New Brunswick Drug Plans Formulary August 2019 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 23 C Cardiovascular System 31 D Dermatologicals 81 G Genito Urinary System and Sex Hormones 89 H Systemic Hormonal Preparations excluding Sex Hormones 100 J Antiinfectives for Systemic Use 107 L Antineoplastic and Immunomodulating Agents 129 M Musculo-Skeletal System 147 N Nervous System 156 P Antiparasitic Products, Insecticides and Repellants 223 R Respiratory System 225 S Sensory Organs 234 V Various 240 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 - 12 III Special Authorization Criteria.....................................................................A - 14 IV Provisional Benefits....................................................................................A - 104 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. 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). August 8, 2019 I New Brunswick Drug Plans Legislative Plans Fees Eligibility Authority A $9.05 per prescription up to an Eligible residents of the province Prescription Drug annual copay ceiling of $500 for who are sixty-five years of age or Payment Act and GIS recipients. older Regulations $15.00 per prescription with no annual copay ceiling for non-GIS recipients B $50 per year registration fee; Persons with cystic fibrosis who are Prescription Drug 20% of cost of prescription to a eligible residents and registered with Payment Act and maximum of $20 per prescription the Department of Health Regulations up to an annual copay ceiling of $500 per family unit Prescription and D Premiums and copays Uninsured New Brunswick residents are based on income Catastrophic Drug Insurance Act and Regulation E $4 per prescription(1); up to an Persons in licensed residential facilities Health Services Act annual copay ceiling of $250 who hold a valid health card issued by and Regulations per person the Department of Social Development F $4 per prescription(1) for adults (18 Department of Social Development Health Services Act years and over) clients and Regulations $2 per prescription(1) for children (under 18 years); up to an annual copay ceiling of $250 per family unit G None Children in care of the Minister of the Health Services Act Department of Social Development and Regulations and special needs children H $50 per year premium; copay Persons with multiple sclerosis who Prescription Drug ranges from zero to 100 per cent are eligible residents and registered Payment Act and for each prescription with the Department of Health Regulations I None Publicly Funded, Pharmacist Public Health Administered Seasonal Influenza Vacccine P None Publically funded drugs for the Public Health management of active or latent tuberculosis (TB) infection. August 8, 2019 II New Brunswick Drug Plans Plans Fees Eligibility Legislative Authority R $50 per year registration fee; Solid organ transplant recipients Prescription Drug 20% of cost of prescription to a who are eligible residents and Payment Act and maximum of $20 per prescription registered with the Department of Regulations up to an annual ceiling of $500 per Health family unit T $50 per year registration fee; Persons with growth Prescription Drug 20% of cost of prescription to a hormone deficiency who are Payment Act and maximum of $20 per prescription eligible residents and Regulations up to an annual ceiling of $500 per registered with the family unit Department of Health U $50 per year registration fee; HIV-infected persons who Prescription Drug 20% of cost of prescription to a are eligible residents and Payment Act and maximum of $20 per prescription registered with the Regulations up to an annual ceiling of $500 per Department of Health family unit V None Eligible residents of Nursing Homes Prescription Drug as defined in the Nursing Home Act Payment Act and operated by a licensee under the Act Regulations W $9.05 per prescription Extra Mural Program patients who are in Hospital Services possession of a Prescription Drug Act Authorization Form (1) Does not apply to prescriptions for certain drugs (e.g. contraceptives and methadone for the treatment of opioid use disorder). August 8, 2019 III 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 (e.g. drugs obtained through Health Canada's Special Access Program, experimental or investigational drugs) - Non-prescription drugs - Natural health products (e.g. vitamins and minerals, herbal remedies, probiotics, homeopathic medicines, traditional medicines) - Cannabis or cannabis products - Nutritional supplements and food products - Weight loss products - Products for the treatment of erectile/sexual dysfunction, or infertility - Drugs for the prevention of travel acquired diseases - Products for esthetic or cosmetic purposes - Soaps, cleansers, shampoos, antiseptics, or disinfectants - Diagnostic agents and point-of-care testing kits - Medical supplies, devices and equipment (e.g. prostheses, first aid supplies, ostomy supplies, diabetes test strips and syringes, etc.) - Vaccines August 8, 2019 IV Legend 1 M01 ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS 2 M01A ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS, NON-STEROIDS 3 M01AE PROPIONIC ACID DERIVATIVES 4 M01AE02 NAPROXEN 6 7 8 9 ECT 5 Orl 5 250mg 5 Naproxen EC 02350785 SAS ADEFGVW Teva-Naprox EC 02243312 TEV ADEFGVW ECT Orl 375mg Naprosyn E 02162415 MTP ADEFGVW Apo-Naproxen EC 02246700 APX ADEFGVW Naproxen EC 02350793 SAS ADEFGVW Mylan-Naproxen EC 02243432 MYL ADEFGVW 10 pms-Naproxen EC (Disc/non disp Mar 4/19) 02294702 PMS ADEFGVW Teva-Naprox EC 02243313 TEV ADEFGVW 1 Second level ATC, therapeutic subgroup 2 Third level ATC, pharmacological subgroup 3 Fourth level ATC, chemical subgroup 4 Fifth level ATC, chemical substance 5 Dosage form, route and strength. Strength represents the amount of ingredients present in a solid dosage form (tablet) or in one gram or one millilitre of a product (cream, liquid, etc.) 6 Brand or manufacturers' product name approved by Health Canada. 7 Drug Identification Number (DIN) 8 Manufacturers' identification code. See Appendix I-D for details. 9 Drug plans for which the product is a benefit. See page II for details. Please note that products marked (SA) are only eligible for coverage under NB Drug Plans through special authorization. 10 Manufacturer has discontinued this product. It will be deleted from the Formulary on the date indicated. August 8, 2019 V A ALIMENTARY TRACT AND METABOLISM A01 STOMATOLOGICAL PREPARATIONS A01A STOMATOLOGICAL PREPARATIONS A01AC CORTICOSTEROIDS FOR LOCAL ORAL TREATMENT A01AC01 TRIAMCINOLONE Pst Den 0.1% Oracort 01964054 TAR ADEFGV A01AD OTHER AGENTS FOR LOCAL ORAL TREATMENT A01AD02 BENZYDAMINE Liq Buc 0.15% pms-Benzydamine 02239537 PMS ADEFGV A02 DRUGS FOR ACID RELATED DISORDERS A02A ANTACIDS A02AD COMBINATIONS AND COMPLEXES OF ALUMINIUM, CALCIUM AND MAGNESIUM COMPOUNDS A02AD01 ORDINARY SALT COMBINATIONS ALUMINUM / MAGNESIUM Sus Orl 45.6 mg / 40 mg Diovol 01966529 CHU G Sus Orl 120 mg / 60 mg Diovol EX 00491217 CHU G A02AH ANTACIDS WITH SODIUM BICARBONATE A02AH01 SODIUM BICARBONATE Tab Orl 500 mg Jamp-Sodium Bicarbonate 80030520 JPC (SA) Sandoz Sodium Bicarbonate 80022194 SDZ (SA) A02B DRUGS FOR PEPTIC ULCER AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) A02BA H2-RECEPTOR ANTAGONISTS A02BA01 CIMETIDINE Tab Orl 200 mg Cimetidine 00584215 AAP ADEFGV Tab Orl 300 mg Cimetidine 00487872 AAP ADEFGV A02BA02 RANITIDINE Liq Orl 15 mg/mL