alberta health and wellness drug benefit list - group … · febuxostat special authorization...
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Alberta Health and Wellness
Drug Benefit List
Effective July 1, 2012
78BInquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780) 498-8370 (Edmonton) (403) 294-4041 (Calgary) 1-800-361-9632 (Toll Free) FAX Number: (780) 498-8384 1-877-828-4106 (Toll Free) 109BWebsite: http://www.health.alberta.ca/services/drug-benefit-list.html Administered by Alberta Blue Cross on behalf of Alberta Health and Wellness. The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Binder and contents: $42.00 ($40.00 + $2.00 G.S.T.) Contents only: $36.75 ($35.00 + $1.75 G.S.T.) A cheque or money order must accompany the request for copies.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. i EFFECTIVE JULY 1, 2012
1BTable of Contents
79BPART 1 80BSECTION 1—POLICIES AND GUIDELINES
Introduction Acknowledgments ..................................................................................................................................1.1 Eligibility .................................................................................................................................................1.1 Additional Notes Regarding Application of the List ................................................................................1.1 Legend ...................................................................................................................................................1.3 Example of Drug Product Listings .........................................................................................................1.4 Drug Review Procedure .........................................................................................................................1.5 Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics ......................1.7 Submissions for Drug Reviews Interpretation Notices ...........................................................................................................................1.10 Submission Requirements ...................................................................................................................1.12 Criteria for Listing Drug Products .........................................................................................................1.23 Interchangeable Drug Products – Additional Criteria ..........................................................................1.25 Interchangeable Drug Products – Additional Criteria Appendices ......................................................1.29 Review of Benefit Status (ROBS) Criteria ...........................................................................................1.36 Supply Shortage Policy for Drug Products ..........................................................................................1.37 Units of Issue for Pricing ......................................................................................................................1.38 Policy for Administering Interchangeability Challenges .......................................................................1.40 Your Comments are Important to Us ...................................................................................................1.42 Price Policy Definitions ............................................................................................................................................1.43 Alberta Price Confirmation (APC) ........................................................................................................1.46 Interim APC ..........................................................................................................................................1.48 Fixed Pricing Rules (For Interchangeable Drugs) ...............................................................................1.49 Non-Fixed Pricing Rules (For Brand and Other Drugs) .......................................................................1.49 Exceptions ...........................................................................................................................................1.50 Price Reductions ..................................................................................................................................1.51 Minister’s Authority ...............................................................................................................................1.51 Least Cost Alternative (LCA) Price Policy ...........................................................................................1.54 Maximum Allowable (MAC) Price Policy ..............................................................................................1.55 Restricted Benefits Restricted Benefits ...............................................................................................................................1.56 Limited Restricted Benefits ..................................................................................................................1.57 Products Designated as Limited Restricted Benefits ...........................................................................1.57 Special Authorization Guidelines Special Authorization Policy ................................................................................................................1.58 Special Authorization Procedures ....................................................................................................... 1A.1 Special Authorization Forms ............................................................................................................... 1A.2 Drug Special Authorization Request Form ......................................................................................... 1A.4 Donepezil/Galantamine/Rivastigmine Special Authorization Request Form ...................................... 1A.6 Clopidogrel Special Authorization Request Form ............................................................................... 1A.8
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 ii
83B84B3BTable of Contents, continued
Darbepoetin/Epoetin Special Authorization Request Form ..................................................................... 1A.10 Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form ....................................................................................................... 1A.13 Ezetimibe Special Authorization Request Form ...................................................................................... 1A.15 Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form .......................................................................................................................................... 1A.17 Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form .............................. 1A.19 Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form ................................... 1A.21 Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form .......................................................................................................................................... 1A.23 Select Quinolones Special Authorization Request Form ........................................................................ 1A.25 Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Nasal Spray Salmon for Osteoporosis Special Authorization Request Form ....................................................................................................... 1A.28 Celecoxib Special Authorization Request Form ...................................................................................... 1A.31 Filgrastim/Pegfilgrastim Special Authorization Request Form ................................................................ 1A.33 Fentanyl Special Authorization Request Form ........................................................................................ 1A.35 Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form .......................................................................................................................................... 1A.37 Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form .......................................................................................................................................... 1A.39 Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form .................................................................................................................... 1A.41 Rituximab for Rheumatoid Arthritis Special Authorization Request Form .............................................. 1A.43 Imiquimod Special Authorization Request Form ..................................................................................... 1A.45 Dutasteride/Finasteride Special Authorization Request Form ................................................................ 1A.47 Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form ............... 1A.49 Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form .................................... 1A.51 Montelukast/Zafirlukast Special Authorization Request Form ................................................................ 1A.53 Febuxostat Special Authorization Request Form .................................................................................... 1A.55 Denosumab Special Authorization Request Form .................................................................................. 1A.57 Omalizumab Special Authorization Request Form ................................................................................. 1A.59 Eculizumab Special Authorization Request Form.................................................................................. 1A.61 Eculizumab Consent Form..................................................................................................................... 1A.63
81BSECTION 2—MULTIPLE SCLEROSIS (MS) DRUG COVERAGE Clinical Criteria for Coverage .......................................................................................................................2.1 Contraindications to Coverage .....................................................................................................................2.1 Alberta Multiple Sclerosis (MS) Drug Review Panel ....................................................................................2.2 Process for Multiple Sclerosis (MS) Drug Coverage ....................................................................................2.2 Avonex/Betaseron/Copaxone/Extavia/Rebif/Tysabri MS Drug Coverage Application .................................2.4 Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program ...................................................2.10
SECTION 3—CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
Special Authorization Policy ..................................................................................................................3.1
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. iii EFFECTIVE JULY 1, 2012
Criteria for Coverage ..............................................................................................................................3.3
83B84B3BTable of Contents, continued
SECTION 3A—CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
Criteria for Coverage ..................................................................................................................... ……..3A Role of the Prescribers .......................................................................................................................... 3A Criteria for Optional Special Authorization of Select Drug Products ................................................... 3A.1
SECTION 4—RARE DISEASES DRUG COVERAGE PROGRAM Rare Diseases Drug Coverage ........................................................................................................ …..4.1 Contraindications ...................................................................................................................................4.1 Rare Diseases Drugs Eligible for Coverage ..........................................................................................4.2 Alberta Rare Diseases Clinical Review Panel .......................................................................................4.2 Process for Rare Diseases Drug Coverage...........................................................................................4.2
85BPART 2
86BPHARMACOLOGIC–THERAPEUTIC CLASSIFICATION OF DRUGS 00:00 Non-Classified Drugs ..................................................................................................... 1 04:00 Antihistamine Drugs ....................................................................................................... 3 08:00 Anti-Infective Agents ...................................................................................................... 5 10:00 Antineoplastic Agents ................................................................................................... 21 12:00 Autonomic Drugs .......................................................................................................... 23 20:00 Blood Formulation, Coagulation and Thrombosis ........................................................ 29 24:00 Cardiovascular Drugs ................................................................................................... 35 28:00 Central Nervous System Agents .................................................................................. 71 34:00 Dental Agents ............................................................................................................. 121 36:00 Diagnostic Agents ...................................................................................................... 123 40:00 Electrolytic, Caloric, and Water Balance .................................................................... 125 48:00 Respiratory Tract Agents............................................................................................ 129 52:00 Eye, Ear, Nose and Throat (EENT) Preparations ...................................................... 131 56:00 Gastrointestinal Drugs ................................................................................................ 141 60:00 Gold Compounds ....................................................................................................... 151 64:00 Heavy Metal Antagonists............................................................................................ 153 68:00 Hormones and Synthetic Substitutes ......................................................................... 155 80:00 Serums, Toxoids and Vaccines .................................................................................. 171 84:00 Skin and Mucous Membrane Agents ......................................................................... 173 86:00 Smooth Muscle Relaxants.......................................................................................... 183 88:00 Vitamins ...................................................................................................................... 185 92:00 Miscellaneous Therapeutic Agents ............................................................................ 187 94:00 Devices ....................................................................................................................... 191
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 iv
88B83B84B3BTable of Contents, continued
87BAPPENDICES Appendix 1 Abbreviations ............................................................................................................. 190 Appendix 2 Pharmaceutical Manufacturers ................................................................................. 191
INDICES Index 1 Alphabetical List of Pharmaceutical Products .................................................................. 193 Index 2 Numerical List by Drug Identification Number .................................................................. 226
Section 1 Policies and Guidelines
PART 1
SECTION 1
Policies and
Guidelines
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 1 EFFECTIVE JULY 1, 2012
INTRODUCTION Acknowledgments
Alberta Health and Wellness acknowledges the important role Alberta Blue Cross continues to play in the production of the List and in the development of an overall strategy and initiatives to better manage Alberta Health and Wellness sponsored drug programs.
Eligibility The Alberta Health and Wellness Drug Benefit List defines the drugs and drug products that are covered by Alberta government-sponsored drug programs. These programs are for Albertans and their dependents who are covered by: 1. the Alberta Blue Cross Non-Group Coverage (Group 1) offered by the Alberta Health Care
Insurance Plan, 2. the Alberta Blue Cross Coverage for Seniors (Group 66) provided to all Alberta senior
citizens and those on the Alberta Widows’ Pension Plan (Group 66A), or 3. the drug coverage provided to individuals approved by Alberta Health and Wellness for
Palliative Care Drug Coverage. (For these individuals the Palliative Care Drug Benefit Supplement must also be considered), or
4. the drug coverage provided to Alberta Human Services and Alberta Seniors (AISH) clients. (For these clients the Alberta Human Services Drug Benefit Supplement must also be considered.)
Additional Notes Regarding Application of the List
1. The List is not intended to be used as a scientific reference or prescribing guide.
2. Formularies used by hospitals and continuing care facilities are developed independently of the List.
3. Drugs are classified according to the Pharmacologic–Therapeutic classifications (PTC) developed by the American Society of Health-System Pharmacists for the purpose of the American Hospital Formulary Service.
Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions or excerpts from the original content.
Where necessary, additional PTCs may have been assigned by Alberta Health and Wellness to facilitate product location in the List.
4. Where appropriate, the Compendium of Pharmaceuticals and Specialties, published by the Canadian Pharmacist’s Association, was used as a reference source for the trade name, generic name, manufacturer, strength and dosage form.
The Canadian Pharmacist’s Association is not responsible for the accuracy of transpositions or excerpts from the original content.
5. Other reference sources used for the trade name, generic name, manufacturer, strength and dosage form are: completed Drug Identification Number (DIN) notification form Notice of Compliance (NOC) Product Monograph
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 2
6. DINs listed reflect current manufacturer information available as of March 31, 2012.
7. Alberta Health and Wellness reserves the right to make changes, without notice, to the List through the on-line interactive List, and any such changes to the on-line interactive List are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 3 EFFECTIVE JULY 1, 2012
Legend
Pharmacologic–Therapeutic classification.
Pharmacologic–Therapeutic sub-classification.
Nonproprietary or generic ingredient name of the drug.
Drug strength and dosage form.
The Drug Identification Number (DIN), assigned by the Therapeutic Products Directorate (TPD), Health Protection Branch, Health Canada.
A box containing an X to the left of the DIN indicates that the product is not interchangeable with other products or interchangeability has not been assessed within the category.
All active ingredients of combination products are listed.
Strengths of active ingredients are listed in the same order as the ingredients. This example indicates that the topical cream contains 1% hydrocortisone acetate and 10% urea.
Brand name of the drug.
Three letter identification code assigned to each manufacturer. The codes are listed in Appendix 2 at the end of the List.
For products which are marked as non-interchangeable, the price is indicated in regular type (not bold type). These prices are supplied by the manufacturer and are expressed in decimal dollars.
For those products which are single source, the price is indicated in regular type (not bold type). These prices are supplied by the manufacturer and are expressed in decimal dollars.
Interchangeable grouping where the Least Cost Alternative (LCA) Price Policy has not been applied. This example indicates these two products are deemed interchangeable. These prices are supplied by the manufacturer and are expressed in decimal dollars.
The LCA Price for the selected interchangeable category appears in bold type. The LCA price is the maximum price which will be paid. The prices listed are expressed as decimal dollars. An authorized health care provider may request special authorization if a particular brand is essential in the care of a patient where the LCA Price would otherwise apply. For further information refer to the Special Authorization Guidelines section of the AHWDBL or List.
Products or devices designated as restricted benefits and limited restricted benefits are identified by a comment after the generic name. The comment indicates “RESTRICTED BENEFIT” or “LIMITED RESTRICTED BENEFIT” along with an explanation of the limits and/or restrictions. In this example, coverage of Accolate is restricted to the treatment of asthma in patients 12 to 18 years of age inclusive. For more information about products or devices designated as restricted benefits, refer to the restricted benefits section of the List.
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ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1 • 4
7BExample of Drug Product Listings
08:00 ANTI-INFECTIVE AGENTS 08:12.12.04 ANTIBACTERIALS MACROLIDES (ERYTHROMYCINS)
ERYTHROMYCIN 250 MG ORAL TABLET
00000682020 ERYTHRO-BASE AAP $ 0.1828 250 MG ORAL CAPSULE (ENTERIC-COATED PELLET)
00000726672 ERYTHRO-EC AAP $ 0.4193 00000607142 ERYC PFI $ 0.4916
28:00 CENTRAL NERVOUS SYSTEM AGENTS 28:08:04.92 ANALGESICS AND ANTIPYRETICS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
NAPROXEN 250 MG ORAL ENTERIC-COATED TABLET
00002246699 APO-NAPROXEN EC APX $ 0.1068 $ 0.1570 00002365847 AVA-NAPROXEN EC AVA $ 0.1068 $ 0.1570 00002350785 NAPROXEN EC SNS $ 0.1068 $ 0.1570 00002243312 NOVO-NAPROX EC TEV $ 0.1068 $ 0.1570 00002162792 NAPROSYN E HLR $ 0.1068 $ 0.4487
MAC pricing has been applied based on the LCA price for 1 x 250 mg oral tablet.
68:00 HORMONES AND SYNTHETIC SUBSTITUTES 68:16.04 ESTROGENS AND ANTIESTROGENS (ESTROGENS)
CONJUGATED ESTROGENS 0.3 MG ORAL TABLET
00002043394 PREMARIN WAY $ 0.3117 0.625 MG ORAL TABLET
00000265470 C.E.S VCL $ 0.1090 00002043408 PREMARIN WAY $ 0.3117
84:00 SKIN AND MUCOUS MEMBRANE AGENTS 84:06 ANTI-INFLAMMATORY AGENTS
HYDROCORTISONE ACETATE/ UREA 1 % * 10 % TOPICAL CREAM
00000503134 UREMOL-HC GSK $ 0.1877 1 % * 10 % TOPICAL LOTION
00000560022 UREMOL-HC GSK $ 0.1044 HYDROCORTISONE
1 % TOPICAL LOTION 00000578541 SARNA HC GSK $ 0.1008 00000192600 EMO-CORT GSK $ 0.1706
48:00 RESPIRATORY TRACT AGENTS 48:10.24 ANTI-INFLAMMATORY AGENTS (LEUKOTRIENE MODIFIERS)
ZAFIRLUKAST RESTRICTED BENEFIT - This product is a benefit for patients 12 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to the Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
20 MG ORAL TABLET 00002236606 ACCOLATE AZC $ 0.8054
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ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 5 EFFECTIVE JULY 1, 2012
DRUG REVIEWS
The Minister of Health and Wellness makes the final decisions on changes to the Alberta Health and Wellness Drug Benefit List (List) after considering the recommendations of the Expert Committee on Drug Evaluation and Therapeutics (Expert Committee), and/or the Canadian Expert Drug Advisory Committee (CEDAC), and/or Alberta Health and Wellness. Drug manufacturers wishing to have their drug product(s) listed on the List are required to make submissions in accordance with the procedures and criteria published in the List. Common Drug Review Alberta is a participant in the national Common Drug Review procedure (CDR Procedure*) and considers recommendations from CEDAC. Submissions relating to the New Chemical Entities and New Combination Products that have received a Health Canada Notice of Compliance (NOC) should be directed to the CDR Directorate for consideration, and must comply with the CDR Procedure requirements.
• New Chemical Entity is an active moiety that has not been previously approved for sale in Canada by Health Canada and marketed in Canada. • New Combination Product consists of two or more active moieties that have not previously been approved for sale in Canada and marketed in Canada in that combination. It may consist of either two or more new active moieties or two or more old active moieties or a combination of new and old active moieties.
Expert Committee on Drug Evaluation and Therapeutics Drug Reviews The Minister of Health and Wellness has established an Expert Committee on Drug Evaluation and Therapeutics to refine and maintain the List on an ongoing basis. All drug products not eligible for review under the CDR Procedure or the Interchangeable Expedited Review procedure must be reviewed by the Expert Committee prior to their determination as benefits on the List. The Expert Committee considers the scientific, therapeutic, clinical and socio-economic merits of drug products. The Committee receives advice and assistance from external consultants and agencies when needed. The Expert Committee makes recommendations on the List to Alberta Health and Wellness through the Executive Director, Pharmaceutical Funding and Guidance, Health Policy and Service Standards Division. Interchangeable Reviews Drug products may be considered for listing as interchangeable through Expedited Review or Full Review. Expedited Review drug products are not required to undergo a full review by the Expert Committee. Interchangeable drug product submissions will be screened by Alberta Blue Cross to determine eligibility for an Expedited Review and the results provided to Alberta Health and Wellness. Interchangeable drug submissions requiring Full Review will be reviewed by the Expert Committee under its usual drug review procedure.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 6
Referrals Alberta Health and Wellness at all times and in all circumstances reserves the right to refer any submission to the CDR Procedure and/or the Expert Committee for further advice or for a full review. Deferrals The Expert Committee and/or Alberta Health and Wellness reserve the right to defer any submission it deems appropriate in order to ensure that it may complete a review in a manner that protects patient safety and maintains the integrity of the AHWDBL and the government-sponsored drug programs. Examples of reasons for deferrals include, but are not limited to:
1. To request additional information in order to conduct a review and prepare recommendations;
2. Where additional time, research and/or consultation is required before a review can be completed or a recommendation can be made;
3. Where new or novel issues are raised; 4. Where issues, questions or concerns relating to any of the listing criteria or factors
arise, including but not limited to: (a) interchangeable safety issues, (b) whether the criteria requires expansion or clarification, (c) the drug product, (d) the listing, (e) the price, (f) any other relevant criteria or factor.
*Information regarding the CDR Procedure may be obtained through the Canadian Agency for Drugs and Technologies in Health.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 7 EFFECTIVE JULY 1, 2012
Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics
Committee Members
James L. SILVIUS, BA, MD, FRCPC Chair Clinical Associate Professor Geriatric Medicine University of Calgary 10301 Southport Lane SW Calgary, Alberta T2W 1S7 Robert J. HERMAN, MD, FRCPC Vice-Chair Professor Division of General Internal Medicine Faculty of Medicine University of Calgary Health Science Centre 3330 Hospital Drive NW Calgary, Alberta T2N 4N1 Margaret BARR, BSc(Pharm) Pharmacist 5238-42 Street Ponoka, Alberta T4J 1C9 Jeffrey A. JOHNSON, BSP, MSc, PhD Professor School of Public Health University of Alberta 2-040 Li Ka Shing Centre Edmonton, Alberta T6G 2N3 Saibal NANDY, MBBS, MRCPsych, FRCPC Psychiatrist 101-1424 Southview Drive SE Medicine Hat, Alberta T1B 4E7 Glen J. PEARSON, BScPhm, PharmD, FCSHP Associate Professor of Medicine Co-Director, Cardiac Transplant Clinic Director of Research, Cardiovascular Risk Reduction Clinic Division of Cardiology 2C2 Walter Mackenzie Health Sciences Centre Edmonton, Alberta T6G 2B7 Cheryl A. SADOWSKI, BSc(Pharm), PharmD, FCSHP Associate Professor 3-171 Edmonton Clinic Health Academy 11405-87 Avenue Edmonton, Alberta T6G 1C9
Committee Members (cont’d) Kelly B. ZARNKE, MD, MSc, FRCPC Associate Professor and Head, Division of General Internal Medicine Chief, Division of General Internal Medicine, Alberta Health Services Health Sciences Centre, Room 1470 University of Calgary 3330 Hospital Drive NW Calgary, Alberta T2N 4N1 Alberta Health and Wellness Liaison Steve LONG, BSc(Pharm), MBA Executive Director Pharmaceutical Funding and Guidance Branch Health Workforce Division Alberta Health and Wellness 11th Floor, 10025 Jasper Avenue NW Edmonton, Alberta T5J 1S6 Mark HARASYMUK, BSc(Pharm) Director, PFG Operations Pharmaceutical Funding and Guidance Branch Health Workforce Division Alberta Health and Wellness 11th Floor, 10025 Jasper Avenue NW Edmonton, Alberta T5J 1S6 Administrative/Scientific Support Carlyn VOLUME-SMITH, BSc(Pharm), MSc, PhD Senior Manager Scientific and Research Services Alberta Blue Cross 10009 - 108 Street NW Edmonton, Alberta T5J 3C5 Sherry DIELEMAN, BSc(Pharm), MSc Senior Pharmacist Associate Scientific and Research Services Alberta Blue Cross Micheal S. GUIRGUIS, BSc(Pharm), PhD Senior Scientific Associate Scientific and Research Services Alberta Blue Cross Rhonda C. SHKROBOT, BSc(Pharm) Senior Pharmacist Associate Scientific and Research Services Alberta Blue Cross
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 8
SUBMISSIONS for DRUG REVIEWS 1) Only submissions satisfying all of the submission requirements of the applicable category of
drug product that are deemed complete by the applicable submission deadline date will be put forward for review.
2) In addition to the submission requirements, the Expert Committee and/or Alberta Health and Wellness, at their sole discretion, reserve the right to request the drug product file from Health Canada’s Therapeutic Products Directorate (TPD), or any additional information from the manufacturer, CEDAC, or any other entity that the Expert Committee and/or Alberta Health and Wellness consider necessary, which may result in a delay in the listing recommendation for the drug product.
3) There is no obligation or guarantee that every completed submission will be reviewed, and/or a recommendation made, by a specific date or at the next scheduled meeting of the Expert Committee.
4) Pre-NOC submissions may be made; however, the submission will only be reviewed once it is complete.
5) Any request by a manufacturer to hold a submission will result in a submission being deemed incomplete as of the date of the request. A submission on hold will only be considered complete once correspondence is received from a manufacturer to proceed with the submission.
6) Only one (1) copy of a submission for a drug product is required. A determination by Alberta Blue Cross that a submission is complete is preliminary and made only for the purposes of forwarding the submission for review.
7) Drug manufacturers are permitted to provide other information they feel may be important to the review of a submission e.g. selected references or additional studies completed after a drug product had been submitted to the Therapeutic Products Directorate, Health Canada. Comparative studies with other listed drug products are most relevant.
8) Information on submission deadlines are posted on the Alberta Health and Wellness Drug Benefit List website which can be accessed at http://www.ab.bluecross.ca/dbl/manufacturers.html. Notice of Significant Changes - By making a submission, and if a drug product is listed on the List, manufacturers acknowledge and agree that they are required to notify the Senior Manager, Scientific and Research Services of any significant change to listed drug products. Significant changes are considered to be changes in NOC, DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or any change that could potentially affect the bioavailability or bioequivalence of a drug product. All submissions should be sent to the attention of: Senior Manager Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 9 EFFECTIVE JULY 1, 2012
All inquiries should be directed to: Coordinator Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5 Phone: (780) 498-8098 Fax: (780) 498-3534
Email: [email protected]
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 10
Interpretation Notices
From time to time, or as circumstances warrant, certain practices or procedures may be adopted by the Committee pertaining to the interpretation of the procedures and criteria published in the AHWDBL Policies and Guidelines. In order to assist manufacturers in preparing and submitting effective drug review submissions, the Expert Committee has determined that, where it deems appropriate, notice of these practices will be provided to manufacturers through “Interpretation Notices”. The Notices are intended to be a guide to assist manufacturers, but in situations where the Notices lead to inconsistencies or conflicts, the criteria in the Drug Review Procedure and Submission Requirements and Criteria, will apply. Notices will be published electronically and it continues to be the responsibility of manufacturers to monitor amendments to the AHWDBL. For convenience only, hard copies of Notices may be provided with the AHWDBL Interim Updates where deemed appropriate by Alberta Blue Cross.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 11 EFFECTIVE JULY 1, 2012
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INTERPRETATION NOTICE #1
INTERCHANGEABILITY and NON-CANADIAN REFERENCE PRODUCTS
The Submission Requirements and Criteria of the AHWDBL require manufacturers to provide the Expert Committee on Drug Evaluation and Therapeutics (“Expert Committee”) with data comparing the submitted drug product to the reference drug product. Under the Interchangeable Drug Products Criteria, manufacturers are also required to demonstrate bioequivalence with the reference drug product in accordance with the Criteria. At various times, some manufacturers have submitted interchangeability submissions using a Non-Canadian Reference Product (NCRP). After reviewing several submissions, the Expert Committee has adopted the practice of permitting manufacturers to demonstrate bioequivalency by providing data comparing the submitted drug product to a NCRP that meets the Criteria for use of a Non-Canadian Reference Product as set out in Health Canada’s Drugs Directorate Policy regarding the use of a Non-Canadian Reference Product under the provisions of Section C.08.002.1(c) of the Food and Drug Regulations (the “NCRP Criteria”). Important Note: Health Canada does not determine interchangeability and therefore, a determination by Health Canada that a product meets the NCRP Criteria is not sufficient proof for the Expert Committee’s purposes. The Expert Committee will continue to consider and assess all of the submission materials, and make its own determination whether the NCRP Criteria, the Submission Requirements and the Criteria are met, and whether the product may be designated as interchangeable. The practice in these situations is that, after receipt of the submission, Alberta Blue Cross makes a request to Health Canada for a copy of the Therapeutic Products Directorate’s review (TPD File) for the submitted product(s). Manufacturers are advised that, in order to avoid a possible deferral, they may include a full copy of the TPD File in their submission. If necessary, submissions may be deferred until the TPD File is received. Product submissions may, at the discretion of Alberta Blue Cross, be scheduled for review if the TPD File is received 7 days prior to the meeting date. As with all submissions, the Expert Committee retains the right to request additional materials from the manufacturer, Health Canada or any other entity it determines appropriate in order to conduct its review. Issue Date: November 9, 2006
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 12
SUBMISSION REQUIREMENTS
The following Submission Requirements pertain to submissions not eligible for review under the CDR Procedure. A) New Chemical Entities/Single Source Drug Products The following submission requirements pertain to New Chemical Entities, New Combination Products where one or more of the active moieties have never been listed on the List, and other single source drug products that have never been listed on the List; and are not eligible for review under the CDR Procedure. Submissions for drug products in this category should first be directed to the CDR Directorate. 1. Consent Letter
• an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada
2. Letter Confirming Ability to Supply • a letter signed by a senior official providing assurance that the manufacturer is able to
supply the specific drug product and strength from the time of listing in a quantity sufficient to meet the anticipated demand in Alberta for a minimum of 6 months.
3. A hard copy and electronic (CD) copy of the following from the Common Technical Document:
a. Clinical Overview (Module 2.5), and b. Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6).
Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu.
4. Copy of completed Drug Identification Number (DIN) notification form 5. Copy of Notice of Compliance (NOC) 6. Current Patent Status
• a signed statement from the manufacturer stating that the submitted product does not infringe any patents
• expiry date(s) of all Canadian patent(s) 7. Price Information
• The proposed price for Alberta (which must be in compliance with the Price Policy) 8. Product Monograph
• in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product Monograph compatible with Microsoft Word is required
9. Economic Information • a comprehensive pharmacoeconomic analysis in accordance with: the “Guidelines for
the economic evaluation of health technologies: Canada [3rd Edition]”. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2006.; cost-effectiveness and cost-utility data and the impact on “direct” healthcare costs are most useful
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 13 EFFECTIVE JULY 1, 2012
• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug Benefit List form. Note: copies of the most recent version of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or Fax: (780) 498-3534.
10. If requested, the manufacturer must provide written confirmation from the CDR Directorate that the drug product is not eligible for review under the CDR Procedure.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 14
B) Changes to Special Authorization or Restricted Benefit Status of Listed Single Source Drug Products Due to a New Indication The following submission requirements pertain to single source drug products currently listed via special authorization or as restricted benefits that have received a new indication from Health Canada, where the manufacturer wishes to request expansion of the coverage criteria or change in benefit status due to the new indication and where the drug products are not eligible for review under the CDR Procedure. Submissions for drug products in this category that have been previously reviewed under the CDR Procedure should first be directed to the CDR Directorate. 1. Consent Letter
• an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada
2. Letter Confirming Ability to Supply • a letter signed by a senior official providing assurance that the manufacturer is able to
supply the specific drug product and strength from the time of listing in a quantity sufficient to meet the anticipated demand in Alberta for a minimum of 6 months.
3. Justification for the Expanded Coverage Criteria or Change in Benefit Status • a separate document indicating the reason for and evidence to justify the need for the
expanded coverage criteria or change in benefit status due to the new indication 4. A hard copy and electronic (CD) copy of the following from the Common Technical Document:
o Clinical Overview (Module 2.5), and o Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6)
5. Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu. Copy of Notice of Compliance (NOC) for the new indication.
6. Current Patent Status • a signed statement from the manufacturer stating that the submitted product does not
infringe any patents • expiry date(s) of all Canadian patent(s)
7. Price Information • The proposed price for Alberta (which must be in compliance with the Price
Policy) 8. Product Monograph (revised to include the new indication)
• in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product Monograph compatible with Microsoft Word is required
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 15 EFFECTIVE JULY 1, 2012
9. Economic Information • a comprehensive pharmacoeconomic analysis prepared with respect to the new
indication only in accordance with: the “Guidelines for the economic evaluation of health technologies: Canada [3rd Edition]”. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2006.; cost-effectiveness and cost-utility data and the impact on “direct” healthcare costs are most useful
• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug
Benefit List form prepared with respect to the new indication only. Note: copies of the most recent version of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or
Fax: (780) 498-3534. 10. If requested, the manufacturer must provide written confirmation from the CDR
Directorate that the drug product is not eligible for review under the CDR Procedure.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 16
C) Line Extension Drug Products
The following submission requirements pertain to new strengths and formulations or reformulations of drug products that are currently listed or are under consideration for listing on the List and where products are not eligible for review under the CDR Procedure. Submissions for drug products in this category that have previously been reviewed under the CDR Procedure should first be directed to the CDR Directorate.
1. Consent Letter • an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate
to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada
2. Letter Confirming Ability to Supply • a letter signed by a senior official providing assurance that the manufacturer is able to
supply the specific drug product and strength from the time of listing in a quantity sufficient to meet the anticipated demand in Alberta for a minimum of 6 months.
3. Justification for the Line Extension • a separate document indicating the reason for and evidence to justify the need for the
new strength, formulation or reformulation of the drug product 4. A hard copy and electronic (CD) copy of the following from the Common Technical Document:
Clinical Overview (Module 2.5), and Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6).
Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu. In the event a Comprehensive Summary was not prepared for Health Canada (i.e. clinical studies have not been conducted on the new strength, formulation or reformulation) then the manufacturer must provide evidence establishing a clear linkage between the submitted product(s) and a currently listed product(s). This can be in the form of:
i. bioequivalence data; or ii. evidence of formulation proportionality (i.e. a comparison of master
formulae for all submitted strengths) and evidence of a similar dissolution profile.
5. Copy of completed Drug Identification Number (DIN) notification form 6. Copy of Notice of Compliance (NOC) 7. Current Patent Status
• a signed statement from the manufacturer stating that the submitted product does not infringe any patents
• expiry date(s) of all Canadian patent(s) 8. Copy of completed and approved Certified Product Information Document (CPID)
• in lieu of the CPID, a Master Formula and Final Product Specifications must be provided
9. Price Information • The proposed price for Alberta (which must be in compliance with the Price Policy)
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 17 EFFECTIVE JULY 1, 2012
10. Product Monograph (revised to include the line extension) • in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product
Monograph compatible with Microsoft Word 11. Economic Information
• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug Benefit List form. Note: copies of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or Fax: (780) 498-3534.
12. If requested, the manufacturer must provide written confirmation from the CDR Directorate that the drug product is not eligible for review under the CDR Procedure.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 18
D) Interchangeable Drug Products The following submission requirements pertain to multisource drug products submitted for listing in an interchangeable grouping in the Alberta Health and Wellness Drug Benefit List.
For Expedited and Full Reviews:
1. Consent Letter • an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate
to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada
2. Letter Confirming Ability to Supply • a letter signed by a senior official providing assurance that the manufacturer is able to
supply the specific drug product and strength from the time of listing in a quantity sufficient to meet the anticipated demand in Alberta for a minimum of 6 months.
3. Copy of completed Drug Identification Number (DIN) notification form 4. Copy of Notice of Compliance (NOC)
• Note: For Old Drug Products (a drug product where the active ingredient is designated as an “old drug” by Health Canada and the drug product was approved on the basis of a DIN application), a Notice of Compliance is not required.
5. Current Patent Status • a signed statement from the manufacturer stating that the submitted product does not
infringe any patents 6. For Pseudo-Generic Drug Products: Letters from both the manufacturer of the
submission drug product and the manufacturer of the innovator brand or a currently listed drug product within the submission product’s interchangeable grouping, stating that the submission drug product is manufactured under the identical master formula and manufacturing and quality control specifications, as the innovator brand or the currently listed drug product.
7. Price Information • The proposed pricing in Alberta must be in compliance with the Price Policy.
Exceptions to the Fixed Pricing Rules may be considered at the sole discretion of the Minister. Accordingly, a request for an exception (as per sections 18-21 of the Price Policy) must accompany a submission that does not meet the Price Policy in order for it to be deemed complete.
8. Copy of completed and approved Certified Product Information Document (CPID) Note: In lieu of the CPID, a Master Formula and Final Product Specifications must be provided
9. Product Monograph • in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product
Monograph compatible with Microsoft Word is required Note: For Old Drug Products, the Prescribing Information may be provided in lieu of the Product Monograph.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 19 EFFECTIVE JULY 1, 2012
For FULL REVIEWS ONLY, the following ADDITIONAL information must be provided: 10. Evidence that the listing criteria for interchangeable drug products has been met. See
Criteria for Listing Drug Products and Interchangeable Drug Products sections for specific applicable criteria.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 20
E) Resubmissions Resubmission Requests – General 1. A resubmission request may be made for a Drug Product that is not currently listed on
the AHWDBL or List (collectively referred to as the “AHWDBL”) in a case where the Drug Product:
a. was previously listed on the AHWDBL; b. was the subject of a previous submission for listing on the AHWDBL; or c. is listed on the AHWDBL but is subject to restrictions.
2. A resubmission request: a. must comply with the requirements set out below; and b. may be made by a Manufacturer for a Drug Product only once in a 12 month
period, running from April 1st through to March 31st, unless the Minister of Alberta Health and Wellness (Minister), in the Minister’s sole discretion, invites a Manufacturer to make a resubmission request.
3. The Minister, the Expert Committee on Drug Evaluation and Therapeutics (Expert
Committee), and Alberta Health and Wellness (AHW): a. may request information in addition to the requirements set out below; and b. may from time to time set deadlines by which a resubmission request may be
made, or a request for additional information must be provided.
4. In the case where: a. additional information has been requested by the Minister, the Expert
Committee or AHW, the resubmission request is not considered to be complete unless and until the requested additional information is provided to the Minister, the Expert Committee or AHW; and
b. a deadline has been set as referred to above, failure to provide a complete resubmission request within such deadline means that a resubmission request will not be reviewed by the Expert Committee or AHW or considered by the Minister.
5. The Minister may, in the Minister’s sole discretion, refer a Drug Product, that was the
subject of a resubmission request which meets the requirements set out in this policy, to an Alberta Price Confirmation (APC) or Interim APC process.
6. In the event that a Drug Product is referred to an APC or Interim APC process, the
Manufacturer must comply with the Price Policy and the Terms and Conditions of the APC or Interim APC. A referral to an APC or Interim APC or the submission of a Price Confirmation or Confirmed Price for the Drug Product by the Manufacturer does not obligate the Minister to list a Drug Product on the AHWDBL.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 21 EFFECTIVE JULY 1, 2012
7. In the event that the Minister, in the Minister’s sole discretion, requires additional advice or input on a resubmission request, the Minister may refer the resubmission request to the CDR Procedure, the Expert Committee or any other entity for further advice or a full review.
8. For additional clarity, the provisions outlined under the “Submissions for Drug Reviews” are also deemed to apply to resubmission requests except as specifically modified by the provisions in this subsection “E) Resubmissions”, in which case this subsection applies.
Resubmission Requests Requiring Expert Committee Review
9. In addition to the requirements in “Resubmission Requests – General” above, this section applies to a resubmission request for a Drug Product that was reviewed by the Expert Committee and a decision was made by the Minister to:
a. not add the Drug Product to the AHWDBL for reasons other than those specified
in section 12 below; b. add the Drug Product to the AHWDBL with restrictions; or c. maintain current listing status of the Drug Product on the AHWDBL despite the
Manufacturer’s request for change. 10. A general resubmission request may be made for a previously submitted Drug Product
on the Resubmission for the Alberta Health and Wellness Drug Benefit List form. The form can be obtained at www.ab.bluecross.ca/dbl/manfacturers.html or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross by phone at (780) 498-8098 or by fax at (780) 498-3534.
11. A resubmission request must be complete and must include:
a. a completed Resubmission for the Alberta Health and Wellness Drug Benefit List form. A resubmission request requires review by the Expert Committee and a recommendation made by the Expert Committee for the Minister’s consideration for listing or not listing the Drug Product on the AHWDBL. The form must contain new information not previously submitted for a review of the Drug Product by the Expert Committee, unless otherwise indicated;
b. an unconditional consent letter authorizing AHW and its employees, contractors, consultants and agents to collect and use information respecting a Drug Product and to disclose the subject information to AHW, its employees, contractors, consultants and agents, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services (AHS) and the government of a province or territory in Canada. Information that may be collected, used and disclosed includes, but is not limited to, all Drug Product submission and resubmission information and information about the Drug Product in the possession of Health Canada, CADTH, all persons, parties or entities involved in the CDR Procedure, PMPRB, AHS, AHW, the Expert Committee, and the government of a province or territory;
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 22
c. a confirmation letter signed by a senior official of the Manufacturer stating that the Manufacturer is able and willing to supply the Alberta market with the subject Drug Product in a quantity consistent with applicable APC or Interim APC requirements; and
d. a revised Budget Impact Assessment (BIA) form in the case where new economic information about the Drug Product is available, that has not been previously submitted, to support the resubmission request.
Resubmission Requests based on the AHWDBL Price Policy
12. In addition to the requirements in “Resubmission Requests – General” above, this section applies to resubmission requests for a Drug Product that:
a. has not been listed on the AHWDBL, or that has been removed from the
AHWDBL, by the Minister where the requirements of an Alberta Price Confirmation (APC), Interim APC or the Price Policy were not satisfied; or
b. has been removed from the AHWDBL at the request of the Manufacturer.
13. A price policy resubmission request may be made on the Alberta Price Policy Resubmission Form for the Alberta Health and Wellness Drug Benefit List. The form can be obtained at www.ab.bluecross.ca/dbl/manfacturers.html or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross by phone at (780) 498-8098 or by fax at (780) 498-3534.
14. A resubmission request must be complete and must include:
a. a completed Alberta Price Policy Resubmission Form for the Alberta Health and Wellness Drug Benefit List ;
b. an unconditional consent letter authorizing AHW and its employees, contractors , consultants and agents to collect and use information respecting a Drug Product and to disclose the subject information to AHW, its employees, contractors, consultants and agents, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services (AHS) and the government of a province or territory in Canada. Information that may be collected, used and disclosed includes, but is not limited to, all Drug Product submission and resubmission information and information about the Drug Product in the possession of Health Canada, CADTH, all persons, parties or entities involved in the CDR Procedure, PMPRB, AHS, AHW, the Expert Committee, and the government of a province or territory; and
c. a confirmation letter signed by a senior official of the Manufacturer stating that the Manufacturer is able and willing to supply the Alberta market with the subject Drug Product in a quantity consistent with applicable APC or Interim APC requirements.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 23 EFFECTIVE JULY 1, 2012
Criteria for Listing Drug Products
• The Criteria for Listing Drug Products apply to all drug product submissions.
• If more than one criterion apply, at the sole discretion of the Expert Committee on Drug Evaluation and Therapeutics (Expert Committee), Alberta Health and Wellness or the Minister, the most stringent and/or appropriate combination of criteria will apply.
• For multisource drug products seeking a designation of interchangeability, the drug product must also meet the additional criteria outlined under “Interchangeable Drug Products”.
1. Clinical studies must have demonstrated the safety and efficacy of the product in appropriate populations. 2. The product must:
a. possess therapeutic advantage over other presently accepted therapies or treatments of the disease entity for which the product is indicated, or b. be more cost-effective than presently accepted therapy.
3. Assessment of therapeutic advantage may include consideration of: i. clinical efficacy; ii. risk/benefit ratio; iii. toxicity; iv. compliance; v. clinical outcomes; vi. Health Canada warnings and advisories; vii. population health issues; or viii. any other factor which affects the therapeutic value of the product.
4. The Expert Committee, Alberta Health and Wellness and/or the Minister may, in addition to all of the factors listed above, also consider any factors that they consider appropriate, including but not limited to any or all of the following:
i. the recommendations from the CDR review, ii. failure by a manufacturer to supply a sufficient quantity of drug product to
meet the demand in Alberta (as determined by Alberta Health and Wellness at its sole discretion, and based on any information it deems appropriate),
iii. failure by a manufacturer to provide (A) a Price Confirmation, or (B) a Price Confirmation or Confirmed Price in accordance with the Price
Policy and/or the Alberta Price Confirmation (APC) Terms and Conditions;
iv. failure by a manufacturer to comply with any APC Terms and Conditions;
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 24
v. type of drug, drug product, class or category and indications for use, vi. other available alternative products, treatments or therapies, vii. whether the product is interchangeable, viii. cost of the product and/or potential cost savings or impact on drug
expenditures under the List, ix. volume of use and amounts paid out for similar products, classes or
categories, x. utilization patterns xi. expenditure management and resources, xii. patent issues, xiii. coverage provided by other programs, xiv. for interchangeable products, concerns that are related to or affect the
interchangeability of the drug product, xv. issues, concerns, objectives, goals and/or mandates related to any
government policies, plans or programs, and xvi. patient care concerns related to factors external to the drug product.
5. New Chemical Entities, New Combination Products and other single source products not eligible for review under the CDR Procedure may, at the sole discretion of Alberta Health and Wellness and/or the Minister, be considered for priority review and possible addition to the List if the product submission is otherwise complete, and the product has been granted “Priority Review” status by the Therapeutic Products Directorate, Health Canada. A copy of documentation from the Therapeutic Products Directorate granting ‘Priority Review’ status is required.
6. The onus is on the manufacturer to formally request, in writing, consideration on a priority review basis if, in the opinion of the manufacturer, the product meets any of the above priority review criteria. Request for priority review does not automatically mean that the submission will be considered on that basis. The decision whether to conduct a priority review will be made by Alberta Health and Wellness and/or the Minister at their sole option and discretion.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 25 EFFECTIVE JULY 1, 2012
Interchangeable Drug Products - Additional Criteria
Principle: Decisions respecting interchangeability and drug lists remain in the domain of the institution responsible for the costs of the product which includes hospitals, provincial governments and other third party payers (6/9/95 Canada Gazette Part ll, Vol. 129, No. 18) Preface: The Alberta Health and Wellness Drug Benefit List (AHWDBL) contains designations of interchangeability for approved multisource drug products. The Expert Committee on Drug Evaluation and Therapeutics makes recommendations on interchangeability to Alberta Health and Wellness through the Executive Director, Pharmaceutical Funding and Guidance Branch, Health Policy and Service Standards Division. The Minister of Health and Wellness makes the final decisions on interchangeability after reviewing the recommendations of the Expert Committee and/or Alberta Health and Wellness. Definitions: (Note: additional definitions in the applicable Appendices may apply) Interchangeable Drug Product: An interchangeable drug product is a drug product that has been designated as interchangeable by the Minister of Health and Wellness after reviewing the recommendations of the Expert Committee or Alberta Health and Wellness. Recommendations regarding interchangeability are made taking into consideration the scientific, therapeutic, clinical and socio-economic merits of drug products in accordance with the published criteria. Drug products designated as interchangeable are expected to be safe when interchanged with other drug products in the interchangeable grouping, and to have the same therapeutic effectiveness when administered to patients under the conditions specified in the labeling. The designation of interchangeability is made only for the purpose of funding of drug benefits covered under the Alberta government-sponsored drug benefit programs and is not to be used as a scientific reference or prescribing guide. Multisource Drug Product: Drug products are considered to be multisource drug products when they are manufactured and/or distributed by more than one manufacturer. Pharmaceutical Alternative: Drug products may be considered to be pharmaceutical alternatives if they use the same route of administration and contain the same active therapeutic ingredient(s) but are different salts, esters or complexes of that moiety, or are different dosage forms or strengths. Pharmaceutical Equivalent: Drug products are considered to be pharmaceutical equivalents if they contain the same active therapeutic ingredient(s), are of comparable dosage form(s), route of administration and are identical in strength or concentration. Pseudo-Generic Drug Product: A pseudo-generic drug product is a drug product that is manufactured under the identical master formulae and manufacturing and quality control specifications as a) the innovator brand of the drug; or b) any drug product that is currently listed on the AHWDBL within the submission product’s interchangeable grouping.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 26
TPD Reports - refers collectively to the following Health Canada Therapeutic Products Directorate (TPD) guidance publications as of December 31, 2009: o Conduct and Analysis of Bioavailability and Bioequivalence Studies - Part A: Oral
Dosage Formulations Used for Systemic Effects, and Part B: Oral Modified Release Formulations; (which may be referred to in the List as “TPD Part A”, and “TPD Part B”); and
o Report C: Report on Bioavailability of Oral Dosage Formations, Not in Modified Release Form, of Drugs used for System Effects, Having Complicated or Variable Pharmacokinetics (which may be referred to in the List as “TPD Report C”); and
o Bioequivalence Requirements: Comparative Bioavailability Studies Conducted in the Fed State. Interchangeable Reviews:
A. The Expert Committee and/or Alberta Health and Wellness and/or the Minister may, in addition to considering the Interchangeable Drug Products criteria, also consider any other criteria in the AHWDBL, including but not limited to the Criteria for Listing Drug Products.
B. Recommendations regarding interchangeability are made taking into consideration the scientific, therapeutic, clinical and socio-economic merits of drug products in accordance with the published criteria. Drug products designated as interchangeable are expected to be safe when interchanged with other drug products in the interchangeable grouping, and to have the same therapeutic effect when administered to patients under the conditions specified in the labeling.
C. Issuance of a Notice of Compliance by the TPD which includes a Declaration of Equivalence does not mean the drug product will automatically be designated as interchangeable.
Expedited Reviews 1. Multisource drug products seeking a listing designation as interchangeable may be eligible for an expedited review if:
a. The drug product submission complies with the submission requirements.
b. The drug product does NOT fall into any of the categories of drug products that require a Full Review (below), unless the drug product is a Pseudo-Generic Drug Product.
c. The drug product is not a subsequent entry biologic (subsequent entry biologics are not eligible for review as interchangeable products).
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 27 EFFECTIVE JULY 1, 2012
d. The drug product has been granted a Notice of Compliance by Health Canada that includes a declaration of bioequivalence with a Canadian brand/innovator reference product that is listed (or at the sole discretion of Alberta Health and Wellness and/or the Minister, has been previously listed) on the Alberta Health and Wellness Drug Benefit List.
e. The drug product must be a pharmaceutical equivalent to the Canadian innovator reference product.
f. The proposed price in Alberta provided in the manufacturer’s submission complies with the Price Policy.
g. Even if the drug submission review is expedited, Alberta Health and Wellness and/or the Minister may refuse to list a drug product, or the listing of the drug product may be delayed, if the manufacturer has failed
(A) to provide a Price Confirmation, (B) to provide a Price Confirmation or Confirmed Price in accordance with the Price
Policy and/or the applicable APC Terms and Conditions; or (C) to comply with the terms and conditions of an applicable APC.
Full Reviews Multisource drug products seeking a listing designation as interchangeable that fall within the categories listed below are required to undergo a Full Review by the Expert Committee. The following additional interchangeability criteria will apply to Full Reviews: 1. The drug product must be a
a. pharmaceutical equivalent; or b. pharmaceutical alternative,
as determined at the sole discretion of the Expert Committee. 2. The drug product is not a subsequent entry biologic (subsequent entry biologics are not
eligible for review as interchangeable products).
3. The proposed price in Alberta contained in the manufacturer’s submission complies with the Price Policy.
4. The drug product has been demonstrated to be bioequivalent, or has provided evidence of comparative therapeutic efficacy, with the reference drug product as outlined below;
a. For drug products in the following categories, for which bioequivalence studies
CAN be conducted:
i. For Critical Dose Drug Products, the drug product must meet the criteria in the Critical Dose Drug Product Appendix.
ii. For Non-Linear Drug Products, the drug product must meet the criteria in the Non-Linear Drug Product Appendix.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 28
iii. For Rapid Onset Drug Products, the drug product must meet the criteria in the Rapid Onset Drug Product Appendix.
iv. For Drug Products for which Bioequivalence is Supported by Metabolite Data, the drug product must meet the criteria in the Drug Products with Metabolite Data Appendix.
v. For Drug Products for which Bioequivalence is Supported by Measurement of the Drug in a Matrix other than Plasma or Serum (e.g., Whole Blood, Urine, Tissue), the drug product must meet the criteria in the Drug Product with Alternate Matrix Measurement Appendix.
vi. For Old Drug Products, the product must meet the criteria in the Old Drug Product Appendix.
vii. For Drug products which possess complex delivery systems, the product must meet the criteria in the Complex Delivery System Drug Product Appendix.
b. For drug products in the above categories for which bioequivalence studies
CANNOT be conducted:
i) Evidence of comparative therapeutic efficacy of the submitted product with the reference product via:
(A) a therapeutic equivalence study; or (B) Studies that meet the requirements and standards for pharmacodynamic studies outlined in TPD Report C;
and
ii) Sufficient rationale for why a bioequivalence study cannot be conducted.
c. For drug product submissions using a Non-Canadian Reference Product (NCRP):
i) An NCRP may only be used when it meets the Criteria for use of a Non-
Canadian Reference Product as set out in Health Canada’s Drugs Directorate Policy regarding the use of a Non- Canadian Reference Product under the provisions of Section C.08.002.1(c) of the Food and Drug Regulations (the “NCRP Criteria”). See also Interpretation Notice #1.
ii) If the NCRP Criteria is met, the drug product must demonstrate bioequivalence to the NCRP through studies that meet the requirements and standards of the applicable TPD Reports.
5. The drug product must meet all other criteria outlined in the applicable Appendix.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 29 EFFECTIVE JULY 1, 2012
6. In addition, the Expert Committee may also consider any other factor that may affect the interchangeability of a drug product, including but not limited to:
• characteristics of the drug product (e.g. shape, scoring, configuration, packaging, labelling);
• excipients and non-medicinal ingredient(s) (e.g. sugar, sodium); • expiration times; • storage conditions.
Interchangeable Drug Products - Additional Criteria APPENDICES
Critical Dose Drug Product Appendix Critical Dose Drug: Is a drug where comparatively small differences in dose or concentration lead to dose- and concentration-dependent, serious therapeutic failures and/or serious adverse drug reactions which may be persistent, irreversible, slowly reversible or life threatening, which could result in inpatient hospitalization or prolongation of existing hospitalization, persistent disability or incapacity, or death. Critical dose drugs include:
a) Any drug listed in Appendix I - List of Critical Dose Drugs of Health Canada’s Guidance for Industry entitled Bioequivalence Requirements: Critical Dose Drugs; and
b) Any other drug that the Expert Committee determines meets the above definition, which determination may include consideration of any other matter that may affect the interchangeability of a product containing a critical dose drug.
Criteria: Bioequivalence studies must meet the requirements and standards in the TPD Reports, with the exception that the following standards will be used: 1. The 90% confidence interval of the relative mean AUC of the test to reference formulation
should be within 90.0 to 112.0%; the relevant AUC or AUCs as described in TPD Reports A and B are to be determined.
2. The 90% confidence interval of the relative mean measured Cmax of the test to reference formulation should be between 80.0 and 125.0%.
3. These requirements are to be met in both the fasted and fed states. 4. These standards should be met on log transformed parameters calculated from the
measured data and from data corrected for measured drug content (percent potency of label claim).
5. If a steady-state study is required, the 90% confidence interval of the relative mean measured Cmin of the test to reference formulation should also be between 80.0 and 125.0%.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 30
Non-Linear Drug Product Appendix Non-Linear Drug: A drug is considered to be a Non-Linear Drug if the Health Canada approved product monograph for the Canadian innovator drug product states that it is a non-linear drug. Criteria: 1. Bioequivalence studies must meet the requirements and standards in the TPD Reports, and these requirements and standards should be met in single dose studies in both the fasted and fed states, with the following exceptions:
a) if non-linearity occurs after the drug enters the systemic circulation, a fed study may be waived unless there is sufficient evidence, at the Expert Committee’s sole discretion, that a product exhibits a food effect; or b) if a condition (fasted or fed) for product ingestion is contraindicated, that condition may be waived in a bioequivalence trial. For bioequivalence testing the fasting and fed doses should be the same.
2. At the sole discretion of the Expert Committee, it may be acceptable to conduct bioequivalence studies at either the highest or lowest strength of a range of proportionally formulated strengths as outlined below:
a) For drugs with non-linear pharmacokinetics in the single unit dose range of approved strengths resulting in greater than proportional increases in AUC with increasing dose, the bioequivalence studies should be conducted on at least the highest strength. That is, where non-linearity arises from capacity-limited clearance, the highest strength for the proposed indications should be tested. For drugs where the non-linear concentration range is reached only after multiple doses within the approved dosing regimen, studies utilizing multiple units of the highest formulation strength or steady-state studies in the non-linear range may be required. Where steady-state studies are conducted, single dose studies will not be required. In all situations, safety in dosing should be considered.
b) For drugs with non-linear pharmacokinetics in the single unit dose range of approved strengths resulting in less than proportional increases in AUC with increasing dose, the bioequivalence studies should be conducted on at least the lowest strength (single dose unit). That is, where non-linearity arises from capacity-limited absorption, the test dose should be a single unit of the lowest strength.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 31 EFFECTIVE JULY 1, 2012
Rapid Onset Drug Product Appendix
Rapid Onset Drugs: Are as defined in TPD Report C. Criteria: Bioequivalence studies must meet the requirements and standards in the TPD Reports, except that the relative mean AUCReftmax of the test to reference formulation should be within 80 to 125%, where AUCReftmax for a test product is defined as the area under the curve to the time of the maximum concentration of the reference product, calculated for each study subject.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 32
Drug Product with Metabolite Data Appendix For drug product submissions for which evidence of bioequivalence is supported by metabolite, rather than the parent drug, data. Criteria:
1. Bioequivalence studies must meet the requirements and standards in the TPD Reports.
2. If the parent drug is not detectable due to rapid biotransformation or limitations in available assay methodology, the use of metabolite data may be acceptable.
3. The measured metabolite must be a primary (first step) measureable by a validated assay, and there must be sufficient scientific justification for a waiver of the measurement of the parent drug and the use of metabolite data.
4. The choice of using the metabolite instead of the parent drug is to be clearly stated, a priori, in the objective of the study in the study protocol.
5. The use of metabolite concentrations in urine is not acceptable.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 33 EFFECTIVE JULY 1, 2012
Drug Product with Alternate Matrix Measurement Appendix
For drug product submissions for which bioequivalence data is supported by measurement of the drug in a matrix other than plasma or serum (e.g., whole blood, urine, extravascular tissue). Criteria:
• Bioequivalence studies must meet the requirements and standards in the TPD Reports.
• The assay used for measurement of the drug (or metabolite) must be validated for the alternate matrix of measurement.
• Sufficient rationale for why the use of an alternate matrix measurement study is appropriate.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 34
Old Drug Product Appendix Old Drugs: Are drug products where the active therapeutic ingredient(s) is designated as an “old drug” by Health Canada and the drug product is approved on the basis of a DIN application (i.e. an NOC is not issued by Health Canada). Criteria:
1. Bioequivalence studies must meet the requirements and standards in the TPD Reports.
2. For old drug products for which bioequivalence studies CANNOT be conducted, the submission must include:
i) Evidence of comparative therapeutic efficacy of the submitted product with the reference product via:
(A) a therapeutic equivalence study; or (B) studies that meet the requirements and standards for pharmacodynamic studies outlined in TPD Report C; or (C) surrogate comparisons using in vivo or in vitro test methods.
and
ii) Sufficient rationale for why a bioequivalence study cannot be conducted.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 35 EFFECTIVE JULY 1, 2012
Complex Delivery System Drug Product Appendix Complex Delivery System Drugs: Are drug products that possess complex drug release characteristics in the pharmaceutical dosage form that are intended to:
(1) deliver the drug at a rate that is independent of time and the concentration of the drug (i.e. zero order process), or (2) deliver the drug to a specific physiological site (i.e. site-specific release).
Criteria: 1. Bioequivalence studies must meet the requirements and standards in the TPD Reports. 2. A detailed description of the pharmaceutical dosage forms and specific drug release characteristics of the submitted drug product and reference drug product must be provided to permit evaluation of the similarity of drug release of the respective formulations.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 36
Review of Benefit Status (ROBS) Criteria
The Expert Committee and/or Alberta Health and Wellness may at any time review the benefit status of a drug product, a group of drug products, a class or classes of drug products, or a category or categories of drug products listed or being considered for listing on the AHWDBL (collectively “Products”). The Expert Committee and/or Alberta Health and Wellness may, at their sole option and discretion, recommend altering or discontinuing the benefit status for Products if one or more of the following criteria are met. These are general criteria only, which are intended to be applied flexibly, having regard to each individual case. The criteria may be modified or adapted as the situation may require, and not all criteria will apply to each case:
1. There has been a significant change to the Product(s). Significant changes may include changes in NOC, DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, or any change that could potentially affect the bioavailability or bioequivalence of a product.
2. The Product(s), no longer possesses demonstrated therapeutic advantage compared to other presently accepted therapies or treatments of the disease entity for which the Product(s) is/are indicated. Assessment of therapeutic advantage may include consideration of clinical efficacy, risk/benefit ratio, toxicity, compliance, clinical outcomes, Health Canada advisories, population health issues, and any factor which affects the therapeutic value of the product, class or category.
3. The Product(s) is/are no longer cost-effective compared to other presently accepted therapies or treatments of the disease entity for which the Product(s) is/are indicated.
4. To enable broader coverage of higher priority Product(s). 5. When a product has been discontinued by the manufacturer. 6. When Product(s) is/are changed from prescription to non-prescription status, the Expert
Committee may recommend continuing, altering or discontinuing benefit status of the Product(s) based upon scientific, therapeutic, clinical and socio-economic merits of the Product(s).
7. For all ROBS reviews, the Expert Committee, Alberta Health and Wellness and/or the Minister may, in addition to all of the factors listed above, also consider any factors that they consider appropriate, including but not limited to any of the criteria for listing drug products and interchangeable drug products.
Unsolicited information from manufacturers relating to ROBS Reviews will not be put before the
Expert Committee. However, if the Expert Committee determines that a change in benefit status
may be warranted, manufacturers of the affected Product(s) will be notified and provided with an
opportunity to make submissions to the Expert Committee prior to the final recommendation
being made. Notification will include advice regarding the form of submission that will be
accepted, the deadline for filing the submission and any other relevant advice. Any submissions
that do not comply with the notification advice will not be put before the Expert Committee.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 37 EFFECTIVE JULY 1, 2012
Supply Shortages
Where a manufacturer has not supplied, or is not supplying, a sufficient quantity of drug product to meet the demand in Alberta (as determined by Alberta Health and Wellness at its sole option and discretion, and based on any information it deems appropriate):
1. If the unavailable product is a single-source product on the List, products not otherwise allowed as benefits may be added temporarily or temporarily reimbursed for the Alberta government-sponsored drug programs.
3. Products added or reimbursed under this policy may remain as temporary benefits until the supply shortage is rectified.
4. In order to remain as benefits after the shortage is rectified, manufacturers of these products must follow the usual submission and review process for listing.
5. Alberta Health and Wellness may recover any cost difference from the manufacturer unable to supply a drug product.
6. Alberta Health and Wellness may at its sole discretion, take any other steps or require any information from a manufacturer or other person, that is reasonably required to manage a supply shortage.
7. Alberta Health and Wellness may:
• refuse to list any product of the manufacturer, • refuse to consider any product submission of the manufacturer for expedited or
priority review; or • cancel or modify the listing of the product that is not meeting the supply demand.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 38
Units of Issue for Pricing
These units of issue are used for presenting prices in the List. Dosage Form Unit of Issue Priced in AHWDBL
Ampoules ............................................................. Millilitre Bladder Irrigation Solutions .................................. Millilitre Dental Pastes ....................................................... Gram Devices................................................................. Device Inhalation Capsules .............................................. Capsule Inhalation Cartridges ............................................ Cartridge Inhalation Disks .................................................... Disk Inhalation Solutions or Suspensions .................... Millilitre – all preparations including nebules Inhalation Unit Dose Solution ............................... Millilitre Injections .............................................................. Vial – where reconstitution is required (or ………………………………………………………..Millilitre or Unit where indicated) Injections .............................................................. Millilitre – where no reconstitution is required ……………………………………………………….(or Vial where indicated) Injections – Cartridges ......................................... Millilitre Injections – Emulsion ........................................... Millilitre Injections – Syringes ............................................ Syringe (or Millilitre where indicated) Injection – Implant ................................................ System Injection Syringe/Oral Capsule ............................ Kit Injection Vial/Oral Capsule ................................... Kit Injection Vial/Oral Tablet ...................................... Kit Injection Syringe/Oral Tablet ................................ Kit Intrauterine Insert ................................................. System Irrigating Solutions ............................................... Millilitre Lock Flush ............................................................ Millilitre Metered Dose Aerosols........................................ Dose Metered Inhalation Powder .................................. Dose Nasal Metered Dose Aerosols ............................. Dose Nasal Metered or Unit Dose Sprays .................... Dose Nasal Solutions .................................................... Millilitre Nasal Sprays ........................................................ Millilitre Ophthalmic Solutions or Suspensions or Drops..................................... Millilitre Ophthalmic Gels or Ointment ............................... Gram Ophthalmic Long Acting Gellan Solutions............ Millilitre Oral Caplets ......................................................... Caplet Oral Capsules – all formulations .......................... Capsule Oral Drops ........................................................... Millilitre Oral Granules ....................................................... Bulk size – Gram Individual Packet..................................................Packet
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 39 EFFECTIVE JULY 1, 2012
Units of Issue for Pricing, continued
Dosage Form Unit of Issue Priced in AHWDBL Oral Liquids – all formulations .................................... …...Millilitre Oral Powders .............................................................. …...Gram (or Dose where indicated) Oral Powder Packets…………………………………….. Individual Packet Oral Rinses ................................................................. …...Millilitre Oral Tablets – all formulations .......................................... Tablet Oral Tablets – oral contraceptives .................................... Tablet Oral Tablet/Capsule .......................................................... Kit Oral Wafer ........................................................................ Wafer Otic Ointments or Gels ..................................................... Gram Otic Solutions or Suspensions or Drops .................................................. Millilitre (or Vial where indicated)
Rectal Enemas ................................................................. Enema Rectal Foams .................................................................... Gram Rectal Ointments .............................................................. Gram Rectal Retention Enemas ................................................. Enema Rectal Suppositories - all formulations ............................. Suppository Scalp Lotions .................................................................... Millilitre Scalp Solutions ................................................................. Millilitre Sublingual Metered Dose Spray.........................................Dose Sublingual Tablet .............................................................. Tablet Topical Bars ...................................................................... Gram Topical Cleansers ............................................................. Millilitre Topical Creams/Ointments - all formulations ................... Gram Topical Gauzes ................................................................. Dressing Topical Gels - all formulations .......................................... Gram Topical Jellies ................................................................... Millilitre Topical Lotions.................................................................. Millilitre or Gram Topical Powders ............................................................... Gram Topical Solutions ............................................................. Millilitre Topical Washes ................................................................ Millilitre or Gram Transdermal Gel ............................................................... Gram Transdermal Patches ....................................................... Patch Vaginal Capsules or Ovules or Tablets ............................ Capsule or Ovule or Tablet Vaginal Creams or Ointments or Gels .............................. Gram Vaginal Douches............................................................... Millilitre Vaginal Ovule/Topical Cream ........................................... Kit Vaginal Slow Release Rings ........................................... Ring Vaginal Suppositories ....................................................... Suppository
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 40
Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics: Policy for Administering Interchangeability Challenges
Note: This Policy is not applicable for drug products that are eligible for, and are reviewed under, the Expedited Review Process for interchangeable drug products. From time-to-time, the Expert Committee on Drug Evaluation and Therapeutics receives unsolicited information (“Challenge Information”) from a manufacturer (the “Challenger”) suggesting that additional information should be taken into account when a submission for interchangeability for a multisource product is being considered by the Expert Committee. Alberta Health and Wellness is not prepared to have any Challenge Information considered by the Expert Committee unless the manufacturer whose product is being challenged (the “Applicant”) is provided with a full copy of the Challenge Information and is given an opportunity to respond to it.
As a result, Alberta Health & Wellness has developed and approved the following process for the handling of Challenge Information.
1. Challenge Information must comply with the following conditions. 2. Challenge information must be received by Alberta Blue Cross:
• For first-entry interchangeable product submissions – Within 15 days of the date of issuance of the NOC for the Applicant’s product.
• For all other submissions, by the submission deadline date. 3. All Challenge Information must include an unconditional Written Consent
4. If the above unconditional Written Consent is not submitted as required, the Challenge Information will not be considered by the Expert Committee.
, signed by the Challenger, authorizing Alberta Health and Wellness and its agent/designate to (a) disclose to the Applicant all Challenge Information; and (b) to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and Challenge Information and any information in the possession of Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada.
5. If Written Consent is submitted as required, the Challenge Information will be duplicated in its entirety and forwarded by Alberta Blue Cross to the Applicant, inviting a response (“Applicant Response”). The Applicant Response must be received by Alberta Blue Cross no later than 15 days after the date of the letter from Alberta Blue Cross.
6. If an Applicant Response is not received by Alberta Blue Cross within the time provided, only the Challenge Information will be provided to the Expert Committee for consideration. If an Applicant Response is received within the time provided, both the Applicant Response and the Challenge Information will be provided to the Expert Committee for consideration.
7. No further information may be submitted to the Expert Committee for consideration.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 41 EFFECTIVE JULY 1, 2012
8. The Applicant Response should only address information contained in the Challenge Information. Anything in the Applicant Response that does not relate to information contained in the Challenge Information may, at the sole discretion of the Expert Committee, be disregarded.
9. It is a condition of each and every Submission and Challenge that the terms, conditions,
criteria and time limitations contained in this policy will apply and that: a) Applicants, by filing a Submission and Applicant Response; and, b) Challengers, by submitting Challenge Information agree to and are bound by this policy.
10. In the event the anticipated Applicant submission is not received, Challenge Information will be destroyed 6 months after receipt.
Inquiries may be made to: Senior Manager
Scientific and Research Services Alberta Blue Cross 10009 - 108 Street NW Edmonton AB T5J 3C5 Phone: (780) 498-5978 Fax: (780) 498-3534
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 42
Your Comments are Important to Us
To improve the high standards established for this publication, the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics would like to offer you an opportunity for input. Should you have any concerns and/or suggestions concerning product listings or criteria for coverage of products available via special authorization, etc. please let us know.
Please note: this is not a mechanism for an appeal for a specific patient.
If you are writing in support of a product listing change or a revision to the special authorization criteria for coverage, you must provide evidence in support of your comments from the peer-reviewed scientific literature. In order to meet the expectations of stakeholders relative to objectivity and transparency, all individuals providing comments are required to advise the Expert Committee of any potential conflicts of interest below (please check appropriate box):
Conflict of Interest: Yes No If Yes, please indicate the nature of the potential conflict of interest below:
____________________________________________________________________________________ ____________________________________________________________________________________ Please provide your comments in the space provided below:
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Contact Information: Name and Address: __________________________________________________________________ Phone/Fax: __________________________________________________________________________ Please print form and mail/fax to: Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics c/o Senior Manager
Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5 FAX to: (780) 498-3534
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 43 EFFECTIVE JULY 1, 2012
AHWDBL - Updated Price Policy
Effective May 17, 2012 PRICE POLICY ____________________________________________________ DEFINITIONS In this Price Policy, Alberta Blue Cross or ABC or Blue Cross means the ABC Benefits Corporation, Alberta Health and Wellness Drug Benefit List, List or AHWDBL means, unless otherwise indicated, the most recent drug benefit list (including drug benefit listing policies and processes and benefit supplements) published by the Minister from time to time, Alberta Price Confirmation or APC means an Alberta Price Confirmation that may be issued by the Minister from time to time, APC Terms and Conditions means the terms and conditions outlined in an APC, Base Cost means the price per unit of issue, less any permitted Distribution Allowance, submitted in respect of a Drug Product in a Drug Product submission or in a prior APC (whichever is most recent), Brand Drug means an originator/brand Drug Product listed or under consideration for listing in the AHWDBL, Brand Price means the price of the Brand Drug published in the May AHWDBL in an Established IC Grouping or, if there is more than one originator/brand product in the Established IC Grouping, the Brand Price is the lowest published price of a Brand Drug in the Established IC Grouping, Confirmed Price means a Confirmed Price as set out in clause 3, Distribution Allowance means an amount which may not exceed 7.5% of the Confirmed Price of a Drug Product subject to the Non-Fixed Pricing Rules. Device means a product approved by Health Canada as a device and listed or under consideration for listing by the Minister on the AHWDBL, Drug Product means anything that is listed or under consideration for listing by the Minister on the AHWDBL, Drug Program Act or DPA means the Drug Program Act of Alberta, Effective Brand Price means the price of the Brand Drug published in the AHWDBL in the New IC Grouping effective the date Alberta Blue Cross received the IC Drug submission or submissions (that trigger the creation of the New IC Grouping) in accordance with the AHWDBL submission requirements or, if there is more than one Brand Drug, the Effective Brand Price is the published price of the lowest priced Brand Drug in the New IC Grouping, Effective Other Drug Price means the price of the Other Drug published in the AHWDBL in the New IC Grouping effective the date Alberta Blue Cross received the IC Drug submission or submissions (that trigger the creation of the New IC Grouping) in accordance with the AHWDBL submission requirements,
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 44
Effective Period means the Effective Period stated in an APC, Entry IC Drug means a Drug Product that is listed or under consideration for listing in a New IC Grouping, Established IC Grouping means an IC Grouping that was established on or before May 1, 2012 and listed in the May AHWDBL, Fixed Price means the applicable Fixed Price as set out in the Fixed Pricing Rules, IC Drug means a Drug Product that is listed, or is under consideration for listing, as interchangeable with one or more Drug Products as determined by the Minister in accordance with the requirements relating to interchangeability in the AHWDBL, IC Grouping means a category on the AHWDBL where there are two or more IC Drugs listed or under consideration for listing as part of one grouping on the AHWDBL as determined by the Minister, Interim APC means an APC issued by the Minister for one or more Drug Products, or one or more categories or groupings of Drug Products during an Effective Period, Interim APC Terms and Conditions means the terms and conditions outlined in an Interim APC, Least Cost Alternative Price or LCA Price means the maximum amount established by the Minister which will be paid by the Government of Alberta for a Drug Product in an Established IC Grouping or New IC Grouping for members of a Plan, Licensed Pharmacy means a pharmacy that is licensed or required to be licensed under the Pharmacy and Drug Act of Alberta, List has the same meaning as “Alberta Health and Wellness Drug Benefit List”, MAC Grouping means a grouping of Drug Products that have been listed in the AHWDBL and are subject to a MAC Price; a MAC Grouping may include a grouping of IC Drugs, in which case the grouping shall be treated as an Established IC Grouping, Manufacturer means an entity that manufactures, sells or distributes a Drug Product, Maximum Allowable Cost Price or MAC Price means the maximum amount established by the Minister that will be paid by the Government of Alberta for a Drug Product in a MAC Grouping for members of a Plan, May AHWDBL means the AHWDBL published by the Minister on or about May 1, 2012, Minister means Her Majesty the Queen in Right of Alberta, as represented by the Minister of Health and Wellness, New IC Grouping means an IC Grouping that was established or may be established after May 1, 2012, Other Drug means a Drug Product that is not an IC Drug, an Entry IC Drug, or a Brand Drug listed or under consideration for listing on the AHWDBL. For further clarity, the status of an Other Drug Product changes to that of an IC Drug when another IC Drug is listed or under consideration for listing in the same grouping as the Other Drug, which grouping becomes an IC Grouping,
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 45 EFFECTIVE JULY 1, 2012
Plan means a plan or program for which the Government of Alberta provides benefits in respect of Drug Products listed on the AHWDBL, Price Confirmation means the package of documents identified in an APC which must be completed and submitted in accordance with this Price Policy and the APC Terms and Conditions, Product Listing Agreement or PLA means a product listing agreement that is entered into or may be entered into by the Minister in respect of any Drug Product in accordance with the Minister’s Product Listing Agreement Policy, including any Drug Product that is listed or under consideration for listing on the AHWDBL, Product Listing Agreement Policy means any product listing agreement policy (including any processes related thereto) that may be published by the Minister from time to time.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 46
ALBERTA PRICE CONFIRMATION (APC)
1. The Minister may from time to time issue an Alberta Price Confirmation (APC), where a Manufacturer will be invited to submit a Price Confirmation, with one or more Confirmed Prices, in accordance with the APC Terms and Conditions.
2. The Manufacturer must ensure that a Price Confirmation and a Confirmed Price submitted by a Manufacturer comply with this Price Policy and the APC Terms and Conditions.
3. For purposes of an APC and submitting a Price Confirmation, and subject to exceptions permitted by and approved under the Price Policy, the Confirmed Price for a Drug Product is:
a. For a Drug Product subject to the Fixed Pricing Rules, a price that is less than or equal to the Fixed Price (per unit of issue) as defined in the Price Policy (and shown in the Base Cost column of the electronic APC that may be accessed through the Alberta Blue Cross Manufacturer/vendor Online Services web site).
b. For a Drug Product subject to the Non-Fixed Pricing Rules:
i. either
(a) the Base Cost, or
(b) a revised Base Cost, as set out in section 21,
both of which must not exceed the highest price permitted in the Non-Fixed Pricing Rules.
4. In addition, a Confirmed Price:
a. is applicable to a Drug Product regardless of the package size for each Drug Product; b. must not include the Goods and Services Tax (GST) or any other tax; and c. must not include any amount for a Distribution Allowance.
5. Exceptions to the Fixed Pricing and Non-Fixed Pricing Rules may be requested.
6. If an exception is requested for a Drug Product in a Price Confirmation, but is not approved by the Minister, the Manufacturer will not be given another opportunity to submit a new Price Confirmation or a new Confirmed Price in respect of such Drug Product, unless:
a. the Minister, at the Minister’s sole discretion, determines it is advisable to do so; or b. the Manufacturer follows the applicable resubmission process referred to in the
AHWDBL.
7. (a) The Manufacturer is responsible for ensuring that sufficient supply of a Drug Product, for which a Confirmed Price has been submitted, is available for the Alberta market for the duration of the Effective Period.
(b) If the Manufacturer anticipates that it may be unable to comply with the provisions of section 7(a), the Manufacturer must advise Alberta Blue Cross immediately in writing.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 47 EFFECTIVE JULY 1, 2012
8.
a. For a Drug Product subject to the Fixed Pricing Rules, the Manufacturer agrees and warrants that the Confirmed Price is the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period.
b. For a Drug Product subject to the Non-Fixed Pricing Rules, the Manufacturer agrees and warrants that the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period is the Confirmed Price plus a Distribution Allowance provided such Drug Product is distributed or sold only through a licensed wholesaler.
c. For a Drug Product subject to the Non-Fixed Pricing Rules, the Manufacturer agrees and warrants that the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period is the Confirmed Price, provided such Drug Product is not distributed or sold only through a licensed wholesaler.
9. Further, the Manufacturer agrees that it will take all necessary steps to ensure that any distributor, wholesaler or other person with whom it enters into a contract or any other arrangement, including (without limitation) the transfer or assignment of any or all rights and/or obligations in connection with a Drug Product that is listed on the AHWDBL:
i. makes the Drug Product available for sale to a Licensed Pharmacy, for the duration of the Effective Period, at a price that does not exceed the maximum price permitted for such Drug Product as set out in clause 8 (a), 8 (b), or 8 (c), as applicable and
ii. complies with the Price Policy and all the APC Terms and Conditions relating to such Drug Product.
10. The Minister may consider a Price Confirmation or Confirmed Price and may, at the
Minister’s sole discretion:
a. accept none, one or more Price Confirmations (with or without any request for an exception to the Fixed Pricing or Non-Fixed Pricing Rules (as applicable)); and
b. accept none, one or more Confirmed Prices (with or without any request for an exception to the Fixed Pricing or Non-Fixed Pricing Rules (as applicable)) submitted in one or more Price Confirmations.
11. Notwithstanding the acceptance of a Confirmed Price, the Minister is not obligated to pay that price for members of a Plan, but may establish special or exceptional prices, including but not limited to establishing:
a. an LCA Price, b. a MAC Price, or c. a special or exceptional price.
12. When considering a Price Confirmation or Confirmed Price for acceptance, and in determining whether to establish an LCA Price, a MAC Price, or a special or exceptional price, the Minister may consider any factor or criteria outlined in the AHWDBL, any matter permitted by the Drug Program Act, or any matter that the Minister determines is in the public interest.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 48
INTERIM APC
13. Notwithstanding the acceptance of a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, in the event that, during an Effective Period:
a. a new Drug Product is being considered for listing in an Established IC Grouping,
New IC Grouping or MAC Grouping, b. a Manufacturer submits a price reduction in accordance with this Price Policy for a
Drug Product listed in an Established IC Grouping, New IC Grouping or MAC Grouping, or
c. for any reason that the Minister determines that it is advisable to do so,
the Minister may, at the Minister’s sole discretion, issue an Interim APC for one or more Drug Products, or one or more groupings of Drug Products.
14. If a Manufacturer submits a new Drug Product submission for review and listing on the
AHWDBL, and an Interim APC is issued, the Manufacturer must submit a Confirmed Price for that Drug Product that:
a. is equal to or less than the price as outlined in the Drug Product submission, and b. does not exceed the prices permitted under this Price Policy,
or the Drug Product may not be listed or the listing of the Drug Product may be delayed.
15. When an Interim APC is issued, all Manufacturers who have a Drug Product listed in the affected Established IC Grouping, New IC Grouping or MAC Grouping will be invited, but are not required, to submit a new Price Confirmation and Confirmed Price for the affected Drug Product, and in the event that a new Price Confirmation for an affected Drug Product is not submitted, or if a Price Confirmation with the same Confirmed Price for the affected Drug Product is submitted, then the Confirmed Price shown in the most recent AHWDBL (prior to the issuance of the Interim APC) shall continue to apply to the affected Drug Product.
16. In the event the Minister issues an Interim APC, and a Price Confirmation or all or part of a Price Confirmation, or one or more Confirmed Prices are accepted as a result of the Interim APC, the Interim APC Terms and Conditions supercede any previous APC or Interim APC Terms and Conditions for the affected Drug Products for the remainder of the Effective Period, with the exception of an affected Drug Product that continues to subsist on the AWHDBL in accordance with the provisions of section 15. For further clarity, this provision does not affect the Minister’s unfettered discretion at any time to make any decisions or take any steps including (without limitation) to amend a published price, an LCA Price, a MAC Price, the Price Policy, the Product Listing Agreement Policy, the AHWDBL or make any other adjustments the Minister considers advisable.
17. Publication of amended Confirmed Prices is at the discretion of the Minister.
18. Unless permitted in this Price Policy or by the Minister, at the Minister’s sole discretion, a Price Confirmation and a Confirmed Price may not exceed a Price Confirmation and a Confirmed Price for a Drug Product that has been submitted and approved by the Minister through a prior APC relating to such Drug Product.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 49 EFFECTIVE JULY 1, 2012
19. The provisions in this Price Policy that apply to an APC also apply to an Interim APC, and where the term APC is used in such sections, it shall be deemed to read Interim APC in the case of an Interim APC. This section does not apply to section 16.
FIXED PRICING RULES
20. The Fixed Pricing Rules apply to any Drug Product, other than any Brand Drug or Other Drug, that is listed or under consideration for listing on the AHWDBL. Effective July 1, 2012, a Confirmed Price:
a. must not exceed the Fixed Price as follows:
i. For an IC Drug listed or under consideration for listing in an Established IC Grouping , the Fixed Price will be less than or equal to:
A. 35% of the Brand Price; B. If there is no Brand Price, or if the Brand Price is equal
to the LCA Price for that Established IC Grouping in the May AHWDBL, 62.5% of the lowest price published in the Established IC Grouping in the May AHWDBL.
ii. For an Entry IC Drug, the Fixed Price will be less than or equal to:
A. 35% of the Effective Brand Price, where the Drug Product is listed or under consideration for listing in a New IC Grouping which includes or will include a Brand Drug; or
B. 35% of the Effective Other Drug Price, where the Drug Product is listed or under consideration for listing in a New IC Grouping which includes or will include an Other Drug,
b. and must not include a Distribution Allowance.
NON-FIXED PRICING RULES (FOR BRAND DRUGS AND OTHER DRUGS)
21. Effective July 1, 2012, the Confirmed Price for a Brand Drug and an Other Drug must comply with the following:
a. The Confirmed Price must be less than or equal to:
i. the Base Cost; or
ii. a revised Base Cost may be submitted that is equal to (i) the Base Cost plus (ii) a percentage (%) of the Base Cost that is equal to the annual average percentage change from the previous year of the Consumer Price Index for Canada, all items, not seasonally adjusted, published by Statistics Canada.
b. and the Confirmed Price must not include a Distribution Allowance.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 50
c. The Confirmed Price in respect of a Drug Product may only increase once per 12 month period commencing on April 1st in one year and continuing through March 31st
in the next year, and must be submitted through a Price Confirmation. EXCEPTIONS
22. Notwithstanding the Fixed Pricing Rules and the Non-Fixed Pricing Rules, exceptions to the Fixed Pricing Rules and Non-Fixed Pricing Rules may be considered at the sole discretion of the Minister. Where an exception is requested, the Minister reserves the right to request such additional evidence and information in support of such request as the Minister deems appropriate.
23. The Minister may, but is not required to, consider exceptions where:
a. For an Entry IC Drug, there was a decrease of greater than 20% in the price of the Brand Drug or the Other Drug (as applicable) published in the AHWDBL within the 12 months preceding the date that the Drug Product submission in respect of the Entry IC Drug was received by Alberta Blue Cross;
b. For Drug Products with: i. less than 250 claims1
ii. an annual net cost; and
2
of less than $50,000;
for Plans, as calculated by the Minister and based on claims experience information provided by Alberta Blue Cross relating to Plans, for the period of time that the Drug Product was listed on the AHWDBL in the previous 12 months;
c. The manufacturing and distribution costs for a Drug Product exceed the maximum price for such Drug Product permitted by the Fixed Pricing Rules or Non-Fixed Pricing Rules (as applicable3
d. Where exceptional circumstances exist
);
4
, and the Minister determines that an exception is appropriate.
24. Exceptions will not be considered for an IC Drug if the Confirmed Price for another Drug Product in the Established IC Grouping or New IC Grouping is at or below the Fixed Price.
25. Requests for an exception may delay the listing or price publication of the Drug Product.
1 “claims” means the total number of prescriptions submitted for reimbursement to the Plans for all Drug Products in the grouping. 2 “cost” means the drug material cost for claims 3 Please provide a breakdown of the costs attributed to (a) the costs for each raw material separately, including that of the active pharmaceutical ingredient, (b) the cost of manufacturing (excluding costs of raw materials), (c) cost of distribution (including direct distribution fees paid to distributors but excluding all rebates/professional allowances), and (d) other (if applicable, please specify what “other” costs represent). Rebates/professional allowances must be excluded from all costs provided herein. Costs must be stated in one unit of measure consistent for all costs requested herein (for example, cost per tablet). 4 Exceptional circumstances include, but are not limited to, circumstances where, in the opinion of the Minister, significant patient safety or access concerns, or significant increased costs to the Plans could result if the Drug Product was not available on the AHWDBL.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 51 EFFECTIVE JULY 1, 2012
PRICE REDUCTIONS
26. During an Effective Period, further price reductions for Drug Products listed on the AHWDBL will be considered as follows:
a. For IC Drugs and Drug Products listed in a MAC Grouping if the proposed price is
i. 5% less than, or ii. would represent an annual net cost5
savings of more than $100,000 for the Plans, as calculated by the Minister, for the period of time that the Drug Product was listed on the AHWDBL in the previous 12 months, in comparison to
the LCA Price or MAC Price published at the time Alberta Blue Cross receives the proposed price reduction.
b. For all other Drug Products, by notifying the Minister by sending a written notice to Alberta Blue Cross.
27. Establishment of a new LCA Price or MAC Price and publication of a reduced price is subject to:
b. the Manufacturer submitting a Price Confirmation and a reduced Confirmed Price for the new price in accordance with the APC Terms and Conditions;
c. acceptance of the new Confirmed Price by the Minister; and d. the Minister’s sole discretion regarding the establishment of a new LCA Price or MAC
Price, and the time, place and method of publication. MINISTER’S AUTHORITY
28. Notwithstanding anything to the contrary, where
a. no Price Confirmation and Confirmed Price is submitted in respect of a Drug Product;
b. there is a failure to submit a Price Confirmation or Confirmed Price in respect of a Drug Product in accordance with the APC Terms and Conditions;
c. there is a rejection or non-acceptance of a Price Confirmation, or of all or part of a Price Confirmation, or of one or more Confirmed Prices, or of a request for an exception to either the Fixed Pricing Rules or Non-Fixed Pricing Rules;
d. there is a failure by the Manufacturer to comply with the APC Terms and Conditions in respect of a Drug Product listed or under consideration for listing on the AHWDBL;
e. the Minister considers that a PLA that is satisfactory to the Minister must be entered into prior to and/or as a condition of the listing, or continued listing, of a Drug Product on the AHWDBL;
the Minister may, at the Minister’s sole discretion, do any one or more of the following:
i. cancel the listing of, 5 “cost” means the drug material cost for claims
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 52
ii. modify the listing of,
iii. refuse to add to the AHWDBL,
iv. refuse to expedite the submission of,
v. cancel or modify the benefit payable for,
vi. modify or impose rules, terms, restrictions or conditions (including the execution of a PLA satisfactory to the Minister) relating to, or
vii. take any other action in relation to
the Drug Product for any period of time deemed appropriate by the Minister.
29. Notwithstanding any other provision in this Price Policy, and for the avoidance of doubt, the Minister, in his sole discretion, has and retains the sole right to determine all matters relating to the listing or continued listing of a Drug Product on the AHWDBL, including (without limitation) the sole right to determine:
a. whether or not the Fixed Pricing Rules or the Non-Fixed Pricing Rules apply to a
Drug Product, b. whether or not a Drug Product is to be considered as an IC Drug, a Brand Drug,
or an Other Drug for purposes of this Price Policy and an APC, and c. whether or not a PLA must be executed as a condition of the listing or continued
listing of a Drug Product on the AHWDBL
30. For further clarity, in all cases where the execution of a PLA in respect of a Drug Product is required as a condition of the listing or continued listing of a Drug Product on the AHWDBL, the provisions of the Product Listing Agreement Policy must be satisfied. Nothing in this Price Policy is intended to limit or override the application or any provisions of the Product Listing Agreement Policy. The requirements for listing or continued listing of a Drug Product outlined in the AHWDBL, including (without limitation) this Price Policy, as well as the Product Listing Agreement Policy must be satisfied.
31. Notwithstanding anything to the contrary, and notwithstanding the acceptance of a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, the Minister shall have the unfettered discretion to
a. make any decisions or take any steps to amend a published price, an LCA Price, a MAC Price, a special or exceptional price, the Price Policy, the Product Listing Agreement Policy, the AHWDBL or make any other adjustments the Minister considers advisable;
b. make any decisions, take any actions or steps, or do anything that is authorized by the Drug Program Act;
c. pursue, negotiate and enter into agreements with one or more Manufacturers, distributors or vendors, including (without limitation) a PLA Agreement,
d. make arrangements with other persons to provide access to Drug Products for members of the Plans,
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 53 EFFECTIVE JULY 1, 2012
e. make any decisions, or take any actions or steps, or do anything that the Minister considers appropriate (including, without limitation, issuing an APC), and
f. terminate an APC, a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, or the listing of any or all Drug Products on the AHWDBL, upon 10 days written notice to any affected Manufacturer, which notice is deemed to be given by the Minister and received by the Manufacturer upon (a) publication of the written notice on the AHWDBL website operated by Alberta Blue Cross, or (b) by sending the notice via telefax to the last known telefax number of the Manufacturer, and the method of notice is at the Minister’s discretion,
in order to maintain the integrity of the AHWDBL, to ensure reasonable access to treatment for members of the Plans, or to serve the public interest.
32. Subject to section 31, where the Minister amends the Price Policy during an Effective Period, the Minister shall provide Manufacturers of Drug Products listed on the AHWDBL as at that date with 30 days notice of such amendment, and the Minister may also issue an APC in relation to any Drug Product affected by such amendment.
33.The Minister reserves the right to pursue any remedies available to the Minister in the event of any non-compliance with, or any breach of, the Price Policy or APC Terms and Conditions.
34. a. The Minister, Alberta Blue Cross, and their respective officers, employees, and
agents, are not liable for any actions, damages, claims, liabilities, costs, expenses, or losses in any way, including consequential, special, indirect, incidental, punitive or special damages, costs, expenses, or losses (including, without limitation, lost profits and opportunity costs) arising out of or relating to an APC, an Interim APC, any Price Confirmation, a Confirmed Price, or the AHWDBL, even if the Minister or Alberta Blue Cross have been advised of the possibility of such damages beforehand. The provisions of this clause shall apply regardless of the form of action, damage, claim, liability, cost, expense, or loss, whether in contract, statute, tort (including, without limitation, negligence), or otherwise, and
b. in no event shall the maximum aggregate liability of the Minister, Alberta Blue Cross, and their respective officers, employees, and agents, for damages related to an APC, an Interim APC, a Price Confirmation, a Confirmed Price, or the AHWDBL be greater than $25,000, or the Manufacturer’s actual costs of preparing and submitting a Price Confirmation in response to an APC, whichever is less.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 54
LEAST COST ALTERNATIVE (LCA) PRICE POLICY 1. The Least Cost Alternative Price or LCA Price means the maximum amount established by
the Minister which will be paid by the Government of Alberta for a Drug Product in an Established or New IC Grouping for members of a Plan.
2. Where the Minister establishes an LCA Price in Established and New IC Groupings the LCA
Price: a. is the lowest unit cost for a Drug Product in an IC Grouping that was submitted by the Manufacturer and accepted by the Minister in the most recent Alberta Price Confirmation.
b. appears in bold type in the far right column of the AHWDBL.
c. applies to all Drug Products in the applicable IC Grouping, unless the Minister determines that an exception should be made.
3. Where the Minister establishes an LCA Price in Established and New IC Groupings, the
Government of Alberta will pay the Actual Acquisition Cost for the Drug Product to a maximum of the LCA Price.
4. Notwithstanding section 2 above, the LCA Price Policy does not apply to:
• conjugated estrogens; • devices; and • injectable Drug Products with different package sizes in an IC Grouping.
5. Subject to a Special Authorization being granted pursuant to section 6, where a physician
prescribes or a patient chooses an IC Drug that is priced higher than the LCA Price established by the Minister in the applicable IC Grouping, the patient will be responsible for any additional costs (being the difference in price between the higher-priced IC Drug and the LCA Price).
6. A physician may request Special Authorization if an IC Drug that is priced higher than the
applicable LCA Price is essential in the care of a patient. For further information refer to the Special Authorization Guidelines section of the AHWDBL.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 55 EFFECTIVE JULY 1, 2012
MAXIMUM ALLOWABLE (MAC) PRICE POLICY 1. The MAC Price means the maximum amount established by the Minister which will be paid
by the Government of Alberta for a Drug Product in a MAC Grouping for members of a Plan. 2. A MAC Grouping means a grouping of Drug Products that have been listed in the AHWDBL
or the List as being subject to a MAC Price; a MAC Grouping may include a grouping of IC Drugs, in which case the grouping shall be treated as an Established IC Grouping.
3. Where the Minister has established a MAC Price for a MAC Grouping: a. The MAC Price appears in bold italic type and is displayed in the AHWDBL in the
second column from the right where two price columns are listed. A comment in bold italic type appears following a MAC Grouping to explain the basis for establishing the MAC Price.
b. The Government of Alberta will pay the Actual Acquisition Cost for the Drug Product
to a maximum of the MAC Price. 4. The MAC Price Policy applies to the following MAC Groupings:
PTC 28:08.04.92 Selected Oral Modified-Release Dosage Forms of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
• PTC 40:12 Potassium Chloride (K+) 8 mEq Oral Sustained-Release Tablets
5. Subject to a Special Authorization being granted, where a physician prescribes or a patient
chooses a Drug Product in a MAC Grouping that is priced higher- than a MAC Price established by the Minister for the applicable MAC Grouping, the patient will be responsible for any additional costs (being the difference in price between the higher-priced Drug Product and the MAC Price).
6. A physician may request Special Authorization if the Drug Product that is priced higher than the applicable MAC Price is essential in the care of a patient. For further information refer to the Special Authorization Guidelines section of the AHWDBL.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 56
RESTRICTED BENEFITS
Restricted Benefits
Selected devices or drug products are eligible benefits with restrictions in the Alberta Health and Wellness Drug Benefit List. For these products a comment is displayed in the List after the ingredient name. The comment initially states “RESTRICTED BENEFIT” and is followed by an explanation of the restriction. For an example, refer to the Legend in the Introduction section of the List.
Products Designated as Restricted Benefits
The products listed below are restricted benefits in the List.
PTC 00:00:02 Diabetic Supplies Blood Glucose Test Strips, Blood Letting Lancet, Insulin Pen Needles,
Insulin Syringes, Urine Test Strips PTC 08:18.08.20 Lamivudine 100 mg oral tablet Tenofovir Disoproxil Fumarate 300 mg oral tablet
PTC 08:18.20 Peginterferon Alfa-2A 180 mcg/0.5 ml injection syringe and 180 mg/ml injection
PTC 08:18.32 Adefovir Dipivoxil 10 mg oral tablet Entecavir 0.5 mg oral tablet PTC 12:20.04 Cyclobenzaprine HCL 10 mg oral tablet
PTC 12:92:00 Varenicline Tartrate 0.5 mg oral tablet Varenicline Tartrate 1 mg oral tablet
PTC 20:12.04.92 Rivaroxaban 10 mg oral tablet
PTC 28:16.08.04 Risperidone 1 mg/ml oral solution Aripiprazole 2 mg oral tablet Aripiprazole 5 mg oral tablet
PTC 28:32.28 Naratriptan HCL 1 mg and 2.5 mg oral tablet
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 57 EFFECTIVE JULY 1, 2012
Rizatriptan Benzoate 5 mg oral tablet, 10 mg oral tablet, 5 mg oral wafer and 10 mg oral wafer
Sumatriptan Hemisulfate 5 mg/dose and 20 mg/dose unit dose nasal spray
Sumatriptan Succinate 50 mg oral tablet, 100 mg oral tablet and 6 mg/syr injection syringe Zolmitriptan 2.5 mg oral tablet, 2.5 mg oral dispersible tablet and 5 mg/dose unit dose nasal
spray PTC 48:10.24 Montelukast Sodium 4 mg oral chewable tablet, 5 mg oral chewable tablet, 10 mg oral tablet,
and 4 mg oral granule Zafirlukast 20 mg oral tablet PTC 52:08.08 Mometasone Furoate 50 mcg/dose aqueous nasal spray
PTC 52:92:00 Ranibizumab 2.3 mg/vial injection
PTC 56:22.92 Aprepitant/Aprepitant 80 mg/125 mg capsule
PTC 92:36:00 Leflunomide 10 mg oral tablet and 20 mg oral tablet
PTC 94:00:00 Aerosol Holding Chamber Aerosol Holding Chamber/Mask - Infant Aerosol Holding Chamber/Mask - Pediatric Aerosol Holding Chamber Mask - Adult
Limited Restricted Benefits
Selected drug products are eligible benefits with limits and restrictions in the Alberta Health and Wellness Drug Benefit List. For these products a comment is displayed in the List after the ingredient name. The comment initially states “LIMITED RESTRICTED BENEFIT” and is followed by an explanation of the limits and restrictions. For an example, refer to the Legend in the Introduction of the List.
Product(s) Designated as Limited Restricted Benefits
The product(s) listed below are limited restricted benefits in the List.
PTC 20:12.18
Clopidogrel Bisulfate 75 mg oral tablet
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1 • 58
SPECIAL AUTHORIZATION GUIDELINES Special Authorization Policy
Drug Products Eligible for Consideration by Special Authorization Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products not
1. The drug is covered by Alberta Health and Wellness under specified criteria (listed in the following sections). Drug Products and indications other than those specified are not eligible for consideration by special authorization.
eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization.
2. The drug is normally covered by another government program or agency for a specific approved clinical condition, but is needed for the treatment of a clinical condition that is not covered by that government program or agency.
3. The drug is required because other drug products listed in the Alberta Health and Wellness Drug Benefit List are contraindicated or inappropriate because of the clinical condition of the patient.
4. The particular brand of drug is considered essential in the care of a patient, where the LCA price policy would otherwise apply. Coverage of a specific brand may be considered where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with alternate brands in an interchangeable grouping. Coverage of a brand name product will not
5. A particular drug product or dosage form of a drug is essential in the care of a patient where the MAC price policy would otherwise apply. Exceptions may occur at the product level. Coverage may be considered only where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with the drug product which establishes the MAC pricing.
be considered in situations where the interchangeable grouping includes a pseudo-generic to the brand name drug.
Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.
Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage prior to the expiration date of the Approved Period, unless
Auto-Renewal Process
the Auto-Renewal Process or Step Therapy Approval Process apply (see below).
Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).
1. For initial approval, a special authorization request must be submitted. If approval is granted, it will be effective for the Approval Period outlined in the drug product’s Special Authorization criteria.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1 • 59 EFFECTIVE JULY 1, 2012
2. As long as the patient has submitted a claim for the drug product within the preceding Approval Period (example: within the preceding 6 months), approval will be automatically renewed for a further Approval Period (example: a further 6 months). There is no need for the prescriber to submit a new request as the automated real-time claims adjudication system will read the patient’s claims history to determine if a claim has been made within the preceding Approval Period.
3. If the patient does not
make a claim for the drug product during the Approval Period, the approval will lapse and a new special authorization request must be submitted.
Step Therapy Approval Process Select drug products are eligible for coverage via the step therapy process, outlined below.
1. If the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months, the claim for the step therapy drug will be approved.
2. The automated real-time claims adjudication system will read the patient’s claims history to determine if the required First-Line* drug product(s) have been claimed within the preceding 12 months.
3. Subsequent claims for drug product(s) permitted by step therapy will continue to be approved as long as the drug product has been claimed within the preceding 12 months.
4. The regular special authorization approval process will continue to be available for step therapy approvals for those patients whose First-Line* drug claims cannot be adjudicated through the automated real-time claims adjudication system.
* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’s Special Authorization criteria, are required to be utilized before reimbursement for the drug product is permitted.
Drug Products Not Eligible for Consideration by Special Authorization The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List. 2. Drug products not yet reviewed by the Alberta Health and Wellness Expert Committee on
Drug Evaluation and Therapeutics. This applies to: products where a complete submission has been received from the manufacturer and
the product is under review, products where an incomplete submission has been received from the manufacturer,
and products where the manufacturer has not made a submission for review.
Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.
3. Drug products that have completed the review process and are not included on the List. 4. Most drugs available through Health Canada’s Special Access Program. 5. Drug products when prescribed for cosmetic indications. 6. Nonprescription or over-the-counter drug products are generally not eligible.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 1
38BSpecial Authorization Procedures
A prescriber’s request for special authorization should be directed by mail or FAX to: Clinical Drug Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5
FAX: (780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free fax for all other areas
1. For most drug products, written requests from a prescriber may be submitted on the general Drug
Special Authorization Request (form number ABC 20061).
Select drug products such as Donepezil/Galantamine/Rivastigmine (form number ABC 30776), Clopidogrel (form number ABC 30786), Darbepoetin/Epoetin (form number ABC 30888), Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis (form number ABC 30902), Ezetimibe (form number ABC 30925), Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin (form number ABC 30932), Peginterferon Alfa-2a for Chronic Hepatitis C (form number ABC 30944), Etanercept for Juvenile Idiopathic Rheumatoid Arthritis (form number ABC 30948), Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis (form number ABC 30964), Select Quinolones (form number 30966), Alendronate/Raloxifene/ Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis (form number ABC 31086), Celecoxib (form number ABC 31140), Filgrastim/Pegfilgrastim (form number ABC 31150) Fentanyl (form number ABC 31169), Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis (Form number ABC 31192), Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis (form number ABC 31195), Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease (form number ABC 31200), Rituximab for Rheumatoid Arthritis (form number ABC 31205), Imiquimod (form number ABC 31222), Dutasteride/Finasteride (form number ABC 31257), Paliperidone/Risperidone Prolonged Release Injection (form number ABC 31258), Abatacept for Juvenile Idiopathic Arthritis (form number ABC 31291), Montelukast/Zafirlukast (form number ABC 31313), Febuxostat (form number 31376), Denosumab (form number 31377), Omalizumab (form number 31406) and Eculizumab (form number ABC 31386 and ABC 31408) have a unique special authorization request form. All requests for these drug products must be submitted using the applicable form.
Special authorization request forms can be found on the following pages.
2. A separate request is required for each patient.
3. For a request for special authorization to be considered, the prescriber (an individual authorized by law to prescribe) must contact Alberta Blue Cross and provide the following information:
Patient Identification patient’s name, address and card holder’s name (if different than the patient’s), Alberta Blue Cross identification number or coverage number/client number of any other applicable
coverage (e.g. Alberta Human Services and Alberta Seniors (AISH) or Alberta Personal Health number, and
date of birth.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 2 EFFECTIVE JULY 1, 2012
Prescriber Identification name of prescriber (e.g. physician, dentist, or optometrist), address, telephone number and FAX number (if applicable), and professional association registration number (e.g. College of Physicians and Surgeons, Alberta Dental
Association, or Alberta College of Optometrists registration number).
Drug Requested name, strength and dosage form, dosage schedule, and proposed duration of therapy.
Reason for the Request diagnosis and/or indication for which the drug is being used, information regarding previous medications which have been used
and the patient’s response to therapy where appropriate, proposed results of therapy, and any additional information that may assist in making a decision on the
request for special authorization.
39BSpecial Authorization Forms
Special Authorization forms can be found on the following pages:
Drug Special Authorization Request Form (ABC 20061) Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776) - All
requests for donepezil HCl, galantamine hydrobromide or rivastigmine hydrogen tartrate and must be submitted using this form only.
Clopidogrel Special Authorization Request Form (ABC 30786) - All requests for clopidogrel bisulfate must be submitted using this form only.
Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888) - All requests for darbepoetin or epoetin alfa must be submitted using this form only.
Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902) - All requests for abatacept, adalimumab, anakinra, etanercept, golimumab, infliximab or tocilizumab for Rheumatoid Arthritis must be submitted using this form only.
Ezetimibe Special Authorization Request Form (ABC 30925) - All requests for ezetimibe must be submitted using this form only.
Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) - All requests for peginterferon alfa-2a/ribavirin or peginterferon alfa-2b/ribavirin must be submitted using this form only.
Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944) - All requests for peginterferon alfa-2a for Chronic Hepatitis C must be submitted using this form only.
Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 30948) - All requests for etanercept for Juvenile Idiopathic Arthritis must be submitted using this form only.
Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964) - All requests for adalimumab, etanercept, golimumab or infliximab for Psoriatic Arthritis must be submitted using this form only.
Select Quinolones Special Authorization Request Form (ABC 30966) - All requests for ciprofloxacin, levofloxacin, moxifloxacin or ofloxacin must be submitted using this form only.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 3
Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form (ABC 31086) - All requests for alendronate, raloxifene, risedronate or synthetic calcitonin salmon for Osteoporosis must be submitted using this form only.
Celecoxib Special Authorization Request Form (ABC 31140) – All requests for celecoxib must be submitted using this form only.
Filgrastim/Pegfilgrastim Special Authorization Request Form (form number ABC 31150) – All request for filgrastim or pegfilgrastim must be submitted using this form only.
Fentanyl Special Authorization Request Form (form number ABC 31169) - All requests for fentanyl or fentanyl citrate must be submitted using this form only.
Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192) - All requests for adalimumab, etanercept, infliximab or ustekinumab for Plaque Psoriasis must be submitted using this form only.
Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195) - All requests for adalimumab, etanercept, golimumab or infliximab for Ankylosing Spondylitis must be submitted using this form only.
Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form (ABC 31200) - All requests for adalimumab for Moderately to Severely Active Crohn's Disease or infliximab for Moderately to Severely Active Crohn’s/Fistulizing Crohn’s Disease must be submitted using this form only.
Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205) - All requests for abatacept or rituximab for Rheumatoid Arthritis must be submitted using this form only.
Imiquimod Special Authorization Request Form (ABC 31222) – All requests for imiquimod must be submitted using this form only.
Dutasteride/Finasteride Special Authorization Request Form (ABC 31257) – All requests for dutasteride or finasteride must be submitted using this form only.
Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258) – All requests for paliperidone/risperidone prolonged release injection must be submitted using this form only.
Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291) - All requests for abatacept for Juvenile Idiopathic Arthritis must be submitted using this form only.
Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313) – All requests for montelukast or zafirlukast must be submitted using this form only.
Febuxostat Special Authorization Request Form (ABC 31376) – All requests for febuxostat must be submitted using this form only.
Denosumab Special Authorization Request Form (ABC 31377) – All requests for denosumab must be submitted using this form only.
Omalizumab Special Authorization Request Form (ABC 31406)- All requests for omalizumab must be submitted using this form only.
Eculizumab Special Authorization Request Form (ABC 31386) – All requests for eculizumab must be submitted using this form only.
Eculizumab Consent Form (ABC 31408) -– All requests for eculizumab must be accompanied by this form.
The following official forms are provided for your convenience to photocopy and use as required. Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please DO NOT mail or re-fax your request
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 4 EFFECTIVE JULY 1, 2012
40BDrug Special Authorization Request Form
On the reverse is the official Drug Special Authorization Request Form (ABC 20061).
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
DRUG SPECIAL AUTHORIZATION REQUEST
Please complete all required sections to allow your request to be processed. PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
NEW RENEWAL DRUG REQUEST Note: Request may or may not be approved by Alberta Blue Cross Drug(s), Dosage(s) and Duration Requested:
Diagnosis and / or Indication which drug is being used to treat: (Include applicable information regarding previous medications, patient response to therapy and proposed results of therapy.)
Additional information relating to request:
PRESCRIBER’S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 20061 (R11/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 6 EFFECTIVE JULY 1, 2012
Donepezil/Galantamine/Rivastigmine Special Authorization Request Form
On the reverse is the official Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).
• All requests for donepezil HCl, galantamine hydrobromide or rivastigmine hydrogen tartrate must be submitted using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
DONEPEZIL/GALANTAMINE/RIVASTIGMINE SPECIAL AUTHORIZATION REQUEST FORM
Please complete ALL sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross
Alberta Human Services
Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION
PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA
CARNA
ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
CITY , PROVINCE PHONE:
FAX:
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of DONEPEZIL, GALANTAMINE, RIVASTIGMINE For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4. Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination. Special authorization coverage may be granted for a maximum of 24 months per request. For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided. Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug.
Note: • an MMSE score below 10 or an InterRAI-Cognitive Performance Scale score greater than 4 at any time will result in discontinuation
of coverage.
PLEASE COMPLETE ALL SECTIONS TO ALLOW YOUR REQUEST TO BE PROCESSED
Indicate which drug is requested:
Donepezil Galantamine Rivastigmine
Please confirm the diagnosis for which this drug is requested: For the treatment of: Dementia of the Alzheimer’s Type other, please specify: __________________________________________________
Please provide a current MMSE or InterRAI-Cognitive Performance Scale score* and the date the exam was administered: MMSE Score: _____________________ InterRAI-Cognitive Performance Scale Score: _____________ Date of exam: _____________________ Date of exam: ______________________________________
PRESCRIBER'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5 ABC 30776 (R12/2011) The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of Independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 8 EFFECTIVE JULY 1, 2012
Clopidogrel Special Authorization Request Form
On the reverse is the official Clopidogrel Special Authorization Request Form (ABC 30786). • All requests for clopidogrel bisulfate must be submitted using the Clopidogrel Special
Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
CLOPIDOGREL SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE
IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Post-Stent Coverage Section I (Must complete for requests for post-stent coverage)
For the prevention of thrombosis, for one month, when prescribed following intravascular bare metal stent placement. Patients who have received one month of coverage via the Limited Restricted Benefit will not be eligible for additional coverage under this criterion. * For the prevention of thrombosis, for up to 12 months, when prescribed following intravascular drug eluting stent (DES) placement. Patients who have received one month of coverage via the Limited Restricted Benefit may be eligible for an additional 11 months of coverage (i.e., up to 12 months of coverage) following the submission of a special authorization request. * * Special Authorization for post-stent coverage is required when the prescriber prescribing the medication is not a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery; for treatment after repeat stents; or for continued coverage of up to 12 months following intravascular drug eluting stent (DES) placement.
Please indicate the type and date of the stent: Date of stenting procedure: ________________________________________
bare metal stent (1 month of coverage)
drug eluting stent (12 months of coverage)
For additional coverage, please proceed to Section II below
Other Criteria for Coverage For the prevention of cerebrovascular (e.g. stroke, TIA) and non-cerebrovascular ischemic events in patients who have a contraindication to ASA. Special Authorization for this criterion may be granted for 24 months. For use in patients who have experienced a non-cerebrovascular ischemic event while on ASA. Special Authorization for this criterion may be granted for 24 months. For use in patients who have experienced a cerebrovascular ischemic event (e.g. stroke, TIA) while on dipyridamole/ASA (Aggrenox) or for whom dipyridamole/ASA (Aggrenox) is contraindicated. Special Authorization for this criterion may be granted for 24 months. Coverage will not be considered when clopidogrel and ASA/dipyridamole are intended for use in combination. Section II (Complete ALL that apply) Does this patient have a contraindication/intolerance to ASA? YES NO
Please indicate the cerebrovascular ischemic event experienced: Please specify the non-cerebrovascular ischemic event experienced:
stroke TIA
Did the cerebrovascular event occur while this patient was on dipyridamole/ASA (Aggrenox)?
Please indicate which anti-platelet therapy this patient was on when the non-cerebrovascular event occurred:
YES NO ASA other (specify):_____________________________
If applicable, please indicate which product this patient has a contraindication/intolerance to: Patient was not on anti-platelet therapy
dipyridamole/ASA (Aggrenox) dipyridamole
PRESCRIBER 'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30786 (R11/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 10 EFFECTIVE JULY 1, 2012
Darbepoetin/Epoetin Special Authorization Request Form
On the reverse is the official Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888). • All requests for darbepoetin or epoetin alfa must be submitted using the Darbepoetin/Epoetin
Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
DARBEPOETIN/EPOETIN SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross
Alberta Human Services
Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION
PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA
CARNA
ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
CITY , PROVINCE PHONE: FAX:
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Indicate which drug is requested (check one box): Darbepoetin Epoetin
PLEASE COMPLETE ALL APPLICABLE SECTIONS TO ALLOW YOUR REQUEST TO BE PROCESSED
ANEMIA OF CHRONIC RENAL FAILURE (does not
anemia of chronic renal failure
apply to epoetin 30,000 or 40,000 IU/mL strengths)
other, please specify: ____________________________
This section applies only to patients who received a renal transplant: Please indicate if the renal transplant is failing or has failed:
Yes No Hemoglobin level: For patients with prior special authorization for darbepoetin or epoetin with
Alberta Blue Cross: currentFor hemoglobin level (g/L): new patients: pre-treatment
Please provide the current iron status:
hemoglobin level (g/L):
Serum ferritin is >100 mcg/L: Yes No AND
CHEMOTHERAPY-INDUCED ANEMIA (includes epoetin 30,000 and 40,000 IU/mL strengths)
Transferrin saturation is >20%: Yes No
Please specify the type of cancer: _________________________________________________
other, please specify: _____________________________
For the treatment of anemia: Please indicate if the anemia is chemotherapy-induced:
Yes No, please specify: ____________________
Please provide the patient’s hemogloblin level (g/L):
Please specify the reason why blood transfusions are not an option: Transfusion reactions in the past Difficulty cross-matching the patient
Iron overload Other, please specify:____________________________
ANEMIA IN AZT-TREATED/HIV INFECTED PATIENTS (does not
anemia in AZT-treated/HIV infected patients apply to darbepoetin nor the epoetin 30,000 or 40,000 IU/mL strength)
other, please specify: __________________________________________________________________________________________
Additional information relating to request: PRESCRIBER 'S SIGNATURE DATE Please forward this request to:
Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30888 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
Criteria for Coverage:
DARBEPOETIN
“For the treatment of anemia of chronic renal failure in patients with low hemoglobin (<100 g/L). Hemoglobin levels should be maintained within 100 – 110 g/L. According to current practice guidelines patients’ iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin >100 mcg/L and transferrin saturation >20%.” “For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Aranesp should be reduced by about 25%.” In order to comply with the second criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient’s transferrin saturation, along with results of liver function tests if applicable. For the first criterion, renewal requests may be considered if the patient’s hemoglobin is < 120 g/L while on Aranesp. For the second criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Aranesp.
EPOETIN (ALL strengths except 30,000 and 40,000 IU/mL)
“For the treatment of anemia of chronic renal failure in patients with low hemoglobin (< 100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients’ iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin >100 mcg/L and transferrin saturation >20%.” "For the treatment of anemia in AZT-treated/HIV infected patients." "For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%.” In order to comply with the third criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests if applicable. For the first criterion, renewal requests may be considered if the patient’s hemoglobin is < 120 g/L while on Eprex. For the third criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Eprex.
EPOETIN 30,000 and 40,000 IU/mL strengths
"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%. Patients may be granted a maximum allowable dose of 40,000 IU per week.” In order to comply with this criterion, if the patient has iron overload the prescriber must state this in the request, or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests, if applicable. Renewal requests may be considered if the patient's hemoglobin is <110 g/L while on Eprex. ABC 30888 (R12/2011)
DARBEPOETIN/EPOETIN SPECIAL AUTHORIZATION CRITERIA
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 13
Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form
On the reverse is the official Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
• All requests for abatacept, adalimumab, anakinra, etanercept, golimumab, infliximab or tocilizumab for Rheumatoid Arthritis must be submitted using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ABATACEPT/ADALIMUMAB/ANAKINRA/ETANERCEPT/GOLIMUMAB/ INFLIXIMAB/TOCILIZUMAB for Rheumatoid Arthritis
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No: NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Enbrel, Humira, Kineret or Remicade drug benefits. Personal and health information is required in order to determine eligibility and, in the event you are approved to receive drug benefits, to maintain eligibility, process payments and conduct the Alberta Post-Marketing Study Addressing ENBREL/HUMIRA/KINERET/REMICADE (“Study”). The Study will assist Alberta Health and Wellness to monitor, plan, evaluate and manage the cost-effectiveness of providing Enbrel, Humira, Kineret or Remicade as a benefit under the AHWDBL. Therefore, your consent is required as set out herein. Important: In order to be eligible for, and to maintain eligibility for, Enbrel, Humira, Kineret or Remicade drug benefit both you and your physician(s) must agree to and continue to actively and consistently participate in the Study as required by Alberta Blue Cross, Alberta Health and Wellness, its affiliates and agents throughout the special authorization period. Refusal to provide the requested consent will result in benefits being denied, and withdrawal of consent will result in benefits being revoked.
I hereby authorize: (A)The below physician(s) to disclose to Alberta Blue Cross, Alberta Human Services, and Alberta Seniors (the "Designated Recipients") any of my personal or health information contained on this Request Form or requested by the Designated Recipients (collectively “My Information”); and (B) The Designated Recipients to use and collect My Information for the purposes stated on this form; and (C) The Designated Recipients to disclose My Information to any affiliates or agents of the Designated Recipients for the purposes stated on this form. I acknowledge that: I have been made aware of the reasons why my health information is needed, and the risks and benefits of consenting or refusing to consent to disclosure of my health information; and (2) I am aware that I may revoke this consent (in writing) at anytime. Signature/Effective Date Patient’s Signature
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO. STREET ADDRESS
CITY , PROVINCE PHONE:
FAX:
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis: Current weight (kg): Indicate requested drug: Tocilizumab Dosage:
Dosing Frequency: Rheumatoid Arthritis Other (specify)
Abatacept Etanercept
Adalimumab Infliximab
Anakinra Golimumab
Scores: * DAS28 Score ___.____ OR ACR20 (renewals only) Date: _____________
AND HAQ Score ___.___ ___ Date: _____________ * New requests for patients currently maintained on the requested biologics require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.
Please provide reason if a switch to a different biologic agent is requested:
Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
For all biologics EXCEPT Abatacept: Will the patient be maintained on methotrexate in combination with the requested biologic? YES NO
For Abatacept ONLY: Will the patient be maintained on methotrexate or another DMARD in combination with Abatacept? YES NO
If NO to any of the above, please specify reason:
Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required for ALL FOUR of the following:
Methotrexate PO: Methotrexate SC or IM: Methotrexate with another DMARD other than leflunomide (specify agent) : Leflunomide:
Please provide the following information for all NEW anakinra/tocilizumab requests: Previous medications utilized: Indicate the contraindication or adverse effects related to the following:
Abatacept: Adalimumab: Etanercept: Infliximab: Golimumab: Rituximab: Tocilizumab:
PRESCRIBER'S SIGNATURE DATE
Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
I am currently an active participant in the Alberta Post-Marketing Study addressing Enbrel / Humira / Kineret / Remicade
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30902 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 15
Ezetimibe Special Authorization Request Form
On the reverse is the official Ezetimibe Special Authorization Request Form (ABC 30925).
• All requests for ezetimibe must be submitted using the Ezetimibe Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
EZETIMIBE SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of EZETIMIBE For the treatment of hypercholesterolemia in patients who are intolerant to statins or in whom a statin is contraindicated and who are at high cardiovascular risk*, or; For the treatment of hypercholesterolemia when used in combination with a statin in patients failing to achieve target LDL with a statin at maximum tolerable dose or maximum recommended dose as per respective product monograph and who are at high cardiovascular risk* Special authorization may be granted for 6 months. This product is eligible for auto-renewal.
*High cardiovascular risk is defined as possessing one of the following: 1) pre-existing cardiovascular disease and/or cerebrovascular disease, or 2) diabetes, or 3) familial hypercholesterolemia, or 4) greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool,
OR 5) three or more of the following risk factors:
• family history of premature cardiovascular disease
• smoking • hypertension
• obesity • glucose intolerance • renal disease.
NEW Please provide the following information for all NEW requests: A. Diagnosis: hypercholesterolemia other, please specify
B. Information regarding previous STATIN use: Statin(s) HAS been utilized. Please specify which statin has been utilized (including dose and duration):
Nature of response to STATIN: Intolerance Failure to achieve target LDL Other
Statin(s) has NOT been utilized. Contraindication? Yes No Please elaborate: C. Presence of CARDIOVASCULAR risk factors (CHECK ALL THAT APPLY):
In order to comply with the above criteria check at least three of the following: family history of premature cardiovascular disease smoking hypertension obesity glucose intolerance renal disease AND/OR In order to comply with the above criteria check at least one of the following:
pre-existing cardiovascular disease and/or cerebrovascular disease diabetes familial hypercholesterolemia greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool
D. Additional information relating to request:
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30925 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 17
Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form
On the reverse is the official Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932).
• All requests for peginterferon alfa-2a/ribavirin or peginterferon alfa-2b/ribavirin must be submitted using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
PEGINTERFERON ALFA-2A+RIBAVIRIN/PEGINTERFERON ALFA-2B+RIBAVIRIN
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Pegetron or Pegasys RBV drug benefits. Information from your prescriber is required to determine eligibility. Your consent is required: (A) for your prescriber to release necessary and relevant information to Alberta Blue Cross, Alberta Health and Wellness and, if requested, to Alberta Human Services and Alberta Seniors; and (B) for Alberta Blue Cross to release that and related usage information to Alberta Health and Wellness.
I hereby authorize: (A) my prescriber to release to Alberta Blue Cross, Alberta Health and Wellness, and (if they request it) to Alberta Human Services and Alberta Seniors (the aforesaid being the "designated recipients"); and (B) Alberta Blue Cross to release to Alberta Health and Wellness the information on this form and information relating to my usage of and experience with the drug and treatment results, and I consent to the designated recipients collecting such information. Date: Patient’s Signature:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Drug Requested: Diagnosis of chronic hepatitis C: Evidence of active liver disease:
Peginterferon Alfa-2a+Ribavirin (E.g. Pegasys RBV)
Peginterferon Alfa-2b+Ribavirin (E.g. Pegetron)
Both: a) is the patient anti-HCV positive,
pre-treatment................................ AND; b) is the patient serum HCV RNA
positive (by PCR), pre-treatment......................................
YES NO Not Tested
Either: a) does the patient have elevated liver enzymes
(ALT and/or AST), pre-treatment ……………. OR; b) does the patient have an abnormal liver
biopsy (inflammation and/or fibrosis)
YES NO Not Tested
If the patient is anti-HCV negative but serum HCV RNA positive, please explain:
If patient is currently on Peginterferon Alfa-2a + Ribavirin or Peginterferon Alfa-2b + Ribavirin indicate start date:
Year / Month / Day
INITIAL REQUEST: EXTENSION REQUEST: Initial length of approval:
Advanced fibrosis or cirrhosis (regardless of genotype)……………………………………………... 48 weeks
Genotype 1..…………………………………………14 weeks Is a baseline serum sample stored for future testing? YES NO
Genotype 2 or 3 with HIV co-infection……….14 weeks Is a baseline serum sample stored for future testing? YES NO
Genotype 1, 2 or 3 post-liver transplant……..26 weeks
Initial and maximum length of approval: Genotype 2 or 3 (not co-infected with HIV)....….24 weeks Genotype 4, 5 or 6…..…………………………….. 48 weeks
Request for treatment extension at 14 weeks: For Genotype 1 (non-liver transplant) patients and Genotype 2 or 3 patients with HIV co-infection: Is the patient serum HCV RNA negative at 12 weeks?
YES
NO
Patient may be eligible for additional 34 weeks of coverage (total 48 wks) Has the patient achieved a reduction of viral load by at least 2 logs (100 fold)?
YES
NO
The patient may be eligible for an additional 14 weeks of therapy to confirm response. Additional serum HCV RNA test results are required at 24 weeks
Request for treatment extension at 26 weeks: For Genotype 1, 2 or 3 post-liver transplant patients and for patients from the above section that achieved a 2-log drop but were not serum HCV negative at 12 weeks: Is the patient serum HCV RNA negative at 24 weeks?
YES NO The patient may be eligible for a total of 48 weeks of therapy. PREVIOUS THERAPY: Consideration may be given in patients who have previously received therapy who meet at least one of the following criteria: Advanced fibrosis or cirrhosis. Patient relapsed following non-pegylated interferon/ribavirin combination therapy. Patient failed to respond to or relapsed following interferon monotherapy Additional information relating to request:
PRESCRIBER 'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30932 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JUYL 1, 2012 Section 1A • 19
Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form
On the reverse is the official Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944).
• All requests for peginterferon alfa-2a for Chronic Hepatitis C must be submitted using the Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
PEGINTERFERON ALFA-2A for Chronic Hepatitis C SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Pegasys drug benefits. Information from your prescriber is required to determine eligibility. Your consent is required: (A) for your prescriber to release necessary and relevant information to Alberta Blue Cross, Alberta Health and Wellness and, if requested, to Alberta Human Services and Alberta Seniors; and (B) for Alberta Blue Cross to release that and related usage information to Alberta Health and Wellness.
I hereby authorize: (A) my prescriber to release to Alberta Blue Cross, Alberta Health and Wellness, and (if they request it) to Alberta Human Services and Alberta Seniors (the aforesaid being the “designated recipients”); and (B) Alberta Blue Cross to release to Alberta Health and Wellness the information on this form and information relating to my usage of and experience with the drug and treatment results, and I consent to the designated recipients collecting such information.
Date Patient’s Signature
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
DIAGNOSIS OF CHRONIC HEPATITIS C: EVIDENCE OF ACTIVE LIVER DISEASE: Both: a) is the patient anti-HCV positive,
pre-treatment…......................…………… AND; b) is the patient serum HCV RNA positive (by PCR),
pre-treatment…........................
YES NO Not Tested
Either: a) does the patient have elevated liver enzymes
(ALT and/or AST), pre-treatment…….……………
OR; b) does the patient have an abnormal liver biopsy
(inflammation and/or fibrosis)...……………………
YES NO Not Tested
If the patient is anti-HCV negative but serum HCV RNA positive, please explain:
If patient is currently on peginterferon alfa-2a, indicate start date:
Year / Month / Day
INITIAL REQUEST: EXTENSION REQUEST:
Is the patient intolerant to ribavirin? YES NO Request for treatment extension at 14 weeks (excluding patients with advanced fibrosis and cirrhosis):
Is the patient serum HCV RNA negative at 12 weeks?
YES → Patient may be eligible for additional 34 weeks of coverage (total 48 wks)
NO → Has the patient achieved a reduction of viral load by at least 2 logs (100 fold)?
YES → Patient may be eligible for additional 34 weeks of coverage (total 48 wks)
NO
Is a baseline serum sample stored for future testing? YES NO
Initial length of approval: Advanced fibrosis or cirrhosis (regardless of genotype)…… 48 weeks
Genotype 1…………..…………………………………….………. 14 weeks
Genotype 2 or 3 …………………………..…………………….… 14 weeks
Genotype 4, 5 or 6 .………………………………………………. 14 weeks
PREVIOUS THERAPY: Consideration may be given to patients who have previously received therapy and who meet at least one of the following:
Advanced fibrosis or cirrhosis. Patient relapsed following non-pegylated interferon/ribavirin combination therapy. Additional information relating to request:
PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services
10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30944 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 21
Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form
On the reverse is the official Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form (ABC 30948).
• All requests for etanercept for Juvenile Idiopathic Rheumatoid Arthritis must be submitted using the Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ETANERCEPT for Juvenile Idiopathic Arthritis SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Enbrel drug benefits. Personal and health information is required in order to determine eligibility and, in the event you are approved to receive drug benefits, to maintain eligibility, process payments and conduct the Alberta Post-Marketing Study Addressing ENBREL (“Study”). The Study will assist Alberta Health and Wellness to monitor, plan, evaluate and manage the cost-effectiveness of providing Enbrel as a benefit under the AHWDBL. Therefore, your consent is required as set out herein. Important: In order to be eligible for, and to maintain eligibility for Enbrel drug benefit both you and your physician(s) must agree to and continue to actively and consistently participate in the Study as required by Alberta Blue Cross, Alberta Health and Wellness, its affiliates and agents throughout the special authorization period. Refusal to provide the requested consent will result in benefits being denied, and withdrawal of consent will result in benefits being revoked.
I hereby authorize: (A)The below physician(s) to disclose to Alberta Blue Cross, Alberta Health and Wellness, Alberta Human Services, and Alberta Seniors (the "Designated Recipients") any of my personal or health information contained on this Request Form or requested by the Designated Recipients (collectively “My Information”); and (B) The Designated Recipients to use and collect My Information for the purposes stated on this form; and (C) The Designated Recipients to disclose My Information to any affiliates or agents of the Designated Recipients for the purposes stated on this form. I acknowledge that: I have been made aware of the reasons why my health information is needed, and the risks and benefits of consenting or refusing to consent to disclosure of my health information; and (2) I am aware that I may revoke this consent (in writing) at anytime. ___________________________________ ___________________________________ Signature Effective Date Patient or Guardian Signature: ___________________________________ Print Name of Guardian
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis:
Polyarticular Juvenile Idiopathic Arthritis
Other (specify)
Patient’s current weight (kg): _________ Requested dose (mg/kg): ___________
JRA30 Date of assessment:___________________________
1. Rheumatologist global 4. No. of joints assessment (0-10) ______________________ with LROM ______________
2. Patient global assessment (0-10) __________ 5. CHAQ (0-3) ______________
3. Number of active joints* __________________ 6. ESR (mm/hr) ________ or CRP ________
*joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both
Please provide the following information for ALL new requests: Previous DMARDs utilized (specify agent): Dose, duration and response is required: Additional information relating to request PRESCRIBER'S SIGNATURE DATE Please forward this request to:
Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: (780) 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
I am currently an active participant in the Alberta Post-Marketing Study addressing Enbrel ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30948 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 23
Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form
On the reverse is the official Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).
• All requests for adalimumab, etanercept, golimumab or infliximab for Psoriatic Arthritis must be submitted using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ADALIMUMAB/ETANERCEPT/GOLIMUMAB/INFLIXIMAB for Psoriatic Arthritis
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION
PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests:
Diagnosis: Polyarticular Psoriatic Arthritis Pauciarticular Psoriatic ArthritisJoints affected:
Knee joint(s) Hip joint(s) Other (specify): Other (specify):
Current weight (kg):
Indicate requested drug:
Dosage: Dosing Frequency: Adalimumab
Etanercept Golimumab Infliximab
Scores:*
DAS28 Score ___._____ OR ACR20 (renewals only) Date:______________
AND
HAQ Score ___.___ ___ Date: ______________
Please provide reason if a switch to a different biologic agent is requested:
Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
* New requests for patients currently maintained on the requested biologic require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.
Will the patient be maintained on methotrexate in combination with the requested biologic?
YES NO (If not, please specify reason):
Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required for ALL THREE of the following:
Methotrexate PO:
Methotrexate SC or IM:
DMARD other than MTX (specify agent):
Additional information relating to request (e.g. reasons why any of the above therapies were not tried):
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30964 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 25
Select Quinolones Special Authorization Request Form
On the reverse is the official Select Quinolones Special Authorization Request Form (ABC 30966). • All requests for ciprofloxacin, levofloxacin, moxifloxacin or ofloxacin must be submitted using
the Select Quinolones Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
SELECT QUINOLONES* *ciprofloxacin/levofloxacin/moxifloxacin/ofloxacin
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed. Incomplete requests CANNOT BE EXPEDITED.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Only the following conditions may be authorized for coverage. Drug Requested and Condition requiring quinolone treatment: Please check the boxes that apply to your patient.
CIPROFLOXACIN Respiratory Tract Infection: End stage COPD with or without bronchiectasis, where there has been
documentation of previous Pseudomonas aeruginosa colonization/infection Pneumonic illness in cystic fibrosis Genitourinary Tract Infection: Urinary Tract Infection Prostatitis Prophylaxis of urinary tract surgical procedures Gonococcal infection Skin & Soft Tissue / Bone & Joint Infection: Malignant / invasive otitis externa Bone / joint infection due to gram-negative organism(s) Therapy / step-down therapy of polymicrobial infection in combination with
clindamycin or metronidazole, e.g. diabetic foot infection, decubitus ulcers Gastrointestinal Tract Infection: Bacterial gastroenteritis where antimicrobial therapy is indicated Typhoid fever (enteric fever) Therapy / step-down therapy of polymicrobial infection in combination with
clindamycin or metronidazole, e.g. intra-abdominal infections Other: Prophylaxis of adult contacts of cases of invasive meningococcal disease Therapy / step-down therapy of hospital acquired gram-negative infections Empiric therapy of febrile neutropenia in combination with other appropriate
agents Exception case of allergy or intolerance to all other appropriate therapies
as defined by relevant guidelines/references, i.e. AMA CPGs or Bugs & Drugs
LEVOFLOXACIN MOXIFLOXACIN Community acquired pneumonia after failure of first line therapy,
as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy
Community acquired pneumonia in patients with co morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking)
Acute exacerbation of chronic bronchitis after failure of first and
Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with β–lactam (penicillin & cephalosporin) allergy
second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy
For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases.
OFLOXACIN Pelvic inflammatory disease Epididymo-orchitis/epididymitis most likely due to enteric
organisms For the treatment of Chlamydial infection For the treatment of Gonococcal infection For use in other current Health Canada approved indications
when prescribed by a specialist in Infectious Diseases
Please specify details: For use in other current Health Canada approved indications when
prescribed by a specialist in Infectious Diseases
PHYSICIAN'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5
FAX: 780-498-8384 in Edmonton 1-877-828-4106 toll-free all other areas
ONCE YOU HAVE CONFIRMED YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30966 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
BACKGROUND INFORMATION REGARDING SELECT QUINOLONE SPECIAL AUTHORIZATION PROCESS
Optional Special Authorization introduced for quinolones At the request of Alberta Health and Wellness, Alberta Employment and Immigration, Alberta Seniors and Community Supports and Alberta Children and Youth Services, Alberta Blue Cross applied criteria effective September 15, 2005 for coverage of select quinolone antibiotics covered through their drug benefit programs:
• ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin. Norfloxacin continues to be eligible for coverage as an unrestricted benefit. Rationale These criteria are the result of a comprehensive evidence-based review undertaken as an initiative of the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics through the Review of Benefit Status (ROBS) process. This review examined systemic antimicrobial agents currently covered via the Alberta Health and Wellness Drug Benefit List. The mandate of the review was to encourage optimal utilization and to help prevent antimicrobial resistance. The review was conducted according to the established ROBS process, and included systematic reviews of the medical literature and analysis of current utilization patterns. External Alberta physicians and pharmacists with expertise in the treatment of infectious diseases provided advice and assistance for this review process. Information and experience from other provincial jurisdictions that have undertaken similar antimicrobial reviews were also taken into consideration in this review. The review was completed in accordance with pre-determined guiding principles that sought to allow optimal practice to proceed, ensuring optimal use and helping prevent resistance, while at the same time being unencumbered by undue paperwork and unnecessary restrictions.
Role of Physicians In conjunction with these new criteria, physicians have two options by which patients may be eligible for coverage of these specific antimicrobial products. This offers a streamlined alternative to traditional Special Authorization. 1) Physicians can register to be a designated prescriber. Registration allows for patients to receive coverage of quinolones
without Special Authorization as long as the prescription is written for one of the criteria for coverage set out in the Alberta Health and Wellness Drug Benefit List. These criteria are attached for your reference. Should a designated physician wish to prescribe one of the select quinolones outside the coverage criteria, they may do so but must indicate this on the prescription; however, patients will not be eligible for payment under the government-sponsored program for such prescriptions and the patient may choose to receive the product at their expense.
2) Physicians who choose not to register will be considered ‘non-designated prescribers’.
• Such physicians will be required to apply for Special Authorization on the patient’s behalf. • A patient’s claims for prescriptions written by non-designated physicians will be subject to a first fill forgiveness
rule. This means the first claim will be paid but subsequent claims for the same active ingredient (irrespective of strength, route and form) within a 90 day period will require Special Authorization.
• Special authorization requests must be submitted using the Select Quinolones Special Authorization Request Form. If the appropriate sections of this request form are completed and coverage criteria are met, the request will be processed within approximately 6 to 18 hours of receiving the request. Subsequent claims will be rejected unless Special Authorization is granted.
To register to become a designated prescriber
please return your completed registration by FAX to 1-877-305-9911. For more information, please contact
Clinical Drug Services, Alberta Blue Cross, at 780-498-8368.
® The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 30966 SA form and comm (R12/2011)
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 1A • 28 EFFECTIVE JULY 1, 2012
Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form
On the reverse is the official Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form (ABC 31086).
• All requests for alendronate, raloxifene, risedronate or synthetic calcitonin salmon for Osteoporosis must be submitted using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ALENDRONATE / RALOXIFENE / RISEDRONATE / SYNTHETIC CALCITONIN SALMON NASAL SPRAY FOR OSTEOPOROSIS
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests:
Indicate which drug is requested (check ONE box)*: Alendronate (10mg, 70mg, 70mg + 5600U vitamin D3) Raloxifene Risedronate Synthetic Calcitonin Salmon Nasal Spray *Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, denosumab, etidronate, raloxifene, risedronate) when intended for use as combination therapy. Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab. Please provide the following information for all NEW requests:
Diagnosis: For the treatment of Osteoporosis Osteopenia Bone pain secondary to: ______________________________ Other, please specify: __________________________
Has the patient experienced FRACTURES related to the diagnosis? NO YES
Information regarding previous etidronate use: Etidronate HAS been utilized.
Nature of response to etidronate: Lack of response (i.e. demonstrated as a > 2% loss in bone mineral density in one year) Intolerance Other (please specify):________________________________________________________
Etidronate has NOT been utilized: Contraindication. Please elaborate:____________________________________________________________________________ Other reason(s) etidronate was NOT tried (please specify):_________________________________________________________
Additional information relating to request:
RENEWAL This product is eligible for auto-renewal for the treatment of osteoporosis. A Special Authorization renewal request is required only if the Special Authorization approval for the treatment of osteoporosis has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy: PRESCRIBER'S SIGNATURE DATE Please forward this request to:
• Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31086 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALENDRONATE / RALOXIFENE / RISEDRONATE / SYNTHETIC CALCITONIN SALMON NASAL SPRAY FOR OSTEOPOROSIS
SPECIAL AUTHORIZATION CRITERIA Patients may or may not meet eligibility requirements as established by
Alberta Government sponsored drug programs.
Criteria for Coverage:
ALENDRONATE** (10mg, 70mg, 70mg + 5600U vitamin D3 oral tablets) RALOXIFENE RISEDRONATE** Special Authorization Criteria for OSTEOPOROSIS “For the treatment of osteoporosis in patients who have documented hip, vertebral or other fractures. Special authorization for may be granted for 6 months.” “For the treatment of osteoporosis in patients with documented evidence of intolerance or lack of response to etidronate (i.e. demonstrated as a > 2 % loss in bone mineral density in one year). Special authorization may be granted for 6 months.” “Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy.” These products are eligible for auto-renewal for the treatment of osteoporosis.
**Please note: alendronate and risedronate also have Special Authorization criteria for Paget’s disease. Please refer to the Alberta Health and Wellness Drug Benefit List for alendronate and risedronate’s other criteria for the indication of Paget’s disease.
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html
SYNTHETIC CALCITONIN SALMON Nasal Spray Special Authorization Criteria: "For the treatment of osteoporosis in patients with documented evidence of intolerance or lack of response to etidronate (i.e. demonstrated as a >2% loss in bone mineral density in one year). Special authorization may be granted for 6 months." "Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy." This product is eligible for auto-renewal.
ABC 31086 (R12/2011)
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 31
Celecoxib Special Authorization Request Form
On the reverse is the official Celebrex Special Authorization Request Form (ABC 31140).
• All requests for celecoxib must be submitted using the Celecoxib Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 401-1150 in Edmonton and area 1-888-401-1150 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
CELECOXIB SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY, PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of CELECOXIB
For patients who are at high risk of upper gastrointestinal (GI) complications due to a proven history of prior complicated GI events (e.g. GI perforation, obstruction or major bleeding), OR
For patients who have a documented history of ulcers proven radiographically and/or endoscopically.
Special authorization may be granted for 6 months.
This product is eligible for auto-renewal.
NEW Please provide the following information for NEW requests (check ALL that apply):
1) Is this patient at high risk of upper GI complications? Yes No
2) Does this patient have a documented history of ulcers? Yes No
Additional information relating to request:
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FOR CELECOXIB REQUESTS ONLY: • FAX: 780-401-1150 in Edmonton •1-888-401-1150 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
THIS SECTION IS FOR ALBERTA BLUE CROSS USE ONLY
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31140 (R11/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 33
Filgrastim/Pegfilgrastim Special Authorization Request Form
On the reverse is the official Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150)
• All requests for filgrastim or pegfilgrastim must be submitted using the Filgrastim/Pegfilgrastim Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
FILGRASTIM/PEGFILGRASTIM SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Indicate which drug is requested (check ONE box): FILGRASTIM (complete Section I or II) PEGFILGRASTIM (complete Section I only) Criteria for Coverage of FILGRASTIM Criteria for Coverage of PEGFILGRASTIM To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-neoplastic drugs with curative intent. This drug must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). For the reduction in the duration of neutropenia, fever, antibiotic use and hospitalization, following induction and consolidation treatment for acute myeloid leukemia. This drug must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). To increase neutrophil counts and to reduce the incidence and duration of infection in patients with a diagnosis of congenital, cyclic or idiopathic neutropenia. This drug must be prescribed by the Directors of Divisions of Hematology in tertiary care centres (or their designates). For the treatment of patients undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy when prescribed by a designated prescriber. Please note for the first criterion: Coverage cannot be considered for palliative patients.
To decrease the incidence of infection, as manifested by febrile neutropenia, in patients 18 years of age and older with non-myeloid malignancies receiving myelosuppressive anti-neoplastic drugs with curative intent. This drug product must be prescribed by Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). Please note: Coverage cannot be considered for palliative patients.
Section I (Filgrastim requests for the first criterion and all pegfilgrastim requests, check ALL that apply)
Please SPECIFY the type of cancer being treated with chemotherapy for curative intent: _______________________________________ AND Please provide the indication for which the drug is requested:
patient has febrile neutropenia patient had febrile neutropenia from a previous cycle of the same chemotherapy patient will be undergoing a high dose or aggressive chemotherapy where febrile neutropenia is very likely to occur other, please SPECIFY: _______________________________________________________________________________________
Section II (Filgrastim requests for other criteria, check ALL that apply)
Please provide the indication for which filgrastim is requested: patient has neutropenia AND a diagnosis of congenital, cyclic or idiopathic neutropenia OR acute myeloid leukemia
other, please SPECIFY: _____________________________________________
patient is undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy
Additional information relating to request: PRESCRIBER'S SIGNATURE DATE Please forward this request to:
Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: (780) 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31150 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 35
Fentanyl Special Authorization Request Form
On the reverse is the official Fentanyl Special Authorization Request Form (ABC 31169). • All requests for fentanyl or fentanyl citrate must be submitted using the Fentanyl Special
Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
FENTANYL SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO. STREET ADDRESS
CITY , PROVINCE PHONE:
FAX:
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
CRITERIA FOR COVERAGE OF FENTANYL Fentanyl Injection For the treatment of persistent, severe chronic pain in those patients who cannot swallow, or who are intolerant of, morphine and/or hydromorphone, if not contraindicated. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.
Fentanyl Patch For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who cannot swallow. Special authorization may be granted for 6 months. For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who require opioid therapy at a total daily dose of at least 60 mg/day oral morphine equivalents. Patients must have tried and not been able to tolerate at least two discrete courses of therapy with two of the following agents: morphine, hydromorphone and oxycodone, if not contraindicated. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.
NEW Please provide the following for all new patients:
Product(s) requested: FENTANYL INJECTION FENTANYL PATCH
Nature of the patient’s pain: Persistent, severe chronic pain Other:
For FENTANYL PATCH requests: Patients must have tried at least two discrete courses* of therapy with two of the required agents: morphine, hydromorphone and oxycodone.
* A discrete course is defined as a separate treatment course, which may involve more than one agent, used at one time to manage the patient’s condition.
Treatment course 1: MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug): morphine
hydromorphone
oxycodone
other (specify)
Treatment course 2: MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug): morphine
hydromorphone
oxycodone
other (specify)
For FENTANYL INJECTION requests:
Previous MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug):
morphine
hydromorphone
If patient is unable to swallow, please provide information regarding specific reasons patient is unable take oral medications:
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER 'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780 498-8384 Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31169 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULYL 1, 2012 Section 1A • 37
Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form
On the reverse is the official Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).
• All requests for adalimumab, etanercept, infliximab or ustekinumab for Plaque Psoriasis must be submitted using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
57BOnce your request has successfully transmitted, please do not mail or re-fax your request
ADALIMUMAB/ETANERCEPT/INFLIXIMAB/USTEKINUMAB for
Plaque Psoriasis SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests:
Diagnosis:
Plaque Psoriasis
Other (specify): _______________________
Indicate requested drug: Adalimumab Etanercept Infliximab Ustekinumab
Current Weight (Kg):
Dosage:
Dosing Frequency:
Location: Significant involvement of face, palms of the hands, soles of the feet or genital region: YES NO
Scores:
PASI__________ Date__________________
DLQI__________ Date__________________
Please provide reason if a switch to a different biologic agent is requested: Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
Please provide the following information for all NEW requests:
Previous medications/therapies utilized: Dose, duration and response is required for the following:
Methotrexate PO:
Methotrexate SC or IM:
Cyclosporine:
Phototherapy:
Additional information relating to request (e.g. reasons why any of the above therapies were not tried): PRESCRIBER’S SIGNATURE DATE Please forward this request to:
Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5
FAX: 780- 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31192 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 39
Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form
On the reverse is the official Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).
• All requests for adalimumab, etanercept, golimumab or infliximab for Ankylosing Spondylitis must be submitted using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
59BOnce your request has successfully transmitted, please do not mail or re-fax your request.
ADALIMUMAB/ETANERCEPT/GOLIMUMAB/INFLIXIMAB for Ankylosing Spondylitis
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis: Current
weight (kg): Indicate requested drug:
Adalimumab
Etanercept
Golimumab
Infliximab
Dosage: Dosing frequency:
Ankylosing Spondylitis (meeting modified NY criteria)
Other (please SPECIFY): ____________________________
Please provide the following information for all NEW requests: Previous medications utilized: Have two or more NSAIDs been tried for a minimum of 4 weeks each at maximum tolerated or recommended doses?
YES (please SPECIFY below) NO
Please SPECIFY the NSAID Please SPECIFY the dose, duration, and response
NSAID #1:
NSAID #2:
Other, please SPECIFY: Please provide the following information for all NEW* requests:
BASDAI #1 Date:
BASDAI #2: Date:
Spinal Pain VAS #1 (cm): Date:
Spinal Pain VAS #2 (cm): Date:
* New requests for patients currently maintained on the requested biologic require pre-treatment scores. Scores 1 and 2 for each parameter must be at least 8 weeks apart.
Please provide the following information for all RENEWAL requests:
BASDAI Date:
Spinal pain VAS (cm) Date:
Please provide reason if a switch to a different biologic agent is requested:
Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
Additional information relating to request:
PRESCRIBER'S SIGNATURE DATE
Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31195 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 41
Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form
On the reverse is the official Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form (ABC 31200).
• All requests for adalimumab for Moderately to Severely Active Crohn's Disease or infliximab for Moderately to Severely Active Crohn’s/Fistulizing Crohn’s Disease must be submitted using the Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
-
ADALIMUMAB for Crohn’s / INFLIXIMAB for Crohn’s / Fistulizing Crohn’s Disease SPECIAL AUTHORIZATION REQUEST FORM
Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE ID/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis:
Moderately to Severely Active Crohn’s Fistulizing Crohn’s
Indicate requested drug:
Adalimumab Dose:____________ Frequency:___________ Date of last dose:__________________
Infliximab Dose:____________ Frequency:___________ Date of last dose:__________________
Current weight (kg):___________ Other (specify) __________
For INITIAL request, please indicate if the drug is requested for NEW patient who has never been treated with the requested drug by any health care provider
EXISTING patient who is being treated, or have previously been treated with the requested drug
Please provide reason if a switch to a different biologic agent or change in dose is requested:
Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
Infliximab For Fistulizing Crohn’s Disease: Adalimumab or Infliximab For Moderately to Severely Active Crohn’s Disease:
INITIAL request: Dose, duration and response is required for all medications previously utilized:
INITIAL request: Dose, duration and response is required for all medications previously utilized:
Azathioprine: Azathioprine:
6-mercaptopurine: 6-mercaptopurine: Antibiotics (specify the drug name): Methotrexate: NEW patient: Does the patient have actively draining perianal or enterocutaneous fistula(s) that have recurred or persisted despite previous therapy:
Yes No
Mesalamine: Glucocorticoid(s) (specify drug name): For ALL requests for Moderately to Severely Active Crohn’s Disease, please provide
Modified Harvey-Bradshaw Index score: _______________
Date of score: _______________
EXISTING patient: Please indicate response to treatment with infliximab:
Closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline.
Incomplete response (specify): Additional information relating to request (e.g. reasons why any of the above therapies were not tried): PRESCRIBER'S SIGNATURE DATE Please forward this request to:
Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31200 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 43
Rituximab for Rheumatoid Arthritis Special Authorization Request Form
On the reverse is the official Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205).
• All requests for rituximab for Rheumatoid Arthritis must be submitted using the Rituximab for Rheumatoid Arthritis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
RITUXIMAB for Rheumatoid Arthritis
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY, PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis:
Rheumatoid Arthritis Other (specify)
Dosage: Dosing Frequency:
Please provide reason if a switch from a different biologic agent to rituximab is requested: Date of last dose:
_________________________________
Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
Scores:*
DAS28 Score __________
Date: __________________ AND HAQ Score ____________
Date: __________________
Requests for Re-treatment after 2 dose course Date of initial dose of the previous course of therapy:
_____________________ Response Scores 16-24 weeks after initial dose of previous course of therapy: DAS28 Score _______ Date: _____________ AND HAQ Score _________ Date: _____________ Current scores: DAS28 Score ________ Date: _____________ AND HAQ Score _________ Date: _____________
* New requests for patients currently maintained on the requested biologic also require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.
Will the patient be maintained on methotrexate in combination with rituximab? YES NO (If not, please specify reason):
Please provide the following information for all NEW requests: Previous medications/therapies utilized: Dose, duration and response is required for ALL FIVE of the following:
Methotrexate PO: Methotrexate SC or IM: Methotrexate with another DMARD other than leflunomide (specify agent) Leflunomide: Anti-TNF therapy:
Additional information relating to request (e.g. reasons why any of the above therapies were not tried):
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31205 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 45
Imiquimod Special Authorization Request Form
On the reverse is the official Imiquimod Special Authorization Request Form (ABC 31222). • All requests for imiquimod must be submitted using the Imiquimod Special Authorization
Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
IMIQUIMOD SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of IMIQUIMOD For the treatment of Actinic Keratosis located on the head and neck in patients who have failed treatment with cryotherapy (where appropriate) and 5-fluorouracil (5-FU). Special authorization may be granted for 6 months. This product is eligible for auto-renewal.
NEW Please provide the following information for NEW requests (check ALL that apply):
Diagnosis: Actinic Keratosis → Area affected:
Head or neck Other (specify): ______________________________________________________ Other (specify):
Previous medications/therapies utilized: Please indicate if the following medication/therapy have been tried and the response:
1) cryotherapy: Yes → Response:
Lack of response Intolerance Other (specify):__________________
No → Not appropriate Other (specify):___________________________________ AND
2) 5-fluorouracil (5-FU): Yes→ Response:
Lack of response Intolerance Other (specify):____________________ No (specify reason, if applicable): __________________________________________________
Additional information relating to request
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31222 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 47
Dutasteride/Finasteride Special Authorization Request Form
On the reverse is the official Dutasteride/Finasteride Special Authorization Request Form (ABC 31257). • All requests for dutasteride or finasteride must be submitted using the Dutasteride/Finasteride
Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
DUTASTERIDE/FINASTERIDE SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Indicate which drug is requested (check one box): Dutasteride Finasteride
Criteria for Coverage of DUTASTERIDE / FINASTERIDE For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.
NEW Please provide the following information for NEW requests (Section 1, AND Section 2 or 3 must be completed):
Section 1: Diagnosis:
Benign Prostatic Hyperplasia Other (specify): ________________________________________
Section 2: Surgical Risk: Is the patient a poor surgical risk? → no yes If yes, please specify any underlying medical condition(s) or other circumstances by which this patient would be deemed a poor surgical risk:
Has this patient had surgical intervention (TURP) for this condition in the past? yes no
Section 3: Enlarged Prostate: Does this patient have enlarged prostate with moderate to severe symptoms suggestive of obstruction?
yes
no
Additional information relating to request
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5.
ABC 31257 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 49
Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form
On the reverse is the official Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).
• All requests for paliperidone or risperidone prolonged release injection must be submitted using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
PALIPERIDONE/RISPERIDONE PROLONGED RELEASE INJECTION SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY, PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Indicate which drug is requested: Risperidone Prolonged Release Injection Paliperidone Prolonged Release Injection
NEW Please provide the following information for NEW requests:
Diagnosis: schizophrenia or related psychotic disorder other, please specify
Compliance Issues: Has this patient demonstrated a pattern of significant non-compliance with other dosage forms that is compromising or has compromised this patient’s therapeutic success?
Yes No If no, please elaborate:
Previous drug therapy (CHECK ALL THAT APPLY): In order to comply with criteria, check at least two of the following:
Experiences extra-pyramidal symptoms with either an oral or depot first generation antipsychotic agent that precludes the use of a first generation antipsychotic depot product
Is refractory to trials of at least two other antipsychotic therapies (Note: one trial must include a first generation antipsychotic agent)
Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy
Additional information relating to request
RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31258 (R02/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 51
Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form
On the reverse is the official Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291).
• All requests for abatacept for Juvenile Idiopathic Arthritis must be submitted using the Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form only.
• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ABATACEPT for Juvenile Idiopathic Arthritis
SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE:
PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis:
Polyarticular Juvenile Idiopathic Arthritis Other (specify)
Current weight (kg): Dosage: Dosing Frequency:
Current JRA30 FLARE score (provide for ALL requests) JRA30 RESPONSE score at 16 to 20 weeks after first dose of previous abatacept treatment (provide for RETREATMENT requests)
Date of assessment:___________________________ 1. Rheumatologist global 4. No. of joints
assessment (0-10) ___________ with LROM ___________
2. Patient global 5. CHAQ (0-3) ___________
assessment (0-10) ___________
3. No. of active joints* ___________ 6. ESR (mm/hr) __________
or CRP ______________ *joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both.
Date of assessment:___________________________ 1. Rheumatologist global 4. No. of joints
assessment (0-10) ___________ with LROM ___________
2. Patient global 5. CHAQ (0-3) ___________
assessment (0-10) ___________
3. No. of active joints* ___________ 6. ESR (mm/hr) __________
or CRP ______________ *joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both.
Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required:
DMARD(s) (specify agents):
Etanercept:
Other (specify agent) :
Additional information relating to request (e.g. reasons why any of the above therapies were not tried):
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31291 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 53
63BMontelukast/Zafirlukast Special Authorization Request Form
On the reverse is the official Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313). • All requests for montelukast or zafirlukast must be submitted using the
Montelukast/Zafirlukast Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
MONTELUKAST/ZAFIRLUKAST SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Indicate which drug is requested (check one box): Montelukast (5mg + 10mg) Zafirlukast (20mg)
Criteria for Coverage of MONTELUKAST / ZAFIRLUKAST For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria: a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, OR b) cannot operate inhaler devices.
For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists.
Special authorization for both criteria may be granted for 6 months. This product is eligible for auto-renewal. Note: Refer to the Alberta Health and Wellness Drug Benefit List for Restricted Benefit coverage of patients 2 to 18 years of age inclusive for Montelukast and 12 to 18 years of age inclusive for Zafirlukast.
NEW Please provide the following information for NEW requests (Section 1, AND Section 2 or 3 must be completed): Section 1: Indication:
Prophylaxis and chronic treatment of asthma (If yes, proceed to Section 2A or 2B only). Prophylaxis of exercise-induced bronchoconstriction (If yes, proceed to Section 3 only). Other (specify): ______________________________________________________________________________________________
Section 2: Prophylaxis and chronic treatment of asthma: A. Previous Medication Use: Is the patient maintained on inhaled glucocorticosteroids?
Yes No (If no, specify reason):_________________________________________________
Is the patient on a long-acting beta 2 agonist (e.g. salmeterol or formoterol)? Yes → Response: Persistent symptoms
Other (specify)_______________________________________________ No (If no, specify reason):________________________________________________________
B. Use of Inhaler Device Please indicate if the patient has difficulty using an inhaler device:
Yes (Please elaborate on the nature of the difficulty)____________ ______________________________
No
Section 3: Prophylaxis of exercise induced bronchoconstriction: Does this patient have tachyphylaxis with long-acting beta 2 agonists? Yes No Other (specify): ___________________________ Additional information relating to request:
RENEWAL: This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31313 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 55
63BFebuxostat Special Authorization Request Form
On the reverse is the official Febuxostat Special Authorization Request Form (ABC 31376). • All requests for febuxostat must be submitted using the Febuxostat Special Authorization
Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
FEBUXOSTAT SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of FEBUXOSTAT For patients with symptomatic gout who have documented hypersensitivity OR severe intolerance to allopurinol, AND intolerance or lack of response to sulfinpyrazone AND probenecid. Special authorization may be granted for 6 months. This product is eligible for auto-renewal. Please note: Coverage cannot be considered for lack of response to allopurinol.
NEW Please provide the following information for NEW requests (check ALL that apply):
Diagnosis: Symptomatic gout Other (specify): _________________________________________________________________
Previous medications utilized: Information is required for ALL THREE of the following: 1) allopurinol has been utilized.
documented hypersensitivity severe intolerance Other (specify):_______________________________
allopurinol has NOT been utilized. Please specify reason, if applicable:_________________________________________
AND 2) sulfinpyrazone has been utilized :
Intolerance Lack of response Other (specify):__________________________________________ sulfinpyrazone has NOT been utilized. Please specify reason, if applicable:_____________________________________
AND 3) probenecid has been utilized :
Intolerance Lack of response Other (specify):__________________________________________ probenecid has NOT been utilized. Please specify reason, if applicable): _______________________________________
Additional information relating to request
RENEWAL:This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy.
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31376 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 57
63BDenosumab Special Authorization Request Form
On the reverse is the official Denosumab Special Authorization Request Form (ABC 31377). • All requests for denosumab must be submitted using the Denosumab Special Authorization
Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
Please complete all required sections to allow your request to be processed.
DENOSUMAB SPECIAL AUTHORIZATION REQUEST FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL
Alberta Blue Cross Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION
CPSA CARNA ACP
ACO ADA+C Other
REGISTRATION NO.
STREET ADDRESS
PHONE:
FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Criteria for Coverage of DENOSUMAB For the treatment of postmenopausal osteoporosis in women for whom oral bisphosphonates are contraindicated due to hypersensitivity OR an endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia), AND Who have at least two of the following:
- Age of greater than or equal to 75 years - A prior fragility fracture - A bone mineral density (BMD) T-score of of less than or equal to -2.5
Special authorization may be granted for 12 months. Patients will be limited to receiving one dose of denosumab per prescription at their pharmacy. Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy.
NEW Please provide the following information for NEW requests:
Diagnosis: Postmenopausal osteoporosis Other (specify): ________________________________________
Please indicate which of the following pertain to this patient (check ALL that apply): contraindication to oral bisphosphonates
If so, must specify nature of contraindication _____________________________________________________ endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia)
prior fragility fracture bone mineral density (BMD) T-Score of less than or equal to -2.5
Additional information relating to request
RENEWAL: This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy.
PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5.
ABC 31377 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 59
63B63BOmalizumab Special Authorization Request Form
On the reverse is the official Omalizumab Special Authorization Request Form (ABC 31406). • All requests for omalizumab must be submitted using the Omalizumab Special Authorization
Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
OMALIZUMAB SPECIAL AUTHORIZATION REQUEST FORM
PATIENT INFORMATION Patients may or may not meet eligibility requirements as established
by Alberta Government sponsored drug programs. PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross
Alberta Human Services Alberta Seniors Other
DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER
STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:
SPECIALIST IN RESPIROLOGY OR CLINICAL IMMUNOLOGIST INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA
CARNA ACP
ACO ADA+C Other
REGISTRATION NO. STREET ADDRESS
PHONE: FAX: CITY , PROVINCE
POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED
Please provide the following information for ALL requests: Diagnosis:
Confirmation of Severe Asthma Other (specify)
Date of Confirmation of Diagnosis : Current weight (kg):
Smoker Non-Smoker
Laboratory Data (For renewals only FEV1 is required) Scores (For renewals only AQLQ and one ACQ-5 are required) Total serum human immunoglobulin (IgE) Value (IU/ml)
Date Asthma Quality of Life Questionnaire (AQLQ – Juniper) Score
Date
Confirmation of IgE mediated allergy to a perennial allergen by clinical history and allergy skin testing
Date
ACQ-5
Score #1 Date
FEV1 Date Score #2 Date
Please provide the following information for NEW requests: Number of exacerbations of asthma within the previous 12 month period that resulted in: An Emergency Room visit / Hospitalization: Unscheduled physician visits resulting in oral corticosteroids: Please check one of the following :
One or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit within the previous year while on systemic corticosteroids: OR One or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit requiring documented use of systemic corticosteroids (oral corticosteroids initiated or increased for at least 3 days, or parenteral corticosteroids); OR Three or more severe exacerbations of asthma within the previous year, which required an unscheduled physician visit and resulted in courses (or chronic use >50% of the year) of systemic corticosteroids.
Previous medications utilized: Name of Medication, dose, duration and response is required for ALL of the following: High-dose inhaled corticosteroids :
Long-acting beta-2 agonists :
Oral corticosteroids :
Chronic use (>50% of the year) of oral corticosteroids? YES NO
Please provide the following information for all RENEWAL requests: Number of exacerbations of asthma within the previous 12 month period that resulted in: An Emergency Room visit / Hospitalization: Unscheduled physician visits resulting in oral corticosteroids: Please check ALL of the following that apply :
Patient demonstrated at least a 25% reduction in the number of exacerbations, which required oral corticosteroids from the 12 months prior to initiation of omalizumab that required systemic corticosteroids. For patients that were on chronic (>50% of the year) courses of oral corticosteroids use in the prior 12 months to initiation of omalizumab, tapering of oral corticosteroid use by at least 25% from baseline. A reduction in the number of exacerbations that have led to a hospital admission or emergency room visits, compared to the 12 months prior to the commencement of omalizumab.
PRESCRIBER'S SIGNATURE DATE
Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5
FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31406 (2011/12) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 1A • 61
Eculizumab Special Authorization Request Form and Consent Form
On the reverse is the official Eculizumab Special Authorization Request Form (ABC 31386) and the official Eculizumab Consent Form (ABC 31408)
• All requests for eculizumab must be submitted using the Eculizumab Special Authorization Request Form and Eculizumab Consent Form.
• Photocopy these forms and use as required. • Submit completed forms by FAX to Alberta Blue Cross:
(780) 401-1150 in Edmonton and area 1-888-401-1150 toll-free for all other areas
Once your request has successfully transmitted, please do not mail or re-fax your request.
ECULIZUMAB SPECIAL AUTHORIZATION REQUEST FORM Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION Page 1 of 4 Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day
Street Address City Province Postal Code
Identification/Client/Coverage No: Coverage
Type: Alberta Blue Cross Alberta Human Services
Alberta Seniors Other
SPECIALIST IN HEMATOLOGY INFORMATION Surname First Name Middle Initial
Street Address City Province Postal Code
Telephone Number Fax Number College of Physicians and Surgeons Registration No.
Date Form Completed Last Consult Date Specialist in Hematology Signature
INFORMATION REQUIRED
For INITIAL REQUESTS please complete the first 2 pages, and submit laboratory data and consent form as attachments. For SIX-MONTH RENEWALS please complete applicable sections of the first 3 pages, and submit laboratory data as an attachment. For ANNUAL RENEWALS please complete applicable sections of all 4 pages, and submit laboratory data as an attachment. Note: Additional pages may be attached as required. Please submit all required pages and attachments together. TREATMENT REQUESTED
Eculizumab (Soliris) Dosage and Frequency Requested
Check which situation applies and provide date requested.
New to Drug: Planned treatment start date (YY/MM/DD) New to Coverage (on drug already): Date treatment began (YY/MM/DD) Renewal
CONFIRMATION OF DIAGNOSIS (Complete on initial request) Yes No Date (YY/MM/DD) Lab result Does the patient have a PNH granulocyte clone size (by flow cytometry and/or FLAER test) equal to or greater than 10%?
Does the patient have a Lactate Dehydrogenase (LDH) level at least 1.5 times the upper limit of normal?
Please mail this request to: Alberta Blue Cross, Clinical Drug Services
10009-108 Street NW, Edmonton, Alberta T5J 3C5
Or fax to 780-401-1150 in Edmonton 1-888-401-1150 toll-free all other areas
Case Number
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31386 (2011/12) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ECULIZUMAB CONSENT FORM
Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.
PATIENT INFORMATION Page 1 of 2 Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day
Street Address City Province Postal Code
Identification/Client/Coverage No: Coverage
Type: Alberta Blue Cross Alberta Human Services
Alberta Seniors Other
SPECIALIST IN HEMATOLOGY INFORMATION Surname First Name Middle Initial
Street Address City Province Postal Code
Telephone Number Fax Number College of Physicians and Surgeons Registration No.
PATIENT CONSENT FOR SERVICE I have received a copy of the policy relating to Eculizumab in the current version of the Alberta Health and Wellness Drug Benefit List (AHWDBL), as updated from time to time (the Policy) and have read and understand the requirements of a patient receiving Alberta government sponsored funded treatment.
I agree to comply with the requirements for coverage as set out in the Policy, including (without limitation) the requirements for monitoring, review and data collection.
I understand and agree that I must continue to qualify for, and continue to be a member of, an Alberta government sponsored drug program to continue to be eligible for eculizumab coverage in accordance with the Policy.
I understand and agree that approval for initial and continued coverage is conditional upon meeting and continuing to meet the requirements of the Policy.
I understand that my consent must be and is ongoing and my failure to comply with the requirements as set out in the Policy may preclude me from continuing to be eligible for eculizumab coverage.
I understand that prior to potential discontinuance of eculizumab coverage, as outlined in the Policy, my Specialist in Hematology will receive notice of this in writing. I understand that my Specialist in Hematology has a responsibility to notify me, and to work with me to address the reason for potential withdrawal of eculizumab coverage.
I understand that therapy may be withdrawn at the request of the patient or the patient’s parent/guardian at any time. Notification of withdrawal from therapy must be made by the Specialist in Hematology or patient in writing. I understand there may be side effects from medication and I have discussed the risks and benefits of this treatment with my Specialist in Hematology.
I, either as the patient or as the patient’s parent/guardian (as appropriate), and on behalf of the patient’s heirs and my estate and any other person claiming through the patient, hereby release the Minister, the Minister’s delegate, the Minister’s agents and employees from any and all liability and all claims for any and all damages, injuries, loss and costs which may arise directly or indirectly in relation to or in connection with the Application and coverage, funding and use of eculizumbab for the patient pursuant to the Policy, including (without limitation) all claims relating to coverage, any changes in coverage, any restrictions or conditions of coverage, discontinuance of coverage, and the patient’s use of eculizumab. I agree and acknowledge that this release is binding on the patient, the patient’s heirs and estate, and any other person claiming through the patient against the Minister, the Minister’s agents and employees.
Name of Patient: ___________________________________________________
Signature of Patient (for patients > or equal to 18 years old): _________________________________ Date: ____________________
Name of Parent/Guardian (for patients <18 years old): _______________________________________________________________
Signature of Parent/Guardian (for patients <18 years old): ___________________________________ Date: ____________________
The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31408 (12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
Section 2 Multiple Sclerosis (M
S) Drug C
overage
SECTION 2
Multiple Sclerosis (MS) Drug Coverage
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST MULTIPLE SCLEROSIS (MS) DRUG COVERAGE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 2 • 1 EFFECTIVE JULY 1, 2012
MULTIPLE SCLEROSIS (MS) DRUG COVERAGE
Selected drug products used in the treatment of relapsing multiple sclerosis (MS) may be considered for coverage for patients covered under Alberta government-sponsored drug programs. For further information regarding eligibility for Alberta government-sponsored drug programs, refer to the Introduction section of the List.
In order to be eligible for Multiple Sclerosis (MS) Drug Coverage, an individual must:
have valid Alberta government-sponsored drug coverage; meet specific clinical criteria according to Multiple Sclerosis (MS) Drug Coverage program
requirements; have a Multiple Sclerosis (MS) Drug Coverage Application form(s) submitted on their behalf to Alberta
Blue Cross by any “MS Neurologist” identified by the Alberta Multiple Sclerosis (MS) Drug Review Panel, and
have their Application approved by the Review Panel.
64BClinical Criteria to be considered for Coverage
To be considered for coverage of Avonex, Betaseron/Extavia, Copaxone, and Rebif, patients must be assessed by an “MS Neurologist” and meet the following clinical criteria: have a diagnosis of clinically definite relapsing-remitting multiple sclerosis:
• have had at least two attacks/exacerbations of MS during the previous two years. (An attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 48 hours in the absence of fever, not associated with withdrawal from steroids. Attacks must be separated by a period of at least one month.)
• are ambulatory with or without aid (i.e. a cane or walker). OR to be considered for coverage of Betaseron/Extavia: have a diagnosis of secondary progressive multiple sclerosis with relapses:
• have had at least two attacks/exacerbations of MS during the previous two years. (An attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 72 hours in the absence of fever, not associated with withdrawal from steroids, and preceded by stability for at least one month. Attacks must be separated by a period of at least one month.)
• have an EDSS score of less than or equal to 5.5. To be considered for coverage of Tysabri, see the clinical criteria as listed in the Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program.
65BContraindications to Coverage
In addition to meeting the above clinical criteria, the patient must have none of the following contraindications:
Significant illness likely to alter compliance or substantially reduce life expectancy. Active, severe depression: in the absence of a depression waiver from a psychologist or psychiatrist.
The depression waiver must accompany the Multiple Sclerosis (MS) Drug Coverage Application form(s) for patients with active, severe depression.
Planned or current pregnancy, nursing women. Contraindications for Tysabri, refer to the clinical criteria as listed in the Drug Products Under Multiple
Sclerosis (MS) Drug Coverage Program.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST MULTIPLE SCLEROSIS (MS) DRUG COVERAGE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 2 • 2
66BAlberta Multiple Sclerosis (MS) Drug Review Panel
The Alberta Multiple Sclerosis (MS) Drug Review Panel is an external review panel composed of neurologists and other health professionals with expertise in MS, appointed by the Minister of Health and Wellness.
The Review Panel’s functions include:
making recommendations to Alberta Health and Wellness on Multiple Sclerosis (MS) Drug Coverage program requirements, including maintenance of the eligibility criteria;
identifying “MS Neurologists” for the purposes of this program, and; reviewing applications for Multiple Sclerosis (MS) Drug Coverage.
67BProcess for Multiple Sclerosis (MS) Drug Coverage
Participating “MS Neurologists” must complete a separate Multiple Sclerosis (MS) Drug Coverage Application form(s) for each patient. The completed application may be forwarded to Alberta Blue Cross by mail or by facsimile.
Alberta Blue Cross, in providing administrative support to the Review Panel, receives and screens each application for completeness, then forwards it to the Review Panel for assessment. Alberta Blue Cross responds to applicants on the Review Panel’s behalf. After an application is assessed by the Review Panel, Alberta Blue Cross notifies the “MS Neurologist” and the patient by letter of the Review Panel’s decision. If the patient is approved for Multiple Sclerosis (MS) Drug Coverage an MS Nurse (a nurse with extensive knowledge of MS and MS therapies) will provide the patient with education regarding: (i) potential benefits and limitations of therapy, (ii) side-effects, (iii) how drug administration will be taught, (iv) how the patient will be followed, (v) how the patient can access help or information, (vi) how the treatment will be reimbursed and the requirements for reimbursement, (vii) indications for treatment to possibly be discontinued, and (viii) what should be reported and to whom. The MS Nurse will also ensure that the prescribing neurologist is aware of the timelines for the necessary ongoing follow-up to ensure safe and appropriate ongoing use of therapies. A new Multiple Sclerosis (MS) Drug Coverage Application form(s) must be completed by an “MS Neurologist” to review coverage if the patient requires a different Multiple Sclerosis (MS) Drug and for renewal requests.
To be eligible for Multiple Sclerosis (MS) Drug Coverage, prescriptions must be written by an “MS Neurologist” identified by the Review Panel. Regular monitoring of patients during the first year of therapy is needed in order to ensure the appropriate treatment option and dose, and to minimize the potential for wastage. Therefore, prescription quantities are limited to a one-month supply for the first year of therapy. This also applies to drug changes and to patients new or transferring to this program. Once the patient has been stabilized on a MS drug (excluding Tysabri) and dosage for one year and received program renewal authorization, up to 100 days’ supply may be dispensed at a time.
Government will not be responsible for reimbursement of costs associated with wastage or improper storage of the drug.
Prior approval must be granted to ensure coverage. Approval is granted for a specific period, to a maximum of 12 months unless otherwise indicated. If continued treatment is necessary, it is the responsibility of the patient and “MS Neurologist” to re-apply for drug coverage prior to the expiry date of the authorization period.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST MULTIPLE SCLEROSIS (MS) DRUG COVERAGE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 2 • 3 EFFECTIVE JULY 1, 2012
Completed Multiple Sclerosis (MS) Drug Coverage Application forms should be directed by mail or FAX to: Clinical Drug Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5
(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Applicant must be covered on an Alberta Government sponsored drug program. Page 1 of 6
PATIENT INFORMATION Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day
Street Address City Province Postal Code
Identification/Client/Coverage No: Coverage
Type:
Alberta Blue Cross Alberta Human Services
Alberta Seniors Other
MS NEUROLOGIST INFORMATION Surname First Name Middle Initial College of Physicians and Surgeons
Registration No.
Street Address City Province Postal Code
Telephone Number Fax Number Last Consult Date
Date Form Completed MS Neurologist’s Signature
MS NURSE INFORMATION Surname First Name MS Nurse Signature Telephone Number Fax Number
TREATMENT REQUESTED (Check only one box and indicate dosage - complete for each request.)
Avonex/Avonex PS (interferon beta-1a)
Betaseron (interferon beta-1b)
Copaxone (glatiramer acetate)
Extavia (interferon beta-1b)
Rebif (interferon beta-1a)
Tysabri (natalizumab)
Planned Start Date Dosage and Frequency Requested
New to Program: start upon approval/bridging New to Program: on drug already Drug change Renewal
DIAGNOSIS (Check all that apply. McDonald1(Page 2) diagnostic criteria must be met. MRI reports must be enclosed to confirm MRI criteria are met.)
For Avonex/Avonex PS, Betaseron/Extavia, Copaxone, Rebif, Tysabri: Relapsing-remitting multiple sclerosis
For Betaseron/Extavia only:
Secondary progressive multiple sclerosis with relapses
Ambulatory with or without aid Ambulatory to 100 m without an aid (EDSS ≤ 5.5)
Have had at least two attacks/exacerbations of MS during the last two years, or in the two years prior to starting MS disease modifying therapy2(Page 2). A gadolinium enhancing MRI lesion at least 3 months before or after an attack may substitute for one attack.
APPLICATION INFORMATION REQUIRED: Avonex/Avonex PS, Betaseron/Extavia, Copaxone, and Rebif requests please complete section 1 only (Pages 1-3).
Tysabri (new to program) requests please complete sections 1 and 2 (Pages 1-5). Patients on Tysabri already, complete sections 1, 2, and 3 (Pages 1-6).
Tysabri (renewal) requests please complete sections 1 and 3 (Pages 1-3 and 6). Please mail this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5
Or fax to: Alberta Blue Cross, Clinical Drug Services 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas
Case Number
Notice to Applicant: The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Section 1: Complete for ALL MS Drug applications Patient’s Alberta Personal
Health Number (only) Page 2 of 6
PREVIOUS MS DISEASE MODIFYING TREATMENT (Complete for each request.)
DRUG DATE STARTED DATE STOPPED REASON FOR DRUG STOPPAGE*
* Examples of reasons drug may be stopped: lack of efficacy, intolerability, non-compliance, pregnancy, financial reasons, interferon antibody positive
CONTRAINDICATIONS (Complete for each request.)
Yes No
1. Significant illness likely to alter compliance or substantially reduce life expectancy........................................................................... 2. Planned or current pregnancy, or nursing............................................................................................................................................ 3. a. Active, severe depression; or ……………………………………………………………………………………………………………..
b. Active, severe depression; waiver from a psychologist or psychiatrist attached3......................................................................... 4. Progression without relapse4...........................................................................................................................................................….
OTHER CLINICAL DATA (Complete for each request.)
Age: Gender: Male Female Date of onset: ___________/___________(Year/Month)5
Current Prescribed Medications:
Allergies:
Page 1 and 2: 1. McDonald Criteria (Ann Neurol 2001; 50:121-127) Summary: patients must meet one of the following conditions:
a) 2 attacks confirmed by objective findings and evidence of 2 clinically objective lesions. b) 2 attacks confirmed by objective findings, and 1 clinically objective lesion, and either dissemination in space by MRI as below or at least 2 MRI lesions
and CSF oligoclonal bands or increased IgG index. c) 1 attack confirmed by objective findings, and 2 clinically objective lesion sites, and dissemination in time by MRI. d) 1 attack confirmed by objective findings, and 1 clinically objective lesion, and dissemination in space by MRI [or 2 MRI lesions and + CSF] and
dissemination in time by MRI. Dissemination in space by MRI: (3 of 4 of the following): 1) 1 gd+ lesion or 9 T2 hyperintense lesions (cord or brain); 2) 1 infratentorial lesion; 3) 1 juxtacortical lesion; 4) 3 periventricular lesions Dissemination in time by MRI: Either 1) a gd+ lesion on an MRI at least 3 (or more) months after an attack, at a different site; or, 2) a new T2 lesion at least 3 months after scan that was completed at least 3 months after the initial documented attack, at a different site.
2. In RRMS an attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 48 hours in the absence of fever, and not associated with withdrawal from steroids. In SPMS it is more difficult to differentiate attacks from disease fluctuation; therefore, attacks must meet these criteria, must have lasted at least 72 hours, and new neurologic deficits must have been documented by a physician. Attacks must be separated by a period of at least one month.
3. Required prior to approval for all patients who have not been on treatment for at least 6 months. 4. Progression is worsening neurologic impairment not due to residual deficits from attacks. 5. Consider onset as the time of first convincing MS symptoms. This would include episodes such as transverse myelitis or optic neuritis, but not (in most
cases) non-specific symptoms such as dizziness, visual blurring or fatigue.
Case Number
ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Section 1: Complete for ALL MS Drug applications Patient’s Alberta Personal
Health Number (only) Page 3 of 6
QUALIFYING ATTACKS (Not required for renewals.)
TWO MOST RECENT ATTACKS:
Date of attack onset (or MRI):
MRI ATTACK EQUIVALENT
(Y/N)
SEVERITY6 RECOVERY FUNCTIONAL SYSTEMS INVOLVED OBJECTIVE CHANGES
(SPMS ONLY)
Year Month Day Yes No
Mild Moderate Severe Very Severe
None Incomplete Complete
Pyramidal Sensory Cerebellar Brain Stem Bowel/bladder Visual Cognitive/cerebral
Yes No
Year Month Day Yes No
Mild Moderate Severe Very Severe
None Incomplete Complete
Pyramidal Sensory Cerebellar Brain Stem Bowel/bladder Visual Cognitive/cerebral
Yes No
BASELINE AND FOLLOW-UP DATA (Complete for each request.)
PRE DRUG
YY/MM/DD
CURRENT if on drug
YY/MM/DD
YEAR 1
YY/MM/DD
YEAR 2
YY/MM/DD
YEAR 3
YY/MM/DD
YEAR 4
YY/MM/DD
Date7 (Year / Month / Day)
EDSS
Pyramidal
Cerebellar
Brain Stem
Visual Score
Sensory
Bowel/Bladder
Cognitive
# of attacks during 2 yrs prior to baseline assessment
# of attacks during the last 12 months
Relapse at time of assessment (Yes or No)
Progressive course (Yes or No)
Interferon antibodies (Yes, No, Not applicable, or Unknown)
6. Severity: Mild - symptoms present but no change in function; Moderate - requires modification or more time to carry out activity; Severe - unable to carry
out usual activity; Very Severe - requires others to provide personal care for them. 7. Date of examination must be 0-6 months preceding this request, or if already on drug, from the most recent annual assessment.
Case Number
ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Section 2: Complete for NEW Tysabri requests Patient’s Alberta Personal Health Number (only)
Page 4 of 6
ELIGIBILITY Yes No
Patient has previously been demonstrated to have at least nine T2 hyperintense lesions on brain MRI NEUTRALIZING ANTIBODIES, INTOLERANCE, OR REFRACTORY TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Patient has demonstrated one of the following: I. NEUTRALIZING ANTIBODIES to INTERFERON Yes No Clinically significant titres, report must be provided
OR II. INTOLERANCE TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Yes No 'Intolerance' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT. Describe the intolerance and response to management techniques tried in detail below (or attach letter):
OR
III. REFRACTORY TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Within a 12 month period on drug: Yes No
a. The patient reported adherence to the interferon beta at the standard dose defined as receiving 80% of prescribed dosing
EITHER b or c:
b. The patient experienced two relapses (neurologic deficits must have persisted for at least 3 months for one of the relapses; an exception may be considered where the second relapse is severe6(page 3) and the application is submitted within 3 months of the relapse onset):
Date of Onset YYYY/MM/DD Neurologic Deficits (describe) Persistence of Deficits:
Clinical Relapse 1 (>30 days from initiation of DMT)
Residual Deficits: Yes No If Yes, how long after onset were deficits detected (e.g., 3 months):
Clinical Relapse 2 (>30 days from relapse 1)
If applying within 3 months of onset, also describe severity of deficits: Residual Deficits: Yes No
If Yes, how long after onset were deficits detected (e.g., 3 months):
OR c. The patient experienced one relapse and one inflammatory event on MRI report (neurologic deficits must have persisted for at least 1 month for the relapse):
Date of Onset YYYY/MM/DD Neurologic Deficits (describe) Persistence of Deficits:
Clinical Relapse (>30 days from initiation of DMT)
Neurologic deficits on examination at least one month after relapse onset: Yes No
MRI (>90 days from clinical relapse; attach reports) A definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse; OR The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size. - To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have been completed at least one month after starting DMT. - To confirm that the MRI lesions were not associated with the relapse, the relapse can not have occurred between the 2 MRI scans. - To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.
Yes No
Case Number
ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Section 2: Complete for NEW Tysabri requests Patient’s Alberta Personal Health Number (only)
Page 5 of 6
INTOLERANCE OR REFRACTORY TO GLATIRAMER ACETATE (Copaxone) Patient has demonstrated one of the following:
I. INTOLERANCE TO GLATIRAMER ACETATE (Copaxone) Yes No 'Intolerance' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT. Describe the intolerance and response to management techniques tried in detail below (or attach letter):
OR
II. REFRACTORY TO GLATIRAMER ACETATE (Copaxone) Within a 12 month period on drug:
Yes No
a. The patient reported adherence to the glatiramer acetate at the standard dose defined as receiving 80% of prescribed dosing EITHER b or c:
b. The patient experienced two relapses (neurologic deficits must have persisted for at least 3 months for one of the relapses; an exception may be considered where the second relapse is severe6(page 3) and the application is submitted within 3 months of the relapse onset):
Date of Onset YYYY/MM/DD Neurologic Deficits (describe) Persistence of Deficits:
Clinical Relapse 1 (>30 days from initiation of DMT)
Residual Deficits: Yes No If Yes, how long after onset were deficits detected (e.g., 3 months):
Clinical Relapse 2 (>30 days from relapse 1)
If applying within 3 months of onset, also describe severity of deficits: Residual Deficits: Yes No
If Yes, how long after onset were deficits detected (e.g., 3 months):
OR c. The patient experienced one relapse and one inflammatory event on MRI report (neurologic deficits must have persisted for at least 1 month for the relapse):
Date of Onset YYYY/MM/DD Neurologic Deficits (describe) Persistence of Deficits:
Clinical Relapse (>30 days from initiation of DMT)
Neurologic deficits on examination at least one month after relapse onset: Yes No
MRI (>90 days from clinical relapse; attach reports) A definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse; OR The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size. - To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have been completed at least one month after starting DMT. - To confirm that the MRI lesions were not associated with the relapse, the relapse can not have occurred between the 2 MRI scans. - To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.
Yes No
CONTRAINDICATIONS (Does the patient have any of the following?): Yes No
1. Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)………………………………..
2. Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)…
3. History of progressive multifocal leukoencephalopathy (PML)…………………………………………………………………………………………..
4. Concurrent malignancy, or significant illness likely to alter compliance or substantially reduce life expectancy ………………………………….
5. Planned or current pregnancy, or nursing …………………………………………………………………………………………………………………
Case Number ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan
AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION
Section 3: Complete for Tysabri Renewals and patients Patient’s Alberta Personal Health Number (only)
Page 6 of 6 currently on Tysabri
Tysabri treatment start date (YYYY/MM/DD): ________________ Yes No
The patient has not missed any doses, or delayed any doses by more than 1 week with the exception of medically authorized delays (Rationale for such delays must be justified in a narrative; only serious medical conditions are acceptable)
The patient must be assessed by an MS Neurologist and have an MRI with gadolinium at least every 12 months (attach reports)
NEUTRALIZING ANTIBODIES TO TYSABRI (Complete for patients currently on Tysabri.)
There must be evidence that neutralizing antibodies to Tysabri are absent (attach report):
Are neutralizing antibodies absent at 6 to 8 months after initiation of therapy?
Yes If Yes: no further testing is required No If No: Are neutralizing antibodies absent on repeat testing? Yes No
RESPONSE TO TYSABRI (Complete for ALL patients on Tysabri, update for each request.)
On assessment, the MS Neurologist must confirm in writing that the patient is a 'responder': Yes No There has been no more than one inflammatory event in the last year (defined as either a clinical relapse or gadolinium enhancing lesion): If no, the patient had four or more relapses in the year prior to starting treatment, and there is at least a 50% reduction in relapse rate over the entire Tysabri treatment period.
PRIOR to Tysabri treatment: Indicate confirmed inflammatory events over the 2 years prior to initiation of treatment with Tysabri (include all independent clinical relapses and MRI events):
WHILE ON Tysabri treatment: Indicate all confirmed inflammatory events after initiation of treatment with Tysabri (include all independent clinical relapses and MRI events):
MRI Clinical relapse
Date of onset/MRI (YYYY/MM/DD)
No inflammatory events
MRI Clinical relapse
Date of onset/MRI (YYYY/MM/DD)
CONTRAINDICATIONS (Complete at every renewal. Does the patient have any of the following?): Yes No
1. Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)………………………………….
2. Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)…..
3. History of progressive multifocal leukoencephalopathy (PML)…………………………………………………………………………………………….
4. Concurrent malignancy, or significant illness likely to alter compliance or substantially reduce life expectancy ……………………………………
5. Planned or current pregnancy, or nursing …………………………………………………………………………………………………………………..
Case Number ABC 30771 (R02/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTMULTIPLE SCLEROSIS (MS) DRUG COVERAGE
GLATIRAMER ACETATE
INTERFERON BETA-1A
INTERFERON BETA-1B
20 MG / SYR INJECTION SYRINGE
6 MIU / VIAL INJECTION
44 MCG / ML INJECTION CARTRIDGE
88 MCG / ML INJECTION CARTRIDGE
6 MIU / SYR INJECTION SYRINGE
22 MCG / SYR INJECTION SYRINGE
44 MCG / SYR INJECTION SYRINGE
9.6 MIU / VIAL INJECTION
00002245619
00002237770
00002318253
00002318261
00002269201
00002237319
00002237320
0000216964900002337819
COPAXONE
AVONEX (30 MCG)
REBIF (1.5 ML CARTRIDGE)
REBIF (1.5 ML CARTRIDGE)
AVONEX PS/PEN (30 MCG/0.5 ML)
REBIF (0.5 ML SYRINGE)
REBIF (0.5 ML SYRINGE)
BETASERON (0.3 MG)EXTAVIA (0.3 MG)
TMP
BIO
SRO
SRO
BIO
SRO
SRO
BHPNOV
43.2000
365.8568
240.9300
293.3061
381.0075
120.4650
146.6530
99.3593 99.3593
EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$$
The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis, and who participate in Alberta government-sponsored drug programs.
The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis, and who participate in Alberta government-sponsored drug programs.
The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis OR secondary progressive multiple sclerosis with relapses, and who participate in Alberta government-sponsored drug programs.
10Section 2 .
Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTMULTIPLE SCLEROSIS (MS) DRUG COVERAGE
PRODUCT IS NOT INTERCHANGEABLE
NATALIZUMAB
EFFECTIVE JULY 1, 2012
"Natalizumab coverage may be provided for the treatment of relapsing remitting multiple sclerosis (RRMS) to reduce the frequency of clinical exacerbations, to decrease the number andvolume of active brain lesions identified on magnetic resonance imaging (MRI) scans and to delay the progression of physical disability, in adult patients (18 years of age or older) who have active RRMS that is causing CNS injury, who have previously been demonstrated to have at least nine T2 hyperintense lesions on brain MRI, and who are refractory or intolerant to both interferon beta (Avonex, Betaseron/Extavia or Rebif) and glatiramer acetate (Copaxone). Patients who develop neutralizing antibodies to interferon will be considered to have failed interferon.
Neutralizing Antibodies to interferon
If neutralizing antibodies are present, a report indicating clinically significant titres must be provided.
Refractory
When the above agents are taken at the recommended doses 'Refractory' is defined as:Within a 12-month period the patient has:
1) Been adherent to the disease modifying therapy (DMT) (i.e., greater than 80% of approved doses have been administered);
AND
2a) Experienced at least two relapses confirmed by the presence of neurologic deficits on examination.- The first qualifying relapse must have begun at least one month after treatment initiation- There must be at least one month between the onset of relapses- Neurologic deficits must have persisted for at least 3 months for one of the relapses. Alternatively, information on a second qualifying relapse with severe deficits (defined as unable to carry out usual activities of daily living), submitted within 3 months of the date of onset, will beconsidered.
OR
2b) Experienced one relapse confirmed by the presence of neurologic deficits on examination.- This relapse must have begun at least one month after treatment initiation.- Neurologic deficits must have persisted for at least 1 month
AND
Have evidence of active inflammatory MS disease activity on brain or spine MRI that:- started/occurred during treatment with DMT, and- was not associated with a clinical relapse
MRI evidence may be:- a definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse;OR- The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size.- To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have beencompleted at least one month after starting DMT.- To confirm that the MRI lesions were not associated with the relapse, the relapse cannot have occurred between the 2 MRI scans.- To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.
11Section 2 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTMULTIPLE SCLEROSIS (MS) DRUG COVERAGE
NATALIZUMAB
EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
Documentation supporting this criterion requires a radiologist's report that directly compares 2 brain MRI scans and that indicates the MRI scan dates, and that clearly states that 2 or more new, or newly enlarging, T2 lesions at least 3 mm in size are present on the second scan.
Intolerant
'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in the product monograph, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT.
Contraindications
Coverage will not be approved if any of the following contraindications exist:- Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)- Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)- History of progressive multifocal leukoencephalopathy (PML)- Concurrent malignancy or significant illness likely to alter compliance or substantially reduce life expectancy- Planned or current pregnancy, or nursing
Coverage
For coverage, this drug must be prescribed by a Specialist in Neurology ("MS Neurologist") who has been identified by the Alberta MS Drug Review Panel.
Initial Coverage
- Within the 2 years prior to the Tysabri application, the patient must meet the same relapse criteria that are required for other MS therapies considered for MS Drug Coverage (2 relapses during the last 2 years, one of which may be an MRI enhancing lesion). In most cases this will be satisfied by the treatment failure demonstrated but, if a patient failed interferon and glatirameracetate more than one year earlier, ongoing active disease must be confirmed. Exceptions may be made for patients switching due to recent development of intolerance or neutralizing antibodies.- Coverage will not be approved when any DMT or other immunosuppressive therapy is to be used in combination with Tysabri (except corticosteroids which can be used for up to 12 weeks during Tysabri initiation in patients with coexisting Crohn's Disease or similar situations).- Patients who have failed Tysabri will not be eligible for a subsequent trial of Tysabri (except in exceptional circumstances).
Following this assessment, coverage may be approved for 13 doses of 300 mg (i.e., one dose administered every 4 weeks for a period of 12 months). Patients will be limited to receiving 1 dose (4 weeks supply) of Tysabri per prescription at their pharmacy.
Continued Coverage
For continued coverage beyond 13 doses, the patient must meet the following criteria:
1) At the first renewal there must be evidence that neutralizing antibodies to Tysabri are absent. This requires an initial test between 6 to 8 months of treatment. If neutralizing antibodies are absent, no further testing is required. If neutralizing antibodies are present, testing must be repeated prior to the renewal request.
2) The patient must be assessed by an MS Neurologist and have an MRI with gadolinium at least every 12 months;
12Section 2 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTMULTIPLE SCLEROSIS (MS) DRUG COVERAGE
PRODUCT IS NOT INTERCHANGEABLE
NATALIZUMAB
20 MG / ML INJECTION00002286386 TYSABRI BIO 166.2756
EFFECTIVE JULY 1, 2012
$
AND
3) On assessment, the MS Neurologist must confirm in writing that the patient is a 'responder' that meets all of the following criteria:- There has been no more than one inflammatory event in the last year (defined as either a clinical relapse or gadolinium enhancing lesion). The rare exception is a patient who has had four or more relapses in the year prior to starting treatment; in this case there must be at least a 50% reduction in relapse rate over the entire Tysabri treatment period.- The patient has not missed any doses, or delayed any doses by more than 1 week with the exception of medically authorized delays (rationale for such delays must be justified in a narrative; only serious medical conditions are acceptable).- None of the contraindications identified above exist.
Following this assessment, continued coverage may be approved for maintenance therapy of 300 mg every 4 weeks for a period of 12 months. Patients will be limited to receiving 1 dose of Tysabri per prescription at their pharmacy."
13Section 2 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 3 Criteria for Special A
uthorization of Select Drug Products
SECTION 3
Criteria for Special Authorization
of Select Drug Products
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 3 • 1 EFFECTIVE JULY 1, 2012
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The drug products listed in this section may be considered for coverage by special authorization for patients covered under Alberta Health and Wellness-sponsored drug programs. (For Alberta Human Services and Alberta Seniors (AISH) clients, the special authorization criteria for coverage can be found in the Criteria for Special Authorization of Select Drug Products section of the Alberta Human Services Drug Benefit Supplement.)
68BSpecial Authorization Policy
99BDRUG PRODUCTS ELIGIBLE FOR CONSIDERATION BY SPECIAL AUTHORIZATION Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products Unot U eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization. 1. The drug is covered by Alberta Health and Wellness under specified criteria (listed in the following
sections). Drug Products and indications other than those specified are not eligible for consideration by special authorization.
2. The drug is normally covered by another government program or agency for a specific approved clinical condition, but is needed for the treatment of a clinical condition that is not covered by that government program or agency.
3. The drug is required because other drug products listed in the Alberta Health and Wellness Drug Benefit List are contraindicated or inappropriate because of the clinical condition of the patient.
4. The particular brand of drug is considered essential in the care of a patient, where the LCA price policy would otherwise apply. Coverage of a specific brand may be considered where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with alternate brands in an interchangeable grouping. Coverage of a brand name product will UnotU be considered in situations where the interchangeable grouping includes a pseudo-generic to the brand name drug.
5. A particular drug product or dosage form of a drug is essential in the care of a patient where the MAC price policy would otherwise apply. Exceptions may occur at the product level. Coverage may be considered only where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with the drug product which establishes the MAC pricing.
Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.
Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage UpriorU to the expiration date of the Approved Period, UunlessU the Auto-Renewal Process or Step Therapy Approval Process apply (see below).
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 3 • 2
100BAUTO-RENEWAL PROCESS Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).
1. For initial approval, a special authorization request must be submitted. If approval is granted, it will be effective for the Approval Period outlined in the drug product’s Special Authorization criteria
2. As long as the patient has submitted a claim for the drug product within the preceding Approval Period (example: within the preceding 6 months), approval will be automatically renewed for a further Approval Period (example: a further 6 months). There is no need for the prescriber to submit a new request as the automated real-time claims adjudication system will read the patient’s claims history to determine if a claim has been made within the preceding Approval Period.
3. If the patient does UnotU make a claim for the drug product during the Approval Period, the approval will lapse and a new special authorization request must be submitted.
101BSTEP THERAPY APPROVAL PROCESS
102BSelect drug products are eligible for coverage via the step therapy process, outlined below.
1. 103BIf the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months, the claim for the step therapy drug will be approved.
2. 104BThe automated real-time claims adjudication system will read the patient’s claims history to determine if the required First-Line* drug product(s) have been claimed within the preceding 12 months.
3. 105BSubsequent claims for drug product(s) permitted by step therapy will continue to be approved as long as the drug product has been claimed within the preceding 12 months.
4. 106BThe regular special authorization approval process will continue to be available for step therapy approvals for those patients whose First-Line* drug claims cannot be adjudicated through the automated real-time claims adjudication system.
* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’s Special Authorization criteria, are required to be utilized before reimbursement for the drug product is permitted.
107BDRUG PRODUCTS NOT ELIGIBLE FOR CONSIDERATION BY SPECIAL AUTHORIZATION
The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List. 2. Drug products not yet reviewed by the Alberta Health and Wellness Expert Committee on Drug
Evaluation and Therapeutics. This applies to: * products where a complete submission has been received from the manufacturer and the product is
under review, * products where an incomplete submission has been received from the manufacturer, and * products where the manufacturer has not made a submission for review.
Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.
3. Drug products that have completed the review process and are not included on the List. 4. Most drugs available through Health Canada’s Special Access Program. 5. Drug products when prescribed for cosmetic indications. 6. Nonprescription or over-the-counter drug products are generally not eligible.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 3 • 3 EFFECTIVE JULY 1, 2012
69BCriteria for Coverage
Wording that appears within quotation marks (“ ”) in this section is the official special authorization criteria, as recommended by the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics, and approved by the Minister of Health and Wellness. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.
Products Available Through Health Canada’s Special Access Program
PEMOLINE “For the treatment of attention deficit hyperactivity disorder where approval has been provided by Health Canada’s Special Access Program.”
37.5 MG ORAL TABLET DIN N/A* CYLERT ABB
75 MG ORAL TABLET DIN N/A* CYLERT ABB
*As Cylert has been withdrawn from market, the DINs are no longer valid. Where authorizations for Cylert have been granted, coverage for this product will be provided under PIN 00000999917.
Other Products
The remaining drug products in this section are listed alphabetically according to the generic ingredient name of the drug. These products can be found on the following pages.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ABATACEPT
4 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate or other DMARDS, for the reduction in signs and symptoms of severely active Rheumatoid Arthritis(RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for five doses of up to 1000 mg/dose administered at 0, 2, 4, 8 and 12 weeks.-Patients will be limited to receiving one dose of abatacept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond five doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial five doses to determine response between 12 and 16 weeks of receiving the initial dose.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for one dose of up to 1000 mgevery 4 weeks for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- confirmation of maintenance of ACR20, OR- maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ABATACEPT
5 EFFECTIVE JULY 1, 2012 Section 3 .
All requests (including renewal requests) for abatacept for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
Juvenile Idiopathic Arthritis:
"Special authorization coverage may be provided for the reduction in signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in patients 6 years of age and older who:- Have 5 or more active joints (defined by either swelling or limitation of motion plus pain and/or tenderness), AND- Are refractory to one or more disease modifying anti-rheumatic agents (DMARDS) conventionally used in children (minimum three month trial), AND- Are refractory to or intolerant to etanercept (minimum 12 week trial).
'Refractory' is defined as lack of effect at the recommended doses and duration of treatments aslisted above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in the product monographs.
For coverage, this drug must be prescribed by a prescriber affiliated with a Pediatric Rheumatology Clinic in Edmonton or Calgary ("Pediatric Rheumatology Specialist").
- Coverage may be approved for one dose of 10 mg/kg (maximum dose 1000 mg) at 0, 2, 4, 8, 12 and 16 weeks (total of six doses).- Patients will be limited to receiving one dose of abatacept per prescription at their pharmacy.
For potential coverage for retreatment with abatacept following a subsequent disease flare, the patient must meet the following criteria:1) The patient must be assessed by a Pediatric Rheumatology Specialist after the initial 16 weeks, but no longer than 20 weeks after, treatment with this biologic agent to determine and document initial treatment response.2) The Pediatric Rheumatology Specialist must confirm in writing that the patient is a responder that meets the following criteria (JRA30):- 30% improvement from baseline in at least three of the following six response variables, with worsening of 30% or more in no more than one of the six variables. The variables include: i. global assessment of the severity of the disease by the Pediatric Rheumatology Specialist, ii. global assessment of overall well-being by the patient or parent, iii. number of active joints (joints with swelling not due to deformity or joints with limitation of motion with pain tenderness or both), iv. number of joints with limitation of motion, v. functional ability based on CHAQ scores, vi. ESR or CRP3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported.
Following assessment and confirmation of initial treatment response, coverage for retreatment with abatacept may be approved for one dose of 10 mg/kg (maximum dose 1000 mg) at 0, 2*, 4,8, 12 and 16 weeks (total of up to six doses; *the week 2 dose on retreatment is optional, to be administered at the discretion of the Pediatric Rheumatology Specialist). In order to be considered for coverage for retreatment, the patient must meet the following criteria:1) The patient has been assessed by a Pediatric Rheumatology Specialist and the presence of disease flare confirmed. Disease flare is defined as worsening of at least 30% or greater in at least 3 of 6 JRA30 variables for JIA and 30% or greater improvement in no more than one variable.2) The Pediatric Rheumatology Specialist must confirm in writing that the patient has had an initial treatment response (as assessed above) and that the patient has experienced a disease flare (as defined above)."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ABATACEPT
250 MG / VIAL (BASE) INJECTION00002282097 ORENCIA BMS 460.9097
6 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
Section 3 .
Please note: Coverage is provided for treatment of disease flares only. However, if a patient experiences a subsequent flare within 12 months of initiation of treatment with abatacept, they may be eligible for continuous coverage (i.e., one dose of 10 mg/kg (maximum dose 1000 mg) every 4 weeks) for a maximum period of two years, provided the patient has demonstrated a response to initial treatment."
All requests (including renewal requests) for abatacept for Juvenile Idiopathic Arthritis must be completed using the Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ADALIMUMAB
7 EFFECTIVE JULY 1, 2012 Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial) [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily)
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness or its agent, throughout the special authorization approval period ("RA Specialist"). The patient must also provide all consents and authorizations required to permit the RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the RA Specialist does not continually, actively and consistently participate in the Study.
- Initial coverage may be approved for five doses as follows: An initial 40 mg dose, followed by additional 40 mg doses at 2, 4, 6 and 8 weeks after the first dose.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond five doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial five doses to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for 40 mg every other week for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ADALIMUMAB
8 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- confirmation of maintenance of ACR20, or - maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for adalimumab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
Psoriatic Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 40 mg administered every other week for 8 weeks.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after, to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ADALIMUMAB
9 EFFECTIVE JULY 1, 2012 Section 3 .
- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for doses of 40 mg every other week, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests. It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for adalimumab for Psoriatic Arthritis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis SpecialAuthorization Request Form (ABC 30964).
Ankylosing Spondylitis:
"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:
- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 12 weeks as follows: An initial 40 mg dose, followed by additional 40 mg doses administered every two weeks for up to 12 weeks after the first dose.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ADALIMUMAB
10 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
For continued coverage beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed at 12 weeks by an RA Specialist after the initial 12 weeks of therapy to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.
Following this assessment, continued coverage may be approved for one 40 mg dose every other week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for adalimumab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).
Moderately to Severely Active Crohn's Disease:
"Special authorization coverage may be approved for coverage of adalimumab for the reduction in signs and symptoms and induction and maintenance of clinical remission of Moderately to Severely Active Crohn's Disease in patients who meet the following criteria:
- Adalimumab must be prescribed by a Specialist in Gastroenterology or a physician appropriately trained by the University of Alberta or the University of Calgary and recognized as a prescriber by Alberta Blue Cross for adalimumab for coverage for the treatment of Moderately to Severely Active Crohn's Disease patients ('Specialist').- Patients must be 18 years of age or older to be considered for coverage of adalimumab.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients may be allowed to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy (both primary loss of response and secondary loss of response) or due to serious adverse effects or contraindications. An adequatetrial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
Prior to initiation of adalimumab therapy for New Patients:
'New Patients' are patients who have never been treated with adalimumab by any health care provider.
Moderately to Severely Active Crohn's Disease:
Prior to initiation of adalimumab therapy, New Patients must have a current Modified (without the physical exam) Harvey Bradshaw Index score of greater than or equal to 7 (New Patient's Baseline Score), AND be Refractory.
Refractory is defined as one or more of the following:1) Serious adverse effects or reactions to the treatments specified below; OR 2) Contraindications (as defined in product monographs) to the treatments specified below; OR3) Previous documented lack of effect at doses and for duration of all treatments specified below: a) mesalamine: minimum of 3 grams/day for a minimum of 6 weeks; AND refractory to, or dependent on, glucocorticoids: following at least one tapering dosing schedule of 40 mg/day,
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ADALIMUMAB
11 EFFECTIVE JULY 1, 2012 Section 3 .
tapering by 5 mg each week to 20 mg, then tapering by 2.5 mg each week to zero, or similar.
[Note: Patients who have used the above treatments in combination will not be required to be challenged with individual treatments as monotherapy]
ANDb) Immunosuppressive therapy as follows: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 3 months; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 3 months; OR- Methotrexate: minimum or 15 mg/week for a minimum of 3 months.OR - Immunosuppressive therapy discontinued at less than 3 months due to serious adverse effectsor reactions.
Applications for coverage must include information regarding the dosages and duration of trial ofeach treatment the patient received, a description of any adverse effects, reactions, contraindications and/or lack of effect, as well as any other information requested by Alberta Blue Cross.
Coverage Criteria for Moderately to Severely Active Crohn's Disease
- New Patients must meet the criteria above prior to being considered for approval. - All approvals are also subject to the following applicable criteria.
Induction Dosing for New Patients:
- Coverage for Induction Dosing may only be approved for New Patients (those who have never been treated with adalimumab by any health care provider).- 'Induction Dosing' means a maximum of one 160 mg dose of adalimumab per New Patient at week 0 followed by an 80 mg dose at week 2.- New Patients are eligible to receive Induction Dosing only once, after which time the Maintenance Dosing for New Patients and Continued Coverage for Maintenance Dosing criteria will apply.- As an interim measure, 40 mg doses of adalimumab will be provided at weeks 4, 6, 8 and 10 toallow time to determine whether the New Patient meets coverage criteria for Maintenance Dosing below.
Maintenance Dosing:
'Maintenance Dosing' means one 40 mg dose of adalimumab per patient provided no more often than every other week starting at week 4 for a period of 12 months to:- New Patients following the completion of Induction Dosing; OR - Existing Patients, who are patients that are being treated, or have previously been treated, withadalimumab.
Maintenance Dosing for New Patients after Completion of Induction Dosing:
- The New Patient must be assessed by a Specialist within 12 weeks after the initiation of Induction Dosing to determine response by obtaining a Modified Harvey Bradshaw Index score for patients with Moderately to Severely Active Crohn's Disease; AND- The Specialist must confirm the Modified Harvey Bradshaw Index score shows a decrease from the New Patient's Baseline Score of greater than or equal to 3 points for patients with Moderately to Severely Active Crohn's.
Maintenance Dosing for Existing Patients:
- The patient must be assessed by a Specialist annually (within 2 months of the expiry of a patient's special authorization) at least 2 weeks after the day a dose of adalimumab was administered to the patient and prior to administration of the next dose to obtain: a Modified
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ADALIMUMAB
12 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
Harvey Bradshaw Index Score (Existing Patient's Baseline Score) for Moderately to Severely Active Crohn's Disease; AND - these measures must be provided to Alberta Blue Cross for assessment for continued coverage for maintenance dosing.
Continued Coverage for Maintenance Dosing:
Continued coverage may be considered for one 40 mg dose of adalimumab per patient providedno more often than every other week for a period of 12 months, if the following criteria are met atthe end of each 12 month period:
- The New Patient or the Existing Patient must be assessed by a Specialist annually (within 2 months of the expiry of a patient's special authorization) at least 2 weeks after the day a dose of adalimumab was administered to the patient and prior to administration of the next dose to obtain: a Modified Harvey Bradshaw Index Score for Moderately to Severely Active Crohn's Disease; AND- For New Patients: The Specialist must confirm that the patient has maintained a greater than or equal to 3 point decrease from the New Patient's Baseline Score for Moderately to Severely Active Crohn's; OR- For Existing Patients: The Specialist must confirm that the patient has maintained the Existing Patient's Baseline Score."
All requests (including renewal requests) for adalimumab for Moderately to Severely Active Crohn's Disease must be completed using the Adalimumab for Crohn's/Infliximab for Crohn's/Fistulizing Crohn's Special Authorization Request Form (ABC 31200).
Plaque Psoriasis:
"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)
Patients who have a contraindication to either cyclosporine or methotrexate will be required to complete an adequate trial of the other pre-requisite medication prior to potential coverage beingconsidered.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be prescribed by a Specialist in Dermatology ("Dermatology Specialist").
- Initial coverage may be approved for an initial dose of 80 mg, followed by one 40 mg dose every other week beginning one week after the first dose, for a total of nine doses.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ADALIMUMAB
40 MG / SYR INJECTION SYRINGE00002258595 HUMIRA ABB 729.4200
13 EFFECTIVE JULY 1, 2012
$
Section 3 .
trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond nine doses, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial nine doses to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.
Following this assessment, continued coverage may be considered for one 40 mg dose of adalimumab every other week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to becontinuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for adalimumab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ALENDRONATE SODIUM
10 MG ORAL TABLET
40 MG ORAL TABLET
70 MG ORAL TABLET
000022487280000228808700002247373
0000225810200002201038
00002352966000022997120000224873000002258110000022863350000228400600002275279000022881090000226171500002245329
APO-ALENDRONATESANDOZ ALENDRONATETEVA-ALENDRONATE
CO ALENDRONATEFOSAMAX
ALENDRONATEALENDRONATE-FCAPO-ALENDRONATECO ALENDRONATEMYLAN-ALENDRONATEPMS-ALENDRONATE-FCRATIO-ALENDRONATESANDOZ ALENDRONATETEVA-ALENDRONATEFOSAMAX
APXSDZTEV
COBMFC
SNSMELAPXCOBMYPPMSRPHSDZTEVMFC
0.6911 0.6911 0.6911
2.6097 4.0743
3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835
10.2385
14 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$$
$$$$$$$$$$
Section 3 .
"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization may be granted for 6 months."
"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year).Special authorization for this criteria may be granted for 6 months."
"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy."
"Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."
"For the treatment of Paget's disease. Special Authorization for this criteria may be granted to a maximum of 6 months."
All requests for alendronate sodium for Osteoporosis must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).
The following product(s) are eligible for auto-renewal for the treatment of osteoporosis.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ALENDRONATE SODIUM/ VITAMIN D3
ALFUZOSIN HCL
AMPICILLIN
70 MG * 5,600 UNIT ORAL TABLET
10 MG ORAL SUSTAINED-RELEASE TABLET
250 MG ORAL CAPSULE
500 MG ORAL CAPSULE
00002314940
00002315866000023142820000230467800002245565
00000020877
00000020885
FOSAVANCE
APO-ALFUZOSINNOVO-ALFUZOSIN PRSANDOZ ALFUZOSINXATRAL
NOVO-AMPICILLIN
NOVO-AMPICILLIN
MFC
APXTEVSDZSAV
TEV
TEV
4.5533
0.4966 0.4966 0.4966 1.0251
0.3657
0.7091
15 EFFECTIVE JULY 1, 2012
$
$$$$
$
$
Section 3 .
"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures."
"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year)."
"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy.""Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."
"Special authorization for these criteria may be granted for 6 months."
All requests for alendronate sodium/vitamin D3 must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): DOXAZOSIN OR TERAZOSIN
"For the treatment of the symptoms of benign prostatic hyperplasia (BPH) in patients who are unresponsive to a six-week trial with a non-selective alpha-blocker (e.g., terazosin ) or in whom non-selective alpha-blockers are not tolerated or are contraindicated."
"Special authorization may be granted for 24 months"
"For the treatment of infections caused by susceptible Shigella and Salmonella."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ANAKINRA
16 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) in whom other biologics are contraindicated or in patients whohave experienced serious adverse events while on other biologics and who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND - Leflunomide (minimum 10 week trial at 20 mg daily).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness or its agent, throughout the special authorization approval period ("RA Specialist"). The patient must also provide all consents and authorizations required to permit the RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the RA Specialist does not continually, actively and consistently participate in the Study.
- Initial coverage may be approved for one 100 mg dose administered daily for 8 weeks.- Patients will be limited to receiving a one-month supply of anakinra per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks but no longer than 12 weeksafter treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for one 100 mg dose administered once daily for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ANAKINRA
AZITHROMYCIN
AZTREONAM
100 MG / SYR INJECTION SYRINGE
600 MG ORAL TABLET
75 MG / VIAL INHALATION POWDER FOR SOLUTION
00002245913
00002330911000022560880000226164200002231143
00002329840
KINERET
AZITHROMYCINCO AZITHROMYCINPMS-AZITHROMYCINZITHROMAX
CAYSTON
BVM
SNSCOBPMSPFI
GIL
47.9010
6.0000 6.0000 6.0000
12.0693
48.1564
17 EFFECTIVE JULY 1, 2012
$
$$$$
$
Section 3 .
2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for anakinra must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for RheumatoidArthritis Special Authorization Request Form (ABC 30902).
"For the prevention of disseminated Mycobacterium avium complex disease in patients with advanced HIV infection or other immunocompromised conditions.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): TOBRAMYCIN INHALATION SOLUTION
"For the treatment of chronic pulmonary Pseudomonas aeruginosa infections when used as cyclic treatment (28-day cycles) in patients 6 years of age and older with moderate to severe cystic fibrosis (CF) and deteriorating clinical condition despite treatment with inhaled tobramycin."
"Coverage will not be considered when inhaled tobramycin and inhaled aztreonam are intended for use in combination."
"Special authorization may be granted for 6 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
BENZOYL PEROXIDE
BUDESONIDE
BUSERELIN ACETATE
CABERGOLINE
10 % TOPICAL (ALCOHOL) GEL
20 % TOPICAL (ALCOHOL) GEL
3 MG ORAL CONTROLLED-RELEASE CAPSULE
1 MG / ML (BASE) NASAL SOLUTION
1 MG / ML (BASE) INJECTION
6.3 MG (BASE) INJECTION IMPLANT
0.5 MG ORAL TABLET
00000263699
00000373036
00002229293
00002225158
00002225166
00002228955
0000230140700002242471
PANOXYL 10
PANOXYL 20
ENTOCORT
SUPREFACT INTRANASAL
SUPREFACT
SUPREFACT DEPOT
CO CABERGOLINEDOSTINEX
GSK
GSK
AZC
SAV
SAV
SAV
COBPAL
0.1462
0.1905
1.5860
7.8200
11.1436
756.8100
8.8550 13.6901
18 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$$
Section 3 .
"For the treatment of severe acne as defined by scarring acne.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"For the treatment of inflammatory bowel disease (e.g. Crohn's, ulcerative colitis, ulcerative ileitis, etc.). This drug product must be prescribed by a specialist in Gastroenterology, Internal Medicine or Pediatrics (or by a specialist in General Surgery on a case-by-case basis, in geographic areas where access to these specialties is not available).
Special authorization may be granted for 12 months."
The following product(s) are eligible for auto-renewal.
"When prescribed for non-cancer, non-cosmetic or non-fertility indications.
Special authorization may be granted for 6 months."
Information is required regarding the patient's diagnosis/indication for use of this medication.
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): BROMOCRIPTINE
"For the treatment of hyperprolactinemia in patients who are intolerant to or who have failed bromocriptine. Special authorization may be granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CASPOFUNGIN
CEFADROXIL
CELECOXIB
CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE
50 MG / VIAL INJECTION
70 MG / VIAL INJECTION
500 MG ORAL CAPSULE
100 MG ORAL CAPSULE
200 MG ORAL CAPSULE
1 % (BASE) * 5 % TOPICAL GEL
00002244265
00002244266
0000224077400002235134
00002239941
00002239942
0000224847200002243158
CANCIDAS
CANCIDAS
APO-CEFADROXILNOVO-CEFADROXIL
CELEBREX
CELEBREX
BENZACLINCLINDOXYL
MFC
MFC
APXTEV
PFI
PFI
VCLGSK
222.0000
222.0000
0.8421 0.8421
0.6828
1.3659
0.8918 0.9064
19 EFFECTIVE JULY 1, 2012
$
$
$$
$
$
$$
Section 3 .
"For esophageal candidiasis in patients who are intolerant to fluconazole and itraconazole, or who have failed both agents as evidenced by significant clinical deterioration due to the fungal infection during a course of therapy or no resolution after a full course of therapy."
"For the treatment of skin and skin structure infections."
"1) For patients who are at high risk of upper gastrointestinal (GI) complications due to a proven history of prior complicated GI events (e.g. GI perforation, obstruction or major bleeding) or
2) For patients who have a documented history of ulcers proven radiographically and/or endoscopically.
Special authorization for both criteria may be granted for 6 months."
All requests for celecoxib must be completed using the Celecoxib Special Authorization RequestForm (ABC 31140).
The following product(s) are eligible for auto-renewal.
"For the treatment of severe acne as defined by scarring acne.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CLOPIDOGREL BISULFATE
75 MG (BASE) ORAL TABLET00002252767000023030270000235153600002348004000023593160000229316100002238682
APO-CLOPIDOGRELCO CLOPIDOGRELMYLAN-CLOPIDOGRELPMS-CLOPIDOGRELSANDOZ CLOPIDOGRELTEVA-CLOPIDOGRELPLAVIX
APXCOBMYPPMSSDZTEVSAV
0.9279 0.9279 0.9279 0.9279 0.9279 0.9279 2.6512
20 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
Section 3 .
(Refer to 20:12.18 of the Alberta Health and Wellness Drug Benefit List for one month of coverage, following the first intravascular stent placement, when prescribed by a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery.)
"For the prevention of thrombosis, for one month, when prescribed following intravascular bare metal stent placement. Patients who have received one month of coverage via the Limited Restricted Benefit will not be eligible for additional coverage under this criterion." **
"For the prevention of thrombosis, for up to 12 months, when prescribed following intravascular drug eluting stent (DES) placement. Patients who have received one month of coverage via the Limited Restricted Benefit may be eligible for an additional 11 months of coverage (i.e., up to 12 months of coverage) following the submission of a special authorization request." **
"For the prevention of cerebrovascular (e.g. stroke, TIA) and non-cerebrovascular ischemic events in patients who have a contraindication to ASA. Special authorization for this criterion may be granted for 24 months."
"For use in patients who have experienced a non-cerebrovascular ischemic event while on ASA.Special authorization for this criterion may be granted for 24 months."
"For use in patients who have experienced a cerebrovascular ischemic event (e.g. stroke, TIA) while on dipyridamole/ASA (Aggrenox) or for whom dipyridamole/ASA (Aggrenox) is contraindicated. Special authorization for this criterion may be granted for 24 months."
"Coverage will not be considered when clopidogrel and dipyridamole/ASA are intended for use in combination."
** Special Authorization for post-stent coverage is required when the prescriber prescribing the medication is not a designated prescriber, for treatment after repeat stents, or for continued coverage of up to 12 months following intravascular drug eluting stent (DES) placement.
In order to comply with the first and second criteria, information is required regarding the date, type of stent, and stenting procedure. In order to comply with the third criterion, information is required as to why ASA cannot be used. In order to comply with the fourth criterion, information is required regarding the type of ischemic event experienced while on ASA. In order to comply with the fifth criterion, information is required regarding the type of ischemic event experienced while on dipyridamole/ASA (Aggrenox) and/or why dipyridamole/ASA (Aggrenox) cannot be used.
All requests for clopidogrel bisulfate must be completed using the Clopidogrel Special Authorization Request Form (ABC 30786).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CYCLOSPORINE
CYPROTERONE ACETATE
10 MG ORAL CAPSULE
25 MG ORAL CAPSULE
50 MG ORAL CAPSULE
100 MG ORAL CAPSULE
100 MG / ML ORAL SOLUTION
50 MG ORAL TABLET
100 MG / ML INJECTION
00002237671
0000224707300002150689
0000224707400002150662
0000224282100002150670
0000224432400002150697
0000070443100002245898
00000704423
NEORAL
SANDOZ CYCLOSPORINENEORAL
SANDOZ CYCLOSPORINENEORAL
SANDOZ CYCLOSPORINENEORAL
APO-CYCLOSPORINENEORAL
ANDROCURCYPROTERONE
ANDROCUR DEPOT
NOV
SDZNOV
SDZNOV
SDZNOV
APXNOV
PMSAAP
PMS
0.6238
1.3050 1.4500
2.5450 2.8270
5.0900 5.6560
3.7708 5.0276
1.4339 1.5141
26.8130
21 EFFECTIVE JULY 1, 2012
$
$$
$$
$$
$$
$$
$
Section 3 .
"For the treatment of severe psoriasis in those patients where other standard therapy has failed. This drug product must be prescribed by a specialist in Dermatology."
"For the treatment of severe rheumatoid arthritis in patients who are unable to tolerate or have failed an adequate trial of methotrexate. This drug product must be prescribed by a specialist in Rheumatology (or by a Specialist in Internal Medicine with an interest in Rheumatology on a case-by-case basis, in geographic areas where access to this specialty is not available)."
"For the treatment of steroid dependent and steroid resistant nephrotic syndrome. Consideration will be given where cyclosporine is used for the induction and maintenance of remissions or for the maintenance of steroid induced remissions. This drug product must be prescribed by a specialist in Pediatrics or Nephrology."
"Special authorization for all criteria may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"When prescribed for non-cancer, non-cosmetic indications.
Special authorization may be granted for 6 months."
Information is required regarding the patient's diagnosis/indication for use of this medication.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DABIGATRAN ETEXILATE
DANAPAROID SODIUM
110 MG ORAL CAPSULE
150 MG ORAL CAPSULE
1,250 UNIT / ML INJECTION
00002312441
00002358808
00002129043
PRADAX
PRADAX
ORGARAN
BOE
BOE
MFC
1.6000
1.6000
33.7083
22 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): WARFARIN
For at-risk patients (CHADS2 score of greater than or equal to 1) with non-valvular atrial fibrillation (AF) for the prevention of stroke and systemic embolism AND in whom:
a) Anticoagulation is inadequate (at least 35% of INR testing results outside the desired range) following a reasonable trial on warfarin (minimum two months of therapy); ORb) Anticoagulation with warfarin is contraindicated as per the product monograph or not possibledue to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home).
Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate less than 30mL/min) OR hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis; OR prosthetic heart valves.should not receive dabigatran.
Patients 75 years of age and greater should have documented stable renal function (creatinine clearance or estimated glomerular filtration rate maintained for at least three months of 30-49 ml/min for 110mg twice daily dosing or greater than or equal to 50 ml/min for 150mg twice daily dosing).
Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see Drug Product Monograph).
Patients starting the drug product should have ready access to appropriate medical services to manage a major bleeding event.
There is currently no data to support that the Drug Product provides adequate anticoagulation inpatients with rheumatic valvular disease or those with prosthetic heart valves, so Drug Product isnot recommended in these populations.
Special Authorization may be granted for 24 months.
"For the treatment of patients with heparin-induced thrombocytopenia."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DARBEPOETIN
DARIFENACIN HYDROBROMIDE
10 MCG / SYR INJECTION SYRINGE
20 MCG / SYR INJECTION SYRINGE
100 MCG / ML INJECTION SYRINGE
200 MCG / ML INJECTION SYRINGE
500 MCG / ML INJECTION SYRINGE
7.5 MG (BASE) ORAL EXTENDED-RELEASE TABLET
15 MG (BASE) ORAL EXTENDED-RELEASE TABLET
00002246354
00002246355
00002246357
00002246358
00002246360
00002273217
00002273225
ARANESP (0.4 ML SYRINGE)
ARANESP (0.5 ML SYRINGE)
ARANESP (0.3/ 0.4/ 0.5 ML SYR)
ARANESP (0.3/ 0.4/ 0.5/ 0.65 ML SYR)
ARANESP (0.3/0.4/0.6/1.0 ML SYR)
ENABLEX
ENABLEX
AMG
AMG
AMG
AMG
AMG
NOV
NOV
26.8000
53.6000
268.0000
536.0000
1444.1900
1.5023
1.5023
23 EFFECTIVE JULY 1, 2012
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
$
$
$
$
$
$
$
Section 3 .
"For the treatment of anemia of chronic renal failure in patients with low hemoglobin (<100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients' iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin > 100 mcg/L and transferrin saturation > 20%."
"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/Lper month, the dose of Aranesp should be reduced by about 25%."
In order to comply with the second criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrinsaturation, along with the results of liver function tests if applicable.
For the first criterion, renewal requests may be considered if the patient's hemoglobin is < 120 g/L while on Aranesp.
For the second criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Aranesp.
All requests for darbepoetin must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN
"For patients who are intolerant to oxybutynin.
Special authorization may be granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DEFERASIROX
DENOSUMAB
125 MG ORAL DISPERSIBLE TABLET FOR SUSPENSION
250 MG ORAL DISPERSIBLE TABLET FOR SUSPENSION
500 MG ORAL DISPERSIBLE TABLET FOR SUSPENSION
60 MG / SYR INJECTION SYRINGE
00002287420
00002287439
00002287447
00002343541
EXJADE
EXJADE
EXJADE
PROLIA
NOV
NOV
NOV
AMG
10.1348
20.2696
40.5400
339.5700
24 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): DEFEROXAMINE
"For patients who require iron chelation therapy but who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of deferoxamine, or for whom deferoxamine is contraindicated.
Contraindications may include one or more of the following: known or suspected sensitivity to deferoxamine, recurrent injection or infusion-site reactions associated with deferoxamine administration (e.g., cellulitis), inability to obtain or maintain vascular access, severe needle phobia, concomitant bleeding disorders, immunocompromised patients with a risk of infection with parenteral administration, or risk of bleeding due to anticoagulation.
According to the product monograph, Exjade (deferasirox) is contraindicated in high risk myelodysplastic syndrome (MDS) patients, any other MDS patient with a life expectancy less than one year and patients with other hematological and nonhematological malignancies who are not expected to benefit from chelation therapy due to the rapid progression of their disease.
Special authorization may be granted for 24 months."
"For the treatment of postmenopausal osteoporosis in women for whom oral bisphosphonates arecontraindicated due to hypersensitivity OR an endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia), AND who have at least two of the following:- Age greater than or equal to 75 years- A prior fragility fracture- A bone mineral density (BMD) T-score of less than or equal to -2.5
Special authorization may be granted for 12 months.
Patients will be limited to receiving one dose of denosumab per prescription at their pharmacy.
Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy.
All requests for denosumab must be completed using the Denosumab Special Authorization Request Form (ABC 31377).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DONEPEZIL HCL
DUTASTERIDE
5 MG ORAL TABLET
10 MG ORAL TABLET
0.5 MG ORAL CAPSULE
00002232043
00002232044
00002247813
ARICEPT
ARICEPT
AVODART
PFI
PFI
GSK
4.8187
4.8187
1.6570
25 EFFECTIVE JULY 1, 2012
$
$
$
Section 3 .
"For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4.
Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination.
Special authorization coverage may be granted for a maximum of 24 months per request.
For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided.
Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug."
All requests (including renewal requests) for donepezil HCI must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).
"For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction.
Special authorization may be granted for 6 months"
Information is required regarding the medical condition(s) or circumstances by which this patient would be deemed a poor surgical risk.
All requests (including renewal requests) for dutasteride must be completed using the Dutasteride/Finasteride Special Authorization Request Form (ABC 31257).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ECULIZUMAB
26 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
ECULIZUMAB
1. ELIGIBILITY CRITERIA FOR ECULIZUMAB COVERAGE
In order to maintain the integrity of the AHWDBL, and having regard to the financial and social implications of covering eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria (PNH), the following special authorization criteria must be satisfied. In order to be eligible for eculizumab coverage for the treatment of PNH, a patient must have submitted a completed Application and have satisfied all of the following requirements:
The patient must:1) Be diagnosed with PNH in accordance with the requirements specified in the Clinical Criteria for eculizumab;2) Have Alberta government-sponsored drug coverage;3) Meet the Registration Requirements; 4) Satisfy the Clinical Criteria for eculizumab (initial or continued coverage, as appropriate); AND5) Meet the criteria specified in Contraindications to Coverage and Discontinuance of Coverage.
There is no guarantee that any application, whether for initial or continued coverage, will be approved. Depending on the circumstances of each case, the Minister or the Minister's delegate may:- approve an Application;- approve an Application with conditions;- deny an Application;- discontinue an approved Application; OR- defer an Application pending the provision of further supporting information.
The process for review and approval is explained in further detail below.
2. REGISTRATION REQUIREMENTS
If the patient is a citizen or permanent resident of Canada, the patient must be continuously registered in the Alberta Health Care Insurance Plan for a minimum of one (1) year prior to an application for coverage unless: - the patient is less than one (1) year of age at the date of the application, then the patient's parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of one (1) year; OR- the patient has moved to Alberta from another province or territory in Canada (the" province of origin"), and immediately prior to moving to Alberta, was covered for eculizumab in the province of origin by a provincial or territorial government sponsored drug plan, (or the province of origin provided equivalent coverage for eculizumab as does Alberta) and the patient has been registered in the Alberta Health Care Insurance Plan (the patient must provide supporting documentation from the province of origin to prove prior coverage). If the patient is not a citizen or permanent resident of Canada, the patient must be continuously registered in the Alberta Health Care Insurance Plan for a minimum of five (5) years prior to an application for coverage unless:- the patient is less than five years of age at the date of the application, then the patients parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of five years; OR- the patient has moved to Alberta from another province or territory in Canada (the "province of origin"), and immediately prior to moving to Alberta, was covered for eculizumab in the province of origin by a provincial or territorial government sponsored drug plan, (or the province of origin provided equivalent coverage for eculizumab as does Alberta) and the patient has been registered in the Alberta Health Care Insurance Plan (the patient must provide supporting documentation from the province of origin to prove prior coverage).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ECULIZUMAB
27 EFFECTIVE JULY 1, 2012 Section 3 .
The Minister reserves the right to modify or waive the Registration Requirements applicable to a given patient if the patient or the patient's parent/guardian/legal representative can establish to the satisfaction of the Minister that the patient has not moved to Alberta for the sole/primary purpose of obtaining coverage of eculizumab.
3. CLINICAL CRITERIA
In addition to meeting Sections 1 and Sections 2 herein, to be considered for coverage of eculizumab, a patient must be assessed by a Specialist in Hematology (i.e. a physician who holds specialty certification in Hematology from the Royal College of Physicians and Surgeons of Canada) and meet all of the following clinical criteria (initial or continued coverage, as appropriate).
a. CLINICAL CRITERIA - INITIAL COVERAGEAll of the following Clinical Criteria must be established on the basis of evidence to the satisfaction of the Minister or the Minister's delegate for initial coverage:
1) The diagnosis of PNH must have been established by flow cytometry and/or a FLAER test. The proportion of circulating cells of each type which are GPI-deficient and hence of the PNH clone is quantitated by flow cytometry. Patients must have a: - PNH granulocyte clone size equal to or greater than 10%, AND - Raised LDH (value at least 1.5 times the upper limit of normal for the reporting laboratory).
2) Patients with a clone size equal to or greater than 10% also require AT LEAST ONE of the following:- Thrombosis: Evidence that the patient has had a thrombotic or embolic event which required the institution of therapeutic anticoagulant therapy;- Transfusions: Evidence that the patient has been transfused with at least four (4) units of red blood cells in the last twelve (12) months;- Anemia: Evidence that the patient has chronic or recurrent anemia where causes other than hemolysis have been excluded and demonstrated by more than one measure of less than or equal to 70g/L or by more than one measure of less than or equal to 100 g/L with concurrent symptoms of anemia;- Pulmonary insufficiency: Evidence that the patient has debilitating shortness of breath and/or chest pain resulting in limitation of normal activity (New York Heart Association Class III) and/or established diagnosis of pulmonary arterial hypertension, where causes other than PNH have been excluded;- Renal insufficiency: Evidence that the patient has a history of renal insufficiency, demonstratedby an eGFR less than or equal to 60mL/min/1.73m2, where causes other than PNH have been excluded; OR- Smooth muscle spasm: Evidence that the patient has recurrent episodes of severe pain requiring hospitalisation and/or narcotic analgesia, where causes other than PNH have been excluded.
AND
3) All patients must receive meningococcal vaccination with a quadravalent vaccine (A, C, Y andW135) at least two (2) weeks prior to receiving the first dose of eculizumab. All patients must bemonitored and revaccinated according to current medical guidelines for vaccine use. Treating physicians will be required to submit confirmation of meningococcal vaccination in order for their patients to continue to be eligible for treatment with eculizumab.
b. CLINICAL CRITERIA - CONTINUED COVERAGEAll of the following Clinical Criteria must be established on the basis of evidence to the satisfaction of the Minister or the Minister's delegate for continued coverage:1) Patient eligibility must be reviewed six (6) months after commencing therapy and every six (6)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ECULIZUMAB
28 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
months thereafter;
AND
2) Continued eligibility will be subject to the assessment of evidence, in accordance with the following monitoring requirements, which demonstrates:- Clinical improvement in the patient, OR- Stabilization of the patient's condition;
Monitoring requirements;
The patient's Specialist in Hematology must provide the following monitoring information every six (6) months:- Lactate dehydrogenase (LDH);- Full blood count and reticulocytes;- Transfusion history for previous six months;- Iron studies;- Urea, electrolytes and eGFR; - Recent clinical history; AND- Any other information requested by the Minister, the Minister's delegate, or an Expert Advisor.
The patient's Specialist in Hematology must provide the following monitoring information every twelve (12) months:- Confirmation that the patient has been vaccinated or revaccinated (meningococcal) according to current medical guidelines for vaccine use;- Progress reports on the clinical symptoms that formed the basis of initial eligibility;- Quality of life, through clinical narrative; - Granulocyte clone size (by flow cytometry): AND- Any other information requested by the Minister, the Minister's delegate, or an Expert Advisor.
c. CONTRAINDICATIONS TO COVERAGE
In addition to meeting all of the Initial Coverage Clinical Criteria or the Continued Coverage Clinical Criteria referred to above (as appropriate), the patient must not have any of the followingcontraindications:- Small granulocyte clone size - a granulocyte clone size below 10%; - Aplastic anaemia with two or more of the following: neutrophil count below 0.5 x 109/L, platelet count below 20 x 109/L, reticulocytes below 25 x 109/L, or severe bone marrow hypocellularity; - Patients with a presence of another life threatening or severe disease where the long term prognosis is unlikely to be influenced by therapy (for example acute myeloid leukaemia or high-risk myelodysplastic syndrome); OR- The presence of another medical condition that in the opinion of the Minister or Minister's delegate might reasonably be expected to compromise a response to therapy.
d. DISCONTINUANCE OF COVERAGE
Coverage may be discontinued where one or more of the following situations apply:- The patient or the patient's Specialist in Hematology fails to comply adequately with treatment or measures, including monitoring requirements, taken to evaluate the effectiveness of the therapy;- There is a failure to provide the Minister, the Minister's delegate, or an Expert Advisor with information as required or as requested;- If in the opinion of the Minister or the Minister's delegate, therapy fails to relieve the symptoms of disease that originally resulted in the patient being approved by the Minister or the Minister's delegate; - The patient has (or develops) a condition referred to in Contraindications to Coverage.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ECULIZUMAB
29 EFFECTIVE JULY 1, 2012 Section 3 .
The patient's Specialist in Hematology will be advised if their patient is at risk of being withdrawnfrom treatment for failure to comply with the above requirements or other perceived "non-compliance" and given a reasonable period of time to respond prior to coverage being discontinued.
4. PROCESS FOR ECULIZUMAB COVERAGE
For both initial and continued coverage the following documents (the Application) must be completed and submitted:
- An Eculizumab Special Authorization Request Form completed by the patient's Specialist in Hematology;- An Eculizumab Consent Form completed by the patient, or a patient's parent/guardian/legal representative, and the patients Specialist in Hematology (for any initial coverage application); AND- Any other documentation that may be required by the Minister or the Minister's delegate.
a. EXPERT REVIEW
Once the Minister or the Minister's delegate has confirmed that the patient meets the Registration Requirement or granted a waiver of the Registration Requirement, the Application will be given to one or more Expert Advisors for review.
The Application, together with the recommendation or recommendations of the Expert Advisor(s), is then forwarded to the Minister or the Minister's delegate for a decision regarding coverage.
After the Minister or Minister's delegate has rendered a decision, the patient's Specialist in Hematology and the patient or patient's parent/guardian/legal representative will be notified by letter of the Minister's decision.
5. APPROVAL OF COVERAGEThe Minister or the Minister's delegate's decision in respect of an Application will specify the effective date of eculizumab coverage, if coverage is approved.
Initial coverage may be approved for a period of up to six (6) months as follows: One dose of 600mg of eculizumab administered weekly for the first four (4) weeks of treatment (total of four 600mg doses), followed by one dose of 900mg of eculizumab administered every two (2) weeks from week five (5) of treatment (total of eleven 900mg doses).
Continued coverage may be approved for up to one dose of 900mg of eculizumab administered every two (2) weeks, for a period of six (6) months (total of thirteen 900mg doses).
If a patient is approved for coverage, prescriptions for eculizumab must be written by a Specialist in Hematology. To avoid wastage, prescription quantities are limited to a one-month supply. Extended quantity and vacation supplies are not permitted. The Government is not responsible and will not pay for costs associated with wastage or improper storage of eculizumab.
Approval of coverage is granted for a specific period, to a maximum of six (6) months. If continued treatment is necessary, it is the responsibility of the patient or patient's parent/guardian/legal representative and the Specialist in Hematology to submit a new Application to re-apply for eculizumab coverage, and receive a decision thereon, prior to the expiry date of the authorization period.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ECULIZUMAB
EPOETIN ALFA
300 MG / VIAL INJECTION
30,000 UNIT / SYR INJECTION SYRINGE
40,000 UNIT / SYR INJECTION SYRINGE
00002322285
00002288680
00002240722
SOLIRIS
EPREX
EPREX
API
JAI
JAI
6742.5000
420.9400
420.9400
30 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
Section 3 .
"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%. Patients may be granted a maximum allowable dose of 40,000 IU per week."
In order to comply with this criterion, if the patient has iron overload the prescriber must state this in the request, or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests, if applicable.
Renewal requests may be considered if the patient's hemoglobin is <110 g/L while on Eprex."
All requests for epoetin alfa must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).
6. WITHDRAWAL
Therapy may be withdrawn at the request of the patient or the patient's parent/guardian/legal representative at any time. Notification of withdrawal from therapy must be made by the Specialist in Hematology or patient in writing.
Applications, withdrawal requests, and any other information to be provided must be sent to Clinical Drug Services, Alberta Blue Cross.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
EPOETIN ALFA
1,000 UNIT / SYR INJECTION SYRINGE
2,000 UNIT / SYR INJECTION SYRINGE
3,000 UNIT / SYR INJECTION SYRINGE
4,000 UNIT / SYR INJECTION SYRINGE
5,000 UNIT / SYR INJECTION SYRINGE
6,000 UNIT / SYR INJECTION SYRINGE
8,000 UNIT / SYR INJECTION SYRINGE
10,000 UNIT / SYR INJECTION SYRINGE
20,000 UNIT / SYR INJECTION SYRINGE
00002231583
00002231584
00002231585
00002231586
00002243400
00002243401
00002243403
00002231587
00002243239
EPREX (0.5 ML SYRINGE)
EPREX (0.5 ML SYRINGE)
EPREX (0.3 ML SYRINGE)
EPREX (0.4 ML SYRINGE)
EPREX (0.5 ML SYRINGE)
EPREX (0.6 ML SYRINGE)
EPREX (0.8 ML SYRINGE)
EPREX (1 ML SYRINGE)
EPREX (0.5 ML SYRINGE)
JAI
JAI
JAI
JAI
JAI
JAI
JAI
JAI
JAI
14.2500
28.5000
42.7500
57.0000
71.2500
85.5000
114.0000
142.5000
280.6200
31 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$
$
Section 3 .
"For the treatment of anemia of chronic renal failure in patients with low hemoglobin (< 100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients' iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin > 100 mcg/L and transferrin saturation > 20%."
"For the treatment of anemia in AZT-treated/HIV infected patients."
"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/Lper month, the dose of Eprex should be reduced by about 25%."
In order to comply with the third criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrinsaturation, along with the results of liver function tests if applicable.
For the first criterion, renewal requests may be considered if the patient's hemoglobin is < 120 g/L while on Eprex.
For the third criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Eprex.
All requests for epoetin alfa must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ERTAPENEM
ERYTHROMYCIN/ TRETINOIN
1 G / VIAL INJECTION
4 % * 0.01 % TOPICAL GEL
4 % * 0.025 % TOPICAL GEL
4 % * 0.05 % TOPICAL GEL
00002247437
00002015994
00001905112
00001945262
INVANZ
STIEVAMYCIN MILD
STIEVAMYCIN REGULAR
STIEVAMYCIN FORTE
MFC
GSK
GSK
GSK
49.9500
0.8302
0.8302
0.8302
32 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
Section 3 .
"For therapy of complicated polymicrobial skin and skin structure infections."
"For the therapy of community-acquired intra-abdominal infections."
"For culture & susceptibility directed therapy against infections with Enterobacteriaceae producing AmpC or extended-spectrum beta-lactamases (ESBLs) where there is resistance to first line agents."
"For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."
In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required.
"For the treatment of severe acne as defined by scarring acne.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ETANERCEPT
33 EFFECTIVE JULY 1, 2012 Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:
- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness or its agent, throughout the special authorization approval period ("RA Specialist"). The patient must also provide all consents and authorizations required to permit the RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the RA Specialist does not continually, actively and consistently participate in the Study.
- Initial coverage may be approved for 50 mg per week for 8 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for 50 mg per week, for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ETANERCEPT
34 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for etanercept for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
Juvenile Idiopathic Arthritis:
"Special authorization coverage may be provided for the reduction in signs and symptoms of severely active polyarticular juvenile idiopathic arthritis (JIA) in patients 4 years of age and older who:- Have 5 or more active joints (defined by either swelling or limitation of motion plus pain and/or tenderness), AND- Are refractory to one or more disease modifying anti-rheumatic agents (DMARDS) conventionally used in children (minimum three month trial).
"Refractory" is defined as one or more of the following: lack of effect, serious adverse effects (e.g., leukopenia, hepatitis) or contraindications to treatments as defined in the product monographs.
For coverage, this drug must be prescribed by a prescriber affiliated with a Pediatric Rheumatology Clinic in Edmonton or Calgary who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness and its agent, throughout the special authorization approval period (Pediatric RA Specialist). The patient or patient's guardian must also provide all consents and authorizations required to permit the Pediatric RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the Pediatric RA Specialist does not continually, actively and consistently participate in the Study.
- Coverage may be approved for 0.8 mg/kg/dose (maximum dose 50 mg) weekly for 12 weeks.- Patients will be limited to receiving a one-month supply of Enbrel per prescription at their pharmacy.
For continued coverage of this agent beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed by a Pediatric RA Specialist after 12 weeks, but no longer than16 weeks after, treatment with this biologic agent to determine response.2) The Pediatric RA Specialist must confirm in writing that the patient is a responder that meets the following criteria (JRA30):- 30% improvement from baseline in at least three of the following six response variables, with worsening of 30% or more in no more than one of the six variables. The variables include: i. global assessment of the severity of the disease by the Pediatric RA Specialist, ii. global assessment of overall well-being by the patient or parent, iii. number of active joints (joints with swelling not due to deformity or joints with limitation of motion with pain tenderness or both), iv. number of joints with limitation of motion, v. functional ability based on CHAQ scores, vi. ESR or CRP
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ETANERCEPT
35 EFFECTIVE JULY 1, 2012 Section 3 .
3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported in each request
Following this assessment, continued coverage may be approved for 0.8 mg/kg/dose (maximumdose 50 mg) weekly, for a maximum of twelve months. After twelve months, in order to be considered for continued coverage, the patient must be re-assessed every twelve months by a Pediatric RA Specialist and must meet the following criteria:1) The patient has been assessed by a Pediatric RA Specialist to determine response, and2) The Pediatric RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by maintenance of the JRA30,3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported in each request.
