Formulary
Exceptional Access Program (EAP)
The Individual Clinical Review process is being phased out and a more streamlined Exceptional Access Program (EAP) has been created to handle requests for drugs that are not listed in the Formulary. For more information please visit the EAP section.
Drug Benefit Prices (DBPs) for products reimbursed under the EAP
Pursuant to section 15 of O.Reg. 201/96 made under the Ontario Drug Benefit Act (ODBA), the Executive Officer (EO) has entered into agreements with manufacturers to establish Drug Benefit Prices (DBPs) for products reimbursed under the Exceptional Access Program (EAP).
For the following products reimbursed under the EAP, the Health Network System (HNS) will adjudicate claims at the DBP listed below.
| DIN | Trade Name | Strength | Dosage Form | DBP |
|---|---|---|---|---|
| Effective date: April 28, 2023 | ||||
|
02509474 |
Ajovy |
225mg/1.5mL |
Inj Sol-1.5mL Pref Autoinj Pk (Preservative-Free) |
$560.9800 |
|
02497859 |
Ajovy |
225mg/1.5mL |
Inj Sol-1.5mL Pref Syr Pk (Preservative-Free) |
$560.9800 |
|
02369613 |
Banzel |
100mg |
Tab |
$0.8730 |
|
02369621 |
Banzel |
200mg |
Tab |
$1.7459 |
|
02369648 |
Banzel |
400mg |
Tab |
$3.8043 |
|
02513099 |
Braftovi |
75mg |
Cap |
$51.9585 |
|
02491788 |
Calquence |
100mg |
Cap |
$142.7738 |
|
02397447 |
Caripul |
0.5mg |
Inj-10mL Vial Pk |
$19.2400 |
|
02397455 |
Caripul |
1.5mg |
Inj-10mL Vial Pk |
$38.5900 |
|
02245619 |
Copaxone |
20mg/mL |
Inj Pref Syr-1mL Pk |
$50.6522 |
|
02491087 |
Emgality |
120mg/mL |
Inj Sol-1mL Pref Pen (Preservative-Free) |
$577.8000 |
|
02491060 |
Emgality |
120mg/mL |
Inj Sol-1mL Pref Syr (Preservative-Free) |
$577.8000 |
|
02497867 |
Entyvio |
108mg/0.68mL |
Inj Sol-0.68mL Pref Pen (Preservative-Free) |
$850.4600 |
|
02497875 |
Entyvio |
108mg/0.68mL |
Inj Sol-0.68mL Pref Syr (Preservative-Free) |
$850.4600 |
|
02436841 |
Entyvio |
300mg |
Inj Sol-Vial |
$3401.8600 |
|
02478374 |
Erleada |
60mg |
Tab |
$31.1400 |
|
02473232 |
Fasenra |
30mg/mL |
Inj Sol-Pref Syr (Preservative Free) |
$4115.5400 |
|
02496135 |
Fasenra Pen |
30mg/mL |
Inj Sol-1mL Pref Autoinj (Preservative-Free) |
$4036.8000 |
|
02230845 |
Flolan |
0.5mg |
Inj-Vial Pk |
$22.7600 |
|
02230848 |
Flolan |
1.5mg/Vial |
Inj-5mL Vial Pk |
$45.5200 |
|
02401703 |
Genotropin GoQuick |
5.3mg powder for solution |
Pre-filled pen |
$154.5840 |
|
02401711 |
Genotropin GoQuick |
12mg powder for solution |
Pre-filled pen |
$349.9880 |
|
02401762 |
Genotropin MiniQuick |
0.6mg powder for solution |
Prefilled syringe |
$17.5000 |
|
02401770 |
Genotropin MiniQuick |
0.8mg powder for solution |
Prefilled syringe |
$23.3329 |
|
02401789 |
Genotropin MiniQuick |
1.0mg powder for solution |
Prefilled syringe |
$29.1657 |
|
02401797 |
Genotropin MiniQuick |
1.2mg powder for solution |
Prefilled syringe |
$35.0000 |
|
02401800 |
Genotropin MiniQuick |
1.4mg powder for solution |
Prefilled syringe |
$40.8314 |
|
02401819 |
Genotropin MiniQuick |
1.6mg powder for solution |
Prefilled syringe |
$46.6657 |
|
