Home > First Nations & Inuit Health > Non-Insured Health Benefits > Health Provider Information > Drug/Pharmacy Information > Drug Benefit List

Drug Benefit List

Limited Use Benefits and Criteria

08:00 ANTI-INFECTIVE AGENTS

08:12.24 TETRACYCLINES

MINOCYCLINE HCL

Limited use benefit (prior approval required).

For:
a. - patients who cannot tolerate other tetracyclines.
b. - patients with severe widespread acne who have failed on tetracycline.

50MG Capsule: 02084090 APO-MINOCYCLINE APX; 02239667 DOM-MINOCYCLINE DPC; 02237875 MED-MINOCYCLINE MEC; 02173514 MINOCIN STI; 02108143 NOVO-MINOCYCLINE NOP; 02153394 PDL-MINOCYCLINE PDL; 02239238 PMS-MINOCYCLINE PMS; 01914138 RATIO-MINOCYCLINE RPH; 02237313 RHOXAL-MINOCYCLINE SDZ; 02242080 RIVA-MINOCYCLINE RIV

100MG Capsule: 02084104 APO-MINOCYCLINE APX; 02239668 DOM-MINOCYCLINE DPC; 02237876 MED-MINOCYCLINE MEC; 02173506 MINOCIN STI; 02239982 MINOCYCLINE IVX; 02108151 NOVO-MINOCYCLINE NOP; 02154366 PDL-MINOCYCLINE PDL; 02239239 PMS-MONOCYCLINE PMS; 01914146 RATIO-MINOCYCLINE RPH; 02237314 RHOXAL-MINOCYCLINE SDZ; 02242081 RIVA-MINOCYCLINE RIV

08:12.28 MISCELLANEOUS ANTIBIOTICS

LINEZOLID

Limited use benefit (prior approval required).

Tablets:

For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:

When linezolid cannot be administered orally in the above mentioned situations.

2MG/ML Injection: 02243685 ZYVOXAM PFI

600MG Tablet: 02243684 ZYVOXAM PFI

08:18.08 ANTIRETROVIRALS

AMPRENAVIR

Limited use benefit (prior approval required).

For the management of HIV disease in patients who have failed other protease inhibitor combinations, or for patients who experienced a lack of tolerability to other protease inhibitors.

50MG Capsule: 02243541 AGENERASE GSK

150MG Capsule: 02243542 AGENERASE GSK

15MG/ML Oral Liquid: 02243543 AGENERASE GSK

ATAZANAVIR SULFATE

Limited use benefit (prior approval required).

For the management of HIV in patients who failed other protease inhibitor combinations, or for patients who experienced a lack of tolerability to other protease inhibitors

150MG Capsule: 02248610 REYATAZ BMS

200MG Capsule: 02248611 REYATAZ BMS

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naïve, upon the written request of a hepatologist or other specialist in this area.

a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved. A further 24 week supply may be approved if patient has a viral reduction of at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).

b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180MCG/0.5ML Injection: 02248077 PEGASYS HLR

180MCG/1ML Injection: 02248078 PEGASYS HLR

PEGINTERFERON ALFA-2A, RIBAVIRIN

180MCG/0.5ML & 200MG Injection & Tablet: 02253429 PEGASYS RBV HLR

180MCG/1ML & 200MG Injection & Tablet: 02253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2B

74MCG/VIAL Injection: 02242966 UNITRON PEG SCH

118.4MCG/VIAL Injection: 02242967 UNITRON PEG SCH

177.6MCG/VIAL Injection: 02242968 UNITRON PEG SCH

222MCG/VIAL Injection: 02242969 UNITRON PEG SCH

PEGINTERFERON ALFA-2B, RIBAVIRIN

50MCG/0.5ML & 200MG Injection & Capsule: 02246026 PEGETRON SCH; 02254573 PEGETRON REDIPEN SCH

80MCG/0.5ML & 200MG Injection & Capsule: 02246027 PEGETRON SCH; 02254581 PEGETRON REDIPEN SCH

100MCG/0.5ML & 200MG Injection & Capsule: 02246028 PEGETRON SCH; 02254603 PEGETRON REDIPEN SCH

120MCG/0.5ML & 200MG Injection & Capsule: 02246029 PEGETRON SCH; 02254638 PEGETRON REDIPEN SCH

150MCG/0.5ML & 200MG Injection & Capsule: 02246030 PEGETRON SCH; 02254646 PEGETRON REDIPEN SCH

10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

IMATINIB MESYLATE

Limited use benefit (prior approval required).

a.- For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy.
b.- For the treatment of patients with gastrointestinal stromal tumour.
c.- For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML).

