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

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

Inquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780) 498-8370 (Edmonton) (403) 294-4041 (Calgary) 1-800-361-9632 (Toll Free) FAX Number: (780) 498-8406 1-877-305-9911 (Toll Free) 109BWebsite: Hhttp://www.health.alberta.ca/services/drug-benefit-list.html Administered by Alberta Blue Cross on behalf of Alberta Health. The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Copies of the Alberta Drug Benefit List are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: 42.00 (40.00 + 2.00 G.S.T.) Contents only: 36.75 (35.00 + 1.75 G.S.T.) A cheque or money order must accompany the request for copies. ABC 40211/81160 (R2018/02)

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... 2-1 Part 3 Special Authorization... 3-1 EFFECTIVE FEBRUARY 1, 2018

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 00002436507 STM MERREM 500 MG / VIAL INJECTION MEROPENEM 00002218488 AZC MERREM 1G / VIAL INJECTION MEROPENEM 00002218496 AZC PRIMAXIN 500 MG / 500 MG / VIAL INJECTION IMIPENEM/ CILASTATIN SODIUM 00000717282 MFC Added Product(s) Trade Name / Strength / Form Generic Description DIN MFR ACH-ESCITALOPRAM 10 MG TABLET ESCITALOPRAM 00002434652 AHI ACH-ESCITALOPRAM 20 MG TABLET ESCITALOPRAM 00002434660 AHI APO-PHENYTOIN SODIUM 100 MG CAPSULE PHENYTOIN SODIUM 00002460912 ATENOLOL 50 MG TABLET ATENOLOL 00002466465 SNS ATENOLOL 100 MG TABLET ATENOLOL 00002466473 SNS CCP-CITALOPRAM 20 MG TABLET CITALOPRAM HYDROBROMIDE 00002459914 CEL CCP-CITALOPRAM 40 MG TABLET CITALOPRAM HYDROBROMIDE 00002459922 CEL CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN 00002466120 SNS JAMP-HYDRALAZINE 10 MG TABLET HYDRALAZINE HCL 00002457865 JAMP-HYDRALAZINE 25 MG TABLET HYDRALAZINE HCL 00002457873 JAMP-HYDRALAZINE 50 MG TABLET HYDRALAZINE HCL 00002457881 MINT-CLONIDINE 0.1 MG TABLET CLONIDINE HCL 00002462192 MINT-CLONIDINE 0.2 MG TABLET CLONIDINE HCL 00002462206 MYLAN-PROPAFENONE 150 MG TABLET PROPAFENONE HCL 00002457172 MYP MYLAN-PROPAFENONE 300 MG TABLET PROPAFENONE HCL 00002457164 MYP ODAN-BENZYDAMINE 0.15% ORAL RINSE BENZYDAMINE HCL 00002463105 ODN PANTOPRAZOLE T 40 MG ENTERIC-COATED TABLET RAN-GLICLAZIDE MR 60 MG SUSTAINED- RELEASE TABLET PANTOPRAZOLE MAGNESIUM 00002466147 SNS GLICLAZIDE 00002439328 RAN EFFECTIVE FEBRUARY 1, 2018 1

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, 2018. Generic Description Strength / Form New LCA Price BENZYDAMINE HCL 0.15% RINSE 0.0548 CLONIDINE HCL 0.1 MG TABLET 0.1358 CLONIDINE HCL 0.2 MG TABLET 0.2424 HYDRALAZINE HCL 10 MG TABLET 0.0709 HYDRALAZINE HCL 25 MG TABLET 0.1218 HYDRALAZINE HCL 50 MG TABLET 0.1912 PHENYTOIN SODIUM 100 MG CAPSULE 0.0665 Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until February 28, 2018. 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 00000441619 APO-HYDRALAZINE 25 MG TABLET HYDRALAZINE HCL 00000441627 APO-HYDRALAZINE 50 MG TABLET HYDRALAZINE HCL 00000441635 PHARIXIA 0.15% ORAL RINSE BENZYDAMINE HCL 00002229777 PPH TEVA-CLONIDINE 0.1 MG TABLET CLONIDINE HCL 00002046121 TEV TEVA-CLONIDINE 0.2 MG TABLET CLONIDINE HCL 00002046148 TEV XIGDUO 5 MG / 850 MG TABLET XIGDUO 5 MG / 1000 MG TABLET DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE/ METFORMIN HCL DAPAGLIFLOZIN PROPANEDIOL MONOHYDRATE/ METFORMIN HCL 00002449935 AZC 00002449943 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 00002414716 APH ACT IRBESARTAN 75 MG TABLET IRBESARTAN 00002328070 MYP ACT IRBESARTAN 150 MG TABLET IRBESARTAN 00002328089 MYP 2 EFFECTIVE FEBRUARY 1, 2018

