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Drug Benefit List
Limited Use Benefits and Criteria
08:00 ANTI-INFECTIVE AGENTS
08:12.24 TETRACYCLINES
MINOCYCLINE HCL
Limited use benefit (prior approval required).
For:
a. - patients who cannot tolerate other tetracyclines.
b. - patients with severe widespread acne who have failed on tetracycline.
- 50MG Capsule
- 02084090 APO-MINOCYCLINE APX
- 02239667 DOM-MINOCYCLINE DPC
- 02237875 MED-MINOCYCLINE MEC
- 02173514 MINOCIN STI
- 02108143 NOVO-MINOCYCLINE NOP
- 02153394 PDL-MINOCYCLINE PDL
- 02294419 PMS-MINOCYCLINE PMS
- 02239238 PMS-MINOCYCLINE PMS
- 01914138 RATIO-MINOCYCLINE RPH
- 02242080 RIVA-MINOCYCLINE RIV
- 02237313 SANDOZ-MINOCYCLINE SDZ
- 100MG Capsule
- 02084104 APO-MINOCYCLINE APX
- 02239668 DOM-MINOCYCLINE DPC
- 02237876 MED-MINOCYCLINE MEC
- 02173506 MINOCIN STI
- 02239982 MINOCYCLINE IVX
- 02108151 NOVO-MINOCYCLINE NOP
- 02154366 PDL-MINOCYCLINE PDL
- 02294427 PMS-MINOCYCLINE PMS
- 02239239 PMS-MONOCYCLINE PMS
- 01914146 RATIO-MINOCYCLINE RPH
- 02242081 RIVA-MINOCYCLINE RIV
- 02237314 SANDOZ-MINOCYCLINE SDZ
08:12.28 MISCELLANEOUS ANTIBIOTICS
LINEZOLID
Limited use benefit (prior approval required).
Tablets:
For treatment of proven vancomycin-resistant enterococci (VRE) infections when
other antibiotics are not available, and for the treatment of proven Methicillin-Resistant
Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or
who had an idiosyncratic reaction with Vancomycin.
I.V. solution:
When linezolid cannot be administered orally in the above mentioned situations.
08:14.08 AZOLES
VORICONAZOLE
Limited use benefit (prior approval required).
For the treatment of:
a. - patients with invasive aspergillosis.
b. - culture proven invasive candidiasis with documented resistance to fluconazole.
08:18.08 ANTIRETROVIRALS
AMPRENAVIR
Limited use benefit (prior approval required).
For the management of HIV disease in patients who have failed other protease
inhibitor combinations, or for patients who experienced a lack of tolerability
to other protease inhibitors.
DARUNAVIR
Limited use benefit (prior approval required).
For the management of HIV in patients who failed or have experienced adverse
events to three or more listed protease inhibitors.
EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required).
For the treatment of HIV-1 infection adults where the virus is susceptible to each of tenofovir, emtricitabine and efavirenz, and:
a. - Atripla is used to replace existing therapy with its component drugs, or
b. - the patient is treatment naïve, or
c. - the patient has established viral suppression but requires antiretroviral therapy modification due to intolerance or adverse effects.
Note: Criteria will be confirmed against medication history.
EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required).
For the treatment of patients with HIV infection where the virus is susceptible to both emtricitabine and tenofovir AND where the triple-entity antiretroviral agent (tenofovir/ emtricitabine/efavirenz) is not indicated due to one of the following:
a. - efavirenz resistance
b. - adverse effects secondary to efavirenz
RALTEGRAVIR
Limited use benefit (prior approval required).
For the treatment of HIV infection in patients who are antiretroviral experienced and have virologic failure due to resistance to at least one agent from each of the three major classes of antiretroviral agents, nucleoside/tide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors.
TENOFOVIR DISOPROXIL FUMARATE
Limited use benefit (prior approval required).
For the management of HIV disease in patients who have failed or have experienced
adverse events to an alternative nucleoside reverse transcriptase inhibitor.
TIPRANAVIR
Limited use benefit (prior approval required).
For the management of HIV disease in patients
a. - who have failed all currently listed protease inhibitors
b. - intolerant to all currently listed protease inhibitors
08:18.20 INTERFERONS
PEGINTERFERON ALFA-2A
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve,
upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved.
A further 24 week supply may be approved if patient has a viral reduction of
at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will
be approved. Renewals will not be covered
PEGINTERFERON ALFA-2A, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve,
upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved.
A further 24 week supply may be approved if patient has a viral reduction of
at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will
be approved. Renewals will not be covered
PEGINTERFERON ALFA-2B
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve,
upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved.
A further 24 week supply may be approved if patient has a viral reduction of
at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will
be approved. Renewals will not be covered
PEGINTERFERON ALFA-2B, RIBAVIRIN
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis C in patients who are treatment naïve,
upon the written request of a hepatologist or other specialist in this area.
a. - For genotypes 1, 4, 5 and 6, an initial 24 week supply will be approved.
A further 24 week supply may be approved if patient has a viral reduction of
at least 2 logs or HCV is undetectable at 12 weeks (48 weeks total).
b. - For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will
be approved. Renewals will not be covered
08:18.32 NUCLEOSIDES AND NUCLEOTIDES
ADEFOVIR DIPIVOXIL
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of = 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.
ENTECAVIR
Limited use benefit (prior approval required).
For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.
