Alberta Human Services Drug Benefit Supplement · ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT...

Alberta Human Services Drug Benefit Supplement

Effective April 1, 2018

ABC 40211/81160 (R2018/04)

Inquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton, AB T5J 3C5 Telephone Number: (780) 498-8370 (Edmonton) (403) 294-4041 (Calgary) 1-800-361-9632 (Toll Free) FAX Number: (780) 498-8384 1-877-828-4106 (Toll Free)

Website: http://www.humanservices.alberta.ca/alberta-supports.html Administered by Alberta Blue Cross on behalf of Alberta Human Services. The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Copies of the Alberta Human Services Drug Benefit Supplement are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: $42.00 ($40.00 + $2.00 G.S.T.) Contents only: $36.75 ($35.00 + $1.75 G.S.T.) A cheque or money order must accompany the request for copies.

http://www.humanservices.alberta.ca/alberta-supports.html

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.

EFFECTIVE APRIL 1, 2018 i

1BTable of Contents

79BPART 1 80BSECTION 1—POLICIES AND GUIDELINES

Introduction Eligibility .................................................................................................................................................1.1 Additional Notes Regarding Application of the Supplement ..................................................................1.1 Interchangeable Drug Products .............................................................................................................1.1 Restricted Benefits Restricted Benefits .................................................................................................................................1.2 Special Authorization Guidelines Special Authorization Policy ..................................................................................................................1.3 Special Authorization Procedures ....................................................................................................... 1A.1

SECTION 2—PRICE POLICY Price Policy Price Policy ............................................................................................................................................2.1 Additional Units of Issue for Pricing .......................................................................................................2.1 Excluded Drug Products ........................................................................................................................2.1

SECTION 3—CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

Special Authorization Policy ..................................................................................................................3.1 Criteria for Coverage ..............................................................................................................................3.2

83B84B3BSECTION 3A— CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

Criteria for Optional Special Authorization of Select Drug Products ..................................................... 3A Criteria for Coverage .............................................................................................................................. 3A Role of the Prescribers .......................................................................................................................... 3A

85BSECTION 4—RARE DISEASES DRUG COVERAGE PROGRAM Rare Diseases Drug Coverage ..............................................................................................................4.1 Contraindications ...................................................................................................................................4.1 Rare Diseases Drugs Eligible for Coverage ..........................................................................................4.2 Alberta Rare Diseases Clinical Review Panel .......................................................................................4.2 Process for Rare Diseases Drug Coverage...........................................................................................4.2



EFFECTIVE APRIL 1, 2018 ii

Table of Contents, continued

PART 2

86bPharmacologic–Therapeutic Classification of Drugs 00:00 Non-Classified Drugs ................................................................................................................ 1 02:00 Pediatric Cough and Cold Preparations .................................................................................... 1 04:00 Antihistamine Drugs .................................................................................................................. 1 08:00 Anti-Infective Agents ................................................................................................................. 2 12:00 Autonomic Drugs ....................................................................................................................... 2 20:00 Blood Formation, Coagulation and Thrombosis ........................................................................ 3 28:00 Central Nervous System Agents ............................................................................................... 3 40:00 Electrolytic, Caloric, and Water Balance ................................................................................... 5 52:00 Eye, Ear, Nose and Throat Preparations .................................................................................. 6 56:00 Gastrointestinal Drugs ............................................................................................................... 7 84:00 Skin and Mucous Membrane Agents ........................................................................................ 8 88:00 Vitamins ................................................................................................................................... 10 92:00 Miscellaneous Therapeutic Agents ......................................................................................... 11

Appendices Appendix 1 Pharmaceutical Manufacturers ............................................................................................. 12 Appendix 2 Alphabetical List of Pharmaceutical Products ...................................................................... 13 Appendix 3 Numerical List by Drug Identification Number ...................................................................... 18

PART 1

SECTION 1

Policies and

Guidelines

Section 1 Policies and Guidelines



EFFECTIVE APRIL 1, 2018 Section 1 • 1

INTRODUCTION

Eligibility

The Alberta Human Services Drug Benefit Supplement (HSDBS) defines the drugs and drug products that are covered for Alberta Human Services clients in addition to the drugs and drug products defined in the Alberta Drug Benefit List (with certain exclusions).

The Supplement was developed to take into consideration the essential needs of clients covered under Alberta Human Services programs.

Additional Notes Regarding Application of the Supplement

1. The Supplement is not intended to be used as a scientific reference or prescribing guide.2. Formularies used by hospitals and continuing care facilities are developed independently of the

Supplement.3. Drugs are classified according to the Pharmacologic–Therapeutic classifications (PTC) developed

by the American Society of Hospital Pharmacists for the purpose of the American HospitalFormulary Service.Permission to use this system has been granted by the American Society of HospitalPharmacists. The Society is not responsible for the accuracy of transpositions or excerpts fromthe original content.Where necessary, additional PTCs may have been assigned by Alberta Blue Cross to facilitateproduct location in the Supplement.

4. Where appropriate, the Compendium of Pharmaceuticals and Specialties, published by theCanadian Pharmaceutical Association, was used as a reference source for the trade name,generic name, manufacturer, strength and dosage form.The Canadian Pharmacist’s Association is not responsible for the accuracy of transpositions orexcerpts from the original content.

5. Other reference sources used for the trade name, generic name, manufacturer, strength anddosage form are: completed Drug Identification Number (DIN) notification form Notice of Compliance (NOC) Product Monograph

6. DINs listed reflect current manufacturer information available as of April 1, 2016.

Interchangeable Drug Products A box containing an X to the left of the DIN or Product Identification Number (PIN) indicates that the product is not interchangeable with other products within the category. Refer to Policies and Guidelines Section 1 of the current Alberta Drug Benefit List for further information regarding interchangeable drug products.




RESTRICTED BENEFITS Restricted Benefits

Selected drug products in the PTCs listed below are eligible benefits with restrictions in the Supplement. For these products a comment is displayed in the HSDBS after the ingredient name or specific strength for each restricted drug product. The comment initially states “RESTRICTED BENEFIT” and is followed by an explanation of the restriction. For eligible drug products, please refer to the applicable PTCs in the HSDBS.

00:00:02 Diabetic Supplies (Blood Glucose Meter) 02:00 Pediatric Cough and Cold Preparations 04:02 Pediatric Antihistamines 12:92 Miscellaneous Autonomic Drugs 20:04.04 Antianemia Drugs

(Iron Preparations) 28:08.04.92 Analgesics and Antipyretics

Nonsteroidal Anti-Inflammatory Agents (Other Nonsteroidal Anti-Inflammatory Agents)

28:16.08.04 Psychotherapeutic Agents Antipsychotics (Atypical Antipsychotics) 56:12 Cathartics & Laxatives 84:04.08.28 Anti-Infectives

Antifungals (Polyenes)

88:16 Vitamin D 88:28 Multivitamin Preparations 88:28:01 Multivitamin Preparations

(Vitamins & Minerals)

Example:

LORATADINE RESTRICTED BENEFIT - This product is a benefit for patients up to 17 years of age inclusive.

1 MG / ML ORAL SYRUP 00002241523 CLARITIN BIC $ 0.0517




SPECIAL AUTHORIZATION GUIDELINESSpecial Authorization Policy

Drug Products Eligible for Consideration by Special Authorization Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products not eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization.

1. The drug is covered by Alberta Health and/or Alberta Human Services under specified criteria(listed in the following sections). Drug Products and indications other than those specified are noteligible for consideration by special authorization.

2. The drug is normally covered by another government program or agency for a specific approvedclinical condition, but is needed for the treatment of a clinical condition that is not covered by thatgovernment program or agency.

3. The drug is required because other drug products listed in the Alberta Drug Benefit List or theAlberta Human Services Drug Benefit Supplement are contraindicated or inappropriate becauseof the clinical condition of the patient.

4. The particular brand of drug is considered essential in the care of a patient, where the LCA pricepolicy would otherwise apply. Coverage of a specific brand may be considered where a patienthas experienced significant allergic reactions or documented untoward therapeutic effects withalternate brands in an interchangeable grouping. Coverage of a brand name product will not beconsidered in situations where the interchangeable grouping includes a pseudo-generic to thebrand name drug.

5. A particular drug product or dosage form of a drug is essential in the care of a patient where theMAC price policy would otherwise apply. Exceptions may occur at the product level. Coveragemay be considered only where a patient has experienced significant allergic reactions ordocumented untoward therapeutic effects with the drug product which establishes the MACpricing.

Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.

Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage prior to the expiration date of the Approved Period, unless the Auto-Renewal Process or Step Therapy Approval Process apply (see below).

Auto-Renewal Process Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).

1. For initial approval, a special authorization request must be submitted. If approval is granted, itwill be effective for the Approval Period outlined in the drug product’s Special Authorizationcriteria.

2. As long as the patient has submitted a claim for the drug product within the preceding ApprovalPeriod (example: within the preceding 6 months), approval will be automatically renewed for afurther Approval Period (example: a further 6 months). There is no need for the prescriber tosubmit a new request as the automated real-time claims adjudication system will read the




patient’s claims history to determine if a claim has been made within the preceding Approval Period.

3. If the patient does not make a claim for the drug product during the Approval Period, the approvalwill lapse and a new special authorization request must be submitted.

Step Therapy Approval Process Select drug products are eligible for coverage via the step therapy process, outlined below.

1. If the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months,the claim for the step therapy drug will be approved.

2. The automated real-time claims adjudication system will read the patient’s claims history todetermine if the required First-Line* drug product(s) have been claimed within the preceding 12months.

3. Subsequent claims for drug product(s) permitted by step therapy will continue to be approved aslong as the drug product has been claimed within the preceding 12 months.

4. The regular special authorization approval process will continue to be available for step therapyapprovals for those patients whose First-Line* drug claims cannot be adjudicated through theautomated real-time claims adjudication system.

* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’sSpecial Authorization criteria, are required to be utilized before reimbursement for the drug product is permitted.

Drug Products Not Eligible for Consideration by Special Authorization The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List or the Supplement.2. Drug products not yet reviewed by Alberta Health and/or Alberta Human Services. This applies

to: products where a complete submission has been received from the manufacturer and the

product is under review, products where an incomplete submission has been received from the manufacturer, and products where the manufacturer has not made a submission for review.Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.

3. Drug products that have completed the review process and are not included on the List or theSupplement.

4. Most drugs available through Health Canada’s Special Access Program.5. Drug products when prescribed for cosmetic indications.6. Nonprescription or over-the-counter drug products are generally not eligible.



EFFECTIVE APRIL 1, 2018 Section 1A • 1

Special Authorization Procedures

A prescriber’s request for special authorization should be directed by mail or FAX to: Clinical Drug Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5

FAX: (780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free fax for all other areas

1. A separate request is required for each patient.

2. For a request for special authorization to be considered, the prescriber (an individual authorizedby law to prescribe) must contact Alberta Blue Cross and provide the following information:

Patient Identification patient’s name, address and card holder’s name (if different than the patient’s), Alberta Blue Cross identification number or coverage number/client number of any other

applicable coverage (e.g. Alberta Human Services or Alberta Personal Health number, and date of birth.

Prescriber Identification name of prescriber (e.g. physician, dentist, or optometrist), address, telephone number and FAX number (if applicable), and professional association registration number (e.g. College of Physicians and Surgeons, Alberta

Dental Association, or Alberta College of Optometrists registration number).

Drug Requested name, strength and dosage form, dosage schedule, and proposed duration of therapy.

Reason for the Request diagnosis and/or indication for which the drug is being used, information regarding previous medications which have been used

and the patient’s response to therapy where appropriate, proposed results of therapy, and any additional information that may assist in making a decision on the

request for special authorization.

3. Special authorization request forms can be found in Alberta Drug Benefit List.

SECTION 2

Price Policy

Section 2 Price Policy




PRICE POLICY Price Policy The Price Policy is stated in the Alberta Drug Benefit List.

Additional Units of Issue for Pricing

Units of issue for pricing in the Supplement are defined in the Policies and Guidelines Section 1 of the List. The following are additional units of issue that apply to the Supplement.

Dosage Form Unit of Issue Priced in HSDBS

Oral Pudding ............................................................... Gram Rectal Pediatric Enema .............................................. Enema Rectal Pediatric Suppository ...................................... Suppository Topical Shampoo ........................................................ Millilitre Oral Gum .................................................................... Piece Topical Rinse .............................................................. Millilitre Topical Cream/Vaginal Cream ................................... Kit Vaginal Tablet/Topical Cream .................................... Kit

Excluded Drug Products

Drugs Used in the Treatment of Infertility All drug products used for the treatment of infertility are excluded as benefits for Alberta Human Services clients and are not eligible for special authorization for this indication.

Other Exclusions from the ADBL The following molecules (all brands, forms, routes, and strengths) in the current Alberta Drug Benefit List are excluded as benefits for Alberta Human Services clients unless coverage has been granted through Special Authorization. (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Supplement for more information.)

