Benefit Drug List

Page 1 of 65
BC Cancer Benefit Drug List

April 2022
DEFINITIONS
Class I Reimbursed for active cancer or approved treatment or approved indication only.
Reimbursed for approved indications only. Completion of the BC Cancer Compassionate Access Program Application (formerly Undesignated Indication Form) is necessary to provide
Restricted Funding (R)
the appropriate clinical information for each patient.
NOTES
1. BC Cancer will reimburse, to the Communities Oncology Network hospital pharmacy, the actual acquisition cost of a Benefit Drug, up to the maximum price as determined by BC Cancer, based on the current brand
and contract price. Please contact the OSCAR Hotline at 1-888-355-0355 if more information is required.
2. Not Otherwise Specified (NOS) code only applicable to Class I drugs where indicated.
3. Intrahepatic use of chemotherapy drugs is not reimbursable unless specified.
4. For queries regarding other indications not specified, please contact the BC Cancer Compassionate Access Program Office at 604.877.6000 x 6277 or cap_bcca@bccancer.bc.ca
DOSAGE TUMOUR PROTOCOL

DRUG APPROVED INDICATIONS CLASS NOTES
FORM SITE CODES
Therapy for Metastatic Castration-Sensitive Prostate Cancer using
abiraterone tablet Genitourinary UGUMCSPABI R
Abiraterone and Prednisone
Palliative Therapy for Metastatic Castration Resistant Prostate Cancer
abiraterone tablet Genitourinary UGUPABI R
Using Abiraterone and prednisone
Treatment of Relapsed/Refractory Chronic Lymphocytic Leukemia or
acalabrutinib capsule Lymphoma LYACAL I
Small Lymphocytic Lymphoma using Acalabrutinib
Treatment of Previously Untreated Chronic Lymphocytic Leukemia or
acalabrutinib capsule Lymphoma ULYFACAL R
Small Lymphocytic Lymphoma using Acalabrutinib
acitretin capsule Lymphoma reversal of early dysplastic and neoplastic stem changes LYNOS I
first-line treatment of epidermal growth factor receptor mutation-positive
afatinib tablet Lung LUAVAFAT I
advanced non-small cell lung cancer with afatinib
aldesleukin injectable Skin & Melanoma Treatment of In-Transit Melanoma with Intralesional Aldesleukin IL-2 SMILALD I
pediatric patients with high risk neuroblastoma treated on the ANBL0032
aldesleukin injectable Pediatric I
study
treatment of pediatric patients with high-risk neuroblastoma who achieve a

aldesleukin injectable Pediatric response to prior first-line multi-agent, multimodal therapy using R
dinutuximab in combination with sargramostim, aldesleukin and tretinoin
treatment of ALK-positive advanced non-small cell lung cancer with

alectinib capsule Lung LUAVALE I
alectinib
treatment of fludarabine-refractory B-chronic lymphocytic leukemia and T-
alemtuzumab injectable Lymphoma LYALEM I
prolymphocytic leukemia
Treatment of Cutaneous T-Cell Lymphoma (Mycosis Fungoides/ Sézary
alitretinoin tablet Lymphoma LYALIT I
Syndrome)
Only reimbursable when

aminolevulinic acid prescribed by physicians in the
topical solution Skin & Melanoma topical therapy for skin cancer with PDT (Photodynamic Therapy) SMPDT I
(LEVULAN® KERASTICK®) Skin Tumour Group within the BC
Cancer Skin PDT Program
amsacrine injectable Leukemia & BMT LKNOS I

patients with thrombocytosis related to a myeloproliferative disorder who
anagrelide capsule Leukemia & BMT have had an inadequate response to or are intolerant of hydroxyurea LKANAG I
and/or interferon
* denotes change
Page 2 of 65
April 2022

FORM SITE CODES
neoadjuvant or adjuvant therapy for breast cancer using anastrozole in
anastrozole tablet Breast BRAJANAS I
postmenopausal women
neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in

anastrozole tablet Breast BRAJLHRHAI I
premenopausal women with high-risk early stage breast cancer
first or second line hormonal treatment for advanced breast cancer in

anastrozole tablet Breast BRAVANAS I
therapy for advanced breast cancer using a LHRH agonist and an
anastrozole tablet Breast BRAVLHRHA I
aromatase inhibitor
therapy of advanced breast cancer using palbociclib and aromatase
anastrozole (cont'd) tablet Breast BRAVPALAI I
inhibitor with or without LHRH agonist
therapy of advanced breast cancer using ribociclib and aromatase
anastrozole (cont'd) tablet Breast BRAVRIBAI I
hormonal treatment for advanced endometrial cancer in postmenopausal

anastrozole (cont'd) tablet Gynecology GOENDAI I
women with contraindications to tamoxifen or intolerant of tamoxifen
anastrozole (cont'd) tablet Gynecology therapy for advanced ovarian cancer using an aromatase inhibitor GOOVAI I
Treatment of Metastatic Castration Sensitive Prostate Cancer using
apalutamide tablet Genitourinary UGUMCSPAPA R
Apalutamide
Treatment of Non- Metastatic Castration Resistant Prostate Cancer Using
apalutamide tablet Genitourinary UGUPAPA R
Apalutamide
first-line induction and consolidation therapy of acute promyelocytic
arsenic trioxide injectable Leukemia & BMT LKATOATRA I
leukemia using arsenic trioxide and tretinoin
arsenic trioxide injectable Leukemia & BMT LKATOP I
leukemia using arsenic trioxide, tretinoin and daunorubicin
induction and consolidation therapy of relapsed acute promyelocytic

arsenic trioxide injectable Leukemia & BMT LKATOR I
leukemia using arsenic trioxide and tretinoin (All-Trans Retinoic Acid)
asparaginase
injectable Leukemia & BMT LKNOS, LYNOS I
(KIDROLASE®)
treatment of acute lymphoblastic leukemia and lymphoblastic lymphoma

asparaginase-erwinia
injectable Leukemia & BMT using asparaginase-Erwinia (Erwinase®) in patients allergic to LKNOS, LYNOS I
(ERWINASE®)
asparaginase (Kidrolase®) or pegaspargase (Oncaspar®)
First-Line Treatment of Advanced Hepatocellular Carcinoma using

atezolizumab injectable Gastrointestinal GIATZB* I
Atezolizumab and Bevacizumab
atezolizumab injectable Lung treatment of advanced non-small cell lung cancer LUAVATZ I
treatment of advanced non-small cell lung cancer using 4-weekly
atezolizumab injectable Lung LUAVATZ4 I
atezolizumab
second-line treatment of recurrent or metastatic merkel cell carcinoma
avelumab injectable Skin & Melanoma SMMCCAVE I
using avelumab
axitinib tablet Genitourinary therapy for metastatic renal cell carcinoma using axitinib GUAXIT I
Treatment of Metastatic Renal Cell Carcinoma Using Pembrolizumab and
axitinib tablet Genitourinary GUAVPEMAX I
Axitinib
azacitidine injectable Leukemia & BMT therapy of acute myeloid leukemia using azacitidine and sorafenib LKAMLAS I
azacitidine (cont'd) injectable Leukemia & BMT therapy of myelodysplastic syndrome ULKMDSA R
bacillus calmette guerin Therapy for High- or Intermediate-Risk Non-Muscle Invasive Bladder
injectable Genitourinary GUBCG I
(BCG) Cancer using BCG
* denotes change
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April 2022

FORM SITE CODES
bendamustine injectable Lymphoma treatment of Non-Hodgkin Lymphoma with bendamustine LYBEND I
bendamustine (cont'd) injectable Lymphoma treatment of Non-Hodgkin Lymphoma with bendamustine and rituximab LYBENDR I
bendamustine injectable Lymphoma treatment of relapsed chronic lymphocytic leukemia with bendamustine LYCLLBEND I
treatment of relapsed/refractory chronic lymphocytic leukemia or small

bendamustine injectable Lymphoma LYCLLBENDR I
lymphocytic lymphoma with bendamustine and rituximab
treatment of previously untreated chronic lymphocytic leukemia (CLL) with
bendamustine (cont'd) injectable Lymphoma LYCLLFBR I
bendamustine and rituximab
treatment of rituximab-refractory follicular lymphoma with obinutuzumab in
bendamustine (cont'd) injectable Lymphoma LYOBBEND I
combination with bendamustine
Treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma and
bendamustine injectable Lymphoma Not Eligible for Transplant using Polatuzumab Vedotin, Bendamustine and LYPOLABR* I
Rituximab
First-Line Treatment of Advanced Hepatocellular Carcinoma using
bevacizumab injectable Gastrointestinal GIATZB* I
Atezolizumab and Bevacizumab
palliative therapy of metastatic colorectal cancer using capecitabine and
bevacizumab injectable Gastrointestinal GIAVCAPB I
bevacizumab
palliative combination chemotherapy for metastatic colorectal cancer using
bevacizumab injectable Gastrointestinal GICIRB I
irinotecan, bevacizumab and capecitabine
bevacizumab injectable Gastrointestinal GICOXB I
oxaliplatin, bevacizumab and capecitabine

bevacizumab (cont'd) injectable Gastrointestinal GIFFIRB I
irinotecan, fluorouracil, folinic acid (leucovorin) and bevacizumab

bevacizumab (cont'd) injectable Gastrointestinal GIFFOXB I
oxaliplatin, fluorouracil, leucovorin, and bevacizumab
bevacizumab (cont'd) injectable Neuro-Oncology patients with relapsed malignant gliomas CNBEV I
alternative treatment of gynecological malignancies using bevacizumab,
bevacizumab (cont'd) injectable Gynecology GOCABRBEV I
carboplatin and paclitaxel NAB (ABRAXANE) Note: Biosimilar bevacizumab
Alternative Treatment of Gynecological Malignancies using Bevacizumab, (ZIRABEV®, MVASI®) is funded
bevacizumab (cont'd) injectable Gynecology GOCISPBEV I
Cisplatin and Paclitaxel for treatment started on or after
primary treatment of metastatic/recurrent cancer of the cervix with November 1st, 2019. AVASTIN®
bevacizumab (cont'd) injectable Gynecology GOCXCATB I
bevacizumab, carboplatin and paclitaxel is funded for treatment started
treatment of platinum resistant epithelial ovarian cancer with bevacizumab prior to November 1st, 2019.
bevacizumab (cont'd) injectable Gynecology GOOVBEVG I
and gemcitabine
treatment of platinum resistant epithelial ovarian cancer with bevacizumab
bevacizumab injectable Gynecology GOOVBEVLD I
and pegylated liposomal doxorubicin
bevacizumab (cont'd) injectable Gynecology GOOVBEVP I
and paclitaxel
bevacizumab injectable Gynecology GOOVBEVV I
and vinorelbine
primary treatment of invasive epithelial ovarian, fallopian tube and primary
bevacizumab (cont'd) injectable Gynecology peritoneal cancer with high risk of relapse using bevacizumab, carboplatin GOOVCATB I
and paclitaxel
treatment with bevacizumab as a single agent or in combination with
bevacizumab (cont'd) Pediatric chemotherapy for pediatric patients with low-grade gliom progressing after I
first-line chemotherapy
therapy for advanced solitary fibrous tumours and hemangiopericytoma
bevacizumab (cont'd) Sarcoma SATEMBEV I
using temozolomide and bevacizumab
Approval from Health Canada
bexarotene (SAP) capsule Lymphoma patients with refractory cutaneous T-cell lymphoma LYMFBEX I Special Access Programme is
required for each patient.
bicalutamide tablet Genitourinary Treatment of Prostate Cancer with High-Dose Bicalutamide GUPHDBIC I Not reimbursed for vasomotor
bicalutamide tablet Genitourinary Non-Steroidal Treatment of Prostate Cancer, at 50 mg po daily GUPNSAA I symptoms (hot flashes)
* denotes change
Page 4 of 65
April 2022

FORM SITE CODES
therapy of non-dysgerminomatous ovarian germ cell cancer using
bleomycin injectable Gynecology GOBEP I
bleomycin, etoposide, and cisplatin
curative therapy for germ cell cancer using with bleomycin, etoposide,
bleomycin injectable Genitourinary GUBEP I Not reimbursed for pleurodesis
cisplatin for germ cell cancers
palliative therapy for kaposi’s sarcoma using vinblastine alternating with
bleomycin injectable Kaposi's Sarcoma KSVB I
vincristine
treatment of Hodgkin lymphoma with doxorubicin, bleomycin, vinblastine,
bleomycin (cont'd) injectable Lymphoma LYABVD I
and dacarbazine
treatment of Hodgkin's Disease with cyclophosphamide, vinblastine,
bleomycin injectable Lymphoma LYCVPPABO I Not reimbursed for pleurodesis
procarbazine and prednisone
Other tumour site code
Not Otherwise
bleomycin injectable followed by ‘NOS’ (e.g. I
Specified LYNOS)
treatment of Philadelphia chromosome (Ph)-positive or Ph-negative
blinatumomab injectable Leukemia & BMT refractory or relapsed pre-B-cell acute lymphoblastic leukemia with ULKBLIN R
blinatumomab
treatment of pediatric patients with Philadelphia chromosome-negative (Ph-
blinatumomab injectable Leukemia & BMT ) relapsed or refractory pre-B-cell acute lymphoblastic leukemia using R
blinatumomab
Bortezomib, Lenalidomide and Dexamethasone for Previously Untreated
bortezomib injectable Myeloma UMYBLDF R
Multiple Myeloma
maintenance therapy for multiple myeloma using bortezomib for patients
bortezomib injectable Myeloma MYBORMTN I
with the high-risk chromosome abnormality
treatment of multiple myeloma using bortezomib, dexamethasone with or

injectable Myeloma MYBORPRE I
without cyclophosphamide as induction pre-stem cell transplant
treatment of relapsed multiple myeloma using bortezomib,

bortezomib injectable Myeloma MYBORREL I
dexamethasone with or without cyclophosphamide
treatment of relapsed and refractory multiple myeloma with daratumumab
bortezomib (cont'd) injectable Myeloma in combination with bortezomib and dexamethasone with or without UMYDARBD R
cyclophosphamide
treatment of multiple myeloma using melphalan, prednisone and weekly
bortezomib (cont'd) injectable Myeloma bortezomib with the option of substituting cyclophosphamide for MYMPBOR I
melphalan
bosutinib tablet Leukemia & BMT treatment of chronic myeloid leukemia using bosutinib LKCMLB I
Treatment of Previously Untreated, Stage IV Hodgkin Lymphoma with

brentuximab vedotin injectable Lymphoma LYAVDBV I
Doxorubicin, Vinblastine, Dacarbazine and Brentuximab Vedotin
treatment of Hodgkin lymphoma and anaplastic large cell lymphoma with

brentuximab vedotin injectable Lymphoma LYBRENTUX I
brentuximab vedotin
treatment for consolidation therapy post-autologous stem cell transplant

brentuximab vedotin injectable Lymphoma LYBV I
(ASCT) for Hodgkin lymphoma using brentuximab vedotin
treatment of CD30-positive peripheral T-Cell Lymphoma (PTCL) with

brentuximab vedotin
injectable Lymphoma doxorubicin, cyclophosphamide, prednisone (CHP) and brentuximab LYCHPBV I
(cont'd)
vedotin
Treatment of Cutaneous T-Cell Lymphoma (CTCL) with Brentuximab
brentuximab vedotin injectable Lymphoma LYCTCLBV I
Vedotin
bromocriptine tablet, capsule Neuro-Oncology therapy for pituitary adenomas using bromocriptine CNB I
* denotes change
Page 5 of 65
April 2022

FORM SITE CODES
long-acting neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in

buserelin Breast BRAJLHRHAI I
injectable premenopausal women with high-risk early stage breast cancer
neoadjuvant or adjuvant therapy for breast cancer using a LHRH agonist

buserelin (cont'd) injectable Breast BRAJLHRHT I
and tamoxifen
buserelin injectable Breast BRAVLHRHA I
aromatase inhibitor
combination therapy with tamoxifen as palliative therapy for metastatic
buserelin injectable Breast BRAVLHRHT I
breast cancer
Not reimbursed for endometriosis
buserelin injectable Breast BRAVPALAI I
Therapy of Advanced Breast Cancer using Palbociclib and Fulvestrant
buserelin injectable Breast BRAVPBFLV I
with or without LHRH Agonist
Therapy of Advanced Breast Cancer using Ribociclib and Fulvestrant with
buserelin injectable Breast BRAVRBFLV I
or without LHRH Agonist
buserelin injectable Breast BRAVRIBAI I
buserelin (cont'd) injectable Genitourinary therapy for prostate cancer using LHRH agonist GUPLHRH I
Tumour site code
Not Otherwise
busulfan tablet followed by ‘NOS’ I
Specified
(e.g. LKNOS)
myeloablative conditioning therapy prior to hematopoietic stem cell
busulfan injectable Leukemia & BMT BMTIVBUCY I
transplantation for myeloid malignancies
busulfan injectable Pediatric pediatric patients who cannot swallow oral busulfan I
palliative therapy for metastatic castration resistant prostate cancer using
cabazitaxel injectable Genitourinary GUPCABA I
cabazitaxel and prednisone
cabergoline tablet Neuro-Oncology therapy for pituitary adenomas using cabergoline CNCAB I
cabozantinib tablet Gastrointestinal Treatment of Advanced Hepatocellular Carcinoma using Cabozantinib UGICABO R
cabozantinib tablet Genitourinary therapy for metastatic renal cell carcinoma using cabozantinib GUCABO I
* denotes change
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April 2022

FORM SITE CODES
capecitabine tablet Breast therapy of adjuvant breast cancer using capecitabine BRAJCAP I
metastatic breast cancer as first line treatment if anthracyclines and
taxanes contraindicated, or where sidfect profile and/or treatment delivery
capecitabine (cont'd) tablet Breast concerns favour initial use of BRAVCAP; second or third line treatment of BRAVCAP I
metastatic breast cancer that has previously responded to an
anthracycline and taxane
capecitabine tablet Breast therapy for metastatic breast cancer using capecitabine and lapatinib BRAVLCAP I
palliative therapy for metastatic breast cancer using trastuzumab and

capecitabine tablet Breast BRAVTCAP I
capecitabine
capecitabine tablet Gastrointestinal adjuvant therapy of colon cancer using capecitabine GIAJCAP I
adjuvant combination chemotherapy for stage III and IIB colon cancer with
capecitabine tablet Gastrointestinal GIAJCAPOX I
oxaliplatin
first line palliative therapy of metastatic or unresectable colorectal
capecitabine (cont'd) tablet Gastrointestinal GIAVCAP I
adenocarcinoma in a patient either not suitable for or refusing GIIRFUFA
palliative therapy of metastatic colorectal cancer using capecitabine and
capecitabine (cont'd) tablet Gastrointestinal GIAVCAPB I
bevacizumab
combined modality therapy for metastatic rectal carcinoma using
capecitabine tablet Gastrointestinal GIAVCRT I
capecitabine and radiation therapy
palliative therapy of metastatic neuroendocrine cancer using
capecitabine tablet Gastrointestinal GIAVTZCAP I
temozolomide and capecitabine
capecitabine (cont'd) tablet Gastrointestinal Adjuvant Therapy of Biliary Cancer using Capecitabine GIBAJCAP I

capecitabine (cont'd) tablet Gastrointestinal GICAPIRI I
irinotecan and capecitabine in patients unsuitable for GIFOLFIRI

capecitabine (cont'd) tablet Gastrointestinal GICAPOX I
oxaliplatin and capecitabine
combination with mitomycin and radiation therapy as curative combined
capecitabine (cont'd) tablet Gastrointestinal GICART I
modality therapy for carcinoma of the anal canal
capecitabine (cont'd) tablet Gastrointestinal GICIRB I
capecitabine (cont'd) tablet Gastrointestinal GICOXB I
curative-intent combined modality therapy for cancer of the anal canal,
capecitabine (cont'd) tablet Gastrointestinal GICPART I
using cisplatin, capecitabine and radiation therapy
adjuvant chemotherapy in gastric cancer patients with D2 resection (node
capecitabine (cont'd) tablet Gastrointestinal negative) or ineligible for adjuvant chemoradiation using oxaliplatin and GIGAJCOX I
capecitabine
adjuvant chemotherapy in gastric cancer patients with completely
capecitabine (cont'd) tablet Gastrointestinal resected gastric cancer using cisplatin and capecitabine and radiation GIGAJCPRT I
therapy
palliative therapy of metastatic or locally advanced anal squamous cell
capecitabine (cont'd) tablet Gastrointestinal GIGAVCC I
carcinoma using cisplatin and capecitabine
Palliative Treatment of Metastatic or Locally Advanced Gastric,
capecitabine (cont'd) tablet Gastrointestinal Gastroesophageal Junction or Esophageal Adenocarcinoma using GIGAVCCT I
Cisplatin, Capecitabine and Trastuzumab
* denotes change
Page 7 of 65
April 2022

FORM SITE CODES
capecitabine (cont'd) tablet Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Capecitabine GIGAVCOX I
and Oxaliplatin
palliative treatment of metastatic or locally advanced gastric,
capecitabine (cont'd) tablet Gastrointestinal gastroesophageal junction, or esophageal adenocarcinoma using GIGAVCOXT I
capecitabine, oxaliplatin and trastuzumab
treatment of operable cancer of the stomach, stomach-esophagus
capecitabine (cont'd) tablet Gastrointestinal junction or lower 1/3 esophagus, given before and after surgery, using GIGECC I
epirubicin, cisplatin and capecitabine
adjuvant chemotherapy for resected pancreatic adenocarcinoma using
capecitabine (cont'd) tablet Gastrointestinal GIPAJGCAP I
capecitabine and gemcitabine
second line treatment of metastatic or unresectable pancreatic
capecitabine (cont'd) tablet Gastrointestinal GIPAVCAP I
adenocarcinoma using capecitabine
Adjuvant or Neoadjuvant Combination Chemotherapy for Stage III Rectal
capecitabine (cont'd) tablet Gastrointestinal GIRAJCOX I
Cancer using Oxaliplatin and Capecitabine
adjuvant capecitabine therapy for stage II and III rectal cancer previously
capecitabine (cont'd) tablet Gastrointestinal GIRCAP I
treated with preoperative radiotherapy
combined modality adjuvant therapy for high risk rectal carcinoma using
capecitabine (cont'd) tablet Gastrointestinal GIRCRT I
capecitabine and radiation therapy
capecitabine (cont'd) tablet Gastrointestinal GIRINFRT I
capecitabine, infusional fluorouracil and radiation therapy
treatment of recurrent or metastatic squamous cell cancer of the head and
capecitabine (cont'd) tablet Head and Neck HNAVCAP I
neck with capecitabine
treatment of recurrent or metastatic nasopharyngeal cancer with
capecitabine (cont'd) tablet Head and Neck HNNAVCAP I
capecitabine
neoadjuvant or adjuvant therapy for breast cancer using carboplatin,
carboplatin injectable Breast BRAJDCARBT I
docetaxel and trastuzumab
palliative therapy for metastatic breast cancer using cisplatin and
carboplatin (cont'd) injectable Breast BRAVGEMP I
gemcitabine
neoadjuvant therapy for triple-negative breast cancer using carboplatin

carboplatin (cont'd) injectable Breast BRLACTWAC I
and weekly paclitaxel followed by doxorubicin and cyclophosphamide
Neoadjuvant Therapy for Triple-Negative Breast Cancer using Dose-

carboplatin (cont'd) injectable Breast Dense Therapy: Carboplatin and Weekly Paclitaxel Followed by BRLACTWACG I
Doxorubicin and Cyclophosphamide
carboplatin injectable Neuro-Oncology carboplatin and etoposide in the treatment of recurrent ependymoma CNCARV I
First-Line Palliative Treatment of Metastatic Anal Squamous Cell

carboplatin (cont'd) injectable Gastrointestinal GIAAVCT I
Carcinoma using Carboplatin and Weekly Paclitaxel
first-line palliative chemotherapy for advanced gallbladder cancer and
carboplatin (cont'd) injectable Gastrointestinal GIAVPG I
cholangiocarcinoma using gemcitabine and cisplatin
neoadjuvant treatment of esophageal and gastroesophageal carcinomas
carboplatin injectable Gastrointestinal GIENACTRT I
using carboplatin, paclitaxel and radiation therapy
alternative treatment of gynecological malignancies using carboplatin and
carboplatin (cont'd) injectable Gynecology GOCABR I
paclitaxel NAB (ABRAXANE)
alternative treatment of gynecological malignancies using bevacizumab,
carboplatin (cont'd) injectable Gynecology GOCABRBEV I
carboplatin and paclitaxel NAB (ABRAXANE)
* denotes change
Page 8 of 65
April 2022

