SC CHEDU ULEOF FPHAR

Transcription

SC
CHEDU
ULEOFFPHAR
RMACE
EUTICA
AL
BEENEFIT
TS
SUMMARYOFC
CHANGE
ES
EFFFECTIVE1Nove
ember2014
2
PHARMACEUTICALBENEFITS
ThesechangestotheScheduleofPharmaceuticalBenefitsareeffectivefrom1November2014.TheScheduleisupdatedonthefirstdayof
eachmonthandisavailableontheInternetatwww.pbs.gov.au.
Fees,PatientContributionsandSafetyNetThresholds
Thefollowingfees,patientcontributionsandsafetynetthresholdsapplyasat1November2014andareincluded,whereapplicable,inprices
publishedintheSchedule—
DispensingFees:
ReadyͲprepared
$6.76
Dangerousdrugfee
$2.71
ExtemporaneouslyͲprepared
$8.80
Allowableadditionalpatientcharge*
$4.19
AdditionalFees(forsafetynetprices):
ReadyͲprepared
$1.15
ExtemporaneouslyͲprepared
$1.50
PatientCoͲpayments:
General
$36.90
Concessional
$6.00
SafetyNetThresholds:
General
$1421.20
Concessional
$360.00
SafetyNetCardIssueFee:
$9.26
*The allowable additional patient charge is a discretionary charge to general patients if a pharmaceutical item has a dispensed price for maximum quantity less than the
general patient co-payment. The pharmacist may charge general patients the allowable additional fee but the fee cannot take the cost of the prescription above the general
patient co-payment for the medicine. This fee does not count towards the Safety Net threshold.
3
SUMMARYOFCHANGES
Additions
Addition–Item
10161T
AminoAcidFormulaWithoutValine,LeucineAndIsoleucine,aminoacidformulawithoutvaline,leucineandisoleucinecontaining
5gofproteinequivalentoralliquid:powderfor,30x6gsachets(MSUDamino5)
10153J
GlucoseIndicatorBlood,glucoseindicatorbloodstrip:diagnostic,100(Contournext)
10164Y GlucoseIndicatorBlood,glucoseindicatorbloodstrip:diagnostic,100(Contournext)
10156M Indacaterol+Glycopyrronium,indacaterol110microgram+glycopyrronium50micrograminhalation:powderfor,30capsules
(ultibrobreezhaler110/50)
10157N Perampanel,perampanel2mgtablet,7(Fycompa)
10162W Perampanel,perampanel4mgtablets,28(Fycompa)
10163X Perampanel,perampanel6mgtablet,28(Fycompa)
10160R Perampanel,perampanel8mgtablet,28(Fycompa)
10151G Perampanel,perampanel10mgtablet,28(Fycompa)
10159Q Perampanel,perampanel12mgtablet,28(Fycompa)
10155L TriglyceridesMediumChainFormula,triglyceridesmediumchainformulaoralliquid:powderfor,400g(Lipistart)
10152H TriglyceridesMediumChainFormula,triglyceridesmediumchainformulaoralliquid:powderfor,400g(Monogen)
10154K TriglyceridesMediumChainFormula,triglyceridesmediumchainformulaoralliquid:powderfor,400g(PeptamenJunior)
10149E Vitamins,MineralsAndTraceElementsWithCarbohydrate,vitamins,mineralsandtraceelementswithcarbohydrateoralliquid:
powderfor,30x6gsachets(FruitiVits)
Addition–Brand
9049G
9049G
9049G
9049G
9050H
9050H
9050H
9050H
9051J
9051J
9051J
9051J
9052K
9052K
9052K
9052K
9053L
9053L
9053L
9053L
9054M
9054M
9054M
9054M
9055N
9055N
APOͲAmlodipine/Atorvastatin5/10,TX–Amlodipine+Atorvastatin,amlodipine5mg+atorvastatin10mgtablet,30