100MG Capsule: 02244725 GLEEVEC NVR

100MG Tablet: 02253275 GLEEVEC NVR

TEMOZOLOMIDE

Limited use benefit (prior approval required).

For treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).

5MG Capsule: 02241093 TEMODAL SCH

20MG Capsule: 02241094 TEMODAL SCH

100MG Capsule: 02241095 TEMODAL SCH

250MG Capsule: 02241096 TEMODAL SCH

12:00 AUTONOMIC DRUGS

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

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

12:12.08 BETA ADRENERGIC AGONISTS

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

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

12:20.00 SKELETAL MUSCLE RELAXANTS

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

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:16.00 HEMATOPOIETIC AGENTS

PEGFILGRASTIM

Limited use benefit (prior approval required).

a. - To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent.
and
b. - Where access to a health care facility is problematic.

10MG/ML Injection: 02249790 NEULASTA AMG

24:00 CARDIOVASCULAR DRUGS

24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBE

Limited use benefit (prior approval required).

a.- For use in combination with a HMG-CoA reductase inhibitor ('statin') in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated “statin” doses.

b.- For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.

10MG Tablet: 02247521 EZETROL MSP

24:12.92 MISCELLANEOUS VASODILATING AGENTS

DIPYRIDAMOLE, ACETYLSALICYLIC ACID

Limited use benefit (prior approval required).

For secondary prevention of stroke or transient ischemic attacks (TIAs) in patients who have failed therapy with ASA alone.

200MG & 25MG Capsule: 02242119 AGGRENOX BOE

24:24.00 BETA ADRENERGIC BLOCKING AGENTS

CARVEDILOL

Limited use benefit (prior approval required).

a.- For patients with systolic heart failure of ischemic or non-ischemic origin, with or without digoxin, PLUS

b.- Concurrent treatment with diuretics and angiotension converting enzyme inhibitors or angiotensin receptor blockers, unless contraindicated.

3.125MG Tablet: 02247933 APO-CARVEDILOL APX; 02229650 COREG GSK; 02248748 DOM-CARVEDILOL DPC; 02246529 NOVO-CARVEDILOL NOP; 02245914 PMS-CARVEDILOL PMS; 02268027 RAN-CARVEDILOL RBY; 02252309 RATIO-CARVEDILOL RPH

6.25MG Tablet: 02247934 APO-CARVEDILOL APX; 02229651 COREG GSK; 02248749 DOM-CARVEDILOL DPC; 02246530 NOVO-CARVEDILOL NOP; 02245915 PMS-CARVEDILOL PMS; 02268035 RAN-CARVEDILOL RBY; 02252317 RATIO-CARVEDILOL RPH

12.5MG Tablet: 02247935 APO-CARVEDILOL APX; 02229652 COREG GSK; 02248750 DOM-CARVEDILOL DPC; 02246531 NOVO-CARVEDILOL NOP; 02245916 PMS-CARVEDILOL PMS; 02268043 RAN-CARVEDILOL RBY; 02252325 RATIO-CARVEDILOL RPH

25MG Tablet: 02247936 APO-CARVEDILOL APX; 02229653 COREG GSK; 02248751 DOM-CARVEDILOL DPC; 02246532 NOVO-CARVEDILOL NOP; 02245917 PMS-CARVEDILOL PMS; 02268051 RAN-CARVEDILOL RBY; 02252333 RATIO-CARVEDILOL RPH

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CELECOXIB

Limited use benefit (prior approval required).

