Update to the Drug Benefit List - Fall 2014

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 the 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.

Additions to the Drug Benefit List

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

Open Benefits

Single-Source Drug Products
DIN MFR Item Name Effective Date
02150352 BAY ST BABY ASPIRIN 80MG TABLET 17-03-2014
02373955 VAE ST LODALIS HCL 625MG TABLET 14-04-2014
80039903 ORM BEDUZIL 200MCG/ML O/L 08-04-2014
02373785 GPB NYDA 50% TOP SOLUTUION 12-02-2014
80000273 WNP ST FOLIC ACID 1MG TABLET 07-05-2014
02412829 NOO LEVEMIR FLEXTOUCH 100U/ML INJECATABLE 07-05-2014
00970387 PAE MONA LISA 5 IUD 23-05-2014
97799494 ROC ACCU-CHEK FASTCLIK LANCET 102 28-03-2014
97799495 ROC ACCU-CHEK FASTCLIK LANCET 204 28-03-2014
97799364 MTD INSULIN PEN NEEDLE 31GX6MM 23-05-2014
97799367 MTD INSULIN PEN NEEDLE 32GX4MM 23-05-2014
97799363 MTD INSULIN PEN NEEDLE 32GX6MM 23-05-2014
97799365 MTD INSULIN PEN NEEDLE 32GX8MM 23-05-2014
02415194 ABB ST CREON MINIMICROSPHERES 6 CAPSULE 28-03-2014
97799386 NOO NOVOFINE PLUS 4MM NEEDLE 31-03-2014
02346672 RLI RELAXA 18-07-2014
80024360 GSK ST K-10 O/L 30-07-2014
80035346 MAN ST MK 8 TABLET 18-06-2014
00037818 ABB BACTERIOSTATIC SOD CHLOR INJECTION 13-06-2014
96899977 TMI AEROTRACH PLUS 07-03-2014
97799369 MTD INSULIN SYRINGES 31GX0.3CC 23-05-2014
97799370 MTD INSULIN SYRINGES 31GX0.5CC 23-05-2014
97799371 MTD INSULIN SYRINGES 31GX1CC 23-05-2014
97799385 BTD BD SYR +NEEDLE 31G 6MM (0.5CC) 28-03-2014
97799384 BTD BD SYR +NEEDLE 31G 6MM (1CC) 28-03-2014
02412322 ATP TRELSTAR 22.5MG/VIAL 28-03-2014
97799914 BAY DIASTIX 50 (NS) 17-05-2014
80041145 ORM ST DECAXIL 400IU/ML O/L 11-02-2014
02417685 ORM ST VIDEXTRA 10000U TABLET 15-04-2014
Multi-Source Drug Products
DIN MFR Item Name Effective Date
02269139 JAP ST ACETYLSALICYLIC ACID 80MG CHEWABLE 17-03-2014
02238545 PMS ST ASAPHEN 80MG EC TABLET 17-03-2014
02009013 PMS ST ASAPHEN CHEW TAB 80 MG 17-03-2014
02280167 ODN ST ASATAB 80MG CHEWABLE TABLET 17-03-2014
02250675 EUR ST EURO-ASA CHEW TABLET 17-03-2014
02283905 JAP ST JAMP-ASA ENTERIC COAT 80MG TABLET 17-03-2014
02296004 EUR ST LOWPRIN 80MG CHEW TABLET 17-03-2014
02295563 EUR ST LOWPRIN 80MG TABLET 17-03-2014
02311496 PRO ST PRO-ASA 80MG EC TABLET 17-03-2014
02311518 PRO ST PRO-ASA 80MG TABLET 17-03-2014