FORM SITE CODES
treatment of advanced/recurrent non-small cell cancer of the cervix with
carboplatin (cont'd) injectable Gynecology GOCXCAD I
carboplatin and docetaxel
primary treatment of advanced/recurrent non-small cell cancer of the
carboplatin (cont'd) injectable Gynecology GOCXCAT I
cervix with carboplatin and paclitaxel
primary treatment of metastatic/recurrent cancer of the cervix with
carboplatin injectable Gynecology GOCXCATB I
bevacizumab, carboplatin and paclitaxel
treatment of primarily advanced or recurrent endometrial cancer using
carboplatin injectable Gynecology GOENDCAD I
treatment of primary advanced or recurrent endometrial cancer using
carboplatin (cont'd) injectable Gynecology GOENDCAT I
carboplatin and paclitaxel
primary treatment with visible or no visible residual tumour (moderate,
high, or extreme risk) or treatment at relapse of invasive epithelial ovarian,
carboplatin (cont'd) injectable Gynecology GOOVCAD I
fallopian tube, and primary peritoneal cancer, using carboplatin and
docetaxel
carboplatin and gemcitabine for the treatment of recurrent platinum-
carboplatin (cont'd) injectable Gynecology GOOVCAG I
sensitive ovarian cancer
first or second line therapy for invasive epithelial ovarian cancer using
carboplatin (cont'd) injectable Gynecology GOOVCARB I
single-agent carboplatin
carboplatin (cont'd) injectable Gynecology peritoneal cancer with high risk of relapse using bevacizumab, carboplatin GOOVCATB I
and paclitaxel
carboplatin (cont'd) injectable Gynecology peritoneal cancer, with no visible residual tumour (moderate-high risk) GOOVCATM I
using carboplatin and paclitaxel
second line treatment using paclitaxel and carboplatin for epithelial ovarian
carboplatin (cont'd) injectable Gynecology GOOVCATR I
cancer relapsing after primary treatment
primary treatment of visible residual (extreme risk) invasive epithelial
carboplatin (cont'd) injectable Gynecology ovarian cancer in ambulatory care settings using paclitaxel and GOOVCATX I
carboplatin
primary treatment of advanced epithelial ovarian, primary peritoneal, or

carboplatin (cont'd) injectable Gynecology GOOVDDCAT I
fallopian tube carcinoma using carboplatin and weekly paclitaxel
first line treatment of epithelial ovarian cancer using doxorubicin pegylated

carboplatin (cont'd) injectable Gynecology GOOVFPLDC I
liposomal and carboplatin
primary treatment of stage III less than or equal to 1 cm visible residual

invasive epithelial ovarian cancer or stage 1 grade 3 or stage II grade 3
carboplatin (cont'd) injectable Gynecology GOOVIPPC I
papillary serous ovarian cancer using intravenous and intraperitoneal
paclitaxel and intraperitoneal carboplatin
second line treatment for epithelial ovarian cancer relapsing after primary
carboplatin (cont'd) injectable Gynecology GOOVPLDC I
treatment using pegylated liposomal doxorubicin (PLD) and carboplatin
carboplatin (cont'd) injectable Gynecology treatment of small-cell gynecologic cancer with cisplatin and etoposide GOSCPE I
treatment of small-cell gynecologic cancer with cisplatin and etoposide

carboplatin (cont'd) injectable Gynecology GOSCPERT I
with radiation therapy
carboplatin (cont'd) injectable Genitourinary palliative therapy for urothelial carcinoma using cisplatin and gemcitabine GUAVPG I
* denotes change
Page 9 of 65
April 2022

FORM SITE CODES
carboplatin (cont'd) injectable Genitourinary adjuvant therapy for stage I high risk seminoma using carboplatin GUSCARB I
carboplatin (cont'd) injectable Genitourinary therapy of genitourinary small cell tumors with a platin and etoposide GUSCPE I
therapy of genitourinary small cell tumors with a platin and etoposide with
carboplatin (cont'd) injectable Genitourinary GUSCPERT I
radiation
treatment of advanced squamous cell carcinoma of the head and neck
carboplatin (cont'd) injectable Head and Neck HNAVFUP I
cancer using fluorouracil and platinum
treatment for unresectable, locoregionally recurrent or metastatic
carboplatin (cont'd) injectable Head and Neck squamous cell carcinoma of the head and neck using paclitaxel and HNAVPC I
cisplatin or carboplatin
First-Line Treatment of Advanced Squamous Cell Carcinoma of the Head

carboplatin (cont'd) injectable Head and Neck UHNAVPCPMB R
and Neck with Paclitaxel, Carboplatin and Pembrolizumab
treatment of recurrent or metastatic squamous cell carcinoma of the head

carboplatin (cont'd) injectable Head and Neck HNAVPD I
and neck with platinum and docetaxel
treatment of recurrent and metastatic squamous cell cancer with platinum
carboplatin (cont'd) injectable Head and Neck HNAVPE I
and etoposide

carboplatin (cont'd) injectable Head and Neck UHNAVPFPMB R
and Neck using Platinum, Fluorouracil and Pembrolizumab
combined chemotherapy (carboplatin and fluorouracil) and radiation

carboplatin (cont'd) injectable Head and Neck treatment for locally advanced squamous cell carcinoma of the head and HNLACAFRT I
neck
treatment of locally advanced squamous cell carcinoma of the head and
carboplatin (cont'd) injectable Head and Neck HNLACART I
neck with concurrent carboplatin and radiation
Treatment of Locally Advanced Squamous Cell Carcinoma of the Head
carboplatin (cont'd) injectable Head and Neck HNLACART3 I
and Neck with Concurrent 3-Weekly Carboplatin and Radiation
treatment for advanced nasopharyngeal cancer of the head and neck
carboplatin (cont'd) injectable Head and Neck HNNAVFUP I
using platinum and fluorouracil
treatment of recurrent and/or metastatic nasopharyngeal cancer with
carboplatin (cont'd) injectable Head and Neck HNNAVPE I
platinum and etoposide
treatment of locoregionally recurrent and/or metastatic nasopharyngeal
carboplatin (cont'd) injectable Head and Neck HNNAVPG I
cancer with platinum and gemcitabine
treatment of recurrent or metastatic nasopharyngeal carcinoma with
carboplatin (cont'd) injectable Head and Neck HNNAVPC I
adjuvant carboplatin and paclitaxel following resection of stage I, II and
carboplatin (cont'd) injectable Lung LUAJPC I
IIIA non-small cell lung cancer
first-line treatment of advanced non-small cell lung cancer with carboplatin
carboplatin (cont'd) injectable Lung LUAVPC I
and paclitaxel
first-line treatment of advanced squamous non-small cell lung cancer with
carboplatin (cont'd) injectable Lung LUAVPCPMB I
paclitaxel, carboplatin and pembrolizumab
treatment of advanced non-small cell lung cancer with platinum and
carboplatin (cont'd) injectable Lung LUAVPG I
gemcitabine
cisplatin (cont'd) injectable Lung LUAVPGPMB I
platinum, gemcitabine and pembrolizumab
first-line treatment of advanced non-small cell lung cancer with platinum
carboplatin (cont'd) injectable Lung LUAVPP I
and pemetrexed
first-line treatment of advanced non-squamous non-small cell lung cancer
carboplatin (cont'd) injectable Lung LUAVPPPMB I
with platinum, pemetrexed and pembrolizumab
treatment of locally advanced non-small cell lung cancer using carboplatin
carboplatin (cont'd) injectable Lung LULACATRT I
and paclitaxel with radiation therapy
* denotes change
Page 10 of 65
April 2022

FORM SITE CODES
treatment of locally advanced non-small cell lung cancer using cisplatin
carboplatin (cont'd) injectable Lung LULAPERT I
and etoposide with radiation therapy
treatment of locally advanced non-small cell lung cancer using alternative

carboplatin (cont'd) injectable Lung LULAPE2RT I
dosing of cisplatin and etoposide with radiation therapy
carboplatin (cont'd) injectable Lung treatment of thymoma with cisplatin and etoposide LUOTPE I
carboplatin (cont'd) injectable Lung treatment of thymoma using cisplatin and etoposide with radiation therapy LUOTPERT I
treatment of cancer of unknown primary involving the thorax with cisplatin

carboplatin (cont'd) injectable Lung LUPUPE I
and etoposide
therapy of extensive stage small cell lung cancer with cisplatin and
carboplatin (cont'd) injectable Lung LUSCPE I
etoposide
therapy of limited stage small cell lung cancer using cisplatin and
carboplatin (cont'd) injectable Lung LUSCPERT I
etoposide with radiation
second line treatment of extensive stage small cell lung cancer (SCLC)
carboplatin (cont'd) injectable Lung LUSCPI I
with irinotecan with or without platinum
treatment of relapsed or refractory advanced stage aggressive B-cell non-

carboplatin (cont'd) injectable Lymphoma LYRICE I
Hodgkin’s lymphoma with ifosfamide, carboplatin, etoposide and rituximab
primary treatment of cancer of unknown primary origin using carboplatin

carboplatin (cont'd) injectable Primary Unknown PUCAT I
and paclitaxel
treatment of recurrent or metastatic Merkel cell carcinoma with cisplatin
carboplatin (cont'd) injectable Skin & Melanoma SMMCCPE I
and etoposide
Other tumour site

Not Otherwise
carboplatin (cont'd) injectable code followed by I
Specified
‘NOS’ (e.g. HNNOS)
* denotes change
Page 11 of 65
April 2022

FORM SITE CODES
therapy of multiple myeloma using carfilzomib and dexamethasone with or
carfilzomib injectable Myeloma UMYCARDEX R
without cyclophosphamide
therapy of multiple myeloma using carfilzomib, lenalidomide with
carfilzomib injectable Myeloma UMYCARLD R
dexamethasone
carmustine injectable Lymphoma topical therapy in cutaneous T-cell lymphoma LYCARTOP I
Other tumour site

Not Otherwise
carmustine injectable code followed by I
Specified
‘NOS’ (e.g. LKNOS)
cemiplimab injectable Skin & Melanoma Cemiplimab for Treatment of Cutaneous Squamous Cell Carcinoma SMAVCEM I
treatment of ALK-positive advanced non-small cell lung cancer (NSCLC)
ceritinib capsule Lung LUAVCER I
with ceritinib
palliative third line treatment of metastatic colorectal cancer with wild-type
cetuximab injectable Gastrointestinal GIAVCETIR I
KRAS using cetuximab and irinotecan
combined cetuximab and radiation treatment for locally advanced
cetuximab (cont'd) injectable Head and Neck HNLACETRT I
squamous cell carcinoma of the head and neck
chlorambucil tablet Lymphoma low grade lymphoma and chronic lymphocytic leukemia LYCHLOR I
chlorambucil tablet Lymphoma treatment of indolent B-cell lymphoma with chlorambucil and rituximab LYCHLRR I
chlorambucil tablet Lymphoma treatment of chronic lymphocytic leukemia with chlorambucil and rituximab LYCLLCHLR I
chlorambucil tablet Lymphoma lymphoma palliative chemotherapy LYPALL I

treatment of previously untreated chronic lymphocytic leukemia using
chlorambucil (cont'd) tablet Lymphoma LYOBCHLOR I
obinutuzumab in combination with chlorambucil
Other tumour site
Not Otherwise code followed by
chlorambucil (cont'd) tablet I
Specified ‘NOS’ (e.g. LKNOS,
LYNOS)
* denotes change
Page 12 of 65
April 2022

FORM SITE CODES
palliative therapy for metastatic breast cancer using cisplatin and
cisplatin injectable Breast BRAVGEMP I
gemcitabine
adjuvant lomustine, cisplatin and vincristine in adult high-risk
cisplatin Neuro-Oncology CNCCV I
injectable medulloblastoma or other primitive neuroectodermal tumour
cisplatin Gastrointestinal GIAVPG I
injectable cholangiocarcinoma using gemcitabine and cisplatin
curative-intent combined modality therapy for cancer of the anal canal,
cisplatin GICPART I
injectable Gastrointestinal using cisplatin, capecitabine and radiation therapy
Note: cisplatin solution and
cisplatin powder (SAP) only funded
hepatic trans-arterial chemoembolization for primary liver cancer or liver
cisplatin (cont'd) injectable Gastrointestinal GIEMBOL I when prescribed by specialists at
metastasis
BC Cancer VC and Royal Jubilee
Hospital
palliative chemotherapy for upper gastrointestinal tract cancer (gastric,

cisplatin (cont'd) injectable Gastrointestinal esophageal, gall bladder carcinoma and cholangiocarcinoma) and GIFUC I
metastatic anal cancer using infusional fluorouracil and cisplatin
combined modality curative therapy for carcinoma of the anal canal using
cisplatin (cont'd) injectable Gastrointestinal GIFUPART I
cisplatin, infusional fluorouracil and radiation therapy
adjuvant chemotherapy of gastric cancer patients with completely
cisplatin (cont'd) injectable Gastrointestinal resected gastric cancer using cisplatin and capecitabine and radiation GIGAJCPRT I
therapy
palliative therapy of metastatic or locally advanced anal squamous cell
cisplatin (cont'd) injectable Gastrointestinal GIGAVCC I
carcinoma using cisplatin and capecitabine
cisplatin (cont'd) injectable Gastrointestinal Gastroesophageal Junction or Esophageal Adenocarcinoma using GIGAVCCT I
Cisplatin, Capecitabine and Trastuzumab
palliative treatment of metastatic or inoperable, locally advanced gastric or
cisplatin (cont'd) injectable Gastrointestinal gastroesophageal junction adenocarcinoma using cisplatin, infusional GIGAVCFT I
fluorouracil and trastuzumab
cisplatin (cont'd) injectable Gastrointestinal junction or lower 1/3 esophagus, given before and after surgery, using GIGECC I
cisplatin (cont'd) injectable Gastrointestinal palliative therapy of neuroendocrine tumours using cisplatin and etoposide GIPE I
hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with

cisplatin (cont'd) Gastrointestinal GIPMHIPEC I
peritoneal mesothelioma using doxorubicin, cisplatin and paclitaxel
injectable
therapy of non-dysgerminomatous ovarian germ cell cancer using
cisplatin (cont'd) injectable Gynecology GOBEP I
bleomycin, etoposide and cisplatin
alternative treatment of gynecological malignancies using cisplatin and
cisplatin (cont'd) injectable Gynecology GOCISP I
paclitaxel
* denotes change
Page 13 of 65
April 2022

FORM SITE CODES
Alternative Treatment of Gynecological Malignancies using Bevacizumab,
cisplatin (cont'd) injectable Gynecology GOCISPBEV I
Cisplatin and Paclitaxel
treatment of high risk squamous carcinoma, adenocarcinoma, or
cisplatin (cont'd) injectable Gynecology adenosquamous carcinoma of the cervix with concurrent cisplatin and GOCXCRT I
radiation
therapy of dysgerminomatous ovarian germ cell cancer using cisplatin and
cisplatin (cont'd) injectable Gynecology GOEP I
etoposide
cisplatin (cont'd) injectable Gynecology invasive epithelial ovarian cancer GOOVCIS I
cisplatin (cont'd) injectable Gynecology treatment of small-cell gynecologic cancer with cisplatin and etoposide GOSCPE I
treatment of small-cell gynecologic cancer with cisplatin and etoposide

cisplatin (cont'd) injectable Gynecology GOSCPERT I
with radiation therapy
cisplatin (cont'd) injectable Genitourinary adjuvant therapy for urothelial carcinoma using cisplatin and gemcitabine GUAJPG I
cisplatin (cont'd) injectable Genitourinary palliative therapy for urothelial carcinoma using cisplatin and gemcitabine GUAVPG I
curative therapy for germ cell cancer using bleomycin, etoposide and
cisplatin (cont'd) injectable Genitourinary GUBEP I
cisplatin
treatment of locally advanced bladder cancer with weekly cisplatin and
cisplatin (cont'd) injectable Genitourinary GUBPWRT I
concurrent radiation
treatment of metastatic adrenalcortical cancer with doxorubicin, etoposide,
cisplatin (cont'd) injectable Genitourinary GUEDPM I
cisplatin and mitotane
cisplatin (cont'd) injectable Genitourinary therapy for nonseminoma germ cell cancer using etoposide-cisplatin GUEP I
combined modality therapy for squamous cell cancer of the genitourinary

cisplatin (cont'd) injectable Genitourinary GUFUPRT I
system using fluorouracil and cisplatin with radiation
therapy for transitional cell cancers of the urothelium using methotrexate,
cisplatin (cont'd) injectable Genitourinary GUMVAC I
vinblastine, doxorubicin and cisplatin
neo-adjuvant therapy for urothelial carcinoma using cisplatin and
cisplatin (cont'd) injectable Genitourinary GUNAJPG I
gemcitabine
cisplatin (cont'd) injectable Genitourinary therapy of genitourinary small cell tumors with a platin and etoposide GUSCPE I
therapy of genitourinary small cell tumors with a platin and etoposide with
cisplatin (cont'd) injectable Genitourinary GUSCPERT I
radiation
advanced therapy for relapsed testicular germ cell cancer using paclitaxel,
cisplatin (cont'd) injectable Genitourinary GUTIP I
ifosfamide and cisplatin
consolidation/ salvage treatment for germ cell cancer using vinblastine,
cisplatin (cont'd) injectable Genitourinary GUVEIP I
cisplatin, ifosfamide and mesna
nonseminoma consolidation/salvage protocol using etoposide, cisplatin,
cisplatin (cont'd) injectable Genitourinary GUVIP2 I
ifosfamide, mesna
cisplatin (cont'd) injectable Head and Neck HNAVFUP I
palliative chemotherapy for advanced head and neck squamous cell
cisplatin (cont'd) injectable Head and Neck HNAVP I
carcinoma with weekly cisplatin
cisplatin (cont'd) injectable Head and Neck squamous cell carcinoma of the head and neck using paclitaxel and HNAVPC I
* denotes change
Page 14 of 65
April 2022

FORM SITE CODES
cisplatin (cont'd) injectable Head and Neck HNAVPD I
treatment of recurrent and metastatic squamous cell cancer with platinum
cisplatin (cont'd) injectable Head and Neck HNAVPE I
and etoposide

cisplatin (cont'd) injectable Head and Neck UHNAVPFPMB R
treatment of locally advanced (alternate) head and neck cancer using

cisplatin (cont'd) injectable Head and Neck HNLAALTPRT I
cisplatin during radiation therapy
cisplatin (cont'd) injectable Head and Neck HNLADCF I
neck with docetaxel, cisplatin and infusional fluorouracil
combined chemotherapy (cisplatin) and radiation treatment for locally
cisplatin (cont'd) injectable Head and Neck HNLAPRT I
advanced squamous cell carcinoma of the head and neck
cisplatin (cont'd) injectable Head and Neck HNNAVFUP I
palliative chemotherapy for advanced head and neck nasopharyngeal
cisplatin (cont'd) injectable Head and Neck HNNAVP I
carcinoma with weekly cisplatin
treatment of recurrent and/or metastatic nasopharyngeal cancer with
cisplatin (cont'd) injectable Head and Neck HNNAVPE I
platinum and etoposide
treatment of locoregionally recurrent and/or metastatic nasopharyngeal
cisplatin (cont'd) injectable Head and Neck HNNAVPG I
induction treatment of locally advanced nasopharyngeal cancer with
cisplatin (cont'd) injectable Head and Neck HNNLAPG I
cisplatin and gemcitabine
treatment of locally advanced nasopharyngeal cancer with concurrent
cisplatin (cont'd) injectable Head and Neck HNNLAPRT I
cisplatin and radiation
treatment of advanced head and neck cancer using cisplatin and
cisplatin (cont'd) injectable Head and Neck HNSAVFUP I
fluorouracil
treatment of advanced salivary gland cancers with cisplatin and
cisplatin (cont'd) injectable Head and Neck HNSAVNP I
vinorelbine
treatment of advanced salivary gland cancers with platinum, doxorubicin
cisplatin (cont'd) injectable Head and Neck HNSAVPAC I
and cyclophospahmide
adjuvant cisplatin and vinorelbine following resection of non-small cell lung
cisplatin (cont'd) injectable Lung LUAJNP I
cancer
Adjuvant Cisplatin and Pemetrexed Following Resection of Non-Small Cell
cisplatin (cont'd) injectable Lung LUAJPP I
Lung Cancer
first-line treatment of advanced non-small cell lung cancer with cisplatin
cisplatin (cont'd) injectable Lung LUAVDC I
and docetaxel
treatment for advanced non-small cell lung cancer with cisplatin and
cisplatin (cont'd) injectable Lung LUAVNP I
vinorelbine
treatment of advanced non-small cell lung cancer with platinum and
cisplatin (cont'd) injectable Lung LUAVPG I
gemcitabine
cisplatin (cont'd) injectable Lung LUAVPGPMB I
cisplatin (cont'd) injectable Lung LUAVPP I
and pemetrexed
cisplatin (cont'd) injectable Lung LUAVPPPMB I
treatment of locally advanced non-small cell lung cancer using cisplatin
cisplatin (cont'd) injectable Lung LULAPERT I
and etoposide with radiation therapy
* denotes change
Page 15 of 65
April 2022

