Appendix D - Formulary for Adjunct Medications Used During Active Cancer Treatment

The Non-Insured Health Benefits (NIHB) Program has established a new formulary to streamline access to adjunctive (non-chemotherapy) medications frequently used by clients undergoing active cancer treatment.

Clients who are approved for oral chemotherapy drugs are given access to all of the medications and nutritional supplements in the formulary. Additionally, clients who request, and are approved, for one of the medications on the formulary for a cancer-related indication are also granted access.

Clients are automatically enrolled for a period of six months. If cancer treatment is of a longer duration, access to the formulary will be granted to align with the treatment duration. In the event that treatment duration is not known and the treatment plan extends beyond six months, access to this formulary may be extended upon request.

08:00 ANTI-INFECTIVE AGENTS

08:12.24 TETRACYCLINES

MINOCYCLINE HYDROCHLORIDE

Table: MINOCYCLINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
50MG Capsule 02084090 MINOCYCLINE AAP
50MG Capsule 02108143 TEVA-MINOCYCLINE TEV
100MG Capsule 02084104 MINOCYCLINE AAP
100MG Capsule 02108151 TEVA-MINOCYCLINE TEV

12:00 AUTONOMIC DRUGS

12:12.08 BETA ADRENERGIC AGONISTS

SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE

Table: SALMETEROL XINAFOATE, FLUTICASONE PROPIONATE
Drug strength and dosage form DIN Brand name Manufacturer code
25MCG & 125MCG Aerosol 02245126 ADVAIR 125 GSK
25MCG & 250MCG Aerosol 02245127 ADVAIR 250 GSK
50MCG & 100MCG Powder 02240835 ADVAIR 100 DISKUS GSK
50MCG & 250MCG Powder 02240836 ADVAIR 250 DISKUS GSK
50MCG & 500MCG Powder 02240837 ADVAIR 500 DISKUS GSK

20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS

20:16.00 HEMATOPOIETIC AGENTS

DARBEPOETIN ALFA

Table: DARBEPOETIN ALFA
Drug strength and dosage form DIN Brand name Manufacturer code
25MCG/ML Solution 02392313 ARANESP AMG
40MCG/ML Solution 02392321 ARANESP AMG
60MCG/ML Solution 02246348 ARANESP AMG
100MCG/ML Solution 02391740 ARANESP AMG
100MCG/ML Solution 02391759 ARANESP AMG
100MCG/ML Solution 02392348 ARANESP AMG
100MCG/ML Solution 99004917 ARANESP AMG
100MCG/ML Solution 99004925 ARANESP AMG
200MCG/ML Solution 02391767 ARANESP AMG
200MCG/ML Solution 02391775 ARANESP AMG
200MCG/ML Solution 02391783 ARANESP AMG
200MCG/ML Solution 02392356 ARANESP AMG
200MCG/ML Solution 99004909 ARANESP AMG
200MCG/ML Solution 99004933 ARANESP AMG
500MCG/ML Solution 02391791 ARANESP AMG
500MCG/ML Solution 02391805 ARANESP AMG
500MCG/ML Solution 02391821 ARANESP AMG
500MCG/ML Solution 02392364 ARANESP AMG
500MCG/ML Solution 09857185 ARANESP AMG

EPOETIN ALFA

Table: EPOETIN ALFA
Drug strength and dosage form DIN Brand name Manufacturer code
1,000U/0.5ML Solution 02231583 EPREX JSO
2,000U/0.5ML Solution 02231584 EPREX JSO
3,000U/0.3ML Solution 02231585 EPREX JSO
4,000U/0.4ML Solution 02231586 EPREX JSO
5000U/0.5ML Solution 02243400 EPREX JSO
6000U/0.6ML Solution 02243401 EPREX JSO
8000U/0.8ML Solution 02243403 EPREX JSO
10,000/ML Solution 02231587 EPREX JSO
20,000U/0.5ML Solution 02243239 EPREX JSO
30,000U/0.75ML Solution 02288680 EPREX JSO
40,000U/ML Solution 02240722 EPREX JSO

PEGFILGRASTIM

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

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:08.12 OPIATE PARTIAL AGONISTS

BUPRENORPHINE (BUTRANS)

Table: BUPRENORPHINE (BUTRANS)
Drug strength and dosage form DIN Brand name Manufacturer code
5MCG Patch 02341174 BUTRANS 5 PFR
10MCG Patch 02341212 BUTRANS 10 PFR
15MCG Patch 02450771 BUTRANS 15 PFR
20MCG Patch 02341220 BUTRANS 20 PFR