10:00 ANTINEOPLASTIC AGENTS
10:00.00 ANTINEOPLASTIC AGENTS
ERLOTINIB HYDROCLORIDE
Limited use benefit (prior approval required).
Treatment of non-small cell lung cancer (NSCLC) after failure of at least one
prior chemotherapy regimen, and whose EGFR expression status is positive or
unknown.
IMATINIB MESYLATE
Limited use benefit (prior approval required).
a.- For the treatment of patients with chronic myeloid leukemia in blast crisis,
accelerated phase, or in chronic phase after failure of interferon-alpha therapy.
b.- For the treatment of patients with gastrointestinal stromal tumour.
c.- For newly diagnosed adult patients with Philadelphia chromosome-positive
chronic myeloid leukemia (CML).
RITUXIMAB
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. Rituximab should not be used in combination with anti-TNF agents.
For continued coverage for rituximab beyond twenty-four weeks, patient must meet all the following criteria:
a. - Initially prescribed by a rheumatologist
b. - Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets
the response criteria of:
c. - a >20% reduction in number of tender and swollen joints
d. - a >20% improvement in physician global assessment scale.
e. - either a >20% improvement in the patient global assessment scale or a >20% reduction in the
acute phase as measured by ESR or CRP.
SUNITINIB MALATE
Limited use benefit (Prior approval required).
Criteria for initial six month coverage
of Sutent:
For patients with histologically proven unresectable or recurrent/metastatic GIST who have failed or
are unable to tolerate imatinib therapy. Sunitinib will not be funded concomitantly with imatinib.
Criteria
for assessment at every six months:
There is no objective evidence of disease progression.
TEMOZOLOMIDE
Limited use benefit (prior approval required).
For:
a. - treatment of adult patients with glioblastoma multiforme or anaplastic
astrocytoma, and documented evidence of recurrence or progression after standard
therapy (resection, radiotherapy, and chemotherapy).
b. - treatment of adult patients with newly diagnosed glioblastoma multiforme
concomitantly with radiotherapy and then as maintenance treatment.
12:00 AUTONOMIC DRUGS
12:04.00 PARASYMPATHOMIMETIC AGENTS
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)
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)
RIVASTIGMINE
Limited use benefit (prior approval required).
Initial six month coverage for cholinesterase inhibitors:
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)
12:08.08 ANTIMUSCARINICS / ANTISPASMODICS
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.
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
FORMOTEROL FUMARATE DIHYDRATE
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.
SALMETEROL XINAFOATE
Limited use benefit (prior approval required).
a. - 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.
b. - For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients
not adequately controlled with ipratropium.
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.
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.
12:92.00 MISCELLANEOUS AUTONOMIC DRUGS
VARENICLINE
Limited use benefit (prior approval 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.
20:00 Blood Formation Coagulation and Thrombosis
20:12.18 PLATELET AGGREGATION INHIBITORS
CLOPIDOGREL BISULFATE
Limited use benefit (one-year duration, prior approval required).
a. - Patients with intra-coronary stent implantation following insertion.
b. - Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment
elevation MI), in combination with ASA.
20:16.00 HEMATOPOIETIC AGENTS
PEGFILGRASTIM
Limited use benefit (prior approval required).
a. - To decrease the incidence of infection, as manifested by febrile neutropenia,
in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic
drugs with curative intent.
and
b. - Where access to a health care facility is problematic.
24:00 CARDIOVASCULAR DRUGS
24:06.05 CHOLESTEROL ABSORPTION INHIBITORS
EZETIMIBE
Limited use benefit (prior approval required).
a.- For use in combination with a HMG-CoA reductase inhibitor ('statin') in
patients with hypercholesterolemia who have not reached target LDL levels despite
the use of maximally tolerated "statin" doses.
b.- For use as monotherapy in the management of hypercholesterolemia in patients
intolerant to HMG-CoA reductase inhibitors.
24:12.92 MISCELLANEOUS VASODILATING AGENTS
DIPYRIDAMOLE, ACETYLSALICYLIC ACID
Limited use benefit (prior approval required).
For secondary prevention of stroke or transient ischemic attacks (TIAs) in
patients who have failed therapy with ASA alone.
24:24.00 BETA ADRENERGIC BLOCKING AGENTS
CARVEDILOL
Limited use benefit (prior approval required).
a.- For patients with systolic heart failure of ischemic or non-ischemic origin,
with or without digoxin, PLUS
b.- Concurrent treatment with diuretics and angiotension converting enzyme
inhibitors or angiotensin receptor blockers, unless contraindicated.
- 3.125MG Tablet
- 02247933 APO-CARVEDILOL APX
- 02248748 DOM-CARVEDILOL DPC
- 02245914 PMS-CARVEDILOL PMS
- 02268027 RAN-CARVEDILOL RBY
- 02252309 RATIO-CARVEDILOL RPH
- 6.25MG Tablet
- 02247934 APO-CARVEDILOL APX
- 02248749 DOM-CARVEDILOL DPC
- 02245915 PMS-CARVEDILOL PMS
- 02268035 RAN-CARVEDILOL RBY
- 02252317 RATIO-CARVEDILOL RPH
- 12.5MG Tablet
- 02247935 APO-CARVEDILOL APX
- 02248750 DOM-CARVEDILOL DPC
- 02245916 PMS-CARVEDILOL PMS
- 02268043 RAN-CARVEDILOL RBY
- 02252325 RATIO-CARVEDILOL RPH
- 25MG Tablet
- 02247936 APO-CARVEDILOL APX
- 02248751 DOM-CARVEDILOL DPC
- 02245917 PMS-CARVEDILOL PMS
- 02268051 RAN-CARVEDILOL RBY
- 02252333 RATIO-CARVEDILOL RPH
28:00 CENTRAL NERVOUS SYSTEM AGENTS
28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CELECOXIB
Limited use benefit (prior approval required).
