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, 2018Inquiries 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, 2018UPDATES 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, 2018UPDATES 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, 2018Drug Additions
PART 2
Drug AdditionsALBERTA 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, 2018ALBERTA 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, 2018ALBERTA 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, 2018Special Authorization
PART 3
Special AuthorizationALBERTA 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, 2018ALBERTA 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, 2018ALBERTA 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, 2018ALBERTA 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, 2018ALBERTA 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, 2018You can also read