02202352 RIV ST RIVASA 80MG CHEW TABLET 17-03-2014
02202360 RIV ST RIVASA 80MG TABLET 17-03-2014
02321750 ZYM ST ZYM-ASA 80MG TABLET 17-03-2014
02321769 ZYM ST ZYM-ASA EC 80MG TABLET 17-03-2014
02414759 PDL ST ALFUZOSIN 10MG TABLET 24-03-2014
02421593 JAP ST JAMP-ALLOPURINOL 100MG TABLET 17-04-2014
02421607 JAP ST JAMP-ALLOPURINOL 200MG TABLET 17-04-2014
02421615 JAP ST JAMP-ALLOPURINOL 300MG TABLET 17-04-2014
02297477 ATP ST ACT AMLODIPINE 2.5MG TABLET 13-02-2014
02395649 PDL ANASTROZOLE 1MG TABLET 20-06-2014
02404990 AUR AURO-ANASTROZOLE 1MG TABLET 11-03-2014
02399490 DOM ST DOM-ATORVASTATIN 20MG TABLET 09-06-2014
02392941 MYL ST MYLAN-ATORVASTATIN 20MG TABLET 20-06-2014
02392968 MYL ST MYLAN-ATORVASTATIN 40MG TABLET 20-06-2014
02392976 MYL ST MYLAN-ATORVASTATIN 80MG TABLET 20-06-2014
02422751 RIV ST RIVA-ATORVASTATIN 10MG TABLET 06-05-2014
02422778 RIV ST RIVA-ATORVASTATIN 20MG TABLET 06-05-2014
02422786 RIV ST RIVA-ATORVASTATIN 40MG TABLET 06-05-2014
02422794 RIV ST RIVA-ATORVASTATIN 80MG TABLET 06-05-2014
02415542 APX APO-AZITHROMYCIN Z 250MG TABLET 03-02-2014
02330210 PMS PMS-BETAHISTINE 16MG TABLET 13-02-2014
02330237 PMS PMS-BETAHISTINE 24MG TABLET 13-02-2014
02361450 JAP JAMP-BISACODYL10MG SUPPOSITORY 13-02-2014
80043628 ODN ST NU-CAL O/L 15-05-2014
02420732 SDZ ST SANDOZ CANDESAR PLUS 32/12.5MG 29-07-2014
02420740 SDZ ST SANDOZ CANDESAR PLUS 32/25MG 29-07-2014
02413590 PDL CARBAMAZEPINE CR 200MG TABLET 24-03-2014
02413604 PDL CARBAMAZEPINE CR 400MG TABLET 24-03-2014
02375095 APX ST CETIRIZINE 10MG TABLET 01-05-2014
02417995 PDL ST VITAMIN D 10 000IU CAPSULE 03-07-2014
02409003 NPH NAT-CITALOPRAM 10MG TABLET 11-03-2014
02409011 NPH NAT-CITALOPRAM 20MG TABLET 11-03-2014
02409038 NPH NAT-CITALOPRAM 40MG TABLET 11-03-2014
02412942 ABB ST ABBOTT-CLOPIDOGREL 75MG TABLET 04-07-2014
80015276 JAP ST JAMP-VITAMINE B12 22-05-2014
02377179 ATM ST MOTION SICKNESS 50MG TABLET 10-03-2014
02403870 MAR MAR-DOMPERIDONE 10MG TABLET 03-02-2014
02415380 APX MYA 28 TABLET 11-06-2014
02401967 APX TRICIRA LO (21 DAY) TABLET 14-07-2014
02401975 APX TRICIRA LO (28 DAY) TABLET 14-07-2014
02419726 APX APO-EXEMESTANE 25MG TABLET 07-05-2014
02407841 GMP MED-EXEMESTANE 25MG TABLET 03-02-2014
02408473 TEP TEVA-EXEMESTANE 25MG TABLET 08-04-2014
80006316 GFP ST FERROUS GLUCONATE 300MG TABLET 10-03-2014
02406101 AUR ST AURO-IRBESARTAN 150MG TABLET 03-02-2014
02406128 AUR ST AURO-IRBESARTAN 300MG TABLET 03-02-2014
02406098 AUR ST AURO-IRBESARTAN 75MG TABLET 03-02-2014
02418207 JAP ST JAMP-IRBESARTAN 150MG TABLET 24-03-2014
02418215 JAP ST JAMP-IRBESARTAN 300MG TABLET 24-03-2014
02418193 JAP ST JAMP-IRBESARTAN 75MG TABLET 24-03-2014
02418223 JAP ST JAMP-IRBESARTAN/HCT 150/12.5MG 24-03-2014
02418231 JAP ST JAMP-IRBESARTAN/HCT 300/12.5MG 24-03-2014
02418258 JAP ST JAMP-IRBESARTAN/HCT 300/25MG 24-03-2014
02412268 SAN ST LACTULOSE 667MG/ML O/L 03-02-2014
02422808 RIV ST RIVA-LANSOPRAZOLE 15MG CAPSULE 19-06-2014
02415828 PDL LEFLUNOMIDE 10MG TABLET 04-04-2014
02415836 PDL LEFLUNOMIDE 20MG TABLET 04-04-2014
02404400 AUR ST AURO-LETROZOLE 2.5MG TABLET 03-02-2014
02398656 RIV RIVA-LETROZOLE 2.5MG TABLET 11-03-2014
02421488 PMS ST PMS-LEVOCARB CR 100/25MG TABLET 04-04-2014
02421496 PMS ST PMS-LEVOCARB CR 200/50MG TABLET 04-04-2014
02403358 AUR ST AURO-LOSARTAN 100MG TABLET 04-02-2014
02403323 AUR ST AURO-LOSARTAN 25MG TABLET 04-02-2014
02403331 AUR ST AURO-LOSARTAN 50MG TABLET 04-02-2014
02394383 PDL ST LOSARTAN 100MG TABLET 07-04-2014
02394367 PDL ST LOSARTAN 25MG TABLET 07-04-2014
02394375 PDL ST LOSARTAN 50MG TABLET 07-04-2014
02405768 MIN ST MINT-LOSARTAN 100MG TABLET 25-03-2014
02405733 MIN ST MINT-LOSARTAN 25MG TABLET 25-03-2014
02405741 MIN ST MINT-LOSARTAN 50MG TABLET 25-03-2014
02415275 STE MERCAPTOPURINE 50MG TABLET 02-04-2014
02413728 PMS PMS-METHYLPHENIDATE ER 18MG 07-05-2014
02413736 PMS PMS-METHYLPHENIDATE ER 27MG 07-05-2014
02413744 PMS PMS-METHYLPHENIDATE ER 36MG 07-05-2014
02413752 PMS PMS-METHYLPHENIDATE ER 54MG 07-05-2014
02411695 AUR AURO-MIRTAZAPINE 15MG TABLET 12-03-2014
02411709 AUR AURO-MIRTAZAPINE 30MG TABLET 12-03-2014
02411717 AUR AURO-MIRTAZAPINE 45MG TABLET 12-03-2014
02229763 PDL PDL-NORTRIPTYLINE 10MG CAPSULE 30-07-2014
02229764 PDL PDL-NORTRIPTYLINE 25MG CAPSULE 30-07-2014
02406632 JAP JAMP-OLANZAPINE ODT 10MG TABLET 10-02-2014
02406640 JAP JAMP-OLANZAPINE ODT 15MG TABLET 10-02-2014
02406624 JAP JAMP-OLANZAPINE ODT 5MG TABLET 10-02-2014
02414104 RBY RAN-OLANZAPINE ODT 10MG TABLET 03-07-2014
02414112 RBY RAN-OLANZAPINE ODT 15MG TABLET 03-07-2014
02414090 RBY RAN-OLANZAPINE ODT 5MG TABLET 03-07-2014
02404095 ATP ACT-OLOPATADINE 0.2% OP SOLUTION 28-03-2014
02402823 APX APO-OLOPATADINE 0.2% OP SOLUTION 28-03-2014
02420171 SDZ SANDOZ OLOPATADINE 0.2% OP SOLUTION 28-03-2014
02421402 SAN ONDANSETRON 4MG TABLET 17-04-2014
02421410 SAN ONDANSETRON 8MG TABLET 17-04-2014
02249677 OMG PAMIDRONATE DISODIUM 6MG/ML 16-07-2014
02411946 MAR MAR-PAROXETINE 10MG TABLET 18-06-2014
02411954 MAR MAR-PAROXETINE 20MG TABLET 18-06-2014
02411962 MAR MAR-PAROXETINE 30MG TABLET 18-06-2014
02421372 MIN MINT-PAROXETINE 10MG TABLET 04-07-2014
02421380 MIN MINT-PAROXETINE 20MG TABLET 04-07-2014
02421399 MIN MINT-PAROXETINE 30MG TABLET 04-07-2014
80013005 JAP ST JAMP-K 600 TABLET 18-06-2014
02399849 MAR MAR-QUETIAPINE 200MG TABLET 03-02-2014
02399822 MAR MAR MAR-QUETIAPINE 25MG TABLET 03-02-2014
02399857 MAR MAR-QUETIAPINE 300MG TABLET 03-02-2014
02417367 SIV QUETIAPINE XR 150MG TABLET 12-03-2014
02417790 PDL QUETIAPINE XR 150MG TABLET 07-05-2014
02417375 SIV QUETIAPINE XR 200MG TABLET 12-03-2014
02417804 PDL QUETIAPINE XR 200MG TABLET 07-05-2014
02417383 SIV QUETIAPINE XR 300MG TABLET 12-03-2014
02417812 PDL QUETIAPINE XR 300MG TABLET 07-05-2014
02417820 PDL QUETIAPINE XR 400MG TABLET 07-05-2014
02417391 SIV QUETIAPINE XR 400MG TABLET 12-03-2014
02417359 SIV QUETIAPINE XR 50MG TABLET 12-03-2014
02417782 PDL QUETIAPINE XR 50MG TABLET 07-05-2014
02340569 PMS ST PMS-QUINAPRIL 10MG TABLET 03-02-2014
02340577 PMS ST PMS-QUINAPRIL 20MG TABLET 03-02-2014
02340585 PMS ST PMS-QUINAPRIL 40MG TABLET 03-02-2014
02340550 PMS ST PMS-QUINAPRIL 5MG TABLET 03-02-2014
02415925 PDL ST QUINAPRIL 10MG TABLET 24-03-2014
02415933 PDL ST QUINAPRIL 20MG TABLET 24-03-2014
02415941 PDL ST QUINAPRIL 40MG TABLET 24-03-2014
02415917 PDL ST QUINAPRIL 5MG TABLET 24-03-2014
02421321 MIN ST MINT-RAMIPRIL 10MG CAPSULE 10-06-2014
02421348 MIN ST MINT-RAMIPRIL 15MG CAPSULE 10-06-2014
02421305 MIN ST MINT-RAMIPRIL 2.5MG CAPSULE 10-06-2014
02421313 MIN ST MINT-RAMIPRIL 5MG CAPSULE 10-06-2014
02415895 PDL ST RAMIPRIL-HCTZ 10/12.5MG TABLET 31-03-2014
02412659 SAN ST RAMIPRIL-HCTZ 10/12.5MG TABLET 03-02-2014
02415909 PDL ST RAMIPRIL-HCTZ 10/25MG TABLET 31-03-2014
02412675 SAN ST RAMIPRIL-HCTZ 10/25MG TABLET 03-02-2014
02415887 PDL ST RAMIPRIL-HCTZ 5/12.5MG TABLET 31-03-2014
02412640 SAN ST RAMIPRIL-HCTZ 5/12.5MG TABLET 03-02-2014
02415887 PDL ST RAMIPRIL-HCTZ 5/12.5MG TABLET 08-04-2014
02412667 SAN ST RAMIPRIL-HCTZ 5/25MG TABLET 03-02-2014
02415968 PDL ST REPAGLINIDE 0.5MG TABLET 03-07-2014
02415976 PDL ST REPAGLINIDE 1MG TABLET 03-07-2014
02415984 PDL ST REPAGLINIDE 2MG TABLET 03-07-2014
02413485 MYL MYLAN-RISPERIDONE ODT 0.5MG 08-04-2014
02413493 MYL MYLAN-RISPERIDONE ODT 1MG 08-04-2014
02413507 MYL MYLAN-RISPERIDONE ODT 2MG 08-04-2014
02413515 MYL MYLAN-RISPERIDONE ODT 3MG 08-04-2014
02413523 MYL MYLAN-RISPERIDONE ODT 4MG 08-04-2014
02423464 RIV RIVA-RIZATRIPTAN ODT 10MG TABLET 18-06-2014
02423456 RIV RIVA-RIZATRIPTAN ODT 5MG TABLET 18-06-2014
02415801 PDL RIZATRIPTAN RDT 10MG TABLET 24-03-2014
02415798 PDL RIZATRIPTAN RDT 5MG TABLET 24-03-2014
02413078 MAR ST MAR-ROSUVASTATIN 10MG TABLET 18-06-2014
02413086 MAR ST MAR-ROSUVASTATIN 20MG TABLET 18-06-2014
02413108 MAR ST MAR-ROSUVASTATIN 40MG TABLET 18-06-2014
02413051 MAR ST MAR-ROSUVASTATIN 5MG TABLET 18-06-2014
02399172 GMP ST MED-ROSUVASTATIN 10MG TABLET 03-02-2014
02399180 GMP ST MED-ROSUVASTATIN 20MG TABLET 03-02-2014
02399199 GMP ST MED-ROSUVASTATIN 40MG TABLET 03-02-2014
02399164 GMP ST MED-ROSUVASTATIN 5MG TABLET 30-02-2014
02419858 SAN SALBUTAMOL HFA 100MCG INHALER 24-03-2014
80034416 JAP JAMP-SODIUM PHOSPHATE O/L 31-03-2014
02319217 SDZ ST SANDOZ TAMSULOSIN 0.4MG CAPSULE 18-06-2014
02413612 PDL ST TAMSULOSIN CR 0.4MG TABLET 24-03-2014
02420082 APX ST APO-TELMISARTAN 40MG TABLET 13-02-2014
02420090 APX ST APO-TELMISARTAN 80MG TABLET 13-02-2014
02420023 APX ST APO-TELMISARTAN/HCTZ 80/12.5MG 13-02-2014
02420031 APX ST APO-TELMISARTAN/HCTZ 80/25MG 13-02-2014
02405040 AUR AURO-VALACYCLOVIR 500MG TABLET 04-02-2014
02414236 AUR ST AURO-VALSARTAN 160MG TABLET 20-06-2014
02414244 AUR ST AURO-VALSARTAN 320MG TABLET 20-06-2014
02414201 AUR ST AURO-VALSARTAN 40MG TABLET 20-06-2014
02414228 AUR ST AURO-VALSARTAN 80MG TABLET 20-06-2014
02414147 DOM ST DOM-VALSARTAN 80MG TABLET 24-03-2014
02408147 AUR ST AURO VALSARTAN 320/12.5MG100 12-03-2014
02408155 AUR ST AURO VALSARTAN 320/25MG 100 12-03-2014
02408120 AUR ST AURO-VALSARTAN HCT 160/12.5MG 12-03-2014
02408139 AUR ST AURO-VALSARTAN HCT 160MG/25MG 12-03-2014
02408112 AUR ST AURO-VALSARTAN HCT 80/12.5MG 12-03-2014
02419521 MIN MINT-ZOLMITRIPTAN 2.5MG TABLET 04-07-2014
02419513 MIN MINT-ZOLMITRIPTAN ODT 2.5MG 04-07-2014

New Limited Use Benefits

Table 1
DIN MFR Item Name Effective Date
02269198 NOV ACLASTA 5MG/100ML IV INJECTION 20-03-2014
02415100 TAR TARO-ZOLEDRONIC ACID 5MG/100ML 09-06-2014
02408082 TEP ZOLEDRONIC ACID 5MG/100ML INJECTION 08-05-2014

Limited use benefit (prior approval required).

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 2
DIN MFR Item Name Effective Date
02409682 APX APO-VORICONAZOLE 200MG TAB 09-06-2014
02409674 APX APO-VORICONAZOLE 50MG TABLET 09-06-2014
02396874 TEP TEVA-VORICONAZOLE 200MG TABLET 09-06-2014
02396866 TEP TEVA-VORICONAZOLE 50MG TABLET 09-06-2014

Limited use benefit (prior approval required).

For the treatment of:

  • patients with invasive aspergillosis.
  • culture proven invasive candidiasis with documented resistance to fluconazole.
Table 3
DIN MFR Item Name Effective Date
02416824 SDZ SANDOZ TACROLIMUS 1MG CAPSULE 03-02-2014
02416832 SDZ SANDOZ TACROLIMUS 5MG CAPSULE 03-02-2014

Limited use benefit (prior approval required).

  • For transplant therapy.
Table 4
DIN MFR Item Name Effective Date
02416794 FRS ST JANUMET XR 50MG/1000MG TABLET 05-05-2014

Limited use benefit (prior approval required).

  • 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 5
DIN MFR Item Name Effective Date
02418118 APX ST APO-SILDENAFIL R 20MG TABLET 07-02-2014

Limited use benefit (prior approval required).

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 6
DIN MFR Item Name Effective Date
02401622 GMP MED-RIVASTIGMINE 3MG CAPSULE 03-02-2014
02401630 GMP MED-RIVASTIGMINE 4.5MG CAPSULE 03-02-2014
02401649 GMP MED-RIVASTIGMINE 6MG CAPSULE 03-02-2014
02416999 PDL RIVASTIGMINE 1.5MG CAPSULE 24-03-2014
02417006 PDL RIVASTIGMINE 3MG CAPSULE 24-03-2014
02417014 PDL RIVASTIGMINE 4.5MG CAPSULE 24-03-2014
02417022 PDL RIVASTIGMINE 6MG CAPSULE 24-03-2014

Limited use benefit (prior approval required).

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; AND
  • 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 7
DIN MFR Item Name Effective Date
02298465 JNO RISPERDAL CONSTA 12.5MG/VIAL 19-08-2014
02255707 JNO RISPERDAL CONSTA SUS 25MG/VIAL 19-08-2014
02255758 JNO RISPERDAL CONSTA SUS 50MG/VIAL 19-08-2014
02255723 JNO RISPERDAL CONSTA SUS37.5MG/VIA 19-08-2014

Limited use benefit (prior approval required).

For the management of manifestations of schizophrenia and related psychotic disorders in patients who have:

  • tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR
  • who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR
  • who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations
Table 8
DIN MFR Item Name Effective Date
02397307 JAP ST JAMP-PIOGLITAZONE 15MG TABLET 17-02-2014

Limited use benefit (prior approval required).

  • For treatment of type 2 diabetic patients who are not adequately controlled by or are intolerant to metformin and sulfonylureas or for whom these products are contraindicated.
Table 9
DIN MFR Item Name Effective Date
02357054 JAP ST JAMP-PANTOPRAZOLE 40MG TABLET 12-03-2014

Limited use benefit (prior approval not required).

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

Table 10
DIN MFR Item Name Effective Date
02417448 MIN ST MINT-PANTOPRAZOLE 40MG TABLET 08-04-2014

Limited use benefit (prior approval not required).

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

Table 11
DIN MFR Item Name Effective Date
02354233 JNO INVEGA SUSTENNA 100MG/1ML 19-08-2014
02354241 JNO INVEGA SUSTENNA 150MG/1.5ML 19-08-2014
02354217 JNO INVEGA SUSTENNA 50MG/0.5ML 19-08-2014
02354225 JNO INVEGA SUSTENNA 75MG/0.75ML 19-08-2014

Limited use benefit (prior approval required).

For the management of manifestations of schizophrenia and related psychotic disorders in patients who have:

  • tried oral risperidone or paliperidone and at least one other antipsychotic agent and continue to be inadequately controlled at maximally tolerated doses; OR
  • who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia; OR
  • who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations
Table 12
DIN MFR Item Name Effective Date
09857387 ALL BOTOX 200U VIAL 08-07-2014
09857386 ALL BOTOX 50U VIAL 08-07-2014

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 overactivity resulting from neurogenic bladder associated with MS or subcervical spinal cord injury.
Table 13
DIN MFR Item Name Effective Date
02420198 JAP ST JAMP-OMEPRAZOLE DR 20MG TABLET 24-03-2014
02402416 RIV ST RIVA-OMEPRAZOLE DR 20MG TABLET 12-03-2014

Limited use benefit (prior approval not required).

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

Table 14
DIN MFR Item Name Effective Date
02401274 AUR AURO-MONTELUKAST 10MG TABLET 04-02-2014

Limited use benefit (prior approval required).

For treatment of:

  • asthma when used in patients on concurrent steroid therapy.
  • asthma patients not well controlled with or intolerant to inhaled corticosteroids.
Table 15
DIN MFR Item Name Effective Date
02422816 RIV ST RIVA-LANSOPRAZOLE 30MG CAPSULE 19-06-2014

Limited use benefit (prior approval not required).

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

Table 16
DIN MFR Item Name Effective Date
02407825 APX APO-IMIQUIMOD 5% CREAM 17-02-2014

Limited use benefit (prior approval required).

For the treatment of condylomata acuminate (genital warts) in patients who have failed:

  • self-applied podophyllotoxin (podofilox 0.5% solution); OR
  • provider-applied podophyllum resin (10%-25%)
Table 17
DIN MFR Item Name Effective Date
02397293 CBT CO IMATINIB 400MG TABLET 24-07-2014

Limited use benefit (prior approval required).

  • For the treatment of patients with chronic myeloid leukemia (CML) in blast crisis, accelerated phase, or in chronic phase.
  • For the treatment of patients with gastrointestinal stromal tumour.
  • For newly diagnosed adult patients with Philadelphia chromosome-positive (CML).
Table 18
DIN MFR Item Name Effective Date
02405814 AUR ST AURO-FINASTERIDE 5MG TABLET 11-03-2014
02355043 ACC ST FINASTERIDE 5MG TABLET 02-04-2014

Limited use benefit (prior approval required).

  • For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha-adrenergic blocker.
    or
  • For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
Table 19
DIN MFR Item Name Effective Date
02400588 AUR AURO-DONEPEZIL 10MG TABLET 11-03-2014
02400561 AUR AURO-DONEPEZIL 5MG TABLET 11-03-2014
02420600 SIV DONEPEZIL 10MG TABLET 07-05-2014
02420597 SIV DONEPEZIL 5MG TABLET 07-05-2014

Limited use benefit (prior approval required).

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; AND
  • 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 20
DIN MFR Item Name Effective Date
02420988 TAR TARO-DICLOFENAC 1.5% TOP SOLUTION 11-06-2014

Limited use benefit (prior approval required).

For the treatment of osteoarthritis when:

  • pain is inadequately controlled with acetaminophen AND a non-steroidal anti-inflammatory (NSAID);
    OR
  • there is contraindication to acetaminophen and NSAID; OR
  • there is intolerance to acetaminophen and NSAID
Table 21
DIN MFR Item Name Effective Date
02368153 AMG XGEVA 120MG/1.7ML(70MG/ML) INJECTION 16-05-2014

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 bony metastases; AND
  • good performance status (ECOG performance status score of 0, 1, or 2).
Table 22
DIN MFR Item Name Effective Date
02398419 TEP ST TEVA-BOSENTAN 125MG TABLET 18-07-2014
02398400 TEP ST TEVA-BOSENTAN 62.5MG TABLET 12-03-2014

Limited use benefit (prior approval required).

Maximum dose covered is 125 mg twice daily.