Generic Description Strength / Form Almotriptan Malate 6.25 mg & 12.5 mg Tablet Naratriptan HCl 1 mg & 2 mg Tablet Rizatriptan Benzoate 5 mg & 10 mg Tablet Rizatriptan Benzoate 5 mg & 10 mg Disintegrating Tablet Sumatriptan Hemisulfate 5 mg / Dose & 10 mg / Dose Nasal Unit Dose Spray Sumatriptan Succinate 50 mg & 100 mg Tablet Sumatriptan Succinate 6 mg / Syringe Injection Syringe Zolmitriptan 2.5 mg Dispersible Tablet Zolmitriptan 2.5 mg Tablet

SECTION 3

Criteria for Special Authorization

of Select Drug Products

Section 3 Criteria for Special A

uthorization of Select Drug Products

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS



CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

The drug products listed in this section may be considered for coverage by special authorization for Alberta Human Services clients.

Special Authorization Policy

Drug Products Eligible for Consideration by Special Authorization Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products not eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization.

1. The drug is covered by Alberta Health and /or Alberta Human Services under specified criteria (listed inthe following sections). Drug Products and indications other than those specified are not eligible forconsideration by special authorization.

2. The drug is normally covered by another government program or agency for a specific approved clinicalcondition, but is needed for the treatment of a clinical condition that is not covered by that governmentprogram or agency.

3. The drug is required because other drug products listed in the Alberta Drug Benefit List or the AlbertaHuman Services Drug Benefit Supplement are contraindicated or inappropriate because of the clinicalcondition of the patient.

4. The particular brand of drug is considered essential in the care of a patient, where the LCA price policywould otherwise apply. Coverage of a specific brand may be considered where a patient hasexperienced significant allergic reactions or documented untoward therapeutic effects with alternatebrands in an interchangeable grouping. Coverage of a brand name product will not be considered insituations where the interchangeable grouping includes a pseudo-generic to the brand name drug.

5. A particular drug product or dosage form of a drug is essential in the care of a patient where the MACprice policy would otherwise apply. Exceptions may occur at the product level. Coverage may beconsidered only where a patient has experienced significant allergic reactions or documented untowardtherapeutic effects with the drug product which establishes the MAC pricing.

Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.

Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage prior to the expiration date of the Approved Period, unless the Auto-Renewal Process or Step Therapy Approval Process apply (see below).

Auto-Renewal Process Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).

1. For initial approval, a special authorization request must be submitted. If approval is granted, it will beeffective for the Approval Period outlined in the drug product’s Special Authorization criteria




2. As long as the patient has submitted a claim for the drug product within the preceding Approval Period(example: within the preceding 6 months), approval will be automatically renewed for a furtherApproval Period (example: a further 6 months). There is no need for the prescriber to submit a newrequest as the automated real-time claims adjudication system will read the patient’s claims history todetermine if a claim has been made within the preceding Approval Period.

3. If the patient does not make a claim for the drug product during the Approval Period, the approval willlapse and a new special authorization request must be submitted.

Step Therapy Approval Process Select drug products are eligible for coverage via the step therapy process, outlined below.

1. If the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months, theclaim for the step therapy drug will be approved.

2. The automated real-time claims adjudication system will read the patient’s claims history to determine ifthe required First-Line* drug product(s) have been claimed within the preceding 12 months.

3. Subsequent claims for drug product(s) permitted by step therapy will continue to be approved as longas the drug product has been claimed within the preceding 12 months.

4. The regular special authorization approval process will continue to be available for step therapyapprovals for those patients whose First-Line* drug claims cannot be adjudicated through theautomated real-time claims adjudication system.

* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’s SpecialAuthorization criteria, are required to be utilized before reimbursement for the drug product is permitted.

Drug Products Not Eligible for Consideration by Special Authorization The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List or the Supplement.2. Drug products not yet reviewed by Alberta Health and/or Alberta Human Services. This applies to:

products where a complete submission has been received from the manufacturer and the product isunder review,

products where an incomplete submission has been received from the manufacturer, and products where the manufacturer has not made a submission for review.Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.

3. Drug products that have completed the review process and are not included on the List or theSupplement.

4. Most drugs available through Health Canada’s Special Access Program.5. Drug products when prescribed for cosmetic indications.6. Nonprescription or over-the-counter drug products are generally not eligible.

Criteria for Coverage

Wording that appears within quotation marks (“ “) in this section is the official special authorization criteria. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.




Products Available through Health Canada’s Special Access Program PEMOLINE “For the treatment of attention deficit hyperactivity disorder where approval has been provided by Health Canada’s Special Access Program.”

37.5 MG ORAL TABLET DIN N/A* CYLERT ABB

75 MG ORAL TABLET DIN N/A* CYLERT ABB

*As Cylert has been withdrawn from market, the DINs are no longer valid. Where authorizations for Cylert havebeen granted, coverage for this product will be provided under PIN 00000999917.

Other Products The remaining drug products in this section are listed alphabetically according to the generic ingredient name of the drug. These products can be found on the following pages.

CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT

ALMOTRIPTAN MALATE

INFANT FORMULA

NARATRIPTAN HCL

6.25 MG (BASE) ORAL TABLET


ORAL POWDER

1 MG (BASE) ORAL TABLET


0000240579200002398435

000024058060000239844300002405334

00000999543

00000999568

0000231429000002237820

000023223230000231430400002237821

APO-ALMOTRIPTANMYLAN-ALMOTRIPTAN

APO-ALMOTRIPTANMYLAN-ALMOTRIPTANSANDOZ ALMOTRIPTAN

PURAMINO A+

NEOCATE WITH DHA & ARA

TEVA-NARATRIPTANAMERGE

SANDOZ NARATRIPTANTEVA-NARATRIPTANAMERGE

APXMYP

APXMYPSDZ

MJO

NUN

TEVGSK

SDZTEVGSK

7.0433 7.0433

2.3478 2.3478 2.3478

0.1275

0.1341

11.9041 14.7050

6.1436 6.1436

15.5017

4 EFFECTIVE APRIL 1, 2018UNIT OF ISSUE - REFER TO PRICE POLICY

$$

$$$

$

$

$$

$$$

Section 3 .

"For the treatment of acute migraine attacks in patients where other standard therapy has failed.Special authorization may be granted for 24 months."

Information is required regarding previous medications utilized and the patient's response to therapy.

The following product(s) are eligible for auto-renewal.

"For use in patients who are unable to tolerate, have failed, or have nutritional requirements which cannot be met with the infant formulas which are unrestricted benefits (listed in PTC 40:20of the Alberta Human Services Drug Benefit Supplement). Information is required regarding the patient's diagnosis, previous infant formulas utilized and the patient's response to therapy, and/or the nutritional requirement which cannot be met with other infant formulas."

"For the treatment of acute migraine attacks in patients where other standard therapy has failed. Special authorization may be granted for 24 months."




"For use in patients who are unable to tolerate, have failed, or have nutritional requirements which cannot be met with the infant formulas which are unrestricted benefits (listed in PTC 40:20 of the Alberta Human Services Drug Benefit Supplement). Information is required regarding the patient's diagnosis, previous infant formulas utilized and the patient's response to therapy, and/or the nutritional requirement which cannot be met with other infant formulas."

"For use in patients who are unable to tolerate, have failed, or have nutritional requirements which cannot be met with the infant formulas which are unrestricted benefits (listed in PTC 40:20 of the Alberta Human Services Drug Benefit Supplement). Information is required regarding the patient's diagnosis, previous infant formulas utilized and the patient's response to therapy, and/or the nutritional requirement which cannot be met with other infant formulas."


PRODUCT IS NOT INTERCHANGEABLE

NUTRITIONAL PRODUCTS

ORAL LIQUID

ORAL POWDER

ORAL PUDDING

0000099940200000999427000009999340000099989000000999886000009994260000099943400000999416000009994750000099943000000999565000009999440000099940800000999435000009995240000099939100000999927000009994210000099955300000999467

0000099993500000999929000009995590000099944400000999415000009999830000099940500000999445000009994470000099956000000999422

0000099940400000999440

BOOST FRUIT FLAVOURED BEVERAGEBOOST HIGH PROTEINENSURE HIGH-PROTEINISOSOURCE 1.0 HPISOSOURCE FIBRE 1.0 HPCOMPLEAT PEDIATRICPEDIASURE PLUS WITH FIBREJEVITY 1.2 CALJEVITY 1.5 CALTWOCAL HNKETOCALPEPTAMENPEPTAMEN JUNIORPEPTAMEN WITH PREBIO 1NEOCATE E028 SPLASHNEOCATE SPLASHMCT OILPEPTAMEN 1.5PEPTAMEN JUNIOR 1.5PEPTAMEN AF 1.2

SCANDISHAKETOLEREXMODULEN IBDDUOCALBENEPROTEINVIVONEX T.E.N.VIVONEX PLUSKETOCALNEOCATE JUNIORNEOCATE JUNIOR WITH PREBIOTIC FIBREVIVONEX PEDIATRIC

ENSUREBOOST

NHNNHNABNNHNNHNNHNABNABNABNABNNUNNHNNHNNHNNUNNUNNHNNHNNHNNHN

AXCNHNNHNNUNNHNNHNNHNNUNNUNNUNNHN

ABNNHN

0.0071 0.0072 0.0080 0.0083 0.0085 0.0101 0.0119 0.0130 0.0150 0.0153 0.0251 0.0270 0.0270 0.0270 0.0295 0.0295 0.0361 0.0388 0.0403 0.0427

0.0376 0.0488 0.0677 0.0692 0.0723 0.0817 0.0826 0.1108 0.1263 0.1263 0.1349

0.0111 0.0122

5 EFFECTIVE APRIL 1, 2018

$$$$$$$$$$$$$$$$$$$$

$$$$$$$$$$$

$$

Section 3 .

For use in patients who are unable to tolerate, have failed, or have nutritional requirements which cannot be met with the nutritional products which are unrestricted benefits (listed in PTC 40:20 of the Alberta Human Services Drug Benefit Supplement).

Information is required regarding the patient's diagnosis, previous nutritional products utilized and the patient's response to therapy, and/or the nutritional requirement which cannot be met with other nutritional products.



RIZATRIPTAN BENZOATE

SUMATRIPTAN HEMISULFATE



5 MG (BASE) ORAL DISINTEGRATING TABLET

10 MG (BASE) ORAL DISINTEGRATING TABLET

5 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY

20 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY

00002393468000023804550000242923300002428512

0000238170200002393476000024411440000238046300002429241000023796780000242852000002240521

00002374730000023934840000237919800002436604000023933600000244290600002446111000023518700000239666100002240518

0000237474900002393492000023792010000243661200002393379000024429140000244613800002351889000023966880000244850500002240519

00002230418

00002230420

APO-RIZATRIPTANJAMP-RIZATRIPTANJAMP-RIZATRIPTAN IRVAN-RIZATRIPTAN

ACT RIZATRIPTANAPO-RIZATRIPTANAURO-RIZATRIPTANJAMP-RIZATRIPTANJAMP-RIZATRIPTAN IRMAR-RIZATRIPTANVAN-RIZATRIPTANMAXALT

ACT RIZATRIPTAN ODTAPO-RIZATRIPTAN RPDMYLAN-RIZATRIPTAN ODTNAT-RIZATRIPTAN ODTPMS-RIZATRIPTAN RDTRIZATRIPTAN ODTRIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTTEVA-RIZATRIPTAN ODTMAXALT RPD

ACT RIZATRIPTAN ODTAPO-RIZATRIPTAN RPDMYLAN-RIZATRIPTAN ODTNAT-RIZATRIPTAN ODTPMS-RIZATRIPTAN RDTRIZATRIPTAN ODTRIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTTEVA-RIZATRIPTAN ODTVAN-RIZATRIPTAN ODTMAXALT RPD

IMITREX

IMITREX

APXJPCJPCVAN

APHAPXAURJPCJPCMARVANMFC

APHAPXMYPNTPPMSSNSSIVSDZTEVMFC

APHAPXMYPNTPPMSSNSSIVSDZTEVVANMFC

GSK

GSK

3.7050 3.7050 3.7050 3.7050

3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050

16.5163

3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050

16.5163

3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050 3.7050

16.5163

15.2588

15.7028


$$$$

$$$$$$$$

$$$$$$$$$$

$$$$$$$$$$$

$

$

Section 3 .