For patients with osteoarthritis who have failed therapy with acetaminophen and who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or
c. - have a history of a serious gastrointestinal complication such as bleeding or perforation.

For patients with rheumatoid arthritis who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs, or
c. - have a history of a serious gastrointestinal complication such as bleeding or perforation.

100MG Capsule: 02239941 CELEBREX PFI

200MG Capsule: 02239942 CELEBREX PFI

MELOXICAM

7.5MG Tablet: 02248973 APO-MELOXICAM APX; 02250012 CO-MELOXICAM COB; 02248605 DOM-MELOXICAM DPC; 02255987 GEN-MELOXICAM GEN; 02242785 MOBICOX BOE; 02258315 NOVO-MELOXICAM NOP; 02248607 PHL-MELOXICAM PHH; 02248267 PMS-MELOXICAM PMS; 02247889 RATIO-MELOXICAM RPH

15MG Tablet: 02248974 APO-MELOXICAM APX; 02250020 CO-MELOXICAM COB; 02248606 DOM-MELOXICAM DPC; 02255995 GEN-MELOXICAM GEN; 02242786 MOBICOX BOE; 02258323 NOVO-MELOXICAM NOP; 02248608 PHL-MELOXICAM PHH; 02248268 PMS-MELOXICAM PMS; 02248031 RATIO-MELOXICAM RPH

28:08.08 OPIATE AGONISTS

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE

Limited use benefit (prior approval required).

For treatment of:
a. - chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or
b. - chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.

50MG Long Acting Tablet: 02230302 CODEINE CONTIN CR PFR

100MG Long Acting Tablet: 02163748 CODEINE CONTIN CR PFR

150MG Long Acting Tablet: 02163780 CODEINE CONTIN CR PFR

200MG Long Acting Tablet: 02163799 CODEINE CONTIN CR PFR

FENTANYL

Limited use benefit (prior approval required).

For the management of chronic pain in patients who are unresponsive or intolerant to at least one long-acting oral sustained released product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.

12.5MCG/H Patch: 02280345 DURAGESIC 12.5 JNO

25MCG/H Patch: 01937383 DURAGESIC 25 JNO

50MCG/H Patch: 01937391 DURAGESIC 50 JNO

75MCG/H Patch: 01937405 DURAGESIC 75 JNO

100MCG/H Patch: 01937413 DURAGESIC 100 JNO

HYDROMORPHONE HCL

Limited use benefit. Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.

For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.

3MG Controlled Release Capsule: 02125323 HYDROMORPH CONTIN PFR

6MG Controlled Release Capsule: 02125331 HYDROMORPH CONTIN PFR

12MG Controlled Release Capsule: 02125366 HYDROMORPH CONTIN PFR

18MG Controlled Release Capsule: 02243562 HYDROMORPH CONTIN PFR

24MG Controlled Release Capsule: 02125382 HYDROMORPH CONTIN PFR

30MG Controlled Release Capsule: 02125390 HYDROMORPH CONTIN PFR

2MG/ML Injection: 00627100 DILAUDID ABB; 02145901 HYDROMORPHONE SDZ

10MG/ML Injection: 00622133 DILAUDID HP ABB; 02145928 HYDROMORPHONE HP 10 SDZ

20MG/ML Injection: 02146118 DILAUDID HP PLUS ABB; 02145936 HYDROMORPHONE HP 20 SDZ

50MG/ML Injection: 02145863 DILAUDID XP ABB; 02146126 HYDROMORPHONE HP 50 SDZ; 99003163 HYDROMORPHONE HP 50 SIL

1MG/ML Oral Liquid: 00786535 DILAUDID ABB; 01916386 PMS-HYDROMORPHONE PMS

3MG Suppository: 00125105 DILAUDID ABB; 01916394 PMS-HYDROMORPHONE PMS

1MG Tablet: 00705438 DILAUDID ABB; 02192101 PHL-HYDROMORPHONE PHH; 00885444 PMS-HYDROMORPHONE PMS

2MG Tablet: 00125083 DILAUDID ABB; 02245703 HYDROMORPH-IR PFR; 02249928 PHL-HYDROMORPHONE PHH; 00885436 PMS-HYDROMORPHONE PMS

