Standard Of Procedures Special Authorization Drugs List-PDF Free Download

Standard of procedures special authorization drugs list
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DRUG DISEASE APPROVAL GUIDELINES RENEWAL, ADCIRCA TADALAFIL Pulmonary Arterial Treatment of primary pulmonary arterial Indefinite N A. Oral Tablet Hypertension hypertension PAH or PAH associated with. PAH connective tissue disease congenital heart disease. DIN 02338327 20 MG or anorexigen use, No response to conventional therapy. WHO functional Class II or III, AFINITOR EVEROLIMUS Metastatic Renal Second line treatment in metastatic RCC of clear 4 months 4 months. Oral Tablet Cell Carcinoma cell morphology after failure to VEGF receptor. RCC of clear cell thyrosine kinase inhibitor sunitinib or sorafenib Absence of progression. DIN 02369257 2 5 MG morphology, DIN 02339501 5 MG ECOG 2. DIN 02339528 10 MG, Neuroendocrine Treatment of well or moderately differentiated 4 months 6 months.
tumours of neuroendocrine tumours of pancreatic origin. pancreatic origin PNET Absence of progression, Unresectable locally advanced or metastatic. disease that has progressed within the last 12, Subependymal giant Treatment of SEGA associated with tuberous 4 months 4 months. cell astrocytoma sclerosis complex TSC that has demonstrated. SEGA serial growth Absence of progression, 3 years of age or older. Not candidate for surgical resection and for, whom immediate surgical intervention is not. Postmenopausal Treatment of postmenopausal women with 4 months 6 months. women with advanced breast cancer, advanced breast Absence of progression.
cancer Hormone receptor positive, HER2 negative, Associated with aromasin. After failure with letrozole or anastrozole, ALERTEC MODAFINIL Symptomatic Symptomatic treatment of excessive sleepiness Indefinite N A. Oral Tablet excessive sleepiness, Hypersomnia with narcolepsy. DIN 02239665 100 MG Hypersomnia associated to sleep apnea despite. the use of a CPAP, MODAFINIL MODAFINIL, Oral Tablet. DIN 02285398, APTIVUS TIPRANAVIR Coordinate with HIV AIDS Provincial.
Oral Capsule Government Program, DIN 02273322 250 MG HIV infection In combination with other antiretroviral agents in 6 months 1 year. treatment experienced HIV 1 infected adult, patients with evidence of HIV 1 replication and. HIV 1 strains resistant to multiple protease, inhibitors. DRUG DISEASE APPROVAL GUIDELINES RENEWAL, ARANESP DARBEPOETINE ALFA If available coordinate with the Provincial. Intravenous Subcutaneous Solution Government Program. DIN 02246354 10 MCG 0 4 ML Anemia Treatment of anemia associated with chronic Indefinite N A. DIN 02246355 20 MCG 0 5 ML kidney disease CKD including patients on. DIN 02246357 30 MCG 0 3 ML dialysis and patients not on dialysis. DIN 02246358 60 MCG 0 3 ML, DIN 02246360 150 MCG 0 3 ML Or.
Treatment of Anemia due to Chemotherapy in, Patients with Non Myeloid Malignancies. AIDS related anemia, AUBAGIO TERIFLUNOMIDE Relapsing Treatment of relapsing remitting multiple 6 months 1 year. Oral Tablet Remitting Multiple Sclerosis RRMS, Sclerosis RRMS. DIN 02416328 14 MG 18 years of age or older, Prescribed by a neurologist. Monotherapy, Number of disabling clinical relapses in the.
last 12 months, AVONEX INTERFERON BETA 1A If available coordinate with the Provincial. Prefilled Serynge or Autoinjector Government Program. DIN 02269201 30 MCG 0 5 ML Relapsing 4 years if 4 years if. Remitting Multiple EDSS 4 EDSS 4, Sclerosis RRMS, Chronic 2 years if 2 years if. Progressive EDSS 4 EDSS 4, Multiple Sclerosis, If isolated ICS 1 year. Single clinical, demyelinating event syndrome, with two clinically ICS 1. silent lesions year, typical of MS, BANZEL RUFINAMIDE Lennox Gastaut Adjunctive treatment of seizures associated with 6 months 1 year.
Oral Tablet Syndrome LGS Lennox Gastaut syndrome, DIN 02369613 100 MG 4 years of age or older. DIN 02369621 200 MG Inadequate response or failure to one or more. DIN 02369648 400 MG other antiepileptic drugs, BARACLUDE ENTECAVIR If available coordinate with the Provincial. Oral Tablet Government Program, DIN 02282224 0 5 MG Hepatitis B virus Treatment of chronic hepatitis B virus infection Indefinite N A. infection with 0 5 mg daily, No resistance to lamivudine and according viral. Treatment of chronic hepatitis B virus infection, with 1 mg daily.