SUMATRIPTAN SUCCINATE

ZOLMITRIPTAN



6 MG / SYR (BASE) INJECTION SYRINGE

2.5 MG ORAL TABLET

2.5 MG ORAL DISPERSIBLE TABLET

5 MG / DOSE NASAL UNIT DOSE SPRAY

0000226838800002268914000022564360000226302500002286521000023855700000228682300002212153

00002257904000022683960000226892200002256444000022630330000228654800002385589000022393670000228683100002212161

0000236169800002212188

00002380951000024216230000239945800002419521000023690360000242153400002324229000023629880000231396000002238660

00002428237000024284740000243876300002243045

00002248993

APO-SUMATRIPTANMYLAN-SUMATRIPTANPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANSUMATRIPTAN DFTEVA-SUMATRIPTAN DFIMITREX DF

ACT SUMATRIPTANAPO-SUMATRIPTANMYLAN-SUMATRIPTANPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANSUMATRIPTAN DFTEVA-SUMATRIPTANTEVA-SUMATRIPTAN DFIMITREX DF

TARO-SUMATRIPTAN (0.5 ML)IMITREX (0.5 ML)

APO-ZOLMITRIPTANJAMP-ZOLMITRIPTANMAR-ZOLMITRIPTANMINT-ZOLMITRIPTANMYLAN-ZOLMITRIPTANNAT-ZOLMITRIPTANPMS-ZOLMITRIPTANSANDOZ ZOLMITRIPTANTEVA-ZOLMITRIPTANZOMIG

JAMP-ZOLMITRIPTAN ODTSEPTA-ZOLMITRIPTAN-ODTVAN-ZOLMITRIPTAN ODTZOMIG RAPIMELT

ZOMIG

APXMYPPMSSDZSNSSIVTEVGSK

APHAPXMYPPMSSDZSNSSIVTEVTEVGSK

TARGSK

APXJPCMARMPIMYPNTPPMSSDZTEVAZC

JPCSEPVANAZC

AZC

2.7732 2.7732 2.7732 2.7732 2.7732 2.7732 2.7732

15.7300

3.0549 3.0549 3.0549 3.0549 3.0549 3.0549 3.0549 3.0549 3.0549

17.3283

33.1745 46.0741

3.5375 3.5375 3.5375 3.5375 3.5375 3.5375 3.5375 3.5375 3.5375

14.8100

1.7532 1.7532 1.7532

14.8100

14.8100


$$$$$$$$

$$$$$$$$$$

$$

$$$$$$$$$$

$$$$

$

Section 3 .




"For the treatment of acute migraine attacks in patients where other standard therapy has failed.Special authorization may be granted for 24 months."




SECTION 3A

Criteria for Optional Special Authorization

of Select Drug Products

Section 3A C

riteria for Optional Special A

uthorization of Select Drug Products

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS


EFFECTIVE APRIL 1, 2018 Section 3A

CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

The drug products listed in this section may be considered for coverage by optional special authorization for Alberta Human Services clients.

Criteria for Coverage

Wording that appears within quotation marks (“ “) in this section is the official Optional Special Authorization Criteria, as recommended by the Alberta Health Expert Committee on Drug Evaluation and Therapeutics, and approved by the Minister of Health. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.

Role of the Prescribers

In conjunction with the criteria, prescribers have two options by which patients may be eligible for coverage of these select optional special authorization drug products.

1) Prescribers can register to be a designated prescriber. Registration allows for patients to receivecoverage of select drug products without Special Authorization as long as the prescription is written for one of the criteria for coverage set out in this section. Should a designated prescriber wish to prescribe one of the select drug products outside the coverage criteria, they may do so but must indicate this on the prescription; however, patients will not be eligible for payment under the Alberta government-sponsored program for such prescription and the patient may choose to receive the product at their expense. The registration form may be found on the previous page.

2) Prescribers who choose not to register will be considered non-designated prescribers. Suchprescribers will be required to apply for Special Authorization on the patient’s behalf.

®*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. ABC 60041 Reg Form (2017/02)

ALBERTA GOVERNMENT SPONSORED DRUG BENEFIT PROGRAMS OPTIONAL SPECIAL AUTHORIZATION

REGISTRATION FOR DESIGNATED PRESCRIBER STATUS for Alberta Drug Benefit List Claim Coverage

Select Quinolone Antibiotics ciprofloxacin, levofloxacin, moxifloxacin

Please complete all sections of this form and return it by fax to Alberta Blue Cross

Registrations will be accepted on an ongoing basis

PRESCRIBER LAST NAME FIRST NAME INITIAL OFFICE PHONE FAX

OFFICE ADDRESS CITY PROVINCE POSTAL CODE

COLLEGE OF PHYSICIANS AND SURGEONS REGISTRATION NUMBER OR PROFESSIONAL REGISTRATION NUMBER

I have reviewed the criteria for coverage of select quinolone products and I agree to abide by and only prescribe in accordance with such criteria as updated from time to time in the Optional Special Authorization section of the Alberta Drug Benefit List.

SIGNATURE OF PRESCRIBER (required) DATE

The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5.

PLEASE RETURN YOUR COMPLETED REGISTRATION BY FAX TO 1-877-305-9911

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

CIPROFLOXACIN

100 MG / ML ORAL SUSPENSION00002237514 CIPRO BAI 0.5750


$

"For the treatment of:

1) Respiratory Tract Infections:-end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection or - pneumonic illness in cystic fibrosis; or

2) Genitourinary Tract Infections:- urinary tract infections, - prostatitis, - prophylaxis of urinary tract surgical procedures or - gonococcal infections; or

3) Skin and Soft Tissue/Bone and Joint Infections:- malignant/invasive otitis externa, - bone/joint infections due to gram negative organisms or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or

4) Gastrointestinal Tract Infections:- bacterial gastroenteritis where antimicrobial therapy is indicated, - typhoid fever (enteric fever), or- therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or

5) Other:- prophylaxis of adult contacts of cases of invasive meningococcal disease, - therapy/step-down therapy of hospital acquired gram negative infections, - empiric therapy of febrile neutropenia in combination with other appropriate agents or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs.- for use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."

All requests for ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 60042).

Section 3A

Patient claims for select quinolone prescriptions written by a non-designated prescriber will be subject to a first forgiveness rule, meaning the first claim will be paid. Subsequent claims for the same product (irrespective of strength, route and form) within a 90-day period would require the prescriber to apply for special authorization for coverage on the patient�s behalf.

.

Criteria For Optional Special Authorization Of Select Drug Products




CIPROFLOXACIN HCL

250 MG (BASE) ORAL TABLET0000224733900002229521000023819070000235331800002386119000023803580000237968600002423553000022456470000216173700002248437000023037280000224682500002248756000023796270000242697800002155958

ACT CIPROFLOXACINAPO-CIPROFLOXAURO-CIPROFLOXACINCIPROFLOXACINCIPROFLOXACINJAMP-CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXMYLAN-CIPROFLOXACINNOVO-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINSEPTA-CIPROFLOXACINVAN-CIPROFLOXACINCIPRO

APHAPXAURSNSSIVJPCMARMPIMYPTEVPMSRANTEVSDZSEPVANBAI

0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 0.4454 2.4964


$$$$$$$$$$$$$$$$$

"For the treatment of

1) Respiratory Tract Infections:- end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection; or - pneumonic illness in cystic fibrosis; or

2) Genitourinary Tract Infections:- urinary tract infections; or - prostatitis; or - prophylaxis of urinary tract surgical procedures; or - gonococcal infections; or

3) Skin and Soft Tissue/Bone and Joint Infections:- malignant/invasive otitis externa; or - bone/joint infections due to gram negative organisms; or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or

4) Gastrointestinal Tract Infections:- bacterial gastroenteritis where antimicrobial therapy is indicated; or - typhoid fever (enteric fever); or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or

5) Other:- prophylaxis of adult contacts of cases of invasive meningococcal disease; or- therapy/step-down therapy of hospital acquired gram negative infections; or- empiric therapy of febrile neutropenia in combination with other appropriate agents; or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs; or- for use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."

All requests for Ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 60042).

Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


CIPROFLOXACIN HCL500 MG (BASE) ORAL TABLET


00002247340000022295220000238192300002353326000023861270000238036600002379694000024235610000224564800002248438000023037360000224682600002248757000023796350000242700100002155966

000022473410000222952300002380374000023797080000242358800002248439000023037440000224682700002248758000023796430000242702800002155974

ACT CIPROFLOXACINAPO-CIPROFLOXAURO-CIPROFLOXACINCIPROFLOXACINCIPROFLOXACINJAMP-CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXMYLAN-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINSEPTA-CIPROFLOXACINVAN-CIPROFLOXACINCIPRO

ACT CIPROFLOXACINAPO-CIPROFLOXJAMP-CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINSEPTA-CIPROFLOXACINVAN-CIPROFLOXACINCIPRO

APHAPXAURSNSSIVJPCMARMPIMYPPMSRANTEVSDZSEPVANBAI

APHAPXJPCMARMPIPMSRANTEVSDZSEPVANBAI

0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 0.5025 2.8166

0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 0.9201 5.1578


$$$$$$$$$$$$$$$$

$$$$$$$$$$$$




LEVOFLOXACIN

250 MG ORAL TABLET

500 MG ORAL TABLET

750 MG ORAL TABLET

00002315424000022847070000224826200002298635

00002315432000022847150000224826300002298643

00002315440000023259420000228564900002298651

ACT LEVOFLOXACINAPO-LEVOFLOXACINNOVO-LEVOFLOXACINSANDOZ LEVOFLOXACIN



APHAPXTEVSDZ

APHAPXTEVSDZ

APHAPXTEVSDZ

1.2038 1.2038 1.2038 1.2038

1.3718 1.3718 1.3718 1.3718

4.8478 4.8478 4.8478 4.8478


$$$$

$$$$

$$$$

"To be prescribed according to ONE of the following criteria:

For the treatment of

1) Community acquired pneumonia after failure of first line therapy, as defined by clinicaldeterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD,diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or

3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, asdefined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or

5) For use in other current Health Canada approved indications when prescribed by a specialistin Infectious Diseases."

All requests for Levofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 60042).



MOXIFLOXACIN HCL

400 MG (BASE) ORAL TABLET000024049230000243224200002443929000024470610000244705300002457814000023833810000237570200002242965

APO-MOXIFLOXACINAURO-MOXIFLOXACINJAMP-MOXIFLOXACINJAMP-MOXIFLOXACINMAR-MOXIFLOXACINMED-MOXIFLOXACINSANDOZ MOXIFLOXACINTEVA-MOXIFLOXACINAVELOX

APXAURJPCJPCMARGMPSDZTEVBAI

1.5230 1.5230 1.5230 1.5230 1.5230 1.5230 1.5230 1.5230 6.0858


$$$$$$$$$

"To be prescribed according to ONE of the following criteria:

For the treatment of

1) Community acquired pneumonia after failure of first line therapy, as defined by clinicaldeterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD,diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or

3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, asdefined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or

5) For use in other current Health Canada approved indications when prescribed by a specialistin Infectious Diseases."

All requests for Moxifloxacin HCl must be completed using the Select Quinolones Special Authorization Request Form (ABC 60042).


SECTION 4

Rare Diseases Drug Coverage Program

Section 4 Rare D

iseases Drug C

overage Program

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT RARE DISEASES DRUG COVERAGE PROGRAM



RARE DISEASES DRUG COVERAGE PROGRAM

Selected drug products used in the treatment of rare diseases may be considered for coverage for individuals covered under Alberta government-sponsored drug programs. The Minister of Health makes the final decisions regarding coverage under this Program, and may list a drug product under this section when the Minister considers it in the public interest to do so.1.

RARE DISEASES DRUG COVERAGE

In order to be eligible for the Rare Diseases Drug Coverage Program, an individual must:

• have Alberta government-sponsored drug coverage;• be continuously registered in the Alberta Health Care Insurance Plan for a minimum of five years

unless: the individual is less than five years of age at the date of the application, then the

individual’s parent/guardian/legal representative must be registered continuously in theAlberta Health Care Insurance Plan for a minimum of five years;

OR

the individual has moved to Alberta from another province or territory in Canada (the“province of origin”), and immediately prior to moving to Alberta, was covered for a drugproduct listed in this section in the province of origin by a provincial or territorialgovernment sponsored drug plan, and the individual has been registered in the AlbertaHealth Care Insurance Plan (the individual must provide supporting documentation fromthe province of origin to prove prior coverage).

• meet the clinical criteria for a rare disease drug product published on the List;• have a Rare Diseases Drug Coverage Application form (“Application”) submitted on their behalf to

Alberta Blue Cross by the individual’s “Rare Disease Specialist”;• have the Application reviewed and approved for coverage by the Alberta Rare Diseases Clinical

Review Panel (“Review Panel”)• complete the required forms, and consent to and acknowledge that

approval for initial and continued coverage is conditional upon clinical outcomes; regular monitoring of the individual’s clinical outcomes will be required, and that coverage will be discontinued if there is inadequate response or the individual’s

condition deteriorates as outlined in the withdrawal criteria established in relation to aspecific rare diseases drug product and/or as assessed by the Review Panel.

Contraindications

In addition to meeting the above criteria, the individual must not have the following contraindications:

• Significant illness, not including one of the rare diseases, likely to substantially alter or reduce lifeexpectancy.

