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

Updates to the Alberta Drug Benefit List Effective September 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) Website: http://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 (R2018/09)

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

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 00002464705 RAP CYSTEAMINE BITARTRATE 00002464713 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 00002435675 Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Step Therapy / Special Authorization -SOLIFENACIN 10 MG TABLET SOLIFENACIN SUCCINATE 00002437996 Drug Product(s) with Changes to Criteria for Coverage DIFICID 200 MG TABLET FIDAXOMICIN 00002387174 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 00002460025 O-ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 00002460033 JAMP-ENTECAVIR 0.5 MG TABLET ENTECAVIR 00002467232 JPC NAT-TENOFOVIR 300 MG TABLET TENOFOVIR DISOPROXIL FUMARATE 00002472511 NTP -ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 00002466635 -ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 00002466643 SANDOZ ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 00002473658 SANDOZ ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 00002473666 EFFECTIVE SEPTEMBER 1, 2018 1

Added Product(s) UPDATES TO THE ALBERTA DRUG BENEFIT LIST APO-PREGABALIN 25 MG CAPSULE PREGABALIN 00002394235 APO-PREGABALIN 50 MG CAPSULE PREGABALIN 00002394243 APO-PREGABALIN 75 MG CAPSULE PREGABALIN 00002394251 APO-PREGABALIN 150 MG CAPSULE PREGABALIN 00002394278 APO-PREGABALIN 300 MG CAPSULE PREGABALIN 00002394294 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 00002457229 QUETIAPINE FUMARATE 00002457237 QUETIAPINE FUMARATE 00002457245 QUETIAPINE FUMARATE 00002457253 QUETIAPINE FUMARATE 00002457261 O-ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 00002460041 O-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 00002460068 O-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 00002460076 O-ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE 00002460084 O-CANDESARTAN 8 MG TABLET CANDESARTAN CILEXETIL 00002445794 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 0.005 % OPHTHALMIC SOLUTION DILTIAZEM HCL 00002465353 MAR DILTIAZEM HCL 00002465361 MAR DILTIAZEM HCL 00002465388 MAR DILTIAZEM HCL 00002465396 MAR DILTIAZEM HCL 00002465418 MAR LATANOPROST 00002426935 GMP MINT-PREGABALIN 25 MG CAPSULE PREGABALIN 00002423804 MPI MINT-PREGABALIN 50 MG CAPSULE PREGABALIN 00002423812 MPI MINT-PREGABALIN 75 MG CAPSULE PREGABALIN 00002424185 MPI MINT-PREGABALIN 150 MG CAPSULE PREGABALIN 00002424207 MPI PHARMA-SIMVASTATIN 10 MG TABLET SIMVASTATIN 00002469987 2 EFFECTIVE SEPTEMBER 1, 2018

Added Product(s), continued UPDATES TO THE ALBERTA DRUG BENEFIT LIST -ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 00002466651 -ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 00002466678 -ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 00002466686 -ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE 00002466694 -LACTULOSE-PHARMA 667 MG / ML ORAL SYRUP -NITROFUTOIN 100 MG CAPSULE (MACROCRYSTALS / MONOHYDRATE) LACTULOSE 00002469391 NITROFUTOIN 00002455676 -PREGABALIN 25 MG CAPSULE PREGABALIN 00002359596 -PREGABALIN 50 MG CAPSULE PREGABALIN 00002359618 -PREGABALIN 75 MG CAPSULE PREGABALIN 00002359626 -PREGABALIN 150 MG CAPSULE PREGABALIN 00002359634 -PREGABALIN 300 MG CAPSULE PREGABALIN 00002359642 -TDOLAPRIL 0.5 MG CAPSULE TDOLAPRIL 00002357755 -TDOLAPRIL 1 MG CAPSULE TDOLAPRIL 00002357763 -TDOLAPRIL 2 MG CAPSULE TDOLAPRIL 00002357771 -TDOLAPRIL 4 MG CAPSULE TDOLAPRIL 00002357798 PREGABALIN 25 MG CAPSULE PREGABALIN 00002403692 SIV PREGABALIN 25 MG CAPSULE PREGABALIN 00002405539 PREGABALIN 50 MG CAPSULE PREGABALIN 00002403706 SIV PREGABALIN 50 MG CAPSULE PREGABALIN 00002405547 PREGABALIN 75 MG CAPSULE PREGABALIN 00002403714 SIV PREGABALIN 75 MG CAPSULE PREGABALIN 00002405555 PREGABALIN 150 MG CAPSULE PREGABALIN 00002403722 SIV PREGABALIN 150 MG CAPSULE PREGABALIN 00002405563 PREGABALIN 300 MG CAPSULE PREGABALIN 00002403730 SIV PREGABALIN 300 MG CAPSULE PREGABALIN 00002405598 -PREGABALIN 25 MG CAPSULE PREGABALIN 00002392801 -PREGABALIN 50 MG CAPSULE PREGABALIN 00002392828 -PREGABALIN 75 MG CAPSULE PREGABALIN 00002392836 -PREGABALIN 150 MG CAPSULE PREGABALIN 00002392844 -PREGABALIN 300 MG CAPSULE PREGABALIN 00002392860 -RAMIPRIL HCTZ 2.5 MG / 12.5 MG TABLET RAMIPRIL/ HYDROCHLOROTHIAZIDE 00002449439 -RAMIPRIL HCTZ 5 MG / 25 MG TABLET RAMIPRIL/ HYDROCHLOROTHIAZIDE 00002449463 EFFECTIVE SEPTEMBER 1, 2018 3

