96:00 Pharmaceutical aids

96:00.00 PHARMACEUTICAL AIDS

ADMINISTRATION DIN

Table: ADMINISTRATION DIN
Drug strength and dosage form DIN Brand name Manufacturer code
Miscellaneous 00903725 REFUSAL TO FILL UNK

ADULT

Limited use benefit (prior approval required).

Criteria for nutritional supplement coverage for adults

  • sole source nutrition (more than 75% of intake is from nutritional supplement)
  • unintentional weight loss
  • wound care
  • pre or post-surgery (6 months before or after date of surgery)
  • other medical conditions not listed
Table: ADULT
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 95900061 BOOST DIABETIC 237ML LIQ NES
Oral Liquid 95999963 BOOST ORIGINAL 237ML LIQ NES
Oral Liquid 95900050 ENSURE 235ML LIQ ABB
Oral Liquid 95900139 ENSURE FIBRE 235ML LIQ ABB
Oral Liquid 95900140 GLUCERNA 237ML LIQ ABB
Oral Liquid 95900076 ISOSOURCE 1.0 HP 250ML LIQ NES
Oral Liquid 95900072 ISOSOURCE 1.2 CAL 1500ML LIQ NES
Oral Liquid 95900071 ISOSOURCE 1.2 CAL 250ML LIQ NES
Oral Liquid 95900073 ISOSOURCE 1.5 CAL 250ML LIQ NES
Oral Liquid 95900209 ISOSOURCE FIBRE 1.2 CAL 250ML LIQ NES
Oral Liquid 95900075 ISOSOURCE FIBRE 1.5 CAL 1500ML LIQ NES
Oral Liquid 95900074 ISOSOURCE FIBRE 1.5 CAL 250ML LIQ NES
Oral Liquid 95900077 ISOSOURCE HN WITH FIBRE 250ML LIQ NES
Oral Liquid 95900217 JEVITY 1.5 CAL ABB
Oral Liquid 95900082 JEVITY 1.5 CAL 235ML LIQ ABB
Oral Liquid 95900078 JEVITY 235ML LIQ ABB
Oral Liquid 95900220 NUTREN 1.5 NES
Oral Liquid 95900088 PEPTAMEN 1.5 1000ML LIQ NES
Oral Liquid 95900087 PEPTAMEN 1.5 250ML LIQ NES
Oral Liquid 95900086 PEPTAMEN 250ML LIQ NES
Oral Liquid 95900091 PEPTAMEN WITH PREBIO 1000ML LIQ NES
Oral Liquid 95900090 PEPTAMEN WITH PREBIO 250ML LIQ NES
Oral Liquid 95900058 RESOURCE 2.0 237ML LIQ NES
Oral Liquid 95900207 RESOURCE DIABETIC 1.5L NES
Oral Liquid 95900062 RESOURCE DIABETIC 250ML LIQ NES
Oral Liquid 95900130 VITAL 1.5 CAL 1000ML LIQ ABB
Oral Liquid 95900128 VITAL PEPTIDE 1 CAL 220ML LIQ ABB
Oral Liquid 95900129 VITAL PEPTIDE 1.5 CAL 220ML LIQ ABB

BASES-EMULSIONS

Limited use benefit (prior approval required).

For the treatment of atopic dermatitis in children 0 to 18 years old.

Coverage is limited to 450 grams per month.

Table: BASES-EMULSIONS
Drug strength and dosage form DIN Brand name Manufacturer code
Cream 09991668 EMOLLIENT FOR ADULTS GSK
ST Cream 99000385 EMOLLIENT FOR CHILDREN WPC

CHILDREN AND YOUTH

Limited use benefit (prior approval required).

Criteria for nutritional supplement coverage for children and youth (19 years and under)

  • sole source nutrition (more than 75% of intake is from nutrition supplement)
  • failure to thrive/growth faltering
  • pre or post-surgery (6 months before or after date of surgery)
  • other medical conditions not listed
Table: CHILDREN AND YOUTH
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 95900131 COMPLEAT PEDIATRIC 250ML LIQ NES
Oral Liquid 95900133 NUTREN JR. 250ML LIQ NES
Oral Liquid 95900177 PEDIASURE 235ML LIQ ABB
Oral Liquid 95900142 PEDIASURE COM. GROW&GAIN 235ML LIQ ABB
Oral Liquid 95900178 PEDIASURE FIBRE 235ML LIQ ABB
Oral Liquid 95900179 PEDIASURE PLUS WITH FIBRE 235 ABB
Oral Liquid 95900135 PEPTAMEN JUNIOR 1.0 CAL 250ML LIQ NES
Oral Liquid 95900136 PEPTAMEN JUNIOR 1.5 CAL 250ML LIQ NES
Oral Liquid 95900137 RESOURCE JUST KIDS 1.5 CAL 237ML LIQ NES
Powder 95900132 NEOCATE JR FIBER&IRON 400G PDR UNK
Powder 95900143 PEDIASURE GROW&GAIN 400G PDR ABB

DEVICE (METHADONE)

Limited use benefit (prior approval is not required).

