Updates to the Drug Benefit List - Winter 2008/2009

• Additions to the Drug Benefit List
  • Open Benefits
  • New Limited Use Benefits
• Addition of Alzheimer's Medication to the Drug Benefit List
• New Indications
• Not Added to Formulary
• Drug Discontinued by the Manufacturer
• Status Change for Proton Pump Inhibitors
• Palliative Care Formulary
• Manufacturer Changes
• Name Changes

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Benefit Definitions

Open Benefits

Open benefits are the drugs listed in the NIHB Drug Benefit List (DBL) which do not have established criteria or prior approval requirements.

Limited Use Benefits

Limited use drugs are those that have been found to be effective in specific circumstances, or which have quantity and frequency limitations. For drugs in this category, specific criteria must be met to be eligible for coverage.

Not Added To Formulary

Drugs not added to formulary are those which are not listed in the NIHB DBL after review by the national Common Drug Review (CDR) process and/or the Federal Pharmacy and Therapeutics Committee (FP&T). These drugs will not be added to the NIHB drug list because published evidence does not support the clinical value or cost of the drug relative to existing therapies. Coverage may be considered in special circumstances upon receipt of a completed "Exception Drugs Request Form". These requests are reviewed on a case by case basis.

Exclusions

Certain drug therapies for particular conditions fall outside of the NIHB mandate and will not be provided as benefits under the NIHB Program (e.g., cosmetic and anti-obesity drugs). As well, certain drugs will be excluded from the NIHB Program as recommended by the CDR and the FP&T because published evidence does not support the clinical value, safety or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.

Note: The appeal process and the emergency supply policy will not apply to excluded drugs.

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Additions to the Drug Benefit List

Open Benefits

Single-Source Drug Products

DIN	MFR	BRAND NAME	Effective date
02312301	ABB	KALETRA 100MG/25MG TABLET	08/01/2009
02318008	ALC	TRAVATAN Z 0.004% OPTH SOL	08/01/2009

