Updates to the Alberta Drug Benefit List - Effective July 1, 2018 - Alberta Blue Cross

 
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Updates to the
Alberta Drug Benefit List

           Effective July 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
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 (R2018/07)
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 Special Authorization ...... 1
          Drug Product(s) with Changes to Criteria for Coverage ................................................................. 1
 Restricted Benefit(s) ................................................................................................................................... 2
          Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit ........... 2
 Added Product(s) ....................................................................................................................................... 2
 New Established Interchangeable (IC) Grouping(s) ................................................................................... 2
 Product(s) with a Price Change.................................................................................................................. 2
 Discontinued Listing(s) ............................................................................................................................... 3
 Part 2 Drug Additions .............................................................................................................................. 2-1
 Part 3 Special Authorization .................................................................................................................... 3-1

                                                                                                                        EFFECTIVE JULY 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
  Trade Name / Strength / Form                    Generic Description                     DIN             MFR
  GLATECT 20 MG / SYRINGE INJECTION               GLATIRAMER ACETATE                      00002460661     PMS

  INVEGA TRINZA (0.875 ML) 175 MG / SYRINGE       PALIPERIDONE PALMITATE                  00002455943     JAI
  INJECTION

  INVEGA TRINZA (1.315 ML) 263 MG / SYRINGE       PALIPERIDONE PALMITATE                  00002455986     JAI
  INJECTION

  INVEGA TRINZA (1.75 ML) 350 MG / SYRINGE        PALIPERIDONE PALMITATE                  00002455994     JAI
  INJECTION

  INVEGA TRINZA (2.625 ML) 525 MG / SYRINGE       PALIPERIDONE PALMITATE                  00002456001     JAI
  INJECTION

Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit/
Special Authorization
  Trade Name / Strength / Form                    Generic Description                     DIN             MFR
  APO-VARENICLINE 0.5 MG TABLET                   VARENICLINE TARTRATE                    00002419882     APX
  APO-VARENICLINE 1 MG TABLET                     VARENICLINE TARTRATE                    00002419890     APX

  MAR-RIZATRIPTAN ODT 5 MG ORAL                   RIZATRIPTAN BENZOATE                    00002462788     MAR
  DISINTEGRATING TABLET

  MAR-RIZATRIPTAN ODT 10 MG ORAL                  RIZATRIPTAN BENZOATE                    00002462796     MAR
  DISINTEGRATING TABLET

Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Special
Authorization
  Trade Name / Strength / Form                    Generic Description                     DIN             MFR
  CUBICIN RF 500 MG / VIAL INJECTION              DAPTOMYCIN                              00002465493     CUB

  MINT-EPLERENONE 25 MG TABLET                    EPLERENONE                              00002471442     MPI

  MINT-EPLERENONE 50 MG TABLET                    EPLERENONE                              00002471450     MPI

Drug Product(s) with Changes to Criteria for Coverage
  Trade Name / Strength / Form                    Generic Description                     DIN             MFR
  JAMP-VANCOMYCIN 125 MG CAPSULE                  VANCOMYCIN HCL                          00002407744     JPC

  JAMP-VANCOMYCIN 250 MG CAPSULE                  VANCOMYCIN HCL                          00002407752     JPC

EFFECTIVE JULY 1, 2018                                1
UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Drug Product(s) with Changes to Criteria for Coverage, continued
  Trade Name / Strength / Form                    Generic Description                     DIN                MFR
  VANCOCIN 125 MG CAPSULE                         VANCOMYCIN HCL                          00000800430        MLI

  VANCOCIN 250 MG CAPSULE                         VANCOMYCIN HCL                          00000788716        MLI

Restricted Benefit(s)
Additional Brand(s) and/or Strength(s) of Drug Product(s) Available by Restricted Benefit
  Trade Name / Strength / Form                    Generic Description                     DIN                MFR
  CYCLOBENZAPRINE 10 MG TABLET                    CYCLOBENZAPRINE HCL                     00002424584        SIV

  PMS-TENOFOVIR 300 MG TABLET                     TENOFOVIR DISOPROXIL FUMARATE           00002453940        PMS

Added Product(s)
  Trade Name / Strength / Form                    Generic Description                     DIN                MFR
  MINT-HYDRALAZINE 10 MG TABLET                   HYDRALAZINE HCL                         00002468778        MPI

