Limited Coverage Drugs - dalteparin

Generic Name

dalteparin

Brand Name

Dosage Form

Strength

Fragmin®

prefilled syringe (PFS)

  • 2,500 IU/0.2 mL
  • 5,000 IU/0.2 mL
  • 7,500 IU/0.3 mL
  • 10,000 IU/0.4 mL
  • 12,500 IU/0.5 mL
  • 15,000 IU/0.6 mL
  • 16,500 IU/0.66 mL
  • 18,000 IU/0.72 mL

ampoule

10,000 IU/mL

vial

25,000 IU/mL

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
  • Up to 10 days' supply
  • 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
  • Up to 3 months, then reassessed
  • Patients with cancer
  • Up to 6 months

Prophylaxis of venous thromboembolism

Special Authority Criteria

Approval Period

For prevention in patients:

 

  • Following elective total knee replacement surgery; OR
  • Up to 14 days
  • Following elective total hip replacement surgery; OR
  • Up to 35 days
  • Following orthopedic surgery for major trauma; OR
  • Up to 10 days
  • With lupus anticoagulant syndrome, antiphospholipid syndrome, or thrombophilia; OR
  • Up to 3 months
  • Before, during or after pregnancy; OR
  • Up to 4 weeks post-partum
  • Following abdominal or pelvic surgery for the management of a malignant tumour (applicable to dalteparin and enoxaparin prescriptions only); OR
  • Up to 10 days
  • Following abdominal or pelvic surgery for the management of a malignant tumour (applicable to dalteparin and enoxaparin prescriptions only) and 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 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 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)