For patients with osteoarthritis who have failed therapy with acetaminophen
and who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs,
or
c. - have a history of a serious gastrointestinal complication such as bleeding
or perforation.
For patients with rheumatoid arthritis who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs,
or
c. - have a history of a serious gastrointestinal complication such as bleeding
or perforation.
MELOXICAM
Limited use benefit (prior approval required).
For patients with osteoarthritis who have failed therapy with acetaminophen
and who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs,
or
c. - have a history of a serious gastrointestinal complication such as bleeding
or perforation.
For patients with rheumatoid arthritis who:
a. - have failed to achieve adequate response with 2 other listed NSAIDs, or
b. - have experienced an adverse event attributable to 2 other listed NSAIDs,
or
c. - have a history of a serious gastrointestinal complication such as bleeding
or perforation.
- 7.5MG Tablet
- 02248973 APO-MELOXICAM APX
- 02250012 CO-MELOXICAM COB
- 02248605 DOM-MELOXICAM DPC
- 02255987 GEN-MELOXICAM GEN
- 02242785 MOBICOX BOE
- 02258315 NOVO-MELOXICAM NOP
- 02248607 PHL-MELOXICAM PHH
- 02248267 PMS-MELOXICAM PMS
- 02247889 RATIO-MELOXICAM RPH
- 15MG Tablet
- 02248974 APO-MELOXICAM APX
- 02250020 CO-MELOXICAM COB
- 02248606 DOM-MELOXICAM DPC
- 02255995 GEN-MELOXICAM GEN
- 02242786 MOBICOX BOE
- 02258323 NOVO-MELOXICAM NOP
- 02248608 PHL-MELOXICAM PHH
- 02248268 PMS-MELOXICAM PMS
- 02248031 RATIO-MELOXICAM RPH
28:08.08 OPIATE AGONISTS
CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE
Limited use benefit (prior approval required).
For treatment of:
a. - chronic pain and palliative care patients as an alternative to products
containing codeine in combination with acetaminophen or ASA with or without
caffeine, or
b. - chronic pain and palliative care patients as an alternative to regular
release codeine tablets when large doses are required.
FENTANYL
Limited use benefit (prior approval required).
For the management of chronic pain in patients who are unresponsive or intolerant
to at least one long-acting oral sustained released product, such as morphine,
hydromorphone and oxycodone, despite appropriate dose titration and adjunctive
therapy including laxatives and antiemetics.
- 25MCG/H Patch
- 01937383 DURAGESIC 25 JNO
- 02249391 RAN-FENTANYL TRANSDERMAL SYSTEM RBY
- 02282941 RATIO-FENTANYL TRANSDERMAL SYSTEM RPH
- 50MCG/H Patch
- 01937391 DURAGESIC 50 JNO
- 02249413 RAN-FENTANYL TRANSDERMAL SYSTEM RBY
- 02282968 RATIO-FENTANYL TRANSDERMAL SYSTEM RPH
- 75MCG/H Patch
- 01937405 DURAGESIC 75 JNO
- 02249421 RAN-FENTANYL TRANSDERMAL SYSTEM RBY
- 02282976 RATIO-FENTANYL TRANSDERMAL SYSTEM RPH
- 100MCG/H Patch
- 01937413 DURAGESIC 100 JNO
- 02249448 RAN-FENTANYL TRANSDERMAL SYSTEM RBY
- 02282984 RATIO-FENTANYL TRANSDERMAL SYSTEM RPH
HYDROMORPHONE HCL
Limited use benefit. Prior approval required for controlled
release capsules only. Regular release dosage forms are full benefits and do
not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as
morphine have been ineffective in controlling pain or in patients experiencing
intolerable side effects.
MEPERIDINE HCL
Limited use benefit (prior approval not required).
Limited to 2 weeks supply for acute pain. Coverage will be limited to 60 tablets
per one month period.
OXYCODONE HCL
Limited use benefit. Prior approval required for controlled
release tablets only. Regular release dosage forms are full benefits and do
not require prior approval.
For treatment of moderate to severe chronic pain when other opioids such as
morphine have been ineffective in controlling pain or in patients experiencing
intolerable side effects.
28:12.92 MISCELLANEOUS ANTICONVULSANTS
LEVETIRACETAM
Limited use benefit (prior approval required).
For the use in combination with other anti-epileptic medication(s) in the treatment
of partial seizures in patients who are refractory to adequate trials of three
anti-epileptic medications used either as monotherapy or in combination. This
product must be prescribed by a Neurologist.
