00:00 Antihistamine Drugs 00:00. Non-Classified Drugs

Transcription

1 00:00 Antihistamine Drugs 00:00 Non-Classified Drugs

2 00:00 NON-CLASSIFIED DRUGS 00:00.02 (DIABETES SUPPLIES) DIABETES SUPPLIES BLOOD GLUCOSE TEST STRIPS BLOOD LETTING LANCET INSULIN PEN NEEDLES INSULIN SYRINGES URINE TEST STRIPS XXX XXX XXX XXX XXX This product is a benefit for patients with diabetes who are currently and regularly using insulin Eligible individuals will have coverage to a maximum of 600 per person each benefit year for eligible diabetic supplies purchased from a licensed pharmacy. UNIT OF ISSUE - REFER TO PRICE POLICY 1 EFFECTIVE APRIL 1, 2018

3 04:00 Antihistamine Drugs 04:00 Antihistamine Drugs

4 04:00 ANTIHISTAMINE DRUGS 04:04.04 FIRST GENERATION ANTIHISTAMINES (ETHANOLAMINE DERIVATIVES) DIPHENHYDRAMINE HCL 50 MG / ML INJECTION DIPHENHYDRAMINE :00 ANTIHISTAMINE DRUGS 04:04.12 FIRST GENERATION ANTIHISTAMINES (PHENOTHIAZINE DERIVATIVES) TRIMEPRAZINE TARTRATE 2.5 MG (BASE) ORAL TABLET PANECTYL 5 MG (BASE) ORAL TABLET PANECTYL ERF ERF :00 ANTIHISTAMINE DRUGS 04:92 OTHER ANTIHISTAMINES KETOTIFEN FUMARATE 1 MG (BASE) ORAL TABLET ZADITEN UNIT OF ISSUE - REFER TO PRICE POLICY 3 EFFECTIVE APRIL 1, 2018

5 08:00 Anti-Infective Agents 08:00 Anti-Infective Agents

6 08:00 ANTI-INFECTIVE AGENTS 08:08 ANTHELMINTICS MEBENDAZOLE 100 MG ORAL CHEWABLE TABLET VERMOX JAI :00 ANTI-INFECTIVE AGENTS 08:12.02 ANTIBACTERIALS (AMINOGLYCOSIDES) GENTAMICIN SULFATE 40 MG / ML (BASE) INJECTION GENTAMICIN TOBRAMYCIN 28 MG INHALATION CAPSULE TOBI PODHALER NOV TOBRAMYCIN SULFATE 60 MG / ML (BASE) INHALATION SOLUTION A-TOBRAMYCIN TOBRAMYCIN INHALATION SOLUTION TOBI 40 MG / ML (BASE) INJECTION JAMP-TOBRAMYCIN NOV :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFADROXIL 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 ORAL CAPSULE CEFAZOLIN SODIUM This Drug Product is a benefit for use by Home Parenteral Therapy (HPT) programs only. 500 MG / VIAL (BASE) INJECTION CEFAZOLIN STERILE CEFAZOLIN SODIUM 1 G / VIAL (BASE) INJECTION APO-CEFADROXIL A-CEFADROXIL CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM UNIT OF ISSUE - REFER TO PRICE POLICY 5 EFFECTIVE APRIL 1, 2018

7 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFAZOLIN SODIUM 10 G / VIAL (BASE) INJECTION CEFAZOLIN CEFAZOLIN CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM 100 G / G INJECTION CEFAZOLIN FKC STM FKC CEPHALEXIN 250 MG ORAL TABLET APO-CEPHALEX A-CEPHALEXIN 500 MG ORAL TABLET APO-CEPHALEX A-CEPHALEXIN 250 MG ORAL CAPSULE A-CEPHALEXIN 500 MG ORAL CAPSULE A-CEPHALEXIN 25 MG / ML ORAL SUSPENSION A-CEPHALEXIN MG / ML ORAL SUSPENSION A-CEPHALEXIN :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (SECOND GENERATION CEPHALOSPORINS) CEFPROZIL 250 MG ORAL TABLET APO-CEFPROZIL RAN-CEFPROZIL SANDOZ CEFPROZIL 500 MG ORAL TABLET APO-CEFPROZIL RAN-CEFPROZIL SANDOZ CEFPROZIL RAN RAN PRODUCT IS NOT INTERCHANGEABLE 6 EFFECTIVE APRIL 1, 2018

8 08:00 Anti-Infective Agents 08:00 Anti-Infective Agents

9 08:00 ANTI-INFECTIVE AGENTS 08:08 ANTHELMINTICS MEBENDAZOLE 100 MG ORAL CHEWABLE TABLET VERMOX JAI :00 ANTI-INFECTIVE AGENTS 08:12.02 ANTIBACTERIALS (AMINOGLYCOSIDES) GENTAMICIN SULFATE 40 MG / ML (BASE) INJECTION GENTAMICIN TOBRAMYCIN 28 MG INHALATION CAPSULE TOBI PODHALER NOV TOBRAMYCIN SULFATE 60 MG / ML (BASE) INHALATION SOLUTION A-TOBRAMYCIN TOBRAMYCIN INHALATION SOLUTION TOBI 40 MG / ML (BASE) INJECTION JAMP-TOBRAMYCIN NOV :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFADROXIL 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 ORAL CAPSULE CEFAZOLIN SODIUM This Drug Product is a benefit for use by Home Parenteral Therapy (HPT) programs only. 500 MG / VIAL (BASE) INJECTION CEFAZOLIN STERILE CEFAZOLIN SODIUM 1 G / VIAL (BASE) INJECTION APO-CEFADROXIL A-CEFADROXIL CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM UNIT OF ISSUE - REFER TO PRICE POLICY 5 EFFECTIVE APRIL 1, 2018

