Limited coverage drugs – propranolol hydrochloride

Last updated on October 6, 2022

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 requests