FORM SITE CODES
treatment of locally advanced non-small cell lung cancer using alternative

cisplatin (cont'd) injectable Lung LULAPE2RT I
dosing of cisplatin and etoposide with radiation therapy
cisplatin (cont'd) injectable Lung treatment of malignant mesothelioma with platinum and gemcitabine LUMMPG I
cisplatin (cont'd) injectable Lung treatment of malignant mesothelioma with platinum and pemetrexed LUMMPP I
cisplatin (cont'd) injectable Lung treatment of thymoma with platinum, doxorubicin and cyclophosphamide LUOTPAC I
cisplatin (cont'd) injectable Lung treatment of thymoma with cisplatin and etoposide LUOTPE I
cisplatin (cont'd) injectable Lung treatment of thymoma using cisplatin and etoposide with radiation therapy LUOTPERT I
treatment of cancer of unknown primary involving the thorax with cisplatin

cisplatin (cont'd) injectable Lung LUPUPE I
and etoposide
therapy of extensive stage small cell lung cancer with cisplatin and
cisplatin (cont'd) injectable Lung LUSCPE I
etoposide
therapy of limited stage small cell lung cancer using cisplatin and
cisplatin (cont'd) injectable Lung LUSCPERT I
etoposide with radiation
cisplatin (cont'd) injectable Lung LUSCPI I
cisplatin (cont'd) injectable Lymphoma treatment of lymphoma with gemcitabine, dexamethasone and platinum LYGDP I
treatment of lymphoma with gemcitabine, dexamethasone and platinum

cisplatin (cont'd) injectable Lymphoma LYGDPR I
with rituximab
Treatment of newly diagnosed nasal, extranodal natural killer (NK) or T-

cisplatin (cont'd) injectable Lymphoma cell lymphoma, stage IE to IIE using concurrent radiation and weekly LYVIPDRT I
cisplatin followed by etoposide, ifosfamide, cisplatin and dexamethasone
cisplatin (cont'd) injectable Sarcoma adjuvant therapy for osteosarcoma using doxorubicin and cisplatin SAAJAP I
cisplatin (cont'd) injectable Sarcoma therapy of advanced osteosarcoma using doxorubicin and cisplatin SAAVAP I

cisplatin (cont'd) injectable Sarcoma SAHIPEC I
peritoneal desmoplastic small round cell tumour (DSRCT)
treatment of recurrent or metastatic Merkel cell carcinoma with cisplatin
cisplatin (cont'd) injectable Skin & Melanoma SMMCCPE I
and etoposide
Other tumour site
Not Otherwise
cisplatin (cont'd) injectable code followed by I
Specified
cladribine injectable Lymphoma hairy cell leukemia LYCDA I
bony metastases associated with breast cancer or acute bone pain
clodronate capsule Breast BRAVCLOD I Not reimbursed for hypercalcemia
secondary to metastatic breast cancer
treatment of BRAF V600 mutation-positive unresectable or metastatic
cobimetinib tablet Skin & Melanoma SMAVVC I
melanoma using vemurafenib and cobimetinib
cortisone tablet Genitourinary GUEDPM I
cortisone tablet Genitourinary treatment of adrenal cortical cancer using mitotane GUMITO I
Other tumour site
Not Otherwise
cortisone tablet code followed by I
Specified
‘NOS’ (e.g. GUNOS)
* denotes change
Page 16 of 65
April 2022

FORM SITE CODES
second-line treatment of ALK-positive advanced non-small cell lung
crizotinib tablet Lung LUAVCRIZ I
cancer (NSCLC) with crizotinib
first-line treatment of ALK-positive advanced non-small cell lung cancer
crizotinib (cont'd) tablet Lung LUAVCRIZF I
(NSCLC) with crizotinib
first-line treatment of ROS1-positive advanced non-small cell lung cancer
crizotinib (cont'd) tablet Lung LUAVCRIZR I
with crizotinib
myeloablative conditioning therapy prior to autologous and allogeneic
cyclophosphamide tablet, injectable Leukemia & BMT hematopoietic stem cell transplantation for myeloid malignancies using IV BMTIVBUCY I
busulfan and cyclophosphamide
adjuvant therapy for breast cancer using doxorubicin and
cyclophosphamide tablet, injectable Breast BRAJAC I
cyclophosphamide
neoadjuvant or adjuvant therapy for breast cancer using doxorubicin and
cyclophosphamide (cont'd) tablet, injectable Breast BRAJACT I
cyclophosphamide followed by paclitaxel
neoadjuvant or adjuvant therapy for breast cancer using dose dense

cyclophosphamide (cont'd) tablet, injectable Breast BRAJACTG I
therapy: doxorubicin and cyclophosphamide followed by paclitaxel

cyclophosphamide (cont'd) tablet, injectable Breast BRAJACTT I
cyclophosphamide followed by paclitaxel and trastuzumab

cyclophosphamide tablet, injectable Breast therapy: doxorubicin and cyclophosphamide followed by paclitaxel and BRAJACTTG I
trastuzumab
neoadjuvant or adjuvant therapy for early breast cancer using doxorubicin
cyclophosphamide (cont'd) tablet, injectable Breast BRAJACTW I
and cyclophosphamide followed by weekly paclitaxel
adjuvant therapy for high-risk breast cancer using cyclophosphamide
cyclophosphamide (cont'd) tablet, injectable BRAJCMFPO I
Breast (oral), methotrexate and fluorouracil
neoadjuvant or adjuvant therapy for breast cancer using
cyclophosphamide (cont'd) tablet, injectable BRAJDAC I
Breast cyclophosphamide, doxorubicin and docetaxel
neoadjuvant or adjuvant therapy for breast cancer using docetaxel and
cyclophosphamide (cont'd) tablet, injectable Breast BRAJDC I
cyclophosphamide
adjuvant therapy for breast cancer using fluorouracil, epirubicin and
cyclophosphamide (cont'd) tablet, injectable Breast BRAJFEC I
cyclophosphamide
neoadjuvant or adjuvant therapy for breast cancer using fluorouracil,
cyclophosphamide (cont'd) tablet, injectable Breast BRAJFECD I
epirubicin and cyclophosphamide and docetaxel

cyclophosphamide (cont'd) tablet, injectable BRAJFECDT I
epirubicin and cyclophosphamide followed by docetaxel and trastuzumab
Breast
neoadjuvant or adjuvant therapy for breast cancer using trastuzumab,
cyclophosphamide (cont'd) tablet, injectable Breast BRAJTDC I
docetaxel and cyclophosphamide
palliative therapy for metastatic breast cancer using doxorubicin and
cyclophosphamide (cont'd) tablet, injectable Breast BRAVAC I
cyclophosphamide
palliative therapy for advanced breast cancer using cyclophosphamide,
cyclophosphamide (cont'd) tablet, injectable BRAVCMF I
Breast methotrexate and fluorouracil
palliative therapy for metastatic breast cancer using metronomic low-dose
cyclophosphamide (cont'd) tablet, injectable Breast BRAVCMPO I
oral cyclophosphamide and methotrexate
treatment of locally advanced breast cancer using doxorubicin and
cyclophosphamide (cont'd) tablet, injectable Breast BRLAACD I
cyclophosphamide followed by docetaxel
* denotes change
Page 17 of 65
April 2022

FORM SITE CODES
cyclophosphamide (cont'd) tablet, injectable Breast BRLAACDT I
cyclophosphamide followed by docetaxel and trastuzumab

cyclophosphamide (cont'd) injectable Breast BRLACTWAC I

cyclophosphamide (cont'd) injectable Breast Dense Therapy: Carboplatin and Weekly Paclitaxel Followed by BRLACTWACG I
neoadjuvant therapy for breast cancer using dose dense therapy:

cyclophosphamide (cont'd) injectable Breast BRLATACG I
paclitaxel followed by doxorubicin and cyclophosphamide

cyclophosphamide (cont'd) injectable Breast BRLATWAC I
cyclophosphamide followed by weekly paclitaxel
palliative therapy for relapsed/progressing epithelial ovarian, primary
cyclophosphamide (cont'd) tablet, injectable Gynecology peritoneal, or fallopian tube carcinoma using metronomic low-dose oral GOOVCYCPO I
cyclophosphamide
therapy for high-risk Gestational Trophoblastic Neoplasia (GTN) using
cyclophosphamide (cont'd) tablet, injectable Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
cyclophosphamide and vincristine
palliative therapy for advanced salivary gland cancers using
cyclophosphamide (cont'd) tablet, injectable Head and Neck HNSAVFAC I
cyclophosphamide, doxorubicin and fluorouracil
cyclophosphamide (cont'd) tablet, injectable Head and Neck HNSAVPAC I
treatment of thymoma/thymic carcinoma with cyclophosphamide,
cyclophosphamide (cont'd) tablet, injectable Lung LUOTCAV I
doxorubicin and vincristine
cyclophosphamide (cont'd) tablet, injectable Lung treatment of thymoma with platinum, doxorubicin and cyclophosphamide LUOTPAC I
treatment of extensive small cell lung cancer with cyclophosphamide,

cyclophosphamide (cont'd) tablet, injectable Lung LUSCCAV I
treatment of lymphoma with doxorubicin, cyclophosphamide, vincristine
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCHOP I
and prednisone
treatment of lymphoma with doxorubicin, cyclophosphamide, vincristine,
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCHOPR I
prednisone and rituximab
cyclophosphamide (cont'd) tablet, injectable Lymphoma doxorubicin, cyclophosphamide, prednisone (CHP) and brentuximab LYCHPBV I
vedotin
treatment of relapsed chronic lymphocytic leukemia using
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCLLCVPR I
cyclophosphamide, vincristine, prednisone and rituximab
treatment of Burkitt’s Lymphoma and Leukemia with cyclophosphamide,

cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCODOXMR I
vincristine, doxorubicin, methotrexate, leucovorin and rituximab
advanced indolent lymphoma using cyclophosphamide, vincristine and

cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCVP I
prednisone
treatment of Hodgkin's disease with cyclophosphamide, vinblastine,
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCVPPABO I
treatment of advanced indolent lymphoma using cyclophosphamide,
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCVPR I
vincristine, prednisone and rituximab
therapy of lymphoma, Hodgkin's disease, chronic lymphocytic leukemia or
cyclophosphamide (cont'd) tablet, injectable Lymphoma LYCYCLO I
multiple myeloma using cyclophosphamide
* denotes change
Page 18 of 65
April 2022

FORM SITE CODES
treatment of lymphoma with dose-adjusted etoposide, doxorubicin,
cyclophosphamide (cont'd) tablet, injectable Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
methotrexate
treatment of chronic lymphocytic leukemia (CLL) or prolymphocytic

cyclophosphamide (cont'd) tablet, injectable Lymphoma LYFCR I
leukemia with fludarabine, cyclophosphamide and rituximab
cyclophosphamide (cont'd) tablet, injectable Lymphoma lymphoma palliative chemotherapy LYPALL I

cyclophosphamide (cont'd) tablet, injectable Myeloma MYBORPRE I

cyclophosphamide (cont'd) tablet, injectable Myeloma MYBORREL I
cyclophosphamide (cont'd) tablet, injectable Myeloma UMYCARDEX R
without cyclophosphamide
cyclophosphamide (cont'd) tablet, injectable Myeloma in combination with bortezomib and dexamethasone with or without UMYDARBD R
cyclophosphamide
cyclophosphamide (cont'd) tablet, injectable Myeloma bortezomib with the option of substituting cyclophosphamide for MYMPBOR I
melphalan
single dose cyclophosphamide priming therapy for multiple myeloma prior
cyclophosphamide (cont'd) tablet, injectable Myeloma MYHDC I
to autologous stem cell transplant
SAIME alternating with SAVAC or SAVACM with filgrastim support at
TWO weekly interval for newly diagnosed Ewing's Sarcoma/Ewing’s
cyclophosphamide (cont'd) tablet, injectable Sarcoma SAALT2W I
Family of Tumours, Desmoplastic Intra-Abdominal Small Round Blue Cell
Tumour or Rhabdomyosarcoma
THREE weekly interval for newly diagnosed Ewing's Sarcoma/Ewing’s
cyclophosphamide (cont'd) tablet, injectable Sarcoma SAALT3W I
summary for treatment of recurrent/refractory neuroblastoma, ewing’s
cyclophosphamide (cont'd) tablet, injectable Sarcoma sarcoma, osteogenic sarcoma or rhabdomyosarcoma with SAAVTC I
topotecan/cyclophosphamide
cyclophosphamide (cont'd) tablet, injectable Sarcoma treatment of sarcomas with vincristine, doxorubicin and cyclophosphamide SAVAC I
Treatment of Sarcomas with Pelvic Primaries or Chemotherapy-Induced

cyclophosphamide (cont'd) tablet, injectable Sarcoma SAVACM I
Hematuria using Vincristine, Doxorubicin, Cyclophosphamide and Mesna
Adjuvant Therapy for Rhabdomyosarcoma using Vincristine, Dactinomycin

cyclophosphamide (cont'd) tablet, injectable Sarcoma SAVDC I
and Cyclophosphamide
treatment of recurrent/refractory rhabdomysarcoma in pediatric patients
cyclophosphamide (cont'd) tablet, injectable Pediatric with cyclophosphamide, vinorelbine and temsirolimus on the COG I
ARST0921 protocol
Other tumour site

Not Otherwise
cyclophosphamide (cont'd) tablet, injectable code followed by I
Specified
‘NOS’ (e.g. BRNOS)
* denotes change
Page 19 of 65
April 2022

FORM SITE CODES
cytopenias associated with lymphoproliferative disorder of large granular
cyclosporine capsule Lymphoma LYCSPA I
lymphocytes
treatment of hemophagocytic lymphohistiocytosis with etoposide,
cyclosporine capsule Lymphoma HLHETCSPA I
dexamethasone and cyclosporine
cytarabine injectable Leukemia & BMT therapy of acute myeloid leukemia using low dose cytarabine LKAMLCYT I
Treatment of Acute Myeloid Leukemia using Gemtuzumab Ozogamicin
cytarabine injectable Leukemia & BMT ULKGEMOZ R
with Induction and Consolidation Chemotherapy
treatment of Burkitt’s lymphoma and leukemia with cyclophosphamide,

cytarabine injectable Lymphoma LYCODOXMR I
cytarabine injectable Lymphoma treatment of lymphoma using intrathecal methotrexate and cytarabine LYIT I
treatment of Burkitt’s lymphoma and leukemia with ifosfamide, mesna,

cytarabine (cont'd) injectable Lymphoma LYIVACR I
etoposide, cytarabine and rituximab
therapy for solid tumours using intrathecal methotrexate and/or thiotepa
cytarabine (cont'd) injectable Miscellaneous Origins MOIT I
and/or cytarabine
Other tumour site

Not Otherwise
cytarabine (cont'd) injectable code followed by I
Specified
‘NOS’ (e.g. LYNOS)
* denotes change
Page 20 of 65
April 2022

FORM SITE CODES
adjuvant treatment of stage III and IV, BRAF-mutated, fully resected
dabrafenib capsule Skin & Melanoma SMAJDT I
melanoma using dabrafenib and trametinib
dabrafenib capsule Skin & Melanoma SMAVDAB I
melanoma using dabrafenib
dabrafenib capsule Skin & Melanoma SMAVDT I
treatment of Hodgkin's disease with doxorubicin, bleomycin, vinblastine
dacarbazine injectable Lymphoma LYABVD I
and dacarbazine

dacarbazine (cont'd) injectable Lymphoma LYAVDBV I
adjuvant treatment of patients with soft tissue sarcoma using doxorubicin

dacarbazine (cont'd) injectable Sarcoma SAAJADIC I
and dacarbazine
treatment of patients with soft tissue sarcoma using doxorubicin and
dacarbazine injectable Sarcoma SAAVADIC I
dacarbazine
dacarbazine (cont'd) injectable Sarcoma high dose single agent dacarbazine for metastatic soft tissue sarcoma SADTIC I
therapy for metastatic malignant melanoma using high dose single agent
dacarbazine injectable Skin & Melanoma SMDTIC I
dacarbazine
Other tumour site

Not Otherwise
dacarbazine (cont'd) injectable code followed by I
Specified
‘NOS’ (e.g. SMNOS)

dactinomycin injectable Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
Therapy for Moderate Low-Risk Gestational Trophoblastic Cancer using GOTDMR (previously
dactinomycin (cont'd) injectable Gynecology I
Dactinomycin and Methotrexate GOTDLR)
Therapy for Low-Risk Gestational Trophoblastic Cancer using

dactinomycin (cont'd) injectable Gynecology GOTDLRA I
Dactinomycin
dactinomycin injectable Sarcoma SAVDC I
Other tumour site

Not Otherwise
dactinomycin injectable code followed by I
Specified
‘NOS’ (e.g. SANOS)

daratumumab injectable Myeloma in combination with bortezomib and dexamethasone with or without UMYDARBD R
cyclophosphamide

daratumumab injectable Myeloma UMYDARLD R
in combination with lenalidomide and dexamethasone
Treatment of Non-Metastatic Castration-Resistant Prostate Cancer using

darolutamide tablet Genitourinary UGUNMPDAR R
Darolutamide
treatment of chronic myeloid leukemia and Ph+ acute lymphoblastic
dasatinib tablet Leukemia & BMT LKCMLD I
leukemia
* denotes change
Page 21 of 65
April 2022

FORM SITE CODES

daunorubicin injectable Leukemia & BMT LKATOP I

daunorubicin injectable Leukemia & BMT ULKGEMOZ R
Other tumour site

Not Otherwise
daunorubicin injectable code followed by I
Specified
‘NOS’ (e.g. KSNOS)
degarelix injectable Genitourinary therapy for prostate cancer using LHRH antagonist GUPLHRHA I
neoadjuvant use in patients with non-metastatic operable giant cell tumour
denosumab (XGEVA®) injectable Sarcoma SANADENO I
of the bone
dexamethasone tablet Genitourinary UGUMCSPABI R
dexamethasone tablet Genitourinary UGUPABI R
palliative therapy for metastatic hormone refractory prostate cancer GUPDOC I

dexamethasone tablet Lymphoma HLHETCSPA I
dexamethasone and cycloSPORINE
treatment of refractory or relapsing extranodal natural killer or T-Cell

dexamethasone tablet Lymphoma LYASPMEDEX I
lymphoma using pegaspargase, methotrexate and dexamethasone
dexamethasone (cont'd) tablet Lymphoma treatment of lymphoma with gemcitabine, dexamethasone and platinum LYGDP I
dexamethasone Lymphoma LYGDPR I
tablet with rituximab
dexamethasone (cont'd) Lymphoma lymphoma palliative chemotherapy LYPALL I

tablet
treatment of natural killer or T-Cell Lymphoma using dexamethasone,

dexamethasone Lymphoma LYSMILE I
methotrexate, ifosfamide, pegaspargase and etoposide
tablet
treatment of newly diagnosed nasal, extranodal natural killer (NK) or T-cell Not reimbursed for:
dexamethasone (cont'd) tablet Lymphoma lymphoma, stage IE to IIE using concurrent radiation and weekly cisplatin LYVIPDRT I anti-emetic treatment, steroid
followed by etoposide, ifosfamide, cisplatin and dexamethasone replacement therapy, pre-taxane
use, or appetite stimulation
dexamethasone (cont'd) tablet Myeloma UMYBLDF R
Multiple Myeloma

dexamethasone (cont'd) tablet Myeloma MYBORPRE I

dexamethasone MYBORREL I
tablet Myeloma dexamethasone with or without cyclophosphamide
dexamethasone (cont'd) UMYCARDEX R
tablet Myeloma without cyclophosphamide
dexamethasone (cont'd) tablet Myeloma UMYCARLD R
dexamethasone
dexamethasone in combination with bortezomib and dexamethasone with or without UMYDARBD R
tablet Myeloma cyclophosphamide
* denotes change
Page 22 of 65
April 2022

FORM SITE CODES

dexamethasone (cont'd) tablet Myeloma UMYDARLD R
treatment of previously untreated multiple myeloma and not eligible for

dexamethasone UMYLDF R
stem cell transplant using lenalidomide with low-dose dexamethasone
tablet Myeloma
therapy of relapsed multiple myeloma using lenalidomide with
dexamethasone (cont'd) tablet Myeloma UMYLDREL R
dexamethasone
dexamethasone (cont'd) bortezomib with the option of substituting cyclophosphamide for MYMPBOR I
tablet Myeloma melphalan
dexamethasone therapy of multiple myeloma using pomalidomide with dexamethasone UMYPOMDEX R

tablet Myeloma
patients with primary or metastatic disease exhibiting cerebral edema or Not reimbursed for:
dexamethasone (cont'd) tablet Miscellaneous Origins CNS swelling; management of malignant brain tumours; management of MODEXA I anti-emetic treatment, steroid
CNS lymphoma replacement therapy, pre-taxane
Other tumour site use, or appetite stimulation
Not Otherwise code followed by
dexamethasone (cont'd) tablet I
Specified ‘NOS’ (for e.g.
CNNOS)
Other tumour site

Not Otherwise
dexamethasone (cont'd) injectable code followed by I
Specified
pediatric patients with acute myeloid leukemia receiving anthracycline on

dexrazoxane injectable Pediatric I
the COG AAML1031 protocol
pediatric patients with neuroblastoma treated on the CCG AEWS1031
dexrazoxane injectable Pediatric I
protocol
pediatric patients with rhabdomyosarcoma treated on the COG
dexrazoxane (cont'd) injectable Pediatric I
ARST08P1 protocol
dinutuximab injectable Pediatric response to prior first-line multi-agent, multimodal therapy using R
docetaxel injectable Breast BRAJDAC I
cyclophosphamide, doxorubicin and docetaxel
neoadjuvant or adjuvant therapy for breast cancer using docetaxel and
docetaxel (cont'd) injectable Breast BRAJDC I
cyclophosphamide
neoadjuvant or adjuvant therapy for breast cancer using carboplatin,
docetaxel (cont'd) injectable Breast BRAJDCARBT I
docetaxel and trastuzumab
docetaxel (cont'd) injectable Breast BRAJFECD I

docetaxel (cont'd) injectable Breast BRAJFECDT I
neoadjuvant or adjuvant therapy for breast cancer using trastuzumab,

docetaxel (cont'd) injectable Breast BRAJTDC I
combination with doxorubicin and cyclophosphamide as treatment of
docetaxel (cont'd) injectable Breast BRLAACD I
locally advanced breast cancer
* denotes change
Page 23 of 65
April 2022

