN A
00587966
STIEVA-A
01926470
VITAMIN A ACID
VAL FQW
GSK FQW
VAL FQW
FQW
PEI Pharmacare Formulary …………………………………………………Page - 238 -
0.05% TOPICAL GEL
00641863
STIEVA-A
01926489
VITAMIN A ACID
GSK FQW
VAL FQW
84:24.00 EMOLLIENTS, DECMULCENTS, AND PROTECTANTS
DIMETHYLPOLYSILOXANE
20% TOPICAL CREAM
02060841
BARRIERE
WES NW
84:28.00 KERATOLYTIC AGENTS
UREA
10% TOPICAL CREAM
01946099
UREMOL 10
TCD NW
20% TOPICAL CREAM
00398179
UREMOL 20
TCD NW
10% TOPICAL LOTION
01946102
UREMOL 10
TCD NW
84:32.00 KERATOPLASTIC AGENTS
COAL TAR
1% TOPICAL SHAMPOO
02307146
T/GEL THERAPEUTIC
JJM
NW
84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
ACITRETIN
SEE APPENDIX A FOR SA CRITERIA
10MG CAPSULE
02070847
SORIATANE (SA)
HLR
FNQSW
25MG CAPSULE
02070863
HLR
FNQSW
SORIATANE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 239 -
AZELAIC ACID
15% TOPICAL GEL
02270811
FINACEA
BAY
CALCIPOTRIOL
50UG/G TOPICAL CREAM
02150956
DOVONEX
LEO FNQSW
50UG/G TOPICAL OINTMENT
01976133
DOVONEX
LEO FNQSW
50UG/ML SCALP SOLUTION
02194341
DOVONEX
LEO FNQSW
FLUOROURACIL
5% TOPICAL CREAM
00330582
EFUDEX
VAL
FNQSW
IMIQUIMOD
5% TOPICAL CREAM
02239505
ALDARA
02408725
APO-IMIQUIMOD
VAL
APX
FNQSW
FNQSW
ISOTRETINOIN
10MG CAPSULE
00582344
02257955
ACCUTANE
CLARUS
HLR FQW
MYL FQW
40MG CAPSULE
00582352
02257963
ACCUTANE
CLARUS
HLR FQW
MYL FQW
FNQSW
PODOPHYLLUM RESIN
25% TOPICAL LIQUID
00598208
PODOFILM
PAL
FQW
TACROLIMUS
SEE APPENDIX A FOR SA CRITERIA
0.1% OINTMENT
02244148
PROTOPIC (SA)
AST
FNQSW
SEE APPENDIX A FOR SA CRITERIA
0.03% TOPICAL OINTMENT
02244149
PROTOPIC (SA)
AST
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 240 -
86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
DARIFENACIN
SEE APPENDIX A FOR SA CRITERIA
7.5MG EXTENDED RELEASE TABLET
02273217
ENABLEX (SA)
MRS FNQSW
15MG EXTENDED RELEASE TABLET
02273225
ENABLEX (SA)
MRS FNQSW
FESOTERODINE FUMARATE
SEE APPENDIX A FOR SA CRITERIA
4MG EXTENDED RELEASE TABLET
02380021
TOVIAZ (SA)
PFI
FNQSW
8MG EXTENDED RELEASE TABLET
02380048
TOVIAZ (SA)
PFI
FNQSW
OXYBUTYNIN CHLORIDE
1MG/ML SYRUP
02223376
PMS-OXYBUTYNIN
PMS FNQSW
5MG TABLET
02163543
02230394
02230800
02240550
02350238
APX
NOP
MYL
PMS
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
5MG EXTENDED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02243960
DITROPAN XL (SA)
JAN
FNQSW
10MG EXTENDED RELEASE TABLET
SEE APPENDIX A FOR SA CRITERIA
02243961
DITROPAN XL (SA)
JAN
FNQSW
SOLIFENACIN
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02277263
VESICARE (SA)
AST
FNQSW
10MG TABLET
02277271
AST
FNQSW
APO-OXYBUTYNIN
NOVO-OXYBUTYNIN
MYLAN-OXYBUTYNIN
PMS-OXYBUTYNIN
OXYBUTYNIN
VESICARE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 241 -
TOLTERODINE
SEE APPENDIX A FOR SA CRITERIA
1MG TABLET
02239064
DETROL (SA)
PFI
FNQSW
2MG TABLET
02239065
PFI
FNQSW
2MG EXTENDED RELEASE CAPSULE
02244612
DETROL LA (SA)
PFI
FNQSW
4MG EXTENDED RELEASE CAPSULE
02244613
DETROL LA (SA)
PFI
FNQSW
TROSPIUM – REVISED SA CRITERIA
SEE APPENDIX A FOR SA CRITERIA
20MG TABLET
02275066
TROSEC (SA)
ORX FNQSW
DETROL (SA)
86:16.00 RESPIRATORY SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE
225MG SUSTAINED RELEASE TABLET
02014270
PHYLLOCONTIN
PFR
FNQSW
350MG SUSTAINED RELEASE TABLET
02014289
PHYLLOCONTIN-350
PFR
FNQSW
OXYTRIPHYLLINE
20MG/ML ELIXIR
00476366
CHOLEDYL
ERF
FQSW
THEOPHYLLINE ANHYDROUS
100MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
00692689
APO-THEO-LA
02230085
NOVO-THEOPHYL SR
APX FNQSW
NOP FNQSW
200MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
00692697
APO-THEO-LA
02230086
TEVA-THEOPHYL SR
APX
TEV
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 242 -
300MG SUSTAINED RELEASE TABLET (NOT INTERCHANGEABLE)
00692700
APO-THEO-LA
02230087
NOVO-THEOPHYL SR
APX FNQSW
NOP FNQSW
400MG SUSTAINED RELEASE TABLET
02014165
UNIPHYL
02360101
THEO ER
PFR
AAA
FNQSW
FNQSW
600MG SUSTAINED RELEASE TABLET
02014181
UNIPHYL
02360128
THEO ER
PFR
AAA
FNQSW
FNQSW
5.33MG/ML ORAL SOLUTION
01966219
THEOLAIR
VAL
FNQSW
SDZ
CYT
NW
NW
88:08.00 VITAMIN B
CYANOCOBALAMIN
1MG/ML INJECTION SOLUTION (10ML)
00521515
VITAMIN B12
01987003
CYANOCOBALAMIN
FOLIC ACID
1MG TABLET
00999899
FOLIC ACID
Note: The Drug Identification Number listed is for billing purposes only.
5MG TABLET
00426849
APO-FOLIC
OW
APX
NIACIN
100MG TABLET
00999879
NIACIN
Note: The Drug Identification Number listed is for billing purposes only.
NW
500MG TABLET
00999889
NIACIN
Note: The Drug Identification Number listed is for billing purposes only.
PYRIDOXINE
25 MG Tablet
00268607
VITAMIN B6
FNQW
NW
VAL
OX
PEI Pharmacare Formulary …………………………………………………Page - 243 -
01943200
01225645
VIATMIN B6
VITAMIN B6
ODN OX
JAM OX
88:12.00 VITAMIN C
ASCORBIC ACID (VITAMIN C)
500MG TABLET
00999970
ASCORBIC ACID
Note: The Drug Identification Number listed is for billing purposes only.
NW
88:16.00 VITAMIN D
CALCITRIOL
0.25UG CAPSULE
00481823
ROCALTROL
HLR
FNQSW
0.5UG CAPSULE
00481815
HLR
FNQSW
ROCALTROL
VITAMIN D
1000IU TABLET
00999869
VITAMIN D
Note: The Drug Identification Number listed is for billing purposes only.
VITAMIN D2
50,000IU CAPSULE
02237450
D-FORTE
N
EUR FNQSW
88:20.00 VITAMIN E
VITAMIN E (D-ALPHA TOCOPHERYL ACETATE)
200UNIT CAPSULE
00999849
VITAMIN E
Note: The Drug Identification Number listed is for billing purposes only.
400UNIT CAPSULE
00999859
VITAMIN E
Note: The Drug Identification Number listed is for billing purposes only.
CN
CN
PEI Pharmacare Formulary …………………………………………………Page - 244 -
88:24.00 VITAMIN K ACTIVITY
PHYTONADIONE (VITAMIN K1)
10MG/ML INJECTION SOLUTION (1ML)
00804312
VITAMIN K1
SDZ
NQ
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS – PEDIATRIC CHEWABLE TABLET
02031388
ADEKS
AXC C
92:00.00 MISCELLANEOUS THERAPEUTIC AGENTS
ETHINY ESTRADIOL & CYPROTERONE
0.035MG & 2MG TABLET
02233542
DIANE-35
02290308
CYESTRA-35
02309556
NOVO-CYPROTERONE/ETHINYL ESTRADIOL
BAY
PAL
BAY
ETIDRONATE DISODIUM
SEE APPENDIX A FOR SA CRITERIA
200MG TABLET
02245330
MYLAN-ETIDRONATE (SA)
02248686
CO ETIDRONATE (SA)
MYL FNQSW
COB FNQSW
ETIDRONATE DISODIUM & CALCIUM CARBONATE
400MG & 500MG TABLET (PACKAGE)
02247323
MYLAN-ETI-CAL CARE PAC
02263866
CO-ETIDROCAL
02324199
NOVO-ETDRONATECAL
02353210
ETRIDOCAL
MYL
COB
NOP
SNS
FINGOLIMOD
SEE APPENDIX A FOR CRITERIA
0.5MG CAPSULE
02365480
GILENYA (SA)
NVR MQ
FQW
FQW
FQW
FNQSW
FNQSW
FNQSW
FNQSW
GLATIRAMER ACETATE
SEE APPENDIX A FOR SA CRITERIA
PEI Pharmacare Formulary …………………………………………………Page - 245 -
20MG PRE-FILLED SYRINGE
02245619
COPAXONE (SA)
TVM MQ
GLUCAGON (RECOMBINANT DNA ORIGIN) (NOT INTERCHANGEABLE)
SEE APPENDIX A FOR SA CRITERIA (NURSING HOME PROGRAM DOES NOT REQUIRE
A SPECIAL AUTHORIZATION REQUEST.)
INJECTION KIT
02243297
GLUCAGON KIT (SA)
LIL
NQW
GLUCAGON (HUMAN RECOMBINANT) (NOT INTERCHANGEABLE)
SEE APPENDIX A FOR SA CRITERIA
INJECTION VIAL
02333619
GLUCAGEN VIAL (SA)
PAL
QW
INJECTION KIT
02333627
PAL
QW
INFLIXIMAB
SEE APPENDIX A FOR SA CRITERIA
100MG/VIAL INJECTION
02244016
REMICADE (SA)
JAN
MQ
INTERFERON BETA-1A
SEE APPENDIX A FOR SA CRITERIA
30MCG INJECTION POWDER
02269201
AVONEX (SA)
BGN MQ
30MCG PREFILLED SYRINGE, 30MCG PEN WITH AUTO-INJECTOR
02269201
AVONEX PS (SA)
BGN MQ
22MCG SYRINGE
02237319
REBIF (SA)
SRO MQ
44MCG SYRINGE
02237320
REBIF (SA)
SRO MQ
66MCG/1.5ML PRE-FILLED CARTRIDGE
02318253
REBIF MULTIDOSE (SA)
SRO MQ
132MCG/1.5ML PRE-FILLED CARTRIDGE
02318261
REBIF MULTIDOSE (SA)
SRO MQ
GLUCAGEN KIT (SA)
INTERFERON BETA-1B
SEE APPENDIX A FOR SA CRITERIA
0.3MG INJECTION POWDER
PEI Pharmacare Formulary …………………………………………………Page - 246 -
02169649
02337819
BETASERON (SA) (NOT INTERCHANGEABLE)
EXTAVIA (SA) (NOT INTERCHANGEABLE)
BAY MQ
NVR MQ
LEFLUNOMIDE
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02241888
ARAVA (SA)
02256495
APO-LEFLUNOMIDE (SA)
02261251
NOVO-LEFLUNOMIDE (SA)
02283964
SANDOZ-LEFLUOMIDE (SA)
02288265
PMS-LEFLUNOMIDE (SA)
02319225
MYLAN-LEFLUNOMIDE (SA)
02351668
LEFLUNOMIDE (SA)
AVN
APX
NOP
SDZ
PMS
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
20MG TABLET
02241889
02256509
02261278
02283972
02288273
02319233
02351676
AVN
APX
NOP
SDZ
PMS
MYL
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
MONTELUKAST
SEE APPENDIX A FOR SA CRITERIA
4MG CHEWABLE TABLET
02243602
SINGULAIR (SA)
02330385
SANDOZ-MONTELUKAST (SA)
02354977
PMS-MONTELUKAST (SA)
02355507
TEVA-MONTELUKAST (SA)
02377608
APO-MONTELUKAST (SA)
02379317
MONTELUKAST (SA)
02380749
MYLAN-MONTELUKAST (SA)
02382458
MONTELUKAST (SA)
02399865
MAR-MONTELUKAST (SA)
02402793
RAN-MONTELUKAST (SA)
02408627
MINT-MONTELUKAST (SA)
MSD
SDZ
PMS
TEV
APX
SNS
MYL
SIV
MAR
RAN
MNT
FQW
FQW
FQW
FQW
FQW
FQW
FQW
FQW
FQW
FQW
FQW
5MG CHEWABLE TABLET
02238216
SINGULAIR (SA)
02330393
SANDOZ-MONTELUKAST (SA)
02354985
PMS-MONTELUKAST (SA)
02355515
TEVA-MONTELUKAST (SA)
02377616
APO-MONTELUKAST (SA)
02379325
MONTELUKAST (SA)
MSD
SDZ
PMS
TEV
APX
SNS
FQW
FQW
FQW
FQW
FQW
FQW
ARAVA (SA)
APO-LEFLUNOMIDE (SA)
NOVO-LEFLUNOMIDE (SA)
SANDOZ -EFLUOMIDE (SA)
PMS-LEFLUNOMIDE (SA)
MYLAN-LEFLUNOMIDE (SA)
LEFLUNOMIDE (SA)
PEI Pharmacare Formulary …………………………………………………Page - 247 -
02380757
02382466
02399873
02402807
02408635
MYLAN-MONTELUKAST (SA)
MONTELUKAST (SA)
MAR-MONTELUKAST (SA)
RAN-MONTELUKAST (SA)
MINT-MONTELUKAST (SA)
MYL
SIV
MAR
RAN
MNT
FQW
FQW
FQW
FQW
FQW
10MG TABLET
02238217
02328593
02355523
02368226
02373947
02374609
02379236
02379333
02382474
02389517
02391422
02401274
02399997
02408643
SINGULAIR (SA)
SANDOZ-MONTELUKAST (SA)
TEVA-MONTELUKAST (SA)
MYLAN-MONTELUKAST (SA)
PMS-MONTELUKAST (SA)
APO-MONTELUKAST (SA)
MONTELUKAST SODIUM (SA)
MONTELUKAST (SA)
MONTELUKAST (SA)
RAN-MONTELUKAST (SA)
JAMP-MONTELUKAST (SA)
AURO-MONTELUKAST (SA)
MAR-MONTELUKAST (SA)
MINT-MONTELUKAST (SA)
MSD
SDZ
TEV
MYL
PMS
APX
ACH
SNS
SIV
RAN
JPC
ARO
MAR
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FQW
4MG GRANULES IN PACKET
02247997
SINGULAIR (SA)
02358611
SANDOZ-MONTELUKAST (SA)
MSD FQW
SDZ FQW
*MYCOPHENOLATE MOFETIL
250MG CAPSULE
02192748
CELLCEPT
02320630
SANDOZ-MYCOPHENOLATE
02352559
APO-MYCOPHENOLATE
02364883
NOVO-MYCOPHENOLATE
02371154
MYLAN-MYCOPHENOLATE
02383780
MYCOPHENOLATE MOFETIL
02386399
JAMP-MYCOPHENOLATE
HLR
SDZ
APX
NOP
MYL
ACH
JPC
T
T
T
T
T
T
T
500MG TABLET
02237484
02313855
02352567
02348675
02370549
02379996
02378574
02380382
HLR
SDZ
APX
NOP
MYL
COB
ACH
JPC
T
T
T
T
T
T
T
T
CELLCEPT
SANDOZ-MYCOPHENOLATE
APO-MYCOPHENOLATE
NOVO-MYCOPHENOLATE
MYLAN-MYCOPHENOLATE
CO-MYCOPHENOLATE
MYCOPHENOLATE MOFETIL
JAMP-MYCOPHENOLATE
PEI Pharmacare Formulary …………………………………………………Page - 248 -
*MYCOPHENOLATE SODIUM
180MG ENTERIC-COATED TABLET
02264560
MYFORTIC
NVR T
360MG ENTERIC-COATED TABLET
02264579
MYFORTIC
NVR
OCTREOTIDE
SEE APPENDIX A FOR SA CRITERIA
200UG/ML INJECTION (5ML)
02049392
SANDOSTATIN (SA)
02248642
OCTREOTIDE OMEGA (SA)
02299445
OCTREOTIDE (SA)
NVR FNQSW
OMG FNQSW
NOP FNQSW
ONABOTULINUMTOXINA
SEE APPENDIX A FOR SA CRITERIA
200UNITS/VIAL
01981501
BOTOX (SA)
ALL
PAMIDRONATE DISODIUM
SEE APPENDIX A FOR SA CRITERIA
30MG INJECTION
02059762
AREDIA (SA)
02244550
PAMIDRONATE DISODIUM (SA)
NVR FNQSW
HOS FNQSW
60MG INJECTION
02244551
PAMIDRONATE DISODIUM (SA)
HOS FNQSW
90MG INJECTION
02059789
AREDIA (SA)
02244552
PAMIDRONATE DISODIUM (SA)
NVR FNQSW
HOS FNQSW
PENTOSAN POLYSULFATE SO4
SEE APPENDIX A FOR SA CRITERIA
100MG CAPSULE
02029448
ELMIRON (SA)
JAN
PHENYLALANINE-REDUCED FOODS
NUTRITIONAL FORMULA (NOT INTERCHANGEABLE)
00030800
PHENEX-1
ROS P
04444444
00368020
ROS P
MJS P
PHENEX-2
PHENYL-FREE
T
Q
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 249 -
QUINAGOLIDE
SEE APPENDIX A FOR SA CRITERIA
75MCG TABLET
02223767
NORPROLAC (SA)
FEI
FNQSW
150MCG TABLET
02223775
NORPROLAC (SA)
FEI
FNQSW
RISEDRONATE SODIUM
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02242518
ACTONEL (SA)
02298376
TEVA-RISEDRONATE (SA)
WCC FNQSW
TEV FNQSW
30MG TABLET
02239146
02298384
ACTONEL (SA)
TEVA-RISEDRONATE (SA)
WCC FNQSW
TEV FNQSW
35MG TABLET
02246896
02298392
02319861
02302209
02327295
02353687
02368552
02357984
02370255
02411407
ACTONEL (SA)
TEVA-RISEDRONATE (SA)
RATIO-RISEDRONATE (SA)
PMS-RISEDRONATE (SA)
SANDOZ-RISEDRONATE (SA)
APO-RISEDRONATE (SA)
JAMP-RISEDRONATE (SA)
MYLAN-RISEDRONATE (SA)
SANIS-RISEDRONATE (SA)
RISEDRONATE (SA)
WCC FNQSW
TEV FNQSW
RPH FNQSW
PMS FNQSW
SDZ FNQSW
APX FNQSW
JPC FNQSW
MYL FNQSW
SNS FNQSW
SIV FNQSW
SEVELAMER HCL
SEE APPENDIX A FOR SA CRITERIA
800MG TABLET
02244310
RENAGEL (SA)
AVN FNQSW
SIROLIMUS
1MG/ML ORAL SOLUTION
02243237
RAPAMUNE
PFI
T
1MG TABLET
02247111
PFI
T
RAPAMUNE
SODIUM CROMOGLYCATE
SEE APPENDIX A FOR SA CRITERIA
100MG CAPSULE
PEI Pharmacare Formulary …………………………………………………Page - 250 -
00500895
NALCROM (SA)
AVN FQSW
1% INHALATION SOLUTION (2ML)
02046113
PMS SODIUM CROMOGLYCATE
PMS FNQSW
SORAFENIB TOSYLATE
SEE APPENDIX A FOR SA CRITERIA
200 MG TABLET
02284227
NEXAVAR (SA)
BAY
MQ
*TACROLIMUS
0.5MG CAPSULE
02243144
PROGRAF
AST
T
1MG CAPSULE
02175991
02416824
PROGRAF
SANDOZ-TACROLIMUS
AST
SDZ
T
T
5MG CAPSULE
02175983
02416832
PROGRAF
SANDOZ-TACROLIMUS
AST
SDZ
T
T
*TAMSULOSIN
0.4MG SUSTAINED RELEASE CAPSULE
02281392
NOVO-TAMSULOSIN
02294265
RATIO-TAMSULOSIN
02295121
SANDOZ-TAMSULOSIN
02298570
MYLAN-TAMSULOSIN
02319217
SANDOZ-TAMSULOSIN
NOP
RPH
SDZ
MYL
SDZ
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
0.4MG CONTROL RELEASE TABLET
02270102
FLOMAX CR
02340208
SANDOZ-TAMSULOSIN
02362406
APO-TAMULOSIN
02368242
TEVA-TAMSULOSIN
BOE
SDZ
APX
TEV
FNQSW
FNQSW
FNQSW
FNQSW
TETRABENAZINE
SEE APPENDIX A FOR SA CRITERIA
25MG TABLET
02199270
NITOMAN (SA)
02402424
PMS-TETRABENAZINE (SA)
02407590
APO-TETRABENAZINE (SA)
02410338
TETRABENAZINE (SA)
BVL
PMS
APX
STE
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 251 -
TOCILIZUMAB
SEE APPENDIX A FOR SA CRITERIA
80MG/4ML IV VIAL
02350092
ACTEMRA (SA)
HLR
Q
200MG/10ML IV VIAL
02350106
ACTEMRA (SA)
HLR
Q
400MG/20ML IV VIAL
02350114
ACTEMRA (SA)
HLR
Q
TRIMEPRAZINE TARTRATE
2.5MG TABLET
01926306
PANECTYL
ERF
FNQW
5MG TABLET
01926292
ERF
FNQW
ZARIFLUKAST
SEE APPENDIX A FOR SA CRITERIA
20MG TABLET
02236606
ACCOLATE (SA)
AST
FNQSW
ZOLEDRONIC ACID
SEE APPENDIX A FOR SA CRITERIA
5MG/100ML INJECTION
02269198
ACLASTA (SA)
NVR FNQSW
PANECTYL
92:00.08 ALFA REDUCTASE INHIBITORS
DUTASTERIDE
SEE APPENDIX A FOR SA CRITERIA
0.5MG CAPSULE
02247813
AVODART (SA)
GSK FNQSW
FINASTERIDE
SEE APPENDIX A FOR SA CRITERIA
5MG TABLET
02010909
PROSCAR (SA)
02306905
RATIO-FINASTERIDE (SA)
02348500
TEVA-FINASTERIDE (SA)
02322579
SANDOZ-FINASTERIDE (SA)
02310112
PMS-FINASTERIDE (SA)
MDS
RPM
TEV
SDZ
PMS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
PEI Pharmacare Formulary …………………………………………………Page - 252 -
02354462
02355043
02356058
02357224
02365383
02371820
02389878
02405814
CO-FINASTERIDE (SA)