1 Section 1 of the ADBL does not apply to the Rare Diseases Drug Coverage Program



EFFECTIVE APRIL 1, 2018 Section 4• 2

Rare Diseases Drugs Eligible for Coverage

Drug products approved by Health Canada for the treatment of Rare Diseases may be considered for coverage in accordance with this section.

Rare Diseases are genetic, lysosmal storage disorders occurring at a rate of less than one per 50,000 for the Canadian population for a specific disease (as determined by Alberta Health).

As of April 1, 2009, drug products for the treatment of the following rare diseases are currently under consideration for coverage: • Gaucher’s disease• Fabry disease• MPS-I (Hurler/Hurler Scheie)• Hunter disease• Pompe disease

Alberta Rare Diseases Clinical Review Panel

The Alberta Rare Diseases Clinical Review Panel (“Review Panel”) is a review panel composed of specialists treating rare diseases and other health professionals with clinical expertise, appointed by the Minister of Health.

The Review Panel’s functions include: • Providing advice to Alberta Health regarding the Rare Diseases Drug Coverage Program;• Reviewing and applying clinical knowledge and skills to individual applications for Rare Diseases

Drug Coverage; and• Providing advice to the Expert Committee on Drug Evaluation and Therapeutics regarding drug

products under consideration for coverage under this section, clinical criteria for rare diseasesdrug products and identifying appropriate “Rare Disease Specialists”.

Process for Rare Diseases Drug Coverage

Participating “Rare Disease Specialists” must complete a Rare Diseases Drug Coverage Application form for each individual. The form must be the one specific to the rare diseases drug product being requested. The completed application may be forwarded to Alberta Blue Cross by mail or by facsimile.

To be considered for Rare Diseases Drug Coverage, the “Rare Disease Specialist” must confirm the individual (or individual’s parent/guardian/legal representative) has been provided with information regarding the Rare Diseases Drug Coverage Program and have completed the required forms.

Alberta Blue Cross, in providing administrative support to the Review Panel, receives and screens each application for completeness, then forwards to Alberta Health to confirm that the individual has met the Alberta Health Care Insurance Plan registration requirement (please see above). Once it




has been confirmed that the individual meets the Alberta Health Care Insurance Plan registration requirement, Alberta Blue Cross forwards the application to the Review Panel for assessment. Alberta Blue Cross responds to applicants on the Review Panel’s behalf. After an application has been assessed by the Review Panel, Alberta Blue Cross notifies the individual’s “Rare Disease Specialist” and the individual or individual’s parent/guardian/legal representative by letter of the Review Panel’s decision. Eligibility will be effective the date coverage is approved by the Review Panel.

Renewals require a new drug product specific Rare Diseases Drug Coverage Application form that is completed by a “Rare Disease Specialist”.

To be eligible for Rare Diseases Drug Coverage, prescriptions must be written by a “Rare Disease Specialist” as identified by the eligibility criteria for the drug product. To avoid wastage, prescription quantities are limited to a one-month supply. Extended quantity and vacation supplies are not permitted. Out-of-country claims will only be reimbursed in accordance with standard rules and regulations; individuals should verify with Alberta Blue Cross these rules and regulations prior to obtaining drug products out of the country.

Government will not be responsible for reimbursement of costs associated with wastage or improper storage of rare diseases drug products.

Prior approval must be granted to ensure coverage. Approval is granted for a specific period, to a maximum of 12 months. If continued treatment is necessary, it is the responsibility of the individual or individual’s parent/guardian/legal representative and the “Rare Disease Specialist” to re-apply for drug product coverage prior to the expiry date of the authorization period.

PART 2

Pharmacologic – Therapeutic Classification of Drugs

Pharmacologic -Therapeutic C

lassification of Drugs


BLOOD GLUCOSE METER

DIABETES SUPPLIES

BROMPHENIRAMINE MALEATE/ PHENYLEPHRINE HCL

DEXTROMETHORPHAN HBR/ PSEUDOEPHEDRINE HCL

CYPROHEPTADINE HCL

DESLORATADINE

0.4 MG / ML * 1 MG / ML ORAL LIQUID

1.5 MG / ML * 3 MG / ML ORAL LIQUID

4 MG ORAL TABLET

0.5 MG / ML ORAL SYRUP

00000990024

000009999550000099994100000990058000009900450000099005700000999985000009999520000099994200000999957

00002243980

00002044013

000023322480000075771300002245667

00002247193

BLOOD GLUCOSE METER

BLOOD GLUCOSE TEST STRIPSBLOOD LETTING LANCETGLUCOSE CALIBRATION SOLUTIONINFUSION SETS (TUBING & NEEDLE)INSULIN CARTRIDGES / RESERVOIRSINSULIN PEN NEEDLESINSULIN SYRINGESLANCING DEVICEURINE TEST STRIPS

DIMETAPP COLD

ROBITUSSIN CHILDRENS COUGH AND COLD

CYPROHEPTADINEPMS-CYPROHEPTADINE HCLEURO-CYPROHEPTADINE

AERIUS KIDS

XXX

XXXXXXXXXXXXXXXXXXXXXXXXXXX

PDH

PDH

JPCPPHSDZ

BIC

(DIABETES SUPPLIES)

NON-CLASSIFIED DRUGS

PEDIATRIC COUGH AND COLD PREPARATIONS

ANTIHISTAMINE DRUGS

PEDIATRIC ANTIHISTAMINES

00

02

04

:00

:00

:00

00:00.02

02:00

04:02

0.0000

0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

0.0513

0.0508

0.2310 0.2345 0.2483

0.0700

1UNIT OF ISSUE - REFER TO PRICE POLICY EFFECTIVE APRIL 1, 2018

$

$$$$$$$$$

$

$

$$$

$

The blood glucose meter is a benefit upon written order from a physician, and is limited to a "one time" benefit not exceeding $70.00 per participant.

RESTRICTED BENEFIT - This product is a benefit for patients 6 to 17 years of age inclusive.

RESTRICTED BENEFIT - This product is a benefit for patients 6 to 17 years of age inclusive.

RESTRICTED BENEFIT - This product is a benefit for patients up to 17 years of age inclusive.





DIPHENHYDRAMINE HCL

LORATADINE

FLUCONAZOLE

BUPROPION HCL

NICOTINE

2.5 MG / ML ORAL ELIXIR

1 MG / ML ORAL SYRUP

150 MG ORAL CAPSULE

150 MG ORAL SUSTAINED-RELEASE TABLET

1 MG / DOSE BUCCAL SPRAY

2 MG ORAL GUM

4 MG ORAL GUM

10 MG / DOSE INHALATION CARTRIDGE

7 MG/DAY TRANSDERMAL PATCH


00002298503

00002241523

00002241895000024324710000242879200002282348

00002238441

00080038858

00002091933

00002091941

00002241742

000019430570000224122700002093111

000019430650000224122600002093138

DIPHENHYDRAMINE

CLARITIN

APO-FLUCONAZOLE-150JAMP-FLUCONAZOLEMAR-FLUCONAZOLE-150PMS-FLUCONAZOLE

ZYBAN

NICORETTE QUICKMIST

NICORETTE

NICORETTE

NICORETTE INHALER

HABITROL 7 MG/DAYTRANSDERMAL NICOTINE 7 MG/DAYNICODERM 7 MG/DAY


JPC

BIC

APXJPCMARPMS

VCL

MCL

JJI

JJI

JJI

GKCGKCJJI

GKCGKCJJI

(AZOLES)

ANTIHISTAMINE DRUGS

ANTI-INFECTIVE AGENTS

AUTONOMIC DRUGS

PEDIATRIC ANTIHISTAMINES

ANTIFUNGALS

MISCELLANEOUS AUTONOMIC DRUGS

04

08

12

:00

:00

:00

04:02

08:14.08

12:92

0.0303

0.0517

3.9400 3.9400 3.9400 3.9400

1.0027

0.2119

0.3027

0.3027

0.7567

2.6786 2.7257 3.6157

2.6786 2.7257 3.6157


$

$

$$$$

$

$

$

$

$

$$$

$$$



RESTRICTED BENEFIT - Coverage is limited to a lifetime maximum of $500.00 per participant for all over the counter smoking cessation products listed in the Alberta Human Services Drug Benefit Supplement.



NICOTINE

FERROUS FUMARATE

FERROUS SULFATE

IBUPROFEN


60 MG / ML ORAL SUSPENSION

30 MG / ML ORAL SOLUTION

30 MG / ML ORAL LIQUID


75 MG / ML ORAL DROPS

20 MG / ML ORAL SUSPENSION

000019430730000224122800002093146

0008002982200001923439

00000792675

00080008295

0000075846900000017884

000022373850008000830900000762954

0000224236500002232297


JAMP-FERROUS FUMARATEPALAFER

PMS-FERROUS SULFATE

JAMP FERROUS SULFATE

FERODANFER-IN-SOL

FERODAN INFANTJAMP FERROUS SULFATE INFANT DROPSFER-IN-SOL

CHILDREN'S MOTRINCHILDREN'S ADVIL

GKCGKCJJI

JPCVCL

PMS

JPC

ODNMJO

ODNJPCMJO

MCLPDH

(IRON PREPARATIONS)

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

AUTONOMIC DRUGS

BLOOD FORMULATION, COAGULATION AND THROMBOSIS

CENTRAL NERVOUS SYSTEM AGENTS

MISCELLANEOUS AUTONOMIC DRUGS

ANTIANEMIA DRUGS

ANALGESICS AND ANTIPYRETICS

12

20

28

:00

:00

:00

12:92

20:04.04

28:08.04.92

2.6786 2.7257 3.6157

0.0821 0.0900

0.0272

0.0272

0.0272 0.0519

0.1432 0.1432 0.2558

0.0458 0.0639


$$$

$$

$

$

$$

$$$

$$




(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)




ACETAMINOPHEN

ARIPIPRAZOLE

500 MG ORAL TABLET

32 MG / ML ORAL SOLUTION




120 MG RECTAL SUPPOSITORY



10 MG ORAL TABLET

15 MG ORAL TABLET

20 MG ORAL TABLET

30 MG ORAL TABLET

00002355299000019391220000054500700002229977000004823230000055940700000723908

00002027798

00000884553

00000875996

00002027801

00002230434

00002230436

00002230437

00002322390

00002322404

00002322412

00002322455

JAMP-ACETAMINOPHEN BLAZONJAMP-ACETAMINOPHEN EXTRA STRENGTHAPO-ACETAMINOPHENAPO-ACETAMINOPHEN (CAPLET)NOVO GESIC FORTETYLENOL EXTRA STRENGTHTYLENOL EXTRA-STRENGTH (CAPLET)

PEDIATRIX

CHILDRENS TEMPRA

TEMPRA D.S.

PEDIATRIX

ACET 120

ACET 325

ACET 650

ABILIFY

ABILIFY

ABILIFY

ABILIFY

JPCJPCAPXAPXTEVMCLMCL

TEV

PAL

PAL

TEV

PPH

PPH

PPH

OTS

OTS

OTS

OTS

(MISCELLANEOUS ANALGESICS AND ANTIPYRETICS)

ANTIPSYCHOTICS



ANALGESICS AND ANTIPYRETICS

PSYCHOTHERAPEUTIC AGENTS

28

28

:00

:00

28:08.92

28:16.08.04

0.0271 0.0271 0.0285 0.0285 0.0285 0.1163 0.1163

0.0434

0.0393

0.0393

0.1510

0.8450

0.8450

0.8450

4.0055

4.0055

4.0055

4.0055


$$$$$$$

$

$

$

$

$

$

$

$

$

$

$

RESTRICTED BENEFIT - This product is a benefit for Alberta Human Services clients 13 years of age and older.




