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08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES

LEVOFLOXACIN

Limited use benefit (prior approval not required).

Coverage will be limited to a maximum of 14 days.

250mg Tablet: 2284707 APO-LEVOFLOXACIN APX; 2315424 CO-LEVOFLOXACIN COB; 2236841 LEVAQUIN JNO; 2313979 MYLAN-LEVOFLOXACIN MYL; 2248262 NOVO-LEVOFLOXACIN TEV; 2284677 PMS-LEVOFLOXACIN PMS; 2298635 SANDOZ LEVOFLOXACIN SDZ

500mg Tablet: 2284715 APO-LEVOFLOXACIN APX; 2315432 CO-LEVOFLOXACIN COB; 2236842 LEVAQUIN JNO; 2313987 MYLAN-LEVOFLOXACIN MYL; 2248263 NOVO-LEVOFLOXACIN TEV; 2284685 PMS-LEVOFLOXACIN PMS; 2298643 SANDOZ LEVOFLOXACIN SDZ

750mg Tablet: 2325942 APO-LEVOFLOXACIN APX; 2315440 CO-LEVOFLOXACIN COB; 2246804 LEVAQUIN JNO; 2285649 NOVO-LEVOFLOXACIN TEV; 2305585 PMS-LEVOFLOXACIN PMS; 2298651 SANDOZ LEVOFLOXACIN SDZ

08:12.24 TETRACYCLINES

MINOCYCLINE HCL

Limited use benefit (prior approval required).

For:

patients who cannot tolerate other tetracyclines.
patients with severe widespread acne who have failed on tetracycline.

50mg Capsule: 2084090 APO-MINOCYCLINE APX; 2239667 DOM-MINOCYCLINE DPC; 2153394 MINOCYCLINE PDL; 2287226 MINOCYCLINE SAN; 2230735 MYLAN-MINOCYCLINE MYL; 2108143 NOVO-MINOCYCLINE TEV; 2239238 PMS-MINOCYCLINE PMS; 2294419 PMS-MINOCYCLINE PMS; 2242080 RIVA-MINOCYCLINE RIV; 2237313 SANDOZ-MINOCYCLINE SDZ

100mg Capsule: 2084104 APO-MINOCYCLINE APX; 2239668 DOM-MINOCYCLINE DPC; 2173506 MINOCIN STI; 2154366 MINOCYCLINE PDL; 2239982 MINOCYCLINE IVX; 2287234 MINOCYCLINE SAN; 2230736 MYLAN-MINOCYCLINE MYL; 2108151 NOVO-MINOCYCLINE TEV; 2294427 PMS-MINOCYCLINE PMS; 2239239 PMS-MONOCYCLINE PMS; 2242081 RIVA-MINOCYCLINE RIV; 2237314 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.

2mg/mL Injection: 2243685 ZYVOXAM PFI

600mg Tablet: 2243684 ZYVOXAM PFI

08:14.08 AZOLES

VORICONAZOLE

Limited use benefit (prior approval required).

For the treatment of:

patients with invasive aspergillosis.
culture proven invasive candidiasis with documented resistance to fluconazole.

50mg Tablet: 2256460 VFEND PFI

200mg Tablet: 2256479 VFEND PFI

08:18.08 ANTIRETROVIRALS

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:

Atripla is used to replace existing therapy with its component drugs, or
the patient is treatment naďve, or
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.

600mg & 200mg & 300mg Tablet: 2300699 ATRIPLA BMS

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:

efavirenz resistance
adverse effects secondary to efavirenz

200mg/300mg Tablet: 2274906 TRUVADA GIL

ETRAVIRINE

Limited use benefit (prior approval required).

For use in combination with other antiretroviral agents for treatment-experienced patients with HIV-1 infection who:

have failed prior antiretroviral therapy; and
have HIV-1 strains resistant to multiple antiretroviral agents, including NNRTIs

100mg Tablet: 2306778 INTELENCE JNO

MARAVIROC

Limited use benefit (prior approval required). For the treatment of HIV-1 infection, given in combination with other antiretroviral agents, in patients who have:

CR5 tropic viruses; and
documented resistance to at least one agent from each of the three major classes of antiretroviral agents (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitors)

150mg Tablet: 2299844 CELSENTRI GSK

300mg Tablet: 2299852 CELSENTRI GSK

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.

400mg Tablet: 2301881 ISENTRESS FRS

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.

245mg Tablet: 2247128 VIREAD GIL

TIPRANAVIR

Limited use benefit (prior approval required).

For the management of HIV disease in patients

who have failed all currently listed protease inhibitors
intolerant to all currently listed protease inhibitors

250mg Capsule: 2273322 APTIVUS BOE

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 naďve, upon the written request of a hepatologist or other specialist in this area.

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).
For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180mcg/0.5mL Injection: 2248077 PEGASYS HLR

180mcg/1mL Injection: 2248078 PEGASYS HLR

PEGINTERFERON ALFA-2A, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naďve, upon the written request of a hepatologist or other specialist in this area.

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).
For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

180mcg/0.5mL & 200mg Injection & Tablet: 2253429 PEGASYS RBV HLR

180mcg/1mL & 200mg Injection & Tablet: 2253410 PEGASYS RBV HLR

PEGINTERFERON ALFA-2B

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naďve, upon the written request of a hepatologist or other specialist in this area.

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).
For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.

74mcg/Vial Injection: 2242966 UNITRON PEG SCH

118.4mcg/Vial Injection: 2242967 UNITRON PEG SCH

177.6mcg/Vial Injection: 2242968 UNITRON PEG SCH

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naďve, upon the written request of a hepatologist or other specialist in this area.

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).
For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered.

222mcg/Vial Injection: 2242969 UNITRON PEG SCH

PEGINTERFERON ALFA-2B, RIBAVIRIN

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C in patients who are treatment naďve, upon the written request of a hepatologist or other specialist in this area.

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).
For genotypes 2 or 3, initial coverage for a maximum of 24 weeks will be approved. Renewals will not be covered

50mcg/0.5mL & 200mg Injection & Capsule: 2246026 PEGETRON SCH; 2254573 PEGETRON REDIPEN SCH

80mcg/0.5mL & 200mg Injection & Capsule: 2246027 PEGETRON SCH; 2254581 PEGETRON REDIPEN SCH

100mcg/0.5mL & 200mg Injection & Capsule: 2246028 PEGETRON SCH; 2254603 PEGETRON REDIPEN SCH

120mcg/0.5mL & 200mg Injection & Capsule: 2246029 PEGETRON SCH; 2254638 PEGETRON REDIPEN SCH

150mcg/0.5mL & 200mg Injection & Capsule: 2246030 PEGETRON SCH; 2254646 PEGETRON REDIPEN SCH

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.

