Appendix C: End of life care formulary
Effective April 1, 2009, recipients diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the Non-Insured Health Benefits (NIHB) drug benefit list. The End of life care formulary includes medications and nutritional supplements used to provide comfort to those near the end of life.
Requests for any of the Drug Identification Numbers (DIN) below will generate an End of life care application form, faxed to the prescribing physician. Once completed and submitted, the recipient will be eligible for all medications on the End of life care formulary if the following criteria are met:
The recipient:
- is not receiving care in a provincially funded hospital or provincially funded long-term care facility
- has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within 6 months or less
Once approved, the recipient will be eligible for all medications on the End of life care formulary for 6 months without the need for further prior approval. If coverage is required beyond the initial 6 months, an additional 6 months may be granted upon receipt of another End of life care application form completed.
During the 6 month coverage period, a maximum 30 day supply will be reimbursed at any one time.
12:00 AUTONOMIC DRUGS
12:08.08 ANTIMUSCARINICS / ANTISPASMODICS
ATROPINE SULFATE
Table: ATROPINE SULFATE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
0.4MG/ML Solution |
02094681 |
ATROPINE |
ALV |
0.4MG/ML Solution |
00960624 |
ATROPINE SULFATE |
UNK |
0.6MG/ML Solution |
00012076 |
ATROPINE SULFATE |
GSK |
0.6MG/ML Solution |
00392693 |
ATROPINE SULFATE |
SDZ |
0.6MG/ML Solution |
00392782 |
ATROPINE SULFATE |
SDZ |
GLYCOPYRROLATE
Table: GLYCOPYRROLATE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
0.2MG/ML Liquid |
02382857 |
GLYCOPYRROLATE |
OMG |
0.2MG Solution |
02382849 |
GLYCOPYRROLATE MULTIDOSE |
OMG |
0.2MG/ML Solution |
02039508 |
GLYCOPYRROLATE |
SDZ |
1MG Solution |
02469332 |
CUVPOSA |
PEI |
HYOSCINE BUTYLBROMIDE
Table: HYOSCINE BUTYLBROMIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
20MG/ML Solution |
00363839 |
BUSCOPAN |
SAC |
20MG/ML Solution |
02229868 |
HYOSCINE BUTYLBROMIDE |
SDZ |
SCOPOLAMINE HYDROBROMIDE
Table: SCOPOLAMINE HYDROBROMIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
0.4MG/ML Solution |
00541869 |
SCOPOLAMINE |
PFI |
0.4MG/ML Solution |
02242810 |
SCOPOLAMINE |
OMG |
0.6MG/ML Solution |
00541877 |
SCOPOLAMINE |
PFI |
0.6MG/ML Solution |
02242811 |
SCOPOLAMINE |
OMG |
28:00 CENTRAL NERVOUS SYSTEM AGENTS
28:04.92 GENERAL ANESTHETICS, MISC.
KETAMINE HYDROCHLORIDE
Table: KETAMINE HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
10MG/ML Solution |
00224391 |
KETALAR |
ERF |
10MG/ML Solution |
02246795 |
KETAMINE |
SDZ |
10MG/ML Solution |
02387301 |
KETAMINE |
SDZ |
50MG/ML Solution |
00224405 |
KETALAR |
ERF |
50MG/ML Solution |
02246796 |
KETAMINE |
SDZ |
50MG/ML Solution |
02387328 |
KETAMINE |
SDZ |
50MG/ML Solution |
02387336 |
KETAMINE |
SDZ |
28:08.08 OPIATE AGONISTS
EXTEMPORANEOUS MIXTURE
Table: EXTEMPORANEOUS MIXTURE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
Injection |
99506019 |
FENTANYL STERILE INFUSION |
UNK |
Injection |
99506017 |
HYDROMORPHONE HP STERILE INFUSION |
UNK |
