|
ACETAMINOPHEN |
Analgesic |
Tylenol, Panadol |
|
|
ACETAMINOPHEN + CODEINE |
Analgesic |
Tylenol #1,2,3,4, Lenoltec, Emtec, Empracet |
|
|
ACETAMINOPHEN + OXYCODONE |
Analgesic |
Percocet, Oxycocet, Endocet, Oxy -12 |
|
|
ACYCLOVIR |
Anti-viral |
Zovirax, Avirax |
|
|
ALLOPURINOL |
Lowers uric acid levels associated with treatment of cancer |
Zyloprim |
|
|
AMITRIPTYLINE |
Depression, Neuropathic pain |
Elavil, Novo-Triptyn |
|
|
AMOXICILLIN/CLAVULANATE |
Antibiotic |
Amoxil |
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 14 day course. |
|
ASPIRIN |
Analgesic |
Aspirin, ASA, Entrophen |
Does not include low dose (81mg) aspirin products. |
|
ASPIRIN + CODEINE |
Analgesic |
Frosst 292, MEP 282 |
|
|
ASPIRIN + OXYCODONE |
Analgesic |
Percodan, Oxycodan |
|
|
BENZYDAMINE |
Mouth/throat sores due to mucositis |
Tantum |
|
|
BETAMETHASONE |
Steroid - topical antiinflammatory |
Betnovate, Celestoderm, Diprolene |
|
|
BETHANECHOL |
Urinary tract analgesic |
Urecholine |
|
|
BISACODYL |
Laxative |
Dulcolax |
|
|
CARBAMAZEPINE |
Anti-convulsant, neuropathic pain |
Tegretol |
Not for pre-existing seizures. |
|
CEPHALEXIN |
Anti-biotic |
Keflex |
|
|
CHLORAL HYDRATE |
Sedative/Hynoptic |
Noctec |
|
|
CHLORPROMAZINE |
Anti-nauseant/anti-emetic |
Largactil |
|
|
CIMETIDINE |
Anti-ulcer - reduces acid secretion |
Tagamet |
|
|
CIPROFLOXACIN |
Anti-biotic |
Cipro (Regular release products only.) |
|
|
CLARITHROMYCIN |
Anti-biotic |
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 14 day course. |
|
CLINDAMYCIN |
Anti-biotic |
Dalacin |
|
|
CLOTRIMAZOLE |
Anti-fungal |
Canesten, Clotrimaderm |
|
|
CLOXACILLIN |
Anti-biotic |
Orbenin |
|
|
CODEINE |
Analgesic |
Codeine |
|
|
COTRIMOXAZOLE |
Anti-biotic |
Septra, Bactrim, Trimel, Sulfatrim |
|
|
DEXAMETHASONE |
Steroid-antiinflammatory, antinausea |
Decadron |
|
|
DEXTROMETHORPHAN |
Antitussive-related to lung cancer only |
Novahistex DM, Robitussin DM |
Lung Cancer only. |
|
DIAZEPAM |
Sedative/hynoptic |
Valium |
|
|
DIMENHYDRINATE |
Anti-nauseant/anti-emetic |
Gravol, Travel tabs |
|
|
DIPHENHYDRAMINE |
Anti-histamine - allergic reactions |
Benadryl, Allernix |
|
|
DIPHENOXYLATE |
Anti-diarrheal |
Lomotil |
|
|
DIVALPROEX SODIUM |
Neuropathic pain |
Epival |
Not for pre-existing seizures. |
|
DOCUSATE SODIUM |
Stool softener |
Colace |
|
|
DOMPERIDONE |
Anti-nauseant/anti-emetic |
Motilium |
|
|
DOXEPIN |
Depression, neuropathic pain, sedative |
Sinequan |
|
|
ERYTHROMYCIN |
Anti-biotic |
Erythromid |
|
|
FENTANYL |
Analgesic |
Duragesic |
|
|
FERROUS GLUCONATE
FERROUS SULFATE |
Iron supplement |
Lowest cost generic brands only. |
Not for pre-existing anemias prior to cancer treatments |
|
FLUCONAZOLE |
Anti-fungal
|
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 10 day course. |
|
FUROSEMIDE |
Diuretic |
Lasix |
Not for pre-existing condition. |
|
GABAPENTIN |
Anti-convulsant, neuropathic pain |
Neurontin |
Not for pre-existing seizures. |
|
GLYCERIN |
Laxative - rectal only |
Glycerin |
|
|
HYDROCODONE |
Antitussive -related to lung cancer only |
Tussionex, Novahistex DH, Caldomine-DH |
|
|
HYDROCORTISONE |
Steroid - topical antiinflammatory |
Cream and Ointment |
|
|
HYDROMORPHONE |
Analgesic |
Dilaudid, Hydromorph Contin |
|
|
HYDROXYZINE |
Anti-histamine - allergic reactions |
Atarax |
|
|
IBUPROFEN |
