Summary of Changes to the Alberta Drug Benefit List Effective April 1, 2016
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 109B
H
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 (R2016/04)
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Table of Contents Special Authorization .................................................................................................................................. 1
New Drug Product(s) Available by Special Authorization ............................................................... 1
Added Product(s) ....................................................................................................................................... 1 Least Cost Alternative (LCA) Price Change(s) ........................................................................................... 1 Product(s) with a Price Change.................................................................................................................. 3 Discontinued Listing(s) ............................................................................................................................... 5 Product(s) Removed from the ADBL as Price Policy Requirements Not Satisfied .................................... 7
EFFECTIVE APRIL 1, 2016
SUMMARY OF CHANGES 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. Criteria for coverage of Alberta Human Services can be found in the April 1, 2016 Alberta Human Services Drug Benefit Supplement.
New Drug Product(s) Available by Special Authorization Trade Name / Strength / Form
Generic Description
DIN
MFR
INFLECTRA 100 MG / VIAL INJECTION
INFLIXIMAB
00002419475
CHH
Trade Name / Strength / Form
Generic Description
DIN
MFR
APO-CAPTO 12.5 MG TABLET
CAPTOPRIL
00000893595
APX
APO-CAPTO 25 MG TABLET
CAPTOPRIL
00000893609
APX
APO-CAPTO 50 MG TABLET
CAPTOPRIL
00000893617
APX
APO-CAPTO 100 MG TABLET
CAPTOPRIL
00000893625
APX
Added Product(s)
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 May 1, 2016. Groupings affected by a price increase, will be effective April 1, 2016. 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
BENAZEPRIL HCL
5 MG TABLET
0.6610
BENAZEPRIL HCL
20 MG TABLET
0.8969
BUPROPION HCL
150 MG EXTENDED-RELEASE TABLET
0.4181
BUPROPION HCL
300 MG EXTENDED-RELEASE TABLET
0.8361
CARBAMAZEPINE
20 MG / ML ORAL SUSPENSION
0.0616
CARBAMAZEPINE
200 MG TABLET
0.2432
CHOLESTYRAMINE RESIN
4 G / ORAL POWDER PACKET
1.6281
CLOBAZAM
10 MG TABLET
0.1152
CODEINE PHOSPHATE/ ACETAMINOPHEN
60 MG / 300 MG TABLET
0.1526
CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE
30 MG / 300 MG / 15 MG TABLET
0.0887
EFFECTIVE APRIL 1, 2016
1
New LCA Price
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Least Cost Alternative (LCA) Price Change(s), continued Generic Description
Strength / Form
HYDROCORTISONE SODIUM SUCCINATE
100 MG / VIAL INJECTION
2.5585
HYDROCORTISONE SODIUM SUCCINATE
250 MG / VIAL INJECTION
4.3494
HYDROCORTISONE SODIUM SUCCINATE