10mg Tablet: 2247823 HEPSERA GIL

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.

0.5mg Tablet: 2282224 BARACLUDE BMS

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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.

100mg Tablet: 2269015 TARCEVA HLR

150mg Tablet: 2269023 TARCEVA HLR

IMATINIB MESYLATE

Limited use benefit (prior approval required).

For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase after failure of interferon-alpha therapy.
For the treatment of patients with gastrointestinal stromal tumour.
For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML).

100mg Tablet: 2253275 GLEEVEC NVR

400mg Tablet: 2253283 GLEEVEC NVR

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:

Initially prescribed by a rheumatologist
Patient has been assessed after the twentieth to twenty-fourth week of rituximab therapy and meets the response criteria of:
a >20% reduction in number of tender and swollen joints
a >20% improvement in physician global assessment scale.
either a >20% improvement in the patient global assessment scale or a >20% reduction in the acute phase as measured by ESR or CRP.

10mg/mL Injection: 2241927 RITUXAN HLR

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.

12.5mg Capsule: 2280795 SUTENT PFI

25mg Capsule: 2280809 SUTENT PFI

50mg Capsule: 2280817 SUTENT PFI

TEMOZOLOMIDE

Limited use benefit (prior approval required).

For:

treatment of adult patients with glioblastoma multiforme or anaplastic astrocytoma, and documented evidence of recurrence or progression after standard therapy (resection, radiotherapy, and chemotherapy).
treatment of adult patients with newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as maintenance treatment.

5mg Capsule: 2241093 TEMODAL SCH

20mg Capsule: 2241094 TEMODAL SCH

100mg Capsule: 2241095 TEMODAL SCH

140mg Capsule: 2312794 TEMODAL FRS

180mg Capsule: 2312816 TEMODAL FRS

250mg Capsule: 2241096 TEMODAL SCH

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)

5mg Tablet: 2232043 ARICEPT PFI

10mg Tablet: 2232044 ARICEPT PFI

GALANTAMINE

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

Diagnosis of mild to moderate Alzheimer’s disease; AND
Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND
Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

Diagnosis is still mild to moderate Alzheimer’s disease; AND
MMSE score > 10; AND
GDS score between 4 to 6; AND
Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change)
1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

8mg Extended Release Capsule: 2339439 MYLAN-GALANTAMINE ER MYL; 2316943 PAT-GALANTAMINE ER JNO; 2266717 REMINYL ER JNO

16mg Extended Release Capsule: 2339447 MYLAN-GALANTAMINE ER MYL; 2316951 PAT-GALANTAMINE ER JNO; 2266725 REMINYL ER JNO

24mg Extended Release Capsule: 2339455 MYLAN-GALANTAMINE ER MYL; 2316978 PAT-GALANTAMINE ER JNO; 2266733 REMINYL ER JNO

12:04.00 PARASYMPATHOMIMETIC AGENTS

RIVASTIGMINE

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

Diagnosis of mild to moderate Alzheimer’s disease; AND
Mini Mental State Exam (MMSE) score of 10-26, established within the last 60 days; AND
Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

Diagnosis is still mild to moderate Alzheimer’s disease; AND
MMSE score > 10; AND
GDS score between 4 to 6; AND
Improvement or stabilization in at least one of the following domains (please indicate improved, worsened, or no change)
1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)

1.5mg Capsule: 2336715 APO-RIVASTIGMINE APX; 2242115 EXELON NVR; 2332809 MYLAN-RIVASTIGMINE MYL; 2305984 NOVO-RIVASTIGMINE TEV; 2306034 PMS-RIVASTIGMINE PMS; 2311283 RATIO-RIVASTIGMINE RPH; 2324563 SANDOZ RIVASTIGMINE SDZ

3mg Capsule: 2336723 APO-RIVASTIGMINE APX; 2242116 EXELON NVR; 2332817 MYLAN-RIVASTIGMINE MYL; 2305992 NOVO-RIVASTIGMINE TEV; 2306042 PMS-RIVASTIGMINE PMS; 2311291 RATIO-RIVASTIGMINE RPH; 2324571 SANDOZ RIVASTIGMINE SDZ

4.5mg Capsule: 2336731 APO-RIVASTIGMINE APX; 2242117 EXELON NVR; 2332825 MYLAN-RIVASTIGMINE MYL; 2306018 NOVO-RIVASTIGMINE TEV; 2306050 PMS-RIVASTIGMINE PMS; 2311305 RATIO-RIVASTIGMINE RPH; 2324598 SANDOZ RIVASTIGMINE SDZ

6mg Capsule: 2336758 APO-RIVASTIGMINE APX; 2242118 EXELON NVR; 2332833 MYLAN-RIVASTIGMINE MYL; 2306026 NOVO-RIVASTIGMINE TEV; 2306069 PMS-RIVASTIGMINE PMS; 2311313 RATIO-RIVASTIGMINE RPH; 2324601 SANDOZ RIVASTIGMINE SDZ

2mg/mL Oral Liquid: 2245240 EXELON NVR

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 (3 months) of ipatropium, at a dose of 8-12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability and Lung Function Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on level ground (MRC 3 to 4); 50% ≤ FEV1 < 80% predicted, FEV1/FVC <0.7

Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing (MRC 5), or in the presence of chronic respiratory failure or clinical signs of right heart failure; 30% ≤ FEV1 < 50% predicted, FEV1/FVC <0.7

18mcg Powder for Inhalation (Capsule): 2246793 SPIRIVA BOE

12:12.08 BETA ADRENERGIC AGONISTS

FORMOTEROL FUMARATE

Limited use benefit (prior approval required).

For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of a rapid onset, short duration bronchodilator. Oxeze is not intended for the relief of acute asthma symptoms: patients must have access to an inhaled fast-acting bronchodilator (beta-2 agonist) for symptomatic relief.

12mcg/Capsule Powder for Inhalation: 2230898 FORADIL NVR

FORMOTEROL FUMARATE DIHYDRATE

Limited use benefit (prior approval required).

For the treatment of asthma in patients who are using optimal corticosteroid therapy and experiencing breakthrough symptoms requiring regular use of rapid onset, shot duration bronchodilator

6mcg/Dose Dry Powder Inhaler: 2237225 OXEZE TURBUHALER AZC

12mcg/Dose Dry Powder Inhaler: 2237224 OXEZE TURBUHALER AZC

FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE

Limited use benefit (prior approval required).

For the treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids ( e.g. fluticasone 250 - 500 mcg daily, or the equivalent) as the sole agent and require addition of a long- acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

6mcg & 100mcg/Inhalation Inhaler: 2245385 SYMBICORT 100 TURBUHALER AZC

6mcg & 200mcg/Inhalation Inhaler: 2245386 SYMBICORT 200 TURBUHALER AZC

SALMETEROL XINAFOATE

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. 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.
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with ipratropium.

