New Brunswick Drug Plans Formulary

1 New Brunswick drug Plans Formulary March 2018 Administered by Medavie Blue Cross on Behalf of the Government of New Brunswick TABLE OF CONTENTS Page Introduction .. I New Brunswick drug Plans .. II Exclusions .. IV Legend .. V Anatomical Therapeutic Chemical (ATC) Classification of Drugs A Alimentary Tract and Metabolism .. 1 B Blood and Blood Forming Organs .. 25 C Cardiovascular System .. 36 D Dermatologicals .. 85 G Genito Urinary System and Sex Hormones .. 98 H Systemic Hormonal Preparations excluding Sex Hormones .. 111 J Antiinfectives for Systemic Use .. 120 L Antineoplastic and Immunomodulating Agents .. 147 M Musculo-Skeletal System .. 168 N Nervous System .. 180 P Antiparasitic Products, Insecticides and Repellants.

2 250 R Respiratory System .. 252 S Sensory Organs .. 265 V Various .. 273 Appendices I-A Abbreviations of Dosage Forms .. A - 1 I-B Abbreviations of Routes .. A - 4 I-C Abbreviations of Units .. A - 6 I-D Abbreviations of Manufacturers Names .. A - 8 II Extemporaneous Preparations .. A - 10 III Special Authorization .. A - 11 III Special Authorization Criteria .. A - 13 IV Provisional Benefits .. A - 94 March 2018 I New Brunswick drug Plans Formulary Introduction The New Brunswick drug Plans provides prescription drug coverage to eligible New Brunswick residents (see pages II and III). The New Brunswick drug Plans Formulary is a list of the drugs which are eligible benefits under the drug Plans . All drugs considered for listing as benefits must be reviewed according to the drug review process.

3 Most drugs listed in the New Brunswick drug Plans Formulary are regular benefits which are reimbursed with no criteria or prior approval requirements. Some drugs require special authorization in order to be reimbursed. Certain drug products are not eligible benefits and are identified on the exclusion list (see Formulary page IV). March 2018 II New Brunswick drug Plans Plans Fees Eligibility Legislative Authority A $ per prescription up to an annual copay ceiling of $500 for GIS recipients. $ per prescription with no annual copay ceiling for non-GIS recipients Eligible residents of the province who are sixty-five years of age or older Prescription drug Payment Act and Regulations B $50 per year registration fee; 20% of cost of prescription to a maximum of $20 per prescription up to an annual copay ceiling of $500 per family unit Persons with cystic fibrosis who are eligible residents and registered with the Department of Health Prescription drug Payment Act and Regulations D Premiums and copays are based on income Uninsured New Brunswick residents Prescription and Catastrophic drug Insurance Act and Regulation E $4 per prescription(1).

4 Up to an annual copay ceiling of $250 per person Persons in licensed residential facilities who hold a valid health card issued by the Department of Social Development Health Services Act and Regulations F $4 per prescription(1) for adults (18 years and over) $2 per prescription(1) for children (under 18 years); up to an annual copay ceiling of $250 per family unit Department of Social Development clients Regional Health Authorities Act and Regulations G None Children in care of the Minister of the Department of Social Development and special needs children Health Services Act and Regulations H $50 per year premium; copay ranges from zero to 100 per cent for each prescription Persons with multiple sclerosis who are eligible residents and registered with the Department of Health Prescription drug Payment Act and Regulations I None Publicly Funded, Pharmacist Administered Seasonal Influenza Vaccine Public Health P None Publically funded drugs for the management of active or latent tuberculosis (TB) infection.

5 Public Health March 2018 III New Brunswick drug Plans Plans Fees Eligibility Legislative Authority R $50 per year registration fee; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit Solid organ transplant recipients who are eligible residents and registered with the Department of Health Prescription drug Payment Act and Regulations T $50 per year registration fee; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit Persons with growth hormone deficiency who are eligible residents and registered with the Department of Health Prescription drug Payment Act and Regulations U $50 per year registration fee; 20% of cost of prescription to a maximum of $20 per prescription up to an annual ceiling of $500 per family unit HIV-infected persons who are eligible residents and registered with the Department of Health Prescription drug Payment Act and Regulations V None Eligible residents of Nursing Homes as defined in the Nursing Home Act operated by a licensee under the Act Prescription drug Payment Act and Regulations W $ per prescription Extra Mural Program patients who are in possession of a Prescription drug Authorization Form Regional Health Authorities Act (1) Does not apply to prescriptions for certain drugs ( contraceptives and methadone for the treatment of opioid use disorder).

6 March 2018 IV Exclusions The following classes of products, except those specifically listed on the Formulary , are excluded as benefits under the New Brunswick drug Plans . Drugs not authorized for sale and use in Canada Over-the-counter (OTC) or non-prescription drugs, vitamins, and minerals Dietary or nutritional supplements and food products Weight loss products Products for the treatment of erectile/sexual dysfunction, or infertility Products for esthetic or cosmetic purposes Soaps, cleansers, shampoos, antiseptics, or disinfectants Drugs for the prevention of travel acquired diseases Diagnostic agents and point-of-care testing kits Medical supplies, devices and equipment ( prostheses, first aid supplies, ostomy supplies, diabetes test strips and syringes, etc.)

