NT Pharmacare Formulary

Updated August 1, 2025

 

WHEREAS, the Extended Health Benefits Policy 49.07, Schedule 2 Drug Benefits states:

  • Section 2(i) states: The Department of Health and Social Services utilizes the federal government’s Non-Insured Health Drug Benefits List as the as the NWT pharmacare formulary, unless limited or delisted in accordance accordance with 3(ii) of this Schedule.
  • Section 3(ii) The Deputy Minister reserves the right to limit coverage, issue directives and delist products on the Non-Insured Health Benefits Drug List when setting the NT Pharmacare Formulary.

The NT Pharmacare Formulary covers eligible drugs listed on the NIHB Drug Benefit List with the following exclusions:

Drug

DIN(s)

Indication and notes

Cuvposa

02469332

Severe Drooling

Eylea Pre-Filled Syringe

02505355

Diabetic Macular Edema

Wet age-related macular degeneration

Retinal vein occlusion

Biologic Originators

Humira

Lovenox

Enbrel

Remicade

Lantus

Humalog

NovoRapid

Neupogen

Neulasta

Rituxan

Copaxone

Stelara

Prolia

Xgeva

Lucentis

Forteo

 

Transition period for these Biologic originators has ended

 

New clients are required to start on biosimilar.
Riabni 02513447

Rheumatoid Arthritis

Granulomatosis polyangiitis

Microscopic polyangiitis
Procysbi

02464705

02464713		 Nephropatic cystinosis
Onpattro 02489252 Hereditary transthyretin-mediated amyloidosis
Zolgensma 02509695 Spinal Muscular Atrophy
Soliris 0232285 Paroxysmal nocturnal hemoglobinuria
Strensiq

02444615

02444623

02444631

02444658		 Hypophosphatasia
Naglazyme 02412683 Maroteaux-Lamy syndrome
Brineura 02484013 Batten Disease
Givlaari 02506343 Acute hepatic porphyria
Kanuma 02469596 Lysosomal acid lipase deficiency

The NT Pharmacare Formulary covers eligible drugs listed on the NIHB Drug Benefit List with the following criteria differences:

Drug

DIN(s)

Indication

XARELTO

02378604, 02378612

Stroke prevention in atrial fibrillation

Deep Vien Thrombosis

Pulmonary Embolism

Criteria

Limited Use (Prior Approval Required)

Criteria for rivaroxaban 15 mg, 20mg tablets (Xarelto) for stroke prevention in atrial fibrillation (SPAF)

For at-risk patients (CHADS2 score ≥1) with non-valvular atrial fibrillation who require rivaroxaban for the prevention of stroke and systemic embolism and in whom:

  • anticoagulation is inadequate (outside the desired INR range for at least 35% of the tests) with a two-month trial of warfarin; or
  • anticoagulation with warfarin is contraindicated; or
  • anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home)

Criteria for rivaroxaban 15 mg, 20mg tablets (Xarelto)

 For the treatment of venous thromboembolism:

  • Deep vein thrombosis (DVT) or pulmonary embolism (PE).

Note: Generic rivaroxaban is listed as open benefit

 

JANUVIA

02303922,02388839,02388847

Diabetes mellitus (Type 2)

Criteria

Limited Use (Prior Approval Required)

  • For the treatment of patients with type 2 diabetes mellitus who did not achieve glycemic control or who demonstrated intolerance to an adequate trial of metformin and a sulfonylurea.

 

 

OZEMPIC

02471469, 02471477, 02540258

Diabetes mellitus (Type 2)

Criteria

Limited Use (Prior Approval Required)

  • For the treatment of Type 2 diabetes in combination with metformin alone, when diet and exercise plus maximal tolerated dose of metformin do not achieve adequate glycemic control.

 

FLASH AND CONTINUOUS GLUCOSE MONITOR SYSTEMS

Dexcom G6, Dexcom G7, Freestyle Libre, Freestyle Libre 2

 

Criteria

Limited Use (Prior Approval Required)

Flash and continuous glucose monitoring systems coverage criteria:

  • Children 19 years of age and younger on intensive insulin therapy (administration of short-acting insulin three or more times per day).
  • Clients with type 1 diabetes, as verified by short-acting insulin claims history.