BloomstheChemistAmlodipine/Atorvastatin5/10,IB–Amlodipine+Atorvastatin,amlodipine5mg+atorvastatin10mgtablet,
30
ChemmartAmlodipine/Atorvastatin5/10,CH–Amlodipine+Atorvastatin,amlodipine5mg+atorvastatin10mgtablet,30
TerryWhiteChemistsAmlodipine/Atorvastatin5/10,TW–Amlodipine+Atorvastatin,amlodipine5mg+atorvastatin10mg
tablet,30
30
tablet,30
30
tablet,30
30
tablet,30
BloomstheChemistAmlodipine/Atorvastatin10/10,IB–Amlodipine+Atorvastatin,amlodipine10mg+atorvastatin10mg
tablet,30
tablet,30
tablet,30
tablet,30
4
9055N
9055N
9056P
9056P
9056P
9056P
8702B
5076E
5364H
1299J
5361E
5077F
5365J
1300K
5362F
2532G
8495D
2479L
8496E
1370D
1368B
1369C
8532C
8532C
8532C
8246B
8248D
3439B
5151D
1207M
1324Q
1325R
1913Q
8449Q
1978D
1977C
5261X
8016X
5260W
1760P
2236Q
8836C
2237R
8837D
8266C
tablet,30
tablet,30
tablet,30
tablet,30
CitalopramActavis,UA–Citalopram,citalopram10mgtablet,28
DiclofenacAN,EA–Diclofenac,diclofenacsodium25mgtablet:enteric,50tablets
DiclofenacAN,EA–Diclofenac,diclofenacsodium25mgtablet:enteric,50tablets(PalliativeCare)
AridonAPN5,FM–Donepezil,donepezilhydrochloride5mgtablet,28
EnalaprilAN,EA–Enalapril,enalaprilmaleate5mgtablet,30
APOͲIndapamideSR,TX–Indapamide,indapamidehemihydrate1.5mgtablet:modifiedrelease,90tablets
ChemmartIndapamideSR,CH–Indapamide,indapamidehemihydrate1.5mgtablet:modifiedrelease,90tablets
TerryWhiteChemistsIndapamideSR,TW–Indapamide,indapamidehemihydrate1.5mgtablet:modifiedrelease,90tablets
IrbesartanActavis75,UA–Irbesartan,irbesartan75mgtablet,30
IrbesartanActavis300,UA–Irbesartan,irbesartan300mgtablet,30
DiaforminXR1000,AF–Metformin,metforminhydrochloride1gtablet:modifiedrelease,60tablets
MetoclopramideAN,EA–Metoclopramide,metoclopramidehydrochloride10mgtablet,25
MetoclopramideAN,EA–Metoclopramide,metoclopramidehydrochloride10mgtablet,25
MetoprololAN,EA–MetoprololTartrate,METOPROLOLTARTRATETablet50mg,100
MetoprololAN,EA–MetoprololTartrate,METOPROLOLTARTRATETablet100mg,60
Momasone,QA–Mometasone,mometasonefuroate0.1%(1mg/g)cream,15g
PerindoprilCombiActavis4/1.25,GN–Perindopril+Indapamide,perindoprilerbumine4mg+indapamidehemihydrate1.25mg
tablet,30
APOͲRanitidine,TX–Ranitidine,ranitidine150mgtablet,60
APOͲRanitidine,TX–Ranitidine,ranitidine300mgtablet,30
RoxithromycinAN,EA–Roxithromycin,roxithromycin300mgtablet,5
SertralineAN,EA–Sertraline,sertraline50mgtablet,30
APOͲZolmitriptan,TX–Zolmitriptan,zolmitriptan2.5mgtablet,2
Addition–EquivalenceIndicator
8532C
3439B
NatrilixSR,SE–Indapamide,indapamidehemihydrate1.5mgtablet:modifiedrelease,90tablets
DiabexXR1000,AL–Metformin,metforminhydrochloride1gtablet:modifiedrelease,60tablets
Deletions
Deletion–Item
2776D
Ethinyloestradiol+Norethisterone,ethinyloestradiol35microgram+norethisterone500microgramtablet[48](&)
ethinyloestradiol35microgram+norethisterone1mgtablet[36](&)inertsubstancetablet[28],112[4x28](Improvil28Day)
Deletion–Brand
2729P
2729P
2729P
ChemmartBaclofen,CH–Baclofen,baclofen10mgtablet,100
GenRxBaclofen,GX–Baclofen,baclofen10mgtablet,100
TerryWhiteChemistsBaclofen,TW–Baclofen,baclofen10mgtablet,100