50mcg/inhalation Powder Diskus: 2231129 SEREVENT DISKUS GSK

50mcg/Inhalation Powder for Inhalation: 2214261 SEREVENT DISKHALER GSK

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

Limited use benefit (prior approval required).

For treatment of reversible obstructive airway disease in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g., fluticasone 250- 500mcg daily, or the equivalent) as a sole agent and require addition of a long-acting beta agonist. Patients using this combination product must also have access to a short-acting bronchodilator for symptomatic relief.

For the treatment of moderate* to severe* chronic obstructive pulmonary disease (COPD), in patients who continue to be symptomatic after an adequate trial (2-4 months) of ipatropium, at a dose of 12 puffs daily.

*Canadian Thoracic Society COPD Classification by Symptoms/Disability
Moderate: shortness of breath from COPD causing the patient to stop after walking about 100 meters (after a few minutes) on the level Severe: shortness of breath from COPD leaving the patient too breathless to leave the house or breathless after undressing, or in the presence of chronic respiratory failure or clinical signs of right heart failure.

By Symptom/Disability:
Moderate: shortness of breath from COPD causing the patient to stop after walking approximately 100 meters (or after a few minutes) on the level. Severe: shortness of breath from COPD resulting in the patient being too breathless to leave the house or breathless after undressing, or the presence of chronic respiratory failure or clinical signs of right heart failure.

25mcg & 125mcg Inhaler: 2245126 ADVAIR GSK

25mcg & 250mcg Inhaler: 2245127 ADVAIR GSK

50mcg & 100mcg Inhaler: 2240835 ADVAIR DISKUS 100 GSK

50mcg & 250mcg Inhaler: 2240836 ADVAIR DISKUS 250 GSK

50mcg & 500mcg Inhaler: 2240837 ADVAIR DISKUS 500 GSK

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: 2177145 APO-CYCLOBENZAPRINE APX; 2220644 CYCLOBENZAPRINE PDL; 2287064 CYCLOBENZAPRINE SAN; 2238633 DOM-CYCLOBENZAPRINE DPC; 2231353 MYLAN-CYCLOPRINE MYL; 2171848 NU-CYCLOBENZAPRINE NXP; 2249359 PHL-CYCLOBENZAPRINE PHH; 2212048 PMS-CYCLOBENZAPRINE PMS; 2236506 RATIO-CYCLOBENZAPRINE RPH; 2242079 RIVA-CYCLOBENZAPRINE RIV; 2080052 TEVA-CYCLOPRINE TEV

TIZANIDINE HCL

Limited use benefit (prior approval required).

For treatment of spasticity in patients with multiple sclerosis, who have failed therapy with or are intolerant to baclofen.

4mg Tablet: 2259893 APO-TIZANIDINE APX; 2272059 MYLAN-TIZANIDINE MYL; 2239170 ZANAFLEX ELN

12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

NICOTINE (GUM)

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

For smoking cessation:
Coverage is limited to 945 pieces during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.

2mg Gum: 2091933 NICORETTE JNO; 80000396 THRIVE NVR

4mg Gum: 2091941 NICORETTE PLUS PMJ; 80000118 NICOTINE GUM PER; 80000402 THRIVE NVR

NICOTINE (INHALER)

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

For smoking cessation:
Coverage is limited to 945 during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for nicotine gum or lozenges when one year has elapsed from the day the initial prescription was filled.

10mg Inhaler: 2241742 NICORETTE JNO

NICOTINE (LOZENGE)

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

1mg Lozenge: 80007461 THRIVE NVR

2mg Lozenge: 2247347 NICORETTE LOZENGE JNO; 80007464 THRIVE NVR

4mg Lozenge: 2247348 NICORETTE LOZENGE JNO

NICOTINE (PATCH)

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

For smoking cessation:
Coverage will be provided for up to the allowable number of patches for one of the following products, during a one-year period. The year starts on the date the first prescription is filled. The number of patches covered in the one-year period is:

Habitrol 84 patches or
Nicoderm 70 patches or
Nicotrol 70 patches

Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.

5mg Patch: 2028697 NICOTROL TRANSDERMAL PFI

7mg Patch: 1943057 HABITROL NVC

8.3mg/10cm2 Patch: 2065738 NICOTROL TRANSDERMAL JNO

10mg Patch: 2029405 NICOTROL TRANSDERMAL PFI

14mg Patch: 1943065 HABITROL NVC

15mg Patch: 2029413 NICOTROL TRANSDERMAL PFI

16.6mg/20cm2 Patch: 2065754 NICOTROL TRANSDERMAL JNO

17.5mg Patch: 2241227 TRANSDERMAL NICOTINE NVC

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

Habitrol 84 patches or
Nicoderm 70 patches or
Nicotrol 70 patches

Once this quantity has been reached, the client is eligible again for coverage for nicotine patches when one year has elapsed from the day the initial prescription was filled.

21mg Patch: 1943073 HABITROL NVC

24.9mg/30cm2 Patch: 2065762 NICOTROL TRANSDERMAL JNO

35mg Patch: 2241226 TRANSDERMAL NICOTINE NVC

36mg Patch: 2093111 NICODERM PMJ

52.5mg Patch: 2241228 TRANSDERMAL NICOTINE NVC

78mg Patch: 2093138 NICODERM PMJ

114mg Patch: 2093146 NICODERM PMJ

VARENICLINE

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

Coverage will be limited to 165 tablets during a one-year period. The year starts on the date the first prescription is filled. Once this quantity has been reached, the client is eligible again for coverage for varenicline (Champix^®) when one year has elapsed from the day the initial prescription was filled.

0.5mg Tablet: 2291177 CHAMPIX PFI

0.5mg & 1mg Tablet: 2298309 CHAMPIX STARTER PACK PFI

1mg Tablet: 2291185 CHAMPIX PFI

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20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:12.04 ANTICOAGULANTS

RIVAROXABAN

Limited use benefit (prior approval not required).

For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to two weeks.

10mg Tablet: 2316986 XARELTO BAY

20:12.18 PLATELET AGGREGATION INHIBITORS

CLOPIDOGREL BISULFATE

Limited use benefit (one-year duration, prior approval required).

Patients with intra-coronary stent implantation following insertion.
Patients with acute coronary syndrome (ACS) (unstable angina or non-ST-segment elevation MI), in combination with ASA.

75mg Tablet: 2238682 PLAVIX SAC

20:16.00 HEMATOPOIETIC AGENTS

PEGFILGRASTIM

Limited use benefit (prior approval required).

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
Where access to a health care facility is problematic.

