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Prior Authorization Criteria

While the Prior Authorization process may make specific medications available to certain cardholders beyond the standard eligible drug list, Prior Authorization is not applicable to all medications or to all plan designs. We encourage members to confirm the status of their medication by logging onto our Member Services Site, downloading our Member Mobile App or calling our Customer Contact Centre.

Drug Name Chemical Name Criteria Comments
Vyndaqel tafamidis meglumine

Requests for Special Authorization are considered for the treatment of adult patients with cardiomyopathy due to transthyretin-mediated amyloidosis, wild-type or hereditary, to reduce cardiovascular mortality and cardiovascular-related hospitalization.

Vyndamax tafamidis meglumine

Requests for Special Authorization are considered for the treatment of adult patients with cardiomyopathy due to transthyretin-mediated amyloidosis (ATTR-CM), wild-type or hereditary, to reduce cardiovascular mortality and cardiovascular-related hospitalization.

Braftovi + Mektovi encorafenib + binimetinib

Requests for Special Authorization will be considered:

- Braftovi (encorafenib) in combination with Mektovi (binimetinib), for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600 mutation, as detected by a validated test.

Reblozyl luspatercept

Requests for Special Authorization are considered for:

- the treatment of adult patients with red blood cell (RBC) transfusion-dependent anemia associated with beta(â)-thalassemia.

Firdapse amifampridine phosphate

Requests for special authorization are considered for the symptomatic treatment of Lambert-Eaton Myasthenic Syndrome (LEMS) in adults.

Ruzurgi amifampridine

Requests for special authorization are considered for the symptomatic treatment of Lambert-Eaton myasthenic syndrome (LEMS) in patients 6 years of age and older.

Riabni rituximab

Requests for Special Authorization are considered:

- to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies.

- the induction of remission in adult patients with severely active Granulomatosis with Polyangiitis (GPA, also known as Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA).

Neupro rotigotine

Requests for special authorization will be considered for the treatment of the signs and symptoms of idiopathic Parkinson’s disease.

Vascepa icosapent ethyl

Requests for special authorization are considered to reduce the risk of cardiovascular events (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularization or hospitalization for unstable angina) in statin-treated patients with elevated triglycerides, who are at high risk of cardiovascular events due to:

- established cardiovascular disease, or

- diabetes, and at least one other cardiovascular risk factor

Emgality galcanezumab

Requests for special authorization are considered for the prevention of migraine in adults who have at least 4 migraine days per month.

Spravato esketamine hydrochloride

Requests for special authorization are considered in combination with a SSRI or SNRI, for the treatment of major depressive disorder in adults who have not responded adequately to at least two separate courses of treatment with different antidepressants, each of adequate dose and duration, in the current moderate to severe depressive episode.

Brenzys etanercept

Requests for special authorization are considered for:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

(a) Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

- patients with ankylosing spondylitis who have failed a six-month trial of two different non-steroidal anti-inflammatory drugs (NSAIDS).

- treatment of adult patients with chronic moderate to severe plaque psoriasis (PsO) who are candidates for systemic therapy or phototherapy.

- treatment of pediatric patients ages 4 to 17 years with chronic severe PsO who are candidates for systemic therapy or phototherapy. Data on safety and efficacy are limited in the age group 4 to 6 years

- reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in patients aged 4 to 17 years who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

- reducing signs and symptoms, inhibiting the progression of structural damage of active arthritis, and improving physical function in adult patients with psoriatic arthritis (PsA).


Inflectra infliximab

Rheumatoid Arthritis:

- Requests for special authorization will be considered for use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

- Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

- The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Ankylosing Spondylitis:

-Requests for special authorization will be considered for the reduction of signs and symptoms and improvement in physical function in patients with active ankylosing spondylitis when the following criteria have been met:

- Diagnosis of ankylosing spondylitis AND :

- Medication is being prescribed by, or in consultation with, a rheumatologist or a specialist in the field of rheumatology AND:

- The patient has undergone a trial treatment of at least three months with 2 NSAIDs AND/OR the patient exhibits uveitis (iritis)

Psoriatic Arthritis:

- Requests for special authorization will be considered for the treatment of adult patients with active psoriatic arthritis (PSA) who meet ALL of the following criteria:

- The medication is prescribed by or in consultation with a rheumatologist, or a specialist in the field of RA or PsA

- The patient has had an inadequate response or intolerance to at least 2 disease modifying anti-rheumatic drugs (DMARDs), one of which must be methotrexate unless contraindicated . Patients must have had a trial of at least 3 months with these agents

Plaque Psoriasis:

- Requests for Special Authorization will be considered for adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy who meet ALL of the following criteria:

- Patient has been diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, (or a specialist, such as Internal Medicine),

- Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in he same manner as equal to or more than 10%.

- Patient has failed systemic therapy (for example with methotrexate. cyclosporine, or acitretin (Soriatane); must have had a trial of methotrexate (unless contraindicated).

- Patient has failed photochemical therapy,

- Patient is at least 18 years (adult in the submission) of age.

Crohn's Disease & Fistulizing Crohn’s Disease:

- Requests for special authorization will be considered for the reduction of signs and symptoms and induction and maintenance of clinical remission in adult patients with moderately to severely active Crohn’s disease when the following criteria have been met:

- Diagnosis of moderately to severely active Crohn’s disease AND:

- The patient must have had an inadequate response to conventional therapy

Ulcerative Colitis:

- Requests for special authorization will be considered for the reduction of signs and symptoms, inducing clinical remission, inducing mucosal healing, and reducing or eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Pediatric Crohn's Disease:

- reduction of signs and symptoms and induction and maintenance of clinical remission in pediatric patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy (corticosteroid and/or aminosalicylate and/or immunosuppressant).

Pediatric Ulcerative Colitis:

- reduction of signs and symptoms, induction and maintenance of clinical remission, and induction of mucosal healing in pediatric patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy (i.e., aminosalicylate and/or corticosteroid and/or an immunosuppressant).


Hulio adalimumab

Requests for special authorization are considered for:

Rheumatoid Arthritis

- reducing the signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis.

Polyarticular Juvenile Idiopathic Arthritis

- in combination with methotrexate, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients, 2 years of age and older who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Psoriatic Arthritis

- reducing the signs and symptoms of active arthritis and inhibiting the progression of structural damage and improving the physical function in adult psoriatic arthritis patients.

Ankylosing Spondylitis

- reducing signs and symptoms in adult patients with active ankylosing spondylitis who have had an inadequate response to conventional therapy.

Adult Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants.

Pediatric Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 13 to 17 years of age weighing ≥ 40 kg with severely active Crohn’s disease and/or who have had an inadequate response or were intolerant to conventional therapy (a corticosteroid and/or aminosalicylate and/or an immunosuppressant) and/or a tumour necrosis factor alpha antagonist.

Ulcerative Colitis

- treatment of adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy including corticosteroids and/or azathioprine or 6-mercaptopurine (6-MP) or who are intolerant to such therapies.

Hidradenitis Suppurativa

- treatment of active moderate to severe hidradenitis suppurativa in adult and adolescent patients (12 to 17 years of age weighing ≥ 30 kg) who have not responded to conventional therapy (including systemic antibiotics).

Plaque Psoriasis

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, HULIO® should be used after phototherapy has been shown to be ineffective or inappropriate.

Adult Uveitis

- treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Pediatric Uveitis

- treatment of chronic non-infectious anterior uveitis in pediatric patients from 2 years of age who have had an inadequate response to or are intolerant to conventional therapy, or in whom conventional therapy is inappropriate.

Hyrimoz adalimumab

Requests for special authorization are considered for:

Rheumatoid Arthritis

- reducing the signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis.

Polyarticular Juvenile Idiopathic Arthritis

- in combination with methotrexate, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients, 2 years of age and older who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Psoriatic Arthritis

- reducing the signs and symptoms of active arthritis and inhibiting the progression of structural damage and improving the physical function in adult psoriatic arthritis patients.

Ankylosing Spondylitis

- reducing signs and symptoms in patients with active ankylosing spondylitis who have had an inadequate response to conventional therapy.

Adult Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants.

Ulcerative Colitis

- treatment of adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy including corticosteroids and/or azathioprine or 6-mercaptopurine (6-MP) or who are intolerant to such therapies.

Hidradenitis Suppurativa

- treatment of active moderate to severe hidradenitis suppurativa in adult patients, who have not responded to conventional therapy (including systemic antibiotics).

Plaque Psoriasis

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, HYRIMOZ should be used after phototherapy has been shown to be ineffective or inappropriate.

Adult Uveitis

- treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Idacio adalimumab

Requests for special authorization are considered for:

Rheumatoid Arthritis

- reducing the signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis.

Polyarticular Juvenile Idiopathic Arthritis

- in combination with methotrexate, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients, 2 years of age and older who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Psoriatic Arthritis

- reducing the signs and symptoms of active arthritis and inhibiting the progression of structural damage and improving the physical function in adult psoriatic arthritis patients.

Ankylosing Spondylitis

- reducing signs and symptoms in adult patients with active ankylosing spondylitis who have had an inadequate response to conventional therapy.

Adult Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants.

Pediatric Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 13 to 17 years of age weighing ≥ 40 kg with severely active Crohn’s disease and/or who have had an inadequate response or were intolerant to conventional therapy (a corticosteroid and/or aminosalicylate and/or an immunosuppressant) and/or a tumour necrosis factor alpha antagonist.

Ulcerative Colitis

- treatment of adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy including corticosteroids and/or azathioprine or 6-mercaptopurine (6-MP) or who are intolerant to such therapies.

Hidradenitis Suppurativa

- treatment of active moderate to severe hidradenitis suppurativa in adult and adolescent patients (12 to 17 years of age weighing ≥ 30 kg) who have not responded to conventional therapy (including systemic antibiotics).

Plaque Psoriasis

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, Idacio® should be used after phototherapy has been shown to be ineffective or inappropriate.

Adult Uveitis

- treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Pediatric Uveitis

- treatment of chronic non-infectious anterior uveitis in pediatric patients from 2 years of age who have had an inadequate response to or are intolerant to conventional therapy, or in whom conventional therapy is inappropriate.

Amgevita adalimumab

Requests for special authorization are considered for:

Rheumatoid Arthritis

- reducing the signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis (RA).

Polyarticular Juvenile Idiopathic Arthritis

- in combination with MTX, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in patients, 2 years of age and older who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Psoriatic Arthritis

- reducing the signs and symptoms of active arthritis and inhibiting the progression of structural damage and improving the physical function in adult psoriatic arthritis patients (PsA).

Ankylosing Spondylitis

- reducing signs and symptoms in adult patients with active ankylosing spondylitis (AS) who have had an inadequate response to conventional therapy.

Adult Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease (CD) who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants.

Pediatric Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 13 to 17 years of age weighing ≥ 40 kg with severely active Crohn’s disease and/or who have had an inadequate response or were intolerant to conventional therapy (a corticosteroid and/or aminosalicylate and/or an immunosuppressant) and/or a tumour necrosis factor (TNF) alpha antagonist.

Ulcerative Colitis

- treatment of adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy including corticosteroids, azathioprine and/or 6-mercaptopurine (6-MP) or who are intolerant to such therapies.

Hidradenitis Suppurativa

- treatment of active moderate to severe hidradenitis suppurativa (HS) in adult and adolescent patients (12 to 17 years of age weighing ≥ 30 kg), who have not responded to conventional therapy (including systemic antibiotics).

Plaque Psoriasis

- treatment of adult patients with chronic moderate to severe plaque psoriasis (Ps) who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, AMGEVITA should be used after phototherapy has been shown to be ineffective or inappropriate.

Adult Uveitis

- treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Pediatric Uveitis

- treatment of chronic non-infectious anterior uveitis in pediatric patients from 2 years of age who have had an inadequate response to or are intolerant to conventional therapy, or in whom conventional therapy is inappropriate.

Hadlima adalimumab

Requests for special authorization are considered for:

Rheumatoid Arthritis

- reducing the signs and symptoms, inducing major clinical response and clinical remission, inhibiting the progression of structural damage and improving physical function in adult patients with moderately to severely active rheumatoid arthritis.

Polyarticular Juvenile Idiopathic Arthritis

- in combination with methotrexate, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients, 2 years of age and older, who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Psoriatic Arthritis

- reducing the signs and symptoms of active arthritis and inhibiting the progression of structural damage and improving the physical function in adult psoriatic arthritis patients.

Ankylosing Spondylitis

- reducing signs and symptoms in adult patients with active ankylosing spondylitis who have had an inadequate response to conventional therapy.

Adult Crohn’s Disease

- reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants.

Ulcerative Colitis

- treatment of adult patients with moderately to severely active ulcerative colitis (UC) who have had an inadequate response to conventional therapy including corticosteroids and/or azathioprine or 6-mercaptopurine (6-MP) or who are intolerant to such therapies.

Hidradenitis Suppurativa

- treatment of active moderate to severe hidradenitis suppurativa in adult and adolescent patients (12 to 17 years of age weighing ≥ 30 kg), who have not responded to conventional therapy (including systemic antibiotics).

Plaque Psoriasis

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, HADLIMATM (or HADLIMATM PushTouchTM) should be used after phototherapy has been shown to be ineffective or inappropriate.

Adult Uveitis

- treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Pediatric Uveitis

- treatment of chronic non-infectious anterior uveitis in pediatric patients from 2 years of age who have had an inadequate response to or are intolerant to conventional therapy, or in whom conventional therapy is inappropriate.

Ofev nintedanib

Requests for special authorization will be considered for:

- the treatment of Idiopathic Pulmonary Fibrosis (IPF).

- the treatment of other chronic fibrosing interstitial lung diseases (ILDs) with a progressive phenotype (also known as progressive fibrosing ILD).

Nyvepria pegfilgrastim

Requests for special authorization are considered for decreasing the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs.

Ziextenzo pegfilgrastim

Requests for special authorization are considered for decreasing the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs.

Venclexta venetoclax

Requests for special authorization will be considered:

- in combination with rituximab for the treatment of patients with chronic lymphocytic leukemia (CLL) who have received at least one prior therapy.

- in combination with obinutuzumab, for the treatment of patients with previously untreated chronic lymphocytic leukemia (CLL).

Tremfya guselkumab

Requests for special authorization are considered for:

- the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

- the treatment of adult patients with active psoriatic arthritis.

Zejula niraparib tosylate

Requests for Special Authorization are considered for:

- the maintenance treatment of female adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy.

- as monotherapy for the maintenance treatment of female adult patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to first-line platinum-based chemotherapy.

Lonsurf trifluridine/tipiracil

Requests for special authorization are considered for:

- the treatment of adult patients with metastatic colorectal cancer who have been previously treated with, or are not candidates for, available therapies including fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapies, anti-VEGF biological agents, and, if RAS wild-type, anti-EGFR agents.

- the treatment of adult patients with metastatic gastric cancer or adenocarcinoma of the gastroesophageal junction, who have been previously treated with at least two prior lines of chemotherapy including a fluoropyrimidine, a platinum, and either a taxane or irinotecan and if appropriate with HER2/neu-targeted therapy.

Otezla apremilast

Requests for special authorization will be considered for:

- the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.

- alone or in combination with methotrexate for the treatment of active psoriatic arthritis in adult patients who have had an inadequate response, intolerance, or contraindication to a prior disease-modifying anti-rheumatic drug (DMARD)

- the treatment of adult patients with oral ulcers associated with Behçet’s disease who are candidates for systemic therapy.

Calquence acalabrutinib

Requests for Special Authorization are considered for:

- in combination with obinutuzumab or as monotherapy for the treatment of patients with previously untreated chronic lymphocytic leukemia (CLL)

- as monotherapy for the treatment of patients with CLL who have received at least one prior therapy

- for the treatment of patients with mantle cell lymphoma (MCL) who have received at least one prior therapy

Jorveza budesonide

Requests for special authorization are considered for induction of clinico-pathological remission in adults with eosinophilic esophagitis (EoE).

Kynmobi apomorphine hydrochloride

Requests for special authorization are considered for the acute, intermittent treatment of “OFF” episodes in patients with Parkinson’s disease (PD).

Rozlytrek entrectinib

Requests for special authorization are considered for the treatment of patients with ROS1-positive locally advanced or metastatic non-small cell lung cancer (NSCLC) not previously treated with crizotinib.

Tremfya guselkumab

Requests for special authorization are considered for:

- the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

- the treatment of adult patients with active psoriatic arthritis.

Cesamet nabilone Requests for special authorization will be considered for: - the management of severe nausea and vomiting associated with cancer chemotherapy in patients who have failed other antinauseants (e.g. Stemetil, Zofran), are intolerant to other antinauseants or have a medical reason why they cannot take other antinauseants
Cimzia certolizumab

Requests for special authorization for Cimzia™ are considered for:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:
(a) Diagnosis of moderate to severe rheumatoid arthritis AND:
The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:
(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

- alone or in combination with MTX in adult patients with moderately to severely active PsA who have failed one or more disease-modifying anti-rheumatic drugs (DMARDs).

- for reducing signs and symptoms in adult patients with active ankylosing spondylitis (AS) who have had an inadequate response to conventional therapy.

- the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy.

- the treatment of adults with severe active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and / or magnetic resonance imaging (MRI) evidence who have had an inadequate response to, or are intolerant to nonsteroidal anti-inflammatory drugs (NSAIDs).

Cinqair reslizumab

Requests for Special Authorization are considered for add-on maintenance treatment of adult patients with severe eosinophilic asthma who:

- are inadequately controlled with medium-to-high-dose inhaled corticosteroids and an additional asthma controller(s) (eg, LABA) and

- have a blood eosinophil count of ≥400 cells/μL at initiation of the treatment or a level of 3% or more in induced sputum eosinophil count of total cells.

Cipralex & Cipralex Meltz escitalopram Requests are considered for patients suffering from depression, generalized anxiety disorder and social anxiety disorder (social phobia) in patients who have failed other regular benefit antidepressants, or have a medical reason why other regular benefit antidepressants can't be used. Regular benefit antidpressants include sertraline (Zoloft), fluoxetine (Prozac), mirtazapine (Remeron), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa).
Climacteron testosterone and estradiol Requests for special authorization are considered for: - patients who can not use or tolerate oral hormone replacement therapy
Climara estradiol Requests for special authorization are considered for: - patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine) - patients with a contraindication to oral therapy (e.g. dysphagia or liver disease) - patients who have not had symptom relief with oral hormone replacement therapy
Clindets Pledgets clindamycin

Requests for special authorization will be considered for:

- the treatment of acne vulgaris and/or papular and pustular acne which has failed other treatments (e.g. tretinoin, benzoyl peroxide or topical clindamycin)

- the treatment of acne vulgaris and/or papular acne if the patient is intolerant or allergic to other therapies (e.g. tretinoin, benzoyl peroxide or topical clindamycin)

Clozaril clozapine Requests for special authorization are considered for: - patients resistant to treatment with other anti-psychotics (e.g. olanzapine, risperidone, haloperidol, pimozide)
Combivir lamivudine/zidovudine Requests for special authorization are considered for HIV- naïve infected patients and in treatment-experienced adult patients who have failed prior antiretroviral therapy.
Complera emtricitabine/rilpivirine/ tenofovir Requests for special authorization for Complera are considered for: The treatment of HIV type 1 infection in antiretroviral treatment-naïve adult patients
Comtan entacapone Requests for special authorization are considered for: patients with Parkinson's disease who are currently on levodopa/carbidopa or levodopa/benserazide therapy and experience end-of-dose "wearing off".
Copaxone glatiramer acetate Requests for special authorization are considered for: - Patients with a diagnosis of relapsing-remitting multiple sclerosis or RRMS that has progressed to SPMS who have suffered a minimum of two exacerbations in the previous two years and who must be able to walk with or without a walking aid. - For all requests the diagnosis must be made by a neurologist.
Coreg carvedilol Requests for special authorization are considered for : - mild, moderate or severe congestive heart failure patients who are also using a diuretic, ACE-inhibitor and may or may not be using digitalis.
Cortiment budesonide Requests for special authorization are considered for the induction of remission in patients with active, mild to moderate ulcerative colitis.
Cosentyx secukinumab

Requests for special authorization will be considered for:
- the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.
- the treatment of adult patients with active ankylosing spondylitis who have responded inadequately to conventional therapy.
- the treatment of adult patients with active psoriatic arthritis when the response to previous disease-modifying anti-rheumatic drug (DMARD) therapy has been inadequate.

Cotazym pancrelipase Requests for special authorization are considered for pancreatic enzyme replacement therapy in established pancreatic insufficiency where pancreatic enzymes are absent from or present in insufficient amount in the intestine.
Cotellic cobimetinib Requests for special authorization will be considered for use in combination with vemurafenib for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600 mutation.
Creon pancrelipase Requests for special authorization are considered for pancreatic enzyme replacement therapy in established pancreatic insufficiency where pancreatic enzymes are absent from or present in insufficient amount in the intestine.
Crinone progesterone gel

Requests for special authorization are considered for:

Women undergoing an assisted reproductive technology (ART) treatment to induce cycles that require luteal phase support (i.e. history of spontaneous abortion).

Cyclosporine cyclosporine

Requests for special authorization are considered for: patients who have undergone a solid organ or bone marrow transplant, for treatment of severe psoriasis; for patients who have failed conventional therapy with other agents (only requests from dermatologists are to be considered) for treatment of severe active rheumatoid arthritis; for patients in whom classic anti-rheumatics are ineffective or inappropriate (only requests from rheumatologists are to be considered) for treatment of steroid-dependent and steroid-resistant nephrotic syndrome due to glomerular disease (only requests from nephrologists or internists are to be considered).

Cymbalta duloxetine hydrochloride

For those plans where Cymbalta is included as an eligible benefit, requests for special authorization will be considered for clients with the following diagnosis:
- adult patients for the management of neuropathic pain associated with diabetic peripheral neuropathy (DPN)

NOTE: Requests for Cymbalta for the treatment of major depressive disorder (MDD) will NOT be considered for reimbursement, UNLESS patient demonstrates that they have tried and failed a mimimum of 3 prior antidpressant drugs in the past.
Please note that for several plans, Cymbalta is NOT INCLUDED as an eligible benefit for any indication.

Daklinza daclatasvir dihydrochloride

Daklinza in combination with Sovaldi is not eligible for coverage for the treatment of genotype 3 chronic hepatitis C (CHC) patients. Alternative cost effective treatment options are eligible for coverage including Epclusa (pan genotypic, 12 weeks), with or without ribavirin.

Daxas roflumilast Requests for special authorization for Daxas™ are considered for Adults patients with severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis (i.e., patients with a history of chronic cough and sputum) and with a history of frequent exacerbations
DDAVP Tablets desmopressin

Requests for special authorization will be considered for :

- the management of vasopressin sensitive central diabetes insipidus and the control of temporary polyuria and polydipsia following head trauma, hypophysectomy (removal of pituitary) or surgery in the pituitary region, in patients who for medical reasons are unable to use the nasal formulation.

- the short term management of nocturnal enuresis (bedwetting) in children five years of age and older, who have normal ability to concentrate urine.

Delestrogen estradiol valerate

Requests for special authorization are considered for:

- palliative treatment of inoperable progressing prostatic carcinoma in males

- hormone replacement therapy in females

- treatment advanced mammary carcinoma in post menopausal women.