FORM SITE CODES
docetaxel (cont'd) injectable Breast BRLAACDT I
first, second, or third line treatment of metastatic breast cancer patients
docetaxel (cont'd) injectable Breast with ECOG performance status 0, 1, or 2, and greater than 3 month life BRAVDOC I
expectancy
weekly docetaxel regimen for metastatic breast cancer patients with poor
docetaxel (cont'd) injectable Breast tolerance to 3-weekly docetaxel regimen (BRAVDOC) or high doses of BRAVDOC7 I
dexamethasone used in BRAVDOC
palliative therapy for metastatic breast cancer using gemcitabine and
docetaxel (cont'd) injectable Breast BRAVGEMD I
docetaxel
palliative therapy for metastatic breast cancer using pertuzumab,
docetaxel (cont'd) injectable Breast trastuzumab (Herceptin®) and docetaxel as first-line treatment for BRAVPTRAD I
advanced breast cancer
palliative treatment of metastatic esophagogastric adenocarcinoma with
docetaxel (cont'd) injectable Gastrointestinal GIAVDOC I
docetaxel
perioperative treatment of resectable adenocarcinoma of the stomach,
docetaxel (cont'd) injectable Gastrointestinal gastroesophageal junction or lower 1/3 esophagus using docetaxel, GIGFLODOC I
oxaliplatin, infusional fluorouracil, and leucovorin
combination with carboplatin as primary treatment of advanced/recurrent

docetaxel (cont'd) injectable Gynecology GOCXCAD I
non-small cell cancer of the cervix in ambulatory care settings
treatment of primarily advanced or recurrent endometrial cancer using

docetaxel (cont'd) injectable Gynecology GOENDCAD I
primary treatment with visible or no visible residual tumour (moderate,
high, or extreme risk) or treatment at relapse of invasive epithelial ovarian,
docetaxel (cont'd) injectable Gynecology GOOVCAD I
fallopian tube, and primary peritoneal cancer, using carboplatin and
docetaxel
treatment of progressive, platinum-refractory epithelial ovarian carcinoma,
docetaxel (cont'd) injectable Gynecology GOOVDOC I
primary peritoneal
combination with gemcitabine for advanced or recurrent uterine sarcoma
docetaxel (cont'd) injectable Gynecology GOSADG I
cancer
Intravesical Therapy for Non-Muscle Invasive Bladder Cancer using
docetaxel (cont'd) injectable Genitourinary GUBGEMDOC I
Gemcitabine and Docetaxel
docetaxel (cont'd) injectable Genitourinary intravesical use for bladder cancer if BCG and mitomycin C not available GUNOS I
docetaxel (cont'd) injectable Genitourinary palliative therapy for metastatic hormone refractory prostate cancer GUPDOC I
first-line treatment of castration sensitive, metastatic prostate cancer

docetaxel (cont'd) injectable Genitourinary using docetaxel and androgen deprivation therapy with LHRH agonist or GUPDOCADT I
LHRH antagonist with or without antiandrogen, or surgical castration

docetaxel (cont'd) injectable Head and Neck HNAVDOC I
and neck with docetaxel
docetaxel (cont'd) injectable Head and Neck HNAVPD I
* denotes change
Page 24 of 65
April 2022

FORM SITE CODES
docetaxel (cont'd) injectable Head and Neck HNLADCF I
combination with cisplatin as first line treatment of advanced non-small
docetaxel (cont'd) injectable Lung LUAVDC I
lung cancer
docetaxel (cont'd) injectable Lung second-line treatment of non-small cell lung cancer LUAVDOC I
combination with gemcitabine as second or third line therapy for soft
docetaxel (cont'd) injectable Sarcoma SAAVGEMD I
tissue sarcomas
adjuvant therapy for breast cancer using doxorubicin and
doxorubicin injectable Breast BRAJAC I
cyclophosphamide
doxorubicin injectable Breast BRAJACT I

doxorubicin (cont'd) injectable Breast BRAJACTG I

doxorubicin injectable Breast BRAJACTT I

doxorubicin (cont'd) injectable Breast therapy: doxorubicin and cyclophosphamide followed by paclitaxel and BRAJACTTG I
trastuzumab
doxorubicin injectable Breast BRAJACTW I
doxorubicin (cont'd) injectable Breast BRAJDAC I
cyclophosphamide, doxorubicin and docetaxel
doxorubicin injectable Breast palliative therapy for metastatic breast cancer using weekly doxorubicin BRAVA7 I
palliative therapy for metastatic breast cancer using doxorubicin and

doxorubicin (cont'd) injectable Breast BRAVAC I
cyclophosphamide
doxorubicin (cont'd) injectable Breast BRLAACD I
cyclophosphamide followed by docetaxel
doxorubicin (cont'd) injectable Breast BRLAACDT I

doxorubicin (cont'd) injectable Breast BRLACTWAC I

doxorubicin (cont'd) injectable Breast Dense Therapy: Carboplatin and Weekly Paclitaxel Followed by BRLACTWACG I

doxorubicin (cont'd) injectable Breast BRLATACG I

doxorubicin (cont'd) injectable Breast BRLATWAC I
doxorubicin (cont'd) injectable Gastrointestinal palliative therapy for hepatoma using doxorubicin GIA I
transarterial chemoembolization (TACE) of hepatocellular carcinoma using
doxorubicin (cont'd) injectable Gastrointestinal GIDEBTACE I
drug-eluting bead (DEB) loaded with doxorubicin
* denotes change
Page 25 of 65
April 2022

FORM SITE CODES
Note: only funded when prescribed

doxorubicin (cont'd) injectable Gastrointestinal GIEMBOL I by specialists at BC Cancer VC &
metastasis
Royal Jubilee Hospital
palliative therapy for pancreatic endocrine tumours using streptozocin and

doxorubicin (cont'd) injectable Gastrointestinal GIENDO2 I
doxorubicin

doxorubicin (cont'd) injectable Gastrointestinal GIPMHIPEC I
doxorubicin (cont'd) injectable Genitourinary palliative therapy for advanced adrenal cortical cancer using doxorubicin GUAVD I
treatment of metastatic adrenalcortical cancer with doxorubicin, etoposide, Not reimbursed for bladder
doxorubicin (cont'd) injectable Genitourinary GUEDPM I
cisplatin and mitotane instillations
doxorubicin (cont'd) injectable Genitourinary GUMVAC I
doxorubicin (cont'd) injectable Gynecology for use in patients with advanced endometrial cancer GOENDD I
doxorubicin (cont'd) injectable Gynecology for use in patients with advanced uterine sarcoma GOSAD I
doxorubicin (cont'd) injectable Head and Neck palliative therapy for advanced thyroid cancers using doxorubicin HNOTAVD I
doxorubicin (cont'd) injectable Head and Neck HNSAVFAC I
doxorubicin (cont'd) injectable Head and Neck HNSAVPAC I
doxorubicin (cont'd) injectable Lung LUOTCAV I
doxorubicin (cont'd) injectable Lung treatment of thymoma with platinum, doxorubicin, and cyclophosphamide LUOTPAC I

doxorubicin (cont'd) injectable Lung LUSCCAV I
doxorubicin (cont'd) injectable Lymphoma LYABVD I
and dacarbazine

doxorubicin (cont'd) injectable Lymphoma LYAVDBV I

doxorubicin (cont'd) injectable Lymphoma LYCHOP I
and prednisone
doxorubicin (cont'd) injectable Lymphoma LYCHOPR I
central nervous system prophylaxis with high dose methotrexate, CHOP
doxorubicin (cont'd) injectable Lymphoma LYCHOPRMTX I
and rituximab in diffuse large B-cell lymphoma
doxorubicin (cont'd) injectable Lymphoma doxorubicin, cyclophosphamide, prednisone (CHP) and brentuximab LYCHPBV I
vedotin
treatment of burkitt’s lymphoma and leukemia with cyclophosphamide,

doxorubicin (cont'd) injectable Lymphoma LYCODOXMR I
* denotes change
Page 26 of 65
April 2022

FORM SITE CODES
doxorubicin (cont'd) injectable Lymphoma LYCVPPABO I
doxorubicin (cont'd) injectable Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
methotrexate
doxorubicin (cont'd) injectable Lymphoma lymphoma palliative chemotherapy LYPALL I
therapy for advanced soft tissue sarcoma using doxorubicin, ifosfamide-
doxorubicin (cont'd) injectable Sarcoma SAAI I
mesna
3-day doxorubicin, ifosfamide and mesna for use in patients with
doxorubicin (cont'd) injectable Sarcoma SAAI3 I
advanced soft tissue sarcoma
doxorubicin for adjuvant use for patients with non-metastatic operable
doxorubicin (cont'd) injectable Sarcoma SAAJA I
large high grade soft tissue sarcoma
adjuvant treatment of patients with soft tissue sarcoma using doxorubicin
doxorubicin (cont'd) injectable Sarcoma SAAJADIC I
and dacarbazine
doxorubicin (cont'd) injectable Sarcoma adjuvant therapy for osteosarcoma using doxorubicin and cisplatin SAAJAP I

doxorubicin (cont'd) injectable Sarcoma SAALT2W I
doxorubicin (cont'd) tablet, injectable Sarcoma SAALT3W I
doxorubicin (cont'd) injectable Sarcoma therapy for advanced soft tissue sarcoma using doxorubicin SAAVA I
treatment of patients with soft tissue sarcoma using doxorubicin and
doxorubicin (cont'd) injectable Sarcoma SAAVADIC I
dacarbazine
doxorubicin (cont'd) injectable Sarcoma therapy of advanced osteosarcoma using doxorubicin and cisplatin SAAVAP I
doxorubicin (cont'd) injectable Sarcoma treatment of sarcomas with vincristine, doxorubicin and cyclophosphamide SAVAC I

doxorubicin (cont'd) injectable Sarcoma SAVACM I
Other tumour site

Not Otherwise Not reimbursed for bladder
doxorubicin (cont'd) injectable code followed by I
Specified instillations
* denotes change
Page 27 of 65
April 2022

FORM SITE CODES
doxorubicin pegylated treatment of platinum resistant epithelial ovarian cancer with bevacizumab
injectable Gynecology GOOVBEVLD I
liposomal and pegylated liposomal doxorubicin
doxorubicin pegylated first line treatment of epithelial ovarian cancer using doxorubicin pegylated
injectable Gynecology GOOVFPLDC I
liposomal liposomal and carboplatin
doxorubicin pegylated treatment of epithelial ovarian cancer relapsing after primary treatment
injectable Gynecology GOOVLDOX I
liposomal using pegylated liposomal doxorubicin
doxorubicin pegylated treatment of epithelial ovarian cancer relapsing after primary treatment
injectable Gynecology GOOVPLDC I
liposomal using pegylated liposomal doxorubicin and carboplatin
doxorubicin pegylated
injectable Kaposi's Sarcoma Kaposi’s sarcoma KSLDO I
liposomal
doxorubicin pegylated Treatment of Relapsed or Refractory Hodgkin Lymphoma with
injectable Lymphoma LYGVLD I
liposomal Gemcitabine, Vinorelbine and Doxorubicin Pegylated Liposomal
drug-eluting bead (DEB)
loaded with doxorubicin transarterial chemoembolization (TACE) of hepatocellular carcinoma using
other Gastrointestinal GIDEBTACE I
(DC Bead® or drug-eluting bead (DEB) loaded with doxorubicin
HepaSphere™)
treatment of locally advanced non-small cell lung cancer using
durvalumab injectable Lung LULADUR I
durvalumab
treatment of locally advanced non-small cell lung cancer using 4-weekly
durvalumab injectable Lung LULADUR4 I
durvalumab
First-Line Treatment of ROS1-Positive Advanced Non-Small Cell Lung
entrectinib capsule Lung ULUAVENT* R
Cancer (NSCLC) with Entrectinib
Therapy for Metastatic Castration Sensitive Prostate Cancer using
enzalutamide tablet Genitourinary UGUMCSPENZ R
Enzalutamide
Therapy for Non-Metastatic Castration Resistant Prostate Cancer Using
enzalutamide tablet Genitourinary UGUNMPENZ R
Enzalutamide
enzalutamide tablet Genitourinary UGUPENZ R
Using Enzalutamide
epirubicin injectable Breast BRAJFEC I
cyclophosphamide
epirubicin injectable Breast BRAJFECD I

epirubicin (cont'd) injectable Breast BRAJFECDT I

epirubicin (cont'd) injectable Gastrointestinal junction or lower 1/3 esophagus, given before and after surgery, using GIGECC I
epirubicin (cont'd) injectable Genitourinary intravesical use for bladder cancer if BCG and mitomycin C not available GUNOS I
Other tumour site

Not Otherwise
epirubicin (cont'd) injectable code followed by I
Specified
eribulin injectable Breast Palliative Therapy for Metastatic Breast Cancer using Eribulin BRAVERIB I
eribulin injectable Sarcoma Palliative Therapy for Metastatic Sarcoma using Eribulin SAAVERIB I
erlotinib tablet Lung second or third line treatment of advanced non-small cell lung cancer LUAVERL I
maintenance therapy of advanced non-small cell lung cancer after first-line

erlotinib tablet Lung LUAVMTNE I
chemotherapy
* denotes change
Page 28 of 65
April 2022

FORM SITE CODES
capsule/
etoposide Neuro-Oncology carboplatin and etoposide in the treatment of recurrent ependymoma CNCARV I
injectable
capsule/ palliative treatment of patients with recurrent malignant gliomas and
etoposide Neuro-Oncology CNETO I
injectable ependymoma using low dose etoposide
capsule/ therapy for recurrent malignant brain tumours using temozolomide and
etoposide Neuro-Oncology CNTMZETO I
injectable etoposide
capsule/
etoposide Gastrointestinal palliative therapy of neuroendocrine tumours using cisplatin and etoposide GIPE I
injectable
capsule/ therapy of non-dysgerminomatous ovarian germ cell cancer using
etoposide Gynecology GOBEP I
injectable bleomycin, etoposide and cisplatin
capsule/ therapy of dysgerminomatous ovarian germ cell cancer using cisplatin and
etoposide Gynecology GOEP I
capsule/ treatment of relapsed/progressing epithelial ovarian, primary peritoneal, or
etoposide Gynecology GOOVETO I
injectable fallopian tube carcinoma using etoposide
capsule/
etoposide (cont'd) Gynecology treatment of small-cell gynecologic cancer with cisplatin and etoposide GOSCPE I
injectable
capsule/ treatment of small-cell gynecologic cancer with cisplatin and etoposide
etoposide Gynecology GOSCPERT I
injectable with radiation therapy
capsule/
etoposide (cont'd) Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
injectable
capsule/ curative therapy for germ cell cancer using bleomycin, etoposide and
etoposide (cont'd) Genitourinary GUBEP I
injectable cisplatin
capsule/ treatment of metastatic adrenalcortical cancer with doxorubicin, etoposide,
etoposide (cont'd) Genitourinary GUEDPM I
injectable cisplatin and mitotane
capsule/
etoposide (cont'd) Genitourinary therapy for nonseminoma germ cell cancer using etoposide-cisplatin GUEP I
injectable
capsule/
etoposide (cont'd) Genitourinary therapy of genitourinary small cell tumours with a platin and etoposide GUSCPE I
injectable
capsule/ therapy of genitourinary small cell tumors with a platin and etoposide with
etoposide (cont'd) Genitourinary GUSCPERT I
injectable radiation
capsule/ nonseminoma consolidation/salvage protocol using etoposide, cisplatin,
etoposide Genitourinary GUVIP2 I
injectable ifosfamide, mesna
capsule/ treatment of recurrent and metastatic squamous cell cancer with platinum
etoposide (cont'd) Head and Neck HNAVPE I
injectable and etoposide
capsule/ treatment of recurrent and/or metastatic nasopharyngeal cancer with
etoposide (cont'd) Head and Neck HNNAVPE I
injectable platinum and etoposide
capsule/ treatment of locally advanced non-small cell lung cancer using cisplatin
etoposide (cont'd) Lung LULAPERT I
injectable and etoposide with radiation
capsule/ treatment of locally advanced non-small cell lung cancer using alternative
etoposide (cont'd) Lung LULAPE2RT I
injectable dosing of cisplatin and etoposide with radiation therapy
* denotes change
Page 29 of 65
April 2022

FORM SITE CODES
capsule/
etoposide (cont'd) Lung treatment of thymoma with cisplatin and etoposide LUOTPE I
injectable
capsule/
etoposide (cont'd) Lung treatment of thymoma using cisplatin and etoposide with radiation therapy LUOTPERT I
injectable
capsule/ treatment of cancer of unknown primary involving the thorax with cisplatin
etoposide (cont'd) Lung LUPUPE I
capsule/ therapy of extensive stage small cell lung cancer with cisplatin and
etoposide (cont'd) Lung LUSCPE I
capsule/ therapy of limited stage small cell lung cancer using cisplatin and
etoposide (cont'd) Lung LUSCPERT I
injectable etoposide with radiation
capsule/ palliative therapy of extensive stage small cell lung cancer with oral
etoposide (cont'd) Lung LUSCPOE I
capsule/ treatment of hemophagocytic lymphohistiocytosis with etoposide,
etoposide (cont'd) Lymphoma HLHETCSPA I
injectable dexamethasone and cycloSPORINE
capsule/
etoposide (cont'd) Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
injectable
methotrexate
capsule/ treatment of burkitt’s lymphoma and leukemia with ifosfamide, mesna,
etoposide (cont'd) Lymphoma LYIVACR I
injectable etoposide, cytarabine and rituximab
capsule/
etoposide (cont'd) Lymphoma lymphoma palliative chemotherapy LYPALL I
injectable
capsule/ treatment of relapsed or refractory advanced stage aggressive B-cell non-

etoposide (cont'd) Lymphoma LYRICE I
injectable Hodgkin’s lymphoma with ifosfamide, carboplatin, etoposide and rituximab
capsule/ treatment of natural killer or T-Cell Lymphoma using dexamethasone,

etoposide (cont'd) Lymphoma LYSMILE I
injectable methotrexate, ifosfamide, pegaspargase and etoposide
treatment of newly diagnosed nasal, extranodal natural killer (NK) or T-cell

capsule/
etoposide (cont'd) Lymphoma lymphoma, stage IE to IIE using concurrent radiation and weekly cisplatin LYVIPDRT I
injectable
followed by etoposide, ifosfamide, cisplatin and dexamethasone

capsule/ TWO weekly interval for newly diagnosed Ewing's Sarcoma/Ewing’s
etoposide (cont'd) Sarcoma SAALT2W I
injectable Family of Tumours, Desmoplastic Intra-Abdominal Small Round Blue Cell
capsule/ THREE weekly interval for newly diagnosed Ewing's Sarcoma/Ewing’s
etoposide (cont'd) SAALT3W I
injectable Family of Tumours, Desmoplastic Intra-Abdominal Small Round Blue Cell
capsule/ 3-Day etoposide & ifosfamide-mesna for patients with advanced soft
etoposide (cont'd) Sarcoma SAAVIME3 I
injectable tissue or bony sarcomas
* denotes change
Page 30 of 65
April 2022

FORM SITE CODES
capsule/
etoposide (cont'd) Sarcoma etoposide, ifosfamide-mesna (SAIME) for use in sarcomas SAIME I
injectable
capsule/ treatment of recurrent or metastatic Merkel cell carcinoma with cisplatin
etoposide (cont'd) Skin & Melanoma SMMCCPE I
Other tumour site

capsule/ Not Otherwise
etoposide (cont'd) code followed by I
injectable Specified
everolimus tablet Breast therapy for advanced breast cancer using everolimus and exemestane BRAVEVEX I
treatment of advanced neuroendocrine tumours of gastrointestinal origin

everolimus tablet Gastrointestinal UGINETEV R
(non-functional) using everolimus
Note: AFINITOR® DISPERZTM
everolimus tablet Gastrointestinal palliative treatment of advanced pancreatic neuroendocrine tumours GIPNEVER I formulation not funded
everolimus tablet Genitourinary therapy for advanced renal cancer using everolimus GUEVER I
treatment of advanced neuroendocrine tumours of lung origin (non-
everolimus (cont'd) tablet Lung ULUNETEV R
functional) using everolimus
neoadjuvant or adjuvant therapy for breast cancer using exemestane in
exemestane tablet Breast BRAJEXE I

exemestane tablet Breast BRAJLHRHAI I
exemestane tablet Breast therapy for advanced breast cancer using everolimus and exemestane BRAVEVEX I

exemestane tablet Breast BRAVEXE I
exemestane (cont'd) tablet Breast BRAVLHRHA I
aromatase inhibitor
exemestane (cont'd) tablet Gynecology GOENDAI I
women
Note: NEUPOGEN® brand will

for inpatient administration only - see BC PharmaCare Special Authority
filgrastim (GRASTOFIL®) injectable FILGRASTIM only be reimbursed for pediatric
Form for indications covered
inpatient administration
fludarabine injectable/ tablet Leukemia & BMT BMTNOS I
treatment of chronic lymphocytic leukemia or prolymphocytic leukemia with

fludarabine injectable/ tablet Lymphoma LYCLLFLUDR I
fludarabine and rituximab
treatment of chronic lymphocytic leukemia (CLL) or prolymphocytic

fludarabine injectable/ tablet Lymphoma LYFCR I
leukemia with fludarabine, cyclophosphamide and rituximab
fludarabine injectable/ tablet Lymphoma chronic lymphocytic leukemia or low grade lymphoma LYFLU I
fludarabine injectable/ tablet Lymphoma treatment of relapsed indolent lymphoma with fludarabine and rituximab LYFLUDR I
fludarabine injectable/ tablet Pediatric pediatric patients with AML treated on the CCG-2961 study
I
fludrocortisone tablet Genitourinary GUEDPM I
fludrocortisone (cont'd) tablet Genitourinary mineralocorticoid deficiency associated with mitotane use GUMITO I
* denotes change
Page 31 of 65
April 2022

FORM SITE CODES
fluorouracil injectable Breast BRAJCMFPO I
(oral), methotrexate and fluorouracil
fluorouracil (cont'd) injectable Breast BRAJFEC I
cyclophosphamide
fluorouracil injectable Breast BRAJFECD I

fluorouracil (cont'd) injectable Breast BRAJFECDT I

fluorouracil (cont'd) injectable Breast BRAVCMF I
methotrexate and fluorouracil
adjuvant combination chemotherapy for stage III and stage IIB colon
fluorouracil (cont'd) injectable Gastrointestinal GIAJFFOX I
cancer using oxaliplatin, fluorouracil and folinic acid (leucovorin)
adjuvant therapy of colon cancer using fluorouracil injection and infusion

fluorouracil (cont'd) injectable Gastrointestinal GIAJFL I
and leucovorin infusion

fluorouracil (cont'd) injectable Gastrointestinal GIAVFL I
fluorouracil injection and infusion and folinic acid (leucovorin) infusion
combined modality therapy for locally advanced esophageal cancer using

fluorouracil (cont'd) injectable Gastrointestinal GIEFFOXRT I
oxaliplatin, fluorouracil, leucovorin, and radiation therapy
Note: only funded when prescribed

fluorouracil (cont'd) injectable Gastrointestinal GIEMBOL I by specialists at BC Cancer VC &
metastasis

fluorouracil (cont'd) injectable Gastrointestinal GIENDO2 I
doxorubicin

fluorouracil (cont'd) injectable Gastrointestinal GIFFIRB I

fluorouracil (cont'd) injectable Gastrointestinal GIFFIRPAN I
irinotecan, fluorouracil, leucovorin, and panitumumab

fluorouracil (cont'd) injectable Gastrointestinal GIFFOXB I

fluorouracil (cont'd) injectable Gastrointestinal GIFFOXPAN I
oxaliplatin, fluorouracil, leucovorin, and panitumumab
palliative combination chemotherapy for advanced pancreatic

fluorouracil (cont'd) injectable Gastrointestinal adenocarcinoma using irinotecan, oxaliplatin, fluorouracil and folinic acid GIFIRINOX I
(leucovorin)
fluorouracil (cont'd) injectable Gastrointestinal GIFOLFIRI I
irinotecan, fluorouracil and folinic acid (leucovorin)
fluorouracil (cont'd) injectable Gastrointestinal GIFOLFOX I
oxaliplatin, fluorouracil and folinic acid (leucovorin)
* denotes change
Page 32 of 65
April 2022

