92:00 Unclassified therapeutic agents

92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS

EXTEMPORANEOUS MIXTURE

Table: EXTEMPORANEOUS MIXTURE
Drug strength and dosage form DIN Brand name Manufacturer code
Capsule 99505003 PHENAZOPYRIDINE COMPOUNDED UNK
Cream 99500000 HYDROCORTISONE POWDER AND CLOTRIMAZOLE CREAM UNK
Cream 99500010 LCD IN CORTICOSTEROID CREAM UNK
Cream 99500009 LCD IN NON-MEDICATED CREAM UNK
Cream 99500002 MENTHOL &/OR CAMPHOR IN STEROID UNK
Cream 99500004 MISCELLANEOUS COMPOUNDED TOPICAL CREAM UNK
Cream 99500001 STEROID AND ANTIFUNGAL CREAM UNK
Cream 99500006 SULFUR IN NON-MEDICATED CREAM UNK
Lotion 99502001 MENTHOL & CAMPHOR IN CORTICOSTEROID LOTION UNK
Lotion 99502002 MISCELLANEOUS COMPOUNDED EXTERNAL LOTION UNK
Miscellaneous 99505005 H2RA SOLID UNK
Miscellaneous 00915000 STERILE EXTEMPORANEOUS MIXTURE (QC) UNK
Ointment 99501006 ALL PURPOSE NIPPLE OINTMENT UNK
Ointment 99501003 CALCIUM CHANNEL BLOCKER IN OINTMENT UNK
Ointment 99501008 DILTIAZEM IN OINTMENT UNK
Ointment 99501000 LCD IN CORTICOSTEROID OINTMENT UNK
Ointment 99501005 LCD IN NON-MEDICATED OINTMENT UNK
Ointment 99501004 MISCELLANEOUS COMPOUNDED TOPICAL OINTMENT UNK
Ointment 99501002 SULFUR IN NON-MEDICATED OINTMENT UNK
Ophthalmic Solution 99507002 ANTIBIOTIC DROPS UNK
Ophthalmic Solution 99507001 ANTIFUNGAL DROPS UNK
Ophthalmic Solution 99507003 ANTIVIRAL DROPS UNK
Oral Liquid 99503028 ANTACID AND LIDOCAINE ORAL LIQUID UNK
Oral Liquid 99503029 MAGIC MOUTHWASH UNK
Oral Liquid 99503025 MISCELLANEOUS COMPOUNDED INTERNAL LIQUID UNK
Powder 99505004 BACKORDER INTERNAL POWDER UNK
Powder 99505000 MISCELLANEOUS COMPOUNDED INTERNAL POWDER UNK

EXTEMPORANEOUS MIXTURE (GENDER AFFIRMING)

Limited use benefit (prior approval required).

For gender affirming hormone therapy.

Table: EXTEMPORANEOUS MIXTURE (GENDER AFFIRMING)
Drug strength and dosage form DIN Brand name Manufacturer code
Injection 00915312 GENDER AFFIRMING HORMONES UNK
Liquid 00915311 GENDER AFFIRMING TOPICAL HORMONES UNK

EXTEMPORANEOUS MIXTURE (LU)

Limited use benefit (prior approval required).

Table: EXTEMPORANEOUS MIXTURE (LU)
Drug strength and dosage form DIN Brand name Manufacturer code
Injection 99506021 MISCELLANEOUS COMPOUNDED INJECTION/INFUSION UNK
Miscellaneous 99504001 MISC LIMITED USE EXTERNAL COMPOUND MIXTURE UNK
Ophthalmic And Otic Solution 99507000 MISCELLANEOUS COMPOUNDED EYE/EAR DROP UNK
Oral Liquid 99503033 MISC LIMITED USE COMPOUND INTERNAL UNK
Oral Liquid 99503032 OPIOID COMPOUNDED UNK
Powder 99504000 MISCELLANEOUS COMPOUNDED EXTERNAL POWDER UNK
Suppository 99508000 MISCELLANEOUS COMPOUNDED SUPPOSITORY UNK

EXTEMPORANEOUS MIXTURE (NSAID)

Limited use benefit (prior approval not required).

Coverage will be limited to 100 grams every 30 days.

Table: EXTEMPORANEOUS MIXTURE (NSAID)
Drug strength and dosage form DIN Brand name Manufacturer code
Gel 99501007 NSAID IN TRANSDERMAL BASE UNK
Ointment 99501009 TRANSDERMAL LIDOCAINE W/NSAID UNK

GOSERELIN ACETATE

Table: GOSERELIN ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
10.8MG/DEPOT Implant 02225905 ZOLADEX LA UNK

OCTREOTIDE ACETATE

Table: OCTREOTIDE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG/VIAL Powder For Suspension (Sustained Release) 02239323 SANDOSTATIN LAR NVR
20MG/VIAL Powder For Suspension (Sustained Release) 02239324 SANDOSTATIN LAR NVR
30MG/VIAL Powder For Suspension (Sustained Release) 02239325 SANDOSTATIN LAR NVR
50MCG/ML Solution 02248639 OCTREOTIDE ACETATE OMEGA OMG
50MCG/ML Solution 00839191 SANDOSTATIN NVR
100MCG/ML Solution 02248640 OCTREOTIDE ACETATE OMEGA OMG
100MCG/ML Solution 00839205 SANDOSTATIN NVR
200MCG/ML Solution 02248642 OCTREOTIDE ACETATE OMEGA OMG
200MCG/ML Solution 02049392 SANDOSTATIN NVR
500MCG/ML Solution 02248641 OCTREOTIDE ACETATE OMEGA OMG

PENTOSAN POLYSULFATE SODIUM

Table: PENTOSAN POLYSULFATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 02029448 ELMIRON JSO

QUINAGOLIDE (QUINAGOLIDE HYDROCHLORIDE)

Table: QUINAGOLIDE (QUINAGOLIDE HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code
0.075MG Tablet 02223767 NORPROLAC FEI

USTEKINUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • psoriasis according to established criteria.

(Please refer to Appendix A).

