28:00 Central Nervous System Agents

ACETYLSALICYLIC ACID

Limited use benefit (prior approval is not required).

ASA 80 mg tablets are a benefit to clients age 21 years and under to allow access for use in pediatric conditions (e.g. Kawasaki syndrome).

CELECOXIB

DICLOFENAC DIETHYLAMINE

Limited use benefit (prior approval not required).

Coverage is limited to 100 grams per month.

DICLOFENAC SODIUM

DICLOFENAC SODIUM (TOPICAL)

Limited use benefit (prior approval required).

For the treatment of osteoarthritis when:

• pain is inadequately controlled with acetaminophen and a non-steroidal anti-inflammatory (NSAID); or
• there is contraindication to acetaminophen and NSAID; or
• there is intolerance to acetaminophen and NSAID.

DIFLUNISAL

FLURBIPROFEN

IBUPROFEN

INDOMETHACIN

KETOPROFEN

MEFENAMIC ACID

MELOXICAM

MISOPROSTOL, DICLOFENAC SODIUM

NAPROXEN

PIROXICAM

SULINDAC

TIAPROFENIC ACID

ACETAMINOPHEN, CAFFEINE CITRATE, CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

ACETAMINOPHEN, CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

ACETAMINOPHEN, OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

ACETYLSALICYLIC ACID, OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

BUPRENORPHINE (SUBLOCADE)

Limited use benefit (prior approval required).

For the management of moderate to severe opioid use disorder in adult patients who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product; and

Patient must be induced and stabilized on an equivalent of 8 mg to 24 mg per day of transmucosal buprenorphine for a minimum of 7 days.

Note:

• the prescriber has experience in the diagnosis and management of opioid use disorder and certified under Sublocade Certification Program.
• Sublocade must be administered subcutaneously in the abdominal region by a healthcare provider.
• Sublocade should be used as part of a complete treatment plan that includes counselling and psychosocial support.
• client will be added to the Client Safety Program (CSP).

CODEINE MONOHYDRATE, CODEINE SULFATE TRIHYDRATE

Limited use benefit (prior approval required).

For treatment of:

• chronic pain and patients that requires end of life care as an alternative to products containing codeine in combination with acetaminophen or ASA with or without caffeine; or
• chronic pain and patients that requires end of life care as an alternative to regular release codeine tablets when large doses are required.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

CODEINE PHOSPHATE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

FENTANYL

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

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

HYDROMORPHONE HYDROCHLORIDE

Limited use benefit.

Prior approval required for controlled release capsules only. Regular release dosage forms are full benefits and do not require prior approval.

For treatment of moderate to severe chronic pain when other opioids such as morphine have been ineffective in controlling pain or in patients experiencing intolerable side effects.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

METHADONE HYDROCHLORIDE

METHADONE HYDROCHLORIDE (BC ONLY)

METHADONE HYDROCHLORIDE (METADOL)

Limited use benefit (prior approval required) with the following criteria:

For the management of moderate to severe cancer pain or chronic non-cancer pain, as an alternative to other opioids; or

For the management of pain for patients that requires end of life care. Pharmacists may only dispense a maximum supply of 30 days at one time.

MORPHINE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

MORPHINE SULFATE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

MORPHINE SULFATE (KADIAN)

Limited use benefit (prior approval required).

For the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate; or

For the treatment of chronic pain.

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

OXYCODONE HYDROCHLORIDE

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy, NIHB has implemented an opioid dose limit of 200 mg morphine equivalents per day for chronic non-cancer pain. This limit will be calculated based on the total dose of all opioids a client is receiving from NIHB within a 30-day period (i.e. 6000 morphine equivalents over 30 days).

BUPRENORPHINE (BUTRANS)

Limited use benefit (prior approval required).

For the following medical conditions:

• pain due to cancer
• chronic non-cancer pain-causing limitations in activities of daily living.
• prevention of precipitated withdrawal during buprenorphine/naloxone induction (max 3 x 20 mcg patches are covered)
• patient requires end of life care (diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less)

*Guidelines indicate little evidence for opioid use for fibromyalgia, headache or back or neck pain without a neuropathic component.

BUPRENORPHINE (SUBLOCADE)

Limited use benefit (prior approval required).

For the management of moderate to severe opioid use disorder in adult patients who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product; and

Patient must be induced and stabilized on an equivalent of 8 mg to 24 mg per day of transmucosal buprenorphine for a minimum of 7 days.

Note:

• the prescriber has experience in the diagnosis and management of opioid use disorder and certified under Sublocade Certification Program.
• Sublocade must be administered subcutaneously in the abdominal region by a healthcare provider.
• Sublocade should be used as part of a complete treatment plan that includes counselling and psychosocial support.
• client will be added to the Client Safety Program (CSP).

BUPRENORPHINE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the management of patients with opioid use disorder, in combination with psychosocial support:

• patient is stabilized on a dose of no more than 8 mg per day of sublingual buprenorphine/naloxone for the preceding 90 days; and
• patient is under the care of a health care provider with experience in the diagnosis and management of opioid use disorder; and
• the prescriber has been trained to implant the buprenorphine subdermal implant.

