BULLETIN # 75 · 2018. 7. 19. · Bulletin #75 Effective: January 23, 2014 DIN TRADE NAME GENERIC STRENGTH FORM MFR* 02407914 02407922 AJ-Vancomycin vancomycin 500 mg/vL 1 g/vL Injection

The following amendments will take effect on January 23, 2014

The amended Manitoba Specified Drug Regulation and Drug Interchangeability Formulary Regulation will beavailable on the Manitoba Health websitehttp://www.gov.mb.ca/health/mdbif on the effectivedate of January 23, 2014

Bulletin 75 is currently available for download:http://www.gov.mb.ca/health/mdbif/bulletin75.pdf

BULLETIN # 75Manitoba Drug Benefits and

Interchangeability Formulary Amendments

Inside This IssuePart 1 Additions Page 1-6Part 2 Additions Page 6-7Part 3 Additions Page 8-9New Interchangeable Categories Page 9-11New Interchangeable Products Page 11-20Product Deletions Page 20-21Category Deletions Page 21Interchangeable Product Price Changes Page 22-24Discontinued Products Page 24Manufacturer Updates Page 25

Bulletin #75Effective: January 23, 2014

DIN TRADE NAME GENERIC STRENGTH FORM MFR*

0240791402407922

AJ-Vancomycin vancomycin500 mg/vL

1 g/vLInjection AJC

0238579102385805

Amlodipine amlodipine5 mg

10 mgTablets SIP

02401541 Amoxicillin amoxicillin 250 mg/5 mL Oral Suspension SIP

0240149502401509

Amoxicillin amoxicillin250 mg500 mg

Capsules SIP

024107450241075302410761

Apo-Lorazepam Sublingual

lorazepam0.5 mg

1 mg2 mg

Sublingual Tablets

APX

02245058 Apo-Omeprazole(moved from Part 3)

omeprazole 20 mg Capsules APX

0234557902345587

Apo-Rabeprazole(moved from Part 3)

rabeprazole10 mg20 mg

Tablets APX

024087670240877502408783

Apo-Quinapril/HCTZ quinapril/HCTZ10/12.5 mg20/12.5 mg

20/25 mgTablets APX

02407590 Apo-Tetrabenazine tetrabenazine 25 mg Tablets APX

0224359502243596

Asmanex Twisthaler mometasone200 mcg400 mcg

Metered Dose Inhaler

MFX

0238305502383063

Bisoprolol bisoprolol5 mg

10 mgTablet SIP

Part 1 Additions

02383063 10 mg

02379260023792790237928702379295

Candesartan candesartan

4 mg8 mg

16 mg32 mg

Tablets ACH

02385813 Clopidogrel clopidogrel 75 mg Tablets SIP

0237444702374455

Fluoxetine fluoxetine10 mg20 mg

Capsules SIP

02392526 Gabapentin gabapentin 600 mg Tablets ACH

02388200 Gabapentin gabapentin 600 mg Tablets SIP

02373068 GD-Latanoprost/Timolol latanoprost/timolol maleate 50 mcg/5 mg/mLOphthalmic

SolutionGEM

023822960238232602382334

Heparin heparin1,000 U/mL5,000 U/mL

10,000 U/mLInjection PFI

0240824402408252

Jamp-Losartan HCTZ losartan/HCTZ50/12.5 mg100/25 mg

Tablets JPC

02406969 Jamp-Zopiclone zopiclone 5 mg Tablets JPC

1 of 25


023888630238887102388898

Losartan losartan25 mg50 mg

100 mgTablets SAH

0219091500846503

Losec(moved from Part 3)

omeprazole 20 mgTablets

CapsulesAZC

02379562 Mar-Anastrozole anastrozole 1 mg Tablets MAR

023719790237198702371995

Mar-Atenolol atenolol25 mg50 mg

100 mgTablets MAR

023718710237189802371901

Mar-Citalopram citalopram10 mg20 mg40 mg

Tablets MAR

02403870 Mar-Domperidone domperidone 10 mg Tablets MAR

0239290902392917

Mar-Fluoxetine fluoxetine10 mg20 mg

Capsules MAR

023914730239148102391503

Mar-Gabapentin gabapentin100 mg300 mg400 mg

Capsules MAR

02373424 Mar-Letrozole letrozole 2.5 mg Tablets MAR

0237862002378639

Mar-Metformin metformin500 mg850 mg

Tablets MAR

0238908802389096 Mar Olanzapine ODT olanzapine ODT

5 mg10 mg Tablets MAR02389096

02389118Mar-Olanzapine ODT olanzapine ODT 10 mg

15 mgTablets MAR

0237173102371758

Mar-Ondansetron ondansetron4 mg8 mg

Tablets MAR

02399822023998300239984902399857

Mar-Quetiapine quetiapine

25 mg100 mg200 mg300 mg

Tablets MAR

023717660237177402371782023717900237180402371812

Mar-Risperidone risperidone

0.25 mg0.5 mg

1 mg2 mg3 mg4 mg

Tablets MAR

023994150239942302399431

Mar-Sertraline sertraline25 mg50 mg

100 mgTablets MAR

2 of 25


0237503602375044023750520237506002375079

Mar-Simvastatin simvastatin

5 mg10 mg20 mg40 mg80 mg

Tablets MAR

0238677102386798

Mar-Zopiclone zopiclone5 mg

7.5 mgTablets MAR

02408910 Mint-Clopidogrel clopidogrel 75 mg Tablets MPH

023978030239781102397838

Mint-Rosuvastatin rosuvastatin10 mg20 mg40 mg

Tablets MPH

0241024902410257

Mirvala 21Mirvala 28

desogestrel/ethinyl estradiol 0.15/0.03 mg Tablets APX

0238207502382083

Mylan-Bupropion XL bupropion HCL150 mg300 mg

Tablets MYL

02381524 Mylan-Efavirenz efavirenz 600 mg Tablets MYL

02407442024074500240746902407477

Mylan-Nitro Patch nitroglycerine

40 mg80 mg

120 mg160 mg

Patches MYL

02329433 Mylan-Omeprazole(moved from Part 3)

omeprazole 20 mg Capsules MYL

0240839202408406

Mylan-Rabeprazole(moved from Part 3)


