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First Nations & Inuit Health

Updates to the Drug Benefit List - Summer 2010

Warning This content was archived on June 24, 2013.

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The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First Nations and recognized Inuit throughout Canada.  Visit our Web Site

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" from the attending licensed practitioner. These requests are reviewed on a case by case basis.
Exclusions
Certain drug therapies for particular conditions fall outside the NIHB Program's mandate and will not be provided as benefits (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 does not apply to excluded drugs.

DIN (Drug Identification Number)
MFR (Three letter identification code assigned to manufacturer name)
ST (Short-term Dispensing Policy Drug)

Additions to the Drug Benefit List

Open Benefits

Single-Source Drug Products
DIN MFR Brand Name Effective Date
02332922 AZE STATACAND PLUS 32MG/12.5MG TABLET A10-08-2010
02332957 AZE STATACAND PLUS 32MG/25MG TABLET A10-08-2010
02338432 AJNO PREZISTA 75MG TABLET A09-07-2010
02279479 ASAC APIDRA 100UNIT/ML CARTRIDGE A04-08-2010
00762903 AMJO STTRI-VI-SOL DROPS A13-08-2010

 

Multi-Source Drug Products
DIN MFR Brand Name Effective Date
02280167 ODN ASATAB 80MG CHEWABLE TABLET 27-08-2010
80002703 ODN NU-CAL D 400MG TABLET  27-08-2010
02267217 WAC STASACOL 800MG TABLET 24-06-2010
02286246  SAN STACEBUTOLOL 100MG TABLET 25-08-2010
02286254 SAN STACEBUTOLOL 200MG TABLET  25-08-2010
02286262  SAN STACEBUTOLOL 400MG TABLET  25-08-2010
02286556 SAN ACYCLOVIR 200MG TABLET  25-08-2010
02286564 SAN ACYCLOVIR 400MG TABLET  25-08-2010
02286572 SAN ACYCLOVIR 800MG TABLET  25-08-2010
02342804  ZYM  STZYM-AMLODIPINE 10MG TABLET  25-05-2010
02342790  ZYM STZYM-AMLODIPINE 5MG TABLET  25-05-2010
02295261 APX STAPO-ATORVASTATIN 10MG TABLET 18-06-2010
02295288 APX  STAPO-ATORVASTATIN 20MG TABLET  18-06-2010
02295296  APX STAPO-ATORVASTATIN 40MG TABLET  18-06-2010
02295318  APX STAPO-ATORVASTATIN 80MG TABLET  18-06-2010
02348705 SAN STATORVASTATIN 10MG TABLET  09-08-2010
02348713 SAN STATORVASTATIN 20MG TABLET  09-08-2010
02348721  SAN STATORVASTATIN 40MG TABLET  09-08-2010
02348748 SAN STATORVASTATIN 80MG TABLET  09-08-2010
02310899  CBT  STCO ATORVASTATIN 10MG TABLET  18-06-2010
02310902 CBT  STCO ATORVASTATIN 20MG TABLET 18-06-2010
02310910  CBT  STCO ATORVASTATIN 40MG TABLET 18-06-2010
02310929  CBT STCO ATORVASTATIN 80MG TABLET 18-06-2010
02288346  PFI  STGD-ATORVASTATIN 10MG TABLET  18-06-2010
02288354 PFI STGD-ATORVASTATIN 20MG TABLET 18-06-2010
02288362 PFI STGD-ATORVASTATIN 40MG TABLET 18-06-2010
