Alberta Health and Wellness Drug Benefit List - Group … · Febuxostat Special Authorization Request Form ... Product Monograph . ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST

Alberta Health and Wellness

Drug Benefit List

Effective July 1, 2012

78BInquiries 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) 498-8384 1-877-828-4106 (Toll Free) 109BWebsite: http://www.health.alberta.ca/services/drug-benefit-list.html Administered by Alberta Blue Cross on behalf of Alberta Health and Wellness. 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.

http://www.health.alberta.ca/services/drug-benefit-list.html�

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. i EFFECTIVE JULY 1, 2012

1BTable of Contents

79BPART 1 80BSECTION 1—POLICIES 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 Review Procedure .........................................................................................................................1.5 Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics ......................1.7 Submissions for Drug Reviews Interpretation Notices ...........................................................................................................................1.10 Submission Requirements ...................................................................................................................1.12 Criteria for Listing Drug Products .........................................................................................................1.23 Interchangeable Drug Products – Additional Criteria ..........................................................................1.25 Interchangeable Drug Products – Additional Criteria Appendices ......................................................1.29 Review of Benefit Status (ROBS) Criteria ...........................................................................................1.36 Supply Shortage Policy for Drug Products ..........................................................................................1.37 Units of Issue for Pricing ......................................................................................................................1.38 Policy for Administering Interchangeability Challenges .......................................................................1.40 Your Comments are Important to Us ...................................................................................................1.42 Price Policy Definitions ............................................................................................................................................1.43 Alberta Price Confirmation (APC) ........................................................................................................1.46 Interim APC ..........................................................................................................................................1.48 Fixed Pricing Rules (For Interchangeable Drugs) ...............................................................................1.49 Non-Fixed Pricing Rules (For Brand and Other Drugs) .......................................................................1.49 Exceptions ...........................................................................................................................................1.50 Price Reductions ..................................................................................................................................1.51 Minister’s Authority ...............................................................................................................................1.51 Least Cost Alternative (LCA) Price Policy ...........................................................................................1.54 Maximum Allowable (MAC) Price Policy ..............................................................................................1.55 Restricted Benefits Restricted Benefits ...............................................................................................................................1.56 Limited Restricted Benefits ..................................................................................................................1.57 Products Designated as Limited Restricted Benefits ...........................................................................1.57 Special Authorization Guidelines Special Authorization Policy ................................................................................................................1.58 Special Authorization Procedures ....................................................................................................... 1A.1 Special Authorization Forms ............................................................................................................... 1A.2 Drug Special Authorization Request Form ......................................................................................... 1A.4 Donepezil/Galantamine/Rivastigmine Special Authorization Request Form ...................................... 1A.6 Clopidogrel Special Authorization Request Form ............................................................................... 1A.8

https://www.ab.bluecross.ca/dbl/pdfs/30776.pdf�


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 ii

83B84B3BTable of Contents, continued

Darbepoetin/Epoetin Special Authorization Request Form ..................................................................... 1A.10 Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab 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 Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form ................................... 1A.21 Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form .......................................................................................................................................... 1A.23 Select Quinolones Special Authorization Request Form ........................................................................ 1A.25 Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Nasal Spray Salmon for Osteoporosis Special Authorization Request Form ....................................................................................................... 1A.28 Celecoxib Special Authorization Request Form ...................................................................................... 1A.31 Filgrastim/Pegfilgrastim Special Authorization Request Form ................................................................ 1A.33 Fentanyl Special Authorization Request Form ........................................................................................ 1A.35 Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form .......................................................................................................................................... 1A.37 Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form .......................................................................................................................................... 1A.39 Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form .................................................................................................................... 1A.41 Rituximab for Rheumatoid Arthritis Special Authorization Request Form .............................................. 1A.43 Imiquimod Special Authorization Request Form ..................................................................................... 1A.45 Dutasteride/Finasteride Special Authorization Request Form ................................................................ 1A.47 Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form ............... 1A.49 Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form .................................... 1A.51 Montelukast/Zafirlukast Special Authorization Request Form ................................................................ 1A.53 Febuxostat Special Authorization Request Form .................................................................................... 1A.55 Denosumab Special Authorization Request Form .................................................................................. 1A.57 Omalizumab Special Authorization Request Form ................................................................................. 1A.59 Eculizumab Special Authorization Request Form.................................................................................. 1A.61 Eculizumab Consent Form..................................................................................................................... 1A.63

81BSECTION 2—MULTIPLE SCLEROSIS (MS) DRUG COVERAGE Clinical Criteria for Coverage .......................................................................................................................2.1 Contraindications to Coverage .....................................................................................................................2.1 Alberta Multiple Sclerosis (MS) Drug Review Panel ....................................................................................2.2 Process for Multiple Sclerosis (MS) Drug Coverage ....................................................................................2.2 Avonex/Betaseron/Copaxone/Extavia/Rebif/Tysabri MS Drug Coverage Application .................................2.4 Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program ...................................................2.10

SECTION 3—CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

Special Authorization Policy ..................................................................................................................3.1


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. iii EFFECTIVE JULY 1, 2012

Criteria for Coverage ..............................................................................................................................3.3

83B84B3BTable of Contents, continued

SECTION 3A—CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

Criteria for Coverage ..................................................................................................................... ……..3A Role of the Prescribers .......................................................................................................................... 3A Criteria for Optional Special Authorization of Select Drug Products ................................................... 3A.1

SECTION 4—RARE DISEASES DRUG COVERAGE PROGRAM Rare Diseases Drug Coverage ........................................................................................................ …..4.1 Contraindications ...................................................................................................................................4.1 Rare Diseases Drugs Eligible for Coverage ..........................................................................................4.2 Alberta Rare Diseases Clinical Review Panel .......................................................................................4.2 Process for Rare Diseases Drug Coverage...........................................................................................4.2

85BPART 2

86BPHARMACOLOGIC–THERAPEUTIC CLASSIFICATION OF DRUGS 00:00 Non-Classified Drugs ..................................................................................................... 1 04:00 Antihistamine Drugs ....................................................................................................... 3 08:00 Anti-Infective Agents ...................................................................................................... 5 10:00 Antineoplastic Agents ................................................................................................... 21 12:00 Autonomic Drugs .......................................................................................................... 23 20:00 Blood Formulation, Coagulation and Thrombosis ........................................................ 29 24:00 Cardiovascular Drugs ................................................................................................... 35 28:00 Central Nervous System Agents .................................................................................. 71 34:00 Dental Agents ............................................................................................................. 121 36:00 Diagnostic Agents ...................................................................................................... 123 40:00 Electrolytic, Caloric, and Water Balance .................................................................... 125 48:00 Respiratory Tract Agents............................................................................................ 129 52:00 Eye, Ear, Nose and Throat (EENT) Preparations ...................................................... 131 56:00 Gastrointestinal Drugs ................................................................................................ 141 60:00 Gold Compounds ....................................................................................................... 151 64:00 Heavy Metal Antagonists............................................................................................ 153 68:00 Hormones and Synthetic Substitutes ......................................................................... 155 80:00 Serums, Toxoids and Vaccines .................................................................................. 171 84:00 Skin and Mucous Membrane Agents ......................................................................... 173 86:00 Smooth Muscle Relaxants.......................................................................................... 183 88:00 Vitamins ...................................................................................................................... 185 92:00 Miscellaneous Therapeutic Agents ............................................................................ 187 94:00 Devices ....................................................................................................................... 191


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 iv

88B83B84B3BTable of Contents, continued

87BAPPENDICES Appendix 1 Abbreviations ............................................................................................................. 190 Appendix 2 Pharmaceutical Manufacturers ................................................................................. 191

INDICES Index 1 Alphabetical List of Pharmaceutical Products .................................................................. 193 Index 2 Numerical List by Drug Identification Number .................................................................. 226

Section 1 Policies and Guidelines

PART 1

SECTION 1

Policies and

Guidelines


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.

Section 1 • 1 EFFECTIVE JULY 1, 2012

INTRODUCTION Acknowledgments

Alberta Health and Wellness acknowledges the important role Alberta Blue Cross continues to play in the production of the List and in the development of an overall strategy and initiatives to better manage Alberta Health and Wellness sponsored drug programs.

Eligibility The Alberta Health and Wellness Drug Benefit List defines the drugs and drug products that are covered by Alberta government-sponsored drug programs. These programs are for Albertans and their dependents who are covered by: 1. the Alberta Blue Cross Non-Group Coverage (Group 1) offered by the Alberta Health Care

Insurance Plan, 2. the Alberta Blue Cross Coverage for Seniors (Group 66) provided to all Alberta senior

citizens and those on the Alberta Widows’ Pension Plan (Group 66A), or 3. the drug coverage provided to individuals approved by Alberta Health and Wellness for

Palliative Care Drug Coverage. (For these individuals the Palliative Care Drug Benefit Supplement must also be considered), or

4. the drug coverage provided to Alberta Human Services and Alberta Seniors (AISH) clients. (For these clients the Alberta Human Services Drug Benefit Supplement must also be considered.)

Additional Notes Regarding Application of the List

1. The List is not intended to be used as a scientific reference or prescribing guide.

2. Formularies used by hospitals and continuing care facilities are developed independently of the List.

3. Drugs are classified according to the Pharmacologic–Therapeutic classifications (PTC) developed by the American Society of Health-System Pharmacists for the purpose of the American Hospital Formulary Service.

Permission to use this system has been granted by the American Society of Health-System Pharmacists. The Society is not responsible for the accuracy of transpositions or excerpts from the original content.

Where necessary, additional PTCs may have been assigned by Alberta Health and Wellness to facilitate product location in the List.

4. Where appropriate, the Compendium of Pharmaceuticals and Specialties, published by the Canadian Pharmacist’s Association, was used as a reference source for the trade name, generic name, manufacturer, strength and dosage form.

The Canadian Pharmacist’s Association is not responsible for the accuracy of transpositions or excerpts from the original content.

5. Other reference sources used for the trade name, generic name, manufacturer, strength and dosage form are: completed Drug Identification Number (DIN) notification form Notice of Compliance (NOC) Product Monograph



EFFECTIVE JULY 1, 2012 Section 1 • 2

6. DINs listed reflect current manufacturer information available as of March 31, 2012.

7. Alberta Health and Wellness reserves the right to make changes, without notice, to the List through the on-line interactive List, and any such changes to the on-line interactive List are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.




Legend

Pharmacologic–Therapeutic classification.

Pharmacologic–Therapeutic sub-classification.

Nonproprietary or generic ingredient name of the drug.

Drug strength and dosage form.

The Drug Identification Number (DIN), assigned by the Therapeutic Products Directorate (TPD), Health Protection Branch, Health Canada.

A box containing an X to the left of the DIN indicates that the product is not interchangeable with other products or interchangeability has not been assessed within the category.

All active ingredients of combination products are listed.

Strengths of active ingredients are listed in the same order as the ingredients. This example indicates that the topical cream contains 1% hydrocortisone acetate and 10% urea.

Brand name of the drug.

Three letter identification code assigned to each manufacturer. The codes are listed in Appendix 2 at the end of the List.

For products which are marked as non-interchangeable, the price is indicated in regular type (not bold type). These prices are supplied by the manufacturer and are expressed in decimal dollars.

For those products which are single source, the price is indicated in regular type (not bold type). These prices are supplied by the manufacturer and are expressed in decimal dollars.

Interchangeable grouping where the Least Cost Alternative (LCA) Price Policy has not been applied. This example indicates these two products are deemed interchangeable. These prices are supplied by the manufacturer and are expressed in decimal dollars.

The LCA Price for the selected interchangeable category appears in bold type. The LCA price is the maximum price which will be paid. The prices listed are expressed as decimal dollars. An authorized health care provider may request special authorization if a particular brand is essential in the care of a patient where the LCA Price would otherwise apply. For further information refer to the Special Authorization Guidelines section of the AHWDBL or List.

Products or devices designated as restricted benefits and limited restricted benefits are identified by a comment after the generic name. The comment indicates “RESTRICTED BENEFIT” or “LIMITED RESTRICTED BENEFIT” along with an explanation of the limits and/or restrictions. In this example, coverage of Accolate is restricted to the treatment of asthma in patients 12 to 18 years of age inclusive. For more information about products or devices designated as restricted benefits, refer to the restricted benefits section of the List.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1 • 4

7BExample of Drug Product Listings

08:00 ANTI-INFECTIVE AGENTS 08:12.12.04 ANTIBACTERIALS MACROLIDES (ERYTHROMYCINS)

ERYTHROMYCIN 250 MG ORAL TABLET

00000682020 ERYTHRO-BASE AAP $ 0.1828 250 MG ORAL CAPSULE (ENTERIC-COATED PELLET)

00000726672 ERYTHRO-EC AAP $ 0.4193 00000607142 ERYC PFI $ 0.4916

28:00 CENTRAL NERVOUS SYSTEM AGENTS 28:08:04.92 ANALGESICS AND ANTIPYRETICS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)

NAPROXEN 250 MG ORAL ENTERIC-COATED TABLET

00002246699 APO-NAPROXEN EC APX $ 0.1068 $ 0.1570 00002365847 AVA-NAPROXEN EC AVA $ 0.1068 $ 0.1570 00002350785 NAPROXEN EC SNS $ 0.1068 $ 0.1570 00002243312 NOVO-NAPROX EC TEV $ 0.1068 $ 0.1570 00002162792 NAPROSYN E HLR $ 0.1068 $ 0.4487

MAC pricing has been applied based on the LCA price for 1 x 250 mg oral tablet.

68:00 HORMONES AND SYNTHETIC SUBSTITUTES 68:16.04 ESTROGENS AND ANTIESTROGENS (ESTROGENS)

CONJUGATED ESTROGENS 0.3 MG ORAL TABLET

00002043394 PREMARIN WAY $ 0.3117 0.625 MG ORAL TABLET

00000265470 C.E.S VCL $ 0.1090 00002043408 PREMARIN WAY $ 0.3117

84:00 SKIN AND MUCOUS MEMBRANE AGENTS 84:06 ANTI-INFLAMMATORY AGENTS

HYDROCORTISONE ACETATE/ UREA 1 % * 10 % TOPICAL CREAM

00000503134 UREMOL-HC GSK $ 0.1877 1 % * 10 % TOPICAL LOTION

00000560022 UREMOL-HC GSK $ 0.1044 HYDROCORTISONE

1 % TOPICAL LOTION 00000578541 SARNA HC GSK $ 0.1008 00000192600 EMO-CORT GSK $ 0.1706

48:00 RESPIRATORY TRACT AGENTS 48:10.24 ANTI-INFLAMMATORY AGENTS (LEUKOTRIENE MODIFIERS)

ZAFIRLUKAST RESTRICTED BENEFIT - This product is a benefit for patients 12 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to the Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)

20 MG ORAL TABLET 00002236606 ACCOLATE AZC $ 0.8054

10 12

14

12

34

5

131313

13131313

9

7

8

77777

116

15

7777777

1313

7

5




DRUG REVIEWS

The Minister of Health and Wellness makes the final decisions on changes to the Alberta Health and Wellness Drug Benefit List (List) after considering the recommendations of the Expert Committee on Drug Evaluation and Therapeutics (Expert Committee), and/or the Canadian Expert Drug Advisory Committee (CEDAC), and/or Alberta Health and Wellness. Drug manufacturers wishing to have their drug product(s) listed on the List are required to make submissions in accordance with the procedures and criteria published in the List. Common Drug Review Alberta is a participant in the national Common Drug Review procedure (CDR Procedure*) and considers recommendations from CEDAC. Submissions relating to the New Chemical Entities and New Combination Products that have received a Health Canada Notice of Compliance (NOC) should be directed to the CDR Directorate for consideration, and must comply with the CDR Procedure requirements.

• New Chemical Entity is an active moiety that has not been previously approved for sale in Canada by Health Canada and marketed in Canada. • New Combination Product consists of two or more active moieties that have not previously been approved for sale in Canada and marketed in Canada in that combination. It may consist of either two or more new active moieties or two or more old active moieties or a combination of new and old active moieties.

Expert Committee on Drug Evaluation and Therapeutics Drug Reviews The Minister of Health and Wellness has established an Expert Committee on Drug Evaluation and Therapeutics to refine and maintain the List on an ongoing basis. All drug products not eligible for review under the CDR Procedure or the Interchangeable Expedited Review procedure must be reviewed by the Expert Committee prior to their determination as benefits on the List. The Expert Committee considers the scientific, therapeutic, clinical and socio-economic merits of drug products. The Committee receives advice and assistance from external consultants and agencies when needed. The Expert Committee makes recommendations on the List to Alberta Health and Wellness through the Executive Director, Pharmaceutical Funding and Guidance, Health Policy and Service Standards Division. Interchangeable Reviews Drug products may be considered for listing as interchangeable through Expedited Review or Full Review. Expedited Review drug products are not required to undergo a full review by the Expert Committee. Interchangeable drug product submissions will be screened by Alberta Blue Cross to determine eligibility for an Expedited Review and the results provided to Alberta Health and Wellness. Interchangeable drug submissions requiring Full Review will be reviewed by the Expert Committee under its usual drug review procedure.




Referrals Alberta Health and Wellness at all times and in all circumstances reserves the right to refer any submission to the CDR Procedure and/or the Expert Committee for further advice or for a full review. Deferrals The Expert Committee and/or Alberta Health and Wellness reserve the right to defer any submission it deems appropriate in order to ensure that it may complete a review in a manner that protects patient safety and maintains the integrity of the AHWDBL and the government-sponsored drug programs. Examples of reasons for deferrals include, but are not limited to:

1. To request additional information in order to conduct a review and prepare recommendations;

2. Where additional time, research and/or consultation is required before a review can be completed or a recommendation can be made;

3. Where new or novel issues are raised; 4. Where issues, questions or concerns relating to any of the listing criteria or factors

arise, including but not limited to: (a) interchangeable safety issues, (b) whether the criteria requires expansion or clarification, (c) the drug product, (d) the listing, (e) the price, (f) any other relevant criteria or factor.

*Information regarding the CDR Procedure may be obtained through the Canadian Agency for Drugs and Technologies in Health.




Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics

Committee Members

James L. SILVIUS, BA, MD, FRCPC Chair Clinical Associate Professor Geriatric Medicine University of Calgary 10301 Southport Lane SW Calgary, Alberta T2W 1S7 Robert J. HERMAN, MD, FRCPC Vice-Chair Professor Division of General Internal Medicine Faculty of Medicine University of Calgary Health Science Centre 3330 Hospital Drive NW Calgary, Alberta T2N 4N1 Margaret BARR, BSc(Pharm) Pharmacist 5238-42 Street Ponoka, Alberta T4J 1C9 Jeffrey A. JOHNSON, BSP, MSc, PhD Professor School of Public Health University of Alberta 2-040 Li Ka Shing Centre Edmonton, Alberta T6G 2N3 Saibal NANDY, MBBS, MRCPsych, FRCPC Psychiatrist 101-1424 Southview Drive SE Medicine Hat, Alberta T1B 4E7 Glen J. PEARSON, BScPhm, PharmD, FCSHP Associate Professor of Medicine Co-Director, Cardiac Transplant Clinic Director of Research, Cardiovascular Risk Reduction Clinic Division of Cardiology 2C2 Walter Mackenzie Health Sciences Centre Edmonton, Alberta T6G 2B7 Cheryl A. SADOWSKI, BSc(Pharm), PharmD, FCSHP Associate Professor 3-171 Edmonton Clinic Health Academy 11405-87 Avenue Edmonton, Alberta T6G 1C9

Committee Members (cont’d) Kelly B. ZARNKE, MD, MSc, FRCPC Associate Professor and Head, Division of General Internal Medicine Chief, Division of General Internal Medicine, Alberta Health Services Health Sciences Centre, Room 1470 University of Calgary 3330 Hospital Drive NW Calgary, Alberta T2N 4N1 Alberta Health and Wellness Liaison Steve LONG, BSc(Pharm), MBA Executive Director Pharmaceutical Funding and Guidance Branch Health Workforce Division Alberta Health and Wellness 11th Floor, 10025 Jasper Avenue NW Edmonton, Alberta T5J 1S6 Mark HARASYMUK, BSc(Pharm) Director, PFG Operations Pharmaceutical Funding and Guidance Branch Health Workforce Division Alberta Health and Wellness 11th Floor, 10025 Jasper Avenue NW Edmonton, Alberta T5J 1S6 Administrative/Scientific Support Carlyn VOLUME-SMITH, BSc(Pharm), MSc, PhD Senior Manager Scientific and Research Services Alberta Blue Cross 10009 - 108 Street NW Edmonton, Alberta T5J 3C5 Sherry DIELEMAN, BSc(Pharm), MSc Senior Pharmacist Associate Scientific and Research Services Alberta Blue Cross Micheal S. GUIRGUIS, BSc(Pharm), PhD Senior Scientific Associate Scientific and Research Services Alberta Blue Cross Rhonda C. SHKROBOT, BSc(Pharm) Senior Pharmacist Associate Scientific and Research Services Alberta Blue Cross




SUBMISSIONS for DRUG REVIEWS 1) Only submissions satisfying all of the submission requirements of the applicable category of

drug product that are deemed complete by the applicable submission deadline date will be put forward for review.

2) In addition to the submission requirements, the Expert Committee and/or Alberta Health and Wellness, at their sole discretion, reserve the right to request the drug product file from Health Canada’s Therapeutic Products Directorate (TPD), or any additional information from the manufacturer, CEDAC, or any other entity that the Expert Committee and/or Alberta Health and Wellness consider necessary, which may result in a delay in the listing recommendation for the drug product.

3) There is no obligation or guarantee that every completed submission will be reviewed, and/or a recommendation made, by a specific date or at the next scheduled meeting of the Expert Committee.

4) Pre-NOC submissions may be made; however, the submission will only be reviewed once it is complete.

5) Any request by a manufacturer to hold a submission will result in a submission being deemed incomplete as of the date of the request. A submission on hold will only be considered complete once correspondence is received from a manufacturer to proceed with the submission.

6) Only one (1) copy of a submission for a drug product is required. A determination by Alberta Blue Cross that a submission is complete is preliminary and made only for the purposes of forwarding the submission for review.

7) Drug manufacturers are permitted to provide other information they feel may be important to the review of a submission e.g. selected references or additional studies completed after a drug product had been submitted to the Therapeutic Products Directorate, Health Canada. Comparative studies with other listed drug products are most relevant.

8) Information on submission deadlines are posted on the Alberta Health and Wellness Drug Benefit List website which can be accessed at http://www.ab.bluecross.ca/dbl/manufacturers.html. Notice of Significant Changes - By making a submission, and if a drug product is listed on the List, manufacturers acknowledge and agree that they are required to notify the Senior Manager, Scientific and Research Services of any significant change to listed drug products. Significant changes are considered to be changes in NOC, DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, manufacturing specifications or any change that could potentially affect the bioavailability or bioequivalence of a drug product. All submissions should be sent to the attention of: Senior Manager Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5

http://www.ab.bluecross.ca/dbl/manufacturers.html�




All inquiries should be directed to: Coordinator Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5 Phone: (780) 498-8098 Fax: (780) 498-3534

Email: [email protected]

mailto:[email protected]�




Interpretation Notices

From time to time, or as circumstances warrant, certain practices or procedures may be adopted by the Committee pertaining to the interpretation of the procedures and criteria published in the AHWDBL Policies and Guidelines. In order to assist manufacturers in preparing and submitting effective drug review submissions, the Expert Committee has determined that, where it deems appropriate, notice of these practices will be provided to manufacturers through “Interpretation Notices”. The Notices are intended to be a guide to assist manufacturers, but in situations where the Notices lead to inconsistencies or conflicts, the criteria in the Drug Review Procedure and Submission Requirements and Criteria, will apply. Notices will be published electronically and it continues to be the responsibility of manufacturers to monitor amendments to the AHWDBL. For convenience only, hard copies of Notices may be provided with the AHWDBL Interim Updates where deemed appropriate by Alberta Blue Cross.





INTERPRETATION NOTICE #1

INTERCHANGEABILITY and NON-CANADIAN REFERENCE PRODUCTS

The Submission Requirements and Criteria of the AHWDBL require manufacturers to provide the Expert Committee on Drug Evaluation and Therapeutics (“Expert Committee”) with data comparing the submitted drug product to the reference drug product. Under the Interchangeable Drug Products Criteria, manufacturers are also required to demonstrate bioequivalence with the reference drug product in accordance with the Criteria. At various times, some manufacturers have submitted interchangeability submissions using a Non-Canadian Reference Product (NCRP). After reviewing several submissions, the Expert Committee has adopted the practice of permitting manufacturers to demonstrate bioequivalency by providing data comparing the submitted drug product to a NCRP that meets the Criteria for use of a Non-Canadian Reference Product as set out in Health Canada’s Drugs Directorate Policy regarding the use of a Non-Canadian Reference Product under the provisions of Section C.08.002.1(c) of the Food and Drug Regulations (the “NCRP Criteria”). Important Note: Health Canada does not determine interchangeability and therefore, a determination by Health Canada that a product meets the NCRP Criteria is not sufficient proof for the Expert Committee’s purposes. The Expert Committee will continue to consider and assess all of the submission materials, and make its own determination whether the NCRP Criteria, the Submission Requirements and the Criteria are met, and whether the product may be designated as interchangeable. The practice in these situations is that, after receipt of the submission, Alberta Blue Cross makes a request to Health Canada for a copy of the Therapeutic Products Directorate’s review (TPD File) for the submitted product(s). Manufacturers are advised that, in order to avoid a possible deferral, they may include a full copy of the TPD File in their submission. If necessary, submissions may be deferred until the TPD File is received. Product submissions may, at the discretion of Alberta Blue Cross, be scheduled for review if the TPD File is received 7 days prior to the meeting date. As with all submissions, the Expert Committee retains the right to request additional materials from the manufacturer, Health Canada or any other entity it determines appropriate in order to conduct its review. Issue Date: November 9, 2006




SUBMISSION REQUIREMENTS

The following Submission Requirements pertain to submissions not eligible for review under the CDR Procedure. A) New Chemical Entities/Single Source Drug Products The following submission requirements pertain to New Chemical Entities, New Combination Products where one or more of the active moieties have never been listed on the List, and other single source drug products that have never been listed on the List; and are not eligible for review under the CDR Procedure. Submissions for drug products in this category should first be directed to the CDR Directorate. 1. Consent Letter

• an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada

2. Letter Confirming Ability to Supply • a letter signed by a senior official providing assurance that the manufacturer is able to

supply the specific drug product and strength from the time of listing in a quantity sufficient to meet the anticipated demand in Alberta for a minimum of 6 months.

3. A hard copy and electronic (CD) copy of the following from the Common Technical Document:

a. Clinical Overview (Module 2.5), and b. Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6).

Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu.

4. Copy of completed Drug Identification Number (DIN) notification form 5. Copy of Notice of Compliance (NOC) 6. Current Patent Status

• a signed statement from the manufacturer stating that the submitted product does not infringe any patents

• expiry date(s) of all Canadian patent(s) 7. Price Information

• The proposed price for Alberta (which must be in compliance with the Price Policy) 8. Product Monograph

• in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product Monograph compatible with Microsoft Word is required

9. Economic Information • a comprehensive pharmacoeconomic analysis in accordance with: the “Guidelines for

the economic evaluation of health technologies: Canada [3rd Edition]”. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2006.; cost-effectiveness and cost-utility data and the impact on “direct” healthcare costs are most useful




• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug Benefit List form. Note: copies of the most recent version of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or Fax: (780) 498-3534.

10. If requested, the manufacturer must provide written confirmation from the CDR Directorate that the drug product is not eligible for review under the CDR Procedure.




B) Changes to Special Authorization or Restricted Benefit Status of Listed Single Source Drug Products Due to a New Indication The following submission requirements pertain to single source drug products currently listed via special authorization or as restricted benefits that have received a new indication from Health Canada, where the manufacturer wishes to request expansion of the coverage criteria or change in benefit status due to the new indication and where the drug products are not eligible for review under the CDR Procedure. Submissions for drug products in this category that have been previously reviewed under the CDR Procedure should first be directed to the CDR Directorate. 1. Consent Letter

• an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada



3. Justification for the Expanded Coverage Criteria or Change in Benefit Status • a separate document indicating the reason for and evidence to justify the need for the

expanded coverage criteria or change in benefit status due to the new indication 4. A hard copy and electronic (CD) copy of the following from the Common Technical Document:

o Clinical Overview (Module 2.5), and o Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6)

5. Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu. Copy of Notice of Compliance (NOC) for the new indication.

6. Current Patent Status • a signed statement from the manufacturer stating that the submitted product does not

infringe any patents • expiry date(s) of all Canadian patent(s)

7. Price Information • The proposed price for Alberta (which must be in compliance with the Price

Policy) 8. Product Monograph (revised to include the new indication)

• in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product Monograph compatible with Microsoft Word is required




9. Economic Information • a comprehensive pharmacoeconomic analysis prepared with respect to the new

indication only in accordance with: the “Guidelines for the economic evaluation of health technologies: Canada [3rd Edition]”. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2006.; cost-effectiveness and cost-utility data and the impact on “direct” healthcare costs are most useful

• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug

Benefit List form prepared with respect to the new indication only. Note: copies of the most recent version of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or

Fax: (780) 498-3534. 10. If requested, the manufacturer must provide written confirmation from the CDR

Directorate that the drug product is not eligible for review under the CDR Procedure.




C) Line Extension Drug Products

The following submission requirements pertain to new strengths and formulations or reformulations of drug products that are currently listed or are under consideration for listing on the List and where products are not eligible for review under the CDR Procedure. Submissions for drug products in this category that have previously been reviewed under the CDR Procedure should first be directed to the CDR Directorate.

1. Consent Letter • an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate

to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada



3. Justification for the Line Extension • a separate document indicating the reason for and evidence to justify the need for the

new strength, formulation or reformulation of the drug product 4. A hard copy and electronic (CD) copy of the following from the Common Technical Document:

Clinical Overview (Module 2.5), and Clinical Summary (modules 2.7.1, 2.7.3, 2.7.4 and 2.7.6).

Note: If a Common Technical Document was not prepared for Health Canada, a Comprehensive Summary may be acceptable in lieu. In the event a Comprehensive Summary was not prepared for Health Canada (i.e. clinical studies have not been conducted on the new strength, formulation or reformulation) then the manufacturer must provide evidence establishing a clear linkage between the submitted product(s) and a currently listed product(s). This can be in the form of:

i. bioequivalence data; or ii. evidence of formulation proportionality (i.e. a comparison of master

formulae for all submitted strengths) and evidence of a similar dissolution profile.

5. Copy of completed Drug Identification Number (DIN) notification form 6. Copy of Notice of Compliance (NOC) 7. Current Patent Status

• a signed statement from the manufacturer stating that the submitted product does not infringe any patents

• expiry date(s) of all Canadian patent(s) 8. Copy of completed and approved Certified Product Information Document (CPID)

• in lieu of the CPID, a Master Formula and Final Product Specifications must be provided

9. Price Information • The proposed price for Alberta (which must be in compliance with the Price Policy)




10. Product Monograph (revised to include the line extension) • in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product

Monograph compatible with Microsoft Word 11. Economic Information

• a completed Budget Impact Assessment for the Alberta Health and Wellness Drug Benefit List form. Note: copies of this form can be obtained by accessing the Alberta Health and Wellness Drug Benefit List website at www.ab.bluecross.ca/dbl/manufacturers.html, or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross at Phone: (780) 498-8098 or Fax: (780) 498-3534.

12. If requested, the manufacturer must provide written confirmation from the CDR Directorate that the drug product is not eligible for review under the CDR Procedure.




D) Interchangeable Drug Products The following submission requirements pertain to multisource drug products submitted for listing in an interchangeable grouping in the Alberta Health and Wellness Drug Benefit List.

For Expedited and Full Reviews:

1. Consent Letter • an unrestricted letter authorizing Alberta Health and Wellness and its agent/designate

to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and information in the possession of Health Canada, CADTH, PMPRB, Alberta Health Services and the government of any province or territory in Canada



3. Copy of completed Drug Identification Number (DIN) notification form 4. Copy of Notice of Compliance (NOC)

• Note: For Old Drug Products (a drug product where the active ingredient is designated as an “old drug” by Health Canada and the drug product was approved on the basis of a DIN application), a Notice of Compliance is not required.

5. Current Patent Status • a signed statement from the manufacturer stating that the submitted product does not

infringe any patents 6. For Pseudo-Generic Drug Products: Letters from both the manufacturer of the

submission drug product and the manufacturer of the innovator brand or a currently listed drug product within the submission product’s interchangeable grouping, stating that the submission drug product is manufactured under the identical master formula and manufacturing and quality control specifications, as the innovator brand or the currently listed drug product.

7. Price Information • The proposed pricing in Alberta must be in compliance with the Price Policy.

Exceptions to the Fixed Pricing Rules may be considered at the sole discretion of the Minister. Accordingly, a request for an exception (as per sections 18-21 of the Price Policy) must accompany a submission that does not meet the Price Policy in order for it to be deemed complete.

8. Copy of completed and approved Certified Product Information Document (CPID) Note: In lieu of the CPID, a Master Formula and Final Product Specifications must be provided

9. Product Monograph • in addition to a hard copy, an electronic (CD) copy of the TPD-approved Product

Monograph compatible with Microsoft Word is required Note: For Old Drug Products, the Prescribing Information may be provided in lieu of the Product Monograph.




For FULL REVIEWS ONLY, the following ADDITIONAL information must be provided: 10. Evidence that the listing criteria for interchangeable drug products has been met. See

Criteria for Listing Drug Products and Interchangeable Drug Products sections for specific applicable criteria.




E) Resubmissions Resubmission Requests – General 1. A resubmission request may be made for a Drug Product that is not currently listed on

the AHWDBL or List (collectively referred to as the “AHWDBL”) in a case where the Drug Product:

a. was previously listed on the AHWDBL; b. was the subject of a previous submission for listing on the AHWDBL; or c. is listed on the AHWDBL but is subject to restrictions.

2. A resubmission request: a. must comply with the requirements set out below; and b. may be made by a Manufacturer for a Drug Product only once in a 12 month

period, running from April 1st through to March 31st, unless the Minister of Alberta Health and Wellness (Minister), in the Minister’s sole discretion, invites a Manufacturer to make a resubmission request.

3. The Minister, the Expert Committee on Drug Evaluation and Therapeutics (Expert

Committee), and Alberta Health and Wellness (AHW): a. may request information in addition to the requirements set out below; and b. may from time to time set deadlines by which a resubmission request may be

made, or a request for additional information must be provided.

4. In the case where: a. additional information has been requested by the Minister, the Expert

Committee or AHW, the resubmission request is not considered to be complete unless and until the requested additional information is provided to the Minister, the Expert Committee or AHW; and

b. a deadline has been set as referred to above, failure to provide a complete resubmission request within such deadline means that a resubmission request will not be reviewed by the Expert Committee or AHW or considered by the Minister.

5. The Minister may, in the Minister’s sole discretion, refer a Drug Product, that was the

subject of a resubmission request which meets the requirements set out in this policy, to an Alberta Price Confirmation (APC) or Interim APC process.

6. In the event that a Drug Product is referred to an APC or Interim APC process, the

Manufacturer must comply with the Price Policy and the Terms and Conditions of the APC or Interim APC. A referral to an APC or Interim APC or the submission of a Price Confirmation or Confirmed Price for the Drug Product by the Manufacturer does not obligate the Minister to list a Drug Product on the AHWDBL.




7. In the event that the Minister, in the Minister’s sole discretion, requires additional advice or input on a resubmission request, the Minister may refer the resubmission request to the CDR Procedure, the Expert Committee or any other entity for further advice or a full review.

8. For additional clarity, the provisions outlined under the “Submissions for Drug Reviews” are also deemed to apply to resubmission requests except as specifically modified by the provisions in this subsection “E) Resubmissions”, in which case this subsection applies.

Resubmission Requests Requiring Expert Committee Review

9. In addition to the requirements in “Resubmission Requests – General” above, this section applies to a resubmission request for a Drug Product that was reviewed by the Expert Committee and a decision was made by the Minister to:

a. not add the Drug Product to the AHWDBL for reasons other than those specified

in section 12 below; b. add the Drug Product to the AHWDBL with restrictions; or c. maintain current listing status of the Drug Product on the AHWDBL despite the

Manufacturer’s request for change. 10. A general resubmission request may be made for a previously submitted Drug Product

on the Resubmission for the Alberta Health and Wellness Drug Benefit List form. The form can be obtained at www.ab.bluecross.ca/dbl/manfacturers.html or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross by phone at (780) 498-8098 or by fax at (780) 498-3534.

11. A resubmission request must be complete and must include:

a. a completed Resubmission for the Alberta Health and Wellness Drug Benefit List form. A resubmission request requires review by the Expert Committee and a recommendation made by the Expert Committee for the Minister’s consideration for listing or not listing the Drug Product on the AHWDBL. The form must contain new information not previously submitted for a review of the Drug Product by the Expert Committee, unless otherwise indicated;

b. an unconditional consent letter authorizing AHW and its employees, contractors, consultants and agents to collect and use information respecting a Drug Product and to disclose the subject information to AHW, its employees, contractors, consultants and agents, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services (AHS) and the government of a province or territory in Canada. Information that may be collected, used and disclosed includes, but is not limited to, all Drug Product submission and resubmission information and information about the Drug Product in the possession of Health Canada, CADTH, all persons, parties or entities involved in the CDR Procedure, PMPRB, AHS, AHW, the Expert Committee, and the government of a province or territory;

http://www.ab.bluecross.ca/dbl/manfacturers.html�




c. a confirmation letter signed by a senior official of the Manufacturer stating that the Manufacturer is able and willing to supply the Alberta market with the subject Drug Product in a quantity consistent with applicable APC or Interim APC requirements; and

d. a revised Budget Impact Assessment (BIA) form in the case where new economic information about the Drug Product is available, that has not been previously submitted, to support the resubmission request.

Resubmission Requests based on the AHWDBL Price Policy

12. In addition to the requirements in “Resubmission Requests – General” above, this section applies to resubmission requests for a Drug Product that:

a. has not been listed on the AHWDBL, or that has been removed from the

AHWDBL, by the Minister where the requirements of an Alberta Price Confirmation (APC), Interim APC or the Price Policy were not satisfied; or

b. has been removed from the AHWDBL at the request of the Manufacturer.

13. A price policy resubmission request may be made on the Alberta Price Policy Resubmission Form for the Alberta Health and Wellness Drug Benefit List. The form can be obtained at www.ab.bluecross.ca/dbl/manfacturers.html or by contacting the Coordinator, Scientific and Research Services, Alberta Blue Cross by phone at (780) 498-8098 or by fax at (780) 498-3534.

14. A resubmission request must be complete and must include:

a. a completed Alberta Price Policy Resubmission Form for the Alberta Health and Wellness Drug Benefit List ;

b. an unconditional consent letter authorizing AHW and its employees, contractors , consultants and agents to collect and use information respecting a Drug Product and to disclose the subject information to AHW, its employees, contractors, consultants and agents, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services (AHS) and the government of a province or territory in Canada. Information that may be collected, used and disclosed includes, but is not limited to, all Drug Product submission and resubmission information and information about the Drug Product in the possession of Health Canada, CADTH, all persons, parties or entities involved in the CDR Procedure, PMPRB, AHS, AHW, the Expert Committee, and the government of a province or territory; and

c. a confirmation letter signed by a senior official of the Manufacturer stating that the Manufacturer is able and willing to supply the Alberta market with the subject Drug Product in a quantity consistent with applicable APC or Interim APC requirements.

http://www.ab.bluecross.ca/dbl/manfacturers.html�




Criteria for Listing Drug Products

• The Criteria for Listing Drug Products apply to all drug product submissions.

• If more than one criterion apply, at the sole discretion of the Expert Committee on Drug Evaluation and Therapeutics (Expert Committee), Alberta Health and Wellness or the Minister, the most stringent and/or appropriate combination of criteria will apply.

• For multisource drug products seeking a designation of interchangeability, the drug product must also meet the additional criteria outlined under “Interchangeable Drug Products”.

1. Clinical studies must have demonstrated the safety and efficacy of the product in appropriate populations. 2. The product must:

a. possess therapeutic advantage over other presently accepted therapies or treatments of the disease entity for which the product is indicated, or b. be more cost-effective than presently accepted therapy.

3. Assessment of therapeutic advantage may include consideration of: i. clinical efficacy; ii. risk/benefit ratio; iii. toxicity; iv. compliance; v. clinical outcomes; vi. Health Canada warnings and advisories; vii. population health issues; or viii. any other factor which affects the therapeutic value of the product.

4. The Expert Committee, Alberta Health and Wellness and/or the Minister may, in addition to all of the factors listed above, also consider any factors that they consider appropriate, including but not limited to any or all of the following:

i. the recommendations from the CDR review, ii. failure by a manufacturer to supply a sufficient quantity of drug product to

meet the demand in Alberta (as determined by Alberta Health and Wellness at its sole discretion, and based on any information it deems appropriate),

iii. failure by a manufacturer to provide (A) a Price Confirmation, or (B) a Price Confirmation or Confirmed Price in accordance with the Price

Policy and/or the Alberta Price Confirmation (APC) Terms and Conditions;

iv. failure by a manufacturer to comply with any APC Terms and Conditions;




v. type of drug, drug product, class or category and indications for use, vi. other available alternative products, treatments or therapies, vii. whether the product is interchangeable, viii. cost of the product and/or potential cost savings or impact on drug

expenditures under the List, ix. volume of use and amounts paid out for similar products, classes or

categories, x. utilization patterns xi. expenditure management and resources, xii. patent issues, xiii. coverage provided by other programs, xiv. for interchangeable products, concerns that are related to or affect the

interchangeability of the drug product, xv. issues, concerns, objectives, goals and/or mandates related to any

government policies, plans or programs, and xvi. patient care concerns related to factors external to the drug product.

5. New Chemical Entities, New Combination Products and other single source products not eligible for review under the CDR Procedure may, at the sole discretion of Alberta Health and Wellness and/or the Minister, be considered for priority review and possible addition to the List if the product submission is otherwise complete, and the product has been granted “Priority Review” status by the Therapeutic Products Directorate, Health Canada. A copy of documentation from the Therapeutic Products Directorate granting ‘Priority Review’ status is required.

6. The onus is on the manufacturer to formally request, in writing, consideration on a priority review basis if, in the opinion of the manufacturer, the product meets any of the above priority review criteria. Request for priority review does not automatically mean that the submission will be considered on that basis. The decision whether to conduct a priority review will be made by Alberta Health and Wellness and/or the Minister at their sole option and discretion.




Interchangeable Drug Products - Additional Criteria

Principle: Decisions respecting interchangeability and drug lists remain in the domain of the institution responsible for the costs of the product which includes hospitals, provincial governments and other third party payers (6/9/95 Canada Gazette Part ll, Vol. 129, No. 18) Preface: The Alberta Health and Wellness Drug Benefit List (AHWDBL) contains designations of interchangeability for approved multisource drug products. The Expert Committee on Drug Evaluation and Therapeutics makes recommendations on interchangeability to Alberta Health and Wellness through the Executive Director, Pharmaceutical Funding and Guidance Branch, Health Policy and Service Standards Division. The Minister of Health and Wellness makes the final decisions on interchangeability after reviewing the recommendations of the Expert Committee and/or Alberta Health and Wellness. Definitions: (Note: additional definitions in the applicable Appendices may apply) Interchangeable Drug Product: An interchangeable drug product is a drug product that has been designated as interchangeable by the Minister of Health and Wellness after reviewing the recommendations of the Expert Committee or Alberta Health and Wellness. Recommendations regarding interchangeability are made taking into consideration the scientific, therapeutic, clinical and socio-economic merits of drug products in accordance with the published criteria. Drug products designated as interchangeable are expected to be safe when interchanged with other drug products in the interchangeable grouping, and to have the same therapeutic effectiveness when administered to patients under the conditions specified in the labeling. The designation of interchangeability is made only for the purpose of funding of drug benefits covered under the Alberta government-sponsored drug benefit programs and is not to be used as a scientific reference or prescribing guide. Multisource Drug Product: Drug products are considered to be multisource drug products when they are manufactured and/or distributed by more than one manufacturer. Pharmaceutical Alternative: Drug products may be considered to be pharmaceutical alternatives if they use the same route of administration and contain the same active therapeutic ingredient(s) but are different salts, esters or complexes of that moiety, or are different dosage forms or strengths. Pharmaceutical Equivalent: Drug products are considered to be pharmaceutical equivalents if they contain the same active therapeutic ingredient(s), are of comparable dosage form(s), route of administration and are identical in strength or concentration. Pseudo-Generic Drug Product: A pseudo-generic drug product is a drug product that is manufactured under the identical master formulae and manufacturing and quality control specifications as a) the innovator brand of the drug; or b) any drug product that is currently listed on the AHWDBL within the submission product’s interchangeable grouping.




TPD Reports - refers collectively to the following Health Canada Therapeutic Products Directorate (TPD) guidance publications as of December 31, 2009: o Conduct and Analysis of Bioavailability and Bioequivalence Studies - Part A: Oral

Dosage Formulations Used for Systemic Effects, and Part B: Oral Modified Release Formulations; (which may be referred to in the List as “TPD Part A”, and “TPD Part B”); and

o Report C: Report on Bioavailability of Oral Dosage Formations, Not in Modified Release Form, of Drugs used for System Effects, Having Complicated or Variable Pharmacokinetics (which may be referred to in the List as “TPD Report C”); and

o Bioequivalence Requirements: Comparative Bioavailability Studies Conducted in the Fed State. Interchangeable Reviews:

A. The Expert Committee and/or Alberta Health and Wellness and/or the Minister may, in addition to considering the Interchangeable Drug Products criteria, also consider any other criteria in the AHWDBL, including but not limited to the Criteria for Listing Drug Products.

B. Recommendations regarding interchangeability are made taking into consideration the scientific, therapeutic, clinical and socio-economic merits of drug products in accordance with the published criteria. Drug products designated as interchangeable are expected to be safe when interchanged with other drug products in the interchangeable grouping, and to have the same therapeutic effect when administered to patients under the conditions specified in the labeling.

C. Issuance of a Notice of Compliance by the TPD which includes a Declaration of Equivalence does not mean the drug product will automatically be designated as interchangeable.

Expedited Reviews 1. Multisource drug products seeking a listing designation as interchangeable may be eligible for an expedited review if:

a. The drug product submission complies with the submission requirements.

b. The drug product does NOT fall into any of the categories of drug products that require a Full Review (below), unless the drug product is a Pseudo-Generic Drug Product.

c. The drug product is not a subsequent entry biologic (subsequent entry biologics are not eligible for review as interchangeable products).




d. The drug product has been granted a Notice of Compliance by Health Canada that includes a declaration of bioequivalence with a Canadian brand/innovator reference product that is listed (or at the sole discretion of Alberta Health and Wellness and/or the Minister, has been previously listed) on the Alberta Health and Wellness Drug Benefit List.

e. The drug product must be a pharmaceutical equivalent to the Canadian innovator reference product.

f. The proposed price in Alberta provided in the manufacturer’s submission complies with the Price Policy.

g. Even if the drug submission review is expedited, Alberta Health and Wellness and/or the Minister may refuse to list a drug product, or the listing of the drug product may be delayed, if the manufacturer has failed

(A) to provide a Price Confirmation, (B) to provide a Price Confirmation or Confirmed Price in accordance with the Price

Policy and/or the applicable APC Terms and Conditions; or (C) to comply with the terms and conditions of an applicable APC.

Full Reviews Multisource drug products seeking a listing designation as interchangeable that fall within the categories listed below are required to undergo a Full Review by the Expert Committee. The following additional interchangeability criteria will apply to Full Reviews: 1. The drug product must be a

a. pharmaceutical equivalent; or b. pharmaceutical alternative,

as determined at the sole discretion of the Expert Committee. 2. The drug product is not a subsequent entry biologic (subsequent entry biologics are not

eligible for review as interchangeable products).

3. The proposed price in Alberta contained in the manufacturer’s submission complies with the Price Policy.

4. The drug product has been demonstrated to be bioequivalent, or has provided evidence of comparative therapeutic efficacy, with the reference drug product as outlined below;

a. For drug products in the following categories, for which bioequivalence studies

CAN be conducted:

i. For Critical Dose Drug Products, the drug product must meet the criteria in the Critical Dose Drug Product Appendix.

ii. For Non-Linear Drug Products, the drug product must meet the criteria in the Non-Linear Drug Product Appendix.




iii. For Rapid Onset Drug Products, the drug product must meet the criteria in the Rapid Onset Drug Product Appendix.

iv. For Drug Products for which Bioequivalence is Supported by Metabolite Data, the drug product must meet the criteria in the Drug Products with Metabolite Data Appendix.

v. For Drug Products for which Bioequivalence is Supported by Measurement of the Drug in a Matrix other than Plasma or Serum (e.g., Whole Blood, Urine, Tissue), the drug product must meet the criteria in the Drug Product with Alternate Matrix Measurement Appendix.

vi. For Old Drug Products, the product must meet the criteria in the Old Drug Product Appendix.

vii. For Drug products which possess complex delivery systems, the product must meet the criteria in the Complex Delivery System Drug Product Appendix.

b. For drug products in the above categories for which bioequivalence studies

CANNOT be conducted:

i) Evidence of comparative therapeutic efficacy of the submitted product with the reference product via:

(A) a therapeutic equivalence study; or (B) Studies that meet the requirements and standards for pharmacodynamic studies outlined in TPD Report C;

and

ii) Sufficient rationale for why a bioequivalence study cannot be conducted.

c. For drug product submissions using a Non-Canadian Reference Product (NCRP):

i) An NCRP may only be used when it meets the Criteria for use of a Non-

Canadian Reference Product as set out in Health Canada’s Drugs Directorate Policy regarding the use of a Non- Canadian Reference Product under the provisions of Section C.08.002.1(c) of the Food and Drug Regulations (the “NCRP Criteria”). See also Interpretation Notice #1.

ii) If the NCRP Criteria is met, the drug product must demonstrate bioequivalence to the NCRP through studies that meet the requirements and standards of the applicable TPD Reports.