10 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFAZOLIN SODIUM 10 G / VIAL (BASE) INJECTION CEFAZOLIN CEFAZOLIN CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM 100 G / G INJECTION CEFAZOLIN FKC STM FKC CEPHALEXIN 250 MG ORAL TABLET APO-CEPHALEX A-CEPHALEXIN 500 MG ORAL TABLET APO-CEPHALEX A-CEPHALEXIN 250 MG ORAL CAPSULE A-CEPHALEXIN 500 MG ORAL CAPSULE A-CEPHALEXIN 25 MG / ML ORAL SUSPENSION A-CEPHALEXIN MG / ML ORAL SUSPENSION A-CEPHALEXIN :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (SECOND GENERATION CEPHALOSPORINS) CEFPROZIL 250 MG ORAL TABLET APO-CEFPROZIL RAN-CEFPROZIL SANDOZ CEFPROZIL 500 MG ORAL TABLET APO-CEFPROZIL RAN-CEFPROZIL SANDOZ CEFPROZIL RAN RAN PRODUCT IS NOT INTERCHANGEABLE 6 EFFECTIVE APRIL 1, 2018

11 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (SECOND GENERATION CEPHALOSPORINS) CEFUROXIME AXETIL 250 MG (BASE) ORAL TABLET APO-CEFUROXIME O-CEFUROXIME CEFTIN 500 MG (BASE) ORAL TABLET APO-CEFUROXIME O-CEFUROXIME CEFTIN GSK GSK :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (THIRD GENERATION CEPHALOSPORINS) CEFIXIME 400 MG ORAL TABLET O-CEFIXIME SUPRAX 20 MG / ML ORAL SUSPENSION SUPRAX ODN ODN CEFOTAXIME SODIUM 1 G / VIAL (BASE) INJECTION CEFOTAXIME SODIUM 2 G / VIAL (BASE) INJECTION CEFOTAXIME SODIUM STM STM CEFTAZIDIME 1 G / VIAL INJECTION FORTAZ 2 G / VIAL INJECTION FORTAZ 6 G / VIAL INJECTION FORTAZ GSK GSK GSK CEFTRIAXONE SODIUM 0.25 G / VIAL (BASE) INJECTION CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION BP 1 G / VIAL (BASE) INJECTION CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION BP STM CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION CEFTRIAXONE SODIUM FOR INJECTION BP STM 2 G / VIAL (BASE) INJECTION STM UNIT OF ISSUE - REFER TO PRICE POLICY 7 EFFECTIVE APRIL 1, 2018

12 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS CEPHALOSPORINS (THIRD GENERATION CEPHALOSPORINS) CEFTRIAXONE SODIUM 10 G / VIAL (BASE) INJECTION CEFTRIAXONE SODIUM STM :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS B-LACTAMS (CARBAPENEMS) ERTAPENEM 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.) 1 G / VIAL INJECTION INVANZ MFC IMIPENEM/ CILASTATIN SODIUM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or Hematology, 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 Hematology, or a designated prescriber.) 500 MG / VIAL * 500 MG / VIAL (BASE) INJECTION PRIMAXIN MFC MEROPENEM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or Hematology, 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 Hematology, or a designated prescriber.) 500 MG / VIAL INJECTION MERREM 1 G / VIAL INJECTION MEROPENEM FOR INJECTION USP MERREM AZC STM AZC PRODUCT IS NOT INTERCHANGEABLE 8 EFFECTIVE APRIL 1, 2018

13 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS B-LACTAMS (CEPHAMYCINS) CEFOXITIN 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.) 1 G / VIAL (BASE) INJECTION CEFOXITIN CEFOXITIN SODIUM 2 G / VIAL (BASE) INJECTION CEFOXITIN CEFOXITIN SODIUM :00 ANTI-INFECTIVE AGENTS 08:12.08 ANTIBACTERIALS (CHLORAMPHENICOL) CHLORAMPHENICOL SODIUM SUCCINATE 1 G / VIAL (BASE) INJECTION CHLOROMYCETIN ERF :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MACROLIDES (ERYTHROMYCINS) ERYTHROMYCIN 250 MG ORAL TABLET ERYTHRO-BASE 333 MG ORAL CAPSULE (ENTERIC-COATED PELLET) ERYC ERYTHROMYCIN STEARATE 250 MG ORAL TABLET ERYTHRO-S 500 MG ORAL TABLET ERYTHRO-S UNIT OF ISSUE - REFER TO PRICE POLICY 9 EFFECTIVE APRIL 1, 2018

14 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MACROLIDES (OTHER MACROLIDES) AZITHROMYCIN 250 MG ORAL TABLET APO-AZITHROMYCIN Z AZITHROMYCIN AZITHROMYCIN JAMP-AZITHROMYCIN MAR-AZITHROMYCIN MYLAN-AZITHROMYCIN NOVO-AZITHROMYCIN AZITHROMYCIN SANDOZ AZITHROMYCIN ZITHROMAX 600 MG ORAL TABLET ACT AZITHROMYCIN -AZITHROMYCIN MAR 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.) 20 MG / ML ORAL SUSPENSION AZITHROMYCIN SANDOZ AZITHROMYCIN ZITHROMAX 40 MG / ML ORAL SUSPENSION GD-AZITHROMYCIN -AZITHROMYCIN SANDOZ AZITHROMYCIN ZITHROMAX GMD CLARITHROMYCIN 250 MG ORAL TABLET CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN RAN-CLARITHROMYCIN SANDOZ CLARITHROMYCIN A-CLARITHROMYCIN BIAXIN BID 500 MG ORAL TABLET CLARITHROMYCIN SANDOZ CLARITHROMYCIN A-CLARITHROMYCIN BIAXIN BID 500 MG ORAL EXTENDED-RELEASE TABLET ACT CLARITHROMYCIN XL APO-CLARITHROMYCIN XL BIAXIN XL RAN BGP BGP BGP PRODUCT IS NOT INTERCHANGEABLE 10 EFFECTIVE APRIL 1, 2018

