NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY FORMULAIRE DU PROGRAMME DE MÉDICAMENTS SUR ORDONNANCE DU NOUVEAU-BRUNSWICK SEPTEMBER 2005 SEPTEMBRE 2005 NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY Copyright - 2005 The Queen In the right of The Province of New Brunswick as represented by The Honourable Elvy Robichaud Minister of Health and Wellness ADMINISTERED BY MEDAVIE BLUE CROSS ON BEHALF OF THE GOVERNMENT OF NEW BRUNSWICK TABLE OF CONTENTS Page Introduction to the New Brunswick Prescription Drug Program Formulary I The New Brunswick Prescription Drug Program I New Brunswick Prescription Drug Program Plans II - III Exclusions IV - V Extemporaneous Preparations and Placebos VI Benefit Review Process VII Product Deletion VII Submission Requirements VIII Legend IX Comment Sheet X Pharmacologic - Therapeutic Classification of Drugs 4:00 Antihistamines 1 8:00 Anti-Infective Agents 2 10:00 Antineoplastic Agents 31 12:00 Autonomic Drugs 36 20:00 Blood Formation and Coagulation 46 24:00 Cardiovascular Agents 53 28:00 Central Nervous System Agent 84 40:00 Electrolytic, Caloric and Water Balance 136 48:00 Antitussives, Expectorants & Mucolytic Agents 141 52:00 Eye, Ear, Nose and Throat (EENT) Preparations 143 56:00 Gastrointestinal Drugs 156 60:00 Gold Compounds 165 64:00 Heavy Metal Antagonists 166 68:00 Hormones and Synthetic Substitutes 167 80:00 Serums, Toxoids, and Vaccines 184 84:00 Skin and Mucous Membrane Agents 185 86:00 Smooth Muscle Relaxants 204 88:00 Vitamins 206 92:00 Unclassified Therapeutic Agents 209 TABLE OF CONTENTS Page Appendices I-A Abbreviations of Dosage Forms A-1 - A-3 I-B Abbreviations of Routes A-4 - A-5 I-C Abbreviations of Units A-6 - A-7 II Abbreviations of Manufacturers' Names A-8 - A-9 III Extemporaneous Preparations A-10 IV Special Authorization A-11 IV Special Authorization Drug Criteria A-12 NEW BRUNSWICK PRESCRIPTION DRUG PROGRAM FORMULARY Introduction New Brunswick Prescription Drug Program The New Brunswick Prescription Drug Program (NBPDP) provides prescription drug coverage to eligible New Brunswick residents. The NBPDP Formulary is a listing of all drugs and drug products which have been determined by the Minister of Health and Wellness to be entitled services. Such drugs and drug products must be listed in the NBPDP Formulary, in order to be considered current eligible benefits. Entitled services which are considered to be interchangeable and available for product selection are noted. The drugs are listed by Therapeutic Category in accordance with that established by the AHFS Drug Information. Each entry is cross-indexed by trade name, generic name and drug identification number (DIN). The NBPDP Formulary is updated quarterly and produced once yearly on compact disc (CD). Each provider pharmacy and authorized dispensing physician is provided with an electronic copy of the publication on (CD). An electronic copy on CD is available upon request to all physicians registered with Medicare. An electronic copy in Portable Document Format (PDF) is also maintained on the NBPDP web page; www.gnb.ca/0051/0212/index-e.asp. To have your name added to the e-mail mailing list to receive an electronic copy, please send a message to [email protected]. I September 2005 New Brunswick Prescription Drug Program Plans Participating Legislative Plans Fees Beneficiaries Authority A $9.05 per prescription up to an Eligible residents of the province Prescription Drug annual copay ceiling of $250 who are sixty-five years of age Payment Act and for GIS recipients. or older Regulations $15.00 per prescription with no annual ceiling for non-GIS recipients B $50 per year registration fee(1); Persons with cystic fibrosis who Prescription Drug 20% of cost of prescription to a are eligible residents and Payment Act and maximum of $20 per registered with the Department Regulations prescription up to an annual of Health and Wellness ceiling of $500 per family unit E $4 per prescription; up to an Persons in licensed residential Health Services annual copay ceiling of $250 facilities who are in receipt of Act and per person(2) financial assistance from the Regulations Department of Family & Community Services and hold a valid health card issued by Family & Community Social Services F $4 per prescription for adults Family and Community Services Health Services (18 years and over) clients Act and $2 per prescription for children Regulations (under 18 years); up to an annual copay ceiling of $250 per family unit(2) G None Children in care of the Minister Health Services of Health and Wellness and Act and special needs children Regulations H $50 per year premium; copay Persons with multiple sclerosis Prescription Drug ranges from zero to 100 per who are eligible residents and Payment Act and cent for each prescription registered with the Department Regulations of Health and Wellness R $50 per year registration fee(1); 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 registered with the Department Regulations prescription up to an annual of Health and Wellness ceiling of $500 per