Tablets MYLg

0241348502413493024135070241351502413523

Mylan-Risperidone ODT risperidone

0.5 mg1 mg2 mg3 mg4 mg

Tablets MYL

02364905 Next Choice levonorgestrel 0.75 mgKit

(tablets)COB

02295415 Novo-Omeprazole(moved from Part 3)

omeprazole 20 mg Tablets TEV

02357534 Novo-Valacyclovir valacyclovir 500 mg Tablets TEV

02377209 NovoRapid FlexTouch insulin aspart 100 IU/mL Injection NOO

02348691 Omeprazole(moved from Part 3)

omeprazole 20 mg Capsules SAH

0224379602243797

Pariet(moved from Part 3)


Tablets JAN

0238173702381745

PAT-Rabeprazole(moved from Part 3)


Tablets PAT

3 of 25


02320738 pms-Anastrozole anastrozole 1 mg Tablets PMS

02391171023911980239120102391228

pms-Candesartan candesartan

4 mg8 mg

16 mg32 mg

Tablets PMS

02348004 pms-Clopidogrel clopidogrel 75 mg Tablets PMS

023922240239223202392240

pms-Losartan-HCTZ losartan/HCTZ50/12.5 mg

100/12.5 mg100/25 mg

Tablets PMS

02405776 pms-Nevirapine nevirapine 200 mg Tablets PMS

02320851 pms-Omeprazole(moved from Part 3)

omeprazole 20 mg Capsules PMS

02310260 pms-Omeprazole DR(moved from Part 3)

omeprazole 20 mg Tablets PMS

0231080502310813

pms-Rabeprazole EC(moved from Part 3)


Tablets PMS

023785310237855802378566

pms-Rosuvastatin rosuvastatin10 mg20 mg40 mg

Tablets PMS

0239123602391244

pms-Telmisartan telmisartan40 mg80 mg

Tablets PMS

0240166502401673

pms-Telmisartan HCTZ telmisartan/HCTZ80/12.5 mg

80/25 mgTablets PMS

02401673p

80/25 mg

02322498 pms-Testosterone testosterone 40 mg Tablets PMS

02312999023130060231301402344564

pms-Valsartan valsartan

40 mg80 mg

160 mg320 mg

Tablets PMS

023897030238973802389746

Pravastatin pravastatin10 mg20 mg40 mg

Tablets SIP

02387794023878080238782402387832

Quetiapine quetiapine

25 mg100 mg200 mg300 mg

Tablets ACH

02317893023179070231792302317931

Quetiapine quetiapine

25 mg100 mg200 mg300 mg

Tablets SIP

0235651102356538

Rabeprazole (moved from Part 3)


Tablets SAH

4 of 25


024068100240682902406837

Ran-Irbesartan irbesartan75 mg

150 mg300 mg

Tablets RAN

0237487002403617

Ran-Omeprazole(moved from Part 3)

omeprazole 20 mgTablets

CapsulesRAN

0229807402298082

Ran-Rabeprazole(moved from Part 3)


Tablets RAN

0238595302385961

Ranitidine ranitidine150 mg300 mg

Tablets SIP

02296071 ratio-Fluticasone fluticasone 50 mcg Nasal Spray TEV

02260867 ratio-Omeprazole(moved from Part 3)

omeprazole 20 mg Tablets TEV

024056360240564402405652

Rosuvastatin rosuvastatin10 mg20 mg40 mg

Tablets SAH

02296446 Sandoz Omeprazole(moved from Part 3)

omeprazole 20 mg Capsules SDZ

0231417702314185

Sandoz Rabeprazole(moved from Part 3)


Tablets SDZ

0236864102368668

Septa-Atenolol atenolol50 mg

100 mgTablets STP

0235527202355280

Septa-Citalopram citalopram20 mg40 mg

Tablets STP

0237976702379775

Septa-Metformin metformin500 mg850

Tablets STP02379775

p850 mg

0238629102386305023863130238632102386348

Simvastatin simvastatin

5 mg10 mg20 mg40 mg80 mg

Tablets SIP

022833950228340902283417

Somatuline Autogel lanreotide60 mg/0.3 mL90 mg/0.3 mL

120 mg/0.5 mLInjection IPL

0238894402388952

Telmisartan telmisartan40 mg80 mg

Tablets SAH

02410338 Tetrabenazine tetrabenazine 25 mg Tablets SMI

0240002202400030

Teva-Capecitabine capecitabine150 mg500 mg

Tablet TEV

02389762 Teva-Efavinrez efavirenz 600 mg Tablets TEV

0229663202296640

Teva-Rabeprazole(moved from Part 3)


Tablets TEV

5 of 25


0236700902367017023670250236703302367041

Valsartan HCT valsartan

80/12.5 mg160/12.5 mg

160/25 mg320/12.5 mg

320/25 mg

Tablets SAH

023859290238593702385945

Venlafaxine XR venlafaxine37.5 mg

75 mg150 mg

Capsules SIP

0241078802410796

Zamine 21Zamine 28

drospirenone/ethinyl estradiol 3/0.03 mg Tablets APX

023617440236175202361760

Zenhale formoterol/mometasone5 mcg/50 mcg

5 mcg/100 mcg5 mcg/200 mcg

Metered Dose Inhaler

MFX

*Abbreviation of Manufacturers' Names

0239714502397153

CO Diclo-Miso diclofenac/misoprostol50 mg/200 mcg75 mg/200 mcg

Tablets COB

02355043 Finasteride finasteride 5 mg Tablets ACH

For the treatment of symptomatic benign prostatic hyperplasia.

