Drug Benefit List
Special Formulary for Chronic Renal Failure Patients
October 2006
The Special Formulary for Chronic Renal Failure Patients defines selected
drugs (for example: darbepoetin alfa, calcium products, water-soluble
multivitamin products and selected nutritional products formulated for
renal patients) that are covered for identified eligible Non-Insured
Health Benefits (NIHB) clients in chronic renal failure.
These drugs are covered in addition to the drugs and products listed
in the NIHB Drug Benefit List.
20:00 BLOOD FORMATION COAGULATION AND THROMBOSIS
20:16.00 HEMATOPOIETIC AGENTS
DARBEPOETIN ALFA
- 25MCG/ML Injection
- 02246354 ARANESP AMG *
- 40MCG/ML Injection
- 02246355 ARANESP AMG *
- 100MCG/ML Injection
- 02246357 ARANESP AMG *
- 200MCG/ML Injection
- 02246358 ARANESP AMG *
- 500MCG/ML Injection
- 02246360 ARANESP AMG *
EPOETIN ALFA
- 20,000IU/ML Injection
- 02206072 EPREX JNO *
- 5,000IU/ML Injection
- 02243400 EPREX JNO *
- 1,000IU/0.5ML Prefilled Syringe
- 02231583 EPREX JNO *
- 2,000IU/0.5ML Prefilled Syringe
- 02231584 EPREX JNO *
- 3,000IU/0.3ML Prefilled Syringe
- 02231585 EPREX JNO *
- 4,000IU/0.4ML Prefilled Syringe
- 02231586 EPREX JNO *
- 6,000IU/0.6ML Prefilled Syringe
- 02243401 EPREX JNO *
- 8,000IU/0.8ML Prefilled Syringe
- 02243403 EPREX JNO *
- 10,000IU/ML Prefilled Syringe
- 02231587 EPREX JNO *
- 40,000IU/ML Prefilled Syringe
- 02240722 EPREX JNO *
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM (CALCIUM GLUCONOLACTATE, CALCIUM CARBONATE)
- 300MG & 2940MG Effervescent Tablet
- 02232482 CALCIUM SANDOZ NVC *
- 1750MG & 2327MG Effervescent Tablet
- 02232483 GRAMCAL NVC *
CALCIUM CARBONATE
- 500MG Capsule
- 00648353 CALSAN NVC *
- 500MG Chewable Tablet
- 00705373 CALCIUM WAM *
- 00648345 CALSAN NVC *
- 250MG Tablet
- 00682047 APO-CAL 250 APX *
- 00645958 CALCIUM NOP *
- 02042983 OS-CAL
250 WYA *
- 500MG Tablet
- 00722332 CALCIUM PVR *
- 01970240 TUMS GSK *
PHOSPHORUS
- 500MG Effervescent Tablet
- 00225819 PHOSPHATE-NOVARTIS NVR *
ZINC GLUCONATE
- 50MG Tablet
- 00503169 ZINC VTH *
- 00505463 ZINC JAM *
ZINC SULFATE
- 220MG Tablet
- 00575593 EGOZINC PMS *
56:00 GASTROINTESTINAL DRUGS
56:04.00 ANTACIDS AND ADSORBENTS
ALUMINUM HYDROXIDE
- 500MG Capsule
- 02135620 BASALJEL AXC
- 60MG/ML Liquid
- 00572527 ALUGEL ATL
- 64MG/ML Liquid
- 02125862 AMPHOJEL AXC
- 600MG Tablet
- 02124971 AMPHOJEL AXC
CALCIUM CARBONATE
- 750MG Tablet
- 01967932 TUMS
EXTRA STRENGTH GSK *
- 1000MG Tablet
- 02151138 TUMS
ULTRA STRENGTH GSK *
88:00 VITAMINS
88:08.00 VITAMIN B COMPLEX
VITAMIN B COMPLEX
- Tablet
- 00123803 B COMPLEX
PLUS C JAM *
88:12.00 VITAMIN C
VITAMIN B COMPLEX WITH VITAMIN C
- Tablet
- 02245391 DIAMINE EUO *
88:28.00 MULTIVITAMIN PREPARATIONS
MULTIVITAMINS
- Tablet
- 02244872 REPLAVITE WNP *
- 00558796 STRESS
PLEX C JAM *
- 02166623 STRESSTABS WRI *
92:00 UNCLASSIFIED THERAPEUTIC AGENTS
92:00.00 UNCLASSIFIED THERAPEUTIC AGENTS
SEVELAMER HYDROCHLORIDE
Limited Use Benefit ( Prior approval required ).
a. - patients with elevated phosphate levels OR elevated phosphate X
calcium product despite dietary restriction of phosphate and use of calcium-based
phosphate binders (short term elevations should be managed with aluminium
based binders)
b. - patients with elevated calcium levels despite discontinuation of
calcium binder, and Vitamin D analogue and/or modification of dialysate
calcium
c. - patients with adynamic bone disease and low PTH levels (<100
pg/ml or <0.9 pmol/L) with normal or elevated calcium levels
- 800MG Tablet
- 02244310 RENAGEL GEE *
96:00 PHARMACEUTICAL AIDS
96:00.00 PHARMACEUTICAL AIDS
NUTRITIONAL SUPPLEMENT
- Liquid
- 09853723 NEPRO ABB *
- 00907995 NOVASOURCE NVR *
- 09853731 SUPLENA ABB *
- 235ML Liquid
- 99002639 NEPRO ABB *
- 99002647 SUPLENA ABB *
- Powder
- 09991056 RESOURCE BENEPROTEIN NVR *
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