Summary of Changes to the Alberta Drug Benefit List
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- Nickolas McCoy
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1 Summary of Changes to the Alberta Drug Benefit List Effective April 1, 2018
2 Inquiries should be directed to: Pharmacy Services Alberta Blue Cross Street NW Edmonton AB T5J 3C5 Telephone Number: (780) (Edmonton) (403) (Calgary) (Toll Free) FAX Number: (780) (Toll Free) Website: http: / / / services / drug-benefit-list.html Administered by Alberta Blue Cross on behalf of Alberta Health. 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 Drug Benefit List are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: $42.00 ($ $2.00 G.S.T.) Contents only: $36.75 ($ $1.75 G.S.T.) A cheque or money order must accompany the request for copies. ABC 40211/81160 (R2018/04)
3 Table of Contents Special Authorization... 1 Drug Product(s) with Changes to Criteria for Coverage... 1 Added Product(s)... 1 Least Cost Alternative (LCA) Price Change(s)... 1 Product(s) with a Price Change... 3 Discontinued Listing(s)... 4 Product(s) Removed from the ADBL as Price Policy Requirements Not Satisfied... 8 EFFECTIVE APRIL 1, 2018
4 Special Authorization Drug Product(s) with Changes to Criteria for Coverage DAKLINZA 30 MG DACLATASVIR DIHYDROCHLORIDE BMS DAKLINZA 60 MG DACLATASVIR DIHYDROCHLORIDE BMS EPCLUSA 400 MG / 100 MG SOFOSBUVIR/ VELPATASVIR GIL HARVONI 400 MG / 90 MG SOFOSBUVIR/ LEDIPASVIR GIL SOVALDI 400 MG SOFOSBUVIR GIL XOLAIR 150 MG / VIAL INJECTION OMALIZUMAB NOV ZEPATIER 50 MG / 100 MG ELBASVIR/ GRAZOPREVIR MFC Added Product(s) ACT DEXTROAMPHETAMINE SR 15 MG SUSTAINED-RELEASE CAPSULE METOJECT SUBCUTANEOUS 17.5 MG / SYRINGE INJECTION METOJECT SUBCUTANEOUS 20 MG / SYRINGE INJECTION METOJECT SUBCUTANEOUS 22.5 MG / SYRINGE INJECTION METOJECT SUBCUTANEOUS 25 MG / SYRINGE INJECTION DEXTROAMPHETAMINE SULFATE APH METHOTREXATE SODIUM MDX METHOTREXATE SODIUM MDX METHOTREXATE SODIUM MDX METHOTREXATE SODIUM MDX SERTRALINE 25 MG CAPSULE SERTRALINE HCL JPC SERTRALINE 50 MG CAPSULE SERTRALINE HCL JPC SERTRALINE 100 MG CAPSULE SERTRALINE HCL JPC Least Cost Alternative (LCA) Price Change(s) The following established IC Grouping(s) are affected and a revised LCA price has been established. Groupings affected by a price decrease, will be effective May 1, Groupings affected by a price increase, will be effective April 1, Please review the online Alberta Drug Benefit List at https: / / / dbl / idbl_main1.html for further information. Generic Description Strength / Form New LCA Price AMCINONIDE 0.1% TOPICAL CREAM CARBAMAZEPINE 20 MG / ML ORAL SUSPENSION CLOBAZAM 10 MG EFFECTIVE APRIL 1,
