Drug Access Listing

250 mg tab | 500 mg tab

Multiple

Special Authorization Status^1,2: Form
Coverage: High-Cost Drug Program*, Catastrophic Drug Plan**

Special Authorization Criteria^1,2:

• In combination with prednisone for the treatment of mCRPC in patients who:

• Are asymptomatic or mildly symptomatic after failure of ADT, OR
• Have received prior chemotherapy containing docetaxel after failure of ADT

Notes^1,2:

• Prescriptions written by PEI oncologists do not require Special Authorization form
• Patients must apply for coverage to the High-Cost Drug Program* http://healthpei.ca/pharmacareforms

*High-Cost Drug Program: Approved high-cost medications for persons eligible for PEI Medicare and approved for coverage for one or more of the medications included in the program. Patients must apply for coverage on an annual basis and provide income information to the program.

**Catastrophic Drug Program: Once an applicant’s out of pocket eligible drug expenses exceed the annual household limit the program will cover any further eligible drug expenses in the program year.

1. PEI Pharmacare Formulary [3-22] 
2. PEI Oncology Formulary [4-22]

Janssen (Janssen BioAdvance Patient Assistance Program): Access Here   
JAMP (JAMP Care): Access Here 
Sentrex Health Solutions: Access Here 
Pharma-science: Access Here 
Apotex: Access Here 
ApoAssist: Access Here

250 mg Tab

Multiple

• In combination with androgen deprivation therapy (ADT) for the treatment of patients with mCSPC who have had no prior ADT, or are within 6 months of beginning ADT, in the metastatic setting.

Notes^1,2:

• Prescriptions written by PEI oncologists do not require Special Authorization form
• Patients must apply for coverage to the High-Cost Drug Program http://healthpei.ca/pharmacareforms

1. PEI Pharmacare Formulary [3-22] 
2. PEI Oncology Formulary [4-22]

Janssen (Janssen BioAdvance Patient Assistance Program): Access Here   
JAMP (JAMP Care): Access Here 
Sentrex Health Solutions: Access Here 
Pharma-science: Access Here 
Apotex: Access Here 
ApoAssist: Access Here

10 mg Tab | 70 mg PO

Multiple

Covered under multiple provincial programs including: Generic Drug Program, Senior Drug Program, Family Health Benefit Drug Program (form), Financial Assistance Drug Program, Nursing Home Program or Institutional Pharmacy Program, and Catastrophic Drug Program* (form)

*Catastrophic Drug Program: Once an applicant’s out of pocket eligible drug expenses exceed the annual household limit the program will cover any further eligible drug expenses in the program year.

1. PEI Pharmacare Formulary [3-22]

Apotex: Access Here

Tablet, PO, 60mg, 240mg

02478374

Patients must apply for coverage under the High-Cost Drug Program. If written by an oncologist, this medication does not require the submission of a Pharmacare Special Authorization form.1

Eligibility1:

• In combination with androgen deprivation therapy (ADT) for nmCRPC patients who meet all of the following criteria:

• No detectable distant metastasis (M0) by either CT, MRI or technetium‐99m bone scan
• At high risk of developing metastases (PSADT ≤ 10 months during continuous ADT)
• Have a good performance status and no risk factors for seizures

• Treatment should continue until unacceptable toxicity or radiographic disease

Clinical Notes1:

• Castration‐resistance must be demonstrated during continuous ADT and is defined as 3 PSA rises at least one week apart,with the last PSA> 2 ng/mL
• Castrate levels of testosterone must be maintained.
• Patients with N1 disease, pelvic lymph nodes < 2cm in short axis located below the common iliac vessels are eligible for apalutamide
• Apalutamide will not be funded for patients who experience disease progression on enzalutamide
• Patients receiving apalutamide for the treatment of non‐metastatic CRPC will be eligible for funding of abiraterone at the time of disease progression to metastatic CRPC. Enzalutamide is not funded for patients who experience disease progression to metastatic CRPC while on apalutamide
• Either abiraterone or enzalutamide may be used to treat metastatic CRPC in patients who discontinued apalutamide in the non‐metastatic setting due to intolerance without disease progression.

** 60 mg tablet funded, 240 mg tablet pending provincial funding decision

1. Health PEI Drug Formulary for Oncology [7  -23]

Janssen BioAdvance Patient Assistance Program: Access Here

Tablet, PO, 60mg, 240mg

02478374

Patients much apply for coverage under the High-Cost Drug Program. If written by an oncologist, this medication does not require the submission of a Pharmacare Special Authorization form.1

Eligibility1:

• In combination with androgen deprivation therapy (ADT) for mCSPC patients who meet all of the following criteria:

• No prior ADT OR are within siz months of beginning ADT in the metastatic setting

Clinical Notes1:

• Patients should have a good performance status and no risk factors for seizures
• Treatment should continue until acceptable toxicity or disease progression

Claim Notes1:

• Patients receiving apalutamide for the treatment of metastatic CSPC will be eligible for funding of abiraterone at the time of disease progression to metastatic CRPC.
• Enzalutamide is not funded for patients who experience disease progression to metastatic CRPC while on apalutamide.

