Summary of Changes to the Alberta Health and Wellness Drug Benefit List

Transcription

1 Summary of Changes to the Alberta Health and Wellness Drug Benefit List Effective April 1, 2010

2 ABC 40211/81160 (R2010/04)

3 Table of Contents Special Authorization...1 New Drug Product(s) Available by Special Authorization...1 Additional Brand(s) and/or Strength(s) of Drug Products Available by Special Authorization...1 Drug Product(s) with Changes to Criteria for Coverage...2 Drug Product(s) Available by Step Therapy/ Special Authorization...3 Change in Status from Unrestricted Benefit to Step Therapy/ Special Authorization...4 Discontinued Special Authorization Drug Product(s)...5 Deleted Listing(s)...6 Optional Special Authorization...6 Additional Brand(s) and/or Strengths of Drug Product(s) Available by Optional Special Authorization...6 Discontinued Optional Special Authorization Drug Product(s)...6 Restricted Benefits...6 Drug Product(s) Added as a Restricted Benefit...6 Added Product(s)...7 Newly Interchangeable Product(s) Least Cost Alternative (LCA) Change(s) Discontinued Listing(s) Deleted Listing(s) Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied Please review the Alberta Health and Wellness Drug Benefit List in addition to this Summary of Changes. EFFECTIVE APRIL 1, 2010

4 Special Authorization The following drug products will be considered for coverage by special authorization for patients covered under Alberta Health and Wellness government-sponsored drug programs. Criteria for coverage of Alberta Employment and Immigration, Alberta Children and Youth Services and Alberta Seniors and Community Supports (AISH) clients can be found in the April 1, 2010 Summary of Changes section of the Alberta Employment and Immigration Drug Benefit Supplement. New Drug Product(s) Available by Special Authorization OMNITROPE 3.3 MG / VIAL INJECTION SOMATROPIN R-DNA ORIGIN SDZ OMNITROPE 6.7 MG / ML INJECTION SOMATROPIN R-DNA ORIGIN SDZ Additional Brand(s) and/or Strength(s) of Drug Products Available by Special Authorization APO-RIVASTIGMINE 6 MG CAPSULE MYLAN-RIVASTIGMINE 6 MG CAPSULE NOVO-RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE RIVASTIGMINE HYDROGEN TARTRATE RIVASTIGMINE HYDROGEN TARTRATE APX MYP TEV PHL-ALENDRONATE-FC 70 MG ALENDRONATE SODIUM PHH PMS-RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE PMS RAN-FENTANYL MATRIX 12 MCG/HR TRANSDERMAL PATCH RAN-FENTANYL MATRIX 25 MCG/HR TRANSDERMAL PATCH RAN-FENTANYL MATRIX 50 MCG/HR TRANSDERMAL PATCH RAN-FENTANYL MATRIX 75 MCG/HR TRANSDERMAL PATCH RAN-FENTANYL MATRIX 100 MCG/HR TRANSDERMAL PATCH FENTANYL RAN FENTANYL RAN FENTANYL RAN FENTANYL RAN FENTANYL RAN RATIO-RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE HYDROGEN TARTRATE RPH SANDOZ FENTANYL PATCH 12 MCG/HR TRANSDERMAL PATCH SANDOZ FENTANYL PATCH 25 MCG/HR TRANSDERMAL PATCH FENTANYL SDZ FENTANYL SDZ EFFECTIVE APRIL 1,

5 Additional Brand(s) and/or Strength(s) of Drug Products Available by Special Authorization SANDOZ FENTANYL PATCH 50 MCG/HR TRANSDERMAL PATCH SANDOZ FENTANYL PATCH 75 MCG/HR TRANSDERMAL PATCH SANDOZ FENTANYL PATCH 100 MCG/HR TRANSDERMAL PATCH FENTANYL SDZ FENTANYL SDZ FENTANYL SDZ Drug Product(s) with Changes to Criteria for Coverage ARANESP (0.4 ML SYRINGE) 10 MCG / SYR INJECTION SYRINGE ARANESP (0.5 ML SYRINGE) 20 MCG / SYR INJECTION SYRINGE ARANESP (0.3/ 0.4/ 0.5 ML SYR) 100 MCG / ML INJECTION SYRINGE ARANESP (0.3/ 0.4/ 0.5/ 0.65 ML SYR) 200 MCG / ML INJECTION SYRINGE ARANESP (0.3/0.4/0.6/1.0 ML SYR) 500 MCG / ML INJECTION SYRINGE DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG DARBEPOETIN AMG ENBREL 25 MG / VIAL INJECTION ETANERCEPT AMG ENBREL 50 MG / SYR INJECTION SYRINGE ETANERCEPT AMG EPREX 20,000 UNIT / ML INJECTION EPOETIN ALFA JOI EPREX (0.5 ML SYRINGE) 1,000 UNIT / SYR INJECTION SYRINGE EPREX (0.5 ML SYRINGE) 2,000 UNIT / SYR INJECTION SYRINGE EPREX (0.3 ML SYRINGE) 3,000 UNIT / SYR INJECTION SYRINGE EPREX (0.4 ML SYRINGE) 4,000 UNIT / SYR INJECTION SYRINGE EPREX (0.5 ML SYRINGE) 5,000 UNIT / SYR INJECTION SYRINGE EPOETIN ALFA JOI EPOETIN ALFA JOI EPOETIN ALFA JOI EPOETIN ALFA JOI EPOETIN ALFA JOI 2 EFFECTIVE APRIL 1, 2010

6 Drug Product(s) with Changes to Criteria for Coverage, continued EPREX (0.6 ML SYRINGE) 6,000 UNIT / SYR INJECTION SYRINGE EPREX (0.8 ML SYRINGE) 8,000 UNIT / SYR INJECTION SYRINGE EPREX (1 ML SYRINGE) 10,000 UNIT / SYR INJECTION SYRINGE EPREX (0.5 ML SYRINGE) 20,000 UNIT / SYR INJECTION SYRINGE EXJADE 125 MG ORAL DISPERSIBLE FOR SUSPENSION EXJADE 250 MG ORAL DISPERSIBLE FOR SUSPENSION EXJADE 500 MG ORAL DISPERSIBLE FOR SUSPENSION EPOETIN ALFA JOI EPOETIN ALFA JOI EPOETIN ALFA JOI EPOETIN ALFA JOI DEFERASIROX NOV DEFERASIROX NOV DEFERASIROX NOV EZETROL 10 MG EZETIMIBE MFC HUMIRA 40 MG / SYR INJECTION SYRINGE KINERET 100 MG / SYR INJECTION SYRINGE NEULASTA (0.6 ML SYRINGE) 6 MG / SYR INJECTION SYRINGE ADALIMUMAB ABB ANAKINRA BVM PEGFILGRASTIM AMG NEUPOGEN 0.3 MG / ML INJECTION FILGRASTIM AMG ORENCIA 250 MG / VIAL INJECTION ABATACEPT BMS REMICADE 100 MG / VIAL INJECTION INFLIXIMAB SCH RITUXAN 10 MG / ML INJECTION RITUXIMAB HLR Drug Product(s) Available by Step Therapy/ Special Authorization MINT-PIOGLITAZONE 15 MG PIOGLITAZONE HCL MPI MINT-PIOGLITAZONE 30 MG PIOGLITAZONE HCL MPI MINT-PIOGLITAZONE 45 MG PIOGLITAZONE HCL MPI PHL-PIOGLITAZONE 15 MG PIOGLITAZONE HCL PHH PHL-PIOGLITAZONE 30 MG PIOGLITAZONE HCL PHH PHL-PIOGLITAZONE 45 MG PIOGLITAZONE HCL PHH EFFECTIVE APRIL 1,

7 Drug Product(s) Available by Step Therapy/ Special Authorization, continued VESICARE 5 MG SOLIFENACIN SUCCINATE ASP VESICARE 10 MG SOLIFENACIN SUCCINATE ASP Change in Status from Unrestricted Benefit to Step Therapy/ Special Authorization ACTOS 15 MG PIOGLITAZONE HCL TAK ACTOS 30 MG PIOGLITAZONE HCL TAK ACTOS 45 MG PIOGLITAZONE HCL TAK APO-PIOGLITAZONE 15 MG PIOGLITAZONE HCL APX APO-PIOGLITAZONE 30 MG PIOGLITAZONE HCL APX APO-PIOGLITAZONE 45 MG PIOGLITAZONE HCL APX AVANDAMET 1 MG / 500 MG ROSIGLITAZONE MALEATE/ METFORMIN HCL AVANDAMET 2 MG / 500 MG ROSIGLITAZONE MALEATE/ METFORMIN HCL GSK GSK AVANDAMET 2 MG / 1000 MG AVANDAMET 4 MG / 500 MG AVANDAMET 4 MG / 1000 MG ROSIGLITAZONE MALEATE/ METFORMIN HCL ROSIGLITAZONE MALEATE/ METFORMIN HCL ROSIGLITAZONE MALEATE/ METFORMIN HCL GSK GSK GSK AVANDIA 2 MG ROSIGLITAZONE MALEATE GSK AVANDIA 4 MG ROSIGLITAZONE MALEATE GSK AVANDIA 8 MG ROSIGLITAZONE MALEATE GSK CO PIOGLITAZONE 15 MG PIOGLITAZONE HCL COB CO PIOGLITAZONE 30 MG PIOGLITAZONE HCL COB CO PIOGLITAZONE 45 MG PIOGLITAZONE HCL COB MYLAN-PIOGLITAZONE 15 MG MYLAN-PIOGLITAZONE 30 MG MYLAN-PIOGLITAZONE 45 MG NOVO-PIOGLITAZONE 15 MG NOVO-PIOGLITAZONE 30 MG PIOGLITAZONE HCL MYP PIOGLITAZONE HCL MYP PIOGLITAZONE HCL MYP PIOGLITAZONE HCL TEV PIOGLITAZONE HCL TEV 4 EFFECTIVE APRIL 1, 2010

8 Change in Status from Unrestricted Benefit to Step Therapy/ Special Authorization, continued NOVO-PIOGLITAZONE 45 MG PIOGLITAZONE HCL TEV PMS-PIOGLITAZONE 15 MG PIOGLITAZONE HCL PMS PMS-PIOGLITAZONE 30 MG PIOGLITAZONE HCL PMS PMS-PIOGLITAZONE 45 MG PIOGLITAZONE HCL PMS RATIO-PIOGLITAZONE 15 MG RATIO-PIOGLITAZONE 30 MG RATIO-PIOGLITAZONE 45 MG SANDOZ PIOGLITAZONE 15 MG SANDOZ PIOGLITAZONE 30 MG SANDOZ PIOGLITAZONE 45 MG PIOGLITAZONE HCL RPH PIOGLITAZONE HCL RPH PIOGLITAZONE HCL RPH PIOGLITAZONE HCL SDZ PIOGLITAZONE HCL SDZ PIOGLITAZONE HCL SDZ Discontinued Special Authorization Drug Product(s) The following drug product(s) previously available by special authorization have been discontinued. No new requests or requests for renewal will be approved effective April 1, APO-DILTIAZ SR 60 MG SUSTAINED-RELEASE CAPSULE APO-DILTIAZ SR 90 MG SUSTAINED-RELEASE CAPSULE APO-DILTIAZ SR 120 MG SUSTAINED-RELEASE CAPSULE DILTIAZEM HCL APX DILTIAZEM HCL APX DILTIAZEM HCL APX DURICEF 500 MG CAPSULE CEFADROXIL BMS MEGACE 160 MG MEGESTROL ACETATE BMS EFFECTIVE APRIL 1,

9 Deleted Listing(s) The following drug product(s) previously available by special authorization has been deleted and will no longer be honored for claims processing by Alberta Blue Cross effective May 31, FUCITHALMIC (UNPRESERVED) 1% OPHTHALMIC GEL FUSIDIC ACID LEO Optional Special Authorization The following drug product(s) may be considered for coverage by optional special authorization for Alberta Health and Wellness-sponsored drug programs. Criteria for coverage of Alberta Employment and Immigration, Alberta Children and Youth Services and Alberta Seniors and Community Supports (AISH) clients can be found in the April 1, 2010 Full Update of the Alberta Employment and Immigration Drug Benefit Supplement. Please refer to Section 3A of the online Alberta Health and Wellness Drug Benefit List at for further information regarding the Optional Special Authorization of Select Drug Products criteria and related forms. Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Optional Special Authorization CIPROFLOXACIN 250 MG CIPROFLOXACIN HCL RAN CIPROFLOXACIN 500 MG CIPROFLOXACIN HCL RAN CIPROFLOXACIN 750 MG CIPROFLOXACIN HCL RAN Discontinued Optional Special Authorization Drug Product(s) The following drug product(s) previously available by optional special authorization have been discontinued. The following DIN(s) will be honored for claims processing by Alberta Blue Cross until May 31, NOVO-OFLOXACIN 400 MG OFLOXACIN TEV TARO-CIPROFLOXACIN 250 MG TARO-CIPROFLOXACIN 500 MG CIPROFLOXACIN HCL TAR CIPROFLOXACIN HCL TAR Restricted Benefits Drug Product(s) Added as a Restricted Benefit PHL-CYCLOBENZAPRINE 10 MG CYCLOBENZAPRINE HCL PHH 6 EFFECTIVE APRIL 1, 2010

10 Added Product(s) AMLODIPINE 5 MG AMLODIPINE BESYLATE RAN AMLODIPINE 10 MG AMLODIPINE BESYLATE RAN APIDRA 100 UNIT / ML INJECTION CARTRIDGE INSULIN GLULISINE (RDNA ORIGIN) SAV APO-GLICLAZIDE MR 30 MG SUSTAINED-RELEASE GLICLAZIDE APX APO-OLANZAPINE 2.5 MG OLANZAPINE APX APO-OLANZAPINE 5 MG OLANZAPINE APX APO-OLANZAPINE 7.5 MG OLANZAPINE APX APO-OLANZAPINE 10 MG OLANZAPINE APX APO-OLANZAPINE 15 MG OLANZAPINE APX APO-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE APO-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE APO-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE VENLAFAXINE HCL APX VENLAFAXINE HCL APX VENLAFAXINE HCL APX ATACAND PLUS 32 MG / 12.5 MG ATACAND PLUS 32 MG / 25 MG CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE AZC AZC CEFPROZIL 250 MG CEFPROZIL RAN CEFPROZIL 500 MG CEFPROZIL RAN CEFPROZIL 50 MG / ML ORAL SUSPENSION CEFPROZIL RAN CITALOPRAM 20 MG CITALOPRAM HYDROBROMIDE RAN CITALOPRAM 40 MG CITALOPRAM HYDROBROMIDE RAN CO FLUCONAZOLE 150 MG CAPSULE FLUCONAZOLE COB CO OLANZAPINE 2.5 MG OLANZAPINE COB CO OLANZAPINE 5 MG OLANZAPINE COB CO OLANZAPINE 7.5 MG OLANZAPINE COB CO OLANZAPINE 10 MG OLANZAPINE COB EFFECTIVE APRIL 1,

11 Added Product(s), continued CO OLANZAPINE 15 MG OLANZAPINE COB CO OLANZAPINE ODT 5 MG ORAL DISINTEGRATING CO OLANZAPINE ODT 10 MG ORAL DISINTEGRATING OLANZAPINE COB OLANZAPINE COB CO ONDANSETRON 4 MG CO ONDANSETRON 8 MG ONDANSETRON HCL DIHYDRATE ONDANSETRON HCL DIHYDRATE COB COB CO ROPINIROLE 0.25 MG ROPINIROLE HCL COB CO ROPINIROLE 1 MG ROPINIROLE HCL COB CO ROPINIROLE 2 MG ROPINIROLE HCL COB CO ROPINIROLE 5 MG ROPINIROLE HCL COB COVERSYL PLUS HD 8 MG / 2.5 MG PERINDOPRIL ERBUMINE/ INDAPAMIDE HEMIHYDRATE SEV GD-AMLODIPINE 5 MG AMLODIPINE BESYLATE GMD GD-AMLODIPINE 10 MG AMLODIPINE BESYLATE GMD JAMP-AMLODIPINE 5 MG AMLODIPINE BESYLATE JPC JAMP-AMLODIPINE 10 MG AMLODIPINE BESYLATE JPC JAMP-FOSINOPRIL 10 MG FOSINOPRIL SODIUM JPC JAMP-FOSINOPRIL 20 MG FOSINOPRIL SODIUM JPC JAMP-QUETIAPINE 25 MG QUETIAPINE FUMARATE JPC JAMP-QUETIAPINE 100 MG QUETIAPINE FUMARATE JPC JAMP-QUETIAPINE 200 MG QUETIAPINE FUMARATE JPC JAMP-QUETIAPINE 300 MG QUETIAPINE FUMARATE JPC JAMP-RAMIPRIL 1.25 MG CAPSULE RAMIPRIL JPC JAMP-RAMIPRIL 2.5 MG CAPSULE RAMIPRIL JPC JAMP-RAMIPRIL 5 MG CAPSULE RAMIPRIL JPC JAMP-RAMIPRIL 10 MG CAPSULE RAMIPRIL JPC JAMP-SIMVASTATIN 5 MG SIMVASTATIN JPC JAMP-SIMVASTATIN 10 MG SIMVASTATIN JPC JAMP-SIMVASTATIN 20 MG SIMVASTATIN JPC JAMP-SIMVASTATIN 40 MG SIMVASTATIN JPC 8 EFFECTIVE APRIL 1, 2010

12 Added Product(s), continued JAMP-SIMVASTATIN 80 MG SIMVASTATIN JPC MYLAN-OMEPRAZOLE (CAPSULE) 10 MG CAPSULE/SUSTAINED RELEASE MYLAN-OMEPRAZOLE (CAPSULE) 20 MG CAPSULE/SUSTAINED RELEASE OMEPRAZOLE MYP OMEPRAZOLE MYP NG CITALOPRAM 20 MG CITALOPRAM HYDROBROMIDE NGP NG CITALOPRAM 40 MG CITALOPRAM HYDROBROMIDE NGP NOVO-LANSOPRAZOLE 15 MG DELAYED RELEASE CAPSULE NOVO-LANSOPRAZOLE 30 MG DELAYED RELEASE CAPSULE LANSOPRAZOLE TEV LANSOPRAZOLE TEV PHL-AMLODIPINE 2.5 MG AMLODIPINE BESYLATE PHH PHL-AMLODIPINE 5 MG AMLODIPINE BESYLATE PHH PHL-AMLODIPINE 10 MG AMLODIPINE BESYLATE PHH PHL-ATENOLOL 25 MG ATENOLOL PHH PHL-ATENOLOL 50 MG ATENOLOL PHH PHL-ATENOLOL 100 MG ATENOLOL PHH PHL-AZITHROMYCIN 250 MG AZITHROMYCIN PHH PHL-BACLOFEN 10 MG BACLOFEN PHH PHL-BACLOFEN 20 MG BACLOFEN PHH PHL-CARVEDILOL MG CARVEDILOL PHH PHL-CARVEDILOL 6.25 MG CARVEDILOL PHH PHL-CARVEDILOL 12.5 MG CARVEDILOL PHH PHL-CARVEDILOL 25 MG CARVEDILOL PHH PHL-CITALOPRAM 20 MG CITALOPRAM HYDROBROMIDE PHH PHL-CITALOPRAM 40 MG CITALOPRAM HYDROBROMIDE PHH PHL-CLONAZEPAM 0.5 MG CLONAZEPAM PHH PHL-CLONAZEPAM 1 MG CLONAZEPAM PHH PHL-CLONAZEPAM 2 MG CLONAZEPAM PHH PHL-CLONAZEPAM-R 0.5 MG CLONAZEPAM PHH PHL-FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL PHH PHL-FLUOXETINE 20 MG CAPSULE FLUOXETINE HCL PHH EFFECTIVE APRIL 1,

13 Added Product(s), continued PHL-GABAPENTIN 100 MG CAPSULE GABAPENTIN PHH PHL-GABAPENTIN 300 MG CAPSULE GABAPENTIN PHH PHL-GABAPENTIN 400 MG CAPSULE GABAPENTIN PHH PHL-MIRTAZAPINE 30 MG MIRTAZAPINE PHH PHL-ONDANSETRON 4 MG PHL-ONDANSETRON 8 MG PHL-PANTOPRAZOLE 40 MG ENTERIC-COATED ONDANSETRON HCL DIHYDRATE ONDANSETRON HCL DIHYDRATE PANTOPRAZOLE SODIUM SESQUIHYDRATE PHH PHH PHH PHL-PAROXETINE 20 MG PAROXETINE HCL PHH PHL-PAROXETINE 30 MG PAROXETINE HCL PHH PHL-RANITIDINE 150 MG RANITIDINE HCL PHH PHL-RANITIDINE 300 MG RANITIDINE HCL PHH PHL-RISPERIDONE 0.25 MG RISPERIDONE PHH PHL-RISPERIDONE 0.5 MG RISPERIDONE PHH PHL-RISPERIDONE 1 MG RISPERIDONE PHH PHL-RISPERIDONE 2 MG RISPERIDONE PHH PHL-RISPERIDONE 3 MG RISPERIDONE PHH PHL-RISPERIDONE 4 MG RISPERIDONE PHH PHL-SERTRALINE 25 MG CAPSULE SERTRALINE HCL PHH PHL-SERTRALINE 50 MG CAPSULE SERTRALINE HCL PHH PHL-SERTRALINE 100 MG CAPSULE SERTRALINE HCL PHH PHL-SIMVASTATIN 5 MG SIMVASTATIN PHH PHL-SIMVASTATIN 10 MG SIMVASTATIN PHH PHL-SIMVASTATIN 20 MG SIMVASTATIN PHH PHL-SIMVASTATIN 40 MG SIMVASTATIN PHH PHL-SIMVASTATIN 80 MG SIMVASTATIN PHH PHL-TOPIRAMATE 25 MG TOPIRAMATE PHH PHL-TOPIRAMATE 100 MG TOPIRAMATE PHH PHL-TOPIRAMATE 200 MG TOPIRAMATE PHH PMS-AMLODIPINE 2.5 MG AMLODIPINE BESYLATE PMS PMS-OLANZAPINE ODT 5 MG ORAL DISINTEGRATING OLANZAPINE PMS 10 EFFECTIVE APRIL 1, 2010

14 Added Product(s), continued PMS-OLANZAPINE ODT 10 MG ORAL DISINTEGRATING PMS-OMEPRAZOLE (DELAYED RELEASE ) 20 MG CAPSULE/SUSTAINED RELEASE OLANZAPINE PMS OMEPRAZOLE PMS PMS-RAMIPRIL 1.25 MG CAPSULE RAMIPRIL PMS PMS-RAMIPRIL 2.5 MG CAPSULE RAMIPRIL PMS PMS-RAMIPRIL 5 MG CAPSULE RAMIPRIL PMS PMS-RAMIPRIL 10 MG CAPSULE RAMIPRIL PMS PMS-ROPINIROLE 0.25 MG ROPINIROLE HCL PMS PMS-ROPINIROLE 1 MG ROPINIROLE HCL PMS PMS-ROPINIROLE 2 MG ROPINIROLE HCL PMS PMS-ROPINIROLE 5 MG ROPINIROLE HCL PMS PMS-TERBINAFINE 250 MG TERBINAFINE HCL PMS PREMARIN 0.3 MG CONJUGATED ESTROGENS WAY PREMARIN MG CONJUGATED ESTROGENS WAY PREMARIN 1.25 MG CONJUGATED ESTROGENS WAY RAMIPRIL 1.25 MG CAPSULE RAMIPRIL RAN RAMIPRIL 2.5 MG CAPSULE RAMIPRIL RAN RAMIPRIL 5 MG CAPSULE RAMIPRIL RAN RAMIPRIL 10 MG CAPSULE RAMIPRIL RAN RAN-AMLODIPINE 5 MG AMLODIPINE BESYLATE RAN RAN-AMLODIPINE 10 MG AMLODIPINE BESYLATE RAN RAN-FOSINOPRIL 10 MG FOSINOPRIL SODIUM RAN RAN-FOSINOPRIL 20 MG FOSINOPRIL SODIUM RAN RAN-GABAPENTIN 100 MG CAPSULE GABAPENTIN RAN RAN-GABAPENTIN 300 MG CAPSULE GABAPENTIN RAN RAN-GABAPENTIN 400 MG CAPSULE GABAPENTIN RAN RAN-RANITIDINE 150 MG RANITIDINE HCL RAN RAN-RANITIDINE 300 MG RANITIDINE HCL RAN RAN-SIMVASTATIN 5 MG SIMVASTATIN RAN RAN-SIMVASTATIN 10 MG SIMVASTATIN RAN RAN-SIMVASTATIN 20 MG SIMVASTATIN RAN EFFECTIVE APRIL 1,

15 Added Product(s), continued RAN-SIMVASTATIN 40 MG SIMVASTATIN RAN RAN-SIMVASTATIN 80 MG SIMVASTATIN RAN RBX-RISPERIDONE 0.25 MG RISPERIDONE RAN RBX-RISPERIDONE 0.5 MG RISPERIDONE RAN RBX-RISPERIDONE 1 MG RISPERIDONE RAN RBX-RISPERIDONE 2 MG RISPERIDONE RAN RBX-RISPERIDONE 3 MG RISPERIDONE RAN RBX-RISPERIDONE 4 MG RISPERIDONE RAN RISPERIDONE 0.25 MG RISPERIDONE RAN RISPERIDONE 0.5 MG RISPERIDONE RAN RISPERIDONE 1 MG RISPERIDONE RAN RISPERIDONE 2 MG RISPERIDONE RAN RISPERIDONE 3 MG RISPERIDONE RAN RISPERIDONE 4 MG RISPERIDONE RAN ROPINIROLE 0.25 MG ROPINIROLE HCL RAN ROPINIROLE 1 MG ROPINIROLE HCL RAN ROPINIROLE 2 MG ROPINIROLE HCL RAN ROPINIROLE 5 MG ROPINIROLE HCL RAN SANDOZ AZITHROMYCIN 20 MG / ML ORAL SUSPENSION SANDOZ AZITHROMYCIN 40 MG / ML ORAL SUSPENSION SANDOZ OLANZAPINE ODT 5 MG ORAL DISINTEGRATING SANDOZ OLANZAPINE ODT 10 MG ORAL DISINTEGRATING AZITHROMYCIN SDZ AZITHROMYCIN SDZ OLANZAPINE SDZ OLANZAPINE SDZ SIMVASTATIN 5 MG SIMVASTATIN RAN SIMVASTATIN 10 MG SIMVASTATIN RAN SIMVASTATIN 20 MG SIMVASTATIN RAN SIMVASTATIN 40 MG SIMVASTATIN RAN SIMVASTATIN 80 MG SIMVASTATIN RAN TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE TAMSULOSIN HCL RAN 12 EFFECTIVE APRIL 1, 2010

16 Added Product(s), continued VENTOLIN HFA 100 MCG / DOSE METERED DOSE AEROSOL SALBUTAMOL GSK Newly Interchangeable Product(s) APO-CLOZAPINE 25 MG CLOZAPINE APX APO-CLOZAPINE 100 MG CLOZAPINE APX Least Cost Alternative (LCA) Change(s) The following established IC Groupings are affected by the pricing change policy and a and a new LCA has been established. Please review the online Alberta Health and Wellness Drug Benefit List at for further information. Generic Description Strength / Form New LCA Price ACYCLOVIR 200 MG ACYCLOVIR 400 MG ALENDRONATE SODIUM 40 MG ALFUZOSIN HCL 10 MG SUSTAINED-RELEASE AMIODARONE HCL 200 MG AMLODIPINE BESYLATE 2.5 MG AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM 500 MG / 125 MG MG / 125 MG MG / 6.25 MG / ML ORAL SUSPENSION MG / 12.5 MG / ML ORAL SUSPENSION MG / 11.4 MG / ML ORAL SUSPENSION ATENOLOL 25 MG ATENOLOL 50 MG ATENOLOL 100 MG ATENOLOL/ CHLORTHALIDONE 50 MG / 25 MG ATENOLOL/ CHLORTHALIDONE 100 MG / 25 MG EFFECTIVE APRIL 1,

17 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price AZITHROMYCIN 250 MG AZITHROMYCIN 20 MG / ML ORAL SUSPENSION AZITHROMYCIN 40 MG / ML ORAL SUSPENSION AZITHROMYCIN 600 MG BISOPROLOL FUMARATE 5 MG BISOPROLOL FUMARATE 10 MG BRIMONIDINE TARTRATE 0.2 % OPHTHALMIC SOLUTION BUPROPION HCL 100 MG SUSTAINED-RELEASE BUSPIRONE HCL 10 MG CABERGOLINE 0.5 MG CARVEDILOL MG CARVEDILOL 6.25 MG CARVEDILOL 12.5 MG CARVEDILOL 25 MG CEFPROZIL 250 MG CEFPROZIL 500 MG CEFPROZIL 25 MG / ML ORAL SUSPENSION CEFPROZIL 50 MG / ML ORAL SUSPENSION CEFUROXIME AXETIL 250 MG CEFUROXIME AXETIL 500 MG CILAZAPRIL/ HYDROCHLOROTHIAZIDE 5 MG / 12.5 MG CITALOPRAM HYDROBROMIDE 20 MG CITALOPRAM HYDROBROMIDE 40 MG CLARITHROMYCIN 500 MG CLOBETASOL 17-PROPIONATE 0.05 % TOPICAL CREAM CLOBETASOL 17-PROPIONATE 0.05 % TOPICAL OINTMENT CLOBETASOL 17-PROPIONATE 0.05 % SCALP LOTION CLOMIPHENE CITRATE 50 MG CLOMIPRAMINE HCL 50 MG CLONIDINE HCL MG CLONIDINE HCL 0.1 MG CLONIDINE HCL 0.2 MG CODEINE PHOSPHATE/ ACETAMINOPHEN 60 MG / 300 MG EFFECTIVE APRIL 1, 2010

18 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price CYCLOBENZAPRINE HCL 10 MG CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE 50 MG CAPSULE CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE 100 MG ORAL SOLUTION DEFEROXAMINE MESYLATE 2 G / VIAL INJECTION DEFEROXAMINE MESYLATE 500 MG / VIAL INJECTION DESMOPRESSIN ACETATE 0.1 MG DESMOPRESSIN ACETATE 0.2 MG DESONIDE 0.05 % TOPICAL OINTMENT DEXAMETHASONE 0.5 MG DEXAMETHASONE 4 MG DIAZEPAM 5 MG DICLOFENAC SODIUM 25 MG ENTERIC-COATED DICLOFENAC SODIUM 75 MG SUSTAINED-RELEASE DICLOFENAC SODIUM 100 MG SUSTAINED-RELEASE DIFLUNISAL 250 MG DIHYDROERGOTAMINE MESYLATE 1 MG / ML INJECTION DILTIAZEM HCL 120 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM HCL 180 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM HCL 240 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM HCL 300 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM HCL 120 MG EXTENDED-RELEASE CAPSULE DILTIAZEM HCL 180 MG EXTENDED-RELEASE CAPSULE DILTIAZEM HCL 240 MG EXTENDED-RELEASE CAPSULE DILTIAZEM HCL 300 MG EXTENDED-RELEASE CAPSULE DILTIAZEM HCL 360 MG EXTENDED-RELEASE CAPSULE DIMETHYL SULFOXIDE 50 % BLADDER IRRIGATION SOLUTION DIPYRIDAMOLE 50 MG DOMPERIDONE MALEATE 10 MG DOXAZOSIN MESYLATE 1 MG DOXAZOSIN MESYLATE 2 MG DOXAZOSIN MESYLATE 4 MG EFFECTIVE APRIL 1,

19 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price DOXEPIN HCL 25 MG CAPSULE DOXEPIN HCL 50 MG CAPSULE DOXEPIN HCL 75 MG CAPSULE DOXEPIN HCL 100 MG CAPSULE ENALAPRIL MALEATE 2.5 MG ENALAPRIL MALEATE 5 MG ENALAPRIL MALEATE 10 MG ENALAPRIL MALEATE 20 MG ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE 10 MG / 25 MG ERYTHROMYCIN ERYTHROMYCIN 250 MG CAPSULE (ENTERIC-COATED PELLET) 333 MG CAPSULE (ENTERIC-COATED PELLET) ETIDRONATE DISODIUM/ CALCIUM CARBONATE 400 MG / 500 MG FENOFIBRATE 100 MG FENOFIBRATE 160 MG CAPSULE / FENOFIBRATE 200 MG CAPSULE FENTANYL 12 MCG/HR TRANSDERMAL PATCH FLECAINIDE ACETATE 50 MG FLUCONAZOLE 50 MG FLUCONAZOLE 100 MG FLUCONAZOLE 150 MG CAPSULE FLUCONAZOLE 2 MG / ML INJECTION FLUOXETINE HCL 10 MG CAPSULE FLUTAMIDE 250 MG FOSINOPRIL SODIUM 10 MG FOSINOPRIL SODIUM 20 MG GABAPENTIN 100 MG CAPSULE GABAPENTIN 300 MG CAPSULE GABAPENTIN 400 MG CAPSULE GEMFIBROZIL 600 MG GLICLAZIDE 30 MG SUSTAINED-RELEASE EFFECTIVE APRIL 1, 2010

20 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price GLICLAZIDE 80 MG HEPARIN SODIUM 100 UNIT / ML INJECTION LOCK FLUSH HEPARIN SODIUM 10,000 UNIT / ML INJECTION HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE 25 MG / 25 MG MG / 50 MG HYDROCORTISONE 100 MG RECTAL ENEMA HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE 0.5 % / 1 % /.5 % RECTAL OINTMENT HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN 10 MG / 20 MG / 10 MG RECTAL SUPPOSITORY 5 MG / 5 MG / 10 MG / 10 MG RECTAL SUPPOSITORY 5 MG / 5 MG / 10 MG/ 10 MG / G RECTAL OINTMENT HYDROMORPHONE HCL 1 MG HYDROMORPHONE HCL 1 MG / ML LIQUID HYDROMORPHONE HCL 20 MG / ML INJECTION HYDROXYCHLOROQUINE SULFATE 200 MG INDAPAMIDE HEMIHYDRATE 1.25 MG INDAPAMIDE HEMIHYDRATE 2.5 MG IPRATROPIUM BROMIDE 250 MCG / ML INHALATION SOLUTION IPRATROPIUM BROMIDE 0.03 % NASAL SPRAY IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE 0.2 MG / 1 MG / ML INHALATION SOLUTION ISOSORBIDE-5-MONONITRATE 60 MG EXTENDED-RELEASE KETOROLAC TROMETHAMINE 10 MG LANSOPRAZOLE 15 MG DELAYED RELEASE CAPSULE LANSOPRAZOLE 30 MG DELAYED RELEASE CAPSULE LEVETIRACETAM 250 MG LEVETIRACETAM 500 MG LEVETIRACETAM 750 MG LEVODOPA/ CARBIDOPA 100 MG / 25 MG SUSTAINED-RELEASE EFFECTIVE APRIL 1,

21 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price LEVOFLOXACIN 250 MG LEVOFLOXACIN 500 MG LEVOFLOXACIN 750 MG LIDOCAINE 5 % TOPICAL OINTMENT LIDOCAINE HCL 2 % ORAL LIQUID LISINOPRIL 5 MG LISINOPRIL 10 MG LISINOPRIL 20 MG LISINOPRIL/ HYDROCHLOROTHIAZIDE 10 MG / 12.5 MG LISINOPRIL/ HYDROCHLOROTHIAZIDE 20 MG / 12.5 MG LISINOPRIL/ HYDROCHLOROTHIAZIDE 20 MG / 25 MG LISINOPRIL/ HYDROCHLOROTHIAZIDE (TYPE P) LISINOPRIL/ HYDROCHLOROTHIAZIDE (TYPE P) 10 MG / 12.5 MG MG / 12.5 MG LITHIUM CARBONATE 300 MG CAPSULE L-TRYPTOPHAN 500 MG L-TRYPTOPHAN 1 G L-TRYPTOPHAN 500 MG CAPSULE MEDROXYPROGESTERONE ACETATE 150 MG / ML INJECTION MEGESTROL ACETATE 160 MG METFORMIN HCL 850 MG METHYLPHENIDATE HCL 20 MG EXTENDED-RELEASE METHYLPREDNISOLONE ACETATE 80 MG / ML INJECTION METOPROLOL TARTRATE 100 MG SUSTAINED-RELEASE METOPROLOL TARTRATE 200 MG SUSTAINED-RELEASE MINOCYCLINE HCL 50 MG CAPSULE MINOCYCLINE HCL 100 MG CAPSULE MIRTAZAPINE 30 MG MOCLOBEMIDE 150 MG MOCLOBEMIDE 300 MG MOMETASONE FUROATE 0.1 % TOPICAL OINTMENT MORPHINE SULFATE 100 MG SUSTAINED-RELEASE MORPHINE SULFATE 200 MG SUSTAINED-RELEASE EFFECTIVE APRIL 1, 2010

22 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price MUPIROCIN 2 % TOPICAL OINTMENT NAPROXEN 250 MG ENTERIC-COATED NAPROXEN 375 MG ENTERIC-COATED NAPROXEN 500 MG ENTERIC-COATED NIFEDIPINE 60 MG EXTENDED-RELEASE NITROGLYCERIN 0.4 MG / DOSE SUBLINGUAL METERED DOSE SPRAY NIZATIDINE 150 MG CAPSULE NIZATIDINE 300 MG CAPSULE NORFLOXACIN 400 MG NORTRIPTYLINE HCL 10 MG CAPSULE NORTRIPTYLINE HCL 25 MG CAPSULE NYSTATIN 100,000 UNIT / ML ORAL SUSPENSION OCTREOTIDE ACETATE 50 MCG / ML INJECTION OCTREOTIDE ACETATE 100 MCG / ML INJECTION OCTREOTIDE ACETATE 200 MCG / ML INJECTION OCTREOTIDE ACETATE 500 MCG / ML INJECTION OLANZAPINE 2.5 MG OLANZAPINE 5 MG OLANZAPINE 7.5 MG OLANZAPINE 10 MG OLANZAPINE 15 MG OLANZAPINE 5 MG ORAL DISINTEGRATING OLANZAPINE 10 MG ORAL DISINTEGRATING ONDANSETRON HCL DIHYDRATE 2 MG / ML INJECTION PANTOPRAZOLE SODIUM SESQUIHYDRATE 40 MG ENTERIC-COATED PIOGLITAZONE HCL 15 MG PIOGLITAZONE HCL 30 MG PIOGLITAZONE HCL 45 MG PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG PRAVASTATIN SODIUM 10 MG EFFECTIVE APRIL 1,

23 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price PRAVASTATIN SODIUM 20 MG PRAVASTATIN SODIUM 40 MG PREDNISOLONE ACETATE 1 % OPHTHALMIC SUSPENSION QUETIAPINE FUMARATE 25 MG QUETIAPINE FUMARATE 100 MG QUETIAPINE FUMARATE 200 MG QUETIAPINE FUMARATE 300 MG RABEPRAZOLE SODIUM 10 MG ENTERIC-COATED RABEPRAZOLE SODIUM 20 MG ENTERIC-COATED RALOXIFENE HCL 60 MG RAMIPRIL 2.5 MG CAPSULE / RAMIPRIL 5 MG CAPSULE/ RAMIPRIL 10 MG CAPSULE / SALBUTAMOL 100 MCG / DOSE METERED DOSE AEROSOL SALBUTAMOL SULFATE 0.5 MG / ML INHALATION SOLUTION SELEGILINE HCL 5 MG SERTRALINE HCL 25 MG CAPSULE SERTRALINE HCL 50 MG CAPSULE SERTRALINE HCL 100 MG CAPSULE SOTALOL HCL 80 MG SOTALOL HCL 160 MG SUMATRIPTAN SUCCINATE 50 MG SUMATRIPTAN SUCCINATE 100 MG TAMSULOSIN HCL 0.4 MG SUSTAINED-RELEASE CAPSULE TESTOSTERONE CYPIONATE 100 MG / ML INJECTION THIAMINE HCL 100 MG / ML INJECTION TIMOLOL MALEATE 0.25 % OPHTHALMIC SOLUTION TIZANIDINE HCL 4 MG TOBRAMYCIN 0.3 % OPHTHALMIC SOLUTION TRAVOPROST % OPHTHALMIC SOLUTION TRETINOIN 0.01 % TOPICAL GEL TRETINOIN % TOPICAL GEL TRIAMCINOLONE ACETONIDE 10 MG / ML INJECTION EFFECTIVE APRIL 1, 2010

24 Least Cost Alternative (LCA) Change(s), continued Generic Description Strength / Form New LCA Price VALACYCLOVIR 500 MG WARFARIN SODIUM 1 MG WARFARIN SODIUM 2 MG WARFARIN SODIUM 2.5 MG WARFARIN SODIUM 3 MG WARFARIN SODIUM 4 MG WARFARIN SODIUM 5 MG WARFARIN SODIUM 10 MG Discontinued Listing(s) The following DIN(s) will be honored for claims processing by Alberta Blue Cross until May 31, ADULT AEROCHAMBER PLUS W/ MASK ADULT DEVICE AEROSOL HOLDING CHAMBER/MASK TMI AEROCHAMBER PLUS DEVICE AEROSOL HOLDING CHAMBER TMI AMATINE 2.5 MG MIDODRINE HCL SHB AMATINE 5 MG MIDODRINE HCL SHB ANZEMET 50 MG DOLASETRON MESYLATE SAV APO-DICLO SR 75 MG SUSTAINED-RELEASE APO-DICLO SR 100 MG SUSTAINED-RELEASE DICLOFENAC SODIUM APX DICLOFENAC SODIUM APX APO-DIGOXIN MG DIGOXIN APX APO-DIGOXIN 0.25 MG DIGOXIN APX APO-LABETALOL 100 MG LABETALOL HCL APX APO-LABETALOL 200 MG LABETALOL HCL APX APO-LEVOCARB CR 200 / 50 MG SUSTAINED-RELEASE APO-LITHIUM CARBONATE SR 300 MG SUSTAINED-RELEASE LEVODOPA/ CARBIDOPA APX LITHIUM CARBONATE APX EFFECTIVE APRIL 1,

25 Discontinued Listing(s), continued APO-NIFED PA 10 MG SUSTAINED-RELEASE APO-NIFED PA 20 MG SUSTAINED-RELEASE NIFEDIPINE APX NIFEDIPINE APX BETALOC 50 MG METOPROLOL TARTRATE AZC BETALOC 100 MG METOPROLOL TARTRATE AZC BETALOC DURULES 200 MG SUSTAINED-RELEASE METOPROLOL TARTRATE AZC CAPOTEN 12.5 MG CAPTOPRIL BMS CAPTOPRIL 12.5 MG CAPTOPRIL ZMC CAPTOPRIL 25 MG CAPTOPRIL ZMC CAPTOPRIL 50 MG CAPTOPRIL ZMC CAPTOPRIL 100 MG CAPTOPRIL ZMC CHILD AEROCHAMBER PLUS WITH MASK PEDIATRIC DEVICE AEROSOL HOLDING CHAMBER/MASK TMI CO MIRTAZAPINE 30 MG MIRTAZAPINE COB ESTRADERM-50 (4 MG/PTH) 50 MCG/DAY TRANSDERMAL PATCH FIORINAL 50 MG / 40 MG / 330 MG ESTRADIOL-17B NOV BUTALBITAL/ CAFFEINE/ ASA NOV GEN-MEDROXY 2.5 MG GEN-MEDROXY 5 MG GEN-MEDROXY 10 MG MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MYP MYP MYP GEN-NORTRIPTYLINE 10 MG CAPSULE GEN-NORTRIPTYLINE 25 MG CAPSULE NORTRIPTYLINE HCL MYP NORTRIPTYLINE HCL MYP GEN-PIROXICAM 20 MG CAPSULE PIROXICAM MYP INFANT AEROCHAMBER PLUS WITH MASK INFANT DEVICE AEROSOL HOLDING CHAMBER/MASK TMI M.O.S.-1 1 MG / ML ORAL SYRUP MORPHINE HCL VCL 22 EFFECTIVE APRIL 1, 2010

26 Discontinued Listing(s), continued M.O.S.-20 CONCENTRATE 20 MG / ML ORAL SYRUP MORPHINE HCL VCL MODURET 50 MG / 5 MG HYDROCHLOROTHIAZIDE/ AMILORIDE HCL PRP MYLAN-BUSPIRONE 10 MG BUSPIRONE HCL MYP MYLAN-DILTIAZEM CD 120 MG CONTROLLED-DELIVERY CAPSULE MYLAN-DILTIAZEM CD 180 MG CONTROLLED-DELIVERY CAPSULE MYLAN-DILTIAZEM CD 240 MG CONTROLLED-DELIVERY CAPSULE MYLAN-DILTIAZEM CD 300 MG CONTROLLED-DELIVERY CAPSULE MYLAN-TEMAZEPAM 15 MG CAPSULE MYLAN-TEMAZEPAM 30 MG CAPSULE DILTIAZEM HCL MYP DILTIAZEM HCL MYP DILTIAZEM HCL MYP DILTIAZEM HCL MYP TEMAZEPAM MYP TEMAZEPAM MYP NOVO-PREDNISONE 5 MG PREDNISONE TEV NOVO-PREDNISONE 50 MG PREDNISONE TEV NOVO-RYTHRO ESTOLATE 25 MG / ML ORAL SUSPENSION NU-DICLO SR 75 MG SUSTAINED-RELEASE NU-DICLO SR 100 MG SUSTAINED-RELEASE ERYTHROMYCIN ESTOLATE TEV DICLOFENAC SODIUM NXP DICLOFENAC SODIUM NXP NU-LOXAPINE 5 MG LOXAPINE SUCCINATE NXP NU-LOXAPINE 10 MG LOXAPINE SUCCINATE NXP NU-LOXAPINE 25 MG LOXAPINE SUCCINATE NXP NU-LOXAPINE 50 MG LOXAPINE SUCCINATE NXP NU-NIFEDIPINE-PA 10 MG SUSTAINED-RELEASE NIFEDIPINE NXP EFFECTIVE APRIL 1,

27 Discontinued Listing(s), continued NU-NIFEDIPINE-PA 20 MG SUSTAINED-RELEASE NIFEDIPINE NXP OGEN MG ESTROPIPATE PFI OGEN 1.25 MG ESTROPIPATE PFI OGEN 2.5 MG ESTROPIPATE PFI PERCODAN 5 MG / 325 MG OXYCODONE HCL/ ASA BMS PMS-DESIPRAMINE 10 MG DESIPRAMINE HCL PMS PMS-DESIPRAMINE 25 MG DESIPRAMINE HCL PMS PMS-DICLOFENAC 25 MG ENTERIC-COATED PMS-DICLOFENAC 50 MG ENTERIC-COATED PMS-MEFENAMIC ACID 250 MG CAPSULE DICLOFENAC SODIUM PMS DICLOFENAC SODIUM PMS MEFENAMIC ACID PMS PMS-METHOTRIMEPRAZINE 5 MG PMS-METHOTRIMEPRAZINE 25 MG PMS-METHOTRIMEPRAZINE 50 MG RATIO-BECLOMETHASONE DIPROP AQ 50 MCG / DOSE NASAL METERED DOSE SPRAY METHOTRIMEPRAZINE MALEATE METHOTRIMEPRAZINE MALEATE METHOTRIMEPRAZINE MALEATE BECLOMETHASONE DIPROPIONATE PMS PMS PMS RPH RATIO-BENZYDAMINE 0.15% ORAL RINSE RATIO-CLINDAMYCIN 150 MG CAPSULE RATIO-CLINDAMYCIN 300 MG CAPSULE BENZYDAMINE HCL RPH CLINDAMYCIN HCL RPH CLINDAMYCIN HCL RPH TARO-SIMVASTATIN 10 MG SIMVASTATIN TAR TARO-SIMVASTATIN 20 MG SIMVASTATIN TAR TARO-SIMVASTATIN 40 MG SIMVASTATIN TAR TESTOSTERONE CYPIONATE 100 MG / ML INJECTION TESTOSTERONE CYPIONATE CYT TORADOL IM 30 MG / ML INJECTION KETOROLAC TROMETHAMINE HLR TRIAMCINOLONE DIACETATE 40 MG / ML INJECTION TRIAMCINOLONE DIACETATE CYT 24 EFFECTIVE APRIL 1, 2010

28 Discontinued Listing(s), continued ULTRAQUIN 4% TOPICAL CREAM HYDROQUINONE CDX VIBRA-TABS 100 MG DOXYCYCLINE HYCLATE PFI ZYM-METFORMIN 850 MG METFORMIN HCL ZMC Deleted Listing(s) The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2010, the listed product(s) will no longer be a benefit and will not be considered for coverage by special authorization. APO-CHLORPROPAMIDE 100 MG APO-CHLORPROPAMIDE 250 MG CHLORPROPAMIDE APX CHLORPROPAMIDE APX APO-TOLBUTAMIDE 500 MG TOLBUTAMIDE APX HUMALOG MIX 25 % / 75 % INJECTION CARTRIDGE INSULIN LISPRO/ INSULIN LISPRO PROTAMINE LIL The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2010, 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 31, 2010, claims will no longer pay for these products. DOM-ATENOLOL 50 MG ATENOLOL DPC DOM-BACLOFEN 10 MG BACLOFEN DPC DOM-BACLOFEN 20 MG BACLOFEN DPC DOM-BROMOCRIPTINE 2.5 MG BROMOCRIPTINE MESYLATE DPC DOM-BUSPIRONE 10 MG BUSPIRONE HCL DPC DOM-CAPTOPRIL 12.5 MG CAPTOPRIL DPC DOM-CAPTOPRIL 25 MG CAPTOPRIL DPC DOM-CAPTOPRIL 50 MG CAPTOPRIL DPC DOM-CAPTOPRIL 100 MG CAPTOPRIL DPC DOM-CLONAZEPAM-R 0.5 MG CLONAZEPAM DPC DOM-CLONAZEPAM 2 MG CLONAZEPAM DPC DOM-CYCLOBENZAPRINE 10 MG CYCLOBENZAPRINE HCL DPC DOM-DESIPRAMINE 25 MG DESIPRAMINE HCL DPC EFFECTIVE APRIL 1,

29 Deleted Listing(s), continued DOM-DESIPRAMINE 50 MG DESIPRAMINE HCL DPC DOM-DICLOFENAC 25 MG ENTERIC-COATED DOM-DICLOFENAC 50 MG ENTERIC-COATED DOM-DICLOFENAC-SR 75 MG SUSTAINED-RELEASE DOM-DICLOFENAC-SR 100 MG SUSTAINED-RELEASE DICLOFENAC SODIUM DPC DICLOFENAC SODIUM DPC DICLOFENAC SODIUM DPC DICLOFENAC SODIUM DPC DOM-DOMPERIDONE 10 MG DOMPERIDONE MALEATE DPC DOM-FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL DPC DOM-GEMFIBROZIL 600 MG GEMFIBROZIL DPC DOM-GLYBURIDE 2.5 MG GLYBURIDE DPC DOM-GLYBURIDE 5 MG GLYBURIDE DPC DOM-METOPROLOL-L 50 MG DOM-METOPROLOL-L 100 MG METOPROLOL TARTRATE DPC METOPROLOL TARTRATE DPC DOM-SOTALOL 160 MG SOTALOL HCL DPC DOM-TRAZODONE 50 MG TRAZODONE HCL DPC DOM-TRAZODONE 100 MG TRAZODONE HCL DPC PMS-ASA EC 650 MG ENTERIC- COATED ASA PMS PMS-CAPTOPRIL 12.5 MG CAPTOPRIL PMS PMS-CAPTOPRIL 25 MG CAPTOPRIL PMS PMS-CAPTOPRIL 50 MG CAPTOPRIL PMS PMS-CAPTOPRIL 100 MG CAPTOPRIL PMS PMS-DESIPRAMINE 50 MG DESIPRAMINE HCL PMS PMS-DESIPRAMINE 75 MG DESIPRAMINE HCL PMS PMS-DIPHENHYDRAMINE HYDROCHLORIDE 50 MG / ML INJECTION PMS-GENTAMICIN 0.1% TOPICAL OINTMENT DIPHENHYDRAMINE HCL PMS GENTAMICIN SULFATE PMS 26 EFFECTIVE APRIL 1, 2010

30 Deleted Listing(s), continued PMS-GENTAMICIN 0.3% OTIC SOLUTION PMS-HALOPERIDOL 2 MG / ML ORAL SOLUTION GENTAMICIN SULFATE PMS HALOPERIDOL PMS PMS-MEDROXYPROGESTERONE 2.5 MG PMS-MEDROXYPROGESTERONE 5 MG PMS-MEDROXYPROGESTERONE 10 MG MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE PMS PMS PMS PMS-PAMIDRONATE 30 MG / VIAL INJECTION PMS-PROCHLORPERAZINE 5 MG PMS-PROCHLORPERAZINE 10 MG PMS-PROCHLORPERAZINE 10 MG RECTAL SUPPOSITORY PAMIDRONATE DISODIUM PMS PROCHLORPERAZINE PMS PROCHLORPERAZINE PMS PROCHLORPERAZINE PMS SANDOZ SOTALOL 160 MG SOTALOL HCL SDZ Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2010, 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 31, 2010, claims will no longer pay for these products. AIROMIR CFC-FREE 100 MCG / DOSE METERED DOSE AEROSOL SALBUTAMOL GRC APO-AMOXI CLAV 25 MG / ML / 6.25 MG / ML ORAL SUSPENSION AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM APX APO-CEFPROZIL 25 MG / ML ORAL SUSPENSION CEFPROZIL APX APO-DOXEPIN 25 MG CAPSULE DOXEPIN HCL APX APO-DOXEPIN 50 MG CAPSULE DOXEPIN HCL APX APO-LEVETIRACETAM 750 MG LEVETIRACETAM APX EFFECTIVE APRIL 1,

31 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued APO-LISINOPRIL 5 MG LISINOPRIL APX APO-LISINOPRIL 10 MG LISINOPRIL APX APO-LISINOPRIL 20 MG LISINOPRIL APX APO-NABUMETONE 500 MG NABUMETONE APX APO-NIZATIDINE 300 MG CAPSULE NIZATIDINE APX APO-PRAVASTATIN 10 MG PRAVASTATIN SODIUM APX APO-PRAVASTATIN 20 MG PRAVASTATIN SODIUM APX APO-PRAVASTATIN 40 MG PRAVASTATIN SODIUM APX BELLERGAL SPACETABS 0.2 MG / 0.6 MG / 40 MG SUSTAINED-RELEASE BELLADONNA/ ERGOTAMINE TARTRATE/ PHENOBARBITAL TPI BENOXYL 10% TOPICAL LOTION BENZOYL PEROXIDE STI BENOXYL 20% TOPICAL LOTION BENZOYL PEROXIDE STI CLINDOXYL 1% / 5% TOPICAL GEL CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE STI CO LISINOPRIL 5 MG S LISINOPRIL COB CO LISINOPRIL 10 MG S LISINOPRIL COB CO LISINOPRIL 20 MG S LISINOPRIL COB CO PRAVASTATIN 10 MG PRAVASTATIN SODIUM COB CO PRAVASTATIN 20 MG PRAVASTATIN SODIUM COB CO PRAVASTATIN 40 MG PRAVASTATIN SODIUM COB CUPRIMINE 250 MG CAPSULE PENICILLAMINE ATP CYCLOCORT 0.1% TOPICAL CREAM AMCINONIDE STI CYCLOCORT 0.1% TOPICAL LOTION AMCINONIDE STI CYCLOCORT 0.1% TOPICAL OINTMENT DELATESTRYL 200 MG / ML INJECTION AMCINONIDE STI TESTOSTERONE ENANTHATE TMD EMO-CORT 1% TOPICAL CREAM HYDROCORTISONE TCD EMO-CORT 2.5% TOPICAL CREAM HYDROCORTISONE TCD EMO-CORT 1% TOPICAL LOTION HYDROCORTISONE TCD EMO-CORT 2.5% TOPICAL LOTION HYDROCORTISONE TCD EMO-CORT 2.5% SCALP LOTION HYDROCORTISONE TCD 28 EFFECTIVE APRIL 1, 2010

32 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued FLUCONAZOLE 2 MG / ML INJECTION FML LIQUIFILM 0.1% OPHTHALMIC SUSPENSION FLUCONAZOLE TEV FLUOROMETHOLONE ALL GEN-NIZATIDINE 300 MG CAPSULE NIZATIDINE MYP GRAVERGOL 1 MG / 100 MG / 50 MG CAPSULE ERGOTAMINE TARTRATE/ CAFFEINE/ DIMENHYDRINATE AXS KEMSOL 70% TOPICAL SOLUTION DIMETHYL SULFOXIDE AXS LEVAQUIN 250 MG LEVOFLOXACIN JOI LEVAQUIN 500 MG LEVOFLOXACIN JOI METHOTREXATE SOD. (UNPRESERVED) 25 MG / ML INJECTION METHOTREXATE SODIUM TEV MINOCIN 50 MG CAPSULE MINOCYCLINE HCL STI MINOCIN 100 MG CAPSULE MINOCYCLINE HCL STI MYLAN-COMBO STERINEBS 0.2 MG / ML * 1 MG / ML INHALATION SOLUTION IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE MYP MYLAN-LISINOPRIL 5 MG LISINOPRIL MYP MYLAN-LISINOPRIL 10 MG LISINOPRIL MYP MYLAN-LISINOPRIL 20 MG LISINOPRIL MYP MYLAN-NABUMETONE 500 MG MYLAN-NITRO 0.4 MG / DOSE SUBLINGUAL METERED DOSE SPRAY MYLAN-PRAVASTATIN 10 MG MYLAN-PRAVASTATIN 20 MG MYLAN-PRAVASTATIN 40 MG NABUMETONE MYP NITROGLYCERIN MYP PRAVASTATIN SODIUM MYP PRAVASTATIN SODIUM MYP PRAVASTATIN SODIUM MYP NERISONE 0.1% TOPICAL CREAM DIFLUCORTOLONE VALERATE STI NERISONE OILY 0.1% TOPICAL CREAM NERISONE 0.1% TOPICAL OINTMENT DIFLUCORTOLONE VALERATE STI DIFLUCORTOLONE VALERATE STI EFFECTIVE APRIL 1,

