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).

Memory, reasoning and perception (e.g., names, tasks, MMSE)
Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

5MG Tablet: 02232043 ARICEPT PFI

10MG Tablet: 02232044 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).

Memory, reasoning and perception (e.g., names, tasks, MMSE)
Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

8MG Extended Release Capsule: 02266717 REMINYL ER JNO

16MG Extended Release Capsule: 02266725 REMINYL ER JNO

24MG Extended Release Capsule: 02266733 REMINYL ER JNO

NEOSTIGMINE BROMIDE

15MG Tablet: 00869945 PROSTIGMIN VAE

PYRIDOSTIGMINE BROMIDE

180MG Sustained Release Tablet: 00869953 MESTINON-SR VAE

60MG Tablet: 00869961 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).

Memory, reasoning and perception (e.g., names, tasks, MMSE)
Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

1.5MG Capsule: 02242115 EXELON NOV

3MG Capsule: 02242116 EXELON NOV

4.5MG Capsule: 02242117 EXELON NOV

6MG Capsule: 02242118 EXELON NOV

2MG/ML Oral Liquid: 02245240 EXELON NOV

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE

250MCG/ML Inhalation Solution (Multi-Dose): 02126222 APO-IPRAVENT APX; 02239131 GEN-IPRATROPIUM GEN; 02210479 NOVO-IPRAMIDE NOP; 02231136 PMS-IPRATROPIUM PMS

125MCG/ML Inhalation Solution (Unit Dose): 02231135 PMS-IPRATROPIUM UDV PMS; 02097176 RATIO-IPRATROPIUM UDV RPH

250MCG/ML Inhalation Solution (Unit Dose): 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

0.03% Nasal Spray: 02246083 APO-IPRAVENT APX; 02240508 DOM-IPRATROPIUM DPC; 02239627 PMS-IPRATROPIUM PMS

0.06% Nasal Spray: 02246084 APO-IPRAVENT APX

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

SCOPOLAMINE BUTYLBROMIDE

10MG Tablet: 00363812 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 (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

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12:12.04 ALPHA ADRENERGIC AGONISTS

MIDODRINE HCL

2.5MG Tablet: 01934392 AMATINE SHI

5MG Tablet: 01934406 AMATINE SHI

12:12.08 BETA ADRENERGIC AGONISTS

FENOTEROL HBR

100MCG/INHALATION Inhaler: 02006383 BEROTEC BOE

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/CAP Powder for Inhalation: 02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE

6MCG/DOSE Dry Powder Inhaler: 02237225 OXEZE TURBUHALER AZC

12MCG/DOSE Dry Powder Inhaler: 02237224 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: 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): 02243789 RATIO-IPRA SAL RPH

ORCIPRENALINE SULFATE

2MG/ML Syrup: 02236783 APO-ORCIPRENALINE APX; 02152568 RATIO-ORCIPRENALINE RPH; 02192675 TANTA-ORCIPRENALINE TAN

SALBUTAMOL

5MG/ML Inhalation Solution (Multi-Dose): 02139324 DOM-SALBUTAMOL DPC; 02232987 GEN-SALBUTAMOL GEN; 02069571 PMS-SALBUTAMOL PMS; 00860808 RATIO-SALBUTAMOL RPH; 02154412 SANDOZ-SALBUTAMOL SDZ; 02213486 VENTOLIN GSK

0.5MG/ML Inhalation Solution (Unit Dose): 02208245 PMS-SALBUTAMOL PMS; 02239365 RATIO-SALBUTAMOL RPH

1MG/ML Inhalation Solution (Unit Dose): 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): 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

400MCG Powder for Inhalation (Capsule): 00895415 VENTOLIN ROTACAPS GSK *

200MCG Powder for Inhalation (Disk): 99000369 VENTODISK & DISKHALER GSK *

400MCG Powder for Inhalation (Disk): 99000377 VENTODISK GSK *

2MG Tablet: 02146843 APO-SALVENT APX

4MG Tablet: 02146851 APO-SALVENT APX; 02165376 NU-SALBUTAMOL NXP

SALMETEROL XINAFOATE

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. 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.
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.

50MCG/DOSE Powder Diskus: 02231129 SEREVENT DISKUS 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* 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 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

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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

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

1MG & 100MG Tablet: 00176095 CAFERGOT NVR

METHYSERGIDE MALEATE

2MG Tablet: 00027499 SANSERT NVR

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12:20.04 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: 02177145 APO-CYCLOBENZAPRINE APX; 02220644 CYCLOBENZAPRINE PDL; 02238633 DOM-CYCLOBENZAPRINE DPC; 02231353 GEN-CYCLOPRINE GEN; 02080052 NOVO-CYCLOPRINE NOP; 02171848 NU-CYCLOBENZAPRINE NXP; 02249359 PHL-CYCLOBENZAPRINE PHH; 02212048 PMS-CYCLOBENZAPRINE PMS; 02236506 RATIO-CYCLOBENZAPRINE RPH; 02242079 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: 02259893 APO-TIZANIDINE APX; 02272059 GEN-TIZANIDINE GEN; 02239170 ZANAFLEX ELN

12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTROLENE SODIUM

25MG Capsule: 01997602 DANTRIUM PGP

100MG Capsule: 01997653 DANTRIUM PGP

12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS

BACLOFEN

10MG Tablet: 02139332 APO-BACLOFEN APX; 02152584 BACLOFEN PDL; 02138271 DOM-BACLOFEN DPC; 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; 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

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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 JNO

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 JNO

16.6MG/20CM2 Patch (Nicotrol): 02065754 NICOTROL TRANSDERMAL JNO

24.9MG/30CM2 Patch (Nicotrol): 02065762 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.