56:00 Gastrointestinal Drugs

BISMUTH SUBSALICYLATE

Limited use benefit (prior approval not required).

Coverage will be limited to 8 tablets a day every 14 days, followed by a 28 day lockout; or

Coverage will be limited to 120mL a day every 14 days, followed by a 28 day lockout.

MAGNESIUM OXIDE

SODIUM BICARBONATE

LOPERAMIDE HYDROCHLORIDE

BISACODYL

CITRIC ACID, MAGNESIUM OXIDE, SODIUM PICOSULFATE

GLYCERINE

MACROGOL, POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE, SODIUM SULFATE

MAGNESIUM CITRATE

MAGNESIUM HYDROXIDE

MINERAL OIL

POLYETHYLENE GLYCOL 3350

POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE

POLYETHYLENE GLYCOL 3350, SODIUM SULFATE, SODIUM BICARBONATE, SODIUM CHLORIDE, POTASSIUM CHLORIDE, BISACODYL

PSYLLIUM MUCILLOID

SENNOSIDES

SODIUM PHOSPHATE

SORBITOL, SODIUM CITRATE, SODIUM LAURYL SULFOACETATE

URSODIOL

LACTASE

LIPASE, AMYLASE, PROTEASE

IPECAC

NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)

Limited use benefit (prior approval required).

When used in combination with dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (eg. cisplatin > 70mg/m2).

DIMENHYDRINATE

Limited use benefit (prior approval not required).

The NIHB Program implemented a dose coverage limit for dimenhydrinate in June 2017 as part of a strategy to address safety concerns and potential misuse.

The dimenhydrinate dose limit is currently 400 mg per day for a total of 12,000 mg of dimenhydrinate in a 30-day period.

This limit applies only to the 15 mg and 50 mg tablets. Dimenhydrinate in liquid, suppository and injectable forms are not included in this limit.

DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE

GRANISETRON HYDROCHLORIDE

ONDANSETRON HYDROCHLORIDE

APREPITANT

Limited use benefit (prior approval required).

When used in combination with a 5-HT3 antagonist and dexamethasone for the prevention of acute and delayed nausea and vomiting due to highly emetogenic cancer chemotherapy (e.g. Cisplatin > 70mg/m2).

DOXYLAMINE SUCCINATE, PYRIDOXINE HYDROCHLORIDE

NABILONE

CIMETIDINE

FAMOTIDINE

NIZATIDINE

RANITIDINE HCL

RANITIDINE HYDROCHLORIDE

MISOPROSTOL

SUCRALFATE

AMOXICILLIN, CLARITHROMYCIN, LANSOPRAZOLE

LANSOPRAZOLE

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

LANSOPRAZOLE ODT

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

For children 12 years of age or under who are unable to swallow the capsule formulation; or

For patients with dysphagia or a feeding tube when the use of the capsule formulation is not possible.

(Please refer to Appendix A).

OMEPRAZOLE MAGNESIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

PANTOPRAZOLE MAGNESIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

PANTOPRAZOLE SODIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

RABEPRAZOLE SODIUM

Limited use benefit (prior approval not required).

Coverage will be limited to 400 tablets/capsules every 180 days.

(Please refer to Appendix A).

DOMPERIDONE MALEATE

METOCLOPRAMIDE HYDROCHLORIDE

BETAMETHASONE SODIUM PHOSPHATE

HYDROCORTISONE ACETATE

MESALAZINE

OLSALAZINE SODIUM

OBETICHOLIC ACID

Limited use benefit (prior approval required).

Criteria for initial 12-month coverage:

The patient has a confirmed diagnosis of primary biliary cholangitis (PBC), defined as:

• positive antimitochondrial antibodies (AMA); or
• liver biopsy results consistent with PBC.
• and

The patient is under the care of a gastroenterologist, hepatologist or internal medicine specialist with experience in the treatment of PBC.

and

The patient has received ursodeoxycholic acid (UDCA) for a minimum of 12 months and has experienced an inadequate response to UDCA and can benefit from the addition of obeticholic acid. An inadequate response is defined as:

• alkaline phosphatase (ALP) ≥ 1.67 x upper limit of normal (ULN); and/or
• bilirubin > ULN and < 2 x ULN; and/or
• evidence of compensated cirrhosis by fibroscan or biopsy.
• or

The patient has experienced documented and unmanageable intolerance to UDCA.

Criteria for renewal every 12 months:

The patient continues to benefit from treatment with obeticholic acid as evidenced by:

• a reduction in the ALP level to less than 1.67 x ULN; or
• a 15% reduction in the ALP level compared with values before beginning treatment with obeticholic acid.

PINAVERIUM BROMIDE

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.

VEDOLIZUMAB

Limited use benefit (prior approval required).

For the treatment of:

• Crohn's disease according to established criteria.
• ulcerative colitis according to established criteria.

(Please refer to Appendix A).