02288370 PFI STGD-ATORVASTATIN 80MG TABLET 18-06-2010
02302675  NOP  STNOVO-ATORVASTATIN 10MG TABLET 18-06-2010
02302683 NOP STNOVO-ATORVASTATIN 20MG TABLET  18-06-2010
02302691 NOP  STNOVO-ATORVASTATIN 40MG TABLET 18-06-2010
02302713  NOP STNOVO-ATORVASTATIN 80MG TABLET  18-06-2010
02313448  PMS  STPMS-ATORVASTATIN 10MG TABLET 18-06-2010
02313456 PMS STPMS-ATORVASTATIN 20MG TABLET  18-06-2010
02313464  PMS STPMS-ATORVASTATIN 40MG TABLET  18-06-2010
02313472 PMS STPMS-ATORVASTATIN 80MG TABLET 18-06-2010
02313707  RBY STRAN-ATORVASTATIN 10MG TABLET 18-06-2010
02313715 RBY  STRAN-ATORVASTATIN 20MG TABLET 18-06-2010
02313723 RBY STRAN-ATORVASTATIN 40MG TABLET  18-06-2010
02313758 RBY STRAN-ATORVASTATIN 80MG TABLET  18-06-2010
02350297  RPH STRATIO-ATORVASTATIN 10MG TABLET 18-06-2010
02350319 RPH  STRATIO-ATORVASTATIN 20MG TABLET  18-06-2010
02350327 RPH STRATIO-ATORVASTATIN 40MG TABLET  18-06-2010
02350335 RPH STRATIO-ATORVASTATIN 80MG TABLET 18-06-2010
02324946  SDZ STSANDOZ ATORVASTATIN 10MG TABLET  14-07-2010
02324954  SDZ  STSANDOZ ATORVASTATIN 20MG TABLET 14-07-2010
02324962  SDZ  STSANDOZ ATORVASTATIN 40MG TABLET 14-07-2010
02324970  SDZ  STSANDOZ ATORVASTATIN 80MG TABLET  14-07-2010
02330881  SAN AZITHROMYCIN 250MG TABLET  14-06-2010
02273411 ODN STBISACODYL-ODAN 5MG TABLET 24-08-2010
02338106 ZYM  STZYM-CARVEDILOL 12.5MG TABLET 25-05-2010
02338114  ZYM  STZYM-CARVEDILOL 25MG TABLET  25-05-2010
02338068 ZYM  STZYM-CARVEDILOL 3.125MG TABLET  25-05-2010
02338092 ZYM  STZYM-CARVEDILOL 6.25MG TABLET 25-05-2010
02306239  ODN CITALOPRAM-ODAN 4MG TABLET  27-08-2010
02306247 ODN  CITALOPRAM-ODAN 8MG TABLET 27-08-2010
02345676 ZYM ZYM-CLONAZEPAM 0.5MG TABLET  25-05-2010
02286092  SAN STFENOFIBRATE MICRO 200MG CAPSULE  25-08-2010
02248699 ODN  STFERODAN 300MG TABLET 25-05-2010
02287072 SAN STGLICLAZIDE 80MG TABLET 25-08-2010
02343096 SAN HYDROXYUREA 500MG CAPSULE  24-08-2010
02343029 SAN LAMOTRIGINE 100MG TABLET 25-08-2010
02343037 SAN LAMOTRIGINE 150MG TABLET  25-08-2010
02343010 SAN LAMOTRIGINE 25MG TABLET 25-08-2010
02348969  CBT LETROZOLE 2.5MG TABLET  28-05-2010
02347997  TEP  LETROZOLE 2.5MG TABLET 14-07-2010
02322315 GMP  MED-LETROZOLE 2.5MG TABLET 13-07-2010
02284707 APX APO-LEVOFLOXACIN 250MG TABLET 05-06-2010
02284715 APX APO-LEVOFLOXACIN 500MG TABLET 05-06-2010
02315424 CBT CO-LEVOFLOXACIN 250MG TABLET 05-07-2010
02315432 CBT CO-LEVOFLOXACIN 500MG TABLET 05-07-2010
02286920  DOM DOM-LEVOFLOXACIN 250MG TABLET  05-07-2010
02286939  DOM DOM-LEVOFLOXACIN 500MG TABLET 05-07-2010
02313979 GEN GEN-LEVOFLOXACIN 250MG TABLET  05-07-2010
02313987  GEN GEN-LEVOFLOXACIN 500MG TABLET  05-07-2010
02236841 JNO LEVAQUIN 250MG TABLET  05-07-2010
02236842 JNO  LEVAQUIN 500MG TABLET  05-07-2010
02307200  SOR  LEVOFLOXACIN 250MG TABLET 05-07-2010
02307219  SOR LEVOFLOXACIN 500MG TABLET 05-07-2010
02248262 NOP NOVO-LEVOFLOXACIN 250MG TABLET 05-07-2010
02248263  NOP NOVO-LEVOFLOXACIN 500MG TABLET 05-07-2010
02286947  PMI  PHL-LEVOFLOXACIN 250MG TABLET  05-07-2010
02286955  PMI PHL-LEVOFLOXACIN 500MG TABLET  05-07-2010
02284677  PMS PMS-LEVOFLOXACIN 250MG TABLET  05-07-2010
02284685  PMS  PMS-LEVOFLOXACIN 500MG TABLET  05-07-2010
02298635  SDZ SANDOZ LEVOFLOXACIN 250MG TABLET 05-07-2010
02298643  SDZ  SANDOZ LEVOFLOXACIN 500MG TABLET  05-07-2010
02280159  VTH STLORATADINE 10MG TABLET 12-08-2010
02248608 PMI  PHL-MELOXICAM 15MG TABLETB 25-05-2010
02248607 PMI  PHL-MELOXICAM 7.5MG TABLET 25-05-2010
02325179 ZYM ZYM-MIRTAZAPINE 15MG TABLET  27-05-2010
02325187  ZYM  ZYM-MIRTAZAPINE 30MG TABLET  27-05-2010
97799526  BTD BD AUTOSHIELD PEN NEEDLE 17-09-2010
97799527  BTD BD ULTRA-FINE NANO PEN NEEDLE 26-08-2010
97799543  UMI  ULTI 29GX1/2 INC SHARP CONTAINER  21-06-2010
97799545 UMI  ULTI 31GX1/4 INC SHARP CONTAINER 21-06-2010
97799544 UMI  ULTI 31GX5/16 INC SHARP CONTAINER  21-06-2010
02349167  MYL STMYLAN-NIFEDIPINE ER 30MG TABLET  18-05-2010
02325691  CBT CO OLANZAPINE 15MG TABLET 27-05-2010
02325659 CBT  CO OLANZAPINE 2.5MG TABLET  27-05-2010
02325713 CBT CO OLANZAPINE 20MG TABLET  27-05-2010
02325667 CBT  CO OLANZAPINE 5MG TABLET  27-05-2010
02325675  CBT CO OLANZAPINE 7.5MG TABLET 27-05-2010
02306212 ODN  ONDANSETRON-ODAN 4MG TABLET 27-08-2010
02306220  ODN ONDANSETRON-ODAN 8MG TABLET 27-08-2010
02344440 ZYM ZYM-ONDANSETRON 4MG TABLET 25-05-2010
02344459 ZYM  ZYM-ONDANSETRON 8MG TABLET  25-05-2010
02282844 SAN PAROXETINE 10MG TABLET 26-08-2010
02282852 SAN PAROXETINE 20MG TABLET  26-08-2010
02282860  SAN PAROXETINE 30MG TABLET 26-08-2010
09991007  WIL  POLYETHYLENE GLYCOL POWDER  07-06-2010
80004415  ODN  STODAN K-20 20MMOL LA TABLET 25-05-2010
02343053  SAN STPROPAFENONE 150MG TABLET  25-08-2010
02343061 SAN STPROPAFENONE 300MG TABLET 25-08-2010
02336480  RBY  RAN-RANITIDINE 150MG TABLET 24-08-2010
02336502 RBY  RAN-RANITIDINE 300MG TABLET  24-08-2010
02336715  APX  APO-RIVASTIGMINE 1.5MG TABLET  27-08-2010
02336723  APX  APO-RIVASTIGMINE 3MG TABLET  27-08-2010
02336731  APX  APO-RIVASTIGMINE 4.5MG TABLET  27-08-2010
02336758  APX  APO-RIVASTIGMINE 6MG TABLET  27-08-2010
02284731  SAN STSIMVASTATIN 10MG TABLET 25-08-2010
02284758 SAN STSIMVASTATIN 20MG TABLET  25-08-2010
02284766  SAN STSIMVASTATIN 40MG TABLET  25-08-2010
02284723 SAN STSIMVASTATIN 5MG TABLET  25-08-2010
02284774  SAN STSIMVASTATIN 80MG TABLET 25-08-2010
80000689 ODN  PHOSLAX ORAL LIQUID  24-08-2010