FINASTERIDE (SA)
MYLAN-FINASTERIDE (SA)
JAMP-FINASTERIDE (SA)
APO-FINASTERIDE (SA)
RAN-FINASTERIDE (SA)
MINT-FINASTERIDE (SA)
AURO-FINASTERIDE (SA)
COB
ACH
MYL
JPC
APX
RAN
MNT
ARO
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
92:16.00 ANTIGOUT AGENTS
ALLOPURINOL
100MG TABLET
00402818
02396327
02402769
ZYLOPRIM
MAR-ALLOPURINOL
APO-ALLOPURINOL
AAA FNQSW
MAR FNQSW
APX FNQSW
200MG TABLET
00479799
02396335
02402777
ZYLOPRIM
MAR-ALLOPURINOL
APO-ALLOPURINOL
AAA FNQSW
MAR FNQSW
APX FNQSW
300MG TABLET
00402796
02396343
02402785
ZYLOPRIM
MAR-ALLOPURINOL
APO-ALLOPURINOL
AAA FNQSW
MAR FNQSW
APX FNQSW
COLCHICINE
0.6MG TABLET
00572349
02402181
COLCHICINE-ODAN
PMS-COLCHICINE
ODN FNQSW
PMS FNQSW
FEBUXOSTAT
SEE APPENDIX A FOR SA CRITERIA
80MG TABLETS
02357380
ULORIC
TAK
Q
PEI Pharmacare Formulary …………………………………………………Page - 253 -
BONE RESORPTION INHIBITORS
ALENDRONATE & CHOLECALCIFEROL
SEE APPENDIX A FOR SA CRITERIA
70MG/5600 UNIT TABLET
02314940
FOSAVANCE (SA)
02403641
TEVA-ALENDRONATE/CHOLECALCIFEROL (SA)
MSD FNQSW
TEV FNQSW
ALENDRONATE SODIUM
SEE APPENDIX A FOR SA CRITERIA
10MG TABLET
02201011
FOSAMAX (SA)
02247373
TEVA-ALENDRONATE (SA)
02248728
APO-ALENDRONATE (SA)
02270129
MYLAN-ALENDRONATE (SA)
02288087
SANDOZ-ALENDRONATE (SA)
02381486
ALENDRONATE SODIUM (SA)
02384701
RAN-ALENDRONATE (SA)
02388545
AURO-ALENDRONATE (SA)
02394863
MINT-ALENDRONATE (SA)
MSD
TEV
APX
MYL
SDZ
ACH
RAN
ARO
MNT
40MG TABLET
02201038
02258102
FOSAMAX (SA)
CO-ALENDRONATE (SA)
MSD FNQSW
COB FNQSW
70MG TABLET
02245329
02248730
02258110
02261715
02275279
02284006
02288109
02286335
02299712
02352966
02381494
02385031
02384701
02388553
02394871
FOSAMAX (SA)
APO-ALENDRONATE (SA)
CO-ALENDRONATE (SA)
TEVA-ALENDRONATE (SA)
RATIO-ALENDRONATE (SA)
PMS-ALENDRONATE (SA)
SANDOZ-ALENDRONATE (SA)
MYLAN-ALENDRONATE (SA)
ALENDRONATE (SA)
ALENDRONATE (SA)
ALENDRONATE SODIUM (SA)
JAMP-ALENDRONATE (SA)
RAN-ALENDRONATE (SA)
AURO-ALENDRONATE (SA)
MINT-ALENDRONATE (SA)
MSD
APX
COB
TEV
RPH
PMS
SDZ
MYL
SIV
SNS
ACH
JPC
RAN
ARO
MNT
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
DENOSUMAB
SEE APPENDIX A FOR SA CRITERIA
PEI Pharmacare Formulary …………………………………………………Page - 254 -
60MG/ML SC SYRINGE
02343541
PROLIA (SA)
AMG FNQSW
92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ABATACEPT
SEE APPENDIX A FOR SA CRITERIA
250 MG VIAL
02282097
ORENCIA (SA)
BMS MQ
ADALIMUMAB
SEE APPENDIX A FOR SA CRITERIA
40MG/0.8ML PRE-FILLED SYRINGE
02258595
HUMIRA (SA)
ABB
MQ
BOSENTAN
SEE APPENDIX A FOR CRITERIA
62.5 MG TABLET
02244981
TRACLEER (SA)
02383012
PMS-BOSENTAN (SA)
02383497
MYLAN-BOSENTAN (SA)
02386194
CO-BOSENTAN (SA)
02386275
SANDOZ-BOSENTAN (SA)
02398400
TEVA-BOSENTAN (SA)
ACT
PMS
MYL
COB
SDZ
TEV
MQ
MQ
MQ
MQ
MQ
MQ
125 MG TABLET
02244982
02383020
02383500
02386208
02386283
02398419
ACT
PMS
MYL
COB
SDZ
TEV
MQ
MQ
MQ
MQ
MQ
MQ
TRACLEER (SA)
PMS-BOSENTAN (SA)
MYLAN-BOSENTAN (SA)
CO-BOSENTAN (SA)
SANDOZ-BOSENTAN (SA)
TEVA-BOSENTAN (SA)
CERTOLIZUMAB
SEE APPENDIX A FOR CRITERIA
200MG/ML
02331675
CIMZIA (SA)
UCB MQ
ETANERCEPT
SEE APPENDIX A FOR SA CRITERIA
25MG/VIAL INJECTION
02242903
ENBREL (SA)
AMG MQ
PEI Pharmacare Formulary …………………………………………………Page - 255 -
50MG/ML PRE-FILLED SYRINGE
02274728
ENBREL (SA)
AMG MQ
GOLIMUMAB
SEE APPENDIX A FOR SA CRITERIA
50MG/0.5ML SYRINGE
02324776
SIMPONI (SA)
MSD MQ
50MG/0.5ML AUTO-INJECTOR
02324784
SIMPONI (SA)
MSD MQ
92:44.00 IMMUNOSUPPRESSIVE AGENTS
AZATHIOPRINE
50MG TABLET
00004596
02231491
02236819
02242907
02343002
IMURAN
MYLAN-AZATHIOPRINE
TEVA-AZATHIOPRINE
APO-AZATHIOPRINE
AZATHIOPRINE
GSK
MYL
TEV
APX
SNS
FNQSW
FNQSW
FNQSW
FNQSW
FNQSW
*CYCLOSPORINE
10MG CAPSULE
02237671
NEORAL
NVR T
25MG CAPSULE
02150689
02247073
NEORAL
SANDOZ-CYCLOSPORINE
NVR T
SDZ T
50MG CAPSULE
02150662
02247074
NEORAL
SANDOZ-CYCLOSPORINE
NVR T
SDZ T
100MG CAPSULE
02150670
NEORAL
02242821
SANDOZ-CYCLOSPORINE
NVR T
SDZ T
100MG/ML ORAL SOLUTION
02150697
NEORAL
02244324
APO-CYCLOSPORINE
NVR T
APX T
PEI Pharmacare Formulary …………………………………………………Page - 256 -
*TACROLIMUS
0.5MG EXTENDED RELEASE CAPSULE
02296462
ADVAGRAF
AST
T
1MG EXTENDED RELEASE CAPSULE
02296470
ADVAGRAF
AST
T
3MG EXTENDED RELEASE CAPSULE
02331667
ADVAGRAF
AST
T
5MG EXTENDED RELEASE CAPSULE
02296489
ADVAGRAF
AST
T
PROFESSIONAL SERVICES
MEDICATION REVIEW
93899926
93899924
93899925
93899923
BASIC MEDICATION REVIEW
BASIC MEDICATION REVIEW FOLLOW-UP
DIABETES MEDICATION REVIEW
DIABETES MEDICATION REVIEW FOLLOW-UP
DNSW
DNSW
DNW
DNW
COMPLIANCE PACKAGING
CDP APPLICATION SUPPORT
THERAPEUTIC SUBSTITUTION
REFUSAL TO FILL
PRESCRIPTION ADAPTATION
DFMSW
Q
FNSW
FNSVW
DFMNVWZ
OTHER SERVICES
93899914
93899915
93899916
93899917
93899918
PEI Pharmacare Formulary …………………………………………………Page - 257 -
APPENDIX A
Special Authorization Criteria
NOTES REGARDING SPECIAL AUTHORIZATION (SA) COVERAGE
$
Special Authorizations are reviewed by drug program staff.
$
Not all medications currently approved for sale in Canada will be considered for Special
Authorization coverage.
$
Special Authorization coverage will not be considered for any medications approved for sale in
Canada since January 2000 that have not been reviewed, and approved, for coverage by either
the Canadian Expert Drug Advisory Committee (CEDAC), the Pan-Canadian Oncology Drug
Review (P-CODR) or the Atlantic Expert Advisory Committee (AEAC).
$
Special Authorization coverage will normally only be approved for the treatment of indications
and in dosages listed in the official product monograph approved by Health Canada and
published in the most recent edition of the Compendium of Pharmaceuticals and Specialities
(CPS).
$
Special Authorization coverage will potentially be considered for any drug not listed as an open
benefit under the:
$
Family Health Benefit Program
$
Financial Assistance Program
$
Nursing Home / Institutional Program
$
Seniors Drug Cost Assistance Plan
$
Special Authorization coverage will be limited to selected drugs with specific criteria under the:
$
AIDS/HIV Program
$
Diabetes Control Program
$
High Cost Drugs Program
$
Home Oxygen Program
$
Transplant Drugs Program
$
Special Authorization coverage will not be considered under the:
$
Community Mental Health Program
$
Cystic Fibrosis Program
$
Eprex Program
$
Growth Hormone Program
$
Hepatitis Program
$
Immunization Program
$
Intron A Program
$
Meningitis Program
$
Nutrition Services Program
$
Phenylketonuria Program
$
Quit Smoking Program
$
Rabies Program
$
Rheumatic Fever Program
$
Sexually Transmitted Diseases Program
$
Tuberculosis Program
PEI Pharmacare Formulary …………………………………………………Page - 258 -
$
Prescribers may apply for Special Authorization coverage by mailing or faxing a completed
Special Authorization to:
Special Authorizations
PEI Pharmacare
P.O. Box 2000
Charlottetown, PEI, C1A 7N8
Fax: 1-902-368-4905
$
Information that must be completed on, or included with the Special Authorization includes:
$
Patient=s name, personal health number (PHN), date of birth, mailing address, and
telephone number;
$
Name, dose, and dosage regimen of the medication requested;
$
Anticipated length of therapy of the medication requested;
$
Specific diagnosis or indication being treated using the medication requested;
$
Reason(s) for the request;
$
Other comments, including copies of culture and sensitivity reports for antibiotic
requests, copies of relevant test results and relevant advice received from consultants or
specialists; and
$
Physician=s name, address, and signature. No request will be considered without a
valid physician=s signature.
$
Special Authorizations with insufficient information to properly assess the request will be
returned to the physician.
$
Please allow up to three weeks for the processing of Special Authorizations.
$
Copies of the Special Authorization Forms are available by contacting the PEI Pharmacare
office at 1-877-577-3737 or online at http://healthpei.ca/pharmacareforms .
$
For some drugs a patient application is required in addition to the Special Authorization form.
The patient application form is available by contacting the PEI Pharmacare office at 1-877-5773737 or online at http://healthpei.ca/pharmacareforms .
$
Patients and prescribers are notified by letter if coverage has been approved. Patients
should take a copy of the approval letter to their pharmacy to initiate coverage.
$
The duration of approval of Special Authorization coverage may range from a one time
only fill to coverage with no end date. This will be based upon the medication requested
and the condition being treated.
$
Medications approved through the Special Authorization process are limited to a
maximum 30 (thirty) day supply per fill unless otherwise noted in drug criteria.
$
If additional information is required or if the request is denied, a letter is sent to the
PEI Pharmacare Formulary …………………………………………………Page - 259 -
patient and physician notifying them of the need for additional information or reason for
the denial. Payment of the medication is the responsibility of the patient in these cases.
$
If the request is approved, patients may be reimbursed for one fill of the medication
received during the assessment period, after which all of the requested information has
been received. No reimbursement will be provided for medication received by the
patient prior to receipt of the Special Authorization by the Drug Programs Office.
$
If it is anticipated that a patient will continue to require the product beyond the last day of
approval, the physician is required to request an extension of coverage at least four
weeks before its expiration. Coverage will not be continued automatically.
CRITERIA FOR COVERAGE OF SPECIFIC MEDICATIONS
The following are criteria for Special Authorization coverage of specific medications. Coverage
may be granted for other products in certain instances.
Abatacept - see Rheumatoid Arthritis Biologic Agents
Acamprosate, delayed release, tablet, 333mg (Campral-MYL)
For the maintenance of abstinence from alcohol in patients with a diagnosis of 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. The maximum treatment duration is 12 months.
Accolate - see Zariflukast
Acitretin, capsule, 10mg, 25mg (Soriatane-HLR)
For the treatment of severe intractable psoriasis, Darier=s Disease, ichthyosiform
dermatoses, palmoplantar pustulosis and other disorders of keratinization.
Aclasta - see Zoledronic Acid
Actonel 5mg & 35mg - see Bisphosphonates
Actonel 30mg - see Risedronate
Actos - see Thiazolidinediones
Adalimumab - see Ankylosing Spondylitis Biologic Agents OR
- see Crohn=s Disease Biologic Agents OR
- see Psoriatic Arthritis Biologic Agents OR
PEI Pharmacare Formulary …………………………………………………Page - 260 -
- see Rheumatoid Arthritis Biologic Agents
Adefovir Dipivoxil, tablet, 10mg (Hepsera – GIL)
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.
Advair - see Salmeterol & Fluticasone
Advair Diskus - see Salmeterol & Fluticasone
Agrylin - see Anagrelide
Alendronate 10mg & 70mg - see Bisphosphonates
Alendronate, tablet, 40mg (Fosamax-MSD and generics)
For the treatment of Paget=s disease of the bone for a maximum 6 month period. A copy
of the radiological or specialist report supporting the diagnosis must accompany the
Special Authorization.
Alertec - see Modafinil
Almotriptan, tablet, 6.25mg, 12.5mg (Axert-JAN)
For the treatment of migraine headaches where other standard therapies, such as oral
analgesics have failed AND the patient has not responded to oral Sumatriptan.
Coverage is limited to 6 tablets per 30 day period. Anyone requiring more than 6
doses per 30 day period should be considered for migraine prophylaxis therapy if not
already receiving such therapy.
Amatine - see Midodrine HCl
Ambrisentan - see Pulmonary Arterial Hypertension (PAH) Therapies
Amerge - see Naratriptan HCl
Anagrelide, capsule, 0.5mg (Agrylin-SHR and generics)
For the treatment of essential thrombocythemia (ET) in patients who have:
a) Failed Hydroxyurea therapy (does not provide sufficient platelet reduction) or
b) Have intolerable side effects to Hydroxyurea therapy.
Andriol - see Testosterone Undecanoate
PEI Pharmacare Formulary …………………………………………………Page - 261 -
AndroGel- see Testosterone
Ankylosing Spondylitis Biologic Agents
Adalimumab, kit, 40mg/0.8ml (Humira-ABB)
Approvals will be for a maximum adult dose of 40mg every two weeks.
Etanercept, pre-filled syringe, 50mg/ml; injection powder, 25mg/kit (Enbrel-AMG)
Approvals will be for a maximum adult dose of 50mg per week or 25mg twice weekly.
Golimumab, Syringe, 50mg/0.5ml; auto-injector, 50mg/0.5ml (Simponi-MSD)
Approvals will be for a maximum adult dose of 50mcg once monthly.
Infliximab, injection powder, 100mg/vial (Remicade-JAN)
Approvals will be for a maximum adult dose of 5mg/kg at 0, 2, and 6 weeks then every 6
to 8 weeks.
For the treatment of patients with moderate to severe ankylosing spondylitis ( Bath AS Disease
Activity Index (BASDAI) score $4 on 10 point scale who:
a) 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
b) 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.
Approvals for Ankylosing Spondylitis anti-TNF agents will be for a maximum of six
months, and will NOT be considered in combination with other biologic agents.
Requests for renewal must include information showing the beneficial effects of the treatment,
specifically:
a) a decrease of at least two points on the BASDAI scale, compared with pre-treatment
score OR
b) patient and expert opinion of an adequate clinical response as indicated by a
significant functional improvement (measured by outcomes such as Health
Assessment Questionnaire (HAQ) or ability to return to work).
The request for coverage must be made by a rheumatologist or prescriber with a
specialty in rheumatology, using the Ankylosing Spondylitis Special Authorization form
available from the Drug Programs office or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage through the High Cost Drug Program. The patient
PEI Pharmacare Formulary …………………………………………………Page - 262 -
application is available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms .
Apixaban, tablet, 2.5mg, 5mg (Eliquis-BMS)
For the prevention of stroke and systemic embolism in at-risk patients with non-valvular
atrial fibrillation for whom:
a) Anticoagulation is inadequate following at least a two month trial of 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 apixaban for atrial
fibrillation:
a) Patients with impaired renal function (creatinine clearance or estimated glomerular
filtration rate < 25 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 CHADS2 score of ≥ 1.