Added Product(s), continued UPDATES TO THE ALBERTA DRUG BENEFIT LIST SANDOZ ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 00002473674 SANDOZ ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 00002473682 SANDOZ ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 00002473690 SANDOZ ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE 00002473704 SANDOZ PRAVASTATIN 10 MG TABLET PRAVASTATIN SODIUM 00002468700 SANDOZ PRAVASTATIN 20 MG TABLET PRAVASTATIN SODIUM 00002468719 SANDOZ PRAVASTATIN 40 MG TABLET PRAVASTATIN SODIUM 00002468727 SANDOZ PREGABALIN 25 MG CAPSULE PREGABALIN 00002390817 SANDOZ PREGABALIN 50 MG CAPSULE PREGABALIN 00002390825 SANDOZ PREGABALIN 75 MG CAPSULE PREGABALIN 00002390833 SANDOZ PREGABALIN 150 MG CAPSULE PREGABALIN 00002390841 SANDOZ PREGABALIN 300 MG CAPSULE PREGABALIN 00002390868 SANDOZ TDOLAPRIL 0.5 MG CAPSULE TDOLAPRIL 00002325721 SANDOZ TDOLAPRIL 1 MG CAPSULE TDOLAPRIL 00002325748 SANDOZ TDOLAPRIL 2 MG CAPSULE TDOLAPRIL 00002325756 SANDOZ TDOLAPRIL 4 MG CAPSULE TDOLAPRIL 00002325764 A-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 00002464179 A-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 00002464187 New Established Interchangeable (IC) Grouping(s) The following IC Grouping(s) have been established and LCA pricing will be applied effective October 1, 2018. Generic Description Strength / Form New LCA Price NITROFUTOIN 100 MG CAPSULE (MACROCRYSTALS / MONOHYDRATE) 0.5974 PREGABALIN 25 MG CAPSULE 0.1481 PREGABALIN 50 MG CAPSULE 0.2324 PREGABALIN 75 MG CAPSULE 0.3007 PREGABALIN 150 MG CAPSULE PREGABALIN 300 MG CAPSULE RAMIPRIL/ HYDROCHLOROTHIAZIDE 2.5 MG / 12.5 MG TABLET 0.1495 RAMIPRIL/ HYDROCHLOROTHIAZIDE 5 MG / 25 MG TABLET 0.1915 TDOLAPRIL 0.5 MG CAPSULE 0.1395 TDOLAPRIL 1 MG CAPSULE 0.3523 TDOLAPRIL 2 MG CAPSULE 0.4049 4 EFFECTIVE SEPTEMBER 1, 2018