15 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MACROLIDES (OTHER MACROLIDES) CLARITHROMYCIN 25 MG / ML ORAL SUSPENSION CLARITHROMYCIN TARO-CLARITHROMYCIN BIAXIN 50 MG / ML ORAL SUSPENSION CLARITHROMYCIN TARO-CLARITHROMYCIN BIAXIN TAR BGP TAR BGP :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (NATURAL PENICILLINS) PENICILLIN G SODIUM 1,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM 5,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM 10,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM FKC FKC FKC PENICILLIN V POTASSIUM 300 MG ORAL TABLET PEN-VK 25 MG / ML ORAL LIQUID APO-PEN-VK 60 MG / ML ORAL LIQUID APO-PEN-VK :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (AMINOPENICILLINS) AMOXICILLIN TRIHYDRATE 125 MG (BASE) ORAL CHEWABLE TABLET NOVAMOXIN 250 MG (BASE) ORAL CHEWABLE TABLET NOVAMOXIN UNIT OF ISSUE - REFER TO PRICE POLICY 11 EFFECTIVE APRIL 1, 2018

16 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (AMINOPENICILLINS) AMOXICILLIN TRIHYDRATE 250 MG (BASE) ORAL CAPSULE AMOXICILLIN AMOXICILLIN APO-AMOXI O-AMOXICILLIN MYLAN-AMOXICILLIN NOVAMOXIN AMOXICILLIN 500 MG (BASE) ORAL CAPSULE AMOXICILLIN AMOXICILLIN APO-AMOXI O-AMOXICILLIN MYLAN-AMOXICILLIN NOVAMOXIN AMOXICILLIN 25 MG / ML (BASE) ORAL SUSPENSION APO-AMOXI NOVAMOXIN NOVAMOXIN SUGAR-REDUCED AMOXICILLIN 50 MG / ML (BASE) ORAL SUSPENSION AMOXICILLIN AMOXICILLIN AMOXICILLIN SUGAR-REDUCED APO-AMOXI NOVAMOXIN NOVAMOXIN SUGAR-REDUCED -AMOXICILLIN AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM 250 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV 500 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV CLAVULIN-500F 875 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV CLAVULIN MG / ML (BASE) * 6.25 MG / ML (BASE) ORAL SUSPENSION CLAVULIN-125F 40 MG / ML (BASE) * 5.7 MG / ML (BASE) ORAL SUSPENSION CLAVULIN MG / ML (BASE) * 12.5 MG / ML (BASE) ORAL SUSPENSION CLAVULIN-250F 80 MG / ML (BASE) * 11.4 MG / ML (BASE) ORAL SUSPENSION CLAVULIN-400 GSK GSK GSK GSK GSK GSK PRODUCT IS NOT INTERCHANGEABLE 12 EFFECTIVE APRIL 1, 2018

17 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (AMINOPENICILLINS) AMPICILLIN 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.) 250 MG ORAL CAPSULE NOVO-AMPICILLIN 500 MG ORAL CAPSULE NOVO-AMPICILLIN AMPICILLIN SODIUM 250 MG / VIAL (BASE) INJECTION AMPICILLIN SODIUM 500 MG / VIAL (BASE) INJECTION AMPICILLIN SODIUM 1 G / VIAL (BASE) INJECTION AMPICILLIN SODIUM 2 G / VIAL (BASE) INJECTION AMPICILLIN SODIUM :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (PENICILLINASE-RESISTANT PENICILLINS) CLOXACILLIN SODIUM 250 MG (BASE) ORAL CAPSULE NOVO-CLOXIN 500 MG (BASE) ORAL CAPSULE NOVO-CLOXIN 25 MG / ML (BASE) ORAL LIQUID NOVO-CLOXIN 500 MG / VIAL (BASE) INJECTION CLOXACILLIN 1 G / VIAL (BASE) INJECTION CLOXACILLIN 2 G / VIAL (BASE) INJECTION CLOXACILLIN STM STM STM UNIT OF ISSUE - REFER TO PRICE POLICY 13 EFFECTIVE APRIL 1, 2018

18 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS PENICILLINS (EXTENDED-SPECTRUM PENICILLINS) PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or Hematology, 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 Hematology, or a designated prescriber.) 2 G / VIAL (BASE) * 250 MG / VIAL (BASE) INJECTION PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 3 G / VIAL (BASE) * 375 MG / VIAL (BASE) INJECTION PIPERACILLIN/TAZOBACTAM 4 G / VIAL (BASE) * 500 MG / VIAL (BASE) INJECTION PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM PIPERACILLIN/TAZOBACTAM STM TGT STM TGT STM TGT :00 ANTI-INFECTIVE AGENTS 08:12.18 ANTIBACTERIALS (QUINOLONES) NORFLOXACIN 400 MG ORAL TABLET NOVO-NORFLOXACIN :00 ANTI-INFECTIVE AGENTS 08:12.20 ANTIBACTERIALS (SULFONAMIDES) SULFAMETHOXAZOLE/ TRIMETHOPRIM 100 MG * 20 MG ORAL TABLET APO-SULFATRIM 400 MG * 80 MG ORAL TABLET APO-SULFATRIM 800 MG * 160 MG ORAL TABLET APO-SULFATRIM DS PRODUCT IS NOT INTERCHANGEABLE 14 EFFECTIVE APRIL 1, 2018

19 08:00 ANTI-INFECTIVE AGENTS 08:12.20 ANTIBACTERIALS (SULFONAMIDES) SULFAMETHOXAZOLE/ TRIMETHOPRIM 40 MG / ML * 8 MG / ML ORAL SUSPENSION A-TRIMEL 80 MG / ML * 16 MG / ML INJECTION SEPTRA APC SULFASALAZINE 500 MG ORAL TABLET SULFASALAZINE 500 MG ORAL ENTERIC-COATED TABLET SULFASALAZINE :00 ANTI-INFECTIVE AGENTS 08:12.24 ANTIBACTERIALS (TETRACYCLINES) DOXYCYCLINE HYCLATE 100 MG (BASE) ORAL TABLET APO-DOXY DOXYCYCLINE A-DOXYCYCLINE 100 MG (BASE) ORAL CAPSULE APO-DOXY DOXYCYCLINE A-DOXYCYCLINE MINOCYCLINE HCL 50 MG (BASE) ORAL CAPSULE APO-MINOCYCLINE MINOCYCLINE MYLAN-MINOCYCLINE NOVO-MINOCYCLINE MINOCYCLINE 100 MG (BASE) ORAL CAPSULE APO-MINOCYCLINE MINOCYCLINE MYLAN-MINOCYCLINE NOVO-MINOCYCLINE TETRACYCLINE HCL 250 MG ORAL CAPSULE TETRACYCLINE UNIT OF ISSUE - REFER TO PRICE POLICY 15 EFFECTIVE APRIL 1, 2018

