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First Nations, Inuit and Aboriginal Health

Drug Benefit List - April 2009

Pharmacologic-Therapeutic Classification List of Drugs

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

ABATACEPT

Limited use benefit (prior approval required).

Prescribed by a rheumatologist for treatment of adult patients with severely active rheumatoid arthritis who have failed to respond to a trial of an anti-TNF agent. Treatment should be combined with methotrexate. Abatacept should not be used in combination with anti-TNF agents.

250MG/VIAL Injection
02282097 ORENCIA 250MG/VIAL INJ 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.
  • Crohn's disease according to established criteria.

(Please refer to Appendix A).

40MG/Vial Injection
02258595 HUMIRA ABB

ALENDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:

  1. osteoporosis in patients who have documented hip, vertebral or other fractures
  2. osteoporosis in patients with intolerance or lack of response to etidronate or etidronate/calcium
  3. Paget's Disease
5MG Tablet
02248727 APO-ALENDRONATE APX
02233055 FOSAMAX FRS
02270110 GEN-ALENDRONATE GEN
02248251 NOVO-ALENDRONATE NOP
02288079 SANDOZ ALENDRONATE SDZ
10MG Tablet
02248728 APO-ALENDRONATE APX
02201011 FOSAMAX FRS
02270129 GEN-ALENDRONATE GEN
02247373 NOVO-ALENDRONATE NOP
02288087 SANDOZ ALENDRONATE SDZ
40MG Tablet
02258102 CO-ALENDRONATE COB
02201038 FOSAMAX FRS
70MG Tablet
02303078 ALENDRONATE-70 PDL
02248730 APO-ALENDRONATE APX
02258110 CO-ALENDRONATE COB
02245329 FOSAMAX FRS
02286335 GEN-ALENDRONATE GEN
02261715 NOVO-ALENDRONATE NOP
02273179 PMS-ALENDRONATE PMS
02284006 PMS-ALENDRONATE FC PMS
02275279 RATIO-ALENDRONATE RPH
02270889 RIVA-ALENDRONATE RIV
02288109 SANDOZ ALENDRONATE SDZ
02302004 ZYM-ALENDRONATE ZYM

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
02315866 APO-ALFUZOSIN ER APX
02304678 SANDOZ ALFUZOSIN SDZ
02245565 XATRAL SAC

ALLOPURINOL

100MG Tablet
00449687 ALLOPRIN VAE
00555681 ALLOPURINOL PDL
00402818 APO-ALLOPURINOL APX
00364282 NOVO-PUROL NOP
00004588 ZYLOPRIM GSK
200MG Tablet
00514209 ALLOPRIN VAE
02130157 ALLOPURINOL PDL
00479799 APO-ALLOPURINOL APX
00565342 NOVO-PUROL NOP
300MG Tablet
00454354 ALLOPRIN VAE
00555703 ALLOPURINOL PDL
00402796 APO-ALLOPURINOL APX
00363693 NOVO-PUROL NOP
00294322 ZYLOPRIM GSK

AZATHIOPRINE

50MG Tablet
02242907 APO-AZATHIOPRINE APX
00004596 IMURAN GSK
02248843 NU-AZATHIOPRINE NXP

BETAHISTINE HCL

16MG Tablet
02280191 NOVO-BETAHISTINE NOP
02243878 SERC SPH
24MG Tablet
02280205 NOVO-BETAHISTINE NOP
02247998 SERC SPH

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

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
02301407 CO CABERGOLINE CBT
02242471 DOSTINEX PFI

COLCHICINE

0.6MG Tablet
00572349 COLCHICINE ODN
1MG Tablet
00621374 COLCHICINE ODN

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

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2MG & 35MCG Tablet
02290308 CYESTRA-35 PMS
02233542 DIANE-35 BAY
02309556 NOVO-CYPROTERONE/ETHINYL ESTRADIOL NOP

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.
0.5MG Capsule
02247813 AVODART GSK

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.

(Please refer to Appendix A).