Injection |
99506018 |
MORPHINE HP STERILE INFUSION |
UNK |
FENTANYL
Table: FENTANYL
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
12MCG/HR Patch |
02454440 |
APO-FENTANYL MATRIX |
APX |
12MCG/HR Patch |
02334186 |
DURAGESIC |
JSO |
12MCG/HR Patch |
99100480 |
FENTANYL |
JNO |
12MCG/HR Patch |
02376768 |
PAT-FENTANYL MATRIX |
KLA |
25MCG/HR Patch |
02304120 |
FENTANYL TRANSDERMAL SYSTEM |
ACG |
25MCG/HR Patch |
02376776 |
PAT-FENTANYL MATRIX |
KLA |
25MCG/HR Patch |
02325403 |
RAN-FENTANYL MATRIX |
RBY |
37MCG/HR Patch |
02386860 |
CO FENTANYL |
OBT |
37MCG/HR Patch |
02327139 |
SANDOZ FENTANYL |
SDZ |
50MCG/HR Patch |
02304139 |
FENTANYL TRANSDERMAL SYSTEM |
ACG |
50MCG/HR Patch |
02376784 |
PAT-FENTANYL MATRIX |
KLA |
50MCG/HR Patch |
02325411 |
RAN-FENTANYL MATRIX |
RBY |
75MCG/HR Patch |
02304147 |
FENTANYL TRANSDERMAL SYSTEM |
ACG |
75MCG/HR Patch |
02376792 |
PAT-FENTANYL MATRIX |
KLA |
75MCG/HR Patch |
02325438 |
RAN-FENTANYL MATRIX |
RBY |
100MCG/HR Patch |
02304155 |
FENTANYL TRANSDERMAL SYSTEM |
ACG |
100MCG/HR Patch |
02376806 |
PAT-FENTANYL MATRIX |
KLA |
100MCG/HR Patch |
02325446 |
RAN-FENTANYL MATRIX |
RBY |
FENTANYL CITRATE
Table: FENTANYL CITRATE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
50MCG Liquid |
02384124 |
FENTANYL CITRATE SDZ |
SDZ |
50MCG/ML Solution |
00888346 |
FENTANYL CITRATE |
PFI |
50MCG/ML Solution |
02240434 |
FENTANYL CITRATE |
SDZ |
HYDROMORPHONE HYDROCHLORIDE
Table: HYDROMORPHONE HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
2MG/ML Solution |
02145901 |
HYDROMORPHONE |
SDZ |
10MG Solution |
02460610 |
HYDROMORPHONE HYDROCHLORIDE HP 10 |
RAX |
10MG/ML Solution |
02145928 |
HYDROMORPHONE HP |
SDZ |
20MG/ML Solution |
02145936 |
HYDROMORPHONE HP |
SDZ |
50MG/ML Solution |
02146126 |
HYDROMORPHONE HP |
SDZ |
50MG/ML Solution |
99003163 |
HYDROMORPHONE HP |
UNK |
100MG/ML Solution |
02244797 |
HYDROMORPHONE HP FORTE |
SDZ |
METHADONE HYDROCHLORIDE (BC ONLY)
Table: METHADONE HYDROCHLORIDE (BC ONLY)
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
Powder |
09991180 |
METHADONE PDR (PAIN) |
UNK |
Powder |
09991552 |
METHADONE PDR (END OF LIFE) |
UNK |
METHADONE HYDROCHLORIDE (METADOL)
Table: METHADONE HYDROCHLORIDE (METADOL)
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
1MG/ML Solution |
02247694 |
METADOL |
PAL |
1MG Tablet |
02247698 |
METADOL |
PAL |
5MG Tablet |
02247699 |
METADOL |
PAL |
10MG Tablet |
02247700 |
METADOL |
PAL |
25MG Tablet |
02247701 |
METADOL |
PAL |
MORPHINE SULFATE
Table: MORPHINE SULFATE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
2MG/ML Liquid |
02242484 |
MORPHINE SULFATE |
SDZ |
10MG Liquid |
00392588 |
MORPHINE SULFATE |
SDZ |
15MG Liquid |
00392561 |
MORPHINE SULFATE |
SDZ |
50MG/ML Liquid |
02137267 |
MORPHINE SULPHATE |
HOS |
0.5MG/ML Solution |
02021056 |
MORPHINE LP EPIDURAL |
SDZ |
0.5MG/ML Solution |
01949047 |
MORPHINE-EPD |
PFI |
1MG/ML Solution |
02021048 |
MORPHINE LP |
SDZ |
1MG/ML Solution |
01980696 |
MORPHINE SULFATE |
SDZ |
1MG/ML Solution |
01949055 |
MORPHINE-EPD |
PFI |
2MG/ML Solution |
00850314 |
MORPHINE SULFATE |
PFI |
2MG/ML Solution |
01964437 |
MORPHINE SULFATE |
SDZ |
5MG/ML Solution |
01964429 |
MORPHINE SULFATE |
SDZ |
10MG/ML Solution |
00850322 |
