Update to the Drug Benefit List - Spring 2015

The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including prescription and non-prescription drugs, for registered First Nations and recognized Inuit throughout Canada.

Benefit Definitions

Open benefits
Open benefits are the drugs listed in the NIHB Drug Benefit List (DBL) which do not have established criteria or prior approval requirements.
Limited use benefits
Limited use drugs are those that have been found to be effective in specific circumstances, or which have quantity and frequency limitations.  For drugs in this category, specific criteria must be met to be eligible for coverage.
Not added to the formulary
Drugs not added to formulary are those which are not listed in the NIHB DBL after review by the national Common Drug Review (CDR) process and/or the NIHB Drugs and Therapeutics Advisory Committee (DTAC). These drugs will not be added to the NIHB drug list because published evidence does not support the clinical value or cost of the drug relative to existing therapies. Coverage may be considered in special circumstances upon receipt of a completed "Exception Drugs Request Form" from the attending licensed practitioner. These requests are reviewed on a case-by-case basis.
Exclusion
Certain drug therapies for particular conditions fall outside the NIHB Program's mandate and will not be provided as benefits (e.g., cosmetic and anti-obesity drugs).  As well, certain drugs will be excluded from the NIHB Program as recommended by the CDR and the DTAC because published evidence does not support the clinical value, safety or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.

Note: The appeal process and the emergency supply policy does not apply to excluded drugs.

DIN (Drug Identification Number)
MFR (Manufacturer)
ST (Short-Term Dispensing Policy Drug)

Additions to the Drug Benefit List

Open Benefits

Table 1 - Single-Source Drug Products
DIN MFR ITEM NAME Effective Date
02404834 MEM EMERGENCY ACNE VANISHING WIPES 05-01-2015
02404621 JOM OIL-FREE ACNE WASH CLEANSER 05-01-2015
02315211 VAE PURIFYING CLEANSER 05-01-2015
02413353 GSK SPECTRO ACNECARE WASH 05-01-2015
02243158 GSK CLINDOXYL GEL 13-02-2015
02382822 GSK CLINDOXYL ADV 1.0/3.0% GEL 13-02-2015
02248472 VAE BENZACLIN TOPICAL GEL 13-02-2015
02414678 PFI PREMARIN 0.3MG TABLET 26-11-2014
02414686 PFI PREMARIN 0.625MG TABLET 26-11-2014
02414694 PFI PREMARIN 1.25MG TABLET 26-11-2014
02242119 BOE STAGGRENOX  CAPSULE 18-02-2015
02414945 VII TIVICAY 50MG TABLET 23-09-2014
02225271 VAE BENZAMYCIN GEL 13-02-2015
02377098 TEP DIVIGEL 0.25MG TRANSDERMAL GEL 21-01-2015
02424835 TEP DIVIGEL 0.5MG TRANSDERMAL GEL 21-01-2015
02424843 TEP DIVIGEL 1MG TRANSDERMAL GEL 21-01-2015
02257270 ALL ZYMAR 3MG/ML OPHTHALMIC SOLUTUION 01-12-2014
97799913 BAY KETOSTIX 50 28-01-2015
02369362 ALL ACUVAIL 0.45% OPHTHALMIC SOLUTION 11-02-2015
02231507 JNO LACTAID ULTRA TABLET 06-01-2015
97799946 ROC ACCU-CHEK SOFTCLIX LANCETS 29-01-2015
97799690 BTD BD ULTRAFINE 33G LANCETS 06-02-2015
97799825 BAY FINGERSTIX LANCETS 29-01-2015
97799826 BAY FREESTYLE LANCETS 29-01-2015
97799918 BAY MICROLET LANCETS 29-01-2015
97799804 TYC MONOLET (MONOJECT) 21G 29-01-2015
97799801 TYC MONOLET THIN (MONOJECT) 28G 29-01-2015
97799970 JAJ ONETOUCH ULTRASOFT LANCETS 29-01-2015
97799348 SKY ULTILET CLASSIC LANCETS 17-11-2014
02399466 FEI STPENTASA 1G TABLET LA 20-02-2015
02252260 ALC VIGAMOX 0.5% OPHTHALMIC SOLUTUION 01-12-2014
97799334 MTD MONTKIDDY BLUE NEEDLES 32GX4MM 24-02-2015
97799337 MTD MONTKIDDY GREEN NEEDLES 32GX4 24-02-2015
97799335 MTD MONTKIDDY PINK NEEDLES 32GX4MM 24-02-2015
97799336 MTD MONTKIDDY YELLOW NEEDLES 32GX4 24-02-2015
02411393 ALC ILEVRO 0.3% OPHTHALMIC SUSPENSION 11-02-2015
02308983 ALC NEVANAC 0.1% OPHTHALMIC SOLUTION 01-12-2014
02367289 BOE VIRAMUNE XR 400MG TABLET 23-09-2014
02291924 PFI BICILLIN L-A INJECTION 04-03-2015
02419106 BOE COMBIVENT RESPIMAT 100/20MCG 04-01-2015
02193221 OMG THIAMIJECT 100MG/ML INJECTION 14-10-2014
00000981 ALC MYDRIACYL 0.5% OPHTHALMIC SOLUTION 20-10-2014
00001007 ALC MYDRIACYL 1% OPHTHALMIC SOLUTION 20-10-2014
02230402 LUK STCLOPIXOL 10MG TABLET 09-01-2015
02230403 LUK STCLOPIXOL 25MG TABLET 09-01-2015
02230405 LUK CLOPIXOL ACUPHASE 50MG/ML INJECTION 09-01-2015
02230406 LUK CLOPIXOL DEPOT 200MG/ML 09-01-2015
 
Table 2 - Multi-Source Drug Products
DIN MFR ITEM NAME Effective Date
02427176 SAN STASA EC 80MG TABLET 17-12-2014
02426811 SAN STASA EC 81MG TABLET 18-12-2014
02243974 PED STASAPHEN 81MG TABLET 04-09-2014
02420279 RIV STRIVASA 81 MG EC TABLET 15-01-2015
02381486 ACC STALENDRONATE SODIUM 10MG TABLET 11-12-2014
02381478 ACC STALENDRONATE SODIUM 5MG TABLET 11-12-2014
02381494 ACC STALENDRONATE SODIUM 70MG TABLET 11-12-2014
00654523 PMS STPMS-AMITRIPTYLINE 10MG TABLET 11-02-2015
02429861 MAR STMAR-AMITRIPTYLINE 10MG TABLET 05-01-2015
02429888 MAR STMAR-AMITRIPTYLINE 25MG TABLET 05-01-2015
02429896 MAR STMAR-AMITRIPTYLINE 50MG TABLET 05-01-2015
02429918 MAR STMAR-AMITRIPTYLINE 75MG TABLET 05-01-2015
02326043 TEP STTEVA-AMITRIPTYLINE 10MG TABLET 13-02-2015
02326051 TEP STTEVA-AMITRIPTYLINE 25MG TABLET 13-02-2015
02326078 TEP STTEVA-AMITRIPTYLINE 50MG TABLET 13-02-2015
02429225 JAP STAMLODIPINE 10MG TABLET 21-11-2014
02429217 JAP STAMLODIPINE 5MG TABLET 21-11-2014
02351218 ACC ANASTROZOLE 1MG TABLET 11-12-2014
02417855 NPH NAT-ANASTROZOLE 1MG TABLET 20-02-2015
02407256 AUR STAURO-ATORVASTATIN 10MG TABLET 24-12-2014
02399482 DOM STDOM-ATORVASTATIN 10MG TABLET 29-01-2015
02399504 DOM STDOM-ATORVASTATIN 40MG TABLET 29-01-2015
02274566 PFI GD-AZITHROMYCIN 100MG/5ML O/L 04-02-2015
02418452 PMS PMS-AZITHROMYCIN 100MG/5ML O/L 26-11-2014
02418460 PMS PMS-AZITHROMYCIN 200MG/5ML O/L 26-11-2014
02357852 VAO CELESTODERM V 0.1% OINTMENT 02-12-2014
02410893 JAP BISACODYL 5MG SUPPOSITORY 26-11-2014
02431637 ODN STCALCITRIOL-ODAN 0.25MCG CAPSULE 08-12-2014
02239356 WAM STCALCIUM 500MG CHEW TABLET 26-01-2015
80004123 EUR STCARBOCAL O/L 26-01-2015
80006794 WAM STCALCIUM +VIT D 500MG/400IU TABLET 26-01-2015
80021716 WAM STCALCIUM +VIT D 600MG/400IU TABLET 26-01-2015
80025722 JAP STCALCIUM LACTOGLUCONATE +VIT D 26-01-2015
80027026 JAP STJAMP-CALCIUM 500MG CHEW TABLET 26-01-2015
80018540 JAP STJAMP CALCIUM CARB 500 + VIT D 25-02-2015
80012594 BMI STBIOCAL-D FORTE 500MG/400IU TABLET 20-01-2015
02379287 ACC STACH-CANDESARTAN 16MG TABLET 16-12-2014
02379295 ACC STACH-CANDESARTAN 32MG TABLET 16-12-2014
02379260 ACC STACH-CANDESARTAN 4MG TABLET 16-12-2014
02379279 ACC STACH-CANDESARTAN 8MG TABLET 16-12-2014
02435845 SAN STCANDESARTAN 32MG TABLET 16-02-2015
02422069 PDL STCANDESARTAN 32MG TABLET 20-11-2014
02425424 RIV STRIVA-CANDESARTAN 16MG TABLET 17-12-2014
02425432 RIV STRIVA-CANDESARTAN 32MG TABLET 17-12-2014
02425408 RIV STRIVA-CANDESARTAN 4MG TABLET 17-12-2014
02425416 RIV STRIVA-CANDESARTAN 8MG TABLET 17-12-2014
02392275 PDL STCANDESARTAN-HCTZ 16/12.5MG TABLET 20-11-2014
02426757 ACC ACH-CAPECITABINE 150MG TABLET 11-12-2014
02426765 ACC ACH-CAPECITABINE 500MG TABLET 11-12-2014
02421917 SDZ SANDOZ CAPECITABINE 150MG TABLET 26-11-2014
02421925 SDZ SANDOZ CAPECITABINE 500MG TABLET 26-11-2014
02407515 TAR STTARO-CARBAMAZEPINE 200MG TABLET 25-08-2014
02418517 AUR STAURO-CARVEDILOL 12.5MG TABLET 26-08-2014
02418525 AUR STAURO-CARVEDILOL 25MG TABLET 26-08-2014
02418495 AUR STAURO-CARVEDILOL 3.125MG TABLET 26-08-2014
02418509 AUR STAURO-CARVEDILOL 6.25MG TABLET 26-08-2014
02432773 AUR AURO-CEFIXIME 400MG TABLET 16-12-2014
02427192 PHA STPRIVA-CETIRIZINE 20MG TABLET 21-01-2015
02384272 SUS G.U.M. PAROEX 1.2MG/ML O/L 28-10-2014
02430517 JAP STCITALOPRAM 10MG TABLET 21-11-2014
02430541 JAP STCITALOPRAM 20MG TABLET 21-11-2014
02430568 JAP STCITALOPRAM 40MG TABLET 21-11-2014
02421739 ECL STECL-CITALOPRAM 10MG TABLET 26-11-2014
02413345 APX APO-CLARITHROMYCIN XL 500MG TABLET 01-10-2014
02413795 MYL CYANOCOBALAMIN 1MG/ML INJECTION 20-11-2014
02420147 JAP JAMP-CYANOCOBALAMIN 1000MG/ML 21-11-2014
02239695 PMT STVITAMIN B12 250MCG TABLET 15-10-2014
00626112 OMA VITAMIN B12 INJECTION 20-11-2014
02424584 SIV CYCLOBENZAPRINE 10MG TABLET 15-01-2015
02417464 ATP RECLIPSEN 28 TABLET 25-08-2014
02420813 ATP RECLIPSEN 21 TABLET 25-08-2014
02240341 PDL STDIVALPROEX 125MG EC TABLET 20-11-2014
02426838 SAN STDOCUSATE SODIUM 100MG CAPSULE 21-11-2014
02418428 AUR AURO-EFAVIRENZ 600MG TABLET 01-12-2014
02295016 APX STAPO-ESCITALOPRAM 10MG TABLET 03-10-2014
02295024 APX STAPO-ESCITALOPRAM 20MG TABLET 03-10-2014
02397358 AUR STAURO-ESCITALOPRAM 10MG TABLET 03-10-2014
02397374 AUR STAURO-ESCITALOPRAM 20MG TABLET 03-10-2014
02313561 CBT STCO ESCITALOPRAM 10MG TABLET 03-10-2014
02313588 CBT STCO ESCITALOPRAM 20MG TABLET 03-10-2014
02424401 PDL STESCITALOPRAM 10MG TABLET 03-10-2014
02430118 SAN STESCITALOPRAM 10MG TABLET 19-11-2014
02430126 SAN STESCITALOPRAM 20MG TABLET 19-11-2014
02424428 PDL STESCITALOPRAM 20MG TABLET 03-10-2014
02429780 JAP STJAMP-ESCITALOPRAM 10MG TABLET 20-11-2014
02429799 JAP STJAMP-ESCITALOPRAM 20MG TABLET 20-11-2014
02423480 MAR STMAR-ESCITALOPRAM 10MG TABLET 03-10-2014
02423502 MAR STMAR-ESCITALOPRAM 20MG TABLET 03-10-2014
02309467 MYL STMYLAN-ESCITALOPRAM 10MG TABLET 15-01-2015
02309475 MYL STMYLAN-ESCITALOPRAM 20MG TABLET 15-01-2015
02303949 PMS STPMS-ESCITALOPRAM 10MG TABLET 03-10-2014
02303965 PMS STPMS-ESCITALOPRAM 20MG TABLET 03-10-2014
02426331 PHA STPRIVA-ESCITALOPRAM 10MG TABLET 03-10-2014
02426358 PHA STPRIVA-ESCITALOPRAM 20MG TABLET 03-10-2014
02385481 RBY STRAN-ESCITALOPRAM 10MG TABLET 12-12-2014
02385503 RBY STRAN-ESCITALOPRAM 20MG TABLET 12-12-2014
02428830 RIV STRIVA-ESCITALOPRAM  10MG TABLET 03-10-2014
02428857 RIV STRIVA-ESCITALOPRAM  20MG TABLET 03-10-2014
02364077 SDZ STSANDOZ ESCITALOPRAM 10MG TABLET 03-10-2014
02364085 SDZ STSANDOZ ESCITALOPRAM 20MG TABLET 03-10-2014
02318180 TEP STTEVA-ESCITALOPRAM 10MG TABLET 03-10-2014
02318202 TEP STTEVA-ESCITALOPRAM 20MG TABLET 03-10-2014
02324873 PDL FAMCICLOVIR 250MG TABLET 20-11-2014
02324881 PDL FAMCICLOVIR 500MG TABLET 20-11-2014
80002426 WNP STFERROUS GLUCONATE 35MG TABLET 22-09-2014
02393441 ACC STACH-FLUOXETINE 10MG CAPSULE 21-01-2015
02383241 ACC STACH-FLUOXETINE 20MG CAPSULE 21-01-2015
80053274 JAP STJAMP-FOLIC 1MG TABLET 13-02-2015
02423286 MIN STMINT-GLICLAZIDE MR 30MG TABLET 01-10-2014
02425947 MIN STMINT-HYDROCHLOROTHIAZIDE 12.5MG 28-08-2014
02426196 MIN STMINT-HYDROCHLOROTHIAZIDE 25MG 28-08-2014
02426218 MIN STMINT-HYDROCHLOROTHIAZIDE 50MG 28-08-2014
02422999 MIN STMINT-IRBESARTAN 150MG TABLET 20-02-2015
02423006 MIN STMINT-IRBESARTAN 300MG TABLET 20-02-2015
02422980 MIN STMINT-IRBESARTAN 75MG TABLET 20-02-2015
02425327 RIV STRIVA-IRBESARTAN 150MG TABLET 16-12-2014
02425335 RIV STRIVA-IRBESARTAN 300MG TABLET 16-12-2014
02425319 RIV STRIVA-IRBESARTAN 75MG TABLET 16-12-2014
80012039 WNP STIRON 60MG TABLET 22-09-2014
02428210 SIV STLAMOTRIGINE 100MG TABLET 20-01-2015
02428229 SIV STLAMOTRIGINE 150MG TABLET 20-01-2015
02428202 SIV STLAMOTRIGINE 25MG TABLET 20-01-2015
02414775 DOM STDOM-LANSOPRAZOLE 30MG CAPSULE 26-08-2014
02433001 PMS STLANSOPRAZOLE 15MG CAPSULE 16-02-2015
02433028 PMS STLANSOPRAZOLE 30MG CAPSULE 20-02-2015
02410370 SIV STLANSOPRAZOLE-15 15MG CAPSULE 11-12-2014
02375508 RIV LATANOPROST 50MCG/ML 26-11-2014
02426935 GMP MED-LATANOPROST 50MCG/ML OPTHALMIC SOLUTION 16-02-2015
02317125 PMS PMS-LATANOPROST 50MCG/ML OPHTHALMIC 26-11-2014
02421585 NPH STNAT-LETROZOLE 2.5MG TABLET 20-02-2015
02415879 PDL LEVOFLOXACIN 500MG TABLET 20-11-2014
02424983 SPT STSEPTA-LOSARTAN 100MG TABLET 25-08-2014
02424967 SPT STSEPTA-LOSARTAN 25MG TABLET 25-08-2014
02424975 SPT STSEPTA-LOSARTAN 50MG TABLET 25-08-2014
02394405 PDL STLOSARTAN-HCTZ 100/12.5MG TABLET 20-11-2014
02394413 PDL STLOSARTAN-HCTZ 100/25MG TABLET 20-11-2014
02394391 PDL STLOSARTAN-HCTZ 50/12.5MG TABLET 20-11-2014
02427656 SAN STLOSARTAN/HCTZ 100/12.5MG TABLET 28-08-2014
02427664 SAN STLOSARTAN/HCTZ 100/25MG TABLET 28-08-2014
02427648 SAN STLOSARTAN/HCTZ 50/12.5MG TABLET 28-08-2014
02428547 SPT STSEPTA-LOSARTAN HCTZ 100/25MG 19-11-2014
02428539 SPT STSEPTA-LOSARTAN HCTZ 50/12.5MG 19-11-2014
02324334 PDL MELOXICAM 15MG TABLET 20-11-2014
02421828 ECL STECL-METFORMIN 500MG TABLET 10-09-2014
02421836 ECL STECL-METFORMIN 850MG TABLET 10-09-2014
02419173 JAP JAMP-METHOTREXATE 25MG/ML INJECTION 21-11-2014
02417626 MYL METHOTREXATE 25MG/ML INJECTION 26-11-2014
02432560 MAR STMAR-MODAFINIL 100MG TABLET 05-01-2015
02420260 TEP STTEVA-MODAFINIL 100MG TABLET 10-09-2014
02420538 ACP STACCEL-OLANZAPINE 2.5MG TABLET 25-09-2014
02325683 ATP STCO OLANZAPINE 10MG TABLET 20-01-2015
02421267 MAR STMAR-OLANZAPINE 10MG TABLET 20-11-2014
02421275 MAR STMAR-OLANZAPINE 15MG TABLET 20-11-2014
02421232 MAR STMAR-OLANZAPINE 2.5MG TABLET 20-11-2014
02421240 MAR STMAR-OLANZAPINE 5MG TABLET 20-11-2014
02421259 MAR STMAR-OLANZAPINE 7.5MG TABLET 20-11-2014
02416549 ACC STOMEPRAZOLE MAGNESIUM DR 20MG 22-10-2014
02416565 MAR STMAR-PANTOPRAZOLE 40MG TABLET 27-08-2014
02431327 RIV STPANTOPRAZOLE 40MG TABLET 24-11-2014
02428180 SIV STPANTOPRAZOLE-40 TABLET 10-09-2014
02425378 PHA STPRIVA-PANTOPRAZOLE 40MG TABLET 21-01-2015
02431777 SDZ STSANDOZ PAROXETINE 10MG TABLET 20-02-2015
02431785 SDZ STSANDOZ PAROXETINE 20MG TABLET 20-02-2015
02431793 SDZ STSANDOZ PAROXETINE 30MG TABLET 20-02-2015
02357569 JAP JAMPOLYCIN 10000/500IU OINTMENT 21-11-2014
80026265 BMI STBIO K-20 POTASSIUM TABLET LA 04-11-2014
80040416 PMS STPHARMA-K20 LA TABLET 20-02-2015
02412985 BGP STABBOTT-QUETIAPINE 100MG TABLET 26-08-2014
02412993 BGP STABBOTT-QUETIAPINE 200MG TABLET 26-08-2014
02412977 BGP STABBOTT-QUETIAPINE 25MG TABLET 26-08-2014
02413000 BGP STABBOTT-QUETIAPINE 300MG TABLET 26-08-2014
02387808 ACC STQUETIAPINE 100MG TABLET 20-02-2015
02387824 ACC STQUETIAPINE 200MG TABLET 20-02-2015
02387794 ACC STQUETIAPINE 25MG TABLET 20-02-2015
02387832 ACC STQUETIAPINE 300MG TABLET 20-02-2015
02290995 PFI STGD-QUINAPRIL 10MG TABLET 20-11-2014
02291002 PFI STGD-QUINAPRIL 20MG TABLET 20-11-2014
02291010 PFI STGD-QUINAPRIL 40MG TABLET 20-11-2014
02290987 PFI STGD-QUINAPRIL 5MG TABLET 20-11-2014
02422638 BGP STABBOTT-RABEPRAZOLE 10MG TABLET 01-12-2014
02422646 BGP STABBOTT-RABEPRAZOLE 20MG TABLET 11-09-2014
02420457 MAR STMAR-RAMIPRIL 1.25MG CAPSULE 20-11-2014
02420481 MAR STMAR-RAMIPRIL 10MG CAPSULE 20-11-2014
02420503 MAR STMAR-RAMIPRIL 15MG CAPSULE 20-11-2014
02420465 MAR STMAR-RAMIPRIL 2.5MG CAPSULE 20-11-2014
02420473 MAR STMAR-RAMIPRIL 5MG CAPSULE 20-11-2014
02425548 RBY STRAN-RAMIPRIL 15MG CAPSULE 20-02-2015
02273705 PFI STGD-SERTRALINE 100MG CAPSULE 20-11-2014
02273683 PFI STGD-SERTRALINE 25MG CAPSULE 20-11-2014
02273691 PFI STGD-SERTRALINE 50MG CAPSULE 20-11-2014
02405156 AUR STAURO-SIMVASTATIN 10MG TABLET 25-08-2014
02405164 AUR STAURO-SIMVASTATIN 20MG TABLET 25-08-2014
02405172 AUR STAURO-SIMVASTATIN 40MG TABLET 25-08-2014
02405148 AUR STAURO-SIMVASTATIN 5MG TABLET 25-08-2014
02405180 AUR STAURO-SIMVASTATIN 80MG TABLET 25-08-2014
02243333 SAC FERRLECIT 12.5MG/ML INJECTION 15-09-2014
02427117 SAN STTAMSULOSIN CR 0.4 TABLET 28-08-2014
02429667 SIV STTAMSULOSIN CR 0.4MG TABLET 05-01-2015
02407485 ACC STTELMISARTAN 40MG TABLET 20-02-2015
02407493 ACC STTELMISARTAN 80MG TABLET 20-02-2015
02419114 ACC STACH-TELMISARTAN HCTZ 80/12.5MG 20-02-2015
02419122 ACC STACH-TELMISARTAN HCTZ 80/25MG 20-02-2015
02421186 TAR TARO-TESTOSTERONE 40MG CAPSULE 03-12-2014
02271141 PMS STDOM-TOPIRAMATE 25MG TABLET 20-02-2015
02431815 SDZ STSANDOZ TOPIRAMATE 100MG TABLET 20-02-2015
02431823 SDZ STSANDOZ TOPIRAMATE 200MG TABLET 20-02-2015
02431807 SDZ STSANDOZ TOPIRAMATE 25MG TABLET 20-02-2015
02395746 ACC STTOPIRAMATE 100MG TABLET 20-02-2015
02395754 ACC STTOPIRAMATE 200MG TABLET 20-02-2015
02395738 ACC STTOPIRAMATE 25MG TABLET 20-02-2015
02415739 APX APO-TRAVOPROST Z 0.004% OPHTHALMIC SOLUTION 01-10-2014
02413167 SDZ SANDOZ TRAVOPROST .004% SOLUTION 01-10-2014
02412063 TEP TEVA-TRAVOPROST Z 0.004% OPHTHALMIC SOLUTION 01-10-2014
02413825 TEP TEVA-VALGANCICLOVIR 450MG TABLET 19-01-2015
02425467 RIV STRIVA-VALSARTAN 160MG TABLET 16-12-2014
02425475 RIV STRIVA-VALSARTAN 320MG TABLET 16-12-2014
02425440 RIV STRIVA-VALSARTAN 40MG TABLET 16-12-2014
02425459 RIV STRIVA-VALSARTAN 80MG TABLET 16-12-2014
02360047 PFI STGD-VENLAFAXINE XR 150MG CAPSULE 20-11-2014
02360020 PFI STGD-VENLAFAXINE XR 37.5MG CAPSULE 20-11-2014
02360039 PFI STGD-VENLAFAXINE XR 75MG CAPSULE 20-11-2014
02324164 PDL STPRO-VERAPAMIL SR 180MG TABLET 20-11-2014
80006939 WNP STLB VITAMIN B12 1000MCG TABLET 21-01-2015
80004053 WNP STVITAMIN B12 250MCG TABLET 15-10-2014
02245348 WNP STVITAMIN C 500MG CHEWABLE TABLET 11-09-2014
80015278 WAM STVITAMIN D 1000IU CHEW TABLET 26-01-2015
80028362 JAP STVITAMIN D 1000IU DROPS 26-01-2015
80007346 JAP STVITAMIN D 200IU/ML O/L 26-01-2015
80028371 JAP STVITAMIN D INFANT 1000IU DROPS 26-01-2015

New Limited Use Benefits

Table 3
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02421623 JAP JAMP-ZOLMITRIPTAN 2.5MG TABLET 10-09-2014
02428237 JAP JAMP-ZOLMITRIPTAN ODT 2.5MG TABLET 15-01-2015
02399458 MAR MAR-ZOLMITRIPTAN 2.5MG TABLET 18-09-2014
02428474 SPT SEPTA-ZOLMITRIPTAN-ODT 2.5MG 19-11-2014

A total of 12 tablets (or injections) are permitted in a 30-day period.

Table 4
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02422433 REC ZOLEDRONIC ACID 5MG INJECTION 25-08-2014

For the treatment of Paget's disease. Coverage will be granted for one dose per 12 month period. OR

For women with postmenopausal osteoporosis who would otherwise be eligible for coverage of oral bisphosphonates, but who have a contraindication to bisphosphonates due to hypersensitivity or abnormalities of the esophagus (e.g, esophageal stricture or achalasia); AND who have at least two of the following:

  • age >70 years
  • a prior fragility fracture
  • a bone mineral density (BMD) T-score ≤ -2.5.
Table 5
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
00480215 NVC AQUASOL E 15-01-2015
00122831 JAM STVITAMIN E CAP 200IU NAT SOURCE 15-01-2015
00122858 JAM STVITAMIN E CAP 400IU NAT SOURCE 15-01-2015

For use in malabsorption.

Table 6
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02162075 NVC STAQUASOL E DROPS 50IU/ML 15-01-2015

For use in malabsorption.

Table 7
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02368544 AZE STBRILINTA 90MG TABLET 09-02-2015

For the treatment of Acute Coronary Syndrome, defined as unstable angina or myocardial infarction, when initiated in hospital in consultation with a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, Internal Medicine or General Surgery. Treatment must be in combination with low dose ASA. Special authorization may be granted for 12 months.

Table 8
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02416816 SDZ SANDOZ TACROLIMUS 0.5MG CAPSULE 05-01-2015

For transplant therapy.

Table 9
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02418355 GIL SOVALDI 400MG TABLET 18-02-2015

For the treatment of chronic Hepatitis C in adult patients with compensated liver disease, including cirrhosis, if the following clinical criteria and conditions are met:

  • Patients with Genotype 1 CHC infection, in combination with pegylated-interferon and ribavirin (PEG IFN/RBV):
    • Fibrosis stage F2 or greater
    • Treatment naïve
    If approved, treatment should not exceed a duration of 12 weeks.
  • Patients with Genotype 2 CHC infection, in combination with RBV:
    • Fibrosis stage F2 or greater
    • Previous treatment experience with Peg-IFN/RBV ; OR
    • A medical contraindication to Peg-IFN/RBV
    If approved, treatment should not exceed a duration of 12 weeks.
  • Patients with Genotype 3 CHC infection, in combination with RBV:
    • Fibrosis stage F2 or greater
    • Previous treatment experience with Peg-IFN/RBV ; OR
    • A medical contraindication to Peg-IFN/RBV
    If approved, treatment should not exceed a duration of 24 weeks.
Table 10
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02416441 KEG GALEXOS 150MG CAPSULE 17-11-2014

For the treatment of chronic Hepatitis C in treatment-naïve and treatment-experienced patients who meet all of the following criteria:

  • Chronic hepatitis C virus (HCV) genotype 1 infection
  • Detectable levels of HCV RNA in the last six months
  • Fibrosis stage F2 or greater (Metavir scale or equivalent)
  • Patient has not received a prior full therapeutic course of boceprevir or telaprevir.
Table 11
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02412179 PMS STPMS-SILDENAFIL R 20MG TABLET 03-12-2014

Maximum dose covered is 20 mg three times a day.

Patients with World Health Organization (WHO) class III pulmonary artery hypertension (PAH), either idiopathic (i.e. primary) or associated with a congenital or systemic condition (e.g. connective tissue disease) and confirmed by right heart catheterization; AND

  • Who have failed to respond to conventional therapy; OR
  • Who have contraindications to conventional agents.
Table 12
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02389185 AZE STKOMBOGLYZE 2.5/1000MG TABLET 12-01-2015
02389169 AZE STKOMBOGLYZE 2.5/500MG TABLET 12-01-2015
02389177 AZE STKOMBOGLYZE 2.5/850MG TABLET 12-01-2015

For the treatment of patients with type 2 diabetes mellitus who: did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin AND a sulfonylurea.

Table 13                  
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02429241 JAP JAMP-RIZATRIPTAN IR 10MG TABLET 21-11-2014
02429233 JAP JAMP-RIZATRIPTAN IR 5MG TABLET 21-11-2014
02396688 TEP TEVA-RIZATRIPTAN RDT 10MG 21-01-2015
02396661 TEP TEVA-RIZATRIPTAN RDT 5MG 21-01-2015

A total of 12 tablets (or injections) are permitted in a 30-day period.

Table 14
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02406306 AUR STAURO-RISEDRONATE 35MG TABLET 26-08-2014

For the treatment of:

  1. Osteoporosis in patients who are 60 years of age and over, or
  2. Osteoporosis in patients who have documented hip, vertebral or other fractures or
  3. Paget's Disease or
  4. Osteoporosis in patients with no evidence of fracture but who have a high (>20%) 10-year fracture risk or
  5. Osteoporosis in patients with moderate 10-year fracture risk (10-20%) and use of systemic glucocorticoid therapy > 3 months
Table 15
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02417561 MAR STMAR-PREGABALIN 150MG CAPSULE 21-11-2014
02417529 MAR STMAR-PREGABALIN 25MG CAPSULE 21-11-2014
02417537 MAR STMAR-PREGABALIN 50MG CAPSULE 21-11-2014
02417545 MAR STMAR-PREGABALIN 75MG CAPSULE 21-11-2014
02408694 MYL STMYL-PREGABALIN 150MG CAPSULE 01-10-2014
02408651 MYL STMYL-PREGABALIN 25MG CAPSULE 01-10-2014
02408708 MYL STMYL-PREGABALIN 300MG CAPSULE 01-10-2014
02408678 MYL STMYL-PREGABALIN 50MG CAPSULE 01-10-2014
02408686 MYL STMYL-PREGABALIN 75MG CAPSULE 01-10-2014

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 with a TCA.

Table 16
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02383780 ACC ACH-MYCOPHENOLATE 250MG CAPSULE 16-02-2015
02378574 ACC MYCOPHENOLATE 500MG TABLET 16-02-2015

For transplant therapy.

Table 17
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02410265 ACC ACH-MONTELUKAST CHEW 4MG TABLET 22-01-2015
02410273 ACC ACH-MONTELUKAST CHEW 5MG TABLET 22-01-2015
02379236 ACC MONTELUKAST 10MG TABLET 22-01-2015

For treatment of:

  1. asthma when used in patients on concurrent steroid therapy.
  2. asthma patients not well controlled with or intolerant to inhaled corticosteroids.
Table 18
DIN MFR ITEM NAME Effective Date
02239238 PMS PMS-MINOCYCLINE 50MG CAPSULE 09-01-2015

Limited use benefit (prior approval required).

For:

  1. patients who cannot tolerate other tetracyclines.
  2. patients with severe widespread acne who have failed on tetracycline.
Table 19
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02426552 APX APO-LINEZOLID 600MG TABLET 01-10-2014
02402637 TEP LINEZOLID 2MG/ML INJECTION 20-11-2014
02422689 SDZ SANDOZ LINEZOLID 600MG TABLET 01-10-2014

Tablets:
For treatment of proven vancomycin-resistant enterococci (VRE) infections when other antibiotics are not available, and for the treatment of proven Methicillin-Resistant Staphylococcus aureus (MRSA) infections in patients who cannot tolerate or who had an idiosyncratic reaction with Vancomycin.

I.V. solution:
When linezolid cannot be administered orally in the above mentioned situations.

Table 20
DIN MFR ITEM NAME Effective Date
Limited use benefit with quantity and frequency limits (prior approval is not required).
02408295 BAY JAYDESS 13.5MG UNIT 20-10-2014

Coverage is granted for 1 device every 2 years.

Table 21
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02414805 ABB STABBOTT-LEVETIRACETAM 250MG TABLET 27-08-2014
02414791 ABB STABBOTT-LEVETIRACETAM 500MG TABLET 27-08-2014
02414783 ABB STABBOTT-LEVETIRACETAM 750MG TABLET 27-08-2014
02399776 ACC STLEVETIRACETAM 250MG TABLET 21-01-2015
02399784 ACC STLEVETIRACETAM 500MG TABLET 21-01-2015
02399792 ACC STLEVETIRACETAM 750MG TABLET 21-01-2015

For the use in combination with other anti-epileptic medication(s) in the treatment of partial seizures in patients who are refractory to adequate trials of two anti-epileptic medications used either as monotherapy or in combination.

Table 22
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02371081 MEZ XEOMIN 50 UNIT/VIAL INJECTION 20-08-2014

For 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 23
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02416581 PDL GALANTAMINE ER 16MG CAPSULE 15-09-2014
02416603 PDL GALANTAMINE ER 24MG CAPSULE 15-09-2014
02416573 PDL GALANTAMINE ER 8MG CAPSULE 15-09-2014
02420848 MAR MAR-GALANTAMINE ER 16MG CAPSULE 05-01-2015
02420856 MAR MAR-GALANTAMINE ER 24MG CAPSULE 05-01-2015
02420821 MAR MAR-GALANTAMINE ER 8MG CAPSULE 05-01-2015

Initial six 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; AND
  • Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
  • Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

  • Diagnosis is still mild to moderate Alzheimer's disease; AND
  • MMSE score > 10; OR
  • GDS score between 4 to 6; AND
  • Improvement or stabilization in at least one of the following domains:
    (please indicate improved, worsened, or no change)
    1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
    2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
    3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
    4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
Table 24
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02416840 ACC STGABAPENTIN 100MG CAPSULE 21-01-2015
02416859 ACC STGABAPENTIN 300MG CAPSULE 21-01-2015
02416867 ACC STGABAPENTIN 400MG CAPSULE 21-01-2015
02392526 ACC STGABAPENTIN 600MG TABLET 15-01-2015
02431289 SAN STGABAPENTIN 600MG TABLET 20-02-2015
02431297 SAN STGABAPENTIN 800MG TABLET 20-02-2015
02392534 ACC STGABAPENTIN 800MG TABLET 15-01-2015
02285819 PFI STGD-GABAPENTIN 100MG CAPSULE 20-11-2014
02285827 PFI STGD-GABAPENTIN 300MG CAPSULE 20-11-2014
02285835 PFI STGD-GABAPENTIN 400MG CAPSULE 20-11-2014
02285851 PFI STGD-GABAPENTIN 800MG TABLET 20-11-2014

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 100-day period, for a total daily dose of 4000mg/day.

Table 25
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02414716 ATP STACT EZETIMIBE 10MG TABLET 03-10-2014
02427826 APX STAPO-EZETIMIBE 10MG TABLET 19-10-2014
02431300 SAN STEZETIMIBE 10MG TABLET 20-02-2015
02422549 PDL STEZETIMIBE 10MG TABLET 03-10-2014
02429659 SIV STEZETIMIBE 10MG TABLET 03-10-2014
02423235 JAP STJAMP-EZETIMIBE 10MG TABLET 03-10-2014
02422662 MAR STMAR-EZETIMIBE 10MG TABLET 03-10-2014
02423243 MIN STMINT-EZETIMIBE 10MG TABLET 03-10-2014
02378035 MYL STMYLAN-EZETIMIBE 10MG TABLET 03-10-2014
02416409 PMS STPMS-EZETIMIBE 10MG TABLET 03-10-2014
02425238 PHA STPRIVA-EZETIMIBE 10MG TABLET 03-10-2014
02419548 RBY STRAN-EZETIMIBE 10MG TABLET 03-10-2014
02424436 RIV STRIVA-EZETIMIBE 10MG TABLET 03-10-2014
02354101 TEP STTEVA-EZETIMIBE 10MG TABLET 03-10-2014
  1. For use in combination with a HMG-CoA reductase inhibitor ("statin") in patients with hypercholesterolemia who have not reached target LDL levels despite the use of maximally tolerated "statin" doses.
  2. For use as monotherapy in the management of hypercholesterolemia in patients intolerant to HMG-CoA reductase
Table 26
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02430576 PMS PMS-ENTECAVIR 0.5MG TABLET 03-12-2014

For the treatment of chronic hepatitis B infection in patients with cirrhosis documented on radiologic or histologic grounds and a HBV DNA concentration above 2000IU/mL.

Table 27
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02412691 ATP STACT DUTASTERIDE 0.5MG CAPSULE 15-09-2014
02404206 APX STAPO-DUTASTERIDE 0.5MG CAPSULE 15-09-2014
02429012 SIV STDUTASTERIDE 0.5MG CAPSULE 05-01-2015
02421712 PDL STDUTASTERIDE 0.5MG CAPSULE 15-09-2014
02416298 GMP STMED-DUTASTERIDE 0.5MG CAPSULE 26-11-2014
02428873 MIN STMINT-DUTASTERIDE 0.5MG CAPSULE 20-11-2014
02393220 PMS STPMS-DUTASTERIDE 0.5MG CAPSULE 15-09-2014
02427753 RIV STRIVA-DUTASTERIDE 0.5MG CAPSULE 20-11-2014
02424444 SDZ STSANDOZ DUTASTERIDE 0.5MG CAPSULE 15-09-2014
02424444 SDZ STSANDOZ DUTASTERIDE 0.5MG CAPSULE 18-09-2014
02408287 TEP STTEVA-DUTASTERIDE 0.5MG CAPSULE 15-09-2014
  1. For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an adrenergic blocker or
  2. For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
Table 28
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02419874 ACP ACCEL-DONEPEZIL 10MG TABLET 18-11-2014
02419866 ACP ACCEL-DONEPEZIL 5MG TABLET 18-11-2014
02402653 ACC DONEPEZIL 10MG TABLET 16-12-2014
02402645 ACC DONEPEZIL 5MG TABLET 16-12-2014
02416956 JAP JAMP-DONEPEZIL 10MG TABLET 21-11-2014
02416948 JAP JAMP-DONEPEZIL 5MG TABLET 21-11-2014
02428490 SPT SEPTA-DONEPEZIL 10MG TABLET 19-11-2014
02428482 SPT SEPTA-DONEPEZIL 5MG TABLET 19-11-2014

Initial six 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; AND
  • Global Deterioration Scale (GDS) score between 4 to 6, established within the last 60 days
  • Continued coverage beyond 6 months will be based on improvement or stabilization of cognition, function or behaviour.

Criteria for coverage at every six month interval:

  • Diagnosis is still mild to moderate Alzheimer's disease; AND
  • MMSE score > 10; OR
  • GDS score between 4 to 6; AND
  • Improvement or stabilization in at least one of the following domains:
    (please indicate improved, worsened, or no change)
    1. Memory, reasoning and perception (e.g., names, tasks, MMSE)
    2. Instrumental activities of daily living (IADLs: e.g., telephone, shopping, meal preparation)
    3. Basic activities of daily living (e.g., bathing, dressing, hygiene, toileting)
    4. Neuropsychiatric symptoms (e.g., agitation, delusions, hallucination, apathy)
Table 29
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02356783 PMS PMS-DICLOFENAC 1.5% SOLUTION 18-12-2014

For the treatment of osteoarthritis when:

  • Pain is inadequately controlled with acetaminophen AND a non-steroidal anti-inflammory drug (SAID); OR
  • There is contraindication to acetaminophen and NSIAD; OR
  • There is intolerance to acetaminophen and NSAID.
Table 30
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02419963 ACP STACCEL-CLOPIDOGREL 75MG TABLET 17-10-2014
02416387 AUR STAURO-CLOPIDOGREL 75MG TABLET 25-08-2014
02415550 JAP STJAMP-CLOPIDOGREL 75MG TABLET 10-09-2014
02422255 MAR STMAR-CLOPIDOGREL 75MG TABLET 05-01-2015

Limit of 12 months following a client's initial cardiovascular event (stroke, acute coronary syndrome (ACS) or stent).

Continued coverage beyond one year will be provided for patients with a previous stroke or transient ischemic attack (TIA) and be considered for patients with ACS or stent placement with appropriate rationale from the client`s cardiologist or treating physician.

Table 31
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02418932 APX APO-CELECOXIB 100MG CAPSULE 12-12-2014
02418940 APX APO-CELECOXIB 200MG CAPSULE 12-12-2014
02426382 BMI BIO-CELECOXIB 100MG CAPSULE 13-02-2015
02426390 BMI BIO-CELECOXIB 200MG CAPSULE 13-02-2015
02429675 SIV CELECOXIB 100MG CAPSULE 12-12-2014
02424371 PDL CELECOXIB 100MG CAPSULE 13-02-2015
02429683 SIV CELECOXIB 200MG CAPSULE 12-12-2014
02424398 PDL CELECOXIB 200MG CAPSULE 13-02-2015
02420155 ATP CO CELECOXIB 100MG CAPSULE 12-12-2014
02420163 ATP CO CELECOXIB 200MG CAPSULE 12-12-2014
02291975 PFI GD-CELECOXIB 100MG CAPSULE 13-02-2015
02291983 PFI GD-CELECOXIB 200MG CAPSULE 13-02-2015
02424533 JAP JAMP-CELECOXIB 100MG CAPSULE 03-02-2015
02424541 JAP JAMP-CELECOXIB 200MG CAPSULE 03-02-2015
02420058 MAR MAR-CELECOXIB 100MG CAPSULE 13-02-2015
02420066 MAR MAR-CELECOXIB 200MG CAPSULE 13-02-2015
02412497 MIN MINT-CELECOXIB 100MG CAPSULE 12-12-2014
02412500 MIN MINT-CELECOXIB 200MG CAPSULE 12-12-2014
02423278 MYL MYLAN-CELECOXIB 100MG CAPSULE 12-12-2014
02399881 MYL MYLAN-CELECOXIB 200MG CAPSULE 12-12-2014
02355442 PMS PMS-CELECOXIB 100MG CAPSULE 12-12-2014
02355450 PMS PMS-CELECOXIB 200MG CAPSULE 14-12-2014
02426366 PHA PRIVA-CELECOXIB 100MG CAPSULE 13-02-2015
02426374 PHA PRIVA-CELECOXIB 200MG CAPSULE 13-02-2015
02412373 RBY RAN-CELECOXIB 100MG CAPSULE 12-12-2014
02412381 RBY RAN-CELECOXIB 200MG CAPSULE 12-12-2014
02425386 RIV RIVA-CELECOX 100MG CAPSULE 13-02-2015
02425394 RIV RIVA-CELECOX 200MG CAPSULE 13-02-2015
02321246 SDZ SANDOZ CELECOXIB 100MG CAPSULE 12-12-2014
02321254 SDZ SANDOZ CELECOXIB 200MG CAPSULE 12-12-2014
02288915 TEP TEVA-CELECOXIB 100MG CAPSULE 12-12-2014
02288923 TEP TEVA-CELECOXIB 200MG CAPSULE 12-12-2014

For patients who have:

  • A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation); OR
  • Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).
Table 32
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
00972037 WIL CAFFEINE CITRATE POWDER 04-02-2015

For children up to 1 year of age.

Table 33
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02408090 MYL STMYLAN-BUPRENORPHINE/NALOXONE  2/0.5MG 26-02-2015
02408104 MYL STMYLAN-BUPRENORPHINE/NALOXONE  8/2MG 26-02-2015
02424851 TEP STTEVA-BUPRENORPHINE/NALOXONE 2MG 26-02-2015
02424878 TEP STTEVA-BUPRENORPHINE/NALOXONE 8MG 26-02-2015

A rationale for using Suboxone instead of the alternative (i.e. methadone); and

In cases where the client lives in a remote or isolated location, confirmation is required that the community has the ability to support Suboxone administration. These supports include the safe daily witnessing, storage and handling of the Suboxone doses. After this confirmation, NIHB will approve the Suboxone for the client.

The client must be 16 years or older.

Table 34
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
09857502 ABB FREESTYLE PRECISION TEST STRIP 29-10-2014

The number of test strips that will be covered by the NIHB Program will depend on the client's medical treatment:

  • Clients managing diabetes with insulin will be allowed 500 test strips per 100 days. A client can test up to five times per day.
  • Clients managing diabetes with diabetes medication with a high risk of causing low blood sugar will be allowed 400 test strips per 365 days. A client can test once daily.
  • Clients managing diabetes with diabetes medication with a low risk of causing low blood sugar will be allowed 200 test strips per 365 days. A client can test three to four times per week.
  • Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) will be allowed 200 test strips per 365 days. A client can test three to four times per week.
Table 35
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02404877 RIV STRIVA-ALPRAZOLAM 0.25MG TABLET 11-12-2014
02404885 RIV STRIVA-ALPRAZOLAM 0.5MG TABLET 11-12-2014
02404893 RIV STRIVA-ALPRAZOLAM 1MG TABLET 11-12-2014

To promote safe, therapeutically effective and efficient use ofdrug therapy NIHB has implemented a benzodiazepine dose limit of 40 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. 4 000 diazepam equivalents over 100 days). According to the product monograph for diazepam, the recommended usual adult dosage is up to 40 mg per day.

Table 36
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02424029 PDL ALMOTRIPTAN 12.5MG TABLET 20-11-2014

A total of 12 tablets (or injections) are permitted in a 30-day period.

Table 37
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02429160 SDZ STSDZ-ALENDRONATE/CHOLECALCIFEROL 70MG/5600U 05-11-2014

For the treatment of:

  1. Paget's Disease OR
  2. Osteoporosis in patients who are 60 years of age or over OR
  3. Osteoporosis in patients under 60 who have documented hip, vertebral or other fractures OR
  4. Osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk OR
  5. Osteoporosis or risk of osteoporosis in patients under 60 who have been, or who will be, on systemic corticosteroid therapy equivalent to a dose of prednisone = 7.5mg per day for =3 months.
Table 38
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02420333 APX APO-ADEFOVIR 10MG TABLET 10-09-2014

For the treatment of chronic hepatitis B infection when used in combination with lamivudine in patients who have developed failure to lamivudine, as defined by an increase in HBV DNA of = 1 log10 IU/mL above the nadir, measured on two separate occasions within an interval of at least one month, after the first three months of lamivudine therapy, and when failure to lamivudine is not due to poor adherence to therapy.

Table 39
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval required).
02409720 AZE TUDORZA GENUAIR 400MCG INHALER 08-12-2014

For patients with chronic obstructive pulmonary disease (COPD) and who:

  • did not respond to a trial of ipratropium (Atrovent); OR
  • did not have a previous trial of ipratropium, but who have moderate to severe COPD, defined as <60% FEV1, FEV1/FVC<0.7 and MRC 3 to 5.
Table 40
DIN MFR ITEM NAME Effective Date
Limited use benefit (prior approval is not required).
02355299 JAP STJAMP-ACETAMINOPHEN 500MG TABLET 17-12-2014

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® #3) or oxycodone (i.e. Percocet®). A total of 360 grams of acetaminophen is permitted in a 100-day period, for a total daily dose of 3600mg/day.

Criteria Changes

Listing of Bicillin

Effective March 4, 2015 NIHB has listed Bicillin® L-A injection as an open benefit on the Drug Benefit list (DBL).

This change in listing status applies to the following DIN:

  • 02291924 Bicillin L-A injection

Change in the Listing Criteria of Kadian

Effective November 17, 2014, the listing status of Kadian (sustained released morphine sulphate) changed from open benefit to limited use (LU) with the following LU criteria:

  • For the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate OR
  • For the treatment of chronic pain.

If Kadian is being requested for opioid dependence treatment, the client will be placed in the Non-Insured Health Benefit (NIHB) Prescription Monitoring Program (PMP) where coverage of opioids benzodiazepines, stimulants or gabapentin will each be limited to a sole prescriber. Please note that the sole prescriber does not need to be the Kadian prescriber, however may be designated upon request.

Change in the Listing Criteria of Prometrium

Effective December 1, 2014, Prometrium became a limited use benefit (LU). This is based on a recommendation from the NIHB Drugs and Therapeutics Advisory Committee (DTAC) who recommended that Prometrium be listed with the following criteria:

For women

  • With post-menopausal symptoms with intolerance to medroxyprogesterone OR
  • At risk of preterm labour OR
  • For prevention of miscarriage

Change in the Listing Criteria of Vitamin E

Effective January 15, 2015, vitamin E became a LU benefit based on a recommendation from the NIHB DTAC. The listing status of oral vitamin E products was changed from open benefit to limited use benefit with the following criteria:

  • For the treatment of vitamin E malabsorption (e.g. as seen with cystic fibrosis).

Please note that, effective January 15, 2015 vitamin E topical ointment products were removed from the DBL.

Change in the Listing Status of Aggrenox

Effective February 18, 2015 NIHB has listed Aggrenox as an open benefit on the DBL.  The listing status of Aggrenox was changed from a limited use benefit to an open benefit.

This change in listing status will apply to the following DIN:

  • 02242119 AGGRENOX 200MG/25MG CAPSULE

Change and Addition in the Listing Status of Acne Products

Based on recommendations from the NIHB DTAC, effective January 15, 2015, the listing status of benzoyl peroxide products including gel, lotion, soap and washes, above 5% changed from open benefit to not listed. This DTAC recommendation is based on evidence presented that >5% benzoyl peroxide is no more effective and is irritating to the skin. The following products are no longer listed on the DBL:

  • Panoxyl-10 -10% Gel
  • Panoxyl-20 -20% Gel
  • Solugel 8% Gel
  • Benzoyl 10% Lotion
  • Panoxyl-10 -10% Soap
  • Benzac W 10% Wash

Effective January 15, 2015, additional products of benzoylperoxide in strengths of 2.5% were listed on the DBL:

  • Emergency Acne Vanishing Wipes
  • Oil-Free Acne Wash Cleanser
  • Purifying Cleanser
  • Spectro Acnecare Wash

In addition, the following items were also added to the DBL:

  • Clindoxyl Gel
  • Clindoxyl Adv 1.0/3.0% Gel
  • Benzaclin Topical Gel
  • Benzamycin Gel
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