10mg/mL Injection: 2249790 NEULASTA AMG

24:00 CARDIOVASCULAR DRUGS

24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBE

Limited use benefit (prior approval required).

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.
For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase inhibitors.

10mg Tablet: 2247521 EZETROL MSP

24:12.12 PHOSPHODIESTERASE INHIBITORS

SILDENAFIL CITRATE

Limited use benefit (prior approval required).

Maximum dose covered is 20 mg three times a day Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents.

20mg Tablet: 2319500 RATIO-SILDENAFIL R RPH; 2279401 REVATIO PFI

TADALAFIL

Limited use benefit (prior approval required).

Maximum dose covered is 40 mg daily Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to conventional therapy; OR who have contraindications to conventional agents

20mg Tablet: 2338327 ADCIRCA LIL

24:12.92 MISCELLANEOUS VASODILATING AGENTS

AMBRISENTAN

Limited use benefit (prior approval required).

Maximum dose covered is 10 mg once daily.

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND who have failed to respond to sildenafil OR tadalafil; OR who have contraindications to sildenafil OR tadalafil.

5mg Tablet: 02307065 VOLIBRIS GSK

10mg Tablet: 02307073 VOLIBRIS GSK

BOSENTAN

Limited use benefit (prior approval required).

Maximum dose covered is 125 mg twice daily

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND
who have failed to respond to sildenafil OR tadalafil; OR
who have contraindications to sildenafil OR tadalafil.

62.5mg Tablet: 02244981 TRACLEER ACN

125mg Tablet: 02244982 TRACLEER ACN

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.

200mg & 25mg Capsule: 02242119 AGGRENOX BOE

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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:

have failed to achieve adequate response with 2 other listed NSAIDs, or
have experienced an adverse event attributable to 2 other listed NSAIDs, or
have a history of a serious gastrointestinal complication such as bleeding or perforation.

For patients with rheumatoid arthritis who:

have failed to achieve adequate response with 2 other listed NSAIDs, or
have experienced an adverse event attributable to 2 other listed NSAIDs, or
have a history of a serious gastrointestinal complication such as bleeding or perforation.

100mg Capsule: 02239941 CELEBREX PFI

200mg Capsule: 02239942 CELEBREX PFI

28:08.08 OPIATE AGONISTS

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE

Limited use benefit (prior approval required). For treatment of:

chronic pain and palliative care patients as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine, or
chronic pain and palliative care patients as an alternative to regular release codeine tablets when large doses are required.

50mg Long Acting Tablet: 02230302 CODEINE CONTIN CR PFR

100mg Long Acting Tablet: 02163748 CODEINE CONTIN CR PFR

150mg Long Acting Tablet: 02163780 CODEINE CONTIN CR PFR

200mg Long Acting Tablet: 02163799 CODEINE CONTIN CR PFR

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.

12mcg/h Transdermal Patch: 02341379 PMS-FENTANYL MTX PMS; 02330105 RAN-FENTANYL MATRIX RBY; 02311925 RATIO-FENTANYL RPH; 02327112 SANDOZ FENTANYL SDZ

Limited use benefit (prior approval required).

25mcg/h Transdermal Patch: 02275813 DURAGESIC MAT JNO; 02314630 NOVO-FENTANYL TEV; 02341387 PMS-FENTANYL MTX PMS; 02330113 RAN-FENTANYL MATRIX RBY; 02282941 RATIO-FENTANYL RPH; 02327120 SANDOZ FENTANYL SDZ

50mcg/h Transdermal Patch: 02275821 DURAGESIC MAT JNO; 02314649 NOVO-FENTANYL TEV; 02341395 PMS-FENTANYL MTX PMS; 02330121 RAN-FENTANYL MATRIX RBY; 02282968 RATIO-FENTANYL RPH; 02327147 SANDOZ FENTANYL SDZ

75mcg/h Transdermal Patch: 02275848 DURAGESIC MAT JNO; 02314657 NOVO-FENTANYL TEV; 02341409 PMS-FENTANYL MTX PMS; 02330148 RAN-FENTANYL MATRIX RBY; 02282976 RATIO-FENTANYL RPH; 02327155 SANDOZ FENTANYL SDZ

100mcg/h Transdermal Patch: 02275856 DURAGESIC MAT JNO; 02314665 NOVO-FENTANYL TEV; 02341417 PMS-FENTANYL MTX PMS; 02330156 RAN-FENTANYL MATRIX RBY; 02282984 RATIO-FENTANYL RPH; 02327163 SANDOZ FENTANYL SDZ

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.

3mg Controlled Release Capsule: 02125323 HYDROMORPH CONTIN PFR

4.5mg Controlled Release Capsule: 02359502 HYDROMORPH CONTIN PFR

6mg Controlled Release Capsule: 02125331 HYDROMORPH CONTIN PFR

9mg Controlled Release Capsule: 02359510 HYDROMORPH CONTIN PFR

12mg Controlled Release Capsule: 02125366 HYDROMORPH CONTIN PFR

18mg Controlled Release Capsule: 02243562 HYDROMORPH CONTIN PFR

24mg Controlled Release Capsule: 02125382 HYDROMORPH CONTIN PFR

30mg Controlled Release Capsule: 02125390 HYDROMORPH CONTIN PFR

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.

50mg Tablet: 02138018 DEMEROL SAC

METHADONE HCL

Limited use benefit (prior approval required) with the following criteria:

Prescriber is registered with Health Canada and is eligible to prescribe methadone for the management of pain. AND For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids. OR, For the management of pain for palliative care patients. Pharmacists may only dispense a maximum supply of 30 days at one time.

Methadone pseudo DINs listed for the treatment of pain should not be used for methadone maintenance therapy. Methadone for the treatment of opioid dependency is an open benefit covered under the NIHB Program (Methadone maintenance therapy pseudo DIN 908835). For information regarding the adjudication rules of methadone for the treatment of opioid dependency, please refer to the NIHB Provider Guide for Pharmacy Benefits.

1mg/mL Oral Liquid: 02247694 METADOL PAL

10mg/mL Oral Liquid: 02241377 METADOL PAL

Powder: 09991180 METHADONE POWDER (PAIN)

1mg Tablet: 02247698 METADOL PAL

5mg Tablet: 02247699 METADOL PAL

10mg Tablet: 02247700 METADOL PAL

25mg Tablet: 02247701 METADOL PAL

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE HCL/NALOXONE HCL

Limited use benefit (prior approval required).

For the treatment of opioid dependence in patients who have a contraindication to methadone due to:

Evidence of (or high risk for) QT interval prolongation; and
Prescribed by a physician with experience in substitution treatment in Opioid drug dependence or completion of an accredited Suboxone Education Program.