500 MG / VIAL INJECTION
6.5244
HYDROCORTISONE SODIUM SUCCINATE
1 G / VIAL INJECTION
HYDROMORPHONE HCL
1 MG / ML ORAL LIQUID
0.0739
HYDROXYZINE HCL
2 MG / ML ORAL SYRUP
0.0490
IPRATROPIUM BROMIDE
0.3% NASAL SPRAY
IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE
0.2 MG / ML / 1 MG / ML INHALATION SOLUTION
0.5318
LEVOTHYROXINE SODIUM
0.05 MG TABLET
0.0305
LEVOTHYROXINE SODIUM
0.1 MG TABLET
0.0375
LEVOTHYROXINE SODIUM
0.15 MG TABLET
0.0416
LEVOTHYROXINE SODIUM
0.2 MG TABLET
0.0440
LOSARTAN POTASSIUM
25 MG TABLET
0.1961
LOSARTAN POTASSIUM
50 MG TABLET
0.1961
LOSARTAN POTASSIUM
100 MG TABLET
0.1961
METHYLPREDNISOLONE SODIUM SUCCINATE
40 MG / VIAL INJECTION
4.7801
METHYLPREDNISOLONE SODIUM SUCCINATE
125 MG / VIAL INJECTION
10.4010
METHYLPREDNISOLONE SODIUM SUCCINATE
500 MG / VIAL INJECTION
24.6960
METHYLPREDNISOLONE SODIUM SUCCINATE
1 G / VIAL INJECTION
37.9336
MOMETASONE FUROATE
0.1% TOPICAL LOTION
0.3557
MORPHINE SULFATE
100 MG SUSTAINED-RELEASE TABLET
2.6844
MORPHINE SULFATE
200 MG SUSTAINED-RELEASE TABLET
4.9912
MUPIROCIN
2% TOPICAL OINTMENT
0.4331
NITROGLYCERIN
0.4 MG / HR TRANSDERMAL PATCH
0.4938
NITROGLYCERIN
0.6 MG / HR TRANSDERMAL PATCH
0.4938
NORETHINDRONE
0.35 MG (28 DAY) TABLET
0.3925
OCTREOTIDE ACETATE
50 MCG / ML INJECTION
1.8260
2
New LCA Price
11.0019
0.7910
EFFECTIVE APRIL 1, 2016
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Least Cost Alternative (LCA) Price Change(s), continued Generic Description
Strength / Form
New LCA Price
OCTREOTIDE ACETATE
100 MCG / ML INJECTION
3.4431
OCTREOTIDE ACETATE
500 MCG / ML INJECTION
16.1725
PHENYTOIN
25 MG / ML ORAL SUSPENSION
0.0372
PREDNISOLONE ACETATE
1% OPHTHALMIC SUSPENSION
4.3350
PREDNISOLONE SODIUM PHOSPHATE
1 MG / ML ORAL LIQUID
0.1027
RISEDRONATE SODIUM
5 MG TABLET
1.6729
RISEDRONATE SODIUM
30 MG TABLET
10.8388
SALBUTAMOL SULFATE
5 MG / ML INHALATION SOLUTION
0.3870
SODIUM POLYSTYRENE SULFONATE ORAL POWDER
0.1851
TEMAZEPAM
15 MG ORAL CAPSULE
0.1313
TEMAZEPAM
30 MG ORAL CAPSULE
0.1579
TRIAMCINOLONE ACETONIDE
0.1% TOPICAL CREAM
0.1024
ZOLMITRIPTAN
2.5 MG DISPERSIBLE TABLET
2.1477
Product(s) With A Price Change The following product(s) had a Price Decrease. The previous higher price will be recognized until April 30, 2016. For products within an established IC Grouping, the LCA price may apply. Please see the April 1, 2016 ADBL for a complete listing of products and their corresponding prices. Trade Name / Strength / Form
Generic Description
DIN
MFR
ACCUTANE 40 MG CAPSULE
ISOTRETINOIN
00000582352
HLR
ACTEMRA 80 MG / 4 ML VIAL INJECTION
TOCILIZUMAB
00002350092
HLR
ACTEMRA 200 MG / 10 ML VIAL INJECTION
TOCILIZUMAB
00002350106
HLR
ACTEMRA 400 MG / 20 ML VIAL INJECTION
TOCILIZUMAB
00002350114
HLR
00001916882
GSK
CLAVULIN-125F ORAL SUSPENSION AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM FRAXIPARINE 9,500 IU / ML INJECTION SYRINGE
NADROPARIN CALCIUM
00002236913
ASN
FRAXIPARINE FORTE 19,000 IU / ML INJECTION SYRINGE
NADROPARIN CALCIUM
