Updates to the Alberta Drug Benefit List. Effective November 1, 2018
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1 Updates to the Alberta Drug Benefit List Effective November 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: 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: ( G.S.T.) Contents only: ( G.S.T.) A cheque or money order must accompany the request for copies. ABC 40211/81160 (R2018/11)
3 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Table of Contents Special Authorization... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit / Special Authorization... 1 Restricted Benefit(s)... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit... 1 Added Product(s)... 1 New Established Interchangeable (IC) Grouping(s)... 2 Product(s) with a Price Change... 3 Discontinued Listing(s)... 3 Part 2 Drug Additions Part 3 Special Authorization EFFECTIVE NOVEMBER 1, 2018
4 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Special Authorization The following drug product(s) will be considered for coverage by Special Authorization for patients covered under Alberta government-sponsored drug programs. Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit / Special Authorization Trade Name / Strength / Form Generic Description DIN MFR MEROPENEM 500 MG INJECTION MEROPENEM MEROPENEM 1 G INJECTION MEROPENEM Restricted Benefit(s) Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit Trade Name / Strength / Form Generic Description DIN MFR A-ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE A-ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE A-ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE A-ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE Added Product(s) Trade Name / Strength / Form Generic Description DIN MFR APO-LANSOPRAZOLE-AMOXICILLIN- CLARITHROMYCIN 30 MG / 500 MG / 500 MG TABLET / CAPSULE LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/ CLARITHROMYCIN APO-SOLIFENACIN 5 MG TABLET SOLIFENACIN SUCCINATE APO-SOLIFENACIN 10 MG TABLET SOLIFENACIN SUCCINATE O-PRAVASTATIN 10 MG TABLET PRAVASTATIN SODIUM O-PRAVASTATIN 20 MG TABLET PRAVASTATIN SODIUM O-PRAVASTATIN 40 MG TABLET PRAVASTATIN SODIUM O-PREGABALIN 25 MG CAPSULE PREGABALIN O-PREGABALIN 50 MG CAPSULE PREGABALIN O-PREGABALIN 75 MG CAPSULE PREGABALIN O-PREGABALIN 150 MG CAPSULE PREGABALIN JAMP-FOSFOMYCIN 3 G ORAL POWDER PACKET FOSFOMYCIN TROMETHAMINE MIDODRINE 2.5 MG TABLET MIDODRINE HCL MIDODRINE 5 MG TABLET MIDODRINE HCL EFFECTIVE NOVEMBER 1,
5 Added Product(s), continued UPDATES TO THE ALBERTA DRUG BENEFIT LIST Trade Name / Strength / Form Generic Description DIN MFR PHARMA-RAMIPRIL (CAPSULE) 1.25 MG CAPSULE / TABLET PHARMA-RAMIPRIL (CAPSULE) 2.5 MG CAPSULE / TABLET PHARMA-RAMIPRIL (CAPSULE) 5 MG CAPSULE / TABLET PHARMA-RAMIPRIL (CAPSULE) 10 MG CAPSULE / TABLET QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET RAMIPRIL RAMIPRIL RAMIPRIL RAMIPRIL QUETIAPINE FUATE QUETIAPINE FUATE QUETIAPINE FUATE QUETIAPINE FUATE QUETIAPINE FUATE A-PREGABALIN 25 MG CAPSULE PREGABALIN A-PREGABALIN 50 MG CAPSULE PREGABALIN A-PREGABALIN 75 MG CAPSULE PREGABALIN A-PREGABALIN 150 MG CAPSULE PREGABALIN A-PREGABALIN 300 MG CAPSULE PREGABALIN New Established Interchangeable (IC) Grouping(s) The following IC Grouping(s) have been established and LCA pricing will be applied effective November 1, Generic Description Strength / Form New LCA Price FOSFOMYCIN TROMETHAMINE 3 G ORAL POWDER PACKET LANSOPRAZOLE/ AMOXICILLIN/ CLARITHROMYCIN 30 MG / 500 MG / 500 MG TABLET / CAPSULE MEROPENEM 500 MG INJECTION MIDODRINE HCL 2.5 MG TABLET MIDODRINE HCL 5 MG TABLET EFFECTIVE NOVEMBER 1, 2018
