12:00 Autonomic Drugs
12:04.00 PARASYMPATHOMIMETIC AGENTS
BETHANECHOL CHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
10MG Tablet | 01947958 | DUVOID | PAL |
25MG Tablet | 01947931 | DUVOID | PAL |
50MG Tablet | 01947923 | DUVOID | PAL |
DONEPEZIL HYDROCHLORIDE
Limited use benefit (prior approval required).
Initial 12 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; or
- Montreal Cognitive Assessment (MoCA) score of 10-26, established within the last 60 days; or
- Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days.
Continued coverage beyond 12 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every 12 month interval:
- clinically meaningful response as determined by stabilization or improvement while on therapy; and
- Alzheimer's disease has not progressed to GDS stage 7 or MMSE or MoCA less than 10.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST5MG Tablet | 02362260 | APO-DONEPEZIL | APX |
ST5MG Tablet | 02232043 | ARICEPT | PFI |
ST5MG Tablet | 02400561 | AURO-DONEPEZIL | AUR |
ST5MG Tablet | 02412853 | BIO-DONEPEZIL | BMI |
ST5MG Tablet | 02402645 | DONEPEZIL | ACC |
ST5MG Tablet | 02416417 | DONEPEZIL | PDL |
ST5MG Tablet | 02420597 | DONEPEZIL | SIV |
ST5MG Tablet | 02426846 | DONEPEZIL | SAN |
5MG Tablet | 02475278 | DONEPEZIL | RIV |
ST5MG Tablet | 02416948 | JAMP-DONEPEZIL | JMP |
ST5MG Tablet | 02402092 | MAR-DONEPEZIL | MAR |
5MG Tablet | 02467453 | M-DONEPEZIL | MAN |
5MG Tablet | 02408600 | MINT-DONEPEZIL | MIN |
ST5MG Tablet | 02439557 | NAT-DONEPEZIL | NPH |
ST5MG Tablet | 02322331 | PMS-DONEPEZIL | PMS |
ST5MG Tablet | 02328666 | SANDOZ DONEPEZIL | SDZ |
ST5MG Tablet | 02428482 | SEPTA DONEPEZIL | SPT |
ST5MG Tablet | 02381508 | TARO-DONEPEZIL | SUN |
ST5MG Tablet | 02340607 | TEVA-DONEPEZIL | TEV |
ST10MG Tablet | 02362279 | APO-DONEPEZIL | APX |
ST10MG Tablet | 02232044 | ARICEPT | PFI |
ST10MG Tablet | 02400588 | AURO-DONEPEZIL | AUR |
ST10MG Tablet | 02412861 | BIO-DONEPEZIL | BMI |
ST10MG Tablet | 02402653 | DONEPEZIL | ACC |
ST10MG Tablet | 02416425 | DONEPEZIL | PDL |
ST10MG Tablet | 02420600 | DONEPEZIL | SIV |
ST10MG Tablet | 02426854 | DONEPEZIL | SAN |
10MG Tablet | 02475286 | DONEPEZIL | RIV |
ST10MG Tablet | 02416956 | JAMP-DONEPEZIL | JMP |
ST10MG Tablet | 02402106 | MAR-DONEPEZIL | MAR |
10MG Tablet | 02467461 | M-DONEPEZIL | MAN |
10MG Tablet | 02408619 | MINT-DONEPEZIL | MIN |
ST10MG Tablet | 02439565 | NAT-DONEPEZIL | NPH |
ST10MG Tablet | 02322358 | PMS-DONEPEZIL | PMS |
ST10MG Tablet | 02328682 | SANDOZ DONEPEZIL | SDZ |
ST10MG Tablet | 02428490 | SEPTA DONEPEZIL | SPT |
ST10MG Tablet | 02381516 | TARO-DONEPEZIL | SUN |
ST10MG Tablet | 02340615 | TEVA-DONEPEZIL | TEV |
GALANTAMINE HYDROBROMIDE
Limited use benefit (prior approval required).
Initial 12 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; or
- Montreal Cognitive Assessment (MoCA) score of 10-26, established within the last 60 days; or
- Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days.