- 250MG Tablet
- 02285924 APO-LEVETIRACETAM APX
- 02274183 CO-LEVETIRACETAM COB
- 02247027 KEPPRA UCB
- 02296101 PMS-LEVETIRACETAM PMS
- 500MG Tablet
- 02285932 APO-LEVETIRACETAM APX
- 02274191 CO-LEVETIRACETAM COB
- 02247028 KEPPRA UCB
- 02296128 PMS-LEVETIRACETAM PMS
- 750MG Tablet
- 02285940 APO-LEVETIRACETAM APX
- 02274205 CO-LEVETIRACETAM COB
- 02247029 KEPPRA UCB
- 02296136 PMS-LEVETIRACETAM PMS
28:16.04 ANTIDEPRESSANTS
BUPROPION HCL (WELLBUTRIN)
Limited use benefit (prior approval required).
For treatment of depression in patients unresponsive to or intolerant of other
listed antidepressants. (Note: this product will not be approved for coverage
for smoking cessation).
- 150MG Sustained Release Tablet
- 02260239 NOVO-BUPROPION SR NOP
- 02313421 PMS-BUPROPION SR PMS
- 02285665 RATIO-BUPROPION RPH
- 02275082 SANDOZ-BUPROPION SR SDZ
- 02237825 WELLBUTRIN SR BPC
BUPROPION HCL (ZYBAN)
Limited use benefit with quantity and frequency limits (prior
approval is not required).
For smoking cessation:
Coverage is limited to 180 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 bupropion HCl when one year has
elapsed from the day the initial prescription was filled.
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40:20.00 CALORIC AGENTS
LEVOCARNITINE
Limited use benefit (prior approval required).
For treatment of carnitine deficiency.
48:00 Respiratory Tract Agents
48:10.24 LEUKOTRIENE MODIFIERS
MONTELUKAST
Limited use benefit (prior approval required).
For treatment of:
a. - asthma when used in patients on concurrent steroid therapy.
b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
ZAFIRLUKAST
Limited use benefit (prior approval required).
For treatment of:
a. - asthma when used in patients on concurrent steroid therapy.
b. - asthma patients not well controlled with or intolerant to inhaled corticosteroids.
52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
52:04.04 EENT - ANTIBACTERIALS
CIPROFLOXACIN HCL, DEXAMETHASONE
Limited use benefit (prior approval required).
a. - For clients 16 years old and under, approved immediately.
b. - For clients with acute otitis media with otorrhea through tympanostomy tubes who require treatment.
c. - For clients with acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane.
CIPROFLOXACIN HCL, HYDROCORTISONE
Limited use benefit (prior approval required).
For treatment of acute diffuse bacterial external otitis. Criteria for coverage
include:
a. - failure to respond to other listed topical antibiotics, or
b. - contraindications to other listed topical antibiotics.
52:28.00 EENT - MOUTHWASHES AND GARGLES
BENZYDAMINE HCL
Limited use benefit (prior approval required).
For:
a. - treatment of radiation mucositis and oral ulcerative complications of
chemotherapy.
b. - use in immunocompromised patients who are at risk of mucosal breakdown.
- 0.15% Rinse
- 02239044 APO-BENZYDAMINE APX
- 02239537 DOM-BENZYDAMINE DPC
- 02229799 NOVO-BENZYDAMINE NOP
- 02229777 PMS-BENZYDAMINE PMS
- 02230170 RATIO-BENZYDAMINE RPH
- 01966065 TANTUM MMH
52:40.04 EENT - ALPHA-ADRENERGIC AGONISTS
BRIMONIDINE TARTRATE (ALPHAGAN P)
Limited use benefit (prior approval required).
For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium
chloride.
52:92.00 MISCELLANEOUS EENT DRUGS
VERTEPORFIN
Limited use benefit (prior approval required).
For treatment of age related macular degeneration for patients with this diagnosis
who are being treated by a certified ophthalmologist.
56:00 GASTROINTESTINAL DRUGS
56:12.00 CATHARTICS AND LAXATIVES
BISACODYL (POLYETHYLENE GLYCOL BASE)
Limited use benefit (prior approval required).
For treatment of constipation in patients with spinal cord injury.
56:22.92 MISCELLANEOUS ANTIEMETICS
APREPITANT
Limited use benefit (prior approval required).
When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. Cisplatin > 70mg/m2) in patients who have experienced emesis despite treatment with a combination of a 5-HT3 antagonist and dexamethasone in a previous cycle of highly emetogenic chemotherapy.
56:28.36 PROTON-PUMP INHIBITORS
LANSOPRAZOLE
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;
- All PPIs are equally efficacious
- Double dose PPI is not necessary for initial therapy
- Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
Effective April 1, 2009, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 200 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. - For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. - Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit - Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett's esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 200 tablets/capsules per 180 days through the prior approval process.
Effective April 1, 2009, the limited use criteria for Pantoloc (40mg tablets, including generics), Prevacid (15mg and 30mg capsules) and Losec 10mg tablets will be:
Limited use benefit (prior approval required).
Coverage will be limited to 200 tablets/capsules every 180 days.
As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met: - patient has tried at least 30 days of Omeprazole (Losec®) AND - patient has tried at least 30 days of Rabeprazole sodium (Pariet®). Total trial of 60 days will be confirmed against medication history
PLUS
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated to a 4 week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months.
Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
*a> Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition.
OMEPRAZOLE MAGNESIUM (PA)
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;
- All PPIs are equally efficacious
- Double dose PPI is not necessary for initial therapy
- Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
Effective April 1, 2009, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 200 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs. - For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit. - Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit - Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett's esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 200 tablets/capsules per 180 days through the prior approval process.
Effective April 1, 2009, the limited use criteria for Pantoloc (40mg tablets, including generics), Prevacid (15mg and 30mg capsules) and Losec 10mg tablets will be:
Limited use benefit (prior approval required).