Multi-Source Drug Products

DIN	MFR	BRAND NAME	Effective date
00510696	APX	APO-ASEN ECT 325MG TABLET	21/10/2008
02291037	APX	APO-DILTIAZ TZ 120MG ER CAPSULE	06/10/2008
02291045	APX	APO-DILTIAZ TZ 180MG ER CAPSULE	06/10/2008
02291053	APX	APO-DILTIAZ TZ 240MG ER CAPSULE	06/10/2008
02291061	APX	APO-DILTIAZ TZ 300MG ER CAPSULE	06/10/2008
02291088	APX	APO-DILTIAZ TZ 360MG ER CAPSULE	06/10/2008
02293358	APX	APO-GABAPENTIN 600MG TABLET	03/09/2008
02293358	APX	APO-GABAPENTIN 600MG TABLET	03/09/2008
02293366	APX	APO-GABAPENTIN 800MG TABLET	03/09/2008
02291967	APX	APO-ONDASETRON 4MG/5ML OL	27/08/2008
02313928	APX	APO-QUETIAPINE 100MG TABLET	06/10/2008
02313936	APX	APO-QUETIAPINE 200MG TABLET	06/10/2008
02313901	APX	APO-QUETIAPINE 25MG TABLET	06/10/2008
02313944	APX	APO-QUETIAPINE 300MG TABLET	06/10/2008
02290812	APX	APO-TIMOP 0.5% OP GEL	17/11/2008
02316099	CBT	CO-QUETIAPINE 100MG TABLET	06/10/2008
02316110	CBT	CO-QUETIAPINE 200MG TABLET	06/10/2008
02316080	CBT	CO-QUETIAPINE 25MG TABLET	06/10/2008
02316129	CBT	CO-QUETIAPINE 300MG TABLET	06/10/2008
00472476	APX	ENTERIC COATED ASA 650MG TABLET	21/10/2008
02297868	GEN	GEN-ODANSETRON 4MG TABLET	01/11/2008
02307812	CBT	GEN-QUETIAPINE 100MG TABLET	08/10/2008
02307839	CBT	GEN-QUETIAPINE 200MG TABLET	08/10/2008
02307804	CBT	GEN-QUETIAPINE 25MG TABLET	08/10/2008
02307847	CBT	GEN-QUETIAPINE 300MG TABLET	08/10/2008
02301156	GEN	GEN-RAMIPRIL 1.25MG CAPSULE	10/09/2008
02301148	GEN	GEN-RAMIPRIL 1.25MG CAPSULE	10/09/2008
02301172	GEN	GEN-RAMIPRIL 10MG CAPSULE	10/09/2008
02301164	GEN	GEN-RAMIPRIL 5MG CAPSULE	10/09/2008
02301148	GEN	GEN-RAMPIRIL 1.25MG CAPSULE	10/09/2008
02301172	GEN	GEN-RAMPIRIL 10MG CAPSULE	10/09/2008
02301156	GEN	GEN-RAMPIRIL 2.5MG CAPSULE	10/09/2008
02301164	GEN	GEN-RAMPIRIL 5MG CAPSULE	10/09/2008
02310295	GEN	GEN-VENLAFAXINE XR 150MG CAPSULE	06/10/2008
02310279	GEN	GEN-VENLAFAXINE XR 37.5MG CAPSULE	06/10/2008
02310287	GEN	GEN-VENLAFAXINE XR 75MG CAPSULE	06/10/2008
02313405	JAP	JAMP-CITALOPRAM 20MG TABLET	24/10/2008
02313413	JAP	JAMP-CITALOPRAM 40MG TABLET	24/10/2008
02305259	MIN	MINT-ODANSETRON 4MG TABLET	24/10/2008
02305267	MIN	MINT-ODANSETRON 8MG TABLET	24/10/2008
02315653	MIN	MINT-TOPIRAMATE 100MG TABLET	06/01/2009
02315661	MIN	MINT-TOPIRAMATE 200MG TABLET	06/01/2009
02315645	MIN	MINT-TOPIRAMATE 25MG TABLET	06/01/2009
02284243	NOP	NOVO-QUETIAPINE 100MG TABLET	26/09/2008
02284251	NOP	NOVO-QUETIAPINE 150MG TABLET	26/09/2008
02284278	NOP	NOVO-QUETIAPINE 200MG TABLET	26/09/2008
02284235	NOP	NOVO-QUETIAPINE 25MG TABLET	26/09/2008
02284226	NOP	NOVO-QUETIAPINE 300MG TABLET	26/09/2008
02315963	PMS	PMS-CETIRIZINE 20MG TABLET	24/10/2008
02302624	PMS	PMS-DICLOFENAC 25MG DR TABLET	10/09/2008
02302616	PMS	PMS-DICLOFENAC 25MG DR TABLET	10/09/2008
02302616	PMS	PMS-DICLOFENAC 25MG DR TABLET	10/09/2008
02302624	PMS	PMS-DICLOFENAC 50MG DR TABLET	10/09/2008
00836133	PMS	PMS-IBUPROFEN 400MG TABLET	10/09/2008
00836133	PMS	PMS-IBUPROFEN 400MG TABLET	10/10/2008
00839264	PMS	PMS-IBUPROFEN 600MG TABLET	10/09/2008
00839264	PMS	PMS-IBUPROFEN 600MG TABLET	10/09/2008
02296578	PMS	PMS-QUETIAPINE 100MG TABLET	23/09/2008
02296594	PMS	PMS-QUETIAPINE 200MG TABLET	23/09/2008
02296551	PMS	PMS-QUETIAPINE 25MG TABLET	23/09/2008
02296608	PMS	PMS-QUETIAPINE 300MG TABLET	23/09/2008
02312085	PMS	PMS-TOPIRAMATE 50MG TABLET	08/01/2009
02312247	RBY	RAN-ODANSETRON 4MG TABLET	24/10/2008
02312255	RBY	RAN-ODANSETRON 8MG TABLET	24/10/2008
02310503	RBY	RAN-RAMIPRIL 1.25MG CAPSULE	08/10/2008
02310546	RBY	RAN-RAMIPRIL 10MG CAPSULE	08/10/2008
02310511	RBY	RAN-RAMIPRIL 2.5MG CAPSULE	08/10/2008
02310538	RBY	RAN-RAMIPRIL 5MG CAPSULE	08/10/2008
02311712	RAT	RATIO-QUETIAPINE 100MG TABLET	23/09/2008
02311747	RAT	RATIO-QUETIAPINE 200MG TABLET	23/09/2008
02311704	RAT	RATIO-QUETIAPINE 25MG TABLET	23/09/2008
02311755	RAT	RATIO-QUETIAPINE 300MG TABLET	23/09/2008
02303361	RIV	RIVA-FLUVOX 100MG TABLET	24/10/2008
02315327	RIV	RIVA-METOPROLOL-L 100MG TABLET	24/11/2008
02315300	RIV	RIVA-METOPROLOL-L 25MG TABLET	24/11/2008
02315319	RIV	RIVA-METOPROLOL-L 50MG TABLET	24/11/2008
02299364	RIV	RIVA-OXYBUTYNIN 5MG TABLET	24/10/2008
02316706	RIV	RIVA-QUETIAPINE 100MG TABLET	07/01/2009
02316722	RIV	RIVA-QUETIAPINE 200MG TABLET	07/01/2009
02316692	RIV	RIVA-QUETIAPINE 25MG TABLET	07/01/2009
02316730	RIV	RIVA-QUETIAPINE 300MG TABLET	07/01/2009
02316447	RIV	RIVA-VALACYCLOVIR 500MG CAPLET	06/01/2009
02266539	SDZ	SANDOZ-CLARITHROMYCIN 250MG TABLET	26/09/2008
02266547	SDZ	SANDOZ-CLARITHROMYCIN 500MG TABLET	26/09/2008
02261936	SDZ	SANDOZ-DICLOFENAC 100MG SUPPOSITORIES	26/11/2008
02261928	SDZ	SANDOZ-DICLOFENAC 50MG SUPPOSITORIES	26/11/2008
02315262	SDZ	SANDOZ-PRAMIPEXOLE 0.25MG TABLET	24/11/2008
02315270	SDZ	SANDOZ-PRAMIPEXOLE 0.5MG TABLET	24/11/2008
02315289	SDZ	SANDOZ-PRAMIPEXOLE 1.0MG TABLET	24/11/2008
02315297	SDZ	SANDOZ-PRAMIPEXOLE 1.5MG TABLET	24/11/2008
02314002	SDZ	SANDOZ-QUETIAPINE 100MG TABLET	23/09/2008
02314010	SDZ	SANDOZ-QUETIAPINE 200MG TABLET	23/09/2008
02313995	SDZ	SANDOZ-QUETIAPINE 25MG TABLET	23/09/2008
02314029	SDZ	SANDOZ-QUETIAPINE 300MG TABLET	23/09/2008
02314177	SDZ	SANDOZ-RABEPRAZOLE 10MG EC TABLET	10/09/2008
02314185	SDZ	SANDOZ-RABEPRAZOLE 20MG EC TABLET	10/09/2008

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New Limited Use Benefits

Single-Source Drug Products

DIN	MFR	BRAND NAME	Effective date
02298805	FRS	EMEND 125MG CAPSULE	19/11/2008
02298791	FRS	EMEND 80MG CAPSULE	19/11/2008
02298813	FRS	EMEND TRIPACK	19/11/2008

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.

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Multi-Source Drug Products

DIN	MFR	BRAND NAME	Effective date
02315866	APX	APO-ALFUZOSIN ER 10MG TABLET	15/10/2008
02304678	SDZ	SANDOZ-ALFUZOSIN 10MG TABLET	24/10/2008

Prior approval required.

For treatment of Benihn Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to other alpha-adrenergic blockers.

DIN	MFR	BRAND NAME	Effective date
02301334	APX	APO-BRIMONIDINE P 0.15% OPHTH SOLUTION	15/10/2008

Prior approval required.

For patients who are intolerant to brimonidine tartrate 0.2% or benzalkonium chloride.

DIN	MFR	BRAND NAME	Effective date
02313421	PMS	PMS-BUPROPION SR 150MG TABLET	23/10/2008

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).

DIN	MFR	BRAND NAME	Effective date
02316463	RIV	RIVA-PANTOPRAZOLE 40MG EC TABLET	06/01/2009

See "Status Change for Proton Pump Inhibitors"                 

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Addition of Alzheimer's Medication to the Drug Benefit List

DIN	MFR	BRAND NAME	Effective date
02232044	PFI	ARICEPT 10MG TABLET	22/12/2008
02232043	PFI	ARICEPT 5MG TABLET	22/12/2008
02242115	NOV	EXELON 1.5MG CAPSULE	22/12/2008
02242116	NOV	EXELON 3MG CAPSULE	22/12/2008
02242117	NOV	EXELON 4.5MG CAPSULE	22/12/2008
02242118	NOV	EXELON 6MG CAPSULE	22/12/2008
02245240	NOV	EXELON ORAL SOLUTION	22/12/2008
02266725	JNO	REMINYL ER 16MG CAPSULE	22/12/2008
02266733	JNO	REMINYL ER 24MG CAPSULE	22/12/2008
02266717	JNO	REMINYL ER 8MG CAPSULE	22/12/2008

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)

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New Indications

The following indications will be added to the NIHB Drug Benefit List:

DIN	MFR	BRAND NAME	Effective date
02242903	IMX	ENBREL 25MG INJECTION	08/12/2008
02274728	IMX	ENBREL 50MG INJECTION	08/12/2008
02258595	ABB	HUMIRA 40MG/0.8ML INJECTION	08/12/2008

Indication(s): RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND ANKYLOSING SPONDYLITIS

Prior approval required.