Resistance to lamivudine and according viral, Failure of treatment with adefovir or being. intolerant to adefovir, DRUG DISEASE APPROVAL GUIDELINES RENEWAL. BENLYSTA BELIMUMAB Validate the administration site if in an hospital. Intravenous Solution setting must be free of charge. DIN 02370050 120 MG 5 ML, DIN 02370069 400 MG 20 ML Systemic Lupus In addition to standard therapy in patients with 6 months 6 months. Erythematosus moderate to severe SLE, SLE According to the treatment. 18 years of age or older response, Prescribed by a rheumatologist.
Achieving and maintaining an, Autoantibody within last 3 months ANA improvement for SELENA. or dsDNA SLEDAI score score 4 vs, initial request, SELENA SLEDAI score 6 and who have not. responded intolerant or contraindicated to, corticosteroid and hydroxychloroquine. BETASERON INTERFERON BETA 1B If available coordinate with the Provincial. Subcutaneous Solution Government Program, DIN 02169649 0 3 MG Relapsing 4 years if 4 years if. Remitting Multiple EDSS 4 EDSS 4, Sclerosis RRMS, Chronic 2 years if 2 years if.
Progressive EDSS 4 EDSS 4, Multiple Sclerosis, If isolated ICS 1 year. Single clinical, demyelinating event syndrome, with two clinically ICS 1. silent lesions year, typical of MS, DRUG DISEASE APPROVAL GUIDELINES RENEWAL. BOTOX BOTULINUM TOXIN Validate the administration site if in an hospital. Intramuscular Solution setting must be free of charge. Blepharospasm 12 years of age or older 1 year Indefinite. DIN 01981501 100 IU Strabismus, Cervical dystonia Spasmodic torticollis treatment in adult patients 1 year Indefinite. Hyperhidrosis of Excessive sweating second line treatment 1 year Indefinite. the Axillae, Maximum of 200 Units per treatment, Focal spasticity In the management of focal spasticity including 1 year Indefinite.
the treatment of upper limb spasticity associated, with stroke in adults. Chronic migraine For the prophylaxis of headaches in adults with 1 year 1 year. chronic migraine, Headaches lasting 4 hours a day or longer. 15 days month x 3 months, Previous medication, Maximum of 200 Units per treatment. Neurogenic Treatment of urinary incontinence due to 1 year 1 year. detrusor neurogenic detrusor overactivity resulting from. overactivity neurogenic bladder associated with multiple. associated with a sclerosis or subcervical spinal cord injury. neurological, condition Adults, Inadequate response or intolerant to. anticholinergic agents, CAPRELSA VAND TANIB Medullary thyroid Treatment of symptomatic or progressive 3 months 6 months.
Oral Tablet cancer medullary thyroid cancer in adult patients with. unresectable locally advanced or metastatic, DIN 02378582 100 MG disease. DIN 02378590 300 MG, CIALIS TADALAFIL Benign Prostatic Continuous therapy 2 5 or 5 mg once a day 3 months 6 months. Oral Tablet Hyperplasia BPH, Failure to standard treatment. DIN 02296888 2 5 MG, DIN 02296896 5 MG, CIALIS TADALAFIL Erectile Treatment of erectile dysfunction ED in men 18 1 year 1 year. Oral Tablet Dysfunction ED years of age or older, DIN 02296888 2 5 MG NOTE Organic erectile dysfunction e g diabetes.
DIN 02296896 5 MG related vascular related Indefinite if. DIN 02248088 10 MG If no ED clause annual, DIN 02248089 20 MG not eligible Erectile dysfunction with neurological cause ceiling. e g spinal cord injury SCI nerve damage, as a result of a prostatectomy or TURP. Drug induced erectile dysfunction where it, would be inappropriate to alter the dosage or to. discontinue the use of the drug in question, Mixed psychogenic organic erectile. dysfunction, DRUG DISEASE APPROVAL GUIDELINES RENEWAL.
CIMZIA CERTOLIZUMAB PEGOL Rheumatoid A confirmed diagnosis of moderate to severe 1 year 1 year. Subcutaneous Solution Arthritis rheumatoid arthritis with persistent active. RA disease 8 or more affected joints Improvement of 20 for. DIN 02331675 200 MG ML affected joints, Patients who does not respond to methotrexate. adequately at a dose equal to or greater than Improvement of 20 for. 15mg per week and to another disease SRV or CRP or HAQ or. modifying antirheumatic drugs for a period of return to work. 3 months or more, One of the following, Erosion confirmed by X Ray. Increase of SRV or CRP, Positive rheumatoid factor. COMPLERA Coordinate with HIV AIDS Provincial, EMTRICITABINE TENOFOVIR Government Program. DISOPROXIL FUMARATE RILPIVIRINE, Oral Tablet HIV infection In monotherapy for the treatment of HIV 1 6 months 1 year.