Prescribers may consider an antiplatelet regimen or oral anticoagulation for patients with
a CHADS2 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. Documented stable renal function is defined as creatinine clearance or estimated
glomerular filtration rate maintained for at least 3 months.
a) Dosing: the usual recommended dose is 5 mg twice daily; a reduced dose of
apixaban 2.5 mg twice daily is recommended for patients with at least two [2] of the
following: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 133
micromole/litre.
b) Since renal impairment can increase bleeding risk, renal function should be
regularly monitored. Other factors that increase bleeding risk should also be assessed
and monitored (see apixaban product monograph).
c) Patients starting apixaban should have ready access to appropriate medical
services to manage a major bleeding event.
d) There is currently no data to support that apixaban provides adequate
anticoagulation in patients with rheumatic valvular disease or those with prosthetic heart
valves. As a result, apixaban is not recommended for these patient populations.
PEI Pharmacare Formulary …………………………………………………Page - 263 -
Aprepitant, capsule, 80mg, 125mg, 80mg & 125mg package (Emend, Emend Tri-Pack)
For use in combination with a 5-HT antagonist and dexamethasone in adult cancer
patients treated with chemotherapy that includes Cisplatin as a single day therapy
greater than or equal to ($) 70 mg/m2 to prevent acute and delayed nausea and
vomiting.
The 5-HT antagonist should only be used on the first day of Cisplatin therapy with
Aprepitant continuing on days 2 and 3.
The dose of Dexamethasone may be adjusted due to the increased levels of
Dexamethasone when combined with Aprepitant.
Aranesp - see Darbepoetin Alfa
Arava - see Leflunomide
Aredia - see Pamidronate Disodium
Aricept - see Cholinesterase Inhibitors (ChEI)
Aripiprazole, tablet, 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Abilify-BMS)
For the treatment of schizophrenia and schizoaffective disorders in patients who have a
contraindication to a trial of at least TWO less expensive antipsychotic because of
intolerance or lack of response
Asenapine, sublingual tablet, 5mg, 10mg (Saphris-MSD)
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.
Avandamet - see Rosiglitazone Maleate & Metformin
Avandia - see Thiazolidinediones
Avelox - see Moxifloxacin
Avodart - see Dutasteride
PEI Pharmacare Formulary …………………………………………………Page - 264 -
Avonex - see Multiple Sclerosis Agents
Axert - see Almotriptan
Azithromycin, tablet, 250mg, 600mg; oral suspension, 20mg/mL, 40mg/mL (Zithromax-PFI
and generics).
Note: For AIDS/HIV, Cystic Fibrosis, Sexually Transmitted Diseases, and Tuberculosis
Programs, no Special Authorization is Required.
a) For the treatment of upper and lower respiratory tract infections known to be
resistant to or not responding to alternative antibiotics, including Erythromycin. Up to
5 days of therapy will be considered for coverage of the 250mg tablet. Up to 10 days
of therapy will be considered for all other strengths.
b) For the treatment of moderate to severe exacerbations of chronic bronchitis.
c) For the treatment of infections in patients allergic to alternative antibiotics.
d) For the treatment of infections requiring a macrolide when there is documented
intolerance to Erythromycin.
e) For the completion of hospital initiated treatment with macrolides or quinolones.
f) For the prevention and treatment of Mycobacterium avium complex.
Baraclude – see Entecavir
Benzydamine HCl, oral rinse, 0.15% (Tantum Oral Rinse-MDA and generics)
For oncology patients only.
Betahistine HCL, tablet, 16mg, 24mg (Serc-SLV and generics)
For the symptomatic treatment of recurrent episodes of vertigo associated with
Meniere=s disease.
Betamethasone Dipropionate & Calcipotriol, topical gel, 50mcg/0.5mg/gm (Dovobet-LEO)
For the treatment of patients with scalp psoriasis:
Who have failed a trial with a topical steroid alone AND;
Who have failed a trial with a topical steroid and calcipotriol together.
Betaseron - see Multiple Sclerosis Agents
Biaxin - see Clarithromycin
Biphentin - see Methylphenidate
Bisacodyl, suppository (water based), 10mg (Magic Bullet)
For the treatment of bowel incontinence where alternative therapies have failed.
Bisphosphonates
PEI Pharmacare Formulary …………………………………………………Page - 265 -
Alendronate, tablet, 10mg, 70mg (Fosamax-MSD and generics)
Alendronate & Cholecalciferol, tablet, 70mg/5600unit (Fosavance-MSD)
Risedronate, tablet, 5mg, 35mg (Actonel-PGA and generics)
a) For the treatment of osteoporosis in patients with a documented fragility fracture.
b) For use in patients without documented fracture but with a high 10-year fracture risk
(see fracture risk tables). A copy of the bone density report, including the T-score,
supporting the diagnosis must accompany the Special Authorization.
c) For prophylaxis of corticosteroid induced osteoporosis in patients who will be or have
been on systemic corticosteroid therapy for $ 3 months.
Reference: Siminoski K. et al. 2005. Recommendations for bone mineral density reporting in
Canada. Can. Assoc. Radiol. J. 56:178-
Boceprevir, capsule, 200mg (Victrelis – MSD)
For the treatment of chronic hepatitis C genotype 1 infection in combination with
peginterferon alpha/ribavirin (PegIFNα/RBV), if the following criteria are met:
• detectable levels of hepatitis C virus (HCV) RNA prior to treatment
• fibrosis stage of F2, F3, or F4 as determined by a biopsy/fibroscan where available OR
recommendation of a hepatologist or a prescriber with a specialty in hepatitis
• one course of treatment only (up to 44 weeks duration)
Notes:
• Response guided therapy should be considered in patients for whom this is
appropriate.
• Therapy should be discontinued in all patients with HCV RNA levels are ≥ 100 IU/ml at
treatment week 12, or confirmed HCV RNA positive at treatment week 24.
Boceprevir/Ribavirin/P-Alfa-2B, pen injection kit, 200mg/80mcg, 200mg/100mcg,
200mg/120mcg, 200mg/150mcg (Victrelis Triple-MSD)
For the treatment of chronic hepatitis C genotype 1 infection in combination with
peginterferon alpha/ribavirin (PegIFNα/RBV), if the following criteria are met:
• detectable levels of hepatitis C virus (HCV) RNA prior to treatment
• fibrosis stage of F2, F3, or F4 as determined by a biopsy/fibroscan where available OR
PEI Pharmacare Formulary …………………………………………………Page - 266 -
recommendation of a hepatologist or a prescriber with a specialty in hepatitis
• one course of treatment only (up to 44 weeks duration)
Notes:
• Response guided therapy should be considered in patients for whom this is
appropriate.
• Therapy should be discontinued in all patients with HCV RNA levels are ≥ 100 IU/ml at
treatment week 12, or confirmed HCV RNA positive at treatment week 24.
Bosentan - see Pulmonary Arterial Hypertension (PAH) Therapies
Brilinta – see Ticagrelor
Budesonide, inhalation solution, 0.125mg/mL, 0.25mg/mL, 0.5mg/mL (Pulmicort
Nebuamp-AZE)
Note: For Nursing Home Program, no Special Authorization is required.
a) For use in clients on the Nursing Home Program.
b) For use in children under 6 years of age. The pharmacy must call the drug programs
office to have coverage set up initially. Coverage will be in place until the child=s
sixth birthday.
c) Other uses will be considered on a case by case basis where there are extreme
circumstances.
Budesonide, capsule, 3mg; enema, 2mg/100mL (Entocort-AZE)
For the treatment of Crohn's disease or Colitis in patients for whom Prednisone is
contraindicated or in whom significant side effects have occurred.
Buprenorphine & Naloxone, sublingual tablet, 2mg/0.5mg, 8mg/2mg (Suboxone-MSD)
Criteria A: Applies to eligible clients in the following Pharmacare programs - Family
Health Benefit / Financial Assistance / Nursing Home / Opioid Replacement Therapy /
Seniors / Catastrophic Drug Program
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
(e.g. sweating, insomnia, etc.) will not be considered to be hypersensitivity.
• Patients must be 18 years or older
Criteria B: Applies to eligible clients in the Opioid Replacement Therapy Program only
For the treatment of opioid dependence for patients (ages 18 to 24) by physicians through the
Opioid Replacement Therapy (ORT) Program.
• Approvals will be for up to 24 months at a time
• Patients must be 18 years or older
PEI Pharmacare Formulary …………………………………………………Page - 267 -
Bupropion HCl, tablet, 100mg, 150mg (Wellbutrin SR-GSK and generics)
For the symptomatic relief of depressive illness.
The maximum dose that will be approved is 300mg per day.
Bupropion HCl, tablet, 150mg (Zyban-GSK)
Note: For Quit Smoke program, no Special Authorization is required.
For smoking cessation therapy.
NOTE: Treatment is limited to a maximum of 12 weeks.
Campral – see Acamprosate
Capecitabine, tablet, 150mg, 500mg (Xeloda-HLR)
a) For the treatment of metastatic breast cancer in patients who have failed or are
intolerant to intravenous drugs or for use in combination with intravenous drugs
for aggressive, high risk disease.
Patients must have an ECOG status of 0 - 2*.
b) As an adjuvant for the curative treatment of colon cancer after surgery, alone or
in combination with intravenous drugs.
Patients must have an ECOG status of 0 - 2*.
c) For use in metastatic colon cancer as a single agent or in combination with
intravenous drugs.
d) As an adjuvant for the curative treatment of rectal cancer before or after
surgery, alone or in combination with intravenous drugs, or during radiotherapy
treatment.
•
•
•
Patients who are asymptomatic and those who are symptomatic and in bed less than
50% of the time.
Must be requested and prescribed by a specialist in hematology or medical
oncology.
Coverage will be limited to a maximum of 12 months at one time. Coverage beyond
this will require completion and submission of a new Special Authorization.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The
patient application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
PEI Pharmacare Formulary …………………………………………………Page - 268 -
Carbamazepine, suspension, 100mg/5ml (Tegretol-NVR and generics)
For use in patients for indications as defined in the CPS, and who cannot use
carbamazepine chewable, regular and controlled release tablets.
Carbidopa & Levodopa & Entacapone, tablet, 12.5mg/50mg/200mg, 25mg/100mg/200mg,
37.5mg/150mg/200mg, 18.75mg/75mg/200mg, 31.25mg/125mg/200mg (Stalevo-NVR)
For the treatment of Parkinson's disease in patients who are not well controlled and are
experiencing significant "wearing off" symptoms despite optimal therapy with
levodopa/carbidopa and are currently stablilized on levodopa/carbidopa and entacapone
separately.
Carvedilol, tablet, 3.125mg, 6.25mg, 12.5mg, 25mg (Coreg-HLR and generics)
For the treatment of stable symptomatic heart failure with systolic dysfunction (i.e. left
ventricular ejection fraction (LVEF) less than or equal to 40%).
Cefprozil, tablets, 250mg, 500mg; oral suspension, 25mg/mL 50mg/mL (Cefzil-BMS and
generics)
a) Step-down care following hospital separation in patients treated with intravenous
cephalosporins. Up to 10 days of therapy will be considered.
b) For the treatment of patients with asthma or COPD not responding to alternative
antibiotics. Up to 10 days of therapy will be considered.
c) For the treatment of infections caused by organisms known to be resistant to
alternative antibiotics. Up to 10 days of therapy will be considered.
d) For the treatment of patients known to be allergic to penicillin and who fail to respond
to alternative antibiotics. Up to 10 days of therapy will be considered. (Note:
patients who have experienced immediate hypersensitivity to penicillin should
not receive cephalosporins)
Ceftin - see Cefuroxime
Cefuroxime Axetil, tablets, 250mg, 500mg; oral suspension, 25mg/mL, 50mg/mL
(Ceftin-GSK and generics)
Note: For Cystic Fibrosis and Nursing Home programs no Special Authorization is
required.
a) Step-down care following hospital separation in patients treated with intravenous
cephalosporins. Up to 10 days of therapy will be considered.
b) For the treatment of patients with asthma or COPD not responding to alternative
antibiotics. Up to 10 days of therapy will be considered.
c) For the treatment of infections caused by organisms known to be resistant to
alternative antibiotics. Up to 10 days of therapy will be considered.
d) For the treatment of patients known to be allergic to penicillin and who fail to respond
to alternative antibiotics. Up to 10 days of therapy will be considered. (Note:
patients who have experienced immediate hypersensitivity to penicillin should
not receive cephalosporins.)
PEI Pharmacare Formulary …………………………………………………Page - 269 -
Cefzil - see Cefprozil
Certolizumab - see Rheumatoid Arthritis Biologic Agents
Cesamet - see Nabilone
Chlorhexidine, oral rinse, 0.12% (Peridex-MDA, Perichlor-PMS)
For the treatment of periodontal disease in long term care residents who need
assistance in mouth care upon request or recommendation from a dentist. A copy of
the recommendation from the dentist may be required.
Cholinesterase Inhibitors (ChEI)
Donepezil, tablet, 5mg, 10mg (Aricept-PFI)
Galantamine, extended-release capsule, 8mg, 16mg, 24mg (Reminyl ER-JAN and
generics)
Rivastigmine, capsule, 1.5mg, 3mg, 4.5mg, 6mg (Exelon-NVR and generics)
For the treatment of patients with a diagnosis of mild to moderate probable Alzheimer=s
Disease (AD) or possible Alzheimer=s Disease with a vascular component, with Lewy
bodies, or other factors (as specified) and who meet the following criteria:
a) Initial 90-day Trial
An initial 90-day trial using an available ChEI is available to patients who:
$
Have a diagnosis of probable or possible AD, AND
$
Are 65 years of age or older (Coverage for patients less than 65 years of
age will be considered upon receipt of a written consultation from a
neurologist, psychiatrist or geriatrician supporting the diagnosis and
treatment), AND
$
Have not previously used a ChEI, AND
$
Have a Mini Mental State Examination (MMSE) score of between 10 and
24. An MMSE score of 25 or 26 will be considered upon receipt of a
written consultation from a neurologist, psychiatrist or geriatrician
supporting the diagnosis and treatment.
All MMSEs must be completed within 90-days of the request for coverage.
Patients unable to tolerate the first ChEI or where their MMSE score remained
between 10 and 24, but declined significantly during the trial, may also qualify for
a second 90-day trial using a different ChEI. Patients must stop the first ChEI
before coverage for the second 90-day trial of a ChEI will be approved.
b) Continued Coverage
Continued coverage of ChEIs may be available to patients who:
$
Participated in a 90-day trial of a ChEI during which their MMSE score
remained between 10 and 24 and either stabilized or improved, OR
PEI Pharmacare Formulary …………………………………………………Page - 270 -
Have been previously approved for 12-months of coverage, during which
their MMSE score remained above 10 and either stabilized or improved.
All MMSEs must be completed within 90-days of the request for coverage.
$
Continued coverage will not be approved for patients where their latest MMSE
score is less than 10 or has dramatically decreased during the previous trial or
monitoring period.
Continued coverage will be approved for a maximum of twelve (12) months at a
time.
Requests for initial and continued coverage must be made using the
Alzheimers Special Authorization Form available from the Drug Programs
office or online at http://healthpei.ca/pharmacareforms .
Chronic Obstructive Pulmonary Disease Medications
Formoterol Fumerate, powder for inhalation (capsule), 12ug/dose (Foradil-NVR);
powder for inhalation (inhaler), 6ug/dose, 12ug/dose (Oxeze Turbuhaler-AZE)
Formoterol & Budesonide, powder for inhalation, 6ug & 100ug per dose, 6ug &
200ug per dose (Symbicort Turbuhaler-AZE)
Salmeterol Xinafoate, aerosol powder disk, 50μg/dose (Serevent Diskus-GSK,
Serevent Diskhaler-GSK)
Salmeterol & Fluticasone, aerosol inhalation, 25ug & 125ug per dose, 25ug &
250ug per dose (Advair-GSK); inhaled powder disk, 50ug & 100ug per dose, 50ug
& 250ug per dose, 50ug & 500ug per dose (Advair Diskus- GSK)
Tiotropium, capsule for inhalation, 18ug/dose (Spiriva-BOE)
Glycopyrroonium Bromide, capsule for inhalation, 50mcg (Seebri Breezhaler-NVR)
a) For the treatment of mild, moderate, and severe chronic obstructive pulmonary
disease (COPD) (i.e. MRC score $ 2) in patients who continue to be symptomatic
after a 3 month trial of ipratropium at a dose of 12 puffs/day and appropriate use of
short-acting beta2-agonists.
b) For the treatment of moderate to severe chronic obstructive pulmonary disease
(COPD) (i.e. MRC score 3 to 5) without a trial of short-acting agents (e.g. ipratropium
and beta2-agonists) where spirometry shows moderate to severe airflow obstruction
(i.e. FEV1 < 60% predicted AND low FEV1/FVC <0.7). A copy of the spirometry
report must accompany the Special Authorization.
Note: The drug programs will not pay for concurrent use of Tiotropium and
Ipratropium.
Note: Concurrent use of Tiotropium and long acting beta2-agonists or long
acting beta2-agonists/inhaled corticosteroids will only be considered in
patients where FEV1 < 60% predicted AND FEV1/FVC <0.7. A copy of
the spirometry report must accompany the Special Authorization.
PEI Pharmacare Formulary …………………………………………………Page - 271 -
Ciloxan - see Ciprofloxacin, ophthalmic solution
Cimzia – see Rheumatoid Arthritis Biologic Agents
Cipro - see Ciprofloxacin, tablet
Cipro XL - see Ciprofloxacin, extended release tablet
Ciprodex - see Ciprofloxacin & Dexamethasone
Ciprofloxacin, ophthalmic solution, 0.3%; ophthalmic ointment, 0.3% (Ciloxan-ALC and
generics)
For the treatment of ophthalmic infections caused by susceptible bacteria and not
responding to alternative agents.
Ciprofloxacin HCl, tablet, 250mg, 500mg, 750mg (Cipro-BAY and generics)
Note: For Cystic Fibrosis, Nursing Home and Tuberculosis Programs, no Special
Authorization is required.
a) For the treatment of pseudomonas infections not responding to alternative therapy.
Up to 10 days of therapy will be considered.
b) For the treatment of infections in persons allergic to alternative agents. Up to 10
days of therapy will be considered.
c) For the treatment of infections in immunocompromised patients including diabetic
foot and complications of orthopaedic surgery. Up to four weeks (28 days) of
therapy will be considered.
d) For the treatment of chronic bacterial prostatitis. Up to four weeks (28 days) of
therapy will be considered.
Ciprofloxacin, extended release tablet, 1000mg (Cipro XL-BAY)
For the treatment of complicated urinary tract infections in patients unresponsive or
allergic to other oral agents.
Ciprofloxacin & Dexamethasone, otic suspension, 0.3% / 0.1% (Ciprodex-ALC)
a) For the treatment of patients with acute otitis media with otorrhea through
tympanostomy tubes who require treatment.
b) For the treatment of patients with acute otitis externa in the presence of
tympanostomy tubes or known perforation of the tympanic membrane.
Clarithromycin, oral suspension, 25mg/mL, 50mg/mL; tablets, 250mg, 500mg;
extended-release tablet, 500mg (Biaxin-ABB, Biaxin XL-ABB and generics)
Note: For AIDS/HIV, Cystic Fibrosis and Nursing Home Programs, no Special
Authorization is required.
a) For the treatment of upper and lower respiratory tract infections known to be
resistant to or not responding to alternative antibiotics, including Erythromycin. Up to
10 days of therapy will be considered.
PEI Pharmacare Formulary …………………………………………………Page - 272 -
b) For the treatment of moderate to severe exacerbations of chronic bronchitis.
c) For the treatment of infections in patients allergic to alternative antibiotics.
d) For the treatment of infections requiring a macrolide when there is documented
intolerance to Erythromycin.
e) For the completion of hospital initiated treatments with macrolides or quinolones.
f) For the prevention and treatment of Mycobacterium avium complex.
g) One week of therapy will be considered for individuals with documented duodenal or
gastric ulcers and a recent documented positive helicobacter pylori test.