Continued coverage beyond 12 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every 12 month interval:
- clinically meaningful response as determined by stabilization or improvement while on therapy; and
- Alzheimer's disease has not progressed to GDS stage 7 or MMSE or MoCA less than 10.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST8MG Capsule (Extended Release) | 02425157 | AURO-GALANTAMINE ER | AUR |
ST8MG Capsule (Extended Release) | 02443015 | GALANTAMINE | SAN |
ST8MG Capsule (Extended Release) | 02416573 | GALANTAMINE ER | PDL |
ST8MG Capsule (Extended Release) | 02420821 | MAR-GALANTAMINE ER | MAR |
ST8MG Capsule (Extended Release) | 02339439 | MYLAN-GALANTAMINE ER | MYL |
ST8MG Capsule (Extended Release) | 02316943 | PAT-GALANTAMINE ER | JSO |
ST8MG Capsule (Extended Release) | 02398370 | PMS-GALANTAMINE ER | PMS |
ST16MG Capsule (Extended Release) | 02425165 | AURO-GALANTAMINE ER | AUR |
ST16MG Capsule (Extended Release) | 02443023 | GALANTAMINE | SAN |
ST16MG Capsule (Extended Release) | 02416581 | GALANTAMINE ER | PDL |
ST16MG Capsule (Extended Release) | 02420848 | MAR-GALANTAMINE ER | MAR |
ST16MG Capsule (Extended Release) | 02339447 | MYLAN-GALANTAMINE ER | MYL |
ST16MG Capsule (Extended Release) | 02316951 | PAT-GALANTAMINE ER | JSO |
ST16MG Capsule (Extended Release) | 02398389 | PMS-GALANTAMINE ER | PMS |
ST24MG Capsule (Extended Release) | 02425173 | AURO-GALANTAMINE ER | AUR |
ST24MG Capsule (Extended Release) | 02443031 | GALANTAMINE | SAN |
ST24MG Capsule (Extended Release) | 02416603 | GALANTAMINE ER | PDL |
ST24MG Capsule (Extended Release) | 02420856 | MAR-GALANTAMINE ER | MAR |
ST24MG Capsule (Extended Release) | 02339455 | MYLAN-GALANTAMINE ER | MYL |
ST24MG Capsule (Extended Release) | 02316978 | PAT-GALANTAMINE ER | JSO |
ST24MG Capsule (Extended Release) | 02398397 | PMS-GALANTAMINE ER | PMS |
NEOSTIGMINE BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST15MG Tablet | 00869945 | PROSTIGMIN | VAE |
PILOCARPINE HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST5MG Tablet | 02402483 | PILOCARPINE HYDROCHLORIDE | RAX |
ST5MG Tablet | 02216345 | SALAGEN | AMD |
PYRIDOSTIGMINE BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST60MG Tablet | 00869961 | MESTINON | BSH |
ST180MG Tablet (Extended Release) | 00869953 | MESTINON-SR | BSH |
RIVASTIGMINE HYDROGEN TARTRATE
Limited use benefit (prior approval required).
Initial 12 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; or
- Montreal Cognitive Assessment (MoCA) score of 10-26, established within the last 60 days; or
- Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days.
Continued coverage beyond 12 months will be based on improvement or stabilization of cognition, function or behaviour.