4MG Tablet: 00125121 DILAUDID ABB; 02245704 HYDROMORPH-IR PFR; 02249936 PHL-HYDROMORPHONE PHH; 00885401 PMS-HYDROMORPHONE PMS

8MG Tablet: 00786543 DILAUDID ABB; 02245705 HYDROMORPH-IR PFR; 02192144 PHL-HYDROMORPHONE PHH; 00885428 PMS-HYDROMORPHONE PMS

OXYCODONE HCL

Limited use benefit. Prior approval required for controlled release tablets only. Regular release dosage forms are full benefits and do not require prior approval.

For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.

10MG Controlled Release Tablet: 02202441 OXYCONTIN PFR

20MG Controlled Release Tablet: 02202468 OXYCONTIN PFR

40MG Controlled Release Tablet: 02202476 OXYCONTIN PFR

80MG Controlled Release Tablet: 02202484 OXYCONTIN PFR

10MG Suppository: 00392480 SUPEUDOL SIL

20MG Suppository: 00392472 SUPEUDOL SIL

5MG Tablet: 02231934 OXY-IR PFR; 00789739 SUPEUDOL SDZ

10MG Tablet: 02240131 OXY-IR PFR; 00443948 SUPEUDOL SDZ

20MG Tablet: 02240132 OXY-IR PFR; 02262983 SUPEUDOL SDZ

28:12.92 MISCELLANEOUS ANTICONVULSANTS

LEVETIRACETAM

Limited use benefit (prior approval required).

For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of three anti-epileptic medications used either as monotherapy or in combination. This product must be prescribed by a Neurologist.

250MG Tablet: 02274183 CO-LEVETIRACETAM COB; 02247027 KEPPRA UCB

500MG Tablet: 02274191 CO-LEVETIRACETAM COB; 02247028 KEPPRA UCB

750MG Tablet: 02274205 CO-LEVETIRACETAM COB; 02247029 KEPPRA UCB

28:16.04 ANTIDEPRESSANTS

BUPROPION HCL (WELLBUTRIN)

Limited use benefit (prior approval required).

For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).

100MG Sustained Release Tablet: 02275074 SANDOZ-BUPROPION SR SDZ; 02237824 WELLBUTRIN SR BPC

150MG Sustained Release Tablet: 02260239 NOVO-BUPROPION SR NOP; 02275082 SANDOZ-BUPROPION SR SDZ; 02237825 WELLBUTRIN SR BPC

BUPROPION HCL (ZYBAN)

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

For smoking cessation:
Coverage is limited to 180 tablets 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 bupropion HCl when one year has elapsed from the day the initial prescription was filled.

150MG Sustained Release Tablet: 02238441 ZYBAN SR BPC

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:20.00 CALORIC AGENTS

LEVOCARNITINE

Limited use benefit (prior approval required).

For treatment of carnitine deficiency.

100MG/ML Oral Liquid: 02144336 CARNITOR SIG

200MG/ML Solution: 02144344 CARNITOR IV SIG

330MG Tablet: 02144328 CARNITOR SIG

48:00 Respiratory Tract Agents

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST

Limited use benefit (prior approval required).

For treatment of:
a. - asthma when used in patients on concurrent steroid therapy.
b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.

4MG Chewable Tablet: 02243602 SINGULAIR FRS

5MG Chewable Tablet: 02238216 SINGULAIR FRS

4MG Granules: 02247997 SINGULAIR FRS

10MG Tablet: 02238217 SINGULAIR FRS

ZAFIRLUKAST

20MG Tablet: 02236606 ACCOLATE AZC

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:04.04 EENT - ANTIBACTERIALS

CIPROFLOXACIN HCL, HYDROCORTISONE

Limited use benefit (prior approval required).

For treatment of acute diffuse bacterial external otitis. Criteria for coverage include:
a. - failure to respond to other listed topical antibiotics, or
b. - contraindications to other listed topical antibiotics.