8mg & 2mg Sublingual Tablet: 02295709 SUBOXONE RBP; 09991204 SUBOXONE MAINTENANCE RBP

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 two 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; 02353342 LEVETIRACETAM SAN; 02296101 PMS-LEVETIRACETAM PMS

500mg Tablet: 02285932 APO-LEVETIRACETAM APX; 02274191 CO LEVETIRACETAM COB; 02247028 KEPPRA UCB; 02353350 LEVETIRACETAM SAN; 02296128 PMS-LEVETIRACETAM PMS; 02311380 PRO-LEVETIRACETAM PDL

750mg Tablet: 02285940 APO-LEVETIRACETAM APX; 02274205 CO LEVETIRACETAM COB; 02247029 KEPPRA UCB; 02353369 LEVETIRACETAM SAN; 02296136 PMS-LEVETIRACETAM PMS; 02311399 PRO-LEVETIRACETAM PDL

28:16.04 ANTIDEPRESSANTS

BUPROPION HCL (WELLBUTRIN)

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

Coverage of Wellbutrin XL and Bupropion SR is limited to 300 mg per day. (Note: this product will not be approved for coverage for smoking cessation).

100mg Sustained Release Tablet: 02331616 BUPROPION SR PDL; 02325373 PMS-BUPROPION SR PMS; 02285657 RATIO-BUPROPION RPH; 02275074 SANDOZ-BUPROPION SR SDZ

150mg Sustained Release Tablet: 02325357 BUPROPION SR PDL; 02313421 PMS-BUPROPION SR PMS; 02285665 RATIO-BUPROPION RPH; 02275082 SANDOZ-BUPROPION SR SDZ; 02237825 WELLBUTRIN SR VAE; 02275090 WELLBUTRIN XL VAE

300mg Sustained Release Tablet: 02275104 WELLBUTRIN XL VAE

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.

150mg Sustained Release Tablet: 02238441 ZYBAN VAE

DULOXETINE HCL

Limited use benefit (prior approval required).

For the treatment of neuropathic pain in patients with diabetes who have:

failed an adequate trial with TWO alternative agents (such as a tricyclic antidepressant or anticonvulsant) due to intolerance or lack of response or
a contraindication to alternative agents The dose of duloxetine will be limited to a maximum of 60 mg daily. Note that NIHB has adopted a Common Drug Review CEDAC recommendation that Cymbalta NOT be added to public drug plan formularies for the treatment of major depressive disorder.

30mg Sustained Release Capsule: 02301482 CYMBALTA LIL

60mg Sustained Release Capsule: 02301490 CYMBALTA LIL

28:16.08 ANTIPSYCHOTIC AGENTS

ARIPIPRAZOLE

Limited use benefit (prior approval required).

For the treatment of schizophrenia and schizoaffective disorders in patients who have

Intolerance or lack of response to an adequate trial of another antipsychotic agent; OR
A contraindication to another antipsychotic agent

2mg Tablet: 02322374 ABILIFY BMS

5mg Tablet: 02322382 ABILIFY BMS

10mg Tablet: 02322390 ABILIFY BMS

15mg Tablet: 02322404 ABILIFY BMS

20mg Tablet: 02322412 ABILIFY BMS

30mg Tablet: 02322455 ABILIFY BMS

ZIPRASIDONE HCL MONOHYDRATE

Limited use benefit (prior approval required).

For the treatment of schizophrenia and schizoaffective disorders in patients who have:

intolerance or lack of response to an adequate trial of another antipsychotic agent or
a contraindication to another antipsychotic agent

20MG Capsule: 02298597 ZELDOX PFI

40MG Capsule: 02298600 ZELDOX PFI

60mg Capsule: 02298619 ZELDOX PFI

80mg Capsule: 02298627 ZELDOX PFI

28:20.92 MISC ANOREXIGENIC AGENTS & RESPIRATORY & CEREBRAL STIMULANT

METHYLPHENIDATE HCL

The limited use benefit (prior approval required) criteria for Concerta® (and generics) are:

For the treatment of patients aged 6 to 18 with Attention Deficit Hyperactivity Disorder (ADHD) who demonstrate significant and problematic disruptive behaviour or who have problems with inattention that interferes with learning AND
For whom the medication is prescribed by, or in consultation with, a specialist in pediatric psychiatry, pediatrics, or a general practitioner with expertise in ADHD, AND
For whom sustained release methylphenidate (i.e., Ritalin® SR) or sustained release dextroamphetamine (i.e., Dexedrine Spansules) has not adequately controlled the symptoms of the disorder.

18mg Extended Release Tablet: 02247732 CONCERTA JNO; 02315068 NOVO-METHYLPHENIDATE ER TEV

27mg Extended Release Tablet: 02250241 CONCERTA JNO; 02315076 NOVO-METHYLPHENIDATE ER TEV

36mg Extended Release Tablet: 02247733 CONCERTA JNO; 02315084 NOVO-METHYLPHENIDATE ER TEV

54mg Extended Release Tablet: 02330377 APO-METHYLPHENIDATE ER APX; 02247734 CONCERTA JNO; 02315092 NOVO-METHYLPHENIDATE ER TEV

28:36.20 ANTIPARKINSONIAN AGENTS - DOPAMINE RECEPTOR AGONISTS

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 COB; 02242471 DOSTINEX PFI

28:92.00 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

ACAMPROSATE CALCIUM

Limited use benefit (prior approval required).

For patients who have been abstinent from alcohol for at least four days and where available, are currently enrolled in an alcohol addiction treatment program

333mg Sustained Release Tablet: 02293269 CAMPRAL MYL

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40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:20.00 CALORIC AGENTS

LEVOCARNITINE

100mg/mL Oral Liquid: 02144336 CARNITOR SIG

200mg/mL Solution: 02144344 CARNITOR IV SIG

330mg Tablet: 02144328 CARNITOR SIG

48:00 RESPIRATORY TRACT AGENTS

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST

Limited use benefit (prior approval required).

For treatment of:

asthma when used in patients on concurrent steroid therapy.
asthma patients not well controlled with or intolerant to inhaled corticosteroids.

4mg Chewable Tablet: 02354977 PMS-MONTELUKAST PMS; 02330385 SANDOZ MONTELUKAST SDZ; 02243602 SINGULAIR FRS; 02355507 TEVA-MONTELUKAST TEV

5mg Chewable Tablet: 02354985 PMS-MONTELUKAST PMS; 02330393 SANDOZ MONTELUKAST SDZ; 02238216 SINGULAIR FRS; 02355515 TEVA-MONTELUKAST TEV

4mg Granules: 02358611 SANDOZ MONTELUKAST SDZ; 02247997 SINGULAIR FRS

10mg Tablet: 02374609 APO-MONTELUKAST APX; 02368226 MYLAN-MONTELUKAST MYL; 02373947 PMS-MONTELUKAST PMS; 02328593 SANDOZ MONTELUKAST SDZ; 02238217 SINGULAIR FRS; 02355523 TEVA-MONTELUKAST TEV

ZAFIRLUKAST

Limited use benefit (prior approval required).

For treatment of:

asthma when used in patients on concurrent steroid therapy.
asthma patients not well controlled with or intolerant to inhaled corticosteroids.

20mg Tablet: 02236606 ACCOLATE AZC

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:04.04 EENT - ANTIBACTERIALS

CIPROFLOXACIN HCL, DEXAMETHASONE

Limited use benefit (prior approval required).

for children 16 years old and under
for acute otitis media with otorrhea through tympanostomy tubes who require treatment
for acute otitis externa in the presence of tympanostomy tube or known perforation of the tympanic membrane

0.3%/0.1% Otic Solution: 02252716 CIPRODEX ALC

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HCL

Limited use benefit (prior approval required).

For:

treatment of radiation mucositis and oral ulcerative complications of chemotherapy.
use in immunocompromised patients who are at risk of mucosal breakdown.

0.15% Rinse: 02239044 APO-BENZYDAMINE APX; 02239537 DOM-BENZYDAMINE DPC; 02229777 PMS-BENZYDAMINE PMS; 02229799 TEVA-BENZYDAMINE TEV; 02310422 TEVA-BENZYDAMINE TEV

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.

0.15% Ophth Solution: 02248151 ALPHAGAN P ALL; 02301334 APO-BRIMONIDINE P APX

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.

15mg/Vial Injection: 02242367 VISUDYNE QLT

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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.

10mg Suppository: 02241091 MAGIC BULLET DCM

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.

80mg Capsule: 02298791 EMEND FRS

125mg Capsule: 02298805 EMEND FRS

125mg & 80mg Capsule: 02298813 EMEND TRI PACK FRS

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 July 5, 2010, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 400 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 400 tablets/capsules per 180 days through the prior approval process.

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

15mg Sustained Release Capsule: 02293811 APO-LANSOPRAZOLE APX; 02357682 LANSOPRAZOLE SAN; 02353830 MYLAN-LANSOPRAZOLE MYL; 02280515 NOVO-LANSOPRAZOLE TEV; 02165503 PREVACID TAK

30mg Sustained Release Capsule: 02293838 APO-LANSOPRAZOLE APX; 02357690 LANSOPRAZOLE SAN; 02366282 LANSOPRAZOLE PDL; 02353849 MYLAN-LANSOPRAZOLE MYL; 02280523 NOVO-LANSOPRAZOLE TEV; 02165511 PREVACID TAK

LANSOPRAZOLE ODT

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.

Effective July 5, 2010, all proton pump inhibitors (open benefit and limited use (LU) PPIs) will have a maximum quantity limit of 400 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

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

15mg Orally Disintegrating Tablet: 02249464 PREVACID FASTAB TAK

30mg Orally Disintegrating Tablet: 02249472 PREVACID FASTAB TAK

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.

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

Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days.

10mg Delayed Release Tablet: 02230737 LOSEC AZC; 02260859 RATIO-OMEPRAZOLE RPH

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.

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

Limited use benefit (prior approval not required). Coverage will be limited to 400 tablets/capsules every 180 days.

10mg Capsule: 02119579 LOSEC AZC; 02329425 MYLAN-OMEPRAZOLE MYL; 02296438 SANDOZ OMEPRAZOLE SDZ

20mg Capsule: 02245058 APO-OMEPRAZOLE APX; 00846503 LOSEC AZC; 02329433 MYLAN-OMEPRAZOLE MYL; 02339927 OMEPRAZOLE PDL; 02348691 OMEPRAZOLE SAN; 02320851 PMS-OMEPRAZOLE PMS; 02296446 SANDOZ OMEPRAZOLE SDZ

20mg Delayed Release Tablet: 02190915 LOSEC AZC; 02310260 PMS-OMEPRAZOLE PMS; 02260867 RATIO-OMEPRAZOLE RPH

PANTOPRAZOLE MAGNESIUM

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.

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

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

40mg Enteric Coated Tablet: 02267233 TECTA NYC

PANTOPRAZOLE 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.

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

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

40mg Delayed Release Tablet: 02292920 APO-PANTOPRAZOLE APX; 02300486 CO PANTOPRAZOLE COB; 02299585 MYLAN-PANTOPRAZOLE MYL; 02285487 NOVO-PANTOPRAZOLE TEV; 02229453 PANTOLOC NYC; 02309866 PANTOPRAZOLE MEL; 02310201 PANTOPRAZOLE SOR; 02318695 PANTOPRAZOLE PDL; 02307871 PMS-PANTOPRAZOLE PMS; 02305046 RAN-PANTOPRAZOLE RBY; 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.

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

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

10mg Enteric Coated Tablet: 02296632 NOVO-RABEPRAZOLE TEV; 02243796 PARIET EC JNO; 02310805 PMS-RABEPRAZOLE PMS; 02315181 PRO-RABEPRAZOLE PDL; 02356511 RABEPRAZOLE EC SAN; 02298074 RAN-RABEPRAZOLE RBY; 02330083 RIVA-RABEPRAZOLE EC RIV; 02314177 SANDOZ-RABEPRAZOLE SDZ

20mg Enteric Coated Tablet: 02296640 NOVO-RABEPRAZOLE TEV; 02243797 PARIET EC JNO; 02310813 PMS-RABEPRAZOLE PMS; 02315203 PRO-RABEPRAZOLE PDL; 02356538 RABEPRAZOLE EC SAN; 02298082 RAN-RABEPRAZOLE RBY; 02330091 RIVA-RABEPRAZOLE RIV; 02314185 SANDOZ-RABEPRAZOLE SDZ

Top of Page

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.

2.6mg & 11.4mg Device: 02253186 NUVARING ORG

68:16.12 ESTROGEN AGONISTS-ANTAGONISTS

RALOXIFENE HCL

Limited use benefit (prior approval required).

For:

secondary prevention of osteoporosis in women who experience failure on bisphosphonates.
secondary prevention of osteoporosis in women who have a personal history or a first degree relative with a history of breast cancer.

60mg Tablet: 02279215 APO-RALOXIFENE APX; 02239028 EVISTA LIL; 02312298 NOVO-RALOXIFENE TEV; 02358921 PMS-RALOXIFENE PMS

68:20.04 BIGUANIDES

SITAGLIPTIN/METFORMIN

Limited use benefit (prior approval required).

Type 2 diabetes mellitus patients who are not adequately controlled by an adequate trial of metformin AND sulfonylureas or for whom these products are contraindicated or not tolerated

50mg & 1000mg Tablet: 02333872 JANUMET FRS

50mg & 500mg Tablet: 02333856 JANUMET FRS

50mg & 850mg Tablet: 02333864 JANUMET FRS

68:20.05

SITAGLIPTIN

Limited use benefit (prior approval required).

Type 2 diabetes mellitus patients who are not adequately controlled by an adequate trial of metformin AND sulfonylureas or for whom these products are contraindicated or not tolerated

100mg Tablet: 02303922 JANUVIA FRS

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: 02303442 ACCEL PIOGLITAZONE ACP; 02242572 ACTOS LIL; 02302942 APO-PIOGLITAZONE APX; 02302861 CO PIOGLITAZONE COB; 02307634 DOM-PIOGLITAZONE DPC; 02326477 MINT-PIOGLITAZONE MIN; 02298279 MYLAN-PIOGLITAZONE MYL; 02274914 NOVO-PIOGLITAZONE TEV; 02307669 PHL-PIOGLITAZONE PHH; 02303124 PMS-PIOGLITAZONE PMS; 02312050 PRO-PIOGLITAZONE PDL; 02301423 RATIO-PIOGLITAZONE RPH; 02297906 SANDOZ PIOGLITAZONE SDZ; 02320754 ZYM-PIOGLITAZONE ZYM

30mg Tablet: 02303450 ACCEL PIOGLITAZONE ACP; 02242573 ACTOS LIL; 02302950 APO-PIOGLITAZONE APX; 02302888 CO PIOGLITAZONE COB; 02307642 DOM-PIOGLITAZONE DPC; 02326485 MINT-PIOGLITAZONE MIN; 02298287 MYLAN-PIOGLITAZONE MYL; 02274922 NOVO-PIOGLITAZONE TEV; 02307677 PHL-PIOGLITAZONE PHH; 02303132 PMS-PIOGLITAZONE PMS; 02312069 PRO-PIOGLITAZONE PDL; 02301431 RATIO-PIOGLITAZONE RPH; 02297914 SANDOZ PIOGLITAZONE SDZ; 02320762 ZYM-PIOGLITAZONE ZYM

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.

45mg Tablet: 02303469 ACCEL PIOGLITAZONE ACP; 02242574 ACTOS LIL; 02302977 APO-PIOGLITAZONE APX; 02302896 CO PIOGLITAZONE COB; 02307650 DOM-PIOGLITAZONE DPC; 02326493 MINT-PIOGLITAZONE MIN; 02298295 MYLAN-PIOGLITAZONE MYL; 02274930 NOVO-PIOGLITAZONE TEV; 02307723 PHL-PIOGLITAZONE PHH; 02303140 PMS-PIOGLITAZONE PMS; 02312077 PRO-PIOGLITAZONE PDL; 02301458 RATIO-PIOGLITAZONE RPH; 02297922 SANDOZ PIOGLITAZONE SDZ; 02320770 ZYM-PIOGLITAZONE ZYM

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.

2mg Tablet: 02241112 AVANDIA GSK

4mg Tablet: 02241113 AVANDIA GSK

8mg Tablet: 02241114 AVANDIA GSK

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. OR For treatment of pain due to osteoporotic fractures of the vertebra in patients requiring an alternative pain reliever (eg. due to co-morbidities, intolerance to alternatives or severe pain not controlled by alternatives) for a period of 3 months

200IU/Dose Nasal Spray: 02247585 APO-CALCITONIN APX; 02240775 MIACALCIN NVR; 02261766 SANDOZ-CALCITONIN SDZ

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.

1% Cream: 02247238 ELIDEL NVC

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.

0.03% Ointment: 02244149 PROTOPIC AST

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.

0.1% Ointment: 02244148 PROTOPIC AST

86:00 SMOOTH MUSCLE RELAXANTS

86:12.00 GENITOURINARY SMOOTH MUSCLE RELAXANTS

DARIFENACIN HYDROBROMIDE

7.5mg Long Acting Tablet: 02273217 ENABLEX NVR

15mg Long Acting Tablet: 02273225 ENABLEX NVR

SOLIFENACIN SUCCINATE

Limited use benefit (prior approval required).

For symptomatic relief in patients with an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence in patients who have failed on or are intolerant of therapy with oxybutynin.

5mg Tablet: 02277263 VESICARE AST

10mg Tablet: 02277271 VESICARE AST

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.

2mg Extended Release Capsule: 02244612 DETROL LA PFI

4mg Extended Release Capsule: 02244613 DETROL LA PFI

1mg Tablet: 02239064 DETROL PFI

2mg Tablet: 02239065 DETROL PFI

TROSPIUM CHLORIDE

Limited use benefit (prior approval required).

20mg Tablet: 02275066 TROSEC ORY

Top of Page

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.

Drop: 00762946 POLY-VI-SOL MJO

Liquid: 00558079 INFANTOL HOR

Tablet: 80011134 CENTRUM JUNIOR COMPLETE PFI; 80020794 CENTRUM JUNIOR COMPLETE PFI; 02247975 FLINTSTONES EXTRA C BCD

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; 80005770 PRENATAL & POSTPARTUM PMT; 02241235 PRENATAL AND POSTPARTUM SDR

VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID

Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

Oral Liquid: 80008471 JAMP-MULTIVITAMIN A/D/C DROPS JMP

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

USTEKINUMAB

Limited use benefit (prior approval required).

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

Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region and
Intolerance or lack of response to methotrexate and cyclosporine or
A contraindication to methotrexate and/or cyclosporine and
Intolerance or lack of response to phototherapy or
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).

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

0.5mg Capsule: 02247813 AVODART GSK

FINASTERIDE

Limited use benefit (prior approval required).

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

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

92:16.00

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:

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

5mg Tablet: 02248727 APO-ALENDRONATE APX; 02288079 SANDOZ ALENDRONATE SDZ; 02248251 TEVA-ALENDRONATE TEV

10mg Tablet: 02248728 APO-ALENDRONATE APX; 02201011 FOSAMAX FRS; 02270129 MYLAN-ALENDRONATE MYL; 02288087 SANDOZ ALENDRONATE SDZ; 02247373 TEVA-ALENDRONATE TEV

40mg Tablet: 02258102 CO ALENDRONATE COB; 02201038 FOSAMAX FRS

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:

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

70mg/2800U Tablet: 02276429 FOSAVANCE FRS

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

RISEDRONATE SODIUM

Limited use benefit (prior approval required).

For the treatment of:

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

5mg Tablet: 02242518 ACTONEL PGP; 02298376 NOVO-RISEDRONATE TEV

30mg Tablet: 02239146 ACTONEL PGP; 02298384 NOVO-RISEDRONATE TEV

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).