5 Least Cost Alternative (LCA) Price Change(s), continued Generic Description Strength / Form New LCA Price CODEINE PHOSPHATE/ ACETAMINOPHEN 60 MG / 300 MG DESMOPRESSIN ACETATE 0.1 MG DESMOPRESSIN ACETATE 0.2 MG ESTRADIOL-17B 50 MCG / DAY TRANSDERMAL PATCH ESTRADIOL-17B 75 MCG / DAY TRANSDERMAL PATCH ESTRADIOL-17B 100 MCG / DAY TRANSDERMAL PATCH HYDROMORPHONE HCL 1 MG / ML ORAL LIQUID HYDROXYZINE HCL 2 MG / MLORAL SYRUP IPRATROPIUM BROMIDE 0.03% NASAL SPRAY LEVOTHYROXINE SODIUM 0.05 MG LEVOTHYROXINE SODIUM 0.1 MG LEVOTHYROXINE SODIUM 0.15 MG LEVOTHYROXINE SODIUM 0.2 MG MOMETASONE FUROATE 0.1% TOPICAL LOTION PHENYTOIN 25 MG / ML ORAL SUSPENSION PIMOZIDE 4 MG PIOGLITAZONE HCL 15 MG PIOGLITAZONE HCL 30 MG PIOGLITAZONE HCL 45 MG PREDNISOLONE SODIUM PHOSPHATE 1 MG / ML ORAL LIQUID SUCRALFATE 1 G TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 30 MG CAPSULE TRIAMCINOLONE ACETONIDE 40 MG / ML INJECTION VALPROIC ACID 250 MG CAPSULE VALPROIC ACID 50 MG / ML ORAL SYRUP Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until April 30, For products within an established LCA or MAC Grouping, the established LCA or MAC price may apply. Please see the April 1, 2018 ADBL for a complete listing of products and their corresponding prices. ACCEL-PIOGLITAZONE 15 MG PIOGLITAZONE HCL ACP ACCEL-PIOGLITAZONE 30 MG PIOGLITAZONE HCL ACP 2 EFFECTIVE APRIL 1, 2018
6 Product(s) with a Price Change, continued ACT LOSARTAN 50 MG LOSARTAN POTASSIUM APH ACT LOSARTAN 100 MG LOSARTAN POTASSIUM APH ACUVAIL 0.45% OPHTHALMIC SOLUTION KETOROLAC TROMETHAMINE ALL ANUGESIC-HC 0.5% / 1% / 0.5% RECTAL OINTMENT ANUGESIC-HC 10 MG / 20 MG / 10 MG RECTAL SUPPOSITORY HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE MCL MCL APO-LOSARTAN 25 MG LOSARTAN POTASSIUM APX APO-LOSARTAN 50 MG LOSARTAN POTASSIUM APX APO-LOSARTAN 100 MG LOSARTAN POTASSIUM APX AURO-LOSARTAN 25 MG LOSARTAN POTASSIUM AUR AURO-LOSARTAN 50 MG LOSARTAN POTASSIUM AUR AURO-LOSARTAN 100 MG LOSARTAN POTASSIUM AUR BIO-LOSARTAN 25 MG LOSARTAN POTASSIUM BMD BIO-LOSARTAN 50 MG LOSARTAN POTASSIUM BMD BIO-LOSARTAN 100 MG LOSARTAN POTASSIUM BMD BRENZYS 50 MG / SYRINGE AUTO INJECTOR SYRINGE ETANERCEPT SSB BRENZYS 50 MG / SYRINGE INJECTION ETANERCEPT SSB ISOPTIN SR 240 MG SUSTAINED-RELEASE JAMP-K 8 8 MEQ SUSTAINED-RELEASE VERAPAMIL HCL BGP POTASSIUM CHLORIDE (K+) JPC JAMP-LOSARTAN 25 MG LOSARTAN POTASSIUM JPC JAMP-LOSARTAN 50 MG LOSARTAN POTASSIUM JPC JAMP-LOSARTAN 100 MG LOSARTAN POTASSIUM JPC JAMP-ZOLMITRIPTAN ODT 2.5 MG ORAL DISPERSIBLE ZOLMITRIPTAN JPC LOSARTAN 25 MG LOSARTAN POTASSIUM SIV LOSARTAN 50 MG LOSARTAN POTASSIUM SIV LOSARTAN 100 MG LOSARTAN POTASSIUM SIV MINT-LOSARTAN 25 MG LOSARTAN POTASSIUM MPI MINT-LOSARTAN 50 MG LOSARTAN POTASSIUM MPI MINT-LOSARTAN 100 MG LOSARTAN POTASSIUM MPI PMS-SALBUTAMOL POLYNEB 2 MG / ML INHALATION UNIT DOSE SOLUTION SALBUTAMOL SULFATE PMS EFFECTIVE APRIL 1,