5
2730Q
2730Q
2460L
2460L
5046N
5046N
2461M
2461M
5047P
5047P
1335G
1335G
1335G
1473M
1474N
8101J
1542E
8238N
3064G
5388N
5387M
2395C
ChemmartBaclofen,CH–Baclofen,baclofen25mgtablet,100
GenRxBaclofen,GX–Baclofen,baclofen25mgtablet,100
ChemmartCefaclor,CH–Cefaclor,cefaclor125mg/5mLoralliquid:powderfor,100mL
TerryWhiteChemistsCefaclor,TW–Cefaclor,cefaclor125mg/5mLoralliquid:powderfor,100mL
ChemmartDiltiazem,CH–Diltiazem,diltiazemhydrochloride60mgtablet,90
GenRxDiltiazem,GX–Diltiazem,diltiazemhydrochloride60mgtablet,90
TerryWhiteChemistsDiltiazem,TW–Diltiazem,diltiazemhydrochloride60mgtablet,90
Diflucan,PF–Fluconazole,fluconazole100mg/50mLinjection,1x50mLvial
Diflucan,PF–Fluconazole,fluconazole200mg/100mLinjection,1x100mLvial
Extavia,NV–InterferonBetaͲ1b,interferonbetaͲ1b8millioninternationalunits(250microgram)injection[15x250microgram
vials](&)inertsubstancediluent[15x1.2mLsyringes],1pack
Ipravent,PF–Ipratropium,ipratropiumbromide250microgram/mLinhalation:solution,30x1mLampoules
Ipravent,PF–Ipratropium,ipratropiumbromide500microgram/mLinhalation:solution,30x1mLampoules
GenRxLactulose,GX–Lactulose,LACTULOSEMixture3.34gper5mL,500mL,1
GenRxLactulose,GX–Lactulose,LACTULOSEMixture3.34gper5mL,500mL,1(PalliativeCare)
GenRxLactulose,GX–Lactulose,LACTULOSEMixture3.34gper5mL,500mL,1(PalliativeCare)
PfizerAustraliaPtyLtd,PF–Methotrexate,methotrexate50mg/2mLinjection,5x2mLvials
Deletion–Restriction
1938B
8478F
TriglyceridesMediumChainFormula,triglyceridesmediumchainformulaoralliquid:powderfor,400g(Lipistart)
TriglyceridesMediumChainFormula,triglyceridesmediumchainformulaoralliquid:powderfor,400g(Monogen)
Deletion–Note
2698B
Abiraterone,abirateroneacetate250mgtablet,120(Zytiga)
Deletion–EquivalenceIndicator
8101J
Betaferon,BN–InterferonBetaͲ1b,interferonbetaͲ1b8millioninternationalunits(250microgram)injection[15x250
microgramvials](&)inertsubstancediluent[15x1.2mLsyringes],1pack
Alterations
Alteration–BrandName
From:
2687K
To:
2687K
Imazam,ER–Azathioprine,azathioprine50mgtablet,100
Imazan,ER–Azathioprine,azathioprine50mgtablet,100
AdvanceNotices
AdvanceNotices–DeletionofItem
ThefollowingitemswillbedeletedfromtheScheduleofPharmaceuticalBenefitson1January2015:
5213J
SodiumChloride,sodiumchloride3%(30g/1000mL)injection,1x1000mLbag(BaxterHealthcarePtyLtd)
2260Y
SodiumChloride,sodiumchloride3%(30g/1000mL)injection,1x1000mLbag(BaxterHealthcarePtyLtd)
5215L
SodiumChloride+Glucose,sodiumchloride0.225%(1.125g/500mL)+glucose3.75%(18.75g/500mL)injection,1x500mLbag
(BaxterHealthcarePtyLtd)
2279Y
SodiumChloride+Glucose,sodiumchloride0.225%(1.125g/500mL)+glucose3.75%(18.75g/500mL)injection,1x500mLbag
(BaxterHealthcarePtyLtd)
5216M SodiumChloride+Glucose,sodiumchloride0.45%(2.25g/500mL)+glucose2.5%(12.5g/500mL)injection,1x500mLbag(Baxter
HealthcarePtyLtd)
2278X
SodiumChloride+Glucose,sodiumchloride0.45%(2.25g/500mL)+glucose2.5%(12.5g/500mL)injection,1x500mLbag(Baxter
HealthcarePtyLtd)
2266G
