Drug Benefit List 2010

12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC AGENTS

BETHANECHOL CHLORIDE

10mg Tablet

1947958 DUVOID SHI

1985671 MYOTONACHOL GLE

25mg Tablet

1947931 DUVOID SHI

1985558 MYOTONACHOL GLE

50mg Tablet

1947923 DUVOID SHI

DONEPEZIL HCL

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

• Diagnosis of mild to moderate Alzheimer’s disease; AND
• Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND
• Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
• Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

• Diagnosis is still mild to moderate Alzheimer’s disease; AND
• MMSE score > 10; AND
• GDS score between 4 to 6; AND
• Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change)
  1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
  2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
  3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
  4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

5mg Tablet

2232043 ARICEPT PFI

10mg Tablet

2232044 ARICEPT PFI

GALANTAMINE

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

• Diagnosis of mild to moderate Alzheimer’s disease; AND
• Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND
• Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
• Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

• Diagnosis is still mild to moderate Alzheimer’s disease; AND
• MMSE score > 10; AND
• GDS score between 4 to 6; AND
• Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change)
  1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
  2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
  3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
  4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

8mg Extended Release Capsule

2266717 REMINYL ER JNO

16mg Extended Release Capsule

2266725 REMINYL ER JNO

24mg Extended Release Capsule

2266733 REMINYL ER JNO

NEOSTIGMINE BROMIDE

15mg Tablet

869945 PROSTIGMIN VAE

PYRIDOSTIGMINE BROMIDE

180mg Sustained Release Tablet

869953 MESTINON-SR VAE

60mg Tablet

869961 MESTINON VAE

RIVASTIGMINE

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

• Diagnosis of mild to moderate Alzheimer’s disease; AND
• Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND
• Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
• Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

• Diagnosis is still mild to moderate Alzheimer’s disease; AND
• MMSE score > 10; AND
• GDS score between 4 to 6; AND
• Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change)
  1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
  2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
  3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
  4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

1.5mg Capsule

2242115 EXELON NOV

2332809 MYLAN-RIVASTIGMINE MYL

2305984 NOVO-RIVASTIGMINE NOP

2306034 PMS-RIVASTIGMINE PMS

2311283 RATIO-RIVASTIGMINE RPH

2324563 SANDOZ RIVASTIGMINE SDZ

3mg Capsule

2242116 EXELON NOV

2332817 MYLAN-RIVASTIGMINE MYL

2305992 NOVO-RIVASTIGMINE NOP

2306042 PMS-RIVASTIGMINE PMS

2311291 RATIO-RIVASTIGMINE RPH

2324571 SANDOZ RIVASTIGMINE SDZ

4.5mg Capsule

2242117 EXELON NOV

2332825 MYLAN-RIVASTIGMINE MYL

2306018 NOVO-RIVASTIGMINE NOP

2306050 PMS-RIVASTIGMINE PMS

2311305 RATIO-RIVASTIGMINE RPH

2324598 SANDOZ RIVASTIGMINE SDZ

6mg Capsule

2242118 EXELON NOV

2332833 MYLAN-RIVASTIGMINE MYL

2306026 NOVO-RIVASTIGMINE NOP

2306069 PMS-RIVASTIGMINE PMS

2311313 RATIO-RIVASTIGMINE RPH

2324601 SANDOZ RIVASTIGMINE SDZ

2mg/mL Oral Liquid

2245240 EXELON NOV

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE

250mcg/mL Inhalation Solution (Multi-Dose)

2126222 APO-IPRAVENT APX

2239131 GEN-IPRATROPIUM GEN

2210479 NOVO-IPRAMIDE NOP

2231136 PMS-IPRATROPIUM PMS

125mcg/mL Inhalation Solution (Unit Dose)

2231135 PMS-IPRATROPIUM UDV PMS

2097176 RATIO-IPRATROPIUM UDV RPH

250mcg/mL Inhalation Solution (Unit Dose)

2216221 GEN-IPRATROPIUM UDV GEN

2231785 NU-IPRATROPIUM UDV NXP

2231244 PMS-IPRATROPIUM UDV PMS

2231245 PMS-IPRATROPIUM UDV PMS

2097168 RATIO-IPRATROPIUM UDV RPH

99001446 RATIO-IPRATROPIUM UDV * RPH

20mcg/Inhalation Inhaler

2247686 ATROVENT HFA BOE

0.03% Nasal Spray

2246083 APO-IPRAVENT APX

2240508 DOM-IPRATROPIUM DPC

2239627 PMS-IPRATROPIUM PMS

0.06% Nasal Spray

2246084 APO-IPRAVENT APX

IPRATROPIUM BROMIDE, SALBUTAMOL

0.2mg & 1mg/mL Inhalation Solution (Unit Dose)