Coverage will be limited to 200 tablets/capsules every 180 days.
As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 30 days of Omeprazole (Losec®) AND
- patient has tried at least 30 days of Rabeprazole sodium (Pariet®).
Total trial of 60 days will be confirmed against medication history
PLUS
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated to a 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat condition
OMEPRAZOLE, OMEPRAZOLE MAGNESIUM (NO PA)
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;
- All PPIs are equally efficacious
- Double dose PPI is not necessary for initial therapy
- Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
Effective April 1, 2009, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 200 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs.
- For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit.
- Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit
- Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett's esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 200 tablets/capsules per 180 days through the prior approval process.
Effective April 1, 2009, Pariet (10mg and 20mg tablets, including generics) and Losec (10mg capsules, 20mg capsules and 20mg tablets, including generics) will move from open benefits to limited use benefits with quantity and frequency limits (prior approval not required). Prior approval is not required unless the quantity limit is exceeded.
Limited use benefit (prior approval not required).
Coverage will be limited to 200 tablets/capsules every 180 days.
PANTOPRAZOLE
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;
- All PPIs are equally efficacious
- Double dose PPI is not necessary for initial therapy
- Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
Effective April 1, 2009, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 200 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs.
- For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit.
- Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit
- Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett's esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 200 tablets/capsules per 180 days through the prior approval process.
Effective April 1, 2009, the limited use criteria for Pantoloc (40mg tablets, including generics), Prevacid (15mg and 30mg capsules) and Losec 10mg tablets will be:
Limited use benefit (prior approval required). Coverage will be limited to 200 tablets/capsules every 180 days.
As part of multi-drug therapy (maximum 7-14 day coverage) for eradication of Helicobacter pylori in individuals with peptic ulcer disease (diagnosed by urea breath test, serology or endoscopically).
Coverage will also be provided if the following prerequisites are met:
- patient has tried at least 30 days of Omeprazole (Losec®) AND
- patient has tried at least 30 days of Rabeprazole sodium (Pariet®).
Total trial of 60 days will be confirmed against medication history
PLUS
- for treatment of confirmed gastric and duodenal ulcers. Or
- for mild to moderate gastroesophageal reflux disease (GERD) in patients who have failed on or not tolerated to a 4-week trial of histamine-2 receptor antagonists. Or
- for severe gastroesophageal reflux disease (GERD) and complications as first-line therapy for a maximum period of 3 months. Patients should be reassessed endoscopically or with step-down therapy using a histamine-2 receptor antagonist. Or
- for treatment of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers where the NSAID must be continued. Or
- for prevention of NSAID-induced ulcers in patients who have a history of ulcer complications, are over the age of 65 years, have comorbid disease such as cardiovascular disease or coagulopathies or are on concomitant medications which increase risk of ulcers or bleeding. Or
- Zollinger-Ellison Syndrome*. Or
- Barrett's Esophagus*. Or
- esophagitis associated with connective tissue disease. Or
- other exceptional circumstances, evaluated on an individual basis.
* Diagnosis must be confirmed by a specialist qualified to diagnose and treat
condition
- 40MG Enteric Coated Tablet
- 02292920 APO-PANTOPRAZOLE APX
- 02300486 CO PANTOPRAZOLE COB
- 02299585 GEN-PANTOPRAZOLE GEN
- 02285487 NOVO-PANTOPRAZOLE NOP
- 02229453 PANTOLOC NCC
- 02307871 PMS-PANTOPRAZOLE PMS
- 02305046 RAN-PANTOPRAZOLE RBL
- 02308703 RATIO-PANTOPRAZOLE RPH
- 02310201 RIVA-PANTOPRAZOLE ZYM
- 02316463 RIVA-PANTOPRAZOLE RIV
- 02301083 SANDOZ-PANTOPRAZOLE SDZ
RABEPRAZOLE SODIUM
The following PPI status change is primarily based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy. The report concluded that;
- All PPIs are equally efficacious
- Double dose PPI is not necessary for initial therapy
- Double dose PPI is effective in H. Pylori eradication; however, treatment is not needed beyond 14 days.
PPI use has been associated with increased risk of hip fracture, community-acquired pneumonia and Clostridium difficile associated diarrhea. Although further study is needed to establish clinical significance, it is prudent to use the lowest dose and shortest duration of therapy required to control symptoms.
Effective April 1, 2009, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 200 tablets/capsules per 180 day period. This quantity limit will be in effect for the entire class of PPIs.
- For example, if a patient fills 30 tablets of rabeprazole, then switch to 30 tablets of omeprazole, then switch to 30 capsules of lansoprazole, this will count as 90 PPI tablets/capsules towards the quantity limit.
- Patients taking two rabeprazole 10mg tablets a day can be switched to one rabeprazole 20mg tablet a day to avoid reaching the quantity limit
- Patients taking two omeprazole 10mg tablets/capsules a day can be switched to one omeprazole 20mg tablet/capsule a day to avoid reaching the quantity limit
Patients with Zollinger Ellison Syndrome, Barrett's esophagus, erosive esophagitis and those who remain symptomatic on a single dose PPI will be eligible for additional doses above 200 tablets/capsules per 180 days through the prior approval process.