SodiumChloride+PotassiumChloride+CalciumChlorideDihydrate,sodiumchloride8.6g/1000mL+potassiumchloride300
mg/1000mL+calciumchloridedihydrate330mg/1000mLinjection,1x1000mLbag(BaxterHealthcarePtyLtd)
ThefollowingitemswillbedeletedfromtheScheduleofPharmaceuticalBenefitson1February2015:
2095G
Ticlopidine,ticlopidinehydrochloride250mgtablet,60(Tilodene)
6
SECTION100–HIGHLYSPECIALISEDDRUGSPROGRAM
AdvanceNotices
AdvanceNotices–DeletionofItem
ThefollowingitemwillbedeletedfromtheScheduleofPharmaceuticalBenefitson1December2014:
9745X
Omalizumab,omalizumab150mginjection[1x150mgvial](&)inertsubstancediluent[1x1.2mLampoule],1pack(Xolair)(Public)
9746Y
Omalizumab,omalizumab150mginjection[1x150mgvial](&)inertsubstancediluent[1x1.2mLampoule],1pack
(Xolair)(Private)
SECTION100–BOTULINUMTOXINPROGRAM
Additions
Addition–Restriction
6103F
BotulinumToxinTypeA,botulinumtoxintypeA100unitsinjection,1x100unitsvial(Botox)
REPATRIATIONPHARMACEUTICALBENEFITS
Deletions
Deletion–Brand
4011D
TerbinafineͲDP,GN–Terbinafine,terbinafine250mgtablet,42
7
GENERALPHARMACEUTICALBENEFITS
Code
Name,Restriction,MannerofAdministration
andForm
Max.Qty
(Packs)
No.of
Rpts
Premium
$
Dispensed
Pricefor
Max.Qty
$
Maximum
Recordable
Valuefor
SafetyNet
$
BrandNameand
Manufacturer
AMINOACIDFORMULAWITHOUTVALINE,LEUCINEANDISOLEUCINE
Restrictedbenefit
Maplesyrupurinedisease
10161T
NP
aminoacidformulawithoutvaline,
leucineandisoleucinecontaining5g
ofproteinequivalentoralliquid:
powderfor,30x6gsachets
12
5
..
*3098.68
36.90
MSUDamino5
VF
‡1
5
..
53.50
36.90
Contournext
IK
GLUCOSEINDICATORBLOOD
10153J
NP
glucoseindicatorbloodstrip:
diagnostic,100
GLUCOSEINDICATORBLOOD
Restrictedbenefit
Bloodglucosemonitoring
Clinicalcriteria:
PatientmustbereceivingtreatmentunderaGPManagementPlanorTeamCareArrangementswhereMedicarebenefitswereorarepayablefor
thepreparationofthePlanorcoordinationoftheArrangements.
Note
Noincreaseinthemaximumquantityornumberofunitsmaybeauthorised.
Note
Noincreaseinthemaximumnumberofrepeatsmaybeauthorised.
10164Y
glucoseindicatorbloodstrip:
diagnostic,100
‡1
11
..
53.50
36.90
Contournext
IK
INDACATEROL+GLYCOPYRRONIUM
Authorityrequired(STREAMLINED)
4655
Chronicobstructivepulmonarydisease(COPD)
Clinicalcriteria:
PatientmusthavebeenstabilisedonacombinationofalongactingmuscarinicantagonistandlongactingbetaͲ2agonist.
Note
ThetreatmentmustnotbeusedincombinationwithanICS/LABA,orLAMAorLABAmonotherapy.
Note
ALAMAincludestiotropium,glycopyrronium,aclidiniumorumeclidinium.
Note
ALABAincludesindacaterol,salmeteroloreformoterol.
Note
ThisproductisnotPBSͲsubsidisedforthetreatmentofasthma.
Note
ThisproductisnotindicatedfortheinitiationofbronchodilatortherapyinCOPD.
10156M
NP
indacaterol110microgram+
glycopyrronium50microgram
inhalation:powderfor,30capsules
1
5
..
PERAMPANEL
4656
Intractablepartialepilepticseizures
TreatmentPhase:Initial
96.38
36.90
ultibrobreezhaler
110/50
NV
8
Code
andForm
Max.Qty
(Packs)
No.of
Rpts
Premium
$
Dispensed
Pricefor
Max.Qty
$
Maximum
Recordable
