20:00 Blood Formation and Coagulation

20:04.04 IRON PREPARATIONS

FERROUS FUMARATE

Table: FERROUS FUMARATE
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Capsule 80061196 MFER FUMARATE MAN
ST300MG Capsule 02237556 EUROFER EUR
ST300MG Capsule 00482064 NEO-FER NEB
ST300MG Capsule 01923420 PALAFER VAE
ST20MG Suspension 80029822 JAMP-FERROUS FUMARATE JMP
ST60MG/ML Suspension 01923439 PALAFER VAE
ST300MG/5ML Suspension 02246590 FERRATE EUR
ST100MG Tablet 80024544 JAMP FERROUS FUMARATE JMP
ST300MG Tablet 00031089 FERROUS FUMARATE WAM

FERROUS GLUCONATE

Table: FERROUS GLUCONATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST300MG Tablet 00545031 APO-FERROUS GLUCONATE APX
ST300MG Tablet 00031097 FERROUS GLUCONATE JMP
ST300MG Tablet 00041157 FERROUS GLUCONATE ADA
ST300MG Tablet 02244532 FERROUS GLUCONATE PMT
ST300MG Tablet 80000435 FERROUS GLUCONATE NUR
ST300MG Tablet 80002426 FERROUS GLUCONATE WNP
ST300MG Tablet 80006316 FERROUS GLUCONATE UNK
ST300MG Tablet 80009681 WAMPOLE FERROUS GLUCONATE WAM
ST324MG Tablet 00582727 IRON FERROUS GLUCONATE VTH

FERROUS SULFATE

Table: FERROUS SULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST30MG/ML Liquid 80008295 JAMP FERROUS SULFATE LIQUID5 JMP
ST75MG/ML Liquid 00762954 ENFAMIL FERINSOL MJO
ST75MG/ML Liquid 80008309 JAMP FERROUS SULFATE JMP
ST6MG/ML Solution 00017884 ENFAMIL FERINSOL MJO
ST6MG/ML Solution 02242863 PEDIAFER EUR
ST15MG/ML Solution 02237385 FERODAN INFANT DROPS ODN
ST15MG/ML Solution 02232202 PEDIAFER EUR
ST15MG/ML Solution 02222574 PMS-FERROUS SULFATE PMS
ST30MG/ML Solution 00758469 FERODAN ODN
ST30MG/ML Solution 00792675 PMS-FERROUS SULFATE PMS
ST125MG/ML Solution 00816035 PMS-FERROUS SULFATE PMS
ST60MG Tablet 80012039 IRON WNP
ST300MG Tablet 02246733 EURO-FERROUS SULFATE EUR
ST300MG Tablet 02248699 FERODAN ODN
ST300MG Tablet 00346918 FERROUS SULFATE PMT
ST300MG Tablet 00782114 FERROUS SULFATE VTH
ST300MG Tablet 00031100 FERROUS SULPHATE JMP
ST300MG Tablet 80057416 M-SULFATE FERREUX MAN
ST300MG Tablet 00586323 PMS-FERROUS SULFATE PMS

IRON

Table: IRON
Drug strength and dosage form DIN Brand name Manufacturer code
ST100MG Capsule 80024232 JAMP-FER JMP
12.5MG/ML Liquid 02243333 FERRLECIT SAC

IRON (IRON ISOMALTOSIDE 1000)

Table: IRON (IRON ISOMALTOSIDE 1000)
Drug strength and dosage form DIN Brand name Manufacturer code
100MG Solution 02477777 MONOFERRIC UNK

IRON DEXTRAN

Table: IRON DEXTRAN
Drug strength and dosage form DIN Brand name Manufacturer code
50MG/ML Liquid 02221780 INFUFER SDZ
50MG/ML Solution 02205963 DEXIRON UNK

IRON SUCROSE

Table: IRON SUCROSE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG/ML Solution 02243716 VENOFER UNK
pDIN For Extemporaneous Mixture 99506015 IRON SUCROSE STERILE INFUSION UNK

POLYSACCHARIDE IRON COMPLEX

Limited use benefit (prior approval not required).

For children 12 years of age or under.

Table: POLYSACCHARIDE IRON COMPLEX
Drug strength and dosage form DIN Brand name Manufacturer code
15MG Powder 80033717 FERAMAX POWDER WATER SOLUBLE POLYSACCHARIDE IRON COMPLEX BSY

20:12.04 ANTICOAGULANTS

ACENOCOUMAROL

Table: ACENOCOUMAROL
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Tablet 00010383 SINTROM PAL
ST4MG Tablet 00010391 SINTROM PAL

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)

Table: APIXABAN
Drug strength and dosage form DIN Brand name Manufacturer code
ST2.5MG Tablet 02377233 ELIQUIS BMS
ST5MG Tablet 02397714 ELIQUIS BMS

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).
Table: DABIGATRAN ETEXILATE MESILATE
Drug strength and dosage form DIN Brand name Manufacturer code
110MG Capsule 02468905 APO-DABIGATRAN APX
ST110MG Capsule 02312441 PRADAXA BOE
150MG Capsule 02468913 APO-DABIGATRAN APX
ST150MG Capsule 02358808 PRADAXA BOE