Descovy emtricitabine Requests for Special Authorization are considered in combination with other antiretrovirals (such as non-nucleoside reverse transcriptase inhibitors or protease inhibitors) for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and pediatric patients 12 years of age and older (and weighing 35 kg).
Dexiron Iron Dextran Complex

Requests for special authorization are considered for :

- documented iron deficiency for patients where oral forms of iron supplementation are contraindicated, not tolerated or have failed

Dextroject dextrose

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Diacomit stiripentol Requests for special authorization for Diacomit are considered for: - use in conjunction with clobazam and valproate as adjunctive therapy of refractory generalized tonic-clonic seizures in patients with severe myoclonic epilepsy in infancy (SMEI, Dravet syndrome) whose seizures are not adequately controlled with clobazam and valproate alone.
Diane-35 cyproterone ethinyl estradiol

Requests for special authorization are considered for :

- female patients with a diagnosis of severe acne, which is unresponsive to oral antibiotics (e.g. tetracycline) and other available treatments (e.g. isotretinoin), with associated symptoms of androgenization including seborrhea and mild hirsutism.

- hirsutism associated with PCOD (polycystic ovarian disease)

Dificid fidaxomicin Requests for special authorization for Dificid will be considered for: Patients (18 years of age or older) in whom treatment of a C. difficile infection (CDI) is required.
Diflucan fluconazole

Requests for special authorization considered for:

- patients who require treatment of severe or life threatening systemic fungal infections including meningitis (oral suspension and tablets)

- patients who require treatment for severe dermatophytoses not responding to other forms of therapy including ketoconazole (oral suspension and tablets)

- patients who require prophylaxis treatment to decrease the incidence of candidiasis in patients undergoing bone marrow transplantation and/or radiation therapy (oral suspension and tablets)

- treatment of oropharyngeal and esophageal candidiasis when other treatments have failed

Ditropan XL oxybutynin extended release tablets

Requests for Special Authorization are considered for:

- overactive bladder with symptoms of urinary frequency, urgency or urge incontinence where the patient has failed on, or proven intolerant to, a previous trial of first-line therapy (oxybutynin)

Divigel estradiol gel

Requests for special authorization for Divigel are considered for:
The treatment of moderate to severe vasomotor symptoms associated with menopause.

Duaklir Genuair aclidinium bromide/formoterol fumarate dihydrate

Requests for special authorization will be considered for:
- the long-term maintenance bronchodilator treatment for airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema.

Dukoral cholera inactivated, whole

Requests for special authorization will be considered for: protection against cholera in adults and children 2 years of age and older who will be visiting areas where there is risk of contracting cholera caused by V. cholerae. -protection against traveller's diarrhea in immunocompromised (e.g. HIV infection, transplant patients) adults and children 2 years of age and older who will be visiting areas where there is risk of contracting traveller's diarrhea caused by enterotoxigenic E. coli

Dysport Therapeutic AbobotulinumtoxinA

Requests for special authorization will be considered for:

- reduce the subjective symptoms and objective signs of cervical dystonia (spasmodic torticollis) in adults.

- for the symptomatic treatment of focal spasticity affecting the upper limbs in adults.

- for the symptomatic treatment of lower limb spasticity in pediatric patients 2 years of age and older

Ebixa memantine hydrochloride

Requests for special authorization will be considered for clients diagnosed with moderate to severe Alzheimer's disease. For approval purposes, moderate to severe corresponds to a Mini Mental State Exam (MMSE) score of 5 to 15 inclusively.

Edurant rilpivirine Requests for special authorization for Edurant are considered for: The treatment of HIV type 1 infection in antiretroviral treatment-naïve adult patients
Effient prasugrel Requests for Special Authorization are considered for: - Secondary prevention of atherothrombotic events in patients with acute coronary syndromes (ACS) who have undergo percutaneous coronary intervention (PCI)/stent implementation and have an increased risk of stent thrombosis
Elidel Cream pimecrolimus Requests for special authorization are considered for : - patients with a diagnosis of moderate to severe atopic dermatitis (eczema) that has not responded to first-line therapy (topical steroids). - Requests for children under two years of age will be reviewed under individual assessment.
Eligard leuprolide Request will be considered for advanced (stage D2) symptomatic carcinoma in patients who find surgical orchiectomy unacceptable or impractical for health reasons
Eliquis apixaban

Requests for Special Authorization are considered for the:

- prevention of venous thromboembolic events (VTEs) in patients who have undergone elective total hip replacement or total knee replacement surgery;

- prevention of stroke and systemic embolism in patients with atrial fibrillation, in whom anticoagulation is warranted, and in whom warfarin therapy has failed, is unsuitable, or is contraindicated;

- the treatment of venous thromboembolic events (deep vein thrombosis [DVT], pulmonary embolism [PE]) and prevention of recurrent DVT and PE in patients for whom warfarin therapy has failed, is unsuitable, or contraindicated.

Emend aprepitant

Requests for Special Authorization are considered for:
patients on a course of cytotoxic chemotherapy who are using a 5-HT3 antagonist (Zofran® and generics, Anzemet®, or Kytril®) and dexamethasone and who meet one of the following criteria:

a) patient is receiving highly emetogenic (cisplatin, mechlorethamine hydrochloride, streptozocin, dacarbazine, carmustine, or dactinomycin) chemotherapy

b) women who are receiving highly emetogenic chemotherapy (as above) or moderately emetogenic cancer chemotherapy consisting of cyclophosphamide and anthracycline

Enablex darifenacin hydrobromide Requests for Special Authorization are considered for: overactive bladder with symptoms of urinary frequency, urgency or urge incontinence where the patient has failed on, or proven intolerant to , a previous trial of first-line therapy (oxybutynin). may be considered for patients who have failed first line therapy, DitropanR (oxybutynin).
Enbrel etanercept

Requests for special authorization are considered for:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

(a) Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

- patients with psoriatic arthritis that does not respond to conventional treatments

- patients with ankylosing spondylitis who have failed a six-month trial of two different non-steroidal anti-inflammatory drugs (NSAIDS).

- patients aged 4 to 17 with moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

Enbrel (psoriasis) etanercept

Requests for Special Authorization will be considered for the treatment of pediatric patients ages 4 to 17 years OR adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy.

Criteria:

1. Patient has been diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, (or a specialist, such as Internal Medicine),

AND

2.Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in he same manner as equal to or more than 10%

AND

3. Patient has failed systemic therapy (for example with methotrexate. cyclosporine, or acitretin (Soriatane); must have had a trial of methotrexate (unless contraindicated),,

AND

4.Patient has failed photochemical therapy

Entocort Capsules budesonide Requests for special authorization are considered for: - patients who are suffering from mild to moderate Crohn's disease affecting the ileum and/or ascending colon.
Entocort Enema budesonide Requests for special authorization will be considered for the management of distal ulcerative colitis (rectum, sigmoid colon and descending colon).
Entresto sacubitril/valsartan Requests for special authorization will be considered for the treatment of heart failure with reduced ejection fraction (HFrEF) in patients with NYHA Class II or III, to reduce the incidence of cardiovascular death and heart failure hospitalisation.
Entyvio vedolizumab

Requests for special authorization will be considered for:
- the treatment of adult patients with moderately to severely active ulcerative colitis who have had an inadequate response, loss of response to, or were intolerant to either conventional therapy or infliximab, a TNF_ antagonist.
- the treatment of adult patients with moderately to severely active Crohn's disease who have had an inadequate response with, lost response to, or were intolerant to immunomodulators or a tumor necrosis factor-alpha (TNF_) antagonist; or have had an inadequate response, intolerance, or demonstrated dependence on corticosteroids.

Epclusa sofosbuvir/velpatasvir

Requests for Special Authorization are considered for the treatment of lab-confirmed pan-genotypic chronic hepatitis C virus (HCV) infection [genotypes 1-6], as monotherapy in adults without cirrhosis or with compensated cirrhosis and in combination with ribavirin in adults with decompensated cirrhosis, for a maximum of 12 weeks. Fibrosis stage must be provided.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME

Epipen epinephrine or adrenalin

Requests for special authorization are considered for:

- patients who have a documented allergy resulting in anaphylactic reactions.

Eprex epoetin alpha

Requests for special authorization are considered for patients suffering from anemia of the following types:

- Anemia of Chronic Renal Failure including patients on dialysis or not on dialysis: Non-dialysis patients with symptomatic anemia should have a hematocrit of less than 30% to be considered for therapy 2

- Anemia secondary to zidovudine treatment of AIDS/HIV: Patients treated with zidovudine (AZT) must have endogenous serum erythropoietin levels of less than or equal to 500 mU/mL and where the dose of zidovudine (AZT) is less than or equal to 4,200 mg/week.

- Anemia in cancer patients: Anemia in patients with non-myeloid malignancies may be disease related or may be secondary to chemotherapy. Treatment in patients with grossly elevated serum erythropoietin levels (>200 mU/mL) is not recommended.

Requests for Eprex treatment prior to an elective-surgical procedure will not be approved.

Erelzi etanercept

Requests for Special Authorization are considered for:

- treatment of moderately to severely active rheumatoid arthritis (RA) in adults.

- treatment of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in patients aged 4 to 17 years who have had an inadequate response to one or more disease-modifying antirheumatic drugs (DMARDs).

- treatment of active ankylosing spondylitis (AS).

- for reducing signs and symptoms, inhibiting the progression of structural damage of active arthritis, and improving physical function in adult patients with psoriatic arthritis (PsA).

- treatment of adult patients with chronic moderate to severe plaque psoriasis (PsO) who are candidates for systemic therapy or phototherapy.

- treatment of pediatric patients ages 4 to 17 years with chronic severe PsO who are candidates for systemic therapy or phototherapy. Data on safety and efficacy are limited in the age group 4 to 6 years.


Esbriet pirfenidone Requests for special authorization for Esbriet are considered for: - the treatment of mild to moderate idiopathic pulmonary fibrosis (IPF) in adults.
Estalis, Estalis Sequi norethindrone acetate and estradiol 17B Requests for special authorization are considered for: - patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine) - patients with a contraindication to oral therapy (e.g. dysphagia or liver disease) - patients who have not had symptom relief with oral hormone replacement therapy
Estracomb estradiol and norethindrone

Requests for special authorization are considered for:

- patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine)

- patients with a contraindication to oral therapy (e.g. dysphagia or liver disease)

- patients who have not had symptom relief with oral hormone replacement therapy

Estraderm estradiol

Requests for special authorization are considered for:

- patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine)

- patients with a contraindication to oral therapy (e.g. dysphagia or liver disease)

- patients who have not had symptom relief with oral hormone replacement therapy

Estradot estradiol

Requests for special authorization are considered for:

- patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine)

- patients with a contraindication to oral therapy (e.g. dysphagia or liver disease)

- patients who have not had symptom relief with oral hormone replacement therapy

Ethanolamine Oleate ethanolamine oleate

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Etibi ethambutol hydrochloride

Requests for special authorization are considered in combination with other antituberculosis medications in the treatment of all forms of tuberculosis, including tuberculous meningitis, caused by Mycobacterium tuberculosis.

Evista raloxifene

Requests for special authorization are considered for the prevention and treatment of osteoporosis in postmenopausal women:

- who have been diagnosed with breast cancer or are at high risk for breast cancer. (High risk is defined as mother, sister, daughter or multiple family members with breast or ovarian cancer).

Exelon rivastigmine

Requests for special authorization is considered for:

-patients diagnosed with Alzheimer's disease of mild to moderate severity. For approval purposes, mild to moderate severity corresponds to a Mini Mental State Exam (MMSE) score of 10 to 26 inclusively.

In advanced Alzheimer's, there is no evidence that the use of this product is beneficial and, therefore, the product is not a benefit. Cases of early-onset dementia (< than 60 years of age) require assessment by a neurologist or geriatrician before this product can be approved.

Exelon patch rivastigmine trasdermal patch

Requests for special authorization are considered for:
-patients diagnosed with Alzheimer's disease of mild to moderate severity. For approval purposes, mild to moderate severity corresponds to a Mini Mental State Exam (MMSE) score of 10 to 26 inclusively.

Exjade deferasirox

Requests for Special Authorization will be considered for patients with the following conditions:
the management of chronic iron overload in patients with transfusion-dependent anemias aged six years and older;
the management of chronic iron overload in patients with transfusion-dependent anemias aged two to five who cannot be adequately treated with deferoxamine. Therapy with Exjade® should be initiated and maintained by physicians experienced in the treatment of chronic iron overload due to blood transfusions.

Extavia interferon beta-1B

Requests for special authorization are considered for:

- Patients with a diagnosis of relapsing-remitting multiple sclerosis or RRMS that has progressed to SPMS. The patient must have suffered a minimum of two exacerbations in the previous two years and must be able to walk with or without a walking aid.

- Patients presenting with a first isolated and well-defined neurologic event as consistent with MS and involving the optic nerve, spinal cord, brain stem or cerebellum. Patients must also have two or more clinically significant lesions of the brain that are at least 3mm in diameter on MRI scans and are characteristic of MS. Patients must also be able to walk with or without a walking aid

- For all requests the diagnosis must be made by a neurologist.

Eylea aflibercept

Requests for Special Authorization for Eylea are considered when prescribed by a qualified ophthalmologist experienced in intravitreal injections, or a retinal specialist. for:
- the treatment of (wet) age-related macular degeneration
- the treatment of diabetic macular edema (DME)
- the treatment of visual impairment due to macular edema secondary to central retinal vein occlusion (CRVO)
- the treatment of visual impairment due to macular edema secondary to branch retinal vein occlusion (BRVO)
- the treatment of myopic choroidal neovascularization (myopic CNV).

Fabrazyme agalsidase

Any requests for Fabrazyme should be redirected to the The Canadian Fabry Disease Initiative (CFDI). All patients in Canada who are known to have Fabry disease or who may have Fabry disease based on a positive family history are encouraged to see a family physician for a referral to the appropriate Canadian Fabry Disease Initiative centre.

Fampyra fampridine Requests for Special Authorization for Fampyra are considered for the: symptomatic improvement of walking in adult patients with multiple sclerosis (MS) with walking disability (EDSS 3.5 7)
Fansidar pyrimethamine, sulfadoxine Requests for special authorization are considered for : - patients requiring treatment for malaria but not for prophylaxis in individuals traveling to an endemic country.
Faslodex fulvestrant

Requests for Special Authorization are considered for:

- for the treatment of estrogen receptor-positive, human epidermal growth receptor 2 (HER2)-negative locally advanced or metastatic breast cancer in postmenopausal women not previously treated with endocrine therapy.

- for the hormonal treatment of locally advanced or metastatic breast cancer in postmenopausal women, regardless of age, who have disease progression following prior anti-estrogen therapy.

Fem HRT norethindrone acetate ethinyl estradiol Requests for special authorization are considered for : - patients suffering from unacceptable adverse effects due to other estrogen therapy (e.g. estrogen-induced hypertension or migraine), or patients who have not had symptom relief with other hormone replacement therapy.
Ferriprox deferiprone Requests for special authorization are considered for: - the treatment of patients with transfusional iron overload due to thalassemia syndromes when current chelation therapy is inadequate
Fibristal ulipristal acetate

Requests for special authorization will be considered for:

- treatment of moderate to severe signs and symptoms of uterine fibroids in adult women of reproductive age, who are eligible for surgery.

- Intermittent treatment of moderate to severe signs and symptoms of uterine fibroids in adult women of reproductive age.

The duration of each treatment course is 3 months.

Firazyr icatibant acetate

Requests for special authorization will be considered for the treatment of acute attacks of hereditary angioedema (HAE) in adults, adolescents and children aged 2 years and older with C1-esterase inhibitor deficiency.

Firmagon degarelix for injection

Requests for special authorization are considered for:
patients with a diagnosis of advanced hormone-dependant prostate cancer in whom androgen deprivation is warranted.

Flolan epoprostenol

Requests for special authorization will be considered for the long-term intravenous treatment of idiopathic or heritable pulmonary arterial hypertension (PAH) or PAH associated with connective tissue diseases (CTD) in patients with WHO Functional Class III-IV symptoms who did not respond adequately to conventional therapy.

Flomax tamsulosin hydrochloride

Requests for special authorization are considered for the treatment of benign prostate hyperplasia (BPH) in patients who have not responded to, who have not tolerated or who can not use alpha blockers on formulary (e.g. terazosin, doxazosin)

Flonase fluticasone

Requests for special authorization are considered for:

- the treatment of seasonal allergic rhinitis in patients four years of age and older who are unable to use beclomethasone and budesonide, are poorly controlled on other nasal steroid products.

Fludara fludarabine Requests for coverage of Fludara 10mg Tablets will be considered as a second-line therapy for patients who have been diagnosed with Chronic Lymphocytic Leukemia (CLL), and have failed other therapies- {e.g. chlorambucil + prednisone, or conventional alkylating regimens such as CVP (cyclophosphamide, vincristine and prednisone)}.
Foradil formoterol fumarate

Requests for special authorization will be considered for:

- patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e. inhaled steroids) and still require short-acting bronchodilator more than twice daily

- patients with severe COPD (chronic obstructive pulmonary disorder) with a reversible component, where symptoms have not responded to first-line therapy, e.g. ipratropium, salbutamol, inhaled steroids, tiotropium

Forteo teriparatide

Requests for Special Authorization for Forteo will be considered under the following circumstances:
Individuals who are intolerant to oral bisphosphonates and Aclasta and Prolia
Individuals with a confirmed trial of antiresorptive therapy (patient compliant and persistent for at least one full year) and has significant BMD loss or unexpected fragility fractures after one full year of treatment
Individuals on current oral corticosteroids and are at very high risk of fracture as defined by:
Already has one or more vertebral fracture
Has very low BMD (T-score -3.5)
Has sustained a fracture while on treatment with an antiresorptive treatment

Forteo® (teriparatide) will be considered experimental and/or investigational for the treatment of any of the following:
A. Children and adolescents; or
B. Individuals with Paget's disease of the bone; or
C. Individuals with hypercalcemia; or
D. Women who are pregnant or nursing; or
E. Individuals who have diagnosed with bone cancer or other cancers that have metastasized to the bones.

Fosamax alendronate

Requests for special authorization for Fosamax will be considered for:

- the treatment of osteoporosis in postmenopausal women and men
who are deemed at high risk of fracture based on any one of the following:
-Prior fragility fracture after age 40, including asymptomatic vertebral fractures identified on X-rays
-Current use of oral corticosteroids (any dose)
-BMD report indicating high ten year fracture risk (defined as > 20%)
who are deemed at moderate risk of fracture based on BMD report, with at least one of the following compelling reasons to warrant treatment:
-Lumbar spine T-score much lower than femoral neck T-score (at least a difference of one full standard deviation)
-Rapid bone density loss ( 4% in the past year)
-Men receiving androgen-deprivation therapy for prostate cancer
-Women receiving aromatase-inhibitor therapy for breast cancer
-Repeated corticosteroid use (oral or parenteral) in last two years, even if patient is not currently on corticosteroid.
-Recurrent falls (2 or more in the past year)

-the treatment of Paget's disease of the bone in individuals who are symptomatic or with alkaline phosphatase level of at least two times the upper limit of normal

Fragmin dalteparin Requests for special authorization are considered for: - patients for the prevention of postoperative venous thromboembolism when undergoing orthopedic or abdominal surgery - treatment of acute deep venous thrombosis. - treatment or prevention of DVT/PE in cancer patients
Frova frovatriptan succinate

Requests for special authorization are considered for:

- patients who have a definite diagnosis of migraine AND have failed to respond to first-line abortive therapy (i.e. NSAIDs and standard analgesic therapy), unless contraindicated.

Fuzeon for injection enfuvirtide

Requests for special authorization are considered for clients who meet the following criteria: HIV positive patients who have failed traditional antiretroviral therapy, defined as those patients who have failed at least 2 susceptible antiretrovirals and whose viral load is more than 5000

Fycompa Perampanel Requests for special authorization for Fycompa will be considered as adjunctive therapy in the management of partial-onset and primary generalized tonic-clonic (PGTC) seizures, in adult patients with epilepsy who are not satisfactorily controlled with conventional therapy.
Galexos in combination with Sovaldi simeprevir / sofosbuvir

Galexos containing regimens are not eligible for coverage for the treatment of hepatitis C virus (CHC) infection genotypes 1 - 4. Alternative cost effective treatment options are eligible for coverage including Epclusa (pan genotypic, 12 weeks), Harvoni (genotype 1, 8 weeks), Holkira Pak (genotype 1, 12 weeks), Zepatier (genotype 1 & 4, 12 weeks) and Technivie (genotype 4, 12 weeks), with or without ribavirin.

Genvoya elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Requests for special authorization will be considered for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and pediatric patients 12 years of age and older (and weighing 35 kg) and with no known mutations associated with resistance to the individual components of GENVOYA.
Gilenya fingolimod

Requests for special authorization for Gilenya are considered for the treatment of:

Adult patients with relapsing remitting multiple sclerosis (RRMS) who have failed therapy with an interferon-beta (i.e., Avonex, Betaseron, Rebif, Extavia) OR glatiramer acetate (Copaxone) OR Aubagio OR Tecfidera. The patient must have suffered a minimum of ONE exacerbations in the previous year and have an EDSS score less than or equal to 5.5.

- for the treatment of patients with relapsing remitting multiple sclerosis (RRMS) who meet all of the following criteria:

- failure to respond to full and adequate courses of at least one interferon or glatiramer acetate OR Aubagio OR Tecfidera

- one or more clinically disabling relapses in the previous year.

- significant increase in T2 lesion load compared with that from a previous MRI scan (i.e. 3 or more new lesions) or at least one gadolinium-enhancing lesion.

- requested and followed by a neurologist experienced in the management of RRMS

Pediatric patients of 10 years to below 18 years of age with relapsing multiple sclerosis to reduce the frequency of clinical exacerbations.

Giotrif afatinib

Les demandes d’autorisation spéciale pour Giotrif sont admissibles dans le cas suivant :

- comme monothérapie chez les patients présentant un adénocarcinome du poumon métastatique (y compris un épanchement pleural diagnostiqué à la cytologie) porteurs de mutation(s) activatrice(s) du récepteur du facteur de croissance épidermique (R-EGF) et n’ayant jamais reçu d’inhibiteur de la tyrosine-kinase du R-EGF.

Glatect glatiramer acetate Requests for Special Authorization are considered for the treatment of ambulatory patients with Relapsing Remitting Multiple Sclerosis (RRMS), including patients who have experienced a single demyelinating event and have lesions typical of multiple sclerosis on brain MRI: - To decrease the frequency of clinical exacerbations - To reduce the number and volume of active brain lesions identified on Magnetic Resonance Imaging (MRI) scans
Gleevec imatinib mesylate

Requests for special authorization are considered for:
- the treatment of patients with unresectable and/or metastatic gastrointestinal stromal tumor (GIST),
- for the treatment of adult patients with chronic myeloid leukemia (CML)
- for the adjuvant treatment of adult patients who are at intermediate to high risk of relapse following-complete resection of Kit (CD117) positive GIST.

Glyxambi empagliflozin and linagliptin

Requests for Special Authorization are considered for use in combination with metformin as an adjunct to diet and exercise, to achieve glycemic control in adult patients with type 2 diabetes mellitus (T2DM):
- inadequately controlled on metformin and empagliflozin, or
- inadequately controlled on metformin and linagliptin.

Grastofil filgrastim Requests for special authorization will be considered: (1) Cancer Patients Receiving Myelosuppressive Chemotherapy; (2) Patients with Acute Myeloid Leukemia; (3) Cancer Patients Receiving Myeloablative Chemotherapy Followed by Bone Marrow Transplantation; (4) Cancer Patients Undergoing Peripheral Blood Progenitor Cell (PBPC) Collection and Therapy; (5) Patients with Severe Chronic Neutropenia (SCN); and (6) Patients with HIV- Infection.
Harvoni Ledipasvir/Sofosbuvir

Requests for Special Authorization are considered for the treatment of lab-confirmed chronic hepatitis C virus (HCV) infection genotype 1, in treatment-naïve adults without cirrhosis and with pre-treatment HCV RNA load < 6 million IU/ml, for a maximum of 8 weeks. Fibrosis stage must be provided.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME.

