Interactive Drug Benefit List
DIN/NPN/PIN 02390299 MYLAN-RILUZOLE 50 MG ORAL TABLET RILUZOLE
280000 CENTRAL NERVOUS SYSTEM AGENTS
289200 MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS
Date Listed/Coverage Update: 01-Dec-2012
Unit Price: 3.4361
LCA Price: 3.4361
MAC Price:

N/A

Unit of Issue: Tablet
Manufacturer: VIATRIS CANADA (MYLAN PHARMACEUTICALS ULC) (MYP)
ATC: N07XX02
1
Interchangeable Products: Yes

Coverage Status: SPECIAL AUTHORIZATION
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)

Special Authorization Request Form:

Drug Special Authorization Request Form (ABC 60015)

SPECIAL AUTHORIZATION

"For use in patients who have probable or definite diagnosis of amyotrophic lateral sclerosis (ALS) as defined by World Federation of Neurology (WFN) criteria who have a vital capacity of >60% predicted and do not have a tracheostomy for invasive ventilation. This drug must be prescribed by a Specialist in Neurology."

"Patients who previously received Rilutek and were not eligible for the Phase IV study can also be considered for coverage if they meet the special authorization criteria."

"Coverage cannot be renewed once the patient has a tracheostomy for the purpose of invasive ventilation."

Review Status / Past Decisions

Indication Reviewing
Body
Submission
Completion
Date
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
Review
Status
N/A Expert Committee 2012/10/23 2012/12/01 Special Authorization
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2012/10/23
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2012/12/01
CDR
Recommendation
Review
Status
Special Authorization
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