Drug Benefit List 2012

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

BETAHISTINE HCL

8mg Tablet

02280183 NOVO-BETAHISTINE TEV

16mg Tablet

02374757 CO BETAHISTINE COB

02243878 SERC SPH

02280191 TEVA-BETAHISTINE TEV

24mg Tablet

02374765 CO BETAHISTINE COB

02247998 SERC SPH

02280205 TEVA-BETAHISTINE TEV

ERGOCALCIFEROL

ST 8288IU/mL Oral Liquid

80003615 ERDOL ODN

EXTEMPORANEOUS MIXTURE

Miscellaneous

00990019 EXTEMPORANEOUS MIXTURE (BC) (SK) (YT) *

00999997 EXTEMPORANEOUS MIXTURE (NB) (NS) (PE) (NL) *

00999999 EXTEMPORANEOUS MIXTURE (NU) (AB) (MB) (QC) (NT) *

00999994 EXTEMPORANEOUS MIXTURE (ON) *

00915000 STERILE EXTEMPORANEOUS MIXTURE (QC)

LANREOTIDE

120mg/0.5mL Injection

02283417 SOMATULINE AUTOGEL IPS

NEDOCROMIL SODIUM

2% Ophth Solution

02241407 ALOCRIL ALL

OCTREOTIDE

10mg/Vial Injection

02239323 SANDOSTATIN LAR NVR

20mg/Vial Injection

02239324 SANDOSTATIN LAR NVR

30mg/Vial Injection

02239325 SANDOSTATIN LAR NVR

50mcg/mL Injection

02248639 OCTREOTIDE ACETATE OMEGA OMG

00839191 SANDOSTATIN NVR

100mcg/mL Injection

02248640 OCTREOTIDE ACETATE OMEGA OMG

00839205 SANDOSTATIN NVR

200mcg/mL Injection

02248642 OCTREOTIDE ACETATE OMEGA OMG

02049392 SANDOSTATIN NVR

500mcg/mL Injection

02248641 OCTREOTIDE ACETATE OMEGA OMG

00839213 SANDOSTATIN NVR

PENTOSAN POLYSULFATE SODIUM

100mg Capsule

02029448 ELMIRON JNO

USTEKINUMAB

Limited use benefit (prior approval required).

For the treatment of moderate to severe psoriasis in patients who meet the following criteria:

1. Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region and
2. Intolerance or lack of response to methotrexate and cyclosporine or
3. A contraindication to methotrexate and/or cyclosporine and
4. Intolerance or lack of response to phototherapy or
5. Inability to access phototherapy

Coverage beyond 16 weeks will be based on a significant reduction in the Body Surface Area (BSA) involved and improvements in the Psoriasis Area Severity Index (PASI) score and the Dermatology Life Quality Index (DLQI).

45mg/0.5mL Injection

02320673 STELARA JNO

92:08.00

DUTASTERIDE

Limited use benefit (prior approval required).

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

ST 0.5mg Capsule

02247813 AVODART GSK

FINASTERIDE

Limited use benefit (prior approval required).

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

ST 5mg Tablet

02365383 APO-FINASTERIDE APX

02354462 CO FINASTERIDE COB

02350270 FINASTERIDE PDL

02356058 MYLAN-FINASTERIDE MYL

02348500 NOVO-FINASTERIDE TEV

02310112 PMS-FINASTERIDE PMS

02010909 PROSCAR FRS

02306905 RATIO-FINASTERIDE RPH

02322579 SANDOZ FINASTERIDE SDZ

92:12.00

LEUCOVORIN CALCIUM

5mg Tablet

02170493 LEUCOVORIN CALCIUM WAY

92:16.00

ALLOPURINOL

ST 100mg Tablet

00449687 ALLOPRIN VAE

00555681 ALLOPURINOL PDL

00402818 ZYLOPRIM AAP

ST 200mg Tablet

00514209 ALLOPRIN VAE

02130157 ALLOPURINOL PDL

00479799 ZYLOPRIM AAP

ST 300mg Tablet

00454354 ALLOPRIN VAE

00294322 ALLOPURINOL APX

00555703 ALLOPURINOL PDL

00402796 ZYLOPRIM AAP

COLCHICINE

ST 0.6mg Tablet

00572349 COLCHICINE ODN

ST 1mg Tablet

00621374 COLCHICINE ODN

FEBUXOSTAT

Limited use benefit (prior approval required). For patients with symptomatic gout who have documented hypersensitivity to allopurinol