Effective April 1, 2009, Pariet (10mg and 20mg tablets, including generics) and Losec (10mg capsules, 20mg capsules and 20mg tablets, including generics) will move from open benefits to limited use benefits with quantity and frequency limits (prior approval not required). Prior approval is not required unless the quantity limit is exceeded.
Limited use benefit (prior approval not required).
Coverage will be limited to 200 tablets/capsules every 180 days.
- 10MG Enteric Coated Tablet
- 02296632 NOVO-RABEPRAZOLE NOP
- 02243796 PARIET EC JNO
- 02310805 PMS-RABEPRAZOLE PMS
- 02298074 RAN-RABEPRAZOLE RBY
- 02314177 SANDOZ-RABEPRAZOLE SDZ
- 20MG Enteric Coated Tablet
- 02296640 NOVO-RABEPRAZOLE NOP
- 02243797 PARIET EC JNO
- 02310813 PMS-RABEPRAZOLE RPH
- 02298082 RAN-RABEPRAZOLE RBY
- 02314185 SANDOZ-PANTOPRAZOLE SDZ
68:00 HORMONES AND SYNTHETIC SUBSTITUTES
68:12.00 CONTRACEPTIVES
ETHINYL ESTRADIOL, ETONOGESTREL
Limited use benefit (prior approval required).
For patients who are intolerant to or unable to take oral contraceptives.
68:16.12 ESTROGEN AGONISTS-ANTAGONISTS
RALOXIFENE HCL
Limited use benefit (prior approval required).
For:
a.- secondary prevention of osteoporosis in women who experience failure on
bisphosphonates.
b. - secondary prevention of osteoporosis in women who have a personal history
or a first degree relative with a history of breast cancer.
68:20.28 THIAZOLIDINEDIONES
PIOGLITAZONE HCL
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled
by or are intolerant to metformin and sulfonylureas or for whom these products
are contraindicated.
- 15MG Tablet
- 02242572 ACTOS LIL
- 02302942 APO-PIOGLITAZONE APX
- 02302861 CO PIOGLITAZONE CBT
- 02298279 GEN-PIOGLITAZONE GEN
- 02274914 NOVO-PIOGLITAZONE NOP
- 02303124 PMS-PIOGLITAZONE PMS
- 02312050 PRO-PIOGLITAZONE PDL
- 02301423 RATIO-PIOGLITAZONE RPH
- 02297906 SANDOZ PIOGLITAZONE SDZ
- 30MG Tablet
- 02242573 ACTOS LIL
- 02302950 APO-PIOGLITAZONE APX
- 02302888 CO PIOGLITAZONE CBT
- 02298287 GEN-PIOGLITAZONE GEN
- 02274922 NOVO-PIOGLITAZONE NOP
- 02303132 PMS-PIOGLITAZONE PMS
- 02312069 PRO-PIOGLITAZONE PDL
- 02301431 RATIO-PIOGLITAZONE RPH
- 02297914 SANDOZ PIOGLITAZONE SDZ
- 45MG Tablet
- 02242574 ACTOS LIL
- 02302977 APO-PIOGLITAZONE APX
- 02302896 CO PIOGLITAZONE CBT
- 02298295 GEN-PIOGLITAZONE GEN
- 02274930 NOVO-PIOGLITAZONE NOP
- 02303140 PMS-PIOGLITAZONE PMS
- 02312077 PRO-PIOGLITAZONE PDL
- 02301458 RATIO-PIOGLITAZONE RPH
- 02297922 SANDOZ PIOGLITAZONE SDZ
ROSIGLITAZONE MALEATE
Limited use benefit (prior approval required).
For treatment of type 2 diabetic patients who are not adequately controlled
by or are intolerant to metformin and sulfonylureas or for whom these products
are contraindicated.
68:24.00 PARATHYROID
CALCITONIN SALMON (MIACALCIN)
Limited use benefit (prior approval required).
For treatment of patients with postmenopausal osteoporosis who have failed
therapy, are intolerant to, or who have contraindications to both bisphosphonates
and raloxifene.
84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)
84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
PIMECROLIMUS
Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced
side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.
TACROLIMUS (PROTOPIC)
Limited use benefit (prior approval required).
For patients who have failed topical corticosteroid therapy or have experienced
side effects from such treatment.
Note: Contraindicated in children less than 2 years of age.
86:00 SMOOTH MUSCLE RELAXANTS
86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS
TOLTERODINE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms
of urinary frequency, urgency or urge incontinence or any combination of these
in patients who have failed on or are intolerant of therapy with oxybutynin.
TROSPIUM CHLORIDE
Limited use benefit (prior approval required).
For the symptomatic relief of patients with an overactive bladder with symptoms
of urinary frequency, urgency or urge incontinence or any combination of these
in patients who have failed on or are intolerant of therapy with oxybutynin.
88:00 VITAMINS
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS (PEDIATRIC)
Limited use benefit (prior approval is not required).
Pediatric multivitamins are benefits for children up to 6 years of age.
MULTIVITAMINS (PRENATAL)
Limited use benefit (prior approval is not required.).
Prenatal and postnatal vitamins are benefits only for women of childbearing
age (12 to 50 years).
- Tablet
- 80001842 CENTRUM MATERNA WAY
- 02229535 MULTI-PRE AND POST NATAL PED
- 00815241 NEO-TINIC NEO
- 02241235 PRENATAL AND POSTPARTUM SDR
- 02244374 PRENATAL VITAMINS AND MINERALS PMT
PRENATAL VITAMIN
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
ADALIMUMAB
Limited use benefit (prior approval required).