DALTEPARIN SODIUM

Table: DALTEPARIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
2,500IU/0.2ML Solution 02132621 FRAGMIN PFI
3,500IU/0.28ML Solution 02430789 FRAGMIN PFI
5,000IU/0.2ML Solution 02132648 FRAGMIN PFI
7,500IU/0.3ML Solution 02352648 FRAGMIN PFI
10,000IU/0.4ML Solution 02352656 FRAGMIN PFI
10,000IU/ML Solution 02132664 FRAGMIN PFI
12,500IU/0.5ML Solution 02352664 FRAGMIN PFI
15,000IU/0.6ML Solution 02352672 FRAGMIN PFI
18,000IU/0.72ML Solution 02352680 FRAGMIN PFI
25,000IU/ML Solution 02231171 FRAGMIN PFI

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)

Table: EDOXABAN (EDOXABAN TOSYLATE MONOHYDRATE)
Drug strength and dosage form DIN Brand name Manufacturer code
15MG Tablet 02458640 LIXIANA SEV
30MG Tablet 02458659 LIXIANA SEV
60MG Tablet 02458667 LIXIANA SEV

ENOXAPARIN SODIUM

Table: ENOXAPARIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
30MG/0.3ML Solution 02012472 LOVENOX SAC
40MG/0.4ML Solution 02236883 LOVENOX SAC
60MG/0.6ML Solution 02378426 LOVENOX SAC
80MG/0.8ML Solution 02378434 LOVENOX SAC
100MG/1ML Solution 02378442 LOVENOX SAC
150MG/1.0ML Solution 02242692 LOVENOX HP SAC
150MG/ML Solution 02378469 LOVENOX HP SAC
300MG/3ML Solution 02236564 LOVENOX SAC

HEPARIN

Table: HEPARIN
Drug strength and dosage form DIN Brand name Manufacturer code
Injection 09991680 HEPARIN IV FLUSH SYR UNK

HEPARIN SODIUM

Table: HEPARIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
100U/ML Liquid 00727520 HEPARIN LEO LEO
1,000U/ML Liquid 00453811 HEPARIN LEO LEO
1,000 U/ML Solution 02303086 HEPARIN SODIUM (MULTIDOSE VIAL-WITH PRESERVATIVE) SDZ
10,000 U/ML Solution 02303108 HEPARIN SODIUM (MULTIDOSE VIAL-WITH PRESERVATIVE) SDZ
10,000 U/ML Solution 02303094 HEPARIN SODIUM (SINGLE USE VIAL-PRESERVATIVE FREE) SDZ
5000U Solution 02456958 HEPARIN SODIUM UNK
10,000U Solution 02392453 HEPARIN SODIUM FKD

NADROPARIN CALCIUM

Table: NADROPARIN CALCIUM
Drug strength and dosage form DIN Brand name Manufacturer code
9,500IU/ML Solution 02236913 FRAXIPARINE ASP
19,000IU/ML Solution 02240114 FRAXIPARINE FORTE ASP

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).

Table: RIVAROXABAN
Drug strength and dosage form DIN Brand name Manufacturer code
ST15MG Tablet 02378604 XARELTO BAY
ST20MG Tablet 02378612 XARELTO BAY

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.

Table: RIVAROXABAN (10)
Drug strength and dosage form DIN Brand name Manufacturer code
ST10MG Tablet 02316986 XARELTO BAY

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.
Table: RIVAROXABAN (CAD,PAD)
Drug strength and dosage form DIN Brand name Manufacturer code
2.5MG Tablet 02480808 XARELTO BAY

TINZAPARIN SODIUM

Table: TINZAPARIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
2,500IU/0.25ML Solution 02229755 INNOHEP LEO
3,500IU/0.35ML Solution 02358158 INNOHEP LEO
4,500IU/0.45ML Solution 02358166 INNOHEP LEO
8,000IU/0.4ML Solution 02429462 INNOHEP LEO
10,000IU/0.5ML Solution 02231478 INNOHEP LEO
10,000IU/ML Solution 02167840 INNOHEP LEO
12,000IU/0.6ML Solution 02429470 INNOHEP LEO
14,000IU/0.7ML Solution 02358174 INNOHEP LEO
16,000IU/0.8ML Solution 02429489 INNOHEP LEO
18,000IU/0.9ML Solution 02358182 INNOHEP LEO
20,000IU/ML Solution 02229515 INNOHEP LEO