  MINT-HYDRALAZINE 25 MG TABLET                   HYDRALAZINE HCL                         00002468786        MPI

  MINT-HYDRALAZINE 50 MG TABLET                   HYDRALAZINE HCL                         00002468794        MPI

New Established Interchangeable (IC) Grouping(s)
The following IC Grouping(s) have been established and LCA pricing will be applied effective August 1, 2018.
  Generic Description                             Strength / Form                               New LCA Price
  EPLERENONE                                      25 MG TABLET                                      2.0595

  EPLERENONE                                      50 MG TABLET                                      2.0595

  VARENICLINE TARTRATE                            0.5 MG TABLET                                     1.3855

  VARENICLINE TARTRATE                            1 MG TABLET                                       1.3853

Product(s) with a Price Change
The following product(s) had a Price Decrease. The previous higher price will be recognized until July 31, 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         APX

  APO-HYDRALAZINE 25 MG TABLET                   HYDRALAZINE HCL                         00000441627         APX

  APO-HYDRALAZINE 50 MG TABLET                   HYDRALAZINE HCL                         00000441635         APX

  JAMP-HYDRALAZINE 10 MG TABLET                  HYDRALAZINE HCL                         00002457865         JPC

                                                       2                                 EFFECTIVE JULY 1, 2018
UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Product(s) with a Price Change, continued
  Trade Name / Strength / Form                    Generic Description                      DIN               MFR
  JAMP-HYDRALAZINE 25 MG TABLET                   HYDRALAZINE HCL                          00002457873       JPC

  JAMP-HYDRALAZINE 50 MG TABLET                   HYDRALAZINE HCL                          00002457881       JPC

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 July 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 August 1, 2018 claims will no longer pay for these product(s).
  Trade Name / Strength / Form                     Generic Description                      DIN              MFR
  ACT FINASTERIDE 5 MG TABLET                      FINASTERIDE                              00002354462      APH

  ACT RAMIPRIL 1.25 MG CAPSULE                     RAMIPRIL                                 00002295482      APH

  ACT RISPERIDONE 1 MG TABLET                      RISPERIDONE                              00002282607      APH

  ACT VALSARTAN 80 MG TABLET                       VALSARTAN                                00002337495      APH

  ACT VALSARTAN 320 MG TABLET                      VALSARTAN                                00002337517      APH

  BELLERGAL SPACETABS                              BELLADONNA/ ERGOTAMINE                   00000176141      PAL
  0.2 MG / 0.6 MG / 40 MG SUSTAINED-RELEASE        TARTRATE/ PHENOBARBITAL
  TABLET

  CYCLOCORT 0.1% TOPICAL CREAM                     AMCINONIDE                               00002192284      GSK

  MIRAPEX 1 MG TABLET                              PRAMIPEXOLE DIHYDROCHLORIDE              00002237146      BOE

  MYLAN-AZITHROMYCIN 250 MG TABLET                 AZITHROMYCIN                             00002278359      MYP

  MYLAN-DONEPEZIL 5 MG TABLET                      DONEPEZIL HCL                            00002359472      MYP

  MYLAN-DULOXETINE 30 MG                           DULOXETINE HYDROCHLORIDE                 00002426633      MYP
  DELAYED-RELEASE CAPSULE

  MYLAN-DULOXETINE 60 MG                           DULOXETINE HYDROCHLORIDE                 00002426641      MYP
  DELAYED-RELEASE CAPSULE

  MYLAN-FAMOTIDINE 40 MG TABLET                    FAMOTIDINE                               00002196026      MYP

  MYLAN-LOSARTAN HCTZ 50 MG / 12.5 MG              LOSARTAN POTASSIUM/                      00002378078      MYP
  TABLET                                           HYDROCHLOROTHIAZIDE

  MYLAN-LOSARTAN HCTZ 100 MG / 12.5 MG             LOSARTAN POTASSIUM/                      00002378086      MYP
  TABLET                                           HYDROCHLOROTHIAZIDE

  MYLAN-LOSARTAN HCTZ 100 MG / 25 MG               LOSARTAN POTASSIUM/                      00002378094      MYP
  TABLET                                           HYDROCHLOROTHIAZIDE

  MYLAN-OMEPRAZOLE 20 MG                           OMEPRAZOLE                               00002329433      MYP
  DELAYED-RELEASE CAPSULE

  MYLAN-ROSUVASTATIN 40 MG TABLET                  ROSUVASTATIN CALCIUM                     00002381303      MYP

  MYLAN-ZOPICLONE 5 MG TABLET                      ZOPICLONE                                00002296616      MYP

EFFECTIVE JULY 1, 2018                                  3
UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Discontinued Listing(s), continued
 Trade Name / Strength / Form             Generic Description                DIN             MFR
 PMS-REPAGLINIDE 0.5 MG TABLET            REPAGLINIDE                        00002354926     PMS

 PMS-REPAGLINIDE 1 MG TABLET              REPAGLINIDE                        00002354934     PMS

 PMS-REPAGLINIDE 2 MG TABLET              REPAGLINIDE                        00002354942     PMS

 TEVA-ENALAPRIL 5 MG TABLET               ENALAPRIL MALEATE                  00002233005     TEV

 TEVA-ENALAPRIL 10 MG TABLET              ENALAPRIL MALEATE                  00002233006     TEV

 TEVA-ENALAPRIL 20 MG TABLET              ENALAPRIL MALEATE                  00002233007     TEV

 TEVA-PRAMIPEXOLE 1 MG TABLET             PRAMIPEXOLE DIHYDROCHLORIDE        00002269325     TEV

                                              4                             EFFECTIVE JULY 1, 2018
Drug Additions
      PART 2

Drug Additions
ALBERTA DRUG BENEFIT LIST UPDATE

                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
                        00002177145         APO-CYCLOBENZAPRINE                                  APX                    $     0.1022
                        00002348853         AURO-CYCLOBENZAPRINE                                 AUR                    $     0.1022
                        00002287064         CYCLOBENZAPRINE                                      SNS                    $     0.1022
                        00002424584         CYCLOBENZAPRINE                                      SIV                    $     0.1022
                        00002357127         JAMP-CYCLOBENZAPRINE                                 JPC                    $     0.1022
                        00002231353         MYLAN-CYCLOBENZAPRINE                                MYP                    $     0.1022
                        00002212048         PMS-CYCLOBENZAPRINE                                  PMS                    $     0.1022
                        00002080052         TEVA-CYCLOBENZAPRINE                                 TEV                    $     0.1022

                 HYDRALAZINE HCL
                   10 MG    ORAL TABLET
                        00000441619         APO-HYDRALAZINE                                      APX                    $     0.0355
                        00002457865         JAMP-HYDRALAZINE                                     JPC                    $     0.0355
                        00002468778         MINT-HYDRALAZINE                                     MPI                    $     0.0355
                   25 MG    ORAL TABLET
                        00000441627         APO-HYDRALAZINE                                      APX                    $     0.0609
                        00002457873         JAMP-HYDRALAZINE                                     JPC                    $     0.0609
                        00002468786         MINT-HYDRALAZINE                                     MPI                    $     0.0609
                   50 MG    ORAL TABLET
                        00000441635         APO-HYDRALAZINE                                      APX                    $     0.0956
                        00002457881         JAMP-HYDRALAZINE                                     JPC                    $     0.0956
                        00002468794         MINT-HYDRALAZINE                                     MPI                    $     0.0956

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 JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE

                 RIZATRIPTAN BENZOATE
                 RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age
                 inclusive for the treatment of acute migraine attacks in patients where standard therapy has
                 failed. (Refer to Criteria for Special Authorization of Select Drug Products of the List for
                 eligibility in patients 65 years of age and older; and Criteria for Special Authorization of
                 Select Drug Products of the Alberta Human Services Drug Benefit Supplement for eligibility
                 in Alberta Human Services clients.)

                    5 MG (BASE)       ORAL DISINTEGRATING TABLET
                         00002393484         APO-RIZATRIPTAN RPD                                     APX                    $        3.7050
                         00002465086         JAMP-RIZATRIPTAN ODT                                    JPC                    $        3.7050
                         00002462788         MAR-RIZATRIPTAN ODT                                     MAR                    $        3.7050
                         00002379198         MYLAN-RIZATRIPTAN ODT                                   MYP                    $        3.7050
                         00002436604         NAT-RIZATRIPTAN ODT                                     NTP                    $        3.7050
                         00002393360         PMS-RIZATRIPTAN RDT                                     PMS                    $        3.7050
                         00002442906         RIZATRIPTAN ODT                                         SNS                    $        3.7050
                         00002446111         RIZATRIPTAN ODT                                         SIV                    $        3.7050
                         00002351870         SANDOZ RIZATRIPTAN ODT                                  SDZ                    $        3.7050
                         00002396661         TEVA-RIZATRIPTAN ODT                                    TEV                    $        3.7050
                         00002240518         MAXALT RPD                                              MFC                    $       16.5163
                    10 MG (BASE)       ORAL DISINTEGRATING TABLET
                         00002393492         APO-RIZATRIPTAN RPD                                     APX                    $        3.7050
                         00002465094         JAMP-RIZATRIPTAN ODT                                    JPC                    $        3.7050
                         00002462796         MAR-RIZATRIPTAN ODT                                     MAR                    $        3.7050
                         00002379201         MYLAN-RIZATRIPTAN ODT                                   MYP                    $        3.7050
                         00002436612         NAT-RIZATRIPTAN ODT                                     NTP                    $        3.7050
                         00002393379         PMS-RIZATRIPTAN RDT                                     PMS                    $        3.7050
                         00002442914         RIZATRIPTAN ODT                                         SNS                    $        3.7050
                         00002446138         RIZATRIPTAN ODT                                         SIV                    $        3.7050
                         00002351889         SANDOZ RIZATRIPTAN ODT                                  SDZ                    $        3.7050
                         00002396688         TEVA-RIZATRIPTAN ODT                                    TEV                    $        3.7050
                         00002448505         VAN-RIZATRIPTAN ODT                                     VAN                    $        3.7050
                         00002240519         MAXALT RPD                                              MFC                    $       16.5163