00002240114
ASN
IMITREX DF 100 MG TABLET
SUMATRIPTAN SUCCINATE
00002212161
GSK
EFFECTIVE APRIL 1, 2016
3
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Product(s) With A Price Change, continued Trade Name / Strength / Form
Generic Description
DIN
MFR
JAMP-ALENDRONATE 70 MG TABLET
ALENDRONATE SODIUM
00002385031
JPC
JAMP-ALPRAZOLAM 0.25 MG TABLET
ALPRAZOLAM
00002400111
JPC
JAMP-ALPRAZOLAM 0.5 MG TABLET
ALPRAZOLAM
00002400138
JPC
JAMP-CANDESARTAN 32 MG TABLET
CANDESARTAN CILEXETIL
00002386534
JPC
JAMP-CELECOXIB 100 MG CAPSULE CELECOXIB
00002424533
JPC
JAMP-CELECOXIB 200 MG CAPSULE CELECOXIB
00002424541
JPC
JAMP-CIPROFLOXACIN 250 MG TABLET
CIPROFLOXACIN HCL
00002380358
JPC
JAMP-CIPROFLOXACIN 500 MG TABLET
CIPROFLOXACIN HCL
00002380366
JPC
JAMP-CIPROFLOXACIN 750 MG TABLET
CIPROFLOXACIN HCL
00002380374
JPC
JAMP-FINASTERIDE 5 MG TABLET
FINASTERIDE
00002357224
JPC
JAMP-FLUOXETINE 10 MG CAPSULE FLUOXETINE HCL
00002401894
JPC
JAMP-FLUOXETINE 20 MG CAPSULE FLUOXETINE HCL
00002386402
JPC
JAMP-IRBESARTAN 150 MG TABLET
IRBESARTAN
00002418207
JPC
JAMP-IRBESARTAN 300 MG TABLET
IRBESARTAN
00002418215
JPC
JAMP-IRBESARTAN 75 MG TABLET
IRBESARTAN
00002418193
JPC
JAMP-LOSARTAN 25 MG TABLET
LOSARTAN POTASSIUM
00002398834
JPC
JAMP-LOSARTAN 50 MG TABLET
LOSARTAN POTASSIUM
00002398842
JPC
JAMP-LOSARTAN 100 MG TABLET
LOSARTAN POTASSIUM
00002398850
JPC
JAMP-ONDANSETRON 4 MG TABLET ONDANSETRON HCL DIHYDRATE
00002313685
JPC
JAMP-ONDANSETRON 8 MG TABLET ONDANSETRON HCL DIHYDRATE
00002313693
JPC
JAMP-RIZATRIPTAN 10 MG TABLET
RIZATRIPTAN BENZOATE
00002380463
JPC
JAMP-RIZATRIPTAN IR 10 MG TABLET
RIZATRIPTAN BENZOATE
00002429241
JPC
JAMP-ROPINIROLE 0.25 MG TABLET
ROPINIROLE HCL
00002352338
JPC
JAMP-SERTRALINE 25 MG CAPSULE SERTRALINE HCL
00002357143
JPC
JAMP-SERTRALINE 50 MG CAPSULE SERTRALINE HCL
00002357151
JPC
LACTAID ULTRA 9000 UNIT CAPLET
LACTASE
00002231507
MCL
MOVISSE 0.35 MG (28 DAY) TABLET
NORETHINDRONE
00002410303
FMP
4
EFFECTIVE APRIL 1, 2016
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Product(s) With A Price Change, continued Trade Name / Strength / Form
Generic Description
DIN
MFR
NICORETTE 2 MG ORAL GUM
NICOTINE
00002091933
JJI
NICORETTE 4 MG ORAL GUM
NICOTINE
00002091941
JJI
NICORETTE INHALER 10 MG / DOSE
NICOTINE
00002241742
JJI
RATIO-ECTOSONE 0.1% SCALP LOTION
BETAMETHASONE VALERATE
00000653217
RPH
BETAMETHASONE DIPROPIONATE
00000809187
RPH
LOSARTAN POTASSIUM
00002424967
SEP
LOSARTAN POTASSIUM
00002424975
SEP
LOSARTAN POTASSIUM
00002424983
SEP
ZOLMITRIPTAN
00002428474
SEP
RATIO-TOPISONE 0.05% TOPICAL LOTION SEPTA-LOSARTAN 25 MG TABLET SEPTA-LOSARTAN 50 MG TABLET SEPTA-LOSARTAN 100 MG TABLET SEPTA-ZOLMITRIPTAN-ODT 2.5 MG ORALLY DISPERSIBLE TABLET
Discontinued Listing(s) Notification of discontinuation has been received from the manufacturers. The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2016, 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, 2016 claims will no longer pay for these products. Trade Name / Strength / Form