WARFARIN SODIUM

Table: WARFARIN SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST1MG Tablet 02242924 APO-WARFARIN APX
ST1MG Tablet 01918311 COUMADIN BMS
ST1MG Tablet 02242680 TARO-WARFARIN TAR
ST2MG Tablet 02242925 APO-WARFARIN APX
ST2MG Tablet 01918338 COUMADIN BMS
ST2MG Tablet 02242681 TARO-WARFARIN TAR
ST2.5MG Tablet 02242926 APO-WARFARIN APX
ST2.5MG Tablet 01918346 COUMADIN BMS
ST2.5MG Tablet 02242682 TARO-WARFARIN TAR
ST3MG Tablet 02245618 APO-WARFARIN APX
ST3MG Tablet 02240205 COUMADIN BMS
ST3MG Tablet 02242683 TARO-WARFARIN TAR
ST4MG Tablet 02242927 APO-WARFARIN APX
ST4MG Tablet 02007959 COUMADIN BMS
ST4MG Tablet 02242684 TARO-WARFARIN TAR
ST5MG Tablet 02242928 APO-WARFARIN APX
ST5MG Tablet 01918354 COUMADIN BMS
ST5MG Tablet 02242685 TARO-WARFARIN TAR
6MG Tablet 02240206 COUMADIN BMS
ST6MG Tablet 02242686 TARO-WARFARIN TAR
ST7.5MG Tablet 02242697 TARO-WARFARIN TAR
ST10MG Tablet 02242929 APO-WARFARIN APX
ST10MG Tablet 01918362 COUMADIN BMS
ST10MG Tablet 02242687 TARO-WARFARIN TAR

20:12.14 PLATELET AGGREGATION INHIBITORS

ANAGRELIDE HYDROCHLORIDE

Table: ANAGRELIDE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST0.5MG Capsule 02236859 AGRYLIN SHI
ST0.5MG Capsule 02274949 PMS-ANAGRELIDE PMS
ST0.5MG Capsule 02260107 SANDOZ ANAGRELIDE SDZ

20:12.18 PLATELET AGGREGATION INHIBITORS

CLOPIDOGREL BISULFATE

Table: CLOPIDOGREL BISULFATE
Drug strength and dosage form DIN Brand name Manufacturer code
ST75MG Tablet 02303027 ACT CLOPIDOGREL TEV
ST75MG Tablet 02252767 APO-CLOPIDOGREL APX
ST75MG Tablet 02416387 AURO-CLOPIDOGREL AUR
ST75MG Tablet 02385813 CLOPIDOGREL SIV
ST75MG Tablet 02394820 CLOPIDOGREL PDL
ST75MG Tablet 02400553 CLOPIDOGREL SAN
ST75MG Tablet 02378507 DOM-CLOPIDOGREL DPC
ST75MG Tablet 02415550 JAMP-CLOPIDOGREL JMP
ST75MG Tablet 02422255 MAR-CLOPIDOGREL MAR
ST75MG Tablet 02238682 PLAVIX SAC
ST75MG Tablet 02348004 PMS-CLOPIDOGREL PMS
ST75MG Tablet 02388529 RIVA-CLOPIDOGREL RIV
ST75MG Tablet 02359316 SANDOZ CLOPIDOGREL SDZ
ST75MG Tablet 02379813 TARO-CLOPIDOGREL RBY
ST75MG Tablet 02293161 TEVA-CLOPIDOGREL TEV

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.

Table: TICAGRELOR
Drug strength and dosage form DIN Brand name Manufacturer code
60MG Tablet 02455005 BRILINTA AZC
ST90MG Tablet 02368544 BRILINTA AZC

TICLOPIDINE HYDROCHLORIDE

Table: TICLOPIDINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
ST250MG Tablet 02237701 TICLOPIDINE AAP

20:16.00 HEMATOPOIETIC AGENTS

FILGRASTIM

Table: FILGRASTIM
Drug strength and dosage form DIN Brand name Manufacturer code
300MCG/ML Injection 09853464 NEUPOGEN (ON) AMG
300MCG/ML Injection 99001454 NEUPOGEN (QC) AMG
300MCG Solution 02441489 GRASTOFIL APX
300MCG/ML Solution 01968017 NEUPOGEN AMG
480MCG Solution 02454548 GRASTOFIL APX

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.

Table: PEGFILGRASTIM
Drug strength and dosage form DIN Brand name Manufacturer code
10MG Solution 02484153 FULPHILA BGP
10MG/ML Solution 02249790 NEULASTA AMG

PEGFILGRASTIM (LAPELGA)

Table: PEGFILGRASTIM (LAPELGA)
Drug strength and dosage form DIN Brand name Manufacturer code
6MG Solution 02474565 LAPELGA APX

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

Table: PLERIXAFOR
Drug strength and dosage form DIN Brand name Manufacturer code
20MG Solution 02377225 MOZOBIL SAC

20:24.00 HEMORRHEOLOGIC AGENTS

PENTOXIFYLLINE

Table: PENTOXIFYLLINE
Drug strength and dosage form DIN Brand name Manufacturer code
ST400MG Tablet (Extended Release) 02230090 PENTOXIFYLLINE AAP

20:28.16 HEMOSTATICS

TRANEXAMIC ACID

Table: TRANEXAMIC ACID
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet 02064405 CYKLOKAPRON PFI
500MG Tablet 02409097 GD-TRANEXAMIC ACID PFI
500MG Tablet 02401231 TRANEXAMIC ACID RAX
pDIN For Extemporaneous Mixture 99503006 TRANEXAMIC DENTAL MOUTHWASH UNK
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