2231675 COMBIVENT BOE

2272695 GEN-COMBO GEN

2243789 RATIO-IPRA SAL RPH

SCOPOLAMINE BUTYLBROMIDE

10mg Tablet

363812 BUSCOPAN 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 (3 months) of ipatropium, at a dose of 8-12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung Function Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% ≤ FEV1 < 80% predicted, FEV1/FVC <0.7

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% ≤ FEV1 < 50% predicted, FEV1/FVC <0.7

18mcg Powder for Inhalation (Capsule)

2246793 SPIRIVA BOE

12:12.04 ALPHA ADRENERGIC AGONISTS

MIDODRINE HCL

2.5mg Tablet

1934392 AMATINE SHI

5mg Tablet

1934406 AMATINE SHI

12:12.08 BETA ADRENERGIC AGONISTS

FORMOTEROL FUMARATE

Limited use benefit (prior approval required).

For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze 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.

12mcg/Capsule Powder for Inhalation

2230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE

6mcg/Dose Dry Powder Inhaler

2237225 OXEZE TURBUHALER AZC

12mcg/Dose Dry Powder Inhaler

2237224 OXEZE TURBUHALER AZC

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

2245385 SYMBICORT 100 TURBUHALER AZC

6mcg & 200mcg/Inhalation Inhaler

2245386 SYMBICORT 200 TURBUHALER AZC

ORCIPRENALINE SULFATE

2mg/mL Syrup

2236783 APO-ORCIPRENALINE APX

2192675 TANTA-ORCIPRENALINE TAN

SALBUTAMOL

5mg/mL Inhalation Solution (Multi-Dose)

2139324 DOM-SALBUTAMOL DPC

2232987 GEN-SALBUTAMOL GEN

2069571 PMS-SALBUTAMOL PMS

860808 RATIO-SALBUTAMOL RPH

2154412 SANDOZ-SALBUTAMOL SDZ

2213486 VENTOLIN GSK

0.5mg/mL Inhalation Solution (Unit Dose)

2208245 PMS-SALBUTAMOL PMS

2239365 RATIO-SALBUTAMOL RPH

SALBUTAMOL

1mg/mL Inhalation Solution (Unit Dose)

2216949 DOM-SALBUTAMOL DPC

1926934 GEN-SALBUTAMOL GEN

2084333 MED-SALBUTAMOL MEC

2231783 NU-SALBUTAMOL NXP

2208229 PMS-SALBUTAMOL PMS

1986864 RATIO-SALBUTAMOL RPH

2213419 VENTOLIN PF GSK

2mg/mL Inhalation Solution (Unit Dose)

2173360 GEN-SALBUTAMOL PF GEN

2231784 NU-SALBUTAMOL NXP

2208237 PMS-SALBUTAMOL PMS

2239366 RATIO-SALBUTAMOL RPH

2213427 VENTOLIN PF GSK

100mcg/Inhalation Inhaler

2232570 AIROMIR MMH

2245669 APO-SALVENT CFC FREE APX

2326450 NOVO-SALBUTAMOL HFA NOP

2244914 RATIO-SALBUTAMOL HFA RPH

2241497 VENTOLIN HFA GSK

0.4mg/mL Oral Liquid

2212390 VENTOLIN GSK

400mcg Powder for Inhalation (Capsule)

895415 VENTOLIN ROTACAPS * GSK

200mcg Powder for Inhalation (Disk)

99000369 VENTODISK & DISKHALER * GSK

400mcg Powder for Inhalation (Disk)

99000377 VENTODISK * GSK

2mg Tablet

2146843 APO-SALVENT APX

4mg Tablet

2146851 APO-SALVENT APX

2165376 NU-SALBUTAMOL NXP

SALMETEROL XINAFOATE

Limited use benefit (prior approval required).

1. For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. 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.
2. For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.

50mcg/inhalation Powder Diskus

2231129 SEREVENT DISKUS GSK

50mcg/Inhalation Powder for Inhalation

2214261 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* 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.

