08:00 Anti-Infective Agents

IVERMECTIN

MEBENDAZOLE

PYRANTEL PAMOATE

AMIKACIN SULFATE

Limited use benefit (prior approval required).

GENTAMICIN SULFATE

TOBRAMYCIN

CEFADROXIL

CEFAZOLIN SODIUM

CEFIXIME

CEFPROZIL

CEFTAZIDIME

Limited use benefit (prior approval required).

CEFTRIAXONE SODIUM

CEFUROXIME AXETIL

CEPHALEXIN

AZTREONAM

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients if the following criteria are met:

• patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
• prescribed by a clinician with experience in the diagnosis and treatment of CF.

ERTAPENEM

Limited use benefit (prior approval required).

MEROPENEM

Limited use benefit (prior approval required).

AZITHROMYCIN

CLARITHROMYCIN

ERYTHROMYCIN

ERYTHROMYCIN STEARATE

FIDAXOMICIN

Limited use benefit (prior approval required).

For the treatment of confirmed severe* Clostridium Difficile infection (CDI); and

• fidaxomicin has been prescribed or recommended by an infectious disease specialist or gastroenterologist; and
• there is a documented allergy (immune-mediated reaction) or severe intolerance to oral vancomycin resulting in discontinuation of vancomycin.
• or
• after an unsuccessful but adequate** trial of oral vancomycin; and
• retreatment with vancomycin is not an option***; and
• the patient is at a high risk of hospitalization due to severe complications; and
• fidaxomicin is being used as monotherapy.

Notes:

*. Severe infection is defined as having any of the following symptoms: white blood cell count > 15,000 mm3 and fever; acute kidney injury with rising serum creatinine ≥ 1.5 times premorbid level or ≥ 175 micromoles/L; pseudomembranous colitis, hypotension, shock or megacolon.

**. An adequate trial of oral vancomycin is considered to be at least 10 days of therapy with a dose of at least 125mg four times daily.

***. Retreatment with fidaxomicin in recurrent CDI will be considered in symptomatic patients who require treatment of a previously resolved CDI episode. This is defined as a subsequent CDI episode occurring within 2 to 8 weeks of a previous episode from the date of diagnosis.

AMOXICILLIN

AMOXICILLIN, CLAVULANIC ACID

AMPICILLIN

CLOXACILLIN SODIUM

PENICILLIN G BENZATHINE

PENICILLIN G POTASSIUM

PENICILLIN G SODIUM

PENICILLIN V POTASSIUM

PIPERACILLIN, TAZOBACTAM

Limited use benefit (prior approval required).

CIPROFLOXACIN HYDROCHLORIDE

LEVOFLOXACIN HEMIHYDRATE

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 day lockout.

LEVOFLOXACIN HEMIHYDRATE (QUINSAIR)

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients 18 years or older if the following criteria are met:

• patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
• prescribed by a clinician with experience in the diagnosis and treatment of CF; and
• patient has had a previous trial of tobramycin by inhalation that has been ineffective or not tolerated or tobramycin is contraindicated; and
• patient is not using another inhaled antibiotic(s) to treat pulmonary P. aeruginosa infections, either concurrently or for antibiotic cycling during off-treatment periods.

Note: NIHB coverage is limited to 240 mg twice daily in cycles of 28 days on followed by 28 days off.

MOXIFLOXACIN HYDROCHLORIDE

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 day lockout.

NORFLOXACIN

SULFAMETHOXAZOLE, TRIMETHOPRIM

SULFASALAZINE

DOXYCYCLINE HYCLATE

MINOCYCLINE HYDROCHLORIDE

TETRACYCLINE HYDROCHLORIDE

CLINDAMYCIN HYDROCHLORIDE

CLINDAMYCIN PALMITATE HYDROCHLORIDE

CLINDAMYCIN PHOSPHATE

COLISTIN

Limited use benefit (prior approval required).

For the management of cystic fibrosis (CF) in patients if the following criteria are met:

• patient has CF with chronic pulmonary Pseudomonas aeruginosa infections; and
• prescribed by a clinician with experience in the diagnosis and treatment of CF.

LINEZOLID

Limited use benefit (prior approval required).

Tablets:

• for treatment of proven vancomycin-resistant enterococci (VRE) infections; or
• for the treatment of proven methicillin-resistant staphylococcus aureus (MRSA) infections in patients who cannot tolerate vancomycin.

I.V. solution:

• when linezolid cannot be administered orally in the above mentioned situations.