Table: USTEKINUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
45MG/0.5ML Solution 02320673 STELARA JSO
90MG/ML Solution 02320681 STELARA JSO

92:01.00 NATURAL HEALTH PRODUCTS

CANTHARIDIN

Table: CANTHARIDIN
Drug strength and dosage form DIN Brand name Manufacturer code
1%(W/V) Liquid 80023975 CANTHARONE 07 DOR

ISOPROPYL ALCOHOL

Table: ISOPROPYL ALCOHOL
Drug strength and dosage form DIN Brand name Manufacturer code
70% WIPE, MEDICATED 80074942 MEDISURE ALCOHOL WIPES MDS

LACTASE

Table: LACTASE
Drug strength and dosage form DIN Brand name Manufacturer code
ST150MG Tablet 80018706 LACTASE 4500 FCCLU JAM

NATURAL HEALTH PRODUCT

Table: NATURAL HEALTH PRODUCT
Drug strength and dosage form DIN Brand name Manufacturer code
1% Cream 80066699 CORTIVERA H VAN

PSYLLIUM MUCILLOID

Table: PSYLLIUM MUCILLOID
Drug strength and dosage form DIN Brand name Manufacturer code
ST3G Powder 80013276 METAMUCIL FIBRE THERAPY SMOOTH TEXTURE PGI
ST3G Powder 80013287 METAMUCIL FIBRE THERAPY SMOOTH TEXTURE SUGAR FREE PGI
ST3G Powder 80015505 METAMUCIL SMOOTH TEXTURE UNFLAVOURED UNSWEETENED PGI

92:01.28 

MULTIVITAMINS (PRENATAL)

Limited use benefit (prior approval is not required.).

Prenatal and postnatal vitamins are benefits only for clients of childbearing age (12 to 50 years).

Table: MULTIVITAMINS (PRENATAL)
Drug strength and dosage form DIN Brand name Manufacturer code
ST Capsule 80081007 MATERNA PRENATAL DHA NES

92:01.88 VITAMIN B COMPLEX

CALCIUM, VITAMIN D

Table: CALCIUM, VITAMIN D
Drug strength and dosage form DIN Brand name Manufacturer code
500-400MGU Tablet 80090977 BIO CAL-D3 BMI

VITAMIN C

Table: VITAMIN C
Drug strength and dosage form DIN Brand name Manufacturer code
ST500MG Tablet 80092665 VITAMIN C JAM

VITAMIN D

Table: VITAMIN D
Drug strength and dosage form DIN Brand name Manufacturer code
1000UI Capsule 80089250 BIO-VITAMINE D3 BMI

92:05.00 SERUMS

ALLERGENIC EXTRACTS POLLENS

Table: ALLERGENIC EXTRACTS POLLENS
Drug strength and dosage form DIN Brand name Manufacturer code
40000U Liquid 02247755 OMEGA ALLERGENIC EXTRACTS POLLENS (SUSPAL) OMG

APIS MELLIFERA VENOM PROTEIN EXTRACT

Table: APIS MELLIFERA VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
1.1MG Powder For Solution 01948903 PHARMALGEN HONEY BEE VENOM ALK
120MCG Powder For Solution 01948911 PHARMALGEN HONEY BEE VENOM ALK

DOLICHOVESPULA ARENARIA VENOM PROTEIN

Table: DOLICHOVESPULA ARENARIA VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 01948946 PHARMALGEN YELLOW HORNET VENOM PROTEIN ALK

DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT

Table: DOLICHOVESPULA MACULATA VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 01949004 PHARMALGEN WHITE FACED HORNET VENOM ALK

HONEY BEE VENOM PROTEIN EXTRACT

Table: HONEY BEE VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 02226197 VENOMIL HONEY BEE VENOM JUB
550MCG Powder For Solution 02220075 HYMENOPTERA VENOM PRODUCT HONEY BEE VENOM JUB

NON POLLEN

Table: NON POLLEN
Drug strength and dosage form DIN Brand name Manufacturer code
100,000U Liquid 00299979 ALLERGENIC EXTRACT NON POLLENS ALK

POLISTES SPP VENOM PROTEIN EXTRACT

Table: POLISTES SPP VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
1.1MG Powder For Solution 01948970 PHARMALGEN WASP VENOM PROTEIN ALK

POLLEN

Table: POLLEN
Drug strength and dosage form DIN Brand name Manufacturer code
4,300U/ML Liquid 00464988 POLLINEX R BEN
100,000U Liquid 00299987 ALLERGENIC EXTRACT POLLENS ALK

POLLEN AND NON POLLEN

Table: POLLEN AND NON POLLEN
Drug strength and dosage form DIN Brand name Manufacturer code
20,000U Liquid 00648922 CENTER-AL ALK

VENOM PROTEIN EXTRACT

Table: VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
3,300MCG Powder For Solution 01948873 PHARMALGEN MIXED VESPID VENOM PROTEIN ALK

VESPULA SPP VENOM PROTEIN EXTRACT

Table: VESPULA SPP VENOM PROTEIN EXTRACT
Drug strength and dosage form DIN Brand name Manufacturer code
1.1MG Powder For Solution 01948954 PHARMALGEN YELLOW JACKET VENOM PROTEIN ALK
120MCG Powder For Solution 01948962 PHARMALGEN YELLOW JACKET VENOM PROTEIN ALK

WASP VENOM PROTEIN

Table: WASP VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 02226219 VENOMIL WASP VENOM PROTEIN JUB
550MCG Powder For Solution 02220091 HYMENOPTERA VENOM PRODUCT WASP VENOM PROTEIN JUB

WHITE FACED HORNET VENOM PROTEIN

Table: WHITE FACED HORNET VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 02226235 VENOMIL WHITE-FACED HORNET VENOM PROTEIN JUB

WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN

Table: WHITE FACED HORNET VENOM PROTEIN, YELLOW HORNET VENOM PROTEIN, YELLOW JACKET VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 01948881 PHARMALGEN MIXED VESPID VENOM PROTEIN ALK
120MCG Powder For Solution 02226294 VENOMIL MIXED VESPID VENOM PROTEIN JUB
550MCG Powder For Solution 02221314 HYMENOPTERA VENOM PRODUCT MIXED VESPID VENOM PROTEIN JUB

YELLOW HORNET VENOM PROTEIN

Table: YELLOW HORNET VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG/ML Powder For Solution 02226251 VENOMIL YELLOW HORNET VENOM PROTEIN JUB
550MCG Powder For Solution 02220083 HYMENOPTERA VENOM PRODUCTS YELLOW HORNET VENOM PROTEIN JUB