02401827 |
Genotropin MiniQuick |
1.8mg powder for solution |
Prefilled syringe |
$52.4986 |
|
02401835 |
Genotropin MiniQuick |
2.0mg powder for solution |
Prefilled syringe |
$58.3314 |
|
02243077 |
Humatrope |
3.15mL |
6mg Cartridge |
$315.2500 |
|
02243078 |
Humatrope |
3.15mL |
12mg Cartridge |
$630.5000 |
|
02243079 |
Humatrope |
3.15mL |
24mg Cartridge |
$1261.0100 |
|
02230418 |
Imitrex Nasal Spray |
5mg/Dose |
Nas Sp-2 Dose Pk |
$35.0000 |
|
02230420 |
Imitrex Nasal Spray |
20mg/Dose |
Nas Sp |
$18.0000 |
|
02389630 |
Inlyta |
1mg |
Tab |
$20.5073 |
|
02389649 |
Inlyta |
5mg |
Tab |
$102.5387 |
|
02434814 |
Jakavi |
10mg |
Tab |
$91.8338 |
|
02388014 |
Jakavi |
15mg |
Tab |
$91.9914 |
|
02388022 |
Jakavi |
20mg |
Tab |
$91.9930 |
|
02473569 |
Kisqali |
200mg |
Tab |
$88.9671 |
|
02240115 |
Lamictal |
5mg |
Chew Tab |
$0.2070 |
|
02450321 |
Lenvima |
10mg Caps Per Dose |
Daily Dose Pk |
$77.6195 |
|
02450313 |
Lenvima |
14mg Caps Per Dose |
Daily Dose Pk |
$121.3666 |
|
02450305 |
Lenvima |
20mg Caps Per Dose |
Daily Dose Pk |
$182.0609 |
|
02450291 |
Lenvima |
24mg Caps Per Dose |
Daily Dose Pk |
$242.7333 |
|
02484056 |
Lenvima |
4mg/Dose |
Cap |
$35.3853 |
|
02468220 |
Lenvima |
8mg/Dose |
Cap |
$70.7752 |
|
02484129 |
Lenvima |
12mg/Dose |
Cap |
$106.1559 |
|
02475200 |
Lynparza |
100mg |
Tab |
$69.9482 |
|
02475219 |
Lynparza |
150mg |
Tab |
$69.9482 |
|
02409623 |
Mekinist |
0.5mg |
Tab |
$81.7520 |
|
02409658 |
Mekinist |
2mg |
Tab |
$325.6493 |
|
02513080 |
Mektovi |
15mg |
Tab |
$37.7410 |
|
02247694 |
Metadol |
1mg/mL |
O/L |
$0.1394/mL |
|
02241377 |
Metadol |
10mg/mL |
O/L |
$0.5039/mL |
|
02449781 |
Nucala |
100mg/mL |
Inj Pd-Vial Pk |
$2207.7400 |
|
02492989 |
Nucala |
100mg/mL |
Inj Sol-Pref Auto-Injector |
$2207.7400 |
|
02492997 |
Nucala |
100mg/mL |
Inj Sol-Pref Syr |
$2207.7400 |
|
02463121 |
Ocaliva |
5mg |
Tab |
$108.4110 |
|
02463148 |
Ocaliva |
10mg |
Tab |
$108.4110 |
|
02129043 |
Orgaran |
750U/Vial |
Inj-Vial Pk |
$29.9769 |
|
02443651 |
pH 12 Sterile Diluent for Flolan |
94mg/73.3mg/50mL Vial |
Inj Sol-50mL Vial Pk |
$11.9150 |
|
02237319 |
Rebif |
22mcg |
Inj-Syr Pk |
$165.5460 |
|
02237320 |
Rebif |
44mcg |
Inj-Syr Pk |
$201.5353 |
|
02318253 |
Rebif |
66mcg |
Inj-Cart Pk |
$496.6292 |
|
02318261 |
Rebif |
132mcg |
Inj-Cart Pk |
$604.5931 |
|
02445727 |
Revestive |
5mg Vial |
Pd for Inj-Vial Pk |
$925.0000/ Vial |
|
02272199 |
Somavert |
10mg |
Pd for Inj-Vial Pk |
$130.4300 |
|
02272202 |
Somavert |
15mg |
Pd for Inj-Vial Pk |
$195.6400 |
|
02272210 |
Somavert |
20mg |
Pd for Inj-Vial Pk |
$260.8500 |
|
02448831 |
Somavert |
25mg |
Pd for Inj-Vial Pk |
$326.0600 |
|
02448858 |
Somavert |
30mg |
Pd for Inj-Vial Pk |
$391.2800 |
|
02409607 |
Tafinlar |
50mg |
Cap |
$47.5667 |
|
02409615 |
Tafinlar |
75mg |
Cap |
$71.2168 |
|
02456214 |
Tagrisso |
40mg |
Tab |
$312.8137 |
|
02456222 |
Tagrisso |
80mg |
Tab |
$312.8137 |
|
02368250 |
Tasigna |
150mg |
Cap |
$31.2988 |
|
02315874 |
Tasigna |
200mg |
Cap |
$43.5677 |
|
02451158 |
Uptravi |
200mcg |