(ATYPICAL ANTIPSYCHOTICS)



SODIUM CHLORIDE/ POTASSIUM CHLORIDE (K+)(CL-)/ SODIUM CITRATE,ACID/ DEXTROSE

SODIUM CHLORIDE/ SODIUM CITRATE,ACID/ DEXTROSE/ POTASSIUM CITRATE (K+)

SODIUM/ POTASSIUM/ CHLORIDE/ CITRATE/ DEXTROSE

SODIUM/ POTASSIUM/ CHLORIDE/ CITRATE/ ZINC/ DEXTROSE

INFANT FORMULA

470 MG / G * 300 MG / G * 530 MG / G * 3.56 G / G ORAL POWDER

470 MG * 530 MG * 3.56 G * 390 MG ORAL POWDER PACKET

0.045 MEQ / ML * 0.02 MEQ / ML * 0.035 MEQ / ML * 0.03 MEQ / ML * 0.025 G / ML ORAL LIQUID

0.045 MEQ / ML * 0.02 MEQ / ML * 0.035 MEQ / ML * 0.014 MEQ / ML * 0.0078 MG / ML * 0.025 G / ML ORAL SOLUTION

0.045 MEQ / ML * 0.02 MEQ / ML * 0.035 MEQ / ML * 0.0255 MEQ / ML * 0.0078 MG / ML * 0.025 G / ML ORAL SOLUTION

ORAL LIQUID

ORAL POWDER

00001931563

00080027403

0000063036500002219883

00080072902

00080074173

00000999449

00000999465000009997880000099956400000999520

GASTROLYTE

JAMP REHYDRALYTE

PEDIALYTEPEDIATRIC ELECTROLYTE

PEDIALYTE (UNFLAVOURED)

PEDIALYTE (FLAVOURED)

ALIMENTUM

SIMILAC NEOSURESIMILAC ALIMENTUMENFAMIL ENFACARE A+NUTRAMIGEN A+ HYPOALLERGENIC

SAV

JPC

ABNPPH

ABN

ABN

ABN

ABNABNMJOMJO

ELECTROLYTIC, CALORIC, AND WATER BALANCE


REPLACEMENT PREPARATIONS

CALORIC AGENTS

40

40

:00

:00

40:12

40:20

0.1622

0.7010

0.0074 0.0074

0.0074

0.0074

0.0066

0.0403 0.0419 0.0453 0.0457


$

$

$$

$

$

$

$$$$




NUTRITIONAL PRODUCTS

SODIUM CROMOGLYCATE

SODIUM CHLORIDE

ORAL LIQUID

ORAL LIQUID

2 % OPHTHALMIC SOLUTION

0.9 % NASAL SOLUTION

0000099988900000999932000009994180000099941900000999413000009999200000099992100000999895000009998880000099989600000999966000009999020000099990100000999525000009999400000099991800000999409000009900560000099954500000999458000009994140000999887700000999964000009999330000099002900000989998000009999380000098999600000989997

00000999483

0000200927700002230621

00080024901

ISOSOURCE 1.2BOOST 1.5 PLUS CALORIESNUTREN JUNIORNUTREN JUNIOR FIBRE W PREBIO 1RESOURCE DIABETICBOOSTBOOST PLUS CALORIESISOSOURCE FIBRE 1.2ISOSOURCE 1.5ISOSOURCE FIBRE 1.5COMPLEATENSURE PLUSENSURE REGULARENSURE SCFOS FIBREGLUCERNAENSURE FIBRERESOURCE 2.0NOVASOURCE RENALNEPRORESOURCE KID ESSENTIALS 1.5 CALSUPLENAISOSOURCE 2.0NUTREN 2.0PEDIASUREPEDIASURE FIBREPEDIASURE PEPTIDE 1 CALJEVITY 1 CALVITAL PEPTIDE 1 CALVITAL PEPTIDE 1.5 CAL

BOOST DIABETIC

CROMOLYNOPTICROM

SALINEX

NHNNHNNHNNHNNHNNHNNHNNHNNHNNHNNHNABNABNABNABNABNNHNNHNABNNHNABNNHNNHNABNABNABNABNABNABN

NHN

PPHALL

SDZ


EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

CALORIC AGENTS

ANTIALLERGIC AGENTS

MISCELLANEOUS EENT DRUGS

40

52

52

:00

:00

:00

40:20

52:02

52:92

0.0062 0.0065 0.0066 0.0066 0.0069 0.0072 0.0072 0.0073 0.0074 0.0074 0.0080 0.0080 0.0080 0.0080 0.0080 0.0081 0.0085 0.0088 0.0094 0.0096 0.0098 0.0107 0.0107 0.0109 0.0109 0.0110 0.0112 0.0119 0.0119

0.0072

0.9500 1.0130

0.1650


$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$

$$

$

Not eligible for coverage for AISH (Group 19823 Section X) clients.

Not a benefit for Alberta Human Services Group 19824 and Group 20403 clients.



LOPERAMIDE HCL

BISACODYL

DOCUSATE SODIUM

GLYCERIN

POLYETHYLENE GLYCOL/ POTASSIUM CHLORIDE (K+)/ SODIUM SULFATE/ SODIUM CHLORIDE/ SODIUM BICARBONATE

POLYETHYLENE GLYCOL/ SODIUM SULFATE/ SODIUM BICARBONATE/ SODIUM CHLORIDE/ POTASSIUM CHLORIDE (K+)

2 MG ORAL TABLET

0.13 MG / ML ORAL SOLUTION

5 MG ORAL ENTERIC-COATED TABLET




RECTAL PEDIATRIC SUPPOSITORY

238.18 G / G * 3.05 G / G * 22.96 G / G * 5.85 G / G * 6.76 G / G ORAL POWDER

238.8 G / G * 22.7 G / G * 6.7 G / G * 5.8 G / G * 3 G / G ORAL POWDER

000022120050000213259100002228351

00002291800

0000054502300000254142

0000224109100000003875

000008702260000069503300002086018

00002090163

00002020815

00000777838

00000677442

APO-LOPERAMIDENOVO-LOPERAMIDE (CAPLET)PMS-LOPERAMIDE (CAPLET)

IMODIUM

APO-BISACODYLDULCOLAX

THE MAGIC BULLETDULCOLAX

RATIO-DOCUSATE SODIUMSELAXCOLACE

COLACE

GLYCERIN INFANT

PEG-LYTE

COLYTE

APXTEVPMS

MCL

APXSAV

DCMSAV

TEVODNWSB

WSB

TEV

PPH

PPH

GASTROINTESTINAL DRUGS


ANTIDIARRHEA AGENTS

CATHARTICS AND LAXATIVES

56

56

:00

:00

56:08

56:12

0.0952 0.0952 0.0952

0.0347

0.0450 0.1950

0.9000 1.1604

0.0220 0.0220 0.0232

0.1770

0.1706

0.0748

0.0748


$$$

$

$$

$$

$$$

$

$

$

$

RESTRICTED BENEFIT - This product is a benefit for patients 18 years of age and older for bowel cleansing prior to procedures (such as colonoscopy). Coverage is restricted to a total of 840g (i.e. 3 fills of 280g) per patient per year.

RESTRICTED BENEFIT - This product is a benefit for patients 18 years of age and older for bowel cleansing prior to procedures (such as colonoscopy). Coverage is restricted to a total of 840g (i.e. 3 fills of 280g) per patient per year.






SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE

LACTASE

DIMENHYDRINATE

CLOTRIMAZOLE

10.4 G / ENM * 3.9 G / ENM RECTAL ENEMA

10.4 G / ENM * 3.9 G / ENM RECTAL PEDIATRIC ENEMA

3,000 UNIT ORAL TABLET



50 MG ORAL TABLET



1 % TOPICAL CREAM

1 % VAGINAL CREAM

2 % VAGINAL CREAM

10 % VAGINAL CREAM

0000209690000000009911

00000108065

00002230653

00002230654

0008007035800002231507

0000036376600000021423

00000392553

00000392545

00002239432

0000081236600002150891

0000081237400002150905

00002150883

LAX-A NEMAFLEET ENEMA

FLEET ENEMA PEDIATRIC (65 ML)

LACTAID

EXTRA STRENGTH LACTAID

JAMP-LACTASE ENZYMELACTAID ULTRA (CAPLET)

APO-DIMENHYDRINATETEVA-DIMENATE

SANDOZ DIMENHYDRINATE

SANDOZ DIMENHYDRINATE

CANESTEN EXTERNAL CREAM REFILL

CLOTRIMADERMCANESTEN 6

CLOTRIMADERMCANESTEN 3

CANESTEN 1

PPHJJI

MCL

MCL

MCL

JPCMCL

APXTEV

SDZ

SDZ

BIC

TARBIC

TARBIC

BIC

(ANTIHISTAMINES)

ANTIFUNGALS




SKIN AND MUCOUS MEMBRANE AGENTS

CATHARTICS AND LAXATIVES

DIGESTANTS

ANTIEMETICS

ANTI-INFECTIVES

56

56

56

84

:00

:00

:00

:00

56:12

56:16

56:22.08

84:04.08.08

2.9600 3.8800

3.9000

0.1407

0.2069

0.2928 0.3517

0.0225 0.0225

0.6080

0.6195

0.3962

0.2045 0.2560

0.4091 0.5120

2.5599


$$

$

$

$

$$

$$

$

$

$

$$

$$

$


(AZOLES)



CLOTRIMAZOLE/ CLOTRIMAZOLE

MICONAZOLE NITRATE

NYSTATIN

DIMETHICONE

ISOPROPYL MYRISTATE

PERMETHRIN

1 % * 10 % TOPICAL/VAGINAL CREAM/CREAM

200 MG * 1 % VAGINAL/TOPICAL TABLET/CREAM

500 MG * 1 % VAGINAL/TOPICAL TABLET/CREAM

2 % VAGINAL CREAM

100,000 UNIT / G TOPICAL CREAM

100,000 UNIT / G TOPICAL OINTMENT

50 % TOPICAL SOLUTION

50 % TOPICAL SOLUTION

5 % TOPICAL CREAM

5 % TOPICAL LOTION

10 MG / ML TOPICAL RINSE

00002230509

00002264099

00002264102

00002231106

0000219423600000716871

00002194228

00002373785

00002279592

00002219905

00002231348

0000077136800002231480

CANESTEN 1 CREAM COMBI-PAK

CANESTEN 3 COMFORTAB COMBI-PAK

CANESTEN 1 COMFORTAB COMBI-PAK

MICOZOLE

RATIO-NYSTATINNYADERM

RATIO-NYSTATIN

NYDA

RESULTZ

NIX DERMAL

KWELLADA-P

NIX CREMEKWELLADA-P CREME

BIC

BIC

BIC

TAR

TEVTAR

TEV

GXP

MFI

GKC

MTC

IPHMTC

ANTIFUNGALS

ANTIFUNGALS

(SCABICIDES AND PEDICULICIDES)




ANTI-INFECTIVES

ANTI-INFECTIVES

ANTI-INFECTIVES

84

84

84

:00

:00

:00

84:04.08.08

84:04.08.28

84:04.12

13.9755

13.9755

13.9755

0.2668

0.0633 0.0665

0.1276

0.4484

0.1022

0.4977

0.5053

0.1907 0.2328


$

$

$

$

$$

$

$

$

$

$

$$


(AZOLES)

(POLYENES)




PYRETHRINS/ PIPERONYL BUTOXIDE

VITAMIN D3

VITAMIN A ACETATE/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ SODIUM ASCORBATE/ VITAMIN D/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE)

VITAMIN A PALMITATE/ VITAMIN D/ ASCORBIC ACID

VITAMIN A PALMITATE/ VITAMIN D/ SODIUM ASCORBATE/ THIAMINE HCL/ RIBOFLAVIN (VITAMIN B2)/ NIACINAMIDE (NICOTINAMIDE)

0.33 % * 3 % TOPICAL SHAMPOO

400 UNIT / ML ORAL LIQUID

400 UNIT / ML ORAL DROPS

1,600 UNIT (BASE) * 1.5 MG * 1.5 MG * 1 MG * 3 MCG * 50 MG * 400 UNIT * 0.1 MG * 8 MG ORAL CHEWABLE TABLET

2,500 UNIT / ML (BASE) * 667 UNIT / ML * 50 MG / ML ORAL DROPS

1,500 UNIT / ML * 400 UNIT / ML * 30 MG / ML * 0.5 MG / ML * 0.6 MG / ML * 4 MG / ML ORAL DROPS

00002125447

0008003815500080041145

000800030380000076288100080019649

00002247975

00000762903

00000762946

R & C SHAMPOO WITH CONDITIONER

DECAXIL LIQUIDDECAXIL DROPS

JAMP-VITAMIN DD-VI-SOL INFANTD3-DOL

FLINTSTONES MULTI VITAMINS W EXTRA C

TRI-VI-SOL

POLY-VI-SOL

MTC

JPCJPC

JPCMJOJPC

BIC

MJO

MJO

(SCABICIDES AND PEDICULICIDES)


VITAMINS

VITAMINS

ANTI-INFECTIVES

VITAMIN D

MULTIVITAMIN PREPARATIONS

84

88

88

:00

:00

:00

84:04.12

88:16

88:28

0.1558

0.1497 5.3892

0.1497 0.1996 5.3892

0.1305

0.2346

0.2346


$

$$

$$$

$

$

$







BETA CAROTENE/ VITAMIN A ACETATE/ VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE)/ ASCORBIC ACID/ FOLIC ACID/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ NIACINAMIDE (NICOTINAMIDE)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ VITAMIN D3/ BIOTIN/ CALCIUM D-PANTOTHENATE/ CALCIUM CARBONATE/ MAGNESIUM OXIDE/ POTASSIUM IODIDE/ FERROUS FUMARATE/ CUPRIC OXIDE/ ZINC OXIDE/ CHROMIUM CHLORIDE/ MANGANESE SULFATE/ SODIUM MOLYBDATE/ SODIUM SELENATE

