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 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 14 days
Up to 35 days
Up to 10 days
Up to 3 months
Up to 10 days
|
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).