28:12.92 MISCELLANEOUS ANTICONVULSANTS

PREGABALIN

Table: PREGABALIN
Drug strength and dosage form DIN Brand name Manufacturer code
25MG Capsule 02480727 AG-PREGABALIN ANG
ST25MG Capsule 02394235 APO-PREGABALIN APX
ST25MG Capsule 02433869 AURO-PREGABALIN AUR
ST25MG Capsule 02402556 DOM-PREGABALIN DPC
ST25MG Capsule 02435977 JAMP-PREGABALIN JMP
ST25MG Capsule 02268418 LYRICA PFI
ST25MG Capsule 02417529 MAR-PREGABALIN MAR
ST25MG Capsule 02423804 MINT-PREGABALIN MIN
25MG Capsule 02479117 NRA-PREGABALIN UNK
ST25MG Capsule 02359596 PMS-PREGABALIN PMS
25MG Capsule 02396483 PREGABALIN PDL
ST25MG Capsule 02403692 PREGABALIN SIV
ST25MG Capsule 02405539 PREGABALIN SAN
25MG Capsule 02476304 PREGABALIN RIV
ST25MG Capsule 02392801 RAN-PREGABALIN RBY
ST25MG Capsule 02377039 RIVA-PREGABALIN RIV
ST25MG Capsule 02390817 SANDOZ PREGABALIN SDZ
ST25MG Capsule 02361159 TEVA-PREGABALIN TEV
50MG Capsule 02480735 AG-PREGABALIN ANG
ST50MG Capsule 02394243 APO-PREGABALIN APX
ST50MG Capsule 02433877 AURO-PREGABALIN AUR
ST50MG Capsule 02402564 DOM-PREGABALIN DPC
ST50MG Capsule 02435985 JAMP-PREGABALIN JMP
ST50MG Capsule 02268426 LYRICA PFI
ST50MG Capsule 02417537 MAR-PREGABALIN MAR
ST50MG Capsule 02423812 MINT-PREGABALIN MIN
50MG Capsule 02479125 NRA-PREGABALIN UNK
ST50MG Capsule 02359618 PMS-PREGABALIN PMS
50MG Capsule 02396505 PREGABALIN PDL
ST50MG Capsule 02403706 PREGABALIN SIV
ST50MG Capsule 02405547 PREGABALIN SAN
50MG Capsule 02476312 PREGABALIN RIV
ST50MG Capsule 02392828 RAN-PREGABALIN RBY
ST50MG Capsule 02377047 RIVA-PREGABALIN RIV
ST50MG Capsule 02390825 SANDOZ PREGABALIN SDZ
ST50MG Capsule 02361175 TEVA-PREGABALIN TEV
75MG Capsule 02480743 AG-PREGABALIN ANG
ST75MG Capsule 02394251 APO-PREGABALIN APX
ST75MG Capsule 02433885 AURO-PREGABALIN AUR
ST75MG Capsule 02402572 DOM-PREGABALIN DPC
ST75MG Capsule 02435993 JAMP-PREGABALIN JMP
ST75MG Capsule 02268434 LYRICA PFI
ST75MG Capsule 02417545 MAR-PREGABALIN MAR
ST75MG Capsule 02424185 MINT-PREGABALIN MIN
75MG Capsule 02479133 NRA-PREGABALIN UNK
ST75MG Capsule 02359626 PMS-PREGABALIN PMS
75MG Capsule 02396513 PREGABALIN PDL
ST75MG Capsule 02403714 PREGABALIN SIV
ST75MG Capsule 02405555 PREGABALIN SAN
75MG Capsule 02476320 PREGABALIN RIV
ST75MG Capsule 02392836 RAN-PREGABALIN RBY
ST75MG Capsule 02377055 RIVA-PREGABALIN RIV
ST75MG Capsule 02390833 SANDOZ PREGABALIN SDZ
ST75MG Capsule 02361183 TEVA-PREGABALIN TEV
150MG Capsule 02480751 AG-PREGABALIN ANG
ST150MG Capsule 02394278 APO-PREGABALIN APX
ST150MG Capsule 02433907 AURO-PREGABALIN AUR
ST150MG Capsule 02402580 DOM-PREGABALIN DPC
ST150MG Capsule 02436000 JAMP-PREGABALIN JMP
ST150MG Capsule 02268450 LYRICA PFI
ST150MG Capsule 02417561 MAR-PREGABALIN MAR
ST150MG Capsule 02424207 MINT-PREGABALIN MIN
150MG Capsule 02479168 NRA-PREGABALIN UNK
ST150MG Capsule 02359634 PMS-PREGABALIN PMS
150MG Capsule 02396521 PREGABALIN PDL
ST150MG Capsule 02403722 PREGABALIN SIV
ST150MG Capsule 02405563 PREGABALIN SAN
150MG Capsule 02476347 PREGABALIN RIV
ST150MG Capsule 02392844 RAN-PREGABALIN RBY
ST150MG Capsule 02377063 RIVA-PREGABALIN RIV
ST150MG Capsule 02390841 SANDOZ PREGABALIN SDZ
ST150MG Capsule 02361205 TEVA-PREGABALIN TEV
ST300MG Capsule 02394294 APO-PREGABALIN APX
ST300MG Capsule 02436019 JAMP-PREGABALIN JMP
ST300MG Capsule 02268485 LYRICA PFI
ST300MG Capsule 02359642 PMS-PREGABALIN PMS
300MG Capsule 02396548 PREGABALIN PDL
ST300MG Capsule 02403730 PREGABALIN SIV
ST300MG Capsule 02405598 PREGABALIN SAN
300MG Capsule 02476371 PREGABALIN RIV
ST300MG Capsule 02392860 RAN-PREGABALIN RBY
ST300MG Capsule 02377071 RIVA-PREGABALIN RIV
ST300MG Capsule 02390868 SANDOZ PREGABALIN SDZ
ST300MG Capsule 02361248 TEVA-PREGABALIN TEV

