© 2013 Alberta Health Services. This material is provided on an "as is", "where is" basis. Alberta Health Services
does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability,
completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for
the advice of a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of
these materials, and for any claims, actions, demands or suits arising from such use.
CALGARY ZONE
High Cost Drug Funding Request Form – fentanyl patch
SUBMIT ANNUALY FROM DATE OF INITIAL DRUG PROVISION
Patient Information
Patient Code1
Care Centre
Date of Birth (YMD)
/
/
Physician Information
Surname
First
New
Renewal
NOTE: Funding may or may not be approved by Alberta Health Services, Calgary
Approved for use under the following conditions:
Check Condition:
1. Residents with persistent, severe, chronic pain who require continuous around-the-clock
analgesia for an extended period of time but who cannot swallow or who have a
malabsorption syndrome leading to inability to benefit from long acting opioid preparations.
2. Residents with persistent, severe chronic pain who require continuous around-the-clock
analgesia for an extended period of time and who require opioid therapy at a total daily
dose of at least 60 mg/day oral morphine equivalents. Patients must have tried and failed
with at least two discrete courses of therapy with two of the following agents: morphine,
hydromorphone and oxycodone, if not contraindicated.

A discrete course is defined as a separate treatment course, which may involve more
than 1 agent, used at one time to manage the patient's condition.

A failed opioid trial occurs when dosage titration to achieve pain control is not possible
due to unacceptable side effects such as uncontrollable nausea & vomiting,
distressing hallucinations, excessive sedation and severe cognitive impairment.
3. Residents admitted to a continuing care centre receiving opioid therapy covered by this
protocol are eligible for continued use of the opioid upon review, unless a change is
clinically indicated.
4. Residents residing in a continuing care centre and currently receiving opioid therapy
covered by this protocol are eligible for continued use of the opioid, unless a change is
clinically indicated.
5. The patient’s medication profile must be reviewed in full by a pharmacist, whenever a new
prescription or dose change for fentanyl patch therapy is received.
Patients awaiting transfer from a CHR acute care site to continuing care should have the drug use evaluated, when
possible, prior to long term care placement for compliance with criterion 1 or 2. The findings of this evaluation should
be communicated to the Long Term Care pharmacy provider by the acute care site to aid in the completion of the
High Cost Drug (HCD-08) Funding Request Form-fentanyl which would be completed and processed as per the
HCD List Policy and Procedure. In the event that use does not comply with criterion 1 or 2, it is reasonable to
convert topical fentanyl therapy to an alternate opioid (morphine, hydromorphone, or oxycodone) and route of
administration.
Drug Dose:
Physician & Pharmacy Provider have ensured compliance with Use Conditions?
Yes
No
Additional Information Relating to Request (i.e. previous drug trial information including doses and
duration, frequency of follow-up with specialist, consult report information, etc.):
Physician’s or Pharmacist’s
Name:
Initial Drug Provision
Date (Y/M/D)
/
/
Processing Instructions: Pharmacy Provider email
to Supportive Living and Long Term Care at:
cc.drugmanagement@albertahealthservices.ca
OR Physician fax to: (403) 943-0232
DO NOT THIN FROM CHART
1
Patient Code: First four letters of surname, followed by first two letters of given name
HCD Funding Request Form: HCD-08
Revision: 09.04.24
© 2013 Alberta Health Services. This material is provided on an "as is", "where is" basis. Alberta Health Services
does not make any representation or warranty, express, implied or statutory, as to the accuracy, reliability,
CALGARY ZONE
completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for
the advice
TO TYPE WITHIN EACH CELL, USE THE TAB
KEYof a qualified health professional. Alberta Health Services expressly disclaims all liability for the use of
these materials, and for any claims, actions, demands or suits arising from such use.
102597 © (2008/2009)
HCD Funding Request Form: HCD-08
Revision: 09.04.24