02407744 125 mg

For patients receiving long-term diclofenac sodium enteric coated tablets who require the addition of

Part 2 Additions

misprostol.

0240774402407752

Jamp-Vancomycin vancomycin125 mg250 mg

Capsules JPC

For the treatment of pseudomembranous colitis unresponsive to metronidazole.

023796860237969402379708

Mar-Ciprofloxacin ciprofloxacin250 mg500 mg750 mg

Tablets MAR

023796270237963502379643

Septa-Ciprofloxacin ciprofloxacin250 mg500 mg750 mg

Tablets STP

(a) Step down care following hospital separation in patients treated with parenteral antibiotics;(b) Treatment of Pseudomonal infections or resistant gram‑negative infections;(c) Treatment of resistant Gonococcal infections;(d) Treatment of infections in persons allergic to alternative agents (eg. penicillins, cephalosporins and sulfonamides);(e) Treatment of infections in immunocompromised patients;(f) Treatment of diabetic foot infections and complications of orthopedic surgery;(g) Treatment of chronic bacterial prostatitis.

6 of 25


023998650239987302399997

Mar-Montelukast montelukast4 mg5 mg

10 mgTablets MAR

023793170237932502379333

Montelukast montelukast4 mg5 mg

10 mgTablets SAH

02382474 Montelukast montelukast 10 mg Tablets SIP

023549770235498502373947

pms-Montelukast montelukast4 mg5 mg

10 mgTablets PMS

0239909102399083

Nutropin NuSpin AQ somatropin5 mg/2 mL

20 mg/2 mLInjection HLR

closed.

02341379 12 mcg

(a) Indicated as adjunctive therapy for asthma in cases where: (i) maximum doses inhaled corticosteroids have not effectively controlled symptoms, or (ii) evidence of serious adverse effects associated with corticosteroids exists, eg. adrenal suppression, increased lung infections;(b) Indicated as first line therapy for exercise induced asthma.

(a) For the long term management of children who have growth failure due to an inadequate secretion of normal endogenous growth hormone;(b) For the treatment of children who have growth failure associated with chronic renal failure insufficiency up to the time of renal transplant;(c) For treatment of short stature associated with Turner Syndrome in patients whose epiphyses are not

02341387023413950234140902341417

pms-Fentanyl MTX fentanyl25 mcg50 mcg75 mcg

100 mcg

Patches PMS

0239336002393379

pms-Rizatriptan ODT rizatriptan5 mg

10 mgTablets PMS

0224880402248805

Teva-Clarithromycin clarithromycin250 mg500 mg

Tablets TEV

For the treatment of patients:(a) Not responding to or intolerant of alternative antibiotics (eg. amoxicillin and erythromycin);(b) With mycobacterial infections due to mycobacterium avium and mycobacterium intracellulare;(c) In combination therapy in the treatment of H. Pylori;(d) Pneumonia;(e) Infections requiring a macrolide (including CAP in patients 65 and older) with documented intoleranceto erythromycin.

For the treatment of pain in patients unable to tolerate analgesics or when there is failure to adequately control pain with oral analgesics or in patients for whom oral analgesics are deemed inappropiate.

For the treatment of ACUTE migraine attacks in patients where standard therapy has failed.

7 of 25


The following products will be considered for Pharmacare reimbursement upon an individual prescriber/patient request basis.

0241125302411261024112880241129602411318024113260241133402411342

Apo-Amlodipine/Atorvastatin

amlodipine/atorvastatin

5/10 mg5/20 mg5/40 mg5/80 mg

10/10 mg10/20 mg10/40 mg10/80 mg

Tablets APX

As per Caduet criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02258595 Humira(New Indication)

adalimumab 40 mg/0.8mL Injection ABV

For the treatment of Polyarticular Juvenile Idiopathic Arthritis. Further criteria may be obtained from the EDS office at Manitoba Health.

023997760239978402399792

Levetiracetam levetiracetam250 mg500 mg750 mg

Tablets ACH

As per Keppra criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02398370 8 mg

Part 3 Additions

023983700239838902398397

pms-Galantamine ER galantamine8 mg

16 mg24 mg

Tablets PMS

As per Reminyl ER criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

023549260235493402354942

pms-Repaglinide repaglinide0.5 mg

1 mg2 mg

Tablets PMS

As per Gluconorm criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02302209 pms-Risedronate risedronate 35 mg Tablets PMS

As per Actonel criteria (http://www.gov.mb.ca/health/mdbif/edsnotice.pdf).

02241927 Rituxan(New Indication)

rituximab 10 mg/mL Injection HLR

As induction-remission therapy for patients with severely active Granulomatosis with Polyangitis (GPA)and Microscopic Polyangitis (MPA) in whom the use of cyclophosamide has failed; or the use ofcyclophosamide is not appropiate.