Criteria for initial one year coverage for a MAXIMUM dose of 50mg weekly for etanercept and a MAXIMUM dose of 40mg every 2 weeks for adalimumab:

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.

DIN	MFR	BRAND NAME	Effective date
02258595	ABB	HUMIRA 40MG/0.8ML INJECTION	08/12/2008

Indication(s): CROHN'S DISEASE

Prior approval required.

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.

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Not Added to Formulary

The following drug products will not be added to the NIHB Drug Benefit List:

DIN	MFR	BRAND NAME
02308444	APX	PIPERACILLIN/TAZOBACTAM 2G/0.25G VIAL
02318452	APX	PIPERACILLIN/TAZOBACTAM 3G/0.375G VIAL
02308460	APX	PIPERACILLIN/TAZOBACTAM 4G/0.5G VIAL

Drugs Discontinued by the Manufacturer

DIN	MFR	BRAND NAME
00265489	VAE	C.E.S  1.25MG TABLET
02097389	BPC	CARDIZEM 60MG TABLET
00344877	BMS	CYTOXAN 25MG TABLET
00426539	VAE	DUONALE 70% SOLUTION
02243529	NOV	ESTALIS-SEQUI PATCH
02243530	NOV	ESTALIS-SEQUI PATCH
01999788	BMS	KENALOG IN ORABASE 0.1% OINTMENT
00514217	VAE	M.O.S 5MG/ML SYRUP
02221950	SAC	SURGAM 300MG TABLET
01914006	BMS	SYMMETREL 100MG CAPSULE
00894710	JNO	TERAZOL 3 80MG OVULES
01926497	SAC	VITAMIN A ACID 0.01% CREAM
01926500	SAC	VITAMIN A ACID 0.025% CREAM
01926519	SAC	VITAMIN A ACID 0.05% CREAM
01926527	SAC	VITAMIN A ACID 0.1% CREAM
00294853	VAE	VITAMIN B1 100MG TABLET
00263958	VAE	VITAMIN B6 100MG TABLET
00268607	VAE	VITAMIN B6 25MG TABLET
02237824	BPC	WELLBUTRIN SR 100MG TABLET

Status Change for Proton Pump Inhibitors

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

DIN	MFR	BRAND NAME	Effective date
02245058	APO	APO-OMEPRAZOLE 20MG CAPSULE	01/04/2009
02292920	APO	APO-PANTOPRAZOLE 40MG TABLET	01/04/2009
02300486	COB	CO-PANTOPRAZOLE 40MG TABLET	01/04/2009
02299585	GEN	GEN-PANTOPRAZOLE 40MG TABLET	01/04/2009
02119579	AZE	LOSEC 10MG CAPSULE	01/04/2009
02230737	AZE	LOSEC 10MG TABLET	01/04/2009
00846503	AZE	LOSEC 20MG CAPSULE	01/04/2009
02190915	AZE	LOSEC 20MG SR TABLET	01/04/2009
02285487	NOV	NOVO-PANTOPRAZOLE 40MG TABLET	01/04/2009
02296632	NOV	NOVO-RABEPRAZOLE 10MG TABLET	01/04/2009
02296640	NOV	NOVO-RABEPRAZOLE 20MG TABLET	01/04/2009
02229453	NYD	PANTOLOC 40MG TABLET	01/04/2009
02243796	JNO	PARIET 10MG TABLET	01/04/2009
02243797	JNO	PARIET 20MG TABLET	01/04/2009
02307871	PMS	PMS-PANTOPRAZOLE 40MG TABLET	01/04/2009
02310805	PMS	PMS-RABEPRAZOLE 10MG TABLET	01/04/2009
02310813	PMS	PMS-RABPERAZOLE 20MG TABLET	01/04/2009
02165503	TAK	PREVACID 15MG CAPSULE	01/04/2009
02165511	TAK	PREVACID 30MG CAPSULE	01/04/2009
02305046	RAN	RAN-PANTOPRAZOLE 40MG TABLET	01/04/2009
02298074	RAN	RAN-RABEPRAZOLE 10MG TABLET	01/04/2009
02298082	RAN	RAN-RABEPRAZOLE 20MG TABLET	01/04/2009
02260859	RAT	RATIO-OMEPRAZOLE 10MG TABLET	01/04/2009
02260867	RAT	RATIO-OMEPRAZOLE 20MG SR TABLET	01/04/2009
02308703	RAT	RATIO-PANTOPRAZOLE 40MG TABLET	01/04/2009
02296438	SDZ	SANDOZ-OMEPRAZOLE 10MG CAPSULE	01/04/2009
02296446	SDZ	SANDOZ-OMEPRAZOLE 20MG CAPSULE	01/04/2009
02301083	SDZ	SANDOZ-PANTOPRAZOLE 40MG TABLET	01/04/2009
02314177	SDZ	SANDOZ-RABEPRAZOLE 10MG TABLET	01/04/2009
02314185	SDZ	SANDOZ-RABEPRAZOLE 20MG TABLET	01/04/2009

