Drug Benefit List

12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC AGENTS

BETHANECHOL CHLORIDE

10MG Tablet

01947958     DUVOID     SHI

01985671     MYOTONACHOL     GLE

00759171     PMS-BETHANECHOL     PMS

25MG Tablet

01947931     DUVOID     SHI

01985558     MYOTONACHOL     GLE

00739162     PMS-BETHANECHOL     PMS

50MG Tablet

01947923     DUVOID     SHI

00759198     PMS-BETHANECHOL     PMS

NEOSTIGMINE BROMIDE

15MG Tablet

00869945     PROSTIGMIN     VAE

PYRIDOSTIGMINE BROMIDE

180MG Sustained Release Tablet

00869953     MESTINON-SR     VAE

60MG Tablet

00869961     MESTINON     VAE

12:08.04 ANTIPARKINSONIAN AGENTS

BENZTROPINE MESYLATE

1MG/ML Injection

02238903     BENZTROPINE OMEGA     OMG

2MG Tablet

00426857     APO-BENZTROPINE     APX

00563862     BENZTROPINE     PDL

00587265     PMS-BENZTROPINE     PMS

ETHOPROPAZINE HCL

50MG Tablet

01927744     PARSITAN     ERF

PROCYCLIDINE HCL

0.5MG/ML Elixir

00587362     PMS-PROCYCLIDINE     PMS

2.5MG Tablet

00649392     PMS-PROCYCLIDINE     PMS

5MG Tablet

00587354     PMS-PROCYCLIDINE     PMS

ROPINIROLE HCL

0.25MG Tablet

02232565     REQUIP     GSK

1MG Tablet

02232567     REQUIP     GSK

2MG Tablet

02232568     REQUIP     GSK

5MG Tablet

02232569     REQUIP     GSK

TRIHEXYPHENIDYL HCL

0.4MG/ML Liquid

00885398     PMS-TRIHEXYPHENIDYL     PMS

2MG Tablet

00545058     APO-TRIHEX     APX

00572802     TRIHEXYPHEN     PRO

5MG Tablet

00545074     APO-TRIHEX     APX

00572799     TRIHEXYPHEN     PDL

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE

250MCG/ML Inhalation Solution (Multi-Dose)

02126222     APO-IPRAVENT     APX

00731439     ATROVENT     BOE

02239131     GEN-IPRATROPIUM     GEN

02210479     NOVO-IPRAMIDE     NOP

02231136     PMS-IPRATROPIUM     PMS

02097141     RATIO-IPRATROPIUM     RPH

125MCG/ML Inhalation Solution (Unit Dose)

02026759     ATROVENT UDV     BOE

02231135     PMS-IPRATROPIUM UDV     PMS

02097176     RATIO-IPRATROPIUM UDV     RPH

250MCG/ML Inhalation Solution (Unit Dose)

01950681     ATROVENT UDV     BOE

02216221     GEN-IPRATROPIUM UDV     GEN

02231785     NU-IPRATROPIUM UDV     NXP

02231244     PMS-IPRATROPIUM UDV     PMS

02231245     PMS-IPRATROPIUM UDV     PMS

02097168     RATIO-IPRATROPIUM UDV     RPH

99001446     RATIO-IPRATROPIUM UDV     RPH     *

20MCG/INHALATION Inhaler HFA

02247686     ATROVENT HFA     BOE

TIOTROPIUM BROMIDE MONOHYDRATE

Limited use benefit (prior approval required).

For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability
Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure.

18MCG Powder for Inhalation (Capsule)

02246793     SPIRIVA     BOE

12:12.00 SYMPATHOMIMETIC AGENTS

SALBUTAMOL

400MCG Powder for Inhalation (Capsule)

00895415     VENTOLIN ROTACAPS     GSK     *

SALMETEROL XINAFOATE

Serevent is indicated as adjunctive therapy for asthmatic patients who are using optimum anti-inflammatory treatment and yet experiencing breakthrough symptoms, requiring an inhaled short-acting bronchodilator more than twice daily. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

Chronic Obstructive Lung Disease (COPD): Serevent is indicated for long term, twice daily (morning and evening) administration in the maintenance treatment of bronchospasm and relief of dyspnea associated with COPD, including chronic bronchitis and emphysema. Serevent should be used as adjunctive brochodilator treatment for patients who have inadequate relief of symptoms with short-acting bronchodilator medications.

