Drug Benefit List 2012

12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC AGENTS

BETHANECHOL CHLORIDE

10mg Tablet

01947958 DUVOID SHI

25mg Tablet

01947931 DUVOID SHI

50mg Tablet

01947923 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

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)

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

02339439 MYLAN-GALANTAMINE ER MYL

02316943 PAT-GALANTAMINE ER JNO

02266717 REMINYL ER JNO

16mg Extended Release Capsule

02339447 MYLAN-GALANTAMINE ER MYL

02316951 PAT-GALANTAMINE ER JNO

02266725 REMINYL ER JNO

24mg Extended Release Capsule

02339455 MYLAN-GALANTAMINE ER MYL

02316978 PAT-GALANTAMINE ER JNO

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)

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

02336715 APO-RIVASTIGMINE APX

02242115 EXELON NVR

02332809 MYLAN-RIVASTIGMINE MYL

02305984 NOVO-RIVASTIGMINE TEV

02306034 PMS-RIVASTIGMINE PMS

02311283 RATIO-RIVASTIGMINE RPH

02324563 SANDOZ RIVASTIGMINE SDZ

3mg Capsule

02336723 APO-RIVASTIGMINE APX

02242116 EXELON NVR

02332817 MYLAN-RIVASTIGMINE MYL

02305992 NOVO-RIVASTIGMINE TEV

02306042 PMS-RIVASTIGMINE PMS

02311291 RATIO-RIVASTIGMINE RPH

02324571 SANDOZ RIVASTIGMINE SDZ

4.5mg Capsule

02336731 APO-RIVASTIGMINE APX

02242117 EXELON NVR

02332825 MYLAN-RIVASTIGMINE MYL

02306018 NOVO-RIVASTIGMINE TEV

02306050 PMS-RIVASTIGMINE PMS

02311305 RATIO-RIVASTIGMINE RPH

02324598 SANDOZ RIVASTIGMINE SDZ

6mg Capsule

02336758 APO-RIVASTIGMINE APX

02242118 EXELON NVR

02332833 MYLAN-RIVASTIGMINE MYL

02306026 NOVO-RIVASTIGMINE TEV

02306069 PMS-RIVASTIGMINE PMS

02311313 RATIO-RIVASTIGMINE RPH

02324601 SANDOZ RIVASTIGMINE SDZ

2mg/mL Oral Liquid

02245240 EXELON NVR

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

IPRATROPIUM BROMIDE

250mcg/mL Inhalation Solution (Multi-Dose)

02126222 APO-IPRAVENT APX

02239131 MYLAN-IPRATROPIUM MYL

02210479 NOVO-IPRAMIDE TEV

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 MYLAN-IPRATROPIUM UDV MYL

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

02247686 ATROVENT HFA BOE

0.03% Nasal Spray

02246083 APO-IPRAVENT APX

02163705 ATROVENT BOE

02240508 DOM-IPRATROPIUM DPC

02239627 PMS-IPRATROPIUM PMS

0.06% Nasal Spray

02246084 APO-IPRAVENT APX

02163713 ATROVENT BOE

IPRATROPIUM BROMIDE, SALBUTAMOL

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

02231675 COMBIVENT BOE

02272695 MYLAN-COMBO MYL

02243789 RATIO-IPRA SAL RPH

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 (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)

02246793 SPIRIVA BOE

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

02230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE

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 rapid onset, shot duration bronchodilator

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

ORCIPRENALINE SULFATE

2mg/mL Syrup

02236783 APO-ORCIPRENALINE APX

SALBUTAMOL

5mg/mL Inhalation Solution (Multi-Dose)

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 MYLAN-SALBUTAMOL PF MYL

02231783 NU-SALBUTAMOL NXP

02208229 PMS-SALBUTAMOL PMS

01986864 RATIO-SALBUTAMOL RPH

02213419 VENTOLIN PF GSK

2mg/mL Inhalation Solution (Unit Dose)