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 Inhaler

2245126 ADVAIR GSK

25mcg & 250mcg Inhaler

2245127 ADVAIR GSK

50mcg & 100mcg Inhaler

2240835 ADVAIR DISKUS 100 GSK

50mcg & 250mcg Inhaler

2240836 ADVAIR DISKUS 250 GSK

50mcg & 500mcg Inhaler

2240837 ADVAIR DISKUS 500 GSK

TERBUTALINE SULFATE

500mcg/Inhalation Powder for Inhalation

786616 BRICANYL TURBUHALER AZC

12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS

EPINEPHRINE

0.15mg/0.15mL Injection

2268205 TWINJECT PAL

0.5mg/mL Injection

578657 EPIPEN JR AXL

1mg/mL Injection

155357 ADRENALIN ERF

721891 EPINEPHRINE ABB

509558 EPIPEN AXL

2247310 TWINJECT PAL

EPINEPHRINE

1mg/mL Topical Solution

155365 ADRENALIN ERF

PSEUDOEPHEDRINE HCL, TRIPROLIDINE HCL

60mg & 2.5mg Tablet

2238302 ACTIFED PFI

12:16.00 SYMPATHOLYTIC AGENTS

DIHYDROERGOTAMINE MESYLATE

1mg/mL Injection

27243 DIHYDROERGOTAMINE STE

2241163 DIHYDROERGOTAMINE SDZ

4mg/mL Nasal Spray

2228947 MIGRANAL STE

ERGOTAMINE TARTRATE, CAFFEINE

1mg & 100mg Tablet

176095 CAFERGOT NVR

METHYSERGIDE MALEATE

2mg Tablet

27499 SANSERT NVR

12:20.24 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS

CYCLOBENZAPRINE HCL

Limited use benefit (prior approval is not required).

For relief of muscle spasm associated with acute, painful musculoskeletal conditions. Coverage is limited to 60mg per day for three (3) weeks, renewable every two (2) months.

10mg Tablet

2177145 APO-CYCLOBENZAPRINE APX

2220644 CYCLOBENZAPRINE PDL

2238633 DOM-CYCLOBENZAPRINE DPC

2231353 GEN-CYCLOPRINE GEN

2080052 NOVO-CYCLOPRINE NOP

2171848 NU-CYCLOBENZAPRINE NXP

2249359 PHL-CYCLOBENZAPRINE PHH

2212048 PMS-CYCLOBENZAPRINE PMS

2236506 RATIO-CYCLOBENZAPRINE RPH

2242079 RIVA-CYCLOBENZAPRINE RIV

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

2259893 APO-TIZANIDINE APX

2272059 GEN-TIZANIDINE GEN

2239170 ZANAFLEX ELN

12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTROLENE SODIUM

25mg Capsule

1997602 DANTRIUM PGP

100mg Capsule

1997653 DANTRIUM PGP

12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS

BACLOFEN

10mg Tablet

2139332 APO-BACLOFEN APX

2152584 BACLOFEN PDL

2138271 DOM-BACLOFEN DPC

2088398 GEN-BACLOFEN GEN

455881 LIORESAL NVR

2084449 MED-BACLOFEN MEC

2136090 NU-BACLO NXP

2236963 PHL-BACLOFEN PHH

2063735 PMS-BACLOFEN PMS

2236507 RATIO-BACLOFEN RPH

2242150 RIVA-BACLOFEN RIV

20mg Tablet

2139391 APO-BACLOFEN APX

2152592 BACLOFEN PDL

2138298 DOM-BACLOFEN DPC

2088401 GEN-BACLOFEN GEN

636576 LIORESAL DS NVR

2084457 MED-BACLOFEN MEC

2136104 NU-BACLO NXP

2236964 PHL-BACLOFEN PHH

2063743 PMS-BACLOFEN PMS

2236508 RATIO-BACLOFEN RPH

2242151 RIVA-BACLOFEN RIV

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

2091933 NICORETTE JNO

4mg Gum

2091941 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)

1943057 HABITROL NVC

14mg Patch (Habitrol)

1943065 HABITROL NVC

21mg Patch (Habitrol)

1943073 HABITROL NVC

36mg Patch (Nicoderm)

2093111 NICODERM PMJ

78mg Patch (Nicoderm)

2093138 NICODERM PMJ

114mg Patch (Nicoderm)

2093146 NICODERM PMJ

8.3mg/10cm2 Patch (Nicotrol)

2065738 NICOTROL TRANSDERMAL JNO

16.6mg/20cm2 Patch (Nicotrol)

2065754 NICOTROL TRANSDERMAL JNO

24.9mg/30cm2 Patch (Nicotrol)

2065762 NICOTROL TRANSDERMAL JNO

VARENICLINE

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

Coverage will be limited to 165 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 varenicline (Champix^®) when one year has elapsed from the day the initial prescription was filled.

0.5mg Tablet

2291177 CHAMPIX PFI

0.5mg & 1mg Tablet

2298309 CHAMPIX STARTER PACK PFI

1mg Tablet

2291185 CHAMPIX PFI