FORM SITE CODES
fluorouracil (cont'd) injectable Gastrointestinal GIFUART I
mitomycin, fluorouracil and radiation therapy
palliative chemotherapy for upper gastrointestinal tract cancer (gastric,

fluorouracil (cont'd) injectable Gastrointestinal esophageal, gall bladder carcinoma and cholangiocarcinoma) and GIFUC I
metastatic anal cancer using infusional fluorouracil and cisplatin
fluorouracil (cont'd) injectable Gastrointestinal GIFUPART I
cisplatin, infusional fluorouracil and radiation therapy
fluorouracil (cont'd) injectable Gastrointestinal negative) or ineligible for adjuvant chemoradiation using oxaliplatin, GIGAJFFOX I
fluorouracil, and leucovorin
palliative treatment of metastatic or inoperable, locally advanced gastric or
fluorouracil (cont'd) injectable Gastrointestinal gastroesophageal junction adenocarcinoma using cisplatin, infusional GIGAVCFT I
fluorouracil and trastuzumab
fluorouracil (cont'd) injectable Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Oxaliplatin, GIGAVFFOX I
Fluorouracil and Leucovorin
palliative treatment of metastatic or locally advanced HER-2 positive
fluorouracil (cont'd) injectable Gastrointestinal gastric, gastroesophageal junction, or esophageal adenocarcinoma using GIGAVFFOXT I
oxaliplatin, fluorouracil, leucovorin, and trastuzumab
fluorouracil (cont'd) injectable Gastrointestinal gastroesophageal junction or lower 1/3 esophagus using docetaxel, GIGFLODOC I
palliative combination chemotherapy for metastatic gastric or esophageal

fluorouracil (cont'd) injectable Gastrointestinal GIGFOLFIRI I
adenocarcinoma using irinotecan, fluorouracil and folinic acid (leucovorin)

fluorouracil (cont'd) injectable Gastrointestinal peritoneal carcinomatosis from limited advanced colorectal and GIHIPEC I
appendiceal carcinomas using oxaliplatin and fluorouracil
fluorouracil (cont'd) injectable Gastrointestinal GIPAJFIROX I
irinotecan, oxaliplatin, fluorouracil and leucovorin
Second-Line Treatment for Metastatic Pancreatic Cancer using
fluorouracil (cont'd) injectable Gastrointestinal GIPAVFFIRI I
Irinotecan, Fluorouracil and Leucovorin
Palliative Combination Chemotherapy for Metastatic Pancreatic Cancer
fluorouracil (cont'd) injectable Gastrointestinal GIPAVFFOX I
using Oxaliplatin, Fluorouracil and Leucovorin
fluorouracil (cont'd) injectable Gastrointestinal GIRAJFFOX I
Cancer using Oxaliplatin, Fluorouracil and Leucovorin
fluorouracil (cont'd) injectable Gastrointestinal GIRINFRT I
capecitabine, infusional fluorouracil and radiation therapy
fluorouracil (cont'd) injectable Genitourinary GUFUPRT I
* denotes change
Page 33 of 65
April 2022

FORM SITE CODES
fluorouracil and leucovorin for recurrent head and neck cancer (squamous
fluorouracil (cont'd) injectable Head and Neck HNAVFUFA I
cell carcinoma)
fluorouracil (cont'd) injectable Head and Neck HNAVFUP I

fluorouracil (cont'd) injectable Head and Neck UHNAVPFPMB R
combined chemotherapy (carboplatin and fluorouracil) and radiation

fluorouracil (cont'd) injectable Head and Neck treatment for locally advanced squamous cell carcinoma of the head and HNLACAFRT I
neck
fluorouracil (cont'd) injectable Head and Neck HNLADCF I
fluorouracil and leucovorin for recurrent head and neck cancer
fluorouracil (cont'd) injectable Head and Neck HNNAVFUFA I
(nasopharyngeal)
fluorouracil (cont'd) injectable Head and Neck HNNAVFUP I
fluorouracil (cont'd) injectable Head and Neck HNSAVFAC I
treatment of advanced head and neck cancer using cisplatin and
fluorouracil (cont'd) injectable Head and Neck HNSAVFUP I
fluorouracil
Other tumour site

Not Otherwise
fluorouracil (cont'd) injectable code followed by I
Specified
fluorouracil eyedrops Ocular Topical Therapy for Ocular Malignancies using Fluorouracil Eye Drops OCFU I
fluorouracil topical cream Skin & Melanoma skin cancer SMNOS I

Not reimbursed for vasomotor
flutamide tablet Genitourinary nonsteroidal treatment of prostate cancer GUPNSAA I
symptoms (hot flashes)
fulvestrant injectable Breast BRAVPBFLV I
fulvestrant injectable Breast BRAVRBFLV I
first-line treatment of epidermal growth factor receptor mutation-positive
gefitinib tablet Lung LUAVGEFF I
advanced NSCLC
gemcitabine injectable Breast palliative therapy for metastatic breast cancer using gemcitabine BRAVGEM I
palliative therapy for metastatic breast cancer using gemcitabine and
gemcitabine injectable Breast BRAVGEMD I
docetaxel
as palliative therapy for metastatic breast cancer using cisplatin and
gemcitabine (cont'd) injectable Breast BRAVGEMP I
gemcitabine
gemcitabine injectable Breast treatment of metastatic breast cancer using gemcitabine and paclitaxel BRAVGEMT I

gemcitabine (cont'd) injectable Gastrointestinal GIAVPG I
cholangiocarcinoma using gemcitabine and cisplatin
gemcitabine (cont'd) injectable Gastrointestinal GIPAJGCAP I
capecitabine and gemcitabine
gemcitabine (cont'd) injectable Gastrointestinal adjuvant chemotherapy for pancreatic adenocarcinoma using gemcitabine GIPAJGEM I
palliative chemotherapy for pancreatic adenocarcinoma, gallbladder

gemcitabine injectable Gastrointestinal GIPGEM I
cancer, and cholangiocarcinoma using gemcitabine
* denotes change
Page 34 of 65
April 2022

FORM SITE CODES
first line treatment of locally advanced and metastatic pancreatic cancer
gemcitabine (cont'd) injectable Gastrointestinal GIPGEMABR I
with paclitaxel NAB (ABRAXANE) and gemcitabine
gemcitabine (cont'd) injectable Gynecology GOOVBEVG I
and gemcitabine
carboplatin and gemcitabine for the treatment of recurrent platinum-
gemcitabine injectable Gynecology GOOVCAG I
sensitive ovarian cancer
palliative chemotherapy for re-treatment of ovarian, tubal, and peritoneal
gemcitabine injectable Gynecology GOOVGEM I
cancer using gemcitabine
combination with docetaxel for advanced or recurrent uterine sarcoma
gemcitabine (cont'd) injectable Gynecology GOSADG I
cancer
gemcitabine (cont'd) injectable Genitourinary adjuvant therapy for urothelial carcinoma using cisplatin and gemcitabine GUAJPG I
combination with cisplatin for advanced transitional cell carcinoma of the

gemcitabine (cont'd) injectable Genitourinary GUAVPG I
bladder
intravesical therapy for non-muscle invasive bladder cancer using
gemcitabine (cont'd) injectable Genitourinary GUBGEM I
gemcitabine
Intravesical Therapy for Non-Muscle Invasive Bladder Cancer using
gemcitabine (cont'd) injectable Genitourinary GUBGEMDOC I
Gemcitabine and Docetaxel
gemcitabine (cont'd) injectable Genitourinary combination with cisplatin as neoadjuvant therapy for urothelial carcinoma GUNAJPG I
gemcitabine (cont'd) injectable Genitourinary palliative therapy for germ cell cancers using paclitaxel and gemcitabine GUTAXGEM I
treatment of loco-regionally recurrent and/or metastatic nasopharyngeal

gemcitabine (cont'd) injectable Head and Neck HNNAVGEM I
cancer with gemcitabine
treatment of local-regionally recurrent and/or metastatic nasopharyngeal
gemcitabine (cont'd) injectable Head and Neck HNNAVPG I
as induction treatment of locally advanced nasopharyngeal cancer with
gemcitabine (cont'd) injectable Head and Neck HNNLAPG I
cisplatin and gemcitabine
combination with cisplatin or carboplatin as treatment of advanced non-
gemcitabine (cont'd) injectable Lung LUAVPG I
small cell lung cancer
gemcitabine (cont'd) injectable Lung LUAVPGPMB I
gemcitabine (cont'd) injectable Lung treatment of malignant mesothelioma with platinum and gemcitabine LUMMPG I
gemcitabine (cont'd) injectable Lymphoma treatment of lymphoma with gemcitabine, dexamethasone and platinum LYGDP I

gemcitabine (cont'd) injectable Lymphoma LYGDPR I
with rituximab
Treatment of Newly Diagnosed or Relapsed/Refractory Natural Killer or T-

gemcitabine (cont'd) injectable Lymphoma LYGEMOXPEG* I
Cell Lymphoma using Gemcitabine, Oxaliplatin and Pegaspargase
Treatment of Relapsed or Refractory Hodgkin Lymphoma with

gemcitabine (cont'd) injectable Lymphoma LYGVLD I
Gemcitabine, Vinorelbine and Doxorubicin Pegylated Liposomal
gemcitabine (cont'd) injectable Lymphoma palliative chemotherapy of lymphomas LYPALL I
treatment of pediatric patients with relapsed Hodgkin lymphoma with a

gemcitabine (cont'd) injectable Pediatric I
combination of ifosfamide, mesna, gemcitabine and vinorelbine (IGEV)
combination with docetaxel as second or third line therapy for soft tissue
gemcitabine (cont'd) injectable Sarcoma SAAVGEMD I
sarcomas
gemtuzumab ozogamicin injectable Leukemia & BMT LKGEMOZ I
Therapy of Relapsed or Refractory FLT3+ Acute Myeloid Leukemia using
gilteritinib tablet Leukemia & BMT ULKAMLGIL R
Gilteritinib
* denotes change
Page 35 of 65
April 2022

FORM SITE CODES
long acting neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in

goserelin Breast BRAJLHRHAI I
long acting neoadjuvant or adjuvant therapy for breast cancer using a LHRH agonist
goserelin Breast BRAJLHRHT I
injectable and tamoxifen
long acting therapy for advanced breast cancer using a LHRH agonist and an
goserelin (cont'd) Breast BRAVLHRHA I
injectable aromatase inhibitor
long acting combination therapy with tamoxifen palliative therapy for metastatic breast
goserelin (cont'd) Breast BRAVLHRHT I
injectable cancer
long acting therapy of advanced breast cancer using palbociclib and aromatase Not reimbursed for endometriosis
goserelin (cont'd) Breast BRAVPALAI I
injectable inhibitor with or without LHRH agonist
long acting Therapy of Advanced Breast Cancer using Palbociclib and Fulvestrant
goserelin (cont'd) Breast BRAVPBFLV I
injectable with or without LHRH Agonist
long acting Therapy of Advanced Breast Cancer using Ribociclib and Fulvestrant with
goserelin (cont'd) Breast BRAVRBFLV I
injectable or without LHRH Agonist
long acting therapy of advanced breast cancer using ribociclib and aromatase
goserelin (cont'd) Breast BRAVRIBAI I
injectable inhibitor with or without LHRH agonist
long acting
goserelin (cont'd) Genitourinary therapy for prostate cancer using LHRH agonist GUPLHRH I
injectable
hydrocortisone tablet, injectable Lymphoma HLHETCSPA I
Other tumour site Not reimbursed for supportive care

Not Otherwise
hydrocortisone (cont'd) tablet, injectable code followed by I
Specified
Myeloid neoplasms, including but not limited to: Acute myeloid leukemia,
Myelodysplastic syndromes (e.g. Refractory anemia), Myeloproliferative
hydroxyurea capsule Leukemia & BMT LKNOS I
disease (e.g. Chronic myeloid leukemia, Polycythemia, Essential
thrombocythemia)
Lymphoid neoplasms, including but not limited to: Lymphoproliferative
hydroxyurea capsule Lymphoma LYNOS I
disease, Myeloma
ibritumomab 90Y Palliative therapy for lymphoma using radioimmunotherapy: rituximab-
injectable Lymphoma LYRITZ I
(ZEVALIN®) priming for ibritumomab 90Y (ZEVALIN®)
treatment of previously untreated chronic lymphocytic leukemia or small
ibrutinib capsule Lymphoma ULYFIBRU R
lymphocytic lymphoma using ibrutinib
treatment of relapsed or refractory chronic lymphocytic leukemia or small
ibrutinib capsule Lymphoma LYIBRU I
lymphocytic lymphoma using ibrutinib
ibrutinib (cont'd) capsule Lymphoma treatment of relapsed/refractory mantle-cell lymphoma using ibrutinib LYMIBRU I
Tumour site code

Not Otherwise
idarubicin injectable followed by ‘NOS’ I
Specified
(e.g. BRNOS)
idelalisib tablet Lymphoma LYIDELAR I
lymphocytic lymphoma using idelalisib and rituximab
* denotes change
Page 36 of 65
April 2022

FORM SITE CODES
ifosfamide injectable Genitourinary GUTIP I
ifosfamide injectable Genitourinary GUVEIP I
ifosfamide (cont'd) injectable Genitourinary GUVIP2 I
ifosfamide, mesna
treatment of burkitt’s lymphoma and leukemia with ifosfamide, mesna,
ifosfamide (cont'd) injectable Lymphoma LYIVACR I
treatment of relapsed or refractory advanced stage aggressive B-cell non-

ifosfamide (cont'd) injectable Lymphoma LYRICE I
Hodgkin’s lymphoma with ifosfamide, carboplatin, etoposide and rituximab
treatment of natural killer or T-Cell Lymphoma using dexamethasone,

ifosfamide (cont'd) injectable Lymphoma LYSMILE I
treatment of newly diagnosed nasal, extranodal natural killer (NK) or T-cell

ifosfamide (cont'd) injectable Lymphoma lymphoma, stage IE to IIE using concurrent radiation and weekly cisplatin LYVIPDRT I
followed by etoposide, ifosfamide, cisplatin and dexamethasone

ifosfamide injectable Pediatric I

ifosfamide injectable Sarcoma SAAI I
mesna
ifosfamide (cont'd) injectable Sarcoma SAAI3 I
ifosfamide (cont'd) injectable Sarcoma SAALT2W I
ifosfamide (cont'd) injectable Sarcoma SAALT3W I
ifosfamide injectable Sarcoma therapy for advanced soft tissue sarcoma using ifosfamide SAAVI I
ifosfamide injectable Sarcoma 3-day ifosfamide for use in patients with advanced soft tissue sarcoma SAAVI3 I
3-Day etoposide & ifosfamide-mesna for patients with advanced soft
ifosfamide injectable Sarcoma SAAVIME3 I
tissue or bony sarcomas
ifosfamide injectable Sarcoma etoposide, ifosfamide-mesna (SAIME) for use in sarcomas SAIME I
Other tumour site

Not Otherwise
ifosfamide (cont'd) injectable code followed by I
Specified
* denotes change
Page 37 of 65
April 2022

FORM SITE CODES
therapy for chronic myeloid leukemia and Ph+ acute lymphoblastic
imatinib capsule/tablet Leukemia & BMT LKCMLI I
leukemia
pediatric patients with Philadelphia chromosome positive acute
imatinib capsule/tablet Pediatric I
lymphoblastic leukemia
adjuvant therapy of C-Kit positive high risk gastrointestinal stromal cell
imatinib capsule/tablet Sarcoma SAAJGI I
tumours
advanced c-kit positive and c-kit negative gastrointestinal stromal cell
imatinib (cont'd) capsule/tablet Sarcoma SAAVGI I
tumours
advanced c-kit positive gastrointestinal stromal cell tumors using 800 mg
imatinib capsule/tablet Sarcoma SAAVGIDD I
dosing of imatinib
imatinib capsule/tablet Skin & Melanoma treatment of advanced c-kit melanoma using imatinib SMAVI I
topical immunotherapy for in-transit melanoma metastases, cutaneous
imiquimod topical cream Skin & Melanoma SMIMI I
lymphoma, basal cell carcinoma using imiquimod
treatment of relapsed or refractory pre-B-cell acute lymphoblastic leukemia
inotuzumab ozogamicin injectable Leukemia & BMT ULKINOZ R
with inotuzumab ozogamicin
treatment of metastatic or advanced renal cell carcinoma using ipilimumab
ipilimumab injectable Genitourinary GUAVIPNI I
and nivolumab
first-line treatment of unresectable or metastatic melanoma using
injectable Skin & Melanoma SMAVFIPI I
ipilimumab
treatment of advanced and metastatic melanoma after prior systemic
ipilimumab injectable Skin & Melanoma SMAVIPI I
therapy
treatment of unresectable or metastatic melanoma using ipilimumab and
ipilimumab injectable Skin & Melanoma SMAVIPNI I
nivolumab
palliative third line treatment of metastatic colorectal cancer with wild-type
irinotecan injectable Gastrointestinal GIAVCETIR I
KRAS using cetuximab and irinotecan
Palliative Therapy of Metastatic Colorectal Cancer using Irinotecan and
irinotecan (cont'd) injectable Gastrointestinal GIAVRALIR I
Raltitrexed in Patients Intolerant to Fluorouracil or Capecitabine

irinotecan (cont'd) injectable Gastrointestinal GICAPIRI I
irinotecan and capecitabine in patients unsuitable for GIFOLFIRI

irinotecan injectable Gastrointestinal GICIRB I

irinotecan injectable Gastrointestinal GIFFIRB I

irinotecan injectable Gastrointestinal GIFFIRPAN I
* denotes change
Page 38 of 65
April 2022

FORM SITE CODES
irinotecan (cont'd) injectable Gastrointestinal adenocarcinoma using irinotecan, oxaliplatin, fluorouracil and folinic acid GIFIRINOX I
(leucovorin)
irinotecan (cont'd) injectable Gastrointestinal GIFOLFIRI I
second line palliative combination chemotherapy for metastatic gastric or
irinotecan (cont'd) injectable Gastrointestinal esophageal adenocarcinoma using irinotecan, fluorouracil and folinic acid GIGFOLFIRI I
(leucovorin)
irinotecan (cont'd) injectable Gastrointestinal palliative chemotherapy of metastatic colorectal cancer using irinotecan GIIR I
palliative therapy of metastatic colorectal cancer in patients who may not

irinotecan injectable Gastrointestinal GIIRINALT I
tolerate the 3-weekly irinotecan schedule of GIIR
irinotecan injectable Gastrointestinal GIPAJFIROX I
irinotecan injectable Gastrointestinal GIPAVFFIRI I
irinotecan injectable Lung LUSCPI I
pediatric patients treated on the COG protocol ARST0531 for intermediate-
irinotecan (cont'd) injectable Pediatric I
risk rhabdomyosarcoma
pediatric patients with recurrent pediatric neuroblastoma treated on the
COG protocol ANBL0421
pediatric patients with high risk renal tumors treated on the COG protocol
AREN0321
pediatric patients with high risk rhabdomyosarcoma treated on the COG
protocol ARSTO431
ARST08P1 protocol
pediatric patients with recurrent/refractory medulloblastomas/CNS PNET
of childhood treated on the COG ACNS0821 protocol
isotretinoin (ACCUTANE) capsule Pediatric pediatric patients with high risk neuroblastoma I
pediatric patients treated on the COG protocol ACNS0332 for above

isotretinoin (ACCUTANE™) capsule Pediatric I
average risk medulloblastoma/PNE
lanreotide injectable Neuro-Oncology treatment of growth hormone secreting pituitary adenoma using lanreotide CNLAN I
symptomatic management of functional carcinoid and neuroendocrine

lanreotide (cont'd) injectable Gastrointestinal UGILAN R
tumours of the GI Tract using lanreotide
lapatinib tablet Breast therapy for metastatic breast cancer using capecitabine and lapatinib BRAVLCAP I
* denotes change
Page 39 of 65
April 2022

FORM SITE CODES
lenalidomide capsule Leukemia & BMT therapy of myelodysplastic syndrome using lenalidomide ULKMDSL R
lenalidomide capsule Myeloma UMYBLDF R
Multiple Myeloma
lenalidomide capsule Myeloma UMYCARLD R
dexamethasone

lenalidomide capsule Myeloma UMYDARLD R
treatment of previously untreated multiple myeloma and not eligible for

lenalidomide capsule Myeloma UMYLDF R
stem cell transplant using lenalidomide with low-dose dexamethasone
therapy of relapsed multiple myeloma using lenalidomide with

lenalidomide (cont'd) capsule Myeloma UMYLDREL R
dexamethasone
lenalidomide capsule Myeloma maintenance therapy of multiple myeloma using lenalidomide UMYLENMTN R
lenvatinib capsule Gastrointestinal Therapy of Advanced Hepatocellular Carcinoma using Lenvatinib GILEN I
therapy for locally recurrent or metastatic, RAI-refractory differentiated
lenvatinib capsule Head and Neck HNOTLEN I
thyroid cancer using lenvatinib
neoadjuvant or adjuvant therapy for breast cancer using letrozole in
letrozole tablet Breast BRAJLET I

letrozole (cont'd) tablet Breast BRAJLHRHAI I

letrozole tablet Breast BRAVLET I
letrozole (cont'd) tablet Breast BRAVLHRHA I
aromatase inhibitor
letrozole tablet Breast BRAVPALAI I
letrozole tablet Breast BRAVRIBAI I

letrozole (cont'd) tablet Gynecology GOENDAI I
women with contraindications to tamoxifen or intolerant of tamoxifen
hormonal treatment for advanced ovarian cancer in postmenopausal

letrozole (cont'd) tablet Gynecology GOOVAI I
women
* denotes change
Page 40 of 65
April 2022

FORM SITE CODES
treatment of meningeal disease using high-dose methotrexate with
leucovorin calcium tablet, injectable Breast BRAVHDMTX I
leucovorin rescue
adjuvant combination chemotherapy for Stage III and Stage IIB colon
leucovorin calcium tablet, injectable Gastrointestinal GIAJFFOX I
cancer using oxaliplatin, fluorouracil and folinic acid (Leucovorin)
adjuvant therapy of colon cancer using fluorouracil injection and infusion

leucovorin calcium tablet, injectable Gastrointestinal GIAJFL I
and leucovorin infusion

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIAVFL I
fluorouracil injection and infusion and folinic acid (leucovorin) infusion

