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 requests

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• HLTH 5328 - Special Authority request (PDF, 656KB)