6 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until November 30, For products within an established IC Grouping, the LCA price may apply. Trade Name / Strength / Form Generic Description DIN MFR MEROPENEM FOR INJECTION USP 1 G INJECTION MEROPENEM STM MIDODRINE 2.5 MG TABLET MIDODRINE HCL AAP MIDODRINE 5 MG TABLET MIDODRINE HCL AAP Discontinued Listing(s) Notification of discontinuation has been received from the manufacturer(s). The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective November 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 December 1, 2018 claims will no longer pay for these product(s). Trade Name / Strength / Form Generic Description DIN MFR ACEBUTOLOL 100 MG TABLET ACEBUTOLOL HCL ACEBUTOLOL 200 MG TABLET ACEBUTOLOL HCL ACEBUTOLOL 400 MG TABLET ACEBUTOLOL HCL APO-IRBESARTAN/HCTZ 300 MG / 25 MG TABLET IRBESARTAN/ HYDROCHLOROTHIAZIDE APO-OFLOXACIN 0.3 % OPHTHALMIC SOLUTION OFLOXACIN APO-REPAGLINIDE 0.5 MG TABLET REPAGLINIDE APO-TELMISARTAN 40 MG TABLET TELMISARTAN FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL FLUOXETINE 20 MG CAPSULE FLUOXETINE HCL MODERIBA 400 MG TABLET RIBAVIRIN ABV MYLAN-CANDESARTAN 32 MG TABLET CANDESARTAN CILEXETIL MYP MYLAN-HYDROXYCHLOROQUINE 200 MG TABLET HYDROXYCHLOROQUINE SULFATE MYP MYLAN-OLANZAPINE 15 MG TABLET OLANZAPINE MYP MYLAN-PANTOPRAZOLE 40 MG ENTERIC- COATED TABLET PANTOPRAZOLE SODIUM MYP MYLAN-ROSUVASTATIN 20 MG TABLET ROSUVASTATIN CALCIUM MYP MYLAN-TELMISARTAN 80 MG TABLET TELMISARTAN MYP MYLAN-VALSARTAN 80 MG TABLET VALSARTAN MYP MYLAN-VALSARTAN 320 MG TABLET VALSARTAN MYP EFFECTIVE NOVEMBER 1,
7 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR MYLAN-VENLAFAXINE XR 150 MG EXTENDED- RELEASE CAPSULE VENLAFAXINE HCL MYP MYLAN-ZOLMITRIPTAN 2.5 MG TABLET ZOLMITRIPTAN MYP NAT-ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM NTP NAT-ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM NTP RATIO-ATORVASTATIN 20 MG TABLET ATORVASTATIN CALCIUM RATIO-ATORVASTATIN 40 MG TABLET ATORVASTATIN CALCIUM RATIO-CIPROFLOXACIN 500 MG TABLET CIPROFLOXACIN HCL SECTRAL 200 MG TABLET ACEBUTOLOL HCL SAV A-DOMPERIDONE 10 MG TABLET DOMPERIDONE MALEATE A-LISINOPRIL (TYPE P) 5 MG TABLET LISINOPRIL A-PRAMIPEXOLE 1.5 MG TABLET PRAMIPEXOLE DIHYDROCHLORIDE A-QUETIAPINE 25 MG TABLET QUETIAPINE FUATE A-QUETIAPINE 200 MG TABLET QUETIAPINE FUATE A-ITIDINE 150 MG TABLET ITIDINE HCL A-ITIDINE 300 MG TABLET ITIDINE HCL EFFECTIVE NOVEMBER 1, 2018
8 Drug Additions PART 2 Drug Additions
9 ALBERTA DRUG BENEFIT LIST UPDATE ARIPIPRAZOLE 2 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE A-ARIPIPRAZOLE ABILIFY OTS ALBERTA HEALTH RESTRICTED BENEFIT This Drug Product is a benefit for patients 13 to 17 years of age inclusive. 5 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE A-ARIPIPRAZOLE ABILIFY OTS ALBERTA HEALTH RESTRICTED BENEFIT This Drug Product is a benefit for patients 13 to 17 years of age inclusive. 10 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE ABILIFY 30 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE -ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE ABILIFY OTS OTS FOSFOMYCIN TROMETHAMINE 3 G (BASE) ORAL POWDER PACKET JAMP-FOSFOMYCIN MONUROL PAL LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/ CLARITHROMYCIN 30 MG * 500 MG (BASE) * 500 MG ORAL TABLET/CAPSULE APO-LANSOPRAZOLE-AMOXICILLIN- CLARITHROMYCIN HP-PAC (KIT) BGP The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 2. 1 EFFECTIVE NOVEMBER 1, 2018
10 ALBERTA DRUG BENEFIT LIST UPDATE MEROPENEM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or Hematology, or a designated prescriber. (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or Hematology, or a designated prescriber.) 500 MG / VIAL INJECTION MEROPENEM MERREM 1 G / VIAL INJECTION MEROPENEM MEROPENEM FOR INJECTION USP MERREM PFI STM PFI MIDODRINE HCL 2.5 MG ORAL TABLET MIDODRINE MIDODRINE 5 MG ORAL TABLET MIDODRINE MIDODRINE AAP AAP PRAVASTATIN SODIUM 10 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN O-PRAVASTATIN JAMP-PRAVASTATIN PRAVASTATIN MINT-PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN SANDOZ PRAVASTATIN A-PRAVASTATIN 20 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN O-PRAVASTATIN JAMP-PRAVASTATIN -PRAVASTATIN MINT-PRAVASTATIN -PRAVASTATIN PRAVASTATIN PRAVASTATIN -PRAVASTATIN SANDOZ PRAVASTATIN TABLETS A-PRAVASTATIN PRAVACHOL APH APH BMS The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. PRODUCT IS NOT INTERCHANGEABLE 2. 2 EFFECTIVE NOVEMBER 1, 2018
11 ALBERTA DRUG BENEFIT LIST UPDATE PRAVASTATIN SODIUM 40 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN O-PRAVASTATIN JAMP-PRAVASTATIN PRAVASTATIN MINT-PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN SANDOZ PRAVASTATIN TABLETS A-PRAVASTATIN PRAVACHOL APH BMS PREGABALIN 25 MG ORAL CAPSULE APO-PREGABALIN O-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN A-PREGABALIN 50 MG ORAL CAPSULE APO-PREGABALIN O-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN A-PREGABALIN 75 MG ORAL CAPSULE APO-PREGABALIN O-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN A-PREGABALIN 150 MG ORAL CAPSULE APO-PREGABALIN O-PREGABALIN MINT-PREGABALIN -PREGABALIN PREGABALIN PREGABALIN -PREGABALIN SANDOZ PREGABALIN A-PREGABALIN The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 2. 3 EFFECTIVE NOVEMBER 1, 2018
12 ALBERTA DRUG BENEFIT LIST UPDATE PREGABALIN 300 MG ORAL CAPSULE APO-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN A-PREGABALIN QUETIAPINE FUATE 50 MG (BASE) ORAL EXTENDED-RELEASE TABLET APO-QUETIAPINE XR QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 150 MG (BASE) ORAL EXTENDED-RELEASE TABLET APO-QUETIAPINE XR QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 200 MG (BASE) ORAL EXTENDED-RELEASE TABLET APO-QUETIAPINE XR QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 300 MG (BASE) ORAL EXTENDED-RELEASE TABLET APO-QUETIAPINE XR QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 400 MG (BASE) ORAL EXTENDED-RELEASE TABLET APO-QUETIAPINE XR QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR AZC AZC AZC AZC AZC The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. PRODUCT IS NOT INTERCHANGEABLE 2. 4 EFFECTIVE NOVEMBER 1, 2018