Criteria for coverage at every 12 month interval:
- clinically meaningful response as determined by stabilization or improvement while on therapy; and
- Alzheimer's disease has not progressed to GDS stage 7 or MMSE or MoCA less than 10.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST1.5MG Capsule | 02336715 | APO-RIVASTIGMINE | APX |
ST1.5MG Capsule | 02242115 | EXELON | NVR |
ST1.5MG Capsule | 02485362 | JAMP RIVASTIGMINE | JMP |
ST1.5MG Capsule | 02401614 | MED-RIVASTIGMINE | GMP |
ST1.5MG Capsule | 02306034 | PMS-RIVASTIGMINE | PMS |
ST1.5MG Capsule | 02416999 | RIVASTIGMINE | PDL |
ST1.5MG Capsule | 02324563 | SANDOZ RIVASTIGMINE | SDZ |
ST3MG Capsule | 02336723 | APO-RIVASTIGMINE | APX |
ST3MG Capsule | 02242116 | EXELON | NVR |
ST3MG Capsule | 02485370 | JAMP RIVASTIGMINE | JMP |
ST3MG Capsule | 02401622 | MED-RIVASTIGMINE | GMP |
ST3MG Capsule | 02306042 | PMS-RIVASTIGMINE | PMS |
ST3MG Capsule | 02417006 | RIVASTIGMINE | PDL |
ST3MG Capsule | 02324571 | SANDOZ RIVASTIGMINE | SDZ |
ST4.5MG Capsule | 02336731 | APO-RIVASTIGMINE | APX |
ST4.5MG Capsule | 02242117 | EXELON | NVR |
ST4.5MG Capsule | 02485389 | JAMP RIVASTIGMINE | JMP |
ST4.5MG Capsule | 02401630 | MED-RIVASTIGMINE | GMP |
ST4.5MG Capsule | 02306050 | PMS-RIVASTIGMINE | PMS |
ST4.5MG Capsule | 02417014 | RIVASTIGMINE | PDL |
ST4.5MG Capsule | 02324598 | SANDOZ RIVASTIGMINE | SDZ |
ST6MG Capsule | 02336758 | APO-RIVASTIGMINE | APX |
ST6MG Capsule | 02242118 | EXELON | NVR |
ST6MG Capsule | 02485397 | JAMP RIVASTIGMINE | JMP |
ST6MG Capsule | 02401649 | MED-RIVASTIGMINE | GMP |
ST6MG Capsule | 02306069 | PMS-RIVASTIGMINE | PMS |
ST6MG Capsule | 02417022 | RIVASTIGMINE | PDL |
ST6MG Capsule | 02324601 | SANDOZ RIVASTIGMINE | SDZ |
ST2MG/ML Solution | 02245240 | EXELON | NVR |
12:08.08 ANTIMUSCARINICS / ANTISPASMODICS
ACLIDINIUM BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
400MCG Powder | 02409720 | TUDORZA GENUAIR | AZC |
GLYCOPYRRONIUM BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
50MCG Capsule | 02394936 | SEEBRI BREEZHALER | NVR |
HYOSCINE BUTYLBROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST10MG Tablet | 00363812 | BUSCOPAN | SAC |
INDACATEROL MALEATE, GLYCOPYRRONIUM BROMIDE
Open benefit (prior approval is not required).
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry or standardized scale*; and
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA)
*As defined by the Canadian Thoracic Society COPD classification. 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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
110MCG & 50MCG Capsule | 02418282 | ULTIBRO BREEZHALER | NVR |
IPRATROPIUM BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
20MCG/INHALATION Aerosol | 02247686 | ATROVENT HFA | BOE |
0.03% Nasal Spray | 02240508 | DOM-IPRATROPIUM | DPC |
0.03% Nasal Spray | 02239627 | PMS-IPRATROPIUM | PMS |
21MCG Nasal Spray | 02246083 | IPRAVENT | AAP |
42MCG Nasal Spray | 02246084 | IPRAVENT | AAP |
125MCG/ML Solution | 02231135 | PMS-IPRATROPIUM | PMS |
250MCG/ML Solution | 02126222 | APO-IPRAVENT | APX |
250MCG/ML Solution | 02231136 | PMS-IPRATROPIUM | PMS |
250MCG/ML Solution | 02231244 | PMS-IPRATROPIUM | PMS |
250MCG/ML Solution | 02231245 | PMS-IPRATROPIUM | PMS |
250MCG/ML Solution | 99001446 | RATIO-IPRATROPIUM | RPH |
250MCG/ML Solution | 02216221 | TEVA-IPRATROPIUM STERINEBS | TEV |
IPRATROPIUM BROMIDE, SALBUTAMOL SULFATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.2MG & 1MG/ML Solution | 02272695 | TEVA-COMBO STERINEBS | TEV |
100MCG & 20MCG Solution | 02419106 | COMBIVENT RESPIMAT | BOE |
TIOTROPIUM BROMIDE MONOHYDRATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
18MCG Capsule | 02246793 | SPIRIVA | BOE |
2.5MCG Solution | 02435381 | SPIRIVA RESPIMAT | BOE |
TRIMEBUTINE MALEATE
Limited use benefit (prior approval required).
