Palliative Care Drug Benefit Supplement
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1 Palliative Care Drug Benefit Supplement Effective April 1, 2007
2 Inquiries Inquiries should be directed to: Pharmacy Services Alberta Blue Cross Street NW Edmonton AB T5J 3C5 Telephone Number: (780) (Edmonton) (403) (Calgary) (Toll Free) FAX Number: (780) (Toll Free) Website: Administered by Alberta Blue Cross on behalf of Alberta Health and Wellness. Additional copies of the Alberta Health and Wellness Palliative Care Drug Benefit Supplement Publication, which include Quarterly Updates, and Additions To the List are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Please note: Quarterly Updates will be mailed to you upon effective dates. Binder and contents: $42.80 ($ $2.80 G.S.T.) Contents only: $37.45 ($ $2.45 G.S.T.) A cheque or money order must accompany the request for additional copies. Changes may be made, without notice, to the List/Supplement through the on-line interactive List/Supplement, and any such changes to the on-line interactive List/Supplement are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper/cd Rom version or updates. Please visit for the most current Palliative Care Drug Benefit Supplement information. ABC /81160 (04/2007)
3 Table of Contents PALLIATIVE CARE DRUG BENEFIT SUPPLEMENT SECTION 1 - SUMMARY OF CHANGES SECTION 2 - INTRODUCTION AND THERAPEUTIC CLASSIFICATION OF DRUGS Introduction Eligibility...1 Notes...1 Price Policy...1 Interchangeable Drug Products...1 Excluded Special Authorization Drug Products...2 Pharmacological-Therapeutic Classification of Drugs 10:00 Antineoplastic Agents :00 Central Nervous System Drugs :08:08 Opiate Agonists :00 Electrolytic, Caloric, Water Balance :12 Replacement Preparations :00 Gastrointestinal Drugs :12 Cathartics & Laxatives :00 Local Anesthetics...5 APPENDICES Appendix 1 - Pharmaceutical Manufacturers...7 Appendix 2 - Alphabetical List of Pharmaceutical Products...8 Appendix 3 - Numerical List by Drug Identification Number...9 i EFFECTIVE APRIL 1, 2007
4 SECTION 1 Section 1 Summary of Changes Summary of Changes
5 SUMMARY OF CHANGES None to report at this time. Section 1 1 EFFECTIVE APRIL 1, 2007
6 SECTION 2 Introduction and Therapeutic Classification of Drugs Section 2 Introduction and Therapeutic Classification of Drugs
7 INTRODUCTION Eligibility Benefits for the Palliative Care Drug Coverage are defined by the Alberta Health and Wellness Drug Benefit List and the Palliative Care Drug Benefit Supplement (which defines select hydrating agents, laxatives and other products as additional benefits). In order for patients to be eligible for Palliative Care Drug Coverage, an application for the Palliative Care Drug Program must be completed and signed by both the patient (or guardian) and the physician. This Palliative Care Drug Program application form must be forwarded to Alberta Health and Wellness for their consideration and approval. Notes Palliative Care Drug Coverage will pay the prescription charge for hydrating agents using the guidelines for injectable drugs as referenced in the Schedule of Prices in Appendix A of the ABC Benefits Corporation Pharmacy Agreement. Price Policy All prices printed in the Supplement and the List are based on responses to a Request for Quotation (RFQ) for the period of time during which the Supplement and List are effective. An RFQ was sent to all pharmaceutical manufacturers whose products are included or were under review for possible addition to the Supplement and/or the List. It is the manufacturer s/vendor s responsibility to ensure supply of all products for which price quotes have been submitted. Failure to