Drug Benefit List 2010

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

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

2282097 ORENCIA BMS

ADALIMUMAB

Limited use benefit (prior approval required).

For the treatment of:

1. Rheumatoid Arthritis according to established criteria.
2. Psoriatic Arthritis according to established criteria.
3. Ankylosing Spondylitis according to established criteria.
4. Psoriasis according to established criteria.
5. Crohn's disease according to established criteria.

(Please refer to Appendix A).

40mg/0.8mL Injection

9857327 HUMIRA PEN ABB

97799757 HUMIRA PEN ABB

9857326 HUMIRA PRE-FILL ABB

97799756 HUMIRA PRE-FILL ABB

40mg/Vial Injection

2258595 HUMIRA ABB

ALENDRONATE 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

5mg Tablet

2248727 APO-ALENDRONATE APX

2233055 FOSAMAX FRS

2270110 GEN-ALENDRONATE GEN

2248251 NOVO-ALENDRONATE NOP

2288079 SANDOZ ALENDRONATE SDZ

10mg Tablet

2248728 APO-ALENDRONATE APX

2201011 FOSAMAX FRS

2270129 GEN-ALENDRONATE GEN

2247373 NOVO-ALENDRONATE NOP

2288087 SANDOZ ALENDRONATE SDZ

ALENDRONATE 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

40mg Tablet

2258102 CO ALENDRONATE COB

2201038 FOSAMAX FRS

70mg Tablet

2303078 ALENDRONATE-70 PDL

2248730 APO-ALENDRONATE APX

2258110 CO ALENDRONATE COB

2245329 FOSAMAX FRS

2286335 GEN-ALENDRONATE GEN

2261715 NOVO-ALENDRONATE NOP

2299712 PHL-ALENDRONATE PMI

2273179 PMS-ALENDRONATE PMS

2284006 PMS-ALENDRONATE FC PMS

2275279 RATIO-ALENDRONATE RPH

2270889 RIVA-ALENDRONATE RIV

2288109 SANDOZ ALENDRONATE SDZ

2302004 ZYM-ALENDRONATE ZYM

ALENDRONATE SODIUM, VITAMIN D3

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

70mg/2800U Tablet

2276429 FOSAVANCE FRS

70mg/5600U Tablet

2314940 FOSAVANCE MSP

ALFUZOSIN HYDROCHLORIDE

10mg Sustained Release Tablet

2315866 APO-ALFUZOSIN ER APX

2304678 SANDOZ ALFUZOSIN SDZ

2245565 XATRAL SAC

ALLOPURINOL

100mg Tablet

449687 ALLOPRIN VAE

555681 ALLOPURINOL PDL

402818 APO-ALLOPURINOL APX

364282 NOVO-PUROL NOP

200mg Tablet

514209 ALLOPRIN VAE

2130157 ALLOPURINOL PDL

479799 APO-ALLOPURINOL APX

565342 NOVO-PUROL NOP

300mg Tablet

454354 ALLOPRIN VAE

555703 ALLOPURINOL PDL

402796 APO-ALLOPURINOL APX

363693 NOVO-PUROL NOP

294322 ZYLOPRIM GSK

AZATHIOPRINE

50mg Tablet

2242907 APO-AZATHIOPRINE APX

4596 IMURAN GSK

2248843 NU-AZATHIOPRINE NXP

BETAHISTINE HCL

16mg Tablet

2280191 NOVO-BETAHISTINE NOP

2243878 SERC SPH

24mg Tablet

2280205 NOVO-BETAHISTINE NOP

2247998 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

1981501 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

2301407 CO CABERGOLINE COB

2242471 DOSTINEX PFI

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

2324032 XEOMIN MEZ

COLCHICINE

0.6mg Tablet

572349 COLCHICINE ODN

1mg Tablet

621374 COLCHICINE ODN

CYCLOSPORINE

Limited use benefit (prior approval required).

For transplant therapy.