Clopidogrel Bisulfate, tablet, 75mg (Plavix-AVN)
a) For the secondary prevention of the following vascular ischemic events in patients
with a history of symptomatic atherosclerotic disease:
i) Ischemic stroke or transient ischemic attack (TIA) in patients with a
documented severe allergy to ASA (manifested by anaphylactic reaction,
asthma, or nasal polyps) or who experience a recurrent thrombotic event (stroke,
symptoms of TIA) while taking ASA;
ii) Myocardial infarction (MI) in patients with a documented severe allergy to ASA
(manifested by anaphylactic reaction, asthma, or nasal polyps); or
iii) Peripheral artery disease (PAD) in patients who have a documented severe
allergy to ASA (manifested by anaphylactic reaction, asthma, or nasal polyps).
iv) Unstable angina in patients with a documented severe allergy to ASA or
experience GI hemorrhage while on ASA.
b) For the prevention of thrombosis in patients post intra coronary stent implantation
for a period of up to six months (180 days) for Bare Metal Stents (BMS) and 12
months (365 days) for Drug Eluting Stents (DES).
c) For use in combination with ASA in patients with non-ST-segment elevation acute
coronary syndrome (i.e. unstable angina or non-ST-segment elevation myocardial
infarction) for a period of up to three months (90 days). Up to 12 months of therapy
will be considered for patients with a second event of acute coronary syndrome
within 12 months, or with complex or extensive coronary artery disease (eg diffuse
three vessel coronary artery disease not amenable to revascularization or who have
had a previous stroke, TIA or symptomatic peripheral artery disease).
GI intolerance to ASA is not considered a criterion for coverage of Clopidogrel, although
severe cases (e.g. gastric ulceration or bleeds) may be considered.
Requests for Clopidogrel Bisulfate (Plavix-AVN) must be made using the Plavix Special
Authorization form which is available from the Drug Programs office or on-line at
http://healthpei.ca/pharmacareforms .
Clozapine, tablet, 25mg, 100mg (Clozaril-NVR and generics)
Clozapine is only available upon registration of the patient, prescriber, and
pharmacy with a Clozapine Support and Assistance Network.
Clozapine is only to be dispensed to patients upon receipt of 7 day, 14 day or 28
day hematological test results by the pharmacy.
PEI Pharmacare Formulary …………………………………………………Page - 273 -
For the treatment of patients with schizophrenia refractory to other treatments upon
written request or recommendation of a psychiatrist. A copy of the recommendation
must accompany the Special Authorization.
Clozaril - see Clozapine
Codeine, controlled release tablet, 50mg, 100mg, 150mg, 200mg (Codeine Contin-PFR)
For the treatment of documented mild to moderate chronic pain that is not well controlled
by short-acting codeine products or where patients are well controlled on acetaminophen
or ASA combinations but the codeine dose is limited by the amount of acetaminophen or
ASA. Coverage will be limited to doses of 200 mg every 12 hours or less.
Codeine Contin - see Codeine
Comtan - see Entacapone
Copaxone - see Multiple Sclerosis Agents
Coreg - see Carvedilol
Crizotinib, capsule, 200mg, 250mg (Xalkori-PFI)
For use as second-line therapy for the treatment of patients with ALK-positive advanced
non-small cell lung cancer (NSCLC) with ECOG performance status ≤2.
The request for coverage must be made and the medication prescribed by a specialist in
haematology or medical oncology, or a general practitioner acting under the direction of
those specialists, using the Special Authorization Request for Coverage of High Cost
Cancer Drugs available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Crohn=s Disease Biologic Agents
A) Moderate to Severe Crohn=s Disease
For the treatment of moderate to severe Crohn=s Disease in patients who:
1. Have a Harvey Bradshaw Index score of 7 or more, AND
2. Have not responded to 5-ASA products (minimum trial of 3 grams per day for 6
weeks), AND
3. Have not responded to or are intolerant to glucocorticosteroid therapy (e.g.
Prednisone) or where such therapy is contraindicated, AND
4. Have not responded to or are intolerant to immunosupressive therapy
(Azathioprine, Mercaptopurine or Methotrexate) or where such therapy is
contraindicated.
PEI Pharmacare Formulary …………………………………………………Page - 274 -
Adalimumab, kit, 40mg/0.8ml (Humira-ABB)
Initial 12 week approval for Adalimumab will allow for an induction dose of 160mg
followed by 80mg two weeks later, then 40mg every two weeks thereafter.
Coverage for ongoing therapy will require reassessment of the patient and
submission of a new Crohn=s Disease Special Authorization form. Continued
coverage may be approved at a dose not exceeding 40mg every 2 weeks.
Infliximab, injection powder, 100mg/vial (Remicade-JAN)
Initial approval for Infliximab will allow for 3 doses of 5mg/kg/dose administered at
0, 2, and 6 weeks. Renewal of coverage will require reassessment of the patient
and submission of a new Crohn=s Disease Special Authorization form. Continued
coverage will be approved at a dose not exceeding 5mg/kg every 8 weeks.
B) Fistulizing Crohn=s Disease
For the treatment of fistulizing Crohn=s Disease in patients who:
1. Have a Harvey Bradshaw Index score of 7 or more, AND
2. Have an actively draining perianal or enercutaneious fistula(e) that have recurred
or persisted despite a course of appropriate antibiotic therapy (e.g. Ciprofloxacin
with or without Metronidazole for a minimum of 3 weeks), AND
3. Have not responded to or are intolerant to immunosupressive therapy
(Azathioprine, Mercaptopurine or Methotrexate) or where such therapy is
contraindicated.
Infliximab, injection powder, 100mg/vial (Remicade-JAN)
Initial approval for Infliximab will allow for 3 doses of 5mg/kg/dose administered at
0, 2, and 6 weeks. Renewal of coverage will require reassessment of the patient
and submission of a new Crohn=s Disease Special Authorization form. Continued
coverage will be approved at a dose not exceeding 5mg/kg every 8 weeks.
The request for coverage must be made by a gastroenterologist using the Crohn=s
Disease Special Authorization form available from the Drug Programs office or
online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage to the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Cyclobenzaprine, tablet, 10mg (Generics)
As an adjunct to rest and physical therapy for relief of muscle spasm associated with
acute, painful musculoskeletal conditions not responding or experiencing severe adverse
reactions to alternative therapy. A maximum of three weeks (21 days) of therapy will
be considered.
Dabigatran, capsule, 110mg, 150mg (Pradaxa-BOE)
PEI Pharmacare Formulary …………………………………………………Page - 275 -
For the prevention of stroke and systemic embolism in at-risk patients with non-valvular
atrial fibrillation for whom:
a) Anticoagulation is inadequate following at least a two month trial of 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 dabigatran for atrial
fibrillation:
a) Patients with impaired renal function (creatinine clearance or estimated glomerular
filtration rate < 30mL/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 CHADS2 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.
The request for coverage must be made using the Dabigatran/Rivaroxaban Special
Authorization form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms
Dalteparin - see Low Molecular Weight Heparins
Darbepoetin Alfa, pre-filled syringe 25ug/mL, 40ug/mL, 100ug/mL, 200ug/mL
(Aranesp-AMG)
PEI Pharmacare Formulary …………………………………………………Page - 276 -
For the treatment of severe anemia related to chronic renal failure in patients with:
a)
Normocytic normochromic anemia, requiring transfusions in patients who have
evidence of iron overload (Ferritin > 1000 ng/mL), OR
b)
Anemia requiring blood transfusions in patients having symptomatic angina and/or
heart failure, OR
c)
Anemia requiring transfusion in patients with difficulties in blood grouping and
febrile reactions due to antibodies, OR
d)
Anemia requiring transfusions in patients who have high levels of panel reactive
anti HLA antibodies, OR
e)
Severe normocytic normochromic anemia (Hb < 100 g/L) whose only symptom is
fatigue and have never received transfusions.
The request for coverage must be made by a nephrologist or be based upon a
consultation with a nephrologist. A copy of the consultation must accompany the
request.
The request for coverage must be made using the Erythropoietin Program
Approval Form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms .
Darifenacin, extended release tablet, 7.5mg, 15mg (Enablex-NVR)
For the treatment of over-active bladder (not stress incontinence) in patients who cannot
tolerate or have an insufficient response to an adequate trial (e.g. 3 months) of immediate
release oxybutynin.
Dasatinib, tablet, 20mg, 50mg, 70mg (Sprycel-BMS)
For use as a single agent for the treatment of adults with chronic, accelerated or blast
phase chronic myelogenous leukemia (CML) and Philadelphia chromosome acute
lymphoblastic leukemia (Ph+ ALL) with resistance or intolerance to prior therapy including
Imatinib.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
DDAVP - see Desmopressin
Deferasirox, dispersible tablet, 125mg, 250mg, 500mg (Exjade – NVR)
PEI Pharmacare Formulary …………………………………………………Page - 277 -
For the treatment of patients who require iron chelation but in whom deferoxamine is
contraindicated.
Denosumab, pre-filled syringe, 60mg/ml (Prolia – AMG)
For the treatment of osteoporosis in postmenopausal women who were previously
approved or would otherwise be eligible for coverage of oral bisphosphonates and who:
1. Have experienced a further significant decline in BMD after 1 year of continuous
bisphosphonate therapy and meet at least two of the following criteria:
•
Age greater than 75 years
•
A prior fragility fracture
•
A BMD t-score of less than or equal to -2.5
OR
2. Have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the
esophagus (e.g. esophageal stricture or achalasia) and have at least two of the following:
•
Age greater than 75 years
•
A prior fragility fracture
•
A BMD t-score of less than or equal to -2.5
Notes:
Hypersensitivity or abnormalities are 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.
In all cases, patients receiving Prolia (denosumab) must not be receiving concomitant
bisphosphonate therapy.The recommended dose of Prolia (denosumab) is a single SC injection
of 60 mg, once every 6 months.
Desmopressin, oral disintegrating tablet, 60ug, 120ug, 240ug (DDAVP Melt-FEI); tablet,
0.1mg, 0.2mg (DDAVP-FEI and generics)
a)
For the treatment of diabetes insipidus in patients unable to tolerate the intranasal
solution or when the intranasal solution is ineffective.
b)
For the treatment of enuresis in children over 5 years and under 16 years of age
refractory to bed wetting alarms or alternative agents.
Desmopressin, intranasal solution, 10ug/dose, (DDAVP-FEI); intranasal solution (spray
pump), 10ug/dose (DDAVP-FEI and generics)
a)
For the treatment of diabetes insipidus. The maximum recommended daily
dosage is 40μg.
Detrol - see Tolterodine
Detrol LA - see Tolterodine
Dexiron - see Iron Dextran Complex
Dicetel – see Pinaverium
Didronel - see Etidronate
PEI Pharmacare Formulary …………………………………………………Page - 278 -
Dienogest, tablet, 2mg (Visanne-BAY)
For the managementof pelvic pain associated with endometriosis in patients for whom
one or more less costly options are either ineffective or cannot be used.
Diflucan - see Fluconazole
Dihydroergotamine Mesylate, nasal spray, 4mg/mL (Migranal-NVR)
For the treatment of migraine headaches where other standard therapies such as oral
analgesics have failed.
Coverage is limited to 6 bottles per 30 day period. Anyone requiring more than 6
bottles per 30 day period should be considered for migraine prophylaxis therapy if they
are not already receiving such therapy.
Dilaudid HP - see Hydromorphone, injection solution
Dilaudid XP - see Hydromorphone, injection solution
Diphenoxylate HCl & Atropine Sulfate, tablet, 2.5mg/0.025mg (Lomotil-PFI)
An adjunct in the management of diarrhea not responding to alternative therapy.
Ditropan XL - see Oxybutynin Chloride
Donepezil - see Cholinesterase Inhibitors (ChEI)
Dronabinol, capsule, 2.5mg, 5mg (Marinol-SLV)
a)
For the treatment of severe nausea and vomiting associated with cancer
chemotherapy in patients who have not been well controlled by standard stepwise
antiemetic therapy.
b)
For the treatment of acquired immune deficiency syndrome (AIDS)-related
anorexia associated with weight loss.
Duloxetine hydrochloride, delayed release capsule, 30mg, 60mg (Cymbalta – LIL)
For the treatment of neuropathic pain in diabetic patients who are unresponsive to
adequate courses of at least TWO less costly alternative agents such as a tricyclic
antidepressant and anticonvulsant agents. The maximum allowable dose is 60 mg daily.
Duragesic - see Fentanyl
Dutasteride, capsule, 0.5mg, (Avodart-GSK)
Approval will be for 0.5mg daily.
For the treatment of symptomatic Benign Prostatic Hyperplasia (BPH) when alphablockers are contraindicated, not tolerated, or failed.
PEI Pharmacare Formulary …………………………………………………Page - 279 -
Initial coverage is limited to 6 months. Continued coverage requires assessment for
adequate response and resubmission of a Standard Special Authorization request form.
Elmiron - see Pentosan Polysulfate Sodium
Emend - see Aprepitant
Enbrel - see Ankylosing Spondylitis Biologic Agents OR
- see Psoriatic Arthritis Biologic Agents OR
- see Rheumatoid Arthritis Biologic Agents
Enablex – see Darifenacin
Enfuvirtide, injection kit, 90mg/mL (Fuzeon-HLR)
For the treatment of AIDS in patients:
a)
Who have a CD4 count greater than 100 cells/mm3; AND
b)
Who have a viral load less than 100,000 copies/mL; AND
c)
Who have previously received less than 11 antiretroviral agents; AND
d)
Where therapy with Enfurvirtide is planned in combination with at least one other
antiretroviral drug to which sensitivity has been demonstrated on resistance
testing.
Enoxaparin - see Low Molecular Weight Heparins
Entacapone, tablet, 200mg (Comtan-NVR)
Note: For Nursing Home Program, no Special Authorization is required.
For the treatment of the signs and symptoms of Parkinson=s Disease in patients who are
experiencing motor fluctuations despite optimal treatment with Levodopa/Carboxylase
therapy upon written request or recommendation of a neurologist. A copy of the
recommendation must accompany the Special Authorization.
Entecavir, tablet, 0.5mg (Baraclude – BMS)
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.
Entocort - see Budesonide
Epinephrine, auto-injector, 0.15mg per dose, 0.3mg per dose (EpiPen-ALX, Twinject-ALX,
Allerject-AVN)
For the emergency treatment of anaphylactic reactions, when out of reach of immediate
medical attention.
PEI Pharmacare Formulary …………………………………………………Page - 280 -
Coverage is limited to one unit at a time.
To allow for the replacement of used or expired units, the pharmacy must contact the PEI
Pharmacare office and coverage will be provided on the day of the fill.
Additional physician requests are not required for replacement units once the initial
request has been approved.
NOTE: These products are not interchangeable.
EpiPen - see Epinephrine
EpiPen Jr. - see Epinephrine
Epoetin Alfa, pre-filled syringe, 10,000IU/mL (Eprex-JAN)
For the treatment of severe anemia related to chronic renal failure in patients with:
a)
Normocytic normochromic anemia, requiring transfusions in patients who have
evidence of iron overload (Ferritin > 1000 ng/mL), OR
b)
Anemia requiring blood transfusions in patients having symptomatic angina and/or
heart failure, OR
c)
Anemia requiring transfusion in patients with difficulties in blood grouping and
febrile reactions due to antibodies, OR
d)
Anemia requiring transfusions in patients who have high levels of panel reactive
anti HLA antibodies, OR
e)
Severe normocytic normochromic anemia (Hb < 100 g/L) whose only symptom is
fatigue and have never received transfusions.
The request for coverage must be made by a nephrologist or be based upon a
consultation with a nephrologist. A copy of the consultation must accompany the
request.
The request for coverage must be made using the Erythropoietin Program
Approval Form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms .
Epoprostenol - see Pulmonary Arterial Hypertension (PAH) Therapies
Eprex - see Epoetin Alfa
Erlotinib, tablet, 25mg, 100mg, 150mg (Tarceva-HLR)
For use as monotherapy for the treatment of patients with locally advanced or metastatic
NSCLC after failure of at least one prior chemotherapy regimen and whose EGFR
expression status is positive or unknown.
The request for coverage must be made and the medication prescribed by a
PEI Pharmacare Formulary …………………………………………………Page - 281 -
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Estradiol, transdermal patch, 25ug, 50ug, 75ug, 100ug (Estradot-NVR and generics)
For the treatment of patients with a documented intolerance to oral estrogen products.
Estradot - see Estradiol
Etanercept - see Ankylosing Spondylitis Biologic Agents OR
- see Psoriatic Arthritis Biologic Agents OR
- see Rheumatoid Arthritis Biologic Agents
Etidronate, tablet, 200mg (Didronel-PGA and generics)
For the treatment of symptomatic Paget's disease of the bone for a 6 month period.
Coverage can be renewed after a drug holiday of at least 90 days.
Exelon - see Cholinesterase Inhibitors (ChEI)
Extavia - see Multiple Sclerosis Agents
Ezetrol - see Ezetimibe
Ezetimibe, tablet, 10mg (Ezetrol-FRS)
a)
For the treatment of hypercholesterolemia, as adjunctive therapy with statins, in
patients who have not reached treatment goals on maximum tolerated statin
therapy alone.
b)
For the treatment of hypercholesterolemia, as monotherapy, in patients who are
intolerant to statins and, when appropriate, fibrates.
Febuxostat, tablet, 80mg (Uloric-TAK)
For the treatment of symptomatic gout in patients 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, transdermal patch, 12ug/hr, 25ug/hr, 37ug/hr, 50ug/hr, 75ug/hr, 100ug/hr
(Duragesic-JAN and generics)
For the treatment of severe chronic pain that is not well controlled by short and
PEI Pharmacare Formulary …………………………………………………Page - 282 -
long-acting Morphine and Hydromorphone products.
Fesoterodine Fumarate, extended release tablet, 4mg,8mg (Toviaz-PFI)
For the treatment of over active bladder (not stress incontinence) in patients who cannot
tolerate or have an insufficient response to an adequate trial (e.g. 3 months) of immediate
release oxybutynin.
Filgrastim, parenteral liquid, 300mcg/1mL, 480mcg/1.6mL (Neupogen-AMG)
Chemotherapy Support
a)
For use in patients treated with curative intent, where maintaining maximal dose
intensity is likely to improve the cure rate, and where the risk of neutropenic fever
is greater than 20%.
b)
For use in patients treated with curative intent, after an episode of neutropenic
fever or where treatment is delayed beyond one week due to neutropenia.
High Dose Chemotherapy With Stem Cell Support
For use in mobilizing stem cells in preparation for stem cell collection.
Neutropenic fever is defined as a body temperature of $ 38.5oC (as a single
measurement) or > 38oC three times in a 24 hour period and neutropenia with an
absolute netrophil count (ACN) < 0.5 x 109/L.
Must be requested and prescribed by a specialist in hematology or medical
oncology.
The manufacturer recommends an initial dose of 5mcg/kg/day. The dosage can be
rounded off to 300mcg or 480mcg to avoid wastage.
When dose scavenging techniques are not available, the following recommendations are
suggested:
$
Patients # 70 kg use 1 mL vial (300mcg)
$
Patients > 70 kg use 1.6 mL vial (480mcg)
Coverage will be limited to a maximum of 3 months. Coverage beyond this will require
completion and submission of a new Special Authorization form.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
PEI Pharmacare Formulary …………………………………………………Page - 283 -
Finasteride, tablet, 5mg (Proscar-MSD and generics)
Approval will be for 5mg daily.
For the treatment of symptomatic Benign Prostatic Hyperplasia (BPH):
a) When alpha-blockers are contraindicated, not tolerated, or failed OR
b) In combination with an alpha-blocker when alpha-blocker therapy has been tried as
monotherapy and a partial response has been observed.
Initial coverage is limited to 6 months. Continued coverage requires assessment for
adequate response and resubmission of a Standard Special Authorization request form.
Fingolimod - See Multiple Sclerosis Agents
Flexeril - see Cyclobenzaprine
Flolan - see Pulmonary Arterial Hypertension (PAH) Therapies
Floxin - see Ofloxacin
Fluconazole, tablet, 50mg, 100mg (Diflucan-PFI and generics)
Note: For AIDS/HIV program no Special Authorization is required.
a)
For the treatment of severe or life-threatening systemic fungal infections.
b)
For the treatment of severe dermatophytoses not responding to other forms of
therapy.
Fludara - see Fludarabine
Fludarabine, tablet, 10mg (Fludara-BAY)
For the treatment of chronic lymphocytic leukemia (CLL) in patients with an ECOG
performance status of 0 to 2 when the patient has failed to respond to, or relapsed during/
after previous therapy with an alkylating agent and intravenous administration is not
desirable.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Foradil - see Formoterol
PEI Pharmacare Formulary …………………………………………………Page - 284 -
Formoterol Fumerate, powder for inhalation (capsule), 12ug/dose (Foradil-NVR); powder
for inhalation (inhaler), 6ug/dose, 12ug/dose (Oxeze Turbuhaler-AZE)
a)
For the treatment of asthma when used in patients on concurrent steroid therapy.
b)
For the treatment of COPD, see Chronic Obstructive Pulmonary Disease.
