NT Pharmacare Formulary | Health and Social Services

Jump to navigation

Updated April 12, 2024

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

Section 2 states: The Department of Health and Social Services utilizes the federal government’s Non-Insured Health Drug Benefits List as the approved pharmacare formulary that identifies the drug benefits for Senior Citizens and each Specified Disease Condition.
Section 2(i) states: The Department of Health and Social Services reserves the right to limit coverage, issue directives and delist products on the pharmacare formulary.

The NT Pharmacare Formulary will be updated monthly.

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

Drug	DIN(s)	Indication and notes
Vraylar	02526794, 02526808, 02526816, 02526824	Schizophrenia
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		Transition period for these Biologic originators ended on June 20, 2022 for existing clients on these products. 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

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.