10mg Capsule

2237671 NEORAL NVR

25mg Capsule

2150689 NEORAL NVR

2247073 SANDOZ-CYCLOSPORINE SDZ

50mg Capsule

2150662 NEORAL NVR

2247074 SANDOZ-CYCLOSPORINE SDZ

100mg Capsule

2150670 NEORAL NVR

2242821 SANDOZ-CYCLOSPORINE SDZ

100mg/mL Solution

2150697 NEORAL NVR

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

2mg & 35mcg Tablet

2290308 CYESTRA-35 PMS

2233542 DIANE-35 BAY

2309556 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

2247813 AVODART GSK

ERGOCALCIFEROL

8288IU/mL Oral Liquid

80003615 ERDOL ODN

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

2242903 ENBREL IMX

50mg/mL Injection

2274728 ENBREL IMX

99100373 ENBREL SURECLICK AMG

ETIDRONATE DISODIUM

200mg Tablet

2248686 CO ETIDRONATE COB

1997629 DIDRONEL PGP

2245330 GEN-ETIDRONATE GEN

ETIDRONATE DISODIUM, CALCIUM CARBONATE

400mg & 500mg Tablet

2263866 CO-ETIDROCAL COB

2176017 DIDROCAL PGP

2247323 GEN-ETI-CAL CP GEN

2324199 NOVO-ETIDRONATECAL KIT NOP

EXTEMPORANEOUS MIXTURE

Miscellaneous

990019 EXTEMPORANEOUS MIXTURE *

999994 EXTEMPORANEOUS MIXTURE *

999997 EXTEMPORANEOUS MIXTURE *

999999 EXTEMPORANEOUS MIXTURE *

915000 STERILE EXTEMPORANEOUS MIXTURE (QC)

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

2348500 NOVO-FINASTERIDE NOP

2310112 PMS-FINASTERIDE PMS

2010909 PROSCAR FRS

2306905 RATIO-FINASTERIDE RPH

2322579 SANDOZ FINASTERIDE SDZ

FLUNARIZINE HCL

5mg Capsule

2246082 APO-FLUNARIZINE APX

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

2324784 SIMPONI AUTO INJECTOR CER

2324776 SIMPONI PRE-FILLED SYRINGE CER

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

2244016 REMICADE CEN

LANREOTIDE

60mg/0.3mL Injection

2283395 SOMATULINE AUTOGEL IPS

90mg/0.3mL Injection

2283409 SOMATULINE AUTOGEL IPS

120mg/0.5mL Injection

2283417 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

2256495 APO-LEFLUNOMIDE APX

2241888 ARAVA SAC

2319225 GEN-LEFLUNOMIDE GEN

2261251 NOVO-LEFLUNOMIDE NOP

2288265 PMS-LEFLUNOMIDE PMS

2283964 SANDOZ LEFLUNOMIDE SDZ

20mg Tablet

2256509 APO-LEFLUNOMIDE APX

2241889 ARAVA SAC

2319233 GEN-LEFLUNOMIDE GEN

2261278 NOVO-LEFLUNOMIDE NOP

2288273 PMS-LEFLUNOMIDE PMS

2283972 SANDOZ LEFLUNOMIDE SDZ

LEUCOVORIN CALCIUM

5mg Tablet

2170493 LEUCOVORIN CALCIUM WAY

MYCOPHENOLATE MOFETIL

Limited use benefit (prior approval required).

For transplant therapy.

250mg Capsule

2192748 CELLCEPT HLR

500mg Tablet

2237484 CELLCEPT HLR

MYCOPHENOLATE SODIUM

Limited use benefit (prior approval required).

For transplant therapy.

180mg Enteric Coated Tablet

2264560 MYFORTIC NVR

360mg Enteric Coated Tablet

2264579 MYFORTIC NVR

NEDOCROMIL SODIUM

2% Ophth Solution

2241407 ALOCRIL ALL

OCTREOTIDE

10mg/Vial Injection

2239323 SANDOSTATIN LAR NVR

20mg/Vial Injection

2239324 SANDOSTATIN LAR NVR

30mg/Vial Injection

2239325 SANDOSTATIN LAR NVR

50mcg/mL Injection

2248639 OCTREOTIDE ACETATE OMEGA OMG

839191 SANDOSTATIN NVR

100mcg/mL Injection

2248640 OCTREOTIDE ACETATE OMEGA OMG

839205 SANDOSTATIN NVR

200mcg/mL Injection

2248642 OCTREOTIDE ACETATE OMEGA OMG

2049392 SANDOSTATIN NOV

500mcg/mL Injection

2248641 OCTREOTIDE ACETATE OMEGA OMG

839213 SANDOSTATIN NVR

PAMIDRONATE DISODIUM

30mg Injection

2059762 AREDIA IV NVR

2244550 PAMIDRONATE DISODIUM MAY

2264951 RHOXAL-PAMIDRONATE RHO

60mg Injection

2244551 PAMIDRONATE DISODIUM HOS

2264978 RHOXAL-PAMIDRONATE SDZ

PAMIDRONATE DISODIUM

90mg Injection

2059789 AREDIA IV NVR

2244552 PAMIDRONATE DISODIUM MAY

2245999 PMS-PAMIDRONATE PMS

2264986 RHOXAL-PAMIDRONATE SDZ

PENTOSAN POLYSULFATE SODIUM

100mg Capsule

2029448 ELMIRON JNO

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

5mg Tablet

2242518 ACTONEL PGP

2298376 NOVO-RISEDRONATE NOP

30mg Tablet

2239146 ACTONEL PGP

2298384 NOVO-RISEDRONATE NOP

35mg Tablet

2246896 ACTONEL PGP

2298392 NOVO-RISEDRONATE NOP

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

2243237 RAPAMUNE WAY

1mg Tablet

2247111 RAPAMUNE WAY

TAMSULOSIN HCL

0.4mg Long Acting Capsule

2281392 NOVO-TAMSULOSIN NOP

2294885 RAN-TAMSULOSIN RBY

2294265 RATIO-TAMSULOSIN RPH

2295121 SANDOZ TAMSULOSIN SDZ

0.4mg Long Acting Tablet

2270102 FLOMAX CR BOE

TAMSULOSIN HYDROCHLORIDE

0.4mg Sustained Release Capsule

2298570 GEN-TAMSULOSIN MYL

TETRABENAZINE

25mg Tablet

2199270 NITOMAN LHL

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

2320673 STELARA JNO

WATER

100% Injection

38202 STERILE WATER * ABB

99002264 STERILE WATER *

905178 WATER FOR INJECTION *

905194 WATER FOR INJECTION *

905224 WATER FOR INJECTION *

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

2269198 ACLASTA NOV

92:44.00

TACROLIMUS

Limited use benefit (prior approval required).

For transplant therapy.

0.5mg Capsule

2243144 PROGRAF AST

1mg Capsule

2175991 PROGRAF AST

5mg Capsule

2175983 PROGRAF AST

5mg/mL Injection

2176009 PROGRAF AST

0.5mg Long Acting Capsule

2296462 ADVAGRAF AST

1mg Long Acting Capsule

2296470 ADVAGRAF AST

5mg Long Acting Capsule

2296489 ADVAGRAF AST