Hectorol doxercalciferol Requests for special authorization are considered for: - management of secondary hyperparathyroidism in patients undergoing chronic renal dialysis where other treatments (usually One-Alpha, Rocaltrol or a form of calcitriol or calciferol) are either ineffective or not tolerated
Hemangiol propranolol

Requests for special authorization are considered for the treatment of proliferating infantile hemangioma requiring systemic therapy:

• Life- or function-threatening hemangioma,

• Ulcerated hemangioma with pain and/or lack of response to simple wound care measures,

• Hemangioma with a risk of permanent scarring or disfigurement.

Hepsera adefovir dipivoxil

Requests for special authorization are considered for clients in whom a diagnosis of chronic hepatitis B has been made.
Hepsera is to be prescribed by or in consultation with a hepatologist, gastroenterologist or infectious disease specialist. These requests may include the following: A. Patients who cannot tolerate lamivudine or for whom lamivudine is contraindicated. B. Patients with lamivudine-resistant chronic hepatitis B who have failed on, or relapsed after lamivudine treatment; have developed viral resistance to lamivudine. C. Patients with severe liver disease who have decompensated chronic hepatitis B; have evidence of severe fibrosis or cirrhosis; are pre- or post-liver transplantation. The recurrence of chronic hepatitis B after liver transplantation results in increased risk for graft failure and death of patients. have compensated chronic hepatitis B and are at risk of liver decompensation (e.g., Chronic Hepatitis B flare, highly replicative HBV). D. Patients with HBV/HIV co-infection who are not on antiviral agents but require HBV treatment only (treatment for these patients should be undertaken in conjunction with infectious disease specialist physician).

Heptovir lamivudine Requests for special authorization are considered for the treatment of patients with chronic hepatitis B and evidence of hepatitis B virus (HBV) replication.
Hexalen altretamine Requests for special authorization are considered for: - Adjunct therapy in combination with other established antineoplastic agents -Second-line therapy in combination or alone in patients who have not responded or who have relapsed on other regimens, i.e. cysplatin-based chemotherapy regimen.
Holkira Pak ombitasvir/paritaprévir/ritonavir et dasabuvir

Requests for Special Authorization are considered for the treatment of lab-confirmed chronic hepatitis C virus (HCV) infection, with fibrosis stage F2 or greater, in adult patients with genotype 1a or 1b without cirrhosis or genotype 1b with cirrhosis, for a maximum of 12 weeks.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME.

Humatrope somatropin

Requests for special authorization are considered for:

- Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy.

- Turner Syndrome - Patients who have short stature associated with Turner Syndrome

- Adults Growth Hormone Deficiency - Replacement of endogenous growth hormone in adults with growth hormone deficiency who meets either of the following two criteria:

(A) Adult Onset (AO) - Patients who have growth hormone deficiency, either alone or associated with multiple hormone deficiencies (hypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma; OR

(B) Childhood Onset (CO) - Patients who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes.

Humira adalimumab

Requests for Special Authorization are considered for:

Rheumatoid Arthritis:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

(a) Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Psoriatic Arthritis:

- Patients with moderate to severe psoriatic arthritis who have had an inadequate response to at least two disease modifying antirheumatic drugs (DMARDS), one of which must be methotrexate unless contraindicated.

Ankylosing Spondylitis:

- Patients with moderate to severe ankylosing spondylitis who have failed to respond to sequential use of at least 2 NSAIDs at optimum dose. If there is a history of recurrent uveitis as a manifestation of ankylosing spondylitis, reimbursement can be authorized as first line therapy.

Crohn’s Disease:

- Patients with moderately to severely active Crohn’s disease who have had an inadequate response , or intolerance to:

A 6 week trial of sulfasalazine if there is mild active Crohn’s disease involving the colon OR oral or intravenous corticosteroids for more severe Crohn’s disease

AND A trial of immunosuppresants (i.e., azathioprine, 6-mercaptopurine or methotrexate) for a minimum of 3 months unless the severity of the disease requires earlier use of TNF inhibitors.

Fistuliizing Crohn’s Disease:

- Patients with fistuliizing Crohn’s disease who have had an inadequate response or intolerance to An appropriate course of antibiotic therapy AND A 3 month trial of immunosuppressants (i.e., azathioprine, 6-mercaptopurine, methotrexate)

Polyarticular Juvenile Idiopathic Arthritis

- in combination with methotrexate, reducing signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients, 2 years of age and older who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs (DMARDs). HUMIRA® can be used as monotherapy in case of intolerance to methotrexate or when continued treatment with methotrexate is not appropriate.

Ulcerative Colitis:

-reducing signs and symptoms, inducing and maintaining clinical remission, inducing and maintaining mucosal healing, and reducing or eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Pediatric Crohn’s Disease

- Patients (between 13 and 17 years of age) diagnosed with pediatric Crohn’s Disease weighing ≥ 40 kg with severely active Crohn’s disease and/or who have had an inadequate response or were intolerant to conventional therapy (a corticosteroid and/or aminosalicylate and/or an immunosuppressant) and/or a tumour necrosis factor alpha antagonist.

Plaque Psoriasis:

- adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy.

1. Patient has been diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, (or a specialist, such as Internal Medicine),

AND

2. Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in the same manner as equal to or more than 10>#/p###

AND

3. Patient has failed systemic therapy (for example with methotrexate. cyclosporine, or acitretin (Soriatane); must have had a trial of methotrexate (unless contraindicated),,

AND

4. Patient has failed photochemical therapy,

AND

5. Patient is at least 18 years (adult in the submission) of age.Requests for Special Authorization will be considered for the treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy.

Hidradenitis Suppurativa:

- For the treatment of active moderate to severe hidradenitis suppurativa in adult and adolescent patients (12 to 17 years of age weighing ≥ 30 kg) who have not responded to conventional therapy (including systemic antibiotics).

Uveitis:

- For the treatment of non-infectious uveitis (intermediate, posterior and panuveitis) in adult patients with inadequate response to corticosteroids or as corticosteroid sparing treatment in corticosteroid-dependent patients.

Humira should not be used in combination with other TNF antagonists. The medication must have been prescribed by, or in consultation with, a specialist (i.e., rheumatologist, gastroenterologist, internal medicine specialist).

Pediatric Uveitis:

- For the treatment of chronic non-infectious anterior uveitis in pediatric patients from 2 years of age who have had an inadequate response to or are intolerant to conventional therapy, or in whom conventional therapy is inappropriate.

Ibrance palbociclib

Requests for special authorization will be considered for the treatment of patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative locally advanced ormetastatic breast cancer in combination with:

- an aromatase inhibitor as initial endocrine-based therapy; or

- fulvestrant in patients with disease progression after prior endocrine therapy. Pre- or perimenopausal women must also be treated with a luteinizing hormone releasing hormone (LHRH) agonist.

Iclusig ponatinib hydrochloride

Requests for special authorization will be considered for the treatment of adult patients with chronic phase, accelerated phase, or blast phase chronic myeloid leukemia (CML) or Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL) for whom other tyrosine kinase inhibitor (TKI) therapy is not appropriate, including CML or Ph+ ALL that is T315I mutation positive or where there is prior TKI resistance or intolerance.

Ilevro nepafenac Requests for special authorization will be considered for management of pain and inflammation associated with cataract surgery.
Imbruvica ibrutinib

Requests for special authorization are considered for:

- the treatment of patients with previously untreated active Chronic Lymphocytic Leukemia (CLL), including those with 17p deletion.

- in combination with obinutuzumab for the treatment of patients with previously untreated active CLL, including those with 17p deletion.

- the treatment of patients with CLL who have received at least one prior therapy, including those with 17p deletion.

- the treatment of patients with relapsed or refractory mantle cell lymphoma (MCL)

- the treatment of patients with Waldenstrm's macroglobulinemia (WM).

Imitrex sumatriptan Requests for special authorization are considered for: - patients who have a definite diagnoses of migraine AND have failed to respond to first-line abortive therapy (e.g. NSAIDs and standard analgesic therapy), unless contraindicated.
Imovane zopiclone Requests for special authorization are considered for: - the short term treatment of insomnia
Incivek telaprevir Requests for special authorization for Incivek are considered for: The treatment of chronic hepatitis C genotype 1 infection in adults with compensated liver disease
Inflectra infliximab

Rheumatoid Arthritis:

- Requests for special authorization will be considered for use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

- Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

- The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Ankylosing Spondylitis:

-Requests for special authorization will be considered for the reduction of signs and symptoms and improvement in physical function in patients with active ankylosing spondylitis when the following criteria have been met:

- Diagnosis of ankylosing spondylitis AND :

- Medication is being prescribed by, or in consultation with, a rheumatologist or a specialist in the field of rheumatology AND:

- The patient has undergone a trial treatment of at least three months with 2 NSAIDs AND/OR the patient exhibits uveitis (iritis)

Psoriatic Arthritis:

- Requests for special authorization will be considered for the treatment of adult patients with active psoriatic arthritis (PSA) who meet ALL of the following criteria:

- The medication is prescribed by or in consultation with a rheumatologist, or a specialist in the field of RA or PsA

- The patient has had an inadequate response or intolerance to at least 2 disease modifying anti-rheumatic drugs (DMARDs), one of which must be methotrexate unless contraindicated . Patients must have had a trial of at least 3 months with these agents

Plaque Psoriasis:

- Requests for Special Authorization will be considered for adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy who meet ALL of the following criteria:

- Patient has been diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, (or a specialist, such as Internal Medicine),

- Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in he same manner as equal to or more than 10%.

- Patient has failed systemic therapy (for example with methotrexate. cyclosporine, or acitretin (Soriatane); must have had a trial of methotrexate (unless contraindicated).

- Patient has failed photochemical therapy,

- Patient is at least 18 years (adult in the submission) of age.

Crohn's Disease & Fistulizing Crohn’s Disease:

- Requests for special authorization will be considered for the reduction of signs and symptoms and induction and maintenance of clinical remission in adult patients with moderately to severely active Crohn’s disease when the following criteria have been met:

- Diagnosis of moderately to severely active Crohn’s disease AND:

- The patient must have had an inadequate response to conventional therapy

Ulcerative Colitis:

- Requests for special authorization will be considered for the reduction of signs and symptoms, inducing clinical remission, inducing mucosal healing, and reducing or eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Infufer iron dextran complex Requests for special authorization are considered for: - documented iron deficiency for patients where oral forms of iron supplementation are contraindicated, not tolerated or have failed
Inlyta axitinib

Requests for Individual Consideration for Inlyta will be considered for:

Patients with metastatic renal cell carcinoma (RCC) of clear cell morphology, after failure of initial treatment with sunitinib (Sutent®), sorafenib (Nexavar®) or pazopanib (Votrient). In addition, Inlyta should be reimbursed only if it is used as an alternative to everolimus (Afinitor) in cases when the patient is intolerant to or has a contraindication to the latter.

Innohep tinzaparin Requests for special authorization are considered for: - the prevention of postoperative venous thromboembolism when undergoing orthopedic or general surgery - treatment of acute deep venous thrombosis.
Inspra eplerenone Requests for special authorization are considered: - to reduce the risk of mortality following myocardial infarction (MI) in clinically stable patients who have evidence of heart failure and left ventricular systolic dysfunction (ejection fraction 40%).
Intelence etravirine

Requests for special authorization are considered for clients who meet the following criteria:

to be used in combination with other antiretroviral agents in treatment experienced adult patients who are infected with HIV-1 and who have documented resistance to at least one agent from each of the three major classes of antiretroviral agents [nucleoside reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors (PI)]

Intron A Interferon Alfa-2b

Requests for special authorization are considered for:

- Chronic Non-A, Non-B/C Hepatitis

- Chronic Active Hepatitis B: Candidates must be: HBeAg or HBV DNA positive, HIV negative, and have hepatitis but not decompensated liver disease.

- Chronic Myelogenous Leukemia: Reserved for patients who are not candidates for bone marrow transplant or have relapsed after one marrow transplant.

-Multiple Myeloma

- Non-Hodgkin's Lymphoma

- Malignant Melanoma

- AIDS Related Kaposi's Sarcoma

- Hairy Cell Leukemia: In patients where cladribine and/or pentostatin has failed or is not indicated.

- Basal Cell Carcinoma: Detailed information as to why surgery and/or radiation are deemed not appropriate must be provided

- Condylomata Acuminata

Invega paliperidone Requests for Special Authorization are considered for: - the treatment of schizophrenia in patients who have tried and failed with risperidone therapy (Risperdal), or have a medical reason why risperidone can't be used.
Invokana canagliflozin

Requests for Special Authorization are considered for:

Monotherapy: As an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.

In combination with Metformin or a Sulfonylurea in adult patients with type 2 diabetes mellitus to improve glycemic control when diet and exercise plus monotherapy with one of these agents does not provide adequate glycemic control.

In combination with metformin and either a sulfonylurea or pioglitazone in adult patients with type 2 diabetes mellitus to improve glycemic control when diet, exercise, and dual therapy (with metformin plus either a sulfonylurea or pioglitazone) do not provide adequate glycemic control.

As add-on combination therapy with insulin (with or without metformin) in adult patients with type 2 diabetes mellitus as an adjunct to diet and exercise to improve glycemic control when diet and exercise, and therapy with insulin (with or without metformin) do not provide adequate glycemic control.

As an adjunct to diet, exercise, and standard of care therapy to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction and nonfatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease (CVD).

As an adjunct to diet, exercise, and standard of care therapy to reduce the risk of end-stage kidney disease, doubling of serum creatinine, and cardiovascular (CV) death in adult patients with type 2 diabetes mellitus and diabetic nephropathy with albuminuria (>33.9 mg/mmol).


Ionamin phentermine Requests for special authorization are considered for: - adults with BMI greater than, or equal to, 30Kg/m2 -adults with BMI greater than, or equal to, 27kg/m2, in the presence of other risk factors e.g. hypertension, dyslipidemia, diabetes
Iopidine apraclonidine Requests for special authorization are considered for : - patients who are at risk for increases in intraocular pressure following ophthalmic surgery.
Iressa gefitinib Requests for Special Authorization are considered for: Patients with locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC) who have activating mutations of the EGFR-TK, and are not currently hospitalized.
Isentress raltegravir Requests for special authorization are considered for HIV- naïve infected patients and in treatment-experienced adult patients who have failed prior antiretroviral therapy.
Isoniazid isoniazid Requests for special authorization for Isoniazid are considered for: - Treatment of active respiratory and nonrespiratory tuberculosis in a regimen with other antituberculosis drugs. - Treatment of latent tuberculosis infection. - Treatment of nontuberculous mycobacterial infections (e.g., M. kansasii).
Jadenu deferasirox

Requests for Special Authorization will be considered for patients with the following conditions:
the management of chronic iron overload in patients with transfusion-dependent anemias aged six years and older;
the management of chronic iron overload in patients with transfusion-dependent anemias aged two to five who cannot be adequately treated with deferoxamine.

Therapy with Jadenu should be initiated and maintained by physicians experienced in the treatment of chronic iron overload due to blood transfusions.

Jakavi ruxolitinib

Requests for Special Authorization are considered for:

- Patients who require treatment of splenomegaly and/or its symptoms resulting from myelofibrosis.

- The control of hematocrit in adult patients with polycythemia vera (PV) resistant to or intolerant of a cytoreductive agent.

Jalyn dutasteride/ tamsulosin Requests for special authorization are considered for clients with a diagnosis of moderate symptomatic benign prostatic hyperplasia
Janumet XR metformin hydrochloride

Requests for Special Authorization are considered for:
- as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin or in patients already being treated with the combination of sitagliptin and metformin.

Januvia sitagliptin phosphate

Requests for special authorization for Januvia™ will be considered for:
- Monotherapy therapy in adult patients with type 2 diabetes who are who have a contraindication to metformin.
- Combination therapy with metformin or a sulfonylures in adult patients with type 2 diabetes who have been inadequately controlled on a metformin plus a sulfonylurea combination regimen.

Jardiance empagliflozin

Requests for Special Authorization are considered for:

Monotherapy:

- for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.

Add-on combination:

- in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with:

- metformin,

- metformin and a sulfonylurea,

- pioglitazone (alone or with metformin),

- basal or prandial insulin (alone or with metformin),

when the existing therapy, along with diet and exercise, does not provide adequate glycemic control

Add-on combination in patients with established cardiovascular disease:

- as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with type 2 diabetes mellitus and established cardiovascular disease who have inadequate glycemic control.

Jentadueto linagliptin-metformin fixed dose combination

Requests for special authorization are considered for adults as adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus (T2DM) when treatment with both linagliptin and metformin is appropriate, in patients inadequately controlled on metformin alone or in patients already being treated and well controlled with the free combination of linagliptin and metformin or in combination with a sulfonylurea (i.e., triple combination therapy).

Jetrea ocriplasmin Requests for special authorization will be considered for the treatment of symptomatic vitreomacular adhesion (VMA).
Jinarc tolvaptan Requests for special authorization will be considered to slow the progression of kidney enlargement in patients with autosomal dominant polycystic kidney disease (ADPKD).
Kaletra lopinavir/ritonavir

Requests for special authorization are considered for clients who meet the following criteria:

- patients who have a confirmed diagnosis of HIV infection

Kazano alogliptin

Requests for Special Authorization for Kazano are considered for:
To improve glycemic control in adult patients ( 18 years old) with type 2 diabetes mellitus:
- as an adjunct to diet and exercise in patients inadequately controlled on metformin or in patients already being treated with the combination of alogliptin and metformin.
- in combination with pioglitazone when diet and exercise plus dual therapy with metformin and pioglitazone do not provide adequate glycemic control.
- in combination with insulin, when insulin and metformin do not provide adequate glycemic control.

Keppra levetiracetam As adjunctive therapy in the management of patients with epilepsy who are not satisfactorily controlled with conventional therapy. Requests may be considered for children under the age of 18 years if requested from a neurologist, pediatrician, or specialist in the area of treating patients with epilepsy.
Kevzara sarilumab Requests for Special Authorization are considered for the treatment of adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response or intolerance to one or more biologic or non-biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDs).
Kineret anakinra

Requests for reimbursement for Kineret will be considered for

the treatment of adult patients with moderate to severe rheumatoid arthritis who have had an inadequate response to treatment with two DMARDs (one of which must me methotrexate unless contraindicated) AND to two TNF-alpha inhibitors. Medication must have been prescribed by, or in consultation with, a rheumatologist.

Komboglyze saxagliptin/metformin hydrochloride

Requests for Special Authorization are considered for:
- use as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin and metformin or who are inadequately controlled on metformin alone.
- use in combination with premixed or long/intermediate acting insulin as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin, metformin and premixed or long/intermediate acting insulin or who are inadequately controlled on metformin and premixed or long/intermediate acting insulin alone.

Kuvan sapropterin

Requests are considered for patients who have a diagnosis of Phenylketonuria (PKU), with baseline blood phenylalanine (Phe) levels > 360 μmol/L despite compliance with all recommendations for dietary intervention and monitoring, who have demonstrated a response to the initial 3 month trial of sapropterin [reimbursed through the manufacturer] and who meet the following criteria:

A >30% reduction in blood phenylalanine concentration compared with baseline* AND clinically meaningful improvement in neurocognitive or neurobehavioral function as determined by a healthcare professional

OR

A >30% reduction in blood phenylalanine concentration compared with baseline* AND demonstrated increase in dietary protein tolerance based on targets set between the clinician and patient

* Copy of test report is required.

Kytril granisetron hydrochloride

Requests for special authorization are considered for:

- patients who suffer from nausea and vomiting with chemotherapy treatment.

Lamisil Tablets terbinafine hydrochloride

Requests for special authorization are considered for:

- patients who have a diagnosis of dermatophyte-induced infection of the skin and nails or tineal skin infection requiring oral therapy.

Lanoxin Injection digoxin Requests for special authorization are considered for: - patients when other routes of administration (e.g. oral) are contraindicated AND a registered and qualified professional in an appropriate health care setting will be administering the drug intramuscularly.
Lariam mefloquine hydrochloride

Requests for treatment of malaria will be considered on an individual basis.

Requests for the prevention of malaria will not be considered.

Since malaria is not prevalent in Canada, consequently, medications used solely for the prevention of malaria (Lariam and Paludrine- [now discontinued]) are not eligible benefits.

Lasix Special furosemide Requests for special authorization are considered for diuresis in clients with severely impaired renal function who have been resistant to treatment with conventional doses of furosemide.
Latuda lurasidone hydrochloride

Requests for Special Authorization are considered:
- as monotherapy or as adjunctive therapy with lithium or valproate for the acute management of depressive episodes associated with bipolar I disorder.
- the treatment of schizophrenia in patients who have tried and failed therapy with Seroquel® or Risperdal®, or have a medical reason why Risperdal or Seroquel can't be used.

Lemtrada alemtuzumab

Requests for special authorization will be considered for:

- the management of adult patients with relapsing remitting multiple sclerosis (RRMS), with highly active disease defined by clinical and imaging features, despite an adequate course of treatment with at least two other disease modifying treatments (DMTs), or where any other DMT is contraindicated or otherwise unsuitable.

Lixiana edoxaban

Requests for Special Authorization are considered for:

- Prevention of stroke and systemic embolic events in patients with atrial fibrillation, in whom anticoagulation is appropriate, and in whom warfarin therapy has failed, is unsuitable, or is contraindicated;

- Treatment of venous thromboembolism (VTE) (deep vein thrombosis [DVT], pulmonary embolism [PE]) and the prevention of recurrent DVT and PE in patients for whom warfarin therapy has failed, is unsuitable, or contraindicated.

Lovenox enoxaparin

Requests for special authorization are considered for:

- the prophylaxis of thromboembolic disorders (deep vein thrombosis) in patients undergoing: orthopedic surgery of the hip or knee; high risk abdominal, gynecological, or urological surgeries; colorectal surgery

- the prophylaxis of deep vein thrombosis (DVT) in medical patients who are at moderate risk of DVT and who are bedridden due to moderate to severe acute cardiac insufficiency (NYHA Class III or IV heart failure), acute respiratory failure revealing or complicating chronic respiratory insufficiency not requiring ventilatory support and acute respiratory infections (excluding septic shock), who require short-term prophylaxis of deep vein thrombosis

- treatment of deep venous thrombosis with or without pulmonary embolism

- treatment of unstable angina or non-Q wave myocardial infarction, concurrently with ASA

- treatment of acute-ST segment Elevation Myocardial Infarction (STEMI), including patients to be managed medically or with subsequent Percutaneous Coronary Intervention (PCI)Requests for special authorization are considered for:

- patients who require thromboprophylaxis related to abdominal surgery or orthopedic surgery of the hip or knee

Lucentis ranibizumab

Requests for Special Authorization are considered for:
- the treatment of neovascular (wet) age-related macular degeneration
- the treatment of visual impairment due to diabetic macular edema
- the treatment of visual impairment due to macular edema secondary to retinal vein occlusion
when prescribed by a qualified ophthalmologist experienced in intravitreal injections, or a retinal specialist.
- the treatment of visual impairment due to choroidal neovascularisation (CNV) secondary to pathologic myopia (PM)

Lupron, Lupron Depot leuprolide Request for special authorization will be considered for : - the treatment of children with central precocious puberty. - patients with advanced (stage D2) symptomatic carcinoma of the prostate in patients who find surgical orchiectomy unacceptable - treatment of patients with endometriosis, including pain relief and the reduction of endometriosis lesions.
Lyrica pregabalin

Requests for special authorization for Lyrica will be considered for patients with:
neuropathic pain, including pain associated with diabetic peripheral neuropathy & post herpetic neuralgia
fibromyalgia
who have not responded are have not tolerated treatment with an antidepressant (i.e., a tricyclic antidepressant, SSRI, SNRI) AND gabapentin, or whom a trial of these agents is inappropriate.

