products and pricing on the alberta blue cross drug price ... · 00000821772 d-tab 10,000 unit...

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective March 12, 2021 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000999041 3M CAVILON NO STING BARRIER FILM (WIPES) TOP DEFAUL MMH MIS 1.2783 00002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.3529 00002192683 3TC 150 MG TABLET ORL TAB GSK TAB 5.4647 00002247825 3TC 300 MG TABLET ORL TAB GSK TAB 10.9713 00002162113 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL CLC G 0.2207 00002166607 5 BENZAGEL 5% TOPICAL LOTION TOP LOT NVC ML 0.1984 00000437999 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ INJ DEFAUL BAX ML 0.0035 00000037974 50% DEXTROSE 500 MG/ML INJECTION USP INJ DEFAUL HSP ML 0.6076 00080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.2167 00002473496 AA-TELMISARTAN-AMLODIPINE 80 MG/10 MG TABLET ORL TAB AAP TAB 0.5472 00002473488 AA-TELMISARTAN-AMLODIPINE 80 MG/5 MG TABLET ORL TAB AAP TAB 0.5472 00080097021 ABBY-IRON 20 MGML ORAL LIQUID ORL LIQ ABY ML 0.0705 00080094612 ABBY-K 100 MG/ML ORAL LIQUID ORL LIQ ABY ML 0.0400 00002231590 ABELCET 5MG/ML LIPID COMPLEX INJECTION INJ DEFAUL SGM ML 10.1755 00001919385 ABENOL 120 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.5417 00001919393 ABENOL 325 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.6692 00001919407 ABENOL 650 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.7683 00002281066 ABRAXANE 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 971.0000 00002245677 ABREVA 10% TOPICAL CREAM TOP CRM GKC G 7.2800 00001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.0510 00002463644 ACARIZAX 12 UNIT SQ-HDM TABLET SLG SLT ALK TAB 4.1080 00002463776 ACCEL-CANDESARTAN 16 MG TABLET ORL TAB ACP TAB 0.2281 00002463784 ACCEL-CANDESARTAN 32 MG TABLET ORL TAB ACP TAB 0.2281 00002463768 ACCEL-CANDESARTAN 8 MG TABLET ORL TAB ACP TAB 0.2281 00002463865 ACCEL-CANDESARTAN/HCTZ 16 MG/12.5 MG TABLET ORL TAB ACP TAB 0.2156 00002463849 ACCEL-CANDESARTAN/HCTZ 32 MG/12.5 MG TABLET ORL TAB ACP TAB 0.2156 00002463857 ACCEL-CANDESARTAN/HCTZ 32 MG/25 MG TABLET ORL TAB ACP TAB 0.2156 00002355248 ACCEL-CITALOPRAM 10 MG TABLET ORL TAB ACP TAB 0.0715 00002355256 ACCEL-CITALOPRAM 20 MG TABLET ORL TAB ACP TAB 0.1200 00002355264 ACCEL-CITALOPRAM 40 MG TABLET ORL TAB ACP TAB 0.1200 00002303442 ACCEL-PIOGLITAZONE 15 MG TABLET ORL TAB ACP TAB 0.3170 00002303450 ACCEL-PIOGLITAZONE 30 MG TABLET ORL TAB ACP TAB 0.4550 00002303469 ACCEL-PIOGLITAZONE 45 MG TABLET ORL TAB ACP TAB 0.6900 00002461501 ACCEL-SEVELAMER 800 MG TABLET ORL TAB ACP TAB 1.2634 00002479826 ACCEL-SILDENAFIL 100 MG TABLET ORL TAB ACP TAB 2.9475 00002479796 ACCEL-SILDENAFIL 25 MG TABLET ORL TAB ACP TAB 2.6550 00002479818 ACCEL-SILDENAFIL 50 MG TABLET ORL TAB ACP TAB 2.8350 00002164396 ACEBUTOLOL-100 100 MG TABLET ORL TAB PDL TAB 0.0787 00002164418 ACEBUTOLOL-200 200 MG TABLET ORL TAB PDL TAB 0.1177 00002164426 ACEBUTOLOL-400 400 MG TABLET ORL TAB PDL TAB 0.2466 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 1 of 129

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Page 1: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999041 3M CAVILON NO STING BARRIER FILM (WIPES) TOP DEFAUL MMH MIS 1.278300002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.352900002192683 3TC 150 MG TABLET ORL TAB GSK TAB 5.464700002247825 3TC 300 MG TABLET ORL TAB GSK TAB 10.971300002162113 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL CLC G 0.220700002166607 5 BENZAGEL 5% TOPICAL LOTION TOP LOT NVC ML 0.198400000437999 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ INJ DEFAUL BAX ML 0.003500000037974 50% DEXTROSE 500 MG/ML INJECTION USP INJ DEFAUL HSP ML 0.607600080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.216700002473496 AA-TELMISARTAN-AMLODIPINE 80 MG/10 MG TABLET ORL TAB AAP TAB 0.547200002473488 AA-TELMISARTAN-AMLODIPINE 80 MG/5 MG TABLET ORL TAB AAP TAB 0.547200080097021 ABBY-IRON 20 MGML ORAL LIQUID ORL LIQ ABY ML 0.070500080094612 ABBY-K 100 MG/ML ORAL LIQUID ORL LIQ ABY ML 0.040000002231590 ABELCET 5MG/ML LIPID COMPLEX INJECTION INJ DEFAUL SGM ML 10.175500001919385 ABENOL 120 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.541700001919393 ABENOL 325 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.669200001919407 ABENOL 650 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.768300002281066 ABRAXANE 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 971.000000002245677 ABREVA 10% TOPICAL CREAM TOP CRM GKC G 7.280000001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.051000002463644 ACARIZAX 12 UNIT SQ-HDM TABLET SLG SLT ALK TAB 4.108000002463776 ACCEL-CANDESARTAN 16 MG TABLET ORL TAB ACP TAB 0.228100002463784 ACCEL-CANDESARTAN 32 MG TABLET ORL TAB ACP TAB 0.228100002463768 ACCEL-CANDESARTAN 8 MG TABLET ORL TAB ACP TAB 0.228100002463865 ACCEL-CANDESARTAN/HCTZ 16 MG/12.5 MG TABLET ORL TAB ACP TAB 0.215600002463849 ACCEL-CANDESARTAN/HCTZ 32 MG/12.5 MG TABLET ORL TAB ACP TAB 0.215600002463857 ACCEL-CANDESARTAN/HCTZ 32 MG/25 MG TABLET ORL TAB ACP TAB 0.215600002355248 ACCEL-CITALOPRAM 10 MG TABLET ORL TAB ACP TAB 0.071500002355256 ACCEL-CITALOPRAM 20 MG TABLET ORL TAB ACP TAB 0.120000002355264 ACCEL-CITALOPRAM 40 MG TABLET ORL TAB ACP TAB 0.120000002303442 ACCEL-PIOGLITAZONE 15 MG TABLET ORL TAB ACP TAB 0.317000002303450 ACCEL-PIOGLITAZONE 30 MG TABLET ORL TAB ACP TAB 0.455000002303469 ACCEL-PIOGLITAZONE 45 MG TABLET ORL TAB ACP TAB 0.690000002461501 ACCEL-SEVELAMER 800 MG TABLET ORL TAB ACP TAB 1.263400002479826 ACCEL-SILDENAFIL 100 MG TABLET ORL TAB ACP TAB 2.947500002479796 ACCEL-SILDENAFIL 25 MG TABLET ORL TAB ACP TAB 2.655000002479818 ACCEL-SILDENAFIL 50 MG TABLET ORL TAB ACP TAB 2.835000002164396 ACEBUTOLOL-100 100 MG TABLET ORL TAB PDL TAB 0.078700002164418 ACEBUTOLOL-200 200 MG TABLET ORL TAB PDL TAB 0.117700002164426 ACEBUTOLOL-400 400 MG TABLET ORL TAB PDL TAB 0.2466

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 1 of 129

Page 2: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002230435 ACET 160 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.624200001999648 ACET CODEINE 30 TABLET ORL TAB PMS TAB 0.165500002483343 ACETAMINOPHEN 10 MG/ML INJECTION INJ DEFAUL AVP ML 0.150000001977415 ACETAMINOPHEN 325 MG CAPLET ORL TAB TLI TAB 0.059200000374148 ACETAMINOPHEN 325 MG TABLET ORL TAB WAM TAB 0.018400001938088 ACETAMINOPHEN 325 MG TABLET ORL TAB JPC TAB 0.012000000789801 ACETAMINOPHEN 325 MG TABLET ORL TAB TLI TAB 0.059200000605751 ACETAMINOPHEN 325 MG TABLET ORL TAB VTH TAB 0.027200000789798 ACETAMINOPHEN 500 MG TABLET ORL TAB TLI TAB 0.024300001905864 ACETAMINOPHEN 80 MG/ML ORAL DROPS ORL DPS TLI ML 0.130000002272482 ACETAMINOPHEN ARTHRITIS PAIN 650 MG EXT.REL TABLET ORL ERT PRI TAB 0.075500002028174 ACETAMINOPHEN COMPOUND WITH CODEINE CAPLET ORL TAB PPH TAB 0.026000001905856 ACETAMINOPHEN COMPRIME A CROQUER 80 MG ORL TAB TLI TAB 0.100000002255251 ACETAMINOPHEN EXT STR EASY TO SWALLOW 500 MG TAB ORL TAB PMT TAB 0.066000000605778 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB WTR TAB 0.030600002285797 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB VTH TAB 0.060000001958836 ACETAMINOPHEN ORAL SOLUTION FOR CHILDREN USP ORL SOL TLI ML 0.029600002143933 ACETAMINOPHEN WITH CODEINE CAPLET ORL TAB ROG TAB 0.046000002025337 ACETAMINOPHEN WITH CODEINE TABLET ORL TAB PMS TAB 0.026000002251914 ACETAMINOPHEN, CAFFEINE & 8 MG CODEINE PHOS. TAB ORL TAB PMT TAB 0.039600002017431 ACETAMINOPHENE 160 MGCO.CROQUABLE POUR ENFANT ORL CTB RIV TAB 0.147500002022214 ACETAMINOPHENE 325 MG COMPRIME ORL TAB RIV TAB 0.011400002362228 ACETAMINOPHENE 500 MG CAPLET ORL TAB RIV TAB 0.014900002022222 ACETAMINOPHENE 500 MG COMPRIME ORL TAB RIV TAB 0.014900002017458 ACETAMINOPHENE 80MGCO.CROQUABLE POUR ENFANT ORL CTB RIV TAB 0.100000000834319 ACETAZONE FORTE C-8 TABLET ORL TAB RPH TAB 0.449500001999656 ACET-CODEINE 60 MG TABLET ORL TAB PMS TAB 0.264000002300435 ACETYLCYSTEINE 20% INHALATION SOLUTION INH SOL ALV ML 2.100000002459906 ACETYLCYSTEINE 20% INHALATION SOLUTION USP INH SOL TGT ML 2.750000002269139 ACETYLSALICYLIC ACID 80 MG CHEWABLE TABLET ORL CTB JPC TAB 0.056000002351218 ACH-ANASTROZOLE 1 MG TABLET ORL TAB AHI TAB 2.546000002426757 ACH-CAPECITABINE 150 MG TABLET ORL TAB AHI TAB 1.464000002426765 ACH-CAPECITABINE 500 MG TABLET ORL TAB AHI TAB 4.880000002490986 ACH-IMATINIB 100 MG TABLET ORL TAB AHI TAB 20.455600002490994 ACH-IMATINIB 400 MG TABLET ORL TAB AHI TAB 81.822700002383780 ACH-MYCOPHENOLATE 250 MG CAPSULE ORL CAP AHI CAP 1.0310

00002450879 ACH-QUETIAPINE FUMARATE XR 150 MG EXTENDED-REL TAB ORL ERT AHI TAB 0.4927

00002450887 ACH-QUETIAPINE FUMARATE XR 200 MG EXTENDED-REL TAB ORL ERT AHI TAB 0.6662

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 2 of 129

Page 3: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002450895 ACH-QUETIAPINE FUMARATE XR 300 MG EXTENDED-REL TAB ORL ERT AHI TAB 0.9777

00002450909 ACH-QUETIAPINE FUMARATE XR 400 MG EXTENDED-REL TAB ORL ERT AHI TAB 1.3270

00002450860 ACH-QUETIAPINE FUMARATE XR 50 MG EXTENDED-REL TAB ORL ERT AHI TAB 0.250200002247551 ACID REDUCER 75 MG TABLET ORL TAB PMS TAB 0.106700080042609 ACIDOPHILUS PROBIOTIC COMPLETE CAPSULE ORL CAP WNP CAP 0.367000080011789 ACIDOPHILUS WITH BIFIDUS CAPSULE ORL CAP WNP CAP 0.1082

00002439247 ACT AMPHETAMINE XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.0758

00002439255 ACT AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.3250

00002439263 ACT AMPHETAMINE XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.5743

00002439271 ACT AMPHETAMINE XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.8235

00002439298 ACT AMPHETAMINE XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 3.0729

00002439239 ACT AMPHETAMINE XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 1.826600002394898 ACT ANASTROZOLE 1 MG TABLET ORL TAB APH TAB 2.546000002255553 ACT ATENOLOL 100 MG TABLET ORL TAB APH TAB 0.182100002255545 ACT ATENOLOL 50 MG TABLET ORL TAB APH TAB 0.110700002301407 ACT CABERGOLINE 0.5 MG TABLET ORL TAB APH TAB 10.6188

00002397145 ACT DICLO-MISO 50 MG/200 MCG ENTERIC-COATED TABLET ORL ECT APH TAB 0.3149

00002397153 ACT DICLO-MISO 75 MG/200 MCG ENTERIC-COATED TABLET ORL ECT APH TAB 0.428600002370441 ACT DILTIAZEM T 120 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 0.213300002370492 ACT DILTIAZEM T 180 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 0.288900002370506 ACT DILTIAZEM T 240 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 0.383200002370514 ACT DILTIAZEM T 300 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 0.471900002370522 ACT DILTIAZEM T 360 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 0.577800002305682 ACT FAMCICLOVIR 125 MG TABLET ORL TAB APH TAB 2.024000002305690 ACT FAMCICLOVIR 250 MG TABLET ORL TAB APH TAB 2.720000002305704 ACT FAMCICLOVIR 500 MG TABLET ORL TAB APH TAB 4.228100002250012 ACT MELOXICAM 7.5 MG TABLET ORL TAB APH TAB 0.491400002324067 ACT MEMANTINE 10 MG TABLET ORL TAB APH TAB 1.6357

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 3 of 129

Page 4: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002441934 ACT METHYLPHENIDATE ER 18 MG EXTENDED-RELEASE TAB ORL ERT APH TAB 1.4276

00002441942 ACT METHYLPHENIDATE ER 27 MG EXTENDED-RELEASE TAB ORL ERT APH TAB 1.6475

00002441950 ACT METHYLPHENIDATE ER 36 MG EXTENDED-RELEASE TAB ORL ERT APH TAB 1.8674

00002441969 ACT METHYLPHENIDATE ER 54 MG EXTENDED-RELEASE TAB ORL ERT APH TAB 2.307200002327570 ACT OLANZAPINE ODT 10 MG ORAL DISINT. TABLET ORL DISNTAB TEV TAB 0.714300002327597 ACT OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB TEV TAB 7.597700002262754 ACT PAROXETINE 20 MG TABLET ORL TAB APH TAB 0.325000002297310 ACT PRAMIPEXOLE 0.5 MG TABLET ORL TAB APH TAB 1.386000002446820 ACT PROGESTERONE INJECTION 50 MG/ML INJECTION INJ DEFAUL APH ML 5.861000002437961 ACT PROPOFOL 10 MG/ML INJECTION INJ DEFAUL APH ML 0.460000002248570 ACT RANITIDINE 150 MG TABLET ORL TAB TEV TAB 0.119700002248571 ACT RANITIDINE 300 MG TABLET ORL TAB APH TAB 0.225300002395282 ACT TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APH CAP 113.596000002395290 ACT TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APH CAP 159.036000002395274 ACT TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APH CAP 22.720000002395312 ACT TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APH CAP 283.984000002441160 ACT TEMOZOLOMIDE 5 MG CAPSULE ORL CAP APH CAP 6.6300

00002454297 ACT-ESCITALOPRAM ODT 10 MG ORAL DISINTEGRATING TAB ORL DISNTAB APH TAB 1.5707

00002454300 ACT-ESCITALOPRAM ODT 20 MG ORAL DISINTEGRATING TAB ORL DISNTAB APH TAB 1.672300002249405 ACTIVELLE 1 MG/0.5 MG TABLET ORL TAB NNA TAB 2.558900002309009 ACTIVELLE LD 0.5 MG/0.1 MG TABLET ORL TAB NNA TAB 2.558900002316838 ACTONEL 150 MG TABLET ORL TAB ALL TAB 58.570000002370417 ACTONEL DR 35 MG DELAYED-RELEASE TABLET ORL DRT ALL TAB 13.562500002248722 ACULAR LS 0.4% OPH SOLUTION OPH SOL ALL ML 3.560000002236916 ACYCLOVIR SODIUM 25 MG/ML INJECTION INJ DEFAUL PFI ML 4.862000002236926 ACYCLOVIR SODIUM 50 MG/ML INJECTION INJ DEFAUL FKC ML 12.584000002456524 ACYCLOVIR SODIUM 50 MG/ML INJECTION INJ DEFAUL STM ML 12.584000002281074 ACZONE 5% TOPICAL GEL TOP GEL VCL G 1.114800002240255 ADACEL INJECTION INJ DEFAUL SFP ML 73.500000002352044 ADACEL-POLIO INJECTION INJ DEFAUL SFP ML 79.900000002313766 ADALAT XL PLUS 20 MG/81 MG TABLET ORL ERT BAI TAB 0.655500002313774 ADALAT XL PLUS 30 MG/81 MG TABLET ORL ERT BAI TAB 0.617000002313782 ADALAT XL PLUS 60 MG/81 MG TABLET ORL ERT BAI TAB 0.937300000266507 ADASEPT 0.5% TOPICAL LIQUID TOP LIQ ODN ML 0.0350

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 4 of 129

Page 5: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002290081 ADASEPT BP5 ACNE GEL 5% TOPICAL GEL TOP GEL ODN ML 0.179000002401347 ADCETRIS 50MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL STG VIAL 4840.000000002338327 ADCIRCA 20 MG TABLET ORL TB LIL TAB 12.157300002248809 ADDERALL XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.442100002248810 ADDERALL XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.735300002248811 ADDERALL XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.028600002248812 ADDERALL XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.321800002248813 ADDERALL XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.615200002248808 ADDERALL XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.148900002473550 ADDYI 100 MG TABLET ORL TAB SPH TAB 8.000000002412764 ADEMPAS 0.5 MG TABLET ORL TAB BAI TAB 43.720000002412772 ADEMPAS 1 MG TABLET ORL TAB BAI TAB 43.720000002412799 ADEMPAS 1.5 MG TABLET ORL TAB BAI TAB 43.720000002412802 ADEMPAS 2 MG TABLET ORL TAB BAI TAB 43.720000002412810 ADEMPAS 2.5 MG TABLET ORL TAB BAI TAB 43.720000002464349 ADLYXINE STARTER KIT INJ DEFAUL SAV ML 18.993300002469901 ADMELOG 100 UNIT/ML INJECTION INJ DEFAUL SAV ML 2.270000002469898 ADMELOG 100 UNIT/ML INJECTION CARTRIDGE INJ DEFAUL SAV ML 3.000000002469871 ADMELOG PEN 100 UNIT/ML INJECTION INJ DEFAUL SAV ML 3.000000080031182 ADULT ESSENTIALS OMEGA-3 GUMMY ORL CTB LSN TAB 0.066600002296462 ADVAGRAF 0.5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 1.970000002296470 ADVAGRAF 1 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 2.520000002331667 ADVAGRAF 3 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 7.560000002296489 ADVAGRAF 5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 12.620000080025646 ADVANCED B COMPLEX ORL CAP AOR CAP 0.294100002443562 ADVIL 12 HOUR 600 MG EXTENDED-RELEASE TABLET ORL ERT PDH TAB 0.276200001933558 ADVIL 200 MG TABLET ORL TAB PDH TAB 0.187000002036312 ADVIL COLD AND SINUS CAPLET ORL TAB PDH TAB 0.388000002248645 ADVIL COLD AND SINUS PLUS CAPLET ORL TAB PDH TAB 0.426000002244577 ADVIL EXTRA STRENGTH 400 MG CAPLET ORL TAB PDH TAB 0.278800002248231 ADVIL EXTRA STRENGTH LIQUI-GEL 400 MG CAPSULE ORL CAP PDH CAP 0.397000001933531 ADVIL IBUPROFEN 200 MG CAPLET ORL TAB PDH TAB 0.150400002246403 ADVIL JUNIOR STRENGTH CHEWABLE TABLET ORL CTB GKC TAB 0.319500002241769 ADVIL LIQUI-GELS 200 MG CAPSULE ORL CAP PDH CAP 0.283300002242522 ADVIL PEDIATRIC 40 MG/ML SUSPENSION DROPS ORL DPS GKC ML 0.316000002243919 AERIUS 5 MG TABLET ORL TAB SCH TAB 0.956000002467909 AERMONY RESPICLICK 113 MCG/DOSE METERED INH PWD INH MIP TEV DOSE 0.516000002467917 AERMONY RESPICLICK 232 MCG/DOSE METERED INH PWD INH MIP TEV DOSE 0.802500002467895 AERMONY RESPICLICK 55 MCG/DOSE METERED INH PWD INH MIP TEV DOSE 0.2827

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 5 of 129

Page 6: Products and Pricing on the Alberta Blue Cross Drug Price ... · 00000821772 d-tab 10,000 unit tablet orl tab riv tab 0.2100 00002432854 duavive 0.45 mg/20 mg tablet orl tab pfi tab

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00096899957 AEROBIKA OSC POSITIVE EXPIRATORY PRESS THERAPY SYS DEFAUL DEV TMI DEV 52.000000096899950 AEROCHAMBER 2 GO AVHC WITH MOUTHPIECE DEFAUL ADUDEV TMI DEV 44.990000000990110 AEROCHAMBER 2 GO AVHC WITH MOUTHPIECE DEFAUL ADUDEV TMI DEV 44.990000002339528 AFINITOR 10 MG TABLET ORL TAB NOV TAB 194.655000002369257 AFINITOR 2.5 MG TABLET ORL TAB NOV TAB 194.655000002339501 AFINITOR 5 MG TABLET ORL TAB NOV TAB 194.655000002425645 AFINITOR DISPERZ 2 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 193.499000002425653 AFINITOR DISPERZ 3 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 193.499000002425661 AFINITOR DISPERZ 5 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 193.499000002473283 AFLURIA TETRA 0.5 ML SINGLE-DOSE SYR INJ INJ DEFAUL SER SYR 13.750000002473313 AFLURIA TETRA MULTI-DOSE VIAL INJ INJ DEFAUL SER ML 25.500000002481863 AG-ALLOPURINOL 100 MG TABLET ORL TAB AGP TAB 0.078000002481871 AG-ALLOPURINOL 200 MG TABLET ORL TAB AGP TAB 0.130000002481898 AG-ALLOPURINOL 300 MG TABLET ORL TAB AGP TAB 0.212500002369249 AG-AMLODIPINE 10 MG TABLET ORL TAB AGP TAB 0.199300002369230 AG-AMLODIPINE 5 MG TABLET ORL TAB AGP TAB 0.134300002369176 AG-ATENOLOL 25 MG TABLET ORL TAB AGP TAB 0.052100002374617 AG-CITALOPRAM 10 MG TABLET ORL TAB AGP TAB 0.071500002339390 AG-CITALOPRAM 20 MG TABLET ORL TAB AGP TAB 0.133200002339404 AG-CITALOPRAM 40 MG TABLET ORL TAB AGP TAB 0.120000002485419 AG-CYCLOBENZAPRINE 10 MG TABLET ORL TAB AGP TAB 0.102200002432692 AG-DONEPEZIL 10 MG TABLET ORL TAB AGP TAB 0.458600002432684 AG-DONEPEZIL 5 MG TABLET ORL TAB AGP TAB 0.458600002242119 AGGRENOX 200 MG/25 MG CAPSULE ORL CAP BOE CAP 0.908700002474409 AG-IRBESARTAN 150 MG TABLET ORL TAB AGP TAB 0.228100002474417 AG-IRBESARTAN 300 MG TABLET ORL TAB AGP TAB 0.228100002474395 AG-IRBESARTAN 75 MG TABLET ORL TAB AGP TAB 0.228100002441217 AG-LOSARTAN 100 MG TABLET ORL TAB AGP TAB 0.161600002441195 AG-LOSARTAN 25 MG TABLET ORL TAB AGP TAB 0.161600002441209 AG-LOSARTAN 50 MG TABLET ORL TAB AGP TAB 0.161600002481308 AG-METOPROLOL-L 25 MG TABLET ORL TAB AGP TAB 0.064300002482835 AG-MONTELUKAST 10 MG TABLET ORL TAB AGP TAB 0.423100002484757 AG-MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL AGP ML 3.756700002475731 AG-OLMESARTAN 20 MG TABLET ORL TAB AGP TAB 0.298400002475758 AG-OLMESARTAN 40 MG TABLET ORL TAB AGP TAB 0.298400002478781 AG-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT AGP TAB 0.201600002475537 AG-PAROXETINE 10 MG TABLET ORL TAB AGP TAB 0.304600002346850 AGRIFLU INJECTION SYRINGE INJ DEFAUL SEQ SYR 8.500000002428881 AGRIFLU MULTI-DOSE VIAL INJECTION INJ DEFAUL SEQ ML 16.2000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002492490 AG-RIZATRIPTAN ODT 10 MG ORALLY DISINT. TABLET ORL DISNTAB AGP TAB 3.705000002236859 AGRYLIN 0.5 MG CAPSULE ORL CAP SHB CAP 6.266200002480417 AG-SILDENAFIL 100 MG TABLET ORL TAB AGP TAB 9.200000002438453 AG-ZOLMITRIPTAN ODT 2.5 MG ORAL DISP. TABLET ORL DISPTAB AGP TAB 3.537500002410265 AHI-MONTELUKAST 4 MG CHEWABLE TABLET ORL CTB AHI TAB 0.275700002410273 AHI-MONTELUKAST 5 MG CHEWABLE TABLET ORL CTB AHI TAB 0.308300002487306 AIMOVIG 140 MG/ML PREFILLED AUTOINJECTOR INJ NDL NOV SYR 532.000000002479613 AIMOVIG 70 MG/ML PREFILLED AUTOINJECTOR INJ NDL NOV SYR 532.000000002497859 AJOVY 225 MG/1.5 ML INJECTION SYRINGE INJ NDL TEV SYR 585.000000002494175 AKLIEF 50 MCG/G TOPICAL CREAM TOP CRM GAL G 2.273200002468735 AKYNZEO 0.5 MG/300 MG CAPSULE ORL CAP PUR CAP 141.950000000001147 ALBALON 0.1% OPH SOLUTION OPH SOL ALL ML 0.593300000480452 ALCOHOL PREP TOPICAL PAD TOP PAD PFD PAD 0.035700000809357 ALCOHOL SWABS BD BTD DEFAUL DEFAUL WPI MIS 0.020000000180408 ALDACTAZIDE-25 TABLET ORL TAB PFI TAB 0.237300000594377 ALDACTAZIDE-50 TABLET ORL TAB PFI TAB 0.503200000285455 ALDACTONE 100 MG TABLET ORL TAB PFI TAB 0.368600000028606 ALDACTONE 25 MG TABLET ORL TAB PFI TAB 0.156300002254506 ALDURAZYME 0.58 MG/ML INJECTION INJ DEFAUL GZM ML 209.000000002458136 ALECENSARO 150 MG CAPSULE ORL CAP HLR CAP 42.166600002381478 ALENDRONATE SODIUM 5 MG TABLET ORL TAB AHI TAB 1.037100002303078 ALENDRONATE-70 70 MG TABLET ORL TAB PDL TAB 2.172500002301733 ALEVE 220 MG TABLET ORL TAB BAI TAB 0.224000002361795 ALEVE LIQUID GEL 220 MG CAPSULE ORL CAP BAI CAP 0.270000080014418 ALIGN PROBIOTIC CAPSULE ORL CAP PGI CAP 1.071400002253437 ALIMTA 500 MG/VIAL INJECTION INJ DEFAUL LIL VIAL 2750.000000000004715 ALKERAN 2 MG TABLET ORL TAB APC TAB 1.874000002231462 ALLEGRA 12 HOUR 60 MG TABLET ORL TAB SAV TAB 0.379200002242819 ALLEGRA 24 HOUR 120 MG TABLET ORL TAB SAV TAB 0.800000002239853 ALLEGRA-D SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.508000002146142 ALLER-AIDE 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.034200002176483 ALLER-AIDE 25 MG CAPLET ORL TAB ROG TAB 0.219800000271411 ALLERDRYL 50 MG CAPSULE ORL CAP VCL CAP 0.130300000299987 ALLERGENIC EXTRACT POLLENS 100000 UNIT/ML INJ INJ DEFAUL ALK ML 7.500000001949454 ALLERGY 25 MG TABLET ORL TAB TAN TAB 0.093800000764647 ALLERGY DROPS 0.012% OPH SOLUTION OPH SOL BSH ML 0.177300002141728 ALLERGY FORMULA 25 MG CAPLET ORL TAB PRI TAB 0.120000002240266 ALLERGY RELIEF 10 MG TABLET ORL TAB APX TAB 0.408300002375990 ALLERGY REMEDY 10 MG TABLET ORL TAB APX TAB 0.196700002230398 ALLERGY TABLETS EXTRA STRENGTH 50 MG TABLET ORL TAB TAN TAB 0.1625

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 7 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002382059 ALLERJECT 1:1000 (0.15 MG) AUTO INJECTOR SYRINGE INJ NDL KAI SYR 88.560000002382067 ALLERJECT 1:1000 (0.3 MG) AUTO INJECTOR SYRINGE INJ NDL KAI SYR 88.560000000804193 ALLERNIX 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.059900002097583 ALLERNIX 25 MG CAPLET ORL TAB ROG TAB 0.266200002097575 ALLERNIX EXTRA STRENGTH 50 MG CAPLET ORL TAB ROG TAB 0.187900002369656 ALLERNIX MULTI SYMPTOM 5 MG TABLET ORL TAB ROG TAB 0.512000002240265 ALLER-RELIEF 10 MG TABLET ORL TAB APX TAB 0.408300000555681 ALLOPURINOL 100 MG TABLET ORL TAB PDL TAB 0.078000002130157 ALLOPURINOL 200 MG TABLET ORL TAB PDL TAB 0.130000000555703 ALLOPURINOL 300 MG TABLET ORL TAB PDL TAB 0.212500000569801 ALMAGEL 200 ORAL LIQUID ORL LIQ ATL ML 0.021100000815527 ALMAGEL PLUS ORAL SUSPENSION ORL SUS ATL ML 0.008700002424029 ALMOTRIPTAN 12.5 MG TABLET ORL TAB PDL TAB 7.043300000893560 ALOMIDE 0.1% (BASE) OPH SOLUTION OPH SOL NOV ML 1.265000002381710 ALOXI 0.05 MG/ML INJECTION INJ DEFAUL PUR ML 19.454000002381729 ALOXI 0.5 MG CAPSULE ORL CAP PUR CAP 69.900000080005881 ALPHA LIPOIC ACID 100MG CAPSULE ORL CAP WNP CAP 0.105500002248151 ALPHAGAN P 0.15% OPHTHALMIC SOLUTION OPH SOL ALL ML 3.716000001908189 ALPRAZOLAM-0.25 MG TABLET ORL TAB PDL TAB 0.060900001908170 ALPRAZOLAM-0.5 MG TABLET ORL TAB PDL TAB 0.072800002248706 ALPRAZOLAM-1 1 MG TABLET ORL TAB PDL TAB 0.309900002422956 ALPROLIX 3000 UNIT/VIAL INJECTION INJ DEFAUL BVT VIAL 4320.000000002320924 ALREX 0.2% OPHTHALMIC SUSPENSION OPH SUS BSH ML 5.900000000999538 ALSOY INFANT FORMULA ORAL POWDER ORL PWR NHN G 0.036500002281112 ALTACE 15 MG CAPSULE ORL CAP/TAB VCL CAP 1.328000002479222 ALUNBRIG 180 MG TABLET ORL TAB TAK TAB 336.960000002479206 ALUNBRIG 30 MG TABLET ORL TAB TAK TAB 112.320000002479214 ALUNBRIG 90 MG TABLET ORL TAB TAK TAB 336.960000002479230 ALUNBRIG 90 MG/180 MG TABLET INITIATION PACK ORL TAB TAK TAB 336.960000002241630 AMBISOME 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 121.000000002230575 AMETOP 4% TOPICAL GEL TOP GEL SNE G 2.703300002242971 AMIKACIN SULFATE 250 MG/ML INJECTION INJ DEFAUL SDZ ML 44.572000000497193 AMINOPHYLLINE 25 MG/ML INJECTION INJ DEFAUL HSP ML 0.460000000370991 AMITRIPTYLINE 10 MG TABLET ORL TAB PDL TAB 0.043500000371009 AMITRIPTYLINE 25 MG TABLET ORL TAB PDL TAB 0.082900000456349 AMITRIPTYLINE 50 MG TABLET ORL TAB PDL TAB 0.154000002326817 AMLODIPINE 10 MG TABLET ORL TAB PDL TAB 0.199300002326795 AMLODIPINE 2.5 MG TABLET ORL TAB PDL TAB 0.076700002326809 AMLODIPINE 5 MG TABLET ORL TAB PDL TAB 0.134300000638064 AMOSAN 68.6% MOUTHWASH ORL MWH OLB ML 0.3340

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 8 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002495929 AMOXICILLIN SOD./POTASSIUM CLAV 1000/200 MG INJ INJ DEFAUL SDZ VIAL 20.270000002495937 AMOXICILLIN SOD./POTASSIUM CLAV 2000/200 MG INJ INJ DEFAUL SDZ VIAL 30.400000002495910 AMOXICILLIN SOD./POTASSIUM CLAV 500/100 MG INJ INJ DEFAUL SDZ VIAL 10.130000002125862 AMPHOJEL 320 MG/5ML ORAL LIQUID ORL LIQ AXC ML 0.017900002124971 AMPHOJEL 600 MG TABLET ORL TAB AUP TAB 0.125000002227002 AMPICILLIN 1 G/VIAL INJECTION INJ DEFAUL FKC VIAL 5.175000002226995 AMPICILLIN 2 G/VIAL INJECTION INJ DEFAUL FKC VIAL 10.350000002227029 AMPICILLIN 250 MG/VIAL INJECTION INJ DEFAUL FKC VIAL 2.947000002227010 AMPICILLIN 500 MG/VIAL INJECTION INJ DEFAUL FKC VIAL 3.091000002462338 AMPICILLIN SODIUM FOR INJECTION BP 1 G/VIAL INJ INJ DEFAUL AUR VIAL 5.588600002462346 AMPICILLIN SODIUM FOR INJECTION BP 2 G/VIAL INJ INJ DEFAUL AUR VIAL 11.178000002462303 AMPICILLIN SODIUM FOR INJECTION BP 250 MG/VIAL INJ INJ DEFAUL AUR VIAL 3.180000002462311 AMPICILLIN SODIUM FOR INJECTION BP 500 MG/VIAL INJ INJ DEFAUL AUR VIAL 3.338000080006771 A-MULSION ORAL LIQUID ORL LIQ SRL ML 0.400000002221861 ANANDRON 50 MG TABLET ORL TAB CAG TAB 2.410000002395649 ANASTROZOLE 1 MG TABLET ORL TAB PDL TAB 0.952300002442736 ANASTROZOLE 1 MG TABLET ORL TAB SNS TAB 2.545700002245345 ANDROGEL (2.5 G/PACKET) 1% TOPICAL GEL TOP GEL BGP G 0.936500002245346 ANDROGEL (5 G/PACKET) 1% TOPICAL GEL TOP GEL BGP G 0.828100002249499 ANDROGEL (75 G/PUMP) 1% TOPICAL GEL TOP GEL BGP G 0.946300002268825 ANGELIQ 1 MG/1 MG TABLET ORL TAB BAI TAB 0.782100002364700 ANTHELIOS ULTRA-FLUID TOPICAL LOTION TOP LOT LRP ML 0.288000002230251 ANTIBIOTIC TOPICAL OINTMENT USP TOP ONT TAR G 0.150000002241532 ANTI-NAUSEANT 50 MG TABLET ORL TAB VTH TAB 0.038000002222132 ANTIPHLOGISTINE RUB A-535 NO ODOUR 13.3% TOP OINT TOP ONT CHD G 0.0630

00000990104 ANTI-STATIC COMPACT SPACE CHAMBER PLUS MOUTHPIECE DEFAUL DEV MPI DEV 23.550000000990107 ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ LG MASK DEFAUL ADUDEV MPI DEV 39.8600

00000990106 ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ MED MASK DEFAUL PEDDEV MPI DEV 37.6700

00000990105 ANTI-STATIC COMPACT SPACE CHAMBER PLUS W/ SM MASK DEFAUL INFDEV MPI DEV 37.670000000476242 ANUGESIC-HC RECTAL SUPPOSITORY RT SUP MCL SUP 1.365000001945939 ANUSOL 0.5% RECTAL OINTMENT RT ONT MCL G 0.184300001945920 ANUSOL 10 MG RECTAL SUPPOSITORY RT SUP MCL SUP 0.475000001945912 ANUSOL PLUS RECTAL OINTMENT RT ONT MCL G 0.217300001945904 ANUSOL PLUS RECTAL SUPPOSITORY RT SUP MCL SUP 0.635000080017904 AOR CHROMIUM PICOLINATE 600 MCG CAPSULE ORL CAP AOR CAP 0.133300080005832 AOR N.A.C. 500 MG CAPSULE ORL CAP AOR CAP 0.137500002396769 APO-ABACAVIR 300 MG TABLET ORL TAB APX TAB 5.9207

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002399539 APO-ABACAVIR-LAMIVUDINE 600 MG/300 MG TABLET ORL TAB APX TAB 20.357300002416255 APO-ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABLET ORL TAB APX TAB 15.461300002491397 APO-ABIRATERONE 250 MG FILM COATED TABLET ORL TAB APX TAB 26.031300002491400 APO-ABIRATERONE 500 MG FILM COATED TABLET ORL TAB APX TAB 52.062500002229873 APO-ACETAMINOPHEN 325 MG CAPLET ORL TAB APX TAB 0.032600000544981 APO-ACETAMINOPHEN 325 MG TABLET ORL TAB APX TAB 0.072500002477130 APO-ACYCLOVIR 5% TOPICAL OINTMENT TOP ONT APX G 12.312500002248728 APO-ALENDRONATE 10 MG TABLET ORL TAB APX TAB 0.498600002454467 APO-ALENDRONATE/VITAMIN D3 70 MG/2800 UNIT TABLET ORL TAB APX TAB 3.730000002243611 APO-ALPRAZ 1 MG TABLET ORL TAB APX TAB 0.309900002243612 APO-ALPRAZ TS 2 MG TABLET ORL TAB APX TAB 0.550800002475383 APO-AMBRISENTAN 10 MG TABLET ORL TAB APX TAB 106.328700002475375 APO-AMBRISENTAN 5 MG TABLET ORL TAB APX TAB 106.328700002411318 APO-AMLODIPINE-ATORVASTATIN 10 MG/10 MG TABLET ORL TAB APX TAB 0.919400002411326 APO-AMLODIPINE-ATORVASTATIN 10 MG/20 MG TABLET ORL TAB APX TAB 1.023400002411334 APO-AMLODIPINE-ATORVASTATIN 10 MG/40 MG TABLET ORL TAB APX TAB 1.062400002411342 APO-AMLODIPINE-ATORVASTATIN 10 MG/80 MG TABLET ORL TAB APX TAB 1.062400002411253 APO-AMLODIPINE-ATORVASTATIN 5 MG/10 MG TABLET ORL TAB APX TAB 0.755100002411261 APO-AMLODIPINE-ATORVASTATIN 5 MG/20 MG TABLET ORL TAB APX TAB 0.859100002411288 APO-AMLODIPINE-ATORVASTATIN 5 MG/40 MG TABLET ORL TAB APX TAB 0.898100002411296 APO-AMLODIPINE-ATORVASTATIN 5 MG/80 MG TABLET ORL TAB APX TAB 0.898100002230880 APO-AMOXI 50 MG/ML SUGAR FREE ORAL SUSPENSION ORL SUS APX ML 0.0540

00002445506 APO-AMPHETAMINE XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 2.0758

00002445514 APO-AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 2.3250

00002445522 APO-AMPHETAMINE XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 2.5743

00002445530 APO-AMPHETAMINE XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 2.8235

00002445549 APO-AMPHETAMINE XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 3.0729

00002445492 APO-AMPHETAMINE XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 1.826600002374420 APO-ANASTROZOLE 1 MG TABLET ORL TAB APX TAB 2.546000002318024 APO-ATOMOXETINE 10 MG CAPSULE ORL CAP APX CAP 2.314000002318083 APO-ATOMOXETINE 100 MG CAPSULE ORL CAP APX CAP 4.352000002318032 APO-ATOMOXETINE 18 MG CAPSULE ORL CAP APX CAP 2.652300002318040 APO-ATOMOXETINE 25 MG CAPSULE ORL CAP APX CAP 2.928100002318059 APO-ATOMOXETINE 40 MG CAPSULE ORL CAP APX CAP 3.3377

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002318067 APO-ATOMOXETINE 60 MG CAPSULE ORL CAP APX CAP 3.702300002318075 APO-ATOMOXETINE 80 MG CAPSULE ORL CAP APX CAP 3.996000002296063 APO-BICALUTAMIDE 50 MG TABLET ORL TAB APX TAB 4.057300002260077 APO-BRIMONIDINE 0.2% OPHTHALMIC SOLUTION OPH SOL APX ML 1.156000002365340 APO-CANDESARTAN 4 MG TABLET ORL TAB APX TAB 0.340000000893625 APO-CAPTO 100 MG TABLET ORL TAB APX TAB 1.039500000893595 APO-CAPTO 12.5 MG TABLET ORL TAB APX TAB 0.212000000893609 APO-CAPTO 25 MG TABLET ORL TAB APX TAB 0.300000000893617 APO-CAPTO 50 MG TABLET ORL TAB APX TAB 0.559000002467496 APO-CEFEPIME 1 G/VIAL INJECTION INJ DEFAUL APX VIAL 16.880000002467518 APO-CEFEPIME 2 G/VIAL INJECTION INJ DEFAUL APX VIAL 33.750000002231603 APO-CETIRIZINE 10 MG TABLET ORL TAB APX TAB 0.408300002453363 APO-CETIRIZINE 20 MG TABLET ORL TAB APX TAB 0.753500002298953 APO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL APX G 7.743300002291134 APO-CILAZAPRIL 1 MG TABLET ORL TAB APX TAB 0.311500002452693 APO-CINACALCET 30 MG TABLET ORL TAB APX TAB 10.194700002452707 APO-CINACALCET 60 MG TABLET ORL TAB APX TAB 18.590000002452715 APO-CINACALCET 90 MG TABLET ORL TAB APX TAB 27.051700002274744 APO-CLARITHROMYCIN 250 MG TABLET ORL TAB APX TAB 0.420900002274752 APO-CLARITHROMYCIN 500 MG TABLET ORL TAB APX TAB 0.831800002245232 APO-CLINDAMYCIN 150 MG CAPSULE ORL CAP APX CAP 0.221700002245233 APO-CLINDAMYCIN 300 MG CAPSULE ORL CAP APX CAP 0.443400002475162 APO-CLOBETASOL 0.05% TOPICAL SPRAY TOP SPR APX ML 1.925900002494051 APO-COLESEVELAM 625 MG TABLET ORL TAB APX TAB 0.889600002468891 APO-DABIGATRAN 75 MG CAPSULE ORL CAP APX CAP 1.455300002487241 APO-DARUNAVIR 600 MG TABLET ORL TAB APX TAB 14.609800002487268 APO-DARUNAVIR 800 MG TABLET ORL TAB APX TAB 19.820300002470721 APO-DASATINIB 100 MG TABLET ORL TAB APX TAB 132.267000002470705 APO-DASATINIB 20 MG TABLET ORL TAB APX TAB 32.882300002470713 APO-DASATINIB 50 MG TABLET ORL TAB APX TAB 66.178300002481499 APO-DASATINIB 70 MG TABLET ORL TAB APX TAB 72.933700002481502 APO-DASATINIB 80 MG TABLET ORL TAB APX TAB 117.3257

00002466996 APO-DESVENLAFAXINE 100 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 2.3410

00002466988 APO-DESVENLAFAXINE 50 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 2.341000002243433 APO-DICLO RAPIDE 50 MG TABLET ORL TAB APX TAB 0.393700002354403 APO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL APX ML 0.516500000895644 APO-DIPYRIDAMOLE (FC) 25 MG TABLET ORL TAB APX TAB 0.263300000895652 APO-DIPYRIDAMOLE (FC) 50 MG TABLET ORL TAB APX TAB 0.3685

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000895660 APO-DIPYRIDAMOLE (FC) 75 MG TABLET ORL TAB APX TAB 0.496300002296055 APO-DORZOLAMIDE 2% OPHTHALMIC SOLUTION OPH SOL APX ML 1.688000002468247 APO-EFAVIRENZ/EMTRICITABINE/TENOFOVIR TABLET ORL TAB APX TAB 22.660000002386054 APO-ELETRIPTAN 20 MG TABLET ORL TAB APX TAB 10.085000002386062 APO-ELETRIPTAN 40 MG TABLET ORL TAB APX TAB 10.085000002321459 APO-ENTACAPONE 200 MG TABLET ORL TAB APX TAB 0.401000002461870 APO-ERLOTINIB 100 MG TABLET ORL TAB APX TAB 47.466700002461889 APO-ERLOTINIB 150 MG TABLET ORL TAB APX TAB 71.200000002461862 APO-ERLOTINIB 25 MG TABLET ORL TAB APX TAB 11.866700002339099 APO-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT APX TAB 1.869000002339102 APO-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC APX TAB 1.869000002292025 APO-FAMCICLOVIR 125 MG TABLET ORL TAB APX TAB 2.024000002292041 APO-FAMCICLOVIR 250 MG TABLET ORL TAB APX TAB 2.720000002292068 APO-FAMCICLOVIR 500 MG TABLET ORL TAB APX TAB 4.228000000545031 APO-FERROUS GLUCONATE 300 MG TABLET ORL TAB AAP TAB 0.040400002294745 APO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM APX DOSE 0.183100002426471 APO-FROVATRIPTAN 2.5 MG TABLET ORL TAB APX TAB 12.503300002293358 APO-GABAPENTIN 600 MG TABLET ORL TAB APX TAB 1.304500002293366 APO-GABAPENTIN 800 MG TABLET ORL TAB APX TAB 1.739300002327260 APO-GATIFLOXACIN 0.3% OPHTHALMIC SOLUTION OPH SOL APX ML 2.032000002468050 APO-GEFITINIB 250 MG TABLET ORL TAB APX TAB 62.305000002247937 APO-HYDROXYUREA 500 MG CAPSULE ORL CAP APX CAP 1.020300000441643 APO-IBUPROFEN 200 MG TABLET ORL TAB APX TAB 0.112000002355337 APO-IMATINIB 100 MG TABLET ORL TAB APX TAB 20.455700002355345 APO-IMATINIB 400 MG TABLET ORL TAB APX TAB 81.822700002369052 APO-LAMIVUDINE 150 MG TABLET ORL TAB APX TAB 3.626900002369060 APO-LAMIVUDINE 300 MG TABLET ORL TAB APX TAB 7.253700002375540 APO-LAMIVUDINE-ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB APX TAB 7.830900002358514 APO-LETROZOLE 2.5 MG TABLET ORL TAB APX TAB 2.756000002243880 APO-LORATADINE 10 MG TABLET ORL TAB APX TAB 0.626700002248974 APO-MELOXICAM 15 MG TABLET ORL TAB APX TAB 0.567000002248973 APO-MELOXICAM 7.5 MG TABLET ORL TAB APX TAB 0.491400002366487 APO-MEMANTINE 10 MG TABLET ORL TAB APX TAB 1.6357

00002460653 APO-METFORMIN ER 1000 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 1.015300002305062 APO-METFORMIN ER 500 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 0.5158

00002452731 APO-METHYLPHENIDATE ER 18 MG EXTENDED REL. TABLET ORL ERT APX TAB 1.4276

00002452758 APO-METHYLPHENIDATE ER 27 MG EXTENDED REL. TABLET ORL ERT APX TAB 1.6475

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 12 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002452766 APO-METHYLPHENIDATE ER 36 MG EXTENDED REL. TABLET ORL ERT APX TAB 1.8674

00002330377 APO-METHYLPHENIDATE ER 54 MG EXTENDED REL. TABLET ORL ERT APX TAB 2.307200002248562 APO-METRONIDAZOLE 500 MG CAPSULE ORL CAP APX CAP 0.931300002286610 APO-MIRTAZAPINE 15 MG TABLET ORL TAB APX TAB 0.375000002286637 APO-MIRTAZAPINE 45 MG TABLET ORL TAB APX TAB 1.125000002406373 APO-MOXIFLOXACIN 0.5 % OPHTHALMIC SOLUTION OPH SOL APX ML 3.756700002352559 APO-MYCOPHENOLATE 250 MG CAPSULE ORL CAP APX CAP 1.031000002352567 APO-MYCOPHENOLATE 500 MG TABLET ORL TAB APX TAB 2.062000002372738 APO-MYCOPHENOLIC ACID 180 MG ENTERIC-COATED TAB ORL ECT APX TAB 1.698000002372746 APO-MYCOPHENOLIC ACID 360 MG ENTERIC-COATED TAB ORL ECT APX TAB 3.396000002246699 APO-NAPROXEN EC 250 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.106800002365499 APO-NARATRIPTAN 1 MG TABLET ORL TAB APX TAB 8.433800002365502 APO-NARATRIPTAN 2.5 MG TABLET ORL TAB APX TAB 6.143700002333015 APO-OLANZAPINE 20 MG TABLET ORL TAB APX TAB 10.309300002360632 APO-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB APX TAB 5.355300002360640 APO-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB APX TAB 7.597700002305054 APO-OLOPATADINE 0.1% OPHTHALMIC SOLUTION OPH SOL APX ML 5.226000002402823 APO-OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL APX ML 10.452000002284294 APO-OXCARBAZEPINE 150 MG TABLET ORL TAB APX TAB 0.620900002284308 APO-OXCARBAZEPINE 300 MG TABLET ORL TAB APX TAB 0.910200002284316 APO-OXCARBAZEPINE 600 MG TABLET ORL TAB APX TAB 1.8204

00002366754 APO-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.4741

00002394766 APO-OXYCODONE CR 15 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.5300

00002366762 APO-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.7112

00002394774 APO-OXYCODONE CR 30 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.8700

00002306530 APO-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.2326

00002366746 APO-OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.3150

00002394782 APO-OXYCODONE CR 60 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.5750

00002366789 APO-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 2.276600002292912 APO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT APX TAB 1.2750

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 13 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002240907 APO-PAROXETINE 10 MG TABLET ORL TAB APX TAB 1.043000002468581 APO-PERINDOPRIL/AMLODIPINE 14 MG/10 MG TABLET ORL TAB APX TAB 0.977500002468565 APO-PERINDOPRIL/AMLODIPINE 3.5 MG/2.5 MG TABLET ORL TAB APX TAB 0.807500002468573 APO-PERINDOPRIL/AMLODIPINE 7 MG/5 MG TABLET ORL TAB APX TAB 0.892500002297574 APO-PERINDOPRIL-INDAPAMIDE 4 MG/1.25 MG TABLET ORL TAB APX TAB 0.511300002453061 APO-PERINDOPRIL-INDAPAMIDE 8 MG/2.5 MG TABLET ORL TAB APX TAB 0.571800000755885 APO-PINDOL 10 MG TABLET ORL TAB APX TAB 0.232300000755893 APO-PINDOL 15 MG TABLET ORL TAB APX TAB 0.889400000755877 APO-PINDOL 5 MG TABLET ORL TAB APX TAB 0.136100000642886 APO-PIROXICAM 10 MG CAPSULE ORL CAP APX CAP 0.442600000642894 APO-PIROXICAM 20 MG CAPSULE ORL CAP APX CAP 0.742200002292386 APO-PRAMIPEXOLE 0.5 MG TABLET ORL TAB APX TAB 1.386000002491591 APO-PRUCALOPRIDE 1 MG TABLET ORL TAB APX TAB 2.014500002491605 APO-PRUCALOPRIDE 2 MG TABLET ORL TAB APX TAB 3.102500002254522 APO-QUININE 300 MG CAPSULE ORL CAP APX CAP 0.375000002325381 APO-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB APX CAP 0.855000002368722 APO-RAMIPRIL/HCTZ 10 MG/12.5 MG TABLET ORL TAB APX TAB 0.276500002354039 APO-RAMIPRIL/HCTZ 10 MG/25 MG TABLET ORL TAB APX TAB 0.131700002354004 APO-RAMIPRIL/HCTZ 2.5 MG/12.5 MG TABLET ORL TAB APX TAB 0.206700002354012 APO-RAMIPRIL/HCTZ 5 MG/12.5 MG TABLET ORL TAB APX TAB 0.217000002404680 APO-RASAGILINE 0.5 MG TABLET ORL TAB APX TAB 6.128500002404699 APO-RASAGILINE 1 MG TABLET ORL TAB APX TAB 6.128500002352583 APO-RILUZOLE 50 MG TABLET ORL TAB APX TAB 3.436200002377721 APO-RISEDRONATE 150 MG TABLET ORL TAB APX TAB 40.950000002337746 APO-ROPINIROLE 0.25 MG TABLET ORL TAB APX TAB 0.070900002337770 APO-ROPINIROLE 2 MG TABLET ORL TAB APX TAB 0.312200002337800 APO-ROPINIROLE 5 MG TABLET ORL TAB APX TAB 0.859600002248203 APO-SILDENAFIL 100 MG TABLET ORL TAB APX TAB 9.200000002248201 APO-SILDENAFIL 25 MG TABLET ORL TAB APX TAB 8.290000002248202 APO-SILDENAFIL 50 MG TABLET ORL TAB APX TAB 8.847500002422107 APO-TADALAFIL 10 MG TABLET ORL TAB APX TAB 11.925000002422085 APO-TADALAFIL 2.5 MG TABLET ORL TAB APX TAB 3.647000002422115 APO-TADALAFIL 20 MG TABLET ORL TAB APX TAB 12.357500002422093 APO-TADALAFIL 5 MG TABLET ORL TAB APX TAB 3.647000002421933 APO-TADALAFIL PAH 20 MG TABLET ORL TB APX TAB 11.472500000812404 APO-TAMOX 10 MG TABLET ORL TAB APX TAB 0.175000000812390 APO-TAMOX 20 MG TABLET ORL TAB APX TAB 0.350000002413094 APO-TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APX CAP 113.596000002413116 APO-TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APX CAP 159.036000002413124 APO-TEMOZOLOMIDE 180 MG CAPSULE ORL CAP APX CAP 253.6726

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 14 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002413043 APO-TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APX CAP 22.720000002413132 APO-TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APX CAP 283.984000002413035 APO-TEMOZOLOMIDE 5 MG CAPSULE ORL CAP APX CAP 5.850000002426153 APO-TRAMADOL 50 MG TABLET ORL TAB APX TAB 0.638600002336790 APO-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB APX TAB 0.626400002437635 APO-TRIAMCINOLONE AQ 55 MCG METERED DOSE SPRAY NAS SPM APX DOSE 0.170000002471655 APO-VARDENAFIL 10 MG TABLET ORL TAB APX TAB 10.397500002471663 APO-VARDENAFIL 20 MG TABLET ORL TAB APX TAB 11.680000002471647 APO-VARDENAFIL 5 MG TABLET ORL TAB APX TAB 9.320000002246894 APO-VERAP SR 180 MG SUSTAINED-RELEASE TABLET ORL SRT APX TAB 0.520400001946323 APO-ZIDOVUDINE 100 MG CAPSULE ORL CAP APX CAP 1.397700002434946 APO-ZOLPIDEM ODT 10 MG SUBLINGUAL DISINT TABLET SLG DISNTAB APX TAB 1.188300002436159 APO-ZOLPIDEM ODT 5 MG SUBLINGUAL DISINT. TABLET SLG DISNTAB APX TAB 1.182700002375885 APPRILON 40 MG MODIFIED RELEASE CAPSULE ORL MRC GAL CAP 2.856100000723754 APRESOLINE 20 MG/VIAL INJECTION INJ DEFAUL STM VIAL 11.650000002273322 APTIVUS 250 MG CAPSULE ORL CAP BOE CAP 8.250000002162075 AQUASOL E 50 UNIT/ML ORAL DROPS ORL DPS NOV ML 0.874400002269465 ARICEPT RDT 10 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PFI TAB 5.013200002269457 ARICEPT RDT 5 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PFI TAB 5.013200002224135 ARIMIDEX 1 MG TABLET ORL TAB AZC TAB 5.475000002488027 ARIPIPRAZOLE 10 MG TABLET ORL TAB PDL TAB 1.075300002488035 ARIPIPRAZOLE 15 MG TABLET ORL TAB PDL TAB 1.269300002488000 ARIPIPRAZOLE 2 MG TABLET ORL TAB PDL TAB 0.809300002488043 ARIPIPRAZOLE 20 MG TABLET ORL TAB PDL TAB 1.001700002488051 ARIPIPRAZOLE 30 MG TABLET ORL TAB PDL TAB 1.001700002488019 ARIPIPRAZOLE 5 MG TABLET ORL TAB PDL TAB 0.904700080008677 ARNICA 7% GEL TOP GEL BCI G 0.131400080015109 ARNICA GEL-CREAM RUB A535 TOPICAL GEL TOP GEL CHD G 0.097100080030403 ARNICARE TOPICAL GEL TOP GEL BCI G 0.143200002242705 AROMASIN 25 MG TABLET ORL TAB PFI TAB 5.585700002286653 ARTHRITIS PAIN 650 MG EXTENDED RELIEF TABLET ORL ERT VTH TAB 0.079200002371146 ARTHRITIS PAIN RELIEF 650 MG EXTENDED-RELEASE TAB ORL ERT VTH TAB 0.049800002229570 ARTIFICIAL TEARS OPH SOLUTION OPH SOL PPH ML 0.292700002354535 ARTIFICIAL TEARS OPHTHALMIC SOLUTION OPH SOL TEV ML 0.240700000530336 ASA 325 MG TABLET ORL TAB VTH TAB 0.025000002244993 ASA 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.036100002449277 ASA 81 MG ENTERIC-COATED TABLET ORL ECT TLI TAB 0.056000002372177 ASA 81 MG ENTERIC-COATED TABLET ORL ECT VTH TAB 0.053000002433044 ASA 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.056000002427176 ASA EC 80 MG TABLET ORL TAB SNS TAB 0.0560

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 15 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002426811 ASA EC 81 MG ENTERIC-COATED TABLET ORL ECT SNS TAB 0.053000002046253 ASADOL 325 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.012500002009013 ASAPHEN 80 MG TABLET ORL TAB PMS TAB 0.056000002243974 ASAPHEN 81 MG CHEWABLE TABLET ORL CTB PMS TAB 0.074900002238545 ASAPHEN E.C. 80 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.056000002242281 ASAPHEN E.C. 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.074900002280167 ASATAB 80 MG CHEWABLE TABLET ORL CTB ODN TAB 0.058000002352427 ASATAB EC 325 MG ENTERIC-COATED TABLET ORL ECT ODN TAB 0.029500000266086 ASCORBIC ACID 500 MG TABLET ORL TAB PMT TAB 0.030000002150328 ASPIRIN 325 MG TABLET ORL TAB BAI TAB 0.100800002289970 ASPIRIN 81 MG QUICK CHEWS CHEWABLE TABLET ORL CTB BIC TAB 0.1393

00002316897 ASPIRIN STOMACH GUARD EXTRA STRENGTH 500 MG CAPLET ORL TAB BIC TAB 0.098800002239090 ATACAND 4 MG TABLET ORL TAB AZC TAB 0.820700000013668 ATASOL FORTE 500 MG TABLET ORL TAB CHD TAB 0.059800000293504 ATASOL-15 TABLET ORL TAB CHD TAB 0.091000000293490 ATASOL-8 TABLET ORL TAB CHD TAB 0.070300002498707 ATECTURA BREEZHALER 150 MCG/160 MCG INH CAPSULE INH CAP NOV CAP 1.936000002498693 ATECTURA BREEZHALER 150 MCG/320 MCG INH CAPSULE INH CAP NOV CAP 1.936000002498685 ATECTURA BREEZHALER 150 MCG/80 MCG INH CAPSULE INH CAP NOV CAP 1.936000002326701 ATENOLOL 25 MG TABLET ORL TAB PDL TAB 0.067600000828793 ATENOLOL-100 MG TABLET ORL TAB PDL TAB 0.182100000828807 ATENOLOL-50 MG TABLET ORL TAB PDL TAB 0.110700002445883 ATOMOXETINE 10 MG CAPSULE ORL CAP SIV CAP 2.314000002467747 ATOMOXETINE 10 MG CAPSULE ORL CAP SNS CAP 2.314000002396904 ATOMOXETINE 10 MG CAPSULE ORL CAP PDL CAP 1.404000002467828 ATOMOXETINE 100 MG CAPSULE ORL CAP SNS CAP 4.352000002467755 ATOMOXETINE 18 MG CAPSULE ORL CAP SNS CAP 2.652300002396912 ATOMOXETINE 18 MG CAPSULE ORL CAP PDL CAP 1.609300002445905 ATOMOXETINE 18 MG CAPSULE ORL CAP SIV CAP 2.652300002467763 ATOMOXETINE 25 MG CAPSULE ORL CAP SNS CAP 2.928000002396920 ATOMOXETINE 25 MG CAPSULE ORL CAP PDL CAP 1.776700002445913 ATOMOXETINE 25 MG CAPSULE ORL CAP SIV CAP 2.928000002396939 ATOMOXETINE 40 MG CAPSULE ORL CAP PDL CAP 2.025000002467771 ATOMOXETINE 40 MG CAPSULE ORL CAP SNS CAP 3.337300002445948 ATOMOXETINE 40 MG CAPSULE ORL CAP SIV CAP 3.337300002445956 ATOMOXETINE 60 MG CAPSULE ORL CAP SIV CAP 3.702300002396947 ATOMOXETINE 60 MG CAPSULE ORL CAP PDL CAP 2.246300002467798 ATOMOXETINE 60 MG CAPSULE ORL CAP SNS CAP 3.702300002467801 ATOMOXETINE 80 MG CAPSULE ORL CAP SNS CAP 3.9960