Coverage is granted for 1 device.

Table: DEVICE (METHADONE)
Drug strength and dosage form DIN Brand name Manufacturer code
Miscellaneous 91500016 METHADONE LOCK BOX UNK

FRUCTOSE

Table: FRUCTOSE
Drug strength and dosage form DIN Brand name Manufacturer code
Powder 00905631 FRUCTOSE UNK

INFANT FORMULATION

Limited use benefit (prior approval required).

Criteria for infant formula coverage < 1 year of age (corrected gestational age for prematurity)

  • contraindications for breastfeeding HIV, hepatitis C, active tuberculosis and herpetic lesions on breast. Please note, contraindications are in accordance with respective Health Canada and World Health Organization guidance.
  • prematurity or low birth weight
  • failure to thrive/growth faltering
  • cow milk protein allergy
  • other medical conditions not listed
Table: INFANT FORMULATION
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 95900007 ENFAMIL A+ 237ML LIQ MJO
Oral Liquid 95900003 ENFAMIL A+ 385ML LIQ MJO
Oral Liquid 95900152 ENFAMIL A+ ENFACARE 385ML LIQ MJO
Oral Liquid 95900012 ENFAMIL LOWER IRON 385ML LIQ MJO
Oral Liquid 95900026 NUTRAMIGEN A+ 945ML LIQ MJO
Oral Liquid 95900000 SIMILAC ALIMENTUM 237ML LIQ ABB
Oral Liquid 95900001 SIMILAC ALIMENTUM 945ML LIQ ABB
Powder 95900164 ENFAMIL A+ 663G PDR MJO
Powder 95900009 ENFAMIL A+ ENFACARE 363G PDR MJO
Powder 95900155 ENFAMIL LOWER IRON 900G PDR MJO
Powder 95900023 NEOCATE 400G PDR UNK
Powder 95900021 NEOCATE JUNIOR 400G PDR UNK
Powder 95900022 NEOCATE ONE 400G UNK
Powder 95900025 NEOCATE W/ DHA & ARA 400G PDR UNK
Powder 95900027 NUTRAMIGEN A+ LGG 561G PDR MJO
Powder 95900035 PURAMINO A+ 400G PDR MJO
Powder 95900112 PURAMINO A+ JUNIOR 400G PDR MJO
Powder 95900047 SIMILAC ALIMENTUM 400G PDR ABB
Powder 95900184 SIMILAC LOWER IRON 850G PDR ABB
Powder 95900036 SIMILAC NEOSURE 363G PDR ABB
Powder 95900044 SIMILAC PM 60/40 450G PDR ABB

NUTRITIONAL SUPPLEMENT

Table: NUTRITIONAL SUPPLEMENT
Drug strength and dosage form DIN Brand name Manufacturer code
Thickening Agent (Powder) 95900123 SOURCE THICKEN UP 227G PDR NES

THICKENING AGENT

Table: THICKENING AGENT
Drug strength and dosage form DIN Brand name Manufacturer code
Kit 09991194 SIMPLY THICK 64OZ BOTTLE PUMP UNK
Powder 95900213 PURATHICK 125G PDR UNK
Powder 12137029 RESOURCE THICKEN CLEAR NVC
Powder 09991163 RESOURCE THICKEN UP 6.4G NVC
Thickening Agent (Kit) 95900118 SIMPLY THICK 64OZ BOTTLE PUMP UNK
Thickening Agent (Powder) 95900190 GELMIX JAR 125G PDR UNK
Thickening Agent (Powder) 95900113 RESOURCE THICKEN CLEAR 125G NES
Thickening Agent (Powder) 95900114 RESOURCE THICKEN UP 6.4G NES
Thickening Agent (Powder) 95900185 SIMPLY THICK HONEY 12G PDR UNK
Thickening Agent (Powder) 95900186 SIMPLY THICK NECTAR 6G PDR UNK

THICKENING GEL

Table: THICKENING GEL
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 09991164 SIMPLY THICK HONEY UNK
Oral Liquid 09991035 SIMPLY THICK NECTAR UNK
Thickening Agent (Powder) 95900119 SIMPLY THICK HONEY 200G UNK
Thickening Agent (Powder) 95900120 SIMPLY THICK NECTAR 200G UNK

WATER

Table: WATER
Drug strength and dosage form DIN Brand name Manufacturer code
Solution 00905178 STERILE WATER UNK
Solution 99002264 STERILE WATER UNK
Syringe 09991563 STERILE WATER PF UNK
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