Summary of Changes to the Alberta Human Services Drug Benefit Supplement Effective April 1, 2012
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) 498-8384 1-877-828-4106 (Toll Free) 109BWebsite: HUhttp://www.health.alberta.ca/AHCIP/drug-benefit-list.htmlU Administered by Alberta Blue Cross on behalf of Alberta Health and Wellness. 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 Health and Wellness 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 (R2012/04)
Table of Contents Special Authorization... 1 Discontinued Special Authorization Drug Product(s)... 1 Product(s) Removed from the HSDBS as Price Policy Requirements Not Satisfied... 1 Please review the Alberta Health and Wellness Drug Benefit List in addition to this Summary of Changes EFFECTIVE APRIL 1, 2012
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 Human Services, Alberta Children s Services and Alberta Seniors (AISH) clients can be found in the April 1, 2012 Summary of Changes section of the Alberta Human Services Drug Benefit Supplement. 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, 2012. FOSAMAX 10 MG TABLET ALENDRONATE SODIUM 00002201011 MFC KETEK 400 MG TABLET TELITHROMYCIN 00002247520 SAV PANOXYL 10 % TOPICAL BAR BENZOYL PEROXIDE 00000527661 GSK PEGASYS RBV (KIT) 180 MCG / 200 MG INJECTION VIAL/TABLET PEGETRON (KIT) 100 MCG / 200 MG INJECTION VIAL/CAPSULE PEGINTERFERON ALFA-2A/ RIBAVIRIN PEGINTERFERON ALFA-2B/ RIBAVIRIN 00002253410 HLR 00002246028 MFC STIEVA-A 0.025 % TOPICAL SOLUTION TRETINOIN 00000578568 GSK Product(s) Removed from the HSDBS as Price Policy Requirements Not Satisfied The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2012, 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 April 30, 2012, claims will no longer pay for these products. ALLERNIX 2.5 MG / ML ORAL ELIXIR DIPHENHYDRAMINE HCL 00000804193 ROG ATASOL FORTE 500 MG TABLET ACETAMINOPHEN 00000013668 CHD CHILDREN'S MOTRIN 20 MG / ML ORAL SUSPENSION CHILDREN'S ADVIL 20 MG / ML ORAL SUSPENSION CHILDRENS TYLENOL 80 MG CHEWABLE TABLET IBUPROFEN 00002242365 MCL IBUPROFEN 00002232297 WCH ACETAMINOPHEN 00002238295 MCL DIMETAPP COLD 0.4 MG / ML / 1 MG / ML ORAL LIQUID BROMPHENIRAMINE MALEATE/ PHENYLEPHRINE HCL 00002243980 WCH GRAVOL 15 MG CHEWABLE TABLET DIMENHYDRINATE 00000511196 CHD GRAVOL 3 MG / ML ORAL SYRUP DIMENHYDRINATE 00000230197 CHD EFFECTIVE APRIL 1, 2012 1
Product(s) Removed from the HSDBS as Price Policy Requirements Not Satisfied, continued GRAVOL 50 MG TABLET DIMENHYDRINATE 00000013803 CHD GRAVOL 25 MG RECTAL SUPPOSITORY GRAVOL ADULT 100 MG RECTAL SUPPOSITORY DIMENHYDRINATE 00000783595 CHD DIMENHYDRINATE 00000013609 CHD IMODIUM (CAPLET) 2 MG TABLET LOPERAMIDE HCL 00002183862 MCL IMODIUM 0.13 MG / ML ORAL SOLUTION LOPERAMIDE HCL 00002291800 MCL MONISTAT 7 2% VAGINAL CREAM 00002084309 MCL MONISTAT 3 4% VAGINAL CREAM 00002244005 MCL MONISTAT 3 400 MG VAGINAL OVULE MONISTAT 1 1,200 MG VAGINAL OVULE 00002126605 MCL 00002239601 MCL MONISTAT 7 DUAL-PAK 100 MG / 2 % VAGINAL/TOPICAL MONISTAT 3 DUAL-PAK 400 MG / 2 % VAGINAL/TOPICAL MONISTAT-1 COMBINATION PACK 1,200 MG / 2 % VAGINAL/TOPICAL 00002126257 MCL 00002126249 MCL 00002239600 MCL OVOL 40 MG / ML ORAL DROPS SIMETHICONE 00000013617 CHD REACTINE 1 MG / ML ORAL SYRUP CETIRIZINE HCL 00002238337 JJM ROBITUSSIN CHILDRENS COUGH AND COLD 1.5 MG / ML / 3 MG / ML ORAL LIQUID DEXTROMETHORPHAN HBR/ PSEUDOEPHEDRINE HCL 00002044013 WCH TYLENOL EXT STR (CAPLET) 500 MG TABLET ACETAMINOPHEN 00000723908 MCL TYLENOL EXTRA STRENGTH 500 MG TABLET ACETAMINOPHEN 00000559407 MCL 2 EFFECTIVE APRIL 1, 2012