Product	Benefit Status Effective April 1, 2009
Pariet 10mg Tablet, including generics	LU with quantity and frequency limit, PA* not required**
Pariet 20mg Tablet, including generics	LU with quantity and frequency limit, PA* not required**
Losec 10mg Capsule	LU with quantity and frequency limit, PA* not required**
Losec 20mg Capsule, including generics	LU with quantity and frequency limit, PA* not required**
Losec 20mg Tablet, including generics	LU with quantity and frequency limit, PA* not required**
Losec 10mg Tablet	LU with quantity and frequency limit, PA* required
Pantoloc 40mg Tablet, including generics	LU with quantity and frequency limit, PA* required
Prevacid 15mg Capsule	LU with quantity and frequency limit, PA* required
Prevacid 30mg Capsule	LU with quantity and frequency limit, PA* required

*PA: Prior approval
**Prior approval is not required unless the quantity limit is exceeded

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 following proton pump inhibitors 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.

Pariet 10mg, including generics
Pariet 20mg, including generics
Losec 20mg tablets, including generics
Losec 20mg capsules, including generics
Losec 10mg capsules, including generics

Effective April 1, 2009, the limited use criteria for Pantoloc (40mg tablets), Prevacid (15mg and 30mg capsules) and Losec 10mg tablets will be;

Limited use drug status (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

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Palliative Care Formulary

Effective April 1, 2009, recipients diagnosed with a terminal illness and who are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the NIHB Drug Benefit List. The Palliative Care Formulary includes medications used to provide comfort to those near the end of life. These include:

DIN	BRAND NAME	Effective date
00960624	ATROPINE SULPHATE 0.4MG/ML INJECTION	01/04/2009
00392782	ATROPINE SULPHATE 0.4MG/ML INJECTION	01/04/2009
00467231	ATROPINE SULPHATE 0.4MG/ML INJECTION	01/04/2009
00467258	ATROPINE SULPHATE 0.6MG/ML INJECTION	01/04/2009
00012076	ATROPINE SULPHATE 0.6MG/ML INJECTION	01/04/2009
00392693	ATROPINE SULPHATE 0.6MG/ML INJECTION	01/04/2009
00363839	BUSCOPAN 20MG/ML INJECTION	01/04/2009
02065614	DIAZEMULS 5MG/ML INJECTION	01/04/2009
00399728	DIAZEPAM 5MG.ML INJECTION	01/04/2009
01937413	DURAGESIC 100MCG PATCH	01/04/2009
02280345	DURAGESIC 12MCG PATCH	01/04/2009
01937383	DURAGESIC 25MCG PATCH	01/04/2009
01937391	DURAGESIC 50MCG PATCH	01/04/2009
01937405	DURAGESIC 75MCG PATCH	01/04/2009
00888346	FENTANYL CITRATE 0.05MG/ML INJECTION	01/04/2009
02240234	FENTANYL CITRATE 0.05MG/ML INJECTION	01/04/2009
02126648	FENTANYL CITRATE 0.05MG/ML INJECTION	01/04/2009
02039508	GLYCOPYRROLATE 0.2MG/ML INJECTION	01/04/2009
02229868	HYOSCINE 20MG/ML INJECTION	01/04/2009
02243278	LORAZEPAM 4MG/ML INJECTION	01/04/2009
02185431	METOCLOPRIMIDE 5MG/ML INJECTION	01/04/2009
02243563	METOCLOPRIMIDE OMEGA 5MG/ML INJECTION	01/04/2009
02240285	MIDAZOLAM 1MG/ML INJECTION	01/04/2009
02243934	MIDAZOLAM 1MG/ML INJECTION	01/04/2009
02242904	MIDAZOLAM 1MG/ML INJECTION	01/04/2009
02242905	MIDAZOLAM 5MG/ML INJECTION	01/04/2009
02240286	MIDAZOLAM 5MG/ML INJECTION	01/04/2009
02243935	MIDAZOLAM 5MG/ML INJECTION	01/04/2009
01927698	NOZINAN 25MG/ML INJECTION	01/04/2009
02249448	RAN FENTANYL 100MCG PATCH	01/04/2009
02249421	RAN FENTANYL 75MCG PATCH	01/04/2009
02249391	RAN-FENTANYL 25MCG PATCH	01/04/2009
02249413	RAN-FENTANYL 50MCG PATCH	01/04/2009
02282984	RATIO-FENTANYL 100MCG PATCH	01/04/2009
02311925	RATIO-FENTANYL 12MCG PATCH	01/04/2009
02282941	RATIO-FENTANYL 25MCG PATCH	01/04/2009
02282968	RATIO-FENTANYL 50MCG PATCH	01/04/2009
02282976	RATIO-FENTANYL 75MCG PATCH	01/04/2009
00541869	SCOPOLAMINE HYDROBROMIDE 0.4MG/ML INJECTION	01/04/2009
00541877	SCOPOLAMINE HYDROBROMIDE 0.6MG/ML INJECTION	01/04/2009