Note: Patients using these products must also have access to a short-acting beta-2
agonist bronchodilator for the relief of acute symptoms.
Formoterol & Budesonide, powder for inhalation, 6ug & 100ug per dose, 6ug & 200ug per
dose (Symbicort Turbuhaler-AZE)
a)
For the treatment of asthma in patients who are not well controlled on a regular
and adequate course of inhaled steroid therapy prior to the request for
combination therapy. Continuation of current coverage requires regular use of an
adequate dose of this medication.
b)
For the treatment of COPD, see Chronic Obstructive Pulmonary Disease.
Note: Patients using this product must also have access to a short-acting beta-2
agonist bronchodilator for the relief of acute symptoms.
Fosamax 10mg & 70mg - see Bisphosphonates
Fosamax 40mg - see Alendronate
Fosavance – see Bisphosphonates
Fragmin - see Low Molecular Weight Heparins
Fuzeon - see Enfuvirtide
Galantamine - see Cholinesterase Inhibitors (ChEI)
Gatifloxacin, ophthalmic drops, 0.3% (Zymar-ALL)
For the treatment/prevention of bacterial conjunctivitis associated with eye surgery.
Glatiramer Acetate - see Multiple Sclerosis Agents
Gleevec - see Imatinib
Gilenya – see Multiple Sclerosis Agents
Glucagen – see Glucagon (Human Recombinant)
Glucagon (Human Recombinant), vial, 1mg; kit, 1mg (Glucagen - PAL)
Note: Not interchangeable. IM administration only.
For emergency treatment of severe hypoglycaemia in patients treated with insulin when
PEI Pharmacare Formulary …………………………………………………Page - 285 -
unconsciousness precludes oral carbohydrates.
Glucagon – see Glucagon (Recombinant DNA Origin)
Glucagon (Recombinant DNA Origin), vial,1mg (Glucagon – LIL)
Note: Nursing Home Program does not require a special authorization. Not
interchangeable.
For emergency treatment of severe hypoglycaemia in patients treated with insulin when
unconsciousness precludes oral carbohydrates.
Glycopyrronium Bromide, inhalation capsule, 50mcg (Seebri Breezhaler – NVR)
a) For the treatment of mild, moderate, and severe chronic obstructive pulmonary disease
(COPD) (i.e. MRC score $ 2) in patients who continue to be symptomatic after a 3 month
trial of ipratropium at a dose of 12 puffs/day and appropriate use of short-acting beta2agonists.
b) For the treatment of moderate to severe chronic obstructive pulmonary disease (COPD)
(i.e. MRC score 3 to 5) without a trial of short-acting agents (e.g. ipratropium and beta2agonists) where spirometry shows moderate to severe airflow obstruction (i.e. FEV1 < 60%
predicted AND low FEV1/FVC <0.7). A copy of the spirometry report must accompany the
Special Authorization.
Golimumab – see Ankylosing Spondylitis Biologic Agents OR
see Psoriatic Arthritis Biolgoic Agents OR
see Rheumatoid Arthritis Biolgoic Agents
Hepsera – see Adefovir Dipivoxil
Hp-PAC - see Lansoprazole & Clarithromycin & Amoxicillin
Humira - see Ankylosing Spondylitis Biologic Agents OR
- see Crohn=s Disease Biologic Agents OR
- see Psoriatic Arthritis Biologic Agents OR
- see Rheumatoid Arthritis Biologic Agents
Hydromorph Contin - see Hydromorphone, controlled-release capsule
Hydromorphone HCl, controlled-release capsule, 3mg, 4.5mg, 6mg, 9mg, 12mg, 18mg,
24mg, 30mg (Hydromorph Contin-PFR)
For the treatment of patients with documented severe chronic pain that is not well
controlled by short and long-acting Morphine and short-acting Hydromorphone products.
Hydromorphone HCl, injection solution, 10mg/mL, 50mg/mL (Dilaudid HP-JAN,
Dilaudid XP-JAN)
Note: For Nursing Home Program, no Special Authorization is required.
For the treatment of severe chronic pain that is not well controlled by short and
PEI Pharmacare Formulary …………………………………………………Page - 286 -
long-acting oral Morphine and Hydromorphone products:
For other patients upon written request or recommendation from a palliative care
or pain clinic. A copy of the recommendation must accompany the Special
Authorization.
Hydromorphone HP - see Hydromorphone, injection solution
Imatinib, tablet, 100mg, 400mg (Gleevec-NVR)
a)
For the treatment of patients who have documented evidence of Philadelphia
chromosome positive (Ph+) chronic myeloid leukemia (CML), with an ECOG
performance status of 0 - 2*.
b)
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.
c)
For the treatment of patients with C-Kit positive (CD117), metastatic or locally
advanced, inoperable gastrointestinal stromal tumours (GIST) and who have an
ECOG performance status of 0 - 2*.
Must be prescribed by a hematologist or oncologist.
•
Patients who are asymptomatic and those who are symptomatic and in bed less than
50% of the time.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request
for Coverage of High Cost Cancer Drugs available from the Drug Programs Office
or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage to the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms
Imitrex - see Sumatriptan
Incivek – see Telaprevir
Indacaterol, capsule,inhalation powder, 75mcg (Onbrez-NVR)
a) For the treatment of mild, moderate, and severe chronic obstructive pulmonary disease
(COPD) (i.e. MRC score ≥ 2) in patients who continue to be symptomatic after a 3 month
trial of ipratropium at a dose of 12 puffs/day and appropriate use of short-acting beta2agonists.
b) For the treatment of moderate to severe chronic obstructive pulmonary disease
(COPD) (i.e. MRC score 3 to 5) without a trial of short-acting agents (e.g. ipratropium and
beta2-agonists) where spirometry shows moderate to severe airflow obstruction (i.e.
PEI Pharmacare Formulary …………………………………………………Page - 287 -
FEV1 < 60% predicted AND low FEV1/FVC <0.7). A copy of the spirometry report must
accompany the Special Authorization.
Infliximab - see Ankylosing Spondylitis Biologic Agents OR
- see Crohn=s Disease Biologic Agents OR
- see Rheumatoid Arthritis Biologic Agents
Infufer - see Iron Dextran Complex
Innohep – see Low Molecular Weight Heparins
Interferon Alfa-2B, premixed solution, 6 million IU/mL, 10 million IU/mL; multi-dose pen, 15
million IU/mL, 25 million IU/mL, 50 million IU/mL (Intron A-MSD)
For the treatment of Hairy Cell Leukemia, AIDS-related Kaposi=s Sarcoma, and Basal Cell
Carcinoma.
The request for coverage must be made to the Chief Health Officer (telephone:
902-368-4996).
Interferon Beta-1A - see Multiple Sclerosis Agents
Interferon Beta-1B - see Multiple Sclerosis Agents
Intron A - see Interferon Alfa-2B
Iron Dextran Complex, injection solution, 50mg/mL (Infufer-SAB, Dexiron-MYL)
For the treatment of documented iron deficiency anemia (Hgb less than 115 g/L for men
or 100 g/L for women) when patients are intolerant to oral iron replacement products.
Note: Coverage for dialysis patients is provided under the Dialysis Program.
Itraconazole, capsule, 200mg (Sporanox-JAN)
a)
For the treatment of severe systemic fungal infections not responding to
alternative therapy.
b)
For the treatment of severe or resistant fungal infections in immunocompromised
patients not responding to alternative therapy.
c)
For the treatment of severe onychomycosis caused by dermatophyte fungi not
responding to alternative therapy, as diagnosed by a dermatologist or attending
physician.
Ketoconazole, tablet, 200mg (generics)
Note: For AIDS/HIV program no Special Authorization is required.
a)
For the treatment of severe or life-threatening systemic fungal infections.
b)
For the treatment of severe dermatophytoses not responding to other forms of
therapy.
PEI Pharmacare Formulary …………………………………………………Page - 288 -
Kytril – see Granisetron
Lacosamide, tablet, 50mg, 100mg, 150mg, 200mg (Vimpat-UCB)
For adjunctive therapy in patients with refractory partial-onset seizures who meet all of
the following criteria:
a)
Are under the care of a physician experienced in the treatment of epilepsy, AND
b)
Are currently receiving two or more antiepileptic drugs, AND
c)
In whom all other antiepileptic drugs are ineffective or not appropriate.
Lamisil - see Terbinafine
Lansoprazole - see Proton Pump Inhibitors
Lansoprazole & Clarithromycin & Amoxicillin, 7-day package, 30mg & 500mg & 500mg
(Hp-PAC-ABB)
One week of therapy will be considered for individuals with documented duodenal or
gastric ulcers and a recent documented positive helicobacter pylori test.
Leflunomide, tablet, 10mg, 20mg (Arava-AVT and generics)
For the treatment of patients with active Rheumatoid Arthritis who:
a)
Have not responded to or have had intolerable toxicity to an adequate trial of
Methotrexate and at least one of the following DMARDs (disease modifying
antirheumatic drugs): IM Gold, Sulfasalazine, Hydroxychloroquine, Azathioprine,
Chloroquine, or Penicillamine, OR
b)
Are intolerant to or has a contraindication to Methotrexate and are refractory to at
least two of the following DMARDs (disease modifying antirheumatic drugs): IM
Gold, Sulfasalazine, Hydroxychloroquine, Azathioprine, Chloroquine, or
Penicillamine.
Levaquin - see Levofloxacin
Levodopa & Carbidopa, controlled release tablet, 100mg & 25mg, 200mg & 50mg
(Sinemet CR-BMS and generics)
Note: For Nursing Home Program, no Special Authorization is required.
For patients with dyskinesia who have experienced adverse effects related to drug level
fluctuations, such as On/Off or wearing-off phenomena, while being treated with
immediate release Levodopa and Carbidopa.
Levofloxacin, tablet, 250mg, 500mg (Levaquin-JAN and generics)
Note: For Cystic Fibrosis and Nursing Home Programs, no Special Authorization is
required.
a)
For the treatment of infections in persons allergic to alternative agents. Up to 10
days of therapy will be considered.
PEI Pharmacare Formulary …………………………………………………Page - 289 -
b)
c)
For the treatment of infections in patients with asthma or COPD not responding to
first-line antibiotics. Up to 10 days of therapy will be considered.
For the treatment of infections caused by organisms known to be resistant to
alternative antibiotics. Up to 10 days of therapy will be considered.
Linezolid, tablet, 600mg (Zyvoxam-PHU)
(a)
For the treatment of proven VRE (Vancomycin-Resistant Entercoccus) infections.
Must be prescribed in consultation with a specialist in infectious diseases. A
copy of a C&S report demonstrating Vancomycin resistance must accompany the
request. Up to 28 days of therapy will be considered.
(b)
For the treatment of proven MRSA (Methicillin-Resistant Staph. Aureus) and
MRSE (Methicillin-Resistant Staph. Epidermidis) infections in patients who are
unresponsive or intolerant to Vancomycin. Must be prescribed in consultation
with a specialist in infectious diseases. A copy of a C&S report demonstrating
Vancomycin resistance must accompany the request. Up to 28 days of therapy
will be considered.
Lomotil - see Diphenoxylate HCl & Atropine Sulfate
Losec - see Proton Pump Inhibitors
Lovenox - see Low Molecular Weight Heparins
Low Molecular Weight Heparins
Dalteparin, pre-filled syringe, 2500 iu, 5000 iu, 7500 iu, 10000 iu, 12500 iu, 15000 iu,
18000 iu; multi-dose vial (3.8ml), 25000 iu/ml (Fragmin-Pfizer)
Enoxaparin, pre-filled syringe, 30mg, 40mg, 60mg, 80mg, 100mg, 120mg, 150mg;
multi-dose vial, (3ml) 100mg/ml (Lovenox-Sanofi)
Tinzaparin, vial, 10000unit/mL, 20000unit/mL; syringe, 2500unit/0.25mL,
3500unit/0.35mL, 4500unit/0.45mL, 10000unit/0.5mL, 14000unit/0.7mL,
18000unit/0.9mL (Innohep-LEO)
For the acute treatment of deep vein thrombosis (DVT) and/or pulmonary embolism (PE)
for a maximum of 10 days.
For prophylaxis in hip replacement and hip fracture surgery, approval is limited to a
maximum of 35 days.
For prophylaxis in knee replacement surgery, approval is limited to a maximum of 10
days.
For prophylaxis in high risk surgery, approval is limited to maximum of 10 days.
PEI Pharmacare Formulary …………………………………………………Page - 290 -
The request for coverage must be made using the Low Molecular Weight Heparin Special
Authorization form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms
Lucentis - see Ranibizumab
Magic Bullet - see Bisacodyl
Marinol - see Dronabinol
Megace - see Megestrol Acetate
Megestrol Acetate, tablet, 40mg, 160mg (Megace-BMS and generics)
Note: For AIDS/HIV Program, no Special Authorization is required.
a)
b)
For the adjunctive or palliative treatment of recurrent, inoperable or metastatic
carcinoma of the breast and endometrium.
For the palliative treatment of hormone responsive advanced (Stage D2)
carcinoma of the prostate.
Mometasone Furoate/Formoterol Fumarate Dihydrate, inhaler, 50mcg/5mcg,
100mcg/5mcg, 200mcg/5mcg (Zenhale-MSD)
For the treatment of asthma in patients 12 years of age and older who are not well
controlled on a regular and adequate course of inhaled steroid therapy prior to the
request for combination therapy. Continuation of current coverage requires regular use of
an adequate dose of this medication.
Maximum dose is 800mcg/20mcg (4 puffs) per day
Metadol - see Methadone
Methadone, tablet, 1mg, 5mg, 10mg, 25mg (Metadol-PMS)
For the management of severe chronic or malignant pain that is not well controlled by
short and long-acting Morphine and Hydromorphone as well as Fentanyl products.
Methadone Solution, 10/mg/ml (Methadose-MAL)
For the management of patients undergoing therapy for opiod dependence.
NOTE: Not interchangeable
Methylphenidate HCl, controlled release capsule, 10mg, 15mg, 20mg, 30mg, 40mg, 50mg,
60mg, 80mg (Biphentin-PFR)
For the treatment of children age 6 to 18 years of age diagnosed with ADHD, who require
12 hours of continuous drug coverage due to academic and psycho-social need and who
meet the following:
Demonstrate significant and problematic disruptive behaviour OR have problems with
PEI Pharmacare Formulary …………………………………………………Page - 291 -
inattention that interferes with learning;
AND
Have been tried on methylphenidate (Ritalin) immediate or sustained-release tablets with
unsatisfactory results.
Must be prescribed or recommended by a pediatrician, psychiatrist, or general
practitioner with expertise in the treatment of ADHD.
The maximum daily approved dosage will be 1mg/kg/day to a maximum of 80mg
per day.
Methysergide Maleate, tablet, 2mg (Sansert-NVR)
For the prophylaxis of recurrent vascular headaches. Coverage will be provided for up to
6 months at a time with a 3-4 week medication free interval between courses of therapy.
Midodrine HCl, tablet, 2.5mg, 5mg (Amatine-RBP)
For the treatment of neurogenic types of idiopathic orthostatic hypotension, that is in the
Bradbury-Eggleston or Shy-Drager Syndromes.
Migranal - see Dihydroergotamine Mesylate
Minocin - see Minocycline
Minocycline HCl, capsule, 50mg, 100mg (Minocin-STI and generics)
For the treatment of acne unresponsive to Tetracycline.
Mirapex - see Pramipexole Dihydrochloride
Modafinil, tablet, 100mg (Alertec-SHR and generics)
For the treatment of patients with a confirmed sleep-laboratory diagnosis of narcolepsy or
idiopathic CNS hypersomnia.
Montelukast, chewable tablet, 4mg, 5mg; tablet, 10mg (Singulair-MSD)
For the adjunctive treatment of asthma in patients not well controlled with regular use of
inhaled corticosteroids. Only appropriate dosing as shown in the current Compendium of
Pharmaceuticals and Specialties (CPS) will be considered.
Morphine Sulfate, injection solution, 50mg/mL (Morphine Sulfate-SAB)
For the treatment of severe chronic pain that is not well controlled by short and
long-acting oral Morphine and Hydromorphone products:
a)
For patients covered by the Nursing Home Program without a Special
Authorization.
b)
For other patients upon written request or recommendation from a palliative care
or pain clinic. A copy of the recommendation must accompany the Special
Authorization.
PEI Pharmacare Formulary …………………………………………………Page - 292 -
Moxifloxacin, ophthalmic drops, 0.5% (Vigamox-ALC)
For the treatment/prevention of bacterial conjunctivitis associated with eye surgery.
Moxifloxacin, tablet, 400mg (Avelox-BAY)
Note: For Nursing Home and Cystic Fibrosis Programs, no Special Authorization is
required.
a)
b)
For the treatment of severe pneumonia in nursing home patients
For the completion of therapy instituted in the hospital setting for the treatment of
severe community acquired pneumonia.
Multiple Sclerosis Agents
Glatiramer Acetate, syringe, 20mg/mL (Copaxone-TVM)
Interferon Beta-1A, injection powder, 30mcg (Avonex-BGN); pre-filled syringe,
30mcg (Avonex PS-BGN); pre-filled cartridge, 66mcg/1.5ml, 132mcg/1.5ml (RebifSRO); pre-filled syringe, 22mcg, 44mcg (Rebif-SRO)
Interferon Beta-1B, injection powder, 0.3mg (Betaseron-BAY); injection powder,
0.3mg (Extavia-NVR)
For the treatment of patients 18 years of age or older, diagnosed with relapsing-remitting
and secondary progressive multiple sclerosis, who have had two attacks within the past
two years, and have an EDSS score of 6.5 or less.
Fingolimod, capsule, 0.5mg (Gilenya-NVR)
For the treatment of patients with Relapsing Remitting Multiple Sclerosis (RRMS) who
meet all of the following criteria:
a) Failure to respond to full and adequate courses* of at least one interferon OR glatiramer
acetate; OR documented intolerance** to both therapies
b) One or more clinically disabling relapses in the previous year
c) Significant increase in T2 lesion load compared with that from a previous MRI scan (i.e. 3
or more new lesions) or at least one gadolinium-enhancing lesion
d) Requested and followed by a neurologist experienced in the management of RRMS
e) Recent Expanded Disability Status Scale (EDSS) score of less than or equal to 5.5 (i.e.
patients must be able to ambulate at least 100 meters without assistance)
* Failure to respond to full and adequate courses: defined as a trial of at least 6
months of interferon or glatiramer therapy AND experienced at least one disabling
PEI Pharmacare Formulary …………………………………………………Page - 293 -
relapse (attack) while on interferon or glatiramer therapy (MRI report does not need to
be submitted with the request)
***Intolerance is defined as: documented serious adverse effects or contraindications
that are incomplete with further use of that class of drug.
Dosage: 0.5 mg once daily
Approval period: Up to 12 months
Exclusion Criteria:
a) Do not fund combination therapy of Gilenya with other disease modifying therapies (e.g.
Avonex, Betaseron, Copaxone, Rebif, Extavia, Tysabri) nor in combination with Fampyra.
b) Do not fund in patients with EDSS > 5.5
c) Do not fund in patients who have had a heart attack or stroke in the last 6 months of
funding request, history of sick sinus syndrome, atrioventricular block, significant QT
prolongation, bradycardia, ischemic heart disease, or congestive heart failure
d) Patients < 18 years of age
e) Needle phobia or preference for oral therapy over injection in patients without clinical
contraindication to interferon or glatiramer therapy
f)
Skin reactions at the site of injection do NOT qualify as a contraindication to interferon or
glatiramer therapy
Renewal:
a) Date and details of the most recent neurological examination and EDSS scores must be
provided (exam must have occurred within that last 90 days).
b) Patients must be stable or have experienced no more than 1 disabling attack/relapse in
the past year; AND
c) Recent Expanded Disability Status Scale (EDSS) score of 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: 12 months
The request for coverage must be made by a neurologist using the PEI Multiple
PEI Pharmacare Formulary …………………………………………………Page - 294 -
Sclerosis Medications Program Medical Screening Form available from the Drug
Programs office or online at http://healthpei.ca/pharmacareforms
Patients must also apply for coverage to the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms
Nabilone, capsules, 0.5mg, 1mg (Cesamet-VAL)
a)
For the treatment of severe nausea and vomiting associated with cancer
chemotherapy in patients who have not been well controlled by standard stepwise
antiemetic therapy.
b)
For the treatment of acquired immune deficiency syndrome (AIDS)-related
anorexia associated with weight loss.