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, 2018. Generic Description Strength / Form New LCA Price TDOLAPRIL 4 MG CAPSULE 0.4995 VARENICLINE TARTRATE/ VARENICLINE TARTRATE 0.5 MG / 1 MG TABLET 1.3804 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, 2018. Please review the online Alberta Drug Benefit List at https://www.ab.bluecross.ca/dbl/idbl_main1.html for further information. Generic Description Strength / Form New LCA Price ARIPIPRAZOLE 2 MG TABLET 0.8092 ARIPIPRAZOLE 5 MG TABLET 0.9046 ARIPIPRAZOLE 10 MG TABLET 1.0754 ARIPIPRAZOLE 15 MG TABLET 1.2692 ARIPIPRAZOLE 20 MG TABLET 1.0017 ARIPIPRAZOLE 30 MG TABLET 1.0017 QUETIAPINE FUMARATE 50 MG 0.2501 QUETIAPINE FUMARATE 150 MG 0.4926 QUETIAPINE FUMARATE 200 MG 0.6661 QUETIAPINE FUMARATE 300 MG 0.9776 QUETIAPINE FUMARATE 400 MG 1.3270 Product(s) with a Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until September 30, 2018. For products within an established IC Grouping, the LCA price may apply. APO-ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 00002471086 APO-ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 00002471094 APO-ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 00002471108 APO-ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 00002471116 APO-ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 00002471124 APO-ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE 00002471132 EFFECTIVE SEPTEMBER 1, 2018 5

UPDATES TO THE ALBERTA DRUG BENEFIT LIST Product(s) with a Price Change, continued CLINDOXYL ADV 1 % / 3 % TOPICAL GEL CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE 00002382822 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 00002407671 QUETIAPINE FUMARATE 00002407698 QUETIAPINE FUMARATE 00002407701 QUETIAPINE FUMARATE 00002407728 QUETIAPINE FUMARATE 00002407736 QUETIAPINE FUMARATE 00002395444 QUETIAPINE FUMARATE 00002395452 QUETIAPINE FUMARATE 00002395460 QUETIAPINE FUMARATE 00002395479 QUETIAPINE FUMARATE 00002395487 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 00002357399 APH ACT ROSUVASTATIN 20 MG TABLET ROSUVASTATIN CALCIUM 00002339781 APH ACT ZOPICLONE 5 MG TABLET ZOPICLONE 00002271931 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 00002314649 FENTANYL 00002314657 RABEPRAZOLE SODIUM 00002345587 MYLAN-ACEBUTOLOL 100 MG TABLET ACEBUTOLOL HCL 00002237721 MYP 6 EFFECTIVE SEPTEMBER 1, 2018

UPDATES TO THE ALBERTA DRUG BENEFIT LIST Discontinued Listing(s), continued MYLAN-ACEBUTOLOL 200 MG TABLET ACEBUTOLOL HCL 00002237722 MYP MYLAN-ACEBUTOLOL 400 MG TABLET ACEBUTOLOL HCL 00002237723 MYP MYLAN-TELMISARTAN 40 MG TABLET TELMISARTAN 00002376717 MYP EFFECTIVE SEPTEMBER 1, 2018 7

Drug Additions PART 2 Drug Additions

ALBERTA DRUG BENEFIT LIST UPDATE ARIPIPRAZOLE 2 MG ORAL TABLET 00002471086 APO-ARIPIPRAZOLE 00002460025 O-ARIPIPRAZOLE 00002466635 -ARIPIPRAZOLE 00002473658 SANDOZ ARIPIPRAZOLE 00002322374 ABILIFY OTS 0.8092 0.8092 0.8092 0.8092 3.0878 ALBERTA HEALTH RESTRICTED BENEFIT This Drug Product is a benefit for patients 13 to 17 years of age inclusive. 5 MG ORAL TABLET 00002471094 APO-ARIPIPRAZOLE 00002460033 O-ARIPIPRAZOLE 00002466643 -ARIPIPRAZOLE 00002473666 SANDOZ ARIPIPRAZOLE 00002322382 ABILIFY OTS 0.9046 0.9046 0.9046 0.9046 3.4757 ALBERTA HEALTH RESTRICTED BENEFIT This Drug Product is a benefit for patients 13 to 17 years of age inclusive. 10 MG ORAL TABLET 00002471108 APO-ARIPIPRAZOLE 00002460041 O-ARIPIPRAZOLE 00002466651 -ARIPIPRAZOLE 00002473674 SANDOZ ARIPIPRAZOLE 00002322390 ABILIFY 15 MG ORAL TABLET 00002471116 APO-ARIPIPRAZOLE 00002460068 O-ARIPIPRAZOLE 00002466678 -ARIPIPRAZOLE 00002473682 SANDOZ ARIPIPRAZOLE 00002464179 A-ARIPIPRAZOLE 00002322404 ABILIFY 20 MG ORAL TABLET 00002471124 APO-ARIPIPRAZOLE 00002460076 O-ARIPIPRAZOLE 00002466686 -ARIPIPRAZOLE 00002473690 SANDOZ ARIPIPRAZOLE 00002464187 A-ARIPIPRAZOLE 00002322412 ABILIFY 30 MG ORAL TABLET 00002471132 00002460084 00002466694 00002473704 00002322455 APO-ARIPIPRAZOLE O-ARIPIPRAZOLE -ARIPIPRAZOLE SANDOZ ARIPIPRAZOLE ABILIFY OTS OTS OTS OTS 1.0754 1.0754 1.0754 1.0754 4.0055 1.2692 1.2692 1.2692 1.2692 1.2692 4.0055 1.0017 1.0017 1.0017 1.0017 1.0017 4.0055 1.0017 1.0017 1.0017 1.0017 4.0055 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

