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

Transcription

1 Updates to the Alberta Drug Benefit List Effective September 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 (R2018/09)

3 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Table of Contents Special Authorization... 1 New Drug Product(s) Available by Special Authorization... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit / Special Authorization... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Step Therapy / Special Authorization... 1 Drug Product(s) with Changes to Criteria for Coverage... 1 Restricted Benefit(s)... 1 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit... 1 Added Product(s)... 2 New Established Interchangeable (IC) Grouping (s)... 4 Least Cost Alternative (LCA) Price Change(s)... 5 Product(s) with a Price Change... 5 Discontinued Listing(s)... 6 Part 2 Drug Additions Part 3 Special Authorization EFFECTIVE SEPTEMBER 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. New Drug Product(s) Available by Special Authorization PROCYSBI 25 MG DELAYED-RELEASE CAPSULE PROCYSBI 50 MG DELAYED-RELEASE CAPSULE CYSTEAMINE BITARTRATE RAP CYSTEAMINE BITARTRATE RAP Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit / Special Authorization APO-VARENICLINE (STARTER PACK) 0.5 MG / 1 MG TABLET VARENICLINE TARTRATE/ VARENICLINE TARTRATE Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Step Therapy / Special Authorization -SOLIFENACIN 10 MG TABLET SOLIFENACIN SUCCINATE Drug Product(s) with Changes to Criteria for Coverage DIFICID 200 MG TABLET FIDAXOMICIN MFC Restricted Benefit(s) Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit O-ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE O-ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE JAMP-ENTECAVIR 0.5 MG TABLET ENTECAVIR JPC NAT-TENOFOVIR 300 MG TABLET TENOFOVIR DISOPROXIL FUMARATE NTP -ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE EFFECTIVE SEPTEMBER 1,

5 Added Product(s) UPDATES TO THE ALBERTA DRUG BENEFIT LIST APO-PREGABALIN 25 MG CAPSULE PREGABALIN APO-PREGABALIN 50 MG CAPSULE PREGABALIN APO-PREGABALIN 75 MG CAPSULE PREGABALIN APO-PREGABALIN 150 MG CAPSULE PREGABALIN APO-PREGABALIN 300 MG CAPSULE PREGABALIN APO-QUETIAPINE XR 50 MG APO-QUETIAPINE XR 150 MG APO-QUETIAPINE XR 200 MG APO-QUETIAPINE XR 300 MG APO-QUETIAPINE XR 400 MG QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE O-ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE O-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE O-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE O-ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE O-CANDESARTAN 8 MG TABLET CANDESARTAN CILEXETIL MAR-DILTIAZEM T 120 MG EXTENDED-RELEASE CAPSULE MAR-DILTIAZEM T 180 MG EXTENDED-RELEASE CAPSULE MAR-DILTIAZEM T 240 MG EXTENDED-RELEASE CAPSULE MAR-DILTIAZEM T 300 MG EXTENDED-RELEASE CAPSULE MAR-DILTIAZEM T 360 MG EXTENDED-RELEASE CAPSULE MED-LATANOPROST % OPHTHALMIC SOLUTION DILTIAZEM HCL MAR DILTIAZEM HCL MAR DILTIAZEM HCL MAR DILTIAZEM HCL MAR DILTIAZEM HCL MAR LATANOPROST GMP MINT-PREGABALIN 25 MG CAPSULE PREGABALIN MPI MINT-PREGABALIN 50 MG CAPSULE PREGABALIN MPI MINT-PREGABALIN 75 MG CAPSULE PREGABALIN MPI MINT-PREGABALIN 150 MG CAPSULE PREGABALIN MPI PHARMA-SIMVASTATIN 10 MG TABLET SIMVASTATIN EFFECTIVE SEPTEMBER 1, 2018

6 Added Product(s), continued UPDATES TO THE ALBERTA DRUG BENEFIT LIST -ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE LACTULOSE-PHARMA 667 MG / ML ORAL SYRUP -NITROFUTOIN 100 MG CAPSULE (MACROCRYSTALS / MONOHYDRATE) LACTULOSE NITROFUTOIN PREGABALIN 25 MG CAPSULE PREGABALIN PREGABALIN 50 MG CAPSULE PREGABALIN PREGABALIN 75 MG CAPSULE PREGABALIN PREGABALIN 150 MG CAPSULE PREGABALIN PREGABALIN 300 MG CAPSULE PREGABALIN TDOLAPRIL 0.5 MG CAPSULE TDOLAPRIL TDOLAPRIL 1 MG CAPSULE TDOLAPRIL TDOLAPRIL 2 MG CAPSULE TDOLAPRIL TDOLAPRIL 4 MG CAPSULE TDOLAPRIL PREGABALIN 25 MG CAPSULE PREGABALIN SIV PREGABALIN 25 MG CAPSULE PREGABALIN PREGABALIN 50 MG CAPSULE PREGABALIN SIV PREGABALIN 50 MG CAPSULE PREGABALIN PREGABALIN 75 MG CAPSULE PREGABALIN SIV PREGABALIN 75 MG CAPSULE PREGABALIN PREGABALIN 150 MG CAPSULE PREGABALIN SIV PREGABALIN 150 MG CAPSULE PREGABALIN PREGABALIN 300 MG CAPSULE PREGABALIN SIV PREGABALIN 300 MG CAPSULE PREGABALIN PREGABALIN 25 MG CAPSULE PREGABALIN PREGABALIN 50 MG CAPSULE PREGABALIN PREGABALIN 75 MG CAPSULE PREGABALIN PREGABALIN 150 MG CAPSULE PREGABALIN PREGABALIN 300 MG CAPSULE PREGABALIN RAMIPRIL HCTZ 2.5 MG / 12.5 MG TABLET RAMIPRIL/ HYDROCHLOROTHIAZIDE RAMIPRIL HCTZ 5 MG / 25 MG TABLET RAMIPRIL/ HYDROCHLOROTHIAZIDE EFFECTIVE SEPTEMBER 1,

7 Added Product(s), continued UPDATES TO THE ALBERTA DRUG BENEFIT LIST SANDOZ ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE SANDOZ PRAVASTATIN 10 MG TABLET PRAVASTATIN SODIUM SANDOZ PRAVASTATIN 20 MG TABLET PRAVASTATIN SODIUM SANDOZ PRAVASTATIN 40 MG TABLET PRAVASTATIN SODIUM SANDOZ PREGABALIN 25 MG CAPSULE PREGABALIN SANDOZ PREGABALIN 50 MG CAPSULE PREGABALIN SANDOZ PREGABALIN 75 MG CAPSULE PREGABALIN SANDOZ PREGABALIN 150 MG CAPSULE PREGABALIN SANDOZ PREGABALIN 300 MG CAPSULE PREGABALIN SANDOZ TDOLAPRIL 0.5 MG CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL 1 MG CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL 2 MG CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL 4 MG CAPSULE TDOLAPRIL A-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE A-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE New Established Interchangeable (IC) Grouping(s) The following IC Grouping(s) have been established and LCA pricing will be applied effective October 1, Generic Description Strength / Form New LCA Price NITROFUTOIN 100 MG CAPSULE (MACROCRYSTALS / MONOHYDRATE) PREGABALIN 25 MG CAPSULE PREGABALIN 50 MG CAPSULE PREGABALIN 75 MG CAPSULE PREGABALIN 150 MG CAPSULE PREGABALIN 300 MG CAPSULE RAMIPRIL/ HYDROCHLOROTHIAZIDE 2.5 MG / 12.5 MG TABLET RAMIPRIL/ HYDROCHLOROTHIAZIDE 5 MG / 25 MG TABLET TDOLAPRIL 0.5 MG CAPSULE TDOLAPRIL 1 MG CAPSULE TDOLAPRIL 2 MG CAPSULE EFFECTIVE SEPTEMBER 1, 2018

8 UPDATES TO THE ALBERTA DRUG BENEFIT LIST New Established Interchangeable (IC) Grouping(s), continued The following IC Grouping(s) have been established and LCA pricing will be applied effective October 1, Generic Description Strength / Form New LCA Price TDOLAPRIL 4 MG CAPSULE VARENICLINE TARTRATE/ VARENICLINE TARTRATE 0.5 MG / 1 MG TABLET 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 October 1, Please review the online Alberta Drug Benefit List at for further information. Generic Description Strength / Form New LCA Price ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 30 MG TABLET QUETIAPINE FUMARATE 50 MG QUETIAPINE FUMARATE 150 MG QUETIAPINE FUMARATE 200 MG QUETIAPINE FUMARATE 300 MG QUETIAPINE FUMARATE 400 MG Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until September 30, For products within an established IC Grouping, the LCA price may apply. APO-ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE APO-ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE APO-ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE APO-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE APO-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE APO-ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE EFFECTIVE SEPTEMBER 1,

9 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Product(s) with a Price Change, continued CLINDOXYL ADV 1 % / 3 % TOPICAL GEL CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE GSK SANDOZ QUETIAPINE XRT 50 MG SANDOZ QUETIAPINE XRT 150 MG SANDOZ QUETIAPINE XRT 200 MG SANDOZ QUETIAPINE XRT 300 MG SANDOZ QUETIAPINE XRT 400 MG A-QUETIAPINE XR 50 MG A-QUETIAPINE XR 150 MG A-QUETIAPINE XR 200 MG A-QUETIAPINE XR 300 MG A-QUETIAPINE XR 400 MG QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE 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 September 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 October 1, 2018 claims will no longer pay for these product(s). ACT IRBESARTAN / HCT 150 MG / 12.5 MG TABLET IRBESARTAN/ HYDROCHLOROTHIAZIDE APH ACT ROSUVASTATIN 20 MG TABLET ROSUVASTATIN CALCIUM APH ACT ZOPICLONE 5 MG TABLET ZOPICLONE APH APO-FENTANYL 50 (50 MCG / HR) TSDERMAL PATCH APO-FENTANYL 75 (75 MCG / HR) TSDERMAL PATCH APO-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET FENTANYL FENTANYL RABEPRAZOLE SODIUM MYLAN-ACEBUTOLOL 100 MG TABLET ACEBUTOLOL HCL MYP 6 EFFECTIVE SEPTEMBER 1, 2018

10 UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued MYLAN-ACEBUTOLOL 200 MG TABLET ACEBUTOLOL HCL MYP MYLAN-ACEBUTOLOL 400 MG TABLET ACEBUTOLOL HCL MYP MYLAN-TELMISARTAN 40 MG TABLET TELMISARTAN MYP EFFECTIVE SEPTEMBER 1,

11 Drug Additions PART 2 Drug Additions

12 ALBERTA DRUG BENEFIT LIST UPDATE ARIPIPRAZOLE 2 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ 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 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 15 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE A-ARIPIPRAZOLE ABILIFY 20 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE A-ARIPIPRAZOLE ABILIFY 30 MG ORAL TABLET APO-ARIPIPRAZOLE O-ARIPIPRAZOLE -ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE ABILIFY OTS OTS OTS OTS 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 SEPTEMBER 1, 2018

13 ALBERTA DRUG BENEFIT LIST UPDATE CANDESARTAN CILEXETIL 8 MG ORAL TABLET ACT CANDESARTAN APO-CANDESARTAN O-CANDESARTAN CANDESARTAN CANDESARTAN CANDESARTAN CILEXETIL JAMP-CANDESARTAN MYLAN-CANDESARTAN CANDESARTAN CANDESARTAN SANDOZ CANDESARTAN A-CANDESARTAN ATACAND APH SIV AHI JPC MYP AZC DILTIAZEM HCL 120 MG ORAL EXTENDED-RELEASE CAPSULE ACT DILTIAZEM T MAR-DILTIAZEM T SANDOZ DILTIAZEM T A-DILTIAZEM HCL ER TIAZAC 180 MG ORAL EXTENDED-RELEASE CAPSULE ACT DILTIAZEM T MAR-DILTIAZEM T SANDOZ DILTIAZEM T A-DILTIAZEM HCL ER TIAZAC 240 MG ORAL EXTENDED-RELEASE CAPSULE ACT DILTIAZEM T MAR-DILTIAZEM T SANDOZ DILTIAZEM T A-DILTIAZEM HCL ER TIAZAC 300 MG ORAL EXTENDED-RELEASE CAPSULE ACT DILTIAZEM T MAR-DILTIAZEM T SANDOZ DILTIAZEM T A-DILTIAZEM HCL ER TIAZAC 360 MG ORAL EXTENDED-RELEASE CAPSULE ACT DILTIAZEM T MAR-DILTIAZEM T SANDOZ DILTIAZEM T A-DILTIAZEM HCL ER TIAZAC APH MAR VTC VCL APH MAR VTC VCL APH MAR VTC VCL APH MAR VTC VCL APH MAR VTC VCL ENTECAVIR RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. 0.5 MG ORAL TABLET APO-ENTECAVIR O-ENTECAVIR JAMP-ENTECAVIR ENTECAVIR BARACLUDE JPC 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 SEPTEMBER 1, 2018

14 ALBERTA DRUG BENEFIT LIST UPDATE LACTULOSE 667 MG / ML ORAL SYRUP APO-LACTULOSE JAMP-LACTULOSE LACTULOSE LACTULOSE LACTULOSE-PHARMA RATIO-LACTULOSE A-LACTULOSE JPC LATANOPROST % OPHTHALMIC SOLUTION APO-LATANOPROST CO LATANOPROST GD-LATANOPROST MED-LATANOPROST SANDOZ LATANOPROST XALATAN APH GMD GMP PFI NITROFUTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE) NITROFUTOIN MACROBID ASC PRAVASTATIN SODIUM 10 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN JAMP-PRAVASTATIN MAR-PRAVASTATIN MINT-PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN SANDOZ PRAVASTATIN TABLETS A-PRAVASTATIN 20 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN JAMP-PRAVASTATIN MAR-PRAVASTATIN MINT-PRAVASTATIN -PRAVASTATIN PRAVASTATIN PRAVASTATIN -PRAVASTATIN SANDOZ PRAVASTATIN TABLETS A-PRAVASTATIN PRAVACHOL APH JPC MAR MPI SIV APH JPC MAR MPI SIV BMS 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 SEPTEMBER 1, 2018

15 ALBERTA DRUG BENEFIT LIST UPDATE PRAVASTATIN SODIUM 40 MG ORAL TABLET ACT PRAVASTATIN APO-PRAVASTATIN JAMP-PRAVASTATIN MAR-PRAVASTATIN MINT-PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN PRAVASTATIN SANDOZ PRAVASTATIN TABLETS A-PRAVASTATIN PRAVACHOL APH JPC MAR MPI SIV BMS PREGABALIN 25 MG ORAL CAPSULE APO-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN 50 MG ORAL CAPSULE APO-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN 75 MG ORAL CAPSULE APO-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN 150 MG ORAL CAPSULE APO-PREGABALIN MINT-PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN SANDOZ PREGABALIN 300 MG ORAL CAPSULE APO-PREGABALIN -PREGABALIN PREGABALIN PREGABALIN -PREGABALIN SANDOZ PREGABALIN MPI SIV MPI SIV MPI SIV MPI SIV SIV 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 SEPTEMBER 1, 2018

16 ALBERTA DRUG BENEFIT LIST UPDATE QUETIAPINE FUMARATE 50 MG (BASE) ORAL APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 150 MG (BASE) ORAL APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 200 MG (BASE) ORAL APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 300 MG (BASE) ORAL APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR 400 MG (BASE) ORAL APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR AZC AZC AZC AZC AZC RAMIPRIL/ HYDROCHLOROTHIAZIDE 2.5 MG * 12.5 MG ORAL TABLET RAMIPRIL HCTZ ALTACE HCT 5 MG * 25 MG ORAL TABLET RAMIPRIL HCTZ ALTACE HCT VCL VCL SIMVASTATIN 10 MG ORAL TABLET APO-SIMVASTATIN O-SIMVASTATIN JAMP-SIMVASTATIN MAR-SIMVASTATIN MINT-SIMVASTATIN MYLAN-SIMVASTATIN PHARMA-SIMVASTATIN SIMVASTATIN SIMVASTATIN SIMVASTATIN SIMVASTATIN A-SIMVASTATIN ZOCOR JPC MAR MPI MYP SIV 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 2. 5 EFFECTIVE SEPTEMBER 1, 2018