80mg Tablet

02357380 ULORIC TAK

92:24.00

ALENDRONATE SODIUM

Limited use benefit (prior approval required).

For the treatment of:

1. Osteoporosis in patients who are 60 years of age or over
   OR
2. Paget's Disease OR
3. Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR
4. Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR
5. Osteoporosis in patients under 60 with moderate 10-year fracture risk AND use of systemic glucocorticoid therapy >3 months

ST 5mg Tablet

02248727 APO-ALENDRONATE APX

02288079 SANDOZ ALENDRONATE SDZ

02248251 TEVA-ALENDRONATE TEV

ST 10mg Tablet

02248728 APO-ALENDRONATE APX

02201011 FOSAMAX FRS

02270129 MYLAN-ALENDRONATE MYL

02288087 SANDOZ ALENDRONATE SDZ

02247373 TEVA-ALENDRONATE TEV

ST 40mg Tablet

02258102 CO ALENDRONATE COB

02201038 FOSAMAX FRS

Limited use benefit (prior approval required).

For the treatment of:

1. Osteoporosis in patients who are 60 years of age or over
   OR
2. Paget's Disease OR
3. Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR
4. Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR
5. Osteoporosis in patients under 60 with moderate 10-year fracture risk AND use of systemic glucocorticoid therapy >3 months

ST 70mg Tablet

02299712 ALENDRONATE MEL

02302004 ALENDRONATE SOR

02352966 ALENDRONATE SAN

02303078 ALENDRONATE-70 PDL

02248730 APO-ALENDRONATE APX

02258110 CO ALENDRONATE COB

02282763 DOM-ALENDRONATE DPC

02245329 FOSAMAX FRS

02286335 MYLAN-ALENDRONATE MYL

02273179 PMS-ALENDRONATE PMS

02284006 PMS-ALENDRONATE FC PMS

02275279 RATIO-ALENDRONATE RPH

02270889 RIVA-ALENDRONATE RIV

02288109 SANDOZ ALENDRONATE SDZ

02261715 TEVA-ALENDRONATE TEV

ALENDRONATE SODIUM, VITAMIN D3

Limited use benefit (prior approval required).

For the treatment of:

1. Osteoporosis in patients who are 60 years of age or over
   OR
2. Paget's Disease OR
3. Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR
4. Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR
5. Osteoporosis in patients under 60 with moderate 10-year fracture risk AND use of systemic glucocorticoid therapy >3 months

ST 70mg/2800U Tablet

02276429 FOSAVANCE FRS

ST 70mg/5600U Tablet

02314940 FOSAVANCE MSP

DENOSUMAB

Limited use benefit (prior approval required).

For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but for whom:

• bisphosphonates are contraindicated due to hypersensitivity or abnormalities of the esophagus (e.g., esophageal stricture or achalasia); AND
• Have at least two of the following:
  • age >70 years
  • a prior fragility fracture
  • a bone mineral density (BMD) T-score ≤ -2.5