Approval is for a maximum of four lifetime doses. One package of 4 implants is approved at every 6 months (e.g. four times X package of 4 implants)

BUPRENORPHINE HYDROCHLORIDE, NALOXONE HYDROCHLORIDE

Limited use benefit (prior approval required).

For the treatment of opioid dependence when:

• the client must be 16 years or older.
• in cases where the client lives in a remote or isolated location, confirmation is required that the community has the ability to support buprenorphine/naloxone administration. These supports include the safe daily witnessing, storage and handling of the buprenorphine/naloxone doses. After this confirmation, NIHB will approve the buprenorphine/naloxone for the client.

ACETAMINOPHEN

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on acetaminophen. The limit accumulates against the amount of acetaminophen claimed to the program from plain acetaminophen and/or acetaminophen in combination with opioids such as codeine (i.e. Tylenol(r) #3) or oxycodone (i.e. Percocet(r)). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

FLOCTAFENINE

NALOXONE HYDROCHLORIDE

NALTREXONE HYDROCHLORIDE

PHENOBARBITAL

PRIMIDONE

CLOBAZAM

CLONAZEPAM

Limited use benefit (prior approval is not required).

To promote safe, therapeutically effective and efficient use of drug therapy NIHB has implemented a benzodiazepine dose limit of 30 mg diazepam equivalents per day. This limit will be calculated based on the total dose of all benzodiazepines a client is receiving from NIHB within a 100-day period (i.e. 3 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 30 mg per day.

PHENYTOIN

ETHOSUXIMIDE

BRIVARACETAM

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

• are under the care of a physician experienced in the treatment of epilepsy; and
• are currently receiving two or more antiepileptic medications; and
• have failed or demonstrated intolerance to at least two other antiepileptic medications; and
• are not receiving concurrent therapy with levetiracetam.

CARBAMAZEPINE

ESLICARBAZEPINE ACETATE

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

• are under the care of a physician experienced in the treatment of epilepsy; and
• are currently receiving two or more antiepileptic medications; and
• have failed or demonstrated intolerance to at least two other antiepileptic medications.

GABAPENTIN

Limited use benefit (prior approval is not required).

For safety reasons NIHB has implemented a dose limit on gabapentin. The limit accumulates against the amount of gabapentin claimed to the program. A total of 400 grams of gabapentin is permitted in a 30-day period, for a total daily dose of 4000 mg/day.

The gabapentin dose limit will be further reduced to 3600 mg per day. The new limit will be implemented region-by-region.

LACOSAMIDE

Limited use benefit (prior approval required).

For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of the following criteria:

• are under the care of a physician experienced in the treatment of epilepsy; and
• are currently receiving two or more antiepileptic medications; and
• have failed or demonstrated intolerance to at least two other antiepileptic medications.

LAMOTRIGINE

LEVETIRACETAM

OXCARBAZEPINE

OXCARBAZEPINE (SUSPENSION)

Limited use benefit (prior approval is not required).

For patients 19 years of age or over who are unable to swallow the tablet formulation due to:

• tube feeding; or
• severe dysphagia

Note: Trileptal (oxcarbazepine) suspension is an open benefit for patients 18 years of age and under and does not require prior approval for these patients.

• Oxcarbazepine tablets are an open benefit for patients of all ages and do not require prior approval.

PERAMPANEL

Limited use benefit (prior approval required).

For adjunctive therapy in patients with refractory partial-onset seizures or primary generalized tonic-clonic (PGTC) seizures who meet all of the following criteria:

• are under the care of a physician experienced in the treatment of epilepsy; and
• are currently receiving two or more antiepileptic medications; and
• have failed or demonstrated intolerance to at least two other antiepileptic medications.

PREGABALIN

Limited use benefit (prior approval required).

For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA); or

For the treatment of neuropathic pain in patients who have a contraindication or intolerance to a tricyclic antidepressant (TCA).

Coverage is limited to a maximum of 600mg per day.

RUFINAMIDE

Limited use benefit (prior approval required).

For the adjunctive treatment of seizures associated with Lennox-Gastaux syndrome in adults and children 4 years and older when prescribed by a neurologist or experienced specialist. Patient has failed or is intolerant to or has contraindications to at least two adjunctive antiepileptic drugs.

TOPIRAMATE

VALPROIC ACID (DIVALPROEX SODIUM)

VALPROIC ACID (SODIUM VALPROATE)

VIGABATRIN

AMITRIPTYLINE HYDROCHLORIDE

BUPROPION HYDROCHLORIDE (WELLBUTRIN)

BUPROPION HYDROCHLORIDE (ZYBAN)

Limited use benefit with quantity and frequency limits (prior approval is not required).

For smoking cessation:

Coverage is limited to 180 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 bupropion hydrochloride when one year has elapsed from the day the initial prescription was filled.

CITALOPRAM HYDROBROMIDE

CLOMIPRAMINE HYDROCHLORIDE

DESIPRAMINE HYDROCHLORIDE

DOXEPIN HYDROCHLORIDE

DULOXETINE HYDROCHLORIDE

ESCITALOPRAM OXALATE

FLUOXETINE HYDROCHLORIDE