20 08:00 ANTI-INFECTIVE AGENTS 08:12.28 ANTIBACTERIALS (MISCELLANEOUS ANTIBACTERIALS) SPIRAMYCIN 750,000 IU ORAL CAPSULE ROVAMYCINE-250 1,500,000 IU ORAL CAPSULE ROVAMYCINE-500 ODN ODN :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS ANTIBACTERIALS (GLYCOPEPTIDES) VANCOMYCIN HCL 125 MG (BASE) ORAL CAPSULE JAMP-VANCOMYCIN VANCOCIN MLI RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber MG (BASE) ORAL CAPSULE JAMP-VANCOMYCIN VANCOCIN MLI 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 (BASE) INJECTION VANCOMYCIN HCL 1 G / VIAL (BASE) INJECTION VANCOMYCIN HCL 10 G / VIAL INJECTION STERILE VANCOMYCIN HCL VANCOMYCIN HCL STM STM FKC STM RESTRICTED BENEFIT This Drug Product is a benefit for use by Home Parenteral Therapy (HPT) programs only. PRODUCT IS NOT INTERCHANGEABLE 16 EFFECTIVE APRIL 1, 2018

21 08:00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS ANTIBACTERIALS (LINCOMYCINS) CLINDAMYCIN HCL 150 MG (BASE) ORAL CAPSULE APO-CLINDAMYCIN O-CLINDAMYCIN MYLAN-CLINDAMYCIN A-CLINDAMYCIN 300 MG (BASE) ORAL CAPSULE APO-CLINDAMYCIN O-CLINDAMYCIN MYLAN-CLINDAMYCIN A-CLINDAMYCIN CLINDAMYCIN PALMITATE HCL 15 MG / ML (BASE) ORAL SOLUTION DALACIN C PALMITATE CLINDAMYCIN PHOSPHATE 150 MG / ML (BASE) INJECTION CLINDAMYCIN CLINDAMYCIN (60 & 120 ML) DALACIN C PHOSPHATE :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS ANTIBACTERIALS (OXAZOLIDINONES) LINEZOLID 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.) 600 MG ORAL TABLET APO-LINEZOLID SANDOZ LINEZOLID ZYVOXAM :00 ANTI-INFECTIVE AGENTS 08: ANTIBACTERIALS MISCELLANEOUS ANTIBACTERIALS (POLYMYXINS) COLISTIMETHATE SODIUM 150 MG / VIAL INJECTION COLISTIMETHATE FOR INJECTION STM UNIT OF ISSUE - REFER TO PRICE POLICY 17 EFFECTIVE APRIL 1, 2018

22 08:00 ANTI-INFECTIVE AGENTS 08:14.04 ANTIFUNGALS (ALLYLAMINES) TERBINAFINE HCL 250 MG (BASE) ORAL TABLET ACT TERBINAFINE APO-TERBINAFINE O-TERBINAFINE -TERBINAFINE TERBINAFINE TERBINAFINE A-TERBINAFINE LAMISIL NOV :00 ANTI-INFECTIVE AGENTS 08:14.08 ANTIFUNGALS (AZOLES) FLUCONAZOLE 50 MG ORAL TABLET ACT FLUCONAZOLE APO-FLUCONAZOLE MYLAN-FLUCONAZOLE NOVO-FLUCONAZOLE FLUCONAZOLE 100 MG ORAL TABLET ACT FLUCONAZOLE APO-FLUCONAZOLE MYLAN-FLUCONAZOLE NOVO-FLUCONAZOLE FLUCONAZOLE 10 MG / ML ORAL SUSPENSION DIFLUCAN 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.) 2 MG / ML INJECTION DIFLUCAN PRODUCT IS NOT INTERCHANGEABLE 18 EFFECTIVE APRIL 1, 2018

23 08:00 ANTI-INFECTIVE AGENTS 08:14.08 ANTIFUNGALS (AZOLES) ITRACONAZOLE 100 MG ORAL CAPSULE MINT-ITRACONAZOLE SPORANOX 10 MG / ML ORAL SOLUTION SPORANOX MPI JAI RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber. JAI (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.) KETOCONAZOLE 200 MG ORAL TABLET APO-KETOCONAZOLE A-KETOCONAZOLE VORICONAZOLE 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.) 50 MG ORAL TABLET APO-VORICONAZOLE SANDOZ VORICONAZOLE A-VORICONAZOLE VFEND 200 MG ORAL TABLET APO-VORICONAZOLE SANDOZ VORICONAZOLE A-VORICONAZOLE VFEND 40 MG / ML ORAL SUSPENSION VFEND 200 MG / VIAL INJECTION VFEND UNIT OF ISSUE - REFER TO PRICE POLICY 19 EFFECTIVE APRIL 1, 2018

24 08:00 ANTI-INFECTIVE AGENTS 08:14.16 ANTIFUNGALS (ECHINOCANDINS) CASPOFUNGIN 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.) 50 MG / VIAL INJECTION CASPOFUNGIN CANCIDAS 70 MG / VIAL INJECTION CASPOFUNGIN CANCIDAS MDA MFC MDA MFC :00 ANTI-INFECTIVE AGENTS 08:14.28 ANTIFUNGALS (POLYENES) AMPHOTERICIN B 50 MG / VIAL INJECTION FUNGIZONE IV BMS NYSTATIN 100,000 UNIT / ML ORAL SUSPENSION JAMP-NYSTATIN -NYSTATIN RATIO-NYSTATIN :00 ANTI-INFECTIVE AGENTS 08:16.92 ANTIMYCOBACTERIALS (MISCELLANEOUS ANTIMYCOBACTERIALS) DAPSONE 100 MG ORAL TABLET DAPSONE RIFABUTIN RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber. NTI (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.) 150 MG ORAL CAPSULE MYCOBUTIN PRODUCT IS NOT INTERCHANGEABLE 20 EFFECTIVE APRIL 1, 2018

25 08:00 08:00 ANTI-INFECTIVE AGENTS 08: LAMIVUDINE RESTRICTED BENEFIT - This product is a benefit when initiated by a Specialist in Internal Medicine or a designated prescriber. 100 MG ORAL TABLET ANTIVIRALS ANTI-INFECTIVE AGENTS 08:18.20 ANTIRETROVIRALS (NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS) APO-LAMIVUDINE HBV HEPTOVIR ANTIVIRALS GSK TENOFOVIR DISOPROXIL FUMARATE RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. 300 MG (BASE) ORAL TABLET APO-TENOFOVIR O-TENOFOVIR MYLAN-TENOFOVIR DISOPROXIL A-TENOFOVIR VIREAD GIL (INTERFERONS) PEGINTERFERON ALFA-2A RESTRICTED BENEFIT 08:00 This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. (For eligibility for the treatment of chronic hepatitis C refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for Alberta Human Services clients.) 180 MCG / SYR INJECTION SYRINGE PEGASYS (0.5 ML SYRINGE) HLR ANTI-INFECTIVE AGENTS 08:18.32 ANTIVIRALS (NUCLEOSIDES AND NUCLEOTIDES) ACYCLOVIR 200 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR 400 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR UNIT OF ISSUE - REFER TO PRICE POLICY 21 EFFECTIVE APRIL 1, 2018

26 08:00 ANTI-INFECTIVE AGENTS 08:18.32 ANTIVIRALS (NUCLEOSIDES AND NUCLEOTIDES) ACYCLOVIR 800 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR 40 MG / ML ORAL SUSPENSION GANCICLOVIR SODIUM 500 MG / VIAL (BASE) INJECTION VALACYCLOVIR 500 MG ORAL TABLET APO-VALACYCLOVIR (CAPLET) O-VALACYCLOVIR CO VALACYCLOVIR JAMP-VALACYCLOVIR MAR-VALACYCLOVIR MYLAN-VALACYCLOVIR (CAPLET) VALACYCLOVIR (CAPLET) SANDOZ VALACYCLOVIR A-VALACYCLOVIR VALACYCLOVIR VALACYCLOVIR VALTREX (CAPLET) 1,000 MG ORAL TABLET ZOVIRAX CYTOVENE APO-VALACYCLOVIR (CAPLET) MYLAN-VALACYCLOVIR (CAPLET) -VALACYCLOVIR (CAPLET) GSK HLR MAR GSK ADEFOVIR DIPIVOXIL 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. 10 MG ORAL TABLET APO-ADEFOVIR HEPSERA GIL ENTECAVIR RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. 0.5 MG ORAL TABLET APO-ENTECAVIR O-ENTECAVIR ENTECAVIR BARACLUDE BMS PRODUCT IS NOT INTERCHANGEABLE 22 EFFECTIVE APRIL 1, 2018

27 08:00 ANTI-INFECTIVE AGENTS 08:18.32 ANTIVIRALS (NUCLEOSIDES AND NUCLEOTIDES) VALGANCICLOVIR HCL 450 MG (BASE) ORAL TABLET APO-VALGANCICLOVIR O-VALGANCICLOVIR A-VALGANCICLOVIR VALCYTE 50 MG / ML ORAL SUSPENSION VALCYTE HLR HLR :00 ANTI-INFECTIVE AGENTS 08:30.08 ANTIPROTOZOALS (ANTIMALARIALS) CHLOROQUINE PHOSPHATE 250 MG ORAL TABLET A-CHLOROQUINE HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABLET APO-HYDROXYQUINE MINT-HYDROXYCHLOROQUINE MYLAN-HYDROXYCHLOROQUINE PLAQUENIL SULFATE MPI SAV PRIMAQUINE PHOSPHATE 15 MG (BASE) ORAL TABLET PRIMAQUINE PHOSPHATE SAV QUININE SULFATE 200 MG ORAL CAPSULE APO-QUININE JAMP-QUININE A-QUININE 300 MG ORAL CAPSULE APO-QUININE JAMP-QUININE A-QUININE :00 ANTI-INFECTIVE AGENTS 08:30.92 ANTIPROTOZOALS (MISCELLANEOUS ANTIPROTOZOALS) ATOVAQUONE 150 MG / ML ORAL SUSPENSION MEPRON GSK UNIT OF ISSUE - REFER TO PRICE POLICY 23 EFFECTIVE APRIL 1, 2018

28 08:00 ANTI-INFECTIVE AGENTS 08:30.92 ANTIPROTOZOALS (MISCELLANEOUS ANTIPROTOZOALS) METRONIDAZOLE 250 MG ORAL TABLET METRONIDAZOLE 5 MG / ML INJECTION FLAGYL METRONIDAZOLE BAX :00 ANTI-INFECTIVE AGENTS 08:36 URINARY ANTI-INFECTIVES FOSFOMYCIN TROMETHAMINE 3 G (BASE) ORAL POWDER PACKET MONUROL PAL NITROFURANTOIN 50 MG ORAL TABLET NITROFURANTOIN 100 MG ORAL TABLET NITROFURANTOIN 50 MG ORAL CAPSULE (MACROCRYSTALS) A-NITROFURANTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS) A-NITROFURANTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE) MACROBID ASC TRIMETHOPRIM 100 MG ORAL TABLET TRIMETHOPRIM 200 MG ORAL TABLET TRIMETHOPRIM PRODUCT IS NOT INTERCHANGEABLE 24 EFFECTIVE APRIL 1, 2018