Nabumetone, tablets, 500mg (Relafen-GSK and generics)
For patients requiring treatment with an NSAID where there has been failure or
intolerance to at least three NSAIDS (including at least one enteric coated NSAID).
Nalcrom - see Sodium Cromoglycate
Naltrexone, tablet, 50mg (Revia-APX)
For the treatment of alcohol dependence, as an adjunct to a comprehensive
psychotherapeutic or psychological alcoholism counseling program to support
abstinence, and reduce the risk of relapse.
Eligibility is initially restricted to a three month period with reassessment at that time for
further coverage. Continued coverage will require information on the outcome of therapy
as well as the patient’s compliance with treatment programs.
Naratriptan HCl, tablet, 1mg, 2.5mg (Amerge-GSK)
For the treatment of migraine headaches where other standard therapies, such as oral
analgesics have failed AND the patient has not responded to oral Sumatriptan.
Coverage is limited to 6 tablets per 30 day period. Anyone requiring more than 6
doses per 30 day period should be considered for migraine prophylaxis therapy if they
are not already receiving such therapy.
Neupogen - see Filgrastrim
Nexavar - see Sorafenib
Nilotinib, capsule, 150mg, 200mg (Tasigna-NVR)
For the treatment of leukemia (CML, progressed or intolerant of imatinib)
a) As a single second line agent for the treatment of adults with chronic or accelerated
phase CML with resistance or intolerance to prior therapy.
PEI Pharmacare Formulary …………………………………………………Page - 295 -
These second line criteria include:
· Patients with CML in chronic phase who are intolerant to oral tyrosine kinase
inhibitors (TKIs) (i.e. imatinib or dasatinib or both)
· Patients with CML in chronic phase who are resistant to imatinib
· Patients with CML that have progressed to accelerated phase while on imatinib
therapy
b) In any one patient, only two of the TKIs will be funded within these criteria during their
lifetime.
c) If a patient develops grade 3 or 4 toxicity to one of the TKIs used within 3 months of
initiating therapy, access to a third agent will be funded.
d) Sequential use of nilotinib and dasatinib is not permitted except in the circumstance
described above (i.e. grade 3 or 4 toxicity).
The request for coverage must be made and the medication prescribed by a specialist in
haematology or medical oncology, or a general practitioner acting under the direction of
those specialists, using the Special Authorization Request for Coverage of High Cost
Cancer Drugs available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Nilutamide, tab, 50mg (Anadron-AVN)
In the treatment of metastatic prostatic carcinoma (Stage D2) in conjunction with surgical
or chemical castration.
Nitoman - see Tetrabenazine
Nizoral - see Ketoconazole
Norfloxacin, tablet, 400mg (Noroxin-MSD and generics)
Note: For Nursing Home program no Special Authorization is required.
a)
For the treatment of urinary tract infections caused by Pseudomonas aeruginosa.
Up to 10 days of therapy will be considered.
b)
For the treatment of urinary tract infections not responding to alternative therapy.
Up to 10 days of therapy will be considered.
c)
For the treatment of urinary tract infections in persons allergic to alternative
agents. Up to 10 days of therapy will be considered.
d)
Prophylaxis of chronic urinary tract infections in persons allergic to alternative
agents or where prophylaxis with alternative agents has failed.
(Note: Recommended dosage is 200mg at bedtime)
Noroxin - see Norfloxacin
Norprolac – see Quinagolide
PEI Pharmacare Formulary …………………………………………………Page - 296 -
Ocuflox - see Ofloxacin
Octreotide, injection, 200ug/mL (5mL) (Sandostatin-NVR)
For the management of terminal malignant bowel obstruction.
Ofloxacin, ophthalmic solution, 0.3% (Ocuflox and generics)
Note: For Nursing Home Program, no Special Authorization is required.
For the treatment of ophthalmic infections caused by susceptible bacteria and not
responding to alternative agents.
Ofloxacin, tablet, 200mg, 300mg, 400mg (Floxin-JAN and generics)
Note: For Nursing Home Program, no Special Authorization is required.
a)
b)
c)
d)
For the treatment of infections in persons allergic to alternative agents. Up to 10
days of therapy will be considered.
For the treatment of chronic bacterial prostatitis. Up to six weeks (42 days) of
therapy will be considered.
For the prophylaxis of infection in immunocompromised patients. Up to 10 days
of therapy will be considered.
For the treatment of urinary tract infections unresponsive to other antibiotics. Up
to 10 days of therapy will be considered.
Olanzapine, orally disintegrating tablet, 5mg, 10mg, 15mg (Zyprexa Zydis-LIL and
generics); tablet, 2.5mg, 5mg, 7.5mg, 10mg, 15mg (Zyprexa-LIL and generics)
Family Health Benefit and Financial
Assistance Programs (No Special
Authorization Required)
Nursing Home Program, Seniors Drug
Cost Assistance Plan and Catastrophic
Drug Plan
(Special Authorization Required)
For the treatment of patients with
schizophrenia and related psychotic
disorders and the acute treatment of manic
or mixed episodes in bipolar disorder:
For the treatment of patients with
schizophrenia and related psychotic
disorders and the acute treatment of
manic or mixed episodes in bipolar
disorder upon written request or
recommendation of a psychiatrist or
geriatrician. A copy of the
recommendation must accompany the
Special Authorization.
(a) Upon prescription by a psychiatrist or
geriatrician; or
(b) From other practitioners in consultation
with a psychiatrist or geriatrician.
Consultation with the psychiatrist or
geriatrician may be in person or by phone.
A statement such as APrescribed in
Consultation With Dr. *****@ will be
required on the prescription or if
ordered by telephone, the pharmacist
PEI Pharmacare Formulary …………………………………………………Page - 297 -
must request and include the name of
the consulting psychiatrist or
geriatrician on the transcribed
prescription.
Omeprazole - see Proton Pump Inhibitors
Onabotulinumtoxina, injection, 200units/vial (Botox-ALL)
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 HCl, tablet, 4mg, 8mg (Zofran-GSK and generics)
For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy (i.e.
containing Cisplatin); receiving moderately emetogenic chemotherapy (i.e. containing
Cyclophosphamide, Doxorubicin, Epirubicin, or Melphalan); or receiving radiation therapy and
who have:
a)
Experienced adverse effects to Metoclopramide, Prochlorperazine, or
Dexamethasone or have a specific contraindication which does not allow use of
these drugs as antiemetics or,
b)
Continued episodes of nausea and vomiting related to chemotherapy which have
not responded to therapeutic doses of Metoclopramide, Prochlorperazine, or
Dexamethasone.
A maximum of 10 tablets per cycle of chemotherapy will be approved.
Only requests for the oral dosage forms are eligible for consideration.
Oxeze - see Formoterol
Oxybutynin Chloride, extended release tablet, 5mg, 10mg (Ditropan XL-JAN
For the treatment of over-active bladder (not stress incontinence) after a reasonable trial
(e.g. 3 months) of Oxybutynin immediate release is not tolerated.
Oxycarbazepine, tablet, 150mg, 300mg, 600mg (Trileptal-NVR and generics)
For use in patients who have a diagnosis of epilepsy and have had an inadequate
response to or are intolerant to at least 3 other formulary agents (prior or current use),
including Carbamazepine.
PEI Pharmacare Formulary …………………………………………………Page - 298 -
Pamidronate Disodium, injection powder, 30mg, 60mg, 90mg vial (Aredia-NVR and
generics)
For the management of tumour-induced hypercalcemia following adequate saline
rehydration or conditions associated with increased osteoclast activity.
Pantoloc - see Proton Pump Inhibitors
Pantoprazole Magnesium - see Proton Pump Inhibitors
Pantoprazole Sodium - see Proton Pump Inhibitors
Pariet - see Proton Pump Inhibitors
Pazopanib, tablet, 200mg (Votrient-GSK)
1. As a first-line treatment for patients with advanced or metastatic clear cell renal
carcinoma and good performance status.
2. 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.
Renewal criteria: Written confirmation that the patient has benefited from therapy and is
expected to continue to do so.
Pegasys - see Peginterferon Alfa-2A
Pegasys RBV - see Peginterferon Alfa-2A & Ribavirin
Pegetron Redipen - see Peginterferon Alfa-2B & Ribavirin
Peginterferon Alfa-2A, vial, 180ug/mL; pre-filled syringe, 180ug/mL (Pegasys-HLR)
For the treatment of Hepatitis C.
The request for coverage must be made to the Chief Health Officer (telephone:
902-368-4996).
Peginterferon Alfa-2A & Ribavirin, vial, 180ug/mL & capsule, 200mg; pre-filled syringe,
180ug/mL & capsule 200mg (Pegasys RBV-HLR)
For the treatment of Hepatitis C.
The request for coverage must be made to the Chief Health Officer
(telephone: 902-368-4996).
Peginterferon Alfa-2B & Ribavirin, pen, 80ug/0.5mL & capsule, 200mg; pen, 100ug/mL &
capsule, 200mg; pen, 120ug/mL & capsule, 200mg; pen, 150ug/mL & capsule, 200mg
(Pegetron Redipen-MSD)
For the treatment of Hepatitis C.
PEI Pharmacare Formulary …………………………………………………Page - 299 -
The request for coverage must be made to the Chief Health Officer
(telephone: 902-368-4996).
Pentosan Polysulfate Sodium, capsule, 100mg (Elmiron-JAN)
For the treatment of interstitial cystitis where other treatments have failed.
Perichlor - see Chlorhexidine
Peridex - see Chlorhexidine
Pilocarpine, tablet, 5mg (Salagen-PFI)
For oncology patients only, for the treatment of the symptoms of xerostomia due to
salivary gland hypofunction caused by radiotherapy for cancer of the head and neck.
Patients must have tried and failed non-prescription measures (e.g. Moi-Stir).
Pioglitazone - see Thiazolidinediones
Plavix - see Clopidogrel
Pradaxa – see Dabigatran
Pramipexole Dihydrochloride, tablet, 0.25mg, 0.5mg, 1mg, 1.5mg (Mirapex-BOE and
generics)
Note: For Nursing Home Program, no Special Authorization is required.
For the treatment of the signs and symptoms of Parkinson=s Disease in patients who are
experiencing motor fluctuations despite optimal treatment with Levodopa/Carboxylase
therapy upon written request or recommendation of a neurologist. A copy of the
recommendation must accompany the Special Authorization.
Prevacid - see Proton Pump Inhibitors
Prevacid Fastab - see Proton Pump Inhibitors
Prezista - see Darunavir
Prolia – see Denosumab
Proton Pump Inhibitors
Lansoprazole, delayed release capsule, 15mg, 30mg (Prevacid-TAP);
Lansoprazole, delayed release tablet, 15mg, 30mg (Prevacid Fastab-TAP);
Omeprazole, capsule, 20mg (Losec-AZE and generics);
Omeprazole, delayed release tablet, 20mg (Losec-AZE and generics);
Pantoprazole Magnesium, enteric tablet, 40mg (Tecta-NYC)
Pantoprazole Sodium, enteric tablet, 20mg, 40mg (Pantoloc-NYC and generics);
PEI Pharmacare Formulary …………………………………………………Page - 300 -
Rabeprazole, tablet, 10mg, 20mg (Pariet-JAN and gererics)
* Doses of Omeprazole 20mg daily, Pantoprazole Magnesium 40mg daily ,
Pantoprazole Sodium 20mg or 40mg up to one unit daily, and up to Rabeprazole
20mg daily DO NOT require a Special Authorization.
For doses of Omeprazole and Rabeprazole greater than 20mg per day and greater than
40mg per day of Pantoprazole Magnesium, greater than one unit/day of Pantoprazole
Sodium 20mg or 40mg, and all doses of Lansoprazole WHERE evidence is provided of
resistance to two recent 12 week trials (ie within 6 months) of a standard dose (20mg
daily) of Omeprazole, Rabeprazole, Pantoprazole Magnesium 40mg daily and greater
than one unit per day of Pantoprazole Sodium 20mg or 40mg.
Up to 12 weeks of therapy will be considered for
a)
Gastric and Duodenal Ulcers
b)
Esophagitis
Long term therapy will be considered for
c)
Erosive Esophagitis
d)
Barrett=s Esophagitis
e)
Zollinger-Ellison Syndrome
f)
Helicobacter pylori Eradication (Omeprazole , Rabeprazole, Pantoprazole
Magnesium, or Pantoprazole Sodium only.
One week of therapy will be considered for individuals with documented duodenal
or gastric ulcers and a recent documented positive helicobacter pylori test.
Protopic - see Tacrolimus
Proscar - see Finasteride
Psoriatic Arthritis Biologic Agents
Adalimumab, kit, 40mg/0.8ml (Humira-ABB)
Approvals will be for a maximum adult dose of 40mg every two weeks.
Etanercept, pre-filled syringe, 50mg/ml; injection powder, 25mg/kit (Enbrel-AMG)
Approvals will be for a maximum adult dose of 50mg per week or 25 mg twice weekly.
Golimumab, Syringe, 50mg/0.5ml; auto-injector, 50mg/0.5ml (Simponi-MSD)
Approvals will be for a maximum adult dose of 50mcg once monthly.
For the treatment of active psoriatic arthritis in patients who meet the following criteria:
a) Have at least three active and tender joints AND
b) Have not responded to an adequate trial with two DMARDs or have an intolerance or
contraindication to DMARDs.
Approvals for initial coverage of Psoriatic Arthritis anti-TNF agents will be 4 months.
PEI Pharmacare Formulary …………………………………………………Page - 301 -
Coverage will NOT be considered in combination with other biologic agents.
Reassessment for coverage is dependent on patient achieving an improvement in symptoms of at
least 20% (ACR20) or response using the Psoriatic Arthritis Response Criteria.
The request for coverage must be made by a rheumatologist or prescriber with a specialty
in rheumatology, using the Psoriatic Arthritis Special Authorization form available from the
Drug Programs office or online at http://healthpei.ca/pharmacareforms
Patients must also apply for coverage through the High Cost Drug Program. The patient
application is available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms
Pulmicort Nebuamps - see Budesonide
Pulmonary Arterial Hypertension (PAH) Therapies
Ambrisentan, tablet, 5mg, 10mg (Volibris-GSK)
Bosentan, tablet, 62.5mg, 125mg (Tracleer-ACT)
Epoprostentol, powder for solution (injection), 0.5mg. 1.5mg (Caripul-ACT)
Epoprostentol, powder for solution (injection), 0.5mg, 1.5mg (Flolan-GSK)
Sildenafil, tablet, 20 mg (Revatio-PFI and generics)
GENERAL COVERAGE CRITERIA
Coverage is limited to the treatment of Idiopathic Arterial Hypertension (IPAH) and
Pulmonary Arterial Hypertension (PAH) secondary to scleroderma, congenital heart
disease or HIV.
Coverage will only be approved in a step-wise manner of Sildenafil to Bosentan or
Ambrisentan to Flolan or Caripul (see specific criteria for coverage of these medications
below). Coverage of the next medication in the sequence will only be considered where a
patient has failed or was intolerant to therapy with the previous medication or where the
previous medication is contraindicated.
Coverage will only be provided for one medication at a time. There will be no coverage
allowed for tapering off or overlap of medications.
Coverage will be limited to medication and associated diluent costs only. No coverage will
be provided for equipment or medical supplies (e.g. pumps, IV tubing, IV catheters, etc.).
Coverage will be based upon a monthly supply of mediation with no more than one
prescription for a given medication and strength being covered in a given 30-day period.
Coverage must be requested and all medications prescribed by a Pulmonary Arterial
Hypertension (PAH) specialist.
Diagnosis of pulmonary arterial hypertension (PAH) must be confirmed by right heart
catherization.
PEI Pharmacare Formulary …………………………………………………Page - 302 -
STEP 1 - Sildenafil, tablet, 20mg (Revatio-PFI and generics)
Idiopathic Pulmonary Arterial Hypertension (IPAH) (functional class III)
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 (CCB) or are intolerant to CCB.
Pulmonary Arterial Hypertension (PAH) secondary to connective tissue disease
(functional class III)
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 (e.g. diuretics, Digoxin,
Warfarin, and calcium channel blockers).
Note: Dosage is limited to 20mg given three times daily.
STEP 2 - Bosentan, tablet, 62.5mg, 125mg (Tracleer-ACT) OR
Ambrisentan, tablet, 5mg, 10mg (Volibris-GSK)
Note: Ambrisentan dosage is limited to 10mg given once daily.
Idiopathic Pulmonary Arterial Hypertension (IPAH) (functional class III and IV)
For the treatment of patients with World Health Organization (WHO) functional
class III and IV 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 (CCB) or are intolerant to CCB
AND Sildenafil therapy or where such therapies are contraindicated.
Pulmonary Arterial Hypertension (PAH) secondary to scleroderma, congenital heart
disease, or HIV (functional class III and IV)
For the treatment of patients with World Health Organization (WHO) functional
class III and IV pulmonary arterial hypertension (PAH) associated with
scleroderma, congenital heart disease, or HIV who do not respond to conventional
therapy (e.g. diuretics, Digoxin, Warfarin, and calcium channel blockers) AND
Sildenafil therapy or where such therapies are contraindicated.
STEP 3 - Epoprostentol, powder for solution (injection), 0.5mg, 1.5mg (Flolan-GSK, CaripulACT)
Coverage will be limited to patients who meet the criteria for STEP 2 AND do not
respond to Bosentan or Ambrisentan or where these therapies are contraindicated.
Note: Coverage will be limited to medication and associated diluent costs
PEI Pharmacare Formulary …………………………………………………Page - 303 -
only. No coverage will be provided for equipment or medical supplies
(e.g. pumps, IV tubing, IV catheters, etc.).
Patients must also apply for coverage through the High Cost Drug Program. The patient
application is available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms.
Quetiapine, tablet, 25mg, 100mg, 150mg, 200mg, 300mg (Seroquel-AZE and generics)
Family Health Benefit and Financial
Assistance Programs (No Special
Authorization Required)
Nursing Home Program, Seniors Drug
Cost Assistance Plan and
Catastrophic Drug Plan
(Special Authorization)
For the treatment of patients with
schizophrenia and related psychotic disorders
and the acute treatment of manic or mixed
episodes in bipolar disorder:
For the treatment of patients with
schizophrenia and related psychotic
disorders and the acute treatment of
manic or mixed episodes in bipolar
disorder upon written request or
recommendation of a psychiatrist or
geriatrician. A copy of the
recommendation must accompany the
Special Authorization.
(a) Upon prescription by a psychiatrist or
geriatrician; or
(b) From other practitioners in consultation
with a psychiatrist or geriatrician.
Consultation with the psychiatrist or
geriatrician may be in person or by phone. A
statement such as APrescribed in
Consultation With Dr. *****@ will be required
on the prescription or if ordered by
telephone, the pharmacist must request
and include the name of the consulting
psychiatrist or geriatrician on the
transcribed prescription.
Quinagolide, tablet, 75mcg, 150mcg (Norprolac-FEI)
For the treatment of patients with hyperprolactinemia who have failed or are intolerant to
bromocriptine.
Rabeprazole - see Proton Pump Inhibitors
Ranibizumab, vial, 2.3mg/ 0.23ml (Lucentis-NVR)
For the treatment of the better seeing affected eye for patients with neovascular (wet)
age-related macular degeneration (AMD) where all of the following apply to the eye to be
treated:
PEI Pharmacare Formulary …………………………………………………Page - 304 -
Criteria For Initial Coverage (loading dose for 3 consecutive months):
a) Best Corrected Visual Acuity (BCVA) is between 6/12 and 6/96 AND
b) The lesion size is less than or equal to 12 disc areas in greatest linear dimension AND
c) There is evidence of recent (< 3 months) presumed disease progression (blood vessel
growth, as indicated by fluorescein angiography, optical coherence tomography (OCT), or
recent visual acuity changes.
The interval between doses should not be shorter than one month. Administration is to be
done by a qualified ophthalmologist experienced in intravitreal injections.
Criteria For Continued Coverage:
Treatment with ranibizumab should be continued only in people who maintain adequate
response to therapy.
Ranibizumab should be discontinued if any of the following occur:
a) 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 OR
b) 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 OR
c) There is evidence of deterioration of the lesion morphology despite optimum treatment
over 3 consecutive visits.
