Limited Coverage Drugs - Dalteparin

 

Generic Name / Strength / Form
Fragmin / 2,500 Iu(Anti-Xa)/0.2 mL / SYRINGE
Fragmin / 5,000 Iu(Anti-Xa)/0.2 mL / SYRINGE
Fragmin / 7,500 Iu(Anti-Xa)/0.3 mL / SYRINGE
Fragmin / 10,000 Iu(Anti-Xa)/0.4 mL / SYRINGE
Fragmin / 12,500 Iu(Anti-Xa)/0.5 mL / SYRINGE
Fragmin / 15,000 Iu(Anti-Xa)/0.6 mL / SYRINGE
Fragmin / 18,000 Iu(Anti-Xa)/0.72 mL / SYRINGE
Fragmin / 10,000 Iu(Anti-Xa)/mL / AMPUL
Fragmin / 25,000 Iu(Anti-Xa)/mL 25,000/mL / VIAL

 

TREATMENT OF VENOUS THROMBOEMBOLISM

Special Authority Criteria

Approval Period

For the treatment of:

patients with acute deep vein thrombosis or pulmonary embolus who continue to receive care after leaving an acute care (hospital) setting. This treatment bridges the time gap to achieve therapeutic INR on oral anticoagulants.

OR

patients with treatment failure of oral anticoagulant therapy (recurrence of one or more deep vein thromboses or pulmonary emboli in patients with therapeutic INR on oral anticoagulants).

OR

patients, associated with cancer, who have failed, or who are unable to tolerate, oral therapy with warfarin.

 

Up to 10 days' supply


 

 

Up to 3 months, then reassessed
 

 

Up to 6 months

 

PROPHYLAXIS OF VENOUS THROMBOEMBOLISM

Special Authority Criteria Approval Period

For prevention in patients:

following elective total knee replacement surgery

OR

following elective total hip replacement surgery

OR

following orthopedic surgery for major trauma

OR

with lupus anticoagulant syndrome, antiphospholipid syndrome, or thrombophilia

OR

before, during or after pregnancy

OR

following abdominal or pelvic surgery for the management of a malignant tumour (applicable to dalteparin and enoxaparin prescriptions only)

OR

following abdominal or pelvic surgery for the management of a malignant tumour (applicable to dalteparin and enoxaparin prescriptions onlyand who are at high risk (defined as those with previous history of VTE and/or anesthesia lasting longer than 2 hours and/or bed rest lasting 4 days or longer following surgery)

Up to 14 days

 

Up to 35 days

 

Up to 10 days

 

Up to 3 months

 


Up to 4 weeks post-partum

 

Up to 10 days

 

 


Up to 28 days for high risk patients

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 his/her 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)