5. The drug product must meet all other criteria outlined in the applicable Appendix.




6. In addition, the Expert Committee may also consider any other factor that may affect the interchangeability of a drug product, including but not limited to:

• characteristics of the drug product (e.g. shape, scoring, configuration, packaging, labelling);

• excipients and non-medicinal ingredient(s) (e.g. sugar, sodium); • expiration times; • storage conditions.

Interchangeable Drug Products - Additional Criteria APPENDICES

Critical Dose Drug Product Appendix Critical Dose Drug: Is a drug where comparatively small differences in dose or concentration lead to dose- and concentration-dependent, serious therapeutic failures and/or serious adverse drug reactions which may be persistent, irreversible, slowly reversible or life threatening, which could result in inpatient hospitalization or prolongation of existing hospitalization, persistent disability or incapacity, or death. Critical dose drugs include:

a) Any drug listed in Appendix I - List of Critical Dose Drugs of Health Canada’s Guidance for Industry entitled Bioequivalence Requirements: Critical Dose Drugs; and

b) Any other drug that the Expert Committee determines meets the above definition, which determination may include consideration of any other matter that may affect the interchangeability of a product containing a critical dose drug.

Criteria: Bioequivalence studies must meet the requirements and standards in the TPD Reports, with the exception that the following standards will be used: 1. The 90% confidence interval of the relative mean AUC of the test to reference formulation

should be within 90.0 to 112.0%; the relevant AUC or AUCs as described in TPD Reports A and B are to be determined.

2. The 90% confidence interval of the relative mean measured Cmax of the test to reference formulation should be between 80.0 and 125.0%.

3. These requirements are to be met in both the fasted and fed states. 4. These standards should be met on log transformed parameters calculated from the

measured data and from data corrected for measured drug content (percent potency of label claim).

5. If a steady-state study is required, the 90% confidence interval of the relative mean measured Cmin of the test to reference formulation should also be between 80.0 and 125.0%.




Non-Linear Drug Product Appendix Non-Linear Drug: A drug is considered to be a Non-Linear Drug if the Health Canada approved product monograph for the Canadian innovator drug product states that it is a non-linear drug. Criteria: 1. Bioequivalence studies must meet the requirements and standards in the TPD Reports, and these requirements and standards should be met in single dose studies in both the fasted and fed states, with the following exceptions:

a) if non-linearity occurs after the drug enters the systemic circulation, a fed study may be waived unless there is sufficient evidence, at the Expert Committee’s sole discretion, that a product exhibits a food effect; or b) if a condition (fasted or fed) for product ingestion is contraindicated, that condition may be waived in a bioequivalence trial. For bioequivalence testing the fasting and fed doses should be the same.

2. At the sole discretion of the Expert Committee, it may be acceptable to conduct bioequivalence studies at either the highest or lowest strength of a range of proportionally formulated strengths as outlined below:

a) For drugs with non-linear pharmacokinetics in the single unit dose range of approved strengths resulting in greater than proportional increases in AUC with increasing dose, the bioequivalence studies should be conducted on at least the highest strength. That is, where non-linearity arises from capacity-limited clearance, the highest strength for the proposed indications should be tested. For drugs where the non-linear concentration range is reached only after multiple doses within the approved dosing regimen, studies utilizing multiple units of the highest formulation strength or steady-state studies in the non-linear range may be required. Where steady-state studies are conducted, single dose studies will not be required. In all situations, safety in dosing should be considered.

b) For drugs with non-linear pharmacokinetics in the single unit dose range of approved strengths resulting in less than proportional increases in AUC with increasing dose, the bioequivalence studies should be conducted on at least the lowest strength (single dose unit). That is, where non-linearity arises from capacity-limited absorption, the test dose should be a single unit of the lowest strength.




Rapid Onset Drug Product Appendix

Rapid Onset Drugs: Are as defined in TPD Report C. Criteria: Bioequivalence studies must meet the requirements and standards in the TPD Reports, except that the relative mean AUCReftmax of the test to reference formulation should be within 80 to 125%, where AUCReftmax for a test product is defined as the area under the curve to the time of the maximum concentration of the reference product, calculated for each study subject.




Drug Product with Metabolite Data Appendix For drug product submissions for which evidence of bioequivalence is supported by metabolite, rather than the parent drug, data. Criteria:

1. Bioequivalence studies must meet the requirements and standards in the TPD Reports.

2. If the parent drug is not detectable due to rapid biotransformation or limitations in available assay methodology, the use of metabolite data may be acceptable.

3. The measured metabolite must be a primary (first step) measureable by a validated assay, and there must be sufficient scientific justification for a waiver of the measurement of the parent drug and the use of metabolite data.

4. The choice of using the metabolite instead of the parent drug is to be clearly stated, a priori, in the objective of the study in the study protocol.

5. The use of metabolite concentrations in urine is not acceptable.




Drug Product with Alternate Matrix Measurement Appendix

For drug product submissions for which bioequivalence data is supported by measurement of the drug in a matrix other than plasma or serum (e.g., whole blood, urine, extravascular tissue). Criteria:

• Bioequivalence studies must meet the requirements and standards in the TPD Reports.

• The assay used for measurement of the drug (or metabolite) must be validated for the alternate matrix of measurement.

• Sufficient rationale for why the use of an alternate matrix measurement study is appropriate.




Old Drug Product Appendix Old Drugs: Are drug products where the active therapeutic ingredient(s) is designated as an “old drug” by Health Canada and the drug product is approved on the basis of a DIN application (i.e. an NOC is not issued by Health Canada). Criteria:

1. Bioequivalence studies must meet the requirements and standards in the TPD Reports.

2. For old drug products for which bioequivalence studies CANNOT be conducted, the submission must include:

i) Evidence of comparative therapeutic efficacy of the submitted product with the reference product via:

(A) a therapeutic equivalence study; or (B) studies that meet the requirements and standards for pharmacodynamic studies outlined in TPD Report C; or (C) surrogate comparisons using in vivo or in vitro test methods.

and

ii) Sufficient rationale for why a bioequivalence study cannot be conducted.




Complex Delivery System Drug Product Appendix Complex Delivery System Drugs: Are drug products that possess complex drug release characteristics in the pharmaceutical dosage form that are intended to:

(1) deliver the drug at a rate that is independent of time and the concentration of the drug (i.e. zero order process), or (2) deliver the drug to a specific physiological site (i.e. site-specific release).

Criteria: 1. Bioequivalence studies must meet the requirements and standards in the TPD Reports. 2. A detailed description of the pharmaceutical dosage forms and specific drug release characteristics of the submitted drug product and reference drug product must be provided to permit evaluation of the similarity of drug release of the respective formulations.




Review of Benefit Status (ROBS) Criteria

The Expert Committee and/or Alberta Health and Wellness may at any time review the benefit status of a drug product, a group of drug products, a class or classes of drug products, or a category or categories of drug products listed or being considered for listing on the AHWDBL (collectively “Products”). The Expert Committee and/or Alberta Health and Wellness may, at their sole option and discretion, recommend altering or discontinuing the benefit status for Products if one or more of the following criteria are met. These are general criteria only, which are intended to be applied flexibly, having regard to each individual case. The criteria may be modified or adapted as the situation may require, and not all criteria will apply to each case:

1. There has been a significant change to the Product(s). Significant changes may include changes in NOC, DIN, product name, manufacturer or distributor, indication, product monograph, packaging, formulation, or any change that could potentially affect the bioavailability or bioequivalence of a product.

2. The Product(s), no longer possesses demonstrated therapeutic advantage compared to other presently accepted therapies or treatments of the disease entity for which the Product(s) is/are indicated. Assessment of therapeutic advantage may include consideration of clinical efficacy, risk/benefit ratio, toxicity, compliance, clinical outcomes, Health Canada advisories, population health issues, and any factor which affects the therapeutic value of the product, class or category.

3. The Product(s) is/are no longer cost-effective compared to other presently accepted therapies or treatments of the disease entity for which the Product(s) is/are indicated.

4. To enable broader coverage of higher priority Product(s). 5. When a product has been discontinued by the manufacturer. 6. When Product(s) is/are changed from prescription to non-prescription status, the Expert

Committee may recommend continuing, altering or discontinuing benefit status of the Product(s) based upon scientific, therapeutic, clinical and socio-economic merits of the Product(s).

7. For all ROBS reviews, the Expert Committee, Alberta Health and Wellness and/or the Minister may, in addition to all of the factors listed above, also consider any factors that they consider appropriate, including but not limited to any of the criteria for listing drug products and interchangeable drug products.

Unsolicited information from manufacturers relating to ROBS Reviews will not be put before the

Expert Committee. However, if the Expert Committee determines that a change in benefit status

may be warranted, manufacturers of the affected Product(s) will be notified and provided with an

opportunity to make submissions to the Expert Committee prior to the final recommendation

being made. Notification will include advice regarding the form of submission that will be

accepted, the deadline for filing the submission and any other relevant advice. Any submissions

that do not comply with the notification advice will not be put before the Expert Committee.




Supply Shortages

Where a manufacturer has not supplied, or is not supplying, a sufficient quantity of drug product to meet the demand in Alberta (as determined by Alberta Health and Wellness at its sole option and discretion, and based on any information it deems appropriate):

1. If the unavailable product is a single-source product on the List, products not otherwise allowed as benefits may be added temporarily or temporarily reimbursed for the Alberta government-sponsored drug programs.

3. Products added or reimbursed under this policy may remain as temporary benefits until the supply shortage is rectified.

4. In order to remain as benefits after the shortage is rectified, manufacturers of these products must follow the usual submission and review process for listing.

5. Alberta Health and Wellness may recover any cost difference from the manufacturer unable to supply a drug product.

6. Alberta Health and Wellness may at its sole discretion, take any other steps or require any information from a manufacturer or other person, that is reasonably required to manage a supply shortage.

7. Alberta Health and Wellness may:

• refuse to list any product of the manufacturer, • refuse to consider any product submission of the manufacturer for expedited or

priority review; or • cancel or modify the listing of the product that is not meeting the supply demand.




Units of Issue for Pricing

These units of issue are used for presenting prices in the List. Dosage Form Unit of Issue Priced in AHWDBL

Ampoules ............................................................. Millilitre Bladder Irrigation Solutions .................................. Millilitre Dental Pastes ....................................................... Gram Devices................................................................. Device Inhalation Capsules .............................................. Capsule Inhalation Cartridges ............................................ Cartridge Inhalation Disks .................................................... Disk Inhalation Solutions or Suspensions .................... Millilitre – all preparations including nebules Inhalation Unit Dose Solution ............................... Millilitre Injections .............................................................. Vial – where reconstitution is required (or ………………………………………………………..Millilitre or Unit where indicated) Injections .............................................................. Millilitre – where no reconstitution is required ……………………………………………………….(or Vial where indicated) Injections – Cartridges ......................................... Millilitre Injections – Emulsion ........................................... Millilitre Injections – Syringes ............................................ Syringe (or Millilitre where indicated) Injection – Implant ................................................ System Injection Syringe/Oral Capsule ............................ Kit Injection Vial/Oral Capsule ................................... Kit Injection Vial/Oral Tablet ...................................... Kit Injection Syringe/Oral Tablet ................................ Kit Intrauterine Insert ................................................. System Irrigating Solutions ............................................... Millilitre Lock Flush ............................................................ Millilitre Metered Dose Aerosols........................................ Dose Metered Inhalation Powder .................................. Dose Nasal Metered Dose Aerosols ............................. Dose Nasal Metered or Unit Dose Sprays .................... Dose Nasal Solutions .................................................... Millilitre Nasal Sprays ........................................................ Millilitre Ophthalmic Solutions or Suspensions or Drops..................................... Millilitre Ophthalmic Gels or Ointment ............................... Gram Ophthalmic Long Acting Gellan Solutions............ Millilitre Oral Caplets ......................................................... Caplet Oral Capsules – all formulations .......................... Capsule Oral Drops ........................................................... Millilitre Oral Granules ....................................................... Bulk size – Gram Individual Packet..................................................Packet




Units of Issue for Pricing, continued

Dosage Form Unit of Issue Priced in AHWDBL Oral Liquids – all formulations .................................... …...Millilitre Oral Powders .............................................................. …...Gram (or Dose where indicated) Oral Powder Packets…………………………………….. Individual Packet Oral Rinses ................................................................. …...Millilitre Oral Tablets – all formulations .......................................... Tablet Oral Tablets – oral contraceptives .................................... Tablet Oral Tablet/Capsule .......................................................... Kit Oral Wafer ........................................................................ Wafer Otic Ointments or Gels ..................................................... Gram Otic Solutions or Suspensions or Drops .................................................. Millilitre (or Vial where indicated)

Rectal Enemas ................................................................. Enema Rectal Foams .................................................................... Gram Rectal Ointments .............................................................. Gram Rectal Retention Enemas ................................................. Enema Rectal Suppositories - all formulations ............................. Suppository Scalp Lotions .................................................................... Millilitre Scalp Solutions ................................................................. Millilitre Sublingual Metered Dose Spray.........................................Dose Sublingual Tablet .............................................................. Tablet Topical Bars ...................................................................... Gram Topical Cleansers ............................................................. Millilitre Topical Creams/Ointments - all formulations ................... Gram Topical Gauzes ................................................................. Dressing Topical Gels - all formulations .......................................... Gram Topical Jellies ................................................................... Millilitre Topical Lotions.................................................................. Millilitre or Gram Topical Powders ............................................................... Gram Topical Solutions ............................................................. Millilitre Topical Washes ................................................................ Millilitre or Gram Transdermal Gel ............................................................... Gram Transdermal Patches ....................................................... Patch Vaginal Capsules or Ovules or Tablets ............................ Capsule or Ovule or Tablet Vaginal Creams or Ointments or Gels .............................. Gram Vaginal Douches............................................................... Millilitre Vaginal Ovule/Topical Cream ........................................... Kit Vaginal Slow Release Rings ........................................... Ring Vaginal Suppositories ....................................................... Suppository




Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics: Policy for Administering Interchangeability Challenges

Note: This Policy is not applicable for drug products that are eligible for, and are reviewed under, the Expedited Review Process for interchangeable drug products. From time-to-time, the Expert Committee on Drug Evaluation and Therapeutics receives unsolicited information (“Challenge Information”) from a manufacturer (the “Challenger”) suggesting that additional information should be taken into account when a submission for interchangeability for a multisource product is being considered by the Expert Committee. Alberta Health and Wellness is not prepared to have any Challenge Information considered by the Expert Committee unless the manufacturer whose product is being challenged (the “Applicant”) is provided with a full copy of the Challenge Information and is given an opportunity to respond to it.

As a result, Alberta Health & Wellness has developed and approved the following process for the handling of Challenge Information.

1. Challenge Information must comply with the following conditions. 2. Challenge information must be received by Alberta Blue Cross:

• For first-entry interchangeable product submissions – Within 15 days of the date of issuance of the NOC for the Applicant’s product.

• For all other submissions, by the submission deadline date. 3. All Challenge Information must include an unconditional Written Consent

4. If the above unconditional Written Consent is not submitted as required, the Challenge Information will not be considered by the Expert Committee.

, signed by the Challenger, authorizing Alberta Health and Wellness and its agent/designate to (a) disclose to the Applicant all Challenge Information; and (b) to access, discuss, use, collect from, and disclose to its agents, consultants, Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH) and all persons, parties or entities involved in the CDR Procedure, the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada, all submission information and Challenge Information and any information in the possession of Health Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), the Patented Medicine Price Review Board (PMPRB), Alberta Health Services and the government of any province or territory in Canada.

5. If Written Consent is submitted as required, the Challenge Information will be duplicated in its entirety and forwarded by Alberta Blue Cross to the Applicant, inviting a response (“Applicant Response”). The Applicant Response must be received by Alberta Blue Cross no later than 15 days after the date of the letter from Alberta Blue Cross.

6. If an Applicant Response is not received by Alberta Blue Cross within the time provided, only the Challenge Information will be provided to the Expert Committee for consideration. If an Applicant Response is received within the time provided, both the Applicant Response and the Challenge Information will be provided to the Expert Committee for consideration.

7. No further information may be submitted to the Expert Committee for consideration.




8. The Applicant Response should only address information contained in the Challenge Information. Anything in the Applicant Response that does not relate to information contained in the Challenge Information may, at the sole discretion of the Expert Committee, be disregarded.

9. It is a condition of each and every Submission and Challenge that the terms, conditions,

criteria and time limitations contained in this policy will apply and that: a) Applicants, by filing a Submission and Applicant Response; and, b) Challengers, by submitting Challenge Information agree to and are bound by this policy.

10. In the event the anticipated Applicant submission is not received, Challenge Information will be destroyed 6 months after receipt.

Inquiries may be made to: Senior Manager

Scientific and Research Services Alberta Blue Cross 10009 - 108 Street NW Edmonton AB T5J 3C5 Phone: (780) 498-5978 Fax: (780) 498-3534




Your Comments are Important to Us

To improve the high standards established for this publication, the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics would like to offer you an opportunity for input. Should you have any concerns and/or suggestions concerning product listings or criteria for coverage of products available via special authorization, etc. please let us know.

Please note: this is not a mechanism for an appeal for a specific patient.

If you are writing in support of a product listing change or a revision to the special authorization criteria for coverage, you must provide evidence in support of your comments from the peer-reviewed scientific literature. In order to meet the expectations of stakeholders relative to objectivity and transparency, all individuals providing comments are required to advise the Expert Committee of any potential conflicts of interest below (please check appropriate box):

Conflict of Interest: Yes No If Yes, please indicate the nature of the potential conflict of interest below:

____________________________________________________________________________________ ____________________________________________________________________________________ Please provide your comments in the space provided below:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Contact Information: Name and Address: __________________________________________________________________ Phone/Fax: __________________________________________________________________________ Please print form and mail/fax to: Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics c/o Senior Manager

Scientific and Research Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5 FAX to: (780) 498-3534


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1 • 43 EFFECTIVE JULY 1, 2012

AHWDBL - Updated Price Policy

Effective May 17, 2012 PRICE POLICY ____________________________________________________ DEFINITIONS In this Price Policy, Alberta Blue Cross or ABC or Blue Cross means the ABC Benefits Corporation, Alberta Health and Wellness Drug Benefit List, List or AHWDBL means, unless otherwise indicated, the most recent drug benefit list (including drug benefit listing policies and processes and benefit supplements) published by the Minister from time to time, Alberta Price Confirmation or APC means an Alberta Price Confirmation that may be issued by the Minister from time to time, APC Terms and Conditions means the terms and conditions outlined in an APC, Base Cost means the price per unit of issue, less any permitted Distribution Allowance, submitted in respect of a Drug Product in a Drug Product submission or in a prior APC (whichever is most recent), Brand Drug means an originator/brand Drug Product listed or under consideration for listing in the AHWDBL, Brand Price means the price of the Brand Drug published in the May AHWDBL in an Established IC Grouping or, if there is more than one originator/brand product in the Established IC Grouping, the Brand Price is the lowest published price of a Brand Drug in the Established IC Grouping, Confirmed Price means a Confirmed Price as set out in clause 3, Distribution Allowance means an amount which may not exceed 7.5% of the Confirmed Price of a Drug Product subject to the Non-Fixed Pricing Rules. Device means a product approved by Health Canada as a device and listed or under consideration for listing by the Minister on the AHWDBL, Drug Product means anything that is listed or under consideration for listing by the Minister on the AHWDBL, Drug Program Act or DPA means the Drug Program Act of Alberta, Effective Brand Price means the price of the Brand Drug published in the AHWDBL in the New IC Grouping effective the date Alberta Blue Cross received the IC Drug submission or submissions (that trigger the creation of the New IC Grouping) in accordance with the AHWDBL submission requirements or, if there is more than one Brand Drug, the Effective Brand Price is the published price of the lowest priced Brand Drug in the New IC Grouping, Effective Other Drug Price means the price of the Other Drug published in the AHWDBL in the New IC Grouping effective the date Alberta Blue Cross received the IC Drug submission or submissions (that trigger the creation of the New IC Grouping) in accordance with the AHWDBL submission requirements,




Effective Period means the Effective Period stated in an APC, Entry IC Drug means a Drug Product that is listed or under consideration for listing in a New IC Grouping, Established IC Grouping means an IC Grouping that was established on or before May 1, 2012 and listed in the May AHWDBL, Fixed Price means the applicable Fixed Price as set out in the Fixed Pricing Rules, IC Drug means a Drug Product that is listed, or is under consideration for listing, as interchangeable with one or more Drug Products as determined by the Minister in accordance with the requirements relating to interchangeability in the AHWDBL, IC Grouping means a category on the AHWDBL where there are two or more IC Drugs listed or under consideration for listing as part of one grouping on the AHWDBL as determined by the Minister, Interim APC means an APC issued by the Minister for one or more Drug Products, or one or more categories or groupings of Drug Products during an Effective Period, Interim APC Terms and Conditions means the terms and conditions outlined in an Interim APC, Least Cost Alternative Price or LCA Price means the maximum amount established by the Minister which will be paid by the Government of Alberta for a Drug Product in an Established IC Grouping or New IC Grouping for members of a Plan, Licensed Pharmacy means a pharmacy that is licensed or required to be licensed under the Pharmacy and Drug Act of Alberta, List has the same meaning as “Alberta Health and Wellness Drug Benefit List”, MAC Grouping means a grouping of Drug Products that have been listed in the AHWDBL and are subject to a MAC Price; a MAC Grouping may include a grouping of IC Drugs, in which case the grouping shall be treated as an Established IC Grouping, Manufacturer means an entity that manufactures, sells or distributes a Drug Product, Maximum Allowable Cost Price or MAC Price means the maximum amount established by the Minister that will be paid by the Government of Alberta for a Drug Product in a MAC Grouping for members of a Plan, May AHWDBL means the AHWDBL published by the Minister on or about May 1, 2012, Minister means Her Majesty the Queen in Right of Alberta, as represented by the Minister of Health and Wellness, New IC Grouping means an IC Grouping that was established or may be established after May 1, 2012, Other Drug means a Drug Product that is not an IC Drug, an Entry IC Drug, or a Brand Drug listed or under consideration for listing on the AHWDBL. For further clarity, the status of an Other Drug Product changes to that of an IC Drug when another IC Drug is listed or under consideration for listing in the same grouping as the Other Drug, which grouping becomes an IC Grouping,



Plan means a plan or program for which the Government of Alberta provides benefits in respect of Drug Products listed on the AHWDBL, Price Confirmation means the package of documents identified in an APC which must be completed and submitted in accordance with this Price Policy and the APC Terms and Conditions, Product Listing Agreement or PLA means a product listing agreement that is entered into or may be entered into by the Minister in respect of any Drug Product in accordance with the Minister’s Product Listing Agreement Policy, including any Drug Product that is listed or under consideration for listing on the AHWDBL, Product Listing Agreement Policy means any product listing agreement policy (including any processes related thereto) that may be published by the Minister from time to time.




ALBERTA PRICE CONFIRMATION (APC)

1. The Minister may from time to time issue an Alberta Price Confirmation (APC), where a Manufacturer will be invited to submit a Price Confirmation, with one or more Confirmed Prices, in accordance with the APC Terms and Conditions.

2. The Manufacturer must ensure that a Price Confirmation and a Confirmed Price submitted by a Manufacturer comply with this Price Policy and the APC Terms and Conditions.

3. For purposes of an APC and submitting a Price Confirmation, and subject to exceptions permitted by and approved under the Price Policy, the Confirmed Price for a Drug Product is:

a. For a Drug Product subject to the Fixed Pricing Rules, a price that is less than or equal to the Fixed Price (per unit of issue) as defined in the Price Policy (and shown in the Base Cost column of the electronic APC that may be accessed through the Alberta Blue Cross Manufacturer/vendor Online Services web site).

b. For a Drug Product subject to the Non-Fixed Pricing Rules:

i. either

(a) the Base Cost, or

(b) a revised Base Cost, as set out in section 21,

both of which must not exceed the highest price permitted in the Non-Fixed Pricing Rules.

4. In addition, a Confirmed Price:

a. is applicable to a Drug Product regardless of the package size for each Drug Product; b. must not include the Goods and Services Tax (GST) or any other tax; and c. must not include any amount for a Distribution Allowance.

5. Exceptions to the Fixed Pricing and Non-Fixed Pricing Rules may be requested.

6. If an exception is requested for a Drug Product in a Price Confirmation, but is not approved by the Minister, the Manufacturer will not be given another opportunity to submit a new Price Confirmation or a new Confirmed Price in respect of such Drug Product, unless:

a. the Minister, at the Minister’s sole discretion, determines it is advisable to do so; or b. the Manufacturer follows the applicable resubmission process referred to in the

AHWDBL.

7. (a) The Manufacturer is responsible for ensuring that sufficient supply of a Drug Product, for which a Confirmed Price has been submitted, is available for the Alberta market for the duration of the Effective Period.

(b) If the Manufacturer anticipates that it may be unable to comply with the provisions of section 7(a), the Manufacturer must advise Alberta Blue Cross immediately in writing.



8.

a. For a Drug Product subject to the Fixed Pricing Rules, the Manufacturer agrees and warrants that the Confirmed Price is the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period.

b. For a Drug Product subject to the Non-Fixed Pricing Rules, the Manufacturer agrees and warrants that the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period is the Confirmed Price plus a Distribution Allowance provided such Drug Product is distributed or sold only through a licensed wholesaler.

c. For a Drug Product subject to the Non-Fixed Pricing Rules, the Manufacturer agrees and warrants that the maximum price at which the Drug Product will be available for sale to a Licensed Pharmacy for the duration of the Effective Period is the Confirmed Price, provided such Drug Product is not distributed or sold only through a licensed wholesaler.

9. Further, the Manufacturer agrees that it will take all necessary steps to ensure that any distributor, wholesaler or other person with whom it enters into a contract or any other arrangement, including (without limitation) the transfer or assignment of any or all rights and/or obligations in connection with a Drug Product that is listed on the AHWDBL:

i. makes the Drug Product available for sale to a Licensed Pharmacy, for the duration of the Effective Period, at a price that does not exceed the maximum price permitted for such Drug Product as set out in clause 8 (a), 8 (b), or 8 (c), as applicable and

ii. complies with the Price Policy and all the APC Terms and Conditions relating to such Drug Product.

10. The Minister may consider a Price Confirmation or Confirmed Price and may, at the

Minister’s sole discretion:

a. accept none, one or more Price Confirmations (with or without any request for an exception to the Fixed Pricing or Non-Fixed Pricing Rules (as applicable)); and

b. accept none, one or more Confirmed Prices (with or without any request for an exception to the Fixed Pricing or Non-Fixed Pricing Rules (as applicable)) submitted in one or more Price Confirmations.

11. Notwithstanding the acceptance of a Confirmed Price, the Minister is not obligated to pay that price for members of a Plan, but may establish special or exceptional prices, including but not limited to establishing:

a. an LCA Price, b. a MAC Price, or c. a special or exceptional price.

12. When considering a Price Confirmation or Confirmed Price for acceptance, and in determining whether to establish an LCA Price, a MAC Price, or a special or exceptional price, the Minister may consider any factor or criteria outlined in the AHWDBL, any matter permitted by the Drug Program Act, or any matter that the Minister determines is in the public interest.




INTERIM APC

13. Notwithstanding the acceptance of a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, in the event that, during an Effective Period:

a. a new Drug Product is being considered for listing in an Established IC Grouping,

New IC Grouping or MAC Grouping, b. a Manufacturer submits a price reduction in accordance with this Price Policy for a

Drug Product listed in an Established IC Grouping, New IC Grouping or MAC Grouping, or

c. for any reason that the Minister determines that it is advisable to do so,

the Minister may, at the Minister’s sole discretion, issue an Interim APC for one or more Drug Products, or one or more groupings of Drug Products.

14. If a Manufacturer submits a new Drug Product submission for review and listing on the

AHWDBL, and an Interim APC is issued, the Manufacturer must submit a Confirmed Price for that Drug Product that:

a. is equal to or less than the price as outlined in the Drug Product submission, and b. does not exceed the prices permitted under this Price Policy,

or the Drug Product may not be listed or the listing of the Drug Product may be delayed.

15. When an Interim APC is issued, all Manufacturers who have a Drug Product listed in the affected Established IC Grouping, New IC Grouping or MAC Grouping will be invited, but are not required, to submit a new Price Confirmation and Confirmed Price for the affected Drug Product, and in the event that a new Price Confirmation for an affected Drug Product is not submitted, or if a Price Confirmation with the same Confirmed Price for the affected Drug Product is submitted, then the Confirmed Price shown in the most recent AHWDBL (prior to the issuance of the Interim APC) shall continue to apply to the affected Drug Product.

16. In the event the Minister issues an Interim APC, and a Price Confirmation or all or part of a Price Confirmation, or one or more Confirmed Prices are accepted as a result of the Interim APC, the Interim APC Terms and Conditions supercede any previous APC or Interim APC Terms and Conditions for the affected Drug Products for the remainder of the Effective Period, with the exception of an affected Drug Product that continues to subsist on the AWHDBL in accordance with the provisions of section 15. For further clarity, this provision does not affect the Minister’s unfettered discretion at any time to make any decisions or take any steps including (without limitation) to amend a published price, an LCA Price, a MAC Price, the Price Policy, the Product Listing Agreement Policy, the AHWDBL or make any other adjustments the Minister considers advisable.

17. Publication of amended Confirmed Prices is at the discretion of the Minister.

18. Unless permitted in this Price Policy or by the Minister, at the Minister’s sole discretion, a Price Confirmation and a Confirmed Price may not exceed a Price Confirmation and a Confirmed Price for a Drug Product that has been submitted and approved by the Minister through a prior APC relating to such Drug Product.



19. The provisions in this Price Policy that apply to an APC also apply to an Interim APC, and where the term APC is used in such sections, it shall be deemed to read Interim APC in the case of an Interim APC. This section does not apply to section 16.

FIXED PRICING RULES

20. The Fixed Pricing Rules apply to any Drug Product, other than any Brand Drug or Other Drug, that is listed or under consideration for listing on the AHWDBL. Effective July 1, 2012, a Confirmed Price:

a. must not exceed the Fixed Price as follows:

i. For an IC Drug listed or under consideration for listing in an Established IC Grouping , the Fixed Price will be less than or equal to:

A. 35% of the Brand Price; B. If there is no Brand Price, or if the Brand Price is equal

to the LCA Price for that Established IC Grouping in the May AHWDBL, 62.5% of the lowest price published in the Established IC Grouping in the May AHWDBL.

ii. For an Entry IC Drug, the Fixed Price will be less than or equal to:

A. 35% of the Effective Brand Price, where the Drug Product is listed or under consideration for listing in a New IC Grouping which includes or will include a Brand Drug; or

B. 35% of the Effective Other Drug Price, where the Drug Product is listed or under consideration for listing in a New IC Grouping which includes or will include an Other Drug,

b. and must not include a Distribution Allowance.

NON-FIXED PRICING RULES (FOR BRAND DRUGS AND OTHER DRUGS)

21. Effective July 1, 2012, the Confirmed Price for a Brand Drug and an Other Drug must comply with the following:

a. The Confirmed Price must be less than or equal to:

i. the Base Cost; or

ii. a revised Base Cost may be submitted that is equal to (i) the Base Cost plus (ii) a percentage (%) of the Base Cost that is equal to the annual average percentage change from the previous year of the Consumer Price Index for Canada, all items, not seasonally adjusted, published by Statistics Canada.

b. and the Confirmed Price must not include a Distribution Allowance.




c. The Confirmed Price in respect of a Drug Product may only increase once per 12 month period commencing on April 1st in one year and continuing through March 31st

in the next year, and must be submitted through a Price Confirmation. EXCEPTIONS

22. Notwithstanding the Fixed Pricing Rules and the Non-Fixed Pricing Rules, exceptions to the Fixed Pricing Rules and Non-Fixed Pricing Rules may be considered at the sole discretion of the Minister. Where an exception is requested, the Minister reserves the right to request such additional evidence and information in support of such request as the Minister deems appropriate.

23. The Minister may, but is not required to, consider exceptions where:

a. For an Entry IC Drug, there was a decrease of greater than 20% in the price of the Brand Drug or the Other Drug (as applicable) published in the AHWDBL within the 12 months preceding the date that the Drug Product submission in respect of the Entry IC Drug was received by Alberta Blue Cross;

b. For Drug Products with: i. less than 250 claims1

ii. an annual net cost; and

2

of less than $50,000;

for Plans, as calculated by the Minister and based on claims experience information provided by Alberta Blue Cross relating to Plans, for the period of time that the Drug Product was listed on the AHWDBL in the previous 12 months;

c. The manufacturing and distribution costs for a Drug Product exceed the maximum price for such Drug Product permitted by the Fixed Pricing Rules or Non-Fixed Pricing Rules (as applicable3

d. Where exceptional circumstances exist

);

4

, and the Minister determines that an exception is appropriate.

24. Exceptions will not be considered for an IC Drug if the Confirmed Price for another Drug Product in the Established IC Grouping or New IC Grouping is at or below the Fixed Price.

25. Requests for an exception may delay the listing or price publication of the Drug Product.

1 “claims” means the total number of prescriptions submitted for reimbursement to the Plans for all Drug Products in the grouping. 2 “cost” means the drug material cost for claims 3 Please provide a breakdown of the costs attributed to (a) the costs for each raw material separately, including that of the active pharmaceutical ingredient, (b) the cost of manufacturing (excluding costs of raw materials), (c) cost of distribution (including direct distribution fees paid to distributors but excluding all rebates/professional allowances), and (d) other (if applicable, please specify what “other” costs represent). Rebates/professional allowances must be excluded from all costs provided herein. Costs must be stated in one unit of measure consistent for all costs requested herein (for example, cost per tablet). 4 Exceptional circumstances include, but are not limited to, circumstances where, in the opinion of the Minister, significant patient safety or access concerns, or significant increased costs to the Plans could result if the Drug Product was not available on the AHWDBL.



PRICE REDUCTIONS

26. During an Effective Period, further price reductions for Drug Products listed on the AHWDBL will be considered as follows:

a. For IC Drugs and Drug Products listed in a MAC Grouping if the proposed price is

i. 5% less than, or ii. would represent an annual net cost5

savings of more than $100,000 for the Plans, as calculated by the Minister, for the period of time that the Drug Product was listed on the AHWDBL in the previous 12 months, in comparison to

the LCA Price or MAC Price published at the time Alberta Blue Cross receives the proposed price reduction.

b. For all other Drug Products, by notifying the Minister by sending a written notice to Alberta Blue Cross.

27. Establishment of a new LCA Price or MAC Price and publication of a reduced price is subject to:

b. the Manufacturer submitting a Price Confirmation and a reduced Confirmed Price for the new price in accordance with the APC Terms and Conditions;

c. acceptance of the new Confirmed Price by the Minister; and d. the Minister’s sole discretion regarding the establishment of a new LCA Price or MAC

Price, and the time, place and method of publication. MINISTER’S AUTHORITY

28. Notwithstanding anything to the contrary, where

a. no Price Confirmation and Confirmed Price is submitted in respect of a Drug Product;

b. there is a failure to submit a Price Confirmation or Confirmed Price in respect of a Drug Product in accordance with the APC Terms and Conditions;

c. there is a rejection or non-acceptance of a Price Confirmation, or of all or part of a Price Confirmation, or of one or more Confirmed Prices, or of a request for an exception to either the Fixed Pricing Rules or Non-Fixed Pricing Rules;

d. there is a failure by the Manufacturer to comply with the APC Terms and Conditions in respect of a Drug Product listed or under consideration for listing on the AHWDBL;

e. the Minister considers that a PLA that is satisfactory to the Minister must be entered into prior to and/or as a condition of the listing, or continued listing, of a Drug Product on the AHWDBL;

the Minister may, at the Minister’s sole discretion, do any one or more of the following:

i. cancel the listing of, 5 “cost” means the drug material cost for claims




ii. modify the listing of,

iii. refuse to add to the AHWDBL,

iv. refuse to expedite the submission of,

v. cancel or modify the benefit payable for,

vi. modify or impose rules, terms, restrictions or conditions (including the execution of a PLA satisfactory to the Minister) relating to, or

vii. take any other action in relation to

the Drug Product for any period of time deemed appropriate by the Minister.

29. Notwithstanding any other provision in this Price Policy, and for the avoidance of doubt, the Minister, in his sole discretion, has and retains the sole right to determine all matters relating to the listing or continued listing of a Drug Product on the AHWDBL, including (without limitation) the sole right to determine:

a. whether or not the Fixed Pricing Rules or the Non-Fixed Pricing Rules apply to a

Drug Product, b. whether or not a Drug Product is to be considered as an IC Drug, a Brand Drug,

or an Other Drug for purposes of this Price Policy and an APC, and c. whether or not a PLA must be executed as a condition of the listing or continued

listing of a Drug Product on the AHWDBL

30. For further clarity, in all cases where the execution of a PLA in respect of a Drug Product is required as a condition of the listing or continued listing of a Drug Product on the AHWDBL, the provisions of the Product Listing Agreement Policy must be satisfied. Nothing in this Price Policy is intended to limit or override the application or any provisions of the Product Listing Agreement Policy. The requirements for listing or continued listing of a Drug Product outlined in the AHWDBL, including (without limitation) this Price Policy, as well as the Product Listing Agreement Policy must be satisfied.

31. Notwithstanding anything to the contrary, and notwithstanding the acceptance of a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, the Minister shall have the unfettered discretion to

a. make any decisions or take any steps to amend a published price, an LCA Price, a MAC Price, a special or exceptional price, the Price Policy, the Product Listing Agreement Policy, the AHWDBL or make any other adjustments the Minister considers advisable;

b. make any decisions, take any actions or steps, or do anything that is authorized by the Drug Program Act;

c. pursue, negotiate and enter into agreements with one or more Manufacturers, distributors or vendors, including (without limitation) a PLA Agreement,

d. make arrangements with other persons to provide access to Drug Products for members of the Plans,



e. make any decisions, or take any actions or steps, or do anything that the Minister considers appropriate (including, without limitation, issuing an APC), and

f. terminate an APC, a Price Confirmation, or all or part of a Price Confirmation, or one or more Confirmed Prices, or the listing of any or all Drug Products on the AHWDBL, upon 10 days written notice to any affected Manufacturer, which notice is deemed to be given by the Minister and received by the Manufacturer upon (a) publication of the written notice on the AHWDBL website operated by Alberta Blue Cross, or (b) by sending the notice via telefax to the last known telefax number of the Manufacturer, and the method of notice is at the Minister’s discretion,

in order to maintain the integrity of the AHWDBL, to ensure reasonable access to treatment for members of the Plans, or to serve the public interest.

32. Subject to section 31, where the Minister amends the Price Policy during an Effective Period, the Minister shall provide Manufacturers of Drug Products listed on the AHWDBL as at that date with 30 days notice of such amendment, and the Minister may also issue an APC in relation to any Drug Product affected by such amendment.

33.The Minister reserves the right to pursue any remedies available to the Minister in the event of any non-compliance with, or any breach of, the Price Policy or APC Terms and Conditions.

34. a. The Minister, Alberta Blue Cross, and their respective officers, employees, and

agents, are not liable for any actions, damages, claims, liabilities, costs, expenses, or losses in any way, including consequential, special, indirect, incidental, punitive or special damages, costs, expenses, or losses (including, without limitation, lost profits and opportunity costs) arising out of or relating to an APC, an Interim APC, any Price Confirmation, a Confirmed Price, or the AHWDBL, even if the Minister or Alberta Blue Cross have been advised of the possibility of such damages beforehand. The provisions of this clause shall apply regardless of the form of action, damage, claim, liability, cost, expense, or loss, whether in contract, statute, tort (including, without limitation, negligence), or otherwise, and

b. in no event shall the maximum aggregate liability of the Minister, Alberta Blue Cross, and their respective officers, employees, and agents, for damages related to an APC, an Interim APC, a Price Confirmation, a Confirmed Price, or the AHWDBL be greater than $25,000, or the Manufacturer’s actual costs of preparing and submitting a Price Confirmation in response to an APC, whichever is less.




LEAST COST ALTERNATIVE (LCA) PRICE POLICY 1. The Least Cost Alternative Price or LCA Price means the maximum amount established by

the Minister which will be paid by the Government of Alberta for a Drug Product in an Established or New IC Grouping for members of a Plan.

2. Where the Minister establishes an LCA Price in Established and New IC Groupings the LCA

Price: a. is the lowest unit cost for a Drug Product in an IC Grouping that was submitted by the Manufacturer and accepted by the Minister in the most recent Alberta Price Confirmation.

b. appears in bold type in the far right column of the AHWDBL.

c. applies to all Drug Products in the applicable IC Grouping, unless the Minister determines that an exception should be made.

3. Where the Minister establishes an LCA Price in Established and New IC Groupings, the

Government of Alberta will pay the Actual Acquisition Cost for the Drug Product to a maximum of the LCA Price.

4. Notwithstanding section 2 above, the LCA Price Policy does not apply to:

• conjugated estrogens; • devices; and • injectable Drug Products with different package sizes in an IC Grouping.

5. Subject to a Special Authorization being granted pursuant to section 6, where a physician

prescribes or a patient chooses an IC Drug that is priced higher than the LCA Price established by the Minister in the applicable IC Grouping, the patient will be responsible for any additional costs (being the difference in price between the higher-priced IC Drug and the LCA Price).

6. A physician may request Special Authorization if an IC Drug that is priced higher than the

applicable LCA Price is essential in the care of a patient. For further information refer to the Special Authorization Guidelines section of the AHWDBL.



MAXIMUM ALLOWABLE (MAC) PRICE POLICY 1. The MAC Price means the maximum amount established by the Minister which will be paid

by the Government of Alberta for a Drug Product in a MAC Grouping for members of a Plan. 2. A MAC Grouping means a grouping of Drug Products that have been listed in the AHWDBL

or the List as being subject to a MAC Price; a MAC Grouping may include a grouping of IC Drugs, in which case the grouping shall be treated as an Established IC Grouping.

3. Where the Minister has established a MAC Price for a MAC Grouping: a. The MAC Price appears in bold italic type and is displayed in the AHWDBL in the

second column from the right where two price columns are listed. A comment in bold italic type appears following a MAC Grouping to explain the basis for establishing the MAC Price.

b. The Government of Alberta will pay the Actual Acquisition Cost for the Drug Product

to a maximum of the MAC Price. 4. The MAC Price Policy applies to the following MAC Groupings:

PTC 28:08.04.92 Selected Oral Modified-Release Dosage Forms of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• PTC 40:12 Potassium Chloride (K+) 8 mEq Oral Sustained-Release Tablets

5. Subject to a Special Authorization being granted, where a physician prescribes or a patient

chooses a Drug Product in a MAC Grouping that is priced higher- than a MAC Price established by the Minister for the applicable MAC Grouping, the patient will be responsible for any additional costs (being the difference in price between the higher-priced Drug Product and the MAC Price).

6. A physician may request Special Authorization if the Drug Product that is priced higher than the applicable MAC Price is essential in the care of a patient. For further information refer to the Special Authorization Guidelines section of the AHWDBL.




RESTRICTED BENEFITS

Restricted Benefits

Selected devices or drug products are eligible benefits with restrictions in the Alberta Health and Wellness Drug Benefit List. For these products a comment is displayed in the List after the ingredient name. The comment initially states “RESTRICTED BENEFIT” and is followed by an explanation of the restriction. For an example, refer to the Legend in the Introduction section of the List.

Products Designated as Restricted Benefits

The products listed below are restricted benefits in the List.

PTC 00:00:02 Diabetic Supplies Blood Glucose Test Strips, Blood Letting Lancet, Insulin Pen Needles,

Insulin Syringes, Urine Test Strips PTC 08:18.08.20 Lamivudine 100 mg oral tablet Tenofovir Disoproxil Fumarate 300 mg oral tablet

PTC 08:18.20 Peginterferon Alfa-2A 180 mcg/0.5 ml injection syringe and 180 mg/ml injection

PTC 08:18.32 Adefovir Dipivoxil 10 mg oral tablet Entecavir 0.5 mg oral tablet PTC 12:20.04 Cyclobenzaprine HCL 10 mg oral tablet

PTC 12:92:00 Varenicline Tartrate 0.5 mg oral tablet Varenicline Tartrate 1 mg oral tablet

PTC 20:12.04.92 Rivaroxaban 10 mg oral tablet

PTC 28:16.08.04 Risperidone 1 mg/ml oral solution Aripiprazole 2 mg oral tablet Aripiprazole 5 mg oral tablet

PTC 28:32.28 Naratriptan HCL 1 mg and 2.5 mg oral tablet




Rizatriptan Benzoate 5 mg oral tablet, 10 mg oral tablet, 5 mg oral wafer and 10 mg oral wafer

Sumatriptan Hemisulfate 5 mg/dose and 20 mg/dose unit dose nasal spray

Sumatriptan Succinate 50 mg oral tablet, 100 mg oral tablet and 6 mg/syr injection syringe Zolmitriptan 2.5 mg oral tablet, 2.5 mg oral dispersible tablet and 5 mg/dose unit dose nasal

spray PTC 48:10.24 Montelukast Sodium 4 mg oral chewable tablet, 5 mg oral chewable tablet, 10 mg oral tablet,

and 4 mg oral granule Zafirlukast 20 mg oral tablet PTC 52:08.08 Mometasone Furoate 50 mcg/dose aqueous nasal spray

PTC 52:92:00 Ranibizumab 2.3 mg/vial injection

PTC 56:22.92 Aprepitant/Aprepitant 80 mg/125 mg capsule

PTC 92:36:00 Leflunomide 10 mg oral tablet and 20 mg oral tablet

PTC 94:00:00 Aerosol Holding Chamber Aerosol Holding Chamber/Mask - Infant Aerosol Holding Chamber/Mask - Pediatric Aerosol Holding Chamber Mask - Adult

Limited Restricted Benefits

Selected drug products are eligible benefits with limits and restrictions in the Alberta Health and Wellness Drug Benefit List. For these products a comment is displayed in the List after the ingredient name. The comment initially states “LIMITED RESTRICTED BENEFIT” and is followed by an explanation of the limits and restrictions. For an example, refer to the Legend in the Introduction of the List.

Product(s) Designated as Limited Restricted Benefits

The product(s) listed below are limited restricted benefits in the List.

PTC 20:12.18

Clopidogrel Bisulfate 75 mg oral tablet




SPECIAL AUTHORIZATION GUIDELINES Special Authorization Policy

Drug Products Eligible for Consideration by Special Authorization Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products not

1. The drug is covered by Alberta Health and Wellness under specified criteria (listed in the following sections). Drug Products and indications other than those specified are not eligible for consideration by special authorization.

eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization.

2. The drug is normally covered by another government program or agency for a specific approved clinical condition, but is needed for the treatment of a clinical condition that is not covered by that government program or agency.

3. The drug is required because other drug products listed in the Alberta Health and Wellness Drug Benefit List are contraindicated or inappropriate because of the clinical condition of the patient.

4. The particular brand of drug is considered essential in the care of a patient, where the LCA price policy would otherwise apply. Coverage of a specific brand may be considered where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with alternate brands in an interchangeable grouping. Coverage of a brand name product will not

5. A particular drug product or dosage form of a drug is essential in the care of a patient where the MAC price policy would otherwise apply. Exceptions may occur at the product level. Coverage may be considered only where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with the drug product which establishes the MAC pricing.

be considered in situations where the interchangeable grouping includes a pseudo-generic to the brand name drug.

Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.

Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage prior to the expiration date of the Approved Period, unless

Auto-Renewal Process

the Auto-Renewal Process or Step Therapy Approval Process apply (see below).

Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).

1. For initial approval, a special authorization request must be submitted. If approval is granted, it will be effective for the Approval Period outlined in the drug product’s Special Authorization criteria.




2. As long as the patient has submitted a claim for the drug product within the preceding Approval Period (example: within the preceding 6 months), approval will be automatically renewed for a further Approval Period (example: a further 6 months). There is no need for the prescriber to submit a new request as the automated real-time claims adjudication system will read the patient’s claims history to determine if a claim has been made within the preceding Approval Period.

3. If the patient does not

make a claim for the drug product during the Approval Period, the approval will lapse and a new special authorization request must be submitted.

Step Therapy Approval Process Select drug products are eligible for coverage via the step therapy process, outlined below.

1. If the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months, the claim for the step therapy drug will be approved.

2. The automated real-time claims adjudication system will read the patient’s claims history to determine if the required First-Line* drug product(s) have been claimed within the preceding 12 months.

3. Subsequent claims for drug product(s) permitted by step therapy will continue to be approved as long as the drug product has been claimed within the preceding 12 months.

4. The regular special authorization approval process will continue to be available for step therapy approvals for those patients whose First-Line* drug claims cannot be adjudicated through the automated real-time claims adjudication system.

* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’s Special Authorization criteria, are required to be utilized before reimbursement for the drug product is permitted.

Drug Products Not Eligible for Consideration by Special Authorization The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List. 2. Drug products not yet reviewed by the Alberta Health and Wellness Expert Committee on

Drug Evaluation and Therapeutics. This applies to: products where a complete submission has been received from the manufacturer and

the product is under review, products where an incomplete submission has been received from the manufacturer,

and products where the manufacturer has not made a submission for review.

Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.

3. Drug products that have completed the review process and are not included on the List. 4. Most drugs available through Health Canada’s Special Access Program. 5. Drug products when prescribed for cosmetic indications. 6. Nonprescription or over-the-counter drug products are generally not eligible.


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JULY 1, 2012 Section 1A • 1

38BSpecial Authorization Procedures

A prescriber’s request for special authorization should be directed by mail or FAX to: Clinical Drug Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5

FAX: (780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free fax for all other areas

1. For most drug products, written requests from a prescriber may be submitted on the general Drug

Special Authorization Request (form number ABC 20061).

Select drug products such as Donepezil/Galantamine/Rivastigmine (form number ABC 30776), Clopidogrel (form number ABC 30786), Darbepoetin/Epoetin (form number ABC 30888), Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis (form number ABC 30902), Ezetimibe (form number ABC 30925), Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin (form number ABC 30932), Peginterferon Alfa-2a for Chronic Hepatitis C (form number ABC 30944), Etanercept for Juvenile Idiopathic Rheumatoid Arthritis (form number ABC 30948), Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis (form number ABC 30964), Select Quinolones (form number 30966), Alendronate/Raloxifene/ Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis (form number ABC 31086), Celecoxib (form number ABC 31140), Filgrastim/Pegfilgrastim (form number ABC 31150) Fentanyl (form number ABC 31169), Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis (Form number ABC 31192), Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis (form number ABC 31195), Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease (form number ABC 31200), Rituximab for Rheumatoid Arthritis (form number ABC 31205), Imiquimod (form number ABC 31222), Dutasteride/Finasteride (form number ABC 31257), Paliperidone/Risperidone Prolonged Release Injection (form number ABC 31258), Abatacept for Juvenile Idiopathic Arthritis (form number ABC 31291), Montelukast/Zafirlukast (form number ABC 31313), Febuxostat (form number 31376), Denosumab (form number 31377), Omalizumab (form number 31406) and Eculizumab (form number ABC 31386 and ABC 31408) have a unique special authorization request form. All requests for these drug products must be submitted using the applicable form.

Special authorization request forms can be found on the following pages.

2. A separate request is required for each patient.

3. For a request for special authorization to be considered, the prescriber (an individual authorized by law to prescribe) must contact Alberta Blue Cross and provide the following information:

Patient Identification patient’s name, address and card holder’s name (if different than the patient’s), Alberta Blue Cross identification number or coverage number/client number of any other applicable

coverage (e.g. Alberta Human Services and Alberta Seniors (AISH) or Alberta Personal Health number, and

date of birth.


The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. Section 1A • 2 EFFECTIVE JULY 1, 2012

Prescriber Identification name of prescriber (e.g. physician, dentist, or optometrist), address, telephone number and FAX number (if applicable), and professional association registration number (e.g. College of Physicians and Surgeons, Alberta Dental

Association, or Alberta College of Optometrists registration number).

Drug Requested name, strength and dosage form, dosage schedule, and proposed duration of therapy.

Reason for the Request diagnosis and/or indication for which the drug is being used, information regarding previous medications which have been used

and the patient’s response to therapy where appropriate, proposed results of therapy, and any additional information that may assist in making a decision on the

request for special authorization.

39BSpecial Authorization Forms

Special Authorization forms can be found on the following pages:

Drug Special Authorization Request Form (ABC 20061) Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776) - All

requests for donepezil HCl, galantamine hydrobromide or rivastigmine hydrogen tartrate and must be submitted using this form only.

Clopidogrel Special Authorization Request Form (ABC 30786) - All requests for clopidogrel bisulfate must be submitted using this form only.

Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888) - All requests for darbepoetin or epoetin alfa must be submitted using this form only.

Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902) - All requests for abatacept, adalimumab, anakinra, etanercept, golimumab, infliximab or tocilizumab for Rheumatoid Arthritis must be submitted using this form only.

Ezetimibe Special Authorization Request Form (ABC 30925) - All requests for ezetimibe must be submitted using this form only.

Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) - All requests for peginterferon alfa-2a/ribavirin or peginterferon alfa-2b/ribavirin must be submitted using this form only.

Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944) - All requests for peginterferon alfa-2a for Chronic Hepatitis C must be submitted using this form only.

Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 30948) - All requests for etanercept for Juvenile Idiopathic Arthritis must be submitted using this form only.

Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964) - All requests for adalimumab, etanercept, golimumab or infliximab for Psoriatic Arthritis must be submitted using this form only.

Select Quinolones Special Authorization Request Form (ABC 30966) - All requests for ciprofloxacin, levofloxacin, moxifloxacin or ofloxacin must be submitted using this form only.



Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form (ABC 31086) - All requests for alendronate, raloxifene, risedronate or synthetic calcitonin salmon for Osteoporosis must be submitted using this form only.

Celecoxib Special Authorization Request Form (ABC 31140) – All requests for celecoxib must be submitted using this form only.

Filgrastim/Pegfilgrastim Special Authorization Request Form (form number ABC 31150) – All request for filgrastim or pegfilgrastim must be submitted using this form only.

Fentanyl Special Authorization Request Form (form number ABC 31169) - All requests for fentanyl or fentanyl citrate must be submitted using this form only.

Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192) - All requests for adalimumab, etanercept, infliximab or ustekinumab for Plaque Psoriasis must be submitted using this form only.

Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195) - All requests for adalimumab, etanercept, golimumab or infliximab for Ankylosing Spondylitis must be submitted using this form only.

Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form (ABC 31200) - All requests for adalimumab for Moderately to Severely Active Crohn's Disease or infliximab for Moderately to Severely Active Crohn’s/Fistulizing Crohn’s Disease must be submitted using this form only.

Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205) - All requests for abatacept or rituximab for Rheumatoid Arthritis must be submitted using this form only.

Imiquimod Special Authorization Request Form (ABC 31222) – All requests for imiquimod must be submitted using this form only.

Dutasteride/Finasteride Special Authorization Request Form (ABC 31257) – All requests for dutasteride or finasteride must be submitted using this form only.

Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258) – All requests for paliperidone/risperidone prolonged release injection must be submitted using this form only.

Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291) - All requests for abatacept for Juvenile Idiopathic Arthritis must be submitted using this form only.

Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313) – All requests for montelukast or zafirlukast must be submitted using this form only.

Febuxostat Special Authorization Request Form (ABC 31376) – All requests for febuxostat must be submitted using this form only.

Denosumab Special Authorization Request Form (ABC 31377) – All requests for denosumab must be submitted using this form only.

Omalizumab Special Authorization Request Form (ABC 31406)- All requests for omalizumab must be submitted using this form only.

Eculizumab Special Authorization Request Form (ABC 31386) – All requests for eculizumab must be submitted using this form only.

Eculizumab Consent Form (ABC 31408) -– All requests for eculizumab must be accompanied by this form.

The following official forms are provided for your convenience to photocopy and use as required. Submit completed forms by FAX to Alberta Blue Cross:

(780) 498-8384 in Edmonton and area 1-877-828-4106 toll-free for all other areas

Once your request has successfully transmitted, please DO NOT mail or re-fax your request



40BDrug Special Authorization Request Form

On the reverse is the official Drug Special Authorization Request Form (ABC 20061).

• Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:


Once your request has successfully transmitted, please do not mail or re-fax your request.

DRUG SPECIAL AUTHORIZATION REQUEST

Please complete all required sections to allow your request to be processed. PATIENT INFORMATION COVERAGE TYPE:

PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross Alberta Human Services Alberta Seniors Other

DATE OF BIRTH: Year / Month / Day ALBERTA PERSONAL HEALTH NUMBER

STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No:

PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION

CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:

FAX: CITY , PROVINCE

POSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED

NEW RENEWAL DRUG REQUEST Note: Request may or may not be approved by Alberta Blue Cross Drug(s), Dosage(s) and Duration Requested:

Diagnosis and / or Indication which drug is being used to treat: (Include applicable information regarding previous medications, patient response to therapy and proposed results of therapy.)

Additional information relating to request:

PRESCRIBER’S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.

The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 20061 (R11/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.



Donepezil/Galantamine/Rivastigmine Special Authorization Request Form

On the reverse is the official Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).

• All requests for donepezil HCl, galantamine hydrobromide or rivastigmine hydrogen tartrate must be submitted using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form only.




DONEPEZIL/GALANTAMINE/RIVASTIGMINE SPECIAL AUTHORIZATION REQUEST FORM

Please complete ALL sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.

PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL

Alberta Blue Cross

Alberta Human Services

Alberta Seniors Other



PRESCRIBER INFORMATION

PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION

CPSA

CARNA

ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

CITY , PROVINCE PHONE:

FAX:


Criteria for Coverage of DONEPEZIL, GALANTAMINE, RIVASTIGMINE For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4. Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination. Special authorization coverage may be granted for a maximum of 24 months per request. For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided. Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug.

Note: • an MMSE score below 10 or an InterRAI-Cognitive Performance Scale score greater than 4 at any time will result in discontinuation

of coverage.

PLEASE COMPLETE ALL SECTIONS TO ALLOW YOUR REQUEST TO BE PROCESSED

Indicate which drug is requested:

Donepezil Galantamine Rivastigmine

Please confirm the diagnosis for which this drug is requested: For the treatment of: Dementia of the Alzheimer’s Type other, please specify: __________________________________________________

Please provide a current MMSE or InterRAI-Cognitive Performance Scale score* and the date the exam was administered: MMSE Score: _____________________ InterRAI-Cognitive Performance Scale Score: _____________ Date of exam: _____________________ Date of exam: ______________________________________

PRESCRIBER'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5 ABC 30776 (R12/2011) The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of Independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross plan.



Clopidogrel Special Authorization Request Form

On the reverse is the official Clopidogrel Special Authorization Request Form (ABC 30786). • All requests for clopidogrel bisulfate must be submitted using the Clopidogrel Special

Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:



Please complete all required sections to allow your request to be processed.

CLOPIDOGREL SPECIAL AUTHORIZATION REQUEST FORM

Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.

PATIENT INFORMATION COVERAGE TYPE:



STREET ADDRESS CITY PROV POSTAL CODE

IDENTIFICATION/CLIENT/COVERAGE No:

PRESCRIBER INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA

CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Criteria for Post-Stent Coverage Section I (Must complete for requests for post-stent coverage)

For the prevention of thrombosis, for one month, when prescribed following intravascular bare metal stent placement. Patients who have received one month of coverage via the Limited Restricted Benefit will not be eligible for additional coverage under this criterion. * For the prevention of thrombosis, for up to 12 months, when prescribed following intravascular drug eluting stent (DES) placement. Patients who have received one month of coverage via the Limited Restricted Benefit may be eligible for an additional 11 months of coverage (i.e., up to 12 months of coverage) following the submission of a special authorization request. * * Special Authorization for post-stent coverage is required when the prescriber prescribing the medication is not a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery; for treatment after repeat stents; or for continued coverage of up to 12 months following intravascular drug eluting stent (DES) placement.

Please indicate the type and date of the stent: Date of stenting procedure: ________________________________________

bare metal stent (1 month of coverage)

drug eluting stent (12 months of coverage)

For additional coverage, please proceed to Section II below

Other Criteria for Coverage For the prevention of cerebrovascular (e.g. stroke, TIA) and non-cerebrovascular ischemic events in patients who have a contraindication to ASA. Special Authorization for this criterion may be granted for 24 months. For use in patients who have experienced a non-cerebrovascular ischemic event while on ASA. Special Authorization for this criterion may be granted for 24 months. For use in patients who have experienced a cerebrovascular ischemic event (e.g. stroke, TIA) while on dipyridamole/ASA (Aggrenox) or for whom dipyridamole/ASA (Aggrenox) is contraindicated. Special Authorization for this criterion may be granted for 24 months. Coverage will not be considered when clopidogrel and ASA/dipyridamole are intended for use in combination. Section II (Complete ALL that apply) Does this patient have a contraindication/intolerance to ASA? YES NO

Please indicate the cerebrovascular ischemic event experienced: Please specify the non-cerebrovascular ischemic event experienced:

stroke TIA

Did the cerebrovascular event occur while this patient was on dipyridamole/ASA (Aggrenox)?

Please indicate which anti-platelet therapy this patient was on when the non-cerebrovascular event occurred:

YES NO ASA other (specify):_____________________________

If applicable, please indicate which product this patient has a contraindication/intolerance to: Patient was not on anti-platelet therapy

dipyridamole/ASA (Aggrenox) dipyridamole

PRESCRIBER 'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30786 (R11/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan



Darbepoetin/Epoetin Special Authorization Request Form

On the reverse is the official Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888). • All requests for darbepoetin or epoetin alfa must be submitted using the Darbepoetin/Epoetin

Special Authorization Request Form only.




DARBEPOETIN/EPOETIN SPECIAL AUTHORIZATION REQUEST FORM




Alberta Blue Cross

Alberta Human Services





PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION

CPSA

CARNA

ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

CITY , PROVINCE PHONE: FAX:


Indicate which drug is requested (check one box): Darbepoetin Epoetin

PLEASE COMPLETE ALL APPLICABLE SECTIONS TO ALLOW YOUR REQUEST TO BE PROCESSED

ANEMIA OF CHRONIC RENAL FAILURE (does not

anemia of chronic renal failure

apply to epoetin 30,000 or 40,000 IU/mL strengths)

other, please specify: ____________________________

This section applies only to patients who received a renal transplant: Please indicate if the renal transplant is failing or has failed:

Yes No Hemoglobin level: For patients with prior special authorization for darbepoetin or epoetin with

Alberta Blue Cross: currentFor hemoglobin level (g/L): new patients: pre-treatment

Please provide the current iron status:

hemoglobin level (g/L):

Serum ferritin is >100 mcg/L: Yes No AND

CHEMOTHERAPY-INDUCED ANEMIA (includes epoetin 30,000 and 40,000 IU/mL strengths)

Transferrin saturation is >20%: Yes No

Please specify the type of cancer: _________________________________________________

other, please specify: _____________________________

For the treatment of anemia: Please indicate if the anemia is chemotherapy-induced:

Yes No, please specify: ____________________

Please provide the patient’s hemogloblin level (g/L):

Please specify the reason why blood transfusions are not an option: Transfusion reactions in the past Difficulty cross-matching the patient

Iron overload Other, please specify:____________________________

ANEMIA IN AZT-TREATED/HIV INFECTED PATIENTS (does not

anemia in AZT-treated/HIV infected patients apply to darbepoetin nor the epoetin 30,000 or 40,000 IU/mL strength)

other, please specify: __________________________________________________________________________________________

Additional information relating to request: PRESCRIBER 'S SIGNATURE DATE Please forward this request to:

Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30888 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.

Criteria for Coverage:

DARBEPOETIN

“For the treatment of anemia of chronic renal failure in patients with low hemoglobin (<100 g/L). Hemoglobin levels should be maintained within 100 – 110 g/L. According to current practice guidelines patients’ iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin >100 mcg/L and transferrin saturation >20%.” “For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Aranesp should be reduced by about 25%.” In order to comply with the second criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient’s transferrin saturation, along with results of liver function tests if applicable. For the first criterion, renewal requests may be considered if the patient’s hemoglobin is < 120 g/L while on Aranesp. For the second criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Aranesp.

EPOETIN (ALL strengths except 30,000 and 40,000 IU/mL)

“For the treatment of anemia of chronic renal failure in patients with low hemoglobin (< 100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients’ iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin >100 mcg/L and transferrin saturation >20%.” "For the treatment of anemia in AZT-treated/HIV infected patients." "For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%.” In order to comply with the third criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests if applicable. For the first criterion, renewal requests may be considered if the patient’s hemoglobin is < 120 g/L while on Eprex. For the third criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Eprex.

EPOETIN 30,000 and 40,000 IU/mL strengths

"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%. Patients may be granted a maximum allowable dose of 40,000 IU per week.” In order to comply with this criterion, if the patient has iron overload the prescriber must state this in the request, or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests, if applicable. Renewal requests may be considered if the patient's hemoglobin is <110 g/L while on Eprex. ABC 30888 (R12/2011)

DARBEPOETIN/EPOETIN SPECIAL AUTHORIZATION CRITERIA




Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form

On the reverse is the official Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).

• All requests for abatacept, adalimumab, anakinra, etanercept, golimumab, infliximab or tocilizumab for Rheumatoid Arthritis must be submitted using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form only.




ABATACEPT/ADALIMUMAB/ANAKINRA/ETANERCEPT/GOLIMUMAB/ INFLIXIMAB/TOCILIZUMAB for Rheumatoid Arthritis

SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed.


PATIENT INFORMATION COVERAGE TYPE: PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross

Alberta Human Services Alberta Seniors Other


STREET ADDRESS CITY PROV POSTAL CODE IDENTIFICATION/CLIENT/COVERAGE No: NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Enbrel, Humira, Kineret or Remicade drug benefits. Personal and health information is required in order to determine eligibility and, in the event you are approved to receive drug benefits, to maintain eligibility, process payments and conduct the Alberta Post-Marketing Study Addressing ENBREL/HUMIRA/KINERET/REMICADE (“Study”). The Study will assist Alberta Health and Wellness to monitor, plan, evaluate and manage the cost-effectiveness of providing Enbrel, Humira, Kineret or Remicade as a benefit under the AHWDBL. Therefore, your consent is required as set out herein. Important: In order to be eligible for, and to maintain eligibility for, Enbrel, Humira, Kineret or Remicade drug benefit both you and your physician(s) must agree to and continue to actively and consistently participate in the Study as required by Alberta Blue Cross, Alberta Health and Wellness, its affiliates and agents throughout the special authorization period. Refusal to provide the requested consent will result in benefits being denied, and withdrawal of consent will result in benefits being revoked.

I hereby authorize: (A)The below physician(s) to disclose to Alberta Blue Cross, Alberta Human Services, and Alberta Seniors (the "Designated Recipients") any of my personal or health information contained on this Request Form or requested by the Designated Recipients (collectively “My Information”); and (B) The Designated Recipients to use and collect My Information for the purposes stated on this form; and (C) The Designated Recipients to disclose My Information to any affiliates or agents of the Designated Recipients for the purposes stated on this form. I acknowledge that: I have been made aware of the reasons why my health information is needed, and the risks and benefits of consenting or refusing to consent to disclosure of my health information; and (2) I am aware that I may revoke this consent (in writing) at anytime. Signature/Effective Date Patient’s Signature


CARNA ACP

ACO ADA+C Other

REGISTRATION NO. STREET ADDRESS


FAX:


Please provide the following information for ALL requests: Diagnosis: Current weight (kg): Indicate requested drug: Tocilizumab Dosage:

Dosing Frequency: Rheumatoid Arthritis Other (specify)

Abatacept Etanercept

Adalimumab Infliximab

Anakinra Golimumab

Scores: * DAS28 Score ___.____ OR ACR20 (renewals only) Date: _____________

AND HAQ Score ___.___ ___ Date: _____________ * New requests for patients currently maintained on the requested biologics require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.

Please provide reason if a switch to a different biologic agent is requested:

Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.

For all biologics EXCEPT Abatacept: Will the patient be maintained on methotrexate in combination with the requested biologic? YES NO

For Abatacept ONLY: Will the patient be maintained on methotrexate or another DMARD in combination with Abatacept? YES NO

If NO to any of the above, please specify reason:

Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required for ALL FOUR of the following:

Methotrexate PO: Methotrexate SC or IM: Methotrexate with another DMARD other than leflunomide (specify agent) : Leflunomide:

Please provide the following information for all NEW anakinra/tocilizumab requests: Previous medications utilized: Indicate the contraindication or adverse effects related to the following:

Abatacept: Adalimumab: Etanercept: Infliximab: Golimumab: Rituximab: Tocilizumab:

PRESCRIBER'S SIGNATURE DATE

Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

I am currently an active participant in the Alberta Post-Marketing Study addressing Enbrel / Humira / Kineret / Remicade




Ezetimibe Special Authorization Request Form

On the reverse is the official Ezetimibe Special Authorization Request Form (ABC 30925).

• All requests for ezetimibe must be submitted using the Ezetimibe Special Authorization Request Form only.




EZETIMIBE SPECIAL AUTHORIZATION REQUEST FORM








CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Criteria for Coverage of EZETIMIBE For the treatment of hypercholesterolemia in patients who are intolerant to statins or in whom a statin is contraindicated and who are at high cardiovascular risk*, or; For the treatment of hypercholesterolemia when used in combination with a statin in patients failing to achieve target LDL with a statin at maximum tolerable dose or maximum recommended dose as per respective product monograph and who are at high cardiovascular risk* Special authorization may be granted for 6 months. This product is eligible for auto-renewal.

*High cardiovascular risk is defined as possessing one of the following: 1) pre-existing cardiovascular disease and/or cerebrovascular disease, or 2) diabetes, or 3) familial hypercholesterolemia, or 4) greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool,

OR 5) three or more of the following risk factors:

• family history of premature cardiovascular disease

• smoking • hypertension

• obesity • glucose intolerance • renal disease.

NEW Please provide the following information for all NEW requests: A. Diagnosis: hypercholesterolemia other, please specify

B. Information regarding previous STATIN use: Statin(s) HAS been utilized. Please specify which statin has been utilized (including dose and duration):

Nature of response to STATIN: Intolerance Failure to achieve target LDL Other

Statin(s) has NOT been utilized. Contraindication? Yes No Please elaborate: C. Presence of CARDIOVASCULAR risk factors (CHECK ALL THAT APPLY):

In order to comply with the above criteria check at least three of the following: family history of premature cardiovascular disease smoking hypertension obesity glucose intolerance renal disease AND/OR In order to comply with the above criteria check at least one of the following:

pre-existing cardiovascular disease and/or cerebrovascular disease diabetes familial hypercholesterolemia greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool

D. Additional information relating to request:

RENEWAL This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:

PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas




Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form

On the reverse is the official Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932).

• All requests for peginterferon alfa-2a/ribavirin or peginterferon alfa-2b/ribavirin must be submitted using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form only.




PEGINTERFERON ALFA-2A+RIBAVIRIN/PEGINTERFERON ALFA-2B+RIBAVIRIN




Alberta Blue Cross Alberta Human Services Alberta Seniors Other



NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Pegetron or Pegasys RBV drug benefits. Information from your prescriber is required to determine eligibility. Your consent is required: (A) for your prescriber to release necessary and relevant information to Alberta Blue Cross, Alberta Health and Wellness and, if requested, to Alberta Human Services and Alberta Seniors; and (B) for Alberta Blue Cross to release that and related usage information to Alberta Health and Wellness.

I hereby authorize: (A) my prescriber to release to Alberta Blue Cross, Alberta Health and Wellness, and (if they request it) to Alberta Human Services and Alberta Seniors (the aforesaid being the "designated recipients"); and (B) Alberta Blue Cross to release to Alberta Health and Wellness the information on this form and information relating to my usage of and experience with the drug and treatment results, and I consent to the designated recipients collecting such information. Date: Patient’s Signature:


CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Drug Requested: Diagnosis of chronic hepatitis C: Evidence of active liver disease:

Peginterferon Alfa-2a+Ribavirin (E.g. Pegasys RBV)

Peginterferon Alfa-2b+Ribavirin (E.g. Pegetron)

Both: a) is the patient anti-HCV positive,

pre-treatment................................ AND; b) is the patient serum HCV RNA

positive (by PCR), pre-treatment......................................

YES NO Not Tested

Either: a) does the patient have elevated liver enzymes

(ALT and/or AST), pre-treatment ……………. OR; b) does the patient have an abnormal liver

biopsy (inflammation and/or fibrosis)

YES NO Not Tested

If the patient is anti-HCV negative but serum HCV RNA positive, please explain:

If patient is currently on Peginterferon Alfa-2a + Ribavirin or Peginterferon Alfa-2b + Ribavirin indicate start date:

Year / Month / Day

INITIAL REQUEST: EXTENSION REQUEST: Initial length of approval:

Advanced fibrosis or cirrhosis (regardless of genotype)……………………………………………... 48 weeks

Genotype 1..…………………………………………14 weeks Is a baseline serum sample stored for future testing? YES NO

Genotype 2 or 3 with HIV co-infection……….14 weeks Is a baseline serum sample stored for future testing? YES NO

Genotype 1, 2 or 3 post-liver transplant……..26 weeks

Initial and maximum length of approval: Genotype 2 or 3 (not co-infected with HIV)....….24 weeks Genotype 4, 5 or 6…..…………………………….. 48 weeks

Request for treatment extension at 14 weeks: For Genotype 1 (non-liver transplant) patients and Genotype 2 or 3 patients with HIV co-infection: Is the patient serum HCV RNA negative at 12 weeks?

YES

NO

Patient may be eligible for additional 34 weeks of coverage (total 48 wks) Has the patient achieved a reduction of viral load by at least 2 logs (100 fold)?

YES

NO

The patient may be eligible for an additional 14 weeks of therapy to confirm response. Additional serum HCV RNA test results are required at 24 weeks

Request for treatment extension at 26 weeks: For Genotype 1, 2 or 3 post-liver transplant patients and for patients from the above section that achieved a 2-log drop but were not serum HCV negative at 12 weeks: Is the patient serum HCV RNA negative at 24 weeks?

YES NO The patient may be eligible for a total of 48 weeks of therapy. PREVIOUS THERAPY: Consideration may be given in patients who have previously received therapy who meet at least one of the following criteria: Advanced fibrosis or cirrhosis. Patient relapsed following non-pegylated interferon/ribavirin combination therapy. Patient failed to respond to or relapsed following interferon monotherapy Additional information relating to request:

PRESCRIBER 'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas



The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE JUYL 1, 2012 Section 1A • 19

Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form

On the reverse is the official Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944).

• All requests for peginterferon alfa-2a for Chronic Hepatitis C must be submitted using the Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form only.




PEGINTERFERON ALFA-2A for Chronic Hepatitis C SPECIAL AUTHORIZATION REQUEST FORM







NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Pegasys drug benefits. Information from your prescriber is required to determine eligibility. Your consent is required: (A) for your prescriber to release necessary and relevant information to Alberta Blue Cross, Alberta Health and Wellness and, if requested, to Alberta Human Services and Alberta Seniors; and (B) for Alberta Blue Cross to release that and related usage information to Alberta Health and Wellness.

I hereby authorize: (A) my prescriber to release to Alberta Blue Cross, Alberta Health and Wellness, and (if they request it) to Alberta Human Services and Alberta Seniors (the aforesaid being the “designated recipients”); and (B) Alberta Blue Cross to release to Alberta Health and Wellness the information on this form and information relating to my usage of and experience with the drug and treatment results, and I consent to the designated recipients collecting such information.

Date Patient’s Signature


CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



DIAGNOSIS OF CHRONIC HEPATITIS C: EVIDENCE OF ACTIVE LIVER DISEASE: Both: a) is the patient anti-HCV positive,

pre-treatment…......................…………… AND; b) is the patient serum HCV RNA positive (by PCR),

pre-treatment…........................

YES NO Not Tested

Either: a) does the patient have elevated liver enzymes

(ALT and/or AST), pre-treatment…….……………

OR; b) does the patient have an abnormal liver biopsy

(inflammation and/or fibrosis)...……………………

YES NO Not Tested

If the patient is anti-HCV negative but serum HCV RNA positive, please explain:

If patient is currently on peginterferon alfa-2a, indicate start date:

Year / Month / Day

INITIAL REQUEST: EXTENSION REQUEST:

Is the patient intolerant to ribavirin? YES NO Request for treatment extension at 14 weeks (excluding patients with advanced fibrosis and cirrhosis):

Is the patient serum HCV RNA negative at 12 weeks?

YES → Patient may be eligible for additional 34 weeks of coverage (total 48 wks)

NO → Has the patient achieved a reduction of viral load by at least 2 logs (100 fold)?

YES → Patient may be eligible for additional 34 weeks of coverage (total 48 wks)

NO

Is a baseline serum sample stored for future testing? YES NO

Initial length of approval: Advanced fibrosis or cirrhosis (regardless of genotype)…… 48 weeks

Genotype 1…………..…………………………………….………. 14 weeks

Genotype 2 or 3 …………………………..…………………….… 14 weeks

Genotype 4, 5 or 6 .………………………………………………. 14 weeks

PREVIOUS THERAPY: Consideration may be given to patients who have previously received therapy and who meet at least one of the following:

Advanced fibrosis or cirrhosis. Patient relapsed following non-pegylated interferon/ribavirin combination therapy. Additional information relating to request:

PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services

10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas


The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30944 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.



Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form

On the reverse is the official Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form (ABC 30948).

• All requests for etanercept for Juvenile Idiopathic Rheumatoid Arthritis must be submitted using the Etanercept for Juvenile Idiopathic Rheumatoid Arthritis Special Authorization Request Form only.




ETANERCEPT for Juvenile Idiopathic Arthritis SPECIAL AUTHORIZATION REQUEST FORM







NOTIFICATION: PATIENT CONSENT: You may be eligible to receive Enbrel drug benefits. Personal and health information is required in order to determine eligibility and, in the event you are approved to receive drug benefits, to maintain eligibility, process payments and conduct the Alberta Post-Marketing Study Addressing ENBREL (“Study”). The Study will assist Alberta Health and Wellness to monitor, plan, evaluate and manage the cost-effectiveness of providing Enbrel as a benefit under the AHWDBL. Therefore, your consent is required as set out herein. Important: In order to be eligible for, and to maintain eligibility for Enbrel drug benefit both you and your physician(s) must agree to and continue to actively and consistently participate in the Study as required by Alberta Blue Cross, Alberta Health and Wellness, its affiliates and agents throughout the special authorization period. Refusal to provide the requested consent will result in benefits being denied, and withdrawal of consent will result in benefits being revoked.

I hereby authorize: (A)The below physician(s) to disclose to Alberta Blue Cross, Alberta Health and Wellness, Alberta Human Services, and Alberta Seniors (the "Designated Recipients") any of my personal or health information contained on this Request Form or requested by the Designated Recipients (collectively “My Information”); and (B) The Designated Recipients to use and collect My Information for the purposes stated on this form; and (C) The Designated Recipients to disclose My Information to any affiliates or agents of the Designated Recipients for the purposes stated on this form. I acknowledge that: I have been made aware of the reasons why my health information is needed, and the risks and benefits of consenting or refusing to consent to disclosure of my health information; and (2) I am aware that I may revoke this consent (in writing) at anytime. ___________________________________ ___________________________________ Signature Effective Date Patient or Guardian Signature: ___________________________________ Print Name of Guardian


CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Please provide the following information for ALL requests: Diagnosis:

Polyarticular Juvenile Idiopathic Arthritis

Other (specify)

Patient’s current weight (kg): _________ Requested dose (mg/kg): ___________

JRA30 Date of assessment:___________________________

1. Rheumatologist global 4. No. of joints assessment (0-10) ______________________ with LROM ______________

2. Patient global assessment (0-10) __________ 5. CHAQ (0-3) ______________

3. Number of active joints* __________________ 6. ESR (mm/hr) ________ or CRP ________

*joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both

Please provide the following information for ALL new requests: Previous DMARDs utilized (specify agent): Dose, duration and response is required: Additional information relating to request PRESCRIBER'S SIGNATURE DATE Please forward this request to:

Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: (780) 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

I am currently an active participant in the Alberta Post-Marketing Study addressing Enbrel ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.




Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form

On the reverse is the official Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).

• All requests for adalimumab, etanercept, golimumab or infliximab for Psoriatic Arthritis must be submitted using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form only.




ADALIMUMAB/ETANERCEPT/GOLIMUMAB/INFLIXIMAB for Psoriatic Arthritis








PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA

CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Please provide the following information for ALL requests:

Diagnosis: Polyarticular Psoriatic Arthritis Pauciarticular Psoriatic ArthritisJoints affected:

Knee joint(s) Hip joint(s) Other (specify): Other (specify):

Current weight (kg):

Indicate requested drug:

Dosage: Dosing Frequency: Adalimumab

Etanercept Golimumab Infliximab

Scores:*

DAS28 Score ___._____ OR ACR20 (renewals only) Date:______________

AND

HAQ Score ___.___ ___ Date: ______________



* New requests for patients currently maintained on the requested biologic require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.

Will the patient be maintained on methotrexate in combination with the requested biologic?

YES NO (If not, please specify reason):

Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required for ALL THREE of the following:

Methotrexate PO:

Methotrexate SC or IM:

DMARD other than MTX (specify agent):

Additional information relating to request (e.g. reasons why any of the above therapies were not tried):

PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





EFFECTIVE JULY 1, 2012 Section 1A • 25

Select Quinolones Special Authorization Request Form

On the reverse is the official Select Quinolones Special Authorization Request Form (ABC 30966). • All requests for ciprofloxacin, levofloxacin, moxifloxacin or ofloxacin must be submitted using

the Select Quinolones Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:



SELECT QUINOLONES* *ciprofloxacin/levofloxacin/moxifloxacin/ofloxacin

SPECIAL AUTHORIZATION REQUEST FORM Please complete all required sections to allow your request to be processed. Incomplete requests CANNOT BE EXPEDITED.







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Only the following conditions may be authorized for coverage. Drug Requested and Condition requiring quinolone treatment: Please check the boxes that apply to your patient.

CIPROFLOXACIN Respiratory Tract Infection: End stage COPD with or without bronchiectasis, where there has been

documentation of previous Pseudomonas aeruginosa colonization/infection Pneumonic illness in cystic fibrosis Genitourinary Tract Infection: Urinary Tract Infection Prostatitis Prophylaxis of urinary tract surgical procedures Gonococcal infection Skin & Soft Tissue / Bone & Joint Infection: Malignant / invasive otitis externa Bone / joint infection due to gram-negative organism(s) Therapy / step-down therapy of polymicrobial infection in combination with

clindamycin or metronidazole, e.g. diabetic foot infection, decubitus ulcers Gastrointestinal Tract Infection: Bacterial gastroenteritis where antimicrobial therapy is indicated Typhoid fever (enteric fever) Therapy / step-down therapy of polymicrobial infection in combination with

clindamycin or metronidazole, e.g. intra-abdominal infections Other: Prophylaxis of adult contacts of cases of invasive meningococcal disease Therapy / step-down therapy of hospital acquired gram-negative infections Empiric therapy of febrile neutropenia in combination with other appropriate

agents Exception case of allergy or intolerance to all other appropriate therapies

as defined by relevant guidelines/references, i.e. AMA CPGs or Bugs & Drugs

LEVOFLOXACIN MOXIFLOXACIN Community acquired pneumonia after failure of first line therapy,

as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy

Community acquired pneumonia in patients with co morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking)

Acute exacerbation of chronic bronchitis after failure of first and

Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with β–lactam (penicillin & cephalosporin) allergy

second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy

For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases.

OFLOXACIN Pelvic inflammatory disease Epididymo-orchitis/epididymitis most likely due to enteric

organisms For the treatment of Chlamydial infection For the treatment of Gonococcal infection For use in other current Health Canada approved indications

when prescribed by a specialist in Infectious Diseases

Please specify details: For use in other current Health Canada approved indications when

prescribed by a specialist in Infectious Diseases

PHYSICIAN'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5

FAX: 780-498-8384 in Edmonton 1-877-828-4106 toll-free all other areas

ONCE YOU HAVE CONFIRMED YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30966 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.

BACKGROUND INFORMATION REGARDING SELECT QUINOLONE SPECIAL AUTHORIZATION PROCESS

Optional Special Authorization introduced for quinolones At the request of Alberta Health and Wellness, Alberta Employment and Immigration, Alberta Seniors and Community Supports and Alberta Children and Youth Services, Alberta Blue Cross applied criteria effective September 15, 2005 for coverage of select quinolone antibiotics covered through their drug benefit programs:

• ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin. Norfloxacin continues to be eligible for coverage as an unrestricted benefit. Rationale These criteria are the result of a comprehensive evidence-based review undertaken as an initiative of the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics through the Review of Benefit Status (ROBS) process. This review examined systemic antimicrobial agents currently covered via the Alberta Health and Wellness Drug Benefit List. The mandate of the review was to encourage optimal utilization and to help prevent antimicrobial resistance. The review was conducted according to the established ROBS process, and included systematic reviews of the medical literature and analysis of current utilization patterns. External Alberta physicians and pharmacists with expertise in the treatment of infectious diseases provided advice and assistance for this review process. Information and experience from other provincial jurisdictions that have undertaken similar antimicrobial reviews were also taken into consideration in this review. The review was completed in accordance with pre-determined guiding principles that sought to allow optimal practice to proceed, ensuring optimal use and helping prevent resistance, while at the same time being unencumbered by undue paperwork and unnecessary restrictions.

Role of Physicians In conjunction with these new criteria, physicians have two options by which patients may be eligible for coverage of these specific antimicrobial products. This offers a streamlined alternative to traditional Special Authorization. 1) Physicians can register to be a designated prescriber. Registration allows for patients to receive coverage of quinolones

without Special Authorization as long as the prescription is written for one of the criteria for coverage set out in the Alberta Health and Wellness Drug Benefit List. These criteria are attached for your reference. Should a designated physician wish to prescribe one of the select quinolones outside the coverage criteria, they may do so but must indicate this on the prescription; however, patients will not be eligible for payment under the government-sponsored program for such prescriptions and the patient may choose to receive the product at their expense.

2) Physicians who choose not to register will be considered ‘non-designated prescribers’.

• Such physicians will be required to apply for Special Authorization on the patient’s behalf. • A patient’s claims for prescriptions written by non-designated physicians will be subject to a first fill forgiveness

rule. This means the first claim will be paid but subsequent claims for the same active ingredient (irrespective of strength, route and form) within a 90 day period will require Special Authorization.

• Special authorization requests must be submitted using the Select Quinolones Special Authorization Request Form. If the appropriate sections of this request form are completed and coverage criteria are met, the request will be processed within approximately 6 to 18 hours of receiving the request. Subsequent claims will be rejected unless Special Authorization is granted.

To register to become a designated prescriber

please return your completed registration by FAX to 1-877-305-9911. For more information, please contact

Clinical Drug Services, Alberta Blue Cross, at 780-498-8368.

® The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 30966 SA form and comm (R12/2011)



Section 1A • 28 EFFECTIVE JULY 1, 2012

Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form

On the reverse is the official Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon Nasal Spray for Osteoporosis Special Authorization Request Form (ABC 31086).

• All requests for alendronate, raloxifene, risedronate or synthetic calcitonin salmon for Osteoporosis must be submitted using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form only.




ALENDRONATE / RALOXIFENE / RISEDRONATE / SYNTHETIC CALCITONIN SALMON NASAL SPRAY FOR OSTEOPOROSIS








CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:




Indicate which drug is requested (check ONE box)*: Alendronate (10mg, 70mg, 70mg + 5600U vitamin D3) Raloxifene Risedronate Synthetic Calcitonin Salmon Nasal Spray *Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, denosumab, etidronate, raloxifene, risedronate) when intended for use as combination therapy. Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab. Please provide the following information for all NEW requests:

Diagnosis: For the treatment of Osteoporosis Osteopenia Bone pain secondary to: ______________________________ Other, please specify: __________________________

Has the patient experienced FRACTURES related to the diagnosis? NO YES

Information regarding previous etidronate use: Etidronate HAS been utilized.

Nature of response to etidronate: Lack of response (i.e. demonstrated as a > 2% loss in bone mineral density in one year) Intolerance Other (please specify):________________________________________________________

Etidronate has NOT been utilized: Contraindication. Please elaborate:____________________________________________________________________________ Other reason(s) etidronate was NOT tried (please specify):_________________________________________________________


RENEWAL This product is eligible for auto-renewal for the treatment of osteoporosis. A Special Authorization renewal request is required only if the Special Authorization approval for the treatment of osteoporosis has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy: PRESCRIBER'S SIGNATURE DATE Please forward this request to:

• Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas


ALENDRONATE / RALOXIFENE / RISEDRONATE / SYNTHETIC CALCITONIN SALMON NASAL SPRAY FOR OSTEOPOROSIS

SPECIAL AUTHORIZATION CRITERIA Patients may or may not meet eligibility requirements as established by

Alberta Government sponsored drug programs.

Criteria for Coverage:

ALENDRONATE** (10mg, 70mg, 70mg + 5600U vitamin D3 oral tablets) RALOXIFENE RISEDRONATE** Special Authorization Criteria for OSTEOPOROSIS “For the treatment of osteoporosis in patients who have documented hip, vertebral or other fractures. Special authorization for may be granted for 6 months.” “For the treatment of osteoporosis in patients with documented evidence of intolerance or lack of response to etidronate (i.e. demonstrated as a > 2 % loss in bone mineral density in one year). Special authorization may be granted for 6 months.” “Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy.” These products are eligible for auto-renewal for the treatment of osteoporosis.

**Please note: alendronate and risedronate also have Special Authorization criteria for Paget’s disease. Please refer to the Alberta Health and Wellness Drug Benefit List for alendronate and risedronate’s other criteria for the indication of Paget’s disease.

http://www.health.alberta.ca/AHCIP/drug-benefit-list.html

SYNTHETIC CALCITONIN SALMON Nasal Spray Special Authorization Criteria: "For the treatment of osteoporosis in patients with documented evidence of intolerance or lack of response to etidronate (i.e. demonstrated as a >2% loss in bone mineral density in one year). Special authorization may be granted for 6 months." "Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy." This product is eligible for auto-renewal.

ABC 31086 (R12/2011)




Celecoxib Special Authorization Request Form

On the reverse is the official Celebrex Special Authorization Request Form (ABC 31140).

• All requests for celecoxib must be submitted using the Celecoxib Special Authorization Request Form only.





CELECOXIB SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:

FAX: CITY, PROVINCE


Criteria for Coverage of CELECOXIB

For patients who are at high risk of upper gastrointestinal (GI) complications due to a proven history of prior complicated GI events (e.g. GI perforation, obstruction or major bleeding), OR

For patients who have a documented history of ulcers proven radiographically and/or endoscopically.

Special authorization may be granted for 6 months.

This product is eligible for auto-renewal.

NEW Please provide the following information for NEW requests (check ALL that apply):

1) Is this patient at high risk of upper GI complications? Yes No

2) Does this patient have a documented history of ulcers? Yes No



PRESCRIBER’S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FOR CELECOXIB REQUESTS ONLY: • FAX: 780-401-1150 in Edmonton •1-888-401-1150 toll-free all other areas


THIS SECTION IS FOR ALBERTA BLUE CROSS USE ONLY





Filgrastim/Pegfilgrastim Special Authorization Request Form

On the reverse is the official Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150)

• All requests for filgrastim or pegfilgrastim must be submitted using the Filgrastim/Pegfilgrastim Special Authorization Request Form only.





FILGRASTIM/PEGFILGRASTIM SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Indicate which drug is requested (check ONE box): FILGRASTIM (complete Section I or II) PEGFILGRASTIM (complete Section I only) Criteria for Coverage of FILGRASTIM Criteria for Coverage of PEGFILGRASTIM To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-neoplastic drugs with curative intent. This drug must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). For the reduction in the duration of neutropenia, fever, antibiotic use and hospitalization, following induction and consolidation treatment for acute myeloid leukemia. This drug must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). To increase neutrophil counts and to reduce the incidence and duration of infection in patients with a diagnosis of congenital, cyclic or idiopathic neutropenia. This drug must be prescribed by the Directors of Divisions of Hematology in tertiary care centres (or their designates). For the treatment of patients undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy when prescribed by a designated prescriber. Please note for the first criterion: Coverage cannot be considered for palliative patients.

To decrease the incidence of infection, as manifested by febrile neutropenia, in patients 18 years of age and older with non-myeloid malignancies receiving myelosuppressive anti-neoplastic drugs with curative intent. This drug product must be prescribed by Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates). Please note: Coverage cannot be considered for palliative patients.

Section I (Filgrastim requests for the first criterion and all pegfilgrastim requests, check ALL that apply)

Please SPECIFY the type of cancer being treated with chemotherapy for curative intent: _______________________________________ AND Please provide the indication for which the drug is requested:

patient has febrile neutropenia patient had febrile neutropenia from a previous cycle of the same chemotherapy patient will be undergoing a high dose or aggressive chemotherapy where febrile neutropenia is very likely to occur other, please SPECIFY: _______________________________________________________________________________________

Section II (Filgrastim requests for other criteria, check ALL that apply)

Please provide the indication for which filgrastim is requested: patient has neutropenia AND a diagnosis of congenital, cyclic or idiopathic neutropenia OR acute myeloid leukemia

other, please SPECIFY: _____________________________________________

patient is undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy

Additional information relating to request: PRESCRIBER'S SIGNATURE DATE Please forward this request to:

Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: (780) 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31150 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan




Fentanyl Special Authorization Request Form

On the reverse is the official Fentanyl Special Authorization Request Form (ABC 31169). • All requests for fentanyl or fentanyl citrate must be submitted using the Fentanyl Special

Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:




FENTANYL SPECIAL AUTHORIZATION REQUEST FORM


PATIENT INFORMATION COVERAGE TYPE PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross





CPSA CARNA ACP

ACO ADA+C Other



FAX:


CRITERIA FOR COVERAGE OF FENTANYL Fentanyl Injection For the treatment of persistent, severe chronic pain in those patients who cannot swallow, or who are intolerant of, morphine and/or hydromorphone, if not contraindicated. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.

Fentanyl Patch For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who cannot swallow. Special authorization may be granted for 6 months. For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who require opioid therapy at a total daily dose of at least 60 mg/day oral morphine equivalents. Patients must have tried and not been able to tolerate at least two discrete courses of therapy with two of the following agents: morphine, hydromorphone and oxycodone, if not contraindicated. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.

NEW Please provide the following for all new patients:

Product(s) requested: FENTANYL INJECTION FENTANYL PATCH

Nature of the patient’s pain: Persistent, severe chronic pain Other:

For FENTANYL PATCH requests: Patients must have tried at least two discrete courses* of therapy with two of the required agents: morphine, hydromorphone and oxycodone.

* A discrete course is defined as a separate treatment course, which may involve more than one agent, used at one time to manage the patient’s condition.

Treatment course 1: MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug): morphine

hydromorphone

oxycodone

other (specify)

Treatment course 2: MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug): morphine

hydromorphone

oxycodone

other (specify)

For FENTANYL INJECTION requests:

Previous MEDICATION used & RESPONSE to each drug (or CONTRAINDICATIONS to drug):

morphine

hydromorphone

If patient is unable to swallow, please provide information regarding specific reasons patient is unable take oral medications:


PRESCRIBER 'S SIGNATURE DATE Please forward this request to: • Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 • FAX: 780 498-8384 Edmonton • 1-877-828-4106 toll-free all other areas

ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31169 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.



EFFECTIVE JULYL 1, 2012 Section 1A • 37

Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form

On the reverse is the official Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).

• All requests for adalimumab, etanercept, infliximab or ustekinumab for Plaque Psoriasis must be submitted using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form only.



57BOnce your request has successfully transmitted, please do not mail or re-fax your request

ADALIMUMAB/ETANERCEPT/INFLIXIMAB/USTEKINUMAB for

Plaque Psoriasis SPECIAL AUTHORIZATION REQUEST FORM








CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:




Diagnosis:

Plaque Psoriasis

Other (specify): _______________________

Indicate requested drug: Adalimumab Etanercept Infliximab Ustekinumab

Current Weight (Kg):

Dosage:

Dosing Frequency:

Location: Significant involvement of face, palms of the hands, soles of the feet or genital region: YES NO

Scores:

PASI__________ Date__________________

DLQI__________ Date__________________

Please provide reason if a switch to a different biologic agent is requested: Note: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.

Please provide the following information for all NEW requests:

Previous medications/therapies utilized: Dose, duration and response is required for the following:

Methotrexate PO:

Methotrexate SC or IM:

Cyclosporine:

Phototherapy:

Additional information relating to request (e.g. reasons why any of the above therapies were not tried): PRESCRIBER’S SIGNATURE DATE Please forward this request to:

Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5

FAX: 780- 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form

On the reverse is the official Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).

• All requests for adalimumab, etanercept, golimumab or infliximab for Ankylosing Spondylitis must be submitted using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form only.



59BOnce your request has successfully transmitted, please do not mail or re-fax your request.

ADALIMUMAB/ETANERCEPT/GOLIMUMAB/INFLIXIMAB for Ankylosing Spondylitis








CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Please provide the following information for ALL requests: Diagnosis: Current

weight (kg): Indicate requested drug:

Adalimumab

Etanercept

Golimumab

Infliximab

Dosage: Dosing frequency:

Ankylosing Spondylitis (meeting modified NY criteria)

Other (please SPECIFY): ____________________________

Please provide the following information for all NEW requests: Previous medications utilized: Have two or more NSAIDs been tried for a minimum of 4 weeks each at maximum tolerated or recommended doses?

YES (please SPECIFY below) NO

Please SPECIFY the NSAID Please SPECIFY the dose, duration, and response

NSAID #1:

NSAID #2:

Other, please SPECIFY: Please provide the following information for all NEW* requests:

BASDAI #1 Date:

BASDAI #2: Date:

Spinal Pain VAS #1 (cm): Date:

Spinal Pain VAS #2 (cm): Date:

* New requests for patients currently maintained on the requested biologic require pre-treatment scores. Scores 1 and 2 for each parameter must be at least 8 weeks apart.

Please provide the following information for all RENEWAL requests:

BASDAI Date:

Spinal pain VAS (cm) Date:





Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form

On the reverse is the official Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form (ABC 31200).

• All requests for adalimumab for Moderately to Severely Active Crohn's Disease or infliximab for Moderately to Severely Active Crohn’s/Fistulizing Crohn’s Disease must be submitted using the Adalimumab for Crohn’s/Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form only.




