Product Details

Fragmin

Dalteparin Sodium
3500 IU/0.28 mL
Solution for Injection
Prefilled Syringe

DIN/PIN/NPN

02430789

Manufacturer

Pfizer Canada Inc.

Formulary Listing Date

2016-03-30  

Unit Price

8.3110

Amount MOH Pays

8.3110

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

B01AB04

Interchangeable Products

NO  

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
186 1 year

For acute treatment of deep venous thrombosis (DVT), for a maximum of three weeks;
187 1 year

For DVT in pregnant or lactating females;
188 1 year

For DVT in patients whom treatment with warfarin is not tolerated, or contraindicated;
189 1 year

For DVT in patients who have failed treatment with warfarin.
 

EAP Criteria

Therapeutic Class Reimbursement Criteria
Anticoagulants

Dalteparin

  • Brand(s): Fragmin
  • Dosage Form/Strength: Check formulary or e-formulary for funded products

For peri-operative bridging for patients who require long-term warfarin therapy and must temporarily discontinue it before and after surgery, and who are at moderate- to high-risk for an embolic event while off warfarin. 

Standard Approval Duration: As requested up to a maximum of 10 days before the date of surgery plus up to 7 days after surgery.

For post-operative prophylaxis of DVT for patients who had hip or knee surgery, and cannot use warfarin. 

Standard Approval Duration: As requested up to a maximum of 30 days starting on the day of surgery.

For the post-operative prophylaxis of venous thromboembolism following abdominal or pelvic surgery for cancer in patients who do not have a history of or risk factors for heparin-induced thrombocytopenia. 

Standard Approval Duration: Maximum of 30 days

For extended treatment of symptomatic acute venous thromboembolism (VTE) in patients with cancer for whom warfarin treatment is not appropriate on a case-by-case basis. 

Standard Approval Duration: 6 months

EAP Drug Request Form:

Standard Form for EAP Drug Requests
Anticoagulants – Telephone Request Service (TRS) Drugs

Dalteparin

  • Brand(s): Fragmin
  • Dosage Form/Strength: Check e-formulary for funded strengths

NOTE: Low Molecular Weight Heparins (LMWHs) are currently listed on the ODB Formulary as Limited Use (LU) benefits for the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE) in certain patient groups. Please consult the Formulary for further details.

  1. For peri-operative bridging for patients who require long-term warfarin therapy and must temporarily discontinue it before and after surgery, and who are at moderate- to high-risk for an embolic event while off warfarin.

    Standard Approval Duration: As requested, up to a maximum of 10 days before the date of surgery plus up to 7 days after the date of hospital discharge 

  1. For post-operative prophylaxis of DVT for patients who had hip or knee surgery and cannot use warfarin.

    Standard Approval Duration: As requested, up to a maximum of 30 days starting on the day of surgery 

  1. For the post-operative prophylaxis of venous thromboembolism following abdominal or pelvic surgery for cancer in patients who do not have a history of or risk factors for heparin-induced thrombocytopenia.

    Standard Approval Duration: Maximum of 30 days. 

  1. For extended treatment of symptomatic acute venous thromboembolism (VTE) in patients with cancer, who cannot use warfarin.

    Standard Approval Duration: As requested, up to 6 months

Product Monograph

View Monograph