2MG & 10MG/ML Otic Suspension: 02240035 CIPRO HC ALC

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCL

Limited use benefit (prior approval required).

For:
a. - treatment of radiation mucositis and oral ulcerative complications of chemotherapy.
b. - use in immunocompromised patients who are at risk of mucosal breakdown.

0.15% Rinse: 02239044 APO-BENZYDAMINE APX; 02239537 DOM-BENZYDAMINE DPC; 02229799 NOVO-BENZYDAMINE NOP; 02229777 PMS-BENZYDAMINE PMS; 02230170 RATIO-BENZYDAMINE RPH; 01966065 TANTUM MMH

52:92.00 MISCELLANEOUS EENT DRUGS

BRIMONIDINE TARTRATE (ALPHAGAN P)

Limited use benefit (prior approval required).

For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.

0.15% Ophth Solution: 02248151 ALPHAGAN P ALL

VERTEPORFIN

Limited use benefit (prior approval required).

For treatment of age related macular degeneration for patients with this diagnosis who are being treated by a certified ophthalmologist.

15MG/VIAL Injection: 02242367 VISUDYNE QLT

56:00 GASTROINTESTINAL DRUGS

56:12.00 CATHARTICS AND LAXATIVES

BISACODYL (POLYETHYLENE GLYCOL BASE)

Limited use benefit (prior approval required).

For treatment of constipation in patients with spinal cord injury.

10MG Suppository: 02241091 MAGIC BULLET DCM

56:28.36 PROTON-PUMP INHIBITORS

LANSOPRAZOLE

Limited use drug status (prior approval required)
Coverage will be provided:
- as part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 60 days of Apo-Omeprazole® (Generic) and
- patient has tried at least 60 days of Rabeprazole sodium (Pariet®). Total trial of 120 days will be confirmed against medication history:
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated and 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition

15MG Sustained Release Capsule: 02165503 PREVACID ABB

30MG Sustained Release Capsule: 02165511 PREVACID ABB

OMEPRAZOLE

10MG Capsule: 02119579 LOSEC AZC

20MG Capsule: 00846503 LOSEC AZC

OMEPRAZOLE MAGNESIUM

10MG Delayed Release Tablet: 02230737 LOSEC AZC

20MG Delayed Release Tablet: 02190915 LOSEC AZC

PANTOPRAZOLE

40MG Enteric Coated Tablet: 02229453 PANTOLOC SPH

68:00 HORMONES AND SYNTHETIC SUBSTITUTES

68:12.00 CONTRACEPTIVES

ETHINYL ESTRADIOL, NORELGESTROMIN

Limited use benefit (prior approval required).

For the treatment of patients who are intolerant to or unable to take oral contraceptives.

0.6MG & 6MG Transdermal System: 02248297 EVRA JNO

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCL

Limited use benefit (prior approval required).

For:
a.- secondary prevention of osteoporosis in women who experience failure on bisphosphonates.
b. - secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60MG Tablet: 02239028 EVISTA LIL

68:20.28 THIAZOLIDINEDIONES

PIOGLITAZONE HCL

Limited use benefit (prior approval required).

For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.

15MG Tablet: 02242572 ACTOS LIL

30MG Tablet: 02242573 ACTOS LIL

45MG Tablet: 02242574 ACTOS LIL

ROSIGLITAZONE MALEATE

2MG Tablet: 02241112 AVANDIA GSK

4MG Tablet: 02241113 AVANDIA GSK

8MG Tablet: 02241114 AVANDIA GSK

68:24.00 PARATHYROID

CALCITONIN SALMON (MIACALCIN)

Limited use benefit (prior approval required).

For treatment of patients with postmenopausal osteoporosis who have failed therapy, are intolerant to, or who have contraindications to both bisphosphonates and raloxifene.

200IU/dose Nasal Spray: 02247585 APO-CALCITONIN APX; 02240775 MIACALCIN NVR

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

TACROLIMUS (PROTOPIC)

Limited use benefit (prior approval required).

Prescribed by a dermatologist, to be used in patients who have failed topical corticosteroid therapy or have experienced side effects from such treatment.