02286548 SAN SUMATRIPTAN 100MG TABLET  24-08-2010
02286513 SAN SUMATRIPTAN 25MG TABLET  24-08-2010
02286521 SAN SUMATRIPTAN 50MG TABLET  24-08-2010
97799509 UMI ULTI SYG WITH ULTIG 29G 1/2 INCH NEEDLE 21-06-2010
97799507  UMI  ULTI SYG WITH ULTIG 29G 1/2 INCH NEEDLE  21-06-2010
97799508  UMI  ULTI SYG WITH ULTIG 29G 1/2 INCH NEEDLE  21-06-2010
97799551 UMI ULTI SYG WITH ULTIG 30G 1/2 INCH NEEDLE 21-06-2010
97799550  UMI ULTI SYG WITH ULTIG 30G 1/2 INCH NEEDLE 21-06-2010
97799549  UMI  ULTI SYG WITH ULTIG 30G 1/2 INCH NEEDLE  21-06-2010
97799506 UMI  ULTI SYG WITH ULTIG 30G 5/16 INCH NEEDLE 21-06-2010
97799505  UMI  ULTI SYG WITH ULTIG 30G 5/16 INCH NEEDLE  21-06-2010
97799504 UMI ULTI SYG WITH ULTIG 30G 5/16 INCH NEEDLE  21-06-2010
97799546 UMI ULTI SYG WITH ULTIG 31G 5/16 INCH NEEDLE 21-06-2010
97799547  UMI ULTI SYG WITH ULTIG 31G 5/16 INCH NEEDLE  21-06-2010
97799548 UMI ULTI SYG WITH ULTIG 31G 5/16 INCH NEEDLE 21-06-2010
97799513  UMI ULTICARE 0.3CC 31G SYG 5/16 INCH NEEDLE  21-06-2010
97799518  UMI ULTICARE 0.5CC 28G SYG 1/2 INCH NEEDLE 21-06-2010
97799512  UMI ULTICARE 0.5CC 31G SYG 5/16 INCH NEEDLE 21-06-2010
97799511 UMI ULTICARE 1CC 31G SYG 5/16 INCH NEEDLE 21-06-2010
97799997 AUC ULTICARE INSULIN SYRINGE 29G.1CC 21-06-2010
97799999 AUC ULTICARE INSULIN SYRINGE 29G.3CC  21-06-2010
97799998 AUC ULTICARE INSULIN SYRINGE 29G.5CC  21-06-2010
97799994 AUC ULTICARE INSULIN SYRINGE 30G.1CC 21-06-2010
97799996  AUC ULTICARE INSULIN SYRINGE 30G.3CC  21-06-2010
97799995 AUC ULTICARE INSULIN SYRINGE 30G.5CC 21-06-2010
97799510  UMI  ULTICARE LOW DEAD SPACE SYRINGE 21-06-2010
97799906  AUC ULTIGUARD INSULIN SYRINGE 29G.1CC 21-06-2010
97799908 AUC  ULTIGUARD INSULIN SYRINGE 29G.3CC 21-06-2010
97799907  AUC  ULTIGUARD INSULIN SYRINGE 29G.5CC  21-06-2010
97799903  AUC ULTIGUARD INSULIN SYRINGE 30G.1CC  21-06-2010
97799905  AUC  ULTIGUARD INSULIN SYRINGE 30G.3CC  21-06-2010
97799904  AUC  ULTIGUARD INSULIN SYRINGE 30G.5CC  21-06-2010
09857334  RAT STRATIO-TAMSULOSIN 0.4MG ER CAPSULE 04-08-2010
02296039  PAL  STTAPAZOLE 10MG TABLET 29-06-2010
02343045 SAN STTICLOPIDINE 250MG TABLET 25-08-2010
02325144 ZYM  ZYM-TOPIRAMATE 100MG TABLET 18-05-2010
02325152 ZYM ZYM-TOPIRAMATE 200MG TABLET 18-05-2010
02325136  ZYM ZYM-TOPIRAMATE 25MG TABLET 18-05-2010
02351579 MYL MYLAN-VALACYCLOVIR 500MG TABLET  14-07-2010
02344114 SAN  WARFARIN 10MG TABLET 26-08-2010
02344025 SAN WARFARIN 1MG TABLET 26-08-2010
02344041 SAN  WARFARIN 2.5MG TABLET  26-08-2010
02344033  SAN WARFARIN 2MG TABLET  26-08-2010
02344068  SAN WARFARIN 3MG TABLET 26-08-2010
02344076 SAN WARFARIN 4MG TABLET 26-08-2010
02344084 SAN  WARFARIN 5MG TABLET 26-08-2010
02344092 SAN WARFARIN 6MG TABLET 26-08-2010

