Palliative Coverage Drug Benefit Supplement
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1 Palliative Coverage Drug Benefit Supplement Effective April 1, 2017
2 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) 109BWebsite: Administered by Alberta Blue Cross on behalf of Alberta Health. The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Copies of the Alberta Drug Benefit List Publication are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: ( G.S.T.) Contents only: ( G.S.T.) A cheque or money order must accompany the request for 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 version or updates. Please visit for the most current Palliative Coverage Drug Benefit Supplement information. ABC 40211/81160 (R2017/04)
3 Table of Contents PALLIATIVE COVERAGE DRUG BENEFIT SUPPLEMENT SECTION 1 - INTRODUCTION AND THERAPEUTIC CLASSIFICATION OF DRUGS Introduction Eligibility... i Price Policy... i Interchangeable Drug Products... i Excluded Special Authorization Drug Products... ii Pharmacologic-Therapeutic Classification of Drugs 10:00 Antineoplastic Agents :00 Central Nervous System Drugs :00 Electrolytic, Caloric, and Water Balance :00 Gastrointestinal Drugs :00 Local Anesthetics... 4 APPENDICES Appendix 1 - Pharmaceutical Manufacturers... 5 Appendix 2 - Alphabetical List of Pharmaceutical Products... 6 Appendix 3 - Numerical List by Drug Identification Number... 7 EFFECTIVE APRIL 1, 2017 i
4 SECTION 1 Introduction and Therapeutic Classification of Drugs Section 1 Introduction and Therapeutic Classification of Drugs
5 INTRODUCTION Eligibility Benefits for Palliative Coverage are defined by the Alberta Drug Benefit List and the Palliative Coverage Drug Benefit Supplement (which defines select hydrating agents, laxatives and other products as additional benefits). In order for patients to be eligible for Palliative Coverage, an application for the Palliative Coverage Program must be completed and signed by both the patient (or guardian) and the physician. This Palliative Coverage Program application form must be forwarded to Alberta Health for their consideration and approval. Price Policy The Price Policy is stated in the Alberta Drug Benefit List. 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 Drug Benefit List for further information regarding interchangeable drug products. EFFECTIVE APRIL 1, 2017 i
6 Excluded Special Authorization Drug Products The following drug product(s) are listed in the special authorization section (Section 3) of the Alberta Drug Benefit List, however, special authorization coverage for these drug product(s) cannot be considered for those patients with Palliative Coverage: Trade Name / Strength / Form Generic Description DIN MFR NEULASTA (0.6 ML SYRINGE) 6 MG / SYR INJECTION SYRINGE PEGFILGRASTIM AMG NEUPOGEN 0.3 MG / ML INJECTION FILGRASTIM AMG Excluded Criteria: "In patients with non-myeloid malignancies, receiving myelosuppresive anti-neoplastic drugs with curative intent, to decrease the incidence of infection, as manifested by febrile neutropenia." EFFECTIVE APRIL 1, 2017 ii.