-

ADALIMUMAB for Crohn’s / INFLIXIMAB for Crohn’s / Fistulizing Crohn’s Disease SPECIAL AUTHORIZATION REQUEST FORM






STREET ADDRESS CITY PROV POSTAL CODE ID/CLIENT/COVERAGE No:


CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:




Moderately to Severely Active Crohn’s Fistulizing Crohn’s

Indicate requested drug:

Adalimumab Dose:____________ Frequency:___________ Date of last dose:__________________

Infliximab Dose:____________ Frequency:___________ Date of last dose:__________________

Current weight (kg):___________ Other (specify) __________

For INITIAL request, please indicate if the drug is requested for NEW patient who has never been treated with the requested drug by any health care provider

EXISTING patient who is being treated, or have previously been treated with the requested drug

Please provide reason if a switch to a different biologic agent or change in dose is requested:


Infliximab For Fistulizing Crohn’s Disease: Adalimumab or Infliximab For Moderately to Severely Active Crohn’s Disease:

INITIAL request: Dose, duration and response is required for all medications previously utilized:

INITIAL request: Dose, duration and response is required for all medications previously utilized:

Azathioprine: Azathioprine:

6-mercaptopurine: 6-mercaptopurine: Antibiotics (specify the drug name): Methotrexate: NEW patient: Does the patient have actively draining perianal or enterocutaneous fistula(s) that have recurred or persisted despite previous therapy:

Yes No

Mesalamine: Glucocorticoid(s) (specify drug name): For ALL requests for Moderately to Severely Active Crohn’s Disease, please provide

Modified Harvey-Bradshaw Index score: _______________

Date of score: _______________

EXISTING patient: Please indicate response to treatment with infliximab:

Closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline.

Incomplete response (specify): Additional information relating to request (e.g. reasons why any of the above therapies were not tried): PRESCRIBER'S SIGNATURE DATE Please forward this request to:

Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





Rituximab for Rheumatoid Arthritis Special Authorization Request Form

On the reverse is the official Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205).

• All requests for rituximab for Rheumatoid Arthritis must be submitted using the Rituximab for Rheumatoid Arthritis Special Authorization Request Form only.




RITUXIMAB for Rheumatoid Arthritis








CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:

FAX: CITY, PROVINCE



Rheumatoid Arthritis Other (specify)

Dosage: Dosing Frequency:

Please provide reason if a switch from a different biologic agent to rituximab is requested: Date of last dose:

_________________________________


Scores:*

DAS28 Score __________

Date: __________________ AND HAQ Score ____________

Date: __________________

Requests for Re-treatment after 2 dose course Date of initial dose of the previous course of therapy:

_____________________ Response Scores 16-24 weeks after initial dose of previous course of therapy: DAS28 Score _______ Date: _____________ AND HAQ Score _________ Date: _____________ Current scores: DAS28 Score ________ Date: _____________ AND HAQ Score _________ Date: _____________

* New requests for patients currently maintained on the requested biologic also require pre-treatment scores. Scores must be provided to the correct number of decimal places. DAS28 should be reported to one decimal place and HAQ should be reported to two decimal places.

Will the patient be maintained on methotrexate in combination with rituximab? YES NO (If not, please specify reason):

Please provide the following information for all NEW requests: Previous medications/therapies utilized: Dose, duration and response is required for ALL FIVE of the following:

Methotrexate PO: Methotrexate SC or IM: Methotrexate with another DMARD other than leflunomide (specify agent) Leflunomide: Anti-TNF therapy:


PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





Imiquimod Special Authorization Request Form

On the reverse is the official Imiquimod Special Authorization Request Form (ABC 31222). • All requests for imiquimod must be submitted using the Imiquimod Special Authorization

Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:




IMIQUIMOD SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Criteria for Coverage of IMIQUIMOD For the treatment of Actinic Keratosis located on the head and neck in patients who have failed treatment with cryotherapy (where appropriate) and 5-fluorouracil (5-FU). Special authorization may be granted for 6 months. This product is eligible for auto-renewal.


Diagnosis: Actinic Keratosis → Area affected:

Head or neck Other (specify): ______________________________________________________ Other (specify):

Previous medications/therapies utilized: Please indicate if the following medication/therapy have been tried and the response:

1) cryotherapy: Yes → Response:

Lack of response Intolerance Other (specify):__________________

No → Not appropriate Other (specify):___________________________________ AND

2) 5-fluorouracil (5-FU): Yes→ Response:

Lack of response Intolerance Other (specify):____________________ No (specify reason, if applicable): __________________________________________________

Additional information relating to request



ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST. The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31222 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.




Dutasteride/Finasteride Special Authorization Request Form

On the reverse is the official Dutasteride/Finasteride Special Authorization Request Form (ABC 31257). • All requests for dutasteride or finasteride must be submitted using the Dutasteride/Finasteride

Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:




DUTASTERIDE/FINASTERIDE SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Indicate which drug is requested (check one box): Dutasteride Finasteride

Criteria for Coverage of DUTASTERIDE / FINASTERIDE For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction. Special authorization may be granted for 6 months. This product is eligible for auto-renewal.

NEW Please provide the following information for NEW requests (Section 1, AND Section 2 or 3 must be completed):

Section 1: Diagnosis:

Benign Prostatic Hyperplasia Other (specify): ________________________________________

Section 2: Surgical Risk: Is the patient a poor surgical risk? → no yes If yes, please specify any underlying medical condition(s) or other circumstances by which this patient would be deemed a poor surgical risk:

Has this patient had surgical intervention (TURP) for this condition in the past? yes no

Section 3: Enlarged Prostate: Does this patient have enlarged prostate with moderate to severe symptoms suggestive of obstruction?

yes

no





The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5.

ABC 31257 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.




Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form

On the reverse is the official Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).

• All requests for paliperidone or risperidone prolonged release injection must be submitted using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form only.





PALIPERIDONE/RISPERIDONE PROLONGED RELEASE INJECTION SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:

FAX: CITY, PROVINCE


Indicate which drug is requested: Risperidone Prolonged Release Injection Paliperidone Prolonged Release Injection

NEW Please provide the following information for NEW requests:

Diagnosis: schizophrenia or related psychotic disorder other, please specify

Compliance Issues: Has this patient demonstrated a pattern of significant non-compliance with other dosage forms that is compromising or has compromised this patient’s therapeutic success?

Yes No If no, please elaborate:

Previous drug therapy (CHECK ALL THAT APPLY): In order to comply with criteria, check at least two of the following:

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

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

Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy









Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form

On the reverse is the official Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291).

• All requests for abatacept for Juvenile Idiopathic Arthritis must be submitted using the Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form only.




ABATACEPT for Juvenile Idiopathic Arthritis








CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:




Polyarticular Juvenile Idiopathic Arthritis Other (specify)

Current weight (kg): Dosage: Dosing Frequency:

Current JRA30 FLARE score (provide for ALL requests) JRA30 RESPONSE score at 16 to 20 weeks after first dose of previous abatacept treatment (provide for RETREATMENT requests)

Date of assessment:___________________________ 1. Rheumatologist global 4. No. of joints

assessment (0-10) ___________ with LROM ___________

2. Patient global 5. CHAQ (0-3) ___________

assessment (0-10) ___________

3. No. of active joints* ___________ 6. ESR (mm/hr) __________

or CRP ______________ *joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both.

Date of assessment:___________________________ 1. Rheumatologist global 4. No. of joints

assessment (0-10) ___________ with LROM ___________

2. Patient global 5. CHAQ (0-3) ___________

assessment (0-10) ___________

3. No. of active joints* ___________ 6. ESR (mm/hr) __________

or CRP ______________ *joints with swelling not due to deformity or joints with limitation of motion with pain, tenderness or both.

Please provide the following information for all NEW requests: Previous medications utilized: Dose, duration and response is required:

DMARD(s) (specify agents):

Etanercept:

Other (specify agent) :


PRESCRIBER'S SIGNATURE DATE Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5 FAX: 780 498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas





63BMontelukast/Zafirlukast Special Authorization Request Form

On the reverse is the official Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313). • All requests for montelukast or zafirlukast must be submitted using the

Montelukast/Zafirlukast Special Authorization Request Form only. • Photocopy this form and use as required. • Submit completed forms by FAX to Alberta Blue Cross:




MONTELUKAST/ZAFIRLUKAST SPECIAL AUTHORIZATION REQUEST FORM







CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Indicate which drug is requested (check one box): Montelukast (5mg + 10mg) Zafirlukast (20mg)

Criteria for Coverage of MONTELUKAST / ZAFIRLUKAST For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria: a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, OR b) cannot operate inhaler devices.

For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists.

Special authorization for both criteria may be granted for 6 months. This product is eligible for auto-renewal. Note: Refer to the Alberta Health and Wellness Drug Benefit List for Restricted Benefit coverage of patients 2 to 18 years of age inclusive for Montelukast and 12 to 18 years of age inclusive for Zafirlukast.

NEW Please provide the following information for NEW requests (Section 1, AND Section 2 or 3 must be completed): Section 1: Indication:

Prophylaxis and chronic treatment of asthma (If yes, proceed to Section 2A or 2B only). Prophylaxis of exercise-induced bronchoconstriction (If yes, proceed to Section 3 only). Other (specify): ______________________________________________________________________________________________

Section 2: Prophylaxis and chronic treatment of asthma: A. Previous Medication Use: Is the patient maintained on inhaled glucocorticosteroids?

Yes No (If no, specify reason):_________________________________________________

Is the patient on a long-acting beta 2 agonist (e.g. salmeterol or formoterol)? Yes → Response: Persistent symptoms

Other (specify)_______________________________________________ No (If no, specify reason):________________________________________________________

B. Use of Inhaler Device Please indicate if the patient has difficulty using an inhaler device:

Yes (Please elaborate on the nature of the difficulty)____________ ______________________________

No

Section 3: Prophylaxis of exercise induced bronchoconstriction: Does this patient have tachyphylaxis with long-acting beta 2 agonists? Yes No Other (specify): ___________________________ Additional information relating to request:

RENEWAL: This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy:







63BFebuxostat Special Authorization Request Form

On the reverse is the official Febuxostat Special Authorization Request Form (ABC 31376). • All requests for febuxostat must be submitted using the Febuxostat Special Authorization





FEBUXOSTAT SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Criteria for Coverage of FEBUXOSTAT For patients with symptomatic gout who have documented hypersensitivity OR severe intolerance to allopurinol, AND intolerance or lack of response to sulfinpyrazone AND probenecid. Special authorization may be granted for 6 months. This product is eligible for auto-renewal. Please note: Coverage cannot be considered for lack of response to allopurinol.


Diagnosis: Symptomatic gout Other (specify): _________________________________________________________________

Previous medications utilized: Information is required for ALL THREE of the following: 1) allopurinol has been utilized.

documented hypersensitivity severe intolerance Other (specify):_______________________________

allopurinol has NOT been utilized. Please specify reason, if applicable:_________________________________________

AND 2) sulfinpyrazone has been utilized :

Intolerance Lack of response Other (specify):__________________________________________ sulfinpyrazone has NOT been utilized. Please specify reason, if applicable:_____________________________________

AND 3) probenecid has been utilized :

Intolerance Lack of response Other (specify):__________________________________________ probenecid has NOT been utilized. Please specify reason, if applicable): _______________________________________


RENEWAL:This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy.







63BDenosumab Special Authorization Request Form

On the reverse is the official Denosumab Special Authorization Request Form (ABC 31377). • All requests for denosumab must be submitted using the Denosumab Special Authorization





DENOSUMAB SPECIAL AUTHORIZATION REQUEST FORM







CPSA CARNA ACP

ACO ADA+C Other

REGISTRATION NO.

STREET ADDRESS

PHONE:



Criteria for Coverage of DENOSUMAB For the treatment of postmenopausal osteoporosis in women for whom oral bisphosphonates are contraindicated due to hypersensitivity OR an endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia), AND Who have at least two of the following:

- Age of greater than or equal to 75 years - A prior fragility fracture - A bone mineral density (BMD) T-score of of less than or equal to -2.5

Special authorization may be granted for 12 months. Patients will be limited to receiving one dose of denosumab per prescription at their pharmacy. Coverage cannot be provided for two or more osteoporosis medications (alendronate, calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intended for use as combination therapy.

NEW Please provide the following information for NEW requests:

Diagnosis: Postmenopausal osteoporosis Other (specify): ________________________________________

Please indicate which of the following pertain to this patient (check ALL that apply): contraindication to oral bisphosphonates

If so, must specify nature of contraindication _____________________________________________________ endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia)

prior fragility fracture bone mineral density (BMD) T-Score of less than or equal to -2.5


RENEWAL: This product is eligible for auto-renewal. A Special Authorization renewal request is required only if the Special Authorization approval has lapsed (i.e. the patient has not made a claim for the drug product during the Approval Period). Please indicate response to therapy.








63B63BOmalizumab Special Authorization Request Form

On the reverse is the official Omalizumab Special Authorization Request Form (ABC 31406). • All requests for omalizumab must be submitted using the Omalizumab Special Authorization




OMALIZUMAB SPECIAL AUTHORIZATION REQUEST FORM

PATIENT INFORMATION Patients may or may not meet eligibility requirements as established

by Alberta Government sponsored drug programs. PATIENT SURNAME FIRST NAME INITIAL Alberta Blue Cross




SPECIALIST IN RESPIROLOGY OR CLINICAL IMMUNOLOGIST INFORMATION PRESCRIBER SURNAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION CPSA

CARNA ACP

ACO ADA+C Other


PHONE: FAX: CITY , PROVINCE



Confirmation of Severe Asthma Other (specify)

Date of Confirmation of Diagnosis : Current weight (kg):

Smoker Non-Smoker

Laboratory Data (For renewals only FEV1 is required) Scores (For renewals only AQLQ and one ACQ-5 are required) Total serum human immunoglobulin (IgE) Value (IU/ml)

Date Asthma Quality of Life Questionnaire (AQLQ – Juniper) Score

Date

Confirmation of IgE mediated allergy to a perennial allergen by clinical history and allergy skin testing

Date

ACQ-5

Score #1 Date

FEV1 Date Score #2 Date

Please provide the following information for NEW requests: Number of exacerbations of asthma within the previous 12 month period that resulted in: An Emergency Room visit / Hospitalization: Unscheduled physician visits resulting in oral corticosteroids: Please check one of the following :

One or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit within the previous year while on systemic corticosteroids: OR One or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit requiring documented use of systemic corticosteroids (oral corticosteroids initiated or increased for at least 3 days, or parenteral corticosteroids); OR Three or more severe exacerbations of asthma within the previous year, which required an unscheduled physician visit and resulted in courses (or chronic use >50% of the year) of systemic corticosteroids.

Previous medications utilized: Name of Medication, dose, duration and response is required for ALL of the following: High-dose inhaled corticosteroids :

Long-acting beta-2 agonists :

Oral corticosteroids :

Chronic use (>50% of the year) of oral corticosteroids? YES NO

Please provide the following information for all RENEWAL requests: Number of exacerbations of asthma within the previous 12 month period that resulted in: An Emergency Room visit / Hospitalization: Unscheduled physician visits resulting in oral corticosteroids: Please check ALL of the following that apply :

Patient demonstrated at least a 25% reduction in the number of exacerbations, which required oral corticosteroids from the 12 months prior to initiation of omalizumab that required systemic corticosteroids. For patients that were on chronic (>50% of the year) courses of oral corticosteroids use in the prior 12 months to initiation of omalizumab, tapering of oral corticosteroid use by at least 25% from baseline. A reduction in the number of exacerbations that have led to a hospital admission or emergency room visits, compared to the 12 months prior to the commencement of omalizumab.


Please forward this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5

FAX: 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas ONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST.

The information collected by this form is collected pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purpose of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 31406 (2011/12) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.




Eculizumab Special Authorization Request Form and Consent Form

On the reverse is the official Eculizumab Special Authorization Request Form (ABC 31386) and the official Eculizumab Consent Form (ABC 31408)

• All requests for eculizumab must be submitted using the Eculizumab Special Authorization Request Form and Eculizumab Consent Form.

• Photocopy these forms and use as required. • Submit completed forms by FAX to Alberta Blue Cross:



ECULIZUMAB SPECIAL AUTHORIZATION REQUEST FORM Patients may or may not meet eligibility requirements as established by Alberta Government sponsored drug programs.

PATIENT INFORMATION Page 1 of 4 Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day

Street Address City Province Postal Code

Identification/Client/Coverage No: Coverage

Type: Alberta Blue Cross Alberta Human Services


SPECIALIST IN HEMATOLOGY INFORMATION Surname First Name Middle Initial


Telephone Number Fax Number College of Physicians and Surgeons Registration No.

Date Form Completed Last Consult Date Specialist in Hematology Signature

INFORMATION REQUIRED

For INITIAL REQUESTS please complete the first 2 pages, and submit laboratory data and consent form as attachments. For SIX-MONTH RENEWALS please complete applicable sections of the first 3 pages, and submit laboratory data as an attachment. For ANNUAL RENEWALS please complete applicable sections of all 4 pages, and submit laboratory data as an attachment. Note: Additional pages may be attached as required. Please submit all required pages and attachments together. TREATMENT REQUESTED

Eculizumab (Soliris) Dosage and Frequency Requested

Check which situation applies and provide date requested.

New to Drug: Planned treatment start date (YY/MM/DD) New to Coverage (on drug already): Date treatment began (YY/MM/DD) Renewal

CONFIRMATION OF DIAGNOSIS (Complete on initial request) Yes No Date (YY/MM/DD) Lab result Does the patient have a PNH granulocyte clone size (by flow cytometry and/or FLAER test) equal to or greater than 10%?

Does the patient have a Lactate Dehydrogenase (LDH) level at least 1.5 times the upper limit of normal?

Please mail this request to: Alberta Blue Cross, Clinical Drug Services

10009-108 Street NW, Edmonton, Alberta T5J 3C5

Or fax to 780-401-1150 in Edmonton 1-888-401-1150 toll-free all other areas

Case Number


ECULIZUMAB CONSENT FORM


PATIENT INFORMATION Page 1 of 2 Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day



Type: Alberta Blue Cross Alberta Human Services


SPECIALIST IN HEMATOLOGY INFORMATION Surname First Name Middle Initial


Telephone Number Fax Number College of Physicians and Surgeons Registration No.

PATIENT CONSENT FOR SERVICE I have received a copy of the policy relating to Eculizumab in the current version of the Alberta Health and Wellness Drug Benefit List (AHWDBL), as updated from time to time (the Policy) and have read and understand the requirements of a patient receiving Alberta government sponsored funded treatment.

I agree to comply with the requirements for coverage as set out in the Policy, including (without limitation) the requirements for monitoring, review and data collection.

I understand and agree that I must continue to qualify for, and continue to be a member of, an Alberta government sponsored drug program to continue to be eligible for eculizumab coverage in accordance with the Policy.

I understand and agree that approval for initial and continued coverage is conditional upon meeting and continuing to meet the requirements of the Policy.

I understand that my consent must be and is ongoing and my failure to comply with the requirements as set out in the Policy may preclude me from continuing to be eligible for eculizumab coverage.

I understand that prior to potential discontinuance of eculizumab coverage, as outlined in the Policy, my Specialist in Hematology will receive notice of this in writing. I understand that my Specialist in Hematology has a responsibility to notify me, and to work with me to address the reason for potential withdrawal of eculizumab coverage.

I understand that therapy may be withdrawn at the request of the patient or the patient’s parent/guardian at any time. Notification of withdrawal from therapy must be made by the Specialist in Hematology or patient in writing. I understand there may be side effects from medication and I have discussed the risks and benefits of this treatment with my Specialist in Hematology.

I, either as the patient or as the patient’s parent/guardian (as appropriate), and on behalf of the patient’s heirs and my estate and any other person claiming through the patient, hereby release the Minister, the Minister’s delegate, the Minister’s agents and employees from any and all liability and all claims for any and all damages, injuries, loss and costs which may arise directly or indirectly in relation to or in connection with the Application and coverage, funding and use of eculizumbab for the patient pursuant to the Policy, including (without limitation) all claims relating to coverage, any changes in coverage, any restrictions or conditions of coverage, discontinuance of coverage, and the patient’s use of eculizumab. I agree and acknowledge that this release is binding on the patient, the patient’s heirs and estate, and any other person claiming through the patient against the Minister, the Minister’s agents and employees.

Name of Patient: ___________________________________________________

Signature of Patient (for patients > or equal to 18 years old): _________________________________ Date: ____________________

Name of Parent/Guardian (for patients <18 years old): _______________________________________________________________

Signature of Parent/Guardian (for patients <18 years old): ___________________________________ Date: ____________________


Section 2 Multiple Sclerosis (M

S) Drug C

overage

SECTION 2

Multiple Sclerosis (MS) Drug Coverage

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST MULTIPLE SCLEROSIS (MS) DRUG COVERAGE


MULTIPLE SCLEROSIS (MS) DRUG COVERAGE

Selected drug products used in the treatment of relapsing multiple sclerosis (MS) may be considered for coverage for patients covered under Alberta government-sponsored drug programs. For further information regarding eligibility for Alberta government-sponsored drug programs, refer to the Introduction section of the List.

In order to be eligible for Multiple Sclerosis (MS) Drug Coverage, an individual must:

have valid Alberta government-sponsored drug coverage; meet specific clinical criteria according to Multiple Sclerosis (MS) Drug Coverage program

requirements; have a Multiple Sclerosis (MS) Drug Coverage Application form(s) submitted on their behalf to Alberta

Blue Cross by any “MS Neurologist” identified by the Alberta Multiple Sclerosis (MS) Drug Review Panel, and

have their Application approved by the Review Panel.

64BClinical Criteria to be considered for Coverage

To be considered for coverage of Avonex, Betaseron/Extavia, Copaxone, and Rebif, patients must be assessed by an “MS Neurologist” and meet the following clinical criteria: have a diagnosis of clinically definite relapsing-remitting multiple sclerosis:

• have had at least two attacks/exacerbations of MS during the previous two years. (An attack 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. Attacks must be separated by a period of at least one month.)

• are ambulatory with or without aid (i.e. a cane or walker). OR to be considered for coverage of Betaseron/Extavia: have a diagnosis of secondary progressive multiple sclerosis with relapses:

• have had at least two attacks/exacerbations of MS during the previous two years. (An attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 72 hours in the absence of fever, not associated with withdrawal from steroids, and preceded by stability for at least one month. Attacks must be separated by a period of at least one month.)

• have an EDSS score of less than or equal to 5.5. To be considered for coverage of Tysabri, see the clinical criteria as listed in the Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program.

65BContraindications to Coverage

In addition to meeting the above clinical criteria, the patient must have none of the following contraindications:

Significant illness likely to alter compliance or substantially reduce life expectancy. Active, severe depression: in the absence of a depression waiver from a psychologist or psychiatrist.

The depression waiver must accompany the Multiple Sclerosis (MS) Drug Coverage Application form(s) for patients with active, severe depression.

Planned or current pregnancy, nursing women. Contraindications for Tysabri, refer to the clinical criteria as listed in the Drug Products Under Multiple

Sclerosis (MS) Drug Coverage Program.



66BAlberta Multiple Sclerosis (MS) Drug Review Panel

The Alberta Multiple Sclerosis (MS) Drug Review Panel is an external review panel composed of neurologists and other health professionals with expertise in MS, appointed by the Minister of Health and Wellness.

The Review Panel’s functions include:

making recommendations to Alberta Health and Wellness on Multiple Sclerosis (MS) Drug Coverage program requirements, including maintenance of the eligibility criteria;

identifying “MS Neurologists” for the purposes of this program, and; reviewing applications for Multiple Sclerosis (MS) Drug Coverage.

67BProcess for Multiple Sclerosis (MS) Drug Coverage

Participating “MS Neurologists” must complete a separate Multiple Sclerosis (MS) Drug Coverage Application form(s) for each patient. The completed application may be forwarded to Alberta Blue Cross by mail or by facsimile.

Alberta Blue Cross, in providing administrative support to the Review Panel, receives and screens each application for completeness, then forwards it to the Review Panel for assessment. Alberta Blue Cross responds to applicants on the Review Panel’s behalf. After an application is assessed by the Review Panel, Alberta Blue Cross notifies the “MS Neurologist” and the patient by letter of the Review Panel’s decision. If the patient is approved for Multiple Sclerosis (MS) Drug Coverage an MS Nurse (a nurse with extensive knowledge of MS and MS therapies) will provide the patient with education regarding: (i) potential benefits and limitations of therapy, (ii) side-effects, (iii) how drug administration will be taught, (iv) how the patient will be followed, (v) how the patient can access help or information, (vi) how the treatment will be reimbursed and the requirements for reimbursement, (vii) indications for treatment to possibly be discontinued, and (viii) what should be reported and to whom. The MS Nurse will also ensure that the prescribing neurologist is aware of the timelines for the necessary ongoing follow-up to ensure safe and appropriate ongoing use of therapies. A new Multiple Sclerosis (MS) Drug Coverage Application form(s) must be completed by an “MS Neurologist” to review coverage if the patient requires a different Multiple Sclerosis (MS) Drug and for renewal requests.

To be eligible for Multiple Sclerosis (MS) Drug Coverage, prescriptions must be written by an “MS Neurologist” identified by the Review Panel. Regular monitoring of patients during the first year of therapy is needed in order to ensure the appropriate treatment option and dose, and to minimize the potential for wastage. Therefore, prescription quantities are limited to a one-month supply for the first year of therapy. This also applies to drug changes and to patients new or transferring to this program. Once the patient has been stabilized on a MS drug (excluding Tysabri) and dosage for one year and received program renewal authorization, up to 100 days’ supply may be dispensed at a time.

Government will not be responsible for reimbursement of costs associated with wastage or improper storage of the drug.

Prior approval must be granted to ensure coverage. Approval is granted for a specific period, to a maximum of 12 months unless otherwise indicated. If continued treatment is necessary, it is the responsibility of the patient and “MS Neurologist” to re-apply for drug coverage prior to the expiry date of the authorization period.



Completed Multiple Sclerosis (MS) Drug Coverage Application forms should be directed by mail or FAX to: Clinical Drug Services Alberta Blue Cross 10009 108 Street NW Edmonton, Alberta T5J 3C5


AVONEX/BETASERON/COPAXONE/EXTAVIA/REBIF/TYSABRI MS DRUG COVERAGE APPLICATION

Applicant must be covered on an Alberta Government sponsored drug program. Page 1 of 6

PATIENT INFORMATION Patient Surname First Name Middle Initial Sex Date of Birth Alberta Personal Health Number M / F Year Month Day



Type:

Alberta Blue Cross Alberta Human Services


MS NEUROLOGIST INFORMATION Surname First Name Middle Initial College of Physicians and Surgeons

Registration No.


Telephone Number Fax Number Last Consult Date

Date Form Completed MS Neurologist’s Signature

MS NURSE INFORMATION Surname First Name MS Nurse Signature Telephone Number Fax Number

TREATMENT REQUESTED (Check only one box and indicate dosage - complete for each request.)

Avonex/Avonex PS (interferon beta-1a)

Betaseron (interferon beta-1b)

Copaxone (glatiramer acetate)

Extavia (interferon beta-1b)

Rebif (interferon beta-1a)

Tysabri (natalizumab)

Planned Start Date Dosage and Frequency Requested

New to Program: start upon approval/bridging New to Program: on drug already Drug change Renewal

DIAGNOSIS (Check all that apply. McDonald1(Page 2) diagnostic criteria must be met. MRI reports must be enclosed to confirm MRI criteria are met.)

For Avonex/Avonex PS, Betaseron/Extavia, Copaxone, Rebif, Tysabri: Relapsing-remitting multiple sclerosis

For Betaseron/Extavia only:

Secondary progressive multiple sclerosis with relapses

Ambulatory with or without aid Ambulatory to 100 m without an aid (EDSS ≤ 5.5)

Have had at least two attacks/exacerbations of MS during the last two years, or in the two years prior to starting MS disease modifying therapy2(Page 2). A gadolinium enhancing MRI lesion at least 3 months before or after an attack may substitute for one attack.

APPLICATION INFORMATION REQUIRED: Avonex/Avonex PS, Betaseron/Extavia, Copaxone, and Rebif requests please complete section 1 only (Pages 1-3).

Tysabri (new to program) requests please complete sections 1 and 2 (Pages 1-5). Patients on Tysabri already, complete sections 1, 2, and 3 (Pages 1-6).

Tysabri (renewal) requests please complete sections 1 and 3 (Pages 1-3 and 6). Please mail this request to: Alberta Blue Cross, Clinical Drug Services 10009-108 Street NW, Edmonton, Alberta T5J 3C5

Or fax to: Alberta Blue Cross, Clinical Drug Services 780-498-8384 in Edmonton • 1-877-828-4106 toll-free all other areas

Case Number

Notice to Applicant: The information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sections 33 and 34 of the Freedom of Information and Protection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions regarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll-free at 1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 - 108 Street, Edmonton AB T5J 3C5. ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.


Section 1: Complete for ALL MS Drug applications Patient’s Alberta Personal

Health Number (only) Page 2 of 6

PREVIOUS MS DISEASE MODIFYING TREATMENT (Complete for each request.)

DRUG DATE STARTED DATE STOPPED REASON FOR DRUG STOPPAGE*

* Examples of reasons drug may be stopped: lack of efficacy, intolerability, non-compliance, pregnancy, financial reasons, interferon antibody positive

CONTRAINDICATIONS (Complete for each request.)

Yes No

1. Significant illness likely to alter compliance or substantially reduce life expectancy........................................................................... 2. Planned or current pregnancy, or nursing............................................................................................................................................ 3. a. Active, severe depression; or ……………………………………………………………………………………………………………..

b. Active, severe depression; waiver from a psychologist or psychiatrist attached3......................................................................... 4. Progression without relapse4...........................................................................................................................................................….

OTHER CLINICAL DATA (Complete for each request.)

Age: Gender: Male Female Date of onset: ___________/___________(Year/Month)5

Current Prescribed Medications:

Allergies:

Page 1 and 2: 1. McDonald Criteria (Ann Neurol 2001; 50:121-127) Summary: patients must meet one of the following conditions:

a) 2 attacks confirmed by objective findings and evidence of 2 clinically objective lesions. b) 2 attacks confirmed by objective findings, and 1 clinically objective lesion, and either dissemination in space by MRI as below or at least 2 MRI lesions

and CSF oligoclonal bands or increased IgG index. c) 1 attack confirmed by objective findings, and 2 clinically objective lesion sites, and dissemination in time by MRI. d) 1 attack confirmed by objective findings, and 1 clinically objective lesion, and dissemination in space by MRI [or 2 MRI lesions and + CSF] and

dissemination in time by MRI. Dissemination in space by MRI: (3 of 4 of the following): 1) 1 gd+ lesion or 9 T2 hyperintense lesions (cord or brain); 2) 1 infratentorial lesion; 3) 1 juxtacortical lesion; 4) 3 periventricular lesions Dissemination in time by MRI: Either 1) a gd+ lesion on an MRI at least 3 (or more) months after an attack, at a different site; or, 2) a new T2 lesion at least 3 months after scan that was completed at least 3 months after the initial documented attack, at a different site.

2. In RRMS an attack is defined as the appearance of new symptoms or worsening of old symptoms, lasting at least 48 hours in the absence of fever, and not associated with withdrawal from steroids. In SPMS it is more difficult to differentiate attacks from disease fluctuation; therefore, attacks must meet these criteria, must have lasted at least 72 hours, and new neurologic deficits must have been documented by a physician. Attacks must be separated by a period of at least one month.

3. Required prior to approval for all patients who have not been on treatment for at least 6 months. 4. Progression is worsening neurologic impairment not due to residual deficits from attacks. 5. Consider onset as the time of first convincing MS symptoms. This would include episodes such as transverse myelitis or optic neuritis, but not (in most

cases) non-specific symptoms such as dizziness, visual blurring or fatigue.

Case Number



Section 1: Complete for ALL MS Drug applications Patient’s Alberta Personal

Health Number (only) Page 3 of 6

QUALIFYING ATTACKS (Not required for renewals.)

TWO MOST RECENT ATTACKS:

Date of attack onset (or MRI):

MRI ATTACK EQUIVALENT

(Y/N)

SEVERITY6 RECOVERY FUNCTIONAL SYSTEMS INVOLVED OBJECTIVE CHANGES

(SPMS ONLY)

Year Month Day Yes No

Mild Moderate Severe Very Severe

None Incomplete Complete

Pyramidal Sensory Cerebellar Brain Stem Bowel/bladder Visual Cognitive/cerebral

Yes No

Year Month Day Yes No

Mild Moderate Severe Very Severe

None Incomplete Complete

Pyramidal Sensory Cerebellar Brain Stem Bowel/bladder Visual Cognitive/cerebral

Yes No

BASELINE AND FOLLOW-UP DATA (Complete for each request.)

PRE DRUG

YY/MM/DD

CURRENT if on drug

YY/MM/DD

YEAR 1

YY/MM/DD

YEAR 2

YY/MM/DD

YEAR 3

YY/MM/DD

YEAR 4

YY/MM/DD

Date7 (Year / Month / Day)

EDSS

Pyramidal

Cerebellar

Brain Stem

Visual Score

Sensory

Bowel/Bladder

Cognitive

# of attacks during 2 yrs prior to baseline assessment

# of attacks during the last 12 months

Relapse at time of assessment (Yes or No)

Progressive course (Yes or No)

Interferon antibodies (Yes, No, Not applicable, or Unknown)

6. Severity: Mild - symptoms present but no change in function; Moderate - requires modification or more time to carry out activity; Severe - unable to carry

out usual activity; Very Severe - requires others to provide personal care for them. 7. Date of examination must be 0-6 months preceding this request, or if already on drug, from the most recent annual assessment.

Case Number



Section 2: Complete for NEW Tysabri requests Patient’s Alberta Personal Health Number (only)

Page 4 of 6

ELIGIBILITY Yes No

Patient has previously been demonstrated to have at least nine T2 hyperintense lesions on brain MRI NEUTRALIZING ANTIBODIES, INTOLERANCE, OR REFRACTORY TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Patient has demonstrated one of the following: I. NEUTRALIZING ANTIBODIES to INTERFERON Yes No Clinically significant titres, report must be provided

OR II. INTOLERANCE TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Yes No 'Intolerance' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT. Describe the intolerance and response to management techniques tried in detail below (or attach letter):

OR

III. REFRACTORY TO INTERFERON BETA (Avonex, Betaseron/Extavia, or Rebif) Within a 12 month period on drug: Yes No

a. The patient reported adherence to the interferon beta at the standard dose defined as receiving 80% of prescribed dosing

EITHER b or c:

b. The patient experienced two relapses (neurologic deficits must have persisted for at least 3 months for one of the relapses; an exception may be considered where the second relapse is severe6(page 3) and the application is submitted within 3 months of the relapse onset):

Date of Onset YYYY/MM/DD Neurologic Deficits (describe) Persistence of Deficits:

Clinical Relapse 1 (>30 days from initiation of DMT)

Residual Deficits: Yes No If Yes, how long after onset were deficits detected (e.g., 3 months):

Clinical Relapse 2 (>30 days from relapse 1)

If applying within 3 months of onset, also describe severity of deficits: Residual Deficits: Yes No

If Yes, how long after onset were deficits detected (e.g., 3 months):

OR c. The patient experienced one relapse and one inflammatory event on MRI report (neurologic deficits must have persisted for at least 1 month for the relapse):


Clinical Relapse (>30 days from initiation of DMT)

Neurologic deficits on examination at least one month after relapse onset: Yes No

MRI (>90 days from clinical relapse; attach reports) A definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse; OR The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size. - To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have been completed at least one month after starting DMT. - To confirm that the MRI lesions were not associated with the relapse, the relapse can not have occurred between the 2 MRI scans. - To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.

Yes No

Case Number



Section 2: Complete for NEW Tysabri requests Patient’s Alberta Personal Health Number (only)

Page 5 of 6

INTOLERANCE OR REFRACTORY TO GLATIRAMER ACETATE (Copaxone) Patient has demonstrated one of the following:

I. INTOLERANCE TO GLATIRAMER ACETATE (Copaxone) Yes No 'Intolerance' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT. Describe the intolerance and response to management techniques tried in detail below (or attach letter):

OR

II. REFRACTORY TO GLATIRAMER ACETATE (Copaxone) Within a 12 month period on drug:

Yes No

a. The patient reported adherence to the glatiramer acetate at the standard dose defined as receiving 80% of prescribed dosing EITHER b or c:

b. The patient experienced two relapses (neurologic deficits must have persisted for at least 3 months for one of the relapses; an exception may be considered where the second relapse is severe6(page 3) and the application is submitted within 3 months of the relapse onset):


Clinical Relapse 1 (>30 days from initiation of DMT)

Residual Deficits: Yes No If Yes, how long after onset were deficits detected (e.g., 3 months):

Clinical Relapse 2 (>30 days from relapse 1)

If applying within 3 months of onset, also describe severity of deficits: Residual Deficits: Yes No

If Yes, how long after onset were deficits detected (e.g., 3 months):

OR c. The patient experienced one relapse and one inflammatory event on MRI report (neurologic deficits must have persisted for at least 1 month for the relapse):


Clinical Relapse (>30 days from initiation of DMT)

Neurologic deficits on examination at least one month after relapse onset: Yes No

MRI (>90 days from clinical relapse; attach reports) A definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse; OR The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size. - To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have been completed at least one month after starting DMT. - To confirm that the MRI lesions were not associated with the relapse, the relapse can not have occurred between the 2 MRI scans. - To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.

Yes No

CONTRAINDICATIONS (Does the patient have any of the following?): Yes No

1. Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)………………………………..

2. Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)…

3. History of progressive multifocal leukoencephalopathy (PML)…………………………………………………………………………………………..

4. Concurrent malignancy, or significant illness likely to alter compliance or substantially reduce life expectancy ………………………………….

5. Planned or current pregnancy, or nursing …………………………………………………………………………………………………………………

Case Number ABC 30771 (R12/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan


Section 3: Complete for Tysabri Renewals and patients Patient’s Alberta Personal Health Number (only)

Page 6 of 6 currently on Tysabri

Tysabri treatment start date (YYYY/MM/DD): ________________ Yes No

The patient has not missed any doses, or delayed any doses by more than 1 week with the exception of medically authorized delays (Rationale for such delays must be justified in a narrative; only serious medical conditions are acceptable)

The patient must be assessed by an MS Neurologist and have an MRI with gadolinium at least every 12 months (attach reports)

NEUTRALIZING ANTIBODIES TO TYSABRI (Complete for patients currently on Tysabri.)

There must be evidence that neutralizing antibodies to Tysabri are absent (attach report):

Are neutralizing antibodies absent at 6 to 8 months after initiation of therapy?

Yes If Yes: no further testing is required No If No: Are neutralizing antibodies absent on repeat testing? Yes No

RESPONSE TO TYSABRI (Complete for ALL patients on Tysabri, update for each request.)

On assessment, the MS Neurologist must confirm in writing that the patient is a 'responder': Yes No There has been no more than one inflammatory event in the last year (defined as either a clinical relapse or gadolinium enhancing lesion): If no, the patient had four or more relapses in the year prior to starting treatment, and there is at least a 50% reduction in relapse rate over the entire Tysabri treatment period.

PRIOR to Tysabri treatment: Indicate confirmed inflammatory events over the 2 years prior to initiation of treatment with Tysabri (include all independent clinical relapses and MRI events):

WHILE ON Tysabri treatment: Indicate all confirmed inflammatory events after initiation of treatment with Tysabri (include all independent clinical relapses and MRI events):

MRI Clinical relapse

Date of onset/MRI (YYYY/MM/DD)

No inflammatory events

MRI Clinical relapse

Date of onset/MRI (YYYY/MM/DD)

CONTRAINDICATIONS (Complete at every renewal. Does the patient have any of the following?): Yes No

1. Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)………………………………….

2. Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)…..

3. History of progressive multifocal leukoencephalopathy (PML)…………………………………………………………………………………………….

4. Concurrent malignancy, or significant illness likely to alter compliance or substantially reduce life expectancy ……………………………………

5. Planned or current pregnancy, or nursing …………………………………………………………………………………………………………………..

Case Number ABC 30771 (R02/2011) ®The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan.

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTMULTIPLE SCLEROSIS (MS) DRUG COVERAGE

GLATIRAMER ACETATE

INTERFERON BETA-1A

INTERFERON BETA-1B

20 MG / SYR INJECTION SYRINGE

6 MIU / VIAL INJECTION

44 MCG / ML INJECTION CARTRIDGE

88 MCG / ML INJECTION CARTRIDGE

6 MIU / SYR INJECTION SYRINGE

22 MCG / SYR INJECTION SYRINGE


9.6 MIU / VIAL INJECTION

00002245619

00002237770

00002318253

00002318261

00002269201

00002237319

00002237320

0000216964900002337819

COPAXONE

AVONEX (30 MCG)

REBIF (1.5 ML CARTRIDGE)

REBIF (1.5 ML CARTRIDGE)

AVONEX PS/PEN (30 MCG/0.5 ML)

REBIF (0.5 ML SYRINGE)

REBIF (0.5 ML SYRINGE)

BETASERON (0.3 MG)EXTAVIA (0.3 MG)

TMP

BIO

SRO

SRO

BIO

SRO

SRO

BHPNOV

43.2000

365.8568

240.9300

293.3061

381.0075

120.4650

146.6530

99.3593 99.3593

EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY

$

$

$

$

$

$

$

$$

The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis, and who participate in Alberta government-sponsored drug programs.

The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis, and who participate in Alberta government-sponsored drug programs.

The following drug products may be considered for coverage under the Multiple Sclerosis (MS) Drug Coverage program for patients who have a diagnosis of relapsing-remitting multiple sclerosis OR secondary progressive multiple sclerosis with relapses, and who participate in Alberta government-sponsored drug programs.

10Section 2 .

Drug Products Under Multiple Sclerosis (MS) Drug Coverage Program



PRODUCT IS NOT INTERCHANGEABLE

NATALIZUMAB

EFFECTIVE JULY 1, 2012

"Natalizumab coverage may be provided for the treatment of relapsing remitting multiple sclerosis (RRMS) to reduce the frequency of clinical exacerbations, to decrease the number andvolume of active brain lesions identified on magnetic resonance imaging (MRI) scans and to delay the progression of physical disability, in adult patients (18 years of age or older) who have active RRMS that is causing CNS injury, who have previously been demonstrated to have at least nine T2 hyperintense lesions on brain MRI, and who are refractory or intolerant to both interferon beta (Avonex, Betaseron/Extavia or Rebif) and glatiramer acetate (Copaxone). Patients who develop neutralizing antibodies to interferon will be considered to have failed interferon.

Neutralizing Antibodies to interferon

If neutralizing antibodies are present, a report indicating clinically significant titres must be provided.

Refractory

When the above agents are taken at the recommended doses 'Refractory' is defined as:Within a 12-month period the patient has:

1) Been adherent to the disease modifying therapy (DMT) (i.e., greater than 80% of approved doses have been administered);

AND

2a) Experienced at least two relapses confirmed by the presence of neurologic deficits on examination.- The first qualifying relapse must have begun at least one month after treatment initiation- There must be at least one month between the onset of relapses- Neurologic deficits must have persisted for at least 3 months for one of the relapses. Alternatively, information on a second qualifying relapse with severe deficits (defined as unable to carry out usual activities of daily living), submitted within 3 months of the date of onset, will beconsidered.

OR

2b) Experienced one relapse confirmed by the presence of neurologic deficits on examination.- This relapse must have begun at least one month after treatment initiation.- Neurologic deficits must have persisted for at least 1 month

AND

Have evidence of active inflammatory MS disease activity on brain or spine MRI that:- started/occurred during treatment with DMT, and- was not associated with a clinical relapse

MRI evidence may be:- a definite gadolinium enhancing T1 lesion (not questionable faint enhancement) that was present on an MRI obtained at least 3 months after initiation of DMT and not within 3 months of a relapse;OR- The appearance of 2 or more new, or newly enlarging, T2 hyperintense lesions, greater than 3 mm in size.- To confirm that these new T2 lesions occurred on treatment, the baseline MRI must have beencompleted at least one month after starting DMT.- To confirm that the MRI lesions were not associated with the relapse, the relapse cannot have occurred between the 2 MRI scans.- To confirm that the T2 lesions occurred during the 12 month qualifying period, both MRI scans and the relapse must occur within a 12 month period.

11Section 2 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


NATALIZUMAB

EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY

Documentation supporting this criterion requires a radiologist's report that directly compares 2 brain MRI scans and that indicates the MRI scan dates, and that clearly states that 2 or more new, or newly enlarging, T2 lesions at least 3 mm in size are present on the second scan.

Intolerant

'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in the product monograph, or a persisting adverse event that is unresponsive to recommended management techniques and which is incompatible with further use of that class of DMT.

Contraindications

Coverage will not be approved if any of the following contraindications exist:- Any evidence of disease progression independent of relapses (i.e., has developed secondary progressive MS)- Immune compromised due to immunosuppressant or antineoplastic therapy or due to immunodeficiency (HIV, leukemia, lymphoma, etc.)- History of progressive multifocal leukoencephalopathy (PML)- Concurrent malignancy or significant illness likely to alter compliance or substantially reduce life expectancy- Planned or current pregnancy, or nursing

Coverage

For coverage, this drug must be prescribed by a Specialist in Neurology ("MS Neurologist") who has been identified by the Alberta MS Drug Review Panel.

Initial Coverage

- Within the 2 years prior to the Tysabri application, the patient must meet the same relapse criteria that are required for other MS therapies considered for MS Drug Coverage (2 relapses during the last 2 years, one of which may be an MRI enhancing lesion). In most cases this will be satisfied by the treatment failure demonstrated but, if a patient failed interferon and glatirameracetate more than one year earlier, ongoing active disease must be confirmed. Exceptions may be made for patients switching due to recent development of intolerance or neutralizing antibodies.- Coverage will not be approved when any DMT or other immunosuppressive therapy is to be used in combination with Tysabri (except corticosteroids which can be used for up to 12 weeks during Tysabri initiation in patients with coexisting Crohn's Disease or similar situations).- Patients who have failed Tysabri will not be eligible for a subsequent trial of Tysabri (except in exceptional circumstances).

Following this assessment, coverage may be approved for 13 doses of 300 mg (i.e., one dose administered every 4 weeks for a period of 12 months). Patients will be limited to receiving 1 dose (4 weeks supply) of Tysabri per prescription at their pharmacy.

Continued Coverage

For continued coverage beyond 13 doses, the patient must meet the following criteria:

1) At the first renewal there must be evidence that neutralizing antibodies to Tysabri are absent. This requires an initial test between 6 to 8 months of treatment. If neutralizing antibodies are absent, no further testing is required. If neutralizing antibodies are present, testing must be repeated prior to the renewal request.

2) The patient must be assessed by an MS Neurologist and have an MRI with gadolinium at least every 12 months;




NATALIZUMAB

20 MG / ML INJECTION00002286386 TYSABRI BIO 166.2756

EFFECTIVE JULY 1, 2012

$

AND

3) On assessment, the MS Neurologist must confirm in writing that the patient is a 'responder' that meets all of the following criteria:- There has been no more than one inflammatory event in the last year (defined as either a clinical relapse or gadolinium enhancing lesion). The rare exception is a patient who has had four or more relapses in the year prior to starting treatment; in this case there must be at least a 50% reduction in relapse rate over the entire Tysabri treatment period.- The patient has not missed any doses, or delayed any doses by more than 1 week with the exception of medically authorized delays (rationale for such delays must be justified in a narrative; only serious medical conditions are acceptable).- None of the contraindications identified above exist.

Following this assessment, continued coverage may be approved for maintenance therapy of 300 mg every 4 weeks for a period of 12 months. Patients will be limited to receiving 1 dose of Tysabri per prescription at their pharmacy."


Section 3 Criteria for Special A

uthorization of Select Drug Products

SECTION 3

Criteria for Special Authorization

of Select Drug Products

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS


CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

The drug products listed in this section may be considered for coverage by special authorization for patients covered under Alberta Health and Wellness-sponsored drug programs. (For Alberta Human Services and Alberta Seniors (AISH) clients, the special authorization criteria for coverage can be found in the Criteria for Special Authorization of Select Drug Products section of the Alberta Human Services Drug Benefit Supplement.)

68BSpecial Authorization Policy

99BDRUG PRODUCTS ELIGIBLE FOR CONSIDERATION BY SPECIAL AUTHORIZATION Drug products may be considered for coverage by special authorization under one or more of the following circumstances, unless a specific product falls under the criteria for drug products Unot U eligible for consideration by special authorization. Please see the end of this section for information regarding drug products not eligible for consideration by special authorization. 1. The drug is covered by Alberta Health and Wellness under specified criteria (listed in the following

sections). Drug Products and indications other than those specified are not eligible for consideration by special authorization.

2. The drug is normally covered by another government program or agency for a specific approved clinical condition, but is needed for the treatment of a clinical condition that is not covered by that government program or agency.

3. The drug is required because other drug products listed in the Alberta Health and Wellness Drug Benefit List are contraindicated or inappropriate because of the clinical condition of the patient.

4. The particular brand of drug is considered essential in the care of a patient, where the LCA price policy would otherwise apply. Coverage of a specific brand may be considered where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with alternate brands in an interchangeable grouping. Coverage of a brand name product will UnotU be considered in situations where the interchangeable grouping includes a pseudo-generic to the brand name drug.

5. A particular drug product or dosage form of a drug is essential in the care of a patient where the MAC price policy would otherwise apply. Exceptions may occur at the product level. Coverage may be considered only where a patient has experienced significant allergic reactions or documented untoward therapeutic effects with the drug product which establishes the MAC pricing.

Prior approval must be granted by Alberta Blue Cross to ensure coverage by special authorization. For those special authorization requests that are approved, the effective date for authorization is the beginning of the month in which the physician’s request is received by Alberta Blue Cross.