Macugen pegaptanib Requests for special authorization will be considered for: - the treatment of (wet) age-related macular degeneration.
Malarone atovaquone/proguanil Requests for special authorization are considered for: - patients who have a definitive diagnosis of malaria - prevention of malaria will NOT be considered for coverage
Marinol delta-9-tetrahydrocannabinol

Requests for special authorization will be considered for :

- the treatment of severe nausea and vomiting associated with cancer chemotherapy in patients who have failed, are intolerant to or have a medical reason they cannot take other antinauseants (i.e. Stemetil, Zofran).

- the treatment of AIDS-related anorexia associated with weight loss in patients who have failed, are intolerant to or have a medical reason they cannot take Megace (megestrol).

Maxalt rizatriptan Requests for special authorization are considered for: - patients who have a definite diagnosis of migraine AND have failed to respond to first-line abortive therapy (e.g. NSAIDs and standard analgesic therapy) unless contraindicated.
Mefloquine Mefloquine Hydrochloride

Requests for special authorization are considered for:

- patients who have a definitive diagnosis of malaria

- prevention of malaria will NOT be considered for coverage

Meridia sibutramine

Requests for special authorization are considered for weight reduction in conjunction with a reduced calorie diet and an exercise program and for long-term maintenance of weight loss in patients:

- with a BMI greater than 30kg/m2

- with greater than 27kg/m2 in the presence of comorbidities such as elevated blood pressure, heart disease, diabetes or arthritis.

Miacalcin Nasal Spray synthetic calcitonin

Requests for special authorization are considered for:
- the treatment of osteoporosis in females greater than five years postmenopause with low bone mass. These patients must have bone density of at least 2.0 standard deviations below premenopausal mean or have a history or presence of osteoporotic fracture.

This includes patients:
a) who cannot tolerate treatment with estrogens; or
b) in whom estrogens are contraindicated.

Migranal dihydroergotamine mesylate Requests for special authorization are considered for: - patients who have a definite diagnoses of migraine AND have failed to respond to first-line abortive therapy (e.g. NSAIDs and standard analgesic therapy) unless contraindicated.
Minirin desmopressin acetate Requests for special authorization for Minirin will be considered for clients who have been determined to be intolerant to other medications, sensitive to other medications, or refractory to other therapies
Mirapex pramipexole Requests for special authorization will be considered for treatment of the signs and symptoms of Parkinson's disease , when the patient has failed, cannot tolerate or is unable to take levodopa, bromocriptine or pergolide, or as an adjunct to levodopa.
Movantik naloxegol (naloxegol oxalate)

Requests for special authorization will be considered for:

- the treatment of opioid-induced constipation (OIC) in adult patients with non-cancer pain who have had an inadequate response to laxative(s).

Mozobil Plerixafor

Requests for special authorization for Mozobil will be considered for:
- in combination with granulocyte-colony stimulating factor to mobilize hematopoietic stem cells (HSCs) to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin's lymphoma (NHL) and multiple myeloma (MM). Some patients with NHL and MM are able meet minimal and target HSC collection criteria with G-CSF alone.

Muse alprostadil Requests for special authorization are considered for: -patients suffering from erectile dysfunction, regardless of etiology
Myfortic mycophenolic acid

Requests for special authorization are considered for:

- prophylaxis of organ rejection in patients receiving allogenic renal, cardiac or hepatic transplants

Myrbetriq mirabegron

Requests for special authorization for Myrbetriq will be considered for:
- treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence and urinary frequency

Nasacort triamcinolone acetonide Requests for special authorization will be considered for: - patients with allergic rhinitis who, for medical reasons, cannot use budesonide or beclomethasone or who have failed therapy with budesonide or beclomethasone.
Neoral cyclosporine

Requests for special authorization are considered for:

- patients who have undergone a solid organ or bone marrow transplant

- for treatment of severe psoriasis for patients who have failed conventional therapy with other agents (only requests from dermatologists are to be considered)

- for treatment of severe active rheumatoid arthritis for patients in whom classic anti-rheumatics are ineffective or inappropriate (only requests from rheumatologists are to be considered)

- for treatment of steroid-dependent and steroid-resistant nephrotic syndrome due to glomerular disease (only requests from nephrologists or internists are to be considered).

Nesina alogliptin

Requests for Special Authorization for Nesina are considered for:
To improve glycemic control in adult patients with type 2 diabetes mellitus (T2DM)
- as monotherapy as an adjunct to diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance
- in combination with metformin when diet and exercise plus metformin alone do not provide adequate glycemic control
- in combination with a sulfonylurea (SU) when diet and exercise plus a SU alone do not provide adequate glycemic control
- in combination with pioglitazone when diet and exercise plus pioglitazone alone do not provide adequate glycemic control
- in combination with pioglitazone and metformin when diet and exercise plus dual therapy with these agents do not provide adequate glycemic control
- in combination with insulin (with or without metformin) when diet and exercise plus a stable dose of insulin (with or without metformin) do not provide adequate glycemic control.

Neulasta (solution for injection) pegfilgrastim

Requests for special authorization are considered for clients who are receiving myelosupressive chemotherapy and require prevention of febrile neutropenic episodes. Requests should be made by, or in consultation with, a specialist in Oncology, Hematology, Infectious diseases, or Internal medicine

Neupogen GCSF filgrastim

Requests for special authorization are considered for patients who:

- are receiving myelosuppressive chemotherapy and require prevention of febrile neutropenic episodes

- are suffering from chronic neutropenia (congenital, idiopathic or cyclic) to increase neutrophil counts and reduce the severity and duration of infections

- are a post bone marrow transplant patient, until neutrophil counts recover.

Requests should be made by, or in consultation with, a specialist in oncology, hematology, infectious diseases or internal medicine.

Nevanac ophthalmic suspension nepafenac

Requests for Special Authorization are considered:
- for the management of pain and inflammation associated with cataract surgery.

Nexavar sorafenib

Requests are considered for special authorization for:
- the treatment of advanced or metastatic Renal Cell (clear cell) Carcinoma (RCC) in patients who failed prior cytokine therapy or who are considered unsuitable for such initial therapy.
- the treatment of unresectable (inoperable) hepatocellular carcinoma (HCC).
- the treatment of patients with locally advanced or metastatic, progressive differentiated thyroid carcinoma (DTC) refractory to radioactive iodine.

Nexium esomeprazole

Requests for special authorization are considered for patients
a) Who have failed at least 3 other PPIs: Pariet (rabeprazole), generic omeprazole, Prevacid (lansoprazole) OR Tecta (pantoprazole magnesium)
b) Have a medical reason why Pariet (rabeprazole), generic omeprazole, Prevacid (lansoprazole) OR Tecta (pantoprazole magnesium) cannot be used AND
c) Being treated for one of the following conditions:

1. Duodenal Ulcer
2. Gastric Ulcer
3. Reflux Esophagitis
4. Zollinger-Ellison Syndrome:
5. Eradication of Helicobacter Pylori:
Patients with newly diagnosed H pylori positive duodenal or gastric
ulcer, clients with H Pylori infection and proven relapsing duodenal or
gastric ulcers (including those on maintenance therapy for recurrent PUD),
and H Pylori-positive clients who are sufficiently symptomatic (from
gastritis, non-ulcer dyspepsia, etc...) to require maintenance therapy

6. Previous upper GI bleed
7. Prevention or treatment of NSAID-induced sequelae. This includes clients
who are currently taking NSAIDs or have recently stopped but require short
term treatment (up to eight weeks).

Norditropin Nordiflex Somatropin

Requests for special authorization are considered for:

- Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy.

- the treatment of children with short stature associated with Turner syndrome.

Norvir ritonavir Requests for special authorization are considered for clients who meet the following criteria: - patients who have a confirmed diagnosis of HIV infection
Nucala mepolizumab

Requests for special authorization will be considered as add-on maintenance treatment for adults, adolescents, and children (aged 6 years and older) with severe eosinophilic asthma who:

- are inadequately controlled with high-dose inhaled corticosteroids (patients ≥ 18 years of age) or medium-to-high-dose inhaled corticosteroids (patients 6-17 years of age) and an additional asthma controller(s) (e.g., LABA); and

- have a blood eosinophil count of ≥ 150 cells/ìL (0.15 GI/L) at initiation of treatment with NUCALA OR ≥ 300 cells/ìL (0.3 GI/L) in the past 12 months.

Nutropin, Nutropin Nuspin somatropin Requests for special authorization are considered for: - Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy. - Children with Chronic Renal Insufficiency up to time of renal transplantation - Turner Syndrome - Patients who have short stature associated with Turner Syndrome - Adults Growth Hormone Deficiency - Replacement of endogenous growth hormone in adults with growth hormone deficiency who meets either of the following two criteria: (A) Adult Onset (AO) - Patients who have growth hormone deficiency, either alone or associated with multiple hormone deficiencies (hypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma; OR (B) Childhood Onset (CO) - Patients who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes.
Oesclim estradiol

Requests for special authorization are considered for:

- patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine)

- patients with a contraindication to oral therapy (e.g. dysphagia or liver disease)

- patients who have not had symptom relief with oral hormone replacement therapy

Ofev nintedanib Requests for special authorization will be considered for: - the treatment of Idiopathic Pulmonary Fibrosis (IPF).
Olux E Clobetasol propionate

Requests for special authorization are considered for patients requiring treatment of
inflammatory and pruritic manifestations of moderate to severe atopic dermatitis.

Omnaris 50mcg nasal spray ciclesonide

Requests for special authorization are considered for:
- the treatment of seasonal allergic rhinitis in patients 12 years of age and olderwho are unable to use beclomethasone or budesonide, are poorly controlled on other nasal steroid products.

Omnitrope Somatropin

Requests for special authorization are considered for:

- Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy.

- Turner Syndrome - Patients who have short stature associated with Turner Syndrome

- Adults Growth Hormone Deficiency - Replacement of endogenous growth hormone in adults with growth hormone deficiency who meets either of the following two criteria:

(A) Adult Onset (AO) - Patients who have growth hormone deficiency, either alone or associated with multiple hormone deficiencies (hypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma; OR

(B) Childhood Onset (CO) - Patients who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes.

Onbrez indacaterol maleate

Requests for special authorization for Onbrez will be considered for:
- patients with moderate to severe chronic obstructive pulmonary disease (COPD) with a reversible component, where symptoms have not responded to first line therapy, i.e., ipratropium, salbuatmol, tiotropium.

Onglyza saxagliptin

Requests for Special Authorization will be considered for:

- patients with type 2 diabetes mellitus to improve glycemic control in combination with metformin when metformin used alone, with diet and exercise, does not provide adequate glycemic control

- patients with type 2 diabetes mellitus to improve glycemic control in combination with sulfonylurea when sulfonylurea used alone, with diet and exercise, does not provide adequate glycemic control

- patients with type 2 diabetes mellitus to improve glycemic control in combination with premixed or long/intermediate acting insulin (with or without metformin) when premixed or long/intermediate acting insulin (with or without metformin) used alone, with diet and exercise, do not provide adequate glycemic control

- patients with type 2 diabetes mellitus to improve glycemic control in combination with metformin and a sulfonylurea when dual therapy with these two agents, with diet and exercise, does not provide adequate glycemic control

Onreltea brimonidine tartrate

Requests for special authorization will be considered for the topical treatment of facial erythema of rosacea in adults 18 years of age or older.

Opsumit macitentan

Requests for Special Authorization for Opsumit are considered for the:
- the long-term treatment of pulmonary arterial hypertension (PAH, WHO Group l) to reduce morbidity in patients of WHO Functional Class II or III whose PAH is either idiopathic or heritable, or associated with connective tissue disease or congenital heart disease. Opsumit is effective when used as monotherapy or in combination with phosphodiesterase-5 inhbitors.

Oralair Grass Pollen Allergen Extract

Requests for Special Authorization are considered for the treatment of symptoms of seasonal grass pollen allergic rhinitis with or without conjunctivitis.

Orencia abatacept

Requests for reimbursement of Orencia will be considered for use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:
- Diagnosis of moderate to severe rheumatoid arthritis AND:
The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:
- The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Orencia (juvenile RA) abatacept

Requests for reimbursement of Orencia® will be considered for the treatment of pediatric patients (6 years of age and older) who have been diagnosed with Juvenile Rheumatoid Arthritis (JRA) or Juvenile Idiopathic Arthritis (JIA) who have had an inadequate response to treatment with one or more DMARDs, AND Enbrel®. Medication must have been prescribed by, or in consultation with a rheumatologist.

Ostac clodronate Requests for special authoriation will be considered for: - management of hypercalcemia of malignancy - as an adjunct in the management of osteolysis resulting from bone metastases of malignant tumors
Otezla apremilast

Requests for special authorization will be considered for:
- the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.
- alone or in combination with methotrexate for the treatment of active psoriatic arthritis in adult patients who have had an inadequate response, intolerance, or contraindication to a prior disease-modifying anti-rheumatic drug (DMARD)

Oxeze formoterol fumarate dihydrate

Requests for special authorization will be considered for:

- patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e. inhaled steroids) and still require short-acting bronchodilator more than twice daily

- patients with severe COPD (chronic obstructive pulmonary disorder) with a reversible component, where symptoms have not responded to first-line therapy, e.g. ipratropium, salbutamol, inhaled steroids, tiotropium

Oxytrol Transdermal System oxybutin transdermal system ("patch") 36mg (3.9mg/day)

Requests will be considered for the treatment of an overactive bladder with symptoms of urinary frequency, urgency or urge incontinence where the client has failed, or proven intolerant to, a previous trial of first line oral therapy such as oxybutin. Requests for the treatment of stress incontinence will not be considered.

Ozurdex dexamethasone Requests for special authorization for Ozurdex will be considered for: - the treatment of macular edema following central retinal vein occlusion (CRVO). - the treatment of non-infectious uveitis affecting the posterior segment of the eye. - the treatment of adult patients with diabetic macular edema (DME) who are pseudophakic.
Pancrease pancreliapse (lipase, amylase, protease) Requests for special authorization are considered for pancreatic enzyme replacement therapy in established pancreatic insufficiency where pancreatic enzymes are absent from or present in insufficient amount in the intestine.
Pantoloc pantoprazole

Requests for special authorization are considered for patients
a) Who have failed 2 of the 3 following drugs:
Pariet (rabeprazole), generic omeprazole OR Tecta (pantoprazole magnesium)
b) Have a medical reason why Pariet (rabeprazole) or generic
omeprazole or Tecta (pantoprazole magnesium) cannot be used AND
c) Being treated for one of the following conditions:

1. Duodenal Ulcer
2. Gastric Ulcer
3. Reflux Esophagitis
4. Zollinger-Ellison Syndrome:
5. Eradication of Helicobacter Pylori:
Patients with newly diagnosed H pylori positive duodenal or gastric
ulcer, clients with H Pylori infection and proven relapsing duodenal or
gastric ulcers (including those on maintenance therapy for recurrent PUD),
and H Pylori-positive clients who are sufficiently symptomatic (from
gastritis, non-ulcer dyspepsia, etc...) to require maintenance therapy

6. Previous upper GI bleed
7. Prevention or treatment of NSAID-induced sequelae. This includes clients
who are currently taking NSAIDs or have recently stopped but require short
term treatment (up to eight weeks).

Pegasys (for hepatitis B) peginterferon alfa-2a Requests for special authorization are considered for clients in whom a diagnosis of chronic hepatitis B has been made. Pegasys is to be prescribed only by physicians who are familiar with the treatment of chronic hepatitis B.
Pegasys RBV Ribavirin (capsules) and peginterferon alfa-2a (powder for solution- subcutaneous inj) Requests for special authorization are considered for: patients in whom a diagnosis of chronic hepatitis C has been made. Pegetron is to be prescribed only by physicians who are familiar with the treatment of chronic hepatitis C.
Pegetron ribavirin, peginterferon alfa-2b

Requests for special authorization are considered for:

- patients in whom a diagnosis of chronic hepatitis C has been made. Pegetron is to be prescribed only by physicians who are familiar with the treatment of chronic hepatitis C.

Pennsaid diclofenac sodium 1.5% solution

Requests for special authorization will be considered for osteoarthritis of the knee and other related musculoskeletal conditions (e.g. tendonitis, bursitis, sprains, strains) in patient who have failed on at least two oral NSAIDS or are unable to tolerate at least two oral NSAIDS, or who have medical reasons why oral NSAIDS cannot be used (e.g. drug interactions with warfarin, previous GI bleed).

Peridex chlorhexidine gluconate Requests for special authorization are considered for : - patients suffering from moderate to severe gingivitis associated with bleeding and inflammation or co-existing gingivitis and periodontitis
Picato ingenol mebutate

Requests for special authorization for Picato will be considered for:
- the topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults

Plegridy peginterferon beta-1a

Requests for special authorization are considered for the treatment of relapsing remitting multiple sclerosis (RRMS) for adult patients:
- to reduce the frequency of clinical exacerbations
- to slow the progression of disability.

For all requests the diagnosis must be made by a neurologist.

Pomalyst pomalidomide Requests for special authorization are considered in combination with dexamethasone for patients with multiple myeloma (MM) for whom both bortezomib and lenalidomide have failed and who have received at least two prior treatment regimens and have demonstrated disease progression on the last regimen.
Posanol and Posanol DRT posaconazole

Requests for Special Authorization are considered for:

prophylaxis of Aspergillus and Candida infections in patients, 13 years of age and older, who are at high risk of developing these infections, such as patients with prolonged neutropenia or hematopoietic stem cell transplant (HSCT) recipients.

treatment of invasive aspergillosis in patients 13 years of age or older with disease that is refractory to amphotericin B or itraconazole, or in patients who are intolerant of these medicinal products. Refractoriness is defined as progression of infection or failure to improve after a minimum of 7 days of prior therapeutic doses of effective antifungal therapy.

treatment of oropharyngeal candidiasis (OPC) in patients 13 years of age or older.

Potaba potassium aminobenzoate

Requests for special authorization are considered for:
- patients suffering from Peyronie's disease, scleroderma, dermatomyositis, or morphea and linear scleroderma.

Pradaxa dabigatran

Requests for Special Authorization are considered for the:

- prevention of venous thromboembolic events (VTE) in patients who have undergone elective total hip replacement (THR) or total knee replacement (TKR) surgery;

- treatment of venous thromboembolism events (deep vein thrombosis [DVT], pulmonary embolism [PE]) and prevention of recurrent DVT and PEin patients for whom warfarin therapy has failed, is unsuitable, or contraindicated;

- prevention of stroke and systemic embolism in patients with atrial fibrillation, in whom anticoagulation is warranted, and in whom warfarin therapy has failed, is unsuitable, or is contraindicated.

Prevacid lansoprazole

Requests for special authorization are considered for patients
a) Who have failed 2 of the 3 following drugs:
Pariet (rabeprazole), generic omeprazole OR Tecta (pantoprazole madnesium)
b) Have a medical reason why Pariet (rabeprazole), generic
omeprazole or Tecta (pantoprazole magnesium) cannot be used AND
c) Being treated for one of the following conditions:

1. Duodenal Ulcer
2. Gastric Ulcer
3. Reflux Esophagitis
4. Zollinger-Ellison Syndrome:
5. Eradication of Helicobacter Pylori:
Patients with newly diagnosed H pylori positive duodenal or gastric
ulcer, clients with H Pylori infection and proven relapsing duodenal or
gastric ulcers (including those on maintenance therapy for recurrent PUD),
and H Pylori-positive clients who are sufficiently symptomatic (from
gastritis, non-ulcer dyspepsia, etc...) to require maintenance therapy

6. Previous upper GI bleed
7. Prevention or treatment of NSAID-induced sequelae. This includes clients
who are currently taking NSAIDs or have recently stopped but require short
term treatment (up to eight weeks).

Prezcobix Cobicistat & Darunavir (Darunavir Ethanolate) Requests for special authorization will be considered for: - in combination with other antiretroviral agents for the treatment of HIV infection in treatment-naïve and in treatment-experienced patients without DRV RAMS
Prezista Darunavir Requests for special authorization are considered for HIV- naïve infected patients and in treatment-experienced adult patients who have failed prior antiretroviral therapy.
Primaquine primaquine phosphate Requests for special authorization are considered for : - patients requiring treatment for malaria but not for prophylaxis in individuals traveling to an endemic country.
Prograf tacrolimus Requests for special authorization are considered for: - patients for the prophylaxis of organ rejection and for the treatment of refractory rejection in patients receiving liver or kidney transplants.
Prolastin-C alpha-1 antitrypsin proteinase inhibitor

Requests for special authorization are considered for:

-patients with emphysema due to alpha-1 antitrypsin deficiency when ALL of the following criteria are meet:

1. Patient is a non-smoker

2. Patient is over 18 years of age

3. Patient has a low serum concentration of alpha-1 antitrypsin (AAT) <50 mg/dl or < 11 uM/L 0r 0.8 g/L (35% of normal), which is considered the threshold thought to protect against emphysema; and

4. Patient has progressive emphysema with a documented rate of decline in FEV1.

Prolia denosumab

Requests for special authorization are considered for:

Osteoporosis in post-menopausal women who meet Special Authorization criteria for reimbursement of alendronate and/or risedronate for the treatment of osteporosis

AND have at least one of the following:

  • Intolerant to oral bisphosphonates
  • Contraindication to oral bisphosphonates

The treatment to increase bone mass in men with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy

The treatment to increase bone mass in men with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT), who are at high risk for fracture.

The treatment to increase bone mass in women with nonmetastatic breast cancer receiving adjuvant aromatase inhibitor (AI) therapy, who have low bone mass and are at high risk for fracture.

The treatment to increase bone mass in women and men at high risk for fracture due to sustained systemic glucocorticoid therapy.

Prometrium progesterone

Requests for special authorization are considered for :

- hormonal replacement therapy during menopause for patients with one of the following conditions:

- hypercholesterolemia
-documented infarct, angina or peripheral vascular disease
- two major risk factors for heart disease;
- diabetes
- hypertension
- post-menopausal
- smoking
- family history of coronary heart disease
- intolerance to other progestational products on the formulary (e.g. medroxyprogesterone)

Proscar finasteride

Requests for special authorization are considered for :

- patients with a diagnosis of moderate symptomatic benign prostatic hyperplasia who are not candidates for immediate surgery. These patients would otherwise be considered for elective surgery or qualify as poor surgical candidates.

Protopic tacrolimus

Requests for special authorization are considered for :

- patients with a diagnosis of moderate to severe atopic dermatitis (eczema) that has not responded to first-line therapy (topical corticosteroids).

Requests for children under two years of age will be reviewed under individual assessment.

Pulmozyme (dornase alfa) recombinant

Requests for special authorization are considered for:
- the management of cystic fibrosis (CF) patients to reduce the frequency of respiratory infections requiring parenteral antibiotics and to improve pulmonary function. Safety and efficacy of daily administration have not been demonstrated in patients with FVC < 40% of predicted, or for longer than 12 months.

Quinsair levofloxacin

Requests for Special Authorization are considered for the management of cystic fibrosis (CF) in patients aged 18 years or older with chronic pulmonary Pseudomonas aeruginosa (P. aeruginosa) infections.

Rapamune sirolimus Requests for special authorization will be considered for prophylaxis of organ rejection in patients receiving allogenic renal transplants in combination with cyclosporine and corticosteroids.
Rasilez aliskiren

Requests for Special Authorization are considered for:
- Patients who have a diagnosis of mild to moderate essential hypertension
AND
Have tried at least 2 other anti- hypertensive medications

Rebif interferon beta-1a

Requests for special authorization are considered for:

- Patients with a diagnosis of relapsing-remitting multiple sclerosis or RRMS that has progressed to SPMS. The patient must have suffered a minimum of two exacerbations in the previous two years and must be able to walk with or without a walking aid.