**60mg tablet funded, 240mg tablet pending provincial funding decision

1. Health PEI Drug Formulary for Oncology [7  -23]

Janssen BioAdvance Patient Assistance Program: Access Here

300 mg Tab

Not Specified

Eligibility: 

• In combination with androgen deprivation therapy (ADT) for the treatment of patients with non‐metastatic castration‐resistant prostate cancer (nmCRPC) who are at high risk of developing metastases (defined as PSADT of ≤ 10 months during continuous ADT). 
• Patients should have a good performance status. 
• Treatment should continue until unacceptable toxicity or radiographic disease progression. 

Clinical Notes: 

• Castration‐resistance must be demonstrated during continuous ADT and is defined as 3 PSA rises at least one week apart, with the last PSA> 2 ng/mL. 
• Patients should have no detectable distant metastases by either CT, MRI or technetium‐99m bone scan 
• Castrate levels of testosterone must be maintained. 
• Patients with N1 disease, pelvic lymph nodes < 2cm in short axis located below the aortic bifurcation are eligible for darolutamide. 
• Darolutamide will not be funded for patients who experience disease progression on apalutamide or enzalutamide. 
• Patients receiving darolutamide for the treatment of non‐metastatic CRPC will be eligible for funding of abiraterone at the time of disease progression to metastatic CRPC. Enzalutamide is not funded for patients who experience disease progression to metastatic CRPC while on darolutamide. 
• Either abiraterone or enzalutamide may be used to treat metastatic CRPC in patients who discontinued darolutamide in the non‐metastatic setting due to intolerance without disease progression. 

Prescriptions written by PEI oncologists do not require Special Authorization 

Patients requesting coverage through the High-Cost Drug Program must submit a patient application, available from the Drug Programs Office or online at http://healthpei.ca/pharmacareforms.  

1. PEI Pharmacare Formulary

NUBEQA® DART Patient Support Program: 

Toll free: 1-833-955-3278 

Fax:1-877-208-4393 

Email: info@dartsupport.ca 

300 mg Tab

Not Specified

Eligibility: 

• In combination with docetaxel and androgen deprivation therapy (ADT) for the treatment of patients with metastatic castration‐sensitive prostate cancer (mCSPC).  
• Patients must have had either no prior ADT or are within 6 months of beginning ADT in the metastatic setting. 

Renewal Criteria: 

• Confirmation that the patient has responded to treatment and there is no evidence of disease progression. 

Clinical Notes: 

• Patients should have a good performance status. 
• Treatment should continue until unacceptable toxicity or disease progression. 

Claim Notes: 

• Requests will not be considered for patients who are within 1 year of completing adjuvant ADT in the nonmetastatic setting. 
• Patients who experience disease progression on apalutamide or enzalutamide are not eligible. 

Prescriptions written by PEI oncologists do not require Special Authorization 

Patients requesting coverage through the High-Cost Drug Program must submit a patient application, available from the Drug Programs Office or online at http://healthpei.ca/pharmacareforms.  

1. PEI Formulary

NUBEQA® DART Patient Support Program: 

Toll free: 1-833-955-3278 

Fax:1-877-208-4393 

Email: info@dartsupport.ca 

60 mg / ml Syr

02343541

Special Authorization Status^1,2: Form

Coverage: Senior Drug Program, Family Health Benefit Drug Program (form), Financial Assistance Drug Program, Nursing Home Program or Institutional Pharmacy Program and Catastrophic Drug Program* (form)^1,2

Special Authorization Criteria^1,2:

• For the treatment of osteoporosis in men who meet the following criteria:

• Have a contraindication to oral bisphosphonates
  High risk for fracture, or refractory or intolerant to other available osteoporosis therapies

Clinical Notes^1,2:

• Refractory is defined as a fragility fracture or evidence of a decline in bone mineral density below pre-treatment baseline levels, despite adherence for one year to other available osteoporosis therapies
• High fracture risk is defined as:

• Moderate 10-year fracture risk (10% to 20%) as defined by the CAROC tool or the FRAX tool with a prior fragility fracture; OR
• High 10-year fracture risk (≥ 20%) as defined by the CAROC or FRAX tool

*Catastrophic Drug Program: Once an applicant’s out of pocket eligible drug expenses exceed the annual household limit the program will cover any further eligible drug expenses in the program year.