ALBERTA DRUG BENEFIT LIST UPDATE CANDESARTAN CILEXETIL 8 MG ORAL TABLET 00002376539 ACT CANDESARTAN 00002365359 APO-CANDESARTAN 00002445794 O-CANDESARTAN 00002388707 CANDESARTAN 00002388928 CANDESARTAN 00002379279 CANDESARTAN CILEXETIL 00002386518 JAMP-CANDESARTAN 00002379139 MYLAN-CANDESARTAN 00002391198 -CANDESARTAN 00002380692 -CANDESARTAN 00002326965 SANDOZ CANDESARTAN 00002366312 A-CANDESARTAN 00002239091 ATACAND APH SIV AHI JPC MYP AZC 1.2490 DILTIAZEM HCL 120 MG ORAL EXTENDED-RELEASE CAPSULE 00002370441 ACT DILTIAZEM T 00002465353 MAR-DILTIAZEM T 00002245918 SANDOZ DILTIAZEM T 00002271605 A-DILTIAZEM HCL ER 00002231150 TIAZAC 180 MG ORAL EXTENDED-RELEASE CAPSULE 00002370492 ACT DILTIAZEM T 00002465361 MAR-DILTIAZEM T 00002245919 SANDOZ DILTIAZEM T 00002271613 A-DILTIAZEM HCL ER 00002231151 TIAZAC 240 MG ORAL EXTENDED-RELEASE CAPSULE 00002370506 ACT DILTIAZEM T 00002465388 MAR-DILTIAZEM T 00002245920 SANDOZ DILTIAZEM T 00002271621 A-DILTIAZEM HCL ER 00002231152 TIAZAC 300 MG ORAL EXTENDED-RELEASE CAPSULE 00002370514 ACT DILTIAZEM T 00002465396 MAR-DILTIAZEM T 00002245921 SANDOZ DILTIAZEM T 00002271648 A-DILTIAZEM HCL ER 00002231154 TIAZAC 360 MG ORAL EXTENDED-RELEASE CAPSULE 00002370522 00002465418 00002245922 00002271656 00002231155 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 0.2133 0.2133 0.2133 0.2133 0.9217 0.2889 0.2889 0.2889 0.2889 1.2312 0.3832 0.3832 0.3832 0.3832 1.6331 0.4719 0.4719 0.4719 0.4719 2.0454 0.5778 0.5778 0.5778 0.5778 2.4625 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 00002396955 APO-ENTECAVIR 00002448777 O-ENTECAVIR 00002467232 JAMP-ENTECAVIR 00002430576 -ENTECAVIR 00002282224 BARACLUDE JPC BMS 5.5000 5.5000 5.5000 5.5000 22.4620 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

ALBERTA DRUG BENEFIT LIST UPDATE LACTULOSE 667 MG / ML ORAL SYRUP 00002242814 APO-LACTULOSE 00002295881 JAMP-LACTULOSE 00002412268 LACTULOSE 00000703486 -LACTULOSE 00002469391 -LACTULOSE-PHARMA 00000854409 RATIO-LACTULOSE 00002331551 A-LACTULOSE JPC 0.0145 0.0145 0.0145 0.0145 0.0145 0.0145 0.0145 LATANOPROST 0.005 % OPHTHALMIC SOLUTION 00002296527 APO-LATANOPROST 00002254786 CO LATANOPROST 00002373041 GD-LATANOPROST 00002426935 MED-LATANOPROST 00002367335 SANDOZ LATANOPROST 00002231493 XALATAN APH GMD GMP PFI 3.6320 3.6320 3.6320 3.6320 3.6320 11.8680 NITROFUTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE) 00002455676 -NITROFUTOIN 00002063662 MACROBID ASC 0.5974 0.7859 PRAVASTATIN SODIUM 10 MG ORAL TABLET 00002248182 ACT PRAVASTATIN 00002243506 APO-PRAVASTATIN 00002330954 JAMP-PRAVASTATIN 00002432048 MAR-PRAVASTATIN 00002317451 MINT-PRAVASTATIN 00002247655 -PRAVASTATIN 00002356546 PRAVASTATIN 00002389703 PRAVASTATIN 00002284421 -PRAVASTATIN 00002468700 SANDOZ PRAVASTATIN TABLETS 00002247008 A-PRAVASTATIN 20 MG ORAL TABLET 00002248183 00002243507 00002330962 00002432056 00002317478 00002247656 00002356554 00002389738 00002284448 00002468719 00002247009 00000893757 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 1.1243 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

ALBERTA DRUG BENEFIT LIST UPDATE PRAVASTATIN SODIUM 40 MG ORAL TABLET 00002248184 ACT PRAVASTATIN 00002243508 APO-PRAVASTATIN 00002330970 JAMP-PRAVASTATIN 00002432064 MAR-PRAVASTATIN 00002317486 MINT-PRAVASTATIN 00002247657 -PRAVASTATIN 00002356562 PRAVASTATIN 00002389746 PRAVASTATIN 00002284456 -PRAVASTATIN 00002468727 SANDOZ PRAVASTATIN TABLETS 00002247010 A-PRAVASTATIN 00002222051 PRAVACHOL APH JPC MAR MPI SIV BMS 1.3543 PREGABALIN 25 MG ORAL CAPSULE 00002394235 APO-PREGABALIN 00002423804 MINT-PREGABALIN 00002359596 -PREGABALIN 00002403692 PREGABALIN 00002405539 PREGABALIN 00002392801 -PREGABALIN 00002390817 SANDOZ PREGABALIN 50 MG ORAL CAPSULE 00002394243 APO-PREGABALIN 00002423812 MINT-PREGABALIN 00002359618 -PREGABALIN 00002403706 PREGABALIN 00002405547 PREGABALIN 00002392828 -PREGABALIN 00002390825 SANDOZ PREGABALIN 75 MG ORAL CAPSULE 00002394251 APO-PREGABALIN 00002424185 MINT-PREGABALIN 00002359626 -PREGABALIN 00002403714 PREGABALIN 00002405555 PREGABALIN 00002392836 -PREGABALIN 00002390833 SANDOZ PREGABALIN 150 MG ORAL CAPSULE 00002394278 APO-PREGABALIN 00002424207 MINT-PREGABALIN 00002359634 -PREGABALIN 00002403722 PREGABALIN 00002405563 PREGABALIN 00002392844 -PREGABALIN 00002390841 SANDOZ PREGABALIN 300 MG ORAL CAPSULE 00002394294 00002359642 00002403730 00002405598 00002392860 00002390868 APO-PREGABALIN -PREGABALIN PREGABALIN PREGABALIN -PREGABALIN SANDOZ PREGABALIN MPI SIV MPI SIV MPI SIV MPI SIV SIV 0.1481 0.1481 0.1481 0.1481 0.1481 0.1481 0.1481 0.2324 0.2324 0.2324 0.2324 0.2324 0.2324 0.2324 0.3007 0.3007 0.3007 0.3007 0.3007 0.3007 0.3007 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