- Patients presenting with a first isolated and well-defined neurologic event as consistent with MS and involving the optic nerve, spinal cord, brain stem or cerebellum. Patients must also have two or more clinically significant lesions of the brain that are at least 3mm in diameter on MRI scans and are characteristic of MS. Patients must also be able to walk with or without a walking aid

-For all requests the diagnosis must be made by a neurologist.

Relistor methylnaltrexone bromide Requests for Special Authorization are considered for Relistor™ for clients who have a diagnosis of: - opioid-induced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient
Relpax eletriptan Requests for special authorization are considered for: - patients who have a definite diagnoses of migraine AND have failed to respond to first-line abortive therapy (e.g. NSAIDs and standard analgesic therapy), unless contraindicated.
Remicade infliximab

Rheumatoid Arthritis:
- Requests for special authorization of Remicade® will be considered for use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:
- Diagnosis of moderate to severe rheumatoid arthritis AND:
The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:
- The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Crohn's Disease & Fistulizing Crohn's Disease:
- Requests for special authorization will be considered for Remicade® for the reduction of signs and symptoms and induction and maintenance of clinical remission in adult patients with moderately to severely active Crohn's disease when the following criteria have been met:
- Diagnosis of moderately to severely active Crohn's disease AND:
- The patient must have had an inadequate response to conventional therapy

Ankylosing Spondylitis:
-Requests for special authorization for Remicade® will be considered for the reduction of signs and symptoms and improvement in physical function in patients with active ankylosing spondylitis when the following criteria have been met:
- Diagnosis of ankylosing spondylitis AND :
Medication is being prescribed by, or in consultation with, a rheumatologist or a specialist in the field of rheumatology AND:
- The patient has undergone a trial treatment of at least three months with 2 NSAIDs AND/OR the patient exhibits uveitis (iritis)

Ulcerative Colitis:
-Requests for special authorization will be considered for Remicade® for the reduction of signs and symptoms, inducing clinical remission, inducing mucosal healing, and reducing or eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy.

Psoriatic Arthritis
- Requests for special authorization will be considered for the treatment of adult patients with active psoriatic arthritis (PSA) who meet ALL of the following criteria:
- The medication is prescribed by or in consultation with a rheumatologist, or a specialist in the field of RA or PsA
- The patient has had an inadequate response or intolerance to at least 2 disease modifying anti-rheumatic drugs (DMARDs), one of which must be methotrexate unless contraindicated . Patients must have had a trial of at least 3 months with these agents

Plaque Psoriasis:
- Requests for Special Authorization will be considered for adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy who meet ALL of the following criteria:
- Patient has been diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, (or a specialist, such as Internal Medicine),
- Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in he same manner as equal to or more than 10%.
- Patient has failed systemic therapy (for example with methotrexate. cyclosporine, or acitretin (Soriatane); must have had a trial of methotrexate (unless contraindicated).
- Patient has failed photochemical therapy,
- Patient is at least 18 years (adult in the submission) of age.

Reminyl, Reminyl ER galantamine Requests for special authorization is considered for: - patients diagnosed with Alzheimer's disease of mild to moderate severity. For approval purposes, mild to moderate severity corresponds to a Mini Mental State Exam (MMSE) score of 10 to 26 inclusively In advanced Alzheimer's, there is no evidence that the use of this product is beneficial and therefore the product is not a benefit. Cases of early-onset dementia (< than 60 years of age) require assessment by a neurologist or geriatrician before this product can be approved.
Repatha evolocumab

Requests for Special Authorization for Repatha are considered for the reduction of LDL-C in:

Heterozygous Familial Hypercholesterolemia:

Patient has been diagnosed with Heterozygous Familial Hypercholesterolemia with documented baseline LDL-C > 4.9 mmol/; AND

Tendon xanthomas are present in the patient, or in any 1st degree relative (parent, sibling, child), or in 2nd degree relative (grandparent, uncle, aunt).

OR

Homozygous Familial Hypercholesterolemia:

Patient has been diagnosed with Homozygous Familial Hypercholesterolemia with documented baseline LDL-C >13mmol/L; AND

Tendon xanthomas are present in the patient; OR

Evidence of heterozygous familial hypercholesterolemia in both parents is provided.

OR

Atherosclerotic Cardiovascular Disease (ASCVD) - Secondary Prevention:

Patient is an adult with a confirmed diagnosis of clinical Atherosclerotic Cardiovascular Disease (ASCVD), as defined below.

Patient has ONEor more of the following in their medical history:

A. Coronary Heart Disease

Acute coronary syndrome

History of myocardial infarction (MI)

Stable or unstable angina

Coronary or other arterial revascularization

B. Cerebral Disease - Stroke or transient ischemic attack

C. Peripheral arterial disease (including abdominal aortic aneurysm)

Requirements for all requests:

Physician confirmation that patient has been provided nutritional counselling as part of treatment plan;

Recent reatedtest report of LDL-C >2.4 mmol/L (within 3 months of request date);

Documented statin medication history demonstrating patient adherence to maximally tolerated dose;

If statin dose is not maximized, physician confirmed and documented patient contraindication to statins (e.g. pregnancy, nursing, active liver disease) will be required; OR

Physician confirmed documented patient intolerance to statins (e.g. myositis, rhabdomyolysis) AND

Confirmation that other conditions have been ruled out as predisposing factors (drug interactions, untreated hypothyroidism, febrile illness, acute renal failure, biliary obstruction, alcoholism) AND

Confirmation that the patient has trialed and failed at least 2 different statins, one of which is at the lowest dose as a re-challenge.

Patient must be enrolled in the RepathaREADY™ Patient Support Program (the SP;

For all ASCVD requests, patients will be required to have documented trial of ezetimibe for at least 3 months.

Initial Renewal after maximum of 6 month trial:

Recent LDL-C test report demonstrating a minimum 50% reduction in the Patient's LDL-C after 12 week trial on Repatha (up to maximum of 24 weeks of use) and a demonstrated continued statin adherence.

Annual Renewals

Subsequent annual renewals will require that the Patient is continuing to derive clinical benefit from the drug and has demonstrated continued statin adherence. (Repatha's criteria)

Requip ropinirole

Requests for special authorization will be considered for:

- treatment of the signs and symptoms of Parkinson's disease when the patient has failed, cannot tolerate or is unable to take levodopa, bromocriptine or pergolide, or as an adjunct to levodopa.

Resotran prucalopride

Requests for special authorization for Resotran are considered for:
The treatment of chronic constipation in women for whom treatment with at least two laxatives from different classes at the highest tolerated recommended doses for at least 6 months has failed to provide adequate relief for constipation

Restasis cyclosporine

Requests for special authorization for Restasis are considered for patients with:
Moderate to moderately severe dry eyes (DEWS severity level of 2 3) who have not responded to treatment with preservative-free artificial tears.
Therapy with Restasis must be initiated by an ophthalmologist (or optometrist, in those provinces in which optometrists have been granted prescribing authority.)

Retisol-A tretinoin, avobenzone, octinoxate Requests for special authorization are considered for: - treatment of acne vulgaris
Retrovir zidovudine Requests for special authorization for Retrovir are considered for: - treatment of HIV infection when antiretroviral therapy is warranted.
Revatio sildenafil Requests for special authorization may be considered for the treatment of primary arterial hypertension (PPH), OR pulmonary hypertension secondary to connective tissue disease, in patients with WHO functional class III who have not responded to conventional therapy.
Revia naltrexone hydrochloride Requests for special authorization are considered for patients who are alcohol dependent as a component of a comprehensive psychotherapeutic or psychological alcoholism counselling program to support abstinence, and reduce the risk of relapse.
Revlimid lenalidomide

Requests for Special Authorization are considered for:

- the treatment of patients with transfusiondependent anemia due to Low- or Intermediate-1-risk myelodysplastic syndromes associated with a deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.

- in combination with dexamethasone for the treatment of multiple myeloma patients who are not eligible for stem cell transplant.

Revolade Eltrombopag olamine

Requests for special authorization for Revolade will be considered for:

- the treatment of chronic immune thrombocytopenia purpura (ITP) to increase platelet counts in adult and pediatric patients one year and older who have had an insufficient response to corticosteroids or immunoglobulins.

- Adults (≥18 years of age) to increase platelet counts in thrombocytopenic patients with chronic hepatitis C virus (HCV) infection to allow the initiation and maintenance of interferon-based therapy.

- for the treatment of adult patients with severe aplastic anemia (SAA) who have had an insufficient response to immunosuppressive therapy.

Rexulti brexpiprazole

Requests for Special Authorization are considered for:

- the treatment of schizophrenia in adults

- as an adjunct to antidepressants for the treatment of major depressive disorder (MDD) in adult patients with an inadequate response to prior antidepressant treatments during the current episode

Rhovane zopiclone Requests for special authorization are considered for: - the short term treatment of insomnia
Rifadin rifampin Requests for special authorization will be considered for prophylaxis of bacterial meningitis in persons exposed to a primary case and for treatment of bacterial and mycobacterial infections (other than tuberculosis) when it is an appropriate antibiotic.
Rituxan rituximab

Requests for Special Authorization for Rituxan are considered for
- the reduction of signs and symptoms in adult patients with moderately or severely active rheumatoid arthritis who have had an inadequate response, or tolerance to one or more tumour necrosis factor (TNF) inhibitor therapies
- Induction remission therapy for patients with severely active granulomatosis with polyangitis (GPA) or microscopic polyangiitis (MPA) in whom the use of cyclophosphamide has failed or is not appropriate

Rosiver ivermectin Requests for special authorization will be considered for the topical treatment of inflammatory lesions (papules and pustules) of rosacea in adults 18 years of age or older.
Sabril vigabatrin

Requests for special authorization will be considered for epileptic patients as adjunctive therapy in the management of patients who are not satisfactorily controlled with conventional therapy (e.g. carbamazepine, phenytoin). Requests will also be considered for the treatment of infantile spasms (West syndrome). Requests may be considered for children under the age of 18 years if requested from a neuologist, pediatrician, or specialist in the area of treating patients with epilepsy

Saizen for injection somatropin

Requests for special authorization are considered for:

- Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy.

- Children with Chronic Renal Insufficiency up to time of renal transplantation

- Turner Syndrome - Patients who have short stature associated with Turner Syndrome

- Adults Growth Hormone Deficiency - Replacement of endogenous growth hormone in adults with growth hormone deficiency who meets either of the following two criteria:

(A) Adult Onset (AO) - Patients who have growth hormone deficiency, either alone or associated with multiple hormone deficiencies (hypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma; OR

(B) Childhood Onset (CO) - Patients who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes.

Salagen pilocarpine Requests for special authorization are considered for: - patients who are experiencing salivary gland hyposecretion following radiation therapy of the head and neck - patents who are experiencing symptoms of dry mouth (xerostomia) and dry eyes (xerophthalmia) due to Sjogren's syndrome.
Saliject sodium salicylate

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Sandimmune cyclosporine

Requests for special authorization will be considered for clients who have
- undergone a solid organ or bone marrow transplant
- OR for treatment of severe psoriasis for clients who have failed conventional therapy with other agents (only requests from dermatologists are to be considered)
- OR for treatment of severe active rheumatoid arthritis for clients in whom classic anti-rheumatics are ineffective or inappropriate (only requests from rhematologists are to be considered)
-OR for treatment of steroid-dependent and steroid-resistant nephrotic syndrome due to glomerular disease (only requests from nephrologists or internists are to be considered).

Sandostatin, Sandostatin LAR octreotide acetate Requests for special authorization are considered for: - patients who have a diagnosis of metastatic carcinoid tumor, vasoactive intestinal peptide tumors and have symptoms of severe diarrhea and flushing episodes which are not controlled - patients who have a diagnosis of acromegaly and surgical resection, pituitary irradiation and/or bromocriptine mesylate at maximum doses are not indicated. In all cases the client has been instructed on the technique for sub-cutaneous self-administration or a qualified and licensed professional will be administering the drug.
Sanorex mazindol Requests for special authorization are considered for: - Adults with BMI greater than, or equal to, 30kg/m2 - Adults with BMI greater than, or equal to, 27kg/m2, in the presence of other risk factors (e.g. hypertension, diabetes, hyperlipidemia)
Saphris asenapine

Requests for special authorization for Saphris are considered for:
The treatment of schizophrenia in those patients for whom therapy with risperidone, olanzapine, or quetiapine has failed or is not appropriate.
The treatment of manic episodes in patients with bipolar I disorder for whom therapy with risperidone, olanzapine, or quetiapine has failed or is not appropriate.

Saxenda liraglutide

Requests for special authorization are considered for use as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:
- 30 kg/m2 or greater (obese), or
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or dyslipidemia) and who have failed a previous weight management intervention.

Sclerodex sodium chloride

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Sclerodine sodium iodide

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Sebivo telbivudine

Requests for special authorization are considered for adults of 16 years and older with compensated liver disease with evidence of viral replication and active liver inflammation in whom a diagnosis of chronic hepatitis B has been made.

Sebivo® is to be prescribed by or in consultation with a hepatologist, infectious disease specialist, or gastroenterologist.

These requests may include the following:

A. Patients who cannot tolerate lamivudine or for whom lamivudine is contraindicated, OR

B. Patients with lamivudine-resistant chronic hepatitis B who
have failed on, or relapsed after lamivudine treatment;
have developed viral resistance to lamivudine, OR

C. Patients with severe liver disease who
have decompensated chronic hepatitis B;
have evidence of severe fibrosis or cirrhosis;
are pre- or post-liver transplantation. The recurrence of chronic hepatitis B after liver transplantation
results in increased risk for graft failure and death of patients.
have compensated chronic hepatitis B and are at risk of liver decompensation (e.g., Chronic Hepatitis B flare, highly replicative HBV), OR

D. Patients with HBV/HIV co-infection who are not on antiviral agents but require HBV treatment only-
(treatment should be undertaken in consultation with a hepatologist, infectious
disease specialist, or gastroenterologist)

Sensipar cinacalcet hydrochloride

Requests for coverage of Sensipar may be considered for patients with
secondary hyperparathyroidism [a complication of chronic kidney disease (CKD)] on dialysis with PTH that is elevated above 33 pmol/L on more than 2 occasions, or rising and one of the following:
a. A previous parathyroidectomy
b. Are not eligible for surgical parathyroidectomy due to high operative risk medical conditions
c. Have calcific uremic arteriolopathy (CUA)
d. Standard therapy (vitamin D sterols and phosphate binders) has failed.
e. Vitamin D Sterols are contraindicated due to hypercalcemia (total calcium > 2.5 mmol/L on at least 2 occasions) AND/OR hyperphosphatemia (serum phosphorus > 1.8 mmol/L on at least 2 occasions)

Serevent salmeterol xinafoate

Requests for special authorization will be considered for:

- patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e., inhaled steroids) and still require short-acting bronchodilator more than twice daily

- patients with severe COPD (chronic obstructive pulmonary disorder) with a reversible component, where symptoms have not responded to first-line therapy, e.g. ipratropium, salbutamol, inhaled steroids

Seroquel XR quetiapine fumarate extended-release

Requests for special authorization will be considered for:

The treatment of schizophrenia in patients who:
1. have tried and failed therapy with one or more of any form (including generic or brand, immediate or extended release) of either quetiapine, olanzapine or risperidone; or

2. have a medical reason why one or more of any form of quetiapine, olanzapine or risperidone cannot be used.

The treatment of bipolar disorder in patients who:
1. have tried and failed therapy with one or more of a conventional mood stabilizer (e.g., lithium, divalproex) and one or more of any form of quetiapine, olanzapine or risperidone; or

2. have a medical reason why one or more of any form of lithium, divalproex, quetiapine, risperidone or olanzapine cannot be used.

The treatment of major depressive disorder who:
1. have tried and failed antidepressant drug therapy due to lack of efficacy and/or lack of tolerability.

Simponi golimumab

Requests for special authorization for Simponi™ are considered for:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:
(a) Diagnosis of moderate to severe rheumatoid arthritis AND:
The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:
(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

- adult patients to reduce the signs and symptoms associated with active ankylosing spondylitis (AS) in patients who have failed a six-month trial of 2 different non-steroidal anti-inflammatory drugs (NSAIDS).

- adult patients, alone or in combination with methotrexate, to reduce the signs and symptoms of moderately to severely active psoriatic arthritis (PsA). Patients must have failed at least 2 disease modifying antirheumatic drugs (DMARDS), one of which must be methotrexate unless contraindicated.

- adult patients with moderately to severely active Ulcerative Colitis (UC) who have had an inadequate response to, or have medical contraindications for, conventional therapy including corticosteroids, aminosalicylates, azathioprine (AZA), or 6-mercaptopurine (6-MP), for:
- Inducing and maintaining clinical response (reduction in signs and symptoms);
- Inducing clinical remission
- Achieving sustained clinical remission in induction responders;
- Improving endoscopic appearance of the mucosa during induction.

Singulair montelukast

Requests for special authorization will be considered for:

- patients two years of age and older for:

- prophylaxis and chronic treatment of asthma, when the patient has been treated with an optimal dose of inhaled steroids that does not control symptoms, or in patients who are unable to use inhaled corticosteroids.

- the treatment of ASA-sensitive asthmatics when the patient has been treated with an optimal dose of inhaled steroids that does not control symptoms, or in patients who are unable to use inhaled corticosteroids.

- the prevention of exercise-induced bronchostriction in patients who are not adequately managed with a beta2-agonist (e.g. salbutamol) or unable to use beta2-agonists

Requests for the treatment of perennial or seasonal allergic rhinitis will not be considered unless the patient has a diagnosis of asthma.

Somatuline Autogel lanreotide acetate

Request for special authorization will be considered for:

- long-term treatment of patients with acromegaly due to pituitary tumours who have had an inadequate response to - or cannot be treated with surgery and/or radiotherapy.

- for the relief of symptoms associated with acromegaly. (reduces blood levels of growth hormone and IGF-I).

- for the treatment of enteropancreatic neuroendocrine tumors in patients with grade 1 (G1) or a subset of grade 2 (G2; equivalent to Ki67<10%) unresectable, locally advanced or metastatic disease to delay progression.

Somavert pegvisomant

Request for special authorization will be considered for the treatment of acromegaly in patients who have had an inadequate response to surgery, and/or radiation therapy or for whom these therapies are not appropriate. The goal of treatment is to normalize serum insulin-like growth factor-I (IGF-I) levels and to improve clinical signs and symptoms.

Sovaldi sofosbuvir

Sovaldi containing regimens are not eligible for coverage for the treatment of hepatitis C virus (CHC) infection genotypes 1 - 4. Alternative cost effective treatment options are eligible for coverage including Epclusa (pan genotypic, 12 weeks), Harvoni (genotype 1, 8 weeks), Holkira Pak (genotype 1, 12 weeks), Zepatier (genotype 1 & 4, 12 weeks) and Technivie (genotype 4, 12 weeks), with or without ribavirin.

Sporanox itraconazole

Requests for special authorization are considered for :

- treatment of severe or life threatening systemic fungal infections

- treatment of non-life threatening histoplasmosis and blastomycosis

- treatment of cutaneous fungal infections or onychomycosis when other treatments have failed (e.g. ketoconazole, terbinafine)

Sprycel dasatinib monohydrate

Requests for special authorization are considered for patients with a diagnosis of CML who have tried and failed Gleevec as first-line therapy and patients with Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) with resistance or intolerance to prior therapy. The prescribing physician must be a Hematologist, Oncologist, Internist or physician experienced in the treatment of patients with CML.

Stadol butorphanol tartrate

Requests for special authorization are considered for:

- patients who fail to obtain pain relief from NSAIDs, standard analgesic therapy (including narcotics) and ergotamine preparations (when diagnosis is migraine)

- If the diagnosis is migraine - failure to respond or contraindication to prophylactic agents, or a frequency of headaches that is not sufficient to justify trial of prophylactic therapy.

Stalevo carbidopa/levodopa/entacapone Requests for special authorization are considered for: patients with Parkinson's disease who are currently on levodopa/carbidopa or levodopa/benserazide therapy and experience end-of-dose "wearing off" and are considered to be good candidates for combination therapy.
Stelara ustekinumab

Requests for special authorization for Stelara are considered for:

Adults:

Plaque Psoriasis:

- for the treatment of adult patients with chronic, moderate to severe plaque psoriasis in those patients who have failed systemic therapy with methotrexate, cyclosporine, or acitretin AND photochemical therapy.

Psoriatic Arthritis:

- for the treatment of adult patients with active psoriatic arthritis (PSA) who meet ALL of the following criteria:

- The medication is prescribed by or in consultation with a rheumatologist, or a specialist in the field of RA or PsA

- The patient has had an inadequate response or intolerance to at least 2 disease modifying anti-rheumatic drugs (DMARDs), one of which must be methotrexate unless contraindicated . Patients must have had a trial of at least 3 months with these agents.

Crohn’s Disease:

- for the treatment of adult patients with moderately to severely active Crohn’s disease, who have had an inadequate response, loss of response to, or were intolerant to either immunomodulators or one or more tumour necrosis factor-alpha (TNFα) antagonists, or have had an inadequate response, intolerance or demonstrated dependence on corticosteroids.

Ulcerative Colitis:

- for the treatment of adult patients with moderately to severely active ulcerative colitis who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a biologic or have medical contraindications to such therapies.

Pediatrics:

Plaque Psoriasis:

- for the treatment of chronic moderate to severe plaque psoriasis in pediatric patients (children and adolescents) from 6 to 17 years of age, who are inadequately controlled by, or are intolerant to, other systemic therapies or phototherapies.


Stemgen ancestim

Requests for special authorization are considered for patients who require bone marrow transplant for:

- use in combination with Neupogen (filgrastim) to provide a sustained increase in the number of PBPC (peripheral blood progenitor cell) capable of engraftment, to increase the likelihood of patients reaching a PBPC target, and to reduce the number of aphereses required to collect a target number of PBPC

Requests will also be considered for patients receiving myelosuppressive or myeloblative chemotherapy.

Requests should be made by, or in consultation with, a specialist in oncology, hematology, infectious diseases or internal medicine.

Stieva-A Forte tretinoin

Requests for special authorization are considered for:
- patients experiencing acne vulgaris

Stievamycin tretinoin and erythromycin

Requests for special authorization are considered for treatment of acne vulgaris. Requests will not be considered for photodamaged skin or intrinsic aging and related symptoms, such as aging or hyperpigmentation.

Stievamycin Forte tretinoin and erythromycin

Requests for special authorization are considered for treatment of acne vulgaris. Requests will not be considered for photodamaged skin or intrinsic aging and related symptoms, such as aging or hyperpigmentation.

Stievamycin Mild tretinoin and erythromycin

Requests for special authorization are considered for treatment of acne vulgaris. Requests will not be considered for photodamaged skin or intrinsic aging and related symptoms, such as aging or hyperpigmentation.

Stivarga Regorafenib Requests for special authorization considered: For treatment of patients with metastatic and/or unresectable gastrointestinal stromal tumors (GIST) who have had disease progression on or intolerance to imatinib mesylate and sunitinib malate treatment.
Strattera atomoxetine Requests for special authorization considered the treatment of Attention- Deficit/Hyperactivity Disorder (ADHD) in children 6 years of age and over, adolescents, and adults.
Stribild elvitegravir/cobicistat/emtricitabine/tenifovir Consideration for Special Authorization: STRIBILD is indicated as a complete regimen for the treatment of HIV-1 infection in antiretroviral treatment-naïve adult patients aged 18 years and older.
Suboxone Buprenorphine and Naloxone Requests for special authorization for Suboxone will be considered for: - the treatment of patients with opioid dependence in whom methadone is contraindicated. (Patients at risk of or having QT prolongation, or hypersensitivity to methadone).
SUN-BENZ benzydamine Requests for special authorization are considered for : - patients who suffer from mucositis (inflammation of mouth or throat mucosa) related to radiation therapy.
Suprefact Depot buserelin

Requests for special authorization are considered for:

- men with advanced (Stage D) symptomatic carcinoma of the prostate where surgical orchiectomy is not a therapeutic option

- treatment of endometriosis for a maximum duration of six to nine months

Sutent (metastatic renal cell carcinoma) sunitinib

Requests for special authorization for Sutent are considered for patients with metastatic renal cell carcinoma of clear cell histology who have received no prior systemic therapies or who have received prior treatment with cytokines for metastatic disease.