Non-steroidal - antiinflammatory |
Motrin, Advil |
|
|
KETOCONAZOLE |
Anti-fungal |
Nizoral |
|
|
LACTULOSE |
Laxative |
Lactulose, Laxilose |
|
|
LEVOFLOXACIN |
Anti-biotic
|
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 7 day course. |
|
LOPERAMIDE |
Anti-diarrhea |
Imodium |
|
|
LORAZEPAM |
Sedative/Hynoptic, antinausea |
Ativan |
|
|
MEPERIDINE |
Analgesic |
Demerol |
|
|
METHADONE |
Analgesic |
Methadone |
|
|
METOCLOPRAMIDE |
Anti-nauseant/anti-emetic |
Maxeran, Reglan |
|
|
METRONIDAZOLE |
Anti-biotic |
Flagyl |
Compounded liquid up to a maximum benefit 10 day course and total maximum cost (including compounding and dispensing fees) $30.00. |
|
MORPHINE |
Analgesic |
M-Eslon, Statex, MOS, MS-IR, Morphitec (Note - MS Contin NOT covered) |
|
|
Mouthwash/Mouth rinse – compounded (other than Pink Lady) |
For mouth sores/mucositis only. |
FVCC mouthwash |
Maximum $30.00 including dispensing & compound fees. |
|
Mouthwash/Mouth rinse – Pink Lady |
For mouth sores/mucositis only. |
Pink Lady |
|
|
MOXIFLOXACIN |
Anti-biotic
|
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 10 day course. |
|
NABILONE |
Anti-nauseant/anti-emetic |
Cesamet |
When prescribed by a cancer doctor |
|
NAPROXEN |
Non-steroidal antiinflammatory |
Naprosyn |
|
|
NORFLOXACIN |
Anti-biotic
|
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 10 day course. |
|
NYSTATIN |
Anti-fungal |
Nilstat, Mycostatin, Nyaderm |
|
|
ONDANSETRON |
Anti-nauseant/anti-emetic |
Zofran |
Availability to be increased to now include patients registered with the Pharmacare Palliative Care Benefits Program as long as patients are receiving palliative chemotherapy or radiation therapy only. |
|
OXYCODONE regular release only |
Analgesic |
Endodan, Percocet, Oxy-IR, Supeudol (Regular release formulations only.) |
|
|
OXAZEPAM |
Sedative/Hynoptic |
Serax |
|
|
PHENAZOPYRIDINE |
Urinary tract analgesic |
Pyridium |
|
|
PENICILLIN V |
Anti-biotic |
|
|
|
PHENYTOIN |
Anti-convulsant - related to brain cancer only, neuropathic pain |
Dilantin |
Not for pre-existing seizures. |
|
PREDNISONE |
Steroid - antiinflammatory |
Deltasone |
|
|
PROCHLORPERAZINE |
Anti-nauseant/anti-emetic |
Stemetil |
|
|
Radiation Reaction Skin Cream/Ointment – compounded |
For Radiation skin reactions only. |
Variety of combinations. Max cost $30.00 including compounding & dispensing fees. |
When prescribed by a cancer doctor |
|
RANITIDINE |
Anti-ulcer - reduces acid secretion |
Zantac, other generic brands. Lowest cost alternative brand required |
Up to maximum dose of 150mg twice daily and up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Not a benefit for pre-existing gastro-intestinal conditions. |
|
SALBUTAMOL |
Bronchial dilation-lung cancer |
Ventolin |
Lung Cancer only. |
|
SCOPOLAMINE/HYOSCINE BUTYLBROMIDE |
Anti-spasmodic for urinary frequency & diarrhea-oral or rectal |
Buspar, Buscopan |
|
|
SENNOSIDES |
Laxative |
Senna, Senokot, Glysennid |
|
|
SILVER SULFADIAZINE |
Topical antibiotic |
Cream, Dermazin |
|
|
VALACYCLOVIR |
Anti-viral
|
|
Up to the cost of oral solid dosage forms only. Patient to pay additional cost of oral liquids. Maximum benefit 10 day course. |
|
VALPROIC ACID |
Anti-convulsant, neuropathic pain |
Depakene |
Not for pre-existing seizures. |
|
WARFARIN |
Anti-coagulant |
Coumadin |
Not for pre-existing conditions. |