50MCG/DOSE Powder Diskus

02231129     SEREVENT DISKUS     GSK

12:12.04 ALPHA ADRENERGIC AGONISTS

MIDODRINE HCL

2.5MG Tablet

01934392     AMATINE     SHI

02278677     APO-MIDODRINE     APX

5MG Tablet

01934406     AMATINE     SHI

02278685     APO-MIDODRINE     APX

12:12.08 BETA ADRENERGIC AGONISTS

FENOTEROL HBR

1MG/ML Inhalation Solution (Multi-Dose)

00541389     BEROTEC     BOE

0.25MG/ML Inhalation Solution (Unit Dose)

02056712     BEROTEC UDV     BOE

0.625MG/ML Inhalation Solution (Unit Dose)

02056704     BEROTEC UDV     BOE

100MCG/INHALATION Inhaler

02006383     BEROTEC     BOE

FORMOTEROL FUMARATE

Formoterol fumarate is indicated as adjunctive therapy for asthmatic patients who are using optimum anti-inflammatory treatment and yet experiencing breakthrough symptoms, requiring an inhaled short-acting bronchodilator more than twice daily. Formoterol fumarate is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

6MCG/DOSE Dry Powder Inhaler

02237225     OXEZE TURBUHALER     AZC

12MCG/DOSE Dry Powder Inhaler

02237224     OXEZE TURBUHALER     AZC

12MCG/CAP Powder for Inhalation

02230898     FORADIL     NVR

FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE

Limited use benefit (prior approval required).

For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

6MCG & 100MCG/INHALATION Inhaler

02245385     SYMBICORT 100 TURBUHALER     AZC

6MCG & 200MCG/INHALATION Inhaler

02245386     SYMBICORT 200 TURBUHALER     AZC

IPRATROPIUM BROMIDE, SALBUTAMOL

0.2MG & 1MG/ML Inhalation Solution (Unit Dose)

02231675     COMBIVENT     BOE

02272695     GEN-COMBO     GEN

02243789     RATIO-IPRA SAL     RPH

20MCG & 100MCG/INHALATION Inhaler

02163721     COMBIVENT     BOE

ORCIPRENALINE SULFATE

2MG/ML Syrup

02236783     APO-ORCIPRENALINE     APX

02152568     RATIO-ORCIPRENALINE     RPH

02192675     TANTA-ORCIPRENALINE     TAN

SALBUTAMOL

5MG/ML Inhalation Solution (Multi-Dose)

02046741     APO-SALVENT     APX

02139324     DOM-SALBUTAMOL     DPC

02232987     GEN-SALBUTAMOL     GEN

02069571     PMS-SALBUTAMOL     PMS

00860808     RATIO-SALBUTAMOL     RPH

02154412     RHOXAL-SALBUTAMOL     RHO

02213486     VENTOLIN     GSK

0.5MG/ML Inhalation Solution (Unit Dose)

02243828     APO-SALVENT     APX

02208245     PMS-SALBUTAMOL     PMS

02239365     RATIO-SALBUTAMOL     RPH

02213400     VENTOLIN PF     GSK

1MG/ML Inhalation Solution (Unit Dose)

02231488     APO-SALVENT     APX

02259583     BCI-SALBUTAMOL     BCI

02216949     DOM-SALBUTAMOL     DPC

01926934     GEN-SALBUTAMOL     GEN

02084333     MED-SALBUTAMOL     MEC

02231783     NU-SALBUTAMOL     NXP

02208229     PMS-SALBUTAMOL     PMS

01986864     RATIO-SALBUTAMOL     RPH

02213419     VENTOLIN PF     GSK

2MG/ML Inhalation Solution (Unit Dose)

02231678     APO-SALVENT     APX

02173360     GEN-SALBUTAMOL PF     GEN

02231784     NU-SALBUTAMOL     NXP

02208237     PMS-SALBUTAMOL     PMS

02239366     RATIO-SALBUTAMOL     RPH

02213427     VENTOLIN PF     GSK

100MCG/INHALATION Inhaler CFC-Free

02232570     AIROMIR     MMH

02245669     APO-SALVENT CFC FREE     APX

100MCG/INHALATION Inhaler HFA

02244914     RATIO-SALBUTAMOL HFA     RPH

02241497     VENTOLIN HFA     GSK

0.4MG/ML Oral Liquid

02091186     PMS-SALBUTAMOL     PMS

02212390     VENTOLIN     GSK

200MCG Powder for Inhalation (Disk)

02214997     VENTODISK     GSK

99000369     VENTODISK & DISKHALER     GSK     *

400MCG Powder for Inhalation (Disk)

02215004     VENTODISK     GSK

99000377     VENTODISK     GSK     *

2MG Tablet

02146843     APO-SALVENT     APX

4MG Tablet

02146851     APO-SALVENT     APX

02165376     NU-SALBUTAMOL     NXP

SALMETEROL XINAFOATE

Serevent is indicated as adjunctive therapy for asthmatic patients who are using optimum anti-inflammatory treatment and yet experiencing breakthrough symptoms, requiring an inhaled short-acting bronchodilator more than twice daily. Serevent is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

Chronic Obstructive Lung Disease (COPD): Serevent is indicated for long term, twice daily (morning and evening) administration in the maintenance treatment of bronchospasm and relief of dyspnea associated with COPD, including chronic bronchitis and emphysema. Serevent should be used as adjunctive brochodilator treatment for patients who have inadequate relief of symptoms with short-acting bronchodilator medications.

25MCG/INHALATION Inhaler

02211742     SEREVENT     GSK

50MCG/INHALATION Powder for Inhalation

02214261     SEREVENT DISKHALER     GSK

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

Limited use benefit (prior approval required).