Generic Description
DIN
MFR
ACT CLOMIPRAMINE 25 MG TABLET
CLOMIPRAMINE HCL
00002244817
APH
ACT CLOMIPRAMINE 50 MG TABLET
CLOMIPRAMINE HCL
00002244818
APH
APO-CLOMIPRAMINE 25 MG TABLET
CLOMIPRAMINE HCL
00002040778
APX
APO-CLOMIPRAMINE 50 MG TABLET
CLOMIPRAMINE HCL
00002040751
APX
AREDIA 30 MG / VIAL INJECTION
PAMIDRONATE DISODIUM
00002059762
NOV
AREDIA 90 MG / VIAL INJECTION
PAMIDRONATE DISODIUM
00002059789
NOV
DIACOMIT 500 MG ORAL POWDER PACKET
STIRIPENTOL
00002398982
BCF
DIAZEMULS 5 MG / ML EMULSION INJECTION
DIAZEPAM
00002065614
PFI
DICLOFENAC SODIUM SR 75 MG SUSTAINED-RELEASE TABLET
DICLOFENAC SODIUM
00002352400
SNS
DOVONEX 50 MCG / ML SCALP SOLUTION
CALCIPOTRIOL
00002194341
LEO
FLUOR-A-DAY 5.56 MG / ML ORAL DROPS
SODIUM FLUORIDE
00000610100
PMS
MYLAN-ETIDRONATE 200 MG TABLET
ETIDRONATE DISODIUM
00002245330
MYP
EFFECTIVE APRIL 1, 2016
5
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Discontinued Listing(s), continued Trade Name / Strength / Form
Generic Description
DIN
MFR
RAN-CARVEDILOL 3.125 MG TABLET
CARVEDILOL
00002268027
RAN
RAN-CARVEDILOL 6.25 MG TABLET
CARVEDILOL
00002268035
RAN
RAN-CARVEDILOL 12.5 MG TABLET
CARVEDILOL
00002268043
RAN
RAN-CARVEDILOL 25 MG TABLET
CARVEDILOL
00002268051
RAN
RAN-FLUOXETINE 10 MG CAPSULE
FLUOXETINE HCL
00002405695
RAN
RAN-FLUOXETINE 20 MG CAPSULE
FLUOXETINE HCL
00002405709
RAN
RAN-OLANZAPINE 15 MG TABLET
OLANZAPINE
00002403102
RAN
RAN-OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE
OMEPRAZOLE
00002403617
RAN
RATIO-RIVASTIGMINE 4.5 MG CAPSULE
RIVASTIGMINE HYDROGEN TARTRATE
00002311305
RPH
SANDOZ CLONAZEPAM 1 MG TABLET
CLONAZEPAM
00002233982
SDZ
SANDOZ FLUVASTATIN 40 MG CAPSULE
FLUVASTATIN SODIUM
00002400243
SDZ
SANDOZ MINOCYCLINE 100 MG CAPSULE
MINOCYCLINE HCL
00002237314
SDZ
SANDOZ MINOCYCLINE 50 MG CAPSULE
MINOCYCLINE HCL
00002237313
SDZ
SANDOZ SOTALOL 80 MG TABLET
SOTALOL HCL
00002257831
SDZ
TEVA-TEMAZEPAM 15 MG CAPSULE
TEMAZEPAM
00002230095
TEV
TWINJECT 1:1000 (0.15 MG) INJECTION AUTO INJECTOR
EPINEPHRINE
00002268205
PAL
TWINJECT 1:1000 (0.3 MG) INJECTION AUTO INJECTOR
EPINEPHRINE
00002247310
PAL
VIBRAMYCIN 100 MG CAPSULE
DOXYCYCLINE HYCLATE
00000024368
PFI
VICTRELIS 200 MG CAPSULE
BOCEPREVIR
00002370816
MFC
VICTRELIS TRIPLE 200MG / 200MG / 100MCG / 0.5ML INJECTION KIT
BOCEPREVIR/ RIBAVIRIN/ PEGINTERFERON ALFA-2B
00002371456
MFC
VICTRELIS TRIPLE 200MG / 200MG / 120MCG / 0.5MLINJECTION KIT
BOCEPREVIR/ RIBAVIRIN/ PEGINTERFERON ALFA-2B
00002371464
MFC
VICTRELIS TRIPLE 200MG / 200MG / 150MCG / 0.5ML INJECTION KIT
BOCEPREVIR/ RIBAVIRIN/ PEGINTERFERON ALFA-2B
00002371472
MFC
VICTRELIS TRIPLE 200MG / 200MG / 80MCG / 0.5ML INJECTION KIT
BOCEPREVIR/ RIBAVIRIN/ PEGINTERFERON ALFA-2B
00002371448
MFC
6
EFFECTIVE APRIL 1, 2016
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Product(s) Removed from the ADBL as Price Policy Requirements Not Satisfied The Alberta government-sponsored drug programs previously covered the following drug product(s). Effective April 1, 2016, 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, 2016 claims will no longer pay for these products. Trade Name / Strength / Form