0.03% Ointment: 02244149 PROTOPIC AST

0.1% Ointment: 02244148 PROTOPIC AST

86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

TOLTERODINE

Limited use benefit (prior approval required).

For the symptomatic relief of patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence or any combination of these in patients who have failed on or are intolerant of therapy with oxybutynin.

2MG Extended Release Capsule: 02244612 DETROL LA PFI

4MG Extended Release Capsule: 02244613 DETROL LA PFI

1MG Tablet: 02239064 DETROL PFI

2MG Tablet: 02239065 DETROL PFI

88:00 VITAMINS

88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVITAMINS (PEDIATRIC)

Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

Chewable Tablet: 01932586 GARFIELD MULTIVITAMINS WRI; 00336300 MULTI-VITAMINS CHILD NOP

Drop: 00558060 INFANTOL HOR; 00762946 POLY-VI-SOL MJO

Liquid: 00558079 INFANTOL HOR

Tablet: 02247975 FLINTSTONES EXTRA C BCD

MULTIVITAMINS (PRENATAL)

Limited use benefit (prior approval is not required.).

Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).

Tablet: 02231880 MATERNA WAY; 02248555 MATERNA WAY; 02229535 MULTI-PRE AND POST NATAL PED; 00815241 NEO-TINIC NEO; 02103044 ORIFER F SAC; 02226960 PRENATAL VTH; 02240840 PRENATAL AND POSTPARTUM VTH; 02241235 PRENATAL AND POSTPARTUM SDR; 02244374 PRENATAL VITAMINS AND MINERALS PMT

VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID

Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

2,500IU & 666.67IU & 50MG/ML Drop: 02229790 PEDIAVIT EUR; 00762903 TR- VI-SOL MJO

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ADALIMUMAB

CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR ADALIMUMAB
Note: Initial coverage is provided for 12 weeks of 40mg every other week of adalimumab ONLY.
-Prescribed by a rheumatologist AND
-To be used for the treatment of severely active rheumatoid arthritis OR
-To be used to treat severely active rheumatoid arthritis in patients who are intolerant or has contraindications to methotrexate (see below)
Patient is refractory to:
-Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65 years of age) for more than 8 weeks. AND
-Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks.
PLUS
-Leflunomide: 20mg daily for 10 weeks
PLUS
-Gold: weekly injections for 20 weeks OR
-Sulfaslazine: at least 2 gm daily for 3 months OR
-Azathioprine: 2-3mg/kg/day for 3 months
PLUS One of the following combinations:
-Methotrexate with cyclosporine (minimum 4 month trial on both) OR
-Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
-Methotrexate with gold (minimum 12 week trial) OR
-Methotrexate with leflunomide (minimum 8 week trial) OR
-In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to a combination of a least 2 DMARDs.
CRITERIA FOR CONTINUED COVERAGE FOR ADALIMUMAB BEYOND TWELVE WEEKS
Patient meets all the following criteria:
Initially prescribed by a rheumatologist
Patient has been assessed after the eighth to twelfth week of adalimumab therapy and meets the following response criteria
>20% reduction in number of tender and swollen joints PLUS
>20% improvement in physician global assessment scale PLUS EITHER
>20% improvement in the patient global assessment scale, OR
>20% reduction in the acute phase as measured by ESR or CRP

40MG/Vial Injection: 02258595 HUMIRA ABB

ALENDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures
b. - osteoporosis in patients with intolerance or lack of response to etidronate or etidronate/calcium
c. - Paget's Disease

5MG Tablet: 02248727 APO-ALENDRONATE APX; 02233055 FOSAMAX FRS; 02270110 GEN-ALENDRONATE GEN; 02248251 NOVO-ALENDRONATE NOP

10MG Tablet: 02248728 APO-ALENDRONATE APX; 02201011 FOSAMAX FRS; 02270129 GEN-ALENDRONATE GEN; 02247373 NOVO-ALENDRONATE NOP

40MG Tablet: 02258102 CO-ALENDRONATE COB; 02201038 FOSAMAX FRS

70MG Tablet: 02248730 APO-ALENDRONATE APX; 02258110 CO-ALENDRONATE COB; 02245329 FOSAMAX FRS; 02261715 NOVO-ALENDRONATE NOP; 02273179 PMS-ALENDRONATE PMS; 02275279 RATIO-ALENDRONATE RPH

ALFUZOSIN HYDROCHLORIDE

Limited use benefit (prior approval required).