Tab |
$70.5245 |
|
02451166 |
Uptravi |
400mcg |
Tab |
$70.5245 |
|
02451174 |
Uptravi |
600mcg |
Tab |
$70.5245 |
|
02451182 |
Uptravi |
800mcg |
Tab |
$70.5245 |
|
02451190 |
Uptravi |
1000mcg |
Tab |
$70.5245 |
|
02451204 |
Uptravi |
1200mcg |
Tab |
$70.5245 |
|
02451212 |
Uptravi |
1400mcg |
Tab |
$70.5245 |
|
02451220 |
Uptravi |
1600mcg |
Tab |
$70.5245 |
| Effective date: March 31, 2023 | ||||
09857395 |
Avonex Pen |
30mcg/0.5mL |
Pref AutoInj Pen |
$491.2525 |
02269201 |
Avonex PS |
30mcg/0.5mL |
Pref Syr |
$491.2525 |
02501600 |
Inqovi |
35mg & 100mg |
Tab |
$1172.0000 |
02245913 |
Kineret |
150mg/mL Inj |
Pref Syr-0.67mL Pk |
$54.6182 |
02177757 |
M-Eslon |
200mg |
ER Cap |
$4.5151 |
09857573 |
M-Eslon |
200mg |
ER Cap |
$4.5151 |
02444402 |
Plegridy |
63mcg/0.5mL & 94mcg/0.5mL |
Pref Syr-Kit Pk |
$1879.4900 |
02444399 |
Plegridy |
125mcg/0.5mL |
Pref Syr |
$1879.4900 |
09857557 |
Plegridy |
63mcg/0.5mL & 94mcg/0.5mL |
Pref Pen-Kit Pk |
$1879.4900 |
09857556 |
Plegridy |
125mcg/0.5mL |
Pref Pen |
$1879.4900 |
| Effective date: March 9, 2023 | ||||
02512963 |
Brukinsa |
80mg |
Cap |
$67.9833 |
| Effective date: February 27, 2023 | ||||
02505541 |
Reblozyl |
25mg/Vial |
Pd for Sol-Vial Pk |
$2189.0000/Vial |
02505568 |
Reblozyl |
75mg/Vial |
Pd for Sol-Vial Pk |
$6567.0000/Vial |
| Effective date: February 24, 2023 | ||||
02490315 |
Vitrakvi |
25mg |
Cap |
$52.3375 |
02490323 |
Vitrakvi |
100mg |
Cap |
$209.3500 |
02490331 |
Vitrakvi |
20mg/mL |
Oral Sol-100mL |
$4187.0000/Pk |
| Effective date: February 21, 2023 | ||||
02499827 |
Tukysa |
50mg |
Tab |
$60.1700 |
02499835 |
Tukysa |
150mg |
Tab |
$119.5000 |
| Effective date February 3, 2023 | ||||
| 02499681 | Enspryng | 120mg/mL | Inj Sol-Pref Syr (Preservative-Free) | $9450.0000/Pref Syr |
| Effective date January 31, 2023 | ||||
| 02298791 | Emend | 80mg | Cap | $35.3082 |
| 02298805 | Emend | 125mg | Cap | $34.9776 |
| Effective date: December 1, 2022 | ||||
| 02524252 | Dupixent | 200mg/1.14mL | Inj Sol-1.14mL Pref Pen (Preservative-Free) | $978.7000 |
| Effective date: November 14, 2022 | ||||
| 02510197 | Onureg | 200mg | Tab | $952.0000 |
| 02510200 | Onureg | 300mg | Tab | $1428.0000 |
| Effective date: September 15, 2022 | ||||
| 02517841 | Vyndamax | 61mg | Cap | $534.2800 |
| Effective date: September 8, 2022 | ||||
| 02502445 | Inrebic | 100mg | Cap | $84.3930 |
| Effective date: August 11, 2022 | ||||
| 02515067 | Waymade-Trientine | 250mg | Cap | $20.0000 |
| Effective date August 15, 2022 | ||||
| 02500264 | Kynmobi | 10mg | Soluble Film | $9.5400 |
| 02500272 | Kynmobi | 15mg | Soluble Film | $9.5400 |
| 02500280 | Kynmobi | 20mg | Soluble Film | $9.5400 |
| 02500299 | Kynmobi | 25mg | Soluble Film | $9.5400 |
| 02500302 | Kynmobi | 30mg | Soluble Film | $9.5400 |
| Effective date August 4, 2022 | ||||
| 02483629 | Crysvita | 10mg/mL | Inj Sol-Vial | $451.4940/mg |
| 02483637 | Crysvita | 20mg/mL | Inj Sol-Vial | $451.4950/mg |
| 02483645 | Crysvita | 30mg/mL | Inj Sol-Vial | $451.4947/mg |