Coverage will not be approved for patients :
a) Receiving concurrent treatment with verteporfin.
b) With permanent retinal damage as defined by the Royal College of Ophthalmology
guidelines.
Coverage is limited to a maximum of one vial for the better seeing affected eye in any 30
day period. Coverage must be renewed every 12 months.
The request for coverage must be made by an ophthalmologist, using the Standard Special
Authorization request form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms
Patients must also apply for coverage through the High Cost Drug Program. The patient
application is available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms
Rebif - see Multiple Sclerosis Agents
Relafen - see Nabumetone
Remicade - see Ankylosing Spondylitis Biologic Agents OR
- see Crohn=s Disease Biologic Agents OR
PEI Pharmacare Formulary …………………………………………………Page - 305 -
- see Rheumatoid Arthritis Biologic Agents
Reminyl ER - see Cholinesterase Inhibitors (ChEI)
Renagel - see Sevelamer
Revatio - see Pulmonary Arterial Hypertension (PAH) Therapies
ReVia - see Naltrexone
Requip - see Ropinirole
Rheumatoid Arthritis Biologic Agents
Abatacept, vial, 250mg (Orencia-BMS)
Maximum adult dose is 500mg for patients < 60kg, 750mg for patients 60 to 100kg,
1000mg for patients > 100kg, given at 0, 2, 4, 8 weeks and every 4 weeks thereafter.
Pediatric patients 6-17 years of age and < 75kg, coverage is for 10mg/kg based on weight
at administration (pediatric patients > 75kg to be treated at adult dose) given at 0, 2, 4, 8
weeks and every 4 weeks thereafter.
Adalimumab, pre-filled syringe, 40mg/0.8mL (Humira-ABB)
Maximum adult dose is 40mg every two weeks.
Certolizumab, vial, 200mg/ml (Cimzia-UCB)
Maximum adult dose for Rheumatoid Arthritis is 400mg (given as two Sc injections of
200mg) given at 0,2,4 weeks then 200mg every 2 weeks thereafter.
*Initial approval is three (3) months.
Etanercept, pre-filled syringe, 50mg/ml; injection powder, 25mg/kit (Enbrel-AMG)
Maximum adult dose is 50mg weekly or 25mg twice weekly. Pediatric patients 4-17 years
of age, coverage is for 0.8mg/kg/weekly to a maximum of 50mg weekly.
Golimumab, Syringe, 50mg/0.5ml; auto-injector, 50mg/0.5ml (Simponi-MSD)
Approvals will be for a maximum adult dose of 50mcg once monthly.
Infliximab, injection powder, 100mg/vial (Remicade-JAN)
Initial approval for adults is for Infliximab is for 3mg/kg/dose given at 0, 2, and 6 weeks.
For the treatment of Rheumatoid Arthritis in patients who:
i) Have not responded to a trial of at least 3 months of Leflunomide, AND
ii) Have not responded to or have had intolerable toxicity to an adequate trial of
Methotrexate and at least one of the following DMARDs (disease modifying
antirheumatic drugs): IM Gold, Sulfasalazine, Hydroxychloroquine, Azathioprine,
PEI Pharmacare Formulary …………………………………………………Page - 306 -
Chloroquine, or Penicillamine, OR
iii) Are intolerant to or have a contraindication to Methotrexate and are refractory
to at least two of the following DMARDs (disease modifying antirheumatic drugs):
IM Gold, Sulfasalazine, Hydroxychloroquine, Azathioprine, Chloroquine, or
Penicillamine, OR
iv) Are not a candidate for combination DMARD therapy but have had an
adequate trial of Methotrexate and at least two of the following DMARDs in
sequence: IM Gold, Sulfasalazine, Hydroxychloroquine, Azathioprine,
Chloroquine, or Penicillamine.
An adequate trial is considered to be 5 months for IM Gold, 6 months for
Penicillamine, 4 months for Hydroxychloroquine, and 3 months for all other
traditional DMARDs.
Unless limited by toxicity, the Methotrexate dosage should be increased up to
25mg/week unless a response is achieved at a lower dose.
Renewal of coverage will require reassessment of the patient and submission of
a new Special Authorization form.
Initial approval* will be for a 6 month period.
Coverage will NOT be considered for use in combination with other biologic agents.
Rituximab, vial, 10mg/ml (Rituxan-HLR)
Maximum adult dose is 1000 mg by IV infusion followed two weeks later by the
second 1000 mg IV infusion.
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.
a)
Rituximab will NOT be considered in combination with other biologic
agents.
b)
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.
The request for coverage must be made by a rheumatologist or prescriber with a specialty
in rheumatology, using the Rheumatoid Arthritis Special Authorization form available from
the Drug Programs office or online at http://healthpei.ca/pharmacareforms
Patients must also apply for coverage through the High Cost Drug Program. The patient
application is available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms
PEI Pharmacare Formulary …………………………………………………Page - 307 -
Risedronate 5mg & 35mg - see Bisphosphonates
Risedronate, tablet, 30mg (Actonel-PGA and generics)
For the treatment of Paget=s disease of the bone for a maximum 2 month period. One
additional 2 month course of treatment may be considered after a drug holiday of at least 60
days. A copy of the radiological or specialist report supporting the diagnosis must accompany
the Special Authorization.
Risperdal - see Risperidone regular tablet
Risperdal Consta - see Risperidone prolonged release injection
Risperdal M-Tab - see Risperidone orally disintegrating tablet
Risperidone, regular tablet, 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (Risperdal-JAN and generics)
Family Health Benefit and
Financial Assistance
Programs (No Special
Authorization Required)
Nursing Home Program
Seniors Drug Cost Assistance
Plan
(Special Authorization Required)
(a) Dosages up to a maximum
of 2mg daily (1mg twice daily)
may be provided for the
symptomatic management of
inappropriate behaviour due to
aggression and/or psychosis with
dementia in patients who have
failed or are intolerant to a trial of
conventional neuroleptics:
i. Upon prescription by a
psychiatrist or geriatrician; or
ii. From other practitioners in
consultation with a psychiatrist or
geriatrician.
(a) Dosages up to a maximum
of 2mg daily (1mg twice daily)
may be provided without a
Special Authorization for the
symptomatic management of
inappropriate behaviour due to
aggression and/or psychosis
with dementia in patients who
have failed or are intolerant to a
trial of conventional
neuroleptics.
(a) Dosages up to a maximum of
2mg daily (1mg twice daily) may be
provided for the symptomatic
management of inappropriate
behaviour due to aggression and/or
psychosis with dementia in patients
who have failed or are intolerant to a
trial of conventional neuroleptics
upon written request or
recommendation of a psychiatrist or
geriatrician. A copy of the
recommendation must
accompany the Special
Authorization.
(b) For the treatment of patients
with schizophrenia and related
psychotic disorders and the
acute treatment of manic or
mixed episodes in bipolar
disorder:
i. Upon prescription by a
psychiatrist or geriatrician; or
ii. From other practitioners in
(b) Dosages of more than 2mg
daily will be considered upon
written request or
recommendation of a
psychiatrist or geriatrician. A
copy of the recommendation
must accompany the Special
Authorization.
(c) For the treatment of patients
with schizophrenia and related
psychotic disorders and the
(b) For the treatment of patients
with schizophrenia and related
psychotic disorders and the acute
treatment of manic or mixed
episodes in bipolar disorder upon
written request or recommendation
of a psychiatrist or geriatrician. A
copy of the recommendation must
accompany the Special
PEI Pharmacare Formulary …………………………………………………Page - 308 -
consultation with a psychiatrist or
geriatrician.
Consultation with the
psychiatrist or geriatrician
may be in person or by phone.
A statement such as
APrescribed in Consultation
With Dr. *****@ will be required
on the prescription or if
ordered by telephone, the
pharmacist must request and
include the name of the
consulting psychiatrist or
geriatrician on the transcribed
prescription.
acute treatment of manic or
mixed episodes in bipolar
disorder upon written request or
recommendation of a
psychiatrist. A copy of the
recommendation must
accompany the Special
Authorization.
Authorization.
Risperidone, orally disintegrating tablet, 0.5mg, 1mg, 2mg, 3mg, 4mg (Risperdal M-Tab-JAN)
Coverage under all eligible programs requires the submission of a Special Authorization.
Coverage will be limited to patients who meet the criteria for regular Risperidone tablets
(see above) AND who are unable to use regular Risperidone tablets.
Risperidone, oral solution, 1mg/ml (Risperdal oral solution-JAN and generics)
Coverage under all eligible programs requires the submission of a Special Authorization.
Coverage will be limited to patients who meet the criteria for regular Risperidone tablets (see
above) AND who are unable to use regular Risperidone tablets.
Risperidone, prolonged release injection, 12.5mg/2mL, 25mg/2mL, 37.5mg/2mL, 50mg/2mL
(Risperdal Consta-JAN)
For the treatment of schizophrenia or schizoaffective disorder in patients who have:
a)
A history of non-adherence.
AND
b)
Inadequate control or significant side-effects from two or more oral antipsychotic
medications.
AND
c)
Inadequate control or significant side-effects from at least one long-acting depot
antipsychotic agent.
NOTE: Must be requested and prescribed by a psychiatrist.
Only doses up to 50mg every two weeks will be approved.
Rituxan – see Rheumatoid Arthritis Biologic Agents
Rituximab – see Rheumatoid Arthritis Biologic Agents
PEI Pharmacare Formulary …………………………………………………Page - 309 -
Rivaroxaban, tablet, 10mg, 15mg, 20mg (Xarelto-BAY)
For the prophylaxis of venous thromboembolism (VTE) following total knee replacement
surgery for up to 14 days after surgery or total hip replacement surgery for up to 35 days
after surgery as an alternative to low molecular weight heparins. The maximum dose of
rivaroxaban that will be reimbursed is 10 mg daily.
The request for coverage must be made using the Low Molecular Weight Heparin Special
Authorization form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms
For the prevention of stroke and systemic embolism in at-risk patients with non-valvular
atrial fibrillation for whom:
a) Anticoagulation is inadequate following at least a two month trial of 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 CHADS2 score of ≥ 1.
Although the ROCKET-AF trial included patients with higher CHADS2 scores (≥2), other
landmark studies with the other newer oral anticoagulants demonstrated a therapeutic
benefit in patients with a CHADS2 score of 1. Prescribers may consider an antiplatelet
regimen or oral anticoagulation for patients with a CHADS2 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 three months (i.e. 30-49 mL/min for
15 mg once daily dosing or ≥ 50 mL/min for 20 mg once daily dosing).
PEI Pharmacare Formulary …………………………………………………Page - 310 -
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, so 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.
The request for coverage must be made using the Dabigatran/Rivaroxaban Special
Authorization form available from the Drug Programs office or online at
http://healthpei.ca/pharmacareforms
Rivastigmine - see Cholinesterase Inhibitors (ChEI)
Ropinirole, tablet, 0.25mg, 1mg, 2mg, 5mg (Requip-GSK and generics)
Note: For Nursing Home Program, no Special Authorization is required.
For the treatment of the signs and symptoms of Parkinson=s Disease in patients who are
experiencing motor fluctuations despite optimal treatment with Levodopa/Carboxylase therapy
upon written request or recommendation of a neurologist. A copy of the recommendation
must accompany the Special Authorization.
Rosiglitazone - see Thiazolidinediones
Rosiglitazone Maleate & Metformin, tablet, 1mg & 500mg, 2mg & 500mg, 4mg & 500mg, 2mg &
1000mg, 4mg & 1000mg (Avandamet-GLA)
For the treatment of patients registered with the Diabetes Control Program, diagnosed with
Type II diabetes and who are currently stabilized on equivalent strengths of Rosiglitazone and
Metformin.
Rufinamide, tablet, 100mg, 200mg, 400mg (Banzel-EIS)
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 syndromeassociated seizures, AND
• are currently receiving two or more antiepileptic drugs, AND
• in whom less costly antiepileptic drugs are ineffective or not appropriate.
Salagen - see Pilocarpine
Salmeterol Xinafoate, aerosol powder disk, 50μg/dose (Serevent Diskus-GSK)
a)
For the treatment of asthma when used in patients on concurrent steroid therapy.
b)
For the treatment of COPD, see Chronic Obstructive Pulmonary Disease.
Note: Patients using this product must also have access to a short-acting beta-2
agonist bronchodilator for the relief of acute symptoms.
Salmeterol & Fluticasone, aerosol inhalation, 25ug & 125ug per dose, 25ug & 250ug per dose
PEI Pharmacare Formulary …………………………………………………Page - 311 -
(Advair-GSK); inhaled powder disk, 50ug & 100ug per dose, 50ug & 250ug per dose, 50ug &
500ug per dose (Advair Diskus- GSK)
a)
For the treatment of asthma in patients who are not well controlled on a regular and
adequate course of inhaled steroid therapy prior to the request for combination
therapy. Continuation of current coverage requires regular use of an adequate dose
of this medication.
b)
For the treatment of COPD, see Chronic Obstructive Pulmonary Disease.
Note: Patients using this product must also have access to a short-acting beta-2
agonist bronchodilator for the relief of acute symptoms.
Sandostatin - see Octreotide
Sansert - Methysergide Maleate
Seebri Breezhaler – see Glycopyrronium Bromide
Serc - see Betahistine
Serevent - see Salmeterol
Serevent Diskus - see Salmeterol
Seroquel - see Quetiapine
Sevelamer, tablet, 400mg, 800mg (Renagel-GZY)
For the treatment of hyperphosphetemia (>1.8 mmol/L) and calciphylaxis (calcific
arteriolopathy) or hypercalcemia after failure on a magnesium-based binder.
Initial coverage will be for a three-month period. Renewals will require a decrease of more
than 0.7 mmol of phosphate.
NOTE: Must be requested by a nephrologist.
Sildenafil - see Pulmonary Arterial Hypertension (PAH) Therapies
Simponi – see Ankylosing Spondylitis Biologic Agents OR
see Psoriatic Arthritis Biologic Agents OR
see Rheumatoid Arthritis Biologic Agents
Sinemet CR - see Levodopa & Carbidopa
Singulair - see Montelukast
Sodium Cromoglycate, capsule, 100mg (Nalcrom-AVN)
a)
For the treatment of patients who experience severe reactions to foods which cannot
PEI Pharmacare Formulary …………………………………………………Page - 312 -
b)
be avoided.
For the treatment of patients with Crohn=s Disease or ulcerative colitis not responding
to traditional therapy.
Solifenacin, tablet, 5mg, 10mg (Vesicare-AST)
For the treatment of over-active bladder (not stress incontinence) in patients who
cannot tolerate or have an insufficient response to an adequate trial (e.g. 3
months) of immediate release oxybutynin.
Sorafenib, tablet, 200mg (Nexavar-BAY)
a)
For use as a single agent second line treatment in patients with documented evidence
of histologically confirmed advanced or metastatic clear cell renal cell carcinoma,
considered to be intermediate or low risk (according to Memorial Sloan-Kettering
(MSKCC) prognostic score, see below), have an ECOG performance status of 0 or 1
and progressed after prior cytokine therapy (or intolerance) within the previous 8
months. In any one patient all of the following conditions must be met:
$
Sorafenib may be a second line option only after cytokine therapy.
$
Sorafenib may not be used after another tyrosine kinase inhibitor (i.e.
Sunitinib) as sequential therapy.
In the event of severe toxicity within the first 8 weeks of therapy, a switch to another
tyrosine kinase inhibitor (i.e. Sunitinib) may be allowed.
a) For use in patients with Child-Pugh Class A advanced hepatocellular carcinoma, who
have progressed on trans-arterial chemoembolization (TACE) or are not suitable for
the TACE procedure, and have an ECOG performance status of 0 to 2. Renewal of
coverage requires no further progression of the patient=s disease as evidenced by
radiological or scan results. Copies of the results must accompany the Special
Authorization.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request for
Coverage of High Cost Cancer Drugs available from the Drug Programs Office or
online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Soriatane - see Acitretin
Spiriva - see Tiotropium
Sporanox - see Itraconazole
Sprycel - see Dasatinib
PEI Pharmacare Formulary …………………………………………………Page - 313 -
Stalevo – see Carbidopa & Levodopa & Entacapone
Suboxone – see Buprenorphine
Sumatriptan, tablet, 25mg, 50mg, 100mg; nasal spray, 5mg, 20mg; injection 6mg/0.5mL
(Imitrex DF-GSK and generics)
For the treatment of migraine headaches where other standard therapies, such as oral
analgesics have failed.
Coverage for the injectable form will only be considered if the tablet and nasal dosage
forms are not appropriate.
Coverage is limited to 6 tablets or 6 sprays or 6 syringes per 30 day period. Anyone
requiring more than 6 doses per 30 day period should be considered for migraine prophylaxis
therapy if they are not already receiving such therapy.
Sun-Benz - see Benzydamine
Sunitinib, capsule, 12.5mg, 25mg, 50mg (Sutent-PFI)
a)
For use as a single agent first line treatment in patients with documented evidence of
histologically confirmed advanced or metastatic clear cell renal cell carcinoma who
have an ECOG performance status of 0 or 1. In any one patient all of the following
conditions must be met:
$
Sunitinib may be a first line option.
$
Sunitinib may not be used after another tyrosine kinase inhibitor (i.e.
Sorafenib) as sequential therapy.
In the event of severe toxicity within the first 8 weeks of therapy, a switch to another
tyrosine kinase inhibitor (i.e. Sorafenib) may be allowed.
b)
For use as a single agent for the treatment of advanced gastrointestinal stromal tumor
(GIST) patients after failure of Imatinib due to intolerance or resistance.
The request for coverage must be made and the medication prescribed by a
specialist in haematology or medical oncology, or a general practitioner acting
under the direction of those specialists, using the Special Authorization Request for
Coverage of High Cost Cancer Drugs available from the Drug Programs Office or
online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Sutent - see Sunitinib
PEI Pharmacare Formulary …………………………………………………Page - 314 -
Symbicort Turbuhaler - see Formoterol & Budesonide
Tacrolimus, topical ointment, 0.1% (Protopic-AST)
For intermittent use in 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 on
face versus intermediate to high potency for trunk and extremities).
Tacrolimus, topical ointment, 0.03% (Protopic-AST)
For use in children greater than 2 years of age with refractory atopic dermatitis for a period of
up to 12 months.
Tantum Oral Rinse - see Benzydamine
Tarceva – Erlotinib
Tasigna – see Nilotinib
Tecta - see Proton Pump Inhibitors
Telaprevir, tablet, 375mg (Incivek – VER)
For the treatment of chronic hepatitis C genotype 1 infection in combination with peginterferon
alpha/ribavirin (PegIFNα/RBV), if the following criteria are met:
• detectable levels of hepatitis C virus (HCV) RNA prior to treatment
• fibrosis stage of F2, F3, or F4 as determined by a biopsy/fibroscan where available OR
recommendation of a hepatologist or a prescriber with a specialty in hepatitis
• one course treatment only (12 weeks duration)
Notes:
• Response guided therapy should be considered in patients for whom this is appropriate.
• 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.
Temodal – see Temozolomide
Temozolomide, capsule, 5mg, 20mg, 100mg, 140mg, 250mg (Temodal – MSD)
For the treatment of brain tumors (Malignant glioma)
The request for coverage under the High Cost Drug Program must be made and the
medication prescribed by a specialist in haematology or medical oncology, or a general
practitioner acting under the direction of those specialists, using the Special Authorization
Request for Coverage of High Cost Cancer Drugs available from the Drug Programs
Office or online at http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
PEI Pharmacare Formulary …………………………………………………Page - 315 -
Terbinafine, tablet, 250mg (Lamisil-GSK and various generics)
For the treatment of severe onychomycosis caused by dermatophyte fungi.
Testim – see Testosterone
Testosterone, transdermal gel, 25mg/2.5gm packet, 50mg/5gm packet (AndroGel-ABB);
50mg/5gm tube (Testim-PAL)
Note: Not interchangeable.
For the treatment of congenital and acquired primary or secondary hypogonadism in
males with a specific diagnosis of;
Primary - Cryptorchidism, Klinefelter's, orichidectomy, 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 biochemical tests before initiating any testosterone therapy. Limited to 5 g/day
gel.
Older males with non-specific symptoms of fatigue, malaise or depression who
have low testosterone (T) levels do not satisfy these criteria.
Testosterone Undecanoate, capsule, 40mg (Andriol-MSD)
For patients with a documented deficiency in whom treatment with depo-testosterone
products have been unsuccessful, intolerable or are medically contraindicated.
