Alberta Drug Benefit List - Alberta Blue Cross - Group benefits · PDF file ·...
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Alberta Drug Benefit List Effective April 1, 2018
Alberta Drug Benefit List - Alberta Blue Cross - Group benefits · PDF file · 2017-03-30Alberta Blue Cross 10009 108 Street NW ... DBL is not intended to be, and must not be used
78BInquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780) 498-8370 (Edmonton)
109BWebsite: http://www.health.alberta.ca/services/drug-benefit-list.html Administered by Alberta Blue Cross on behalf of Alberta Health.
The Drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool. Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product.
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.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE APRIL 1, 2018 i
1BTable of Contents
79BPART 1 80BSECTION 1POLICIES AND GUIDELINES
Introduction Acknowledgments ..................................................................................................................................1.1 Eligibility .................................................................................................................................................1.1 Additional Notes Regarding Application of the List ................................................................................1.1 Legend ...................................................................................................................................................1.3 Example of Drug Product Listings .........................................................................................................1.4 Drug Reviews .........................................................................................................................................1.5 Alberta Health Expert Committee on Drug Evaluation and Therapeutics ............................................1.7 Submissions for Drug Reviews Submissions for Drug Reviews ..............................................................................................................1.8 Criteria for Listing Drug Products .........................................................................................................1.10 Interchangeable Drug Products Additional Criteria ..........................................................................1.12 Interchangeable Drug Products Additional Criteria Appendices ......................................................1.17 Review of Benefit Status (ROBS) Criteria ...........................................................................................1.24 Submission Requirements ...................................................................................................................1.25 Non-Innovator Policy............................................................................................................................1.40 Supply Shortages .................................................................................................................................1.42 Units of Issue for Pricing ......................................................................................................................1.43 Policy for Administering Interchangeability Challenges .......................................................................1.45 Your Comments are Important to Us ...................................................................................................1.47 Restricted Benefits Restricted Benefits ...............................................................................................................................1.48 Products Designated as Restricted Benefits .......................................................................................1.48 Limited Restricted Benefits ..................................................................................................................1.51 Special Authorization Guidelines Special Authorization Policy ................................................................................................................1.52 Special Authorization Procedures ....................................................................................................... 1A.1 Special Authorization Forms ............................................................................................................... 1A.2 Prescriber Registration Forms ............................................................................................................ 1A.5 Drug Special Authorization Request Form ......................................................................................... 1A.6 Donepezil/Galantamine/Rivastigmine Special Authorization Request Form ...................................... 1A.8 Darbepoetin/Epoetin Special Authorization Request Form .............................................................. 1A.10 Abatacept/Adalimumab/Anakinra/Certolizumab/Etanercept/Golimumab/Infliximab/Tocilizumab/ Tofacitinib for Rheumatoid Arthritis Special Authorization Request Form ........................................ 1A.13 Ezetimibe Special Authorization Request Form ............................................................................... 1A.15 Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form .................................................................................................................................................. 1A.17 Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form........................ 1A.19 Adalimumab/Etanercept/Tocilizumab for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form ............................................................................................................. 1A.21 Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form ............................................................................................................. 1A.23
https://www.ab.bluecross.ca/dbl/pdfs/30776.pdf
ALBERTA DRUG BENEFIT LIST
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
EFFECTIVE APRIL 1, 2018 ii
Table of Contents, continued Select Quinolones Special Authorization Request Form .................................................................. 1A.25 Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form ......... 1A.28 Celecoxib Special Authorization Request Form ............................................................................... 1A.30 Filgrastim/Pegfilgrastim/Plerixafor Special Authorization Request Form ......................................... 1A.32 Fentanyl Special Authorization Request Form ................................................................................. 1A.35 Adalimumab/Etanercept/Infliximab/Secukinumab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form ............................................................................................................. 1A.37 Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form ............................................................................................................. 1A.39 Adalimumab/Vedolizumab for Crohns/Infliximab for Crohns/Fistulizing Crohns Disease Special Authorization Request Form ............................................................................................................. 1A.41 Rituximab for Rheumatoid Arthritis Special Authorization Request Form ........................................ 1A.43 Imiquimod Special Authorization Request Form .............................................................................. 1A.45 Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form ................................................................................................................................... 1A.47 Abatacept for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form ......... 1A.50 Montelukast/Zafirlukast Special Authorization Request Form .......................................................... 1A.52 Febuxostat Special Authorization Request Form ............................................................................. 1A.54 Denosumab/Zoledronic Acid for Osteoperosis Special Authorization Request Form ...................... 1A.56 Omalizumab for Asthma Special Authorization Request Form ........................................................ 1A.58 Eculizumab Special Authorization Request Form............................................................................. 1A.60
Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request Form ................................................................................................................................... 1A.67 Tocilizumab for Systemic Juvenile Idiopathic Arthritis
