Limited Coverage Drugs - propranolol hydrochloride

Generic Name

propranolol hydrochloride         
Strength 

3.75 mg/mL

Form

Oral solution

Special Authority Criteria

Approval Period

INITIAL

For the treatment of proliferating infantilei hemangioma requiring systemic therapy, when:

  • The patient has life- or function-threatening hemangioma.
    OR
  • The patient has ulcerated hemangioma with pain or a lack of response to wound care measures.
    OR
  • The patient’s hemangioma presents a risk of permanent scarring or disfigurement.

6 months

RENEWAL

For the continued treatment of proliferating infantile hemangioma, when the patient has had an incompleteii response to a 6-month course of treatment with propranolol oral solution.

6 monthsiii 

Special Notes

  1. PharmaCare considers coverage of infants for initial coverage up to 5 months of age. The age for treatment initiation will be corrected in cases of prematurity.
  2. The prescriber must provide details of the patient’s response versus pre-treatment baseline.
  3. PharmaCare provides a maximum of 2 years total coverage.

Practitioner Exemptions

  • No practitioner exemptions.

Special Authority Request Form(s)