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 00002328100 MYP ACT PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE SODIUM 00002300486 APH ACT RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 00002295490 MYP ACT RAMIPRIL 10 MG CAPSULE RAMIPRIL 00002295512 MYP ACT SERTRALINE 100 MG CAPSULE SERTRALINE HCL 00002287412 APH ACT SIMVASTATIN 10 MG TABLET SIMVASTATIN 00002248104 APH ACT SIMVASTATIN 20 MG TABLET SIMVASTATIN 00002248105 APH ACT SIMVASTATIN 40 MG TABLET SIMVASTATIN 00002248106 APH ACT SIMVASTATIN 80 MG TABLET SIMVASTATIN 00002248107 APH BENTYLOL 10 MG / 5 ML SYRUP DICYCLOMINE HCL 00002102978 AXC CEFZIL 50 MG / ML SUSPENSION CEFPROZIL 00002163683 BMS CEFZIL 250 MG TABLET CEFPROZIL 00002163659 BMS CEFZIL 500 MG TABLET CEFPROZIL 00002163667 BMS CIPROFLOXACIN 250 MG TABLET CIPROFLOXACIN HCL 00002332132 RAN CIPROFLOXACIN 500 MG TABLET CIPROFLOXACIN HCL 00002332140 RAN CIPROFLOXACIN 750 MG TABLET CIPROFLOXACIN HCL 00002332159 RAN CITALOPRAM 20 MG TABLET CITALOPRAM HYDROBROMIDE 00002331950 RAN CITALOPRAM 40 MG TABLET CITALOPRAM HYDROBROMIDE 00002331977 RAN CLAFORAN 1 G / VIAL INJECTION CEFOTAXIME SODIUM 00002225093 SAV CLAFORAN 2 G / VIAL INJECTION CEFOTAXIME SODIUM 00002225107 SAV CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 00002442035 SIV CO FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL 00002242177 APH DEPAKENE 250 MG CAPSULE VALPROIC ACID 00000443840 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 00002400421 SNS DILTIAZEM HCL 00002400448 SNS DILTIAZEM HCL 00002400456 SNS DILTIAZEM HCL 00002400464 SNS EMO-CORT 2.5% TOPICAL CREAM HYDROCORTISONE 00000595799 GSK EFFECTIVE FEBRUARY 1, 2018 3

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 00001926845 SAV GABAPENTIN 100 MG CAPSULE GABAPENTIN 00002332582 RAN GABAPENTIN 300 MG CAPSULE GABAPENTIN 00002332590 RAN ISOPTO CARPINE 1% OPHTHALMIC SOLUTION PILOCARPINE HCL 00000000841 ALC K-10 10% 1.33 MEQ / ML LIQUID POTASSIUM CHLORIDE (K+)(CL-) 00080024360 GSK LISINOPRIL 5 MG TABLET LISINOPRIL 00002332167 RAN LISINOPRIL 10 MG TABLET LISINOPRIL 00002332175 RAN LISINOPRIL 20 MG TABLET LISINOPRIL 00002332183 RAN LOTENSIN 5 MG TABLET BENAZEPRIL HCL 00000885835 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 00002420821 MAR GALANTAMINE HYDROBROMIDE 00002420848 MAR GALANTAMINE HYDROBROMIDE 00002420856 MAR METROCREAM 0.75% TOPICAL CREAM METRONIDAZOLE 00002226839 GAL MYLAN-ACEBUTOLOL (TYPE S) 400 MG TABLET ACEBUTOLOL HCL 00002237887 MYP MYLAN-CARVEDILOL 3.125 MG TABLET CARVEDILOL 00002347512 MYP MYLAN-CARVEDILOL 6.25 MG TABLET CARVEDILOL 00002347520 MYP MYLAN-CARVEDILOL 12.5 MG TABLET CARVEDILOL 00002347555 MYP MYLAN-CARVEDILOL 25 MG TABLET CARVEDILOL 00002347571 MYP MYLAN-CIMETIDINE 600 MG TABLET CIMETIDINE 00002227460 MYP MYLAN-CIPROFLOXACIN 750 MG TABLET CIPROFLOXACIN HCL 00002245649 MYP MYLAN-CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 00002230950 MYP MYLAN-FENOFIBRATE MICRO 200 MG CAPSULE FENOFIBRATE 00002240210 MYP MYLAN-FINASTERIDE 5 MG TABLET FINASTERIDE 00002356058 MYP MYLAN-GABAPENTIN 400 MG CAPSULE GABAPENTIN 00002248261 MYP MYLAN-GLICLAZIDE 80 MG TABLET GLICLAZIDE 00002229519 MYP MYLAN-IRBESARTAN 300 MG TABLET IRBESARTAN 00002347326 MYP MYLAN-MONTELUKAST 10 MG TABLET MONTELUKAST SODIUM 00002368226 MYP 4 EFFECTIVE FEBRUARY 1, 2018