17 ALBERTA DRUG BENEFIT LIST UPDATE TENOFOVIR DISOPROXIL FUMARATE RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. 300 MG (BASE) ORAL TABLET APO-TENOFOVIR O-TENOFOVIR MYLAN-TENOFOVIR DISOPROXIL NAT-TENOFOVIR TENOFOVIR A-TENOFOVIR VIREAD MYP NTP GIL TDOLAPRIL 0.5 MG ORAL CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL MAVIK 1 MG ORAL CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL MAVIK 2 MG ORAL CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL MAVIK 4 MG ORAL CAPSULE TDOLAPRIL SANDOZ TDOLAPRIL MAVIK BGP BGP BGP BGP VARENICLINE TARTRATE/ VARENICLINE TARTRATE RESTRICTED BENEFIT - This product is a benefit in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Coverage will be granted for a total of 12 weeks. 0.5 MG * 1 MG ORAL TABLET APO-VARENICLINE (STARTER PACK) CHAMPIX (STARTER PACK) PFI 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 SEPTEMBER 1, 2018

18 Special Authorization PART 3 Special Authorization

19 ALBERTA DRUG BENEFIT LIST UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE "For the treatment of severe acne as defined by scarring acne. Special Authorization may be granted for 6 months." The following product(s) are eligible for auto-renewal. 1 % * 3 % TOPICAL GEL CLINDOXYL ADV GSK CYSTEAMINE BITARTRATE "For use in patients with an established diagnosis of infantile nephropathic cystinosis with documented cystinosin, lysosomal cystine transporter gene mutation. For coverage, this drug must be prescribed by or in consultation with physician with experience in the diagnosis and management of cystinosis. Special authorization may be granted for 12 months." This product is eligible for auto-renewal. 25 MG ORAL DELAYED-RELEASE CAPSULE PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE PROCYSBI RAP RAP FIDAXOMICIN For the treatment of: 1) C. difficile infection (CDI) where the patient has failed, or is intolerant of oral vancomycin; or 2) Patients with third or greater recurrence of CDI (i.e. 4th or greater episode of CDI) Note: - Fidaxomicin should not be used as an add-on to existing therapy (metronidazole or vancomycin). - Not studied in multiple recurrences or those with life-threatening or fulminant CDI, toxic megacolon, or inflammatory bowel disease. Special authorization coverage for fidaxomicin will be provided for one treatment course (10 days) plus one additional treatment course for an early relapse occurring within 8 weeks of the start of the most recent fidaxomicin course. New episode of CDI after 8 weeks will require treatment with first line therapy before fidaxomicin coverage may be considered. All requests (including renewal requests) for fidaxomicin must be completed using the Fidaxomicin Special Authorization Request Form (ABC 60014). 200 MG ORAL TABLET DIFICID 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 SEPTEMBER 1, 2018

20 ALBERTA DRUG BENEFIT LIST UPDATE CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS SOLIFENACIN SUCCINATE The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process. FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN "For patients who are intolerant to oxybutynin. Special authorization may be granted for 24 months." Note: If a claim for the Step therapy drug product is rejected, pharmacists can use their professional judgment to determine the appropriateness of using the intervention code(s) noted below to re-submit a claim. The pharmacist is responsible to document on the patient's record the rationale for using the second-line therapy drug. UP - First-line therapy ineffective UQ - First-line therapy not tolerated 10 MG ORAL TABLET O-SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN MINT-SOLIFENACIN -SOLIFENACIN -SOLIFENACIN SANDOZ SOLIFENACIN SOLIFENACIN SOLIFENACIN SUCCINATE A-SOLIFENACIN VESICARE JPC GMP MPI MDA ASP VARENICLINE TARTRATE/ VARENICLINE TARTRATE For subsequent prescriptions, patients may obtain this product via special authorization with the following criteria for coverage: "For use in patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counseling. Special authorization coverage may be granted for a maximum of 24 weeks of therapy per year." This product is not eligible for auto-renewal. 0.5 MG * 1 MG ORAL TABLET APO-VARENICLINE (STARTER PACK) CHAMPIX (STARTER PACK) PFI 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 SEPTEMBER 1, 2018