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Reason for Use code 441 In combination with low-dose ASA for patients with: - Non-ST elevation acute coronary syndrome (ACS)* (unstable angina or myocardial infarction [MI]); OR - ST-segment elevation myocardial infarction (STEMI); OR - Stent thrombosis while taking clopidogrel plus low-dose ASA. Treatment must be initiated in hospital. Notes: A) *ACS without ST elevation is defined as 2 of 3 of the following criteria: 1. ST-segment changes on electrocardiogram (ECG) indicating ischemia 2. Positive biomarker indicating myocardial necrosis 3. One of the following: - Greater than or equal to 60 years of age - Previous MI or coronary artery bypass graft (CABG) - Coronary artery disease (CAD) with greater than or equal to 50% stenosis in greater than or equal to 2 vessels - Previous ischemic stroke, transient ischemic attack (TIA; hospital-based diagnosis), carotid stenosis (greater than or equal to 50%), or cerebral revascularization - Diabetes mellitus - Peripheral artery disease - Chronic renal dysfunction B) Co-administration of ticagrelor with high maintenance dose ASA (greater than 150mg daily) is not recommended. C) Definite stent thrombosis, according to the Academic Research Consortium, is a total occlusion originating in or within 5 mm of the stent, or is a visible thrombus within the stent, or is within 5 mm of the stent in the presence of an acute ischemic clinical syndrome within 48 hours. Definite stent thrombosis must be confirmed by angiography or by pathologic confirmation of acute thrombosis. D) Ticagrelor is contraindicated in patients with active pathological bleeding, in those with a history of intracranial hemorrhage and moderate to severe hepatic impairment. Coverage limit: LU Authorization Period: 1 year

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 Ticagrelor · DIN 02531801 Manufacturer: Jamp Pharma Corporation; listing date 2024-05-31 Health Canada: Marketed since 2024-03-28 · brand JAMP TICAGRELOR · ATC B01AC24 TICAGRELOR · form Tablet · route Oral · ingredients TICAGRELOR 90 MG · company Jamp pharma corporation · schedule Prescription

DIN 02531801: Jamp Ticagrelor Raw flags: sec12=Y, sec3=Y Item: 201200088; group id 261; item number 0511; lccId 00230; manufacturer id JPC Source form: Tab; strength: 90mg Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below Source prices (unrounded): $0.3960; ministry $0.3960 Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=02531801 Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=102090

Interchangeable products

Apo-Ticagrelor · DIN 02482630 · $0.3960 Brilinta · DIN 02368544 · $0.3960 M-Ticagrelor · DIN 02529769 · $0.3960 Taro-Ticagrelor · DIN 02492598 · $0.3960

Shortage status: not checked (no credentials)