For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250-500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

For the treatment of moderate** to severe **COPD, if a patient continues to be symptomatic after an adequate trial (2-4 months) of ipatroprium at a dose of 4 puffs four times daily and short-acting beta 2-agonists (indicating poor control).

**Canadian Thoracic Society COPD classification
By Symptom/Disability:
Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level.
Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure.

25MCG & 125MCG INHALATION Inhaler

02245126     ADVAIR     GSK

25MCG & 250MCG INHALATION Inhaler

02245127     ADVAIR     GSK

50MCG & 100MCG Inhaler

02240835     ADVAIR DISKUS 100     GSK

50MCG & 250MCG Inhaler

02240836     ADVAIR DISKUS 250     GSK

50MCG & 500MCG Inhaler

02240837     ADVAIR DISKUS 500     GSK

TERBUTALINE SULFATE

500MCG/INHALATION Powder for Inhalation

00786616     BRICANYL TURBUHALER     AZC

12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE

0.15MG/0.15ML Injection

02268205     TWINJECT     PAL

0.5MG/ML Injection

00578657     EPIPEN JR     AXL

1MG/ML Injection

00155357     ADRENALIN     ERF

00721891     EPINEPHRINE     ABB

00509558     EPIPEN     AXL

02247310     TWINJECT     PAL

1MG/ML Topical Solution

00155365     ADRENALIN     ERF

EPINEPHRINE HCL (RACEMIC)

2.25% Inhalation Solution

01927582     VAPONEFRIN     AVT

PSEUDOEPHEDRINE HCL, TRIPROLIDINE HCL

60MG & 2.5MG Tablet

02238302     ACTIFED     PFI

12:16.00 SYMPATHOLYTIC AGENTS

DIHYDROERGOTAMINE MESYLATE

1MG/ML Injection

00027243     DIHYDROERGOTAMINE     STE

02241163     DIHYDROERGOTAMINE     SDZ

4MG/ML Nasal Spray

02228947     MIGRANAL     STE

ERGOTAMINE TARTRATE, CAFFEINE

2MG & 100MG Suppository

00782920     CAFERGOT     NVR

1MG & 100MG Tablet

00176095     CAFERGOT     NVR

METHYSERGIDE MALEATE

2MG Tablet

00027499     SANSERT     NVR

12:20.00 SKELETAL MUSCLE RELAXANTS

BACLOFEN

10MG Tablet

02139332     APO-BACLOFEN     APX

02152584     BACLOFEN     PDL

02138271     DOM-BACLOFEN     DPC

02238445     FTP-BACLOFEN     FTP

02088398     GEN-BACLOFEN     GEN

00455881     LIORESAL     NVR

02084449     MED-BACLOFEN     MEC

02136090     NU-BACLO     NXP

02236963     PHL-BACLOFEN     PHH

02063735     PMS-BACLOFEN     PMS

02236507     RATIO-BACLOFEN     RPH

02242150     RIVA-BACLOFEN     RIV

20MG Tablet

02139391     APO-BACLOFEN     APX

02152592     BACLOFEN     PDL

02138298     DOM-BACLOFEN     DPC

02238446     FTP-BACLOFEN     FTP

02088401     GEN-BACLOFEN     GEN

00636576     LIORESAL DS     NVR

02084457     MED-BACLOFEN     MEC

02136104     NU-BACLO     NXP

02236964     PHL-BACLOFEN     PHH

02063743     PMS-BACLOFEN     PMS

02236508     RATIO-BACLOFEN     RPH

02242151     RIVA-BACLOFEN     RIV

DANTROLENE SODIUM

25MG Capsule

01997602     DANTRIUM     PGP

100MG Capsule

01997653     DANTRIUM     PGP

TIZANIDINE HCL

Limited use benefit (prior approval required).

For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.

4MG Tablet

02259893     APO-TIZANIDINE     APX

02239170     ZANAFLEX     ELN

12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

NICOTINE (GUM)

Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:
Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum when one year has elapsed from the day the initial prescription was filled.

2MG Gum

02091933     NICORETTE     PMJ

4MG Gum

02091941     NICORETTE PLUS     PMJ

NICOTINE (PATCH)

Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:
Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is:
Habitrol 84 patches or
Nicoderm 70 patches or
Nicotrol 70 patches

Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.

7MG Patch (Habitrol)

01943057     HABITROL     NVC

14MG Patch (Habitrol)

01943065     HABITROL     NVC

21MG Patch (Habitrol)

01943073     HABITROL     NVC

36MG Patch (Nicoderm)

02093111     NICODERM     PMJ

78MG Patch (Nicoderm)

02093138     NICODERM     PMJ

114MG Patch (Nicoderm)

02093146     NICODERM     PMJ

8.3MG/10CM2 Patch (Nicotrol)

02065738     NICOTROL TRANSDERMAL     PFI

16.6MG/20CM2 Patch (Nicotrol)

02065754     NICOTROL TRANSDERMAL     PFI

24.9MG/30CM2 Patch (Nicotrol)

02065762     NICOTROL TRANSDERMAL     PFI