DIN 02374129 200 MG 300 MG 25 MG, Antiretroviral treatment naive adults. HIV 1 RNA 100 000 copies mL, COPAXONE GLATIRAMER ACETATE If available coordinate with the Provincial. Subcutaneous Solution Government Program, DIN 02245619 20 MG ML Relapsing 4 years if 4 years if. Remitting Multiple EDSS 4 EDSS 4, Sclerosis RRMS, Chronic 2 years if 2 years if. Progressive EDSS 4 EDSS 4, Multiple Sclerosis, If isolated ICS 1 year.
Single clinical, demyelinating event syndrome, with two clinically ICS 1. silent lesions year, typical of MS, DIACOMIT STIRIPENTOL Refractory Treatment of refractory generalized tonic clonic 6 months 1 year. Oral Capsule Powder for Suspension myoclonic epilepsy seizures in patients with severe myoclonic. epilepsy in infancy, DIN 02398958 250 MG, DIN 02398966 500 MG 3 years of age or older. DIN 02398974 250 MG PCK In conjunction with clobazam and valproate. DIN 02398982 500 MG PCK After failure with clobazam and valproate. DRUG DISEASE APPROVAL GUIDELINES RENEWAL, ENBREL ETANERCEPT Rheumatoid A confirmed diagnosis of moderate to severe 1 year 2 years. Subcutaneous Solution Arthritis rheumatoid arthritis with persistent active. RA disease 8 or more affected joints Improvement of 20 for. DIN 02274728 50 MG ML affected joints, DIN 02242903 25 MG And.
Patients who does not respond to methotrexate, adequately at a dose equal to or greater than Improvement of 20 for. 15mg per week and to another disease SRV or CRP or HAQ or. modifying antirheumatic drugs for a period of return to work. 3 months or more, One of the following, Erosion confirmed by X Ray. Increase of SRV or CRP, Positive rheumatoid factor. 4 years of age or older 1 year 2 years, Juvenile Idiopathic. Arthritis JIA 5 or more affected joints and failure or Improvement of 20 for. contraindications to methotrexate and to affected joints. another disease modifiying antirheumatic drugs, for a period of 3 months or more And.
0 8mg kg max 50mg sc every week Improvement of 20 for. SRV or CRP or improvement, of CHAQ or return to school. A confirmed diagnosis of moderate to severe 1 year 2 years. Psoriatic Arthritis psoriatic arthritis with persistent and active. PA disease more than 3 affected joints Improvement of 20 for. affected joints, Failure or contraindications to methotrexate. and to another disease modifiying And, antirheumatic drugs for a period of 3 months. or more Improvement of 20 for, SRV or CRP or a 0 2 point. HAQ 1 diminution for the HAQ score, or return to work.
1 year 2 years, Ankylosing No response to NSAIDs, Spondylitis AS A 2 2 points diminution for. BASDAI score 4 the BASDI score or 50 or, return to work. 4 months 1 year, Chronic moderate Treatment of adult patients with chronic. to severe plaque moderate to severe plaque psoriasis who are Improvement of 75 for the. psoriasis candidates for systemic therapy or phototherapy PASI score. No response contraindications intolerance or Or, inaccessibility to phototherapy. 18 years of age or older Improvement of 50 for the. Treated by a dermatologist PASI score and a 5 points. Failure or inappropriate to systemic therapy improvement for DLQI. by two of the following antipsoriatic agents, methotrexate cyclosporine or acitretin Or.
Psoriasis Area Severtiy Index PASI 10 or Significant improvement of. extensive plaques on the face the palms of the lesions on the face the palms. hands the soles of the feet or the genital area of the hands the soles of the. feet or the genital area, Dermatology Life Quality Index DLQI 10. DRUG DISEASE APPROVAL GUIDELINES RENEWAL, EPREX EPOETINE ALFA If available coordinate with the Provincial. Intravenous Subcutaneous Solution Government Program. DIN 02243239 20000 IU 0 5 ML Anemia of Chronic Treatment of anemia associated with chronic renal Indefinite N A. DIN 02288680 30000 IU 0 75 ML Renal Failure failure including patients on dialysis and patients. DIN 02231587 10000 IU ML Dialysis not on dialysis with Hb 100g L. DIN 02126591 10000 IU ML, DIN 02231583 1000 IU 0 5 ML. DIN 02231584 2000 IU 0 5 ML, DIN 02126575 2000 IU ML Anemia in HIV Treatment of transfusion dependent anemia Indefinite N A. DIN 02231585 3000 IU 0 3 ML infected Patients related to therapy with zidovudine in HIV. DIN 02240722 40000 IU ML infected patients, DIN 02231586 4000 IU 0 4 ML.
DIN 02126583 4000 IU ML Endogenous serum erythropoietin level is 500. DIN 02243400 5000 IU 0 5 ML mU mL and when patients are receiving a dose. DIN 02243401 6000 IU 0 6 ML of zidovudine 4200 mg week. Anemia due to Treatment of anemia due to chemotherapy i. 1 UPDATED March 3rd 2014 Standard of procedures Special Authorization Drugs 1 General Section For all of the following drugs Claims should be coordinate with the

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