1. PEI Pharmacare Formulary [3-22] 
2. PEI Oncology Formulary [4-22]

ProVital Program: Access Here

-

-

No listing information as of Mar. 2022.

-

The VICTORY Program: Access Here

40 mg capsule

02407329

Eligibility: 

For treatment of patients with metastatic castration resistant prostate cancer who: 

• Are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy with an ECOG performance status ≤ 1 and have not received prior chemotherapy and would be an alternative to abiraterone for patients and not sequential therapy in this asymptomatic or mildly symptomatic patient population 

OR 

• Have progressed on docetaxel-based chemotherapy with an ECOG performance status ≤ 2 and no risk factors for seizures and would be an alternative to abiraterone for patients and not sequential therapy in this symptomatic post docetaxel chemotherapy setting 

Notes: 

• Enzalutamide will not be reimbursed in combination with abiraterone. 

• Use of enzalutamide in the past docetaxel setting is not permitted if previously used in the prechemotherapy setting 

Prescriptions written by PEI oncologists do not require written Special Authorization.  

Patients requesting coverage through the High-Cost Drug Program must submit a patient application, available from the Drug Programs Office or online at http://healthpei.ca/pharmacareforms. 

PEI Pharmacare Formulary 

Xtandi Patient Assistance Program (XPAP): 

Patient Enrolment and Consent Form (English) 

Formulaire D’inscription et de Consentement du Patient (French) 

40 mg capsule

02407329 

Eligibility: 

In combination with androgen deprivation therapy (ADT) for the treatment of patients with non-metastatic castration-resistant prostate cancer (nmCRPC) who are at high risk of developing metastases1. 

• Patients should have a good performance status and no risk factors for seizures. Treatment should continue until unacceptable toxicity or radiographic disease progression. 

Clinical Notes: 

• Castration-resistance must be demonstrated during continuous ADT and is defined as 3 PSA rises at least one week apart, with the last PSA> 2 ng/mL. 

• Castrate levels of testosterone must be maintained. 

• Patients with N1 disease, pelvic lymph nodes < 2cm in short axis located below the common iliac vessels are eligible for enzalutamide. 

• Enzalutamide will not be funded for patients who experience disease progression on apalutamide. 

• Patients receiving enzalutamide for the treatment of non-metastatic CRPC will be eligible for funding of abiraterone at the time of disease progression to metastatic CRPC.  

1High risk of developing metastases is defined as a prostate-specific antigen (PSA) doubling time of ≤ 10 months during continuous ADT 

Prescriptions written by PEI oncologists do not require written Special Authorization.  

Patients requesting coverage through the High-Cost Drug Program must submit a patient application, available from the Drug Programs Office or online at http://healthpei.ca/pharmacareforms. 

PEI Pharmacare Formulary 

Xtandi Patient Assistance Program (XPAP): 

Patient Enrolment and Consent Form (English) 

Formulaire D’inscription et de Consentement du Patient (French) 

40 mg capsule

02407329 

Eligibility: 

In combination with androgen deprivation therapy (ADT) for the treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC). Patients must have had either no prior ADT or are within six months of beginning ADT in the metastatic setting.  

Clinical Notes: 

• Patients should have a good performance status and no risk factors for seizures. 

• Treatment should continue until unacceptable toxicity or disease progression. 

Prescriptions written by PEI oncologists do not require written Special Authorization.  

Patients requesting coverage through the High-Cost Drug Program must submit a patient application, available from the Drug Programs Office or online at http://healthpei.ca/pharmacareforms. 

PEI Pharmacare Formulary 

Xtandi Patient Assistance Program (XPAP): 

Patient Enrolment and Consent Form (English) 

Formulaire D’inscription et de Consentement du Patient (French) 

Dual-action tablet, PO/ Comprimé à double action, PO: 100mg niraparib/500mg abiraterone acetate

02538563

Pending provincial funding decision

N/A

Janssen BioAdvance Patient Assistance Program: Access Here

100 mg tab | 150 mg tab

100mg: 02475200 | 150mg: 02475219

For the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) who meet all the following criteria:  

• Deleterious or suspected deleterious germline and/or somatic mutations in the homologous recombination repair (HRR) genes BRCA1, BRCA2 or ATM; and  
• Disease progression on prior treatment with androgen-receptor-axis-targeted (ARAT) therapy. 
   

Renewal Criteria: Written confirmation that the patient has responded to treatment and there is no evidence of disease progression. 

Clinical Notes: 

• Patients must have a good performance status. 
• Treatment should be discontinued upon disease progression or unacceptable toxicity. 

Health PEI Formulary Drugs

AstraZeneca Patient Support Program: Access Here

AstraZeneca Patient Assistance Program: Access Here