20:00 Blood Formation and Coagulation

FERROUS FUMARATE

FERROUS GLUCONATE

FERROUS SULFATE

IRON

IRON (IRON ISOMALTOSIDE 1000)

IRON DEXTRAN

IRON SUCROSE

POLYSACCHARIDE IRON COMPLEX

Limited use benefit (prior approval not required).

For children 12 years of age or under.

ACENOCOUMAROL

APIXABAN

Limited use benefit (prior approval required).

For at-risk patients (CHADS2 score ≥1) with non-valvular atrial fibrillation who require apixaban for the prevention of stroke and systemic embolism and in whom:

• anticoagulation is inadequate (outside the desired INR range for at least 35% of the tests) with a two-month trial of warfarin; or
• anticoagulation with warfarin is contraindicated; or
• anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
• or

For the treatment of venous thromboembolism: deep vein thrombosis (DVT) or pulmonary embolism (PE)

DABIGATRAN ETEXILATE MESILATE

Limited use benefit (prior approval required).

For at-risk patients (CHADS2 score ≥1) with non-valvular atrial fibrillation who require dabigatran etexilate for the prevention of stroke and systemic embolism and in whom:

• anticoagulation is inadequate (outside the desired INR range for at least 35% of the tests) with a two-month trial of warfarin; or
• anticoagulation with warfarin is contraindicated; or
• anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).

DALTEPARIN SODIUM

EDOXABAN (EDOXABAN TOSYLATE MONOHYDRATE)

Limited use benefit (prior approval required).

For at-risk patients (CHADS2 score ≥1) with non-valvular atrial fibrillation who require edoxaban for the prevention of stroke and systemic embolism and in whom:

• anticoagulation is inadequate (outside the desired INR range for at least 35% of the tests) with a two-month trial of warfarin; or
• anticoagulation with warfarin is contraindicated; or
• anticoagulation with warfarin is not possible due to inability to regularly monitor via INR testing (i.e., no access to INR testing services at a laboratory, clinic, pharmacy and at home).
• or

For the treatment of venous thromboembolism: deep vein thrombosis (DVT) or pulmonary embolism (PE)

ENOXAPARIN SODIUM

HEPARIN

HEPARIN SODIUM

NADROPARIN CALCIUM

RIVAROXABAN

Limited use benefit (prior approval required).

Criteria for rivaroxaban 15 mg, 20mg tablets (Xarelto) for stroke prevention in atrial fibrillation (SPAF)

For at-risk patients (CHADS2 score ≥1) with non-valvular atrial fibrillation who require rivaroxaban for the prevention of stroke and systemic embolism and in whom:

• anticoagulation is inadequate (outside the desired INR range for at least 35% of the tests) with a two-month trial of warfarin; or
• anticoagulation with warfarin is contraindicated; or
• anticoagulation is not possible due to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e., no access to INR testing service at a laboratory, clinic, pharmacy, and at home)

Criteria for rivaroxaban 15 mg, 20mg tablets (Xarelto)

For the treatment of venous thromboembolism: deep vein thrombosis (DVT) or pulmonary embolism (PE).

RIVAROXABAN (10)

Limited use benefit (prior approval not required).

For the prevention of venous thromboembolism following total knee replacement or total hip replacement surgery, for up to 35 days.

RIVAROXABAN (CAD,PAD)

Limited use benefit (prior approval required).

Rivaroxaban will be used in combination with acetylsalicylic acid for the prevention of stroke, myocardial infarction, and cardiovascular death, and for the prevention of acute limb ischemia and mortality in patients with concomitant coronary artery disease (CAD) and peripheral artery disease (PAD) as defined below:

1. Patient has CAD defined as having one or more of the following:

• myocardial infarction within the last 20 years; or
• multi-vessel coronary disease (i.e., stenosis of ≥ 50% in two or more coronary arteries, or in one coronary territory if at least one other territory has been revascularized) with symptoms or history of stable or unstable angina; or
• multi-vessel percutaneous coronary intervention; or
• multi-vessel coronary artery bypass graft surgery
• and
• aged 65 years or older; or
• aged younger than 65 years and presents with documented atherosclerosis or revascularization involving at least two vascular beds (coronary and other vascular) or has at least two additional risk factors.*

* Additional risk factors include: current smoker, diabetes mellitus, estimated glomerular filtration rate <60mL/min, heart failure, non-lacunar ischemic stroke 1 month or more ago.

and

2. Patient has PAD defined as having one or more of the following:

• previous aorto-femoral bypass surgery, limb bypass surgery, or percutaneous transluminal angioplasty revascularization of the iliac or infrainguinal arteries; or
• previous limb or foot amputation for arterial vascular disease; or
• history of intermittent claudication with an anklebrachial index less than 0.90 or significant peripheral artery stenosis (≥ 50%) documented by angiography or by duplex ultrasound; or
• previous carotid revascularization or asymptomatic carotid artery stenosis greater than or equal to 50%, as diagnosed by duplex ultrasound or angiography.

TINZAPARIN SODIUM

WARFARIN SODIUM

ANAGRELIDE HYDROCHLORIDE

CLOPIDOGREL BISULFATE

TICAGRELOR

Limited use benefit (prior approval not required).

For the treatment of Acute Coronary Syndrome, defined as unstable angina or myocardial infarction, when initiated in hospital in consultation with a specialist in cardiology, cardiac surgery, cardiovascular & thoracic surgery, internal medicine or general surgery. Treatment must be in combination with low dose ASA.

Special authorization may be granted for 12 months.

TICLOPIDINE HYDROCHLORIDE

FILGRASTIM

PEGFILGRASTIM

Limited use benefit (prior approval required).

Chemotherapy support

Primary prophylaxis

• for use in previously untreated patients receiving a moderate to severely myelosuppressive chemotherapy regimen (i.e. ≥40% incidence of febrile neutropenia). Febrile neutropenia is defined as a temperature ≥38.5°C or >38.0°C three times in a 24 hour period and neutropenia with an absolute neutrophil count (ANC) <0.5 x 109/L.

Secondary prophylaxis

• for use in patients receiving myelosuppressive chemotherapy who have experienced an episode of febrile neutropenic sepsis or profound neutropenia in a previous cycle of chemotherapy; or
• for use in patients who have experienced a dose reduction or treatment delay longer than one week, due to neutropenia.

The recommended dosage of pegfilgrastim is a single subcutaneous injection of 6 mg, administered once per cycle of chemotherapy. Pegfilgrastim should be administered no sooner than 24 hours after the administration of cytotoxic chemotherapy.

PEGFILGRASTIM (LAPELGA)

PLERIXAFOR

Limited use benefit (prior approval required).

For use in combination with filgrastim to mobilize hematopoietic stem cells for subsequent autologous transplantation in patients with:

• Non-Hodgkin's lymphoma (NHL); or
• multiple myeloma (MM);
• and
• prescribed by an oncologist or hematologist.

and if one of the following are met

• a PBCD34+ count of < 10 cells/uL after 4 days of filgrastim; or
• less than 50% of the target CD34 yield is achieved on the 1st day of apheresis (after being mobilized with filgrastim alone or following chemotherapy); or
• if a patient has failed a previous stem cell mobilization with filgrastim alone or following chemotherapy.

Reimbursement is limited to a maximum of 4 doses (0.24mg/kg given daily) for a single mobilization attempt.

The dose of Mozobil is limited to a maximum of 40mg per day

PENTOXIFYLLINE

TRANEXAMIC ACID