For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to other alpha- adrenergic blockers.

10MG Sustained Release Tablet: 02245565 XATRAL SAC

BOTULINUM TOXIN TYPE A

Limited use benefit (prior approval required).

For the treatment of focal dystonias and hyperhydrosis.

100IU Injection: 01981501 BOTOX ALL

CABERGOLINE

Limited use benefit (prior approval required).

For treatment of hyperprolactinemia in patients who have failed therapy with or are intolerant to bromocriptine.

0.5MG Tablet: 02242471 DOSTINEX PFI

CYCLOSPORINE

Limited use benefit (prior approval required).

For transplant therapy.

10MG Capsule: 02237671 NEORAL NVR

25MG Capsule: 02150689 NEORAL NVR; 02247073 RHOXAL-CYCLOSPORINE RHO

50MG Capsule: 02150662 NEORAL NVR

100MG Capsule: 02150670 NEORAL NVR; 02242821 RHOXAL-CYCLOSPORINE SDZ

100MG/ML Solution: 02150697 NEORAL NVR

DUTASTERIDE

Limited use benefit (prior approval required).

a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker.
or
b. - For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.

0.5MG Capsule: 02247813 AVODART GSK

ETANERCEPT

CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR ETANERCEPT
Note: Initial coverage is provided for 12 weeks of 25mg twice weekly for etanercept ONLY.
-Prescribed by a rheumatologist AND
-To be used for the treatment of severely active rheumatoid arthritis OR
-To be used to treat severely active rheumatoid arthritis in patients who are intolerant or has contraindications to methotrexate (see below)
Patient is refractory to:
-Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65 years of age) for more than 8 weeks. AND
-Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks.
PLUS
-Leflunomide: 20mg daily for 10 weeks
PLUS
-Gold: weekly injections for 20 weeks OR
-Sulfaslazine: at least 2 gm daily for 3 months OR
-Azathioprine: 2-3mg/kg/day for 3 months
PLUS One of the following combinations:
-Methotrexate with cyclosporine (minimum 4 month trial on both) OR
-Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
-Methotrexate with gold (minimum 12 week trial) OR
-Methotrexate with leflunomide (minimum 8 week trial) OR
-In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to a combination of a least 2 DMARDs.
CRITERIA FOR CONTINUED COVERAGE FOR ETANERCEPT BEYOND TWELVE WEEKS
Patient meets all the following criteria:
Initially prescribed by a rheumatologist
Patient has been assessed after the eighth to twelfth week of etanercept therapy and meets the following response criteria
>20% reduction in number of tender and swollen joints PLUS
>20% improvement in physician global assessment scale PLUS EITHER
>20% improvement in the patient global assessment scale, OR
>20% reduction in the acute phase as measured by ESR or CRP

