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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Date modified:: 2020-10-15