MORPHINE SULFATE |
PFI |
25MG/ML Solution |
00676411 |
MORPHINE HP |
SDZ |
50MG/ML Solution |
00617288 |
MORPHINE HP |
SDZ |
28:12.04 ANTICONVULSANTS - BARBITURATES
PHENOBARBITAL
Table: PHENOBARBITAL
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
30MG Solution |
02304082 |
PHENOBARBITAL SODIUM |
SDZ |
120MG Solution |
02304090 |
PHENOBARBITAL SODIUM |
SDZ |
28:12.12 ANTICONVULSANTS - HYDANTOINS
PHENYTOIN
Table: PHENYTOIN
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
50MG Liquid |
00780626 |
PHENYTOIN SODIUM |
SDZ |
28:16.08 ANTIPSYCHOTIC AGENTS
METHOTRIMEPRAZINE HYDROCHLORIDE
Table: METHOTRIMEPRAZINE HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
25MG/ML Solution |
01927698 |
NOZINAN |
SAC |
28:24.08 ANXIOLYTICS, SEDATIVES AND HYPNOTICS - BENZODIAZEPINES
DIAZEPAM
Table: DIAZEPAM
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
5MG/ML Solution |
00399728 |
DIAZEPAM |
SDZ |
5MG/ML Solution |
02386143 |
DIAZEPAM |
SDZ |
DIAZEPAM (DIASTAT)
Table: DIAZEPAM (DIASTAT)
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
ST5MG/ML Gel |
02238162 |
DIASTAT |
VAE |
ST5MG/ML Gel |
09853340 |
DIASTAT 2X10MG RECTAL PACK |
ELN |
ST5MG/ML Gel |
09853430 |
DIASTAT 2X15MG RECTAL PACK |
ELN |
LORAZEPAM
Table: LORAZEPAM
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
4MG/ML Liquid |
02243278 |
LORAZEPAM |
SDZ |
2MG/ML Solution |
02438704 |
LORAZEPAM |
SDZ |
MIDAZOLAM
Table: MIDAZOLAM
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
1MG/ML Solution |
02240285 |
MIDAZOLAM |
SDZ |
1MG/ML Solution |
02242904 |
MIDAZOLAM |
FKD |
1MG/ML Solution |
02243934 |
MIDAZOLAM |
NOP |
5MG Solution |
02423766 |
MIDAZOLAM |
PFI |
5MG/ML Solution |
02240286 |
MIDAZOLAM |
SDZ |
5MG/ML Solution |
02242905 |
MIDAZOLAM |
FKD |
5MG/ML Solution |
02243935 |
MIDAZOLAM |
NOP |
5MG/ML Solution |
02382903 |
MIDAZOLAM |
SDZ |
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40:28.08 LOOP DIURETICS
FUROSEMIDE
Table: FUROSEMIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
10MG Liquid |
00527033 |
FUROSEMIDE |
SDZ |
10MG/ML Solution |
02382539 |
FUROSEMIDE |
SDZ |
10MG/ML Solution |
02384094 |
FUROSEMIDE |
ALV |
52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
52:92.00 MISCELLANEOUS EENT DRUGS
ARTIFICIAL SALIVA
Table: ARTIFICIAL SALIVA
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
0.05MG Spray |
02238696 |
MOISTIR |
PMS |
56:00 GASTROINTESTINAL DRUGS
56:08.00 ANTIDIARRHEA AGENTS
DIPHENOXYLATE HYDROCHLORIDE, ATROPINE SULFATE
Table: DIPHENOXYLATE HYDROCHLORIDE, ATROPINE SULFATE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
2.5MG & 0.025MG Tablet |
00036323 |
LOMOTIL |
PFI |
56:22.20 5-HT3 RECEPTOR ANTAGONISTS
GRANISETRON HYDROCHLORIDE
Table: GRANISETRON HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
1MG Liquid |
02322765 |
GRANISETRON HYDROCHLORIDE |
OMG |
1MG/ML Solution |
02385414 |
GRANISETRON |
SDZ |
ONDANSETRON HYDROCHLORIDE
Table: ONDANSETRON HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
2MG/ML Injection |
02291703 |
ONDANSETRON W/P |
APX |
2MG/ML Injection |
09857324 |
ZOFRAN (ON) |
GSK |
2MG/ML Injection |
09857325 |
ZOFRAN (ON) |
GSK |
2MG Liquid |
02271761 |
ONDANSETRON OMEGA -(PRESERVATIVE FREE SINGLE DOSE VIALS) |
OMG |
2MG Liquid |
02271788 |