Requests for any of the above DINs will generate a Palliative Care Application Form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:

The recipient:

1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility and
2. has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less

Once approved, the recipient will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another Palliative Care Application Form completed.

Please note: During the six month coverage period, a maximum 30 day supply will be reimbursed at any one time.

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Manufacturer Changes

DIN	BRAND NAME	OLD MFR	NEW MFR
00705438	DILAUDID 1MG TABLET	ABB	PFR
00786535	DILAUDID 1MG/ML ORAL LIQUID	ABB	PFR
00125083	DILAUDID 2MG TABLET	ABB	PFR
00627100	DILAUDID 2MG/ML INJECTION, USP	ABB	PFR
00125103	DILAUDID 3MG SUPPOSITORIES	ABB	PFR
02145863	DILAUDID XP 50MG/ML INJECTION	ABB	PFR
00622133	DILAUDID-HP 10MG/ML INJECTION	ABB	PFR
02146118	DILAUDID-HP PLUS 20MG/ML INJECTION	ABB	PFR
02264374	EUTHYROX 100MCG TABLET	GEN	SRO
02264390	EUTHYROX 112MCG TABLET	GEN	SRO
02264404	EUTHYROX 125MCG TABLET	GEN	SRO
02264412	EUTHYROX 137MCG TABLET	GEN	SRO
02264420	EUTHYROX 150MCG TABLET	GEN	SRO
02264439	EUTHYROX 175MCG TABLET	GEN	SRO
02264447	EUTHYROX 200MCG TABLET	GEN	SRO
02264323	EUTHYROX 25MCG TABLET	GEN	SRO
02264455	EUTHYROX 300MCG TABLET	GEN	SRO
02264331	EUTHYROX 50MCG TABLET	GEN	SRO
02264358	EUTHYROX 75MCG TABLET	GEN	SRO
02264366	EUTHYROX 88MCG TABLET	GEN	SRO

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Name Changes

DIN	MFR	OLD BRAND NAME	NEW BRAND NAME
44123038	BAY	ASCENSIA BREEZE 2 BG TEST STRIPS	BREEZE 2 BLOOD GLUCOSE TEST STRIPS
44123037	BAY	ASCENSIA CONTOUR BG TEST STRIPS	CONTOUR BLOOD GLUCOSE TEST
02299372	RIV	PMS-RAMIPRIL 1.25MG CAPSULE	RAMIPRIL 1.25MG CAPSULE
02255332	RIV	PMS-RAMIPRIL 10MG CAPSULE	RAMIPRIL 10MG CAPSULE
02255316	RIV	PMS-RAMIPRIL 2.5MG CAPSULE	RAMIPRIL 2.5MG CAPSULE
02255324	RIV	PMS-RAMIPRIL 5MG CAPSULE	RAMIPRIL 5MG CAPSULE