Sutent for GIST sunitinib malate

Request for special authorization are considered for patients with a diagnosis of GIST who have tried and failed Gleevec as first-line therapy.

Symbicort Turbuhaler budesonide, formoterol

Requests for special authorization will be considered for:

- patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e., inhaled steroids) and still require short-acting bronchodilator more than twice daily

- patients with severe COPD (chronic obstructive pulmonary disorder) with a reversible component, where symptoms have not responded to first-line therapy, e.g. ipratropium, salbutamol, inhaled steroids, tiotropium

Synacthen Depot tetracosactide zinc hydroxide

Requests for special authorization are considered :

- when the patient is undergoing testing for adrenocortical function.

Synarel nafarelin acetate Requests for special authorization will be considered for: - women requiring hormonal treatment of endometriosis including pain relief and reduction of endometriotic lesions in women older then 18 years
Synjardy empagliflozin / metformin

Requests for special authorization will be considered as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on:
metformin;
sulfonylurea in combination with metformin;
pioglitazone in combination with metformin;
insulin in combination with metformin;

Or in patients already being treated and achieving glycemic control with:
metformin and empagliflozin as separate tablets;
sulfonylurea in combination with metformin and empagliflozin as separate tablets;
pioglitazone in combination with metformin and empagliflozin as separate tablets;
insulin in combination with metformin and empagliflozin as separate tablets

Tafinlar dabrafenib Requests for special authorization for Tafinlar will be considered for: - monotherapy for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600 mutation. A validated test is required to identify BRAF V600 mutation status.
Tafinlar & Mekinist Combination dabrafenib/trametinib

Requests for Special Authorization for Tafinlar (dabrafenib), in combination with Mekinist (trametinib) are considered for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600 mutation.

Requests for Special Authorization for Tafinlar (dabrafenib), in combination with Mekinist(trametinib) are considered for the adjuvant treatment of patients with melanoma with a BRAF V600 mutation and involvement of lymph node(s), following complete resection.

Tantum benzydamine Requests for special authorization are considered for: - patients who suffer from mucositis (inflammation of mouth or throat mucosa) related to radiation therapy.
Tarceva erlotinib

Requests for Special Authorization are considered for:

- monotherapy for the first-line treatment of patients with locally advanced (stage III b, not amenable to curative therapy) or metastatic (stage IV) non-small cell lung cancer (NSCLC) with EGFR activating mutations

- monotherapy for maintenance treatment in patients with locally advanced or metastatic non-small cell lung cancer with EGFR activating mutations after 4 cycles of standard platinum-based first-line chemotherapy.

- monotherapy for the treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen, and whose EGFR expression status is positive

Tasigna nilotinib

Requests for special authorization are considered for patients with:
Newly diagnosed Philadelphia chromosome positive (Ph+) chronic myeloid leukemia (CML) in chronic phase
Ph+ chronic or accelerated phase CML with resistance or intolerance to prior therapy

Tecfidera Dimethyl fumarate

Requests for special authorization are considered as monotherapy for adult patients for the treatment of relapsing remitting multiple sclerosis (MS) to reduce the frequency of clinical exacerbations and to delay the progression of disability.

Technivie ombitasvir/paritaprevir/ritonavir

Requests for Special Authorization are considered for the treatment of adults with lab-confirmed genotype 4 chronic hepatitis C virus infection without cirrhosis who are either treatment naïve or previously treated with peg-interferon and ribavirin for a maximum of 12 weeks.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME.

Temodal temozolomide

Temodal capsules are indicated for the treatment of adult patients with glioblastoma multiforme (GBM) or anaplastic astrocytoma (AA) (with radiation therapy) and documented evidence of recurrence or progression after standard therapy.

Tenuate diethylpropion Requests for special authorization are considered for: - Adults with BMI greater than, or equal to, 30Kg/m2 - Adults with BMI greater than, or equal to, 27kg/m2, in the presence of other risk factors (e.g. hypertension, diabetes, hyperlipidemia)
Testim gel 1% testosterone gel 1%

Requests for special authorization for Testim1% gel will be considered for replacement therapy in males associated with a deficiency or absence of endogenous testosterone. The deficiency of testosterone should be established by measurement of free testosterone levels on morning blood samples on at least 2 occasions.

Thalomid thalidomide Requests for special authorization for Thalomid® are considered for the treatment of patients with previously untreated multiple myeloma, in combination with melphalan and prednisone, who are over the age of 65.
Tivicay dolutegravir

Requests for special authorization for Tivicay are considered for the treatment of human immunodeficiency virus (HIV-1) infection in adults and in INSTI-naïve children weighing at least 30 kg.

Tobi & Tobi Podhaler tobramycin TOBI® Podhaler® is indicated for the management of cystic fibrosis (CF) in patients 6 years or older with chronic pulmonary Psuedomonas aeruginosa infections. This is the same indication as TOBI®.
Toctino alitretinoin Requests for special authorization for Toctino™ are considered for adult patients with severe chronic hand eczema refractory to potent topical corticosteroids. Patients must have had an adequate trial of at least 4 weeks duration of at least 2 high-potency corticosteroids.
Topamax, Topamax Sprinkles topiramate Requests for special authorization will be considered for: Adjunctive therapy of patients (adults and children over 2 years old) with epilepsy who are not satisfactorily controlled with conventional therapy or as monotherapy for the management of newly diagnosed epilepsy in adults and children six years and older. Migraine prophylaxis for patients who have failed, or have a contraindication for, standard drugs used for prophylaxis. Bipolar disorder for patients in whom conventional therapy cannot be tried or have failed. Management of neuropathic pain when all other treatments have failed (including gabapentin
Toradol ketorolac

Requests for special authorization are considered for short term management (not to exceed 5 days for post surgical or 7 days for musculoskeletal pain) for moderate to moderately severe acute pain, acute musculoskeletal trauma and post partum uterine cramping.
Requests will also be considered for the intermittent use for conditions such as migraine headaches and dental pain

Toviaz fesoterodine Requests for special authorization for Toviaz will be considered for: - the treatment of patients with overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence, or any combination of these symptoms.
Tracleer bosentan Requests for special authorization are considered for clients who have a diagnosis of pulmonary arterial hypertension (PAH) with a) WHO functional class III and IV primary pulmonary hypertension (PPH), or b) pulmonary hypertension secondary to scleroderma.
Trajenta linagliptin

Requests for special authorization for Trajenta™ will be considered for:
- Monotherapy in adult patients with type 2 diabetes who have a contraindication to metformin.
- Combination therapy with metformin or a sulfonylures in adult patients with type 2 diabetes who have been inadequately controlled on a metformin plus a sulfonylurea combination regimen.

Trelstar triptorelin pamoate for injection suspension

Request for Special Authorization will be considered for the treatment of patients with hormone dependent advanced (stage D2) carcinoma of the prostate gland.

Trileptal oxcarbazepine

Requests for special authorization are considered for adults with partial seizures, as adjunctive therapy or monotherapy, and for children six years of age and older with partial seizures as adjunctive therapy. All patients must have uncontrolled seizures while on other medication, have contraindications to other medications or be unable to tolerate other medications (e.g.carbamazepine, phenytoin, valproic acid, divalproex)

Triumeq abacavir (abacavir sulfate) & dolutegravir (dolutegravir sodium) & Lamivudine

Requests for special authorization will be considered for the treatment of Human Immunodeficiency Virus (HIV-1) infection in adults.

Tromboject sodium tetradecyl sulfate

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Trombovar sodium tetradecyl sulfate

Requests for special authorization will be considered for sclerosing of varicose veins in patients with complications (e.g. venous insufficiency leading to deep vein thrombosis, severe bleeding or infection, ulcers or sores on skin due to lack of oxygen, phlebitis).
Requests will not be considered for treatment of varicose to alleviate leg muscle fatigue, leg cramps or for cosmetic reasons.

Trosec trospium Requests for Special Authorization are considered for: - overactive bladder with symptoms of urinary frequency, urgency or urge incontinence where the patient has failed on, or proven intolerant to, a previous trial of first-line therapy (oxybutynin)
Trulicity dulaglutide Requests for special authorization are considered for: Adult patients with inadequately controlled type 2 diabetes mellitus, who have had a trial of both metformin and at least one sulfonylurea.
Truvada emtricitabine/ tenofer disoproxil fumarate

Requests for special authorization are considered for the following:
- the management of HIV-1 infection in adults, in combination with other antiretroviral agents.
- in combination with safer sex practices for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 infection in adults at high risk.

Tryptan tryptophan Requests for special authorization are considered for clients as an adjunct to antidepressant therapy in the management of depressive disorders or as an adjunct to lithium therapy in the management of bipolar affective disorders.
Twinject epinephrine or adrenalin Requests for special authorization are considered for: - patients who have a documented allergy resulting in anaphylactic reactions.
Tykerb lapatinib

Requests for special authorization will be considered in combination with capecitabine for the treatment of patients with metastatic breast cancer whose tumours overexpress ErbB2 (HER2). Patients should have progressed on taxanes and anthracycline before starting this therapy. In addition, patients should have progressed on prior trastuzumab therapy in the metastatic setting.

Tysabri natalizumab

Requests for Special Authorization will be considered for patients who:

-are no less than 18 years of age;
-have been clinically diagnosed with and currently have the relapsing-remitting form of multiple sclerosis (safety and efficacy with chronic progressive MS have not been established);
-requests for Tysabri for the treatment of secondary progressive, primary progressive and progressive relapsing MS will be declined.
-have failed or are intolerant to one of the interferon beta products (Avonex®, Betaseron or Rebif®), AND have failed or are intolerant to Copaxone® (glatiramer) ;
-will be using Tysabri as monotherapy only;
-are being prescribed Tysabri by an MS-specialist or a neurologist;
-present with an EDSS score of 5.5 or less (ie. patient must be ambulatory);
-show a significant increase in T2 lesion load as compared to previous MRI or at least one gadolinium-enhancing lesion
AND,
-have had at least 2 relapses in the previous 12 month period;

Requests for Special Authorization will also be considered for patients who:
-have NOT failed or are intolerant to BOTH an interferon beta product AND Copaxone
IF
-showing an increase in EDSS score of 2.0 or greater over the previous 12 month period.
-all other criteria remain the same for these patients.

Requests for Special Authorization are considered for patients:
-no less than 18 years of age
-Clinically diagnosed relapsing-remitting form of multiple sclerosis (safety and efficacy with chronic progressive MS have not been established)
-Failed or intolerant to Copaxone® (glatiramer), AND have failed or intolerant to one of the interferon beta products (Avonex®, Betaseron or Rebif®)
-Being used as monotherapy only.
-Prescriber must be a neurologist or an MS-specialist (or in consultation with one)

Ultibro Breezehaler Indacaterol (as maleate)/glycopyrronium (as bromide)

Requests for special authorization will be considered for:
- the long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.

Ultrase pancrelipase Requests for special authorization are considered for pancreatic enzyme replacement therapy in established pancreatic insufficiency where pancreatic enzymes are absent from or present in insufficient amount in the intestine.
Unitron-Peg peginterferon-alfa-2b Requests for special authorization are considered for : - patients in whom a diagnosis of Chronic Hepatitis C has been made. Unitron Peg is to be prescribed only by physicians who are familiar with the treatment of Chronic Hepatitis C.
Uptravi selexipag

Requests for special authorization will be considered for the long-term treatment of idiopathic pulmonary arterial hypertension (iPAH), heritable pulmonary arterial hypertension (HPAH), PAH associated with connective tissue disorders and PAH associated with congenital heart disease, in adult patients with WHO functional class (FC) II–III to delay disease progression.

Valcyte valganciclovir hydrochloride

Requests for special authorization will be considered for the treatment of CMV retinitis in adult patients with AIDS, as well as for the prevention of CMV retinitis in solid organ transplant patients at risk. (This drug does not fall under the list of provincial drug assistance medications for the treatment of the viral load associated with HIV/AIDS).

Vesanoid tretinoin Requests for special authorization are considered for: - the induction of remission in acute promyelocytic leukemia (APL)
Vfend voriconazole

Requests for reimbursement of oral Vfend will be considered for the treatment of invasive aspergillosis (approved indication in Canada) as well as for the treatment of Candidemia and the following Candida infections: disseminated infections in the skin and infections in abdomen, kidney, bladder wall and wounds.

Victoza liraglutide

Requests for special authorization for Victoza™ are considered for:
Adult patients with inadequately controlled type 2 diabetes mellitus, who have had a trial of both metformin and at least one sulfonylurea

Victrelis/Victrelis Triple boceprevir

Requests for special authorization for Victrelis/Victrelis Triple are considered for:
The treatment of chronic hepatitis C genotype 1 infection in adults with compensated liver disease

Vimovo naproxen / esomeprazole

Adult patients requiring the chronic use of NSAIDs who are at risk of developing gastric ulcers and who:

1. have tried and failed therapy with one or more of any drug containing any form (including generic or brand, immediate or extended release) of PARIET (rabeprazole), LOSEC (omeprazole), PREVACID (lansoprazole), TECTA (pantoprazole magnesium) or PANTOLOC (pantoprazole sodium); with Naproxen Sodium

2. have a medical reason why one or more of any form of rabeprazole, omeprazole, lansoprazole, pantoprazole magnesium or pantoprazole sodium cannot be used with Naproxen Sodium.

Viokase pancrelipase Requests for special authorization are considered for pancreatic enzyme replacement therapy in established pancreatic insufficiency where pancreatic enzymes are absent from or present in insufficient amount in the intestine.
Viramune XR nevirapine

Requests for special authorization are considered for:
- adults with diagnosed with HIV-1 infection in combination with other antiretroviral agents

Viread tenofovir disoproxil (as fumarate)

Request for special authorization will be considered for treatment of HIV infection when, because of intolerance or resistance, it is impossible to offer the patient a viable three-drug regimen from other antivirals on formulary.
Requests are also considered for the treatment of chronic hepatitis B in patients 18 years of age and older and who have failed treatment with lamivudine. Prescribed only by or in consultation with a hepatologist, infectious disease specialist, or gastroenterologist.

Visanne dienogest

Requests for special authorization for Visanne™ will be considered for:
Management of endometriosis associated pelvic pain in female patients for whom less hormonal options such as oral contraceptives or medroxyprogesterone are either ineffective or cannot be used

Visudyne verteporfin

Reimbursement will be considered for the treatment of (wet) age-related macular degeneration (AMD) in patients with predominantly classic choroidal neovascularization (CNV), pathologic myopia and presumed ocular histoplasmosis.

Only requests from ophthalmologists will be considered.

Vitamin B12 cobalamin

Requests for special authorization are considered for:
- patients with a medical diagnosis (other than weight loss) that require treatment with vitamin B6 or vitamin B12.

Vitamin B6 pyridoxine

Requests for special authorization are considered for:

- patients with a medical diagnosis (other than weight loss) that require treatment with vitamin B6 or vitamin B12.

Vivelle estradiol

Requests for special authorization are considered for:

- patients suffering from unacceptable adverse effects due to oral estrogen therapy (e.g. estrogen-induced hypertension or migraine)

- patients with a contraindication to oral therapy (e.g. dysphagia or liver disease)

- patients who have not had symptom relief with oral hormone replacement therapy

Volibris ambrisentan

Requests for Special Authorization are considered for Volibris for clients who have a diagnosis of:
a) primary (idiopathic) pulmomary arterial hypertension, OR
b) pulmonary arterial hypertension associated with connective tissue disease (CTD),
in patients with WHO functional III symptoms who have not responded to conventional therapy

Votrient pazopanib

Requests for special authorization for Votrient™ are considered
for patients with metastatic renal cell carcinoma who have received no prior systemic therapies or who have received prior treatment with cytokines for metastatic disease

Wellbutrin bupropion hydrochloride

Requests for special authorization are considered for the symptomatic treatment of depressive illness.

Requests for smoking cessation will not be considered.

Xalkori crizotinib

Requests for special authorization are considered for:
- as monotherapy for use in patients with anaplastic lymphoma kinase (ALK)-positive locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC).

Xatral alfuzosin

Requests for special authorization are considered for the treatment of benign prostate hyperplasia (BPH) in patients who have not responded to, who have not tolerated or who can not use alpha blockers on formulary (e.g. terazosin, doxazosin)

Xeljanz Tofacitinib citrate

Requests for special authorization will be considered in combination with methotrexate or as monotherapy, will be considered for adult patients with moderate to severe rheumatoid arthritis who have tried and failed 2 DMARDs (eg. methotrexate).

Requests for special authorization will be considered for the treatment of adult patients with moderately to severely active ulcerative colitis (UC) with an inadequate response, loss of response or intolerance to either conventional UC therapy or a TNF-inhibitor.

Requests for special authorization will be considered in combination with methotrexate (MTX) or another conventional synthetic disease-modifying antirheumatic drug (DMARD), is indicated for reducing the signs and symptoms of psoriatic arthritis (PsA) in adult patients with active PsA when the response to previous DMARD therapy has been inadequate.

Xeloda capecitabine

Requests for special authorization will be considered for:

Breast Cancer:
Combination Therapy: XELODA in combination with docetaxel is indicated for the
treatment of patients with advanced or metastatic breast cancer after failure of prior
anthracycline containing chemotherapy.
Monotherapy: XELODA is also indicated for the treatment of advanced or metastatic
breast cancer after failure of standard therapy including a taxane, unless therapy with a
taxane is clinically contraindicated.

Colorectal Cancer:
the first-line treatment of patients with metastatic colorectal cancer.

Xenical orlistat

Requests for special authorization are considered for weight reduction in conjunction with a reduced calorie diet and an exercise program and for long-term maintenance of weight loss in patients:

- with a BMI greater than 30kg/m2

- with greater than 27kg/m2 in the presence of comorbidities such as elevated blood pressure, heart disease, diabetes or arthritis.

Xeomin Clostridium Botulinum neurotoxin type A

Requests for special authorization are considered for:

- patients 18 years of age and older with blepharospasm where treatment is currently being provided by an ophthalmologist or internist experienced in the use of botulinum toxin for the above indications.

- patients 18 years of age and older with cervical dystonia (spasmodic torticollis) where treatment is currently being provided by an internist experienced in the use of botulinum toxin for this indication

- patients 18 years of age and older with post-stroke spasticity of the upper limb where treatment is currently being provided by an internist experienced in the use of botulinum toxin for this indication

Xgeva denosumab

Requests for special authorization are considered for:

- Reducing the risk of developing skeletal-related events in patients with multiple myeloma and in patients with bone metastases from breast cancer, prostate cancer, non-small cell lung cancer, and other solid tumours.

- Treatment of adults and skeletally mature adolescents with giant cell tumour of bone that is unresectable or where surgical resection is likely to result in severe morbidity.

Xiaflex Collagenase clostridium histolyticum

Requests for special authorization will be considered for:
- The treatment of adult patients with Dupuytren’s contracture with a palpable cord.
- The treatment of adult men with Peyronie’s disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy.

Xigduo dapagliflozin/metformin hydrochloride

Requests for special authorization are considered for:
- use as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already being treated with dapagliflozin and metformin as separate tablets and achieving glycemic control.
- for use in combination with a sulfonylurea as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already achieving glycemic control with dapagliflozin, metformin and a sulfonylurea.
- for use in combination with sitagliptin as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already achieving glycemic control with dapagliflozin, metformin and sitagliptin.
- for use in combination with insulin as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already achieving glycemic control with dapagliflozin, metformin and insulin.

Xolair omalizumab

Requests for Special Authorization approval of Xolair® will depend on the following criteria including, but not limited to:

- Patient is diagnosed with allergic asthma as established by skin or blood tests and history
- Patient is diagnosed with moderate to severe persistent Asthma
- Patient is being prescribed Xolair® and followed by a specialist (such as):
- a Respirologist with certification from the Royal College of Physicians & Surgeons or Collège des Médicins du Quebéc or
- a Pediatrician with Respirologist designation or
- either an Internist or Pedicatrician with clinical Immunology and Allergy certification by either of the two bodies mentioned above
- Environmental issues considered and addressed as reasonably possible
- Patient has had inadequate response to or has developed intolerable side effects to first line maintenance therapies
- Baseline IgE level
- Evidence of reversible disease
- Patient's weight
- Patient is a non-smoker

Because these cases are not always easily definable using black and white criteria, each case will be reviewed by our Respirology physician to confirm that Xolair® would be an effective medication to include in the patient's overall treatment plan. For efficient claims processing, please ensure a special authorization form is completed and accompanied by supporting documentation including those mentioned above.

Xtandi enzalutamide

Requests for special authorization will be considered for:

Treatment of metastatic castration-resistant prostate cancer (CRPC) in patients who:

- are chemotherapy-naïve with asymptomatic or mildly symptomatic disease after failure of androgen deprivation therapy.

- have received docetaxel therapy.

Treatment of patients with non-metastatic castration-resistant prostate cancer (NM-CRPC).

Treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC).

Xyrem sodium oxybate

Requests for special authorization for Xyrem will be considered only for patients meeting all
of the criteria:
a) Enrolled in the Xyrem Success Program (see below for details);
b) Diagnosis of cataplexy associated with narcolepsy
c) Currently receiving treatment with a CNS stimulant
d) No current use of alcohol, sedative hypnotics, or other CNS depressants
e) Age > 18 years of age.

Note: Xyrem is available only through a single central pharmacy, and patients must enrol in the Xyrem Success Program in order to receive the medication.

Yervoy ipilimumab Requests for special authorization will be considered for: - the treatment of unresectable or metastatic melanoma.
Zaditen ketotifen

Requests for special authorization are considered for:

- the treatment of pediatric asthma in patients >3 years of age, with diagnosis of chronic mild atopic asthma, whose symptoms have failed to be controlled by other therapeutic approaches e.g. bronchodilators inhaled corticosteroids)

Zaxine rifaximin

Requests for special authorization will be considered for:

- the reduction in risk of overt hepatic encephalopathy (HE) recurrence in patients ≥18 years of age.

- for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults.

Zelboraf vemurafenib

Requests for Special Authorization for Zelboraf are considered for the treatment of BRAV V600 mutation-positive unresectable stage IIIc or IV metastatic melanoma.

Zeldox capsules ziprasidone hydrochloride

Requests for Special Authorization are considered for:
- the treatment of schizophrenia in patients who have tried and failed with either risperidone (Risperdal), or quetiapine (Seroquel) or have a medical reason why either of these medications can't be used.

Zenhale Mometasone furoate/formoterol fumarate

Requests for special authorization will be considered for:
- patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e., inhaled steroids) and still require short-acting bronchodilator more than twice daily

Zepatier elbasvir/grazoprevir

Requests for Special Authorization are considered for the treatment of lab-confirmed chronic hepatitis C virus (HCV) infection, with fibrosis stage F2 or greater, in adult patients with genotype 1 or genotype 4 with or without cirrhosis, who have not had on-treatment virologic failures, for a maximum of 12 weeks.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME.

Zofran Tablets, Liquid and ODT ondansetron Requests for special authorization are considered for: - patients on a course of cytotoxic chemotherapy who meet one of the following criteria: a) patients receiving highly emetogenic (cisplatin, mechlorethamine hydrochloride, streptozocin, dacarbazine, carmustine, or dactinomycin) or moderately emetogenic chemotherapy (cyclophosphamide, doxorubicin, carboplatin, mitomycin, asparaginase epirubicin or melphalan); b) patients with nausea and vomiting secondary to chemotherapy agents other than those mentioned above and who have not responded to therapeutic doses of conventional antiemetics (metoclopramide, prochlorperazine, dexamethasone) or can not take any of the conventional antiemetics because of adverse effects or specific contraindication. - patients receiving abdominal radiation therapy who have not responded to therapeutic doses of conventional antiemetics (metoclopramide, prochlorperazine, dexamethasone) or can not take any of the conventional antiemetics because of adverse effects or specific contraindication.
Zoladex goserelin

Requests for Special Authorization are considered for the treatment of hormone-dependent advanced carcinoma of the prostate , hormonal dependent breast cancer and for the hormonal management of endometriosis.