| Effective date July 21, 2022 | ||||
| 02495244 | Vascepa | 1g | Cap | $2.4500 |
| Effective date July 8, 2022 | ||||
| 02526670 | Trikafta | 50mg/25mg/37.5mg & 75mg | Tab | $280.0000/Tab |
| Effective date May 31, 2022 | ||||
| 02474263 | Humira | 20mg/0.2mL | Inj Sol-Pref Syr Pk | $397.0500 |
| 09854785 | Humira (Pediatric) | 40mg/0.8mL | Inj Sol-Vial Pk | $794.1000 |
| Effective date May 6, 2022 | ||||
| 02458039 | Venclexta | 10mg | Tab | $7.0800 |
| 02458047 | Venclexta | 50mg | Tab | $35.4000 |
| 02458055 | Venclexta | 100mg | Tab | $70.8000 |
| 02458063 | Venclexta | 10mg & 50mg & 100mg | Tabs (Starter Kit Pk) | $1833.7200/Kit Pk |
| Effective date April 29, 2022 | ||||
| 02273322 | Aptivus | 250mg | Cap | $8.7972 |
| 02480824 | Cabometyx | 20mg | Tab | $301.2944 |
| 02480832 | Cabometyx | 40mg | Tab | $301.2944 |
| 02480840 | Cabometyx | 60mg | Tab | $301.2944 |
| 02415666 | Giotrif | 20mg | Tab | $77.4784 |
| 02415674 | Giotrif | 30mg | Tab | $77.4784 |
| 02415682 | Giotrif | 40mg | Tab | $77.4784 |
| 02472961 | Kevzara | 131.6mg/mL | Inj Sol-Pref Pen | $745.6900 |
| 02460521 | Kevzara | 131.6mg/mL | Inj Sol Pref Syr | $745.6900 |
| 02472988 | Kevzara | 175.0mg/mL | Inj Sol-Pref Pen | $745.6900 |
| 02460548 | Kevzara | 175.0mg/mL | Inj Sol-Pref Syr | $745.6900 |
| 02322854 | Nplate | 250mcg/0.5mL | Pd for Inj-Vial Pk | $1033.0200 |
| 02322862 | Nplate | 500mcg/1mL | Pd for Inj-Vial Pk | $2066.0700 |
| 02372525 | OxyNEO | 10mg | CR Tab | $0.9850 |
| 09857408 | OxyNEO | 10mg | CR Tab | $0.9850 |
| 02372533 | OxyNEO | 15mg | CR Tab | $1.1905 |
| 09857409 | OxyNEO | 15mg | CR Tab | $1.1905 |
| 02372797 | OxyNEO | 20mg | CR Tab | $1.4770 |
| 09857410 | OxyNEO | 20mg | CR Tab | $1.4770 |
| 02372541 | OxyNEO | 30mg | CR Tab | $1.9555 |
| 09857411 | OxyNEO | 30mg | CR Tab | $1.9555 |
| 02372568 | OxyNEO | 40mg | CR Tab | $2.5515 |
| 09857412 | OxyNEO | 40mg | CR Tab | $2.5515 |
| 09857413 | OxyNEO | 80mg | CR Tab | $4.7330 |
| 02244310 | Renagel | 800mg | Tab | $1.7187 |
| 02384256 | Xalkori | 200mg | Tab | $131.4300 |
| 02384264 | Xalkori | 250mg | Tab | $131.4300 |
| 02368153 | Xgeva | 120mg/1.7mL | Inj Sol-Vial Pk | $648.1100 |
| 02489783 | Zejula | 100mg | Cap | $133.2346 |
| Effective date March 28, 2022 | ||||
| 02514931 | Evrysdi | 0.75mg/mL | Pd for Oral Sol | $193.9725/mg |
| Effective date March 25, 2022 | ||||
| 02511355 | Kesimpta | 20mg/0.4mL | Inj Sol-0.4mL Pref SensoReady Pen Pk | $2208.3300 |
| 02504855 | MAR-Trientine | 250mg | Cap | $20.0000 |
| 02496429 | Mayzent | 0.25mg | Tab | $22.3285 |
| 02496437 | Mayzent | 2mg | Tab | $89.3150 |
| Effective date February 10, 2022 | ||||
| 02479206 | Alunbrig | 30mg | Tab | $112.3214 |
| 02479214 | Alunbrig | 90mg | Tab | $336.9643 |
| 02479222 | Alunbrig | 180mg | Tab | $336.9643 |
| 02479230 | Alunbrig | 90mg & 180mg | Tabs (Starter Kit Pk) | $9435.0000/Kit Pk |
| Effective date January 14, 2022 | ||||
| 02505614 | Takhzyro | 300mg/2mL | Inj Sol-Pref Syr (Preservative-Free) | $68.4600/mg |
| Effective date December 23, 2021 | ||||