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIEFFOXRT I

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIFFIRB I

leucovorin calcium (cont'd) injectable Gastrointestinal GIFFIRPAN I

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIFFOXB I

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIFFOXPAN I

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal adenocarcinoma using irinotecan, oxaliplatin, fluorouracil and folinic acid GIFIRINOX I
(leucovorin)
leucovorin calcium tablet, injectable Gastrointestinal GIFOLFIRI I
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIFOLFOX I
oxaliplatin, fluorouracil and folinic acid (leucovorin)
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal negative) or ineligible for adjuvant chemoradiation using oxaliplatin, GIGAJFFOX I
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Oxaliplatin, GIGAVFFOX I
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal gastric, gastroesophageal junction, or esophageal adenocarcinoma using GIGAVFFOXT I
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal gastroesophageal junction or lower 1/3 esophagus using docetaxel, GIGFLODOC I
palliative combination chemotherapy for metastatic gastric or esophageal

leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIGFOLFIRI I
adenocarcinoma using irinotecan, fluorouracil and folinic acid (leucovorin)
* denotes change
Page 41 of 65
April 2022

FORM SITE CODES
leucovorin calcium (cont'd) injectable Gastrointestinal GIPAJFIROX I
leucovorin calcium (cont'd) injectable Gastrointestinal GIPAVFFIRI I
leucovorin calcium (cont'd) injectable Gastrointestinal GIPAVFFOX I
leucovorin calcium (cont'd) tablet, injectable Gastrointestinal GIRAJFFOX I
leucovorin calcium (cont'd) tablet, injectable Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
leucovorin calcium (cont'd) tablet, injectable Gynecology I
fluorouracil and leucovorin for recurrent head and neck cancer (squamous
leucovorin calcium (cont'd) tablet, injectable Head and Neck HNAVFUFA I
cell carcinoma)
fluorouracil and leucovorin for recurrent head and neck cancer
leucovorin calcium (cont'd) tablet, injectable Head and Neck HNNAVFUFA I
(nasopharyngeal)

leucovorin calcium (cont'd) tablet, injectable Lymphoma LYASPMEDEX I

leucovorin calcium (cont'd) tablet, injectable Lymphoma LYCHOPRMTX I
treatment of Burkitt’s lymphoma and leukemia with cyclophosphamide,

leucovorin calcium (cont'd) tablet, injectable Lymphoma LYCODOXMR I
Treatment of Primary and Secondary CNS Lymphoma with High-Dose

leucovorin calcium (cont'd) tablet, injectable Lymphoma LYHDMRTEM I
Methotrexate, Rituximab and Temozolomide
treatment of natural killer or T-Cell lymphoma using dexamethasone,

leucovorin calcium (cont'd) tablet, injectable Lymphoma LYSMILE I
Other tumour site

Not Otherwise
leucovorin calcium (cont'd) tablet, injectable code followed by I
Specified
* denotes change
Page 42 of 65
April 2022

FORM SITE CODES
long acting neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in
leuprolide Breast BRAJLHRHAI I
injectable, long neoadjuvant or adjuvant therapy for breast cancer using a LHRH agonist
leuprolide Breast BRAJLHRHT I
acting injectable and tamoxifen
injectable, long therapy for advanced breast cancer using a LHRH agonist and an
leuprolide (cont'd) Breast BRAVLHRHA I
acting injectable aromatase inhibitor
injectable, long combination therapy with tamoxifen palliative therapy for metastatic breast
leuprolide Breast BRAVLHRHT I
acting injectable cancer
Not reimbursed for endometriosis.
injectable, long therapy of advanced breast cancer using palbociclib and aromatase Leuprolide acetate IM (LUPRON®)
leuprolide (cont'd) Breast BRAVPALAI I
acting injectable inhibitor with or without LHRH agonist and SC (ELIGARD®) injectables
are both reimbursable for prostate
injectable, long Therapy of Advanced Breast Cancer using Palbociclib and Fulvestrant cancer indications (GUPLHRH).
leuprolide Breast BRAVPBFLV I
acting injectable with or without LHRH Agonist
injectable, long Therapy of Advanced Breast Cancer using Ribociclib and Fulvestrant with
leuprolide Breast BRAVRBFLV I
acting injectable or without LHRH Agonist
injectable, long therapy of advanced breast cancer using ribociclib and aromatase
leuprolide Breast BRAVRIBAI I
acting injectable inhibitor with or without LHRH agonist
injectable, long
leuprolide Genitourinary therapy for prostate cancer using LHRH agonist GUPLHRH I
acting injectable
lomustine capsule Neuro-Oncology lomustine for treatment of recurrent malignant brain tumors CNCCNU I
lomustine capsule Neuro-Oncology CNCCV I
medulloblastoma or other primitive neuroectodermal tumour
modified PCV chemotherapy of brain tumours using procarbazine,
lomustine (cont'd) capsule Neuro-Oncology CNMODPCV I
lomustine and vincristine
lomustine (cont'd) capsule Lymphoma lymphoma palliative chemotherapy LYPALL I
Other tumour site

Not Otherwise
lomustine (cont'd) capsule code followed by I
Specified
‘NOS’ (e.g. CNNOS)
Peptide Receptor Radionuclide Therapy (PRRT) using 177Lu-Dotatate

177 radio-
Lu-Dotatate Gastrointestinal (LUTATHERA) for Treatment in Patients with Somatostatin Receptor UGIPRRT R
pharmaceutical
Positive Midgut Neuroendocrine Tumours
Approval from Health Canada
mechlorethamine
topical gel Lymphoma topical mechlorethamine in cutaneous T-Cell lymphoma LYMECHLOR I Special Access Programme is
(chlormethine) (SAP)
required for each patient
Not reimbursed for appetite

medroxyprogesterone tablet Gynecology non-aromatase inhibitor hormonal treatment of endometrial cancer GOENDH I
stimulation or replacement therapy.
megestrol tablet Breast breast cancer BRAVMEG I Not reimbursed for appetite
stimulation or symptom
megestrol tablet Gynecology non-aromatase inhibitor hormonal treatment of endometrial cancer GOENDH I management
* denotes change
Page 43 of 65
April 2022

FORM SITE CODES
conditioning therapy for autologous stem cell transplant using high dose
melphalan tablet, injectable Leukemia & BMT BMTMM0301 I
melphalan in the treatment of multiple myeloma
melphalan tablet, injectable Myeloma treatment of multiple myeloma using melphalan and prednisone MYMP I

melphalan tablet, injectable Myeloma bortezomib with the option of substituting cyclophosphamide for MYMPBOR I
melphalan
Other tumour site

Not Otherwise
melphalan tablet, injectable code followed by I
Specified
Tumour site code

Not Otherwise
6-mercaptopurine tablet followed by ‘NOS’ I
Specified
(e.g. LKNOS)
therapy for relapsed testicular germ cell cancer using paclitaxel,
mesna injectable Genitourinary GUTIP I
ifosfamide and cisplatin (TIP)
mesna Genitourinary GUVEIP I
mesna injectable GUVIP2 I
Genitourinary ifosfamide, mesna
Treatment of Burkitt’s lymphoma and leukemia with ifosfamide, mesna,
mesna (cont'd) injectable Lymphoma LYIVACR I
treatment of relapsed or refractory advanced stage aggressive B-Cell Non-
mesna (cont'd) injectable Hodgkin’s Lymphoma with ifosfamide, carboplatin, etoposide and LYRICE I
rituximab
treatment of Natural Killer or T-Cell Lymphoma using dexamethasone,
mesna (cont'd) injectable LYSMILE I
treatment of newly diagnosed Nasal, Extranodal Natural Killer (NK) or T-

mesna (cont'd) injectable cell lymphoma, using concurrent radiation and weekly cisplatin followed by LYVIPDRT I Approved for use ONLY as an uro-
etoposide, ifosfamide, cisplatin and dexamethasone protector for ifosfamide or high
dose cyclophosphamide
mesna injectable Pediatric I

mesna injectable Sarcoma SAAI I
mesna
mesna (cont'd) injectable Sarcoma SAAI3 I
mesna (cont'd) injectable Sarcoma SAALT2W I
mesna (cont'd) injectable Sarcoma SAALT3W I
* denotes change
Page 44 of 65
April 2022

FORM SITE CODES
mesna (cont'd) injectable Sarcoma therapy for advanced soft tissue sarcoma using ifosfamide SAAVI I
mesna injectable 3-day ifosfamide for use in patients with advanced soft tissue sarcoma SAAVI3 I
Sarcoma
3-day etoposide & ifosfamide-mesna for patients with advanced soft
mesna injectable SAAVIME3 I
Sarcoma tissue or bony sarcomas
mesna (cont'd) injectable Sarcoma etoposide, ifosfamide-mesna (SAIME) for use in sarcomas SAIME I
Approved for use ONLY as an uro-
Treatment of Sarcomas with Pelvic Primaries or Chemotherapy-Induced protector for ifosfamide or high
mesna (cont'd) injectable Sarcoma SAVACM I
Hematuria using Vincristine, Doxorubicin, Cyclophosphamide and Mesna dose cyclophosphamide
mesna dosage modification for hematuria secondary to
mesna (cont'd) injectable Supportive Care SCMESNA I
oxazaphosphorines
Other tumour site

Not Otherwise
mesna (cont'd) injectable code followed by I
Specified
‘NOS’ (e.g. SANOS)

methotrexate tablet, injectable Breast BRAJCMFPO I
(oral), methotrexate and fluorouracil
methotrexate (cont'd) tablet, injectable Breast BRAVCMF I
methotrexate and fluorouracil
treatment of meningeal disease using high-dose methotrexate with
methotrexate (cont'd) tablet, injectable Breast BRAVHDMTX I
leucovorin rescue
methotrexate tablet, injectable Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
methotrexate (cont'd) tablet, injectable Gynecology I

methotrexate tablet, injectable Genitourinary GUMVAC I
treatment of head and neck cancer using methotrexate as standard Not reimbursed for rheumatoid
methotrexate tablet, injectable Head and Neck HNAVM I
therapy arthritis, psoriasis.
methotrexate (cont'd) tablet, injectable Kaposi's Sarcoma therapy for Kaposi's Sarcoma using vinblastine-vincristine KSVB I
methotrexate (cont'd) tablet, injectable Lymphoma HLHETCSPA I

methotrexate (cont'd) tablet, injectable Lymphoma LYASPMEDEX I

methotrexate (cont'd) tablet, injectable Lymphoma LYCHOPRMTX I
treatment of burkitt’s lymphoma and leukemia with cyclophosphamide,

methotrexate (cont'd) tablet, injectable Lymphoma LYCODOXMR I

methotrexate (cont'd) tablet, injectable Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
methotrexate
* denotes change
Page 45 of 65
April 2022

FORM SITE CODES
methotrexate (cont'd) tablet, injectable Lymphoma LYHDMRTEM I
Central Nervous System Prophylaxis with High-Dose Methotrexate in
methotrexate (cont'd) tablet, injectable Lymphoma LYHDMTXPRO I
Diffuse Large B-Cell Lymphoma
methotrexate (cont'd) tablet, injectable Lymphoma treatment of lymphoma using intrathecal methotrexate and cytarabine LYIT I
treatment of Burkitt’s Lymphoma and Leukemia with ifosfamide, mesna,

methotrexate (cont'd) tablet, injectable Lymphoma LYIVACR I
methotrexate (cont'd) tablet, injectable Lymphoma lymphoma palliative chemotherapy LYPALL I

Not reimbursed for rheumatoid
treatment of natural killer or T-Cell Lymphoma using dexamethasone, arthritis, psoriasis.
methotrexate (cont'd) tablet, injectable Lymphoma LYSMILE I

methotrexate (cont'd) tablet, injectable Miscellaneous Origins MOIT I
and/or cytarabine
palliative therapy for aggressive fibromatosis using weekly or alternate
methotrexate (cont'd) tablet, injectable Sarcoma SAMV I
week methotrexate and vinblastine intravenously
Other tumour site

Not Otherwise
methotrexate (cont'd) tablet, injectable code followed by I
Specified
‘NOS’ (e.g. MYNOS)
Treatment of Cutaneous T-Cell Lymphoma (Sézary Syndrome) with

methoxsalen injectable Lymphoma LYMFECP I
Extracorporeal Photopheresis
Only reimbursable when
prescribed by physicians in the
methyl aminolevulinate
topical cream Skin & Melanoma topical therapy for skin cancer with PDT (Photodynamic Therapy) SMPDT I Skin Tumour Group within the Skin
(METVIX®)
PDT Program of the BC Cancer
Agency
therapy of FLT3+ acute myeloid leukemia using midostaurin in
midostaurin capsule Leukemia & BMT LKAMLMIDO I
combination with induction and consolidation chemotherapy
combined modality therapy for carcinoma of the anal canal using
mitomycin injectable Gastrointestinal GICART I
mitomycin, capecitabine and radiation therapy
Only funded when prescribed by
mitomycin injectable Gastrointestinal GIEMBOL I specialists at BC Cancer VC &
metastasis
mitomycin (cont'd) injectable Gastrointestinal GIFUART I
mitomycin, fluorouracil and radiation therapy
chemotherapy of pseudomyxoma peritonei using intraperitoneal mitomycin
mitomycin (cont'd) injectable Gastrointestinal GIFUIP I
and fluorouracil
* denotes change
Page 46 of 65
April 2022

FORM SITE CODES
mitomycin (cont'd) injectable Gastrointestinal peritoneal carcinomatosis from limited advanced colorectal and GIHIPEC I
mitomycin (cont'd) injectable Genitourinary GUFUPRT I
intravesical therapy for non-muscle invasive cell bladder cancer using GUBMITO
mitomycin injectable Genitourinary I
mitomycin
mitomycin eye drops Ocular eye drops as topical therapy for ocular malignancies OCMITO I
Other tumour site

Not Otherwise
mitomycin (cont'd) injectable code followed by I
Specified
mitotane tablet Genitourinary treatment of advanced adrenal cortical cancer GUMITO I

mitotane tablet Genitourinary GUEDPM I
palliative therapy for hormone-refractory prostate cancer using
mitoxantrone injectable Genitourinary GUPMX I
mitoxantrone and prednisone
Other tumour site

Not Otherwise
mitoxantrone injectable code followed by I
Specified
nilotinib tablet Leukemia & BMT Treatment of Chronic Myeloid Leukemia using Nilotinib LKCMLN I
prostate carcinoma patients who are intolerant to bicalutamide or Not reimbursed for vasomotor
nilutamide tablet Genitourinary GUPNSAA I
flutamide, at 150 mg po daily symptoms (hot flashes)
Maintenance Treatment of Newly Diagnosed Platinum Responsive
niraparib capsule Gynecology UGOOVFNIRM R
Epithelial Ovarian Cancer using Niraparib
Maintenance Treatment of Relapsed Platinum Sensitive and Responsive
niraparib capsule Gynecology UGOOVNIRAM R
Epithelial Ovarian Cancer using Niraparib
treatment of metastatic or advanced renal cell carcinoma using ipilimumab
nivolumab injectable Genitourinary GUAVIPNI I
and nivolumab
treatment of metastatic or advanced renal cell carcinoma using nivolumab GUAVNIV I
treatment of metastatic or advanced renal cell carcinoma using 4-weekly

nivolumab (cont'd) injectable Genitourinary GUAVNIV4 I
nivolumab
Palliative Therapy for Unresectable, Platinum-Refractory, Recurrent or

nivolumab injectable Head and Neck HNAVNIV I
Metastatic Squamous Cell Cancer of the Head and Neck using Nivolumab
Palliative Therapy for Unresectable, Platinum-Refractory, Recurrent or

nivolumab injectable Head and Neck Metastatic Squamous Cell Cancer of the Head and Neck using 4-Weekly HNAVNIV4 I
Nivolumab
nivolumab injectable Lung treatment of advanced non-small cell lung cancer using nivolumab LUAVNIV I
nivolumab injectable Lung LUAVNIV4 I
nivolumab
Lymphoma treatment of relapsed or refractory Hodgkin lymphoma using nivolumab LYNIV I
treatment of relapsed or refractory Hodgkin lymphoma using 4-weekly

Lymphoma LYNIV4 I
nivolumab
adjuvant treatment of resected stage III-IV NED melanoma using
nivolumab injectable Skin & Melanoma SMAJNIV I
nivolumab
* denotes change
Page 47 of 65
April 2022

FORM SITE CODES
adjuvant treatment of resected stage III-IV NED melanoma using 4-weekly
nivolumab (cont'd) injectable Skin & Melanoma SMAJNIV4 I
nivolumab
treatment of unresectable or metastatic melanoma using ipilimumab and
nivolumab injectable Skin & Melanoma SMAVIPNI I
nivolumab
nivolumab injectable Skin & Melanoma treatment of unresectable or metastatic melanoma using nivolumab SMAVNIV I
treatment of unresectable or metastatic melanoma using 4-weekly

nivolumab injectable Skin & Melanoma SMAVNIV4 I
nivolumab
treatment of previously untreated chronic lymphocytic leukemia using
obinutuzumab injectable Lymphoma LYOBCHLOR I
obinutuzumab in combination with chlorambucil
treatment of rituximab-refractory follicular lymphoma with obinutuzumab in
obinutuzumab injectable Lymphoma LYOBBEND I
combination with bendamustine
obinutuzumab injectable Lymphoma LYVENOB I
Small Lymphocytic Lymphoma using Venetoclax and Obinutuzumab
short acting
octreotide Neuro-Oncology treatment of growth hormone secreting pituitary adenoma CNNOS I
injectable
management of non-functional neuroendocrine tumours of the GI tract;
octreotide injectable Gastrointestinal symptomatic management of functional carcinoid and neuroendocrine GINOS I
tumours of the GI tract
long acting
octreotide Neuro-Oncology treatment of growth hormone secreting pituitary adenoma CNOCTLAR I
injectable
long acting
octreotide Gastrointestinal management of non-functional neuroendocrine tumours of the GI tract GINFOCLAR I
injectable
long acting symptomatic management of functional carcinoid and neuroendocrine
octreotide Gastrointestinal GIOCTLAR I
injectable tumors of the GI tract
Maintenance Treatment of Newly Diagnosed BRCA-Mutated Platinum
olaparib tablet Gynecology GOOVFOLAM I
Responsive Epithelial Ovarian Cancer using Olaparib
Note: capsule formulation not
Maintenance Treatment of Relapsed, BRCA-Mutated, Platinum Sensitive funded
olaparib tablet Gynecology GOOVOLAPM I
and Responsive Epithelial Ovarian Cancer using Olaparib
treatment of EGFR T790M mutation-positive advanced non-small cell lung

osimertinib tablet Lung LUAVOSI I
cancer with osimertinib
first-line treatment of EGFR mutation-positive advanced non-small cell
osimertinib tablet Lung LUAVOSIF I
lung cancer with osimertinib
oxaliplatin injectable Gastrointestinal GIAJCAPOX I
capecitabine
oxaliplatin (cont'd) injectable Gastrointestinal GIAJFFOX I
fluorouracil and folinic acid
adjuvant combination chemotherapy for node-positive colon cancer using
oxaliplatin injectable Gastrointestinal oxaliplatin and raltitrexed in patients intolerant to fluorouracil or GIAJRALOX I
capecitabine
Palliative Therapy of Metastatic Colorectal Cancer using Oxaliplatin and
oxaliplatin injectable Gastrointestinal GIAVRALOX I
oxaliplatin injectable Gastrointestinal GICAPOX I
oxaliplatin and capecitabine
oxaliplatin (cont'd) injectable Gastrointestinal GICOXB I
* denotes change
Page 48 of 65
April 2022

FORM SITE CODES

oxaliplatin (cont'd) injectable Gastrointestinal GIEFFOXRT I

oxaliplatin injectable Gastrointestinal GIFFOXB I

oxaliplatin injectable Gastrointestinal GIFFOXPAN I

oxaliplatin (cont'd) injectable Gastrointestinal adenocarcinoma using irinotecan, oxaliplatin, fluorouracil and folinic acid GIFIRINOX I
(leucovorin)
palliative combination chemotherapy for metastatic colorectal cancer with
oxaliplatin (cont'd) injectable Gastrointestinal GIFOLFOX I
fluorouracil and folinic acid
oxaliplatin (cont'd) injectable Gastrointestinal negative) or ineligible for adjuvant chemoradiation using oxaliplatin and GIGAJCOX I
capecitabine
oxaliplatin injectable Gastrointestinal negative) or ineligible for adjuvant chemoradiation using oxaliplatin, GIGAJFFOX I
oxaliplatin injectable Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Capecitabine GIGAVCOX I
and Oxaliplatin
oxaliplatin injectable Gastrointestinal gastroesophageal junction, or esophageal adenocarcinoma using GIGAVCOXT I
oxaliplatin (cont'd) injectable Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Oxaliplatin, GIGAVFFOX I
oxaliplatin injectable Gastrointestinal gastric, gastroesophageal junction, or esophageal adenocarcinoma using GIGAVFFOXT I
oxaliplatin injectable Gastrointestinal gastroesophageal junction or lower 1/3 esophagus using docetaxel, GIGFLODOC I
oxaliplatin (cont'd) injectable Gastrointestinal peritoneal carcinomatosis from limited advanced colorectal and GIHIPEC I
oxaliplatin (cont'd) injectable Gastrointestinal GIPAJFIROX I
oxaliplatin (cont'd) injectable Gastrointestinal GIPAVFFOX I
oxaliplatin injectable Gastrointestinal GIRAJCOX I
Cancer using Oxaliplatin and Capecitabine
oxaliplatin injectable Gastrointestinal GIRAJFFOX I
Treatment of Newly Diagnosed or Relapsed/Refractory Natural Killer or T-

oxaliplatin (cont'd) injectable Lymphoma LYGEMOXPEG* I
Cell Lymphoma using Gemcitabine, Oxaliplatin and Pegaspargase
* denotes change
Page 49 of 65
April 2022

FORM SITE CODES
paclitaxel injectable Breast BRAJACT I

paclitaxel injectable Breast BRAJACTG I

paclitaxel (cont'd) injectable Breast BRAJACTT I

paclitaxel (cont'd) injectable Breast therapy: doxorubicin and cyclophosphamide followed by paclitaxel and BRAJACTTG I
trastuzumab
paclitaxel (cont'd) injectable Breast BRAJACTW I
adjuvant therapy for breast cancer using weekly paclitaxel and
paclitaxel injectable Breast BRAJTTW I
trastuzumab
paclitaxel injectable Breast treatment of metastatic breast cancer using gemcitabine and paclitaxel BRAVGEMT I

paclitaxel (cont'd) injectable Breast trastuzumab (Herceptin®), and paclitaxel as first-line treatment for BRAVPTRAT I
paclitaxel (cont'd) injectable Breast palliative therapy for metastatic breast cancer using paclitaxel BRAVTAX I
palliative therapy for metastatic breast cancer using weekly paclitaxel

paclitaxel injectable Breast BRAVTW I
(given weekly for 3 weeks out of 4 weeks) (replaces BRAVT7)

paclitaxel (cont'd) injectable Breast BRLACTWAC I

paclitaxel (cont'd) injectable Breast Dense Therapy: Carboplatin and Weekly Paclitaxel Followed by BRLACTWACG I

paclitaxel (cont'd) injectable Breast BRLATACG I

paclitaxel injectable Breast BRLATWAC I
First-Line Palliative Treatment of Metastatic Anal Squamous Cell
paclitaxel (cont'd) injectable Gastrointestinal GIAAVCT I
Carcinoma using Carboplatin and Weekly Paclitaxel
neoadjuvant treatment of esophageal and gastroesophageal carcinomas
paclitaxel (cont'd) injectable Gastrointestinal GIENACTRT I
using carboplatin, paclitaxel and radiation therapy
second-line therapy for metastatic or locally advanced gastric or
paclitaxel (cont'd) injectable Gastrointestinal gastroesophageal junction cancer using weekly paclitaxel and GIGAVRAMT I
ramucirumab

paclitaxel (cont'd) injectable Gastrointestinal GIPMHIPEC I
* denotes change
Page 50 of 65
April 2022