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 00002408392 MYP RABEPRAZOLE SODIUM 00002408406 MYP MYLAN-RISEDRONATE 35 MG TABLET RISEDRONATE SODIUM 00002357984 MYP MYLAN-SELEGILINE 5 MG TABLET SELEGILINE HCL 00002231036 MYP NEXT CHOICE 0.75 MG TABLET LEVONORGESTREL 00002364905 MYP ORTHO 0.5 / 35 (21 DAY) 0.5 MG / 0.035 MG TABLET ORTHO 0.5 / 35 (28 DAY) 0.5 MG / 0.035 MG TABLET ORTHO 1 / 35 (21 DAY) 1 MG / 0.035 MG TABLET ORTHO 1 / 35 (28 DAY) 1 MG / 0.035 MG TABLET ORTHO 7 / 7 / 7 (21 DAY) 0.5 MG / 0.035 MG / 0.75 MG / 0.035 MG / 1 MG / 0.035 MG TABLET ORTHO 7 / 7 / 7 (28 DAY) 0.5 MG / 0.035 MG / 0.75 MG / 0.035 MG / 1 MG / 0.035 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 00000317047 JAI 00000340731 JAI 00000372846 JAI 00000372838 JAI 00000602957 JAI 00000602965 JAI PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE SODIUM 00002385759 SIV PEGASYS RBV (KIT) 180 MCG / 200 MCG INJECTION SYRINGE / TABLET PEGINTERFERON ALFA-2A/ RIBAVIRIN 00002253429 HLR PERCOCET-DEMI 2.5 MG / 325 MG TABLET OXYCODONE HCL/ ACETAMINOPHEN 00001916491 BMS PERCOCET 5 MG / 325 MG TABLET OXYCODONE HCL/ ACETAMINOPHEN 00001916475 BMS PLAN B 0.75 MG TABLET LEVONORGESTREL 00002241674 PAL PRAVASTATIN 10 MG TABLET PRAVASTATIN SODIUM 00002332191 RAN PRAVASTATIN 20 MG TABLET PRAVASTATIN SODIUM 00002332205 RAN PRAVASTATIN 40 MG TABLET PRAVASTATIN SODIUM 00002332213 RAN RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 00002332299 RAN RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 00002332302 RAN RAMIPRIL 5 MG CAPSULE RAMIPRIL 00002332310 RAN EFFECTIVE FEBRUARY 1, 2018 5

UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR RAMIPRIL 10 MG CAPSULE RAMIPRIL 00002332329 RAN RATIO-ACLAVULANATE 500 MG / 125 MG TABLET AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM 00002243771 TEV RATIO-AMCINONIDE 0.1% TOPICAL CREAM AMCINONIDE 00002247098 TEV RATIO-AMCINONIDE 0.1 % TOPICAL LOTION AMCINONIDE 00002247097 TEV RATIO-AMCINONIDE 0.1 % TOPICAL OINTMENT AMCINONIDE 00002247096 TEV RATIO-ATENOLOL 50 MG TABLET ATENOLOL 00002171791 TEV RATIO-ATENOLOL 100 MG TABLET ATENOLOL 00002171805 TEV RATIO-ATORVASTATIN 80 MG TABLET ATORVASTATIN CALCIUM 00002350335 TEV RATIO-DEXAMETHASONE 0.5 MG TABLET DEXAMETHASONE 00002240684 TEV RATIO-DEXAMETHASONE 4 MG TABLET DEXAMETHASONE 00002240687 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 00002266717 JAI GALANTAMINE HYDROBROMIDE 00002266725 JAI RISPERIDONE 00002247704 JAI RISPERIDONE 00002247705 JAI RISPERIDONE 00002247706 JAI RISPERIDONE 0.25 MG TABLET RISPERIDONE 00002332051 RAN RISPERIDONE 0.5 MG TABLET RISPERIDONE 00002332078 RAN RISPERIDONE 1 MG TABLET RISPERIDONE 00002332086 RAN RISPERIDONE 2 MG TABLET RISPERIDONE 00002332094 RAN RISPERIDONE 3 MG TABLET RISPERIDONE 00002332108 RAN RISPERIDONE 4 MG TABLET RISPERIDONE 00002332116 RAN ROPINIROLE 0.25 MG TABLET ROPINIROLE HCL 00002332361 RAN ROPINIROLE 1 MG TABLET ROPINIROLE HCL 00002332426 RAN ROPINIROLE 2 MG TABLET ROPINIROLE HCL 00002332434 RAN ROPINIROLE 5 MG TABLET ROPINIROLE HCL 00002332442 RAN SEROPHENE 50 MG TABLET CLOMIPHENE CITRATE 00000893722 SRO SIMVASTATIN 5 MG TABLET SIMVASTATIN 00002331969 RAN 6 EFFECTIVE FEBRUARY 1, 2018

UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued Trade Name / Strength / Form Generic Description DIN MFR SIMVASTATIN 10 MG TABLET SIMVASTATIN 00002331985 RAN SIMVASTATIN 20 MG TABLET SIMVASTATIN 00002331993 RAN SIMVASTATIN 40 MG TABLET SIMVASTATIN 00002332000 RAN SIMVASTATIN 80 MG TABLET SIMVASTATIN 00002332019 RAN SOTALOL 80 MG TABLET SOTALOL HCL 00002385988 SIV SOTALOL 160 MG TABLET SOTALOL HCL 00002385996 SIV SUNVEPRA 100 MG CAPSULE ASUNAPREVIR 00002452294 BMS TEVA-ALENDRONATE 10 MG TABLET ALENDRONATE SODIUM 00002247373 TEV TEVA-DORZOTIMOL 2% / 0.5% OPHTHALMIC SOLUTION DORZOLAMIDE HCL/ TIMOLOL MALEATE 00002320525 TEV TOBRAMYCIN USP 40 MG / ML INJECTION TOBRAMYCIN SULFATE 00002382814 MYP VOLTAREN 100 MG RECTAL SUPPOSITORY DICLOFENAC SODIUM 00000632732 NOV EFFECTIVE FEBRUARY 1, 2018 7

Drug Additions PART 2 Drug Additions

ALBERTA DRUG BENEFIT LIST UPDATE ATENOLOL 50 MG ORAL TABLET 00002255545 ACT ATENOLOL 00000773689 APO-ATENOL 00002238316 ATENOLOL 00002466465 ATENOLOL 00002367564 JAMP-ATENOLOL 00002371987 MAR-ATENOLOL 00002368021 MINT-ATENOL 00002146894 MYLAN-ATENOLOL 00002237600 PMS-ATENOLOL 00002267985 RAN-ATENOLOL 00002368641 SEPTA-ATENOLOL 00002039532 TENORMIN 100 MG ORAL TABLET 00002255553 00000773697 00002238318 00002466473 00002367572 00002371995 00002368048 00002147432 00002237601 00002267993 00002368668 00002039540 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 0.6086 1.0006 BENZYDAMINE HCL 0.15 % ORAL RINSE 00002463105 ODAN-BENZYDAMINE 00002229777 PHARIXIA ODN PPH 0.0548 0.0548 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

ALBERTA DRUG BENEFIT LIST UPDATE CITALOPRAM HYDROBROMIDE 20 MG (BASE) ORAL TABLET 00002355256 ACCEL-CITALOPRAM 00002248050 ACT CITALOPRAM 00002246056 APO-CITALOPRAM 00002275562 AURO-CITALOPRAM 00002459914 CCP-CITALOPRAM 00002353660 CITALOPRAM 00002387956 CITALOPRAM 00002430541 CITALOPRAM 00002313405 JAMP-CITALOPRAM 00002371898 MAR-CITALOPRAM 00002304686 MINT-CITALOPRAM 00002429705 MINT-CITALOPRAM 00002246594 MYLAN-CITALOPRAM 00002409011 NAT-CITALOPRAM 00002248010 PMS-CITALOPRAM 00002285622 RAN-CITALO 00002248170 SANDOZ CITALOPRAM 00002355272 SEPTA-CITALOPRAM 00002293218 TEVA-CITALOPRAM 00002438747 VAN-CITALOPRAM 00002239607 CELEXA 40 MG (BASE) ORAL TABLET 00002355264 00002248051 00002246057 00002275570 00002459922 00002353679 00002387964 00002430568 00002313413 00002371901 00002304694 00002429713 00002246595 00002409038 00002248011 00002285630 00002248171 00002355280 00002293226 00002438755 00002239608 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 1.3818 1.3818 CLARITHROMYCIN 250 MG ORAL TABLET 00002442469 CLARITHROMYCIN 00002466120 CLARITHROMYCIN 00002247573 PMS-CLARITHROMYCIN 00002361426 RAN-CLARITHROMYCIN 00002266539 SANDOZ CLARITHROMYCIN 00002248804 TEVA-CLARITHROMYCIN 00001984853 BIAXIN BID SIV SNS PMS RAN SDZ TEV BGP 0.4122 0.4122 0.4122 0.4122 0.4122 0.4122 1.6833 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

ALBERTA DRUG BENEFIT LIST UPDATE CLONIDINE HCL 0.1 MG ORAL TABLET 00002462192 MINT-CLONIDINE 00002046121 TEVA-CLONIDINE 0.2 MG ORAL TABLET 00002462206 MINT-CLONIDINE 00002046148 TEVA-CLONIDINE TEV TEV 0.1358 0.1358 0.2424 0.2424 ESCITALOPRAM 10 MG ORAL TABLET 00002434652 ACH-ESCITALOPRAM 00002313561 ACT ESCITALOPRAM 00002295016 APO-ESCITALOPRAM 00002397358 AURO-ESCITALOPRAM 00002429039 ESCITALOPRAM 00002430118 ESCITALOPRAM 00002429780 JAMP-ESCITALOPRAM 00002423480 MAR-ESCITALOPRAM 00002407418 MINT-ESCITALOPRAM 00002309467 MYLAN-ESCITALOPRAM 00002440296 NAT-ESCITALOPRAM 00002303949 PMS-ESCITALOPRAM 00002385481 RAN-ESCITALOPRAM 00002364077 SANDOZ ESCITALOPRAM 00002318180 TEVA-ESCITALOPRAM 00002263238 CIPRALEX 20 MG ORAL TABLET 00002434660 00002313588 00002295024 00002397374 00002429047 00002430126 00002429799 00002423502 00002407434 00002309475 00002440318 00002303965 00002385503 00002364085 00002318202 00002263254 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 1.7900 1.9111 GLICLAZIDE 60 MG ORAL SUSTAINED-RELEASE TABLET 00002407124 APO-GLICLAZIDE MR 00002423294 MINT-GLICLAZIDE MR 00002439328 RAN-GLICLAZIDE MR 00002461331 SANDOZ GLICLAZIDE MR 00002356422 DIAMICRON MR RAN SDZ SEV 0.0632 0.0632 0.0632 0.0632 0.2529 HYDRALAZINE HCL 10 MG ORAL TABLET 00000441619 APO-HYDRALAZINE 00002457865 JAMP-HYDRALAZINE 25 MG ORAL TABLET 00000441627 APO-HYDRALAZINE 00002457873 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 0.0709 0.0709 0.1218 0.1218 2. 3 EFFECTIVE FEBRUARY 1, 2018

ALBERTA DRUG BENEFIT LIST UPDATE HYDRALAZINE HCL 50 MG ORAL TABLET 00000441635 APO-HYDRALAZINE 00002457881 JAMP-HYDRALAZINE 0.1912 0.1912 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 00000717282 PRIMAXIN MFC 25.6921 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 00002218488 MERREM 1 G / VIAL INJECTION 00002436507 MEROPENEM FOR INJECTION USP 00002218496 MERREM AZC STM AZC 26.3500 44.7950 52.7000 PANTOPRAZOLE MAGNESIUM 40 MG ORAL ENTERIC-COATED TABLET 00002408570 MYLAN-PANTOPRAZOLE T 00002441853 PANTOPRAZOLE MAGNESIUM 00002466147 PANTOPRAZOLE T 00002440628 TEVA-PANTOPRAZOLE MAGNESIUM 00002267233 TECTA MYP ALH SNS TEV TAK 0.1875 0.1875 0.1875 0.1875 0.7500 PHENYTOIN SODIUM 100 MG ORAL CAPSULE 00002460912 APO-PHENYTOIN SODIUM 00000022780 DILANTIN PFI 0.0665 0.0853 PROPAFENONE HCL 150 MG ORAL TABLET 00002243324 APO-PROPAFENONE 00002457172 MYLAN-PROPAFENONE 00000603708 RYTHMOL 300 MG ORAL TABLET 00002243325 00002457164 00000603716 APO-PROPAFENONE MYLAN-PROPAFENONE RYTHMOL MYP BGP MYP BGP 0.2965 0.2965 1.2012 0.5227 0.5227 2.1172 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

Special Authorization PART 3 Special Authorization

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 00000717282 PRIMAXIN MFC 25.6921 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

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 00002218488 MERREM 1 G / VIAL INJECTION 00002436507 00002218496 MEROPENEM FOR INJECTION USP MERREM AZC STM AZC 26.3500 44.7950 52.7000 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