Updates to the Alberta Drug Benefit List. Effective February 1, 2018

Size: px

Start display at page:

Download "Updates to the Alberta Drug Benefit List. Effective February 1, 2018"

Joseph Heath
6 years ago
Views:

1 Updates to the Alberta Drug Benefit List Effective February 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) 109BWebsite: Hhttp:// 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 (R2018/02)

3 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Table of Contents Drug Product(s) with Changes to Criteria for Coverage... 1 Added Product(s)... 1 New Established Interchangeable (IC) Grouping(s)... 2 Product(s) with a Price Change... 2 Discontinued Listing(s)... 2 Part 2 Drug Additions Part 3 Special Authorization EFFECTIVE FEBRUARY 1, 2018

4 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Drug Product(s) with Changes to Criteria for Coverage Trade Name / Strength / Form Generic Description DIN MFR MEROPENEM FOR INJECTION USP 1G / VIAL INJECTION MEROPENEM STM MERREM 500 MG / VIAL INJECTION MEROPENEM AZC MERREM 1G / VIAL INJECTION MEROPENEM AZC PRIMAXIN 500 MG / 500 MG / VIAL INJECTION IMIPENEM/ CILASTATIN SODIUM MFC Added Product(s) Trade Name / Strength / Form Generic Description DIN MFR ACH-ESCITALOPRAM 10 MG TABLET ESCITALOPRAM AHI ACH-ESCITALOPRAM 20 MG TABLET ESCITALOPRAM AHI APO-PHENYTOIN SODIUM 100 MG CAPSULE PHENYTOIN SODIUM ATENOLOL 50 MG TABLET ATENOLOL SNS ATENOLOL 100 MG TABLET ATENOLOL SNS CCP-CITALOPRAM 20 MG TABLET CITALOPRAM HYDROBROMIDE CEL CCP-CITALOPRAM 40 MG TABLET CITALOPRAM HYDROBROMIDE CEL CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN SNS JAMP-HYDRALAZINE 10 MG TABLET HYDRALAZINE HCL JAMP-HYDRALAZINE 25 MG TABLET HYDRALAZINE HCL JAMP-HYDRALAZINE 50 MG TABLET HYDRALAZINE HCL MINT-CLONIDINE 0.1 MG TABLET CLONIDINE HCL MINT-CLONIDINE 0.2 MG TABLET CLONIDINE HCL MYLAN-PROPAFENONE 150 MG TABLET PROPAFENONE HCL MYP MYLAN-PROPAFENONE 300 MG TABLET PROPAFENONE HCL MYP ODAN-BENZYDAMINE 0.15% ORAL RINSE BENZYDAMINE HCL ODN PANTOPRAZOLE T 40 MG ENTERIC-COATED TABLET RAN-GLICLAZIDE MR 60 MG SUSTAINED- RELEASE TABLET PANTOPRAZOLE MAGNESIUM SNS GLICLAZIDE RAN EFFECTIVE FEBRUARY 1,

5 UPDATES TO THE ALBERTA DRUG BENEFIT LIST New Established Interchangeable (IC) Grouping(s) The following IC Grouping(s) have been established and LCA pricing will be applied effective March 1, Generic Description Strength / Form New LCA Price BENZYDAMINE HCL 0.15% RINSE CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL 0.2 MG TABLET HYDRALAZINE HCL 10 MG TABLET HYDRALAZINE HCL 25 MG TABLET HYDRALAZINE HCL 50 MG TABLET PHENYTOIN SODIUM 100 MG CAPSULE Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until February 28, For products within an established IC Grouping, the LCA price may apply. Trade Name / Strength / Form Generic Description DIN MFR APO-HYDRALAZINE 10 MG TABLET HYDRALAZINE HCL APO-HYDRALAZINE 25 MG TABLET HYDRALAZINE HCL APO-HYDRALAZINE 50 MG TABLET HYDRALAZINE HCL PHARIXIA 0.15% ORAL RINSE BENZYDAMINE HCL PPH TEVA-CLONIDINE 0.1 MG TABLET CLONIDINE HCL TEV TEVA-CLONIDINE 0.2 MG TABLET CLONIDINE HCL TEV XIGDUO 5 MG / 850 MG TABLET XIGDUO 5 MG / 1000 MG TABLET DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE/ METFORMIN HCL DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE/ METFORMIN HCL AZC AZC 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 February 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 March 1, 2018 claims will no longer pay for these product(s). Trade Name / Strength / Form Generic Description DIN MFR ACT EZETIMIBE 10 MG TABLET EZETIMIBE APH ACT IRBESARTAN 75 MG TABLET IRBESARTAN MYP ACT IRBESARTAN 150 MG TABLET IRBESARTAN MYP 2 EFFECTIVE FEBRUARY 1, 2018