FORM SITE CODES
alternative treatment of gynecological malignancies using cisplatin and
paclitaxel (cont'd) injectable Gynecology GOCISP I
paclitaxel
Alternative Treatment of Gynecological Malignancies using Bevacizumab,
paclitaxel (cont'd) injectable Gynecology GOCISPBEV I
Cisplatin and Paclitaxel
combination with carboplatin as primary treatment of advanced/recurrent

paclitaxel (cont'd) injectable Gynecology GOCXCAT I
non-small cell cancer of the cervix in ambulatory care settings
paclitaxel (cont'd) injectable Gynecology primarily advanced or recurrent endometrial cancer GOENDCAT I
paclitaxel (cont'd) injectable Gynecology peritoneal cancer with high risk of relapse using bevacizumab, carboplatin GOOVCATB I
and paclitaxel

paclitaxel (cont'd) injectable Gynecology GOOVCATM I
peritoneal cancer, with no visible residual tumour (moderate-high risk)
ovarian cancer relapsing after complete remission of at least 4 months’

paclitaxel (cont'd) injectable Gynecology GOOVCATR I
duration in response to primary treatment with carboplatin and paclitaxel
primary treatment of visible residual (extreme risk) invasive epithelial

paclitaxel (cont'd) injectable Gynecology GOOVCATX I
ovarian cancer
primary treatment of metastatic/recurrent cancer of the cervix with
paclitaxel (cont'd) injectable Gynecology GOCXCATB I
bevacizumab, carboplatin and paclitaxel
paclitaxel (cont'd) injectable Gynecology GOOVBEVP R
and paclitaxel
primary treatment of advanced epithelial ovarian, primary peritoneal, or

paclitaxel (cont'd) injectable Gynecology GOOVDDCAT I
fallopian tube carcinoma using carboplatin and weekly paclitaxel
primary treatment of stage III less than or equal to 1 cm visible residual

paclitaxel (cont'd) injectable Gynecology invasive epithelial ovarian cancer using intravenous and intraperitoneal GOOVIPPC I
paclitaxel and intraperitoneal carboplatin
progressive, platinum-refractory ovarian carcinoma, primary peritoneal
paclitaxel (cont'd) injectable Gynecology GOOVTAX3 I
carcinoma or fallopian tube carcinoma
paclitaxel (cont'd) injectable Genitourinary palliative therapy for germ cell cancers using paclitaxel and gemcitabine GUTAXGEM I
paclitaxel (cont'd) injectable Genitourinary GUTIP I
paclitaxel (cont'd) injectable Head and Neck squamous cell carcinoma of the head and neck using paclitaxel and HNAVPC I

paclitaxel (cont'd) injectable Head and Neck UHNAVPCPMB R
treatment of recurrent or metastatic nasopharyngeal carcinoma with

paclitaxel (cont'd) injectable Head and Neck HNNAVPC I
* denotes change
Page 51 of 65
April 2022

FORM SITE CODES
adjuvant carboplatin and paclitaxel following resection of stage I, II and
paclitaxel (cont'd) injectable Lung LUAJPC I
IIIA non-small cell lung cancer
combination with carboplatin as first line treatment of advanced non-small
paclitaxel (cont'd) injectable Lung LUAVPC I
cell lung cancer
paclitaxel (cont'd) injectable Lung LUAVPCPMB I
treatment of locally advanced non-small cell lung cancer using carboplatin
paclitaxel (cont'd) injectable Lung LULACATRT I
and paclitaxel with radiation therapy
primary treatment of cancer of unknown primary origin using carboplatin
paclitaxel (cont'd) injectable Primary Unknown PUCAT I
and paclitaxel
treatment of recurrent or resistant pediatric malignant germ cell tumors

paclitaxel (cont'd) injectable Pediatric I
with paclitaxel, ifosfamide and carboplatin (COG protocol AGCT0521)
Metastatic or Unresectable Angiosarcoma using Weekly Paclitaxel (3

paclitaxel (cont'd) injectable Sarcoma SAAVTW I
Weeks out of 4 Weeks Schedule)
paclitaxel NAB Palliative Therapy for Metastatic Breast Cancer using PACLitaxel NAB
injectable Breast BRAVABR I
(ABRAXANE) (ABRAXANE)
paclitaxel NAB First Line Treatment of Locally Advanced and Metastatic Pancreatic
injectable Gastrointestinal GIPGEMABR I
(ABRAXANE) Cancer with PACLitaxel NAB (ABRAXANE) and Gemcitabine
paclitaxel NAB Alternative Treatment of Gynecological Malignancies Using CARBOplatin
injectable Gynecology GOCABR I
(ABRAXANE) and PACLitaxel NAB (ABRAXANE)
paclitaxel NAB Alternative Treatment of Gynecological Malignancies Using Bevacizumab,
injectable Gynecology GOCABRBEV I
(ABRAXANE) CARBOplatin and PACLitaxel NAB (ABRAXANE)
Therapy of Advanced Breast Cancer using Palbociclib and Aromatase
palbociclib capsule Breast BRAVPALAI I
Inhibitor with or without LHRH Agonist
palbociclib capsule Breast BRAVPBFLV I
adjuvant therapy for breast cancer in post-menopausal women using
pamidronate injectable Breast BRAJPAM I
pamidronate
bony metastases associated with breast cancer for patients who do not
pamidronate injectable Breast BRAVCLOD I
tolerate oral clodronate Not reimbursed for hypercalcemia
prevention of skeletal related events secondary to breast cancer using
pamidronate injectable Breast BRAVPAM I
pamidronate
pamidronate injectable Myeloma multiple myeloma MYPAM I
palliative third-line treatment of metastatic colorectal cancer using
panitumumab injectable Gastrointestinal GIAVPANI I
panitumumab with wild type KRAS

panitumumab injectable Gastrointestinal GIFFIRPAN I

panitumumab injectable Gastrointestinal GIFFOXPAN I
pazopanib tablet Genitourinary palliative therapy for renal cell carcinoma using pazopanib GUPAZO I
* denotes change
Page 52 of 65
April 2022

FORM SITE CODES
pegaspargase treatment of refractory or relapsing extranodal natural killer or T-Cell
injectable Lymphoma LYASPMEDEX I
(ONCASPAR®) lymphoma using pegaspargase, methotrexate and dexamethasone
pegaspargase Treatment of Newly Diagnosed or Relapsed/Refractory Natural Killer or T-

injectable Lymphoma LYGEMOXPEG* I
(ONCASPAR®) Cell Lymphoma using Gemcitabine, Oxaliplatin and Pegaspargase
pegaspargase treatment of natural killer or T-Cell Lymphoma using dexamethasone,

injectable Lymphoma LYSMILE I
(ONCASPAR®) methotrexate, ifosfamide, pegaspargase and etoposide
pegaspargase treatment of acute lymphoblastic leukemia and lymphoblastic lymphoma
injectable Lymphoma LKNOS, LYNOS I
(ONCASPAR®) using pegaspargase (ONCOSPAR)
pegaspargase
injectable Pediatric pediatric patients with leukemia or lymphoma I
(ONCASPAR®) (cont'd)
peginterferon alfa-2a injectable Leukemia & BMT therapy of chronic myeloid neoplasms and hypereosinophilic syndrome LKPEGIFN I
First-Line Treatment of dMMR/MSI-H Metastatic Colorectal Cancer using

pembrolizumab injectable Gastrointestinal UGIAVPEM R
Pembrolizumab
First-Line Treatment of dMMR/MSI-H Metastatic Colorectal Cancer using
pembrolizumab injectable Gastrointestinal UGIAVPEM6 R
6-Weekly Pembrolizumab
treatment of locally advanced or metastatic urothelial carcinoma using
pembrolizumab injectable Genitourinary GUAVPEM I
pembrolizumab
treatment of locally advanced or metastatic urothelial carcinoma using 6-
pembrolizumab injectable Genitourinary GUAVPEM6 I
weekly pembrolizumab
Treatment of Metastatic Renal Cell Carcinoma Using Pembrolizumab and
pembrolizumab injectable Genitourinary GUAVPEMAX I
Axitinib
pembrolizumab injectable Head and Neck UHNAVPCPMB R
pembrolizumab injectable Head and Neck UHNAVPFPMB R
pembrolizumab injectable Head and Neck UHNAVPMBF R
and Neck with Pembrolizumab
pembrolizumab injectable Head and Neck UHNAVPMBF6 R
and Neck using 6-Weekly Pembrolizumab
Maintenance Treatment of Advanced Squamous Cell Carcinoma of the
pembrolizumab injectable Head and Neck HNAVPMBM I
Head and Neck with Pembrolizumab
Maintenance Treatment of Advanced Squamous Cell Carcinoma of the
pembrolizumab injectable Head and Neck HNAVPMBM6 I
Head and Neck using 6-Weekly Pembrolizumab
pembrolizumab injectable Lung LUAVPCPMB I
pembrolizumab injectable Lung LUAVPGPMB I
second-line treatment of advanced non-small cell lung cancer using
pembrolizumab injectable Lung LUAVPMB I
pembrolizumab
pembrolizumab injectable Lung LUAVPMB6 I
pembrolizumab
first-line treatment of advanced non-small cell lung cancer using
pembrolizumab injectable Lung LUAVPMBF I
pembrolizumab
first-line treatment of advanced non-small cell lung cancer using 6-weekly
pembrolizumab injectable Lung LUAVPMBF6 I
pembrolizumab
maintenance therapy of advanced non-small cell lung cancer with
pembrolizumab injectable Lung LUAVPMBM I
pembrolizumab
maintenance therapy of advanced non-small cell lung cancer with 6-
pembrolizumab injectable Lung LUAVPMBM6 I
maintenance therapy of advanced non-squamous non-small cell lung
pembrolizumab injectable Lung LUAVPPMBM I
cancer with pemetrexed and pembrolizumab
pembrolizumab injectable Lung LUAVPPPMB I
treatment of relapsed or refractory hodgkin lymphoma using
pembrolizumab injectable Lymphoma LYPEM I
pembrolizumab
* denotes change
Page 53 of 65
April 2022

FORM SITE CODES
treatment of relapsed or refractory hodgkin lymphoma using 6-weekly
pembrolizumab (cont'd) injectable Lymphoma LYPEM6 I
pembrolizumab
adjuvant treatment of resected stage III – IV NED melanoma using
pembrolizumab injectable Skin & Melanoma SMAJPEM I
pembrolizumab
adjuvant treatment of resected stage III – IV NED melanoma using 6-
pembrolizumab injectable Skin & Melanoma SMAJPEM6 I
pembrolizumab (cont'd) injectable Skin & Melanoma treatment of unresectable or metastatic melanoma using pembrolizumab SMAVPEM I
treatment of unresectable or metastatic melanoma using 6-weekly

pembrolizumab (cont'd) injectable Skin & Melanoma SMAVPEM6 I
pembrolizumab
Adjuvant Cisplatin and Pemetrexed Following Resection of Non-Small Cell
pemetrexed injectable Lung LUAJPP I
Lung Cance
pemetrexed injectable Lung second-line treatment of advanced non-small cell lung cancer LUAVPEM I
maintenance therapy of advanced non-small cell lung cancer after first-line
pemetrexed injectable Lung LUAVPMTN I
chemotherapy
pemetrexed injectable Lung LUAVPP I
and pemetrexed
maintenance therapy of advanced non-squamous non-small cell lung
pemetrexed injectable Lung LUAVPPMBM I
cancer with pemetrexed and pembrolizumab
pemetrexed injectable Lung LUAVPPPMB I
pemetrexed (cont'd) injectable Lung treatment of malignant mesothelioma with platinum and pemetrexed LUMMPP I

pertuzumab injectable Breast trastuzumab (Herceptin®) and docetaxel as first-line treatment for BRAVPTRAD I
pertuzumab (cont'd) injectable Breast trastuzumab (Herceptin®), and paclitaxel as first-line treatment for BRAVPTRAT I
plerixafor injectable hematopoietic stem cell mobilization PLERIXAFOR I
Treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma and
polatuzumab vedotin injectable Lymphoma Not Eligible for Transplant using Polatuzumab Vedotin, Bendamustine and LYPOLABR* I
Rituximab
pomalidomide capsule Myeloma therapy of multiple myeloma using pomalidomide with dexamethasone UMYPOMDEX R
treatment of chronic myeloid leukemia and Ph+ acute lymphoblastic

ponatinib tablet Leukemia & BMT ULKCMLP R
leukemia using ponatinib
treatment of relapsed or refractory Peripheral T-Cell lymphoma (PTCL)
pralatrexate injectable Lymphoma ULYPRA R
with pralatrexate
prednisolone suspension Pediatric pediatric patients I
palliative therapy for metastatic castration resistant prostate cancer sing
prednisone tablet Genitourinary GUPCABA I
cabazitaxel and prednisone
UGUMCSPABI R
prednisone (cont'd) tablet Genitourinary UGUPABI R
prednisone tablet Genitourinary palliative therapy for metastatic hormone refractory prostate cancer GUPDOC I
palliative therapy for hormone-refractory prostate cancer using

prednisone (cont'd) tablet Genitourinary GUPMX I
mitoxantrone and prednisone
prednisone tablet Lymphoma LYCHOP I
and prednisone
prednisone (cont'd) tablet Lymphoma LYCHOPR I
* denotes change
Page 54 of 65
April 2022

FORM SITE CODES
prednisone (cont'd) tablet Lymphoma LYCHOPRMTX I
prednisone (cont'd) tablet Lymphoma doxorubicin, cyclophosphamide, prednisone (CHP) and brentuximab LYCHPBV I
vedotin
prednisone tablet Lymphoma LYCLLCVPR I
prednisone (cont'd) tablet Lymphoma LYCVP I
prednisone
prednisone (cont'd) tablet Lymphoma LYCVPPABO I
prednisone tablet Lymphoma LYCVPR I
therapy of lymphoma, Hodgkin's disease, chronic lymphocytic leukemia or
prednisone tablet Lymphoma LYCYCLO I
multiple myeloma using cyclophosphamide
prednisone (cont'd) tablet Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
methotrexate
prednisone (cont'd) tablet Lymphoma lymphoma palliative chemotherapy LYPALL I
prednisone (cont'd) tablet Myeloma UMYBLDF R
Multiple Myeloma

prednisone (cont'd) tablet Myeloma MYBORPRE I

prednisone (cont'd) tablet Myeloma MYBORREL I
prednisone (cont'd) tablet Myeloma in combination with bortezomib and dexamethasone with or without UMYDARBD R
cyclophosphamide

prednisone (cont'd) tablet Myeloma UMYDARLD R
prednisone (cont'd) tablet Myeloma treatment of multiple myeloma using melphalan and prednisone MYMP I
prednisone (cont'd) tablet Myeloma bortezomib with the option of substituting cyclophosphamide for MYMPBOR I
melphalan
Other tumour site

Not Otherwise
prednisone (cont'd) tablet code followed by I
Specified
* denotes change
Page 55 of 65
April 2022

FORM SITE CODES
procarbazine capsule Neuro-Oncology CNMODPCV I
procarbazine capsule Neuro-Oncology standard procarbazine for second-line treatment of recurrent brain tumor CNPROC I

procarbazine (cont'd) capsule Lymphoma LYCVPPABO I
procarbazine capsule Lymphoma lymphoma palliative chemotherapy LYPALL I
Other tumour site

Not Otherwise
procarbazine (cont'd) capsule code followed by I
Specified
‘NOS’ (e.g. CNNOS)
radiotherapy for metastatic castration resistant prostate cancer using radium-
radium-223 Genitourinary GUPRAD I
pharmaceutical 223
adjuvant combination chemotherapy for node-positive colon cancer using
raltitrexed injectable Gastrointestinal oxaliplatin and raltitrexed in patients intolerant to fluorouracil or GIAJRALOX I
capecitabine
Palliative Therapy of Metastatic Colorectal Cancer using Irinotecan and
GIAVRALIR I
Palliative Therapy of Metastatic Colorectal Cancer using Oxaliplatin and
GIAVRALOX I
unresectable or metastatic colorectal adenocarcinoma for patients with
raltitrexed injectable Gastrointestinal GIRALT I
previous fluorouracil toxicity
second-line therapy for metastatic or locally advanced gastric or
ramucirumab injectable Gastrointestinal gastroesophageal junction cancer using weekly paclitaxel and GIGAVRAMT I
ramucirumab
third line treatment of advanced gastrointestinal stromal cell tumours
regorafenib tablet Sarcoma SAAVGR I
(GIST's) using regorafenib
regorafenib tablet Gastrointestinal treatment of advanced hepatocellular carcinoma using regorafenib GIREGO I

ribociclib tablet Breast BRAVRBFLV I
Therapy of Advanced Breast Cancer using Ribociclib and Aromatase
ribociclib tablet Breast BRAVRIBAI I
Inhibitor with or without LHRH Agonist
* denotes change
Page 56 of 65
April 2022

FORM SITE CODES
IV injectable pre-emptive rituximab therapy of Epstein-Barr virus related post-transplant
rituximab Leukemia & BMT BMTLPDRIT I
only lymphoproliferative disease
IV / 1400 mg SC
rituximab Lymphoma treatment of Non-Hodgkin Lymphoma with bendamustine and rituximab LYBENDR I
injectable
IV / 1400 mg SC
rituximab Lymphoma treatment of indolent B-cell lymphoma with chlorambucil and rituximab LYCHLRR I
injectable
in combination with CHOP (cyclophosphamide, doxorubicin, prednisone,

IV / 1400 mg SC
rituximab (cont'd) Lymphoma vincristine), in all stages of newly diagnosed diffuse large B-cell lymphoma LYCHOPR I
injectable
and mantle cell lymphoma, advanced stage at diagnosis
Note: Biosimilar rituximab
IV / 1400 mg SC central nervous system prophylaxis with high dose methotrexate, CHOP (RIXIMYO®, RUXIENCE®) is
rituximab Lymphoma LYCHOPRMTX I
injectable and rituximab in diffuse large B-cell lymphoma funded for intravenous rituximab
IV / 1600 mg SC treatment of relapsed/refractory chronic lymphocytic leukemia or small started on or after August 1st,
rituximab Lymphoma LYCLLBENDR I
injectable lymphocytic lymphoma with bendamustine and rituximab 2020. RITUXAN® is funded for
IV / 1600 mg SC intravenous rituximab started prior
rituximab Lymphoma treatment of chronic lymphocytic leukemia with chlorambucil and rituximab LYCLLCHLR I
injectable to and continue beyond August
IV / 1600 mg SC treatment of relapsed chronic lymphocytic leukemia using 1st, 2020.
rituximab Lymphoma LYCLLCVPR I
injectable cyclophosphamide, vincristine, prednisone and rituximab
IV / 1600 mg SC treatment of previously untreated chronic lymphocytic leukemia (CLL) with
LYCLLFBR I
injectable bendamustine and rituximab
IV / 1600 mg SC treatment of chronic lymphocytic leukemia or prolymphocytic leukemia with
rituximab (cont'd) Lymphoma LYCLLFLUDR I
injectable fludarabine and rituximab
IV / 1400 mg SC treatment of Burkitt’s lymphoma and leukemia with cyclophosphamide,

rituximab (cont'd) Lymphoma LYCODOXMR I
injectable vincristine, doxorubicin, methotrexate, leucovorin and rituximab
IV / 1400 mg SC
rituximab (cont'd) Lymphoma combination with CVP for advanced stage indolent lymphoma at diagnosis LYCVPR I
injectable
* denotes change
Page 57 of 65
April 2022

FORM SITE CODES
IV / 1400 mg SC
rituximab (cont'd) Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
injectable
methotrexate
IV / 1600 mg SC treatment of chronic lymphocytic leukemia (CLL) or prolymphocytic

rituximab (cont'd) Lymphoma LYFCR I
injectable leukemia with fludarabine, cyclophosphamide and rituximab
IV / 1400 mg SC
rituximab Lymphoma treatment of relapsed indolent lymphoma with fludarabine and rituximab LYFLUDR I
injectable
IV / 1400 mg SC treatment of lymphoma with gemcitabine, dexamethasone and platinum
rituximab (cont'd) Lymphoma LYGDPR I
injectable with rituximab
IV / 1400 mg SC Treatment of Primary and Secondary CNS Lymphoma with High-Dose
rituximab (cont'd) Lymphoma LYHDMRTEM I
injectable Methotrexate, Rituximab and Temozolomide
IV / 1600 mg SC treatment of relapsed/refractory chronic lymphocytic leukemia or small
rituximab (cont'd) Lymphoma LYIDELAR I
injectable lymphocytic lymphoma using idelalisib and rituximab
IV / 1400 mg SC treatment of Burkitt’s lymphoma and leukemia with ifosfamide, mesna, Note: Biosimilar rituximab
rituximab (cont'd) Lymphoma LYIVACR I
injectable etoposide, cytarabine and rituximab (RIXIMYO®, RUXIENCE®) is
Treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma and funded for intravenous rituximab
IV / 1400 mg SC started on or after August 1st,
rituximab (cont'd) Lymphoma Not Eligible for Transplant using Polatuzumab Vedotin, Bendamustine and LYPOLABR* I
injectable 2020. RITUXAN® is funded for
Rituximab
intravenous rituximab started prior
IV / 1400 mg SC treatment of relapsed or refractory advanced stage aggressive B-cell non- to and continue beyond August
rituximab (cont'd) Lymphoma LYRICE I
injectable Hodgkin’s lymphoma with ifosfamide, carboplatin, etoposide and rituximab 1st, 2020.
follicular lymphoma progressive despite alkylating agents and purine
IV / 1400 mg SC analogues (fludarabine or cladribine), post-transplant lymphoproliferative
rituximab (cont'd) Lymphoma LYRITUX I
injectable disease, or newly diagnosed (within 6 months) asymptomatic advanced
follicular lymphoma
IV injectable palliative therapy for lymphoma using radioimmunotherapy: rituximab-
Lymphoma LYRITZ I
only priming for ibritumomab 90Y (ZEVALIN®)
IV / 1400 mg SC
rituximab (cont'd) Lymphoma maintenance treatment of indolent lymphoma LYRMTN I
injectable
IV / 1600 mg SC treatment of relapsed/refractory chronic lymphocytic leukemia or small
rituximab (cont'd) Lymphoma LYVENETOR I
injectable lymphocytic lymphoma using venetoclax and rituximab
pediatric patients treated on the COG protocols ANHL0221 for CD20
IV injectable positive post-transplant lymphoproliferative disease following solid organ
Pediatric I
only transplantation and ANHL01P1 for newly diagnosed advanced B-cell
leukemia/lymphoma
treatment of relapsed or refractory Peripheral T-Cell lymphoma (PTCL)
romidepsin injectable Lymphoma ULYROMI R
with romidepsin
ruxolitinib tablet Leukemia & BMT treatment of symptomatic myelofibrosis with ruxolitinib ULKMFRUX R
ruxolitinib tablet Leukemia & BMT treatment of polycythemia vera with ruxolitinib ULKPCVRUX R
* denotes change
Page 58 of 65
April 2022