YELLOW JACKET VENOM PROTEIN

Table: YELLOW JACKET VENOM PROTEIN
Drug strength and dosage form DIN Brand name Manufacturer code
120MCG Powder For Solution 02226286 VENOMIL YELLOW JACKET VENOM PROTEIN JUB
550MCG Powder For Solution 02220113 HYMENOPTERA VENOM PRODUCT YELLOW JACKET VENOM PROTEIN JUB

92:08.00 5 ALFA REDUCTASE INHIBITORS

DUTASTERIDE

Table: DUTASTERIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Capsule 02412691 ACT DUTASTERIDE TEV
ST0.5MG Capsule 02404206 APO-DUTASTERIDE APX
ST0.5MG Capsule 02469308 AURO-DUTASTERIDE AUR
ST0.5MG Capsule 02247813 AVODART GSK
ST0.5MG Capsule 02421712 DUTASTERIDE PDL
ST0.5MG Capsule 02429012 DUTASTERIDE SIV
ST0.5MG Capsule 02443058 DUTASTERIDE SAN
ST0.5MG Capsule 02484870 JAMP DUTASTERIDE JMP
ST0.5MG Capsule 02416298 MED-DUTASTERIDE GMP
ST0.5MG Capsule 02428873 MINT-DUTASTERIDE MIN
ST0.5MG Capsule 02393220 PMS-DUTASTERIDE PMS
ST0.5MG Capsule 02427753 RIVA-DUTASTERIDE RIV
ST0.5MG Capsule 02424444 SANDOZ DUTASTERIDE SDZ
ST0.5MG Capsule 02408287 TEVA-DUTASTERIDE TEV

FINASTERIDE

Table: FINASTERIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02355043 ACH-FINASTERIDE ACC
ST5MG Tablet 02365383 APO-FINASTERIDE APX
ST5MG Tablet 02405814 AURO-FINASTERIDE AUR
ST5MG Tablet 02376709 DOM-FINASTERIDE DPC
ST5MG Tablet 02350270 FINASTERIDE PDL
ST5MG Tablet 02445077 FINASTERIDE SAN
ST5MG Tablet 02447541 FINASTERIDE SIV
ST5MG Tablet 02357224 JAMP-FINASTERIDE JMP
ST5MG Tablet 02389878 MINT-FINASTERIDE MIN
ST5MG Tablet 02310112 PMS-FINASTERIDE PMS
ST5MG Tablet 02010909 PROSCAR FRS
ST5MG Tablet 02371820 RAN-FINASTERIDE RBY
5MG Tablet 02455013 RIVA-FINASTERIDE RIV
ST5MG Tablet 02322579 SANDOZ FINASTERIDE SDZ
ST5MG Tablet 02348500 TEVA-FINASTERIDE TEV

92:12.00 ANTIDOTES

LEUCOVORIN CALCIUM

Table: LEUCOVORIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Tablet 02170493 LEDERLE LEUCOVORIN PFI

92:16.00 ANTIGOUT AGENTS

ALLOPURINOL

Table: ALLOPURINOL
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Tablet 02481863 AG-ALLOPURINOL ANG
ST100MG Tablet 00555681 ALLOPURINOL PDL
ST100MG Tablet 02402769 APO-ALLOPURINOL APX
ST100MG Tablet 02421593 JAMP-ALLOPURINOL JMP
ST100MG Tablet 02396327 MAR-ALLOPURINOL MAR
ST100MG Tablet 00402818 ZYLOPRIM AAP
200MG Tablet 02481871 AG-ALLOPURINOL ANG
ST200MG Tablet 02130157 ALLOPURINOL PDL
ST200MG Tablet 02402777 APO-ALLOPURINOL APX
ST200MG Tablet 02421607 JAMP-ALLOPURINOL JMP
ST200MG Tablet 02396335 MAR-ALLOPURINOL MAR
ST200MG Tablet 00479799 ZYLOPRIM AAP
300MG Tablet 02481898 AG-ALLOPURINOL ANG
ST300MG Tablet 00294322 ALLOPURINOL APX
ST300MG Tablet 00555703 ALLOPURINOL PDL
ST300MG Tablet 02402785 APO-ALLOPURINOL APX
ST300MG Tablet 02421615 JAMP-ALLOPURINOL JMP
ST300MG Tablet 02396343 MAR-ALLOPURINOL MAR
ST300MG Tablet 00402796 ZYLOPRIM AAP
ST pDIN For Extemporaneous Mixture 99503018 ALLOPURINOL ORAL LIQUID UNK

COLCHICINE

Table: COLCHICINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.6MG Tablet 00572349 COLCHICINE ODN
ST0.6MG Tablet 02373823 JAMP-COLCHICINE JMP
ST0.6MG Tablet 02402181 PMS-COLCHICINE PMS
0.6MG Tablet 00287873 SANDOZ COLCHICINE SDZ

FEBUXOSTAT

Limited use benefit (prior approval required).

For patients with symptomatic gout who have documented hypersensitivity to allopurinol.

Table: FEBUXOSTAT
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG Tablet 02490870 JAMP FEBUXOSTAT JMP
ST80MG Tablet 02473607 MAR-FEBUXOSTAT MAR
ST80MG Tablet 02466198 TEVA-FEBUXOSTAT TEV
ST80MG Tablet 02357380 ULORIC TAK

92:20.00 IMMUNOMODULAROTY AGENTS

FINGOLIMOD (FINGOLIMOD HYDROCHLORIDE)

Limited use benefit (prior approval required).

Initial Coverage (one year):

For the treatment of patients with Relapsing Remitting Multiple Sclerosis (RRMS) who meet all of the following criteria:

  • failure to respond to full and adequate courses of at least one initial disease-modifying therapy (an interferon, glatiramer acetate, dimethyl fumarate, ocrelizumab or teriflunomide) or documented intolerance to at least 2 therapies; and
  • one or more clinically disabling relapses in the previous year; and
  • significant increase in T2 lesion load compared with that from a previous MRI scan or at least one gadolinium-enhancing lesion; and
  • requested and followed by a neurologist experienced in the management of RRMS; and
  • recent Expanded Disability Status Scale (EDSS) score.

Renewal Coverage (two years):

  • EDSS scores must be provided (exam must have occurred within that last 90 days).
  • patients must be stable or have experienced no more than 1 disabling attack/relapse in the past year.
Table: FINGOLIMOD (FINGOLIMOD HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code
0.5MG Capsule 02475669 ACH-FINGOLIMOD ACC
0.5MG Capsule 02469936 APO-FINGOLIMOD APX
0.5MG Capsule 02365480 GILENYA NVR
0.5MG Capsule 02487772 JAMP FINGOLIMOD JMP
0.5MG Capsule 02474743 MAR-FINGOLIMOD MAR
0.5MG Capsule 02469715 MYLAN-FINGOLIMOD MYL
0.5MG Capsule 02469782 PMS-FINGOLIMOD PMS
0.5MG Capsule 02482606 SANDOZ FINGOLIMOD SDZ
0.5MG Capsule 02469618 TARO-FINGOLIMOD TAR
0.5MG Capsule 02469561 TEVA-FINGOLIMOD TEV

GLATIRAMER ACETATE

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.
Table: GLATIRAMER ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG Solution 02245619 COPAXONE TEV
20MG Solution 02460661 GLATECT PMS

INTERFERON 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.
Table: INTERFERON BETA-1A
Drug strength and dosage form DIN Brand name Manufacturer code
30MCG Injection 09857395 AVONEX PEN UNK
30MCG Injection 99100763 AVONEX PEN UNK
60MCG Powder For Solution 02267594 AVONEX UNK
22MCG Solution 02237319 REBIF SRO
30MCG Solution 02269201 AVONEX UNK
44MCG Solution 02237318 REBIF SRO
44MCG Solution 02237320 REBIF SRO
66MCG Solution 02318253 REBIF SRO
132MCG Solution 02318261 REBIF SRO
132MCG Solution 02318288 REBIF SRO

INTERFERON BETA-1B

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.
Table: INTERFERON BETA-1B
Drug strength and dosage form DIN Brand name Manufacturer code
0.3MG Injection 99100555 BETASERON INITIATION KIT BAY
0.3MG Powder For Solution 02169649 BETASERON BAY
0.3MG Powder For Solution 02337819 EXTAVIA NVR

OCRELIZUMAB

Limited use benefit (prior approval required).

1. For the treatment of relapsing-remitting multiple sclerosis (RRMS) diagnosed according to the 2017 McDonald clinical criteria and magnetic resonance imaging (MRI) evidence who meet all of the following criteria:

  • prescribed by a neurologist experienced in the management of RRMS; and
  • 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. Expanded Disability Status Scale score (EDSS) of 5.5 or less.
  • patient is 18 years of age or older.

*. A clinical relapse is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 24 hours in the absence of fever, preceded by stability for at least one month.

**. MRI activity is defined as any new multiple sclerosis lesion/s, expanding lesion/s, and/or enhancing lesion/s.

or

2. For the treatment of primary progressive multiple sclerosis (PPMS) diagnosed according to the 2017 McDonald clinical criteria and magnetic resonance imaging (MRI) evidence who meet all of the following criteria:

Initial Coverage (one year)

  • prescribed by a neurologist experienced in the management of PPMS; and
  • expanded Disability Status Scale (EDSS) between 3.0 and 6.5; and
  • score of at least 2.0 on the Functional Systems scale (FSS) for the pyramidal system due to lower extremity findings; and
  • disease duration of less than 15 years for those with an EDSS greater than 5.0 or less than 10 years for those with an EDSS of 5.0 of less; and
  • patient is 18 years of age or older.

Renewal Coverage for PPMS (one year):

  • EDSS of less than 7.0.
Table: OCRELIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
30MG Solution 02467224 OCREVUS HLR

TERIFLUNOMIDE

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.
Table: TERIFLUNOMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
14MG Tablet 02416328 AUBAGIO GEE

92:24.00 BONE RESORPTION INHIBITORS

ALENDRONATE SODIUM

Table: ALENDRONATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02381478 ACH-ALENDRONATE ACC
ST5MG Tablet 02248727 APO-ALENDRONATE APX
ST5MG Tablet 02384698 RAN-ALENDRONATE RBY
ST5MG Tablet 02248251 TEVA-ALENDRONATE TEV
ST10MG Tablet 02381486 ACH-ALENDRONATE ACC
ST10MG Tablet 02248728 APO-ALENDRONATE APX
ST10MG Tablet 02388545 AURO-ALENDRONATE AUR
ST10MG Tablet 02384701 RAN-ALENDRONATE RBY
ST10MG Tablet 02288087 SANDOZ ALENDRONATE SDZ
ST10MG Tablet 02247373 TEVA-ALENDRONATE TEV
ST70MG Tablet 02381494 ACH-ALENDRONATE ACC
ST70MG Tablet 02299712 ALENDRONATE SIV
ST70MG Tablet 02352966 ALENDRONATE SAN
ST70MG Tablet 02303078 ALENDRONATE-70 PDL
ST70MG Tablet 02248730 APO-ALENDRONATE APX
ST70MG Tablet 02388553 AURO-ALENDRONATE AUR
ST70MG Tablet 02282763 DOM-ALENDRONATE DPC
ST70MG Tablet 02245329 FOSAMAX FRS
ST70MG Tablet 02385031 JAMP-ALENDRONATE JMP
ST70MG Tablet 02394871 MINT-ALENDRONATE MIN
ST70MG Tablet 02273179 PMS-ALENDRONATE PMS
ST70MG Tablet 02284006 PMS-ALENDRONATE PMS
ST70MG Tablet 02384728 RAN-ALENDRONATE RBY
ST70MG Tablet 02270889 RIVA-ALENDRONATE RIV
ST70MG Tablet 02288109 SANDOZ ALENDRONATE SDZ
ST70MG Tablet 02261715 TEVA-ALENDRONATE TEV

ALENDRONATE SODIUM, CHOLECALCIFEROL

Table: ALENDRONATE SODIUM, CHOLECALCIFEROL
Drug strength and dosage form DIN Brand name Manufacturer code
ST70MG & 2,800U Tablet 02454467 APO-ALENDRONATE/VITAMIN D3 APX
ST70MG & 2,800U Tablet 02276429 FOSAVANCE FRS
ST70MG & 2,800U Tablet 02403633 TEVA-ALENDRONATE/CHOLECALCIFEROL TEV
ST70MG & 5,600U Tablet 02454475 APO-ALENDRONATE/VITAMIN D3 APX
ST70MG & 5,600U Tablet 02314940 FOSAVANCE FRS
ST70MG & 5,600U Tablet 02429160 SANDOZ ALENDRONATE/CHOLECALCIFEROL SDZ
ST70MG & 5,600U Tablet 02403641 TEVA-ALENDRONATE/CHOLECALCIFEROL TEV

DENOSUMAB (PROLIA)

Limited use benefit (prior approval required).

For the treatment of osteoporosis in patients who have a significant fracture risk defined as either:

  • moderate 10-year fracture risk (10% to 20%) with a prior fragility fracture; or
  • high 10-year fracture risk (≥ 20%);
  • and
  • have a contraindication to oral bisphosphonates (e.g. hypersensitivity, esophageal abnormality, renal impairment); or
  • have failed or have an intolerance to oral bisphosphonates (e.g. hypersensitivity, esophageal abnormality, renal impairment).
Table: DENOSUMAB (PROLIA)
Drug strength and dosage form DIN Brand name Manufacturer code
60MG/ML Solution 02343541 PROLIA AMG

DENOSUMAB (XGEVA)

Limited use benefit (prior approval required).

For the prevention of skeletal-related events (SREs) in patients with castrate-resistant prostate cancer (CRPC) with:

  • one or more documented bone metastases; and
  • good performance status (ECOG performance status score of 0, 1, or 2).
Table: DENOSUMAB (XGEVA)
Drug strength and dosage form DIN Brand name Manufacturer code
120MG/1.7ML Solution 02368153 XGEVA AMG

ETIDRONATE DISODIUM

Table: ETIDRONATE DISODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST200MG Tablet 02248686 ACT ETIDRONATE TEV

PAMIDRONATE DISODIUM

Table: PAMIDRONATE DISODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
6MG Solution 02249677 PAMIDRONATE OMG
9MG Solution 02246599 PAMIDRONATE FKD
9MG Solution 02249685 PAMIDRONATE DISODIUM OMEGA OMG
30MG Solution 02244550 PAMIDRONATE DISODIUM PFI
60MG Solution 02244551 PAMIDRONATE DISODIUM PFI
90MG Solution 02244552 PAMIDRONATE DISODIUM PFI
90MG Solution 02245999 PMS-PAMIDRONATE PMS

RISEDRONATE SODIUM

Table: RISEDRONATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST5MG Tablet 02298376 TEVA-RISEDRONATE TEV
ST30MG Tablet 02298384 TEVA-RISEDRONATE TEV
ST35MG Tablet 02370255 RISEDRONATE SAN
ST35MG Tablet 02411407 RISEDRONATE-35 SIV
ST35MG Tablet 02298392 TEVA-RISEDRONATE TEV
ST150MG Tablet 02413809 TEVA-RISEDRONATE TEV

RISEDRONATE SODIUM (RISEDRONATE SODIUM HEMIPENTAHYDRATE)

Table: RISEDRONATE SODIUM (RISEDRONATE SODIUM HEMIPENTAHYDRATE)
Drug strength and dosage form DIN Brand name Manufacturer code
ST35MG Tablet 02246896 ACTONEL ALL
ST35MG Tablet 02353687 APO-RISEDRONATE APX
ST35MG Tablet 02406306 AURO-RISEDRONATE AUR
ST35MG Tablet 02309831 DOM-RISEDRONATE DPC
ST35MG Tablet 02368552 JAMP-RISEDRONATE JMP
ST35MG Tablet 02302209 PMS-RISEDRONATE PMS
ST35MG Tablet 02347474 RISEDRONATE PDL
ST35MG Tablet 02341077 RIVA-RISEDRONATE RIV
ST35MG Tablet 02327295 SANDOZ RISEDRONATE SDZ
ST150MG Tablet 02316838 ACTONEL ALL
ST150MG Tablet 02377721 APO-RISEDRONATE APX
ST150MG Tablet 02424177 PMS-RISEDRONATE PMS

ZOLEDRONIC ACID MONOHYDRATE

Limited use benefit (prior approval required).

Maximum dose covered is 5mg per 12-month period

For the treatment of Paget's disease; or

For the treatment of osteoporosis in patients who have a significant fracture risk defined as either:

  • moderate 10-year fracture risk (10% to 20%) with a prior fragility fracture; or
  • high 10-year fracture risk (≥ 20%); and
  • have a contraindication to oral bisphosphonates (e.g. hypersensitivity, esophageal abnormality, renal impairment);or
  • have failed or have an intolerance to oral bisphosphonates (e.g. hypersensitivity, esophageal abnormality, renal impairment).
Table: ZOLEDRONIC ACID MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG/100ML Solution 02269198 ACLASTA NVR
5MG/100ML Solution 02415100 TARO-ZOLEDRONIC ACID TAR
5MG/100ML Solution 02422433 ZOLEDRONIC ACID REC

92:32.00 

ICATIBANT

Limited use benefit (prior approval required).

For the treatment of acute attacks of hereditary angioedema (HAE) in adults with lab-confirmed C1-esterase inhibitor deficiency (type I or type II); and

  • treatment of acute non-laryngeal attacks of at least moderate severity; or
  • treatment of acute laryngeal attacks; and
  • is prescribed by physician with experience in the treatment of HAE.

Note: Limited to two (2) doses of prefilled syringes per dispense.

Table: ICATIBANT
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Solution 02425696 FIRAZYR UNK

92:36.00 DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ABATACEPT

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • polyarticular juvenile idiopathic arthritis (pJIA) according to established criteria.

(Please refer to Appendix A).

Table: ABATACEPT
Drug strength and dosage form DIN Brand name Manufacturer code
250MG Powder For Solution 02282097 ORENCIA BMS
125MG Solution 02402475 ORENCIA BMS

ADALIMUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.
  • psoriasis according to established criteria.
  • Crohn's disease according to established criteria.
  • polyarticular juvenile idiopathic arthritis (pJIA) according to established criteria.
  • ulcerative colitis according to established criteria.
  • hidradenitis suppurativa according to established criteria.

(Please refer to Appendix A).

Table: ADALIMUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
40MG/VIAL Solution 02258595 HUMIRA ABV

CERTOLIZUMAB PEGOL

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.

(Please refer to Appendix A).

Table: CERTOLIZUMAB PEGOL
Drug strength and dosage form DIN Brand name Manufacturer code
200MG Solution 02465574 CIMZIA UCB
200MG/ML Solution 02331675 CIMZIA UCB

ETANERCEPT

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.
  • polyarticular juvenile idiopathic arthritis (pJIA) according to established criteria.

(Please refer to Appendix A).

Table: ETANERCEPT
Drug strength and dosage form DIN Brand name Manufacturer code
25MG/VIAL Injection 02242903 ENBREL PED
50MG/ML Injection 02274728 ENBREL PED
50MG/ML Injection 99100373 ENBREL SURECLICK AMG

ETANERCEPT (BRENZYS)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.

(Please refer to Appendix A).

Table: ETANERCEPT (BRENZYS)
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Solution 02455323 BRENZYS UNK
50MG Solution 02455331 BRENZYS UNK

ETANERCEPT (ERELZI)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.
  • polyarticular juvenile idiopathic arthritis (pJIA) according to established criteria.

(Please refer to Appendix A).

Table: ETANERCEPT (ERELZI)
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Solution 02462877 ERELZI SDZ
50MG Solution 02462850 ERELZI SDZ
50MG Solution 02462869 ERELZI SDZ

GOLIMUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.
  • ulcerative colitis according to established criteria.

(Please refer to Appendix A).

Table: GOLIMUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/0.5ML Solution 02324776 SIMPONI JSO
50MG/0.5ML Solution 02324784 SIMPONI JSO
100MG/ML Solution 02413175 SIMPONI JSO
100MG/ML Solution 02413183 SIMPONI JSO

INFLIXIMAB (INFLECTRA)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • psoriatic arthritis according to established criteria.
  • ankylosing spondylitis according to established criteria.
  • psoriasis according to established criteria.
  • Crohn's disease according to established criteria.
  • fistulizing Crohn's disease according to established criteria.
  • ulcerative colitis according to established criteria.

(Please refer to Appendix A).

Table: INFLIXIMAB (INFLECTRA)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Powder For Solution 02419475 INFLECTRA HOS
100MG Powder For Solution 02470373 RENFLEXIS UNK

INFLIXIMAB (REMICADE)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • Crohn's disease according to established criteria.
  • fistulizing Crohn's disease according to established criteria.

(Please refer to Appendix A).

Table: INFLIXIMAB (REMICADE)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG/VIAL Powder For Solution 02244016 REMICADE JSO

LEFLUNOMIDE

Table: LEFLUNOMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02478862 ACCEL-LEFLUNOMIDE ACP
ST10MG Tablet 02256495 APO-LEFLUNOMIDE APX
ST10MG Tablet 02241888 ARAVA SAC
10MG Tablet 02351668 LEFLUNOMIDE SAN
ST10MG Tablet 02415828 LEFLUNOMIDE PDL
10MG Tablet 02288265 PMS-LEFLUNOMIDE PMS
ST10MG Tablet 02283964 SANDOZ LEFLUNOMIDE SDZ
ST10MG Tablet 02261251 TEVA-LEFLUNOMIDE TEV
ST20MG Tablet 02478870 ACCEL-LEFLUNOMIDE ACP
ST20MG Tablet 02256509 APO-LEFLUNOMIDE APX
ST20MG Tablet 02241889 ARAVA SAC
ST20MG Tablet 02351676 LEFLUNOMIDE SAN
ST20MG Tablet 02415836 LEFLUNOMIDE PDL
ST20MG Tablet 02288273 PMS-LEFLUNOMIDE PMS
ST20MG Tablet 02283972 SANDOZ LEFLUNOMIDE SDZ
ST20MG Tablet 02261278 TEVA-LEFLUNOMIDE TEV

SARILUMAB

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.

(Please refer to Appendix A).

Table: SARILUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
150MG Solution 02460521 KEVZARA SAC
150MG Solution 02472961 KEVZARA SAC
200MG Solution 02460548 KEVZARA SAC
200MG Solution 02472988 KEVZARA SAC

TOCILIZUMAB (IV)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • systemic juvenile idiopathic arthritis (sJIA) according to established criteria.
  • polyarticular juvenile idiopathic arthritis (pJIA) according to established criteria.

(Please refer to Appendix A).

Table: TOCILIZUMAB (IV)
Drug strength and dosage form DIN Brand name Manufacturer code
80MG/4ML Solution 02350092 ACTEMRA HLR
200MG/10ML Solution 02350106 ACTEMRA HLR
400MG/20ML Solution 02350114 ACTEMRA HLR

TOCILIZUMAB (SC)

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.
  • giant cell arteritis according to established criteria.

(Please refer to Appendix A).

Table: TOCILIZUMAB (SC)
Drug strength and dosage form DIN Brand name Manufacturer code
162MG Solution 02424770 ACTEMRA HLR
162MG Solution 02483327 ACTEMRA HLR

TOFACITINIB CITRATE

Limited use benefit (prior approval required).

For the treatment of:

  • rheumatoid arthritis according to established criteria.

(Please refer to Appendix A).

Table: TOFACITINIB CITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Tablet 02423898 XELJANZ PFI
11MG Tablet (Extended Release) 02470608 XELJANZ XR PFI

92:44.00 IMMUNOSUPPRESSIVE AGENTS

ALEMTUZUMAB

Limited use benefit (prior approval required).

Coverage is provided for two years (i.e. two treatment courses/ total of eight doses) for adult patients who meet all of the following criteria:

For the treatment of relapsing-remitting multiple sclerosis (RRMS) diagnosed according to the 2017 McDonald clinical criteria and magnetic resonance imaging (MRI) evidence; and

  • prescribed by a specialist with experience in the treatment of multiple sclerosis; and
  • highly active disease defined by clinical and imaging features (i.e. significant increase in T2 lesion load compared with that from a previous MRI scan or at least one gadolinium-enhancing lesion) - MRI report does not need to be submitted with the request; and
  • failure to respond to full and adequate courses of at least two trials of disease-modifying therapies (DMT) for at least six months each or where any other DMT is contraindicated or otherwise unsuitable; and
  • at least one relapse while on at least six months of a DMT within the last 10 years, and
  • at least two attacks (first episode or relapse) in the previous two years, with at least one attack in the previous year; and
  • an Expanded Disability Status Scale (EDSS) score of five (5) or less.
Table: ALEMTUZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
12MG Solution 02418320 LEMTRADA GEE

AZATHIOPRINE

Table: AZATHIOPRINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST50MG Tablet 02242907 APO-AZATHIOPRINE APX
ST50MG Tablet 02243371 AZATHIOPRINE-50 PDL
ST50MG Tablet 00004596 IMURAN ASP
ST50MG Tablet 02236819 TEVA-AZATHIOPRINE TEV
ST pDIN For Extemporaneous Mixture 99503019 AZATHIOPRINE ORAL LIQUID UNK

CLADRIBINE

Limited use benefit (prior approval required).

Initial Coverage (two years):

For the treatment of patients with Relapsing Remitting Multiple Sclerosis (RRMS) who meet all of the following criteria:

  • failure to respond to full and adequate courses* of at least ONE initial disease-modifying therapy (DMT) (interferon, glatiramer, dimethyl fumarate, ocrelizumab or teriflunomide) or documented intolerance** to at least 2 DMTs; and
  • one or more clinically disabling relapses in the previous year; and
  • significant increase in T2 lesion load compared with that from a previous MRI scan or at least one gadolinium-enhancing lesion; and
  • requested and followed by a neurologist experienced in the management of RRMS; and
  • recent Expanded Disability Status Scale (EDSS) score***

* failure to respond is defined as: a trial of at least 6 months and experienced at least one disabling relapse (attack) while on an initial DMT.

** intolerance is defined as: documented serious adverse effects or contraindications that are incompatible with further use of that class of drug.

*** recent Expanded Disability Status Scale (EDSS) score less than or equal to 5.5 (i.e. patients must be able to ambulate at least 100 meters without assistance).

Table: CLADRIBINE
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Tablet 02470179 MAVENCLAD SRO

CYCLOSPORINE

Limited use benefit (prior approval required).

For transplant therapy.

Table: CYCLOSPORINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Capsule 02237671 NEORAL NVR
ST25MG Capsule 02150689 NEORAL NVR
ST25MG Capsule 02247073 SANDOZ CYCLOSPORINE SDZ
ST50MG Capsule 02150662 NEORAL NVR
ST50MG Capsule 02247074 SANDOZ CYCLOSPORINE SDZ
ST100MG Capsule 02150670 NEORAL NVR
ST100MG Capsule 02242821 SANDOZ CYCLOSPORINE SDZ
ST100MG/ML Solution 02244324 APO-CYCLOSPORINE APX
ST100MG/ML Solution 02150697 NEORAL NVR

MEPOLIZUMAB

Limited use benefit (prior approval required).

For initial 12-month coverage:

For the adjunctive treatment of severe eosinophilic asthma in adults who are inadequately controlled with high-dose inhaled corticosteroids plus one or more additional asthma controller(s) (e.g. long-acting beta-agonist); and

  • have had a blood eosinophil count of ≥0.15x109/L before initiation of Nucala (levels must have been drawn within 3 months of the start of treatment); or
  • have had a blood eosinophil count of ≥0.3x109/L within the 12-month period prior to starting Nucala
  • and
  • show reversibility on spirometry (a rise in FEV1of at least 12% and at least 200 mL);
  • and
  • have experienced two or more clinically significant asthma exacerbations* in the past 12 months period prior to starting Nucala; or
  • have received maintenance therapy with daily oral corticosteroids for at least 3 months prior to starting Nucala.

For 12-month renewal coverage:

For the adjunctive treatment of severe eosinophilic asthma in adult patients who have experienced a decrease in clinically significant exacerbations with mepolizumab treatment as demonstrated by:

  • patient has experienced a decrease in clinically significant asthma exacerbations* with Nucala treatment; or
  • patient`s oral corticosteroid maintenance dose decreased by at least 25 % from the pre-treatment dose.

Coverage for Nucala is provided for a maximum dose of 100 mg every four weeks.

* A clinically significant asthma exacerbation is defined as worsening of asthma such that the treating physician elected to administer systemic glucocorticoids for at least three days or the patient visited an emergency department or was hospitalized.

Table: MEPOLIZUMAB
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Powder For Solution 02449781 NUCALA GSK
100MG Solution 02492989 NUCALA GSK
100MG Solution 02492997 NUCALA GSK

MYCOPHENOLATE MOFETIL

Limited use benefit (prior approval required).

For transplant therapy.

Table: MYCOPHENOLATE MOFETIL
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Capsule 02383780 ACH-MYCOPHENOLATE ACC
ST250MG Capsule 02352559 APO-MYCOPHENOLATE APX
ST250MG Capsule 02192748 CELLCEPT HLR
ST250MG Capsule 02386399 JAMP-MYCOPHENOLATE JMP
ST250MG Capsule 02457369 MYCOPHENOLATE MOFETIL SAN
ST250MG Capsule 02371154 MYLAN-MYCOPHENOLATE MYL
ST250MG Capsule 02320630 SANDOZ MYCOPHENOLATE SDZ
ST250MG Capsule 02364883 TEVA-MYCOPHENOLATE TEV
ST200MG Powder For Suspension 02242145 CELLCEPT HLR
ST500MG Tablet 02352567 APO-MYCOPHENOLATE APX
ST500MG Tablet 02237484 CELLCEPT HLR
ST500MG Tablet 02380382 JAMP-MYCOPHENOLATE JMP
ST500MG Tablet 02378574 MYCOPHENOLATE ACC
ST500MG Tablet 02457377 MYCOPHENOLATE MOFETIL SAN
ST500MG Tablet 02370549 MYLAN-MYCOPHENOLATE MYL
ST500MG Tablet 02313855 SANDOZ MYCOPHENOLATE SDZ
ST500MG Tablet 02348675 TEVA-MYCOPHENOLATE TEV

MYCOPHENOLATE SODIUM

Limited use benefit (prior approval required).

For transplant therapy.

Table: MYCOPHENOLATE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST180MG Tablet (Enteric Coated) 02372738 APO-MYCOPHENOLIC ACID APX
ST180MG Tablet (Enteric Coated) 02264560 MYFORTIC NVR
ST360MG Tablet (Enteric Coated) 02372746 APO-MYCOPHENOLIC ACID APX
ST360MG Tablet (Enteric Coated) 02264579 MYFORTIC NVR

SIROLIMUS

Limited use benefit (prior approval required).

Coverage will be provided as a second line therapy for patients failing mycophenolate mofetil.