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New Limited Use Benefits

Multi-Source Drug Products
DIN MFR Brand Name Effective Date
02325373 PMS PMS-BUPROPION SR 100MG TABLET 14-06-2010

Limited use benefit (prior approval required).

For treatment of depression in patients unresponsive to or intolerant of other listed antidepressants. (Note: this product will not be approved for coverage for smoking cessation).

02341417  PMS PMS-FENTANYL MTX 100MCG/HR 28-06-2010
02341379  PMS PMS-FENTANYL MTX 12MCG/HR 28-06-2010
02341387  PMS PMS-FENTANYL MTX 25MCG/HR 28-06-2010
02341395 PMS  PMS-FENTANYL MTX 50MCG/HR 28-06-2010
02341409  PMS PMS-FENTANYL MTX 75MCG/HR   28-06-2010

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 product, such as morphine, hydromorphone and oxycodone, despite appropriate dose titration and adjunctive therapy including laxatives and antiemetics.

02348500  NOP STNOVO-FINASTERIDE 5MG TABLET 18-05-2010
02310112  PMS  STPMS-FINASTERIDE 5MG TABLET  18-05-2010
02306905 RPH  STRATIO-FINASTERIDE 5MG TABLET 18-05-2010

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-adrenergic blocker not sufficient.

02287234 SAN  MINOCYCLINE 100MG CAPSULE 26-08-2010
02287226 SAN MINOCYCLINE 50MG CAPSULE 26-08-2010

Limited use benefit (prior approval required).

For:

  1. patients who cannot tolerate other tetracyclines.
  2. patients with severe widespread acne who have failed on tetracycline.
02320754  ZYM STZYM-PIOGLITAZONE 15MG TABLET 23-06-2010
02320762  ZYM STZYM-PIOGLITAZONE 30MG TABLET 23-06-2010
02320770 ZYM STZYM-PIOGLITAZONE 45MG TABLET  23-06-2010

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

Not Added to Formulary

The following drugs will not be added to the NIHB Drug Benefit List:
DIN MFR ITEM NAME
02244126  LEO DOVOBET OINTMENT (CALCIPOTRIOL/BETAMETHASONE)
02331675 UCB CIMZIA 200MG/ML INJECTION (CERTOLIZUMAB)
02330989  SAC MULTAQ 400MG TABLET (DRONEDARONE)
02337282 JNO  JURNISTA 16MG TABLET (HYDROMORPHONE HYDROCHLORIDE)
02337290 JNO  JURNISTA 32MG TABLET (HYDROMORPHONE HYDROCHLORIDE)
02337266  JNO JURNISTA 4MG TABLET (HYDROMORPHONE HYDROCHLORIDE)
02337274 JNO JURNISTA 8MG TABLET (HYDROMORPHONE HYDROCHLORIDE)
02347156 BCM  VYVANSE 20MG CAPSULE (LISDEXAMPHETAMINE)
02322951  BCM VYVANSE 30MG CAPSULE (LISDEXAMPHETAMINE)
02347164 BCM  VYVANSE 40MG CAPSULE (LISDEXAMPHETAMINE)
02322978 BCM VYVANSE 50MG CAPSULE (LISDEXAMPHETAMINE)
02321114 BSH LOTEMAX 0.5% OPHTHALMIC SUSPENSION (LOTEPREDNOL ETABONATE)
02333554  BMS ONGLYZA 5MG TABLET (SAXAGLIPTIN)

 

The following indication will not be added to the NIHB Drug Benefit List:
DIN MFR BRAND NAME
02301881  FRS  ISENTRESS 40MG TABLET (RALTEGRAVIR)

For the treatment of treatment-naïve adults with HIV.


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Major Changes

Exclusion of Zopiclone

The status of zopiclone has been revised after consideration of it's clinical evidence and drug use trends, in consultation with the NIHB Program's Drug Use Evaluation Advisory Committee (DUEAC). Effective January 1, 2011, zopiclone will be an Exclusion under the NIHB Drug Program, and will no longer be reimbursed as a benefit. Clients who have received coverage for zopiclone since July 1, 2010, may, upon their physician's request,have zopiclone coverage extended for up to one year to allow sufficient time to find alternate therapy for insomnia.

Electronic Drug Submission Process

Please be advised that all submissions for products to be reviewed for inclusion on the NIHB Drug Benefit List, including copies of submissions reviewed by the Common Drug Review (CDR), must be sent to the NIHB Program electronically. Please send all drug submissions to the following email address: NIHB.Drug.Submissions@hc-sc.gc.ca

Only one (1) copy of the submission is required. Receipt of submission will be acknowledged electronically.