48:00 RESPIRATORY TRACT AGENTS

48:10.24 LEUKOTRIENE MODIFIERS

MONTELUKAST SODIUM

Table: MONTELUKAST SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
ST4MG Granules 02358611 SANDOZ MONTELUKAST SDZ
ST4MG Granules 02247997 SINGULAIR FRS
ST10MG Tablet 02374609 APO-MONTELUKAST APX
ST10MG Tablet 02401274 AURO-MONTELUKAST AUR
10MG Tablet 02445735 BIO-MONTELUKAST UNK
ST10MG Tablet 02376695 DOM-MONTELUKAST DPC
ST10MG Tablet 02391422 JAMP-MONTELUKAST JMP
ST10MG Tablet 02399997 MAR-MONTELUKAST MAR
ST10MG Tablet 02408643 MINT-MONTELUKAST MIN
ST10MG Tablet 02379333 MONTELUKAST SAN
ST10MG Tablet 02379856 MONTELUKAST PDL
ST10MG Tablet 02382474 MONTELUKAST SIV
ST10MG Tablet 02379236 MONTELUKAST SODIUM ACC
ST10MG Tablet 02373947 PMS-MONTELUKAST PMS
ST10MG Tablet 02389517 RAN-MONTELUKAST RBY
ST10MG Tablet 02398826 RIVA-MONTELUKAST RIV
ST10MG Tablet 02328593 SANDOZ MONTELUKAST SDZ
ST10MG Tablet 02238217 SINGULAIR FRS
ST10MG Tablet 02355523 TEVA-MONTELUKAST TEV
4MG Tablet (Chewable) 02377608 APO-MONTELUKAST APX
ST4MG Tablet (Chewable) 02422867 AURO-MONTELUKAST AUR
ST4MG Tablet (Chewable) 02442353 JAMP-MONTELUKAST JMP
ST4MG Tablet (Chewable) 02399865 MAR-MONTELUKAST MAR
ST4MG Tablet (Chewable) 02408627 MINT-MONTELUKAST MIN
ST4MG Tablet (Chewable) 02379821 MONTELUKAST PDL
ST4MG Tablet (Chewable) 02382458 MONTELUKAST SIV
ST4MG Tablet (Chewable) 02354977 PMS-MONTELUKAST PMS
ST4MG Tablet (Chewable) 02402793 RAN-MONTELUKAST RBY
ST4MG Tablet (Chewable) 02330385 SANDOZ MONTELUKAST SDZ
ST4MG Tablet (Chewable) 02243602 SINGULAIR FRS
ST4MG Tablet (Chewable) 02355507 TEVA-MONTELUKAST TEV
ST5MG Tablet (Chewable) 02377616 APO-MONTELUKAST APX
ST5MG Tablet (Chewable) 02422875 AURO-MONTELUKAST AUR
ST5MG Tablet (Chewable) 02442361 JAMP-MONTELUKAST JMP
ST5MG Tablet (Chewable) 02399873 MAR-MONTELUKAST MAR
ST5MG Tablet (Chewable) 02408635 MINT-MONTELUKAST MIN
ST5MG Tablet (Chewable) 02379848 MONTELUKAST PDL
ST5MG Tablet (Chewable) 02382466 MONTELUKAST SIV
ST5MG Tablet (Chewable) 02354985 PMS-MONTELUKAST PMS
ST5MG Tablet (Chewable) 02402807 RAN-MONTELUKAST RBY
ST5MG Tablet (Chewable) 02330393 SANDOZ MONTELUKAST SDZ
ST5MG Tablet (Chewable) 02238216 SINGULAIR FRS
ST5MG Tablet (Chewable) 02355515 TEVA-MONTELUKAST TEV

