Limited coverage criteria – prostaglandin injection
Last updated on March 21, 2025
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Generic name |
prostaglandin compounded injection papaverine in combination with phentolamine OR prostaglandin in combination with papaverine or phentolamine (BiMix) 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:
- prostaglandin – PIN 66123910
- papaverine in combination with phentolamine OR prostaglandin in combination with papaverine or phentolamine (BiMix) – PIN 66123495
- prostaglandin in combination with papaverine and phentolamine (TriMix) – PIN 66123483
- 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