Criteria for initial one year coverage for a MAXIMUM dose of 40mg every 2 weeks for RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS:
1. Prescribed by a rheumatologist, AND
2. Patient has had a tuberculin skin test performed
3. For the treatment of severely active RHEUMATOID ARTHRITIS:
- Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks
PLUS a minimum of two of the following:
- leflunomide: 20mg daily for 10 weeks OR
- gold: weekly injections for 20 weeks OR
- cyclosporine: 2-5 mg/kg/day for 12 weeks OR
- azathioprine: 2-3 mg/kg/day for 3 months OR
- sulfasalazine at least 2g daily for 3 months
PLUS one of the following combinations:
- methotrexate with cyclosporine (minimum 4 month trial on both) OR
- methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
- methotrexate with gold (minimum 12 week trial) OR
- in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS
4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following:
- five or more swollen joints
- if less than five swollen joints, at least one joint proximal to, or including wrist or ankle
- more than one joint with erosion on imaging study
- dactylitis of two or more digits
- tenosynovitis refractory to oral NSAIDs and steroid injections
- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)
- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4
- daily use of corticosteroids
- use of opioids > 12 hours per day for pain resulting from inflammation
Patient is refractory to:
- NSAIDs and
- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks PLUS a minimum of one of the following:
- leflunomide: 20mg daily for 10 weeks OR
- gold: weekly injections for 20 weeks OR
- cyclosporine: 2-5 mg/kg/day for 12 weeks OR
- sulfasalazine at least 2g daily for 3 months
5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:
- BASDAI > 4 AND
- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.
NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.
Initial coverage for the treatment of moderately to severely active CROHN'S DISEASE will allow for an induction dose of adalimumab 160mg followed by 80mg 2 weeks later. Maintenance therapy will only be provided at a dose not exceeding 40mg every two weeks. Criteria for initial four week coverage for the treatment of moderate to severely active Crohn's disease:
Patient is an adult with moderate to severely active Crohn's disease refractory to:
- therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks);
PLUS
- glucorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks; OR
- treatment discontinued due to serious adverse reactions; OR
- contraindication to glucorticoid therapy;
PLUS
- azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months; OR
- 6-mercaptopurine 50 to 70mg/day for a minimum of 3 months; OR
- methotrexate 15 to 25mg/week for a minimum of 3 months
ALENDRONATE SODIUM
Limited use benefit (prior approval required).
For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures
b. - osteoporosis in patients with intolerance or lack of response to etidronate
or etidronate/calcium
c. - 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
- 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 SDC
- 02245565 XATRAL SAC
BOTULINUM TOXIN TYPE A
Limited use benefit (prior approval required).
For the treatment of:
a. - strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm
or VII nerve disorder in patients 12 years of age or older
b. - cervical dystonia (spasmodic torticollis)
CABERGOLINE
Limited use benefit (prior approval required).
For treatment of hyperprolactinemia in patients who have failed therapy with
or are intolerant to bromocriptine.
CYCLOSPORINE
Limited use benefit (prior approval required).
For transplant therapy.
DUTASTERIDE
Limited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do
not tolerate or have not responded to an adrenergic blocker.
or
b. - For use in combination therapy when monotherapy with an alpha-blocker
is not sufficient.
ETANERCEPT
Limited use benefit (prior approval required).
Criteria for initial one year coverage for a MAXIMUM dose of 50mg weekly:
1. Prescribed by a rheumatologist, AND
2. Patient has had a tuberculin skin test performed
3. For the treatment of severely active RHEUMATOID ARTHRITIS:
- Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks
PLUS a minimum of two of the following:
- leflunomide: 20mg daily for 10 weeks OR
- gold: weekly injections for 20 weeks OR
- cyclosporine: 2-5 mg/kg/day for 12 weeks OR
- azathioprine: 2-3 mg/kg/day for 3 months OR
- sulfasalazine at least 2g daily for 3 months
PLUS one of the following combinations:
- methotrexate with cyclosporine (minimum 4 month trial on both) OR
- methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
- methotrexate with gold (minimum 12 week trial) OR
- in patients who are intolerant or who have contraindication to methotrexate therapy, or are refractory to a combination of at least 2 DMARDS
4. For the treatment of moderate to severe PSORIATIC ARTHRITIS with at least two of the following:
- five or more swollen joints
- if less than five swollen joints, at least one joint proximal to, or including wrist or ankle
- more than one joint with erosion on imaging study
- dactylitis of two or more digits
- tenosynovitis refractory to oral NSAIDs and steroid injections
- enthesitis refractory to oral NSAIDs and steroid injections (not required for Achilles tendon)
- inflammatory spinal symptoms refractory to two NSAIDs (minimum four weeks trial each) and has a BASDAI greater than 4
- daily use of corticosteroids
- use of opioids > 12 hours per day for pain resulting from inflammation
Patient is refractory to:
- NSAIDs and
- methotrexate weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks
PLUS a minimum of one of the following:
- leflunomide: 20mg daily for 10 weeks OR
- gold: weekly injections for 20 weeks OR
- cyclosporine: 2-5 mg/kg/day for 12 weeks OR
- sulfasalazine at least 2g daily for 3 months
5. For the treatment of ANKYLOSING SPONDYLITIS when the following criteria are met:
- BASDAI > 4 AND
- patient is refractory to a three month trial of at least 3 NSAIDs at maximum tolerated dose AND for peripheral joint involvement, patient is refractory to weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65 years of age) for more than 8 weeks AND sulfasalazine 2g/day for four months.
NOTE: For axial involvement, patient does not need to be tried on methotrexate or sulfasalazine.
FINASTERIDE
Limited use benefit (prior approval required).
a. - For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do
not tolerate or have not responded to an alpha-adrenergic blocker.
or
b. - For use in combination therapy when monotherapy with an alpha-blocker
is not sufficient.
INFLIXIMAB
CRITERIA FOR INITIAL TWELVE WEEKS OF COVERAGE FOR INFLIXIMAB FOR RHEUMATOID ARTHRITIS
-Prescribed by a rheumatologist
-Infliximab for use in combination with methotrexate for the treatment of severely active rheumatoid
arthritis
Note: Initial coverage is provided for 3 doses of 3mg/kg of infliximab ONLY.
Patient is refractory to:
-Methotrexate: oral therapy at 20mg or greater total weekly dosage (15mg or greater if patient is <65
years of age) for more than 8 weeks. AND
-Methotrexate: weekly parenteral (SC or IM) at 20mg or greater (15mg or greater if patient is >65
years of age) for more than 8 weeks.
PLUS
-Leflunomide: 20mg daily for 10 weeks
PLUS
-Gold: weekly injections for 20 weeks OR
-Sulfaslazine: at least 2 gm daily for 3 months OR
-Azathioprine: 2-3mg/kg/day for 3 months
PLUS One of the following combinations:
-Methotrexate with cyclosporine (minimum 4 month trial on both) OR
-Methotrexate with hydroxychloroquine and sulfasalazine (minimum 4 month trial on triple therapy) OR
-Methotrexate with gold (minimum 12 week trial) OR
-Methotrexate with leflunomide (minimum 8 week trial) OR
-In patients who are intolerant or who have contraindications to methotrexate therapy, refractory to
a combination of a least 2 DMARDs.
PLUS
Etanercept or Adalimumab: minimum of 12 week trial
CRITERIA FOR CONTINUED COVERAGE FOR INFLIXIMAB BEYOND TWELVE WEEKS
Patient meets all the following criteria:
- Initially prescribed by a rheumatologist
- Previous failure to etanercept or adalimumab
- Patient has been assessed after the eighth to twelfth week of infliximab therapy and meets the following
response criteria
>20% reduction in number of tender and swollen joints PLUS
>20% improvement in physician global assessment scale
PLUS EITHER
>20% improvement in the patient global assessment scale, OR
>20% reduction in the acute phase as measured by ESR or CRP
REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR FISTULIZING CROHN'S DISEASE
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued
coverage, patient must be reassessed after the initial doses.
-Infliximab is being prescribed by a gastroenterologist
-Patient is an adult with actively draining perianal or entercutaneous fistula(e) that have recurred
or persisted despite:
1.a course of appropriate antibiotic therapy (e.g. ciprofloxacin with or without metronidazole for a
minimum of 3 weeks)
PLUS
2.immunosuppressive therapy:
-azathioprine 2 to 2.5mg/kg/day for a minimum of 6 weeks or treatment discontinued at < 6 weeks due
to severe adverse reactions.
OR
-6-mercaptopurine 50-70mg/day for a minimum of 6 weeks or treatment discontinued at <6 weeks due to
severe adverse reactions.
OR
-Other.
REQUEST FOR INITIAL COVERAGE OF INFLIXIMAB FOR SEVERE ACTIVE CROHN'S DISEASE
The initial coverage will allow for 3 doses of 5mg/kg/dose, administered at 0, 2 and 6 weeks. For continued
coverage, patient must be reassessed after the initial doses.
-Infliximab is being prescribed by a gastroenterologist
-Patient is an adult with severe active Crohn's disease that has recurred or persisted despite:
1. Therapy with 5-ASA products (at least 3g/day for a minimum of 6 weeks).
PLUS
2. Glucocorticoids equivalent to prednisone 40mg/day for a minimum of 2 weeks.
OR Treatment discontinued due to serious adverse reactions.
OR Contraindication to glucocorticoid therapy.
PLUS
3. Azathioprine 2 to 2.5mg/kg/day for a minimum of 3 months.
OR
6-mercaptopurine 50 to 70mg/day for a minimum of 3 months.
OR
Methotrexate 15 to 25mg/week for a minimum of 3 months.
LEFLUNOMIDE
Limited use benefit (prior approval required).
For treatment of patients with rheumatoid arthritis who:
a. - have failed treatment with methotrexate.
b. - 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
MYCOPHENOLATE MOFETIL
Limited use benefit (prior approval required).
For transplant therapy.
MYCOPHENOLATE SODIUM
Limited use benefit (prior approval required).
For transplant therapy.
RISEDRONATE SODIUM
Limited use benefit (prior approval required).
For treatment of:
a. - osteoporosis in patients who have documented hip, vertebral or other fractures.
b. - osteoporosis in patients who are intolerant of or do not respond to etidronate
or etidronate/calcium.
c. - Paget's disease.
SIROLIMUS
Limited use benefit (prior approval required).
Coverage will be provided as a second line therapy for patients failing mycophenolate
mofetil.
TACROLIMUS
Limited use benefit (prior approval required).
For transplant therapy.
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
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.