25MG/VIAL Injection
02242903 ENBREL IMX
50MG/ML Injection
02274728 ENBREL IMX

ETIDRONATE DISODIUM

200MG Tablet
02248686 CO-ETIDRONATE COB
01997629 DIDRONEL PGP
02245330 GEN-ETIDRONATE GEN

ETIDRONATE DISODIUM, CALCIUM CARBONATE

400MG & 500MG Tablet
02263866 CO-ETIDROCAL COB
02176017 DIDROCAL PGP
400MG & 500MG Tablet
02247323 GEN-ETI-CAL CP GEN

EXTEMPORANEOUS MIXTURE

Miscellaneous
00990019 EXTEMPORANEOUS MIXTURE  *
00999994 EXTEMPORANEOUS MIXTURE  *
00999997 EXTEMPORANEOUS MIXTURE  *
00999999 EXTEMPORANEOUS MIXTURE  *

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.
5MG Tablet
02010909 PROSCAR FRS

FLUNARIZINE HCL

5MG Capsule
02246082 APO-FLUNARIZINE APX
00846341 SIBELIUM PMS

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 CER

LANREOTIDE

60MG/0.3ML Injection
02283395 SOMATULINE AUTOGEL IPS
90MG/0.3ML Injection
02283409 SOMATULINE AUTOGEL IPS
120MG/0.5ML Injection
02283417 SOMATULINE AUTOGEL IPS

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
02319225 GEN-LEFLUNOMIDE GEN
02261251 NOVO-LEFLUNOMIDE NOP
02288265 PMS-LEFLUNOMIDE PMS
02283964 SANDOZ LEFLUNOMIDE SDZ
20MG Tablet
02256509 APO-LEFLUNOMIDE APX
02241889 ARAVA SAC
02319233 GEN-LEFLUNOMIDE GEN
02261278 NOVO-LEFLUNOMIDE NOP
02288273 PMS-LEFLUNOMIDE PMS
02283972 SANDOZ LEFLUNOMIDE SDZ

LEUCOVORIN CALCIUM

5MG Tablet
02170493 LEUCOVORIN CALCIUM WAY

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

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 NOV
500MCG/ML Injection
02248641 OCTREOTIDE ACETATE OMEGA OMG
00839213 SANDOSTATIN NVR

PAMIDRONATE DISODIUM

30MG Injection
02059762 AREDIA IV NVR
02244550 PAMIDRONATE DISODIUM MAY
02245998 PMS-PAMIDRONATE PMS
02264951 RHOXAL-PAMIDRONATE RHO
60MG Injection
02244551 PAMIDRONATE DISODIUM HOS
02264978 RHOXAL-PAMIDRONATE SDZ
90MG Injection
02059789 AREDIA IV NVR
02244552 PAMIDRONATE DISODIUM MAY
02245999 PMS-PAMIDRONATE PMS
02264986 RHOXAL-PAMIDRONATE SDZ

PENTOSAN POLYSULFATE SODIUM

100MG Capsule
02029448 ELMIRON JNO

RISEDRONATE SODIUM

Limited use benefit (prior approval required).

For treatment of:

  1. osteoporosis in patients who have documented hip, vertebral or other fractures.
  2. osteoporosis in patients who are intolerant of or do not respond to etidronate or etidronate/calcium.
  3. 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 Capsule
02281392 NOVO-TAMSULOSIN NOP
02294885 RAN-TAMSULOSIN RBY
02294265 RATIO-TAMSULOSIN RPH
02295121 SANDOZ TAMSULOSIN SDZ
0.4MG Long Acting Tablet
02270102 FLOMAX CR BOE
0.4MG Sustained Release Capsule
02238123 FLOMAX SR BOE

TETRABENAZINE

25MG Tablet
02199270 NITOMAN LHL

WATER

100% Injection
99002264 STERILE WATER AUT *
00905178 WATER FOR INJECTION UNK *
00905194 WATER FOR INJECTION  *
00905224 WATER FOR INJECTION UNK *
00038202 WATER STERILE ABB *

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.

5MG/100ML Injection
02269198 ACLASTA NOV
Pharmacologic-Therapeutic Classification List of Drugs
Date Modified: 2009-07-24

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