VITAMIN A ACETATE/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ BIOTIN/ SODIUM ASCORBATE/ VITAMIN D/ VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE)/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE)/ CALCIUM D-PANTOTHENATE/ CALCIUM PHOSPHATE DIBASIC/ CUPRIC OXIDE/ FERROUS FUMARATE/ CALCIUM PHOSPHATE DIBASIC

VITAMIN A ACETATE/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ SODIUM ASCORBATE/ VITAMIN D/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE)/ FERROUS FUMARATE

INSTANT FOOD THICKENER

2,500 IU * 1,000 IU * 30 IU * 85 MG * 1 MG * 1.4 MG * 1.4 MG * 18 MG * 1.9 MG * 2.6 MCG * 400 IU * 30 MCG * 6 MG * 250 MG * 50 MG * 220 MCG * 27 MG * 1 MG * 7.5 MG * 30 MCG * 2 MG * 50 MCG * 30 MCG ORAL TABLET

1,600 UNIT (BASE) * 1.5 MG * 1.5 MG * 1 MG * 3 MCG * 30 MCG * 50 MG * 400 UNIT * 10 UNIT * 0.1 MG * 8 MG *10 MG (BASE) * 160 MG (BASE) * 1 MG (BASE) * 4 MG (BASE) * 125 MG (BASE) ORAL CHEWABLE TABLET

1,600 UNIT (BASE) * 1.5 MG * 1.5 MG * 1 MG * 3 MCG * 50 MG * 400 UNIT * 0.1 MG * 8 MG * 4 MG (BASE) ORAL CHEWABLE TABLET

ORAL POWDER

00080001842

00002247973

00002247995

000009994550000099945300000999561

NESTLE MATERNA

FLINTSTONES MULTIPLE VITAMINS COMPLETE

FLINTSTONES MULTI VITAMINS PLUS IRON

CONSIST-RITERESOURCE THICKENUPRESOURCE THICKENUP CLEAR

NES

BIC

BIC

DFINHNNHN

(VITAMINS & MINERALS)

VITAMINS

MISCELLANEOUS THERAPEUTIC AGENTS

MULTIVITAMIN PREPARATIONS

88

92

:00

:00

88:28.01

92:00

0.1456

0.1212

0.1305

0.0179 0.0223 0.3065


$

$

$

$$$



APPENDICES

Pharmaceutical Manufacturers Alphabetical List of

Pharmaceutical Products Numerical List by Drug

Identification Number

Appendices

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT APPENDIX 2 - PHARMACEUTICAL MANUFACTURERS

Appendix 2 Pharmaceutical Manufacturers

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE APRIL 1, 2018 12

0BA

ABN Abbott Nutrition ALL Allergan Inc. APH Actavis Pharma Company APX Apotex Inc. AUR Auro Pharma Inc. AXC Aptalis Pharma Canada Inc. AZC AstraZeneca Canada Inc.

1BB BAI Bayer Inc. BIC Bayer Inc. Consumer Care

2B 3BD

DCM D & C Mobility Solutions Inc. DFI Donmar Foods Incorporated G GMP Generic Medical Partners GKC GlaxoSmithKline Consumer Healthcare GSK GlaxoSmithKline GXP G Pohl Boskamp GMBH & Co/Pediapharm

7BI IPH Insight Pharmaceuticals LLC 8BJ JJI Johnson & Johnson Inc. JPC Jamp Pharma Corporation

9B 10B 11BM

MAR Marcan Pharmaceuticals Inc MCL McNeil Consumer Healthcare MFC Merck Canada Inc. MFI Medical Futures Inc. MJO Mead Johnson Nutrition (Canada) Co. MPI Mint Pharmaceuticals Inc. MTC MedTech Products Inc. MYP Mylan Pharmaceuticals ULC

12BN NES Nestle Canada Inc. NHN Nestle Health Science NTP Natco Pharma (Canada) Inc. NUN Nutricia North America

13BO ODN Odan Laboratories Ltd. OTS Otsuka Pharmaceutical Co. Ltd.

P

PAL Paladin Labs Inc. PDH Pfizer Consumer Healthcare PMS Pharmascience Inc. PPH Pendopharm Inc.

R

RAN Ranbaxy Pharmaceuticals Canada Inc. 16B

S SAV Sanofi-Aventis SDZ Sandoz Canada Inc. SEP Septa Pharmaceuticals Inc. SIV Sivem Pharmaceuticals SNS Sanis Health Inc.

T TAR Taro Pharmaceuticals Inc. TEV Teva Canada Limited

18BV VAN Vanc Pharmaceuticals Inc. VCL Valeant Canada LP

W WSB Boyd Pharmaceuticals

X XXX Miscellaneous Manufacturers

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT APPENDIX 2 – ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS

Appendix 2: Alphabetical List of Pharmaceutical Products

Product Name Page Product Name Page


EFFECTIVE APRIL 1, 2018 13

A

ABILIFY ......................................................................... 4 ACET 120 ..................................................................... 4 ACET 325 ..................................................................... 4 ACET 650 ..................................................................... 4 ACETAMINOPHEN ....................................................... 4 ACT CIPROFLOXACIN .................................... SEC 3A.2 ACT CIPROFLOXACIN .................................... SEC 3A.3 ACT LEVOFLOXACIN ..................................... SEC 3A.4 ACT RIZATRIPTAN ........................................... SEC 3.6 ACT RIZATRIPTAN ODT ................................... SEC 3.6 ACT SUMATRIPTAN ......................................... SEC 3.7 AERIUS KIDS ............................................................... 1 ALIMENTUM ................................................................. 5 ALMOTRIPTAN MALATE .................................. SEC 3.4 AMERGE ........................................................... SEC 3.4 APO-ACETAMINOPHEN .............................................. 4 APO-ACETAMINOPHEN (CAPLET) ............................. 4 APO-ALMOTRIPTAN ......................................... SEC 3.4 APO-BISACODYL ......................................................... 7 APO-CIPROFLOX ............................................ SEC 3A.2 APO-CIPROFLOX ............................................ SEC 3A.3 APO-DIMENHYDRINATE ............................................. 8 APO-FLUCONAZOLE-150 ............................................ 2 APO-LEVOFLOXACIN ..................................... SEC 3A.4 APO-LOPERAMIDE ...................................................... 7 APO-MOXIFLOXACIN ..................................... SEC 3A.5 APO-RIZATRIPTAN ........................................... SEC 3.6 APO-RIZATRIPTAN RPD .................................. SEC 3.6 APO-SUMATRIPTAN ......................................... SEC 3.7 APO-ZOLMITRIPTAN ........................................ SEC 3.7 ARIPIPRAZOLE ............................................................ 4 AURO-CIPROFLOXACIN ................................ SEC 3A.2 AURO-CIPROFLOXACIN ................................ SEC 3A.3 AURO-MOXIFLOXACIN .................................. SEC 3A.5 AURO-RIZATRIPTAN ........................................ SEC 3.6 AVELOX ........................................................... SEC 3A.5

B

BENEPROTEIN ................................................. SEC 3.5 BETA CAROTENE/ VITAMIN A ACETATE/ VITAMIN E

(DL-ALPHA TOCOPHERYL ACETATE)/ ASCORBIC ACID/ FOLIC ACID/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ NIACINAMIDE (NICOTINAMIDE)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ VITAMIN D3/ BIOTIN/ CALCIUM D-PANTOTHENATE/ CALCIUM CARBONATE/ MAGNESIUM OXIDE/ POTASSIUM IODIDE/ FERROUS FUMARATE/ CUPRIC OXIDE/ ZINC OXIDE/ CHROMIUM CHLORIDE/ MANGANESE SULFATE/ SODIUM MOLYBDATE/ SODIUM SELENATE .............................................. 11

BISACODYL.................................................................. 7 BLOOD GLUCOSE METER ......................................... 1

BLOOD GLUCOSE TEST STRIPS ............................... 1 BLOOD LETTING LANCET ........................................... 1 BOOST .......................................................................... 6 BOOST ...............................................................SEC 3.5 BOOST 1.5 PLUS CALORIES....................................... 6 BOOST DIABETIC ........................................................ 6 BOOST FRUIT FLAVOURED BEVERAGE ........SEC 3.5 BOOST HIGH PROTEIN ....................................SEC 3.5 BOOST PLUS CALORIES............................................. 6 BROMPHENIRAMINE MALEATE/ PHENYLEPHRINE

HCL ........................................................................... 1 BUPROPION HCL ......................................................... 2

C

CANESTEN 1 ................................................................ 8 CANESTEN 1 COMFORTAB COMBI-PAK ................... 9 CANESTEN 1 CREAM COMBI-PAK ............................. 9 CANESTEN 3 ................................................................ 8 CANESTEN 3 COMFORTAB COMBI-PAK ................... 9 CANESTEN 6 ................................................................ 8 CANESTEN EXTERNAL CREAM REFILL .................... 8 CHILDREN'S ADVIL ...................................................... 3 CHILDREN'S MOTRIN .................................................. 3 CHILDRENS TEMPRA .................................................. 4 CIPRO ............................................................. SEC 3A.1 CIPRO ............................................................. SEC 3A.2 CIPRO ............................................................. SEC 3A.3 CIPROFLOXACIN ........................................... SEC 3A.1 CIPROFLOXACIN ........................................... SEC 3A.2 CIPROFLOXACIN ........................................... SEC 3A.3 CIPROFLOXACIN HCL ................................... SEC 3A.2 CIPROFLOXACIN HCL ................................... SEC 3A.3 CLARITIN ...................................................................... 2 CLOTRIMADERM ......................................................... 8 CLOTRIMAZOLE ........................................................... 8 CLOTRIMAZOLE/ CLOTRIMAZOLE ............................. 9 COLACE ........................................................................ 7 COLYTE ........................................................................ 7 COMPLEAT ................................................................... 6 COMPLEAT PEDIATRIC ....................................SEC 3.5 CONSIST-RITE ........................................................... 11 CROMOLYN .................................................................. 6 CYPROHEPTADINE ..................................................... 1 CYPROHEPTADINE HCL ............................................. 1

D

D-VI-SOL INFANT ....................................................... 10 D3-DOL ....................................................................... 10 DECAXIL DROPS ....................................................... 10 DECAXIL LIQUID ........................................................ 10 DESLORATADINE ........................................................ 1 DEXTROMETHORPHAN HBR/ PSEUDOEPHEDRINE

HCL ........................................................................... 1 DIABETES SUPPLIES .................................................. 1





DIMENHYDRINATE ...................................................... 8 DIMETAPP COLD ......................................................... 1 DIMETHICONE ............................................................. 9 DIPHENHYDRAMINE ................................................... 2 DIPHENHYDRAMINE HCL ........................................... 2 DOCUSATE SODIUM ................................................... 7 DULCOLAX ................................................................... 7 DUOCAL ............................................................ SEC 3.5

E

ENFAMIL ENFACARE A+ ............................................. 5 ENSURE ............................................................ SEC 3.5 ENSURE FIBRE ............................................................ 6 ENSURE HIGH-PROTEIN ................................. SEC 3.5 ENSURE PLUS ............................................................. 6 ENSURE REGULAR ..................................................... 6 ENSURE SCFOS FIBRE .............................................. 6 EURO-CYPROHEPTADINE ......................................... 1 EXTRA STRENGTH LACTAID ..................................... 8

F

FER-IN-SOL .................................................................. 3 FERODAN .................................................................... 3 FERODAN INFANT ....................................................... 3 FERROUS FUMARATE ................................................ 3 FERROUS SULFATE ................................................... 3 FLEET ENEMA ............................................................. 8 FLEET ENEMA PEDIATRIC (65 ML) ............................ 8 FLINTSTONES MULTI VITAMINS PLUS IRON.......... 11 FLINTSTONES MULTI VITAMINS W EXTRA C ......... 10 FLINTSTONES MULTIPLE VITAMINS COMPLETE .. 11 FLUCONAZOLE ............................................................ 2

G

GASTROLYTE .............................................................. 5 GLUCERNA .................................................................. 6 GLUCOSE CALIBRATION SOLUTION ........................ 1 GLYCERIN .................................................................... 7 GLYCERIN INFANT ...................................................... 7

H

HABITROL 14 MG/DAY ................................................ 2 HABITROL 21 MG/DAY ................................................ 3 HABITROL 7 MG/DAY .................................................. 2

I

IBUPROFEN ................................................................. 3 IMITREX ............................................................ SEC 3.6 IMITREX (0.5 ML) .............................................. SEC 3.7 IMITREX DF ....................................................... SEC 3.7