Once a child with JIA has had two disease-free years, it is common clinical practice for drug treatment to be stopped."
All requests (including renewal requests) for etanercept for Juvenile Idiopathic Arthritis must be completed using the Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 30948).
Psoriatic Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 50 mg per week for 8 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy. - Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond 8 weeks, the patient must meet the following criteria: The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ETANERCEPT
36 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after treatment to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria: - ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for 50 mg per week, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at theend of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for etanercept for Psoriatic Arthritis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).
Ankylosing Spondylitis:
"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:
- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 50 mg per week for 12 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ETANERCEPT
37 EFFECTIVE JULY 1, 2012 Section 3 .
- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed at week 12 by an RA Specialist after the initial twelve weeks oftherapy to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.
Following this assessment, continued coverage may be approved for 50 mg per week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for etanercept for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).
Plaque Psoriasis:
"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)
Patients who have a contraindication to either cyclosporine or methotrexate will be required to complete an adequate trial of the other pre-requisite medication prior to potential coverage beingconsidered.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be prescribed by a Specialist in Dermatology ("Dermatology Specialist").
-Initial coverage may be approved for up to 100 mg per week for 12 weeks.-Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ETANERCEPT
EZETIMIBE
25 MG / VIAL INJECTION
50 MG / SYR INJECTION SYRINGE
10 MG ORAL TABLET
00002242903
00002274728
00002247521
ENBREL
ENBREL
EZETROL
AMG
AMG
MFC
189.4150
378.9425
1.7927
38 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
Note: 1 x 50 mg syringe is interchangeable with 2 x 25 mg vials
$
$
$
Section 3 .
which it is being prescribed.
For continued coverage beyond 12 weeks, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial 12 weeks of therapy to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI
Following this assessment, continued coverage may be considered for 50 mg per week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapyby meeting criteria as outlined in (2) above."
All requests (including renewal requests) for etanercept for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).
"For the treatment of hypercholesterolemia in patients who are intolerant to statins or in whom a statin is contraindicated and who are at high cardiovascular risk*; or
For the treatment of hypercholesterolemia when used in combination with a statin in patients failing to achieve target LDL with a statin at maximum tolerable dose or maximum recommendeddose as per respective product monograph and who are at high cardiovascular risk*:
* High cardiovascular risk is defined as possessing one of the following:1) Pre-existing cardiovascular disease and/or cerebrovascular disease, or2) Diabetes, or3) Familial hypercholesterolemia, or4) Greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool, or5) Three or more of the following risk factors:- Family history of premature cardiovascular disease- Smoking- Hypertension- Obesity- Glucose intolerance- Renal disease.
Special authorization for these criteria may be granted for 6 months."
All requests for ezetimibe must be completed using the Ezetimibe Special Authorization RequestForm (ABC 30925).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
FEBUXOSTAT
FENTANYL
80 MG ORAL TABLET
12 MCG/HR TRANSDERMAL PATCH
25 MCG/HR TRANSDERMAL PATCH
00002357380
00002311925000023413790000233010500002327112
0000231463000002341387000023301130000228294100002327120
ULORIC
RATIO-FENTANYLPMS-FENTANYL MTXRAN-FENTANYL MATRIXSANDOZ FENTANYL PATCH
NOVO-FENTANYL 25PMS-FENTANYL MTXRAN-FENTANYL MATRIXRATIO-FENTANYLSANDOZ FENTANYL PATCH
TAK
RPHPMSRANSDZ
TEVPMSRANRPHSDZ
1.5900
2.2300 2.2320 2.2320 2.2320
3.7188 3.7188 3.7188 3.7188 3.7188
39 EFFECTIVE JULY 1, 2012
$
$$$$
$$$$$
Section 3 .
"For patients with symptomatic gout who have documented hypersensitivity OR severe intolerance to allopurinol, AND intolerance or lack of response to sulfinpyrazone AND probenecid.
Special authorization may be granted for 6 months."
Please note: Coverage cannot be considered for lack of response to allopurinol.
All requests for febuxostat must be completed using the Febuxostat Special Authorization Request Form (ABC 31376).
The following product(s) are eligible for auto-renewal.
"For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who cannot swallow.Special authorization may be granted for 6 months."
"For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who require opioid therapy at a total daily dose of at least 60 mg/day oral morphine equivalents. Patients must havetried and not been able to tolerate at least two discrete courses of therapy with two of the following agents: morphine, hydromorphone and oxycodone, if not contraindicated. Special authorization may be granted for 6 months."
Information is required regarding previous medications utilized and the patient's response to therapy. Also, information regarding the number of discrete (separate) courses of these medications is required. A discrete course is defined as a separate treatment course, which mayinvolve more than 1 agent, used at one time to manage the patient's condition.
All requests for fentanyl must be completed using the Fentanyl Special Authorization Request Form (ABC 31169).
(Please note: The following fentanyl products are benefits not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative Care Drug Coverage. Refer tothe Palliative Care Drug Benefit Supplement for additional information on this coverage.)
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FENTANYL
FENTANYL CITRATE
50 MCG/HR TRANSDERMAL PATCH
75 MCG/HR TRANSDERMAL PATCH
100 MCG/HR TRANSDERMAL PATCH
0.05 MG / ML (BASE) INJECTION
0000231464900002341395000023301210000228296800002327147
0000231465700002341409000023301480000228297600002327155
0000231466500002341417000023301560000228298400002327163
00000888346
NOVO-FENTANYL 50PMS-FENTANYL MTXRAN-FENTANYL MATRIXRATIO-FENTANYLSANDOZ FENTANYL PATCH
NOVO-FENTANYL 75PMS-FENTANYL MTXRAN-FENTANYL MATRIXRATIO-FENTANYLSANDOZ FENTANYL PATCH
NOVO-FENTANYL 100PMS-FENTANYL MTXRAN-FENTANYL MATRIXRATIO-FENTANYLSANDOZ FENTANYL PATCH
FENTANYL CITRATE
TEVPMSRANRPHSDZ
TEVPMSRANRPHSDZ
TEVPMSRANRPHSDZ
HSP
7.0000 7.0000 7.0000 7.0000 7.0000
9.8438 9.8438 9.8438 9.8438 9.8438
12.2500 12.2500 12.2500 12.2500 12.2500
1.7543
40 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
$$$$$
$$$$$
$
Section 3 .
"For the treatment of persistent, severe chronic pain in those patients who cannot swallow, or who are intolerant of, morphine and/or hydromorphone, if not contraindicated. Special authorization may be granted for 6 months."
Information is required regarding previous medications utilized and the patient's response to therapy. Information should include the use of agents such as morphine and/or hydromorphone, if not contraindicated for the patient.
All requests for fentanyl citrate must be completed using the Fentanyl Special Authorization Request Form (ABC 31169).
(Please note: The following fentanyl citrate product is a benefit not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative Care Drug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
FILGRASTIM
FINASTERIDE
0.3 MG / ML INJECTION
5 MG ORAL TABLET
00001968017
0000236538300002354462000023550430000235722400002356058000023485000000231011200002371820000023069050000232257900002010909
NEUPOGEN
APO-FINASTERIDECO FINASTERIDEFINASTERIDEJAMP-FINASTERIDEMYLAN-FINASTERIDENOVO-FINASTERIDEPMS-FINASTERIDERAN-FINASTERIDERATIO-FINASTERIDESANDOZ FINASTERIDEPROSCAR
AMG
APXCOBAHIJPCMYPTEVPMSRANRPHSDZMFC
186.8181
0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 1.9182
41 EFFECTIVE JULY 1, 2012
$
$$$$$$$$$$$
Section 3 .
"To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppresive anti-neoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."
"For the reduction in the duration of neutropenia, fever, antibiotic use and hospitalization following induction and consolidation treatment for acute myeloid leukemia. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."
"To increase neutrophil counts and to reduce the incidence and duration of infection in patients with a diagnosis of congenital, cyclic or idiopathic neutropenia. This drug product must be prescribed by the Directors of Divisions of Hematology in tertiary care centres (or their designates)."
"For the treatment of patients undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy when prescribed by a designated prescriber."
All requests for filgrastim must be completed using the Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150).
Please note for the first criterion: Coverage cannot be considered for palliative patients.
"For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction.
Special authorization may be granted for 6 months."
Information is required regarding the medical condition(s) or circumstances by which this patient would be deemed a poor surgical risk.
All requests (including renewal requests) for finasteride must be completed using the Dutasteride/Finasteride Special Authorization Request Form (ABC 31257).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FLUCONAZOLE
FLUTAMIDE
GALANTAMINE HYDROBROMIDE
10 MG / ML ORAL SUSPENSION
250 MG ORAL TABLET
8 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
16 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
24 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
00002024152
00002238560000022300890000223010400000637726
00002339439000023169430000237795000002266717
00002339447000023169510000237796900002266725
00002339455000023169780000237797700002266733
DIFLUCAN
APO-FLUTAMIDENOVO-FLUTAMIDEPMS-FLUTAMIDEEUFLEX
MYLAN-GALANTAMINE ERPAT-GALANTAMINE ERTEVA-GALANTAMINE ERREMINYL ER
MYLAN-GALANTAMINE ERPAT-GALANTAMINE ERTEVA-GALANTAMINE ERREMINYL ER
MYLAN-GALANTAMINE ERPAT-GALANTAMINE ERTEVA-GALANTAMINE ERREMINYL ER
PFI
APXTEVPMSMFC
MYPPATTEVJAI
MYPPATTEVJAI
MYPPATTEVJAI
0.9909
1.3530 1.3530 1.3530 1.3922
1.8906 1.8906 1.8906 5.0249
1.8906 1.8906 1.8906 5.0249
1.8906 1.8906 1.8906 5.0249
42 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$
$$$$
$$$$
$$$$
Section 3 .
"For susceptible infections in immunocompromised patients (e.g. patients with AIDS, cancer, or transplant patients)."
"When prescribed for non-cancer, non-cosmetic indications.
Special authorization may be granted for 6 months."
Information is required regarding the patient's diagnosis/indication for use of this medication.
The following product(s) are eligible for auto-renewal.
"For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4.
Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination.
Special authorization coverage may be granted for a maximum of 24 months per request.
For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided.
Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug."
All requests (including renewal requests) for galantamine hydrobromide must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
GOLIMUMAB
43 EFFECTIVE JULY 1, 2012 Section 3 .
Ankylosing Spondylitis:
"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 50 mg once per month for four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond four doses the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial four doses to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND- Reduction of the Spinal Pain VAS by 2 cm or more.
Following this assessment, continued coverage may be approved for 50 mg once per month for a further 12 month period. Should continued coverage criteria be met, coverage will only be granted for 12 doses per 12 month period. Ongoing coverage may be considered if the patient isre-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for golimumab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).
Psoriatic Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriatic arthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
GOLIMUMAB
44 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 50 mg per month for four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond four doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after four doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for 50 mg per month, for a further 12 month period. Should coverage criteria be met, coverage will only be granted for 12 doses per 12-month period. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for golimumab for Psoriatic Arthritis must be completedusing the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
GOLIMUMAB
45 EFFECTIVE JULY 1, 2012 Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for 50 mg per month for a total of four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond four doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after four doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for 50 mg per month, for a further 12 month period. Should continued coverage criteria be met, coverage will only be granted for 12 doses per 12 month period. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
GOLIMUMAB
GOSERELIN ACETATE
50 MG / SYR INJECTION SYRINGE
3.6 MG / SYR (BASE) INJECTION SYRINGE
10.8 MG / SYR (BASE) INJECTION SYRINGE
0000232477600002324784
00002049325
00002225905
SIMPONISIMPONI
ZOLADEX
ZOLADEX LA
JAIJAI
AZC
AZC
1447.0000 1447.0000
390.5000
1113.0000
46 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
Section 3 .
requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for golimumab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
"When prescribed for non-cancer, non-cosmetic or non-fertility indications.
Special authorization may be granted for 6 months."
Information is required regarding the patient's diagnosis/indication for use of this medication.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
IMIPENEM/ CILASTATIN SODIUM
IMIQUIMOD
250 MG / VIAL * 250 MG / VIAL (BASE) INJECTION
500 MG / VIAL * 500 MG / VIAL (BASE) INJECTION
50 MG/G / G TOPICAL CREAM
00000717274
00000717282
00002239505
PRIMAXIN
PRIMAXIN
ALDARA
MFC
MFC
MEP
13.0400
24.3800
50.3370
47 EFFECTIVE JULY 1, 2012
$
$
$
Section 3 .
"For the treatment of:
1) "Second-line therapy of intra-abdominal sepsis where there is failure of first-line therapy (e.g. ampicillin + gentamicin + metronidazole), as defined by clinical deterioration after 72 h of antibiotic therapy or lack of improvement after completion of antibiotic therapy or
2) Second-line therapy of severe polymicrobial skin and skin structure infections (e.g. limb threatening diabetic foot) or
3) Empiric therapy of mixed synergistic necrotizing gangrene (Fournier's gangrene) or
4) Therapy of severe ventilator-associated pneumonia where Pseudomonas and Staphylococcus aureus coverage is needed or
5) Second-line therapy of infections due to gram-negative organisms producing inducible beta-lactamases (i.e. Enterobacter spp., Citrobacter freundii complex, Serratia spp., Morganella spp., Providencia spp., Proteus vulgaris, Proteus penneri and some Hafnia spp.) or extended spectrum beta-lactamases where there is resistance to first-line agents (trimethoprim/sulfamethoxazole, ciprofloxacin and aminoglycosides) or
6) For use in other Health Canada approved indications in consultation with a specialist in Infectious Diseases."
In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required.
"For the treatment of Actinic Keratosis located on the head and neck in patients who have failed treatment with cryotherapy (where appropriate) and 5-fluorouracil (5-FU).
Special authorization may be granted for 6 months."
All requests for imiquimod must be completed using the Imiquimod Special Authorization Request Form (ABC 31222).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INFLIXIMAB
48 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:
- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial) [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily)
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness or its agent, throughout the special authorization approval period ("RA Specialist"). The patient must also provide all consents and authorizations required to permit the RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the RA Specialist does not continually, actively and consistently participate in the Study.
- Initial coverage may be approved for three doses as follows: An initial dose of 3 mg/kg, followed by additional 3 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for one 3 mg/kg dose every 8 weeks for a period of 12 months [Note: For patients who have an incomplete response, consideration may be given to adjusting the dose up to 10 mg/kg and/or treating as often as every 4 weeks]. Ongoing coverage may be considered only if the following criteria are met at theend of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
INFLIXIMAB
49 EFFECTIVE JULY 1, 2012 Section 3 .
therapy as indicated by:- confirmation of maintenance of ACR20, OR - maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for infliximab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
Moderately to Severely Active Crohn's Disease and Fistulizing Crohn's Disease:
"Special authorization coverage may be approved for coverage of infliximab for the reduction in signs and symptoms and induction and maintenance of clinical remission of Moderately to Severely Active Crohn's Disease and/or treatment of Fistulizing Crohn's Disease in patients whomeet the following criteria:
- Infliximab must be prescribed by a Specialist in Gastroenterology or a physician appropriately trained by the University of Alberta or the University of Calgary and recognized as a prescriber by Alberta Blue Cross for infliximab for coverage for the treatment of Moderately to Severely Active Crohn's Disease and/or Fistulizing Crohn's Disease patients (`Specialist').- Patients must be 18 years of age or older to be considered for coverage of infliximab.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients may be allowed to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy (both primary loss of response and secondary loss of response) or due to serious adverse effects or contraindications. An adequatetrial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
Prior to initiation of infliximab therapy for New Patients:
'New Patients' are patients who have never been treated with infliximab by any health care provider.
Moderately to Severely Active Crohn's Disease:
Prior to initiation of infliximab therapy, New Patients must have a current Modified (without the physical exam) Harvey Bradshaw Index score of greater than or equal to 7 (New Patient's Baseline Score), AND be Refractory.
Refractory is defined as one or more of the following:1) Serious adverse effects or reactions to the treatments specified below; OR 2) Contraindications (as defined in product monographs) to the treatments specified below; OR3) Previous documented lack of effect at doses and for duration of all treatments specified below: a) mesalamine: minimum of 3 grams/day for a minimum of 6 weeks; AND refractory to, or dependent on, glucocorticoids: following at least one tapering dosing schedule of 40 mg/day, tapering by 5 mg each week to 20 mg, then tapering by 2.5 mg each week to zero, or similar;
[Note: Patients who have used the above treatments in combination will not be required to be challenged with individual treatments as monotherapy]
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INFLIXIMAB
50 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
ANDb) Immunosuppressive therapy as follows: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 3 months; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 3 months; OR- Methotrexate: minimum or 15 mg/week for a minimum of 3 months.OR - Immunosuppressive therapy discontinued at less than 3 months due to serious adverse effectsor reactions.
Applications for coverage must include information regarding the dosages and duration of trial ofeach treatment the patient received, a description of any adverse effects, reactions, contraindications and/or lack of effect, as well as any other information requested by Alberta Blue Cross.
Fistulizing Crohn's Disease:
Prior to initiation of infliximab therapy, New Patients must have actively draining perianal or enterocutaneous fistula(s) that have recurred or persisted despite:
a) A course of an appropriate dose of antibiotic therapy (e.g. ciprofloxacin or metronidazole) for a minimum of 3 weeks; ANDb) Immunosuppressive therapy: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 6 weeks; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 6 weeks; OR - Immunosuppressive therapy discontinued at less than 6 weeks due to serious adverse effects or reactions.
[Note: Patients who have used the above treatments in combination for the treatment of Fistulizing Crohn's will not be required to be challenged with individual treatments as monotherapy]
Applications for coverage must include information regarding the dosages and duration of trial ofeach treatment the patient received, a description of any adverse effects, reactions, contraindications and/or lack of effect, as well as any other information requested by Alberta Blue Cross.
Coverage Criteria for Moderately to Severely Active Crohn's Disease AND/OR Fistulizing Crohn's Disease
- New Patients must meet the criteria above prior to being considered for approval. - All approvals are also subject to the following applicable criteria.
Induction Dosing for New Patients:
- Coverage for Induction Dosing may only be approved for New Patients (those who have never been treated with infliximab by any health care provider).- 'Induction Dosing' means a maximum of one 5 mg/kg dose of infliximab per New Patient at each 0, 2 and 6 weeks (for a maximum total of three doses).- New Patients are eligible to receive Induction Dosing only once, after which time the Maintenance Dosing for New Patients and Continued Coverage for Maintenance Dosing criteria will apply.
Maintenance Dosing:
'Maintenance Dosing' means one 5 mg/kg dose of infliximab per patient provided no more often than every 8 weeks for a period of 12 months to:- New Patients following the completion of Induction Dosing; OR - Existing Patients, who are patients that are being treated, or have previously been treated, withinfliximab.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
INFLIXIMAB
51 EFFECTIVE JULY 1, 2012 Section 3 .
Maintenance Dosing for New Patients after Completion of Induction Dosing:
- The New Patient must be assessed by a Specialist between weeks 10 and 14 after the initiation of Induction Dosing to determine response by obtaining a Modified Harvey Bradshaw Index score for patients with Moderately to Severely Active Crohn's Disease and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND- The Specialist must confirm the Modified Harvey Bradshaw Index score shows a decrease from the New Patient's Baseline Score of greater than or equal to 3 points for patients with Moderately to Severely Active Crohn's and/or confirm closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's.
Maintenance Dosing for Existing Patients:
- The patient must be assessed by a Specialist at least 4 to 8 weeks after the day the last dose of infliximab was administered to the patient and prior to administration of the next dose to obtain: a Modified Harvey Bradshaw Index Score (Existing Patient's Baseline Score) for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no orminimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND
- these measures must be provided to Alberta Blue Cross for assessment for continued coverage for maintenance dosing.
(For existing patients with Moderately to Severely Active Crohn's Disease with an incomplete response or for existing patients with Fistulizing Crohn's who respond then lose their response, the dose may be adjusted to 10 mg/kg by making an additional special authorization request to Alberta Blue Cross for the increased dose.)
Continued Coverage for Maintenance Dosing:
Continued coverage may be considered for one 5 mg/kg dose of infliximab per patient provided no more often than every 8 weeks for a period of 12 months, if the following criteria are met at the end of each 12 month period:
- The New Patient or the Existing Patient must be assessed by a Specialist at least 4 to 6 weeksafter the day the last dose of infliximab was administered to the patient and prior to the administration of the next dose to obtain a Modified Harvey Bradshaw Index Score for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no orminimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND- For New Patients: The Specialist must confirm that the patient has maintained a greater than or equal to 3 point decrease from the New Patient's Baseline Score for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; OR- For Existing Patients: The Specialist must confirm that the patient has maintained the Existing Patient's Baseline Score and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's.
(For new and existing patients with Moderately to Severely Active Crohn's Disease with an incomplete response or for new and existing patients with Fistulizing Crohn's who respond then lose their response, the maintenance dose may be adjusted to 10 mg/kg by making an additional special authorization request to Alberta Blue Cross for the increased dose.)"
All requests (including renewal requests) for infliximab for Moderately to Severely Active Crohn'sThe DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INFLIXIMAB
52 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
Disease and Fistulizing Crohn's Disease must be completed using the Adalimumab for Crohn's/Infliximab for Crohn's/Fistulizing Crohn's Disease Special Authorization Request Form (ABC 31200).
Ankylosing Spondylitis:
"Special authorization coverage may be provided for the reduction in the signs and symptoms and improvement in physical function of severely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:
- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for three doses as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.
Following this assessment, continued coverage may be approved for one 5 mg/kg dose of infliximab every 6 to 8 weeks for a period of 12 months. Ongoing coverage may be considered ifthe patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for infliximab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).
Psoriatic Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
INFLIXIMAB
53 EFFECTIVE JULY 1, 2012 Section 3 .
arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for three doses as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for one 5 mg/kg dose every 8 weeks, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests. It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for infliximab for Psoriatic Arthritis must be completed The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INFLIXIMAB
54 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).
Plaque Psoriasis:
"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)
Patients who have a contraindication to either cyclosporine or methotrexate will be required to complete an adequate trial of the other pre-requisite medication prior to potential coverage beingconsidered.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be prescribed by a Specialist in Dermatology ("Dermatology Specialist").
- Initial coverage may be approved as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond three doses, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial three doses to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, or- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.
Following this assessment, continued coverage may be considered for one 5 mg/kg dose of infliximab every 8 weeks for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for infliximab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
INFLIXIMAB
IPRATROPIUM BROMIDE
ITRACONAZOLE
LACOSAMIDE
100 MG / VIAL INJECTION
125 MCG / ML INHALATION UNIT DOSE SOLUTION
250 MCG / ML INHALATION UNIT DOSE SOLUTION
10 MG / ML ORAL SOLUTION
50 MG ORAL TABLET
100 MG ORAL TABLET
00002244016
0000223113500002097176
00002216221000022312440000223124500002097168
00002231347
00002357615
00002357623
REMICADE
PMS-IPRATROPIUMRATIO-IPRATROPIUM UDV
MYLAN-IPRATROPIUM STERINEBSPMS-IPRATROPIUM (1ML)PMS-IPRATROPIUM (2ML)RATIO-IPRATROPIUM UDV
SPORANOX
VIMPAT
VIMPAT
JAI
PMSRPH
MYPPMSPMSRPH
JAI
UCB
UCB
940.0000
0.3295 0.3295
0.6590 0.6590 0.6590 0.6590
0.7830
2.3200
3.3200
55 EFFECTIVE JULY 1, 2012
$
$$
$$$$
$
$
$
Section 3 .
Authorization Request Form (ABC 31192).
"For use in patients with manual dexterity problems or visual limitations who are unable to prepare a dose of the drug using the multi-dose solution."
"For use in patients who are hypersensitive to preservatives contained in multi-dose solutions."
"Special authorization for both criteria may be granted for 24 months."
Information is required regarding the nature of the difficulties experienced by the patient in preparing a dose using the multi-dose preparation; or the nature of the patient's hypersensitivity to the preservatives contained in the multi-dose solution.
The following product(s) are eligible for auto-renewal.
"For the treatment of oral and/or esophageal candidiasis in immunocompromised patients who are intolerant to fluconazole, or who have failed fluconazole as evidenced by significant clinical deterioration due to the fungal infection during a course of therapy or no resolution after a full course of therapy."
"For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of thefollowing criteria:- Are currently receiving two or more antiepileptic medications, AND- Have failed or demonstrated intolerance to three other antiepileptic medications, AND- Therapy must be initiated by a Neurologist.
For the purpose of administering these criteria failure is defined as inability to achieve satisfactory seizure control.
Coverage may be granted for a maximum dose of 400 mg daily.
Special authorization may be granted for six months."
Each of these products is eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
LACOSAMIDE
LANREOTIDE ACETATE
LEUPROLIDE ACETATE
150 MG ORAL TABLET
200 MG ORAL TABLET
60 MG / SYR INJECTION SYRINGE
90 MG / SYR INJECTION SYRINGE
120 MG / SYR INJECTION SYRINGE
3.75 MG / VIAL INJECTION
5 MG / ML INJECTION
7.5 MG / VIAL INJECTION
11.25 MG / VIAL INJECTION
22.5 MG / VIAL INJECTION
00002357631
00002357658
00002283395
00002283409
00002283417
00000884502
00000727695
00000836273
00002239834
00002230248
VIMPAT
VIMPAT
SOMATULINE AUTOGEL (0.3 ML SYRINGE)
SOMATULINE AUTOGEL (0.3 ML SYRINGE)
SOMATULINE AUTOGEL (0.5 ML SYRINGE)
LUPRON DEPOT
LUPRON
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
UCB
UCB
TCI
TCI
TCI
ABB
ABB
ABB
ABB
ABB
4.3200
5.3200
1102.0000
1470.0000
1840.0000
347.1800
67.6464
387.9700
1034.4100
1071.0000
56 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
Section 3 .
"For the treatment of acromegaly when prescribed by or in consultation with a Specialist in Internal Medicine.
Special authorization may be granted for 12 months."
The following product(s) are eligible for auto-renewal.
"When prescribed for non-cancer, non-cosmetic or non-fertility indications.
Special authorization may be granted for 6 months."
Information is required regarding the patient's diagnosis/indication for use of this medication.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LEVOCARNITINE
LINAGLIPTIN
330 MG ORAL TABLET
100 MG / ML ORAL SOLUTION
200 MG / ML INJECTION
5 MG ORAL TABLET
00002144328
00002144336
00002144344
00002370921
CARNITOR
CARNITOR
CARNITOR
TRAJENTA
PPC
PPC
PPC
BOE
1.3078
0.3961
12.5220
2.5500
57 EFFECTIVE JULY 1, 2012
$
$
$
$
Section 3 .
"For the treatment of primary carnitine deficiency. Information is required regarding the ratio of acyl:free carnitine and total plasma carnitine levels."
"For the treatment of patients with an inborn error of metabolism that results in secondary carnitine deficiency. Information is required regarding the patient's diagnosis."
"Special authorization may be granted for 6 months."
In order to comply with the first criteria: Information is required regarding pre-treatment acyl:freecarnitine and total plasma carnitine levels.
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMINSECOND-LINE DRUG PRODUCT(S): SULFONYLUREASAND WHERE INSULIN IS NOT AN OPTION
As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND- a sulfonylurea, AND- for whom insulin is not an option.
Or, for whom these products are contraindicated.
Special authorization may be granted for 24 months.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
LINEZOLID
MEGESTROL ACETATE
MEGESTROL ACETATE
600 MG ORAL TABLET
40 MG / ML ORAL SUSPENSION
40 MG ORAL TABLET
160 MG ORAL TABLET
00002243684
00002168979
00002195917
00002195925
ZYVOXAM
MEGACE OS
MEGESTROL
MEGESTROL
PFI
BMS
AAP
AAP
72.1263
1.6404
1.0073
4.2630
58 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
Section 3 .
"For the treatment of non-cancer indications (e.g. cachexia in HIV/AIDS patients and cancer patients) in patients who cannot swallow tablets.
Special authorization may be granted for 6 months."
(Please note: The above megestrol acetate product is a benefit not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative CareDrug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)
The following product(s) are eligible for auto-renewal.
"For the treatment of non-cancer indications (e.g. cachexia in HIV/AIDS patients and cancer patients).
Special authorization may be granted for 6 months."
(Please note: The above megestrol acetate products are benefits not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative CareDrug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)
The following product(s) are eligible for auto-renewal.
"For the treatment of:
1) Vancomycin-resistant enterococcus infections or
2) Methicillin-resistant Staphylococcus aureus (MRSA)/methicillin-resistant coagulase-negative Staphylococcus infections in patients who are unresponsive to or intolerant of vancomycin or
3) Susceptible organisms in patients severely intolerant or allergic to all other appropriate alternatives (e.g. beta-lactam antibiotics, clindamycin, trimethoprim/sulfamethoxazole and vancomycin) or to facilitate patient discharge from hospital where it otherwise would not be possible.
This product must be prescribed in consultation with a specialist in Infectious Diseases in all instances."
In order to comply with the above criteria, information is required regarding the type of infection and organisms involved. Information is also required regarding previous antibiotic therapy that has been utilized and the patient's response to therapy and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. The specialist in Infectious Diseases that recommended this drug is also required.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
MEROPENEM
METHYLPREDNISOLONE ACETATE/ NEOMYCIN SULFATE/ ALUMINUM CHLORHYDROXIDE COMPLEX/ SULFUR
MODAFINIL
500 MG / VIAL INJECTION
1 G / VIAL INJECTION
2.5 MG / ML * 2.5 MG / ML * 100 MG / ML * 50 MG / ML TOPICAL LOTION
100 MG ORAL TABLET
00002218488
00002218496
00000195057
0000228539800002239665
MERREM
MERREM
NEO-MEDROL ACNE
MODAFINILALERTEC
AZC
AZC
PFI
AAPSHB
25.2600
50.5200
0.2602
0.9990 1.3174
59 EFFECTIVE JULY 1, 2012
$
$
$
$$
Section 3 .
1) "As an alternative to imipenem for severe polymicrobial infections involving gram-negative organisms resistant to first-line agents in patients with documented seizure disorder/CNS abnormality or
2) As an alternative agent for severe polymicrobial infections involving gram-negative organismsresistant to first-line agents and to imipenem but susceptible to meropenem or
3) Therapy of meningitis due to gram-negative organisms producing inducible beta-lactamases (i.e. Enterobacter spp., Citrobacter freundii complex, Serratia spp., Morganella spp., Providenciaspp., Proteus vulgaris, Proteus penneri and some Hafnia spp.) or
4) For treatment of CNS infections due to gram-negative organisms that are resistant to third-generation cephalosporins but are susceptible to meropenem or
5) Therapy for infections involving multi-resistant Pseudomonas aeruginosa, where there is documented susceptibility to meropenem or
6) For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."
In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required.
"For the treatment of severe acne as defined by scarring acne."
"For the treatment of acne rosacea and seborrheic dermatitis."
"Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"For the treatment of documented narcolepsy. This drug product must be prescribed by a specialist in Neurology or Psychiatry, or a sleep specialist affiliated with a recognized level 1 lab.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
MONTELUKAST SODIUM
10 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL CHEWABLE TABLET
00002374609000023793330000236822600002373947000023285930000235552300002238217
00002377616000023793250000238075700002354985000023303930000235551500002238216
APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKAST FCSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR
APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKASTSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR
APXSNSMYPPMSSDZTEVMFC
APXSNSMYPPMSSDZTEVMFC
0.8483 0.8483 0.8483 0.8483 0.8483 0.8483 2.4238
0.5776 0.5776 0.5776 0.5776 0.5776 0.5776 1.6503
60 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
Section 3 .
(Refer to 48:10.24 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 6 to 18 years of age inclusive).
"For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria:a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, orb) cannot operate inhaler devices."
"For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists."
"Special authorization for both criteria may be granted for 6 months."
In order to comply with the first criteria, information should indicate either a) current use of inhaled steroids and contraindications or poor response to long-acting beta 2 agonists (e.g. salmeterol or formoterol) or,b) the nature of the patient's difficulties with using inhaler devices.
In order to comply with the second criteria, information should include the nature of the patient's response to long-acting beta 2 agonists (e.g. salmeterol or formoterol).
All requests (including renewal requests) for montelukast must be completed using the Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
NARATRIPTAN HCL
OCTREOTIDE ACETATE
1 MG (BASE) ORAL TABLET
2.5 MG (BASE) ORAL TABLET
50 MCG / ML (BASE) INJECTION
100 MCG / ML (BASE) INJECTION
200 MCG / ML (BASE) INJECTION
500 MCG / ML (BASE) INJECTION
10 MG / VIAL (BASE) INJECTION
0000231429000002237820
000023223230000231430400002237821
0000224863900000839191
0000224864000000839205
0000224864200002049392
0000224864100000839213
00002239323
NOVO-NARATRIPTANAMERGE
SANDOZ NARATRIPTANNOVO-NARATRIPTANAMERGE
OCTREOTIDE ACETATE OMEGASANDOSTATIN
OCTREOTIDE ACETATE OMEGASANDOSTATIN
OCTREOTIDE ACETATE OMEGASANDOSTATIN
OCTREOTIDE ACETATE OMEGASANDOSTATIN
SANDOSTATIN LAR
TEVGSK
SDZTEVGSK
OMGNOV
OMGNOV
OMGNOV
OMGNOV
NOV
8.4338 14.1715
6.1437 6.1438
14.9372
1.9076 5.0700
3.6007 9.5700
6.9268 18.4100
16.9230 44.9780
1315.7400
61 EFFECTIVE JULY 1, 2012
$$
$$$
$$
$$
$$
$$
$
Section 3 .
(Refer to 28:32.28 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 18 to 64 years of age inclusive.)
"For the treatment of acute migraine attacks in patients 65 years of age and older where other standard therapy has failed."
"For the treatment of acute migraine attacks in patients 65 years of age and older who have been using naratriptan hydrochloride prior to turning 65."
"Special authorization for both criteria may be granted for 24 months."
In order to comply with the first criteria, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
"For control of symptoms in patients with metastatic carcinoid and vasoactive intestinal peptide-secreting tumors (VIPomas) when prescribed by or in consultation with a Specialist in Internal Medicine, Palliative Care or General Surgery."
"For the treatment of acromegaly when prescribed by or in consultation with a Specialist in Internal Medicine."
"For the treatment of intractable diarrhea which has not responded to less costly therapy [e.g. associated with (secondary to) AIDS, intra-abdominal fistulas, short bowel syndrome]. Treatmentfor these indications must be prescribed by or in consultation with a Specialist in, Internal Medicine, Palliative Care, or General Surgery."
"Special authorization may be granted for 12 months."
In order to comply with the third criterion, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
OCTREOTIDE ACETATE20 MG / VIAL (BASE) INJECTION
30 MG / VIAL (BASE) INJECTION00002239324
00002239325
SANDOSTATIN LAR
SANDOSTATIN LAR
NOV
NOV
1699.8900
2180.9400
62 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
Section 3 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
OMALIZUMAB
63 EFFECTIVE JULY 1, 2012 Section 3 .
Special authorization coverage may be provided for adults and adolescents (12 years of age and above) with severe persistent asthma who are identified as having severe disease despite optimized standard therapy. Optimized standard therapy defined by a full trial of, and documented compliance with:
- high dose inhaled corticosteroid (budesonide 1600 micrograms per day or fluticasone propionate 1000 micrograms per day or equivalent) for at least twelve (12) months; AND,- long-acting beta-2 agonist therapy (at least salmeterol 50 micrograms daily or 24 micrograms of formoterol fumarate daily) for at least twelve (12) months; AND,- Therapeutic trial with systemic corticosteroids (at least 10mg per day prednisolone (or equivalent)) for at least 4 weeks in the previous twelve (12) months, unless contraindicated or not tolerated. For coverage, the drug must be initiated and monitored by a respirologist or clinical immunologist or allergist and meet the following clinical criteria (Initial Coverage or Continued Coverage, as appropriate). Patients will be limited to receiving a one (1) month supply of omalizumab per prescription at their pharmacy.
INITIAL COVERAGE:Special authorization requests must meet all of the following criteria for initial approval:
1) Confirmation of severe asthma through recent clinical and physiologic review with exclusion of other obstructive airways processes contributing to symptoms of severe asthma (i.e. psychogenic dyspnea; cardiac dyspnea);
2) Must be a non-smoker;
3) Confirmation of IgE mediated allergy to a perennial allergen by clinical history and allergy skintesting;
4) Baseline IgE level greater than/equal to 30 IU/mL and less than/equal to 700 IU/mL;
5) A weight between 20kg and 150kg;
6) An Asthma Control Questionnaire (ACQ-5) of at least 1.25, on at least two occasions over thepast 6 months in a stable state;
7) Must provide documentation:- Spirometry measurement of FEV1;- Asthma Quality of Life Questionnaire (AQLQ - Juniper) score;- Number of exacerbations of asthma within the previous twelve (12) month period that resulted in: - an emergency room visit or hospitalization; - unscheduled physician visits resulting in oral corticosteroids; - chronic use (greater than 50% of the year) of oral corticosteroids;
8) One (1) or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit within the previous year while on systemic corticosteroids; OR - One (1) or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit requiring documented use of systemic corticosteroids (oral corticosteroids initiated or increased for at least three (3) days, or parenteral corticosteroids); OR- Three (3) or more severe exacerbations of asthma within the previous year which required an unscheduled physician visit and resulted in courses (or chronic use greater than 50% of the year) of systemic corticosteroids.
Initial coverage may be approved for twenty-eight (28) weeks based on the recommended dose and dosage adjustment outlined in the Health Canada approved Product Monograph.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
OMALIZUMAB
OXYBUTYNIN CHLORIDE
150 MG / VIAL INJECTION
10 MG ORAL EXTENDED-RELEASE TABLET
15 MG ORAL EXTENDED-RELEASE TABLET
00002260565
00002273578
00002273586
XOLAIR
UROMAX
UROMAX
NOV
PUR
PUR
600.0000
1.3655
1.4710
64 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
Section 3 .
CONTINUED MAINTENANCE TREATMENT:A patient must be assessed for response to initial coverage of omalizumab with a minimum of twenty-four (24) weeks of therapy with omalizumab, and this assessment must be submitted to Alberta Blue Cross no later than four (4) weeks from the date of assessment.
The assessment must be done by the respirologist or clinical immunologist or allergist or such other clinicians as the Minister may designate who initiated therapy. If the following criteria are met, special authorization may be granted for a further twelve (12) month period. Continued coverage may be considered if the following criteria are met at the end of each additional twelve (12) month period:
1) Demonstrated that the patient has an Improvement in FEV1 greater than 12% (and for adults a minimum greater than 200 mL) from initiation of therapy; ORUnchanged FEV1 with a clinically meaningful Improvement in Asthma Quality of Life Questionnaire score from baseline (greater than/equal to 0.5 mean from baseline); AND - a decrease in the ACQ-5 of at least 0.5; OR - a ACQ-5 score of less than/equal to 1.
2) Patients must demonstrate at least a 25% reduction in the number of exacerbations, which required oral corticosteroids from the twelve (12) months prior to initiation of omalizumab that required systemic corticosteroids; ORFor patients that were on chronic (greater than 50% of the year) courses of oral corticosteroids use in the prior twelve (12) months to initiation of omalizumab, tapering of oral corticosteroid useby at least 25% from baseline.
3) A reduction in the number of exacerbations that have led to a hospital admission or emergency room visits, compared to the twelve (12) months prior to the commencement of omalizumab.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): IMMEDIATE RELEASE OXYBUTYNIN
"For patients who are intolerant of immediate release oxybutynin."
"Special authorization may be granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PALIPERIDONE PALMITATE
PAPAVERINE HCL
PEGFILGRASTIM
50 MG / SYR (BASE) INJECTION SYRINGE
75 MG / SYR (BASE) INJECTION SYRINGE
100 MG / SYR (BASE) INJECTION SYRINGE
150 MG / SYR (BASE) INJECTION SYRINGE
32.5 MG / ML INJECTION
6 MG / SYR INJECTION SYRINGE
00002354217
00002354225
00002354233
00002354241
00000009881
00002249790
INVEGA SUSTENNA (0.5 ML SYR)
INVEGA SUSTENNA (0.75 ML SYR)
INVEGA SUSTENNA (1 ML SYR)
INVEGA SUSTENNA (1.5 ML SYR)
PAPAVERINE HCL
NEULASTA (0.6 ML SYRINGE)
JAI
JAI
JAI
JAI
SDZ
AMG
304.1000
456.1800
456.1800
608.2200
1.7163
2499.0000
65 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
Section 3 .
"For the management of the manifestations of schizophrenia in patients who demonstrate a pattern of significant non-compliance that compromises therapeutic success AND who meet at least two of three of the following criteria:- Experiences extra-pyramidal symptoms with either an oral or depot first generation antipsychotic agent that precludes the use of a first generation antipsychotic depot product; OR- Is refractory to trials of at least two other antipsychotic therapies (Note: one trial must include afirst generation antipsychotic agent); OR- Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy.
Special Authorization may be granted for six months."
All requests (including renewal requests) for paliperidone prolonged release injection must becompleted using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).
The following product(s) are eligible for auto-renewal.
"For the relief of cerebral or peripheral ischemia with arterial spasm.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"To decrease the incidence of infection, as manifested by febrile neutropenia, in patients 18 years of age and older with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."
All requests for pegfilgrastim must be completed using the Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150).
Please note: Coverage cannot be considered for palliative patients.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PEGINTERFERON ALFA-2A
66 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
(Refer to 08:18.20 of the Alberta Health and Wellness Drug Benefit List for coverage of peginterferon alfa-2a for the treatment of Chronic Hepatitis B.)
Chronic Hepatitis C
"For the treatment of chronic hepatitis C in patients with evidence of active liver disease, who qualify for treatment with Pegasys RBV (peginterferon alfa-2a/ribavirin) but who are intolerant to ribavirin.
All Chronic Hepatitis C Patients Prior to Initiation of Therapy:
- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three weeks before anticipated start date of therapy, please submit to Alberta Blue Cross a Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC30944), along with appropriate lab results. In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.
All Chronic Hepatitis C Patients (with the Exception of Advanced Fibrosis or Cirrhosis Patients):
Prior to initiation of therapy:
- Patients must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Patients may receive an initial approval for 14 weeks of coverage.
At 12 weeks of treatment:
- HCV RNA testing is required for all patients at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample, and the 12 week serum sample, for evaluation of continued coverage.
Renewal approval period (for patients meeting criteria):
- Patients who respond to therapy, as measured by a reduction of viral load by at least 2 logs (100 fold) or HCV RNA not detected at 12 weeks, may be approved for an additional 34 weeks of coverage (total 48 weeks).
All Chronic Hepatitis C Patients with Advanced Fibrosis or Cirrhosis:
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage.
Consideration for therapy in chronic hepatitis C patients who have previously received therapy:
- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:
- Advanced fibrosis or cirrhosis.- Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy."
In order to comply with this criterion: Confirmation of the diagnosis of chronic hepatitis C and The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PEGINTERFERON ALFA-2A
180 MCG / SYR INJECTION SYRINGE00002248077 PEGASYS (0.5 ML SYRINGE) HLR 395.8400
67 EFFECTIVE JULY 1, 2012
$
Section 3 .
presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of a liver biopsy. All requests for peginterferon alfa-2a for Chronic Hepatitis C must be completed using the Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PEGINTERFERON ALFA-2A/ RIBAVIRIN
68 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
"For the treatment of chronic hepatitis C in patients with evidence of active liver disease.
Prior to initiation of Pegasys RBV therapy:
- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three (3) weeks before anticipated start date of therapy, please submit a Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) along with appropriate lab results to Alberta Blue Cross.
All Patients (with the Exception of Post-Liver Transplant Patients and Advanced Fibrosis or Cirrhosis Patients):
Prior to initiation of Pegasys RBV therapy:
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection, may receive an initial approval for 14 weeks of coverage.- Genotype 2 or 3 patients may receive initial and maximal approval for 24 weeks of coverage.These patients will not be eligible for continued approval.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.
At 12 weeks of treatment:
- HCV RNA testing is required for all Genotype 1 patients and Genotype 2 or 3 patients with HIVco-infection at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample and the 12th week serum sample for evaluation of continued coverage.
Renewal approval period (for patients meeting criteria):
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who respond to therapy as measured by a negative HCV RNA status at 12 weeks, may be approved for an additional 34 weeks of coverage (i.e. total 48 weeks).- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who achieve areduction in viral load by at least 2 logs (100 fold) but do not possess negative HCV RNA status at week 12 may be approved for an additional 14 weeks of coverage. Patients should be retested for HCV RNA status at 24 weeks:- Patients who respond to therapy, as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 20 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.
Post-Liver Transplant Patients:
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Genotype 1 and Genotype 2 or 3 patients may receive an initial approval for 26 weeks of coverage.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.
At 24 weeks of treatment:The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PEGINTERFERON ALFA-2A/ RIBAVIRIN
180 MCG * 200 MG INJECTION SYRINGE/TABLET00002253429 PEGASYS RBV (KIT) HLR 395.8400
69 EFFECTIVE JULY 1, 2012
$
Section 3 .
- HCV RNA testing is required for all Genotype 1 and Genotype 2 or 3 patients at the 24th week of treatment.
Renewal approval period (for patients meeting criteria):
- Genotype 1 and Genotype 2 or 3 patients who respond to therapy as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 22 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.
Advanced Fibrosis or Cirrhosis Patients:
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage.
Consideration for therapy in ALL patients (including post-liver transplant patients) who have previously received therapy:
- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:- Advanced fibrosis or cirrhosis. - Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy.- Patients who have failed to respond to or relapsed following interferon monotherapy."
Confirmation of the diagnosis of chronic hepatitis C and presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of liver biopsy. All requests for peginterferon alfa-2a/ribavirin must be completed using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PEGINTERFERON ALFA-2B/ RIBAVIRIN
70 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
"For the treatment of chronic hepatitis C in patients with evidence of active liver disease.
Prior to initiation of Pegetron therapy:
- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three (3) weeks before anticipated start date of therapy, please submit a Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) along with appropriate lab results to Alberta Blue Cross.
All Patients (with the Exception of Post-Liver Transplant Patients and Advanced Fibrosis or Cirrhosis Patients):
Prior to initiation of Pegetron therapy:
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection, may receive an initial approval for 14 weeks of coverage.- Genotype 2 or 3 patients may receive initial and maximal approval for 24 weeks of coverage.These patients will not be eligible for continued approval.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.
At 12 weeks of treatment:
- HCV RNA testing is required for all Genotype 1 patients and Genotype 2 or 3 patients with HIVco-infection at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample and the 12th week serum sample for evaluation of continued coverage.
Renewal approval period (for patients meeting criteria):
- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who respond to therapy as measured by a negative HCV RNA status at 12 weeks, may be approved for an additional 34 weeks of coverage (i.e. total 48 weeks).- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who achieve a reduction in viral load by at least 2 logs (100 fold) but do not possess negative HCV RNA status at week 12 may be approved for an additional 14 weeks of coverage. Patients should be retested for HCV RNA status at 24 weeks:- Patients who respond to therapy, as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 20 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.
Post-Liver Transplant Patients:
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Genotype 1 and Genotype 2 or 3 patients may receive an initial approval for 26 weeks of coverage.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.
At 24 weeks of treatment:The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PEGINTERFERON ALFA-2B/ RIBAVIRIN
50 MCG * 200 MG INJECTION VIAL/CAPSULE
150 MCG * 200 MG INJECTION VIAL/CAPSULE
80 MCG * 200 MG INJECTION SYRINGE/CAPSULE
100 MCG * 200 MG INJECTION SYRINGE/CAPSULE
120 MCG * 200 MG INJECTION SYRINGE/CAPSULE
150 MCG * 200 MG INJECTION SYRINGE/CAPSULE
00002246026
00002246030
00002254581
00002254603
00002254638
00002254646
PEGETRON (KIT)
PEGETRON (KIT)
PEGETRON REDIPEN (KIT)
PEGETRON REDIPEN (KIT)
PEGETRON REDIPEN (KIT)
PEGETRON REDIPEN (KIT)
MFC
MFC
MFC
MFC
MFC
MFC
752.2000
831.1800
752.2000
752.2000
831.1800
831.1800
71 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
Section 3 .
- HCV RNA testing is required for all Genotype 1 and Genotype 2 or 3 patients at the 24th week of treatment.
Renewal approval period (for patients meeting criteria):
- Genotype 1 and Genotype 2 or 3 patients who respond to therapy as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 22 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.
Advanced Fibrosis or Cirrhosis Patients:
Initial Alberta Blue Cross approval periods (for patients meeting criteria):
- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage. Consideration for therapy in ALL patients (including post-liver transplant patients) who have previously received therapy:
- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:- Advanced fibrosis or cirrhosis. - Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy.- Patients who have failed to respond to or relapsed following interferon monotherapy."
Confirmation of the diagnosis of chronic hepatitis C and presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of liver biopsy. All requests for peginterferon alfa-2b/ribavirin must be completed using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PIOGLITAZONE HCL
15 MG (BASE) ORAL TABLET
30 MG (BASE) ORAL TABLET
45 MG (BASE) ORAL TABLET
000023034420000230294200002363232000023028610000232647700002298279000022749140000230766900002303124000023014230000229790600002242572
00002303450000023029500000236324000002302888000023264850000229828700002274922000023076770000233958700002303132000023014310000229791400002242573
00002303469000023029770000236325900002302896000023264930000229829500002274930000023077230000233959500002303140000023014580000229792200002242574
ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS
ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPIOGLITAZONE HYDROCHLORIDEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS
ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPIOGLITAZONE HYDROCHLORIDEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS
ACPAPXAVACOBMPIMYPTEVPHHPMSRPHSDZTAK
ACPAPXAVACOBMPIMYPTEVPHHAHIPMSRPHSDZTAK
ACPAPXAVACOBMPIMYPTEVPHHAHIPMSRPHSDZTAK
0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 2.3171
1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 3.2462
1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 4.8811
72 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$
$$$$$$$$$$$$$
$$$$$$$$$$$$$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMIN
"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin or who are intolerant to metformin (e.g. dermatologic reactions) or for whom the product is contraindicated."
Special authorization may be granted for 24 months.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM
QUINAGOLIDE
2 G / VIAL (BASE) * 250 MG / VIAL (BASE) INJECTION
3 G / VIAL (BASE) * 375 MG / VIAL (BASE) INJECTION
4 G / VIAL (BASE) * 500 MG / VIAL (BASE) INJECTION
0.075 MG ORAL TABLET
0.15 MG ORAL TABLET
0000230844400002299623
00002170817
0000230845200002299631
00002170795
0000230846000002299658
00002170809
00002223767
00002223775
PIPERACILLIN AND TAZOBACTAMPIPERACILLIN SODIUM/TAZOBACTAM SODIUMTAZOCIN
PIPERACILLIN AND TAZOBACTAMPIPERACILLIN SODIUM/TAZOBACTAM SODIUMTAZOCIN
PIPERACILLIN AND TAZOBACTAMPIPERACILLIN SODIUM/TAZOBACTAM SODIUMTAZOCIN
NORPROLAC
NORPROLAC
APXSDZ
WAY
APXSDZ
WAY
APXSDZ
WAY
FEI
FEI
9.6120 9.6120
11.9220
14.4180 14.4180
17.8830
19.2250 19.2250
23.8450
1.0900
1.6300
73 EFFECTIVE JULY 1, 2012
$$
$
$$
$
$$
$
$
$
Section 3 .
For the treatment of:
1) "Second-line therapy of intra-abdominal sepsis where there are serious adverse events due to first-line therapy or documented failure of first-line therapy (e.g. ampicillin + gentamicin + metronidazole), as defined by clinical deterioration after 72 h of antibiotic therapy or lack of improvement after completion of antibiotic therapy or 2) Second-line therapy of severe polymicrobial skin and skin structure infections (e.g. limb threatening diabetic foot) or
3) Therapy of severe ventilator-associated pneumonia where Pseudomonas and Staphylococcus aureus coverage is needed, or
4) Therapy for infections involving multi-resistant Pseudomonas aeruginosa from pulmonary secretions in cystic fibrosis patients, lung transplant patients or patients with bronchiectasis , where there is documented susceptibility to piperacillin/tazobactam sodium, or
5) For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."
In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): BROMOCRIPTINE
"For the treatment of hyperprolactinemia in patients who are intolerant to or who have failed bromocriptine. Special authorization may be granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RALOXIFENE HCL
RIFABUTIN
RILUZOLE
60 MG ORAL TABLET
150 MG ORAL CAPSULE
50 MG ORAL TABLET
00002279215000023122980000235892100002239028
00002063786
00002242763
APO-RALOXIFENENOVO-RALOXIFENEPMS-RALOXIFENEEVISTA
MYCOBUTIN
RILUTEK
APXTEVPMSLIL
PFI
SAV
0.8457 0.8457 0.8457 1.8805
3.9821
9.8173
74 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$
$
$
Section 3 .
"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization for this criteria may be granted for 6 months."
"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year).Special authorization for this criteria may be granted for 6 months."
"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy."
"Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."
All requests for raloxifene HCl must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).
The following product(s) are eligible for auto-renewal.
"For the prevention of disseminated Mycobacterium avium complex disease in patients with advanced HIV infection or other immunocompromised conditions.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"For use in patients who have probable or definite diagnosis of amyotrophic lateral sclerosis (ALS) as defined by World Federation of Neurology (WFN) criteria who have a vital capacity of >60% predicted and do not have a tracheostomy for invasive ventilation. This drug must be prescribed by a Specialist in Neurology."
"Patients who previously received Rilutek and were not eligible for the Phase IV study can also be considered for coverage if they meet the special authorization criteria."
"Coverage cannot be renewed once the patient has a tracheostomy for the purpose of invasive ventilation."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RISEDRONATE SODIUM
5 MG ORAL TABLET
30 MG ORAL TABLET
35 MG ORAL TABLET
0000229837600002242518
0000229838400002239146
000023536870000236481600002357984000022983920000230220900002319861000023702550000232729500002246896
NOVO-RISEDRONATEACTONEL
NOVO-RISEDRONATEACTONEL
APO-RISEDRONATEAVA-RISEDRONATEMYLAN-RISEDRONATENOVO-RISEDRONATEPMS-RISEDRONATERATIO-RISEDRONATERISEDRONATESANDOZ RISEDRONATEACTONEL
TEVWCC
TEVWCC
APXAVAMYPTEVPMSRPHSNSSDZWCC
1.3897 1.9125
9.0033 12.4090
3.9224 3.9224 3.9224 3.9224 3.9224 3.9224 3.9224 3.9224
10.4250
75 EFFECTIVE JULY 1, 2012
$$
$$
$$$$$$$$$
Section 3 .
"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization may be granted for 6 months."
"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year).Special authorization for this criteria may be granted for 6 months."
"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy."
"Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."
"For the treatment of Paget's disease. Special Authorization for this criteria may be granted to amaximum of 2 months. Renewal requests may be considered following an observation period ofat least 2 months."
"Coverage cannot be provided for two or more medications used in the treatment of Paget'sdisease when these medications are intended for use in combination or when therapy with twoor more medications overlap."
All requests for risedronate sodium for Osteoporosis must be completed using theAlendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis SpecialAuthorization Request Form (ABC 31086).
The following product(s) are eligible for auto-renewal for the treatment of osteoporosis.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RISPERIDONE
25 MG / VIAL INJECTION
37.5 MG / VIAL INJECTION
50 MG / VIAL INJECTION
00002255707
00002255723
00002255758
RISPERDAL CONSTA
RISPERDAL CONSTA
RISPERDAL CONSTA
JAI
JAI
JAI
161.0900
241.6200
322.1600
76 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
Section 3 .
"For the management of the manifestations of schizophrenia and related psychotic disorders in patients who demonstrate a pattern of significant non-compliance that compromises therapeutic success AND who meet at least two of three of the following criteria:- Experiences extra-pyramidal symptoms with either an oral or depot first generation antipsychotic agent that precludes the use of a first generation antipsychotic depot product; OR- Is refractory to trials of at least two other antipsychotic therapies (Note: one trial must include a first generation antipsychotic agent); OR- Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy.
Special Authorization may be granted for six months."
All requests (including renewal requests) for risperidone prolonged release injection must be completed using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RITUXIMAB
10 MG / ML INJECTION00002241927 RITUXAN HLR 45.3100
77 EFFECTIVE JULY 1, 2012
$
Section 3 .
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to: - Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily); AND- One anti-tumor necrosis factor (anti-TNF) therapy (e.g., etanercept, infliximab or adalimumab) (minimum 12 week trial).
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications totreatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for a dose of 1000 mg of rituximab administered at 0 and 2 weeks (total of 2 - 1000 mg doses).- Patients will be limited to receiving one dose of rituximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For coverage for an additional two-dose course of therapy, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after each course of therapy, between 16 and 24 weeks after receiving the initial dose of each course of therapy, to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- An improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place] following the initial course of rituximab; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places] following the initial course of rituximab.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above, AND3) The patient must have experienced a subsequent loss of effect as defined by a worsening greater than or equal to 0.6 in the DAS28 score AND possess a DAS28 score of greater than or equal to 3.2.
Subsequent courses of therapy cannot be considered prior to 24 weeks elapsing from the initial dose of the previous course of therapy."
All requests (including renewal requests) for rituximab for Rheumatoid Arthritis must be completed using the Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RIVASTIGMINE HYDROGEN TARTRATE
1.5 MG (BASE) ORAL CAPSULE
3 MG (BASE) ORAL CAPSULE
4.5 MG (BASE) ORAL CAPSULE
6 MG (BASE) ORAL CAPSULE
2 MG / ML (BASE) ORAL SOLUTION
00002336715000023328090000230598400002306034000023112830000232456300002242115
00002336723000023328170000230599200002306042000023112910000232457100002242116
00002336731000023328250000230601800002306050000023113050000232459800002242117
00002336758000023328330000230602600002306069000023113130000232460100002242118
00002245240
APO-RIVASTIGMINEMYLAN-RIVASTIGMINENOVO-RIVASTIGMINEPMS-RIVASTIGMINERATIO-RIVASTIGMINESANDOZ RIVASTIGMINEEXELON
APO-RIVASTIGMINEMYLAN-RIVASTIGMINENOVO-RIVASTIGMINEPMS-RIVASTIGMINERATIO-RIVASTIGMINESANDOZ RIVASTIGMINEEXELON
APO-RIVASTIGMINEMYLAN-RIVASTIGMINENOVO-RIVASTIGMINEPMS-RIVASTIGMINERATIO-RIVASTIGMINESANDOZ RIVASTIGMINEEXELON
APO-RIVASTIGMINEMYLAN-RIVASTIGMINENOVO-RIVASTIGMINEPMS-RIVASTIGMINERATIO-RIVASTIGMINESANDOZ RIVASTIGMINEEXELON
EXELON
APXMYPTEVPMSRPHSDZNOV
APXMYPTEVPMSRPHSDZNOV
APXMYPTEVPMSRPHSDZNOV
APXMYPTEVPMSRPHSDZNOV
NOV
0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059
0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059
0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059
0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059
1.3700
78 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$$
$$$$$$$
$
Section 3 .
"For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4.
Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination.
Special authorization coverage may be granted for a maximum of 24 months per request.
For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided.
Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug."
All requests (including renewal requests) for rivastigmine hydrogen tartrate must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RIZATRIPTAN BENZOATE
ROSIGLITAZONE MALEATE
10 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL DISINTEGRATING TABLET
10 MG (BASE) ORAL DISINTEGRATING TABLET
2 MG (BASE) ORAL TABLET
4 MG (BASE) ORAL TABLET
8 MG (BASE) ORAL TABLET
00002240521
00002374730000023791980000235187000002240518
00002374749000023792010000235188900002240519
00002241112
00002241113
00002241114
MAXALT
CO RIZATRIPTAN ODTMYLAN-RIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTMAXALT RPD
CO RIZATRIPTAN ODTMYLAN-RIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTMAXALT RPD
AVANDIA
AVANDIA
AVANDIA
MFC
COBMYPSDZMFC
COBMYPSDZMFC
GSK
GSK
GSK
15.2201
5.3270 5.3270 5.3270
15.2201
5.3270 5.3270 5.3270
15.2201
1.3755
2.1584
3.0865
79 EFFECTIVE JULY 1, 2012
$
$$$$
$$$$
$
$
$
Section 3 .
(Refer to 28:32.28 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 18 to 64 years of age inclusive.)
"For the treatment of acute migraine attacks in patients 65 years of age and older where other standard therapy has failed."
"For the treatment of acute migraine attacks in patients 65 years of age and older who have been using rizatriptan benzoate prior to turning 65."
"Special authorization for both criteria may be granted for 24 months."
In order to comply with the first criteria, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMIN
"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin or who are intolerant to metformin (e.g. dermatologic reactions) or for whom the product is contraindicated."
Special authorization may be granted for 24 months.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ROSIGLITAZONE MALEATE/ METFORMIN HCL
SAXAGLIPTIN HCL
1 MG (BASE) * 500 MG ORAL TABLET
2 MG (BASE) * 500 MG ORAL TABLET
2 MG (BASE) * 1,000 MG ORAL TABLET
4 MG (BASE) * 500 MG ORAL TABLET
4 MG (BASE) * 1,000 MG ORAL TABLET
5 MG (BASE) ORAL TABLET
00002247085
00002247086
00002248440
00002247087
00002248441
00002333554
AVANDAMET
AVANDAMET
AVANDAMET
AVANDAMET
AVANDAMET
ONGLYZA
GSK
GSK
GSK
GSK
GSK
BMS
0.6421
1.1611
1.2682
1.5946
1.7337
2.7560
80 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMIN
"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin."
Special authorization may be granted for 24 months.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMINSECOND-LINE DRUG PRODUCT(S): SULFONYLUREASAND WHERE INSULIN IS NOT AN OPTION
As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND- a sulfonylurea, AND- for whom insulin is not an option.
Or, for whom these products are contraindicated.
Special authorization may be granted for 24 months.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SITAGLIPTIN PHOSPHATE MONOHYDRATE
SITAGLIPTIN PHOSPHATE MONOHYDRATE/ METFORMIN HCL
100 MG ORAL TABLET
50 MG * 500 MG ORAL TABLET
50 MG * 850 MG ORAL TABLET
50 MG * 1,000 MG ORAL TABLET
00002303922
00002333856
00002333864
00002333872
JANUVIA
JANUMET
JANUMET
JANUMET
MFC
MFC
MFC
MFC
2.8863
1.5641
1.5641
1.5641
81 EFFECTIVE JULY 1, 2012
$
$
$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMINSECOND-LINE DRUG PRODUCT(S): SULFONYLUREASAND WHERE INSULIN IS NOT AN OPTION
As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND- a sulfonylurea, AND- for whom insulin is not an option.
Or, for whom these products are contraindicated.
Special authorization may be granted for 24 months.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): METFORMINSECOND-LINE DRUG PRODUCT(S): SULFONYLUREASAND WHERE INSULIN IS NOT AN OPTION
As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND- a sulfonylurea, AND- for whom insulin is not an option.
Or, for whom these products are contraindicated.
Special authorization may be granted for 24 months.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
SOLIFENACIN SUCCINATE
SOMATROPIN
SOMATROPIN R-DNA ORIGIN
5 MG ORAL TABLET
10 MG ORAL TABLET
6 MG / VIAL INJECTION
12 MG / VIAL INJECTION
3.3 MG / VIAL INJECTION
5 MG / VIAL INJECTION
5.83 MG / ML INJECTION
6.7 MG / ML INJECTION
8 MG / ML INJECTION
8.8 MG / VIAL INJECTION
00002277263
00002277271
00002243077
00002243078
0000232506300002215136
00002237971
00002350122
00002325071
0000235013000002350149
00002272083
VESICARE
VESICARE
HUMATROPE
HUMATROPE
OMNITROPESAIZEN
SAIZEN
SAIZEN
OMNITROPE
SAIZEN (1.5 ML)SAIZEN (2.5 ML)
SAIZEN
ASP
ASP
LIL
LIL
SDZSRO
SRO
SRO
SDZ
SROSRO
SRO
1.5000
1.5000
280.0200
560.0400
103.8667 144.9000
217.5200
261.0000
207.7333
348.0000 348.0000
348.0300
82 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$$
$
$
$
$$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN
"For patients who are intolerant to oxybutynin.
Special authorization may be granted for 24 months."
"For replacement of endogenous growth hormone in adults with severe growth hormone deficiency. Information is required regarding the results of a diagnostic insulin tolerance test. Growth hormone values less than 3 mcg/litre during hypoglycemia are indicative of severe growth hormone deficiency.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"For replacement of endogenous growth hormone in adults with severe growth hormone deficiency. Information is required regarding the results of a diagnostic insulin tolerance test. Growth hormone values less than 3 mcg/litre during hypoglycemia are indicative of severe growth hormone deficiency.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SULFUR/ SULFACETAMIDE SODIUM
SUMATRIPTAN HEMISULFATE
5 % * 10 % TOPICAL LOTION
5 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY
20 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY
00002220407
00002230418
00002230420
SULFACET-R
IMITREX
IMITREX
VCL
GSK
GSK
0.9628
14.3859
14.8045
83 EFFECTIVE JULY 1, 2012
$
$
$
Section 3 .
"For the treatment seborrheic dermatitis and bacterial folliculitis.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
(Refer to 28:32.28 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 18 to 64 years of age inclusive.)
"For the treatment of acute migraine attacks in patients 65 years of age and older where other standard therapy has failed."
"For the treatment of acute migraine attacks in patients 65 years of age and older who have been using sumatriptan prior to turning 65."
"Special authorization for both criteria may be granted for 24 months."
In order to comply with the first criteria, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
SUMATRIPTAN SUCCINATE
50 MG (BASE) ORAL TABLET
100 MG (BASE) ORAL TABLET
6 MG / SYR (BASE) INJECTION SYRINGE
000022683880000236625800002257890000022689140000228682300002256436000022630250000228652100002212153
00002268396000023662660000225790400002268922000022393670000228683100002256444000022630330000228654800002212161
0000236169800002212188
APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF
APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF
SUMATRIPTAN SUN (0.5 ML)IMITREX (0.5 ML)
APXAVACOBMYPTEVPMSSDZSNSGSK
APXAVACOBMYPTEVTEVPMSSDZSNSGSK
SPGGSK
7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350
15.1567
7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600
16.6968
16.5889 44.0900
84 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$
$$$$$$$$$$
$$
Section 3 .
(Refer to 28:32.28 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 18 to 64 years of age inclusive.)
"For the treatment of acute migraine attacks in patients 65 years of age and older where other standard therapy has failed."
"For the treatment of acute migraine attacks in patients 65 years of age and older who have been using sumatriptan prior to turning 65."
"Special authorization for both criteria may be granted for 24 months."
In order to comply with the first criteria, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SYNTHETIC CALCITONIN SALMON (SALCATONIN)
TACROLIMUS
200 IU / DOSE NASAL METERED DOSE SPRAY
0.1 % TOPICAL OINTMENT
000022475850000226176600002240775
00002244148
APO-CALCITONINSANDOZ CALCITONIN NSMIACALCIN
PROTOPIC
APXSDZNOV
ASP
1.4000 1.4000 2.1888
2.3005
85 EFFECTIVE JULY 1, 2012
$$$
$
Section 3 .
"For use in patients 16 years of age and older with atopic dermatitis affecting face and flexures who are unable to tolerate or have failed topical steroid therapy."
"For use in patients 16 years of age and older with atopic dermatitis who require ongoinguse of potent (Class 3 or higher) topical steroids over greater than 30 % of body surface area."
"Special authorization for all criteria may be granted for 6 months."
Information is required regarding the patient's diagnosis, previous medications utilized (including specific topical steroids) and the patient's response to therapy. In order to comply with the first criteria, information is also required regarding the area(s) affected. In order to comply with the second criteria, information is also required regarding the percentage body surface area affected.
The following product(s) are eligible for auto-renewal.
"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a >2% loss in bone mineral density in one year).Special authorization may be granted for 6 months."
"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use ascombination therapy."
"Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."
All requests for synthetic calcitonin salmon must be completed using theAlendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TACROLIMUS
TESTOSTERONE
TESTOSTERONE UNDECANOATE
0.03 % TOPICAL OINTMENT
12.2 MG TRANSDERMAL PATCH
24.3 MG TRANSDERMAL PATCH
40 MG ORAL CAPSULE
00002244149
00002239653
00002245972
00000782327
PROTOPIC
ANDRODERM (2.5 MG/DAY)
ANDRODERM (5 MG/DAY)
ANDRIOL
ASP
PAL
PAL
MFC
2.1498
1.9959
3.9919
0.9400
86 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
Section 3 .
"For use in patients 2 to 15 years of age inclusive with atopic dermatitis who are unable to tolerate or have failed topical steroid therapy."
"For use in patients 2 to 15 years of age inclusive with atopic dermatitis who require ongoing use of potent (Class 3 or higher) topical steroids."
"For use in patients 16 years of age and older with atopic dermatitis affecting face and flexures who are unable to tolerate or have failed topical steroid therapy."
"For use in patients 16 years of age and older with atopic dermatitis who require ongoinguse of potent (Class 3 or higher) topical steroids over greater than 30 % of body surface area."
"Special authorization for all criteria may be granted for 6 months."
Information is required regarding the patient's diagnosis, previous medications utilized (including specific topical steroids) and the patient's response to therapy. In order to comply with the third criteria, information is also required regarding the area(s) affected. In order to comply with the fourth criteria, information is also required regarding the percentage body surface area affected.
The following product(s) are eligible for auto-renewal.
"For use in males for the treatment of congenital and acquired primary and secondary hypogonadism."
"Coverage cannot be considered when used for the treatment of androgen decline in the aging male (ADAM)."
"Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
"For use in males for the treatment of congenital and acquired primary and secondary hypogonadism."
"Coverage cannot be considered when used for the treatment of androgen decline in the aging male (ADAM)." "Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TETRABENAZINE
TIZANIDINE HCL
25 MG ORAL TABLET
4 MG (BASE) ORAL TABLET
00002199270
000022598930000227205900002239170
NITOMAN
APO-TIZANIDINEMYLAN-TIZANIDINEZANAFLEX
VCL
APXMYPPAL
6.9360
0.3686 0.3686 0.7746
87 EFFECTIVE JULY 1, 2012
$
$$$
Section 3 .
"For the treatment of hyperkinetic movement disorders when prescribed by specialists in Neurology, Psychiatry, or Geriatric Medicine.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): DIAZEPAM OR BACLOFEN
"For the treatment of spasticity in patients with documented evidence of intolerance or lack of response to diazepam or baclofen. Special authorization is granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TOCILIZUMAB
88 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .
Rheumatoid Arthritis:
"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:
- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily); AND- At least one anti-tumor necrosis factor (anti-TNF) therapy (e.g., etanercept, infliximab oradalimumab) (minimum 12 week trial); AND- Abatacept or rituximab (minimum 12 - 16 week trial).
Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").
- Initial coverage may be approved for one dose of 4 mg/kg or 8 mg/kg (up to a maximum of 800mg per dose) of tocilizumab administered at 0, 4, 8, 12 and 16 weeks (total of 5 doses).- Patients will be limited to receiving one dose of tocilizumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception ofanakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum thecompletion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they weredeemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except underexceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage beyond the initial 5 doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 16 weeks, but no longer than 20 weeks after treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.
Following this assessment, continued coverage may be approved for one dose of 4 mg/kg to 8 mg/kg (up to a maximum of 800 mg per dose) every 4 weeks, for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TOCILIZUMAB
TOLTERODINE L-TARTRATE
TRETINOIN
80 MG / VIAL INJECTION
200 MG / VIAL INJECTION
400 MG / VIAL INJECTION
2 MG ORAL EXTENDED-RELEASE CAPSULE
4 MG ORAL EXTENDED-RELEASE CAPSULE
0.01 % TOPICAL CREAM
0.025 % TOPICAL CREAM
0.05 % TOPICAL CREAM
0.1 % TOPICAL CREAM
0.01 % TOPICAL GEL
0.025 % TOPICAL GEL
00002350092
00002350106
00002350114
00002244612
00002244613
00000657204
00000578576
00000518182
00000662348
00001926462
0000192647000000587966
ACTEMRA (4 ML)
ACTEMRA (10 ML)
ACTEMRA (20 ML)
DETROL LA
DETROL LA
STIEVA-A
STIEVA-A
STIEVA-A
STIEVA-A FORTE
VITAMIN A ACID
VITAMIN A ACIDSTIEVA-A
HLR
HLR
HLR
PFI
PFI
GSK
GSK
GSK
GSK
VCL
VCLGSK
179.2000
448.0000
896.0000
1.9122
1.9122
0.2996
0.2996
0.2996
0.2996
0.2964
0.2964 0.2996
89 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$
$
$
$$
Section 3 .
therapy as indicated by:- Confirmation of maintenance of ACR20, OR - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewalrequests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."
All requests (including renewal requests) for tocilizumab for Rheumatoid Arthritis must becompleted using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN
"For patients who are intolerant to oxybutynin."
"Special authorization may be granted for 24 months."
"For the treatment of severe acne as defined by scarring acne.
Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TRETINOIN
TROSPIUM CHLORIDE
0.05 % TOPICAL GEL
20 MG ORAL TABLET
0000192648900000641863
00002275066
VITAMIN A ACIDSTIEVA-A
TROSEC
VCLGSK
SUN
0.2964 0.2996
0.7635
90 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
Section 3 .
The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.
FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN
"For patients who are intolerant to oxybutynin."
"Special authorization may be granted for 24 months."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
USTEKINUMAB
45 MG INJECTION VIAL OR SYRINGE00002320673 STELARA (0.5 ML VIAL OR SYRINGE) JAI 4399.5900
91 EFFECTIVE JULY 1, 2012
For this product - pricing has been established on a per vial or syringe basis.$
Section 3 .
"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory to or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)
Patients who have a contraindication to either cyclosporine or methotrexate will be required to complete an adequate trial of the other pre-requisite medication prior to potential coverage beingconsidered.
'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.
For coverage, this drug must be prescribed by a Specialist in Dermatology ("Dermatology Specialist").
- Initial coverage may be approved for three doses of 45 mg at weeks 0, 4 and 16.- Patients will be limited to receiving one dose per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.
For continued coverage, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial16 weeks of therapyto determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.
Following this assessment, continued coverage may be considered for 45 mg every 12 weeks for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."
All requests (including renewal requests) for ustekinumab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
VALGANCICLOVIR HCL
VANCOMYCIN HCL
VARENICLINE TARTRATE
450 MG (BASE) ORAL TABLET
125 MG (BASE) ORAL CAPSULE
250 MG (BASE) ORAL CAPSULE
0.5 MG (BASE) ORAL TABLET
1 MG (BASE) ORAL TABLET
00002245777
00000800430
00000788716
00002291177
00002291185
VALCYTE
VANCOCIN
VANCOCIN
CHAMPIX
CHAMPIX
HLR
MLI
MLI
PFI
PFI
22.8582
7.5573
15.1141
1.7206
1.7205
92 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
Section 3 .
"For the treatment of CMV retinitis in patients with acquired immunodeficiency syndrome (AIDS).""Special authorization may be granted for 12 months."
"For the prevention of CMV disease in solid organ transplant patients at risk (i.e. risk is defined as donor +ve/recipient -ve for CMV, or recipient +ve post-active treatment of CMV disease with IV ganciclovir, or recipient +ve in patients receiving antilymphocyte antibody [ALA]). For the purpose of administering this criterion, islet transplant recipients are at similar risk of CMV disease to patients undergoing a solid organ transplant and qualify for drug coverage.""Special authorization may be granted for 100 days."
"For the prevention of CMV disease in kidney transplant patients at risk (i.e. risk is defined as donor +ve/recipient -ve for CMV, or recipient +ve post-active treatment of CMV disease with IV ganciclovir, or recipient +ve in patients receiving antilymphocyte antibody [ALA]).""Special authorization may be granted for 200 days."
"For the treatment of:
1) Clostridium difficile enteritis if there is clinical deterioration or documented failure on metronidazole therapy. Documented failure is defined as no clinical improvement after 5 days oftherapy or
2) Laboratory confirmed relapse of Clostridium difficile enteritis with symptoms after 2 courses ofmetronidazole therapy or
3) Clostridium difficile enteritis if there is documented or impending toxic megacolon or
4) Clostridium difficile enteritis if there is intolerance or side effects to metronidazole therapy."
For subsequent prescriptions, patients may obtain this product via special authorization with the following criteria for coverage:
"For use in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling.
Special authorization coverage may be granted for a maximum of 24 weeks of therapy per year."
This product is not eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
VARENICLINE TARTRATE/ VARENICLINE TARTRATE
VORICONAZOLE
0.5 MG * 1 MG ORAL TABLET
50 MG ORAL TABLET
200 MG ORAL TABLET
200 MG / VIAL INJECTION
00002298309
00002256460
00002256479
00002256487
CHAMPIX (STARTER PACK)
VFEND
VFEND
VFEND
PFI
PFI
PFI
PFI
1.7208
12.4818
49.9064
142.9416
93 EFFECTIVE JULY 1, 2012
$
$
$
$
Section 3 .
For subsequent prescriptions, patients may obtain this product via special authorization with the following criteria for coverage:
"For use in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling.
Special authorization coverage may be granted for a maximum of 24 weeks of therapy per year."
This product is not eligible for auto-renewal.
"For the treatment of invasive aspergillosis for post-hospital discharge only."
"For treatment of culture proven invasive candidiasis with documented resistance to fluconazole."
"This medication must be prescribed in consultation with a specialist in Infectious Diseases."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ZAFIRLUKAST
ZOLEDRONIC ACID
ZOLEDRONIC ACID
20 MG ORAL TABLET
0.05 MG / ML INJECTION
0.8 MG / ML INJECTION
00002236606
00002269198
00002248296
ACCOLATE
ACLASTA
ZOMETA CONCENTRATE
AZC
NOV
NOV
0.7492
6.7080
110.8160
94 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
Section 3 .
"For the treatment of Paget's disease. Special Authorization for this criterion may be granted for one dose per 12 month period."
"Coverage cannot be provided for two or more medications used in the treatment of Paget's disease when these medications are intended for use in combination or when therapy with two or more medications overlap."
"For the treatment of tumor-induced hypercalcemia in patients with documented evidence of intolerance or lack of response to clodronate or pamidronate. Special authorization may be granted for 6 months."
The following product(s) are eligible for auto-renewal.
(Refer to 48:10.24 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 12 to 18 years of age inclusive).
"For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria:
a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, or
b) cannot operate inhaler devices."
"For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists."
"Special authorization for both criteria may be granted for 6 months."
In order to comply with the first criteria, information should indicate either a) current use of inhaled steroids and contraindications or poor response to long-acting beta 2 agonists (e.g. salmeterol or formoterol) or, b) the nature of the patient's difficulties with using inhaler devices. In order to comply with the second criteria, information should include the nature of the patient's response to long-acting beta 2 agonists (e.g. salmeterol or formoterol).
All requests (including renewal requests) for zafirlukast must be completed using the Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313).
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ZOLMITRIPTAN
2.5 MG ORAL TABLET
2.5 MG ORAL DISPERSIBLE TABLET
5 MG / DOSE NASAL UNIT DOSE SPRAY
0000236903600002324229000023629880000231396000002238660
00002324768000023629960000234254500002243045
00002248993
MYLAN-ZOLMITRIPTANPMS-ZOLMITRIPTANSANDOZ ZOLMITRIPTANTEVA-ZOLMITRIPTANZOMIG
PMS-ZOLMITRIPTAN ODTSANDOZ ZOLMITRIPTAN ODTTEVA-ZOLMITRIPTAN ODZOMIG RAPIMELT
ZOMIG
MYPPMSSDZTEVAZC
PMSSDZTEVAZC
AZC
5.2110 5.2110 5.2110 5.2110
13.8500
5.2110 5.2110 5.2110
13.8500
13.8500
95 EFFECTIVE JULY 1, 2012
$$$$$
$$$$
$
Section 3 .
(Refer to 28:32.28 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 18 to 64 years of age inclusive.)
"For the treatment of acute migraine attacks in patients 65 years of age and older where other standard therapy has failed."
"For the treatment of acute migraine attacks in patients 65 years of age and older who have been using zolmitriptan prior to turning 65."
"Special authorization for both criteria may be granted for 24 months."
In order to comply with the first criteria, information is required regarding previous medications utilized and the patient's response to therapy.
The following product(s) are eligible for auto-renewal.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 3A C
riteria for Optional Special A
uthorization of Select Drug Products
SECTION 3A
Criteria for Optional Special Authorization
of Select Drug Products
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize Professional judgment.
Section 3A EFFECTIVE JULY 1, 2012
CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
The drug products listed in this section may be considered for coverage by optional special authorization for patients covered under Alberta Health and Wellness-sponsored drug programs. (For Alberta Human Services and Alberta Seniors (AISH) clients, the optional special authorization criteria for coverage can be found in the Criteria for Optional Special Authorization of Select Drug Products section of the Alberta Human Services Drug Benefit Supplement.)
70BCriteria for Coverage
Wording that appears within quotation marks (“ “) in this section is the official optional special authorization criteria, as recommended by the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics, and approved by the Minister of Health and Wellness. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.
71BRole of the Prescribers
In conjunction with the criteria, prescribers have two options by which patients may be eligible for coverage of these select optional special authorization drug products.
1) Prescribers can register to be a designated prescriber. Registration allows for patients to receive coverage of select drug products without special authorization as long as the prescription is written for one of the criteria for coverage set out in this section. Should a designated prescriber wish to prescribe one of the select drug products outside the coverage criteria, they may do so but must indicate this on the prescription; however, patients will not be eligible for payment under the Alberta government-sponsored program for such prescription and the patient may choose to receive the product at their expense. The registration form may be found on the previous page.
2) Prescribers who choose not to register will be considered non-designated prescribers. Such prescribers will be required to apply for special authorization on the patient’s behalf.
ALBERTA GOVERNMENT SPONSORED DRUG BENEFIT PROGRAMS OPTIONAL SPECIAL AUTHORIZATION
REGISTRATION FOR DESIGNATED PRESCRIBER STATUS for Alberta Health and Wellness Drug Benefit List Claim Coverage
Select Quinolone Antibiotics
ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin
Please complete all sections of this form and return it by fax to Alberta Blue Cross
Registrations will be accepted on an ongoing basis
PRESCRIBER SURNAME FIRST NAME INITIAL OFFICE PHONE: FAX:
OFFICE ADDRESS CITY PROVINCE POSTAL CODE
COLLEGE OF PHYSICIANS AND SURGEONS REGISTRATION NO. OR PROFESSIONAL REGISTRATION NO.
I have reviewed the criteria for coverage of select quinolone products, and I agree to abide by and only prescribe in accordance with such criteria as updated from time to time in the Optional Special Authorization section of the Alberta Health and Wellness Drug Benefit List.
SIGNATURE OF PRESCRIBER (required): DATE:
The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5.
PLEASE RETURN YOUR COMPLETED REGISTRATION BY FAX TO 1-877-305-9911 ABC 81897 Reg Form (R12/2011)
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
CIPROFLOXACIN
100 MG / ML ORAL SUSPENSION00002237514 CIPRO BAI 0.5699
1 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
"For the treatment of:
1) Respiratory Tract Infections: -end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection or - pneumonic illness in cystic fibrosis; or
2) Genitourinary Tract Infections: - urinary tract infections, - prostatitis, - prophylaxis of urinary tract surgical procedures or - gonococcal infections; or
3) Skin and Soft Tissue/Bone and Joint Infections: - malignant/invasive otitis externa, - bone/joint infections due to gram negative organisms or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or
4) Gastrointestinal Tract Infections: - bacterial gastroenteritis where antimicrobial therapy is indicated, - typhoid fever (enteric fever), or- therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or
5) Other: - prophylaxis of adult contacts of cases of invasive meningococcal disease, - therapy/step-down therapy of hospital acquired gram negative infections, - empiric therapy of febrile neutropenia in combination with other appropriate agents or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs.- for use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."
All requests for ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).
Section 3A
Patient claims for select quinolone prescriptions written by a non-designated prescriber will be subject to a first forgiveness rule, meaning the first claim will be paid. Subsequent claims for the same product (irrespective of strength, route and form) within a 90-day period would require the prescriber to apply for special authorization for coverage on the patient�s behalf.
.
Criteria For Optional Special Authorization Of Select Drug Products
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
PRODUCT IS NOT INTERCHANGEABLE
CIPROFLOXACIN HCL
250 MG (BASE) ORAL TABLET00002229521000023321320000235331800002247339000023796860000231742700002245647000021617370000224843700002303728000022468250000224875600002155958
APO-CIPROFLOXCIPROFLOXACINCIPROFLOXACINCO CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXACINMYLAN-CIPROFLOXACINNOVO-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINCIPRO
APXRANSNSCOBMARMPIMYPTEVPMSRANRPHSDZBAI
0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 2.4742
2 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$$
"For the treatment of
1) Respiratory Tract Infections: - end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection; or - pneumonic illness in cystic fibrosis; or
2) Genitourinary Tract Infections: - urinary tract infections; or - prostatitis; or - prophylaxis of urinary tract surgical procedures; or - gonococcal infections; or
3) Skin and Soft Tissue/Bone and Joint Infections: - malignant/invasive otitis externa; or - bone/joint infections due to gram negative organisms; or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or
4) Gastrointestinal Tract Infections: - bacterial gastroenteritis where antimicrobial therapy is indicated; or - typhoid fever (enteric fever); or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or
5) Other: - prophylaxis of adult contacts of cases of invasive meningococcal disease; or- therapy/step-down therapy of hospital acquired gram negative infections; or- empiric therapy of febrile neutropenia in combination with other appropriate agents; or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs; or- for use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."
All requests for Ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).
Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
CIPROFLOXACIN HCL500 MG (BASE) ORAL TABLET
750 MG (BASE) ORAL TABLET
00002229522000023321400000235332600002247340000023796940000231743500002245648000021617450000224843800002303736000022468260000224875700002155966
00002229523000023321590000235333400002247341000023797080000231744300002245649000021617530000224843900002303744000022468270000224875800002155974
APO-CIPROFLOXCIPROFLOXACINCIPROFLOXACINCO CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXACINMYLAN-CIPROFLOXACINNOVO-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINCIPRO
APO-CIPROFLOXCIPROFLOXACINCIPROFLOXACINCO CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXACINMYLAN-CIPROFLOXACINNOVO-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINCIPRO
APXRANSNSCOBMARMPIMYPTEVPMSRANRPHSDZBAI
APXRANSNSCOBMARMPIMYPTEVPMSRANRPHSDZBAI
1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 2.7915
1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 5.1118
3 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$$
$$$$$$$$$$$$$
Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
PRODUCT IS NOT INTERCHANGEABLE
LEVOFLOXACIN
250 MG ORAL TABLET
500 MG ORAL TABLET
750 MG ORAL TABLET
0000228470700002361027000023154240000231397900002248262000022846770000229863500002236841
0000228471500002361035000023154320000231398700002248263000022846850000229864300002236842
000023154400000228564900002325942000023055850000229865100002246804
APO-LEVOFLOXACINAVA-LEVOFLOXACINCO LEVOFLOXACINMYLAN-LEVOFLOXACINNOVO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN
APO-LEVOFLOXACINAVA-LEVOFLOXACINCO LEVOFLOXACINMYLAN-LEVOFLOXACINNOVO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN
CO LEVOFLOXACINNOVO-LEVOFLOXACINAPO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN
APXAVACOBMYPTEVPMSSDZJAI
APXAVACOBMYPTEVPMSSDZJAI
COBTEVAPXPMSSDZJAI
1.8655 1.8655 1.8655 1.8655 1.8655 1.8655 1.8655 4.9581
2.1050 2.1050 2.1050 2.1050 2.1050 2.1050 2.1050 5.5946
4.8478 4.8478 4.8479 4.8479 4.8480 9.8990
4 EFFECTIVE JULY 1, 2012
$$$$$$$$
$$$$$$$$
$$$$$$
"To be prescribed according to ONE of the following criteria:
For the treatment of
1) Community acquired pneumonia after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or
2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or
3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or
4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or
5) For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."
All requests for Levofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).
Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS
MOXIFLOXACIN HCL
OFLOXACIN
400 MG (BASE) ORAL TABLET
200 MG ORAL TABLET
300 MG ORAL TABLET
400 MG ORAL TABLET
00002242965
00002231529
00002231531
00002231532
AVELOX
OFLOXACIN
OFLOXACIN
OFLOXACIN
BAI
AAP
AAP
AAP
5.9428
1.3041
1.5323
1.5323
5 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
"To be prescribed according to ONE of the following criteria:
For the treatment of
1) Community acquired pneumonia after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or
2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or
3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or
4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or
5) For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."
All requests for Moxifloxacin HCl must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).
"To be prescribed according to ONE of the following criteria:
For the treatment of
1) Pelvic inflammatory disease; or
2) Epididymo-orchitis/epididymitis most likely due to enteric organisms; or
3) Chlamydia infection; or
4) Gonococcal infection; or
5) For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."
All requests for Ofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).
Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 4 Rare D
iseases Drug C
overage Program
SECTION 4
Rare Diseases Drug Coverage Program
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST RARE DISEASES DRUG COVERAGE PROGRAM
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 4 • 1 EFFECTIVE JULY 1, 2012
RARE DISEASES DRUG COVERAGE PROGRAM
Selected drug products used in the treatment of rare diseases may be considered for coverage for individuals covered under Alberta government-sponsored drug programs. The Minister of Health and Wellness makes the final decisions regarding coverage under this Program, and may list a drug product under this section when the Minister considers it in the public interest to do so.1
.
RARE DISEASES DRUG COVERAGE
In order to be eligible for the Rare Diseases Drug Coverage Program, an individual must: • have Alberta government-sponsored drug coverage; • be continuously registered in the Alberta Health Care Insurance Plan for a minimum of five
years unless: the individual is less than five years of age at the date of the application, then the
individual’s parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of five years;
OR the individual has moved to Alberta from another province or territory in Canada (the
“province of origin”), and immediately prior to moving to Alberta, was covered for a drug product listed in this section in the province of origin by a provincial or territorial government sponsored drug plan, and
• meet the clinical criteria for a rare disease drug product published on the List;
the individual has been registered in the Alberta Health Care Insurance Plan (the individual must provide supporting documentation from the province of origin to prove prior coverage).
• have a Rare Diseases Drug Coverage Application form (“Application”) submitted on their behalf to Alberta Blue Cross by the individual’s “Rare Disease Specialist”;
• have the Application reviewed and approved for coverage by the Alberta Rare Diseases Clinical Review Panel (“Review Panel”)
• complete the required forms, and consent to and acknowledge that approval for initial and continued coverage is conditional upon clinical outcomes; regular monitoring of the individual’s clinical outcomes will be required, and that coverage will be discontinued if there is inadequate response or the individual’s
condition deteriorates as outlined in the withdrawal criteria established in relation to a specific rare diseases drug product and/or as assessed by the Review Panel.
Contraindications
In addition to meeting the above criteria, the individual must not have the following contraindications: • Significant illness, not including one of the rare diseases, likely to substantially alter or reduce
life expectancy.
1 Section 1 of the AHWDBL does not apply to the Rare Diseases Drug Coverage Program
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 Section 4 • 2
Rare Diseases Drugs Eligible for Coverage
Drug products approved by Health Canada for the treatment of Rare Diseases may be considered for coverage in accordance with this section. Rare Diseases are genetic, lysosmal storage disorders occurring at a rate of less than one per 50,000 for the Canadian population for a specific disease (as determined by Alberta Health and Wellness). As of April 1, 2009, drug products for the treatment of the following rare diseases are currently under consideration for coverage: • Gaucher’s disease • Fabry disease • MPS-I (Hurler/Hurler Scheie) • Hunter disease • Pompe disease
Alberta Rare Diseases Clinical Review Panel
The Alberta Rare Diseases Clinical Review Panel (“Review Panel”) is a review panel composed of specialists treating rare diseases and other health professionals with clinical expertise, appointed by the Minister of Health and Wellness. The Review Panel’s functions include: • Providing advice to Alberta Health and Wellness regarding the Rare Diseases Drug Coverage
Program; • Reviewing and applying clinical knowledge and skills to individual applications for Rare
Diseases Drug Coverage; and • Providing advice to the Expert Committee on Drug Evaluation and Therapeutics regarding
drug products under consideration for coverage under this section, clinical criteria for rare diseases drug products and identifying appropriate “Rare Disease Specialists”.
Process for Rare Diseases Drug Coverage
Participating “Rare Disease Specialists” must complete a Rare Diseases Drug Coverage Application form for each individual. The form must be the one specific to the rare diseases drug product being requested. The completed application may be forwarded to Alberta Blue Cross by mail or by facsimile. To be considered for Rare Diseases Drug Coverage, the “Rare Disease Specialist” must confirm the individual (or individual’s parent/guardian/legal representative) has been provided with information regarding the Rare Diseases Drug Coverage Program and have completed the required forms.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST RARE DISEASES DRUG COVERAGE PROGRAM
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Section 4 • 3 EFFECTIVE JULY 1, 2012
Alberta Blue Cross, in providing administrative support to the Review Panel, receives and screens each application for completeness, then forwards to Alberta Health and Wellness to confirm that the individual has met the Alberta Health Care Insurance Plan registration requirement (please see above). Once it has been confirmed that the individual meets the Alberta Health Care Insurance Plan registration requirement, Alberta Blue Cross forwards the application to the Review Panel for assessment. Alberta Blue Cross responds to applicants on the Review Panel’s behalf. After an application has been assessed by the Review Panel, Alberta Blue Cross notifies the individual’s “Rare Disease Specialist” and the individual or individual’s parent/guardian/legal representative by letter of the Review Panel’s decision. Eligibility will be effective the date coverage is approved by the Review Panel. Renewals require a new drug product specific Rare Diseases Drug Coverage Application form that is completed by a “Rare Disease Specialist”. To be eligible for Rare Diseases Drug Coverage, prescriptions must be written by a “Rare Disease Specialist” as identified by the eligibility criteria for the drug product. To avoid wastage, prescription quantities are limited to a one-month supply. Extended quantity and vacation supplies are not permitted. Out-of-country claims will only be reimbursed in accordance with standard rules and regulations; individuals should verify with Alberta Blue Cross these rules and regulations prior
to obtaining drug products out of the country.
Government will not be responsible for reimbursement of costs associated with wastage or improper storage of rare diseases drug products. Prior approval must be granted to ensure coverage. Approval is granted for a specific period, to a maximum of 12 months. If continued treatment is necessary, it is the responsibility of the individual or individual’s parent/guardian/legal representative and the “Rare Disease Specialist” to re-apply for drug product coverage prior to the expiry date of the authorization period.
Pharmacologic -Therapeutic C
lassification of Drugs
PART 2
Pharmacologic – Therapeutic Classification of Drugs
00:00
Non-Classified Drugs
00:00 Antihistam
ine Drugs
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIABETES SUPPLIES
0000099995500000999941000009999850000099995200000999957
BLOOD GLUCOSE TEST STRIPSBLOOD LETTING LANCETINSULIN PEN NEEDLESINSULIN SYRINGESURINE TEST STRIPS
XXXXXXXXXXXXXXX
NON-CLASSIFIED DRUGS00:00
00:00.02
0.0000 0.0000 0.0000 0.0000 0.0000
1 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
This product is a benefit for patients with diabetes who are currently and regularly using insulin.
Eligible individuals will have coverage to a maximum of $600 per person each benefit year for eligible diabetic supplies purchased from a licensed pharmacy.
(DIABETES SUPPLIES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
04:00 Antihistam
ine Drugs
04:00
Antihistamine Drugs
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIPHENHYDRAMINE HCL
PROMETHAZINE HCL
TRIMEPRAZINE TARTRATE
KETOTIFEN FUMARATE
50 MG / ML INJECTION
25 MG / ML (BASE) INJECTION
2.5 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
1 MG (BASE) ORAL TABLET
0.2 MG / ML (BASE) ORAL SYRUP
00000596612
00000567434
00001926306
00001926292
00000577308
00002176084
DIPHENHYDRAMINE
PROMETHAZINE
PANECTYL
PANECTYL
ZADITEN
NOVO-KETOTIFEN
SDZ
SDZ
ERF
ERF
TEV
TEV
ANTIHISTAMINE DRUGS
ANTIHISTAMINE DRUGS
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
FIRST GENERATION ANTIHISTAMINES
OTHER ANTIHISTAMINES
04
04
04
:00
:00
:00
04:04.04
04:04.12
04:92
3.7630
1.0698
0.2710
0.3325
1.6722
0.1397
3 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
(ETHANOLAMINE DERIVATIVES)
(PHENOTHIAZINE DERIVATIVES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
08:00 Anti-Infective A
gents
08:00
Anti-Infective Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
MEBENDAZOLE
GENTAMICIN SULFATE
TOBRAMYCIN
TOBRAMYCIN SULFATE
CEFAZOLIN SODIUM
CEPHALEXIN
100 MG ORAL CHEWABLE TABLET
40 MG / ML (BASE) INJECTION
28 MG INHALATION CAPSULE
60 MG / ML (BASE) INHALATION SOLUTION
10 MG / ML (BASE) INJECTION
40 MG / ML (BASE) INJECTION
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
10 G / VIAL (BASE) INJECTION
250 MG ORAL TABLET
500 MG ORAL TABLET
250 MG ORAL CAPSULE
500 MG ORAL CAPSULE
25 MG / ML ORAL SUSPENSION
00000556734
00002242652
00002365154
00002239630
00002241209
00002241210
00002237137
00002237138
00002237140
0000076872300000583413
0000076871500000583421
00000342084
00000342114
00000342106
VERMOX
GENTAMICIN
TOBI PODHALER
TOBI
TOBRAMYCIN
TOBRAMYCIN
CEFAZOLIN
CEFAZOLIN
CEFAZOLIN
APO-CEPHALEXNOVO-LEXIN
APO-CEPHALEXNOVO-LEXIN
NOVO-LEXIN
NOVO-LEXIN
NOVO-LEXIN
JAI
SDZ
NOV
NOV
SDZ
SDZ
PPC
PPC
PPC
APXTEV
APXTEV
TEV
TEV
TEV
(FIRST GENERATION CEPHALOSPORINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
08
:00
:00
:00
08:08
08:12.02
08:12.06.04
3.8536
2.7581
12.8588
10.2870
2.1535
2.9860
2.5000
3.7500
35.0000
0.2250 0.2250
0.4500 0.4500
0.3515
0.6646
0.0885
5 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$$
$$
$
$
$
(AMINOGLYCOSIDES)
CEPHALOSPORINS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CEPHALEXIN
CEFPROZIL
50 MG / ML ORAL SUSPENSION
250 MG ORAL TABLET
500 MG ORAL TABLET
25 MG / ML ORAL SUSPENSION
50 MG / ML ORAL SUSPENSION
00000342092
00002292998000023472450000236284800002332035000022935280000230217900002163659
00002293005000023472530000236285600002332043000022935360000230218700002163667
000022939430000234726100002362864000023292040000230342600002163675
00002293951000023472880000236287200002332027000022935790000230343400002163683
NOVO-LEXIN
APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILCEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL
APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILCEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL
APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL
APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILCEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL
TEV
APXAURAVARANRANSDZBMS
APXAURAVARANRANSDZBMS
APXAURAVARANSDZBMS
APXAURAVARANRANSDZBMS
(FIRST GENERATION CEPHALOSPORINS)
(SECOND GENERATION CEPHALOSPORINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
:00
:00
08:12.06.04
08:12.06.08
0.1390
0.6319 0.6319 0.6319 0.6319 0.6319 0.6319 1.8054
1.2389 1.2389 1.2389 1.2389 1.2389 1.2389 3.5398
0.0618 0.0618 0.0618 0.0618 0.0618 0.1765
0.1234 0.1234 0.1234 0.1234 0.1234 0.1234 0.3526
6 EFFECTIVE JULY 1, 2012
$
$$$$$$$
$$$$$$$
$$$$$$
$$$$$$$
CEPHALOSPORINS
CEPHALOSPORINS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CEFUROXIME AXETIL
CEFIXIME
CEFOTAXIME SODIUM
CEFTAZIDIME
CEFTRIAXONE SODIUM
250 MG (BASE) ORAL TABLET
500 MG (BASE) ORAL TABLET
400 MG ORAL TABLET
20 MG / ML ORAL SUSPENSION
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
2 G / VIAL (BASE) INJECTION
1 G / VIAL INJECTION
2 G / VIAL INJECTION
6 G / VIAL INJECTION
0.25 G / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
2 G / VIAL (BASE) INJECTION
00002244393000023448230000224265600002212277
00002244394000023448310000224265700002212285
00000868981
00000868965
00002225085
00002225093
00002225107
00002212218
00002212226
00002212234
00002292866
0000229227000002292874
0000229228900002292882
APO-CEFUROXIMEAURO-CEFUROXIMERATIO-CEFUROXIMECEFTIN
APO-CEFUROXIMEAURO-CEFUROXIMERATIO-CEFUROXIMECEFTIN
SUPRAX
SUPRAX
CLAFORAN
CLAFORAN
CLAFORAN
FORTAZ
FORTAZ
FORTAZ
CEFTRIAXONE FOR INJECTION USP
CEFTRIAXONE FOR INJECTION USPCEFTRIAXONE FOR INJECTION USP
CEFTRIAXONE FOR INJECTION USPCEFTRIAXONE FOR INJECTION USP
APXAURRPHGSK
APXAURRPHGSK
SAV
SAV
SAV
SAV
SAV
GSK
GSK
GSK
APX
SDZAPX
SDZAPX
(SECOND GENERATION CEPHALOSPORINS)
(THIRD GENERATION CEPHALOSPORINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
:00
:00
08:12.06.08
08:12.06.12
0.7237 0.7237 0.7237 1.6527
1.4337 1.4337 1.4337 3.2740
3.5400
0.4166
6.0900
9.5800
19.1800
22.5880
44.4110
133.2967
7.5250
23.8000 23.8000
29.3125 29.3125
7 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$
$$$$
$
$
$
$
$
$
$
$
$
$$
$$
CEPHALOSPORINS
CEPHALOSPORINS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CHLORAMPHENICOL SODIUM SUCCINATE
ERYTHROMYCIN
ERYTHROMYCIN ESTOLATE
ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN STEARATE
1 G / VIAL (BASE) INJECTION
250 MG ORAL TABLET
250 MG ORAL CAPSULE (ENTERIC-COATED PELLET)
333 MG ORAL CAPSULE (ENTERIC-COATED PELLET)
50 MG / ML (BASE) ORAL SUSPENSION
600 MG (BASE) ORAL TABLET
40 MG / ML (BASE) ORAL SUSPENSION
80 MG / ML (BASE) ORAL SUSPENSION
250 MG ORAL TABLET
500 MG ORAL TABLET
00000312363
00000682020
0000072667200000607142
0000192593800000873454
00000262595
00000637416
00000605859
00000652318
00000545678
00000688568
CHLOROMYCETIN
ERYTHRO-BASE
ERYTHRO-ECERYC
ERYTHRO-ECERYC
NOVO-RYTHRO ESTOLATE
ERYTHRO-ES
NOVO-RYTHRO EES
NOVO-RYTHRO EES
ERYTHRO-S
ERYTHRO-S
ERF
AAP
AAPPFI
AAPPFI
TEV
AAP
TEV
TEV
AAP
AAP
(ERYTHROMYCINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
:00
:00
08:12.08
08:12.12.04
18.4123
0.1828
0.4193 0.4916
0.4657 0.5462
0.1270
0.3363
0.0967
0.1464
0.2118
0.5425
8 EFFECTIVE JULY 1, 2012
$
$
$$
$$
$
$
$
$
$
$
(CHLORAMPHENICOL)
MACROLIDES
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AZITHROMYCIN
CLARITHROMYCIN
250 MG ORAL TABLET
20 MG / ML ORAL SUSPENSION
40 MG / ML ORAL SUSPENSION
250 MG ORAL TABLET
500 MG ORAL TABLET
500 MG ORAL EXTENDED-RELEASE TABLET
25 MG / ML ORAL SUSPENSION
50 MG / ML ORAL SUSPENSION
000022474230000236336400002330881000022553400000227453100002278359000022678450000227858800002261634000022752870000226582600002212021
0000236337200002315157000022743880000233238800002223716
0000236338000002315165000022743960000233239600002223724
0000224885600002247573000022478180000226653900001984853
000023663980000224885700002247574000022478190000226654700002126710
00002244756
00002146908
00002244641
APO-AZITHROMYCINAVA-AZITHROMYCINAZITHROMYCINCO AZITHROMYCINGD-AZITHROMYCINMYLAN-AZITHROMYCINNOVO-AZITHROMYCINPHL-AZITHROMYCINPMS-AZITHROMYCINRATIO-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX
AVA-AZITHROMYCINNOVO-AZITHROMYCINPMS-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX
AVA-AZITHROMYCINNOVO-AZITHROMYCINPMS-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX
MYLAN-CLARITHROMYCINPMS-CLARITHROMYCINRATIO-CLARITHROMYCINSANDOZ CLARITHROMYCINBIAXIN BID
AVA-CLARITHROMYCINMYLAN-CLARITHROMYCINPMS-CLARITHROMYCINRATIO-CLARITHROMYCINSANDOZ CLARITHROMYCINBIAXIN BID
BIAXIN XL
BIAXIN
BIAXIN
APXAVASNSCOBGMDMYPTEVPHHPMSRPHSDZPFI
AVATEVPMSSDZPFI
AVATEVPMSSDZPFI
MYPPMSRPHSDZABB
AVAMYPPMSRPHSDZABB
ABB
ABB
ABB
(OTHER MACROLIDES)
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
08:00
08:12.12.92
1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 5.0290
0.4090 0.4090 0.4090 0.4090 1.0871
0.5796 0.5796 0.5796 0.5796 1.5404
0.5892 0.5892 0.5892 0.5892 1.6833
1.6293 1.6293 1.6293 1.6293 1.6293 3.3271
2.5144
0.2924
0.5674
9 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$
$$$$$
$$$$$
$$$$$
$$$$$$
$
$
$
MACROLIDES
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PENICILLIN G SODIUM
PENICILLIN V POTASSIUM
AMOXICILLIN TRIHYDRATE
1,000,000 IU / VIAL INJECTION
5,000,000 IU / VIAL INJECTION
10,000,000 IU / VIAL INJECTION
300 MG ORAL TABLET
25 MG / ML ORAL LIQUID
60 MG / ML ORAL LIQUID
125 MG (BASE) ORAL CHEWABLE TABLET
250 MG (BASE) ORAL CHEWABLE TABLET
250 MG (BASE) ORAL CAPSULE
500 MG (BASE) ORAL CAPSULE
25 MG / ML (BASE) ORAL SUSPENSION
00001930672
00000883751
00001930680
0000064221500000021202
00000642223
0000039160300000642231
00002036347
00002036355
0000235271000000628115000022381710000040672400002230243
0000235272900000628123000022381720000040671600002230244
000023527450000235276100000452149000019341710000062813100002230245
PENICILLIN G SODIUM
PENICILLIN G SODIUM
PENICILLIN G SODIUM
APO-PEN-VKNOVO-PEN-VK
APO-PEN-VK
NOVO-PEN-VKAPO-PEN-VK
NOVAMOXIN
NOVAMOXIN
AMOXICILLINAPO-AMOXIMYLAN-AMOXICILLINNOVAMOXINPMS-AMOXICILLIN
AMOXICILLINAPO-AMOXIMYLAN-AMOXICILLINNOVAMOXINPMS-AMOXICILLIN
AMOXICILLINAMOXICILLIN SUGAR-REDUCEDNOVAMOXINNOVAMOXIN SUGAR-REDUCEDAPO-AMOXIPMS-AMOXICILLIN
TEV
TEV
TEV
APXTEV
APX
TEVAPX
TEV
TEV
SNSAPXMYPTEVPMS
SNSAPXMYPTEVPMS
SNSSNSTEVTEVAPXPMS
(NATURAL PENICILLINS)
(AMINOPENICILLINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
:00
:00
08:12.16.04
08:12.16.08
2.9003
6.1617
10.7537
0.0710 0.0710
0.0535
0.0472 0.0618
0.4505
0.6519
0.1750 0.1750 0.1750 0.1750 0.1750
0.3417 0.3417 0.3417 0.3417 0.3417
0.0352 0.0352 0.0352 0.0352 0.0353 0.0353
10 EFFECTIVE JULY 1, 2012
$
$
$
$$
$
$$
$
$
$$$$$
$$$$$
$$$$$$
PENICILLINS
PENICILLINS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AMOXICILLIN TRIHYDRATE
AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM
AMPICILLIN SODIUM
50 MG / ML (BASE) ORAL SUSPENSION
250 MG (BASE) * 125 MG (BASE) ORAL TABLET
500 MG (BASE) * 125 MG (BASE) ORAL TABLET
875 MG (BASE) * 125 MG (BASE) ORAL TABLET
25 MG / ML (BASE) * 6.25 MG / ML (BASE) ORAL SUSPENSION
40 MG / ML (BASE) * 5.7 MG / ML (BASE) ORAL SUSPENSION
50 MG / ML (BASE) * 12.5 MG / ML (BASE) ORAL SUSPENSION
80 MG / ML (BASE) * 11.4 MG / ML (BASE) ORAL SUSPENSION
250 MG / VIAL (BASE) INJECTION
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
2 G / VIAL (BASE) INJECTION
000023527530000235278800000628158000004521300000193416300002230246
00002243350
000022437710000224335100001916858
00002245623000022481380000224702100002238829
000022439860000224464600001916882
00002238831
000022439870000224464700001916874
00002238830
00000872644
00000872652
00001933345
00001933353
AMOXICILLINAMOXICILLIN SUGAR-REDUCEDAPO-AMOXINOVAMOXINNOVAMOXIN SUGAR-REDUCEDPMS-AMOXICILLIN
APO-AMOXI CLAV
RATIO-ACLAVULANATEAPO-AMOXI CLAVCLAVULIN-500F
APO-AMOXI CLAVNOVO-CLAVAMOXINRATIO-ACLAVULANATECLAVULIN-875
APO-AMOXI CLAVRATIO-ACLAVULANATE 125FCLAVULIN-125F
CLAVULIN-200
APO-AMOXI CLAVRATIO-ACLAVULANATE 250FCLAVULIN-250F
CLAVULIN-400
AMPICILLIN SODIUM
AMPICILLIN SODIUM
AMPICILLIN SODIUM
AMPICILLIN SODIUM
SNSSNSAPXTEVTEVPMS
APX
RPHAPXGSK
APXTEVRPHGSK
APXRPHGSK
GSK
APXRPHGSK
GSK
TEV
TEV
TEV
TEV
(AMINOPENICILLINS)
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
08:00
08:12.16.08
0.0540 0.0540 0.0540 0.0540 0.0540 0.0540
0.9375
0.6673 0.8911 1.4800
0.8355 0.8355 0.8355 2.2205
0.0517 0.0517 0.1170
0.1440
0.0869 0.0869 0.2011
0.2753
2.8193
2.9568
4.9500
9.9000
11 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$
$
$$$
$$$$
$$$
$
$$$
$
$
$
$
$
PENICILLINS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CLOXACILLIN SODIUM
NORFLOXACIN
SULFAMETHOXAZOLE/ TRIMETHOPRIM
250 MG (BASE) ORAL CAPSULE
500 MG (BASE) ORAL CAPSULE
25 MG / ML (BASE) ORAL LIQUID
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
2 G / VIAL (BASE) INJECTION
400 MG ORAL TABLET
100 MG * 20 MG ORAL TABLET
400 MG * 80 MG ORAL TABLET
800 MG * 160 MG ORAL TABLET
40 MG / ML * 8 MG / ML ORAL SUSPENSION
80 MG / ML * 16 MG / ML INJECTION
00000337765
00000337773
00000337757
00001912429
00001975447
00001912410
000022295240000223768200002246596
00000445266
0000044527400000510637
0000044528200000510645
00000726540
00000550086
NOVO-CLOXIN
NOVO-CLOXIN
NOVO-CLOXIN
CLOXACILLIN SODIUM
CLOXACILLIN SODIUM
CLOXACILLIN SODIUM
APO-NORFLOXNOVO-NORFLOXACINPMS-NORFLOXACIN
APO-SULFATRIM
APO-SULFATRIMNOVO-TRIMEL
APO-SULFATRIM DSNOVO-TRIMEL DS
NOVO-TRIMEL
SEPTRA
TEV
TEV
TEV
TEV
TEV
TEV
APXTEVPMS
APX
APXTEV
APXTEV
TEV
TPI
(PENICILLINASE-RESISTANT PENICILLINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
08
:00
:00
:00
08:12.16.12
08:12.18
08:12.20
0.3515
0.6646
0.0898
5.5097
6.7724
8.8389
0.7628 0.7628 0.7628
0.0911
0.0482 0.0482
0.1221 0.1221
0.0954
1.3239
12 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$$$
$
$$
$$
$
$
PENICILLINS
(QUINOLONES)
(SULFONAMIDES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
SULFASALAZINE
DOXYCYCLINE HYCLATE
MINOCYCLINE HCL
TETRACYCLINE HCL
500 MG ORAL TABLET
500 MG ORAL ENTERIC-COATED TABLET
100 MG (BASE) ORAL TABLET
100 MG (BASE) ORAL CAPSULE
50 MG (BASE) ORAL CAPSULE
100 MG (BASE) ORAL CAPSULE
250 MG ORAL CAPSULE
0000059846100002064480
0000059848800002064472
000008742560000235124200002158574
00000740713000023512340000072525000000024368
000020840900000228722600002230735000021081430000229441900002237313
000020841040000228723400002230736000021081510000229442700002237314
00000580929
PMS-SULFASALAZINESALAZOPYRIN
PMS-SULFASALAZINESALAZOPYRIN EN-TABS
APO-DOXYDOXYCYCLINENOVO-DOXYLIN
APO-DOXYDOXYCYCLINENOVO-DOXYLINVIBRAMYCIN
APO-MINOCYCLINEMINOCYCLINEMYLAN-MINOCYCLINENOVO-MINOCYCLINEPMS-MINOCYCLINESANDOZ MINOCYCLINE
APO-MINOCYCLINEMINOCYCLINEMYLAN-MINOCYCLINENOVO-MINOCYCLINEPMS-MINOCYCLINESANDOZ MINOCYCLINE
TETRACYCLINE
PMSPFI
PMSPFI
APXSNSTEV
APXSNSTEVPFI
APXSNSMYPTEVPMSSDZ
APXSNSMYPTEVPMSSDZ
AAP
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
:00
:00
08:12.20
08:12.24
0.2221 0.2557
0.3382 0.4027
0.5860 0.5860 0.5860
0.5860 0.5860 0.5860 1.7304
0.3344 0.3344 0.3344 0.3344 0.3344 0.3344
0.6458 0.6458 0.6458 0.6458 0.6458 0.6458
0.0657
13 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$
$$$
$$$$
$$$$$$
$$$$$$
$
(SULFONAMIDES)
(TETRACYCLINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
VANCOMYCIN HCL
CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PHOSPHATE
COLISTIMETHATE SODIUM
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
150 MG (BASE) ORAL CAPSULE
300 MG (BASE) ORAL CAPSULE
15 MG / ML (BASE) ORAL SOLUTION
150 MG / ML (BASE) INJECTION
150 MG / VIAL INJECTION
0000224182000002342855
0000224182100002342863
0000224523200002364719000022583310000224170900000030570
0000224523300002364727000022583580000224171000002182866
00000225851
000022305400000223053500000260436
00002244849
PMS-VANCOMYCINVAL-VANCO
PMS-VANCOMYCINVAL-VANCO
APO-CLINDAMYCINAVA-CLINDAMYCINMYLAN-CLINDAMYCINTEVA-CLINDAMYCINDALACIN C
APO-CLINDAMYCINAVA-CLINDAMYCINMYLAN-CLINDAMYCINTEVA-CLINDAMYCINDALACIN C
DALACIN C PALMITATE
CLINDAMYCINCLINDAMYCIN (60 & 120 ML)DALACIN C PHOSPHATE
COLISTIMETHATE FOR INJECTION
PMSVLP
PMSVLP
APXAVAMYPTEVPFI
APXAVAMYPTEVPFI
PFI
SDZSDZPFI
STM
(GLYCOPEPTIDES)
(LINCOMYCINS)
(POLYMYXINS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
ANTIBACTERIALS
ANTIBACTERIALS
08
08
08
:00
:00
:00
08:12.28.16
08:12.28.20
08:12.28.28
31.0500 31.0500
58.9900 58.9900
0.3541 0.3541 0.3541 0.3541 0.9412
0.7082 0.7082 0.7082 0.7082 1.8823
0.1243
3.3250 3.3250 4.0994
32.9446
14 EFFECTIVE JULY 1, 2012
$$
$$
$$$$$
$$$$$
$
$$$
$
MISCELLANEOUS ANTIBACTERIALS
MISCELLANEOUS ANTIBACTERIALS
MISCELLANEOUS ANTIBACTERIALS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TERBINAFINE HCL
FLUCONAZOLE
ITRACONAZOLE
KETOCONAZOLE
250 MG (BASE) ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
2 MG / ML INJECTION
100 MG ORAL CAPSULE
200 MG ORAL TABLET
00002262177000022403460000223989300002320134000022547270000224250300002240807000022942730000235312100002031116
0000223737000002281260000022452920000223697800002245643
0000223737100002281279000022452930000223697900002245644
000022479220000224774900000891835
00002047454
0000223723500002231061
SANDOZ TERBINAFINENOVO-TERBINAFINEAPO-TERBINAFINEAURO-TERBINAFINECO TERBINAFINEMYLAN-TERBINAFINEPMS-TERBINAFINEPMS-TERBINAFINETERBINAFINELAMISIL
APO-FLUCONAZOLECO FLUCONAZOLEMYLAN-FLUCONAZOLENOVO-FLUCONAZOLEPMS-FLUCONAZOLE
APO-FLUCONAZOLECO FLUCONAZOLEMYLAN-FLUCONAZOLENOVO-FLUCONAZOLEPMS-FLUCONAZOLE
FLUCONAZOLEFLUCONAZOLE OMEGADIFLUCAN
SPORANOX
APO-KETOCONAZOLENOVO-KETOCONAZOLE
SDZTEVAPXAURCOBMYPPMSPMSSNSNOV
APXCOBMYPTEVPMS
APXCOBMYPTEVPMS
TEVOMGPFI
JAI
APXTEV
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIFUNGALS
ANTIFUNGALS
08
08
:00
:00
08:14.04
08:14.08
1.8525 1.8526 1.8527 1.8527 1.8527 1.8527 1.8527 1.8527 1.8527 4.1300
1.8241 1.8241 1.8241 1.8241 1.8241
3.2354 3.2354 3.2354 3.2354 3.2354
0.3187 0.3187 0.5014
4.1109
0.9393 0.9393
15 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$
$$$$$
$$$$$
$$$
$
$$
(ALLYLAMINES)
(AZOLES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
AMPHOTERICIN B
NYSTATIN
DAPSONE
LAMIVUDINE
TENOFOVIR DISOPROXIL FUMARATE
50 MG / VIAL INJECTION
500,000 UNIT ORAL TABLET
100,000 UNIT / ML ORAL SUSPENSION
100 MG ORAL TABLET
100 MG ORAL TABLET
300 MG (BASE) ORAL TABLET
00000029149
00002194198
0000079266700002194201
00002041510
00002239193
00002247128
FUNGIZONE IV
RATIO-NYSTATIN
PMS-NYSTATINRATIO-NYSTATIN
DAPSONE
HEPTOVIR
VIREAD
BMS
RPH
PMSRPH
NTI
GSK
GIL
(NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS)
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIFUNGALS
ANTIMYCOBACTERIALS
ANTIVIRALS
08
08
08
:00
:00
:00
08:14.28
08:16.92
08:18.08.20
72.4931
0.2594
0.0520 0.0520
1.3400
4.7088
17.8030
16 EFFECTIVE JULY 1, 2012
$
$
$$
$
$
$
RESTRICTED BENEFIT - This product is a benefit when initiated by a Specialist in Internal Medicine or a designated prescriber.
RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber.
(POLYENES)
(MISCELLANEOUS ANTIMYCOBACTERIALS)
ANTIRETROVIRALS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PEGINTERFERON ALFA-2A
ACYCLOVIR
ADEFOVIR DIPIVOXIL
ENTECAVIR
180 MCG / SYR INJECTION SYRINGE
200 MG ORAL TABLET
400 MG ORAL TABLET
800 MG ORAL TABLET
40 MG / ML ORAL SUSPENSION
10 MG ORAL TABLET
0.5 MG ORAL TABLET
00002248077
000022865560000220762100002242784000022859590000207862700000634506
000022865640000220764800002242463000022859670000207863500001911627
0000228657200002207656000022424640000228597500002078651
00000886157
00002247823
00002282224
PEGASYS (0.5 ML SYRINGE)
ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIRZOVIRAX
ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIRZOVIRAX
ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIR
ZOVIRAX
HEPSERA
BARACLUDE
HLR
SNSAPXMYPTEVRPHGSK
SNSAPXMYPTEVRPHGSK
SNSAPXMYPTEVRPH
GSK
GIL
BMS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIVIRALS
ANTIVIRALS
08
08
:00
:00
08:18.20
08:18.32
395.8400
0.6397 0.6397 0.6397 0.6397 0.6397 1.3063
1.2700 1.2700 1.2700 1.2700 1.2700 2.6320
1.7848 1.7848 1.7848 1.7848 1.7848
0.2557
23.2786
22.0000
17 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$$
$$$$$$
$$$$$
$
$
$
RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. (For eligibility for the treatment of chronic hepatitis C refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for Alberta Human Services and Alberta Seniors (AISH) clients.)
RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber.
RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber.
(INTERFERONS)
(NUCLEOSIDES AND NUCLEOTIDES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
GANCICLOVIR SODIUM
VALACYCLOVIR
IODOQUINOL
CHLOROQUINE PHOSPHATE
HYDROXYCHLOROQUINE SULFATE
PRIMAQUINE PHOSPHATE
PYRIMETHAMINE
500 MG / VIAL (BASE) INJECTION
500 MG ORAL TABLET
1,000 MG ORAL TABLET
210 MG ORAL TABLET
650 MG ORAL TABLET
250 MG ORAL TABLET
200 MG ORAL TABLET
15 MG (BASE) ORAL TABLET
25 MG ORAL TABLET
00002162695
0000229582200002331748000023515790000229845700002219492
00002354705
00001997769
00001997750
00000021261
000022466910000225260000002017709
00002017776
00000004774
CYTOVENE
APO-VALACYCLOVIR (CAPLET)CO VALACYCLOVIRMYLAN-VALACYCLOVIR (CAPLET)PMS-VALACYCLOVIR (CAPLET)VALTREX (CAPLET)
APO-VALACYCLOVIR (CAPLET)
DIODOQUIN
DIODOQUIN
NOVO-CHLOROQUINE
APO-HYDROXYQUINEMYLAN-HYDROXYCHLOROQUINEPLAQUENIL SULFATE
PRIMAQUINE PHOSPHATE
DARAPRIM
HLR
APXCOBMYPPMSGSK
APX
GLE
GLE
TEV
APXMYPSAV
SAV
COR
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIVIRALS
ANTIPROTOZOALS
ANTIPROTOZOALS
08
08
08
:00
:00
:00
08:18.32
08:30.04
08:30.08
42.0380
1.2765 1.2765 1.2765 1.2765 3.3927
3.0531
0.6488
0.8051
0.4020
0.2620 0.2620 0.6154
0.3988
1.3770
18 EFFECTIVE JULY 1, 2012
$
$$$$$
$
$
$
$
$$$
$
$
(NUCLEOSIDES AND NUCLEOTIDES)
(AMEBICIDES)
(ANTIMALARIALS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
QUININE SULFATE
ATOVAQUONE
METRONIDAZOLE
NITROFURANTOIN
TRIMETHOPRIM
200 MG ORAL CAPSULE
300 MG ORAL CAPSULE
150 MG / ML ORAL SUSPENSION
250 MG ORAL TABLET
5 MG / ML INJECTION
50 MG ORAL TABLET
100 MG ORAL TABLET
50 MG ORAL CAPSULE (MACROCRYSTALS)
100 MG ORAL CAPSULE (MACROCRYSTALS)
100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE)
100 MG ORAL TABLET
200 MG ORAL TABLET
0000225451400000021008
0000225452200000021016
00002217422
00000545066
00000649074
00000319511
00000312738
00002231015
00002231016
00002063662
00002243116
00002243117
APO-QUININENOVO-QUININE
APO-QUININENOVO-QUININE
MEPRON
METRONIDAZOLE
METRONIDAZOLE
NITROFURANTOIN
NITROFURANTOIN
NOVO-FURANTOIN
NOVO-FURANTOIN
MACROBID
TRIMETHOPRIM
TRIMETHOPRIM
APXTEV
APXTEV
GSK
AAP
HSP
AAP
AAP
TEV
TEV
WCC
AAP
AAP
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTI-INFECTIVE AGENTS
ANTIPROTOZOALS
ANTIPROTOZOALS
URINARY ANTI-INFECTIVES
08
08
08
:00
:00
:00
08:30.08
08:30.92
08:36
0.2390 0.2390
0.2888 0.3750
2.6162
0.0595
0.1739
0.1670
0.2227
0.3984
0.7638
0.7230
0.2566
0.5273
19 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$
$
$
$
$
$
$
$
$
$
$
(ANTIMALARIALS)
(MISCELLANEOUS ANTIPROTOZOALS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
10:00 Antineoplastic A
gents
10:00
Antineoplastic Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
METHOTREXATE
METHOTREXATE SODIUM
2.5 MG ORAL TABLET
10 MG ORAL TABLET
25 MG / ML (BASE) INJECTION
25 MG / ML (BASE) INJECTION
000021829630000217069800002244798
00002182750
0000209970500002182955
00002182777
APO-METHOTREXATEMETHOTREXATERATIO-METHOTREXATE SODIUM
METHOTREXATE
METHOTREXATE SOD.(UNPRESERVED)METHOTREXATE SOD.(UNPRESERVED)
METHOTREXATE SOD. (PRESERVED)
APXWAYRPH
HSP
TEVHSP
HSP
ANTINEOPLASTIC AGENTS10:00
10:00
0.6325 0.6325 0.6325
2.5018
4.3574 6.0100
8.3719
21 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$
$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
12:00 Autonom
ic Drugs
12:00
Autonomic Drugs
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
NEOSTIGMINE BROMIDE
PILOCARPINE HCL
PYRIDOSTIGMINE BROMIDE
ATROPINE SULFATE
BELLADONNA/ ERGOTAMINE TARTRATE/ PHENOBARBITAL
DICYCLOMINE HCL
GLYCOPYRROLATE
HYOSCINE BUTYLBROMIDE
15 MG ORAL TABLET
5 MG ORAL TABLET
60 MG ORAL TABLET
180 MG ORAL SUSTAINED-RELEASE TABLET
0.4 MG / ML INJECTION
0.6 MG / ML INJECTION
0.2 MG * 0.6 MG * 40 MG ORAL SUSTAINED-RELEASE TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
2 MG / ML ORAL SYRUP
10 MG / ML INJECTION
0.2 MG / ML INJECTION
10 MG ORAL TABLET
20 MG / ML INJECTION
00000869945
00002216345
00000869961
00000869953
00000392782
00000392693
00000176141
00002103087
00002103095
00002102978
00000392812
00002039508
00000363812
00000363839
PROSTIGMIN
SALAGEN
MESTINON
MESTINON-SR
ATROPINE SULFATE
ATROPINE SULFATE
BELLERGAL SPACETABS
BENTYLOL
BENTYLOL
BENTYLOL
DICYCLOMINE HYDROCHLORIDE
GLYCOPYRROLATE
BUSCOPAN
BUSCOPAN
VCL
PFI
VCL
VCL
SDZ
SDZ
TPI
AXC
AXC
AXC
SDZ
SDZ
BOE
BOE
AUTONOMIC DRUGS
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
ANTICHOLINERGIC AGENTS
12
12
:00
:00
12:04
12:08.08
0.4562
1.1150
0.4484
0.9807
1.7023
1.8512
1.2848
0.1169
0.2207
0.0626
3.3395
3.4419
0.3222
4.3860
23 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
(ANTIMUSCARINICS / ANTISPASMODICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE
TIOTROPIUM BROMIDE MONOHYDRATE
MIDODRINE HCL
BUDESONIDE/ FORMOTEROL FUMARATE DIHYDRATE
FORMOTEROL FUMARATE
20 MCG / DOSE METERED DOSE AEROSOL
250 MCG / ML INHALATION SOLUTION
0.03 % NASAL SPRAY
0.2 MG / ML * 1 MG / ML (BASE) INHALATION SOLUTION
18 MCG INHALATION CAPSULE
2.5 MG ORAL TABLET
5 MG ORAL TABLET
100 MCG / DOSE * 6 MCG / DOSE METERED INHALATION POWDER
200 MCG / DOSE * 6 MCG / DOSE METERED INHALATION POWDER
12 MCG INHALATION CAPSULE
00002247686
00002126222000022391310000221047900002231136
0000223962700002163705
000022726950000224378900002231675
00002246793
00002278677
00002278685
00002245385
00002245386
00002230898
ATROVENT HFA
APO-IPRAVENTMYLAN-IPRATROPIUMNOVO-IPRAMIDEPMS-IPRATROPIUM
PMS-IPRATROPIUMATROVENT
MYLAN-COMBO STERINEBSRATIO-IPRA SAL UDVCOMBIVENT UDV
SPIRIVA
MIDODRINE
MIDODRINE
SYMBICORT 100 TURBUHALER
SYMBICORT 200 TURBUHALER
FORADIL
BOE
APXMYPTEVPMS
PMSBOE
MYPRPHBOE
BOE
AAP
AAP
AZC
AZC
NOV
(SELECTIVE BETA 2-ADRENERGIC AGONISTS)
AUTONOMIC DRUGS
AUTONOMIC DRUGS
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
12
12
12
:00
:00
:00
12:08.08
12:12.04
12:12.08.12
0.0946
0.3456 0.3456 0.3456 0.3456
0.5561 0.9930
0.2936 0.2936 0.6030
2.1667
0.3378
0.5630
0.5208
0.6771
0.8181
24 EFFECTIVE JULY 1, 2012
$
$$$$
$$
$$$
$
$
$
$
$
$
(ANTIMUSCARINICS / ANTISPASMODICS)
(ALPHA-ADRENERGIC AGONISTS)
BETA-ADRENERGIC AGONISTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FORMOTEROL FUMARATE DIHYDRATE
ORCIPRENALINE SULFATE
SALBUTAMOL
SALBUTAMOL SULFATE
SALMETEROL XINAFOATE
SALMETEROL XINAFOATE/ FLUTICASONE PROPIONATE
6 MCG / DOSE METERED INHALATION POWDER
12 MCG / DOSE METERED INHALATION POWDER
2 MG / ML ORAL SYRUP
100 MCG / DOSE METERED DOSE AEROSOL
2 MG (BASE) ORAL TABLET
4 MG (BASE) ORAL TABLET
0.5 MG / ML (BASE) INHALATION SOLUTION
1 MG / ML (BASE) INHALATION SOLUTION
5 MG / ML (BASE) INHALATION SOLUTION
2 MG / ML (BASE) INHALATION UNIT DOSE SOLUTION
50 MCG / DOSE (BASE) METERED INHALATION POWDER
50 MCG / DOSE (BASE) INHALATION DISK
25 MCG / DOSE (BASE) * 125 MCG / DOSE METERED DOSE AEROSOL
25 MCG / DOSE (BASE) * 250 MCG / DOSE METERED DOSE AEROSOL
00002237225
00002237224
00002236783
000022325700000224566900002241497
00002146843
00002146851
0000220824500002239365
00001926934000022082290000198686400002213419
00002069571000008608080000215441200002213486
00002173360000022082370000223936600002213427
00002231129
00002214261
00002245126
00002245127
OXEZE TURBUHALER
OXEZE TURBUHALER
APO-ORCIPRENALINE
AIROMIR CFC-FREEAPO-SALVENT CFC FREEVENTOLIN HFA
APO-SALVENT
APO-SALVENT
PMS-SALBUTAMOLRATIO-SALBUTAMOL UNIT DOSE P.F
MYLAN-SALBUTAMOL STERINEBS P.F.PMS-SALBUTAMOLRATIO-SALBUTAMOL SULF U.D.P.F.VENTOLIN NEBULES P.F.
PMS-SALBUTAMOLRATIO-SALBUTAMOLSANDOZ SALBUTAMOLVENTOLIN
MYLAN-SALBUTAMOL STERINEBS P.F.PMS-SALBUTAMOL POLYNEBRATIO-SALBUTAMOL UNI DOSE P.F.VENTOLIN NEBULES P.F.
SEREVENT DISKUS
SEREVENT
ADVAIR 125
ADVAIR 250
AZC
AZC
APX
MEPAPXGSK
APX
APX
PMSRPH
MYPPMSRPHGSK
PMSRPHSDZGSK
MYPPMSRPHGSK
GSK
GSK
GSK
GSK
(SELECTIVE BETA 2-ADRENERGIC AGONISTS)
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
12:00
12:12.08.12
0.5540
0.7380
0.0574
0.0250 0.0325 0.0325
0.1274
0.2134
0.1074 0.1074
0.1555 0.1555 0.1555 0.4134
0.3774 0.3774 0.3774 1.0030
0.2954 0.2954 0.2954 0.7852
0.9350
3.7400
0.7999
1.1356
25 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$$$
$
$
$$
$$$$
$$$$
$$$$
$
$
$
$
BETA-ADRENERGIC AGONISTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SALMETEROL XINAFOATE/ FLUTICASONE PROPIONATE
TERBUTALINE SULFATE
EPINEPHRINE
EPINEPHRINE HCL
DIHYDROERGOTAMINE MESYLATE
ERGOLOID MESYLATES
ERGOTAMINE TARTRATE/ CAFFEINE
50 MCG / DOSE (BASE) * 100 MCG / DOSE METERED INHALATION POWDER
50 MCG / DOSE (BASE) * 250 MCG / DOSE METERED INHALATION POWDER
50 MCG / DOSE (BASE) * 500 MCG / DOSE METERED INHALATION POWDER
0.5 MG / DOSE METERED INHALATION POWDER
0.15 MG / SYR INJECTION SYRINGE
0.3 MG / SYR INJECTION SYRINGE
1 MG / ML INJECTION
4 MG / ML NASAL SPRAY
1 MG / ML INJECTION
1 MG ORAL TABLET
1 MG * 100 MG ORAL TABLET
00002240835
00002240836
00002240837
00000786616
0000226820500000578657
0000224731000000509558
00000155357
00002228947
0000224116300000027243
00000176176
00000176095
ADVAIR 100 DISKUS
ADVAIR 250 DISKUS
ADVAIR 500 DISKUS
BRICANYL TURBUHALER
TWINJECT AUTO INJECTOREPIPEN JR
TWINJECT AUTO INJECTOREPIPEN
ADRENALIN
MIGRANAL
DIHYDROERGOTAMINE MESYLATEDIHYDROERGOTAMINE (DHE)
HYDERGINE
CAFERGOT
GSK
GSK
GSK
AZC
PALKNG
PALKNG
ERF
STM
SDZSTM
STM
NOV
(SELECTIVE BETA 2-ADRENERGIC AGONISTS)
AUTONOMIC DRUGS
AUTONOMIC DRUGS
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS
12
12
12
:00
:00
:00
12:12.08.12
12:12.12
12:16
1.3365
1.5998
2.2712
0.0764
82.4580 82.6200
82.4580 82.6200
0.5626
10.2043
3.7933 3.8210
1.0029
0.8286
26 EFFECTIVE JULY 1, 2012
$
$
$
$
$$
$$
$
$
$$
$
$
BETA-ADRENERGIC AGONISTS
(ALPHA- AND BETA-ADRENERGIC AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CYCLOBENZAPRINE HCL
DANTROLENE SODIUM
BACLOFEN
10 MG ORAL TABLET
25 MG ORAL CAPSULE
100 MG ORAL CAPSULE
10 MG ORAL TABLET
20 MG ORAL TABLET
0.05 MG / ML INJECTION
0.5 MG / ML INJECTION
2 MG / ML INJECTION
0000217714500002287064000022313530000208005200002212048
00001997602
00001997653
0000213933200002371413000022870210000208839800002236963000020637350000223650700000455881
0000213939100002371421000022870480000208840100002236964000020637430000223650800000636576
00002131048
00002131056
00002131064
APO-CYCLOBENZAPRINECYCLOBENZAPRINEMYLAN-CYCLOBENZAPRINENOVO-CYCLOPRINEPMS-CYCLOBENZAPRINE
DANTRIUM
DANTRIUM
APO-BACLOFENAVA-BACLOFENBACLOFENMYLAN-BACLOFENPHL-BACLOFENPMS-BACLOFENRATIO-BACLOFENLIORESAL
APO-BACLOFENAVA-BACLOFENBACLOFENMYLAN-BACLOFENPHL-BACLOFENPMS-BACLOFENRATIO-BACLOFENLIORESAL D.S.
LIORESAL INTRATHECAL
LIORESAL INTRATHECAL
LIORESAL INTRATHECAL
APXSNSMYPTEVPMS
JHP
JHP
APXAVASNSMYPPHHPMSRPHNOV
APXAVASNSMYPPHHPMSRPHNOV
NOV
NOV
NOV
AUTONOMIC DRUGS
AUTONOMIC DRUGS
AUTONOMIC DRUGS
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
12
12
12
:00
:00
:00
12:20.04
12:20.08
12:20.12
0.3727 0.3727 0.3727 0.3727 0.3727
0.3780
0.7684
0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.6688
0.4898 0.4898 0.4898 0.4898 0.4898 0.4898 0.4898 1.3018
13.8277
10.3610
41.4444
27 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
$
$
$$$$$$$$
$$$$$$$$
$
$
$
RESTRICTED BENEFIT - Coverage is limited to 126 tablets per plan participant per year as anadjunct to rest and physical therapy for the treatment of acute muscle spasm.
(CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS)
(DIRECT-ACTING SKELETAL MUSCLE RELAXANTS)
(GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
VARENICLINE TARTRATE
VARENICLINE TARTRATE/ VARENICLINE TARTRATE
0.5 MG (BASE) ORAL TABLET
1 MG (BASE) ORAL TABLET
0.5 MG * 1 MG ORAL TABLET
00002291177
00002291185
00002298309
CHAMPIX
CHAMPIX
CHAMPIX (STARTER PACK)
PFI
PFI
PFI
AUTONOMIC DRUGS
MISCELLANEOUS AUTONOMIC DRUGS
12:00
12:92
1.7205
1.7206
1.7206
28 EFFECTIVE JULY 1, 2012
$
$
$
RESTRICTED BENEFIT - This product is a benefit in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Coverage will be granted for a total of 12 weeks."
RESTRICTED BENEFIT - This product is a benefit in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Coverage will be granted for a total of 12 weeks."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
20:00 Blood Form
ation, Coagulation and Throm
bosis
20:00
Blood Formation, Coagulation and Thrombosis
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
IRON DEXTRAN COMPLEX
ACENOCOUMAROL
WARFARIN SODIUM
50 MG / ML INJECTION
1 MG ORAL TABLET
4 MG ORAL TABLET
1 MG ORAL TABLET
2 MG ORAL TABLET
2.5 MG ORAL TABLET
3 MG ORAL TABLET
0000220596300002221780
00000010383
00000010391
000022429240000224446200002265273000022426800000234402500001918311
000022429250000224446300002265281000022426810000234403300001918338
000022429260000224446400002265303000022426820000234404100001918346
000022456180000228749800002265311000022426830000234406800002240205
DEXIRONINFUFER
SINTROM
SINTROM
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
LPISDZ
PAL
PAL
APXMYPTEVTARSNSBMS
APXMYPTEVTARSNSBMS
APXMYPTEVTARSNSBMS
APXMYPTEVTARSNSBMS
(COUMARIN DERIVATIVES)
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
ANTIANEMIA DRUGS
ANTITHROMBOTIC AGENTS
20
20
:00
:00
20:04.04
20:12.04.08
13.7500 13.7910
0.5087
1.5997
0.1147 0.1147 0.1147 0.1147 0.1147 0.3277
0.1213 0.1213 0.1213 0.1213 0.1213 0.3467
0.0971 0.0971 0.0971 0.0971 0.0971 0.2775
0.1504 0.1504 0.1504 0.1504 0.1504 0.4297
29 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$$$$$$
$$$$$$
$$$$$$
$$$$$$
(IRON PREPARATIONS)
ANTICOAGULANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
WARFARIN SODIUM
DALTEPARIN SODIUM
4 MG ORAL TABLET
5 MG ORAL TABLET
6 MG ORAL TABLET
7.5 MG ORAL TABLET
10 MG ORAL TABLET
10,000 IU / ML INJECTION
25,000 IU / ML INJECTION
2,500 IU / SYR INJECTION SYRINGE
5,000 IU / SYR INJECTION SYRINGE
7,500 IU / SYR INJECTION SYRINGE
10,000 IU / SYR INJECTION SYRINGE
12,500 IU / SYR INJECTION SYRINGE
15,000 IU / SYR INJECTION SYRINGE
000022429270000224446500002265338000022426840000234407600002007959
000022429280000224446600002265346000022426850000234408400001918354
00002242686
00002242697
0000224292900002244467000022426870000234411400001918362
00002132664
00002231171
00002132621
00002132648
00002352648
00002352656
00002352664
00002352672
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN
TARO-WARFARIN
TARO-WARFARIN
APO-WARFARINMYLAN-WARFARINTARO-WARFARINWARFARINCOUMADIN
FRAGMIN
FRAGMIN
FRAGMIN (0.2 ML SYRINGE)
FRAGMIN (0.2 ML SYRINGE)
FRAGMIN (0.3 ML SYRINGE)
FRAGMIN (0.4 ML SYRINGE)
FRAGMIN (0.5 ML SYRINGE)
FRAGMIN (0.6 ML SYRINGE)
APXMYPTEVTARSNSBMS
APXMYPTEVTARSNSBMS
TAR
TAR
APXMYPTARSNSBMS
PFI
PFI
PFI
PFI
PFI
PFI
PFI
PFI
(COUMARIN DERIVATIVES)
(HEPARINS)
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
ANTITHROMBOTIC AGENTS
ANTITHROMBOTIC AGENTS
20
20
:00
:00
20:12.04.08
20:12.04.16
0.1504 0.1504 0.1504 0.1504 0.1504 0.4297
0.0973 0.0973 0.0973 0.0973 0.0973 0.2780
0.2895
0.3111
0.1746 0.1746 0.1746 0.1746 0.4989
15.9291
39.8199
5.0440
10.0880
15.1320
20.1760
25.2200
30.2640
30 EFFECTIVE JULY 1, 2012
$$$$$$
$$$$$$
$
$
$$$$$
$
$
$
$
$
$
$
$
ANTICOAGULANTS
ANTICOAGULANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DALTEPARIN SODIUM
ENOXAPARIN SODIUM
HEPARIN SODIUM
NADROPARIN CALCIUM
TINZAPARIN SODIUM
18,000 IU / SYR INJECTION SYRINGE
100 MG / ML INJECTION
30 MG / SYR INJECTION SYRINGE
100 MG / ML INJECTION SYRINGE
150 MG / ML INJECTION SYRINGE
1,000 UNIT / ML INJECTION
10,000 UNIT / ML INJECTION
25,000 UNIT / ML INJECTION
100 UNIT / ML INJECTION LOCK FLUSH
9,500 IU / ML INJECTION SYRINGE
19,000 IU / ML INJECTION SYRINGE
10,000 IU / ML INJECTION
20,000 IU / ML INJECTION
2,500 IU / SYR INJECTION SYRINGE
3,500 IU / SYR INJECTION SYRINGE
4,500 IU / SYR INJECTION SYRINGE
10,000 IU / SYR INJECTION SYRINGE
14,000 IU / SYR INJECTION SYRINGE
00002352680
00002236564
00002012472
00002236883
00002242692
00000453811
00000579718
00000453781
00000727520
00002236913
00002240114
00002167840
00002229515
00002229755
00002358158
00002358166
00002231478
00002358174
FRAGMIN (0.72 ML SYRINGE)
LOVENOX
LOVENOX (0.3 ML SYRINGE)
LOVENOX (0.4 - 1 ML SYRINGE)
LOVENOX HP (0.8ML/1ML SYRINGE)
HEPARIN LEO
HEPARIN LEO
HEPARIN LEO
HEPARIN LEO
FRAXIPARINE (.3-1ML SYR)
FRAXIPARINE FORTE (.6-1ML SYR)
INNOHEP
INNOHEP
INNOHEP (0.25 ML SYRINGE)
INNOHEP (0.35 ML SYRINGE)
INNOHEP (0.45 ML SYRINGE)
INNOHEP (0.5 ML SYRINGE)
INNOHEP (0.7 ML SYRINGE)
PFI
SAV
SAV
SAV
SAV
LEO
LEO
LEO
LEO
GSK
GSK
LEO
LEO
LEO
LEO
LEO
LEO
LEO
(HEPARINS)
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
ANTITHROMBOTIC AGENTS
20:00
20:12.04.16
36.3160
20.9300
6.3200
20.9310
31.3960
0.5158
2.5671
8.2155
0.4387
9.1290
18.2580
16.7604
34.0445
16.9070
16.8950
16.9000
34.5058
34.5263
31 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
For this product - pricing has been established on a per millilitre basis.
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
ANTICOAGULANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TINZAPARIN SODIUM
FONDAPARINUX SODIUM
RIVAROXABAN
CLOPIDOGREL BISULFATE
18,000 IU / SYR INJECTION SYRINGE
2.5 MG / SYR INJECTION SYRINGE
7.5 MG / SYR INJECTION SYRINGE
10 MG ORAL TABLET
75 MG ORAL TABLET
00002358182
00002245531
00002258056
00002316986
00002252767000023030270000235153600002348004000023593160000229316100002238682
INNOHEP (0.9 ML SYRINGE)
ARIXTRA (0.5 ML SYRINGE)
ARIXTRA (0.6 ML SYRINGE)
XARELTO
APO-CLOPIDOGRELCO CLOPIDOGRELMYLAN-CLOPIDOGRELPMS-CLOPIDOGRELSANDOZ CLOPIDOGRELTEVA-CLOPIDOGRELPLAVIX
LEO
GSK
GSK
BAI
APXCOBMYPPMSSDZTEVSAV
(HEPARINS)
(MISCELLANEOUS ANTICOAGULANTS)
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
ANTITHROMBOTIC AGENTS
ANTITHROMBOTIC AGENTS
ANTITHROMBOTIC AGENTS
20
20
20
:00
:00
:00
20:12.04.16
20:12.04.92
20:12.18
34.5217
15.7561
25.5250
8.8598
0.9279 0.9279 0.9279 0.9279 0.9279 0.9279 2.6512
32 EFFECTIVE JULY 1, 2012
$
$
$
$
$$$$$$$
RESTRICTED BENEFIT - This product is a benefit for the prophylaxis of venous thromboembolic events in patients who have undergone elective total hip replacement or total knee replacement surgery. Coverage is restricted to two 14-day courses of therapy per patientper year.
LIMITED RESTRICTED BENEFIT - This product is a benefit for patients for the prevention of thrombosis, following intravascular stent placement, when prescribed by a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery. This benefit is limited to one month of coverage for the first stent placement only. (For eligibility for repeat stents, other indications, or continued coverage up to 12 months following intravascular drug eluting stent (DES) placement refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Employment and Immigration Drug Benefit Supplement for Alberta Employment and Immigration, Alberta Children and Youth Services and Alberta Seniors and Community Supports (AISH) clients.)
ANTICOAGULANTS
ANTICOAGULANTS
(PLATELET AGGREGATION INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIPYRIDAMOLE/ ASA
TICLOPIDINE HCL
PENTOXIFYLLINE
TRANEXAMIC ACID
200 MG * 25 MG ORAL CAPSULE
250 MG ORAL TABLET
400 MG ORAL SUSTAINED-RELEASE TABLET
500 MG ORAL TABLET
00002242119
000022377010000223684800002243587
0000223009000002221977
00002064405
AGGRENOX
APO-TICLOPIDINENOVO-TICLOPIDINESANDOZ TICLOPIDINE
APO-PENTOXIFYLLINE SRTRENTAL
CYKLOKAPRON
BOE
APXTEVSDZ
APXSAV
PFI
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
BLOOD FORMULATION, COAGULATION AND THROMBOSIS
ANTITHROMBOTIC AGENTS
HEMORRHEOLOGIC AGENTS
ANTIHEMORRHAGIC AGENTS
20
20
20
:00
:00
:00
20:12.18
20:24
20:28.16
0.8492
0.4303 0.4303 0.4303
0.5846 0.8097
1.1530
33 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$
$$
$
(PLATELET AGGREGATION INHIBITORS)
(HEMOSTATICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
24:00 Cardiovascular D
rugs
24:00
Cardiovascular Drugs
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DISOPYRAMIDE
PROCAINAMIDE HCL
MEXILETINE HCL
FLECAINIDE ACETATE
PROPAFENONE HCL
100 MG ORAL CAPSULE
150 MG ORAL CAPSULE
250 MG ORAL SUSTAINED-RELEASE TABLET
500 MG ORAL SUSTAINED-RELEASE TABLET
750 MG ORAL SUSTAINED-RELEASE TABLET
100 MG ORAL CAPSULE
200 MG ORAL CAPSULE
50 MG ORAL TABLET
100 MG ORAL TABLET
150 MG ORAL TABLET
300 MG ORAL TABLET
00002224801
00002224828
00000638692
00000638676
00000638684
00002230359
00002230360
0000227553800001966197
0000227554600001966200
0000224332400000603708
0000224332500000603716
RYTHMODAN
RYTHMODAN
PROCAN SR
PROCAN SR
PROCAN SR
NOVO-MEXILETINE
NOVO-MEXILETINE
FLECAINIDETAMBOCOR
FLECAINIDETAMBOCOR
APO-PROPAFENONERYTHMOL
APO-PROPAFENONERYTHMOL
SAV
SAV
ERF
ERF
ERF
TEV
TEV
AAPMEP
AAPMEP
APXABB
APXABB
(CLASS IA ANTIARRYTHMICS)
(CLASS IB ANTIARRYTHMICS)
(CLASS IC ANTIARRYTHMICS)
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
CARDIAC DRUGS
CARDIAC DRUGS
24
24
24
:00
:00
:00
24:04.04.04
24:04.04.08
24:04.04.12
0.2714
0.3924
0.3675
0.5065
0.8155
1.0203
1.3663
0.4253 0.5384
0.8505 1.0770
0.4275 1.1834
0.7537 2.0859
35 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$$
$$
$$
$$
ANTIARRHYTHMIC AGENTS
ANTIARRHYTHMIC AGENTS
ANTIARRHYTHMIC AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
AMIODARONE HCL
DIGOXIN
CHOLESTYRAMINE RESIN
COLESTIPOL HCL
100 MG ORAL TABLET
200 MG ORAL TABLET
0.0625 MG ORAL TABLET
0.125 MG ORAL TABLET
0.25 MG ORAL TABLET
0.05 MG / ML ORAL ELIXIR
0.05 MG / ML INJECTION
0.25 MG / ML INJECTION
4 G ORAL POWDER PACKET
1 G ORAL TABLET
5 G ORAL POWDER PACKET
00002292173
000023643360000224619400002364263000022406040000224247200002240071000022438360000223983500002036282
00002335700
00002335719
00002335727
00002242320
00002048272
00002048264
0000089096000002210320
00002132680
0000064297500002132699
PMS-AMIODARONE
AMIODARONEAPO-AMIODARONEAVA-AMIODARONEMYLAN-AMIODARONEPMS-AMIODARONERATIO-AMIODARONESANDOZ AMIODARONETEVA-AMIODARONECORDARONE
TOLOXIN
TOLOXIN
TOLOXIN
TOLOXIN PEDIATRIC
DIGOXIN PEDIATRIC
DIGOXIN
OLESTYR LIGHTOLESTYR REGULAR
COLESTID
COLESTIDCOLESTID ORANGE
PMS
SNSAPXAVAMYPPMSRPHSDZTEVWAY
PPH
PPH
PPH
PPH
SDZ
SDZ
MMTMMT
PFI
PFIPFI
(CLASS III ANTIARRYTHMICS)
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
CARDIAC DRUGS
ANTILIPEMIC AGENTS
24
24
24
:00
:00
:00
24:04.04.20
24:04.08
24:06.04
0.7269
0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 2.0589
0.2516
0.2516
0.2516
1.0411
7.2279
2.9116
1.4900 1.4900
0.2576
0.9211 0.9211
36 EFFECTIVE JULY 1, 2012
$
$$$$$$$$$
$
$
$
$
$
$
$$
$
$$
ANTIARRHYTHMIC AGENTS
(CARDIOTONIC AGENTS)
(BILE ACID SEQUESTRANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
BEZAFIBRATE
FENOFIBRATE
GEMFIBROZIL
400 MG ORAL SUSTAINED-RELEASE TABLET
100 MG ORAL TABLET
67 MG ORAL CAPSULE
100 MG ORAL CAPSULE
200 MG ORAL CAPSULE
160 MG ORAL CAPSULE/TABLET
600 MG ORAL TABLET
300 MG ORAL CAPSULE
00002083523
0000224685900002356570000022890830000228804400002241601
0000224318000002243551
00002225980
0000223986400002364409000022860920000224021000002243552000022735510000225003900002146959
0000224686000002356589000022890910000228805200002241602
00001979582000022304760000214207400002230183
00001979574000021854070000224170400002239951
BEZALIP
APO-FENO-SUPERFENOFIBRATE-SNOVO-FENOFIBRATE-SSANDOZ FENOFIBRATE SLIPIDIL SUPRA
APO-FENO-MICRONOVO-FENOFIBRATE MICRONIZED
APO-FENOFIBRATE
APO-FENO-MICROAVA-FENOFIBRATE MICROFENOFIBRATE MICROMYLAN-FENOFIBRATE MICRONOVO-FENOFIBRATE MICRONIZEDPMS-FENOFIBRATE MICRORATIO-FENOFIBRATE MCLIPIDIL MICRO
APO-FENO-SUPER (TABLET)FENOFIBRATE-S (TABLET)NOVO-FENOFIBRATE-S (TABLET)SANDOZ FENOFIBRATE S (TABLET)LIPIDIL SUPRA (TABLET)
APO-GEMFIBROZILMYLAN-GEMFIBROZILNOVO-GEMFIBROZILPMS-GEMFIBROZIL
APO-GEMFIBROZILMYLAN-GEMFIBROZILNOVO-GEMFIBROZILPMS-GEMFIBROZIL
ACV
APXSNSTEVSDZFAB
APXTEV
APX
APXAVASNSMYPTEVPMSRPHFAB
APXSNSTEVSDZFAB
APXMYPTEVPMS
APXMYPTEVPMS
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.06
1.8269
0.5407 0.5407 0.5407 0.5409 1.1130
0.4325 0.4325
0.6105
0.6806 0.6806 0.6806 0.6806 0.6806 0.6806 0.6806 1.0890
0.4488 0.4488 0.4488 0.4488 1.2823
0.5157 0.5157 0.5157 0.5157
0.1853 0.1853 0.1853 0.1853
37 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$
$$
$
$$$$$$$$
$$$$$
$$$$
$$$$
(FIBRIC ACID DERIVATIVES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ATORVASTATIN CALCIUM10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
40 MG (BASE) ORAL TABLET
80 MG (BASE) ORAL TABLET
0000229526100002348705000023108990000228834600002373203000023026750000231344800002313707000023502970000232494600002230711
0000229528800002348713000023109020000228835400002373211000023026830000231345600002313715000023503190000232495400002230713
0000229529600002348721000023109100000228836200002373238000023026910000231346400002313723000023503270000232496200002230714
0000229531800002348748000023109290000228837000002373246000023027130000231347200002313758000023503350000232497000002243097
APO-ATORVASTATINATORVASTATINCO ATORVASTATINGD-ATORVASTATINMYLAN-ATORVASTATINNOVO-ATORVASTATINPMS-ATORVASTATINRAN-ATORVASTATINRATIO-ATORVASTATINSANDOZ ATORVASTATINLIPITOR
APO-ATORVASTATINATORVASTATINCO ATORVASTATINGD-ATORVASTATINMYLAN-ATORVASTATINNOVO-ATORVASTATINPMS-ATORVASTATINRAN-ATORVASTATINRATIO-ATORVASTATINSANDOZ ATORVASTATINLIPITOR
APO-ATORVASTATINATORVASTATINCO ATORVASTATINGD-ATORVASTATINMYLAN-ATORVASTATINNOVO-ATORVASTATINPMS-ATORVASTATINRAN-ATORVASTATINRATIO-ATORVASTATINSANDOZ ATORVASTATINLIPITOR
APO-ATORVASTATINATORVASTATINCO ATORVASTATINGD-ATORVASTATINMYLAN-ATORVASTATINNOVO-ATORVASTATINPMS-ATORVASTATINRAN-ATORVASTATINRATIO-ATORVASTATINSANDOZ ATORVASTATINLIPITOR
APXSNSCOBGMDMYPTEVPMSRANRPHSDZPFI
APXSNSCOBGMDMYPTEVPMSRANRPHSDZPFI
APXSNSCOBGMDMYPTEVPMSRANRPHSDZPFI
APXSNSCOBGMDMYPTEVPMSRANRPHSDZPFI
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.08
0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 1.7431
0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 2.1788
0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 2.3420
0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 2.3421
38 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$
$$$$$$$$$$$
$$$$$$$$$$$
$$$$$$$$$$$
(HMG-COA REDUCTASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FLUVASTATIN SODIUM
LOVASTATIN
80 MG (BASE) ORAL EXTENDED-RELEASE TABLET
20 MG (BASE) ORAL CAPSULE
40 MG (BASE) ORAL CAPSULE
20 MG ORAL TABLET
40 MG ORAL TABLET
00002250527
00002061562
00002061570
00002220172000023642390000224857200002353229000022431270000224654200002246013000022458220000224705600000795860
00002220180000023642470000224857300002353237000022431290000224654300002246014000022458230000224705700000795852
LESCOL XL
LESCOL
LESCOL
APO-LOVASTATINAVA-LOVASTATINCO LOVASTATINLOVASTATINMYLAN-LOVASTATINNOVO-LOVASTATINPMS-LOVASTATINRATIO-LOVASTATINSANDOZ LOVASTATINMEVACOR
APO-LOVASTATINAVA-LOVASTATINCO LOVASTATINLOVASTATINMYLAN-LOVASTATINNOVO-LOVASTATINPMS-LOVASTATINRATIO-LOVASTATINSANDOZ LOVASTATINMEVACOR
NOV
NOV
NOV
APXAVACOBSNSMYPTEVPMSRPHSDZMFC
APXAVACOBSNSMYPTEVPMSRPHSDZMFC
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.08
1.4756
0.8732
1.2261
0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 2.0609
1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 3.7647
39 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$$$$$$$$$$
$$$$$$$$$$
(HMG-COA REDUCTASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PRAVASTATIN SODIUM10 MG ORAL TABLET
20 MG ORAL TABLET
40 MG ORAL TABLET
000022435060000224818200002330954000023174510000225709200002247008000022476550000233219100002356546000022844210000224785600000893749
000022435070000224818300002330962000023174780000225710600002247009000022476560000233220500002356554000022844480000224785700000893757
000022435080000224818400002330970000023174860000225711400002247010000022476570000233221300002356562000022844560000224785800002222051
APO-PRAVASTATINCO PRAVASTATINJAMP-PRAVASTATINMINT-PRAVASTATINMYLAN-PRAVASTATINNOVO-PRAVASTATINPMS-PRAVASTATINPRAVASTATINPRAVASTATINRAN-PRAVASTATINSANDOZ PRAVASTATINPRAVACHOL
APO-PRAVASTATINCO PRAVASTATINJAMP-PRAVASTATINMINT-PRAVASTATINMYLAN-PRAVASTATINNOVO-PRAVASTATINPMS-PRAVASTATINPRAVASTATINPRAVASTATINRAN-PRAVASTATINSANDOZ PRAVASTATINPRAVACHOL
APO-PRAVASTATINCO PRAVASTATINJAMP-PRAVASTATINMINT-PRAVASTATINMYLAN-PRAVASTATINNOVO-PRAVASTATINPMS-PRAVASTATINPRAVASTATINPRAVASTATINRAN-PRAVASTATINSANDOZ PRAVASTATINPRAVACHOL
APXCOBJPCMPIMYPTEVPMSRANSNSRANSDZBMS
APXCOBJPCMPIMYPTEVPMSRANSNSRANSDZBMS
APXCOBJPCMPIMYPTEVPMSRANSNSRANSDZBMS
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.08
0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.9530
0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 1.1243
0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 1.3543
40 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$
$$$$$$$$$$$$
$$$$$$$$$$$$
(HMG-COA REDUCTASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ROSUVASTATIN CALCIUM5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
40 MG (BASE) ORAL TABLET
0000233797500002339765000023812650000237852300002382644000023387260000235460800002265540
0000233798300002339773000023812730000237853100002382652000023387340000235461600002247162
0000233799100002339781000023812810000237855800002382660000023387420000235462400002247163
0000233800900002339803000023813030000237856600002382679000023387500000235463200002247164
APO-ROSUVASTATINCO ROSUVASTATINMYLAN-ROSUVASTATINPMS-ROSUVASTATINRAN-ROSUVASTATINSANDOZ ROSUVASTATINTEVA-ROSUVASTATINCRESTOR
APO-ROSUVASTATINCO ROSUVASTATINMYLAN-ROSUVASTATINPMS-ROSUVASTATINRAN-ROSUVASTATINSANDOZ ROSUVASTATINTEVA-ROSUVASTATINCRESTOR
APO-ROSUVASTATINCO ROSUVASTATINMYLAN-ROSUVASTATINPMS-ROSUVASTATINRAN-ROSUVASTATINSANDOZ ROSUVASTATINTEVA-ROSUVASTATINCRESTOR
APO-ROSUVASTATINCO ROSUVASTATINMYLAN-ROSUVASTATINPMS-ROSUVASTATINRAN-ROSUVASTATINSANDOZ ROSUVASTATINTEVA-ROSUVASTATINCRESTOR
APXCOBMYPPMSRANSDZTEVAZC
APXCOBMYPPMSRANSDZTEVAZC
APXCOBMYPPMSRANSDZTEVAZC
APXCOBMYPPMSRANSDZTEVAZC
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.08
0.4854 0.4854 0.4854 0.4854 0.4854 0.4854 0.4854 1.2900
0.5117 0.5117 0.5117 0.5117 0.5117 0.5117 0.5117 1.3600
0.6396 0.6396 0.6396 0.6396 0.6396 0.6396 0.6396 1.7000
0.7487 0.7487 0.7487 0.7487 0.7487 0.7487 0.7487 1.9900
41 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$
$$$$$$$$
$$$$$$$$
$$$$$$$$
(HMG-COA REDUCTASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SIMVASTATIN5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
0000224701100002248103000023310200000237503600002372932000022465820000228154600002269252000023291310000228472300002331969000023788840000225014400000884324
000022470120000224810400002331039000023750440000237294000002246583000022815540000226926000002329158000022478280000228473100002331985000023788920000225015200000884332
000022470130000224810500002331047000023750520000237295900002246737000022815620000226927900002329166000022478300000228475800002331993000023789060000225016000000884340
APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR
APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSANDOZ SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR
APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSANDOZ SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR
APXCOBJPCMARMPIMYPPHHPMSRANSNSRANODNTEVMFC
APXCOBJPCMARMPIMYPPHHPMSRANSDZSNSRANODNTEVMFC
APXCOBJPCMARMPIMYPPHHPMSRANSDZSNSRANODNTEVMFC
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
24:00
24:06.08
0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 1.0584
0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 2.0819
0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729
42 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$
(HMG-COA REDUCTASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
SIMVASTATIN
CLONIDINE HCL
METHYLDOPA
40 MG ORAL TABLET
80 MG ORAL TABLET
0.1 MG ORAL TABLET
0.2 MG ORAL TABLET
125 MG ORAL TABLET
250 MG ORAL TABLET
000022470140000224810600002331055000023750600000237296700002246584000022815700000226928700002329174000022478310000228476600002332000000023789140000225017900000884359
000022470150000224810700002331063000023750790000237297500002246585000022815890000226929500002329182000022478330000228477400002332019000023789220000225018700002240332
0000204612100000259527
0000204614800000291889
00000360252
00000360260
APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSANDOZ SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR
APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSANDOZ SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR
NOVO-CLONIDINECATAPRES
NOVO-CLONIDINECATAPRES
METHYLDOPA
METHYLDOPA
APXCOBJPCMARMPIMYPPHHPMSRANSDZSNSRANODNTEVMFC
APXCOBJPCMARMPIMYPPHHPMSRANSDZSNSRANODNTEVMFC
TEVBOE
TEVBOE
AAP
AAP
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
HYPOTENSIVE AGENTS
24
24
:00
:00
24:06.08
24:08.16
0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729
0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729
0.1765 0.1853
0.3149 0.3306
0.0989
0.1433
43 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$
$$
$$
$
$
(HMG-COA REDUCTASE INHIBITORS)
(CENTRAL ALPHA-AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
METHYLDOPA
DIAZOXIDE
HYDRALAZINE HCL
MINOXIDIL
ETHACRYNIC ACID
FUROSEMIDE
500 MG ORAL TABLET
100 MG ORAL CAPSULE
10 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
2.5 MG ORAL TABLET
10 MG ORAL TABLET
25 MG ORAL TABLET
20 MG ORAL TABLET
40 MG ORAL TABLET
00000426830
00000503347
00000441619
00000441627
00000441635
00000514497
00000514500
00002258528
0000039678800002364573000023514200000033773000002224690
0000036216600002364581000023514390000033774900002224704
METHYLDOPA
PROGLYCEM
APO-HYDRALAZINE
APO-HYDRALAZINE
APO-HYDRALAZINE
LONITEN
LONITEN
EDECRIN
APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDELASIX
APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDELASIX
AAP
MFC
APX
APX
APX
PFI
PFI
VCL
APXAVASNSTEVSAV
APXAVASNSTEVSAV
(LOOP DIURETICS)
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
HYPOTENSIVE AGENTS
HYPOTENSIVE AGENTS
24
24
24
:00
:00
:00
24:08.16
24:08.20
24:08.24.08
0.2537
1.6179
0.1347
0.2314
0.3633
0.3432
0.7565
3.3000
0.0373 0.0373 0.0373 0.0373 0.0873
0.0558 0.0558 0.0558 0.0558 0.1307
44 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$
$$$$$
$$$$$
(CENTRAL ALPHA-AGONISTS)
(DIRECT VASODILATORS)
DIURETICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FUROSEMIDE
OLMESARTAN MEDOXOMIL
OLMESARTAN MEDOXOMIL/ HYDROCHLOROTHIAZIDE
ISOSORBIDE DINITRATE
80 MG ORAL TABLET
500 MG ORAL TABLET
10 MG / ML ORAL SOLUTION
10 MG / ML INJECTION
20 MG ORAL TABLET
40 MG ORAL TABLET
20 MG * 12.5 MG ORAL TABLET
40 MG * 12.5 MG ORAL TABLET
40 MG * 25 MG ORAL TABLET
10 MG ORAL TABLET
30 MG ORAL TABLET
5 MG ORAL SUBLINGUAL TABLET
20 MG ORAL SUSTAINED-RELEASE TABLET
00000707570000023646030000235144700000765953
00002224755
00002224720
00000527033
00002318660
00002318679
00002319616
00002319624
00002319632
00000441686
00000441694
00000670944
00000740721
APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDE
LASIX SPECIAL
LASIX
FUROSEMIDE
OLMETEC
OLMETEC
OLMETEC PLUS
OLMETEC PLUS
OLMETEC PLUS
ISDN
ISDN
ISDN
CEDOCARD-SR
APXAVASNSTEV
SAV
SAV
SDZ
MFC
MFC
MFC
MFC
MFC
AAP
AAP
AAP
PAL
(LOOP DIURETICS)
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
HYPOTENSIVE AGENTS
VASODILATING AGENTS
24
24
24
:00
:00
:00
24:08.24.08
24:08.44.08
24:12.08
0.1220 0.1220 0.1220 0.1220
3.0150
0.2756
0.8047
1.0187
1.0187
1.0187
1.0187
1.0187
0.0365
0.0857
0.0621
0.4195
45 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$
$
$
$
$
$
$
$
$
$
$
$
$
DIURETICS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
(NITRATES AND NITRITES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ISOSORBIDE-5-MONONITRATE
NITROGLYCERIN
ALPROSTADIL
DIPYRIDAMOLE
60 MG ORAL EXTENDED-RELEASE TABLET
0.3 MG ORAL SUBLINGUAL TABLET
0.6 MG ORAL SUBLINGUAL TABLET
0.4 MG / DOSE SUBLINGUAL METERED DOSE SPRAY
2 % TOPICAL OINTMENT
0.2 MG/HR TRANSDERMAL PATCH
0.4 MG/HR TRANSDERMAL PATCH
0.6 MG/HR TRANSDERMAL PATCH
0.8 MG/HR TRANSDERMAL PATCH
500 MCG / ML INJECTION
25 MG ORAL TABLET
50 MG ORAL TABLET
75 MG ORAL TABLET
000022728300000230128800002126559
00000037613
00000037621
000022435880000223899800002231441
00001926454
00001911910000022307320000216280600000584223
00001911902000022307330000216352700000852384
00001911929000022307340000216353500002046156
00002011271
00000559253
00000895644
00000895652
00000895660
APO-ISMNPMS-ISMNIMDUR
NITROSTAT
NITROSTAT
MYLAN-NITRORHO-NITRO PUMPSPRAYNITROLINGUAL PUMPSPRAY
NITROL
NITRO-DUR 0.2TRINIPATCH 0.2MINITRAN 0.2TRANSDERM-NITRO 0.2
NITRO-DUR 0.4TRINIPATCH 0.4MINITRAN 0.4TRANSDERM-NITRO 0.4
NITRO-DUR 0.6TRINIPATCH 0.6MINITRAN 0.6TRANSDERM-NITRO 0.6
NITRO-DUR 0.8
PROSTIN VR
APO-DIPYRIDAMOLE (FC)
APO-DIPYRIDAMOLE (FC)
APO-DIPYRIDAMOLE (FC)
APXPMSAZC
PFI
PFI
MYPSDZSAV
PAL
MFCPALMEPNOV
MFCPALMEPNOV
MFCPALMEPNOV
MFC
PFI
APX
APX
APX
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
VASODILATING AGENTS
24
24
:00
:00
24:12.08
24:12.92
0.3523 0.3523 0.6850
0.1169
0.1169
0.0421 0.0421 0.0730
0.6390
0.5667 0.5780 0.5941 0.6616
0.6400 0.6528 0.6712 0.7474
0.6400 0.6528 0.6714 0.7474
1.1100
241.1150
0.2633
0.2932
0.4397
46 EFFECTIVE JULY 1, 2012
$$$
$
$
$$$
$
$$$$
$$$$
$$$$
$
$
$
$
$
(NITRATES AND NITRITES)
(MISCELLANEOUS VASODILATING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
NYLIDRIN HCL
SODIUM TETRADECYL SULFATE
DOXAZOSIN MESYLATE
PRAZOSIN HCL
6 MG ORAL TABLET
1 % INJECTION
1 MG (BASE) ORAL TABLET
2 MG (BASE) ORAL TABLET
4 MG (BASE) ORAL TABLET
1 MG (BASE) ORAL TABLET
2 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
00001926713
00000511234
0000224058800002240498000022427280000224452700001958100
0000224058900002240499000022427290000224452800001958097
0000224059000002240500000022427300000224452900001958119
0000088280100001934198
0000088282800001934201
0000088283600001934228
ARLIDIN
TROMBOJECT
APO-DOXAZOSINMYLAN-DOXAZOSINNOVO-DOXAZOSINPMS-DOXAZOSINCARDURA
APO-DOXAZOSINMYLAN-DOXAZOSINNOVO-DOXAZOSINPMS-DOXAZOSINCARDURA
APO-DOXAZOSINMYLAN-DOXAZOSINNOVO-DOXAZOSINPMS-DOXAZOSINCARDURA
APO-PRAZONOVO-PRAZIN
APO-PRAZONOVO-PRAZIN
APO-PRAZONOVO-PRAZIN
ERF
OMG
APXMYPTEVPMSPFI
APXMYPTEVPMSPFI
APXMYPTEVPMSPFI
APXTEV
APXTEV
APXTEV
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
SCLEROSING AGENTS
ALPHA-ADRENERGIC BLOCKING AGENTS
24
24
24
:00
:00
:00
24:12.92
24:16
24:20
0.4756
3.7500
0.2176 0.2176 0.2176 0.2176 0.5784
0.2610 0.2610 0.2610 0.2610 0.6938
0.3395 0.3395 0.3395 0.3395 0.9022
0.1371 0.1371
0.1862 0.1862
0.2560 0.2560
47 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$$$$$
$$$$$
$$$$$
$$
$$
$$
(MISCELLANEOUS VASODILATING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TAMSULOSIN HCL
TERAZOSIN HCL
0.4 MG ORAL EXTENDED-RELEASE TABLET
0.4 MG ORAL SUSTAINED-RELEASE CAPSULE
1 MG (BASE) ORAL TABLET
2 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
00002362406000023662310000234020800002368242
00002298570000022813920000229426500002295121
000022345020000224351800002218941000023504750000223080500000818658
000022345030000224351900002218968000023504830000223080600000818682
000022345040000224352000002218976000023504910000223080700000818666
000022345050000224352100002218984000023505050000223080800000818674
APO-TAMSULOSIN CRAVA-TAMSULOSIN CRSANDOZ TAMSULOSIN CRTEVA-TAMSULOSIN CR
MYLAN-TAMSULOSINNOVO-TAMSULOSINRATIO-TAMSULOSINSANDOZ TAMSULOSIN
APO-TERAZOSINPMS-TERAZOSINRATIO-TERAZOSINTERAZOSINTEVA-TERAZOSINHYTRIN
APO-TERAZOSINPMS-TERAZOSINRATIO-TERAZOSINTERAZOSINTEVA-TERAZOSINHYTRIN
APO-TERAZOSINPMS-TERAZOSINRATIO-TERAZOSINTERAZOSINTEVA-TERAZOSINHYTRIN
APO-TERAZOSINPMS-TERAZOSINRATIO-TERAZOSINTERAZOSINTEVA-TERAZOSINHYTRIN
APXAVASDZTEV
MYPTEVRPHSDZ
APXPMSRPHSNSTEVABB
APXPMSRPHSNSTEVABB
APXPMSRPHSNSTEVABB
APXPMSRPHSNSTEVABB
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
24:00
24:20
0.2100 0.2100 0.2100 0.2100
0.3415 0.3415 0.3415 0.3415
0.2563 0.2563 0.2563 0.2563 0.2563 0.7323
0.3258 0.3258 0.3258 0.3258 0.3258 0.9309
0.4425 0.4425 0.4425 0.4425 0.4425 1.2642
0.6477 0.6477 0.6477 0.6477 0.6477 1.8506
48 EFFECTIVE JULY 1, 2012
$$$$
$$$$
$$$$$$
$$$$$$
$$$$$$
$$$$$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ACEBUTOLOL HCL
ATENOLOL
100 MG (BASE) ORAL TABLET
200 MG (BASE) ORAL TABLET
400 MG (BASE) ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
0000228624600002147602000023637980000223772100002237885000022045170000191014000001926543
0000228625400002147610000023638010000223772200002237886000022045250000191015900001926551
0000228626200002147629000023638280000223772300002237887000022045330000191016700001926578
00002368013000023036470000224658100002266660
0000077368900002255545000023675640000237198700002368021000021468940000223831600002237600000022679850000217179100002231731000023686410000191206200002039532
ACEBUTOLOLAPO-ACEBUTOLOLAVA-ACEBUTOLOLMYLAN-ACEBUTOLOLMYLAN-ACEBUTOLOL (TYPE S)NOVO-ACEBUTOLOLRHOTRALSECTRAL
ACEBUTOLOLAPO-ACEBUTOLOLAVA-ACEBUTOLOLMYLAN-ACEBUTOLOLMYLAN-ACEBUTOLOL (TYPE S)NOVO-ACEBUTOLOLRHOTRALSECTRAL
ACEBUTOLOLAPO-ACEBUTOLOLAVA-ACEBUTOLOLMYLAN-ACEBUTOLOLMYLAN-ACEBUTOLOL (TYPE S)NOVO-ACEBUTOLOLRHOTRALSECTRAL
MINT-ATENOLMYLAN-ATENOLOLPMS-ATENOLOLTEVA-ATENOLOL
APO-ATENOLCO ATENOLOLJAMP-ATENOLOLMAR-ATENOLOLMINT-ATENOLMYLAN-ATENOLOLPHL-ATENOLOLPMS-ATENOLOLRAN-ATENOLOLRATIO-ATENOLOLSANDOZ ATENOLOLSEPTA-ATENOLOLTEVA-ATENOLTENORMIN
SNSAPXAVAMYPMYPTEVSDZSAV
SNSAPXAVAMYPMYPTEVSDZSAV
SNSAPXAVAMYPMYPTEVSDZSAV
MPIMYPPMSTEV
APXCOBJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVAZC
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.1298 0.1298 0.1298 0.1298 0.1298 0.1298 0.1298 0.3450
0.1947 0.1947 0.1947 0.1947 0.1947 0.1947 0.1947 0.5176
0.3875 0.3875 0.3875 0.3875 0.3875 0.3875 0.3875 1.0300
0.1081 0.1081 0.1081 0.1081
0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.5970
49 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$
$$$$$$$$
$$$$$$$$
$$$$
$$$$$$$$$$$$$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ATENOLOL
ATENOLOL/ CHLORTHALIDONE
BISOPROLOL FUMARATE
100 MG ORAL TABLET
50 MG * 25 MG ORAL TABLET
100 MG * 25 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
0000077369700002255553000023675720000237199500002368048000021474320000223831800002237601000022679930000217180500002231733000023686680000191205400002039540
000022487630000230291800002049961
000022487640000230292600002049988
00002256134000022674700000230263200002247439
0000225617700002363895000022674890000230264000002247440
APO-ATENOLCO ATENOLOLJAMP-ATENOLOLMAR-ATENOLOLMINT-ATENOLMYLAN-ATENOLOLPHL-ATENOLOLPMS-ATENOLOLRAN-ATENOLOLRATIO-ATENOLOLSANDOZ ATENOLOLSEPTA-ATENOLOLTEVA-ATENOLTENORMIN
APO-ATENIDONETEVA-ATENOLTHALIDONETENORETIC 50/25
APO-ATENIDONETEVA-ATENOLTHALIDONETENORETIC 100/25
APO-BISOPROLOLNOVO-BISOPROLOLPMS-BISOPROLOLSANDOZ BISOPROLOL
APO-BISOPROLOLAVA-BISOPROLOLNOVO-BISOPROLOLPMS-BISOPROLOLSANDOZ BISOPROLOL
APXCOBJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVAZC
APXTEVAZC
APXTEVAZC
APXTEVPMSSDZ
APXAVATEVPMSSDZ
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.9813
0.3195 0.3195 0.6640
0.5236 0.5236 1.0880
0.1378 0.1378 0.1378 0.1378
0.2284 0.2284 0.2284 0.2284 0.2284
50 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$$$
$$$
$$$
$$$$
$$$$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CARVEDILOL
LABETALOL HCL
3.125 MG ORAL TABLET
6.25 MG ORAL TABLET
12.5 MG ORAL TABLET
25 MG ORAL TABLET
100 MG ORAL TABLET
200 MG ORAL TABLET
5 MG / ML INJECTION
0000224793300002370735000023649130000234751200002248752000022459140000226802700002252309
0000224793400002370743000023649210000234752000002248753000022459150000226803500002252317
0000224793500002370751000023649480000234755500002248754000022459160000226804300002252325
00002247936000023707860000236495600002347571000022459170000226805100002252333
00002106272
00002106280
00002231689
APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPHL-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL
APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPHL-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL
APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPHL-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL
APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL
TRANDATE
TRANDATE
LABETALOL HYDROCHLORIDE
APXAVASNSMYPPHHPMSRANRPH
APXAVASNSMYPPHHPMSRANRPH
APXAVASNSMYPPHHPMSRANRPH
APXAVASNSMYPPMSRANRPH
PAL
PAL
SDZ
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728
0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728
0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728
0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728
0.2677
0.4733
1.2930
51 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$
$$$$$$$$
$$$$$$$$
$$$$$$$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
METOPROLOL TARTRATE
NADOLOL
25 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
100 MG ORAL SUSTAINED-RELEASE TABLET
200 MG (BASE) ORAL SUSTAINED-RELEASE TABLET
1 MG / ML (BASE) INJECTION
40 MG ORAL TABLET
80 MG ORAL TABLET
160 MG ORAL TABLET
00002246010000023568130000230205500002248855
000006186320000074935400002364824000023648400000235682100002350394000021745450000223080300002354187000008426480000064803500000397423
00000618640000007511700000236483200002364859000023568480000235040800002174553000022308040000224787600002354195000008426560000064804300000397431
000022851690000230339600000658855
000022851770000230341800000534560
00000590819
0000078250500002126753
0000078246700002126761
00000782475
APO-METOPROLOLJAMP-METOPROLOL-LMYLAN-METOPROLOLPMS-METOPROLOL-L
APO-METOPROLOLAPO-METOPROLOL (TYPE L)AVA-METOPROLOLAVA-METOPROLOL (TYPE L)JAMP-METOPROLOL-LMETOPROLOLMYLAN-METOPROLOL (TYPE L)PMS-METOPROLOL-LSANDOZ METOPROLOL (TYPE L)TEVA-METOPROLTEVA-METOPROL (FC)LOPRESOR
APO-METOPROLOLAPO-METOPROLOL (TYPE L)AVA-METOPROLOLAVA-METOPROLOL (TYPE L)JAMP-METOPROLOL-LMETOPROLOLMYLAN-METOPROLOL (TYPE L)PMS-METOPROLOL-LSANDOZ METOPROLOL (TYPE L)SANDOZ METOPROLOL (TYPE L)TEVA-METOPROLTEVA-METOPROL (FC)LOPRESOR
APO-METOPROLOL SRSANDOZ METOPROLOL SRLOPRESOR SR
APO-METOPROLOL SRSANDOZ METOPROLOL SRLOPRESOR SR
LOPRESOR
APO-NADOLNOVO-NADOLOL
APO-NADOLNOVO-NADOLOL
APO-NADOL
APXJPCMYPPMS
APXAPXAVAAVAJPCSNSMYPPMSSDZTEVTEVNOV
APXAPXAVAAVAJPCSNSMYPPMSSDZSDZTEVTEVNOV
APXSDZNOV
APXSDZNOV
NOV
APXTEV
APXTEV
APX
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.0643 0.0643 0.0643 0.0643
0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.2781
0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.5706
0.1312 0.1312 0.3116
0.2499 0.2499 0.5655
1.1953
0.2465 0.2465
0.3515 0.3515
1.2046
52 EFFECTIVE JULY 1, 2012
$$$$
$$$$$$$$$$$$
$$$$$$$$$$$$$
$$$
$$$
$
$$
$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PINDOLOL
PINDOLOL/ HYDROCHLOROTHIAZIDE
PROPRANOLOL HCL
5 MG ORAL TABLET
10 MG ORAL TABLET
15 MG ORAL TABLET
10 MG * 25 MG ORAL TABLET
10 MG * 50 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
40 MG ORAL TABLET
80 MG ORAL TABLET
120 MG ORAL TABLET
60 MG ORAL SUSTAINED-RELEASE CAPSULE
80 MG ORAL SUSTAINED-RELEASE CAPSULE
120 MG ORAL SUSTAINED-RELEASE CAPSULE
160 MG ORAL SUSTAINED-RELEASE CAPSULE
0000075587700000869007000022315360000226178200000417270
0000075588500000869015000022315370000226179000000443174
0000075589300000869023000022315390000226180400000417289
00000568627
00000568635
0000040278800000496480
0000066371900000740675
0000040275300000496499
0000040276100000496502
00000504335
00002042231
00002042258
00002042266
00002042274
APO-PINDOLNOVO-PINDOLPMS-PINDOLOLSANDOZ PINDOLOLVISKEN
APO-PINDOLNOVO-PINDOLPMS-PINDOLOLSANDOZ PINDOLOLVISKEN
APO-PINDOLNOVO-PINDOLPMS-PINDOLOLSANDOZ PINDOLOLVISKEN
VISKAZIDE 10/25
VISKAZIDE 10/50
APO-PROPRANOLOLNOVO-PRANOL
APO-PROPRANOLOLNOVO-PRANOL
APO-PROPRANOLOLNOVO-PRANOL
APO-PROPRANOLOLNOVO-PRANOL
APO-PROPRANOLOL
INDERAL-LA
INDERAL-LA
INDERAL-LA
INDERAL-LA
APXTEVPMSSDZNOV
APXTEVPMSSDZNOV
APXTEVPMSSDZNOV
NOV
NOV
APXTEV
APXTEV
APXTEV
APXTEV
APX
WAY
WAY
WAY
WAY
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.2147 0.2147 0.2147 0.2147 0.5706
0.3666 0.3666 0.3666 0.3666 0.9744
0.5318 0.5318 0.5318 0.5318 1.4135
0.8746
0.8746
0.0192 0.0192
0.0346 0.0346
0.0348 0.0348
0.0585 0.0585
0.3091
0.5562
0.6272
0.9656
1.1420
53 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
$$$$$
$$$$$
$
$
$$
$$
$$
$$
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SOTALOL HCL
TIMOLOL MALEATE
80 MG ORAL TABLET
160 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
0000221042800002363674000022706250000222977800002231181000022383260000208422800002257831
0000216779400002363682000022706330000222977900002231182000022383270000208423600002257858
0000075584200001947796
0000075585000001947818
0000075586900001947826
APO-SOTALOLAVA-SOTALOLCO SOTALOLMYLAN-SOTALOLNOVO-SOTALOLPMS-SOTALOLRATIO-SOTALOLSANDOZ SOTALOL
APO-SOTALOLAVA-SOTALOLCO SOTALOLMYLAN-SOTALOLNOVO-SOTALOLPMS-SOTALOLRATIO-SOTALOLSANDOZ SOTALOL
APO-TIMOLNOVO-TIMOL
APO-TIMOLNOVO-TIMOL
APO-TIMOLNOVO-TIMOL
APXAVACOBMYPTEVPMSRPHSDZ
APXAVACOBMYPTEVPMSRPHSDZ
APXTEV
APXTEV
APXTEV
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
24:00
24:24
0.3708 0.3708 0.3708 0.3708 0.3708 0.3708 0.3708 0.3708
0.4058 0.4058 0.4058 0.4058 0.4058 0.4058 0.4058 0.4058
0.1649 0.1649
0.2572 0.2572
0.5005 0.5005
54 EFFECTIVE JULY 1, 2012
$$$$$$$$
$$$$$$$$
$$
$$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AMLODIPINE BESYLATE
FELODIPINE
2.5 MG ORAL TABLET
5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
2.5 MG ORAL EXTENDED-RELEASE TABLET
5 MG ORAL EXTENDED-RELEASE TABLET
0000232676000002295148
000023312840000233193400002273373000022974850000228013200002331071000023571940000237171500002362651000022721130000232677900002284065000023218580000225960500002284383000023577120000225049700000878928
000023312920000233194200002273381000022974930000228014000002331098000023572080000237172300002362678000022721210000232678700002284073000023218660000225961300002284391000023577200000225050000000878936
0000222198500002057778
000022802640000222199300000851779
PHL-AMLODIPINEPMS-AMLODIPINE
AMLODIPINEAMLODIPINEAPO-AMLODIPINECO AMLODIPINEGD-AMLODIPINEJAMP-AMLODIPINEJAMP-AMLODIPINEMAR-AMLODIPINEMINT-AMLODIPINEMYLAN-AMLODIPINEPHL-AMLODIPINEPMS-AMLODIPINERAN-AMLODIPINERATIO-AMLODIPINESANDOZ AMLODIPINESEPTA-AMLODIPINETEVA-AMLODIPINENORVASC
AMLODIPINEAMLODIPINEAPO-AMLODIPINECO AMLODIPINEGD-AMLODIPINEJAMP-AMLODIPINEJAMP-AMLODIPINEMAR-AMLODIPINEMINT-AMLODIPINEMYLAN-AMLODIPINEPHL-AMLODIPINEPMS-AMLODIPINERAN-AMLODIPINERATIO-AMLODIPINESANDOZ AMLODIPINESEPTA-AMLODIPINETEVA-AMLODIPINENORVASC
RENEDILPLENDIL
SANDOZ FELODIPINERENEDILPLENDIL
PHHPMS
SNSRANAPXCOBGMDJPCJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVPFI
SNSRANAPXCOBGMDJPCJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVPFI
SAVAZC
SDZSAVAZC
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
24:00
24:28.08
0.2684 0.2684
0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 1.3426
0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 1.9930
0.3170 0.5090
0.4620 0.4633 0.6800
55 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$
$$
$$$
(DIHYDROPYRIDINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
FELODIPINE
NIFEDIPINE
DILTIAZEM HCL
10 MG ORAL EXTENDED-RELEASE TABLET
20 MG ORAL EXTENDED-RELEASE TABLET
30 MG ORAL EXTENDED-RELEASE TABLET
60 MG ORAL EXTENDED-RELEASE TABLET
5 MG ORAL CAPSULE
10 MG ORAL CAPSULE
30 MG ORAL TABLET
60 MG ORAL TABLET
120 MG ORAL EXTENDED-RELEASE TABLET
180 MG ORAL EXTENDED-RELEASE TABLET
240 MG ORAL EXTENDED-RELEASE TABLET
300 MG ORAL EXTENDED-RELEASE TABLET
360 MG ORAL EXTENDED-RELEASE TABLET
120 MG ORAL CONTROLLED-DELIVERY CAPSULE
000022220000000228027200000851787
00002237618
0000234916700002155907
0000232114900002155990
00000725110
00000755907
0000077137600000862924
0000077138400000862932
00002256738
00002256746
00002256754
00002256762
00002256770
00002230997000023706110000224253800002355752000022297810000224333800002097249
RENEDILSANDOZ FELODIPINEPLENDIL
ADALAT XL
MYLAN-NIFEDIPINE EXTENDED RELEASEADALAT XL
MYLAN-NIFEDIPINE EXTENDED RELEASEADALAT XL
NIFEDIPINE
NIFEDIPINE
APO-DILTIAZNOVO-DILTAZEM
APO-DILTIAZNOVO-DILTAZEM
TIAZAC XC
TIAZAC XC
TIAZAC XC
TIAZAC XC
TIAZAC XC
APO-DILTIAZ CDCO DILTIAZEM CDNOVO-DILTAZEM CDPMS-DILTIAZEM CDRATIO-DILTIAZEM CDSANDOZ DILTIAZEM CDCARDIZEM CD
SAVSDZAZC
BAI
MYPBAI
MYPBAI
AAP
AAP
APXTEV
APXTEV
VCL
VCL
VCL
VCL
VCL
APXCOBTEVPMSRPHSDZVCL
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS
24
24
:00
:00
24:28.08
24:28.92
0.6733 0.6733 1.0207
1.2487
0.6171 0.7177
0.9374 1.1285
0.3679
0.4877
0.1866 0.1866
0.3273 0.3273
0.8194
1.0887
1.4470
1.4441
1.4447
0.5157 0.5157 0.5157 0.5157 0.5157 0.5157 1.4734
56 EFFECTIVE JULY 1, 2012
$$$
$
$$
$$
$
$
$$
$$
$
$
$
$
$
$$$$$$$
(DIHYDROPYRIDINES)
(MISCELLANEOUS CALCIUM-CHANNEL BLOCKING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DILTIAZEM HCL180 MG ORAL CONTROLLED-DELIVERY CAPSULE
240 MG ORAL CONTROLLED-DELIVERY CAPSULE
300 MG ORAL CONTROLLED-DELIVERY CAPSULE
120 MG ORAL EXTENDED-RELEASE CAPSULE
180 MG ORAL EXTENDED-RELEASE CAPSULE
240 MG ORAL EXTENDED-RELEASE CAPSULE
300 MG ORAL EXTENDED-RELEASE CAPSULE
00002230998000023706380000224253900002355760000022297820000224333900002097257
00002230999000023706460000224254000002355779000022297830000224334000002097265
00002229526000023706540000224254100002355787000022297840000224334100002097273
0000229103700002370441000022716050000224591800002231150
0000229104500002370492000022716130000224591900002231151
0000229105300002370506000022716210000224592000002231152
0000229106100002370514000022716480000224592100002231154
APO-DILTIAZ CDCO DILTIAZEM CDNOVO-DILTAZEM CDPMS-DILTIAZEM CDRATIO-DILTIAZEM CDSANDOZ DILTIAZEM CDCARDIZEM CD
APO-DILTIAZ CDCO DILTIAZEM CDNOVO-DILTAZEM CDPMS-DILTIAZEM CDRATIO-DILTIAZEM CDSANDOZ DILTIAZEM CDCARDIZEM CD
APO-DILTIAZ CDCO DILTIAZEM CDNOVO-DILTAZEM CDPMS-DILTIAZEM CDRATIO-DILTIAZEM CDSANDOZ DILTIAZEM CDCARDIZEM CD
APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC
APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC
APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC
APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC
APXCOBTEVPMSRPHSDZVCL
APXCOBTEVPMSRPHSDZVCL
APXCOBTEVPMSRPHSDZVCL
APXCOBTEVSDZVCL
APXCOBTEVSDZVCL
APXCOBTEVSDZVCL
APXCOBTEVSDZVCL
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
24:00
24:28.92
0.6846 0.6846 0.6846 0.6846 0.6846 0.6846 1.9559
0.9080 0.9080 0.9080 0.9080 0.9080 0.9080 2.5944
1.1351 1.1351 1.1351 1.1351 1.1351 1.1351 3.2431
0.2987 0.2987 0.2987 0.2987 0.8533
0.4045 0.4045 0.4045 0.4045 1.1556
0.5365 0.5365 0.5365 0.5365 1.5328
0.6607 0.6607 0.6607 0.6607 1.8878
57 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$$
$$$$$
$$$$$
$$$$$
$$$$$
(MISCELLANEOUS CALCIUM-CHANNEL BLOCKING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DILTIAZEM HCL
VERAPAMIL HCL
BENAZEPRIL HCL
360 MG ORAL EXTENDED-RELEASE CAPSULE
80 MG ORAL TABLET
120 MG ORAL TABLET
120 MG ORAL SUSTAINED-RELEASE TABLET
180 MG ORAL SUSTAINED-RELEASE TABLET
240 MG ORAL SUSTAINED-RELEASE TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
0000229108800002370522000022716560000224592200002231155
0000078248300002237921
0000078249100002237922
000022468930000221034700001907123
000022468940000221035500001934317
0000224689500002210363000022119200000223779100000742554
0000229033200000885835
00002290340
0000227391800000885851
APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC
APO-VERAPMYLAN-VERAPAMIL
APO-VERAPMYLAN-VERAPAMIL
APO-VERAP SRMYLAN-VERAPAMIL SRISOPTIN SR
APO-VERAP SRMYLAN-VERAPAMIL SRISOPTIN SR
APO-VERAP SRMYLAN-VERAPAMIL SRNOVO-VERAMIL SRPMS-VERAPAMIL SRISOPTIN SR
BENAZEPRILLOTENSIN
BENAZEPRIL
BENAZEPRILLOTENSIN
APXCOBTEVSDZVCL
APXMYP
APXMYP
APXMYPABB
APXMYPABB
APXMYPTEVPMSABB
AAPNOV
AAP
AAPNOV
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24
24
:00
:00
24:28.92
24:32.04
0.8089 0.8089 0.8089 0.8089 2.3112
0.2735 0.2735
0.4250 0.4250
0.5078 0.5078 1.3448
0.5315 0.5315 1.5186
0.7088 0.7088 0.7088 0.7088 2.0252
0.5995 0.7795
0.6595
0.8135 1.0577
58 EFFECTIVE JULY 1, 2012
$$$$$
$$
$$
$$$
$$$
$$$$$
$$
$
$$
(MISCELLANEOUS CALCIUM-CHANNEL BLOCKING AGENTS)
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CAPTOPRIL
CILAZAPRIL
CILAZAPRIL/ HYDROCHLOROTHIAZIDE
12.5 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
1 MG ORAL TABLET
2.5 MG ORAL TABLET
5 MG ORAL TABLET
5 MG * 12.5 MG ORAL TABLET
000008935950000216355100001942964
000008936090000216357800001942972
000008936170000216358600001942980
000008936250000216359400001942999
0000229113400002283778000022804420000235096300002266350
00002291142000023509710000228521500002283786000022663690000228045000001911473
00002291150000023509980000228522300002283794000022663770000228046900001911481
000022849870000231373100002181479
APO-CAPTOMYLAN-CAPTOPRILNOVO-CAPTORIL
APO-CAPTOMYLAN-CAPTOPRILNOVO-CAPTORIL
APO-CAPTOMYLAN-CAPTOPRILNOVO-CAPTORIL
APO-CAPTOMYLAN-CAPTOPRILNOVO-CAPTORIL
APO-CILAZAPRILMYLAN-CILAZAPRILPMS-CILAZAPRILCILAZAPRILNOVO-CILAZAPRIL
APO-CILAZAPRILCILAZAPRILCO CILAZAPRILMYLAN-CILAZAPRILNOVO-CILAZAPRILPMS-CILAZAPRILINHIBACE
APO-CILAZAPRILCILAZAPRILCO CILAZAPRILMYLAN-CILAZAPRILNOVO-CILAZAPRILPMS-CILAZAPRILINHIBACE
APO-CILAZAPRIL/HCTZNOVO-CILAZAPRIL/HCTZINHIBACE PLUS
APXMYPTEV
APXMYPTEV
APXMYPTEV
APXMYPTEV
APXMYPPMSSNSTEV
APXSNSCOBMYPTEVPMSHLR
APXSNSCOBMYPTEVPMSHLR
APXTEVHLR
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
0.1325 0.1325 0.1325
0.1875 0.1875 0.1875
0.3494 0.3494 0.3494
0.6497 0.6497 0.6497
0.2492 0.2492 0.2492 0.2804 0.2804
0.2755 0.2755 0.2755 0.2755 0.2755 0.2755 0.7323
0.3201 0.3201 0.3201 0.3201 0.3201 0.3201 0.8508
0.4170 0.4170 0.8507
59 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$$$
$$$
$$$
$$$$$
$$$$$$$
$$$$$$$
$$$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ENALAPRIL MALEATE
ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE
2.5 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
5 MG * 12.5 MG ORAL TABLET
10 MG * 25 MG ORAL TABLET
000020200250000236345300002291878000023000360000230068000002300079000023522300000229993300000851795
000020198840000236346100002291886000023000440000223300500002300087000023522490000229994100000708879
000020198920000236348800002291894000023000520000223300600002300095000023522570000229996800000670901
000020199060000236349600002291908000023000600000223300700002300109000023522650000229997600000670928
0000230022200002352923
000023529310000230023000000657298
APO-ENALAPRILAVA-ENALAPRILCO ENALAPRILMYLAN-ENALAPRILNOVO-ENALAPRILPMS-ENALAPRILRAN-ENALAPRILSANDOZ ENALAPRILVASOTEC
APO-ENALAPRILAVA-ENALAPRILCO ENALAPRILMYLAN-ENALAPRILNOVO-ENALAPRILPMS-ENALAPRILRAN-ENALAPRILSANDOZ ENALAPRILVASOTEC
APO-ENALAPRILAVA-ENALAPRILCO ENALAPRILMYLAN-ENALAPRILNOVO-ENALAPRILPMS-ENALAPRILRAN-ENALAPRILSANDOZ ENALAPRILVASOTEC
APO-ENALAPRILAVA-ENALAPRILCO ENALAPRILMYLAN-ENALAPRILNOVO-ENALAPRILPMS-ENALAPRILRAN-ENALAPRILSANDOZ ENALAPRILVASOTEC
NOVO-ENALAPRIL/HCTZAPO-ENALAPRIL MALEATE/HCTZ
APO-ENALAPRIL MALEATE/HCTZNOVO-ENALAPRIL/HCTZVASERETIC
APXAVACOBMYPTEVPMSRANSDZMFC
APXAVACOBMYPTEVPMSRANSDZMFC
APXAVACOBMYPTEVPMSRANSDZMFC
APXAVACOBMYPTEVPMSRANSDZMFC
TEVAPX
APXTEVMFC
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.7803
0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.9231
0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 1.1092
0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 1.3385
0.4927 0.4941
0.6108 0.6108 1.1425
60 EFFECTIVE JULY 1, 2012
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
$$
$$$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FOSINOPRIL SODIUM
LISINOPRIL
10 MG ORAL TABLET
20 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
00002266008000023325660000233100400002262401000022945240000224780200001907107
00002266016000023325740000233101200002262428000022945320000224780300001907115
0000221748100002271443000023615310000233216700002274833000022851180000229220300002294230000022567970000229987900002289199000022850610000204933300000839388
0000221750300002271451000023615580000233217500002274841000022851260000229221100002294249000022568000000229988700002289202000022850880000204937600000839396
APO-FOSINOPRILFOSINOPRILJAMP-FOSINOPRILMYLAN-FOSINOPRILRAN-FOSINOPRILTEVA-FOSINOPRILMONOPRIL
APO-FOSINOPRILFOSINOPRILJAMP-FOSINOPRILMYLAN-FOSINOPRILRAN-FOSINOPRILTEVA-FOSINOPRILMONOPRIL
APO-LISINOPRILCO LISINOPRILJAMP-LISINOPRILLISINOPRILMYLAN-LISINOPRILNOVO-LISINOPRIL (TYPE Z)PMS-LISINOPRILRAN-LISINOPRILRATIO-LISINOPRIL PRATIO-LISINOPRIL ZSANDOZ LISINOPRILTEVA-LISINOPRIL (TYPE P)ZESTRILPRINIVIL
APO-LISINOPRILCO LISINOPRILJAMP-LISINOPRILLISINOPRILMYLAN-LISINOPRILNOVO-LISINOPRIL (TYPE Z)PMS-LISINOPRILRAN-LISINOPRILRATIO-LISINOPRIL PRATIO-LISINOPRIL ZSANDOZ LISINOPRILTEVA-LISINOPRIL (TYPE P)ZESTRILPRINIVIL
APXRANJPCMYPRANTEVBMS
APXRANJPCMYPRANTEVBMS
APXCOBJPCRANMYPTEVPMSRANRPHRPHSDZTEVAZCMFC
APXCOBJPCRANMYPTEVPMSRANRPHRPHSDZTEVAZCMFC
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
0.3194 0.3194 0.3194 0.3194 0.3194 0.3194 0.9125
0.3841 0.3841 0.3841 0.3841 0.3841 0.3841 1.0973
0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.5594 0.5983
0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.6723 0.7189
61 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$$$$$$$$$
$$$$$$$$$$$$$$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LISINOPRIL
LISINOPRIL/ HYDROCHLOROTHIAZIDE
PERINDOPRIL ERBUMINE
20 MG ORAL TABLET
10 MG * 12.5 MG ORAL TABLET
20 MG * 12.5 MG ORAL TABLET
20 MG * 25 MG ORAL TABLET
10 MG * 12.5 MG ORAL TABLET
20 MG * 12.5 MG ORAL TABLET
20 MG * 25 MG ORAL TABLET
2 MG ORAL TABLET
4 MG ORAL TABLET
0000221751100002271478000023615660000233218300002274868000022851340000229223800002294257000022568190000229989500002289229000022850960000204938400000839418
00002261979000023628800000236294500002297736000023023650000230176800002103729
00002261987000023628990000236295300002297744000023023730000230177600002045737
000023629020000236296100002297752000023023810000230178400002045729
00002302136
0000230214400000884413
00002302152
00002123274
00002123282
APO-LISINOPRILCO LISINOPRILJAMP-LISINOPRILLISINOPRILMYLAN-LISINOPRILNOVO-LISINOPRIL (TYPE Z)PMS-LISINOPRILRAN-LISINOPRILRATIO-LISINOPRIL PRATIO-LISINOPRIL ZSANDOZ LISINOPRILTEVA-LISINOPRIL (TYPE P)ZESTRILPRINIVIL
APO-LISINOPRIL/HCTZAVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC
APO-LISINOPRIL/HCTZAVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC
AVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC
NOVO-LISINOPRIL/HCTZ (TYPE P)
NOVO-LISINOPRIL/HCTZ (TYPE P)PRINZIDE
NOVO-LISINOPRIL/HCTZ (TYPE P)
COVERSYL
COVERSYL
APXCOBJPCRANMYPTEVPMSRANRPHRPHSDZTEVAZCMFC
APXAVASNSMYPSDZTEVAZC
APXAVASNSMYPSDZTEVAZC
AVASNSMYPSDZTEVAZC
TEV
TEVMFC
TEV
SEV
SEV
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.8078 0.8645
0.3256 0.3256 0.3256 0.3256 0.3256 0.3256 0.8654
0.3913 0.3913 0.3913 0.3913 0.3913 0.3913 1.0400
0.3913 0.3913 0.3913 0.3913 0.3913 1.0400
0.4076
0.3506 0.8904
0.6068
0.6526
0.8170
62 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$$$
$$$$$$$
$$$$$$$
$$$$$$
$
$$
$
$
$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PERINDOPRIL ERBUMINE
PERINDOPRIL ERBUMINE/ INDAPAMIDE HEMIHYDRATE
QUINAPRIL HCL
QUINAPRIL HCL/ HYDROCHLOROTHIAZIDE
RAMIPRIL
8 MG ORAL TABLET
4 MG * 1.25 MG ORAL TABLET
8 MG * 2.5 MG ORAL TABLET
5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
40 MG (BASE) ORAL TABLET
10 MG (BASE) * 12.5 MG ORAL TABLET
20 MG (BASE) * 12.5 MG ORAL TABLET
20 MG * 25 MG ORAL TABLET
1.25 MG ORAL CAPSULE/TABLET
2.5 MG ORAL CAPSULE/TABLET
00002246624
00002246569
00002321653
00001947664
00001947672
00001947680
00001947699
00002237367
00002237368
00002237369
00002251515000023632670000229548200002331101000023011480000229536900002332299000023105030000229139800002221829
000022515310000236327500002295490000023311280000230115600002247917000023323020000237484600002310511000022914010000224794500002221837
COVERSYL
COVERSYL PLUS
COVERSYL PLUS HD
ACCUPRIL
ACCUPRIL
ACCUPRIL
ACCUPRIL
ACCURETIC 10/12.5
ACCURETIC 20/12.5
ACCURETIC 20/25
APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)ALTACE (CAPSULE)
APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)TEVA-RAMIPRIL (CAPSULE)ALTACE (CAPSULE)
SEV
SEV
SEV
PFI
PFI
PFI
PFI
PFI
PFI
PFI
APXAVACOBJPCMYPPMSRANRANSDZSAV
APXAVACOBJPCMYPPMSRANSNSRANSDZTEVSAV
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
1.1436
0.9843
1.1436
0.8976
0.8976
0.8976
0.8976
0.8974
0.8974
0.8682
0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.7077
0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.8167
63 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$$$$$$$$$$
$$$$$$$$$$$$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RAMIPRIL
RAMIPRIL/ HYDROCHLOROTHIAZIDE
TRANDOLAPRIL
5 MG ORAL CAPSULE/TABLET
10 MG ORAL CAPSULE/TABLET
2.5 MG * 12.5 MG ORAL TABLET
5 MG * 12.5 MG ORAL TABLET
5 MG * 25 MG ORAL TABLET
10 MG * 12.5 MG ORAL TABLET
10 MG * 25 MG ORAL TABLET
0.5 MG ORAL CAPSULE
1 MG ORAL CAPSULE
2 MG ORAL CAPSULE
000022515740000236328300002295504000023311360000230116400002247918000023323100000237485400002310538000022914280000224794600002221845
000022515820000236329100002295512000023311440000230117200002247919000023323290000237486200002310546000022914360000224794700002221853
0000234213800002283131
0000234214600002283158
0000234216200002283174
0000234215400002283166
0000234217000002283182
00002231457
00002231459
00002231460
APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)TEVA-RAMIPRIL (CAPSULE)ALTACE (CAPSULE)
APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)TEVA-RAMIPRIL (CAPSULE)ALTACE (CAPSULE)
PMS-RAMIPRIL-HCTZALTACE HCT
PMS-RAMIPRIL-HCTZALTACE HCT
PMS-RAMIPRIL-HCTZALTACE HCT
PMS-RAMIPRIL-HCTZALTACE HCT
PMS-RAMIPRIL-HCTZALTACE HCT
MAVIK
MAVIK
MAVIK
APXAVACOBJPCMYPPMSRANSNSRANSDZTEVSAV
APXAVACOBJPCMYPPMSRANSNSRANSDZTEVSAV
PMSSAV
PMSSAV
PMSSAV
PMSSAV
PMSSAV
ABB
ABB
ABB
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.04
0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.8167
0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 1.0343
0.2250 0.2989
0.2263 0.3829
0.2263 0.3829
0.2865 0.4875
0.2865 0.4875
0.4030
0.6901
0.7931
64 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$
$$$$$$$$$$$$
$$
$$
$$
$$
$$
$
$
$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TRANDOLAPRIL
CANDESARTAN CILEXETIL
CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE
EPROSARTAN MESYLATE
EPROSARTAN MESYLATE/ HYDROCHLOROTHIAZIDE
4 MG ORAL CAPSULE
8 MG ORAL TABLET
16 MG ORAL TABLET
32 MG ORAL TABLET
16 MG * 12.5 MG ORAL TABLET
32 MG * 12.5 MG ORAL TABLET
32 MG * 25 MG ORAL TABLET
400 MG (BASE) ORAL TABLET
600 MG (BASE) ORAL TABLET
600 MG * 12.5 MG ORAL TABLET
00002239267
00002365359000023792790000237653900002379139000023269650000236631200002239091
00002365367000023792870000237654700002379147000023269730000236632000002239092
0000237929500002376555000023791550000236633900002311658
00002244021
00002332922
00002332957
00002240432
00002243942
00002253631
MAVIK
APO-CANDESARTANCANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANSANDOZ CANDESARTANTEVA-CANDESARTANATACAND
APO-CANDESARTANCANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANSANDOZ CANDESARTANTEVA-CANDESARTANATACAND
CANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANTEVA-CANDESARTANATACAND
ATACAND PLUS
ATACAND PLUS
ATACAND PLUS
TEVETEN
TEVETEN
TEVETEN PLUS
ABB
APXAHICOBMYPSDZTEVAZC
APXAHICOBMYPSDZTEVAZC
AHICOBMYPTEVAZC
AZC
AZC
AZC
ABB
ABB
ABB
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24
24
:00
:00
24:32.04
24:32.08
0.9785
0.4455 0.4455 0.4455 0.4455 0.4455 0.4455 1.1840
0.4455 0.4455 0.4455 0.4455 0.4455 0.4455 1.1840
0.4455 0.4455 0.4455 0.4455 1.1840
1.1700
1.1700
1.1700
0.7075
1.0836
1.0836
65 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$$$
$$$$$$$
$$$$$
$
$
$
$
$
$
(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
IRBESARTAN
IRBESARTAN/ HYDROCHLOROTHIAZIDE
75 MG ORAL TABLET
150 MG ORAL TABLET
300 MG ORAL TABLET
150 MG * 12.5 MG ORAL TABLET
300 MG * 12.5 MG ORAL TABLET
000023733190000232807000002372347000023472960000231706000002316390000023284610000231597100002237923
000023733270000232808900002372371000023473180000231707900002316404000023284880000231599800002237924
000023733350000232810000002372398000023473260000231708700002316412000023284960000231600500002237925
000023733430000235739900002372886000023285180000236320800002330512000023374280000231601300002241818
000023733510000235740200002372894000023285260000236321600002330520000023374360000231602100002241819
AVA-IRBESARTANCO IRBESARTANIRBESARTANMYLAN-IRBESARTANPMS-IRBESARTANRATIO-IRBESARTANSANDOZ IRBESARTANTEVA-IRBESARTANAVAPRO
AVA-IRBESARTANCO IRBESARTANIRBESARTANMYLAN-IRBESARTANPMS-IRBESARTANRATIO-IRBESARTANSANDOZ IRBESARTANTEVA-IRBESARTANAVAPRO
AVA-IRBESARTANCO IRBESARTANIRBESARTANMYLAN-IRBESARTANPMS-IRBESARTANRATIO-IRBESARTANSANDOZ IRBESARTANTEVA-IRBESARTANAVAPRO
AVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZPMS-IRBESARTAN-HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZAVALIDE 150/12.5
AVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZPMS-IRBESARTAN-HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZAVALIDE 300/12.5
AVACOBSNSMYPPMSRPHSDZTEVSAV
AVACOBSNSMYPPMSRPHSDZTEVSAV
AVACOBSNSMYPPMSRPHSDZTEVSAV
AVACOBSNSPMSRANRPHSDZTEVSAV
AVACOBSNSPMSRANRPHSDZTEVSAV
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.08
0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633
0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633
0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633
0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633
0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633
66 EFFECTIVE JULY 1, 2012
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
IRBESARTAN/ HYDROCHLOROTHIAZIDE
LOSARTAN POTASSIUM
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
300 MG * 25 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
50 MG * 12.5 MG ORAL TABLET
100 MG * 12.5 MG ORAL TABLET
0000232853400002373378000023574100000237290800002363224000023305390000233744400002316048
00002379058000023548290000236827700002309750000023133320000238083800002182815
00002353504000023548370000236828500002309769000023133400000235796800002182874
00002353512000023548450000236829300002309777000023133590000235797600002182882
0000237123500002378078000023133750000235826300002230047
0000237124300002378086000023624490000237714400002297841
PMS-IRBESARTAN-HCTZAVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZ
APO-LOSARTANCO LOSARTANMYLAN-LOSARTANPMS-LOSARTANSANDOZ LOSARTANTEVA-LOSARTANCOZAAR
APO-LOSARTANCO LOSARTANMYLAN-LOSARTANPMS-LOSARTANSANDOZ LOSARTANTEVA-LOSARTANCOZAAR
APO-LOSARTANCO LOSARTANMYLAN-LOSARTANPMS-LOSARTANSANDOZ LOSARTANTEVA-LOSARTANCOZAAR
APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCTTEVA-LOSARTAN/HCTZHYZAAR
APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCTTEVA-LOSARTAN/HCTZHYZAAR
PMSAVACOBSNSRANRPHSDZTEV
APXCOBMYPPMSSDZTEVMFC
APXCOBMYPPMSSDZTEVMFC
APXCOBMYPPMSSDZTEVMFC
APXMYPSDZTEVMFC
APXMYPSDZTEVMFC
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.08
0.4205 0.4206 0.4206 0.4206 0.4206 0.4206 0.4206 0.4206
0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590
0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590
0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590
0.4407 0.4407 0.4407 0.4407 1.2590
0.4314 0.4314 0.4314 0.4314 1.2327
67 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$
$$$$$$$
$$$$$$$
$$$$$$$
$$$$$
$$$$$
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
TELMISARTAN
TELMISARTAN/ AMLODIPINE BESYLATE
TELMISARTAN/ HYDROCHLOROTHIAZIDE
100 MG * 25 MG ORAL TABLET
40 MG ORAL TABLET
80 MG ORAL TABLET
40 MG * 5 MG ORAL TABLET
40 MG * 10 MG ORAL TABLET
80 MG * 5 MG ORAL TABLET
80 MG * 10 MG ORAL TABLET
80 MG * 12.5 MG ORAL TABLET
80 MG * 25 MG ORAL TABLET
0000237125100002378094000023133830000237715200002241007
00002376717000023759580000232017700002240769
00002376725000023759660000232018500002240770
00002371022
00002371030
00002371049
00002371057
000023735640000233028800002244344
000023735720000237925200002318709
APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCT DSTEVA-LOSARTAN/HCTZHYZAAR DS
MYLAN-TELMISARTANSANDOZ TELMISARTANTEVA-TELMISARTANMICARDIS
MYLAN-TELMISARTANSANDOZ TELMISARTANTEVA-TELMISARTANMICARDIS
TWYNSTA
TWYNSTA
TWYNSTA
TWYNSTA
MYLAN-TELMISARTAN HCTZTEVA-TELMISARTAN HCTZMICARDIS PLUS
MYLAN-TELMISARTAN HCTZTEVA-TELMISARTAN HCTZMICARDIS PLUS
APXMYPSDZTEVMFC
MYPSDZTEVBOE
MYPSDZTEVBOE
BOE
BOE
BOE
BOE
MYPTEVBOE
MYPTEVBOE
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.08
0.4407 0.4407 0.4407 0.4407 1.2590
0.4080 0.4080 0.4080 1.1657
0.4080 0.4080 0.4080 1.1657
0.6818
0.6818
0.6818
0.6818
0.4080 0.4080 1.1657
0.4080 0.4080 1.1657
68 EFFECTIVE JULY 1, 2012
$$$$$
$$$$
$$$$
$
$
$
$
$$$
$$$
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
VALSARTAN
VALSARTAN/ HYDROCHLOROTHIAZIDE
80 MG ORAL TABLET
160 MG ORAL TABLET
320 MG ORAL TABLET
80 MG * 12.5 MG ORAL TABLET
160 MG * 12.5 MG ORAL TABLET
160 MG * 25 MG ORAL TABLET
320 MG * 12.5 MG ORAL TABLET
00002371529000023671220000233749500002363100000023567590000235665100002244781
00002371537000023671300000233750900002363119000023567670000235667800002244782
000023715450000236714900002337517000023567750000235668600002289504
000023825470000236706800002373734000023566940000235699600002241900
000023825550000236707600002373742000023567080000235700300002241901
000023825630000236708400002373750000023567160000235701100002246955
000023825710000236709200002373769000023567240000235703800002308908
APO-VALSARTANAVA-VALSARTANCO VALSARTANRAN-VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN
APO-VALSARTANAVA-VALSARTANCO VALSARTANRAN-VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN
APO-VALSARTANAVA-VALSARTANCO VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN
APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT
APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT
APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT
APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT
APXAVACOBRANSDZTEVNOV
APXAVACOBRANSDZTEVNOV
APXAVACOBSDZTEVNOV
APXAVAMYPSDZTEVNOV
APXAVAMYPSDZTEVNOV
APXAVAMYPSDZTEVNOV
APXAVAMYPSDZTEVNOV
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24:00
24:32.08
0.4514 0.4514 0.4514 0.4514 0.4514 0.4514 1.1996
0.4512 0.4512 0.4512 0.4512 0.4512 0.4512 1.1993
0.4347 0.4347 0.4347 0.4347 0.4347 1.1554
0.4492 0.4492 0.4492 0.4492 0.4492 1.1939
0.4504 0.4504 0.4504 0.4504 0.4504 1.1971
0.4519 0.4519 0.4519 0.4519 0.4519 1.2011
0.4452 0.4452 0.4452 0.4452 0.4452 1.1832
69 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$
$$$$$$
$$$$$$
$$$$$$
$$$$$$
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
VALSARTAN/ HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE
SPIRONOLACTONE
320 MG * 25 MG ORAL TABLET
25 MG * 25 MG ORAL TABLET
50 MG * 50 MG ORAL TABLET
25 MG ORAL TABLET
100 MG ORAL TABLET
000023825980000236710600002373777000023567320000235704600002308916
0000061323100000180408
0000065718200000594377
0000061321500000028606
0000061322300000285455
APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT
NOVO-SPIROZINEALDACTAZIDE 25
NOVO-SPIROZINEALDACTAZIDE 50
NOVO-SPIROTONALDACTONE
NOVO-SPIROTONALDACTONE
APXAVAMYPSDZTEVNOV
TEVPFI
TEVPFI
TEVPFI
TEVPFI
CARDIOVASCULAR DRUGS
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
24
24
:00
:00
24:32.08
24:32.20
0.4452 0.4452 0.4452 0.4452 0.4452 1.1832
0.1216 0.1307
0.2571 0.2771
0.1194 0.1307
0.2780 0.3080
70 EFFECTIVE JULY 1, 2012
$$$$$$
$$
$$
$$
$$
(ANGIOTENSIN II RECEPTOR ANTAGONISTS)
(MINERALOCORTICOID (ALDOSTERONE) RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
28:00 Central N
ervous System A
gents
28:00
Central Nervous System Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
COMPOUND PRESCRIPTION
COMPOUND PRESCRIPTION
ASA
BUTALBITAL/ CAFFEINE/ ASA
TOPICAL
TOPICAL
TOPICAL
TOPICAL
650 MG ORAL ENTERIC-COATED TABLET
50 MG * 40 MG * 330 MG ORAL TABLET
50 MG * 40 MG * 330 MG ORAL CAPSULE
00000999105
00000999205
00000999102
00000999202
00000010340
00000608211
0000060823800000226327
COMPD- NSAID/ ANALG/MUSCLE RELAX (NOT DICLOFENAC)-TOPICAL
COMPD-NSAID/ ANALG/MUSCLE RELAX (NOT DICLOFENAC)-TOPICAL
COMPOUND-DICLOFENAC (TOPICAL)
COMPOUND- DICLOFENAC (TOPICAL)
ENTROPHEN 10
RATIO-TECNAL
RATIO-TECNALFIORINAL
XXX
XXX
XXX
XXX
PPH
RPH
RPHNOV
(SALICYLATES)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS
28
28
28
:00
:00
:00
28:08
28:08.04
28:08.04.24
0.0000
0.0000
0.0000
0.0000
0.0818
0.6265
1.0304 1.5175
71 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
(NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DICLOFENAC SODIUM
DICLOFENAC SODIUM/ MISOPROSTOL
75 MG ORAL SUSTAINED-RELEASE TABLET
100 MG ORAL SUSTAINED-RELEASE TABLET
25 MG ORAL ENTERIC-COATED TABLET
50 MG ORAL ENTERIC-COATED TABLET
50 MG RECTAL SUPPOSITORY
100 MG RECTAL SUPPOSITORY
50 MG * 200 MCG ORAL TABLET
75 MG * 200 MCG ORAL TABLET
00002162814000023666810000235240000002158582000022315040000226190100000782459
000020911940000236670300002048698000022315050000226194400000590827
0000083917500002366665000008085390000230261600002261952
00000839183000023666730000235239700000808547000023026240000226196000000514012
00002231506000022412240000226192800000632724
000022315080000226193600000632732
00001917056
00002229837
APO-DICLO SRAVA-DICLOFENAC SRDICLOFENAC SODIUM SRNOVO-DIFENAC SRPMS-DICLOFENAC-SRSANDOZ DICLOFENAC SRVOLTAREN SR
APO-DICLO SRAVA-DICLOFENAC SRNOVO-DIFENAC SRPMS-DICLOFENAC-SRSANDOZ DICLOFENAC SRVOLTAREN SR
APO-DICLOAVA-DICLOFENACNOVO-DIFENACPMS-DICLOFENACSANDOZ DICLOFENAC
APO-DICLOAVA-DICLOFENACDICLOFENAC SODIUMNOVO-DIFENACPMS-DICLOFENACSANDOZ DICLOFENACVOLTAREN
PMS-DICLOFENACSANDOZ DICLOFENACSANDOZ DICLOFENACVOLTAREN
PMS-DICLOFENACSANDOZ DICLOFENACVOLTAREN
ARTHROTEC-50
ARTHROTEC-75
APXAVASNSTEVPMSSDZNOV
APXAVATEVPMSSDZNOV
APXAVATEVPMSSDZ
APXAVASNSTEVPMSSDZNOV
PMSSDZSDZNOV
PMSSDZNOV
PFI
PFI
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.04.92
0.4491 0.4491 0.4491 0.4491 0.4491 0.4491 1.1937
0.6402 0.6402 0.6402 0.6402 0.6402 1.7016
0.1189 0.1189 0.1189 0.1189 0.1189
0.3257 0.3257 0.3257 0.3257 0.3257 0.3257 0.8656
0.4891 0.4891 0.4891 1.2999
0.6583 0.6583 1.7496
0.6053
0.8239
72 EFFECTIVE JULY 1, 2012
$ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567
$ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756
$ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378
MAC pricing has been applied based on the LCA Price for 3 x 25 mg oral enteric-coated tablets.
MAC pricing has been applied based on the LCA Price for 4 X 25 mg oral enteric-coated tablets.
MAC pricing has been applied based on the LCA Price for 2 x 25 mg oral enteric-coated tablets.
$$$$$$$
$$$$$$
$$$$$
$$$$$$$
$$$$
$$$
$
$
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIFLUNISAL
ETODOLAC
FLOCTAFENINE
FLURBIPROFEN
IBUPROFEN
INDOMETHACIN
250 MG ORAL TABLET
500 MG ORAL TABLET
200 MG ORAL CAPSULE
300 MG ORAL CAPSULE
200 MG ORAL TABLET
400 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
300 MG ORAL TABLET
400 MG ORAL TABLET
600 MG ORAL TABLET
25 MG ORAL CAPSULE
50 MG ORAL CAPSULE
50 MG RECTAL SUPPOSITORY
100 MG RECTAL SUPPOSITORY
0000204849300002039486
00002039494
00002232317
00002232318
00002244680
00002244681
0000191204600002100509
0000191203800002100517
00000441651
0000050605200000629340
0000058511400000629359
00000337420
00000337439
00002231799
0000193413900002231800
NOVO-DIFLUNISAL FCAPO-DIFLUNISAL
APO-DIFLUNISAL
ETODOLAC
ETODOLAC
FLOCTAFENINE
FLOCTAFENINE
APO-FLURBIPROFENNOVO-FLURPROFEN
APO-FLURBIPROFENNOVO-FLURPROFEN
APO-IBUPROFEN
APO-IBUPROFENNOVO-PROFEN
APO-IBUPROFENNOVO-PROFEN
NOVO-METHACIN
NOVO-METHACIN
SANDOZ INDOMETHACIN
RATIO-INDOMETHACINSANDOZ INDOMETHACIN
TEVAPX
APX
AAP
AAP
AAP
AAP
APXTEV
APXTEV
APX
APXTEV
APXTEV
TEV
TEV
SDZ
RPHSDZ
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.04.92
0.5366 0.5646
0.7150
0.7600
0.7600
0.4175
0.8123
0.2221 0.2221
0.3039 0.3039
0.1087
0.0474 0.0474
0.1313 0.1313
0.0871
0.1511
0.8225
0.8910 0.8910
73 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$
$
$
$$
$$
$
$$
$$
$
$
$
$$
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
KETOPROFEN
KETOROLAC TROMETHAMINE
MEFENAMIC ACID
NABUMETONE
NAPROXEN
200 MG ORAL SUSTAINED-RELEASE TABLET
50 MG ORAL ENTERIC-COATED TABLET
100 MG ORAL ENTERIC-COATED TABLET
50 MG ORAL CAPSULE
100 MG RECTAL SUPPOSITORY
10 MG ORAL TABLET
10 MG / ML INJECTION
30 MG / ML INJECTION
250 MG ORAL CAPSULE
500 MG ORAL TABLET
125 MG ORAL TABLET
250 MG ORAL TABLET
375 MG ORAL TABLET
500 MG ORAL TABLET
00002172577
00000790435
00000842664
00000790427
00002015951
000022290800000223020100002162660
00002162644
00002239944
00002229452
00002238639000022445630000234328200002240867
00000522678
000005226510000235075000000565350
00000600806000023658200000235076900000627097
00000592277000023658390000235077700000589861
KETOPROFEN SR
KETOPROFEN-E
KETOPROFEN-E
KETOPROFEN
PMS-KETOPROFEN
APO-KETOROLACNOVO-KETOROLACTORADOL
TORADOL
KETOROLAC TROMETHAMINE
MEFENAMIC
APO-NABUMETONEMYLAN-NABUMETONENABUMETONENOVO-NABUMETONE
APO-NAPROXEN
APO-NAPROXENNAPROXENTEVA-NAPROX
APO-NAPROXENAVA-NAPROXENNAPROXENTEVA-NAPROX
APO-NAPROXENAVA-NAPROXENNAPROXENTEVA-NAPROX
AAP
AAP
AAP
AAP
PMS
APXTEVHLR
HLR
SDZ
AAP
APXMYPSNSTEV
APX
APXSNSTEV
APXAVASNSTEV
APXAVASNSTEV
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.04.92
1.3890
0.3373
0.6823
0.3373
1.1453
0.4085 0.4085 0.6922
2.2380
4.0000
0.4988
0.3625 0.3625 0.3625 0.3625
0.0781
0.1068 0.1068 0.1068
0.1458 0.1458 0.1458 0.1458
0.2110 0.2110 0.2110 0.2110
74 EFFECTIVE JULY 1, 2012
$ 1.4670
MAC pricing has been applied based on the price for 2 x 100 mg oral enteric-coated tablets.
$
$
$
$
$
$$$
$
$
$
$$$$
$
$$$
$$$$
$$$$
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
NAPROXEN
NAPROXEN SODIUM
750 MG ORAL SUSTAINED-RELEASE TABLET
250 MG ORAL ENTERIC-COATED TABLET
375 MG ORAL ENTERIC-COATED TABLET
500 MG ORAL ENTERIC-COATED TABLET
25 MG / ML ORAL SUSPENSION
500 MG RECTAL SUPPOSITORY
275 MG ORAL TABLET
550 MG ORAL TABLET
00002162466
0000224669900002365847000023507850000224331200002162792
00002246700000023658550000224343200002350793000022947020000224331300002162415
00002246701000023658630000224102400002350807000022947100000224331400002162423
00002162431
00002017237
00000784354000023510130000077838900002162725
00001940309000023510210000202660000002162717
NAPROSYN SR
APO-NAPROXEN ECAVA-NAPROXEN ECNAPROXEN ECTEVA-NAPROX ECNAPROSYN E
APO-NAPROXEN ECAVA-NAPROXEN ECMYLAN-NAPROXEN ECNAPROXEN ECPMS-NAPROXEN ECTEVA-NAPROX ECNAPROSYN E
APO-NAPROXEN ECAVA-NAPROXEN ECMYLAN-NAPROXEN ECNAPROXEN ECPMS-NAPROXEN ECTEVA-NAPROX ECNAPROSYN E
NAPROSYN
PMS-NAPROXEN
APO-NAPRO-NANAPROXEN SODIUMTEVA-NAPROX SODIUMANAPROX
APO-NAPRO-NA DSNAPROXEN SODIUM DSTEVA-NAPROX SODIUM DSANAPROX DS
HLR
APXAVASNSTEVHLR
APXAVAMYPSNSPMSTEVHLR
APXAVAMYPSNSPMSTEVHLR
HLR
PMS
APXSNSTEVHLR
APXSNSTEVHLR
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.04.92
1.3211
0.1570 0.1570 0.1570 0.1570 0.4174
0.2062 0.2062 0.2062 0.2062 0.2062 0.2062 0.5479
0.3718 0.3718 0.3718 0.3718 0.3718 0.3718 0.9882
0.0626
0.8883
0.3422 0.3422 0.3422 0.6239
0.6667 0.6667 0.6667 1.2012
75 EFFECTIVE JULY 1, 2012
$ 0.2916
$ 0.1068 $ 0.1068 $ 0.1068 $ 0.1068 $ 0.1068
$ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458
$ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110
UNIT OF ISSUE - REFER TO PRICE POLICY
MAC pricing has been applied based on the LCA price for 2 x 375 mg oral tablets.
MAC pricing has been applied based on the LCA price for 1 x 250 mg oral tablet.
MAC pricing has been applied based on the LCA price for 1 x 375 mg oral tablet.
MAC pricing has been applied based on the LCA price for 1 x 500 mg oral tablet.
$
$$$$$
$$$$$$$
$$$$$$$
$
$
$$$$
$$$$
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PIROXICAM
SULINDAC
TENOXICAM
TIAPROFENIC ACID
ASA/ CODEINE PHOSPHATE/ CAFFEINE CITRATE
BUTALBITAL/ CODEINE PHOSPHATE/ ASA/ CAFFEINE
10 MG ORAL CAPSULE
20 MG ORAL CAPSULE
20 MG RECTAL SUPPOSITORY
150 MG ORAL TABLET
200 MG ORAL TABLET
20 MG ORAL TABLET
200 MG ORAL TABLET
300 MG ORAL TABLET
375 MG * 15 MG * 30 MG ORAL TABLET
50 MG * 15 MG * 330 MG * 40 MG ORAL CAPSULE
50 MG * 30 MG * 330 MG * 40 MG ORAL CAPSULE
0000064288600000695718
0000064289400000695696
00002154463
0000077835400000745588
0000077836200000745596
00002230661
0000213611200002179679
0000213612000002179687
00002234510
0000060820300000176192
0000060818100000176206
APO-PIROXICAMNOVO-PIROCAM
APO-PIROXICAMNOVO-PIROCAM
PMS-PIROXICAM
APO-SULINNOVO-SUNDAC
APO-SULINNOVO-SUNDAC
TENOXICAM
APO-TIAPROFENICNOVO-TIAPROFENIC
APO-TIAPROFENICNOVO-TIAPROFENIC
282
RATIO-TECNAL-C 1/4FIORINAL-C 1/4
RATIO-TECNAL-C 1/2FIORINAL-C 1/2
APXTEV
APXTEV
PMS
APXTEV
APXTEV
AAP
APXTEV
APXTEV
PPH
RPHNOV
RPHNOV
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS
28
28
:00
:00
28:08.04.92
28:08.08
0.3210 0.3210
0.5195 0.5195
2.0580
0.3824 0.3824
0.3920 0.3920
1.1552
0.3437 0.3437
0.3257 0.3257
0.0683
1.1051 1.6274
1.3532 1.9928
76 EFFECTIVE JULY 1, 2012
$$
$$
$
$$
$$
$
$$
$$
$
$$
$$
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CODEINE PHOSPHATE
CODEINE PHOSPHATE/ ACETAMINOPHEN
CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE
CODEINE PHOSPHATE/ ASA/ CAFFEINE CITRATE
CODEINE PHOSPHATE/ ASA/ MEPROBAMATE/ CAFFEINE CITRATE
COMPOUND PRESCRIPTION
15 MG ORAL TABLET
30 MG ORAL TABLET
30 MG / ML INJECTION
30 MG * 300 MG ORAL TABLET
60 MG * 300 MG ORAL TABLET
1.6 MG / ML * 32 MG / ML ORAL ELIXIR
15 MG * 300 MG * 15 MG ORAL TABLET
30 MG * 300 MG * 15 MG ORAL TABLET
30 MG * 375 MG * 30 MG ORAL TABLET
15 MG * 350 MG * 200 MG * 30 MG ORAL TABLET
00000593435
00000593451
00000544884
00000608882
0000062146300002163918
00002163942
0000065324100002163934
0000065327600002163926
00002238645
00002238646
00000999108
00000999208
RATIO-CODEINE
RATIO-CODEINE
CODEINE PHOSPHATE
RATIO-EMTEC-30
RATIO-LENOLTEC NO.4TYLENOL NO. 4
TYLENOL WITH CODEINE
RATIO-LENOLTEC NO.2TYLENOL NO. 2
RATIO-LENOLTEC NO.3TYLENOL NO. 3
292
282 MEP
COMPOUND NARCOTIC MIXTURES - ORAL AND INJECTION
COMPOUND NARCOTIC MIXTURES - ORAL AND INJECTION
RPH
RPH
SDZ
RPH
RPHJAI
JAI
RPHJAI
RPHJAI
PPH
PPH
XXX
XXX
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
0.0765
0.1284
1.3116
0.1616
0.1685 0.1877
0.1043
0.0807 0.0807
0.0798 0.0888
0.1766
0.2205
0.0000
0.0000
77 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$$
$
$$
$$
$
$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
HYDROMORPHONE HCL1 MG ORAL TABLET
2 MG ORAL TABLET
4 MG ORAL TABLET
8 MG ORAL TABLET
3 MG ORAL CONTROLLED-RELEASE CAPSULE
4.5 MG ORAL CONTROLLED-RELEASE CAPSULE
6 MG ORAL CONTROLLED-RELEASE CAPSULE
9 MG ORAL CONTROLLED-RELEASE CAPSULE
12 MG ORAL CONTROLLED-RELEASE CAPSULE
18 MG ORAL CONTROLLED-RELEASE CAPSULE
24 MG ORAL CONTROLLED-RELEASE CAPSULE
30 MG ORAL CONTROLLED-RELEASE CAPSULE
1 MG / ML ORAL LIQUID
2 MG / ML INJECTION
10 MG / ML INJECTION
20 MG / ML INJECTION
50 MG / ML INJECTION
00002364115000007054380000088544400002319403
00002319411000023641230000012508300000885436
00002364131000001251210000088540100002319438
00002364158000007865430000088542800002319446
00002125323
00002359502
00002125331
00002359510
00002125366
00002243562
00002125382
00002125390
0000191638600000786535
0000214590100000627100
0000214592800000622133
00002145936
00002146126
APO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONETEVA-HYDROMORPHONE
TEVA-HYDROMORPHONEAPO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONE
APO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONETEVA-HYDROMORPHONE
APO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONETEVA-HYDROMORPHONE
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
HYDROMORPH CONTIN
PMS-HYDROMORPHONEDILAUDID
HYDROMORPHONEDILAUDID
HYDROMORPHONE HPDILAUDID-HP
HYDROMORPHONE HP 20
HYDROMORPHONE HP 50
APXPURPMSTEV
TEVAPXPURPMS
APXPURPMSTEV
APXPURPMSTEV
PUR
PUR
PUR
PUR
PUR
PUR
PUR
PUR
PMSPUR
SDZPUR
SDZPUR
SDZ
SDZ
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
0.0959 0.0959 0.0959 0.0959
0.1416 0.1417 0.1417 0.1417
0.2240 0.2240 0.2240 0.2240
0.3528 0.3528 0.3528 0.3528
0.6745
0.8140
1.0115
1.3340
1.7530
2.5290
3.2365
3.8775
0.0665 0.0792
0.9450 1.1400
2.3380 2.7900
4.5100
13.1500
78 EFFECTIVE JULY 1, 2012
$$$$
$$$$
$$$$
$$$$
$
$
$
$
$
$
$
$
$$
$$
$$
$
$
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
HYDROMORPHONE HCL
MEPERIDINE HCL
METHADONE COMPOUND
METHADONE HCL
MORPHINE HCL
250 MG / VIAL INJECTION
3 MG RECTAL SUPPOSITORY
50 MG ORAL TABLET
50 MG / ML INJECTION
75 MG / ML INJECTION
100 MG / ML INJECTION
ORAL LIQUID
1 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
25 MG ORAL TABLET
1 MG / ML ORAL SOLUTION
10 MG / ML ORAL LIQUID
30 MG ORAL SUSTAINED-RELEASE TABLET
60 MG ORAL SUSTAINED-RELEASE TABLET
1 MG / ML ORAL SYRUP
5 MG / ML ORAL SYRUP
10 MG / ML ORAL SYRUP
20 MG / ML ORAL SYRUP
00002085895
00001916394
00002138018
00000725765
00000725757
00000725749
00000999995
00002247698
00002247699
00002247700
00002247701
00002247694
00002241377
00000776181
00000776203
00000607762
00000607770
00000690783
00000690791
DILAUDID STERILE POWDER
PMS-HYDROMORPHONE
DEMEROL
MEPERIDINE HYDROCHLORIDE
MEPERIDINE HYDROCHLORIDE
MEPERIDINE HYDROCHLORIDE
METHADONE
METADOL
METADOL
METADOL
METADOL
METADOL
METADOL CONCENTRATE
M.O.S.-SR
M.O.S.-SR
RATIO-MORPHINE
RATIO-MORPHINE
RATIO-MORPHINE
RATIO-MORPHINE
PUR
PMS
SAV
SDZ
SDZ
SDZ
XXX
PAL
PAL
PAL
PAL
PAL
PAL
VCL
VCL
RPH
RPH
RPH
RPH
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
70.1425
2.9640
0.1503
0.8930
0.9395
0.9953
0.0000
0.1689
0.5627
0.9003
1.6879
0.1017
0.3676
0.4614
0.8134
0.0151
0.0602
0.1931
0.5489
79 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
MORPHINE SULFATE5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
25 MG ORAL TABLET
30 MG ORAL TABLET
50 MG ORAL TABLET
15 MG ORAL SUSTAINED-RELEASE TABLET
30 MG ORAL SUSTAINED-RELEASE TABLET
60 MG ORAL SUSTAINED-RELEASE TABLET
100 MG ORAL SUSTAINED-RELEASE TABLET
200 MG ORAL SUSTAINED-RELEASE TABLET
10 MG ORAL EXTENDED-RELEASE CAPSULE
15 MG ORAL EXTENDED-RELEASE CAPSULE
30 MG ORAL EXTENDED-RELEASE CAPSULE
60 MG ORAL EXTENDED-RELEASE CAPSULE
100 MG ORAL EXTENDED-RELEASE CAPSULE
000005946520000200977300002014203
000005946440000200976500002014211
00002014238
0000059463600002009749
00002014254
0000067596200002009706
00002350815000023027640000224479000002015439
00002350890000023027720000224479100002014297
00002350912000023027800000224479200002014300
000023509200000230279900002014319
000023509470000230280200002014327
00002019930
00002177749
00002019949
00002019957
00002019965
STATEXM.O.S. SULFATEMS.IR
STATEXM.O.S. SULFATEMS.IR
MS.IR
STATEXM.O.S. SULFATE
MS.IR
STATEXM.O.S. SULFATE
MORPHINE SRNOVO-MORPHINE SRSANDOZ MORPHINE SRMS CONTIN
MORPHINE SRNOVO-MORPHINE SRSANDOZ MORPHINE SRMS CONTIN
MORPHINE SRNOVO-MORPHINE SRSANDOZ MORPHINE SRMS CONTIN
MORPHINE SRNOVO-MORPHINE SRMS CONTIN
MORPHINE SRNOVO-MORPHINE SRMS CONTIN
M-ESLON
M-ESLON
M-ESLON
M-ESLON
M-ESLON
PALVCLPUR
PALVCLPUR
PUR
PALVCL
PUR
PALVCL
SNSTEVSDZPUR
SNSTEVSDZPUR
SNSTEVSDZPUR
SNSTEVPUR
SNSTEVPUR
ETP
ETP
ETP
ETP
ETP
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
0.1100 0.1129 0.1240
0.1700 0.1745 0.1930
0.3440
0.2250 0.2309
0.4410
0.3450 0.3541
0.2559 0.2559 0.2559 0.6800
0.3872 0.3872 0.3872 1.0290
0.6822 0.6822 0.6822 1.8130
1.0400 1.0400 2.7640
1.9335 1.9335 5.1390
0.2984
0.3447
0.5145
0.9132
1.9654
80 EFFECTIVE JULY 1, 2012
$$$
$$$
$
$$
$
$$
$$$$
$$$$
$$$$
$$$
$$$
$
$
$
$
$
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
MORPHINE SULFATE
OPIUM/ BELLADONNA
200 MG ORAL EXTENDED-RELEASE CAPSULE
10 MG ORAL SUSTAINED-RELEASE CAPSULE
20 MG ORAL SUSTAINED-RELEASE CAPSULE
50 MG ORAL SUSTAINED-RELEASE CAPSULE
100 MG ORAL SUSTAINED-RELEASE CAPSULE
1 MG / ML ORAL SYRUP
5 MG / ML ORAL SYRUP
20 MG / ML ORAL DROPS
50 MG / ML ORAL DROPS
0.5 MG / ML INJECTION
1 MG / ML INJECTION
10 MG / ML INJECTION
15 MG / ML INJECTION
25 MG / ML INJECTION
50 MG / ML INJECTION
5 MG RECTAL SUPPOSITORY
10 MG RECTAL SUPPOSITORY
20 MG RECTAL SUPPOSITORY
30 MG RECTAL SUPPOSITORY
65 MG * 15 MG RECTAL SUPPOSITORY
00002177757
00002242163
00002184435
00002184443
00002184451
00000591467
00000591475
00000621935
00000705799
00002021056
00002021048
00000392588
00000392561
00000676411
00000617288
00000632228
00000632201
00000596965
00000639389
00001901869
M-ESLON
KADIAN
KADIAN
KADIAN
KADIAN
STATEX
STATEX
STATEX
STATEX
MORPHINE LP EPIDURAL
MORPHINE LP EPIDURAL
MORPHINE SULFATE
MORPHINE SULFATE
MORPHINE HP 25
MORPHINE HP 50
STATEX
STATEX
STATEX
STATEX
SANDOZ OPIUM & BELLADONNA
ETP
ABB
ABB
ABB
ABB
PAL
PAL
PAL
PAL
SDZ
SDZ
SDZ
SDZ
SDZ
SDZ
PAL
PAL
PAL
PAL
SDZ
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
3.9306
0.3680
0.7151
1.3145
2.2926
0.0200
0.0803
0.4980
0.9464
1.0623
2.1247
0.9209
0.9349
2.6884
3.7116
1.6690
1.8640
2.2190
2.4340
2.6791
81 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
OXYCODONE HCL
OXYCODONE HCL/ ACETAMINOPHEN
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
5 MG ORAL CONTROLLED-RELEASE TABLET
10 MG ORAL CONTROLLED-RELEASE TABLET
15 MG ORAL CONTROLLED-RELEASE TABLET
20 MG ORAL CONTROLLED-RELEASE TABLET
30 MG ORAL CONTROLLED-RELEASE TABLET
40 MG ORAL CONTROLLED-RELEASE TABLET
60 MG ORAL CONTROLLED-RELEASE TABLET
80 MG ORAL CONTROLLED-RELEASE TABLET
10 MG RECTAL SUPPOSITORY
20 MG RECTAL SUPPOSITORY
2.5 MG * 325 MG ORAL TABLET
5 MG * 325 MG ORAL TABLET
0000231997700000789739
000023199850000044394800002240131
000023199930000226298300002240132
00002258129
0000220244100002372525
0000232319200002372533
0000237279700002202468
0000232320600002372541
0000237256800002202476
0000232321400002372576
0000237258400002202484
00000392480
00000392472
00001916491
000023246280000191654800002361361000006081650000230789800001916475
PMS-OXYCODONESUPEUDOL
PMS-OXYCODONESUPEUDOLOXY-IR
PMS-OXYCODONESUPEUDOLOXY-IR
OXYCONTIN
OXYCONTINOXYNEO
OXYCONTINOXYNEO
OXYNEOOXYCONTIN
OXYCONTINOXYNEO
OXYNEOOXYCONTIN
OXYCONTINOXYNEO
OXYNEOOXYCONTIN
SUPEUDOL
SUPEUDOL
PERCOCET DEMI
APO-OXYCODONEENDOCETOXYCODONE/ACETRATIO-OXYCOCETSANDOZ-OXYCODONE ACETPERCOCET
PMSSDZ
PMSSDZPUR
PMSSDZPUR
PUR
PURPUR
PURPUR
PURPUR
PURPUR
PURPUR
PURPUR
PURPUR
SDZ
SDZ
BMS
APXBMSSNSRPHSDZBMS
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:00
28:08.08
0.1287 0.1332
0.1896 0.2283 0.3860
0.2964 0.3965 0.6710
0.6300
0.8780 0.8780
1.0600 1.0600
1.3170 1.3190
1.7400 1.7400
2.2825 2.2900
3.1500 3.1500
4.2160 4.2300
2.1034
2.6698
0.6299
0.1285 0.1285 0.1285 0.1285 0.1285 0.7706
82 EFFECTIVE JULY 1, 2012
$$
$$$
$$$
$
$$
$$
$$
$$
$$
$$
$$
$
$
$
$$$$$$
(OPIATE AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
OXYCODONE HCL/ ASA
BUPRENORPHINE HCL/ NALOXONE HYDROCHLORIDE DIHYDRATE
PENTAZOCINE HCL
PENTAZOCINE LACTATE
PRIMIDONE
CLOBAZAM
5 MG * 325 MG ORAL TABLET
2 MG (BASE) * 0.5 MG (BASE) ORAL SUBLINGUAL TABLET
8 MG (BASE) * 2 MG (BASE) ORAL SUBLINGUAL TABLET
50 MG (BASE) ORAL TABLET
30 MG / ML INJECTION
125 MG ORAL TABLET
250 MG ORAL TABLET
10 MG ORAL TABLET
00000608157
00002295695
00002295709
00002137984
00002241976
00000399310
00000396761
000022446380000223833400002244474
RATIO-OXYCODAN
SUBOXONE
SUBOXONE
TALWIN
TALWIN
PRIMIDONE
PRIMIDONE
APO-CLOBAZAMNOVO-CLOBAZAMPMS-CLOBAZAM
RPH
RBC
RBC
SAV
HSP
AAP
AAP
APXTEVPMS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS
ANTICONVULSANTS
ANTICONVULSANTS
28
28
28
28
:00
:00
:00
:00
28:08.08
28:08.12
28:12.04
28:12.08
0.3879
2.6700
4.7300
0.4337
11.9700
0.0553
0.0870
0.1537 0.1537 0.1537
83 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$$$
(OPIATE AGONISTS)
(OPIATE PARTIAL AGONISTS)
(BARBITURATES)
(BENZODIAZEPINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
CLONAZEPAM
PHENYTOIN
PHENYTOIN SODIUM
0.25 MG ORAL TABLET
0.5 MG ORAL TABLET
1 MG ORAL TABLET
2 MG ORAL TABLET
50 MG ORAL CHEWABLE TABLET
6 MG / ML ORAL SUSPENSION
25 MG / ML ORAL SUSPENSION
30 MG ORAL CAPSULE
100 MG ORAL CAPSULE
50 MG / ML INJECTION
00002179660
0000217788900002270641000022309500000223902400002145227000022369480000204870100002207818000021036560000223396000000382825
00002270668000021452350000204872800002233982
000021778970000227067600002230951000022390250000214524300002048736000021037370000223398500000382841
00000023698
00000023442
0000225089600000023450
00000022772
00000022780
00000780626
PMS-CLONAZEPAM
APO-CLONAZEPAMCO CLONAZEPAMMYLAN-CLONAZEPAMNOVO-CLONAZEPAMPHL-CLONAZEPAMPHL-CLONAZEPAM-RPMS-CLONAZEPAMPMS-CLONAZEPAM-RRATIO-CLONAZEPAMSANDOZ CLONAZEPAMRIVOTRIL
CO CLONAZEPAMPHL-CLONAZEPAMPMS-CLONAZEPAMSANDOZ CLONAZEPAM
APO-CLONAZEPAMCO CLONAZEPAMMYLAN-CLONAZEPAMNOVO-CLONAZEPAMPHL-CLONAZEPAMPMS-CLONAZEPAMRATIO-CLONAZEPAMSANDOZ CLONAZEPAMRIVOTRIL
DILANTIN INFATABS
DILANTIN-30
TARO-PHENYTOINDILANTIN-125
DILANTIN
DILANTIN
PHENYTOIN SODIUM
PMS
APXCOBMYPTEVPHHPHHPMSPMSRPHSDZHLR
COBPHHPMSSDZ
APXCOBMYPTEVPHHPMSRPHSDZHLR
PFI
PFI
TARPFI
PFI
PFI
SDZ
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS
28
28
:00
:00
28:12.08
28:12.12
0.0719
0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.1982
0.1487 0.1487 0.1487 0.1487
0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.3417
0.0724
0.0399
0.0311 0.0470
0.0528
0.0734
2.4465
84 EFFECTIVE JULY 1, 2012
$
$$$$$$$$$$$
$$$$
$$$$$$$$$
$
$
$$
$
$
$
(BENZODIAZEPINES)
(HYDANTOINS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ETHOSUXIMIDE
METHSUXIMIDE
CARBAMAZEPINE
DIVALPROEX SODIUM (VALPROIC ACID EQUIV.)