FORM SITE CODES
pediatric patients with neuroblastoma treated on the COG ANBL0032
sargramostim (SAP) injectable Pediatric I
protocol
pediatric patients with relapsed neuroblastoma treated on the COG
sargramostim injectable Pediatric I Approval from Health Canada
ANBL1021 protocol
Special Access Programme is
treatment of pediatric patients with high-risk neuroblastoma who achieve a required for each patient
sargramostim injectable Pediatric response to prior first-line multi-agent, multimodal therapy using R
treatment of Multicentric Castleman’s Disease (MCD) negative for Human

siltuximab injectable Lymphoma Immunodeficiency Virus (HIV) and Human Herpes Virus-8 (HHV-8) Using LYSILTUX I
siltuximab
sorafenib tablet Gastrointestinal Therapy for Advanced Hepatocellular Carcinoma using Sorafenib GISORAF I
sorafenib tablet Genitourinary palliative therapy for renal cell carcinoma in patients after cytokine failure GUSORAF I
sorafenib tablet Leukemia & BMT therapy of acute myeloid leukemia using azacitidine and sorafenib LKAMLAS I
streptozocin injectable Gastrointestinal GIENDO2 I
doxorubicin Approval from Health Canada
Other tumour site Special Access Programme is
Not Otherwise required for each patient
streptozocin injectable code followed by I
Specified
‘NOS’ (e.g. GINOS)
sunitinib capsule Gastrointestinal as palliative treatment of advance pancreatic neuroendocrine tumours GIPNSUNI I
palliative therapy for renal cell carcinoma in patients who are not suitable
sunitinib capsule Genitourinary GUSUNI I
candidates for interferon
second line treatment of advanced c-kit positive gastrointestinal stromal
sunitinib (cont'd) capsule Sarcoma SAAVGS I
cell tumours (GIST's) after imatinib
neoadjuvant or adjuvant therapy for breast cancer using a LHRH agonist
tamoxifen tablet Breast BRAJLHRHT I
and tamoxifen
tamoxifen tablet Breast neoadjuvant or adjuvant therapy for breast cancer using tamoxifen BRAJTAM I
tamoxifen (cont'd) tablet Breast palliative therapy for breast cancer using a LHRH agonist and tamoxifen BRAVLHRHT I
tamoxifen tablet Breast palliative therapy for breast cancer BRAVTAM I

endometrial cancernon-aromatase inhibitor hormonal treatment of
tamoxifen tablet Gynecology GOENDH I
endometrial cancer
tamoxifen tablet Gynecology therapy for advanced ovarian cancer using tamoxifen GOOVTAM I
tamoxifen (cont'd) tablet Head and Neck treatment of recurrent/metastatic salivary gland cancers HNSAVTAM I
tamoxifen tablet Sarcoma recurrent desmoid tumors/aggressive fibromatosis SATAM I
* denotes change
Page 59 of 65
April 2022

FORM SITE CODES
concomitant (dual modality) and 12 cycles of adjuvant temozolomide for

temozolomide capsule Neuro-Oncology CNAJ12TZRT I
newly diagnosed astrocytomas and oligodendrogliomas with radiation
concomitant and adjuvant temozolomide for newly diagnosed malignant

temozolomide capsule Neuro-Oncology CNAJTZRT I
gliomas with radiation
treatment of elderly newly diagnosed glioma patient with concurrent and
temozolomide capsule Neuro-Oncology CNELTZRT I
adjuvant temozolomide and radiation therapy
therapy for newly diagnosed malignant brain tumours with MGMT
temozolomide capsule Neuro-Oncology CNTEM60 I
methylation in elderly patients using temozolomide
temozolomide capsule Neuro-Oncology therapy for malignant brain tumours CNTEMOZ I
therapy for malignant brain tumours using metronomic dosing of
temozolomide (cont'd) capsule Neuro-Oncology CNTEMOZMD I
temozolomide
therapy for recurrent malignant brain tumours using temozolomide and
temozolomide (cont'd) capsule Neuro-Oncology CNTMZETO I
etoposide
palliative therapy of metastatic neuroendocrine cancer using
temozolomide (cont'd) capsule Gastrointestinal GIAVTZCAP I
temozolomide and capecitabine
temozolomide (cont'd) capsule Lymphoma LYHDMRTEM I
temozolomide (cont'd) capsule Pediatric pediatric patients with brain tumours I
pediatric patients treated on the COG protocol ANBL0421 for recurrent
temozolomide capsule Pediatric I
neuroblastoma
temozolomide (cont'd) capsule Pediatric I
ARST08P1 protocol
therapy for advanced solitary fibrous tumours and hemangiopericytoma
temozolomide (cont'd) capsule Sarcoma SATEMBEV I
using temozolomide and bevacizumab
temozolomide (cont'd) capsule Skin & Melanoma palliative therapy for malignant melanoma with brain metastases SMAVTMZ I
temsirolimus injectable Genitourinary therapy for advanced renal cancer using temsirolimus GUTEM I
temsirolimus injectable Pediatric with cyclophosphamide, vinorelbine and temsirolimus on the COG I
ARST0921 protocol
Tumour site code
Not Otherwise
teniposide injectable followed by ‘NOS’ I
Specified
(e.g. GUNOS)
Not reimbursed for symptom
testosterone enanthate injectable Breast palliative therapy for metastatic breast cancer BRAVTEST I management or appetite
stimulation
Tumour site code
Not Otherwise
thioguanine tablet followed by ‘NOS’ I
Specified
(e.g. LYNOS)
* denotes change
Page 60 of 65
April 2022

FORM SITE CODES

thiotepa injectable Miscellaneous Origins MOIT I
and/or cytarabine
Other tumour site

Not Otherwise
thiotepa (cont'd) injectable code followed by I
Specified
thyrotropin alfa injectable Head and Neck radioiodine imaging in patients with thyroid cancer and treatment HNOTTSH I
treatment of relapsed/progressive epithelial ovarian, fallopian tube or
topotecan injectable Gynecology GOOVTOP I
primary peritoneal cancer using topotecan
topotecan (cont'd) injectable Lung second line treatment of recurrent small cell lung cancer LUSCTOP I
topotecan (cont'd) injectable Pediatric pediatric sarcoma I
intermediate-risk (COG ANBL0532) and high risk (COG ANBL0531)
topotecan injectable Pediatric I
pediatric neuroblastoma
summary for treatment of recurrent/refractory neuroblastoma, ewing’s
topotecan injectable Sarcoma sarcoma, osteogenic sarcoma or rhabdomyosarcoma with SAAVTC I
topotecan/cyclophosphamide
adjuvant treatment of stage III and IV, BRAF-mutated, fully resected
trametinib tablet Skin & Melanoma SMAJDT I
trametinib tablet Skin & Melanoma SMAVDT I
trametinib tablet Skin & Melanoma SMAVTRA I
melanoma using trametinib
trastuzumab injectable Breast BRAJACTT I
trastuzumab therapy: doxorubicin and cyclophosphamide followed by paclitaxel and BRAJACTTG I
trastuzumab Note: Biosimilar trastuzumab
neoadjuvant or adjuvant therapy for breast cancer using carboplatin, (HERZUMA®, TRAZIMERA®) is
trastuzumab (cont'd) Injectable Breast BRAJDCARBT I
docetaxel and trastuzumab funded for treatment started on or
after February 1st, 2020, except
neoadjuvant or adjuvant therapy for breast cancer using fluorouracil, HERCEPTIN® continues to be
trastuzumab Injectable Breast BRAJFECDT I
epirubicin and cyclophosphamide followed by docetaxel and trastuzumab funded when trastuzumab is used
neoadjuvant or adjuvant therapy for breast cancer using trastuzumab, with pertuzumab for advanced
trastuzumab Injectable Breast BRAJTDC I breast cancer (BRAVPTRAD,
BRAVPTRAT). HERCEPTIN® is
Adjuvant Therapy for Breast Cancer using Trastuzumab Following the
trastuzumab Injectable Breast BRAJTR I funded for treatment started prior
Completion of Chemotherapy (Sequential)
to February 1st, 2020.
adjuvant therapy for breast cancer using weekly paclitaxel and
trastuzumab injectable Breast BRAJTTW I
trastuzumab
trastuzumab injectable Breast trastuzumab (Herceptin®) and docetaxel as first-line treatment for BRAVPTRAD I
* denotes change
Page 61 of 65
April 2022

FORM SITE CODES
trastuzumab (cont'd) injectable Breast trastuzumab (Herceptin®), and paclitaxel as first-line treatment for BRAVPTRAT I
palliative therapy for metastatic breast cancer using trastuzumab and
trastuzumab injectable Breast BRAVTCAP I
capecitabine
single agent therapy for metastatic breast cancer progressing after 1 prior
trastuzumab injectable Breast regimens (e.g., taxane) and responding to trastuzumab in combination BRAVTR I
with paclitaxel, with paclitaxel and carboplatin, or with vinorelbine
combination with 3-weekly vinorelbine as palliative therapy for metastatic Note: Biosimilar trastuzumab
trastuzumab (cont'd) Injectable Breast BRAVTRVIN I (HERZUMA®, TRAZIMERA®) is
breast cancer
funded for treatment started on or
trastuzumab (cont'd) Injectable Breast BRLAACDT I after February 1st, 2020, except
HERCEPTIN® continues to be
Palliative Treatment of Metastatic or Locally Advanced Gastric, funded when trastuzumab is used
trastuzumab (cont'd) Injectable Gastrointestinal Gastroesophageal Junction or Esophageal Adenocarcinoma using GIGAVCCT I with pertuzumab for advanced
Cisplatin, Capecitabine and Trastuzumab breast cancer (BRAVPTRAD,
palliative treatment of metastatic or inoperable, locally advanced gastric or BRAVPTRAT). HERCEPTIN® is
trastuzumab (cont'd) Injectable Gastrointestinal gastroesophageal junction adenocarcinoma using cisplatin, infusional GIGAVCFT I funded for treatment started prior
fluorouracil and trastuzumab to February 1st, 2020.
trastuzumab (cont'd) Injectable Gastrointestinal gastroesophageal junction, or esophageal adenocarcinoma using GIGAVCOXT I
trastuzumab (cont'd) Injectable Gastrointestinal Gastroesophageal Junction or Esophageal Carcinoma using Oxaliplatin, GIGAVFFOXT I
continuation of palliative treatment of metastatic or inoperable, locally
trastuzumab (cont'd) injectable Gastrointestinal advanced gastric or gastroesophageal junction adenocarcinoma using GIGAVTR I
trastuzumab
trastuzumab emtansine adjuvant therapy for breast cancer using trastuzumab emtansine
injectable Breast UBRAJKAD R
(KADCYLA) (KADCYLA)
trastuzumab emtansine palliative therapy for metastatic breast cancer using trastuzumab
injectable Breast BRAVKAD I
(KADCYLA) emtansine (KADCYLA)
treosulfan injectable Leukemia & BMT BMTNOS I
pre-conditioning therapy with treosulfan for pediatric patients at risk for
treosulfan (SAP) injectable Pediatric busulfan-related toxicity prior to hematopoietic stem cell transplantation for R
malignant conditions
tretinoin (VESANOID®) capsule Leukemia & BMT acute promyelocytic leukemia LKNOS I
tretinoin (VESANOID®) first-line induction and consolidation therapy of acute promyelocytic
capsule Leukemia & BMT LKATOATRA I
(cont'd) leukemia using arsenic trioxide and tretinoin
tretinoin (VESANOID®) capsule Leukemia & BMT LKATOP I
induction and consolidation therapy of relapsed acute promyelocytic

tretinoin (VESANOID®) capsule Leukemia & BMT LKATOR I
leukemia using arsenic trioxide and tretinoin (All-Trans Retinoic Acid)

tretinoin (VESANOID®) capsule Leukemia & BMT response to prior first-line multi-agent, multimodal therapy using R
Third- or Later-Line Therapy for Advanced Gastroesophageal Carcinoma

trifluridine-tipiracil tablet Gastrointestinal GIGAVTRFT I
using Trifluridine-Tipiracil
* denotes change
Page 62 of 65
April 2022

FORM SITE CODES
treatment for locally advanced or metastatic medullary thyroid cancer
vandetanib tablet Head and Neck HNOTVAN I
using vandetanib
vemurafenib tablet Skin & Melanoma SMAVVEM I
melanoma using vemurafenib
vemurafenib tablet Skin & Melanoma SMAVVC I
melanoma using vemurafenib and cobimetinib
venetoclax tablet Lymphoma ULYVENETO R
lymphocytic lymphoma using venetoclax
venetoclax tablet Lymphoma LYVENETOR I
lymphocytic lymphoma using venetoclax and rituximab
venetoclax tablet Lymphoma LYVENOB I
Small Lymphocytic Lymphoma using Venetoclax and Obinutuzumab
vinblastine injectable Genitourinary GUMVAC I
vinblastine injectable Genitourinary GUVEIP I
vinblastine injectable Kaposi's Sarcoma therapy for Kaposi's Sarcoma using vinblastine-vincristine KSVB I
vinblastine injectable Lymphoma LYABVD I
and dacarbazine

vinblastine injectable Lymphoma LYAVDBV I

vinblastine injectable Lymphoma LYCVPPABO I
vinblastine (cont'd) injectable Lymphoma lymphoma palliative chemotherapy LYPALL I
palliative therapy for aggressive fibromatosis using weekly or alternate
vinblastine (cont'd) injectable Sarcoma SAMV I
week methotrexate and vinblastine intravenously
Other tumour site

Not Otherwise
vinblastine injectable code followed by I
Specified

vincristine injectable Neuro-Oncology CNCCV I
medulloblastoma or other primitive neuroectodermal tumour
vincristine (cont'd) injectable Neuro-Oncology CNMODPCV I
vincristine (cont'd) injectable Gynecology etoposide, methotrexate, leucovorin (folinic acid), dactinomycin, GOTDEMACO I
vincristine (cont'd) injectable Kaposi's sarcoma therapy for Kaposi's Sarcoma using vinblastine-vincristine KSVB I
vincristine (cont'd) injectable Lung LUOTCAV I
vincristine (cont'd) injectable Lung LUSCCAV I
vincristine (cont'd) injectable Lymphoma LYCHOP I
and prednisone
vincristine (cont'd) injectable Lymphoma LYCHOPR I
* denotes change
Page 63 of 65
April 2022

FORM SITE CODES
vincristine (cont'd) injectable Lymphoma LYCHOPRMTX I
vincristine (cont'd) injectable Lymphoma LYCLLCVPR I
treatment of Burkitt’s Lymphoma and Leukemia with cyclophosphamide,

vincristine (cont'd) injectable Lymphoma LYCODOXMR I

vincristine (cont'd) injectable Lymphoma LYCVP I
prednisone
vincristine (cont'd) injectable Lymphoma LYCVPPABO I
vincristine (cont'd) injectable Lymphoma LYCVPR I
vincristine (cont'd) injectable Lymphoma vincristine, cyclophosphamide, prednisone and rituximab with intrathecal LYEPOCHR I
methotrexate
vincristine (cont'd) injectable Lymphoma lymphoma palliative chemotherapy LYPALL I
vincristine (cont'd) injectable Sarcoma SAALT2W I
vincristine (cont'd) injectable Sarcoma SAALT3W I
* denotes change
Page 64 of 65
April 2022

FORM SITE CODES
vincristine (cont'd) injectable Sarcoma treatment of sarcomas with vincristine, doxorubicin and cyclophosphamide SAVAC I

vincristine (cont'd) injectable Sarcoma SAVACM I

vincristine (cont'd) injectable Sarcoma SAVDC I
Other tumour site

Not Otherwise
vincristine (cont'd) injectable code followed by I
Specified
vinorelbine injectable Breast palliative therapy for metastatic breast cancer BRAVNAV I
combination with 3-weekly trastuzumab as palliative therapy for metastatic
vinorelbine injectable Breast BRAVTRVIN I
breast cancer
vinorelbine injectable Gynecology GOOVBEVV I
and vinorelbine
palliative chemotherapy for re-treatment of ovarian, tubal, and peritoneal
vinorelbine injectable Gynecology GOOVVIN I
cancer
combination with cisplatin as treatment of advanced salivary gland
vinorelbine injectable Head and Neck HNSAVNP I
cancers with cisplatin and vinorelbine
adjuvant cisplatin and vinorelbine following resection of stage I, II and IIIA
vinorelbine (cont'd) injectable Lung LUAJNP I
non-small cell lung cancer
combination with cisplatin as treatment for advanced non-small cell lung
vinorelbine (cont'd) injectable Lung LUAVNP I
cancer
vinorelbine (cont'd) injectable Lung advanced non-small cell lung cancer in elderly patients LUAVVIN I
vinorelbine (cont'd) injectable Lung malignant mesothelioma LUMMVIN I
Treatment of Relapsed or Refractory Hodgkin Lymphoma with
vinorelbine (cont'd) injectable Lymphoma LYGVLD I
Gemcitabine, Vinorelbine and Doxorubicin Pegylated Liposomal
pediatric patients treated on the COG protocol AHOD0521 for
vinorelbine (cont'd) injectable Pediatric I
refractory/recurrent Hodgkin’s disease

vinorelbine (cont'd) injectable Pediatric I

vinorelbine (cont'd) injectable Pediatric with cyclophosphamide, vinorelbine and temsirolimus on the COG I
ARST0921 protocol
vismodegib capsule Skin & Melanoma treatment of metastatic or locally advanced basal cell carcinoma SMAVVIS I
transarterial radioembolisation of hepatocellular carcinoma with portal

yttrium-90 injectable Gastrointestinal GIYTT I
venous invasion or T3 tumours, and metastatic neuroendocrine tumours
adjuvant therapy for breast cancer in post-menopausal women using

zoledronic acid injectable Breast BRAJZOL5 I
zoledronic acid
adjuvant therapy for breast cancer in post-menopausal women using 3-
BRAJZOL2 I
monthly zoledronic acid
treatment of acute bone pain secondary to breast cancer metastases
BRAVZOL I
using IV zoledronic acid
zoledronic acid injectable Breast treatment of multiple myeloma with zoledronic acid MYZOL I
* denotes change
Page 65 of 65
April 2022

FORM SITE CODES
Protocol Code Definitions
Bone Marrow Transplantation BMT
Breast BR
Gastrointestinal GI
Genitourinary GU
Gynecologic GO
Head and Neck HN
Kaposi’s sarcoma KS
Leukemia LK
Lung LU
Lymphoma LY
Miscellaneous Origin MO
Myeloma MY
Neuro-Oncology CN
Ocular OC
Primary Unknown PU
Sarcoma SA
Skin & Melanoma SM
* denotes change

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Page 1 of 65

BC Cancer Benefit Drug List

DOSAGE TUMOUR PROTOCOL

treatment of pediatric patients with high-risk neuroblastoma who achieve a

treatment of ALK-positive advanced non-small cell lung cancer with

Only reimbursable when

amsacrine injectable Leukemia & BMT LKNOS I

DOSAGE TUMOUR PROTOCOL

neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in

first or second line hormonal treatment for advanced breast cancer in

hormonal treatment for advanced endometrial cancer in postmenopausal

induction and consolidation therapy of relapsed acute promyelocytic

treatment of acute lymphoblastic leukemia and lymphoblastic lymphoma

First-Line Treatment of Advanced Hepatocellular Carcinoma using

DOSAGE TUMOUR PROTOCOL

treatment of relapsed/refractory chronic lymphocytic leukemia or small

palliative combination chemotherapy for metastatic colorectal cancer using

palliative combination chemotherapy for metastatic colorectal cancer using

DOSAGE TUMOUR PROTOCOL

treatment of multiple myeloma using bortezomib, dexamethasone with or

treatment of relapsed multiple myeloma using bortezomib,

Treatment of Previously Untreated, Stage IV Hodgkin Lymphoma with

treatment of Hodgkin lymphoma and anaplastic large cell lymphoma with

treatment for consolidation therapy post-autologous stem cell transplant

treatment of CD30-positive peripheral T-Cell Lymphoma (PTCL) with

DOSAGE TUMOUR PROTOCOL

long-acting neoadjuvant or adjuvant ovarian suppression and aromatase inhibitor in

neoadjuvant or adjuvant therapy for breast cancer using a LHRH agonist

DOSAGE TUMOUR PROTOCOL

palliative therapy for metastatic breast cancer using trastuzumab and

palliative combination chemotherapy for metastatic colorectal cancer using

palliative combination chemotherapy for metastatic colorectal cancer using

DOSAGE TUMOUR PROTOCOL

neoadjuvant therapy for triple-negative breast cancer using carboplatin

Neoadjuvant Therapy for Triple-Negative Breast Cancer using Dose-

First-Line Palliative Treatment of Metastatic Anal Squamous Cell

DOSAGE TUMOUR PROTOCOL

primary treatment of advanced epithelial ovarian, primary peritoneal, or

first line treatment of epithelial ovarian cancer using doxorubicin pegylated

primary treatment of stage III less than or equal to 1 cm visible residual

treatment of small-cell gynecologic cancer with cisplatin and etoposide

DOSAGE TUMOUR PROTOCOL

First-Line Treatment of Advanced Squamous Cell Carcinoma of the Head

treatment of recurrent or metastatic squamous cell carcinoma of the head

First-Line Treatment of Advanced Squamous Cell Carcinoma of the Head

combined chemotherapy (carboplatin and fluorouracil) and radiation

DOSAGE TUMOUR PROTOCOL

treatment of locally advanced non-small cell lung cancer using alternative

treatment of cancer of unknown primary involving the thorax with cisplatin

treatment of relapsed or refractory advanced stage aggressive B-cell non-

primary treatment of cancer of unknown primary origin using carboplatin

Other tumour site

DOSAGE TUMOUR PROTOCOL

Other tumour site

chlorambucil tablet Lymphoma lymphoma palliative chemotherapy LYPALL I

DOSAGE TUMOUR PROTOCOL

palliative chemotherapy for upper gastrointestinal tract cancer (gastric,

hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with

DOSAGE TUMOUR PROTOCOL