Special authorization is granted for a defined period as indicated in each applicable special authorization drug product criteria (the “Approval Period”). If continued treatment is necessary beyond the Approval Period, it is the responsibility of the patient and physician to re-apply for coverage UpriorU to the expiration date of the Approved Period, UunlessU the Auto-Renewal Process or Step Therapy Approval Process apply (see below).



100BAUTO-RENEWAL PROCESS Selected drug products are eligible for the following auto-renewal process (for eligibility, see the Special Authorization criteria for each drug product).

1. For initial approval, a special authorization request must be submitted. If approval is granted, it will be effective for the Approval Period outlined in the drug product’s Special Authorization criteria

2. As long as the patient has submitted a claim for the drug product within the preceding Approval Period (example: within the preceding 6 months), approval will be automatically renewed for a further Approval Period (example: a further 6 months). There is no need for the prescriber to submit a new request as the automated real-time claims adjudication system will read the patient’s claims history to determine if a claim has been made within the preceding Approval Period.

3. If the patient does UnotU make a claim for the drug product during the Approval Period, the approval will lapse and a new special authorization request must be submitted.

101BSTEP THERAPY APPROVAL PROCESS

102BSelect drug products are eligible for coverage via the step therapy process, outlined below.

1. 103BIf the patient has made a claim for the First-Line* drug product(s) within the preceding 12 months, the claim for the step therapy drug will be approved.

2. 104BThe automated real-time claims adjudication system will read the patient’s claims history to determine if the required First-Line* drug product(s) have been claimed within the preceding 12 months.

3. 105BSubsequent claims for drug product(s) permitted by step therapy will continue to be approved as long as the drug product has been claimed within the preceding 12 months.

4. 106BThe regular special authorization approval process will continue to be available for step therapy approvals for those patients whose First-Line* drug claims cannot be adjudicated through the automated real-time claims adjudication system.

* A First-Line drug product includes any drug(s) or drug product(s) that, under the drug product’s Special Authorization criteria, are required to be utilized before reimbursement for the drug product is permitted.

107BDRUG PRODUCTS NOT ELIGIBLE FOR CONSIDERATION BY SPECIAL AUTHORIZATION

The following categories of drug products are not eligible for special authorization: 1. Drug products deleted from the List. 2. Drug products not yet reviewed by the Alberta Health and Wellness Expert Committee on Drug

Evaluation and Therapeutics. This applies to: * products where a complete submission has been received from the manufacturer and the product is

under review, * products where an incomplete submission has been received from the manufacturer, and * products where the manufacturer has not made a submission for review.

Drug products not yet reviewed may encompass new pharmaceutical products, new strengths of products already listed, reformulated products and new interchangeable (generic) products.

3. Drug products that have completed the review process and are not included on the List. 4. Most drugs available through Health Canada’s Special Access Program. 5. Drug products when prescribed for cosmetic indications. 6. Nonprescription or over-the-counter drug products are generally not eligible.



69BCriteria for Coverage

Wording that appears within quotation marks (“ ”) in this section is the official special authorization criteria, as recommended by the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics, and approved by the Minister of Health and Wellness. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.

Products Available Through Health Canada’s Special Access Program

PEMOLINE “For the treatment of attention deficit hyperactivity disorder where approval has been provided by Health Canada’s Special Access Program.”

37.5 MG ORAL TABLET DIN N/A* CYLERT ABB

75 MG ORAL TABLET DIN N/A* CYLERT ABB

*As Cylert has been withdrawn from market, the DINs are no longer valid. Where authorizations for Cylert have been granted, coverage for this product will be provided under PIN 00000999917.

Other Products

The remaining drug products in this section are listed alphabetically according to the generic ingredient name of the drug. These products can be found on the following pages.

CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST

ABATACEPT

4 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY Section 3 .

Rheumatoid Arthritis:

"Special authorization coverage may be provided for use in combination with methotrexate or other DMARDS, for the reduction in signs and symptoms of severely active Rheumatoid Arthritis(RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).

'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in product monographs.

For coverage, this drug must be initiated by a Specialist in Rheumatology ("RA Specialist").

- Initial coverage may be approved for five doses of up to 1000 mg/dose administered at 0, 2, 4, 8 and 12 weeks.-Patients will be limited to receiving one dose of abatacept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond five doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial five doses to determine response between 12 and 16 weeks of receiving the initial dose.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for one dose of up to 1000 mgevery 4 weeks for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- confirmation of maintenance of ACR20, OR- maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."




ABATACEPT

5 EFFECTIVE JULY 1, 2012 Section 3 .

All requests (including renewal requests) for abatacept for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).

Juvenile Idiopathic Arthritis:

"Special authorization coverage may be provided for the reduction in signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis (JIA) in patients 6 years of age and older who:- Have 5 or more active joints (defined by either swelling or limitation of motion plus pain and/or tenderness), AND- Are refractory to one or more disease modifying anti-rheumatic agents (DMARDS) conventionally used in children (minimum three month trial), AND- Are refractory to or intolerant to etanercept (minimum 12 week trial).

'Refractory' is defined as lack of effect at the recommended doses and duration of treatments aslisted above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications to treatments as defined in the product monographs.

For coverage, this drug must be prescribed by a prescriber affiliated with a Pediatric Rheumatology Clinic in Edmonton or Calgary ("Pediatric Rheumatology Specialist").

- Coverage may be approved for one dose of 10 mg/kg (maximum dose 1000 mg) at 0, 2, 4, 8, 12 and 16 weeks (total of six doses).- Patients will be limited to receiving one dose of abatacept per prescription at their pharmacy.

For potential coverage for retreatment with abatacept following a subsequent disease flare, the patient must meet the following criteria:1) The patient must be assessed by a Pediatric Rheumatology Specialist after the initial 16 weeks, but no longer than 20 weeks after, treatment with this biologic agent to determine and document initial treatment response.2) The Pediatric Rheumatology Specialist must confirm in writing that the patient is a responder that meets the following criteria (JRA30):- 30% improvement from baseline in at least three of the following six response variables, with worsening of 30% or more in no more than one of the six variables. The variables include: i. global assessment of the severity of the disease by the Pediatric Rheumatology Specialist, ii. global assessment of overall well-being by the patient or parent, iii. number of active joints (joints with swelling not due to deformity or joints with limitation of motion with pain tenderness or both), iv. number of joints with limitation of motion, v. functional ability based on CHAQ scores, vi. ESR or CRP3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported.

Following assessment and confirmation of initial treatment response, coverage for retreatment with abatacept may be approved for one dose of 10 mg/kg (maximum dose 1000 mg) at 0, 2*, 4,8, 12 and 16 weeks (total of up to six doses; *the week 2 dose on retreatment is optional, to be administered at the discretion of the Pediatric Rheumatology Specialist). In order to be considered for coverage for retreatment, the patient must meet the following criteria:1) The patient has been assessed by a Pediatric Rheumatology Specialist and the presence of disease flare confirmed. Disease flare is defined as worsening of at least 30% or greater in at least 3 of 6 JRA30 variables for JIA and 30% or greater improvement in no more than one variable.2) The Pediatric Rheumatology Specialist must confirm in writing that the patient has had an initial treatment response (as assessed above) and that the patient has experienced a disease flare (as defined above)."



ABATACEPT

250 MG / VIAL (BASE) INJECTION00002282097 ORENCIA BMS 460.9097

6 EFFECTIVE JULY 1, 2012UNIT OF ISSUE - REFER TO PRICE POLICY

$

Section 3 .

Please note: Coverage is provided for treatment of disease flares only. However, if a patient experiences a subsequent flare within 12 months of initiation of treatment with abatacept, they may be eligible for continuous coverage (i.e., one dose of 10 mg/kg (maximum dose 1000 mg) every 4 weeks) for a maximum period of two years, provided the patient has demonstrated a response to initial treatment."

All requests (including renewal requests) for abatacept for Juvenile Idiopathic Arthritis must be completed using the Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 31291).




ADALIMUMAB



"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial) [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily)

Special authorization coverage of this agent may be provided for use as monotherapy in adult patients for whom methotrexate is contraindicated and/or for those patients who have experienced serious adverse effects.


For coverage, this drug must be initiated by a Specialist in Rheumatology who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness or its agent, throughout the special authorization approval period ("RA Specialist"). The patient must also provide all consents and authorizations required to permit the RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the RA Specialist does not continually, actively and consistently participate in the Study.

- Initial coverage may be approved for five doses as follows: An initial 40 mg dose, followed by additional 40 mg doses at 2, 4, 6 and 8 weeks after the first dose.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond five doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial five doses to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for 40 mg every other week for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:



ADALIMUMAB


1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- confirmation of maintenance of ACR20, or - maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for adalimumab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).

Psoriatic Arthritis:

"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).




- Initial coverage may be approved for 40 mg administered every other week for 8 weeks.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after, to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:




ADALIMUMAB


- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for doses of 40 mg every other week, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests. It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for adalimumab for Psoriatic Arthritis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis SpecialAuthorization Request Form (ABC 30964).

Ankylosing Spondylitis:

"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:

- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.



- Initial coverage may be approved for 12 weeks as follows: An initial 40 mg dose, followed by additional 40 mg doses administered every two weeks for up to 12 weeks after the first dose.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.



ADALIMUMAB


For continued coverage beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed at 12 weeks by an RA Specialist after the initial 12 weeks of therapy to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.

Following this assessment, continued coverage may be approved for one 40 mg dose every other week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for adalimumab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).

Moderately to Severely Active Crohn's Disease:

"Special authorization coverage may be approved for coverage of adalimumab for the reduction in signs and symptoms and induction and maintenance of clinical remission of Moderately to Severely Active Crohn's Disease in patients who meet the following criteria:

- Adalimumab must be prescribed by a Specialist in Gastroenterology or a physician appropriately trained by the University of Alberta or the University of Calgary and recognized as a prescriber by Alberta Blue Cross for adalimumab for coverage for the treatment of Moderately to Severely Active Crohn's Disease patients ('Specialist').- Patients must be 18 years of age or older to be considered for coverage of adalimumab.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients may be allowed to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy (both primary loss of response and secondary loss of response) or due to serious adverse effects or contraindications. An adequatetrial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

Prior to initiation of adalimumab therapy for New Patients:

'New Patients' are patients who have never been treated with adalimumab by any health care provider.


Prior to initiation of adalimumab therapy, New Patients must have a current Modified (without the physical exam) Harvey Bradshaw Index score of greater than or equal to 7 (New Patient's Baseline Score), AND be Refractory.

Refractory is defined as one or more of the following:1) Serious adverse effects or reactions to the treatments specified below; OR 2) Contraindications (as defined in product monographs) to the treatments specified below; OR3) Previous documented lack of effect at doses and for duration of all treatments specified below: a) mesalamine: minimum of 3 grams/day for a minimum of 6 weeks; AND refractory to, or dependent on, glucocorticoids: following at least one tapering dosing schedule of 40 mg/day,




ADALIMUMAB


tapering by 5 mg each week to 20 mg, then tapering by 2.5 mg each week to zero, or similar.

[Note: Patients who have used the above treatments in combination will not be required to be challenged with individual treatments as monotherapy]

ANDb) Immunosuppressive therapy as follows: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 3 months; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 3 months; OR- Methotrexate: minimum or 15 mg/week for a minimum of 3 months.OR - Immunosuppressive therapy discontinued at less than 3 months due to serious adverse effectsor reactions.

Applications for coverage must include information regarding the dosages and duration of trial ofeach treatment the patient received, a description of any adverse effects, reactions, contraindications and/or lack of effect, as well as any other information requested by Alberta Blue Cross.

Coverage Criteria for Moderately to Severely Active Crohn's Disease

- New Patients must meet the criteria above prior to being considered for approval. - All approvals are also subject to the following applicable criteria.

Induction Dosing for New Patients:

- Coverage for Induction Dosing may only be approved for New Patients (those who have never been treated with adalimumab by any health care provider).- 'Induction Dosing' means a maximum of one 160 mg dose of adalimumab per New Patient at week 0 followed by an 80 mg dose at week 2.- New Patients are eligible to receive Induction Dosing only once, after which time the Maintenance Dosing for New Patients and Continued Coverage for Maintenance Dosing criteria will apply.- As an interim measure, 40 mg doses of adalimumab will be provided at weeks 4, 6, 8 and 10 toallow time to determine whether the New Patient meets coverage criteria for Maintenance Dosing below.

Maintenance Dosing:

'Maintenance Dosing' means one 40 mg dose of adalimumab per patient provided no more often than every other week starting at week 4 for a period of 12 months to:- New Patients following the completion of Induction Dosing; OR - Existing Patients, who are patients that are being treated, or have previously been treated, withadalimumab.

Maintenance Dosing for New Patients after Completion of Induction Dosing:

- The New Patient must be assessed by a Specialist within 12 weeks after the initiation of Induction Dosing to determine response by obtaining a Modified Harvey Bradshaw Index score for patients with Moderately to Severely Active Crohn's Disease; AND- The Specialist must confirm the Modified Harvey Bradshaw Index score shows a decrease from the New Patient's Baseline Score of greater than or equal to 3 points for patients with Moderately to Severely Active Crohn's.

Maintenance Dosing for Existing Patients:

- The patient must be assessed by a Specialist annually (within 2 months of the expiry of a patient's special authorization) at least 2 weeks after the day a dose of adalimumab was administered to the patient and prior to administration of the next dose to obtain: a Modified



ADALIMUMAB


Harvey Bradshaw Index Score (Existing Patient's Baseline Score) for Moderately to Severely Active Crohn's Disease; AND - these measures must be provided to Alberta Blue Cross for assessment for continued coverage for maintenance dosing.

Continued Coverage for Maintenance Dosing:

Continued coverage may be considered for one 40 mg dose of adalimumab per patient providedno more often than every other week for a period of 12 months, if the following criteria are met atthe end of each 12 month period:

- The New Patient or the Existing Patient must be assessed by a Specialist annually (within 2 months of the expiry of a patient's special authorization) at least 2 weeks after the day a dose of adalimumab was administered to the patient and prior to administration of the next dose to obtain: a Modified Harvey Bradshaw Index Score for Moderately to Severely Active Crohn's Disease; AND- For New Patients: The Specialist must confirm that the patient has maintained a greater than or equal to 3 point decrease from the New Patient's Baseline Score for Moderately to Severely Active Crohn's; OR- For Existing Patients: The Specialist must confirm that the patient has maintained the Existing Patient's Baseline Score."

All requests (including renewal requests) for adalimumab for Moderately to Severely Active Crohn's Disease must be completed using the Adalimumab for Crohn's/Infliximab for Crohn's/Fistulizing Crohn's Special Authorization Request Form (ABC 31200).

Plaque Psoriasis:

"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)

Patients who have a contraindication to either cyclosporine or methotrexate will be required to complete an adequate trial of the other pre-requisite medication prior to potential coverage beingconsidered.


For coverage, this drug must be prescribed by a Specialist in Dermatology ("Dermatology Specialist").

- Initial coverage may be approved for an initial dose of 80 mg, followed by one 40 mg dose every other week beginning one week after the first dose, for a total of nine doses.- Patients will be limited to receiving a one-month supply of adalimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate




ADALIMUMAB

40 MG / SYR INJECTION SYRINGE00002258595 HUMIRA ABB 729.4200

13 EFFECTIVE JULY 1, 2012

$

Section 3 .

trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond nine doses, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial nine doses to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.

Following this assessment, continued coverage may be considered for one 40 mg dose of adalimumab every other week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to becontinuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for adalimumab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).



ALENDRONATE SODIUM

10 MG ORAL TABLET

40 MG ORAL TABLET

70 MG ORAL TABLET

000022487280000228808700002247373

0000225810200002201038

00002352966000022997120000224873000002258110000022863350000228400600002275279000022881090000226171500002245329

APO-ALENDRONATESANDOZ ALENDRONATETEVA-ALENDRONATE

CO ALENDRONATEFOSAMAX

ALENDRONATEALENDRONATE-FCAPO-ALENDRONATECO ALENDRONATEMYLAN-ALENDRONATEPMS-ALENDRONATE-FCRATIO-ALENDRONATESANDOZ ALENDRONATETEVA-ALENDRONATEFOSAMAX

APXSDZTEV

COBMFC

SNSMELAPXCOBMYPPMSRPHSDZTEVMFC

0.6911 0.6911 0.6911

2.6097 4.0743

3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835 3.5835

10.2385


$$$

$$

$$$$$$$$$$

Section 3 .

"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization may be granted for 6 months."

"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year).Special authorization for this criteria may be granted for 6 months."

"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy."

"Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."

"For the treatment of Paget's disease. Special Authorization for this criteria may be granted to a maximum of 6 months."

All requests for alendronate sodium for Osteoporosis must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).

The following product(s) are eligible for auto-renewal for the treatment of osteoporosis.




ALENDRONATE SODIUM/ VITAMIN D3

ALFUZOSIN HCL

AMPICILLIN

70 MG * 5,600 UNIT ORAL TABLET

10 MG ORAL SUSTAINED-RELEASE TABLET

250 MG ORAL CAPSULE

500 MG ORAL CAPSULE

00002314940

00002315866000023142820000230467800002245565

00000020877

00000020885

FOSAVANCE

APO-ALFUZOSINNOVO-ALFUZOSIN PRSANDOZ ALFUZOSINXATRAL

NOVO-AMPICILLIN

NOVO-AMPICILLIN

MFC

APXTEVSDZSAV

TEV

TEV

4.5533

0.4966 0.4966 0.4966 1.0251

0.3657

0.7091


$

$$$$

$

$

Section 3 .

"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures."

"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a > 2% loss in bone mineral density in one year)."

"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy.""Requests for other osteoporosis medications covered via special authorization will not be considered until 6 months after the last dose of denosumab."

"Special authorization for these criteria may be granted for 6 months."

All requests for alendronate sodium/vitamin D3 must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).

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

The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.

FIRST-LINE DRUG PRODUCT(S): DOXAZOSIN OR TERAZOSIN

"For the treatment of the symptoms of benign prostatic hyperplasia (BPH) in patients who are unresponsive to a six-week trial with a non-selective alpha-blocker (e.g., terazosin ) or in whom non-selective alpha-blockers are not tolerated or are contraindicated."

"Special authorization may be granted for 24 months"

"For the treatment of infections caused by susceptible Shigella and Salmonella."



ANAKINRA


"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) in whom other biologics are contraindicated or in patients whohave experienced serious adverse events while on other biologics and who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND - Leflunomide (minimum 10 week trial at 20 mg daily).




- Initial coverage may be approved for one 100 mg dose administered daily for 8 weeks.- Patients will be limited to receiving a one-month supply of anakinra per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks but no longer than 12 weeksafter treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for one 100 mg dose administered once daily for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;




ANAKINRA

AZITHROMYCIN

AZTREONAM


600 MG ORAL TABLET

75 MG / VIAL INHALATION POWDER FOR SOLUTION

00002245913

00002330911000022560880000226164200002231143

00002329840

KINERET

AZITHROMYCINCO AZITHROMYCINPMS-AZITHROMYCINZITHROMAX

CAYSTON

BVM

SNSCOBPMSPFI

GIL

47.9010

6.0000 6.0000 6.0000

12.0693

48.1564


$

$$$$

$

Section 3 .

2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for anakinra must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for RheumatoidArthritis Special Authorization Request Form (ABC 30902).

"For the prevention of disseminated Mycobacterium avium complex disease in patients with advanced HIV infection or other immunocompromised conditions.

Special authorization may be granted for 6 months."



FIRST-LINE DRUG PRODUCT(S): TOBRAMYCIN INHALATION SOLUTION

"For the treatment of chronic pulmonary Pseudomonas aeruginosa infections when used as cyclic treatment (28-day cycles) in patients 6 years of age and older with moderate to severe cystic fibrosis (CF) and deteriorating clinical condition despite treatment with inhaled tobramycin."

"Coverage will not be considered when inhaled tobramycin and inhaled aztreonam are intended for use in combination."

"Special authorization may be granted for 6 months."



BENZOYL PEROXIDE

BUDESONIDE

BUSERELIN ACETATE

CABERGOLINE

10 % TOPICAL (ALCOHOL) GEL

20 % TOPICAL (ALCOHOL) GEL

3 MG ORAL CONTROLLED-RELEASE CAPSULE

1 MG / ML (BASE) NASAL SOLUTION

1 MG / ML (BASE) INJECTION

6.3 MG (BASE) INJECTION IMPLANT

0.5 MG ORAL TABLET

00000263699

00000373036

00002229293

00002225158

00002225166

00002228955

0000230140700002242471

PANOXYL 10

PANOXYL 20

ENTOCORT

SUPREFACT INTRANASAL

SUPREFACT

SUPREFACT DEPOT

CO CABERGOLINEDOSTINEX

GSK

GSK

AZC

SAV

SAV

SAV

COBPAL

0.1462

0.1905

1.5860

7.8200

11.1436

756.8100

8.8550 13.6901


$

$

$

$

$

$

$$

Section 3 .

"For the treatment of severe acne as defined by scarring acne.



"For the treatment of inflammatory bowel disease (e.g. Crohn's, ulcerative colitis, ulcerative ileitis, etc.). This drug product must be prescribed by a specialist in Gastroenterology, Internal Medicine or Pediatrics (or by a specialist in General Surgery on a case-by-case basis, in geographic areas where access to these specialties is not available).



"When prescribed for non-cancer, non-cosmetic or non-fertility indications.


Information is required regarding the patient's diagnosis/indication for use of this medication.



FIRST-LINE DRUG PRODUCT(S): BROMOCRIPTINE

"For the treatment of hyperprolactinemia in patients who are intolerant to or who have failed bromocriptine. Special authorization may be granted for 24 months."




CASPOFUNGIN

CEFADROXIL

CELECOXIB

CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE

50 MG / VIAL INJECTION


500 MG ORAL CAPSULE

100 MG ORAL CAPSULE

200 MG ORAL CAPSULE

1 % (BASE) * 5 % TOPICAL GEL

00002244265

00002244266

0000224077400002235134

00002239941

00002239942

0000224847200002243158

CANCIDAS

CANCIDAS

APO-CEFADROXILNOVO-CEFADROXIL

CELEBREX

CELEBREX

BENZACLINCLINDOXYL

MFC

MFC

APXTEV

PFI

PFI

VCLGSK

222.0000

222.0000

0.8421 0.8421

0.6828

1.3659

0.8918 0.9064


$

$

$$

$

$

$$

Section 3 .

"For esophageal candidiasis in patients who are intolerant to fluconazole and itraconazole, or who have failed both agents as evidenced by significant clinical deterioration due to the fungal infection during a course of therapy or no resolution after a full course of therapy."

"For the treatment of skin and skin structure infections."

"1) For patients who are at high risk of upper gastrointestinal (GI) complications due to a proven history of prior complicated GI events (e.g. GI perforation, obstruction or major bleeding) or

2) For patients who have a documented history of ulcers proven radiographically and/or endoscopically.

Special authorization for both criteria may be granted for 6 months."

All requests for celecoxib must be completed using the Celecoxib Special Authorization RequestForm (ABC 31140).







CLOPIDOGREL BISULFATE

75 MG (BASE) ORAL TABLET00002252767000023030270000235153600002348004000023593160000229316100002238682

APO-CLOPIDOGRELCO CLOPIDOGRELMYLAN-CLOPIDOGRELPMS-CLOPIDOGRELSANDOZ CLOPIDOGRELTEVA-CLOPIDOGRELPLAVIX

APXCOBMYPPMSSDZTEVSAV

0.9279 0.9279 0.9279 0.9279 0.9279 0.9279 2.6512


$$$$$$$

Section 3 .

(Refer to 20:12.18 of the Alberta Health and Wellness Drug Benefit List for one month of coverage, following the first intravascular stent placement, when prescribed by a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery.)

"For the prevention of thrombosis, for one month, when prescribed following intravascular bare metal stent placement. Patients who have received one month of coverage via the Limited Restricted Benefit will not be eligible for additional coverage under this criterion." **

"For the prevention of thrombosis, for up to 12 months, when prescribed following intravascular drug eluting stent (DES) placement. Patients who have received one month of coverage via the Limited Restricted Benefit may be eligible for an additional 11 months of coverage (i.e., up to 12 months of coverage) following the submission of a special authorization request." **

"For the prevention of cerebrovascular (e.g. stroke, TIA) and non-cerebrovascular ischemic events in patients who have a contraindication to ASA. Special authorization for this criterion may be granted for 24 months."

"For use in patients who have experienced a non-cerebrovascular ischemic event while on ASA.Special authorization for this criterion may be granted for 24 months."

"For use in patients who have experienced a cerebrovascular ischemic event (e.g. stroke, TIA) while on dipyridamole/ASA (Aggrenox) or for whom dipyridamole/ASA (Aggrenox) is contraindicated. Special authorization for this criterion may be granted for 24 months."

"Coverage will not be considered when clopidogrel and dipyridamole/ASA are intended for use in combination."

** Special Authorization for post-stent coverage is required when the prescriber prescribing the medication is not a designated prescriber, for treatment after repeat stents, or for continued coverage of up to 12 months following intravascular drug eluting stent (DES) placement.

In order to comply with the first and second criteria, information is required regarding the date, type of stent, and stenting procedure. In order to comply with the third criterion, information is required as to why ASA cannot be used. In order to comply with the fourth criterion, information is required regarding the type of ischemic event experienced while on ASA. In order to comply with the fifth criterion, information is required regarding the type of ischemic event experienced while on dipyridamole/ASA (Aggrenox) and/or why dipyridamole/ASA (Aggrenox) cannot be used.

All requests for clopidogrel bisulfate must be completed using the Clopidogrel Special Authorization Request Form (ABC 30786).




CYCLOSPORINE

CYPROTERONE ACETATE

10 MG ORAL CAPSULE

25 MG ORAL CAPSULE

50 MG ORAL CAPSULE

100 MG ORAL CAPSULE

100 MG / ML ORAL SOLUTION

50 MG ORAL TABLET

100 MG / ML INJECTION

00002237671

0000224707300002150689

0000224707400002150662

0000224282100002150670

0000224432400002150697

0000070443100002245898

00000704423

NEORAL

SANDOZ CYCLOSPORINENEORAL



APO-CYCLOSPORINENEORAL

ANDROCURCYPROTERONE

ANDROCUR DEPOT

NOV

SDZNOV

SDZNOV

SDZNOV

APXNOV

PMSAAP

PMS

0.6238

1.3050 1.4500

2.5450 2.8270

5.0900 5.6560

3.7708 5.0276

1.4339 1.5141

26.8130


$

$$

$$

$$

$$

$$

$

Section 3 .

"For the treatment of severe psoriasis in those patients where other standard therapy has failed. This drug product must be prescribed by a specialist in Dermatology."

"For the treatment of severe rheumatoid arthritis in patients who are unable to tolerate or have failed an adequate trial of methotrexate. This drug product must be prescribed by a specialist in Rheumatology (or by a Specialist in Internal Medicine with an interest in Rheumatology on a case-by-case basis, in geographic areas where access to this specialty is not available)."

"For the treatment of steroid dependent and steroid resistant nephrotic syndrome. Consideration will be given where cyclosporine is used for the induction and maintenance of remissions or for the maintenance of steroid induced remissions. This drug product must be prescribed by a specialist in Pediatrics or Nephrology."

"Special authorization for all criteria may be granted for 6 months."


"When prescribed for non-cancer, non-cosmetic indications.






DABIGATRAN ETEXILATE

DANAPAROID SODIUM

110 MG ORAL CAPSULE

150 MG ORAL CAPSULE

1,250 UNIT / ML INJECTION

00002312441

00002358808

00002129043

PRADAX

PRADAX

ORGARAN

BOE

BOE

MFC

1.6000

1.6000

33.7083


$

$

$

Section 3 .


FIRST-LINE DRUG PRODUCT(S): WARFARIN

For at-risk patients (CHADS2 score of greater than or equal to 1) with non-valvular atrial fibrillation (AF) for the prevention of stroke and systemic embolism AND in whom:

a) Anticoagulation is inadequate (at least 35% of INR testing results outside the desired range) following a reasonable trial on warfarin (minimum two months of therapy); ORb) Anticoagulation with warfarin is contraindicated as per the product monograph or not possibledue to inability to regularly monitor via International Normalized Ratio (INR) testing (i.e. no access to INR testing services at a laboratory, clinic, pharmacy, and at home).

Patients with impaired renal function (creatinine clearance or estimated glomerular filtration rate less than 30mL/min) OR hemodynamically significant rheumatic valvular heart disease, especially mitral stenosis; OR prosthetic heart valves.should not receive dabigatran.

Patients 75 years of age and greater should have documented stable renal function (creatinine clearance or estimated glomerular filtration rate maintained for at least three months of 30-49 ml/min for 110mg twice daily dosing or greater than or equal to 50 ml/min for 150mg twice daily dosing).

Since renal impairment can increase bleeding risk, renal function should be regularly monitored. Other factors that increase bleeding risk should also be assessed and monitored (see Drug Product Monograph).

Patients starting the drug product should have ready access to appropriate medical services to manage a major bleeding event.

There is currently no data to support that the Drug Product provides adequate anticoagulation inpatients with rheumatic valvular disease or those with prosthetic heart valves, so Drug Product isnot recommended in these populations.

Special Authorization may be granted for 24 months.

"For the treatment of patients with heparin-induced thrombocytopenia."




DARBEPOETIN

DARIFENACIN HYDROBROMIDE



100 MCG / ML INJECTION SYRINGE



7.5 MG (BASE) ORAL EXTENDED-RELEASE TABLET

15 MG (BASE) ORAL EXTENDED-RELEASE TABLET

00002246354

00002246355

00002246357

00002246358

00002246360

00002273217

00002273225

ARANESP (0.4 ML SYRINGE)

ARANESP (0.5 ML SYRINGE)

ARANESP (0.3/ 0.4/ 0.5 ML SYR)

ARANESP (0.3/ 0.4/ 0.5/ 0.65 ML SYR)

ARANESP (0.3/0.4/0.6/1.0 ML SYR)

ENABLEX

ENABLEX

AMG

AMG

AMG

AMG

AMG

NOV

NOV

26.8000

53.6000

268.0000

536.0000

1444.1900

1.5023

1.5023


For this product - pricing has been established on a per millilitre basis.



$

$

$

$

$

$

$

Section 3 .

"For the treatment of anemia of chronic renal failure in patients with low hemoglobin (<100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients' iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin > 100 mcg/L and transferrin saturation > 20%."

"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/Lper month, the dose of Aranesp should be reduced by about 25%."

In order to comply with the second criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrinsaturation, along with the results of liver function tests if applicable.

For the first criterion, renewal requests may be considered if the patient's hemoglobin is < 120 g/L while on Aranesp.

For the second criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Aranesp.

All requests for darbepoetin must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).


FIRST-LINE DRUG PRODUCT(S): OXYBUTYNIN

"For patients who are intolerant to oxybutynin.




DEFERASIROX

DENOSUMAB

125 MG ORAL DISPERSIBLE TABLET FOR SUSPENSION




00002287420

00002287439

00002287447

00002343541

EXJADE

EXJADE

EXJADE

PROLIA

NOV

NOV

NOV

AMG

10.1348

20.2696

40.5400

339.5700


$

$

$

$

Section 3 .


FIRST-LINE DRUG PRODUCT(S): DEFEROXAMINE

"For patients who require iron chelation therapy but who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of deferoxamine, or for whom deferoxamine is contraindicated.

Contraindications may include one or more of the following: known or suspected sensitivity to deferoxamine, recurrent injection or infusion-site reactions associated with deferoxamine administration (e.g., cellulitis), inability to obtain or maintain vascular access, severe needle phobia, concomitant bleeding disorders, immunocompromised patients with a risk of infection with parenteral administration, or risk of bleeding due to anticoagulation.

According to the product monograph, Exjade (deferasirox) is contraindicated in high risk myelodysplastic syndrome (MDS) patients, any other MDS patient with a life expectancy less than one year and patients with other hematological and nonhematological malignancies who are not expected to benefit from chelation therapy due to the rapid progression of their disease.


"For the treatment of postmenopausal osteoporosis in women for whom oral bisphosphonates arecontraindicated due to hypersensitivity OR an endoscopically or radiographically confirmed untreatable abnormality of the esophagus which delays esophageal emptying (e.g., stricture or achalasia), AND who have at least two of the following:- Age greater than or equal to 75 years- A prior fragility fracture- A bone mineral density (BMD) T-score of less than or equal to -2.5


Patients will be limited to receiving one dose of denosumab per prescription at their pharmacy.

Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use as combination therapy.

All requests for denosumab must be completed using the Denosumab Special Authorization Request Form (ABC 31377).





DONEPEZIL HCL

DUTASTERIDE

5 MG ORAL TABLET

10 MG ORAL TABLET

0.5 MG ORAL CAPSULE

00002232043

00002232044

00002247813

ARICEPT

ARICEPT

AVODART

PFI

PFI

GSK

4.8187

4.8187

1.6570


$

$

$

Section 3 .

"For the treatment of Alzheimer's disease in patients with an MMSE (Mini Mental State Exam) score between 10-26 and/or an InterRAI-Cognitive Performance Scale score between 1-4.

Coverage cannot be provided for two or more medications used in the treatment of Alzheimer's disease (donepezil, galantamine, rivastigmine) when these medications are intended for use in combination.

Special authorization coverage may be granted for a maximum of 24 months per request.

For each request, an updated MMSE score or InterRAI-Cognitive Performance Scale score and the date on which the exam was administered must be provided.

Renewal requests may be considered for patients where the updated MMSE score is 10 or higher or the InterRAI-Cognitive Performance Scale is 4 or lower while on this drug."

All requests (including renewal requests) for donepezil HCI must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).

"For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction.

Special authorization may be granted for 6 months"

Information is required regarding the medical condition(s) or circumstances by which this patient would be deemed a poor surgical risk.

All requests (including renewal requests) for dutasteride must be completed using the Dutasteride/Finasteride Special Authorization Request Form (ABC 31257).




ECULIZUMAB


ECULIZUMAB

1. ELIGIBILITY CRITERIA FOR ECULIZUMAB COVERAGE

In order to maintain the integrity of the AHWDBL, and having regard to the financial and social implications of covering eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria (PNH), the following special authorization criteria must be satisfied. In order to be eligible for eculizumab coverage for the treatment of PNH, a patient must have submitted a completed Application and have satisfied all of the following requirements:

The patient must:1) Be diagnosed with PNH in accordance with the requirements specified in the Clinical Criteria for eculizumab;2) Have Alberta government-sponsored drug coverage;3) Meet the Registration Requirements; 4) Satisfy the Clinical Criteria for eculizumab (initial or continued coverage, as appropriate); AND5) Meet the criteria specified in Contraindications to Coverage and Discontinuance of Coverage.

There is no guarantee that any application, whether for initial or continued coverage, will be approved. Depending on the circumstances of each case, the Minister or the Minister's delegate may:- approve an Application;- approve an Application with conditions;- deny an Application;- discontinue an approved Application; OR- defer an Application pending the provision of further supporting information.

The process for review and approval is explained in further detail below.

2. REGISTRATION REQUIREMENTS

If the patient is a citizen or permanent resident of Canada, the patient must be continuously registered in the Alberta Health Care Insurance Plan for a minimum of one (1) year prior to an application for coverage unless: - the patient is less than one (1) year of age at the date of the application, then the patient's parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of one (1) year; OR- the patient has moved to Alberta from another province or territory in Canada (the" province of origin"), and immediately prior to moving to Alberta, was covered for eculizumab in the province of origin by a provincial or territorial government sponsored drug plan, (or the province of origin provided equivalent coverage for eculizumab as does Alberta) and the patient has been registered in the Alberta Health Care Insurance Plan (the patient must provide supporting documentation from the province of origin to prove prior coverage). If the patient is not a citizen or permanent resident of Canada, the patient must be continuously registered in the Alberta Health Care Insurance Plan for a minimum of five (5) years prior to an application for coverage unless:- the patient is less than five years of age at the date of the application, then the patients parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of five years; OR- the patient has moved to Alberta from another province or territory in Canada (the "province of origin"), and immediately prior to moving to Alberta, was covered for eculizumab in the province of origin by a provincial or territorial government sponsored drug plan, (or the province of origin provided equivalent coverage for eculizumab as does Alberta) and the patient has been registered in the Alberta Health Care Insurance Plan (the patient must provide supporting documentation from the province of origin to prove prior coverage).




ECULIZUMAB


The Minister reserves the right to modify or waive the Registration Requirements applicable to a given patient if the patient or the patient's parent/guardian/legal representative can establish to the satisfaction of the Minister that the patient has not moved to Alberta for the sole/primary purpose of obtaining coverage of eculizumab.

3. CLINICAL CRITERIA

In addition to meeting Sections 1 and Sections 2 herein, to be considered for coverage of eculizumab, a patient must be assessed by a Specialist in Hematology (i.e. a physician who holds specialty certification in Hematology from the Royal College of Physicians and Surgeons of Canada) and meet all of the following clinical criteria (initial or continued coverage, as appropriate).

a. CLINICAL CRITERIA - INITIAL COVERAGEAll of the following Clinical Criteria must be established on the basis of evidence to the satisfaction of the Minister or the Minister's delegate for initial coverage:

1) The diagnosis of PNH must have been established by flow cytometry and/or a FLAER test. The proportion of circulating cells of each type which are GPI-deficient and hence of the PNH clone is quantitated by flow cytometry. Patients must have a: - PNH granulocyte clone size equal to or greater than 10%, AND - Raised LDH (value at least 1.5 times the upper limit of normal for the reporting laboratory).

2) Patients with a clone size equal to or greater than 10% also require AT LEAST ONE of the following:- Thrombosis: Evidence that the patient has had a thrombotic or embolic event which required the institution of therapeutic anticoagulant therapy;- Transfusions: Evidence that the patient has been transfused with at least four (4) units of red blood cells in the last twelve (12) months;- Anemia: Evidence that the patient has chronic or recurrent anemia where causes other than hemolysis have been excluded and demonstrated by more than one measure of less than or equal to 70g/L or by more than one measure of less than or equal to 100 g/L with concurrent symptoms of anemia;- Pulmonary insufficiency: Evidence that the patient has debilitating shortness of breath and/or chest pain resulting in limitation of normal activity (New York Heart Association Class III) and/or established diagnosis of pulmonary arterial hypertension, where causes other than PNH have been excluded;- Renal insufficiency: Evidence that the patient has a history of renal insufficiency, demonstratedby an eGFR less than or equal to 60mL/min/1.73m2, where causes other than PNH have been excluded; OR- Smooth muscle spasm: Evidence that the patient has recurrent episodes of severe pain requiring hospitalisation and/or narcotic analgesia, where causes other than PNH have been excluded.

AND

3) All patients must receive meningococcal vaccination with a quadravalent vaccine (A, C, Y andW135) at least two (2) weeks prior to receiving the first dose of eculizumab. All patients must bemonitored and revaccinated according to current medical guidelines for vaccine use. Treating physicians will be required to submit confirmation of meningococcal vaccination in order for their patients to continue to be eligible for treatment with eculizumab.

b. CLINICAL CRITERIA - CONTINUED COVERAGEAll of the following Clinical Criteria must be established on the basis of evidence to the satisfaction of the Minister or the Minister's delegate for continued coverage:1) Patient eligibility must be reviewed six (6) months after commencing therapy and every six (6)



ECULIZUMAB


months thereafter;

AND

2) Continued eligibility will be subject to the assessment of evidence, in accordance with the following monitoring requirements, which demonstrates:- Clinical improvement in the patient, OR- Stabilization of the patient's condition;

Monitoring requirements;

The patient's Specialist in Hematology must provide the following monitoring information every six (6) months:- Lactate dehydrogenase (LDH);- Full blood count and reticulocytes;- Transfusion history for previous six months;- Iron studies;- Urea, electrolytes and eGFR; - Recent clinical history; AND- Any other information requested by the Minister, the Minister's delegate, or an Expert Advisor.

The patient's Specialist in Hematology must provide the following monitoring information every twelve (12) months:- Confirmation that the patient has been vaccinated or revaccinated (meningococcal) according to current medical guidelines for vaccine use;- Progress reports on the clinical symptoms that formed the basis of initial eligibility;- Quality of life, through clinical narrative; - Granulocyte clone size (by flow cytometry): AND- Any other information requested by the Minister, the Minister's delegate, or an Expert Advisor.

c. CONTRAINDICATIONS TO COVERAGE

In addition to meeting all of the Initial Coverage Clinical Criteria or the Continued Coverage Clinical Criteria referred to above (as appropriate), the patient must not have any of the followingcontraindications:- Small granulocyte clone size - a granulocyte clone size below 10%; - Aplastic anaemia with two or more of the following: neutrophil count below 0.5 x 109/L, platelet count below 20 x 109/L, reticulocytes below 25 x 109/L, or severe bone marrow hypocellularity; - Patients with a presence of another life threatening or severe disease where the long term prognosis is unlikely to be influenced by therapy (for example acute myeloid leukaemia or high-risk myelodysplastic syndrome); OR- The presence of another medical condition that in the opinion of the Minister or Minister's delegate might reasonably be expected to compromise a response to therapy.

d. DISCONTINUANCE OF COVERAGE

Coverage may be discontinued where one or more of the following situations apply:- The patient or the patient's Specialist in Hematology fails to comply adequately with treatment or measures, including monitoring requirements, taken to evaluate the effectiveness of the therapy;- There is a failure to provide the Minister, the Minister's delegate, or an Expert Advisor with information as required or as requested;- If in the opinion of the Minister or the Minister's delegate, therapy fails to relieve the symptoms of disease that originally resulted in the patient being approved by the Minister or the Minister's delegate; - The patient has (or develops) a condition referred to in Contraindications to Coverage.




ECULIZUMAB


The patient's Specialist in Hematology will be advised if their patient is at risk of being withdrawnfrom treatment for failure to comply with the above requirements or other perceived "non-compliance" and given a reasonable period of time to respond prior to coverage being discontinued.

4. PROCESS FOR ECULIZUMAB COVERAGE

For both initial and continued coverage the following documents (the Application) must be completed and submitted:

- An Eculizumab Special Authorization Request Form completed by the patient's Specialist in Hematology;- An Eculizumab Consent Form completed by the patient, or a patient's parent/guardian/legal representative, and the patients Specialist in Hematology (for any initial coverage application); AND- Any other documentation that may be required by the Minister or the Minister's delegate.

a. EXPERT REVIEW

Once the Minister or the Minister's delegate has confirmed that the patient meets the Registration Requirement or granted a waiver of the Registration Requirement, the Application will be given to one or more Expert Advisors for review.

The Application, together with the recommendation or recommendations of the Expert Advisor(s), is then forwarded to the Minister or the Minister's delegate for a decision regarding coverage.

After the Minister or Minister's delegate has rendered a decision, the patient's Specialist in Hematology and the patient or patient's parent/guardian/legal representative will be notified by letter of the Minister's decision.

5. APPROVAL OF COVERAGEThe Minister or the Minister's delegate's decision in respect of an Application will specify the effective date of eculizumab coverage, if coverage is approved.

Initial coverage may be approved for a period of up to six (6) months as follows: One dose of 600mg of eculizumab administered weekly for the first four (4) weeks of treatment (total of four 600mg doses), followed by one dose of 900mg of eculizumab administered every two (2) weeks from week five (5) of treatment (total of eleven 900mg doses).

Continued coverage may be approved for up to one dose of 900mg of eculizumab administered every two (2) weeks, for a period of six (6) months (total of thirteen 900mg doses).

If a patient is approved for coverage, prescriptions for eculizumab must be written by a Specialist in Hematology. To avoid wastage, prescription quantities are limited to a one-month supply. Extended quantity and vacation supplies are not permitted. The Government is not responsible and will not pay for costs associated with wastage or improper storage of eculizumab.

Approval of coverage is granted for a specific period, to a maximum of six (6) months. If continued treatment is necessary, it is the responsibility of the patient or patient's parent/guardian/legal representative and the Specialist in Hematology to submit a new Application to re-apply for eculizumab coverage, and receive a decision thereon, prior to the expiry date of the authorization period.



ECULIZUMAB

EPOETIN ALFA


30,000 UNIT / SYR INJECTION SYRINGE


00002322285

00002288680

00002240722

SOLIRIS

EPREX

EPREX

API

JAI

JAI

6742.5000

420.9400

420.9400


$

$

$

Section 3 .

"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/L per month, the dose of Eprex should be reduced by about 25%. Patients may be granted a maximum allowable dose of 40,000 IU per week."

In order to comply with this criterion, if the patient has iron overload the prescriber must state this in the request, or alternatively, information is required regarding the patient's transferrin saturation, along with the results of liver function tests, if applicable.

Renewal requests may be considered if the patient's hemoglobin is <110 g/L while on Eprex."

All requests for epoetin alfa must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).

6. WITHDRAWAL

Therapy may be withdrawn at the request of the patient or the patient's parent/guardian/legal representative at any time. Notification of withdrawal from therapy must be made by the Specialist in Hematology or patient in writing.

Applications, withdrawal requests, and any other information to be provided must be sent to Clinical Drug Services, Alberta Blue Cross.




EPOETIN ALFA










00002231583

00002231584

00002231585

00002231586

00002243400

00002243401

00002243403

00002231587

00002243239

EPREX (0.5 ML SYRINGE)







EPREX (1 ML SYRINGE)


JAI

JAI

JAI

JAI

JAI

JAI

JAI

JAI

JAI

14.2500

28.5000

42.7500

57.0000

71.2500

85.5000

114.0000

142.5000

280.6200


$

$

$

$

$

$

$

$

$

Section 3 .

"For the treatment of anemia of chronic renal failure in patients with low hemoglobin (< 100 g/L). Hemoglobin levels should be maintained within 100 - 110 g/L. According to current practice guidelines patients' iron status should be monitored regularly, and wherever possible patients should be iron replete as demonstrated by serum ferritin > 100 mcg/L and transferrin saturation > 20%."

"For the treatment of anemia in AZT-treated/HIV infected patients."

"For the treatment of chemotherapy-induced anemia in patients with non-myeloid malignancies with low hemoglobin (<100 g/L) in whom blood transfusions are not possible due to transfusion reactions, cross-matching difficulties or iron overload. If hemoglobin is rising by more than 20 g/Lper month, the dose of Eprex should be reduced by about 25%."

In order to comply with the third criterion: if the patient has iron overload the prescriber must state this in the request or alternatively, information is required regarding the patient's transferrinsaturation, along with the results of liver function tests if applicable.

For the first criterion, renewal requests may be considered if the patient's hemoglobin is < 120 g/L while on Eprex.

For the third criterion, renewal requests may be considered if the patient's hemoglobin is < 110 g/L while on Eprex.

All requests for epoetin alfa must be completed using the Darbepoetin/Epoetin Special Authorization Request Form (ABC 30888).



ERTAPENEM

ERYTHROMYCIN/ TRETINOIN

1 G / VIAL INJECTION

4 % * 0.01 % TOPICAL GEL



00002247437

00002015994

00001905112

00001945262

INVANZ

STIEVAMYCIN MILD

STIEVAMYCIN REGULAR

STIEVAMYCIN FORTE

MFC

GSK

GSK

GSK

49.9500

0.8302

0.8302

0.8302


$

$

$

$

Section 3 .

"For therapy of complicated polymicrobial skin and skin structure infections."

"For the therapy of community-acquired intra-abdominal infections."

"For culture & susceptibility directed therapy against infections with Enterobacteriaceae producing AmpC or extended-spectrum beta-lactamases (ESBLs) where there is resistance to first line agents."

"For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."

In order to comply with all of the above criteria, information is required regarding the type of infection and organisms involved. Also, where the criteria restrict coverage of the requested drug to non-first line therapy, information is required regarding previous first-line antibiotic therapy that has been utilized, the patient's response to therapy, and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. Also, where applicable, the specialist in Infectious Diseases that recommended this drug is required.







ETANERCEPT



"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:

- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).




- Initial coverage may be approved for 50 mg per week for 8 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond 8 weeks, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for 50 mg per week, for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:



ETANERCEPT


1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for etanercept for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).

Juvenile Idiopathic Arthritis:

"Special authorization coverage may be provided for the reduction in signs and symptoms of severely active polyarticular juvenile idiopathic arthritis (JIA) in patients 4 years of age and older who:- Have 5 or more active joints (defined by either swelling or limitation of motion plus pain and/or tenderness), AND- Are refractory to one or more disease modifying anti-rheumatic agents (DMARDS) conventionally used in children (minimum three month trial).

"Refractory" is defined as one or more of the following: lack of effect, serious adverse effects (e.g., leukopenia, hepatitis) or contraindications to treatments as defined in the product monographs.

For coverage, this drug must be prescribed by a prescriber affiliated with a Pediatric Rheumatology Clinic in Edmonton or Calgary who agrees to and continues to actively and consistently participate in the Alberta Post-Marketing Study ("Study") as required by Alberta Health and Wellness and its agent, throughout the special authorization approval period (Pediatric RA Specialist). The patient or patient's guardian must also provide all consents and authorizations required to permit the Pediatric RA Specialist to actively and consistently participate in the Study. Special authorization approval for the patient may be revoked if the Pediatric RA Specialist does not continually, actively and consistently participate in the Study.

- Coverage may be approved for 0.8 mg/kg/dose (maximum dose 50 mg) weekly for 12 weeks.- Patients will be limited to receiving a one-month supply of Enbrel per prescription at their pharmacy.