6 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR ACT IRBESARTAN 300 MG TABLET IRBESARTAN MYP ACT PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE SODIUM APH ACT RAMIPRIL 2.5 MG CAPSULE RAMIPRIL MYP ACT RAMIPRIL 10 MG CAPSULE RAMIPRIL MYP ACT SERTRALINE 100 MG CAPSULE SERTRALINE HCL APH ACT SIMVASTATIN 10 MG TABLET SIMVASTATIN APH ACT SIMVASTATIN 20 MG TABLET SIMVASTATIN APH ACT SIMVASTATIN 40 MG TABLET SIMVASTATIN APH ACT SIMVASTATIN 80 MG TABLET SIMVASTATIN APH BENTYLOL 10 MG / 5 ML SYRUP DICYCLOMINE HCL AXC CEFZIL 50 MG / ML SUSPENSION CEFPROZIL BMS CEFZIL 250 MG TABLET CEFPROZIL BMS CEFZIL 500 MG TABLET CEFPROZIL BMS CIPROFLOXACIN 250 MG TABLET CIPROFLOXACIN HCL RAN CIPROFLOXACIN 500 MG TABLET CIPROFLOXACIN HCL RAN CIPROFLOXACIN 750 MG TABLET CIPROFLOXACIN HCL RAN CITALOPRAM 20 MG TABLET CITALOPRAM HYDROBROMIDE RAN CITALOPRAM 40 MG TABLET CITALOPRAM HYDROBROMIDE RAN CLAFORAN 1 G / VIAL INJECTION CEFOTAXIME SODIUM SAV CLAFORAN 2 G / VIAL INJECTION CEFOTAXIME SODIUM SAV CLONAZEPAM 0.5 MG TABLET CLONAZEPAM SIV CO FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL APH DEPAKENE 250 MG CAPSULE VALPROIC ACID BGP DILTIAZEM CD 120 MG CONTROLLED- DELIVERY CAPSULE DILTIAZEM CD 180 MG CONTROLLED- DELIVERY CAPSULE DILTIAZEM CD 240 MG CONTROLLED- DELIVERY CAPSULE DILTIAZEM CD 300 MG CONTROLLED- DELIVERY CAPSULE DILTIAZEM HCL SNS DILTIAZEM HCL SNS DILTIAZEM HCL SNS DILTIAZEM HCL SNS EMO-CORT 2.5% TOPICAL CREAM HYDROCORTISONE GSK EFFECTIVE FEBRUARY 1,

7 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR FLAGYSTATIN 100 MG / G / 20,000 UNIT / G VAGINAL CREAM METRONIDAZOLE/ NYSTATIN SAV GABAPENTIN 100 MG CAPSULE GABAPENTIN RAN GABAPENTIN 300 MG CAPSULE GABAPENTIN RAN ISOPTO CARPINE 1% OPHTHALMIC SOLUTION PILOCARPINE HCL ALC K-10 10% 1.33 MEQ / ML LIQUID POTASSIUM CHLORIDE (K+)(CL-) GSK LISINOPRIL 5 MG TABLET LISINOPRIL RAN LISINOPRIL 10 MG TABLET LISINOPRIL RAN LISINOPRIL 20 MG TABLET LISINOPRIL RAN LOTENSIN 5 MG TABLET BENAZEPRIL HCL NOV MAR-GALANTAMINE ER 8 MG EXTENDED- RELEASE CAPSULE MAR-GALANTAMINE ER 16 MG EXTENDED- RELEASE CAPSULE MAR-GALANTAMINE ER 24 MG EXTENDED- RELEASE CAPSULE GALANTAMINE HYDROBROMIDE MAR GALANTAMINE HYDROBROMIDE MAR GALANTAMINE HYDROBROMIDE MAR METROCREAM 0.75% TOPICAL CREAM METRONIDAZOLE GAL MYLAN-ACEBUTOLOL (TYPE S) 400 MG TABLET ACEBUTOLOL HCL MYP MYLAN-CARVEDILOL MG TABLET CARVEDILOL MYP MYLAN-CARVEDILOL 6.25 MG TABLET CARVEDILOL MYP MYLAN-CARVEDILOL 12.5 MG TABLET CARVEDILOL MYP MYLAN-CARVEDILOL 25 MG TABLET CARVEDILOL MYP MYLAN-CIMETIDINE 600 MG TABLET CIMETIDINE MYP MYLAN-CIPROFLOXACIN 750 MG TABLET CIPROFLOXACIN HCL MYP MYLAN-CLONAZEPAM 0.5 MG TABLET CLONAZEPAM MYP MYLAN-FENOFIBRATE MICRO 200 MG CAPSULE FENOFIBRATE MYP MYLAN-FINASTERIDE 5 MG TABLET FINASTERIDE MYP MYLAN-GABAPENTIN 400 MG CAPSULE GABAPENTIN MYP MYLAN-GLICLAZIDE 80 MG TABLET GLICLAZIDE MYP MYLAN-IRBESARTAN 300 MG TABLET IRBESARTAN MYP MYLAN-MONTELUKAST 10 MG TABLET MONTELUKAST SODIUM MYP 4 EFFECTIVE FEBRUARY 1, 2018

8 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR MYLAN-RABEPRAZOLE 10 MG ENTERIC- COATED TABLET MYLAN-RABEPRAZOLE 20 MG ENTERIC- COATED TABLET RABEPRAZOLE SODIUM MYP RABEPRAZOLE SODIUM MYP MYLAN-RISEDRONATE 35 MG TABLET RISEDRONATE SODIUM MYP MYLAN-SELEGILINE 5 MG TABLET SELEGILINE HCL MYP NEXT CHOICE 0.75 MG TABLET LEVONORGESTREL MYP ORTHO 0.5 / 35 (21 DAY) 0.5 MG / MG TABLET ORTHO 0.5 / 35 (28 DAY) 0.5 MG / MG TABLET ORTHO 1 / 35 (21 DAY) 1 MG / MG TABLET ORTHO 1 / 35 (28 DAY) 1 MG / MG TABLET ORTHO 7 / 7 / 7 (21 DAY) 0.5 MG / MG / 0.75 MG / MG / 1 MG / MG TABLET ORTHO 7 / 7 / 7 (28 DAY) 0.5 MG / MG / 0.75 MG / MG / 1 MG / MG TABLET NORETHINDRONE/ ETHINYL ESTRADIOL NORETHINDRONE/ ETHINYL ESTRADIOL NORETHINDRONE/ ETHINYL ESTRADIOL NORETHINDRONE/ ETHINYL ESTRADIOL NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL JAI JAI JAI JAI JAI JAI PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE SODIUM SIV PEGASYS RBV (KIT) 180 MCG / 200 MCG INJECTION SYRINGE / TABLET PEGINTERFERON ALFA-2A/ RIBAVIRIN HLR PERCOCET-DEMI 2.5 MG / 325 MG TABLET OXYCODONE HCL/ ACETAMINOPHEN BMS PERCOCET 5 MG / 325 MG TABLET OXYCODONE HCL/ ACETAMINOPHEN BMS PLAN B 0.75 MG TABLET LEVONORGESTREL PAL PRAVASTATIN 10 MG TABLET PRAVASTATIN SODIUM RAN PRAVASTATIN 20 MG TABLET PRAVASTATIN SODIUM RAN PRAVASTATIN 40 MG TABLET PRAVASTATIN SODIUM RAN RAMIPRIL 1.25 MG CAPSULE RAMIPRIL RAN RAMIPRIL 2.5 MG CAPSULE RAMIPRIL RAN RAMIPRIL 5 MG CAPSULE RAMIPRIL RAN EFFECTIVE FEBRUARY 1,

9 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR RAMIPRIL 10 MG CAPSULE RAMIPRIL RAN RATIO-ACLAVULANATE 500 MG / 125 MG TABLET AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM TEV RATIO-AMCINONIDE 0.1% TOPICAL CREAM AMCINONIDE TEV RATIO-AMCINONIDE 0.1 % TOPICAL LOTION AMCINONIDE TEV RATIO-AMCINONIDE 0.1 % TOPICAL OINTMENT AMCINONIDE TEV RATIO-ATENOLOL 50 MG TABLET ATENOLOL TEV RATIO-ATENOLOL 100 MG TABLET ATENOLOL TEV RATIO-ATORVASTATIN 80 MG TABLET ATORVASTATIN CALCIUM TEV RATIO-DEXAMETHASONE 0.5 MG TABLET DEXAMETHASONE TEV RATIO-DEXAMETHASONE 4 MG TABLET DEXAMETHASONE TEV REMINYL ER 8 MG EXTENDED-RELEASE CAPSULE REMINYL ER 16 MG EXTENDED-RELEASE CAPSULE RISPERDAL M-TAB 0.5 MG ORAL DISINTEGRATING TABLET RISPERDAL M-TAB 1 MG ORAL DISINTEGRATING TABLET RISPERDAL M-TAB 2 MG ORAL DISINTEGRATING TABLET GALANTAMINE HYDROBROMIDE JAI GALANTAMINE HYDROBROMIDE JAI RISPERIDONE JAI RISPERIDONE JAI RISPERIDONE JAI RISPERIDONE 0.25 MG TABLET RISPERIDONE RAN RISPERIDONE 0.5 MG TABLET RISPERIDONE RAN RISPERIDONE 1 MG TABLET RISPERIDONE RAN RISPERIDONE 2 MG TABLET RISPERIDONE RAN RISPERIDONE 3 MG TABLET RISPERIDONE RAN RISPERIDONE 4 MG TABLET RISPERIDONE RAN ROPINIROLE 0.25 MG TABLET ROPINIROLE HCL RAN ROPINIROLE 1 MG TABLET ROPINIROLE HCL RAN ROPINIROLE 2 MG TABLET ROPINIROLE HCL RAN ROPINIROLE 5 MG TABLET ROPINIROLE HCL RAN SEROPHENE 50 MG TABLET CLOMIPHENE CITRATE SRO SIMVASTATIN 5 MG TABLET SIMVASTATIN RAN 6 EFFECTIVE FEBRUARY 1, 2018

10 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR SIMVASTATIN 10 MG TABLET SIMVASTATIN RAN SIMVASTATIN 20 MG TABLET SIMVASTATIN RAN SIMVASTATIN 40 MG TABLET SIMVASTATIN RAN SIMVASTATIN 80 MG TABLET SIMVASTATIN RAN SOTALOL 80 MG TABLET SOTALOL HCL SIV SOTALOL 160 MG TABLET SOTALOL HCL SIV SUNVEPRA 100 MG CAPSULE ASUNAPREVIR BMS TEVA-ALENDRONATE 10 MG TABLET ALENDRONATE SODIUM TEV TEVA-DORZOTIMOL 2% / 0.5% OPHTHALMIC SOLUTION DORZOLAMIDE HCL/ TIMOLOL MALEATE TEV TOBRAMYCIN USP 40 MG / ML INJECTION TOBRAMYCIN SULFATE MYP VOLTAREN 100 MG RECTAL SUPPOSITORY DICLOFENAC SODIUM NOV EFFECTIVE FEBRUARY 1,

11 Drug Additions PART 2 Drug Additions

12 ALBERTA DRUG BENEFIT LIST UPDATE ATENOLOL 50 MG ORAL TABLET ACT ATENOLOL APO-ATENOL ATENOLOL ATENOLOL JAMP-ATENOLOL MAR-ATENOLOL MINT-ATENOL MYLAN-ATENOLOL PMS-ATENOLOL RAN-ATENOLOL SEPTA-ATENOLOL TENORMIN 100 MG ORAL TABLET ACT ATENOLOL APO-ATENOL ATENOLOL ATENOLOL JAMP-ATENOLOL MAR-ATENOLOL MINT-ATENOL MYLAN-ATENOLOL PMS-ATENOLOL RAN-ATENOLOL SEPTA-ATENOLOL TENORMIN APH SIV SNS MAR MYP PMS RAN SEP AZC APH SIV SNS MAR MYP PMS RAN SEP AZC BENZYDAMINE HCL 0.15 % ORAL RINSE ODAN-BENZYDAMINE PHARIXIA ODN PPH 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 FEBRUARY 1, 2018

13 ALBERTA DRUG BENEFIT LIST UPDATE CITALOPRAM HYDROBROMIDE 20 MG (BASE) ORAL TABLET ACCEL-CITALOPRAM ACT CITALOPRAM APO-CITALOPRAM AURO-CITALOPRAM CCP-CITALOPRAM CITALOPRAM CITALOPRAM CITALOPRAM JAMP-CITALOPRAM MAR-CITALOPRAM MINT-CITALOPRAM MINT-CITALOPRAM MYLAN-CITALOPRAM NAT-CITALOPRAM PMS-CITALOPRAM RAN-CITALO SANDOZ CITALOPRAM SEPTA-CITALOPRAM TEVA-CITALOPRAM VAN-CITALOPRAM CELEXA 40 MG (BASE) ORAL TABLET ACCEL-CITALOPRAM ACT CITALOPRAM APO-CITALOPRAM AURO-CITALOPRAM CCP-CITALOPRAM CITALOPRAM CITALOPRAM CITALOPRAM JAMP-CITALOPRAM MAR-CITALOPRAM MINT-CITALOPRAM MINT-CITALOPRAM MYLAN-CITALOPRAM NAT-CITALOPRAM PMS-CITALOPRAM RAN-CITALO SANDOZ CITALOPRAM SEPTA-CITALOPRAM TEVA-CITALOPRAM VAN-CITALOPRAM CELEXA ACP APH AUR CEL SNS SIV MAR MYP NTP PMS RAN SDZ SEP TEV VAN LBC ACP APH AUR CEL SNS SIV MAR MYP NTP PMS RAN SDZ SEP TEV VAN LBC CLARITHROMYCIN 250 MG ORAL TABLET CLARITHROMYCIN CLARITHROMYCIN PMS-CLARITHROMYCIN RAN-CLARITHROMYCIN SANDOZ CLARITHROMYCIN TEVA-CLARITHROMYCIN BIAXIN BID SIV SNS PMS RAN SDZ TEV BGP 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 FEBRUARY 1, 2018

