12:00 Autonomic Drugs

12:04.00 PARASYMPATHOMIMETIC AGENTS

BETHANECHOL CHLORIDE

Table: 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.
Table: DONEPEZIL HYDROCHLORIDE
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.
Table: GALANTAMINE HYDROBROMIDE
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

Table: NEOSTIGMINE BROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet 00869945 PROSTIGMIN VAE

PILOCARPINE HYDROCHLORIDE

Table: 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

Table: 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.
Table: RIVASTIGMINE HYDROGEN TARTRATE
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

Table: ACLIDINIUM BROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
400MCG Powder 02409720 TUDORZA GENUAIR AZC

GLYCOPYRRONIUM BROMIDE

Table: GLYCOPYRRONIUM BROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MCG Capsule 02394936 SEEBRI BREEZHALER NVR

HYOSCINE BUTYLBROMIDE

Table: 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.

Table: INDACATEROL MALEATE, GLYCOPYRRONIUM BROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
110MCG & 50MCG Capsule 02418282 ULTIBRO BREEZHALER NVR

IPRATROPIUM BROMIDE

Table: 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

Table: 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

Table: 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.

Table: TRIMEBUTINE MALEATE
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

Table: 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.

Table: UMECLIDINIUM BROMIDE, VILANTEROL TRIFENATATE
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

Table: 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.

Table: ACLIDINIUM BROMIDE, FORMOTEROL FUMARATE DIHYDRATE
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).
Table: FLUTICASONE FUROATE, VILANTEROL TRIFENATATE
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.

Table: FLUTICASONE FUROATE, VILANTEROL TRIFENATATE (ASTHMA)
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.

Table: FORMOTEROL FUMARATE
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.

Table: FORMOTEROL FUMARATE DIHYDRATE
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).
Table: FORMOTEROL FUMARATE DIHYDRATE, BUDESONIDE
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.

Table: FORMOTEROL FUMARATE DIHYDRATE, MOMETASONE FUROATE
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.
Table: INDACATEROL MALEATE
Drug strength and dosage form DIN Brand name Manufacturer code
75MCG Capsule 02376938 ONBREZ BREEZHALER NVR

OLODATEROL HYDROCHLORIDE, TIOTROPIUM BROMIDE MONOHYDRATE

Table: 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

Table: ORCIPRENALINE SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
2MG/ML Syrup 02236783 ORCIPRENALINE AAP

SALBUTAMOL SULFATE

Table: 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.

Table: SALMETEROL XINAFOATE
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).
Table: SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
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

Table: 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

Table: 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

Table: 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

Table: 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

Table: 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.

Table: CYCLOBENZAPRINE HYDROCHLORIDE
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.

Table: TIZANIDINE HYDROCHLORIDE
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

Table: 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

Table: 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.

Table: NICOTINE (GUM)
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.

Table: NICOTINE (INHALER)
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.

Table: NICOTINE (LOZENGE)
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.

Table: NICOTINE (PATCH)
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.

Table: NICOTINE (SPRAY)
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.

Table: VARENICLINE TARTRATE
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
Date modified: