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Ontario coverage, price, criteria word for word, Health Canada status and shortages for one product

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PETROLATUM/MINERAL OIL

All products: Limited Use (codes 49)

Other products in the same Health Canada class (S01XA) — coverage varies; not interchangeable

  • Dextran + hydroxypropyl methylcellulose + polyquad (Tears Naturale II): limited Use
  • Methylcellulose (Isopto Tears): limited Use
  • Polyvinyl alcohol (Liquifilm Tears): limited Use
  • Polyvinyl alcohol + polyvinylpyrrolidone (Tears Plus): limited Use

Lacri-Lube · DIN 00210889 · 55% & 42.5% · Oph Oint-3.5g Pk

Limited Use — Reason for Use code 49 requiredMarketed · checked 2026-09-19
StatusLimited Use — Reason for Use code 49 required
Write on scriptLU code 49 (patient must meet the criteria below)
Patient paysPatient pays: program not supplied; amount cannot be determined.
Private plan unknown: ask. If yes, check its coverage and payer coordination; if no, see the public routes below.
Ontario Limited Use criteria — code 49
Reason for Use code 49 For patients with objective evidence of keratoconjunctivitis sicca as confirmed by filamentary keratopathy on slit lamp examination or biopsy. Coverage limit: LU Authorization Period: Indefinite
No interchangeable product listed in the Ontario extract
Lacri-Lube · DIN 00210889 Manufacturer: Allergan Inc.; listing date 1996-10-01 Health Canada: Marketed since 2024-07-09 · brand REFRESH LACRI-LUBE · ATC S01XA20 ARTIFICIAL TEARS AND OTHER INDIFFERENT PREPARATIONS. · form Ointment · route Ophthalmic · ingredients MINERAL OIL 42.5 %, WHITE PETROLATUM 57.3 % · company Abbvie corporation · schedule Non-prescription drugs
Check this DIN again · Health Canada product record

Lacri-Lube: Formulary list price $7.9000/unit (unit not stated in source; not the patient's cost)

Ministry pays: $7.9000 per source unit.

Source explanation: The formulary price is what ODB pays; the cash price at the counter is set by the pharmacy.

Formulary data: Ontario extract of Aug 26, 2026 · Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=9820 · Verify on the e-Formulary ↗ (DIN 00210889)

Source record
DIN 00210889: Lacri-Lube Raw flags: sec12=Y, sec3=Y Item: 523600070; group id 636; item number 1607; lccId 00091; manufacturer id ALL Source form: Oph Oint-3.5g Pk; strength: 55% & 42.5% Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below Source prices (unrounded): $7.9000; ministry $7.9000 Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=00210889 Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=9820
Shortage status: not checked (no credentials)
Other drugs in the same formulary class (52:36 Other Eye, Ear, Nose and Throat Agents) and how they are covered

Matched class: 52:36 Other Eye, Ear, Nose and Throat Agents

Drug-class inventory only. Lists recorded Ontario formulary products, not every Canadian medication; does not recommend treatment. Covered without a code on the Ontario formulary: BETAXOLOL HCL, DICLOFENAC SODIUM, LEVOBUNOLOL HCL Some products covered without a code (check the product listing): ACETAZOLAMIDE, METHAZOLAMIDE, SODIUM CROMOGLYCATE, TIMOLOL MALEATE 52:36 Other Eye, Ear, Nose and Throat Agents

DEXTRAN 70 & HYDROXYPROPYL METHYLCELLULOSE & POLYQUAD

· 1 products · Limited Use, codes 49 · strengths: 0.1%/0.3%/0.001% · Oph Sol

METHYLCELLULOSE

· 2 products · Limited Use, codes 49 · strengths: 0.5%, 1% · Oph Sol, Oph-Sol

POLYVINYL ALCOHOL

· 1 products · Limited Use, codes 49 · strengths: 1.4% · Oph-Sol

POLYVINYL ALCOHOL & POLYVINYLPYRROLIDONE

· 1 products · Limited Use, codes 49 · strengths: · Oph-Sol

ACETAZOLAMIDE

· 2 products · General benefit (1), Listed, not a benefit (1) · strengths: 250mg · Tab

BETAXOLOL HCL

· 1 products · General benefit · strengths: 0.25% · Oph Susp

DICLOFENAC SODIUM

· 6 products · General benefit · strengths: 0.1% · Oph Sol

LEVOBUNOLOL HCL

· 1 products · General benefit · strengths: 0.5% · Oph Sol

METHAZOLAMIDE

· 2 products · Listed, not a benefit (1), General benefit (1) · strengths: 50mg · Tab

SODIUM CROMOGLYCATE

· 2 products · General benefit (1), Listed, not a benefit (1) · strengths: 2% · Oph Sol

TIMOLOL MALEATE

· 10 products · Listed, not a benefit (2), General benefit (8) · strengths: 0.25%, 0.5% · Oph Gellan Sol, Oph Sol

AFLIBERCEPT

· 6 products · Limited Use, codes 729, 730, 731 (4), Limited Use, codes 694, 695 (2) · strengths: 2mg/0.05mL, 8mg/0.07mL · Inj Sol-0.05mL Pref Syr (Preservative-Free), Inj Sol-0.07mL Pref Syr, Inj Sol-0.07mL Vial Pk, Sol for Intravitreal Inj-0.05mL Vial Pk Source: formulary-ed43-front-matter.txt Part V; ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26; class 52:36 and 20 more
Full class listing Related classes: 52:04 Anti-Infectives, 52:08 Anti-Inflammatory Agents, 52:16 Local Anesthetics, 52:20 Miotics, 52:24 Mydriatics, 52:32 Vasoconstrictors Same formulary class, not same indication: class membership alone does not establish equivalent uses.
What the Health Canada label says it is for
Product monograph unavailable: no link