7 Pharmacologic Therapeutic Classification of Drugs Pharmacologic -Therapeutic Classification of Drugs
8 10:00 ANTINEOPLASTIC AGENTS 10:00 MEGESTROL ACETATE 40 MG ORAL TABLET MEGESTROL 160 MG ORAL TABLET MEGESTROL 40 MG / ML ORAL SUSPENSION MEGACE OS AAP AAP BMS :00 CENTRAL NERVOUS SYSTEM AGENTS 28:08.08 ANALGESICS AND ANTIPYRETICS (OPIATE AGONISTS) FENTANYL 12 MCG/HR TRANSDERMAL PATCH CO FENTANYL MYLAN-FENTANYL MATRIX FENTANYL MTX RAN-FENTANYL MATRIX SANDOZ FENTANYL PATCH A-FENTANYL 25 MCG/HR TRANSDERMAL PATCH APO-FENTANYL CO FENTANYL MYLAN-FENTANYL MATRIX FENTANYL MTX RAN-FENTANYL MATRIX SANDOZ FENTANYL PATCH A-FENTANYL 50 MCG/HR TRANSDERMAL PATCH APO-FENTANYL CO FENTANYL MYLAN-FENTANYL MATRIX FENTANYL MTX RAN-FENTANYL MATRIX SANDOZ FENTANYL PATCH A-FENTANYL 75 MCG/HR TRANSDERMAL PATCH APO-FENTANYL CO FENTANYL MYLAN-FENTANYL MATRIX FENTANYL MTX RAN-FENTANYL MATRIX SANDOZ FENTANYL PATCH A-FENTANYL 100 MCG/HR TRANSDERMAL PATCH APO-FENTANYL 100 CO FENTANYL MYLAN-FENTANYL MATRIX -FENTANYL MTX RAN-FENTANYL MATRIX SANDOZ FENTANYL PATCH A-FENTANYL APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN SDZ UNIT OF ISSUE - REFER TO PRICE POLICY 1 EFFECTIVE APRIL 1, 2017
9 28:00 40:00 56:00 CENTRAL NERVOUS SYSTEM AGENTS 28:08.08 FENTANYL CITRATE 0.05 MG / ML (BASE) INJECTION FENTANYL CITRATE PARENTERAL SOLUTIONS (LARGE & SMALL VOL) INJECTION POTASSIUM CHLORIDE (K+) 149 MG / ML INJECTION POTASSIUM CHLORIDE SODIUM CHLORIDE 0.9 % INJECTION BISACODYL 5 MG ORAL ENTERIC-COATED TABLET APO-BISACODYL APX DULCOLAX SAV Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Coverage Drug Coverage program. 10 MG RECTAL SUPPOSITORY DULCOLAX SAV Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Coverage Drug Coverage program. DOCUSATE CALCIUM (OPIATE AGONISTS) ELECTROLYTIC, CALORIC, AND WATER BALANCE 40:12 GASTROINTESTINAL DRUGS 56:12 ANALGESICS AND ANTIPYRETICS REPLACEMENT PREPARATIONS 0.9% SODIUM CHLORIDE 3.3% DEXT/ 0.3% NACL (2/3-1/3) 3.3% DEXT/0.3% NACL/20 MEQ KCL 3.3% DEXT/0.3% NACL/40 MEQ KCL 5% DEXTROSE (D5W) 5% DEXTROSE/ 0.15% KCL 20 MEQ 5% DEXTROSE/ 0.3% KCL 40 MEQ LACTATED RINGER'S SODIUM CHLORIDE CATHARTICS AND LAXATIVES 240 MG ORAL CAPSULE JAMP-DOCUSATE CALCIUM A-DOCUSATE CALCIUM DOCUSATE CALCIUM SDZ HSP HSP JPC PRODUCT IS NOT INTERCHANGEABLE 2 EFFECTIVE APRIL 1, 2017
10 56:00 GASTROINTESTINAL DRUGS 56:12 DOCUSATE SODIUM 100 MG ORAL CAPSULE SELAX DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM SOFLAX A-DOCUSATE SODIUM APO-DOCUSATE SODIUM COLACE 200 MG ORAL CAPSULE SOFLAX 4 MG / ML ORAL SYRUP RATIO-DOCUSATE SODIUM SELAX ODN COLACE WSB DOCUSATE SODIUM Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Coverage Drug Coverage program. 50 MG / ML ORAL SYRUP DOCUSATE SODIUM 10 MG / ML ORAL DROPS COLACE WSB POLYETHYLENE GLYCOL G / G ORAL POWDER EMOLAX LAX-A-DAY RELAXA SENNOSIDES CATHARTICS AND LAXATIVES 8.6 MG ORAL TABLET JAMP-SENNA SENNOSIDES SENNATAB SENNOSIDES SENOKOT 12 MG ORAL TABLET SENNOSIDES SENNOSIDES 1.7 MG / ML ORAL LIQUID JAMP SENNAQUIL 1.7 MG / ML ORAL SYRUP SENOKOT SENNOSIDES/ DOCUSATE SODIUM 8.6 MG * 50 MG ORAL TABLET SENOKOT S SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE 10.4 G / ENM * 3.9 G / ENM RECTAL ENEMA ENEMOL ODN TAR SNS APX WSB JPC PPH PPI JPC JPC PUR JPC JPC PUR PUR PPH UNIT OF ISSUE - REFER TO PRICE POLICY 3 EFFECTIVE APRIL 1, 2017
