Limited Coverage Drugs - dalteparin
Generic Name |
dalteparin |
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Brand Name |
Dosage Form |
Strength |
Fragmin® |
prefilled syringe (PFS) |
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ampoule |
10,000 IU/mL |
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vial |
25,000 IU/mL |
Treatment of venous thromboembolism
Special Authority Criteria |
Approval Period |
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For the treatment of: |
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Prophylaxis of venous thromboembolism
Special Authority Criteria |
Approval Period |
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For prevention in patients: |
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Practitioner Exemptions
- PharmaCare coverage will be provided for a patient who meets the Limited Coverage criteria, and whose prescription is written by an orthopedic surgeon who has entered into a Collaborative Prescribing Agreement.
- Due to the individual nature of each Collaborative Prescribing Agreement, the agreement must be signed by the prescriber and not their delegate.
Special Notes
- The total duration of therapy includes the period during which doses are administered post-operatively in an acute care (hospital) setting. The approval period is for the balance of the total duration after discharge (i.e., for outpatients only).
Special Authority Request Form(s)
- HLTH 5338 - Low Molecular Weight Heparin–Dalteparin/Enoxaparin/Nadroparin/Tinzaparin Form (PDF, 548KB)
- HLTH 5469 - Venous Thromboembolism In Cancer Patients (PDF, 573KB)