Valuefor
SafetyNet
$
BrandNameand
Manufacturer
Clinicalcriteria:
ThetreatmentmustbeincombinationwithtwoormoreantiͲepilepticdrugswhichincludesonesecondͲlineadjunctiveagent,
AND
TheconditionmusthavefailedtobecontrolledsatisfactorilybyotherantiͲepilepticdrugs,whichincludesatleastonefirstͲlineantiͲepilepticagent
andatleasttwosecondͲlineadjunctiveantiͲepilepticagents.
Treatmentcriteria:
Mustbetreatedbyaneurologist.
10157N
perampanel2mgtablet,7
2
1
..
*52.64
36.90
Fycompa
EI
PERAMPANEL
4658
Intractablepartialepilepticseizures
TreatmentPhase:Continuing
Clinicalcriteria:
Patientmusthavepreviouslybeenissuedwithanauthorityprescriptionforthisdrug.
Note
ContinuingTherapyOnly:
Forprescribingbynursepractitionersascontinuingtherapyonly,wherethetreatmentof,andprescribingofmedicinefor,apatienthasbeen
initiatedbyamedicalpractitioner.FurtherinformationcanbefoundintheExplanatoryNotesforNursePractitioners.
10162W
NP
10163X
NP
10160R
NP
10151G
NP
10159Q
NP
perampanel4mgtablets,28
1
5
..
188.80
36.90
Fycompa
EI
1
5
..
273.00
36.90
Fycompa
EI
1
5
..
355.72
36.90
Fycompa
EI
1
5
..
355.72
36.90
Fycompa
EI
1
5
..
355.72
36.90
Fycompa
EI
TRIGLYCERIDESMEDIUMCHAINFORMULA
Restrictedbenefit
Dietarymanagementofconditionsrequiringasourceofmediumchaintriglycerides
Clinicalcriteria:
Patientmusthavefatmalabsorptionduetoliverdisease;OR
Patientmusthavefatmalabsorptionduetoshortgutsyndrome;OR
Patientmusthavefatmalabsorptionduetocysticfibrosis;OR
Patientmusthavefatmalabsorptionduetogastrointestinaldisorders.
Note
Note
Note
Notindicatedforthetreatmentofintractablechildhoodepilepsyorcerebrospinalfluidglucosetransporterdefectrequiringaketogenicdiet.
10155L
NP
10152H
NP
10154K
NP
triglyceridesmediumchainformulaoral
liquid:powderfor,400g
8
5
..
*443.16
36.90
Lipistart
VF
8
5
..
*421.64
36.90
Monogen
SB
8
5
..
*411.80
36.90
PeptamenJunior
NT
TRIGLYCERIDESMEDIUMCHAINFORMULA
Restrictedbenefit
Hyperlipoproteinaemiatype1
Restrictedbenefit
Longchainfattyacidoxidationdisorders
Restrictedbenefit
9
Code
andForm
Max.Qty
(Packs)
No.of
Rpts
Premium
$
Dispensed
Pricefor
Max.Qty
$
Maximum
Recordable
Valuefor
SafetyNet
$
BrandNameand
Manufacturer
Chylousascites
Restrictedbenefit
Chylothorax
Note
Note
Note
Notindicatedforthetreatmentofintractablechildhoodepilepsyorcerebrospinalfluidglucosetransporterdefectrequiringaketogenicdiet.
1938B
NP
8478F
NP
8
5
..
*443.16
36.90
Lipistart
VF
8
5
..
*421.64
36.90
Monogen
SB
VITAMINS,MINERALSANDTRACEELEMENTSWITHCARBOHYDRATE
Authorityrequired
Dietarymanagementofconditionsrequiringahighlyrestrictivetherapeuticdiet
Clinicalcriteria:
Patientmusthaveinsufficientvitaminandmineralintakeduetoaspecificdiagnosisrequiringahighlyrestrictivetherapeuticdiet,
AND
Patientmustbeunabletoadequatelymeetvitamin,mineralandtraceelementneedswithotherproprietaryvitaminandmineralpreparations.
Populationcriteria:
Patientmustbeaged3yearsorolder.
Note
FruitiVitsmustonlybeusedunderstrictsupervisionofadietitianandapaediatrician.
10149E
NP
vitamins,mineralsandtraceelements