| 02495007 | Rozlytrek | 100mg | Cap | $47.6667 |
| 02495015 | Rozlytrek | 200mg | Cap | $95.3333 |
| Effective date December 3, 2021 | ||||
| 02510049 | Dupixent | 150mg/mL | Inj Sol-2mL Pref Pen Pk | $978.7000 |
| Effective date December 1, 2021 | ||||
| 02495058 | Xospata | 40mg | Tab | $286.7300 |
| Effective date November 23, 2021 | ||||
| 02459795 | Xolair | 150mg/mL | Inj Sol-1mL Pref Syr Pk | $641.6000 |
| Effective date October 29, 2021 | ||||
| 02509695 | Zolgensma | 2 x 1013 VG/mL | Inj Sol-Vial Combi Pk | $2,910,500.0000 |
| Effective date September 22, 2021 | ||||
| 02517140 | Trikafta | 100mg/50mg/75mg & 150mg | Tab | $280.0000/Tab |
| Effective date June 25, 2021 | ||||
| 02463040 | Orkambi | 125mg/100mg | Tab | $170.5357 |
| 02451379 | Orkambi | 125mg/200mg | Tab | $170.5357 |
| Effective date June 8, 2021 | ||||
| 02496348 | Nubeqa | 300mg | Tab | $28.3440 | Effective date June 7, 2021 |
| 02485559 | Renvela | 0.8g | Pd for Susp | $1.2634/Sachet |
| 02485567 | Renvela | 2.4g | Pd for Susp | $3.7902/Sachet |
| Effective date May 12, 2021 | ||||
| 02495732 | Vyndaqel | 20mg | Cap | $133.5700 | Effective date May 6, 2021 |
| 02492504 | Dupixent | 200mg/1.14mL | Inj Sol-1.14mL Pref Syr (Preservative-Free) | $978.7000 |
| 02470365 | Dupixent | 150mg/mL | Inj Sol-2mL Pref Syr (Preservative-Free) | $978.7000 | Effective date: April 30, 2021 |
| 02337819 | Extavia | 0.3mg | Pd for Inj - Vial | $104.6920 |
| 02437333 | Iclusig | 15mg | Tab | $157.0815 |
| 02437341 | Iclusig | 45mg | Tab | $351.0267 |
| 02434407 | Imbruvica | 140mg | Cap | $99.8350 |
| 02247698 | Metadol | 1mg | Tab | $0.1979 |
| 02247699 | Metadol | 5mg | Tab | $0.6511 |
| 02247700 | Metadol | 10mg | Tab | $1.0816 |
| 02247701 | Metadol | 25mg | Tab | $1.9023 |
| 02459132 | Movapo | 10mg/mL | Inj Sol-Pref Pen 3mL Pk | $45.5400/Pref Pen |
| 02466236 | Rydapt | 25mg | Cap | $172.6250 |
| 02326442 | Tykerb | 250mg | Tab | $24.7910 |
| 02286386 | Tysabri | 300mg/15mL | Inj Sol-15mL Vial Pk | $3,596.1729 |
| 02260565 | Xolair | 150mg | Inj Pd-6mL Vial Pk | $652.9800/Vial |
| 02436779 | Zykadia | 150mg | Cap | $53.3880 | Effective date April 22, 2021 |
| 02436523 | Ferriprox | 100mg/mL | Oral Solution | $3.3495/mL |
| 02436558 | Ferriprox | 1000mg | Tab | $33.4740 | Effective date April 20, 2021 |
| 02415690 | Opsumit | 10mg | Tab | $132.0550 | Effective date April 8, 2021 |
| 02469596 | Kanuma | 2mg/mL | Inj Sol-10mL Vial Pk (Preservative-Free) | $8546.0000 |
| 02489252 | Onpattro | 2mg/mL | Inj Sol (Preservative-Free) | $2100.4813/mL | Effective date March 25, 2021 |
| 02472104 | Lonsurf | 15mg & 6.14mg | Tab | $76.2500 |
| 02472112 | Lonsurf | 20mg & 8.19mg | Tab | $78.5385 | Effective date March 3, 2021 |
| 02484137 | Verkazia | 0.1% w/v | Top Oph Emuls-0.3mL Pk | $3.6667/single-dose container | Effective date February 26, 2021 |
| 02465493 | Cubicin RF | 500mg/Vial | Pd for Inj Sol-Vial Pk | $161.0000/Vial | Effective date: February 2, 2021 |