13 ALBERTA DRUG BENEFIT LIST UPDATE RAMIPRIL 1.25 MG ORAL CAPSULE/TABLET APO-RAMIPRIL (CAPSULE) O-RAMIPRIL (CAPSULE) JAMP-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) PHARMA-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) VAN-RAMIPRIL (CAPSULE) ALTACE (CAPSULE) 2.5 MG ORAL CAPSULE/TABLET APO-RAMIPRIL (CAPSULE) O-RAMIPRIL (CAPSULE) JAMP-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) MINT-RAMIPRIL (CAPSULE) PHARMA-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) A-RAMIPRIL (CAPSULE) VAN-RAMIPRIL (CAPSULE) ALTACE (CAPSULE) 5 MG ORAL CAPSULE/TABLET ACT RAMIPRIL (CAPSULE) APO-RAMIPRIL (CAPSULE) O-RAMIPRIL (CAPSULE) JAMP-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) MINT-RAMIPRIL (CAPSULE) PHARMA-RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) A-RAMIPRIL (CAPSULE) VAN-RAMIPRIL (CAPSULE) ALTACE (CAPSULE) 10 MG ORAL CAPSULE/TABLET APO-RAMIPRIL (CAPSULE) O-RAMIPRIL (CAPSULE) JAMP-RAMIPRIL (CAPSULE) -RAMIPRIL (CAPSULE) MINT-RAMIPRIL (CAPSULE) PHARMA-RAMIPRIL (CAPSULE) -RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) RAMIPRIL (CAPSULE) -RAMIPRIL (CAPSULE) A-RAMIPRIL (CAPSULE) VAN-RAMIPRIL (CAPSULE) ALTACE (CAPSULE) VAN VCL VAN VCL APH VAN VCL VAN VCL The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 2. 5 EFFECTIVE NOVEMBER 1, 2018
14 ALBERTA DRUG BENEFIT LIST UPDATE SOLIFENACIN SUCCINATE 5 MG ORAL TABLET APO-SOLIFENACIN O-SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN MINT-SOLIFENACIN SOLIFENACIN SOLIFENACIN SANDOZ SOLIFENACIN SOLIFENACIN SOLIFENACIN SUCCINATE A-SOLIFENACIN VESICARE 10 MG ORAL TABLET APO-SOLIFENACIN O-SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN MINT-SOLIFENACIN -SOLIFENACIN -SOLIFENACIN SANDOZ SOLIFENACIN SOLIFENACIN SOLIFENACIN SUCCINATE A-SOLIFENACIN VESICARE GMP MDA ASP GMP MDA ASP The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. PRODUCT IS NOT INTERCHANGEABLE 2. 6 EFFECTIVE NOVEMBER 1, 2018
15 Special Authorization PART 3 Special Authorization
16 ALBERTA DRUG BENEFIT LIST UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS MEROPENEM (Refer to Section 1 - Restricted Benefits of the Alberta Drug Benefit List for coverage of the product when prescribed by a Specialist in Infectious Diseases or Hematology, or a designated prescriber.) "1) For second-line therapy of infections due to gram-negative organisms producing inducible beta-lactamases or extended spectrum beta-lactamases where there is resistance to first-line agents or 2) For therapy for infections involving multi-resistant Pseudomonas aeruginosa, where there is documented susceptibility to meropenem or 3) For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."* *Special Authorization is only required when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or Hematology, or a designated prescriber. In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required. 500 MG / VIAL INJECTION MEROPENEM MERREM 1 G / VIAL INJECTION MEROPENEM MEROPENEM FOR INJECTION USP MERREM PFI STM PFI The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. UNIT OF ISSUE - REFER TO PRICE POLICY 3. 1 EFFECTIVE NOVEMBER 1, 2018
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