Criteria for initial one year coverage:

Prescribed by a rheumatologist, AND
Patient has had a tuberculin skin test performed
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

Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years with moderate to severe active polyarticular JUVENILE IODIOPATHIC ARTHRITIS who have failed to respond to a trial of etanercept. Criteria will be confirmed against patient’s medication history.

Note: Initial 16-week coverage for juvenile idiopathic arthritis is provided at a dose of 10 mg/kg for children weighing < 75 kg; 750 mg for children weighing 75 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2, and 4 weeks, then every 4 weeks. Coverage beyond 16 weeks will be based on improvement in number of active joints, number of joints with loss of range of motion, ESR, Physician Global Assessment scale, Patient or Parent Global Assessment scale and Child Health Assessment Questionnaire.

250mg/Vial Injection: 02282097 ORENCIA BMS

ADALIMUMAB

Limited use benefit (prior approval required).

Criteria for initial one year coverage for a MAXIMUM dose of 40mg every 2 weeks:

Prescribed by a rheumatologist, AND
Patient has had a tuberculin skin test performed
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
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
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.
For the treatment of patients with moderate to severe PSORIASIS who meet all of the following criteria:
- Body surface area involvement greater than 10% and/or significant involvement of the face, hands, feet or genital region AND
- Intolerance or lack of response to methotrexate AND cyclosporine OR
- A contraindication to methotrexate and/or cyclosporine AND
- Intolerance or lack of response to phototherapy OR
- 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).
For the treatment of moderately to severely active CROHN'S DISEASE. Initial treatment 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;

40mg/Vial Injection: 02258595 HUMIRA ABB

ETANERCEPT

Limited use benefit (prior approval required).

Criteria for initial one year coverage for a MAXIMUM dose of 50mg weekly:

Prescribed by a rheumatologist, AND
Patient has had a tuberculin skin test performed
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
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
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.
For the treatment of severely active polyarticular JUVENILE IDIOPATHIC ARTHRITIS in children 4 to 17 years where the following criteria are met:
- ≥ 5 swollen joints; AND
- ≥ 3 joints with limited range of motion and/or pain/tenderness; AND
- Condition is refractory to an adequate trial of a therapeutic dose of methotrexate. An adequate trial is defined as at least 3 months of parenteral methotrexate at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)

25mg/Vial Injection: 02242903 ENBREL IMX

50mg/mL Injection: 02274728 ENBREL IMX; 99100373 ENBREL SURECLICK (QC) AMG

GOLIMUMAB

Limited use benefit (prior approval required).

Criteria for initial one year coverage for a MAXIMUM dose of 50 mg every month for RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS, ANKYLOSING SPONDYLITIS:

Prescribed by a rheumatologist, AND
Patient has had a tuberculin skin test performed AND
For the treatment of severely active RHEUMATOID ARTHRITIS:
- Patient is refractory to methotrexate weekly parenteral (SC or IM) at 20 mg 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 OR
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 OR
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.

50mg/0.5mL Injection: 02324784 SIMPONI AUTO INJECTOR JNO; 02324776 SIMPONI PRE-FILLED SYRINGE JNO

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.

100mg/Vial Injection: 02244016 REMICADE CEN

LEFLUNOMIDE

Limited use benefit (prior approval required).

For treatment of patients with rheumatoid arthritis who:

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.
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 AND

Prescribed by a rheumatologist AND
Patient has had a tuberculin skin test performed.

Note: Treatment should be combined with methotrexate or other DMARD. Tocilizumab should not be used in combination with anti-TNF agents.

80mg/4ml Injection: 02350092 ACTEMRA HLR

200mg/10ml Injection: 02350106 ACTEMRA HLR

400mg/20ml Injection: 02350114 ACTEMRA HLR

92:44.00

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

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

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

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:

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

100IU Injection: 01981501 BOTOX ALL

CLOSTRIDIUM BOTULINUM NEUROTOXIN

Limited use benefit (prior approval required). For:

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
the treatment of cervical dystonia (spasmodic torticollis)

100U/vial Injection: 02324032 XEOMIN MEZ

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Drug Benefit List 2012

08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES

LEVOFLOXACIN

08:12.24 TETRACYCLINES

MINOCYCLINE HCL

08:12.28 MISCELLANEOUS ANTIBIOTICS

LINEZOLID

08:14.08 AZOLES

VORICONAZOLE

08:18.08 ANTIRETROVIRALS

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

ETRAVIRINE

MARAVIROC

RALTEGRAVIR

TENOFOVIR DISOPROXIL FUMARATE

TIPRANAVIR

08:18.20 INTERFERONS

PEGINTERFERON ALFA-2A

PEGINTERFERON ALFA-2A, RIBAVIRIN

PEGINTERFERON ALFA-2B

PEGINTERFERON ALFA-2B, RIBAVIRIN

08:18.32 NUCLEOSIDES AND NUCLEOTIDES

ADEFOVIR DIPIVOXIL

ENTECAVIR

10:00 ANTINEOPLASTIC AGENTS

10:00.00 ANTINEOPLASTIC AGENTS

ERLOTINIB HYDROCLORIDE

IMATINIB MESYLATE

RITUXIMAB

SUNITINIB MALATE

TEMOZOLOMIDE

12:00 AUTONOMIC DRUGS

12:04.00 PARASYMPATHOMIMETIC AGENTS

DONEPEZIL HCL

GALANTAMINE

12:04.00 PARASYMPATHOMIMETIC AGENTS

RIVASTIGMINE

12:08.08 ANTIMUSCARINICS / ANTISPASMODICS

TIOTROPIUM BROMIDE MONOHYDRATE

12:12.08 BETA ADRENERGIC AGONISTS

FORMOTEROL FUMARATE

FORMOTEROL FUMARATE DIHYDRATE

FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE

SALMETEROL XINAFOATE

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS

CYCLOBENZAPRINE HCL

TIZANIDINE HCL

12:92.00 MISCELLANEOUS AUTONOMIC DRUGS

NICOTINE (GUM)

NICOTINE (INHALER)

NICOTINE (LOZENGE)

NICOTINE (PATCH)

VARENICLINE

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:12.04 ANTICOAGULANTS

RIVAROXABAN

20:12.18 PLATELET AGGREGATION INHIBITORS

CLOPIDOGREL BISULFATE

20:16.00 HEMATOPOIETIC AGENTS

PEGFILGRASTIM

24:00 CARDIOVASCULAR DRUGS

24:06.05 CHOLESTEROL ABSORPTION INHIBITORS

EZETIMIBE

24:12.12 PHOSPHODIESTERASE INHIBITORS

SILDENAFIL CITRATE

TADALAFIL

24:12.92 MISCELLANEOUS VASODILATING AGENTS

AMBRISENTAN

BOSENTAN

DIPYRIDAMOLE, ACETYLSALICYLIC ACID

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.04 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS