Update to the Drug Benefit List – Fall 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. 

Visit our Web Site at: www.healthcanada.gc.ca/nihb

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 BRAND NAME Effective Date
02381389 VAE ST EDARBI 40MG TABLET 04-08-2015
02381397 VAE ST EDARBI 80MG TABLET 04-08-2015
02430789 PFI FRAGMIN 3500U/0.28ML SYRINGE 24-08-2015
09991401 BTD ST BD PRECISIONGLIDE 18GX1 23-07-2015
09991402 BTD ST BD PRECISIONGLIDE 18GX1 1/2 23-07-2015
09991385 BTD ST BD PRECISIONGLIDE 25GX5/8 23-07-2015
09991386 BTD ST BD PRECISIONGLIDE 25GX7/8 23-07-2015
09991384 BTD ST BD PRECISIONGLIDE 26GX1/2 23-07-2015
09991383 BTD ST BD PRECISIONGLIDE 26GX3/8 23-07-2015
09991382 BTD ST BD PRECISIONGLIDE 27GX1 1/4 23-07-2015
09991381 BTD ST BD PRECISIONGLIDE 27GX1/2 23-07-2015
97799433 BTD ST BD AUTOSHIELD DUO SAFETY PEN NEEDLE 26-08-2015
97799399 DRX ST INSUPEN 32GX4MM NEEDLE 24-09-2015
97799383 DRX ST INSUPEN 33GX4MM 24-09-2015
97799991 AUC ST UNIFINE 31G.12MM 23-07-2015
97799993 AUC ST UNIFINE 31G.6MM 23-07-2015
97799992 AUC ST UNIFINE 31G.8MM 23-07-2015
97799426 AUC ST UNIFINE PENTIPS 31GX5MM 23-07-2015
09991363 BTD ST BD LUER-LOK TIP 10ML SYRINGE 23-07-2015
09991349 BTD ST BD LUER-LOK TIP 18GX1 1/2 23-07-2015
09991376 BTD ST BD LUER-LOK TIP 1ML SYRINGE 23-07-2015
09991368 BTD ST BD LUER-LOK TIP 20ML SYRINGE 13-08-2015
09991338 BTD ST BD LUER-LOK TIP 25GX1 23-07-2015
09991337 BTD ST BD LUER-LOK TIP 25GX1 1/2 23-07-2015
09991339 BTD ST BD LUER-LOK TIP 25GX5/8 23-07-2015
09991377 BTD ST BD LUER-LOK TIP 30ML SYRINGE 13-08-2015
09991371 BTD ST BD LUER-LOK TIP 3ML SYRINGE 13-08-2015
09991373 BTD ST BD LUER-LOK TIP 5ML SYRINGE 13-08-2015
09991364 BTD ST BD SLIP TIP 10ML SYRINGE 23-07-2015
09991375 BTD ST BD SLIP TIP 1ML SYRINGE 13-08-2015
09991369 BTD ST BD SLIP TIP 20ML SYRINGE 13-08-2015
09991378 BTD ST BD SLIP TIP 30ML SYRINGE 13-08-2015
09991372 BTD ST BD SLIP TIP 3ML SYRINGE 13-08-2015
09991374 BTD ST BD SLIP TIP 5ML SYRINGE 13-08-2015
09991361 BTD ST BD SLIP TIP SUB Q 26G 23-07-2015
09991360 BTD ST BD TUBERCULIN 21GX1 23-07-2015
09991359 BTD ST BD TUBERCULIN 25GX5/8 23-07-2015
09991358 BTD ST BD TUBERCULIN 26GX3/8 23-07-2015
09991357 BTD ST BD TUBERCULIN 27GX1/2 23-07-2015
09991356 BTD ST BD TUBERCULIN 27GX1/2 23-07-2015
97799887 BTD ST ULTRA 29G. 3/10CC 23-07-2015
97799888 BTD ST ULTRA 29G.1/2CC 23-07-2015
97799889 BTD ST ULTRA 29G.1CC 23-07-2015
97799890 BTD ST ULTRA-FINE II 30G.1CC 23-07-2015
97799886 BTD ST ULTRA-FINE II 30GX0.3 CC 23-07-2015
97799885 BTD ST ULTRA-FINE II 30GX0.5CC 23-07-2015
02429470 LEO INNOHEP 12000IU/0.6ML INJECTION 02-03-2015
Table 2 - Multi-Source Drug Products
DIN MFR BRAND NAME Effective Date
02435527 JAP ST JAMP-AMITRIPTYLINE 10MG TABLET   16-10-2015
02435535 JAP ST JAMP-AMITRIPTYLINE 25MG TABLET 16-10-2015
02435543 JAP ST JAMP-AMITRIPTYLINE 50MG TABLET 16-10-2015
02435551 JAP ST JAMP-AMITRIPTYLINE 75MG TABLET 21-10-2015
02401576 SIV AMOXICILLIN 250MG/5ML GRANULE 08-09-2015
02433060 JAP JAMP-AMOXICILLIN 250MG CAPSULE 16-10-2015
02433079 JAP JAMP-AMOXICILLIN 500MG CAPSULE 16-10-2015
02417936 REC ST REDDY-ATORVASTATIN 10MG TABLET 08-09-2015
02417944 REC ST REDDY-ATORVASTATIN 20MG TABLET 08-09-2015
02417952 REC ST REDDY-ATORVASTATIN 40MG TABLET 08-09-2015
02417960 REC ST REDDY-ATORVASTATIN 80MG TABLET 08-09-2015
02357860 VAE CELESTODERM V/2 0.05% CREAM      21-09-2015
02357879 VAE CELESTODERM V/2 0.05% OINTMENT 22-07-2015
02431629 SPT ST SEPTA-CITALOPRAM 10MG TABLET 16-10-2015
02440180 TAR CLINDAMYCIN/BENZOYL PEROXIDE 1/5% GEL 30-09-2015
02229380 TAR CLOTRIMAZOLE 1% CREAM 15-10-2015
02441020 APX APO-DICLOFENAC OPHTHALMIC SOLUTION 0.1% 30-09-2015
02440296 NPH ST NAT-ESCITALOPRAM 10MG TABLET 01-09-2015
02440318 NPH ST NAT-ESCITALOPRAM 20MG TABLET 01-09-2015
80059198 MAN ST M-FER GLUCONATE 300MG TABLET 10-09-2015
80057416 MAN ST M-SULFATE FERREUX 300MG TABLET 11-08-2015
80061488 MAN ST M-FOLIQUE 1MG TABLET            10-09-2015
02438658 MYL ST MYLAN-GLICLAZIDE MR 30MG TABLET  24-09-2015
80057189 JAP JAMP-HYDROCORTISONE 1% CREAM  03-09-2015
80057191 JAP JAMP-HYDROCORTISONE 1% LOTION    03-09-2015
02242930 TAR HYDROCORTISONE ACETATE 0.5% CREAM 26-10-2015
02436256 ATP ACT LATANOPROST/TIMOLOL OPHTHALMIC SOLUTION 28-09-2015
02418959 APX ST ALLERTIN TABLETLETS 10MG TABLET     25-09-2015
02442132 SIV ST METOPROLOL-L 100MG TABLET          08-09-2015
02442116 SIV ST METOPROLOL-L 25MG TABLET        08-09-2015
02442124 SIV ST METOPROLOL-L 50MG TABLET           08-09-2015
02410303 FAM MOVISSE 0.35MG TABLET              11-08-2015
02417286 JAP ST JAMP OLANZAPINE (FC) 10MG TABLET 28-10-2015
02417294 JAP ST JAMP OLANZAPINE (FC) 15MG TABLET 28-10-2015
02417243 JAP ST JAMP OLANZAPINE (FC) 2.5MG TABLET 28-10-2015
02417308 JAP ST JAMP OLANZAPINE (FC) 20MG TABLET 28-10-2015
02417251 JAP ST JAMP OLANZAPINE (FC) 5MG TABLET  28-10-2015
02417278 JAP ST JAMP OLANZAPINE (FC) 7.5MG TABLET 28-10-2015
02438003 MIN ST MINT-QUETIAPINE 25MG TABLET      29-09-2015
02439166 NPH ST NAT-QUETIAPINE 100MG TABLET     08-09-2015
02439182 NPH ST NAT-QUETIAPINE 200MG TABLET        08-09-2015
02439158 NPH ST NAT-QUETIAPINE 25MG TABLET      08-09-2015
02439190 NPH ST NAT-QUETIAPINE 300MG TABLET     08-09-2015
02424258 AUR ST AURO-REPAGLINIDE 0.5MG TABLET    16-10-2015
02424266 AUR ST AURO-REPAGLINIDE 1MG TABLET      16-10-2015
02424274 AUR ST AURO-REPAGLINIDE 2MG TABLET 16-10-2015
02347091 SDZ SANDOZ VALACYCLOVIR 500MG TABLET 16-10-2015
02435179 AUR AURO-VALGANCICLOVIR 450MG TABLET 28-10-2015

New Limited Use

Table 3 – Alprazolam
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

To promote safe, therapeutically effective and efficient use of drug 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.

02417634 NPH ST NAT-ALPRAZOLAM 0.25MG TABLET 25-08-2015
02417642 NPH ST NAT-ALPRAZOLAM 0.5MG TABLET 25-08-2015
02417650 NPH ST NAT-ALPRAZOLAM 1MG TABLET 25-08-2015
Table 4 – Aripiprazole
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

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

  1. Tried oral risperidone or paliperidone; AND
  2. At least one other antipsychotic agent; AND
  3. Continue to be  inadequately controlled at maximally tolerated doses OR
  4. Who are currently receiving a conventional depot antipsychotic and are experiencing significant side effects such as
    extrapyramidal symptoms or tardive dyskinesia OR
  5. Who have a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as
    repeated hospitalizations
02420864 OTS ABILIFY MAINTENA 300MG INJECTION    24-09-2015
02420872 OTS ABILIFY MAINTENA 400MG INJECTION    24-09-2015
Table 5 – Celecoxib
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

For patients who have:

  1. A history of serious gastrointestinal complications (e.g. ulcer, bleeding, perforation); OR
  2. Multiple (at least two) risk factors for serious gastrointestinal complications (e.g. age >60, concurrent use of ASA, SSRIs, corticosteroids, anticoagulants or antiplatelet agents).
02442639 SDZ ST SDZ CELECOXIB 100MG CAPSULE 30-09-2015
02442647 SDZ ST SDZ CELECOXIB 200MG CAPSULE 30-09-2015
Table 6 – Clonazepam
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

To promote safe, therapeutically effective and efficient use of drug 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.

02442027 SIV ST CLONAZEPAM 0.25MG TABLET 08-09-2015
02442035 SIV ST CLONAZEPAM 0.5MG TABLET 08-09-2015
02442043 SIV ST CLONAZEPAM 1MG TABLET 08-09-2015
02442051 SIV ST CLONAZEPAM 2MG TABLET 08-09-2015
Table 7 – Dextroamphetamine Sulfate
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

The NIHB Program introduced a dose coverage limit for stimulants on February 25, 2015 as part of a strategy to deal with the potential misuse and abuse of these medications. The stimulant dose coverage limit is set at 150 mg of methylphenidate equivalentstABLE 7 Footnote * per day for adults and children. This limit is calculated based on the total dose of all stimulants that patients are receiving from NIHB. The Program will continue to monitor the utilization of stimulants and adjust the eligible dose limit as required.

Table 7 Footnotes

Table 7 Footnote *

To convert to methylphenidate equivalents, 1 mg of METHYLPHENIDATE, or LISDEXAMFETAMINE is equal to 0.5 mg DEXTROAMPHETAMINE

Return to table 7 footnote * referrer

02443236 APX APO-DEXTROAMPHETAMINE 5MG TABLET 01-09-2015
Table 8 – Donepezil
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

Initial six month coverage for cholinesterase inhibitors:

  1. Diagnosis of mild to moderate Alzheimer's disease; AND
    1. Please provide Mini Mental State Exam (MMSE) score established within the last 60 days (Patient must have a score
      between 10-26); AND
    2. Please provide Global Deterioration Scale (GDS) score established within the last 60 days (Patient must have a score
      between 4-6).

Criteria for coverage at every six month interval:

  1. Diagnosis is still mild to moderate Alzheimer's disease; AND
  2. MMSE score > 10; OR
  3. GDS score between 4 to 6; AND
  4. 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)
02425351 ECL ST ECL-DONEPEZIL 10MG TABLET 25-08-2015
02425343 ECL ST ECL-DONEPEZIL 5MG TABLET 25-08-2015
02439565 NPH ST NAT-DONEPEZIL 10MG TABLET 01-09-2015
02439557 NPH ST NAT-DONEPEZIL 5MG TABLET 01-09-2015
Table 9 – Dutasteride
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

  1. For treatment of Benign Prostatic Hyperplasia (BPH) in patients who do not tolerate or have not responded to an alpha- adrenergic blocker; OR
  2. For use in combination therapy when monotherapy with an alpha-blocker is not sufficient.
02443058 SAN ST DUTASTERIDE 0.5MG CAPSULE 06-10-2015
Table 10 – Imatinib
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

  1. For the treatment of patients with chronic myeloid leukemia in blast crisis, accelerated phase, or in chronic phase.
  2. For the treatment of patients with gastrointestinal stromal tumour
  3. For newly diagnosed adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (CML)
02431114 PMS PMS-IMATINIB 100MG TABLET 11-08-2015
02431122 PMS PMS-IMATINIB 400MG TABLET 11-08-2015
Table 11 – Insulin Pump Supplies
DIN MFR BRAND NAME Effective Date

Patient has type 1 diabetes; AND

The insulin pump should have been prescribed /recommended by an endocrinologist or a specialist prescriber with experience in the use of insulin pumps in children, adolescent and/or adults.

97799674 AMS CARTRIDGE FOR IR200 2ML       15-09-2015
97799683 AMS COMFORT ANGLED INFUSION SET 17MM  15-09-2015
97799682 AMS COMFORT ANGLED INFUSION SET 17MM           15-09-2015
97799679 AMS COMFORT SRT ANGLED INFUSION SET 13 15-09-2015
97799678 AMS COMFORT SRT ANGLED INFUSION SET 13 15-09-2015
97799610 AMS CONTACT DETACH 90 DEG INFUSION SET 15-09-2015
97799672 AMS CONTACT DETACH 90 DEG INFUSION SET 15-09-2015
97799687 AMS INSET II 90 DEG INFUSION SET 6MM  15-09-2015
97799685 AMS INSET II 90 DEG INFUSION SET 6MM  15-09-2015
97799686 AMS INSET II 90 DEG INFUSION SET 9MM  15-09-2015
97799684 AMS INSET II 90 DEG INFUSION SET 9MM  15-09-2015
97799438 MDT MIO INFUSION SET BLUE         15-09-2015
97799491 MDT MIO INFUSION SET BLUE         15-09-2015
97799490 MDT MIO INFUSION SET CLEAR        15-09-2015
97799489 MDT MIO INFUSION SET CLEAR        15-09-2015
97799437 MDT MIO INFUSION SET PINK         15-09-2015
97799492 MDT MIO INFUSION SET PINK         15-09-2015
97799715 MDT PARADIGM SILHOUETTE 13MMX 43' 15-09-2015
97799485 MDT PARADIGM SILHOUETTE 13MMX18"  15-09-2015
97799716 MDT PARADIGM SILHOUETTE 13MMX23'  15-09-2015
97799484 MDT PARADIGM SILHOUETTE 13MMX32"  15-09-2015
97799718 MDT PARADIGM SILHOUETTE 17MMX23'  15-09-2015
97799483 MDT PARADIGM SILHOUETTE 17MMX32"  15-09-2015
97799719 MDT PARADIGM SILHOUETTE 17MMX43'  15-09-2015
97799529 MDT PARADIGM SILHOUETTE CANNULA 13 15-09-2015
97799528 MDT PARADIGM SILHOUETTE CANNULA 17 15-09-2015
97799521 MDT PARADIGM SURE-T 29G 6MMX18'   15-09-2015
97799520 MDT PARADIGM SURE-T 29G 6MMX23'   15-09-2015
97799519 MDT PARADIGM SURE-T 29G 8MMX23'   15-09-2015
09991327 OMD PODS 15-09-2015
97799744 MDT QUICK-SET 6MMX23' TUBING 15-09-2015
97799743 MDT QUICK-SET 6MMX43' TUBING      15-09-2015
97799742 MDT QUICK-SET 9MMX23' TUBING      15-09-2015
97799741 MDT QUICK-SET 9MMX43' TUBING      15-09-2015
97799488 MDT QUICK-SET INFUSION SET        15-09-2015
97799486 MDT QUICK-SET INFUSION SET        15-09-2015
97799487 MDT QUICK-SET INFUSION SET        15-09-2015
97799650 DIS RAPID-D INFUSION SET 10MM/110 21-08-2015
97799652 DIS RAPID-D INFUSION SET 10MM/60CM 14-09-2015
97799651 DIS RAPID-D INFUSION SET 10MM/80CM 26-08-2015
97799656 DIS RAPID-D INFUSION SET 6MM/110CM 14-09-2015
97799658 DIS RAPID-D INFUSION SET 6MM/60CM 14-09-2015
97799657 DIS RAPID-D INFUSION SET 6MM/80CM 14-09-2015
97799653 DIS RAPID-D INFUSION SET 8MM/110CM 14-09-2015
97799655 DIS RAPID-D INFUSION SET 8MM/60CM 14-09-2015
97799654 DIS RAPID-D INFUSION SET 8MM/80CM 14-09-2015
97799707 MDT RESERVOIR PARADIGM 5X1.8ML    15-09-2015
97799706 MDT RESERVOIR PARADIGM 7X3.0ML    15-09-2015
97799644 DIS TENDER-1 INFUSION SET 17MM/110 14-09-2015
97799646 DIS TENDER-1 INFUSION SET 17MM/60 14-09-2015
97799645 DIS TENDER-1 INFUSION SET 17MM/80 14-09-2015
97799647 DIS TENDER-1 MINI INF SET 13MM/110 14-09-2015
97799649 DIS TENDER-1 MINI INFUSION SET 13MM/60 15-09-2015
97799648 DIS TENDER-1 MINI INFUSION SET 13MM/80 14-09-2015
97799638 DIS TENDER-2 INFUSION SET 17MM/110 14-09-2015
97799640 DIS TENDER-2 INFUSION SET 17MM/60 14-09-2015
97799639 DIS TENDER-2 INFUSION SET 17MM/80 14-09-2015
97799641 DIS TENDER-2 MINI INF SET 13MM/110 14-09-2015
97799643 DIS TENDER-2 MINI INFUSION SET 13MM/60 14-09-2015
97799642 DIS TENDER-2 MINI INFUSION SET 13MM/80 14-09-2015
97799665 DIS ULTRAFLEX - 1 10MM/110CM      14-09-2015
97799667 DIS ULTRAFLEX - 1 10MM/60CM       14-09-2015
97799666 DIS ULTRAFLEX - 1 10MM/80CM       14-09-2015
97799668 DIS ULTRAFLEX - 1 8MM/110CM       14-09-2015
97799670 DIS ULTRAFLEX - 1 8MM/60CM        14-09-2015
97799669 DIS ULTRAFLEX - 1 8MM/80CM        14-09-2015
Table 12 – Levetiracetam
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

For 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.

02442531 SIV LEVETIRACETAM 250MG TABLET      08-09-2015
02442558 SIV LEVETIRACETAM 500MG TABLET      08-09-2015
02442566 SIV LEVETIRACETAM 750MG TABLET      08-09-2015
02440202 NPH NAT-LEVETIRACETAM 250MG TABLET     08-09-2015
02440210 NPH NAT-LEVETIRACETAM 500MG TABLET     08-09-2015
02440229 NPH NAT-LEVETIRACETAM 750MG TABLET     08-09-2015
Table 13 – Moxifloxacin
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

Coverage will be limited to 14 tablets every 14 days, followed by a 14 days lockout.

02242965 BAY AVELOX 400MG TABLET 26-08-2015
Table 14 – Ombitasvir, Paritaprevir, Ritonavir, Dasabuvir
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

For the treatment of chronic hepatitis C virus (HCV) Genotype 1 infection in adults with a liver fibrosis stage ≥ F2 (Metavir
score or equivalent).

Criteria & Duration

  • Treatment naïve and experienced Genotype 1b, non-cirrhoticTable 14 Footnote * - 12 weeks
  • Treatment naïve and experienced Genotype 1a, non-cirrhotic - 12 weeks in combination with RBV
  • Treatment naïve and experienced Genotype1b, cirrhotic - 12 weeks in combination with RBV
  • Treatment naïve and experienced (prior relapsers and prior partial responders) Genotype 1a, cirrhotic - 12 weeks in combination with RBV
  • Treatment experienced Genotype 1a, with cirrhosis, and who have had a previous null response to pegIFN and RBV - 24 weeks in combination with RBV

Table 14 Footnotes

Table 14 Footnote *

Holkira Pak with ribavirin is recommended in patients with an unknown Genotype 1 subtype or with mixed Genotype 1 infection

Return to table 14 footnote * referrer

Not eligible for coverage:

  • Patients currently being treated with another HCV antiviral agent
  • Patients who have previously received a treatment course of Holkira Pak (Re-treatment requests will not be considered).
02436027 ABV HOLKIRA PAK 12.5/75/50/250MG  06-10-2015
Table 15 - Omeprazole
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

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

02439549 NPH ST NAT-OMEPRAZOLE DR 20MG TABLET      01-09-2015
Table 16 – Pantoprazole Magnesium
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval not required).