ONDANSETRON OMEGA -(WITH PRESERVATIVE MULTIDOSE VIAL) |
OMG |
2MG Solution |
02420414 |
JAMP-ONDANSETRON |
JMP |
2MG Solution |
02420422 |
JAMP-ONDANSETRON |
JMP |
2MG Solution |
02462257 |
ONDANSETRON |
RAX |
2MG Solution |
02464578 |
ONDANSETRON |
RAX |
2MG Solution |
02279436 |
ONDANSETRON -(WITH PRESERVATIVE) |
SDZ |
2MG Solution |
02461420 |
ONDANSETRON BP |
AUR |
2MG Solution |
02213745 |
ZOFRAN |
NVR |
2MG/ML Solution |
02265524 |
ONDANSETRON |
TEV |
2MG/ML Solution |
02274418 |
ONDANSETRON |
SDZ |
2MG/ML Solution |
02279428 |
ONDANSETRON |
SDZ |
2MG/ML Solution |
02390019 |
ONDANSETRON |
MYL |
2MG/ML Solution |
02390051 |
ONDANSETRON |
MYL |
56:22.92 MISCELLANEOUS ANTIEMETICS
NABILONE
Table: NABILONE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
0.25MG Capsule |
02441497 |
APO-NABILONE |
APX |
0.25MG Capsule |
02345897 |
APP-NABILONE |
UNK |
0.25MG Capsule |
02380897 |
PMS-NABILONE |
PMS |
0.5MG Capsule |
02441500 |
APO-NABILONE |
APX |
0.5MG Capsule |
02345927 |
APP-NABILONE |
UNK |
1MG Capsule |
02441519 |
APO-NABILONE |
APX |
1MG Capsule |
02345935 |
APP-NABILONE |
UNK |
SCOPOLAMINE
Table: SCOPOLAMINE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
1.5MG Patch |
00550094 |
TRANSDERM-V |
NVC |
1.5MG Patch |
80024336 |
TRANSDERM-V |
NVR |
56:28.12 HISTAMINE H2-ANTAGONISTS
FAMOTIDINE
Table: FAMOTIDINE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
10MG Solution |
02247735 |
FAMOTIDINE OMEGA -(WITHOUT PRESERVATIVE) |
OMG |
RANITIDINE HYDROCHLORIDE
Table: RANITIDINE HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
25MG/ML Solution |
02256711 |
RANITIDINE |
SDZ |
56:32.00 PROKINETIC AGENTS
METOCLOPRAMIDE HYDROCHLORIDE
Table: METOCLOPRAMIDE HYDROCHLORIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
5MG/ML Liquid |
02185431 |
METOCLOPRAMIDE |
SDZ |
5MG/ML Liquid |
02243563 |
METOCLOPRAMIDE OMEGA |
OMG |
56:92.00 MISCELLANEOUS GI DRUGS
METHYLNALTREXONE BROMIDE
Table: METHYLNALTREXONE BROMIDE
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
20MG Solution |
02308215 |
RELISTOR |
SLX |
20MG Solution |
02356481 |
RELISTOR |
SLX |
20MG Solution |
02356503 |
RELISTOR |
SLX |
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 |
91500004 |
STERILE PREPERATION FEE |
UNK |
NUTRITIONAL SUPPLEMENT
Table: NUTRITIONAL SUPPLEMENT
Drug strength and dosage form |
DIN |
Brand name |
Manufacturer code |
Oral Liquid |
95900049 |
BOOST 1.0 STANDARD 237ML LIQ |
NVC |
Oral Liquid |
95900053 |
BOOST 1.5 |
NES |
Oral Liquid |
95900051 |
BOOST FRUIT BEVERAGE 235ML LIQ |
NES |
Oral Liquid |
95900054 |
BOOST HIPROTEIN 237ML LIQ |
NES |
Oral Liquid |
95900050 |
ENSURE 235ML LIQ |
ABB |
Oral Liquid |
95900061 |
BOOST DIABETIC 237ML LIQ |
NES |
Oral Liquid |
95900052 |
BOOST PLUS 237ML LIQ |
NES |
Oral Liquid |
95999975 |
BOOST PLUS CALORIES 237ML LIQ |
NES |
Oral Liquid |
95900056 |
ENSURE HIGH PROTEIN 235ML LIQ |
ABB |
Oral Liquid |
95900057 |
ENSURE PLUS 235ML LIQ |
ABB |
Oral Liquid |
95900181 |
ENSURE PLUS CALORIES 235ML LIQ |
ABB |
Oral Liquid |
95900204 |
ENSURE PROTEIN MAX 235ML LIQ |
ABB |
Oral Liquid |
95900141 |
GLUCERNA TUBE FEEDING 235ML LIQ |
ABB |
Powder |
95900055 |
BOOST JUST PROTEIN 588G PDR |
NES |
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