For the treatment and relief of symptoms associated with functional bowel disorders including Irritable Bowel Syndrome (IBS), spastic colon, spastic colitis and mucous colitis; or
In postoperative paralytic ileus in order to accelerate the resumption of the intestinal transit following abdominal surgery.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
100MG Tablet | 02349027 | AA-TRIMEBUTINE | AAP |
100MG Tablet | 02245663 | TRIMEBUTINE | AAP |
200MG Tablet | 02349035 | AA-TRIMEBUTINE | AAP |
200MG Tablet | 02245664 | TRIMEBUTINE | AAP |
UMECLIDINIUM BROMIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
62.5MCG Powder | 02423596 | INCRUSE ELLIPTA | GSK |
UMECLIDINIUM BROMIDE, VILANTEROL TRIFENATATE
Open benefit (prior approval is not required).
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry or standardized scale*; and
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA)
*As defined by the Canadian Thoracic Society COPD classification. 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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
62.5MCG/25MCG Powder | 02418401 | ANORO ELLIPTA | GSK |
12:12.04 ALPHA ADRENERGIC AGONISTS
MIDODRINE HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
2.5MG Tablet | 02278677 | APO-MIDODRINE | APX |
2.5MG Tablet | 02473984 | MAR-MIDODRINE | MAR |
5MG Tablet | 02278685 | APO-MIDODRINE | APX |
5MG Tablet | 02473992 | MAR-MIDODRINE | MAR |
12:12.08 BETA ADRENERGIC AGONISTS
ACLIDINIUM BROMIDE, FORMOTEROL FUMARATE DIHYDRATE
Open benefit with (prior approval is not required).
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry or standardized scale*; and
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA)
*As defined by the Canadian Thoracic Society COPD classification. 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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
400MCG & 12MCG Powder | 02439530 | DUAKLIR GENUAIR | AZC |
FLUTICASONE FUROATE, VILANTEROL TRIFENATATE
Limited use benefit (prior approval required).
For the treatment of asthma in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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.
or
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry; or
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA).
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
100MCG & 25MCG Powder | 02408872 | BREO ELLIPTA | GSK |
FLUTICASONE FUROATE, VILANTEROL TRIFENATATE (ASTHMA)
Limited use benefit (prior approval required).
For the treatment of asthma in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
200MCG & 25MCG Powder | 02444186 | BREO ELLIPTA | GSK |
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; or
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
12MCG/CAPSULE Capsule | 02230898 | 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, short duration bronchodilator.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
6MCG/DOSE Powder | 02237225 | OXEZE TURBUHALER | AZC |
12MCG/DOSE Powder | 02237224 | OXEZE TURBUHALER | AZC |
FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE
Limited use benefit (prior approval required).
For the treatment of asthma in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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; or
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry; or
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA).
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
6MCG & 100MCG/INHALATION Powder | 02245385 | SYMBICORT 100 TURBUHALER | AZC |
6MCG & 200MCG/INHALATION Powder | 02245386 | SYMBICORT 200 TURBUHALER | AZC |
FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATE
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, short duration bronchodilator.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
5MCG & 100MCG/INHALATION Aerosol | 02361752 | ZENHALE | FRS |
5MCG & 200MCG/INHALATION Aerosol | 02361760 | ZENHALE | FRS |
5MCG & 50MCG/INHALATION Aerosol | 02361744 | ZENHALE | FRS |
INDACATEROL MALEATE
Limited use benefit (prior approval required).