7 Product(s) with a Price Change, continued SANDOZ LOSARTAN 25 MG LOSARTAN POTASSIUM SDZ SANDOZ LOSARTAN 50 MG LOSARTAN POTASSIUM SDZ SANDOZ LOSARTAN 100 MG LOSARTAN POTASSIUM SDZ TEVA-LOSARTAN 25 MG LOSARTAN POTASSIUM TEV TEVA-LOSARTAN 50 MG LOSARTAN POTASSIUM TEV TEVA-LOSARTAN 100 MG LOSARTAN POTASSIUM TEV TEVA-SALBUTAMOL STERINEBS P.F. 2 MG / ML INHALATION UNIT DOSE SOLUTION SALBUTAMOL SULFATE TEV VAN-PIOGLITAZONE 15 MG PIOGLITAZONE HCL VAN VAN-PIOGLITAZONE 30 MG PIOGLITAZONE HCL VAN VAN-PIOGLITAZONE 45 MG PIOGLITAZONE HCL VAN VAN-ZOLMITRIPTAN ODT 2.5 MG ORAL DISPERSIBLE ZOLMITRIPTAN VAN Discontinued Listing(s) Notification of discontinuation has been received from the manufacturers. The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2018, the listed product(s) will no longer be a benefit and will not be considered for coverage by special authorization. A transition period will be applied and, as of May 1, 2018 claims will no longer pay for these products. ACT BETAHISTINE 16 MG BETAHISTINE DIHYDROCHLORIDE APH ACT ETIDRONATE 200 MG ETIDRONATE DISODIUM APH ACT LOSARTAN 25 MG LOSARTAN POTASSIUM APH ACT LOSARTAN/HCT 100 MG / 12.5 MG LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE APH ARANESP (0.3 / 0.4 / 0.5 ML SYRINGE) 100 MCG INJECTION ARANESP (0.3 / 0.4 / 0.5 / 0.65 ML SYRINGE) 200 MCG INJECTION ARANESP (0.3 / 0.4 / 0.6 / 1.0 ML SYRINGE) 500 MCG INJECTION ARANESP (0.4 ML SYRINGE) 10 MCG INJECTION SYRINGE ARANESP (0.5 ML SYRINGE) 20 MCG INJECTION SYRINGE DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG BENTYLOL 10 MG DICYCLOMINE HCL AXC BENTYLOL 20 MG DICYCLOMINE HCL AXC 4 EFFECTIVE APRIL 1, 2018
8 Discontinued Listing(s), continued CEFPROZIL 250 MG CEFPROZIL RAN CEFPROZIL 500 MG CEFPROZIL RAN CEFZIL 25 MG ORAL SUSPENSION CEFPROZIL BMS CLOXACILLIN SODIUM 500 MG INJECTION CLOXACILLIN SODIUM TEV CLOXACILLIN SODIUM 1 G INJECTION CLOXACILLIN SODIUM TEV CLOXACILLIN SODIUM 2 G INJECTION CLOXACILLIN SODIUM TEV CO LISINOPRIL 10 MG LISINOPRIL APH CO LISINOPRIL 20 MG LISINOPRIL APH CYCLOCORT 0.1% TOPICAL LOTION AMCINONIDE GSK CYCLOCORT 0.1% TOPICAL OINTMENT AMCINONIDE GSK DIPROLENE GLYCOL 0.05 % TOPICAL GLYCOL LOTION BETAMETHASONE DIPROPIONATE MFC FLUCONAZOLE 2 MG INJECTION