Limited coverage drugs – prostaglandin 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:

• 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 requests

• Log in to eForms
• HLTH 5328 - Special Authority request form (PDF, 656KB)