| 02480948 | Takhzyro | 300mg/2mL | Inj Sol-Vial (Preservative-Free) | $68.4600/mg | Effective date January 29, 2021 |
| 02481383 | Tegsedi | 284mg/1.5mL | Inj Sol-1.5mL Pref Syr | $8,043.4874 | Effective date December 4, 2020 |
| 02493535 | Ibrance | 75mg | Tab | $253.9123 |
| 02493543 | Ibrance | 100mg | Tab | $253.9123 |
| 02493551 | Ibrance | 125mg | Tab | $253.9123 |
| Effective date May 11, 2020 | ||||
| 02475472 | Radicava | 30mg/100mL | Inj Sol-2x30mg Bags Pk | $920.0000/Pk |
| Effective date April 28, 2020 | ||||
| 02470179 | Mavenclad | 10mg | Tab | $3212.0000 |
| Effective date March 31, 2020 | ||||
| 02292165 | Duodopa | 20mg/mL & 5mg/mL | Intestinal Gel (100mL Cassette) | $169.8100 |
| Effective date March 4, 2020 | ||||
| 02483971 | Cresemba | 100mg | Cap | $78.8300 |
| 02483998 | Cresemba | 200mg/Vial | Pd for Sol-Vial Pk (Preservative-Free) | $400.0000/Vial |
| Effective date February 26, 2020 | ||||
| 02483327 | Actemra | 162mg/0.9mL | Auto-Injector (Preservative-Free) | $355.0000/ Auto-Injector |
| 02471574 | Velphoro | 500mg | Chew Tab | $4.2036 |
| Effective date January 22, 2020 | ||||
| 02469375 | Prevymis | 240mg | Tab | $238.7160 |
| 02469367 | Prevymis | 20mg/mL | Inj Sol-240mL Vial Pk | $238.7160 |
| 02469383 | Prevymis | 480mg | Tab | $238.7160 |
| 02469405 | Prevymis | 20mg/mL | Inj Sol-480mL Vial Pk | $469.0910 |
| Effective date November 11, 2019 | ||||
| 02484013 | Brineura | 30mg/mL | Inj Sol-5mL Vial Pk | $100.6667/mg | Effective date September 12, 2019 |
| 02467224 | Ocrevus | 30mg/mL | Inj Sol-10mL Vial Pk (Preservative Free) | $8150.0000/Vial |
| Effective date June 28, 2019 | ||||
| 02443066 | Ofev | 100mg | Cap | $28.4168 |
| 02443074 | Ofev | 150mg | Cap | $56.8336 | Effective date May 13, 2019 |
| 02468042 | Galafold | 123mg | Cap | $1700.0000 |
| 02427184 | Vimizim | 5mg/5mL | Inj Sol-5mL Vial Pk (Preservative Free) | $1091.0900/Vial |
| Effective date April 30, 2019 | ||||
| 02419149 | Bosulif | 100mg | Tab | $38.9787 |
| 02452340 | Cotellic | 20mg | Tab | $125.1025 |
| 02409267 | Erivedge | 150mg | Cap | $313.1904 |
| 02247725 | Fuzeon | 108mg/Vial | Inj-3mL Vial Pk | $42.3230 |
| 09857447 | Gleevec | 100mg | Tab | $29.7475 |
| 09857448 | Gleevec | 400mg | Tab | $118.9900 |
| 02388006 | Jakavi | 5mg | Tab | $86.6275 |
| 02376393 | Nutropin AQ NuSpin 10 | 10mg/2mL | Inj Disposable-Pen | $407.4200 |
| 02399083 | Nutropin AQ NuSpin 20 | 20mg/2mL | Inj Sol-20mg Cart Pk | $814.8400 |
| 02399091 | Nutropin AQ NuSpin 5 | 5mg/2mL | Inj Sol-5mg Cart Pk | $203.7100 |
| 02248077 | Pegasys | 180mcg/0.5mL | Pref Syr-0.5mL Pk | $419.7000 |
| 02046733 | Pulmozyme | 1mg/mL | Inj-2.5mL Pk | $40.7397 |
| 02241927 | Rituxan | 10mg/mL | Inj-10mL Vial Pk | $482.3050/Vial |
| 09857407 | Rituxan | 10mg/mL | Inj-50mL Vial Pk | $2411.5400/Vial |
| 02380242 | Zelboraf | 240mg | Tab | $35.5539 |
| Effective date April 17, 2019 | ||||
| 02458136 | Alecensaro | 150mg | Cap | $42.1666 |
| Effective date April 10, 2019 | ||||
| 02418320 | Lemtrada | 12mg/1.2mL | Inj Sol-12mg/1.2mL Vial | $1085.9258/mg |