Zoladex LA goserelin

Requests for Special Authorization will be considered for the treatment of hormone-dependent advanced carcinoma of the prostate and for the hormonal management of endometriosis.

Zomig zolmitriptan

Requests for special authorization are considered for:

- patients who have a definite diagnosis of migraine AND have failed to respond to first-line abortive therapy (i.e. NSAIDs and standard analgesic therapy), unless contraindicated.

Zonalon doxepin

Requests for special authorization are considered for :

- patients for the short-term (up to eight days) topical relief of histamine mediated pruritis of moderate severity, especially accompanying conditions such as eczematous dermatitis.

Zovirax Ointment, Cream acyclovir Requests for special authorization are considered for: -patients who suffer from: - initial episode of genital herpes simplex infection; - a non life-threatening cutaneous herpes simplex virus infection if patient is immunocompromised; - when a recurrent herpes simplex infection is unusually severe or disabling. Requests for the treatment of herpes simplex (cold sores) are not eligible for consideration.
Zydelig idelalisib

Requests for special authorization will be considered:

- in combination with rituximab for the treatment of patients with relapsed chronic lymphocytic leukemia (CLL).

Zykadia ceritinib

Requests for special authorization will be considered as monotherapy for use in patients with anaplastic lymphoma kinase (ALK)-positive locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC) who have progressed on or who were intolerant to crizotinib.

Zytiga abiraterone

Requests for special authorization will be considered for:

- in combination with prednisone for the treatment of metastatic prostate cancer (castration-resistant prostate cancer, mCRPC) in patients who:

- are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy

- have received prior chemotherapy containing docetaxel after failure of androgen deprivation therapy

- in combination with prednisone and androgen deprivation therapy (ADT) for the treatment of patients with newly diagnosed hormone-sensitive high-risk metastatic prostate cancer who may have received up to 3 months of prior ADT.

Zyvoxam linezolid

Requests for special authorization are considered for clients who have been diagnosed with:
Vancomycin Resistant Enterococcus (VRE) infections, or nosocomial pneumonia caused by methicillin-resistant Staphyloccus aureus,or complicated skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus and other susceptible organisms.Requests will only be considered when prescribed or recommended by an infectious disease specialist.

Lynparza olaparib

Requests for Special Authorization are considered for:

Ovarian Cancer:

- as monotherapy for the maintenance treatment of adult patients with newly diagnosed advanced BRCA-mutated high-grade epithelial ovarian, fallopian tube or primary peritoneal cancer who are in response (complete response or partial response) to first-line platinum-based chemotherapy. Patients must have confirmation of BRCA mutation (identified by either germline or tumour testing) before LYNPARZA treatment is initiated.

- As monotherapy maintenance treatment of adult patients with platinum-sensitive relapsed BRCA-mutated high-grade epithelial ovarian, fallopian tube or primary peritoneal cancer who are in response (complete response or partial response) to platinum-based chemotherapy.

Radicava edaravone

Requests for Special Authorization are considered to slow the loss of function in patients with amyotrophic lateral sclerosis (ALS), as measured by the ALS Functional Rating Scale - Revised (ALSFRSR).

Zejula niraparib tosylate

Requests for Special Authorization are considered for the maintenance treatment of female adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy.

Tagrisso osimertinib

Requests for Special Authorization are considered for the first-line treatment of patients with locally advanced (not amenable to curative therapies), or metastatic non-small cell lung cancer (NSCLC) whose tumours have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations (either alone or in combination with other EGFR mutations).

Fulphila pegfilgrastim

Requests for special authorization are considered for decreasing the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs.

Ruxience rituximab

Requests for special authorization are considered for:

- to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies.

in combination with glucocorticoids is indicated for the induction of remission in adult patients with severely active Granulomatosis with Polyangiitis (GPA, also known as Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA).

Rybelsus semaglutide

Requests for Special Authorization are considered as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus:

- as monotherapy when metformin is considered inappropriate due to intolerance or contraindications;

- in combination with other medicinal products for the treatment of diabetes for patient populations and drug combinations tested).

Rinvoq upadacitinib

Requests for Special Authorization are considered for for the treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate.

Avsola infliximab

Requests for special authorization will be considered for:

- reduction of signs and symptoms, induction and maintenance of clinical remission and mucosal healing, and reduction or elimination of corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy (ie, aminosalicylate and/or corticosteroid and/or an immunosuppressant).

- reduction of signs and symptoms, induction and maintenance of clinical remission, and induction of mucosal healing in pediatric patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy (ie, aminosalicylate and/or corticosteroid and/or an immunosuppressant). The safety and efficacy of infliximab have not been established in patients less than 6 years of age.

- reduction of signs and symptoms, induction and maintenance of clinical remission and mucosal healing and reduction of corticosteroid use in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to a corticosteroid and/or aminosalicylate. AVSOLA can be used alone or in combination with conventional therapy.

- treatment of fistulising Crohn’s disease, in adult patients who have not responded despite a full and adequate course of therapy with conventional treatment.

- the reduction of signs and symptoms and improvement in physical function in patients with active ankylosing spondylitis who have responded inadequately, or are intolerant to, conventional therapies.

- reduction of signs and symptoms and induction and maintenance of clinical remission in pediatric patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy (corticosteroid and/or aminosalicylate and/or an immunosuppressant). The safety and efficacy of infliximab is not established in patients less than 9 years of age.

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. For patients with chronic moderate plaque psoriasis, AVSOLA should be used after phototherapy has been shown to be ineffective or inappropriate. When assessing the severity of psoriasis, the physician should consider the extent of involvement, location of lesions, response to previous treatments, and impact of disease on the patient’s quality of life.

- reduction of signs and symptoms, induction of major clinical response, and inhibition of the progression of structural damage of active arthritis, and improvement in physical function in patients with psoriatic arthritis.

- use in combination with methotrexate for the reduction in signs and symptoms, inhibition of the progression of structural damage and improvement in physical function in adult patients with moderately to severely active rheumatoid arthritis.


Verzenio abemaciclib

Requests for Special Authorization are considered for the treatment of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer:

- in combination with an aromatase inhibitor in postmenopausal women as initial endocrinebased therapy.

- in combination with fulvestrant in women with disease progression following endocrine therapy. Pre- or perimenopausal women must also be treated with a gonadotropin-releasing hormone (GnRH) agonist.

Alecensaro alectinib

Requests for Special Authorization are considered for:

- the first-line treatment of patients with anaplastic lymphoma kinase (ALK)-positive, locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC).

- as monotherapy for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive, locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC) who have progressed on or are intolerant to crizotinib.

Nivestym filgrastim

Requests for special authorization will be considered:

(1) Cancer Patients Receiving Myelosuppressive Chemotherapy;

(2) Patients with Acute Myeloid Leukemia;

(3) Cancer Patients Receiving Myeloablative Chemotherapy Followed by Bone Marrow Transplantation;

(4) Cancer Patients Undergoing Peripheral Blood Progenitor Cell (PBPC) Collection and Therapy;

(5) Patients with Severe Chronic Neutropenia (SCN); and

(6) Patients with HIV- Infection.

Beovu brolucizumab

Requests for special authorization will be considered when prescribed by a qualified ophthalmologist experienced in intravitreal injections, or a retinal specialist. for the treatment of neovascular (wet) age-related macular degeneration (AMD).

Nubeqa darolutamide

Requests for special authorization will be considered for the treatment of patients with non-metastatic castration resistant prostate cancer (nmCRPC).

Xospata gilteritinib

Requests for special authorization will be considered for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with a FMS-like tyrosine kinase 3 (FLT3) mutation.

Riximyo rituximab

Requests for special authorization will be considered in combination with methotrexate in adult patients to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies.

Envarsus PA tacrolimus

Requests for special authorization are considered for the prophylaxis of organ rejection in allogenic kidney or liver transplant adult patients in combination with other immunosuppressants.

Mayzent siponimod

Requests for Special Authorization are considered for the treatment of patients with secondary progressive multiple sclerosis (SPMS) with active disease evidenced by relapses or imaging features characteristic of multiple sclerosis inflammatory activity, to delay the progression of physical disability.

Vocabria cabotegravir tablets

Requests for special authorization will be considered in combination with Edurant (rilpivirine tablets), as a complete regimen for short-term treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults who are virologically stable and suppressed (HIV-1 RNA less than 50 copies/mL) as:

- an oral lead-in to assess tolerability of cabotegravir prior to initiating Cabenuva

- oral bridging therapy for missed Cabenuva injections

Cabenuva cabotegravir and rilpivirine extended release injectable suspensions

Requests for special authorization will be considered as a complete regimen for the treatment of HIV-1 infection in adults to replace the current antiretroviral regimen in patients who are virologically stable and suppressed (HIV-1 RNA less than 50 copies/mL).

Enerzair Breezhaler indacaterol / glycopyrronium / mometasone furoate

Requests for Special Authorization are considered as a maintenance treatment of asthma in adult patients not adequately controlled with a maintenance combination of a long-acting beta2-agonist and a medium or high dose of an inhaled corticosteroid who experienced one or more asthma exacerbations in the previous 12 months.

Osnuvo teriparatide

Requests for Special Authorization are considered for:

- the treatment of postmenopausal women with severe osteoporosis who are at high risk of fracture or who have failed or are intolerant to previous osteoporosis therapy.

- to increase bone mass in men with primary or hypogonadal severe osteoporosis who have failed or are intolerant to previous osteoporosis therapy. The effects of teriparatide on risk for fracture in men have not been demonstrated.

- the treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in men and women who are at increased risk for fracture.

Genotropin somatropin

Requests for special authorization are considered for:

  • Pediatric Growth Hormone Deficiency - Patients who have growth failure due to growth hormone inadequacy.
  • Turner Syndrome - Patients who have short stature associated with Turner Syndrome
  • Adults Growth Hormone Deficiency - Replacement of endogenous growth hormone in adults with growth hormone deficiency who meets either of the following two criteria:

(A) Adult Onset (AO) - Patients who have growth hormone deficiency, either alone or associated with multiple hormone deficiencies (hypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma; OR

(B) Childhood Onset (CO) - Patients who were growth hormone deficient during childhood as a result of congenital, genetic, acquired, or idiopathic causes.

Maviret glecaprevir/pibrentasvir

Requests for Special Authorization are considered for the treatment of lab-confirmed pan-genotypic chronic hepatitis C virus (HCV) infection [genotypes 1-6], as monotherapy in adults and adolescent patients 12 to 18 years of age without cirrhosis or with compensated cirrhosis.

NOTE: PATIENT APPROVALS WILL BE LIMITED TO ONE HEPATITIS C TREATMENT PER LIFETIME.

Akynzeo netupitant/palonosetron (as palonosetron hydrochloride)

Requests for special authorization will be considered for:

  • prevention of acute and delayed nausea and vomiting associated with highly emetogenic cancer chemotherapy
  • prevention of acute nausea and vomiting associated with moderately emetogenic cancer therapy that is uncontrolled by a 5-HT3 receptor antagonist alone.
Caripul epoprostenol

Requests for Special Authorization are considered for the the long-term intravenous treatment of idiopathic pulmonary arterial hypertension (iPAH), heritable pulmonary arterial hypertension (HPAH) and pulmonary arterial hypertension associated with connective tissue disease in NYHA functional Class III and Class IV patients who did not respond adequately to conventional therapy.

Ocaliva obeticholic acid

Requests for Special Authorization are considered for the treatment of primary biliary cholangitis (PBC) in combination with ursodeoxycholic acid (UDCA) in adults with an inadequate response to UDCA, or as monotherapy in adults unable to tolerate UDCA

Praluent alirocumab

Requests for Special Authorization for Praluent are considered for the reduction of LDL-C in:

Heterozygous Familial Hypercholesterolemia (HeFH): Patient is an adult with a confirmed diagnosis of Heterozygous Familial Hypercholesterolemia, as defined below.

A. Patient had documented baseline total cholesterol > 7.5 mmol/L at diagnosis or baseline LDL-C > 4.9 mmol/L at diagnosis; and

B. Tendon xanthomas are present in the patient, or in any 1st degree relative (parent, sibling, child), or in 2nd degree relative (grandparent, uncle, aunt); or

C. Family history of myocardial infarction before the age of 50 years in a 2nd degree relative or before the age of 60 years in a 1st degree relative; or

D. Family history of total cholesterol concentration above 7.5 mmol/L in a 1st or 2nd degree relative.

Atherosclerotic Cardiovascular Disease (CVD): Patient is an adult with a confirmed diagnosis of atherosclerotic cardiovascular disease, as defined below.

Patient has ONE or more of the following in their medical history:

A. Coronary Heart Disease

  • Acute coronary syndrome
  • History of myocardial infarction (MI)
  • Stable or unstable angina
  • Coronary or other arterial revascularization

B. Cerebral Disease - Stroke or transient ischemic attack

C. Peripheral arterial disease

*In additional to maximally tolerated statin, patient should have trialed ezetimibe for at least 3 months.

Requirements for all requests:

  • Patient is enrolled in the MyPRALUENTCoach™ Patient Support Program (the “PSP”);
  • Physician provided recent “treated” report of LDL-C >2.4 mmol/L (within 3 months of request date);
  • Physician confirmed that patient has been provided nutritional counselling as part of treatment plan;
  • Patient is currently maximized on a statin* OR
  • Physician confirmed and documented patient contraindication to a statin (e.g. pregnancy, nursing, active liver disease); OR
  • Physician confirmed and documented patient intolerance to a statin (myositis, rhabdomyolysis) AND has ruled out the following conditions as possible predisposing factors (drug interactions, untreated hypothyroidism, febrile illness, acute renal failure, biliary obstruction, alcoholism) AND the patient has trialed and failed at least 2 different statins, one of which is at the lowest dose with a re-challenge.

Renewals:

Initial (Year 1): Physician has provided recent LDL-C report demonstrating a minimum 40% reduction in the patient’s LDL-C after 12 week trial on Praluent™ (up to maximum of 24 weeks of use) and a demonstrated statin adherence as per Medavie Blue Cross’ internal metric.

Subsequent: Subsequent annual renewals will require that the patient is continuing to derive clinical benefit from the drug and has demonstrated statin adherence as per Medavie Blue Cross’ internal metric.

Mavenclad cladribine

Requests for special authorization are considered as monotherapy for the treatment of adult patients with relapsing-remitting multiple sclerosis (RRMS) to reduce the frequency of clinical exacerbations and delay the progression of disability.

Rydapt midostauriin

Requests for special authorization are considered in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation chemotherapy for the treatment of adult patients with newly diagnosed FLT3-mutated acute myeloid leukemia (AML).

A validated test is required to confirm the FLT3 mutation status of AML.

Dupixent Dupilumab

Requests for Special Authorization are considered for:

  • Patients 12 years of age and older and diagnosed with moderate-to severe atopic dermatitis
  • Being treated by a dermatologist, or in consultation with a dermatologist
  • With Physician’s Global Assessment (PGA) score of 3 or higher (moderate-to-severe on a scale of 0–4) AND a body surface area (BSA) of 10% or higher
  • Who have previously tried and failed (or been intolerant to) phototherapy if indicated and accessible
  • And have previously tried and failed (or been intolerant to) medium-potency to high-potency topical corticosteroids AND topical calcineurin inhibitors
  • Patient is enrolled in the patient support program (Freedom)

Renewal: Patient is continuing to derive clinical benefit from the drug (PGA score ≤1 & at least a 20% decrease in BSA from baseline)

Xiidra lifitegrast

Requests for special authorization are considered for the treatment of the signs and symptoms of dry eye disease.

Ozempic semaglutide

Requests for special authorization are considered for adult patients with inadequately controlled type 2 diabetes mellitus, who have had a trial of both metformin and at least one sulfonylurea

Renflexis infliximab

Requests for special authorization are considered for:

- use in combination with methotrexate for the reduction in signs and symptoms, inhibition of the progression of structural damage and improvement in physical function in adult patients with moderately to severely active rheumatoid arthritis.

- the reduction of signs and symptoms and improvement in physical function in patients with active ankylosing spondylitis who have responded inadequately, or are intolerant to, conventional therapies.

- reduction of signs and symptoms, induction and maintenance of clinical remission and mucosal healing and reduction of corticosteroid use in adult patients with moderately to severely active Crohn’s disease who have had an inadequate response to a corticosteroid and/or aminosalicylate.

- reduction of signs and symptoms and induction and maintenance of clinical remission in pediatric patients with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy (corticosteroid and/or aminosalicylate and/or an immunosuppressant).

- treatment of fistulising Crohn’s disease, in adult patients who have not responded despite a full and adequate course of therapy with conventional treatment.

- reduction of signs and symptoms, induction and maintenance of clinical remission and mucosal healing, and reduction or elimination of corticosteroid use in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy (i.e., aminosalicylate and/or corticosteroid and/or an immunosuppressant).

- reduction of signs and symptoms, induction and maintenance of clinical remission, and induction of mucosal healing in pediatric patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy (i.e., aminosalicylate and/or corticosteroid and/or an immunosuppressant).

- reduction of signs and symptoms, induction of major clinical response, and inhibition of the
progression of structural damage of active arthritis, and improvement in physical function in patients with psoriatic arthritis.

- treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy.

Taltz ixekizumab

Requests for special authorization are considered for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Adlyxine lixisenatide

Requests for special authorization are considered for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus in combination with:

- metformin,
- a sulfonylurea (alone or with metformin)
- pioglitazone (alone or with metformin),
- a basal insulin (alone or with metformin),
when the therapy listed above does not provide adequate glycemic control.

Trelegy Ellipta fluticasone furoate/umeclidinium/vilanterol

Requests for Special Authorization are considered for:

- the long-term, once daily, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema

- to reduce exacerbations of COPD in patients with a history of exacerbations

Vosevi sofosbuvir/velpatasvir/voxilaprevir

Requests for Special Authorization are considered for the treatment of chronic hepatitis C virus (HCV) infection in adult patients, without cirrhosis or with compensated cirrhosis, who have:

- genotype 1, 2, 3, 4, 5, or 6 infection and have previously been treated with an HCV regimen containing an NS5A inhibitor;

- genotype 1, 2, 3, or 4 infection and have been previously treated with an HCV regimen containing sofosbuvir without an NS5A inhibitor.

Ocrevus ocrelizumab

Requests for special authorization are considered for:

- for the treatment of adult patients with relapsing remitting multiple sclerosis (RRMS) with active disease defined by clinical and imaging features.

- for the management of adult patients with early primary progressive multiple sclerosis (PPMS) as defined by disease duration and level of disability, in conjunction with imaging features characteristic of inflammatory activity.

Probuphine buprenorphine hydrochloride subdermal implant

Requests for special authorization are considered for the management of opioid dependence in patients clinically stabilized on no more than 8 mg of sublingual buprenorphine in combination with counseling and psychosocial support.

Contrave naltrexone HCl and bupropion HCl

Requests for special authorization are considered as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of:

  • 30 kg/m2 or greater (obese) or
  • 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., controlled hypertension, type 2 diabetes mellitus, or dyslipidemia).
Lapelga pegfilgrastim

Requests for special authorization are considered for decreasing the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs.

Prevymis letermovir

Requests for special authorization are considered for the prophylaxis of cytomegalovirus (CMV) infection in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant (HSCT).

Kisqali ribociclib

Requests for special authorization are considered in combination with:

- an aromatase inhibitor for the treatment of pre/perimenopausal or postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer, as initial endocrine-based therapy;

In pre/perimenopausal women, the endocrine therapy should be combined with a luteinizing hormone releasing hormone (LHRH) agonist.

- fulvestrant for the treatment of postmenopausal women with HR-positive, HER2-negative advanced or metastatic breast cancer, as initial endocrine-based therapy or following disease progression on endocrine therapy.

Juluca dolutegravir/rilpivirine

Requests for special authorization are considered for the treatment of human immunodeficiency virus (HIV-1) infection in adults who are virologically stable and suppressed (HIV-1 RNA less than 50 copies per mL).

Siliq brodalumab

Requests for special authorization are considered for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.

Biktarvy bictegravir/emtricitabine/tenofovir alafenamide

Requests for special authorization are considered for the treatment of human immunodeficiency virus-1 (HIV-1) infection in adults with no known substitution associated with resistance to the individual components of BIKTARVY.

Arbesda Respiclick fluticasone propionate/salmeterol xinafoate

Requests for special authorization are considered for the treatment of asthma in patients aged 12 years and older.

Xarelto rivaroxaban

Requests for special authorization for Xarelto 2.5mg are considered in combination with 75 mg – 100 mg acetylsalicylic acid (ASA), is indicated for the prevention of stroke, myocardial infarction and cardiovascular death, and for the prevention of acute limb ischemia and mortality in patients with coronary artery disease (CAD) with or without peripheral artery disease (PAD).

Orilissa elagolix

Requests for special authorization are considered for the treatment of moderate to severe pain associated with endometriosis.

Soliqua insulin glargine and lixisenatide

Requests for special authorization are considered as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus inadequately controlled on basal insulin (less than 60 units daily) alone or in combination with metformin.

Venclexta venetoclax Requests for special authorization will be considered in combination with rituximab for the treatment of patients with chronic lymphocytic leukemia (CLL) who have received at least one prior therapy.
Olumiant baricitinib

Requests for special authorization are considered in combination with methotrexate (MTX), for reducing the signs and symptoms of moderate to severe rheumatoid arthritis (RA) in adult patients who have responded inadequately to one or more disease-modifying anti-rheumatic drugs (DMARDs).

Erleada apalutamide

Requests for Special Authorization are considered for:

- the treatment of patients with non-metastatic castration-resistant prostate cancer (NM-CRPC).

- for the treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC).

Alunbrig brigatinib

Requests for Special Authorization will be considered:

- as a monotherapy treatment of adult patients with anaplastic lymphoma kinase (ALK)-positive metastatic non–small cell lung cancer (NSCLC) who have progressed on or who were intolerant to an ALK inhibitor (crizotinib).

- as a monotherapy for the first line treatment of adult patients with anaplastic lymphoma kinase (ALK)-positive locally advanced (not amenable to curative therapy) or metastatic non-small cell lung cancer (NSCLC).

Pifeltro doravirine

Requests for special authorization are considered in combination with other antiretroviral medicinal products, for the treatment of adults infected with HIV-1 without past or present evidence of viral resistance to doravirine.

Lenvima lenvatinib

Requests for Special Authorization are considered for the first-line treatment of adult patients with unresectable hepatocellular carcinoma (HCC).

Cresemba isavuconazole (isavuconazonium sulfate)

Requests for special authorization will be considered for use in adults for the treatment of:

- Invasive aspergillosis

- Invasive mucormycosis

Skyrizi risankizumab

Requests for special authorization are considered for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Dovato dolutegravir (DTG) and lamivudine (3TC)

Requests for special authorization are considered for the treatment of Human Immunodeficiency Virus type 1 (HIV-1) infection in adults and adolescents 12 years of age and older and weighing at least 40 kg.

Onstryv safinamide

Requests for special authorization will be considered as an add-on therapy to a regimen that includes levodopa for the treatment of the signs and symptoms of idiopathic Parkinson’s disease (PD) in patients experiencing “off” episodes while on a stable dose of levodopa.

Evenity romosozumab

Requests for special authorization will be considered for treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture.

