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PEI Drug Programs

Formulary Update

Issue 09-01

February 20, 2009

Effective March 1, 2009, the following medications will be covered by the PEI Drug Programs:

High Cost Cancer Medications

The following cancer medications will be covered through the High Cost Drugs Program to patients who meet established clinical criteria. A completed Special Authorization form must be received by the Drug Programs office before coverage will be considered. Patients or their care givers to complete a High Cost Drugs Program application and to submit it along with income verification information to the Drug Programs office. This information will be used to calculate the patient’s

share of the prescription cost.

DASATINIB 20MG TABLET 02293129

SPRYCEL

50MG TABLET 02293137

SPRYCEL

BMS

BMS

70MG TABLET 02293145

SPRYCEL

BMS

For use as a single agent for the treatment of adults with chronic, accelerated or blast phase chronic myelogenous leukemia (CML) and Philadelphia chromosome acute lymphoblastic leukemia (Ph+ ALL) with resistance or intolerance to prior therapy including imatinib.

ERLOTINIB 25MG TABLET 02269007

TARCEVA

100MG TABLET 02269015

TARCEVA

150MG TABLET 02269023

TARCEVA

HLR

HLR

HLR

For use as monotherapy for the treatment of patients with locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen and whose EGFR expression status is positive or unknown.

FLUDARABINE 10MG TABLET 02246226

FLUDARA

BAY

For the treatment of chronic lymphocytic leukemia (CLL) in patients with an ECOG performance status of

  • 0

    to 2 when the patient has failed to respond to, or relapsed during/ after previous therapy with an

alkylating agent and intravenous administration is not desirable.

PEI Drug Programs Update - Issue 09-01- Page 1

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