Health and Community Services
Exemestane (Aromasin 25mg & generics)
• First-line therapy in postmenopausal women with advanced breast cancer.
(Indefinite coverage)
• For the adjuvant treatment of postmenopausal women with hormone receptor-positive invasive early breast cancer. (5 years)
• The extended adjuvant treatment of hormone receptor-positive invasive early breast cancer in postmenopausal women who have received approximately 5 years of prior standard adjuvant tamoxifen therapy. (5 years)
• For the treatment of hormone-receptor positive, HER2 negative advanced breast cancer, in postmenopausal women with ECOG performance status ≤ 2 after recurrence or progression following a non-steroidal aromatase inhibitor (letrozole or anastrozole) in combination with everolimus.
Please visit the link below if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf
Updated April 2014
Health and Community Services Ezetimibe (Ezetrol 10mg tablet)
• Co-administration with statins for patients not reaching treatment goals on maximum tolerated doses of statins alone.
• For the treatment of hypercholesterolemia, as monotherapy, in
patients who are intolerant to fibrates (where appropriate) and statins.
Please visit the link below if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf
Updated July 2010
Health and Community Services
Febuxostat (Uloric 80mg tablet)
For the treatment of patients with symptomatic gout who have documented Drug-induced Hypersensitivity Syndrome* to allopurinol.
*is characterized by a major skin manifestation, fever, multi-organ involvement, lymphadenopathy, and hematological abnormalities (eosinophilia, atypical lymphocytes). The onset of symptoms usually occurs two to eight weeks after therapy initiation of the causative drug. At least three of the above listed characteristics should be present including the involvement of at least one extracutaneous organ system.
Please visit the following link if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/nlpdp/criteria.pdf
Updated August 2011
Health and Community Services
Fentanyl (Duragesic 12.5ug, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr transdermal system and generics)
For the treatment of malignant or chronic non-malignant pain* in adult patients who were previously receiving continuous opioid administration (long-acting opioids) or who are unable to take oral therapy.
* Please note: in order to assess requests for coverage in the treatment of non-malignant pain, the Department will require the following information:
Results of any xrays/CT scans/MRIs.
Information relating to any consultations completed and their recommendations (ie., surgical, orthopedic and/or physiotherapy consultations).
Surgical history.
Current analgesic uses, current dosage, and assessment of current level of pain control.
Use of antidepressants and/or anticonvulsants if pain is neuropathic.
Any other information you feel is pertinent to the request.
Please visit the link below if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf
Updated July 2010
Health and Community Services
Feroterol/ipratropium nebules (Duovent nebules)
Failure or intolerance to ipratropium/salbutamol nebules (Combivent).
Please visit the link below if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf
Updated July 2010
Health and Community Services
FESOTERODINE FUMARATE (TOVIAZ 4 MG, 8MG TABLET)
For the treatment of overactive bladder (not stress incontinence) after a reasonable trial, titrated, and of appropriate length* of oxybutynin IR is not tolerated.
*an appropriate trial is considered to be of 12 weeks duration.
Please note that coverage may be considered WITHOUT a Special Authorization request as long as the beneficiary’s medication history in the NLPDP database shows the prior use of a benefit regular release oxybutynin or any long-acting urinary agent (Detrol LA, Uromax, Trosec, Ditropan XL, Vesicare, Toviaz) DIN within the past year.
The claimed dosage must not exceed the dose limitation (see our Benefit Listing at:
www.health.gov.nl.ca/health/prescription/covered_openbenefitdrugs.html for details).
If there is no history of a previous benefit regular release oxybutynin, or any long-acting urinary agent (Detrol LA, Uromax, Trosec, Ditropan XL, Vesicare, Toviaz) claim, the normal Special Authorization Process will be required.
Please visit the following link if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf
Updated April 2013
Health and Community Services Filgrastim (Neupogen 300ug, 480ug)
Coverage is considered for patients receiving moderate to severely myelosuppressive chemotherapy:
Primary prophylaxis:
• When given as an integral part of an aggressive chemotherapy regimen with curative intent in order to maintain dose intensity in compressed interval or dose dense treatment, as specified in a chemotherapy protocol.
o Chemotherapy protocol must be supplied with request
• For use in patients ≥65 years who are receiving CHOP.
Secondary prophylaxis:
• For use in patients receiving myelosuppressive chemotherapy who have experienced an episode of febrile neutropenia, neutropenic sepsis or profound neutropenia in a previous cycle of chemotherapy; OR
• For use in patients who have experienced a dose reduction or treatment delay longer than one week due to neutropenia.
Dosing for chemotherapy support:
• The manufacturer recommends an initial dose of 5ug/kg/day.
• Patients ≤ 70kg use 1ml vial (300ug).
• Patients > 70kg use 1.6ml vial (480ug).
Please visit the link below if you require our standard special authorization form:
http://www.health.gov.nl.ca/health/prescription/standard_specauth_form.pdf