60mg/mL Injection

02343541 PROLIA PRE-FILLED SYR AMG

02343568 PROLIA VIAL AMG

ETIDRONATE DISODIUM

ST 200mg Tablet

02248686 CO ETIDRONATE COB

02245330 MYLAN-ETIDRONATE MYL

ETIDRONATE DISODIUM, CALCIUM CARBONATE

ST 400mg & 500mg Tablet

02263866 CO-ETIDROCAL COB

02176017 DIDROCAL PGP

02353210 ETIDROCAL SAN

02247323 MYLAN-ETI-CAL CP MYL

02324199 NOVO-ETIDRONATECAL KIT TEV

PAMIDRONATE DISODIUM

30mg Injection

02059762 AREDIA IV NVR

02244550 PAMIDRONATE DISODIUM MAY

02264951 SANDOZ-PAMIDRONATE SDZ

60mg Injection

02244551 PAMIDRONATE DISODIUM HOS

02264978 SANDOZ-PAMIDRONATE SDZ

90mg Injection

02059789 AREDIA IV NVR

02244552 PAMIDRONATE DISODIUM MAY

02245999 PMS-PAMIDRONATE PMS

02264986 SANDOZ-PAMIDRONATE SDZ

RISEDRONATE SODIUM

Limited use benefit (prior approval required).

For the treatment of:

1. Osteoporosis in patients who are 65 years of age and over or
2. Osteoporosis in patients who have documented hip, vertebral or other fractures or
3. Paget's Disease or
4. Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or
5. Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months

ST 5mg Tablet

02242518 ACTONEL PGP

02298376 NOVO-RISEDRONATE TEV

ST 30mg Tablet

02239146 ACTONEL PGP

02298384 NOVO-RISEDRONATE TEV

ST 35mg Tablet

02246896 ACTONEL PGP

02353687 APO-RISEDRONATE APX

02309831 DOM-RISEDRONATE DPC

02357984 MYLAN-RISEDRONATE MYL

02298392 NOVO-RISEDRONATE TEV

02302209 PMS-RISEDRONATE PMS

02347474 RISEDRONATE PDL

02370255 RISEDRONATE SAN

02341077 RIVA-RISEDRONATE RIV

02327295 SANDOZ RISEDRONATE SDZ

ZOLEDRONIC ACID

Limited use benefit (prior approval required).

• For the treatment of Paget's disease. Coverage will be granted for one dose per 12 month period. OR.
• For women with postmenopausal osteoporosis who would other be eligible for coverage of oral bisphosphonates*, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); AND who have at least two of the following:
  • age >70 years
  • a prior fragility fracture
  • a bone mineral density (BMD) T-score ≤ -2.5.

5mg/100mL Injection

02269198 ACLASTA NVR

92:36.00

ABATACEPT

Limited use benefit (prior approval required).

For the treatment of:

• Rheumatoid Arthritis according to established criteria.
• Juvenile Idiopathic Arthritis

(Please refer to Appendix A).

250mg/Vial Injection

02282097 ORENCIA BMS

ADALIMUMAB

Limited use benefit (prior approval required).

For the treatment of:

• Rheumatoid Arthritis according to established criteria.
• Psoriatic Arthritis according to established criteria.
• Ankylosing Spondylitis according to established criteria.
• Psoriasis according to established criteria.
• Crohn's disease according to established criteria.

Please refer to Appendix A).

40mg/Vial Injection

02258595 HUMIRA ABB

ETANERCEPT

Limited use benefit (prior approval required).

For the treatment of:

• Rheumatoid Arthritis according to established criteria.
• Psoriatic Arthritis according to established criteria.
• Ankylosing Spondylitis according to established criteria.
• Juvenile Idiopathic Arthritis

(Please refer to Appendix A).

25mg/Vial Injection

02242903 ENBREL IMX

50mg/mL Injection

02274728 ENBREL IMX

99100373 ENBREL SURECLICK (QC) AMG

GOLIMUMAB

Limited use benefit (prior approval required).

For the treatment of:

• Rheumatoid Arthritis according to established criteria.
• Psoriatic Arthritis according to established criteria.
• Ankylosing Spondylitis according to established criteria.

Please refer to Appendix A).

50mg/0.5mL Injection

02324784 SIMPONI AUTO INJECTOR JNO

02324776 SIMPONI PRE-FILLED SYRINGE JNO

INFLIXIMAB

Limited use benefit (prior approval required).

For treatment of:

• Fistulizing Crohn's disease according to established criteria.
• For adult patients with moderately to severely active Crohn's Disease who have had an inadequate response to conventional therapy.
  (Please refer to Appendix A).
  or
• Rheumatoid Arthritis according to established criteria
  (Please refer to Appendix A).