11 72:00 LOCAL ANESTHETICS 72:00 BUPIVACAINE HCL 2.5 MG / ML INJECTION BUPIVACAINE 5 MG / ML INJECTION BUPIVACAINE STM STM BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE 2.5 MG / ML * 5 MCG / ML INJECTION SENSORCAINE WITH EPINEPHRINE 5 MG / ML * 5 MCG / ML INJECTION SENSORCAINE WITH EPINEPHRINE AZC AZC PRODUCT IS NOT INTERCHANGEABLE 4 EFFECTIVE APRIL 1, 2017
12 Appendices APPENDICES Pharmaceutical Manufacturers Alphabetical List of Pharmaceutical Products Numerical List by Drug Identification Number
13 APPENDIX 1 PHARMACEUTICAL MANUFACTURERS Appendix 1 Pharmaceutical Manufacturers AAP APH APX AZC BMS HSP JPC MYP ODN PPH PPI PUR RAN SAV SDZ SNS STM TAR WSB A AA Pharma Inc. Actavis Pharma Company Apotex Inc. AstraZeneca Canada Inc. B Bristol-Myers Squibb H Hospira Healthcare Corporation J Jamp Pharma Corporation M Mylan Pharmaceuticals ULC O Odan Laboratories Ltd. P Pharmascience Inc. Pendopharm Inc. Pediapharm Inc. Purdue Pharma R Ranbaxy Pharmaceuticals Canada Inc. S Sanofi-Aventis Sandoz Canada Inc. Sanis Health Inc. Sterimax Inc. T Taro Pharmaceuticals Inc. Teva Canada Limited W Wellspring Pharmaceuticals/Boyd Pharma X Miscellaneous Manufactures EFFECTIVE APRIL 1,
14 APPENDIX 2 ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS Appendix 2: Alphabetical List of Pharmaceutical Products Product Name Page Product Name Page NUMERIC 0.9% SODIUM CHLORIDE % DEXT/ 0.3% NACL (2/3-1/3) % DEXT/0.3% NACL/20 MEQ KCL % DEXT/0.3% NACL/40 MEQ KCL % DEXTROSE (D5W) % DEXTROSE/ 0.15% KCL 20 MEQ % DEXTROSE/ 0.3% KCL 40 MEQ... 2 A APO-BISACODYL... 2 APO-DOCUSATE SODIUM... 3 APO-FENTANYL APO-FENTANYL APO-FENTANYL APO-FENTANYL B BISACODYL... 2 BUPIVACAINE... 4 BUPIVACAINE HCL... 4 BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE... 4 C CO FENTANYL... 1 COLACE... 3 D DOCUSATE CALCIUM... 2 DOCUSATE SODIUM... 3 DULCOLAX... 2 E EMOLAX... 3 ENEMOL... 3 F FENTANYL... 1 FENTANYL CITRATE... 2 J JAMP SENNAQUIL... 3 JAMP-DOCUSATE CALCIUM... 2 JAMP-SENNA... 3 L LACTATED RINGER'S... 2 LAX-A-DAY... 3 M MEGACE OS... 1 MEGESTROL... 1 MEGESTROL ACETATE... 1 MYLAN-FENTANYL MATRIX... 1 P PARENTERAL SOLUTIONS (LARGE & SMALL VOL). 2 -DOCUSATE CALCIUM DOCUSATE SODIUM FENTANYL MTX SENNOSIDES... 3 POLYETHYLENE GLYCOL POTASSIUM CHLORIDE... 2 POTASSIUM CHLORIDE (K+)... 2 R RAN-FENTANYL MATRIX... 1 RATIO-DOCUSATE SODIUM... 3 RELAXA... 3 S SANDOZ FENTANYL PATCH... 1 SELAX... 3 SENNATAB... 3 SENNOSIDES... 3 SENNOSIDES/ DOCUSATE SODIUM... 3 SENOKOT... 3 SENOKOT S... 3 SENSORCAINE WITH EPINEPHRINE... 4 SODIUM CHLORIDE... 2 SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE 3 SOFLAX... 3 T A-DOCUSATE CALCIUM... 2 A-DOCUSATE SODIUM... 3 A-FENTANYL... 1 EFFECTIVE APRIL 1,
15 APPENDIX 3 NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page EFFECTIVE APRIL 1,
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