Interactive Drug Benefit List
DIN/NPN/PIN 02470055 MDK-NITISINONE 20 MG ORAL CAPSULE NITISINONE
920000 MISCELLANEOUS THERAPEUTIC AGENTS
929200 OTHER MISCELLANEOUS THERAPEUTIC AGENTS
Date Listed/Coverage Update: 01-Jun-2019
Unit Price: 128.1000
LCA Price: N/A
MAC Price:

N/A

Unit of Issue: Capsule
Manufacturer: MENDELIKABS INC. (MEN)
ATC: A16AX04
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 the treatment of adult and pediatric patients with hereditary tyrosinemia type 1 (HT-1) in combination with dietary restriction of tyrosine and phenylalanine, when prescribed by a physician with experience in the diagnosis and management of HT-1."

Special authorization may be granted for 12 months.

The following product(s) are 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
HEREDITARY TYROSINEMIA TYPE 1 Common Drug Review 2017/10/20 2019/06/01 Special Authorization
Indication HEREDITARY TYROSINEMIA TYPE 1
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2017/10/20
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2019/06/01
CDR
Recommendation
Review
Status
Special Authorization
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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.