250 MG ORAL CAPSULE
50 MG / ML ORAL SYRUP
300 MG ORAL CAPSULE
200 MG ORAL TABLET
100 MG ORAL CHEWABLE TABLET
200 MG ORAL CHEWABLE TABLET
200 MG ORAL SUSTAINED-RELEASE TABLET
400 MG ORAL SUSTAINED-RELEASE TABLET
20 MG / ML ORAL SUSPENSION
125 MG (BASE) ORAL ENTERIC-COATED TABLET
250 MG (BASE) ORAL ENTERIC-COATED TABLET
00000022799
00000023485
00000022802
0000078271800000010405
00002231542000022618550000224440300000369810
00002231540000022618630000224440400000665088
00002241882000022315430000226183900000773611
00002241883000022315440000226184700000755583
0000236739400002194333
000022396980000223970100000596418
000022396990000223970200000596426
ZARONTIN
ZARONTIN
CELONTIN
TEVA-CARBAMAZTEGRETOL
PMS-CARBAMAZEPINESANDOZ CARBAMAZEPINETARO-CARBAMAZEPINETEGRETOL
PMS-CARBAMAZEPINESANDOZ CARBAMAZEPINETARO-CARBAMAZEPINETEGRETOL
MYLAN-CARBAMAZEPINE CRPMS-CARBAMAZEPINE-CRSANDOZ CARBAMAZEPINE CRTEGRETOL CR
MYLAN-CARBAMAZEPINE CRPMS-CARBAMAZEPINE-CRSANDOZ CARBAMAZEPINE CRTEGRETOL CR
TARO-CARBAMAZEPINETEGRETOL
APO-DIVALPROEXNOVO-DIVALPROEXEPIVAL
APO-DIVALPROEXNOVO-DIVALPROEXEPIVAL
ERF
ERF
ERF
TEVNOV
PMSSDZTARNOV
PMSSDZTARNOV
MYPPMSSDZNOV
MYPPMSSDZNOV
TARNOV
APXTEVABB
APXTEVABB
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
ANTICONVULSANTS
28
28
:00
:00
28:12.20
28:12.92
0.3203
0.0640
0.5933
0.0795 0.3867
0.0599 0.0599 0.0599 0.1591
0.1181 0.1181 0.1181 0.3139
0.1467 0.1467 0.1467 0.3899
0.2933 0.2933 0.2933 0.7796
0.0541 0.0751
0.1011 0.1011 0.2889
0.1817 0.1817 0.5192
85 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$$
$$$$
$$$$
$$$$
$$$$
$$
$$$
$$$
(SUCCINIMIDES)
(MISCELLANEOUS ANTICONVULSANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DIVALPROEX SODIUM (VALPROIC ACID EQUIV.)
GABAPENTIN
500 MG (BASE) ORAL ENTERIC-COATED TABLET
100 MG ORAL CAPSULE
300 MG ORAL CAPSULE
400 MG ORAL CAPSULE
000022397000000223970300000596434
0000224430400002321203000022561420000224631400002332582000023532450000228581900002361469000022482590000224344600002319055000022608830000224451300002084260
00002244305000023212110000225615000002246315000023325900000235325300002285827000023614850000224826000002243447000023190630000224451400002084279
0000224430600002321238000022561690000224631600002332604000023532610000228583500002361493000022482610000224344800002319071000022609050000224451500002084287
APO-DIVALPROEXNOVO-DIVALPROEXEPIVAL
APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINRATIO-GABAPENTINTEVA-GABAPENTINNEURONTIN
APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINTEVA-GABAPENTINNEURONTIN
APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINRATIO-GABAPENTINTEVA-GABAPENTINNEURONTIN
APXTEVABB
APXAURCOBMELRANSNSGMDJPCMYPPMSRANRPHTEVPFI
APXAURCOBMELRANSNSGMDJPCMYPPMSRANTEVPFI
APXAURCOBMELRANSNSGMDJPCMYPPMSRANRPHTEVPFI
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:00
28:12.92
0.3637 0.3637 1.0392
0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.4247
0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 1.0332
0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 1.2313
86 EFFECTIVE JULY 1, 2012
$$$
$$$$$$$$$$$$$$
$$$$$$$$$$$$$
$$$$$$$$$$$$$$
(MISCELLANEOUS ANTICONVULSANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
LAMOTRIGINE
LEVETIRACETAM
25 MG ORAL TABLET
100 MG ORAL TABLET
150 MG ORAL TABLET
5 MG ORAL CHEWABLE TABLET
250 MG ORAL TABLET
500 MG ORAL TABLET
750 MG ORAL TABLET
00002245208000023430100000226549400002248232000022468970000224335200002142082
00002245209000023430290000226550800002248233000022468980000224335300002142104
00002245210000023430370000226551600002248234000022468990000224696300002142112
00002240115
00002285924000023752490000237167700002274183000023533420000229610100002247027
00002285932000023752570000237168500002274191000023533500000229612800002247028
00002285940000023752650000237169300002274205000023533690000229613600002247029
APO-LAMOTRIGINELAMOTRIGINEMYLAN-LAMOTRIGINENOVO-LAMOTRIGINEPMS-LAMOTRIGINERATIO-LAMOTRIGINELAMICTAL
APO-LAMOTRIGINELAMOTRIGINEMYLAN-LAMOTRIGINENOVO-LAMOTRIGINEPMS-LAMOTRIGINERATIO-LAMOTRIGINELAMICTAL
APO-LAMOTRIGINELAMOTRIGINEMYLAN-LAMOTRIGINENOVO-LAMOTRIGINEPMS-LAMOTRIGINERATIO-LAMOTRIGINELAMICTAL
LAMICTAL
APO-LEVETIRACETAMAURO-LEVETIRACETAMAVA-LEVETIRACETAMCO LEVETIRACETAMLEVETIRACETAMPMS-LEVETIRACETAMKEPPRA
APO-LEVETIRACETAMAURO-LEVETIRACETAMAVA-LEVETIRACETAMCO LEVETIRACETAMLEVETIRACETAMPMS-LEVETIRACETAMKEPPRA
APO-LEVETIRACETAMAURO-LEVETIRACETAMAVA-LEVETIRACETAMCO LEVETIRACETAMLEVETIRACETAMPMS-LEVETIRACETAMKEPPRA
APXSNSMYPTEVPMSRPHGSK
APXSNSMYPTEVPMSRPHGSK
APXSNSMYPTEVPMSRPHGSK
GSK
APXAURAVACOBSNSPMSUCB
APXAURAVACOBSNSPMSUCB
APXAURAVACOBSNSPMSUCB
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:00
28:12.92
0.1438 0.1438 0.1438 0.1438 0.1438 0.1438 0.3821
0.5739 0.5739 0.5739 0.5739 0.5739 0.5739 1.5254
0.8458 0.8458 0.8458 0.8458 0.8458 0.8458 2.2481
0.1630
0.8000 0.8000 0.8000 0.8000 0.8000 0.8000 1.6613
0.9750 0.9750 0.9750 0.9750 0.9750 0.9750 2.0427
1.3500 1.3500 1.3500 1.3500 1.3500 1.3500 2.8283
87 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$$
$
$$$$$$$
$$$$$$$
$$$$$$$
(MISCELLANEOUS ANTICONVULSANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TOPIRAMATE25 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
200 MG ORAL TABLET
15 MG ORAL CAPSULE
25 MG ORAL CAPSULE
000022796140000234580300002370972000022877650000231564500002263351000022488600000227118400002262991000022600500000235685600002230893
00002312085
000022796300000234583800002370980000022877730000231565300002263378000022488610000227119200002263009000022600690000235686400002230894
000022796490000234584600002370999000022877810000231566100002263386000022488620000227120600002263017000022678370000235687200002230896
00002239907
00002239908
APO-TOPIRAMATEAURO-TOPIRAMATEAVA-TOPIRAMATECO TOPIRAMATEMINT-TOPIRAMATEMYLAN-TOPIRAMATENOVO-TOPIRAMATEPHL-TOPIRAMATEPMS-TOPIRAMATESANDOZ TOPIRAMATETOPIRAMATETOPAMAX
PMS-TOPIRAMATE
APO-TOPIRAMATEAURO-TOPIRAMATEAVA-TOPIRAMATECO TOPIRAMATEMINT-TOPIRAMATEMYLAN-TOPIRAMATENOVO-TOPIRAMATEPHL-TOPIRAMATEPMS-TOPIRAMATESANDOZ TOPIRAMATETOPIRAMATETOPAMAX
APO-TOPIRAMATEAURO-TOPIRAMATEAVA-TOPIRAMATECO TOPIRAMATEMINT-TOPIRAMATEMYLAN-TOPIRAMATENOVO-TOPIRAMATEPHL-TOPIRAMATEPMS-TOPIRAMATESANDOZ TOPIRAMATETOPIRAMATETOPAMAX
TOPAMAX SPRINKLE
TOPAMAX SPRINKLE
APXAURAVACOBMPIMYPTEVPHHPMSSDZSNSJAI
PMS
APXAURAVACOBMPIMYPTEVPHHPMSSDZSNSJAI
APXAURAVACOBMPIMYPTEVPHHPMSSDZSNSJAI
JAI
JAI
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:00
28:12.92
0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 1.2787
1.0674
0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 2.4235
1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 3.6190
1.1675
1.2255
88 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$
$
$$$$$$$$$$$$
$$$$$$$$$$$$
$
$
(MISCELLANEOUS ANTICONVULSANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
VALPROIC ACID
VIGABATRIN
MOCLOBEMIDE
PHENELZINE SULFATE
TRANYLCYPROMINE SULFATE
250 MG ORAL CAPSULE
500 MG ORAL ENTERIC-COATED CAPSULE
50 MG / ML ORAL SYRUP
500 MG ORAL TABLET
500 MG ORAL POWDER PACKET
100 MG ORAL TABLET
150 MG ORAL TABLET
300 MG ORAL TABLET
15 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
000022380480000218464800002100630000022307680000223971400000443840
0000221832100002229628
00002238370000022368070000214006300000443832
00002065819
00002068036
0000223214800002239746
0000223215000002239747
0000224045600002239748
00000476552
00001919598
APO-VALPROICMYLAN-VALPROICNOVO-VALPROICPMS-VALPROIC ACIDSANDOZ VALPROICDEPAKENE
NOVO-VALPROICPMS-VALPROIC ACID E.C.
APO-VALPROICPMS-VALPROIC ACIDRATIO-VALPROICDEPAKENE
SABRIL
SABRIL
APO-MOCLOBEMIDENOVO-MOCLOBEMIDE
APO-MOCLOBEMIDENOVO-MOCLOBEMIDE
APO-MOCLOBEMIDENOVO-MOCLOBEMIDE
NARDIL
PARNATE
APXMYPTEVPMSSDZABB
TEVPMS
APXPMSRPHABB
LUI
LUI
APXTEV
APXTEV
APXTEV
ERF
GSK
(MONOAMINE OXIDASE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:12.92
28:16.04.12
0.1908 0.1908 0.1908 0.1908 0.1908 0.5452
0.5197 0.5197
0.0398 0.0398 0.0398 0.1136
0.9110
0.9110
0.2520 0.2520
0.2279 0.2279
0.4476 0.4476
0.3561
0.3759
89 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$
$$
$$$$
$
$
$$
$$
$$
$
$
(MISCELLANEOUS ANTICONVULSANTS)
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DULOXETINE HYDROCHLORIDE
VENLAFAXINE HCL
30 MG (BASE) ORAL DELAYED RELEASE CAPSULE
60 MG (BASE) ORAL DELAYED RELEASE CAPSULE
37.5 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
75 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
150 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE
00002301482
00002301490
0000233168300002304317000023600200000231027900002278545000023800720000227396900002310317000022750230000235471300002237279
0000233169100002304325000023600390000231028700002278553000023800800000227397700002310325000022750310000235472100002237280
0000233170500002304333000023600470000231029500002278561000023800990000227398500002310333000022750580000235474800002237282
CYMBALTA
CYMBALTA
APO-VENLAFAXINE XRCO VENLAFAXINE XRGD-VENLAFAXINE XRMYLAN-VENLAFAXINE XRPMS-VENLAFAXINE XRRAN-VENLAFAXINE XRRATIO-VENLAFAXINE XRSANDOZ VENLAFAXINE XRTEVA-VENLAFAXINE XRVENLAFAXINE XREFFEXOR XR
APO-VENLAFAXINE XRCO VENLAFAXINE XRGD-VENLAFAXINE XRMYLAN-VENLAFAXINE XRPMS-VENLAFAXINE XRRAN-VENLAFAXINE XRRATIO-VENLAFAXINE XRSANDOZ VENLAFAXINE XRTEVA-VENLAFAXINE XRVENLAFAXINE XREFFEXOR XR
APO-VENLAFAXINE XRCO VENLAFAXINE XRGD-VENLAFAXINE XRMYLAN-VENLAFAXINE XRPMS-VENLAFAXINE XRRAN-VENLAFAXINE XRRATIO-VENLAFAXINE XRSANDOZ VENLAFAXINE XRTEVA-VENLAFAXINE XRVENLAFAXINE XREFFEXOR XR
LIL
LIL
APXCOBGMDMYPPMSRANRPHSDZTEVSNSWAY
APXCOBGMDMYPPMSRANRPHSDZTEVSNSWAY
APXCOBGMDMYPPMSRANRPHSDZTEVSNSWAY
(SELECTIVE SEROTONIN- AND NOREPINEPHRINE-REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.16
1.8766
3.7536
0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.9242
0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 1.8488
0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 1.9517
90 EFFECTIVE JULY 1, 2012
$
$
$$$$$$$$$$$
$$$$$$$$$$$
$$$$$$$$$$$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CITALOPRAM HYDROBROMIDE
ESCITALOPRAM OXALATE
10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
30 MG (BASE) ORAL TABLET
40 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
00002370077
0000224605600002331950000023536600000230623900002248050000023134050000237189800002304686000022465940000229321800002248944000022480100000228562200002252112000022481700000235527200002239607
00002296152
0000224605700002331977000023536790000230624700002248051000023134130000237190100002304694000022465950000229322600002248945000022480110000228563000002252120000022481710000235528000002239608
00002263238
00002263254
MINT-CITALOPRAM
APO-CITALOPRAMCITALOPRAMCITALOPRAMCITALOPRAM-ODANCO CITALOPRAMJAMP-CITALOPRAMMAR-CITALOPRAMMINT-CITALOPRAMMYLAN-CITALOPRAMNOVO-CITALOPRAMPHL-CITALOPRAMPMS-CITALOPRAMRAN-CITALORATIO-CITALOPRAMSANDOZ CITALOPRAMSEPTA-CITALOPRAMCELEXA
CTP 30
APO-CITALOPRAMCITALOPRAMCITALOPRAMCITALOPRAM-ODANCO CITALOPRAMJAMP-CITALOPRAMMAR-CITALOPRAMMINT-CITALOPRAMMYLAN-CITALOPRAMNOVO-CITALOPRAMPHL-CITALOPRAMPMS-CITALOPRAMRAN-CITALORATIO-CITALOPRAMSANDOZ CITALOPRAMSEPTA-CITALOPRAMCELEXA
CIPRALEX
CIPRALEX
MPI
APXRANSNSODNCOBJPCMARMPIMYPTEVPHHPMSRANRPHSDZSEPLBC
SUN
APXRANSNSODNCOBJPCMARMPIMYPTEVPHHPMSRANRPHSDZSEPLBC
LBC
LBC
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.20
0.2790
0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 1.3317
0.8750
0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 1.3317
1.6933
1.8027
91 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$$$$$$$$$$$$$
$
$$$$$$$$$$$$$$$$$
$
$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
FLUOXETINE HCL
FLUVOXAMINE MALEATE
10 MG (BASE) ORAL CAPSULE
20 MG (BASE) ORAL CAPSULE
4 MG / ML (BASE) ORAL LIQUID
50 MG ORAL TABLET
100 MG ORAL TABLET
0000221635300002242177000022860680000238056000002237813000022234810000217757900002241371000022434860000221658200002018985
000022163610000236453000002242178000022860760000238057900002237814000022235030000217758700002241374000022434870000221659000000636622
00002231328
0000223132900002363763000022555290000223995300002240682000022184530000224705400001919342
0000223133000002363771000022555370000223995400002240683000022184610000224705500001919369
APO-FLUOXETINECO FLUOXETINEFLUOXETINEMINT-FLUOXETINEMYLAN-FLUOXETINEPHL-FLUOXETINEPMS-FLUOXETINERATIO-FLUOXETINE HYDROCHLORIDESANDOZ FLUOXETINETEVA-FLUOXETINEPROZAC
APO-FLUOXETINEAVA-FLUOXETINECO FLUOXETINEFLUOXETINEMINT-FLUOXETINEMYLAN-FLUOXETINEPHL-FLUOXETINEPMS-FLUOXETINERATIO-FLUOXETINE HYDROCHLORIDESANDOZ FLUOXETINETEVA-FLUOXETINEPROZAC
APO-FLUOXETINE
APO-FLUVOXAMINEAVA-FLUVOXAMINECO FLUVOXAMINENOVO-FLUVOXAMINEPMS-FLUVOXAMINERATIO-FLUVOXAMINESANDOZ FLUVOXAMINELUVOX
APO-FLUVOXAMINEAVA-FLUVOXAMINECO FLUVOXAMINENOVO-FLUVOXAMINEPMS-FLUVOXAMINERATIO-FLUVOXAMINESANDOZ FLUVOXAMINELUVOX
APXCOBSNSMPIMYPPHHPMSRPHSDZTEVLIL
APXAVACOBSNSMPIMYPPHHPMSRPHSDZTEVLIL
APX
APXAVACOBTEVPMSRPHSDZABB
APXAVACOBTEVPMSRPHSDZABB
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.20
0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 1.8379
0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 1.8393
0.5859
0.3063 0.3063 0.3063 0.3063 0.3063 0.3063 0.3063 0.8750
0.5506 0.5506 0.5506 0.5506 0.5506 0.5506 0.5506 1.5730
92 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$
$$$$$$$$$$$$
$
$$$$$$$$
$$$$$$$$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PAROXETINE HCL
SERTRALINE HCL
20 MG (BASE) ORAL TABLET
30 MG (BASE) ORAL TABLET
40 MG (BASE) ORAL TABLET
25 MG (BASE) ORAL CAPSULE
50 MG (BASE) ORAL CAPSULE
00002240908000022627540000224801300002248451000022828520000224775100002247811000022694300000224855700001940481
0000224090900002262762000022480140000224845200002282860000022477520000224781200002254778000022694490000224855800001940473
00002293749
0000223828000002287390000022736830000224251900002245824000022448380000237455200002245159000023535200000224048500002132702
0000223828100002287404000022736910000224252000002245825000022448390000237456000002245160000023535390000224048400001962817
APO-PAROXETINECO PAROXETINEMYLAN-PAROXETINEPAROXETINEPAROXETINEPMS-PAROXETINERATIO-PAROXETINESANDOZ PAROXETINETEVA-PAROXETINEPAXIL
APO-PAROXETINECO PAROXETINEMYLAN-PAROXETINEPAROXETINEPAROXETINEPMS-PAROXETINERATIO-PAROXETINESANDOZ PAROXETINESANDOZ PAROXETINETEVA-PAROXETINEPAXIL
PMS-PAROXETINE
APO-SERTRALINECO SERTRALINEGD-SERTRALINEMYLAN-SERTRALINEPHL-SERTRALINEPMS-SERTRALINERAN-SERTRALINESANDOZ SERTRALINESERTRALINETEVA-SERTRALINEZOLOFT
APO-SERTRALINECO SERTRALINEGD-SERTRALINEMYLAN-SERTRALINEPHL-SERTRALINEPMS-SERTRALINERAN-SERTRALINESANDOZ SERTRALINESERTRALINETEVA-SERTRALINEZOLOFT
APXCOBMYPMELSNSPMSRPHSDZTEVGSK
APXCOBMYPMELSNSPMSRPHSDZSDZTEVGSK
PMS
APXCOBGMDMYPPHHPMSRANSDZSNSTEVPFI
APXCOBGMDMYPPHHPMSRANSDZSNSTEVPFI
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.20
0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 1.8056
0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 1.9183
2.2454
0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.8422
0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 1.6844
93 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$
$$$$$$$$$$$
$
$$$$$$$$$$$
$$$$$$$$$$$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SERTRALINE HCL
TRAZODONE HCL
100 MG (BASE) ORAL CAPSULE
50 MG ORAL TABLET
75 MG ORAL TABLET
100 MG ORAL TABLET
150 MG ORAL TABLET
0000223828200002287412000022737050000224252100002245826000022448400000237457900002245161000023535470000224048100001962779
0000214763700002231683000019372270000214426300002348772
00002237339
0000214764500002231684000019372350000214427100002348780
000021476530000214429800002348799
APO-SERTRALINECO SERTRALINEGD-SERTRALINEMYLAN-SERTRALINEPHL-SERTRALINEPMS-SERTRALINERAN-SERTRALINESANDOZ SERTRALINESERTRALINETEVA-SERTRALINEZOLOFT
APO-TRAZODONEMYLAN-TRAZODONEPMS-TRAZODONETEVA-TRAZODONETRAZODONE
PMS-TRAZODONE
APO-TRAZODONEMYLAN-TRAZODONEPMS-TRAZODONETEVA-TRAZODONETRAZODONE
APO-TRAZODONE DTEVA-TRAZODONETRAZODONE
APXCOBGMDMYPPHHPMSRANSDZSNSTEVPFI
APXMYPPMSTEVSNS
PMS
APXMYPPMSTEVSNS
APXTEVSNS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
(SEROTONIN MODULATORS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.04.20
28:16.04.24
0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 1.7650
0.1384 0.1384 0.1384 0.1384 0.1384
0.3506
0.2473 0.2473 0.2473 0.2473 0.2473
0.3633 0.3633 0.3633
94 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$
$$$$$
$
$$$$$
$$$
ANTIDEPRESSANTS
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AMITRIPTYLINE HCL
CLOMIPRAMINE HCL
DESIPRAMINE HCL
DOXEPIN HCL
10 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
75 MG ORAL TABLET
10 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
10 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
75 MG ORAL TABLET
10 MG (BASE) ORAL CAPSULE
25 MG (BASE) ORAL CAPSULE
50 MG (BASE) ORAL CAPSULE
75 MG (BASE) ORAL CAPSULE
00000335053
00000335061
00000335088
00000754129
000020407860000224481600000330566
000020407780000224481700000324019
000020407510000224481800000402591
00002216248
00002216256
00002216264
00002216272
0000204999600000024325
000019134250000205000500000024333
000019134330000205001300000024341
000019134410000205002100000400750
ELAVIL
ELAVIL
ELAVIL
ELAVIL
APO-CLOMIPRAMINECO CLOMIPRAMINEANAFRANIL
APO-CLOMIPRAMINECO CLOMIPRAMINEANAFRANIL
APO-CLOMIPRAMINECO CLOMIPRAMINEANAFRANIL
APO-DESIPRAMINE
APO-DESIPRAMINE
APO-DESIPRAMINE
APO-DESIPRAMINE
APO-DOXEPINSINEQUAN
NOVO-DOXEPINAPO-DOXEPINSINEQUAN
NOVO-DOXEPINAPO-DOXEPINSINEQUAN
NOVO-DOXEPINAPO-DOXEPINSINEQUAN
AAP
AAP
AAP
AAP
APXCOBSUN
APXCOBSUN
APXCOBSUN
APX
APX
APX
APX
APXERF
TEVAPXERF
TEVAPXERF
TEVAPXERF
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.28
0.0664
0.1211
0.2347
0.3634
0.1290 0.1290 0.2766
0.1758 0.1758 0.3769
0.3237 0.3237 0.6940
0.3804
0.3804
0.6704
0.8915
0.1889 0.2575
0.1576 0.1860 0.3141
0.2923 0.3450 0.5814
0.3916 0.4953 0.8416
95 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$$$
$$$
$$$
$
$
$
$
$$
$$$
$$$
$$$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DOXEPIN HCL
IMIPRAMINE HCL
MAPROTILINE HCL
NORTRIPTYLINE HCL
TRIMIPRAMINE MALEATE
100 MG (BASE) ORAL CAPSULE
150 MG (BASE) ORAL CAPSULE
10 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
75 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
75 MG ORAL TABLET
10 MG (BASE) ORAL CAPSULE
25 MG (BASE) ORAL CAPSULE
12.5 MG (BASE) ORAL TABLET
25 MG (BASE) ORAL TABLET
50 MG (BASE) ORAL TABLET
100 MG (BASE) ORAL TABLET
000019134680000205004800000326925
00001913476
00000360201
00000312797
00000326852
00000644579
00002158612
00002158620
00002158639
0000222351100002364301000022317810000217769200000015229
0000222353800002364328000022317820000217770600000015237
00000740799
00000740802
00000740810
00000740829
NOVO-DOXEPINAPO-DOXEPINSINEQUAN
NOVO-DOXEPIN
IMIPRAMINE
IMIPRAMINE
IMIPRAMINE
IMIPRAMINE
NOVO-MAPROTILINE
NOVO-MAPROTILINE
NOVO-MAPROTILINE
APO-NORTRIPTYLINEAVA-NORTRIPTYLINENOVO-NORTRIPTYLINEPMS-NORTRIPTYLINEAVENTYL
APO-NORTRIPTYLINEAVA-NORTRIPTYLINENOVO-NORTRIPTYLINEPMS-NORTRIPTYLINEAVENTYL
TRIMIPRAMINE
TRIMIPRAMINE
TRIMIPRAMINE
TRIMIPRAMINE
TEVAPXERF
TEV
AAP
AAP
AAP
AAP
TEV
TEV
TEV
APXAVATEVPMSPPH
APXAVATEVPMSPPH
AAP
AAP
AAP
AAP
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE INHIBITORS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.04.28
0.5160 0.6526 1.1089
1.1841
0.1370
0.2471
0.4822
0.6308
0.5957
1.1281
1.5406
0.0893 0.0893 0.0893 0.0893 0.2373
0.1804 0.1804 0.1804 0.1804 0.4794
0.2156
0.2776
0.5434
0.9273
96 EFFECTIVE JULY 1, 2012
$$$
$
$
$
$
$
$
$
$
$$$$$
$$$$$
$
$
$
$
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TRIMIPRAMINE MALEATE
BUPROPION HCL
L-TRYPTOPHAN
75 MG (BASE) ORAL CAPSULE
100 MG ORAL SUSTAINED-RELEASE TABLET
150 MG ORAL SUSTAINED-RELEASE TABLET
150 MG ORAL EXTENDED-RELEASE TABLET
300 MG ORAL EXTENDED-RELEASE TABLET
250 MG ORAL TABLET
500 MG ORAL TABLET
750 MG ORAL TABLET
1 G ORAL TABLET
500 MG ORAL CAPSULE
00002070987
0000228565700002275074
0000236340200002313421000022856650000227508200002237825
00002275090
00002275104
00002239326
000022485380000224033300002029456
00002239327
000022485390000223725000000654531
000022485400000224033400000718149
TRIMIPRAMINE
RATIO-BUPROPION SRSANDOZ BUPROPION SR
AVA-BUPROPION SRPMS-BUPROPION SRRATIO-BUPROPION SRSANDOZ BUPROPION SRWELLBUTRIN SR
WELLBUTRIN XL
WELLBUTRIN XL
TRYPTAN
APO-TRYPTOPHANRATIO-TRYPTOPHANTRYPTAN
TRYPTAN
APO-TRYPTOPHANRATIO-TRYPTOPHANTRYPTAN
APO-TRYPTOPHANRATIO-TRYPTOPHANTRYPTAN
AAP
RPHSDZ
AVAPMSRPHSDZVCL
VCL
VCL
VCL
APXRPHVCL
VCL
APXRPHVCL
APXRPHVCL
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE INHIBITORS)
(MISCELLANEOUS ANTIDEPRESSANTS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.04.28
28:16.04.92
0.7314
0.2103 0.2103
0.3275 0.3275 0.3275 0.3275 0.9356
0.5573
1.1150
0.3719
0.3563 0.3563 0.7438
1.1159
0.7126 0.7126 1.4878
0.3563 0.3563 0.7438
97 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$
$$$$$
$
$
$
$$$
$
$$$
$$$
ANTIDEPRESSANTS
ANTIDEPRESSANTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
MIRTAZAPINE
ARIPIPRAZOLE
CLOZAPINE
15 MG ORAL TABLET
30 MG ORAL TABLET
45 MG ORAL TABLET
2 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
15 MG ORAL TABLET
20 MG ORAL TABLET
30 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
0000225609600002273942
000022866290000236293700002252279000023706890000225611800002259354000022487620000225060800002243910
00002256126
00002322374
00002322382
00002322390
00002322404
00002322412
00002322455
000022480340000224724300000894737
00002305003
MYLAN-MIRTAZAPINEPMS-MIRTAZAPINE
APO-MIRTAZAPINEAVA-MIRTAZAPINEMIRTAZAPINEMIRTAZAPINEMYLAN-MIRTAZAPINENOVO-MIRTAZAPINEPMS-MIRTAZAPINESANDOZ MIRTAZAPINEREMERON
MYLAN-MIRTAZAPINE
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ABILIFY
APO-CLOZAPINEGEN-CLOZAPINECLOZARIL
GEN-CLOZAPINE
MYPPMS
APXAVAMELSNSMYPTEVPMSSDZMFC
MYP
BMS
BMS
BMS
BMS
BMS
BMS
APXMYPNOV
MYP
(MISCELLANEOUS ANTIDEPRESSANTS)
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.04.92
28:16.08.04
0.2344 0.2344
0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 1.2989
1.1576
2.9140
3.2800
3.7800
3.7800
3.7800
3.7800
0.6594 0.6594 0.9420
1.3188
98 EFFECTIVE JULY 1, 2012
$$
$$$$$$$$$
$
$
$
$
$
$
$
$$$
$
RESTRICTED BENEFIT - This Drug Product is a benefit for patients 15 to 17 years of age inclusive for the treatment of schizophrenia.
RESTRICTED BENEFIT - This Drug Product is a benefit for patients 15 to 17 years of age inclusive for the treatment of schizophrenia.
ANTIDEPRESSANTS
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CLOZAPINE
OLANZAPINE
100 MG ORAL TABLET
200 MG ORAL TABLET
2.5 MG ORAL TABLET
5 MG ORAL TABLET
7.5 MG ORAL TABLET
10 MG ORAL TABLET
000022480350000224724400000894745
00002305011
000022817910000237343200002325659000023378780000237281900002303116000023103410000227671200002229250
000022818050000237344000002325667000023378860000237282700002303159000023103680000227672000002229269
000022818130000237345900002325675000023378940000237283500002303167000023103760000227673900002229277
000022818210000237346700002325683000023379080000237284300002303175000023103840000227674700002229285
APO-CLOZAPINEGEN-CLOZAPINECLOZARIL
GEN-CLOZAPINE
APO-OLANZAPINEAVA-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA
APO-OLANZAPINEAVA-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA
APO-OLANZAPINEAVA-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA
APO-OLANZAPINEAVA-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA
APXMYPNOV
MYP
APXAVACOBMYPSNSPMSSDZTEVLIL
APXAVACOBMYPSNSPMSSDZTEVLIL
APXAVACOBMYPSNSPMSSDZTEVLIL
APXAVACOBMYPSNSPMSSDZTEVLIL
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.04
2.6446 2.6446 3.7780
5.2892
0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 1.7972
1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 3.5944
2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 5.3916
2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 7.1888
99 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
$$$$$$$$$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
OLANZAPINE
QUETIAPINE FUMARATE
15 MG ORAL TABLET
5 MG ORAL DISINTEGRATING TABLET
10 MG ORAL DISINTEGRATING TABLET
25 MG (BASE) ORAL TABLET
50 MG ORAL TABLET
100 MG (BASE) ORAL TABLET
0000228184800002325691000023379160000237285100002303183000023103920000227675500002238850
0000236061600002327562000023827090000235297400002303191000023277750000232134300002243086
0000236062400002327570000023827170000235298200002303205000023277830000232135100002243087
000023139010000231608000002330415000023078040000228423500002296551000023531640000231399500002236951
00002361892
000023139280000231609900002330423000023078120000228424300002296578000023531720000231400200002236952
APO-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA
APO-OLANZAPINE ODTCO OLANZAPINE ODTMYLAN-OLANZAPINE ODTOLANZAPINE ODTPMS-OLANZAPINE ODTSANDOZ OLANZAPINE ODTTEVA-OLANZAPINE ODZYPREXA ZYDIS
APO-OLANZAPINE ODTCO OLANZAPINE ODTMYLAN-OLANZAPINE ODTOLANZAPINE ODTPMS-OLANZAPINE ODTSANDOZ OLANZAPINE ODTTEVA-OLANZAPINE ODZYPREXA ZYDIS
APO-QUETIAPINECO QUETIAPINEJAMP-QUETIAPINEMYLAN-QUETIAPINENOVO-QUETIAPINEPMS-QUETIAPINEQUETIAPINESANDOZ QUETIAPINESEROQUEL
PMS-QUETIAPINE
APO-QUETIAPINECO QUETIAPINEJAMP-QUETIAPINEMYLAN-QUETIAPINENOVO-QUETIAPINEPMS-QUETIAPINEQUETIAPINESANDOZ QUETIAPINESEROQUEL
APXCOBMYPSNSPMSSDZTEVLIL
APXCOBMYPSNSPMSSDZTEVLIL
APXCOBMYPSNSPMSSDZTEVLIL
APXCOBJPCMYPTEVPMSSNSSDZAZC
PMS
APXCOBJPCMYPTEVPMSSNSSDZAZC
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.04
4.0571 4.0571 4.0571 4.0571 4.0571 4.0571 4.0571
10.7831
1.3449 1.3449 1.3449 1.3449 1.3449 1.3449 1.3449 3.5746
2.6875 2.6875 2.6875 2.6875 2.6875 2.6875 2.6875 7.1429
0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.5135
0.5614
0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 1.3700
100 EFFECTIVE JULY 1, 2012
$$$$$$$$
$$$$$$$$
$$$$$$$$
$$$$$$$$$
$
$$$$$$$$$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
QUETIAPINE FUMARATE150 MG (BASE) ORAL TABLET
200 MG (BASE) ORAL TABLET
300 MG (BASE) ORAL TABLET
00002284251
000023139360000231611000002330458000023078390000228427800002296594000023531990000231401000002236953
000023139440000231612900002330466000023078470000228428600002296608000023532020000231402900002244107
NOVO-QUETIAPINE
APO-QUETIAPINECO QUETIAPINEJAMP-QUETIAPINEMYLAN-QUETIAPINENOVO-QUETIAPINEPMS-QUETIAPINEQUETIAPINESANDOZ QUETIAPINESEROQUEL
APO-QUETIAPINECO QUETIAPINEJAMP-QUETIAPINEMYLAN-QUETIAPINENOVO-QUETIAPINEPMS-QUETIAPINEQUETIAPINESANDOZ QUETIAPINESEROQUEL
TEV
APXCOBJPCMYPTEVPMSSNSSDZAZC
APXCOBJPCMYPTEVPMSSNSSDZAZC
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.04
1.6222
1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 2.7520
1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 4.0145
101 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$$$$$
$$$$$$$$$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RISPERIDONE0.25 MG ORAL TABLET
0.5 MG ORAL TABLET
1 MG ORAL TABLET
00002282119000023671730000228258500002359529000023717660000235979000002282240000022826900000225843900002252007000022809060000232830500002332051000023568800000230365500002240551
00002282127000023671810000228259300002359537000023717740000235980400002282259000022641880000225844700002252015000022809140000232831300002332078000023568990000230366300002240552
00002282135000023672030000228260700002359545000023717820000235981200002282267000022641960000225845500002252023000022809220000232832100002332086000023569020000227980000002025280
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.04
0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.5409
0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.9061
0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 1.2518
102 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RISPERIDONE2 MG ORAL TABLET
3 MG ORAL TABLET
4 MG ORAL TABLET
00002282143000023672110000228261500002359553000023717900000235982000002282275000022642180000225846300002252031000022809300000232834800002332094000023569100000227981900002025299
00002282151000023672380000228262300002359561000023718040000235983900002282283000022642260000225847100002252058000022809490000232836400002332108000023569290000227982700002025302
00002282178000023672460000228263100002359588000023718120000235984700002282291000022642340000225849800002252066000022809570000232837200002332116000023569370000227983500002025310
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI
(ATYPICAL ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.04
0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 2.4989
1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 3.7486
1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 4.9984
103 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RISPERIDONE
RISPERIDONE TARTRATE
ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE
HALOPERIDOL
0.5 MG ORAL DISINTEGRATING TABLET
1 MG ORAL DISINTEGRATING TABLET
2 MG ORAL DISINTEGRATING TABLET
3 MG ORAL DISINTEGRATING TABLET
4 MG ORAL DISINTEGRATING TABLET
1 MG / ML (BASE) ORAL SOLUTION
20 MG (BASE) ORAL CAPSULE
40 MG (BASE) ORAL CAPSULE
60 MG (BASE) ORAL CAPSULE
80 MG (BASE) ORAL CAPSULE
0.5 MG ORAL TABLET
1 MG ORAL TABLET
00002247704
0000229178900002247705
0000229179700002247706
0000237069700002268086
0000237070000002268094
00002280396000023643440000227926600002236950
00002298597
00002298600
00002298619
00002298627
0000039679600000363685
0000039681800000363677
RISPERDAL M-TAB
PMS-RISPERIDONE ODTRISPERDAL M-TAB
PMS-RISPERIDONE ODTRISPERDAL M-TAB
PMS-RISPERIDONE ODTRISPERDAL M-TAB
PMS-RISPERIDONE ODTRISPERDAL M-TAB
APO-RISPERIDONEAVA-RISPERIDONEPMS-RISPERIDONERISPERDAL
ZELDOX
ZELDOX
ZELDOX
ZELDOX
APO-HALOPERIDOLNOVO-PERIDOL
APO-HALOPERIDOLNOVO-PERIDOL
JAI
PMSJAI
PMSJAI
PMSJAI
PMSJAI
APXAVAPMSJAI
PFI
PFI
PFI
PFI
APXTEV
APXTEV
(ATYPICAL ANTIPSYCHOTICS)
(BUTYROPHENONES)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.08.04
28:16.08.08
0.7450
0.7725 1.0300
1.5281 2.0375
2.1913 3.0550
3.0638 4.0850
0.5312 0.5312 0.5312 1.4118
1.6978
1.9448
1.9448
1.9448
0.0360 0.0360
0.0614 0.0614
104 EFFECTIVE JULY 1, 2012
$
$$
$$
$$
$$
$$$$
$
$
$
$
$$
$$
RESTRICTED BENEFIT - This product is a benefit for patients 18 years of age and older for the management of the manifestations of schizophrenia and related psychotic disorders, as well as in severe dementia for the short-term symptomatic management of inappropriate behavior due to aggression and/or psychosis.
ANTIPSYCHOTICS
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
HALOPERIDOL
HALOPERIDOL DECANOATE
CHLORPROMAZINE HCL
FLUPHENAZINE DECANOATE
FLUPHENAZINE HCL
2 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
5 MG / ML INJECTION
50 MG / ML (BASE) INJECTION
100 MG / ML (BASE) INJECTION
25 MG (BASE) ORAL TABLET
50 MG (BASE) ORAL TABLET
100 MG (BASE) ORAL TABLET
25 MG / ML (BASE) INJECTION
25 MG / ML INJECTION
100 MG / ML INJECTION
1 MG ORAL TABLET
2 MG ORAL TABLET
0000039682600000363669
0000039683400000363650
0000046369800000713449
00000768820
00000808652
00002130297
00002130300
00000232823
00000232807
00000232831
00000743518
00002239636
0000224257000000755575
00000405345
00000410632
APO-HALOPERIDOLNOVO-PERIDOL
APO-HALOPERIDOLNOVO-PERIDOL
APO-HALOPERIDOLNOVO-PERIDOL
NOVO-PERIDOL
HALOPERIDOL
HALOPERIDOL LA
HALOPERIDOL LA
TEVA-CHLORPROMAZINE
TEVA-CHLORPROMAZINE
TEVA-CHLORPROMAZINE
CHLORPROMAZINE HCL
FLUPHENAZINE OMEGA
FLUPHENAZINE OMEGAMODECATE CONCENTRATE
APO-FLUPHENAZINE
APO-FLUPHENAZINE
APXTEV
APXTEV
APXTEV
TEV
SDZ
SDZ
SDZ
TEV
TEV
TEV
SDZ
OMG
OMGBMS
APX
APX
(BUTYROPHENONES)
(PHENOTHIAZINES)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.08.08
28:16.08.24
0.1050 0.1050
0.1487 0.1487
0.1330 0.1330
0.6816
4.4930
6.8465
13.6909
0.1816
0.2078
0.4000
1.0326
4.6320
29.7800 29.7800
0.1739
0.2252
105 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$
$$
$
$
$
$
$
$
$
$
$
$$
$
$
ANTIPSYCHOTICS
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
FLUPHENAZINE HCL
METHOTRIMEPRAZINE HCL
METHOTRIMEPRAZINE MALEATE
PERICYAZINE
PERPHENAZINE
PIPOTIAZINE PALMITATE
THIOPROPERAZINE MESYLATE
5 MG ORAL TABLET
25 MG / ML (BASE) INJECTION
2 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
25 MG (BASE) ORAL TABLET
50 MG (BASE) ORAL TABLET
5 MG ORAL CAPSULE
10 MG ORAL CAPSULE
20 MG ORAL CAPSULE
10 MG / ML ORAL DROPS
2 MG ORAL TABLET
4 MG ORAL TABLET
8 MG ORAL TABLET
16 MG ORAL TABLET
25 MG / ML INJECTION
50 MG / ML INJECTION
10 MG (BASE) ORAL TABLET
00000405361
00001927698
00002238403
00002238404
00002238405
00002238406
00001926780
00001926772
00001926764
00001926756
00000335134
00000335126
00000335118
00000335096
00001926667
00001926675
00001927639
APO-FLUPHENAZINE
NOZINAN
APO-METHOPRAZINE
APO-METHOPRAZINE
APO-METHOPRAZINE
APO-METHOPRAZINE
NEULEPTIL
NEULEPTIL
NEULEPTIL
NEULEPTIL
PERPHENAZINE
PERPHENAZINE
PERPHENAZINE
PERPHENAZINE
PIPORTIL L4
PIPORTIL L4
MAJEPTIL
APX
SAV
APX
APX
APX
APX
ERF
ERF
ERF
ERF
AAP
AAP
AAP
AAP
SAV
SAV
ERF
(PHENOTHIAZINES)
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:00
28:16.08.24
0.1720
3.3370
0.0685
0.0991
0.2547
0.3857
0.1884
0.3069
0.4721
0.3718
0.0626
0.0758
0.0832
0.1274
16.0600
51.7800
0.5442
106 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TRIFLUOPERAZINE HCL
FLUPENTIXOL DECANOATE
FLUPENTIXOL DIHYDROCHLORIDE
THIOTHIXENE
ZUCLOPENTHIXOL ACETATE
ZUCLOPENTHIXOL DECANOATE
1 MG (BASE) ORAL TABLET
2 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
20 MG (BASE) ORAL TABLET
20 MG / ML INJECTION
100 MG / ML INJECTION
0.5 MG ORAL TABLET
3 MG ORAL TABLET
2 MG ORAL CAPSULE
5 MG ORAL CAPSULE
10 MG ORAL CAPSULE
50 MG / ML INJECTION
200 MG / ML INJECTION
00000345539
00000312754
00000312746
00000326836
00000595942
00002156032
00002156040
00002156008
00002156016
00000024430
00000024449
00000024457
00002230405
00002230406
TRIFLUOPERAZINE
TRIFLUOPERAZINE
TRIFLUOPERAZINE
TRIFLUOPERAZINE
TRIFLUOPERAZINE
FLUANXOL DEPOT
FLUANXOL DEPOT
FLUANXOL
FLUANXOL
NAVANE
NAVANE
NAVANE
CLOPIXOL ACUPHASE
CLOPIXOL DEPOT
AAP
AAP
AAP
AAP
AAP
LBC
LBC
LBC
LBC
ERF
ERF
ERF
LBC
LBC
(PHENOTHIAZINES)
(THIOXANTHENES)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
28
28
:00
:00
28:16.08.24
28:16.08.32
0.1340
0.1758
0.2328
0.2790
0.5580
7.1860
35.9300
0.2483
0.5362
0.3171
0.3529
0.4416
14.9140
14.9140
107 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
ANTIPSYCHOTICS
ANTIPSYCHOTICS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ZUCLOPENTHIXOL DIHYDROCHLORIDE
LOXAPINE HCL
LOXAPINE SUCCINATE
PIMOZIDE
DEXTROAMPHETAMINE SULFATE
10 MG (BASE) ORAL TABLET
25 MG (BASE) ORAL TABLET
50 MG / ML (BASE) INJECTION
2.5 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
25 MG (BASE) ORAL TABLET
50 MG (BASE) ORAL TABLET
2 MG ORAL TABLET
4 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL SUSTAINED-RELEASE CAPSULE
15 MG ORAL SUSTAINED-RELEASE CAPSULE
00002230402
00002230403
00002169991
00002242868
00002230837
00002230838
00002230839
00002230840
0000224543200000313815
0000224543300000313823
00001924516
00001924559
00001924567
CLOPIXOL
CLOPIXOL
LOXAPAC
XYLAC
XYLAC
XYLAC
XYLAC
XYLAC
APO-PIMOZIDEORAP
APO-PIMOZIDEORAP
DEXEDRINE
DEXEDRINE
DEXEDRINE
LBC
LBC
SDZ
MMT
MMT
MMT
MMT
MMT
APXPHH
APXPHH
PAL
PAL
PAL
(THIOXANTHENES)
(MISCELLANEOUS ANTIPSYCHOTICS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS
ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL STIMULANTS
28
28
28
:00
:00
:00
28:16.08.32
28:16.08.92
28:20.04
0.3835
0.9588
7.0419
0.1759
0.1649
0.2745
0.4255
0.5672
0.3093 0.3093
0.4136 0.4671
0.5748
0.8246
1.0081
108 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$
$$
$$
$
$
$
ANTIPSYCHOTICS
ANTIPSYCHOTICS
(AMPHETAMINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
METHYLPHENIDATE HCL
PHENOBARBITAL
5 MG ORAL TABLET
10 MG ORAL TABLET
20 MG ORAL TABLET
20 MG ORAL EXTENDED-RELEASE TABLET
15 MG ORAL TABLET
30 MG ORAL TABLET
60 MG ORAL TABLET
100 MG ORAL TABLET
5 MG / ML ORAL ELIXIR
00002234749
000022493240000058499100000005606
0000058500900000005614
000022666870000232031200000632775
00000178799
00000178802
00000178810
00000178829
00000645575
PMS-METHYLPHENIDATE
APO-METHYLPHENIDATEPMS-METHYLPHENIDATERITALIN
PMS-METHYLPHENIDATERITALIN
APO-METHYLPHENIDATE SRSANDOZ METHYLPHENIDATERITALIN SR
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PHENOBARB
PMS
APXPMSNOV
PMSNOV
APXSDZNOV
PPH
PPH
PPH
PPH
PPH
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL STIMULANTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28
28
:00
:00
28:20.92
28:24.04
0.0995
0.1331 0.1331 0.3539
0.2326 0.6183
0.2820 0.2820 0.6208
0.0874
0.1040
0.1410
0.1930
0.1167
109 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$
$$
$$$
$
$
$
$
$
(MISCELLANEOUS ANOREXIGENIC AGENTS & RESPIRATORYAND CEREBRAL STIMULANTS)
(BARBITURATES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ALPRAZOLAM
BROMAZEPAM
CHLORDIAZEPOXIDE HCL
CHLORDIAZEPOXIDE HCL/ CLIDINIUM BROMIDE
CLORAZEPATE DIPOTASSIUM
DIAZEPAM
0.25 MG ORAL TABLET
0.5 MG ORAL TABLET
1.5 MG ORAL TABLET
3 MG ORAL TABLET
6 MG ORAL TABLET
5 MG ORAL CAPSULE
10 MG ORAL CAPSULE
25 MG ORAL CAPSULE
5 MG * 2.5 MG ORAL CAPSULE
3.75 MG ORAL CAPSULE
7.5 MG ORAL CAPSULE
15 MG ORAL CAPSULE
2 MG ORAL TABLET
5 MG ORAL TABLET
0000234919100000865397000021375340000191348400000548359
0000234920500000865400000021375420000191349200000548367
00002177153
000021771610000223058400000518123
000021771880000223058500000518131
00000522724
00000522988
00000522996
0000061845400000115630
00000860689
00000860700
00000860697
00000405329
00000362158
ALPRAZOLAMAPO-ALPRAZMYLAN-ALPRAZOLAMTEVA-ALPRAZOLXANAX
ALPRAZOLAMAPO-ALPRAZMYLAN-ALPRAZOLAMTEVA-ALPRAZOLXANAX
APO-BROMAZEPAM
APO-BROMAZEPAMNOVO-BROMAZEPAMLECTOPAM
APO-BROMAZEPAMNOVO-BROMAZEPAMLECTOPAM
APO-CHLORDIAZEPOXIDE
APO-CHLORDIAZEPOXIDE
APO-CHLORDIAZEPOXIDE
APO-CHLORAXLIBRAX
APO-CLORAZEPATE
APO-CLORAZEPATE
APO-CLORAZEPATE
APO-DIAZEPAM
APO-DIAZEPAM
SNSAPXMYPTEVPFI
SNSAPXMYPTEVPFI
APX
APXTEVHLR
APXTEVHLR
APX
APX
APX
APXVCL
APX
APX
APX
APX
APX
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:00
28:24.08
0.0760 0.0760 0.0760 0.0760 0.2486
0.0920 0.0920 0.0920 0.0920 0.2973
0.0693
0.0575 0.0575 0.1529
0.0841 0.0841 0.2234
0.0679
0.1070
0.1658
0.2330 0.3074
0.1476
0.1926
0.3856
0.0508
0.0650
110 EFFECTIVE JULY 1, 2012
$$$$$
$$$$$
$
$$$
$$$
$
$
$
$$
$
$
$
$
$
(BENZODIAZEPINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIAZEPAM
FLURAZEPAM HCL
LORAZEPAM
MIDAZOLAM HCL
10 MG ORAL TABLET
5 MG / ML INJECTION
5 MG / ML INJECTION EMULSION
15 MG ORAL CAPSULE
30 MG ORAL CAPSULE
0.5 MG ORAL TABLET
1 MG ORAL TABLET
2 MG ORAL TABLET
0.5 MG ORAL SUBLINGUAL TABLET
1 MG ORAL SUBLINGUAL TABLET
2 MG ORAL SUBLINGUAL TABLET
5 MG / ML (BASE) INJECTION
00000405337
00000399728
00002065614
00000521698
00000521701
0000065574000002041413000023510720000071110100000728187
0000065575900002041421000023510800000063774200000728195
0000065576700002041448000023510990000063775000000728209
00002041456
00002041464
00002041472
00002240286
APO-DIAZEPAM
DIAZEPAM
DIAZEMULS
APO-FLURAZEPAM
APO-FLURAZEPAM
APO-LORAZEPAMATIVANLORAZEPAMNOVO-LORAZEMPMS-LORAZEPAM
APO-LORAZEPAMATIVANLORAZEPAMNOVO-LORAZEMPMS-LORAZEPAM
APO-LORAZEPAMATIVANLORAZEPAMNOVO-LORAZEMPMS-LORAZEPAM
ATIVAN
ATIVAN
ATIVAN
MIDAZOLAM
APX
SDZ
PFI
APX
APX
APXWAYSNSTEVPMS
APXWAYSNSTEVPMS
APXWAYSNSTEVPMS
WAY
WAY
WAY
SDZ
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:00
28:24.08
0.0867
0.7302
1.1429
0.1166
0.1364
0.0359 0.0359 0.0359 0.0359 0.0359
0.0447 0.0447 0.0447 0.0447 0.0447
0.0699 0.0699 0.0699 0.0699 0.0699
0.1073
0.1348
0.2097
3.8140
111 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$$$$$
$$$$$
$$$$$
$
$
$
$
(BENZODIAZEPINES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
NITRAZEPAM
OXAZEPAM
TEMAZEPAM
TRIAZOLAM
BUSPIRONE HCL
CHLORAL HYDRATE
5 MG ORAL TABLET
10 MG ORAL TABLET
10 MG ORAL TABLET
15 MG ORAL TABLET
30 MG ORAL TABLET
15 MG ORAL CAPSULE
30 MG ORAL CAPSULE
0.125 MG ORAL TABLET
0.25 MG ORAL TABLET
10 MG ORAL TABLET
100 MG / ML ORAL SYRUP
00002245230000022340030000222965400000511528
00002245231000022340070000222965500000511536
00000402680
00000402745
00000402737
00002225964000022448140000223009500000604453
00002225972000022448150000223010200000604461
00000808563
00000808571
000022110760000223149200002230942
00000792659
APO-NITRAZEPAMSANDOZ NITRAZEPAMNITRAZADONMOGADON
APO-NITRAZEPAMSANDOZ NITRAZEPAMNITRAZADONMOGADON
APO-OXAZEPAM
APO-OXAZEPAM
APO-OXAZEPAM
APO-TEMAZEPAMCO TEMAZEPAMNOVO-TEMAZEPAMRESTORIL
APO-TEMAZEPAMCO TEMAZEPAMNOVO-TEMAZEPAMRESTORIL
APO-TRIAZO
APO-TRIAZO
APO-BUSPIRONENOVO-BUSPIRONEPMS-BUSPIRONE
PMS-CHLORAL HYDRATE
APXSDZVCLVCL
APXSDZVCLVCL
APX
APX
APX
APXCOBTEVSUN
APXCOBTEVSUN
APX
APX
APXTEVPMS
PMS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28
28
:00
:00
28:24.08
28:24.92
0.0500 0.0500 0.0698 0.1490
0.0748 0.0748 0.1044 0.2230
0.0420
0.0660
0.0900
0.0730 0.0730 0.0730 0.1940
0.0883 0.0883 0.0883 0.2348
0.1496
0.2502
0.3723 0.3723 0.3723
0.0455
112 EFFECTIVE JULY 1, 2012
$$$$
$$$$
$
$
$
$$$$
$$$$
$
$
$$$
$
(BENZODIAZEPINES)
(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
HYDROXYZINE HCL
ZOPICLONE
10 MG ORAL CAPSULE
25 MG ORAL CAPSULE
50 MG ORAL CAPSULE
2 MG / ML ORAL SYRUP
50 MG / ML INJECTION
5 MG ORAL TABLET
7.5 MG ORAL TABLET
0000064605900000738824
0000064602400000738832
0000064601600000738840
0000074181700000024694
00000742813
0000224507700002363534000022719310000229661600002251450000022434260000226791800002246534000022575720000234412200002216167
000022183130000236354200002271958000022385960000225146900002240606000022679260000224248100002008203000022575800000228244500001926799
APO-HYDROXYZINENOVO-HYDROXYZIN
APO-HYDROXYZINENOVO-HYDROXYZIN
APO-HYDROXYZINENOVO-HYDROXYZIN
PMS-HYDROXYZINEATARAX
HYDROXYZINE HCL
APO-ZOPICLONEAVA-ZOPICLONECO ZOPICLONEMYLAN-ZOPICLONENOVO-ZOPICLONEPMS-ZOPICLONERAN-ZOPICLONERATIO-ZOPICLONESANDOZ ZOPICLONEZOPICLONEIMOVANE
APO-ZOPICLONEAVA-ZOPICLONECO ZOPICLONEMYLAN-ZOPICLONENOVO-ZOPICLONEPMS-ZOPICLONERAN-ZOPICLONERATIO-ZOPICLONERHOVANESANDOZ ZOPICLONEZOPICLONEIMOVANE
APXTEV
APXTEV
APXTEV
PMSERF
SDZ
APXAVACOBMYPTEVPMSRANRPHSDZSNSSAV
APXAVACOBMYPTEVPMSRANRPHSDZSDZSNSSAV
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:00
28:24.92
0.1116 0.1116
0.1425 0.1425
0.2068 0.2068
0.0436 0.0519
4.4186
0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 1.0340
0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 1.3056
113 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$
$$
$$
$
$$$$$$$$$$$
$$$$$$$$$$$$
(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LITHIUM CARBONATE
NARATRIPTAN HCL
RIZATRIPTAN BENZOATE
150 MG ORAL CAPSULE
150 MG ORAL CAPSULE
300 MG ORAL CAPSULE
300 MG ORAL CAPSULE
600 MG ORAL CAPSULE
1 MG (BASE) ORAL TABLET
2.5 MG (BASE) ORAL TABLET
10 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL DISINTEGRATING TABLET
000022428370000221613200000461733
0000224283700002013231
000022428380000221614000000236683
0000224283800000406775
00002216159
0000231429000002237820
000023223230000231430400002237821
00002240521
00002374730000023791980000235187000002240518
APO-LITHIUM CARBONATEPMS-LITHIUM CARBONATECARBOLITH
APO-LITHIUM CARBONATELITHANE
APO-LITHIUM CARBONATEPMS-LITHIUM CARBONATECARBOLITH
APO-LITHIUM CARBONATELITHANE
PMS-LITHIUM CARBONATE
NOVO-NARATRIPTANAMERGE
SANDOZ NARATRIPTANNOVO-NARATRIPTANAMERGE
MAXALT
CO RIZATRIPTAN ODTMYLAN-RIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTMAXALT RPD
APXPMSVCL
APXERF
APXPMSVCL
APXERF
PMS
TEVGSK
SDZTEVGSK
MFC
COBMYPSDZMFC
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
ANTIMIGRAINE AGENTS
28
28
:00
:00
28:28
28:32.28
0.0449 0.0449 0.1190
0.0449 0.1019
0.0443 0.0443 0.0924
0.0443 0.1015
0.1429
8.4338 14.1715
6.1437 6.1438
14.9372
15.2201
5.3270 5.3270 5.3270
15.2201
114 EFFECTIVE JULY 1, 2012
$$$
$$
$$$
$$
$
$$
$$$
$
$$$$
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive for the treatment of acute migraine attacks in patients where other standard therapy has failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in patients 65 years of age and older; and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive for the treatment of acute migraine attacks in patients where standard therapy has failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in patients 65 years of age and older; and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
(SELECTIVE SEROTONIN AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RIZATRIPTAN BENZOATE
SUMATRIPTAN HEMISULFATE
SUMATRIPTAN SUCCINATE
10 MG (BASE) ORAL DISINTEGRATING TABLET
5 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY
20 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY
50 MG (BASE) ORAL TABLET
100 MG (BASE) ORAL TABLET
6 MG / SYR (BASE) INJECTION SYRINGE
00002374749000023792010000235188900002240519
00002230418
00002230420
000022683880000236625800002257890000022689140000228682300002256436000022630250000228652100002212153
00002268396000023662660000225790400002268922000022393670000228683100002256444000022630330000228654800002212161
0000236169800002212188
CO RIZATRIPTAN ODTMYLAN-RIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTMAXALT RPD
IMITREX
IMITREX
APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF
APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF
SUMATRIPTAN SUN (0.5 ML)IMITREX (0.5 ML)
COBMYPSDZMFC
GSK
GSK
APXAVACOBMYPTEVPMSSDZSNSGSK
APXAVACOBMYPTEVTEVPMSSDZSNSGSK
SPGGSK
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:00
28:32.28
5.3270 5.3270 5.3270
15.2201
14.3859
14.8045
7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350
15.1567
7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600
16.6968
16.5889 44.0900
115 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$
$
$
$$$$$$$$$
$$$$$$$$$$
$$
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive for the treatment of acute migraine attacks in patients where other standard therapy has failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in patients 65 years of age and older; and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive for the treatment of acute migraine attacks in patients where other standard therapy has failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in patients 65 years of age and older, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
(SELECTIVE SEROTONIN AGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ZOLMITRIPTAN
PIZOTIFEN MALATE
AMANTADINE HCL
2.5 MG ORAL TABLET
2.5 MG ORAL DISPERSIBLE TABLET
5 MG / DOSE NASAL UNIT DOSE SPRAY
0.5 MG (BASE) ORAL TABLET
100 MG ORAL CAPSULE
10 MG / ML ORAL SYRUP
0000236903600002324229000023629880000231396000002238660
00002324768000023629960000234254500002243045
00002248993
00000329320
0000213920000001990403
00002022826
MYLAN-ZOLMITRIPTANPMS-ZOLMITRIPTANSANDOZ ZOLMITRIPTANTEVA-ZOLMITRIPTANZOMIG
PMS-ZOLMITRIPTAN ODTSANDOZ ZOLMITRIPTAN ODTTEVA-ZOLMITRIPTAN ODZOMIG RAPIMELT
ZOMIG
SANDOMIGRAN
MYLAN-AMANTADINEPMS-AMANTADINE HYDROCHLORIDE
PMS-AMANTADINE HYDROCHLORIDE
MYPPMSSDZTEVAZC
PMSSDZTEVAZC
AZC
PAL
MYPPMS
PMS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS
ANTIPARKINSONIAN AGENTS
28
28
28
:00
:00
:00
28:32.28
28:32.92
28:36.04
5.2110 5.2110 5.2110 5.2110
13.8500
5.2110 5.2110 5.2110
13.8500
13.8500
0.3875
0.5179 0.5179
0.1005
116 EFFECTIVE JULY 1, 2012
$$$$$
$$$$
$
$
$$
$
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive for the treatment of acute migraine attacks in patients where other standard therapy has failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in patients 65 years of age and older; and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
(SELECTIVE SEROTONIN AGONISTS)
(MISCELLANEOUS ANTIMIGRAINE AGENTS)
(ADAMANTANES)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
BENZTROPINE MESYLATE
ETHOPROPAZINE HCL
PROCYCLIDINE HCL
TRIHEXYPHENIDYL HCL
ENTACAPONE
LEVODOPA/ BENSERAZIDE HCL
1 MG ORAL TABLET
2 MG ORAL TABLET
1 MG / ML INJECTION
50 MG (BASE) ORAL TABLET
2.5 MG ORAL TABLET
5 MG ORAL TABLET
0.5 MG / ML ORAL ELIXIR
2 MG ORAL TABLET
5 MG ORAL TABLET
200 MG ORAL TABLET
50 MG * 12.5 MG (BASE) ORAL CAPSULE
100 MG * 25 MG (BASE) ORAL CAPSULE
200 MG * 50 MG (BASE) ORAL CAPSULE
00000706531
0000042685700000587265
00002238903
00001927744
00000649392
00000587354
00000587362
00000545058
00000545074
000023214590000237555900002243763
00000522597
00000386464
00000386472
PMS-BENZTROPINE
BENZTROPINEPMS-BENZTROPINE
BENZTROPINE OMEGA
PARSITAN
PMS-PROCYCLIDINE
PMS-PROCYCLIDINE
PMS-PROCYCLIDINE
TRIHEXYPHENIDYL
TRIHEXYPHENIDYL
APO-ENTACAPONETEVA-ENTACAPONECOMTAN
PROLOPA 50-12.5
PROLOPA 100-25
PROLOPA 200-50
PMS
PMSPMS
OMG
ERF
PMS
PMS
PMS
AAP
AAP
APXTEVNOV
HLR
HLR
HLR
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS
28
28
28
:00
:00
:00
28:36.08
28:36.12
28:36.16
0.0450
0.0450 0.0450
7.5000
0.2081
0.0624
0.1248
0.2516
0.0369
0.0668
0.6095 0.6095 1.6199
0.2787
0.4588
0.7702
117 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$
$
$
$
$
$
$
$
$$$
$
$
$
(ANTICHOLINERGIC AGENTS)
(CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS)
(DOPAMINE PRECURSORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LEVODOPA/ CARBIDOPA
LEVODOPA/ CARBIDOPA/ ENTACAPONE
BROMOCRIPTINE MESYLATE
100 MG * 10 MG ORAL TABLET
100 MG * 25 MG ORAL TABLET
250 MG * 25 MG ORAL TABLET
100 MG * 25 MG ORAL SUSTAINED-RELEASE TABLET
200 MG * 50 MG ORAL SUSTAINED-RELEASE TABLET
50 MG * 12.5 MG * 200 MG ORAL TABLET
75 MG * 18.75 MG * 200 MG ORAL TABLET
100 MG * 25 MG * 200 MG ORAL TABLET
125 MG * 31.25 MG * 200 MG ORAL TABLET
150 MG * 37.5 MG * 200 MG ORAL TABLET
2.5 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL CAPSULE
000021959330000224449400000355658
000021959410000224449500000513997
000021959680000224449600000328219
0000227287300002028786
00000870935
00002305933
00002337827
00002305941
00002337835
00002305968
00002087324
00002230454
APO-LEVOCARBNOVO-LEVOCARBIDOPASINEMET 100/10
APO-LEVOCARBNOVO-LEVOCARBIDOPASINEMET 100/25
APO-LEVOCARBNOVO-LEVOCARBIDOPASINEMET 250/25
LEVOCARB CRSINEMET CR 100/25
SINEMET CR 200/50
STALEVO
STALEVO
STALEVO
STALEVO
STALEVO
APO-BROMOCRIPTINE
APO-BROMOCRIPTINE
APXTEVMFC
APXTEVMFC
APXTEVMFC
AAPMFC
MFC
NOV
NOV
NOV
NOV
NOV
APX
APX
(ERGOT-DERIVATIVE-DOPAMINE RECEPTOR AGONISTS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS
28
28
:00
:00
28:36.16
28:36.20.04
0.1877 0.1877 0.4554
0.2803 0.2803 0.6800
0.3129 0.3129 0.7591
0.5510 0.7374
1.3603
1.6018
1.6018
1.6018
1.6018
1.6018
0.9782
1.4644
118 EFFECTIVE JULY 1, 2012
$$$
$$$
$$$
$$
$
$
$
$
$
$
$
$
(DOPAMINE PRECURSORS)
DOPAMINE RECEPTOR AGONISTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRAMIPEXOLE DIHYDROCHLORIDE
ROPINIROLE HCL
0.25 MG ORAL TABLET
1 MG ORAL TABLET
1.5 MG ORAL TABLET
0.25 MG (BASE) ORAL TABLET
1 MG (BASE) ORAL TABLET
0000229237800002363305000022973020000237635000002269309000022901110000236760200002315262
00002292394000023633210000229732900002376377000022693250000229014600002315289
00002292408000023633480000229733700002376385000022693330000229015400002315297
0000233774600002316846000023523380000232659000002314037000023323610000235304000002232565
0000233776200002316854000023523460000232661200002314053000023324260000235305900002232567
APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLEPRAMIPEXOLESANDOZ PRAMIPEXOLE
APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLESANDOZ PRAMIPEXOLE
APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLESANDOZ PRAMIPEXOLE
APO-ROPINIROLECO ROPINIROLEJAMP-ROPINIROLEPMS-ROPINIROLERAN-ROPINIROLEROPINIROLEROPINIROLEREQUIP
APO-ROPINIROLECO ROPINIROLEJAMP-ROPINIROLEPMS-ROPINIROLERAN-ROPINIROLEROPINIROLEROPINIROLEREQUIP
APXAVACOBMYPTEVPMSSNSSDZ
APXAVACOBMYPTEVPMSSDZ
APXAVACOBMYPTEVPMSSDZ
APXCOBJPCPMSRANRANSNSGSK
APXCOBJPCPMSRANRANSNSGSK
(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:00
28:36.20.08
0.3679 0.3679 0.3679 0.3679 0.3679 0.3679 0.3679 0.3679
0.7360 0.7360 0.7360 0.7360 0.7360 0.7360 0.7360
0.7360 0.7360 0.7360 0.7360 0.7360 0.7360 0.7360
0.1068 0.1068 0.1068 0.1068 0.1068 0.1068 0.1068 0.2838
0.4271 0.4271 0.4271 0.4271 0.4271 0.4271 0.4271 1.1353
119 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$
$$$$$$$
$$$$$$$
$$$$$$$$
$$$$$$$$
DOPAMINE RECEPTOR AGONISTS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
ROPINIROLE HCL
SELEGILINE HCL
PIZOTIFEN MALATE
2 MG (BASE) ORAL TABLET
5 MG (BASE) ORAL TABLET
5 MG ORAL TABLET
1 MG (BASE) ORAL TABLET
0000233777000002316862000023523540000232662000002314061000023324340000235306700002232568
0000233780000002316870000023523620000232663900002314088000023324420000235307500002232569
000022306410000223103600002068087
00000511552
APO-ROPINIROLECO ROPINIROLEJAMP-ROPINIROLEPMS-ROPINIROLERAN-ROPINIROLEROPINIROLEROPINIROLEREQUIP
APO-ROPINIROLECO ROPINIROLEJAMP-ROPINIROLEPMS-ROPINIROLERAN-ROPINIROLEROPINIROLEROPINIROLEREQUIP
APO-SELEGILINEMYLAN-SELEGILINENOVO-SELEGILINE
SANDOMIGRAN DS
APXCOBJPCPMSRANRANSNSGSK
APXCOBJPCPMSRANRANSNSGSK
APXMYPTEV
PAL
(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
ANTIPARKINSONIAN AGENTS
MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS
28
28
28
:00
:00
:00
28:36.20.08
28:36.32
28:92
0.4699 0.4699 0.4699 0.4699 0.4699 0.4699 0.4699 1.2489
1.2937 1.2937 1.2937 1.2937 1.2937 1.2937 1.2937 3.4384
0.7906 0.7906 0.7906
0.6434
120 EFFECTIVE JULY 1, 2012
$$$$$$$$
$$$$$$$$
$$$
$
DOPAMINE RECEPTOR AGONISTS
(MONOAMINE OXIDASE B INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
34:00 Dental A
gents
34:00
Dental Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
SODIUM FLUORIDE2.21 MG ORAL CHEWABLE TABLET
5.56 MG / ML ORAL DROPS00000575569
00000610100
FLUOR-A-DAY
FLUOR-A-DAY
PMS
PMS
DENTAL AGENTS34:00
34:00
0.0867
0.1734
121 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
36:00 Diagnostic A
gents
36:00
Diagnostic Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
THYROTROPIN ALFA0.9 MG / VIAL INJECTION
00002246016 THYROGEN GZM
DIAGNOSTIC AGENTS
THYROID FUNCTION
36:00
36:60
1363.7200
123 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
40:00 Electrolytic, Caloric, and W
ater Balance
40:00
Electrolytic, Caloric, and Water Balance
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
LACTULOSE
MAGNESIUM GLUCOHEPTONATE
MAGNESIUM GLUCONATE
POTASSIUM CHLORIDE (K+)
POTASSIUM CHLORIDE (K+)(CL-)
POTASSIUM CITRATE (K+)
SODIUM ACID PHOSPHATE/ SODIUM BICARBONATE/ POTASSIUM BICARBONATE
CALCIUM POLYSTYRENE SULPHONATE
667 MG / ML ORAL SYRUP
100 MG / ML ORAL SOLUTION
500 MG ORAL TABLET
8 MEQ ORAL SUSTAINED-RELEASE TABLET
20 MEQ ORAL SUSTAINED-RELEASE TABLET
8 MEQ ORAL SUSTAINED-RELEASE CAPSULE
1.33 MEQ / ML ORAL LIQUID
25 MEQ ORAL EFFERVESCENT TABLET
500 MG (BASE) * 469 MG (BASE) * 123 MG (BASE) ORAL EFFERVESCENT TABLET
ORAL POWDER
0000224281400002295881000007034860000085440900002331551
00000026697
00000555126
0000060288400000074225
00000713376
00002042304
0000223860400080024360
00002085992
00080027202
00002017741
APO-LACTULOSEJAMP-LACTULOSEPMS-LACTULOSERATIO-LACTULOSETEVA-LACTULOSE
ROUGIER MAGNESIUM
MAGLUCATE
APO-KSLOW K
K-DUR
MICRO-K EXTENCAPS
PMS - POTASSIUM CHLORIDEK-10 ORAL LIQUID
K-LYTE
PHOSPHATE-NOVARTIS
RESONIUM CALCIUM
APXJPCPMSRPHTEV
ROG
PMS
APXNOV
MFC
PAL
PMSGSK
WSP
NOV
SAV
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
AMMONIA DETOXICANTS
REPLACEMENT PREPARATIONS
ION-REMOVING AGENTS
40
40
40
:00
:00
:00
40:10
40:12
40:18.18
0.0145 0.0145 0.0145 0.0145 0.0145
0.0200
0.1166
0.0899 0.1475
0.2052
0.0930
0.0146 0.0157
0.5550
0.6858
0.3545
125 EFFECTIVE JULY 1, 2012
$ 0.0899
UNIT OF ISSUE - REFER TO PRICE POLICY
MAC pricing has been applied based on the lowest unit cost for an 8 mEq (K+) oral sustained-release tablet: APO-K.
$$$$$
$
$
$$
$
$
$$
$
$
$
(POTASSIUM-REMOVING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SODIUM POLYSTYRENE SULFONATE
AMILORIDE HCL
HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE/ AMILORIDE HCL
HYDROCHLOROTHIAZIDE/ TRIAMTERENE
CHLORTHALIDONE
250 MG / ML ORAL SUSPENSION
ORAL POWDER
30 G / ENM RECTAL RETENTION ENEMA
5 MG ORAL TABLET
12.5 MG ORAL TABLET
25 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
50 MG * 5 MG ORAL TABLET
25 MG * 50 MG ORAL TABLET
50 MG ORAL TABLET
00000769541
0000075533800002026961
00000769533
00002249510
00002274086
00000326844
00000312800
00000644552
0000078440000001937219
0000044177500000532657
00000360279
SOLYSTAT
PMS-SODIUM POLYSTYRENE SULF.KAYEXALATE
SOLYSTAT
MIDAMOR
PMS-HYDROCHLOROTHIAZIDE
APO-HYDRO
APO-HYDRO
APO-HYDRO
APO-AMILZIDENOVAMILOR
APO-TRIAZIDENOVO-TRIAMZIDE
CHLORTHALIDONE
PPH
PMSSAV
PPH
AAP
PMS
APX
APX
APX
APXTEV
APXTEV
AAP
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ION-REMOVING AGENTS
DIURETICS
DIURETICS
DIURETICS
40
40
40
40
:00
:00
:00
:00
40:18.18
40:28.16
40:28.20
40:28.24
0.1306
0.1696 0.1835
15.3608
0.2717
0.0338
0.0247
0.0344
0.1232
0.1293 0.1293
0.0608 0.0608
0.1242
126 EFFECTIVE JULY 1, 2012
$
$$
$
$
$
$
$
$
$$
$$
$
(POTASSIUM-REMOVING AGENTS)
(POTASSIUM-SPARING DIURETICS)
(THIAZIDE DIURETICS)
(THIAZIDE-LIKE DIURETICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
INDAPAMIDE HEMIHYDRATE
METOLAZONE
PROBENECID
SULFINPYRAZONE
1.25 MG (BASE) ORAL TABLET
2.5 MG (BASE) ORAL TABLET
2.5 MG ORAL TABLET
500 MG ORAL TABLET
200 MG ORAL TABLET
000022452460000224006700002239619
0000222367800002153483000022311840000223962000000564966
00000888400
00000294926
00000441767
APO-INDAPAMIDEMYLAN-INDAPAMIDEPMS-INDAPAMIDE
APO-INDAPAMIDEMYLAN-INDAPAMIDENOVO-INDAPAMIDEPMS-INDAPAMIDELOZIDE
ZAROXOLYN
BENURYL
SULFINPYRAZONE
APXMYPPMS
APXMYPTEVPMSSEV
SAV
VCL
AAP
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ELECTROLYTIC, CALORIC, AND WATER BALANCE
DIURETICS
URICOSURIC AGENTS
40
40
:00
:00
40:28.24
40:40
0.1173 0.1173 0.1173
0.1833 0.1833 0.1833 0.1833 0.4873
0.1937
0.5280
0.2997
127 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$$$$$
$
$
$
(THIAZIDE-LIKE DIURETICS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
48:00 Respiratory Tract A
gents
48:00
Respiratory Tract Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
MONTELUKAST SODIUM
ZAFIRLUKAST
10 MG (BASE) ORAL TABLET
4 MG (BASE) ORAL CHEWABLE TABLET
5 MG (BASE) ORAL CHEWABLE TABLET
4 MG (BASE) ORAL GRANULE
20 MG ORAL TABLET
00002374609000023793330000236822600002373947000023285930000235552300002238217
00002377608000023793170000238074900002354977000023303850000235550700002243602
00002377616000023793250000238075700002354985000023303930000235551500002238216
0000235861100002247997
00002236606
APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKAST FCSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR
APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKASTSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR
APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKASTSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR
SANDOZ MONTELUKASTSINGULAIR
ACCOLATE
APXSNSMYPPMSSDZTEVMFC
APXSNSMYPPMSSDZTEVMFC
APXSNSMYPPMSSDZTEVMFC
SDZMFC
AZC
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
48:00
48:10.24
0.8483 0.8483 0.8483 0.8483 0.8483 0.8483 2.4238
0.5216 0.5216 0.5216 0.5216 0.5216 0.5216 1.4904
0.5776 0.5776 0.5776 0.5776 0.5776 0.5776 1.6503
0.5216 1.4904
0.7492
129 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$
$$$$$$$
$$$$$$$
$$
$
RESTRICTED BENEFIT - This product is a benefit for patients 6 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
RESTRICTED BENEFIT - This product is a benefit for patients 2 to 18 years of age inclusive for the prophylaxis and treatment of asthma.
RESTRICTED BENEFIT - This product is a benefit for patients 6 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
RESTRICTED BENEFIT - This product is a benefit for patients 2 to 18 years of age inclusive for the prophylaxis and treatment of asthma.
RESTRICTED BENEFIT - This product is a benefit for patients 12 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to the Criteria for Special Authorization of Select Drug Products of the List, and Criteria forSpecial Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)
(LEUKOTRIENE MODIFIERS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
SODIUM CROMOGLYCATE
ACETYLCYSTEINE
100 MG ORAL CAPSULE
1 % INHALATION SOLUTION
20 % INHALATION SOLUTION
00000500895
00002046113
0000224309800002091526
NALCROM
PMS-SODIUM CROMOGLYCATE
ACETYLCYSTEINEMUCOMYST
SAV
PMS
SDZWSP
RESPIRATORY TRACT AGENTS
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
MUCOLYTIC AGENTS
48
48
:00
:00
48:10.32
48:24
1.4276
0.7696
0.6800 0.7200
130 EFFECTIVE JULY 1, 2012
$
$
$$
(MAST-CELL STABILIZERS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
52:00 Eye, Ear, Nose and Throat (EEN
T) Preparations
52:00
Eye, Ear, Nose and Throat (EENT) Preparations
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CIPROFLOXACIN HCL
ERYTHROMYCIN
GENTAMICIN SULFATE
NEOMYCIN SULFATE/ POLYMYXIN B SULFATE/ GRAMICIDIN
OFLOXACIN
TOBRAMYCIN
TRIFLURIDINE
0.3 % (BASE) OPHTHALMIC SOLUTION
0.5 % OPHTHALMIC OINTMENT
0.3 % (BASE) OPHTHALMIC SOLUTION
0.3 % (BASE) OPHTHALMIC OINTMENT
0.3 % (BASE) OTIC SOLUTION
0.25 % * 10,000 UNIT / ML * 0.03 MG / ML OTIC/OPHTHALMIC SOLUTION
0.3 % OPHTHALMIC SOLUTION
0.3 % OPHTHALMIC SOLUTION
0.3 % OPHTHALMIC OINTMENT
1 % OPHTHALMIC SOLUTION
0000225393300001945270
00001912755
0000051219200002229440
00002230888
0000051218400002229441
00000807435
000022483980000225257000002143291
000022395770000224175500000513962
00000614254
0000224852900000687456
PMS-CIPROFLOXACINCILOXAN
PMS-ERYTHROMYCIN
GARAMYCINSANDOZ GENTAMICIN SULFATE
SANDOZ GENTAMICIN SULFATE
GARAMYCINSANDOZ GENTAMICIN SULFATE
OPTIMYXIN PLUS
APO-OFLOXACINPMS-OFLOXACINOCUFLOX
PMS-TOBRAMYCINSANDOZ TOBRAMYCINTOBREX
TOBREX
SANDOZ TRIFLURIDINEVIROPTIC
PMSALC
PMS
MFCSDZ
SDZ
MFCSDZ
SDZ
APXPMSALL
PMSSDZALC
ALC
SDZVCL
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFECTIVES
ANTI-INFECTIVES
52
52
:00
:00
52:04.04
52:04.20
0.7639 2.0302
1.2959
0.4060 0.4060
1.4286
1.0320 1.0320
0.7656
0.9203 0.9203 2.4460
0.6560 0.6560 1.7435
2.4728
3.0387 3.0387
131 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$$
$
$$
$
$$$
$$$
$
$$
(ANTIBACTERIALS)
(ANTIVIRALS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
BECLOMETHASONE DIPROPIONATE
BUDESONIDE
CIPROFLOXACIN HCL/ DEXAMETHASONE
DEXAMETHASONE
DEXAMETHASONE SODIUM PHOSPHATE
FLUNISOLIDE
FLUOROMETHOLONE
FLUOROMETHOLONE ACETATE
HYDROCORTISONE ACETATE
MOMETASONE FUROATE
50 MCG / DOSE NASAL METERED DOSE SPRAY
100 MCG / DOSE NASAL METERED DOSE AEROSOL
100 MCG / DOSE NASAL METERED DOSE SPRAY
0.3 % * 0.1 % OTIC SUSPENSION
0.1 % OPHTHALMIC SUSPENSION
0.1 % OPHTHALMIC OINTMENT
0.1 % OTIC/OPHTHALMIC SOLUTION
0.025 % NASAL SPRAY
0.1 % OPHTHALMIC SUSPENSION
0.25 % OPHTHALMIC SUSPENSION
0.1 % OPHTHALMIC SUSPENSION
2.5 % OPHTHALMIC OINTMENT
50 MCG / DOSE NASAL METERED DOSE SPRAY
0000223879600002172712
00002035324
00002230648
00002252716
00000042560
00000042579
00000739839
00002239288
00002238568
00000707511
00000756784
00001980661
00002238465
APO-BECLOMETHASONEMYLAN-BECLO AQ.
RHINOCORT TURBUHALER
MYLAN-BUDESONIDE AQ
CIPRODEX
MAXIDEX
MAXIDEX
SANDOZ DEXAMETHASONE SOD. PHOSPHATE
APO-FLUNISOLIDE
PMS-FLUOROMETHOLONE
FML FORTE
FLAREX
CORTAMED
NASONEX
APXMYP
AZC
MYP
ALC
ALC
ALC
SDZ
APX
PMS
ALL
ALC
SDZ
MFC
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFLAMMATORY AGENTS
52:00
52:08.08
0.0613 0.0613
0.1178
0.1006
3.5533
1.6116
2.4967
1.3079
0.5940
1.7880
2.6260
1.8209
5.7674
0.2065
132 EFFECTIVE JULY 1, 2012
$$
$
$
$
$
$
$
$
$
$
$
$
$RESTRICTED BENEFIT - This product is a benefit for patients 3 to 12 years of age inclusive for the treatment of seasonal allergic rhinitis or perennial allergic rhinitis.
(CORTICOSTEROIDS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PREDNISOLONE ACETATE
BETAMETHASONE SODIUM PHOSPHATE/ GENTAMICIN SULFATE
DEXAMETHASONE/ FRAMYCETIN SULFATE/ GRAMICIDIN
DEXAMETHASONE/ NEOMYCIN SULFATE/ POLYMYXIN B SULFATE
DEXAMETHASONE/ TOBRAMYCIN
FLUMETHASONE PIVALATE/ CLIOQUINOL
PREDNISOLONE ACETATE/ SULFACETAMIDE SODIUM
0.12 % OPHTHALMIC SUSPENSION
1 % OPHTHALMIC SUSPENSION
0.1 % (BASE) * 0.3 % (BASE) OTIC/OPHTHALMIC SOLUTION
0.5 MG / ML * 5 MG / ML * 0.05 MG / ML OTIC/OPHTHALMIC SOLUTION
1 MG / ML * 3.5 MG / ML (BASE) * 6,000 UNIT / ML OPHTHALMIC SUSPENSION
1 MG / G * 3.5 MG / G (BASE) * 6,000 UNIT / G OPHTHALMIC OINTMENT
0.1 % * 0.3 % OPHTHALMIC SUSPENSION
0.1 % * 0.3 % OPHTHALMIC OINTMENT
0.02 % * 1 % OTIC SOLUTION
0.2 % * 10 % OPHTHALMIC SUSPENSION
0.2 % * 10 % OPHTHALMIC OINTMENT
0000191618100000299405
000007004010000191620300000301175
0000068221700002244999
0000224792000002224623
00000042676
00000358177
00000778907
00000778915
00000074454
00000807788
00000307246
SANDOZ PREDNISOLONE ACETATEPRED MILD
RATIO-PREDNISOLONESANDOZ PREDNISOLONE ACETATEPRED FORTE
GARASONESANDOZ PENTASONE
SANDOZ OPTICORTSOFRACORT
MAXITROL
MAXITROL
TOBRADEX
TOBRADEX
LOCACORTEN VIOFORM
BLEPHAMIDE
BLEPHAMIDE S.O.P.
SDZALL
RPHSDZALL
MFCSDZ
SDZSAV
ALC
ALC
ALC
ALC
PAL
ALL
ALL
(COMBINATION ANTI-INFECTIVE/CORTICOSTEROID AGENTS)
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFLAMMATORY AGENTS
ANTI-INFLAMMATORY AGENTS
52
52
:00
:00
52:08.08
52:08.08.00
1.3450 1.7960
1.9400 1.9400 5.2880
1.2813 1.2813
1.3000 1.8663
1.9926
2.7778
2.0400
3.0057
1.4790
2.6623
3.4057
133 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$$
$$
$$
$
$
$
$
$
$
$
(CORTICOSTEROIDS)
CORTICOSTEROIDS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DICLOFENAC SODIUM
KETOROLAC TROMETHAMINE
LIDOCAINE HCL
PROPARACAINE HCL
ATROPINE SULFATE
CYCLOPENTOLATE HCL
HOMATROPINE HYDROBROMIDE
TROPICAMIDE
0.1 % OPHTHALMIC SOLUTION
0.5 % OPHTHALMIC SOLUTION
2 % ORAL LIQUID
0.5 % OPHTHALMIC SOLUTION
1 % OPHTHALMIC SOLUTION
1 % OPHTHALMIC SOLUTION
2 % OPHTHALMIC SOLUTION
5 % OPHTHALMIC SOLUTION
0.5 % OPHTHALMIC SOLUTION
1 % OPHTHALMIC SOLUTION
00001940414
000022474610000224582100001968300
0000196882300000001686
00000035076
00000035017
00000252506
00000000779
00000000787
00000000981
00000001007
VOLTAREN OPHTHA
RATIO-KETOROLACAPO-KETOROLACACULAR
LIDODAN VISCOUSXYLOCAINE VISCOUS
ALCAINE
ISOPTO ATROPINE
CYCLOGYL
ISOPTO HOMATROPINE
ISOPTO HOMATROPINE
MYDRIACYL
MYDRIACYL
ALC
RPHAPXALL
ODNAZC
ALC
ALC
ALC
ALC
ALC
ALC
ALC
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFLAMMATORY AGENTS
LOCAL ANESTHETICS
MYDRIATICS
52
52
52
:00
:00
:00
52:08.20
52:16
52:24
2.5200
1.6000 2.0160 3.3600
0.0525 0.0950
0.6280
0.6279
0.8442
0.6384
0.7605
0.8756
1.1268
134 EFFECTIVE JULY 1, 2012
$
$$$
$$
$
$
$
$
$
$
$
(NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
BENZYDAMINE HCL
COMPOUND PRESCRIPTION
EPINEPHRINE HCL
PHENYLEPHRINE HCL
BRIMONIDINE TARTRATE
BETAXOLOL HCL
0.15 % ORAL RINSE
ORAL
ORAL
1 MG / ML TOPICAL SOLUTION
2.5 % OPHTHALMIC SOLUTION
0.2 % OPHTHALMIC SOLUTION
0.25 % (BASE) OPHTHALMIC SUSPENSION
0000231042200002229777
00000999209
00000999109
00000155365
00000465763
0000226007700002246284000022430260000230542900002236876
00001908448
NOVO-BENZYDAMINEPMS-BENZYDAMINE
COMPD-CHLORHEX. MOUTH RINSE (ANY CONCENTRATION, NOT 0.12%)
COMPD-CHLORHEX. MOUTH RINSE (ANY CONCENTRATION, NOT 12%)
ADRENALIN
MYDFRIN
APO-BRIMONIDINEPMS-BRIMONIDINERATIO-BRIMONIDINESANDOZ BRIMONIDINEALPHAGAN
BETOPTIC S
TEVPMS
XXX
XXX
ERF
ALC
APXPMSRPHSDZALL
ALC
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
MOUTHWASHES AND GARGLES
VASOCONSTRICTORS
ANTIGLAUCOMA AGENTS
ANTIGLAUCOMA AGENTS
52
52
52
52
:00
:00
:00
:00
52:28
52:32
52:40.04
52:40.08
0.0290 0.2900
0.0000
0.0000
0.5545
1.0151
1.2418 1.2418 1.2418 1.2418 3.3005
2.3000
135 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$
$
$$$$$
$
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
(ALPHA-ADRENERGIC AGONISTS)
(BETA-ADRENERGIC AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LEVOBUNOLOL HCL
TIMOLOL MALEATE
ACETAZOLAMIDE
BRINZOLAMIDE
DORZOLAMIDE HCL
METHAZOLAMIDE
0.25 % OPHTHALMIC SOLUTION
0.5 % OPHTHALMIC SOLUTION
0.25 % (BASE) OPHTHALMIC SOLUTION
0.5 % (BASE) OPHTHALMIC SOLUTION
0.25 % (BASE) OPHTHALMIC LONG ACTING GELLAN SOLUTION
0.5 % (BASE) OPHTHALMIC LONG ACTING GELLAN SOLUTION
250 MG ORAL TABLET
1 % OPHTHALMIC SUSPENSION
2 % (BASE) OPHTHALMIC SOLUTION
50 MG ORAL TABLET
0000224171500002031159
00002237991000020311670000224171600000637661
000007558260000208335300002166712
00000755834000020833450000216672000000451207
00002171880
00002171899
00000545015
00002238873
000023163070000221620500002269090
00002245882
SANDOZ LEVOBUNOLOLRATIO-LEVOBUNOLOL
PMS-LEVOBUNOLOLRATIO-LEVOBUNOLOLSANDOZ LEVOBUNOLOLBETAGAN
APO-TIMOPPMS-TIMOLOLSANDOZ TIMOLOL MALEATE
APO-TIMOPPMS-TIMOLOLSANDOZ TIMOLOL MALEATETIMOPTIC
TIMOPTIC-XE
TIMOPTIC-XE
ACETAZOLAMIDE
AZOPT
SANDOZ DORZOLAMIDETRUSOPTTRUSOPT (PRESERVATIVE-FREE)
METHAZOLAMIDE
SDZRPH
PMSRPHSDZALL
APXPMSSDZ
APXPMSSDZMFC
MFC
MFC
AAP
ALC
SDZMFCMFC
AAP
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTIGLAUCOMA AGENTS
ANTIGLAUCOMA AGENTS
52
52
:00
:00
52:40.08
52:40.12
0.9320 1.9143
1.2379 1.2379 1.2379 3.2900
0.9688 0.9688 0.9688
1.2722 1.2722 1.2722 3.6348
3.8799
4.6408
0.1237
3.2844
1.3505 3.8585 3.8639
0.4817
136 EFFECTIVE JULY 1, 2012
$$
$$$$
$$$
$$$$
$
$
$
$
$$$
$
(BETA-ADRENERGIC AGENTS)
(CARBONIC ANHYDRASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CARBACHOL
PILOCARPINE HCL
BIMATOPROST
LATANOPROST
TRAVOPROST
BRIMONIDINE TARTRATE/ TIMOLOL MALEATE
BRINZOLAMIDE/ TIMOLOL MALEATE
1.5 % OPHTHALMIC SOLUTION
3 % OPHTHALMIC SOLUTION
1 % OPHTHALMIC SOLUTION
2 % OPHTHALMIC SOLUTION
4 % OPHTHALMIC SOLUTION
4 % OPHTHALMIC GEL
OPHTHALMIC SOLUTION
0.005 % OPHTHALMIC SOLUTION
0.004 % OPHTHALMIC SOLUTION
0.2 % * 0.5 % (BASE) OPHTHALMIC SOLUTION
1 % * 0.5 % (BASE) OPHTHALMIC SUSPENSION
00000000655
00000000663
00000000841
00000000868
00000000884
00000575240
00002324997
0000229652700002254786000023730410000236733500002231493
00002318008
00002248347
00002331624
ISOPTO CARBACHOL
ISOPTO CARBACHOL
ISOPTO CARPINE
ISOPTO CARPINE
ISOPTO CARPINE
PILOPINE HS
LUMIGAN RC 0.01%
APO-LATANOPROSTCO LATANOPROSTGD-LATANOPROSTSANDOZ LATANOPROSTXALATAN
TRAVATAN Z
COMBIGAN
AZARGA
ALC
ALC
ALC
ALC
ALC
ALC
ALL
APXCOBGMDSDZPFI
ALC
ALL
ALC
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTIGLAUCOMA AGENTS
ANTIGLAUCOMA AGENTS
ANTIGLAUCOMA AGENTS
52
52
52
:00
:00
:00
52:40.20
52:40.28
52:40.92
0.7047
0.8477
0.2142
0.2470
0.2791
2.6142
10.8160
4.1427 4.1427 4.1427 4.1427
11.0106
11.0800
4.0120
4.2840
137 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$$$$$
$
$
$
(MIOTICS)
(PROSTAGLANDIN ANALOGS)
(MISCELLANEOUS ANTIGLAUCOMA AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DORZOLAMIDE HCL/ TIMOLOL MALEATE
LATANOPROST/ TIMOLOL MALEATE
TRAVOPROST/ TIMOLOL MALEATE
APRACLONIDINE HCL
2 % (BASE) * 0.5 % (BASE) OPHTHALMIC SOLUTION
0.005 % * 0.5 % (BASE) OPHTHALMIC SOLUTION
0.004 % * 0.5 % (BASE) OPHTHALMIC SOLUTION
0.5 % OPHTHALMIC SOLUTION
0000229961500002344351000023205250000225869200002240113
00002246619
00002278251
00002076306
APO-DORZO-TIMOPSANDOZ DORZOLAMIDE/ TIMOLOLTEVA-DORZOTIMOLCOSOPT PRESERVATIVE-FREECOSOPT
XALACOM
DUO TRAV
IOPIDINE
APXSDZTEVMFCMFC
PFI
ALC
ALC
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTIGLAUCOMA AGENTS
MISCELLANEOUS EENT DRUGS
52
52
:00
:00
52:40.92
52:92
2.0459 2.0459 2.0459 2.3675 5.8454
12.4603
12.4848
4.4519
138 EFFECTIVE JULY 1, 2012
$$$$$
$
$
$
(MISCELLANEOUS ANTIGLAUCOMA AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
RANIBIZUMAB
2.3 MG / VIAL INJECTION00002296810 LUCENTIS NOV
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
MISCELLANEOUS EENT DRUGS
52:00
52:92
1575.0000
139 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
For this product - pricing has been established on a per vial basis.$
RESTRICTED BENEFIT - This product is a benefit when prescribed by a registered prescriber conditional to the following criteria.
"For the treatment of neovascular (wet) age-related macular degeneration (AMD) if all of the following circumstances apply to the eye to be treated:- The best corrected visual acuity (BCVA) is between 6/12 (20/40) and 6/96 (20/320)- There is active disease activity (choroidal neovascularization) and no permanent structural damage to the central fovea- The lesion size is less than or equal to 12 disc areas in greatest linear dimension- There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluoroscein angiography, optical coherence tomography (OCT) or recent visual acuity changes)- No concurrent verteporfin PDT treatment- Injection will be by a qualified ophthalmologist with experience in intravitreal injections.
The interval between the doses should be no shorter than one month.
Treatment with ranibizumab should be continued only in people who maintain adequate response to therapy.
Ranibizumab should be discontinued if any one of the following occur:- Reduction in BCVA in the treated eye to less than 15 letters (absolute) on 2 consecutive visitsin the treated eye, attributed to AMD in the absence of other pathology,- Reduction in BCVA of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect or adverse event or both.- There is evidence of deterioration of the lesion morphology despite optimum treatment over three consecutive visits."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
56:00 Gastrointestinal D
rugs
56:00
Gastrointestinal Drugs
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DIPHENOXYLATE HCL/ ATROPINE SULFATE
URSODIOL
LIPASE/ AMYLASE/ PROTEASE
2.5 MG * 0.025 MG ORAL TABLET
250 MG ORAL TABLET
500 MG ORAL TABLET
8,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL TABLET
16,000 UNIT * 60,000 UNIT * 60,000 UNIT ORAL TABLET
8,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL CAPSULE
4,000 UNIT * 12,000 UNIT * 12,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
4,500 UNIT * 20,000 UNIT * 25,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
8,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
10,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
10,000 UNIT * 33,200 UNIT * 37,500 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
12,000 UNIT * 39,000 UNIT * 39,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
16,000 UNIT * 48,000 UNIT * 48,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
20,000 UNIT * 55,000 UNIT * 55,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
20,000 UNIT * 65,000 UNIT * 65,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
25,000 UNIT * 74,000 UNIT * 62,500 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)
00000036323
0000227349700002238984
0000227350000002245894
00002230019
00002241933
00000263818
00000789445
00002203324
00000502790
00000789437
00002200104
00002045834
00000789429
00000821373
00002045869
00001985205
LOMOTIL
PMS-URSODIOL CURSO
PMS-URSODIOL CURSO DS
VIOKASE
VIOKASE 16
COTAZYM
PANCREASE MT 4
ULTRASE MS4 MICROSPHERES
COTAZYM ECS 8
PANCREASE MT 10
CREON 10 MINIMICROSPHERES
ULTRASE MT12 MINITABLETS
PANCREASE MT 16
COTAZYM ECS 20
ULTRASE MT20 MINITABLETS
CREON 25 MINIMICROSPHERES
PFI
PMSAXC
PMSAXC
AXC
AXC
ORG
JAI
AXC
ORG
JAI
ABB
AXC
JAI
ORG
AXC
ABB
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
ANTIDIARRHEA AGENTS
CHOLELITHOLYTIC AGENTS
DIGESTANTS
56
56
56
:00
:00
:00
56:08
56:14
56:16
0.4450
0.8808 1.3701
1.6708 2.5988
0.2314
0.3551
0.1866
0.4555
0.2266
0.3368
1.1385
0.2723
0.4432
1.8214
0.8830
0.7679
0.8507
141 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$
$$
$
$
$
$
$
$
$
$
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DIMENHYDRINATE
PROCHLORPERAZINE
DOLASETRON MESYLATE
GRANISETRON HCL
ONDANSETRON
10 MG / ML INJECTION
50 MG / ML INJECTION
5 MG ORAL TABLET
10 MG ORAL TABLET
5 MG / ML INJECTION
10 MG RECTAL SUPPOSITORY
100 MG ORAL TABLET
1 MG (BASE) ORAL TABLET
4 MG ORAL DISINTEGRATING TABLET
8 MG ORAL DISINTEGRATING TABLET
00000392731
00000392537
00000886440
00000886432
00000789747
00000789720
00002231379
0000230889400002185881
00002239372
00002239373
DIMENHYDRINATE I.V.
DIMENHYDRINATE I.M.
APO-PROCHLORAZINE
APO-PROCHLORAZINE
PROCHLORPERAZINE
SANDOZ PROCHLORPERAZINE
ANZEMET
GRANISETRONKYTRIL
ZOFRAN ODT
ZOFRAN ODT
SDZ
SDZ
APX
APX
SDZ
SDZ
SAV
AAPHLR
GSK
GSK
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
ANTIEMETICS
ANTIEMETICS
56
56
:00
:00
56:22.08
56:22.20
0.3274
1.0698
0.1659
0.2025
0.9721
1.1628
29.1580
14.5125 18.0000
13.0890
19.9720
142 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$
$$
$
$
(ANTIHISTAMINES)
(5-HT3 RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ONDANSETRON HCL DIHYDRATE4 MG (BASE) ORAL TABLET
8 MG (BASE) ORAL TABLET
0.8 MG / ML (BASE) ORAL SOLUTION
2 MG / ML (BASE) INJECTION
2 MG / ML (BASE) INJECTION
000022881840000229634900002313685000023717310000230525900002297868000023062120000227861800002258188000023122470000227852900002274310000023760910000226405600002213567
000022881920000229635700002313693000023717580000230526700002297876000023062200000227862600002258196000023122550000227853700002274329000023761050000226406400002213575
0000229196700002229639
00002271761
000002213745
00002271788
00002213745
APO-ONDANSETRONCO ONDANSETRONJAMP-ONDANSETRONMAR-ONDANSETRONMINT-ONDANSETRONMYLAN-ONDANSETRONONDANSETRON-ODANPHL-ONDANSETRONPMS-ONDANSETRONRAN-ONDANSETRONRATIO-ONDANSETRONSANDOZ ONDANSETRONSEPTA-ONDANSETRONTEVA-ONDANSETRONZOFRAN
APO-ONDANSETRONCO ONDANSETRONJAMP-ONDANSETRONMAR-ONDANSETRONMINT-ONDANSETRONMYLAN-ONDANSETRONONDANSETRON-ODANPHL-ONDANSETRONPMS-ONDANSETRONRAN-ONDANSETRONRATIO-ONDANSETRONSANDOZ ONDANSETRONSEPTA-ONDANSETRONTEVA-ONDANSETRONZOFRAN
ONDANSETRONZOFRAN
ONDANSETRON OMEGA (PRESERVATIVE FREE)ZOFRAN
ONDANSETRON OMEGA (WITH PRESERVATIVE)ZOFRAN
APXCOBJPCMARMPIMYPODNPHHPMSRANRPHSDZSEPTEVGSK
APXCOBJPCMARMPIMYPODNPHHPMSRANRPHSDZSEPTEVGSK
AAPGSK
OMG
GSK
OMG
GSK
GASTROINTESTINAL DRUGS
ANTIEMETICS
56:00
56:22.20
5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410
13.3980
7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921
20.4440
1.5710 2.0442
3.7143
9.8720
3.7143
9.8720
143 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$
$$
$
$
$
$
(5-HT3 RECEPTOR ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
APREPITANT
APREPITANT/ APREPITANT
DOXYLAMINE SUCCINATE/ PYRIDOXINE HCL
NABILONE
CIMETIDINE
80 MG ORAL CAPSULE
80 MG * 125 MG ORAL CAPSULE
10 MG * 10 MG ORAL SUSTAINED-RELEASE TABLET
0.5 MG ORAL CAPSULE
1 MG ORAL CAPSULE
200 MG ORAL TABLET
300 MG ORAL TABLET
400 MG ORAL TABLET
600 MG ORAL TABLET
800 MG ORAL TABLET
00002298791
00002298813
00000609129
000023809000000235808500002256193
000023809190000235809300000548375
00000584215
000004878720000222744400000582417
000006000590000222745200000603678
000006000670000222746000000603686
0000222747900000749494
EMEND
EMEND TRI-PACK
DICLECTIN
PMS-NABILONERAN-NABILONECESAMET
PMS-NABILONERAN-NABILONECESAMET
APO-CIMETIDINE
APO-CIMETIDINEMYLAN-CIMETIDINENOVO-CIMETINE
APO-CIMETIDINEMYLAN-CIMETIDINENOVO-CIMETINE
APO-CIMETIDINEMYLAN-CIMETIDINENOVO-CIMETINE
MYLAN-CIMETIDINEAPO-CIMETIDINE
MFC
MFC
DUI
PMSRANVCL
PMSRANVCL
APX
APXMYPTEV
APXMYPTEV
APXMYPTEV
MYPAPX
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
ANTIEMETICS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
56
56
:00
:00
56:22.92
56:28.12
30.1800
30.1800
1.2471
1.1674 1.1674 3.1026
2.3346 2.3346 6.2050
0.0860
0.0860 0.0860 0.0860
0.1350 0.1350 0.1350
0.1702 0.1702 0.1702
0.2430 0.2530
144 EFFECTIVE JULY 1, 2012
$
$
$
$$$
$$$
$
$$$
$$$
$$$
$$
RESTRICTED BENEFIT - This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates).
RESTRICTED BENEFIT - This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates).
(MISCELLANEOUS ANTIEMETICS)
(HISTAMINE H2-ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
FAMOTIDINE
NIZATIDINE
RANITIDINE HCL
20 MG ORAL TABLET
40 MG ORAL TABLET
150 MG ORAL CAPSULE
300 MG ORAL CAPSULE
150 MG (BASE) ORAL TABLET
300 MG (BASE) ORAL TABLET
000019538420000237392000002351102000021960180000202213300000710121
000019538340000237393900002351110000021960260000202214100000710113
00002220156000022404570000217771400000778338
00002220164000022404580000217772200000778346
000007330590000224857000002367378000022077610000082856400002245782000022424530000233648000002353016000008288230000224322900002212331
0000073306700002248571000023673860000220778800000828556000022457830000224245400002336502000023530240000224323000002212358
APO-FAMOTIDINEAVA-FAMOTIDINEFAMOTIDINEMYLAN-FAMOTIDINENOVO-FAMOTIDINEPEPCID
APO-FAMOTIDINEAVA-FAMOTIDINEFAMOTIDINEMYLAN-FAMOTIDINENOVO-FAMOTIDINEPEPCID
APO-NIZATIDINENOVO-NIZATIDINEPMS-NIZATIDINEAXID
APO-NIZATIDINENOVO-NIZATIDINEPMS-NIZATIDINEAXID
APO-RANITIDINECO RANITIDINEMYL-RANITIDINEMYLAN-RANITIDINENOVO-RANIDINEPHL-RANITIDINEPMS-RANITIDINERAN-RANITIDINERANITIDINERATIO-RANITIDINESANDOZ RANITIDINEZANTAC
APO-RANITIDINECO RANITIDINEMYL-RANITIDINEMYLAN-RANITIDINENOVO-RANIDINEPHL-RANITIDINEPMS-RANITIDINERAN-RANITIDINERANITIDINESANDOZ RANITIDINEZANTAC
APXAVASNSMYPTEVMFC
APXAVASNSMYPTEVMFC
APXTEVPMSMMT
APXTEVPMSMMT
APXCOBMYPMYPTEVPHHPMSRANSNSRPHSDZGSK
APXCOBMYPMYPTEVPHHPMSRANSNSSDZGSK
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
56:00
56:28.12
0.3882 0.3882 0.3882 0.3882 0.3882 1.1092
0.7089 0.7089 0.7089 0.7089 0.7089 2.0254
0.3566 0.3566 0.3566 0.9478
0.6347 0.6347 0.6347 1.6870
0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800
0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600
145 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$
$$$$$$
$$$$
$$$$
$$$$$$$$$$$$
$$$$$$$$$$$
(HISTAMINE H2-ANTAGONISTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
RANITIDINE HCL
MISOPROSTOL
SUCRALFATE
15 MG / ML (BASE) ORAL SOLUTION
25 MG / ML (BASE) INJECTION
100 MCG ORAL TABLET
200 MCG ORAL TABLET
1 G ORAL TABLET
200 MG / ML ORAL SUSPENSION
0000228083300002242940
0000225671100002212366
00002244022
00002244023
000021252500000204570200002100622
00002103567
APO-RANITIDINENOVO-RANIDINE
RANITIDINEZANTAC
MISOPROSTOL
MISOPROSTOL
APO-SUCRALFATENOVO-SUCRALATESULCRATE
SULCRATE SUSPENSION PLUS
APXTEV
SDZGSK
AAP
AAP
APXTEVAXC
AXC
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
56
56
56
:00
:00
:00
56:28.12
56:28.28
56:28.32
0.0932 0.0932
1.3310 1.4000
0.2584
0.4303
0.2148 0.2148 0.5710
0.1037
146 EFFECTIVE JULY 1, 2012
$$
$$
$
$
$$$
$
(HISTAMINE H2-ANTAGONISTS)
(PROSTAGLANDINS)
(PROTECTANTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
LANSOPRAZOLE
LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/ CLARITHROMYCIN
OMEPRAZOLE
15 MG ORAL DELAYED RELEASE CAPSULE
30 MG ORAL DELAYED RELEASE CAPSULE
30 MG * 500 MG (BASE) * 500 MG ORAL TABLET/CAPSULE
10 MG ORAL CAPSULE/SUSTAINED RELEASE TABLET
20 MG ORAL CAPSULE/SUSTAINED RELEASE TABLET
0000229381100002357682000023538300000228051500002165503
0000229383800002357690000023538490000228052300002165511
00002238525
0000232942500002296438
00002230737
000022450580000232943300002295415
0000234869100002320851
00002310260
00002374870
00002260867
00002296446
0000084650300002190915
APO-LANSOPRAZOLELANSOPRAZOLEMYLAN-LANSOPRAZOLENOVO-LANSOPRAZOLEPREVACID
APO-LANSOPRAZOLELANSOPRAZOLEMYLAN-LANSOPRAZOLENOVO-LANSOPRAZOLEPREVACID
HP-PAC ( KIT )
MYLAN-OMEPRAZOLE (CAPSULE)SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE TABLET)
APO-OMEPRAZOLE (CAPSULE)MYLAN-OMEPRAZOLE (CAPSULE)NOVO-OMEPRAZOLE (DELAYED RELEASE TABLET)OMEPRAZOLE (CAPSULE)PMS-OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)PMS-OMEPRAZOLE DR (DELAYED RELEASETABLET)RAN-OMEPRAZOLE (DELAYED RELEASE TABLET)RATIO-OMEPRAZOLE (SUSTAINED-RELEASE TABLET)SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE TABLET)
APXSNSMYPTEVABB
APXSNSMYPTEVABB
ABB
MYPSDZ
AZC
APXMYPTEV
SNSPMS
PMS
RAN
RPH
SDZ
AZCAZC
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
56:00
56:28.36
0.7000 0.7000 0.7000 0.7000 2.0000
0.7000 0.7000 0.7000 0.7000 2.0000
84.2700
0.8167 0.8167
1.8200
0.7700 0.7700 0.7700
0.7700 0.7700
0.7700
0.7700
0.7700
0.7700
1.1000 2.2870
147 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
$$$$$
$
$$
$
$$$
$$
$
$
$
$
$$
Please note: For individuals who require alternative administration (capsules to be opened and intact delayed release granules to be sprinkled on applesauce and swallowed immediately or mixed in water or apple juice and administered through a nasogastric tube) application for coverage for the Prevacid brand may be made using the Drug Special Authorization Request Form (ABC 20061), indicating a requirement for alternative administration.