                 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                                           APX                    $        4.8884
                         00002460173         AURO-TENOFOVIR                                          AUR                    $        4.8884
                         00002452634         MYLAN-TENOFOVIR DISOPROXIL                              MYP                    $        4.8884
                         00002453940         PMS-TENOFOVIR                                           PMS                    $        4.8884
                         00002403889         TEVA-TENOFOVIR                                          TEV                    $        4.8884
                         00002247128         VIREAD                                                  GIL                    $       18.4879

                 VANCOMYCIN HCL
                    125 MG (BASE)       ORAL CAPSULE
                         00002407744         JAMP-VANCOMYCIN                                         JPC                    $        5.1800
                         00000800430         VANCOCIN                                                MLI                    $        5.1800
                    250 MG (BASE)       ORAL CAPSULE
                         00002407752         JAMP-VANCOMYCIN                                         JPC                    $       10.3600
                         00000788716         VANCOCIN                                                MLI                    $       10.3600

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 JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE

                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
                        00002419882         APO-VARENICLINE                                      APX                    $     1.3855
                        00002291177         CHAMPIX                                              PFI                    $     1.8437
                   1 MG (BASE)       ORAL TABLET
                        00002419890         APO-VARENICLINE                                      APX                    $     1.3853
                        00002291185         CHAMPIX                                              PFI                    $     1.8432

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 JULY 1, 2018
Special Authorization
             PART 3

Special Authorization
ALBERTA DRUG BENEFIT LIST UPDATE
                                    CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

                 DAPTOMYCIN
                 For the treatment of:
                 - Culture confirmed gram-positive infections from sterile sites, specifically Methicillin-resistant
                 Staphylococcus aureus (MRSA), AND
                 - In patients who do not respond to, or exhibit multidrug intolerance to, or allergy to vancomycin,
                 AND
                 - to facilitate patient discharge from hospital where it otherwise would not be possible.

                 This product must be prescribed in consultation with a specialist in Infectious Diseases in all
                 instances.

                 Special Authorization may be granted for 12 months.

                   500 MG / VIAL     INJECTION
                        00002299909         CUBICIN                                            CUB                    $     184.0000
                        00002465493         CUBICIN RF                                         CUB                    $     184.0000

                 EPLERENONE
                 "For persons suffering from New York Heart Association (NYHA) class II chronic heart failure
                 with left ventricular systolic dysfunction with ejection fraction less than or equal to 35 per cent,
                 as a complement to standard therapy."

                 Special authorization will be granted for 12 months.

                 This product is eligible for auto-renewal.

                 All requests (including renewal requests) for eplerenone must be completed using the
                 Eplerenone/Sacubitril+Valstartan Special Authorization Request Form (ABC 60050).