29 10:00 10:00 Antineoplastic Agents Antineoplastic Agents

30 10:00 ANTINEOPLASTIC AGENTS 10:00 METHOTREXATE 2.5 MG ORAL TABLET APO-METHOTREXATE METHOTREXATE 10 MG ORAL TABLET METHOTREXATE METHOTREXATE SODIUM 25 MG / ML (BASE) INJECTION METHOTREXATE SOD.(UNPRESERVED) METHOTREXATE SOD.(UNPRESERVED) 25 MG / ML (BASE) INJECTION METHOTREXATE (PRESERVED) METHOTREXATE SOD. (PRESERVED) 17.5 MG / SYR (BASE) INJECTION SYRINGE METOJECT SUBCUTANEOUS 20 MG / SYR (BASE) INJECTION SYRINGE METOJECT SUBCUTANEOUS 22.5 MG / SYR (BASE) INJECTION SYRINGE METOJECT SUBCUTANEOUS 25 MG / SYR (BASE) INJECTION SYRINGE METOJECT SUBCUTANEOUS MDX MDX MDX MDX UNIT OF ISSUE - REFER TO PRICE POLICY 25 EFFECTIVE APRIL 1, 2018

31 12:00 Autonomic Drugs 12:00 Autonomic Drugs

32 12:00 AUTONOMIC DRUGS 12:04 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS PILOCARPINE HCL 5 MG ORAL TABLET SALAGEN PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABLET MESTINON 180 MG ORAL SUSTAINED-RELEASE TABLET MESTINON-SR VCL VCL :00 AUTONOMIC DRUGS 12:08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) ACLIDINIUM BROMIDE 400 MCG / DOSE INHALATION METERED INHALATION POWDER TUDORZA GENUAIR AZC ATROPINE SULFATE 0.4 MG / ML INJECTION ATROPINE SULFATE 0.6 MG / ML INJECTION ATROPINE SULFATE BELLADONNA/ ERGOTAMINE TARTRATE/ PHENOBARBITAL 0.2 MG * 0.6 MG * 40 MG ORAL SUSTAINED-RELEASE TABLET BELLERGAL SPACETABS PAL GLYCOPYRROLATE 0.2 MG / ML INJECTION GLYCOPYRROLATE HYOSCINE BUTYLBROMIDE 10 MG ORAL TABLET BUSCOPAN 20 MG / ML INJECTION BUSCOPAN SAV SAV IPRATROPIUM BROMIDE 20 MCG / DOSE INHALATION METERED DOSE AEROSOL ATROVENT HFA 250 MCG / ML INHALATION SOLUTION APO-IPRAVENT MYLAN-IPRATROPIUM IPRATROPIUM 0.03 % NASAL SPRAY IPRATROPIUM ATROVENT BOE SAV IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE 0.2 MG / ML * 1 MG / ML (BASE) INHALATION SOLUTION A-COMBO STERINEBS COMBIVENT UDV BOE UNIT OF ISSUE - REFER TO PRICE POLICY 27 EFFECTIVE APRIL 1, 2018

33 12:00 AUTONOMIC DRUGS 12:08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG / DOSE INHALATION SOLUTION SPIRIVA RESPIMAT 18 MCG INHALATION CAPSULE SPIRIVA BOE BOE UMECLIDINIUM BROMIDE 62.5 MCG / DOSE INHALATION METERED INHALATION POWDER INCRUSE ELLIPTA GSK :00 AUTONOMIC DRUGS 12:12.04 SYMPATHOMIMETIC (ADRENERGIC) AGENTS (ALPHA-ADRENERGIC AGONISTS) MIDODRINE HCL 2.5 MG ORAL TABLET MIDODRINE 5 MG ORAL TABLET MIDODRINE :00 AUTONOMIC DRUGS 12: SYMPATHOMIMETIC (ADRENERGIC) AGENTS BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) FORMOTEROL FUMARATE 12 MCG INHALATION CAPSULE FORADIL NOV FORMOTEROL FUMARATE DIHYDRATE 6 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER 12 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER AZC AZC INDACATEROL MALEATE 75 MCG (BASE) INHALATION CAPSULE ONBREZ BREEZHALER NOV ORCIPRENALINE SULFATE 2 MG / ML ORAL SYRUP ORCIPRENALINE SALBUTAMOL 100 MCG / DOSE INHALATION METERED DOSE AEROSOL SALBUTAMOL HFA AIROMIR CFC-FREE APO-SALVENT CFC FREE VENTOLIN HFA VCL GSK PRODUCT IS NOT INTERCHANGEABLE 28 EFFECTIVE APRIL 1, 2018

34 12:00 AUTONOMIC DRUGS 12:08.08 ANTICHOLINERGIC AGENTS (ANTIMUSCARINICS / ANTISPASMODICS) TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG / DOSE INHALATION SOLUTION SPIRIVA RESPIMAT 18 MCG INHALATION CAPSULE SPIRIVA BOE BOE UMECLIDINIUM BROMIDE 62.5 MCG / DOSE INHALATION METERED INHALATION POWDER INCRUSE ELLIPTA GSK :00 AUTONOMIC DRUGS 12:12.04 SYMPATHOMIMETIC (ADRENERGIC) AGENTS (ALPHA-ADRENERGIC AGONISTS) MIDODRINE HCL 2.5 MG ORAL TABLET MIDODRINE 5 MG ORAL TABLET MIDODRINE :00 AUTONOMIC DRUGS 12: SYMPATHOMIMETIC (ADRENERGIC) AGENTS BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) FORMOTEROL FUMARATE 12 MCG INHALATION CAPSULE FORADIL NOV FORMOTEROL FUMARATE DIHYDRATE 6 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER 12 MCG / DOSE INHALATION METERED INHALATION POWDER OXEZE TURBUHALER AZC AZC INDACATEROL MALEATE 75 MCG (BASE) INHALATION CAPSULE ONBREZ BREEZHALER NOV ORCIPRENALINE SULFATE 2 MG / ML ORAL SYRUP ORCIPRENALINE SALBUTAMOL 100 MCG / DOSE INHALATION METERED DOSE AEROSOL SALBUTAMOL HFA AIROMIR CFC-FREE APO-SALVENT CFC FREE VENTOLIN HFA VCL GSK PRODUCT IS NOT INTERCHANGEABLE 28 EFFECTIVE APRIL 1, 2018