family unit II September 2005 New Brunswick Prescription Drug Program Plans Participating Legislative Plans Fees Beneficiaries Authority T $50 per year registration fee(1); Persons with growth hormone Prescription Drug 20% of cost of prescription to a deficiency who are eligible Payment Act and maximum of $20 per residents and registered with the Regulations prescription up to an annual Department of Health and ceiling of $500 per family unit Wellness U $50 per year registration fee(1); HIV-infected persons who are Prescription Drug 20% of cost of prescription to a eligible residents and registered Payment Act and maximum of $20 per with the Department of Health Regulations prescription up to an annual and Wellness ceiling of $500 per family unit V None Eligible residents of Nursing Prescription Drug Homes as defined in the Nursing Payment Act and Home Act operated by a licensee Regulations under the Act Special Plan dependent (3) Persons approved to have Prescription Drug Authorization payment made for certain drugs Payment Act following medical consultation Non-NBPDP Participating Legislative Fees Plan Beneficiaries Authority W $9.05 per prescription Extra Mural Hospital patients Hospital Services who are in possession of a Act Prescription Drug Authorization Form (1) Family and Community Services clients are exempted from these fees. (2) Exempted from these fees for contraceptives. (3) See Appendix IV. III September 2005 Exclusions While only products listed in the New Brunswick Prescription Drug Program Formulary are benefits the following are some of the specific products not included: 1. Patent medicines such as Jack and Jill Cough Syrup, Extract of Wild Strawberry, etc. 2. Non-prescription acetylsalicylic acid (ASA) preparations except enteric coated ASA products designated as benefits. 3. Non-prescription mouth, throat and nasal preparations, including decongestants 4. Prescription and non-prescription, cough and cold products (e.g. antitussives, expectorants and decongestants) except those listed as benefits for children in care (Plan G) 5. (a) Non-prescription adult vitamins with or without iron supplements (Plans A, E, F [over 18 years of age]) as a dietary supplement (b) Multivitamins (prescription and non-prescription) as a dietary supplement 6. Non-prescription tonics and compounded iron preparations (except single entity iron preparations designated as benefits) 7. Dietary/nutritional supplements and food products 8. Artificial sweetening agents 9. Weight loss products (prescription and non-prescription) 10. Calcium preparations (prescription and non-prescription) as a dietary supplement 11. Laxatives (Plans A, E,F and G) 12. Antacids (Plans A only) 13. Smoking cessation products 14. Ergoloid mesylates, oral, (Hydergine) 15. Potassium supplements, oral, when supplied as K-Lyte effervescent tablets, lime or orange flavoured 16. Retinoic acid (eg. Tretinoin) topical and oral preparations (Plan A only) 17. Cosmetic, health, dental and beauty aids, and cosmetic drugs 18. Soaps, cleansers and shampoos, medicated or otherwise 19. Appliances, devices and medical supplies including prostheses, first aid supplies and syringes IV September 2005 20. Diagnostic agents and point-of-care testing kits 21. Household remedies e.g. calamine lotion, iodine, hydrogen peroxide, antiseptics and disinfectants 22. Injectables or other products normally administered in a hospital setting or requiring a health care professional for administration and/or monitoring to ensure the appropriate standard of patient care is provided 23. Any insured service for which the resident is entitled to benefit under Department of Veterans Affairs, Workplace Health & Safety Compensation Commission or other legislation 24. Delivery, postal or C.O.D. charges 25. Refills in excess of the number specified by the physician or any refill of a prescription older than one year unless approved for refill by the prescriber 26. Antihistamines (Plans A, E, F, V and W) 27. Benzoyl Peroxide preparations in strengths of 5% or less. 28. Lactase Enzyme products. 29. All drug products used for the treatment of infertility. 30. Products for the treatment of impotence and sexual dysfunction. 31. Butorphanol nasal spray. V September 2005 Extemporaneous Preparations Extemporaneous preparations are defined as a drug or mixture of drugs prepared or compounded in a pharmacy according to the order of a prescriber. To be eligible as a benefit, extemporaneous preparations must be listed in Appendix III of this publication or: 1. be specifically tailored to a physician's prescription and 2. contain one or more drugs presently considered a benefit and 3. not duplicate the formulation of a manufactured drug product and 4. not contain drugs in the exclusion list Claims for Extemporaneous Preparations in Appendix III are to be submitted electronically using the PIN assigned to the product. Claims for Extemporaneous Preparations not listed in Appendix III are to be submitted electronically using the DIN of at least one ingredient which is a program benefit.