withcarbohydrateoralliquid:powder
for,30x6gsachets
1
5
..
299.25
36.90
FruitiVits
VF
10
SECTION100(BOTULINUMTOXINPROGRAM)
Code
Max.Qty
(Packs)
Name,Restriction,MannerofAdministrationandForm
Priceex
manufacturer
$
BrandNameand
Manufacturer
BOTULINUMTOXINTYPEA
Criteriaforavailability
Blepharospasmorhemifacialspasm
Populationcriteria:
Note
ArrangementstoprescribethisitemshouldbemadebymedicalpractitionerswiththeDepartmentofHumanServices,contacttelephone
number1800700270.
Note
TheunitsusedtoexpressthepotencyofbotulinumtoxinpreparationscurrentlyavailableforPBSsubsidyarenotequivalent.
Dynamicequinusfootdeformity
Clinicalcriteria:
Theconditionmustbeduetospasticity,
AND
Patientmustbeanambulantcerebralpalsypatient.
Populationcriteria:
Patientmustbeagedfrom2to17yearsinclusive.
Note
number1800700270.
Note
Dynamicequinusfootdeformity
Clinicalcriteria:
Theconditionmustbeduetospasticity,
AND
Patientmustbeanambulantcerebralpalsypatient,
AND
PatientmusthavecommencedonPBSͲsubsidisedtreatmentwithbotulinumtoxintypeApurifiedneurotoxincomplexasapaediatricpatient.
Populationcriteria:
Note
number1800700270.
Note
Spasmodictorticollis
Clinicalcriteria:
Thetreatmentmustbeasmonotherapy;OR
Thetreatmentmustbeasadjunctivetherapytocurrentstandardcare.
Note
number1800700270.
Note
Moderatetoseverespasticityoftheupperlimb
Clinicalcriteria:
Patientmusthavecerebralpalsy.
Populationcriteria:
Patientmustbeagedfrom2to17yearsinclusive.
Note
11
Code
Max.Qty
(Packs)
Priceex
manufacturer
$
BrandNameand
Manufacturer
number1800700270.
Note
Moderatetoseverespasticityoftheupperlimb
Clinicalcriteria:
Patientmusthavecerebralpalsy,
AND
PatientmusthavecommencedonPBSͲsubsidisedtreatmentwithbotulinumtoxintypeApurifiedneurotoxincomplexasapaediatricpatient.
Populationcriteria:
Note
number1800700270.
Note
ContacttheDepartmentofHumanServicesbeforecommencingPBSͲsubsidisedtreatmentincerebralpalsypatientswhohavebeentreatedfor
moderatetoseverespasticityoftheupperlimbwithnonͲPBSͲsubsidisedbotulinumtoxinpriortotheageof18.
Note
Moderatetoseverespasticityoftheupperlimbfollowingastroke
Clinicalcriteria:
Thetreatmentmustbeusedassecondlinetherapywhenstandardmanagementhasfailed(e.g.physiotherapyand/ororalspasticityagents)oras
anadjuncttophysicaltherapy.
Populationcriteria:
Patientmustbeanadult.
ModeratetoseverespasticityisdefinedasMASgreaterthanorequalto3usingmodifiedAshworthscale.
Maximumnumberoftreatmentstobeauthorisedis4(totalBotoxandDysport)perupperlimbperlifetime.Treatmentshouldnotbeinitiated
until3monthspostͲstrokeinpatientswhodonothaveestablishedseverecontracture.Treatmentshouldbediscontinuedifthepatientdoesnot
respond(decreaseofMASgreaterthan1inatleastonejoint)aftertwotreatments.
Thedateofthestrokemustbeprovided.
Contraindicationstotreatmentincludeestablishedseverecontractureandknownsensitivitytobotulinumtoxin.
Note
number1800700270.
Note
Severeprimaryaxillaryhyperhidrosis
Clinicalcriteria:
Patientmusthavepreviouslyfailedorbeintoleranttotopicalaluminiumchloridehexahydrateafteronetotwomonthsoftreatment.