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who:
- are not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist; or
- have moderate to severe COPD, as defined by spirometry.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
75MCG Capsule | 02376938 | ONBREZ BREEZHALER | NVR |
OLODATEROL HYDROCHLORIDE, TIOTROPIUM BROMIDE MONOHYDRATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
2.5MCG & 2.5MCG Solution | 02441888 | INSPIOLTO RESPIMAT | BOE |
ORCIPRENALINE SULFATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
2MG/ML Syrup | 02236783 | ORCIPRENALINE | AAP |
SALBUTAMOL SULFATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
100MCG/INHALATION Aerosol | 02232570 | AIROMIR | VAE |
100MCG/INHALATION Aerosol | 02245669 | APO-SALBUTAMOL HFA | APX |
100MCG/INHALATION Aerosol | 02419858 | SALBUTAMOL HFA | SAN |
100MCG/INHALATION Aerosol | 02326450 | TEVA-SALBUTAMOL HFA | TEV |
100MCG/INHALATION Aerosol | 02241497 | VENTOLIN HFA | GSK |
2MG Capsule | 99111294 | SALBUTAMOL (QC) | UNK |
100MCG Inhaler | 09858115 | SALAMOL CFC-FREE | UNK |
100MCG Inhaler | 09991688 | SALAMOL CFC-FREE | UNK |
100MCG Inhaler | 09858116 | SALBUTAMOL ALDO-UNION (ON) | JMP |
200MCG Powder | 02243115 | VENTOLIN DISKUS | GSK |
0.5MG/ML Solution | 02208245 | PMS-SALBUTAMOL | PMS |
1MG/ML Solution | 02216949 | DOM-SALBUTAMOL | DPC |
1MG/ML Solution | 02208229 | PMS-SALBUTAMOL | PMS |
1MG/ML Solution | 01926934 | TEVA-SALBUTAMOL | TEV |
1MG/ML Solution | 02213419 | VENTOLIN P.F | GSK |
2MG/ML Solution | 02208237 | PMS-SALBUTAMOL | PMS |
2MG/ML Solution | 02173360 | TEVA-SALBUTAMOL | TEV |
2MG/ML Solution | 02213427 | VENTOLIN P.F | GSK |
5MG/ML Solution | 02139324 | DOM-SALBUTAMOL | DPC |
5MG/ML Solution | 02213486 | VENTOLIN RESPIRATOR | GSK |
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; or
For the treatment of Chronic Obstructive Pulmonary Disease (COPD) in patients not adequately controlled with either ipratropium, tiotropium or a short acting beta-agonist.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
50MCG/INHALATION Powder | 02231129 | SEREVENT DISKUS | GSK |
SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
Limited use benefit (prior approval required).
For the treatment of asthma in patients who are not adequately controlled on medium doses of inhaled corticosteroids (e.g. fluticasone 251-500mcg 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; or
For the treatment of chronic obstructive pulmonary disease (COPD) in patients who have:
- moderate to severe COPD, as defined by spirometry; and
- inadequate response to a long-acting beta-2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA).
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
25MCG & 125MCG Aerosol | 02245126 | ADVAIR 125 | GSK |
25MCG & 250MCG Aerosol | 02245127 | ADVAIR 250 | GSK |
50MCG & 100MCG Powder | 02240835 | ADVAIR 100 DISKUS | GSK |
50MCG & 100MCG Powder | 02494507 | PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI | PMS |
50MCG & 100MCG Powder | 02495597 | WIXELA INHUB | MYL |
50MCG & 250MCG Powder | 02240836 | ADVAIR 250 DISKUS | GSK |
50MCG & 250MCG Powder | 02494515 | PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI | PMS |
50MCG & 250MCG Powder | 02495600 | WIXELA INHUB | MYL |
50MCG & 500MCG Powder | 02240837 | ADVAIR 500 DISKUS | GSK |
50MCG & 500MCG Powder | 02494523 | PMS-FLUTICASONE PROPIONATE/SALMETEROL DPI | PMS |
50MCG & 500MCG Powder | 02495619 | WIXELA INHUB | MYL |
TERBUTALINE SULFATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
500MCG/INHALATION Powder | 00786616 | BRICANYL TURBUHALER | AZC |
12:12.12 ALPHA AND BETA ADRENERGIC AGONISTS
EPINEPHRINE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
0.15MG Solution | 02382059 | ALLERJECT | KAL |
0.3MG Solution | 02382067 | ALLERJECT | KAL |
0.5MG/ML Solution | 00578657 | EPIPEN JR | MYL |
1MG/ML Solution | 00155357 | ADRENALIN | ERF |
1MG/ML Solution | 00721891 | EPINEPHRINE | PFI |
1MG/ML Solution | 00509558 | EPIPEN | MYL |
12:16.00 SYMPATHOLYTIC AGENTS
DIHYDROERGOTAMINE MESYLATE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1MG/ML Liquid | 00027243 | DIHYDROERGOTAMINE | RAX |
4MG/ML Liquid | 02228947 | MIGRANAL | RAX |