Revised Criteria for Orcencia

The limited use criteria for Orencia (abatacept) for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) has changed.Failure to respond to a trial of a tumour necrosis factor (TNF) alpha inhibitor (i.e., anti-TNF agent) is no longer required.

Change in DBL Publishing Date

Health Canada maintains an up-to-date NIHB drug benefit list of eligible drugs that are primarily used in a home or ambulatory setting. The drug benefit list indicates to prescribers and pharmacy providers which drug products are eligible NIHB benefits. It is a tool to encourage providers to select the most optimal and cost-effective drug therapy. Pharmacy providers should regularly review the list to ensure that they continue to be aware of the drug benefits included. The NIHB Drug Benefit List (DBL) has previously been published each year in April. Beginning January 2011, the DBL will beposted on our website annually, at the beginning of each calendar year.Changes made to the DBL during the year will continue to be communicated via quarterly NIHB DBL Updates. The NIHB DBL and DBL updates

Please note: the Drug Benefit List will no longer be printed and distributed in hardcopy. For your convience, a pdf version will be availble for printing on our website. If you are unable to access the Internet, you may contact the Provider Call Centre toll free at 1 888 511-4666.

Proton Pump Inhibitors Listing Change

Effective July 5, 2010, the NIHB Program listed the following proton pump inhibitors (PPIs) as limited use benefits with quantity and frequency limits. Prior approval is not required unless the quantity limit is exceeded. A maximum of 400 doses of PPIs every 180 days will be permitted. This quantity limit will begin on the date of the client's first claim for a PPI.

The following PPI's became limited use, prior approval not required:

Losec® 10mg capsules, including generics
Losec® 20mg capsules, including generics
Losec® 20mg tablets, including generics
Pariet® 10mg tablets, including generics
Pariet® 20mg tablets, including generics
Pantoloc® 40mg tablets, including generics
Prevacid® 15mg capsules, including generics
Prevacid® 30mg capsules, including generics

The following PPIs will remain limited use, prior approval required and are subject to the quantity limit:

Prevacid® Fastabs 15mg tablets
Prevacid® Fastabs 30mg tablets
Tecta® 40mg tablets
Losec® 10mg tablets, including generics

The following PPIs will remain exceptions and are subject to the quantity limit:

Losec® Mups 10mg tablets
Losec® Mups 20mg tablets

Revised Criteris and New Day Supply Limit for Oxycontin

The Limited Use criteria for the following items have been revised afterconsideration of their clinical evidence and drug use trends, in consultation with the NIHB Program's Drug Use Evaluation Advisory Committee (DUEAC).

  • OxyContin 5 mg tab (DIN 02258129)
  • OxyContin 10 mg tab (DIN 02202441)
  • OxyContin 15 mg tab (DIN 02323192)
  • OxyContin 20 mg tab (DIN 02202468)
  • OxyContin 30 mg tab (DIN 02323206)
  • OxyContin 40 mg tab (DIN 02202476)
  • OxyContin 60 mg tab (DIN 02323214)
  • OxyContin 80 mg tab (DIN 02202484)

Effective October 18, 2010, NIHB Program clients will be required to meet one of the revised criteria (below) before they will be considered for coverage of OxyContin:

Limited Use Benefit (Prior Approval Required):

  1. for the treatment of moderate to severe cancer pain in patients who cannot tolerate or who have failed treatment with at least one other long-acting opioid (such as sustained-release morphine or controlled-release hydromorphone) OR
  2. for the treatment of moderate to severe non-cancer chronic pain in patients who cannot tolerate or who have failed treatment with at least one other long-acting opioid (such as sustained-release morphine or controlled-release hydromorphone)

Additionally, the NIHB Program will introduce a day supply limit per dispense for OxyContin. Effective October 18, 2010, the maximum day supply limit per dispense for items listed above will be 30 days.