Table: SIROLIMUS
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG/ML Solution 02243237 RAPAMUNE PFI
ST1MG Tablet 02247111 RAPAMUNE PFI

TACROLIMUS MONOHYDRATE

Limited use benefit (prior approval required).

For transplant therapy.

Table: TACROLIMUS MONOHYDRATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Capsule 02243144 PROGRAF AST
ST0.5MG Capsule 02416816 SANDOZ TACROLIMUS SDZ
ST1MG Capsule 02175991 PROGRAF AST
ST1MG Capsule 02416824 SANDOZ TACROLIMUS SDZ
ST5MG Capsule 02175983 PROGRAF AST
ST0.5MG Capsule (Extended Release) 02296462 ADVAGRAF AST
ST1MG Capsule (Extended Release) 02296470 ADVAGRAF AST
ST3MG Capsule (Extended Release) 02331667 ADVAGRAF AST
ST5MG Capsule (Extended Release) 02296489 ADVAGRAF AST
ST5MG Capsule (Immediate Release) 02416832 SANDOZ TACROLIMUS SDZ
5MG/ML Solution 02176009 PROGRAF AST

92:92.00 OTHER MISCELLANEOUS THERAPEUTIC AGENTS

ABOBOTULINUMTOXINA

Limited use benefit (prior approval required).

Treatment of cervical dystonia (spasmodic torticollis) in adults; or

Symptomatic treatment of focal spasticity affecting upper limbs in adults; or

Lower limb spasticity in patients 2 years of age and older.

Table: ABOBOTULINUMTOXINA
Drug strength and dosage form DIN Brand name Manufacturer code
300U Powder For Solution 02460203 DYSPORT THERAPEUTIC IPS
500U Powder For Solution 02456117 DYSPORT THERAPEUTIC IPS

CINACALCET (CINACALCET HYDROCHLORIDE)

Table: CINACALCET (CINACALCET HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code
30MG Tablet 02452693 APO-CINACALCET APX
30MG Tablet 02478900 AURO-CINACALCET AUR
30MG Tablet 02463814 CINACALCET UNK
30MG Tablet 02485028 JAMP CINACALCET JMP
30MG Tablet 02480298 MAR-CINACALCET MAR
30MG Tablet 02481987 M-CINACALCET MAN
30MG Tablet 02434539 MYLAN-CINACALCET MYL
30MG Tablet 02472538 REDDY-CINACALCET REC
30MG Tablet 02456729 SANDOZ CINACALCET SDZ
30MG Tablet 02257130 SENSIPAR AMG
30MG Tablet 02441624 TEVA-CINACALCET TEV
60MG Tablet 02452707 APO-CINACALCET APX
60MG Tablet 02478919 AURO-CINACALCET AUR
60MG Tablet 02463822 CINACALCET UNK
60MG Tablet 02485036 JAMP CINACALCET JMP
60MG Tablet 02480301 MAR-CINACALCET MAR
60MG Tablet 02481995 M-CINACALCET MAN
60MG Tablet 02434547 MYLAN-CINACALCET MYL
60MG Tablet 02472546 REDDY-CINACALCET REC
60MG Tablet 02456737 SANDOZ CINACALCET SDZ
60MG Tablet 02257149 SENSIPAR AMG
60MG Tablet 02441632 TEVA-CINACALCET TEV
90MG Tablet 02452715 APO-CINACALCET APX
90MG Tablet 02478943 AURO-CINACALCET AUR
90MG Tablet 02463830 CINACALCET UNK
90MG Tablet 02485044 JAMP CINACALCET JMP
90MG Tablet 02480328 MAR-CINACALCET MAR
90MG Tablet 02482002 M-CINACALCET MAN
90MG Tablet 02434555 MYLAN-CINACALCET MYL
90MG Tablet 02472554 REDDY-CINACALCET REC
90MG Tablet 02456745 SANDOZ CINACALCET SDZ
90MG Tablet 02257157 SENSIPAR AMG
90MG Tablet 02441640 TEVA-CINACALCET TEV

CYPROTERONE ACETATE

Table: CYPROTERONE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Tablet 00704431 ANDROCUR BAY
50MG Tablet 02245898 CYPROTERONE AAP
50MG Tablet 02390760 MED-CYPROTERONE GMP
50MG Tablet 02395797 RIVA-CYPROTERONE RIV

CYPROTERONE ACETATE, ETHINYL ESTRADIOL

Table: CYPROTERONE ACETATE, ETHINYL ESTRADIOL
Drug strength and dosage form DIN Brand name Manufacturer code
2MG & 35MCG Tablet 02290308 CYESTRA-35 PAL
2MG & 35MCG Tablet 02233542 DIANE-35 BAY
2MG & 35MCG Tablet 02425017 RAN-CYPROTERONE/ETHINYL ESTRADIOL RBY
2MG & 35MCG Tablet 02309556 TEVA-CYPROTERONE / ETHINYL ESTRADIOL TEV

INCOBOTULINUMTOXINA

Limited use benefit (prior approval required).

For the treatment of:

  • strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; or
  • cervical dystonia (spasmodic torticollis).
Table: INCOBOTULINUMTOXINA
Drug strength and dosage form DIN Brand name Manufacturer code
50UNIT/VIAL Powder For Solution 02371081 XEOMIN MEZ
100U/VIAL Powder For Solution 02324032 XEOMIN MEZ

LANREOTIDE ACETATE

Table: LANREOTIDE ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
60MG/0.3ML Solution (Extended Release) 02283395 SOMATULINE AUTOGEL IPS
90MG/0.3ML Solution (Extended Release) 02283409 SOMATULINE AUTOGEL IPS
120MG/0.5ML Solution (Extended Release) 02283417 SOMATULINE AUTOGEL IPS

ONABOTULINUMTOXINA

Limited use benefit (prior approval required).

For the treatment of:

  • strabismus and blepharospasm associated with dystonia, including benign essential blepharospasm or VII nerve disorder in patients 12 years of age or older; or
  • cervical dystonia (spasmodic torticollis); or
  • urinary incontinence due to neurogenic detrusor over activity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury; or
  • overactive bladder.
Table: ONABOTULINUMTOXINA
Drug strength and dosage form DIN Brand name Manufacturer code
50IU Injection 09857386 BOTOX ALL
200IU Injection 09857387 BOTOX ALL
100IU Powder For Solution 01981501 BOTOX ALL
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