14 ALBERTA DRUG BENEFIT LIST UPDATE CLONIDINE HCL 0.1 MG ORAL TABLET MINT-CLONIDINE TEVA-CLONIDINE 0.2 MG ORAL TABLET MINT-CLONIDINE TEVA-CLONIDINE TEV TEV ESCITALOPRAM 10 MG ORAL TABLET ACH-ESCITALOPRAM ACT ESCITALOPRAM APO-ESCITALOPRAM AURO-ESCITALOPRAM ESCITALOPRAM ESCITALOPRAM JAMP-ESCITALOPRAM MAR-ESCITALOPRAM MINT-ESCITALOPRAM MYLAN-ESCITALOPRAM NAT-ESCITALOPRAM PMS-ESCITALOPRAM RAN-ESCITALOPRAM SANDOZ ESCITALOPRAM TEVA-ESCITALOPRAM CIPRALEX 20 MG ORAL TABLET ACH-ESCITALOPRAM ACT ESCITALOPRAM APO-ESCITALOPRAM AURO-ESCITALOPRAM ESCITALOPRAM ESCITALOPRAM JAMP-ESCITALOPRAM MAR-ESCITALOPRAM MINT-ESCITALOPRAM MYLAN-ESCITALOPRAM NAT-ESCITALOPRAM PMS-ESCITALOPRAM RAN-ESCITALOPRAM SANDOZ ESCITALOPRAM TEVA-ESCITALOPRAM CIPRALEX AHI APH AUR SIV SNS MAR MYP NTP PMS RAN SDZ TEV LBC AHI APH AUR SIV SNS MAR MYP NTP PMS RAN SDZ TEV LBC GLICLAZIDE 60 MG ORAL SUSTAINED-RELEASE TABLET APO-GLICLAZIDE MR MINT-GLICLAZIDE MR RAN-GLICLAZIDE MR SANDOZ GLICLAZIDE MR DIAMICRON MR RAN SDZ SEV HYDRALAZINE HCL 10 MG ORAL TABLET APO-HYDRALAZINE JAMP-HYDRALAZINE 25 MG ORAL TABLET APO-HYDRALAZINE JAMP-HYDRALAZINE 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 EFFECTIVE FEBRUARY 1, 2018

15 ALBERTA DRUG BENEFIT LIST UPDATE HYDRALAZINE HCL 50 MG ORAL TABLET APO-HYDRALAZINE JAMP-HYDRALAZINE IMIPENEM/ CILASTATIN SODIUM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases 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 a designated prescriber.) 500 MG / VIAL * 500 MG / VIAL (BASE) INJECTION PRIMAXIN MFC MEROPENEM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases 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 a designated prescriber.) 500 MG / VIAL INJECTION MERREM 1 G / VIAL INJECTION MEROPENEM FOR INJECTION USP MERREM AZC STM AZC PANTOPRAZOLE MAGNESIUM 40 MG ORAL ENTERIC-COATED TABLET MYLAN-PANTOPRAZOLE T PANTOPRAZOLE MAGNESIUM PANTOPRAZOLE T TEVA-PANTOPRAZOLE MAGNESIUM TECTA MYP ALH SNS TEV TAK PHENYTOIN SODIUM 100 MG ORAL CAPSULE APO-PHENYTOIN SODIUM DILANTIN PFI PROPAFENONE HCL 150 MG ORAL TABLET APO-PROPAFENONE MYLAN-PROPAFENONE RYTHMOL 300 MG ORAL TABLET APO-PROPAFENONE MYLAN-PROPAFENONE RYTHMOL MYP BGP MYP BGP 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 FEBRUARY 1, 2018

16 Special Authorization PART 3 Special Authorization

17 ALBERTA DRUG BENEFIT LIST UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS IMIPENEM/ CILASTATIN SODIUM (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 a designated prescriber.) "For the treatment of: 1) Second-line therapy of intra-abdominal sepsis where there is failure of first-line therapy (e.g. ampicillin + gentamicin + metronidazole), as defined by clinical deterioration after 72 h of antibiotic therapy or lack of improvement after completion of antibiotic therapy or 2) Second-line therapy of severe polymicrobial skin and skin structure infections (e.g. limb threatening diabetic foot) or 3) Empiric therapy of mixed synergistic necrotizing gangrene (Fournier's gangrene) or 4) Therapy of severe ventilator-associated pneumonia where Pseudomonas and Staphylococcus aureus coverage is needed or 5) Second-line therapy of infections due to gram-negative organisms producing inducible betalactamases, or extended spectrum beta-lactamases where there is resistance to first-line agents or 6) 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 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 * 500 MG / VIAL (BASE) INJECTION PRIMAXIN MFC 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 FEBRUARY 1, 2018

18 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 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 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 MERREM 1 G / VIAL INJECTION MEROPENEM FOR INJECTION USP MERREM AZC STM 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 3. 2 EFFECTIVE FEBRUARY 1, 2018

Updates to the Alberta Drug Benefit List. Effective November 1, 2018

Updates to the Alberta Drug Benefit List Effective November 1, 2018 Inquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780)