Oral liquid:

• when linezolid cannot be administered orally in the above mentioned situations;
• plus at least one of the following:
• for treatment of proven vancomycin-resistant enterococci (VRE) infections
• for the treatment of proven methicillin-resistant staphylococcus aureus (MRSA) infections in patients who cannot tolerate vancomycin.

RIFAXIMIN

Limited use benefit (prior approval required).

For reducing the risk of overt hepatic encephalopathy (HE) recurrence in patients:

• who are unable to achieve adequate control of HE recurrence with a maximal tolerated dose of lactulose alone; and
• when used in combination with a maximal tolerated dose of lactulose.

VANCOMYCIN HYDROCHLORIDE

Limited use benefit (prior approval required).

Used for the treatment of patients diagnosed with symptomatic Clostridium difficile infection.

Note: Oral vancomycin is not appropriate for systemic infections due to poor absorption from the GI tract.

VANCOMYCIN HYDROCHLORIDE (INJECTION)

TERBINAFINE HYDROCHLORIDE

FLUCONAZOLE

ISAVUCONAZOLE (ISAVUCONAZONIUM SULFATE)

Limited use benefit (prior approval required).

For the treatment of invasive mucormycosis (IM) in adults; or

For the treatment of invasive aspergillosis (IA) in adults when treatment with oral voriconazole has failed; or

Documented intolerance or contraindication to voriconazole.

Cresemba is to be prescribed by or in consultation with an Infectious Disease specialist.

ITRACONAZOLE

KETOCONAZOLE

VORICONAZOLE

Limited use benefit (prior approval required).

For the treatment of patients with invasive aspergillosis; or

For the treatment of culture proven invasive candidiasis with documented resistance to fluconazole.

NYSTATIN

ETHAMBUTOL HYDROCHLORIDE

ISONIAZID

PYRAZINAMIDE

RIFABUTIN

RIFAMPIN

DAPSONE

AMANTADINE HYDROCHLORIDE

ABACAVIR SUFLATE, LAMIVUDINE

ABACAVIR SULFATE

ABACAVIR SULFATE, LAMIVUDINE

ABACAVIR SULFATE, LAMIVUDINE, DOLUTEGRAVIR SODIUM

ABACAVIR SULFATE, LAMIVUDINE, ZIDOVUDINE

ATAZANAVIR SULFATE

DARUNAVIR

DARUNAVIR (DARUNAVIR PROPYLENE GLYCOLATE)

DARUNAVIR ETHANOLATE

DARUNAVIR ETHANOLATE, COBICISTAT

DOLUTEGRAVIR SODIUM

DOLUTEGRAVIR SODIUM, RILPIVIRINE HYDROCHLORIDE

DORAVIRINE

EFAVIRENZ

EFAVIRENZ, EMTRICITABINE, TENOFOVIR DISOPROXIL FUMARATE

EMTRICITABINE, BICTEGRAVIR (BICTEGRAVIR SODIUM), TENOFOVIR ALAFENAMIDE

EMTRICITABINE, COBICISTAT, ELVITEGRAVIR, TENOFOVIR ALAFENAMIDE

EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE, TENOFOVIR ALAFENAMIDE

ETRAVIRINE

FOSAMPRENAVIR CALCIUM

LAMIVUDINE

LAMIVUDINE, DOLUTEGRAVIR SODIUM

LAMIVUDINE, TENOFOVIR DISOPROXIL FUMARATE, DORAVIRINE

LAMIVUDINE, ZIDOVUDINE

LOPINAVIR, RITONAVIR

MARAVIROC

NELFINAVIR MESYLATE

NEVIRAPINE

RALTEGRAVIR POTASSIUM

RILPIVIRINE HYDROCHLORIDE

RITONAVIR

SAQUINAVIR MESYLATE

TENOFOVIR DISOPROXIL FUMARATE

Limited use benefit (prior approval required).

For the treatment of patients with HIV-1 infection who have failed or have experienced adverse events to an alternative agent; or

For the treatment of patients with chronic hepatitis B infection who have cirrhosis documented on radiologic or histologic grounds and a HBV concentration above 2,000 IU/mL.

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, COBICISTAT, ELVITEGRAVIR

TENOFOVIR DISOPROXIL FUMARATE, EMTRICITABINE, RILPIVIRINE HYDROCHLORIDE

TIPRANAVIR

ZIDOVUDINE

INTERFERON ALFA-2B

PEGINTERFERON ALFA-2A

Limited use benefit (prior approval required).

