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Benefit Limitations

There are a number of medication benefits covered under the Program for which limitations on their coverage apply.

Please note that the following limitations apply to all benefit brands in the drug category specified.

For beneficiaries who require product(s) in any of the listed categories but do not meet the specified limitations, prior approval is required under the special authorization process.

Acetaminophen

Coverage is limited as indicated for the following medications:

• Acetaminophen 80mg/ml Drops
  Children under the age of 2 years
• Acetaminophen 32mg/ml Elixir
  Children under the age of 12 years
• Acetaminophen Suppositories
  Children under the age of 12 years

Aerochambers / Optichambers

Coverage is limited to 1 aerochamber per patient once in a 365 day period.

The Intervention Code MR may be used to replace an aerochamber that is lost, broken or stolen. Documentation for use of this code must be noted on the original prescription. If documentation cannot be produced during audit activity, the claim will be considered not validated and will be recovered.

Chlorhexidine 0.12% Mouthwash (compounded versions)

For chemotherapy patients only, the Program covers compounded versions of chlorhexide 0.12% mouthwash. This compound contains chlorhexidine gluconate, flavouring, sweetener, and water. Documentation of chemotherapy should be noted on the original hardcopy (i.e. first fill or when logged) or original prescription by the Pharmacist if not already noted by the Physican.

Docusate Sodium Syrup

Coverage is limited as indicated for the following medication:

• Docusate Sodium 4mg/ml Syrup
  Children under the age of 12 years

Diabetic Test Strips

Coverage of glucose test strips is restricted to:

• beneficiaries who have diabetes and are taking insulin or oral hypoglycemic medications.
• beneficiaries who are not on insulin or oral hypoglycemic medications but are being followed by a Diabetes Nurse Educator, Dietician, or Family Physician, with a letter to confirm same and have an approved special authorization.

Glucose test strips are subject to a maximum of 2500 test strips per 365 day period (starting the date of first claim for test strips) for all beneficiaries. If a beneficiary exceeds this amount, (s)he is required to submit a letter to the Program from the physician indicating the number of times a day they are required to test. A special authorization will be entered in the system.

Dimenhydrinate

Coverage is limited as indicated for the following medication:

• Dimenhydrinate 3mg/ml Liquid
  Children under the age of 12 years

Loratidine

Coverage is limited as indicated for the following medication:

• Loratadine 1mg/ml Syrup
  Children under the age of 12 years

Prenatal Vitamins

These products are limited to women 50 years of age or younger.

Contraceptive Medications and Devices

These products are limited to female beneficiaries.

Pediapred

Coverage is limited as indicated for the following medication:

• Pediapred
  Children under the age of 12 years

Celebrex

Coverage is limited as indicated for the following medication:

• Celebrex
  All beneficiaries 65 years or older regardless of the plan they are covered under.

Please note that for patients who require product(s) in any of the listed categories and yet do not meet the specified limitations, consideration will be given to provide the product under special authorization on receipt of supportive information from the prescribing physician to the Department of Health and Community Services.