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:

  1. is not receiving care in a provincially funded hospital or provincially funded long-term care facility
  2. 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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