Generic Description
DIN
MFR
ACT DICLO-MISO 50 MG / 200 MCG ENTERIC-COATED TABLET
DICLOFENAC SODIUM/ MISOPROSTOL
00002397145
APH
ACT DICLO-MISO 75 MG / 200 MCG ENTERIC-COATED TABLET
DICLOFENAC SODIUM/ MISOPROSTOL
00002397153
APH
ALDACTAZIDE-25 TABLET
HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE
00000180408
PFI
ALDACTAZIDE-50 TABLET
HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE
00000594377
PFI
ALDACTONE 100 MG TABLET
SPIRONOLACTONE
00000285455
PFI
ALDACTONE 25 MG TABLET
SPIRONOLACTONE
00000028606
PFI
AURO-CIPROFLOXACIN 750 MG TABLET
CIPROFLOXACIN HCL
00002381931
AUR
BREVICON 0.5 / 35 (21 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002187086
PFI
BREVICON 0.5 / 35 (28 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002187094
PFI
BREVICON 1 / 35 (21 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002189054
PFI
BREVICON 1 / 35 (28 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002189062
PFI
CARDURA-1 1 MG TABLET
DOXAZOSIN MESYLATE
00001958100
PFI
CARDURA-2 2 MG TABLET
DOXAZOSIN MESYLATE
00001958097
PFI
CARDURA-4 4 MG TABLET
DOXAZOSIN MESYLATE
00001958119
PFI
CEFAZOLIN 500 MG / VIAL USP INJECTION
CEFAZOLIN SODIUM
00002237137
PFI
COLESTID ORAL POWDER PACKET
COLESTIPOL HCL
00000642975
PFI
COLESTID ORANGE 7.5 G ORAL POWDER PACKET
COLESTIPOL HCL
00002132699
PFI
CYKLOKAPRON 500 MG TABLET
TRANEXAMIC ACID
00002064405
PFI
DALACIN C 150 MG CAPSULE
CLINDAMYCIN HCL
00000030570
PFI
DALACIN C 300 MG CAPSULE
CLINDAMYCIN HCL
00002182866
PFI
DEPO-PROVERA 50 MG / ML INJECTION
MEDROXYPROGESTERONE ACETATE
00000030848
PFI
EFFECTIVE APRIL 1, 2016
7
SUMMARY OF CHANGES TO THE ALBERTA DRUG BENEFIT LIST
Product(s) Removed from the ADBL as Price Policy Requirements Not Satisfied, continued Trade Name / Strength / Form
Generic Description
DIN
MFR
ERYC 250 MG CAPSULE (ENTERIC-COATED PELLET)
ERYTHROMYCIN
00000607142
PFI
MIN-OVRAL (21 DAY) TABLET
LEVONORGESTREL/ ETHINYL ESTRADIOL
00002042320
PFI
MIN-OVRAL (28 DAY) TABLET
LEVONORGESTREL/ ETHINYL ESTRADIOL
00002042339
PFI
PROVERA 10 MG TABLET
MEDROXYPROGESTERONE ACETATE
00000729973
PFI
PROVERA 2.5 MG TABLET
MEDROXYPROGESTERONE ACETATE
00000708917
PFI
PROVERA 5 MG TABLET
MEDROXYPROGESTERONE ACETATE
00000030937
PFI
SALAZOPYRIN 500 MG TABLET
SULFASALAZINE
00002064480
PFI
SALAZOPYRIN EN-TABS 500 MG ENTERIC-COATED TABLET
SULFASALAZINE
00002064472
PFI
SELECT 1 / 35 (21 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002197502
PFI
SELECT 1 / 35 (28 DAY) TABLET
NORETHINDRONE/ ETHINYL ESTRADIOL
00002199297
PFI
TROMBOJECT 10 MG / ML INJECTION SODIUM TETRADECYL SULFATE
00000511234
OMG
XANAX 0.25 MG TABLET
ALPRAZOLAM
00000548359
PFI
XANAX 0.5 MG TABLET
ALPRAZOLAM
00000548367
PFI
ZOLEDRONIC ACID CONCENTRATE 4 MG / 5 ML INJECTION
ZOLEDRONIC ACID
00002413701
OMG
8
EFFECTIVE APRIL 1, 2016