For continued coverage of this agent beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed by a Pediatric RA Specialist after 12 weeks, but no longer than16 weeks after, treatment with this biologic agent to determine response.2) The Pediatric RA Specialist must confirm in writing that the patient is a responder that meets the following criteria (JRA30):- 30% improvement from baseline in at least three of the following six response variables, with worsening of 30% or more in no more than one of the six variables. The variables include: i. global assessment of the severity of the disease by the Pediatric RA Specialist, ii. global assessment of overall well-being by the patient or parent, iii. number of active joints (joints with swelling not due to deformity or joints with limitation of motion with pain tenderness or both), iv. number of joints with limitation of motion, v. functional ability based on CHAQ scores, vi. ESR or CRP




ETANERCEPT


3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported in each request

Following this assessment, continued coverage may be approved for 0.8 mg/kg/dose (maximumdose 50 mg) weekly, for a maximum of twelve months. After twelve months, in order to be considered for continued coverage, the patient must be re-assessed every twelve months by a Pediatric RA Specialist and must meet the following criteria:1) The patient has been assessed by a Pediatric RA Specialist to determine response, and2) The Pediatric RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by maintenance of the JRA30,3) Data from all of the six variables comprising the JRA30 and the CHAQ scores must be reported in each request.

Once a child with JIA has had two disease-free years, it is common clinical practice for drug treatment to be stopped."

All requests (including renewal requests) for etanercept for Juvenile Idiopathic Arthritis must be completed using the Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 30948).


"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).




- Initial coverage may be approved for 50 mg per week for 8 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy. - Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond 8 weeks, the patient must meet the following criteria: The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


ETANERCEPT


1) The patient must be assessed by an RA Specialist after 8 weeks, but no longer than 12 weeks after treatment to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria: - ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for 50 mg per week, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at theend of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for etanercept for Psoriatic Arthritis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).


"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:




- Initial coverage may be approved for 50 mg per week for 12 weeks.- Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.




ETANERCEPT


- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond 12 weeks, the patient must meet the following criteria:1) The patient must be assessed at week 12 by an RA Specialist after the initial twelve weeks oftherapy to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.

Following this assessment, continued coverage may be approved for 50 mg per week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for etanercept for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).

Plaque Psoriasis:

"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)




-Initial coverage may be approved for up to 100 mg per week for 12 weeks.-Patients will be limited to receiving a one-month supply of etanercept per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for



ETANERCEPT

EZETIMIBE



10 MG ORAL TABLET

00002242903

00002274728

00002247521

ENBREL

ENBREL

EZETROL

AMG

AMG

MFC

189.4150

378.9425

1.7927


Note: 1 x 50 mg syringe is interchangeable with 2 x 25 mg vials

$

$

$

Section 3 .

which it is being prescribed.

For continued coverage beyond 12 weeks, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial 12 weeks of therapy to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI

Following this assessment, continued coverage may be considered for 50 mg per week for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapyby meeting criteria as outlined in (2) above."

All requests (including renewal requests) for etanercept for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).

"For the treatment of hypercholesterolemia in patients who are intolerant to statins or in whom a statin is contraindicated and who are at high cardiovascular risk*; or

For the treatment of hypercholesterolemia when used in combination with a statin in patients failing to achieve target LDL with a statin at maximum tolerable dose or maximum recommendeddose as per respective product monograph and who are at high cardiovascular risk*:

* High cardiovascular risk is defined as possessing one of the following:1) Pre-existing cardiovascular disease and/or cerebrovascular disease, or2) Diabetes, or3) Familial hypercholesterolemia, or4) Greater than or equal to 20% risk as defined by the Framingham Risk Assessment Tool, or5) Three or more of the following risk factors:- Family history of premature cardiovascular disease- Smoking- Hypertension- Obesity- Glucose intolerance- Renal disease.

Special authorization for these criteria may be granted for 6 months."

All requests for ezetimibe must be completed using the Ezetimibe Special Authorization RequestForm (ABC 30925).





FEBUXOSTAT

FENTANYL

80 MG ORAL TABLET

12 MCG/HR TRANSDERMAL PATCH


00002357380

00002311925000023413790000233010500002327112

0000231463000002341387000023301130000228294100002327120

ULORIC

RATIO-FENTANYLPMS-FENTANYL MTXRAN-FENTANYL MATRIXSANDOZ FENTANYL PATCH

NOVO-FENTANYL 25PMS-FENTANYL MTXRAN-FENTANYL MATRIXRATIO-FENTANYLSANDOZ FENTANYL PATCH

TAK

RPHPMSRANSDZ

TEVPMSRANRPHSDZ

1.5900

2.2300 2.2320 2.2320 2.2320

3.7188 3.7188 3.7188 3.7188 3.7188


$

$$$$

$$$$$

Section 3 .

"For patients with symptomatic gout who have documented hypersensitivity OR severe intolerance to allopurinol, AND intolerance or lack of response to sulfinpyrazone AND probenecid.


Please note: Coverage cannot be considered for lack of response to allopurinol.

All requests for febuxostat must be completed using the Febuxostat Special Authorization Request Form (ABC 31376).


"For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who cannot swallow.Special authorization may be granted for 6 months."

"For the treatment of persistent, severe chronic pain in those patients who require continuous around-the-clock analgesia for an extended period of time in those patients who require opioid therapy at a total daily dose of at least 60 mg/day oral morphine equivalents. Patients must havetried and not been able to tolerate at least two discrete courses of therapy with two of the following agents: morphine, hydromorphone and oxycodone, if not contraindicated. Special authorization may be granted for 6 months."

Information is required regarding previous medications utilized and the patient's response to therapy. Also, information regarding the number of discrete (separate) courses of these medications is required. A discrete course is defined as a separate treatment course, which mayinvolve more than 1 agent, used at one time to manage the patient's condition.

All requests for fentanyl must be completed using the Fentanyl Special Authorization Request Form (ABC 31169).

(Please note: The following fentanyl products are benefits not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative Care Drug Coverage. Refer tothe Palliative Care Drug Benefit Supplement for additional information on this coverage.)




FENTANYL

FENTANYL CITRATE




0.05 MG / ML (BASE) INJECTION

0000231464900002341395000023301210000228296800002327147

0000231465700002341409000023301480000228297600002327155

0000231466500002341417000023301560000228298400002327163

00000888346




FENTANYL CITRATE

TEVPMSRANRPHSDZ

TEVPMSRANRPHSDZ

TEVPMSRANRPHSDZ

HSP

7.0000 7.0000 7.0000 7.0000 7.0000

9.8438 9.8438 9.8438 9.8438 9.8438

12.2500 12.2500 12.2500 12.2500 12.2500

1.7543


$$$$$

$$$$$

$$$$$

$

Section 3 .

"For the treatment of persistent, severe chronic pain in those patients who cannot swallow, or who are intolerant of, morphine and/or hydromorphone, if not contraindicated. Special authorization may be granted for 6 months."

Information is required regarding previous medications utilized and the patient's response to therapy. Information should include the use of agents such as morphine and/or hydromorphone, if not contraindicated for the patient.

All requests for fentanyl citrate must be completed using the Fentanyl Special Authorization Request Form (ABC 31169).

(Please note: The following fentanyl citrate product is a benefit not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative Care Drug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)





FILGRASTIM

FINASTERIDE

0.3 MG / ML INJECTION

5 MG ORAL TABLET

00001968017

0000236538300002354462000023550430000235722400002356058000023485000000231011200002371820000023069050000232257900002010909

NEUPOGEN

APO-FINASTERIDECO FINASTERIDEFINASTERIDEJAMP-FINASTERIDEMYLAN-FINASTERIDENOVO-FINASTERIDEPMS-FINASTERIDERAN-FINASTERIDERATIO-FINASTERIDESANDOZ FINASTERIDEPROSCAR

AMG

APXCOBAHIJPCMYPTEVPMSRANRPHSDZMFC

186.8181

0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 0.6714 1.9182


$

$$$$$$$$$$$

Section 3 .

"To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppresive anti-neoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."

"For the reduction in the duration of neutropenia, fever, antibiotic use and hospitalization following induction and consolidation treatment for acute myeloid leukemia. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."

"To increase neutrophil counts and to reduce the incidence and duration of infection in patients with a diagnosis of congenital, cyclic or idiopathic neutropenia. This drug product must be prescribed by the Directors of Divisions of Hematology in tertiary care centres (or their designates)."

"For the treatment of patients undergoing Peripheral Blood Progenitor Cell (PBPC) collection and therapy when prescribed by a designated prescriber."

All requests for filgrastim must be completed using the Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150).

Please note for the first criterion: Coverage cannot be considered for palliative patients.

"For the treatment of benign prostatic hyperplasia in patients who are poor surgical risks or who have enlarged prostates and have moderate to severe symptoms suggestive of obstruction.


Information is required regarding the medical condition(s) or circumstances by which this patient would be deemed a poor surgical risk.

All requests (including renewal requests) for finasteride must be completed using the Dutasteride/Finasteride Special Authorization Request Form (ABC 31257).




FLUCONAZOLE

FLUTAMIDE

GALANTAMINE HYDROBROMIDE

10 MG / ML ORAL SUSPENSION

250 MG ORAL TABLET

8 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE



00002024152

00002238560000022300890000223010400000637726

00002339439000023169430000237795000002266717

00002339447000023169510000237796900002266725

00002339455000023169780000237797700002266733

DIFLUCAN

APO-FLUTAMIDENOVO-FLUTAMIDEPMS-FLUTAMIDEEUFLEX

MYLAN-GALANTAMINE ERPAT-GALANTAMINE ERTEVA-GALANTAMINE ERREMINYL ER



PFI

APXTEVPMSMFC

MYPPATTEVJAI

MYPPATTEVJAI

MYPPATTEVJAI

0.9909

1.3530 1.3530 1.3530 1.3922

1.8906 1.8906 1.8906 5.0249

1.8906 1.8906 1.8906 5.0249

1.8906 1.8906 1.8906 5.0249


$

$$$$

$$$$

$$$$

$$$$

Section 3 .

"For susceptible infections in immunocompromised patients (e.g. patients with AIDS, cancer, or transplant patients)."

"When prescribed for non-cancer, non-cosmetic indications.









All requests (including renewal requests) for galantamine hydrobromide must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).




GOLIMUMAB



"Special authorization coverage may be provided for the reduction in the signs and symptoms ofseverely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:- a BASDAI greater than or equal to 4 units, demonstrated on 2 occasions at least 8 weeks apartAND- a Spinal Pain VAS of greater than or equal to 4 cm (on a 0-10 cm scale), demonstrated on 2 occasions at least 8 weeks apart AND- who are refractory or intolerant to treatment with 2 or more NSAIDS each taken for a minimum of 4 weeks at maximum tolerated or recommended doses.



- Initial coverage may be approved for 50 mg once per month for four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond four doses the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial four doses to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND- Reduction of the Spinal Pain VAS by 2 cm or more.

Following this assessment, continued coverage may be approved for 50 mg once per month for a further 12 month period. Should continued coverage criteria be met, coverage will only be granted for 12 doses per 12 month period. Ongoing coverage may be considered if the patient isre-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for golimumab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).


"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms of active arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriatic arthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if



GOLIMUMAB


patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).




- Initial coverage may be approved for 50 mg per month for four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond four doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after four doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for 50 mg per month, for a further 12 month period. Should coverage criteria be met, coverage will only be granted for 12 doses per 12-month period. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for golimumab for Psoriatic Arthritis must be completedusing the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).




GOLIMUMAB



"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily).




- Initial coverage may be approved for 50 mg per month for a total of four doses.- Patients will be limited to receiving one dose (50 mg) of golimumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond four doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after four doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for 50 mg per month, for a further 12 month period. Should continued coverage criteria be met, coverage will only be granted for 12 doses per 12 month period. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal



GOLIMUMAB

GOSERELIN ACETATE


3.6 MG / SYR (BASE) INJECTION SYRINGE

10.8 MG / SYR (BASE) INJECTION SYRINGE

0000232477600002324784

00002049325

00002225905

SIMPONISIMPONI

ZOLADEX

ZOLADEX LA

JAIJAI

AZC

AZC

1447.0000 1447.0000

390.5000

1113.0000


UNIT OF ISSUE - REFER TO PRICE POLICY

$$

$

$

Section 3 .

requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for golimumab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).








IMIPENEM/ CILASTATIN SODIUM

IMIQUIMOD

250 MG / VIAL * 250 MG / VIAL (BASE) INJECTION

500 MG / VIAL * 500 MG / VIAL (BASE) INJECTION

50 MG/G / G TOPICAL CREAM

00000717274

00000717282

00002239505

PRIMAXIN

PRIMAXIN

ALDARA

MFC

MFC

MEP

13.0400

24.3800

50.3370


$

$

$

Section 3 .

"For the treatment of:

1) "Second-line therapy of intra-abdominal sepsis where there is failure of first-line therapy (e.g. ampicillin + gentamicin + metronidazole), as defined by clinical deterioration after 72 h of antibiotic therapy or lack of improvement after completion of antibiotic therapy or

2) Second-line therapy of severe polymicrobial skin and skin structure infections (e.g. limb threatening diabetic foot) or

3) Empiric therapy of mixed synergistic necrotizing gangrene (Fournier's gangrene) or

4) Therapy of severe ventilator-associated pneumonia where Pseudomonas and Staphylococcus aureus coverage is needed or

5) Second-line therapy of infections due to gram-negative organisms producing inducible beta-lactamases (i.e. Enterobacter spp., Citrobacter freundii complex, Serratia spp., Morganella spp., Providencia spp., Proteus vulgaris, Proteus penneri and some Hafnia spp.) or extended spectrum beta-lactamases where there is resistance to first-line agents (trimethoprim/sulfamethoxazole, ciprofloxacin and aminoglycosides) or

6) For use in other Health Canada approved indications in consultation with a specialist in Infectious Diseases."


"For the treatment of Actinic Keratosis located on the head and neck in patients who have failed treatment with cryotherapy (where appropriate) and 5-fluorouracil (5-FU).


All requests for imiquimod must be completed using the Imiquimod Special Authorization Request Form (ABC 31222).




INFLIXIMAB




- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial) [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily)



- Initial coverage may be approved for three doses as follows: An initial dose of 3 mg/kg, followed by additional 3 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response. 2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for one 3 mg/kg dose every 8 weeks for a period of 12 months [Note: For patients who have an incomplete response, consideration may be given to adjusting the dose up to 10 mg/kg and/or treating as often as every 4 weeks]. Ongoing coverage may be considered only if the following criteria are met at theend of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to




INFLIXIMAB


therapy as indicated by:- confirmation of maintenance of ACR20, OR - maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for infliximab for Rheumatoid Arthritis must be completed using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).

Moderately to Severely Active Crohn's Disease and Fistulizing Crohn's Disease:

"Special authorization coverage may be approved for coverage of infliximab for the reduction in signs and symptoms and induction and maintenance of clinical remission of Moderately to Severely Active Crohn's Disease and/or treatment of Fistulizing Crohn's Disease in patients whomeet the following criteria:

- Infliximab must be prescribed by a Specialist in Gastroenterology or a physician appropriately trained by the University of Alberta or the University of Calgary and recognized as a prescriber by Alberta Blue Cross for infliximab for coverage for the treatment of Moderately to Severely Active Crohn's Disease and/or Fistulizing Crohn's Disease patients (`Specialist').- Patients must be 18 years of age or older to be considered for coverage of infliximab.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients may be allowed to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy (both primary loss of response and secondary loss of response) or due to serious adverse effects or contraindications. An adequatetrial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

Prior to initiation of infliximab therapy for New Patients:

'New Patients' are patients who have never been treated with infliximab by any health care provider.


Prior to initiation of infliximab therapy, New Patients must have a current Modified (without the physical exam) Harvey Bradshaw Index score of greater than or equal to 7 (New Patient's Baseline Score), AND be Refractory.

Refractory is defined as one or more of the following:1) Serious adverse effects or reactions to the treatments specified below; OR 2) Contraindications (as defined in product monographs) to the treatments specified below; OR3) Previous documented lack of effect at doses and for duration of all treatments specified below: a) mesalamine: minimum of 3 grams/day for a minimum of 6 weeks; AND refractory to, or dependent on, glucocorticoids: following at least one tapering dosing schedule of 40 mg/day, tapering by 5 mg each week to 20 mg, then tapering by 2.5 mg each week to zero, or similar;

[Note: Patients who have used the above treatments in combination will not be required to be challenged with individual treatments as monotherapy]



INFLIXIMAB


ANDb) Immunosuppressive therapy as follows: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 3 months; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 3 months; OR- Methotrexate: minimum or 15 mg/week for a minimum of 3 months.OR - Immunosuppressive therapy discontinued at less than 3 months due to serious adverse effectsor reactions.


Fistulizing Crohn's Disease:

Prior to initiation of infliximab therapy, New Patients must have actively draining perianal or enterocutaneous fistula(s) that have recurred or persisted despite:

a) A course of an appropriate dose of antibiotic therapy (e.g. ciprofloxacin or metronidazole) for a minimum of 3 weeks; ANDb) Immunosuppressive therapy: - Azathioprine: minimum of 2 mg/kg/day for a minimum of 6 weeks; OR - 6-mercaptopurine: minimum of 1 mg/kg/day for a minimum of 6 weeks; OR - Immunosuppressive therapy discontinued at less than 6 weeks due to serious adverse effects or reactions.

[Note: Patients who have used the above treatments in combination for the treatment of Fistulizing Crohn's will not be required to be challenged with individual treatments as monotherapy]


Coverage Criteria for Moderately to Severely Active Crohn's Disease AND/OR Fistulizing Crohn's Disease

- New Patients must meet the criteria above prior to being considered for approval. - All approvals are also subject to the following applicable criteria.

Induction Dosing for New Patients:

- Coverage for Induction Dosing may only be approved for New Patients (those who have never been treated with infliximab by any health care provider).- 'Induction Dosing' means a maximum of one 5 mg/kg dose of infliximab per New Patient at each 0, 2 and 6 weeks (for a maximum total of three doses).- New Patients are eligible to receive Induction Dosing only once, after which time the Maintenance Dosing for New Patients and Continued Coverage for Maintenance Dosing criteria will apply.

Maintenance Dosing:

'Maintenance Dosing' means one 5 mg/kg dose of infliximab per patient provided no more often than every 8 weeks for a period of 12 months to:- New Patients following the completion of Induction Dosing; OR - Existing Patients, who are patients that are being treated, or have previously been treated, withinfliximab.




INFLIXIMAB


Maintenance Dosing for New Patients after Completion of Induction Dosing:

- The New Patient must be assessed by a Specialist between weeks 10 and 14 after the initiation of Induction Dosing to determine response by obtaining a Modified Harvey Bradshaw Index score for patients with Moderately to Severely Active Crohn's Disease and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND- The Specialist must confirm the Modified Harvey Bradshaw Index score shows a decrease from the New Patient's Baseline Score of greater than or equal to 3 points for patients with Moderately to Severely Active Crohn's and/or confirm closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's.

Maintenance Dosing for Existing Patients:

- The patient must be assessed by a Specialist at least 4 to 8 weeks after the day the last dose of infliximab was administered to the patient and prior to administration of the next dose to obtain: a Modified Harvey Bradshaw Index Score (Existing Patient's Baseline Score) for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no orminimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND

- these measures must be provided to Alberta Blue Cross for assessment for continued coverage for maintenance dosing.

(For existing patients with Moderately to Severely Active Crohn's Disease with an incomplete response or for existing patients with Fistulizing Crohn's who respond then lose their response, the dose may be adjusted to 10 mg/kg by making an additional special authorization request to Alberta Blue Cross for the increased dose.)

Continued Coverage for Maintenance Dosing:

Continued coverage may be considered for one 5 mg/kg dose of infliximab per patient provided no more often than every 8 weeks for a period of 12 months, if the following criteria are met at the end of each 12 month period:

- The New Patient or the Existing Patient must be assessed by a Specialist at least 4 to 6 weeksafter the day the last dose of infliximab was administered to the patient and prior to the administration of the next dose to obtain a Modified Harvey Bradshaw Index Score for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no orminimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; AND- For New Patients: The Specialist must confirm that the patient has maintained a greater than or equal to 3 point decrease from the New Patient's Baseline Score for Moderately to Severely Active Crohn's and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's; OR- For Existing Patients: The Specialist must confirm that the patient has maintained the Existing Patient's Baseline Score and/or closure of individual fistulas as evidenced by no or minimal fistula drainage despite gentle finger compression of fistulas that were draining at baseline for Fistulizing Crohn's.

(For new and existing patients with Moderately to Severely Active Crohn's Disease with an incomplete response or for new and existing patients with Fistulizing Crohn's who respond then lose their response, the maintenance dose may be adjusted to 10 mg/kg by making an additional special authorization request to Alberta Blue Cross for the increased dose.)"

All requests (including renewal requests) for infliximab for Moderately to Severely Active Crohn'sThe DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


INFLIXIMAB


Disease and Fistulizing Crohn's Disease must be completed using the Adalimumab for Crohn's/Infliximab for Crohn's/Fistulizing Crohn's Disease Special Authorization Request Form (ABC 31200).


"Special authorization coverage may be provided for the reduction in the signs and symptoms and improvement in physical function of severely active Ankylosing Spondylitis, as defined by the Modified New York criteria for Ankylosing Spondylitis, in adult patients (18 years of age or older) who have active disease as demonstrated by:




- Initial coverage may be approved for three doses as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response.2) The RA Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Reduction of the BASDAI score by at least 50% of the pre-treatment value or by 2 or more units, AND - Reduction of the Spinal Pain VAS by 2 cm or more.

Following this assessment, continued coverage may be approved for one 5 mg/kg dose of infliximab every 6 to 8 weeks for a period of 12 months. Ongoing coverage may be considered ifthe patient is re-assessed by an RA Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for infliximab for Ankylosing Spondylitis must be completed using the Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form (ABC 31195).


"Special authorization coverage may be provided for use in combination with methotrexate for reducing signs and symptoms and inhibiting the progression of structural damage of active




INFLIXIMAB


arthritis in adult patients (18 years of age or older) with moderate to severe polyarticular psoriaticarthritis (PsA) or pauciarticular PsA with involvement of knee or hip joint who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- An adequate trial of another disease modifying anti-rheumatic agent(s) (minimum 4 month trial).




- Initial coverage may be approved for three doses as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond three doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after the initial three doses to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for one 5 mg/kg dose every 8 weeks, for a period of 12 months. Ongoing coverage may be considered if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to therapy as indicated by:- Confirmation of maintenance of ACR20, or- Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewal requests. It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for infliximab for Psoriatic Arthritis must be completed The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


INFLIXIMAB


using the Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form (ABC 30964).

Plaque Psoriasis:

"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)




- Initial coverage may be approved as follows: An initial dose of 5 mg/kg, followed by additional 5 mg/kg doses at 2 and 6 weeks after the first infusion.- Patients will be limited to receiving one dose of infliximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond three doses, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial three doses to determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, or- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.

Following this assessment, continued coverage may be considered for one 5 mg/kg dose of infliximab every 8 weeks for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for infliximab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special




INFLIXIMAB

IPRATROPIUM BROMIDE

ITRACONAZOLE

LACOSAMIDE


125 MCG / ML INHALATION UNIT DOSE SOLUTION

250 MCG / ML INHALATION UNIT DOSE SOLUTION


50 MG ORAL TABLET

100 MG ORAL TABLET

00002244016

0000223113500002097176

00002216221000022312440000223124500002097168

00002231347

00002357615

00002357623

REMICADE

PMS-IPRATROPIUMRATIO-IPRATROPIUM UDV

MYLAN-IPRATROPIUM STERINEBSPMS-IPRATROPIUM (1ML)PMS-IPRATROPIUM (2ML)RATIO-IPRATROPIUM UDV

SPORANOX

VIMPAT

VIMPAT

JAI

PMSRPH

MYPPMSPMSRPH

JAI

UCB

UCB

940.0000

0.3295 0.3295

0.6590 0.6590 0.6590 0.6590

0.7830

2.3200

3.3200


$

$$

$$$$

$

$

$

Section 3 .

Authorization Request Form (ABC 31192).

"For use in patients with manual dexterity problems or visual limitations who are unable to prepare a dose of the drug using the multi-dose solution."

"For use in patients who are hypersensitive to preservatives contained in multi-dose solutions."

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

Information is required regarding the nature of the difficulties experienced by the patient in preparing a dose using the multi-dose preparation; or the nature of the patient's hypersensitivity to the preservatives contained in the multi-dose solution.


"For the treatment of oral and/or esophageal candidiasis in immunocompromised patients who are intolerant to fluconazole, or who have failed fluconazole as evidenced by significant clinical deterioration due to the fungal infection during a course of therapy or no resolution after a full course of therapy."

"For adjunctive therapy in adult patients with refractory partial-onset seizures who meet all of thefollowing criteria:- Are currently receiving two or more antiepileptic medications, AND- Have failed or demonstrated intolerance to three other antiepileptic medications, AND- Therapy must be initiated by a Neurologist.

For the purpose of administering these criteria failure is defined as inability to achieve satisfactory seizure control.

Coverage may be granted for a maximum dose of 400 mg daily.

Special authorization may be granted for six months."

Each of these products is eligible for auto-renewal.



LACOSAMIDE

LANREOTIDE ACETATE

LEUPROLIDE ACETATE

150 MG ORAL TABLET

200 MG ORAL TABLET




3.75 MG / VIAL INJECTION

5 MG / ML INJECTION




00002357631

00002357658

00002283395

00002283409

00002283417

00000884502

00000727695

00000836273

00002239834

00002230248

VIMPAT

VIMPAT

SOMATULINE AUTOGEL (0.3 ML SYRINGE)



LUPRON DEPOT

LUPRON

LUPRON DEPOT

LUPRON DEPOT

LUPRON DEPOT

UCB

UCB

TCI

TCI

TCI

ABB

ABB

ABB

ABB

ABB

4.3200

5.3200

1102.0000

1470.0000

1840.0000

347.1800

67.6464

387.9700

1034.4100

1071.0000


$

$

$

$

$

$

$

$

$

$

Section 3 .

"For the treatment of acromegaly when prescribed by or in consultation with a Specialist in Internal Medicine.










LEVOCARNITINE

LINAGLIPTIN

330 MG ORAL TABLET



5 MG ORAL TABLET

00002144328

00002144336

00002144344

00002370921

CARNITOR

CARNITOR

CARNITOR

TRAJENTA

PPC

PPC

PPC

BOE

1.3078

0.3961

12.5220

2.5500


$

$

$

$

Section 3 .

"For the treatment of primary carnitine deficiency. Information is required regarding the ratio of acyl:free carnitine and total plasma carnitine levels."

"For the treatment of patients with an inborn error of metabolism that results in secondary carnitine deficiency. Information is required regarding the patient's diagnosis."


In order to comply with the first criteria: Information is required regarding pre-treatment acyl:freecarnitine and total plasma carnitine levels.



FIRST-LINE DRUG PRODUCT(S): METFORMINSECOND-LINE DRUG PRODUCT(S): SULFONYLUREASAND WHERE INSULIN IS NOT AN OPTION

As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND- a sulfonylurea, AND- for whom insulin is not an option.

Or, for whom these products are contraindicated.




LINEZOLID

MEGESTROL ACETATE

MEGESTROL ACETATE

600 MG ORAL TABLET


40 MG ORAL TABLET

160 MG ORAL TABLET

00002243684

00002168979

00002195917

00002195925

ZYVOXAM

MEGACE OS

MEGESTROL

MEGESTROL

PFI

BMS

AAP

AAP

72.1263

1.6404

1.0073

4.2630


$

$

$

$

Section 3 .

"For the treatment of non-cancer indications (e.g. cachexia in HIV/AIDS patients and cancer patients) in patients who cannot swallow tablets.


(Please note: The above megestrol acetate product is a benefit not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative CareDrug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)


"For the treatment of non-cancer indications (e.g. cachexia in HIV/AIDS patients and cancer patients).


(Please note: The above megestrol acetate products are benefits not requiring special authorization for individuals approved by Alberta Health and Wellness for Palliative CareDrug Coverage. Refer to the Palliative Care Drug Benefit Supplement for additional information on this coverage.)



1) Vancomycin-resistant enterococcus infections or

2) Methicillin-resistant Staphylococcus aureus (MRSA)/methicillin-resistant coagulase-negative Staphylococcus infections in patients who are unresponsive to or intolerant of vancomycin or

3) Susceptible organisms in patients severely intolerant or allergic to all other appropriate alternatives (e.g. beta-lactam antibiotics, clindamycin, trimethoprim/sulfamethoxazole and vancomycin) or 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."

In order to comply with the above criteria, information is required regarding the type of infection and organisms involved. Information is also required regarding previous antibiotic therapy that has been utilized and the patient's response to therapy and the first line agents the organism is resistant to or why other first-line therapies cannot be used in this patient. The specialist in Infectious Diseases that recommended this drug is also required.




MEROPENEM

METHYLPREDNISOLONE ACETATE/ NEOMYCIN SULFATE/ ALUMINUM CHLORHYDROXIDE COMPLEX/ SULFUR

MODAFINIL



2.5 MG / ML * 2.5 MG / ML * 100 MG / ML * 50 MG / ML TOPICAL LOTION

100 MG ORAL TABLET

00002218488

00002218496

00000195057

0000228539800002239665

MERREM

MERREM

NEO-MEDROL ACNE

MODAFINILALERTEC

AZC

AZC

PFI

AAPSHB

25.2600

50.5200

0.2602

0.9990 1.3174


$

$

$

$$

Section 3 .

1) "As an alternative to imipenem for severe polymicrobial infections involving gram-negative organisms resistant to first-line agents in patients with documented seizure disorder/CNS abnormality or

2) As an alternative agent for severe polymicrobial infections involving gram-negative organismsresistant to first-line agents and to imipenem but susceptible to meropenem or

3) Therapy of meningitis due to gram-negative organisms producing inducible beta-lactamases (i.e. Enterobacter spp., Citrobacter freundii complex, Serratia spp., Morganella spp., Providenciaspp., Proteus vulgaris, Proteus penneri and some Hafnia spp.) or

4) For treatment of CNS infections due to gram-negative organisms that are resistant to third-generation cephalosporins but are susceptible to meropenem or

5) Therapy for infections involving multi-resistant Pseudomonas aeruginosa, where there is documented susceptibility to meropenem or

6) For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."


"For the treatment of severe acne as defined by scarring acne."

"For the treatment of acne rosacea and seborrheic dermatitis."



"For the treatment of documented narcolepsy. This drug product must be prescribed by a specialist in Neurology or Psychiatry, or a sleep specialist affiliated with a recognized level 1 lab.





MONTELUKAST SODIUM

10 MG (BASE) ORAL TABLET

5 MG (BASE) ORAL CHEWABLE TABLET

00002374609000023793330000236822600002373947000023285930000235552300002238217

00002377616000023793250000238075700002354985000023303930000235551500002238216

APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKAST FCSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR

APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKASTSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR

APXSNSMYPPMSSDZTEVMFC


0.8483 0.8483 0.8483 0.8483 0.8483 0.8483 2.4238

0.5776 0.5776 0.5776 0.5776 0.5776 0.5776 1.6503


$$$$$$$

$$$$$$$

Section 3 .

(Refer to 48:10.24 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 6 to 18 years of age inclusive).

"For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria:a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, orb) cannot operate inhaler devices."

"For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists."


In order to comply with the first criteria, information should indicate either a) current use of inhaled steroids and contraindications or poor response to long-acting beta 2 agonists (e.g. salmeterol or formoterol) or,b) the nature of the patient's difficulties with using inhaler devices.

In order to comply with the second criteria, information should include the nature of the patient's response to long-acting beta 2 agonists (e.g. salmeterol or formoterol).

All requests (including renewal requests) for montelukast must be completed using the Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313).





NARATRIPTAN HCL

OCTREOTIDE ACETATE


2.5 MG (BASE) ORAL TABLET

50 MCG / ML (BASE) INJECTION




10 MG / VIAL (BASE) INJECTION

0000231429000002237820

000023223230000231430400002237821

0000224863900000839191

0000224864000000839205

0000224864200002049392

0000224864100000839213

00002239323

NOVO-NARATRIPTANAMERGE

SANDOZ NARATRIPTANNOVO-NARATRIPTANAMERGE

OCTREOTIDE ACETATE OMEGASANDOSTATIN




SANDOSTATIN LAR

TEVGSK

SDZTEVGSK

OMGNOV

OMGNOV

OMGNOV

OMGNOV

NOV

8.4338 14.1715

6.1437 6.1438

14.9372

1.9076 5.0700

3.6007 9.5700

6.9268 18.4100

16.9230 44.9780

1315.7400


$$

$$$

$$

$$

$$

$$

$

Section 3 .

(Refer to 28:32.28 of the Alberta Health and Wellness 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 naratriptan hydrochloride prior to turning 65."


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


"For control of symptoms in patients with metastatic carcinoid and vasoactive intestinal peptide-secreting tumors (VIPomas) when prescribed by or in consultation with a Specialist in Internal Medicine, Palliative Care or General Surgery."

"For the treatment of acromegaly when prescribed by or in consultation with a Specialist in Internal Medicine."

"For the treatment of intractable diarrhea which has not responded to less costly therapy [e.g. associated with (secondary to) AIDS, intra-abdominal fistulas, short bowel syndrome]. Treatmentfor these indications must be prescribed by or in consultation with a Specialist in, Internal Medicine, Palliative Care, or General Surgery."


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




OCTREOTIDE ACETATE20 MG / VIAL (BASE) INJECTION

30 MG / VIAL (BASE) INJECTION00002239324

00002239325

SANDOSTATIN LAR

SANDOSTATIN LAR

NOV

NOV

1699.8900

2180.9400


$

$

Section 3 .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.



OMALIZUMAB


Special authorization coverage may be provided for adults and adolescents (12 years of age and above) with severe persistent asthma who are identified as having severe disease despite optimized standard therapy. Optimized standard therapy defined by a full trial of, and documented compliance with:

- high dose inhaled corticosteroid (budesonide 1600 micrograms per day or fluticasone propionate 1000 micrograms per day or equivalent) for at least twelve (12) months; AND,- long-acting beta-2 agonist therapy (at least salmeterol 50 micrograms daily or 24 micrograms of formoterol fumarate daily) for at least twelve (12) months; AND,- Therapeutic trial with systemic corticosteroids (at least 10mg per day prednisolone (or equivalent)) for at least 4 weeks in the previous twelve (12) months, unless contraindicated or not tolerated. For coverage, the drug must be initiated and monitored by a respirologist or clinical immunologist or allergist and meet the following clinical criteria (Initial Coverage or Continued Coverage, as appropriate). Patients will be limited to receiving a one (1) month supply of omalizumab per prescription at their pharmacy.

INITIAL COVERAGE:Special authorization requests must meet all of the following criteria for initial approval:

1) Confirmation of severe asthma through recent clinical and physiologic review with exclusion of other obstructive airways processes contributing to symptoms of severe asthma (i.e. psychogenic dyspnea; cardiac dyspnea);

2) Must be a non-smoker;

3) Confirmation of IgE mediated allergy to a perennial allergen by clinical history and allergy skintesting;

4) Baseline IgE level greater than/equal to 30 IU/mL and less than/equal to 700 IU/mL;

5) A weight between 20kg and 150kg;

6) An Asthma Control Questionnaire (ACQ-5) of at least 1.25, on at least two occasions over thepast 6 months in a stable state;

7) Must provide documentation:- Spirometry measurement of FEV1;- Asthma Quality of Life Questionnaire (AQLQ - Juniper) score;- Number of exacerbations of asthma within the previous twelve (12) month period that resulted in: - an emergency room visit or hospitalization; - unscheduled physician visits resulting in oral corticosteroids; - chronic use (greater than 50% of the year) of oral corticosteroids;

8) One (1) or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit within the previous year while on systemic corticosteroids; OR - One (1) or more severe exacerbations of asthma requiring a hospital admission or Emergency Room visit requiring documented use of systemic corticosteroids (oral corticosteroids initiated or increased for at least three (3) days, or parenteral corticosteroids); OR- Three (3) or more severe exacerbations of asthma within the previous year which required an unscheduled physician visit and resulted in courses (or chronic use greater than 50% of the year) of systemic corticosteroids.

Initial coverage may be approved for twenty-eight (28) weeks based on the recommended dose and dosage adjustment outlined in the Health Canada approved Product Monograph.



OMALIZUMAB

OXYBUTYNIN CHLORIDE


10 MG ORAL EXTENDED-RELEASE TABLET


00002260565

00002273578

00002273586

XOLAIR

UROMAX

UROMAX

NOV

PUR

PUR

600.0000

1.3655

1.4710


$

$

$

Section 3 .

CONTINUED MAINTENANCE TREATMENT:A patient must be assessed for response to initial coverage of omalizumab with a minimum of twenty-four (24) weeks of therapy with omalizumab, and this assessment must be submitted to Alberta Blue Cross no later than four (4) weeks from the date of assessment.

The assessment must be done by the respirologist or clinical immunologist or allergist or such other clinicians as the Minister may designate who initiated therapy. If the following criteria are met, special authorization may be granted for a further twelve (12) month period. Continued coverage may be considered if the following criteria are met at the end of each additional twelve (12) month period:

1) Demonstrated that the patient has an Improvement in FEV1 greater than 12% (and for adults a minimum greater than 200 mL) from initiation of therapy; ORUnchanged FEV1 with a clinically meaningful Improvement in Asthma Quality of Life Questionnaire score from baseline (greater than/equal to 0.5 mean from baseline); AND - a decrease in the ACQ-5 of at least 0.5; OR - a ACQ-5 score of less than/equal to 1.

2) Patients must demonstrate at least a 25% reduction in the number of exacerbations, which required oral corticosteroids from the twelve (12) months prior to initiation of omalizumab that required systemic corticosteroids; ORFor patients that were on chronic (greater than 50% of the year) courses of oral corticosteroids use in the prior twelve (12) months to initiation of omalizumab, tapering of oral corticosteroid useby at least 25% from baseline.

3) A reduction in the number of exacerbations that have led to a hospital admission or emergency room visits, compared to the twelve (12) months prior to the commencement of omalizumab.


FIRST-LINE DRUG PRODUCT(S): IMMEDIATE RELEASE OXYBUTYNIN

"For patients who are intolerant of immediate release oxybutynin."





PALIPERIDONE PALMITATE

PAPAVERINE HCL

PEGFILGRASTIM

50 MG / SYR (BASE) INJECTION SYRINGE






00002354217

00002354225

00002354233

00002354241

00000009881

00002249790

INVEGA SUSTENNA (0.5 ML SYR)


INVEGA SUSTENNA (1 ML SYR)


PAPAVERINE HCL

NEULASTA (0.6 ML SYRINGE)

JAI

JAI

JAI

JAI

SDZ

AMG

304.1000

456.1800

456.1800

608.2200

1.7163

2499.0000


$

$

$

$

$

$

Section 3 .

"For the management of the manifestations of schizophrenia in patients who demonstrate a pattern of significant non-compliance that compromises therapeutic success AND who meet at least two of three 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 afirst generation antipsychotic agent); OR- Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy.

Special Authorization may be granted for six months."

All requests (including renewal requests) for paliperidone prolonged release injection must becompleted using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).


"For the relief of cerebral or peripheral ischemia with arterial spasm.



"To decrease the incidence of infection, as manifested by febrile neutropenia, in patients 18 years of age and older with non-myeloid malignancies receiving myelosuppressive antineoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates)."

All requests for pegfilgrastim must be completed using the Filgrastim/Pegfilgrastim Special Authorization Request Form (ABC 31150).

Please note: Coverage cannot be considered for palliative patients.



PEGINTERFERON ALFA-2A


(Refer to 08:18.20 of the Alberta Health and Wellness Drug Benefit List for coverage of peginterferon alfa-2a for the treatment of Chronic Hepatitis B.)

Chronic Hepatitis C

"For the treatment of chronic hepatitis C in patients with evidence of active liver disease, who qualify for treatment with Pegasys RBV (peginterferon alfa-2a/ribavirin) but who are intolerant to ribavirin.

All Chronic Hepatitis C Patients Prior to Initiation of Therapy:

- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three weeks before anticipated start date of therapy, please submit to Alberta Blue Cross a Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC30944), along with appropriate lab results. In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.

All Chronic Hepatitis C Patients (with the Exception of Advanced Fibrosis or Cirrhosis Patients):

Prior to initiation of therapy:

- Patients must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.

Initial Alberta Blue Cross approval periods (for patients meeting criteria):

- Patients may receive an initial approval for 14 weeks of coverage.

At 12 weeks of treatment:

- HCV RNA testing is required for all patients at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample, and the 12 week serum sample, for evaluation of continued coverage.

Renewal approval period (for patients meeting criteria):

- Patients who respond to therapy, as measured by a reduction of viral load by at least 2 logs (100 fold) or HCV RNA not detected at 12 weeks, may be approved for an additional 34 weeks of coverage (total 48 weeks).

All Chronic Hepatitis C Patients with Advanced Fibrosis or Cirrhosis:


- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage.

Consideration for therapy in chronic hepatitis C patients who have previously received therapy:

- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:

- Advanced fibrosis or cirrhosis.- Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy."

In order to comply with this criterion: Confirmation of the diagnosis of chronic hepatitis C and The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.




180 MCG / SYR INJECTION SYRINGE00002248077 PEGASYS (0.5 ML SYRINGE) HLR 395.8400


$

Section 3 .

presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of a liver biopsy. All requests for peginterferon alfa-2a for Chronic Hepatitis C must be completed using the Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC 30944). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.



PEGINTERFERON ALFA-2A/ RIBAVIRIN


"For the treatment of chronic hepatitis C in patients with evidence of active liver disease.

Prior to initiation of Pegasys RBV therapy:

- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three (3) weeks before anticipated start date of therapy, please submit a Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) along with appropriate lab results to Alberta Blue Cross.

All Patients (with the Exception of Post-Liver Transplant Patients and Advanced Fibrosis or Cirrhosis Patients):

Prior to initiation of Pegasys RBV therapy:

- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.


- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection, may receive an initial approval for 14 weeks of coverage.- Genotype 2 or 3 patients may receive initial and maximal approval for 24 weeks of coverage.These patients will not be eligible for continued approval.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.


- HCV RNA testing is required for all Genotype 1 patients and Genotype 2 or 3 patients with HIVco-infection at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample and the 12th week serum sample for evaluation of continued coverage.


- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who respond to therapy as measured by a negative HCV RNA status at 12 weeks, may be approved for an additional 34 weeks of coverage (i.e. total 48 weeks).- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who achieve areduction in viral load by at least 2 logs (100 fold) but do not possess negative HCV RNA status at week 12 may be approved for an additional 14 weeks of coverage. Patients should be retested for HCV RNA status at 24 weeks:- Patients who respond to therapy, as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 20 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.

Post-Liver Transplant Patients:


- Genotype 1 and Genotype 2 or 3 patients may receive an initial approval for 26 weeks of coverage.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.

At 24 weeks of treatment:The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.



PEGINTERFERON ALFA-2A/ RIBAVIRIN

180 MCG * 200 MG INJECTION SYRINGE/TABLET00002253429 PEGASYS RBV (KIT) HLR 395.8400


$

Section 3 .

- HCV RNA testing is required for all Genotype 1 and Genotype 2 or 3 patients at the 24th week of treatment.


- Genotype 1 and Genotype 2 or 3 patients who respond to therapy as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 22 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.

Advanced Fibrosis or Cirrhosis Patients:


- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage.

Consideration for therapy in ALL patients (including post-liver transplant patients) who have previously received therapy:

- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:- Advanced fibrosis or cirrhosis. - Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy.- Patients who have failed to respond to or relapsed following interferon monotherapy."

Confirmation of the diagnosis of chronic hepatitis C and presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of liver biopsy. All requests for peginterferon alfa-2a/ribavirin must be completed using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.



PEGINTERFERON ALFA-2B/ RIBAVIRIN


"For the treatment of chronic hepatitis C in patients with evidence of active liver disease.

Prior to initiation of Pegetron therapy:

- To determine treatment duration and prognosis, HCV genotype testing is required for all patients.- At least three (3) weeks before anticipated start date of therapy, please submit a Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932) along with appropriate lab results to Alberta Blue Cross.

All Patients (with the Exception of Post-Liver Transplant Patients and Advanced Fibrosis or Cirrhosis Patients):

Prior to initiation of Pegetron therapy:

- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection must have a baseline serum sample stored for future viral load testing in the event that the week 12 HCV RNA test is positive.


- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection, may receive an initial approval for 14 weeks of coverage.- Genotype 2 or 3 patients may receive initial and maximal approval for 24 weeks of coverage.These patients will not be eligible for continued approval.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.


- HCV RNA testing is required for all Genotype 1 patients and Genotype 2 or 3 patients with HIVco-infection at the 12th week of treatment.- If the HCV RNA test is positive, viral load testing is required on the previously stored baseline serum sample and the 12th week serum sample for evaluation of continued coverage.


- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who respond to therapy as measured by a negative HCV RNA status at 12 weeks, may be approved for an additional 34 weeks of coverage (i.e. total 48 weeks).- Genotype 1 patients and Genotype 2 or 3 patients with HIV co-infection who achieve a reduction in viral load by at least 2 logs (100 fold) but do not possess negative HCV RNA status at week 12 may be approved for an additional 14 weeks of coverage. Patients should be retested for HCV RNA status at 24 weeks:- Patients who respond to therapy, as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 20 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.

Post-Liver Transplant Patients:


- Genotype 1 and Genotype 2 or 3 patients may receive an initial approval for 26 weeks of coverage.- Genotype 4, 5 and 6 patients may receive initial and maximal approval for 48 weeks of coverage. These patients will not be eligible for continued approval.

At 24 weeks of treatment:The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.



PEGINTERFERON ALFA-2B/ RIBAVIRIN

50 MCG * 200 MG INJECTION VIAL/CAPSULE

150 MCG * 200 MG INJECTION VIAL/CAPSULE

80 MCG * 200 MG INJECTION SYRINGE/CAPSULE




00002246026

00002246030

00002254581

00002254603

00002254638

00002254646

PEGETRON (KIT)

PEGETRON (KIT)

PEGETRON REDIPEN (KIT)




MFC

MFC

MFC

MFC

MFC

MFC

752.2000

831.1800

752.2000

752.2000

831.1800

831.1800


$

$

$

$

$

$

Section 3 .

- HCV RNA testing is required for all Genotype 1 and Genotype 2 or 3 patients at the 24th week of treatment.


- Genotype 1 and Genotype 2 or 3 patients who respond to therapy as measured by a negative HCV RNA status at 24 weeks, may be approved for an additional 22 weeks of coverage (i.e. total 48 weeks).- Those who fail to demonstrate negative HCV RNA status at 24 weeks will not be eligible for continued approval.

Advanced Fibrosis or Cirrhosis Patients:


- Patients with advanced fibrosis or cirrhosis may receive approval for 48 weeks of coverage. Consideration for therapy in ALL patients (including post-liver transplant patients) who have previously received therapy:

- Consideration for therapy in patients who have previously received therapy may be given for patients who meet at least one of the following criteria:- Advanced fibrosis or cirrhosis. - Patients who have relapsed following non-pegylated interferon/ribavarin combination therapy.- Patients who have failed to respond to or relapsed following interferon monotherapy."

Confirmation of the diagnosis of chronic hepatitis C and presence of active liver disease is required. Information must include the patient's pre-treatment anti-HCV and serum HCV RNA (by PCR) status. Information is also required regarding whether liver enzymes (ALT/AST) are elevated, or the results of liver biopsy. All requests for peginterferon alfa-2b/ribavirin must be completed using the Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC 30932). In order to meet the requirements of provincial privacy legislation, the patient's signature must be affixed to each completed form.



PIOGLITAZONE HCL




000023034420000230294200002363232000023028610000232647700002298279000022749140000230766900002303124000023014230000229790600002242572

00002303450000023029500000236324000002302888000023264850000229828700002274922000023076770000233958700002303132000023014310000229791400002242573

00002303469000023029770000236325900002302896000023264930000229829500002274930000023077230000233959500002303140000023014580000229792200002242574

ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS

ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPIOGLITAZONE HYDROCHLORIDEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS

ACCEL PIOGLITAZONEAPO-PIOGLITAZONEAVA-PIOGLITAZONECO PIOGLITAZONEMINT-PIOGLITAZONEMYLAN-PIOGLITAZONENOVO-PIOGLITAZONEPHL-PIOGLITAZONEPIOGLITAZONE HYDROCHLORIDEPMS-PIOGLITAZONERATIO-PIOGLITAZONESANDOZ PIOGLITAZONEACTOS

ACPAPXAVACOBMPIMYPTEVPHHPMSRPHSDZTAK

ACPAPXAVACOBMPIMYPTEVPHHAHIPMSRPHSDZTAK

ACPAPXAVACOBMPIMYPTEVPHHAHIPMSRPHSDZTAK

0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 0.8718 2.3171

1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 1.2214 3.2462

1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 1.8365 4.8811


$$$$$$$$$$$$

$$$$$$$$$$$$$

$$$$$$$$$$$$$

Section 3 .


FIRST-LINE DRUG PRODUCT(S): METFORMIN

"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin or who are intolerant to metformin (e.g. dermatologic reactions) or for whom the product is contraindicated."





PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

QUINAGOLIDE

2 G / VIAL (BASE) * 250 MG / VIAL (BASE) INJECTION



0.075 MG ORAL TABLET

0.15 MG ORAL TABLET

0000230844400002299623

00002170817

0000230845200002299631

00002170795

0000230846000002299658

00002170809

00002223767

00002223775

PIPERACILLIN AND TAZOBACTAMPIPERACILLIN SODIUM/TAZOBACTAM SODIUMTAZOCIN



NORPROLAC

NORPROLAC

APXSDZ

WAY

APXSDZ

WAY

APXSDZ

WAY

FEI

FEI

9.6120 9.6120

11.9220

14.4180 14.4180

17.8830

19.2250 19.2250

23.8450

1.0900

1.6300


$$

$

$$

$

$$

$

$

$

Section 3 .