FLUCONAZOLE TEV LUTERA MCG / 20 MCG LUTERA MCG / 20 MCG LEVONORGESTREL/ ETHINYL ESTRADIOL LEVONORGESTREL/ ETHINYL ESTRADIOL APH APH MINT-RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE MPI MINT-RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE MPI MINT-RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE MPI MINT-RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE MPI MINT-RIZATRIPTAN ODT 5 MG DISINTEGRATING MINT-RIZATRIPTAN ODT 10 MG DISINTEGRATING RIZATRIPTAN BENZOATE MPI RIZATRIPTAN BENZOATE MPI NOVAMILOR 50 MG / 5 MG HYDROCHLOROTHIAZIDE/ AMILORIDE HCL TEV NOVO-CILAZAPRIL 2.5 MG CILAZAPRIL TEV NOVO-CLOBETASOL 0.05% TOPICAL CREAM CLOBETASOL 17-PROPIONATE TEV NOVO-CLOBETASOL 0.05% TOPICAL OINTMENT CLOBETASOL 17-PROPIONATE TEV NOVO-FLURPROFEN 50 MG FLURBIPROFEN TEV NOVO-FLURPROFEN 100 MG FLURBIPROFEN TEV NOVO-HYDROXYZIN 10 MG CAPSULE HYDROXYZINE HCL TEV NOVO-RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE TEV EFFECTIVE APRIL 1,
9 Discontinued Listing(s), continued NOVO-RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE TEV NOVO-RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE TEV NOVO-RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE TEV PEGETRON CLEARCLICK (KIT) 100 MCG / 200 MG INJECTION SYRINGE / CAPSULE PMS-DILTIAZEM CD 240 MG CONTROLLED- DELIVERY CAPSULE PMS-DILTIAZEM CD 300 MG CONTROLLED- DELIVERY CAPSULE PEGINTERFERON ALFA-2B/ RIBAVIRIN MFC DILTIAZEM HCL PMS DILTIAZEM HCL PMS PMS-DORZOLAMIDE-TIMOLOL 2% / 0.5% OPHTHALMIC SOLUTION DORZOLAMIDE HCL/ TIMOLOL MALEATE PMS PMS-HYDROMORPHONE 3 MG RECTAL SUPPOSITORY PMS-KETOPROFEN 100 MG RECTAL SUPPOSITORY PMS-LEVOCARB CR 100 MG / 25 MG SUSTAINED-RELEASE PMS-LEVOCARB CR 200 MG / 50 MG SUSTAINED-RELEASE HYDROMORPHONE HCL PMS KETOPROFEN PMS LEVODOPA/ CARBIDOPA PMS LEVODOPA/ CARBIDOPA PMS PMS-LEVOFLOXACIN 250 MG LEVOFLOXACIN PMS PMS-LEVOFLOXACIN 750 MG LEVOFLOXACIN PMS PMS-PAROXETINE 40 MG PAROXETINE HCL PMS PMS-RISPERIDONE ODT 1 MG DISINTEGRATING PMS-RISPERIDONE ODT 2 MG DISINTEGRATING PMS-RISPERIDONE ODT 3 MG DISINTEGRATING PMS-RISPERIDONE ODT 4 MG DISINTEGRATING RISPERIDONE PMS RISPERIDONE PMS RISPERIDONE PMS RISPERIDONE PMS PREVEX B 0.1% TOPICAL OCCLUSIVE CREAM BETAMETHASONE VALERATE GSK RATIO-ACLAVULANATE 875 MG / 125 MG AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM TEV RATIO-ACYCLOVIR 200 MG ACYCLOVIR TEV RATIO-ACYCLOVIR 400 MG ACYCLOVIR TEV RATIO-ACYCLOVIR 800 MG ACYCLOVIR TEV RATIO-BACLOFEN 20 MG BACLOFEN TEV 6 EFFECTIVE APRIL 1, 2018