For the treatment of patients with chronic hepatitis B infection who have a HBV DNA concentration above 2,000 IU/mL without decompensated cirrhosis, upon the written request of a hepatologist or other specialist in this area.

PEGINTERFERON ALFA-2B, RIBAVIRIN

Limited use benefit (prior approval required).

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

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

PEGINTERFERON BETA-1A

Limited use benefit (prior approval required).

As a first-line therapy for the treatment of relapsing remitting multiple sclerosis (RRMS) diagnosed according to the 2017 McDonald clinical criteria and magnetic resonance imaging (MRI) evidence, when prescribed by a neurologist experienced in the management of RRMS.

And for patients who meet all of the following criteria:

• patient has had a clinical relapse and/or new MRI activity in the last two years; and
• patient is fully ambulatory for 100 meters without aids; and
• patient is 18 years of age or older.

OSELTAMIVIR

ACYCLOVIR

ADEFOVIR DIPIVOXIL

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of ≥ 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

ENTECAVIR MONOHYDRATE

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.

FAMCICLOVIR

GANCICLOVIR SODIUM

VALACYCLOVIR HYDROCHLORIDE

VALGANCICLOVIR HYDROCHLORIDE

ELBASVIR, GRAZOPREVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

• treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
• laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

GLECAPREVIR, PIBRENTASVIR

Limited use benefit (prior approval required).

For treatment-naïve or treatment-experienced adult patients with genotypes 1, 2, 3, 4, 5, 6 with; or

For the treatment of direct acting antivirals (DAA)-experienced2 adult patients with genotype 1 with:

• chronic hepatitis C at any fibrosis stage (F0-F4); and
• detectable levels of HCV RNA in the last 12 months;

For genotypes 1, 2, 3, 4, 5 or 6, treatment-experienced is defined as a patient who has been previously treated with interferon, peginterferon (P), ribavirin (R) and/or sofosbuvir (SOF) (PR, SOF + PR, SOF + RBV), but no prior treatment experience with an NS3/4A protease inhibitor or NS5A inhibitor.

• For genotype 1, DAA treatment-experienced is defined as a patient who has been previously treated with DAA regimens containing NS5A inhibitor [daclatasvir (DCV) + SOF or DCV + PR or ledipasvir/sofosbuvir, but no prior treatment experience with NS3/4A protease inhibitors] or containing NS3/4A protease inhibitors [simeprevir+SOF or simeprevir+PR or boceprevir+PR or telaprevir+PR, but no prior treatment experience with an NS5Ainhibitor].

RIBAVIRIN

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

• treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
• laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

SOFOSBUVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

• treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
• laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

SOFOSBUVIR, LEDIPASVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

• treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
• laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

SOFOSBUVIR, VELPATASVIR

Limited use benefit (prior approval required).

For adult patients with chronic hepatitis C infection at any fibrosis stage (F0-F4) who meet all of the following criteria:

• treatment is prescribed by a hepatologist, gastroenterologist, or infectious disease specialist (or other prescriber experienced in treating patients with chronic hepatitis C); and
• laboratory confirmed quantitative HCV RNA level taken in the last 12 months;

Retreatment for failure or re-infection in patients who have received an adequate prior course of direct-acting antivirals will be considered on a case-by-case basis.

SOFOSBUVIR, VELPATASVIR, VOXILAPREVIR

Limited use benefit (prior approval required).

For treatment-experienced adult patients with:

• chronic hepatitis C at any fibrosis stage (F0-F4); and
• detectable levels of HCV RNA in the last 12 months;
• and
• treatment-experienced having failed a prior therapy with an HCV regimen containing:
• NS5A inhibitor: daclatasvir (Daklinza), elbasvir (part of Zepatier), ledipasvir (part of Harvoni), ombitasvir (part of Holkira Pak ), velpatasvir (part of Epclusa ) for genotype 1, 2, 3, 4, 5 or 6; or
• sofosbuvir (Sovaldi) without an NS5A inhibitor for genotype 1, 2, 3 or 4.

PAROMOMYCIN SULFATE

CHLOROQUINE PHOSPHATE

HYDROXYCHLOROQUINE SULFATE

PRIMAQUINE PHOSPHATE

ATOVAQUONE

METRONIDAZOLE

FOSFOMYCIN TROMETHAMINE

NITROFURANTOIN

TRIMETHOPRIM