NIHB has implemented a quantity limit on proton pump inhibitors (PPIs). A total of 400 tablets or capsules are permitted in a 180-day period. This quantity limit is based on the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) report on optimal PPI therapy.

Please indicate reason for exceeding 400 tablets/capsules in 180 days:

  1. Zollinger Ellison Syndrome (may be granted a one-year approval)
  2. Barrett's esophagus (may be granted a one-year approval)
  3. Erosive esophagitis (may be granted a one-year approval)
  4. Change from one PPI to another (single exemption may be granted)
  5. Other.
02408570 MYL ST MYLAN-PANTOPRAZOLE T 40MG TABLET 30-10-2015
Table 17 – Pregabalin
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

  1. For the treatment of neuropathic pain in patients who have failed to effectively treat their pain with a tricyclic antidepressant (TCA)
  2. For the treatment of neuropathic pain in patients who have a contraindication or intolerance with a tricyclic antidepressant (TCA) The dose of pregabalin is limited to a maximum of 600mg per day. Requests for doses over 600mg per day will be considered
02433907 AUR ST AURO-PREGABALIN 150MG CAPSULE     19-10-2015
02433869 AUR ST AURO-PREGABALIN 25MG CAPSULE     19-10-2015
02433877 AUR ST AURO-PREGABALIN 50MG CAPSULE     19-10-2015
02433885 AUR ST AURO-PREGABALIN 75MG CAPSULE     19-10-2015
Table 18 - Progesterone
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

For the treatment of women:

  1. With postmenopausal symptoms who are intolerant to medroxyprogesterone acetate (MPA); OR
  2. Who are at risk of preterm birth. OR
  3. Who are using the medication to prevent miscarriage.
02439913 TEP ST TEVA-PROGESTERONE 100MG CAPSULE   09-09-2015
Table 19 – Ribavirin
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

  • For the treatment of chronic hepatitis C Genotype 2, in accordance with the sofosbuvir criteria, in patients who qualify for treatment with sofosbuvir. OR
  • For the treatment of chronic hepatitis C Genotype 3, in accordance with the sofosbuvir criteria, in patients who qualify for treatment with sofosbuvir.
02439212 PED IBAVYR 200MG TABLET             31-08-2015
02425890 PED IBAVYR 400MG TABLET             31-08-2015
02425904 PED IBAVYR 600MG TABLET 31-08-2015
Table 20 – Solifenacin
DIN MFR BRAND NAME Effective Date

Limited use benefit (prior approval required).

For the symptomatic relief of overactive bladder in patients:

  1. with symptoms of urinary frequency, urgency or urge incontinence; AND
  2. who have failed on or are intolerant to therapy with immediate-release oxybutynin.
02422247 CBT ST ACT SOLIFENACIN 10MG TABLET      21-10-2015
02422239 CBT ST ACT SOLIFENACIN 5MG TABLET      21-10-2015
02399040 SDZ ST SANDOZ SOLIFENACIN 10MG TABLET   21-10-2015
02399032 SDZ ST SANDOZ SOLIFENACIN 5MG TABLET   21-10-2015
02397919 TEP ST TEVA-SOLIFENACIN 10MG TABLET     30-09-2015
02397900 TEP ST TEVA-SOLIFENACIN 5MG TABLET     30-09-2015

Criteria Changes

Listing of Alphagan P

Effective August 26, 2015, Alphagan P 0.15% Ophthalmic Solution (02248151) and Apo-Brimonidine P 0.15% Ophthalmic Solution (02301334) became open benefit. The listing status was changed from limited use to open benefit.

Change in the Listing Criteria of Levofloxacin

Effective September 4, 2015, Levofloxacin tablet became limited use benefit (prior approval not required) on the NIHB DBL. Coverage will be limited to 750mg/day every 14 days, followed by a 14 days lockout.

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