Palliative Care Drug Plan (Plan P) Formulary

This formulary is a general guide and may not reflect recent Plan P formulary changes. See PharmaCare Formulary Search for current listings.

A downloadable PDF version of the Plan P formulary (171 KB) is also available.



     
  • Pharmacists must submit a claim at the time of purchase.
  • PharmaCare may not cover all available formulations and strengths of the drugs listed below.
  • If PharmaCare covers a generic version of a drug, PharmaCare usually covers only part of the cost of the brand product.
  • Some generic products may be only partially covered depending on the price of competing generic products.


Analgesics

Non-opioid

  • acetaminophen

NSAIDs (This category excludes topical NSAIDs)

  • celecoxib
  • diclofenac
  • ibuprofen
  • meloxicam
  • naproxen

Opioids (This category excludes Demerol, pentazocine, butorphanol, anileridine)

  • codeine products (including acetaminophen combinations)
  • fentanyl
  • hydromorphone
  • methadone
  • morphine
  • oxycodone
  • sufentanil

Miscellaneous analgesics

  • ketamine
  • mexiletine
  • xylocaine

Anticoagulants and coagulants

Anticoagulants

  • heparin sodium
  • warfarin

Coagulants – antifibrinolytic agents

  •  tranexamic acid 

Anticonvulsants

  • carbamazepine 
  • gabapentin
  • phenobarbital
  • phenytoin
  • valproic acid

Antidiarrheals

  • bismuth subsalicylate 
  • diphenoxylate
  • loperamide
  • octreotide – as a last resort only (e.g., currently covered for profuse diarrhea in advanced AIDS not responsive to multiple constipating agents).

Antiemetics

  • dexamethasone 
  • dimenhydrinate 
  • domperidone
  • haloperidol
  • metoclopramide – oral, parenteral
  • octreotide – As a last resort only (e.g., currently covered for uncontrolled vomiting from an irreversible bowel obstruction not responsive to the use of multiple antiemetics).
  • prochlorperazine – oral, suppository
  • promethazine

Anti-infectives

Antifungal (oral/topical/vaginal preparations)

  • clotrimazole
  • fluconazole
  • ketoconazole
  • nystatin

Antimicrobials

  • all antimicrobials normally covered by PharmaCare

Antivirals

  • acyclovir
  • famciclovir

Antipruritics

  • diphenhydramine
  • hydroxyzine

Antispasmodics

  • atropine 
  • baclofen
  • benztropine 
  • dantrolene
  • dicyclomine (Bentylol)
  • hyoscyamine (Levsin) 
  • opium and belladonna – suppositories
  • oxybutynin 
  • scopolamine – oral, parenteral, patch

Bone metabolism regulators

  • clodronate 
  • denosumab (Xgeva®)
  • pamidronate
  • zoledronic acid – Covered if a cost-effective usage. For example, if a patient is at home, has an estimated life span of more than 4 weeks, and hospital day care is not available or the patient would need transportation to get to a hospital. In such a case, the physician could administer zoledronic acid over 10-15 minutes via a butterfly needle in a peripheral vein.

Central nervous system stimulants

  • methylphenidate

Congestive heart failure therapy

  • all ACE inhibitors that are normally PharmaCare benefits 
  • all antianginals that are normally PharmaCare benefits
  • all beta blockers that are normally PharmaCare benefits
  • carvedilol 
  • digoxin

Diabetic agents

  • insulin 
  • glyburide
  • metformin

Diuretics

  • amiloride 
  • ethacrynic acid
  • furosemide 
  • hydrochlorothiazide
  • metolazone 
  • spironolactone
  • triamterene

H2 blockers and proton pump inhibitors

  • pantoprazole magnesium 
  • rabeprazole
  • ranitidine

Hemorrhoid therapy (ointment and suppositories)

  • Anusol®, Anusol HC® or equivalent preparations 
  • framycetin
  • pramoxine with and without hydrocortisone 
  • zinc sulfate with and without hydrocortisone

Laxatives

  • bisacodyl 
  • cascara
  • docusate sodium 
  • Fleet® enema 
  • glycerin
  • lactulose
  • Microlax® enema 
  • magnesium citrate
  • magnesium hydroxide (milk of magnesia) 
  • senna
  • senna/docusate combinations

Psychiatric medication

Antidepressants

  • amitriptyline 
  • bupropion
  • citalopram 
  • desipramine 
  • doxepin 
  • escitalopram
  • fluoxetine 
  • fluvoxamine
  • imipramine 
  • mirtazapine
  • nortriptyline
  • paroxetine
  • sertraline 
  • trazodone
  • venlafaxine 
  • zuclopenthixol

Antipsychotics

  • aripiprazole 
  • chlorpromazine
  • haloperidol 
  • loxapine
  • methotrimeprazine 
  • paliperidone
  • risperidone 
  • quetiapine

 Anxiolytics/hypnotics

  • alprazolam 
  • clonazepam
  • diazepam – oral, parenteral
  • lorazepam – oral, sublingual, parenteral 
  • midazolam
  • oxazepam

Respiratory system therapy

Bronchodilators

  • aminophylline tablets 
  • ipratropium – inhalers and nebules
  • salbutamol – inhalers and nebules 
  • theophylline

Inhaled corticosteroids

  • beclomethasone 
  • budesonide
  • ciclesonide
  • fluticasone 
  • mometasone furoate (Asmanex™ Twisthaler™)

Antitussives

  • codeine syrup
  • hydrocodone-phenyltoloxamine

Steroids

  • dexamethasone 
  • prednisone
  • all topical steroids normally covered by PharmaCare

Wound care

  • Fucidin (topical)
  • metronidazole (topical)
  • silver sulfadiazine (topical)

Other

  • azelaic acid topical gel
  • digestive enzymes
  • glycopyrrolate
  • potassium chloride solution
  • simethicone

Last updated: November 16, 2016

Note: PharmaCare formularies are not a replacement for professional medical judgment and advice.

Questions? Please contact us.