For the treatment of:

1) "Second-line therapy of intra-abdominal sepsis where there are serious adverse events due to first-line therapy or documented failure of first-line therapy (e.g. ampicillin + gentamicin + metronidazole), as defined by clinical deterioration after 72 h of antibiotic therapy or lack of improvement after completion of antibiotic therapy or 2) Second-line therapy of severe polymicrobial skin and skin structure infections (e.g. limb threatening diabetic foot) or

3) Therapy of severe ventilator-associated pneumonia where Pseudomonas and Staphylococcus aureus coverage is needed, or

4) Therapy for infections involving multi-resistant Pseudomonas aeruginosa from pulmonary secretions in cystic fibrosis patients, lung transplant patients or patients with bronchiectasis , where there is documented susceptibility to piperacillin/tazobactam sodium, or

5) For use in other Health Canada approved indications, in consultation with a specialist in Infectious Diseases."



FIRST-LINE DRUG PRODUCT(S): BROMOCRIPTINE

"For the treatment of hyperprolactinemia in patients who are intolerant to or who have failed bromocriptine. Special authorization may be granted for 24 months."



RALOXIFENE HCL

RIFABUTIN

RILUZOLE

60 MG ORAL TABLET

150 MG ORAL CAPSULE

50 MG ORAL TABLET

00002279215000023122980000235892100002239028

00002063786

00002242763

APO-RALOXIFENENOVO-RALOXIFENEPMS-RALOXIFENEEVISTA

MYCOBUTIN

RILUTEK

APXTEVPMSLIL

PFI

SAV

0.8457 0.8457 0.8457 1.8805

3.9821

9.8173


$$$$

$

$

Section 3 .

"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization for this criteria may be granted for 6 months."




All requests for raloxifene HCl must be completed using the Alendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).


"For the prevention of disseminated Mycobacterium avium complex disease in patients with advanced HIV infection or other immunocompromised conditions.



"For use in patients who have probable or definite diagnosis of amyotrophic lateral sclerosis (ALS) as defined by World Federation of Neurology (WFN) criteria who have a vital capacity of >60% predicted and do not have a tracheostomy for invasive ventilation. This drug must be prescribed by a Specialist in Neurology."

"Patients who previously received Rilutek and were not eligible for the Phase IV study can also be considered for coverage if they meet the special authorization criteria."

"Coverage cannot be renewed once the patient has a tracheostomy for the purpose of invasive ventilation."




RISEDRONATE SODIUM

5 MG ORAL TABLET

30 MG ORAL TABLET

35 MG ORAL TABLET

0000229837600002242518

0000229838400002239146

000023536870000236481600002357984000022983920000230220900002319861000023702550000232729500002246896

NOVO-RISEDRONATEACTONEL

NOVO-RISEDRONATEACTONEL

APO-RISEDRONATEAVA-RISEDRONATEMYLAN-RISEDRONATENOVO-RISEDRONATEPMS-RISEDRONATERATIO-RISEDRONATERISEDRONATESANDOZ RISEDRONATEACTONEL

TEVWCC

TEVWCC

APXAVAMYPTEVPMSRPHSNSSDZWCC

1.3897 1.9125

9.0033 12.4090

3.9224 3.9224 3.9224 3.9224 3.9224 3.9224 3.9224 3.9224

10.4250


$$

$$

$$$$$$$$$

Section 3 .

"For the treatment of osteoporosis in patients who have documented hip, vertebral or otherfractures. Special authorization may be granted for 6 months."




"For the treatment of Paget's disease. Special Authorization for this criteria may be granted to amaximum of 2 months. Renewal requests may be considered following an observation period ofat least 2 months."

"Coverage cannot be provided for two or more medications used in the treatment of Paget'sdisease when these medications are intended for use in combination or when therapy with twoor more medications overlap."

All requests for risedronate sodium for Osteoporosis must be completed using theAlendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis SpecialAuthorization Request Form (ABC 31086).

The following product(s) are eligible for auto-renewal for the treatment of osteoporosis.



RISPERIDONE




00002255707

00002255723

00002255758

RISPERDAL CONSTA

RISPERDAL CONSTA

RISPERDAL CONSTA

JAI

JAI

JAI

161.0900

241.6200

322.1600


$

$

$

Section 3 .

"For the management of the manifestations of schizophrenia and related psychotic disorders in patients who demonstrate a pattern of significant non-compliance that compromises therapeutic success AND who meet at least two of three 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); OR- Possesses clinical evidence of previous successful treatment with risperidone or paliperidone therapy.

Special Authorization may be granted for six months."

All requests (including renewal requests) for risperidone prolonged release injection must be completed using the Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (ABC 31258).





RITUXIMAB

10 MG / ML INJECTION00002241927 RITUXAN HLR 45.3100


$

Section 3 .

"Special authorization coverage may be provided for use in combination with methotrexate for the reduction in signs and symptoms of severely active Rheumatoid Arthritis (RA) in adult patients (18 years of age or older) who are refractory or intolerant to: - Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4 month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily); AND- One anti-tumor necrosis factor (anti-TNF) therapy (e.g., etanercept, infliximab or adalimumab) (minimum 12 week trial).

'Refractory' is defined as lack of effect at the recommended doses and for duration of treatmentsspecified above.'Intolerant' is defined as demonstrating serious adverse effects or contraindications totreatments as defined in product monographs.


- Initial coverage may be approved for a dose of 1000 mg of rituximab administered at 0 and 2 weeks (total of 2 - 1000 mg doses).- Patients will be limited to receiving one dose of rituximab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception of anakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except under exceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For coverage for an additional two-dose course of therapy, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after each course of therapy, between 16 and 24 weeks after receiving the initial dose of each course of therapy, to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- An improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place] following the initial course of rituximab; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places] following the initial course of rituximab.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above, AND3) The patient must have experienced a subsequent loss of effect as defined by a worsening greater than or equal to 0.6 in the DAS28 score AND possess a DAS28 score of greater than or equal to 3.2.

Subsequent courses of therapy cannot be considered prior to 24 weeks elapsing from the initial dose of the previous course of therapy."

All requests (including renewal requests) for rituximab for Rheumatoid Arthritis must be completed using the Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 31205).



RIVASTIGMINE HYDROGEN TARTRATE

1.5 MG (BASE) ORAL CAPSULE

3 MG (BASE) ORAL CAPSULE

4.5 MG (BASE) ORAL CAPSULE


2 MG / ML (BASE) ORAL SOLUTION

00002336715000023328090000230598400002306034000023112830000232456300002242115

00002336723000023328170000230599200002306042000023112910000232457100002242116

00002336731000023328250000230601800002306050000023113050000232459800002242117

00002336758000023328330000230602600002306069000023113130000232460100002242118

00002245240

APO-RIVASTIGMINEMYLAN-RIVASTIGMINENOVO-RIVASTIGMINEPMS-RIVASTIGMINERATIO-RIVASTIGMINESANDOZ RIVASTIGMINEEXELON




EXELON

APXMYPTEVPMSRPHSDZNOV




NOV

0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059

0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059

0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059

0.9805 0.9805 0.9805 0.9805 0.9805 0.9805 2.6059

1.3700


$$$$$$$

$$$$$$$

$$$$$$$

$$$$$$$

$

Section 3 .






All requests (including renewal requests) for rivastigmine hydrogen tartrate must be completed using the Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC 30776).




RIZATRIPTAN BENZOATE

ROSIGLITAZONE MALEATE


5 MG (BASE) ORAL DISINTEGRATING TABLET





00002240521

00002374730000023791980000235187000002240518

00002374749000023792010000235188900002240519

00002241112

00002241113

00002241114

MAXALT

CO RIZATRIPTAN ODTMYLAN-RIZATRIPTAN ODTSANDOZ RIZATRIPTAN ODTMAXALT RPD


AVANDIA

AVANDIA

AVANDIA

MFC

COBMYPSDZMFC

COBMYPSDZMFC

GSK

GSK

GSK

15.2201

5.3270 5.3270 5.3270

15.2201

5.3270 5.3270 5.3270

15.2201

1.3755

2.1584

3.0865


$

$$$$

$$$$

$

$

$

Section 3 .



"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."






"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin or who are intolerant to metformin (e.g. dermatologic reactions) or for whom the product is contraindicated."




ROSIGLITAZONE MALEATE/ METFORMIN HCL

SAXAGLIPTIN HCL

1 MG (BASE) * 500 MG ORAL TABLET


2 MG (BASE) * 1,000 MG ORAL TABLET


4 MG (BASE) * 1,000 MG ORAL TABLET


00002247085

00002247086

00002248440

00002247087

00002248441

00002333554

AVANDAMET

AVANDAMET

AVANDAMET

AVANDAMET

AVANDAMET

ONGLYZA

GSK

GSK

GSK

GSK

GSK

BMS

0.6421

1.1611

1.2682

1.5946

1.7337

2.7560


$

$

$

$

$

$

Section 3 .



"For the treatment of Type 2 diabetes in patients who have an inadequate response to a sufficient trial (i.e. a minimum of 6 months) of metformin."










SITAGLIPTIN PHOSPHATE MONOHYDRATE

SITAGLIPTIN PHOSPHATE MONOHYDRATE/ METFORMIN HCL

100 MG ORAL TABLET

50 MG * 500 MG ORAL TABLET


50 MG * 1,000 MG ORAL TABLET

00002303922

00002333856

00002333864

00002333872

JANUVIA

JANUMET

JANUMET

JANUMET

MFC

MFC

MFC

MFC

2.8863

1.5641

1.5641

1.5641


$

$

$

$

Section 3 .













SOLIFENACIN SUCCINATE

SOMATROPIN

SOMATROPIN R-DNA ORIGIN

5 MG ORAL TABLET

10 MG ORAL TABLET







8 MG / ML INJECTION


00002277263

00002277271

00002243077

00002243078

0000232506300002215136

00002237971

00002350122

00002325071

0000235013000002350149

00002272083

VESICARE

VESICARE

HUMATROPE

HUMATROPE

OMNITROPESAIZEN

SAIZEN

SAIZEN

OMNITROPE

SAIZEN (1.5 ML)SAIZEN (2.5 ML)

SAIZEN

ASP

ASP

LIL

LIL

SDZSRO

SRO

SRO

SDZ

SROSRO

SRO

1.5000

1.5000

280.0200

560.0400

103.8667 144.9000

217.5200

261.0000

207.7333

348.0000 348.0000

348.0300



$

$

$

$

$$

$

$

$

$$

$

Section 3 .



"For patients who are intolerant to oxybutynin.


"For replacement of endogenous growth hormone in adults with severe growth hormone deficiency. Information is required regarding the results of a diagnostic insulin tolerance test. Growth hormone values less than 3 mcg/litre during hypoglycemia are indicative of severe growth hormone deficiency.



"For replacement of endogenous growth hormone in adults with severe growth hormone deficiency. Information is required regarding the results of a diagnostic insulin tolerance test. Growth hormone values less than 3 mcg/litre during hypoglycemia are indicative of severe growth hormone deficiency.






SULFUR/ SULFACETAMIDE SODIUM

SUMATRIPTAN HEMISULFATE

5 % * 10 % TOPICAL LOTION

5 MG / DOSE (BASE) NASAL UNIT DOSE SPRAY


00002220407

00002230418

00002230420

SULFACET-R

IMITREX

IMITREX

VCL

GSK

GSK

0.9628

14.3859

14.8045


$

$

$

Section 3 .

"For the treatment seborrheic dermatitis and bacterial folliculitis.





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






SUMATRIPTAN SUCCINATE




000022683880000236625800002257890000022689140000228682300002256436000022630250000228652100002212153

00002268396000023662660000225790400002268922000022393670000228683100002256444000022630330000228654800002212161

0000236169800002212188

APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF

APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF

SUMATRIPTAN SUN (0.5 ML)IMITREX (0.5 ML)

APXAVACOBMYPTEVPMSSDZSNSGSK

APXAVACOBMYPTEVTEVPMSSDZSNSGSK

SPGGSK

7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350

15.1567

7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600

16.6968

16.5889 44.0900


$$$$$$$$$

$$$$$$$$$$

$$

Section 3 .



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







SYNTHETIC CALCITONIN SALMON (SALCATONIN)

TACROLIMUS

200 IU / DOSE NASAL METERED DOSE SPRAY

0.1 % TOPICAL OINTMENT

000022475850000226176600002240775

00002244148

APO-CALCITONINSANDOZ CALCITONIN NSMIACALCIN

PROTOPIC

APXSDZNOV

ASP

1.4000 1.4000 2.1888

2.3005


$$$

$

Section 3 .

"For use in patients 16 years of age and older with atopic dermatitis affecting face and flexures who are unable to tolerate or have failed topical steroid therapy."

"For use in patients 16 years of age and older with atopic dermatitis who require ongoinguse of potent (Class 3 or higher) topical steroids over greater than 30 % of body surface area."


Information is required regarding the patient's diagnosis, previous medications utilized (including specific topical steroids) and the patient's response to therapy. In order to comply with the first criteria, information is also required regarding the area(s) affected. In order to comply with the second criteria, information is also required regarding the percentage body surface area affected.


"For the treatment of osteoporosis in patients with documented evidence of intolerance or lack ofresponse to etidronate (i.e. demonstrated as a >2% loss in bone mineral density in one year).Special authorization may be granted for 6 months."

"Coverage cannot be provided for two or more osteoporosis medications (alendronate,calcitonin, denosumab, etidronate, raloxifene, risedronate) when these medications are intendedfor use ascombination therapy."


All requests for synthetic calcitonin salmon must be completed using theAlendronate/Raloxifene/Risedronate/Synthetic Calcitonin Salmon for Osteoporosis Special Authorization Request Form (ABC 31086).




TACROLIMUS

TESTOSTERONE

TESTOSTERONE UNDECANOATE


12.2 MG TRANSDERMAL PATCH

24.3 MG TRANSDERMAL PATCH

40 MG ORAL CAPSULE

00002244149

00002239653

00002245972

00000782327

PROTOPIC

ANDRODERM (2.5 MG/DAY)

ANDRODERM (5 MG/DAY)

ANDRIOL

ASP

PAL

PAL

MFC

2.1498

1.9959

3.9919

0.9400


$

$

$

$

Section 3 .

"For use in patients 2 to 15 years of age inclusive with atopic dermatitis who are unable to tolerate or have failed topical steroid therapy."

"For use in patients 2 to 15 years of age inclusive with atopic dermatitis who require ongoing use of potent (Class 3 or higher) topical steroids."

"For use in patients 16 years of age and older with atopic dermatitis affecting face and flexures who are unable to tolerate or have failed topical steroid therapy."

"For use in patients 16 years of age and older with atopic dermatitis who require ongoinguse of potent (Class 3 or higher) topical steroids over greater than 30 % of body surface area."


Information is required regarding the patient's diagnosis, previous medications utilized (including specific topical steroids) and the patient's response to therapy. In order to comply with the third criteria, information is also required regarding the area(s) affected. In order to comply with the fourth criteria, information is also required regarding the percentage body surface area affected.


"For use in males for the treatment of congenital and acquired primary and secondary hypogonadism."

"Coverage cannot be considered when used for the treatment of androgen decline in the aging male (ADAM)."



"For use in males for the treatment of congenital and acquired primary and secondary hypogonadism."

"Coverage cannot be considered when used for the treatment of androgen decline in the aging male (ADAM)." "Special authorization may be granted for 6 months."





TETRABENAZINE

TIZANIDINE HCL

25 MG ORAL TABLET


00002199270

000022598930000227205900002239170

NITOMAN

APO-TIZANIDINEMYLAN-TIZANIDINEZANAFLEX

VCL

APXMYPPAL

6.9360

0.3686 0.3686 0.7746


$

$$$

Section 3 .

"For the treatment of hyperkinetic movement disorders when prescribed by specialists in Neurology, Psychiatry, or Geriatric Medicine.




FIRST-LINE DRUG PRODUCT(S): DIAZEPAM OR BACLOFEN

"For the treatment of spasticity in patients with documented evidence of intolerance or lack of response to diazepam or baclofen. Special authorization is granted for 24 months."



TOCILIZUMAB




- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who do not exhibit a clinicalresponse to PO methotrexate or experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory; AND- Methotrexate with other disease modifying anti-rheumatic agent(s) (minimum 4-month trial). [e.g., methotrexate with hydroxychloroquine or methotrexate with sulfasalazine]; AND- Leflunomide (minimum 10 week trial at 20 mg daily); AND- At least one anti-tumor necrosis factor (anti-TNF) therapy (e.g., etanercept, infliximab oradalimumab) (minimum 12 week trial); AND- Abatacept or rituximab (minimum 12 - 16 week trial).




- Initial coverage may be approved for one dose of 4 mg/kg or 8 mg/kg (up to a maximum of 800mg per dose) of tocilizumab administered at 0, 4, 8, 12 and 16 weeks (total of 5 doses).- Patients will be limited to receiving one dose of tocilizumab per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another (with the exception ofanakinra) following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum thecompletion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they weredeemed unresponsive to therapy.- Patients will not be permitted to switch from anakinra to other biologic agents except underexceptional circumstances.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage beyond the initial 5 doses, the patient must meet the following criteria:1) The patient must be assessed by an RA Specialist after 16 weeks, but no longer than 20 weeks after treatment to determine response.2) The RA Specialist must confirm in writing that the patient is a 'responder' that meets the following criteria:- ACR20 OR an improvement of 1.2 units in the DAS28 score [reported to one (1) decimal place]; AND- An improvement of 0.22 in HAQ score [reported to two (2) decimal places].It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above.

Following this assessment, continued coverage may be approved for one dose of 4 mg/kg to 8 mg/kg (up to a maximum of 800 mg per dose) every 4 weeks, for a period of 12 months. Ongoing coverage may be considered only if the following criteria are met at the end of each 12-month period:1) The patient has been assessed by an RA Specialist to determine response;2) The RA Specialist must confirm in writing that the patient has maintained a response to




TOCILIZUMAB

TOLTERODINE L-TARTRATE

TRETINOIN




2 MG ORAL EXTENDED-RELEASE CAPSULE


0.01 % TOPICAL CREAM



0.1 % TOPICAL CREAM

0.01 % TOPICAL GEL

0.025 % TOPICAL GEL

00002350092

00002350106

00002350114

00002244612

00002244613

00000657204

00000578576

00000518182

00000662348

00001926462

0000192647000000587966

ACTEMRA (4 ML)

ACTEMRA (10 ML)

ACTEMRA (20 ML)

DETROL LA

DETROL LA

STIEVA-A

STIEVA-A

STIEVA-A

STIEVA-A FORTE

VITAMIN A ACID

VITAMIN A ACIDSTIEVA-A

HLR

HLR

HLR

PFI

PFI

GSK

GSK

GSK

GSK

VCL

VCLGSK

179.2000

448.0000

896.0000

1.9122

1.9122

0.2996

0.2996

0.2996

0.2996

0.2964

0.2964 0.2996


$

$

$

$

$

$

$

$

$

$

$$

Section 3 .

therapy as indicated by:- Confirmation of maintenance of ACR20, OR - Maintenance of a minimum improvement of 1.2 units in DAS28 score [reported to one (1) decimal place] from baseline.3) A current HAQ score [reported to two (2) decimal places] must be included with all renewalrequests.It should be noted that the initial score for the DAS28 or HAQ score on record will be rounded to the correct number of decimal places as indicated above."

All requests (including renewal requests) for tocilizumab for Rheumatoid Arthritis must becompleted using the Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/ Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form (ABC 30902).



"For patients who are intolerant to oxybutynin."







TRETINOIN

TROSPIUM CHLORIDE

0.05 % TOPICAL GEL

20 MG ORAL TABLET

0000192648900000641863

00002275066

VITAMIN A ACIDSTIEVA-A

TROSEC

VCLGSK

SUN

0.2964 0.2996

0.7635


$$

$

Section 3 .



"For patients who are intolerant to oxybutynin."





USTEKINUMAB

45 MG INJECTION VIAL OR SYRINGE00002320673 STELARA (0.5 ML VIAL OR SYRINGE) JAI 4399.5900


For this product - pricing has been established on a per vial or syringe basis.$

Section 3 .

"Special authorization coverage may be provided for the reduction in signs and symptoms of severe, debilitating plaque psoriasis in patients who:- Have a total PASI of 10 or more and a DLQI of more than 10, OR- Who have significant involvement of the face, palms of the hands, soles of the feet or genital region; AND- Who are refractory to or intolerant to:- Methotrexate at 20 mg (PO, SC or IM) or greater total weekly dosage (15 mg or greater if patient is 65 years of age or older) for more than 12 weeks. Patients who experience gastrointestinal intolerance to PO methotrexate must have a trial of parenteral methotrexate before being accepted as refractory, OR- Cyclosporine (6 weeks treatment); AND- Phototherapy (unless restricted by geographic location)




- Initial coverage may be approved for three doses of 45 mg at weeks 0, 4 and 16.- Patients will be limited to receiving one dose per prescription at their pharmacy.- Patients will be permitted to switch from one biologic agent to another following an adequate trial of the first biologic agent if unresponsive to therapy, or due to serious adverse effects or contraindications. An adequate trial is defined as at a minimum the completion of induction dosing (e.g. initial coverage period).- Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to therapy.- Patients are limited to receiving one biologic agent at a time regardless of the condition for which it is being prescribed.

For continued coverage, the patient must meet all of the following criteria:1) The patient must be assessed by a Dermatology Specialist after the initial16 weeks of therapyto determine response.2) The Dermatology Specialist must confirm, in writing, that the patient is a 'responder' that meets the following criteria:- Greater than or equal to 75% reduction in PASI score, OR- Greater than or equal to 50% reduction in PASI score AND improvement of greater than or equal to 5 points in the DLQI.

Following this assessment, continued coverage may be considered for 45 mg every 12 weeks for a period of 12 months. Ongoing coverage may be considered if the patient is re-assessed by a Dermatology Specialist every 12 months and is confirmed to be continuing to respond to therapy by meeting criteria as outlined in (2) above."

All requests (including renewal requests) for ustekinumab for Plaque Psoriasis must be completed using the Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (ABC 31192).



VALGANCICLOVIR HCL

VANCOMYCIN HCL

VARENICLINE TARTRATE






00002245777

00000800430

00000788716

00002291177

00002291185

VALCYTE

VANCOCIN

VANCOCIN

CHAMPIX

CHAMPIX

HLR

MLI

MLI

PFI

PFI

22.8582

7.5573

15.1141

1.7206

1.7205


$

$

$

$

$

Section 3 .

"For the treatment of CMV retinitis in patients with acquired immunodeficiency syndrome (AIDS).""Special authorization may be granted for 12 months."

"For the prevention of CMV disease in solid organ transplant patients at risk (i.e. risk is defined as donor +ve/recipient -ve for CMV, or recipient +ve post-active treatment of CMV disease with IV ganciclovir, or recipient +ve in patients receiving antilymphocyte antibody [ALA]). For the purpose of administering this criterion, islet transplant recipients are at similar risk of CMV disease to patients undergoing a solid organ transplant and qualify for drug coverage.""Special authorization may be granted for 100 days."

"For the prevention of CMV disease in kidney transplant patients at risk (i.e. risk is defined as donor +ve/recipient -ve for CMV, or recipient +ve post-active treatment of CMV disease with IV ganciclovir, or recipient +ve in patients receiving antilymphocyte antibody [ALA]).""Special authorization may be granted for 200 days."


1) Clostridium difficile enteritis if there is clinical deterioration or documented failure on metronidazole therapy. Documented failure is defined as no clinical improvement after 5 days oftherapy or

2) Laboratory confirmed relapse of Clostridium difficile enteritis with symptoms after 2 courses ofmetronidazole therapy or

3) Clostridium difficile enteritis if there is documented or impending toxic megacolon or

4) Clostridium difficile enteritis if there is intolerance or side effects to metronidazole therapy."

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.




VARENICLINE TARTRATE/ VARENICLINE TARTRATE

VORICONAZOLE

0.5 MG * 1 MG ORAL TABLET

50 MG ORAL TABLET

200 MG ORAL TABLET


00002298309

00002256460

00002256479

00002256487

CHAMPIX (STARTER PACK)

VFEND

VFEND

VFEND

PFI

PFI

PFI

PFI

1.7208

12.4818

49.9064

142.9416


$

$

$

$

Section 3 .

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.

"For the treatment of invasive aspergillosis for post-hospital discharge only."

"For treatment of culture proven invasive candidiasis with documented resistance to fluconazole."

"This medication must be prescribed in consultation with a specialist in Infectious Diseases."



ZAFIRLUKAST

ZOLEDRONIC ACID

ZOLEDRONIC ACID

20 MG ORAL TABLET



00002236606

00002269198

00002248296

ACCOLATE

ACLASTA

ZOMETA CONCENTRATE

AZC

NOV

NOV

0.7492

6.7080

110.8160


$

$

$

Section 3 .

"For the treatment of Paget's disease. Special Authorization for this criterion may be granted for one dose per 12 month period."

"Coverage cannot be provided for two or more medications used in the treatment of Paget's disease when these medications are intended for use in combination or when therapy with two or more medications overlap."

"For the treatment of tumor-induced hypercalcemia in patients with documented evidence of intolerance or lack of response to clodronate or pamidronate. Special authorization may be granted for 6 months."


(Refer to 48:10.24 of the Alberta Health and Wellness Drug Benefit List for coverage of patients 12 to 18 years of age inclusive).

"For the prophylaxis and chronic treatment of asthma in patients over the age of 18 who meet one of the following criteria:

a) when used as adjunctive therapy in patients who do not respond adequately to high doses of inhaled glucocorticosteroids and long-acting beta 2 agonists. Patients must be unable to use long-acting beta 2 agonists or have demonstrated persistent symptoms while on long-acting beta 2 agonists, or

b) cannot operate inhaler devices."

"For the prophylaxis of exercise-induced bronchoconstriction in patients over the age of 18 where tachyphylaxis exists for long-acting beta 2 agonists."


In order to comply with the first criteria, information should indicate either a) current use of inhaled steroids and contraindications or poor response to long-acting beta 2 agonists (e.g. salmeterol or formoterol) or, b) the nature of the patient's difficulties with using inhaler devices. In order to comply with the second criteria, information should include the nature of the patient's response to long-acting beta 2 agonists (e.g. salmeterol or formoterol).

All requests (including renewal requests) for zafirlukast must be completed using the Montelukast/Zafirlukast Special Authorization Request Form (ABC 31313).





ZOLMITRIPTAN

2.5 MG ORAL TABLET

2.5 MG ORAL DISPERSIBLE TABLET

5 MG / DOSE NASAL UNIT DOSE SPRAY

0000236903600002324229000023629880000231396000002238660

00002324768000023629960000234254500002243045

00002248993

MYLAN-ZOLMITRIPTANPMS-ZOLMITRIPTANSANDOZ ZOLMITRIPTANTEVA-ZOLMITRIPTANZOMIG

PMS-ZOLMITRIPTAN ODTSANDOZ ZOLMITRIPTAN ODTTEVA-ZOLMITRIPTAN ODZOMIG RAPIMELT

ZOMIG

MYPPMSSDZTEVAZC

PMSSDZTEVAZC

AZC

5.2110 5.2110 5.2110 5.2110

13.8500

5.2110 5.2110 5.2110

13.8500

13.8500


$$$$$

$$$$

$

Section 3 .



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





Section 3A C

riteria for Optional Special A

uthorization of Select Drug Products

SECTION 3A

Criteria for Optional Special Authorization

of Select Drug Products

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize Professional judgment.

Section 3A EFFECTIVE JULY 1, 2012

CRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

The drug products listed in this section may be considered for coverage by optional special authorization for patients covered under Alberta Health and Wellness-sponsored drug programs. (For Alberta Human Services and Alberta Seniors (AISH) clients, the optional special authorization criteria for coverage can be found in the Criteria for Optional Special Authorization of Select Drug Products section of the Alberta Human Services Drug Benefit Supplement.)

70BCriteria for Coverage

Wording that appears within quotation marks (“ “) in this section is the official optional special authorization criteria, as recommended by the Alberta Health and Wellness Expert Committee on Drug Evaluation and Therapeutics, and approved by the Minister of Health and Wellness. Wording that is not enclosed in quotation marks outlines specific information required to interpret criteria, guidelines for submitting requests and/or information regarding conditions under which coverage cannot be provided.

71BRole of the Prescribers

In conjunction with the criteria, prescribers have two options by which patients may be eligible for coverage of these select optional special authorization drug products.

1) Prescribers can register to be a designated prescriber. Registration allows for patients to receive coverage of select drug products without special authorization as long as the prescription is written for one of the criteria for coverage set out in this section. Should a designated prescriber wish to prescribe one of the select drug products outside the coverage criteria, they may do so but must indicate this on the prescription; however, patients will not be eligible for payment under the Alberta government-sponsored program for such prescription and the patient may choose to receive the product at their expense. The registration form may be found on the previous page.

2) Prescribers who choose not to register will be considered non-designated prescribers. Such prescribers will be required to apply for special authorization on the patient’s behalf.

ALBERTA GOVERNMENT SPONSORED DRUG BENEFIT PROGRAMS OPTIONAL SPECIAL AUTHORIZATION

REGISTRATION FOR DESIGNATED PRESCRIBER STATUS for Alberta Health and Wellness Drug Benefit List Claim Coverage

Select Quinolone Antibiotics

ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin

Please complete all sections of this form and return it by fax to Alberta Blue Cross

Registrations will be accepted on an ongoing basis

PRESCRIBER SURNAME FIRST NAME INITIAL OFFICE PHONE: FAX:

OFFICE ADDRESS CITY PROVINCE POSTAL CODE

COLLEGE OF PHYSICIANS AND SURGEONS REGISTRATION NO. OR PROFESSIONAL REGISTRATION NO.

I have reviewed the criteria for coverage of select quinolone products, and I agree to abide by and only prescribe in accordance with such criteria as updated from time to time in the Optional Special Authorization section of the Alberta Health and Wellness Drug Benefit List.

SIGNATURE OF PRESCRIBER (required): DATE:


PLEASE RETURN YOUR COMPLETED REGISTRATION BY FAX TO 1-877-305-9911 ABC 81897 Reg Form (R12/2011)

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LISTCRITERIA FOR OPTIONAL SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS

CIPROFLOXACIN

100 MG / ML ORAL SUSPENSION00002237514 CIPRO BAI 0.5699


$


1) Respiratory Tract Infections: -end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection or - pneumonic illness in cystic fibrosis; or

2) Genitourinary Tract Infections: - urinary tract infections, - prostatitis, - prophylaxis of urinary tract surgical procedures or - gonococcal infections; or

3) Skin and Soft Tissue/Bone and Joint Infections: - malignant/invasive otitis externa, - bone/joint infections due to gram negative organisms or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or

4) Gastrointestinal Tract Infections: - bacterial gastroenteritis where antimicrobial therapy is indicated, - typhoid fever (enteric fever), or- therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or

5) Other: - prophylaxis of adult contacts of cases of invasive meningococcal disease, - therapy/step-down therapy of hospital acquired gram negative infections, - empiric therapy of febrile neutropenia in combination with other appropriate agents or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs.- for use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."

All requests for ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).

Section 3A

Patient claims for select quinolone prescriptions written by a non-designated prescriber will be subject to a first forgiveness rule, meaning the first claim will be paid. Subsequent claims for the same product (irrespective of strength, route and form) within a 90-day period would require the prescriber to apply for special authorization for coverage on the patient�s behalf.

.

Criteria For Optional Special Authorization Of Select Drug Products




CIPROFLOXACIN HCL

250 MG (BASE) ORAL TABLET00002229521000023321320000235331800002247339000023796860000231742700002245647000021617370000224843700002303728000022468250000224875600002155958

APO-CIPROFLOXCIPROFLOXACINCIPROFLOXACINCO CIPROFLOXACINMAR-CIPROFLOXACINMINT-CIPROFLOXACINMYLAN-CIPROFLOXACINNOVO-CIPROFLOXACINPMS-CIPROFLOXACINRAN-CIPROFLOXRATIO-CIPROFLOXACINSANDOZ CIPROFLOXACINCIPRO

APXRANSNSCOBMARMPIMYPTEVPMSRANRPHSDZBAI

0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 0.9309 2.4742


$$$$$$$$$$$$$

"For the treatment of

1) Respiratory Tract Infections: - end stage COPD with or without bronchiectasis, where there has been documentation of previous Pseudomonas aeruginosa colonization/infection; or - pneumonic illness in cystic fibrosis; or

2) Genitourinary Tract Infections: - urinary tract infections; or - prostatitis; or - prophylaxis of urinary tract surgical procedures; or - gonococcal infections; or

3) Skin and Soft Tissue/Bone and Joint Infections: - malignant/invasive otitis externa; or - bone/joint infections due to gram negative organisms; or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. diabetic foot infection, decubitus ulcers; or

4) Gastrointestinal Tract Infections: - bacterial gastroenteritis where antimicrobial therapy is indicated; or - typhoid fever (enteric fever); or - therapy/step-down therapy of polymicrobial infections in combination with clindamycin or metronidazole e.g. intra-abdominal infections; or

5) Other: - prophylaxis of adult contacts of cases of invasive meningococcal disease; or- therapy/step-down therapy of hospital acquired gram negative infections; or- empiric therapy of febrile neutropenia in combination with other appropriate agents; or - exceptional case of allergy or intolerance to all other appropriate therapies as defined by relevant guidelines/references i.e. AMA CPGs or Bugs and Drugs; orfor use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."

All requests for Ciprofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).

Section 3A .The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.


CIPROFLOXACIN HCL500 MG (BASE) ORAL TABLET


00002229522000023321400000235332600002247340000023796940000231743500002245648000021617450000224843800002303736000022468260000224875700002155966

00002229523000023321590000235333400002247341000023797080000231744300002245649000021617530000224843900002303744000022468270000224875800002155974





1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 1.0503 2.7915

1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 1.9233 5.1118


$$$$$$$$$$$$$

$$$$$$$$$$$$$




LEVOFLOXACIN

250 MG ORAL TABLET

500 MG ORAL TABLET

750 MG ORAL TABLET

0000228470700002361027000023154240000231397900002248262000022846770000229863500002236841

0000228471500002361035000023154320000231398700002248263000022846850000229864300002236842

000023154400000228564900002325942000023055850000229865100002246804

APO-LEVOFLOXACINAVA-LEVOFLOXACINCO LEVOFLOXACINMYLAN-LEVOFLOXACINNOVO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN

APO-LEVOFLOXACINAVA-LEVOFLOXACINCO LEVOFLOXACINMYLAN-LEVOFLOXACINNOVO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN

CO LEVOFLOXACINNOVO-LEVOFLOXACINAPO-LEVOFLOXACINPMS-LEVOFLOXACINSANDOZ LEVOFLOXACINLEVAQUIN

APXAVACOBMYPTEVPMSSDZJAI

APXAVACOBMYPTEVPMSSDZJAI

COBTEVAPXPMSSDZJAI

1.8655 1.8655 1.8655 1.8655 1.8655 1.8655 1.8655 4.9581

2.1050 2.1050 2.1050 2.1050 2.1050 2.1050 2.1050 5.5946

4.8478 4.8478 4.8479 4.8479 4.8480 9.8990


$$$$$$$$

$$$$$$$$

$$$$$$

"To be prescribed according to ONE of the following criteria:

For the treatment of

1) Community acquired pneumonia after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or

3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or

5) For use in other current Health Canada approved indications when prescribed by a specialist in Infectious Diseases."

All requests for Levofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).



MOXIFLOXACIN HCL

OFLOXACIN


200 MG ORAL TABLET

300 MG ORAL TABLET

400 MG ORAL TABLET

00002242965

00002231529

00002231531

00002231532

AVELOX

OFLOXACIN

OFLOXACIN

OFLOXACIN

BAI

AAP

AAP

AAP

5.9428

1.3041

1.5323

1.5323


$

$

$

$



1) Community acquired pneumonia after failure of first line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

2) Community acquired pneumonia in patients with co-morbidities (asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition or acute weight loss, hospitalization within previous 3 months, HIV/AIDS, smoking); or

3) Acute exacerbation of chronic bronchitis after failure of first and second line therapy, as defined by clinical deterioration after 72 hours of antibiotic therapy or lack of improvement after completion of antibiotic therapy; or

4) Acute sinusitis after failure of first line therapy, as defined by clinical deterioration after 72 h ofantibiotic therapy or lack of improvement after completion of antibiotic therapy, in patients with beta-lactam (penicillin and cephalosporin) allergy; or


All requests for Moxifloxacin HCl must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).



1) Pelvic inflammatory disease; or

2) Epididymo-orchitis/epididymitis most likely due to enteric organisms; or

3) Chlamydia infection; or

4) Gonococcal infection; or


All requests for Ofloxacin must be completed using the Select Quinolones Special Authorization Request Form (ABC 30966).


Section 4 Rare D

iseases Drug C

overage Program

SECTION 4

Rare Diseases Drug Coverage Program

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST RARE DISEASES DRUG COVERAGE PROGRAM



RARE DISEASES DRUG COVERAGE PROGRAM

Selected drug products used in the treatment of rare diseases may be considered for coverage for individuals covered under Alberta government-sponsored drug programs. The Minister of Health and Wellness makes the final decisions regarding coverage under this Program, and may list a drug product under this section when the Minister considers it in the public interest to do so.1

.

RARE DISEASES DRUG COVERAGE

In order to be eligible for the Rare Diseases Drug Coverage Program, an individual must: • have Alberta government-sponsored drug coverage; • be continuously registered in the Alberta Health Care Insurance Plan for a minimum of five

years unless: the individual is less than five years of age at the date of the application, then the

individual’s parent/guardian/legal representative must be registered continuously in the Alberta Health Care Insurance Plan for a minimum of five years;

OR the individual has moved to Alberta from another province or territory in Canada (the

“province of origin”), and immediately prior to moving to Alberta, was covered for a drug product listed in this section in the province of origin by a provincial or territorial government sponsored drug plan, and

• meet the clinical criteria for a rare disease drug product published on the List;

the individual has been registered in the Alberta Health Care Insurance Plan (the individual must provide supporting documentation from the province of origin to prove prior coverage).

• have a Rare Diseases Drug Coverage Application form (“Application”) submitted on their behalf to Alberta Blue Cross by the individual’s “Rare Disease Specialist”;

• have the Application reviewed and approved for coverage by the Alberta Rare Diseases Clinical Review Panel (“Review Panel”)

• complete the required forms, and consent to and acknowledge that approval for initial and continued coverage is conditional upon clinical outcomes; regular monitoring of the individual’s clinical outcomes will be required, and that coverage will be discontinued if there is inadequate response or the individual’s

condition deteriorates as outlined in the withdrawal criteria established in relation to a specific rare diseases drug product and/or as assessed by the Review Panel.

Contraindications

In addition to meeting the above criteria, the individual must not have the following contraindications: • Significant illness, not including one of the rare diseases, likely to substantially alter or reduce

life expectancy.

1 Section 1 of the AHWDBL does not apply to the Rare Diseases Drug Coverage Program



Rare Diseases Drugs Eligible for Coverage

Drug products approved by Health Canada for the treatment of Rare Diseases may be considered for coverage in accordance with this section. Rare Diseases are genetic, lysosmal storage disorders occurring at a rate of less than one per 50,000 for the Canadian population for a specific disease (as determined by Alberta Health and Wellness). As of April 1, 2009, drug products for the treatment of the following rare diseases are currently under consideration for coverage: • Gaucher’s disease • Fabry disease • MPS-I (Hurler/Hurler Scheie) • Hunter disease • Pompe disease

Alberta Rare Diseases Clinical Review Panel

The Alberta Rare Diseases Clinical Review Panel (“Review Panel”) is a review panel composed of specialists treating rare diseases and other health professionals with clinical expertise, appointed by the Minister of Health and Wellness. The Review Panel’s functions include: • Providing advice to Alberta Health and Wellness regarding the Rare Diseases Drug Coverage

Program; • Reviewing and applying clinical knowledge and skills to individual applications for Rare

Diseases Drug Coverage; and • Providing advice to the Expert Committee on Drug Evaluation and Therapeutics regarding

drug products under consideration for coverage under this section, clinical criteria for rare diseases drug products and identifying appropriate “Rare Disease Specialists”.

Process for Rare Diseases Drug Coverage

Participating “Rare Disease Specialists” must complete a Rare Diseases Drug Coverage Application form for each individual. The form must be the one specific to the rare diseases drug product being requested. The completed application may be forwarded to Alberta Blue Cross by mail or by facsimile. To be considered for Rare Diseases Drug Coverage, the “Rare Disease Specialist” must confirm the individual (or individual’s parent/guardian/legal representative) has been provided with information regarding the Rare Diseases Drug Coverage Program and have completed the required forms.

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST RARE DISEASES DRUG COVERAGE PROGRAM



Alberta Blue Cross, in providing administrative support to the Review Panel, receives and screens each application for completeness, then forwards to Alberta Health and Wellness to confirm that the individual has met the Alberta Health Care Insurance Plan registration requirement (please see above). Once it has been confirmed that the individual meets the Alberta Health Care Insurance Plan registration requirement, Alberta Blue Cross forwards the application to the Review Panel for assessment. Alberta Blue Cross responds to applicants on the Review Panel’s behalf. After an application has been assessed by the Review Panel, Alberta Blue Cross notifies the individual’s “Rare Disease Specialist” and the individual or individual’s parent/guardian/legal representative by letter of the Review Panel’s decision. Eligibility will be effective the date coverage is approved by the Review Panel. Renewals require a new drug product specific Rare Diseases Drug Coverage Application form that is completed by a “Rare Disease Specialist”. To be eligible for Rare Diseases Drug Coverage, prescriptions must be written by a “Rare Disease Specialist” as identified by the eligibility criteria for the drug product. To avoid wastage, prescription quantities are limited to a one-month supply. Extended quantity and vacation supplies are not permitted. Out-of-country claims will only be reimbursed in accordance with standard rules and regulations; individuals should verify with Alberta Blue Cross these rules and regulations prior

to obtaining drug products out of the country.

Government will not be responsible for reimbursement of costs associated with wastage or improper storage of rare diseases drug products. Prior approval must be granted to ensure coverage. Approval is granted for a specific period, to a maximum of 12 months. If continued treatment is necessary, it is the responsibility of the individual or individual’s parent/guardian/legal representative and the “Rare Disease Specialist” to re-apply for drug product coverage prior to the expiry date of the authorization period.

Pharmacologic -Therapeutic C

lassification of Drugs

PART 2

Pharmacologic – Therapeutic Classification of Drugs

00:00

Non-Classified Drugs

00:00 Antihistam

ine Drugs


DIABETES SUPPLIES

0000099995500000999941000009999850000099995200000999957

BLOOD GLUCOSE TEST STRIPSBLOOD LETTING LANCETINSULIN PEN NEEDLESINSULIN SYRINGESURINE TEST STRIPS

XXXXXXXXXXXXXXX

NON-CLASSIFIED DRUGS00:00

00:00.02

0.0000 0.0000 0.0000 0.0000 0.0000



$$$$$

This product is a benefit for patients with diabetes who are currently and regularly using insulin.

Eligible individuals will have coverage to a maximum of $600 per person each benefit year for eligible diabetic supplies purchased from a licensed pharmacy.