25MG/VIAL Injection: 02242903 ENBREL IMX

50MG/ML Injection: 02274728 ENBREL IMX

INFLIXIMAB

CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR INFLIXIMAB FOR RHEUMATOID ARTHRITIS
-Prescribed by a rheumatologist
-Infliximab for use in combination with methotrexate for the treatment of severely active rheumatoid arthritis
Note: Initial coverage is provided for 3 doses of 3mg/kg of infliximab ONLY.
Patient is refractory to:
-Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65 years of age) for more than 8 weeks. AND
-Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks.
PLUS
-Leflunomide: 20mg daily for 10 weeks
PLUS
-Gold: weekly injections for 20 weeks OR
-Sulfaslazine: at least 2 gm daily for 3 months OR
-Azathioprine: 2-3mg/kg/day for 3 months
PLUS One of the following combinations:
-Methotrexate with cyclosporine (minimum 4 month trial on both) OR
-Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
-Methotrexate with gold (minimum 12 week trial) OR
-Methotrexate with leflunomide (minimum 8 week trial) OR
-In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to a combination of a least 2 DMARDs.
PLUS
Etanercept or Adalimumab: minimum of 12 week trial
CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS
Patient meets all the following criteria:
- Initially prescribed by a rheumatologist
- Previous failure to etanercept or adalimumab
- Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following response criteria
>20% reduction in number of tender and swollen joints PLUS
>20% improvement in physician global assessment scale
PLUS EITHER
>20% improvement in the patient global assessment scale, OR
>20% reduction in the acute phase as measured by ESR or CRP
REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR FISTULIZING CROHN'S DISEASE
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses.
-Infliximab is being prescribed by a gastroenterologist
-Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred or persisted despite:
1.a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a minimum of 3 weeks)
PLUS
2.immunosuppressive therapy:
-azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued at < 6 weeks due to severe adverse reactions.
OR
-6-mercaptopurine 50-70mg/day for a minimum of 6 weeks or treatment discontinued at <6 weeks due to severe adverse reactions.
OR
-Other.
REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR SEVERE ACTIVE CROHN'S DISEASE
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued coverage, patient must be reassessed after the initial doses.
-Infliximab is being prescribed by a gastroenterologist
-Patient is an adult with severe active Crohn's disease that has recurred or persisted despite:
1. Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks).
PLUS
2. Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks.
OR Treatment discontinued due to serious adverse reactions.
OR Contraindication to glucocorticoid therapy.
PLUS
3. Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months.
OR
6-mercaptopurine 50 to 70mg/day for a minimum of 3 months.
OR
Methotrexate 15 to 25mg/week for a minimum of 3 months.

100MG/VIAL Injection: 02244016 REMICADE CER

LEFLUNOMIDE

Limited use benefit (prior approval required).

For treatment of patients with rheumatoid arthritis who:
a. - have failed treatment with methotrexate.
b. - cannot tolerate or have contraindications to methotrexate.

10MG Tablet: 02256495 APO-LEFLUNOMIDE APX; 02241888 ARAVA SAC; 02261251 NOVO-LEFLUNOMIDE NOP

20MG Tablet: 02256509 APO-LEFLUNOMIDE APX; 02241889 ARAVA SAC; 02261278 NOVO-LEFLUNOMIDE NOP

MYCOPHENOLATE MOFETIL

Limited use benefit (prior approval required).

For transplant therapy.

250MG Capsule: 02192748 CELLCEPT HLR

500MG Tablet: 02237484 CELLCEPT HLR

MYCOPHENOLATE SODIUM

Limited use benefit (prior approval required).

For transplant therapy.

180MG Enteric Coated Tablet: 02264560 MYFORTIC NVR

360MG Enteric Coated Tablet: 02264579 MYFORTIC NVR

RISEDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures.
b. - osteoporosis in patients who are intolerant of or do not respond to etidronate or etidronate/calcium.
c. - Paget's disease.

5MG Tablet: 02242518 ACTONEL PGP

30MG Tablet: 02239146 ACTONEL PGP

35MG Tablet: 02246896 ACTONEL PGP

SIROLIMUS

Limited use benefit (prior approval required).

Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

1MG/ML Oral Liquid: 02243237 RAPAMUNE WAY

1MG Tablet: 02247111 RAPAMUNE WAY

TACROLIMUS

Limited use benefit (prior approval required).

For transplant therapy.

0.5MG Capsule: 02243144 PROGRAF AST

1MG Capsule: 02175991 PROGRAF AST

5MG Capsule: 02175983 PROGRAF AST

5MG/ML Injection: 02176009 PROGRAF AST

TAMSULOSIN HCL

Limited use benefit (prior approval required).

For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to other alpha- adrenergic blockers.

0.4MG Long Acting Tablet: 02270102 FLOMAX CR BOE

0.4MG Sustained Release Capsule: 02238123 FLOMAX SR BOE


	Last Updated: 2006-09-18		Important Notices