8 of 25


02394936 Seebri Breezehaler glycopyrronium 50 mcgPowder for Inhalation

NVT

For patients with moderate to severe COPD who remain symptomatic despite an adequate trial(3 months) of ipratropium.

0239980602399814

Teva-Imatinib imatinib100 mg400 mg

Tablets TEV

Criteria may be obtained from the EDS office at Manitoba Health.

The following new interchangeable categories and products were added:

Generic Name - Strength - Form

DIN Trade Name Manufacturer

Amlodipine/Atorvastatin - 5/40 mg - Tablets $ 02273268 Caduet PFI02411288 Apo-Amlodipine/Atorvastatin APX



New Interchangeable Categories

Price in Dollars

3.18191.0124

3.18191.0124

3.52001.1200p p


Bupropion HCL - 150 mg - Extended Release Tablets $ 02275090 Wellbutrin XL VAL02382075 Mylan-Bupropion XL MYL

Bupropion HCL - 300 mg - Extended Release Tablets $ 02275104 Wellbutrin XL VAL02382083 Mylan-Bupropion XL MYL

Capecitabine - 150 mg - Tablets $ 02238453 Xeloda HLR02400022 Teva-Capecitabine TEV

Capecitabine - 500 mg - Tablets $ 02238454 Xeloda HLR02400030 Teva-Capecitabine TEV 4.8800

0.3982

1.25140.7963

2.01301.4640

7.0455

1.12003.5200

0.6257

9 of 25


Diclofenac/Misoprostol - 50 mg/200 mcg - Tablets $ 01917056 Arthrotec PFI02397145 CO Diclo-Miso COB

Diclofenac/Misoprostol - 75 mg/200 mcg - Tablets $ 02229837 Arthrotec PFI02397153 CO Diclo-Miso COB

Efavirenz - 600 mg - Tablets $ 02246045 Sustiva SQU02389762 Teva-Efavinrez TEV02381524 Mylan-Efavirenz MYL

Levonorgestrel - 0.75 mg - Tablets $ 02241674 Plan B PAL02364905 Next Choice COB

Lorazepam - 0.5 mg - Sublingual Tablets $ 02041456 Ativan PFI02410745 Apo-Lorazepam Sublingual APX

Lorazepam - 1 mg - Sublingual Tablets $ 02041464 Ativan PFI02410753 Apo-Lorazepam Sublingual APX

Lorazepam - 2 mg - Sublingual Tablets $ 02041472 Ativan PFI02410761 Apo-Lorazepam Sublingual APX

0.67590.4541

0.91990.6179

0.1100

0.2376

9.46006.4500

0.12160.0875

16.733611.4092**8.4984

0.1528

0.1711p p g

Nitroglycerin - 40 mg - Patch $ 01911910 Nitro-Dur 0.2 MFX02407442 Mylan-Nitro Patch 0.2 MYL




Quinapril/HCTZ - 10/12.5 mg - Tablets $ 02237367 Accuretic PFI02408767 Apo-Quinapril/HCTZ APX

0.6545

0.4704

1.2824

1.00210.6865

0.4463

0.73940.4704

0.7392

0.8743

10 of 25


Quinapril/HCTZ - 20/12.5 mg - Tablets $ 02237368 Accuretic PFI02408775 Apo-Quinapril/HCTZ APX

Quinapril/HCTZ - 20/25 mg - Tablets $ 02237369 Accuretic PFI02408783 Apo-Quinapril/HCTZ APX

Risperidone - 0.5 mg - Orally Disintigrating Tablets $02247704 Risperdal M-Tab JAN02413485 Mylan-Risperidone ODT MYL

Testosterone - 40 mg - Capsules $ 00782327 Andriol MFX02322498 pms-Testosterone PMS

Vancomycin - 500 mg/vial - Injection $ per vial 02241820 pms-Vancomycin PMS02407914 AJ-Vancomycin AJC

Vancomycin - 1 g/vial - Injection $ per vial 02241821 pms-Vancomycin PMS02407922 AJ-Vancomycin AJC

0.81950.5588

1.00210.6865

0.9551

68.133458.9900

1.03400.6204

35.707531.0500

New Interchangeable Products

0.6512

The following products have been added to existing interchangeable drug categories:

Amlodipine - 5 mg - Tablets $02385791 Amlodipine SIP

Amlodipine - 10 mg - Tablets $02385805 Amlodipine SIP

Amlodipine/Atorvastatin - 5/10 mg - Tablets $ 02411253 Apo-Amlodipine/Atorvastatin APX




0.2417

0.7551

0.8591

0.8575

0.3587

1.0234

11 of 25


Amoxicillin - 250 mg/5 mL - Oral Suspension $ per mL 02401541 Amoxicillin SIP

Amoxicillin - 250 mg - Capsules $ 02401495 Amoxicillin SIP

Amoxicillin - 500 mg - Capsules $ 02401509 Amoxicillin SIP

Anastrozole - 1 mg - Tablets $02379562 Mar-Anastrozole MAR02320738 pms-Anastrozole PMS

Atenolol - 25 mg - Tablets $02371979 Mar-Atenolol MAR

Atenolol - 50 mg - Tablets $02371987 Mar-Atenolol MAR02368641 Septa-Atenolol STP

Atenolol - 100 mg - Tablets $02371995 Mar-Atenolol MAR02368668 Septa-Atenolol STP