(PROTON-PUMP INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PANTOPRAZOLE
RABEPRAZOLE SODIUM
DOMPERIDONE MALEATE
METOCLOPRAMIDE HCL
40 MG ORAL ENTERIC-COATED TABLET
10 MG ORAL ENTERIC-COATED TABLET
20 MG ORAL ENTERIC-COATED TABLET
10 MG (BASE) ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
000022672330000229292000002363429000023004860000229958500002285487000023098660000237080800002307871000023050460000230108300002229453
00002345579000023108050000235651100002298074000023141770000229663200002243796
00002345587000023108130000235653800002298082000023141850000229664000002243797
0000210361300002364271000023504400000227866900002236466000022680780000191207000002157195
00002230431
00002230432
TECTAAPO-PANTOPRAZOLEAVA-PANTOPRAZOLECO PANTOPRAZOLEMYLAN-PANTOPRAZOLENOVO-PANTOPRAZOLEPANTOPRAZOLEPANTOPRAZOLEPMS-PANTOPRAZOLERAN-PANTOPRAZOLESANDOZ PANTOPRAZOLEPANTOLOC
APO-RABEPRAZOLEPMS-RABEPRAZOLE ECRABEPRAZOLE ECRAN-RABEPRAZOLESANDOZ RABEPRAZOLETEVA-RABEPRAZOLEPARIET
APO-RABEPRAZOLEPMS-RABEPRAZOLE ECRABEPRAZOLE ECRAN-RABEPRAZOLESANDOZ RABEPRAZOLETEVA-RABEPRAZOLEPARIET
APO-DOMPERIDONEAVA-DOMPERIDONEDOMPERIDONEMYLAN-DOMPERIDONEPMS-DOMPERIDONERAN-DOMPERIDONERATIO-DOMPERIDONE MALEATETEVA-DOMPERIDONE
PMS-METOCLOPRAMIDE
PMS-METOCLOPRAMIDE
NYCAPXAVACOBMYPTEVMELSNSPMSRANSDZNYC
APXPMSSNSRANSDZTEVJAI
APXPMSSNSRANSDZTEVJAI
APXAVASNSMYPPMSRANRPHTEV
PMS
PMS
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
PROKINETIC AGENTS
56
56
:00
:00
56:28.36
56:32
0.7500 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 2.0803
0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.6688
0.5033 0.5033 0.5033 0.5033 0.5033 0.5033 1.3377
0.0886 0.0886 0.0886 0.0886 0.0886 0.0886 0.0886 0.0886
0.0556
0.0583
148 EFFECTIVE JULY 1, 2012
$$$$$$$$$$$$
$$$$$$$
$$$$$$$
$$$$$$$$
$
$
(PROTON-PUMP INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
METOCLOPRAMIDE HCL
MESALAZINE
OLSALAZINE SODIUM
PINAVERIUM BROMIDE
1 MG / ML ORAL LIQUID
5 MG / ML INJECTION
500 MG ORAL SUSTAINED-RELEASE TABLET
400 MG ORAL ENTERIC-COATED TABLET
500 MG ORAL ENTERIC-COATED TABLET
800 MG ORAL ENTERIC-COATED TABLET
500 MG RECTAL SUPPOSITORY
1 G RECTAL SUPPOSITORY
1,000 MG RECTAL SUPPOSITORY
1 G / ENM RECTAL ENEMA
2 G / ENM RECTAL ENEMA
4 G / ENM RECTAL ENEMA
250 MG ORAL CAPSULE
50 MG ORAL TABLET
100 MG ORAL TABLET
00002230433
00002185431
00002099683
0000217192900001997580
0000211278700001914030
00002267217
00002112760
00002153564
00002242146
00002153521
00002112795
0000215355600002112809
00002063808
00001950592
00002230684
PMS-METOCLOPRAMIDE
METOCLOPRAMIDE HYDROCHLORIDE
PENTASA
NOVO-5 ASAASACOL
SALOFALKMESASAL
ASACOL 800
SALOFALK
PENTASA
SALOFALK
PENTASA (1G/100ML)
SALOFALK (2G/60G)
PENTASA (4G/100 ML)SALOFALK (4G/60G)
DIPENTUM
DICETEL
DICETEL
PMS
SDZ
FEI
TEVWCC
AXCGSK
WCC
AXC
FEI
AXC
FEI
AXC
FEIAXC
UCB
ABB
ABB
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
GASTROINTESTINAL DRUGS
PROKINETIC AGENTS
ANTI-INFLAMMATORY AGENTS
MISCELLANEOUS GI DRUGS
56
56
56
:00
:00
:00
56:32
56:36
56:92
0.0448
1.3163
0.5569
0.4039 0.5440
0.5375 0.6274
1.0575
1.1882
1.6000
1.7452
3.7000
3.8279
4.4600 6.5003
0.5300
0.3533
0.6160
149 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$$
$$
$
$
$
$
$
$
$$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
TRIMEBUTINE MALEATE100 MG ORAL TABLET
200 MG ORAL TABLET00002245663
0000224566400000803499
TRIMEBUTINE
TRIMEBUTINEMODULON
AAP
AAPAXC
GASTROINTESTINAL DRUGS
MISCELLANEOUS GI DRUGS
56:00
56:92
0.2690
0.5628 0.6622
150 EFFECTIVE JULY 1, 2012
$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
60:00 Gold C
ompounds
60:00
Gold Compounds
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AURANOFIN
GOLD SODIUM THIOMALATE
3 MG ORAL CAPSULE
10 MG / ML INJECTION
25 MG / ML INJECTION
50 MG / ML INJECTION
00001916823
0000224545600001927620
00002245457
0000224545800001927604
RIDAURA
SODIUM AUROTHIOMALATEMYOCHRYSINE
SODIUM AUROTHIOMALATE
SODIUM AUROTHIOMALATEMYOCHRYSINE
XPI
SDZSAV
SDZ
SDZSAV
GOLD COMPOUNDS60:00
60:00
6.0141
9.6600 11.9000
10.9457
18.2100 22.4800
151 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$
$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
64:00 Heavy M
etal Antagonists
64:00
Heavy Metal Antagonists
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DEFEROXAMINE MESYLATE
PENICILLAMINE
500 MG / VIAL INJECTION
2 G / VIAL INJECTION
250 MG ORAL CAPSULE
000022420550000224160000001981242
000022434500000224702200001981250
00000016055
PMS-DEFEROXAMINEDESFERRIOXAMINE MESILATEDESFERAL
PMS-DEFEROXAMINEDESFERRIOXAMINE MESILATEDESFERAL
CUPRIMINE
PMSHSPNOV
PMSHSPNOV
VCL
HEAVY METAL ANTAGONISTS64:00
64:00
7.0600 7.5400
13.9862
28.3500 30.2900 56.1800
3.5767
153 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$
$$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
68:00 Horm
ones and Synthetic Substitutes
68:00
Hormones and Synthetic Substitutes
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
COMPOUND PRESCRIPTION
BECLOMETHASONE DIPROPIONATE
BETAMETHASONE SODIUM PHOSPHATE/ BETAMETHASONE ACETATE
BUDESONIDE
CICLESONIDE
CORTISONE ACETATE
50 MCG / DOSE METERED DOSE AEROSOL
100 MCG / DOSE METERED DOSE AEROSOL
3 MG / ML (BASE) * 3 MG / ML INJECTION
100 MCG / DOSE METERED INHALATION POWDER
200 MCG / DOSE METERED INHALATION POWDER
400 MCG / DOSE METERED INHALATION POWDER
0.125 MG / ML INHALATION SUSPENSION
0.25 MG / ML INHALATION SUSPENSION
0.5 MG / ML INHALATION SUSPENSION
100 MCG / DOSE METERED DOSE AEROSOL
200 MCG / DOSE METERED DOSE AEROSOL
25 MG ORAL TABLET
00000999111
00000999212
00002242029
00002242030
00000028096
00000852074
00000851752
00000851760
00002229099
00001978918
00001978926
00002285606
00002285614
00000280437
COMPOUND HORMONES (ESTROGEN PROGEST TESTOSTERONE)
COMPOUND HORMONES (ESTROGEN PROGEST TESTOSTERONE)
QVAR CFC-FREE
QVAR CFC-FREE
CELESTONE SOLUSPAN
PULMICORT TURBUHALER
PULMICORT TURBUHALER
PULMICORT TURBUHALER
PULMICORT NEBUAMP
PULMICORT NEBUAMP
PULMICORT NEBUAMP
ALVESCO
ALVESCO
CORTISONE ACETATE
XXX
XXX
MEP
MEP
MFC
AZC
AZC
AZC
AZC
AZC
AZC
NYC
NYC
VCL
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
68
68
:00
:00
68:00
68:04
0.0000
0.0000
0.1464
0.2928
10.3140
0.1545
0.3158
0.5568
0.2143
0.4285
0.8570
0.3713
0.6138
0.3200
155 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DEXAMETHASONE
DEXAMETHASONE SODIUM PHOSPHATE
FLUDROCORTISONE ACETATE
FLUTICASONE PROPIONATE
HYDROCORTISONE
HYDROCORTISONE SODIUM SUCCINATE
0.5 MG ORAL TABLET
0.75 MG ORAL TABLET
2 MG ORAL TABLET
4 MG ORAL TABLET
4 MG / ML (BASE) INJECTION
10 MG / ML (BASE) INJECTION
0.1 MG ORAL TABLET
50 MCG / DOSE METERED DOSE AEROSOL
125 MCG / DOSE METERED DOSE AEROSOL
250 MCG / DOSE METERED DOSE AEROSOL
250 MCG / DOSE METERED INHALATION POWDER
500 MCG / DOSE METERED INHALATION POWDER
10 MG ORAL TABLET
20 MG ORAL TABLET
100 MG / VIAL (BASE) INJECTION
250 MG / VIAL (BASE) INJECTION
500 MG / VIAL (BASE) INJECTION
000022610810000196497600002240684
00001964968
00002279363
00001964070000022500550000224068700000489158
0000066422700001977547
0000078390000000874582
00002086026
00002244291
00002244292
00002244293
00002237246
00002237247
00000030910
00000030929
0000087252000000030600
0000087253900000030619
0000087861800000030627
APO-DEXAMETHASONEPMS-DEXAMETHASONERATIO-DEXAMETHASONE
PMS-DEXAMETHASONE
PMS-DEXAMETHASONE
PMS-DEXAMETHASONEAPO-DEXAMETHASONERATIO-DEXAMETHASONEDEXASONE
DEXAMETHASONE SODIUM PHOSPHATEDEXAMETHASONE SODIUM PHOSPHATE
PMS-DEXAMETHASONE SODIUM PHOSPDEXAMETHASONE SODIUM PHOSPHATE
FLORINEF
FLOVENT HFA
FLOVENT HFA
FLOVENT HFA
FLOVENT DISKUS
FLOVENT DISKUS
CORTEF
CORTEF
HYDROCORTISONE SOD. SUCCINATESOLU-CORTEF
HYDROCORTISONE SOD. SUCCINATESOLU-CORTEF
HYDROCORTISONE SOD. SUCCINATESOLU-CORTEF
APXPMSRPH
PMS
PMS
PMSAPXRPHVCL
SDZCYT
PMSSDZ
PAL
GSK
GSK
GSK
GSK
GSK
PFI
PFI
TEVPFI
TEVPFI
TEVPFI
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
68:00
68:04
0.1094 0.1094 0.1094
0.4728
0.4389
0.4263 0.4264 0.4264 0.7877
1.6060 1.6900
1.2830 4.5600
0.2468
0.1994
0.3440
0.6880
0.6880
1.3757
0.1527
0.2756
2.3000 3.6102
3.9100 6.2642
5.8650 9.4679
156 EFFECTIVE JULY 1, 2012
$$$
$
$
$$$$
$$
$$
$
$
$
$
$
$
$
$
$$
$$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
HYDROCORTISONE SODIUM SUCCINATE
METHYLPREDNISOLONE
METHYLPREDNISOLONE ACETATE
METHYLPREDNISOLONE ACETATE/ LIDOCAINE HCL
METHYLPREDNISOLONE SODIUM SUCCINATE
1 G / VIAL (BASE) INJECTION
4 MG ORAL TABLET
16 MG ORAL TABLET
20 MG / ML INJECTION
40 MG / ML INJECTION
80 MG / ML INJECTION
40 MG / ML INJECTION
80 MG / ML INJECTION
40 MG / ML * 10 MG / ML INJECTION
40 MG / VIAL (BASE) INJECTION
125 MG / VIAL (BASE) INJECTION
500 MG / VIAL (BASE) INJECTION
1 G / VIAL (BASE) INJECTION
0000087862600000030635
00000030988
00000036129
00001934325
0000224540000000030759
0000224540600000030767
0000224540700001934333
0000224540800001934341
00000260428
0000223189300002367947
0000223189400002367955
000022318950000003067800002367963
000022412290000003613700002063697
00002367971
HYDROCORTISONE SOD. SUCCINATESOLU-CORTEF
MEDROL
MEDROL
DEPO-MEDROL
METHYLPREDNISOLONE ACETATEDEPO-MEDROL
METHYLPREDNISOLONE ACETATEDEPO-MEDROL
METHYLPREDNISOLONE ACETATE (P)DEPO-MEDROL (PRESERVED)
METHYLPREDNISOLONE ACETATE (P)DEPO-MEDROL (PRESERVED)
DEPO-MEDROL WITH LIDOCAINE
METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)
METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)
METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROLSOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)
METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROLSOLU-MEDROL ACT-O-VIAL (WITH PRESERVATIVE)SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)
TEVPFI
PFI
PFI
PFI
SDZPFI
SDZPFI
SDZPFI
SDZPFI
PFI
TEVPFI
TEVPFI
TEVPFIPFI
TEVPFIPFI
PFI
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
68:00
68:04
9.8900 15.8656
0.3454
0.9954
2.3800
4.1000 5.3400
8.2000 10.3222
4.1000 5.1611
6.9900 7.8960
6.0398
3.9600 6.0710
9.3500 14.4130
22.2002 35.4112 36.1220
34.1000 54.2800 55.3697
55.3700
157 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$
$$
$$
$$
$$
$
$$
$$
$$$
$$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PREDNISOLONE SODIUM PHOSPHATE
PREDNISONE
TRIAMCINOLONE ACETONIDE
DANAZOL
TESTOSTERONE CYPIONATE
TESTOSTERONE ENANTHATE
1 MG / ML (BASE) ORAL LIQUID
1 MG ORAL TABLET
5 MG ORAL TABLET
50 MG ORAL TABLET
10 MG / ML INJECTION
40 MG / ML INJECTION
50 MG ORAL CAPSULE
100 MG ORAL CAPSULE
200 MG ORAL CAPSULE
100 MG / ML INJECTION
200 MG / ML INJECTION
0000224553200002230619
0000027137300000598194
00000312770
00000550957
0000222954000001999761
000022295500000197756300001999869
00002018144
00002018152
00002018160
0000224606300000030783
00000029246
PMS-PREDNISOLONEPEDIAPRED
WINPREDAPO-PREDNISONE
APO-PREDNISONE
APO-PREDNISONE
TRIAMCINOLONE ACETONIDEKENALOG-10
TRIAMCINOLONE ACETONIDETRIAMCINOLONE ACETONIDE USPKENALOG-40
CYCLOMEN
CYCLOMEN
CYCLOMEN
TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE CYPIONATE
DELATESTRYL
PMSSAV
VCLAPX
APX
APX
SDZWSD
SDZCYTWSD
SAV
SAV
SAV
SDZPFI
VCL
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ANDROGENS
68
68
:00
:00
68:04
68:08
0.0478 0.1270
0.1035 0.1072
0.0401
0.1735
2.4500 3.2423
4.7700 4.7700 7.5320
0.9047
1.3425
2.1453
2.3580 2.6977
9.5500
158 EFFECTIVE JULY 1, 2012
$$
$$
$
$
$$
$$$
$
$
$
$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DESOGESTREL/ ETHINYL ESTRADIOL
DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL
DROSPIRENONE/ ETHINYL ESTRADIOL
ETHYNODIOL DIACETATE/ ETHINYL ESTRADIOL
LEVONORGESTREL
LEVONORGESTREL/ ETHINYL ESTRADIOL
LEVONORGESTREL/ ETHINYL ESTRADIOL/ LEVONORGESTREL/ETHINYL ESTRADIOL/ LEVONORGESTREL/ ETHINYL ESTRADIOL
NORETHINDRONE
0.15 MG * 0.03 MG ORAL TABLET
0.15 MG * 0.03 MG ORAL TABLET
0.1 MG * 0.025 MG * 0.125 MG * 0.025 MG * 0.15 MG * 0.025 MG ORAL TABLET
3 MG * 0.03 MG ORAL TABLET
2 MG * 30 MCG ORAL TABLET
0.75 MG ORAL TABLET
52 MG INTRAUTERINE INSERT
100 MCG * 20 MCG ORAL TABLET
150 MCG * 30 MCG ORAL TABLET
100 MCG * 20 MCG ORAL TABLET
150 MCG * 30 MCG ORAL TABLET
50 MCG * 30 MCG * 75 MCG * 40 MCG * 125 MCG * 30 MCG ORAL TABLET
0.35 MG ORAL TABLET
0000231719200002042487
000023172060000204247900002042533
0000225723800002272903
0000226173100002261723
0000047152600000469327
00002241674
00002243005
0000229853800002236974
0000229594600002042320
0000229854600002236975
0000229595400002042339
0000070750300000707600
00000037605
APRI 21MARVELON (21 DAY)
APRI 28MARVELON (28 DAY)ORTHO-CEPT (28 DAY)
LINESSA 28LINESSA 21
YASMIN 28YASMIN 21
DEMULEN 30 (28 DAY)DEMULEN 30 (21 DAY)
PLAN B
MIRENA SYSTEM
AVIANE 21ALESSE (21 DAY)
PORTIA 21MIN-OVRAL (21 DAY)
AVIANE 28ALESSE (28 DAY)
PORTIA 28MIN-OVRAL (28 DAY)
TRIQUILAR (28 DAY)TRIQUILAR (21 DAY)
MICRONOR (28 DAY)
BARMFC
BARMFCJAI
MFCMFC
BAIBAI
PFIPFI
DUR
BHP
BARWAY
BARWAY
BARWAY
BARWAY
BHPBHP
JAI
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
68:00
68:12
0.5436 0.6586
0.4077 0.4939 0.6098
0.4678 0.6238
0.4229 0.5640
0.4732 0.5898
8.6000
329.6100
0.4636 0.7029
0.4636 0.7029
0.3477 0.5271
0.3477 0.5271
0.5236 0.6981
0.6098
159 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$$
$$
$$
$$
$
$
$$
$$
$$
$$
$$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL
NORETHINDRONE/ ETHINYL ESTRADIOL
NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL
NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL
NORGESTIMATE/ ETHINYL ESTRADIOL
NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL
1 MG * 20 MCG ORAL TABLET
1.5 MG * 0.03 MG ORAL TABLET
0.5 MG * 0.035 MG ORAL TABLET
1 MG * 0.035 MG ORAL TABLET
0.5 MG * 0.035 MG * 1 MG * 0.035 MG ORAL TABLET
0.5 MG * 0.035 MG * 0.75 MG * 0.035 MG * 1 MG * 0.035 MG ORAL TABLET
0.25 MG * 0.035 MG ORAL TABLET
0.18 MG * 0.025 MG * 0.215 MG * 0.025 MG * 0.25 MG * 0.025 MG ORAL TABLET
0.18 MG * 0.035 MG * 0.215 MG * 0.035 MG * 0.25 MG * 0.035 MG ORAL TABLET
0000034383800000315966
0000035302700000297143
00002187094000021870860000034073100000317047
000021992970000219750200002189062000021890540000037283800000372846
0000218711600002187108
0000060296500000602957
0000199287200001968440
0000225858700002258560
0000202942100002028700
MINESTRIN 1/20 (28 DAY)MINESTRIN 1/20 (21 DAY)
LOESTRIN 1.5/30 (28 DAY)LOESTRIN 1.5/30 (21 DAY)
BREVICON 0.5/35 (28 DAY)BREVICON 0.5/35 (21 DAY)ORTHO 0.5/35 (28 DAY)ORTHO 0.5/35 (21 DAY)
SELECT 1/35 (28 DAY)SELECT 1/35 (21 DAY)BREVICON 1/35 (28 DAY)BREVICON 1/35 (21 DAY)ORTHO 1/35 (28 DAY)ORTHO 1/35 (21 DAY)
SYNPHASIC (28 DAY)SYNPHASIC (21 DAY)
ORTHO 7/7/7 (28 DAY)ORTHO 7/7/7 (21 DAY)
CYCLEN (28 DAY)CYCLEN (21 DAY)
TRI-CYCLEN LO 28TRI-CYCLEN LO 21
TRI-CYCLEN (28 DAY)TRI-CYCLEN (21 DAY)
PALPAL
PALPAL
PFIPFIJAIJAI
PFIPFIPFIPFIJAIJAI
PFIPFI
JAIJAI
JAIJAI
JAIJAI
JAIJAI
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES
68:00
68:12
0.4653 0.6205
0.4653 0.6205
0.4054 0.5405 0.6098 0.8131
0.2737 0.3651 0.4054 0.5405 0.6098 0.8131
0.3725 0.4967
0.6098 0.8131
0.6098 0.8131
0.4383 0.5843
0.6098 0.8131
160 EFFECTIVE JULY 1, 2012
$$
$$
$$$$
$$$$$$
$$
$$
$$
$$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CONJUGATED ESTROGENS
ESTRADIOL-17B
0.3 MG ORAL TABLET
0.625 MG ORAL TABLET
1.25 MG ORAL TABLET
0.625 MG / G VAGINAL CREAM
0.5 MG ORAL TABLET
1 MG ORAL TABLET
2 MG ORAL TABLET
0.06 % TRANSDERMAL GEL
25 MCG/DAY TRANSDERMAL PATCH
37.5 MCG/DAY TRANSDERMAL PATCH
50 MCG/DAY TRANSDERMAL PATCH
75 MCG/DAY TRANSDERMAL PATCH
100 MCG/DAY TRANSDERMAL PATCH
10 MCG VAGINAL TABLET
25 MCG VAGINAL TABLET
2 MG VAGINAL SLOW-RELEASE RING
00002043394
0000026547000002043408
00002043424
00002043440
00002225190
00002148587
00002148595
00002238704
00002245676000022437220000075684900002247499
00002243999
00002246967000022437240000224400000002231509
000022469680000224400100002247500
00002246969000022440020000075679200002231510
00002325462
00002241332
00002168898
PREMARIN
C.E.S.PREMARIN
PREMARIN
PREMARIN
ESTRACE
ESTRACE
ESTRACE
ESTROGEL
ESTRADOT 25 (0.39 MG/PTH)OESCLIM 25 (5 MG/PTH)ESTRADERM-25 (2 MG/PTH)CLIMARA 25 (2 MG/PTH)
ESTRADOT 37.5 (0.585 MG/PTH)
SANDOZ ESTRADIOL DERM 50 (4 MG/PTH)OESCLIM 50 (10 MG/PTH)ESTRADOT 50 (0.78 MG/PTH)CLIMARA 50 (3.9 MG/PTH)
SANDOZ ESTRADIOL DERM 75 (6 MG/PTH)ESTRADOT 75 (1.17 MG/PTH)CLIMARA 75 (5.7 MG/PTH)
SANDOZ ESTRADIOL DERM 100 (8 MG/PTH)ESTRADOT 100 (1.56 MG/PTH)ESTRADERM-100 (8.0 MG/PTH)CLIMARA 100 (7.8 MG/PTH)
VAGIFEM
VAGIFEM
ESTRING
WAY
VCLWAY
WAY
WAY
SHB
SHB
SHB
MFC
NOVTPINOVBHP
NOV
SDZTPINOVBHP
SDZNOVBHP
SDZNOVNOVBHP
NNA
NNA
PAL
HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ANTIESTROGENS
68:00
68:16.04
0.2900
0.1014 0.2900
0.2900
0.6270
0.1287
0.2486
0.4390
0.3134
2.6098 2.6312 3.3238 4.9175
2.6278
2.1000 2.6397 2.7994 5.2525
2.2375 3.0026 5.6000
2.3375 3.1724 4.0113 5.9225
3.2133
3.2133
65.3934
161 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$
$
$
$
$
$
$
$$$$
$
$$$$
$$$
$$$$
$
$
$
(ESTROGENS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
NORETHINDRONE ACETATE/ ESTRADIOL-17B
CLOMIPHENE CITRATE
ACARBOSE
140 MCG/DAY * 50 MCG/DAY TRANSDERMAL PATCH
250 MCG/DAY * 50 MCG/DAY TRANSDERMAL PATCH
50 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
00002241835
00002241837
0000089372200002091879
00002190885
00002190893
ESTALIS (2.7*.62 MG/PTH)
ESTALIS (4.8*.51 MG/PTH)
SEROPHENECLOMID
GLUCOBAY
GLUCOBAY
NOV
NOV
SROSAV
BAI
BAI
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ANTIESTROGENS
ESTROGENS AND ANTIESTROGENS
ANTIDIABETIC AGENTS
68
68
68
:00
:00
:00
68:16.04
68:16.12
68:20.02
3.0856
3.0856
4.9882 5.5608
0.2642
0.3659
162 EFFECTIVE JULY 1, 2012
$
$
$$
$
$
(ESTROGENS)
(ESTROGEN AGONISTS-ANTAGONISTS)
(ALPHA-GLUCOSIDASE INHIBITORS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
METFORMIN HCL
INSULIN ASPART
INSULIN DETEMIR
INSULIN GLARGINE
500 MG ORAL TABLET
850 MG ORAL TABLET
100 UNIT / ML INJECTION
100 UNIT / ML INJECTION
100 UNIT / ML INJECTION
0000216778600002364506000022577260000237862000002242794000023533770000237884100002148765000020457100000222356200002269031000022429740000224682000002099233
000023645140000225773400002378639000023533850000237886800002229656000022304750000224258900002269058000022429310000224682100002162849
0000224539700002244353
00002271842
000022456890000225193000002294338
APO-METFORMINAVA-METFORMINCO METFORMINMAR-METFORMINMETFORMINMETFORMINMETFORMINMYLAN-METFORMINNOVO-METFORMINPMS-METFORMINRAN-METFORMINRATIO-METFORMIN HYDROCHLORIDESANDOZ METFORMIN FCGLUCOPHAGE
AVA-METFORMINCO METFORMINMAR-METFORMINMETFORMINMETFORMINMYLAN-METFORMINNOVO-METFORMINPMS-METFORMINRAN-METFORMINRATIO-METFORMIN HYDROCHLORIDESANDOZ METFORMIN FCGLUCOPHAGE
NOVORAPIDNOVORAPID CARTRIDGE
LEVEMIR CARTRIDGE
LANTUSLANTUS CARTRIDGELANTUS PEN
APXAVACOBMARMELSNSMARMYPTEVPMSRANRPHSDZSAV
AVACOBMARSNSMARMYPTEVPMSRANRPHSDZSAV
NNANNA
NNA
SAVSAVSAV
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS
68
68
:00
:00
68:20.04
68:20.08
0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.2716
0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.3538
2.7920 3.7733
6.6787
5.9820 6.0027 6.0027
163 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$$$$$$$$$$
$$$$$$$$$$$$
$$
$
$$$
(BIGUANIDES)
(INSULINS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
INSULIN GLULISINE (RDNA ORIGIN)
INSULIN HUMAN BIOSYNTHETIC (ISOPHANE)
INSULIN HUMAN BIOSYNTHETIC (REGULAR)
INSULIN HUMAN BIOSYNTHETIC (REGULAR)/ INSULIN HUMAN BIOSYNTHETIC (ISOPHANE)
INSULIN LISPRO
INSULIN LISPRO/ INSULIN LISPRO PROTAMINE
100 UNIT / ML INJECTION
100 UNIT / ML INJECTION
100 UNIT / ML INJECTION
30 UNIT / ML * 70 UNIT / ML INJECTION
40 UNIT / ML * 60 UNIT / ML INJECTION
50 UNIT / ML * 50 UNIT / ML INJECTION
100 UNIT / ML INJECTION
25 % * 75 % INJECTION
50 % * 50 % INJECTION
000022794600000227947900002294346
00000587737000020242250000195923900002024268
00000586714000020242330000195922000002024284
00000795879000020242170000195921200002025248
00002024314
00002024322
0000222970400002229705
00002240294
00002240297
APIDRAAPIDRA CARTRIDGEAPIDRA PEN
HUMULIN NNOVOLIN GE NPHHUMULIN N CARTRIDGE/KWIKPENNOVOLIN GE NPH CARTRIDGE
HUMULIN RNOVOLIN GE TORONTOHUMULIN R CARTRIDGENOVOLIN GE TORONTO CARTRIDGE
HUMULIN 30/70NOVOLIN GE 30/70HUMULIN 30/70 CARTRIDGENOVOLIN GE 30/70 CARTRIDGE
NOVOLIN GE 40/60 CARTRIDGE
NOVOLIN GE 50/50 CARTRIDGE
HUMALOGHUMALOG CARTRIDGE/KWIKPEN
HUMALOG MIX 25 CARTRIDGE/KWIKPEN
HUMALOG MIX 50 CARTRIDGE/KWIKPEN
SAVSAVSAV
LILNNALILNNA
LILNNALILNNA
LILNNALILNNA
NNA
NNA
LILLIL
LIL
LIL
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
68:00
68:20.08
2.4500 3.2300 3.2667
2.1666 2.1930 2.8350 2.8580
2.1666 2.1930 2.8350 2.8687
2.1666 2.1930 2.8350 2.8553
2.9240
2.9240
2.7110 3.6300
3.6300
3.6299
164 EFFECTIVE JULY 1, 2012
$$$
$$$$
$$$$
$$$$
$
$
$$
$
$
(INSULINS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
REPAGLINIDE
GLICLAZIDE
0.5 MG ORAL TABLET
1 MG ORAL TABLET
2 MG ORAL TABLET
80 MG ORAL TABLET
30 MG ORAL SUSTAINED-RELEASE TABLET
60 MG ORAL SUSTAINED-RELEASE TABLET
0000235566300002321475000023549260000235745300002239924
0000235567100002321483000023549340000235746100002239925
0000235569800002321491000023549420000235748800002239926
000022452470000236351800002287072000022295190000223810300000765996
0000224298700002297795
00002356422
APO-REPAGLINIDECO REPAGLINIDEPMS-REPAGLINIDESANDOZ REPAGLINIDEGLUCONORM
APO-REPAGLINIDECO REPAGLINIDEPMS-REPAGLINIDESANDOZ REPAGLINIDEGLUCONORM
APO-REPAGLINIDECO REPAGLINIDEPMS-REPAGLINIDESANDOZ REPAGLINIDEGLUCONORM
APO-GLICLAZIDEAVA-GLICLAZIDEGLICLAZIDEMYLAN-GLICLAZIDENOVO-GLICLAZIDEDIAMICRON
DIAMICRON MRGLICLAZIDE MR
DIAMICRON MR
APXCOBPMSSDZNNA
APXCOBPMSSDZNNA
APXCOBPMSSDZNNA
APXAVASNSMYPTEVSEV
SEVAAP
SEV
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS
68
68
:00
:00
68:20.16
68:20.20
0.1094 0.1094 0.1094 0.1094 0.3126
0.1138 0.1138 0.1138 0.1138 0.3250
0.1182 0.1182 0.1182 0.1182 0.3376
0.1401 0.1401 0.1401 0.1401 0.1401 0.3725
0.1405 0.1510
0.2529
165 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$$
$$$$$
$$$$$
$$$$$$
$$
$
(MEGLITINIDES)
(SULFONYLUREAS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
GLYBURIDE
GLUCAGON, RDNA ORIGIN
SYNTHETIC CALCITONIN SALMON (SALCATONIN)
COSYNTROPIN ZINC HYDROXIDE COMPLEX
2.5 MG ORAL TABLET
5 MG ORAL TABLET
1 MG / VIAL INJECTION
100 IU / ML INJECTION
200 IU / ML INJECTION
1 MG / VIAL (BASE) INJECTION
0000191365400002363704000023504590000080873300001900927000022480080000191367000002224550
000019136620000236371200002350467000008087410000223673400001900935000022480090000191368900002224569
000023336190000233362700002243297
00002007134
00001926691
00000253952
APO-GLYBURIDEAVA-GLYBURIDEGLYBURIDEMYLAN-GLYBERATIO-GLYBURIDESANDOZ GLYBURIDETEVA-GLYBURIDEDIABETA
APO-GLYBURIDEAVA-GLYBURIDEGLYBURIDEMYLAN-GLYBEPMS-GLYBURIDERATIO-GLYBURIDESANDOZ GLYBURIDETEVA-GLYBURIDEDIABETA
GLUCAGENGLUCAGEN HYPOKITGLUCAGON
CALTINE 100 (100 IU/ML)
CALCIMAR
SYNACTHEN DEPOT
APXAVASNSMYPRPHSDZTEVSAV
APXAVASNSMYPPMSRPHSDZTEVSAV
NPANPALIL
FEI
SAV
NOV
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
ANTIHYPOGLYCEMIC AGENTS
PARATHYROID
PITUITARY
68
68
68
68
:00
:00
:00
:00
68:20.20
68:22.12
68:24
68:28
0.0393 0.0393 0.0393 0.0393 0.0393 0.0393 0.0393 0.1337
0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.2393
77.7150 77.7150 86.3500
7.8200
27.6250
32.2797
166 EFFECTIVE JULY 1, 2012
$$$$$$$$
$$$$$$$$$
$$$
$
$
$
(SULFONYLUREAS)
(GLYCOGENOLYTIC AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DESMOPRESSIN ACETATE
MEDROXYPROGESTERONE ACETATE
PROGESTERONE
0.1 MG ORAL TABLET
0.2 MG ORAL TABLET
10 MCG / DOSE NASAL METERED DOSE SPRAY
150 MCG / DOSE NASAL METERED DOSE SPRAY
0.1 MG / ML NASAL SOLUTION
4 MCG / ML INJECTION
2.5 MG ORAL TABLET
5 MG ORAL TABLET
10 MG ORAL TABLET
100 MG ORAL TABLET
50 MG / ML INJECTION
150 MG / ML INJECTION
100 MG ORAL CAPSULE
50 MG / ML INJECTION
00002284030000022877300000230436800000824305
00002284049000022877490000230437600000824143
0000224246500000836362
00002237860
00000402516
00000873993
0000222128400000708917
0000222129200000030937
0000222130600000729973
00002267640
00000030848
0000232225000000585092
00002166704
00001977652
APO-DESMOPRESSINNOVO-DESMOPRESSINPMS-DESMOPRESSINDDAVP
APO-DESMOPRESSINNOVO-DESMOPRESSINPMS-DESMOPRESSINDDAVP
DESMOPRESSINDDAVP
OCTOSTIM
DDAVP
DDAVP
NOVO-MEDRONEPROVERA
NOVO-MEDRONEPROVERA
NOVO-MEDRONEPROVERA
APO-MEDROXY
DEPO-PROVERA
MEDROXYPROGESTERONE ACETATEDEPO-PROVERA
PROMETRIUM
PROGESTERONE
APXTEVPMSFEI
APXTEVPMSFEI
AAPFEI
FEI
FEI
FEI
TEVPFI
TEVPFI
TEVPFI
APX
PFI
SDZPFI
MFC
CYT
HORMONES AND SYNTHETIC SUBSTITUTES
HORMONES AND SYNTHETIC SUBSTITUTES
PITUITARY
PROGESTINS
68
68
:00
:00
68:28
68:32
0.4973 0.4973 0.4973 1.3217
0.9945 0.9945 0.9945 2.6433
1.5222 1.8880
15.4400
18.8800
10.0600
0.0615 0.1635
0.1216 0.3232
0.2468 0.6559
1.2057
5.3388
22.0000 27.5429
1.0910
5.8605
167 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$$$
$$$$
$$
$
$
$
$$
$$
$$
$
$
$$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
DESSICATED THYROID
LEVOTHYROXINE SODIUM
LIOTHYRONINE SODIUM
30 MG ORAL TABLET
60 MG ORAL TABLET
125 MG ORAL TABLET
0.025 MG ORAL TABLET
0.05 MG ORAL TABLET
0.075 MG ORAL TABLET
0.088 MG ORAL TABLET
0.1 MG ORAL TABLET
0.112 MG ORAL TABLET
0.125 MG ORAL TABLET
0.137 MG ORAL TABLET
0.15 MG ORAL TABLET
0.175 MG ORAL TABLET
0.2 MG ORAL TABLET
0.3 MG ORAL TABLET
5 MCG (BASE) ORAL TABLET
25 MCG (BASE) ORAL TABLET
00000023949
00000023957
00000023965
00002172062
0000221319200002172070
00002172089
00002172097
0000221320600002172100
00002171228
00002172119
00002233852
0000221321400002172127
00002172135
0000221322200002172143
00002172151
00001919458
00001919466
THYROID
THYROID
THYROID
SYNTHROID
ELTROXINSYNTHROID
SYNTHROID
SYNTHROID
ELTROXINSYNTHROID
SYNTHROID
SYNTHROID
SYNTHROID
ELTROXINSYNTHROID
SYNTHROID
ELTROXINSYNTHROID
SYNTHROID
CYTOMEL
CYTOMEL
ERF
ERF
ERF
ABB
TPIABB
ABB
ABB
TPIABB
ABB
ABB
ABB
TPIABB
ABB
TPIABB
ABB
KNG
KNG
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
68:00
68:36.04
0.0535
0.0656
0.0941
0.0865
0.0288 0.0594
0.0935
0.0935
0.0354 0.0732
0.0987
0.0999
0.1687
0.0392 0.0784
0.1071
0.0415 0.0837
0.1154
0.9819
1.0673
168 EFFECTIVE JULY 1, 2012
$
$
$
$
$$
$
$
$$
$
$
$
$$
$
$$
$
$
$
(THYROID AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
METHIMAZOLE
PROPYLTHIOURACIL
5 MG ORAL TABLET
50 MG ORAL TABLET
100 MG ORAL TABLET
00000015741
00000010200
00000010219
TAPAZOLE
PROPYL-THYRACIL
PROPYL-THYRACIL
PAL
PAL
PAL
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
68:00
68:36.08
0.2503
0.2160
0.3380
169 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
(ANTITHYROID AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
80:00 Serums, Toxoids and Vaccines
80:00
Serums, Toxoids and Vaccines
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ALLERGY SERUM
HEPATITIS B VACCINE (RECOMBINANT)
INJECTION
10 MCG / ML INJECTION
20 MCG / ML INJECTION
00000999981
00000749486
00001919431
ALLERGY SERUM
RECOMBIVAX-HB
ENGERIX-B
XXX
MFC
GSK
SERUMS, TOXOIDS, AND VACCINES
SERUMS, TOXOIDS, AND VACCINES
SERUMS
VACCINES
80
80
:00
:00
80:04
80:12
0.0000
21.3500
21.1900
171 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
84:00 Skin and Mucous M
embrane A
gents
84:00
Skin and Mucous Membrane Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
COMPOUND PRESCRIPTION
COMPOUND PRESCRIPTION
FUSIDIC ACID
GENTAMICIN SULFATE
METRONIDAZOLE
TOPICAL
TOPICAL
TOPICAL
TOPICAL
2 % TOPICAL CREAM
0.1 % (BASE) TOPICAL CREAM
0.1 % (BASE) TOPICAL OINTMENT
0.75 % TOPICAL CREAM
1 % TOPICAL CREAM
0.75 % TOPICAL LOTION
1 % TOPICAL GEL
00000999119
00000999112
00000999219
00000999213
00000999103
00000999203
00000586668
00000805386
00000805025
00002226839
0000224291900002156091
00002248206
00002297809
COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL)MISCELLANEOUS TOPICAL COMPOUND
COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL)MISCELLANEOUS TOPICAL COMPOUND
COMPOUND-ANTI-INFECTIVE (TOPICAL)
COMPOUND-ANTI-INFECTIVE (TOPICAL)
FUCIDIN
RATIO-GENTAMICIN SULFATE
RATIO-GENTAMICIN SULFATE
METROCREAM
ROSASOLNORITATE
METROLOTION
METROGEL
XXX
XXX
XXX
XXX
XXX
XXX
LEO
RPH
RPH
GAL
GSKVCL
GAL
GAL
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES
ANTI-INFECTIVES
84
84
84
:00
:00
:00
84:00
84:04
84:04.04
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.6122
0.4425
0.4273
0.5183
0.5203 0.5409
0.5183
0.6285
173 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$
$
$
$
$$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
(ANTIBACTERIALS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
METRONIDAZOLE
METRONIDAZOLE/ NYSTATIN
MUPIROCIN
NEOMYCIN SULFATE/ POLYMYXIN B SULFATE
SODIUM FUSIDATE
TERBINAFINE HCL
KETOCONAZOLE
10 % VAGINAL CREAM
100 MG / G * 20,000 UNIT / G VAGINAL CREAM
500 MG * 100,000 UNIT VAGINAL OVULE
2 % TOPICAL CREAM
2 % TOPICAL OINTMENT
40 MG / ML (BASE) * 200,000 UNIT / ML IRRIGATION SOLUTION
2 % TOPICAL OINTMENT
1 % TOPICAL CREAM
1 % TOPICAL SOLUTION
2 % TOPICAL CREAM
00001926861
00001926845
00001926829
00002239757
0000227998300001916947
00000666157
00000586676
00002031094
00002238703
00002245662
FLAGYL
FLAGYSTATIN
FLAGYSTATIN
BACTROBAN
TARO-MUPIROCINBACTROBAN
NEOSPORIN
FUCIDIN
LAMISIL
LAMISIL
KETODERM
SAV
SAV
SAV
GKC
TARGKC
GSK
LEO
NOV
NOV
TPT
(ALLYLAMINES)
(AZOLES)
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES
ANTI-INFECTIVES
ANTI-INFECTIVES
84
84
84
:00
:00
:00
84:04.04
84:04.08.04
84:04.08.08
0.2322
0.5678
3.1230
0.5481
0.3453 0.5481
1.6862
0.6122
0.5184
0.5262
0.3268
174 EFFECTIVE JULY 1, 2012
$
$
$
$
$$
$
$
$
$
$
(ANTIBACTERIALS)
ANTIFUNGALS
ANTIFUNGALS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CICLOPIROX OLAMINE
AMCINONIDE
BECLOMETHASONE DIPROPIONATE
BETAMETHASONE DIPROPIONATE
BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID
1 % TOPICAL CREAM
0.1 % TOPICAL CREAM
0.1 % TOPICAL OINTMENT
0.1 % TOPICAL LOTION
250 MCG / G TOPICAL CREAM
0.05 % (BASE) TOPICAL CREAM
0.05 % (BASE) TOPICAL GLYCOL CREAM
0.05 % (BASE) TOPICAL OINTMENT
0.05 % (BASE) TOPICAL GLYCOL OINTMENT
0.05 % (BASE) TOPICAL LOTION
0.05 % (BASE) TOPICAL GLYCOL LOTION
0.5 MG / G (BASE) * 30 MG / G TOPICAL OINTMENT
0.5 MG / ML (BASE) * 20 MG / ML TOPICAL LOTION
00002221802
000022470980000224671400002192284
0000224709600002192268
0000224709700002192276
00002089602
0000080499100000323071
0000068862200000849650
0000034492300000805009
0000062936700000849669
0000041724600000809187
0000086297500001927914
00000578436
0000224568800000578428
LOPROX
RATIO-AMCINONIDETARO-AMCINONIDECYCLOCORT
RATIO-AMCINONIDECYCLOCORT
RATIO-AMCINONIDECYCLOCORT
PROPADERM
RATIO-TOPISONEDIPROSONE
DIPROLENE GLYCOLRATIO-TOPILENE
DIPROSONERATIO-TOPISONE
DIPROLENE GLYCOLRATIO-TOPILENE
DIPROSONERATIO-TOPISONE
DIPROLENE GLYCOLRATIO-TOPILENE
DIPROSALIC
RATIO-TOPISALICDIPROSALIC
VCL
RPHTARGSK
RPHGSK
RPHGSK
PAL
RPHMFC
MFCRPH
MFCRPH
MFCRPH
MFCRPH
MFCRPH
MFC
RPHMFC
(HYDROXYPYRIDONES)
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES
ANTI-INFLAMMATORY AGENTS
84
84
:00
:00
84:04.08.20
84:06
0.4731
0.2099 0.2099 0.5580
0.4199 0.5580
0.3533 0.4695
0.4371
0.2046 0.2048
0.5186 0.5186
0.2152 0.2153
0.5186 0.5186
0.1980 0.1980
0.2697 0.2697
0.8371
0.3698 0.4158
175 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$
$$
$$
$
$$
$$
$$
$$
$$
$$
$
$$
ANTIFUNGALS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
BETAMETHASONE SODIUM PHOSPHATE
BETAMETHASONE VALERATE
BUDESONIDE
CLOBETASOL 17-PROPIONATE
COMPOUND PRESCRIPTION
5 MG / ENM (BASE) RECTAL ENEMA
0.05 % (BASE) TOPICAL CREAM
0.1 % (BASE) TOPICAL CREAM
0.1 % (BASE) TOPICAL OCCLUSIVE CREAM
0.05 % (BASE) TOPICAL OINTMENT
0.1 % (BASE) TOPICAL OINTMENT
0.05 % (BASE) TOPICAL LOTION
0.1 % (BASE) TOPICAL LOTION
0.1 % (BASE) SCALP LOTION
2.3 MG / ENM RECTAL ENEMA
0.05 % TOPICAL CREAM
0.05 % TOPICAL OINTMENT
0.05 % SCALP LOTION
TOPICAL
TOPICAL
00002060884
0000071661800000535427
0000071662600000535435
00000804541
00000716642
00000716650
00000653209
00000750050
0000065321700000027944
00002052431
00002093162000019102720000224552300002213265
00002126192000019102800000224552400002213273
0000224552200002213281
00000999107
00000999207
BETNESOL (5MG/100ML)
BETADERM MILDRATIO-ECTOSONE MILD
BETADERM REGULARRATIO-ECTOSONE REGULAR
PREVEX B
BETADERM MILD
BETADERM REGULAR
RATIO-ECTOSONE MILD
RATIO-ECTOSONE REGULAR
RATIO-ECTOSONE SCALPVALISONE SCALP
ENTOCORT (115 ML)
NOVO-CLOBETASOLRATIO-CLOBETASOLTARO-CLOBETASOLDERMOVATE
NOVO-CLOBETASOLRATIO-CLOBETASOLTARO-CLOBETASOLDERMOVATE
TARO-CLOBETASOLDERMOVATE
COMPOUND-CORTICOSTEROIDS - TOPICAL
COMPOUND-CORTICOSTEROIDS - TOPICAL
PAL
TARRPH
TARRPH
GSK
TAR
TAR
RPH
RPH
RPHVLP
AZC
TEVRPHTARTPT
TEVRPHTARTPT
TARTPT
XXX
XXX
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS
84:00
84:06
9.5145
0.0606 0.0606
0.0903 0.0903
0.3600
0.0625
0.0932
0.2530
0.3125
0.0853 0.0853
8.2400
0.2470 0.2470 0.2470 0.6721
0.2470 0.2470 0.2470 0.6721
0.2156 0.5867
0.0000
0.0000
176 EFFECTIVE JULY 1, 2012
$
$$
$$
$
$
$
$
$
$$
$
$$$$
$$$$
$$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
DESONIDE
DESOXIMETASONE
DIFLUCORTOLONE VALERATE
FLUOCINONIDE
HALOBETASOL PROPIONATE
HYDROCORTISONE
0.05 % TOPICAL CREAM
0.05 % TOPICAL OINTMENT
0.05 % TOPICAL CREAM
0.25 % TOPICAL CREAM
0.1 % TOPICAL CREAM
0.1 % TOPICAL OINTMENT
0.05 % TOPICAL CREAM
0.05 % TOPICAL EMOLLIENT CREAM
0.05 % TOPICAL OINTMENT
0.05 % TOPICAL GEL
0.05 % TOPICAL CREAM
1 % TOPICAL CREAM
2.5 % TOPICAL CREAM
1 % TOPICAL OCCLUSIVE CREAM
0.5 % TOPICAL OINTMENT
1 % TOPICAL OINTMENT
1 % TOPICAL LOTION
2.5 % TOPICAL LOTION
100 MG / ENM RECTAL ENEMA
00002229315
00002229323
00002221918
00002221896
0000058782600000587818
00000587834
00000716863
00000598933
00002236996
00002236997
00001962701
00000192597
00000595799
00000804533
00000716685
00000716693
0000057854100000192600
0000085671100000595802
0000023031600002112736
PMS-DESONIDE
PMS-DESONIDE
TOPICORT MILD
TOPICORT
NERISONENERISONE OILY
NERISONE
LYDERM
TIAMOL
LYDERM
LYDERM
ULTRAVATE
EMO-CORT
EMO-CORT
PREVEX HC
CORTODERM MILD
CORTODERM REGULAR
SARNA HCEMO-CORT
SARNA HCEMO-CORT
HYCORT (100MG/60ML)CORTENEMA (100MG/60ML)
PMS
PMS
VCL
VCL
GSKGSK
GSK
TPT
TPT
TPT
TPT
VCL
GSK
GSK
GSK
TAR
TAR
GSKGSK
GSKGSK
VCLAXC
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS
84:00
84:06
0.3085
0.2992
0.4670
0.6730
0.3943 0.3947
0.3943
0.2700
0.2511
0.3478
0.3527
0.8590
0.1718
0.2347
0.2677
0.1404
0.0402
0.0938 0.1587
0.1813 0.2100
5.2786 6.7194
177 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$$
$
$
$
$
$
$
$
$
$
$
$
$$
$$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
HYDROCORTISONE 17-VALERATE
HYDROCORTISONE ACETATE
HYDROCORTISONE ACETATE/ PRAMOXINE HCL
HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE
HYDROCORTISONE ACETATE/ UREA
HYDROCORTISONE ACETATE/ ZINC SULFATE
MOMETASONE FUROATE
0.2 % TOPICAL CREAM
0.2 % TOPICAL OINTMENT
0.5 % TOPICAL CREAM
1 % TOPICAL CREAM
10 % RECTAL FOAM
1 % * 1 % RECTAL FOAM
10 MG * 20 MG * 10 MG RECTAL SUPPOSITORY
0.5 % * 1 % * 0.5 % RECTAL OINTMENT
1 % * 10 % TOPICAL CREAM
1 % * 10 % TOPICAL LOTION
10 MG * 10 MG RECTAL SUPPOSITORY
0.5 % * 0.5 % RECTAL OINTMENT
0.1 % TOPICAL CREAM
0.1 % TOPICAL OINTMENT
0.1 % TOPICAL LOTION
00002242984
00002242985
00000716820
00000716839
00000579335
00000363014
0000224085100002242797
0000223446600002247692
00000503134
00000560022
000006077970000224279800002236399
000006077890000224769100002128446
0000236715700000851744
000022481300000226474900000851736
0000226638500000871095
HYDROVAL
HYDROVAL
HYDERM
HYDERM
CORTIFOAM
PROCTOFOAM-HC
PROCTODAN-HCSANDOZ ANUZINC HC PLUS
PROCTODAN-HCSANDOZ ANUZINC HC PLUS
UREMOL-HC
UREMOL-HC
RATIO-HEMCORT H.C.SANDOZ ANUZINC HCANODAN-HC
RATIO-HEMCORT H.C.SANDOZ ANUZINC HCANODAN-HC
TARO-MOMETASONEELOCOM
RATIO-MOMETASONETARO-MOMETASONEELOCOM
TARO-MOMETASONEELOCOM
TPT
TPT
TAR
TAR
PAL
DUI
ODNSDZ
ODNSDZ
GSK
GSK
RPHSDZODN
RPHSDZODN
TARMFC
RPHTARMFC
TARMFC
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS
84:00
84:06
0.1250
0.1250
0.1720
0.0376
6.1365
1.6572
0.7826 1.0875
0.5218 0.7320
0.1746
0.0971
0.5833 0.5833 0.6075
0.3850 0.3850 0.4130
0.2379 0.6796
0.2253 0.2720 0.6112
0.3124 0.4556
178 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$$
$$
$
$
$$$
$$$
$$
$$$
$$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
TRIAMCINOLONE ACETONIDE
BETAMETHASONE DIPROPIONATE/ CLOTRIMAZOLE
COMPOUND PRESCRIPTION
HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN
LIDOCAINE
0.1 % TOPICAL CREAM
0.5 % TOPICAL CREAM
0.1 % TOPICAL OINTMENT
0.1 % DENTAL PASTE
0.05 % (BASE) * 1 % TOPICAL CREAM
5 MG * 5 MG * 10 MG * 10 MG RECTAL SUPPOSITORY
5 MG / G * 5 MG / G * 10 MG / G * 10 MG / G RECTAL OINTMENT
5 % TOPICAL OINTMENT
0000071696000002194058
00002194066
00002194031
00001964054
00000611174
00000999110
00000999211
000022263910000224788200002242528
00002226383000022473220000224252700002223252
0000208379500000001961
TRIADERM REGULARARISTOCORT R
ARISTOCORT C
ARISTOCORT R
ORACORT
LOTRIDERM
COMBINATION ANTI-INFECTIVE /CORTICOSTEROID
COMBINATION ANTI-INFECTIVE /CORTICOSTEROID
RATIO-PROCTOSONEPROCTOLSANDOZ PROCTOMYXIN HC
RATIO-PROCTOSONEPROCTOLSANDOZ PROCTOMYXIN HCPROCTOSEDYL
LIDODANXYLOCAINE
TARVLP
VLP
VLP
TAR
MFC
XXX
XXX
RPHODNSDZ
RPHODNSDZAXC
ODNAZC
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS
ANTI-INFLAMMATORY AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
84
84
84
:00
:00
:00
84:06
84:06.00
84:08
0.0650 0.1300
1.1523
0.1335
1.1146
0.7295
0.0000
0.0000
0.6000 0.6487 0.6487
0.4000 0.4577 0.4577 0.7823
0.1548 0.2714
179 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$
$
$
$
$$$
$$$$
$$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
(COMBINATION ANTI-INFECTIVE/ANTI-INFLAMMATORY AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
LIDOCAINE HCL
COMPOUND PRESCRIPTION
METHOXSALEN
5-FLUOROURACIL
ACITRETIN
AMINOBENZOATE POTASSIUM
AZELAIC ACID
2 % TOPICAL JELLY
TOPICAL
TOPICAL
10 MG ORAL CAPSULE
10 MG / ML TOPICAL LOTION
50 MG / G TOPICAL CREAM
10 MG ORAL CAPSULE
25 MG ORAL CAPSULE
500 MG ORAL TABLET
500 MG ORAL CAPSULE
15 % TOPICAL GEL
00000001694
00000999104
00000999204
0000025265400001946374
00001907476
00000330582
00002070847
00002070863
00000550175
00000611271
00002270811
XYLOCAINE JELLY
COMPOUND- SALICYLIC ACID (TOPICAL)
COMPOUND- SALICYLIC ACID (TOPICAL)
OXSORALEN ULTRAOXSORALEN
OXSORALEN
EFUDEX
SORIATANE
SORIATANE
POTABA
POTABA
FINACEA
AZC
XXX
XXX
VCLVCL
VCL
VCL
ACV
ACV
GLE
GLE
BAI
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
KERATOLYTIC AGENTS
DEPIGMENTING AND PIGMENTING AGENTS
MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
84
84
84
84
:00
:00
:00
:00
84:08
84:28
84:50.06
84:92
0.4200
0.0000
0.0000
0.4414 0.5926
1.5080
0.8350
1.8544
3.2572
0.3641
0.2768
0.6000
180 EFFECTIVE JULY 1, 2012
$
$
$
$$
$
$
$
$
$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
(PIGMENTING AGENTS)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CALCIPOTRIOL
CALCIPOTRIOL MONOHYDRATE/ BETAMETHASONE DIPROPIONATE
CALCIPOTRIOL/ BETAMETHASONE DIPROPIONATE
COLLAGENASE
ISOTRETINOIN
PODOFILOX
TAZAROTENE
50 MCG / G TOPICAL CREAM
50 MCG / G TOPICAL OINTMENT
50 MCG / ML SCALP SOLUTION
50 MCG / G (BASE) * 0.5 MG / G (BASE) TOPICAL GEL
50 MCG / G * 0.5 MG / G TOPICAL OINTMENT
250 UNIT / G TOPICAL OINTMENT
10 MG ORAL CAPSULE
40 MG ORAL CAPSULE
0.5 % TOPICAL SOLUTION
0.05 % TOPICAL GEL
0.1 % TOPICAL GEL
00002150956
00001976133
00002194341
00002319012
00002244126
00002063670
0000058234400002257955
0000058235200002257963
00002074788
00002230784
00002230785
DOVONEX
DOVONEX
DOVONEX
XAMIOL
DOVOBET
SANTYL
ACCUTANECLARUS
ACCUTANECLARUS
WARTEC
TAZORAC
TAZORAC
LEO
LEO
LEO
LEO
LEO
HPC
HLRMYP
HLRMYP
PAL
ALL
ALL
SKIN AND MUCOUS MEMBRANE AGENTS
MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
84:00
84:92
0.7559
0.7336
0.7593
1.4402
1.4359
2.9167
0.9313 0.9313
1.9003 1.9003
14.2610
1.3212
1.3212
181 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$
$
$
$$
$$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
86:00 Smooth M
uscle Relaxants
86:00
Smooth Muscle Relaxants
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
OXYBUTYNIN CHLORIDE
AMINOPHYLLINE
OXTRIPHYLLINE
OXTRIPHYLLINE/ GUAIFENESIN
THEOPHYLLINE
2.5 MG ORAL TABLET
5 MG ORAL TABLET
1 MG / ML ORAL SYRUP
25 MG / ML INJECTION
20 MG / ML ORAL ELIXIR
20 MG / ML * 10 MG / ML ORAL ELIXIR
100 MG ORAL SUSTAINED-RELEASE TABLET
200 MG ORAL SUSTAINED-RELEASE TABLET
300 MG ORAL SUSTAINED-RELEASE TABLET
400 MG ORAL SUSTAINED-RELEASE TABLET
600 MG ORAL SUSTAINED-RELEASE TABLET
5.3 MG / ML ORAL LIQUID
00002240549
0000216354300002230800000022303940000235023800002240550
00002223376
00000497193
0000079294200000476366
00000476374
00000692689
00000692697
00000692700
00002014165
00002014181
00001966219
PMS-OXYBUTYNIN
APO-OXYBUTYNINMYLAN-OXYBUTYNINNOVO-OXYBUTYNINOXYBUTYNINPMS-OXYBUTYNIN
PMS-OXYBUTYNIN
AMINOPHYLLINE
PMS-OXTRIPHYLLINECHOLEDYL
CHOLEDYL EXPECTORANT
APO-THEO LA
APO-THEO LA
APO-THEO LA
UNIPHYL
UNIPHYL
THEOLAIR
PMS
APXMYPTEVSNSPMS
PMS
HSP
PMSERF
ERF
APX
APX
APX
PUR
PUR
MEP
SMOOTH MUSCLE RELAXANTS
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
86
86
:00
:00
86:12
86:16
0.1428
0.1553 0.1553 0.1553 0.1553 0.1553
0.1183
0.4103
0.0325 0.0367
0.0736
0.1300
0.1350
0.1400
0.4980
0.6032
0.0252
183 EFFECTIVE JULY 1, 2012
UNIT OF ISSUE - REFER TO PRICE POLICY
$
$$$$$
$
$
$$
$
$
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
88:00 Vitamins
88:00
Vitamins
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
CYANOCOBALAMIN
FOLIC ACID
THIAMINE HCL
ALFACALCIDOL
CALCITRIOL
PHYTONADIONE
1,000 MCG / ML INJECTION
5 MG ORAL TABLET
5 MG / ML INJECTION
100 MG / ML INJECTION
0.25 MCG ORAL CAPSULE
1 MCG ORAL CAPSULE
2 MCG / ML ORAL DROPS
2 MCG / ML INJECTION
0.25 MCG ORAL CAPSULE
0.5 MCG ORAL CAPSULE
1 MCG / ML INJECTION
2 MCG / ML INJECTION
2 MG / ML INJECTION
10 MG / ML INJECTION
0000198700300000521515
00000426849
00000816086
0000219322100002243525
00000474517
00000474525
00002240329
00002242502
00000481823
00000481815
00000891738
00000891746
00000781878
00000804312
CYANOCOBALAMINVITAMIN B12
APO-FOLIC
FOLIC ACID
THIAMIJECTTHIAMINE HCL
ONE-ALPHA
ONE-ALPHA
ONE-ALPHA
ONE-ALPHA
ROCALTROL
ROCALTROL
CALCIJEX
CALCIJEX
VITAMIN K1 PEDIATRIC
VITAMIN K1
CYTSDZ
APX
SDZ
OMGCYT
LEO
LEO
LEO
LEO
HLR
HLR
ABB
ABB
SDZ
SDZ
VITAMINS
VITAMINS
VITAMINS
VITAMIN B COMPLEX
VITAMIN D
VITAMIN K ACTIVITY
88
88
88
:00
:00
:00
88:08
88:16
88:24
0.3060 0.3060
0.0404
1.8125
1.1880 1.1880
0.4384
1.3120
5.0127
16.0751
0.9280
1.4758
10.4140
18.8890
4.6381
3.2986
185 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$
$
$$
$
$
$
$
$
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
PIPRADROL HCL/ THIAMINE HCL/ RIBOFLAVIN/ PYRIDOXINE HCL/ NIACINAMIDE/ CHOLINE/ INOSITOL
0.04 MG / ML * 0.22 MG / ML * 0.11 MG / ML * 0.04 MG / ML * 1.11 MG / ML * 2.22 MG / ML * 2.22 MG / ML ORAL LIQUID
00002103052 ALERTONIC ODN
VITAMINS
MULTIVITAMIN PREPARATIONS
88:00
88:28
0.0643
186 EFFECTIVE JULY 1, 2012
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
92:00 Miscellaneous Therapeutic A
gents
92:00
Miscellaneous Therapeutic Agents
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
ALLOPURINOL
AZATHIOPRINE
BETAHISTINE DIHYDROCHLORIDE
BOTULINUM NEUROTOXIN TYPE A (150KD), FREE FROM COMPLEXI
CLODRONATE DISODIUM
CLODRONATE DISODIUM TETRAHYDRATE
CLONIDINE HCL
COLCHICINE
100 MG ORAL TABLET
200 MG ORAL TABLET
300 MG ORAL TABLET
50 MG ORAL TABLET
16 MG ORAL TABLET
100 UNIT / VIAL INJECTION
400 MG ORAL CAPSULE
400 MG ORAL CAPSULE
60 MG / ML INJECTION
0.025 MG ORAL TABLET
0.6 MG ORAL TABLET
1 MG ORAL TABLET
00000402818
00000479799
00000402796
0000224290700002343002000022314910000223681900000004596
000023747570000228019100002243878
00002324032
00002245828
00001984845
00001984837
0000230416300000519251
00000572349
00000621374
ZYLOPRIM
ZYLOPRIM
ZYLOPRIM
APO-AZATHIOPRINEAZATHIOPRINEMYLAN-AZATHIOPRINETEVA-AZATHIOPRINEIMURAN
CO BETAHISTINENOVO-BETAHISTINESERC
XEOMIN
CLASTEON
BONEFOS
BONEFOS
NOVO-CLONIDINEDIXARIT
COLCHICINE
COLCHICINE
AAP
AAP
AAP
APXSNSMYPTEVTPI
COBTEVABB
MPC
SUN
BHP
BHP
TEVBOE
ODN
ODN
MISCELLANEOUS THERAPEUTIC AGENTS92:00
92:00
0.0780
0.1300
0.2125
0.3724 0.3724 0.3724 0.3724 0.9897
0.1770 0.1770 0.4599
330.0000
1.2083
1.8937
12.3906
0.2584 0.2720
0.2665
0.5285
187 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$
$$$$$
$$$
$
$
$
$
$$
$
$
Please note: Xeomin is indicated in adults for the symptomatic management of blepharospasm,cervical dystonia of a predominantly rotational form (spasmodic torticollis), and post-stroke spasticity of the upper limb.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
PRODUCT IS NOT INTERCHANGEABLE
COMPOUND PRESCRIPTION
DIMETHYL SULFOXIDE
ETIDRONATE DISODIUM
ETIDRONATE DISODIUM/ CALCIUM CARBONATE
FLUNARIZINE HCL
LEUCOVORIN CALCIUM
INJECTION
INJECTION
ORAL
ORAL
50 % BLADDER IRRIGATION SOLUTION
200 MG ORAL TABLET
400 MG * 500 MG ORAL TABLET
5 MG (BASE) ORAL CAPSULE
5 MG (BASE) ORAL TABLET
10 MG / ML INJECTION
00000999114
00000999215
00000999999
00000999216
00000999214
00000999113
0000224323100000493392
0000224868600002245330
0000226386600002353210000022473230000232419900002176017
00002246082
00002170493
00002087316
MISCELLANEOUS INJECTABLE COMPOUND
MISCELLANEOUS INJECTABLE COMPOUND
MISCELLANEOUS COMPOUND
MISCELLANEOUS COMPOUND
MISCELLANEOUS ORAL COMPOUND
MISCELLANEOUS ORAL COMPOUND
DIMETHYL SULFOXIDE IRRIGATIONRIMSO-50
CO ETIDRONATEMYLAN-ETIDRONATE
CO ETIDROCALETIDROCALMYLAN-ETI-CAL-CAREPACNOVO-ETIDRONATECALDIDROCAL
FLUNARIZINE
LEDERLE LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM
XXX
XXX
XXX
XXX
XXX
XXX
SDZALV
COBMYP
COBSNSMYPTEVWCC
AAP
WAY
TEV
MISCELLANEOUS THERAPEUTIC AGENTS92:00
92:00
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
1.1840 1.1900
0.5161 0.5161
0.2221 0.2221 0.2221 0.2221 0.4870
0.7204
6.1958
12.2119
188 EFFECTIVE JULY 1, 2012
$
$
$
$
$
$
$$
$$
$$$$$
$
$
$
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.
To be used when the compound has been prepared and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
NAFARELIN ACETATE
ONABOTULINUMTOXINA
PAMIDRONATE DISODIUM
PENTOSAN POLYSULFATE SODIUM
LEFLUNOMIDE
2 MG / ML (BASE) NASAL SOLUTION
INJECTION
30 MG / VIAL INJECTION
60 MG / VIAL INJECTION
90 MG / VIAL INJECTION
100 MG ORAL CAPSULE
10 MG ORAL TABLET
20 MG ORAL TABLET
00002188783
00001981501
00002249669000022649510000224455000002059762
0000226497800002244551
00002249685000022649860000224455200002059789
00002029448
0000225649500002351668000022612510000228396400002241888
0000225650900002351676000022612780000228397200002241889
SYNAREL
BOTOX (50/100/200 UNITS/VIAL)
PAMIDRONATE DISODIUM OMEGAPAMIDRONATE DISODIUMPAMIDRONATE DISODIUMAREDIA
PAMIDRONATE DISODIUMPAMIDRONATE DISODIUM
PAMIDRONATE DISODIUM OMEGAPAMIDRONATE DISODIUMPAMIDRONATE DISODIUMAREDIA
ELMIRON
APO-LEFLUNOMIDELEFLUNOMIDENOVO-LEFLUNOMIDESANDOZ LEFLUNOMIDEARAVA
APO-LEFLUNOMIDELEFLUNOMIDENOVO-LEFLUNOMIDESANDOZ LEFLUNOMIDEARAVA
PFI
ALL
OMGSDZHSPNOV
SDZHSP
OMGSDZHSPNOV
JAI
APXSNSTEVSDZSAV
APXSNSTEVSDZSAV
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
92
92
:00
:00
92:00
92:36
35.7369
3.5700
82.1860 86.6800 93.2900
166.9300
176.7000 188.7400
246.5581 260.3700 278.0600 500.7900
1.6545
4.1027 4.1027 4.1027 4.1027
10.9043
4.1046 4.1046 4.1046 4.1046
10.9093
189 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$
$
$$$$
$$
$$$$
$
$$$$$
$$$$$
For the products within the following three groupings, pricing has been established on a per vialbasis.
RESTRICTED BENEFIT - This product is a benefit for the treatment of rheumatoid arthritis when prescribed by a Specialist in Rheumatology or Internal Medicine.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
94:00 Devices
94:00
Devices
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST
AEROSOL HOLDING CHAMBER
AEROSOL HOLDING CHAMBER/MASK
DEVICE
DEVICE
INFANT DEVICE
PEDIATRIC DEVICE
ADULT DEVICE
DEVICE
0000099001400000990095
000009900800000099008900000990088000009901000000099009900000990091
000009900810000099001500000990096
00000990092
000009900820000099001600000990097
00000990093
0000099001700000990098
00000990094
00000999949
SPACE CHAMBEROPTICHAMBER ADVANTAGE II (CHAMBER ONLY)VORTEXAEROCHAMBER AC BOYZ CHAMBERAEROCHAMBER AC GIRLZ CHAMBERAEROCHAMBER AC BOYZ CHAMBERAEROCHAMBER AC GIRLZ CHAMBERAEROCHAMBER PLUS FLOW-VU W/ MOUTHPIECE
VORTEX BABY WHIRL INFANT MASKSPACE CHAMBER INFANT MASKOPTICHAMBER ADVANTAGE II (WITH SMALL MASK)AEROCHAMBER PLUS FLOW-VU W/ SMALL MASK
VORTEX SPINNER PEDIATRIC MASKSPACE CHAMBER PEDIATRIC MASKOPTICHAMBER ADVANTAGE II (WITH MEDIUM MASK)AEROCHAMBER PLUS FLOW-VU W/ MEDIUMMASK
SPACE CHAMBER ADULT MASKOPTICHAMBER ADVANTAGE II (WITH LARGEMASK)AEROCHAMBER PLUS FLOW-VU W/ LARGE MASK
SEREVENT DISKHALER
KGHACM
KGHTMITMITMITMITMI
KGHKGHACM
TMI
KGHKGHACM
TMI
KGHACM
TMI
GSK
DEVICES94:00
94:00
12.0000 15.6000
19.4977 21.5400 21.5400 23.5500 23.5500 23.5500
8.5023 13.0047 26.8000
37.6700
8.5023 13.0047 26.8000
37.6700
13.0047 29.6000
39.8600
5.4600
191 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY
$$
$$$$$$
$$$
$
$$$
$
$$
$
$
RESTRICTED BENEFIT - Coverage is limited to one aerosol holding chamber per plan participant per year.
RESTRICTED BENEFIT - Coverage is limited to one of each size (infant, pediatric, adult) aerosol holding chamber mask or chamber w/ mask per plan participant per year.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
Appendices
Appendices
Abbreviations Pharmaceutical Manufacturers
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST APPENDIX 1 - ABBREVIATIONS
Appendix 1 Abbreviations
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
190 EFFECTIVE JULY 1, 2012
ASA ........................................... acetylsalicylic acid ENM ........................................... enema FC .............................................. film coated G ................................................ gram(s) HCL............................................ hydrochloride
HR .............................................. hour IU ............................................... international unit(s) MCG........................................... microgram MEQ ........................................... milliequivalent
MG ............................................. milligram ML .............................................. millilitre PTH ............................................ patch SYR............................................ syringe
W................................................ with % ................................................ percent
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST APPENDIX 2 - PHARMACEUTICAL MANUFACTURERS
Appendix 2 Pharmaceutical Manufacturers
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 191 EFFECTIVE JULY 1, 2012
0BA
AAP AA Pharma Inc. ABB Abbott Laboratories Limited ACV Actavis ACM Auto Control Medical Inc. ACP Accel Pharma Inc. AHI Accord Healthcare Inc. ALC Alcon Canada Inc. ALL Allergan Inc. ALV Alveda Pharmaceuticals Inc. AMG Amgen Inc. API Alexion Pharmaceuticals, Inc. APX Apotex Inc. ASP Astellas Pharma Canada, Inc. AUR Auro Pharma Inc. AVA Avanstra Inc. AXC Axcan Pharma Inc. AZC AstraZeneca Canada Inc.
1BB BAI Bayer Inc. BAR Barr laboratories, Inc. BHP Bayer Healthcare Pharmaceuticals BIO Biogen Idec Canada Inc BMS Bristol-Myers Squibb BOE Boehringer Ingelheim (Canada) Ltd. BVM Biovitrum AB
2BC COB Cobalt Pharmaceuticals Inc. COR Corepharma LLC CYT Cytex Pharmaceuticals Inc.
3BD DUI Duchesnay Inc. DUR Duramed Pharmaceuticals Inc.
4BE ERF ERFA Canada Inc. ETP Ethypharm Inc.
5BF FAB Fournier/Abbott Laboratories Limited FEI Ferring Inc.
6BG GAL Galderma Canada Inc. GIL Gilead Sciences Inc. GKC GlaxoSmithKline Consumer Healthcare GLE Glenwood Laboratories Canada Ltd. GMD Genmed, a Division of Pfizer Canada Inc.
GSK GlaxoSmithKline GZM Genzyme Canada Inc.
7BH HLR Hoffman-La Roche Limited HPC Healthpoint Canada ULC HSP Hospira Healthcare Corporation 8BJ JAI Janssen Inc. JHP JHP Pharmaceuticals, LLC JPC Jamp Pharma Corporation
9BK KGH Kego Healthcare KNG King Pharmaceuticals Canada Inc.
10BL LBC Lundbeck Canada Inc. LEO Leo Pharma Inc. LIL Eli Lilly Canada Inc. LPI Luitpold Pharmaceuticals, Inc. LUI Lundbeck Inc.
11BM MAR Marcan Pharmaceuticals Inc MEL Meliapharm Inc. MEP Medicis Pharmaceutical Corporation MFC Merck Canada Inc. MLI Merus Labs Inc. MMT MM Therapeutics Inc. MPC Merz Pharma Canada Ltd. MPI Mint Pharmaceuticals Inc. MYP Mylan Pharmaceuticals ULC
12BN NNA Novo Nordisk Canada Inc. NOV Novartis Pharmaceuticals Canada Inc. NPA Novo Nordisk Canada/Paladin Labs NTI Nucro-Technics Incorporated NYC Nycomed Canada Inc.
13BO ODN Odan Laboratories Ltd. OMG Omega Laboratories Ltd. ORG Organon Canada Ltd.
14BP PAL Paladin Labs Inc. PAT Patriot, a Division of Janssen Inc. PFI Pfizer Canada Inc. PHH Pharmel Inc. PMS Pharmascience Inc.
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST REFRESHED APPENDIX 2 - PHARMACEUTICAL MANUFACTURERS
Appendix 2 Pharmaceutical Manufacturers
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 192 EFFECTIVE JULY 1, 2012
PPC Pharmaceutical Partners of Canada, a Division of Abraxis Bioscience Inc.
PPH Pendopharm Inc. PUR Purdue Pharma
15BR
RAN Ranbaxy Pharmaceuticals Canada Inc RBC Reckitt Benckiser (Canada) Inc. ROG Rougier Pharma Inc. (Div. of ratiopharm) RPH ratiopharm
16BS SAV Sanofi-Aventis SDZ Sandoz Canada Inc. SEP Septa Pharmaceuticals Inc. SEV Servier Canada Inc. SHB Shire Canada Inc. SNS Sanis Health Inc. SPG Sun Pharma Global Fze SRO EMD Serono Canada Inc. STM Sterimax Inc. SUN Sunovion Pharmaceutical Inc.
T TAK Takeda Canada, Inc. TAR Taro Pharmaceuticals Inc. TCI Tercica, Inc. TEV Teva Canada Limited TMI Trudell Medical International TMP Teva Canada Innovation TPI Triton Pharma Inc. TPT Taropharma, a Div. of Taro
Pharmaceuticals Inc.
17BU
UCB UCB Pharma Canada Inc.
18BV VCL Valeant Canada Limittee/Limited VLP Valeo Pharma Inc.
19BW WAY Wyeth Pharmaceuticals WCC Warner Chilcott Canada Co. WSD Westwood Squibb (Div. Bristol-Myers Squibb
Canada) WSP Wellspring Pharmaceutical Canada Corp.
20BX XPI Xediton Pharmaceuticals Inc. XXX Miscellaneous Manufacturers
21B
Indices
Indices
Alphabetical List of Pharmaceutical Products
Numerical List by Drug Identification Number
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 193 EFFECTIVE JULY 1, 2012
NUMERIC
282 ................................................................................ 76 282 MEP ....................................................................... 77 292 ................................................................................ 77 5-FLUOROURACIL ..................................................... 180
A
ABATACEPT ........................................................ SEC 3.6 ABILIFY ......................................................................... 98 ACARBOSE ................................................................ 162 ACCEL PIOGLITAZONE .................................... SEC 3.72 ACCOLATE ................................................................. 129 ACCOLATE ........................................................ SEC 3.94 ACCUPRIL .................................................................... 63 ACCURETIC 10/12.5 .................................................... 63 ACCURETIC 20/12.5 .................................................... 63 ACCURETIC 20/25 ....................................................... 63 ACCUTANE ................................................................ 181 ACEBUTOLOL .............................................................. 49 ACEBUTOLOL HCL ...................................................... 49 ACENOCOUMAROL ..................................................... 29 ACETAZOLAMIDE ...................................................... 136 ACETYLCYSTEINE .................................................... 130 ACITRETIN ................................................................. 180 ACLASTA ........................................................... SEC 3.94 ACTEMRA (10 ML) ............................................ SEC 3.89 ACTEMRA (20 ML) ............................................ SEC 3.89 ACTEMRA (4 ML) .............................................. SEC 3.89 ACTONEL .......................................................... SEC 3.75 ACTOS ............................................................... SEC 3.72 ACULAR ...................................................................... 134 ACYCLOVIR ................................................................. 17 ADALAT XL ................................................................... 56 ADALIMUMAB ................................................... SEC 3.13 ADEFOVIR DIPIVOXIL ................................................. 17 ADRENALIN ................................................................ 135 ADRENALIN .................................................................. 26 ADVAIR 100 DISKUS .................................................... 26 ADVAIR 125 .................................................................. 25 ADVAIR 250 .................................................................. 25 ADVAIR 250 DISKUS .................................................... 26 ADVAIR 500 DISKUS .................................................... 26 AEROCHAMBER AC BOYZ CHAMBER ..................... 191 AEROCHAMBER AC GIRLZ CHAMBER .................... 191 AEROCHAMBER PLUS FLOW-VU W/ LARGE MASK 191 AEROCHAMBER PLUS FLOW-VU W/ MEDIUM MASK
................................................................................ 191 AEROCHAMBER PLUS FLOW-VU W/ MOUTHPIECE191
AEROCHAMBER PLUS FLOW-VU W/ SMALL MASK 191 AEROSOL HOLDING CHAMBER ................................ 191 AEROSOL HOLDING CHAMBER/MASK .................... 191 AGGRENOX .................................................................. 33 AIROMIR CFC-FREE ..................................................... 25 ALCAINE ...................................................................... 134 ALDACTAZIDE 25 ......................................................... 70 ALDACTAZIDE 50 ......................................................... 70 ALDACTONE ................................................................. 70 ALDARA ............................................................. SEC 3.47 ALENDRONATE ................................................ SEC 3.14 ALENDRONATE SODIUM ................................. SEC 3.14 ALENDRONATE SODIUM/ VITAMIN D3 ........... SEC 3.15 ALENDRONATE-FC .......................................... SEC 3.14 ALERTEC .......................................................... SEC 3.59 ALERTONIC................................................................. 186 ALESSE (21 DAY) ....................................................... 159 ALESSE (28 DAY) ....................................................... 159 ALFACALCIDOL .......................................................... 185 ALFUZOSIN HCL ............................................... SEC 3.15 ALLERGY SERUM ....................................................... 171 ALLOPURINOL ............................................................ 187 ALPHAGAN ................................................................. 135 ALPRAZOLAM ............................................................. 110 ALPROSTADIL .............................................................. 46 ALTACE (CAPSULE) ..................................................... 63 ALTACE (CAPSULE) ..................................................... 64 ALTACE HCT ................................................................. 64 ALVESCO .................................................................... 155 AMANTADINE HCL ..................................................... 116 AMCINONIDE .............................................................. 175 AMERGE ..................................................................... 114 AMERGE ........................................................... SEC 3.61 AMILORIDE HCL ......................................................... 126 AMINOBENZOATE POTASSIUM ................................ 180 AMINOPHYLLINE ........................................................ 183 AMIODARONE............................................................... 36 AMIODARONE HCL ...................................................... 36 AMITRIPTYLINE HCL .................................................... 95 AMLODIPINE ................................................................. 55 AMLODIPINE BESYLATE ............................................. 55 AMOXICILLIN ................................................................ 10 AMOXICILLIN ................................................................ 11 AMOXICILLIN SUGAR-REDUCED ................................ 10 AMOXICILLIN SUGAR-REDUCED ................................ 11 AMOXICILLIN TRIHYDRATE......................................... 10 AMOXICILLIN TRIHYDRATE......................................... 11 AMOXICILLIN TRIHYDRATE/ CLAVULANATE
POTASSIUM .............................................................. 11 AMPHOTERICIN B ........................................................ 16 AMPICILLIN ....................................................... SEC 3.15 AMPICILLIN SODIUM .................................................... 11
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 194
ANAFRANIL .................................................................. 95 ANAKINRA ......................................................... SEC 3.17 ANAPROX ..................................................................... 75 ANAPROX DS ............................................................... 75 ANDRIOL ........................................................... SEC 3.86 ANDROCUR ...................................................... SEC 3.21 ANDROCUR DEPOT ......................................... SEC 3.21 ANDRODERM (2.5 MG/DAY) ............................ SEC 3.86 ANDRODERM (5 MG/DAY) ............................... SEC 3.86 ANODAN-HC .............................................................. 178 ANZEMET ................................................................... 142 APIDRA ....................................................................... 164 APIDRA CARTRIDGE ................................................. 164 APIDRA PEN .............................................................. 164 APO-ACEBUTOLOL ..................................................... 49 APO-ACYCLOVIR ......................................................... 17 APO-ALENDRONATE ........................................ SEC 3.14 APO-ALFUZOSIN .............................................. SEC 3.15 APO-ALPRAZ ............................................................. 110 APO-AMILZIDE ........................................................... 126 APO-AMIODARONE ..................................................... 36 APO-AMLODIPINE ....................................................... 55 APO-AMOXI .................................................................. 10 APO-AMOXI .................................................................. 11 APO-AMOXI CLAV........................................................ 11 APO-ATENIDONE......................................................... 50 APO-ATENOL ............................................................... 49 APO-ATENOL ............................................................... 50 APO-ATORVASTATIN .................................................. 38 APO-AZATHIOPRINE ................................................. 187 APO-AZITHROMYCIN .................................................... 9 APO-BACLOFEN .......................................................... 27 APO-BECLOMETHASONE ......................................... 132 APO-BISOPROLOL ...................................................... 50 APO-BRIMONIDINE .................................................... 135 APO-BROMAZEPAM .................................................. 110 APO-BROMOCRIPTINE ............................................. 118 APO-BUSPIRONE ...................................................... 112 APO-CALCITONIN ............................................. SEC 3.85 APO-CANDESARTAN .................................................. 65 APO-CAPTO ................................................................. 59 APO-CARVEDILOL ....................................................... 51 APO-CEFADROXIL............................................ SEC 3.19 APO-CEFPROZIL ........................................................... 6 APO-CEFUROXIME ........................................................ 7 APO-CEPHALEX ............................................................ 5 APO-CHLORAX .......................................................... 110 APO-CHLORDIAZEPOXIDE ....................................... 110 APO-CILAZAPRIL ......................................................... 59 APO-CILAZAPRIL/HCTZ .............................................. 59 APO-CIMETIDINE ....................................................... 144 APO-CIPROFLOX .............................................. SEC 3A.2
APO-CIPROFLOX .............................................. SEC 3A.3 APO-CITALOPRAM ....................................................... 91 APO-CLINDAMYCIN ...................................................... 14 APO-CLOBAZAM ........................................................... 83 APO-CLOMIPRAMINE ................................................... 95 APO-CLONAZEPAM ...................................................... 84 APO-CLOPIDOGREL .................................................... 32 APO-CLOPIDOGREL ........................................ SEC 3.20 APO-CLORAZEPATE .................................................. 110 APO-CLOZAPINE .......................................................... 98 APO-CLOZAPINE .......................................................... 99 APO-CYCLOBENZAPRINE ........................................... 27 APO-CYCLOSPORINE ...................................... SEC 3.21 APO-DESIPRAMINE ...................................................... 95 APO-DESMOPRESSIN ............................................... 167 APO-DEXAMETHASONE ............................................ 156 APO-DIAZEPAM .......................................................... 110 APO-DIAZEPAM .......................................................... 111 APO-DICLO ................................................................... 72 APO-DICLO SR ............................................................. 72 APO-DIFLUNISAL .......................................................... 73 APO-DILTIAZ ................................................................. 56 APO-DILTIAZ CD ........................................................... 56 APO-DILTIAZ CD ........................................................... 57 APO-DILTIAZ TZ ............................................................ 57 APO-DILTIAZ TZ ............................................................ 58 APO-DIPYRIDAMOLE (FC) ........................................... 46 APO-DIVALPROEX ....................................................... 85 APO-DIVALPROEX ....................................................... 86 APO-DOMPERIDONE ................................................. 148 APO-DORZO-TIMOP ................................................... 138 APO-DOXAZOSIN ......................................................... 47 APO-DOXEPIN .............................................................. 95 APO-DOXEPIN .............................................................. 96 APO-DOXY .................................................................... 13 APO-ENALAPRIL ........................................................... 60 APO-ENALAPRIL MALEATE/HCTZ .............................. 60 APO-ENTACAPONE .................................................... 117 APO-FAMOTIDINE ...................................................... 145 APO-FENO-MICRO ....................................................... 37 APO-FENO-SUPER ....................................................... 37 APO-FENO-SUPER (TABLET) ...................................... 37 APO-FENOFIBRATE ..................................................... 37 APO-FINASTERIDE ........................................... SEC 3.41 APO-FLUCONAZOLE .................................................... 15 APO-FLUNISOLIDE ..................................................... 132 APO-FLUOXETINE ........................................................ 92 APO-FLUPHENAZINE ................................................. 105 APO-FLUPHENAZINE ................................................. 106 APO-FLURAZEPAM .................................................... 111 APO-FLURBIPROFEN ................................................... 73 APO-FLUTAMIDE .............................................. SEC 3.42
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 195 EFFECTIVE JULY 1, 2012
APO-FLUVOXAMINE .................................................... 92 APO-FOLIC ................................................................. 185 APO-FOSINOPRIL ........................................................ 61 APO-FUROSEMIDE ...................................................... 44 APO-FUROSEMIDE ...................................................... 45 APO-GABAPENTIN ...................................................... 86 APO-GEMFIBROZIL ..................................................... 37 APO-GLICLAZIDE....................................................... 165 APO-GLYBURIDE ....................................................... 166 APO-HALOPERIDOL .................................................. 104 APO-HALOPERIDOL .................................................. 105 APO-HYDRALAZINE .................................................... 44 APO-HYDRO .............................................................. 126 APO-HYDROMORPHONE ........................................... 78 APO-HYDROXYQUINE ................................................ 18 APO-HYDROXYZINE .................................................. 113 APO-IBUPROFEN......................................................... 73 APO-INDAPAMIDE ..................................................... 127 APO-IPRAVENT............................................................ 24 APO-ISMN .................................................................... 46 APO-K ......................................................................... 125 APO-KETOCONAZOLE ................................................ 15 APO-KETOROLAC ..................................................... 134 APO-KETOROLAC ....................................................... 74 APO-LACTULOSE ...................................................... 125 APO-LAMOTRIGINE ..................................................... 87 APO-LANSOPRAZOLE ............................................... 147 APO-LATANOPROST ................................................. 137 APO-LEFLUNOMIDE .................................................. 189 APO-LEVETIRACETAM ................................................ 87 APO-LEVOCARB ........................................................ 118 APO-LEVOFLOXACIN ....................................... SEC 3A.4 APO-LISINOPRIL .......................................................... 61 APO-LISINOPRIL .......................................................... 62 APO-LISINOPRIL/HCTZ ............................................... 62 APO-LITHIUM CARBONATE ...................................... 114 APO-LORAZEPAM ..................................................... 111 APO-LOSARTAN .......................................................... 67 APO-LOSARTAN/HCTZ ................................................ 67 APO-LOSARTAN/HCTZ ................................................ 68 APO-LOVASTATIN ....................................................... 39 APO-MEDROXY ......................................................... 167 APO-METFORMIN ...................................................... 163 APO-METHOPRAZINE ............................................... 106 APO-METHOTREXATE ................................................ 21 APO-METHYLPHENIDATE ........................................ 109 APO-METHYLPHENIDATE SR .................................. 109 APO-METOPROLOL ..................................................... 52 APO-METOPROLOL (TYPE L) ..................................... 52 APO-METOPROLOL SR ............................................... 52 APO-MINOCYCLINE ..................................................... 13 APO-MIRTAZAPINE ..................................................... 98
APO-MOCLOBEMIDE ................................................... 89 APO-MONTELUKAST ................................................. 129 APO-MONTELUKAST ....................................... SEC 3.60 APO-NABUMETONE ..................................................... 74 APO-NADOL .................................................................. 52 APO-NAPRO-NA ........................................................... 75 APO-NAPRO-NA DS ..................................................... 75 APO-NAPROXEN .......................................................... 74 APO-NAPROXEN EC .................................................... 75 APO-NITRAZEPAM ..................................................... 112 APO-NIZATIDINE ........................................................ 145 APO-NORFLOX ............................................................. 12 APO-NORTRIPTYLINE .................................................. 96 APO-OFLOXACIN ........................................................ 131 APO-OLANZAPINE ...................................................... 100 APO-OLANZAPINE ........................................................ 99 APO-OLANZAPINE ODT ............................................. 100 APO-OMEPRAZOLE (CAPSULE) ............................... 147 APO-ONDANSETRON ................................................ 143 APO-ORCIPRENALINE ................................................. 25 APO-OXAZEPAM ........................................................ 112 APO-OXYBUTYNIN ..................................................... 183 APO-OXYCODONE ....................................................... 82 APO-PANTOPRAZOLE ............................................... 148 APO-PAROXETINE ....................................................... 93 APO-PEN-VK ................................................................. 10 APO-PENTOXIFYLLINE SR .......................................... 33 APO-PIMOZIDE ........................................................... 108 APO-PINDOL ................................................................. 53 APO-PIOGLITAZONE ........................................ SEC 3.72 APO-PIROXICAM .......................................................... 76 APO-PRAMIPEXOLE ................................................... 119 APO-PRAVASTATIN ..................................................... 40 APO-PRAZO .................................................................. 47 APO-PREDNISONE ..................................................... 158 APO-PROCHLORAZINE ............................................. 142 APO-PROPAFENONE ................................................... 35 APO-PROPRANOLOL ................................................... 53 APO-QUETIAPINE ....................................................... 100 APO-QUETIAPINE ....................................................... 101 APO-QUININE ............................................................... 19 APO-RABEPRAZOLE .................................................. 148 APO-RALOXIFENE ............................................ SEC 3.74 APO-RAMIPRIL (CAPSULE) ......................................... 63 APO-RAMIPRIL (CAPSULE) ......................................... 64 APO-RANITIDINE ........................................................ 145 APO-RANITIDINE ........................................................ 146 APO-REPAGLINIDE .................................................... 165 APO-RISEDRONATE ........................................ SEC 3.75 APO-RISPERIDONE .................................................... 102 APO-RISPERIDONE .................................................... 103 APO-RISPERIDONE .................................................... 104
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 196
APO-RIVASTIGMINE ......................................... SEC 3.78 APO-ROPINIROLE ..................................................... 119 APO-ROPINIROLE ..................................................... 120 APO-ROSUVASTATIN .................................................. 41 APO-SALVENT ............................................................. 25 APO-SALVENT CFC FREE .......................................... 25 APO-SELEGILINE....................................................... 120 APO-SERTRALINE ....................................................... 93 APO-SERTRALINE ....................................................... 94 APO-SIMVASTATIN ...................................................... 42 APO-SIMVASTATIN ...................................................... 43 APO-SOTALOL ............................................................. 54 APO-SUCRALFATE .................................................... 146 APO-SULFATRIM ......................................................... 12 APO-SULFATRIM DS ................................................... 12 APO-SULIN ................................................................... 76 APO-SUMATRIPTAN .................................................. 115 APO-SUMATRIPTAN ......................................... SEC 3.84 APO-TAMSULOSIN CR ................................................ 48 APO-TEMAZEPAM ..................................................... 112 APO-TERAZOSIN ......................................................... 48 APO-TERBINAFINE ...................................................... 15 APO-THEO LA ............................................................ 183 APO-TIAPROFENIC ..................................................... 76 APO-TICLOPIDINE ....................................................... 33 APO-TIMOL .................................................................. 54 APO-TIMOP ................................................................ 136 APO-TIZANIDINE............................................... SEC 3.87 APO-TOPIRAMATE ...................................................... 88 APO-TRAZODONE ....................................................... 94 APO-TRAZODONE D ................................................... 94 APO-TRIAZIDE ........................................................... 126 APO-TRIAZO .............................................................. 112 APO-TRYPTOPHAN ..................................................... 97 APO-VALACYCLOVIR (CAPLET) ................................. 18 APO-VALPROIC ........................................................... 89 APO-VALSARTAN ........................................................ 69 APO-VALSARTAN/HCTZ .............................................. 69 APO-VALSARTAN/HCTZ .............................................. 70 APO-VENLAFAXINE XR ............................................... 90 APO-VERAP ................................................................. 58 APO-VERAP SR ........................................................... 58 APO-WARFARIN .......................................................... 29 APO-WARFARIN .......................................................... 30 APO-ZOPICLONE ....................................................... 113 APRACLONIDINE HCL ............................................... 138 APREPITANT .............................................................. 144 APREPITANT/ APREPITANT ..................................... 144 APRI 21 ....................................................................... 159 APRI 28 ....................................................................... 159 ARANESP (0.3/ 0.4/ 0.5 ML SYR)...................... SEC 3.23 ARANESP (0.3/ 0.4/ 0.5/ 0.65 ML SYR) ............. SEC 3.23
ARANESP (0.3/0.4/0.6/1.0 ML SYR) ................. SEC 3.23 ARANESP (0.4 ML SYRINGE)........................... SEC 3.23 ARANESP (0.5 ML SYRINGE)........................... SEC 3.23 ARAVA ......................................................................... 189 AREDIA ........................................................................ 189 ARICEPT ........................................................... SEC 3.25 ARIPIPRAZOLE ............................................................. 98 ARISTOCORT C .......................................................... 179 ARISTOCORT R .......................................................... 179 ARIXTRA (0.5 ML SYRINGE) ........................................ 32 ARIXTRA (0.6 ML SYRINGE) ........................................ 32 ARLIDIN ......................................................................... 47 ARTHROTEC-50 ............................................................ 72 ARTHROTEC-75 ............................................................ 72 ASA ................................................................................ 71 ASA/ CODEINE PHOSPHATE/ CAFFEINE CITRATE ... 76 ASACOL ...................................................................... 149 ASACOL 800................................................................ 149 ATACAND ...................................................................... 65 ATACAND PLUS ............................................................ 65 ATARAX ....................................................................... 113 ATENOLOL .................................................................... 49 ATENOLOL .................................................................... 50 ATENOLOL/ CHLORTHALIDONE ................................. 50 ATIVAN ........................................................................ 111 ATORVASTATIN ............................................................ 38 ATORVASTATIN CALCIUM .......................................... 38 ATOVAQUONE .............................................................. 19 ATROPINE SULFATE .................................................. 134 ATROPINE SULFATE .................................................... 23 ATROVENT.................................................................... 24 ATROVENT HFA ........................................................... 24 AURANOFIN ................................................................ 151 AURO-CEFPROZIL .........................................................6 AURO-CEFUROXIME ......................................................7 AURO-GABAPENTIN .................................................... 86 AURO-LEVETIRACETAM .............................................. 87 AURO-TERBINAFINE .................................................... 15 AURO-TOPIRAMATE .................................................... 88 AVA-ACEBUTOLOL ....................................................... 49 AVA-AMIODARONE ...................................................... 36 AVA-AZITHROMYCIN .....................................................9 AVA-BACLOFEN ........................................................... 27 AVA-BISOPROLOL ........................................................ 50 AVA-BUPROPION SR ................................................... 97 AVA-CARVEDILOL ........................................................ 51 AVA-CEFPROZIL .............................................................6 AVA-CLARITHROMYCIN ................................................9 AVA-CLINDAMYCIN ...................................................... 14 AVA-DICLOFENAC ........................................................ 72 AVA-DICLOFENAC SR .................................................. 72 AVA-DOMPERIDONE .................................................. 148
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 197 EFFECTIVE JULY 1, 2012
AVA-ENALAPRIL .......................................................... 60 AVA-FAMOTIDINE ...................................................... 145 AVA-FENOFIBRATE MICRO ........................................ 37 AVA-FLUOXETINE ....................................................... 92 AVA-FLUVOXAMINE .................................................... 92 AVA-FUROSEMIDE ...................................................... 44 AVA-FUROSEMIDE ...................................................... 45 AVA-GLICLAZIDE ....................................................... 165 AVA-GLYBURIDE ....................................................... 166 AVA-IRBESARTAN ....................................................... 66 AVA-IRBESARTAN/HCTZ ............................................ 66 AVA-IRBESARTAN/HCTZ ............................................ 67 AVA-LEVETIRACETAM ................................................ 87 AVA-LEVOFLOXACIN ....................................... SEC 3A.4 AVA-LISINOPRIL HCT .................................................. 62 AVA-LOVASTATIN........................................................ 39 AVA-METFORMIN ...................................................... 163 AVA-METOPROLOL ..................................................... 52 AVA-METOPROLOL (TYPE L) ..................................... 52 AVA-MIRTAZAPINE ...................................................... 98 AVA-NAPROXEN .......................................................... 74 AVA-NAPROXEN EC .................................................... 75 AVA-NORTRIPTYLINE ................................................. 96 AVA-OLANZAPINE ....................................................... 99 AVA-PANTOPRAZOLE ............................................... 148 AVA-PIOGLITAZONE ........................................ SEC 3.72 AVA-PRAMIPEXOLE .................................................. 119 AVA-RAMIPRIL (TABLET) ............................................ 63 AVA-RAMIPRIL (TABLET) ............................................ 64 AVA-RISEDRONATE ......................................... SEC 3.75 AVA-RISPERIDONE ................................................... 102 AVA-RISPERIDONE ................................................... 103 AVA-RISPERIDONE ................................................... 104 AVA-SOTALOL ............................................................. 54 AVA-SUMATRIPTAN .................................................. 115 AVA-SUMATRIPTAN ......................................... SEC 3.84 AVA-TAMSULOSIN CR ................................................ 48 AVA-TOPIRAMATE....................................................... 88 AVA-VALSARTAN......................................................... 69 AVA-VALSARTAN HCT ................................................ 69 AVA-VALSARTAN HCT ................................................ 70 AVA-ZOPICLONE ....................................................... 113 AVALIDE 150/12.5 ........................................................ 66 AVALIDE 300/12.5 ........................................................ 66 AVANDAMET ..................................................... SEC 3.80 AVANDIA ........................................................... SEC 3.79 AVAPRO ....................................................................... 66 AVELOX ............................................................. SEC 3A.5 AVENTYL ...................................................................... 96 AVIANE 21 .................................................................. 159 AVIANE 28 .................................................................. 159 AVODART .......................................................... SEC 3.25
AVONEX (30 MCG) ............................................. SEC 2.4 AVONEX PS/PEN (30 MCG/0.5 ML) ................... SEC 2.4 AXID ............................................................................. 145 AZARGA ...................................................................... 137 AZATHIOPRINE ........................................................... 187 AZELAIC ACID............................................................. 180 AZITHROMYCIN ..............................................................9 AZITHROMYCIN ................................................ SEC 3.17 AZOPT ......................................................................... 136 AZTREONAM..................................................... SEC 3.17
B
BACLOFEN .................................................................... 27 BACTROBAN ............................................................... 174 BARACLUDE ................................................................. 17 BECLOMETHASONE DIPROPIONATE ...................... 132 BECLOMETHASONE DIPROPIONATE ...................... 155 BECLOMETHASONE DIPROPIONATE ...................... 175 BELLADONNA/ ERGOTAMINE TARTRATE/
PHENOBARBITAL ..................................................... 23 BELLERGAL SPACETABS ............................................ 23 BENAZEPRIL ................................................................. 58 BENAZEPRIL HCL ......................................................... 58 BENTYLOL .................................................................... 23 BENURYL .................................................................... 127 BENZACLIN ....................................................... SEC 3.19 BENZOYL PEROXIDE ....................................... SEC 3.18 BENZTROPINE ............................................................ 117 BENZTROPINE MESYLATE........................................ 117 BENZTROPINE OMEGA ............................................. 117 BENZYDAMINE HCL ................................................... 135 BETADERM MILD ........................................................ 176 BETADERM REGULAR ............................................... 176 BETAGAN .................................................................... 136 BETAHISTINE DIHYDROCHLORIDE .......................... 187 BETAMETHASONE DIPROPIONATE ......................... 175 BETAMETHASONE DIPROPIONATE/ CLOTRIMAZOLE
................................................................................. 179 BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID
................................................................................. 175 BETAMETHASONE SODIUM PHOSPHATE ............... 176 BETAMETHASONE SODIUM PHOSPHATE/
BETAMETHASONE ACETATE................................ 155 BETAMETHASONE SODIUM PHOSPHATE/
GENTAMICIN SULFATE ......................................... 133 BETAMETHASONE VALERATE ................................. 176 BETASERON (0.3 MG) ........................................ SEC 2.4 BETAXOLOL HCL ........................................................ 135 BETNESOL (5MG/100ML) ........................................... 176
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 198
BETOPTIC S ............................................................... 135 BEZAFIBRATE .............................................................. 37 BEZALIP ....................................................................... 37 BIAXIN ............................................................................ 9 BIAXIN BID ..................................................................... 9 BIAXIN XL ....................................................................... 9 BIMATOPROST .......................................................... 137 BISOPROLOL FUMARATE .......................................... 50 BLEPHAMIDE ............................................................. 133 BLEPHAMIDE S.O.P. .................................................. 133 BLOOD GLUCOSE TEST STRIPS ................................. 1 BLOOD LETTING LANCET ............................................ 1 BONEFOS ................................................................... 187 BOTOX (50/100/200 UNITS/VIAL) .............................. 189 BOTULINUM NEUROTOXIN TYPE A (150KD), FREE
FROM COMPLEXI .................................................. 187 BREVICON 0.5/35 (21 DAY) ....................................... 160 BREVICON 0.5/35 (28 DAY) ....................................... 160 BREVICON 1/35 (21 DAY) .......................................... 160 BREVICON 1/35 (28 DAY) .......................................... 160 BRICANYL TURBUHALER ........................................... 26 BRIMONIDINE TARTRATE ........................................ 135 BRIMONIDINE TARTRATE/ TIMOLOL MALEATE ..... 137 BRINZOLAMIDE ......................................................... 136 BRINZOLAMIDE/ TIMOLOL MALEATE ...................... 137 BROMAZEPAM ........................................................... 110 BROMOCRIPTINE MESYLATE .................................. 118 BUDESONIDE ............................................................ 132 BUDESONIDE ............................................................ 155 BUDESONIDE ............................................................ 176 BUDESONIDE ................................................... SEC 3.18 BUDESONIDE/ FORMOTEROL FUMARATE
DIHYDRATE ............................................................. 24 BUPRENORPHINE HCL/ NALOXONE
HYDROCHLORIDE DIHYDRATE ............................. 83 BUPROPION HCL......................................................... 97 BUSCOPAN .................................................................. 23 BUSERELIN ACETATE ..................................... SEC 3.18 BUSPIRONE HCL ....................................................... 112 BUTALBITAL/ CAFFEINE/ ASA .................................... 71 BUTALBITAL/ CODEINE PHOSPHATE/ ASA/ CAFFEINE
.................................................................................. 76
C
C.E.S. .......................................................................... 161 CABERGOLINE ................................................. SEC 3.18 CAFERGOT .................................................................. 26 CALCIJEX ................................................................... 185 CALCIMAR .................................................................. 166 CALCIPOTRIOL .......................................................... 181
CALCIPOTRIOL MONOHYDRATE/ BETAMETHASONE DIPROPIONATE ...................................................... 181
CALCIPOTRIOL/ BETAMETHASONE DIPROPIONATE ................................................................................. 181
CALCITRIOL ................................................................ 185 CALCIUM POLYSTYRENE SULPHONATE ................ 125 CALTINE 100 (100 IU/ML) ........................................... 166 CANCIDAS ........................................................ SEC 3.19 CANDESARTAN CILEXETIL ......................................... 65 CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE
................................................................................... 65 CAPTOPRIL ................................................................... 59 CARBACHOL ............................................................... 137 CARBAMAZEPINE ........................................................ 85 CARBOLITH................................................................. 114 CARDIZEM CD .............................................................. 56 CARDIZEM CD .............................................................. 57 CARDURA ..................................................................... 47 CARNITOR ........................................................ SEC 3.57 CARVEDILOL ................................................................ 51 CASPOFUNGIN ................................................. SEC 3.19 CATAPRES .................................................................... 43 CAYSTON .......................................................... SEC 3.17 CEDOCARD-SR ............................................................ 45 CEFADROXIL .................................................... SEC 3.19 CEFAZOLIN .....................................................................5 CEFAZOLIN SODIUM ......................................................5 CEFIXIME ........................................................................7 CEFOTAXIME SODIUM ..................................................7 CEFPROZIL .....................................................................6 CEFTAZIDIME .................................................................7 CEFTIN ............................................................................7 CEFTRIAXONE FOR INJECTION USP ...........................7 CEFTRIAXONE SODIUM ................................................7 CEFUROXIME AXETIL ....................................................7 CEFZIL .............................................................................6 CELEBREX ........................................................ SEC 3.19 CELECOXIB....................................................... SEC 3.19 CELESTONE SOLUSPAN ........................................... 155 CELEXA ......................................................................... 91 CELONTIN ..................................................................... 85 CEPHALEXIN ..................................................................5 CEPHALEXIN ..................................................................6 CESAMET .................................................................... 144 CHAMPIX ....................................................................... 28 CHAMPIX ........................................................... SEC 3.92 CHAMPIX (STARTER PACK) ........................................ 28 CHAMPIX (STARTER PACK) ............................ SEC 3.93 CHLORAL HYDRATE .................................................. 112 CHLORAMPHENICOL SODIUM SUCCINATE ................8 CHLORDIAZEPOXIDE HCL ........................................ 110 CHLORDIAZEPOXIDE HCL/ CLIDINIUM BROMIDE .. 110
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 199 EFFECTIVE JULY 1, 2012
CHLOROMYCETIN ......................................................... 8 CHLOROQUINE PHOSPHATE .................................... 18 CHLORPROMAZINE HCL .......................................... 105 CHLORTHALIDONE ................................................... 126 CHOLEDYL ................................................................. 183 CHOLEDYL EXPECTORANT ..................................... 183 CHOLESTYRAMINE RESIN ......................................... 36 CICLESONIDE ............................................................ 155 CICLOPIROX OLAMINE ............................................. 175 CILAZAPRIL .................................................................. 59 CILAZAPRIL/ HYDROCHLOROTHIAZIDE ................... 59 CILOXAN .................................................................... 131 CIMETIDINE ............................................................... 144 CIPRALEX .................................................................... 91 CIPRO ................................................................ SEC 3A.1 CIPRO ................................................................ SEC 3A.2 CIPRO ................................................................ SEC 3A.3 CIPRODEX ................................................................. 132 CIPROFLOXACIN .............................................. SEC 3A.1 CIPROFLOXACIN .............................................. SEC 3A.2 CIPROFLOXACIN .............................................. SEC 3A.3 CIPROFLOXACIN HCL ............................................... 131 CIPROFLOXACIN HCL ...................................... SEC 3A.2 CIPROFLOXACIN HCL ...................................... SEC 3A.3 CIPROFLOXACIN HCL/ DEXAMETHASONE ............ 132 CITALOPRAM ............................................................... 91 CITALOPRAM HYDROBROMIDE ................................ 91 CITALOPRAM-ODAN ................................................... 91 CLAFORAN ..................................................................... 7 CLARITHROMYCIN ........................................................ 9 CLARUS ...................................................................... 181 CLASTEON ................................................................. 187 CLAVULIN-125F ........................................................... 11 CLAVULIN-200 ............................................................. 11 CLAVULIN-250F ........................................................... 11 CLAVULIN-400 ............................................................. 11 CLAVULIN-500F ........................................................... 11 CLAVULIN-875 ............................................................. 11 CLIMARA 100 (7.8 MG/PTH) ...................................... 161 CLIMARA 25 (2 MG/PTH) ........................................... 161 CLIMARA 50 (3.9 MG/PTH) ........................................ 161 CLIMARA 75 (5.7 MG/PTH) ........................................ 161 CLINDAMYCIN ............................................................. 14 CLINDAMYCIN (60 & 120 ML) ...................................... 14 CLINDAMYCIN HCL ..................................................... 14 CLINDAMYCIN PALMITATE HCL................................. 14 CLINDAMYCIN PHOSPHATE ...................................... 14 CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE
....................................................................... SEC 3.19 CLINDOXYL ....................................................... SEC 3.19 CLOBAZAM .................................................................. 83 CLOBETASOL 17-PROPIONATE .............................. 176
CLODRONATE DISODIUM ......................................... 187 CLODRONATE DISODIUM TETRAHYDRATE ............ 187 CLOMID ....................................................................... 162 CLOMIPHENE CITRATE ............................................. 162 CLOMIPRAMINE HCL ................................................... 95 CLONAZEPAM .............................................................. 84 CLONIDINE HCL ......................................................... 187 CLONIDINE HCL ........................................................... 43 CLOPIDOGREL BISULFATE ......................................... 32 CLOPIDOGREL BISULFATE ............................. SEC 3.20 CLOPIXOL ................................................................... 108 CLOPIXOL ACUPHASE .............................................. 107 CLOPIXOL DEPOT ...................................................... 107 CLORAZEPATE DIPOTASSIUM ................................. 110 CLOXACILLIN SODIUM ................................................ 12 CLOZAPINE ................................................................... 98 CLOZAPINE ................................................................... 99 CLOZARIL ..................................................................... 98 CLOZARIL ..................................................................... 99 CO ALENDRONATE .......................................... SEC 3.14 CO AMLODIPINE ........................................................... 55 CO ATENOLOL.............................................................. 49 CO ATENOLOL.............................................................. 50 CO ATORVASTATIN ..................................................... 38 CO AZITHROMYCIN .......................................................9 CO AZITHROMYCIN ......................................... SEC 3.17 CO BETAHISTINE ....................................................... 187 CO CABERGOLINE ........................................... SEC 3.18 CO CANDESARTAN ...................................................... 65 CO CILAZAPRIL ............................................................ 59 CO CIPROFLOXACIN ....................................... SEC 3A.2 CO CIPROFLOXACIN ....................................... SEC 3A.3 CO CITALOPRAM ......................................................... 91 CO CLOMIPRAMINE ..................................................... 95 CO CLONAZEPAM ........................................................ 84 CO CLOPIDOGREL ....................................................... 32 CO CLOPIDOGREL ........................................... SEC 3.20 CO DILTIAZEM CD ........................................................ 56 CO DILTIAZEM CD ........................................................ 57 CO DILTIAZEM T ........................................................... 57 CO DILTIAZEM T ........................................................... 58 CO ENALAPRIL ............................................................. 60 CO ETIDROCAL .......................................................... 188 CO ETIDRONATE ........................................................ 188 CO FINASTERIDE ............................................. SEC 3.41 CO FLUCONAZOLE ...................................................... 15 CO FLUOXETINE .......................................................... 92 CO FLUVOXAMINE ....................................................... 92 CO GABAPENTIN .......................................................... 86 CO IRBESARTAN .......................................................... 66 CO IRBESARTAN/HCT ................................................. 66 CO IRBESARTAN/HCT ................................................. 67
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 200
CO LATANOPROST ................................................... 137 CO LEVETIRACETAM .................................................. 87 CO LEVOFLOXACIN ......................................... SEC 3A.4 CO LISINOPRIL ............................................................ 61 CO LISINOPRIL ............................................................ 62 CO LOSARTAN ............................................................ 67 CO LOVASTATIN.......................................................... 39 CO METFORMIN ........................................................ 163 CO OLANZAPINE ....................................................... 100 CO OLANZAPINE ......................................................... 99 CO OLANZAPINE ODT ............................................... 100 CO ONDANSETRON .................................................. 143 CO PANTOPRAZOLE ................................................. 148 CO PAROXETINE ......................................................... 93 CO PIOGLITAZONE .......................................... SEC 3.72 CO PRAMIPEXOLE .................................................... 119 CO PRAVASTATIN ....................................................... 40 CO QUETIAPINE ........................................................ 100 CO QUETIAPINE ........................................................ 101 CO RAMIPRIL (CAPSULE) ........................................... 63 CO RAMIPRIL (CAPSULE) ........................................... 64 CO RANITIDINE.......................................................... 145 CO REPAGLINIDE ...................................................... 165 CO RISPERIDONE ..................................................... 102 CO RISPERIDONE ..................................................... 103 CO RIZATRIPTAN ODT .............................................. 114 CO RIZATRIPTAN ODT .............................................. 115 CO RIZATRIPTAN ODT ..................................... SEC 3.79 CO ROPINIROLE ........................................................ 119 CO ROPINIROLE ........................................................ 120 CO ROSUVASTATIN .................................................... 41 CO SERTRALINE ......................................................... 93 CO SERTRALINE ......................................................... 94 CO SIMVASTATIN ........................................................ 42 CO SIMVASTATIN ........................................................ 43 CO SOTALOL ............................................................... 54 CO SUMATRIPTAN .................................................... 115 CO SUMATRIPTAN ........................................... SEC 3.84 CO TEMAZEPAM........................................................ 112 CO TERBINAFINE ........................................................ 15 CO TOPIRAMATE......................................................... 88 CO VALACYCLOVIR .................................................... 18 CO VALSARTAN........................................................... 69 CO VENLAFAXINE XR ................................................. 90 CO ZOPICLONE ......................................................... 113 CODEINE PHOSPHATE ............................................... 77 CODEINE PHOSPHATE/ ACETAMINOPHEN .............. 77 CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE ................................................................................ 77 CODEINE PHOSPHATE/ ASA/ CAFFEINE CITRATE .. 77 CODEINE PHOSPHATE/ ASA/ MEPROBAMATE/
CAFFEINE CITRATE ................................................ 77 COLCHICINE .............................................................. 187
COLESTID ..................................................................... 36 COLESTID ORANGE ..................................................... 36 COLESTIPOL HCL ........................................................ 36 COLISTIMETHATE FOR INJECTION ............................ 14 COLISTIMETHATE SODIUM ......................................... 14 COLLAGENASE .......................................................... 181 COMBIGAN.................................................................. 137 COMBINATION ANTI-INFECTIVE /CORTICOSTEROID
................................................................................. 179 COMBIVENT UDV ......................................................... 24 COMPD- NSAID/ ANALG/MUSCLE RELAX (NOT
DICLOFENAC)-TOPICAL .......................................... 71 COMPD-CHLORHEX. MOUTH RINSE (ANY
CONCENTRATION, NOT 0.12%) ............................ 135 COMPD-CHLORHEX. MOUTH RINSE (ANY
CONCENTRATION, NOT 12%) ............................... 135 COMPD-NSAID/ ANALG/MUSCLE RELAX (NOT
DICLOFENAC)-TOPICAL .......................................... 71 COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL) ...................... COMPOUND HORMONES (ESTROGEN PROGEST
TESTOSTERONE) ................................................... 155 COMPOUND NARCOTIC MIXTURES - ORAL AND
INJECTION ................................................................ 77 COMPOUND PRESCRIPTION .................................... 135 COMPOUND PRESCRIPTION .................................... 155 COMPOUND PRESCRIPTION .................................... 173 COMPOUND PRESCRIPTION .................................... 176 COMPOUND PRESCRIPTION .................................... 179 COMPOUND PRESCRIPTION .................................... 180 COMPOUND PRESCRIPTION .................................... 188 COMPOUND PRESCRIPTION ...................................... 71 COMPOUND PRESCRIPTION ...................................... 77 COMPOUND- DICLOFENAC (TOPICAL) ...................... 71 COMPOUND- SALICYLIC ACID (TOPICAL) ............... 180 COMPOUND-ANTI-INFECTIVE (TOPICAL) ................ 173 COMPOUND-CORTICOSTEROIDS - TOPICAL ......... 176 COMPOUND-DICLOFENAC (TOPICAL) ....................... 71 COMTAN ..................................................................... 117 CONJUGATED ESTROGENS ..................................... 161 COPAXONE ......................................................... SEC 2.4 CORDARONE ................................................................ 36 CORTAMED................................................................. 132 CORTEF ...................................................................... 156 CORTENEMA (100MG/60ML) ..................................... 177 CORTIFOAM................................................................ 178 CORTISONE ACETATE .............................................. 155 CORTODERM MILD .................................................... 177 CORTODERM REGULAR ........................................... 177 COSOPT ...................................................................... 138 COSOPT PRESERVATIVE-FREE ............................... 138 COSYNTROPIN ZINC HYDROXIDE COMPLEX ......... 166 COTAZYM ................................................................... 141
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 201 EFFECTIVE JULY 1, 2012
COTAZYM ECS 20 ..................................................... 141 COTAZYM ECS 8 ....................................................... 141 COUMADIN ................................................................... 29 COUMADIN ................................................................... 30 COVERSYL ................................................................... 62 COVERSYL ................................................................... 63 COVERSYL PLUS ........................................................ 63 COVERSYL PLUS HD .................................................. 63 COZAAR ....................................................................... 67 CREON 10 MINIMICROSPHERES ............................. 141 CREON 25 MINIMICROSPHERES ............................. 141 CRESTOR ..................................................................... 41 CTP 30 .......................................................................... 91 CUPRIMINE ................................................................ 153 CYANOCOBALAMIN .................................................. 185 CYCLEN (21 DAY) ...................................................... 160 CYCLEN (28 DAY) ...................................................... 160 CYCLOBENZAPRINE ................................................... 27 CYCLOBENZAPRINE HCL ........................................... 27 CYCLOCORT .............................................................. 175 CYCLOGYL ................................................................. 134 CYCLOMEN ................................................................ 158 CYCLOPENTOLATE HCL .......................................... 134 CYCLOSPORINE ............................................... SEC 3.21 CYKLOKAPRON ........................................................... 33 CYMBALTA ................................................................... 90 CYPROTERONE................................................ SEC 3.21 CYPROTERONE ACETATE .............................. SEC 3.21 CYTOMEL ................................................................... 168 CYTOVENE .................................................................. 18
D
DABIGATRAN ETEXILATE ................................ SEC 3.22 DALACIN C ................................................................... 14 DALACIN C PALMITATE .............................................. 14 DALACIN C PHOSPHATE ............................................ 14 DALTEPARIN SODIUM ................................................ 30 DALTEPARIN SODIUM ................................................ 31 DANAPAROID SODIUM .................................... SEC 3.22 DANAZOL ................................................................... 158 DANTRIUM ................................................................... 27 DANTROLENE SODIUM .............................................. 27 DAPSONE ..................................................................... 16 DARAPRIM ................................................................... 18 DARBEPOETIN ................................................. SEC 3.23 DARIFENACIN HYDROBROMIDE .................... SEC 3.23 DDAVP ........................................................................ 167 DEFERASIROX ................................................. SEC 3.24 DEFEROXAMINE MESYLATE ................................... 153
DELATESTRYL............................................................ 158 DEMEROL ..................................................................... 79 DEMULEN 30 (21 DAY) ............................................... 159 DEMULEN 30 (28 DAY) ............................................... 159 DENOSUMAB .................................................... SEC 3.24 DEPAKENE ................................................................... 89 DEPO-MEDROL .......................................................... 157 DEPO-MEDROL (PRESERVED) ................................. 157 DEPO-MEDROL WITH LIDOCAINE ............................ 157 DEPO-PROVERA ........................................................ 167 DEPO-TESTOSTERONE CYPIONATE ....................... 158 DERMOVATE .............................................................. 176 DESFERAL .................................................................. 153 DESFERRIOXAMINE MESILATE ................................ 153 DESIPRAMINE HCL ...................................................... 95 DESMOPRESSIN ........................................................ 167 DESMOPRESSIN ACETATE ....................................... 167 DESOGESTREL/ ETHINYL ESTRADIOL .................... 159 DESOGESTREL/ ETHINYL ESTRADIOL/
DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL ................ 159
DESONIDE .................................................................. 177 DESOXIMETASONE ................................................... 177 DESSICATED THYROID ............................................. 168 DETROL LA ....................................................... SEC 3.89 DEVICE ........................................................................ 191 DEXAMETHASONE ..................................................... 132 DEXAMETHASONE ..................................................... 156 DEXAMETHASONE SODIUM PHOSPHATE .............. 132 DEXAMETHASONE SODIUM PHOSPHATE .............. 156 DEXAMETHASONE/ FRAMYCETIN SULFATE/
GRAMICIDIN............................................................ 133 DEXAMETHASONE/ NEOMYCIN SULFATE/
POLYMYXIN B SULFATE ........................................ 133 DEXAMETHASONE/ TOBRAMYCIN ........................... 133 DEXASONE ................................................................. 156 DEXEDRINE ................................................................ 108 DEXIRON ....................................................................... 29 DEXTROAMPHETAMINE SULFATE ........................... 108 DIABETA ...................................................................... 166 DIABETES SUPPLIES .....................................................1 DIAMICRON................................................................. 165 DIAMICRON MR .......................................................... 165 DIAZEMULS................................................................. 111 DIAZEPAM ................................................................... 110 DIAZEPAM ................................................................... 111 DIAZOXIDE .................................................................... 44 DICETEL ...................................................................... 149 DICLECTIN .................................................................. 144 DICLOFENAC SODIUM ............................................... 134 DICLOFENAC SODIUM ................................................. 72 DICLOFENAC SODIUM SR ........................................... 72
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 202
DICLOFENAC SODIUM/ MISOPROSTOL .................... 72 DICYCLOMINE HCL ..................................................... 23 DICYCLOMINE HYDROCHLORIDE ............................. 23 DIDROCAL .................................................................. 188 DIFLUCAN .................................................................... 15 DIFLUCAN ......................................................... SEC 3.42 DIFLUCORTOLONE VALERATE ............................... 177 DIFLUNISAL ................................................................. 73 DIGOXIN ....................................................................... 36 DIGOXIN PEDIATRIC ................................................... 36 DIHYDROERGOTAMINE (DHE) ................................... 26 DIHYDROERGOTAMINE MESYLATE .......................... 26 DILANTIN ...................................................................... 84 DILANTIN INFATABS ................................................... 84 DILANTIN-125 ............................................................... 84 DILANTIN-30 ................................................................. 84 DILAUDID ..................................................................... 78 DILAUDID STERILE POWDER .................................... 79 DILAUDID-HP ............................................................... 78 DILTIAZEM HCL ........................................................... 56 DILTIAZEM HCL ........................................................... 57 DILTIAZEM HCL ........................................................... 58 DIMENHYDRINATE .................................................... 142 DIMENHYDRINATE I.M. ............................................. 142 DIMENHYDRINATE I.V. .............................................. 142 DIMETHYL SULFOXIDE ............................................. 188 DIMETHYL SULFOXIDE IRRIGATION ....................... 188 DIODOQUIN ................................................................. 18 DIOVAN ........................................................................ 69 DIOVAN-HCT ................................................................ 69 DIOVAN-HCT ................................................................ 70 DIPENTUM ................................................................. 149 DIPHENHYDRAMINE ..................................................... 3 DIPHENHYDRAMINE HCL ............................................. 3 DIPHENOXYLATE HCL/ ATROPINE SULFATE ......... 141 DIPROLENE GLYCOL ................................................ 175 DIPROSALIC .............................................................. 175 DIPROSONE ............................................................... 175 DIPYRIDAMOLE ........................................................... 46 DIPYRIDAMOLE/ ASA .................................................. 33 DISOPYRAMIDE ........................................................... 35 DIVALPROEX SODIUM (VALPROIC ACID EQUIV.) .... 85 DIVALPROEX SODIUM (VALPROIC ACID EQUIV.) .... 86 DIXARIT ...................................................................... 187 DOLASETRON MESYLATE ....................................... 142 DOMPERIDONE ......................................................... 148 DOMPERIDONE MALEATE ....................................... 148 DONEPEZIL HCL ............................................... SEC 3.25 DORZOLAMIDE HCL .................................................. 136 DORZOLAMIDE HCL/ TIMOLOL MALEATE .............. 138 DOSTINEX ......................................................... SEC 3.18 DOVOBET ................................................................... 181
DOVONEX ................................................................... 181 DOXAZOSIN MESYLATE .............................................. 47 DOXEPIN HCL ............................................................... 95 DOXEPIN HCL ............................................................... 96 DOXYCYCLINE ............................................................. 13 DOXYCYCLINE HYCLATE ............................................ 13 DOXYLAMINE SUCCINATE/ PYRIDOXINE HCL ........ 144 DROSPIRENONE/ ETHINYL ESTRADIOL .................. 159 DULOXETINE HYDROCHLORIDE ................................ 90 DUO TRAV .................................................................. 138 DUTASTERIDE .................................................. SEC 3.25
E
ECULIZUMAB .................................................... SEC 3.30 EDECRIN ....................................................................... 44 EFFEXOR XR ................................................................ 90 EFUDEX ...................................................................... 180 ELAVIL ........................................................................... 95 ELMIRON ..................................................................... 189 ELOCOM ..................................................................... 178 ELTROXIN ................................................................... 168 EMEND ........................................................................ 144 EMEND TRI-PACK ...................................................... 144 EMO-CORT.................................................................. 177 ENABLEX .......................................................... SEC 3.23 ENALAPRIL MALEATE .................................................. 60 ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE ... 60 ENBREL ............................................................. SEC 3.38 ENDOCET ..................................................................... 82 ENGERIX-B ................................................................. 171 ENOXAPARIN SODIUM ................................................ 31 ENTACAPONE ............................................................ 117 ENTECAVIR................................................................... 17 ENTOCORT ....................................................... SEC 3.18 ENTOCORT (115 ML) .................................................. 176 ENTROPHEN 10 ............................................................ 71 EPINEPHRINE ............................................................... 26 EPINEPHRINE HCL ..................................................... 135 EPINEPHRINE HCL ....................................................... 26 EPIPEN .......................................................................... 26 EPIPEN JR .................................................................... 26 EPIVAL .......................................................................... 85 EPIVAL .......................................................................... 86 EPOETIN ALFA ................................................. SEC 3.30 EPOETIN ALFA ................................................. SEC 3.31 EPREX ............................................................... SEC 3.30 EPREX (0.3 ML SYRINGE) ............................... SEC 3.31 EPREX (0.4 ML SYRINGE) ............................... SEC 3.31 EPREX (0.5 ML SYRINGE) ............................... SEC 3.31
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 203 EFFECTIVE JULY 1, 2012
EPREX (0.6 ML SYRINGE) ................................ SEC 3.31 EPREX (0.8 ML SYRINGE) ................................ SEC 3.31 EPREX (1 ML SYRINGE) ................................... SEC 3.31 EPROSARTAN MESYLATE ......................................... 65 EPROSARTAN MESYLATE/ HYDROCHLOROTHIAZIDE
.................................................................................. 65 ERGOLOID MESYLATES ............................................. 26 ERGOTAMINE TARTRATE/ CAFFEINE ....................... 26 ERTAPENEM ..................................................... SEC 3.32 ERYC .............................................................................. 8 ERYTHRO-BASE ............................................................ 8 ERYTHRO-EC ................................................................ 8 ERYTHRO-ES ................................................................. 8 ERYTHRO-S ................................................................... 8 ERYTHROMYCIN ....................................................... 131 ERYTHROMYCIN ........................................................... 8 ERYTHROMYCIN ESTOLATE ....................................... 8 ERYTHROMYCIN ETHYLSUCCINATE .......................... 8 ERYTHROMYCIN STEARATE ....................................... 8 ERYTHROMYCIN/ TRETINOIN ......................... SEC 3.32 ESCITALOPRAM OXALATE ......................................... 91 ESTALIS (2.7*.62 MG/PTH) ........................................ 162 ESTALIS (4.8*.51 MG/PTH) ........................................ 162 ESTRACE ................................................................... 161 ESTRADERM-100 (8.0 MG/PTH) ............................... 161 ESTRADERM-25 (2 MG/PTH) .................................... 161 ESTRADIOL-17B ........................................................ 161 ESTRADOT 100 (1.56 MG/PTH) ................................ 161 ESTRADOT 25 (0.39 MG/PTH) .................................. 161 ESTRADOT 37.5 (0.585 MG/PTH).............................. 161 ESTRADOT 50 (0.78 MG/PTH) .................................. 161 ESTRADOT 75 (1.17 MG/PTH) .................................. 161 ESTRING .................................................................... 161 ESTROGEL ................................................................. 161 ETANERCEPT ................................................... SEC 3.38 ETHACRYNIC ACID ..................................................... 44 ETHOPROPAZINE HCL ............................................. 117 ETHOSUXIMIDE ........................................................... 85 ETHYNODIOL DIACETATE/ ETHINYL ESTRADIOL.. 159 ETIDROCAL ................................................................ 188 ETIDRONATE DISODIUM .......................................... 188 ETIDRONATE DISODIUM/ CALCIUM CARBONATE . 188 ETODOLAC .................................................................. 73 EUFLEX ............................................................. SEC 3.42 EVISTA .............................................................. SEC 3.74 EXELON ............................................................. SEC 3.78 EXJADE ............................................................. SEC 3.24 EXTAVIA (0.3 MG) ............................................... SEC 2.4 EZETIMIBE ........................................................ SEC 3.38 EZETROL ........................................................... SEC 3.38
F
FAMOTIDINE ............................................................... 145 FEBUXOSTAT ................................................... SEC 3.39 FELODIPINE .................................................................. 55 FELODIPINE .................................................................. 56 FENOFIBRATE .............................................................. 37 FENOFIBRATE MICRO ................................................. 37 FENOFIBRATE-S .......................................................... 37 FENOFIBRATE-S (TABLET).......................................... 37 FENTANYL ........................................................ SEC 3.39 FENTANYL ........................................................ SEC 3.40 FENTANYL CITRATE ........................................ SEC 3.40 FILGRASTIM...................................................... SEC 3.41 FINACEA ..................................................................... 180 FINASTERIDE ................................................... SEC 3.41 FIORINAL ...................................................................... 71 FIORINAL-C 1/2 ............................................................. 76 FIORINAL-C 1/4 ............................................................. 76 FLAGYL ....................................................................... 174 FLAGYSTATIN............................................................. 174 FLAREX ....................................................................... 132 FLECAINIDE .................................................................. 35 FLECAINIDE ACETATE ................................................ 35 FLOCTAFENINE ............................................................ 73 FLORINEF ................................................................... 156 FLOVENT DISKUS ...................................................... 156 FLOVENT HFA ............................................................ 156 FLUANXOL .................................................................. 107 FLUANXOL DEPOT ..................................................... 107 FLUCONAZOLE ............................................................. 15 FLUCONAZOLE ................................................. SEC 3.42 FLUCONAZOLE OMEGA .............................................. 15 FLUDROCORTISONE ACETATE ................................ 156 FLUMETHASONE PIVALATE/ CLIOQUINOL.............. 133 FLUNARIZINE.............................................................. 188 FLUNARIZINE HCL ..................................................... 188 FLUNISOLIDE.............................................................. 132 FLUOCINONIDE .......................................................... 177 FLUOR-A-DAY ............................................................. 121 FLUOROMETHOLONE ............................................... 132 FLUOROMETHOLONE ACETATE .............................. 132 FLUOXETINE................................................................. 92 FLUOXETINE HCL ........................................................ 92 FLUPENTIXOL DECANOATE ..................................... 107 FLUPENTIXOL DIHYDROCHLORIDE ......................... 107 FLUPHENAZINE DECANOATE................................... 105 FLUPHENAZINE HCL .................................................. 105 FLUPHENAZINE HCL .................................................. 106 FLUPHENAZINE OMEGA ........................................... 105 FLURAZEPAM HCL ..................................................... 111
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 204
FLURBIPROFEN........................................................... 73 FLUTAMIDE ....................................................... SEC 3.42 FLUTICASONE PROPIONATE ................................... 156 FLUVASTATIN SODIUM ............................................... 39 FLUVOXAMINE MALEATE ........................................... 92 FML FORTE ................................................................ 132 FOLIC ACID ................................................................ 185 FONDAPARINUX SODIUM .......................................... 32 FORADIL ....................................................................... 24 FORMOTEROL FUMARATE ........................................ 24 FORMOTEROL FUMARATE DIHYDRATE ................... 25 FORTAZ .......................................................................... 7 FOSAMAX .......................................................... SEC 3.14 FOSAVANCE ..................................................... SEC 3.15 FOSINOPRIL ................................................................ 61 FOSINOPRIL SODIUM ................................................. 61 FRAGMIN ...................................................................... 30 FRAGMIN (0.2 ML SYRINGE) ...................................... 30 FRAGMIN (0.3 ML SYRINGE) ...................................... 30 FRAGMIN (0.4 ML SYRINGE) ...................................... 30 FRAGMIN (0.5 ML SYRINGE) ...................................... 30 FRAGMIN (0.6 ML SYRINGE) ...................................... 30 FRAGMIN (0.72 ML SYRINGE) .................................... 31 FRAXIPARINE (.3-1ML SYR) ....................................... 31 FRAXIPARINE FORTE (.6-1ML SYR) .......................... 31 FUCIDIN ...................................................................... 173 FUCIDIN ...................................................................... 174 FUNGIZONE IV ............................................................. 16 FUROSEMIDE .............................................................. 44 FUROSEMIDE .............................................................. 45 FUSIDIC ACID ............................................................ 173
G
GABAPENTIN ............................................................... 86 GALANTAMINE HYDROBROMIDE ................... SEC 3.42 GANCICLOVIR SODIUM .............................................. 18 GARAMYCIN .............................................................. 131 GARASONE ................................................................ 133 GD-AMLODIPINE.......................................................... 55 GD-ATORVASTATIN .................................................... 38 GD-AZITHROMYCIN ...................................................... 9 GD-GABAPENTIN......................................................... 86 GD-LATANOPROST ................................................... 137 GD-SERTRALINE ......................................................... 93 GD-SERTRALINE ......................................................... 94 GD-VENLAFAXINE XR ................................................. 90 GEMFIBROZIL .............................................................. 37 GEN-CLOZAPINE ......................................................... 98 GEN-CLOZAPINE ......................................................... 99