ALBERTA DRUG BENEFIT LIST UPDATE QUETIAPINE FUMARATE 50 MG (BASE) ORAL 00002457229 APO-QUETIAPINE XR 00002407671 SANDOZ QUETIAPINE XRT 00002395444 A-QUETIAPINE XR 00002300184 SEROQUEL XR 150 MG (BASE) ORAL 00002457237 APO-QUETIAPINE XR 00002407698 SANDOZ QUETIAPINE XRT 00002395452 A-QUETIAPINE XR 00002321513 SEROQUEL XR 200 MG (BASE) ORAL 00002457245 APO-QUETIAPINE XR 00002407701 SANDOZ QUETIAPINE XRT 00002395460 A-QUETIAPINE XR 00002300192 SEROQUEL XR 300 MG (BASE) ORAL 00002457253 APO-QUETIAPINE XR 00002407728 SANDOZ QUETIAPINE XRT 00002395479 A-QUETIAPINE XR 00002300206 SEROQUEL XR 400 MG (BASE) ORAL 00002457261 00002407736 00002395487 00002300214 APO-QUETIAPINE XR SANDOZ QUETIAPINE XRT A-QUETIAPINE XR SEROQUEL XR AZC AZC AZC AZC AZC 0.2501 0.2501 0.2501 1.0003 0.4926 0.4926 0.4926 1.9701 0.6661 0.6661 0.6661 2.6641 0.9776 0.9776 0.9776 3.9101 1.3270 1.3270 1.3270 5.3080 RAMIPRIL/ HYDROCHLOROTHIAZIDE 2.5 MG * 12.5 MG ORAL TABLET 00002449439 -RAMIPRIL HCTZ 00002283131 ALTACE HCT 5 MG * 25 MG ORAL TABLET 00002449463 -RAMIPRIL HCTZ 00002283174 ALTACE HCT VCL VCL 0.1495 0.3048 0.1915 0.3897 SIMVASTATIN 10 MG ORAL TABLET 00002247012 APO-SIMVASTATIN 00002405156 O-SIMVASTATIN 00002375605 JAMP-SIMVASTATIN 00002375044 MAR-SIMVASTATIN 00002372940 MINT-SIMVASTATIN 00002246583 MYLAN-SIMVASTATIN 00002469987 PHARMA-SIMVASTATIN 00002269260 -SIMVASTATIN 00002329158 -SIMVASTATIN 00002284731 SIMVASTATIN 00002386305 SIMVASTATIN 00002250152 A-SIMVASTATIN 00000884332 ZOCOR JPC MAR MPI MYP SIV MFC 2.2268 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

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 00002451980 APO-TENOFOVIR 00002460173 O-TENOFOVIR 00002452634 MYLAN-TENOFOVIR DISOPROXIL 00002472511 NAT-TENOFOVIR 00002453940 -TENOFOVIR 00002403889 A-TENOFOVIR 00002247128 VIREAD MYP NTP GIL 4.8884 4.8884 4.8884 4.8884 4.8884 4.8884 18.4879 TDOLAPRIL 0.5 MG ORAL CAPSULE 00002357755 -TDOLAPRIL 00002325721 SANDOZ TDOLAPRIL 00002231457 MAVIK 1 MG ORAL CAPSULE 00002357763 -TDOLAPRIL 00002325748 SANDOZ TDOLAPRIL 00002231459 MAVIK 2 MG ORAL CAPSULE 00002357771 -TDOLAPRIL 00002325756 SANDOZ TDOLAPRIL 00002231460 MAVIK 4 MG ORAL CAPSULE 00002357798 00002325764 00002239267 -TDOLAPRIL SANDOZ TDOLAPRIL MAVIK BGP BGP BGP BGP 0.1395 0.1395 0.2790 0.3523 0.3523 0.7046 0.4049 0.4049 0.8098 0.4995 0.4995 0.9990 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 00002435675 APO-VARENICLINE (STARTER PACK) 00002298309 CHAMPIX (STARTER PACK) PFI 1.3804 1.8370 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

Special Authorization PART 3 Special Authorization

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 00002382822 CLINDOXYL ADV GSK 0.7800 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 00002464705 PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE 00002464713 PROCYSBI RAP RAP 10.3500 31.0500 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 00002387174 DIFICID MFC 94.6000 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

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 00002446383 00002424347 00002428938 00002443198 00002417731 00002437996 00002399040 00002458268 00002448343 00002397919 00002277271 O-SOLIFENACIN JAMP-SOLIFENACIN MED-SOLIFENACIN MINT-SOLIFENACIN -SOLIFENACIN -SOLIFENACIN SANDOZ SOLIFENACIN SOLIFENACIN SOLIFENACIN SUCCINATE A-SOLIFENACIN VESICARE JPC GMP MPI MDA ASP 0.3041 0.3041 0.3041 0.3041 0.3041 0.3041 0.3041 0.3041 0.3041 0.3041 1.5135 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 00002435675 00002298309 APO-VARENICLINE (STARTER PACK) CHAMPIX (STARTER PACK) PFI 1.3804 1.8370 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