Bisoprolol - 5 mg - Tablets $02383055 Bisoprolol SIP

Bisoprolol - 10 mg - Tablets $02383063 Bisoprolol SIP

1.27291.2729

0.2362

0 1450

0.2362

0.0540

0.1750

0.3417

0.0994

0.0676

0.14370.1437

02383063 Bisoprolol SIP

Candesartan - 4 mg - Tablets $02379260 Candesartan ACH02391171 pms-Candesartan PMS




Ciprofloxacin - 250 mg - Tablets $02379686 Mar-Ciprofloxacin MAR02379627 Septa-Ciprofloxacin STP

**0.1700

**0.2850

**0.2850

0.2850

0.2380

**0.2850

**0.2850

0.2850

0.61860.6186

0.1450

12 of 25




Citalopram - 10 mg - Tablets $02371871 Mar-Citalopram MAR

Citalopram - 20 mg - Tablets $02371898 Mar-Citalopram MAR02355272 Septa-Citalopram STP

Citalopram - 40 mg - Tablets $02371901 Mar-Citalopram MAR02355280 Septa-Citalopram STP

Clarithromycin - 250 mg - Tablets $02248804 Teva-Clarithromycin TEV

Clarithromycin - 500 mg - Tablets $02248805 Teva-Clarithromycin TEV

Clopidogrel - 75 mg - Tablets $02385813 Clopidogrel SIP02408910 Mint-Clopidogrel MPH02348004 pms-Clopidogrel PMS 0.6576

**0.3329

**0.3329

0.6576

0.69790.6979

1.27801.2780

**0.1782

**0.3329

**0.3329

1.0905

2.1909

0.6576

Desogestrel/Ethinyl Estradiol - 0.15/0.03 mg - Tablets $02410249 Mirvala 21 APX

Desogestrel/Ethinyl Estradiol - 0.15/0.03 mg - Tablets $02410257 Mirvala 28 APX

Domperidone - 10 mg - Tablets $02403870 Mar-Domperidone MAR

Drospirenone/Ethinyl Estradiol - 3/0.03 mg - Tablets $02410788 Zamine 21 APX

Drospirenone/Ethinyl Estradiol - 3/0.03 mg - Tablets $02410796 Zamine 28 APX

Fentanyl - 12 mcg - Patches $02341379 pms-Fentanyl MTX PMS


**2.2280

**3.6560

**0.0594

0.5032

0.3774

0.4293

0.3221

13 of 25





Finasteride - 5 mg - Tablets $02355043 Finasteride ACH

Fluoxetine - 10 mg - Capsules $02374447 Fluoxetine SIP02392909 Mar-Fluoxetine MAR

Fluoxetine - 20 mg - Capsules $02374455 Fluoxetine SIP02392917 Mar-Fluoxetine MAR

Fluticasone - 120 dose - 50 mcg - Nasal Spray $ per dose02296071 ratio-Fluticasone RPH

Gabapentin - 100 mg - Capsules $02391473 Mar-Gabapentin MAR


**6.8820

**9.6800

**0.1040

0.4595

0.4598

**0.2530

0.4595

**12.0500

0.4598

0.4633

0.1831

p


Gabapentin - 600 mg - Tablets $02388200 Gabapentin SIP02392526 Gabapentin ACH

Galantamine - 8 mg - Capsules $02398370 pms-Galantamine ER PMS



Imatinib - 100 mg - Tablets $02399806 Teva-Imatinib TEV

0.4522

**0.3015

**1.2465

**1.2465

**1.2465

0.4522

9.5460

14 of 25


Imatinib - 400 mg - Tablets $02399814 Teva-Imatinib TEV

Irbesartan - 75 mg - Tablets $02406810 Ran-Irbesartan RAN



Latanoprost/Timolol - 50 mcg/5 mg/mL - Ophthalmic Solution $ per mL02373068 GD-Latanoprost/Timolol GEM

Letrozole - 2.5 mg - Tablets $02373424 Mar-Letrozole MAR

Levetiracetam - 250 mg - Tablets $02399776 Levetiracetam ACH



Losartan - 25 mg - Tablets $02388863 Losartan SAH

**4.4268

**1.3780

0.3073

0.3073

0.8000

0.9750

1.3500

0.4375

38.1840

0.3073

02388863 Losartan SAH



Losartan/HCTZ - 50/12.5 mg - Tablets $02408244 Jamp-Losartan HCTZ JPC02392224 pms-Losartan-HCTZ PMS

Losartan/HCTZ - 100/12.5 mg - Tablets $02392232 pms-Losartan-HCTZ PMS

Losartan/HCTZ - 100/25 mg - Tablets $02408252 Jamp-Losartan HCTZ JPC02392240 pms-Losartan-HCTZ PMS

Metformin - 500 mg - Tablets $02378620 Mar-Metformin MAR02379767 Septa-Metformin STP

0.3082

**0.3147

**0.3147

**0.0587

0.3148

0.3148

0.4375

**0.0587

0.4375

15 of 25


Metformin - 850 mg - Tablets $02378639 Mar-Metformin MAR02379775 Septa-Metformin STP

Montelukast - 4 mg - Tablets $02379317 Montelukast SAH02399865 Mar-Montelukast MAR02354977 pms-Montelukast PMS

Montelukast - 5 mg - Tablets $02399873 Mar-Montelukast MAR02379325 Montelukast SAH02354985 pms-Montelukast PMS

Montelukast - 10 mg - Tablets $02399997 Mar-Montelukast MAR02379333 Montelukast SAH02382474 Montelukast SIP02373947 pms-Montelukast PMS