GENTAMICIN...................................................................5 GENTAMICIN SULFATE ............................................. 131 GENTAMICIN SULFATE ............................................. 173 GENTAMICIN SULFATE .................................................5 GLATIRAMER ACETATE .................................... SEC 2.4 GLICLAZIDE ................................................................ 165 GLICLAZIDE MR .......................................................... 165 GLUCAGEN ................................................................. 166 GLUCAGEN HYPOKIT ................................................ 166 GLUCAGON................................................................. 166 GLUCAGON, RDNA ORIGIN ....................................... 166 GLUCOBAY ................................................................. 162 GLUCONORM ............................................................. 165 GLUCOPHAGE ............................................................ 163 GLYBURIDE ................................................................ 166 GLYCOPYRROLATE ..................................................... 23 GOLD SODIUM THIOMALATE .................................... 151 GOLIMUMAB ..................................................... SEC 3.46 GOSERELIN ACETATE ..................................... SEC 3.46 GRANISETRON ........................................................... 142 GRANISETRON HCL ................................................... 142
H
HALOBETASOL PROPIONATE .................................. 177 HALOPERIDOL............................................................ 104 HALOPERIDOL............................................................ 105 HALOPERIDOL DECANOATE .................................... 105 HALOPERIDOL LA ...................................................... 105 HEPARIN LEO ............................................................... 31 HEPARIN SODIUM ........................................................ 31 HEPATITIS B VACCINE (RECOMBINANT) ................ 171 HEPSERA ...................................................................... 17 HEPTOVIR ..................................................................... 16 HOMATROPINE HYDROBROMIDE ............................ 134 HP-PAC ( KIT )............................................................. 147 HUMALOG ................................................................... 164 HUMALOG CARTRIDGE/KWIKPEN ........................... 164 HUMALOG MIX 25 CARTRIDGE/KWIKPEN ............... 164 HUMALOG MIX 50 CARTRIDGE/KWIKPEN ............... 164 HUMATROPE .................................................... SEC 3.82 HUMIRA ............................................................. SEC 3.13 HUMULIN 30/70 ........................................................... 164 HUMULIN 30/70 CARTRIDGE ..................................... 164 HUMULIN N ................................................................. 164 HUMULIN N CARTRIDGE/KWIKPEN .......................... 164 HUMULIN R ................................................................. 164 HUMULIN R CARTRIDGE ........................................... 164 HYCORT (100MG/60ML) ............................................. 177 HYDERGINE .................................................................. 26
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 205 EFFECTIVE JULY 1, 2012
HYDERM ..................................................................... 178 HYDRALAZINE HCL ..................................................... 44 HYDROCHLOROTHIAZIDE ........................................ 126 HYDROCHLOROTHIAZIDE/ AMILORIDE HCL .......... 126 HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE ...... 70 HYDROCHLOROTHIAZIDE/ TRIAMTERENE ............ 126 HYDROCORTISONE .................................................. 156 HYDROCORTISONE .................................................. 177 HYDROCORTISONE 17-VALERATE ......................... 178 HYDROCORTISONE ACETATE ................................ 132 HYDROCORTISONE ACETATE ................................ 178 HYDROCORTISONE ACETATE/ PRAMOXINE HCL . 178 HYDROCORTISONE ACETATE/ PRAMOXINE HCL/
ZINC SULFATE ....................................................... 178 HYDROCORTISONE ACETATE/ UREA ..................... 178 HYDROCORTISONE ACETATE/ ZINC SULFATE ..... 178 HYDROCORTISONE SOD. SUCCINATE ................... 156 HYDROCORTISONE SOD. SUCCINATE ................... 157 HYDROCORTISONE SODIUM SUCCINATE ............. 156 HYDROCORTISONE SODIUM SUCCINATE ............. 157 HYDROCORTISONE/ CINCHOCAINE HCL/
FRAMYCETIN SULFATE/ ESCULIN ...................... 179 HYDROMORPH CONTIN ............................................. 78 HYDROMORPHONE .................................................... 78 HYDROMORPHONE HCL ............................................ 78 HYDROMORPHONE HCL ............................................ 79 HYDROMORPHONE HP .............................................. 78 HYDROMORPHONE HP 20 ......................................... 78 HYDROMORPHONE HP 50 ......................................... 78 HYDROVAL ................................................................ 178 HYDROXYCHLOROQUINE SULFATE ......................... 18 HYDROXYZINE HCL .................................................. 113 HYOSCINE BUTYLBROMIDE ...................................... 23 HYTRIN ......................................................................... 48 HYZAAR ........................................................................ 67 HYZAAR DS .................................................................. 68
I
IBUPROFEN ................................................................. 73 IMDUR .......................................................................... 46 IMIPENEM/ CILASTATIN SODIUM.................... SEC 3.47 IMIPRAMINE ................................................................. 96 IMIPRAMINE HCL ......................................................... 96 IMIQUIMOD ....................................................... SEC 3.47 IMITREX ...................................................................... 115 IMITREX ............................................................. SEC 3.83 IMITREX (0.5 ML) ....................................................... 115 IMITREX (0.5 ML) .............................................. SEC 3.84 IMITREX DF ................................................................ 115
IMITREX DF ....................................................... SEC 3.84 IMOVANE .................................................................... 113 IMURAN ....................................................................... 187 INDAPAMIDE HEMIHYDRATE .................................... 127 INDERAL-LA .................................................................. 53 INDOMETHACIN ........................................................... 73 INFLIXIMAB ....................................................... SEC 3.55 INFUFER ....................................................................... 29 INHIBACE ...................................................................... 59 INHIBACE PLUS ............................................................ 59 INNOHEP ....................................................................... 31 INNOHEP (0.25 ML SYRINGE) ..................................... 31 INNOHEP (0.35 ML SYRINGE) ..................................... 31 INNOHEP (0.45 ML SYRINGE) ..................................... 31 INNOHEP (0.5 ML SYRINGE) ....................................... 31 INNOHEP (0.7 ML SYRINGE) ....................................... 31 INNOHEP (0.9 ML SYRINGE) ....................................... 32 INSULIN ASPART ........................................................ 163 INSULIN DETEMIR ...................................................... 163 INSULIN GLARGINE ................................................... 163 INSULIN GLULISINE (RDNA ORIGIN) ........................ 164 INSULIN HUMAN BIOSYNTHETIC (ISOPHANE) ........ 164 INSULIN HUMAN BIOSYNTHETIC (REGULAR) ......... 164 INSULIN HUMAN BIOSYNTHETIC (REGULAR)/ INSULIN
HUMAN BIOSYNTHETIC (ISOPHANE) ................... 164 INSULIN LISPRO ......................................................... 164 INSULIN LISPRO/ INSULIN LISPRO PROTAMINE .... 164 INSULIN PEN NEEDLES .................................................1 INSULIN SYRINGES .......................................................1 INTERFERON BETA-1A ...................................... SEC 2.4 INTERFERON BETA-1B ...................................... SEC 2.4 INVANZ .............................................................. SEC 3.32 INVEGA SUSTENNA (0.5 ML SYR) .................. SEC 3.65 INVEGA SUSTENNA (0.75 ML SYR) ................ SEC 3.65 INVEGA SUSTENNA (1 ML SYR) ..................... SEC 3.65 INVEGA SUSTENNA (1.5 ML SYR) .................. SEC 3.65 IODOQUINOL ................................................................ 18 IOPIDINE ..................................................................... 138 IPRATROPIUM BROMIDE ............................................ 24 IPRATROPIUM BROMIDE ................................ SEC 3.55 IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE . 24 IRBESARTAN ................................................................ 66 IRBESARTAN/ HYDROCHLOROTHIAZIDE .................. 66 IRBESARTAN/ HYDROCHLOROTHIAZIDE .................. 67 IRBESARTAN/HCTZ ...................................................... 66 IRBESARTAN/HCTZ ...................................................... 67 IRON DEXTRAN COMPLEX.......................................... 29 ISDN .............................................................................. 45 ISOPTIN SR ................................................................... 58 ISOPTO ATROPINE .................................................... 134 ISOPTO CARBACHOL ................................................ 137 ISOPTO CARPINE ....................................................... 137
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 206
ISOPTO HOMATROPINE ........................................... 134 ISOSORBIDE DINITRATE ............................................ 45 ISOSORBIDE-5-MONONITRATE ................................. 46 ISOTRETINOIN ........................................................... 181 ITRACONAZOLE .......................................................... 15 ITRACONAZOLE ............................................... SEC 3.55
J
JAMP-AMLODIPINE ..................................................... 55 JAMP-ATENOLOL ........................................................ 49 JAMP-ATENOLOL ........................................................ 50 JAMP-CITALOPRAM .................................................... 91 JAMP-FINASTERIDE ......................................... SEC 3.41 JAMP-FOSINOPRIL ...................................................... 61 JAMP-GABAPENTIN .................................................... 86 JAMP-LACTULOSE .................................................... 125 JAMP-LISINOPRIL ........................................................ 61 JAMP-LISINOPRIL ........................................................ 62 JAMP-METOPROLOL-L ............................................... 52 JAMP-ONDANSETRON .............................................. 143 JAMP-PRAVASTATIN ................................................... 40 JAMP-QUETIAPINE .................................................... 100 JAMP-QUETIAPINE .................................................... 101 JAMP-RAMIPRIL (CAPSULE) ...................................... 63 JAMP-RAMIPRIL (CAPSULE) ...................................... 64 JAMP-RISPERIDONE ................................................. 102 JAMP-RISPERIDONE ................................................. 103 JAMP-ROPINIROLE ................................................... 119 JAMP-ROPINIROLE ................................................... 120 JAMP-SIMVASTATIN .................................................... 42 JAMP-SIMVASTATIN .................................................... 43 JANUMET .......................................................... SEC 3.81
K
K-10 ORAL LIQUID ..................................................... 125 K-DUR ......................................................................... 125 K-LYTE ........................................................................ 125 KADIAN ......................................................................... 81 KAYEXALATE ............................................................. 126 KENALOG-10 .............................................................. 158 KENALOG-40 .............................................................. 158 KEPPRA ........................................................................ 87 KETOCONAZOLE ......................................................... 15 KETOCONAZOLE ....................................................... 174 KETODERM ................................................................ 174 KETOPROFEN ............................................................. 74 KETOPROFEN SR........................................................ 74
KETOPROFEN-E ........................................................... 74 KETOROLAC TROMETHAMINE ................................. 134 KETOROLAC TROMETHAMINE ................................... 74 KETOTIFEN FUMARATE ................................................3 KINERET ........................................................... SEC 3.17 KYTRIL ........................................................................ 142
L
L-TRYPTOPHAN ........................................................... 97 LABETALOL HCL .......................................................... 51 LABETALOL HYDROCHLORIDE .................................. 51 LACOSAMIDE.................................................... SEC 3.55 LACOSAMIDE.................................................... SEC 3.56 LACTULOSE ................................................................ 125 LAMICTAL ..................................................................... 87 LAMISIL ......................................................................... 15 LAMISIL ....................................................................... 174 LAMIVUDINE ................................................................. 16 LAMOTRIGINE .............................................................. 87 LANREOTIDE ACETATE ................................... SEC 3.56 LANSOPRAZOLE ........................................................ 147 LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/
CLARITHROMYCIN ................................................. 147 LANTUS ....................................................................... 163 LANTUS CARTRIDGE ................................................. 163 LANTUS PEN............................................................... 163 LASIX ............................................................................. 44 LASIX ............................................................................. 45 LASIX SPECIAL ............................................................. 45 LATANOPROST .......................................................... 137 LATANOPROST/ TIMOLOL MALEATE ....................... 138 LECTOPAM ................................................................. 110 LEDERLE LEUCOVORIN CALCIUM ........................... 188 LEFLUNOMIDE ............................................................ 189 LESCOL ......................................................................... 39 LESCOL XL ................................................................... 39 LEUCOVORIN CALCIUM ............................................ 188 LEUPROLIDE ACETATE ................................... SEC 3.56 LEVAQUIN ......................................................... SEC 3A.4 LEVEMIR CARTRIDGE ............................................... 163 LEVETIRACETAM ......................................................... 87 LEVOBUNOLOL HCL .................................................. 136 LEVOCARB CR ........................................................... 118 LEVOCARNITINE .............................................. SEC 3.57 LEVODOPA/ BENSERAZIDE HCL .............................. 117 LEVODOPA/ CARBIDOPA .......................................... 118 LEVODOPA/ CARBIDOPA/ ENTACAPONE ................ 118 LEVOFLOXACIN ................................................ SEC 3A.4 LEVONORGESTREL ................................................... 159
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 207 EFFECTIVE JULY 1, 2012
LEVONORGESTREL/ ETHINYL ESTRADIOL ............ 159 LEVONORGESTREL/ ETHINYL ESTRADIOL/
LEVONORGESTREL/ ETHINYL ESTRADIOL/ LEVONORGESTREL/ ETHINYL ESTRADIOL ........ 159
LEVOTHYROXINE SODIUM ...................................... 168 LIBRAX ....................................................................... 110 LIDOCAINE ................................................................. 179 LIDOCAINE HCL ......................................................... 134 LIDOCAINE HCL ......................................................... 180 LIDODAN .................................................................... 179 LIDODAN VISCOUS ................................................... 134 LINAGLIPTIN ..................................................... SEC 3.57 LINESSA 21 ................................................................ 159 LINESSA 28 ................................................................ 159 LINEZOLID ......................................................... SEC 3.58 LIORESAL ..................................................................... 27 LIORESAL D.S. ............................................................. 27 LIORESAL INTRATHECAL ........................................... 27 LIOTHYRONINE SODIUM .......................................... 168 LIPASE/ AMYLASE/ PROTEASE ............................... 141 LIPIDIL MICRO ............................................................. 37 LIPIDIL SUPRA ............................................................. 37 LIPIDIL SUPRA (TABLET) ............................................ 37 LIPITOR ........................................................................ 38 LISINOPRIL .................................................................. 61 LISINOPRIL .................................................................. 62 LISINOPRIL/ HYDROCHLOROTHIAZIDE .................... 62 LISINOPRIL/HCTZ (TYPE Z) ....................................... 62 LITHANE ..................................................................... 114 LITHIUM CARBONATE ............................................... 114 LOCACORTEN VIOFORM .......................................... 133 LOESTRIN 1.5/30 (21 DAY) ........................................ 160 LOESTRIN 1.5/30 (28 DAY) ........................................ 160 LOMOTIL .................................................................... 141 LONITEN ....................................................................... 44 LOPRESOR .................................................................. 52 LOPRESOR SR ............................................................ 52 LOPROX ..................................................................... 175 LORAZEPAM .............................................................. 111 LOSARTAN POTASSIUM ............................................. 67 LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
.................................................................................. 67 LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE
.................................................................................. 68 LOSEC (SUSTAINED-RELEASE CAPSULE) ............. 147 LOSEC (SUSTAINED-RELEASE TABLET) ................ 147 LOTENSIN .................................................................... 58 LOTRIDERM ............................................................... 179 LOVASTATIN ................................................................ 39 LOVENOX ..................................................................... 31 LOVENOX (0.3 ML SYRINGE) ..................................... 31 LOVENOX (0.4 - 1 ML SYRINGE) ................................ 31
LOVENOX HP (0.8ML/1ML SYRINGE) ......................... 31 LOXAPAC .................................................................... 108 LOXAPINE HCL ........................................................... 108 LOXAPINE SUCCINATE ............................................. 108 LOZIDE ........................................................................ 127 LUCENTIS ................................................................... 139 LUMIGAN RC 0.01% ................................................... 137 LUPRON ............................................................ SEC 3.56 LUPRON DEPOT ............................................... SEC 3.56 LUVOX ........................................................................... 92 LYDERM ...................................................................... 177
M
M-ESLON ....................................................................... 80 M-ESLON ....................................................................... 81 M.O.S. SULFATE ........................................................... 80 M.O.S.-SR ...................................................................... 79 MACROBID .................................................................... 19 MAGLUCATE ............................................................... 125 MAGNESIUM GLUCOHEPTONATE ........................... 125 MAGNESIUM GLUCONATE ........................................ 125 MAJEPTIL .................................................................... 106 MAPROTILINE HCL ....................................................... 96 MAR-AMLODIPINE ........................................................ 55 MAR-ATENOLOL ........................................................... 49 MAR-ATENOLOL ........................................................... 50 MAR-CIPROFLOXACIN ..................................... SEC 3A.2 MAR-CIPROFLOXACIN ..................................... SEC 3A.3 MAR-CITALOPRAM ....................................................... 91 MAR-METFORMIN ...................................................... 163 MAR-ONDANSETRON ................................................ 143 MAR-RISPERIDONE ................................................... 102 MAR-RISPERIDONE ................................................... 103 MAR-SIMVASTATIN ...................................................... 42 MAR-SIMVASTATIN ...................................................... 43 MARVELON (21 DAY) ................................................. 159 MARVELON (28 DAY) ................................................. 159 MAVIK ............................................................................ 64 MAVIK ............................................................................ 65 MAXALT ....................................................................... 114 MAXALT ............................................................. SEC 3.79 MAXALT RPD .............................................................. 114 MAXALT RPD .............................................................. 115 MAXALT RPD .................................................... SEC 3.79 MAXIDEX ..................................................................... 132 MAXITROL ................................................................... 133 MEBENDAZOLE ..............................................................5 MEDROL ...................................................................... 157 MEDROXYPROGESTERONE ACETATE ................... 167
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 208
MEFENAMIC ................................................................. 74 MEFENAMIC ACID ....................................................... 74 MEGACE OS ..................................................... SEC 3.58 MEGESTROL ..................................................... SEC 3.58 MEGESTROL ACETATE ................................... SEC 3.58 MEPERIDINE HCL ........................................................ 79 MEPERIDINE HYDROCHLORIDE................................ 79 MEPRON ...................................................................... 19 MEROPENEM .................................................... SEC 3.59 MERREM ........................................................... SEC 3.59 MESALAZINE ............................................................. 149 MESASAL ................................................................... 149 MESTINON ................................................................... 23 MESTINON-SR ............................................................. 23 METADOL ..................................................................... 79 METADOL CONCENTRATE ......................................... 79 METFORMIN .............................................................. 163 METFORMIN HCL ...................................................... 163 METHADONE ............................................................... 79 METHADONE COMPOUND ......................................... 79 METHADONE HCL ....................................................... 79 METHAZOLAMIDE ..................................................... 136 METHIMAZOLE .......................................................... 169 METHOTREXATE ......................................................... 21 METHOTREXATE SOD. (PRESERVED) ...................... 21 METHOTREXATE SOD.(UNPRESERVED) ................. 21 METHOTREXATE SODIUM ......................................... 21 METHOTRIMEPRAZINE HCL .................................... 106 METHOTRIMEPRAZINE MALEATE ........................... 106 METHOXSALEN ......................................................... 180 METHSUXIMIDE ........................................................... 85 METHYLDOPA ............................................................. 43 METHYLDOPA ............................................................. 44 METHYLPHENIDATE HCL ......................................... 109 METHYLPREDNISOLONE ......................................... 157 METHYLPREDNISOLONE ACETATE ........................ 157 METHYLPREDNISOLONE ACETATE (P) .................. 157 METHYLPREDNISOLONE ACETATE/ LIDOCAINE HCL
................................................................................ 157 METHYLPREDNISOLONE ACETATE/ NEOMYCIN
SULFATE/ ALUMINUM CHLORHYDROXIDE COMPLEX/ SULFUR ..................................... SEC 3.59
METHYLPREDNISOLONE SOD SUCCIN. ................. 157 METHYLPREDNISOLONE SODIUM SUCCINATE .... 157 METOCLOPRAMIDE HCL .......................................... 148 METOCLOPRAMIDE HCL .......................................... 149 METOCLOPRAMIDE HYDROCHLORIDE .................. 149 METOLAZONE ........................................................... 127 METOPROLOL ............................................................. 52 METOPROLOL TARTRATE ......................................... 52 METROCREAM .......................................................... 173 METROGEL ................................................................ 173
METROLOTION ........................................................... 173 METRONIDAZOLE ...................................................... 173 METRONIDAZOLE ...................................................... 174 METRONIDAZOLE ........................................................ 19 METRONIDAZOLE/ NYSTATIN ................................... 174 MEVACOR ..................................................................... 39 MEXILETINE HCL .......................................................... 35 MIACALCIN........................................................ SEC 3.85 MICARDIS ..................................................................... 68 MICARDIS PLUS ........................................................... 68 MICRO-K EXTENCAPS ............................................... 125 MICRONOR (28 DAY) ................................................. 159 MIDAMOR .................................................................... 126 MIDAZOLAM ................................................................ 111 MIDAZOLAM HCL ........................................................ 111 MIDODRINE................................................................... 24 MIDODRINE HCL .......................................................... 24 MIGRANAL .................................................................... 26 MIN-OVRAL (21 DAY) ................................................. 159 MIN-OVRAL (28 DAY) ................................................. 159 MINESTRIN 1/20 (21 DAY) .......................................... 160 MINESTRIN 1/20 (28 DAY) .......................................... 160 MINITRAN 0.2 ................................................................ 46 MINITRAN 0.4 ................................................................ 46 MINITRAN 0.6 ................................................................ 46 MINOCYCLINE .............................................................. 13 MINOCYCLINE HCL ...................................................... 13 MINOXIDIL ..................................................................... 44 MINT-AMLODIPINE ....................................................... 55 MINT-ATENOL ............................................................... 49 MINT-ATENOL ............................................................... 50 MINT-CIPROFLOXACIN .................................... SEC 3A.2 MINT-CIPROFLOXACIN .................................... SEC 3A.3 MINT-CITALOPRAM ...................................................... 91 MINT-FLUOXETINE ....................................................... 92 MINT-ONDANSETRON ............................................... 143 MINT-PIOGLITAZONE ....................................... SEC 3.72 MINT-PRAVASTATIN .................................................... 40 MINT-RISPERIDON ..................................................... 102 MINT-RISPERIDON ..................................................... 103 MINT-SIMVASTATIN ..................................................... 42 MINT-SIMVASTATIN ..................................................... 43 MINT-TOPIRAMATE ...................................................... 88 MIRENA SYSTEM ....................................................... 159 MIRTAZAPINE ............................................................... 98 MISCELLANEOUS COMPOUND ................................ 188 MISCELLANEOUS INJECTABLE COMPOUND .......... 188 MISCELLANEOUS ORAL COMPOUND ...................... 188 MISCELLANEOUS TOPICAL COMPOUND ................ 173 MISOPROSTOL ........................................................... 146 MOCLOBEMIDE ............................................................ 89 MODAFINIL........................................................ SEC 3.59
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 209 EFFECTIVE JULY 1, 2012
MODECATE CONCENTRATE .................................... 105 MODULON .................................................................. 150 MOGADON ................................................................. 112 MOMETASONE FUROATE ........................................ 132 MOMETASONE FUROATE ........................................ 178 MONOPRIL ................................................................... 61 MONTELUKAST ......................................................... 129 MONTELUKAST ................................................ SEC 3.60 MONTELUKAST SODIUM .......................................... 129 MONTELUKAST SODIUM ................................. SEC 3.60 MORPHINE HCL ........................................................... 79 MORPHINE HP 25 ........................................................ 81 MORPHINE HP 50 ........................................................ 81 MORPHINE LP EPIDURAL ........................................... 81 MORPHINE SR ............................................................. 80 MORPHINE SULFATE .................................................. 80 MORPHINE SULFATE .................................................. 81 MOXIFLOXACIN HCL ........................................ SEC 3A.5 MS CONTIN .................................................................. 80 MS.IR ............................................................................ 80 MUCOMYST ............................................................... 130 MUPIROCIN ................................................................ 174 MYCOBUTIN ...................................................... SEC 3.74 MYDFRIN .................................................................... 135 MYDRIACYL ............................................................... 134 MYL-RANITIDINE ....................................................... 145 MYLAN-ACEBUTOLOL ................................................. 49 MYLAN-ACEBUTOLOL (TYPE S)................................. 49 MYLAN-ACYCLOVIR .................................................... 17 MYLAN-ALENDRONATE ................................... SEC 3.14 MYLAN-ALPRAZOLAM ............................................... 110 MYLAN-AMANTADINE ............................................... 116 MYLAN-AMIODARONE ................................................ 36 MYLAN-AMLODIPINE ................................................... 55 MYLAN-AMOXICILLIN .................................................. 10 MYLAN-ATENOLOL...................................................... 49 MYLAN-ATENOLOL...................................................... 50 MYLAN-ATORVASTATIN ............................................. 38 MYLAN-AZATHIOPRINE ............................................ 187 MYLAN-AZITHROMYCIN ............................................... 9 MYLAN-BACLOFEN ..................................................... 27 MYLAN-BECLO AQ. ................................................... 132 MYLAN-BUDESONIDE AQ ......................................... 132 MYLAN-CANDESARTAN .............................................. 65 MYLAN-CAPTOPRIL .................................................... 59 MYLAN-CARBAMAZEPINE CR .................................... 85 MYLAN-CARVEDILOL .................................................. 51 MYLAN-CILAZAPRIL .................................................... 59 MYLAN-CIMETIDINE .................................................. 144 MYLAN-CIPROFLOXACIN ................................ SEC 3A.2 MYLAN-CIPROFLOXACIN ................................ SEC 3A.3 MYLAN-CITALOPRAM ................................................. 91
MYLAN-CLARITHROMYCIN ...........................................9 MYLAN-CLINDAMYCIN ................................................. 14 MYLAN-CLONAZEPAM ................................................. 84 MYLAN-CLOPIDOGREL ................................................ 32 MYLAN-CLOPIDOGREL .................................... SEC 3.20 MYLAN-COMBO STERINEBS ....................................... 24 MYLAN-CYCLOBENZAPRINE ...................................... 27 MYLAN-DOMPERIDONE ............................................ 148 MYLAN-DOXAZOSIN .................................................... 47 MYLAN-ENALAPRIL ...................................................... 60 MYLAN-ETI-CAL-CAREPAC ....................................... 188 MYLAN-ETIDRONATE ................................................ 188 MYLAN-FAMOTIDINE ................................................. 145 MYLAN-FENOFIBRATE MICRO .................................... 37 MYLAN-FINASTERIDE ...................................... SEC 3.41 MYLAN-FLUCONAZOLE ............................................... 15 MYLAN-FLUOXETINE ................................................... 92 MYLAN-FOSINOPRIL .................................................... 61 MYLAN-GABAPENTIN .................................................. 86 MYLAN-GALANTAMINE ER .............................. SEC 3.42 MYLAN-GEMFIBROZIL ................................................. 37 MYLAN-GLICLAZIDE ................................................... 165 MYLAN-GLYBE............................................................ 166 MYLAN-HYDROXYCHLOROQUINE ............................. 18 MYLAN-INDAPAMIDE ................................................. 127 MYLAN-IPRATROPIUM ................................................. 24 MYLAN-IPRATROPIUM STERINEBS ............... SEC 3.55 MYLAN-IRBESARTAN ................................................... 66 MYLAN-LAMOTRIGINE ................................................. 87 MYLAN-LANSOPRAZOLE ........................................... 147 MYLAN-LEVOFLOXACIN .................................. SEC 3A.4 MYLAN-LISINOPRIL ...................................................... 61 MYLAN-LISINOPRIL ...................................................... 62 MYLAN-LISINOPRIL HCTZ ........................................... 62 MYLAN-LOSARTAN ...................................................... 67 MYLAN-LOSARTAN HCTZ ............................................ 67 MYLAN-LOSARTAN HCTZ ............................................ 68 MYLAN-LOVASTATIN ................................................... 39 MYLAN-METFORMIN .................................................. 163 MYLAN-METOPROLOL ................................................. 52 MYLAN-METOPROLOL (TYPE L) ................................. 52 MYLAN-MINOCYCLINE ................................................. 13 MYLAN-MIRTAZAPINE ................................................. 98 MYLAN-MONTELUKAST ............................................. 129 MYLAN-MONTELUKAST ................................... SEC 3.60 MYLAN-NABUMETONE ................................................ 74 MYLAN-NAPROXEN EC ............................................... 75 MYLAN-NIFEDIPINE EXTENDED RELEASE................ 56 MYLAN-NITRO .............................................................. 46 MYLAN-OLANZAPINE ................................................. 100 MYLAN-OLANZAPINE ................................................... 99 MYLAN-OLANZAPINE ODT ........................................ 100
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 210
MYLAN-OMEPRAZOLE (CAPSULE) .......................... 147 MYLAN-ONDANSETRON ........................................... 143 MYLAN-OXYBUTYNIN ............................................... 183 MYLAN-PANTOPRAZOLE .......................................... 148 MYLAN-PAROXETINE .................................................. 93 MYLAN-PIOGLITAZONE ................................... SEC 3.72 MYLAN-PRAMIPEXOLE ............................................. 119 MYLAN-PRAVASTATIN ................................................ 40 MYLAN-QUETIAPINE ................................................. 100 MYLAN-QUETIAPINE ................................................. 101 MYLAN-RAMIPRIL (CAPSULE) .................................... 63 MYLAN-RAMIPRIL (CAPSULE) .................................... 64 MYLAN-RANITIDINE .................................................. 145 MYLAN-RISEDRONATE .................................... SEC 3.75 MYLAN-RISPERIDONE .............................................. 102 MYLAN-RISPERIDONE .............................................. 103 MYLAN-RIVASTIGMINE .................................... SEC 3.78 MYLAN-RIZATRIPTAN ODT ....................................... 114 MYLAN-RIZATRIPTAN ODT ....................................... 115 MYLAN-RIZATRIPTAN ODT .............................. SEC 3.79 MYLAN-ROSUVASTATIN ............................................. 41 MYLAN-SALBUTAMOL STERINEBS P.F. .................... 25 MYLAN-SELEGILINE .................................................. 120 MYLAN-SERTRALINE .................................................. 93 MYLAN-SERTRALINE .................................................. 94 MYLAN-SIMVASTATIN ................................................. 42 MYLAN-SIMVASTATIN ................................................. 43 MYLAN-SOTALOL ........................................................ 54 MYLAN-SUMATRIPTAN ............................................. 115 MYLAN-SUMATRIPTAN .................................... SEC 3.84 MYLAN-TAMSULOSIN ................................................. 48 MYLAN-TELMISARTAN ................................................ 68 MYLAN-TELMISARTAN HCTZ ..................................... 68 MYLAN-TERBINAFINE ................................................. 15 MYLAN-TIZANIDINE .......................................... SEC 3.87 MYLAN-TOPIRAMATE ................................................. 88 MYLAN-TRAZODONE .................................................. 94 MYLAN-VALACYCLOVIR (CAPLET) ............................ 18 MYLAN-VALPROIC....................................................... 89 MYLAN-VALSARTAN HCTZ ......................................... 69 MYLAN-VALSARTAN HCTZ ......................................... 70 MYLAN-VENLAFAXINE XR .......................................... 90 MYLAN-VERAPAMIL .................................................... 58 MYLAN-VERAPAMIL SR .............................................. 58 MYLAN-WARFARIN ...................................................... 29 MYLAN-WARFARIN ...................................................... 30 MYLAN-ZOLMITRIPTAN ............................................ 116 MYLAN-ZOLMITRIPTAN ................................... SEC 3.95 MYLAN-ZOPICLONE .................................................. 113 MYOCHRYSINE.......................................................... 151
N
NABILONE ................................................................... 144 NABUMETONE .............................................................. 74 NADOLOL ...................................................................... 52 NADROPARIN CALCIUM .............................................. 31 NAFARELIN ACETATE ............................................... 189 NALCROM ................................................................... 130 NAPROSYN ................................................................... 75 NAPROSYN E................................................................ 75 NAPROSYN SR ............................................................. 75 NAPROXEN ................................................................... 74 NAPROXEN ................................................................... 75 NAPROXEN EC ............................................................. 75 NAPROXEN SODIUM .................................................... 75 NAPROXEN SODIUM DS .............................................. 75 NARATRIPTAN HCL .................................................... 114 NARATRIPTAN HCL .......................................... SEC 3.61 NARDIL .......................................................................... 89 NASONEX ................................................................... 132 NATALIZUMAB .................................................... SEC 2.7 NAVANE ...................................................................... 107 NEO-MEDROL ACNE ........................................ SEC 3.59 NEOMYCIN SULFATE/ POLYMYXIN B SULFATE ..... 174 NEOMYCIN SULFATE/ POLYMYXIN B SULFATE/
GRAMICIDIN............................................................ 131 NEORAL ............................................................ SEC 3.21 NEOSPORIN................................................................ 174 NEOSTIGMINE BROMIDE ............................................ 23 NERISONE .................................................................. 177 NERISONE OILY ......................................................... 177 NEULASTA (0.6 ML SYRINGE) ......................... SEC 3.65 NEULEPTIL ................................................................. 106 NEUPOGEN....................................................... SEC 3.41 NEURONTIN .................................................................. 86 NIFEDIPINE ................................................................... 56 NITOMAN .......................................................... SEC 3.87 NITRAZADON .............................................................. 112 NITRAZEPAM .............................................................. 112 NITRO-DUR 0.2 ............................................................. 46 NITRO-DUR 0.4 ............................................................. 46 NITRO-DUR 0.6 ............................................................. 46 NITRO-DUR 0.8 ............................................................. 46 NITROFURANTOIN ....................................................... 19 NITROGLYCERIN .......................................................... 46 NITROL .......................................................................... 46 NITROLINGUAL PUMPSPRAY ..................................... 46 NITROSTAT ................................................................... 46 NIZATIDINE ................................................................. 145 NORETHINDRONE ..................................................... 159 NORETHINDRONE ACETATE/ ESTRADIOL-17B ...... 162
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 211 EFFECTIVE JULY 1, 2012
NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL ................................................................................ 160
NORETHINDRONE/ ETHINYL ESTRADIOL .............. 160 NORETHINDRONE/ ETHINYL ESTRADIOL/
NORETHINDRONE/ ETHINYL ESTRADIOL .......... 160 NORETHINDRONE/ ETHINYL ESTRADIOL/
NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL .......... 160
NORFLOXACIN ............................................................ 12 NORGESTIMATE/ ETHINYL ESTRADIOL ................. 160 NORGESTIMATE/ ETHINYL ESTRADIOL/
NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL ............. 160
NORITATE .................................................................. 173 NORPROLAC .................................................... SEC 3.73 NORTRIPTYLINE HCL ................................................. 96 NORVASC .................................................................... 55 NOVAMILOR ............................................................... 126 NOVAMOXIN ................................................................ 10 NOVAMOXIN ................................................................ 11 NOVAMOXIN SUGAR-REDUCED ................................ 10 NOVAMOXIN SUGAR-REDUCED ................................ 11 NOVO-5 ASA .............................................................. 149 NOVO-ACEBUTOLOL .................................................. 49 NOVO-ACYCLOVIR ...................................................... 17 NOVO-ALFUZOSIN PR ..................................... SEC 3.15 NOVO-AMPICILLIN............................................ SEC 3.15 NOVO-ATORVASTATIN ............................................... 38 NOVO-AZITHROMYCIN ................................................. 9 NOVO-BENZYDAMINE ............................................... 135 NOVO-BETAHISTINE ................................................. 187 NOVO-BISOPROLOL ................................................... 50 NOVO-BROMAZEPAM ............................................... 110 NOVO-BUSPIRONE ................................................... 112 NOVO-CAPTORIL......................................................... 59 NOVO-CEFADROXIL ......................................... SEC 3.19 NOVO-CHLOROQUINE ................................................ 18 NOVO-CILAZAPRIL ...................................................... 59 NOVO-CILAZAPRIL/HCTZ ........................................... 59 NOVO-CIMETINE ....................................................... 144 NOVO-CIPROFLOXACIN .................................. SEC 3A.2 NOVO-CIPROFLOXACIN .................................. SEC 3A.3 NOVO-CITALOPRAM ................................................... 91 NOVO-CLAVAMOXIN ................................................... 11 NOVO-CLOBAZAM ....................................................... 83 NOVO-CLOBETASOL ................................................. 176 NOVO-CLONAZEPAM .................................................. 84 NOVO-CLONIDINE ..................................................... 187 NOVO-CLONIDINE ....................................................... 43 NOVO-CLOXIN ............................................................. 12 NOVO-CYCLOPRINE ................................................... 27 NOVO-DESMOPRESSIN ............................................ 167
NOVO-DIFENAC ............................................................ 72 NOVO-DIFENAC SR ...................................................... 72 NOVO-DIFLUNISAL FC ................................................. 73 NOVO-DILTAZEM .......................................................... 56 NOVO-DILTAZEM CD ................................................... 56 NOVO-DILTAZEM CD ................................................... 57 NOVO-DILTIAZEM HCL ER .......................................... 57 NOVO-DILTIAZEM HCL ER .......................................... 58 NOVO-DIVALPROEX .................................................... 85 NOVO-DIVALPROEX .................................................... 86 NOVO-DOXAZOSIN ...................................................... 47 NOVO-DOXEPIN ........................................................... 95 NOVO-DOXEPIN ........................................................... 96 NOVO-DOXYLIN ............................................................ 13 NOVO-ENALAPRIL ........................................................ 60 NOVO-ENALAPRIL/HCTZ ............................................. 60 NOVO-ETIDRONATECAL ........................................... 188 NOVO-FAMOTIDINE ................................................... 145 NOVO-FENOFIBRATE MICRONIZED ........................... 37 NOVO-FENOFIBRATE-S ............................................... 37 NOVO-FENOFIBRATE-S (TABLET) .............................. 37 NOVO-FENTANYL 100 ...................................... SEC 3.40 NOVO-FENTANYL 25 ........................................ SEC 3.39 NOVO-FENTANYL 50 ........................................ SEC 3.40 NOVO-FENTANYL 75 ........................................ SEC 3.40 NOVO-FINASTERIDE ........................................ SEC 3.41 NOVO-FLUCONAZOLE ................................................. 15 NOVO-FLURPROFEN ................................................... 73 NOVO-FLUTAMIDE ........................................... SEC 3.42 NOVO-FLUVOXAMINE .................................................. 92 NOVO-FURANTOIN ...................................................... 19 NOVO-GEMFIBROZIL ................................................... 37 NOVO-GLICLAZIDE .................................................... 165 NOVO-HYDROXYZIN .................................................. 113 NOVO-INDAPAMIDE ................................................... 127 NOVO-IPRAMIDE .......................................................... 24 NOVO-KETOCONAZOLE .............................................. 15 NOVO-KETOROLAC ..................................................... 74 NOVO-KETOTIFEN .........................................................3 NOVO-LAMOTRIGINE ................................................... 87 NOVO-LANSOPRAZOLE ............................................ 147 NOVO-LEFLUNOMIDE ................................................ 189 NOVO-LEVOCARBIDOPA ........................................... 118 NOVO-LEVOFLOXACIN .................................... SEC 3A.4 NOVO-LEXIN ...................................................................5 NOVO-LEXIN ...................................................................6 NOVO-LISINOPRIL (TYPE Z) ........................................ 61 NOVO-LISINOPRIL (TYPE Z) ........................................ 62 NOVO-LISINOPRIL/HCTZ (TYPE P) ............................. 62 NOVO-LORAZEM ........................................................ 111 NOVO-LOVASTATIN ..................................................... 39 NOVO-MAPROTILINE ................................................... 96
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 212
NOVO-MEDRONE ...................................................... 167 NOVO-METFORMIN ................................................... 163 NOVO-METHACIN ........................................................ 73 NOVO-MEXILETINE ..................................................... 35 NOVO-MINOCYCLINE .................................................. 13 NOVO-MIRTAZAPINE .................................................. 98 NOVO-MOCLOBEMIDE ................................................ 89 NOVO-MORPHINE SR ................................................. 80 NOVO-NABUMETONE ................................................. 74 NOVO-NADOLOL ......................................................... 52 NOVO-NARATRIPTAN ............................................... 114 NOVO-NARATRIPTAN ...................................... SEC 3.61 NOVO-NIZATIDINE..................................................... 145 NOVO-NORFLOXACIN ................................................. 12 NOVO-NORTRIPTYLINE .............................................. 96 NOVO-OMEPRAZOLE (DELAYED RELEASE TABLET)
................................................................................ 147 NOVO-OXYBUTYNIN ................................................. 183 NOVO-PANTOPRAZOLE ........................................... 148 NOVO-PEN-VK ............................................................. 10 NOVO-PERIDOL ......................................................... 104 NOVO-PERIDOL ......................................................... 105 NOVO-PINDOL ............................................................. 53 NOVO-PIOGLITAZONE ..................................... SEC 3.72 NOVO-PIROCAM .......................................................... 76 NOVO-PRAMIPEXOLE ............................................... 119 NOVO-PRANOL ............................................................ 53 NOVO-PRAVASTATIN .................................................. 40 NOVO-PRAZIN ............................................................. 47 NOVO-PROFEN............................................................ 73 NOVO-QUETIAPINE ................................................... 100 NOVO-QUETIAPINE ................................................... 101 NOVO-QUININE............................................................ 19 NOVO-RALOXIFENE ......................................... SEC 3.74 NOVO-RANIDINE ....................................................... 145 NOVO-RANIDINE ....................................................... 146 NOVO-RISEDRONATE ...................................... SEC 3.75 NOVO-RISPERIDONE ................................................ 102 NOVO-RISPERIDONE ................................................ 103 NOVO-RIVASTIGMINE ...................................... SEC 3.78 NOVO-RYTHRO EES ..................................................... 8 NOVO-RYTHRO ESTOLATE .......................................... 8 NOVO-SELEGILINE.................................................... 120 NOVO-SEMIDE ............................................................. 44 NOVO-SEMIDE ............................................................. 45 NOVO-SOTALOL .......................................................... 54 NOVO-SPIROTON ........................................................ 70 NOVO-SPIROZINE ....................................................... 70 NOVO-SUCRALATE ................................................... 146 NOVO-SUMATRIPTAN ............................................... 115 NOVO-SUMATRIPTAN ...................................... SEC 3.84 NOVO-SUMATRIPTAN DF ......................................... 115
NOVO-SUMATRIPTAN DF ................................ SEC 3.84 NOVO-SUNDAC ............................................................ 76 NOVO-TAMSULOSIN .................................................... 48 NOVO-TEMAZEPAM ................................................... 112 NOVO-TERBINAFINE .................................................... 15 NOVO-TIAPROFENIC ................................................... 76 NOVO-TICLOPIDINE ..................................................... 33 NOVO-TIMOL ................................................................ 54 NOVO-TOPIRAMATE .................................................... 88 NOVO-TRIAMZIDE ...................................................... 126 NOVO-TRIMEL .............................................................. 12 NOVO-TRIMEL DS ........................................................ 12 NOVO-VALPROIC ......................................................... 89 NOVO-VERAMIL SR ...................................................... 58 NOVO-WARFARIN ........................................................ 29 NOVO-WARFARIN ........................................................ 30 NOVO-ZOPICLONE ..................................................... 113 NOVOLIN GE 30/70 ..................................................... 164 NOVOLIN GE 30/70 CARTRIDGE ............................... 164 NOVOLIN GE 40/60 CARTRIDGE ............................... 164 NOVOLIN GE 50/50 CARTRIDGE ............................... 164 NOVOLIN GE NPH ...................................................... 164 NOVOLIN GE NPH CARTRIDGE ................................ 164 NOVOLIN GE TORONTO ............................................ 164 NOVOLIN GE TORONTO CARTRIDGE ...................... 164 NOVORAPID................................................................ 163 NOVORAPID CARTRIDGE ......................................... 163 NOZINAN ..................................................................... 106 NYLIDRIN HCL .............................................................. 47 NYSTATIN ..................................................................... 16
O
OCTOSTIM .................................................................. 167 OCTREOTIDE ACETATE .................................. SEC 3.61 OCTREOTIDE ACETATE .................................. SEC 3.62 OCTREOTIDE ACETATE OMEGA .................... SEC 3.61 OCUFLOX .................................................................... 131 OESCLIM 25 (5 MG/PTH) ............................................ 161 OESCLIM 50 (10 MG/PTH) .......................................... 161 OFLOXACIN ................................................................ 131 OFLOXACIN ...................................................... SEC 3A.5 OLANZAPINE .............................................................. 100 OLANZAPINE ................................................................ 99 OLANZAPINE ODT ...................................................... 100 OLESTYR LIGHT ........................................................... 36 OLESTYR REGULAR .................................................... 36 OLMESARTAN MEDOXOMIL........................................ 45 OLMESARTAN MEDOXOMIL/
HYDROCHLOROTHIAZIDE....................................... 45
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 213 EFFECTIVE JULY 1, 2012
OLMETEC ..................................................................... 45 OLMETEC PLUS........................................................... 45 OLSALAZINE SODIUM ............................................... 149 OMALIZUMAB ................................................... SEC 3.64 OMEPRAZOLE ........................................................... 147 OMEPRAZOLE (CAPSULE) ....................................... 147 OMNITROPE ..................................................... SEC 3.82 ONABOTULINUMTOXINA .......................................... 189 ONDANSETRON ........................................................ 142 ONDANSETRON ........................................................ 143 ONDANSETRON HCL DIHYDRATE........................... 143 ONDANSETRON OMEGA (PRESERVATIVE FREE) . 143 ONDANSETRON OMEGA (WITH PRESERVATIVE) . 143 ONDANSETRON-ODAN ............................................. 143 ONE-ALPHA ............................................................... 185 ONGLYZA .......................................................... SEC 3.80 OPIUM/ BELLADONNA ................................................ 81 OPTICHAMBER ADVANTAGE II (CHAMBER ONLY) 191 OPTICHAMBER ADVANTAGE II (WITH LARGE MASK)
................................................................................ 191 OPTICHAMBER ADVANTAGE II (WITH MEDIUM MASK)
................................................................................ 191 OPTICHAMBER ADVANTAGE II (WITH SMALL MASK)
................................................................................ 191 OPTIMYXIN PLUS ...................................................... 131 ORACORT .................................................................. 179 ORAP .......................................................................... 108 ORCIPRENALINE SULFATE ........................................ 25 ORENCIA ............................................................. SEC 3.6 ORGARAN ......................................................... SEC 3.22 ORTHO 0.5/35 (21 DAY) ............................................. 160 ORTHO 0.5/35 (28 DAY) ............................................. 160 ORTHO 1/35 (21 DAY) ................................................ 160 ORTHO 1/35 (28 DAY) ................................................ 160 ORTHO 7/7/7 (21 DAY) ............................................... 160 ORTHO 7/7/7 (28 DAY) ............................................... 160 ORTHO-CEPT (28 DAY) ............................................. 159 OXAZEPAM ................................................................ 112 OXEZE TURBUHALER ................................................. 25 OXSORALEN .............................................................. 180 OXSORALEN ULTRA ................................................. 180 OXTRIPHYLLINE ........................................................ 183 OXTRIPHYLLINE/ GUAIFENESIN .............................. 183 OXY-IR .......................................................................... 82 OXYBUTYNIN ............................................................. 183 OXYBUTYNIN CHLORIDE ......................................... 183 OXYBUTYNIN CHLORIDE ................................ SEC 3.64 OXYCODONE HCL ....................................................... 82 OXYCODONE HCL/ ACETAMINOPHEN ...................... 82 OXYCODONE HCL/ ASA .............................................. 83 OXYCODONE/ACET .................................................... 82 OXYCONTIN ................................................................. 82
OXYNEO ........................................................................ 82
P
PALIPERIDONE PALMITATE ............................ SEC 3.65 PAMIDRONATE DISODIUM ........................................ 189 PAMIDRONATE DISODIUM OMEGA .......................... 189 PANCREASE MT 10 .................................................... 141 PANCREASE MT 16 .................................................... 141 PANCREASE MT 4 ...................................................... 141 PANECTYL ......................................................................3 PANOXYL 10 ..................................................... SEC 3.18 PANOXYL 20 ..................................................... SEC 3.18 PANTOLOC ................................................................. 148 PANTOPRAZOLE ........................................................ 148 PAPAVERINE HCL ............................................ SEC 3.65 PARIET ........................................................................ 148 PARNATE ...................................................................... 89 PAROXETINE ................................................................ 93 PAROXETINE HCL ........................................................ 93 PARSITAN ................................................................... 117 PAT-GALANTAMINE ER ................................... SEC 3.42 PAXIL ............................................................................. 93 PEDIAPRED ................................................................ 158 PEGASYS (0.5 ML SYRINGE)....................................... 17 PEGASYS (0.5 ML SYRINGE)........................... SEC 3.67 PEGASYS RBV (KIT) ......................................... SEC 3.69 PEGETRON (KIT) .............................................. SEC 3.71 PEGETRON REDIPEN (KIT) ............................. SEC 3.71 PEGFILGRASTIM .............................................. SEC 3.65 PEGINTERFERON ALFA-2A ......................................... 17 PEGINTERFERON ALFA-2A ............................. SEC 3.67 PEGINTERFERON ALFA-2A/ RIBAVIRIN ......... SEC 3.69 PEGINTERFERON ALFA-2B/ RIBAVIRIN ......... SEC 3.71 PENICILLAMINE .......................................................... 153 PENICILLIN G SODIUM ................................................ 10 PENICILLIN V POTASSIUM .......................................... 10 PENTASA .................................................................... 149 PENTASA (1G/100ML) ................................................ 149 PENTASA (4G/100 ML) ............................................... 149 PENTAZOCINE HCL ..................................................... 83 PENTAZOCINE LACTATE ............................................ 83 PENTOSAN POLYSULFATE SODIUM ....................... 189 PENTOXIFYLLINE ......................................................... 33 PEPCID ........................................................................ 145 PERCOCET ................................................................... 82 PERCOCET DEMI ......................................................... 82 PERICYAZINE ............................................................. 106 PERINDOPRIL ERBUMINE ........................................... 62 PERINDOPRIL ERBUMINE ........................................... 63
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 214
PERINDOPRIL ERBUMINE/ INDAPAMIDE HEMIHYDRATE ........................................................ 63
PERPHENAZINE ........................................................ 106 PHENELZINE SULFATE ............................................... 89 PHENOBARB .............................................................. 109 PHENOBARBITAL ...................................................... 109 PHENYLEPHRINE HCL .............................................. 135 PHENYTOIN ................................................................. 84 PHENYTOIN SODIUM .................................................. 84 PHL-AMLODIPINE ........................................................ 55 PHL-ATENOLOL ........................................................... 49 PHL-ATENOLOL ........................................................... 50 PHL-AZITHROMYCIN ..................................................... 9 PHL-BACLOFEN ........................................................... 27 PHL-CARVEDILOL ....................................................... 51 PHL-CITALOPRAM ....................................................... 91 PHL-CLONAZEPAM ..................................................... 84 PHL-CLONAZEPAM-R .................................................. 84 PHL-FLUOXETINE........................................................ 92 PHL-ONDANSETRON ................................................ 143 PHL-PIOGLITAZONE ......................................... SEC 3.72 PHL-RANITIDINE ........................................................ 145 PHL-RISPERIDONE ................................................... 102 PHL-RISPERIDONE ................................................... 103 PHL-SERTRALINE........................................................ 93 PHL-SERTRALINE........................................................ 94 PHL-SIMVASTATIN ...................................................... 42 PHL-SIMVASTATIN ...................................................... 43 PHL-TOPIRAMATE ....................................................... 88 PHOSPHATE-NOVARTIS ........................................... 125 PHYTONADIONE........................................................ 185 PILOCARPINE HCL .................................................... 137 PILOCARPINE HCL ...................................................... 23 PILOPINE HS .............................................................. 137 PIMOZIDE ................................................................... 108 PINAVERIUM BROMIDE ............................................ 149 PINDOLOL .................................................................... 53 PINDOLOL/ HYDROCHLOROTHIAZIDE ...................... 53 PIOGLITAZONE HCL ......................................... SEC 3.72 PIOGLITAZONE HYDROCHLORIDE ................ SEC 3.72 PIPERACILLIN AND TAZOBACTAM ................. SEC 3.73 PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM
....................................................................... SEC 3.73 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
....................................................................... SEC 3.73 PIPORTIL L4 ............................................................... 106 PIPOTIAZINE PALMITATE ......................................... 106 PIPRADROL HCL/ THIAMINE HCL/ RIBOFLAVIN/
PYRIDOXINE HCL/ NIACINAMIDE/ CHOLINE/ INOSITOL ............................................................... 186
PIROXICAM .................................................................. 76 PIZOTIFEN MALATE .................................................. 116
PIZOTIFEN MALATE ................................................... 120 PLAN B ........................................................................ 159 PLAQUENIL SULFATE .................................................. 18 PLAVIX .......................................................................... 32 PLAVIX .............................................................. SEC 3.20 PLENDIL ........................................................................ 55 PLENDIL ........................................................................ 56 PMS - POTASSIUM CHLORIDE .................................. 125 PMS-ALENDRONATE-FC ................................. SEC 3.14 PMS-AMANTADINE HYDROCHLORIDE .................... 116 PMS-AMIODARONE ...................................................... 36 PMS-AMLODIPINE ........................................................ 55 PMS-AMOXICILLIN ....................................................... 10 PMS-AMOXICILLIN ....................................................... 11 PMS-ATENOLOL ........................................................... 49 PMS-ATENOLOL ........................................................... 50 PMS-ATORVASTATIN ................................................... 38 PMS-AZITHROMYCIN .....................................................9 PMS-AZITHROMYCIN ....................................... SEC 3.17 PMS-BACLOFEN ........................................................... 27 PMS-BENZTROPINE ................................................... 117 PMS-BENZYDAMINE .................................................. 135 PMS-BISOPROLOL ....................................................... 50 PMS-BRIMONIDINE .................................................... 135 PMS-BUPROPION SR ................................................... 97 PMS-BUSPIRONE ....................................................... 112 PMS-CARBAMAZEPINE ............................................... 85 PMS-CARBAMAZEPINE-CR ......................................... 85 PMS-CARVEDILOL ....................................................... 51 PMS-CHLORAL HYDRATE ......................................... 112 PMS-CILAZAPRIL .......................................................... 59 PMS-CIPROFLOXACIN ............................................... 131 PMS-CIPROFLOXACIN ..................................... SEC 3A.2 PMS-CIPROFLOXACIN ..................................... SEC 3A.3 PMS-CITALOPRAM ....................................................... 91 PMS-CLARITHROMYCIN ................................................9 PMS-CLOBAZAM .......................................................... 83 PMS-CLONAZEPAM ..................................................... 84 PMS-CLONAZEPAM-R .................................................. 84 PMS-CLOPIDOGREL .................................................... 32 PMS-CLOPIDOGREL ........................................ SEC 3.20 PMS-CYCLOBENZAPRINE ........................................... 27 PMS-DEFEROXAMINE ............................................... 153 PMS-DESMOPRESSIN ............................................... 167 PMS-DESONIDE ......................................................... 177 PMS-DEXAMETHASONE ............................................ 156 PMS-DEXAMETHASONE SODIUM PHOSP ............... 156 PMS-DICLOFENAC ....................................................... 72 PMS-DICLOFENAC-SR ................................................. 72 PMS-DILTIAZEM CD ..................................................... 56 PMS-DILTIAZEM CD ..................................................... 57 PMS-DOMPERIDONE ................................................. 148
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 215 EFFECTIVE JULY 1, 2012
PMS-DOXAZOSIN ........................................................ 47 PMS-ENALAPRIL.......................................................... 60 PMS-ERYTHROMYCIN .............................................. 131 PMS-FENOFIBRATE MICRO ....................................... 37 PMS-FENTANYL MTX ....................................... SEC 3.39 PMS-FENTANYL MTX ....................................... SEC 3.40 PMS-FINASTERIDE ........................................... SEC 3.41 PMS-FLUCONAZOLE ................................................... 15 PMS-FLUOROMETHOLONE ...................................... 132 PMS-FLUOXETINE ....................................................... 92 PMS-FLUTAMIDE .............................................. SEC 3.42 PMS-FLUVOXAMINE .................................................... 92 PMS-GABAPENTIN ...................................................... 86 PMS-GEMFIBROZIL ..................................................... 37 PMS-GLYBURIDE....................................................... 166 PMS-HYDROCHLOROTHIAZIDE ............................... 126 PMS-HYDROMORPHONE ........................................... 78 PMS-HYDROMORPHONE ........................................... 79 PMS-HYDROXYZINE ................................................. 113 PMS-INDAPAMIDE ..................................................... 127 PMS-IPRATROPIUM .................................................... 24 PMS-IPRATROPIUM ......................................... SEC 3.55 PMS-IPRATROPIUM (1ML) ............................... SEC 3.55 PMS-IPRATROPIUM (2ML) ............................... SEC 3.55 PMS-IRBESARTAN ...................................................... 66 PMS-IRBESARTAN-HCTZ ............................................ 66 PMS-IRBESARTAN-HCTZ ............................................ 67 PMS-ISMN .................................................................... 46 PMS-KETOPROFEN ..................................................... 74 PMS-LACTULOSE ...................................................... 125 PMS-LAMOTRIGINE ..................................................... 87 PMS-LEVETIRACETAM ............................................... 87 PMS-LEVOBUNOLOL ................................................. 136 PMS-LEVOFLOXACIN ....................................... SEC 3A.4 PMS-LISINOPRIL.......................................................... 61 PMS-LISINOPRIL.......................................................... 62 PMS-LITHIUM CARBONATE ...................................... 114 PMS-LORAZEPAM ..................................................... 111 PMS-LOSARTAN .......................................................... 67 PMS-LOVASTATIN ....................................................... 39 PMS-METFORMIN...................................................... 163 PMS-METHYLPHENIDATE ........................................ 109 PMS-METOCLOPRAMIDE ......................................... 148 PMS-METOCLOPRAMIDE ......................................... 149 PMS-METOPROLOL-L ................................................. 52 PMS-MINOCYCLINE .................................................... 13 PMS-MIRTAZAPINE ..................................................... 98 PMS-MONTELUKAST ................................................ 129 PMS-MONTELUKAST ....................................... SEC 3.60 PMS-MONTELUKAST FC ........................................... 129 PMS-MONTELUKAST FC .................................. SEC 3.60 PMS-NABILONE ......................................................... 144
PMS-NAPROXEN .......................................................... 75 PMS-NAPROXEN EC .................................................... 75 PMS-NIZATIDINE ........................................................ 145 PMS-NORFLOXACIN .................................................... 12 PMS-NORTRIPTYLINE ................................................. 96 PMS-NYSTATIN ............................................................ 16 PMS-OFLOXACIN ....................................................... 131 PMS-OLANZAPINE ..................................................... 100 PMS-OLANZAPINE ....................................................... 99 PMS-OLANZAPINE ODT ............................................. 100 PMS-OMEPRAZOLE (SUSTAINED-RELEASE
CAPSULE) ............................................................... 147 PMS-OMEPRAZOLE DR (DELAYED RELEASE TABLET)
................................................................................. 147 PMS-ONDANSETRON ................................................ 143 PMS-OXTRIPHYLLINE ................................................ 183 PMS-OXYBUTYNIN ..................................................... 183 PMS-OXYCODONE ....................................................... 82 PMS-PANTOPRAZOLE ............................................... 148 PMS-PAROXETINE ....................................................... 93 PMS-PINDOLOL ............................................................ 53 PMS-PIOGLITAZONE ........................................ SEC 3.72 PMS-PIROXICAM .......................................................... 76 PMS-PRAMIPEXOLE .................................................. 119 PMS-PRAVASTATIN ..................................................... 40 PMS-PREDNISOLONE ................................................ 158 PMS-PROCYCLIDINE ................................................. 117 PMS-QUETIAPINE ...................................................... 100 PMS-QUETIAPINE ...................................................... 101 PMS-RABEPRAZOLE EC ............................................ 148 PMS-RALOXIFENE ........................................... SEC 3.74 PMS-RAMIPRIL (CAPSULE) ......................................... 63 PMS-RAMIPRIL (CAPSULE) ......................................... 64 PMS-RAMIPRIL-HCTZ .................................................. 64 PMS-RANITIDINE ........................................................ 145 PMS-REPAGLINIDE .................................................... 165 PMS-RISEDRONATE ........................................ SEC 3.75 PMS-RISPERIDONE ................................................... 102 PMS-RISPERIDONE ................................................... 103 PMS-RISPERIDONE ................................................... 104 PMS-RISPERIDONE ODT ........................................... 104 PMS-RIVASTIGMINE ........................................ SEC 3.78 PMS-ROPINIROLE ...................................................... 119 PMS-ROPINIROLE ...................................................... 120 PMS-ROSUVASTATIN .................................................. 41 PMS-SALBUTAMOL ...................................................... 25 PMS-SALBUTAMOL POLYNEB .................................... 25 PMS-SERTRALINE ........................................................ 93 PMS-SERTRALINE ........................................................ 94 PMS-SIMVASTATIN ...................................................... 42 PMS-SIMVASTATIN ...................................................... 43 PMS-SODIUM CROMOGLYCATE .............................. 130
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 216
PMS-SODIUM POLYSTYRENE SULF. ...................... 126 PMS-SOTALOL ............................................................. 54 PMS-SULFASALAZINE ................................................ 13 PMS-SUMATRIPTAN .................................................. 115 PMS-SUMATRIPTAN ......................................... SEC 3.84 PMS-TERAZOSIN ......................................................... 48 PMS-TERBINAFINE ...................................................... 15 PMS-TIMOLOL ........................................................... 136 PMS-TOBRAMYCIN ................................................... 131 PMS-TOPIRAMATE ...................................................... 88 PMS-TRAZODONE ....................................................... 94 PMS-URSODIOL C ..................................................... 141 PMS-VALACYCLOVIR (CAPLET) ................................ 18 PMS-VALPROIC ACID .................................................. 89 PMS-VALPROIC ACID E.C. .......................................... 89 PMS-VANCOMYCIN ..................................................... 14 PMS-VENLAFAXINE XR ............................................... 90 PMS-VERAPAMIL SR ................................................... 58 PMS-ZOLMITRIPTAN ................................................. 116 PMS-ZOLMITRIPTAN ........................................ SEC 3.95 PMS-ZOLMITRIPTAN ODT ........................................ 116 PMS-ZOLMITRIPTAN ODT ............................... SEC 3.95 PMS-ZOPICLONE....................................................... 113 PODOFILOX ............................................................... 181 PORTIA 21 .................................................................. 159 PORTIA 28 .................................................................. 159 POTABA ...................................................................... 180 POTASSIUM CHLORIDE (K+) .................................... 125 POTASSIUM CHLORIDE (K+)(CL-) ............................ 125 POTASSIUM CITRATE (K+) ....................................... 125 PRADAX ............................................................ SEC 3.22 PRAMIPEXOLE .......................................................... 119 PRAMIPEXOLE DIHYDROCHLORIDE ....................... 119 PRAVACHOL ................................................................ 40 PRAVASTATIN ............................................................. 40 PRAVASTATIN SODIUM .............................................. 40 PRAZOSIN HCL ............................................................ 47 PRED FORTE ............................................................. 133 PRED MILD ................................................................. 133 PREDNISOLONE ACETATE ...................................... 133 PREDNISOLONE ACETATE/ SULFACETAMIDE
SODIUM .................................................................. 133 PREDNISOLONE SODIUM PHOSPHATE ................. 158 PREDNISONE ............................................................ 158 PREMARIN ................................................................. 161 PREVACID .................................................................. 147 PREVEX B .................................................................. 176 PREVEX HC ............................................................... 177 PRIMAQUINE PHOSPHATE ........................................ 18 PRIMAXIN .......................................................... SEC 3.47 PRIMIDONE .................................................................. 83 PRINIVIL ....................................................................... 61
PRINIVIL ........................................................................ 62 PRINZIDE ...................................................................... 62 PROBENECID ............................................................. 127 PROCAINAMIDE HCL ................................................... 35 PROCAN SR .................................................................. 35 PROCHLORPERAZINE ............................................... 142 PROCTODAN-HC ........................................................ 178 PROCTOFOAM-HC ..................................................... 178 PROCTOL .................................................................... 179 PROCTOSEDYL .......................................................... 179 PROCYCLIDINE HCL .................................................. 117 PROGESTERONE ....................................................... 167 PROGLYCEM ................................................................ 44 PROLIA .............................................................. SEC 3.24 PROLOPA 100-25 ........................................................ 117 PROLOPA 200-50 ........................................................ 117 PROLOPA 50-12.5 ....................................................... 117 PROMETHAZINE .............................................................3 PROMETHAZINE HCL ....................................................3 PROMETRIUM............................................................. 167 PROPADERM .............................................................. 175 PROPAFENONE HCL ................................................... 35 PROPARACAINE HCL ................................................ 134 PROPRANOLOL HCL .................................................... 53 PROPYL-THYRACIL .................................................... 169 PROPYLTHIOURACIL ................................................. 169 PROSCAR ......................................................... SEC 3.41 PROSTIGMIN ................................................................ 23 PROSTIN VR ................................................................. 46 PROTOPIC ........................................................ SEC 3.85 PROTOPIC ........................................................ SEC 3.86 PROVERA ................................................................... 167 PROZAC ........................................................................ 92 PULMICORT NEBUAMP ............................................. 155 PULMICORT TURBUHALER ....................................... 155 PYRIDOSTIGMINE BROMIDE ...................................... 23 PYRIMETHAMINE ......................................................... 18
Q
QUETIAPINE ............................................................... 100 QUETIAPINE ............................................................... 101 QUETIAPINE FUMARATE ........................................... 100 QUETIAPINE FUMARATE ........................................... 101 QUINAGOLIDE .................................................. SEC 3.73 QUINAPRIL HCL ............................................................ 63 QUINAPRIL HCL/ HYDROCHLOROTHIAZIDE ............. 63 QUININE SULFATE ....................................................... 19 QVAR CFC-FREE ........................................................ 155
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 217 EFFECTIVE JULY 1, 2012
R
RABEPRAZOLE EC .................................................... 148 RABEPRAZOLE SODIUM .......................................... 148 RALOXIFENE HCL ............................................ SEC 3.74 RAMIPRIL ..................................................................... 63 RAMIPRIL ..................................................................... 64 RAMIPRIL (CAPSULE) ................................................. 63 RAMIPRIL (CAPSULE) ................................................. 64 RAMIPRIL/ HYDROCHLOROTHIAZIDE ....................... 64 RAN-AMLODIPINE ....................................................... 55 RAN-ATENOLOL .......................................................... 49 RAN-ATENOLOL .......................................................... 50 RAN-ATORVASTATIN .................................................. 38 RAN-CARVEDILOL ....................................................... 51 RAN-CEFPROZIL ........................................................... 6 RAN-CIPROFLOX .............................................. SEC 3A.2 RAN-CIPROFLOX .............................................. SEC 3A.3 RAN-CITALO ................................................................ 91 RAN-DOMPERIDONE ................................................ 148 RAN-ENALAPRIL .......................................................... 60 RAN-FENTANYL MATRIX ................................. SEC 3.39 RAN-FENTANYL MATRIX ................................. SEC 3.40 RAN-FINASTERIDE ........................................... SEC 3.41 RAN-FOSINOPRIL ........................................................ 61 RAN-GABAPENTIN ...................................................... 86 RAN-IRBESARTAN HCTZ ............................................ 66 RAN-IRBESARTAN HCTZ ............................................ 67 RAN-LISINOPRIL .......................................................... 61 RAN-LISINOPRIL .......................................................... 62 RAN-METFORMIN ...................................................... 163 RAN-NABILONE ......................................................... 144 RAN-OMEPRAZOLE (DELAYED RELEASE TABLET)147 RAN-ONDANSETRON ................................................ 143 RAN-PANTOPRAZOLE .............................................. 148 RAN-PRAVASTATIN ..................................................... 40 RAN-RABEPRAZOLE ................................................. 148 RAN-RAMIPRIL (CAPSULE) ........................................ 63 RAN-RAMIPRIL (CAPSULE) ........................................ 64 RAN-RANITIDINE ....................................................... 145 RAN-RISPERIDONE ................................................... 102 RAN-RISPERIDONE ................................................... 103 RAN-ROPINIROLE ..................................................... 119 RAN-ROPINIROLE ..................................................... 120 RAN-ROSUVASTATIN .................................................. 41 RAN-SERTRALINE ....................................................... 93 RAN-SERTRALINE ....................................................... 94 RAN-SIMVASTATIN ...................................................... 42 RAN-SIMVASTATIN ...................................................... 43 RAN-VALSARTAN ........................................................ 69 RAN-VENLAFAXINE XR ............................................... 90
RAN-ZOPICLONE ........................................................ 113 RANIBIZUMAB............................................................. 139 RANITIDINE ................................................................. 145 RANITIDINE ................................................................. 146 RANITIDINE HCL ......................................................... 145 RANITIDINE HCL ......................................................... 146 RATIO-ACLAVULANATE ............................................... 11 RATIO-ACLAVULANATE 125F...................................... 11 RATIO-ACLAVULANATE 250F...................................... 11 RATIO-ACYCLOVIR ...................................................... 17 RATIO-ALENDRONATE .................................... SEC 3.14 RATIO-AMCINONIDE .................................................. 175 RATIO-AMIODARONE .................................................. 36 RATIO-AMLODIPINE ..................................................... 55 RATIO-ATENOLOL ........................................................ 49 RATIO-ATENOLOL ........................................................ 50 RATIO-ATORVASTATIN ............................................... 38 RATIO-AZITHROMYCIN ..................................................9 RATIO-BACLOFEN ........................................................ 27 RATIO-BRIMONIDINE ................................................. 135 RATIO-BUPROPION SR ............................................... 97 RATIO-CARVEDILOL .................................................... 51 RATIO-CEFUROXIME .....................................................7 RATIO-CIPROFLOXACIN .................................. SEC 3A.2 RATIO-CIPROFLOXACIN .................................. SEC 3A.3 RATIO-CITALOPRAM .................................................... 91 RATIO-CLARITHROMYCIN .............................................9 RATIO-CLOBETASOL ................................................. 176 RATIO-CLONAZEPAM .................................................. 84 RATIO-CODEINE ........................................................... 77 RATIO-DEXAMETHASONE ........................................ 156 RATIO-DILTIAZEM CD .................................................. 56 RATIO-DILTIAZEM CD .................................................. 57 RATIO-DOMPERIDONE MALEATE ............................ 148 RATIO-ECTOSONE MILD ........................................... 176 RATIO-ECTOSONE REGULAR ................................... 176 RATIO-ECTOSONE SCALP ........................................ 176 RATIO-EMTEC-30 ......................................................... 77 RATIO-FENOFIBRATE MC ........................................... 37 RATIO-FENTANYL ............................................ SEC 3.39 RATIO-FENTANYL ............................................ SEC 3.40 RATIO-FINASTERIDE ....................................... SEC 3.41 RATIO-FLUOXETINE HYDROCHLORIDE .................... 92 RATIO-FLUVOXAMINE ................................................. 92 RATIO-GABAPENTIN .................................................... 86 RATIO-GENTAMICIN SULFATE ................................. 173 RATIO-GLYBURIDE .................................................... 166 RATIO-HEMCORT H.C. ............................................... 178 RATIO-INDOMETHACIN ............................................... 73 RATIO-IPRA SAL UDV .................................................. 24 RATIO-IPRATROPIUM UDV.............................. SEC 3.55 RATIO-IRBESARTAN .................................................... 66
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 218
RATIO-IRBESARTAN HCTZ ......................................... 66 RATIO-IRBESARTAN HCTZ ......................................... 67 RATIO-KETOROLAC .................................................. 134 RATIO-LACTULOSE ................................................... 125 RATIO-LAMOTRIGINE ................................................. 87 RATIO-LENOLTEC NO.2 .............................................. 77 RATIO-LENOLTEC NO.3 .............................................. 77 RATIO-LENOLTEC NO.4 .............................................. 77 RATIO-LEVOBUNOLOL ............................................. 136 RATIO-LISINOPRIL P ................................................... 61 RATIO-LISINOPRIL P ................................................... 62 RATIO-LISINOPRIL Z ................................................... 61 RATIO-LISINOPRIL Z ................................................... 62 RATIO-LOVASTATIN .................................................... 39 RATIO-METFORMIN HYDROCHLORIDE .................. 163 RATIO-METHOTREXATE SODIUM ............................. 21 RATIO-MOMETASONE .............................................. 178 RATIO-MORPHINE ....................................................... 79 RATIO-NYSTATIN ........................................................ 16 RATIO-OMEPRAZOLE (SUSTAINED-RELEASE
TABLET) ................................................................. 147 RATIO-ONDANSETRON ............................................ 143 RATIO-OXYCOCET ...................................................... 82 RATIO-OXYCODAN ...................................................... 83 RATIO-PAROXETINE ................................................... 93 RATIO-PIOGLITAZONE ..................................... SEC 3.72 RATIO-PREDNISOLONE ............................................ 133 RATIO-PROCTOSONE ............................................... 179 RATIO-RANITIDINE .................................................... 145 RATIO-RISEDRONATE ..................................... SEC 3.75 RATIO-RIVASTIGMINE ..................................... SEC 3.78 RATIO-SALBUTAMOL .................................................. 25 RATIO-SALBUTAMOL SULF U.D.P.F. ......................... 25 RATIO-SALBUTAMOL UNI DOSE P.F. ........................ 25 RATIO-SALBUTAMOL UNIT DOSE P.F ....................... 25 RATIO-SOTALOL.......................................................... 54 RATIO-TAMSULOSIN ................................................... 48 RATIO-TECNAL ............................................................ 71 RATIO-TECNAL-C 1/2 .................................................. 76 RATIO-TECNAL-C 1/4 .................................................. 76 RATIO-TERAZOSIN ...................................................... 48 RATIO-TOPILENE ...................................................... 175 RATIO-TOPISALIC ..................................................... 175 RATIO-TOPISONE...................................................... 175 RATIO-TRYPTOPHAN .................................................. 97 RATIO-VALPROIC ........................................................ 89 RATIO-VENLAFAXINE XR ........................................... 90 RATIO-ZOPICLONE ................................................... 113 REBIF (0.5 ML SYRINGE) ................................... SEC 2.4 REBIF (1.5 ML CARTRIDGE) .............................. SEC 2.4 RECOMBIVAX-HB ...................................................... 171 REMERON .................................................................... 98
REMICADE ........................................................ SEC 3.55 REMINYL ER ..................................................... SEC 3.42 RENEDIL ....................................................................... 55 RENEDIL ....................................................................... 56 REPAGLINIDE ............................................................. 165 REQUIP ....................................................................... 119 REQUIP ....................................................................... 120 RESONIUM CALCIUM ................................................. 125 RESTORIL ................................................................... 112 RHINOCORT TURBUHALER ...................................... 132 RHO-NITRO PUMPSPRAY ........................................... 46 RHOTRAL ...................................................................... 49 RHOVANE ................................................................... 113 RIDAURA ..................................................................... 151 RIFABUTIN ........................................................ SEC 3.74 RILUTEK ............................................................ SEC 3.74 RILUZOLE ......................................................... SEC 3.74 RIMSO-50 .................................................................... 188 RISEDRONATE ................................................. SEC 3.75 RISEDRONATE SODIUM .................................. SEC 3.75 RISPERDAL ................................................................. 102 RISPERDAL ................................................................. 103 RISPERDAL ................................................................. 104 RISPERDAL CONSTA ....................................... SEC 3.76 RISPERDAL M-TAB ..................................................... 104 RISPERIDONE ............................................................ 102 RISPERIDONE ............................................................ 103 RISPERIDONE ............................................................ 104 RISPERIDONE .................................................. SEC 3.76 RISPERIDONE TARTRATE ........................................ 104 RITALIN ....................................................................... 109 RITALIN SR ................................................................. 109 RITUXAN ........................................................... SEC 3.77 RITUXIMAB........................................................ SEC 3.77 RIVAROXABAN ............................................................. 32 RIVASTIGMINE HYDROGEN TARTRATE ........ SEC 3.78 RIVOTRIL ...................................................................... 84 RIZATRIPTAN BENZOATE ......................................... 114 RIZATRIPTAN BENZOATE ......................................... 115 RIZATRIPTAN BENZOATE ............................... SEC 3.79 ROCALTROL ............................................................... 185 ROPINIROLE ............................................................... 119 ROPINIROLE ............................................................... 120 ROPINIROLE HCL ....................................................... 119 ROPINIROLE HCL ....................................................... 120 ROSASOL .................................................................... 173 ROSIGLITAZONE MALEATE ............................ SEC 3.79 ROSIGLITAZONE MALEATE/ METFORMIN HCL
....................................................................... SEC 3.80 ROSUVASTATIN CALCIUM .......................................... 41 ROUGIER MAGNESIUM ............................................. 125 RYTHMODAN ................................................................ 35
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 219 EFFECTIVE JULY 1, 2012
RYTHMOL ..................................................................... 35
S
SABRIL ......................................................................... 89 SAIZEN .............................................................. SEC 3.82 SAIZEN (1.5 ML) ................................................ SEC 3.82 SAIZEN (2.5 ML) ................................................ SEC 3.82 SALAGEN ..................................................................... 23 SALAZOPYRIN ............................................................. 13 SALAZOPYRIN EN-TABS ............................................. 13 SALBUTAMOL .............................................................. 25 SALBUTAMOL SULFATE ............................................. 25 SALMETEROL XINAFOATE ......................................... 25 SALMETEROL XINAFOATE/ FLUTICASONE
PROPIONATE ........................................................... 25 SALMETEROL XINAFOATE/ FLUTICASONE
PROPIONATE ........................................................... 26 SALOFALK .................................................................. 149 SALOFALK (2G/60G) .................................................. 149 SALOFALK (4G/60G) .................................................. 149 SANDOMIGRAN ......................................................... 116 SANDOMIGRAN DS ................................................... 120 SANDOSTATIN .................................................. SEC 3.61 SANDOSTATIN LAR .......................................... SEC 3.61 SANDOSTATIN LAR .......................................... SEC 3.62 SANDOZ FLUOXETINE ............................................... 92 SANDOZ GLYBURIDE ............................................... 166 SANDOZ ALENDRONATE ................................ SEC 3.14 SANDOZ ALFUZOSIN ....................................... SEC 3.15 SANDOZ AMIODARONE .............................................. 36 SANDOZ AMLODIPINE ................................................ 55 SANDOZ ANUZINC HC .............................................. 178 SANDOZ ANUZINC HC PLUS .................................... 178 SANDOZ ATENOLOL ................................................... 49 SANDOZ ATENOLOL ................................................... 50 SANDOZ ATORVASTATIN ........................................... 38 SANDOZ AZITHROMYCIN ............................................. 9 SANDOZ BISOPROLOL ............................................... 50 SANDOZ BRIMONIDINE ............................................ 135 SANDOZ BUPROPION SR ........................................... 97 SANDOZ CALCITONIN NS ................................ SEC 3.85 SANDOZ CANDESARTAN ........................................... 65 SANDOZ CARBAMAZEPINE ........................................ 85 SANDOZ CARBAMAZEPINE CR.................................. 85 SANDOZ CEFPROZIL .................................................... 6 SANDOZ CIPROFLOXACIN .............................. SEC 3A.2 SANDOZ CIPROFLOXACIN .............................. SEC 3A.3 SANDOZ CITALOPRAM ............................................... 91 SANDOZ CLARITHROMYCIN ........................................ 9
SANDOZ CLONAZEPAM .............................................. 84 SANDOZ CLOPIDOGREL ............................................. 32 SANDOZ CLOPIDOGREL ................................. SEC 3.20 SANDOZ CYCLOSPORINE ............................... SEC 3.21 SANDOZ DEXAMETHASONE SOD. PHOSPHATE .... 132 SANDOZ DICLOFENAC ................................................ 72 SANDOZ DICLOFENAC SR .......................................... 72 SANDOZ DILTIAZEM CD .............................................. 56 SANDOZ DILTIAZEM CD .............................................. 57 SANDOZ DILTIAZEM T ................................................. 57 SANDOZ DILTIAZEM T ................................................. 58 SANDOZ DORZOLAMIDE ........................................... 136 SANDOZ DORZOLAMIDE/ TIMOLOL ......................... 138 SANDOZ ENALAPRIL ................................................... 60 SANDOZ ESTRADIOL DERM 100 (8 MG/PTH) .......... 161 SANDOZ ESTRADIOL DERM 50 (4 MG/PTH) ............ 161 SANDOZ ESTRADIOL DERM 75 (6 MG/PTH) ............ 161 SANDOZ FELODIPINE .................................................. 55 SANDOZ FELODIPINE .................................................. 56 SANDOZ FENOFIBRATE S ........................................... 37 SANDOZ FENOFIBRATE S (TABLET) .......................... 37 SANDOZ FENTANYL PATCH ........................... SEC 3.39 SANDOZ FENTANYL PATCH ........................... SEC 3.40 SANDOZ FINASTERIDE ................................... SEC 3.41 SANDOZ FLUOXETINE ................................................. 92 SANDOZ FLUVOXAMINE ............................................. 92 SANDOZ GENTAMICIN SULFATE .............................. 131 SANDOZ GLYBURIDE ................................................ 166 SANDOZ INDOMETHACIN ........................................... 73 SANDOZ IRBESARTAN ................................................ 66 SANDOZ IRBESARTAN HCT ........................................ 66 SANDOZ IRBESARTAN HCT ........................................ 67 SANDOZ LATANOPROST .......................................... 137 SANDOZ LEFLUNOMIDE ............................................ 189 SANDOZ LEVOBUNOLOL .......................................... 136 SANDOZ LEVOFLOXACIN ................................ SEC 3A.4 SANDOZ LISINOPRIL ................................................... 61 SANDOZ LISINOPRIL ................................................... 62 SANDOZ LISINOPRIL HCT ........................................... 62 SANDOZ LOSARTAN .................................................... 67 SANDOZ LOSARTAN HCT ........................................... 67 SANDOZ LOSARTAN HCT DS...................................... 68 SANDOZ LOVASTATIN ................................................. 39 SANDOZ METFORMIN FC .......................................... 163 SANDOZ METHYLPHENIDATE .................................. 109 SANDOZ METOPROLOL (TYPE L) ............................... 52 SANDOZ METOPROLOL SR ........................................ 52 SANDOZ MINOCYCLINE .............................................. 13 SANDOZ MIRTAZAPINE ............................................... 98 SANDOZ MONTELUKAST .......................................... 129 SANDOZ MONTELUKAST ................................ SEC 3.60 SANDOZ MORPHINE SR .............................................. 80
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 220
SANDOZ NARATRIPTAN ........................................... 114 SANDOZ NARATRIPTAN .................................. SEC 3.61 SANDOZ NITRAZEPAM ............................................. 112 SANDOZ OLANZAPINE .............................................. 100 SANDOZ OLANZAPINE ................................................ 99 SANDOZ OLANZAPINE ODT ..................................... 100 SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE
CAPSULE) .............................................................. 147 SANDOZ ONDANSETRON ........................................ 143 SANDOZ OPIUM & BELLADONNA .............................. 81 SANDOZ OPTICORT .................................................. 133 SANDOZ PANTOPRAZOLE ....................................... 148 SANDOZ PAROXETINE ............................................... 93 SANDOZ PENTASONE .............................................. 133 SANDOZ PINDOLOL .................................................... 53 SANDOZ PIOGLITAZONE ................................. SEC 3.72 SANDOZ PRAMIPEXOLE ........................................... 119 SANDOZ PRAVASTATIN ............................................. 40 SANDOZ PREDNISOLONE ACETATE ...................... 133 SANDOZ PROCHLORPERAZINE .............................. 142 SANDOZ PROCTOMYXIN HC ................................... 179 SANDOZ QUETIAPINE ............................................... 100 SANDOZ QUETIAPINE ............................................... 101 SANDOZ RABEPRAZOLE .......................................... 148 SANDOZ RAMIPRIL (TABLET) .................................... 63 SANDOZ RAMIPRIL (TABLET) .................................... 64 SANDOZ RANITIDINE ................................................ 145 SANDOZ REPAGLINIDE ............................................ 165 SANDOZ RISEDRONATE ................................. SEC 3.75 SANDOZ RISPERIDONE ............................................ 102 SANDOZ RISPERIDONE ............................................ 103 SANDOZ RIVASTIGMINE .................................. SEC 3.78 SANDOZ RIZATRIPTAN ODT .................................... 114 SANDOZ RIZATRIPTAN ODT .................................... 115 SANDOZ RIZATRIPTAN ODT ........................... SEC 3.79 SANDOZ ROSUVASTATIN .......................................... 41 SANDOZ SALBUTAMOL .............................................. 25 SANDOZ SERTRALINE ................................................ 93 SANDOZ SERTRALINE ................................................ 94 SANDOZ SIMVASTATIN .............................................. 42 SANDOZ SIMVASTATIN .............................................. 43 SANDOZ SOTALOL ...................................................... 54 SANDOZ SUMATRIPTAN ........................................... 115 SANDOZ SUMATRIPTAN .................................. SEC 3.84 SANDOZ TAMSULOSIN ............................................... 48 SANDOZ TAMSULOSIN CR ......................................... 48 SANDOZ TELMISARTAN ............................................. 68 SANDOZ TERBINAFINE ............................................... 15 SANDOZ TICLOPIDINE ................................................ 33 SANDOZ TIMOLOL MALEATE ................................... 136 SANDOZ TOBRAMYCIN ............................................ 131 SANDOZ TOPIRAMATE ............................................... 88
SANDOZ TRIFLURIDINE ............................................ 131 SANDOZ VALPROIC ..................................................... 89 SANDOZ VALSARTAN .................................................. 69 SANDOZ VALSARTAN HCT.......................................... 69 SANDOZ VALSARTAN HCT.......................................... 70 SANDOZ VENLAFAXINE XR......................................... 90 SANDOZ ZOLMITRIPTAN ........................................... 116 SANDOZ ZOLMITRIPTAN ................................. SEC 3.95 SANDOZ ZOLMITRIPTAN ODT .................................. 116 SANDOZ ZOLMITRIPTAN ODT ........................ SEC 3.95 SANDOZ ZOPICLONE ................................................ 113 SANDOZ-OXYCODONE ACET ..................................... 82 SANTYL ....................................................................... 181 SARNA HC .................................................................. 177 SAXAGLIPTIN HCL ........................................... SEC 3.80 SECTRAL ...................................................................... 49 SELECT 1/35 (21 DAY) ............................................... 160 SELECT 1/35 (28 DAY) ............................................... 160 SELEGILINE HCL ........................................................ 120 SEPTA-AMLODIPINE .................................................... 55 SEPTA-ATENOLOL ....................................................... 49 SEPTA-ATENOLOL ....................................................... 50 SEPTA-CITALOPRAM ................................................... 91 SEPTA-ONDANSETRON ............................................ 143 SEPTRA ......................................................................... 12 SERC ........................................................................... 187 SEREVENT .................................................................... 25 SEREVENT DISKHALER ............................................ 191 SEREVENT DISKUS ..................................................... 25 SEROPHENE............................................................... 162 SEROQUEL ................................................................. 100 SEROQUEL ................................................................. 101 SERTRALINE................................................................. 93 SERTRALINE................................................................. 94 SERTRALINE HCL ........................................................ 93 SERTRALINE HCL ........................................................ 94 SIMPONI ............................................................ SEC 3.46 SIMVASTATIN ............................................................... 42 SIMVASTATIN ............................................................... 43 SIMVASTATIN-ODAN .................................................... 42 SIMVASTATIN-ODAN .................................................... 43 SINEMET 100/10 ......................................................... 118 SINEMET 100/25 ......................................................... 118 SINEMET 250/25 ......................................................... 118 SINEMET CR 100/25 ................................................... 118 SINEMET CR 200/50 ................................................... 118 SINEQUAN .................................................................... 95 SINEQUAN .................................................................... 96 SINGULAIR .................................................................. 129 SINGULAIR ........................................................ SEC 3.60 SINTROM ...................................................................... 29 SITAGLIPTIN PHOSPHATE MONOHYDRATE . SEC 3.81
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 221 EFFECTIVE JULY 1, 2012
SITAGLIPTIN PHOSPHATE MONOHYDRATE/ METFORMIN HCL ......................................... SEC 3.81
SLOW K ...................................................................... 125 SODIUM ACID PHOSPHATE/ SODIUM BICARBONATE/
POTASSIUM BICARBONATE ................................ 125 SODIUM AUROTHIOMALATE .................................... 151 SODIUM CROMOGLYCATE ...................................... 130 SODIUM FLUORIDE ................................................... 121 SODIUM FUSIDATE ................................................... 174 SODIUM POLYSTYRENE SULFONATE .................... 126 SODIUM TETRADECYL SULFATE .............................. 47 SOFRACORT .............................................................. 133 SOLIFENACIN SUCCINATE .............................. SEC 3.82 SOLIRIS ............................................................. SEC 3.30 SOLU-CORTEF .......................................................... 156 SOLU-CORTEF .......................................................... 157 SOLU-MEDROL .......................................................... 157 SOLU-MEDROL ACT-O-VIAL (PRESERVATIVE FREE)
................................................................................ 157 SOLU-MEDROL ACT-O-VIAL (WITH PRESERVATIVE)
................................................................................ 157 SOLYSTAT ................................................................. 126 SOMATROPIN ................................................... SEC 3.82 SOMATROPIN R-DNA ORIGIN ......................... SEC 3.82 SOMATULINE AUTOGEL (0.3 ML SYRINGE) .. SEC 3.56 SOMATULINE AUTOGEL (0.5 ML SYRINGE) .. SEC 3.56 SORIATANE ............................................................... 180 SOTALOL HCL ............................................................. 54 SPACE CHAMBER ..................................................... 191 SPACE CHAMBER ADULT MASK ............................. 191 SPACE CHAMBER INFANT MASK ............................ 191 SPACE CHAMBER PEDIATRIC MASK ...................... 191 SPIRIVA ........................................................................ 24 SPIRONOLACTONE ..................................................... 70 SPORANOX .................................................................. 15 SPORANOX ....................................................... SEC 3.55 STALEVO .................................................................... 118 STATEX ........................................................................ 80 STATEX ........................................................................ 81 STELARA (0.5 ML VIAL OR SYRINGE) ............ SEC 3.91 STIEVA-A ........................................................... SEC 3.89 STIEVA-A ........................................................... SEC 3.90 STIEVA-A FORTE .............................................. SEC 3.89 STIEVAMYCIN FORTE ...................................... SEC 3.32 STIEVAMYCIN MILD ......................................... SEC 3.32 STIEVAMYCIN REGULAR ................................. SEC 3.32 SUBOXONE .................................................................. 83 SUCRALFATE ............................................................ 146 SULCRATE ................................................................. 146 SULCRATE SUSPENSION PLUS .............................. 146 SULFACET-R ..................................................... SEC 3.83 SULFAMETHOXAZOLE/ TRIMETHOPRIM .................. 12
SULFASALAZINE .......................................................... 13 SULFINPYRAZONE ..................................................... 127 SULFUR/ SULFACETAMIDE SODIUM ............. SEC 3.83 SULINDAC ..................................................................... 76 SUMATRIPTAN ........................................................... 115 SUMATRIPTAN ................................................. SEC 3.84 SUMATRIPTAN HEMISULFATE ................................. 115 SUMATRIPTAN HEMISULFATE ....................... SEC 3.83 SUMATRIPTAN SUCCINATE ...................................... 115 SUMATRIPTAN SUCCINATE ............................ SEC 3.84 SUMATRIPTAN SUN (0.5 ML)..................................... 115 SUMATRIPTAN SUN (0.5 ML)........................... SEC 3.84 SUPEUDOL ................................................................... 82 SUPRAX ..........................................................................7 SUPREFACT ..................................................... SEC 3.18 SUPREFACT DEPOT ........................................ SEC 3.18 SUPREFACT INTRANASAL .............................. SEC 3.18 SYMBICORT 100 TURBUHALER .................................. 24 SYMBICORT 200 TURBUHALER .................................. 24 SYNACTHEN DEPOT .................................................. 166 SYNAREL .................................................................... 189 SYNPHASIC (21 DAY) ................................................. 160 SYNPHASIC (28 DAY) ................................................. 160 SYNTHETIC CALCITONIN SALMON (SALCATONIN)
................................................................................. 166 SYNTHETIC CALCITONIN SALMON (SALCATONIN)
....................................................................... SEC 3.85 SYNTHROID ................................................................ 168
T
TACROLIMUS.................................................... SEC 3.85 TACROLIMUS.................................................... SEC 3.86 TALWIN ......................................................................... 83 TAMBOCOR .................................................................. 35 TAMSULOSIN HCL ........................................................ 48 TAPAZOLE .................................................................. 169 TARO-AMCINONIDE ................................................... 175 TARO-CARBAMAZEPINE ............................................. 85 TARO-CLOBETASOL .................................................. 176 TARO-MOMETASONE ................................................ 178 TARO-MUPIROCIN ..................................................... 174 TARO-PHENYTOIN ....................................................... 84 TARO-WARFARIN ......................................................... 29 TARO-WARFARIN ......................................................... 30 TAZAROTENE ............................................................. 181 TAZOCIN ........................................................... SEC 3.73 TAZORAC .................................................................... 181 TECTA ......................................................................... 148 TEGRETOL .................................................................... 85 TEGRETOL CR .............................................................. 85
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 222
TELMISARTAN ............................................................. 68 TELMISARTAN/ AMLODIPINE BESYLATE .................. 68 TELMISARTAN/ HYDROCHLOROTHIAZIDE ............... 68 TEMAZEPAM .............................................................. 112 TENOFOVIR DISOPROXIL FUMARATE ...................... 16 TENORETIC 50/25....................................................... 50 TENORETIC 100/25...................................................... 50 TENORMIN ................................................................... 49 TENORMIN ................................................................... 50 TENOXICAM ................................................................. 76 TERAZOSIN .................................................................. 48 TERAZOSIN HCL.......................................................... 48 TERBINAFINE .............................................................. 15 TERBINAFINE HCL ...................................................... 15 TERBINAFINE HCL .................................................... 174 TERBUTALINE SULFATE ............................................ 26 TESTOSTERONE .............................................. SEC 3.86 TESTOSTERONE CYPIONATE ................................. 158 TESTOSTERONE ENANTHATE ................................ 158 TESTOSTERONE UNDECANOATE .................. SEC 3.86 TETRABENAZINE.............................................. SEC 3.87 TETRACYCLINE ........................................................... 13 TETRACYCLINE HCL ................................................... 13 TEVA-ALENDRONATE ...................................... SEC 3.14 TEVA-ALPRAZOL ....................................................... 110 TEVA-AMIODARONE ................................................... 36 TEVA-AMLODIPINE...................................................... 55 TEVA-ATENOL ............................................................. 49 TEVA-ATENOL ............................................................. 50 TEVA-ATENOLOL......................................................... 49 TEVA-ATENOLTHALIDONE ......................................... 50 TEVA-AZATHIOPRINE ............................................... 187 TEVA-CANDESARTAN ................................................. 65 TEVA-CARBAMAZ ........................................................ 85 TEVA-CHLORPROMAZINE ........................................ 105 TEVA-CLINDAMYCIN ................................................... 14 TEVA-CLOPIDOGREL .................................................. 32 TEVA-CLOPIDOGREL ....................................... SEC 3.20 TEVA-DOMPERIDONE ............................................... 148 TEVA-DORZOTIMOL .................................................. 138 TEVA-ENTACAPONE ................................................. 117 TEVA-FLUOXETINE ..................................................... 92 TEVA-FOSINOPRIL ...................................................... 61 TEVA-GABAPENTIN ..................................................... 86 TEVA-GALANTAMINE ER ................................. SEC 3.42 TEVA-GLYBURIDE ..................................................... 166 TEVA-HYDROMORPHONE .......................................... 78 TEVA-IRBESARTAN ..................................................... 66 TEVA-IRBESARTAN/HCTZ .......................................... 66 TEVA-IRBESARTAN/HCTZ .......................................... 67 TEVA-LACTULOSE .................................................... 125 TEVA-LISINOPRIL (TYPE P) ........................................ 61
TEVA-LISINOPRIL (TYPE P) ......................................... 62 TEVA-LISINOPRIL/HCTZ (TYPE Z) .............................. 62 TEVA-LOSARTAN ......................................................... 67 TEVA-LOSARTAN/HCTZ ............................................... 67 TEVA-LOSARTAN/HCTZ ............................................... 68 TEVA-METOPROL ........................................................ 52 TEVA-METOPROL (FC) ................................................ 52 TEVA-MONTELUKAST ................................................ 129 TEVA-MONTELUKAST ...................................... SEC 3.60 TEVA-NAPROX ............................................................. 74 TEVA-NAPROX EC ....................................................... 75 TEVA-NAPROX SODIUM .............................................. 75 TEVA-NAPROX SODIUM DS ........................................ 75 TEVA-OLANZAPINE .................................................... 100 TEVA-OLANZAPINE ...................................................... 99 TEVA-OLANZAPINE OD ............................................. 100 TEVA-ONDANSETRON ............................................... 143 TEVA-PAROXETINE ..................................................... 93 TEVA-RABEPRAZOLE ................................................ 148 TEVA-RAMIPRIL (CAPSULE)........................................ 63 TEVA-RAMIPRIL (CAPSULE)........................................ 64 TEVA-ROSUVASTATIN ................................................. 41 TEVA-SERTRALINE ...................................................... 93 TEVA-SERTRALINE ...................................................... 94 TEVA-SIMVASTATIN ..................................................... 42 TEVA-SIMVASTATIN ..................................................... 43 TEVA-TAMSULOSIN CR ............................................... 48 TEVA-TELMISARTAN ................................................... 68 TEVA-TELMISARTAN HCTZ ......................................... 68 TEVA-TERAZOSIN ........................................................ 48 TEVA-TRAZODONE ...................................................... 94 TEVA-VALSARTAN ....................................................... 69 TEVA-VALSARTAN/HCTZ ............................................. 69 TEVA-VALSARTAN/HCTZ ............................................. 70 TEVA-VENLAFAXINE XR .............................................. 90 TEVA-ZOLMITRIPTAN ................................................ 116 TEVA-ZOLMITRIPTAN ...................................... SEC 3.95 TEVA-ZOLMITRIPTAN OD .......................................... 116 TEVA-ZOLMITRIPTAN OD ................................ SEC 3.95 TEVETEN ...................................................................... 65 TEVETEN PLUS ............................................................ 65 THEOLAIR ................................................................... 183 THEOPHYLLINE .......................................................... 183 THIAMIJECT ................................................................ 185 THIAMINE HCL ............................................................ 185 THIOPROPERAZINE MESYLATE ............................... 106 THIOTHIXENE ............................................................. 107 THYROGEN ................................................................. 123 THYROID ..................................................................... 168 THYROTROPIN ALFA ................................................. 123 TIAMOL ........................................................................ 177 TIAPROFENIC ACID ..................................................... 76
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 223 EFFECTIVE JULY 1, 2012
TIAZAC ......................................................................... 57 TIAZAC ......................................................................... 58 TIAZAC XC ................................................................... 56 TICLOPIDINE HCL........................................................ 33 TIMOLOL MALEATE ................................................... 136 TIMOLOL MALEATE ..................................................... 54 TIMOPTIC ................................................................... 136 TIMOPTIC-XE ............................................................. 136 TINZAPARIN SODIUM .................................................. 31 TINZAPARIN SODIUM .................................................. 32 TIOTROPIUM BROMIDE MONOHYDRATE ................. 24 TIZANIDINE HCL ............................................... SEC 3.87 TOBI ................................................................................ 5 TOBI PODHALER ........................................................... 5 TOBRADEX ................................................................ 133 TOBRAMYCIN ............................................................ 131 TOBRAMYCIN ................................................................ 5 TOBRAMYCIN SULFATE ............................................... 5 TOBREX ..................................................................... 131 TOCILIZUMAB ................................................... SEC 3.89 TOLOXIN ...................................................................... 36 TOLOXIN PEDIATRIC .................................................. 36 TOLTERODINE L-TARTRATE ........................... SEC 3.89 TOPAMAX ..................................................................... 88 TOPAMAX SPRINKLE .................................................. 88 TOPICORT .................................................................. 177 TOPICORT MILD ........................................................ 177 TOPIRAMATE ............................................................... 88 TORADOL ..................................................................... 74 TRAJENTA ......................................................... SEC 3.57 TRANDATE ................................................................... 51 TRANDOLAPRIL ........................................................... 64 TRANDOLAPRIL ........................................................... 65 TRANEXAMIC ACID ..................................................... 33 TRANSDERM-NITRO 0.2 ............................................. 46 TRANSDERM-NITRO 0.4 ............................................. 46 TRANSDERM-NITRO 0.6 ............................................. 46 TRANYLCYPROMINE SULFATE ................................. 89 TRAVATAN Z .............................................................. 137 TRAVOPROST ........................................................... 137 TRAVOPROST/ TIMOLOL MALEATE ........................ 138 TRAZODONE ................................................................ 94 TRAZODONE HCL........................................................ 94 TRENTAL ...................................................................... 33 TRETINOIN ........................................................ SEC 3.89 TRETINOIN ........................................................ SEC 3.90 TRI-CYCLEN (21 DAY) ............................................... 160 TRI-CYCLEN (28 DAY) ............................................... 160 TRI-CYCLEN LO 21 .................................................... 160 TRI-CYCLEN LO 28 .................................................... 160 TRIADERM REGULAR ............................................... 179 TRIAMCINOLONE ACETONIDE................................. 158