IMODIUM....................................................................... 7 INFANT FORMULA ....................................................... 5 INFANT FORMULA ............................................SEC 3.4 INFUSION SETS (TUBING & NEEDLE) ....................... 1 INSTANT FOOD THICKENER .................................... 11 INSULIN CARTRIDGES / RESERVOIRS ..................... 1 INSULIN PEN NEEDLES .............................................. 1 INSULIN SYRINGES ..................................................... 1 ISOPROPYL MYRISTATE ............................................ 9 ISOSOURCE 1.0 HP ..........................................SEC 3.5 ISOSOURCE 1.2 ........................................................... 6 ISOSOURCE 1.5 ........................................................... 6 ISOSOURCE 2.0 ........................................................... 6 ISOSOURCE FIBRE 1.0 HP...............................SEC 3.5 ISOSOURCE FIBRE 1.2 ............................................... 6 ISOSOURCE FIBRE 1.5 ............................................... 6

J

JAMP FERROUS SULFATE ......................................... 3 JAMP FERROUS SULFATE INFANT DROPS .............. 3 JAMP REHYDRALYTE ................................................. 5 JAMP-ACETAMINOPHEN BLAZON ............................. 4 JAMP-ACETAMINOPHEN EXTRA STRENGTH ........... 4 JAMP-CIPROFLOXACIN ................................ SEC 3A.2 JAMP-CIPROFLOXACIN ................................ SEC 3A.3 JAMP-FERROUS FUMARATE ...................................... 3 JAMP-FLUCONAZOLE ................................................. 2 JAMP-LACTASE ENZYME............................................ 8 JAMP-MOXIFLOXACIN ................................... SEC 3A.5 JAMP-RIZATRIPTAN .........................................SEC 3.6 JAMP-RIZATRIPTAN IR .....................................SEC 3.6 JAMP-VITAMIN D ........................................................ 10 JAMP-ZOLMITRIPTAN ......................................SEC 3.7 JAMP-ZOLMITRIPTAN ODT ..............................SEC 3.7 JEVITY 1 CAL ............................................................... 6 JEVITY 1.2 CAL .................................................SEC 3.5 JEVITY 1.5 CAL .................................................SEC 3.5

K

KETOCAL ...........................................................SEC 3.5 KWELLADA-P ............................................................... 9 KWELLADA-P CREME ................................................. 9

L

LACTAID ....................................................................... 8 LACTAID ULTRA (CAPLET) ......................................... 8 LACTASE ...................................................................... 8 LANCING DEVICE ........................................................ 1 LAX-A NEMA ................................................................. 8 LEVOFLOXACIN ............................................. SEC 3A.4 LOPERAMIDE HCL ....................................................... 7 LORATADINE ................................................................ 2





M

MAR-CIPROFLOXACIN ................................... SEC 3A.2 MAR-CIPROFLOXACIN ................................... SEC 3A.3 MAR-FLUCONAZOLE-150 ........................................... 2 MAR-MOXIFLOXACIN ..................................... SEC 3A.5 MAR-RIZATRIPTAN .......................................... SEC 3.6 MAR-ZOLMITRIPTAN ........................................ SEC 3.7 MAXALT ............................................................. SEC 3.6 MAXALT RPD .................................................... SEC 3.6 MCT OIL ............................................................ SEC 3.5 MED-MOXIFLOXACIN ..................................... SEC 3A.5 MICONAZOLE NITRATE .............................................. 9 MICOZOLE ................................................................... 9 MINT-CIPROFLOX .......................................... SEC 3A.2 MINT-CIPROFLOX .......................................... SEC 3A.3 MINT-ZOLMITRIPTAN ....................................... SEC 3.7 MODULEN IBD .................................................. SEC 3.5 MOXIFLOXACIN HCL ...................................... SEC 3A.5 MYLAN-ALMOTRIPTAN .................................... SEC 3.4 MYLAN-CIPROFLOXACIN .............................. SEC 3A.2 MYLAN-CIPROFLOXACIN .............................. SEC 3A.3 MYLAN-RIZATRIPTAN ODT.............................. SEC 3.6 MYLAN-SUMATRIPTAN .................................... SEC 3.7 MYLAN-ZOLMITRIPTAN ................................... SEC 3.7

N

NARATRIPTAN HCL .......................................... SEC 3.4 NAT-RIZATRIPTAN ODT ................................... SEC 3.6 NAT-ZOLMITRIPTAN ........................................ SEC 3.7 NEOCATE E028 SPLASH ................................. SEC 3.5 NEOCATE JUNIOR ........................................... SEC 3.5 NEOCATE JUNIOR WITH PREBIOTIC FIBRE.. SEC 3.5 NEOCATE SPLASH ........................................... SEC 3.5 NEOCATE WITH DHA & ARA ........................... SEC 3.4 NEPRO ......................................................................... 6 NESTLE MATERNA .................................................... 11 NICODERM 14 MG/DAY .............................................. 2 NICODERM 21 MG/DAY .............................................. 3 NICODERM 7 MG/DAY ................................................ 2 NICORETTE ................................................................. 2 NICORETTE INHALER ................................................. 2 NICORETTE QUICKMIST ............................................ 2 NICOTINE ..................................................................... 2 NICOTINE ..................................................................... 3 NIX CREME .................................................................. 9 NIX DERMAL ................................................................ 9 NOVASOURCE RENAL ................................................ 6 NOVO GESIC FORTE .................................................. 4 NOVO-CIPROFLOXACIN ................................ SEC 3A.2 NOVO-LEVOFLOXACIN .................................. SEC 3A.4 NOVO-LOPERAMIDE (CAPLET) .................................. 7 NUTRAMIGEN A+ HYPOALLERGENIC ....................... 5 NUTREN 2.0 ................................................................. 6 NUTREN JUNIOR ......................................................... 6 NUTREN JUNIOR FIBRE W PREBIO 1 ....................... 6 NUTRITIONAL PRODUCTS ......................................... 6

NUTRITIONAL PRODUCTS...............................SEC 3.5 NYADERM..................................................................... 9 NYDA ............................................................................ 9 NYSTATIN ..................................................................... 9

O

OPTICROM ................................................................... 6

P

PALAFER ...................................................................... 3 PEDIALYTE ................................................................... 5 PEDIALYTE (FLAVOURED).......................................... 5 PEDIALYTE (UNFLAVOURED) .................................... 5 PEDIASURE .................................................................. 6 PEDIASURE FIBRE ...................................................... 6 PEDIASURE PEPTIDE 1 CAL....................................... 6 PEDIASURE PLUS WITH FIBRE .......................SEC 3.5 PEDIATRIC ELECTROLYTE......................................... 5 PEDIATRIX.................................................................... 4 PEG-LYTE ..................................................................... 7 PEPTAMEN ........................................................SEC 3.5 PEPTAMEN 1.5 ..................................................SEC 3.5 PEPTAMEN AF 1.2 ............................................SEC 3.5 PEPTAMEN JUNIOR .........................................SEC 3.5 PEPTAMEN JUNIOR 1.5 ...................................SEC 3.5 PEPTAMEN WITH PREBIO 1 ............................SEC 3.5 PERMETHRIN ............................................................... 9 PMS-CIPROFLOXACIN .................................. SEC 3A.2 PMS-CIPROFLOXACIN .................................. SEC 3A.3 PMS-CYPROHEPTADINE HCL .................................... 1 PMS-FERROUS SULFATE ........................................... 3 PMS-FLUCONAZOLE ................................................... 2 PMS-LOPERAMIDE (CAPLET) ..................................... 7 PMS-RIZATRIPTAN RDT ...................................SEC 3.6 PMS-SUMATRIPTAN .........................................SEC 3.7 PMS-ZOLMITRIPTAN ........................................SEC 3.7 POLY-VI-SOL .............................................................. 10 POLYETHYLENE GLYCOL/ POTASSIUM CHLORIDE

(K+)/ SODIUM SULFATE/ SODIUM CHLORIDE/ SODIUM BICARBONATE ......................................... 7

POLYETHYLENE GLYCOL/ SODIUM SULFATE/ SODIUM BICARBONATE/ SODIUM CHLORIDE/ POTASSIUM CHLORIDE (K+) .................................. 7

PURAMINO A+ ...................................................SEC 3.4 PYRETHRINS/ PIPERONYL BUTOXIDE .................... 10

R

R & C SHAMPOO WITH CONDITIONER.................... 10 RAN-CIPROFLOX ........................................... SEC 3A.2 RAN-CIPROFLOX ........................................... SEC 3A.3 RATIO-CIPROFLOXACIN ............................... SEC 3A.2 RATIO-CIPROFLOXACIN ............................... SEC 3A.3 RATIO-DOCUSATE SODIUM ....................................... 7





RATIO-NYSTATIN ........................................................ 9 RESOURCE 2.0 ............................................................ 6 RESOURCE DIABETIC ................................................ 6 RESOURCE KID ESSENTIALS 1.5 CAL ...................... 6 RESOURCE THICKENUP .......................................... 11 RESOURCE THICKENUP CLEAR ............................. 11 RESULTZ ...................................................................... 9 RIZATRIPTAN BENZOATE ............................... SEC 3.6 RIZATRIPTAN ODT ........................................... SEC 3.6 ROBITUSSIN CHILDRENS COUGH AND COLD ......... 1

S

SALINEX ....................................................................... 6 SANDOZ ALMOTRIPTAN .................................. SEC 3.4 SANDOZ CIPROFLOXACIN ............................ SEC 3A.2 SANDOZ CIPROFLOXACIN ............................ SEC 3A.3 SANDOZ DIMENHYDRINATE ...................................... 8 SANDOZ LEVOFLOXACIN .............................. SEC 3A.4 SANDOZ MOXIFLOXACIN .............................. SEC 3A.5 SANDOZ NARATRIPTAN .................................. SEC 3.4 SANDOZ RIZATRIPTAN ODT ........................... SEC 3.6 SANDOZ SUMATRIPTAN ................................. SEC 3.7 SANDOZ ZOLMITRIPTAN ................................. SEC 3.7 SCANDISHAKE ................................................. SEC 3.5 SELAX .......................................................................... 7 SEPTA-CIPROFLOXACIN ............................... SEC 3A.2 SEPTA-CIPROFLOXACIN ............................... SEC 3A.3 SEPTA-ZOLMITRIPTAN-ODT ........................... SEC 3.7 SIMILAC ALIMENTUM .................................................. 5 SIMILAC NEOSURE ..................................................... 5 SODIUM CHLORIDE .................................................... 6 SODIUM CHLORIDE/ POTASSIUM CHLORIDE

(K+)(CL-)/ SODIUM CITRATE,ACID/ DEXTROSE ... 5 SODIUM CHLORIDE/ SODIUM CITRATE,ACID/

DEXTROSE/ POTASSIUM CITRATE (K+) ............... 5 SODIUM CROMOGLYCATE ........................................ 6 SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE 8 SODIUM/ POTASSIUM/ CHLORIDE/ CITRATE/

DEXTROSE .............................................................. 5 SODIUM/ POTASSIUM/ CHLORIDE/ CITRATE/ ZINC/

DEXTROSE .............................................................. 5 SUMATRIPTAN ................................................. SEC 3.7 SUMATRIPTAN DF ............................................ SEC 3.7 SUMATRIPTAN HEMISULFATE ....................... SEC 3.6 SUMATRIPTAN SUCCINATE ............................ SEC 3.7 SUPLENA ..................................................................... 6

T

TARO-SUMATRIPTAN (0.5 ML) ........................ SEC 3.7 TEMPRA D.S. ............................................................... 4 TEVA-DIMENATE ......................................................... 8 TEVA-MOXIFLOXACIN ................................... SEC 3A.5 TEVA-NARATRIPTAN ....................................... SEC 3.4 TEVA-RIZATRIPTAN ODT ................................ SEC 3.6 TEVA-SUMATRIPTAN ....................................... SEC 3.7 TEVA-SUMATRIPTAN DF ................................. SEC 3.7

TEVA-ZOLMITRIPTAN .......................................SEC 3.7 THE MAGIC BULLET .................................................... 7 TOLEREX ...........................................................SEC 3.5 TRANSDERMAL NICOTINE 14 MG/DAY ..................... 2 TRANSDERMAL NICOTINE 21 MG/DAY ..................... 3 TRANSDERMAL NICOTINE 7 MG/DAY ....................... 2 TRI-VI-SOL .................................................................. 10 TWOCAL HN ......................................................SEC 3.5 TYLENOL EXTRA STRENGTH ..................................... 4 TYLENOL EXTRA-STRENGTH (CAPLET) ................... 4

U

URINE TEST STRIPS ................................................... 1

V

VAN-CIPROFLOXACIN ................................... SEC 3A.2 VAN-CIPROFLOXACIN ................................... SEC 3A.3 VAN-RIZATRIPTAN ...........................................SEC 3.6 VAN-RIZATRIPTAN ODT ...................................SEC 3.6 VAN-ZOLMITRIPTAN ODT ................................SEC 3.7 VITAL PEPTIDE 1 CAL ................................................. 6 VITAL PEPTIDE 1.5 CAL .............................................. 6 VITAMIN A ACETATE/ THIAMINE MONONITRATE/

RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ BIOTIN/ SODIUM ASCORBATE/ VITAMIN D/ VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE)/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE)/ CALCIUM D-PANTOTHENATE/ CALCIUM PHOSPHATE DIBASIC/ CUPRIC OXIDE/ FERROUS FUMARATE/ CALCIUM PHOSPHATE DIBASIC .......................... 11

VITAMIN A ACETATE/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ SODIUM ASCORBATE/ VITAMIN D/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE) .................................................... 10

VITAMIN A ACETATE/ THIAMINE MONONITRATE/ RIBOFLAVIN (VITAMIN B2)/ PYRIDOXINE HCL/ CYANOCOBALAMIN/ SODIUM ASCORBATE/ VITAMIN D/ FOLIC ACID/ NIACINAMIDE (NICOTINAMIDE)/ FERROUS FUMARATE ............ 11

VITAMIN A PALMITATE/ VITAMIN D/ ASCORBIC ACID ................................................................................ 10

VITAMIN A PALMITATE/ VITAMIN D/ SODIUM ASCORBATE/ THIAMINE HCL/ RIBOFLAVIN (VITAMIN B2)/ NIACINAMIDE (NICOTINAMIDE) ... 10

VITAMIN D3 ................................................................ 10 VIVONEX PEDIATRIC .......................................SEC 3.5 VIVONEX PLUS .................................................SEC 3.5 VIVONEX T.E.N. ................................................SEC 3.5

Z

ZOLMITRIPTAN .................................................SEC 3.7





ZOMIG ............................................................... SEC 3.7 ZOMIG RAPIMELT ............................................ SEC 3.7ZYBAN .......................................................................... 2

ALBERTA HUMAN SERVICES DRUG BENEFIT SUPPLEMENT APPENDIX 3 – NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER

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00000003875 .............. 7 00000009911 .............. 8 00000017884 .............. 3 00000021423 .............. 8 00000108065 .............. 8 00000254142 .............. 7 00000363766 .............. 8 00000392545 .............. 8 00000392553 .............. 8 00000482323 .............. 4

00000545007 .............. 4 00000545023 .............. 7 00000559407 .............. 4 00000630365 .............. 5 00000677442 .............. 7 00000695033 .............. 7 00000716871 .............. 9 00000723908 .............. 4 00000757713 .............. 1 00000758469 .............. 3

00000762881 ............ 10 00000762903 ............ 10 00000762946 ............ 10 00000762954 .............. 3 00000771368 .............. 9 00000777838 .............. 7 00000792675 .............. 3 00000812366 .............. 8 00000812374 .............. 8 00000870226 .............. 7

00000875996 .............. 4 00000884553 .............. 4 00000989996 .............. 6 00000989997 .............. 6 00000989998 .............. 6 00000990024 .............. 1 00000990029 .............. 6 00000990045 .............. 1 00000990056 .............. 6 00000990057 .............. 1

00000990058 .............. 1 00000999391 ... SEC 3.5 00000999402 ... SEC 3.5 00000999404 ... SEC 3.5 00000999405 ... SEC 3.5 00000999408 ... SEC 3.5 00000999409 .............. 6 00000999413 .............. 6 00000999414 .............. 6 00000999415 ... SEC 3.5

00000999416 ... SEC 3.5 00000999418 .............. 6 00000999419 .............. 6 00000999421 ... SEC 3.5 00000999422 ... SEC 3.5 00000999426 ... SEC 3.5 00000999427 ... SEC 3.5 00000999430 ... SEC 3.5 00000999434 ... SEC 3.5 00000999435 ... SEC 3.5

00000999440 ... SEC 3.5 00000999444 ... SEC 3.5 00000999445 ... SEC 3.5 00000999447 ... SEC 3.5 00000999449 .............. 5 00000999453 ............ 11 00000999455 ............ 11 00000999458 .............. 6 00000999465 .............. 5 00000999467 ... SEC 3.5

00000999475 ... SEC 3.5 00000999483 .............. 6 00000999520 .............. 5 00000999524 ... SEC 3.5 00000999525 .............. 6 00000999543 ... SEC 3.4 00000999545 .............. 6 00000999553 ... SEC 3.5 00000999559 ... SEC 3.5 00000999560 ... SEC 3.5

00000999561 ............ 11 00000999564 .............. 5 00000999565 ... SEC 3.5 00000999568 ... SEC 3.4 00000999788 .............. 5 00000999886 ... SEC 3.5 00000999888 .............. 6 00000999889 .............. 6 00000999890 ... SEC 3.5 00000999895 .............. 6

00000999896 .............. 6 00000999901 .............. 6 00000999902 .............. 6 00000999918 .............. 6 00000999920 .............. 6 00000999921 .............. 6 00000999927 ... SEC 3.5 00000999929 ... SEC 3.5 00000999932 .............. 6 00000999933 .............. 6

00000999934 ... SEC 3.5 00000999935 ... SEC 3.5 00000999938 .............. 6 00000999940 .............. 6 00000999941 .............. 1 00000999942 .............. 1 00000999944 ... SEC 3.5 00000999952 .............. 1 00000999955 .............. 1 00000999957 .............. 1

00000999964 .............. 6 00000999966 .............. 6 00000999983 ... SEC 3.5 00000999985 .............. 1 00001923439 .............. 3 00001931563 .............. 5 00001939122 .............. 4 00001943057 .............. 2 00001943065 .............. 2 00001943073 .............. 3

00002009277 .............. 6 00002020815 .............. 7 00002027798 .............. 4 00002027801 .............. 4 00002044013 .............. 1 00002086018 .............. 7 00002090163 .............. 7 00002091933 .............. 2 00002091941 .............. 2 00002093111 .............. 2

00002093138 .............. 2 00002093146 .............. 3 00002096900 .............. 8 00002125447 ............ 10 00002132591 .............. 7 00002150883 .............. 8 00002150891 .............. 8 00002150905 .............. 8 00002155958 SEC 3A.2 00002155966 SEC 3A.3

00002155974 SEC 3A.3 00002161737 SEC 3A.2 00002194228 .............. 9 00002194236 .............. 9 00002212005 .............. 7 00002212153 ... SEC 3.7 00002212161 ... SEC 3.7 00002212188 ... SEC 3.7 00002219883 .............. 5 00002219905 .............. 9

00002228351 .............. 7 00002229521 SEC 3A.2 00002229522 SEC 3A.3 00002229523 SEC 3A.3 00002229977 .............. 4 00002230418 .. SEC 3.6 00002230420 .. SEC 3.6 00002230434 .............. 4 00002230436 .............. 4 00002230437 .............. 4

00002230509 .............. 9 00002230621 .............. 6 00002230653 .............. 8 00002230654 .............. 8 00002231106 .............. 9 00002231348 .............. 9 00002231480 .............. 9 00002231507 .............. 8 00002232297 .............. 3 00002237385 .............. 3

00002237514 SEC 3A.1 00002237820 .. SEC 3.4 00002237821 .. SEC 3.4 00002238441 .............. 2 00002238660 .. SEC 3.7 00002239367 .. SEC 3.7 00002239432 .............. 8 00002240518 .. SEC 3.6 00002240519 .. SEC 3.6 00002240521 .. SEC 3.6

00002241091 .............. 7 00002241226 .............. 2 00002241227 .............. 2 00002241228 .............. 3 00002241523 .............. 2 00002241742 .............. 2 00002241895 .............. 2 00002242365 .............. 3 00002242965 SEC 3A.5 00002243045 .. SEC 3.7

00002243980 .............. 1 00002245647 SEC 3A.2 00002245648 SEC 3A.3 00002245667 .............. 1 00002246825 SEC 3A.2 00002246826 SEC 3A.3 00002246827 SEC 3A.3 00002247193 .............. 1 00002247339 SEC 3A.2 00002247340 SEC 3A.3

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00002247341 SEC 3A.3 00002247973 ............ 11 00002247975 ............ 10 00002247995 ............ 11 00002248262 SEC 3A.4 00002248263 SEC 3A.4 00002248437 SEC 3A.2 00002248438 SEC 3A.3 00002248439 SEC 3A.3 00002248756 SEC 3A.2

00002248757 SEC 3A.3 00002248758 SEC 3A.3 00002248993 ... SEC 3.7 00002256436 ... SEC 3.7 00002256444 ... SEC 3.7 00002257904 ... SEC 3.7 00002263025 ... SEC 3.7 00002263033 ... SEC 3.7 00002264099 .............. 9 00002264102 .............. 9

00002268388 ... SEC 3.7 00002268396 ... SEC 3.7 00002268914 ... SEC 3.7 00002268922 ... SEC 3.7 00002279592 .............. 9 00002282348 .............. 2 00002284707 SEC 3A.4 00002284715 SEC 3A.4 00002285649 SEC 3A.4 00002286521 ... SEC 3.7

00002286548 ... SEC 3.7 00002286823 ... SEC 3.7 00002286831 ... SEC 3.7 00002291800 .............. 7 00002298503 .............. 2 00002298635 SEC 3A.4 00002298643 SEC 3A.4 00002298651 SEC 3A.4 00002303728 SEC 3A.2 00002303736 SEC 3A.3

00002303744 SEC 3A.3 00002313960 ... SEC 3.7 00002314290 ... SEC 3.4 00002314304 ... SEC 3.4 00002315424 SEC 3A.4 00002315432 SEC 3A.4 00002315440 SEC 3A.4 00002322323 ... SEC 3.4 00002322390 .............. 4 00002322404 .............. 4

00002322412 .............. 4 00002322455 .............. 4 00002324229 ... SEC 3.7 00002325942 SEC 3A.4 00002332248 .............. 1 00002351870 ... SEC 3.6 00002351889 ... SEC 3.6 00002353318 SEC 3A.2 00002353326 SEC 3A.3 00002355299 .............. 4

00002361698 ... SEC 3.7 00002362988 ... SEC 3.7 00002369036 ... SEC 3.7 00002373785 .............. 9 00002374730 ... SEC 3.6 00002374749 ... SEC 3.6 00002375702 SEC 3A.5 00002379198 ... SEC 3.6 00002379201 ... SEC 3.6 00002379627 SEC 3A.2

00002379635 SEC 3A.3 00002379643 SEC 3A.3 00002379678 ... SEC 3.6 00002379686 SEC 3A.2 00002379694 SEC 3A.3 00002379708 SEC 3A.3 00002380358 SEC 3A.2 00002380366 SEC 3A.3 00002380374 SEC 3A.3 00002380455 ... SEC 3.6

00002380463 ... SEC 3.6 00002380951 ... SEC 3.7 00002381702 ... SEC 3.6 00002381907 SEC 3A.2 00002381923 SEC 3A.3 00002383381 SEC 3A.5 00002385570 ... SEC 3.7 00002385589 ... SEC 3.7 00002386119 SEC 3A.2 00002386127 SEC 3A.3

00002393360 ... SEC 3.6 00002393379 ... SEC 3.6 00002393468 ... SEC 3.6 00002393476 ... SEC 3.6 00002393484 ... SEC 3.6 00002393492 ... SEC 3.6 00002396661 ... SEC 3.6 00002396688 ... SEC 3.6 00002398435 ... SEC 3.4 00002398443 ... SEC 3.4

00002399458 ... SEC 3.7 00002404923 SEC 3A.5 00002405334 ... SEC 3.4 00002405792 ... SEC 3.4 00002405806 ... SEC 3.4 00002419521 ... SEC 3.7 00002421534 ... SEC 3.7 00002421623 ... SEC 3.7 00002423553 SEC 3A.2 00002423561 SEC 3A.3

00002423588 SEC 3A.3 00002426978 SEC 3A.2 00002427001 SEC 3A.3 00002427028 SEC 3A.3 00002428237 ... SEC 3.7 00002428474 ... SEC 3.7 00002428512 ... SEC 3.6 00002428520 ... SEC 3.6 00002428792 .............. 2 00002429233 ... SEC 3.6

00002429241 ... SEC 3.6 00002432242 SEC 3A.5 00002432471 .............. 2 00002436604 ... SEC 3.6 00002436612 ... SEC 3.6 00002438763 ... SEC 3.7 00002441144 ... SEC 3.6 00002442906 ... SEC 3.6 00002442914 ... SEC 3.6 00002443929 SEC 3A.5

00002446111 ... SEC 3.6 00002446138 ... SEC 3.6 00002447053 SEC 3A.5 00002447061 SEC 3A.5 00002448505 ... SEC 3.6 00002457814 SEC 3A.5 00009998877 .............. 6 00080001842 ............ 11 00080003038 ............ 10 00080008295 .............. 3

00080008309 .............. 3 00080019649 ............ 10 00080024901 .............. 6 00080027403 .............. 5 00080029822 .............. 3 00080038155 ............ 10 00080038858 .............. 2 00080041145 ............ 10 00080070358 .............. 8 00080072902 .............. 5

00080074173 .............. 5

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