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New Brunswick Drug Plans Formulary New Brunswick Drug Plans Formulary September 2021 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 22 C Cardiovascular System 30 D Dermatologicals 79 G Genito Urinary System and Sex Hormones 88 H Systemic Hormonal Preparations excluding Sex Hormones 99 J Antiinfectives for Systemic Use 106 L Antineoplastic and Immunomodulating Agents 129 M Musculo-Skeletal System 147 N Nervous System 157 P Antiparasitic Products, Insecticides and Repellants 224 R Respiratory System 226 S Sensory Organs 234 V Various 241 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 Criteria.....................................................................A - 12 IV Provisional Benefits..................................................................................A - 119 New Brunswick Drug Plans Formulary Introduction The Government of New Brunswick provides prescription drug coverage to eligible New Brunswick residents through the New Brunswick Prescription Drug Program, the New Brunswick Drug Plan and other government sponsored plans (collectively known as the New Brunswick Drug Plans). See below for a complete list of plans. The New Brunswick Drug Plans Formulary is a list of the drugs which are eligible benefits under the NB Drug Plans. The Formulary is updated monthly and all drugs considered for listing as benefits must be reviewed according to the Drug Review Process. Most drugs listed in the Formulary are "regular" benefits which are reimbursed with no criteria or prior approval requirements. Some drugs are special authorization benefits and have specific criteria that must be met before they are approved for reimbursement (see Formulary Appendix III). The process and forms for submitting special authorization requests is posted on the NB Drug Plans website. Certain drug products are not eligible benefits and are identified on the exclusion list. The New Brunswick Drug Plans Plan Group Code The New Brunswick Prescription Drug Program (NBPDP) Seniors A Social Development Clients F Adults in Licensed Residential Facilities (Special Care Homes) E Children in Care of the Minister of Social Development and Special Needs Children G Nursing Home Residents V Cystic Fibrosis B Growth Hormone Deficiency T HIV/AIDS U Multiple Sclerosis H Organ Transplant R The New Brunswick Drug Plan D Other Government Sponsored Plans Pharmacist Administered Publicly Funded Vaccines Plan I Tuberculosis P Extra-Mural Program Clients W Medical Abortion Program J Details regarding the New Brunswick Drug Plans are available on the Government of New Brunswick's website. September 9, 2021 I 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 September 9, 2021 II Legend 1 M01 ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS 2 M01A ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS, NON-STEROIDS M01AE 3 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. September 9, 2021 III 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% Odan-Benzydamine 02463105 ODN ADEFGV 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 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 Apo-Ranitidine 02280833 APX DEFGVW Tab Orl 150 mg Apo-Ranitidine 00733059 APX ADEFGVW Jamp-Ranitidine 02463717 JPC ADEFGVW Mar-Ranitidine 02443708 MAR ADEFGVW pms-Ranitidine 02242453 PMS ADEFGVW Ran-Ranitidine 02336480 RAN ADEFGVW Ranitidine 02353016 SAS ADEFGVW Ranitidine 02385953 SIV ADEFGVW September 9, 2021 1 A02BA02 RANITIDINE Tab Orl 300 mg Apo-Ranitidine 00733067 APX ADEFGVW Jamp-Ranitidine 02463725 JPC ADEFGVW Mar-Ranitidine 02443716 MAR ADEFGVW pms-Ranitidine 02242454 PMS ADEFGVW Ran-Ranitidine 02336502 RAN ADEFGVW Ranitidine 02353024 SAS ADEFGVW Ranitidine 02385961 SIV ADEFGVW A02BA03 FAMOTIDINE Tab Orl 20 mg Famotidine (Disc/non disp May 21/22) 02351102 SAS ADEFGV Teva-Famotidine 02022133 TEV ADEFGV Tab Orl 40 mg Famotidine (Disc/non disp May 21/22) 02351110 SAS ADEFGV Teva-Famotidine 02022141 TEV ADEFGV A02BB PROSTAGLANDINS A02BB01 MISOPROSTOL Tab Orl 100 mcg Misoprostol 02244022 AAP ADEFGV Tab Orl 200 mcg Misoprostol 02244023 AAP ADEFGJV A02BC PROTON PUMP INHIBITORS A02BC01 OMEPRAZOLE SRC Orl 20 mg Losec 00846503 AZE ADEFGV Apo-Omeprazole 02245058 APX ADEFGV Omeprazole 02348691 SAS ADEFGV Omeprazole 02411857 SIV ADEFGV pms-Omeprazole 02320851 PMS ADEFGV Sandoz Omeprazole 02296446 SDZ ADEFGV SRT Orl 20 mg Losec 02190915 AZE ADEFGV Jamp-Omeprazole 02420198 JPC ADEFGV Nat-Omeprazole DR 02439549 NAT ADEFGV NRA-Omeprazole 02501880 NRA ADEFGV Omeprazole 02416549 AHI ADEFGV Omeprazole Magnesium 02504294 SAS ADEFGV Teva-Omeprazole 02295415 TEV ADEFGV A02BC02 PANTOPRAZOLE PANTOPRAZOLE MAGNESIUM September 9, 2021 2 A02BC02 PANTOPRAZOLE PANTOPRAZOLE MAGNESIUM ECT Orl 40 mg Tecta 02267233 TAK ADEFGV Mylan-Pantoprazole T 02408570 MYL ADEFGV Pantoprazole Magnesium 02441853 ATS ADEFGV Pantoprazole T 02466147 SAS ADEFGV Teva-Pantoprazole Magnesium 02440628 TEV ADEFGV PANTOPRAZOLE SODIUM ECT Orl 20 mg Pantoloc 02241804 TAK ADEFGV Apo-Pantoprazole 02292912 APX ADEFGV Jamp-Pantoprazole 02408414 JPC ADEFGV Pantoprazole-20 02428172 SIV ADEFGV Sandoz Pantoprazole 02301075 SDZ ADEFGV Teva-Pantoprazole 02285479 TEV ADEFGV ECT Orl 40 mg Pantoloc 02229453 TAK ADEFGV Apo-Pantoprazole 02292920 APX ADEFGV Auro-Pantoprazole 02415208 ARO ADEFGV Jamp Pantoprazole Sodium 02392623 JPC ADEFGV Jamp-Pantoprazole 02357054 JPC ADEFGV M-Pantoprazole 02467372 MRA ADEFGV Mar-Pantoprazole
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