Nevirapine - 200 mg - Tablets $02405776 pms-Nevirapine PMS

Olanzapine - 5 mg - Orally Disintegrating Tablets $02389088 Mar-Olanzapine ODT MAR


0.8195

**0.3646

0.5565

**0.3646

0.8937

1.7857

0.5565

**0.0847

0.8195

**1.2347

0.5565

0.81950.8195

0.5044

**0.0847


Ondansetron - 4 mg - Tablets $02371731 Mar-Ondansetron MAR

Ondansetron - 8 mg - Tablets $02371758 Mar-Ondansetron MAR

Pravastatin - 10 mg - Tablets $02389703 Pravastatin SIP



0.4778

0.4050

**3.3495

**5.1110

2.6777

0.5755

16 of 25


Quetiapine - 25 mg - Tablets $02399822 Mar-Quetiapine MAR02387794 Quetiapine ACH02317893 Quetiapine SIP


Quetiapine - 200 mg - Tablets $02317923 Quetiapine SIP02399849 Mar-Quetiapine MAR02387824 Quetiapine ACH


Ranitidine - 150 mg - Tablets $02385953 Ranitidine SIP

Ranitidine - 300 mg - Tablets $02385961 Ranitidine SIP

Repaglinide - 0.5 mg - Tablets $02354926 pms-Repaglinide PMS

0.3295

**0.6617

0.3600

0.9656

**0.6617

0.9656

0.1235

0.3295

**0.0996

0.12350.1235

0.3295

0.6618

0.9656

0.1800

Repaglinide - 1 mg - Tablets $02354934 pms-Repaglinide PMS

Repaglinide - 2 mg - Tablets $02354942 pms-Repaglinide PMS

Risedronate - 35 mg - Tablets $02302209 pms-Risedronate PMS

Risperidone - 0.25 mg - Tablets $02371766 Mar-Risperidone MAR

Risperidone - 0.5 mg - Tablets $02371774 Mar-Risperidone MAR

Risperidone - 1 mg - Tablets $02371782 Mar-Risperidone MAR


**2.4287

0.1252

0.2097

0.5782

0.2896

**0.1036

**0.1075

17 of 25




Risperidone - 1 mg - Orally Disintigrating Tablets $02413493 Mylan-Risperidone ODT MYL




Rizatriptan - 5 mg - Orally Disintigrating Tablets $02393360 pms-Rizatriptan RDT PMS

Rizatriptan - 10 mg - Orally Disintigrating Tablets $02393379 pms-Rizatriptan RDT PMS

Rosuvastatin - 10 mg - Tablets $02397803 Mint-Rosuvastatin MPH02378531 pms-Rosuvastatin PMS02405636 Rosuvastatin SAH

**1.5280

0.7725

**0.8673

1.1565

3.7050

0.34000.3400

0.3400

2.2913

3.0638

3.7050

Rosuvastatin - 20 mg - Tablets $02397811 Mint-Rosuvastatin MPH02405644 Rosuvastatin SAH02378558 pms-Rosuvastatin PMS

Rosuvastatin - 40 mg - Tablets $02397838 Mint-Rosuvastatin MPH02378566 pms-Rosuvastatin PMS02405652 Rosuvastatin SAH

Sertraline - 25 mg - Tablets $02399415 Mar-Sertraline MAR



0.4975

**0.4231

0.4250

**0.4200

**0.2004

0.4250

0.4975

**0.4000

0.4975

18 of 25


Simvastatin - 5 mg - Tablets $02386291 Simvastatin SIP02375036 Mar-Simvastatin MAR





Telmisartan - 40 mg - Tablets $02388944 Telmisartan SAH02391236 pms-Telmisartan PMS

Telmisartan - 80 mg - Tablets $02388952 Telmisartan SAH02391244 pms-Telmisartan PMS

Telmisartan/HCTZ - 80/12.5 mg - Tablets $

**0.2821

**0.2821

0.2556

**0.5057

**0.6250

**0.6250

**0.62500.6251

0.3954

0.3954

0.6251

0.2556

0.5058

0.6251

g02401665 pms-Telmisartan HCTZ PMS

Telmisartan/HCTZ - 80/25 mg - Tablets $02401673 pms-Telmisartan HCTZ PMS

Tetrabenazine - 25 mg - Tablets $02410338 Tetrabenazine SMI02407590 Apo-Tetrabenazine APX

Valacyclovir - 500 mg - Tablets $02357534 Novo-Valacyclovir TEV

Valsartan - 40 mg - Tablets $02312999 pms-Valsartan PMS



0.2823

**0.2957

**3.3746

**0.2957

1.1873

0.2823

0.3975

3.7121

19 of 25



Valsartan/HCTZ - 80/12.5 mg - Tablets $02367009 Valsartan/HCTZ SAH


Valsartan/HCTZ - 160/25 mg - Tablets $02367025 Valsartan/HCTZ SAH


Valsartan/HCTZ - 320/25 mg - Tablets $02367041 Valsartan/HCTZ SAH

Vancomycin - 125 mg - Capsules $02407744 Jamp-Vancomycin JPC

Vancomycin - 250 mg - Capsules $02407752 Jamp-Vancomycin JPC

Venlafaxine - 37.5 mg - Capsules $02385929 Venlafaxine XR SIP

Venlafaxine - 75 mg - Capsules $02385937 Venlafaxine XR SIP

**0.2843

0.3980

0.3980

0.4141

5.6300

0.4141

11.2500

0.3285

0.1643

0.4141

02385937 Venlafaxine XR SIP

Venlafaxine - 150 mg - Capsules $02385945 Venlafaxine XR SIP

Zopiclone - 5 mg - Tablets $02406969 Jamp-Zopiclone JPC02386771 Mar-Zopiclone MAR

Zopiclone - 7.5 mg - Tablets $02386798 Mar-Zopiclone MAR

** The price has resulted in a change to the lowest price in the category.

The following products have been deleted.