12:16.04 ALPHA-ADRENERGIC BLOCKING AGENTS
ALFUZOSIN HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST10MG Tablet (Extended Release) | 02447576 | ALFUZOSIN | SIV |
ST10MG Tablet (Extended Release) | 02315866 | APO-ALFUZOSIN | APX |
ST10MG Tablet (Extended Release) | 02443201 | AURO-ALFUZOSIN | AUR |
ST10MG Tablet (Extended Release) | 02304678 | SANDOZ ALFUZOSIN | SDZ |
ST10MG Tablet (Extended Release) | 02245565 | XATRAL | SAC |
TAMSULOSIN HYDROCHLORIDE
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST0.4MG Capsule (Sustained Release) | 02294265 | RATIO-TAMSULOSIN | TEV |
ST0.4MG Capsule (Sustained Release) | 09857334 | RATIO-TAMSULOSIN | RPH |
ST0.4MG Capsule (Sustained Release) | 02319217 | SANDOZ TAMSULOSIN | SDZ |
ST0.4MG Capsule (Sustained Release) | 02281392 | TEVA-TAMSULOSIN | TEV |
ST0.4MG Tablet (Extended Release) | 02362406 | APO-TAMSULOSIN | APX |
ST0.4MG Tablet (Extended Release) | 02270102 | FLOMAX | BOE |
ST0.4MG Tablet (Extended Release) | 02340208 | SANDOZ TAMSULOSIN | SDZ |
ST0.4MG Tablet (Extended Release) | 02413612 | TAMSULOSIN | PDL |
ST0.4MG Tablet (Extended Release) | 02427117 | TAMSULOSIN | SAN |
ST0.4MG Tablet (Extended Release) | 02429667 | TAMSULOSIN | SIV |
ST0.4MG Tablet (Extended Release) | 02368242 | TEVA-TAMSULOSIN | TEV |
12:20.04 CENTRALL ACTING SKELETAL MUSCLE RELAXANTS
CYCLOBENZAPRINE HYDROCHLORIDE
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST10MG Tablet | 02177145 | APO-CYCLOBENZAPRINE | APX |
ST10MG Tablet | 02348853 | AURO-CYCLOBENZAPRINE | AUR |
ST10MG Tablet | 02220644 | CYCLOBENZAPRINE | PDL |
ST10MG Tablet | 02287064 | CYCLOBENZAPRINE | SAN |
ST10MG Tablet | 02424584 | CYCLOBENZAPRINE | SIV |
ST10MG Tablet | 02238633 | DOM-CYCLOBENZAPRINE | DPC |
ST10MG Tablet | 02357127 | JAMP-CYCLOBENZAPRINE | JMP |
ST10MG Tablet | 02212048 | PMS-CYCLOBENZAPRINE | PMS |
ST10MG Tablet | 02242079 | RIVA-CYCLOBENZAPRINE | RIV |
ST10MG Tablet | 02080052 | TEVA-CYCLOBENZAPRINE | TEV |
TIZANIDINE HYDROCHLORIDE
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
4MG Tablet | 02239170 | PAL-TIZANIDINE | PAL |
4MG Tablet | 02259893 | TIZANIDINE | AAP |
12:20.08 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
DANTROLENE SODIUM
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
25MG Capsule | 01997602 | DANTRIUM | PPH |
12:20.12 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS
BACLOFEN
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST10MG Tablet | 02139332 | APO-BACLOFEN | APX |
ST10MG Tablet | 02152584 | BACLOFEN | PDL |
ST10MG Tablet | 02287021 | BACLOFEN | SAN |
ST10MG Tablet | 02138271 | DOM-BACLOFEN | DPC |
ST10MG Tablet | 00455881 | LIORESAL | NVR |
ST10MG Tablet | 02088398 | MYLAN-BACLOFEN | MYL |
ST10MG Tablet | 02063735 | PMS-BACLOFEN | PMS |
ST10MG Tablet | 02242150 | RIVA-BACLOFEN | RIV |
ST20MG Tablet | 02139391 | APO-BACLOFEN | APX |
ST20MG Tablet | 02152592 | BACLOFEN | PDL |
ST20MG Tablet | 02287048 | BACLOFEN | SAN |
ST20MG Tablet | 02138298 | DOM-BACLOFEN | DPC |
ST20MG Tablet | 02088401 | MYLAN-BACLOFEN | MYL |
ST20MG Tablet | 02063743 | PMS-BACLOFEN | PMS |
ST20MG Tablet | 02242151 | RIVA-BACLOFEN | RIV |
pDIN For Extemporaneous Mixture | 99503011 | BACLOFEN ORAL LIQUID | UNK |
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST2MG Gum | 02091933 | NICORETTE GUM | KIM |
ST2MG Gum | 80015240 | RUGBY NICOTINE POLACRILEX GUM | ACG |
2MG Gum | 80000396 | THRIVE NICOTINELL GUM | GSK |
ST4MG Gum | 02091941 | NICORETTE GUM | KIM |
ST4MG Gum | 80000118 | NICOTINE GUM | PER |
4MG Gum | 80000402 | THRIVE NICOTINELL GUM | NVC |
NICOTINE (INHALER)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:
Coverage is limited to 945 doses 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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST10MG Spray | 02241742 | NICORETTE INHALER | KIM |
NICOTINE (LOZENGE)
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST1MG Lozenge | 80007461 | THRIVE NICOTINE LOZENGES | NVC |
ST2MG Lozenge | 02247347 | NICORETTE LOZENGE | KIM |
ST2MG Lozenge | 80007464 | THRIVE NICOTINE LOZENGES | NVC |
ST4MG Lozenge | 02247348 | NICORETTE LOZENGE | KIM |
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.