Aimovig erenumab

Requests for special authorization are considered for the prevention of chronic or episodic migraine in adults (18 years or older) with 4-7 migraine days per month of at least moderate disability (MIDAS>11, HIT-6>50) OR ≥8 monthly migraine days over the last 3 months. Patients must have failed or are intolerant to at least two agents from different standard therapy classes for migraine prevention or have contraindication to preventive therapies.

Xultophy insulin degludec / liraglutide

Requests for special authorization are considered as an adjunct to lifestyle modifications, for the once-daily treatment of adults with type 2 diabetes mellitus to improve glycemic control in combination with metformin, with or without sulfonylurea, when these combined with basal insulin (less than 50 units daily) or liraglutide (less than or equal to 1.8 mg daily), do not provide adequate glycemic control.

Sublocade buprenorphine

Requests for special authorization will be considered for the management of moderate to severe opioid use disorder in adult patients who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product.

Iluvien fluocinolone acetonide

Requests for special authorization will be considered for the treatment of diabetic macular edema (DME) in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure.

Truxima rituximab

Requests for Special Authorization are considered:

- in combination with methotrexate is indicated in adult patients to reduce signs and symptoms in adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more tumour necrosis factor (TNF) inhibitor therapies.

- in combination with glucocorticoids for the induction of remission in adult patients with severely active Granulomatosis with Polyangiitis (GPA, also known as Wegener's Granulomatosis) and Microscopic Polyangiitis (MPA).

Fasenra benralizumab

Requests for Special Authorization are considered for add-on maintenance treatment of adult patients with severe eosinophilic asthma.

Enstilar calcipotriol and betamethasone dipropionate

Requests for Special Authorization are considered for the topical treatment of psoriasis vulgaris in adults for up to 4 weeks.

Abilify aripiprazole

Requests for Special Authorization are considered for:

  • the treatment of schizophrenia in patients who have tried and failed therapy with Seroquel® or Risperdal® , or have a medical reason why Risperdal or Seroquel can't be used.
  • for the treatment of schizophrenia in adolescents 15 17 years of age.
  • for the acute treatment of manic or mixed episodes in bipolar I disorder as monotherapy in adolescent patients 13 - 17 years of age.
Abilify Maintena aripiprazole

Requests for Special Authorization are considered for:

- acute and maintenance treatment of schizophrenia in stabilized adult patients.
- for the maintenance monotherapy treatment of bipolar I disorder in adult patients.

Accolate zafirlukast

Requests for special authorization are considered for:

- the prophylaxis and chronic treatment of asthma in adult and pediatric patients 12 years of age and older, when the client has been treated with an optimal dose of inhaled steroids that does not control symptoms

- the prophylaxis and chronic treatment of asthma in adult and pediatric patients 12 years of age and older, when the client is unable to use inhaled corticosteroids.

Aclasta zoledronic acid

Requests for special authorization for Aclasta are considered for:

Osteoporosis in individuals who
meet Special Authorization criteria for reimbursement of alendronate and/or risedronate for the treatment of osteporosis
AND have at least one of the following:
-Intolerant to oral bisphosphonates
-Contraindication to oral bisphosphonates

Paget's disease in individuals who have
serum alkaline phosphatase (SAP) of at least 2 times the upper limit of the age-specific normal reference range
AND
symptomatic disease (bone pain, hearing loss, bone deformities, fractures, or arthritis)
AND
are at risk of complications from Paget's disease (i.e., osteoarthritis, heart failure, kidney stones, or broken bones)

Actemra tocilizumab

Requests for special authorization for Actemra are considered for:

Rheumatoid Arthritis:
- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:
- Diagnosis of moderate to severe rheumatoid arthritis AND:
The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:
- The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

Systemic Juvenile Idiopathic Arthritis:
· for the treatment of active systemic juvenile idiopathic arthritis in patients 2 years of age and older, who have responded inadequately to previous therapy with one or more non steroidal anti-inflammatory drugs (NSAIDs), systemic corticosteroids, and methotrexate

Polyarticular Juvenile Idiopathic Arthritis:
- for the treatment of signs and symptoms of active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older who have responded inadequately to previous therapy with DMARDs and systemic corticosteroids.

Giant Cell Arteritis (GCA) [SC formulation only]
- for the treatment of giant cell arteritis (GCA) in adult patients.

Actonel risendronate

Requests for special authorization for Actonel will be considered for:

- the treatment of osteoporosis in postmenopausal women and men who are deemed at high risk of fracture based on any one of the following:
-Prior fragility fracture after age 40, including asymptomatic vertebral fractures identified on X-rays
-Current use of oral corticosteroids (any dose)
-BMD report indicating high ten year fracture risk (defined as > 20%) who are deemed at moderate risk of fracture based on BMD report, with at least one of the following compelling reasons to warrant treatment:
-Lumbar spine T-score much lower than femoral neck T-score (at least a difference of one full standard deviation)
-Rapid bone density loss ( 4% in the past year)
-Men receiving androgen-deprivation therapy for prostate cancer
-Women receiving aromatase-inhibitor therapy for breast cancer
-Repeated corticosteroid use (oral or parenteral) in last two years, even if patient is not currently on corticosteroid.
-Recurrent falls (2 or more in the past year)
-treatment of Paget's disease of the bone in individuals who are symptomatic or with alkaline phosphatase level of at least two times the upper limit of normal

Adcetris brentuximab vedotin

Requests for special authorization are considered for:

- the treatment of patients with Hodgkin lymphoma (HL) after failure of autologous stem cell transplant (ASCT) or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates.

- the treatment of patients with systemic anaplastic large cell lymphoma (sALCL) after failure of at least one prior multi-agent chemotherapy regimen.

Adcirca tadalafil

Requests for Special Authorization are considered for
for clients who have a diagnosis of:
a) primary (idiopathic) pulmomary arterial hypertension, OR
b) pulmonary arterial hypertension associated with other disease in patients with WHO functional II or III symptoms who have not responded to conventional therapy.


Adempas riociguat

Requests for special authorization will be considered for:
- inoperable chronic thromboembolic pulmonary hypertension (CTEPH, WHO Group 4)
- persistent or recurrent CTEPH after surgical treatment
- pulmonary arterial hypertension (PAH, WHO Group 1), as monotherapy or in combination with endothelin receptor antagonists

Advagraf tacrolimus

Requests for special authorization are considered for:

- patients for the prophylaxis of organ rejection and for the treatment of refractory rejection in patients receiving liver or kidney transplants.

Advair Diskus, Advair Inhaler salmeterol and fluticasone Requests for special authorization will be considered for: - patients with reversible obstructive airway disease who are using optimum anti-inflammatory therapy (i.e., inhaled steroids) and still require short-acting bronchodilator more than twice daily - patients with severe COPD (chronic obstructive pulmonary disorder) with a reversible component, where symptoms have not responded to first-line therapy, e.g. ipratropium, salbutamol, inhaled steroids, tiotropium
Afinitor everolimus

Requests for special authorization will be considered for:

- the treatment of postmenopausal women with hormone receptor-positive, HER2- negative advanced breast cancer in combination with exemestane after recurrence or progression following treatment with letrozole or anastrozole.

- the treatment of patients with metastatic renal cell carcinoma (RCC) of clear cell morphology, after failure of initial treatment with either of the VEGF-receptor TKIs3 sunitinib or sorafenib.

- for the treatment of well- or moderately differentiated neuroendocrine tumours of pancreatic origin (PNET) in patients with unresectable, locally advanced or metastatic disease that has progressed within the last 12 months.

- for the treatment of unresectable, locally advanced or metastatic, welldifferentiated, non-functional neuroendocrine tumours (NET) of gastrointestinal or lung origin in adults with progressive disease.

Agrylin anagrelide

Requests for special authorization are considered for patients who have a diagnosis of: -chronic essential thrombocythemia,
-or thrombocythemia secondary to a myeloproliferative disorder.

Alertec modafinil

Requests for special authorization will be considered for clients who suffer from narcolepsy or obstructive sleep apnea/hypopnea syndrome (OSAHS. Requests for fatigue caused by other medical conditions will only be considered on an exceptional basis and must include diagnosis, other medications tried and response to treatment, expected duration of therapy, and any other information that will support reimbursement of the drug on an individual consideration basis.

Allerject epinephrine

Requests for special authorization are considered for:

- patients who have a documented allergy resulting in anaphylactic reactions.

Aloxi palonosetron hydrochloride

Requests for special authorization for Aloxi are considered for:

- patients receiving highly emetogenic or moderately emetogenic cancer chemotherapy

Amerge naratriptan

Requests for special authorization are considered for:

- patients who have a definite diagnoses of migraine AND have failed to respond to first-line abortive therapy (e.g. NSAIDs and standard analgesic therapy), unless contraindicated.

Amevive alefacept

Requests for Special Authorization are considered for patients diagnosed with chronic plaque psoriasis, and is being treated initially by a dermatologist, or in consultation with a dermatologist, or a specialist, such as Internal Medicine AND Patient has involvement in equal to or more than 10% body surface area. If the area is less than 10%, disabling psoriasis due to anatomic location (i.e., scalp, palmar, foot, or groin involvement) will allow the patient to qualify in the same manner as equal to or more than 10% AND Patient has failed systemic therapy with methotrexate. cyclosporine, or acitretin (Soriatane); AND Patient has failed photochemical therapy AND Patient is at least 16 years of age AND If this is a renewal, a 12 week interval has passed since completion of the last treatment course.

Andriol testosterone undecanoate

Requests for special authorization are considered for:

- testosterone replacement therapy in males with symptoms of testosterone deficiency (including impotence) and a documented low free testosterone level

Androderm testosterone

Requests for special authorization are considered for:

- testosterone replacement therapy in males with symptoms of testosterone deficiency (including impotence) and a documented low free testosterone level

Androgel testosterone

Requests for special authorization will be considered for replacement therapy in males associated with a deficiency or absence of endogenous testosterone. The deficiency of testosterone should be established by measurement of free testosterone levels on morning blood samples on at least two occasions.

Angeliq tablets Drospirenone/Estradiol-17ß

Requests for Special Authorization are considered for:
patients suffering from unacceptable adverse effects due to other estrogen therapy (e.g. estrogen-induced hypertension or migraine), or patients who have not had symptom relief with other hormone replacement therapy.

Anoro Ellipta Umeclidinium (Umeclidinium Bromide)

Requests for Special Authorization for Anoro Ellipta are considered for:
- the long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.

Anzemet dolasetron Requests for special authorization are considered for: - patients who suffer from nausea and vomiting associated with chemotherapy when Zofran (ondansetron) has failed - patients who suffer from nausea and vomiting associated with chemotherapy when patients cannot take Zofran (ondansetron)
Aptiom eslicarbazepine acetate

Requests for special authorization are considered for:

- Adjunctive therapy in the treatment of partial-onset seizures in patients with epilepsy who are not satisfactorily controlled with conventional therapy.

- Monotherapy in the management of partial-onset seizures in adult patients with epilepsy.

Aptivus tipranavir Request for special authorization of Aptivus will be considered for treatment of adult patients diagnosed with HIV-1 infection who are treatment experienced, and have HIV-1 strains resistant to multiple protease inhibitors (PIs). (Like a second-line therapy for drugs in the PI category). Aptivus is co-administered with ritonavir (which enhances the effect of Aptivus), and is NOT approved for use in HIV treatment-naïve patients.
Aranesp darbepoetin alfa

Requests for special authorization are considered for: a) clients suffering from anemia associated with chronic renal failure (CRF). b) the treatment of anemia in patients with nonmyeloid malignancies where anemia is due to the effect of concomitantly asministered chemotherapy. Requests for Aranesp treatment prior to an elective-surgical procedure will not be approved.

Arava leflunomide Requests for special authorization will be considered for: - treatment of rheumatoid arthritis after failure with a DMARD (disease modifying anti-rheumatic drug) such as methotrexate, gold, azathioprine, sulfasalazine, penicillamine, chloroquine, hydroxychloroquine or cyclosporine - treatment of rheumatoid arthritis when there is an intolerance to methotrexate or other DMARD, or methotrexate or other DMARD is contraindicated - treatment of rheumatoid arthritis when being added as adjunctive therapy to methotrexate, when there is disease progression with methotrexate
Aricept donepezil

Requests for special authorization is considered for:

- patients diagnosed with Alzheimer's disease or Lewy Body disease of mild to moderate severity.

For approval purposes, mild to moderate severity corresponds to a Mini Mental State Exam (MMSE) score of 10 to 26 inclusively.

In advanced Alzheimer's, there is no evidence that the use of this product is beneficial and therefore the product is not a benefit. Cases of early-onset dementia (< than 60 years of age) require assessment by a neurologist or geriatrician before this product can be considered.

Arixtra fondaparinux Requests for special authorization are considered for clients who require thromboprophylaxis related to orthopaedic surgery of the hip or knee.
Aromasin exemestane Requests for special authorization are considered for post menopausal women with advanced estrogen receptor-positive breast cancer.
Atripla efavirenz/ tenofovir disoproxil fumarate/emtricitabine

Requests for special authorization are considered for HIV- naïve infected patients and in treatment-experienced adult patients who have failed prior antiretroviral therapy.

Aubagio Teriflunomide Requests for special authorization for Aubagio are considered for adult patients with relapsing remitting multiple sclerosis (RRMS).
Avamys fluticasone furoate

Requests for special authorization are considered for the treatment of the symptoms of seasonal and perennial allergic rhinitis in patients 2 years of age and older.

Avandamet rosiglitazone maleate/metformin hydrochloride

Requests for special authorization for Avandia™ and Avanadamet™ are considered
For the management of type 2 diabetes in patients for whom all other oral medications, in monotherapy or in combination, do not result in adequate glycemic control or are inappropriate due to contraindications or intolerance.

Avandia rosiglitazone maleate

Requests for special authorization for Avandia™ and Avanadamet™ are considered
For the management of type 2 diabetes in patients for whom all other oral medications, in monotherapy or in combination, do not result in adequate glycemic control or are inappropriate due to contraindications or intolerance

Avodart dutasteride Requests for special authorization are considered for clients with a diagnosis of moderate symptomatic benign prostatic hyperplasia who are not candidates for immediate surgery.
Avonex interferon beta-1A

Requests for special authorization are considered for:

- Patients with a diagnosis of relapsing-remitting multiple sclerosis or RRMS that has progressed to SPMS. The patient must have suffered a minimum of two exacerbations in the previous two years and must be able to walk with or without a walking aid.

- Patlients presenting with a first isolated and well-defined neurologic event as consistent with MS and involving the optic nerve, spinal cord, brain stem or cerebellum. Patients must also have two or more clinically significant lesions of the brain that are at least 3mm in diameter on MRI scans and are characteristic of MS. Patients must also be able to walk with or without a walking aid

- For all requests the diagnosis must be made by a neurologist.

Axert almotriptan Requests for special authorization are considered for clients who have a definite diagnosis of migraine AND have failed to respond to first line abortive therapy (i.e. NSAIDs and standard analgesic therapy), unless contraindicated.
Axiron testosterone Requests for special authorization for Axiron are considered for: Testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone (hypogonadism).
Azilect rasagiline mesylate Requests for special authorization will be considered for treatment of the signs and symptoms of Parkinson's disease, when the patient has failed, cannot tolerate or is unable to take levodopa, bromocriptine, or as an adjunct to levodopa
Banzel rufinamide Requests for Special Authorization for Banzel are considered for: Adjunctive treatment of seizures associated with Lennox-Gastuat Syndrome in children over the age of 4 and adult patients
Baraclude entecavir

Requests for special authorization will be considered for treatment of chronic hepatitis B virus infection in adults with evidence of active viral replication and either evidence of persistent elevations in serum transferases (ALT or AST) or histologically active disease. Prescribed only by or in consultation with a hepatologist, infectious disease specialist, or gastroenterologist. These requests may include the following:
A. Patients who cannot tolerate lamivudine or for whom lamivudine is
contraindicated, OR
B. Patients with lamivudine-resistant chronic hepatitis B who
have failed on, or relapsed after lamivudine treatment;
have developed viral resistance to lamivudine, OR
C. Patients with severe liver disease who
have decompensated chronic hepatitis B;
have evidence of severe fibrosis or cirrhosis;
are pre- or post-liver transplantation. The recurrence of chronic hepatitis B after
liver transplantation results in increased risk for graft failure and death of patients.
have compensated chronic hepatitis B and are at risk of liver decompensation
(e.g., Chronic Hepatitis B flare, highly replicative HBV), OR
D. Patients with HBV/HIV co-infection who are not on antiviral agents but require HBV treatment only- (treatment should be undertaken in consultation with a hepatologist or infectious
disease specialist)

BCG Vaccine live bacillus calmette-guérin (BCG)

Requests for special authorization are considered for clients where vaccination is required because of repeated exposure to untreated or inadequately treated active tuberculosis in conditions where usual preventive measures are not possible or have been unsuccessful e.g. in drug resistance AND/OR the client is a health care worker where there is considerable risk of infection AND a registered and qualified professional will be involved in the administration of the vaccine.

Benlysta belimumab

Requests for special authorization will be considered for adult patients with moderate-severe autoantibody positive systemic lupus erythematosus (SLE) who have not responded to, have had intolerable toxicity, or a contraindication to corticosteroids and hydroxychloroquine.

Betaseron interferon beta-1B

Requests for special authorization are considered for:

- Patients with a diagnosis of relapsing-remitting multiple sclerosis or RRMS that has progressed to SPMS. The patient must have suffered a minimum of two exacerbations in the previous two years and must be able to walk with or without a walking aid.

- Patients presenting with a first isolated and well-defined neurologic event as consistent with MS and involving the optic nerve, spinal cord, brain stem or cerebellum. Patients must also have two or more clinically significant lesions of the brain that are at least 3mm in diameter on MRI scans and are characteristic of MS. Patients must also be able to walk with or without a walking aid

-For all requests the diagnosis must be made by a neurologist.

Bonefos clodronate Requests for special authorization will be considered for: - management of hypercalcemia of malignancy - as an adjunct in the management of osteolysis resulting from bone metastases of malignant tumors
Bosulif bosutinib

Requests for special authorization are considered for for the treatment of chronic, accelerated, or blast phase Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML) in adult patients with resistance or intolerance to prior TKI therapy.

Botox onabotulinumtoxinA

Requests for special authorization are considered for:

- patients 12 years of age and older with strabismus or blepharospasm where treatment is currently being provided by an ophthalmologist or internist experienced in the use of botulinum toxin for the above indications.

- adult patients with 7th nerve disorders, cervical dystonia (spasmodic torticollis) or achalasia where treatment is currently being provided by an internist experienced in the use of botulinum toxin for this indication

- patients 2 years of age and older with dynamic equinus foot deformity due to spasticity in pediatric cerebral palsy

- management of hyperhidrosis of the axilla in adult patients who have failed topical antiperspirants and anticholinergic medication or iontophoresis, and treatment is being provided by a dermatologist.

- for the management of focal spasticity, including the treatment of upper limb spasticity associated with stroke in adults

- for the symptomatic treatment of lower limb spasticity associated with stroke in adults

- for prophylaxis of headaches in adult patients with chronic migraine (≥ 15 migraines per month with headaches lasting 4 hours per day or longer) in which treatment with first-line therapy has failed or is inappropriate.

Brenzys etanercept

Requests for special authorization are considered for:

- use in combination therapy with methotrexate for the reduction in signs and symptoms of moderately to severely active rheumatoid arthritis in adult patients, when the following criteria has been met:

(a) Diagnosis of moderate to severe rheumatoid arthritis AND:

The medication must be prescribed by, or in consultation with, a rheumatologist, or a specialist in the field of RA AND:

(b) The patient must have tried and failed a minimum 12 week trial of methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of non-biologic DMARDs are impossible, 3 consecutive non-biologic DMARDs would be acceptable.

- patients with ankylosing spondylitis who have failed a six-month trial of two different non-steroidal anti-inflammatory drugs (NSAIDS).


Breo Ellipta fluticasone furoate/vilanterol (as trifenatate)

Requests for special authorization will be considered for:

- Patients with moderate to severe COPD (chronic obstructive pulmonary disease) where symptoms have not responded to short-acting bronchodilators and have failed treatment with a long acting muscarinic antagonist (LAMA) (e.g. Spiriva or Seebri or Tudorza or Incruse).

- For the once-daily maintenance treatment of asthma in patients aged 18 years and older with reversible obstructive airways disease.

Brilinta ticagrelor

Requests for Special Authorization are considered for:

Brilinta, co-administered with low-dose acetylsalicylic acid (ASA: 75-150 mg), for the secondary prevention of atherothrombotic events in:
- Patients with Acute Coronary Syndromes (ACS)
- Patients with a history of myocardial infarction (MI occurred at least one year ago) and a high risk of developing an atherothrombotic event

Brivlera brivaracetam

Requests for special authorization will be considered as adjunctive therapy in the management of partial-onset seizures in patients 4 years of age and older with epilepsy who are not satisfactorily controlled with conventional therapy.

Burinex bumetanide Requests for special authorization are considered for: - patients with congestive heart failure, renal or hepatic failure who are refractory to OR unable to tolerate furosemide
Byetta exenatide Requests for special authorization for Byetta™ are considered for: Adult patients with inadequately controlled type 2 diabetes mellitus, who have had a trial of both metformin and at least one sulfonylurea
Calcimar calcitonin

Requests for special authorization are considered:

- for patients who have Paget's disease of the bone and have severe pain or evidence of active osteolytic lesions

- to treat hypercalcemia in patients who have cancer, where other measures have been tried and failed to control the hypercalcemia

- to treat pain from recent osteoporotic fracture which can not be relieved by analgesics

Caltine calcitonin

Requests for special authorization are considered:

- for patients who have Paget's disease of the bone and have severe pain or evidence of active osteolytic lesions

- to treat hypercalcemia in clients who have cancer, where other measures have been tried and failed to control the hypercalcemia

- to treat pain from recent osteoporotic fracture which can not be relieved by analgesics

Cambia diclofenac powder for solution

Requests for special authorization are considered for the acute treatment of migraine attacks with or without aura in adults 18 years and older.

Campral acamprosate calcium

Requests for special authorization are considered for:

- patients who are presently abstaining from alcohol use and are enrolled in a comprehensive treatment program

Caprelsa vandetanib

Requests for Special Authorization for Caprelsa are considered for the:
treatment of symptomatic or progressive medullary thyroid cancer in adult patients with unresectable locally advanced or metastatic disease

Carnitor levocarnitine Requests for special authorization are considered for: - patients diagnosed with primary carnitine deficiency or inborn error of metabolism leading to secondary carnitine deficiency
Casodex bicalutamide Requests for special authorization are considered for: - men with Stage 2 metastatic prostate cancer who are receiving an LHRH analogue (Zoladex, Lupron, Suprefact) - men with Stage 2 metastatic prostate cancer who have undergone surgical castration
Cayston powder for inhalation aztreonam

Requests for special authorization are considered for:

- patients with a diagnosis of cystic fibrosis (CF) who have chronic pulmonary Pseudomonas aeruginosa infections and who have tried and failed or do not tolerate treatment with TOBI®

Cellcept mycophenolate mofetil Requests for special authorization are considered for: - prophylaxis of organ rejection in patients receiving allogenic renal, cardiac or hepatic transplants
Celsentri maraviroc

Requests for special authorization are considered for clients who meet the following criteria:

to be used in combination with other antiretroviral agents in treatment experienced adult patients who are infected with CCR5-tropic HIV-1 virus and who have documented resistance to at least one agent from each of the three major classes of antiretroviral agents [nucleoside reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors (PI)]

Vizimpro dacomitinib

Requests for Special Authorization are considered for the first-line treatment of adult patients with unresectable locally advanced or metastatic non-small cell lung cancer (NSCLC) with confirmed epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 L858R substitution mutations.

Drug Name Chemical Name Criteria Comments