Populationcriteria:
Maximumnumberoftreatmentsperyearis3,withnolessthan4monthstoelapsebetweentreatments.
Note
number1800700270.
Note
Note
SpecialPricingArrangementsapply.
Urinaryincontinence
Clinicalcriteria:
Theconditionmustbeduetoneurogenicdetrusoroveractivity,asdemonstratedbyurodynamicstudy,
12
Code
Max.Qty
(Packs)
Priceex
manufacturer
$
BrandNameand
Manufacturer
AND
TheconditionmustbeinadequatelycontrolledbyantiͲcholinergictherapy,
AND
Patientmustexperienceatleast14episodesofurinaryincontinenceperweekpriortocommencementoftreatmentwithbotulinumtoxin,
AND
Thetreatmentmustnotcontinueifthepatientdoesnotachievea50%orgreaterreductionfrombaselineinurinaryincontinenceepisodes6Ͳ12
weeksafterthefirsttreatment,
AND
PatientmustbewillingandabletoselfͲcatheterise.
Populationcriteria:
Patientmusthavemultiplesclerosis;OR
Patientmusthaveaspinalcordinjury;OR
Patientmustbeaged18yearsorolderandhavespinabifida.
Note
number1800700270.
Note
Note
Chronicmigraine
Clinicalcriteria:
Patientmusthaveexperiencedanaverageof15ormoreheadachedayspermonth,withatleast8daysofmigraine,overaperiodofatleast6
months,priortocommencementoftreatmentwithbotulinumtoxin,
AND
Patientmusthaveexperiencedaninadequateresponse,intoleranceoracontraindicationtoatleastthreeprophylacticmigrainemedications
priortocommencementoftreatmentwithbotulinumtoxin,
AND
Patientmusthaveachievedandmaintaineda50%orgreaterreductionfrombaselineinthenumberofheadachedayspermonthaftertwo
treatmentcycles(eachof12weeksduration)inordertobeeligibleforcontinuingPBSͲsubsidisedtreatment.
Populationcriteria:
Patientmustbeanadult.
Medicationoveruseheadachemustbeappropriatelymanagedpriortoinitiationoftreatmentwithbotulinumtoxin.
Note
number1800700270.
Note
Note
Urinaryincontinence
Clinicalcriteria:
Theconditionmustbeduetoidiopathicoveractivebladder,
AND
TheconditionmusthavebeeninadequatelycontrolledbytherapyinvolvingatleasttwoalternativeantiͲcholinergicagents,
AND
Patientmustexperienceatleast14episodesofurinaryincontinenceperweekpriortocommencementoftreatmentwithbotulinumtoxin,
AND
Thetreatmentmustnotcontinueifthepatientdoesnotachievea50%orgreaterreductionfrombaselineinurinaryincontinenceepisodes6Ͳ12
weeksafterthefirsttreatment,
AND
PatientmustbewillingandabletoselfͲcatheterise.
Populationcriteria:
13
Code
Max.Qty
(Packs)
Priceex
manufacturer
$
BrandNameand
Manufacturer
Note
number1800700270.
Note
Note
6103F
botulinumtoxintypeA100unitsinjection,1x100unitsvial
1
415.50
Botox
AG

SC CHEDU ULEOF FPHAR

Transcription

Similar documents

rex Caduet Prior Authorization Request Form

The Samsung Windows 8 tablet that was given away at... either the Samsung Series 7 Slate

Astatin™

How to register your Trustport Mobile Security to USERNAME

the world`s largest online newsstand

ELIZABETH SCHEU AND KNISS View ISO 9001:2008

SQUEE-G Window Wash Tablet - Kem

DeskStore Product Data Sheet - Top-Tec

Competitive Advantages of Siax

TouchSign™