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 16 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002348705 ATORVASTATIN 10 MG TABLET ORL TAB SNS TAB 0.174300002346486 ATORVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.174300002475022 ATORVASTATIN 10 MG TABLET ORL TAB RIV TAB 0.174300002475030 ATORVASTATIN 20 MG TABLET ORL TAB RIV TAB 0.217900002346494 ATORVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.217900002348713 ATORVASTATIN 20 MG TABLET ORL TAB SNS TAB 0.217900002346508 ATORVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.234200002348721 ATORVASTATIN 40 MG TABLET ORL TAB SNS TAB 0.234200002475049 ATORVASTATIN 40 MG TABLET ORL TAB RIV TAB 0.234200002348748 ATORVASTATIN 80 MG TABLET ORL TAB SNS TAB 0.421600002475057 ATORVASTATIN 80 MG TABLET ORL TAB RIV TAB 0.234200002346516 ATORVASTATIN 80 MG TABLET ORL TAB PDL TAB 0.2342

00002466783 ATOVAQUONE AND PROGUANIL HCL 250 MG/100 MG TABLET ORL TAB GLM TAB 4.130800002421429 ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ORL TAB SNS TAB 4.130800002299925 ATRIANCE 5 MG/ML INJECTION INJ DEFAUL NOV ML 10.611300002300699 ATRIPLA TABLET ORL TAB BMG TAB 42.334000002094681 ATROPINE 0.4 MG/ML INJECTION BP INJ DEFAUL ALV ML 2.300000002432188 ATROPINE 0.4 MG/ML INJECTION BP INJ DEFAUL TGT ML 2.288000002094703 ATROPINE 0.6 MG/ML INJECTION INJ DEFAUL ALV ML 2.500000002432196 ATROPINE 0.6 MG/ML INJECTION BP INJ DEFAUL TGT ML 2.488000002148358 ATROPINE SULFATE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.200000002163713 ATROVENT 0.06% NASAL SPRAY NAS SPR BOE ML 2.045300002332477 AURALGAN OTIC SOLUTION OT SOL PAL ML 0.575700002454513 AURO-ABACAVIR/LAMIVUDINE 600 MG/300 MG TABLET ORL TAB AUR TAB 17.962700002471485 AURO-ATOMOXETINE 10 MG CAPSULE ORL CAP AUR CAP 2.314000002471558 AURO-ATOMOXETINE 100 MG CAPSULE ORL CAP AUR CAP 4.352000002471493 AURO-ATOMOXETINE 18 MG CAPSULE ORL CAP AUR CAP 2.652300002471507 AURO-ATOMOXETINE 25 MG CAPSULE ORL CAP AUR CAP 2.928000002471515 AURO-ATOMOXETINE 40 MG CAPSULE ORL CAP AUR CAP 3.337700002471523 AURO-ATOMOXETINE 60 MG CAPSULE ORL CAP AUR CAP 3.702300002471531 AURO-ATOMOXETINE 80 MG CAPSULE ORL CAP AUR CAP 3.996100002449161 AURO-BETAHISTINE 24 MG TABLET ORL TAB AUR TAB 0.498300002500213 AURO-BUSPIRONE 10 MG TABLET ORL TAB AUR TAB 0.351700002445786 AURO-CANDESARTAN 4 MG TABLET ORL TAB AUR TAB 0.340000002497743 AURO-CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION ORL SUS AUR ML 0.318400002497751 AURO-CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION ORL SUS AUR ML 0.568700002478900 AURO-CINACALCET 30 MG TABLET ORL TAB AUR TAB 10.194700002478919 AURO-CINACALCET 60 MG TABLET ORL TAB AUR TAB 18.590000002478943 AURO-CINACALCET 90 MG TABLET ORL TAB AUR TAB 27.0517

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002486121 AURO-DARUNAVIR 600 MG TABLET ORL TAB AUR TAB 14.609800002486148 AURO-DARUNAVIR 800 MG TABLET ORL TAB AUR TAB 19.820300002418428 AURO-EFAVIRENZ 600 MG TABLET ORL TAB AUR TAB 11.210300002478404 AURO-EFAVIRENZ-EMTRICITABINE-TENOFOVIR TABLET ORL TAB AUR TAB 22.654300002479451 AURO-ELETRIPTAN 20 MG TABLET ORL TAB AUR TAB 10.085000002479478 AURO-ELETRIPTAN 40 MG TABLET ORL TAB AUR TAB 10.085000002428148 AURO-FINASTERIDE 1 MG TABLET ORL TAB AUR TAB 1.145700002428334 AURO-GABAPENTIN 600 MG TABLET ORL TAB AUR TAB 1.304500002428342 AURO-GABAPENTIN 800 MG TABLET ORL TAB AUR TAB 1.739300002414414 AURO-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB AUR TAB 7.830800002430592 AURO-LEVOFLOXACIN 250 MG TABLET ORL TAB AUR TAB 1.203800002430606 AURO-LEVOFLOXACIN 500 MG TABLET ORL TAB AUR TAB 1.371800002430614 AURO-LEVOFLOXACIN 750 MG TABLET ORL TAB AUR TAB 4.847800002390892 AURO-MELOXICAM 15 MG TABLET ORL TAB AUR TAB 0.462300002390884 AURO-MELOXICAM 7.5 MG TABLET ORL TAB AUR TAB 0.400700002470284 AURO-METRONIDAZOLE 500 MG CAPSULE ORL CAP AUR CAP 0.931300002411717 AURO-MIRTAZAPINE 45 MG TABLET ORL TAB AUR TAB 1.125000002299801 AURO-MIRTAZAPINE OD 15 MG ORAL DISINT. TABLET ORL DISNTAB AUR TAB 0.273000002299828 AURO-MIRTAZAPINE OD 30 MG ORAL DISINT. TABLET ORL DISNTAB AUR TAB 0.546000002299836 AURO-MIRTAZAPINE OD 45 MG ORAL DISINT. TABLET ORL DISNTAB AUR TAB 0.819000002422867 AURO-MONTELUKAST 4 MG CHEWABLE TABLET ORL CTB AUR TAB 0.275700002422875 AURO-MONTELUKAST 5 MG CHEWABLE TABLET ORL CTB AUR TAB 0.308300002318601 AURO-NEVIRAPINE 200 MG TABLET ORL TAB AUR TAB 2.469200002466392 AURO-NITROFURANTOIN 100 MG CAPSULE ORL CAPMMC AUR CAP 0.657300002448742 AURO-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB AUR TAB 1.071000002448750 AURO-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB AUR TAB 7.597700002383276 AURO-PAROXETINE 10 MG TABLET ORL TAB AUR TAB 1.043000002424088 AURO-PRAMIPEXOLE 0.5 MG TABLET ORL TAB AUR TAB 1.386000002493578 AURO-PROGESTERONE 100 MG CAPSULE ORL CAP AUR CAP 1.435800002442760 AURO-RISEDRONATE 150 MG TABLET ORL TAB AUR TAB 38.330000002414384 AURO-SILDENAFIL 100 MG TABLET ORL TAB AUR TAB 9.200600002414368 AURO-SILDENAFIL 25 MG TABLET ORL TAB AUR TAB 8.290000002414376 AURO-SILDENAFIL 50 MG TABLET ORL TAB AUR TAB 8.848100002435934 AURO-TADALAFIL 10 MG TABLET ORL TAB AUR TAB 11.925000002435896 AURO-TADALAFIL 2.5 MG TABLET ORL TAB AUR TAB 3.647000002435942 AURO-TADALAFIL 20 MG TABLET ORL TAB AUR TAB 12.357500002435926 AURO-TADALAFIL 5 MG TABLET ORL TAB AUR TAB 3.647100002479672 AURO-TRAMADOL 50 MG TABLET ORL TAB AUR TAB 0.6386

00002439050 AURO-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB AUR TAB 0.6264

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 18 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002414201 AURO-VALSARTAN 40 MG TABLET ORL TAB AUR TAB 0.524000002481030 AURO-ZOLMITRIPTAN 2.5 MG TABLET ORL TAB AUR TAB 3.537500002480360 AUVI-Q 0.15 MG AUTO-INJECTOR SYRINGE INJ NDL KAI SYR 170.000000002480379 AUVI-Q 0.3 MG AUTO-INJECTOR SYRINGE INJ NDL KAI SYR 170.000000002298589 AVAMYS 27.5 MCG/DOSE NASAL SPRAY NAS SPM GSK DOSE 0.227200002241114 AVANDIA 8 MG TABLET ORL TAB GSK TAB 3.294300002270994 AVASTIN 25 MG/ML INJECTION INJ DEFAUL HLR ML 129.795000002370999 AVA-TOPIRAMATE 200 MG TABLET ORL TAB AVA TAB 0.885300002237792 AVAXIM 160 U/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 48.000000002243741 AVAXIM-PEDIATRIC 80 UNIT/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 30.000000002240105 AVEENO ANTI-ITCH LOTION TOP LOT JJI ML 0.063500002317508 AVEENO CREAM TOP CRM JJI G 0.022300002241416 AVEENO MOISTURIZING BATH TOP PWR JJI G 0.046100002284642 AZILECT 0.5 MG TABLET ORL TAB TMP TAB 7.883300002284650 AZILECT 1 MG TABLET ORL TAB TMP TAB 7.883300000598577 B COMPLEX 50 TABLET ORL TAB JAM TAB 0.081000000598569 B COMPLEX 75 TABLET ORL TAB JAM TAB 0.161600000123803 B COMPLEX PLUS C TABLET ORL TAB JAM TAB 0.081000002239693 B COMPLEX VITAMINS WITH VITAMIN C TABLET ORL TAB PMT TAB 0.066300080007498 B&C VITAMINS TABLET ORL TAB WBP TAB 0.068800080002409 B12 1000 MCG TABLET ORL TAB WNP TAB 0.085000002245512 B50 COMPLEX CAPSULE ORL CAP WNP CAP 0.089500002241403 B50 COMPLEX WITH LIPOTROPIC FACTORS TABLET ORL TAB PMT TAB 0.078100002231626 B50 VITAMIN B COMPLEX TABLET ORL TAB WNP TAB 0.067900080017771 B6 250 MG TABLET ORL TAB WNP TAB 0.045000080001869 BABY DDROPS 400IU/DROP ORAL LIQUID ORL DPS DDR ML 3.960000001927906 BACID 1 B CAPSULE ORL CAP ERF CAP 0.659800000876488 BACIMYXIN TOPICAL OINTMENT TOP ONT PMS G 0.243300000584908 BACITIN 500 UNIT/G TOPICAL OINTMENT TOP ONT PPH G 0.199300000030708 BACITRACIN 50,000 U/VIAL INJECTION INJ DEFAUL PFI VIAL 12.234000002152584 BACLOFEN 10 MG TABLET ORL TAB PDL TAB 0.159500002152592 BACLOFEN 20 MG TABLET ORL TAB PDL TAB 0.310400000037818 BACTERIOSTATIC SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL PFI ML 0.2250

00002243425 BALANCED B COMPLEX 100 MG SUSTAINED-RELEASE TABLET ORL SRT PMT TAB 0.085000001908855 BALNETAR 2.5% TOPICAL SOLUTION TOP SOL WSD ML 0.049600002493217 BALVERSA 3 MG TABLET ORL TAB JAI TAB 139.680000002493225 BALVERSA 4 MG TABLET ORL TAB JAI TAB 186.240000002493233 BALVERSA 5 MG TABLET ORL TAB JAI TAB 232.800000080052972 BANATROL PLUS ORAL POWDER FOR SOLUTION ORL PWR MDT G 0.0917

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 19 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002492415 BAQSIMI 3 MG/DOSE (SINGLE-USE) NASAL POWDER NAS PWR LIL DOSE 131.600000002060841 BARRIERE 20% TOPICAL CREAM TOP CRM WSP G 0.068600002135620 BASALJEL 500 MG CAPSULE ORL CAP AUP CAP 0.150000099400259 BATTERIES, LEFT HEARING AID DEFAUL DEFAUL XXX MIS 1.500000099400643 BATTERIES, RIGHT HEARING AID DEFAUL DEFAUL XXX UNIT 1.500000002469723 BAVENCIO 20 MG/ML INJECTION INJ DEFAUL SRO ML 132.500000000658413 BAXEDIN 20% SOLUTION TOP SOL OMG ML 0.053200002243966 BAZA CLEANSE & PROTECT 2% TOPICAL LOTION TOP LOT COC ML 0.048500002315793 BAZA PROTECT 2 TOPICAL CREAM TOP CRM COC G 0.059200000075124 BCG VACCINE (FREEZE-DRIED) 1 MG INJECTION INJ DEFAUL SFP VIAL 193.300000000498815 B-COMPLEX 100 SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.215800097799899 BD GLUCOSE 4 G TABLET ORL TAB BTD TAB 0.207000097799281 BD ULTRAFINE 31 G 8MM PEN NEEDLE DEFAUL DEFAUL BTD MIS 0.314200002237567 BEANO 150 UNIT TABLET ORL TAB GSK TAB 0.180000080043158 BEDUZIL 1500 1500 MCG TABLET ORL ERT ORI TAB 0.115800002483513 BELSOMRA 10 MG TABLET ORL TAB MFC TAB 1.367000002483521 BELSOMRA 15 MG TABLET ORL TAB MFC TAB 1.367000002483548 BELSOMRA 20 MG TABLET ORL TAB MFC TAB 1.367000002019736 BENADRYL 12.5 MG/5 ML ORAL ELIXIR ORL ELX MCL ML 0.054000002019701 BENADRYL 2% TOPICAL CREAM TOP CRM MCL G 0.289600002017849 BENADRYL 25 MG CAPLET ORL TAB MCL TAB 0.400000002019671 BENADRYL 50 MG CAPSULE ORL CAP MCL CAP 0.2514

00002061287 BENADRYL ALLERGY JUNIOR STRENGTH CHEWABLE TABLET ORL CTB MCL TAB 0.448300002229367 BENADRYL ALLERGY SINUS HEADACHE CAPLET ORL TAB MCL TAB 0.317500002280868 BENADRYL BUG BITE RELIEF LIQUID TOP LIQ MCL ML 0.329300002019698 BENADRYL CHILDREN'S 1.25 MG/ML ORAL LIQUID ORL LIQ MCL ML 0.060500002239138 BENADRYL EXTRA STRENGTH 50 MG CAPLET ORL TAB MCL TAB 0.409600002280876 BENADRYL SPRAY TOP SPR MCL ML 0.078100000999476 BENEFIBRE ORAL POWDER ORL PWR NVC G 0.039100002370050 BENLYSTA 120 MG /VIAL INJECTION INJ DEFAUL GSK VIAL 293.570000002470489 BENLYSTA 200 MG/ML AUTOINJECTOR INJ NDL GSK SYR 391.095000002370069 BENLYSTA 400 MG /VIAL INJECTION INJ DEFAUL GSK VIAL 978.5600

00002003317 BENYLIN COUGH AND CHEST CONGESTION WARMING SYRUP ORL SYR MCL ML 0.038300001944738 BENYLIN DM 3 MG/ML ORAL SYRUP ORL SYR MCL ML 0.051600002215268 BENYLIN DM FOR CHILDREN 1.5 MG/ML ORAL SYRUP ORL SYR MCL ML 0.052200001944746 BENYLIN DM-D FOR CHILDREN ORAL SYRUP ORL SYR MCL ML 0.052200001944673 BENYLIN DM-D-E ORAL SYRUP ORL SYR MCL ML 0.051600001944762 BENYLIN DM-E ORAL SYRUP ORL SYR MCL ML 0.0516

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 20 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002265427 BENYLIN E EXTRA STR W/ MENTHACTIN 40/3MG/ML SYR ORL SYR MCL ML 0.038300001925199 BENZAC W10 10% TOPICAL WASH TOP WAS GAL G 0.455600002162121 BENZAGEL 5 5% WASH TOP WAS NVC ML 0.060700002225271 BENZAMYCIN TOPICAL GEL TOP GEL VCL G 1.279200002496976 BEOVU 6 MG/0.05 ML INJECTION SYRINGE INJ NDL NOV SYR 1418.000000002456532 BEPREVE 1.5% OPHTHALMIC SOLUTION OPH SOL BSH ML 6.154000002336847 BESIVANCE 0.6% OPHTHALMIC SOLUTION OPH SOL BSH ML 2.816000002473909 BESPONSA 0.9 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 14405.850000000716634 BETADERM 0.1% SCALP LOTION SCP LOT TAR ML 0.085200000158348 BETADINE 10% TOPICAL SOLUTION TOP SOL PUR ML 0.029300000158291 BETADINE MOUTHWASH/GARGLE ORL MWH PUR ML 0.035000000637661 BETAGAN 0.5% OPH SOLUTION OPH SOL ALL ML 3.551000002466457 BETAHISTINE 24 MG TABLET ORL TAB SNS TAB 0.498300002449773 BETEFLAM 2.25 MG TOPICAL PATCH TOP PTH CIP PTH 3.233800002417030 BEXSERO 0.5 ML INJECTION SYRINGE INJ NDL NOV SYR 109.640000002359685 BIACNA 1.2%/0.025% TOPICAL GEL TOP GEL VCL G 1.114000002325985 BICALUTAMIDE 50 MG TABLET ORL TAB AHI TAB 4.057300002382423 BICALUTAMIDE 50 MG TABLET ORL TAB SIV TAB 4.057300002291924 BICILLIN L-A 1,200,000 IU/2 ML INJ SYR INJ NDL PFI SYR 48.215000000297763 BICNU 100 MG/VIAL INJECTION INJ DEFAUL BMS VIAL 120.040000002478579 BIKTARVY TABLET ORL TAB GIL TAB 39.222700002230897 BILTRICIDE 600 MG TABLET ORL TAB BAI TAB 6.290000080026265 BIO K 20 POTASSIUM 20 MEQ TABLET ORL TAB BMD TAB 0.199500002392143 BIO-AMLODIPINE 10 MG TABLET ORL TAB BMD TAB 0.199300002392127 BIO-AMLODIPINE 2.5 MG TABLET ORL TAB BMD TAB 0.076700002392135 BIO-AMLODIPINE 5 MG TABLET ORL TAB BMD TAB 0.134300002392488 BIO-ANASTROZOLE 1 MG TABLET ORL TAB BMD TAB 0.952300002392186 BIO-ATENOLOL 100 MG TABLET ORL TAB BMD TAB 0.182100002392194 BIO-ATENOLOL 25 MG TABLET ORL TAB BMD TAB 0.067600002392178 BIO-ATENOLOL 50 MG TABLET ORL TAB BMD TAB 0.110700080047876 BIOCELL SALTS ORAL LIQUID ORL LIQ AEI ML 0.433300002444887 BIO-CIPROFLOXACIN 500 MG TABLET ORL TAB BMD TAB 0.502500002448475 BIO-CITALOPRAM 10 MG TABLET ORL TAB BMD TAB 0.143200002448491 BIO-CITALOPRAM 20 MG TABLET ORL TAB BMD TAB 0.239700002448513 BIO-CITALOPRAM 40 MG TABLET ORL TAB BMD TAB 0.239700000621366 BIODERM TOPICAL OINTMENT TOP ONT ODN G 0.360000002445034 BIO-DOMPERIDONE 10 MG TABLET ORL TAB BMD TAB 0.042800002425211 BIO-EZETIMIBE 10 MG TABLET ORL TAB BMD TAB 0.326000002448424 BIO-FLUOXETINE 10 MG CAPSULE ORL CAP BMD CAP 0.340400002247371 BIO-FUROSEMIDE 20 MG TABLET ORL TAB BMD TAB 0.0373

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 21 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002247372 BIO-FUROSEMIDE 40 MG TABLET ORL TAB BMD TAB 0.055800002450143 BIO-GABAPENTIN 100 MG CAPSULE ORL CAP BMD CAP 0.074900002450151 BIO-GABAPENTIN 300 MG CAPSULE ORL CAP BMD CAP 0.182100002450178 BIO-GABAPENTIN 400 MG CAPSULE ORL CAP BMD CAP 0.217100002450186 BIO-GABAPENTIN 600 MG TABLET ORL TAB BMD TAB 0.325600080012472 BIOGAIA CHEWABLE TABLET ORL CTB FEI TAB 0.713300080012473 BIOGAIA DROPS ORL DPS FEI ML 4.280000080062995 BIOGAIA ORAL DROPS ORL SUS FEI ML 4.680000002247170 BIO-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.015700002247171 BIO-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.021700002446154 BIO-IRBESARTAN 150 MG TABLET ORL TAB BMD TAB 0.302500002446162 BIO-IRBESARTAN 300 MG TABLET ORL TAB BMD TAB 0.302500002446146 BIO-IRBESARTAN 75 MG TABLET ORL TAB BMD TAB 0.302500080015104 BIO-K EXTRA STRENGTH PROBIOTIC CAPSULE ORL CAP BKP CAP 1.609300000989995 BIO-K PLUS RICE PROBIOTIC DRINK ORL LIQ BKP G 0.031300002450348 BIO-LEVETIRACETAM 250 MG TABLET ORL TAB BMD TAB 0.321000002450356 BIO-LEVETIRACETAM 500 MG TABLET ORL TAB BMD TAB 0.391100002450364 BIO-LEVETIRACETAM 750 MG TABLET ORL TAB BMD TAB 0.541600080006533 BIOMEDIC MULTIVITAMIN ORL CAP VTH CAP 0.060700002216051 BION TEARS OPH SOLUTION OPH SOL ALC ML 0.960400080003128 BIONUTRITION FORMULA 3 CAPSULE ORL CAP BNI CAP 1.166600002449927 BIO-OMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT BMD TAB 0.411700002445867 BIO-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT BMD TAB 0.201600002444909 BIO-PAROXETINE 10 MG TABLET ORL TAB BMD TAB 0.304600002444917 BIO-PAROXETINE 20 MG TABLET ORL TAB BMD TAB 0.325000002444925 BIO-PAROXETINE 30 MG TABLET ORL TAB BMD TAB 0.345300002446251 BIO-PRAVASTATIN 10 MG TABLET ORL TAB BMD TAB 0.291600002446278 BIO-PRAVASTATIN 20 MG TABLET ORL TAB BMD TAB 0.344000002446286 BIO-PRAVASTATIN 40 MG TABLET ORL TAB BMD TAB 0.414300002445069 BIO-SERTRALINE 100 MG CAPSULE ORL CAP BMD CAP 0.420000002445042 BIO-SERTRALINE 25 MG CAPSULE ORL CAP BMD CAP 0.200400002445050 BIO-SERTRALINE 50 MG CAPSULE ORL CAP BMD CAP 0.400000080023605 BIOSIL CAPSULE ORL CAP PRN CAP 0.400000080026421 BIOSTEEL HIGH PERFORMANCE SPORTS POWDER ORL PWR BSL G 0.118900000999783 BIOTENE DRY MOUTH TOOTHPASTE ORL GEL GSK G 0.072000000999776 BIOTENE ORAL BALANCE GEL ORL GEL GSK G 0.171500000999782 BIOTENE ORAL RINSE ORL MWH GSK ML 0.015300000999777 BIOTENE SPRAY ORL SPR GSK ML 0.163700080065916 BIOTIN 10,000 MCG SOFTGEL ORL CAP JMS CAP 0.294400000437522 BIOTIN 250 MCG TABLET ORL TAB JAM TAB 0.0567

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002326302 BI-PEGLYTE KIT ORL ECT/PWR PPH KIT 22.000000002458853 BISACODYL 10 MG RECTAL SUPPOSITORY RT SUP CEL SUP 0.468000002458845 BISACODYL 5 MG RECTAL SUPPOSITORY RT SUP CEL SUP 0.426700002273411 BISACODYL-ODAN 5 MG ENTERIC-COATED TABLET ORL ECT ODN TAB 0.069000002265982 BLEOMYCIN 15 UNIT/VIAL INJECTION INJ DEFAUL FKC VIAL 419.400000002131692 BLEOMYCIN SULFATE 15 UNIT/VIAL INJECTION INJ DEFAUL PFI VIAL 421.380000002454130 BLEXTEN 20 MG TABLET ORL TAB TRI TAB 0.864000000999809 BLINK CONTACTS LUBRICATING EYE DROP OPH DPS AMO ML 0.3687

00080063321 BLOOD PRESSURE FORMULATION COMBO 60 MG CAPSULE ORL CAP BLP CAP 0.336500080053068 BLOOD PRESSURE FORMULATION COMBO CAPSULE ORL CAP BLP CAP 0.348300099400765 BLOOD PRESSURE MONITOR DEFAUL DEFAUL XXX MIS 101.900000080038108 BONESURE CAPSULE ORL CAP BPC CAP 0.299400000999880 BOOST JUST PROTEIN ORAL POWDER ORL PWR NHN G 0.060100002247600 BOOSTRIX INJECTION SYRINGE INJ DEFAUL GSK SYR 30.743000002423405 BORTEZOMIB FOR INJECTION 3.5 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 1402.420000002253992 BOSTON SIMPLUS MULTI-ACTION SOLUTION DEFAUL SOL BSH ML 0.095100002419149 BOSULIF 100 MG TABLET ORL TAB PFI TAB 38.978600002419157 BOSULIF 500 MG TABLET ORL TAB PFI TAB 152.240400002243721 BOTOX (ONABOTULINUMTOXINA) COSMETIC 100 U/VIAL INJ INJ DEFAUL ALL VIAL 357.000000080026680 BOULARDIIMAX CAPSULE ORL CAP RLC CAP 0.483000099401153 BREAST PUMP, ELECTRIC DEFAUL DEFAUL XXX MIS 275.000000099400317 BREAST PUMP, MANUAL DEFAUL DEFAUL XXX MIS 67.250000002187086 BREVICON 0.5/35 (21 DAY) TABLET ORL TAB PFI TAB 0.683300002187094 BREVICON 0.5/35 (28 DAY) TABLET ORL TB PFI TAB 0.512500002189054 BREVICON 1/35 (21 DAY) TABLET ORL TAB PFI TAB 0.683300002189062 BREVICON 1/35 (28 DAY) TABLET ORL TB PFI TAB 0.512500002455005 BRILINTA 60 MG TABLET ORL TAB AZC TAB 1.511000002301334 BRIMONIDINE P 0.15% OPHTHALMIC SOLUTION OPH SOL AAP ML 2.190000002484013 BRINEURA 30 MG/ML INJECTION INJ DEFAUL BMI ML 3020.000000002452987 BRIVLERA 10 MG/ML ORAL SOLUTION ORL SOL UCB ML 0.432000000522791 BRONCHOPHAN FORTE DM ORAL SYRUP ORL SYR ATL ML 0.030600000512990 BSS BALANCED SALT OPH SOLUTION OPH SOL ALC ML 0.433300000729655 BUCKLEY'S DM ORAL LIQUID ORL LIQ BUA ML 0.0489

00080022907 BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB ORL CTB BIC TAB 0.086900002331616 BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.266700000728284 BURINEX 1 MG TABLET ORL TAB KTI TAB 0.790700000728276 BURINEX 5 MG TABLET ORL TAB KTI TAB 3.018300002223163 BUSPIRONE 10 MG TABLET ORL TAB PDL TAB 0.3517

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002242504 BUTORPHANOL 10 MG/ML NASAL SPRAY NAS SPR AAP ML 24.472000002341212 BUTRANS 10 (10 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 28.445000002450771 BUTRANS 15 (15 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 40.057500002341220 BUTRANS 20 (20 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 51.690000002341174 BUTRANS 5 (5 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 15.487500002448610 BYDUREON 2 MG/DOSE INJECTION PEN INJ DEFAUL AZC SYR 50.672500002361817 BYETTA 10 MCG/DOSE (2.4 ML) INJECTION SYRINGE INJ NDL AZC SYR 143.670000002361809 BYETTA 5 MCG/DOSE (1.2 ML) INJECTION SYRINGE INJ NDL AZC SYR 143.670000002399016 BYSTOLIC 10 MG TABLET ORL TAB FLC TAB 1.453000002398990 BYSTOLIC 2.5 MG TABLET ORL TAB FLC TAB 1.453000002399024 BYSTOLIC 20 MG TABLET ORL TAB FLC TAB 1.453000002399008 BYSTOLIC 5 MG TABLET ORL TAB FLC TAB 1.453000002497220 CABENUVA 400 MG/600 MG (2 ML) INJECTION KIT INJ VIAL/VIA VIV KIT 1209.380000002497247 CABENUVA 600 MG/900 MG (3 ML) INJECTION KIT INJ VIAL/VIA VIV KIT 2418.750000002496194 CABLIVI 11 MG/VIAL INJECTION INJ DEFAUL SAV VIAL 6200.000000002480824 CABOMETYX 20 MG TABLET ORL TAB ISP TAB 293.333300002480832 CABOMETYX 40 MG TABLET ORL TAB ISP TAB 293.333300002480840 CABOMETYX 60 MG TABLET ORL TAB ISP TAB 293.333300002273284 CADUET 10 MG/10 MG TABLET ORL TAB UJC TAB 2.523600002273292 CADUET 10 MG/20 MG TABLET ORL TAB UJC TAB 3.146100002273306 CADUET 10 MG/40 MG TABLET ORL TAB UJC TAB 3.296000002273314 CADUET 10 MG/80 MG TABLET ORL TAB UJC TAB 3.296000002273233 CADUET 5 MG/10 MG TABLET ORL TAB UJC TAB 2.390200002273241 CADUET 5 MG/20 MG TABLET ORL TAB UJC TAB 2.818700002273268 CADUET 5 MG/40 MG TABLET ORL TAB UJC TAB 2.979300002273276 CADUET 5 MG/80 MG TABLET ORL TAB UJC TAB 2.979300002238389 CAELYX 2 MG/ML PEGYLATED LIPOSOME INJECTION INJ DEFAUL JAI ML 77.073000002241460 CAL MAG 2:1 WITH D TABLET ORL TAB WNP TAB 0.053600000485969 CALAMINE TOPICAL LOTION TOP LOT ROG ML 0.014400080000159 CALCIA 500 MG/400 IU TABLET ORL TAB MDX TAB 0.149800000730602 CALCIUM & MAGNESIUM WITH VITAMIN D CAPSULE ORL CAP SIS CAP 0.244200002240973 CALCIUM (CARBONATE) W/ VITAMIN D 500 MG/125 U TAB ORL TAB WNP TAB 0.075000080003658 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.025700002240977 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.044900002240240 CALCIUM 500 MG TABLET ORL TAB CEL TAB 0.085000002230645 CALCIUM 500 MG WITH VITAMIN D TABLET ORL TAB WAM TAB 0.079200080009369 CALCIUM 650 MG TABLET ORL TAB PMT TAB 0.034200080031245 CALCIUM 650 MG TABLET ORL TAB WNP TAB 0.023800080000248 CALCIUM 650 MG TABLET ORL TAB JAM TAB 0.072900080007105 CALCIUM 650 MG WITH VITAMIN D 400 IU CAPLET ORL TAB JMS TAB 0.0729

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 24 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002040875 CALCIUM AND MAGNESIUM CAPLET ORL TAB JAM TAB 0.043800002245170 CALCIUM AND MAGNESIUM CITRATE WITH VITAMIN D TAB ORL TAB WNP TAB 0.048800002244861 CALCIUM AND MAGNESIUM WITH VITAMIN D TAB ORL TAB PMT TAB 0.034500002240367 CALCIUM AND MAGNESIUM WITH VITAMIN D TABLET ORL TAB WAM TAB 0.079200002243418 CALCIUM BONE SOLUTION ORL LIQ ULT ML 0.034300000730599 CALCIUM CARBONATE & VITAMIN D3 500 MG/125 U TABLET ORL TAB PMT TAB 0.034500001922238 CALCIUM CARBONATE 500 MG CHEWABLE TABLET ORL CTB WAM TAB 0.098800080062015 CALCIUM CARBONATE 500 MG TABLET ORL TAB SNS TAB 0.021600080003855 CALCIUM CITRATE 300 MG TABLET ORL TAB WNP TAB 0.064200002243766 CALCIUM CITRATE 300 MG TABLET ORL TAB PMT TAB 0.079100002158728 CALCIUM CITRATE 350 MG TABLET ORL TAB SWS TAB 0.094500080003662 CALCIUM CITRATE W/ VITAMIN D 300 MG/200 IU TABLET ORL TAB WNP TAB 0.066900002237590 CALCIUM CITRATE WITH VITAMIN D TABLET ORL TAB JAM TAB 0.081200080002896 CALCIUM FACTOR+ 350 MG TABLET ORL TAB NFN TAB 0.060000002141019 CALCIUM GLUCONATE 94 MG/ML INJECTION INJ DEFAUL FKC ML 1.596000080025345 CALCIUM MAGNESIUM WITH VITAMIN D ORL TAB WNP TAB 0.032100080007103 CALCIUM MAGNESIUM WITH VITAMIN D CAPLET ORL TAB JMS TAB 0.043800002040905 CALCIUM MAGNESIUM WITH VITAMIN D TABLET ORL TAB JAM TAB 0.068500080007265 CALCIUM SOFT CHEWS WITH VITAMIN D ORL CAP JAM CAP 0.216700080017117 CALCIUM WITH VITAMIN D LIQUID GREEN APPLIE ORL LIQ WAM ML 0.036100001906828 CAL-MAG WITH ZINC & VITAMIN D CAPLET ORL TAB SWS TAB 0.090200080027151 CALMOSEPTINE OINTMENT TOP ONT CAL G 0.061900002198630 CALMYLIN ACE 2 MG/ML SYRUP ORL SYR RPH ML 0.096000000535230 CALMYLIN WITH CODEINE COUGH ORAL LIQUID ORL LIQ RPH ML 0.051500002172917 CALMYLIN WITH CODEINE ORAL SYRUP ORL SYR ROG ML 0.054900002491788 CALQUENCE 100 MG CAPSULE ORL CAP AZC CAP 135.975000080003751 CALTRATE 600 TABLET ORL TAB PDH TAB 0.173800080023065 CALTRATE SELECT 600 MG/400 IU TABLET ORL TAB PDH TAB 0.208600080033741 CALTRATE WITH VITAMIN D 600 MG/800 IU TABLET ORL TAB PDH TAB 0.173800080012593 CALTRATE WITH VITAMIN D SOFT CHEWS ORL CTB WAY TAB 0.192200002381680 CAMBIA 50 MG ORAL POWDER PACKET ORL PWDPKT TRI PCKT 10.460000002377942 CANDESARTAN 16 MG TABLET ORL TAB PDL TAB 0.228100002422069 CANDESARTAN 32 MG TABLET ORL TAB PDL TAB 0.285000002388901 CANDESARTAN 4 MG TABLET ORL TAB SNS TAB 0.340000002377934 CANDESARTAN 8 MG TABLET ORL TAB PDL TAB 0.228100002379260 CANDESARTAN CILEXETIL 4 MG TABLET ORL TAB AHI TAB 0.340000002392275 CANDESARTAN-HCTZ 16 MG/12.5 MG TABLET ORL TAB PDL TAB 0.215600080038188 CANDIBACTIN BR TABLET ORL TAB MTG TAB 0.303300080050373 CANDIBACTIN-AR CAPSULE ORL CAP MTG CAP 0.455000002311690 CANESORAL 150 MG CAPSULE ORL CAP BIC CAP 15.4200

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002311739 CANESORAL COMBI-PAK KIT ORL/VAG CAP/CRM BIC KIT 17.630000002311720 CANESTEN 1% EXTERNAL CREAM TOP CRM BIC G 13.310000002150867 CANESTEN 1% TOPICAL CREAM TOP CRM BAI G 0.396000080023975 CANTHARONE 0.7% TOPICAL SOLUTION TOP SOL DLX ML 10.660000000772011 CANTHARONE PLUS TOPICAL SOLUTION TOP SOL DLX ML 11.993300002157101 CAPSAICIN 0.025% TOPICAL CREAM TOP CRM VCL G 0.191700002157128 CAPSAICIN 0.075% TOPICAL CREAM TOP CRM VCL G 0.232500002060043 CARBACHOL 2 MG TABLET ORL TAB BNQ TAB 0.590000002413590 CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.093000002413604 CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.185900002241999 CARBOCAINE 10 MG/ML INJECTION INJ DEFAUL PFI ML 0.722000002242001 CARBOCAINE 20 MG/ML INJECTION INJ DEFAUL PFI ML 1.444500002245511 CARBOCAL D 400 TABLET ORL TAB SDZ TAB 0.120000002011239 CARBOLITH 600 MG CAPSULE ORL CAP VCL CAP 0.208000002126680 CARBOPLATIN 10 MG/ML INJECTION INJ DEFAUL PFI ML 21.224000002397447 CARIPUL 0.5 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 17.780000002397455 CARIPUL 1.5 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 35.650000002324520 CARVEDILOL 12.5 MG TABLET ORL TAB PDL TAB 0.635000002324539 CARVEDILOL 25 MG TABLET ORL TAB PDL TAB 0.635000002324504 CARVEDILOL 3.125 MG TABLET ORL TAB PDL TAB 0.635000002324512 CARVEDILOL 6.25 MG TABLET ORL TAB PDL TAB 0.635000002184478 CASODEX 50 MG TABLET ORL TAB AZC TAB 7.050000002370840 CATHEJELL 2% TOPICAL JELLY TOP JEL PFM ML 8.000000002245859 CATHFLO 1 MG/ML POWDER FOR SOLUTION INJ DEFAUL HLR ML 34.063000002215756 CAVERJECT 20 MCG INJECTION INJ DEFAUL PFI VIAL 32.298000002458799 CCP-ANASTROZOLE 1 MG TABLET ORL TAB CEL TAB 1.272900002459884 CCP-LETROZOLE 2.5 MG TABLET ORL TAB CEL TAB 1.378000000465208 CECLOR 25 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.118300000465216 CECLOR 50 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.216600000360430 CEENU 10 MG CAPSULE ORL CAP BMS CAP 7.890000000360414 CEENU 100 MG CAPSULE ORL CAP BMS CAP 22.455000000360422 CEENU 40 MG CAPSULE ORL CAP BMS CAP 13.602500002237138 CEFAZOLIN 1 G/VIAL USP INJECTION INJ DEFAUL FKC VIAL 69.000000002237137 CEFAZOLIN 500 MG/VIAL USP INJECTION INJ DEFAUL FKC VIAL 2.500000002437112 CEFAZOLIN FOR INJECTION 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 3.230000002437104 CEFAZOLIN FOR INJECTION 500 MG/VIAL INJECTION INJ DEFAUL STM VIAL 2.500000002319039 CEFEPIME 2G/VIAL INJECTION INJ DEFAUL APX VIAL 30.196000002240773 CEFOXITIN 10 G/VIAL USP INJECTION INJ DEFAUL TEV VIAL 105.950000002332027 CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS RAN ML 0.236600000886971 CEFTAZIDIME 1 G/VIAL INJECTION INJ DEFAUL FKC VIAL 27.5900

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002437848 CEFTAZIDIME 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 22.927000002437856 CEFTAZIDIME 2 G/VIAL INJECTION INJ DEFAUL STM VIAL 45.077000000886955 CEFTAZIDIME 2 G/VIAL INJECTION INJ DEFAUL FKC VIAL 54.270000002439522 CEFTAZIDIME 3 G/VIAL INJECTION INJ DEFAUL STM VIAL 67.500000000886963 CEFTAZIDIME 6 G/VIAL INJECTION INJ DEFAUL FKC VIAL 162.940000002437864 CEFTAZIDIME 6 G/VIAL INJECTION INJ DEFAUL STM VIAL 135.300000002212307 CEFTIN 125 MG/5ML ORAL SUSPENSION ORL SUS GSK ML 0.179400002212277 CEFTIN 250 MG TABLET ORL TAB GSK TAB 1.677500002212285 CEFTIN 500 MG TABLET ORL TAB GSK TAB 3.3232

00002409968 CEFTRIAXONE 100 G/SMARTPAK BULK PACKAGE INJECTION INJ DEFAUL FKC G 21.420000002292262 CEFTRIAXONE FOR INJECTION BP 0.25G/VIAL INJECTION INJ DEFAUL SDZ VIAL 7.525000002287668 CEFTRIAXONE SODIUM FOR INJECTION 10 G/VIAL INJ INJ DEFAUL TEV VIAL 214.200000002250292 CEFTRIAXONE SODIUM FOR INJECTION BP 1 G/VIAL INJ INJ DEFAUL HSP VIAL 36.310000002241639 CEFUROXIME 1.5 G/VIAL INJECTION USP INJ DEFAUL FKC VIAL 39.790000002422301 CEFUROXIME 1.5 G/VIAL INJECTION USP INJ DEFAUL STM VIAL 39.790000002422328 CEFUROXIME 7.5 G/VIAL INJECTION USP INJ DEFAUL STM VIAL 149.200000002241640 CEFUROXIME 7.5 G/VIAL INJECTION USP INJ DEFAUL FKC VIAL 149.200000002422298 CEFUROXIME 750 MG/VIAL INJECTION USP INJ DEFAUL STM VIAL 19.890000002241638 CEFUROXIME 750 MG/VIAL INJECTION USP INJ DEFAUL FKC VIAL 19.890000002424371 CELECOXIB 100 MG CAPSULE ORL CAP PDL CAP 0.127900002436299 CELECOXIB 100 MG CAPSULE ORL CAP SNS CAP 0.127900002436302 CELECOXIB 200 MG CAPSULE ORL CAP SNS CAP 0.255800002424398 CELECOXIB 200 MG CAPSULE ORL CAP PDL CAP 0.255800002357852 CELESTODERM-V 0.1% TOPICAL OINTMENT TOP ONT VCL G 0.091100002357879 CELESTODERM-V/2 0.05% TOPICAL OINTMENT TOP ONT VCL G 0.061100002242145 CELLCEPT 200 MG/ ML ORAL SUSPENSION ORL SUS HLR ML 1.977400002192748 CELLCEPT 250 MG CAPSULE ORL CAP HLR CAP 2.080600002237484 CELLCEPT 500 MG TABLET ORL TAB HLR TAB 4.161200002240347 CELLCEPT I.V. 500 MG/VIAL INJECTION POWDER FOR SOL INJ DEFAUL HLR VIAL 33.902500000870153 CELLUVISC 1% OPH SOLUTION OPH SOL ALL ML 0.821700002299844 CELSENTRI 150 MG TABLET ORL TAB PFI TAB 18.184800002299852 CELSENTRI 300 MG TABLET ORL TAB PFI TAB 18.184800080013657 CENTRUM ADVANTAGE TABLET ORL TAB PDH TAB 0.186300080022930 CENTRUM CARDIO TABLET ORL TAB PDH TAB 0.219400080024482 CENTRUM FOR WOMEN ORL TAB PDH TAB 0.144000080043454 CENTRUM FOR WOMEN 50+ TABLET ORL TAB PDH TAB 0.144000080037227 CENTRUM FORTE TABLET ORL TAB PDH TAB 0.129600080020794 CENTRUM JUNIOR COMPLETE CHEWABLE TABLET ORL CTB PDH TAB 0.123800080043120 CENTRUM MEN 50+ TABLET ORL TAB PDH TAB 0.1440

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080065869 CENTRUM MULTIGUMMIES WOMEN GUMMY ORL CTB PDH TAB 0.111500080045822 CENTRUM PRENATAL TABLET ORL TAB PDH TAB 0.145600080017298 CENTRUM SELECT CHEWABLE TABLET 50+ ORL CTB PDH TAB 0.216000080037019 CENTRUM SELECT ESSENTIALS 50+ TABLET ORL TAB PDH TAB 0.153200080005153 CENTRUM SELECT TABLET ORL TAB WCH TAB 0.156300080021452 CENTRUM TABLET ORL TAB PDH TAB 0.091900000828866 CEPHALEXIN 500 MG TABLET ORL TAB PDL TAB 0.450000000999039 CERAVE CREAM TOP CRM VCL G 0.084000000999042 CERAVE EYE CREAM TOP CRM XXX G 1.013400002410923 CERAVE TOPICAL LOTION TOP LOT VCL ML 0.152400002463261 CERDELGA 84 MG CAPSULE ORL CAP SAV CAP 695.000000002230988 CEREBYX 75 MG/ML INJECTION INJ DEFAUL PFI ML 10.100000002230694 CEREZYME 200 U/VIAL INJECTION INJ DEFAUL GZM VIAL 1230.000000002241751 CEREZYME 400 U/VIAL INJECTION INJ DEFAUL GZM VIAL 2460.000000001926683 CERUBIDINE 20 MG/VIAL INJECTION INJ DEFAUL ERF VIAL 97.000000000158356 CERUMENEX 10% OTIC DROPS OT DPS PUR ML 0.574000000221570 CERUMOL OTIC DROPS OT DPS PAL ML 0.536400002342227 CERVARIX 0.5 ML INJECTION INJ DEFAUL GSK ML 201.360000002312263 CESAMET 0.25 MG CAPSULE ORL CAP VCL CAP 1.919600002450526 CETIRIZINE 20 MG TABLET ORL TAB PDL TAB 0.753500002247766 CETROTIDE 0.25 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 90.000000002247767 CETROTIDE 3 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 340.000000002423715 CHARCOAL 260 MG CAPSULE ORL CAP DSE CAP 0.1528

00002186004 CHASE KOLIK (ALCOHOL FREE) GRIPE WATER ORAL LIQUID ORL LIQ SLL ML 0.030000000496685 CHELATED CHROMIUM 200 MCG TABLET ORL TAB JAM TAB 0.072100080009742 CHEWABLE PEPPERMINT VITAMIN D 1000 IU ORL TAB SWS TAB 0.047900080092611 CHEWABLE VITAMIN C 500 MG TABLET ORL CTB JMS TAB 0.055300002236728 CHILDREN'S ACETAMINOPHEN SUSPENSION 32 MG/ML ORL SUS PRI ML 0.089900002248435 CHILDREN'S ADVIL COLD ORAL SUSPENSION ORL SUS PDH ML 0.061300002354799 CHILDREN'S EUROPROFEN 20 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.054100002280175 CHILDREN'S IBUPROFEN SUSPENSION 20 MG/ML ORL SUS PRI ML 0.063000080029912 CHILDREN'S LACTEEZE TABLET ORL TAB GEL TAB 0.179900002238626 CHILDREN'S MOTRIN 40 MG/ML SUSPENSION DROPS ORL DPS MCL ML 0.201700002039990 CHILDREN'S TYLENOL COLD DM ORAL SUSPENSION ORL SUS MCL ML 0.057100002229538 CHILDRENS TYLENOL DECONGESTANT LIQUID ORL LIQ MCL ML 0.0571

00002046040 CHILDREN'S TYLENOL GRAPE 32 MG/ML ORAL SUSPENSION ORL SUS MCL ML 0.057100002247621 CHLORAL HYDRATE-ODAN 100 MG/ML ORAL SYRUP ORL SYR ODN ML 0.071000002462842 CHLORHEXIDINE 0.12% ORAL RINSE ORL MWH EUP ML 0.0171

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000738972 CHLOR-TRIPOLON 4 MG TABLET ORL TAB BIC TAB 0.211700001970399 CHLOR-TRIPOLON N.D. SUSTAINED-RELEASE TABLET ORL TAB SCH TAB 0.434200080015373 CHONDROCARE TABLET ORL TAB MTG TAB 0.450000002247459 CHORIONIC GONADOTROPIN 10,000 UNIT/VIAL INJECTION INJ DEFAUL FKC VIAL 146.000000080005091 CHROMIUM GTF TABLET ORL TAB WNP TAB 0.041200002248088 CIALIS 10 MG TABLET ORL TAB LIL TAB 12.692500002296888 CIALIS 2.5 MG TABLET ORL TAB LIL TAB 3.881800002248089 CIALIS 20 MG TABLET ORL TAB LIL TAB 13.152500002296896 CIALIS 5 MG TABLET ORL TAB LIL TAB 3.924300002238273 CI-CAL 250 MG TABLET ORL TAB SDZ TAB 0.136800002200864 CILOXAN 0.3% OPHTHALMIC OINTMENT OPH ONT NOV G 3.225700000900005 CINGAL DEFAUL DEV PPH ML 106.250000080005972 CINNAMON 500 MG CAPSULE ORL CAP VTH CAP 0.060000002456419 CINQAIR 10 MG/ML INJECTION INJ DEFAUL TMP ML 64.000000002155966 CIPRO 500 MG TABLET ORL TAB BAI TAB 2.816600002251787 CIPRO XL 1000 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.112000002247916 CIPRO XL 500 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.112000002301903 CIPROFLOXACIN 2 MG/ML INJECTION USP INJ DEFAUL PFI ML 0.179200002304759 CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ INJ DEFAUL SDZ ML 0.154000002408813 CISATRACURIUM OMEGA MULTIDOSE 2 MG/ML INJECTION INJ DEFAUL OMG ML 1.880000002126613 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL PFI ML 6.460000002403188 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL TEV ML 6.152400002301849 CITALOPRAM 40 MG TABLET ORL TAB MEL TAB 0.239700002325047 CITALOPRAM-10 10 MG TABLET ORL TAB PDL TAB 0.143200002257513 CITALOPRAM-20 20 MG TABLET ORL TAB PDL TAB 0.133300002257521 CITALOPROM-40 40 MG TABLET ORL TAB PDL TAB 0.239700000519235 CITANEST PLAIN 4% INJECTION INJ DEFAUL DSC ML 0.865800002150158 CITRACAL PLUS D CAPLET ORL TAB SFD TAB 0.125200000701416 CITRAMINS CAPSULE ORL CAP XXX CAP 0.185600080007797 CITRAMINS II CAPSULE ORL CAP XXX CAP 0.185600000262609 CITRO MAG 50 MG ORAL LIQUID ORL LIQ ROG ML 0.015600002324482 CLARITHROMYCIN 250 MG TABLET ORL TAB PDL TAB 0.412200002324490 CLARITHROMYCIN 500 MG TABLET ORL TAB PDL TAB 1.629200002237734 CLARITIN 10 MG RAPID DISSOLVE TONGUE TABLET ORL DISPTAB BIC TAB 0.670000000782696 CLARITIN 10 MG TABLET ORL TAB BIC TAB 0.670000001945157 CLARITIN EXTRA SUSTAINED-RELEASE TABLET ORL SRT BIC TAB 0.670000000442968 CLEARASIL BP PLUS 5% TOPICAL LOTION TOP LOT RBC ML 0.170700002324989 CLEARLAX ORAL POWDER ORL PWR PRI G 0.023100002436736 CLEO-35 2 MG/0.035 MG TABLET ORL TAB ALH TAB 1.285700002408511 CLINDAMYCIN IV INFUSION 12 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.3724

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002408538 CLINDAMYCIN IV INFUSION 18 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.518600002483769 CLINDAMYCIN PHOSPHATE (BASE) 1% TOPICAL SOLUTION TOP SOL TGT ML 0.261300002248525 CLINDAMYCINE-150 150 MG TABLET ORL TAB PDL TAB 0.221700002248526 CLINDAMYCINE-300 300 MG CAPSULE ORL CAP PDL CAP 0.443400002243659 CLINDA-T 1% (BASE) TOPICAL SOLUTION TOP SOL VCL ML 0.238000080007070 CLINIDERM GENTLE SPF 45 LOTION TOP LOT SAH ML 0.241500080012416 CLINPRO 5000 TOOTHPASTE ORL TPT MMH G 0.081900002256398 CLOBEX 0.05% TOPICAL LOTION TOP LOT GAL ML 0.876300002256371 CLOBEX 0.05% TOPICAL SHAMPOO TOP SHP GAL ML 1.389800002299739 CLOBEX 0.05% TOPICAL SPRAY TOP SPR GAL ML 2.826600002394820 CLOPIDOGREL 75 MG TABLET ORL TAB PDL TAB 0.263100000812382 CLOTRIMADERM 1% TOPICAL CREAM TOP CRM TAR G 0.306500002445131 CLOTRIMADERM-FLUCONAZOLE COMBI-PAK KIT ORL/VAG CAP/CRM TAR KIT 14.990000002229380 CLOTRIMAZOLE 1% TOPICAL CREAM USP TOP CRM TAR G 0.210000002400081 CLOXACILLIN FOR INJECTION 10 G/VIAL INJECTION INJ DEFAUL STM VIAL 79.700000002390183 CO EXEMESTANE 25 MG TABLET ORL TAB APH TAB 3.900700080027715 CO Q 10 120 MG CAPSULE ORL CAP JMS CAP 0.279200080006266 CO Q10 100 MG CAPSULE ORL CAP SIS CAP 0.166600080007078 CO Q10 LIQUID ORL LIQ INN ML 0.794100002150417 COATED ASPIRIN 325 MG CAPLET ORL ECT BAI TAB 0.061800002237726 COATED ASPIRIN DAILY LOW DOSE 81 MG ECT ORL ECT BIC TAB 0.118000002150425 COATED ASPIRIN EXTRA STRENGTH 500 MG CAPLET ORL ECT BAI TAB 0.075500002244715 COD LIVER OIL ORL LIQ WNP ML 0.021100000999517 COD LIVER OIL MIS DEFAUL XXX MIS 2.566400002009757 CODEINE 30 MG TABLET ORL TAB RIV TAB 0.077300002163748 CODEINE CONTIN 100 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.806000002163780 CODEINE CONTIN 150 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 1.209000002163799 CODEINE CONTIN 200 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 1.612000002230302 CODEINE CONTIN 50 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.403000000050024 CODEINE PHOSPHATE 5 MG/ML ORAL SYRUP ORL SYR ATL ML 0.063800002248644 COENZYME Q10 100 MG CAPSULE ORL CAP VTH CAP 0.326600002246219 COENZYME Q10 100 MG CAPSULE ORL CAP WNP CAP 0.140300080010367 COENZYME Q10 150 MG SOFTGEL ORL CAP WBP CAP 0.370700080011974 COENZYME Q10 200 MG SOFTGEL ORL CAP WNP CAP 0.247200080006827 COENZYME Q10 30 MG CAPSULE ORL CAP WNP CAP 0.123700080005615 COENZYME Q10 60 MG CAPSULE ORL CAP JMS CAP 0.196900080006674 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.123700080006505 COENZYME Q10 SOFTGEL ORL CAP WNP CAP 0.139000000287873 COLCHICINE 0.6 MG TABLET ORL TAB SDZ TAB 0.256500000642975 COLESTID ORAL POWDER PACKET ORL PWDPKT PFI PCKT 1.1733

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 30 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002132699 COLESTID ORANGE 7.5 G ORAL POWDER PACKET ORL PWDPKT PFI PCKT 1.126000002403544 COLISTIMETHATE FOR INJECTION 150 MG/VIAL INJECTION INJ DEFAUL FKC VIAL 34.250000000999384 COLONOSCOPY KIT DEFAUL DEFAUL XXX MIS 33.000000000476420 COLY-MYCIN M 150 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 39.500000001944363 COMBANTRIN 125 MG TABLET ORL TAB MCL TAB 1.198300001944355 COMBANTRIN 50 MG/ML ORAL SUSPENSION ORL SUS MCL ML 0.278900002419106 COMBIVENT RESPIMAT 20 MCG/100 MCG INH SOLUTION INH SOL BOE DOSE 0.250100002239213 COMBIVIR 150 MG/300 TABLET ORL TAB GSK TAB 11.761200000999855 COMPLEAT ORGANIC VEGETABLE POUCH ORL LIQ NHN ML 0.019500000999857 COMPLEAT PEDIATRIC ORGANIC BLENDS ORAL LIQUID ORL LIQ NHN ML 0.022200002374129 COMPLERA 200 MG/25 MG/300 MG TABLET ORL TAB GIL TAB 41.574000002229633 COMPLETE MULTI-ADULT TABLET ORL TAB WAM TAB 0.060700080011612 COMPLETE PROBIOTIC CAPSULE ORL CAP WNP CAP 0.183500000999760 COMPLEX 15 DAILY FACE CREAM TOP CRM MFC ML 0.063200002247732 CONCERTA 18 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.576900002250241 CONCERTA 27 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.973800002247733 CONCERTA 36 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.370900002247734 CONCERTA 54 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 4.164600001945149 CONDYLINE 0.5% TOPICAL SOLUTION TOP SOL SAV ML 11.937100002417162 CONSTELLA 145 MCG CAPSULE ORL CAP FLC CAP 3.503300002417170 CONSTELLA 290 MCG CAPSULE ORL CAP FLC CAP 5.682000002469510 CONSTELLA 72 MCG CAPSULE ORL CAP FLC CAP 3.511000002472945 CONTRAVE 8 MG/90 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 2.214900002245619 COPAXONE 20 MG/ML INJECTION SYRINGE INJ NDL TMP SYR 48.805100002456915 COPAXONE 40 MG/ML INJECTION INJ DEFAUL TMP SYR 114.312500002224577 COPHYLAC ORAL SOLUTION ORL SOL VCL ML 2.569300080064221 COQ10 DROPS ORL LIQ INN ML 1.470500080012965 COQ10 MRB 60 MG SOFTGEL CAPSULE ORL CAP INN CAP 0.795000080015393 CORAL CALCIUM 180 MG W/ MAGNESIUM AND VIT D CAP ORL CAP EXP CAP 0.108600080021088 CORTATE 0.5% TOPICAL CREAM TOP CRM BAI G 0.137300000579335 CORTIFOAM 10% RECTAL FOAM RT FOA PAL G 6.6733

00002455889 CORTIMENT 9 MG DELAYED AND EXTENDED-RELEASE TABLET ORL DERT FEI TAB 8.737300080066699 CORTIVERA-H 1% TOPICAL CREAM TOP CRM VAN G 0.171800000022381 CORTROSYN 0.25 MG/VIAL INJECTION INJ DEFAUL LYN VIAL 98.760000002452340 COTELLIC 20 MG TABLET ORL TAB HLR TAB 125.102500002099748 COUGH SYRUP WITH CODEINE ORL SYR ROG ML 0.016200001918311 COUMADIN 1 MG TABLET ORL TAB BMS TAB 0.361800001918362 COUMADIN 10 MG TABLET ORL TAB BMS TAB 0.550900001918338 COUMADIN 2 MG TABLET ORL TAB BMS TAB 0.3828

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 31 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001918346 COUMADIN 2.5 MG TABLET ORL TAB BMS TAB 0.306500002240205 COUMADIN 3 MG TABLET ORL TAB BMS TAB 0.474400002007959 COUMADIN 4 MG TABLET ORL TAB BMS TAB 0.474400001918354 COUMADIN 5 MG TABLET ORL TAB BMS TAB 0.307000002240206 COUMADIN 6 MG TABLET ORL TAB BMS TAB 0.516000002243063 COVAN ORAL SYRUP ORL SYR PMS ML 0.057300002246568 COVERSYL PLUS LD 2 MG/0.625 MG TABLET ORL TAB SEV TAB 0.890700080018683 CRANBERRY 500 MG CAPSULE ORL CAP VCL CAP 0.183000080027158 CRANBERRY COMPLEX 500 MG CAPSULE ORL CAP JAM CAP 0.196500002445158 CREON MINIMICROSPHERES MICRO GRANULES ORL GRNUL BGP G 1.762500000299561 CREO-RECTAL ADULTES/ADULTS RECTAL SUPPOSITORY RT SUP CNF SUP 0.7500

00000299596 CREO-RECTAL ENFANTS/CHILDREN RECTAL SUPPOSITORY RT SUP CNF SUP 0.750000000299588 CREO-RECTAL INFANT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.602000002241013 CRINONE 8% VAGINAL GEL VAG GEL SRO G 8.275900002277778 CRITIC-AID CLEAR OINTMENT TOP ONT COC G 0.105800080049374 CRUCERA-SGS CAPSULE ORL CAP THR CAP 0.704200002483629 CRYSVITA 10 MG/ML INJECTION INJ DEFAUL KKL ML 4992.290000002483637 CRYSVITA 20 MG/ML INJECTION INJ DEFAUL KKL ML 9984.580000002483645 CRYSVITA 30 MG/ML INJECTION INJ DEFAUL KKL ML 14976.870000002299909 CUBICIN 500 MG/VIAL INJECTION INJ DEFAUL CUB VIAL 184.000000080011341 CULTURELLE CAPSULE ORL CAP IHE CAP 0.660000080020741 CURCUMIN 400 MG CAPSULE ORL CAP AOR CAP 0.715800000999770 CURCUMIN ACTIVE ORL MIS XXX MIS 0.739200002472996 CUTAQUIG 1 G/ 6 ML INJECTION INJ DEFAUL OCP ML 8.333300002473011 CUTAQUIG 2 G/ 12 ML INJECTION INJ DEFAUL OCP ML 8.333300002473046 CUTAQUIG 4 G/ 24 ML INJECTION INJ DEFAUL OCP ML 8.333300002473054 CUTAQUIG 8 G/ 48 ML INJECTION INJ DEFAUL OCP ML 8.333300002469332 CUVPOSA 1 MG/5 ML ORAL SOLUTION ORL SOL MDX ML 1.3214

00002463393 CYANOCOBALAMIN INJECTION USP 1000 MCG/ML INJECTION INJ DEFAUL TGT ML 2.285000001968440 CYCLEN (21 DAY) TABLET ORL TAB JAI TAB 1.271400001992872 CYCLEN (28 DAY) TABLET ORL TB JAI TAB 0.953600002220644 CYCLOBENZAPRINE 10 MG TABLET ORL TAB PDL TAB 0.372700002148331 CYCLOPENTOLATE HCL 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002148382 CYCLOPENTOLATE HCL 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.200000002290308 CYESTRA-35 TABLET ORL TAB PMS TAB 1.111400002064405 CYKLOKAPRON 500 MG TABLET ORL TAB PFI TAB 1.396100002443805 CYRAMZA 10 MG/ML INJECTION INJ DEFAUL LIL ML 60.200000002238526 CYSTADANE 1 G/SCOOP ORAL POWDER ORL PWR ORP G 4.5524

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080038525 CYSTA-Q CAPSULE ORL CAP SLP CAP 0.666700002126656 CYTARABINE 100 MG/ML INJECTION INJ DEFAUL PFI ML 15.325000080080156 D3 DOL 1000 IU ORAL LIQUID ORL DPS JPC ML 0.104400002444747 DAKLINZA 30 MG TABLET ORL TAB BMS TAB 428.571400002444755 DAKLINZA 60 MG TABLET ORL TAB BMS TAB 428.571400002060604 DALACIN 2% VAGINAL CREAM VAG CRM PAL G 0.918200000030570 DALACIN C 150 MG CAPSULE ORL CAP PFI CAP 1.433400002182866 DALACIN C 300 MG CAPSULE ORL CAP PFI CAP 2.866600000582301 DALACIN T 1% (BASE) TOPICAL SOLUTION TOP SOL PFI ML 0.496700000507415 DAN-GARD 2% TOPICAL SHAMPOO TOP SHP VLP ML 0.040000002490838 DAPTOMYCIN FOR INJECTION 500 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 162.350000002490463 DAPTOMYCIN FOR INJECTION 500 MG/VIAL INJECTION INJ DEFAUL DRL VIAL 162.350000002455951 DARZALEX 100 MG/5 ML INJECTION INJ DEFAUL JAI ML 119.604000002455978 DARZALEX 400 MG/20 ML INJECTION INJ DEFAUL JAI ML 119.604000002498480 DAURISMO 100 MG TABLET ORL TAB PFI TAB 572.823300002498472 DAURISMO 25 MG TABLET ORL TAB PFI TAB 286.411600002359456 DAXAS 500 MCG TABLET ORL TAB AZC TAB 2.232000002507374 DAYVIGO 10 MG TABLET ORL TAB EIS TAB 1.637400002507366 DAYVIGO 5 MG TABLET ORL TAB EIS TAB 1.490000000836362 DDAVP 10 MCG/DOSE NASAL SPRAY NAS SPM FEI DOSE 2.030000002285002 DDAVP MELT 120 MCG ORAL DISINTEGRATING TABLET ORL DISNTAB FEI TAB 2.101000002285010 DDAVP MELT 240 MCG ORAL DISINTEGRATING TABLET ORL DISNTAB FEI TAB 3.782000002284995 DDAVP MELT 60 MCG ORAL DISINTEGRATING TABLET ORL DISNTAB FEI TAB 1.050300080001791 DDROPS 1,000 IU/DROP ORAL LIQUID ORL LIQ DDR ML 1.380000002389282 DECAPEPTYL 0.1 MG/ML INJECTION SYRINGE INJ DEFAUL FEI SYR 15.004300080038155 DECAXIL VITAMIN D 400 IU/ML ORAL LIQUID ORL LIQ JPC ML 0.149700080041145 DECAXIL VITAMIN D3 400 IU ORAL DROPS ORL LIQ JPC ML 5.389200000791172 DECONGEST 0.1 MG NASAL SOLUTION NAS SOL RPH ML 0.151000002236796 DEEP PORE ACNE VANISHING TREATMENT 5% LOTION TOP LOT MNT ML 0.196400002482592 DELSTRIGO 100 MG/300 MG/300 MG TABLET ORL TAB MFC TAB 28.790000002018403 DELSYM 6 MG/ML CONTROLLED-RELEASE SUSPENSION ORL CRSUS NVC ML 0.063400000469327 DEMULEN 30 (21 DAY) TABLET ORL TAB PFI TAB 0.713800000471526 DEMULEN 30 (28 DAY) TABLET ORL TB PFI TAB 0.5725

00002247092 DERMAL THERAPY HAND, ELBOW & KNEE 15% TOPICAL CRM TOP CRM DTR ML 0.064300002247093 DERMAL THERAPY- HEEL CARE CREAM TOP CRM DTR ML 0.079200002239903 DERMALAC 12% CREAM TOP CRM TAR G 0.057100002238053 DERMALAC 12% LOTION TOP LOT TAR ML 0.039600000873292 DERMA-SMOOTHE/FS 0.01% TOPICAL OIL TOP OIL HDI ML 0.297200002230642 DERMATOP 0.1% EMOLLIENT CREAM TOP EMCRM VCL G 1.9970

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 33 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002227517 DERMATOP 0.1% TOPICAL OINTMENT TOP ONT VCL G 1.761200002238407 DERMAZINC 0.25% TOPICAL SPRAY TOP SPR DPI ML 0.275000002300559 DERMOTIC OIL EAR DROPS 0.01% OTIC SOLUTION OT SOL HDI ML 1.700000002454416 DESCOVY 200 MG/10 MG TABLET ORL TAB GIL TAB 26.102000002454424 DESCOVY 200 MG/25 MG TABLET ORL TAB GIL TAB 26.102000002216280 DESIPRAMINE 100 MG TABLET ORL TAB AAP TAB 0.984000001942417 DESITIN DIAPER RASH OINTMENT TOP ONT JJI G 0.058800002298155 DESLORATADINE ALLERGY CONTROL 5 MG TABLET ORL TAB PMS TAB 0.519300002239064 DETROL 1 MG TABLET ORL TAB UJC TAB 1.021700002239065 DETROL 2 MG TABLET ORL TAB UJC TAB 1.021700009991092 DEX-4 GLUCOSE 4 G TABLET ORL CTB AMG TAB 0.207000000999826 DEX-4 TABLET ALL FLAVOURS ORL TAB AMM TAB 0.207000002023865 DEXAMETHASONE 0.1% OPHTHALMIC SOLUTION OT/OPH SOL PSL ML 1.790000002204274 DEXAMETHASONE OMEGA 10 MG/ML INJECTION INJ DEFAUL OMG ML 1.283000002204266 DEXAMETHASONE OMEGA 4 MG/ML INJECTION INJ DEFAUL OMG ML 1.606000002387743 DEXAMETHASONE OMEGA UNIDOSE 10 MG/ML INJECTION INJ DEFAUL OMG ML 4.560000000832030 DEXIDIN 20 MG TOPICAL SOLUTION TOP LIQ ATL ML 0.042700000832111 DEXIDIN 4 % TOPICAL LIQUID TOP LIQ ATL ML 0.029100002354950 DEXILANT 30 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.297700002354969 DEXILANT 60 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.297700002205963 DEXIRON 50 MG/ML INJECTION INJ DEFAUL LPI ML 13.750000000060348 DEXTROSE 5% 5 G/100 ML USP INJECTION INJ DEFAUL BAX ML 0.009600002468514 DEXTROSE 50% 500 MG/ML INJECTION USP INJ DEFAUL PFI ML 0.607600080007766 D-GEL 1000 IU SOFTGEL ORL CAP JPC CAP 0.073700002224550 DIABETA 2.5 MG TABLET ORL TAB SAV TAB 0.146700002224569 DIABETA 5 MG TABLET ORL TAB SAV TAB 0.263700002245391 DIAMINE TABLET ORL TAB EUP TAB 0.063100080028781 DIAMINE TABLET ORL TAB SDZ TAB 0.063100002233542 DIANE-35 2 MG/0.035 MG TABLET ORL TAB BHP TAB 1.953300002337452 DIAPER RASH 15% TOPICAL CREAM TOP CRM HJS G 0.009300002229552 DIARR-EZE 2 MG CAPLET ORL TAB PMS TAB 0.300000002248994 DIARRHEA RELIEF 2 MG TABLET ORL TAB PMS TAB 0.177800002238162 DIASTAT RECTAL DELIVERY SYS 5 MG/ML RECTAL GEL RT GEL VCL SYS 88.245000002385392 DIAZEPAM 5 MG/ML INJECTION INJ DEFAUL ALV ML 12.415000002434571 DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL STM ML 0.622600000870978 DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.202400002351684 DICLOFENAC POTASSIUM 50 MG TABLET ORL TAB SNS TAB 0.393700002476134 DICLOFENAC SODIUM 1.5% TOPICAL SOLUTION TOP SOL TGT ML 0.622700002352397 DICLOFENAC SODIUM 50 MG ENTERIC-COATED TABLET ORL ECT SNS TAB 0.202400002224127 DICLOFENAC-SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.4048

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 34 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002224119 DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.232000002231592 DIFFERIN 0.1% TOPICAL CREAM TOP CRM GAL G 2.282200002148749 DIFFERIN 0.1% TOPICAL GEL TOP GEL GAL G 2.282200002274000 DIFFERIN XP 0.3% TOPICAL GEL TOP GEL GAL G 2.550700002039486 DIFLUNISAL 250 MG TABLET ORL TAB AAP TAB 0.611000002039494 DIFLUNISAL 500 MG TABLET ORL TAB AAP TAB 0.773700080056878 DIGEST GOLD CAPSULE ORL CAP EMI CAP 0.429100080033593 DIGESTA ALPHA CAPSULE ORL CAP SFD CAP 0.548000002048264 DIGOXIN 0.25 MG/ML INJECTION INJ DEFAUL SDZ ML 8.895500002325306 DILTIAZEM TZ 120 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.213300002325314 DILTIAZEM TZ 180 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.288900002325322 DILTIAZEM TZ 240 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.383200002325330 DILTIAZEM TZ 300 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.471900002325349 DILTIAZEM TZ 360 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.577800002231472 DILTIAZEM-CD 120 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.406100002231474 DILTIAZEM-CD 180 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.539200002231475 DILTIAZEM-CD 240 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.715100002231057 DILTIAZEM-CD 300 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.776600002300648 DIMENHYDRINATE 50 MG/ML INJECTION INJ DEFAUL ALV ML 2.500000002428954 DIMENHYDRINATE 50 MG/ML INJECTION USP INJ DEFAUL TGT ML 2.500000002435241 DIMENHYDRINATE 50 MG/ML INJECTION USP (PRESERVED) INJ DEFAUL TGT ML 1.360000002244079 DIMETANE EXPECTORANT C ORAL SYRUP ORL SYR PDH ML 0.091900002244080 DIMETANE EXPECTORANT DC ORAL SYRUP ORL SYR PDH ML 0.124200002243969 DIMETAPP DM COUGH & COLD ORAL LIQUID ORL LIQ PDH ML 0.051300002244078 DIMETAPP-C ORAL SYRUP ORL SYR PDH ML 0.111100002027100 DIONEPHRINE 2.5% OPH SOLUTION OPH SOL DIO ML 0.718000002270528 DIOVAN 40 MG TABLET ORL TAB NOV TAB 1.248200002157624 DIOVOL PLUS AF CHEWABLE TABLET ORL CTB CHD TAB 0.139200002157616 DIOVOL PLUS AF-SUSPENSION ORL SUS CHD ML 0.019900000116815 DIOVOL PLUS ORAL SUSPENSION ORL SUS CHD ML 0.019900000116882 DIOVOL PLUS TABLET ORL TAB CHD TAB 0.139200002257548 DIPHENHYDRAMINE HYDROCHLORIDE 25 MG CAPLET ORL TAB JPC TAB 0.137900002257556 DIPHENHYDRAMINE HYDROCHLORIDE 50 MG CAPLET ORL TAB JPC TAB 0.1659

00002369567 DIPHENHYDRAMINE HYDROCHLORIDE 50 MG/ML INJECTION INJ DEFAUL FKC ML 4.390000002219336 DIPHENIST 50 MG/ML INJECTION INJ DEFAUL OMG ML 4.150000002018950 DIPRIVAN EML IV 10 MG/ML INJECTION INJ DEFAUL APC ML 0.540000000578428 DIPROSALIC 0.5 MG/ML /20 MG/ML TOPICAL LOTION TOP LOT MFC ML 0.451300002243961 DITROPAN XL 10 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.828700002243960 DITROPAN XL 5 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.8287

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002462729 DOBUTAMINE INJECTION USP 12.5 MG/ML INJECTION INJ DEFAUL TGT VIAL 38.930000002245946 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP JPC CAP 0.032800000830267 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP TLI CAP 0.033800002326086 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP PDL CAP 0.025000000794406 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP VTH CAP 0.033400002376121 DOCUSATE SODIUM OBLONG 100 MG CAPSULE ORL CAP JPC CAP 0.032800000614491 DOLORAL 1 MG/ML ORAL SYRUP ORL SYR ATL ML 0.037600000614505 DOLORAL 5 MG/ML ORAL SYRUP ORL SYR ATL ML 0.071500002246331 DOM-AMIODARONE 200 MG TABLET ORL TAB DPC TAB 0.617700002326841 DOM-AMLODIPINE 10 MG TABLET ORL TAB DPC TAB 0.199300002326825 DOM-AMLODIPINE 2.5 MG TABLET ORL TAB DPC TAB 0.076700002326833 DOM-AMLODIPINE 5 MG TABLET ORL TAB DPC TAB 0.134300002229468 DOM-ATENOLOL 100 MG TABLET ORL TAB DPC TAB 0.182100002229467 DOM-ATENOLOL 50 MG TABLET ORL TAB DPC TAB 0.110700002278499 DOM-AZITHROMYCIN 250 MG TABLET ORL TAB DPC TAB 0.9417

00002238223 DOM-CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TAB ORL SRT DPC TAB 0.158900002251280 DOM-CIPROFLOXACIN 500 MG TABLET ORL TAB DPC TAB 0.502500002273055 DOM-CITALOPRAM 10 MG TABLET ORL TAB DPC TAB 0.143200002248942 DOM-CITALOPRAM 20 MG TABLET ORL TAB DPC TAB 0.239700002248943 DOM-CITALOPRAM 40 MG TABLET ORL TAB DPC TAB 0.239700002351005 DOM-CLARITHROMYCIN 500 MG TABLET ORL TAB DPC TAB 1.629200002247230 DOM-CLOBAZAM 10 MG TABLET ORL TAB DPC TAB 0.115200002130998 DOM-CLONAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.041800002131013 DOM-CLONAZEPAM 2 MG TABLET ORL TAB DPC TAB 0.072100002238633 DOM-CYCLOBENZAPRINE 10 MG TABLET ORL TAB DPC TAB 0.372700002130092 DOM-DESIPRAMINE 25 MG TABLET ORL TAB DPC TAB 0.272300002231662 DOM-DICLOFENAC 25 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.1094

00002231664 DOM-DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.232000002238315 DOM-DOMPERIDONE 10 MG TABLET ORL TAB DPC TAB 0.083100002376709 DOM-FINASTERIDE 5 MG TABLET ORL TAB DPC TAB 0.413800002246109 DOM-FLUCONAZOLE 100 MG TABLET ORL TAB DPC TAB 3.204700002246108 DOM-FLUCONAZOLE 50 MG TABLET ORL TAB DPC TAB 1.806500002177617 DOM-FLUOXETINE 10 MG CAPSULE ORL CAP DPC CAP 0.340400002177625 DOM-FLUOXETINE 20 MG CAPSULE ORL CAP DPC CAP 0.331100002241348 DOM-FLUVOXAMINE 100 MG TABLET ORL TAB DPC TAB 0.378300002241347 DOM-FLUVOXAMINE 50 MG TABLET ORL TAB DPC TAB 0.210500002241608 DOM-GEMFIBROZIL 300 MG CAPSULE ORL CAP DPC CAP 0.180300002234514 DOM-GLYBURIDE 5 MG TABLET ORL TAB DPC TAB 0.0573

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002239913 DOM-INDAPAMIDE 1.25 MG TABLET ORL TAB DPC TAB 0.074500002239917 DOM-INDAPAMIDE 2.5 MG TABLET ORL TAB DPC TAB 0.118200002372193 DOM-IRBESARTAN 150 MG TABLET ORL TAB DPC TAB 0.228100002414775 DOM-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC DPC CAP 0.500000002245784 DOM-LORAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.035900002245785 DOM-LORAZEPAM 1 MG TABLET ORL TAB DPC TAB 0.044700002247232 DOM-LOVASTATIN 40 MG TABLET ORL TAB DPC TAB 1.257900002231122 DOM-METOPROLOL-L 100 MG TABLET ORL TAB DPC TAB 0.125000002231121 DOM-METOPROLOL-L 50 MG TABLET ORL TAB DPC TAB 0.062400002376695 DOM-MONTELUKAST FC 10 MG TABLET ORL TAB DPC TAB 0.423100002178729 DOM-NORTRIPTYLINE 10 MG CAPSULE ORL CAP DPC CAP 0.077200002178737 DOM-NORTRIPTYLINE 25 MG CAPSULE ORL CAP DPC CAP 0.156000002125145 DOM-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION ORL SUS DPC ML 0.052100002310007 DOM-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.201600002236857 DOMPERIDONE-10 10 MG TABLET ORL TAB PDL TAB 0.059400002238046 DOM-PINDOLOL 10 MG TABLET ORL TAB DPC TAB 0.232300002238047 DOM-PINDOLOL 15 MG TABLET ORL TAB DPC TAB 0.337000002231650 DOM-PINDOLOL 5 MG TABLET ORL TAB DPC TAB 0.136100002249723 DOM-PRAVASTATIN 10 MG TABLET ORL TAB DPC TAB 0.291600002249731 DOM-PRAVASTATIN 20 MG TABLET ORL TAB DPC TAB 0.344000002320460 DOM-RABEPRAZOLE EC 20 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.133800002287986 DOM-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB DPC CAP 0.103400002287951 DOM-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB DPC CAP 0.081700002309831 DOM-RISEDRONATE 35 MG TABLET ORL TAB DPC TAB 1.977500002396203 DOM-RIZATRIPTAN RDT 10 MG ORAL DISINT. TABLET ORL DISNTAB DPC TAB 3.705000002216949 DOM-SALBUTAMOL 1 MG/ML INHALATION SOLUTION INH SOL DPC ML 0.144600002245750 DOM-SERTRALINE 100 MG CAPSULE ORL CAP DPC CAP 0.330300002245748 DOM-SERTRALINE 25 MG CAPSULE ORL CAP DPC CAP 0.151600002245749 DOM-SERTRALINE 50 MG CAPSULE ORL CAP DPC CAP 0.303200002238634 DOM-SOTALOL 80 MG TABLET ORL TAB DPC TAB 0.296600002270765 DOM-SUMATRIPTAN 100 MG TABLET ORL TAB DPC TAB 3.054900002243749 DOM-TERAZOSIN 10 MG TABLET ORL TAB DPC TAB 0.618300002128969 DOM-TRAZODONE 100 MG TABLET ORL TAB DPC TAB 0.098900002128950 DOM-TRAZODONE 50 MG TABLET ORL TAB DPC TAB 0.055400002414147 DOM-VALSARTAN 80 MG TABLET ORL TAB DPC TAB 0.215900002299305 DOM-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAP ORL ERC DPC CAP 0.182500002240321 DOM-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.507500002389525 DOM-ZOLMITRIPTAN 2.5 MG TABLET ORL TAB DPC TAB 3.537500002246317 DOM-ZOPICLONE 5 MG TABLET ORL TAB DPC TAB 0.099000002240823 DOM-ZOPICLONE 7.5 MG TABLET ORL TAB DPC TAB 0.1250

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002416425 DONEPEZIL 10 MG TABLET ORL TAB PDL TAB 0.458600002475286 DONEPEZIL 10 MG TABLET ORL TAB RIV TAB 0.458600002475278 DONEPEZIL 5 MG TABLET ORL TAB RIV TAB 0.458600002416417 DONEPEZIL 5 MG TABLET ORL TAB PDL TAB 0.458700002491753 DOVATO 50 MG/300 MG TABLET ORL TAB VIV TAB 30.440000002049996 DOXEPIN 10 MG CAPSULE ORL CAP AAP CAP 0.256700002050048 DOXEPIN 100 MG CAPSULE ORL CAP AAP CAP 1.343800002050013 DOXEPIN 50 MG CAPSULE ORL CAP AAP CAP 0.584500002413973 DOXORUBICIN HYDROCHLORIDE 2MG/ML INJECTION USP INJ DEFAUL MYP ML 11.400000000817120 DOXYCIN 100 MG CAPSULE ORL CAP RIV CAP 0.586000000860751 DOXYCIN 100 MG TABLET ORL TAB RIV TAB 0.586000000887064 DOXYTAB 100 MG TABLET ORL TAB PDL TAB 0.5860

00001974335 DR SCHOLL'S CLEAR AWAY WART REMOVER SYSTEM 40% PTH TOP PTH BAI PTH 0.335600080067436 DR. FORMULATED ONCE DAILY WOMEN'S CAPSULE ORL CAP GOL CAP 0.809300001929313 DRISTAN DECONGESTANT NASAL MIST SOLUTION NAS SOL PDH ML 0.317300001929372 DRISTAN LONG LASTING 0.05% NASAL MIST SOLUTION NAS SOL PDH ML 0.3173

00001929380 DRISTAN LONG LASTING MENTHOLATED 0.05% NASAL SPRAY NAS SPR PDH ML 0.317300000298433 DRIXORAL SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.402000000342742 DRYSOL 20% TOPICAL SOLUTION TOP SOL SFD ML 0.453900000821772 D-TAB 10,000 UNIT TABLET ORL TAB RIV TAB 0.210000002432854 DUAVIVE 0.45 MG/20 MG TABLET ORL TAB PFI TAB 2.990000002247208 DUKORAL ORAL SUSPENSION ORL SUS AVE DOSE 37.790000002452650 DULOXETINE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PDL CAP 0.481400002452669 DULOXETINE 60 MG DELAYED-RELEASE CAPSULE ORL DRC PDL CAP 0.976900002499967 DUOBRII 0.01% / 0.045% TOPICAL LOTION TOP LOT VCL G 2.000000002239299 DUOFILM 40% TOPICAL PATCH TOP PTH MMH PTH 0.463300002125706 DUOLUBE OPH OINTMENT OPH ONT BSH G 1.477100000656747 DUONALC E (MILD) 20% TOPICAL SOLUTION TOP SOL VCL ML 0.219600000490156 DUONALC E 47.5% TOPICAL SOLUTION TOP SOL VCL ML 0.219600002492504 DUPIXENT 200 MG INJECTION SYRINGE INJ DEFAUL SAV SYR 978.700000002470365 DUPIXENT 300 MG INJECTION SYRINGE INJ DEFAUL SAV SYR 978.700000002373017 DURELA 100 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 1.140000002373025 DURELA 200 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 2.080000002373033 DURELA 300 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 2.880000002415534 DUREZOL 0.05% OPHTHALMIC EMULSION OPH EML NOV ML 5.400000000999010 DUROLANE DEFAUL DEV QMD ML 159.140000002421712 DUTASTERIDE 0.5 MG CAPSULE ORL CAP PDL CAP 0.302700001947958 DUVOID 10 MG TABLET ORL TAB PAL TAB 0.3836

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001947931 DUVOID 25 MG TABLET ORL TAB PAL TAB 0.621200001947923 DUVOID 50 MG TABLET ORL TAB PAL TAB 0.818100002432889 DYMISTA 50 MCG/137 MCG METERED DOSE NASAL SPRAY NAS SPM MDP DOSE 0.826800002260638 EBIXA 10 MG TABLET ORL TAB LBC TAB 2.590700080042242 EBMFER CAPS 100 MG CAPSULE ORL CAP ETR CAP 0.483300002381389 EDARBI 40 MG TABLET ORL TAB VCL TAB 1.275000002381397 EDARBI 80 MG TABLET ORL TAB VCL TAB 1.275000002397749 EDARBYCLOR 40 MG/12.5 MG TABLET ORL TAB VCL TAB 1.234300002397765 EDARBYCLOR 40 MG/25 MG TABLET ORL TAB VCL TAB 1.234300002397757 EDARBYCLOR 80 MG/12.5 MG TABLET ORL TAB TAK TAB 1.209000002370603 EDURANT 25 MG TABLET ORL TAB JAI TAB 15.965000080009719 EFAMOL 1000 MG CAPSULE ORL CAP FMD CAP 0.166700002209764 EGOZINC-HC RECTAL OINTMENT RT ONT PMS G 0.385000002210517 EGOZINC-HC RECTAL SUPPOSITORY RT SUP PMS SUP 0.583300002438712 EGRIFTA 1 MG/VIAL INJECTION INJ DEFAUL THE VIAL 54.337500002489961 ELETRIPTAN 20 MG TABLET ORL TAB PDL TAB 2.616700002489988 ELETRIPTAN 40 MG TABLET ORL TAB PDL TAB 2.616700002247238 ELIDEL 1% TOPICAL CREAM TOP CRM VCL G 2.488300002248239 ELIGARD 10.2 MG/SYR INJECTION INJ NDL SAV SYR 310.720000002248240 ELIGARD 28.2 MG/SYR INJECTION INJ NDL SAV SYR 891.000000002248999 ELIGARD 35.8 MG/SYR INJECTION INJ NDL SAV SYR 1285.200000002268892 ELIGARD 58.2 MG/SYR INJECTION INJ NDL SAV SYR 1450.000000000627410 ELIXIR DE THEOPHYLLINE ORL ELX ATL ML 0.005800002436329 ELLA 30 MG TABLET ORL TAB LHP TAB 26.820000002430355 ELOCTATE 3000 U/VIAL INJECTION INJ DEFAUL BVT VIAL 1860.000000002103109 ELTOR-120 120 MG SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.282500002298805 EMEND 125 MG CAPSULE ORL CAP MFC CAP 33.575000002491060 EMGALITY 120 MG/ML INJECTION SYRINGE INJ NDL LIL SYR 623.000000002491087 EMGALITY 120 MG/ML PEN INJECTION INJ NDL LIL SYR 623.000000000886858 EMLA TOPICAL CREAM TOP CRM APC G 2.300000002057794 EMLA TOPICAL PATCH TOP PTH APC PTH 3.200000080008611 EMPOWER 18 PLUS CAPSULE ORL CAP TRU CAP 0.416300002334992 ENDOMETRIN 100 MG VAGINAL EFFERVESCENT TABLET VAG EVT FEI TAB 4.285700002501244 ENERZAIR BREEZHALER 150/50/160 MCG INH CAPSULE INH CAP NOV CAP 3.427300000999872 ENFAGROW A+ STEP 3 FORMULA POWDER ORL PWR MJO G 0.029800000999848 ENFAMIL A+ (DHA PLUS) INFANT FORMULA ORL LIQ MJO ML 0.011500000999558 ENFAMIL A+ 2 ORAL INFANT FORMULA LIQUID ORL LIQ MJO ML 0.012300000999604 ENFAMIL A+ 2 ORAL INFANT FORMULA POWDER ORL PWR MJO G 0.062700000999860 ENFAMIL A+ CONCENTRATE ORAL INFANT FORMULA ORL LIQ MJO ML 0.011500000999386 ENFAMIL A+ GENTLEASE INFANT FORMULA POWDER ORL PWR MJO G 0.0549

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00000999387 ENFAMIL A+ GENTLEASE READY-TO-FEED INFANT FORMULA ORL LIQ MJO ML 0.013100000999883 ENFAMIL A+ INFANT FORMULA POWDER ORL PWR MJO G 0.052100000999882 ENFAMIL A+ INFANT FORMULA READY TO FEED LIQUID ORL LIQ MJO ML 0.024900000999383 ENFAMIL A+ LACTOSE FREE ORAL INFANT FORMULA ORL LIQ MJO ML 0.011500000999861 ENFAMIL A+ SPIT UP ORAL INFANT FORMULA POWDER ORL PWR MJO G 0.051800002487020 ENGERIX-B 10 MCG/0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 11.390000002296454 ENGERIX-B 10 MCG/0.5 ML SUSPENSION INJ DEFAUL GSK ML 21.840000001919431 ENGERIX-B 20 MCG/ML INJECTION INJ DEFAUL GSK ML 23.590000002487039 ENGERIX-B 20 MCG/ML INJECTION SYRINGE INJ NDL GSK SYR 24.010000002499681 ENSPRYNG 120 MG/ML INJECTION SYRINGE INJ NDL HLR SYR 9450.000000000999847 ENSURE COMPACT ORL LIQ ABN ML 0.017800000999900 ENSURE ENLIVE ORAL LIQUID ORL LIQ ABN ML 0.007900095900204 ENSURE PROTEIN MAX ORL LIQ ABN ML 0.008000002010526 ENTERIC COATED ASA 325 MG TABLET ORL ECT WTR TAB 0.028000000794244 ENTERIC COATED ASA 650 MG TABLET ORL ECT VTH TAB 0.055000002363127 ENTERIC COATED DAILY LOW DOSE ASA 81 MG ECT ORL ECT VTH TAB 0.056000002246971 ENTEX LA SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.442500001905392 ENTROPHEN 10 SUPER EXTRA STRENGTH 650 MG ECCPT ORL ECT PPH TAB 0.070500000852015 ENTROPHEN 500 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.0686

00002050161 ENTROPHEN REGULAR STRENGTH (CAPLET) 325 MG ECCPT ORL ECT PPH TAB 0.054900000010332 ENTROPHEN REGULAR STRENGTH 325 MG ECT ORL ECT PPH TAB 0.054900002466864 ENTUZITY 500 UNIT/ML INJECTION KWIKPEN INJ DEFAUL LIL ML 15.798300002497867 ENTYVIO 108 MG/0.68 ML INJECTION PEN INJ NDL TAK SYR 822.500000002497875 ENTYVIO 108 MG/0.68 ML INJECTION SYRINGE INJ NDL TAK SYR 822.500000002485877 ENVARSUS PA 0.75 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 2.085900002485885 ENVARSUS PA 1 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 2.607400002485893 ENVARSUS PA 4 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 10.429500000721891 EPINEPHRINE 1 MG/ML INJECTION USP INJ NDL HSP SYR 3.970000000999819 EPSOM SALTS DEFAUL DEFAUL XXX G 0.003200002396971 EPURIS 10 MG CAPSULE ORL CAP CIP CAP 1.260000002396998 EPURIS 20 MG CAPSULE ORL CAP CIP CAP 1.743000002397005 EPURIS 30 MG CAPSULE ORL CAP CIP CAP 2.192700002397013 EPURIS 40 MG CAPSULE ORL CAP CIP CAP 2.5707

00002243801 EQUATE DAILY LOW-DOSE 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.109600080061200 EQUATE PROBIOTIC SUPPLEMENT CAPSULE ORL CAP ORD CAP 0.717900002271249 ERBITUX 2 MG/ML INJECTION INJ DEFAUL LIL ML 7.292400080003615 ERDOL 8288 IU/ML ORAL SOLUTION ORL SOL ODN ML 0.4325

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002441241 ERGONOVINE MALEATE 0.25 MG/ML INJECTION INJ DEFAUL ALV ML 90.000000002409267 ERIVEDGE 150 MG CAPSULE ORL CAP HLR CAP 313.190400002478374 ERLEADA 60 MG TABLET ORL TAB JAI TAB 29.337000000607142 ERYC 250 MG CAPSULE (ENTERIC-COATED PELLET) ORL CAP/ENCP PFI CAP 0.293800002326663 ERYTHROMYCIN 5 MG/G OPH OINTMENT USP OPH ONT LSG G 5.000000002424401 ESCITALOPRAM 10 MG TABLET ORL TAB PDL TAB 0.311000002424428 ESCITALOPRAM 20 MG TABLET ORL TAB PDL TAB 0.331000002442493 ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT SIV TAB 1.869000002394839 ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT PDL TAB 1.588700002394847 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC PDL TAB 1.869000002431173 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC SNS TAB 1.869000002442507 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC SIV TAB 1.869000002244990 ESSENTIAL VITAMINS AND MINERALS TABLET ORL TAB WNP TAB 0.021400002237515 ESTER C 1000 MG TABLET ORL TAB SIS TAB 0.159800002247480 ESTER-C 250 MG CHEWABLE TABLET ORL CTB WNP TAB 0.079900080003499 ESTER-C CAPSULE ORL CAP BPC CAP 0.1496

00000999885 ESTRADIOL 1.55 MG / PROGESTERONE 401 MG COMPOUND ORL CAP XXX CAP 0.964400000727369 ESTRAGYN 1MG/G VAGINAL CREAM VAG CRM SLP G 0.757600000247960 ETIBI 100 MG TABLET ORL TAB VCL TAB 0.231700000247979 ETIBI 400 MG TABLET ORL TAB VCL TAB 0.695100002080036 ETOPOSIDE 20 MG/ML INJECTION INJ DEFAUL TEV ML 15.000000002446189 EUCERIN AQUAPHOR HEALING TOPICAL OINTMENT TOP ONT BEI G 0.095100080030672 EUCERIN COMPLETE REPAIR INTENSIVE LOTION TOP LOT BEI ML 0.052700002476991 EUCRISA 2% TOPICAL OINTMENT TOP ONT PFI G 2.300000000999330 EUFLEXXA DEFAUL DEV FEI ML 46.666700080013021 EUPHORBIUM COMPOSITUM SN ORAL DROPS ORL DPS HEE ML 0.765000000623377 EURAX 10% TOPICAL CREAM TOP CRM CLC G 0.372800080003010 EURO D 800 IU CAPSULE ORL CAP SDZ CAP 0.060000080011428 EURO K 975 975 MG (25 MEQ) EFFERVESCENT TABLET ORL EVT SDZ TAB 0.555000002245668 EURO-CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP ORL SYR SDZ ML 0.098900002242651 EURO-D VITAMIN D3 400 IU CAPSULE ORL CAP SDZ CAP 0.030000002237556 EURO-FER 300 MG CAPSULE ORL CAP SDZ CAP 0.139700002241802 EURO-FER CF CAPSULE ORL CAP SDZ CAP 0.233000002247389 EURO-SENNA 8.6 MG TABLET ORL TAB SDZ TAB 0.046400002264374 EUTHYROX 100 MCG TABLET ORL TAB SRO TAB 0.030600002264390 EUTHYROX 112 MCG TABLET ORL TAB SRO TAB 0.064400002264404 EUTHYROX 125 MCG TABLET ORL TAB SRO TAB 0.065400002264412 EUTHYROX 137 MCG TABLET ORL TAB SRO TAB 0.114800002264420 EUTHYROX 150 MCG TABLET ORL TAB SRO TAB 0.0339

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002264439 EUTHYROX 175 MCG TABLET ORL TAB SRO TAB 0.069900002264447 EUTHYROX 200 MCG TABLET ORL TAB SRO TAB 0.035900002264323 EUTHYROX 25 MCG TABLET ORL TAB SRO TAB 0.056400002264455 EUTHYROX 300 MCG TABLET ORL TAB SRO TAB 0.078500002264331 EUTHYROX 50 MCG TABLET ORL TAB SRO TAB 0.024900002264358 EUTHYROX 75 MCG TABLET ORL TAB SRO TAB 0.061000002264366 EUTHYROX 88 MCG TABLET ORL TAB SRO TAB 0.061000080005494 EVENING PRIMROSE OIL SOFTGEL CAPSULE ORL CAP WNP CAP 0.064400002489597 EVENITY 105 MG/1.17 ML INJECTION SYRINGE INJ NDL AMG SYR 328.390000080030701 EVERY WOMAN'S ONE DAILY TABLET ORL TAB NCH TAB 0.833100002248297 EVRA 6 MG/0.6 MG TRANSDERMAL PATCH TRD PTH JAI PTH 7.146700002243896 EXACT DAILY LOW-DOSE ASA 81 MG ENTERIC-COATED TAB ORL ECT PMS TAB 0.133000001990675 EXCEDRIN EXTRA-STRENGTH CAPLET ORL TAB NVC TAB 0.058800002302853 EXELON PATCH 10 (9.5 MG/24 H) TRD PTH NOV PTH 4.674700002432803 EXELON PATCH 15 (13.3 MG/24 H) TRD PTH NOV PTH 4.515300002302845 EXELON PATCH 5 (4.6 MG/24 H) TRD PTH NOV PTH 4.674700002226030 EX-LAX CHOCOLATED TABLET ORL TAB NVC TAB 0.204400002237524 EX-LAX EXTRA STRENGHT 25 MG TABLET ORL TAB NVC TAB 0.240000002184680 EXOREX 2% TOPICAL GEL TOP GEL YNG ML 0.225000080030277 EXOS VEGAN VANILLA PROTEIN POWDER ORL PWR THR G 0.053900002315955 EXTRA STRENGTH ALLERGY RELIEF 10 MG TABLET ORL TAB PMS TAB 0.173000002314770 EXTRA STRENGTH IBUPROFEN 400 MG TABLET ORL TAB PMS TAB 0.1488

00002376601 EXTRA STRENGTH IBUPROFEN LIQUID GEL 400 MG CAPSULE ORL CAP APX CAP 0.123200002242632 EXTRA STRENGTH MOTRIN IB 300 MG TABLET ORL TAB MCL TAB 0.135500002239141 EXTRA STRENGTH MUSCLE AND BACK PAIN RELIEF ORL TAB VTH TAB 0.190000002244142 EXTRA STRENGTH NIGHTTIME COLD RELIEF TABLET ORL TAB PPH TAB 0.128300080075948 EXTRA STRENGTH PROBIOTIC 30 BILLION CFU ORL DRC BNA CAP 0.3000

00002348071 EXTRA STRENGTH TYLENOL COLD & SINUS DAYTIME TABLET ORL TAB MCL TAB 0.315500000707937 EYE-STREAM EYE LIQUID OPH LIQ ALC ML 0.093000002505355 EYLEA 2 MG/0.05 ML INJECTION SYRINGE INJ NDL BAI SYR 1418.000000002422549 EZETIMIBE 10 MG TABLET ORL TAB PDL TAB 0.181100002248966 FABRAZYME 35 MG/VIAL INJECTION INJ DEFAUL GZM VIAL 5588.000000002248965 FABRAZYME 5 MG/VIAL INJECTION INJ DEFAUL GZM VIAL 798.290000002247745 FAMOTIDINE OMEGA-(W PRES,BENZYL ALC) 10 MG/ML INJ INJ DEFAUL OMG ML 2.415000002247735 FAMOTIDINE OMEGA-(W/O PRESERVATIVE) 10 MG/ML INJ INJ DEFAUL OMG ML 2.550000002379910 FAMPYRA 10 MG SUSTAINED-RELEASE TABLET ORL SRT BIO TAB 9.968200002229110 FAMVIR 125 MG TABLET ORL TAB NOV TAB 3.130000002229129 FAMVIR 250 MG TABLET ORL TAB NOV TAB 4.2460

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002177102 FAMVIR 500 MG TABLET ORL TAB NOV TAB 7.563800002496135 FASENRA 30 MG/ML INJECTION PEN INJ NDL AZC ML 3876.920000002248624 FASLODEX 250 MG/5 ML INJECTION INJ NDL AZC SYR 582.895000002231384 FEMARA 2.5 MG TABLET ORL TAB NOV TAB 6.702000002240360 FENO-MICRO-200 MG CAPSULE ORL CAP PDL CAP 0.272300002496143 FENTANYL 50 MCG/ML (100 MCG/ 2 ML) INJECTION BP INJ DEFAUL STM ML 2.729000002496178 FENTANYL 50 MCG/ML (1000 MCG/ 20 ML) INJECTION BP INJ DEFAUL STM ML 2.728700002496151 FENTANYL 50 MCG/ML (250 MCG/ 5 ML) INJECTION BP INJ DEFAUL STM ML 2.728800002496186 FENTANYL 50 MCG/ML (2500 MCG/ 50 ML) INJECTION BP INJ DEFAUL STM ML 2.728800002385406 FENTANYL CITRATE 50 MCG/ML INJECTION USP INJ DEFAUL TGT ML 2.729000002384124 FENTANYL CITRATE SDZ 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 2.598800002408007 FENTORA 100 MCG EFFERVESCENT TABLET BUC/SLG EVT TMP TAB 11.485400002408015 FENTORA 200 MCG EFFERVESCENT TABLET BUC/SLG EVT TMP TAB 11.485400002408023 FENTORA 400 MCG EFFERVESCENT TABLET BUC/SLG EVT TMP TAB 11.485400002408031 FENTORA 600 MCG EFFERVESCENT TABLET BUC/SLG EVT TMP TAB 11.485400002408058 FENTORA 800 MCG EFFERVESCENT TABLET BUC/SLG EVT TMP TAB 11.485400002377217 FERAHEME 30 MG/ML INJECTION INJ DEFAUL TAK ML 11.029400080033717 FERAMAX 15/1/4 TSP POWDER ORL PWR BIS G 0.216900080013210 FERAMAX 150 150 MG CAPSULE ORL CAP BIS CAP 0.496700080075623 FERAMAX 150 PD 150 MG CAPSULE ORL CAP BIS CAP 0.506700002248699 FERODAN 300 MG TABLET ORL TAB ODN TAB 0.019900002436531 FERRIPROX 500 MG TABLET ORL TAB CCC TAB 15.940000002243333 FERRLECIT 12.5 MG/ ML INJECTION INJ DEFAUL SAV ML 5.272000002138751 FERROUS FUMARATE 200 MG TABLET ORL TAB VTH TAB 0.020900000031089 FERROUS FUMARATE 300 MG TABLET ORL TAB WAM TAB 0.062500002244532 FERROUS GLUCONATE 300 MG TABLET ORL TAB PMT TAB 0.040000000041157 FERROUS GLUCONATE 300 MG TABLET ORL TAB ADA TAB 0.037100080009681 FERROUS GLUCONATE 300 MG TABLET ORL TAB WAM TAB 0.062500000031097 FERROUS GLUCONATE 300 MG TABLET ORL TAB JPC TAB 0.021200000582727 FERROUS GLUCONATE 324 MG TABLET ORL TAB VTH TAB 0.023100002245389 FERROUS GLUCONATE 35 MG TABLET ORL TAB WNP TAB 0.078500080002426 FERROUS GLUCONATE 35 MG TABLET ORL TAB WNP TAB 0.035900000346918 FERROUS SULFATE 300 MG TABLET ORL TAB PMT TAB 0.038500000782114 FERROUS SULFATE 300 MG TABLET ORL TAB WTR TAB 0.034600002441004 FETZIMA 120 MG EXTENDED RELEASE CAPSULE ORL ERC ALL CAP 4.372000002440970 FETZIMA 20 MG EXTENDED RELEASE CAPSULE ORL ERC ALL CAP 3.700700002440989 FETZIMA 40 MG EXTENDED RELEASE CAPSULE ORL ERC ALL CAP 3.840000002440997 FETZIMA 80 MG EXTENDED RELEASE CAPSULE ORL ERC ALL CAP 4.094700002460408 FIASP 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 2.998000002460416 FIASP 100 UNIT/ML INJECTION CARTRIDGE INJ DEFAUL NNA ML 4.0547

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002460424 FIASP FLEXTOUCH 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 4.220000080005803 FIBER PLUS CAPSULE ORL CAP PLT CAP 0.200000002207230 FIBRE LAXATIVE 3.4 G/12 G ORAL POWDER ORL PWR PRI G 0.006000080009650 FIBRE LAXATIVE SMOOTH TEXTURE ORANGE FLAVOUR ORL PWR ACV G 0.010300080009651 FIBRE LAXATIVE UNFLAVOURED ORAL POWDER ORL PWR APH G 0.010900002408163 FIBRISTAL 5 MG TABLET ORL TAB ALL TAB 11.460000002447568 FINASTERIDE 1 MG TABLET ORL TAB SIV TAB 1.145500002445085 FINASTERIDE 1 MG TABLET ORL TAB SNS TAB 1.145500002350270 FINASTERIDE 5 MG TABLET ORL TAB PDL TAB 0.413800002502984 FIRDAPSE 10 MG TABLET ORL TAB KYE TAB 85.0000

00002337037 FIRMAGON 120 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 370.945000002337029 FIRMAGON 80 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 274.180000001926853 FLAGYL 500 MG CAPSULE ORL CAP ODN CAP 0.931300002149133 FLAX SEED OIL 500 MG CAPSULE ORL CAP JAM CAP 0.068100080030423 FLAXSEED OIL 1000 MG CAPSULE ORL CAP XXX CAP 0.048700080000580 FLAXSEED OIL 1000 MG SOFTGEL ORL CAP PMT CAP 0.093700080000840 FLAXSEED OIL LIQUID ORL LIQ VML ML 0.042200000107875 FLEET MINERAL OIL RECTAL ENEMA RT ENM CBF ENM 5.590000002206218 FLEET PHOSPO-SODA ORAL LIQUID ORL LIQ JJM ML 0.083800000999052 FLEXI-T +300 IUD 1 DEFAUL DEFAUL TSN DEV 105.000000000999053 FLEXI-T +380 IUD 1 DEFAUL DEFAUL TSN DEV 105.000000000999051 FLEXI-T 300 IUD 1 DEFAUL DEFAUL TSN DEV 105.000000080021934 FLINTSTONES MULTI VITAMINS COMPLETE CHEWABLE TAB ORL CTB BAI TAB 0.137000080022680 FLINTSTONES MULTIPLE VITAMINS COMPLETE CHEW TAB ORL CTB BAI TAB 0.130500002230845 FLOLAN 0.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 19.740000002230848 FLOLAN 1.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 39.490000002248307 FLONASE ALLERGY RELIEF 50 MCG/DOSE NASAL SPRAY NAS SPM GKC DOSE 0.199800080011335 FLORASMART TABLET ORL TAB RLC TAB 0.416300080013321 FLORASTOR 250 MG CAPSULE ORL CAP BCX CAP 1.015000002237245 FLOVENT DISKUS 100 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.435000002362384 FLUAD INJECTION SYRINGE INJ DEFAUL SEQ SYR 12.600000002434881 FLUAD PEDIATRIC INJECTION SYRINGE INJ DEFAUL SEQ SYR 7.100000002494248 FLUCELVAX QUAD 15 MCG/0.5 ML PRE-FILLED SYR INJ INJ DEFAUL SEQ SYR 25.000000002248443 FLUCONAZOLE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 0.469500002261472 FLUCONAZOLE 2 MG/ML INJECTION INJ DEFAUL BAX ML 0.268000002388448 FLUCONAZOLE INJECTION SDZ 2 MG/ML INJECTION INJ DEFAUL SDZ ML 0.469500002247749 FLUCONAZOLE OMEGA 2 MG/ML INJECTION INJ DEFAUL OMG ML 0.366000002246226 FLUDARA 10 MG TABLET ORL TAB SAV TAB 40.076000002249561 FLUMAZENIL 0.1 MG/ML INJECTION INJ DEFAUL SDZ ML 5.0400

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002352621 FLUMIST INFLUENZA VACCINE NASAL SPRAY NAS SPR AZC ML 72.000000002426544 FLUMIST QUADRIVALENT NASAL SPRAY NAS SPR AZC ML 90.000000001977857 FLUOR A DAY 1.1 MG CHEWABLE TABLET ORL CTB PMS TAB 0.087400002090139 FLUOR-A-DAY 0.56 MG CHEWABLE TABLET ORL CTB PMS TAB 0.084900000012882 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL VCL ML 1.609000002182742 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL PFI ML 2.037600002331721 FLUPENTIXOL DECANOATE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 26.750000002015986 FLUVIRAL S/F SPLIT-VIRION INFLUENZA VACCINE INJ INJ DEFAUL IAF ML 16.000000002420686 FLUVIRAL SUSPENSION FOR INJECTION INJ DEFAUL IAF ML 16.000000002236754 FLUVOXAMINE 100 MG TABLET ORL TAB PDL TAB 0.378300002236753 FLUVOXAMINE 50 MG TABLET ORL TAB PDL TAB 0.210500002445646 FLUZONE HIGH-DOSE INJECTION SYRINGE INJ DEFAUL SFP SYR 60.000000002420643 FLUZONE QUADRIVALENT 0.5 ML/SYRINGE INJECTION INJ DEFAUL SFP SYR 11.0000

00002432730 FLUZONE QUADRIVALENT 5 ML MULTIDOSE VIAL INJECTION INJ DEFAUL SFP ML 20.000000000247855 FML LIQUIFILM 0.1% OPH SUSPENSION OPH SUS ALL ML 3.504000080000549 FOLAPRO 0.8 MG TABLET ORL TAB MTG TAB 0.191600002236747 FOLIC ACID 1 MG TABLET ORL TAB WAM TAB 0.036100080000273 FOLIC ACID 1 MG TABLET ORL TAB WNP TAB 0.032600000318973 FOLIC ACID 1 MG TABLET ORL TAB JAM TAB 0.050000000647039 FOLIC ACID 1 MG TABLET ORL TAB VTH TAB 0.030000000816086 FOLIC ACID 5 MG/ML INJECTION INJ DEFAUL SDZ ML 3.870000002139480 FOLIC ACID 5 MG/ML INJECTION INJ DEFAUL FKC ML 3.162000002048841 FOLIC ACID USP 1 MG TABLET ORL TAB PMT TAB 0.017100002481820 FOLOTYN 20 MG/ML INJECTION INJ DEFAUL SEV ML 2108.633300002435667 FOMEPIZOLE FOR INJECTION 1 G/ML INJ INJ DEFAUL STM ML 820.623300002470357 FOQUEST 100 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 4.829000002470292 FOQUEST 25 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 2.796000002470306 FOQUEST 35 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 3.071000002470314 FOQUEST 45 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 3.336000002470322 FOQUEST 55 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 3.611000002470330 FOQUEST 70 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 4.024000002470349 FOQUEST 85 MG CONTROLLED-RELEASE CAPSULE ORL CRC ELV CAP 4.427000002254689 FORTEO 250 MCG/ML INJECTION INJ DEFAUL LIL ML 392.545800002241568 FORZA-10 TABLET ORL TAB SDZ TAB 0.162800002276429 FOSAVANCE 70 MG/2800 UNIT TABLET ORL TAB MFC TAB 4.995000002303000 FOSINOPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.217700002303019 FOSINOPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.261900002287188 FOSRENOL 1000 MG CHEWABLE TABLET ORL CTB SHB TAB 4.801800002287145 FOSRENOL 250 MG CHEWABLE TABLET ORL CTB SHB TAB 1.2033

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002287153 FOSRENOL 500 MG CHEWABLE TABLET ORL CTB SHB TAB 2.406900002287161 FOSRENOL 750 MG CHEWABLE TABLET ORL CTB SHB TAB 3.621900002450623 FRAXIPARINE 9,500 IU/ML INJECTION SYRINGE INJ NDL APC SYR 36.230000002450658 FRAXIPARINE 9,500 IU/ML INJECTION SYRINGE INJ NDL APC SYR 9.058000002450631 FRAXIPARINE 9,500 IU/ML INJECTION SYRINGE INJ NDL APC SYR 5.435000002450666 FRAXIPARINE FORTE 19,000 IU/ML INJECTION SYRINGE INJ NDL APC SYR 144.940000002450674 FRAXIPARINE FORTE 19,000 IU/ML INJECTION SYRINGE INJ NDL APC SYR 108.700000002221799 FRISIUM 10 MG TABLET ORL TAB LUI TAB 0.439300002257084 FROVA 2.5 MG TABLET ORL TAB ENV TAB 15.302900000989993 FRUCTOSE USP POWDER ORL PWR GNA G 0.071100002474883 FUCIBET 2% / 0.1% TOPICAL CREAM TOP CRM LEO G 1.612700002238578 FUCIDIN H TOPICAL CREAM TOP CRM LEO G 1.541000002243862 FUCITHALMIC 1% VISCOUS OPH DROPS (PRESERVED) OPH GEL AMD G 3.100000002483610 FULVESTRANT 250 MG/5 ML INJECTION INJ NDL SDZ SYR 495.460000002384094 FUROSEMIDE 10 MG/ML INJECTION INJ DEFAUL TGT ML 0.865000002360365 FUROSEMIDE 10MG/ML INJECTION INJ DEFAUL OMG ML 1.050000000496723 FUROSEMIDE 20 TABLET ORL TAB PDL TAB 0.037300000397792 FUROSEMIDE 40 MG TABLET ORL TAB PDL TAB 0.055800000667080 FUROSEMIDE-80 MG TABLET ORL TAB PDL TAB 0.122000000999388 FUSIDIC ACID TABLET ORL TAB XXX TAB 1.168000002247725 FUZEON 108 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 42.323000002332604 GABAPENTIN 400 MG CAPSULE ORL CAP RAN CAP 0.217100002388200 GABAPENTIN 600 MG TABLET ORL TAB SIV TAB 1.304500002431289 GABAPENTIN 600 MG TABLET ORL TAB SNS TAB 1.304500002392526 GABAPENTIN 600 MG TABLET USP ORL TAB AHI TAB 1.304500002388219 GABAPENTIN 800 MG TABLET ORL TAB SIV TAB 1.739300002431297 GABAPENTIN 800 MG TABLET ORL TAB SNS TAB 1.739300002392534 GABAPENTIN 800 MG TABLET USP ORL TAB AHI TAB 1.739300002416581 GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.246300002416603 GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.246300002416573 GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.246300080031773 GALLEXIER HERBAL BITTERS ORAL SOLUTION ORL SOL FMD ML 0.086800080052720 GALT FORTIFIER CAPSULE ORL CAP AEI CAP 0.510600002404761 GANCICLOVIR 500 MG/VIAL INJECTION USP INJ DEFAUL FKC VIAL 48.334400002437058 GARDASIL 9 0.5 ML INJECTION INJ DEFAUL MFC ML 341.740000000896675 GAS X EXTRA STRENGTH TABLET ORL TAB NVC TAB 0.245600002300761 GAS X ULTRA STRENGTH 180 MG CAPSULE ORL CAP NVC CAP 0.217800002159791 GAVISCON HEARTBURN RELIEF CHEWABLE TABLET ORL CTB SKB TAB 0.151200002231538 GAVISCON HEARTBURN RELIEF EXTRA STRENGTH TABLET ORL TAB SKB TAB 0.242000002159775 GAVISCON HEARTBURN RELIEF ORAL LIQUID - FRUIT ORL LIQ SKB ML 0.0225

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002434806 GAZYVA 25 MG/ML INJECTION INJ DEFAUL HLR ML 136.946000002362791 GD-AMLODIPINE/ATORVASTATIN 10 MG/10 MG TABLET ORL TAB UJC TAB 0.919400002362805 GD-AMLODIPINE/ATORVASTATIN 10 MG/20 MG TABLET ORL TAB UJC TAB 1.023400002362813 GD-AMLODIPINE/ATORVASTATIN 10 MG/40 MG TABLET ORL TAB UJC TAB 1.062400002362821 GD-AMLODIPINE/ATORVASTATIN 10 MG/80 MG TABLET ORL TAB UJC TAB 1.062400002362759 GD-AMLODIPINE/ATORVASTATIN 5 MG/10 MG TABLET ORL TAB UJC TAB 0.755100002362767 GD-AMLODIPINE/ATORVASTATIN 5 MG/20 MG TABLET ORL TAB UJC TAB 0.859100002362775 GD-AMLODIPINE/ATORVASTATIN 5 MG/40 MG TABLET ORL TAB UJC TAB 0.898100002362783 GD-AMLODIPINE/ATORVASTATIN 5 MG/80 MG TABLET ORL TAB UJC TAB 0.898100002274566 GD-AZITHROMYCIN 20 MG/ML ORAL SUSPENSION ORL SUS GMD ML 0.372700002274531 GD-AZITHROMYCIN 250 MG TABLET ORL TAB GMD TAB 1.231100002274574 GD-AZITHROMYCIN 40 MG/ML ORAL SUSPENSION ORL SUS GMD ML 0.528000002291975 GD-CELECOXIB 100 MG CAPSULE ORL CAP GMD CAP 0.127900002342235 GD-ELETRIPTAN 20 MG TABLET ORL TAB UJC TAB 10.085000002342243 GD-ELETRIPTAN 40 MG TABLET ORL TAB UJC TAB 10.085000002028107 GEL-KAM 0.4% DENTAL GEL DEN GEL COL G 0.070500001933906 GELUSIL TABLET ORL TAB WSP TAB 0.059800002324210 GEMCITABINE 1 G/VIAL INJECTION INJ DEFAUL AHI VIAL 270.000000002412292 GEMCITABINE 40 MG/ML INJECTION INJ DEFAUL SDZ ML 10.812000002136058 GEMFIBROZIL-600 MG TABLET ORL TAB PDL TAB 0.515700080020663 GENESTRA BRAND HMF INTENSIVE PROBIOTIC ORL CAP SRL CAP 1.716600080034399 GENESTRA BRANDS DIGEST GLUTEN PLUS CAPSULE ORL CAP SRL CAP 0.314300080008885 GENESTRA BRANDS D-MULSION ORL LIQ SRL ML 0.566300080012475 GENESTRA BRANDS D-MULSION 400 ORL LIQ SRL ML 0.236700080067278 GENESTRA BRANDS HMF TRAVEL PROBIOTIC CAPSULE ORL CAP SRL CAP 1.383000002082144 GENTAMICIN (E) 1.2 MG/ML INJECTION INJ DEFAUL BAX ML 0.079400002082152 GENTAMICIN (E) 1.6 MG/ML INJECTION INJ DEFAUL BAX ML 0.089000002268531 GENTAMICIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 6.495500002457008 GENTAMICIN 40 MG/ML INJECTION INJ DEFAUL TGT ML 8.944500002470462 GENTAMICIN INJECTION USP 10 MG/ML INJECTION INJ DEFAUL TGT ML 6.400000002082136 GENTAMICINE (E) 1 MG/ML INJECTION INJ DEFAUL BAX ML 0.046700002231289 GENTEAL 0.3% OPHTHALMIC DROPS OPH DPS ALC ML 0.499000080014125 GENTLE IRON CAPSULE ORL CAP VTH CAP 0.062200002449498 GENVOYA TABLET ORL TAB GIL TAB 45.144000080044443 GI SUSTAIN ORAL POWDER ORL PWR MTG G 0.067600002482533 GILENYA 0.25 MG CAPSULE ORL CAP NOV CAP 85.165000080006550 GINKGO BILOBA 60 MG TABLET ORL TAB WNP TAB 0.081100080031603 GINKGO INTRINSIC ORAL LIQUID ORL LIQ AEI ML 0.250000002415666 GIOTRIF 20 MG TABLET ORL TAB BOE TAB 76.635400002415674 GIOTRIF 30 MG TABLET ORL TAB BOE TAB 76.6354

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002415682 GIOTRIF 40 MG TABLET ORL TAB BOE TAB 76.635400002506343 GIVLAARI 189 MG/ML INJECTION INJ DEFAUL ANT ML 64454.300000080003490 GLA 130 PRIMROSE OIL CAPSULE ORL CAP SRL CAP 0.443800000999006 GLAXAL BASE TOPICAL CREAM TOP CRM XXX G 0.073000002253275 GLEEVEC 100 MG TABLET ORL TAB NOV TAB 29.260000002253283 GLEEVEC 400 MG TABLET ORL TAB NOV TAB 117.040000002248453 GLICLAZIDE-80 MG TABLET ORL TAB PDL TAB 0.093100002410990 GLN-GABAPENTIN 600 MG TABLET ORL TAB GLM TAB 1.304500002411008 GLN-GABAPENTIN 800 MG TABLET ORL TAB GLM TAB 1.739300099400318 GLOVES, LATEX/VINYL, NON-STERILE DEFAUL DEFAUL XXX MIS 15.800000000999014 GLUCOSAMINE 500 MG TABLET ORL TAB XXX TAB 0.033200080000334 GLUCOSAMINE 750 MG TABLET ORL TAB JMS TAB 0.0964

00000999477 GLUCOSAMINE AND CHRONDROITIN ORAL TABLET/CAPSULE ORL TAB/CAP XXX TAB 0.214400000999020 GLUCOSAMINE ORAL AND TOPICAL PRODUCTS MIS DEFAUL XXX MIS 0.080900080000015 GLUCOSAMINE SULFATE 500 MG CAPLET ORL TAB JAM TAB 0.045800080000082 GLUCOSAMINE SULFATE 500 MG CAPSULE ORL CAP WBP CAP 0.043200080000083 GLUCOSAMINE SULFATE 500 MG TABLET ORL TAB WBP TAB 0.036000080001560 GLUCOSAMINE SULFATE 750 MG CAPSULE ORL CAP WNP CAP 0.064300002300451 GLUMETZA 1000 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.258800002268493 GLUMETZA 500 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 0.626300080009026 GLUTAMINE MAXX ORAL POWDER ORL PWR IHS G 0.060000000999537 GLYCERIN ORL DEFAUL XXX MIS 0.0273

00002020815 GLYCERIN INFANTS CHILDREN 90% RECTAL SUPPOSITORY RT PEDSUP TEV SUP 0.162500001926039 GLYCERIN RECTAL SUPPOSITORY RT SUP WSP SUP 0.190000000873462 GLYCERINE 90% RECTAL SUPPOSITORY USP RT SUP MCO SUP 0.085000080006852 GLYCINE ORAL POWDER ORL PWR AOR G 0.063900002229516 GLYCON 500 MG TABLET ORL TAB VCL TAB 0.024700002239214 GLYCON 850 MG TABLET ORL TAB VCL TAB 0.033900002382857 GLYCOPYRROLATE 0.2 MG/ML INJECTION INJ DEFAUL OMG ML 3.975000002382849 GLYCOPYRROLATE 0.2 MG/ML MULTIDOSE INJECTION INJ DEFAUL OMG ML 3.112500002247884 GLYQUIN XM TOPICAL CREAM TOP CRM VCL G 1.250000002459752 GLYXAMBI 10 MG/5 MG TABLET ORL TAB BOE TAB 4.761700002459760 GLYXAMBI 25 MG/5 MG TABLET ORL TAB BOE TAB 4.761700080053026 GOLD BOND ULTIMATE ECZEMA RELIEF SKIN CREAM TOP CRM SAH G 0.027800000652512 GOLYTELY POWDER FOR ORAL LAVAGE SOLUTION ORL PWR BAX G 0.003700002248154 GONAL-F 5.5 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 70.880000002270404 GONAL-F PEN 300 IU/0.5 ML INJECTION SYRINGE INJ NDL SRO SYR 283.500000002270390 GONAL-F PEN 450 IU/0.75 ML INJECTION SYRINGE INJ NDL SRO SYR 425.2500

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002270382 GONAL-F PEN 900 IU/1.5 ML INJECTION SYRINGE INJ NDL SRO SYR 850.500000000999546 GOOD START INFANT FORMULA ORL LIQ NHN ML 0.008700000999859 GOOD START PLUS ORAL INFANT FORMULA ORL PWR NHN G 0.046800000999858 GOOD START PROBIOTIC ORAL INFANT FORMULA ORL PWR NHN G 0.043200000999850 GOOD START SOOTHE INFANT FORMULA ORL PWR NHN G 0.046700000999578 GOOD START STAGE 2 INFANT FORMULA ORL PWR NHN G 0.040400099400649 GRAB BAR FOR TUB (NON PERMANENT) DEFAUL DEFAUL XXX MIS 168.140000002232483 GRAMCAL 1000 MG EFFERVESCENT TABLET ORL EVT NVC TAB 0.729500080006061 GRAPE SEED CAPLET ORL TAB JAM TAB 0.366700002418304 GRASTEK 2800 UNIT SUBLINGUAL TABLET SLG DISNTAB ALK TAB 4.1553

00002254409 GRAVOL 100 MG LONG ACTING SUSTAINED-RELEASE CAPLET ORL SRT CHD TAB 0.531200000511196 GRAVOL 15 MG CHEWABLE TABLET ORL CTB CHD TAB 0.243300000230197 GRAVOL 3 MG/ML ORAL LIQUID ORL SYR CHD ML 0.080300000013803 GRAVOL 50 MG TABLET ORL TAB CHD TAB 0.251000000013609 GRAVOL ADULT 100 MG RECTAL SUPPOSITORY RT SUP CHD SUP 0.638000000783595 GRAVOL CHILDREN 25 MG RECTAL SUPPOSITORIES RT SUP CHD SUP 0.563000002248180 GRAVOL GINGER LOZENGE ORL LOZ CHD LOZ 0.258000000013579 GRAVOL I.M. 50 MG/ML INJECTION INJ DEFAUL CHD ML 1.208000002245718 GRAVOL NATURAL SOURCE 500 MG TABLET ORL TAB CHD TAB 0.258000002384132 GRAVOL QUICK DISSOLVE CHEWABLE 50 MG TABLET ORL CTB CHD TAB 0.427500080014526 GREEN TEA PHYTOSOME COMPLEX CAPSULE ORL CAP JAM CAP 0.214300080012417 GREENS+ BONE BUILDER ORAL POWDER ORL PWR GNH G 0.094800080030259 GUGGULIPID INTRINSIC ORAL LIQUID ORL LIQ AEI ML 1.000000002384272 GUM PAROEX 0.12% ORAL RINSE ORL MWH SUA ML 0.015300000999818 GYNATROF VAGINAL GEL VAG GEL BIK ML 0.833300080003089 HAIR & NAILS CAPSULE ORL CAP VTH CAP 0.098300002377438 HALAVEN 0.5 MG/ML INJECTION INJ DEFAUL EIS ML 270.000000000271691 HALIBUT LIVER OIL SUPER CAPSULE ORL CAP SWS CAP 0.032900000202061 HALIBUT LIVER OIL WITH VITAMIN D CAPSULE ORL CAP WAM CAP 0.026800002366010 HALOPERIDOL (PRESERVATIVE FREE) 5 MG/ML INJECTION INJ DEFAUL OMG ML 4.830000002406411 HALOPERIDOL INJECTION USP 5 MG/ML INJECTION INJ DEFAUL FKC ML 4.600000002187078 HAVRIX 1,440 U/ML INJECTION INJ DEFAUL GSK ML 48.940000002231056 HAVRIX JUNIOR 720 U/0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 24.680000080028366 HAWTHORN INTRINSIC ORAL LIQUID ORL LIQ AEI ML 0.250000080028459 HAWTHORN ORAL TINCTURE ORL TCT TNH ML 0.3790

00002435683 HEARTBURN CONTROL 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT APX CAP 0.653600080065873 HEMA-FER 12 MG TABLET ORL TAB VAN TAB 0.535700002230466 HEMORRHOIDAL RELIEF OINTMENT TOP ONT PRI G 0.2119

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002303086 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL SDZ ML 0.850000002264315 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL FKC ML 3.382000002264307 HEPARIN SODIUM 10,000 IU/ML INJECTION USP INJ DEFAUL FKC ML 6.820000002382326 HEPARIN SODIUM 10,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 5.248000002303108 HEPARIN SODIUM(WITH PRESERVAT)10,000 IU/ML INJ USP INJ DEFAUL SDZ ML 4.273400002239194 HEPTOVIR 5 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.239700002175622 HERBAL WATER TABLET ORL TAB VCL TAB 0.062100002240692 HERCEPTIN 440 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2874.050000002480794 HERZUMA 440 MG/VIAL INJECTION INJ DEFAUL CHH VIAL 1484.700000000575186 HISTANTIL 50 MG TABLET ORL TAB PMS TAB 0.184900002463067 HIZENTRA 200 MG/ML (10 ML SYRINGE) INJECTION SYR INJ DEFAUL CSL ML 18.000000002463059 HIZENTRA 200 MG/ML (5 ML SYRINGE) INJECTION SYR INJ DEFAUL CSL ML 18.000000002370352 HIZENTRA 200 MG/ML INJECTION INJ DEFAUL CSL ML 18.000000001948903 HONEY BEE VENOM 1.1 MG INJ DEFAUL ALG VIAL 60.000000001948911 HONEY BEE VENOM 120 MCG INJ DEFAUL ALG VIAL 60.000000080079954 HONIBE HONEY GUMMIES VITAMIN D ORL CTB ISA TAB 0.126400002470152 HUMALOG JUNIOR 100 UNIT/ML INJECTION KWIKPEN INJ DEFAUL LIL ML 4.232700002078759 HUMATIN 250 MG CAPSULE ORL CAP PFI CAP 2.810000000745626 HUMATROPE 1 MG/ML INJECTION INJ DEFAUL LIL VIAL 233.350000002243079 HUMATROPE 24 MG INJECTION INJ DEFAUL LIL VIAL 1120.080000002458357 HUMIRA 40 MG/0.4 ML INJECTION PEN INJ NDL ABV SYR 762.570000002458349 HUMIRA 40 MG/0.4 ML INJECTION SYRINGE INJ NDL ABV SYR 762.570000002415089 HUMULIN R 100 UNIT/ML INJECTION KWIKPEN INJ DEFAUL LIL ML 3.190700000999015 HYALGAN DEFAUL DEV MDX ML 25.000000000999060 HYDRA+ THICKENED BEVERAGE ORAL LIQUID ORL LIQ LAS ML 0.004400000999868 HYDRASENSE EYE DROPS OPH SOL BIC ML 0.950000002231476 HYDRASENSE NASAL SOLUTION NAS SOL SCH ML 0.059800000465283 HYDREA 500 MG CAPSULE ORL CAP BMS CAP 1.0203

00009991695 HYDROMORPHON ETHYLPHARM KALCEKS 2 MG/ML INJECTION INJ DEFAUL JPC ML 2.059100002460602 HYDROMORPHONE HCL 2 MG/ML INJECTION INJ DEFAUL STM ML 1.961000002460610 HYDROMORPHONE HCL HP 10 MG/ML INJECTION INJ DEFAUL STM ML 4.346000002468468 HYDROMORPHONE HCL HP FORTE 100 MG/ML INJECTION INJ DEFAUL STM ML 77.763000002469413 HYDROMORPHONE HCL INJ HP 50 MG/ML INJECTION INJ DEFAUL STM ML 21.127200002244797 HYDROMORPHONE HP FORTE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 77.763000002382636 HYDROMORPHONE HYDROCHLORIDE 10 MG/ML INJ USP INJ DEFAUL PFI ML 2.420000080002655 HYDROSAL 15% TOPICAL GEL TOP GEL VLP ML 0.506300000564281 HYDROSONE 0.5% CREAM TOP CRM RPH G 0.132700000742813 HYDROXYZINE HCL 50 MG/ML INJECTION USP INJ DEFAUL SDZ ML 26.140000080052965 HYFIBER ORAL LIQUID ORL LIQ MDT ML 0.0524

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999822 HYLO DROPS OPH SOL CNV ML 3.000000000999823 HYLO DUAL OPH SOL CNV ML 3.669000000999824 HYLO GEL OPH GEL CNV ML 4.0000

00002220113 HYMENOPTERA YELLOW JACKET VENOM PROTEIN 550MCG INJ INJ DEFAUL JHS VIAL 260.000000002229868 HYOSCINE BUTYLBROMIDE 20 MG/ML INJECTION INJ DEFAUL SDZ ML 4.746000080029414 HYPER-SAL 7% INHALATION SOLUTION INH SOL KGH ML 0.220800002230697 HYPERTET S/D 250 IU/SYR INJECTION INJ DEFAUL GRL SYR 78.000000002275864 HYPURIN NPH INSULIN ISOPHANE PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.900000002275872 HYPURIN REGULAR INSULIN PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.900000002505258 HYRIMOZ 20 MG/0.4 ML INJECTION SYRINGE INJ NDL SDZ SYR 235.635000002492156 HYRIMOZ 40 MG/0.8 ML INJECTION SYRINGE INJ NDL SDZ SYR 471.270000002492164 HYRIMOZ 40 MG/0.8 ML INJECTION SYRINGE INJ NDL SDZ SYR 471.270000002425904 IBAVYR 600 MG TABLET ORL TAB PPH TAB 34.611900080022866 IBEROGAST ORAL SOLUTION ORL SOL STA ML 0.199900080061808 IBGARD DELAYED-RELEASE CAPSULE ORL DRC IMH CAP 0.716700002453169 IBRANCE 100 MG CAPSULE ORL CAP PFI CAP 253.912400002493543 IBRANCE 100 MG TABLET ORL TAB PFI TAB 253.912400002453177 IBRANCE 125 MG CAPSULE ORL CAP PFI CAP 253.912400002493551 IBRANCE 125 MG TABLET ORL TAB PFI TAB 253.912400002453150 IBRANCE 75 MG CAPSULE ORL CAP PFI CAP 253.912400002493535 IBRANCE 75 MG TABLET ORL TAB PFI TAB 253.912400002498049 IBSRELA 50 MG TABLET ORL TAB KTI TAB 2.840000002368080 IBUPROFEN 200 MG CAPLET ORL TAB VTH TAB 0.100000002357275 IBUPROFEN 200 MG LIQUID CAPSULE ORL CAP VTH CAP 0.068100002368072 IBUPROFEN 200 MG TABLET ORL TAB VTH TAB 0.054700002257912 IBUPROFEN 200 MG TABLET ORL TAB PMT TAB 0.049800002317338 IBUPROFEN 400 MG CAPLET ORL TAB PMT TAB 0.039200002437333 ICLUSIG 15 MG TABLET ORL TAB ARI TAB 142.844600002437341 ICLUSIG 45 MG TABLET ORL TAB ARI TAB 331.639800002485435 IDHIFA 100 MG TABLET ORL TAB CLG TAB 1216.000000002485427 IDHIFA 50 MG TABLET ORL TAB CLG TAB 1216.000000002460351 ILARIS 150 MG/ML INJECTION INJ DEFAUL NOV ML 16000.000000002411393 ILEVRO 0.3% OPHTHALMIC SUSPENSION OPH SUS NOV ML 7.640000002434407 IMBRUVICA 140 MG CAPSULE ORL CAP JAI CAP 97.600000002468816 IMFINZI 50 MG/ML (SINGLE-USE) VIAL INJECTION INJ DEFAUL AZC ML 391.112500002358336 IMIPENEM & CILASTATIN 250 MG/250 MG/VIAL INJ USP INJ DEFAUL SDZ VIAL 11.740000002358344 IMIPENEM & CILASTATIN 500 MG/500 MG/VIAL INJ USP INJ DEFAUL SDZ VIAL 21.940000002376016 IMODIUM 2 MG CAPSULE ORL CAP MCL CAP 0.920000002245185 IMODIUM ADVANCED CAPLET ORL TAB MCL TAB 0.6585

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002230542 IMODIUM QUICK DISSOLVE 2 MG TABLET ORL TAB MCL TAB 0.851000001959042 IMOVAX POLIO INJECTION SYRINGE INJ NDL SFP SYR 47.000000001908286 IMOVAX RABIES VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL SFP VIAL 207.650000002240713 IMUNOVIR 500 MG TABLET ORL TAB RIP TAB 2.100000002244895 IMURAN 50 MG/VIAL INJECTION INJ DEFAUL APC VIAL 104.400000002398869 INDAYO 0.15 MG/0.03 MG (91 DAY) TABLET ORL TBT MYP TAB 0.505100002042266 INDERAL-LA 120 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 1.169300002042274 INDERAL-LA 160 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 1.382800002042231 INDERAL-LA 60 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.673400002042258 INDERAL-LA 80 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.759300002046059 INFANTS' TYLENOL 80 MG/ML ORAL SUSPENSION DROPS ORL DPS MCL ML 0.306000000572519 INFAZINC 15% TOPICAL OINTMENT TOP ONT ATL G 0.026100002269562 INFLUVAC VACCINE INJECTION SYRINGE INJ DEFAUL ABB SYR 7.596000001911473 INHIBACE 2.5 MG TABLET ORL TAB CAG TAB 0.858900002389630 INLYTA 1 MG TABLET ORL TAB PFI TAB 19.617700002389649 INLYTA 5 MG TABLET ORL TAB PFI TAB 98.088800080013031 INNO-Q-NOL 100 MG SOFT GEL CAPSULE ORL CAP INN CAP 1.132500002501600 INQOVI 35 MG/100 MG TABLET ORL TAB OTS TAB 1172.000000080026628 INSTAFLEX JOINT SUPPORT CAPSULE ORL CAP DDI CAP 0.333200000762040 INSTA-GLUCOSE (1 DOSE PER TUBE) ORAL LIQUID ORL LIQ VCL DOSE 3.830000002294990 INSTILLAGEL 2% /0.05% TOPICAL GEL TOP GEL PPH ML 0.966700002306778 INTELENCE 100 MG TABLET ORL TAB JAI TAB 6.450000002375931 INTELENCE 200 MG TABLET ORL TAB JAI TAB 12.619500002065673 INTRALIPID 20% INTRAVENOUS EMULSION INJ DEFAUL FKC ML 0.205000002238675 INTRON A 10 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 121.532000002223406 INTRON A 10,000,000 UNIT/VIAL INJECTION INJ DEFAUL MFC ML 125.820000002238674 INTRON A 6 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 72.920000002409100 INTUNIV XR 1 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.075000002409119 INTUNIV XR 2 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.741300002409127 INTUNIV XR 3 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 4.407500002409135 INTUNIV XR 4 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 5.073800002279320 INVIRASE 500 MG TABLET ORL TAB HLR TAB 4.557800002455455 INVOKAMET 150 MG/1000 MG TABLET ORL TAB JAI TAB 1.619000002455439 INVOKAMET 150 MG/500 MG TABLET ORL TAB JAI TAB 1.619000002455420 INVOKAMET 50 MG/1000 MG TABLET ORL TAB JAI TAB 1.619000002455404 INVOKAMET 50 MG/500 MG TABLET ORL TAB JAI TAB 1.619000000888354 IOPIDINE 1% OPH SOLUTION (UNIT DOSE) OPH SOL NOV ML 64.750000002246084 IPRAVENT 0.06% NASAL SPRAY NAS SPR AAP ML 1.980000002365200 IRBESARTAN 150 MG TABLET ORL TAB PDL TAB 0.228100002365219 IRBESARTAN 300 MG TABLET ORL TAB PDL TAB 0.2281

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002365197 IRBESARTAN 75 MG TABLET ORL TAB PDL TAB 0.228100002365162 IRBESARTAN-HCTZ 150 MG/12.5 MG TABLET ORL TAB PDL TAB 0.228100002365170 IRBESARTAN-HCTZ 300 MG/12.5 MG TABLET ORL TAB PDL TAB 0.228100002365189 IRBESARTAN-HCTZ 300 MG/25 MG TABLET ORL TAB PDL TAB 0.300400002248676 IRESSA 250 MG TABLET ORL TAB AZC TAB 73.300000000670944 ISDN 5 MG SUBLINGUAL TABLET ORL SLT AAP TAB 0.068500002392437 ISENTRESS 100 MG CHEWABLE TABLET ORL CTB MFC TAB 3.983800002392429 ISENTRESS 25 MG CHEWABLE TABLET ORL CTB MFC TAB 0.995800002301881 ISENTRESS 400 MG TABLET ORL TAB MFC TAB 14.030200002465337 ISENTRESS HD 600 MG TABLET ORL TAB MFC TAB 14.030200000999562 ISOMIL INFANT FORMULA ORL LIQ ABN ML 0.031800000897639 ISOPROTERENOL HYDROCHLORIDE 0.2 MG/ML INJECTION INJ DEFAUL SDZ ML 12.019000000000809 ISOPTO TEARS 0.5% OPH DROPS OPH DPS ALC ML 0.514700000000817 ISOPTO TEARS 1.0% OPH DROPS OPH DPS ALC ML 0.514700000272655 ISOTAMINE 300 MG TABLET ORL TAB VCL TAB 0.089900002414295 ISTODAX 10 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 2582.000000002498073 ITULATEK 12 UNIT SQ-BET SUBLINGUAL TABLET SLG SLT ALK TAB 4.400000002333279 IXIARO 6 MCG/0.5ML INJECTION SYRINGE INJ NDL NOV SYR 193.250000002434814 JAKAVI 10 MG TABLET ORL TAB NOV TAB 85.040000002388014 JAKAVI 15 MG TABLET ORL TAB NOV TAB 85.040000002388022 JAKAVI 20 MG TABLET ORL TAB NOV TAB 85.040000002388006 JAKAVI 5 MG TABLET ORL TAB NOV TAB 85.040000002372010 JALYN 0.5 MG/0.4 MG MODIFIED RELEASE CAPSULE ORL MRC GSK CAP 1.756000080067102 JAMIESON OMEGA-3 ORAL LIQUID ORL LIQ JMS ML 0.073500002502305 JAMP ABIRATERONE 250 MG TABLET ORL TAB JPC TAB 26.031300002246040 JAMP CALCIUM 500 MG TABLET ORL TAB JPC TAB 0.021600080018540 JAMP CALCIUM CARBONATE 500 + VIT D 1000 TABLET ORL TAB JPC TAB 0.126300002500094 JAMP CINACALCET 30 MG TABLET ORL TAB JPC TAB 10.194700002500108 JAMP CINACALCET 60 MG TABLET ORL TAB JPC TAB 18.590000002500116 JAMP CINACALCET 90 MG TABLET ORL TAB JPC TAB 27.051700002497131 JAMP FROVATRIPTAN 2.5 MG TABLET ORL TAB JPC TAB 12.503300002500663 JAMP GEFITINIB 250 MG TABLET ORL TAB JPC TAB 62.305000080094870 JAMP LACTOGLUCONATE CAL+VIT D 20 MG/16 IU/ML LIQ ORL LIQ JPC ML 0.046700080096222 JAMP LACTOGLUCONATE CALCIUM 20 MG/ML SOLUTION ORL LIQ JPC ML 0.044600002490633 JAMP METHIMAZOLE 10 MG TABLET ORL TAB JPC TAB 0.518100002417308 JAMP OLANZAPINE FC 20 MG TABLET ORL TAB JPC TAB 10.309300002497409 JAMP OSELTAMIVIR 30 MG CAPSULE ORL CAP JPC CAP 1.573000002497425 JAMP OSELTAMIVIR 75 MG CAPSULE ORL CAP JPC CAP 3.118000002493489 JAMP PRUCALOPRIDE 1 MG TABLET ORL TAB JPC TAB 2.014500002493497 JAMP PRUCALOPRIDE 2 MG TABLET ORL TAB JPC TAB 3.1025

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002491974 JAMP RASAGILINE 0.5 MG TABLET ORL TAB JPC TAB 6.128700002491982 JAMP RASAGILINE 1 MG TABLET ORL TAB JPC TAB 6.128700002498340 JAMP ROSUVASTATIN CALCIUM 10 MG TABLET ORL TAB JPC TAB 0.135400002498359 JAMP ROSUVASTATIN CALCIUM 20 MG TABLET ORL TAB JPC TAB 0.169300002498367 JAMP ROSUVASTATIN CALCIUM 40 MG TABLET ORL TAB JPC TAB 0.199000002498332 JAMP ROSUVASTATIN CALCIUM 5 MG TABLET ORL TAB JPC TAB 0.128400002503506 JAMP SILDENAFIL 100 MG TABLET ORL TAB JPC TAB 9.200000002388308 JAMP-ACET-TRAMADOL 37.5 MG/325 MG TABLET ORL TAB JPC TAB 0.626400080037789 JAMP-AD 5000 IU/ 400 IU CHEWABLE TABLET ORL CTB JPC TAB 0.105300002421593 JAMP-ALLOPURINOL 100 MG TABLET ORL TAB JPC TAB 0.078000002421607 JAMP-ALLOPURINOL 200 MG TABLET ORL TAB JPC TAB 0.130000002421615 JAMP-ALLOPURINOL 300 MG TABLET ORL TAB JPC TAB 0.212500002400111 JAMP-ALPRAZOLAM 0.25 MG TABLET ORL TAB JPC TAB 0.060900002400138 JAMP-ALPRAZOLAM 0.5 MG TABLET ORL TAB JPC TAB 0.072800002400146 JAMP-ALPRAZOLAM 1 MG TABLET ORL TAB JPC TAB 0.309900002400154 JAMP-ALPRAZOLAM 2 MG TABLET ORL TAB JPC TAB 0.550800002435527 JAMP-AMITRIPTYLINE 10 MG TABLET ORL TAB JPC TAB 0.043500002435535 JAMP-AMITRIPTYLINE 25 MG TABLET ORL TAB JPC TAB 0.082900002435543 JAMP-AMITRIPTYLINE 50 MG TABLET ORL TAB JPC TAB 0.154000002435551 JAMP-AMITRIPTYLINE 75 MG TABLET ORL TAB JPC TAB 0.363400002357208 JAMP-AMLODIPINE 10 MG TABLET ORL TAB JPC TAB 0.358700002357186 JAMP-AMLODIPINE 2.5 MG TABLET ORL TAB JPC TAB 0.076700002339080 JAMP-ANASTROZOLE 1 MG TABLET ORL TAB JPC TAB 2.545800002283905 JAMP-ASA 80 MG ENTERIC-COATED TABLET ORL ECT JPC TAB 0.056000002427206 JAMP-ASA 81 MG ENTERIC-COATED TABLET ORL ECT VTH TAB 0.053000002357216 JAMP-BICALUTAMIDE 50 MG TABLET ORL TAB JPC TAB 4.057300002410893 JAMP-BISACODYL 5 MG SUPPOSITORY RT SUP JPC SUP 0.436700002246039 JAMP-BISACODYL 5 MG TABLET ORL TAB JPC TAB 0.042600080068124 JAMP-CALCIUM CITRATE (500MG) LIQ D1000 ORAL LIQUID ORL LIQ JPC ML 0.077900080028892 JAMP-CALCIUM CITRATE 250 MG + VIT D 1000 IU TABLET ORL TAB JPC TAB 0.122400080068122 JAMP-CALCIUM CITRATE LIQ 500 MG ORAL LIQUID ORL LIQ JPC ML 0.073300080007347 JAMP-CALCIUM CITRATE LIQUID D400 ORL LIQ JPC ML 0.077400002451778 JAMP-CETIRIZINE 10 MG TABLET ORL TAB JPC TAB 0.408300002466171 JAMP-CETIRIZINE 20 MG TABLET ORL TAB JPC TAB 0.753500002451751 JAMP-CETIRIZINE 5 MG TABLET ORL TAB JPC TAB 0.377300002472309 JAMP-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL JPC ML 0.622700002391619 JAMP-DICYCLOMINE HCL 10 MG TABLET ORL TAB JPC TAB 0.420000002366088 JAMP-DICYCLOMINE HCL 20 MG TABLET ORL TAB JPC TAB 0.699000002283220 JAMP-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP ORL SYR JPC ML 0.920300002404427 JAMP-DONEPEZIL 10 MG TABLET ORL TAB JPC TAB 0.4586

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 54 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002404419 JAMP-DONEPEZIL 5 MG TABLET ORL TAB JPC TAB 0.458700080036242 JAMP-E 200 IU CHEWABLE TABLET ORL CTB JPC TAB 0.147400002458233 JAMP-EFAVIRENZ 600 MG TABLET ORL TAB JPC TAB 11.210300080024232 JAMP-FER 300 MG CAPSULE ORL CAP JPC CAP 0.130000080025200 JAMP-FER FC 100 MG/ 0.5 MG/ 200 MG CAPSULE ORL CAP JPC CAP 0.228100080024544 JAMP-FERROUS FUMERATE 300 MG TABLET ORL TAB JPC TAB 0.117200080047569 JAMP-FERROUS POLYSACCHARIDE 150 MG CAPSULE ORL CAP JPC CAP 0.390000000031100 JAMP-FERROUS SULFATE 300 MG TABLET ORL TAB JPC TAB 0.016500080053274 JAMP-FOLIC ACID 1 MG TABLET ORL TAB JPC TAB 0.015200002402289 JAMP-GABAPENTIN 600 MG TABLET ORL TAB JPC TAB 1.304500002402297 JAMP-GABAPENTIN 800 MG TABLET ORL TAB JPC TAB 1.739300002472686 JAMP-GRANISETRON 1 MG TABLET ORL TAB JPC TAB 9.000000080057178 JAMP-HYDROCORTISONE ACETATE 1% TOPICAL CREAM TOP CRM JPC G 0.087500080061502 JAMP-HYDROCORTISONE ACETATE 1% UREA 10% LOTION TOP LOT JPC ML 0.1558

00080061501 JAMP-HYDROCORTISONE ACETATE 1% UREA 10% TOP CREAM TOP CRM JPC G 0.150000080057189 JAMP-HYDROCORTISONE CREAM 1% TOPICAL CREAM TOP CRM JPC G 0.125100002401290 JAMP-IBUPROFEN 400 MG TABLET ORL TAB JPC TAB 0.037200002373904 JAMP-INDAPAMIDE 1.25 MG TABLET ORL TAB JPC TAB 0.074700002373912 JAMP-INDAPAMIDE 2.5 MG TABLET ORL TAB JPC TAB 0.118300080047136 JAMP-IRON POLYPEPTIDE 11 MG TABLET ORL TAB JPC TAB 0.500000080023817 JAMP-K-CITRATE 10 MEQ TABLET ORL SRT JPC TAB 0.250000080047847 JAMP-LACTIC ACID 12% TOPICAL LOTION TOP LOT JPC ML 0.035500002373009 JAMP-LETROZOLE 2.5 MG TABLET ORL TAB JPC TAB 2.756000002386836 JAMP-LIDOCAINE 5% TOPICAL OINTMENT TOP ONT JPC G 0.280000002361566 JAMP-LISINOPRIL 20 MG TABLET ORL TAB JPC TAB 0.194500080041590 JAMP-MAGNESIUM 100 MG TABLET ORL TAB JPC TAB 0.079500080009357 JAMP-MAGNESIUM 100 MG/ML ORAL SOLUTION ORL SOL JPC ML 0.021000080043440 JAMP-MAGNESIUM 250 MG TABLET ORL TAB JPC TAB 0.1026

00002419173 JAMP-METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION INJ DEFAUL JPC ML 5.625000002472120 JAMP-MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL JPC ML 3.756700002386399 JAMP-MYCOPHENOLATE 250 MG CAPSULE ORL CAP JPC CAP 1.031000002380382 JAMP-MYCOPHENOLATE 500 MG TABLET ORL TAB JPC TAB 2.062000002405776 JAMP-NEVIRAPINE 200 MG TABLET ORL TAB JPC TAB 2.469200002427745 JAMPOCAINE 2% VISCOUS TOPICAL SOLUTION TOP SOL JPC ML 0.052500002406640 JAMP-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB JPC TAB 5.355300002406659 JAMP-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB JPC TAB 7.597700002458411 JAMP-OLOPATADINE 0.1% OPHTHALMIC SOLUTION OPH SOL JPC ML 5.226000002357569 JAMPOLYCIN 500 U/G / 10000 U/G TOPICAL OINTMENT TOP ONT JPC G 0.3600

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002440717 JAMP-OXCARBAZEPINE 150 MG TABLET ORL TAB JPC TAB 0.620900002440725 JAMP-OXCARBAZEPINE 300 MG TABLET ORL TAB JPC TAB 0.910200002440733 JAMP-OXCARBAZEPINE 600 MG TABLET ORL TAB JPC TAB 1.820400002408414 JAMP-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT JPC TAB 1.275000002368862 JAMP-PAROXETINE 10 MG TABLET ORL TAB JPC TAB 1.043000002420430 JAMP-PIP/TAZ 4 G/500 MG/VIAL INJECTION INJ DEFAUL JPC VIAL 12.110000002380617 JAMP-PYRANTEL PAMOATE 125 MG TABLET ORL TAB JPC TAB 1.265000002412470 JAMP-PYRANTEL PAMOATE 50 MG/ML ORAL SUSPENSION ORL SUS JPC ML 0.666700002331101 JAMP-RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB JPC CAP 0.127400002440334 JAMP-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB JPC CAP 0.855000002405687 JAMP-SILDENAFIL 100 MG TABLET ORL TAB JPC TAB 9.200000002405660 JAMP-SILDENAFIL 25 MG TABLET ORL TAB JPC TAB 8.290000002405679 JAMP-SILDENAFIL 50 MG TABLET ORL TAB JPC TAB 8.847500002469669 JAMP-SILDENAFIL R 20 MG TABLET ORL TAB JPC TAB 7.294000080034416 JAMP-SODIUM PHOSPHATE 0.891 G -2.4 G/5 ML SOLUTION ORL SOL JPC ML 0.443300002451840 JAMP-TADALAFIL 10 MG TABLET ORL TAB JPC TAB 11.925000002451824 JAMP-TADALAFIL 2.5 MG TABLET ORL TAB JPC TAB 3.647100002451859 JAMP-TADALAFIL 20 MG TABLET ORL TAB JPC TAB 12.357500002451832 JAMP-TADALAFIL 5 MG TABLET ORL TAB JPC TAB 3.647100002420309 JAMP-VANCOMYCIN 1 G/VIAL INJECTION INJ DEFAUL JPC VIAL 589.900000002420325 JAMP-VANCOMYCIN 10 G/VIAL INJECTION INJ DEFAUL JPC VIAL 589.900000002420317 JAMP-VANCOMYCIN 5 G/VIAL INJECTION INJ DEFAUL JPC VIAL 509.790000002420295 JAMP-VANCOMYCIN 500 MG/VIAL INJECTION INJ DEFAUL JPC VIAL 31.050000002476088 JAMP-VARDENAFIL 10 MG ORAL DISINTEGRATING TABLET ORL DISNTAB JPC TAB 5.897500002475685 JAMP-VARDENAFIL 10 MG TABLET ORL TAB JPC TAB 10.402500002475693 JAMP-VARDENAFIL 20 MG TABLET ORL TAB JPC TAB 11.680000002475677 JAMP-VARDENAFIL 5 MG TABLET ORL TAB JPC TAB 9.320000080054130 JAMP-VITAMIN A 10, 000 IU CAPSULE ORL CAP JPC CAP 0.043100080009588 JAMP-VITAMIN B1 100 MG TABLET ORL TAB JPC TAB 0.132600080028902 JAMP-VITAMIN B12 1000 MCG RAPID DISSOLVE TABLET ORL TAB JPC TAB 0.088400002449099 JAMP-VITAMIN D 10,000 UNIT CAPSULE ORL CAP JPC CAP 0.210000002379007 JAMP-VITAMIN D 10000 UNIT TABLET ORL TAB JPC TAB 0.210000002449110 JAMP-VITAMIN D 50,000 IU CAPSULE ORL CAP JPC CAP 0.916200080054585 JAMP-VITAMIN K + VITAMIN D TABLET ORL TAB JPC TAB 0.062700080055096 JAMP-VITAMIN K 100 MCG TABLET ORL TAB JPC TAB 0.062700002468395 JAMP-ZOPICLONE 3.75 MG TABLET ORL TAB JPC TAB 0.223100002356805 JAMP-ZOPICLONE 7.5 MG TABLET ORL TAB JPC TAB 0.312500002469146 JELIDO 2% TOPICAL JELLY TOP JEL PPH ML 0.636400002410818 JETREA 0.5 MG/VIAL INJECTION INJ DEFAUL ONV VIAL 3950.000000002369524 JEVTANA 40 MG/ML INJECTION INJ DEFAUL SAV VIAL 5800.0000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002491575 JINARC 15 MG/15 MG COMBINATION PACK ORL TAB OTS TAB 57.667900002491583 JINARC 30 MG/15 MG COMBINATION PACK ORL TAB OTS TAB 57.667900002437503 JINARC 45 MG/15 MG COMBINATION PACK ORL TAB OTS TAB 57.667900002437511 JINARC 60 MG/30 MG COMBINATION PACK ORL TAB OTS TAB 57.667900002437538 JINARC 90 MG/30 MG COMBINATION PACK ORL TAB OTS TAB 57.667900002493675 JORVEZA 1 MG ORAL DISINTEGRATING TABLET ORL DISNTAB AVP TAB 5.500000002413388 JUBLIA 10% TOPICAL SOLUTION TOP SOL VCL ML 11.520000002475774 JULUCA 50 MG/25 MG TABLET ORL TAB VIV TAB 34.867700002420376 JUXTAPID 10 MG CAPSULE ORL CAP AEP CAP 1040.000000002420384 JUXTAPID 20 MG CAPSULE ORL CAP AEP CAP 1040.000000002420341 JUXTAPID 5 MG CAPSULE ORL CAP AEP CAP 1040.000000002412365 KADCYLA 100 MG/VIAL INJ POWDER FOR SOL INJ DEFAUL HLR VIAL 2128.930000002473224 KADCYLA 160 MG/VIAL INJ POWDER FOR SOL INJ DEFAUL HLR VIAL 3406.280000002312301 KALETRA 100 MG/25 MG TABLET ORL TAB ABV TAB 2.899500002285533 KALETRA 200 MG/50 MG TABLET ORL TAB ABV TAB 5.798900002243644 KALETRA 80 MG/ML/20MG/ML ORAL SOLUTION ORL SOL ABV ML 2.320100002442612 KALYDECO 50 MG GRANULES ORL GRNUL VER PCKT 420.000000002442620 KALYDECO 75 MG GRANULES ORL GRNUL VER PCKT 420.000000002496690 KANJINTI 420 MG/VIAL INJECTION INJ DEFAUL AMG VIAL 1417.210000002469596 KANUMA 20 MG/VIAL INJECTION INJ DEFAUL APG VIAL 8546.000000002229952 KAOPECTATE EXTRA STRENGTH SUSPENSION ORL SUS PAL ML 0.029200002229951 KAOPECTATE REGULAR STRENGTH SUSPENSION ORL SUS PAL ML 0.027600002417235 KAZANO 12.5 MG/1000 MG TABLET ORL TAB TAK TAB 1.195000002417219 KAZANO 12.5 MG/500 MG TABLET ORL TAB TAK TAB 1.195000002417227 KAZANO 12.5 MG/850 MG TABLET ORL TAB TAK TAB 1.195000080011529 K-CITRA 2 MEQ/ML SOLUTION ORL LIQ SFD ML 0.056700002243768 K-CITRA POTASSIUM CITRATE 10 MEQ SRT ORL SRT SFD TAB 0.301500000224391 KETALAR 10 MG/ML INJECTION INJ DEFAUL ERF ML 1.700000000224405 KETALAR 50 MG/ML INJECTION INJ DEFAUL ERF ML 5.500000002246796 KETAMINE 50 MG/ML INJECTION USP INJ DEFAUL SDZ ML 5.198000002246795 KETAMINE HYDROCHLORIDE 10 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.645000000790427 KETOPROFEN 50 MG CAPSULE ORL CAP AAP CAP 0.344000002244947 KETOROLAC TROMETHAMINE 30 MG/ML INJECTION INJ DEFAUL FKC ML 4.220000002443376 KETOROLAC TROMETHAMINE 30 MG/ML INJECTION INJ DEFAUL JUN ML 4.410000002400871 KETOTIFEN 0.25 MG/ML OPH SOLUTION OPH SOL STM ML 4.234000002456869 KEYTRUDA 25 MG/ML (4 ML VIAL) INJECTION INJ DEFAUL MFC ML 1100.000000080020666 KID'S LIQUID VITAMIN D 400 IU ORL LIQ WBP ML 0.130600000999854 KIRKLAND SIGNATURE NUTRITIONAL SHAKE ORL LIQ XXX ML 0.003600002473569 KISQALI 200 MG TABLET ORL TAB NOV TAB 84.650000002269341 KIVEXA 600 MG/300 MG TABLET ORL TAB VIV TAB 24.5637

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080080214 KOENA ADULT ACUTE CARE POWDER ORL PWR EXP G 1.4400

00080080349KOENA ADULT EXTRA STRENGTH DELAYED-RELEASE CAPSULE ORL DRC EXP CAP 1.0500

00080081204 KOENA KIDS DAILY CHEWABLE TABLET ORL CTB EXP TAB 0.700000080080348 KOENA PROBIOTIC ADULT DAILY CAPSULE ORL CAP EXP CAP 0.700000001928783 KOFFEX SIROP 3 MG/ML ORAL SYRUP ORL SYR ROG ML 0.019000080052499 KRILL OIL CAPSULE ORL CAP WNP CAP 0.438300080022006 KRILL OIL SOFTGEL CAPSULE ORL CAP WBP CAP 0.219200002350580 KUVAN 100 MG TABLET ORL TAB BMI TAB 33.000000002482207 KUVAN 100 MG/ORAL POWDER SACHET ORL PWDPKT BMI PCKT 33.000000002482215 KUVAN 500 MG/ORAL POWDER SACHET ORL PWDPKT BMI PCKT 165.000000002500264 KYNMOBI 10 MG SUBLINGUAL FILM SLG FILM SUN FILM 9.540000002500272 KYNMOBI 15 MG SUBLINGUAL FILM SLG FILM SUN FILM 9.540000002500280 KYNMOBI 20 MG SUBLINGUAL FILM SLG FILM SUN FILM 9.540000002500299 KYNMOBI 25 MG SUBLINGUAL FILM SLG FILM SUN FILM 9.540000002500302 KYNMOBI 30 MG SUBLINGUAL FILM SLG FILM SUN FILM 9.540000080004073 KYOLIC AGED GARLIC EXTRACT ORAL CAPLET ORL TAB WKG TAB 0.599100002451034 KYPROLIS 60 MG/VIAL INJECTION INJ DEFAUL AMG VIAL 1533.330000002387468 LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION INJ DEFAUL MYP ML 1.293000002231689 LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION INJ DEFAUL SDZ ML 1.390000000210889 LACRI-LUBE OPH OINTMENT OPH ONT ALL G 2.054300002250624 LACRISERT 5 MG OPHTHALMIC INSERT OPH INS ATP DEV 3.594700000999515 LACTOBACILLIUS MIS DEFAUL XXX MIS 0.121800080012831 LACTOBACILLUS ACIDOPHILUS & BIFIDUS ORL CAP SWS CAP 0.122300000468401 LAIT DE MAGNESIE ORL SUSP (MILK OF MAGNESIA) ORL SUS ATL ML 0.008400000999485 LAKOTA ORAL AND TOPICAL PRODUCTS MIS DEFAUL XIX MIS 0.152700002243803 LAMICTAL 2 MG CHEWABLE TABLET ORL CTB GSK TAB 0.184300002302985 LAMOTRIGINE-100 100 MG TABLET ORL TAB PDL TAB 0.278700002302993 LAMOTRIGINE-150 150 MG TABLET ORL TAB PDL TAB 0.410700002302969 LAMOTRIGINE-25 25 MG TABLET ORL TAB PDL TAB 0.069800002366282 LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PDL CAP 0.500000000608734 LANSOYL JELLY 78% ORL GEL AUP G 0.046700002186926 LANSOYL SUGAR FREE JELLY 78% ORL GEL AUP G 0.046700002245689 LANTUS 100 UNIT/ML INJECTION INJ DEFAUL SAV ML 6.169000002251930 LANTUS 100 UNIT/ML INJECTION CARTRIDGE INJ DEFAUL SAV ML 6.190000002294338 LANTUS PEN 100 UNIT/ML INJECTION INJ DEFAUL SAV ML 6.190000000282081 LANVIS 40 MG TABLET ORL TAB APC TAB 4.988000000999566 L-ARGININE ORL CAP XXX CAP 0.231100002375508 LATANOPROST 0.005% OPHTHALMIC SOLUTION OPH SOL RIV ML 3.632000002096900 LAX-A NEMA RECTAL ENEMA RT ENM PPH ENM 3.1100

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999529 LAXATIVE (SENNA, GLYCYRRHIZA, RHAMAUS, RHEUM) ORL DEFAUL XXX MIS 0.189600002246294 LAXATIVE FIBER POWDER ORL PWR DNS G 0.022700080039406 L-CARNITINE 500 MG CAPSULE ORL CAP AOR CAP 0.169200000999417 L-CARNITINE ORAL POWDER ORL PWR XXX G 2.566400002415828 LEFLUNOMIDE 10 MG TABLET ORL TAB PDL TAB 2.643300002415836 LEFLUNOMIDE 20 MG TABLET ORL TAB PDL TAB 2.643300002450321 LENVIMA (10 MG DAILY DOSE) 10 MG CAPSULE ORL CAP EIS CAP 73.085700002484129 LENVIMA (12 MG DAILY DOSE) 4 MG CAPSULE ORL CAP EIS CAP 33.320700002450313 LENVIMA (14 MG DAILY DOSE) 10 MG/4 MG CAPSULE ORL CAP EIS CAP 57.142300002468239 LENVIMA (18 MG DAILY DOSE) 10 MG/4 MG CAPSULE ORL CAP EIS CAP 50.567100002450305 LENVIMA (20 MG DAILY DOSE) 10 MG CAPSULE ORL CAP EIS CAP 85.718700002450291 LENVIMA (24 MG DAILY DOSE) 10 MG/4 MG CAPSULE ORL CAP EIS CAP 76.189800002484056 LENVIMA (4 MG DAILY DOSE) 4 MG CAPSULE ORL CAP EIS CAP 33.320600002468220 LENVIMA (8 MG DAILY DOSE) 4 MG CAPSULE ORL CAP EIS CAP 33.320700002402025 LETROZOLE 2.5 MG TABLET ORL TAB PDL TAB 1.378000002338459 LETROZOLE 2.5 MG TABLET ORL TAB AHI TAB 2.756000002183005 LEUCOVORIN CALCIUM 10 MG/ML INJECTION INJ DEFAUL PFI ML 14.008000000004626 LEUKERAN 2 MG TABLET ORL TAB APC TAB 1.656000002250470 LEVITRA 10 MG TABLET ORL TAB BAI TAB 12.232500002250489 LEVITRA 20 MG TABLET ORL TAB BAI TAB 13.742500002250462 LEVITRA 5 MG TABLET ORL TAB BAI TAB 10.965000002415879 LEVOFLOXACIN 500 MG TABLET ORL TAB PDL TAB 1.371800002245948 LEVOTHYROXINE SODIUM 0.5 MG/VIAL INJECTION INJ DEFAUL FKC VIAL 379.680000002243933 LEVULAN KERASTICK 20% TOPICAL SOLUTION TOP SOL DSP ML 149.446700080005719 L-GLUTAMINE POWDER ORL PWR AOR G 0.167800000999059 LIBERTE COPPER IUD TT380 SHORT 5 YEARS DEFAUL DEFAUL MDI DEV 72.750000000999056 LIBERTE COPPER IUD TT380 STANDARD 10 YEARS DEFAUL DEFAUL MDI DEV 72.750000000999054 LIBERTE UT380 COPPER IUD 380MG SHORT DEFAUL DEFAUL MDI DEV 62.500000000999055 LIBERTE UT380 COPPER IUD 380MG STANDARD DEFAUL DEFAUL MDI DEV 62.500000002487152 LIBTAYO 250 MG/5 ML INJECTION INJ DEFAUL SAV ML 1171.428600002487144 LIBTAYO 350 MG/7 ML INJECTION INJ DEFAUL SAV ML 1171.428600002422026 LIDOCAINE HCL (WITH PRESERVATIVE) 2% INJECTION INJ DEFAUL TGT ML 0.350000002421984 LIDOCAINE HCL 1% INJECTION INJ DEFAUL TGT ML 0.950000002421992 LIDOCAINE HCL 2% INJECTION INJ DEFAUL TGT ML 1.050000002296187 LIDOCAINE HCL 2% INJECTION (BLOCK OR INFILTRATION) INJ LIQ ALV ML 1.050000000436208 LIDOCAINE HYDROCHLORIDE 2% INJECTION INJ DEFAUL HSP ML 6.0760

00002231147 LIDODAN ENDOTRACHEAL 10 MG/DOSE NON-AEROSOL SPRAY TOP SPR ODN DOSE 0.927000000999897 LIFE BRAND BASE TOPICAL CREAM TOP CRM SDG G 0.022100002243101 LIFE BRAND DAILY LOW DOSE ASA 81 MG ECT ORL ECT PMS TAB 0.1597

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080003212 LIFE BRAND ORAL LAXATIVE ORL LIQ HJS ML 0.092000080093799 L'IL CRITTERS GUMMY VITES COMPLETE MULTIVITAMIN ORL CTB CHD TAB 0.053200002481278 LINEZOLID 2 MG/ML INJECTION INJ DEFAUL JPC ML 0.295800000455881 LIORESAL 10 MG TABLET ORL TAB NOV TAB 0.738200000636576 LIORESAL D.S. 20 MG TABLET ORL TAB NOV TAB 1.437100002269082 LIPIDIL EZ 145 MG TABLET ORL TAB BGP TAB 1.152300002269074 LIPIDIL EZ 48 MG TABLET ORL TAB BGP TAB 0.450000000999813 LIPISTART FORMULA ORAL POWDER ORL PWR VTF G 0.094500000999547 LIPO FLAVONOID MIS DEFAUL XXX MIS 0.259900080054024 LIQUID BIOCELL LIFE ORAL LIQUID ORL LIQ JUI ML 0.148800080006893 LIQUID CALCIUM WITH VITAMIN D ORL LIQ WBP ML 0.017600080001853 LIQUID GLUCOSAMINE ORL LIQ JAM ML 0.034300080001800 LIQUID GLUCOSAMINE/CHONDROITIN & MSM LIQUID ORL LIQ WBP ML 0.032100080007222 LIQUID OMEGA-3 PLUS VITAMIN A & D ORL LIQ WNP ML 0.093900000999832 LIQUID PECTIN ORL LIQ XXX ML 0.015900002266695 LITHMAX 300 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.275300080007554 LIV MILIEU ORAL LIQUID ORL LIQ AEI ML 1.000000002020017 LIVOSTIN 50 MCG PER DOSE NASAL SPRAY NAS SPR JAI ML 2.576700080027321 LIVRELIEF EXTRA STRENGTH NERVE PAIN RELIEF TOP CRM DVI G 0.315400080022837 LIVRELIEF PAIN RELIEF CREAM TOP CRM DVI G 0.179200000074462 LOCACORTEN VIOFORM TOPICAL CREAM TOP CRM PAL G 1.179300002490722 LOKELMA 10 G ORAL POWDER PACKET ORL PWDPKT AZC PCKT 25.000000002490714 LOKELMA 5 G ORAL POWDER PACKET ORL PWDPKT AZC PCKT 12.500000002417456 LOLO (28 DAY) TABLET ORL TB ALL TAB 0.644600002472104 LONSURF 15 MG/6.14 MG TABLET ORL TAB TAI TAB 76.250000002472112 LONSURF 20 MG/8.19 MG TABLET ORL TAB TAI TAB 78.538500002221810 LOPROX 1% TOPICAL LOTION TOP LOT VCL ML 0.342200002366444 LORATADINE 10 MG TABLET ORL TAB APX TAB 0.238700002244692 LORATADINE 10 MG TABLET ORL TAB VTH TAB 0.444200002280159 LORATADINE 10 MG TABLET ORL TAB VTH TAB 0.543000002243278 LORAZEPAM 4 MG INJECTION USP INJ DEFAUL SDZ ML 21.200000002388669 LORAZEPAM 4 MG/ML INJECTION USP INJ DEFAUL PFI ML 21.960000002485974 LORBRENA 100 MG TABLET ORL TAB PFI TAB 337.333300002485966 LORBRENA 25 MG TABLET ORL TAB PFI TAB 112.444300002394383 LOSARTAN 100 MG TABLET ORL TAB PDL TAB 0.196100002394367 LOSARTAN 25 MG TABLET ORL TAB PDL TAB 0.196100002394375 LOSARTAN 50 MG TABLET ORL TAB PDL TAB 0.196100002394405 LOSARTAN-HCTZ 100 MG/12.5 MG TABLET ORL TAB PDL TAB 0.308200002394413 LOSARTAN-HCTZ 100 MG/25 MG TABLET ORL TAB PDL TAB 0.314600002394391 LOSARTAN-HCTZ 50 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3146

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002435853 LOTEMAX 0.5% OPHTHALMIC GEL OPH GEL BSH G 4.668000002421941 LOTEMAX 0.5% OPHTHALMIC OINTMENT OPH ONT BSH G 7.057100002321114 LOTEMAX 0.5% OPHTHALMIC SUSPENSION OPH SUS BSH ML 4.940000002169991 LOXAPAC 50 MG/ML INJECTION INJ DEFAUL SDZ ML 24.776000002179709 LOZIDE 1.25 MG TABLET ORL TAB SEV TAB 0.312700000564966 LOZIDE 2.5 MG TABLET ORL TAB SEV TAB 0.511700099400919 LUBRICATING JELLY/3 G PACKET SINGLE USE DEFAUL DEFAUL XXX MIS 0.110000002425629 LUCENTIS 1.65 MG/SYRINGE INJECTION INJ DEFAUL NOV SYR 1575.000000000999821 LUGOL 5% IODINE ORAL SOLUTION ORL SOL PCC ML 0.237500002453207 LUNESTA 1 MG TABLET ORL TAB SUN TAB 1.490000002453215 LUNESTA 2 MG TABLET ORL TAB SUN TAB 1.490000002453223 LUNESTA 3 MG TABLET ORL TAB SUN TAB 1.490000002469170 LUPIN-CEPHALEXIN 25 MG/ML ORAL SUSPENSION ORL SUS LPC ML 0.146200002469189 LUPIN-CEPHALEXIN 50 MG/ML ORAL SUSPENSION ORL SUS LPC ML 0.279700002239833 LUPRON DEPOT 30 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 1428.000000002242934 LUSTRA-AF TOPICAL CREAM TOP CRM MEI G 1.197200002046210 LUTREPULSE 0.8 MG/VIAL INJECTION INJ DEFAUL FEI VIAL 119.030000002269066 LUVERIS 75 IU/VIAL INJECTION INJ DEFAUL SRO VIAL 26.490000002366924 LUXIQ 0.12% TOPICAL FOAM TOP FOA GSK G 0.753100002475200 LYNPARZA 100 MG TABLET ORL TAB AZC TAB 65.892500002475219 LYNPARZA 150 MG TABLET ORL TAB AZC TAB 65.892500002454408 LYNPARZA 50 MG CAPSULE ORL CAP AZC CAP 16.741100002268450 LYRICA 150 MG CAPSULE ORL CAP UJC CAP 2.395300002268477 LYRICA 225 MG CAPSULE ORL CAP UJC CAP 2.395300002268418 LYRICA 25 MG CAPSULE ORL CAP UJC CAP 0.856200002268485 LYRICA 300 MG CAPSULE ORL CAP UJC CAP 2.395300002268426 LYRICA 50 MG CAPSULE ORL CAP UJC CAP 1.343000002268434 LYRICA 75 MG CAPSULE ORL CAP UJC CAP 1.737700000463221 LYSODREN 500 MG TABLET ORL TAB LHP TAB 9.790000002244690 MAALOX ANTACID WITH ANTI-GAS EXTRA STRENGTH SUSP ORL SUS NVC ML 0.021100002244689 MAALOX ANTACID WITH ANTI-GAS ORAL SUSPENSION ORL SUS NVC ML 0.018100002238291 MAALOX QUICK DISSOVE EXTRA STR. CHEWABLE TABLET ORL TAB NVC TAB 0.103100002068400 MAGNESIUM 100 MG TABLET ORL TAB JAM TAB 0.077900080026324 MAGNESIUM 150 MG CAPSULE ORL CAP BCN CAP 0.108700080025339 MAGNESIUM 250 MG TABLET ORL TAB WNP TAB 0.083300002040921 MAGNESIUM 50 MG TABLET ORL TAB JAM TAB 0.054200080005581 MAGNESIUM CITRATE 150 MG CAPSULE ORL CAP WBP CAP 0.078800080005079 MAGNESIUM COMPLEX 250 MG CAPLET ORL TAB JAM TAB 0.108300080013414 MAGNESIUM EXTRA STRENGTH 500 MG TABLET ORL TAB WNP TAB 0.078800080056221 MAGNESIUM GLYCINATE 200 MG CAPSULE ORL CAP ORN CAP 0.1502

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080082915 MAGNESIUM OXIDE 420 MG TABLET ORL TAB JPC TAB 0.133000000299448 MAGNESIUM OXIDE 420 MG TABLET ORL TAB VCL TAB 0.037800080082435 MAGNESIUM OXIDE 835 MG TABLET ORL TAB JPC TAB 0.173300080014800 MAGNESIUM PLUS CALCIUM POWDER FOR SUSPENSION ORL PWRSUS NCC G 0.097300000392618 MAGNESIUM SULFATE 20% INJECTION INJ DEFAUL SDZ ML 1.966700002139499 MAGNESIUM SULFATE 500 MG/ML INJECTION USP INJ DEFAUL FKC ML 0.644400000202045 MAGNOLAX ORAL EMULSION ORL EML PPH ML 0.014000002264935 MALARONE PEDIATRIC TABLET ORL TAB GSK TAB 1.756700002238151 MALARONE TABLET ORL TAB GSK TAB 5.123300080048179 MALTLEVOL-12 ORAL LIQUID ORL LIQ CHD ML 0.022700002243459 MALTLEVOL-12 ORAL LIQUID ORL LIQ CHD ML 0.020600002468034 M-AMLODIPINE 10 MG TABLET ORL TAB MTR TAB 0.199300002468018 M-AMLODIPINE 2.5 MG TABLET ORL TAB MTR TAB 0.076700002468026 M-AMLODIPINE 5 MG TABLET ORL TAB MTR TAB 0.134300000499013 MANDELAMINE 500 MG TABLET ORL TAB ERF TAB 0.510000000899356 MANERIX 150 MG TABLET ORL TAB MED TAB 0.749000002166747 MANERIX 300 MG TABLET ORL TAB MED TAB 1.471000002429861 MAR-AMITRIPTYLINE 10 MG TABLET ORL TAB MAR TAB 0.066400002429888 MAR-AMITRIPTYLINE 25 MG TABLET ORL TAB MAR TAB 0.121100002429896 MAR-AMITRIPTYLINE 50 MG TABLET ORL TAB MAR TAB 0.234700002429918 MAR-AMITRIPTYLINE 75 MG TABLET ORL TAB MAR TAB 0.363400002379562 MAR-ANASTROZOLE 1 MG TABLET ORL TAB MAR TAB 3.328000002305895 MARCAINE 0.25% INJECTION INJ DEFAUL PFI ML 0.821000002241918 MARCAINE 2.5 MG/ML INJECTION INJ DEFAUL PFI ML 0.773000002241919 MARCAINE 5 MG/ML INJECTION INJ DEFAUL PFI ML 0.920000002305909 MARCAINE 5 MG/ML INJECTION INJ DEFAUL PFI ML 0.974200002241917 MARCAINE 7.5 MG/ML INJECTION INJ DEFAUL PFI ML 1.981000002241915 MARCAINE E 2.5 MG/ML INJECTION INJ DEFAUL PFI ML 0.801500002241914 MARCAINE SPINAL 7.5 MG/ML INJECTION INJ DEFAUL PFI ML 12.920000002427133 MAR-CETIRIZINE 10 MG TABLET ORL TAB MAR TAB 0.408300002427141 MAR-CETIRIZINE 20 MG TABLET ORL TAB MAR TAB 0.753500002480298 MAR-CINACALCET 30 MG TABLET ORL TAB MAR TAB 10.194700002480301 MAR-CINACALCET 60 MG TABLET ORL TAB MAR TAB 18.590000002480328 MAR-CINACALCET 90 MG TABLET ORL TAB MAR TAB 27.051700002476185 MAR-FLECAINIDE 100 MG TABLET ORL TAB MAR TAB 0.277900002476177 MAR-FLECAINIDE 50 MG TABLET ORL TAB MAR TAB 0.138900002373424 MAR-LETROZOLE 2.5 MG TABLET ORL TAB MAR TAB 2.756000002422484 MAR-LOSARTAN 100 MG TABLET ORL TAB MAR TAB 0.314700002422468 MAR-LOSARTAN 25 MG TABLET ORL TAB MAR TAB 0.314700002422476 MAR-LOSARTAN 50 MG TABLET ORL TAB MAR TAB 0.3147

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002480115 MAR-METHIMAZOLE 10 MG TABLET ORL TAB MAR TAB 0.518100002389118 MAR-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB MAR TAB 6.962300002389126 MAR-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB MAR TAB 7.590000002389088 MAR-OLANZAPINE ODT 5 MG ORAL DISINT. TABLET ORL DISNTAB MAR TAB 0.357300002497352 MAR-OSELTAMIVIR 30 MG CAPSULE ORL CAP MAR CAP 1.573000002497360 MAR-OSELTAMIVIR 45 MG CAPSULE ORL CAP MAR CAP 2.420000002497379 MAR-OSELTAMIVIR 75 MG CAPSULE ORL CAP MAR CAP 3.118000002411946 MAR-PAROXETINE 10 MG TABLET ORL TAB MAR TAB 1.043000002417561 MAR-PREGABALIN 150 MG CAPSULE ORL CAP MAR CAP 1.865200002417529 MAR-PREGABALIN 25 MG CAPSULE ORL CAP MAR CAP 0.148100002417537 MAR-PREGABALIN 50 MG CAPSULE ORL CAP MAR CAP 1.045800002417545 MAR-PREGABALIN 75 MG CAPSULE ORL CAP MAR CAP 1.353200002420503 MAR-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB MAR CAP 0.855000002413078 MAR-ROSUVASTATIN 10 MG TABLET ORL TAB MAR TAB 0.135400002413086 MAR-ROSUVASTATIN 20 MG TABLET ORL TAB MAR TAB 0.169200002413108 MAR-ROSUVASTATIN 40 MG TABLET ORL TAB MAR TAB 0.199000002413051 MAR-ROSUVASTATIN 5 MG TABLET ORL TAB MAR TAB 0.128400002375036 MAR-SIMVASTATIN 5 MG TABLET ORL TAB MAR TAB 0.184100002375079 MAR-SIMVASTATIN 80 MG TABLET ORL TAB MAR TAB 0.250100002452251 MAR-TADALAFIL 10 MG TABLET ORL TAB MAR TAB 11.925000002452286 MAR-TADALAFIL 2.5 MG TABLET ORL TAB MAR TAB 3.647100002452243 MAR-TADALAFIL 20 MG TABLET ORL TAB MAR TAB 12.357500002452278 MAR-TADALAFIL 5 MG TABLET ORL TAB MAR TAB 3.647100002432102 MAR-TOPIRAMATE 100 MG TABLET ORL TAB MAR TAB 0.458300002432110 MAR-TOPIRAMATE 200 MG TABLET ORL TAB MAR TAB 0.674800002432099 MAR-TOPIRAMATE 25 MG TABLET ORL TAB MAR TAB 0.243300002480859 MAR-TRAMADOL 50 MG TABLET ORL TAB MAR TAB 0.638600002388324 MAR-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MAR TAB 0.626400002441586 MAR-VALACYCLOVIR 500 MG TABLET ORL TAB MAR TAB 0.619800099400933 MATERNITY BELT DEFAUL DEFAUL XXX MIS 71.330000002471167 M-ATORVASTATIN 10 MG TABLET ORL TAB MTR TAB 0.174300002471175 M-ATORVASTATIN 20 MG TABLET ORL TAB MTR TAB 0.217900002471183 M-ATORVASTATIN 40 MG TABLET ORL TAB MTR TAB 0.234200002471191 M-ATORVASTATIN 80 MG TABLET ORL TAB MTR TAB 0.234200000012750 MATULANE 50 MG CAPSULE ORL CAP SGM CAP 56.795800002244533 MAXILENE 4% TOPICAL CREAM TOP CRM RGR G 2.080000002245939 MAXILENE 5 % TOPICAL CREAM TOP CRM RGR G 1.883300002496429 MAYZENT 0.25 MG TABLET ORL TAB NOV TAB 22.328500002496437 MAYZENT 2 MG TABLET ORL TAB NOV TAB 89.315000002502038 M-AZITHROMYCIN 250 MG TABLET ORL TAB MTR TAB 0.9410

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002495465 M-CELECOXIB 100 MG CAPSULE ORL CAP MTR CAP 0.127900002495473 M-CELECOXIB 200 MG CAPSULE ORL CAP MTR CAP 0.255800002481987 M-CINACALCET 30 MG TABLET ORL TAB MTR TAB 5.483700002481995 M-CINACALCET 60 MG TABLET ORL TAB MTR TAB 9.999000002482002 M-CINACALCET 90 MG TABLET ORL TAB MTR TAB 14.550300002479923 M-CLINDAMYCIN 150 MG CAPSULE ORL CAP MTR CAP 0.221700002479931 M-CLINDAMYCIN 300 MG CAPSULE ORL CAP MTR CAP 0.443400002502283 M-CLOPIDOGREL 75 MG TABLET ORL TAB MTR TAB 0.263100002437317 M-DOCUSATE SODIUM 100 MG CAPSULE ORL CAP MTR CAP 0.025000002467461 M-DONEPEZIL 10 MG TABLET ORL TAB MTR TAB 0.458600002467453 M-DONEPEZIL 5 MG TABLET ORL TAB MTR TAB 0.458600002473208 M-DULOXETINE 30 MG DELAYED-RELEASE CAPSULE ORL DRC MTR CAP 0.481300002473216 M-DULOXETINE 60 MG DELAYED-RELEASE CAPSULE ORL DRC MTR CAP 0.976900002379104 MED-ANASTROZOLE 1 MG TABLET ORL TAB GMP TAB 3.328000002399172 MED-ROSUVASTATIN 10 MG TABLET ORL TAB GMP TAB 0.135400002399180 MED-ROSUVASTATIN 20 MG TABLET ORL TAB GMP TAB 0.169200002399199 MED-ROSUVASTATIN 40 MG TABLET ORL TAB GMP TAB 0.199000002399164 MED-ROSUVASTATIN 5 MG TABLET ORL TAB GMP TAB 0.128400002253550 MEDROXY-2.5 2.5 MG TABLET ORL TAB PDL TAB 0.041600002253577 MEDROXY-5 5 MG TABLET ORL TAB PDL TAB 0.082300002428938 MED-SOLIFENACIN 10 MG TABLET ORL TAB GMP TAB 0.304100002428911 MED-SOLIFENACIN 5 MG TABLET ORL TAB GMP TAB 0.304100002244366 MEFLOQUINE 250 MG TABLET ORL TAB AAP TAB 3.695000002040891 MEGA-CAL CALCIUM W/ VITAMIN D 650 MG/200 UNIT CPT ORL TAB JAM TAB 0.102800002242594 MEGA-VIM CAPLET ORL TAB JAM TAB 0.189300002409623 MEKINIST 0.5 MG TABLET ORL TAB NOV TAB 76.984000002409658 MEKINIST 2 MG TABLET ORL TAB NOV TAB 307.938000080000847 MELATONIN 3 MG SUBLINGUAL TABLET ORL SLT WNP TAB 0.053000080015041 MELATONIN 3 MG TABLET ORL TAB JMS TAB 0.075000000999491 MELATONIN ORAL PRODUCTS MIS DEFAUL XXX MIS 0.208200080008343 MELATONIN SUBLINGUAL TABLET ORL SLT WNP TAB 0.079500080006449 MELATONIN TIMED RELEASED ORL TAB PLH TAB 0.085200002353156 MELOXICAM 15 MG TABLET ORL TAB SNS TAB 0.567000002353148 MELOXICAM 7.5 MG TABLET ORL TAB SNS TAB 0.491300002468921 MELPHALAN FOR INJECTION 50 MG/VIAL INJECTION INJ DEFAUL APX VIAL 379.490000002446049 MEMANTINE 10 MG TABLET ORL TAB SIV TAB 1.635700002443082 MEMANTINE 10 MG TABLET ORL TAB SNS TAB 1.635700002279924 MENACTRA A/C/Y/W-135 (0.5ML SINGLE-DOSE) INJECTION INJ DEFAUL SFP ML 210.600000002243820 MENJUGATE VACCINE (10 MCG/25 MCG) .5 ML INJECTION INJ DEFAUL NOV VIAL 89.000000002283093 MENOPUR 75 IU/VIAL INJECTION INJ DEFAUL FEI VIAL 84.0000

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 64 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002347393 MENVEO 0.5 ML INJECTION INJ DEFAUL NOV ML 214.420000002415275 MERCAPTOPURINE 50 MG TABLET ORL TAB STM TAB 2.861200002415224 MEROPENEM FOR INJECTION 1 G/VIAL INJECTION INJ DEFAUL FKC VIAL 47.990000002462893 MEROPENEM FOR INJECTION 1G/VIAL INJECTION INJ DEFAUL AUR VIAL 27.280000002415216 MEROPENEM FOR INJECTION 500 MG/VIAL INJECTION INJ DEFAUL FKC VIAL 21.590000002462885 MEROPENEM FOR INJECTION 500 MG/VIAL INJECTION INJ DEFAUL AUR VIAL 13.640000002047667 MERSYNDOL WITH CODEINE TABLET ORL TAB SAV TAB 0.217500002471418 M-ESCITALOPRAM 10 MG TABLET ORL TAB MTR TAB 1.468000002471426 M-ESCITALOPRAM 20 MG TABLET ORL TAB MTR TAB 1.562900002244931 MESNA 100 MG/ML INJECTION INJ DEFAUL FKC ML 10.796600002241615 METAMUCIL FIBRE APPLE CRISP 3.4 G/2 WAFERS ORL WAF PGI WAF 0.171700002241614 METAMUCIL FIBRE CINNAMON SPICE 3.4 G/2 WAFERS ORL WAF PGI WAF 0.212000002174812 METAMUCIL FIBRE THERAPY 3.4 G/TSP ORAL POWDER ORL PWR PGI G 0.026900002247034 METAMUCIL FIBRE THERAPY CAPSULE ORL CAP PGI CAP 0.1335

00002174782 METAMUCIL FIBRE THERAPY-SMOOTH TEXTURE-ORANGE S.F. ORL PWR PGI G 0.0750

00002174790METAMUCIL SMOOTH TEXTURE-ORANGE 3 G/TBSP ORAL PWDR ORL PWR PGI G 0.0172

00002174804 METAMUCIL SMOOTH UNFLAVORED SUGAR FREE POWDER ORL PWR PGI G 0.035000002242794 METFORMIN 500 MG TABLET ORL TAB MEL TAB 0.044400002464365 METHOTREXATE (PRESERVED) 25 MG/ML INJECTION BP INJ DEFALT AHI ML 3.120000002182971 METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION INJ DEFAUL PFI ML 7.875500002422174 METHOTREXATE 10 MG/0.4ML INJECTION SYRINGE BP INJ NDL PMS SYR 7.000000002417626 METHOTREXATE 25 MG/ML INJECTION (UNPRESERVED) INJ DEFAUL MYP ML 6.250000002327236 METHOTREXATE 25 MG/ML INJECTION BP (UNPRESERVED) INJ DEFAUL AHI ML 8.000000002422204 METHOTREXATE 25 MG/ML INJECTION SYRINGE BP INJ NDL PMS SYR 14.000000002422182 METHOTREXATE 25 MG/ML INJECTION SYRINGE BP INJ NDL PMS SYR 8.400000002422190 METHOTREXATE 25 MG/ML INJECTION SYRINGE BP INJ NDL PMS SYR 11.200000002422166 METHOTREXATE 7.5 MG/0.3 ML INJECTION SYRINGE BP INJ NDL PMS SYR 5.600000002182947 METHOTREXATE SODIUM (UNPRESERVED) 10 MG/ML INJ INJ DEFAUL PFI ML 9.8850

00002491311 METHOTREXATE SUBCUTANEOUS 15 MG/0.3 ML INJ SYRINGE INJ NDL AHI SYR 24.570000002491338 METHOTREXATE SUBCUTANEOUS 17.5 MG/0.35 ML INJ SYR INJ NDL AHI SYR 24.000000002491346 METHOTREXATE SUBCUTANEOUS 20 MG/0.4 ML INJ SYR INJ NDL AHI SYR 26.250000002491354 METHOTREXATE SUBCUTANEOUS 22.5 MG/0.45 ML INJ SYR INJ NDL AHI SYR 26.250000002491362 METHOTREXATE SUBCUTANEOUS 25 MG/0.5 ML INJ SYR INJ NDL AHI SYR 29.250000000868868 METHOXISAL CAPLET ORL TAB RPH TAB 0.277200080027283 METHYLCOBALAMIN 5 MG LOZENGE ORL LOZ AOR LOZ 0.524800002243563 METOCLOPRAMIDE OMEGA 5 MG/ML INJECTION INJ DEFAUL OMG ML 3.392700002320037 METOJECT 10 MG/1 ML INJECTION SYRINGE INJ NDL MDX SYR 29.6400

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002320045 METOJECT 15 MG/1.5 ML INJECTION SYRINGE INJ NDL MDX SYR 32.760000002304767 METOJECT 20 MG/2 ML INJECTION SYRINGE INJ NDL MDX SYR 59.800000002320053 METOJECT 25 MG/2.5 ML INJECTION SYRINGE INJ NDL MDX SYR 65.000000002320029 METOJECT 7.5 MG/0.75 ML INJECTION SYRINGE INJ NDL MDX SYR 28.080000002296713 METOPROLOL - 25 25 MG TABLET ORL TAB PDL TAB 0.064300002351404 METOPROLOL SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.187100002267853 METOPROLOL TARTRATE 1 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.416200000648027 METOPROLOL-100 MG TABLET ORL TAB PDL TAB 0.125000000648019 METOPROLOL-50 MG TABLET ORL TAB PDL TAB 0.062400002092832 METROGEL 0.75% TOPICAL GEL TOP GEL GAL G 3.430500002323273 METVIX 16.8% TOPICAL CREAM TOP CRM GAL G 197.750000002474026 MEZERA 1 G/ACT RECTAL FOAM RT FOA AVP DOSE 7.000000002467437 M-EZETIMIBE 10 MG TABLET ORL TAB MTR TAB 0.181100002085852 MICATIN 2% TOPICAL CREAM TOP CRM WSP G 0.297300002171775 MICONAZOLE 3 DAY OVULE TREATMENT VAG OVL VTH OVL 1.696600002091135 MICRO PLUS 4 REGULAR STRENGTH INJECTION INJ DEFAUL SDZ ML 0.909000002063905 MICROLAX MICRO RECTAL ENEMA RT ENM JJM ENM 1.500000000037605 MICRONOR 0.35 MG (28 DAY) TABLET ORL TB JAI TAB 0.953600000787000 MICRO-ZN 5 MG/ML INJECTION INJ DEFAUL SDZ ML 2.404200002460262 MICTORYL 30 MG CONTROLLED-DELIVERY CAPSULE ORL CDC DUI CAP 1.390000002460270 MICTORYL 45 MG CONTROLLED-DELIVERY CAPSULE ORL CDC DUI CAP 1.390000002240285 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.780000002423758 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL PFI ML 0.834000002242904 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL FKC ML 1.317000002382377 MIDAZOLAM 1 MG/ML INJECTION USP INJ DEFAUL PFI ML 0.582000002382342 MIDAZOLAM 1 MG/ML INJECTION USP INJ DEFAUL PFI ML 0.825000002423766 MIDAZOLAM 5 MG/ML INJECTION INJ DEFAUL PFI ML 4.170000002242905 MIDAZOLAM 5 MG/ML INJECTION INJ DEFAUL FKC ML 4.715000002382385 MIDAZOLAM 5 MG/ML INJECTION USP INJ DEFAUL PFI ML 2.524000002382350 MIDAZOLAM 5 MG/ML INJECTION USP INJ DEFAUL PFI ML 2.300000002382873 MIDAZOLAM INJECTION SDZ 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.780000002444038 MIFEGYMISO 200 MG/200 MCG TABLET ORL/BUC TAB LNP TAB 60.000000000999510 MILK THISTLE MIS DEFAUL XXX MIS 0.074800080000018 MILK THISTLE 150 MG TABLET ORL TAB JMS TAB 0.131900002244622 MILRINONE LACTATE 1 MG/ML INJECTION INJ DEFAUL FKC ML 5.906100001935348 MINERAL OIL (HEAVY) ORL LIQ RBW ML 0.013700000485802 MINERAL OIL 100% ORAL LIQUID ORL LIQ RPH ML 0.013600002246500 MINIRIN 0.1 MG TABLET ORL TAB FEI TAB 1.321600002042320 MIN-OVRAL (21 DAY) TABLET ORL TAB PFI TAB 0.814800002042339 MIN-OVRAL (28 DAY) TABLET ORL TB PFI TAB 0.6111

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 66 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002228319 MINOX 20MG/ML TOPICAL SOLUTION TOP SOL RIV ML 0.495600002480956 MINT-ABACAVIR 300 MG TABLET ORL TAB MPI TAB 5.920700002393573 MINT-ANASTROZOLE 1 MG TABLET ORL TAB MPI TAB 1.782000002491125 MINT-CETIRIZINE 20 MG TABLET ORL TAB MPI TAB 0.753500002423561 MINT-CIPROFLOX 500 MG TABLET ORL TAB MPI TAB 0.502500002465167 MINT-FENOFIBRATE E 145 MG TABLET ORL TAB MPI TAB 0.911300002380560 MINT-FLUOXETINE 10 MG CAPSULE ORL CAP MPI CAP 0.340400002380579 MINT-FLUOXETINE 20 MG CAPSULE ORL CAP MPI CAP 0.331100002425947 MINT-HYDROCHLOROTHIAZIDE 12.5 MG TABLET ORL TAB MPI TAB 0.032200002426196 MINT-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB MPI TAB 0.015700002426218 MINT-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB MPI TAB 0.021700002492334 MINT-IMATINIB 100 MG TABLET ORL TAB MPI TAB 20.455700002492342 MINT-IMATINIB 400 MG TABLET ORL TAB MPI TAB 81.822700002392992 MINT-IRBESARTAN/HCTZ 150/12.5 MG TABLET ORL TAB MPI TAB 0.228100002393018 MINT-IRBESARTAN/HCTZ 300/12.5 MG TABLET ORL TAB MPI TAB 0.228100002393026 MINT-IRBESARTAN/HCTZ 300/25 MG TABLET ORL TAB MPI TAB 0.218400002388774 MINT-METFORMIN 850 MG TABLET ORL TAB MPI TAB 0.033900002436981 MINT-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB MPI TAB 5.355300002437007 MINT-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB MPI TAB 7.597700002422727 MINT-OLOPATADINE 0.1% OPHTHALMIC SOLUTION OPH SOL MPI ML 5.226000002497441 MINT-OSELTAMIVIR 30 MG CAPSULE ORL CAP MPI CAP 1.573000002497476 MINT-OSELTAMIVIR 75 MG CAPSULE ORL CAP MPI CAP 3.118000002421372 MINT-PAROXETINE 10 MG TABLET ORL TAB MPI TAB 1.043000002326477 MINT-PIOGLITAZONE 15 MG TABLET ORL TAB MPI TAB 0.622500002326485 MINT-PIOGLITAZONE 30 MG TABLET ORL TAB MPI TAB 0.872100002326493 MINT-PIOGLITAZONE 45 MG TABLET ORL TAB MPI TAB 1.311300002421348 MINT-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB MPI CAP 0.855100002397811 MINT-ROSUVASTATIN 20 MG TABLET ORL TAB MPI TAB 0.169200002397838 MINT-ROSUVASTATIN 40 MG TABLET ORL TAB MPI TAB 0.199000002393085 MINT-SILDENAFIL 100 MG TABLET ORL TAB MPI TAB 9.200000002393077 MINT-SILDENAFIL 50 MG TABLET ORL TAB MPI TAB 8.847500002423308 MINT-TOLTERODINE 1 MG TABLET ORL TAB MPI TAB 0.491000002423316 MINT-TOLTERODINE 2 MG TABLET ORL TAB MPI TAB 0.491000002389800 MINT-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MPI TAB 0.626400000042544 MIOSTAT 0.01% OPH SOLUTION OPH SOL ALC ML 14.374400002297256 MIRAPEX 0.125 MG TABLET ORL TAB BOE TAB 1.159300002496682 MIRTAZAPINE 45 MG TABLET ORL TAB SIV TAB 1.125000002312786 MIRTAZAPINE-30 30 MG TABLET ORL TAB PDL TAB 0.195000002248846 MISOPROSTOL-200 200 MCG TABLET ORL TAB PDL TAB 0.438900002230451 MITOMYCIN 20 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 377.2000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002230450 MITOMYCIN 5 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 94.300000001948873 MIXED VESPID VENOM PROTEIN 1.1 MG VIAL INJ INJ DEFAUL ALK ML 71.383300001948881 MIXED VESPID VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 71.383300080025624 MK 20 A LIBERATION PROLONGEE 20 MEQ TABLET ORL TAB MTR TAB 0.199500080035346 MK 8 8 MEQ TABLET ORL TAB MTR TAB 0.225000002489805 M-LANSOPRAZOLE 15 MG DELAYED-RELEASE CAPSULE ORL DRC MTR CAP 0.362800002489813 M-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC MTR CAP 0.362700080082655 M-MAGNESIUM OXIDE 835 MG TABLET ORL TAB MTR TAB 0.057700002488183 M-MONTELUKAST 10 MG TABLET ORL TAB MTR TAB 0.423100002472791 M-MOXIFLOXACIN 400 MG TABLET ORL TAB MTR TAB 1.523000000466085 M-M-R II VIRUS VACCINE LIVE ATTENUATED INJECTION INJ DEFAUL MSD VIAL 34.326000000755575 MODECATE CONCENTRATE 100 MG/ML INJECTION INJ DEFAUL BMS ML 29.780000002238696 MOI-STIR SPRAY ORAL LIQUID ORL LIQ PMS ML 0.066600001909142 MOISTUREL TOPICAL CREAM TOP CRM WSD G 0.056700001909169 MOISTUREL TOPICAL LOTION TOP LOT WSD ML 0.020800000999058 MONA LISA 10 IUD COPPER STERILE DEFAUL DEFAUL BSN DEV 74.500000000999057 MONA LISA 5 IUD COPPER STERILE DEFAUL DEFAUL BSN DEV 63.000000002239601 MONISTAT 1 1200 MG VAGINAL OVULE VAG OVL MCL OVL 12.020000002244005 MONISTAT 3 4% VAGINAL CREAM VAG CRM MCL G 0.801300002126605 MONISTAT 3 400 MG VAGINAL OVULE VAG OVL MCL OVL 4.006700002126249 MONISTAT 3 DUAL-PAK KIT VAG/TOP OVL/CRM MCL KIT 13.760000002084309 MONISTAT 7 2% VAGINAL CREAM VAG CRM MCL G 0.343400002126257 MONISTAT 7 DUAL-PAK VAGINAL OVULE/TOPICAL CREAM VAG/TOP OVL/CRM MCL KIT 13.760000002126567 MONISTAT DERM 2% TOPICAL CREAM TOP CRM MCL G 0.393300002239600 MONISTAT-1 COMBINATION PACK VAG OVULE/TOP CREAM VAG/TOP OVL/CRM MCL KIT 13.760000002477777 MONOFERRIC 100 MG/ML INJECTION INJ DEFAUL PFI ML 45.000000002456230 MONOPROST 0.005% OPHTHALMIC SOLUTION OPH SOL LTH ML 3.423300000999332 MONOVISC DEFAUL DEV PMS ML 86.250000002379856 MONTELUKAST 10 MG TABLET ORL TAB PDL TAB 0.423100002379821 MONTELUKAST 4 MG CHEWABLE TABLET ORL CTB PDL TAB 0.946000002379848 MONTELUKAST 5 MG CHEWABLE TABLET ORL CTB PDL TAB 0.946000002021056 MORPHINE LP EPIDURAL 0.5 MG/ML INJECTION INJ DEFAUL SDZ ML 3.541500002350815 MORPHINE SR 15 MG SUSTAINED-RELEASE TABLET ORL SRT SNS TAB 0.231800002350890 MORPHINE SR 30 MG SUSTAINED-RELEASE TABLET ORL SRT SNS TAB 0.350000002474980 MORPHINE SULFATE 10 MG/ML INJECTION BP INJ DEFAUL STM ML 2.505000002242484 MORPHINE SULFATE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 2.736000002382997 MORPHINE SULFATE INJECTION SDZ 10 MG/ML INJ INJ DEFAUL SDZ ML 2.762000080028360 MOTION MEDICINE TOPICAL CREAM TOP CRM NDP G 0.121200002186934 MOTRIN IB 200 MG TABLET ORL TAB MCL TAB 0.125000002442167 MOVANTIK 12.5 MG TABLET ORL TAB KTI TAB 6.2800

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002442175 MOVANTIK 25 MG TABLET ORL TAB KTI TAB 6.280000002359499 MOVIPREP POWDER FOR ORAL LAVAGE SOLUTION ORL PWDPKT MFI PCKT 5.860000002462974 MOXIFLOXACIN 400 MG TABLET ORL TAB PDL TAB 1.523000002467402 M-PAROXETINE 10 MG TABLET ORL TAB MTR TAB 0.304600002467410 M-PAROXETINE 20 MG TABLET ORL TAB MTR TAB 0.325000002467429 M-PAROXETINE 30 MG TABLET ORL TAB MTR TAB 0.345300002482924 M-PERINDOPRIL ERBUMINE 2 MG TABLET ORL TAB MTR TAB 0.163200002482932 M-PERINDOPRIL ERBUMINE 4 MG TABLET ORL TAB MTR TAB 0.204200002482940 M-PERINDOPRIL ERBUMINE 8 MG TABLET ORL TAB MTR TAB 0.283000002476274 M-PRAVASTATIN 10 MG TABLET ORL TAB MTR TAB 0.291600002476282 M-PRAVASTATIN 20 MG TABLET ORL TAB MTR TAB 0.344000002476290 M-PRAVASTATIN 40 MG TABLET ORL TAB MTR TAB 0.414300002467321 M-PREGABALIN 150 MG CAPSULE ORL CAP MTR CAP 0.414500002467291 M-PREGABALIN 25 MG CAPSULE ORL CAP MTR CAP 0.148100002467305 M-PREGABALIN 50 MG CAPSULE ORL CAP MTR CAP 0.232400002467313 M-PREGABALIN 75 MG CAPSULE ORL CAP MTR CAP 0.300700002473534 M-RANITIDINE 150 MG TABLET ORL TAB MTR TAB 0.119700002473542 M-RANITIDINE 300 MG TABLET ORL TAB MTR TAB 0.225300002496542 M-ROSUVASTATIN 10 MG TABLET ORL TAB MTR TAB 0.135400002496550 M-ROSUVASTATIN 20 MG TABLET ORL TAB MTR TAB 0.169200002496569 M-ROSUVASTATIN 40 MG TABLET ORL TAB MTR TAB 0.199000002496534 M-ROSUVASTATIN 5 MG TABLET ORL TAB MTR TAB 0.128400002430037 M-SILDENAFIL 100 MG TABLET ORL TAB MTR TAB 9.200000080001844 MSM 1000 MG ORL TAB WNP TAB 0.068600002125013 MUCAINE ORAL SUSPENSION ORL SUS AXC ML 0.024300000599875 MUCILLIUM 500 MG/G ORAL POWDER ORL PWR PMS G 0.017800002434725 MUCINEX 600 MG EXTENDED RELEASE BI-LAYER TABLET ORL ERT RBI TAB 0.499500080043792 MUCOCLEAR 3% INHALATION SOLUTION INH SOL KGH ML 0.229300000999879 MUKO LUBRICATION JELLY TOP JEL XXX G 0.014600002330989 MULTAQ 400 MG TABLET ORL TAB SAV TAB 2.322000080050211 MULTI COMPLETE DYE FREE MULTIVITAMINS ORL TAB WNP TAB 0.055600000782203 MULTI VITAMIN PLUS IRON TABLET ORL TAB VTH TAB 0.060000000782211 MULTI VITAMIN TABLET ORL TAB VTH TAB 0.027000000586315 MULTI-1000 INJECTION INJ DEFAUL SDZ ML 1.776300002100606 MULTI-12 INJECTION INJ DEFAUL SDZ ML 2.369000080011567 MULTICOMPLETE WITH LUTEIN TABLET ORL TAB PMT TAB 0.037100002244898 MULTIPLE VITAMIN TABLET ORL TAB PMT TAB 0.070000000374083 MULTIPLE VITAMIN WITH MINERAL TABLET ORL TAB ADA TAB 0.110000080033047 MULTISURE FOR MEN 50+ CAPSULE ORL CAP WNP CAP 0.141700002248775 MULTISURE FOR WOMEN ORL CAP WNP CAP 0.0850

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 69 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002248778 MULTISURE FOR WOMEN OVER 50 GELATIN CAPSULE ORL CAP WBP CAP 0.085000002240942 MULTI-TAR PLUS REGULAR TOPICAL SHAMPOO TOP SHP VCL ML 0.038100000999047 MULTIVISK DEFAUL DEV XXX ML 55.000000080001714 MULTIVITAMIN AND MINERAL SUPPLEMENT GUMMIES ORL CTB VTH TAB 0.060300080005483 MULTI-VITAMIN TABLET ORL TAB WNP TAB 0.035100000999522 MULTIVITAMIN WITH MINERALS AND MISC. INGREDIENTS MIS DEFAUL XXX MIS 0.2648

00002242779 MULTIVITAMINS & MULTIMINERALS FORMULA FORTE SR.TAB ORL TAB PMT TAB 0.080000002242939 MULTIVITAMINS + MULTIMINERALS 50+ FORMULA TAB. ORL TAB PMT TAB 0.066500002242780 MULTIVITAMINS AND MULTIMINERALS FORMULA FORTE TAB ORL TAB PMT TAB 0.067800002244864 MULTIVITAMINS FOR ADULTS TABLET ORL TAB PMT TAB 0.030000002247538 MURINE TEARS OPHTHALMIC SOLUTION OPH SOL PBI ML 0.203300000750816 MURO-128 5% OPH OINTMENT OPH ONT BSH G 2.948600000750824 MURO-128 5% OPH SOLUTION OPH SOL BSH ML 0.688000002238595 MUSE 1000 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 55.830000002238593 MUSE 250 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 55.830000002238594 MUSE 500 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 55.830000002470756 MVASI 25 MG/ML (16 ML VIAL) INJECTION INJ DEFAUL AMG ML 96.485600002470748 MVASI 25 MG/ML (4 ML VIAL) INJECTION INJ DEFAUL AMG ML 96.485000002471302 M-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE ORL ERC MTR CAP 0.1927

00002471280 M-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE ORL ERC MTR CAP 0.091300002471299 M-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC MTR CAP 0.182500002415380 MYA 28 TABLET ORL TB APX TAB 0.501400002311054 MYCAMINE 100 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 196.000000002294222 MYCAMINE 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 98.000000002457369 MYCOPHENOLATE MOFETIL 250 MG CAPSULE ORL CAP SNS CAP 1.031000002457377 MYCOPHENOLATE MOFETIL 500 MG TABLET ORL TAB SNS TAB 2.062000002378574 MYCOPHENOLATE MOFETIL 500 MG TABLET ORL TAB AHI TAB 2.062000002479974 MYCOPHENOLATE MOFETIL 500 MG/VIAL INJ PWD FOR SOL INJ DEFAUL STM VIAL 30.512500000000981 MYDRIACYL 0.5% OPH SOLUTION OPH SOL ALC ML 1.067300000001007 MYDRIACYL 1% OPH SOLUTION OPH SOL ALC ML 1.374000002264560 MYFORTIC 180 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 1.997700002264579 MYFORTIC 360 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 3.995300002450682 MYLAN-ABACAVIR/LAMIVUDINE 600 MG/300 MG TABLET ORL TAB MYP TAB 20.357300002456877 MYLAN-ATAZANAVIR 150 MG CAPSULE ORL CAP MYP CAP 5.677200002456885 MYLAN-ATAZANAVIR 200 MG CAPSULE ORL CAP MYP CAP 5.710300002456893 MYLAN-ATAZANAVIR 300 MG CAPSULE ORL CAP MYP CAP 11.216700002402165 MYLAN-ATOVAQUONE/PROGUANIL 250 MG/ 100 MG TABLET ORL TAB MYP TAB 4.1308

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002241003 MYLAN-BUDESONIDE AQ 64 MCG/DOSE MET DOSE NAS SPRAY NAS SPM MYP DOSE 0.084300002434539 MYLAN-CINACALCET 30 MG TABLET ORL TAB MYP TAB 10.194700002434547 MYLAN-CINACALCET 60 MG TABLET ORL TAB MYP TAB 18.590000002434555 MYLAN-CINACALCET 90 MG TABLET ORL TAB MYP TAB 27.051700002381524 MYLAN-EFAVIRENZ 600 MG TABLET ORL TAB MYP TAB 11.210300002461412 MYLAN-EFAVIRENZ/EMTRICITABINE/TENOFOVIR TABLET ORL TAB MYP TAB 22.660000002300052 MYLAN-ENALAPRIL 10 MG TABLET ORL TAB MYP TAB 0.264700002300036 MYLAN-ENALAPRIL 2.5 MG TABLET ORL TAB MYP TAB 0.186300002300060 MYLAN-ENALAPRIL 20 MG TABLET ORL TAB MYP TAB 0.319500002300044 MYLAN-ENALAPRIL 5 MG TABLET ORL TAB MYP TAB 0.220300002383039 MYLAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 1.869000002383047 MYLAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC MYP TAB 1.869000002242920 MYLAN-HYDROXYUREA 500 MG CAPSULE ORL CAP MYP CAP 1.0203

00002458608 MYLAN-NAPROXEN/ESOMEPRAZOLE MR 375 MG/20 MG TABLET ORL TAB MYP TAB 0.9308

00002443449 MYLAN-NAPROXEN/ESOMEPRAZOLE MR 500 MG/20 MG TABLET ORL TAB MYP TAB 0.927300002387727 MYLAN-NEVIRAPINE 200 MG TABLET ORL TAB MYP TAB 1.728500002423421 MYLAN-RIVASTIGMINE PATCH 10 (9.5 MG/24 H) TRD PTH MYP PTH 3.977300002423413 MYLAN-RIVASTIGMINE PATCH 5 (4.6 MG/24 H) TRD PTH MYP PTH 3.977300002268906 MYLAN-SUMATRIPTAN 25 MG TABLET ORL TAB MYP TAB 3.055000002410656 MYLAN-TADALAFIL 10 MG TABLET ORL TAB MYP TAB 11.925000002410621 MYLAN-TADALAFIL 2.5 MG TABLET ORL TAB MYP TAB 3.647100002410664 MYLAN-TADALAFIL 20 MG TABLET ORL TAB MYP TAB 12.357500002410648 MYLAN-TADALAFIL 5 MG TABLET ORL TAB MYP TAB 3.647100002464225 MYLAN-VARDENAFIL 10 MG TABLET ORL TAB MYP TAB 10.397500002464233 MYLAN-VARDENAFIL 20 MG TABLET ORL TAB MYP TAB 11.680000002464209 MYLAN-VARDENAFIL 5 MG TABLET ORL TAB MYP TAB 9.320000000004618 MYLERAN 2 MG TABLET ORL TAB APC TAB 1.760000002479419 MYL-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 1.869000002479427 MYL-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC MYP TAB 1.869000002494388 MYLOTARG 4.5 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 20000.000000002226022 MYOFLEX EXTRA STRENGTH 15% CREAM TOP CRM BIC G 0.064000002284863 MYOZYME 50 MG/VIAL INJECTION INJ DEFAUL GZM VIAL 840.310000002482800 M-ZOPICLONE 3.75 MG TABLET ORL TAB MTR TAB 0.234300002467941 M-ZOPICLONE 5 MG TABLET ORL TAB MTR TAB 0.223100002467968 M-ZOPICLONE 7.5 MG TABLET ORL TAB MTR TAB 0.468500002412683 NAGLAZYME 1 MG/ML INJECTION INJ DEFAUL BMI ML 307.000000002455935 NALOXONE HCL 0.4 MG/ML INJECTION INJ DEFAUL OMG ML 15.0000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002382601 NALOXONE HYDROCHLORIDE (PRES. FREE) 0.4 MG/ML INJ INJ DEFAUL SDZ ML 13.745000002382482 NALOXONE HYDROCHLORIDE 0.4 MG/ML INJ USP INJ DEFAUL TGT ML 13.745000002148714 NALOXONE HYDROCHLORIDE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 20.147500002393034 NALOXONE HYDROCHLORIDE INJECTION 0.4 MG/ML INJ INJ DEFAUL OMG ML 13.750000000999579 NANOVM T/F ORAL POWDER ORL PWR SNU G 0.239200000481408 NAPHCON-A OPH SOLUTION OPH SOL ALC ML 0.474700000618721 NAPROXEN 500 MG TABLET ORL TAB PDL TAB 0.211000002362430 NAPROXEN 220 MG TABLET ORL TAB PMS TAB 0.069600000590762 NAPROXEN 250 MG TABLET ORL TAB PDL TAB 0.106800000655686 NAPROXEN-375 375 MG TABLET ORL TAB PDL TAB 0.145800000887056 NAPROXEN-NA 275 MG TABLET ORL TAB PDL TAB 0.342200002153386 NAPROXEN-NA DF 550 MG TABLET ORL TAB PDL TAB 0.666700002458187 NARCAN 4 MG/0.1 ML NASAL SPRAY NAS SPM ADP DOSE 72.500000002229415 NAROPIN 5 MG/ML INJECTION INJ DEFAUL APC ML 0.480000002213834 NASACORT AQ 55 MCG NASAL METERED DOSE SPRAY NAS SPM SAV DOSE 0.170000002192799 NASAL + SINUS DECONGESTANT RELIEF 60 MG TABLET ORL TAB VTH TAB 0.124200000788503 NASAL DECONGESTANT SPRAY 0.1% NAS LIQ CNF ML 0.092000002494132 NAT-ABIRATERONE 250 MG TABLET ORL TAB NTP TAB 26.031200002417855 NAT-ANASTROZOLE 1 MG TABLET ORL TAB NTP TAB 2.546000002467992 NAT-BOSENTAN 125 MG TABLET ORL TAB NTP TAB 16.044700002467984 NAT-BOSENTAN 62.5 MG TABLET ORL TAB NTP TAB 16.044700002496461 NAT-CETIRIZINE 10 MG TABLET ORL TAB NTP TAB 0.408300002496488 NAT-CETIRIZINE 20 MG TABLET ORL TAB NTP TAB 0.753500002483920 NAT-ERLOTINIB 100 MG TABLET ORL TAB NTP TAB 47.466700002483939 NAT-ERLOTINIB 150 MG TABLET ORL TAB NTP TAB 71.200000002483912 NAT-ERLOTINIB 25 MG TABLET ORL TAB NTP TAB 6.923000002450550 NATESTO (11 G/PUMP) 4.5% NASAL GEL NAS GEL ACE G 6.152700002491796 NAT-GEFITINIB 250 MG TABLET ORL TAB NTP TAB 62.305000002397285 NAT-IMATINIB 100 MG TABLET ORL TAB NTP TAB 20.455700002397293 NAT-IMATINIB 400 MG TABLET ORL TAB NTP TAB 81.822700002498774 NAT-LANTHANUM 1000 MG CHEWABLE TABLET ORL CTB NAT TAB 4.081600002498731 NAT-LANTHANUM 250 MG CHEWABLE TABLET ORL CTB NTP TAB 1.022800002498758 NAT-LANTHANUM 500 MG CHEWABLE TABLET ORL CTB NAT TAB 2.045800002498766 NAT-LANTHANUM 750 MG CHEWABLE TABLET ORL CTB NAT TAB 3.078600002421585 NAT-LETROZOLE 2.5 MG TABLET ORL TAB NTP TAB 2.756000002472635 NAT-OSELTAMIVIR 30 MG CAPSULE ORL CAP NTP CAP 1.573000002472643 NAT-OSELTAMIVIR 45 MG CAPSULE ORL CAP NTP CAP 2.420000002499894 NAT-OSELTAMIVIR 6 MG/ML ORAL SUSPENSION ORL SUS NTP ML 0.281100002457989 NAT-OSELTAMIVIR 75 MG CAPSULE ORL CAP NTP CAP 3.118000080013188 NATURAL CALM MAGNESIUM ORAL POWDER ORL PWR NCC G 0.0948

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 72 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246575 NATURAL SOURCE FIBRE LAXATIVE ORAL POWDER ORL PWR DNS G 0.016800080024078 NATURE'S BOUNTY MAGNESIUM OXIDE 500 MG TABLET ORL TAB VTH TAB 0.059000080029758 NEBUSAL 7% INHALATION SOLUTION MIS DEFAUL STM ML 0.243100080027142 NEILMED NASAL SINUS RINSE NAS PWS NPI PCKT 0.250000002245057 NEISVAC-C 10 MCG/20 MCG INJECTION SYRINGE INJ NDL PFI SYR 80.185000000147680 NEO-BEX (LIDOCAINE HCL) INJECTION VIAL INJ DEFAUL BRO ML 5.585000000999808 NEOCATE NUTRA ORAL POWDER ORL PWR NUN G 0.111300002230593 NEOSTIGMINE OMEGA 0.5 MG/ML INJECTION INJ DEFAUL OMG ML 1.000000002230592 NEOSTIGMINE OMEGA 1 MG/ML INJECTION INJ DEFAUL OMG ML 1.110000001958690 NEOSTRATA HQ 2% GEL TOP GEL CDX G 0.766700000999459 NEOVISC DEFAUL DEV STL ML 49.928300000999049 NEOVISC ONE DEFAUL DEV FID ML 88.750000000999048 NEOVISC PLUS DEFAUL DEV FID ML 59.166700000999849 NEPHEA KID POWDER ORL PWR MXD G 0.130000002490536 NERLYNX 40 MG TABLET ORL TAB KTI TAB 45.000000080007796 NERVOHEEL N TABLET ORL TAB HEE TAB 0.285800002417197 NESINA 12.5 MG TABLET ORL TAB TAK TAB 2.200000002417200 NESINA 25 MG TABLET ORL TAB TAK TAB 2.200000002417189 NESINA 6.25 MG TABLET ORL TAB TAK TAB 2.200000000999448 NESTLE BREAKFAST ANYTIME ORAL LIQUID ORL LIQ NHN ML 0.0048

00000999799 NESTLE GOOD START 1 GOS OMEGA 3+6 INF FORMULA PWD ORL PWR NIN G 0.0468

00000999801 NESTLE GOOD START 1 GOS OMEGA 3+6 LIQ CONCENTRATE ORL LIQ NIN ML 0.011400000999802 NESTLE GOOD START 1 INFANT FORMULA POWDER ORL PWR NIN G 0.0290

00000999804 NESTLE GOOD START 1 LIQ CONCENTRATE INFANT FORMULA ORL LIQ NIN ML 0.0087

00000999798 NESTLE GOOD START 1 PROBIOTIC DHA & ARA INFANT PWR ORL PWR NIN G 0.050000000999803 NESTLE GOOD START 1 READY-TO-FEED TETRA LIQUID ORL LIQ NIN ML 0.012000000999806 NESTLE GOOD START 2 ALSOY OMEGA 3+6 INF FORM PWR ORL PWR NIN G 0.0400

00000999805 NESTLE GOOD START ALSOY OMEGA 3+6 INF FORM POWDER ORL PWR NIN G 0.040000080081007 NESTLE MATERNA PRENATAL DHA CAPSULE ORL CAP NES CAP 0.178500002249790 NEULASTA 6 MG/0.6 ML INJECTION SYRINGE INJ NDL AMG SYR 2555.060000001968017 NEUPOGEN 0.3 MG/ML INJECTION INJ DEFAUL AMG ML 176.133000002420104 NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE INJ NDL AMG SYR 176.133000002420112 NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE INJ NDL AMG SYR 281.812000002403897 NEUPRO 1 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 3.540000002403919 NEUPRO 3 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 6.5000

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 73 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002239717 NEURONTIN 600 MG TABLET ORL TAB UJC TAB 2.034900002239718 NEURONTIN 800 MG TABLET ORL TAB UJC TAB 2.715900001922017 NEUTRAGEL 0.5% SODIUM FLUORIDE GEL DEN GEL GER ML 0.0700

00080006269 NEUTROGENA BODY CLEAR BODY WASH PINK GRAPEFRUIT TOP GEL JJI ML 0.027200002240645 NEUTROGENA T/GEL THERAPEUTIC SHAMPOO TOP SHP JJI ML 0.045200002308983 NEVANAC 0.1% OPHTHALMIC SUSPENSION OPH SUS NOV ML 4.138000080039670 NEW NORDIC HAIR VOLUME TABLET ORL TAB NNO TAB 0.756700002284227 NEXAVAR 200 MG TABLET ORL TAB BAI TAB 46.008800002300524 NEXIUM 10 MG/DOSE DEL REL GRANULES FOR ORAL SUSP ORL DRGRNUL AZC PCKT 2.379300002244521 NEXIUM 20 MG DELAYED-RELEASE TABLET ORL DRT AZC TAB 2.377900002444712 NEXIUM 24HR 20 MG DELAYED-RELEASE CAPSULE ORL DRC PDH CAP 0.709300002244522 NEXIUM 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC AZC TAB 2.380600002499509 NEXPLANON 68 MG SUBDERMAL IMPLANT SUBDERM IMP MFC IMP 285.000000000232459 NIACIN 100 MG TABLET ORL TAB ADA TAB 0.083000000309737 NIACIN 500 MG TABLET ORL TAB JAM TAB 0.067500002242138 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB QVS TAB 0.127700002244702 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB JAM TAB 0.196200000557412 NIACIN YEAST FREE 500 MG TABLET ORL TAB VTH TAB 0.022800002247347 NICORETTE MINI LOZENGE 2 MG ORL LOZ MCL LOZ 0.471400002247348 NICORETTE MINI LOZENGE 4 MG ORL LOZ MCL LOZ 0.471400080007461 NICOTINE LOZENGES; THRIVE LOZENGES 1 MG ORL LOZ NOV LOZ 0.254200080007464 NICOTINE LOZENGES; THRIVE LOZENGES 2 MG ORL LOZ NOV LOZ 0.288900080000117 NICOTINE POLACRILEX; NIC-ASSIST 2 MG GUM ORL GUM PRI PIECE 0.210400080000118 NICOTINE POLACRILEX; NIC-ASSIST 4 MG GUM ORL GUM PCO PIECE 0.253900080000396 NICOTINELL; THRIVE 2 MG ORAL GUM ORL GUM NOV PIECE 0.254200080000402 NICOTINELL; THRIVE 4 MG ORAL GUM ORL GUM NVC PIECE 0.288900002125226 NIDAGEL 0.75% VAGINAL GEL VAG GEL VCL G 0.310700002421631 NIFEDIPINE 30 MG EXTENDED RELEASE TABLET ORL ERT PDL TAB 0.617100002421658 NIFEDIPINE 60 MG EXTENDED RELEASE TABLET ORL ERT PDL TAB 0.937400002402904 NIMENRIX A/C/W-135/Y (0.5 ML SINGLE-DOSE) INJ INJ DEFAUL PFI VIAL 99.480000002325926 NIMOTOP 30 MG TABLET ORL TAB BAI TAB 10.300600002456796 NINLARO 2.3 MG CAPSULE ORL CAP TAK CAP 3068.413300002456818 NINLARO 3 MG CAPSULE ORL CAP TAK CAP 3068.413300002456826 NINLARO 4 MG CAPSULE ORL CAP TAK CAP 3068.413300099400932 NIPPLE SHIELDS DEFAUL DEFAUL XXX MIS 15.000000001926454 NITROL 2% TOPICAL OINTMENT TOP ONT PAL G 0.694800002182920 NIZORAL 2% TOPICAL SHAMPOO TOP SHP MCL ML 0.115200002397927 NOCDURNA 25 MCG SL ORAL DISINTEGRATING TABLET SLG DISNTAB FEI TAB 1.320000002431076 NOCDURNA 50 MCG SL ORAL DISINTEGRATING TABLET SLG DISNTAB FEI TAB 1.3200

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002048485 NOLVADEX-D 20 MG (BASE) TABLET ORL TAB AZC TAB 0.386700080016396 NON-FLUSH/FLUSH FREE NIACIN CAPSULE ORL CAP PLH CAP 0.156000080008766 NORDIC NATURALS ARCTIC COD LIVER OIL ORL LIQ NRD ML 0.110500080007895 NORDIC NATURALS ARCTIC COD LIVER OIL LIQUID ORL LIQ NRD ML 0.082700080002913 NORDIC NATURALS OMEGA-3 LIQUID ORL LIQ NRD ML 0.082700002334860 NORDITROPIN NORDIFLEX 10 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 389.400000002334879 NORDITROPIN NORDIFLEX 15 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 584.100000002334852 NORDITROPIN NORDIFLEX 5 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 194.700000000023760 NORLUTATE 5 MG TABLET ORL TAB PFI TAB 1.700000002357593 NORVIR 100 MG FILM-COATED TABLET ORL TAB ABV TAB 1.533700002049481 NOVAHISTEX DH ADULT ORAL LIQUID ORL LIQ SAV ML 0.186400000021458 NOVOFERROGLUC 300 MG TABLET ORL TAB TEV TAB 0.025400080000435 NOVO-FERROGLUC 300 MG TABLET ORL TAB XXX TAB 0.036000000595829 NOVO-FIBER 469 MG TABLET ORL TAB TEV TAB 0.097900080042720 NOVO-FIBRE 469 MG TABLET ORL TAB TEV TAB 0.097900000389218 NOVO-GESIC 325 MG TABLET ORL TAB TEV TAB 0.032600002108151 NOVO-MINOCYCLINE 100 MG CAPSULE ORL CAP TEV CAP 0.212500002265435 NOVOMIX 30 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 3.742700080041987 NOW GABA 750 MG VEGGIE CAPS CAPSULE ORL CAP NWF CAP 0.249500002322854 NPLATE 250 MCG/0.5 ML VIAL INJECTION INJ DEFAUL AMG VIAL 1021.790000002322862 NPLATE 500 MCG/1 ML VIAL INJECTION INJ DEFAUL AMG VIAL 2043.600000002477637 NRA-CITALOPRAM 10 MG TABLET ORL TAB NRA TAB 0.071500002477645 NRA-CITALOPRAM 20 MG TABLET ORL TAB NRA TAB 0.133300002477653 NRA-CITALOPRAM 40 MG TABLET ORL TAB NRA TAB 0.133300002479753 NRA-PAROXETINE 10 MG TABLET ORL TAB NRA TAB 1.043000002479168 NRA-PREGABALIN 150 MG CAPSULE ORL CAP NRA CAP 0.414500002479117 NRA-PREGABALIN 25 MG CAPSULE ORL CAP NRA CAP 0.148100002479125 NRA-PREGABALIN 50 MG CAPSULE ORL CAP NRA CAP 0.232400002479133 NRA-PREGABALIN 75 MG CAPSULE ORL CAP NRA CAP 0.300700002486237 NRA-QUETIAPINE 25 MG TABLET ORL TAB NRA TAB 0.049400002486199 NRA-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB NRA CAP 0.103400002486172 NRA-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB NRA CAP 0.081700002486180 NRA-RAMIPRIL 5 MG CAPSULE ORL CAP/TAB NRA CAP 0.081700002489384 NRA-RIZATRIPTAN ODT 10 MG ORAL DISINT. TABLET ORL DISNTAB NRA TAB 3.705000002477491 NRA-ROSUVASTATIN 10 MG TABLET ORL TAB NRA TAB 0.135400002477505 NRA-ROSUVASTATIN 20 MG TABLET ORL TAB NRA TAB 0.169200002477483 NRA-ROSUVASTATIN 5 MG TABLET ORL TAB NRA TAB 0.128400002488450 NRA-SERTRALINE 100 MG CAPSULE ORL CAP NRA CAP 0.330300002488434 NRA-SERTRALINE 25 MG CAPSULE ORL CAP NRA CAP 0.151600002488442 NRA-SERTRALINE 50 MG CAPSULE ORL CAP NRA CAP 0.3032

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002476819 NRA-SILDENAFIL 100 MG TABLET ORL TAB NRA TAB 9.200600002477378 NRA-ZOPICLONE 5 MG TABLET ORL TAB NRA TAB 0.234300002477386 NRA-ZOPICLONE 7.5 MG TABLET ORL TAB NRA TAB 0.468500001913980 NUBAIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 17.825000002496348 NUBEQA 300 MG TABLET ORL TAB BAI TAB 28.344000000618098 NU-CAL 500 MG TABLET ORL TAB ODN TAB 0.029000002415585 NUCYNTA 100 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 1.606800002415593 NUCYNTA 150 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 2.150500002415607 NUCYNTA 200 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 2.787800002415615 NUCYNTA 250 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 3.860700002415577 NUCYNTA 50 MG EXTENDED-RELEASE TABLET ORL ERT ENV TAB 1.071700002378299 NUCYNTA IR 100 MG TABLET ORL TAB ENV TAB 1.589100002378272 NUCYNTA IR 50 MG TABLET ORL TAB ENV TAB 1.060600002378280 NUCYNTA IR 75 MG TABLET ORL TAB ENV TAB 1.324600000623385 NUPERCAINAL ANESTHETIC 1% RECTAL OINTMENT RT ONT NVC G 0.140700000999817 NUTRAMIGEN A+ WITH LGG ORAL POWDER ORL PWR MJO G 0.044600080023758 NUTRASEA + D ORAL LIQUID ORL LIQ NWC ML 0.095000080022697 NUTRASEA KIDS ORAL LIQUID ORL LIQ NWC ML 0.074200002376393 NUTROPIN AQ NUSPIN 10 10 MG/2ML PEN CARTRIDGE INJ CTG HLR ML 203.710000002399083 NUTROPIN AQ NUSPIN 20 20 MG/2 ML SOLUTION INJ DEFAUL HLR ML 407.420000002399091 NUTROPIN AQ NUSPIN 5 5 MG/2 ML SOLUTION INJ DEFAUL HLR ML 101.855000002253186 NUVARING 11.4 MG/2.6 MG SLOW-RELEASE VAGINAL RING VAG SDE MFC RING 16.230000000716901 NYADERM 25,000 U/G VAGINAL CREAM VAG CRM TAR G 0.136900000999571 NYSTATIN USP POWDER TOP PWR XXX G 0.232300000999812 OASIS NUTRISOLUTION ORAL LIQUID ORL LIQ OAS ML 0.0057

00002239742 OBUSFORME EXTRA STRENGTH (W ACETAMINOPHEN) CAPLET ORL TAB WAM TAB 0.3611

00002237577 OBUSFORME METHOCARBAMOL & ACETAMINOPHEN CAPLET ORL TAB WAM TAB 0.330600000687766 O-CALCIUM 250 MG AND VITAMIN D TABLET ORL TAB WTR TAB 0.062000000622443 O-CALCIUM 500 MG (BASE) TABLET ORL TAB VTH TAB 0.025700000754951 OCCLUSAL-HP 26% TOPICAL SOLUTION TOP SOL GEU ML 0.895000002024179 OCTOSTIM 15 MCG INJECTION INJ DEFAUL FEI ML 36.288000002237860 OCTOSTIM 150 MCG/DOSE NASAL SPRAY NAS SPM FEI DOSE 16.046400002299445 OCTREOTIDE 200 MCG/ML INJECTION INJ DEFAUL TEV ML 15.584000002299453 OCTREOTIDE 500 MCG/ML INJECTION INJ DEFAUL TEV ML 38.072000000999870 OCUNOX EYE OINTMENT OPH ONT CNV G 2.206000080038562 OCUVITE ADULT 50+ ORL CAP BSH CAP 0.251800002490706 ODAN CLOBETASOL 0.05% TOPICAL SPRAY TOP SPR ODN ML 1.925900080053047 ODAN POLYSACCHARIDE IRON COMPLEX 150 150 MG CAP ORL CAP ODN CAP 0.3900

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000641324 ODAN-ERYTHROMYCIN 5 MG/G OPHTHALMIC OINTMENT OPH ONT ODN G 3.7100

00002495872 ODAN-METHADONE (CHERRY FLAVOUR) 10 MG/ML ORAL SOL ORL LIQ ODN ML 0.112500002495880 ODAN-METHADONE (UNFLAVOURED) 10 MG/ML ORAL SOL ORL LIQ ODN ML 0.112500000358495 ODANS LIQUOR CARBONIS DETERGENS TOP LIQ ODN ML 0.089000080046696 ODAN-SODIUM CHLORIDE 5% OPHTHALMIC OINTMENT OPH ONT ODN G 2.568600080046737 ODAN-SODIUM CHLORIDE 5% OPHTHALMIC SOLUTION OPH SOL ODN ML 0.5993

00002473968 ODAN-SODIUM POLYSTYRENE SULFONATE 250 MG/ML SUSP ORL/RT SUS ODN ML 0.119300002473941 ODAN-SODIUM POLYSTYRENE SULFONATE ORAL POWDER ORL PWR ODN G 0.157300002461463 ODEFSEY TABLET ORL TAB GIL TAB 42.367000002474425 OGIVRI 150 MG/VIAL INJECTION INJ DEFAUL BGP VIAL 506.150000002474433 OGIVRI 440 MG/VIAL INJECTION INJ DEFAUL BGP VIAL 1417.210000002311992 OLANZAPINE 10 MG TABLET ORL TAB PDL TAB 1.275800002312018 OLANZAPINE 15 MG TABLET ORL TAB PDL TAB 1.913600002311968 OLANZAPINE 2.5 MG TABLET ORL TAB PDL TAB 0.177200002421704 OLANZAPINE 20 MG TABLET ORL TAB PDL TAB 5.937700002311976 OLANZAPINE 5 MG TABLET ORL TAB PDL TAB 0.637900002311984 OLANZAPINE 7.5 MG TABLET ORL TAB PDL TAB 0.956800002416522 OLANZAPINE FOR INJECTION 10MG/VIAL INJ INJ DEFAUL SDZ VIAL 25.280000002352982 OLANZAPINE ODT 10 MG ORAL DISINT. TABLET ORL DISNTAB SNS TAB 0.714300002338653 OLANZAPINE ODT 10 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PDL TAB 1.285700002343681 OLANZAPINE ODT 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB SIV TAB 5.355300002352990 OLANZAPINE ODT 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB SNS TAB 5.355300002338661 OLANZAPINE ODT 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PDL TAB 2.677700002343703 OLANZAPINE ODT 20 MG ORAL DISINTEGRATING TABLET ORL DISNTAB SIV TAB 7.597700002425114 OLANZAPINE ODT 20 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PDL TAB 5.937700002352974 OLANZAPINE ODT 5 MG ORAL DISINT. TABLET ORL DISNTAB SNS TAB 0.357300002338645 OLANZAPINE ODT 5 MG ORAL DISINTEGRATING TABLET ORL DISNTAB PDL TAB 0.643400002365677 OLEX 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT PPH TAB 0.663600002488744 OLMESARTAN 20 MG TABLET ORL TAB PDL TAB 0.276300002488752 OLMESARTAN 40 MG TABLET ORL TAB PDL TAB 0.276300002480018 OLUMIANT 2 MG TABLET ORL TAB LIL TAB 49.804000002344408 OLUX-E 0.05% TOPICAL FOAM TOP FOA GSK G 1.444900002239144 OMBRELLE ECRAN SPF 60 TOPICAL CREAM TOP CRM COS G 0.099100002241277 OMBRELLE EXTREME SPF 30 TOPICAL LOTION TOP LOT COS ML 0.087500002303639 OMBRELLE SPF 60 TOPICAL LOTION TOP LOT OMB ML 0.104900002239016 OMBRELLE VAPO SPORT SPF 15 TOPICAL LOTION TOP LOT COS ML 0.086800080008273 OMEGA 3 CAPSULE ORL CAP WNP CAP 0.258700000999496 OMEGA 3 CAPSULE ORL CAP XXX CAP 0.2794

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080003480 OMEGA 3 CAPSULE ORL CAP PMT CAP 0.099000080044844 OMEGA 3 KRILL OIL 500 MG CAPSULE ORL CAP JMS CAP 0.308300080015284 OMEGA 3 LIQUID ORL LIQ WNP ML 0.026100080002435 OMEGA 3 PREMIUM FISH OIL 1000 MG CAPSULE ORL CAP WNP CAP 0.048700080002596 OMEGA 3 SELECT CAPSULE ORL CAP JAM CAP 0.113300080019234 OMEGA 3 TRIPLE STRENGTH 900 MG SOFTGEL ORL CAP WBP CAP 0.164400002240743 OMEGA 3-6-9 CAPSULE ORL CAP JAM CAP 0.164700080000884 OMEGA 3-6-9 CAPSULE ORL CAP JMS CAP 0.160800002247756 OMEGA ALLERG EXTRACT NON-POLLEN AQ 40000 IU/ML INJ INJ DEFAUL OMG ML 265.000000002247755 OMEGA ALLERG. EXTRAC POLLEN SUSPAL 40000 IU/ML INJ INJ DEFAUL OMG ML 265.000000002247754 OMEGA ALLERGENIC EXTRACTS - POLLENS 40000 U/ML INJ INJ DEFAUL OMG ML 49.000000002247757 OMEGA ALLERGENIC EXTS - NON-POLLENS 40000 U/ML INJ INJ DEFAUL OMG ML 49.000000080003127 OMEGA-3 ELITE SOFTGEL ORL CAP WBP CAP 0.051100080061357 OMEGA-3 ORAL LIQUID ORL LIQ WNP ML 0.064000080003179 OMEGA-3 TABLET ORL TAB JAM TAB 0.156200002438968 OMEP 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT SDZ CAP 0.689300002339927 OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT PDL CAP 0.411700002303671 OMNARIS 50 MCG/DOSE METERED DOSE NASAL SPRAY NAS SPM AZC DOSE 0.225400002459647 OMNITROPE 15 MG/1.5 ML INJECTION CARTRIDGE INJ DEFAUL SDZ ML 311.600000002153513 ONCOTICE 800 M UNIT/VIAL FOR BLADDER INSTILLATION BLDIR PWS MFC VIAL 273.140000002390051 ONDANSETRON (WITH PRESERVATIVE) 2 MG/ML INJ INJ DEFALT MYP ML 3.455200002325160 ONDANSETRON 8 MG TABLET ORL TAB PDL TAB 4.9930

00002271761 ONDANSETRON OMEGA (PRESERVATIVE FREE) 2 MG/ML INJ INJ DEFAUL OMG ML 3.455200002271788 ONDANSETRON OMEGA (WITH PRESERVATIVE) 2 MG/ML INJ INJ DEFALT OMG ML 8.125000080020211 ONE A DAY FRUITI-SSENTIAL GUMMIES ORL CTB BAI TAB 0.155500002248292 ONE A DAY MEN 50 PLUS TABLET ORL TAB BIC TAB 0.103700002248319 ONE A DAY WEIGHTSMART TABLET ORL TAB BAI TAB 0.121300080045908 ONE A DAY WOMEN TABLET ORL TAB BAI TAB 0.103700002421208 ONRELTEA 0.33 % TOPICAL GEL TOP GEL GAL G 3.448700002484668 ONSTRYV 100 MG TABLET ORL TAB VLP TAB 6.900000002484641 ONSTRYV 50 MG TABLET ORL TAB VLP TAB 6.900000000750794 OPCON-A OPH SOLUTION OPH SOL BSH ML 0.280000002446634 OPDIVO (100 MG/10 ML) 10 MG/ML INJECTION INJ DEFAUL BMS ML 195.556000002446626 OPDIVO (40 MG/4 ML) 10 MG/ML INJECTION INJ DEFAUL BMS ML 195.555000002415690 OPSUMIT 10 MG FILM COATED TABLET ORL TAB JAI TAB 132.055000000990059 OPTICHAMBER DEVICE DEFAUL DEV ACM DEV 30.720000000990061 OPTICHAMBER LARGE FACE MASK DEVICE DEFAUL ADUDEV ACM DEV 35.340000000990062 OPTICHAMBER MEDIUM FACE MASK DEVICE DEFAUL PEDDEV ACM DEV 28.530000000990063 OPTICHAMBER SMALL FACE MASK DEVICE DEFAUL INFDEV ACM DEV 29.4300

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 78 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999513 OPTI-FAST ORAL POWDER ORL DEFAUL XXX G 2.857100080068954 OPTIFER ALPHA TABLET ORL TAB VOL TAB 0.513700080012786 OPTIMEGA-3 CAPSULE ORL CAP BCN CAP 0.216400000701785 OPTIMYXIN OTIC OPH DROPS OT/OPH DPS EUP ML 1.095000002371189 OPTION 2 0.75 MG TABLET ORL TAB PRI TAB 7.795000080027592 OPUS D-1000 SOFTGEL ORL CAP OPU CAP 0.070000002035286 ORABASE PASTE ORL PST CVO G 1.328000001985396 ORAJEL MAXIMUM STRENGTH GEL ORL GEL CHD G 0.406300099401270 ORAL DIGITAL THERMOMETER DEFAUL DEFAUL XXX MIS 25.000000002381885 ORALAIR 100 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 1.260000002381893 ORALAIR 300 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 3.800000000313823 ORAP 4 MG TABLET ORL TAB PPH TAB 0.481100002236783 ORCIPRENALINE 2 MG/ML ORAL SYRUP ORL SYR AAP ML 0.060000002469693 ORFADIN 4 MG/ML ORAL SUSPENSION ORL SUS BVM ML 42.666600002047535 ORFENACE 100 MG TABLET ORL TAB STM TAB 0.470000002245641 ORGALUTRAN 250 MCG/ 0.5 ML INJECTION SYRINGE INJ NDL MFC SYR 94.710000002129043 ORGARAN 1250 UNIT/ML (750 UNIT/AMP) INJECTION INJ DEFAUL APC ML 44.200000002481332 ORILISSA 150 MG TABLET ORL TAB ABV TAB 6.120000002481340 ORILISSA 200 MG TABLET ORL TAB ABV TAB 6.120000002483831 ORKAMBI 125 MG/100 MG GRANULES ORL GRNUL VER PCKT 341.071400002463040 ORKAMBI 125 MG/100 MG TABLET ORL TAB VER TAB 170.535100002451379 ORKAMBI 125 MG/200 MG TABLET ORL TAB VER TAB 170.535700002483858 ORKAMBI 188 MG/150 MG GRANULES ORL GRNUL VER PCKT 341.071400002209055 ORO-CLENSE 0.12% ORAL RINSE ORL MWH GER ML 0.016500002240336 ORO-MIN REMINERALIZING SOL W FLUORIDE ORAL RINSE ORL RNS XXX ML 0.022500080023808 ORTHO BONE CAPSULE ORL CAP AOR CAP 0.156500000999460 ORTHOVISC DEFAUL DEV PMS ML 54.333300002504006 OSELTAMIVIR PHOSPHATE 30 MG CAPSULE ORL CAP STR CAP 1.049000002504014 OSELTAMIVIR PHOSPHATE 45 MG CAPSULE ORL CAP STR CAP 2.391000002504022 OSELTAMIVIR PHOSPHATE 75 MG CAPSULE ORL CAP STR CAP 2.079000002495589 OSNUVO 250 MCG/ML INJECTION INJ DEFAUL AVP ML 333.662500000999490 OSTENIL DEFAUL DEV TRB ML 50.260000002247548 OSTEOCIT D PLUS TABLET ORL TAB SFD TAB 0.168300002434318 OTEZLA 10 MG/20 MG/30 MG TABLET STARTER PACK ORL TAB AMG TAB 21.079300002434334 OTEZLA 30 MG TABLET ORL TAB AMG TAB 21.079500002459655 OTIXAL 0.3%/0.025% OTIC SOLUTION OT SOL PPI ML 7.373300002238867 OTRIVIN 0.05% DECONGESTANT NASAL SPRAY NAS SPR NVC ML 0.234000000653330 OTRIVIN 0.1% DECONGESTANT NASAL SPRAY NAS SPR NVC ML 0.234000002208903 OTRIVIN COLD & ALLERGY W/ MOISTURIZER 0.1% NAS SPR NAS SPR GSK ML 0.234000002331403 OTRIVIN MOIST 0.1% NASAL SPRAY NAS SPR NVC ML 0.3075

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 79 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000857777 OTRIVIN-SALINE 0.7% NASAL DROPS NAS SOL NVC ML 0.134800000810436 OTRIVIN-SALINE 0.7% NASAL SPRAY NAS SPR NVC ML 0.118700002262088 OVIDREL 250 MCG INJECTION SYRINGE INJ NDL SRO SYR 72.000000002371588 OVIDREL 250 MCG/0.5 ML PEN CARTRIDGE INJECTION INJ DEFAUL SRO ML 144.000000000013617 OVOL 40 MG/ML ORAL DROPS ORL DPS CHD ML 0.402700002239298 OVOL-180 ULTRA STRENGTH 180 MG CAPSULE ORL CAP CHD CAP 0.210900000292990 OVOL-80 80 MG TABLET ORL TAB CHD TAB 0.154200002435071 OXALIPLATIN 5 MG/ML INJECTION INJ DEFAUL TEV ML 46.634500002436957 OXALIPLATIN INJECTION 5 MG/ML INJECTION INJ DEFAUL SDZ ML 46.635000000497754 OXAZEPAM 10 MG TABLET ORL TAB PDL TAB 0.042000000497762 OXAZEPAM 15 MG TABLET ORL TAB PDL TAB 0.066000000497770 OXAZEPAM 30 MG TABLET ORL TAB PDL TAB 0.090000002361361 OXYCODONE/ACET 5 MG/325 MG TABLET ORL TAB SNS TAB 0.128500002231934 OXY-IR 5 MG TABLET ORL TAB PUR TAB 0.285000002139561 OXYTOCIN 10 UNIT/ML INJECTION INJ DEFAUL FKC ML 6.160000002254735 OXYTROL 36 MG TRANSDERMAL PATCH TRD PTH ALL PTH 7.188800080001408 OYSTER SHELL CALCIUM 500 MG CAPLET ORL TAB NCI TAB 0.064400002248374 OYSTER SHELL CALCIUM WITH VIT D 500 MG TABLET ORL TAB VTH TAB 0.026600002463504 OZANEX 1% TOPICAL CREAM TOP CRM CIP G 1.849000002363445 OZURDEX 0.7 MG INTRAVITREAL IMPLANT OPH IMP ALL SYS 1400.240000002320150 PACLITAXEL 6 MG/ML INJECTION USP INJ DEFAUL SDZ ML 74.800000001923420 PALAFER 300 MG CAPSULE ORL CAP GKC CAP 0.229300001923455 PALAFER-CF CAPSULE ORL CAP GKC CAP 0.313300002246597 PAMIDRONATE DISODIUM 30 MG/10 ML VIAL INJECTION INJ DEFAUL FKC ML 15.750000002246598 PAMIDRONATE DISODIUM 60 MG/10 ML INJECTION INJ DEFAUL FKC ML 29.900000002246599 PAMIDRONATE DISODIUM 90 MG/10 ML VIAL INJECTION INJ DEFAUL FKC ML 44.800000002249669 PAMIDRONATE DISODIUM OMEGA 3 MG/ML VIAL INJECTION INJ DEFAUL OMG ML 8.219000002249677 PAMIDRONATE DISODIUM OMEGA 60 MG/10 ML VIAL INJ INJ DEFAUL OMG ML 17.670000002249685 PAMIDRONATE DISODIUM OMEGA 9 MG/ML VIAL INJECTION INJ DEFAUL OMG ML 24.656000002241804 PANTOLOC 20 MG ENTERIC-COATED TABLET ORL ECT TAK TAB 1.808900002318695 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.201600002439107 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.201600002431327 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.201600002306727 PANTOPRAZOLE SODIUM FOR INJECTION 40 MG/VIAL INJ INJ DEFAUL SDZ VIAL 10.960000002428172 PANTOPRAZOLE-20 20 MG ENTERIC-COATED TABLET ORL ECT SIV TAB 1.275000000009881 PAPAVERINE HCL 32.5 MG/ML INJECTION INJ DEFAUL SDZ ML 6.477500002282844 PAROXETINE 10 MG TABLET ORL TAB SNS TAB 1.043000002388227 PAROXETINE 10 MG TABLET ORL TAB SIV TAB 1.043000002248914 PAROXETINE-20 MG TABLET ORL TAB PDL TAB 0.325000002248915 PAROXETINE-30 MG TABLET ORL TAB PDL TAB 0.3453

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002362171 PATADAY 0.2% OPHTHALMIC SOLUTION OPH SOL NOV ML 12.408000002233143 PATANOL 0.1% OPH SOLUTION OPH SOL NOV ML 6.204000000886327 PATE D'IHLE ZINC OXIDE 25% PASTE TOP PST ATL G 0.026700000532576 PATE D'IHLE ZINC OXIDE PASTE TOP PST ROG G 0.0353

00002316951 PAT-GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE ORL ERC PAT CAP 1.2463

00002316978 PAT-GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE ORL ERC PAT CAP 1.2463

00002316943 PAT-GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE ORL ERC PAT CAP 1.246300002381737 PAT-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT PAT TAB 0.120400002381745 PAT-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT PAT TAB 0.133800002027887 PAXIL 10 MG TABLET ORL TAB GSK TAB 1.830300002248503 PAXIL CR 12.5 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 1.929000002248504 PAXIL CR 25 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 2.107300002458551 PAZEO 0.7% OPHTHALMIC SOLUTION OPH SOL NOV ML 12.408000002484706 PDP-AMLODIPINE 1 MG/ML ORAL SOLUTION ORL SOL PPH ML 1.166700000577790 PDP-ISONIAZID 100 MG TABLET ORL TAB PPH TAB 0.879100000577804 PDP-ISONIAZID 300 MG TABLET ORL TAB PPH TAB 0.823200000577812 PDP-ISONIAZID 50 MG/5ML ORAL LIQUID ORL LIQ PPH ML 0.267400002490447 PDP-LEVETIRACETAM 100 MG/ML ORAL SOLUTION ORL SOL PPH ML 0.814200002242863 PEDIAFER 30 MG/ML ORAL SOLUTION USP ORL SYR EXP ML 0.027200002232202 PEDIAFER 75 MG/ML ORAL SOLUTION USP ORL SYR EXP ML 0.143200002162431 PEDIAPHARM NAPROXEN 25 MG/ML ORAL SUSPENSION ORL SUS PPI ML 0.094900000999852 PEDIASURE 1.5 WITH FIBRE - VANILLA ORL LIQ ABN ML 0.010700000098994 PEDIASURE COMPLETE ORAL LIQUID ORL LIQ ABN ML 0.009700080004595 PEDIAVIT D 400 IU DROPS ORL LIQ EXP ML 0.110000080077066 PEDIAVIT VITAMIN D DROPS 400 IU/DROP ORL DPS EXP ML 3.120000002358034 PEG 3350 ORAL POWDER ORL PWR MES G 0.066800002328232 PEGALAX ORAL POWDER ORL PWR MFI G 0.038700002250535 PENLAC NAIL LACQUER 8% TOPICAL SOLUTION TOP SOL VCL G 15.142500002247265 PENNSAID 1.5% TOPICAL SOLUTION TOP SOL PAL ML 1.133500002183080 PENTAMIDINE ISETHIONATE 300 MG/VIAL INJECTION BP INJ DEFAUL PFI VIAL 136.170000002474727 PENTHROX 99.9% COMBINATION PACK INH SOLUTION INH SOL PUR ML 15.000000002474719 PENTHROX 99.9% SINGLE DOSE BOTTLE INH SOLUTION INH SOL PUR ML 10.500000002185938 PEPCID AC 10 MG TABLET ORL TAB MCL TAB 0.337700002273357 PEPCID AC 20 MG TABLET ORL TAB MCL TAB 0.550000002097079 PEPTO-BISMOL 17.6 MG/ML ORAL LIQUID ORL LIQ PGI ML 0.026500002177994 PEPTO-BISMOL CAPLET ORL TAB PGI TAB 0.180800002237315 PEPTO-BISMOL CHEWABLES CHEWABLE TABLET ORL CTB PGI TAB 0.1808

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000254916 PERGONAL 75 UNIT/75 UNIT INJECTION INJ DEFAUL SRO VIAL 46.000000002240433 PERICHLOR 0.12% ORAL RINSE ORL MWH PMS ML 0.021100002237452 PERIDEX 0.12% ORAL RINSE ORL MWH MMH ML 0.025800002488949 PERINDOPRIL ERBUMINE 2 MG TABLET ORL TAB PDL TAB 0.163200002488957 PERINDOPRIL ERBUMINE 4 MG TABLET ORL TAB PDL TAB 0.204200002488965 PERINDOPRIL ERBUMINE 8 MG TABLET ORL TAB PDL TAB 0.283100002207796 PERIOGARD 0.12% ORAL RINSE ORL MWH COL ML 0.016400002467534 PERIOGARD 0.12% ORAL RINSE ORL MWH COL ML 0.016300002247104 PERIOSTAT 20 MG CAPSULE ORL CAP PPH CAP 1.350000002229501 PERI-WASH II ANTISEPTIC 0.1% CLEANSER TOP WAS COC ML 0.014700002405016 PERJETA 420 MG/14 ML INJECTION INJ DEFAUL HLR ML 241.557900002405024 PERJETA-HERCEPTIN 420 MG/440 MG COMBO PACK INJ INJ VIAL/VIA HLR KIT 6255.860000080054655 PERSPIREX PLUS 15% TOPICAL GEL TOP GEL FMI ML 0.515600099400941 PESSARY DEFAUL DEFAUL XXX MIS 120.000000002142872 PETRO CARBO SALVE TOPICAL OINTMENT TOP ONT WKI G 0.088600080017389 PGX 750 DAILY CAPSULE ORL CAP NFN CAP 0.080500002494434 PHARIXIA 1.5 MG/ML ALCOHOL FREE SOLUTION ORL RNS PPH ML 0.096000002229777 PHARIXIA 1.5 MG/ML SOLUTION ORL RNS PPH ML 0.091000080001122 PHARMA-CAL 500 MG ORL CAP PPH CAP 0.021600080004281 PHARMA-CAL D 500 MG/125 IU TABLET ORL TAB PMS TAB 0.068000002371499 PHARMA-D 10,000 UNIT CAPSULE ORL CAP PMS CAP 0.210000080001145 PHARMA-D 400 IU GELCAP ORL CAP PPH CAP 0.030000002371502 PHARMA-D 50,000 UNIT CAPSULE ORL CAP PMS CAP 0.950000080040416 PHARMA-K20 20 MEQ SUSTAINED-RELEASE TABLET ORL TAB/SRT PMS TAB 0.199500002247383 PHARMA-LACTULOSE 667 MG/ML SOLUTION ORL SOL PMS ML 0.014500080038071 PHARMANAC TM ACETYLCYSTEINE 900 MG TABLET ORL TAB BAP TAB 1.020800009858123 PHENELZINE SULFATE USP 15 MG TABLET ORL TAB LPC TAB 0.590800002304090 PHENOBARBITAL SODIUM 120 MG/ML INJECTION USP INJ DEFAUL SDZ ML 18.216000002304082 PHENOBARBITAL SODIUM 30 MG/ML INJECTION USP INJ DEFAUL SDZ ML 16.284000002148455 PHENYLEPHRINE HCL 10% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.2000

00002148447 PHENYLEPHRINE HYDROCHLORIDE OPH SOLUTION (MINIMS) OPH SOL OPT ML 4.200000000780626 PHENYTOIN 50 MG/ML INJECTION INJ DEFAUL SDZ ML 6.078500002431378 PHENYTOIN SODIUM 50 MG/ML INJECTION USP INJ DEFAUL STM ML 5.285600002150638 PHILLIPS MAGNESIA 300 MG CHEWABLE TABLET ORL CTB BAI TAB 0.048700002150646 PHILLIPS MILK OF MAGNESIA 80 MG/ML ORAL LIQUID ORL LIQ BAI ML 0.014300002243578 PHISODERM FACIAL CLEANSER TOP WAS MNT G 0.022500080000689 PHOSLAX ORAL SOLUTION ORL SOL ODN ML 0.376700002230399 PHOSPHATES SOLUTION ORAL LIQUID ORL LIQ PPH ML 0.088700002019876 PHOTOFRIN 75MG/ VIAL INJECTION INJ DEFAUL AXC VIAL 19255.1000

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 82 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002400987 PICATO 0.015% TOPICAL GEL TOP GEL LEO DOSE 134.653300002400995 PICATO 0.05% TOPICAL GEL TOP GEL LEO DOSE 201.980000002254794 PICO SALAX ORAL POWDER ORL PWR FEI PCKT 11.220000002481545 PIFELTRO 100 MG TABLET ORL TAB MFC TAB 16.650000002148463 PILOCARPINE NITRATE 2% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.200000000828424 PINDOLOL-10 MG TABLET ORL TAB PDL TAB 0.232300000828416 PINDOLOL-5 MG TABLET ORL TAB PDL TAB 0.136100002248939 PIPERACILLIN 2 G/VIAL INJECTION USP INJ DEFAUL FKC VIAL 15.280000002248940 PIPERACILLIN 3 G/VIAL INJECTION USP INJ DEFAUL FKC VIAL 22.930000002248941 PIPERACILLIN 4 G/VIAL INJECTION USP INJ DEFAUL FKC VIAL 30.550000002377748 PIPERACILLIN AND TAZOBACTAM 12 G/1.5 G/VIAL INJ INJ DEFAUL STM VIAL 67.500000002330547 PIPERACILLIN SOD/TAZOBACTAM SOD 12G/1500 MG VL INJ INJ DEFAUL SDZ VIAL 67.500000002439131 PIPERACILLIN SOD/TAZOBACTAM SOD 36G/4500 MG VL INJ INJ DEFAUL STM VIAL 202.500000002497085 PIQRAY (250 MG DAILY DOSE) 200 MG/50 MG TABLET ORL TAB NOV TAB 95.230000002497069 PIQRAY 150 MG TABLET ORL TAB NOV TAB 95.230000002497077 PIQRAY 200 MG TABLET ORL TAB NOV TAB 190.460000002237405 PLANTE GUMMI BEAR MULTIPLE VITAMINS ORAL GUM ORL GUM PLI PIECE 0.156600001946897 PMS DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR ORL ELX PMS ML 0.518400002458381 PMS-ABACAVIR-LAMIVUDINE 600 MG/300 MG TABLET ORL TAB PMS TAB 20.357300002492601 PMS-ABIRATERONE 250 MG TABLET ORL TAB PMS TAB 26.031200002501503 PMS-ABIRATERONE 500 MG TABLET ORL TAB PMS TAB 52.062500000792691 PMS-ACETAMINOPHEN 32 MG/ML ORAL SOLUTION ORL SOL PPH ML 0.026000002243435 PMS-ADENOSINE 3 MG/ML INJECTION INJ DEFAUL PMS ML 19.500000000654523 PMS-AMITRIPTYLINE 10 MG TABLET ORL TAB PMS TAB 0.066400002468409 PMS-AMITRIPTYLINE 100 MG TABLET ORL TAB PMS TAB 0.422500000654515 PMS-AMITRIPTYLINE 25 MG TABLET ORL TAB PMS TAB 0.121100000654507 PMS-AMITRIPTYLINE 50 MG TABLET ORL TAB PMS TAB 0.234700002230244 PMS-AMOXICILLIN 500 MG CAPSULE ORL CAP PMS CAP 0.341700002440377 PMS-AMPHETAMINE XR 10 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 2.075800002440385 PMS-AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 2.325000002440407 PMS-AMPHETAMINE XR 25 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 2.823500002440415 PMS-AMPHETAMINE XR 30 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 3.072900002440369 PMS-AMPHETAMINE XR 5 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 1.826600002274949 PMS-ANAGRELIDE 0.5 MG CAPSULE ORL CAP PMS CAP 3.349100002320738 PMS-ANASTROZOLE 1 MG TABLET ORL TAB PMS TAB 2.546000002283700 PMS-ASA EC 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.053800002381028 PMS-ATOMOXETINE 10 MG CAPSULE ORL CAP PMS CAP 2.314000002381036 PMS-ATOMOXETINE 18 MG CAPSULE ORL CAP PMS CAP 2.652300002381044 PMS-ATOMOXETINE 25 MG CAPSULE ORL CAP PMS CAP 2.928100002381052 PMS-ATOMOXETINE 40 MG CAPSULE ORL CAP PMS CAP 3.3377

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002381060 PMS-ATOMOXETINE 60 MG CAPSULE ORL CAP PMS CAP 3.702400002330237 PMS-BETAHISTINE 24 MG TABLET ORL TAB PMS TAB 0.498300002275589 PMS-BICALUTAMIDE 50 MG TABLET ORL TAB PMS TAB 4.057300002383020 PMS-BOSENTAN 125 MG TABLET ORL TAB PMS TAB 48.134000002383012 PMS-BOSENTAN 62.5 MG TABLET ORL TAB PMS TAB 48.134000002391171 PMS-CANDESARTAN 4 MG TABLET ORL TAB PMS TAB 0.340000002315963 PMS-CETIRIZINE 20 MG TABLET ORL TAB PMS TAB 0.753500002416433 PMS-CIPROFLOXACIN XL 500 MG EXTENDED-RELEASE TAB ORL ERT PMS TAB 2.619100002232195 PMS-CLOBETASOL 0.05% SCALP LOTION SCP LOT PMS ML 0.199000002232193 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.227900002309548 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.227900000757713 PMS-CYPROHEPTADINE HCL 4 MG TABLET ORL TAB PPH TAB 0.246200000721344 PMS-DICITRATE ORAL SOLUTION ORL SOL PMS ML 0.047400002356783 PMS-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL PMS ML 0.622700002239753 PMS-DICLOFENAC-K 50 MG TABLET ORL TAB PMS TAB 0.393700000757683 PMS-DIPHENHYDRAMINE 25 MG CAPSULE ORL CAP PPH CAP 0.089900000757691 PMS-DIPHENHYDRAMINE 50 MG CAPSULE ORL CAP PPH CAP 0.109900000664553 PMS-DOCUSATE CALCIUM 240 MG CAPSULE ORL CAP PMS CAP 0.140800000848417 PMS-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP ORL SYR PMS ML 0.984400002487284 PMS-EFAVIRENZ-EMTRICITABINE-TENOFOVIR TABLET ORL TAB PMS TAB 22.660000002434342 PMS-ELETRIPTAN 20 MG TABLET ORL TAB PMS TAB 10.085000002434350 PMS-ELETRIPTAN 40 MG TABLET ORL TAB PMS TAB 10.085000002454386 PMS-ERLOTINIB 100 MG TABLET ORL TAB PMS TAB 47.466700002454394 PMS-ERLOTINIB 150 MG TABLET ORL TAB PMS TAB 71.200000002379171 PMS-ESOMEPRAZOLE 40 MG DELAYED-RELEASE CAPSULE ORL DRT/DRC PMS CAP 1.869000002278081 PMS-FAMCICLOVIR 125 MG TABLET ORL TAB PMS TAB 2.024000002278103 PMS-FAMCICLOVIR 250 MG TABLET ORL TAB PMS TAB 2.720000002278111 PMS-FAMCICLOVIR 500 MG TABLET ORL TAB PMS TAB 4.228100000586323 PMS-FERROUS SULFATE 300 MG TABLET ORL TAB PPH TAB 0.029600002222574 PMS-FERROUS SULFATE INFANT DROPS 75 MG/ML ORL DPS PMS ML 0.190000002320169 PMS-FINASTERIDE 1 MG TABLET ORL TAB PMS TAB 1.145500002282348 PMS-FLUCONAZOLE 150 MG CAPSULE ORL CAP PMS CAP 3.940000002464640 PMS-FLUOXETINE 40 MG CAPSULE ORL CAP PMS CAP 0.662200002464659 PMS-FLUOXETINE 60 MG CAPSULE ORL CAP PMS CAP 0.9933

00002503131 PMS-FLUTICASONE HFA 250 MCG/DOSE METERED DOSE AERO INH AEM PMS DOSE 0.637800002247493 PMS-FUROSEMIDE 20 MG TABLET ORL TAB PMS TAB 0.037300002247494 PMS-FUROSEMIDE 40 MG TABLET ORL TAB PMS TAB 0.074600002255898 PMS-GABAPENTIN 600 MG TABLET ORL TAB PMS TAB 1.304500002247386 PMS-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.0474

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 84 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002247387 PMS-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.055100002324253 PMS-HYDROCODONE 1 MG/ML ORAL SYRUP ORL SYR PMS ML 0.133800000836133 PMS-IBUPROFEN 400 MG TABLET ORL TAB PMS TAB 0.101000002431114 PMS-IMATINIB 100 MG TABLET ORL TAB PMS TAB 20.455700002431122 PMS-IMATINIB 400 MG TABLET ORL TAB PMS TAB 81.822700002502917 PMS-IRON SUCROSE 20 MG/ML INJECTION INJ DEFAUL PMS ML 6.375000002288265 PMS-LEFLUNOMIDE 10 MG TABLET ORL TAB PMS TAB 2.643300002288273 PMS-LEFLUNOMIDE 20 MG TABLET ORL TAB PMS TAB 2.643300002309114 PMS-LETROZOLE 2.5 MG TABLET ORL TAB PMS TAB 2.756000000811874 PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID ORL LIQ PMS ML 0.0950

00002016095 PMS-LOPERAMIDE HYDROCHLORIDE 0.2 MG/ML ORAL LIQUID ORL LIQ PMS ML 0.170200002248268 PMS-MELOXICAM 15 MG TABLET ORL TAB PMS TAB 0.567000002248267 PMS-MELOXICAM 7.5 MG TABLET ORL TAB PMS TAB 0.491400002321130 PMS-MEMANTINE 10 MG TABLET ORL TAB PMS TAB 1.635700002382830 PMS-MEMANTINE 5 MG TABLET ORL TAB PMS TAB 1.8304

00002413728 PMS-METHYLPHENIDATE 18 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.4276

00002413736 PMS-METHYLPHENIDATE 27 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.6475

00002413744 PMS-METHYLPHENIDATE 36 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.8674

00002413752 PMS-METHYLPHENIDATE 54 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 2.307200002432218 PMS-MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL PMS ML 3.756700002380897 PMS-NABILONE 0.25 MG CAPSULE ORL CAP PMS CAP 1.466000002418630 PMS-NIFEDIPINE ER 30 MG EXTENDED-RELEASE TABLET ORL ERT PMS TAB 0.617100002416301 PMS-NIFEDIPINE ER 60 MG EXTENDED-RELEASE TABLET ORL ERT PMS TAB 0.937400002367483 PMS-OLANZAPINE 20 MG TABLET ORL TAB PMS TAB 10.309300002303213 PMS-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB PMS TAB 5.355300002310260 PMS-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT PMS TAB 0.2287

00002309882 PMS-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.4741

00002309890 PMS-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.7112

00002309904 PMS-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 1.2326

00002309912 PMS-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 2.276600002247750 PMS-PAROXETINE 10 MG TABLET ORL TAB PMS TAB 1.0430

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002303124 PMS-PIOGLITAZONE 15 MG TABLET ORL TAB PMS TAB 0.622500002303132 PMS-PIOGLITAZONE 30 MG TABLET ORL TAB PMS TAB 0.872100002303140 PMS-PIOGLITAZONE 45 MG TABLET ORL TAB PMS TAB 1.311300002240363 PMS-POLYTRIMETHOPRIM OPHTHALMIC SOLUTION OPH SOL PMS ML 2.388000002290111 PMS-PRAMIPEXOLE 0.25 MG TABLET ORL TAB PMS TAB 0.195000002290138 PMS-PRAMIPEXOLE 0.5 MG TABLET ORL TAB PMS TAB 1.386000002290146 PMS-PRAMIPEXOLE 1 MG TABLET ORL TAB PMS TAB 0.390100002290154 PMS-PRAMIPEXOLE 1.5 MG TABLET ORL TAB PMS TAB 0.390100002398079 PMS-PREGABALIN 225 MG CAPSULE ORL CAP PMS CAP 1.727000000753661 PMS-PROCHLORPERAZINE 5 MG TABLET ORL TAB PMS TAB 0.165900002476576 PMS-PROGESTERONE 100 MG CAPSULE ORL CAP PMS CAP 1.133000002480247 PMS-PROGESTERONE 200 MG CAPSULE ORL CAP PMS CAP 2.000000002294575 PMS-PROPAFENONE 300 MG TABLET ORL TAB PMS TAB 0.753700002244379 PMS-PROPOFOL 10 MG/ML INJECTION INJ DEFAUL PMS ML 0.460000000815993 PMS-PSEUDOEPHEDRINE HCL 6 MG/ML ORAL SYRUP ORL SYR PMS ML 0.044300000618810 PMS-PYRAZINAMIDE 500 MG TABLET ORL TAB PMS TAB 1.355800002295369 PMS-RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB PMS CAP 0.070800002247919 PMS-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB PMS CAP 0.103400002343932 PMS-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB PMS CAP 0.813300002247917 PMS-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB PMS CAP 0.122700002247918 PMS-RAMIPRIL 5 MG CAPSULE ORL CAP/TAB PMS CAP 0.081700002342146 PMS-RAMIPRIL-HCTZ 5 MG/12.5 MG TABLET ORL TAB PMS TAB 0.217000002342162 PMS-RAMIPRIL-HCTZ 5 MG/25 MG TABLET ORL TAB PMS TAB 0.217000002424177 PMS-RISEDRONATE 150 MG TABLET ORL TAB PMS TAB 40.950000002371642 PMS-SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.200600002371626 PMS-SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 8.289400002371634 PMS-SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 8.848100002412179 PMS-SILDENAFIL R 20 MG TABLET ORL TAB PMS TAB 7.294000002256428 PMS-SUMATRIPTAN 25 MG TABLET ORL TAB PMS TAB 8.990000002409437 PMS-TADALAFIL 10 MG TABLET ORL TAB PMS TAB 11.925000002409410 PMS-TADALAFIL 2.5 MG TABLET ORL TAB PMS TAB 3.647000002409445 PMS-TADALAFIL 20 MG TABLET ORL TAB PMS TAB 12.357500002409429 PMS-TADALAFIL 5 MG TABLET ORL TAB PMS TAB 3.647100002401657 PMS-TRAMADOL-ACET 37.5 MG/325 MG TABLET ORL TAB PMS TAB 0.626400002324768 PMS-ZOLMITRIPTAN ODT 2.5 MG ORAL DISP. TABLET ORL DISPTAB PMS TAB 3.538300002436183 PMS-ZOLPIDEM ODT 10 MG SUBLINGUAL DISINT. TABLET SLG DISNTAB PMS TAB 1.188300002436175 PMS-ZOLPIDEM ODT 5 MG SUBLINGUAL DISINT. TABLET SLG DISNTAB PMS TAB 1.182700000431648 PNEUMOVAX 23 25 MCG/VIAL INJECTION INJ DEFAUL MSD VIAL 27.213000000990067 POCKET CHAMBER DEVICE DEFAUL DEV MMS DEV 15.990000000990069 POCKET CHAMBER PEDIATRIC MEDIUM MASK DEVICE DEFAUL PEDDEV MMS DEV 49.9900

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000598208 PODOFILM 250 MG/ML TOPICAL LIQUID TOP LIQ PMS ML 2.130800000464988 POLLINEX R INJECTION INJ VIAL/SYR BEE VL/SYR 106.362500000999389 POLYCAL ORAL POWDER ORL PWR XXX G 0.022400000999540 POLYRIDE FE MIS DEFAUL XXX MIS 0.564300080045027 POLYRIDE FE ULTRA CAPSULE ORL CAP SFD CAP 0.498300080020979 POLYRIDE-FE 150 MG CAPSULE ORL CAP SFD CAP 0.449200002230844 POLYSPORIN 10,000 U/0.25 MG ANTIBIOTIC TOPICAL CRM TOP CRM JJI G 0.394000002237227 POLYSPORIN ANTIBIOTIC TOPICAL OINTMENT TOP ONT JJI G 0.394000002240568 POLYSPORIN COMPLETE TOPICAL OINTMENT ORL ONT JJI G 0.456000002239155 POLYSPORIN PLUS PAIN RELIEF EAR DROPS OT SOL JJI ML 0.760000002239201 POLYSPORIN PLUS PAIN RELIEF TOPICAL CREAM TOP CRM JJI G 0.426700002239156 POLYSPORIN STERILE OTIC OPH DROPS OT/OPH DPS JJI ML 0.760000002237226 POLYSPORIN TRIPLE ANTIBIOTIC TOPICAL OINTMENT TOP ONT JJI G 0.426700002011956 POLYTRIM OPH SOLUTION OPH SOL ALL ML 3.883000002419580 POMALYST 1 MG CAPSULE ORL CAP CLG CAP 500.000000002419599 POMALYST 2 MG CAPSULE ORL CAP CLG CAP 500.000000002419602 POMALYST 3 MG CAPSULE ORL CAP CLG CAP 500.000000002419610 POMALYST 4 MG CAPSULE ORL CAP CLG CAP 500.000000002424622 POSANOL 100 MG DELAYED-RELEASE TABLET ORL DRT MFC TAB 50.121200002293404 POSANOL 40 MG/ML ORAL SUSPENSION ORL SUS MFC ML 9.737100000316121 POTASSIUM 50 MG TABLET ORL TAB JAM TAB 0.056300080046782 POTASSIUM CHLORIDE 1.33 MEQ ORAL LIQUID ORL LIQ ODN ML 0.041700080028233 POTASSIUM CHLORIDE 20 MEQ TABLET ORL TAB/SRT OPU TAB 0.199500080026332 POTASSIUM CITRATE 10 MMOL 10 MEQ TABLET ORL TAB MTR TAB 0.154500000804789 POTASSIUM PHOSPHATE 224 MG/ML/ 236 MG/ML INJECTION INJ DEFAUL SDZ ML 1.9320

00002139545 POTASSIUM PHOSPHATES 224 MG/ML/236 MG/ML INJECTION INJ DEFAUL FKC ML 0.672500002312433 PRADAXA 75 MG CAPSULE ORL CAP BOE CAP 1.712000002325802 PRAMIPEXOLE 0.25 MG TABLET ORL TAB PDL TAB 0.195000002309130 PRAMIPEXOLE 0.5 MG TABLET ORL TAB SIV TAB 1.386000002325810 PRAMIPEXOLE 0.5 MG TABLET ORL TAB PDL TAB 0.525700002325829 PRAMIPEXOLE 1 MG TABLET ORL TAB PDL TAB 0.390100002325837 PRAMIPEXOLE 1.5 MG TABLET ORL TAB PDL TAB 0.390100000770957 PRAMOX H.C. TOPICAL CREAM TOP CRM DPT G 0.444400001954210 PRAMOX H.C. TOPICAL LOTION TOP LOT DPT ML 0.183300000893757 PRAVACHOL 20 MG TABLET ORL TAB BMS TAB 1.124300002222051 PRAVACHOL 40 MG TABLET ORL TAB BMS TAB 1.354300002243824 PRAVASTATIN-10 10 MG TABLET ORL TAB PDL TAB 0.291600002243825 PRAVASTATIN-20 20 MG TABLET ORL TAB PDL TAB 0.344000002243826 PRAVASTATIN-40 40 MG TABLET ORL TAB PDL TAB 0.4143

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 87 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002148498 PREDNISOLONE SOD PHOS 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 7.000000000607517 PREDNISONE-50 50 MG TABLET ORL TAB PDL TAB 0.173500002474387 PREGABALIN 150 MG CAPSULE ORL CAP ALP CAP 0.414500002396521 PREGABALIN 150 MG CAPSULE ORL CAP PDL CAP 0.414500002396483 PREGABALIN 25 MG CAPSULE ORL CAP PDL CAP 0.148100002474352 PREGABALIN 25 MG CAPSULE ORL CAP ALP CAP 0.148100002396548 PREGABALIN 300 MG CAPSULE ORL CAP PDL CAP 0.414500002396505 PREGABALIN 50 MG CAPSULE ORL CAP PDL CAP 0.232400002474360 PREGABALIN 50 MG CAPSULE ORL CAP ALP CAP 0.232400002474379 PREGABALIN 75 MG CAPSULE ORL CAP ALP CAP 0.300700002396513 PREGABALIN 75 MG CAPSULE ORL CAP PDL CAP 0.300700000999556 PREGESTIMIL A+ INFANT FORMULA ORL PWR MJO G 0.044100002182904 PREGNYL 10,000 UNIT INJECTION INJ DEFAUL MFC VIAL 72.000000002451581 PREGVIT FOLIC 5 TABLET ORL TAB DUI TAB 0.531200002451573 PREGVIT TABLET ORL TAB DUI TAB 0.416700002043386 PREMARIN 25 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 45.210000080075217 PRENATAL 100% COMPLETE MULTI CHEWABLE TABLET ORL CTB JMS TAB 0.236000002244574 PRENATAL VITAMIN AND MINERAL SUPPLEMENT CAPLET ORL TAB WNP TAB 0.073100000886750 PREPARATION H TOPICAL CREAM TOP CRM PDH G 0.254400001926217 PREPARATION H TOPICAL OINTMENT TOP ONT PDH G 0.2276

00080046427 PRESERVISION EYE VIT & MINERAL SUPP AREDS2 FORMULA ORL CAP BSH CAP 0.180000000999899 PRESIDENT'S CHOICE ORAL LIQUID ORL LIQ PNU ML 0.007100000693820 PRESSYN 20 U/ML INJECTION INJ DEFAUL FEI ML 7.900000002249464 PREVACID FASTAB 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB BGP TAB 2.100000002249472 PREVACID FASTAB 30 MG ORAL DISINTEGRATING TABLET ORL DISNTAB BGP TAB 2.100000000804533 PREVEX HC 1% TOPICAL OCCLUSIVE CREAM TOP OCLCRM GSK G 0.270300002210754 PREVIDENT 5000 PLUS DENTAL CREAM DEN CRM COL G 0.201300002335204 PREVNAR 13 SUSPENSION 0.5 ML SYRINGE INJECTION INJ NDL PFI SYR 99.020000002244081 PREVNAR VACCINE 0.5 ML INJECTION INJ DEFAUL PFI ML 180.180000002426501 PREZCOBIX 800 MG/150 MG TABLET ORL TAB JAI TAB 25.187000002369753 PREZISTA 150 MG TABLET ORL TAB JAI TAB 3.892000002324024 PREZISTA 600 MG TABLET ORL TAB JAI TAB 17.188000002338432 PREZISTA 75 MG TABLET ORL TAB JAI TAB 1.893000002393050 PREZISTA 800 MG TABLET ORL TAB JAI TAB 23.318000080033655 PRIMADOPHILUS OPTIMA MAX BIFIDO 90 BILLION CAPSULE ORL CAP ENT CAP 1.428300000999007 PRIMROSE OIL ORL LIQ XXX ML 0.513400000839396 PRINIVIL 10 MG TABLET ORL TAB MFC TAB 0.807500000839418 PRINIVIL 20 MG TABLET ORL TAB MFC TAB 0.971100002239208 PRIORIX VIAL INJECTION INJ DEFAUL GSK VIAL 27.7760

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002321106 PRISTIQ 100 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.341000002321092 PRISTIQ 50 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.341000002490110 PRIVA-AMITRIPTYLINE 10 MG TABLET ORL TAB PMI TAB 0.043500002490129 PRIVA-AMITRIPTYLINE 25 MG TABLET ORL TAB PMI TAB 0.082900002490137 PRIVA-AMITRIPTYLINE 50 MG TABLET ORL TAB PMI TAB 0.154000002490145 PRIVA-AMITRIPTYLINE 75 MG TABLET ORL TAB PMI TAB 0.363400002482886 PRIVA-ATORVASTATIN 10 MG TABLET ORL TAB PMI TAB 0.174300002482894 PRIVA-ATORVASTATIN 20 MG TABLET ORL TAB PMI TAB 0.217900002482908 PRIVA-ATORVASTATIN 40 MG TABLET ORL TAB PMI TAB 0.234200002482916 PRIVA-ATORVASTATIN 80 MG TABLET ORL TAB PMI TAB 0.234200002426366 PRIVA-CELECOXIB 100 MG CAPSULE ORL CAP PMI CAP 0.127900002426374 PRIVA-CELECOXIB 200 MG CAPSULE ORL CAP PMI CAP 0.255800002499355 PRIVA-CINACALCET 30 MG TABLET ORL TAB PMI TAB 2.741800002499363 PRIVA-CINACALCET 60 MG TABLET ORL TAB PMI TAB 4.999500002499371 PRIVA-CINACALCET 90 MG TABLET ORL TAB PMI TAB 7.275200002445328 PRIVA-DOMPERIDONE 10 MG TABLET ORL TAB PMI TAB 0.059400002446677 PRIVA-DONEPEZIL 10 MG TABLET ORL TAB PMI TAB 0.458600002446669 PRIVA-DONEPEZIL 5 MG TABLET ORL TAB PMI TAB 0.458700002490412 PRIVA-DULOXETINE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PMI CAP 0.481300002490420 PRIVA-DULOXETINE 60 MG DELAYED-RELEASE CAPSULE ORL DRC PMI CAP 0.976900002490587 PRIVA-DUTASTERIDE 0.5 MG CAPSULE ORL CAP PMI CAP 0.302700002426331 PRIVA-ESCITALOPRAM 10 MG TABLET ORL TAB PMI TAB 0.311000002426358 PRIVA-ESCITALOPRAM 20 MG TABLET ORL TAB PMI TAB 0.331000002425238 PRIVA-EZETIMIBE 10 MG TABLET ORL TAB PMI TAB 0.181100002450097 PRIVA-GABAPENTIN 100 MG CAPSULE ORL CAP PMI CAP 0.074900002450100 PRIVA-GABAPENTIN 300 MG CAPSULE ORL CAP PMI CAP 0.182100002450119 PRIVA-GABAPENTIN 400 MG CAPSULE ORL CAP PMI CAP 0.217100002450127 PRIVA-GABAPENTIN 600 MG TABLET ORL TAB PMI TAB 0.325600002446502 PRIVA-IRBESARTAN 150 MG TABLET ORL TAB PMI TAB 0.302500002446510 PRIVA-IRBESARTAN 300 MG TABLET ORL TAB PMI TAB 0.302500002446499 PRIVA-IRBESARTAN 75 MG TABLET ORL TAB PMI TAB 0.302500002450380 PRIVA-LEVETIRACETAM 500 MG TABLET ORL TAB PMI TAB 0.391100002446715 PRIVA-LOSARTAN 100 MG TABLET ORL TAB PMI TAB 0.196100002446693 PRIVA-LOSARTAN 25 MG TABLET ORL TAB PMI TAB 0.196100002446707 PRIVA-LOSARTAN 50 MG TABLET ORL TAB PMI TAB 0.196100002449919 PRIVA-OMEPRAZOLE 20 MG SUSTAINED-RELEASE TABLET ORL CAP/SRT PMI TAB 0.411700002425378 PRIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT PMI TAB 0.201600002483238 PRIVA-PERINDOPRIL ERBUMINE 2 MG TABLET ORL TAB PMI TAB 0.163200002483246 PRIVA-PERINDOPRIL ERBUMINE 4 MG TABLET ORL TAB PMI TAB 0.204200002483254 PRIVA-PERINDOPRIL ERBUMINE 8 MG TABLET ORL TAB PMI TAB 0.2831

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002447096 PRIVA-QUETIAPINE 100 MG TABLET ORL TAB PMI TAB 0.237200002447126 PRIVA-QUETIAPINE 200 MG TABLET ORL TAB PMI TAB 0.476400002447088 PRIVA-QUETIAPINE 25 MG TABLET ORL TAB PMI TAB 0.088900002447134 PRIVA-QUETIAPINE 300 MG TABLET ORL TAB PMI TAB 0.695300002448807 PRIVA-SILDENAFIL 100 MG TABLET ORL TAB PMI TAB 9.200000002485745 PRIVA-SIMVASTATIN 10 MG TABLET ORL TAB PMI TAB 0.102300002485753 PRIVA-SIMVASTATIN 20 MG TABLET ORL TAB PMI TAB 0.202300002485761 PRIVA-SIMVASTATIN 40 MG TABLET ORL TAB PMI TAB 0.250100002452499 PRIVA-TADALAFIL 10 MG TABLET ORL TAB PMI TAB 11.925000002452472 PRIVA-TADALAFIL 2.5 MG TABLET ORL TAB PMI TAB 3.647100002452502 PRIVA-TADALAFIL 20 MG TABLET ORL TAB PMI TAB 12.357500002452480 PRIVA-TADALAFIL 5 MG TABLET ORL TAB PMI TAB 3.647100002425874 PRIVA-ZOPICLONE 5 MG TABLET ORL TAB PMI TAB 0.099000002425882 PRIVA-ZOPICLONE 7.5 MG TABLET ORL TAB PMI TAB 0.125000000644315 PRO AMOX-500 MG CAPSULE ORL CAP PDL CAP 0.341700080009485 PRO MAGNESIUM MALATE 100 MG CAPSULE ORL CAP AOR CAP 0.257900002311518 PRO-AAS (CROQUABLE) 80 MG CHEWABLE TABLET ORL CTB PDL TAB 0.056000002311496 PRO-AAS EC 80 MG TABLET ORL ECT PDL TAB 0.560000002309661 PRO-AMIODARONE-200 200 MG TABLET ORL TAB PDL TAB 0.514700000644331 PRO-AMOX 250 MG/5 ML POWDER FOR ORAL SUSPENSION ORL SUS PDL ML 0.054000080026419 PROARGI-9 PLUS ORAL POWDER ORL PWR NHP G 0.125200002310600 PRO-AZITHROMYCINE 250 MG TABLET ORL TAB PDL TAB 0.941700002311038 PRO-BICALUTAMIDE-50 50 MG TABLET ORL TAB PDL TAB 1.610000080025685 PROBIOMAX DF CAPSULE ORL CAP XYG CAP 1.391300080014464 PROBIOTIC 10 BILLION ORL CAP JAM CAP 0.239800080076638 PROBIOTIC 10 BILLION CAPSULE ORL CAP JMS CAP 0.250700080087949 PROBIOTICS 80 BILLION CAPSULE ORL CAP WNP CAP 1.010000002307006 PRO-BISOPROLOL-10 10 MG TABLET ORL TAB PDL TAB 0.104400002306999 PRO-BISOPROLOL-5 5 MG TABLET ORL TAB PDL TAB 0.071500002184486 PROCAINAMIDE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 5.058600080008566 PRO-CAL-D 400 IU ORAL CAPLET ORL DEFAUL PDL TAB 0.120000002311062 PRO-CEFADROXIL-500 500 MG CAPSULE ORL CAP PDL CAP 0.842100002311453 PRO-CEFUROXIME-500 500 MG TABLET ORL TAB PDL TAB 1.433700002317796 PRO-CIPROFLOXACIN 250 MG TABLET ORL TAB PDL TAB 0.618600002317818 PRO-CIPROFLOXACIN 500 MG TABLET ORL TAB PDL TAB 0.502500002311593 PRO-CLONAZEPAM 0.5 MG TABLET ORL TAB PDL TAB 0.049500002311607 PRO-CLONAZEPAM 1 MG TABLET ORL TAB PDL TAB 0.148700002311615 PRO-CLONAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.072100002241799 PROCYTOX 1,000 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 165.520000002241797 PROCYTOX 200 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 70.0300

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 90 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002241795 PROCYTOX 25 MG TABLET ORL TAB ASM TAB 0.901700002241796 PROCYTOX 50 MG TABLET ORL TAB ASM TAB 1.217700002241798 PROCYTOX 500 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 47.180000002241800 PROCYTOX INJECTION INJ DEFAUL ASM VIAL 171.170000002246645 PRODIEM BULK FIBRE THERAPY 625 MG TABLET ORL TAB NVC TAB 0.161400002246576 PRODIEM OVERNIGHT RELIEF THERAPY 15 MG TABLET ORL TAB NVC TAB 0.203000002311429 PRO-ENALAPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.264700002311402 PRO-ENALAPRIL-2.5 2.5 MG TABLET ORL TAB PDL TAB 0.186300002311437 PRO-ENALAPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.319500002311410 PRO-ENALAPRIL-5 5 MG TABLET ORL TAB PDL TAB 0.220300002310236 PRO-FENO-SUPER-160 160 MG TABLET ORL CAP/TAB PDL TAB 0.272300002247909 PROFERRIN 11 MG TABLET ORL TAB CBI TAB 0.699000002310686 PRO-FLUCONAZOLE 100 MG TABLET ORL TAB PDL TAB 2.289000002314991 PRO-FLUOXETINE 10 MG CAPSULE ORL CAP PDL CAP 0.340400002315009 PRO-FLUOXETINE 20 MG CAPSULE ORL CAP PDL CAP 0.331100002310449 PRO-GABAPENTIN 100 MG CAPSULE ORL CAP PDL CAP 0.041600002310457 PRO-GABAPENTIN 300 MG CAPSULE ORL CAP PDL CAP 0.182100002310465 PRO-GABAPENTIN 400 MG CAPSULE ORL CAP PDL CAP 0.120600002310473 PRO-GABAPENTIN 600 MG TABLET ORL TAB PDL TAB 0.958000002310481 PRO-GABAPENTIN 800 MG TABLET ORL TAB PDL TAB 1.277300001977652 PROGESTERONE 50 MG/ML INJECTION USP INJ DEFAUL CYT ML 5.861000000503347 PROGLYCEM 100 MG CAPSULE ORL CAP MFC CAP 1.782500002243144 PROGRAF 0.5 MG CAPSULE ORL CAP ASP CAP 1.970000002175991 PROGRAF 1 MG CAPSULE ORL CAP ASP CAP 2.520000002175983 PROGRAF 5 MG CAPSULE ORL CAP ASP CAP 12.620000080060497 PROGRESSIVE HARMONIZED VEGAN PROTEIN POWDER ORL PWR BPN G 0.058200080053887 PRO-K 20 20 MEQ SUSTAINED-RELEASE TABLET ORL TAB PDL TAB 0.199500002204606 PROLASTIN-C 1 G/VIAL INJECTION INJ DEFAUL GRL VIAL 429.060000002439123 PROLENSA 0.07% OPHTHALMIC SOLUTION OPH SOL BSH ML 8.063300002311372 PRO-LEVETIRACETAM-250 250 MG TABLET ORL TAB PDL TAB 0.321000002311380 PRO-LEVETIRACETAM-500 500 MG TABLET ORL TAB PDL TAB 0.391100002311399 PRO-LEVETIRACETAM-750 750 MG TABLET ORL TAB PDL TAB 0.541600002310988 PRO-LISINOPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.161900002310996 PRO-LISINOPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.194500002310961 PRO-LISINOPRIL-5 5 MG TABLET ORL TAB PDL TAB 0.134700000655643 PRO-LORAZEPAM 0.5 MG TABLET ORL TAB PDL TAB 0.035900000655651 PRO-LORAZEPAM 1.0 MG TABLET ORL TAB PDL TAB 0.044700000655678 PRO-LORAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.069900002314908 PRO-METFORMIN 500 MG TABLET ORL TAB PDL TAB 0.044400002314894 PRO-METFORMIN 850 MG TABLET ORL TAB PDL TAB 0.0610

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002310953 PRO-NAPROXEN EC - 500 500 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.211000002243784 PROPAFENONE-300 300 MG TABLET ORL TAB PDL TAB 0.522700002238213 PROPECIA 1 MG TABLET ORL TAB MFC TAB 1.891800002468336 PROPOFOL 10 MG/ML INJECTION INJ DEFAUL BAX ML 0.460000002437643 PROPOFOL INJECTION 10 MG/ML INJECTION INJ DEFAUL FKC ML 0.460000002225883 PROPRANOLOL HYDROCHLORIDE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 28.985000000010219 PROPYL-THYRACIL 100 MG TABLET ORL TAB PAL TAB 0.373200002317354 PRO-QUETIAPINE 100 MG TABLET ORL TAB PDL TAB 0.237200002317362 PRO-QUETIAPINE 200 MG TABLET ORL TAB PDL TAB 0.476400002317346 PRO-QUETIAPINE 25 MG TABLET ORL TAB PDL TAB 0.088900002317370 PRO-QUETIAPINE 300 MG TABLET ORL TAB PDL TAB 0.695300002311224 PRO-QUININE-300 300 MG CAPSULE ORL CAP PDL CAP 0.375000002315181 PRO-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.066900002310023 PRO-RAMIPRIL-1.25 1.25 MG CAPSULE ORL CAP/TAB PDL CAP 0.070800002310104 PRO-RAMIPRIL-10 10 MG CAPSULE ORL CAP/TAB PDL CAP 0.103400002310066 PRO-RAMIPRIL-2.5 2.5 MG CAPSULE ORL CAP/TAB PDL CAP 0.081700002310074 PRO-RAMIPRIL-5 5 MG CAPSULE ORL CAP/TAB PDL CAP 0.081700002312700 PRO-RISPERIDONE 0.25 MG TABLET ORL TAB PDL TAB 0.103600002312719 PRO-RISPERIDONE 0.5 MG TABLET ORL TAB PDL TAB 0.173500002312727 PRO-RISPERIDONE 1 MG TABLET ORL TAB PDL TAB 0.239700002312735 PRO-RISPERIDONE 2 MG TABLET ORL TAB PDL TAB 0.479500002312743 PRO-RISPERIDONE 3 MG TABLET ORL TAB PDL TAB 0.718000002312751 PRO-RISPERIDONE 4 MG TABLET ORL TAB PDL TAB 0.957400002256975 PROSHIELD PLUS 1% TOPICAL OINTMENT TOP ONT SNE G 0.081300002316536 PRO-SOTALOL 160 MG TABLET ORL TAB PDL TAB 0.162300080030827 PROSTATE FORMULA DOUBLE STRENGTH PLUS ORL CAP WNP CAP 0.187500002313669 PRO-TOPIRAMATE 100 MG TABLET ORL TAB PDL TAB 0.458300002313677 PRO-TOPIRAMATE 200 MG TABLET ORL TAB PDL TAB 0.674800002313650 PRO-TOPIRAMATE 25 MG TABLET ORL TAB PDL TAB 0.243300000287709 PROTYLOL 10 MG CAPSULE ORL CAP PDL CAP 0.060900000513059 PROTYLOL 20 MG TABLET ORL TAB PDL TAB 0.169000002315173 PRO-VALACYCLOVIR 500 MG CAPLET ORL TAB PDL TAB 0.619800000729973 PROVERA 10 MG TABLET ORL TAB PFI TAB 0.915900000708917 PROVERA 2.5 MG TABLET ORL TAB PFI TAB 0.228500000030937 PROVERA 5 MG TABLET ORL TAB PFI TAB 0.451300000172944 PROVIODINE HYDRO 10% TOPICAL LIQUID TOP LIQ ROG ML 0.026000002239656 PROVOCHOLINE 100 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 40.000000002243834 PROVOCHOLINE 1280 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 487.000000002246492 PROVOCHOLINE 160 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 64.0000

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 92 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246493 PROVOCHOLINE 320 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 128.000000002313065 PRO-ZOPICLONE 5 MG TABLET ORL TAB PDL TAB 0.178200002313073 PRO-ZOPICLONE 7.5 MG TABLET ORL TAB PDL TAB 0.125000002468557 PRZ-SILDENAFIL 100 MG TABLET ORL TAB PCI TAB 6.529500080002201 PSN 056 CAPSULE ORL CAP PSN CAP 0.075000080072115 PSYLLIUM CAPSULES ORL CAP VTH CAP 0.062400009858122 PTU 50 MG TABLET ORL TAB PHE TAB 0.500000000466409 PULMOPHYLLINE 5.3 MG/ML ORAL ELIXIR ORL ELX RIV ML 0.008600002046733 PULMOZYME 1 ML AMPOULE INHALATION SOLUTION INH SOL HLR ML 16.295900002242439 PUREGON 100 IU/ML INJECTION INJ DEFAUL MFC ML 97.000000002242441 PUREGON 200 IU/ML INJECTION INJ DEFAUL MFC ML 194.000000002243948 PUREGON 833 IU/ML INJECTION CARTRIDGE INJ CTG MFC ML 808.3333

00080063103 PURELY INSPIRED ORGANIC PROTEIN POWDER (CHOCOLATE) ORL PWR IHS G 0.035000080056141 PUREPALEO PROTEIN ORAL POWDER ORL PWR DFH G 0.054900080039387 PURFEM VAGINAL OVULE VAG OVL MFI OVL 1.924000002317966 PURG-ODAN ORAL POWDER ORL PWDPKT ODN PCKT 9.950000000004723 PURINETHOL 50 MG TABLET ORL TAB TEV TAB 2.861000080009682 PYCNOGENOL 25 MG ORAL CASPULE ORL CAP NFN CAP 0.566500000476714 PYRIDIUM 100 MG TABLET ORL TAB ERF TAB 1.116700000497517 PYRIDOXINE HCL 100 MG/ML INJECTION INJ DEFAUL HSP ML 1.950000002245215 PYRIDOXINE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL BNQ ML 1.207000002339072 Q-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT QDP TAB 0.201600080015945 QUEST TABLET ORL TAB PLH TAB 0.394300002417790 QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.492600002417804 QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.666100002417812 QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.977600002417820 QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 1.327000002417782 QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.250100000695440 QUININE-ODAN 200 MG CAPSULE ORL CAP ODN CAP 0.239000000695459 QUININE-ODAN 300 MG CAPSULE ORL CAP ODN CAP 0.375000080039114 Q-UROL TABLET ORL TAB SLP TAB 0.833300002267667 RABAVERT VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL MFC VIAL 181.160000002423723 RAGWITEK 12 UNIT SUBLINGUAL TABLET SLG TAB ALK TAB 4.155300002299194 RALIVIA 100 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.284700002299208 RALIVIA 200 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 2.367100002299216 RALIVIA 300 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 3.457000002398877 RAN-AMLODIPINE 2.5 MG TABLET ORL TAB RAN TAB 0.076700002380684 RAN-CANDESARTAN 4 MG TABLET ORL TAB RAN TAB 0.3400

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 93 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002425017 RAN-CYPROTERONE/ETHINYL ESTRADIOL 2 MG/0.035MG TAB ORL TAB RAN TAB 1.111400002423979 RAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT RAN TAB 1.869000002423987 RAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC RAN TAB 1.8690

00002330156 RAN-FENTANYL MATRIX 100 MCG/HR TRANSDERMAL PATCH TRD PTH RAN PTH 12.050000002330105 RAN-FENTANYL MATRIX 12 MCG/HR TRANSDERMAL PATCH TRD PTH RAN PTH 2.228000002330113 RAN-FENTANYL MATRIX 25 MCG/HR TRANSDERMAL PATCH TRD PTH RAN PTH 3.656000002330148 RAN-FENTANYL MATRIX 75 MCG/HR TRANSDERMAL PATCH TRD PTH RAN PTH 9.680000002319055 RAN-GABAPENTIN 100 MG CAPSULE ORL CAP RAN CAP 0.041600002319071 RAN-GABAPENTIN 400 MG CAPSULE ORL CAP RAN CAP 0.120600002351706 RAN-IMIPENEM-CILASTATIN 500 MG/500 MG/VIAL INJ INJ DEFAUL RAN VIAL 21.940000000740748 RANITIDINE 150 MG TABLET ORL TAB PDL TAB 0.180000002256711 RANITIDINE 25 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.397600000740756 RANITIDINE 300 MG TABLET ORL TAB PDL TAB 0.360000002269031 RAN-METFORMIN 500 MG TABLET ORL TAB RAN TAB 0.024700002269058 RAN-METFORMIN 850 MG TABLET ORL TAB RAN TAB 0.033900002414112 RAN-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB RAN TAB 5.355400002414090 RAN-OLANZAPINE ODT 5 MG ORAL DISINT. TABLET ORL DISNTAB RAN TAB 0.357500002392852 RAN-PREGABALIN 225 MG CAPSULE ORL CAP RAN CAP 1.727000002452103 RAN-TADALAFIL 10 MG TABLET ORL TAB RAN TAB 11.925000002452111 RAN-TADALAFIL 20 MG TABLET ORL TAB RAN TAB 12.357500002452073 RAN-TADALAFIL 5 MG TABLET ORL TAB RAN TAB 3.647100002388197 RAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB RAN TAB 0.626400002363062 RAN-VALSARTAN 40 MG TABLET ORL TAB RAN TAB 0.523900002361663 RAPAFLO 4 MG CAPSULE ORL CAP ALL CAP 1.896700002361671 RAPAFLO 8 MG CAPSULE ORL CAP ALL CAP 1.896800002247111 RAPAMUNE 1 MG TABLET ORL TAB PFI TAB 8.548600002243237 RAPAMUNE 1 MG/ML ORAL LIQUID ORL LIQ PFI ML 8.548700002302063 RASILEZ 150 MG TABLET ORL TAB NOD TAB 1.340700002302071 RASILEZ 300 MG TABLET ORL TAB NOD TAB 1.340700002332728 RASILEZ HCT 150 MG/12.5 MG TABLET ORL TAB NOD TAB 1.300700002332736 RASILEZ HCT 150 MG/25 MG TABLET ORL TAB NOD TAB 1.300700002332744 RASILEZ HCT 300 MG/12.5 MG TABLET ORL TAB NOD TAB 1.300700002332752 RASILEZ HCT 300 MG/25 MG TABLET ORL TAB NOD TAB 1.300700002350335 RATIO-ATORVASTATIN 80 MG TABLET ORL TAB TEV TAB 0.234200002242931 RATIO-METFORMIN HYDROCHLORIDE 850 MG TABLET ORL TAB TEV TAB 0.033900002194163 RATIO-NYSTATIN 100,000 UNIT/G VAGINAL CREAM VAG CRM RPH G 0.319100000989994 RCF SOY FREE FORMULA ORL LIQ ABN ML 0.021100002238337 REACTINE 1 MG/ML ORAL SYRUP ORL SYR MCL ML 0.0660

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 94 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002223554 REACTINE 10 MG TABLET ORL TAB MCL TAB 0.730000001900978 REACTINE 20 MG TABLET ORL TAB MCL TAB 0.859500002223546 REACTINE 5 MG TABLET ORL TAB MCL TAB 0.506700002246162 REACTINE ALLERGY & SINUS EXTENDED-RELEASE TABLET ORL ERT MCL TAB 0.730000002368064 REACTINE ALLERGY LIQUID GELS 10 MG CAPSULE ORL CAP MCL CAP 0.729600002358352 REACTINE FAST MELT 10 MG ODT ORL ODT MCL TAB 0.649200002245977 RECOMBIVAX HB (DIALYSIS-PRESER FREE) 40 MCG/ML INJ INJ DEFAUL MFC ML 184.800000002243676 RECOMBIVAX HB (PRESERVATIVE FREE) 5MCG/0.5ML INJ INJ DEFAUL MFC ML 22.800000080038685 RECOVERY EXTRA STRENGTH POWDER ORL PWR NMC G 0.148700002463113 REDDY-PROGESTERONE 100 MG CAPSULE ORL CAP DRL CAP 1.133000000897221 REDOXON (LEMON) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.264000000897256 REDOXON (ORANGE) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.246000002138670 REFRESH 1.4% OPH SOLUTION OPH SOL ALL ML 0.853300000999013 REFRESH ENDURA OPH SOLUTION OPH DEV ALL DEV 0.978800002244650 REFRESH LIQUIGEL 1% OPH SOLUTION OPH SOL ALL ML 0.514000002399148 REFRESH OPTIVE ADVANCED NAS SOL ALL ML 0.895000002435578 REFRESH OPTIVE FUSION OPH SOLUTION OPH SOL ALL ML 0.950000002049260 REFRESH PLUS 0.5% OPH SOLUTION OPH SOL ALL ML 0.759200002231008 REFRESH TEARS 0.5% OPH SOLUTION OPH SOL ALL ML 0.416700002242592 REGULAR VITA-VIM CAPLET ORL TAB JAM TAB 0.101200002474093 REKOVELLE 12 MCG/0.36 ML INJECTION CARTRIDGE INJ DEFAUL FEI ML 595.000000002487462 REKOVELLE 12 MCG/0.36 ML PEN INJECTION INJ NDL FEI SYR 214.200000002474085 REKOVELLE 36 MCG/1.08 ML INJECTION CARTRIDGE INJ DEFAUL FEI ML 595.000000002487470 REKOVELLE 36 MCG/1.08 ML PEN INJECTION INJ NDL FEI SYR 642.600000002474077 REKOVELLE 72 MCG/2.16 ML INJECTION CARTRIDGE INJ DEFAUL FEI ML 595.000000002487489 REKOVELLE 72 MCG/2.16 ML PEN INJECTION INJ NDL FEI SYR 1285.200000002240863 RELENZA 5 MG/DOSE INHALATION DISK INH DSK GSK DISC 7.688000002308215 RELISTOR 20 MG/ML INJECTION INJ DEFAUL SLX ML 67.883300002256290 RELPAX 20 MG TABLET ORL TAB UJC TAB 15.200000002256304 RELPAX 40 MG TABLET ORL TAB UJC TAB 15.200000002248542 REMERON RD 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.473300002248543 REMERON RD 30 MG ORAL DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.946700002248544 REMERON RD 45 MG ORAL DISINTEGRATING TABLET ORL DISNTAB MFC TAB 1.420000002244016 REMICADE 100 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 962.680000002344424 REMIFENTANIL 1 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 10.173000002366460 REMIFENTANIL 1 MG/VIAL INJECTION INJ DEFAUL STM VIAL 11.683000002344432 REMIFENTANIL 2 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 20.347000002366479 REMIFENTANIL 2 MG/VIAL INJECTION INJ DEFAUL STM VIAL 23.366000002246552 REMODULIN 1 MG/ML INJECTION INJ DEFAUL NTH ML 45.000000002246555 REMODULIN 10 MG/ML INJECTION INJ DEFAUL NTH ML 450.0000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246553 REMODULIN 2.5 MG/ML INJECTION INJ DEFAUL NTH ML 112.500000002246554 REMODULIN 5 MG/ML INJECTION INJ DEFAUL NTH ML 225.000000080022277 RENA CODE ORAL LIQUID ORL LIQ AEI ML 1.000000002244310 RENAGEL 800 MG TABLET ORL TAB SAV TAB 1.700000002485559 RENVELA 0.8 G ORAL POWDER PACKET ORL PWDPKT SAV PCKT 1.263400002485567 RENVELA 2.4 G ORAL POWDER PACKET ORL PWDPKT SAV PCKT 3.790200002354586 RENVELA 800 MG TABLET ORL TAB SAV TAB 1.263400002415968 REPAGLINIDE 0.5 MG TABLET ORL TAB PDL TAB 0.080800002415976 REPAGLINIDE 1 MG TABLET ORL TAB PDL TAB 0.084000002415984 REPAGLINIDE 2 MG TABLET ORL TAB PDL TAB 0.087300080039889 REPAGYN VAGINAL SUPPOSITORY VAG SUP FAR SUP 2.005000002249057 REPLAGAL 1 MG/ML INJECTION INJ DEFAUL PAL ML 657.142900002377012 RESOTRAN 1 MG FILM-COATED TABLET ORL TAB JAI TAB 2.582500002377020 RESOTRAN 2 MG FILM-COATED TABLET ORL TAB JAI TAB 3.977500009853170 RESOURCE 2.0 ORAL LIQUID ORL LIQ NHN ML 0.008700002355655 RESTASIS 0.05% OPHTHALMIC EMULSION OPH EML ALL ML 9.030800002476835 RESTASIS MULTIDOSE 0.05% OPHTHALMIC EMULSION OPH EML ALL ML 33.385500002318164 RESTORALAX ORAL POWDER ORL PWR BIC G 0.063000000443816 RETIN-A 0.025% TOPICAL GEL TOP GEL VCL G 0.460700000443794 RETIN-A 0.05% TOPICAL CREAM TOP CRM VCL G 0.460700002264633 RETIN-A MICRO 0.04% TOPICAL GEL TOP GEL VCL G 1.279800002243914 RETIN-A MICRO 0.1% GEL TOP GEL VCL G 1.279800002306980 RETISERT 0.59 MG INTRAVITREAL IMPLANT OPH IMP BSH SYS 16000.000000001902660 RETROVIR 100 MG CAPSULE ORL CAP GSK CAP 2.068100001902652 RETROVIR 50 MG/5 ML ORAL SYRUP ORL SYR GSK ML 0.226200002279401 REVATIO 20 MG TABLET ORL TAB UJC TAB 11.847800002213826 REVIA 50 MG TABLET ORL TAB BAR TAB 7.302800002304902 REVLIMID 10 MG CAPSULE ORL CAP CLG CAP 361.000000002317699 REVLIMID 15 MG CAPSULE ORL CAP CLG CAP 382.000000002459418 REVLIMID 2.5 MG CAPSULE ORL CAP CLG CAP 329.500000002440601 REVLIMID 20 MG CAPSULE ORL CAP CLG CAP 403.000000002317710 REVLIMID 25 MG CAPSULE ORL CAP CLG CAP 424.000000002304899 REVLIMID 5 MG CAPSULE ORL CAP CLG CAP 340.000000002361825 REVOLADE 25 MG TABLET ORL TAB NOV TAB 65.000000002361833 REVOLADE 50 MG TABLET ORL TAB NOV TAB 130.000000002248610 REYATAZ 150 MG CAPSULE ORL CAP BMS CAP 11.551700002248611 REYATAZ 200 MG CAPSULE ORL CAP BMS CAP 11.551700002294176 REYATAZ 300 MG CAPSULE ORL CAP BMS CAP 23.103300002220806 RHINARIS LUBRICATING NASAL GEL NAS GEL PMS G 0.268900000732230 RHINARIS NASAL AEROSOL NAS AER PMS DOSE 0.1933