100mg/Vial Injection

02244016 REMICADE CEN

LEFLUNOMIDE

Limited use benefit (prior approval required).

For treatment of patients with rheumatoid arthritis who:

1. have failed treatment with methotrexate: weekly dose (PO, SC or IM) of 20mg or greater (15mg or greater if patient is 65 years of age or older) for more than 8 weeks.
2. cannot tolerate or have contraindications to methotrexate.

10mg Tablet

02256495 APO-LEFLUNOMIDE APX

02241888 ARAVA SAC

02351668 LEFLUNOMIDE SAN

02319225 MYLAN-LEFLUNOMIDE MYL

02261251 NOVO-LEFLUNOMIDE TEV

02288265 PMS-LEFLUNOMIDE PMS

02283964 SANDOZ LEFLUNOMIDE SDZ

20mg Tablet

02256509 APO-LEFLUNOMIDE APX

02241889 ARAVA SAC

02351676 LEFLUNOMIDE SAN

02319233 MYLAN-LEFLUNOMIDE MYL

02261278 NOVO-LEFLUNOMIDE TEV

02288273 PMS-LEFLUNOMIDE PMS

02283972 SANDOZ LEFLUNOMIDE SDZ

TOCILIZUMAB

Limited use benefit (prior approval required).
For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-TNF agent. (Please refer to Appendix A).

80mg/4ml Injection

02350092 ACTEMRA HLR

200mg/10ml Injection

02350106 ACTEMRA HLR

Limited use benefit (prior approval required).
For the treatment of adult patients with moderate to severely active rheumatoid arthritis who have failed to respond to an adequate trial of an anti-TNF agent. (Please refer to Appendix A).

400mg/20ml Injection

02350114 ACTEMRA HLR

92:44.00

AZATHIOPRINE

50mg Tablet

02242907 APO-AZATHIOPRINE APX

02343002 AZATHIOPRINE SAN

02243371 AZATHIOPRINE-50 PDL

00004596 IMURAN GSK

02231491 MYLAN-AZATHIOPRINE MYL

02248843 NU-AZATHIOPRINE NXP

CYCLOSPORINE

Limited use benefit (prior approval required).
For transplant therapy.

10mg Capsule

02237671 NEORAL NVR

25mg Capsule

02150689 NEORAL NVR

02247073 SANDOZ-CYCLOSPORINE SDZ

50mg Capsule

02150662 NEORAL NVR

02247074 SANDOZ-CYCLOSPORINE SDZ

100mg Capsule

02150670 NEORAL NVR

02242821 SANDOZ-CYCLOSPORINE SDZ

100mg/mL Solution

02150697 NEORAL NVR

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

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

Limited use benefit (prior approval required).

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

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

0.5mg Long Acting Capsule

02296462 ADVAGRAF AST

1mg Long Acting Capsule

02296470 ADVAGRAF AST

3mg Long Acting Capsule

02331667 ADVAGRAF AST

5mg Long Acting Capsule

02296489 ADVAGRAF AST

92:92.00

BOTULINUM TOXIN TYPE A

Limited use benefit (prior approval required).

For the treatment of:

1. strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older
2. cervical dystonia (spasmodic torticollis)

100IU Injection

01981501 BOTOX ALL

CLOSTRIDIUM BOTULINUM NEUROTOXIN

Limited use benefit (prior approval required).

For:

1. the treatment of strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older or
2. the treatment of cervical dystonia (spasmodic torticollis)

100U/vial Injection

02324032 XEOMIN MEZ

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2mg & 35mcg Tablet

02290308 CYESTRA-35 PMS

02233542 DIANE-35 BAY

02309556 TEVA-CYPROTERONE/ETHINYL ESTRADIOL TEV

LANREOTIDE

60mg/0.3mL Injection

02283395 SOMATULINE AUTOGEL IPS

90mg/0.3mL Injection

02283409 SOMATULINE AUTOGEL IPS