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Additions to the Short-Term Dispensing Policy Drug List

DIN ITEM NAME
02286246  ACEBUTOLOL 100MG TABLET
02286254 ACEBUTOLOL 200MG TABLET
02286262  ACEBUTOLOL 400MG TABLET
02295261 APO-ATORVASTATIN 10MG TABLET
02295288 APO-ATORVASTATIN 20MG TABLET
02295296  APO-ATORVASTATIN 40MG TABLET
02295318 APO-ATORVASTATIN 80MG TABLET
02267217 ASACOL 800MG TABLET
02332922 ATACAND PLUS 32MG/12.5MG TABLET
02332957  ATACAND PLUS 32MG/25MG TABLET
02348705  ATORVASTATIN 10MG TABLET
02348713  ATORVASTATIN 20MG TABLET
02348721  ATORVASTATIN 40MG TABLET
02348748  ATORVASTATIN 80MG TABLET
02273411 BISACODYL-ODAN 5MG TABLET
02310899  CO ATORVASTATIN 10MG TABLET
02310902  CO ATORVASTATIN 20MG TABLET
02310910  CO ATORVASTATIN 40MG TABLET
02310929 CO ATORVASTATIN 80MG TABLET
02286092  FENOFIBRATE MICRO 200MG CAPSULE
02248699  FERODAN 300MG TABLET
02288346  GD-ATORVASTATIN 10MG TABLET
02288354  GD-ATORVASTATIN 20MG TABLET
02288362 GD-ATORVASTATIN 40MG TABLET
02288370 GD-ATORVASTATIN 80MG TABLET
02287072  GLICLAZIDE 80MG TABLET
02280159 LORATADINE 10MG TABLET
02349167 MYLAN-NIFEDIPINE ER 30MG TABLET
02302675  NOVO-ATORVASTATIN 10MG TABLET
02302683  NOVO-ATORVASTATIN 20MG TABLET
02302691 NOVO-ATORVASTATIN 40MG TABLET
02302713 NOVO-ATORVASTATIN 80MG TABLET
02348500  NOVO-FINASTERIDE 5MG TABLET
80004415  ODAN K-20 20MMOL LA TABLET
02313448  PMS-ATORVASTATIN 10MG TABLET
02313456  PMS-ATORVASTATIN 20MG TABLET
02313464  PMS-ATORVASTATIN 40MG TABLET
02313472 PMS-ATORVASTATIN 80MG TABLET
02310112  PMS-FINASTERIDE 5MG TABLET
02343053 PROPAFENONE 150MG TABLET
02343061 PROPAFENONE 300MG TABLET
02313707  RAN-ATORVASTATIN 10MG TABLET
02313715  RAN-ATORVASTATIN 20MG TABLET
02313723  RAN-ATORVASTATIN 40MG TABLET
02313758  RAN-ATORVASTATIN 80MG TAB
02350297  RATIO-ATORVASTATIN 10MG TABLET
02350319  RATIO-ATORVASTATIN 20MG TABLET
02350327 RATIO-ATORVASTATIN 40MG TABLET
02350335 RATIO-ATORVASTATIN 80MG TABLET
02306905 RATIO-FINASTERIDE 5MG TABLET
09857334  RATIO-TAMSULOSIN 0.4MG ER CAPSULE
02324946 SANDOZ ATORVASTATIN 10MG TABLET
02324954  SANDOZ ATORVASTATIN 20MG TABLET
02324962 SANDOZ ATORVASTATIN 40MG TABLET
02324970 SANDOZ ATORVASTATIN 80MG TABLET
02284731 SIMVASTATIN 10MG TABLET
02284758  SIMVASTATIN 20MG TABLET
02284766  SIMVASTATIN 40MG TABLET
02284723 SIMVASTATIN 5MG TABLET
02284774  SIMVASTATIN 80MG TABLET
02296039  TAPAZOLE 10MG TABLET
02343045  TICLOPIDINE 250MG TABLET
00762903  TRI-VI-SOL DROPS
02342804  ZYM-AMLODIPINE 10MG TABLET
02342790 ZYM-AMLODIPINE 5MG TABLET
02338106 ZYM-CARVEDILOL 12.5MG TABLET
02338114 ZYM-CARVEDILOL 25MG TABLET
02338068 ZYM-CARVEDILOL 3.125MG TABLET
02338092  ZYM-CARVEDILOL 6.25MG TABLET
02320754 ZYM-PIOGLITAZONE 15MG TABLET
02320762 ZYM-PIOGLITAZONE 30MG TABLET
02320770  ZYM-PIOGLITAZONE 45MG TABLET
Date Modified: 2010-10-07

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