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002352699 RHINARIS NASAL GEL NAS GEL PMS G 0.166300002354551 RHINARIS NASAL MIST NAS SPM PMS DOSE 0.153000080058002 RHINARIS NOZOIL NASAL SPRAY NAS SPR PPH ML 0.989000001950541 RHINARIS-CS 2% NASAL SOLUTION NAS SOL PPH ML 0.7677

00002231923 RHINOCORT AQUA 64 MCG/DOSE METERED DOSE NAS. SPRAY NAS SPM MCL DOSE 0.0920

00002035324 RHINOCORT TURBUHALER 100 MCG/METERED DOSE AEROSOL NAS AEM AZC DOSE 0.125200080026370 RHODIOLA ROSEA CAPSULE ORL CAP AOR CAP 0.254600002260107 RHOXAL-ANAGRELIDE 0.5 MG CAPSULE ORL CAP SDZ CAP 3.349100002269589 RHOXAL-GLIMEPIRIDE 1 MG TABLET ORL TAB SDZ TAB 0.818700002269597 RHOXAL-GLIMEPIRIDE 2 MG TABLET ORL TAB SDZ TAB 0.980000002269619 RHOXAL-GLIMEPIRIDE 4 MG TABLET ORL TAB SDZ TAB 1.0487

00002243559 RHOXAL-ORPHENADRINE 100 MG EXTENDED-RELEASE TABLET ORL ERT SDZ TAB 1.192600000309702 RIBOFLAVINE 100 MG TABLET ORL TAB JAM TAB 0.085000080028321 RICOLA THROAT LOZENGE ORL LOZ RIC G 0.030500002091887 RIFADIN 150 MG CAPSULE ORL CAP SAV CAP 0.676500002092808 RIFADIN 300 MG CAPSULE ORL CAP SAV CAP 1.064900002495155 RINVOQ 15 MG EXTENDED-RELEASE TABLET ORL ERT ABV TAB 48.680000002347474 RISEDRONATE 35 MG TABLET ORL TAB PDL TAB 1.977500002298465 RISPERDAL CONSTA 12.5 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 82.000000002457350 RITUXAN SC 120 MG/ML INJECTION INJ DEFAUL HLR ML 198.386700002270889 RIVA-ALENDRONATE 70 MG TABLET ORL TAB RIV TAB 2.102500002247217 RIVA-AMIODARONE 200 MG TABLET ORL TAB RIV TAB 0.514700002331500 RIVA-AMLODIPINE 10 MG TABLET ORL TAB RIV TAB 0.199300002331489 RIVA-AMLODIPINE 2.5 MG TABLET ORL TAB RIV TAB 0.076700002331497 RIVA-AMLODIPINE 5 MG TABLET ORL TAB RIV TAB 0.134300002392259 RIVA-ANASTROZOLE 1 MG TABLET ORL TAB RIV TAB 0.952300002242093 RIVA-ATENOLOL 100 MG TABLET ORL TAB RIV TAB 0.182100002242094 RIVA-ATENOLOL 50 MG TABLET ORL TAB RIV TAB 0.110700002405962 RIVA-ATOMOXETINE 10 MG CAPSULE ORL CAP RIV CAP 2.310000002405970 RIVA-ATOMOXETINE 18 MG CAPSULE ORL CAP RIV CAP 2.652300002405989 RIVA-ATOMOXETINE 25 MG CAPSULE ORL CAP RIV CAP 2.928000002405997 RIVA-ATOMOXETINE 40 MG CAPSULE ORL CAP RIV CAP 3.337300002406004 RIVA-ATOMOXETINE 60 MG CAPSULE ORL CAP RIV CAP 3.702300002422751 RIVA-ATORVASTATIN 10 MG TABLET ORL TAB RIV TAB 0.174300002422778 RIVA-ATORVASTATIN 20 MG TABLET ORL TAB RIV TAB 0.217900002422786 RIVA-ATORVASTATIN 40 MG TABLET ORL TAB RIV TAB 0.234200002422794 RIVA-ATORVASTATIN 80 MG TABLET ORL TAB RIV TAB 0.2342

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002303264 RIVA-CITALOPRAM 20 MG TABLET ORL TAB RIV TAB 0.239700002303272 RIVA-CITALOPRAM 40 MG TABLET ORL TAB RIV TAB 0.239700002242077 RIVA-CLONAZEPAM 0.5 MG TABLET ORL TAB RIV TAB 0.041800002388529 RIVA-CLOPIDOGREL 75 MG TABLET ORL TAB RIV TAB 0.263100002242468 RIVACOCET 5 MG/325 MG TABLET ORL TAB RIV TAB 0.128500002424436 RIVA-EZETIMIBE 10 MG TABLET ORL TAB RIV TAB 0.326000002247306 RIVA-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP RIV CAP 0.272300002251167 RIVA-GABAPENTIN 100 MG CAPSULE ORL CAP RIV CAP 0.041600002251175 RIVA-GABAPENTIN 300 MG CAPSULE ORL CAP RIV CAP 0.101200002251183 RIVA-GABAPENTIN 400 MG CAPSULE ORL CAP RIV CAP 0.120600002341085 RIVA-LATANOPROST 0.005% OPHTHALMIC SOLUTION OPH SOL RIV ML 3.632000002459205 RIVA-LATANOPROST/TIMOLOL 0.005%/0.5% OPH SOLUTION OPH SOL RIV ML 4.428000002492725 RIVA-LEVOFLOXACIN 250 MG TABLET ORL TAB RIV TAB 3.108000002492733 RIVA-LEVOFLOXACIN 500 MG TABLET ORL TAB RIV TAB 3.507000002239081 RIVA-METFORMIN 500 MG TABLET ORL TAB RIV TAB 0.024700002242783 RIVA-METFORMIN 850 MG TABLET ORL TAB RIV TAB 0.033900002265265 RIVA-MIRTAZAPINE 30 MG TABLET ORL TAB RIV TAB 0.195000002228300 RIVANASE AQ 50 MCG/DOSE METER DOSE NASAL SPRAY NAS SPM RIV DOSE 0.061300002337150 RIVA-OLANZAPINE 10 MG TABLET ORL TAB RIV TAB 0.708800002337169 RIVA-OLANZAPINE 15 MG TABLET ORL TAB RIV TAB 1.063100002337126 RIVA-OLANZAPINE 2.5 MG TABLET ORL TAB RIV TAB 0.177200002337134 RIVA-OLANZAPINE 5 MG TABLET ORL TAB RIV TAB 0.354400002337142 RIVA-OLANZAPINE 7.5 MG TABLET ORL TAB RIV TAB 0.531600002339838 RIVA-OLANZAPINE ODT 10 MG ORAL DISINT. TABLET ORL DISNTAB RIV TAB 1.285700002339846 RIVA-OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB RIV TAB 1.913700002392399 RIVA-OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB RIV TAB 2.544700002339811 RIVA-OLANZAPINE ODT 5 MG ORAL DISINT. TABLET ORL DISNTAB RIV TAB 0.643400002402416 RIVA-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT RIV TAB 0.411700002316463 RIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.201600002330083 RIVA-RABEPRAZOLE EC 10 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.066900002341077 RIVA-RISEDRONATE 35 MG TABLET ORL TAB RIV TAB 1.978700002380056 RIVA-ROSUVASTATIN 10 MG TABLET ORL TAB RIV TAB 0.135400002380064 RIVA-ROSUVASTATIN 20 MG TABLET ORL TAB RIV TAB 0.169200002380102 RIVA-ROSUVASTATIN 40 MG TABLET ORL TAB RIV TAB 0.199000002380013 RIVA-ROSUVASTATIN 5 MG TABLET ORL TAB RIV TAB 0.128400002202352 RIVASA CROQUABLE 80 MG TABLET ORL CTB RIV TAB 0.056000001949292 RIVA-SENNA 8.6 MG TABLET ORL TAB RIV TAB 0.046400002240112 RIVASOL-HC RECTAL SUPPOSITORY RT SUP RIV SUP 0.583300001940112 RIVASONE SCALP 0.1% TOPICAL LOTION TOP LOT RIV ML 0.085300002242157 RIVA-SOTALOL 160 MG TABLET ORL TAB RIV TAB 0.1623

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002416999 RIVASTIGMINE 1.5 MG CAPSULE ORL CAP PDL CAP 0.651400002417006 RIVASTIGMINE 3 MG CAPSULE ORL CAP PDL CAP 0.651400002417014 RIVASTIGMINE 4.5 MG CAPSULE ORL CAP PDL CAP 0.651400002417022 RIVASTIGMINE 6 MG CAPSULE ORL CAP PDL CAP 0.651400002316447 RIVA-VALACYCLOVIR 500 MG CAPLET ORL TAB RIV TAB 0.619800002307790 RIVA-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAP ORL ERC RIV CAP 0.346900002307774 RIVA-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAP ORL ERC RIV CAP 0.1643

00002307782 RIVA-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC RIV CAP 0.328500002248082 RIVA-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT RIV TAB 0.507500002278030 RIVA-ZOPICLONE 5 MG TABLET ORL TAB RIV TAB 0.099000002278049 RIVA-ZOPICLONE 7.5 MG TABLET ORL TAB RIV TAB 0.125000002415801 RIZATRIPTAN ODT 10 MG ORAL DISINT. TABLET ORL DISNTAB PDL TAB 3.705000002415798 RIZATRIPTAN ODT 5 MG ORAL DISINT. TABLET ORL DISNTAB PDL TAB 3.705000002247147 ROBAX PLATINUM TABLET ORL TAB PDH TAB 0.636100002026805 ROBAXACET CAPLET ORL TAB PDH TAB 0.468900002231176 ROBAXACET EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.515000001934767 ROBAXACET-8 TABLET ORL TAB PDH TAB 0.727900001930990 ROBAXIN 500 MG TABLET ORL TAB PDH TAB 0.375600001932187 ROBAXIN-750 750 MG TABLET ORL TAB PDH TAB 0.469800002230949 ROBAXISAL EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.515000001934791 ROBAXISAL-C 1/2 TABLET ORL TAB PDH TAB 1.178800001934783 ROBAXISAL-C 1/4 TABLET ORL TAB PDH TAB 0.986700001931032 ROBITUSSIN 20 MG ORAL SYRUP ORL SYR PDH ML 0.050800002142783 ROBITUSSIN 200 MG/5 ML EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.050800001934740 ROBITUSSIN A-C ORAL SYRUP ORL SYR PDH ML 0.101900002068419 ROBITUSSIN COUGH AND COLD ORAL SYRUP ORL SYR PDH ML 0.050800002142775 ROBITUSSIN DM EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.050800001931024 ROBITUSSIN DM ORAL SYRUP ORL SYR PDH ML 0.050800002469774 ROCURONIUM BROMIDE 10 MG/ML INJECTION INJ DEFAUL JUN ML 1.000000002318415 ROCURONIUM BROMIDE 10 MG/ML INJECTION INJ DEFAUL SDZ ML 1.026000002382415 ROCURONIUM BROMIDE INJECTION 10 MG/ML INJECTION INJ DEFAUL OMG ML 2.400000002318121 ROCURONIUM BROMIDE INJECTION 10 MG/ML INJECTION INJ DEFAUL HSP ML 2.778000000393444 ROFACT 150 MG CAPSULE ORL CAP VCL CAP 0.753600000343617 ROFACT 300 MG CAPSULE ORL CAP VCL CAP 1.186200000708925 ROGAINE 20 MG/ML TOPICAL SOLUTION TOP SOL JJI ML 0.610200002242979 ROGITINE 10 MG/ML INJECTION INJ DEFAUL PAL ML 46.996000002440342 ROSIVER 1% TOPICAL CREAM TOP CRM GAL G 2.918200002381184 ROSUVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.135400002381192 ROSUVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.1692

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002381206 ROSUVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.199000002381176 ROSUVASTATIN 5 MG TABLET ORL TAB PDL TAB 0.128400002300591 ROTARIX 1 000 000 CCID50/DOSE (1.5ML) ORAL SUSP ORL SUS GSK DOSE 881.620000002284413 ROTATEQ (2 ML/DOSE) ORAL SOLUTION ORL SOL MFC ML 31.715000002495007 ROZLYTREK 100 MG CAPSULE ORL CAP HLR CAP 47.666600002495015 ROZLYTREK 200 MG CAPSULE ORL CAP HLR CAP 95.333300002248563 RUB A535 DUAL ACTION TOP CRM CHD G 0.066100002222116 RUB A-535 EXTRA STRENGTH TOP CRM CHD G 0.057000080015240 RUGBY NICOTINE POLACRILEX; NIC-ASSIST 2 MG GUM ORL GUM APH PIECE 0.165000002456478 RUPALL 1 MG/ML ORAL SOLUTION ORL SOL PPI ML 0.115500002456451 RUPALL 10 MG TABLET ORL TAB PPI TAB 0.783700002503034 RUZURGI 10 MG TABLET ORL TAB MDK TAB 27.397300002497611 RYBELSUS 14 MG TABLET ORL TAB NNA TAB 6.966300002497581 RYBELSUS 3 MG TABLET ORL TAB NNA TAB 6.966300002497603 RYBELSUS 7 MG TABLET ORL TAB NNA TAB 6.966300002466236 RYDAPT 25 MG CAPSULE ORL CAP NOV CAP 167.924800002453258 S.O.S. NALOXONE HYDROCHLORIDE INJ 0.4 MG/ML INJ INJ DEFAUL SDZ ML 16.5000

00009858115 SALAMOL CFC-FREE 100 MCG/DOSE METERED DOSE AEROSOL INH AEM TEV DOSE 0.027300002064480 SALAZOPYRIN 500 MG TABLET ORL TAB PFI TAB 0.337700002064472 SALAZOPYRIN EN-TABS 500 MG ENTERIC-COATED TABLET ORL ECT PFI TAB 0.5151

00009858116 SALBUTAMOL ALDO-UNION 100 MCG/DOSE METER DOSE AERO INH AEM JPC DOSE 0.043800000623571 SALIJECT 570 MG/ML INJECTION INJ DEFAUL OMG ML 1.850000080024381 SALINEX 9 MG/ML NASAL SPRAY NAS SPR EXP ML 0.130700000779296 SALINEX NASAL LUBRICANT GEL NAS GEL SDZ G 0.140700001910701 SALINEX NASAL LUBRICANT SPRAY NAS SPR SDZ ML 0.169700080004542 SALMON & FISH OILS 1000 MG SOFTGEL ORL CAP WNP CAP 0.056800080003356 SALMON AND FISH OILS ORAL CAPSULE ORL CAP JAM CAP 0.092300000999494 SAME (S-ADENOSYLMETHIONINE) ORL TAB XXX MIS 1.216700002370468 SAMSCA 15 MG TABLET ORL TAB OTS TAB 90.411000002370476 SAMSCA 30 MG TABLET ORL TAB OTS TAB 90.411000000593257 SANDIMMUNE I.V. 50 MG/ML INJECTION INJ DEFAUL NOV ML 4.725000002486393 SANDOZ ABIRATERONE 250 MG TABLET ORL TAB SDZ TAB 26.0312

00002489007 SANDOZ ADAPALENE/BENZOYL PEROXIDE 0.1%/2.5% TOP GL TOP GEL SDZ G 1.2719

00002457296 SANDOZ AMPHETAMINE XR 10 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 2.0758

00002457318 SANDOZ AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 2.3250

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 100 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002457326 SANDOZ AMPHETAMINE XR 20 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 2.5743

00002457334 SANDOZ AMPHETAMINE XR 25 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 2.8235

00002457342 SANDOZ AMPHETAMINE XR 30 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 3.072900002457288 SANDOZ AMPHETAMINE XR 5 MG EXTENDED-RELEASE CAP ORL ERC SDZ CAP 1.826600002338467 SANDOZ ANASTROZOLE 1 MG TABLET ORL TAB SDZ TAB 2.545700002247691 SANDOZ ANUZINC HC OINTMENT RT ONT SDZ G 0.385000002386410 SANDOZ ATOMOXETINE 10 MG CAPSULE ORL CAP SDZ CAP 2.314000002386488 SANDOZ ATOMOXETINE 100 MG CAPSULE ORL CAP SDZ CAP 4.352000002386429 SANDOZ ATOMOXETINE 18 MG CAPSULE ORL CAP SDZ CAP 2.652300002386437 SANDOZ ATOMOXETINE 25 MG CAPSULE ORL CAP SDZ CAP 2.928000002386445 SANDOZ ATOMOXETINE 40 MG CAPSULE ORL CAP SDZ CAP 3.337300002386453 SANDOZ ATOMOXETINE 60 MG CAPSULE ORL CAP SDZ CAP 3.702300002386461 SANDOZ ATOMOXETINE 80 MG CAPSULE ORL CAP SDZ CAP 3.996000002276089 SANDOZ BICALUTAMIDE 50 MG TABLET ORL TAB SDZ TAB 4.057300002247440 SANDOZ BISOPROLOL 10 MG TABLET ORL TAB SDZ TAB 0.104400002386283 SANDOZ BOSENTAN 125 MG TABLET ORL TAB SDZ TAB 48.134000002386275 SANDOZ BOSENTAN 62.5 MG TABLET ORL TAB SDZ TAB 48.134000002326957 SANDOZ CANDESARTAN 4 MG TABLET ORL TAB SDZ TAB 0.340000002421917 SANDOZ CAPECITABINE 150 MG TABLET ORL TAB SDZ TAB 1.464000002421925 SANDOZ CAPECITABINE 500 MG TABLET ORL TAB SDZ TAB 4.8800

00002506882SANDOZ CIPROFLOXACIN/DEXAMETHASONE OTIC SUSPENSION OT SUS SDZ ML 3.2680

00002495023 SANDOZ CLOBETASOL 0.05% TOPICAL SPRAY TOP SPR SDZ ML 1.925900002237450 SANDOZ D-FORTE 50000 IU CAPSULE ORL CAP SDZ CAP 0.228400002261960 SANDOZ DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT SDZ TAB 0.202400002400596 SANDOZ DICLOFENAC MISOPROSTOL 50 MG/200 MCG ECT ORL ECT SDZ TAB 0.314900002400618 SANDOZ DICLOFENAC MISOPROSTOL 75 MG/200 MCG ECT ORL ECT SDZ TAB 0.428600002261774 SANDOZ DICLOFENAC RAPIDE 50 MG TABLET ORL TAB SDZ TAB 0.3937

00002245920 SANDOZ DILTIAZEM T 240 MG EXTENDED-RELEASE CAPSULE ORL ERC SDZ CAP 0.3832

00002245921 SANDOZ DILTIAZEM T 300 MG EXTENDED-RELEASE CAPSULE ORL ERC SDZ CAP 0.471900002247385 SANDOZ DOCUSATE SODIUM 100 MG CAPSULE ORL CAP SDZ CAP 0.032800002484676 SANDOZ EFAVIRENZ/EMTRICITABINE/TENOFOVIR TABLET ORL TAB SDZ TAB 22.6600

00002460920 SANDOZ ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT SDZ TAB 1.8690

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002460939 SANDOZ ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC SDZ TAB 1.869000002492946 SANDOZ EVEROLIMUS 10 MG TABLET ORL TAB SDZ TAB 172.256000002492911 SANDOZ EVEROLIMUS 2.5 MG TABLET ORL TAB SDZ TAB 172.256000002492938 SANDOZ EVEROLIMUS 5 MG TABLET ORL TAB SDZ TAB 172.256000002278634 SANDOZ FAMCICLOVIR 125 MG TABLET ORL TAB SDZ TAB 2.024000002278642 SANDOZ FAMCICLOVIR 250 MG TABLET ORL TAB SDZ TAB 2.720000002278650 SANDOZ FAMCICLOVIR 500 MG TABLET ORL TAB SDZ TAB 4.228100002390701 SANDOZ FENOFIBRATE E 145 MG TABLET ORL TAB SDZ TAB 0.911300002390698 SANDOZ FENOFIBRATE E 48 MG TABLET ORL TAB SDZ TAB 0.356000002288052 SANDOZ FENOFIBRATE S 160 MG TABLET ORL CAP/TAB SDZ TAB 0.2723

00002327139 SANDOZ FENTANYL PATCH 37 MCG/HR TRANSDERMAL PATCH TRD PTH SDZ PTH 8.500000002246590 SANDOZ FER 20 MG/ML ORAL SUSPENSION ORL SUS SDZ ML 0.078000002339471 SANDOZ FINASTERIDE A 1 MG TABLET ORL TAB SDZ TAB 1.145500002487748 SANDOZ GEFITINIB 250 MG TABLET ORL TAB SDZ TAB 62.305000002412926 SANDOZ HYDROCORTISONE 1% CREAM TOP CRM SDZ G 0.200000002469421 SANDOZ HYDROCORTISONE 2.5% TOPICAL CREAM TOP CRM SDZ G 0.332200002344815 SANDOZ LETROZOLE 2.5 MG TABLET ORL TAB SDZ TAB 2.756000002375532 SANDOZ MEMANTINE FCT 10 MG TABLET ORL TAB SDZ TAB 1.635700002354195 SANDOZ METOPROLOL (TYPE L) 100 MG TABLET ORL TAB SDZ TAB 0.125000002354187 SANDOZ METOPROLOL (TYPE L) 50 MG TABLET ORL TAB SDZ TAB 0.062400002456257 SANDOZ MIGLUSTAT 100 MG CAPSULE ORL CAP SDZ CAP 92.267600002250594 SANDOZ MIRTAZAPINE 15 MG TABLET ORL TAB SDZ TAB 0.375000002411520 SANDOZ MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL SDZ ML 3.756700002320630 SANDOZ MYCOPHENOLATE MOFETIL 250 MG CAPSULE ORL CAP SDZ CAP 1.031000002313855 SANDOZ MYCOPHENOLATE MOFETIL 500 MG TABLET ORL TAB SDZ TAB 2.062000002327791 SANDOZ OLANZAPINE ODT 15 MG ORAL DISINT. TABLET ORL DISNTAB SDZ TAB 5.355300002327805 SANDOZ OLANZAPINE ODT 20 MG ORAL DISINT. TABLET ORL DISNTAB SDZ TAB 7.597700002358913 SANDOZ OLOPATADINE 0.1% OPH SOLUTION OPH SOL SDZ ML 5.226000002420171 SANDOZ OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL SDZ ML 10.452000002301075 SANDOZ PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT SDZ TAB 1.275000002269422 SANDOZ PAROXETINE 10 MG TABLET ORL TAB SDZ TAB 1.043000002431777 SANDOZ PAROXETINE 10 MG TABLET ORL TAB SDZ TAB 1.043000002470411 SANDOZ PERINDOPRIL/INDAPAMIDE LD 2 MG/0.625 MG TAB ORL TAB SDZ TAB 0.718700002297906 SANDOZ PIOGLITAZONE 15 MG TABLET ORL TAB SDZ TAB 0.580900002297914 SANDOZ PIOGLITAZONE 30 MG TABLET ORL TAB SDZ TAB 0.813900002297922 SANDOZ PIOGLITAZONE 45 MG TABLET ORL TAB SDZ TAB 1.223700002239234 SANDOZ POLYTRIMETHOPRIM OPH SOLUTION OPH SOL SDZ ML 3.0490

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002496259 SANDOZ POSACONAZOLE 100 MG DELAYED-RELEASE TABLET ORL DRT SDZ TAB 42.603000002315270 SANDOZ PRAMIPEXOLE 0.5 MG TABLET ORL TAB SDZ TAB 1.386000002314002 SANDOZ QUETIAPINE 100 MG TABLET ORL TAB SDZ TAB 0.131800002314010 SANDOZ QUETIAPINE 200 MG TABLET ORL TAB SDZ TAB 0.264700002313995 SANDOZ QUETIAPINE 25 MG TABLET ORL TAB SDZ TAB 0.049400002314029 SANDOZ QUETIAPINE 300 MG TABLET ORL TAB SDZ TAB 0.386300002243229 SANDOZ RANITIDINE 150 MG TABLET ORL TAB SDZ TAB 0.119700002243230 SANDOZ RANITIDINE 300 MG TABLET ORL TAB SDZ TAB 0.225300002426307 SANDOZ RIVASTIGMINE PATCH 10 (9.5 MG/24 H) TRD PTH SDZ PTH 3.977300002426293 SANDOZ RIVASTIGMINE PATCH 5 (4.6 MG/24 H) TRD PTH SDZ PTH 3.977300002247390 SANDOZ SENNA S 8.6 MG/50 MG TABLET ORL TAB SDZ TAB 0.113500002475421 SANDOZ SILODOSIN 4 MG CAPSULE ORL CAP SDZ CAP 1.612300002475448 SANDOZ SILODOSIN 8 MG CAPSULE ORL CAP SDZ CAP 1.612200002247833 SANDOZ SIMVASTATIN 80 MG TABLET ORL TAB SDZ TAB 0.250100002416816 SANDOZ TACROLIMUS 0.5 MG CAPSULE ORL CAP SDZ CAP 1.477500002416824 SANDOZ TACROLIMUS 1 MG CAPSULE ORL CAP SDZ CAP 1.890000002416832 SANDOZ TACROLIMUS 5 MG CAPSULE ORL CAP SDZ CAP 9.465000002413817 SANDOZ TRAVOPROST/TIMOLOL PQ 0.004%/0.5% OPH SOL OPH SOL SDZ ML 11.288000002356740 SANDOZ VALSARTAN 40 MG TABLET ORL TAB SDZ TAB 0.524000002362996 SANDOZ ZOLMITRIPTAN ODT 2.5 MG ORAL DISP. TABLET ORL DISPTAB SDZ TAB 3.540000002253178 SANDOZ-D 10000 UNIT CAPSULE ORL CAP SDZ CAP 0.210000002498235 SARCLISA 100 MG/5 ML INJECTION INJ DEFAUL SAV ML 151.580000002498243 SARCLISA 500 MG/25 ML INJECTION INJ DEFAUL SAV ML 151.579600002266121 SATIVEX BUCCAL SPRAY BUC SPR BHP ML 19.769700002437899 SAXENDA 6 MG/ML PEN INJECTION SYRINGE INJ DEFAUL NNA ML 25.006700080041540 SCHINOUSSA PROBIOTIC WHEY ISOLATE ORAL POWDER ORL PWR QUA G 0.035700001919245 SCHOLL ATHLETE'S FOOT SPRAY 1% TOPICAL POWDER TOP PWR SCH G 0.059400002020939 SCLERODEX INJECTION INJ DEFAUL OMG ML 1.990000002020793 SCLERODINE 6 INJECTION INJ DEFAUL OMG ML 3.275000002242810 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML INJECTION INJ DEFAUL OMG ML 5.550000002242811 SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION INJ DEFAUL OMG ML 6.000000002296659 SEASONALE (91 DAY) TABLET ORL TBT TMP TAB 0.677300002346176 SEASONIQUE (91 DAY) TABLET ORL TAB TMP TAB 0.665100000666106 SEBCUR 4% TOPICAL SHAMPOO TOP SHP DPT ML 0.062500000666114 SEBCUR-T TOPICAL SHAMPOO TOP SHP DPT ML 0.071700000551805 SECARIS NASAL GEL NAS GEL PMS G 0.324000002476223 SEGLUROMET 2.5 MG/1000 MG TABLET ORL TAB MFC TAB 1.225000002476215 SEGLUROMET 2.5 MG/500 MG TABLET ORL TAB MFC TAB 1.225000002476258 SEGLUROMET 7.5 MG/1000 MG TABLET ORL TAB MFC TAB 1.2250

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002476231 SEGLUROMET 7.5 MG/500 MG TABLET ORL TAB MFC TAB 1.225000002197502 SELECT 1/35 (21 DAY) TABLET ORL TAB PFI TAB 0.504300002199297 SELECT 1/35 (28 DAY) TABLET ORL TB PFI TAB 0.378200000633380 SELENIUM 100 MCG TABLET ORL TAB JAM TAB 0.087500000554987 SELENIUM 50 MCG TABLET ORL TAB JAM TAB 0.069900000243000 SELSUN 2.5% TOPICAL SOLUTION TOP SOL ABB ML 0.047500002320320 SELSUN BLUE 1% ANTI-DANDRUFF SHAMPOO TOP SHP SAH ML 0.0236

00002247134 SENNA LAXATIVE & DOCUSATE SODIUM 8.6MG/50MG TABLET ORL TAB VTH TAB 0.115200002237105 SENNA LAXATIVE 8.6 MG TABLET ORL TAB SDR TAB 0.024900080061813 SENNACE 8.6 MG TABLET ORL TAB VAN TAB 0.055500002257130 SENSIPAR 30 MG TABLET ORL TAB AMG TAB 12.065300002257149 SENSIPAR 60 MG TABLET ORL TAB AMG TAB 22.000700002257157 SENSIPAR 90 MG TABLET ORL TAB AMG TAB 32.014700001976141 SENSORCAINE 0.25% INJECTION INJ DEFAUL APC ML 6.820000001976184 SENSORCAINE 0.25% WITH EPINEPHRINE INJECTION INJ DEFAUL APC ML 0.800000001976168 SENSORCAINE 0.5% INJECTION INJ DEFAUL APC ML 0.811000001976206 SENSORCAINE 0.5% WITH EPINEPHRINE INJECTION INJ DEFAUL APC ML 0.952500002357704 SEPTA-AMLODIPINE 2.5 MG TABLET ORL TAB SEP TAB 0.076700002368668 SEPTA-ATENOLOL 100 MG TABLET ORL TAB SEP TAB 0.182100002368633 SEPTA-ATENOLOL 25 MG TABLET ORL TAB SEP TAB 0.067600002368641 SEPTA-ATENOLOL 50 MG TABLET ORL TAB SEP TAB 0.110700002379627 SEPTA-CIPROFLOXACIN 250 MG TABLET ORL TAB SEP TAB 0.618600002379635 SEPTA-CIPROFLOXACIN 500 MG TABLET ORL TAB SEP TAB 0.502500002379643 SEPTA-CIPROFLOXACIN 750 MG TABLET ORL TAB SEP TAB 1.278000002431629 SEPTA-CITALOPRAM 10 MG TABLET ORL TAB SEP TAB 0.143200002428539 SEPTA-LOSARTAN HCTZ 50 MG/12.5 MG TABLET ORL TAB SEP TAB 0.314600002379767 SEPTA-METFORMIN 500 MG TABLET ORL TAB SEP TAB 0.024700002379775 SEPTA-METFORMIN 850 MG TABLET ORL TAB SEP TAB 0.033900002376091 SEPTA-ONDANSETRON 4 MG TABLET ORL TAB SEP TAB 3.350000002376105 SEPTA-ONDANSETRON 8 MG TABLET ORL TAB SEP TAB 5.111000002386909 SEPTA-ZOPICLONE 5 MG TABLET ORL TAB SEP TAB 0.099000002386917 SEPTA-ZOPICLONE 7.5 MG TABLET ORL TAB SEP TAB 0.125000002247998 SERC 24 MG TABLET ORL TAB BGP TAB 0.734900000893722 SEROPHENE 50 MG TABLET ORL TAB SRO TAB 5.145000002239046 SEROSTIM 5 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 1633.000000002241304 SERTRALINE 100 MG CAPSULE ORL CAP PDL CAP 0.330300002241302 SERTRALINE 25 MG CAPSULE ORL CAP PDL CAP 0.151600002241303 SERTRALINE 50 MG CAPSULE ORL CAP PDL CAP 0.303200002468425 SHINGRIX 50 MCG/0.5 ML INJECTION INJ DEFAUL GSK VIAL 129.2000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002240344 SIALOR 25 MG TABLET ORL TAB PMS TAB 0.908200080009846 SIBERIAN GINSENG 650 MG CAPLET ORL TAB JMS TAB 0.140000080039305 SIERRASIL JOINT FORMULA 14 CAPSULE ORL CAP SMM CAP 0.212700002413299 SIGNIFOR 0.3 MG/ML INJECTION INJ DEFAUL NOV ML 79.624000002413302 SIGNIFOR 0.6 MG /ML INJECTION INJ DEFAUL NOV ML 87.901800002413310 SIGNIFOR 0.9 MG /ML INJECTION INJ DEFAUL NOV ML 87.901800002480425 SIGNIFOR LAR 10 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 4974.150000002437252 SIGNIFOR LAR 20 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 4974.150000002480433 SIGNIFOR LAR 30 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 4974.150000002437260 SIGNIFOR LAR 40 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 5048.760000002437279 SIGNIFOR LAR 60 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 5048.760000002406160 SILDENAFIL 100 MG TABLET ORL TAB SNS TAB 9.200000002424320 SILDENAFIL 100 MG TABLET ORL TAB PDL TAB 9.200000002317583 SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.200700002317559 SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 8.290000002406152 SILDENAFIL 50 MG TABLET ORL TAB SNS TAB 8.847500002317575 SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 8.848000002424312 SILDENAFIL 50 MG TABLET ORL TAB PDL TAB 8.847500002398257 SILENOR 3 MG TABLET ORL TAB PAL TAB 0.645000002398265 SILENOR 6 MG TABLET ORL TAB PAL TAB 1.290300080012979 SILICA WITH ZINC CAPLET ORL TAB JAM TAB 0.233300002473623 SILIQ 210 MG/1.5 ML INJECTION SYRINGE INJ NDL VCL SYR 645.000000002338572 SILKIS 3 MCG/G TOPICAL OINTMENT TOP ONT GAL G 1.362500000999893 SIMILAC ADVANCE CONC. OMEGA LIQUID ORL LIQ ABN ML 0.010400000999793 SIMILAC ADVANCE OMEGA 3 & 6 READY-TO-FEED BOTTLE ORL LIQ ABN ML 0.009900000999794 SIMILAC ADVANCE OMEGA 3 & 6 READY-TO-FEED CAN ORL LIQ ABN ML 0.011700000999454 SIMILAC ADVANCE OMEGA INFANT FORMULA ORL PWR ABN G 0.011700000999792 SIMILAC ADVANCE OMEGA-3 & 6 CONCENTRATED LIQUID ORL LIQ ABN ML 0.010400000999791 SIMILAC ADVANCE OMEGA-3 & 6 INFANT FORMULA PWR ORL PWR ABN G 0.041500000999863 SIMILAC ADVANCE STEP 1 FORMULA ORAL LIQUID ORL LIQ ABN ML 0.024000000999580 SIMILAC ADVANCE STEP 2 FORMULA ORAL LIQUID ORL LIQ ABN ML 0.0472

00000999892 SIMILAC ADVANCED IRON FORTIFIED OMEGA 3 & 6 POWDER ORL PWR ABN G 0.046000000999891 SIMILAC GO AND GROW INFANT FORMULA ORAL LIQUID ORL LIQ ABN ML 0.008700000999576 SIMILAC GO AND GROW INFANT FORMULA POWDER ORL PWR ABN G 0.025100000999784 SIMILAC GO AND GROW OMEGA 3 & 6 POWDER ORL PWR NHN G 0.041500000999789 SIMILAC ISOMIL OMEGA-3 & 6 INFANT FORMULA POWDER ORL PWR ABN G 0.030600000999790 SIMILAC ISOMIL STEP 2 INFANT FORMULA POWDER ORL PWR ABN G 0.030600000999894 SIMILAC LOWER IRON ADVANCE POWDER ORL PWR ABN G 0.029900000999875 SIMILAC MOM ORAL LIQUID ORL LIQ ABN ML 0.0080

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999797 SIMILAC PARTIALLY BROKEN DOWN PROTEIN POWDER ORL PWR ABN G 0.041800000999796 SIMILAC SENSITIVE INFANT FORMULA CONCENTRATED LIQ ORL LIQ ABN ML 0.010400000999795 SIMILAC SENSITIVE INFANT FORMULA POWDER ORL PWR ABN G 0.037500000999536 SIMILAC SENSITIVE LACTOSE-FREE ORL DEFAUL XXX MIS 0.053600000999851 SIMILAC TOTAL COMFORT ORL PWR ABN G 0.047100000999542 SIMPLYTHICK ORL GEL STH G 0.393000002417472 SIMPONI I.V. 50 MG/4.0 ML VIAL INJECTION INJ DEFAUL JAI ML 219.855000002247221 SIMVASTATIN-10 MG TABLET ORL TAB PDL TAB 0.202300002247222 SIMVASTATIN-20 MG TABLET ORL TAB PDL TAB 0.250100002247223 SIMVASTATIN-40 MG TABLET ORL TAB PDL TAB 0.250100002247224 SIMVASTATIN-80 80 MG TABLET ORL TAB PDL TAB 0.250100002028786 SINEMET CR 100/25 SUSTAINED-RELEASE TABLET ORL SRT MFC TAB 0.788800000870935 SINEMET CR 200/50 SUSTAINED-RELEASE TABLET ORL SRT MFC TAB 1.455000000024325 SINEQUAN 10 MG CAPSULE ORL CAP AAP CAP 0.370500000326925 SINEQUAN 100 MG CAPSULE ORL CAP AAP CAP 1.464000000024333 SINEQUAN 25 MG CAPSULE ORL CAP AAP CAP 0.454600000024341 SINEQUAN 50 MG CAPSULE ORL CAP AAP CAP 0.843300000400750 SINEQUAN 75 MG CAPSULE ORL CAP AAP CAP 1.113100080027304 SINUS RINSE HYPERTONIC NAS PWS NPI PCKT 0.192900001938371 SINUTAB NO DROWSINESS EXTRA STRENGTH TABLET ORL TAB MCL TAB 0.272900001926004 SINUTAB REGULAR STRENGTH TABLET ORL TAB MCL TAB 0.198800000999867 SLIM FAST ADVANCED NUTRITION SMOOTHIE MIX ORL PWR GLB G 0.038500000481912 SODIUM BICARBONATE 325 MG TABLET ORL TAB SLW TAB 0.032700080022194 SODIUM BICARBONATE 500 MG TABLET ORL TAB SDZ TAB 0.075400000261998 SODIUM BICARBONATE 8.4 % INJECTION INJ DEFAUL PFI ML 0.607600002467585 SODIUM BICARBONATE 8.4% INJECTION USP INJ DEFAUL OMG ML 0.343600002395150 SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL FKC ML 0.101000000037842 SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL HSP ML 0.179400000060208 SODIUM CHLORIDE 0.9% INJECTION USP INJ DEFAUL BAX ML 0.024000000851388 SODIUM CHLORIDE 0.9% NASAL SPRAY NAS SPR SFY ML 0.035700000999807 SODIUM CHLORIDE 1 G CAPSULE ORL CAP GLN CAP 0.162700002139510 SODIUM CHLORIDE 234 MG/ML INJECTION INJ DEFAUL FKC ML 0.421300000402230 SODIUM CHLORIDE 234 MG/ML INJECTION USP INJ DEFAUL OMG ML 0.375000002150204 SODIUM CHLORIDE 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.345000000037834 SODIUM CHLORIDE 9 MG/ML IRRIGATION SOLUTION IR SOL HSP ML 0.043900000402249 SODIUM CHLORIDE BACTERIOSTATIC 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.180000000268313 SODIUM EDECRIN 50 MG/VIAL INJECTION INJ DEFAUL VCL VIAL 544.040000000896187 SODIUM PHOSPHATE INJECTION INJ DEFAUL SDZ ML 1.950000002006758 SOFLAX 4 MG/ML ORAL SYRUP ORL SYR PMS ML 0.023200002224887 SOFRAMYCIN 0.5% OPH SOLUTION OPH SOL ERF ML 1.3663

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002224860 SOFRAMYCIN NASAL SPRAY NAS SPR ERF ML 3.500000001988840 SOFRA-TULLE (10 X 10 CM) TOPICAL GAUZE TOP GAU ERF DRE 1.550000001923986 SOLARCAINE FIRST AID LIDOCAINE 0.5% TOPICAL AEROSO TOP AER SCH G 0.039700000999862 SOLCARB ORAL POWDER ORL PWR MDN G 0.061100002458152 SOLIFENACIN 10 MG TABLET ORL TAB PDL TAB 0.304100002458144 SOLIFENACIN 5 MG TABLET ORL TAB PDL TAB 0.304100002448343 SOLIFENACIN SUCCINATE 10 MG TABLET ORL TAB JUN TAB 0.422300002448335 SOLIFENACIN SUCCINATE 5 MG TABLET ORL TAB MDA TAB 0.422300002478293 SOLIQUA PEN 100 UNIT/ML/33 MCG/ML INJECTION INJ DEFAUL SAV ML 12.653300080002626 SOLUCAL CITRUS ORAL LIQUID ORL DEFAUL JPC ML 0.045700080068920 SOLUCAL D+ 1000 CITRUS ORAL LIQUID ORL LIQ JPC ML 0.047100080069353 SOLUCAL D+ 1000 GREEN APPLE ORL LIQ JPC ML 0.047100080025038 SOLUCAL D+ 1000 RASPBERRY ORAL LIQUID ORL LIQ JPC ML 0.047100000030635 SOLU-CORTEF ACT-O-VIAL 1 G/VIAL (BASE) INJECTION INJ DEFAUL PFI VIAL 18.232000000690333 SOLUVER 20% TOPICAL SOLUTION TOP SOL DPT ML 0.771400000837733 SOLUVER PLUS LIQ 27% TOP SOL DPT ML 1.250000002272199 SOMAVERT 10 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 118.980000002272202 SOMAVERT 15 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 178.470000002272210 SOMAVERT 20 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 237.960000002448831 SOMAVERT 25 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 297.450000002448858 SOMAVERT 30 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 356.940000000483818 SOMNOL 30 MG TABLET ORL TAB AXS TAB 0.114500002237578 SPASMHALT-8 CAPLET ORL TAB PPH TAB 0.343300002237580 SPASMHALT-ASA-8 CAPLET ORL TAB WAM TAB 0.330000000999044 SPECIAL ACCESS - DEKA'S ESSENTIAL LIQUID VITAMIN ORL LIQ XXX ML 1.224300000999811 SPECIAL ACCESS DRUG - CELONTIN ORL CAP XXX CAP 2.328700000999031 SPECIAL ACCESS DRUG - DEFLAZACORT ORL TAB XXX TAB 0.315800000999820 SPECIAL ACCESS DRUG - DODECAVIT 0.5 MG/ML INJ INJ DEFAUL XXX ML 34.177500000999827 SPECIAL ACCESS DRUG - MAGTAB SR 84 MG TABLET DEFAUL DEFAUL XXX TAB 0.3227

00000999810 SPECIAL ACCESS DRUG - MVW COMPLETE D1500 SOFTGEL ORL CAP MVW CAP 0.4705

00000999034 SPECIAL ACCESS DRUG - MVW COMPLETE D3000 CHEW TAB ORL CTB MVW TAB 0.7588

00000999033 SPECIAL ACCESS DRUG - MVW COMPLETE D3000 SOFTGEL ORL CAP MVW CAP 0.5024

00000999035 SPECIAL ACCESS DRUG - MVW COMPLETE FORMULATION DRP ORL DPS MVW ML 0.875700000999036 SPECIAL ACCESS DRUG - OSPOLOT DEFAUL DEFAUL XXX MIS 0.422100000999037 SPECIAL ACCESS DRUG - STEROGYL 15 INJECTION INJ DEFAUL XXX ML 48.353300000999043 SPECIAL ACCESS DRUG - TRIENTINE DEFAUL DEFAUL XXX MIS 10.3593

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080050173 SPECTRALYTE ORAL LIQUID ORL LIQ AEI ML 0.332900080068377 SPECTRAZYME GLUTEN DIGEST CAPSULE ORL CAP MTG CAP 0.499600002214415 SPECTRO ECZEMACARE MEDICATED CREAM TOP CRM GKC G 0.381700002499290 SPRAVATO 28 MG/2 ACT NASAL SPRAY NAS SPU JAI DEV 273.000000080028131 SPRAY NASAL NAS AER IPC ML 0.048700002245903 SPROAM 0.1% CLEANSER TOP WAS COC ML 0.044800002320193 SPRYCEL 100 MG TABLET ORL TAB BMS TAB 155.608300002293129 SPRYCEL 20 MG TABLET ORL TAB BMS TAB 38.685000002293137 SPRYCEL 50 MG TABLET ORL TAB BMS TAB 77.856700002293145 SPRYCEL 70 MG TABLET ORL TAB BMS TAB 85.804200001938991 STANHEXIDINE 2% SOL WITH 4% ISOPROPYL ALCOHOL TOP SOL OMG ML 0.0100

00001938983 STANHEXIDINE 4% WITH 4% ISOPROPYL ALCOHOL SOLUTION TOP SOL OMG ML 0.015700000591467 STATEX 1 MG/ML ORAL SYRUP ORL SYR PAL ML 0.020000002372436 STAXYN 10 MG ORAL DISINTEGRATING TABLET ORL DISNTAB BAI TAB 6.915000002475529 STEGLATRO 15 MG TABLET ORL TAB MFC TAB 2.450000002475510 STEGLATRO 5 MG TABLET ORL TAB MFC TAB 2.450000002459671 STELARA 130 MG/26 ML (5 MG/ML) VIAL INJECTION INJ DEFAUL JAI VIAL 2079.840000002230192 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL PFI VIAL 82.966000002139383 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL FKC VIAL 95.166000002139243 STERILE VANCOMYCIN HCL 5 G/VIAL INJECTION INJ DEFAUL FKC VIAL 509.790000002139375 STERILE VANCOMYCIN HCL 500 MG/VIAL INJ USP INJ DEFAUL FKC VIAL 47.704000002230191 STERILE VANCOMYCIN HCL 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 42.770000002299186 STERILE WATER FOR INJECTION INJ DEFAUL TGT ML 0.140000000402257 STERILE WATER FOR INJECTION DEFAUL INJ OMG ML 0.350000000038245 STERILE WATER FOR INJECTION DEFAUL INJ HSP ML 0.095000002142546 STERILE WATER FOR INJECTION DEFAUL INJ PFI ML 0.191000002247228 STIEPROX 1.5 % TOPICAL SHAMPOO TOP SHP GSK ML 0.098300002125277 STILAMIN 3 MG/AMPOULE INJECTION INJ DEFAUL SRO VIAL 210.000000002403390 STIVARGA 40 MG TABLET ORL TAB BAI TAB 72.620000002357305 STOOL SOFTENER 100 MG CAPSULE ORL CAP VTH CAP 0.029600002483459 STRAMUCIN 2% TOPICAL CREAM TOP CRM GLM G 1.300000002262800 STRATTERA 10 MG CAPSULE ORL CAP LIL CAP 3.059600002279355 STRATTERA 100 MG CAPSULE ORL CAP LIL CAP 5.774600002262819 STRATTERA 18 MG CAPSULE ORL CAP LIL CAP 3.445400002262827 STRATTERA 25 MG CAPSULE ORL CAP LIL CAP 3.847500002262835 STRATTERA 40 MG CAPSULE ORL CAP LIL CAP 4.416800002262843 STRATTERA 60 MG CAPSULE ORL CAP LIL CAP 4.850000002279347 STRATTERA 80 MG CAPSULE ORL CAP LIL CAP 5.261800002243660 STREPTOMYCIN 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 118.3300

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002174383 STRESSEASE MULTIVITAMIN AND MINERAL CAPLET ORL TAB JAM TAB 0.127800080039441 STRESSTABS FOR WOMEN TABLET ORL TAB PDH TAB 0.101700002397137 STRIBILD TABLET ORL TAB GIL TAB 46.389300002480557 STROMECTOL 3 MG TABLET ORL TAB MFC TAB 7.000000000999769 STRONTIUM ORL MIS XXX MIS 0.243300080039461 STRONTIUM SUPPORT II 341 MG CAPSULE ORL CAP AOR CAP 0.243300002370433 SUBLINOX 10 MG SUBLINGUAL DISINTEGRATING TABLET SLG DISNTAB MED TAB 1.411000002391678 SUBLINOX 5 MG SUBLINGUAL DISINTEGRATING TAB SLG DISNTAB MED TAB 1.411000009858127 SUBLOCADE 100 MG/0.5 ML EXTENDED-RELEASE INJ SYR INJ NDL IUK SYR 550.000000009858128 SUBLOCADE 300 MG/1.5 ML EXTENDED-RELEASE INJ SYR INJ NDL IUK SYR 550.000000002502356 SUBOXONE 12 MG/3 MG SL/BUCCAL FILM BUC/SLG FILM IUK FILM 7.095000002468085 SUBOXONE 12 MG/3 MG SUBLINGUAL TABLET SLG SLT IUK TAB 7.243900002468093 SUBOXONE 16 MG/4 MG SUBLINGUAL TABLET SLG SLT IUK TAB 9.658600002502313 SUBOXONE 2 MG/0.5 MG SL/BUCCAL FILM BUC/SLG FILM IUK FILM 2.670000002502348 SUBOXONE 8 MG/2 MG SL/BUCCAL FILM BUC/SLG FILM IUK FILM 4.730000002422336 SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION INJ DEFAUL ALV ML 2.500000002130939 SUCRALFATE-1 1 G TABLET ORL TAB PDL TAB 0.308900002238099 SUDAFED DECONGESTANT 12-HOUR 120 MG CAPLET ORL TAB MCL TAB 0.485000002250217 SUDAFED PE DECONGESTANT 10 MG TABLET ORL TAB MCL TAB 0.300000002246933 SUDOCREM 15.25% TOPICAL CREAM TOP CRM YNG G 0.042800002442213 SUFENTANIL CITRATE 50 MCG/ML INJECTION, USP INJ DEFAUL STM ML 13.550000002244147 SUFENTANIL CITRATE USP 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 15.583000000441767 SULFINPYRAZONE 200 MG TABLET ORL TAB AAP TAB 0.312100000187534 SULFUR TOPICAL SOAP TOP SOP VCL G 0.073300002324660 SUMATRIPTAN 100 MG TABLET ORL TAB PDL TAB 3.054900002324652 SUMATRIPTAN 50 MG TABLET ORL TAB PDL TAB 2.773300000678996 SUPER B COMPLEX CAPSULE ORL CAP SIS CAP 0.258100080002944 SUPER CALCIUM 600 MG WITH VITAMIN D 400 IU ORL TAB JAM TAB 0.139900080011269 SUPER MULTI IRON FREE TABLET ORL TAB NFN TAB 0.214300080023127 SUPER STRAIN ACIDOPHILUS PROBIOTIC 2 BILLION ORL CAP JAM CAP 0.125800002242658 SUPER STRENGTH MOTRIN IB 400 MG TABLET ORL TAB MCL TAB 0.193800080017929 SUPER VITA VIM CAPLET ORL TAB JMS TAB 0.128300002242595 SUPER VITA-VIM CAPLET ORL TAB JAM TAB 0.133400000999816 SUPLASYN DEFAUL DEV MYP ML 37.500000002240749 SUPREFACT DEPOT 9.45 MG IMPLANT INJECTION INJ IMP CAG SYS 1226.760000002239888 SUSTIVA 200 MG CAPSULE ORL CAP BMS CAP 5.222800002239886 SUSTIVA 50 MG CAPSULE ORL CAP BMS CAP 1.305000002246045 SUSTIVA 600 MG TABLET ORL TAB BMS TAB 15.668300002280795 SUTENT 12.5 MG CAPSULE ORL CAP PFI CAP 63.720700002280809 SUTENT 25 MG CAPSULE ORL CAP PFI CAP 127.4411

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002280817 SUTENT 50 MG CAPSULE ORL CAP PFI CAP 254.882500002496305 SUVEXX 85 MG/500 MG TABLET ORL TAB ARZ TAB 9.640000002250322 SWEEN 24 CREAM TOP CRM COC G 0.077600000999833 SWEEN ATRAC-TAIN CREAM TOP CRM XXX ML 0.070900002478080 SYMDEKO TABLET ORL TAB VER TAB 376.500000002473720 SYMTUZA TABLET ORL TAB JAI TAB 50.186000000253952 SYNACTHEN DEPOT 1 MG/ML INJECTION INJ DEFAUL QST VIAL 680.000000002162504 SYNALAR 0.01% TOPICAL SOLUTION TOP SOL VCL ML 0.412800002162512 SYNALAR 0.025% TOPICAL OINTMENT TOP ONT VCL G 0.502200000999878 SYNOLIS-VA DEFAUL DEV APT ML 75.000000000990010 SYNVISC DEFAUL DEV GZB ML 69.471700000999331 SYNVISC ONE DEFAUL DEV GZB ML 70.598300000999040 SYSTANE BION TEARS OPHTHALMIC SOLUTION OPH SOL ALC ML 0.960400000999336 SYSTANE COMPLETE OPH DPS ALC ML 0.922000002248967 SYSTANE LUBRICANT EYE DROPS OPHTHALMIC SOLUTION OPH SOL ALC ML 0.526700002444062 SYSTANE OPHTHALMIC OINTMENT OPH ONT ALC G 1.545700000999333 SYSTANE ULTRA OPH DPS ALC ML 0.932100080032792 SYSTANE VITAMIN- OMEGA 3 CAPSULE ORL CAP ALC CAP 0.219700080032544 SYTRINOL CAPSULE ORL CAP PRA CAP 0.499800002239122 T.R. SWISS ONE 50 MULTIVITAMIN & MINERAL TABLET ORL TAB SWS TAB 0.204800002365871 TACTUPUMP 0.1%/2.5% TOPICAL GEL TOP GEL GAL G 1.556700002446235 TACTUPUMP FORTE 0.3%/2.5% TOPICAL GEL TOP GEL GAL G 2.538400002455374 TADALAFIL 20 MG TABLET ORL TAB PDL TAB 12.357500002455358 TADALAFIL 5 MG TABLET ORL TAB PDL TAB 3.647000002409607 TAFINLAR 50 MG CAPSULE ORL CAP NOV CAP 44.877500002409615 TAFINLAR 75 MG CAPSULE ORL CAP NOV CAP 67.316500002456214 TAGRISSO 40 MG TABLET ORL TAB AZC TAB 294.676300002456222 TAGRISSO 80 MG TABLET ORL TAB AZC TAB 294.676300002505614 TAKHZYRO 150 MG/ML INJECTION SYRINGE INJ DEFAUL SHB ML 10269.000000002304848 TAMIFLU 30 MG CAPSULE ORL CAP HLR CAP 2.115000002304856 TAMIFLU 45 MG CAPSULE ORL CAP HLR CAP 3.254000002381842 TAMIFLU 6 MG/ML ORAL SUSPENSION ORL SUS HLR ML 0.330600002241472 TAMIFLU 75 MG CAPSULE ORL CAP HLR CAP 4.194000002413612 TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.150000002296039 TAPAZOLE 10 MG TABLET ORL TAB PAL TAB 0.639700080060623 TAPIOCA C 1000 MG CAPSULE ORL CAP AOR CAP 0.160000002269015 TARCEVA 100 MG TABLET ORL TAB HLR TAB 56.269700002269023 TARCEVA 150 MG TABLET ORL TAB HLR TAB 84.404700002269007 TARCEVA 25 MG TABLET ORL TAB HLR TAB 14.067700000510335 TARGEL SA TOPICAL LIQUID TOP LIQ ODN G 0.2195

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000344508 TARGEL TOPICAL GEL TOP GEL ODN G 0.192500002339609 TARGIN 10 MG/ 5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.067000002339617 TARGIN 20 MG/ 10 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.602000002339625 TARGIN 40 MG/ 20 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 2.776000002387425 TARGIN 5 MG/ 2.5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.767000002240946 TARKA 2 MG/ 240 MG TABLET ORL TAB BGP TAB 1.769800002238097 TARKA 4 MG/ 240 MG TABLET ORL TAB BGP TAB 1.9640

00002456923 TARO-ADAPALENE/BENZOYL PEROXIDE 0.1%/2.5% TOP GEL TOP GEL TAR G 1.271900002365650 TARO-ANASTROZOLE 1 MG TABLET ORL TAB TAR TAB 1.273000002483149 TARO-BOSENTAN 125 MG TABLET ORL TAB TAR TAB 48.134000002483130 TARO-BOSENTAN 62.5 MG TABLET ORL TAB TAR TAB 48.134000002457490 TARO-CAPECITABINE 150 MG TABLET ORL TAB TAR TAB 1.464000002457504 TARO-CAPECITABINE 500 MG TABLET ORL TAB TAR TAB 4.880000002353288 TARO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL TAR G 7.743300002266938 TARO-CLINDAMYCIN 1% (BASE) TOPICAL SOLUTION TOP SOL TAR ML 0.261300002506203 TARO-CLOBETASOL 0.05% TOPICAL SHAMPOO TOP SHP TAR ML 1.083800002489619 TARO-CLOBETASOL 0.05% TOPICAL SPRAY TOP SPR TAR ML 1.925900002463520 TARO-DEFERASIROX 125 MG DISP TAB FOR ORAL SUSP ORL DTS TAR TAB 2.620300002463547 TARO-DEFERASIROX 500 MG DISP TAB FOR ORAL SUSP ORL DTS TAR TAB 10.482300002420988 TARO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL TAR ML 0.622700002493020 TARO-DOXORUBICIN LIPOSOMAL 2 MG/ML INJECTION INJ DEFAUL TAR ML 66.547000002430940 TARO-EPINEPHRINE 1:1000 AUTO-INJECTOR SYRINGE INJ NDL TAR SYR 67.070000002430959 TARO-EPINEPHRINE 1:2000 AUTO-INJECTOR SYRINGE INJ NDL TAR SYR 67.070000002482398 TARO-FAMPRIDINE 10 MG SUSTAINED-RELEASE TABLET ORL SRT TAR TAB 8.473000002454696 TARO-FENOFIBRATE E 145 MG TABLET ORL TAB SPG TAB 0.911300002480026 TARO-MELPHALAN 50 MG/VIAL INJECTION INJ DEFAUL TAR VIAL 379.490000002264749 TARO-MOMETASONE 0.1% OINTMENT TOP ONT TAR G 0.601300001925350 TARO-SONE 0.05% TOPICAL CREAM TOP CRM TAR G 0.204600002443511 TARO-TEMOZOLOMIDE 100 MG CAPSULE ORL CAP TAR CAP 113.596000002443538 TARO-TEMOZOLOMIDE 140 MG CAPSULE ORL CAP TAR CAP 159.036000002443481 TARO-TEMOZOLOMIDE 20 MG CAPSULE ORL CAP TAR CAP 22.720000002443554 TARO-TEMOZOLOMIDE 250 MG CAPSULE ORL CAP TAR CAP 283.984000002443473 TARO-TEMOZOLOMIDE 5 MG CAPSULE ORL CAP TAR CAP 6.630000002247651 TARO-TERCONAZOLE 0.4% VAGINAL CREAM VAG CRM TAR G 0.635300002463792 TARO-TESTOSTERONE (2.5 G/PACKET) 1% TOPICAL GEL TOP GEL TAR G 0.758300002463806 TARO-TESTOSTERONE (5 G/PACKET) 1% TOPICAL GEL TOP GEL TAR G 0.670400002450429 TARO-TRAMADOL ER 100 MG EXTENDED-RELEASE TABLET ORL ERT TAR TAB 0.785300002450437 TARO-TRAMADOL ER 200 MG EXTENDED-RELEASE TABLET ORL ERT TAR TAB 0.924400002450445 TARO-TRAMADOL ER 300 MG EXTENDED-RELEASE TABLET ORL ERT TAR TAB 1.2854

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002368250 TASIGNA 150 MG CAPSULE ORL CAP NOV CAP 29.187800002315874 TASIGNA 200 MG CAPSULE ORL CAP NOV CAP 41.013100002177080 TAXOTERE 40 MG/ML (80 MG/2 ML) INJECTION INJ DEFAUL SAV ML 456.940000002243894 TAZORAC 0.05% TOPICAL CREAM TOP CRM ALL G 1.428000002243895 TAZORAC 0.1% TOPICAL CREAM TOP CRM ALL G 1.428000000990012 TEAR GEL OPH DEV BSH DEV 0.811000001950010 TEARS ENCORE 1.4% OPH SOLUTION OPH SOL AKN ML 0.971000002246397 TEARS NATURAL FORTE OPH SOLUTION OPH SOL ALC ML 0.408700001943308 TEARS NATURALE FREE OPH SOLUTION OPH SOL ALC ML 0.494400000743445 TEARS NATURALE II OPH SOLUTION OPH SOL ALC ML 0.422000000579408 TEARS PLUS 1.4% OPH SOLUTION OPH SOL ALL ML 0.480000000283991 TEBRAZID 500 MG TABLET ORL TAB VCL TAB 0.498000002492393 TECENTRIQ 60 MG/ML (14 ML VIAL) INJECTION INJ DEFAUL HLR ML 338.800000002462990 TECENTRIQ 60 MG/ML (20 ML VIAL) INJECTION INJ DEFAUL HLR ML 338.800000002420201 TECFIDERA 240 MG DELAYED-RELEASE CAPSULE ORL DRC BIO CAP 34.684300002395223 TELMISARTAN 40 MG TABLET ORL TAB PDL TAB 0.282000002395231 TELMISARTAN 80 MG TABLET ORL TAB PDL TAB 0.282000002395525 TELMISARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.282100002395533 TELMISARTAN-HCTZ 80 MG/25 MG TABLET ORL TAB PDL TAB 0.282100002261553 TELZIR 50 MG/ML ORAL SUSPENSION ORL SUS GSK ML 0.634500002261545 TELZIR 700 MG TABLET ORL TAB GSK TAB 9.164000002241095 TEMODAL 100 MG CAPSULE ORL CAP MFC CAP 156.006000002312794 TEMODAL 140 MG CAPSULE ORL CAP MFC CAP 218.410000002241094 TEMODAL 20 MG CAPSULE ORL CAP MFC CAP 31.200000002241096 TEMODAL 250 MG CAPSULE ORL CAP MFC CAP 390.004000002241093 TEMODAL 5 MG CAPSULE ORL CAP MFC CAP 7.800000000875988 TEMPRA INFANT 80 MG/ML ORAL DROPS ORL DPS PAL ML 0.285300002230661 TENOXICAM 20 MG TABLET ORL TAB AAP TAB 1.178300002242735 TERBINAFINE-250 MG TABLET ORL TAB PDL TAB 0.771400002280248 TESTIM 1% TOPICAL GEL TOP GEL PAL G 0.805500000514462 TETANUS & DIPHTHERIA TOXOIDS ADULT INJECTION INJ LIQ CNG ML 45.120000002148528 TETRACAINE 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.200000002416662 TEVA-ABACAVIR/LAMIVUDINE 600 MG/300 MG TABLET ORL TAB TEV TAB 20.3573

00002403633 TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG/2800 U TAB ORL TAB TEV TAB 3.730000002326043 TEVA-AMITRIPTYLINE 10 MG TABLET ORL TAB TEV TAB 0.066400002326051 TEVA-AMITRIPTYLINE 25 MG TABLET ORL TAB TEV TAB 0.121100002326078 TEVA-AMITRIPTYLINE 50 MG TABLET ORL TAB TEV TAB 0.234700002250500 TEVA-AMLODIPINE 10 MG TABLET ORL TAB TEV TAB 0.199300002250497 TEVA-AMLODIPINE 5 MG TABLET ORL TAB TEV TAB 0.1343