02173360 MYLAN-SALBUTAMOL PF MYL

02231784 NU-SALBUTAMOL NXP

02208237 PMS-SALBUTAMOL PMS

02239366 RATIO-SALBUTAMOL RPH

02213427 VENTOLIN PF GSK

100mcg/Inhalation Inhaler

02232570 AIROMIR MMH

02245669 APO-SALVENT CFC FREE APX

02326450 NOVO-SALBUTAMOL HFA TEV

02241497 VENTOLIN HFA 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).

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

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 Inhaler

02245126 ADVAIR GSK

25mcg & 250mcg 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

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

12:16.04

ALFUZOSIN HYDROCHLORIDE

ST 10mg Sustained Release Tablet

02315866 APO-ALFUZOSIN ER APX

02304678 SANDOZ ALFUZOSIN SDZ

02314282 TEVA-ALFUZOSIN PR TEV

02245565 XATRAL SAC

TAMSULOSIN HCL

ST 0.4mg Long Acting Capsule

02298570 MYLAN-TAMSULOSIN MYL

02294885 RAN-TAMSULOSIN RBY

02294265 RATIO-TAMSULOSIN RPH

09857334 RATIO-TAMSULOSIN RPH

02295121 SANDOZ TAMSULOSIN SDZ

02281392 TEVA-TAMSULOSIN TEV

ST 0.4mg Long Acting Tablet

02362406 APO-TAMSULOSIN APX

02270102 FLOMAX CR BOE

02340208 SANDOZ TAMSULOSIN SDZ

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

02287064 CYCLOBENZAPRINE SAN

02238633 DOM-CYCLOBENZAPRINE DPC

02231353 MYLAN-CYCLOPRINE MYL

02171848 NU-CYCLOBENZAPRINE NXP

02249359 PHL-CYCLOBENZAPRINE PHH

02212048 PMS-CYCLOBENZAPRINE PMS

02236506 RATIO-CYCLOBENZAPRINE RPH

02242079 RIVA-CYCLOBENZAPRINE RIV

02080052 TEVA-CYCLOPRINE TEV

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 MYLAN-TIZANIDINE MYL

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

02287021 BACLOFEN SAN

02138271 DOM-BACLOFEN DPC

00455881 LIORESAL NVR

02088398 MYLAN-BACLOFEN MYL

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

02287048 BACLOFEN SAN

02138298 DOM-BACLOFEN DPC

00636576 LIORESAL DS NVR

02088401 MYLAN-BACLOFEN MYL

02136104 NU-BACLO NXP

02236964 PHL-BACLOFEN PHH

02063743 PMS-BACLOFEN PMS

02236508 RATIO-BACLOFEN RPH

02242151 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 or lozenges when one year has elapsed from the day the initial prescription was

2mg Gum

02091933 NICORETTE JNO

80000396 THRIVE NVR

4mg Gum

02091941 NICORETTE PLUS PMJ

80000118 NICOTINE GUM PER

80000402 THRIVE NVR

NICOTINE (INHALER)

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

For smoking cessation:
Coverage is limited to 945 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 or lozenges when one year has elapsed from the day the initial prescription was filled.

10mg Inhaler

02241742 NICORETTE JNO

NICOTINE (LOZENGE)

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 or lozenges when one year has elapsed from the day the initial prescription was filled.

1mg Lozenge

80007461 THRIVE NVR

2mg Lozenge

02247347 NICORETTE LOZENGE JNO

80007464 THRIVE NVR

4mg Lozenge

02247348 NICORETTE LOZENGE JNO

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.

5mg Patch

02028697 NICOTROL TRANSDERMAL PFI

7mg Patch

01943057 HABITROL NVC

8.3mg/10cm2 Patch

02065738 NICOTROL TRANSDERMAL JNO

10mg Patch

02029405 NICOTROL TRANSDERMAL PFI

14mg Patch

01943065 HABITROL NVC

15mg Patch

02029413 NICOTROL TRANSDERMAL PFI

16.6mg/20cm2 Patch

02065754 NICOTROL TRANSDERMAL JNO

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.

17.5mg Patch

02241227 TRANSDERMAL NICOTINE NVC

21mg Patch

01943073 HABITROL NVC

24.9mg/30cm2 Patch

02065762 NICOTROL TRANSDERMAL JNO

35mg Patch

02241226 TRANSDERMAL NICOTINE NVC

36mg Patch

02093111 NICODERM PMJ

52.5mg Patch

02241228 TRANSDERMAL NICOTINE NVC

78mg Patch

02093138 NICODERM PMJ

114mg Patch

02093146 NICODERM PMJ

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

02291177 CHAMPIX PFI

0.5mg & 1mg Tablet

02298309 CHAMPIX STARTER PACK PFI

1mg Tablet

02291185 CHAMPIX PFI