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Reason for Use code 171 As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated. Coverage limit: LU Authorization Period: Indefinite Reason for Use code 172 As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents. Coverage limit: LU Authorization Period: Indefinite Reason for Use code 387 For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective. Coverage limit: LU Authorization Period: Indefinite

Lowest DBP recovery rule under medically necessary no-substitution claims: 6.2 Medically Necessary "No Substitution" Claims The Side Effect Reporting Form will not have to be renewed. However, the pharmacy must maintain a copy of the prescription that contains a direction that there be no substitution and the required Health Canada Side Effect Reporting Form (completed and signed by the prescriber). The prescriber must write “No Substitution” or “No Sub” on renewal or subsequent new written prescriptions, and indicate “No Substitution” on subsequent new oral prescriptions. The dispenser will be reimbursed the DBP plus a mark-up and the lesser of the posted usual and customary fee or the ODB dispensing fee minus the applicable ODB co-payment amount. Where a completed Side Effect Reporting Form is not available at the pharmacy during an inspection, the difference between the cost of the higher-cost product and the lowest DBP listed for the interchangeable category will be recovered. (ontario.ca, Revision #17; 2026-08-03 ↗) 6.2 Medically Necessary "No Substitution" Claims The Ministry will provide reimbursement of a higher-cost interchangeable product in medically necessary circumstances where a patient has experienced a significant adverse reaction with two (2) lower-cost interchangeable drug products, where available. When a prescriber identifies a patient for which it is medically necessary that a higher cost interchangeable product be provided, the prescriber must: • Complete, sign and forward to the pharmacist a copy of the Health Canada side effect reporting form for each lower-cost interchangeable drug product trialed (Side Effect Reporting Form[s]); and • Write “No Substitution” or “No Sub” on a written prescription or indicate “No Substitution” to the pharmacist in the case of a verbal prescription. The prescriber should keep a copy of the completed form in the patient’s record for future use and reference. In the case of a written prescription, when the pharmacist or dispensing physician receives a prescription with the written notation “No Substitution” or “No Sub”, reimbursement will be provided for the higher-cost interchangeable product only if the prescription is accompanied by a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed. This form must be completely filled out noting the details of the adverse reaction and signed by the prescriber. In the case of a verbal prescription, the prescriber must satisfy the operator of the pharmacy or dispensing physician that a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed has been completed and signed by the prescriber. A written record of this verbal prescription and the completed Health Canada Side Effect Reporting Form must be received by the pharmacy prior to claim submission. Upon receipt, the pharmacist must: • Fax, submit online or mail the completed and signed form to Health Canada’s Canada Vigilance Program; and • Retain his or her copy of the completed and signed Side Effect Reporting Form. (ontario.ca, Revision #17; 2026-08-03 ↗)

Jamp-Dorzolamide · DIN 02453347 Manufacturer: Jamp Pharma Corporation; listing date 2020-02-28 Health Canada: Dormant since 2025-11-01 · brand JAMP-DORZOLAMIDE · ATC S01EC03 DORZOLAMIDE · form Solution · route Ophthalmic · ingredients DORZOLAMIDE (DORZOLAMIDE HYDROCHLORIDE) 2 %/W/V · company Jamp pharma corporation · schedule Prescription

DIN 02453347: Jamp-Dorzolamide Raw flags: sec12=Y, sec3=Y Item: 523600083; group id 623; item number 1590; lccId 00086; manufacturer id JPC Source form: Oph Sol; strength: 2% Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below Source prices (unrounded): $1.4757; ministry $1.4757 Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=02453347 Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=93987

Interchangeable products

Dorzolamide · DIN 02522373 · $1.4757 Med-Dorzolamide · DIN 02457210 · $1.4757 Sandoz Dorzolamide · DIN 02316307 · $1.4757 Trusopt · DIN 02216205 · $1.4757

Shortage status: not checked (no credentials)

Health Canada lists this DIN as Dormant since 2025-11-01 — choose a marketed DIN from the same-category list.