Limited Coverage Drugs - Compounded Erectile Dysfunction Injection

Generic Name / Strength / Form

  • prostaglandin compounded injection OR
  • papaverine in combination with phentolamine OR prostaglandin in combination with papaverine or phentolamine (BiMix) OR
  • prostaglandin in combination with papaverine and phentolamine (TriMix)

Special Authority Criteria

Approval Period

Erectile dysfunction that occurs as a result of vascular or neurological damage that precludes adequate filling of the sinusoidal spaces.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

Prescriptions should be processed under the applicable PIN below:

  • PIN 66123910 - prostaglandin
  • PIN 66123495 - papaverine in combination with phentolamine OR prostaglandin in combination with papaverine or phentolamine (BiMix)
  • PIN 66123483 - prostaglandin in combination with papaverine and phentolamine (TriMix)

Prostaglandin compound preparations containing atropine, chlorpromazine or pilocarpine are not eligible for PharmaCare coverage.

Maximum price is based on acquisition cost of the pharmaceutical grade powder.

Special Authority Request Form(s)