provide a RFQ and/or price quote may result in refusal to list a product, refusal to fast-track a submission, or a discontinued listing. Interchangeable Drug Products A box containing an X ( ) to the left of the DIN or Product Identification Number (PIN) indicates that the product is not interchangeable with other products or interchangeability has not been assessed within the category. Refer to Policies and Guidelines Section 1 of the current Alberta Health and Wellness Drug Benefit List for further information regarding interchangeable drug products. 1 EFFECTIVE APRIL 1, 2007
8 Excluded Special Authorization Drug Products The following drug product(s) are listed in the special authorization section (Section 3) of the Alberta Health and Wellness Drug Benefit List. However, special authorization coverage for these drug product(s) cannot be considered for those patients with Palliative Care Drug Coverage: Trade Name / Strength / Form Generic Description DIN MFG NEULASTA 6 MG/0.6ML INJECTION SYRINGE PEGFILGRASTIM AMG NEUPOGEN 0.3 MG/ML INJECTION FILGRASTIM AMG Exluded Criteria: To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppresive anti-neoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Cancer Board Centres (of their designates). Trade Name / Strength / Form Generic Description DIN MFG HEPTOVIR 100 MG ORAL TABLET LAMIVUDINE GSK Excluded Criteria: For the prevention of Hepatitis B re-infection in patients who are Hepatitis B surface antigen positive and are undergoing high dose, short-term cytotoxic chemotherapy with curative intent or stem cell transplant procedures. EFFECTIVE APRIL 1,
9 10:00 ANTINEOPLASTIC AGENTS 10:00 MEGESTROL ACETATE 40 MG ORAL TABLET APO-MEGESTROL APX $ NU-MEGESTROL NXP $ MG ORAL TABLET APO-MEGESTROL APX $ NU-MEGESTROL NXP $ MEGACE BMS $ MG/ML ORAL SUSPENSION MEGACE OS BMS $ :00 CENTRAL NERVOUS SYSTEM DRUGS 28:08:08 OPIATE AGONISTS FENTANYL 12 MCG / HR TRANSDERMAL PATCH DURAGESIC JOI $ MCG / HR TRANSDERMAL PATCH RAN-FENTANYL RAN $ RATIO-FENTANYL RPH $ DURAGESIC JOI $ MCG / HR TRANSDERMAL PATCH RAN-FENTANYL RAN $ RATIO-FENTANYL RPH $ DURAGESIC JOI $ MCG / HR TRANSDERMAL PATCH RAN-FENTANYL RAN $ RATIO-FENTANYL RPH $ DURAGESIC JOI $ MCG / HR TRANSDERMAL PATCH RAN-FENTANYL RAN $ RATIO-FENTANYL RPH $ DURAGESIC JOI $ FENTANYL CITRATE 0.05 MG / ML (BASE) INJECTION FENTANYL CITRATE HSP $ :00 ELECTROLYTIC, CALORIC, WATER BALANCE 40:12 REPLACEMENT PREPARATIONS PARENTERAL SOLUTIONS (LARGE & SMALL VOL) 0.9% INJECTION % SODIUM CHLORIDE XXX $ % / 0.3% INJECTION % DEXTROSE W 0.3% NACL (2/3-1/3) XXX $ % / 0.3% / 0.15% INJECTION % DEXT/0.3% NACL W 0.15 % KCL 20 MEQ XXX $ % / 0.3% / 0.3% INJECTION % DEXT/0.3% NACL W 0.3% KCL 40 MEQ XXX $ EFFECTIVE APRIL 1, 2007
10 5% INJECTION % DEXTROSE (D5W) XXX $ % / 0.15% INJECTION % DEXTROSE W 0.15% KCL 20 MEQ XXX $ % / 0.3% INJECTION % DEXTROSE W 0.3% KCL 40 MEQ XXX $ INJECTION LACTATED RINGER S XXX $ POTASSIUM CHLORIDE (K+) 2 MEQ / ML INJECTION POTASSIUM CHLORIDE HSP $ SODIUM CHLORIDE 0.9% INJECTION SODIUM CHLORIDE HSP $ :00 GASTROINTESTINAL DRUGS 56:12 CATHARTICS & LAXATIVES BISACODYL 5 MG ORAL ENTERIC-COATED TABLET PMS-BISACODYL PPH $ APO-BISACODYL APX $ DULCOLAX BOE $ MG RECTAL SUPPOSITORY DULCOLAX BOE $ MG RECTAL SUPPOSITORY PMS-BISACODYL PMS $ DULCOLAX BOE $ APO-BISACODYL APX $ DOCUSATE CALCIUM 240 MG ORAL CAPSULE RATIO-DOCUSATE CALCIUM RPH $ CALAX ODN $ NOVO-DOCUSATE CALCIUM NOP $ PMS-DOCUSATE CALCIUM PMS $ DOCUSATE SODIUM 4 MG / ML ORAL SYRUP RATIO-DOCUSATE SODIUM RPH $ SELAX ODN $ COLACE WSP $ PMS-DOCUSATE SODIUM PMS $ MG / ML ORAL DROPS DOCUSATE SODIUM ROG $ SOFLAX PMS $ COLACE WSP $ MG / ML ORAL SYRUP PMS-DOCUSATE SODIUM PMS $ EFFECTIVE APRIL 1,