| Effective date February 4, 2019 | ||||
| 02442302 | Quinsair | 100mg/mL | Inh Sol-2.4mL Amp (Preservative Free) |
$64.4887/amp |
| Effective date November 20, 2018 | ||||
| 02465663 | Spinraza | 2.4mg/mL | Inj Sol-5mL Vial Pk | $9833.3333/mg |
| Effective date October 29, 2018 | ||||
| 02457857 | Hemangiol | 3.75mg/mL | Oral Sol | $2.2808 |
| Effective date September 27, 2018 | ||||
| 02453150 | Ibrance | 75mg | Cap | $253.9123 |
| 02453169 | Ibrance | 100mg | Cap | $253.9123 |
| 02453177 | Ibrance | 125mg | Cap | $253.9123 |
| Effective date September 13, 2018 | ||||
| 02378582 | Caprelsa | 100mg | Tab | $99.1573 |
| 02378590 | Caprelsa | 300mg | Tab | $198.3150 |
| Effective date June 29, 2018 | ||||
| 02329840 | Cayston | 75mg/vial | Pd Inh Sol- Vial Pk | $42.3989 |
| Effective date June 6, 2018 | ||||
| 02444615 | Strensiq | 18mg/0.45mL | Single Use Vial | $1358.6400 |
| 02444623 | Strensiq | 28mg/0.7mL | Single Use Vial | $2113.4400 |
| 02444631 | Strensiq | 40mg/1mL | Single Use Vial | $3019.2000 |
| 02444658 | Strensiq | 80mg/0.8mL | Single Use Vial | $6038.4000 |
| Effective date April 30, 2018 | ||||
| 02412764 | Adempas | 0.5mg | Tab | $43.7200 |
| 02412772 | Adempas | 1mg | Tab | $43.7200 |
| 02412799 | Adempas | 1.5mg | Tab | $43.7200 |
| 02412802 | Adempas | 2mg | Tab | $43.7200 |
| 02412810 | Adempas | 2.5mg | Tab | $43.7200 |
| Effective date April 19, 2018 | ||||
| 02460351 | Ilaris | 150mg/mL | Inj Sol-Vial Pk | $106.6667 per mg |
| 02282097 | Orencia | 250mg/Vial | Inj Pd-Vial Pk | $500.3411 |
| 02402475 | Orencia (Preservative Free) |
125mg/mL | Inj Sol-Pref Syr-1mL Pk | $373.7881 |
| Effective date April 9, 2018 | ||||
| 02453304 | Ravicti | 1.1g/mL | Oral Liquid | $48.0000 |
| Effective date January 31, 2018 | ||||
| 02465574 | Cimzia | 200mg/mL | Inj Sol � Pref Pen | $664.5100 |
| Effective date May 31, 2017 | ||||
| 02428393 | Sodium Thiosulfate Injection USP | 250mg/mL | Inj Sol-50mL Vial Pk | $130.0000 |
| Effective date April 27, 2017 | ||||
| 02350092 | Actemra | 80mg/4mL | Inj Sol-Vial Pk | $182.8000 |
| 02350106 | Actemra | 200mg/10mL | Inj Sol-Vial Pk | $457.0000 |
| 02350114 | Actemra | 400mg/20mL | Inj Sol-Vial Pk | $914.0000 |
| 02424770 | Actemra | 162mg/0.9mL | Inj Sol-Pref Syr | $358.9050 |
| 02419157 | Bosulif | 500mg | Tab | $152.2403 |
| 02361825 | Revolade | 25mg | Tab | $65.0000 |
| 02361833 | Revolade | 50mg | Tab | $130.0000 |
| Effective date March 28, 2017 | ||||
| 02386666 | Seacalphyx | 250mg/mL | Inj Sol | $2.7500/mL |
| Effective date October 19, 2016 | ||||
| 02438798 | Zydelig | 100mg | Tab | $85.3500 |
| 02438801 | Zydelig | 150mg | Tab | $85.3500 |
| Effective date September 16, 2016 | ||||
| 02413175 | Simponi | 100mg/1.0mL | Pre-Filled Syringe | $1555.1700 |
| 02413183 | Simponi | 100mg/1.0mL | Auto-Injector | $1555.1700 |
| Effective date April 29, 2016 | ||||
| 02240325 | Xenical | 120mg | Cap | $1.6574 |
| 02407329 | Xtandi | 40mg | Cap | $29.1954 |
| Effective date January 28, 2016 | ||||
| 02387174 | Dificid | 200mg | Tab | $94.60 |