Tetrabenazine, tablet, 25mg (Nitoman-PRS)
For the treatment of hyperkinetic movement disorders such as Huntington's chorea,
Hemiballismus, Senile Chorea, Tic and Gille's de la Tourette Syndrome and Tardive
Dyskinesia.
Thiazolidinediones
Pioglitazone, tablet, 15mg, 30mg, 45mg (Actos-LIL and generics)
Rosiglitazone, tablet, 2mg, 4mg, 8mg (Avandia-GSK)
For the treatment of patients diagnosed with Type II diabetes, and who have:
a)
Inadequate glycemic control1 on optimal doses2 of Sulfonylurea and Metformin; OR
b)
Demonstrated intolerance or contraindication to Metformin3 and are on optimal doses2
of Sulfonylurea; OR
c)
Demonstrated intolerance or contraindication to Sulfonylurea4 and are on optimal
doses2 of Metformin.
1
Most recent (within the past 12 months) HbA1C required: >7% and <10%. The addition of a
thiazolidinedione would not be expected to decrease the HbA1C to satisfactory levels
in patients with a HbA1C greater than 10.
2
Maximum doses: Metformin 2500mg/day, Chlorpropamide 500mg/day, Gliclazide regular
tablets 320mg/day, Gliclazide modified-release tablets 120mg/day, Glimepiride
PEI Pharmacare Formulary …………………………………………………Page - 316 -
4mg/day, Glyburide 20mg/day.
Metformin: Intolerance - GI adverse effects; Contraindications - renal impairment (SrCr >
130mmol/L) or hepatic failure, acute or chronic metabolic acidosis.
4
Sulfonylureas: Intolerance - Hypoglycemia; Contraindications - sulfa allergy, severe renal
insufficiency (CrCl < 50mL/min).
3
Patients must also apply for coverage to the High Cost Drug Program.
application is available from the Drug Program Office or
http://healthpei.ca/pharmacareforms
The patient
online at
Thyrogen - see Thyrotropin
Thyrotropin, injection, 0.9mg.mL (Thyrogen-GZY)
For use as a single agent in patients who have documented evidence of thyroid cancer, who
have undergone appropriate surgical and/or medical management, and require on-going
evaluation to monitor for recurrence and metastatic disease. This includes:
a)
Primary use in patients with inability to raise an endogenous TSH level ($25 mu/L)
with thyroid hormone withdrawal.
b)
Primary use in cases of documented morbidity in patients for whom severe
hypothyroidism could be life threatening, such as unstable angina, recent
myocardial infarction, class III to IV congestive heart failure, or uncontrolled
psychiatric illness.
c)
Secondary use in patients with previous thyroid hormone withdrawal resulting in a
documented life-threatening event.
(This criteria is for clients of the Catastrophic Drug Program, only)
d)
As a single agent for the preparation of radioiodine remnant ablation in patients with
papillary or follicular thyroid cancer who have undergone thyroidectomy as treatment
for thyroid cancer. Thyrotropin may be used in new patients or patients with
previously incomplete remnant ablation or who have a recurrence of thyroid cancer
and require therapeutic remnant ablation.
Ticagrelor, tablet, 90mg (Brilinta – AZE)
To be taken in combination with ASA 75mg -150mg dailya 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:
STEMIbc
• STEMI patients undergoing primary PCI
NSTEMI or Unstable Anginabc
• Presence of high risk features irrespective of intent to perform revascularization:
• High GRACE risk score (>140)
• High TIMI ris/k score (5-7)
PEI Pharmacare Formulary …………………………………………………Page - 317 -
• Second ACS within 12 months
• Complex or extensive coronary artery disease e.g. diffuse three vessel disease
• Definite documented cerebrovascular or peripheral vascular disease
• Previous CABG
OR
• Undergoing PCI + high risk angiographic anatomyd
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.
Ticlid - see Ticlopidine
Ticlopidine HCL, tablet, 250mg (Ticlid-HLR and generics)
a)
For the secondary prevention of the ischemic stroke or transient ischemic attack
(TIA) in patients with a documented severe allergy to ASA (manifested by
anaphylactic reaction, asthma, or nasal polyps) or who experience a recurrent
thrombotic event (stroke, symptoms of TIA) while taking ASA; or
b)
For the prevention of thrombosis in patients post intra coronary stent implantation for
a period of up to six months.
GI intolerance to ASA is not considered a criterion for coverage of Ticlopidine,
although severe cases (e.g. gastric ulceration or bleeds) may be considered.
Tinzaparin – see Low Molecular Weight Heparins
Tiotropium - see Chronic Obstructive Pulmonary Disease
Tizandine HCl, tablet 4mg (Zanaflex-DPY and generics)
For the second- line treatment for those individuals with spasticity resulting from traumatic
PEI Pharmacare Formulary …………………………………………………Page - 318 -
brain injury, multiple sclerosis, spinal cord injury or cerebral vascular accident and are
intolerant to or have had ineffective results from Baclofen and/or benzodiazepines.
Tocilizumab, IV Vial, 80mg/4l, 200mg/10ml, 400mg/20ml (Actemra-HLR)
Juvenile Idiopathic Arthritis: For the treatment of active systemic juvenile idiopathic
arthritis (sJIA), in patients 2 years of age or older, who have responded inadequately to nonsteroidal 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
Rheumatoid Arthritis: For the treatment of Rheumatoid Arthritis in patients who:
i) Have not responded to a trial of at least 3 months of Leflunomide, AND
ii) Have not responded to or have had intolerable toxicity to an adequate trial of Methotrexate
and at least one of the following DMARDs (disease modifying antirheumatic drugs): IM Gold,
Sulfasalazine, Hydroxychloroquine, Azathioprine, Chloroquine, or Penicillamine, OR
iii) Are intolerant to or have a contraindication to Methotrexate and are refractory to at least
two of the following DMARDs (disease modifying antirheumatic drugs): IM Gold,
Sulfasalazine, Hydroxychloroquine, Azathioprine, Chloroquine, or Penicillamine, OR
iv) Are not a candidate for combination DMARD therapy but have had an adequate trial of
Methotrexate and at least two of the following DMARDs in sequence: IM Gold, Sulfasalazine,
Hydroxychloroquine, Azathioprine, Chloroquine, or Penicillamine.
An adequate trial is considered to be 5 months for IM Gold, 6 months for Penicillamine, 4
months for Hydroxychloroquine, and 3 months for all other traditional DMARDs.
Unless limited by toxicity, the Methotrexate dosage should be increased up to 25mg/week
unless a response is achieved at a lower dose. Renewal of coverage will require
reassessment of the patient and submission of a new Special Authorization form. Initial
approval* will be for a 6 month period. Coverage will NOT be considered for use in
combination with other biologic agents.
Tolterodine, tablet, 1mg, 2mg (Detrol-PFI)
For the treatment of over-active bladder (not stress incontinence) after a reasonable trial
(e.g. 3 months) of Oxybutynin immediate release is not tolerated.
Tolterodine, extended release capsule, 2mg, 4mg (Detrol LA-PFI)
For the treatment of over-active bladder (not stress incontinence) after a reasonable trial
(e.g. 3 months) of Oxybutynin immediate release is not tolerated.
Tracleer - see Pulmonary Arterial Hypertension (PAH) Therapies
Tretinoin, capsule, 10mg (Vesanoid – ROC)
For the treatment of leukemia (Acute Promyelocytic Leukemia) in combination with
PEI Pharmacare Formulary …………………………………………………Page - 319 -
arsenic trioxide (Trisenox) in the first-line setting as a treatment for the induction of
remission and/or consolidation of low to intermediate risk acute promyelocytic leukemia
(APL) and as a consolidation treatment for high risk APL after induction with ATRA plus
chemotherapy for patients with the t(15;17) translocation and PML/RAR-alpha gene
expression.
The request for coverage must be made and the medication prescribed by a specialist in
haematology or medical oncology, or a general practitioner acting under the direction of
those specialists, using the Special Authorization Request for Coverage of High Cost
Cancer Drugs available from the Drug Programs Office or online at
http://healthpei.ca/pharmacareforms .
Patients must also apply for coverage by the High Cost Drug Program. The patient
application is available from the Drug Program Office or online at
http://healthpei.ca/pharmacareforms .
Trileptal - see Oxycarbazepine
Trosec - see Trospium
Trospium, tablet, 20mg (Trosec-ORX)
For the treatment of over-active bladder (not stress incontinence) after a reasonable trial
(e.g. 3 months) of Oxybutynin immediate release is not tolerated.
Twinject - see Epinephrine
Urispas - see Flavoxate
Urso - see Ursodiol
Uromax - see Oxybutynin Chloride
Ursodiol, tablet, 250mg, 500mg (Urso-AXC and generics)
(a)
For the dissolution of radiolucent, noncalcified gallstones of less than 20mm in size in
patients who cannot undergo a cholecystectomy.
(b)
For the management of cholestatic liver disease such as primary biliary cirrhosis.
Valcyte - see Valganciclovir
Valganciclovir, tablet, 450mg (Valcyte-HLR)
(a)
For the treatment of cytomegalovirus (CMV) retinitis in patients with AIDS.
(b)
For the prevention of cytomegalovirus (CMV) disease in solid organ transplant
patients at risk (where either the donor or the recipient is CMV +).
Vancocin - see Vancomycin
PEI Pharmacare Formulary …………………………………………………Page - 320 -
Vancomycin HCl, capsule, 125mg, 250mg (Vancocin-LIL)
For the treatment of antibiotic associated colitis/diarrhea (Pseudomembranous colitis
caused by Clostridium difficile).
Patients must meet one of the following clinical criteria:•
metronidazole 500mg three times daily for 14 days
•
Age≥75 years
•
Lack of response within 5 days on metronidazole
•
Pregnancy & Lactation
•
Diabetic or other neuropathy risk
•
Intolerance to metronidazole including alcohol use
•
Immunocompromised
•
>28 days of metronidazole in past year
•
Previous Cdiff infection with multiple recurrences
•
In long term care (LTC) facility
Failure of
Initial Vancomycin Treatment:
•
Vancomycin 125 mg (orally) four times daily for 10 days
First Recurrence:
•
Vancomycin Pulse Therapy - Vancomycin 250 mg (orally) first dose, then 125 n
mg every 2 days for 3 doses, then 125 mg every 3 days for 5 doses
•
Second Recurrence:
Vancomycin Taper Therapy - Vancomycin 125 mg (orally) four times daily for 7-10
days, then 125 mg two times daily for 7 days, then 125 mg daily for 7 days, then
125 mg every 2 days for 3 doses, then 125 mg every 3 days forain 3 doses
Third Recurrence:
•
Consultation/input from an infectious disease consultant is required
Repeat approvals will only be granted with laboratory evidence of C. difficile
toxin.All regimens above refer to oral therapy.
Vesanoid – see Tretinoin
Vesicare – see Solifenacin
Victrelis – see Boceprevir
PEI Pharmacare Formulary …………………………………………………Page - 321 -
Victrelis Triple – see Boceprevir/Ribavirin/P-Alfa-2B
Vigamox – see Moxifloxacin
Volibris – see Pulmonary Arterial Hypertension (PAH) Therapies
Voriconazole, tablet, 50mg, 200mg (Vfend-PFI)
Candidemia: For the treatment of patients with culture proven invasive candidiasis with
documented resistance to fluconazole.
Aspergillosis, invasive: For the treatment of patients with invasive aspergillosis. Initial
requests will be approved for a maximum of 3 months.
Must be prescribed in consultation with a specialist in infectious diseases or medical
microbiology.
Votrient – see Pazopanib
Wellbutrin SR - see Bupropion HCl
Xalkori – see Crizotinib
Xarelto – see Rivaroxaban
Xeloda - see Capecitabine
Zanaflex - see Tizanidine HCl
Zariflukast, tablet, 20mg (Accolate-AST)
For the adjunctive treatment of asthma in patients not well controlled with regular use of
inhaled corticosteroids. Only appropriate dosing as shown in the current Compendium of
Pharmaceuticals and Specialties (CPS) will be considered.
Ziprasidone hydrochloride. Capsule, 20mg, 40mg, 60mg, 80mg (Zeldox-PFI)
For the treatment of schizophrenia and schizoaffective disorders in patients who have a
contraindication to a trial of at least TWO less expensive antipsychotic agents, or who failed
a trial of at least TWO less expensive antipsychotic agents because of intolerance or lack of
response
Zithromax - see Azithromycin
Zofran - see Ondansetron
Zoledronic acid, injection, 5mg/100mL (Aclasta-NVR)
(1) For the treatment of Paget=s disease of the bone. A copy of the radiological or specialist
report supporting the diagnosis must accompany the Special Authorization.
PEI Pharmacare Formulary …………………………………………………Page - 322 -
(2)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
Zolmitriptan, tablet, 2.5mg (Zomig-AZE)
For the treatment of migraine headaches where other standard therapies, such as oral
analgesics have failed AND the patient has not responded to oral Sumatriptan.
Coverage is limited to 6 tablets per 30 day period. Anyone requiring more than 6 doses
per 30 day period should be considered for migraine prophylaxis therapy if they are not
already receiving such therapy.
Zomig - see Zolmitriptan
Zyban - see Bupropion HCl
Zymar – see Gatifloxacin
Zyprexa - see Olanzapine
Zyprexa Zydis - see Olanzapine
Zyvoxam - see Linezolid
PEI Pharmacare Formulary …………………………………………………Page - 323 -
APPENDIX B
Links to Drug Program Forms
Special Authorization Forms
Alzheimer's Special Authorization Form
Ankylosing Spondylitis Special Authorization Form
Crohn's Disease Special Authorization Form
Enfuvirtide Special Authorization Form
Dabigatran/Rivaroxaban for Atrial Fibrillation Special Authorization Form
High Cost Cancer Special Authorization Form
Low Molecular Weight Heparin Special Authorization Form
Plavix Special Authorization Form
Psoriatic Arthritis Special Authorization Form
Rheumatoid Arthritis Special Authorization Form
Standard Special Authorization Form
Program Application Forms
Erythropoietin Program Approval Form
Pegatron ang Pegasys Approval Form
Family Health Benefits Program - Application Form
High Cost Drug Program - Application Form
Home Oxygen Program - Application Form
PEI Multiple Sclerosis Medications Program Medical Screening Form
PEI Multiple Sclerosis Medications Program Patient Application
PEI Pharmacare Formulary …………………………………………………Page - 324 -
APPENDIX C
AAA
ABB
ABC
ACC
ACH
ACM
ACT
ALC
ALL
ALX
AMG
APX
ARO
AST
AVN
AVP
AXC
AZE
BAX
BAY
BDC
BGN
BHC
BIM
BIN
BLO
BMS
BOE
BTN
BVL
CDC
CLC
COB
CYT
DUI
DUR
D&C
ERF
ETH
FEI
FFR
GAC
GCH
GIL
GMD
GMP
GSK
GZY
HLR
HOS
JAC
List of Manufacturer Abbreviations
AA Pharmaceuticals Inc.
Abbott Laboratories Ltd.
Abbott Diabetes Care
Accel Pharma Inc.
Accord Healthcare
Auto Control medical Inc
Actelion Pharmaceuticals Canada Inc.
Alcon Canada Inc.
Allergan Inc.
Allerex Laboratory Ltd.
Amgen Canada Inc.
Apotex Inc.
Auro Pharma Inc
Astellas Pharma Canada, Inc.
Sanofi Canada Inc.
Sanofi Pasteur
Axcan Pharma Inc.
AstraZeneca Canada Inc.
Baxter Corporation
Bayer Inc.
Becton, Dickison & Co
Biogen Idec Canada Inc.
BHC Medical
Biomed 2002 Inc.
Bionime Corporation
Bausch & Lomb Inc.
Bristol-Myers Squibb Canada
Boehringer Ingelheim (Canada) Ltd.
BTNX Inc.
Biovail Pharmaceuticals Canada
Church & Dwight Canada Corp.
Columbia Laboratories Canada Inc.
Cobalt Pharmaceuticals Inc.
Cytex Pharmaceuticals Inc.
Duchesnay Inc.
Duramed Pharmaceuticals Inc., Subsidiary of Barr Pharmaceuticals Inc.
D&C Mobility Solutions Inc.
Erfa Canada Inc.
Ethypharm Inc.
Ferring Inc.
Fournier Canada Inc.
Galderma Canada Inc.
GlaxoSmithKline Consumer Healthcare
Gilead Sciences, Inc.
GenMed, Division of Pfizer Canada
Generic Medical Partners
GlaxoSmithKline Inc.
Genzyme Canada
Hoffmann-La Roche Limited
Hospira Healthcare Corporation
Jacobus Pharmaceutical Company Inc.
PEI Pharmacare Formulary …………………………………………………Page - 325 -
JAN
JJM
JPC
KEY
LEO
LIL
LSN
LUD
MAR
MCL
MDA
MDC
MFI
MLP
MMT
MNT
MPA
MJS
MRS
MSD
MVL
MYL
NAT
NBC
NGP
NNO
NOP
NYC
NVR
ODN
OMG
ORG
ORX
PAL
PAT
PEN
PFI
PFR
PGA
PHL
PMS
RAN
RBH
RIK
RIV
ROC
ROG
ROS
RPH
SCH
SDZ
SEV
SHR
SIV
Janssen Inc..
Johnson & Johnson - Merck Consumer Pharmaceuticals of Canada
Jamp Pharma
Key Pharmaceuticals, Division of Schering Canada Inc.
Leo Pharma Inc.
Eli Lilly Canada Inc.
Life Scan Canada Ltd.
Lundbeck Canada Inc.
Marcan Pharmaceuticals Inc.
McNeil Consumer Healthcare
3M Pharmaceuticals
Medicis Canada Ltd.
Medical Futures Inc.
Meliapharm Inc.
MM Therapeutics Inc.
Mint Pharmaceuticals
Methapharm Inc.
Mead Johnson Canada, Division of Bristol-Myers Squibb Canada Inc.
Merus Labs
Merck Frosst Canada Ltd.
Meda Valeany Canada
Mylan Pharmaceuticals
Natco Pharma
Novo Biomedical Corp.
Next Generation Pharma
Novo Nordisk Canada Inc.
Novopharm Limited
Nycomed Canada Inc.
Novartis Pharmaceuticals Canada Inc.
Odan Laboratories Ltd.
Omega Laboratories Ltd.
Organon Canada Ltd.
Sepracor Pharmaceuticals Inc.
Paladin Labs Inc.
Patriot Pharmaceuticals, Division of Janssen Inc
Pendopharm, Division of Pharmascience Inc.
Pfizer Canada Inc.
Purdue Pharma
Proctor & Gamble Inc.
Pharmel Inc.
Pharmascience Inc.
Ranbaxy Pharmaceuticals Canada Inc.
Reckitt Benckiser HealthCare
Graceway Pharmaceuticals Inc.
Laboratoire Riva Inc.
Roche Diagnostics
Rougier Pharma Inc., Division of Ratiopharm Inc.
Ross Laboratories, Division of Abbott Laboratories Ltd.
Ratiopharm
Schering Canada Inc.
Sandoz Canada Inc.
Servier Canada Inc.
Shire Biochem Inc.
Sivem Pharmaceutical
PEI Pharmacare Formulary …………………………………………………Page - 326 -
SLV
SNE
SNS
SPT
SRO
STE
STI
SUN
TAK
TAL
TAR
TCD
THI
THM
TEV
TRI
TVM
UCB
VAL
VLO
VII
WAM
WAP
WAT
WAY
WCC
WES
Solvay Pharma Inc.
Smith & Nephew Inc.
Sanis Health Inc.
Septa Pharmaceuticals, Inc.
Serono Canada Inc.
Sterimax Inc.
Stiefel Canada Inc.
Sun Pharmaceutical Industries Inc.
Takeda Canada Inc.
Talecris Biotherapeutics Inc.
Taro Pharmaceuticals Inc.
Trans Canaderm Inc.
Tremblay Harrison Inc.
Theramed Corporation
Teva Canada Ltd.
Triton Pharma Inc.
Teva Neuroscience
UCB Canada Inc.
Valeant Canada Limited
Valeo Pharma Inc.
VIIV Healthcare ULC
Wampole Brands
Waymar Pharmaceuticals Inc.
Watson Pharma
Wyeth Canada
Warner Chilcott Canada Co.
WellSpring Pharmaceutical Canada
PEI Pharmacare Formulary …………………………………………………Page - 327 -

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