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002464160 TEVA-ARIPIPRAZOLE 10 MG TABLET ORL TAB TEV TAB 1.075400002464179 TEVA-ARIPIPRAZOLE 15 MG TABLET ORL TAB TEV TAB 1.269300002464144 TEVA-ARIPIPRAZOLE 2 MG TABLET ORL TAB TEV TAB 0.809300002464187 TEVA-ARIPIPRAZOLE 20 MG TABLET ORL TAB TEV TAB 1.001700002464195 TEVA-ARIPIPRAZOLE 30 MG TABLET ORL TAB TEV TAB 1.001700002443791 TEVA-ATAZANAVIR 150 MG CAPSULE ORL CAP TEV CAP 9.651000002443813 TEVA-ATAZANAVIR 200 MG CAPSULE ORL CAP TEV CAP 9.707700002443821 TEVA-ATAZANAVIR 300 MG CAPSULE ORL CAP TEV CAP 19.068000002314541 TEVA-ATOMOXETINE 10 MG CAPSULE ORL CAP TEV CAP 2.314000002314568 TEVA-ATOMOXETINE 18 MG CAPSULE ORL CAP TEV CAP 2.652300002314576 TEVA-ATOMOXETINE 25 MG CAPSULE ORL CAP TEV CAP 2.928000002314584 TEVA-ATOMOXETINE 40 MG CAPSULE ORL CAP TEV CAP 3.337700002314592 TEVA-ATOMOXETINE 60 MG CAPSULE ORL CAP TEV CAP 3.702300002362511 TEVA-ATOMOXETINE 80 MG CAPSULE ORL CAP TEV CAP 3.996000002380927 TEVA-ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ORL TAB TEV TAB 4.130800002280205 TEVA-BETAHISTINE 24 MG TABLET ORL TAB TEV TAB 0.498300002280183 TEVA-BETAHISTINE 8 MG TABLET ORL TAB TEV TAB 0.2259

00002427419 TEVA-BETAMETHASONE/CALCIPOTRIOL TOPICAL OINTMENT TOP ONT TEV G 1.354000002270226 TEVA-BICALUTAMIDE 50 MG TABLET ORL TAB TEV TAB 4.057300002441624 TEVA-CINACALCET 30 MG TABLET ORL TAB TEV TAB 10.194700002441632 TEVA-CINACALCET 60 MG TABLET ORL TAB TEV TAB 18.590000002441640 TEVA-CINACALCET 90 MG TABLET ORL TAB TEV TAB 27.051700002248804 TEVA-CLARITHROMYCIN 250 MG TABLET ORL TAB TEV TAB 0.412200002248805 TEVA-CLARITHROMYCIN 500 MG TABLET ORL TAB TEV TAB 0.831800002239025 TEVA-CLONAZEPAM 2 MG TABLET ORL TAB TEV TAB 0.072100002388065 TEVA-CLOPIDOGREL 300 MG TABLET ORL TAB TEV TAB 9.544700002053403 TEVA-COTRIDIN EXPECTORANT ORAL SYRUP ORL SYR TEV ML 0.061000002169126 TEVA-COTRIDIN ORAL SYRUP ORL SYR TEV ML 0.055000002462486 TEVA-CYCLOSPORINE 0.05% OPH EMULSION OPH EML TEV ML 3.4308

00002309556 TEVA-CYPROTERONE/ETHINYL ESTRADIOL 2MG/0.035MG TAB ORL TAB TEV TAB 1.111400002239355 TEVA-DIFENAC-K 50 MG TABLET ORL TAB TEV TAB 0.393700002389762 TEVA-EFAVIRENZ 600 MG TABLET ORL TAB TEV TAB 11.210300002393549 TEVA-EFAVIRENZ/EMTRICITABINE/TENOFOVIR TABLET ORL TAB TEV TAB 22.660000002382091 TEVA-ELETRIPTAN 20 MG TABLET ORL TAB TEV TAB 10.085000002382105 TEVA-ELETRIPTAN 40 MG TABLET ORL TAB TEV TAB 10.085000002377705 TEVA-ERLOTINIB 100 MG TABLET ORL TAB TEV TAB 47.466700002377713 TEVA-ERLOTINIB 150 MG TABLET ORL TAB TEV TAB 71.200000002377691 TEVA-ERLOTINIB 25 MG TABLET ORL TAB TEV TAB 11.8667

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002423855 TEVA-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT TEV TAB 1.869000002423863 TEVA-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT/DRC TEV TAB 1.869000002463253 TEVA-EVEROLIMUS 10 MG TABLET ORL TAB TEV TAB 172.256000002463229 TEVA-EVEROLIMUS 2.5 MG TABLET ORL TAB TEV TAB 172.256000002463237 TEVA-EVEROLIMUS 5 MG TABLET ORL TAB TEV TAB 172.256000002408473 TEVA-EXEMESTANE 25 MG TABLET ORL TAB TEV TAB 3.9007

00002453738 TEVA-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM TEV DOSE 0.183100002415844 TEVA-FROVATRIPTAN 2.5 MG TABLET ORL TAB TEV TAB 12.502900002460130 TEVA-FULVESTRANT 250 MG/5 ML INJECTION INJ NDL TEV SYR 495.460000002248457 TEVA-GABAPENTIN 600 MG TABLET ORL TAB TEV TAB 1.304500002247346 TEVA-GABAPENTIN 800 MG TABLET ORL TAB TEV TAB 1.739300002399806 TEVA-IMATINIB 100 MG TABLET ORL TAB TEV TAB 20.455700002399814 TEVA-IMATINIB 400 MG TABLET ORL TAB TEV TAB 81.822700000653233 TEVA-LENOLTEC NO.1 TABLET ORL TAB TEV TAB 0.166000002343657 TEVA-LETROZOLE 2.5 MG TABLET ORL TAB TEV TAB 2.756000002258323 TEVA-MELOXICAM 15 MG TABLET ORL TAB TEV TAB 0.567000002258315 TEVA-MELOXICAM 7.5 MG TABLET ORL TAB TEV TAB 0.491400002261898 TEVA-METOPROL 25 MG TABLET ORL TAB TEV TAB 0.064300002279894 TEVA-MIRTAZAPINE OD 15 MG ORAL DISINT. TABLET ORL DISNTAB TEV TAB 0.273000002279908 TEVA-MIRTAZAPINE OD 30MG ORAL DISINT. TABLET ORL DISNTAB TEV TAB 0.546000002279916 TEVA-MIRTAZAPINE OD 45MG ORAL DISINT. TABLET ORL DISNTAB TEV TAB 0.819000002364883 TEVA-MYCOPHENOLATE 250 MG CAPSULE ORL CAP TEV CAP 1.031000002348675 TEVA-MYCOPHENOLATE 500 MG TABLET ORL TAB TEV TAB 2.062000002392925 TEVA-NABILONE 0.25 MG CAPSULE ORL CAP TEV CAP 1.466000002359707 TEVA-OLANZAPINE 20 MG TABLET ORL TAB TEV TAB 10.309300002285479 TEVA-PANTOPRAZOLE 20 MG ENTERIC-COATED ORAL TAB ORL ECT TEV TAB 1.275000002248556 TEVA-PAROXETINE 10 MG TABLET ORL TAB TEV TAB 1.043000002248558 TEVA-PAROXETINE 30 MG TABLET ORL TAB TEV TAB 0.345300000021288 TEVA-PHENIRAM 4 MG TABLET ORL TAB TEV TAB 0.065500000869015 TEVA-PINDOLOL 10 MG TABLET ORL TAB TEV TAB 0.232300000869023 TEVA-PINDOLOL 15 MG TABLET ORL TAB TEV TAB 0.889400000869007 TEVA-PINDOLOL 5 MG TABLET ORL TAB TEV TAB 0.136100000021695 TEVA-PREDNISONE 5 MG TABLET ORL TAB TEV TAB 0.040100000232378 TEVA-PREDNISONE 50 MG TABLET ORL TAB TEV TAB 0.173500002361221 TEVA-PREGABALIN 225 MG CAPSULE ORL CAP TEV CAP 1.727000002296632 TEVA-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT TEV TAB 0.066900002296640 TEVA-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT TEV TAB 0.133800002418436 TEVA-RASAGILINE 0.5 MG TABLET ORL TAB TEV TAB 6.128700002418444 TEVA-RASAGILINE 1 MG TABLET ORL TAB TEV TAB 6.1287

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 114 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002413809 TEVA-RISEDRONATE 150 MG TABLET ORL TAB TEV TAB 40.950000002264188 TEVA-RISPERIDONE 0.5 MG TABLET ORL TAB TEV TAB 0.173500002326450 TEVA-SALBUTAMOL HFA 100 MCG/DOSE MDA INH AEM TEV DOSE 0.027300002308754 TEVA-SILDENAFIL 100 MG TABLET ORL TAB TEV TAB 9.200600002308738 TEVA-SILDENAFIL 25 MG TABLET ORL TAB TEV TAB 8.290000002308746 TEVA-SILDENAFIL 50 MG TABLET ORL TAB TEV TAB 8.847500002319500 TEVA-SILDENAFIL R 20 MG TABLET ORL TAB TEV TAB 7.294000002286815 TEVA-SUMATRIPTAN DF 25 MG TABLET ORL TAB TEV TAB 8.990000002440164 TEVA-TADALAFIL 10 MG TABLET ORL TAB TEV TAB 11.925000002440148 TEVA-TADALAFIL 2.5 MG TABLET ORL TAB TEV TAB 3.647000002440172 TEVA-TADALAFIL 20 MG TABLET ORL TAB TEV TAB 12.357500002440156 TEVA-TADALAFIL 5 MG TABLET ORL TAB TEV TAB 3.647000000851965 TEVA-TAMOXIFEN 10 MG TABLET ORL TAB TEV TAB 0.175000000851973 TEVA-TAMOXIFEN 20 MG TABLET ORL TAB TEV TAB 0.350000002240346 TEVA-TERBINAFINE 250 MG TABLET ORL TAB TEV TAB 0.771400002486423 TEVA-TERIPARATIDE 250 MCG/ML INJECTION INJ DEFAUL TEV ML 333.662500002299593 TEVA-TOLTERODINE 1 MG TABLET ORL TAB TEV TAB 0.883800002299607 TEVA-TOLTERODINE 2 MG TABLET ORL TAB TEV TAB 0.883800002347180 TEVA-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB TEV TAB 0.626400002415429 TEVA-TRANDOLAPRIL 0.5 MG CAPSULE ORL CAP TEV CAP 0.069800002415437 TEVA-TRANDOLAPRIL 1 MG CAPSULE ORL CAP TEV CAP 0.176200002415445 TEVA-TRANDOLAPRIL 2 MG CAPSULE ORL CAP TEV CAP 0.202500002415453 TEVA-TRANDOLAPRIL 4 MG CAPSULE ORL CAP TEV CAP 0.249800000550507 TEVA-TRIACOMB REGULAR TOPICAL CREAM TOP CRM TEV G 0.423300002357542 TEVA-VALACYCLOVIR 1000 MG TABLET (CAPLET) ORL TAB TEV TAB 3.053100002356643 TEVA-VALSARTAN 40 MG TABLET ORL TAB TEV TAB 0.5240

00002275031 TEVA-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC TEV CAP 0.182500002342545 TEVA-ZOLMITRIPTAN OD 2.5 MG ORAL DISPERSIBLE TAB ORL DISPTAB TEV TAB 2.045000002355205 THALOMID 100 MG CAPSULE ORL CAP CLG CAP 58.940000002355221 THALOMID 200 MG CAPSULE ORL CAP CLG CAP 117.880000002355191 THALOMID 50 MG CAPSULE ORL CAP CLG CAP 29.470000080075777 THE RIGHT FIBRE4 5 G ORAL POWDER ORL PWR WNP G 0.111900002360101 THEO ER 400 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.348000002360128 THEO ER 600 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.421500001966219 THEOLAIR 80 MG/15 ML ORAL LIQUID ORL LIQ VCL ML 0.027800080015438 THERA TEARS NUTRITION CAPSULE ORL CAP AVR CAP 0.1187

00002242082 THERATEARS (PRESERVATIVE-FREE) 0.25% OPH SOLUTION OPH SOL AVR ML 0.686800002248854 THERATEARS 0.25% OPH SOLUTION OPH SOL AVR ML 0.4900

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002488361 TIBELLA 2.5 MG TABLET ORL TAB BIS TAB 2.850000002241382 TIGER BALM ULTRA OINTMENT TOP ONT HPH G 0.201000000755850 TIMOL 10 MG TABLET ORL TAB AAP TAB 0.374700000755869 TIMOL 20 MG TABLET ORL TAB AAP TAB 0.729200000755842 TIMOL 5 MG TABLET ORL TAB AAP TAB 0.240200002242275 TIMOLOL MALEATE-EX 0.25% OPHTHALMIC SOLUTION OPH LAS ALC ML 3.376000002242276 TIMOLOL MALEATE-EX 0.5% OPHTHALMIC SOLUTION OPH LAS ALC ML 4.040000002171880 TIMOPTIC-XE 0.25%(BASE) LONG ACTING GELLAN OPH SOL OPH LAS PUR ML 4.308000009858120 TIMO-STULLN 0.5% OPHTHALMIC SOLUTION OPH SOL PSL ML 1.214000000576050 TINACTIN 1% TOPICAL AEROSOL TOP AER BAI G 0.060900000576034 TINACTIN 1% TOPICAL CREAM TOP CRM BAI G 0.406000000576042 TINACTIN 1% TOPICAL POWDER TOP PWR BAI G 0.063400002461218 TIVICAY 10 MG TABLET ORL TAB VIV TAB 6.675300002461226 TIVICAY 25 MG TABLET ORL TAB VIV TAB 10.097700002414945 TIVICAY 50 MG TABLET ORL TAB VIV TAB 20.289000002259893 TIZANIDINE 4 MG TABLET ORL TAB AAP TAB 0.796300002244826 TNKASE 50 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2874.050000000533688 TOBRAMYCIN 1.2 G/VIAL INJECTION INJ DEFAUL FKC VIAL 199.000000002241209 TOBRAMYCIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 5.795500002241210 TOBRAMYCIN 40 MG/ML INJECTION INJ DEFAUL SDZ ML 3.707000002230640 TOBRAMYCIN 40 MG/ML INJECTION INJ DEFAUL FKC ML 3.531000002337630 TOCTINO 10 MG CAPSULE ORL CAP GST CAP 21.990000002337649 TOCTINO 30 MG CAPSULE ORL CAP GST CAP 21.990000002229566 TOMUDEX 2 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 324.620000002221926 TOPICORT 0.05% TOPICAL GEL TOP GEL VCL G 0.570700002221934 TOPICORT 0.25% TOPICAL OINTMENT TOP ONT VCL G 0.739700000749834 TOPIDERM HC 2% TOPICAL CREAM TOP CRM PAL G 0.286900002390981 TOPOTECAN 4 MG / VIAL INJECTION INJ DEFAUL SDZ VIAL 567.000000002493373 TOUJEO DOUBLESTAR 300 UNIT/ML INJECTION INJ DEFAUL SAV ML 17.622200002441829 TOUJEO SOLOSTAR 300 UNIT/ML INJECTION INJ DEFAUL SAV ML 17.622700002244982 TRACLEER 125 MG TABLET ORL TAB JAI TAB 64.178600002244981 TRACLEER 62.5 MG TABLET ORL TAB JAI TAB 64.178600002264846 TRAMACET 37.5 MG/325 MG TABLET ORL TAB JAI TAB 1.002500002426803 TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB SNS TAB 0.626400002429969 TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB SIV TAB 0.626400002488698 TRANDOLAPRIL 1 MG CAPSULE ORL CAP PDL CAP 0.176200002488701 TRANDOLAPRIL 2 MG CAPSULE ORL CAP PDL CAP 0.202500002488728 TRANDOLAPRIL 4 MG CAPSULE ORL CAP PDL CAP 0.249800002246365 TRANEXAMIC ACID 100 MG/ML INJECTION INJ DEFAUL SDZ ML 3.772500080044392 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 14 MG TRD PTH APH PTH 2.1500

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080044389 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 21 MG TRD PTH APH PTH 2.150000080044393 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 7 MG TRD PTH APH PTH 2.285700080024336 TRANSDERM-V 1.5 MG TOPICAL PATCH TOP PTH NOV PTH 4.925000000605786 TRAVEL AID 50 MG TABLET ORL TAB WTR TAB 0.130000002164361 TRAZODONE-100 100 MG TABLET ORL TAB PDL TAB 0.098900002164388 TRAZODONE-150 D 150 MG TABLET ORL TAB PDL TAB 0.145300002164353 TRAZODONE-50 50 MG TABLET ORL TAB PDL TAB 0.055400002392569 TREANDA 100 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL TMP VIAL 1250.000000002392550 TREANDA 25 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL TMP VIAL 312.500000002412322 TRELSTAR 22.5 MG/VIAL INJECTION INJ DEFAUL ASC VIAL 1659.900000002240000 TRELSTAR 3.75 MG/VIAL INJECTION INJ DEFAUL ASC VIAL 346.310000002243856 TRELSTAR LA 11.25 MG/VIAL INJECTION INJ DEFAUL ASC VIAL 1038.970000002469758 TREMFYA 100 MG/1 ML INJECTION SYRINGE INJ NDL JAI SYR 3059.740000002487314 TREMFYA ONE-PRESS 100 MG/1 ML AUTO-INJECTOR SYR INJ NDL JAI SYR 3059.740000005558035 TRIAD CREAM TOP CRM COC G 0.273200080015032 TRIAMEG H OMEGA 3 500 MG CAPSULE ORL CAP LLN CAP 0.300000000896179 TRIAMINIC DM NIGHTIME ORAL SYRUP ORL SYR NVC ML 0.047400000789828 TRIATEC-30 TABLET ORL TAB TLI TAB 0.130000001977881 TRIATEC-8 FORT TABLET ORL TAB TLI TAB 0.026100002508087 TRI-CIRA 21 TABLET ORL TAB APX TAB 0.685200002508095 TRI-CIRA 28 TABLET ORL TAB APX TAB 0.513900002401967 TRICIRA LO 21 TABLET ORL TB APX TAB 0.637600002401975 TRICIRA LO 28 TABLET ORL TAB APX TAB 0.478200002028700 TRI-CYCLEN (21 DAY) TABLET ORL TAB JAI TAB 1.271400002029421 TRI-CYCLEN (28 DAY) TABLET ORL TB JAI TAB 0.953600002258560 TRI-CYCLEN LO 21 TABLET ORL TB JAI TAB 0.735700002258587 TRI-CYCLEN LO 28 TABLET ORL TAB JAI TAB 0.551800002296381 TRIDURAL 100 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 0.834100002296403 TRIDURAL 200 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 1.047600002296411 TRIDURAL 300 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 1.456800002368676 TRIESENCE 40 MG/ML INJECTION INJ DEFALT NOV ML 42.590000002248264 TRIFEREXX - 150 150 MG ORAL CAPSULE ORL CAP AXS CAP 0.428300002242068 TRILEPTAL 300 MG TABLET ORL TAB NOV TAB 0.950800002244673 TRILEPTAL 60 MG/ML ORAL SUSPENSION ORL SUS NOV ML 0.349000002242069 TRILEPTAL 600 MG TABLET ORL TAB NOV TAB 1.9020

00080002067 TRIPLE STRENGTH ODOURLESS GARLIC SOFTGEL CAPSULE ORL CAP VCL CAP 0.046000002407833 TRISENOX 1 MG/ML AMPOULE INJECTION INJ DEFAUL TMP ML 53.000000002430932 TRIUMEQ TABLET ORL TAB VIV TAB 45.535000000511234 TROMBOJECT 10 MG/ML INJECTION INJ DEFAUL OMG ML 8.3500

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000511226 TROMBOJECT 30 MG/ML INJECTION INJ DEFAUL OMG ML 11.675000080015078 TROPHIC KRILL OIL CAPSULE ORL CAP MTA CAP 0.423700002148536 TROPICAMIDE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 4.200000080000383 TRUEHOPE EMP CAPSULE ORL CAP TRU CAP 0.208700002448599 TRULICITY 0.75 MG/0.5 ML INJECTION PEN INJ DEFAUL LIL ML 101.870000002448602 TRULICITY 1.5 MG/0.5 ML INJECTION PEN INJ DEFAUL LIL ML 101.870000002468751 TRUMENBA (60 MCG/60MCG)/0.5 ML INJECTION SYR INJ NDL PFI SYR 105.680000002274906 TRUVADA 200 MG/300 MG TABLET ORL TAB GIL TAB 27.387000000317268 TUBERSOL TUBERCULIN PPD 5 TUB INJECTION INJ DEFAUL AVE ML 198.000000002499835 TUKYSA 150 MG TABLET ORL TAB STG TAB 119.416700002499827 TUKYSA 50 MG TABLET ORL TAB STG TAB 60.166700001967932 TUMS EXTRA STRENGTH 750 MG CHEWABLE TABLET ORL CTB SKB TAB 0.044200001970240 TUMS REGULAR 500 MG CHEWABLE TABLET ORL CTB SKB TAB 0.032200002151138 TUMS ULTRA STRENGTH 1G CHEWABLE TABLET ORL CTB SKB TAB 0.051500080064116 TURMERIC CURCUMIN 550 MG CAPSULE ORL CAP JMS CAP 0.166700001916971 TUSSIONEX ORAL SUSTAINED-RELEASE SUSPENSION ORL SRSUS SAV ML 0.350800080019103 TUZEN CAPSULE ORL CAP FEI CAP 0.760000002230578 TWINRIX INJECTION SYRINGE INJ NDL GSK SYR 52.480000002237548 TWINRIX JUNIOR 0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 26.310000002285401 TYGACIL 50 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 83.474000002326442 TYKERB 250 MG TABLET ORL TAB NOV TAB 24.641000002246060 TYLENOL 8 HOUR 650 MG EXTENDED-RELIEF CAPLET ORL ERT MCL TAB 0.176200002238885 TYLENOL ARTHRITIS PAIN 650 MG EXT-RELIEF CAPLET ORL ERT MCL TAB 0.163300002276259 TYLENOL COLD EXTRA STRENGTH NIGHTTIME TABLET ORL TAB MCL TAB 0.315500002290510 TYLENOL EXTRA STR. BACK PAIN 400 MG/500 MG TABLET ORL TAB MCL TAB 0.5011

00002347792 TYLENOL FASTMELTS JUNIOR STRENGTH 160 MG CHEW TAB ORL CTB MCL TAB 0.274500002241361 TYLENOL JUNIOR STRENGTH 160 MG SOFT CHEW TABLET ORL CTB MCL TAB 0.281000002163934 TYLENOL NO. 2 WITH CODEINE TABLET ORL TAB JAI TAB 0.110400002163926 TYLENOL NO. 3 WITH CODEINE TABLET ORL TAB JAI TAB 0.121700002163918 TYLENOL NO. 4 WITH CODEINE TABLET ORL TAB JAI TAB 0.256600002181061 TYLENOL NO.1 WITH CODEINE TABLET ORL TAB MCL TAB 0.139600000723894 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.126700000559393 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.149200002130955 TYPHIM VI 50 MCG/ML INJECTION INJ DEFAUL CNG ML 55.000000080028055 UBIQUINOL 100 MG CAPSULE ORL CAP VTH CAP 0.760000080022377 UDO'S CHOICE SUPER 8 PLUS PROBIOTIC ORL CAP FMD CAP 0.990000001966294 ULONE 5 MG ORAL SYRUP ORL SYR MMH ML 0.140600080015173 ULTIMATE FLORA CRITICAL CARE 50 BILLION ORL CAP RLC CAP 0.927900080040326 ULTIMATE FLORA ULTRA POTENT 100 BILLION CAPSULE ORL CAP RLC CAP 1.2000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080034018 ULTIMATE MULTI PROBIOTIC CAPSULE ORL CAP NFN CAP 0.424900080006259 ULTIMATE OMEGA FACTORS 3-6-9 SOFT GEL CAPSULE ORL CAP NFN CAP 0.238700080033880 ULTRA C 1000 TABLET ORL TAB MTG TAB 0.313500080032885 ULTRA C TM 500 500 MG TABLET ORL TAB MTG TAB 0.281700080011779 ULTRA FLORA PLUS CAPSULE ORL CAP MTG CAP 0.411600080011780 ULTRA FLORA PLUS; ULTRA FLORA BALANCE ORL CAP MTG CAP 0.416700002237698 ULTRA STRENGTH PHAZYME 180 MG CAPSULE ORL CAP CBF CAP 0.222100080082729 ULTRACLEAR PLUS ORAL POWDER ORL PWR MTG G 0.118000080025550 ULTRA-FIBER BALANCED CAPLET ORL TAB AAM TAB 0.082500080004965 ULTRA-FIBER SUPPLEMENT CHEWABLE TABLET ORL TAB AAM TAB 0.091700002349469 ULTRAM 50 MG TABLET ORL TAB JAI TAB 0.8505

00002324113 ULTRAQUIN 4% HYDROQUINONE CREAM WITH SUNSCREENS TOP CRM SAH G 1.000000000626724 ULTRAQUIN 4% TOPICAL GEL TOP GEL SAH G 1.000000000632783 ULTRAQUIN PLAIN 4% CREAM TOP CRM SAH G 0.866700001962728 ULTRAVATE 0.05% TOPICAL OINTMENT TOP ONT VCL G 0.994800001946994 UNISOM-2 NIGHTTIME SLEEP AID TAB 25 MG ORL TAB PDH TAB 0.204000002451190 UPTRAVI 1000 MCG TABLET ORL TAB JAI TAB 66.412500002451204 UPTRAVI 1200 MCG TABLET ORL TAB JAI TAB 66.412500002451212 UPTRAVI 1400 MCG TABLET ORL TAB JAI TAB 66.412500002451220 UPTRAVI 1600 MCG TABLET ORL TAB JAI TAB 66.412500002451158 UPTRAVI 200 MCG TABLET ORL TAB JAI TAB 66.412500002451166 UPTRAVI 400 MCG TABLET ORL TAB JAI TAB 66.412500002451174 UPTRAVI 600 MCG TABLET ORL TAB JAI TAB 66.412500002451182 UPTRAVI 800 MCG TABLET ORL TAB JAI TAB 66.412500000999884 URACYST 2% SODIUM CHONDROITIN SULFATE SOLUTION MIS DEFAUL TRI ML 3.727100001946099 UREMOL 10 10% TOPICAL CREAM TOP CRM GKC G 0.076900080079497 UREMOL 10% CREAM TOP CRM ODN G 0.092900000398179 UREMOL 20% TOPICAL CREAM TOP CRM GKC G 0.081100001946102 UREMOL-10 10% TOPICAL LOTION TOP LOT GKC ML 0.043000080005531 URISEC 40 40% TOPICAL CREAM TOP CRM ODN G 1.250000002353997 UROCIT-K 10 MEQ EXTENDED-RELEASE TABLET ORL ERT PAL TAB 0.608700001914022 UROCIT-K 5 MEQ TABLET ORL SRT SFD TAB 0.407900002241411 UROMITEXAN 100 MG/ML INJECTION INJ DEFAUL AST ML 7.798700080030062 UTI CLEANSE TABLET ORL TAB AOR TAB 0.441600080046888 UXOR 7.5% GEL TOP GEL JPC G 0.178700000534471 VAGISIL 5 %/2 % TOPICAL CREAM TOP CRM CMB G 0.120000000999871 VAGISIL PROHYDRATE GEL VAG GEL CMB G 0.226700080008012 VALERIAN INTRINSIC ORAL LIQUID ORL LIQ AEI ML 0.500000000177016 VALISONE-G TOPICAL CREAM TOP CRM VCL G 1.1277

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000232351 VALISONE-G TOPICAL OINTMENT TOP ONT VCL G 1.127700000013285 VALIUM 5 MG TABLET ORL TAB HLR TAB 0.195500002384558 VALSARTAN 160 MG TABLET ORL TAB SIV TAB 0.215900002367742 VALSARTAN 160 MG TABLET ORL TAB PDL TAB 0.215900002384566 VALSARTAN 320 MG TABLET ORL TAB SIV TAB 0.209800002367750 VALSARTAN 320 MG TABLET ORL TAB PDL TAB 0.209800002384523 VALSARTAN 40 MG TABLET ORL TAB SIV TAB 0.524000002366940 VALSARTAN 40 MG TABLET ORL TAB SNS TAB 0.523900002367726 VALSARTAN 40 MG TABLET ORL TAB PDL TAB 0.408000002367734 VALSARTAN 80 MG TABLET ORL TAB PDL TAB 0.215900002384531 VALSARTAN 80 MG TABLET ORL TAB SIV TAB 0.215900002384779 VALSARTAN HCT 320 MG/25 MG TABLET ORL TAB SIV TAB 0.291000002367777 VALSARTAN-HCTZ 160 MG/12.5 MG TABLET ORL TAB PDL TAB 0.295700002367785 VALSARTAN-HCTZ 160 MG/25 MG TABLET ORL TAB PDL TAB 0.295700002367769 VALSARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.295700002246559 VALTREX 1000 MG CAPLET ORL TAB GSK TAB 7.127600002394634 VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJ USP INJ DEFAUL SDZ VIAL 58.990000002502607 VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJ USP INJ DEFAUL JPC VIAL 58.990000002394626 VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJ USP INJ DEFAUL SDZ VIAL 31.050000002502593 VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJ USP INJ DEFAUL JPC VIAL 31.050000002243837 VANIQA 13.9% TOPICAL CREAM TOP CRM ALM G 2.843700002229702 VAQTA 50 U/ML INJECTION INJ DEFAUL MSD ML 51.260000002241047 VARILRIX 2000 UNITS/(0.5 ML) VIAL INJECTION INJ DEFAUL GSK VIAL 62.790000002246081 VARIVAX III VACCINE 1350 U/VIAL INJECTION INJ DEFAUL MFC VIAL 81.850000002495244 VASCEPA 1 G CAPSULE ORL CAP HLS CAP 2.450000002139502 VASOPRESSIN 20 UNIT/ML INJECTION INJ DEFAUL FKC ML 31.451200002223929 VAXIGRIP INFLUENZA VACCINE INJECTION INJ DEFAUL CNG ML 8.350000002308487 VECTIBIX 20 MG/ML (5 ML VIAL) INJECTION INJ DEFAUL AMG ML 128.364000002471574 VELPHORO 500 MG CHEWABLE TABLET ORL CTB VIF TAB 4.203600002481367 VELTASSA 16.8 G ORAL POWDER SACHET ORL PWDPKT VIF PCKT 13.000000002481359 VELTASSA 8.4 G ORAL POWDER SACHET ORL PWDPKT VIF PCKT 13.000000002464241 VEMLIDY 25 MG TABLET ORL TAB GIL TAB 19.553700002458039 VENCLEXTA 10 MG TABLET ORL TAB ABV TAB 7.000000002458063 VENCLEXTA 10 MG/50 MG/100 MG TABLET STARTER PACK ORL TAB ABV TAB 43.166700002458055 VENCLEXTA 100 MG TABLET ORL TAB ABV TAB 70.000000002458047 VENCLEXTA 50 MG TABLET ORL TAB ABV TAB 35.000000080078651 VENIXXA 500 MG TABLET ORL TAB SEV TAB 0.550000002339269 VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.192700002339242 VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.091300002339250 VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.1825

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002243716 VENOFER 20 MG/ML INJECTION INJ DEFAUL LPI ML 7.500000002226286 VENOMIL YELLOW JACKET VENOM PROTEIN 120 MCG INJ INJ DEFAUL BAI VIAL 195.0000

00002243115 VENTOLIN DISKUS 200 MCG/DOSE POWDER FOR INHALATION INH MIP GSK DOSE 0.165800000616192 VEPESID 50 MG CAPSULE ORL CAP CAG CAP 41.587500080033844 VERALAC HYDROSOLUBLE NAIL LACQUER TOP SOL VCL ML 4.009100000839299 VERAPAMIL HYDROCHLORIDE 2.5 MG/ML INJECTION INJ DEFAUL PFI ML 19.725000002166739 VERAPAMIL HYDROCHLORIDE USP 2.5 MG/ML INJECTION INJ DEFAUL SDZ ML 20.857000002411849 VEREGEN 10% TOPICAL OINTMENT TOP ONT PAL G 4.415300002484137 VERKAZIA 0.1% OPHTHALMIC EMULSION OPH EML SAN ML 12.222200000594601 VERSEL 2.5% TOPICAL LOTION TOP LOT VCL ML 0.071600002487101 VERZENIO 100 MG TABLET ORL TAB LIL TAB 97.400000002487128 VERZENIO 150 MG TABLET ORL TAB LIL TAB 97.400000002487136 VERZENIO 200 MG TABLET ORL TAB LIL TAB 97.400000002487098 VERZENIO 50 MG TABLET ORL TAB LIL TAB 97.400000002145839 VESANOID 10 MG CAPSULE ORL CAP CAG CAP 16.386300002451557 VIACORAM 14 MG/10 MG TABLET ORL TAB SEV TAB 1.211300002451530 VIACORAM 3.5 MG/2.5 MG TABLET ORL TAB SEV TAB 1.001000002451549 VIACORAM 7 MG/5 MG TABLET ORL TAB SEV TAB 1.106000000717002 VIADERM K.C. TOPICAL CREAM TOP CRM TAR G 0.423300000717029 VIADERM K.C. TOPICAL OINTMENT TOP ONT TAR G 0.623000002239768 VIAGRA 100 MG TABLET ORL TAB UJC TAB 9.200000002239766 VIAGRA 25 MG TABLET ORL TAB UJC TAB 8.290000002239767 VIAGRA 50 MG TABLET ORL TAB UJC TAB 8.847500002330725 VIBATIV 750 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL PPH VIAL 179.000000002460904 VIBERZI 100 MG TABLET ORL TAB ALL TAB 2.331000002460890 VIBERZI 75 MG TABLET ORL TAB ALL TAB 2.331000002273330 VICKS CHILDREN'S NYQUIL COLD & COUGH ORAL LIQUID ORL LIQ PGI ML 0.026500001938959 VICKS FORMULA 44 ORAL LIQUID ORL LIQ PGI ML 0.034100002050684 VICKS NYQUIL ADULT NIGHTTIME COLD MEDICINE ORL LIQ ORL LIQ PGI ML 0.027600001935747 VICKS VAPORUB TOPICAL OINTMENT TOP ONT PGI G 0.070400002351064 VICTOZA 6 MG/ML PEN INJECTION SYRINGE INJ DEFAUL NNA ML 31.148900002336707 VIDAZA 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 628.000000002244596 VIDEX EC 125 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 4.295000002244597 VIDEX EC 200 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 6.871700002244598 VIDEX EC 250 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 8.515000002244599 VIDEX EC 400 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 13.771700002417685 VIDEXTRA 10,000 UNIT TABLET ORL TAB ORI TAB 0.210000002442256 VIDEXTRA 2000 UNIT SOFTGEL CAPSULE ORL CAP ORI CAP 0.069300002252260 VIGAMOX 0.5% OPHTHALMIC SOLUTION OPH SOL NOV ML 4.5300

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002443724 VIIBRYD 10 MG TABLET ORL TAB FLC TAB 3.219300002443732 VIIBRYD 20 MG TABLET ORL TAB FLC TAB 3.219300002443740 VIIBRYD 40 MG TABLET ORL TAB FLC TAB 4.285300002427184 VIMIZIM 5MG/5ML (SINGLE-USE) VIAL INJECTION INJ DEFAUL BMI VIAL 1199.000000002361701 VIMOVO 375 MG/20 MG TABLET ORL TAB AZC TAB 1.148500002361728 VIMOVO 500 MG/20 MG TABLET ORL TAB AZC TAB 1.144500002183056 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL PFI ML 18.563000002401460 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 17.679000002183013 VINCRISTINE SULFATE 1 MG/ML INJECTION INJ DEFAUL PFI ML 63.365000002143305 VINCRISTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 31.000000000074500 VIOFORM HC TOPICAL CREAM TOP CRM PAL G 1.059300002238617 VIRACEPT 250 MG TABLET ORL TAB AGR TAB 2.117900002248761 VIRACEPT 625 MG TABLET ORL TAB PFI TAB 5.305000002238748 VIRAMUNE 200 MG TABLET ORL TAB BOE TAB 5.284500000687456 VIROPTIC 1% OPHTHALMIC SOLUTION OPH SOL VCL ML 3.518700080061901 VISBIOME ORAL POWDER ORL PWR EGP PCKT 3.300000080030855 VISION CARE CAPSULE ORL CAP PLT CAP 0.899100000568627 VISKAZIDE 10/25 MG TABLET ORL TAB TRI TAB 1.133700000568635 VISKAZIDE 10/50 MG TABLET ORL TAB TRI TAB 1.133700000443174 VISKEN 10 MG TABLET ORL TAB TRI TAB 1.226200000417289 VISKEN 15 MG TABLET ORL TAB TRI TAB 1.778800000417270 VISKEN 5 MG TABLET ORL TAB TRI TAB 0.718200002242367 VISUDYNE 15 MG/VIAL INJECTION INJ DEFAUL VCL VIAL 1703.100000080046319 VITAFUSION FIBER ADULT ORAL GUMMY ORL CTB CHD TAB 0.172100080026366 VITAFUSION MULTI-VITES ORAL GUMMY ORL CTB CHD TAB 0.065700080071138 VITAFUSION VITAMIN B12 GUMMY ORL CTB CHD TAB 0.064300080044606 VITALUX ADVANCED CAPLET ORL TAB ALC TAB 0.208300080072366 VITALUX ADVANCED CHEWABLE TABLET ORL CTB ALC TAB 0.250000080077188 VITALUX ADVANCED PLUS OMEGA-3 CAPSULE ORL CAP ALC CAP 0.280000080016590 VITALUX CAPLET ORL TAB ALC TAB 0.235300080016683 VITALUX PLUS OMEGA 3 CAPSULE ORL CAP ALC CAP 0.210000002240199 VITALUX TR MULTIVITAMIN/MULTIMINERAL TABLET ORL TAB NCI TAB 0.239800080028004 VITALUX-S PLUS OMEGA-3 CAPSULE ORL CAP ALC CAP 0.210000080016576 VITALUX-S TABLET ORL TAB ALC TAB 0.239800000123137 VITAMIN A & D FORTIFIED CAPSULE ORL CAP JAM CAP 0.048200002245311 VITAMIN A 10,000 IU CAPSULE ORL CAP WNP CAP 0.026000000297720 VITAMIN A 10,000 IU CAPSULE ORL CAP JAM CAP 0.057500000999509 VITAMIN B MIS DEFAUL XXX MIS 0.069800080035590 VITAMIN B 100 MG TIME RELEASE TABLET ORL TAB WNP TAB 0.157500000487082 VITAMIN B CMPD 100 SUSTAINED-RELEASE TABLET ORL SRT SWS TAB 0.1603

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000407011 VITAMIN B1 100 MG TABLET ORL TAB JAM TAB 0.056700000294853 VITAMIN B1 100 MG TABLET ORL TAB VCL TAB 0.090000002239350 VITAMIN B1 100 MG TABLET ORL TAB PMT TAB 0.021400000816078 VITAMIN B1 100 MG/ML INJECTION USP INJ DEFAUL SDZ ML 3.810000080009633 VITAMIN B1 50 MG TABLET ORL TAB JPC TAB 0.073700002247479 VITAMIN B100 COMPLEX TABLET ORL TAB WBP TAB 0.108200002023598 VITAMIN B12 100 MCG TABLET ORL TAB PMT TAB 0.056800000450642 VITAMIN B12 100 MCG TABLET ORL TAB VTH TAB 0.070000000331015 VITAMIN B12 100 MCG TABLET ORL TAB JAM TAB 0.067500002237736 VITAMIN B12 1000 MCG TABLET ORL TAB SWS TAB 0.096300080006939 VITAMIN B12 1000 MCG TABLET ORL TAB WNP TAB 0.097400080012952 VITAMIN B12 1000 MCG TABLET ORL TAB JAM TAB 0.101500080003575 VITAMIN B12 1000 MCG TIME RELEASE TABLET ORL ERT PMT TAB 0.047000000626112 VITAMIN B12 1000 MCG/ML INJECTION INJ DEFAUL OMG ML 0.450000080042931 VITAMIN B12 250 MCG GUMMY ORL CTB VTH TAB 0.078700000335940 VITAMIN B12 250 MCG TABLET ORL TAB JAM TAB 0.075000000502758 VITAMIN B12 250 MCG TABLET ORL TAB SWS TAB 0.139700000305243 VITAMIN B12 50 MCG TABLET ORL TAB JAM TAB 0.062500080059976 VITAMIN B12 500 MCG SPRAY ORL SPR JMS ML 0.172200000689726 VITAMIN B12 500 MCG TABLET ORL TAB SNS TAB 0.080000002243767 VITAMIN B12 500 MCG TABLET ORL TAB VTH TAB 0.046500000329185 VITAMIN B6 100 MG TABLET ORL TAB JAM TAB 0.085000002239348 VITAMIN B6 100 MG TABLET ORL TAB PMT TAB 0.022800000450677 VITAMIN B6 100 MG TABLET ORL TAB VTH TAB 0.071900000122645 VITAMIN B6 25 MG TABLET ORL TAB JAM TAB 0.033600080002890 VITAMIN B6 25 MG TABLET ORL TAB JPC TAB 0.019000000331031 VITAMIN B6 250 MG TABLET ORL TAB JAM TAB 0.125000000305227 VITAMIN B6 50 MG TABLET ORL TAB JAM TAB 0.048500000341207 VITAMIN C 1000 MG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.125000000305235 VITAMIN C 1000 MG TABLET ORL TAB JAM TAB 0.100000080044604 VITAMIN C 125 MG GUMMIES ORL CTB VTH TAB 0.130000080040321 VITAMIN C 125 MG GUMMY ORL DEFAUL JAM PIECE 0.145800001922378 VITAMIN C 500 MG TABLET ORL TAB SWS TAB 0.047900001994336 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB JAM TAB 0.071500002243893 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB PMT TAB 0.033300000784591 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB VTH TAB 0.021000000237116 VITAMIN C 500 MG ORANGE FLAVORED CHEWABLE TABLET ORL CTB TEV TAB 0.025700000373699 VITAMIN C 500 MG SUSTAINED-RELEASE CAPSULE ORL SRC JAM CAP 0.110000002163268 VITAMIN C 500 MG TABLET ORL TAB JAM TAB 0.047900000557838 VITAMIN C 500 MG TABLET ORL TAB WTR TAB 0.0132

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000036188 VITAMIN C 500 MG TABLET ORL TAB WAM TAB 0.040000002240883 VITAMIN C 500 MG TABLET ORL TAB WNP TAB 0.035900080003328 VITAMIN C 500 MG TABLET ORL TAB WNP TAB 0.018900080020803 VITAMIN C 500 MG TIMED RELEASE CAPLET ORL SRT JAM TAB 0.1000

00080003525 VITAMIN C BUFFERED WITH CALCIUM ASCORBATE CAPSULE ORL CAP WNP CAP 0.077500002240885 VITAMIN C TABLET ORL TAB WNP TAB 0.040500080001870 VITAMIN D 1,000 IU TAB ORL TAB SIS TAB 0.044000080017530 VITAMIN D 1000 IU CAPSULE ORL CAP JAM CAP 0.039700080008795 VITAMIN D 1000 IU SOFTGEL ORL CAP PRA CAP 0.060800080000436 VITAMIN D 1000 IU TABLET ORL TAB JAM TAB 0.050000000323179 VITAMIN D 1000 UNIT TABLET ORL TAB SWS TAB 0.030500080009578 VITAMIN D 400 IU TABLET ORL TAB VCL TAB 0.023600002240624 VITAMIN D 400 IU TABLET ORL TAB WAM TAB 0.036100080002452 VITAMIN D 400 IU TABLET ORL TAB WNP TAB 0.019200002240858 VITAMIN D 400 IU TABLET ORL TAB PMT TAB 0.011700002229879 VITAMIN D 400 IU TABLET ORL TAB SWS TAB 0.039800002242175 VITAMIN D 400 IU TABLET ORL TAB JAM TAB 0.055600080018025 VITAMIN D DROPS 400 IU ORL LIQ JAM ML 1.118400080015280 VITAMIN D3 1000 IU CAPSULE ORL GEL VTH CAP 0.043500080012364 VITAMIN D3 1000 IU CAPSULE ORL CAP NFN CAP 0.040000080031157 VITAMIN D3 1000 IU CHEWABLE TABLET ORL CTB WNP TAB 0.028800080012124 VITAMIN D3 1000 IU ORAL LIQUID ORL LIQ WBP ML 0.207200080003663 VITAMIN D3 1000 IU TABLET ORL TAB WNP TAB 0.032700002245842 VITAMIN D3 1000 IU TABLET ORL TAB PMT TAB 0.017800080027799 VITAMIN D3 DROPS 1000 IU ORAL LIQUID ORL DPS JMS ML 1.118400080047918 VITAMIN D3 GUMMIES ORL CTB VTH TAB 0.066700000480924 VITAMIN E 100 IU NATURAL SOURCE CAPSULE ORL CAP VTH CAP 0.046800000122823 VITAMIN E 100 IU OBLONG AMBER CAPSULE ORL CAP JAM CAP 0.080000000122831 VITAMIN E 200 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.105000000266108 VITAMIN E 400 IU CAPSULE ORL CAP PMT CAP 0.054200000782181 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.058500002240968 VITAMIN E 400 IU CAPSULE ORL CAP WNP CAP 0.087700000480940 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.074100002240967 VITAMIN E 400 IU CAPSULE ORL CAP WNP CAP 0.054100000122858 VITAMIN E 400 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.133300080013178 VITAMIN E 400 IU SOFTGEL CAPSULE ORL CAP JMS CAP 0.133300000330191 VITAMIN E 800 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.360000002015293 VITAMIN E NATURAL SOURCE 400 UNIT CAPSULE ORL CAP QVS CAP 0.059200000201995 VITAMIN E NF NATURAL SOURCE 400 IU CAPSULE ORL CAP WAM CAP 0.1165

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080030153 VITAMIN K2 100 MCG CAPSULE ORL CAP NFN CAP 0.124800000480878 VITAMINE B12 1200 MCG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.115600000816175 VITAMINE C 600 MG CAPSULE ORL CAP SIS CAP 0.211200002417995 VITAMINE D 10 000 10000 UNIT TABLET ORL TAB PDL TAB 0.210000002490323 VITRAKVI 100 MG CAPSULE ORL CAP BAI CAP 320.830000002490331 VITRAKVI 20 MG/ML ORAL SOLUTION ORL SOL BAI ML 64.166700002490315 VITRAKVI 25 MG CAPSULE ORL CAP BAI CAP 80.210000002248361 VIVAXIM INJECTION INJ DEFAUL SFP SYR 75.500000080028217 VIVISCAL MAXIMUM STRENGTH TABLET ORL TAB IRI TAB 0.636200000885975 VIVOTIF BERNA 6 B CAPSULE ORL CAP SSV CAP 6.445000002486024 VIZIMPRO 15 MG TABLET ORL TAB PFI TAB 116.666700002486032 VIZIMPRO 30 MG TABLET ORL TAB PFI TAB 116.666700002486040 VIZIMPRO 45 MG TABLET ORL TAB PFI TAB 116.666700002497204 VOCABRIA 30 MG TABLET ORL TAB VIV TAB 26.515700002307073 VOLIBRIS 10 MG TABLET ORL TAB GSK TAB 129.136000002307065 VOLIBRIS 5 MG TABLET ORL TAB GSK TAB 129.136000000514012 VOLTAREN 50 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 0.955400002290375 VOLTAREN EMULGEL 1.16% TOPICAL GEL TOP GEL NVC G 0.1337

00002393190 VOLTAREN EMULGEL EXTRA STRENGTH 2.32% TOPICAL GEL TOP GEL GKC G 0.198700002338580 VOLTAREN EMULGEL JOINT PAIN 1.16% TOPICAL GEL TOP GEL NVC G 0.115700000881635 VOLTAREN RAPIDE 50 MG TABLET ORL TAB NOV TAB 0.975500002381966 VORICONAZOLE 200 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 136.580000002352303 VOTRIENT 200 MG TABLET ORL TAB NOV TAB 36.080500080037590 VSL #3 ORAL POWDER ORL PWR FEI PCKT 3.100000080042116 VSL #3 ORAL POWDER ORL PWDPKT FEI PCKT 3.655700002365561 VYLOMA 3.75% TOPICAL CREAM TOP CRM VCL G 39.826700002495732 VYNDAQEL 20 MG CAPSULE ORL CAP PFI CAP 203.070000002439603 VYVANSE 10 MG CAPSULE ORL CAP TAK CAP 2.276900002490226 VYVANSE 10 MG CHEWABLE TABLET ORL CTB TAK TAB 2.276900002490234 VYVANSE 20 MG CHEWABLE TABLET ORL CTB TAK TAB 2.805800002490242 VYVANSE 30 MG CHEWABLE TABLET ORL CTB TAK TAB 3.356000002490250 VYVANSE 40 MG CHEWABLE TABLET ORL CTB TAK TAB 3.906000002490269 VYVANSE 50 MG CHEWABLE TABLET ORL CTB TAK TAB 4.456200002490277 VYVANSE 60 MG CHEWABLE TABLET ORL CTB TAK TAB 5.006300002458071 VYVANSE 70 MG CAPSULE ORL CAP TAK CAP 5.525700080006877 WAMPOLE MINERAL CALCIUM ORAL LIQUID ORL LIQ JPC ML 0.036100080008041 WAMPOLE MULTIVITAMIN LIQUID ORL LIQ WAM ML 0.035000002453703 WAMPOLE-ACETAMINOPHEN/CODEINE/CAFFEINE ORL TAB WAM TAB 0.050400001948970 WASP VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 41.4833

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001910787 WEBBER OINTMENT VITAMIN E 30 IU/G TOPICAL OINTMENT TOP ONT JLF G 0.111600000795232 WEBCOL ALCOHOL PREP JAJ DEFAUL DEFAUL CDD MIS 0.009900080002343 WELLESSE JOINT MOVEMENT GLUCOSAMINE LIQUID ORL LIQ BOT ML 0.0284

00080024468 WESTCOAST NATURALS CALCIUM MAGNES. PHOS. VIT D LIQ ORL LIQ WES ML 0.047100080018599 WESTCOAST NATURALS VITAMIN B12 1000 MCG TABLET ORL TAB WES TAB 0.127700001949004 WHITE FACED HORNET VENOM 120 MCG INJ DEFAUL ALG VIAL 35.683300002136740 WOBENZYM N TABLET ORL TAB MUC TAB 0.349700002424703 WOMEN'S ROGAINE FOAM 5% AEROSOL FOAM TOP FOA JJI G 0.769700099400140 WRIST HAND, OFF-THE-SHELF, LEFT DEFAUL DEFAUL XXX MIS 40.710000099400142 WRIST HAND, OFF-THE-SHELF, RIGHT DEFAUL DEFAUL XXX MIS 40.710000002384256 XALKORI 200 MG CAPSULE ORL CAP PFI CAP 130.000000002384264 XALKORI 250 MG CAPSULE ORL CAP PFI CAP 130.000000000548359 XANAX 0.25 MG TABLET ORL TAB UJC TAB 0.300900000548367 XANAX 0.5 MG TABLET ORL TAB UJC TAB 0.360000000723770 XANAX 1 MG TABLET ORL TAB UJC TAB 0.654200000813958 XANAX TS 2 MG TABLET ORL TAB UJC TAB 1.162800002238453 XELODA 150 MG TABLET ORL TAB HLR TAB 1.947800002238454 XELODA 500 MG TABLET ORL TAB HLR TAB 6.493200002240325 XENICAL 120 MG CAPSULE ORL CAP CAG CAP 1.672300002404044 XERESE 5%/1% TOPICAL CREAM TOP CRM VCL G 7.526000002481553 XERMELO 250 MG TABLET ORL TAB ISP TAB 84.820000002368153 XGEVA 120 MG/VIAL INJECTION INJ DEFAUL AMG VIAL 617.400000002388316 XIAFLEX 0.9 MG/VIAL INJECTION INJ DEFAUL ENV VIAL 1232.780000002471027 XIIDRA 5% OPHTHALMIC SOLUTION OPH SOL SHB ML 17.154200002459795 XOLAIR 150 MG/ML INJECTION SYRINGE INJ DEFAUL NOV SYR 628.840000002459787 XOLAIR 75 MG/0.5 ML INJECTION SYRINGE INJ DEFAUL NOV SYR 274.180000002495058 XOSPATA 40 MG TABLET ORL TAB ASP TAB 286.733300080036707 X-PUR 100% XYLITOL GUM 1.06 G ORAL GUM ORL GUM ORS PIECE 0.010700000866598 X-SEB PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.063900000866601 X-SEB T PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.063900002407329 XTANDI 40 MG CAPSULE ORL CAP ASP CAP 28.345000002474875 XULTOPHY PEN 100 UNIT/ML/ 3.6 MG/ML INJECTION INJ DEFAUL NNA ML 20.590700080042491 XYLIMELTS FOR DRY MOUTH 500 MG LOZENGE ORL LOZ ORA LOZ 0.477300002302411 XYLOCAINE 1% INJECTION INJ DEFAUL AZC ML 0.276000000001791 XYLOCAINE 1% W EPINEPHRINE 1:100,000 INJ INJ DEFAUL AZC ML 0.509500002302438 XYLOCAINE 2% INJECTION INJ DEFAUL AZC ML 0.294500000385484 XYLOCAINE 2% TOPICAL JELLY URH JEL AZC ML 1.050000002373130 XYLOCAINE 2% W EPINEPHRINE 1:200,000 INJECTION ORL DEFAUL AZC ML 0.5095

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 126 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price

00002003767 XYLOCAINE ENDOTRACHEAL 10 MG/DOSE NON-AEROSOL SPR TOP SPR AZC DOSE 0.133200000001732 XYLOCAINE HCL 1% LIQUID (BLOCK OR INFILTRATION) INJ LIQ AZC ML 1.256000000001805 XYLOCAINE HCL 1% W EPINEPHRINE 1:200,000 INJ INJ DEFAUL AZC ML 0.509500000036641 XYLOCAINE HCL 2% PLAIN LIQ (BLOCK OR INFILTRATION) INJ LIQ AZC ML 1.505000000284106 XYLOCAINE HCL SOL 2% W EPINEPHRINE 1:200,000 INJ INJ DEFAUL AZC ML 0.600000000001937 XYLOCARD INJ 20 MG/ML INJECTION INJ DEFAUL APC ML 0.976000002268272 XYREM 500 MG/ML ORAL SOLUTION ORL SOL JAZ ML 2.686800002321157 YAZ 28 TABLET ORL TB BAI TAB 0.590000002387433 YAZ PLUS 28 TABLET ORL TB BAI TAB 0.422900001948954 YELLOW JACKET VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 35.683300001948962 YELLOW JACKET VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 35.683300002379384 YERVOY INTRAVENOUS INFUSION 5 MG/ML INJECTION INJ DEFAUL BMS ML 580.000000000428833 YF-VAX 109648 U/0.5 ML INJECTION INJ DEFAUL SFP VIAL 137.310000000885533 YOHIMBINE-ODAN 2 MG TABLET ORL TAB ODN TAB 0.542000001901885 YOHIMBINE-ODAN 5.4 MG TABLET ORL TAB ODN TAB 0.827500001985604 YOHIMBINE-ODAN 6 MG TABLET ORL TAB ODN TAB 0.849500002242324 ZADITOR 0.25 MG/ML OPH SOLUTION OPH SOL LTH ML 5.556000002230287 ZANTAC 75 MG TABLET ORL TAB GSK TAB 0.429000002277301 ZANTAC MAX STRENGTH NON-PRESCRIPTION 150 MG TAB ORL TAB SAH TAB 0.630000000568392 ZAPEX 10 MG TABLET ORL TAB RIV TAB 0.042000000568406 ZAPEX 15 MG TABLET ORL TAB RIV TAB 0.066000000568414 ZAPEX 30 MG TABLET ORL TAB RIV TAB 0.090000002250519 ZAVESCA 100 MG CAPSULE ORL CAP JAI CAP 108.550000002489783 ZEJULA 100 MG CAPSULE ORL CAP GSK CAP 131.785000002380242 ZELBORAF 240 MG FILM-COATED TABLET ORL TAB HLR TAB 35.5539

00002361752 ZENHALE 100 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.7988

00002361760 ZENHALE 200 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.968100002449684 ZENSA 5% TOPICAL CREAM TOP CRM ALE G 1.000000002506009 ZEPOSIA 0.23 MG/0.46 MG CAPSULE INITIATION PACK ORL CAP BMS CAP 68.500000002505991 ZEPOSIA 0.92 MG CAPSULE ORL CAP BMS CAP 68.500000002216086 ZERIT 15 MG CAPSULE ORL CAP BMS CAP 5.075200002216094 ZERIT 20 MG CAPSULE ORL CAP BMS CAP 5.277300002216108 ZERIT 30 MG CAPSULE ORL CAP BMS CAP 5.679200002216116 ZERIT 40 MG CAPSULE ORL CAP BMS CAP 5.888300002462699 ZEULIDE DEPOT 22.5 MG/VIAL INJECTION INJ DEFAUL VTY VIAL 873.000000002429977 ZEULIDE DEPOT 3.75 MG/VIAL INJECTION INJ DEFAUL VTY VIAL 304.000000002446685 ZEVTERA 500 MG/VIAL INJECTION INJ DEFAUL AVP VIAL 58.4000

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 127 of 129

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002240358 ZIAGEN 20 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.512900002240357 ZIAGEN 300 MG TABLET ORL TAB GSK TAB 7.712000000297666 ZINC 10 MG TABLET ORL TAB JAM TAB 0.060000000441589 ZINC 25 MG TABLET ORL TAB JAM TAB 0.080000000503169 ZINC 50 MG TABLET ORL TAB VTH TAB 0.081500000505463 ZINC 50 MG TABLET ORL TAB JAM TAB 0.087500001922351 ZINC 50 MG TABLET ORL TAB SWS TAB 0.046600000480886 ZINC 50 MG TIMED RELEASE TABLET ORL TAB JAM TAB 0.108300080012983 ZINC COPPER BALANCE 15 MG/2 MG CAPSULE ORL CAP AOR CAP 0.155000002244744 ZINC OXIDE 15 % TOPICAL OINTMENT TOP ONT RWP G 0.027000002239162 ZINCOFAX 15% TOPICAL OINTMENT TOP ONT PAL G 0.087600002239160 ZINCOFAX EXTRA STRENGTH 40% TOPICAL OINTMENT TOP ONT PAL G 0.069900002153432 ZINECARD 250 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 137.060000002153440 ZINECARD 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 274.140000002489449 ZIRABEV 25 MG/ML (16 ML VIAL) INJECTION INJ DEFAUL PFI ML 96.485600002489430 ZIRABEV 25 MG/ML (4 ML VIAL) INJECTION INJ DEFAUL PFI ML 96.485000002239952 ZITHROMAX 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 22.713000002421550 ZOLEDRONIC ACID 4 MG/5 ML INJECTION INJ DEFAUL PFI ML 38.785600002413701 ZOLEDRONIC ACID CONCENTRATE 4 MG/5 ML INJECTION INJ DEFAUL OMG ML 38.785600002327619 ZOLINZA 100 MG CAPSULE ORL CAP MFC CAP 76.179500002379929 ZOLMITRIPTAN 2.5 MG TABLET ORL TAB PDL TAB 3.537500002379988 ZOLMITRIPTAN ODT 2.5 MG ORAL DISPERSIBLE TABLET ORL DISPTAB PDL TAB 3.538300002442671 ZOLMITRIPTAN ODT 2.5 MG ORALLY DISP. TABLET ORL DISPTAB SNS TAB 3.538300002248992 ZOMIG 2.5 MG NASAL SPRAY NAS SPU AZC DOSE 14.960000002468492 ZOPICLONE 5 MG TABLET ORL TAB ALP TAB 0.223100002469154 ZOPICLONE 7.5 MG TABLET ORL TAB ALP TAB 0.468500002375516 ZOSTAVAX II 19,400 UNITS/(0.65 ML) VIAL INJECTION INJ DEFAUL MFC VIAL 187.530000000740306 ZOSTRIX 0.025% TOPICAL CREAM TOP CRM VCL G 0.219200002004240 ZOSTRIX H.P. 0.075% TOPICAL CREAM TOP CRM VCL G 0.280000002039524 ZOVIRAX 5% TOPICAL CREAM TOP CRM VCL G 15.364000000569771 ZOVIRAX 5% TOPICAL OINTMENT TOP ONT VCL G 15.366000000800686 Z-PLUS TOPICAL SHAMPOO TOP SHP DLX ML 0.105300002354772 ZUACTA 0.075% TOPICAL CREAM TOP CRM SAV G 1.847800002340445 ZYCLARA 3.75% TOPICAL CREAM TOP CRM VCL G 41.932000002438798 ZYDELIG 100 MG TABLET ORL TAB GIL TAB 85.350000002438801 ZYDELIG 150 MG TABLET ORL TAB GIL TAB 85.350000002436779 ZYKADIA 150 MG CAPSULE ORL CAP NOV CAP 52.000000002257270 ZYMAR 0.3% OPHTHALMIC SOLUTION OPH SOL ALL ML 2.304000002238851 ZYPREXA 20 MG TABLET ORL TAB LIL TAB 16.406100002247099 ZYPREXA INTRAMUSCULAR 10 MG/VIAL INJECTION INJ DEFAUL LIL VIAL 31.0600

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective March 12, 2021

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002243088 ZYPREXA ZYDIS 15 MG ORAL DISINTEGRATING TABLET ORL DISNTAB LIL TAB 12.429600002243089 ZYPREXA ZYDIS 20 MG ORAL DISINTEGRATING TABLET ORL DISNTAB LIL TAB 16.553600002371065 ZYTIGA 250 MG TABLET ORL TAB JAI TAB 30.625000002457113 ZYTIGA 500 MG TABLET ORL TAB JAI TAB 61.250000002360349 ZYTRAM XL 100 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.487000002286424 ZYTRAM XL 150 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 2.184000002286432 ZYTRAM XL 200 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 2.870000002286440 ZYTRAM XL 300 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 4.144000002286459 ZYTRAM XL 400 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 5.466000002360322 ZYTRAM XL 75 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.147500002243685 ZYVOXAM 2 MG/ML INJECTION INJ DEFAUL PFI ML 0.357400002243686 ZYVOXAM 20 MG/ML ORAL SUSPENSION ORL SUS PFI ML 2.6232

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Page 129 of 129