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:28.00 EENT - MOUTHWASHES AND GARGLES

BENZYDAMINE HYDROCHLORIDE

Table: BENZYDAMINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
0.15% Mouthwash 02239044 APO-BENZYDAMINE APX
0.15% Mouthwash 02229777 PHARIXIA PED
0.15% Mouthwash 02239537 PMS-BENZYDAMINE PMS

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

56:22.00 ANTIEMETICS

NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)

Table: NETUPITANT, PALONOSETRON (PALONOSETRON HYDROCHLORIDE)
Drug strength and dosage form DIN Brand name Manufacturer code
ST300MG & 0.5MG Capsule 02468735 AKYNZEO PFR

56:22.20 5-HT3 RECEPTOR ANTAGONISTS

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

56:22.32 MISCELLANEOUS ANTIEMETICS

APREPITANT

Table: APREPITANT
Drug strength and dosage form DIN Brand name Manufacturer code
ST80MG Capsule 02298791 EMEND FRS
ST125MG & 80MG Capsule 02298813 EMEND TRI-PACK FRS
ST125MG Capsule 02298805 EMEND FRS

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 02312263 CESAMET UNK
0.25MG Capsule 02380897 PMS-NABILONE PMS
0.25MG Capsule 02358077 RAN-NABILONE RBY
0.25MG Capsule 02392925 TEVA-NABILONE TEV
0.5MG Capsule 02393581 ACT NABILONE ACG
0.5MG Capsule 02441500 APO-NABILONE APX
0.5MG Capsule 02256193 CESAMET UNK
0.5MG Capsule 02380900 PMS-NABILONE PMS
0.5MG Capsule 02358085 RAN-NABILONE RBY
0.5MG Capsule 02384884 TEVA-NABILONE TEV
1MG Capsule 02393603 ACT NABILONE ACG
1MG Capsule 02441519 APO-NABILONE APX
1MG Capsule 00548375 CESAMET UNK
1MG Capsule 02380919 PMS-NABILONE PMS
1MG Capsule 02358093 RAN-NABILONE RBY
1MG Capsule 02384892 TEVA-NABILONE TEV

92:00 UNCLASSIFIED THERAPEUTIC AGENTS

92:24.00 BONE RESORPTION INHIBITORS

DENOSUMAB (XGEVA)

Table: DENOSUMAB (XGEVA)
Drug strength and dosage form DIN Brand name Manufacturer code
120MG/1.7ML Solution 02368153 XGEVA AMG

96:00 PHARMACEUTICAL AIDS

96:00.00 PHARMACEUTICAL AIDS

ADULT

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 95900058 RESOURCE 2.0 237ML LIQ NES

CHILDREN AND YOUTH

Table: CHILDREN AND YOUTH
Drug strength and dosage form DIN Brand name Manufacturer code
Oral Liquid 95900142 PEDIASURE COM. GROW&GAIN 235ML LIQ ABB
Powder 95900143 PEDIASURE COM. GROW&GAIN 400G PDR ABB
Powder 95900143 PEDIASURE GROW&GAIN 400G PDR ABB

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 95900051 BOOST FRUIT BEVERAGE 235ML LIQ NES
Oral Liquid 95900054 BOOST HIPROTEIN 237ML LIQ NES
Oral Liquid 95900052 BOOST PLUS 237ML LIQ NES
Oral Liquid 95999975 BOOST PLUS CALORIES 237ML LIQ NES
Oral Liquid 95900070 COMPLEAT MODIFIED 1000ML LIQ NES
Oral Liquid 95900069 COMPLEAT MODIFIED 250ML 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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