7 Vaccines March 2018 V Legend 1. ATC-Therapeutic subgroup 2. ATC- Pharmacological subgroups 3. ATC- Chemical Substance 4. Dosage form, route and strength. Strength represents the amount of ingredients present in a solid dose form (Tablet) or in one gram or one millilitre of a preparation (Cream, Liquid, etc.) 5. Brand or manufacturers' product name 6. drug Identification Number (DIN) 7. Manufacturers' identification code. See Appendix I-D for details 8. drug Plans for which the product is considered to be a benefit 9. Manufacturer has discontinued this product it will be deleted from the list as a benefit on the date indicated March 2018 1 A01 STOMATOLOGICAL PREPARATIONS PRODUITS STOMATOLOGIQUES A01A STOMATOLOGICAL PREPARATIONS PRODUITS STOMATOLOGIQUES A01AC CORTICOSTEROIDS FOR LOCAL ORAL TREATMENT CORTICOST RO DES POUR TRAITEMENT BUCCAL LOCALIS A01AC01 TRIAMCINOLONE TRIAMCINOLONE Pst Den Oracort 01964054 TAR ADEFGVW Pst A01AD OTHER AGENTS FOR LOCAL ORAL TREATMENT AUTRES M DICAMENTS POUR TRAITEMENT BUCCAL LOCALIS A01AD02 BENZYDAMINE BENZYDAMINE Liq Buc Odan-Benzydamine 02463105 ODN ADEFGVW Liq A02 DRUGS FOR ACID RELATED DISORDERS M DICAMENTS CONTRE LES TROUBLES DUS L'HYPERACIDIT A02A ANTACIDS ANTIACIDES A02AD COMBINATIONS AND COMPLEXES OF ALUMINIUM.

8 CALCIUM AND MAGNESIUM COMPOUNDS COMBINAISON DE COMPOS S DE MAGN SIUM, D'ALUMINIUM ET DE CALCIUM A02AD01 ORDINARY SALT COMBINATIONS COMPOSES DE SEL ORDINAIRE ALUMINUM / MAGNESIUM ALUMINIUM / MAGN SIUM Sus Orl / 40mg Diovol 01966529 CHU G Susp Sus Orl 120mg / 60mg Diovol EX 00491217 CHU G Susp A02AH ANTACIDS WITH SODIUM BICARBONATE ANTIACIDES AVEC BICARBONATE DE SODIUM A02AH01 SODIUM BICARBONATE BICARBONATE DE SODIUM Tab Orl 500mg Jamp-Sodium Bicarbonate 80030520 JPC (SA) Co. Sandoz Sodium Bicarbonate 80022194 SDZ (SA) March 2018 2 A02B DRUGS FOR PEPTIC ULCER AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) M DICAMENTS CONTRE L'ULC RE GASTRODUOD NAL ET LE REFLUX GASTRO OESOPHAGIEN A02BA H2-RECEPTOR ANTAGONISTS ANTAGONISTES DES R CEPTEURS H2 A02BA01 CIMETIDINE CIM TIDINE Tab Orl 200mg Apo-Cimetidine 00584215 APX ADEFGVW Co.

9 Tab Orl 300mg Apo-Cimetidine 00487872 APX ADEFGVW Co. Mylan-Cimetidine (Disc/non disp Jun 15/18) 02227444 MYL ADEFGVW Tab Orl 400mg Apo-Cimetidine 00600059 APX ADEFGVW Co. Tab Orl 600mg Apo-Cimetidine 00600067 APX ADEFGVW Co. Mylan-Cimetidine (Disc/non disp Apr 30/20) 02227460 MYL ADEFGVW A02BA02 RANITIDINE RANITIDINE Liq Orl 15mg/mL Apo-Ranitidine 02280833 APX DEFGVW Liq Teva-Ranidine 02242940 TEV DEFGVW Tab Orl 150mg Zantac (Disc/non disp Oct 12/19) 02212331 GSK ABDEFGVW Co. Act Ranitidine 02248570 TEV ABDEFGVW Apo-Ranitidine 00733059 APX ABDEFGVW Mylan-Ranitidine (Disc/non disp Dec 19/18) 02207761 MYL ABDEFGVW pms-Ranitidine 02242453 PMS ABDEFGVW Ranitidine 02353016 SAS ABDEFGVW Ranitidine 02385953 SIV ABDEFGVW Ran-Ranitidine 02336480 RAN ABDEFGVW Sandoz Ranitidine 02243229 SDZ ABDEFGVW Teva-Ranidine 00828564 TEV ABDEFGVW Tab Orl 300mg Zantac (Disc/non disp Oct 12/19) 02212358 GSK ABDEFGVW Co.

10 Act Ranitidine 02248571 TEV ABDEFGVW Apo-Ranitidine 00733067 APX ABDEFGVW Mylan-Ranitidine (Disc/non disp Dec 19/18) 02207788 MYL ABDEFGVW pms-Ranitidine 02242454 PMS ABDEFGVW Ranitidine 02353024 SAS ABDEFGVW Ranitidine 02385961 SIV ABDEFGVW Ran-Ranitidine 02336502 RAN ABDEFGVW Sandoz Ranitidine 02243230 SDZ ABDEFGVW Teva-Ranidine 00828556 TEV ABDEFGVW March 2018 3 A02BA03 FAMOTIDINE FAMOTIDINE Tab Orl 20mg Apo-Famotidine 01953842 APX ADEFGVW Co. Famotidine 02351102 SAS ADEFGVW Mylan-Famotidine 02196018 MYL ADEFGVW Teva-Famotidine 02022133 TEV ADEFGVW Tab Orl 40mg Apo-Famotidine 01953834 APX ADEFGVW Co. Famotidine 02351110 SAS ADEFGVW Mylan-Famotidine (Disc/non disp Feb 1/20) 02196026 MYL ADEFGVW Teva-Famotidine 02022141 TEV ADEFGVW A02BB PROSTAGLANDINS PROSTAGLANDINES A02BB01 MISOPROSTOL MISOPROSTOL Tab Orl 100mcg Misoprostol 02244022 AAP ADEFGVW Co.