02050056 Apo-Doxepin doxepin 150 mg Capsules

02246083 Apo-Ipravent ipratropium bromide 0.03% Nasal Spray

02231494 Apo-Ipravent ipratropium bromide 250 mcg/mL Solution

0.3125

**0.2199

Product Deletions

0.2231

0.3469

20 of 25


02243828 Apo-Salvent salbutamol 1.25 mg/2.5 mL Solution

02231488 Apo-Salvent salbutamol 2.5 mg/2.5 mL Solution

02231678 Apo-Salvent salbutamol 5 mg/2.5 mL Solution

02243231 Dimethyl Sulfoxide dimethyl sulfoxide 500 mg/g Injection

00512192 Garamycin gentamicin 3 mg/mLOphthalmic

Solution

00028339 Garamycin gentamicin 0.3%Ophthalmic Ointment

00512184 Garamycin gentamicin 3 mg/mL Otic Drops02352826 GD-Mirtazapine OD mirtazapine 15 mg Tablets02352834 GD-Mirtazapine OD mirtazapine 30 mg Tablets02352842 GD-Mirtazapine OD mirtazapine 45 mg Tablets02352818 GD-Terbinafine terbinafine 250 mg Tablets02352850 GD-Topiramate topiramate 25 mg Tablets02352877 GD-Topiramate topiramate 100 mg Tablets02352885 GD-Topiramate topiramate 200 mg Tablets02126753 Novo-Nadolol nadolol 40 mg Tablets

02126761 Novo-Nadolol nadolol 80 mg Tablets

02216183 Nutropin somatropin 5 mg Injection

02216191 Nutropin somatropin 10 mg Injection

02221985 Renedil felodipine 2.5 mg Tablets

02221993 Renedil felodipine 5 mg Tablets

00889806 Sandoz Eyelube methylcellulose 0.5%Ophthalmic

Solution

00874965 Sandoz Eyelube methylcellulose 1%Ophthalmic

S l i00874965 Sandoz Eyelube methylcellulose 1%

Solution

02229440 Sandoz Gentamicin gentamicin 5 mg/mLOphthalmic

Solution

- Amantadine - 100 mg - Capsules

- Calcitonin (salmon synthetic) - 200 IU - Nasal Spray

- Felodipine - 2.5 mg - Tablets

- Hydromorphone - 10 mg/mL - Injection

- Pamidronate Disodium - 3 mg/mL - Injection

- Pamidronate Disodium - 9 mg/mL - Injection

- Propafenone - 150 mg - Tablets

- Propafenone - 300 mg - Tablets

- Risperidone - 1 mg/mL - Oral Solution

- Salbutamol Sulfate - 1.25 mg/2.5 mL - Unit Dose Nebules

Category Deletions

21 of 25


The following changes in prices have occurred: ($)