TRIAMCINOLONE ACETONIDE ................................. 179 TRIAMCINOLONE ACETONIDE USP ......................... 158 TRIAZOLAM................................................................. 112 TRIFLUOPERAZINE .................................................... 107 TRIFLUOPERAZINE HCL ............................................ 107 TRIFLURIDINE ............................................................ 131 TRIHEXYPHENIDYL .................................................... 117 TRIHEXYPHENIDYL HCL ........................................... 117 TRIMEBUTINE ............................................................. 150 TRIMEBUTINE MALEATE ........................................... 150 TRIMEPRAZINE TARTRATE...........................................3 TRIMETHOPRIM ........................................................... 19 TRIMIPRAMINE ............................................................. 96 TRIMIPRAMINE ............................................................. 97 TRIMIPRAMINE MALEATE ........................................... 96 TRIMIPRAMINE MALEATE ........................................... 97 TRINIPATCH 0.2 ............................................................ 46 TRINIPATCH 0.4 ............................................................ 46 TRINIPATCH 0.6 ............................................................ 46 TRIQUILAR (21 DAY) .................................................. 159 TRIQUILAR (28 DAY) .................................................. 159 TROMBOJECT .............................................................. 47 TROPICAMIDE ............................................................ 134 TROSEC ............................................................ SEC 3.90 TROSPIUM CHLORIDE ..................................... SEC 3.90 TRUSOPT .................................................................... 136 TRUSOPT (PRESERVATIVE-FREE) .......................... 136 TRYPTAN ...................................................................... 97 TWINJECT AUTO INJECTOR ....................................... 26 TWYNSTA ..................................................................... 68 TYLENOL NO. 2 ............................................................ 77 TYLENOL NO. 3 ............................................................ 77 TYLENOL NO. 4 ............................................................ 77 TYLENOL WITH CODEINE ........................................... 77 TYSABRI .............................................................. SEC 2.7
U
ULORIC ............................................................. SEC 3.39 ULTRASE MS4 MICROSPHERES .............................. 141 ULTRASE MT12 MINITABLETS .................................. 141 ULTRASE MT20 MINITABLETS .................................. 141 ULTRAVATE ................................................................ 177 UNIPHYL ..................................................................... 183 UREMOL-HC ............................................................... 178 URINE TEST STRIPS ......................................................1 UROMAX ........................................................... SEC 3.64 URSO ........................................................................... 141 URSO DS ..................................................................... 141 URSODIOL .................................................................. 141
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 224
USTEKINUMAB ................................................. SEC 3.91
V
VAGIFEM .................................................................... 161 VAL-VANCO ................................................................. 14 VALACYCLOVIR ........................................................... 18 VALCYTE ........................................................... SEC 3.92 VALGANCICLOVIR HCL .................................... SEC 3.92 VALISONE SCALP...................................................... 176 VALPROIC ACID........................................................... 89 VALSARTAN ................................................................. 69 VALSARTAN/ HYDROCHLOROTHIAZIDE .................. 69 VALSARTAN/ HYDROCHLOROTHIAZIDE .................. 70 VALTREX (CAPLET) ..................................................... 18 VANCOCIN ........................................................ SEC 3.92 VANCOMYCIN HCL ...................................................... 14 VANCOMYCIN HCL ........................................... SEC 3.92 VARENICLINE TARTRATE .......................................... 28 VARENICLINE TARTRATE ............................... SEC 3.92 VARENICLINE TARTRATE/ VARENICLINE TARTRATE
.................................................................................. 28 VARENICLINE TARTRATE/ VARENICLINE TARTRATE
....................................................................... SEC 3.93 VASERETIC .................................................................. 60 VASOTEC ..................................................................... 60 VENLAFAXINE HCL ..................................................... 90 VENLAFAXINE XR........................................................ 90 VENTOLIN .................................................................... 25 VENTOLIN HFA ............................................................ 25 VENTOLIN NEBULES P.F. ........................................... 25 VERAPAMIL HCL.......................................................... 58 VERMOX ......................................................................... 5 VESICARE ......................................................... SEC 3.82 VFEND ............................................................... SEC 3.93 VIBRAMYCIN ................................................................ 13 VIGABATRIN ................................................................ 89 VIMPAT .............................................................. SEC 3.55 VIMPAT .............................................................. SEC 3.56 VIOKASE .................................................................... 141 VIOKASE 16 ............................................................... 141 VIREAD ......................................................................... 16 VIROPTIC ................................................................... 131 VISKAZIDE 10/25.......................................................... 53 VISKAZIDE 10/50.......................................................... 53 VISKEN ......................................................................... 53 VITAMIN A ACID ................................................ SEC 3.89 VITAMIN A ACID ................................................ SEC 3.90 VITAMIN B12 .............................................................. 185 VITAMIN K1 ................................................................ 185
VITAMIN K1 PEDIATRIC ............................................. 185 VOLTAREN .................................................................... 72 VOLTAREN OPHTHA .................................................. 134 VOLTAREN SR .............................................................. 72 VORICONAZOLE ............................................... SEC 3.93 VORTEX ...................................................................... 191 VORTEX BABY WHIRL INFANT MASK ...................... 191 VORTEX SPINNER PEDIATRIC MASK ...................... 191
W
WARFARIN .................................................................... 29 WARFARIN .................................................................... 30 WARFARIN SODIUM ..................................................... 29 WARFARIN SODIUM ..................................................... 30 WARTEC ..................................................................... 181 WELLBUTRIN SR .......................................................... 97 WELLBUTRIN XL ........................................................... 97 WINPRED .................................................................... 158
X
XALACOM ................................................................... 138 XALATAN ..................................................................... 137 XAMIOL ....................................................................... 181 XANAX ......................................................................... 110 XARELTO ...................................................................... 32 XATRAL ............................................................. SEC 3.15 XEOMIN ....................................................................... 187 XOLAIR .............................................................. SEC 3.64 XYLAC ......................................................................... 108 XYLOCAINE................................................................. 179 XYLOCAINE JELLY ..................................................... 180 XYLOCAINE VISCOUS ............................................... 134
Y
YASMIN 21 .................................................................. 159 YASMIN 28 .................................................................. 159
Z
ZADITEN ..........................................................................3 ZAFIRLUKAST ............................................................. 129 ZAFIRLUKAST ................................................... SEC 3.94 ZANAFLEX ........................................................ SEC 3.87 ZANTAC ....................................................................... 145
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS
ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS
Product Name Page Product Name Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 225 EFFECTIVE JULY 1, 2012
ZANTAC ...................................................................... 146 ZARONTIN .................................................................... 85 ZAROXOLYN .............................................................. 127 ZELDOX ...................................................................... 104 ZESTORETIC ............................................................... 62 ZESTRIL ....................................................................... 61 ZESTRIL ....................................................................... 62 ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE104 ZITHROMAX ................................................................... 9 ZITHROMAX ...................................................... SEC 3.17 ZOCOR ......................................................................... 42 ZOCOR ......................................................................... 43 ZOFRAN ..................................................................... 143 ZOFRAN ODT ............................................................. 142 ZOLADEX .......................................................... SEC 3.46 ZOLADEX LA ..................................................... SEC 3.46 ZOLEDRONIC ACID .......................................... SEC 3.94 ZOLMITRIPTAN .......................................................... 116 ZOLMITRIPTAN ................................................. SEC 3.95 ZOLOFT ........................................................................ 93 ZOLOFT ........................................................................ 94 ZOMETA CONCENTRATE ................................ SEC 3.94 ZOMIG ........................................................................ 116 ZOMIG ............................................................... SEC 3.95 ZOMIG RAPIMELT...................................................... 116 ZOMIG RAPIMELT............................................. SEC 3.95 ZOPICLONE ............................................................... 113 ZOVIRAX ...................................................................... 17 ZUCLOPENTHIXOL ACETATE .................................. 107 ZUCLOPENTHIXOL DECANOATE............................. 107 ZUCLOPENTHIXOL DIHYDROCHLORIDE ................ 108 ZYLOPRIM .................................................................. 187 ZYPREXA ................................................................... 100 ZYPREXA ..................................................................... 99 ZYPREXA ZYDIS ........................................................ 100 ZYVOXAM .......................................................... SEC 3.58
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS
DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
226 EFFECTIVE JULY 1, 2012
00000000655 .......... 137 00000000663 .......... 137 00000000779 .......... 134 00000000787 .......... 134 00000000841 .......... 137 00000000868 .......... 137 00000000884 .......... 137 00000000981 .......... 134 00000001007 .......... 134 00000001686 .......... 134 00000001694 .......... 180 00000001961 .......... 179 00000004596 .......... 187 00000004774 ............ 18 00000005606 .......... 109 00000005614 .......... 109 00000009881 . SEC 3.65 00000010200 .......... 169 00000010219 .......... 169 00000010340 ............ 71 00000010383 ............ 29 00000010391 ............ 29 00000010405 ............ 85 00000015229 ............ 96 00000015237 ............ 96 00000015741 .......... 169 00000016055 .......... 153 00000020877 . SEC 3.15 00000020885 . SEC 3.15 00000021008 ............ 19 00000021016 ............ 19 00000021202 ............ 10 00000021261 ............ 18 00000022772 ............ 84 00000022780 ............ 84 00000022799 ............ 85 00000022802 ............ 85 00000023442 ............ 84 00000023450 ............ 84 00000023485 ............ 85 00000023698 ............ 84 00000023949 .......... 168 00000023957 .......... 168 00000023965 .......... 168 00000024325 ............ 95 00000024333 ............ 95 00000024341 ............ 95 00000024368 ............ 13 00000024430 .......... 107 00000024449 .......... 107
00000024457 .......... 107 00000024694 .......... 113 00000026697 .......... 125 00000027243 ............ 26 00000027944 .......... 176 00000028096 .......... 155 00000028606 ............ 70 00000029149 ............ 16 00000029246 .......... 158 00000030570 ............ 14 00000030600 .......... 156 00000030619 .......... 156 00000030627 .......... 156 00000030635 .......... 157 00000030678 .......... 157 00000030759 .......... 157 00000030767 .......... 157 00000030783 .......... 158 00000030848 .......... 167 00000030910 .......... 156 00000030929 .......... 156 00000030937 .......... 167 00000030988 .......... 157 00000035017 .......... 134 00000035076 .......... 134 00000036129 .......... 157 00000036137 .......... 157 00000036323 .......... 141 00000037605 .......... 159 00000037613 ............ 46 00000037621 ............ 46 00000042560 .......... 132 00000042579 .......... 132 00000042676 .......... 133 00000074225 .......... 125 00000074454 .......... 133 00000115630 .......... 110 00000125083 ............ 78 00000125121 ............ 78 00000155357 ............ 26 00000155365 .......... 135 00000176095 ............ 26 00000176141 ............ 23 00000176176 ............ 26 00000176192 ............ 76 00000176206 ............ 76 00000178799 .......... 109 00000178802 .......... 109 00000178810 .......... 109 00000178829 .......... 109
00000180408 ............ 70 00000192597 .......... 177 00000192600 .......... 177 00000195057 .SEC 3.59 00000225851 ............ 14 00000226327 ............ 71 00000230316 .......... 177 00000232807 .......... 105 00000232823 .......... 105 00000232831 .......... 105 00000236683 .......... 114 00000252506 .......... 134 00000252654 .......... 180 00000253952 .......... 166 00000259527 ............ 43 00000260428 .......... 157 00000260436 ............ 14 00000262595 .............. 8 00000263699 .SEC 3.18 00000263818 .......... 141 00000265470 .......... 161 00000271373 .......... 158 00000280437 .......... 155 00000285455 ............ 70 00000291889 ............ 43 00000294926 .......... 127 00000297143 .......... 160 00000299405 .......... 133 00000301175 .......... 133 00000307246 .......... 133 00000312363 .............. 8 00000312738 ............ 19 00000312746 .......... 107 00000312754 .......... 107 00000312770 .......... 158 00000312797 ............ 96 00000312800 .......... 126 00000313815 .......... 108 00000313823 .......... 108 00000315966 .......... 160 00000317047 .......... 160 00000319511 ............ 19 00000323071 .......... 175 00000324019 ............ 95 00000326836 .......... 107 00000326844 .......... 126 00000326852 ............ 96 00000326925 ............ 96 00000328219 .......... 118 00000329320 .......... 116
00000330566 ............ 95 00000330582 .......... 180 00000335053 ............ 95 00000335061 ............ 95 00000335088 ............ 95 00000335096 .......... 106 00000335118 .......... 106 00000335126 .......... 106 00000335134 .......... 106 00000337420 ............ 73 00000337439 ............ 73 00000337730 ............ 44 00000337749 ............ 44 00000337757 ............ 12 00000337765 ............ 12 00000337773 ............ 12 00000340731 .......... 160 00000342084 .............. 5 00000342092 .............. 6 00000342106 .............. 5 00000342114 .............. 5 00000343838 .......... 160 00000344923 .......... 175 00000345539 .......... 107 00000353027 .......... 160 00000355658 .......... 118 00000358177 .......... 133 00000360201 ............ 96 00000360252 ............ 43 00000360260 ............ 43 00000360279 .......... 126 00000362158 .......... 110 00000362166 ............ 44 00000363014 .......... 178 00000363650 .......... 105 00000363669 .......... 105 00000363677 .......... 104 00000363685 .......... 104 00000363812 ............ 23 00000363839 ............ 23 00000369810 ............ 85 00000372838 .......... 160 00000372846 .......... 160 00000373036 SEC 3.18 00000382825 ............ 84 00000382841 ............ 84 00000386464 .......... 117 00000386472 .......... 117 00000391603 ............ 10 00000392472 ............ 82
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 227
00000392480 ............ 82 00000392537 .......... 142 00000392561 ............ 81 00000392588 ............ 81 00000392693 ............ 23 00000392731 .......... 142 00000392782 ............ 23 00000392812 ............ 23 00000396761 ............ 83 00000396788 ............ 44 00000396796 .......... 104 00000396818 .......... 104 00000396826 .......... 105 00000396834 .......... 105 00000397423 ............ 52 00000397431 ............ 52 00000399310 ............ 83 00000399728 .......... 111 00000400750 ............ 95 00000402516 .......... 167 00000402591 ............ 95 00000402680 .......... 112 00000402737 .......... 112 00000402745 .......... 112 00000402753 ............ 53 00000402761 ............ 53 00000402788 ............ 53 00000402796 .......... 187 00000402818 .......... 187 00000405329 .......... 110 00000405337 .......... 111 00000405345 .......... 105 00000405361 .......... 106 00000406716 ............ 10 00000406724 ............ 10 00000406775 .......... 114 00000410632 .......... 105 00000417246 .......... 175 00000417270 ............ 53 00000417289 ............ 53 00000426830 ............ 44 00000426849 .......... 185 00000426857 .......... 117 00000441619 ............ 44 00000441627 ............ 44 00000441635 ............ 44 00000441651 ............ 73 00000441686 ............ 45 00000441694 ............ 45 00000441767 .......... 127
00000441775 .......... 126 00000443174 ............ 53 00000443832 ............ 89 00000443840 ............ 89 00000443948 ............ 82 00000445266 ............ 12 00000445274 ............ 12 00000445282 ............ 12 00000451207 .......... 136 00000452130 ............ 11 00000452149 ............ 10 00000453781 ............ 31 00000453811 ............ 31 00000455881 ............ 27 00000461733 .......... 114 00000463698 .......... 105 00000465763 .......... 135 00000469327 .......... 159 00000471526 .......... 159 00000474517 .......... 185 00000474525 .......... 185 00000476366 .......... 183 00000476374 .......... 183 00000476552 ............ 89 00000479799 .......... 187 00000481815 .......... 185 00000481823 .......... 185 00000487872 .......... 144 00000489158 .......... 156 00000493392 .......... 188 00000496480 ............ 53 00000496499 ............ 53 00000496502 ............ 53 00000497193 .......... 183 00000500895 .......... 130 00000502790 .......... 141 00000503134 .......... 178 00000503347 ............ 44 00000504335 ............ 53 00000506052 ............ 73 00000509558 ............ 26 00000510637 ............ 12 00000510645 ............ 12 00000511234 ............ 47 00000511528 .......... 112 00000511536 .......... 112 00000511552 .......... 120 00000512184 .......... 131 00000512192 .......... 131 00000513962 .......... 131
00000513997 .......... 118 00000514012 ............ 72 00000514497 ............ 44 00000514500 ............ 44 00000518123 .......... 110 00000518131 .......... 110 00000518182 .SEC 3.89 00000519251 .......... 187 00000521515 .......... 185 00000521698 .......... 111 00000521701 .......... 111 00000522597 .......... 117 00000522651 ............ 74 00000522678 ............ 74 00000522724 .......... 110 00000522988 .......... 110 00000522996 .......... 110 00000527033 ............ 45 00000532657 .......... 126 00000534560 ............ 52 00000535427 .......... 176 00000535435 .......... 176 00000544884 ............ 77 00000545015 .......... 136 00000545058 .......... 117 00000545066 ............ 19 00000545074 .......... 117 00000545678 .............. 8 00000548359 .......... 110 00000548367 .......... 110 00000548375 .......... 144 00000550086 ............ 12 00000550175 .......... 180 00000550957 .......... 158 00000555126 .......... 125 00000556734 .............. 5 00000559253 ............ 46 00000560022 .......... 178 00000564966 .......... 127 00000565350 ............ 74 00000567434 .............. 3 00000568627 ............ 53 00000568635 ............ 53 00000572349 .......... 187 00000575240 .......... 137 00000575569 .......... 121 00000577308 .............. 3 00000578428 .......... 175 00000578436 .......... 175 00000578541 .......... 177
00000578576 SEC 3.89 00000578657 ............ 26 00000579335 .......... 178 00000579718 ............ 31 00000580929 ............ 13 00000582344 .......... 181 00000582352 .......... 181 00000582417 .......... 144 00000583413 .............. 5 00000583421 .............. 5 00000584215 .......... 144 00000584223 ............ 46 00000584991 .......... 109 00000585009 .......... 109 00000585092 .......... 167 00000585114 ............ 73 00000586668 .......... 173 00000586676 .......... 174 00000586714 .......... 164 00000587265 .......... 117 00000587354 .......... 117 00000587362 .......... 117 00000587737 .......... 164 00000587818 .......... 177 00000587826 .......... 177 00000587834 .......... 177 00000587966 SEC 3.89 00000589861 ............ 74 00000590819 ............ 52 00000590827 ............ 72 00000591467 ............ 81 00000591475 ............ 81 00000592277 ............ 74 00000593435 ............ 77 00000593451 ............ 77 00000594377 ............ 70 00000594636 ............ 80 00000594644 ............ 80 00000594652 ............ 80 00000595799 .......... 177 00000595802 .......... 177 00000595942 .......... 107 00000596418 ............ 85 00000596426 ............ 85 00000596434 ............ 86 00000596612 .............. 3 00000596965 ............ 81 00000598194 .......... 158 00000598461 ............ 13 00000598488 ............ 13
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 228 EFFECTIVE JULY 1, 2012
00000598933 .......... 177 00000600059 .......... 144 00000600067 .......... 144 00000600806 ............ 74 00000602884 .......... 125 00000602957 .......... 160 00000602965 .......... 160 00000603678 .......... 144 00000603686 .......... 144 00000603708 ............ 35 00000603716 ............ 35 00000604453 .......... 112 00000604461 .......... 112 00000605859 .............. 8 00000607142 .............. 8 00000607762 ............ 79 00000607770 ............ 79 00000607789 .......... 178 00000607797 .......... 178 00000608157 ............ 83 00000608165 ............ 82 00000608181 ............ 76 00000608203 ............ 76 00000608211 ............ 71 00000608238 ............ 71 00000608882 ............ 77 00000609129 .......... 144 00000610100 .......... 121 00000611174 .......... 179 00000611271 .......... 180 00000613215 ............ 70 00000613223 ............ 70 00000613231 ............ 70 00000614254 .......... 131 00000617288 ............ 81 00000618454 .......... 110 00000618632 ............ 52 00000618640 ............ 52 00000621374 .......... 187 00000621463 ............ 77 00000621935 ............ 81 00000622133 ............ 78 00000627097 ............ 74 00000627100 ............ 78 00000628115 ............ 10 00000628123 ............ 10 00000628131 ............ 10 00000628158 ............ 11 00000629340 ............ 73 00000629359 ............ 73
00000629367 .......... 175 00000632201 ............ 81 00000632228 ............ 81 00000632724 ............ 72 00000632732 ............ 72 00000632775 .......... 109 00000634506 ............ 17 00000636576 ............ 27 00000636622 ............ 92 00000637416 .............. 8 00000637661 .......... 136 00000637726 . SEC 3.42 00000637742 .......... 111 00000637750 .......... 111 00000638676 ............ 35 00000638684 ............ 35 00000638692 ............ 35 00000639389 ............ 81 00000641863 . SEC 3.90 00000642215 ............ 10 00000642223 ............ 10 00000642231 ............ 10 00000642886 ............ 76 00000642894 ............ 76 00000642975 ............ 36 00000644552 .......... 126 00000644579 ............ 96 00000645575 .......... 109 00000646016 .......... 113 00000646024 .......... 113 00000646059 .......... 113 00000648035 ............ 52 00000648043 ............ 52 00000649074 ............ 19 00000649392 .......... 117 00000652318 .............. 8 00000653209 .......... 176 00000653217 .......... 176 00000653241 ............ 77 00000653276 ............ 77 00000654531 ............ 97 00000655740 .......... 111 00000655759 .......... 111 00000655767 .......... 111 00000657182 ............ 70 00000657204 . SEC 3.89 00000657298 ............ 60 00000658855 ............ 52 00000662348 . SEC 3.89 00000663719 ............ 53
00000664227 .......... 156 00000665088 ............ 85 00000666157 .......... 174 00000670901 ............ 60 00000670928 ............ 60 00000670944 ............ 45 00000675962 ............ 80 00000676411 ............ 81 00000682020 .............. 8 00000682217 .......... 133 00000687456 .......... 131 00000688568 .............. 8 00000688622 .......... 175 00000690783 ............ 79 00000690791 ............ 79 00000692689 .......... 183 00000692697 .......... 183 00000692700 .......... 183 00000695696 ............ 76 00000695718 ............ 76 00000700401 .......... 133 00000703486 .......... 125 00000704423 .SEC 3.21 00000704431 .SEC 3.21 00000705438 ............ 78 00000705799 ............ 81 00000706531 .......... 117 00000707503 .......... 159 00000707511 .......... 132 00000707570 ............ 45 00000707600 .......... 159 00000708879 ............ 60 00000708917 .......... 167 00000710113 .......... 145 00000710121 .......... 145 00000711101 .......... 111 00000713376 .......... 125 00000713449 .......... 105 00000716618 .......... 176 00000716626 .......... 176 00000716642 .......... 176 00000716650 .......... 176 00000716685 .......... 177 00000716693 .......... 177 00000716820 .......... 178 00000716839 .......... 178 00000716863 .......... 177 00000716960 .......... 179 00000717274 .SEC 3.47 00000717282 .SEC 3.47
00000718149 ............ 97 00000725110 ............ 56 00000725250 ............ 13 00000725749 ............ 79 00000725757 ............ 79 00000725765 ............ 79 00000726540 ............ 12 00000726672 .............. 8 00000727520 ............ 31 00000727695 SEC 3.56 00000728187 .......... 111 00000728195 .......... 111 00000728209 .......... 111 00000729973 .......... 167 00000733059 .......... 145 00000733067 .......... 145 00000738824 .......... 113 00000738832 .......... 113 00000738840 .......... 113 00000739839 .......... 132 00000740675 ............ 53 00000740713 ............ 13 00000740721 ............ 45 00000740799 ............ 96 00000740802 ............ 96 00000740810 ............ 96 00000740829 ............ 96 00000741817 .......... 113 00000742554 ............ 58 00000742813 .......... 113 00000743518 .......... 105 00000745588 ............ 76 00000745596 ............ 76 00000749354 ............ 52 00000749486 .......... 171 00000749494 .......... 144 00000750050 .......... 176 00000751170 ............ 52 00000754129 ............ 95 00000755338 .......... 126 00000755575 .......... 105 00000755583 ............ 85 00000755826 .......... 136 00000755834 .......... 136 00000755842 ............ 54 00000755850 ............ 54 00000755869 ............ 54 00000755877 ............ 53 00000755885 ............ 53 00000755893 ............ 53
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 229
00000755907 ............ 56 00000756784 .......... 132 00000756792 .......... 161 00000756849 .......... 161 00000765953 ............ 45 00000765996 .......... 165 00000768715 .............. 5 00000768723 .............. 5 00000768820 .......... 105 00000769533 .......... 126 00000769541 .......... 126 00000771376 ............ 56 00000771384 ............ 56 00000773611 ............ 85 00000773689 ............ 49 00000773697 ............ 50 00000776181 ............ 79 00000776203 ............ 79 00000778338 .......... 145 00000778346 .......... 145 00000778354 ............ 76 00000778362 ............ 76 00000778389 ............ 75 00000778907 .......... 133 00000778915 .......... 133 00000780626 ............ 84 00000781878 .......... 185 00000782327 . SEC 3.86 00000782459 ............ 72 00000782467 ............ 52 00000782475 ............ 52 00000782483 ............ 58 00000782491 ............ 58 00000782505 ............ 52 00000782718 ............ 85 00000783900 .......... 156 00000784354 ............ 75 00000784400 .......... 126 00000786535 ............ 78 00000786543 ............ 78 00000786616 ............ 26 00000788716 . SEC 3.92 00000789429 .......... 141 00000789437 .......... 141 00000789445 .......... 141 00000789720 .......... 142 00000789739 ............ 82 00000789747 .......... 142 00000790427 ............ 74 00000790435 ............ 74
00000792659 .......... 112 00000792667 ............ 16 00000792942 .......... 183 00000795852 ............ 39 00000795860 ............ 39 00000795879 .......... 164 00000800430 . SEC 3.92 00000803499 .......... 150 00000804312 .......... 185 00000804533 .......... 177 00000804541 .......... 176 00000804991 .......... 175 00000805009 .......... 175 00000805025 .......... 173 00000805386 .......... 173 00000807435 .......... 131 00000807788 .......... 133 00000808539 ............ 72 00000808547 ............ 72 00000808563 .......... 112 00000808571 .......... 112 00000808652 .......... 105 00000808733 .......... 166 00000808741 .......... 166 00000809187 .......... 175 00000816086 .......... 185 00000818658 ............ 48 00000818666 ............ 48 00000818674 ............ 48 00000818682 ............ 48 00000821373 .......... 141 00000824143 .......... 167 00000824305 .......... 167 00000828556 .......... 145 00000828564 .......... 145 00000828823 .......... 145 00000836273 . SEC 3.56 00000836362 .......... 167 00000839175 ............ 72 00000839183 ............ 72 00000839191 . SEC 3.61 00000839205 . SEC 3.61 00000839213 . SEC 3.61 00000839388 ............ 61 00000839396 ............ 61 00000839418 ............ 62 00000842648 ............ 52 00000842656 ............ 52 00000842664 ............ 74 00000846503 .......... 147
00000849650 .......... 175 00000849669 .......... 175 00000851736 .......... 178 00000851744 .......... 178 00000851752 .......... 155 00000851760 .......... 155 00000851779 ............ 55 00000851787 ............ 56 00000851795 ............ 60 00000852074 .......... 155 00000852384 ............ 46 00000854409 .......... 125 00000856711 .......... 177 00000860689 .......... 110 00000860697 .......... 110 00000860700 .......... 110 00000860808 ............ 25 00000862924 ............ 56 00000862932 ............ 56 00000862975 .......... 175 00000865397 .......... 110 00000865400 .......... 110 00000868965 .............. 7 00000868981 .............. 7 00000869007 ............ 53 00000869015 ............ 53 00000869023 ............ 53 00000869945 ............ 23 00000869953 ............ 23 00000869961 ............ 23 00000870935 .......... 118 00000871095 .......... 178 00000872520 .......... 156 00000872539 .......... 156 00000872644 ............ 11 00000872652 ............ 11 00000873454 .............. 8 00000873993 .......... 167 00000874256 ............ 13 00000874582 .......... 156 00000878618 .......... 156 00000878626 .......... 157 00000878928 ............ 55 00000878936 ............ 55 00000882801 ............ 47 00000882828 ............ 47 00000882836 ............ 47 00000883751 ............ 10 00000884324 ............ 42 00000884332 ............ 42
00000884340 ............ 42 00000884359 ............ 43 00000884413 ............ 62 00000884502 SEC 3.56 00000885401 ............ 78 00000885428 ............ 78 00000885436 ............ 78 00000885444 ............ 78 00000885835 ............ 58 00000885851 ............ 58 00000886157 ............ 17 00000886432 .......... 142 00000886440 .......... 142 00000888346 SEC 3.40 00000888400 .......... 127 00000890960 ............ 36 00000891738 .......... 185 00000891746 .......... 185 00000891835 ............ 15 00000893595 ............ 59 00000893609 ............ 59 00000893617 ............ 59 00000893625 ............ 59 00000893722 .......... 162 00000893749 ............ 40 00000893757 ............ 40 00000894737 ............ 98 00000894745 ............ 99 00000895644 ............ 46 00000895652 ............ 46 00000895660 ............ 46 00000990014 .......... 191 00000990015 .......... 191 00000990016 .......... 191 00000990017 .......... 191 00000990080 .......... 191 00000990081 .......... 191 00000990082 .......... 191 00000990088 .......... 191 00000990089 .......... 191 00000990091 .......... 191 00000990092 .......... 191 00000990093 .......... 191 00000990094 .......... 191 00000990095 .......... 191 00000990096 .......... 191 00000990097 .......... 191 00000990098 .......... 191 00000990099 .......... 191 00000990100 .......... 191
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 230 EFFECTIVE JULY 1, 2012
00000999102 ............ 71 00000999103 .......... 173 00000999104 .......... 180 00000999105 ............ 71 00000999107 .......... 176 00000999108 ............ 77 00000999109 .......... 135 00000999110 .......... 179 00000999111 .......... 155 00000999112 .......... 173 00000999113 .......... 188 00000999114 .......... 188 00000999119 .......... 173 00000999202 ............ 71 00000999203 .......... 173 00000999204 .......... 180 00000999205 ............ 71 00000999207 .......... 176 00000999208 ............ 77 00000999209 .......... 135 00000999211 .......... 179 00000999212 .......... 155 00000999213 .......... 173 00000999214 .......... 188 00000999215 .......... 188 00000999216 .......... 188 00000999219 .......... 173 00000999941 .............. 1 00000999949 .......... 191 00000999952 .............. 1 00000999955 .............. 1 00000999957 .............. 1 00000999981 .......... 171 00000999985 .............. 1 00000999995 ............ 79 00000999999 .......... 188 00001900927 .......... 166 00001900935 .......... 166 00001901869 ............ 81 00001905112 . SEC 3.32 00001907107 ............ 61 00001907115 ............ 61 00001907123 ............ 58 00001907476 .......... 180 00001908448 .......... 135 00001910140 ............ 49 00001910159 ............ 49 00001910167 ............ 49 00001910272 .......... 176 00001910280 .......... 176
00001911473 ............ 59 00001911481 ............ 59 00001911627 ............ 17 00001911902 ............ 46 00001911910 ............ 46 00001911929 ............ 46 00001912038 ............ 73 00001912046 ............ 73 00001912054 ............ 50 00001912062 ............ 49 00001912070 .......... 148 00001912410 ............ 12 00001912429 ............ 12 00001912755 .......... 131 00001913425 ............ 95 00001913433 ............ 95 00001913441 ............ 95 00001913468 ............ 96 00001913476 ............ 96 00001913484 .......... 110 00001913492 .......... 110 00001913654 .......... 166 00001913662 .......... 166 00001913670 .......... 166 00001913689 .......... 166 00001914030 .......... 149 00001916181 .......... 133 00001916203 .......... 133 00001916386 ............ 78 00001916394 ............ 79 00001916475 ............ 82 00001916491 ............ 82 00001916548 ............ 82 00001916823 .......... 151 00001916858 ............ 11 00001916874 ............ 11 00001916882 ............ 11 00001916947 .......... 174 00001917056 ............ 72 00001918311 ............ 29 00001918338 ............ 29 00001918346 ............ 29 00001918354 ............ 30 00001918362 ............ 30 00001919342 ............ 92 00001919369 ............ 92 00001919431 .......... 171 00001919458 .......... 168 00001919466 .......... 168 00001919598 ............ 89
00001924516 .......... 108 00001924559 .......... 108 00001924567 .......... 108 00001925938 .............. 8 00001926292 .............. 3 00001926306 .............. 3 00001926454 ............ 46 00001926462 .SEC 3.89 00001926470 .SEC 3.89 00001926489 .SEC 3.90 00001926543 ............ 49 00001926551 ............ 49 00001926578 ............ 49 00001926667 .......... 106 00001926675 .......... 106 00001926691 .......... 166 00001926713 ............ 47 00001926756 .......... 106 00001926764 .......... 106 00001926772 .......... 106 00001926780 .......... 106 00001926799 .......... 113 00001926829 .......... 174 00001926845 .......... 174 00001926861 .......... 174 00001926934 ............ 25 00001927604 .......... 151 00001927620 .......... 151 00001927639 .......... 106 00001927698 .......... 106 00001927744 .......... 117 00001927914 .......... 175 00001930672 ............ 10 00001930680 ............ 10 00001933345 ............ 11 00001933353 ............ 11 00001934139 ............ 73 00001934163 ............ 11 00001934171 ............ 10 00001934198 ............ 47 00001934201 ............ 47 00001934228 ............ 47 00001934317 ............ 58 00001934325 .......... 157 00001934333 .......... 157 00001934341 .......... 157 00001937219 .......... 126 00001937227 ............ 94 00001937235 ............ 94 00001940309 ............ 75
00001940414 .......... 134 00001940473 ............ 93 00001940481 ............ 93 00001942964 ............ 59 00001942972 ............ 59 00001942980 ............ 59 00001942999 ............ 59 00001945262 SEC 3.32 00001945270 .......... 131 00001946374 .......... 180 00001947664 ............ 63 00001947672 ............ 63 00001947680 ............ 63 00001947699 ............ 63 00001947796 ............ 54 00001947818 ............ 54 00001947826 ............ 54 00001950592 .......... 149 00001953834 .......... 145 00001953842 .......... 145 00001958097 ............ 47 00001958100 ............ 47 00001958119 ............ 47 00001959212 .......... 164 00001959220 .......... 164 00001959239 .......... 164 00001962701 .......... 177 00001962779 ............ 94 00001962817 ............ 93 00001964054 .......... 179 00001964070 .......... 156 00001964968 .......... 156 00001964976 .......... 156 00001966197 ............ 35 00001966200 ............ 35 00001966219 .......... 183 00001968017 SEC 3.41 00001968300 .......... 134 00001968440 .......... 160 00001968823 .......... 134 00001975447 ............ 12 00001976133 .......... 181 00001977547 .......... 156 00001977563 .......... 158 00001977652 .......... 167 00001978918 .......... 155 00001978926 .......... 155 00001979574 ............ 37 00001979582 ............ 37 00001980661 .......... 132
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 231
00001981242 .......... 153 00001981250 .......... 153 00001981501 .......... 189 00001984837 .......... 187 00001984845 .......... 187 00001984853 .............. 9 00001985205 .......... 141 00001986864 ............ 25 00001987003 .......... 185 00001990403 .......... 116 00001992872 .......... 160 00001997580 .......... 149 00001997602 ............ 27 00001997653 ............ 27 00001997750 ............ 18 00001997769 ............ 18 00001999761 .......... 158 00001999869 .......... 158 00002007134 .......... 166 00002007959 ............ 30 00002008203 .......... 113 00002009706 ............ 80 00002009749 ............ 80 00002009765 ............ 80 00002009773 ............ 80 00002010909 . SEC 3.41 00002011271 ............ 46 00002012472 ............ 31 00002013231 .......... 114 00002014165 .......... 183 00002014181 .......... 183 00002014203 ............ 80 00002014211 ............ 80 00002014238 ............ 80 00002014254 ............ 80 00002014297 ............ 80 00002014300 ............ 80 00002014319 ............ 80 00002014327 ............ 80 00002015439 ............ 80 00002015951 ............ 74 00002015994 . SEC 3.32 00002017237 ............ 75 00002017709 ............ 18 00002017741 .......... 125 00002017776 ............ 18 00002018144 .......... 158 00002018152 .......... 158 00002018160 .......... 158 00002018985 ............ 92
00002019884 ............ 60 00002019892 ............ 60 00002019906 ............ 60 00002019930 ............ 80 00002019949 ............ 80 00002019957 ............ 80 00002019965 ............ 80 00002020025 ............ 60 00002021048 ............ 81 00002021056 ............ 81 00002022133 .......... 145 00002022141 .......... 145 00002022826 .......... 116 00002024152 . SEC 3.42 00002024217 .......... 164 00002024225 .......... 164 00002024233 .......... 164 00002024268 .......... 164 00002024284 .......... 164 00002024314 .......... 164 00002024322 .......... 164 00002025248 .......... 164 00002025280 .......... 102 00002025299 .......... 103 00002025302 .......... 103 00002025310 .......... 103 00002026600 ............ 75 00002026961 .......... 126 00002028700 .......... 160 00002028786 .......... 118 00002029421 .......... 160 00002029448 .......... 189 00002029456 ............ 97 00002031094 .......... 174 00002031116 ............ 15 00002031159 .......... 136 00002031167 .......... 136 00002035324 .......... 132 00002036282 ............ 36 00002036347 ............ 10 00002036355 ............ 10 00002039486 ............ 73 00002039494 ............ 73 00002039508 ............ 23 00002039532 ............ 49 00002039540 ............ 50 00002040751 ............ 95 00002040778 ............ 95 00002040786 ............ 95 00002041413 .......... 111
00002041421 .......... 111 00002041448 .......... 111 00002041456 .......... 111 00002041464 .......... 111 00002041472 .......... 111 00002041510 ............ 16 00002042231 ............ 53 00002042258 ............ 53 00002042266 ............ 53 00002042274 ............ 53 00002042304 .......... 125 00002042320 .......... 159 00002042339 .......... 159 00002042479 .......... 159 00002042487 .......... 159 00002042533 .......... 159 00002043394 .......... 161 00002043408 .......... 161 00002043424 .......... 161 00002043440 .......... 161 00002045702 .......... 146 00002045710 .......... 163 00002045729 ............ 62 00002045737 ............ 62 00002045834 .......... 141 00002045869 .......... 141 00002046113 .......... 130 00002046121 ............ 43 00002046148 ............ 43 00002046156 ............ 46 00002047454 ............ 15 00002048264 ............ 36 00002048272 ............ 36 00002048493 ............ 73 00002048698 ............ 72 00002048701 ............ 84 00002048728 ............ 84 00002048736 ............ 84 00002049325 .SEC 3.46 00002049333 ............ 61 00002049376 ............ 61 00002049384 ............ 62 00002049392 .SEC 3.61 00002049961 ............ 50 00002049988 ............ 50 00002049996 ............ 95 00002050005 ............ 95 00002050013 ............ 95 00002050021 ............ 95 00002050048 ............ 96
00002052431 .......... 176 00002057778 ............ 55 00002059762 .......... 189 00002059789 .......... 189 00002060884 .......... 176 00002061562 ............ 39 00002061570 ............ 39 00002063662 ............ 19 00002063670 .......... 181 00002063697 .......... 157 00002063735 ............ 27 00002063743 ............ 27 00002063786 SEC 3.74 00002063808 .......... 149 00002064405 ............ 33 00002064472 ............ 13 00002064480 ............ 13 00002065614 .......... 111 00002065819 ............ 89 00002068036 ............ 89 00002068087 .......... 120 00002069571 ............ 25 00002070847 .......... 180 00002070863 .......... 180 00002070987 ............ 97 00002074788 .......... 181 00002076306 .......... 138 00002078627 ............ 17 00002078635 ............ 17 00002078651 ............ 17 00002080052 ............ 27 00002083345 .......... 136 00002083353 .......... 136 00002083523 ............ 37 00002083795 .......... 179 00002084090 ............ 13 00002084104 ............ 13 00002084228 ............ 54 00002084236 ............ 54 00002084260 ............ 86 00002084279 ............ 86 00002084287 ............ 86 00002085895 ............ 79 00002085992 .......... 125 00002086026 .......... 156 00002087316 .......... 188 00002087324 .......... 118 00002088398 ............ 27 00002088401 ............ 27 00002089602 .......... 175
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 232 EFFECTIVE JULY 1, 2012
00002091194 ............ 72 00002091526 .......... 130 00002091879 .......... 162 00002093162 .......... 176 00002097168 . SEC 3.55 00002097176 . SEC 3.55 00002097249 ............ 56 00002097257 ............ 57 00002097265 ............ 57 00002097273 ............ 57 00002099233 .......... 163 00002099683 .......... 149 00002099705 ............ 21 00002100509 ............ 73 00002100517 ............ 73 00002100622 .......... 146 00002100630 ............ 89 00002102978 ............ 23 00002103052 .......... 186 00002103087 ............ 23 00002103095 ............ 23 00002103567 .......... 146 00002103613 .......... 148 00002103656 ............ 84 00002103729 ............ 62 00002103737 ............ 84 00002106272 ............ 51 00002106280 ............ 51 00002108143 ............ 13 00002108151 ............ 13 00002112736 .......... 177 00002112760 .......... 149 00002112787 .......... 149 00002112795 .......... 149 00002112809 .......... 149 00002123274 ............ 62 00002123282 ............ 62 00002125250 .......... 146 00002125323 ............ 78 00002125331 ............ 78 00002125366 ............ 78 00002125382 ............ 78 00002125390 ............ 78 00002126192 .......... 176 00002126222 ............ 24 00002126559 ............ 46 00002126710 .............. 9 00002126753 ............ 52 00002126761 ............ 52 00002128446 .......... 178
00002129043 . SEC 3.22 00002130297 .......... 105 00002130300 .......... 105 00002131048 ............ 27 00002131056 ............ 27 00002131064 ............ 27 00002132621 ............ 30 00002132648 ............ 30 00002132664 ............ 30 00002132680 ............ 36 00002132699 ............ 36 00002132702 ............ 93 00002136112 ............ 76 00002136120 ............ 76 00002137534 .......... 110 00002137542 .......... 110 00002137984 ............ 83 00002138018 ............ 79 00002139200 .......... 116 00002139332 ............ 27 00002139391 ............ 27 00002140063 ............ 89 00002142074 ............ 37 00002142082 ............ 87 00002142104 ............ 87 00002142112 ............ 87 00002143291 .......... 131 00002144263 ............ 94 00002144271 ............ 94 00002144298 ............ 94 00002144328 . SEC 3.57 00002144336 . SEC 3.57 00002144344 . SEC 3.57 00002145227 ............ 84 00002145235 ............ 84 00002145243 ............ 84 00002145901 ............ 78 00002145928 ............ 78 00002145936 ............ 78 00002146126 ............ 78 00002146843 ............ 25 00002146851 ............ 25 00002146894 ............ 49 00002146908 .............. 9 00002146959 ............ 37 00002147432 ............ 50 00002147602 ............ 49 00002147610 ............ 49 00002147629 ............ 49 00002147637 ............ 94
00002147645 ............ 94 00002147653 ............ 94 00002148587 .......... 161 00002148595 .......... 161 00002148765 .......... 163 00002150662 .SEC 3.21 00002150670 .SEC 3.21 00002150689 .SEC 3.21 00002150697 .SEC 3.21 00002150956 .......... 181 00002153483 .......... 127 00002153521 .......... 149 00002153556 .......... 149 00002153564 .......... 149 00002154412 ............ 25 00002154463 ............ 76 00002155907 ............ 56 00002155958 SEC 3A.2 00002155966 SEC 3A.3 00002155974 SEC 3A.3 00002155990 ............ 56 00002156008 .......... 107 00002156016 .......... 107 00002156032 .......... 107 00002156040 .......... 107 00002156091 .......... 173 00002157195 .......... 148 00002158574 ............ 13 00002158582 ............ 72 00002158612 ............ 96 00002158620 ............ 96 00002158639 ............ 96 00002161737 SEC 3A.2 00002161745 SEC 3A.3 00002161753 SEC 3A.3 00002162415 ............ 75 00002162423 ............ 75 00002162431 ............ 75 00002162466 ............ 75 00002162644 ............ 74 00002162660 ............ 74 00002162695 ............ 18 00002162717 ............ 75 00002162725 ............ 75 00002162792 ............ 75 00002162806 ............ 46 00002162814 ............ 72 00002162849 .......... 163 00002163527 ............ 46 00002163535 ............ 46
00002163543 .......... 183 00002163551 ............ 59 00002163578 ............ 59 00002163586 ............ 59 00002163594 ............ 59 00002163659 .............. 6 00002163667 .............. 6 00002163675 .............. 6 00002163683 .............. 6 00002163705 ............ 24 00002163918 ............ 77 00002163926 ............ 77 00002163934 ............ 77 00002163942 ............ 77 00002165503 .......... 147 00002165511 .......... 147 00002166704 .......... 167 00002166712 .......... 136 00002166720 .......... 136 00002167786 .......... 163 00002167794 ............ 54 00002167840 ............ 31 00002168898 .......... 161 00002168979 SEC 3.58 00002169649 .. SEC 2.4 00002169991 .......... 108 00002170493 .......... 188 00002170698 ............ 21 00002170795 SEC 3.73 00002170809 SEC 3.73 00002170817 SEC 3.73 00002171228 .......... 168 00002171791 ............ 49 00002171805 ............ 50 00002171880 .......... 136 00002171899 .......... 136 00002171929 .......... 149 00002172062 .......... 168 00002172070 .......... 168 00002172089 .......... 168 00002172097 .......... 168 00002172100 .......... 168 00002172119 .......... 168 00002172127 .......... 168 00002172135 .......... 168 00002172143 .......... 168 00002172151 .......... 168 00002172577 ............ 74 00002172712 .......... 132 00002173360 ............ 25
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 233
00002174545 ............ 52 00002174553 ............ 52 00002176017 .......... 188 00002176084 .............. 3 00002177145 ............ 27 00002177153 .......... 110 00002177161 .......... 110 00002177188 .......... 110 00002177579 ............ 92 00002177587 ............ 92 00002177692 ............ 96 00002177706 ............ 96 00002177714 .......... 145 00002177722 .......... 145 00002177749 ............ 80 00002177757 ............ 81 00002177889 ............ 84 00002177897 ............ 84 00002179660 ............ 84 00002179679 ............ 76 00002179687 ............ 76 00002181479 ............ 59 00002182750 ............ 21 00002182777 ............ 21 00002182815 ............ 67 00002182866 ............ 14 00002182874 ............ 67 00002182882 ............ 67 00002182955 ............ 21 00002182963 ............ 21 00002184435 ............ 81 00002184443 ............ 81 00002184451 ............ 81 00002184648 ............ 89 00002185407 ............ 37 00002185431 .......... 149 00002185881 .......... 142 00002187086 .......... 160 00002187094 .......... 160 00002187108 .......... 160 00002187116 .......... 160 00002188783 .......... 189 00002189054 .......... 160 00002189062 .......... 160 00002190885 .......... 162 00002190893 .......... 162 00002190915 .......... 147 00002192268 .......... 175 00002192276 .......... 175 00002192284 .......... 175
00002193221 .......... 185 00002194031 .......... 179 00002194058 .......... 179 00002194066 .......... 179 00002194198 ............ 16 00002194201 ............ 16 00002194333 ............ 85 00002194341 .......... 181 00002195917 . SEC 3.58 00002195925 . SEC 3.58 00002195933 .......... 118 00002195941 .......... 118 00002195968 .......... 118 00002196018 .......... 145 00002196026 .......... 145 00002197502 .......... 160 00002199270 . SEC 3.87 00002199297 .......... 160 00002200104 .......... 141 00002201038 . SEC 3.14 00002202441 ............ 82 00002202468 ............ 82 00002202476 ............ 82 00002202484 ............ 82 00002203324 .......... 141 00002204517 ............ 49 00002204525 ............ 49 00002204533 ............ 49 00002205963 ............ 29 00002207621 ............ 17 00002207648 ............ 17 00002207656 ............ 17 00002207761 .......... 145 00002207788 .......... 145 00002207818 ............ 84 00002208229 ............ 25 00002208237 ............ 25 00002208245 ............ 25 00002210320 ............ 36 00002210347 ............ 58 00002210355 ............ 58 00002210363 ............ 58 00002210428 ............ 54 00002210479 ............ 24 00002211076 .......... 112 00002211920 ............ 58 00002212021 .............. 9 00002212048 ............ 27 00002212153 .......... 115 00002212153 . SEC 3.84
00002212161 .......... 115 00002212161 .SEC 3.84 00002212188 .......... 115 00002212188 .SEC 3.84 00002212218 .............. 7 00002212226 .............. 7 00002212234 .............. 7 00002212277 .............. 7 00002212285 .............. 7 00002212331 .......... 145 00002212358 .......... 145 00002212366 .......... 146 00002213192 .......... 168 00002213206 .......... 168 00002213214 .......... 168 00002213222 .......... 168 00002213265 .......... 176 00002213273 .......... 176 00002213281 .......... 176 00002213419 ............ 25 00002213427 ............ 25 00002213486 ............ 25 00002213567 .......... 143 00002213575 .......... 143 00002213745 .......... 143 00002214261 ............ 25 00002215136 .SEC 3.82 00002216132 .......... 114 00002216140 .......... 114 00002216159 .......... 114 00002216167 .......... 113 00002216205 .......... 136 00002216221 .SEC 3.55 00002216248 ............ 95 00002216256 ............ 95 00002216264 ............ 95 00002216272 ............ 95 00002216345 ............ 23 00002216353 ............ 92 00002216361 ............ 92 00002216582 ............ 92 00002216590 ............ 92 00002217422 ............ 19 00002217481 ............ 61 00002217503 ............ 61 00002217511 ............ 62 00002218313 .......... 113 00002218321 ............ 89 00002218453 ............ 92 00002218461 ............ 92
00002218488 SEC 3.59 00002218496 SEC 3.59 00002218941 ............ 48 00002218968 ............ 48 00002218976 ............ 48 00002218984 ............ 48 00002219492 ............ 18 00002220156 .......... 145 00002220164 .......... 145 00002220172 ............ 39 00002220180 ............ 39 00002220407 SEC 3.83 00002221284 .......... 167 00002221292 .......... 167 00002221306 .......... 167 00002221780 ............ 29 00002221802 .......... 175 00002221829 ............ 63 00002221837 ............ 63 00002221845 ............ 64 00002221853 ............ 64 00002221896 .......... 177 00002221918 .......... 177 00002221977 ............ 33 00002221985 ............ 55 00002221993 ............ 55 00002222000 ............ 56 00002222051 ............ 40 00002223252 .......... 179 00002223376 .......... 183 00002223481 ............ 92 00002223503 ............ 92 00002223511 ............ 96 00002223538 ............ 96 00002223562 .......... 163 00002223678 .......... 127 00002223716 .............. 9 00002223724 .............. 9 00002223767 SEC 3.73 00002223775 SEC 3.73 00002224550 .......... 166 00002224569 .......... 166 00002224623 .......... 133 00002224690 ............ 44 00002224704 ............ 44 00002224720 ............ 45 00002224755 ............ 45 00002224801 ............ 35 00002224828 ............ 35 00002225085 .............. 7
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 234 EFFECTIVE JULY 1, 2012
00002225093 .............. 7 00002225107 .............. 7 00002225158 . SEC 3.18 00002225166 . SEC 3.18 00002225190 .......... 161 00002225905 . SEC 3.46 00002225964 .......... 112 00002225972 .......... 112 00002225980 ............ 37 00002226383 .......... 179 00002226391 .......... 179 00002226839 .......... 173 00002227444 .......... 144 00002227452 .......... 144 00002227460 .......... 144 00002227479 .......... 144 00002228947 ............ 26 00002228955 . SEC 3.18 00002229080 ............ 74 00002229099 .......... 155 00002229250 ............ 99 00002229269 ............ 99 00002229277 ............ 99 00002229285 ............ 99 00002229293 . SEC 3.18 00002229315 .......... 177 00002229323 .......... 177 00002229440 .......... 131 00002229441 .......... 131 00002229452 ............ 74 00002229453 .......... 148 00002229515 ............ 31 00002229519 .......... 165 00002229521 SEC 3A.2 00002229522 SEC 3A.3 00002229523 SEC 3A.3 00002229524 ............ 12 00002229526 ............ 57 00002229540 .......... 158 00002229550 .......... 158 00002229628 ............ 89 00002229639 .......... 143 00002229654 .......... 112 00002229655 .......... 112 00002229656 .......... 163 00002229704 .......... 164 00002229705 .......... 164 00002229755 ............ 31 00002229777 .......... 135 00002229778 ............ 54
00002229779 ............ 54 00002229781 ............ 56 00002229782 ............ 57 00002229783 ............ 57 00002229784 ............ 57 00002229837 ............ 72 00002230019 .......... 141 00002230047 ............ 67 00002230089 . SEC 3.42 00002230090 ............ 33 00002230095 .......... 112 00002230102 .......... 112 00002230104 . SEC 3.42 00002230183 ............ 37 00002230201 ............ 74 00002230243 ............ 10 00002230244 ............ 10 00002230245 ............ 10 00002230246 ............ 11 00002230248 . SEC 3.56 00002230359 ............ 35 00002230360 ............ 35 00002230394 .......... 183 00002230402 .......... 108 00002230403 .......... 108 00002230405 .......... 107 00002230406 .......... 107 00002230418 .......... 115 00002230418 . SEC 3.83 00002230420 .......... 115 00002230420 . SEC 3.83 00002230431 .......... 148 00002230432 .......... 148 00002230433 .......... 149 00002230454 .......... 118 00002230475 .......... 163 00002230476 ............ 37 00002230535 ............ 14 00002230540 ............ 14 00002230584 .......... 110 00002230585 .......... 110 00002230619 .......... 158 00002230641 .......... 120 00002230648 .......... 132 00002230661 ............ 76 00002230684 .......... 149 00002230711 ............ 38 00002230713 ............ 38 00002230714 ............ 38 00002230732 ............ 46
00002230733 ............ 46 00002230734 ............ 46 00002230735 ............ 13 00002230736 ............ 13 00002230737 .......... 147 00002230768 ............ 89 00002230784 .......... 181 00002230785 .......... 181 00002230800 .......... 183 00002230803 ............ 52 00002230804 ............ 52 00002230805 ............ 48 00002230806 ............ 48 00002230807 ............ 48 00002230808 ............ 48 00002230837 .......... 108 00002230838 .......... 108 00002230839 .......... 108 00002230840 .......... 108 00002230888 .......... 131 00002230893 ............ 88 00002230894 ............ 88 00002230896 ............ 88 00002230898 ............ 24 00002230942 .......... 112 00002230950 ............ 84 00002230951 ............ 84 00002230997 ............ 56 00002230998 ............ 57 00002230999 ............ 57 00002231015 ............ 19 00002231016 ............ 19 00002231036 .......... 120 00002231061 ............ 15 00002231129 ............ 25 00002231135 .SEC 3.55 00002231136 ............ 24 00002231143 .SEC 3.17 00002231150 ............ 57 00002231151 ............ 57 00002231152 ............ 57 00002231154 ............ 57 00002231155 ............ 58 00002231171 ............ 30 00002231181 ............ 54 00002231182 ............ 54 00002231184 .......... 127 00002231244 .SEC 3.55 00002231245 .SEC 3.55 00002231328 ............ 92
00002231329 ............ 92 00002231330 ............ 92 00002231347 SEC 3.55 00002231353 ............ 27 00002231379 .......... 142 00002231441 ............ 46 00002231457 ............ 64 00002231459 ............ 64 00002231460 ............ 64 00002231478 ............ 31 00002231491 .......... 187 00002231492 .......... 112 00002231493 .......... 137 00002231504 ............ 72 00002231505 ............ 72 00002231506 ............ 72 00002231508 ............ 72 00002231509 .......... 161 00002231510 .......... 161 00002231529 SEC 3A.5 00002231531 SEC 3A.5 00002231532 SEC 3A.5 00002231536 ............ 53 00002231537 ............ 53 00002231539 ............ 53 00002231540 ............ 85 00002231542 ............ 85 00002231543 ............ 85 00002231544 ............ 85 00002231583 SEC 3.31 00002231584 SEC 3.31 00002231585 SEC 3.31 00002231586 SEC 3.31 00002231587 SEC 3.31 00002231675 ............ 24 00002231683 ............ 94 00002231684 ............ 94 00002231689 ............ 51 00002231731 ............ 49 00002231733 ............ 50 00002231781 ............ 96 00002231782 ............ 96 00002231799 ............ 73 00002231800 ............ 73 00002231893 .......... 157 00002231894 .......... 157 00002231895 .......... 157 00002232043 SEC 3.25 00002232044 SEC 3.25 00002232148 ............ 89
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 235
00002232150 ............ 89 00002232317 ............ 73 00002232318 ............ 73 00002232565 .......... 119 00002232567 .......... 119 00002232568 .......... 120 00002232569 .......... 120 00002232570 ............ 25 00002233005 ............ 60 00002233006 ............ 60 00002233007 ............ 60 00002233852 .......... 168 00002233960 ............ 84 00002233982 ............ 84 00002233985 ............ 84 00002234003 .......... 112 00002234007 .......... 112 00002234466 .......... 178 00002234502 ............ 48 00002234503 ............ 48 00002234504 ............ 48 00002234505 ............ 48 00002234510 ............ 76 00002234749 .......... 109 00002235134 . SEC 3.19 00002236399 .......... 178 00002236466 .......... 148 00002236507 ............ 27 00002236508 ............ 27 00002236564 ............ 31 00002236606 .......... 129 00002236606 . SEC 3.94 00002236734 .......... 166 00002236783 ............ 25 00002236807 ............ 89 00002236819 .......... 187 00002236841 SEC 3A.4 00002236842 SEC 3A.4 00002236848 ............ 33 00002236876 .......... 135 00002236883 ............ 31 00002236913 ............ 31 00002236948 ............ 84 00002236950 .......... 104 00002236951 .......... 100 00002236952 .......... 100 00002236953 .......... 101 00002236963 ............ 27 00002236964 ............ 27 00002236974 .......... 159
00002236975 .......... 159 00002236978 ............ 15 00002236979 ............ 15 00002236996 .......... 177 00002236997 .......... 177 00002237137 .............. 5 00002237138 .............. 5 00002237140 .............. 5 00002237224 ............ 25 00002237225 ............ 25 00002237235 ............ 15 00002237246 .......... 156 00002237247 .......... 156 00002237250 ............ 97 00002237279 ............ 90 00002237280 ............ 90 00002237282 ............ 90 00002237313 ............ 13 00002237314 ............ 13 00002237319 ... SEC 2.4 00002237320 ... SEC 2.4 00002237339 ............ 94 00002237367 ............ 63 00002237368 ............ 63 00002237369 ............ 63 00002237370 ............ 15 00002237371 ............ 15 00002237514 SEC 3A.1 00002237600 ............ 49 00002237601 ............ 50 00002237618 ............ 56 00002237671 . SEC 3.21 00002237682 ............ 12 00002237701 ............ 33 00002237721 ............ 49 00002237722 ............ 49 00002237723 ............ 49 00002237770 ... SEC 2.4 00002237791 ............ 58 00002237813 ............ 92 00002237814 ............ 92 00002237820 .......... 114 00002237820 . SEC 3.61 00002237821 .......... 114 00002237821 . SEC 3.61 00002237825 ............ 97 00002237860 .......... 167 00002237885 ............ 49 00002237886 ............ 49 00002237887 ............ 49
00002237921 ............ 58 00002237922 ............ 58 00002237923 ............ 66 00002237924 ............ 66 00002237925 ............ 66 00002237971 .SEC 3.82 00002237991 .......... 136 00002238048 ............ 89 00002238103 .......... 165 00002238171 ............ 10 00002238172 ............ 10 00002238216 .......... 129 00002238216 .SEC 3.60 00002238217 .......... 129 00002238217 .SEC 3.60 00002238280 ............ 93 00002238281 ............ 93 00002238282 ............ 94 00002238316 ............ 49 00002238318 ............ 50 00002238326 ............ 54 00002238327 ............ 54 00002238334 ............ 83 00002238370 ............ 89 00002238403 .......... 106 00002238404 .......... 106 00002238405 .......... 106 00002238406 .......... 106 00002238465 .......... 132 00002238525 .......... 147 00002238560 .SEC 3.42 00002238568 .......... 132 00002238596 .......... 113 00002238604 .......... 125 00002238639 ............ 74 00002238645 ............ 77 00002238646 ............ 77 00002238660 .......... 116 00002238660 .SEC 3.95 00002238682 .SEC 3.20 00002238703 .......... 174 00002238704 .......... 161 00002238796 .......... 132 00002238829 ............ 11 00002238830 ............ 11 00002238831 ............ 11 00002238850 .......... 100 00002238873 .......... 136 00002238903 .......... 117 00002238984 .......... 141
00002238998 ............ 46 00002239024 ............ 84 00002239025 ............ 84 00002239028 SEC 3.74 00002239091 ............ 65 00002239092 ............ 65 00002239131 ............ 24 00002239146 SEC 3.75 00002239170 SEC 3.87 00002239193 ............ 16 00002239267 ............ 65 00002239288 .......... 132 00002239323 SEC 3.61 00002239324 SEC 3.62 00002239325 SEC 3.62 00002239326 ............ 97 00002239327 ............ 97 00002239365 ............ 25 00002239366 ............ 25 00002239367 .......... 115 00002239367 SEC 3.84 00002239372 .......... 142 00002239373 .......... 142 00002239505 SEC 3.47 00002239577 .......... 131 00002239607 ............ 91 00002239608 ............ 91 00002239619 .......... 127 00002239620 .......... 127 00002239627 ............ 24 00002239630 .............. 5 00002239636 .......... 105 00002239653 SEC 3.86 00002239665 SEC 3.59 00002239698 ............ 85 00002239699 ............ 85 00002239700 ............ 86 00002239701 ............ 85 00002239702 ............ 85 00002239703 ............ 86 00002239714 ............ 89 00002239746 ............ 89 00002239747 ............ 89 00002239748 ............ 89 00002239757 .......... 174 00002239834 SEC 3.56 00002239835 ............ 36 00002239864 ............ 37 00002239893 ............ 15 00002239907 ............ 88
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 236 EFFECTIVE JULY 1, 2012
00002239908 ............ 88 00002239924 .......... 165 00002239925 .......... 165 00002239926 .......... 165 00002239941 . SEC 3.19 00002239942 . SEC 3.19 00002239944 ............ 74 00002239951 ............ 37 00002239953 ............ 92 00002239954 ............ 92 00002240067 .......... 127 00002240071 ............ 36 00002240113 .......... 138 00002240114 ............ 31 00002240115 ............ 87 00002240131 ............ 82 00002240132 ............ 82 00002240205 ............ 29 00002240210 ............ 37 00002240286 .......... 111 00002240294 .......... 164 00002240297 .......... 164 00002240329 .......... 185 00002240332 ............ 43 00002240333 ............ 97 00002240334 ............ 97 00002240346 ............ 15 00002240432 ............ 65 00002240456 ............ 89 00002240457 .......... 145 00002240458 .......... 145 00002240481 ............ 94 00002240484 ............ 93 00002240485 ............ 93 00002240498 ............ 47 00002240499 ............ 47 00002240500 ............ 47 00002240518 .......... 114 00002240518 . SEC 3.79 00002240519 .......... 115 00002240519 . SEC 3.79 00002240521 .......... 114 00002240521 . SEC 3.79 00002240549 .......... 183 00002240550 .......... 183 00002240551 .......... 102 00002240552 .......... 102 00002240588 ............ 47 00002240589 ............ 47 00002240590 ............ 47
00002240604 ............ 36 00002240606 .......... 113 00002240682 ............ 92 00002240683 ............ 92 00002240684 .......... 156 00002240687 .......... 156 00002240722 . SEC 3.30 00002240769 ............ 68 00002240770 ............ 68 00002240774 . SEC 3.19 00002240775 . SEC 3.85 00002240807 ............ 15 00002240835 ............ 26 00002240836 ............ 26 00002240837 ............ 26 00002240851 .......... 178 00002240867 ............ 74 00002240908 ............ 93 00002240909 ............ 93 00002241007 ............ 68 00002241024 ............ 75 00002241112 . SEC 3.79 00002241113 . SEC 3.79 00002241114 . SEC 3.79 00002241163 ............ 26 00002241209 .............. 5 00002241210 .............. 5 00002241224 ............ 72 00002241229 .......... 157 00002241332 .......... 161 00002241371 ............ 92 00002241374 ............ 92 00002241377 ............ 79 00002241497 ............ 25 00002241600 .......... 153 00002241601 ............ 37 00002241602 ............ 37 00002241674 .......... 159 00002241704 ............ 37 00002241709 ............ 14 00002241710 ............ 14 00002241715 .......... 136 00002241716 .......... 136 00002241755 .......... 131 00002241818 ............ 66 00002241819 ............ 66 00002241820 ............ 14 00002241821 ............ 14 00002241835 .......... 162 00002241837 .......... 162
00002241882 ............ 85 00002241883 ............ 85 00002241888 .......... 189 00002241889 .......... 189 00002241900 ............ 69 00002241901 ............ 69 00002241927 .SEC 3.77 00002241933 .......... 141 00002241976 ............ 83 00002242029 .......... 155 00002242030 .......... 155 00002242055 .......... 153 00002242115 .SEC 3.78 00002242116 .SEC 3.78 00002242117 .SEC 3.78 00002242118 .SEC 3.78 00002242119 ............ 33 00002242146 .......... 149 00002242163 ............ 81 00002242177 ............ 92 00002242178 ............ 92 00002242320 ............ 36 00002242453 .......... 145 00002242454 .......... 145 00002242463 ............ 17 00002242464 ............ 17 00002242465 .......... 167 00002242471 .SEC 3.18 00002242472 ............ 36 00002242481 .......... 113 00002242502 .......... 185 00002242503 ............ 15 00002242518 .SEC 3.75 00002242519 ............ 93 00002242520 ............ 93 00002242521 ............ 94 00002242527 .......... 179 00002242528 .......... 179 00002242538 ............ 56 00002242539 ............ 57 00002242540 ............ 57 00002242541 ............ 57 00002242570 .......... 105 00002242572 .SEC 3.72 00002242573 .SEC 3.72 00002242574 .SEC 3.72 00002242589 .......... 163 00002242652 .............. 5 00002242656 .............. 7 00002242657 .............. 7
00002242680 ............ 29 00002242681 ............ 29 00002242682 ............ 29 00002242683 ............ 29 00002242684 ............ 30 00002242685 ............ 30 00002242686 ............ 30 00002242687 ............ 30 00002242692 ............ 31 00002242697 ............ 30 00002242728 ............ 47 00002242729 ............ 47 00002242730 ............ 47 00002242763 SEC 3.74 00002242784 ............ 17 00002242794 .......... 163 00002242797 .......... 178 00002242798 .......... 178 00002242814 .......... 125 00002242821 SEC 3.21 00002242837 .......... 114 00002242838 .......... 114 00002242868 .......... 108 00002242903 SEC 3.38 00002242907 .......... 187 00002242919 .......... 173 00002242924 ............ 29 00002242925 ............ 29 00002242926 ............ 29 00002242927 ............ 30 00002242928 ............ 30 00002242929 ............ 30 00002242931 .......... 163 00002242940 .......... 146 00002242965 SEC 3A.5 00002242974 .......... 163 00002242984 .......... 178 00002242985 .......... 178 00002242987 .......... 165 00002243005 .......... 159 00002243026 .......... 135 00002243045 .......... 116 00002243045 SEC 3.95 00002243077 SEC 3.82 00002243078 SEC 3.82 00002243086 .......... 100 00002243087 .......... 100 00002243097 ............ 38 00002243098 .......... 130 00002243116 ............ 19
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 237
00002243117 ............ 19 00002243127 ............ 39 00002243129 ............ 39 00002243158 . SEC 3.19 00002243180 ............ 37 00002243229 .......... 145 00002243230 .......... 145 00002243231 .......... 188 00002243239 . SEC 3.31 00002243297 .......... 166 00002243312 ............ 75 00002243313 ............ 75 00002243314 ............ 75 00002243324 ............ 35 00002243325 ............ 35 00002243338 ............ 56 00002243339 ............ 57 00002243340 ............ 57 00002243341 ............ 57 00002243350 ............ 11 00002243351 ............ 11 00002243352 ............ 87 00002243353 ............ 87 00002243400 . SEC 3.31 00002243401 . SEC 3.31 00002243403 . SEC 3.31 00002243426 .......... 113 00002243432 ............ 75 00002243446 ............ 86 00002243447 ............ 86 00002243448 ............ 86 00002243450 .......... 153 00002243486 ............ 92 00002243487 ............ 92 00002243506 ............ 40 00002243507 ............ 40 00002243508 ............ 40 00002243518 ............ 48 00002243519 ............ 48 00002243520 ............ 48 00002243521 ............ 48 00002243525 .......... 185 00002243551 ............ 37 00002243552 ............ 37 00002243562 ............ 78 00002243587 ............ 33 00002243588 ............ 46 00002243602 .......... 129 00002243684 . SEC 3.58 00002243722 .......... 161
00002243724 .......... 161 00002243763 .......... 117 00002243771 ............ 11 00002243789 ............ 24 00002243796 .......... 148 00002243797 .......... 148 00002243836 ............ 36 00002243878 .......... 187 00002243910 ............ 98 00002243942 ............ 65 00002243986 ............ 11 00002243987 ............ 11 00002243999 .......... 161 00002244000 .......... 161 00002244001 .......... 161 00002244002 .......... 161 00002244016 . SEC 3.55 00002244021 ............ 65 00002244022 .......... 146 00002244023 .......... 146 00002244107 .......... 101 00002244126 .......... 181 00002244148 . SEC 3.85 00002244149 . SEC 3.86 00002244265 . SEC 3.19 00002244266 . SEC 3.19 00002244291 .......... 156 00002244292 .......... 156 00002244293 .......... 156 00002244304 ............ 86 00002244305 ............ 86 00002244306 ............ 86 00002244324 . SEC 3.21 00002244344 ............ 68 00002244353 .......... 163 00002244393 .............. 7 00002244394 .............. 7 00002244403 ............ 85 00002244404 ............ 85 00002244462 ............ 29 00002244463 ............ 29 00002244464 ............ 29 00002244465 ............ 30 00002244466 ............ 30 00002244467 ............ 30 00002244474 ............ 83 00002244494 .......... 118 00002244495 .......... 118 00002244496 .......... 118 00002244513 ............ 86
00002244514 ............ 86 00002244515 ............ 86 00002244527 ............ 47 00002244528 ............ 47 00002244529 ............ 47 00002244550 .......... 189 00002244551 .......... 189 00002244552 .......... 189 00002244563 ............ 74 00002244612 .SEC 3.89 00002244613 .SEC 3.89 00002244638 ............ 83 00002244641 .............. 9 00002244646 ............ 11 00002244647 ............ 11 00002244680 ............ 73 00002244681 ............ 73 00002244756 .............. 9 00002244781 ............ 69 00002244782 ............ 69 00002244790 ............ 80 00002244791 ............ 80 00002244792 ............ 80 00002244798 ............ 21 00002244814 .......... 112 00002244815 .......... 112 00002244816 ............ 95 00002244817 ............ 95 00002244818 ............ 95 00002244838 ............ 93 00002244839 ............ 93 00002244840 ............ 94 00002244849 ............ 14 00002244999 .......... 133 00002245058 .......... 147 00002245077 .......... 113 00002245126 ............ 25 00002245127 ............ 25 00002245159 ............ 93 00002245160 ............ 93 00002245161 ............ 94 00002245208 ............ 87 00002245209 ............ 87 00002245210 ............ 87 00002245230 .......... 112 00002245231 .......... 112 00002245232 ............ 14 00002245233 ............ 14 00002245240 .SEC 3.78 00002245246 .......... 127
00002245247 .......... 165 00002245292 ............ 15 00002245293 ............ 15 00002245329 SEC 3.14 00002245330 .......... 188 00002245385 ............ 24 00002245386 ............ 24 00002245397 .......... 163 00002245400 .......... 157 00002245406 .......... 157 00002245407 .......... 157 00002245408 .......... 157 00002245432 .......... 108 00002245433 .......... 108 00002245456 .......... 151 00002245457 .......... 151 00002245458 .......... 151 00002245522 .......... 176 00002245523 .......... 176 00002245524 .......... 176 00002245531 ............ 32 00002245532 .......... 158 00002245565 SEC 3.15 00002245618 ............ 29 00002245619 .. SEC 2.4 00002245623 ............ 11 00002245643 ............ 15 00002245644 ............ 15 00002245647 SEC 3A.2 00002245648 SEC 3A.3 00002245649 SEC 3A.3 00002245662 .......... 174 00002245663 .......... 150 00002245664 .......... 150 00002245669 ............ 25 00002245676 .......... 161 00002245688 .......... 175 00002245689 .......... 163 00002245777 SEC 3.92 00002245782 .......... 145 00002245783 .......... 145 00002245821 .......... 134 00002245822 ............ 39 00002245823 ............ 39 00002245824 ............ 93 00002245825 ............ 93 00002245826 ............ 94 00002245828 .......... 187 00002245882 .......... 136 00002245894 .......... 141
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 238 EFFECTIVE JULY 1, 2012
00002245898 . SEC 3.21 00002245913 . SEC 3.17 00002245914 ............ 51 00002245915 ............ 51 00002245916 ............ 51 00002245917 ............ 51 00002245918 ............ 57 00002245919 ............ 57 00002245920 ............ 57 00002245921 ............ 57 00002245922 ............ 58 00002245972 . SEC 3.86 00002246010 ............ 52 00002246013 ............ 39 00002246014 ............ 39 00002246016 .......... 123 00002246026 . SEC 3.71 00002246030 . SEC 3.71 00002246056 ............ 91 00002246057 ............ 91 00002246063 .......... 158 00002246082 .......... 188 00002246194 ............ 36 00002246284 .......... 135 00002246314 ............ 86 00002246315 ............ 86 00002246316 ............ 86 00002246354 . SEC 3.23 00002246355 . SEC 3.23 00002246357 . SEC 3.23 00002246358 . SEC 3.23 00002246360 . SEC 3.23 00002246534 .......... 113 00002246542 ............ 39 00002246543 ............ 39 00002246569 ............ 63 00002246581 ............ 49 00002246582 ............ 42 00002246583 ............ 42 00002246584 ............ 43 00002246585 ............ 43 00002246594 ............ 91 00002246595 ............ 91 00002246596 ............ 12 00002246619 .......... 138 00002246624 ............ 63 00002246691 ............ 18 00002246699 ............ 75 00002246700 ............ 75 00002246701 ............ 75
00002246714 .......... 175 00002246737 ............ 42 00002246793 ............ 24 00002246804 SEC 3A.4 00002246820 .......... 163 00002246821 .......... 163 00002246825 SEC 3A.2 00002246826 SEC 3A.3 00002246827 SEC 3A.3 00002246859 ............ 37 00002246860 ............ 37 00002246893 ............ 58 00002246894 ............ 58 00002246895 ............ 58 00002246896 . SEC 3.75 00002246897 ............ 87 00002246898 ............ 87 00002246899 ............ 87 00002246955 ............ 69 00002246963 ............ 87 00002246967 .......... 161 00002246968 .......... 161 00002246969 .......... 161 00002247008 ............ 40 00002247009 ............ 40 00002247010 ............ 40 00002247011 ............ 42 00002247012 ............ 42 00002247013 ............ 42 00002247014 ............ 43 00002247015 ............ 43 00002247021 ............ 11 00002247022 .......... 153 00002247027 ............ 87 00002247028 ............ 87 00002247029 ............ 87 00002247054 ............ 92 00002247055 ............ 92 00002247056 ............ 39 00002247057 ............ 39 00002247073 . SEC 3.21 00002247074 . SEC 3.21 00002247085 . SEC 3.80 00002247086 . SEC 3.80 00002247087 . SEC 3.80 00002247096 .......... 175 00002247097 .......... 175 00002247098 .......... 175 00002247128 ............ 16 00002247162 ............ 41
00002247163 ............ 41 00002247164 ............ 41 00002247243 ............ 98 00002247244 ............ 99 00002247310 ............ 26 00002247322 .......... 179 00002247323 .......... 188 00002247339 SEC 3A.2 00002247340 SEC 3A.3 00002247341 SEC 3A.3 00002247373 .SEC 3.14 00002247423 .............. 9 00002247437 .SEC 3.32 00002247439 ............ 50 00002247440 ............ 50 00002247461 .......... 134 00002247499 .......... 161 00002247500 .......... 161 00002247521 .SEC 3.38 00002247573 .............. 9 00002247574 .............. 9 00002247585 .SEC 3.85 00002247655 ............ 40 00002247656 ............ 40 00002247657 ............ 40 00002247686 ............ 24 00002247691 .......... 178 00002247692 .......... 178 00002247694 ............ 79 00002247698 ............ 79 00002247699 ............ 79 00002247700 ............ 79 00002247701 ............ 79 00002247704 .......... 104 00002247705 .......... 104 00002247706 .......... 104 00002247749 ............ 15 00002247751 ............ 93 00002247752 ............ 93 00002247802 ............ 61 00002247803 ............ 61 00002247811 ............ 93 00002247812 ............ 93 00002247813 .SEC 3.25 00002247818 .............. 9 00002247819 .............. 9 00002247823 ............ 17 00002247828 ............ 42 00002247830 ............ 42 00002247831 ............ 43
00002247833 ............ 43 00002247856 ............ 40 00002247857 ............ 40 00002247858 ............ 40 00002247876 ............ 52 00002247882 .......... 179 00002247917 ............ 63 00002247918 ............ 64 00002247919 ............ 64 00002247920 .......... 133 00002247922 ............ 15 00002247933 ............ 51 00002247934 ............ 51 00002247935 ............ 51 00002247936 ............ 51 00002247945 ............ 63 00002247946 ............ 64 00002247947 ............ 64 00002247997 .......... 129 00002248008 .......... 166 00002248009 .......... 166 00002248010 ............ 91 00002248011 ............ 91 00002248013 ............ 93 00002248014 ............ 93 00002248034 ............ 98 00002248035 ............ 99 00002248050 ............ 91 00002248051 ............ 91 00002248077 ............ 17 00002248077 SEC 3.67 00002248103 ............ 42 00002248104 ............ 42 00002248105 ............ 42 00002248106 ............ 43 00002248107 ............ 43 00002248130 .......... 178 00002248138 ............ 11 00002248170 ............ 91 00002248171 ............ 91 00002248182 ............ 40 00002248183 ............ 40 00002248184 ............ 40 00002248206 .......... 173 00002248232 ............ 87 00002248233 ............ 87 00002248234 ............ 87 00002248259 ............ 86 00002248260 ............ 86 00002248261 ............ 86
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 239
00002248262 SEC 3A.4 00002248263 SEC 3A.4 00002248296 . SEC 3.94 00002248347 .......... 137 00002248398 .......... 131 00002248437 SEC 3A.2 00002248438 SEC 3A.3 00002248439 SEC 3A.3 00002248440 . SEC 3.80 00002248441 . SEC 3.80 00002248451 ............ 93 00002248452 ............ 93 00002248472 . SEC 3.19 00002248529 .......... 131 00002248538 ............ 97 00002248539 ............ 97 00002248540 ............ 97 00002248557 ............ 93 00002248558 ............ 93 00002248570 .......... 145 00002248571 .......... 145 00002248572 ............ 39 00002248573 ............ 39 00002248639 . SEC 3.61 00002248640 . SEC 3.61 00002248641 . SEC 3.61 00002248642 . SEC 3.61 00002248686 .......... 188 00002248728 . SEC 3.14 00002248730 . SEC 3.14 00002248752 ............ 51 00002248753 ............ 51 00002248754 ............ 51 00002248756 SEC 3A.2 00002248757 SEC 3A.3 00002248758 SEC 3A.3 00002248762 ............ 98 00002248763 ............ 50 00002248764 ............ 50 00002248855 ............ 52 00002248856 .............. 9 00002248857 .............. 9 00002248860 ............ 88 00002248861 ............ 88 00002248862 ............ 88 00002248944 ............ 91 00002248945 ............ 91 00002248993 .......... 116 00002248993 . SEC 3.95 00002249324 .......... 109
00002249510 .......... 126 00002249669 .......... 189 00002249685 .......... 189 00002249790 . SEC 3.65 00002250039 ............ 37 00002250055 .......... 156 00002250144 ............ 42 00002250152 ............ 42 00002250160 ............ 42 00002250179 ............ 43 00002250187 ............ 43 00002250497 ............ 55 00002250500 ............ 55 00002250527 ............ 39 00002250608 ............ 98 00002250896 ............ 84 00002251450 .......... 113 00002251469 .......... 113 00002251515 ............ 63 00002251531 ............ 63 00002251574 ............ 64 00002251582 ............ 64 00002251930 .......... 163 00002252007 .......... 102 00002252015 .......... 102 00002252023 .......... 102 00002252031 .......... 103 00002252058 .......... 103 00002252066 .......... 103 00002252112 ............ 91 00002252120 ............ 91 00002252279 ............ 98 00002252309 ............ 51 00002252317 ............ 51 00002252325 ............ 51 00002252333 ............ 51 00002252570 .......... 131 00002252600 ............ 18 00002252716 .......... 132 00002252767 . SEC 3.20 00002253429 . SEC 3.69 00002253631 ............ 65 00002253933 .......... 131 00002254514 ............ 19 00002254522 ............ 19 00002254581 . SEC 3.71 00002254603 . SEC 3.71 00002254638 . SEC 3.71 00002254646 . SEC 3.71 00002254727 ............ 15
00002254778 ............ 93 00002254786 .......... 137 00002255340 .............. 9 00002255529 ............ 92 00002255537 ............ 92 00002255545 ............ 49 00002255553 ............ 50 00002255707 .SEC 3.76 00002255723 .SEC 3.76 00002255758 .SEC 3.76 00002256088 .SEC 3.17 00002256096 ............ 98 00002256118 ............ 98 00002256126 ............ 98 00002256134 ............ 50 00002256142 ............ 86 00002256150 ............ 86 00002256169 ............ 86 00002256177 ............ 50 00002256193 .......... 144 00002256436 .......... 115 00002256436 .SEC 3.84 00002256444 .......... 115 00002256444 .SEC 3.84 00002256460 .SEC 3.93 00002256479 .SEC 3.93 00002256487 .SEC 3.93 00002256495 .......... 189 00002256509 .......... 189 00002256711 .......... 146 00002256738 ............ 56 00002256746 ............ 56 00002256754 ............ 56 00002256762 ............ 56 00002256770 ............ 56 00002256797 ............ 61 00002256800 ............ 61 00002256819 ............ 62 00002257092 ............ 40 00002257106 ............ 40 00002257114 ............ 40 00002257238 .......... 159 00002257572 .......... 113 00002257580 .......... 113 00002257726 .......... 163 00002257734 .......... 163 00002257831 ............ 54 00002257858 ............ 54 00002257890 .......... 115 00002257890 .SEC 3.84
00002257904 .......... 115 00002257904 SEC 3.84 00002257955 .......... 181 00002257963 .......... 181 00002258056 ............ 32 00002258102 SEC 3.14 00002258110 SEC 3.14 00002258129 ............ 82 00002258188 .......... 143 00002258196 .......... 143 00002258331 ............ 14 00002258358 ............ 14 00002258439 .......... 102 00002258447 .......... 102 00002258455 .......... 102 00002258463 .......... 103 00002258471 .......... 103 00002258498 .......... 103 00002258528 ............ 44 00002258560 .......... 160 00002258587 .......... 160 00002258595 SEC 3.13 00002258692 .......... 138 00002259354 ............ 98 00002259605 ............ 55 00002259613 ............ 55 00002259893 SEC 3.87 00002260050 ............ 88 00002260069 ............ 88 00002260077 .......... 135 00002260565 SEC 3.64 00002260867 .......... 147 00002260883 ............ 86 00002260905 ............ 86 00002261081 .......... 156 00002261251 .......... 189 00002261278 .......... 189 00002261634 .............. 9 00002261642 SEC 3.17 00002261715 SEC 3.14 00002261723 .......... 159 00002261731 .......... 159 00002261766 SEC 3.85 00002261782 ............ 53 00002261790 ............ 53 00002261804 ............ 53 00002261839 ............ 85 00002261847 ............ 85 00002261855 ............ 85 00002261863 ............ 85
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 240 EFFECTIVE JULY 1, 2012
00002261901 ............ 72 00002261928 ............ 72 00002261936 ............ 72 00002261944 ............ 72 00002261952 ............ 72 00002261960 ............ 72 00002261979 ............ 62 00002261987 ............ 62 00002262177 ............ 15 00002262401 ............ 61 00002262428 ............ 61 00002262754 ............ 93 00002262762 ............ 93 00002262983 ............ 82 00002262991 ............ 88 00002263009 ............ 88 00002263017 ............ 88 00002263025 .......... 115 00002263025 . SEC 3.84 00002263033 .......... 115 00002263033 . SEC 3.84 00002263238 ............ 91 00002263254 ............ 91 00002263351 ............ 88 00002263378 ............ 88 00002263386 ............ 88 00002263866 .......... 188 00002264056 .......... 143 00002264064 .......... 143 00002264188 .......... 102 00002264196 .......... 102 00002264218 .......... 103 00002264226 .......... 103 00002264234 .......... 103 00002264749 .......... 178 00002264951 .......... 189 00002264978 .......... 189 00002264986 .......... 189 00002265273 ............ 29 00002265281 ............ 29 00002265303 ............ 29 00002265311 ............ 29 00002265338 ............ 30 00002265346 ............ 30 00002265494 ............ 87 00002265508 ............ 87 00002265516 ............ 87 00002265540 ............ 41 00002265826 .............. 9 00002266008 ............ 61
00002266016 ............ 61 00002266350 ............ 59 00002266369 ............ 59 00002266377 ............ 59 00002266385 .......... 178 00002266539 .............. 9 00002266547 .............. 9 00002266660 ............ 49 00002266687 .......... 109 00002266717 . SEC 3.42 00002266725 . SEC 3.42 00002266733 . SEC 3.42 00002267217 .......... 149 00002267233 .......... 148 00002267470 ............ 50 00002267489 ............ 50 00002267640 .......... 167 00002267837 ............ 88 00002267845 .............. 9 00002267918 .......... 113 00002267926 .......... 113 00002267985 ............ 49 00002267993 ............ 50 00002268027 ............ 51 00002268035 ............ 51 00002268043 ............ 51 00002268051 ............ 51 00002268078 .......... 148 00002268086 .......... 104 00002268094 .......... 104 00002268205 ............ 26 00002268388 .......... 115 00002268388 . SEC 3.84 00002268396 .......... 115 00002268396 . SEC 3.84 00002268914 .......... 115 00002268914 . SEC 3.84 00002268922 .......... 115 00002268922 . SEC 3.84 00002269031 .......... 163 00002269058 .......... 163 00002269090 .......... 136 00002269198 . SEC 3.94 00002269201 ... SEC 2.4 00002269252 ............ 42 00002269260 ............ 42 00002269279 ............ 42 00002269287 ............ 43 00002269295 ............ 43 00002269309 .......... 119
00002269325 .......... 119 00002269333 .......... 119 00002269430 ............ 93 00002269449 ............ 93 00002270625 ............ 54 00002270633 ............ 54 00002270641 ............ 84 00002270668 ............ 84 00002270676 ............ 84 00002270811 .......... 180 00002271184 ............ 88 00002271192 ............ 88 00002271206 ............ 88 00002271443 ............ 61 00002271451 ............ 61 00002271478 ............ 62 00002271605 ............ 57 00002271613 ............ 57 00002271621 ............ 57 00002271648 ............ 57 00002271656 ............ 58 00002271761 .......... 143 00002271788 .......... 143 00002271842 .......... 163 00002271931 .......... 113 00002271958 .......... 113 00002272059 .SEC 3.87 00002272083 .SEC 3.82 00002272113 ............ 55 00002272121 ............ 55 00002272695 ............ 24 00002272830 ............ 46 00002272873 .......... 118 00002272903 .......... 159 00002273217 .SEC 3.23 00002273225 .SEC 3.23 00002273373 ............ 55 00002273381 ............ 55 00002273497 .......... 141 00002273500 .......... 141 00002273551 ............ 37 00002273578 .SEC 3.64 00002273586 .SEC 3.64 00002273683 ............ 93 00002273691 ............ 93 00002273705 ............ 94 00002273918 ............ 58 00002273942 ............ 98 00002273969 ............ 90 00002273977 ............ 90
00002273985 ............ 90 00002274086 .......... 126 00002274183 ............ 87 00002274191 ............ 87 00002274205 ............ 87 00002274310 .......... 143 00002274329 .......... 143 00002274388 .............. 9 00002274396 .............. 9 00002274531 .............. 9 00002274728 SEC 3.38 00002274833 ............ 61 00002274841 ............ 61 00002274868 ............ 62 00002274914 SEC 3.72 00002274922 SEC 3.72 00002274930 SEC 3.72 00002275023 ............ 90 00002275031 ............ 90 00002275058 ............ 90 00002275066 SEC 3.90 00002275074 ............ 97 00002275082 ............ 97 00002275090 ............ 97 00002275104 ............ 97 00002275279 SEC 3.14 00002275287 .............. 9 00002275538 ............ 35 00002275546 ............ 35 00002276712 ............ 99 00002276720 ............ 99 00002276739 ............ 99 00002276747 ............ 99 00002276755 .......... 100 00002277263 SEC 3.82 00002277271 SEC 3.82 00002278251 .......... 138 00002278359 .............. 9 00002278529 .......... 143 00002278537 .......... 143 00002278545 ............ 90 00002278553 ............ 90 00002278561 ............ 90 00002278588 .............. 9 00002278618 .......... 143 00002278626 .......... 143 00002278669 .......... 148 00002278677 ............ 24 00002278685 ............ 24 00002279215 SEC 3.74
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 241
00002279266 .......... 104 00002279363 .......... 156 00002279460 .......... 164 00002279479 .......... 164 00002279614 ............ 88 00002279630 ............ 88 00002279649 ............ 88 00002279800 .......... 102 00002279819 .......... 103 00002279827 .......... 103 00002279835 .......... 103 00002279983 .......... 174 00002280132 ............ 55 00002280140 ............ 55 00002280191 .......... 187 00002280264 ............ 55 00002280272 ............ 56 00002280396 .......... 104 00002280442 ............ 59 00002280450 ............ 59 00002280469 ............ 59 00002280515 .......... 147 00002280523 .......... 147 00002280833 .......... 146 00002280906 .......... 102 00002280914 .......... 102 00002280922 .......... 102 00002280930 .......... 103 00002280949 .......... 103 00002280957 .......... 103 00002281260 ............ 15 00002281279 ............ 15 00002281392 ............ 48 00002281546 ............ 42 00002281554 ............ 42 00002281562 ............ 42 00002281570 ............ 43 00002281589 ............ 43 00002281791 ............ 99 00002281805 ............ 99 00002281813 ............ 99 00002281821 ............ 99 00002281848 .......... 100 00002282097 ... SEC 3.6 00002282119 .......... 102 00002282127 .......... 102 00002282135 .......... 102 00002282143 .......... 103 00002282151 .......... 103 00002282178 .......... 103
00002282224 ............ 17 00002282240 .......... 102 00002282259 .......... 102 00002282267 .......... 102 00002282275 .......... 103 00002282283 .......... 103 00002282291 .......... 103 00002282445 .......... 113 00002282585 .......... 102 00002282593 .......... 102 00002282607 .......... 102 00002282615 .......... 103 00002282623 .......... 103 00002282631 .......... 103 00002282690 .......... 102 00002282852 ............ 93 00002282860 ............ 93 00002282941 . SEC 3.39 00002282968 . SEC 3.40 00002282976 . SEC 3.40 00002282984 . SEC 3.40 00002283131 ............ 64 00002283158 ............ 64 00002283166 ............ 64 00002283174 ............ 64 00002283182 ............ 64 00002283395 . SEC 3.56 00002283409 . SEC 3.56 00002283417 . SEC 3.56 00002283778 ............ 59 00002283786 ............ 59 00002283794 ............ 59 00002283964 .......... 189 00002283972 .......... 189 00002284006 . SEC 3.14 00002284030 .......... 167 00002284049 .......... 167 00002284065 ............ 55 00002284073 ............ 55 00002284235 .......... 100 00002284243 .......... 100 00002284251 .......... 101 00002284278 .......... 101 00002284286 .......... 101 00002284383 ............ 55 00002284391 ............ 55 00002284421 ............ 40 00002284448 ............ 40 00002284456 ............ 40 00002284677 SEC 3A.4
00002284685 SEC 3A.4 00002284707 SEC 3A.4 00002284715 SEC 3A.4 00002284723 ............ 42 00002284731 ............ 42 00002284758 ............ 42 00002284766 ............ 43 00002284774 ............ 43 00002284987 ............ 59 00002285061 ............ 61 00002285088 ............ 61 00002285096 ............ 62 00002285118 ............ 61 00002285126 ............ 61 00002285134 ............ 62 00002285169 ............ 52 00002285177 ............ 52 00002285215 ............ 59 00002285223 ............ 59 00002285398 .SEC 3.59 00002285487 .......... 148 00002285606 .......... 155 00002285614 .......... 155 00002285622 ............ 91 00002285630 ............ 91 00002285649 SEC 3A.4 00002285657 ............ 97 00002285665 ............ 97 00002285819 ............ 86 00002285827 ............ 86 00002285835 ............ 86 00002285924 ............ 87 00002285932 ............ 87 00002285940 ............ 87 00002285959 ............ 17 00002285967 ............ 17 00002285975 ............ 17 00002286068 ............ 92 00002286076 ............ 92 00002286092 ............ 37 00002286246 ............ 49 00002286254 ............ 49 00002286262 ............ 49 00002286335 .SEC 3.14 00002286386 ... SEC 2.7 00002286521 .......... 115 00002286521 .SEC 3.84 00002286548 .......... 115 00002286548 .SEC 3.84 00002286556 ............ 17
00002286564 ............ 17 00002286572 ............ 17 00002286629 ............ 98 00002286823 .......... 115 00002286823 SEC 3.84 00002286831 .......... 115 00002286831 SEC 3.84 00002287021 ............ 27 00002287048 ............ 27 00002287064 ............ 27 00002287072 .......... 165 00002287226 ............ 13 00002287234 ............ 13 00002287390 ............ 93 00002287404 ............ 93 00002287412 ............ 94 00002287420 SEC 3.24 00002287439 SEC 3.24 00002287447 SEC 3.24 00002287498 ............ 29 00002287730 .......... 167 00002287749 .......... 167 00002287765 ............ 88 00002287773 ............ 88 00002287781 ............ 88 00002288044 ............ 37 00002288052 ............ 37 00002288087 SEC 3.14 00002288109 SEC 3.14 00002288184 .......... 143 00002288192 .......... 143 00002288346 ............ 38 00002288354 ............ 38 00002288362 ............ 38 00002288370 ............ 38 00002288680 SEC 3.30 00002289083 ............ 37 00002289091 ............ 37 00002289199 ............ 61 00002289202 ............ 61 00002289229 ............ 62 00002289504 ............ 69 00002290111 .......... 119 00002290146 .......... 119 00002290154 .......... 119 00002290332 ............ 58 00002290340 ............ 58 00002291037 ............ 57 00002291045 ............ 57 00002291053 ............ 57
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 242 EFFECTIVE JULY 1, 2012
00002291061 ............ 57 00002291088 ............ 58 00002291134 ............ 59 00002291142 ............ 59 00002291150 ............ 59 00002291177 . SEC 3.92 00002291185 . SEC 3.92 00002291398 ............ 63 00002291401 ............ 63 00002291428 ............ 64 00002291436 ............ 64 00002291789 .......... 104 00002291797 .......... 104 00002291878 ............ 60 00002291886 ............ 60 00002291894 ............ 60 00002291908 ............ 60 00002291967 .......... 143 00002292173 ............ 36 00002292203 ............ 61 00002292211 ............ 61 00002292238 ............ 62 00002292270 .............. 7 00002292289 .............. 7 00002292378 .......... 119 00002292394 .......... 119 00002292408 .......... 119 00002292866 .............. 7 00002292874 .............. 7 00002292882 .............. 7 00002292920 .......... 148 00002292998 .............. 6 00002293005 .............. 6 00002293161 . SEC 3.20 00002293218 ............ 91 00002293226 ............ 91 00002293528 .............. 6 00002293536 .............. 6 00002293579 .............. 6 00002293749 ............ 93 00002293811 .......... 147 00002293838 .......... 147 00002293943 .............. 6 00002293951 .............. 6 00002294230 ............ 61 00002294249 ............ 61 00002294257 ............ 62 00002294265 ............ 48 00002294273 ............ 15 00002294338 .......... 163
00002294346 .......... 164 00002294419 ............ 13 00002294427 ............ 13 00002294524 ............ 61 00002294532 ............ 61 00002294702 ............ 75 00002294710 ............ 75 00002295121 ............ 48 00002295148 ............ 55 00002295261 ............ 38 00002295288 ............ 38 00002295296 ............ 38 00002295318 ............ 38 00002295369 ............ 63 00002295415 .......... 147 00002295482 ............ 63 00002295490 ............ 63 00002295504 ............ 64 00002295512 ............ 64 00002295695 ............ 83 00002295709 ............ 83 00002295822 ............ 18 00002295881 .......... 125 00002295946 .......... 159 00002295954 .......... 159 00002296101 ............ 87 00002296128 ............ 87 00002296136 ............ 87 00002296152 ............ 91 00002296349 .......... 143 00002296357 .......... 143 00002296438 .......... 147 00002296446 .......... 147 00002296527 .......... 137 00002296551 .......... 100 00002296578 .......... 100 00002296594 .......... 101 00002296608 .......... 101 00002296616 .......... 113 00002296632 .......... 148 00002296640 .......... 148 00002296810 .......... 139 00002297302 .......... 119 00002297329 .......... 119 00002297337 .......... 119 00002297485 ............ 55 00002297493 ............ 55 00002297736 ............ 62 00002297744 ............ 62 00002297752 ............ 62
00002297795 .......... 165 00002297809 .......... 173 00002297841 ............ 67 00002297868 .......... 143 00002297876 .......... 143 00002297906 .SEC 3.72 00002297914 .SEC 3.72 00002297922 .SEC 3.72 00002298074 .......... 148 00002298082 .......... 148 00002298279 .SEC 3.72 00002298287 .SEC 3.72 00002298295 .SEC 3.72 00002298309 .SEC 3.93 00002298376 .SEC 3.75 00002298384 .SEC 3.75 00002298392 .SEC 3.75 00002298457 ............ 18 00002298538 .......... 159 00002298546 .......... 159 00002298570 ............ 48 00002298597 .......... 104 00002298600 .......... 104 00002298619 .......... 104 00002298627 .......... 104 00002298635 SEC 3A.4 00002298643 SEC 3A.4 00002298651 SEC 3A.4 00002298791 .......... 144 00002298813 .......... 144 00002299585 .......... 148 00002299615 .......... 138 00002299623 .SEC 3.73 00002299631 .SEC 3.73 00002299658 .SEC 3.73 00002299712 .SEC 3.14 00002299879 ............ 61 00002299887 ............ 61 00002299895 ............ 62 00002299933 ............ 60 00002299941 ............ 60 00002299968 ............ 60 00002299976 ............ 60 00002300036 ............ 60 00002300044 ............ 60 00002300052 ............ 60 00002300060 ............ 60 00002300079 ............ 60 00002300087 ............ 60 00002300095 ............ 60
00002300109 ............ 60 00002300222 ............ 60 00002300230 ............ 60 00002300486 .......... 148 00002300680 ............ 60 00002301083 .......... 148 00002301148 ............ 63 00002301156 ............ 63 00002301164 ............ 64 00002301172 ............ 64 00002301288 ............ 46 00002301407 SEC 3.18 00002301423 SEC 3.72 00002301431 SEC 3.72 00002301458 SEC 3.72 00002301482 ............ 90 00002301490 ............ 90 00002301768 ............ 62 00002301776 ............ 62 00002301784 ............ 62 00002302055 ............ 52 00002302136 ............ 62 00002302144 ............ 62 00002302152 ............ 62 00002302179 .............. 6 00002302187 .............. 6 00002302209 SEC 3.75 00002302365 ............ 62 00002302373 ............ 62 00002302381 ............ 62 00002302616 ............ 72 00002302624 ............ 72 00002302632 ............ 50 00002302640 ............ 50 00002302675 ............ 38 00002302683 ............ 38 00002302691 ............ 38 00002302713 ............ 38 00002302764 ............ 80 00002302772 ............ 80 00002302780 ............ 80 00002302799 ............ 80 00002302802 ............ 80 00002302861 SEC 3.72 00002302888 SEC 3.72 00002302896 SEC 3.72 00002302918 ............ 50 00002302926 ............ 50 00002302942 SEC 3.72 00002302950 SEC 3.72
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 243
00002302977 . SEC 3.72 00002303027 . SEC 3.20 00002303116 ............ 99 00002303124 . SEC 3.72 00002303132 . SEC 3.72 00002303140 . SEC 3.72 00002303159 ............ 99 00002303167 ............ 99 00002303175 ............ 99 00002303183 .......... 100 00002303191 .......... 100 00002303205 .......... 100 00002303396 ............ 52 00002303418 ............ 52 00002303426 .............. 6 00002303434 .............. 6 00002303442 . SEC 3.72 00002303450 . SEC 3.72 00002303469 . SEC 3.72 00002303647 ............ 49 00002303655 .......... 102 00002303663 .......... 102 00002303728 SEC 3A.2 00002303736 SEC 3A.3 00002303744 SEC 3A.3 00002303922 . SEC 3.81 00002304163 .......... 187 00002304317 ............ 90 00002304325 ............ 90 00002304333 ............ 90 00002304368 .......... 167 00002304376 .......... 167 00002304678 . SEC 3.15 00002304686 ............ 91 00002304694 ............ 91 00002305003 ............ 98 00002305011 ............ 99 00002305046 .......... 148 00002305259 .......... 143 00002305267 .......... 143 00002305429 .......... 135 00002305585 SEC 3A.4 00002305933 .......... 118 00002305941 .......... 118 00002305968 .......... 118 00002305984 . SEC 3.78 00002305992 . SEC 3.78 00002306018 . SEC 3.78 00002306026 . SEC 3.78 00002306034 . SEC 3.78
00002306042 . SEC 3.78 00002306050 . SEC 3.78 00002306069 . SEC 3.78 00002306212 .......... 143 00002306220 .......... 143 00002306239 ............ 91 00002306247 ............ 91 00002306905 . SEC 3.41 00002307669 . SEC 3.72 00002307677 . SEC 3.72 00002307723 . SEC 3.72 00002307804 .......... 100 00002307812 .......... 100 00002307839 .......... 101 00002307847 .......... 101 00002307871 .......... 148 00002307898 ............ 82 00002308444 . SEC 3.73 00002308452 . SEC 3.73 00002308460 . SEC 3.73 00002308894 .......... 142 00002308908 ............ 69 00002308916 ............ 70 00002309750 ............ 67 00002309769 ............ 67 00002309777 ............ 67 00002309866 .......... 148 00002310112 . SEC 3.41 00002310260 .......... 147 00002310279 ............ 90 00002310287 ............ 90 00002310295 ............ 90 00002310317 ............ 90 00002310325 ............ 90 00002310333 ............ 90 00002310341 ............ 99 00002310368 ............ 99 00002310376 ............ 99 00002310384 ............ 99 00002310392 .......... 100 00002310422 .......... 135 00002310503 ............ 63 00002310511 ............ 63 00002310538 ............ 64 00002310546 ............ 64 00002310805 .......... 148 00002310813 .......... 148 00002310899 ............ 38 00002310902 ............ 38 00002310910 ............ 38
00002310929 ............ 38 00002311283 .SEC 3.78 00002311291 .SEC 3.78 00002311305 .SEC 3.78 00002311313 .SEC 3.78 00002311658 ............ 65 00002311925 .SEC 3.39 00002312085 ............ 88 00002312247 .......... 143 00002312255 .......... 143 00002312298 .SEC 3.74 00002312441 .SEC 3.22 00002313332 ............ 67 00002313340 ............ 67 00002313359 ............ 67 00002313375 ............ 67 00002313383 ............ 68 00002313405 ............ 91 00002313413 ............ 91 00002313421 ............ 97 00002313448 ............ 38 00002313456 ............ 38 00002313464 ............ 38 00002313472 ............ 38 00002313685 .......... 143 00002313693 .......... 143 00002313707 ............ 38 00002313715 ............ 38 00002313723 ............ 38 00002313731 ............ 59 00002313758 ............ 38 00002313901 .......... 100 00002313928 .......... 100 00002313936 .......... 101 00002313944 .......... 101 00002313960 .......... 116 00002313960 .SEC 3.95 00002313979 SEC 3A.4 00002313987 SEC 3A.4 00002313995 .......... 100 00002314002 .......... 100 00002314010 .......... 101 00002314029 .......... 101 00002314037 .......... 119 00002314053 .......... 119 00002314061 .......... 120 00002314088 .......... 120 00002314177 .......... 148 00002314185 .......... 148 00002314282 .SEC 3.15
00002314290 .......... 114 00002314290 SEC 3.61 00002314304 .......... 114 00002314304 SEC 3.61 00002314630 SEC 3.39 00002314649 SEC 3.40 00002314657 SEC 3.40 00002314665 SEC 3.40 00002314940 SEC 3.15 00002315157 .............. 9 00002315165 .............. 9 00002315262 .......... 119 00002315289 .......... 119 00002315297 .......... 119 00002315424 SEC 3A.4 00002315432 SEC 3A.4 00002315440 SEC 3A.4 00002315645 ............ 88 00002315653 ............ 88 00002315661 ............ 88 00002315866 SEC 3.15 00002315971 ............ 66 00002315998 ............ 66 00002316005 ............ 66 00002316013 ............ 66 00002316021 ............ 66 00002316048 ............ 67 00002316080 .......... 100 00002316099 .......... 100 00002316110 .......... 101 00002316129 .......... 101 00002316307 .......... 136 00002316390 ............ 66 00002316404 ............ 66 00002316412 ............ 66 00002316846 .......... 119 00002316854 .......... 119 00002316862 .......... 120 00002316870 .......... 120 00002316943 SEC 3.42 00002316951 SEC 3.42 00002316978 SEC 3.42 00002316986 ............ 32 00002317060 ............ 66 00002317079 ............ 66 00002317087 ............ 66 00002317192 .......... 159 00002317206 .......... 159 00002317427 SEC 3A.2 00002317435 SEC 3A.3
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 244 EFFECTIVE JULY 1, 2012
00002317443 SEC 3A.3 00002317451 ............ 40 00002317478 ............ 40 00002317486 ............ 40 00002318008 .......... 137 00002318253 ... SEC 2.4 00002318261 ... SEC 2.4 00002318660 ............ 45 00002318679 ............ 45 00002318709 ............ 68 00002319012 .......... 181 00002319055 ............ 86 00002319063 ............ 86 00002319071 ............ 86 00002319403 ............ 78 00002319411 ............ 78 00002319438 ............ 78 00002319446 ............ 78 00002319616 ............ 45 00002319624 ............ 45 00002319632 ............ 45 00002319861 . SEC 3.75 00002319977 ............ 82 00002319985 ............ 82 00002319993 ............ 82 00002320134 ............ 15 00002320177 ............ 68 00002320185 ............ 68 00002320312 .......... 109 00002320525 .......... 138 00002320673 . SEC 3.91 00002320851 .......... 147 00002321149 ............ 56 00002321203 ............ 86 00002321211 ............ 86 00002321238 ............ 86 00002321343 .......... 100 00002321351 .......... 100 00002321459 .......... 117 00002321475 .......... 165 00002321483 .......... 165 00002321491 .......... 165 00002321653 ............ 63 00002321858 ............ 55 00002321866 ............ 55 00002322250 .......... 167 00002322285 . SEC 3.30 00002322323 .......... 114 00002322323 . SEC 3.61 00002322374 ............ 98
00002322382 ............ 98 00002322390 ............ 98 00002322404 ............ 98 00002322412 ............ 98 00002322455 ............ 98 00002322579 . SEC 3.41 00002323192 ............ 82 00002323206 ............ 82 00002323214 ............ 82 00002324032 .......... 187 00002324199 .......... 188 00002324229 .......... 116 00002324229 . SEC 3.95 00002324563 . SEC 3.78 00002324571 . SEC 3.78 00002324598 . SEC 3.78 00002324601 . SEC 3.78 00002324628 ............ 82 00002324768 .......... 116 00002324768 . SEC 3.95 00002324776 . SEC 3.46 00002324784 . SEC 3.46 00002324946 ............ 38 00002324954 ............ 38 00002324962 ............ 38 00002324970 ............ 38 00002324997 .......... 137 00002325063 . SEC 3.82 00002325071 . SEC 3.82 00002325462 .......... 161 00002325659 ............ 99 00002325667 ............ 99 00002325675 ............ 99 00002325683 ............ 99 00002325691 .......... 100 00002325942 SEC 3A.4 00002326477 . SEC 3.72 00002326485 . SEC 3.72 00002326493 . SEC 3.72 00002326590 .......... 119 00002326612 .......... 119 00002326620 .......... 120 00002326639 .......... 120 00002326760 ............ 55 00002326779 ............ 55 00002326787 ............ 55 00002326965 ............ 65 00002326973 ............ 65 00002327112 . SEC 3.39 00002327120 . SEC 3.39
00002327147 .SEC 3.40 00002327155 .SEC 3.40 00002327163 .SEC 3.40 00002327295 .SEC 3.75 00002327562 .......... 100 00002327570 .......... 100 00002327775 .......... 100 00002327783 .......... 100 00002328070 ............ 66 00002328089 ............ 66 00002328100 ............ 66 00002328305 .......... 102 00002328313 .......... 102 00002328321 .......... 102 00002328348 .......... 103 00002328364 .......... 103 00002328372 .......... 103 00002328461 ............ 66 00002328488 ............ 66 00002328496 ............ 66 00002328518 ............ 66 00002328526 ............ 66 00002328534 ............ 67 00002328593 .......... 129 00002328593 .SEC 3.60 00002329131 ............ 42 00002329158 ............ 42 00002329166 ............ 42 00002329174 ............ 43 00002329182 ............ 43 00002329204 .............. 6 00002329425 .......... 147 00002329433 .......... 147 00002329840 .SEC 3.17 00002330105 .SEC 3.39 00002330113 .SEC 3.39 00002330121 .SEC 3.40 00002330148 .SEC 3.40 00002330156 .SEC 3.40 00002330288 ............ 68 00002330385 .......... 129 00002330393 .......... 129 00002330393 .SEC 3.60 00002330415 .......... 100 00002330423 .......... 100 00002330458 .......... 101 00002330466 .......... 101 00002330512 ............ 66 00002330520 ............ 66 00002330539 ............ 67
00002330881 .............. 9 00002330911 SEC 3.17 00002330954 ............ 40 00002330962 ............ 40 00002330970 ............ 40 00002331004 ............ 61 00002331012 ............ 61 00002331020 ............ 42 00002331039 ............ 42 00002331047 ............ 42 00002331055 ............ 43 00002331063 ............ 43 00002331071 ............ 55 00002331098 ............ 55 00002331101 ............ 63 00002331128 ............ 63 00002331136 ............ 64 00002331144 ............ 64 00002331284 ............ 55 00002331292 ............ 55 00002331551 .......... 125 00002331624 .......... 137 00002331683 ............ 90 00002331691 ............ 90 00002331705 ............ 90 00002331748 ............ 18 00002331934 ............ 55 00002331942 ............ 55 00002331950 ............ 91 00002331969 ............ 42 00002331977 ............ 91 00002331985 ............ 42 00002331993 ............ 42 00002332000 ............ 43 00002332019 ............ 43 00002332027 .............. 6 00002332035 .............. 6 00002332043 .............. 6 00002332051 .......... 102 00002332078 .......... 102 00002332086 .......... 102 00002332094 .......... 103 00002332108 .......... 103 00002332116 .......... 103 00002332132 SEC 3A.2 00002332140 SEC 3A.3 00002332159 SEC 3A.3 00002332167 ............ 61 00002332175 ............ 61 00002332183 ............ 62
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 245
00002332191 ............ 40 00002332205 ............ 40 00002332213 ............ 40 00002332299 ............ 63 00002332302 ............ 63 00002332310 ............ 64 00002332329 ............ 64 00002332361 .......... 119 00002332388 .............. 9 00002332396 .............. 9 00002332426 .......... 119 00002332434 .......... 120 00002332442 .......... 120 00002332566 ............ 61 00002332574 ............ 61 00002332582 ............ 86 00002332590 ............ 86 00002332604 ............ 86 00002332809 . SEC 3.78 00002332817 . SEC 3.78 00002332825 . SEC 3.78 00002332833 . SEC 3.78 00002332922 ............ 65 00002332957 ............ 65 00002333554 . SEC 3.80 00002333619 .......... 166 00002333627 .......... 166 00002333856 . SEC 3.81 00002333864 . SEC 3.81 00002333872 . SEC 3.81 00002335700 ............ 36 00002335719 ............ 36 00002335727 ............ 36 00002336480 .......... 145 00002336502 .......... 145 00002336715 . SEC 3.78 00002336723 . SEC 3.78 00002336731 . SEC 3.78 00002336758 . SEC 3.78 00002337428 ............ 66 00002337436 ............ 66 00002337444 ............ 67 00002337495 ............ 69 00002337509 ............ 69 00002337517 ............ 69 00002337746 .......... 119 00002337762 .......... 119 00002337770 .......... 120 00002337800 .......... 120 00002337819 ... SEC 2.4
00002337827 .......... 118 00002337835 .......... 118 00002337878 ............ 99 00002337886 ............ 99 00002337894 ............ 99 00002337908 ............ 99 00002337916 .......... 100 00002337975 ............ 41 00002337983 ............ 41 00002337991 ............ 41 00002338009 ............ 41 00002338726 ............ 41 00002338734 ............ 41 00002338742 ............ 41 00002338750 ............ 41 00002339439 . SEC 3.42 00002339447 . SEC 3.42 00002339455 . SEC 3.42 00002339587 . SEC 3.72 00002339595 . SEC 3.72 00002339765 ............ 41 00002339773 ............ 41 00002339781 ............ 41 00002339803 ............ 41 00002340208 ............ 48 00002341379 . SEC 3.39 00002341387 . SEC 3.39 00002341395 . SEC 3.40 00002341409 . SEC 3.40 00002341417 . SEC 3.40 00002342138 ............ 64 00002342146 ............ 64 00002342154 ............ 64 00002342162 ............ 64 00002342170 ............ 64 00002342545 .......... 116 00002342545 . SEC 3.95 00002342855 ............ 14 00002342863 ............ 14 00002343002 .......... 187 00002343010 ............ 87 00002343029 ............ 87 00002343037 ............ 87 00002343282 ............ 74 00002343541 . SEC 3.24 00002344025 ............ 29 00002344033 ............ 29 00002344041 ............ 29 00002344068 ............ 29 00002344076 ............ 30
00002344084 ............ 30 00002344114 ............ 30 00002344122 .......... 113 00002344351 .......... 138 00002344823 .............. 7 00002344831 .............. 7 00002345579 .......... 148 00002345587 .......... 148 00002345803 ............ 88 00002345838 ............ 88 00002345846 ............ 88 00002347245 .............. 6 00002347253 .............. 6 00002347261 .............. 6 00002347288 .............. 6 00002347296 ............ 66 00002347318 ............ 66 00002347326 ............ 66 00002347512 ............ 51 00002347520 ............ 51 00002347555 ............ 51 00002347571 ............ 51 00002348004 .SEC 3.20 00002348500 .SEC 3.41 00002348691 .......... 147 00002348705 ............ 38 00002348713 ............ 38 00002348721 ............ 38 00002348748 ............ 38 00002348772 ............ 94 00002348780 ............ 94 00002348799 ............ 94 00002349167 ............ 56 00002349191 .......... 110 00002349205 .......... 110 00002350092 .SEC 3.89 00002350106 .SEC 3.89 00002350114 .SEC 3.89 00002350122 .SEC 3.82 00002350130 .SEC 3.82 00002350149 .SEC 3.82 00002350238 .......... 183 00002350297 ............ 38 00002350319 ............ 38 00002350327 ............ 38 00002350335 ............ 38 00002350394 ............ 52 00002350408 ............ 52 00002350440 .......... 148 00002350459 .......... 166
00002350467 .......... 166 00002350475 ............ 48 00002350483 ............ 48 00002350491 ............ 48 00002350505 ............ 48 00002350750 ............ 74 00002350769 ............ 74 00002350777 ............ 74 00002350785 ............ 75 00002350793 ............ 75 00002350807 ............ 75 00002350815 ............ 80 00002350890 ............ 80 00002350912 ............ 80 00002350920 ............ 80 00002350947 ............ 80 00002350963 ............ 59 00002350971 ............ 59 00002350998 ............ 59 00002351013 ............ 75 00002351021 ............ 75 00002351072 .......... 111 00002351080 .......... 111 00002351099 .......... 111 00002351102 .......... 145 00002351110 .......... 145 00002351234 ............ 13 00002351242 ............ 13 00002351420 ............ 44 00002351439 ............ 44 00002351447 ............ 45 00002351536 SEC 3.20 00002351579 ............ 18 00002351668 .......... 189 00002351676 .......... 189 00002351870 .......... 114 00002351870 SEC 3.79 00002351889 .......... 115 00002351889 SEC 3.79 00002352230 ............ 60 00002352249 ............ 60 00002352257 ............ 60 00002352265 ............ 60 00002352338 .......... 119 00002352346 .......... 119 00002352354 .......... 120 00002352362 .......... 120 00002352397 ............ 72 00002352400 ............ 72 00002352648 ............ 30
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 246 EFFECTIVE JULY 1, 2012
00002352656 ............ 30 00002352664 ............ 30 00002352672 ............ 30 00002352680 ............ 31 00002352710 ............ 10 00002352729 ............ 10 00002352745 ............ 10 00002352753 ............ 11 00002352761 ............ 10 00002352788 ............ 11 00002352923 ............ 60 00002352931 ............ 60 00002352966 . SEC 3.14 00002352974 .......... 100 00002352982 .......... 100 00002353016 .......... 145 00002353024 .......... 145 00002353040 .......... 119 00002353059 .......... 119 00002353067 .......... 120 00002353075 .......... 120 00002353121 ............ 15 00002353164 .......... 100 00002353172 .......... 100 00002353199 .......... 101 00002353202 .......... 101 00002353210 .......... 188 00002353229 ............ 39 00002353237 ............ 39 00002353245 ............ 86 00002353253 ............ 86 00002353261 ............ 86 00002353318 SEC 3A.2 00002353326 SEC 3A.3 00002353334 SEC 3A.3 00002353342 ............ 87 00002353350 ............ 87 00002353369 ............ 87 00002353377 .......... 163 00002353385 .......... 163 00002353504 ............ 67 00002353512 ............ 67 00002353520 ............ 93 00002353539 ............ 93 00002353547 ............ 94 00002353660 ............ 91 00002353679 ............ 91 00002353687 . SEC 3.75 00002353830 .......... 147 00002353849 .......... 147
00002354187 ............ 52 00002354195 ............ 52 00002354217 . SEC 3.65 00002354225 . SEC 3.65 00002354233 . SEC 3.65 00002354241 . SEC 3.65 00002354462 . SEC 3.41 00002354608 ............ 41 00002354616 ............ 41 00002354624 ............ 41 00002354632 ............ 41 00002354705 ............ 18 00002354713 ............ 90 00002354721 ............ 90 00002354748 ............ 90 00002354829 ............ 67 00002354837 ............ 67 00002354845 ............ 67 00002354926 .......... 165 00002354934 .......... 165 00002354942 .......... 165 00002354977 .......... 129 00002354985 .......... 129 00002354985 . SEC 3.60 00002355043 . SEC 3.41 00002355272 ............ 91 00002355280 ............ 91 00002355507 .......... 129 00002355515 .......... 129 00002355515 . SEC 3.60 00002355523 .......... 129 00002355523 . SEC 3.60 00002355663 .......... 165 00002355671 .......... 165 00002355698 .......... 165 00002355752 ............ 56 00002355760 ............ 57 00002355779 ............ 57 00002355787 ............ 57 00002356058 . SEC 3.41 00002356422 .......... 165 00002356511 .......... 148 00002356538 .......... 148 00002356546 ............ 40 00002356554 ............ 40 00002356562 ............ 40 00002356570 ............ 37 00002356589 ............ 37 00002356651 ............ 69 00002356678 ............ 69
00002356686 ............ 69 00002356694 ............ 69 00002356708 ............ 69 00002356716 ............ 69 00002356724 ............ 69 00002356732 ............ 70 00002356759 ............ 69 00002356767 ............ 69 00002356775 ............ 69 00002356813 ............ 52 00002356821 ............ 52 00002356848 ............ 52 00002356856 ............ 88 00002356864 ............ 88 00002356872 ............ 88 00002356880 .......... 102 00002356899 .......... 102 00002356902 .......... 102 00002356910 .......... 103 00002356929 .......... 103 00002356937 .......... 103 00002356996 ............ 69 00002357003 ............ 69 00002357011 ............ 69 00002357038 ............ 69 00002357046 ............ 70 00002357194 ............ 55 00002357208 ............ 55 00002357224 .SEC 3.41 00002357380 .SEC 3.39 00002357399 ............ 66 00002357402 ............ 66 00002357410 ............ 67 00002357453 .......... 165 00002357461 .......... 165 00002357488 .......... 165 00002357615 .SEC 3.55 00002357623 .SEC 3.55 00002357631 .SEC 3.56 00002357658 .SEC 3.56 00002357682 .......... 147 00002357690 .......... 147 00002357712 ............ 55 00002357720 ............ 55 00002357968 ............ 67 00002357976 ............ 67 00002357984 .SEC 3.75 00002358085 .......... 144 00002358093 .......... 144 00002358158 ............ 31
00002358166 ............ 31 00002358174 ............ 31 00002358182 ............ 32 00002358263 ............ 67 00002358611 .......... 129 00002358808 SEC 3.22 00002358921 SEC 3.74 00002359316 SEC 3.20 00002359502 ............ 78 00002359510 ............ 78 00002359529 .......... 102 00002359537 .......... 102 00002359545 .......... 102 00002359553 .......... 103 00002359561 .......... 103 00002359588 .......... 103 00002359790 .......... 102 00002359804 .......... 102 00002359812 .......... 102 00002359820 .......... 103 00002359839 .......... 103 00002359847 .......... 103 00002360020 ............ 90 00002360039 ............ 90 00002360047 ............ 90 00002360616 .......... 100 00002360624 .......... 100 00002361027 SEC 3A.4 00002361035 SEC 3A.4 00002361361 ............ 82 00002361469 ............ 86 00002361485 ............ 86 00002361493 ............ 86 00002361531 ............ 61 00002361558 ............ 61 00002361566 ............ 62 00002361698 .......... 115 00002361698 SEC 3.84 00002361892 .......... 100 00002362406 ............ 48 00002362449 ............ 67 00002362651 ............ 55 00002362678 ............ 55 00002362848 .............. 6 00002362856 .............. 6 00002362864 .............. 6 00002362872 .............. 6 00002362880 ............ 62 00002362899 ............ 62 00002362902 ............ 62
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE JULY 1, 2012 247
00002362937 ............ 98 00002362945 ............ 62 00002362953 ............ 62 00002362961 ............ 62 00002362988 .......... 116 00002362988 . SEC 3.95 00002362996 .......... 116 00002362996 . SEC 3.95 00002363100 ............ 69 00002363119 ............ 69 00002363208 ............ 66 00002363216 ............ 66 00002363224 ............ 67 00002363232 . SEC 3.72 00002363240 . SEC 3.72 00002363259 . SEC 3.72 00002363267 ............ 63 00002363275 ............ 63 00002363283 ............ 64 00002363291 ............ 64 00002363305 .......... 119 00002363321 .......... 119 00002363348 .......... 119 00002363364 .............. 9 00002363372 .............. 9 00002363380 .............. 9 00002363402 ............ 97 00002363429 .......... 148 00002363453 ............ 60 00002363461 ............ 60 00002363488 ............ 60 00002363496 ............ 60 00002363518 .......... 165 00002363534 .......... 113 00002363542 .......... 113 00002363674 ............ 54 00002363682 ............ 54 00002363704 .......... 166 00002363712 .......... 166 00002363763 ............ 92 00002363771 ............ 92 00002363798 ............ 49 00002363801 ............ 49 00002363828 ............ 49 00002363895 ............ 50 00002364115 ............ 78 00002364123 ............ 78 00002364131 ............ 78 00002364158 ............ 78 00002364239 ............ 39
00002364247 ............ 39 00002364263 ............ 36 00002364271 .......... 148 00002364301 ............ 96 00002364328 ............ 96 00002364336 ............ 36 00002364344 .......... 104 00002364409 ............ 37 00002364506 .......... 163 00002364514 .......... 163 00002364530 ............ 92 00002364573 ............ 44 00002364581 ............ 44 00002364603 ............ 45 00002364719 ............ 14 00002364727 ............ 14 00002364816 . SEC 3.75 00002364824 ............ 52 00002364832 ............ 52 00002364840 ............ 52 00002364859 ............ 52 00002364913 ............ 51 00002364921 ............ 51 00002364948 ............ 51 00002364956 ............ 51 00002365154 .............. 5 00002365359 ............ 65 00002365367 ............ 65 00002365383 . SEC 3.41 00002365820 ............ 74 00002365839 ............ 74 00002365847 ............ 75 00002365855 ............ 75 00002365863 ............ 75 00002366231 ............ 48 00002366258 .......... 115 00002366258 . SEC 3.84 00002366266 .......... 115 00002366266 . SEC 3.84 00002366312 ............ 65 00002366320 ............ 65 00002366339 ............ 65 00002366398 .............. 9 00002366665 ............ 72 00002366673 ............ 72 00002366681 ............ 72 00002366703 ............ 72 00002367068 ............ 69 00002367076 ............ 69 00002367084 ............ 69
00002367092 ............ 69 00002367106 ............ 70 00002367122 ............ 69 00002367130 ............ 69 00002367149 ............ 69 00002367157 .......... 178 00002367173 .......... 102 00002367181 .......... 102 00002367203 .......... 102 00002367211 .......... 103 00002367238 .......... 103 00002367246 .......... 103 00002367335 .......... 137 00002367378 .......... 145 00002367386 .......... 145 00002367394 ............ 85 00002367564 ............ 49 00002367572 ............ 50 00002367602 .......... 119 00002367947 .......... 157 00002367955 .......... 157 00002367963 .......... 157 00002367971 .......... 157 00002368013 ............ 49 00002368021 ............ 49 00002368048 ............ 50 00002368226 .......... 129 00002368226 .SEC 3.60 00002368242 ............ 48 00002368277 ............ 67 00002368285 ............ 67 00002368293 ............ 67 00002368641 ............ 49 00002368668 ............ 50 00002369036 .......... 116 00002369036 .SEC 3.95 00002370077 ............ 91 00002370255 .SEC 3.75 00002370441 ............ 57 00002370492 ............ 57 00002370506 ............ 57 00002370514 ............ 57 00002370522 ............ 58 00002370611 ............ 56 00002370638 ............ 57 00002370646 ............ 57 00002370654 ............ 57 00002370689 ............ 98 00002370697 .......... 104 00002370700 .......... 104
00002370735 ............ 51 00002370743 ............ 51 00002370751 ............ 51 00002370786 ............ 51 00002370808 .......... 148 00002370921 SEC 3.57 00002370972 ............ 88 00002370980 ............ 88 00002370999 ............ 88 00002371022 ............ 68 00002371030 ............ 68 00002371049 ............ 68 00002371057 ............ 68 00002371235 ............ 67 00002371243 ............ 67 00002371251 ............ 68 00002371413 ............ 27 00002371421 ............ 27 00002371529 ............ 69 00002371537 ............ 69 00002371545 ............ 69 00002371677 ............ 87 00002371685 ............ 87 00002371693 ............ 87 00002371715 ............ 55 00002371723 ............ 55 00002371731 .......... 143 00002371758 .......... 143 00002371766 .......... 102 00002371774 .......... 102 00002371782 .......... 102 00002371790 .......... 103 00002371804 .......... 103 00002371812 .......... 103 00002371820 SEC 3.41 00002371898 ............ 91 00002371901 ............ 91 00002371987 ............ 49 00002371995 ............ 50 00002372347 ............ 66 00002372371 ............ 66 00002372398 ............ 66 00002372525 ............ 82 00002372533 ............ 82 00002372541 ............ 82 00002372568 ............ 82 00002372576 ............ 82 00002372584 ............ 82 00002372797 ............ 82 00002372819 ............ 99
ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER
DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 248 EFFECTIVE JULY 1, 2012
00002372827 ............ 99 00002372835 ............ 99 00002372843 ............ 99 00002372851 .......... 100 00002372886 ............ 66 00002372894 ............ 66 00002372908 ............ 67 00002372932 ............ 42 00002372940 ............ 42 00002372959 ............ 42 00002372967 ............ 43 00002372975 ............ 43 00002373041 .......... 137 00002373203 ............ 38 00002373211 ............ 38 00002373238 ............ 38 00002373246 ............ 38 00002373319 ............ 66 00002373327 ............ 66 00002373335 ............ 66 00002373343 ............ 66 00002373351 ............ 66 00002373378 ............ 67 00002373432 ............ 99 00002373440 ............ 99 00002373459 ............ 99 00002373467 ............ 99 00002373564 ............ 68 00002373572 ............ 68 00002373734 ............ 69 00002373742 ............ 69 00002373750 ............ 69 00002373769 ............ 69 00002373777 ............ 70 00002373920 .......... 145 00002373939 .......... 145 00002373947 .......... 129 00002373947 . SEC 3.60 00002374552 ............ 93 00002374560 ............ 93 00002374579 ............ 94 00002374609 .......... 129 00002374609 . SEC 3.60 00002374730 .......... 114 00002374730 . SEC 3.79 00002374749 .......... 115 00002374749 . SEC 3.79 00002374757 .......... 187 00002374846 ............ 63 00002374854 ............ 64
00002374862 ............ 64 00002374870 .......... 147 00002375036 ............ 42 00002375044 ............ 42 00002375052 ............ 42 00002375060 ............ 43 00002375079 ............ 43 00002375249 ............ 87 00002375257 ............ 87 00002375265 ............ 87 00002375559 .......... 117 00002375958 ............ 68 00002375966 ............ 68 00002376091 .......... 143 00002376105 .......... 143 00002376350 .......... 119 00002376377 .......... 119 00002376385 .......... 119 00002376539 ............ 65 00002376547 ............ 65 00002376555 ............ 65 00002376717 ............ 68 00002376725 ............ 68 00002377144 ............ 67 00002377152 ............ 68 00002377608 .......... 129 00002377616 .......... 129 00002377616 . SEC 3.60 00002377950 . SEC 3.42 00002377969 . SEC 3.42 00002377977 . SEC 3.42 00002378078 ............ 67 00002378086 ............ 67 00002378094 ............ 68 00002378523 ............ 41 00002378531 ............ 41 00002378558 ............ 41 00002378566 ............ 41 00002378620 .......... 163 00002378639 .......... 163 00002378841 .......... 163 00002378868 .......... 163 00002378884 ............ 42 00002378892 ............ 42 00002378906 ............ 42 00002378914 ............ 43 00002378922 ............ 43 00002379058 ............ 67 00002379139 ............ 65 00002379147 ............ 65
00002379155 ............ 65 00002379198 .......... 114 00002379198 .SEC 3.79 00002379201 .......... 115 00002379201 .SEC 3.79 00002379252 ............ 68 00002379279 ............ 65 00002379287 ............ 65 00002379295 ............ 65 00002379317 .......... 129 00002379325 .......... 129 00002379325 .SEC 3.60 00002379333 .......... 129 00002379333 .SEC 3.60 00002379686 SEC 3A.2 00002379694 SEC 3A.3 00002379708 SEC 3A.3 00002380072 ............ 90 00002380080 ............ 90 00002380099 ............ 90 00002380560 ............ 92 00002380579 ............ 92 00002380749 .......... 129 00002380757 .......... 129 00002380757 .SEC 3.60 00002380838 ............ 67 00002380900 .......... 144 00002380919 .......... 144 00002381265 ............ 41 00002381273 ............ 41 00002381281 ............ 41 00002381303 ............ 41 00002382547 ............ 69 00002382555 ............ 69 00002382563 ............ 69 00002382571 ............ 69 00002382598 ............ 70 00002382644 ............ 41 00002382652 ............ 41 00002382660 ............ 41 00002382679 ............ 41 00002382709 .......... 100 00002382717 .......... 100 00080024360 .......... 125 00080027202 .......... 125 00002298309 ............ 28 00002291185 ............ 28 00002291177 ............ 28 00002293161 ............ 32 00002359316 ............ 32
00002348004 ............ 32 00002351536 ............ 32 00002303027 ............ 32 00002252767 ............ 32 00002238682 ............ 32