| 02324784 | Simponi | 50mg/0.5mL | Auto-Injector | $1,555.17 |
| 02324776 | Simponi | 50mg/0.5mL | Pre-Filled Syringe | $1,555.17 |
| Effective date November 5, 2015 | ||||
| 02425696 | Firazyr | 30mg/3mL | Pre-filled syringe | $2,700.0000 |
| Effective date July 10, 2015 | ||||
| 02334852 | Norditropin Nordiflex | 5mg/1.5mg | Inj Sol-Pref Pen | $194.7000 |
| 02334860 | Norditropin Nordiflex | 10mg/1.5mg | Inj Sol-Pref Pen | $389.4000 |
| 02334879 | Norditropin Nordiflex | 15mg/1.5mg | Inj Sol-Pref Pen | $584.1000 |
| Effective date June 22, 2015 | ||||
| 02398958 | Diacomit | 250mg | Cap | $5.8984 |
| 02398966 | Diacomit | 500mg | Cap | $11.7783 |
| 02398974 | Diacomit | 250mg/Pk | Pd for Oral Susp | $5.8984 |
| 02398982 | Diacomit | 500mg/Pk | Pd for Oral Susp | $11.7783 |
| Effective date February 26, 2015 | ||||
| 02403390 | Stivarga | 40mg | Tab | $72.6200 |
| Effective date June 20, 2014 | ||||
| 02397412 | Kalydeco | 150mg | Tab | $420.0000 |
| Effective date May 2, 2014 | ||||
| 00745626 | Humatrope | 1mg / mL | 5mg Vial | $233.3500 |
| Effective date April 16, 2014 | ||||
| 02371553 | Incivek | 375mg | Tab | $69.3810 |
| Effective date January 30, 2014 | ||||
| 02244016 | Remicade | 100mg/10mL | Injection | $987.5600 |
| 02284227 | Nexavar | 200mg | Tab | $46.4689 |
| Effective date April 30, 2013 | ||||
| 02237971 | Saizen | 5mg | Inj Pd-5mg vial Pk with Diluent | $224.0500 |
| 02350122 | Saizen | 6mg/Cart (5.83mg/mL) | Inj Cart | $268.8300 |
| 02350130 | Saizen | 12mg/Cart (8mg/mL) | Inj Cart | $537.6600 |
| 02350149 | Saizen | 20mg/Cart (8mg/mL) | Inj Cart | $896.1000 |
| Effective date February 20, 2013 | ||||
| 02350580 | Kuvan | 100mg | Tab | $33.0000 |
| Effective date September 13, 2012 | ||||
| 02355191 | Thalomid | 50mg | Cap | $29.4690 |
| 02355205 | Thalomid | 100mg | Cap | $58.9380 |
| 02355221 | Thalomid | 200mg | Cap | $117.8800 | Effective date August 27, 2012 |
| 02325063 | Omnitrope | 5mg/1.5mL | Inj-5mg Pen Cart Pk | $155.8000 |
| 02325071 | Omnitrope | 10mg/1.5mL | Inj-10mg Pen Cart Pk | $311.6000 |
| Effective date March 19, 2012 | ||||
| 02344939 | Ilaris | 150mg | Powder for solution for sc injection (vial) | $106.6667/mg |
| Effective date October 27, 2011 | ||||
| 02357119 | Vpriv® | 400U | Vial | $1955.0000 |
| Effective date September 30, 2010 | ||||
| 02331675 | Cimzia | 200mg/mL | Pre-Filled Syringe | $664.5100 |
| Effective date October 8, 2009 | ||||
| 02169649 | Betaseron | Inj Pref Syr - 0.3mg | Injection | $110.0000 |
| Effective date June 11, 2009 | ||||
| 02284863 | Myozyme | 50mg/vial | Lyophylized Powder | $840.3100 |
| Effective date May 27, 2009 | ||||
| 02296314 | Elaprase | 2mg/mL | 3mL Vial | $3,800.00 |
Until further notice, for all other products reimbursed under the EAP, pharmacies will continue to be reimbursed their acquisition cost plus the applicable mark-up:
- 8% when the total drug cost is less than $1,000.00;
- 6% when the total drug cost is greater than or equal to $1,000.00.
Public Information