11 100 MG ORAL CAPSULE RATIO-DOCUSATE SODIUM RPH $ APO-DOCUSATE SODIUM APX $ PMS-DOCUSATE SODIUM PMS $ DOCUSATE SODIUM TAR $ SOFLAX PMS $ SELAX ODN $ NOVO-DOCUSATE SODIUM NOP $ COLACE WSP $ MG ORAL CAPSULE SOFLAX PMS $ MG ORAL CAPSULE SELAX 250 ODN $ SENNA 8.6 MG ORAL TABLET RIVA-SENNA RIV $ SENNOSIDES 1.7 MG / ML ORAL SYRUP SENOKOT PUR $ MG ORAL TABLET SANDOZ SENNOSIDES SDZ $ PMS-SENNOSIDES PPH $ SENNATAB PMS $ SENOKOT PUR $ MG ORAL TABLET SANDOZ SENNOSIDES SDZ $ PMS-SENNOSIDES PPH $ SENNOSIDES/DOCUSATE SODIUM 8.6 MG / 50 MG ORAL TABLET SENOKOT S PUR $ SODIUM PHOSPHATE/SODIUM ACID PHOSPHATE 10.4 G / 3.9 G PEDIATRIC ENEMA FLEET ENEMA PEDIATRIC (65 ML) MCL $ G / 3.9 G RECTAL ENEMA ENEMOL PMS $ FLEET ENEMA JJM $ SODIUM CITRATE/SORBITOL/SODIUM LAURYL SULFOACETATE 90 MG / 625 MG / 9 MG RECTAL ENEMA MICROLAX MICRO-ENEMA PFI $ :00 LOCAL ANESTHETICS 72:00 BUPIVACAINE HCL 0.25% INJECTION SENSORCAINE AZC $ % INJECTION SENSORCAINE AZC $ EFFECTIVE APRIL 1, 2007
12 BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE 0.25% INJECTION SENSORCAINE WITH EPINEPHRINE AZC $ % INJECTION SENSORCAINE WITH EPINEPHRINE AZC $ EFFECTIVE APRIL 1,
13 Appendices APPENDICES Pharmaceutical Manufacturers Alphabetical List of Pharmaceutical Products Numerical List by Drug Identification Number
14 Appendix 1: Pharmaceutical Manufacturers A P APX Apotex Inc. PMS Pharmascience Inc. AZC AstraZeneca Canada Inc. PPH Pendopharm Inc. PUR Purdue Pharma B BMS Bristol-Myers Squibb R BOE Boehringer Ingelheim (Canada) Ltd. RAN Ranbaxy Pharmaceuticals Canada Inc. RIV Laboratoire Riva Inc. H ROG Rougier Pharma Inc. (Div. of ratiopharm) HSP Hospira Healthcare Corporation RPH ratiopharm JJM JOI J Johnson & Johnson-Merck Janssen-Ortho Inc. SDZ S Sandoz Canada Inc. MCL M McNeil Consumer Products Co. TAR T Taro Pharmaceuticals Inc. NOP NXP ODN N Novopharm Ltd. Nu-Pharm Inc. O Odan Laboratories Ltd. WSP XXX W Wellspring Pharmaceutical Canada Corp. X Miscellaneous Manufacturers 7 EFFECTIVE APRIL 1, 2007
15 Appendix 2 Alphabetical List of Pharmaceutical Products Product Name Page Product Name Page NUMERIC N 0.9% SODIUM CHLORIDE... 3 NOVO-DOCUSATE CALCIUM % DEXTROSE W 0.3% NACL (2/3-1/3)... 3 NOVO-DOCUSATE SODIUM % DEXT/0.3% NACL NU-MEGESTROL...3 W 0.15 % KCL 20 MEQ % DEXT/0.3% NACL P W 0.3% KCL 40 MEQ % DEXTROSE (D5W)... 4 PARENTERAL SOLUTIONS (LARGE & SMALL VOL)...3 5% DEXTROSE W 0.15% KCL 20 MEQ... 4 PMS-BISACODYL...4 5% DEXTROSE W 0.3% KCL 40 MEQ... 4 PMS-DOCUSATE CALCIUM...4 PMS-DOCUSATE SODIUM...4 A PMS-DOCUSATE SODIUM...5 APO-BISACODYL... 4 PMS-SENNOSIDES...5 APO-DOCUSATE SODIUM... 5 POTASSIUM CHLORIDE...4 APO-MEGESTROL... 3 R B RAN-FENTANYL...3 BISACODYL... 4 RATIO-FENTANYL...3 BUPIVACAINE HCL... 5 RATIO-DOCUSATE CALCIUM...4 BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE... 6 RATIO-DOCUSATE SODIUM...4 RATIO-DOCUSATE SODIUM...5 RIVA-SENNA...5 C CALAX... 4 S COLACE... 4 SELAX...4 COLACE... 5 SELAX...5 SELAX D SENNA...5 SENNATAB...5 DOCUSATE CALCIUM... 4 SENNOSIDES...5 DOCUSATE SODIUM... 4 SENNOSIDES/DOCUSATE SODIUM...5 DOCUSATE SODIUM... 5 SENOKOT...5 DULCOLAX... 4 SENOKOT S...5 DURAGESIC... 3 SENSORCAINE...5 SENSORCAINE WITH EPINEPHRINE...6 E SODIUM CHLORIDE...3 ENEMOL... 5 SODIUM CITRATE/SORBITOL/ SODIUM LAURYL SULFOACETATE...5 F SODIUM PHOSPHATE / SODIUM ACID FENTANYL... 3 PHOSPHATE...5 FENTANYL CITRATE... 3 SOFLAX...4 FLEET ENEMA... 5 SOFLAX...5 FLEET ENEMA PEDITARIC (65ML)... 5 L LACTATED RINGER S... 4 M MEGACE... 3 MEGACE OS... 3 MEGESTROL ACETATE... 3 MICROLAX MICRO - ENEMA... 5 EFFECTIVE APRIL 1,
16 Appendix 3 Numerical List by Drug Identification Numbers DIN Page DIN Page DIN Page EFFECTIVE APRIL 1, 2007
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