33 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued NOVO-BENZYDAMINE 0.15% ORAL RINSE NOVO-LISINOPRIL (TYPE P) 5 MG NOVO-LISINOPRIL (TYPE P) 10 MG NOVO-LISINOPRIL (TYPE P) 20 MG NOVO-LISINOPRIL (TYPE Z) 5 MG BENZYDAMINE HCL TEV LISINOPRIL TEV LISINOPRIL TEV LISINOPRIL TEV LISINOPRIL TEV NOVO-LISINOPRIL10 MG LISINOPRIL TEV NOVO-LISINOPRIL 20 MG LISINOPRIL TEV NOVO-NABUMETONE 500 MG NABUMETONE TEV NOVO-PRAVASTATIN 10 MG PRAVASTATIN SODIUM TEV NOVO-PRAVASTATIN 20 MG PRAVASTATIN SODIUM TEV NOVO-PRAVASTATIN 40 MG PRAVASTATIN SODIUM TEV NOVO-PROFEN 400 MG IBUPROFEN TEV NU-ACYCLOVIR 200 MG ACYCLOVIR NXP NU-ATENOL 50 MG ATENOLOL NXP NU-ATENOL 100 MG ATENOLOL NXP NU-DICLO 50 MG ENTERIC-COATED DICLOFENAC SODIUM NXP NU-MOCLOBEMIDE 150 MG MOCLOBEMIDE NXP NU-PRAVASTATIN 10 MG PRAVASTATIN SODIUM NXP NU-PRAVASTATIN 20 MG PRAVASTATIN SODIUM NXP NU-PRAVASTATIN 40 MG PRAVASTATIN SODIUM NXP OCTREOTIDE 100 MCG / ML INJECTION OCTREOTIDE 200 MCG / ML INJECTION OCTREOTIDE 500 MCG / ML INJECTION OCTREOTIDE ACETATE TEV OCTREOTIDE ACETATE TEV OCTREOTIDE ACETATE TEV OESCLIM 25 (5 MG/PTH) 25 MCG/DAY TRANSDERMAL PATCH ESTRADIOL-17B TPI 30 EFFECTIVE APRIL 1, 2010

34 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued OESCLIM 50 (10 MG/PTH) 50 MCG/DAY TRANSDERMAL PATCH TRANSDERMAL PATCH ESTRADIOL-17B TPI ONDANSETRON (PRESERVED) 2 MG / ML INJECTION ONDANSETRON (UNPRESERVED) 2 MG / ML INJECTION ONDANSETRON HCL DIHYDRATE ONDANSETRON HCL DIHYDRATE SDZ SDZ OPTICHAMBER DEVICE AEROSOL HOLDING CHAMBER ACM OPTICHAMBER SMALL MASK INFANT DEVICE OPTICHAMBER MEDIUM MASK PEDIATRIC DEVICE AEROSOL HOLDING CHAMBER/MASK AEROSOL HOLDING CHAMBER/MASK ACM ACM OPTICHAMBER LARGE MASK ADULT DEVICE AEROSOL HOLDING CHAMBER/MASK ACM OXY-IR 10 MG OXYCODONE HCL PUR OXY-IR 20 MG OXYCODONE HCL PUR PAMIDRONATE DISODIUM 30 MG / VIAL INJECTION PAMIDRONATE DISODIUM 60 MG / VIAL INJECTION PAMIDRONATE DISODIUM OMEGA 60 MG / VIAL INJECTION PAMIDRONATE DISODIUM SDZ PAMIDRONATE DISODIUM SDZ PAMIDRONATE DISODIUM OMG PANOXYL 10% TOPICAL BAR BENZOYL PEROXIDE STI PANOXYL 10 10% TOPICAL (ALCOHOL) GEL PANOXYL 20 20% TOPICAL (ALCOHOL) GEL PARIET 10 MG ENTERIC-COATED PARIET 20 MG ENTERIC-COATED PMS-BENZYDAMINE 0.15% ORAL RINSE PMS-DEFEROXAMINE 2 G / VIAL INJECTION PMS-DEFEROXAMINE 500 MG / VIAL INJECTION BENZOYL PEROXIDE STI BENZOYL PEROXIDE STI RABEPRAZOLE SODIUM JOI RABEPRAZOLE SODIUM JOI BENZYDAMINE HCL PMS DEFEROXAMINE MESYLATE PMS DEFEROXAMINE MESYLATE PMS PMS-IBUPROFEN 400 MG IBUPROFEN PMS EFFECTIVE APRIL 1,

35 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued PMS-LEVETIRACETAM 750 MG PMS-LEVOFLOXACIN 750 MG PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID LEVETIRACETAM PMS LEVOFLOXACIN PMS LIDOCAINE HCL PMS PMS-NIZATIDINE 300 MG CAPSULE NIZATIDINE PMS PMS-PRAVASTATIN 10 MG PRAVASTATIN SODIUM PMS PMS-PRAVASTATIN 20 MG PRAVASTATIN SODIUM PMS PMS-PRAVASTATIN 40 MG PRAVASTATIN SODIUM PMS PRAMOX H.C. 1% / 1% TOPICAL CREAM PREVEX B 0.1% TOPICAL OCCLUSIVE CREAM HYDROCORTISONE ACETATE/ PRAMOXINE HCL BETAMETHASONE 17- VALERATE DPT TCD PREVEX HC 1% TOPICAL OCCLUSIVE CREAM HYDROCORTISONE TCD PROTRIN DF 800 MG / 160 MG SULFAMETHOXAZOLE/ TRIMETHOPRIM PDL PROTYLOL 10 MG CAPSULE DICYCLOMINE HCL PDL PROTYLOL 20 MG DICYCLOMINE HCL PDL RAN-LISINOPRIL 5 MG LISINOPRIL RAN RAN-LISINOPRIL 10 MG LISINOPRIL RAN RAN-LISINOPRIL 20 MG LISINOPRIL RAN RAN-PRAVASTATIN 10 MG PRAVASTATIN SODIUM RAN RAN-PRAVASTATIN 20 MG PRAVASTATIN SODIUM RAN RAN-PRAVASTATIN 40 MG PRAVASTATIN SODIUM RAN RATIO-LISINOPRIL P 5 MG LISINOPRIL RPH RATIO-LISINOPRIL P 10 MG LISINOPRIL RPH RATIO-LISINOPRIL P 20 MG LISINOPRIL RPH RATIO-LISINOPRIL Z 5 MG LISINOPRIL RPH RATIO-LISINOPRIL Z 10 MG LISINOPRIL RPH RATIO-LISINOPRIL Z 20 MG LISINOPRIL RPH RATIO-MORPHINE 1 MG / ML ORAL SYRUP MORPHINE HCL RPH 32 EFFECTIVE APRIL 1, 2010

36 Product(s) Removed from the AHWDBL as Price Policy Requirements Not Satisfied, continued RATIO-MORPHINE 5 MG / ML ORAL SYRUP RATIO-PRAVASTATIN 10 MG RATIO-PRAVASTATIN 20 MG RATIO-PRAVASTATIN 40 MG MORPHINE HCL RPH PRAVASTATIN SODIUM RPH PRAVASTATIN SODIUM RPH PRAVASTATIN SODIUM RPH RATIO-PROCTOSONE 5 MG/G / 5 MG/G / 10 MG/G / 10 MG/G RECTAL OINTMENT RATIO-PROCTOSONE 5 MG / 5 MG / 10 MG /10 MG RECTAL SUPPOSITORY HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN RPH RPH ROSASOL 1% TOPICAL CREAM METRONIDAZOLE STI SABRIL 500 MG VIGABATRIN LUI SABRIL 500 MG ORAL POWDER PACKET VIGABATRIN LUI SANDOZ ANUZINC HC PLUS 10 MG / 20 MG /10 MG RECTAL SUPPOSITORY SANDOZ ANUZINC HC PLUS 0.5% / 1% / 0.5% RECTAL OINTMENT HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE SDZ SDZ SANDOZ GENTAMICIN SULFATE 0.3% OTIC SOLUTION GENTAMICIN SULFATE SDZ SANDOZ LISINOPRIL 5 MG LISINOPRIL SDZ SANDOZ LISINOPRIL 10 MG LISINOPRIL SDZ SANDOZ LISINOPRIL 20 MG LISINOPRIL SDZ SANDOZ PRAVASTATIN 10 MG SANDOZ PRAVASTATIN 20 MG SANDOZ PRAVASTATIN 40 MG PRAVASTATIN SODIUM SDZ PRAVASTATIN SODIUM SDZ PRAVASTATIN SODIUM SDZ EFFECTIVE APRIL 1,