02303442 Accel-Pioglitazone pioglitazone 15 mg Tablet 0.5809



00180408 Aldactazide spironolactone/HCTZ 25/25 mg Tablet 0.1460

00594377 Aldactazide spironolactone/HCTZ 50/50 mg Tablet 0.3095

00028606 Aldactone spironolactone 25 mg Tablet 0.1460

00285455 Aldactone spironolactone 100 mg Tablet 0.3439

02393824 Apo-Valganciclovir valganciclovir 450 mg Tablet **17.4093

02224135 Arimidex anastrozole 1 mg Tablet 5.6320

02239090 Atacand candesartan 4 mg Tablet 0.7957




02244021 Atacand Plus candesartan/HCTZ 16/12.5 mg Tablet 1.3237

02041413 Ativan lorazepam 0.5 mg Tablet 0.0406

02041421 Ativan lorazepam 1 mg Tablet 0.0506

02041448 Ativan lorazepam 2 mg Tablet 0.0792

01958097 Cardura doxazosin 2 mg Tablet 0.7747



02184478 Casodex bicalutamide 50 mg Tablet 7.5570

02155958 Cipro ciprofloxacin 250 mg Tablet 2 7488

Interchangeable Product Price Changes

02155958 Cipro ciprofloxacin 250 mg Tablet 2.7488



02247162 Crestor rosuvastatin 10 mg Tablet 1.5437



02064405 Cyklokapron tranexamic acid 500 mg Tablet 1.2874

00030570 Dalacin C clindamycin 150 mg Tablet 1.0509

02182866 Dalacin C clindamycin 300 mg Tablet 2.1016

00582301 Dalacin T clindamycin 1% Liquid 0.3905

00030783 Depo-Testosterone testosterone 100 mg/mL Injection 3.0569

02233542 Diane-35cyproterone/ethinyl estradiol

2/0.035 mg Tablet 1.7669

00023450 Dilantin diphenylhydantoin 125 mg/5 mL Oral Suspension 0.0533

02275856 Duragesic MAT fentanyl 100 mcg Patch 48.7146




02145901 Hydromorphone hydromorphone 2 mg/mL Injection **1.5500

22 of 25


02126559 Imdur isosorbide-5-monohydrate 60 mg Tablet 0.7777

02190915 Losec omeprazole 20 mg Tablet 2.5704

00846503 Losec omeprazole 20 mg Capsule 1.2210

02170698 Methotrexate methotrexate 2.5 mg Tablet 0.7062

02042320 Min-Ovrallevonorgestrel/ethinyl estradiol

150 mcg/3 mcg Tablet 0.7847

02042339 Min-Ovrallevonorgestrel/ethinyl estradiol

150 mcg/3 mcg Tablet 0.5885

02084260 Neurontin gabapentin 100 mg Capsule 0.474302084279 Neurontin gabapentin 300 mg Capsule 1.153602084287 Neurontin gabapentin 400 mg Capsule 1.374802239717 Neurontin gabapentin 600 mg Tablet 2.062200030937 Provera medroxyprogesterone 5 mg Tablet 0.366200708917 Provera medroxyprogesterone 2.5 mg Tablet 0.185400729973 Provera medroxyprogesterone 10 mg Tablet 0.743302240551 Risperdal risperidone 0.25 mg Tablet 0.633102240552 Risperdal risperidone 0.5 mg Tablet 1.060602025310 Risperdal risperidone 4 mg Tablet 5.850902025280 Risperdal risperidone 1 mg Tablet 1.464702025299 Risperdal risperidone 2 mg Tablet 2.930402025302 Risperdal risperidone 3 mg Tablet 4.387902064480 Salazopyrin sulfasalazine 500 mg Tablet 0.285502247439 Sandoz Bisoprolol bisoprolol 5 mg Tablet 0.099402247440 Sandoz Bisoprolol bisoprolol 10 mg Tablet 0.145002326957 Sandoz Candesartan candesartan 4 mg Tablet 0.2308

02387131 Sandoz Ciprofloxacin ciprofloxacin 0.3%Ophthalmic

Solution**1.2180

02280264 Sandoz Felodipine felodipine 5 mg Tablet **0.5593

02280272 Sandoz Felodipine felodipine 10 mg Tablet **0.8390

02358611 Sandoz Montelukast montelukast 4 mg Granules **0.8400

02247189 Sandoz Ofloxacin ofloxacin 0.3%Ophthalmic

Solution**1.4680

02351889 Sandoz Rizatriptan ODT rizatriptan 10 mg Tablet 3.7050

02351870 Sandoz Rizatriptan ODT rizatriptan 5 mg Tablet 3.7050

00621935 Statex morphine sulfate 20 mg/mL Drops 0.5588

02049961 Tenoretic atenolol/chlorthalidone 50/25 mg Tablet 0.7530

02049988 Tenoretic atenolol/chlorthalidone 100/25 mg Tablet 1.2342

02039532 Tenormin atenolol 50 mg Tablet 0.6765

02039540 Tenormin atenolol 100 mg Tablet 1.1129

02242275 Timolol Maleate-EX timolol 0.25%Ophthalmic

Solution2.9540

02230894 Topamax topiramate 100 mg Tablet 2.7055



23 of 25


02163934 Tylenol No.2acetaminophen with codeine

300/15 mg Tablet 0.1073


300/30 mg Tablet 0.1182


300/60 mg Tablet 0.2499

00800430 Vancocin vancomycin 125 mg Capsules 5.6300

00788716 Vancocin vancomycin 250 mg Capsules 11.2500

00548359 Xanax alprazolam 0.25 mg Tablet 0.2776

00548367 Xanax alprazolam 0.5 mg Tablet 0.3319

00723770 Xanax alprazolam 1 mg Tablet 0.6033

02261723 Yasmin 21drospirenone/ethinyl estradiol

3/0.03 mg Tablet 0.6360

02261731 Yasmin 28drospirenone/ethinyl estradiol

3/0.03 mg Tablet 0.4841

02103729 Zestoretic lisinopril/HCTZ 10/12.5 mg Tablet 0.9818

02045737 Zestoretic lisinopril/HCTZ 20/12.5 mg Tablet 1.1798

02045729 Zestoretic lisinopril/HCTZ 20/25 mg Tablet 1.1798

02049333 Zestril lisinopril 5 mg Tablet 0.6347



02238660 Zomig zolmitriptan 2.5 mg Tablet 15.5650

02243045 Zomig OD zolmitriptan 2.5 mg Tablet 15.5650

** The price change has resulted in a change to the lowest price in the category.

The following products will be deleted with the next Formulary amendments.

00392820 Dicyclomine dicyclomine 10 mg Tablets

02139200 Mylan-Amantadine amantadine 100 mg Capsules02184648 Mylan-Valproic valproic acid 250 mg Capsules02230201 Novo-Ketorolac ketorolac 10 mg Tablets02273551 pms-Fenofibrate Micro fenofibrate 200 mg Tablets02230183 pms-Gemfibrozil gemfibrozil 600 mg Tablets02306069 pms-Rivastigmine rivastigmine 6 mg Capsules

02247461 ratio-Ketorolac ketorolac 0.5%Ophthalmic

Solution

02257564 Sandoz Loperamide loperamide 2 mg Tablets

02247057 Sandoz Lovastatin lovastatin 40 mg Tablets

02239713 Sandoz Valproic valproic acid 500 mg Capsules

Discontinued Products

24 of 25


The following product has had a name change:

02278251 DuoTrav PQ(was DuoTrav)

timolol/travoprost 0.5%/0.004%Ophthalmic

Solution

Manufacturer Updates

25 of 25

Documents

BULLETIN # 75 · 2018. 7. 19. · Bulletin #75 Effective: January 23, 2014 DIN TRADE NAME GENERIC STRENGTH FORM MFR* 02407914 02407922 AJ-Vancomycin vancomycin 500 mg/vL 1 g/vL Injection