                   25 MG     ORAL TABLET
                        00002471442         MINT-EPLERENONE                                    MPI                    $       2.0595
                        00002323052         INSPRA                                             PFI                    $       2.7164
                   50 MG     ORAL TABLET
                        00002471450         MINT-EPLERENONE                                    MPI                    $       2.0595
                        00002323060         INSPRA                                             PFI                    $       2.7164

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 JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE
                                    CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

                 GLATIRAMER ACETATE
                   20 MG / SYR     INJECTION SYRINGE
                        00002460661         GLATECT                                            PMS                    $      32.4000
                         ***Effective July 1, 2018, all new Special Authorization requests for the treatment of Relapsing
                         Remitting Multiple Sclerosis (RRMS) for glatiramer-naive patients will be assessed for coverage
                         with Glatect. Copaxone will not be approved for new glatiramer acetate starts for patients with the
                         indication stated above; however, coverage for Copaxone will continue for patients who are
                         currently well maintained on Copaxone as per maintenance coverage criteria. Additionally, patients
                         will not be permitted to switch from Glatect to Copaxone.***

                         Relapsing Remitting Multiple Sclerosis (RRMS):

                         "Special authorization coverage may be provided for the reduction of the frequency and severity of
                         clinical relapses and reduction of the number and volume of active brain lesions, identified on MRI
                         scans, in ambulatory patients with relapsing remitting multiple sclerosis.

                         Coverage

                         For coverage, this drug must be prescribed by a registered MS Neurologist. A current assessment
                         must be completed by a registered MS Neurologist at every request.

                         To register to become an MS Neurologist please complete the Registration for MS Neurologist
                         Status Form (ABC 60002).

                         Initial Coverage

                         1) The registered MS Neurologist must confirm a diagnosis of RRMS;

                         2) The patient must have active disease which is defined as at least two relapses* of MS during the
                         previous two years or in the two years prior to starting an MS disease modifying therapy (DMT).

                         *A relapse is defined as the appearance of new symptoms or worsening of old symptoms, lasting at
                         least 48 hours in the absence of fever, not associated with withdrawal from steroids. Onset of
                         clinical relapses must be separated by a period of at least one month. At least one definite
                         gadolinium-enhancing T1 MRI lesion (not questionable faint enhancement) obtained at least 90
                         days after initiation of the DMT and at least 90 days before or after a relapse may substitute for one
                         clinical relapse.

                         3) The patient must be ambulatory with or without aid (The registered MS Neurologist must provide
                         a current updated Expanded Disability Status Scale (EDSS) score less than or equal to 6.5).

                         Coverage may be approved for up to 12 months. Patients will be limited to receiving a one-month
                         supply of glatiramer acetate per prescription at their pharmacy for the first 12 months of coverage.

                         Continued Coverage

                         For continued coverage beyond the initial coverage period, the patient must meet the following
                         criteria:

                         1) The patient must be assessed by a registered MS Neurologist;

                         2) The registered MS Neurologist must confirm a diagnosis of RRMS;

                         3) The registered MS Neurologist must provide a current updated EDSS score. The patient must
                         not have an EDSS score of 7.0 or above sustained for one year or more.

                         Coverage of this drug may be considered in a patient with a sustained EDSS score of 7.0 or above
                         in exceptional circumstances. For MS DMT coverage to be considered, details of the exceptional
                         circumstance must be provided in a letter from the registered MS Neurologist and accompany
                         the Special Authorization Request Form.

                         Continued coverage may be approved for up to 12 months. Patients may receive up to 100 days'
                         supply of glatiramer acetate per prescription at their pharmacy.

                         Restarting After an Interruption in Therapy Greater Than 12 Months

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 JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE
                                    CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

                 GLATIRAMER ACETATE
                         In order to be eligible for coverage, after an interruption in therapy greater than 12 months, the
                         patient must meet the following criteria:

                         1) At least one relapse* per 12 month period; or
                         2) At least two relapses* during the previous 24 month period."

                         All requests (including renewal requests) for glatiramer acetate must be completed using the
                         Dimethyl Fumarate/Glatiramer Acetate/Interferon Beta-1a/Interferon Beta-1b/Peginterferon Beta-
                         1a/Teriflunomide Special Authorization Request Form (ABC 60001).

                 PALIPERIDONE PALMITATE
                 "For the management of the manifestations of schizophrenia in patients who demonstrate a
                 pattern of significant non-compliance that compromises therapeutic success and who possess
                 clinical evidence of previous successful treatment with risperidone or paliperidone therapy;

                 AND who meet at least one of the following criteria:

                 - Experiences extra-pyramidal symptoms with either an oral or depot first generation
                 antipsychotic agent that precludes the use of a first generation antipsychotic depot product; OR

                 - Is refractory to trials of at least two other antipsychotic therapies (Note: one trial must include a
                 first generation antipsychotic agent)

                 To be considered for coverage of Invega Trinza, patients must have been maintained on Invega
                 Sustenna for at least four months. The last two doses of Invega Sustenna should be the same
                 dosage strength and dosing interval, before initiating Invega Trinza.

                 Special Authorization may be granted for six months."