10 Discontinued Listing(s), continued RATIO-BUPROPION SR 150 MG SUSTAINED- RELEASE BUPROPION HCL TEV RATIO-CEFUROXIME 250 MG CEFUROXIME AXETIL TEV RATIO-IPRATROPIUM UDV 125 MCG INHALATION UNIT DOSE SOLUTION IPRATROPIUM BROMIDE TEV RATIO-MORPHINE 1 MG ORAL SYRUP MORPHINE HCL TEV RATIO-MORPHINE 5 MG ORAL SYRUP MORPHINE HCL TEV RATIO-MORPHINE 10 MG ORAL SYRUP MORPHINE HCL TEV RATIO-MORPHINE 20 MG ORAL SYRUP MORPHINE HCL TEV RATIO-SALBUTAMOL UNIT DOSE P.F. 0.5 MG INHALATION SOLUTION RECLIPSEN (21 DAY) 0.15 MG / 0.03 MG RECLIPSEN (28 DAY) 0.15 MG / 0.03 MG REMINYL ER 24 MG EXTENDED-RELEASE CAPSULE SALBUTAMOL SULFATE TEV DESOGESTREL/ ETHINYL ESTRADIOL APH DESOGESTREL/ ETHINYL ESTRADIOL APH GALANTAMINE HYDROBROMIDE JAI REQUIP 1 MG ROPINIROLE HCL GSK REQUIP 2 MG ROPINIROLE HCL GSK REQUIP 5 MG ROPINIROLE HCL GSK SINEMET 100 / MG / 10 MG LEVODOPA/ CARBIDOPA MFC SLOW K 8 MEQ SUSTAINED-RELEASE POTASSIUM CHLORIDE (K+) NOV TEGRETOL 100 MG CHEWABLE CARBAMAZEPINE NOV TEGRETOL 200 MG CHEWABLE CARBAMAZEPINE NOV TEVA-TAMSULOSIN 0.4 MG SUSTAINED- RELEASE CAPSULE TAMSULOSIN HCL TEV TEVA-TRIMEL 400 MG / 80 MG SULFAMETHOXAZOLE/ TRIMETHOPRIM TEV TEVA-TRIMEL DS 800 MG / 160 MG SULFAMETHOXAZOLE/ TRIMETHOPRIM TEV VALACYCLOVIR 1000 MG VALACYCLOVIR SIV VANCOMYCIN HYDROCHLORIDE 125 MG CAPSULE VANCOMYCIN HYDROCHLORIDE 250 MG CAPSULE VANCOMYCIN HCL FKC VANCOMYCIN HCL FKC ZANTAC 150 MG RANITIDINE HCL GSK ZANTAC 300 MG RANITIDINE HCL GSK EFFECTIVE APRIL 1,
11 Product(s) Removed from the ADBL as Price Policy Requirements not Satisfied The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2018, the listed product(s) will no longer be a benefit and will not be considered for coverage by special authorization. A transition period will be applied and, as of May 1, 2018 claims will no longer pay for these products. AG-ZOLMITRIPTAN ODT 2.5 MG ORAL DISPERSIBLE ZOLMITRIPTAN AGP ALLERJECT 0.15 MG / SYRINGE INJECTION EPINEPHRINE KAI ALLERJECT 0.3 MG / SYRINGE INJECTION EPINEPHRINE KAI GD-AZITHROMYCIN 20 MG / ML ORAL SUSPENSION AZITHROMYCIN GMD LOSARTAN 25 MG LOSARTAN POTASSIUM SNS LOSARTAN 50 MG LOSARTAN POTASSIUM SNS LOSARTAN 100 MG LOSARTAN POTASSIUM SNS NORFLOX 400 MG NORFLOXACIN AAP ORGARAN 1250 UNIT / ML INJECTION DANAPAROID SODIUM ASN PMS-RAMIPRIL-HCTZ 2.5 MG / 12.5 MG RAMIPRIL/ HYDROCHLOROTHIAZIDE PMS PMS-RAMIPRIL-HCTZ 5 MG / 12.5 MG RAMIPRIL/ HYDROCHLOROTHIAZIDE PMS PMS-RAMIPRIL-HCTZ 5 MG / 25 MG RAMIPRIL/ HYDROCHLOROTHIAZIDE PMS SINEQUAN 10 MG CAPSULE DOXEPIN HCL AAP SINEQUAN 25 MG CAPSULE DOXEPIN HCL AAP SINEQUAN 50 MG CAPSULE DOXEPIN HCL AAP TEVA-ZOLMITRIPTAN OD 2.5 MG ORAL DISPERSIBLE ZOLMITRIPTAN TEV 8 EFFECTIVE APRIL 1, 2018
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