- NIHB clients are eligible to receive:
- up to 252 nicotine patches of any listed brand in a 12-month period; and
- one course of an as-needed nicotine replacement therapy (NRT) product (i.e. gum, lozenge or inhaler) in a 12-month period; and
- up to 180 tablets of Zyban in a 12-month period; and
- up to 165 tablets of Champix in a 12-month period.
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.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST2MG Gum | 80025660 | CHU NICOTINE ANTI SMOKING AID | UNK |
2MG Gum | 94799974 | THRIVE GUM (NS) | NVC |
ST1MG Lozenge | 80061161 | NICHIT | EUR |
ST2MG Lozenge | 80059877 | NICHIT | EUR |
ST7MG Patch | 01943057 | HABITROL | NVC |
ST7MG Patch | 80051602 | NICOTINE TRANSDERMAL | APX |
ST7MG Patch | 80044393 | TRANSDERMAL NICOTINE | ACG |
ST14MG Patch | 01943065 | HABITROL | NVC |
ST14MG Patch | 80051600 | NICOTINE TRANSDERMAL | APX |
ST14MG Patch | 80013549 | NICOTINE TRANSDERMAL SYSTEM | ADD |
ST14MG Patch | 80044392 | TRANSDERMAL NICOTINE | ACG |
ST16MG Patch | 80014321 | NICOTINE TRANSDERMAL SYSTEM | ADD |
ST18MG Patch | 02241227 | TRANSDERMAL NICOTINE PATCHDAY | NVC |
ST21MG Patch | 01943073 | HABITROL | NVC |
ST21MG Patch | 80051603 | NICOTINE TRANSDERMAL | APX |
ST21MG Patch | 80014250 | NICOTINE TRANSDERMAL SYSTEM | ADD |
ST21MG Patch | 80044389 | TRANSDERMAL NICOTINE | ACG |
ST36MG Patch | 02093111 | NICODERM | KIM |
ST53MG Patch | 02241228 | TRANSDERMAL NICOTINE PATCHDAY | NVC |
ST78MG Patch | 02093138 | NICODERM | KIM |
ST114MG Patch | 02093146 | NICODERM | KIM |
NICOTINE (SPRAY)
Limited use benefit with quantity and frequency limits (prior approval is not required).
For smoking cessation:
Coverage is limited to 3450 sprays 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 spray when one year has elapsed from the day the initial prescription was filled.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
1MG Oral Spray | 80038858 | NICORETTE QUICKMIST | KIM |
VARENICLINE TARTRATE
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(r)) when one year has elapsed from the day the initial prescription was filled.
Drug strength and dosage form | DIN | Brand name | Manufacturer code |
---|---|---|---|
ST0.5MG & 1MG Tablet | 02435675 | APO-VARENICLINE | APX |
ST0.5MG & 1MG Tablet | 02298309 | CHAMPIX STARTER PACK | PFI |
0.5MG & 1MG Tablet | 02426781 | TEVA-VARENICLINE | TEV |
ST0.5MG Tablet | 02419882 | APO-VARENICLINE | APX |
ST0.5MG Tablet | 02291177 | CHAMPIX | PFI |
0.5MG Tablet | 02426226 | TEVA-VARENICLINE | TEV |
ST1MG Tablet | 02419890 | APO-VARENICLINE | APX |
ST1MG Tablet | 02291185 | CHAMPIX | PFI |
1MG Tablet | 02426234 | TEVA-VARENICLINE | TEV |