                 All requests (including renewal requests) for paliperidone prolonged release injection must be
                 completed using the Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special
                 Authorization Request Form (ABC 60024).

                 The following product(s) are eligible for auto-renewal.

                   175 MG / SYR (BASE)       INJECTION SYRINGE
                        00002455943         INVEGA TRINZA (0.875 ML SYR)                       JAI                    $     934.2900
                   263 MG / SYR (BASE)       INJECTION SYRINGE
                        00002455986         INVEGA TRINZA (1.315 ML SYR)                       JAI                    $   1401.5400
                   350 MG / SYR (BASE)       INJECTION SYRINGE
                        00002455994         INVEGA TRINZA (1.75 ML SYR)                        JAI                    $   1401.5400
                   525 MG / SYR (BASE)       INJECTION SYRINGE
                        00002456001         INVEGA TRINZA (2.625 ML SYR)                       JAI                    $   1868.6700

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 . 3                         EFFECTIVE JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE
                                    CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

                 RIZATRIPTAN BENZOATE
                 (Refer to 28:32.28 of the Alberta Drug Benefit List for coverage of patients 18 to 64 years of age
                 inclusive.)

                 "For the treatment of acute migraine attacks in patients 65 years of age and older where other
                 standard therapy has failed."

                 "For the treatment of acute migraine attacks in patients 65 years of age and older who have
                 been using rizatriptan benzoate prior to turning 65."

                 "Special authorization for both criteria may be granted for 24 months."

                 In order to comply with the first criteria, information is required regarding previous medications
                 utilized and the patient's response to therapy.

                 The following product(s) are eligible for auto-renewal.
                   5 MG (BASE)       ORAL DISINTEGRATING TABLET
                        00002393484         APO-RIZATRIPTAN RPD                                APX                    $       3.7050
                        00002465086         JAMP-RIZATRIPTAN ODT                               JPC                    $       3.7050
                        00002462788         MAR-RIZATRIPTAN ODT                                MAR                    $       3.7050
                        00002379198         MYLAN-RIZATRIPTAN ODT                              MYP                    $       3.7050
                        00002436604         NAT-RIZATRIPTAN ODT                                NTP                    $       3.7050
                        00002393360         PMS-RIZATRIPTAN RDT                                PMS                    $       3.7050
                        00002442906         RIZATRIPTAN ODT                                    SNS                    $       3.7050
                        00002446111         RIZATRIPTAN ODT                                    SIV                    $       3.7050
                        00002351870         SANDOZ RIZATRIPTAN ODT                             SDZ                    $       3.7050
                        00002396661         TEVA-RIZATRIPTAN ODT                               TEV                    $       3.7050
                        00002240518         MAXALT RPD                                         MFC                    $      16.5163
                   10 MG (BASE)       ORAL DISINTEGRATING TABLET
                        00002393492         APO-RIZATRIPTAN RPD                                APX                    $       3.7050
                        00002465094         JAMP-RIZATRIPTAN ODT                               JPC                    $       3.7050
                        00002462796         MAR-RIZATRIPTAN ODT                                MAR                    $       3.7050
                        00002379201         MYLAN-RIZATRIPTAN ODT                              MYP                    $       3.7050
                        00002436612         NAT-RIZATRIPTAN ODT                                NTP                    $       3.7050
                        00002393379         PMS-RIZATRIPTAN RDT                                PMS                    $       3.7050
                        00002442914         RIZATRIPTAN ODT                                    SNS                    $       3.7050
                        00002446138         RIZATRIPTAN ODT                                    SIV                    $       3.7050
                        00002351889         SANDOZ RIZATRIPTAN ODT                             SDZ                    $       3.7050
                        00002396688         TEVA-RIZATRIPTAN ODT                               TEV                    $       3.7050
                        00002448505         VAN-RIZATRIPTAN ODT                                VAN                    $       3.7050
                        00002240519         MAXALT RPD                                         MFC                    $      16.5163

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 . 4                         EFFECTIVE JULY 1, 2018
ALBERTA DRUG BENEFIT LIST UPDATE
                                    CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

                 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 (BASE)       ORAL TABLET
                        00002419882         APO-VARENICLINE                                    APX                    $       1.3855
                        00002291177         CHAMPIX                                            PFI                    $       1.8437
                   1 MG (BASE)       ORAL TABLET
                        00002419890         APO-VARENICLINE                                    APX                    $       1.3853
                        00002291185         CHAMPIX                                            PFI                    $       1.8432

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 . 5                         EFFECTIVE JULY 1, 2018
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