35 12:00 AUTONOMIC DRUGS 12: SYMPATHOMIMETIC (ADRENERGIC) AGENTS BETA-ADRENERGIC AGONISTS (SELECTIVE BETA 2-ADRENERGIC AGONISTS) SALBUTAMOL SULFATE 2 MG (BASE) ORAL TABLET APO-SALVENT 4 MG (BASE) ORAL TABLET APO-SALVENT 0.5 MG / ML (BASE) INHALATION SOLUTION SALBUTAMOL 1 MG / ML (BASE) INHALATION SOLUTION SALBUTAMOL A-SALBUTAMOL STERINEBS P.F VENTOLIN NEBULES P.F. 5 MG / ML (BASE) INHALATION SOLUTION VENTOLIN 2 MG / ML (BASE) INHALATION UNIT DOSE SOLUTION SALBUTAMOL POLYNEB A-SALBUTAMOL STERINEBS P.F. VENTOLIN NEBULES P.F. GSK GSK GSK SALMETEROL XINAFOATE 50 MCG / DOSE (BASE) INHALATION METERED INHALATION POWDER SEREVENT DISKUS GSK TERBUTALINE SULFATE 0.5 MG / DOSE INHALATION METERED INHALATION POWDER BRICANYL TURBUHALER AZC :00 AUTONOMIC DRUGS 12:12.12 SYMPATHOMIMETIC (ADRENERGIC) AGENTS (ALPHA- AND BETA-ADRENERGIC AGONISTS) 12:00 EPINEPHRINE 0.15 MG / SYR INJECTION SYRINGE EPIPEN JR MYS 0.3 MG / SYR INJECTION SYRINGE EPIPEN MYS EPINEPHRINE HCL 1 MG / ML INJECTION ADRENALIN ERF AUTONOMIC DRUGS 12:16 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS DIHYDROERGOTAMINE MESYLATE 4 MG / ML NASAL SPRAY MIGRANAL 1 MG / ML INJECTION DIHYDROERGOTAMINE (DHE) STM STM UNIT OF ISSUE - REFER TO PRICE POLICY 29 EFFECTIVE APRIL 1, 2018

36 12:00 12:00 AUTONOMIC DRUGS 12:16 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS ERGOLOID MESYLATES 1 MG ORAL TABLET HYDERGINE STM AUTONOMIC DRUGS 12:20.04 SKELETAL MUSCLE RELAXANTS (CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS) :00 CYCLOBENZAPRINE HCL RESTRICTED BENEFIT - Coverage is limited to 126 tablets per plan participant per year as an adjunct to rest and physical therapy for the treatment of acute muscle spasm. 10 MG ORAL TABLET AUTONOMIC DRUGS 12:20.08 APO-CYCLOBENZAPRINE O-CYCLOBENZAPRINE CYCLOBENZAPRINE JAMP-CYCLOBENZAPRINE MYLAN-CYCLOBENZAPRINE -CYCLOBENZAPRINE A-CYCLOBENZAPRINE SKELETAL MUSCLE RELAXANTS (DIRECT-ACTING SKELETAL MUSCLE RELAXANTS) :00 DANTROLENE SODIUM 25 MG ORAL CAPSULE DANTRIUM PAL AUTONOMIC DRUGS 12:20.12 SKELETAL MUSCLE RELAXANTS (GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS) BACLOFEN 10 MG ORAL TABLET APO-BACLOFEN BACLOFEN MYLAN-BACLOFEN BACLOFEN LIORESAL 20 MG ORAL TABLET APO-BACLOFEN BACLOFEN MYLAN-BACLOFEN BACLOFEN LIORESAL D.S MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL 0.5 MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL NOV NOV STM NOV STM NOV PRODUCT IS NOT INTERCHANGEABLE 30 EFFECTIVE APRIL 1, 2018

37 12:00 AUTONOMIC DRUGS 12:20.12 SKELETAL MUSCLE RELAXANTS (GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS) BACLOFEN 2 MG / ML INJECTION BACLOFEN INTRATHECAL LIORESAL INTRATHECAL STM NOV :00 AUTONOMIC DRUGS 12:92 MISCELLANEOUS AUTONOMIC DRUGS 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 (BASE) ORAL TABLET CHAMPIX 1 MG (BASE) ORAL TABLET CHAMPIX 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." MG * 1 MG ORAL TABLET CHAMPIX (STARTER PACK) UNIT OF ISSUE - REFER TO PRICE POLICY 31 EFFECTIVE APRIL 1, 2018

38 20:00 Blood Formulation, Coagulation and Thrombosis 20:00 Blood Formulation, Coagulation and Thrombosis

39 20:00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20:04.04 ANTIANEMIA DRUGS (IRON PREPARATIONS) IRON DEXTRAN COMPLEX 50 MG / ML INJECTION DEXIRON LPI :00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20: ANTITHROMBOTIC AGENTS ANTICOAGULANTS (COUMARIN DERIVATIVES) ACENOCOUMAROL 1 MG ORAL TABLET SINTROM 4 MG ORAL TABLET SINTROM PAL PAL WARFARIN SODIUM 1 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 2 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 2.5 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 3 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 4 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 5 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN 6 MG ORAL TABLET TARO-WARFARIN 7.5 MG ORAL TABLET TARO-WARFARIN 10 MG ORAL TABLET APO-WARFARIN TARO-WARFARIN COUMADIN TAR BMS TAR BMS TAR BMS TAR BMS TAR BMS TAR BMS TAR TAR TAR BMS UNIT OF ISSUE - REFER TO PRICE POLICY 33 EFFECTIVE APRIL 1, 2018

