Home Health iDBL
Interactive Drug Benefit List
DIN/NPN/PIN 02464705 PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE CYSTEAMINE BITARTRATE
920000 MISCELLANEOUS THERAPEUTIC AGENTS
929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS
Date Listed/Coverage Update: 01-Sep-2018
Unit Price: 5.9537
LCA Price: N/A
MAC Price:

N/A
Unit of Issue: Capsule
Manufacturer: HZNP CANADA LIMITED (RAP)
ATC: A16AA04
1
Interchangeable Products: No
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 with an established diagnosis of infantile nephropathic cystinosis with documented high levels of mixed leukocyte (WBC) cystine or granulocyte cystine.

For coverage, this drug must be prescribed by or in consultation with physician with experience in the diagnosis and management of cystinosis.

Special authorization may be granted for 12 months."

This product is eligible for auto-renewal.

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 2020/11/19 2021/05/01 Special Authorization Criteria Change
NEPHROPATHIC CYSTINOSIS Common Drug Review 2017/08/22 2018/09/01 Special Authorization
NEPHROPATHIC CYSTINOSIS Common Drug Review 2017/08/22 2018/01/24 View CDR - List with clinical criteria and/or conditions
Indication N/A
Reviewing
Body		 Expert Committee
Submission
Completion
Date		 2020/11/19
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date		 2021/05/01
CDR
Recommendation
Review
Status		 Special Authorization Criteria Change
Indication NEPHROPATHIC CYSTINOSIS
Reviewing
Body		 Common Drug Review
Submission
Completion
Date		 2017/08/22
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date		 2018/09/01
CDR
Recommendation
Review
Status		 Special Authorization
Indication NEPHROPATHIC CYSTINOSIS
Reviewing
Body		 Common Drug Review
Submission
Completion
Date		 2017/08/22
CDR
Recommendation
Date		 2018/01/24
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation		 View
Review
Status		 CDR - List with clinical criteria and/or conditions
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NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.