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 sildenafil OR tadalafil; OR
  • who have contraindications to sildenafil OR tadalafil.
Table 23
DIN MFR Item Name Effective Date
02384728 RBY ST RAN-ALENDRONATE 70MG TABLET 05-05-2014

Limited use benefit (prior approval required).

For the treatment of:

  • paget's Disease OR
  • osteoporosis in patients who are 60 years of age or over; OR
  • osteoporosis in patients under 60 who have documented hip, vertebral or other fractures; OR
  • osteoporosis in patients under 60 with no evidence of fracture but who have a high (>20%) 10-year fracture risk; OR
  • 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 24
DIN MFR Item Name Effective Date
02402475 BMS ORENCIA 125MG/SYR INJECTABLE 20-03-2014

Limited use benefit (prior approval required).

Coverage is provided for the 2 indications.

1. For the treatment of severely active RHEUMATOID ARTHRITIS:

Criteria for initial for one year coverage:

  • Prescribed by a rheumatologist

Coverage is provided for in adult patients ≥ 18 years for use, in combination with methotrexate (MTX) or other disease modifying anti-rheumatic drugs (DMARDs), for the reduction in signs and symptoms of severely active RA who has failed:

  • MTX (oral or parenteral) at a dose ≥ 20 mg weekly (≥ 15 mg weekly if patient is ≥ 65 years) for a minimum of 12 weeks of continuous treatment. Note: Patients who do not exhibit a clinical response to oral MTX or who experience gastrointestinal intolerance may consider a trial of parenteral MTX.
    AND
  • MTX in combination with at least two other DMARDS, such as sulfasalazine and hydroxychloroquine, for a minimum of 12 weeks of continuous treatment.
    AND
  • Etanercept OR adalimumab OR golimumab OR certolizumab OR abatacept (SC): minimum of 12 weeks trial OR, if the patient has a contraindication or intolerance to MTX and has failed:
  • Combination of at least two DMARDS, such as sulfasalazine, hydroxychloroquine, azathioprine, leflunomide, cyclosporine or gold, for a minimum of 12 weeks of continuous treatment.

Note: Initial one-year coverage for rheumatoid arthritis is provided at a dose of 500 mg for patients weighing < 60 kg; 750 mg for patients weighing 60 to 100 kg; and 1000 mg for patients weighing > 100 kg. Doses are given at 0, 2 and 4 weeks, then every 4 weeks. Coverage beyond one year will be based on improvement in number of swollen joints, number of tender joints, ESR or CRP, duration of morning stiffness, Physician Global Assessment scale and Patient Global Assessment scale.

2. For the treatment of JUVENILE IDIOPATHIC ARTHRITIS in children 6 to 17 years who meet all of the following:

Criteria for initial for one year coverage:

  • Prescribed by a rheumatologist
  • ≥ 5 swollen joints; AND
  • ≥ 3 joints with limited range of motion and/or pain/tenderness; AND
  • Condition is refractory to an adequate trial of a therapeutic dose of MTX. An adequate trial is defined as at least 3 months of oral or parenteral MTX at 10mg/m2 weekly (unless significant toxicity limits the dose tolerated)

Criteria Changes

Criteria Change for Suboxone

Effective September 15 2014, the NIHB Program changed the Limited Use criteria for Suboxone (buprenorphine/naloxone).

The new Suboxone criteria includes:

  • 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.

Addition of pJIA for Tocilizumab (Actermra)

On August 29, 2014, NIHB added LU criteria for the indication of polyarticular juvenile idiopathic arthritis (pJIA) for tocilizumab. The criteria is as follows:

For the treatment of severely active polyarticular juvenile idiopathic arthritis in children 2 to 17 years where the following criteria are met:

  • 5 swollen joints; AND
  • ≥ 3 joints with limited range of motion and/or pain/tenderness; AND
  • Condition is refractory to an adequate trial of a therapeutic dose of methotrexate.

DIN Changes for Onabotulinumtoxin A (Botox)

Effective May 12, 2014, the following DINs are used by NIHB for Botox:

  • Botox 50U 09857386
  • Botox 100U 01981501
  • Botox 200U 09857387
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