40 20:00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20: ANTITHROMBOTIC AGENTS ANTICOAGULANTS (HEPARINS) DALTEPARIN SODIUM 10,000 IU / ML INJECTION FRAGMIN 25,000 IU / ML INJECTION FRAGMIN 2,500 IU / SYR INJECTION SYRINGE FRAGMIN (0.2 ML SYRINGE) 3,500 IU / SYR INJECTION SYRINGE FRAGMIN (0.28 ML SYRINGE) 5,000 IU / SYR INJECTION SYRINGE FRAGMIN (0.2 ML SYRINGE) 7,500 IU / SYR INJECTION SYRINGE FRAGMIN (0.3 ML SYRINGE) 10,000 IU / SYR INJECTION SYRINGE FRAGMIN (0.4 ML SYRINGE) 12,500 IU / SYR INJECTION SYRINGE FRAGMIN (0.5 ML SYRINGE) 15,000 IU / SYR INJECTION SYRINGE FRAGMIN (0.6 ML SYRINGE) 18,000 IU / SYR INJECTION SYRINGE FRAGMIN (0.72 ML SYRINGE) ENOXAPARIN SODIUM 100 MG / ML INJECTION LOVENOX 30 MG / SYR INJECTION SYRINGE LOVENOX (0.3 ML SYRINGE) 40 MG / SYR INJECTION SYRINGE LOVENOX (0.4 ML SYRINGE) 60 MG / SYR INJECTION SYRINGE LOVENOX (0.6 ML SYRINGE) 80 MG / SYR INJECTION SYRINGE LOVENOX (0.8 ML SYRINGE) 100 MG / SYR INJECTION SYRINGE LOVENOX (1 ML SYRINGE) 120 MG / SYR INJECTION SYRINGE LOVENOX (0.8 ML SYRINGE) 150 MG / SYR INJECTION SYRINGE LOVENOX HP (1 ML SYRINGE) SAV SAV SAV SAV SAV SAV SAV SAV HEPARIN SODIUM 1,000 UNIT / ML INJECTION HEPARIN LEO 100 UNIT / ML INJECTION LOCK FLUSH HEPARIN LEO LEO LEO PRODUCT IS NOT INTERCHANGEABLE 34 EFFECTIVE APRIL 1, 2018

41 20:00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20: ANTITHROMBOTIC AGENTS ANTICOAGULANTS (HEPARINS) NADROPARIN CALCIUM 9,500 IU / SYR INJECTION SYRINGE FRAXIPARINE (0.3-1 ML SYR) 19,000 IU / SYR INJECTION SYRINGE FRAXIPARINE FORTE (0.6-1 ML SYR) APC APC TINZAPARIN SODIUM 10,000 IU / ML INJECTION INNOHEP 20,000 IU / ML INJECTION INNOHEP 2,500 IU / SYR INJECTION SYRINGE INNOHEP (0.25 ML SYRINGE) 3,500 IU / SYR INJECTION SYRINGE INNOHEP (0.35 ML SYRINGE) 4,500 IU / SYR INJECTION SYRINGE INNOHEP (0.45 ML SYRINGE) 8,000 IU / SYR INJECTION SYRINGE INNOHEP (0.4 ML SYRINGE) 10,000 IU / SYR INJECTION SYRINGE INNOHEP (0.5 ML SYRINGE) 12,000 IU / SYR INJECTION SYRINGE INNOHEP (0.6 ML SYRINGE) 14,000 IU / SYR INJECTION SYRINGE INNOHEP (0.7 ML SYRINGE) 16,000 IU / SYR INJECTION SYRINGE INNOHEP (0.8 ML SYRINGE) 18,000 IU / SYR INJECTION SYRINGE INNOHEP (0.9 ML SYRINGE) LEO LEO LEO LEO LEO LEO LEO LEO LEO LEO LEO :00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20: ANTITHROMBOTIC AGENTS ANTICOAGULANTS (MISCELLANEOUS ANTICOAGULANTS) FONDAPARINUX SODIUM 2.5 MG / SYR INJECTION SYRINGE ARIXTRA (0.5 ML SYRINGE) FONDAPARINUX SODIUM (0.5 ML SYRINGE) 7.5 MG / SYR INJECTION SYRINGE ARIXTRA (0.6 ML SYRINGE) FONDAPARINUX SODIUM (0.6 ML SYRINGE) APC DRL APC DRL UNIT OF ISSUE - REFER TO PRICE POLICY 35 EFFECTIVE APRIL 1, 2018

42 20:00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20: ANTITHROMBOTIC AGENTS ANTICOAGULANTS (MISCELLANEOUS ANTICOAGULANTS) RIVAROXABAN 10 MG ORAL TABLET XARELTO BAI RESTRICTED BENEFIT -This product is a benefit for the prophylaxis of venous thromboembolic events in patients who have undergone elective total knee replacement surgery. Coverage is restricted to two 14-day courses of therapy per patient per year. This product is a benefit for the prophylaxis of venous thromboembolic events in patients who have undergone elective total hip replacement surgery. Coverage is restricted to two 35-day courses of therapy per patient per year. 20:00 BLOOD FORMULATION, COAGULATION AND THROMBOSIS 20:12.18 ANTITHROMBOTIC AGENTS CLOPIDOGREL BISULFATE 75 MG (BASE) ORAL TABLET DIPYRIDAMOLE/ ASA 200 MG * 25 MG ORAL CAPSULE (PLATELET AGGREGATION INHIBITORS) APO-CLOPIDOGREL O-CLOPIDOGREL CLOPIDOGREL CLOPIDOGREL CO CLOPIDOGREL JAMP-CLOPIDOGREL MAR-CLOPIDOGREL MINT-CLOPIDOGREL MYLAN-CLOPIDOGREL -CLOPIDOGREL RAN-CLOPIDOGREL SANDOZ CLOPIDOGREL A-CLOPIDOGREL PLAVIX AGGRENOX MAR MPI RAN SAV TICAGRELOR RESTRICTED BENEFIT - This product is a benefit for the treatment of Acute Coronary Syndrome, defined as unstable angina or myocardial infarction when initiated in hospital and prescribed by a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, Internal Medicine or General Surgery. Treatment must be in combination with low dose ASA. (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the initiating prescriber is not a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, Internal Medicine or General Surgery.) BOE MG ORAL TABLET BRILINTA AZC PRODUCT IS NOT INTERCHANGEABLE 36 EFFECTIVE APRIL 1, 2018