(DIABETES SUPPLIES)


04:00 Antihistam

ine Drugs

04:00

Antihistamine Drugs


DIPHENHYDRAMINE HCL

PROMETHAZINE HCL

TRIMEPRAZINE TARTRATE

KETOTIFEN FUMARATE






0.2 MG / ML (BASE) ORAL SYRUP

00000596612

00000567434

00001926306

00001926292

00000577308

00002176084

DIPHENHYDRAMINE

PROMETHAZINE

PANECTYL

PANECTYL

ZADITEN

NOVO-KETOTIFEN

SDZ

SDZ

ERF

ERF

TEV

TEV

ANTIHISTAMINE DRUGS

ANTIHISTAMINE DRUGS

ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

FIRST GENERATION ANTIHISTAMINES

OTHER ANTIHISTAMINES

04

04

04

:00

:00

:00

04:04.04

04:04.12

04:92

3.7630

1.0698

0.2710

0.3325

1.6722

0.1397



$

$

$

$

$

$

(ETHANOLAMINE DERIVATIVES)

(PHENOTHIAZINE DERIVATIVES)


08:00 Anti-Infective A

gents

08:00

Anti-Infective Agents


MEBENDAZOLE

GENTAMICIN SULFATE

TOBRAMYCIN

TOBRAMYCIN SULFATE

CEFAZOLIN SODIUM

CEPHALEXIN

100 MG ORAL CHEWABLE TABLET


28 MG INHALATION CAPSULE

60 MG / ML (BASE) INHALATION SOLUTION




1 G / VIAL (BASE) INJECTION


250 MG ORAL TABLET

500 MG ORAL TABLET

250 MG ORAL CAPSULE

500 MG ORAL CAPSULE


00000556734

00002242652

00002365154

00002239630

00002241209

00002241210

00002237137

00002237138

00002237140

0000076872300000583413

0000076871500000583421

00000342084

00000342114

00000342106

VERMOX

GENTAMICIN

TOBI PODHALER

TOBI

TOBRAMYCIN

TOBRAMYCIN

CEFAZOLIN

CEFAZOLIN

CEFAZOLIN

APO-CEPHALEXNOVO-LEXIN

APO-CEPHALEXNOVO-LEXIN

NOVO-LEXIN

NOVO-LEXIN

NOVO-LEXIN

JAI

SDZ

NOV

NOV

SDZ

SDZ

PPC

PPC

PPC

APXTEV

APXTEV

TEV

TEV

TEV

(FIRST GENERATION CEPHALOSPORINS)

ANTI-INFECTIVE AGENTS



ANTHELMINTICS

ANTIBACTERIALS

ANTIBACTERIALS

08

08

08

:00

:00

:00

08:08

08:12.02

08:12.06.04

3.8536

2.7581

12.8588

10.2870

2.1535

2.9860

2.5000

3.7500

35.0000

0.2250 0.2250

0.4500 0.4500

0.3515

0.6646

0.0885


$

$

$

$

$

$

$

$

$

$$

$$

$

$

$

(AMINOGLYCOSIDES)

CEPHALOSPORINS




CEPHALEXIN

CEFPROZIL


250 MG ORAL TABLET

500 MG ORAL TABLET



00000342092

00002292998000023472450000236284800002332035000022935280000230217900002163659

00002293005000023472530000236285600002332043000022935360000230218700002163667

000022939430000234726100002362864000023292040000230342600002163675

00002293951000023472880000236287200002332027000022935790000230343400002163683

NOVO-LEXIN

APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILCEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL


APO-CEFPROZILAURO-CEFPROZILAVA-CEFPROZILRAN-CEFPROZILSANDOZ CEFPROZILCEFZIL


TEV

APXAURAVARANRANSDZBMS


APXAURAVARANSDZBMS


(FIRST GENERATION CEPHALOSPORINS)

(SECOND GENERATION CEPHALOSPORINS)



ANTIBACTERIALS

ANTIBACTERIALS

08

08

:00

:00

08:12.06.04

08:12.06.08

0.1390

0.6319 0.6319 0.6319 0.6319 0.6319 0.6319 1.8054

1.2389 1.2389 1.2389 1.2389 1.2389 1.2389 3.5398

0.0618 0.0618 0.0618 0.0618 0.0618 0.1765

0.1234 0.1234 0.1234 0.1234 0.1234 0.1234 0.3526


$

$$$$$$$

$$$$$$$

$$$$$$

$$$$$$$

CEPHALOSPORINS

CEPHALOSPORINS



CEFUROXIME AXETIL

CEFIXIME

CEFOTAXIME SODIUM

CEFTAZIDIME

CEFTRIAXONE SODIUM



400 MG ORAL TABLET








0.25 G / VIAL (BASE) INJECTION



00002244393000023448230000224265600002212277

00002244394000023448310000224265700002212285

00000868981

00000868965

00002225085

00002225093

00002225107

00002212218

00002212226

00002212234

00002292866

0000229227000002292874

0000229228900002292882

APO-CEFUROXIMEAURO-CEFUROXIMERATIO-CEFUROXIMECEFTIN

APO-CEFUROXIMEAURO-CEFUROXIMERATIO-CEFUROXIMECEFTIN

SUPRAX

SUPRAX

CLAFORAN

CLAFORAN

CLAFORAN

FORTAZ

FORTAZ

FORTAZ

CEFTRIAXONE FOR INJECTION USP

CEFTRIAXONE FOR INJECTION USPCEFTRIAXONE FOR INJECTION USP

CEFTRIAXONE FOR INJECTION USPCEFTRIAXONE FOR INJECTION USP

APXAURRPHGSK

APXAURRPHGSK

SAV

SAV

SAV

SAV

SAV

GSK

GSK

GSK

APX

SDZAPX

SDZAPX

(SECOND GENERATION CEPHALOSPORINS)

(THIRD GENERATION CEPHALOSPORINS)



ANTIBACTERIALS

ANTIBACTERIALS

08

08

:00

:00

08:12.06.08

08:12.06.12

0.7237 0.7237 0.7237 1.6527

1.4337 1.4337 1.4337 3.2740

3.5400

0.4166

6.0900

9.5800

19.1800

22.5880

44.4110

133.2967

7.5250

23.8000 23.8000

29.3125 29.3125


$$$$

$$$$

$

$

$

$

$

$

$

$

$

$$

$$

CEPHALOSPORINS

CEPHALOSPORINS




CHLORAMPHENICOL SODIUM SUCCINATE

ERYTHROMYCIN

ERYTHROMYCIN ESTOLATE

ERYTHROMYCIN ETHYLSUCCINATE

ERYTHROMYCIN STEARATE


250 MG ORAL TABLET

250 MG ORAL CAPSULE (ENTERIC-COATED PELLET)

333 MG ORAL CAPSULE (ENTERIC-COATED PELLET)

50 MG / ML (BASE) ORAL SUSPENSION




250 MG ORAL TABLET

500 MG ORAL TABLET

00000312363

00000682020

0000072667200000607142

0000192593800000873454

00000262595

00000637416

00000605859

00000652318

00000545678

00000688568

CHLOROMYCETIN

ERYTHRO-BASE

ERYTHRO-ECERYC

ERYTHRO-ECERYC

NOVO-RYTHRO ESTOLATE

ERYTHRO-ES

NOVO-RYTHRO EES

NOVO-RYTHRO EES

ERYTHRO-S

ERYTHRO-S

ERF

AAP

AAPPFI

AAPPFI

TEV

AAP

TEV

TEV

AAP

AAP

(ERYTHROMYCINS)



ANTIBACTERIALS

ANTIBACTERIALS

08

08

:00

:00

08:12.08

08:12.12.04

18.4123

0.1828

0.4193 0.4916

0.4657 0.5462

0.1270

0.3363

0.0967

0.1464

0.2118

0.5425


$

$

$$

$$

$

$

$

$

$

$

(CHLORAMPHENICOL)

MACROLIDES



AZITHROMYCIN

CLARITHROMYCIN

250 MG ORAL TABLET



250 MG ORAL TABLET

500 MG ORAL TABLET




000022474230000236336400002330881000022553400000227453100002278359000022678450000227858800002261634000022752870000226582600002212021

0000236337200002315157000022743880000233238800002223716

0000236338000002315165000022743960000233239600002223724

0000224885600002247573000022478180000226653900001984853

000023663980000224885700002247574000022478190000226654700002126710

00002244756

00002146908

00002244641

APO-AZITHROMYCINAVA-AZITHROMYCINAZITHROMYCINCO AZITHROMYCINGD-AZITHROMYCINMYLAN-AZITHROMYCINNOVO-AZITHROMYCINPHL-AZITHROMYCINPMS-AZITHROMYCINRATIO-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX

AVA-AZITHROMYCINNOVO-AZITHROMYCINPMS-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX

AVA-AZITHROMYCINNOVO-AZITHROMYCINPMS-AZITHROMYCINSANDOZ AZITHROMYCINZITHROMAX

MYLAN-CLARITHROMYCINPMS-CLARITHROMYCINRATIO-CLARITHROMYCINSANDOZ CLARITHROMYCINBIAXIN BID

AVA-CLARITHROMYCINMYLAN-CLARITHROMYCINPMS-CLARITHROMYCINRATIO-CLARITHROMYCINSANDOZ CLARITHROMYCINBIAXIN BID

BIAXIN XL

BIAXIN

BIAXIN

APXAVASNSCOBGMDMYPTEVPHHPMSRPHSDZPFI

AVATEVPMSSDZPFI

AVATEVPMSSDZPFI

MYPPMSRPHSDZABB

AVAMYPPMSRPHSDZABB

ABB

ABB

ABB

(OTHER MACROLIDES)


ANTIBACTERIALS

08:00

08:12.12.92

1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 1.8922 5.0290

0.4090 0.4090 0.4090 0.4090 1.0871

0.5796 0.5796 0.5796 0.5796 1.5404

0.5892 0.5892 0.5892 0.5892 1.6833

1.6293 1.6293 1.6293 1.6293 1.6293 3.3271

2.5144

0.2924

0.5674


$$$$$$$$$$$$

$$$$$

$$$$$

$$$$$

$$$$$$

$

$

$

MACROLIDES




PENICILLIN G SODIUM

PENICILLIN V POTASSIUM

AMOXICILLIN TRIHYDRATE

1,000,000 IU / VIAL INJECTION



300 MG ORAL TABLET

25 MG / ML ORAL LIQUID







00001930672

00000883751

00001930680

0000064221500000021202

00000642223

0000039160300000642231

00002036347

00002036355

0000235271000000628115000022381710000040672400002230243

0000235272900000628123000022381720000040671600002230244

000023527450000235276100000452149000019341710000062813100002230245

PENICILLIN G SODIUM

PENICILLIN G SODIUM

PENICILLIN G SODIUM

APO-PEN-VKNOVO-PEN-VK

APO-PEN-VK

NOVO-PEN-VKAPO-PEN-VK

NOVAMOXIN

NOVAMOXIN

AMOXICILLINAPO-AMOXIMYLAN-AMOXICILLINNOVAMOXINPMS-AMOXICILLIN

AMOXICILLINAPO-AMOXIMYLAN-AMOXICILLINNOVAMOXINPMS-AMOXICILLIN

AMOXICILLINAMOXICILLIN SUGAR-REDUCEDNOVAMOXINNOVAMOXIN SUGAR-REDUCEDAPO-AMOXIPMS-AMOXICILLIN

TEV

TEV

TEV

APXTEV

APX

TEVAPX

TEV

TEV

SNSAPXMYPTEVPMS

SNSAPXMYPTEVPMS

SNSSNSTEVTEVAPXPMS

(NATURAL PENICILLINS)

(AMINOPENICILLINS)



ANTIBACTERIALS

ANTIBACTERIALS

08

08

:00

:00

08:12.16.04

08:12.16.08

2.9003

6.1617

10.7537

0.0710 0.0710

0.0535

0.0472 0.0618

0.4505

0.6519

0.1750 0.1750 0.1750 0.1750 0.1750

0.3417 0.3417 0.3417 0.3417 0.3417

0.0352 0.0352 0.0352 0.0352 0.0353 0.0353


$

$

$

$$

$

$$

$

$

$$$$$

$$$$$

$$$$$$

PENICILLINS

PENICILLINS



AMOXICILLIN TRIHYDRATE

AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM

AMPICILLIN SODIUM


250 MG (BASE) * 125 MG (BASE) ORAL TABLET



25 MG / ML (BASE) * 6.25 MG / ML (BASE) ORAL SUSPENSION








000023527530000235278800000628158000004521300000193416300002230246

00002243350

000022437710000224335100001916858

00002245623000022481380000224702100002238829

000022439860000224464600001916882

00002238831

000022439870000224464700001916874

00002238830

00000872644

00000872652

00001933345

00001933353

AMOXICILLINAMOXICILLIN SUGAR-REDUCEDAPO-AMOXINOVAMOXINNOVAMOXIN SUGAR-REDUCEDPMS-AMOXICILLIN

APO-AMOXI CLAV

RATIO-ACLAVULANATEAPO-AMOXI CLAVCLAVULIN-500F

APO-AMOXI CLAVNOVO-CLAVAMOXINRATIO-ACLAVULANATECLAVULIN-875

APO-AMOXI CLAVRATIO-ACLAVULANATE 125FCLAVULIN-125F

CLAVULIN-200

APO-AMOXI CLAVRATIO-ACLAVULANATE 250FCLAVULIN-250F

CLAVULIN-400

AMPICILLIN SODIUM

AMPICILLIN SODIUM

AMPICILLIN SODIUM

AMPICILLIN SODIUM

SNSSNSAPXTEVTEVPMS

APX

RPHAPXGSK

APXTEVRPHGSK

APXRPHGSK

GSK

APXRPHGSK

GSK

TEV

TEV

TEV

TEV

(AMINOPENICILLINS)


ANTIBACTERIALS

08:00

08:12.16.08

0.0540 0.0540 0.0540 0.0540 0.0540 0.0540

0.9375

0.6673 0.8911 1.4800

0.8355 0.8355 0.8355 2.2205

0.0517 0.0517 0.1170

0.1440

0.0869 0.0869 0.2011

0.2753

2.8193

2.9568

4.9500

9.9000


$$$$$$

$

$$$

$$$$

$$$

$

$$$

$

$

$

$

$

PENICILLINS




CLOXACILLIN SODIUM

NORFLOXACIN

SULFAMETHOXAZOLE/ TRIMETHOPRIM



25 MG / ML (BASE) ORAL LIQUID




400 MG ORAL TABLET




40 MG / ML * 8 MG / ML ORAL SUSPENSION

80 MG / ML * 16 MG / ML INJECTION

00000337765

00000337773

00000337757

00001912429

00001975447

00001912410

000022295240000223768200002246596

00000445266

0000044527400000510637

0000044528200000510645

00000726540

00000550086

NOVO-CLOXIN

NOVO-CLOXIN

NOVO-CLOXIN

CLOXACILLIN SODIUM

CLOXACILLIN SODIUM

CLOXACILLIN SODIUM

APO-NORFLOXNOVO-NORFLOXACINPMS-NORFLOXACIN

APO-SULFATRIM

APO-SULFATRIMNOVO-TRIMEL

APO-SULFATRIM DSNOVO-TRIMEL DS

NOVO-TRIMEL

SEPTRA

TEV

TEV

TEV

TEV

TEV

TEV

APXTEVPMS

APX

APXTEV

APXTEV

TEV

TPI

(PENICILLINASE-RESISTANT PENICILLINS)




ANTIBACTERIALS

ANTIBACTERIALS

ANTIBACTERIALS

08

08

08

:00

:00

:00

08:12.16.12

08:12.18

08:12.20

0.3515

0.6646

0.0898

5.5097

6.7724

8.8389

0.7628 0.7628 0.7628

0.0911

0.0482 0.0482

0.1221 0.1221

0.0954

1.3239


$

$

$

$

$

$

$$$

$

$$

$$

$

$

PENICILLINS

(QUINOLONES)

(SULFONAMIDES)



SULFASALAZINE

DOXYCYCLINE HYCLATE

MINOCYCLINE HCL

TETRACYCLINE HCL

500 MG ORAL TABLET

500 MG ORAL ENTERIC-COATED TABLET





250 MG ORAL CAPSULE

0000059846100002064480

0000059848800002064472

000008742560000235124200002158574

00000740713000023512340000072525000000024368

000020840900000228722600002230735000021081430000229441900002237313

000020841040000228723400002230736000021081510000229442700002237314

00000580929

PMS-SULFASALAZINESALAZOPYRIN

PMS-SULFASALAZINESALAZOPYRIN EN-TABS

APO-DOXYDOXYCYCLINENOVO-DOXYLIN

APO-DOXYDOXYCYCLINENOVO-DOXYLINVIBRAMYCIN

APO-MINOCYCLINEMINOCYCLINEMYLAN-MINOCYCLINENOVO-MINOCYCLINEPMS-MINOCYCLINESANDOZ MINOCYCLINE

APO-MINOCYCLINEMINOCYCLINEMYLAN-MINOCYCLINENOVO-MINOCYCLINEPMS-MINOCYCLINESANDOZ MINOCYCLINE

TETRACYCLINE

PMSPFI

PMSPFI

APXSNSTEV

APXSNSTEVPFI

APXSNSMYPTEVPMSSDZ

APXSNSMYPTEVPMSSDZ

AAP



ANTIBACTERIALS

ANTIBACTERIALS

08

08

:00

:00

08:12.20

08:12.24

0.2221 0.2557

0.3382 0.4027

0.5860 0.5860 0.5860

0.5860 0.5860 0.5860 1.7304

0.3344 0.3344 0.3344 0.3344 0.3344 0.3344

0.6458 0.6458 0.6458 0.6458 0.6458 0.6458

0.0657


$$

$$

$$$

$$$$

$$$$$$

$$$$$$

$

(SULFONAMIDES)

(TETRACYCLINES)




VANCOMYCIN HCL

CLINDAMYCIN HCL

CLINDAMYCIN PALMITATE HCL

CLINDAMYCIN PHOSPHATE

COLISTIMETHATE SODIUM








0000224182000002342855

0000224182100002342863

0000224523200002364719000022583310000224170900000030570

0000224523300002364727000022583580000224171000002182866

00000225851

000022305400000223053500000260436

00002244849

PMS-VANCOMYCINVAL-VANCO

PMS-VANCOMYCINVAL-VANCO

APO-CLINDAMYCINAVA-CLINDAMYCINMYLAN-CLINDAMYCINTEVA-CLINDAMYCINDALACIN C

APO-CLINDAMYCINAVA-CLINDAMYCINMYLAN-CLINDAMYCINTEVA-CLINDAMYCINDALACIN C

DALACIN C PALMITATE

CLINDAMYCINCLINDAMYCIN (60 & 120 ML)DALACIN C PHOSPHATE

COLISTIMETHATE FOR INJECTION

PMSVLP

PMSVLP

APXAVAMYPTEVPFI

APXAVAMYPTEVPFI

PFI

SDZSDZPFI

STM

(GLYCOPEPTIDES)

(LINCOMYCINS)

(POLYMYXINS)




ANTIBACTERIALS

ANTIBACTERIALS

ANTIBACTERIALS

08

08

08

:00

:00

:00

08:12.28.16

08:12.28.20

08:12.28.28

31.0500 31.0500

58.9900 58.9900

0.3541 0.3541 0.3541 0.3541 0.9412

0.7082 0.7082 0.7082 0.7082 1.8823

0.1243

3.3250 3.3250 4.0994

32.9446


$$

$$

$$$$$

$$$$$

$

$$$

$

MISCELLANEOUS ANTIBACTERIALS





TERBINAFINE HCL

FLUCONAZOLE

ITRACONAZOLE

KETOCONAZOLE


50 MG ORAL TABLET

100 MG ORAL TABLET

2 MG / ML INJECTION

100 MG ORAL CAPSULE

200 MG ORAL TABLET

00002262177000022403460000223989300002320134000022547270000224250300002240807000022942730000235312100002031116

0000223737000002281260000022452920000223697800002245643

0000223737100002281279000022452930000223697900002245644

000022479220000224774900000891835

00002047454

0000223723500002231061

SANDOZ TERBINAFINENOVO-TERBINAFINEAPO-TERBINAFINEAURO-TERBINAFINECO TERBINAFINEMYLAN-TERBINAFINEPMS-TERBINAFINEPMS-TERBINAFINETERBINAFINELAMISIL

APO-FLUCONAZOLECO FLUCONAZOLEMYLAN-FLUCONAZOLENOVO-FLUCONAZOLEPMS-FLUCONAZOLE

APO-FLUCONAZOLECO FLUCONAZOLEMYLAN-FLUCONAZOLENOVO-FLUCONAZOLEPMS-FLUCONAZOLE

FLUCONAZOLEFLUCONAZOLE OMEGADIFLUCAN

SPORANOX

APO-KETOCONAZOLENOVO-KETOCONAZOLE

SDZTEVAPXAURCOBMYPPMSPMSSNSNOV

APXCOBMYPTEVPMS

APXCOBMYPTEVPMS

TEVOMGPFI

JAI

APXTEV



ANTIFUNGALS

ANTIFUNGALS

08

08

:00

:00

08:14.04

08:14.08

1.8525 1.8526 1.8527 1.8527 1.8527 1.8527 1.8527 1.8527 1.8527 4.1300

1.8241 1.8241 1.8241 1.8241 1.8241

3.2354 3.2354 3.2354 3.2354 3.2354

0.3187 0.3187 0.5014

4.1109

0.9393 0.9393


$$$$$$$$$$

$$$$$

$$$$$

$$$

$

$$

(ALLYLAMINES)

(AZOLES)




AMPHOTERICIN B

NYSTATIN

DAPSONE

LAMIVUDINE

TENOFOVIR DISOPROXIL FUMARATE


500,000 UNIT ORAL TABLET

100,000 UNIT / ML ORAL SUSPENSION

100 MG ORAL TABLET

100 MG ORAL TABLET


00000029149

00002194198

0000079266700002194201

00002041510

00002239193

00002247128

FUNGIZONE IV

RATIO-NYSTATIN

PMS-NYSTATINRATIO-NYSTATIN

DAPSONE

HEPTOVIR

VIREAD

BMS

RPH

PMSRPH

NTI

GSK

GIL

(NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS)




ANTIFUNGALS

ANTIMYCOBACTERIALS

ANTIVIRALS

08

08

08

:00

:00

:00

08:14.28

08:16.92

08:18.08.20

72.4931

0.2594

0.0520 0.0520

1.3400

4.7088

17.8030


$

$

$$

$

$

$

RESTRICTED BENEFIT - This product is a benefit when initiated by a Specialist in Internal Medicine or a designated prescriber.

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.

(POLYENES)

(MISCELLANEOUS ANTIMYCOBACTERIALS)

ANTIRETROVIRALS




ACYCLOVIR

ADEFOVIR DIPIVOXIL

ENTECAVIR


200 MG ORAL TABLET

400 MG ORAL TABLET

800 MG ORAL TABLET


10 MG ORAL TABLET

0.5 MG ORAL TABLET

00002248077

000022865560000220762100002242784000022859590000207862700000634506

000022865640000220764800002242463000022859670000207863500001911627

0000228657200002207656000022424640000228597500002078651

00000886157

00002247823

00002282224

PEGASYS (0.5 ML SYRINGE)

ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIRZOVIRAX

ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIRZOVIRAX

ACYCLOVIRAPO-ACYCLOVIRMYLAN-ACYCLOVIRNOVO-ACYCLOVIRRATIO-ACYCLOVIR

ZOVIRAX

HEPSERA

BARACLUDE

HLR

SNSAPXMYPTEVRPHGSK

SNSAPXMYPTEVRPHGSK

SNSAPXMYPTEVRPH

GSK

GIL

BMS



ANTIVIRALS

ANTIVIRALS

08

08

:00

:00

08:18.20

08:18.32

395.8400

0.6397 0.6397 0.6397 0.6397 0.6397 1.3063

1.2700 1.2700 1.2700 1.2700 1.2700 2.6320

1.7848 1.7848 1.7848 1.7848 1.7848

0.2557

23.2786

22.0000


$

$$$$$$

$$$$$$

$$$$$

$

$

$

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. (For eligibility for the treatment of chronic hepatitis C refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for Alberta Human Services and Alberta Seniors (AISH) clients.)



(INTERFERONS)

(NUCLEOSIDES AND NUCLEOTIDES)




GANCICLOVIR SODIUM

VALACYCLOVIR

IODOQUINOL

CHLOROQUINE PHOSPHATE

HYDROXYCHLOROQUINE SULFATE

PRIMAQUINE PHOSPHATE

PYRIMETHAMINE


500 MG ORAL TABLET

1,000 MG ORAL TABLET

210 MG ORAL TABLET

650 MG ORAL TABLET

250 MG ORAL TABLET

200 MG ORAL TABLET


25 MG ORAL TABLET

00002162695

0000229582200002331748000023515790000229845700002219492

00002354705

00001997769

00001997750

00000021261

000022466910000225260000002017709

00002017776

00000004774

CYTOVENE

APO-VALACYCLOVIR (CAPLET)CO VALACYCLOVIRMYLAN-VALACYCLOVIR (CAPLET)PMS-VALACYCLOVIR (CAPLET)VALTREX (CAPLET)

APO-VALACYCLOVIR (CAPLET)

DIODOQUIN

DIODOQUIN

NOVO-CHLOROQUINE

APO-HYDROXYQUINEMYLAN-HYDROXYCHLOROQUINEPLAQUENIL SULFATE

PRIMAQUINE PHOSPHATE

DARAPRIM

HLR

APXCOBMYPPMSGSK

APX

GLE

GLE

TEV

APXMYPSAV

SAV

COR




ANTIVIRALS

ANTIPROTOZOALS

ANTIPROTOZOALS

08

08

08

:00

:00

:00

08:18.32

08:30.04

08:30.08

42.0380

1.2765 1.2765 1.2765 1.2765 3.3927

3.0531

0.6488

0.8051

0.4020

0.2620 0.2620 0.6154

0.3988

1.3770


$

$$$$$

$

$

$

$

$$$

$

$

(NUCLEOSIDES AND NUCLEOTIDES)

(AMEBICIDES)

(ANTIMALARIALS)



QUININE SULFATE

ATOVAQUONE

METRONIDAZOLE

NITROFURANTOIN

TRIMETHOPRIM

200 MG ORAL CAPSULE

300 MG ORAL CAPSULE


250 MG ORAL TABLET

5 MG / ML INJECTION

50 MG ORAL TABLET

100 MG ORAL TABLET

50 MG ORAL CAPSULE (MACROCRYSTALS)

100 MG ORAL CAPSULE (MACROCRYSTALS)

100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE)

100 MG ORAL TABLET

200 MG ORAL TABLET

0000225451400000021008

0000225452200000021016

00002217422

00000545066

00000649074

00000319511

00000312738

00002231015

00002231016

00002063662

00002243116

00002243117

APO-QUININENOVO-QUININE

APO-QUININENOVO-QUININE

MEPRON

METRONIDAZOLE

METRONIDAZOLE

NITROFURANTOIN

NITROFURANTOIN

NOVO-FURANTOIN

NOVO-FURANTOIN

MACROBID

TRIMETHOPRIM

TRIMETHOPRIM

APXTEV

APXTEV

GSK

AAP

HSP

AAP

AAP

TEV

TEV

WCC

AAP

AAP




ANTIPROTOZOALS

ANTIPROTOZOALS

URINARY ANTI-INFECTIVES

08

08

08

:00

:00

:00

08:30.08

08:30.92

08:36

0.2390 0.2390

0.2888 0.3750

2.6162

0.0595

0.1739

0.1670

0.2227

0.3984

0.7638

0.7230

0.2566

0.5273


$$

$$

$

$

$

$

$

$

$

$

$

$

(ANTIMALARIALS)

(MISCELLANEOUS ANTIPROTOZOALS)


10:00 Antineoplastic A

gents

10:00

Antineoplastic Agents


METHOTREXATE

METHOTREXATE SODIUM

2.5 MG ORAL TABLET

10 MG ORAL TABLET



000021829630000217069800002244798

00002182750

0000209970500002182955

00002182777

APO-METHOTREXATEMETHOTREXATERATIO-METHOTREXATE SODIUM

METHOTREXATE

METHOTREXATE SOD.(UNPRESERVED)METHOTREXATE SOD.(UNPRESERVED)

METHOTREXATE SOD. (PRESERVED)

APXWAYRPH

HSP

TEVHSP

HSP

ANTINEOPLASTIC AGENTS10:00

10:00

0.6325 0.6325 0.6325

2.5018

4.3574 6.0100

8.3719


$$$

$

$$

$


12:00 Autonom

ic Drugs

12:00

Autonomic Drugs


NEOSTIGMINE BROMIDE

PILOCARPINE HCL

PYRIDOSTIGMINE BROMIDE

ATROPINE SULFATE

BELLADONNA/ ERGOTAMINE TARTRATE/ PHENOBARBITAL

DICYCLOMINE HCL

GLYCOPYRROLATE

HYOSCINE BUTYLBROMIDE

15 MG ORAL TABLET

5 MG ORAL TABLET

60 MG ORAL TABLET




0.2 MG * 0.6 MG * 40 MG ORAL SUSTAINED-RELEASE TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

2 MG / ML ORAL SYRUP



10 MG ORAL TABLET


00000869945

00002216345

00000869961

00000869953

00000392782

00000392693

00000176141

00002103087

00002103095

00002102978

00000392812

00002039508

00000363812

00000363839

PROSTIGMIN

SALAGEN

MESTINON

MESTINON-SR

ATROPINE SULFATE

ATROPINE SULFATE

BELLERGAL SPACETABS

BENTYLOL

BENTYLOL

BENTYLOL

DICYCLOMINE HYDROCHLORIDE

GLYCOPYRROLATE

BUSCOPAN

BUSCOPAN

VCL

PFI

VCL

VCL

SDZ

SDZ

TPI

AXC

AXC

AXC

SDZ

SDZ

BOE

BOE

AUTONOMIC DRUGS

AUTONOMIC DRUGS

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

ANTICHOLINERGIC AGENTS

12

12

:00

:00

12:04

12:08.08

0.4562

1.1150

0.4484

0.9807

1.7023

1.8512

1.2848

0.1169

0.2207

0.0626

3.3395

3.4419

0.3222

4.3860


$

$

$

$

$

$

$

$

$

$

$

$

$

$

(ANTIMUSCARINICS / ANTISPASMODICS)




IPRATROPIUM BROMIDE

IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE

TIOTROPIUM BROMIDE MONOHYDRATE

MIDODRINE HCL

BUDESONIDE/ FORMOTEROL FUMARATE DIHYDRATE

FORMOTEROL FUMARATE

20 MCG / DOSE METERED DOSE AEROSOL

250 MCG / ML INHALATION SOLUTION

0.03 % NASAL SPRAY

0.2 MG / ML * 1 MG / ML (BASE) INHALATION SOLUTION

18 MCG INHALATION CAPSULE

2.5 MG ORAL TABLET

5 MG ORAL TABLET

100 MCG / DOSE * 6 MCG / DOSE METERED INHALATION POWDER

200 MCG / DOSE * 6 MCG / DOSE METERED INHALATION POWDER

12 MCG INHALATION CAPSULE

00002247686

00002126222000022391310000221047900002231136

0000223962700002163705

000022726950000224378900002231675

00002246793

00002278677

00002278685

00002245385

00002245386

00002230898

ATROVENT HFA

APO-IPRAVENTMYLAN-IPRATROPIUMNOVO-IPRAMIDEPMS-IPRATROPIUM

PMS-IPRATROPIUMATROVENT

MYLAN-COMBO STERINEBSRATIO-IPRA SAL UDVCOMBIVENT UDV

SPIRIVA

MIDODRINE

MIDODRINE

SYMBICORT 100 TURBUHALER

SYMBICORT 200 TURBUHALER

FORADIL

BOE

APXMYPTEVPMS

PMSBOE

MYPRPHBOE

BOE

AAP

AAP

AZC

AZC

NOV

(SELECTIVE BETA 2-ADRENERGIC AGONISTS)

AUTONOMIC DRUGS

AUTONOMIC DRUGS

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

SYMPATHOMIMETIC (ADRENERGIC) AGENTS


12

12

12

:00

:00

:00

12:08.08

12:12.04

12:12.08.12

0.0946

0.3456 0.3456 0.3456 0.3456

0.5561 0.9930

0.2936 0.2936 0.6030

2.1667

0.3378

0.5630

0.5208

0.6771

0.8181


$

$$$$

$$

$$$

$

$

$

$

$

$

(ANTIMUSCARINICS / ANTISPASMODICS)

(ALPHA-ADRENERGIC AGONISTS)

BETA-ADRENERGIC AGONISTS



FORMOTEROL FUMARATE DIHYDRATE

ORCIPRENALINE SULFATE

SALBUTAMOL

SALBUTAMOL SULFATE

SALMETEROL XINAFOATE

SALMETEROL XINAFOATE/ FLUTICASONE PROPIONATE

6 MCG / DOSE METERED INHALATION POWDER






0.5 MG / ML (BASE) INHALATION SOLUTION



2 MG / ML (BASE) INHALATION UNIT DOSE SOLUTION

50 MCG / DOSE (BASE) METERED INHALATION POWDER

50 MCG / DOSE (BASE) INHALATION DISK

25 MCG / DOSE (BASE) * 125 MCG / DOSE METERED DOSE AEROSOL

25 MCG / DOSE (BASE) * 250 MCG / DOSE METERED DOSE AEROSOL

00002237225

00002237224

00002236783

000022325700000224566900002241497

00002146843

00002146851

0000220824500002239365

00001926934000022082290000198686400002213419

00002069571000008608080000215441200002213486

00002173360000022082370000223936600002213427

00002231129

00002214261

00002245126

00002245127

OXEZE TURBUHALER

OXEZE TURBUHALER

APO-ORCIPRENALINE

AIROMIR CFC-FREEAPO-SALVENT CFC FREEVENTOLIN HFA

APO-SALVENT

APO-SALVENT

PMS-SALBUTAMOLRATIO-SALBUTAMOL UNIT DOSE P.F

MYLAN-SALBUTAMOL STERINEBS P.F.PMS-SALBUTAMOLRATIO-SALBUTAMOL SULF U.D.P.F.VENTOLIN NEBULES P.F.

PMS-SALBUTAMOLRATIO-SALBUTAMOLSANDOZ SALBUTAMOLVENTOLIN

MYLAN-SALBUTAMOL STERINEBS P.F.PMS-SALBUTAMOL POLYNEBRATIO-SALBUTAMOL UNI DOSE P.F.VENTOLIN NEBULES P.F.

SEREVENT DISKUS

SEREVENT

ADVAIR 125

ADVAIR 250

AZC

AZC

APX

MEPAPXGSK

APX

APX

PMSRPH

MYPPMSRPHGSK

PMSRPHSDZGSK

MYPPMSRPHGSK

GSK

GSK

GSK

GSK


AUTONOMIC DRUGS


12:00

12:12.08.12

0.5540

0.7380

0.0574

0.0250 0.0325 0.0325

0.1274

0.2134

0.1074 0.1074

0.1555 0.1555 0.1555 0.4134

0.3774 0.3774 0.3774 1.0030

0.2954 0.2954 0.2954 0.7852

0.9350

3.7400

0.7999

1.1356


$

$

$

$$$

$

$

$$

$$$$

$$$$

$$$$

$

$

$

$





SALMETEROL XINAFOATE/ FLUTICASONE PROPIONATE

TERBUTALINE SULFATE

EPINEPHRINE

EPINEPHRINE HCL

DIHYDROERGOTAMINE MESYLATE

ERGOLOID MESYLATES

ERGOTAMINE TARTRATE/ CAFFEINE

50 MCG / DOSE (BASE) * 100 MCG / DOSE METERED INHALATION POWDER



0.5 MG / DOSE METERED INHALATION POWDER

0.15 MG / SYR INJECTION SYRINGE


1 MG / ML INJECTION

4 MG / ML NASAL SPRAY

1 MG / ML INJECTION

1 MG ORAL TABLET


00002240835

00002240836

00002240837

00000786616

0000226820500000578657

0000224731000000509558

00000155357

00002228947

0000224116300000027243

00000176176

00000176095

ADVAIR 100 DISKUS

ADVAIR 250 DISKUS

ADVAIR 500 DISKUS

BRICANYL TURBUHALER

TWINJECT AUTO INJECTOREPIPEN JR

TWINJECT AUTO INJECTOREPIPEN

ADRENALIN

MIGRANAL

DIHYDROERGOTAMINE MESYLATEDIHYDROERGOTAMINE (DHE)

HYDERGINE

CAFERGOT

GSK

GSK

GSK

AZC

PALKNG

PALKNG

ERF

STM

SDZSTM

STM

NOV


AUTONOMIC DRUGS

AUTONOMIC DRUGS

AUTONOMIC DRUGS



SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS

12

12

12

:00

:00

:00

12:12.08.12

12:12.12

12:16

1.3365

1.5998

2.2712

0.0764

82.4580 82.6200

82.4580 82.6200

0.5626

10.2043

3.7933 3.8210

1.0029

0.8286


$

$

$

$

$$

$$

$

$

$$

$

$


(ALPHA- AND BETA-ADRENERGIC AGONISTS)



CYCLOBENZAPRINE HCL

DANTROLENE SODIUM

BACLOFEN

10 MG ORAL TABLET

25 MG ORAL CAPSULE

100 MG ORAL CAPSULE

10 MG ORAL TABLET

20 MG ORAL TABLET



2 MG / ML INJECTION

0000217714500002287064000022313530000208005200002212048

00001997602

00001997653

0000213933200002371413000022870210000208839800002236963000020637350000223650700000455881

0000213939100002371421000022870480000208840100002236964000020637430000223650800000636576

00002131048

00002131056

00002131064

APO-CYCLOBENZAPRINECYCLOBENZAPRINEMYLAN-CYCLOBENZAPRINENOVO-CYCLOPRINEPMS-CYCLOBENZAPRINE

DANTRIUM

DANTRIUM

APO-BACLOFENAVA-BACLOFENBACLOFENMYLAN-BACLOFENPHL-BACLOFENPMS-BACLOFENRATIO-BACLOFENLIORESAL

APO-BACLOFENAVA-BACLOFENBACLOFENMYLAN-BACLOFENPHL-BACLOFENPMS-BACLOFENRATIO-BACLOFENLIORESAL D.S.

LIORESAL INTRATHECAL



APXSNSMYPTEVPMS

JHP

JHP

APXAVASNSMYPPHHPMSRPHNOV

APXAVASNSMYPPHHPMSRPHNOV

NOV

NOV

NOV

AUTONOMIC DRUGS

AUTONOMIC DRUGS

AUTONOMIC DRUGS

SKELETAL MUSCLE RELAXANTS



12

12

12

:00

:00

:00

12:20.04

12:20.08

12:20.12

0.3727 0.3727 0.3727 0.3727 0.3727

0.3780

0.7684

0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.6688

0.4898 0.4898 0.4898 0.4898 0.4898 0.4898 0.4898 1.3018

13.8277

10.3610

41.4444


$$$$$

$

$

$$$$$$$$

$$$$$$$$

$

$

$

RESTRICTED BENEFIT - Coverage is limited to 126 tablets per plan participant per year as anadjunct to rest and physical therapy for the treatment of acute muscle spasm.

(CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS)

(DIRECT-ACTING SKELETAL MUSCLE RELAXANTS)

(GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTS)




VARENICLINE TARTRATE

VARENICLINE TARTRATE/ VARENICLINE TARTRATE




00002291177

00002291185

00002298309

CHAMPIX

CHAMPIX

CHAMPIX (STARTER PACK)

PFI

PFI

PFI

AUTONOMIC DRUGS

MISCELLANEOUS AUTONOMIC DRUGS

12:00

12:92

1.7205

1.7206

1.7206


$

$

$

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."

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."


20:00 Blood Form

ation, Coagulation and Throm

bosis

20:00

Blood Formation, Coagulation and Thrombosis


IRON DEXTRAN COMPLEX

ACENOCOUMAROL

WARFARIN SODIUM


1 MG ORAL TABLET

4 MG ORAL TABLET

1 MG ORAL TABLET

2 MG ORAL TABLET

2.5 MG ORAL TABLET

3 MG ORAL TABLET

0000220596300002221780

00000010383

00000010391

000022429240000224446200002265273000022426800000234402500001918311

000022429250000224446300002265281000022426810000234403300001918338

000022429260000224446400002265303000022426820000234404100001918346

000022456180000228749800002265311000022426830000234406800002240205

DEXIRONINFUFER

SINTROM

SINTROM

APO-WARFARINMYLAN-WARFARINNOVO-WARFARINTARO-WARFARINWARFARINCOUMADIN




LPISDZ

PAL

PAL

APXMYPTEVTARSNSBMS

APXMYPTEVTARSNSBMS

APXMYPTEVTARSNSBMS

APXMYPTEVTARSNSBMS

(COUMARIN DERIVATIVES)

BLOOD FORMULATION, COAGULATION AND THROMBOSIS


ANTIANEMIA DRUGS

ANTITHROMBOTIC AGENTS

20

20

:00

:00

20:04.04

20:12.04.08

13.7500 13.7910

0.5087

1.5997

0.1147 0.1147 0.1147 0.1147 0.1147 0.3277

0.1213 0.1213 0.1213 0.1213 0.1213 0.3467

0.0971 0.0971 0.0971 0.0971 0.0971 0.2775

0.1504 0.1504 0.1504 0.1504 0.1504 0.4297



$$

$

$

$$$$$$

$$$$$$

$$$$$$

$$$$$$

(IRON PREPARATIONS)

ANTICOAGULANTS




WARFARIN SODIUM

DALTEPARIN SODIUM

4 MG ORAL TABLET

5 MG ORAL TABLET

6 MG ORAL TABLET

7.5 MG ORAL TABLET

10 MG ORAL TABLET

10,000 IU / ML INJECTION


2,500 IU / SYR INJECTION SYRINGE






000022429270000224446500002265338000022426840000234407600002007959

000022429280000224446600002265346000022426850000234408400001918354

00002242686

00002242697

0000224292900002244467000022426870000234411400001918362

00002132664

00002231171

00002132621

00002132648

00002352648

00002352656

00002352664

00002352672



TARO-WARFARIN

TARO-WARFARIN

APO-WARFARINMYLAN-WARFARINTARO-WARFARINWARFARINCOUMADIN

FRAGMIN

FRAGMIN

FRAGMIN (0.2 ML SYRINGE)






APXMYPTEVTARSNSBMS

APXMYPTEVTARSNSBMS

TAR

TAR

APXMYPTARSNSBMS

PFI

PFI

PFI

PFI

PFI

PFI

PFI

PFI

(COUMARIN DERIVATIVES)

(HEPARINS)





20

20

:00

:00

20:12.04.08

20:12.04.16

0.1504 0.1504 0.1504 0.1504 0.1504 0.4297

0.0973 0.0973 0.0973 0.0973 0.0973 0.2780

0.2895

0.3111

0.1746 0.1746 0.1746 0.1746 0.4989

15.9291

39.8199

5.0440

10.0880

15.1320

20.1760

25.2200

30.2640


$$$$$$

$$$$$$

$

$

$$$$$

$

$

$

$

$

$

$

$

ANTICOAGULANTS

ANTICOAGULANTS



DALTEPARIN SODIUM

ENOXAPARIN SODIUM

HEPARIN SODIUM

NADROPARIN CALCIUM

TINZAPARIN SODIUM




100 MG / ML INJECTION SYRINGE

150 MG / ML INJECTION SYRINGE




100 UNIT / ML INJECTION LOCK FLUSH

9,500 IU / ML INJECTION SYRINGE

19,000 IU / ML INJECTION SYRINGE








00002352680

00002236564

00002012472

00002236883

00002242692

00000453811

00000579718

00000453781

00000727520

00002236913

00002240114

00002167840

00002229515

00002229755

00002358158

00002358166

00002231478

00002358174


LOVENOX

LOVENOX (0.3 ML SYRINGE)

LOVENOX (0.4 - 1 ML SYRINGE)

LOVENOX HP (0.8ML/1ML SYRINGE)

HEPARIN LEO

HEPARIN LEO

HEPARIN LEO

HEPARIN LEO

FRAXIPARINE (.3-1ML SYR)

FRAXIPARINE FORTE (.6-1ML SYR)

INNOHEP

INNOHEP

INNOHEP (0.25 ML SYRINGE)





PFI

SAV

SAV

SAV

SAV

LEO

LEO

LEO

LEO

GSK

GSK

LEO

LEO

LEO

LEO

LEO

LEO

LEO

(HEPARINS)



20:00

20:12.04.16

36.3160

20.9300

6.3200

20.9310

31.3960

0.5158

2.5671

8.2155

0.4387

9.1290

18.2580

16.7604

34.0445

16.9070

16.8950

16.9000

34.5058

34.5263








$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

ANTICOAGULANTS




TINZAPARIN SODIUM

FONDAPARINUX SODIUM

RIVAROXABAN

CLOPIDOGREL BISULFATE




10 MG ORAL TABLET

75 MG ORAL TABLET

00002358182

00002245531

00002258056

00002316986

00002252767000023030270000235153600002348004000023593160000229316100002238682


ARIXTRA (0.5 ML SYRINGE)

ARIXTRA (0.6 ML SYRINGE)

XARELTO

APO-CLOPIDOGRELCO CLOPIDOGRELMYLAN-CLOPIDOGRELPMS-CLOPIDOGRELSANDOZ CLOPIDOGRELTEVA-CLOPIDOGRELPLAVIX

LEO

GSK

GSK

BAI

APXCOBMYPPMSSDZTEVSAV

(HEPARINS)

(MISCELLANEOUS ANTICOAGULANTS)







20

20

20

:00

:00

:00

20:12.04.16

20:12.04.92

20:12.18

34.5217

15.7561

25.5250

8.8598

0.9279 0.9279 0.9279 0.9279 0.9279 0.9279 2.6512


$

$

$

$

$$$$$$$

RESTRICTED BENEFIT - This product is a benefit for the prophylaxis of venous thromboembolic events in patients who have undergone elective total hip replacement or total knee replacement surgery. Coverage is restricted to two 14-day courses of therapy per patientper year.

LIMITED RESTRICTED BENEFIT - This product is a benefit for patients for the prevention of thrombosis, following intravascular stent placement, when prescribed by a Specialist in Cardiology, Cardiac Surgery, Cardiovascular & Thoracic Surgery, or General Surgery. This benefit is limited to one month of coverage for the first stent placement only. (For eligibility for repeat stents, other indications, or continued coverage up to 12 months following intravascular drug eluting stent (DES) placement refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Employment and Immigration Drug Benefit Supplement for Alberta Employment and Immigration, Alberta Children and Youth Services and Alberta Seniors and Community Supports (AISH) clients.)

ANTICOAGULANTS

ANTICOAGULANTS

(PLATELET AGGREGATION INHIBITORS)



DIPYRIDAMOLE/ ASA

TICLOPIDINE HCL

PENTOXIFYLLINE

TRANEXAMIC ACID

200 MG * 25 MG ORAL CAPSULE

250 MG ORAL TABLET


500 MG ORAL TABLET

00002242119

000022377010000223684800002243587

0000223009000002221977

00002064405

AGGRENOX

APO-TICLOPIDINENOVO-TICLOPIDINESANDOZ TICLOPIDINE

APO-PENTOXIFYLLINE SRTRENTAL

CYKLOKAPRON

BOE

APXTEVSDZ

APXSAV

PFI





HEMORRHEOLOGIC AGENTS

ANTIHEMORRHAGIC AGENTS

20

20

20

:00

:00

:00

20:12.18

20:24

20:28.16

0.8492

0.4303 0.4303 0.4303

0.5846 0.8097

1.1530


$

$$$

$$

$

(PLATELET AGGREGATION INHIBITORS)

(HEMOSTATICS)


24:00 Cardiovascular D

rugs

24:00

Cardiovascular Drugs


DISOPYRAMIDE

PROCAINAMIDE HCL

MEXILETINE HCL

FLECAINIDE ACETATE

PROPAFENONE HCL

100 MG ORAL CAPSULE

150 MG ORAL CAPSULE




100 MG ORAL CAPSULE

200 MG ORAL CAPSULE

50 MG ORAL TABLET

100 MG ORAL TABLET

150 MG ORAL TABLET

300 MG ORAL TABLET

00002224801

00002224828

00000638692

00000638676

00000638684

00002230359

00002230360

0000227553800001966197

0000227554600001966200

0000224332400000603708

0000224332500000603716

RYTHMODAN

RYTHMODAN

PROCAN SR

PROCAN SR

PROCAN SR

NOVO-MEXILETINE

NOVO-MEXILETINE

FLECAINIDETAMBOCOR

FLECAINIDETAMBOCOR

APO-PROPAFENONERYTHMOL

APO-PROPAFENONERYTHMOL

SAV

SAV

ERF

ERF

ERF

TEV

TEV

AAPMEP

AAPMEP

APXABB

APXABB

(CLASS IA ANTIARRYTHMICS)

(CLASS IB ANTIARRYTHMICS)

(CLASS IC ANTIARRYTHMICS)

CARDIOVASCULAR DRUGS



CARDIAC DRUGS

CARDIAC DRUGS

CARDIAC DRUGS

24

24

24

:00

:00

:00

24:04.04.04

24:04.04.08

24:04.04.12

0.2714

0.3924

0.3675

0.5065

0.8155

1.0203

1.3663

0.4253 0.5384

0.8505 1.0770

0.4275 1.1834

0.7537 2.0859


$

$

$

$

$

$

$

$$

$$

$$

$$

ANTIARRHYTHMIC AGENTS






AMIODARONE HCL

DIGOXIN

CHOLESTYRAMINE RESIN

COLESTIPOL HCL

100 MG ORAL TABLET

200 MG ORAL TABLET



0.25 MG ORAL TABLET

0.05 MG / ML ORAL ELIXIR



4 G ORAL POWDER PACKET

1 G ORAL TABLET

5 G ORAL POWDER PACKET

00002292173

000023643360000224619400002364263000022406040000224247200002240071000022438360000223983500002036282

00002335700

00002335719

00002335727

00002242320

00002048272

00002048264

0000089096000002210320

00002132680

0000064297500002132699

PMS-AMIODARONE

AMIODARONEAPO-AMIODARONEAVA-AMIODARONEMYLAN-AMIODARONEPMS-AMIODARONERATIO-AMIODARONESANDOZ AMIODARONETEVA-AMIODARONECORDARONE

TOLOXIN

TOLOXIN

TOLOXIN

TOLOXIN PEDIATRIC

DIGOXIN PEDIATRIC

DIGOXIN

OLESTYR LIGHTOLESTYR REGULAR

COLESTID

COLESTIDCOLESTID ORANGE

PMS

SNSAPXAVAMYPPMSRPHSDZTEVWAY

PPH

PPH

PPH

PPH

SDZ

SDZ

MMTMMT

PFI

PFIPFI

(CLASS III ANTIARRYTHMICS)




CARDIAC DRUGS

CARDIAC DRUGS

ANTILIPEMIC AGENTS

24

24

24

:00

:00

:00

24:04.04.20

24:04.08

24:06.04

0.7269

0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 0.7747 2.0589

0.2516

0.2516

0.2516

1.0411

7.2279

2.9116

1.4900 1.4900

0.2576

0.9211 0.9211


$

$$$$$$$$$

$

$

$

$

$

$

$$

$

$$


(CARDIOTONIC AGENTS)

(BILE ACID SEQUESTRANTS)



BEZAFIBRATE

FENOFIBRATE

GEMFIBROZIL


100 MG ORAL TABLET

67 MG ORAL CAPSULE

100 MG ORAL CAPSULE

200 MG ORAL CAPSULE

160 MG ORAL CAPSULE/TABLET

600 MG ORAL TABLET

300 MG ORAL CAPSULE

00002083523

0000224685900002356570000022890830000228804400002241601

0000224318000002243551

00002225980

0000223986400002364409000022860920000224021000002243552000022735510000225003900002146959

0000224686000002356589000022890910000228805200002241602

00001979582000022304760000214207400002230183

00001979574000021854070000224170400002239951

BEZALIP

APO-FENO-SUPERFENOFIBRATE-SNOVO-FENOFIBRATE-SSANDOZ FENOFIBRATE SLIPIDIL SUPRA

APO-FENO-MICRONOVO-FENOFIBRATE MICRONIZED

APO-FENOFIBRATE

APO-FENO-MICROAVA-FENOFIBRATE MICROFENOFIBRATE MICROMYLAN-FENOFIBRATE MICRONOVO-FENOFIBRATE MICRONIZEDPMS-FENOFIBRATE MICRORATIO-FENOFIBRATE MCLIPIDIL MICRO

APO-FENO-SUPER (TABLET)FENOFIBRATE-S (TABLET)NOVO-FENOFIBRATE-S (TABLET)SANDOZ FENOFIBRATE S (TABLET)LIPIDIL SUPRA (TABLET)

APO-GEMFIBROZILMYLAN-GEMFIBROZILNOVO-GEMFIBROZILPMS-GEMFIBROZIL

APO-GEMFIBROZILMYLAN-GEMFIBROZILNOVO-GEMFIBROZILPMS-GEMFIBROZIL

ACV

APXSNSTEVSDZFAB

APXTEV

APX

APXAVASNSMYPTEVPMSRPHFAB

APXSNSTEVSDZFAB

APXMYPTEVPMS

APXMYPTEVPMS


ANTILIPEMIC AGENTS

24:00

24:06.06

1.8269

0.5407 0.5407 0.5407 0.5409 1.1130

0.4325 0.4325

0.6105

0.6806 0.6806 0.6806 0.6806 0.6806 0.6806 0.6806 1.0890

0.4488 0.4488 0.4488 0.4488 1.2823

0.5157 0.5157 0.5157 0.5157

0.1853 0.1853 0.1853 0.1853


$

$$$$$

$$

$

$$$$$$$$

$$$$$

$$$$

$$$$

(FIBRIC ACID DERIVATIVES)




ATORVASTATIN CALCIUM10 MG (BASE) ORAL TABLET




0000229526100002348705000023108990000228834600002373203000023026750000231344800002313707000023502970000232494600002230711

0000229528800002348713000023109020000228835400002373211000023026830000231345600002313715000023503190000232495400002230713

0000229529600002348721000023109100000228836200002373238000023026910000231346400002313723000023503270000232496200002230714

0000229531800002348748000023109290000228837000002373246000023027130000231347200002313758000023503350000232497000002243097

APO-ATORVASTATINATORVASTATINCO ATORVASTATINGD-ATORVASTATINMYLAN-ATORVASTATINNOVO-ATORVASTATINPMS-ATORVASTATINRAN-ATORVASTATINRATIO-ATORVASTATINSANDOZ ATORVASTATINLIPITOR




APXSNSCOBGMDMYPTEVPMSRANRPHSDZPFI





ANTILIPEMIC AGENTS

24:00

24:06.08

0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 0.6558 1.7431

0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 0.8198 2.1788

0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 2.3420

0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 0.8812 2.3421


$$$$$$$$$$$

$$$$$$$$$$$

$$$$$$$$$$$

$$$$$$$$$$$

(HMG-COA REDUCTASE INHIBITORS)



FLUVASTATIN SODIUM

LOVASTATIN

80 MG (BASE) ORAL EXTENDED-RELEASE TABLET



20 MG ORAL TABLET

40 MG ORAL TABLET

00002250527

00002061562

00002061570

00002220172000023642390000224857200002353229000022431270000224654200002246013000022458220000224705600000795860

00002220180000023642470000224857300002353237000022431290000224654300002246014000022458230000224705700000795852

LESCOL XL

LESCOL

LESCOL

APO-LOVASTATINAVA-LOVASTATINCO LOVASTATINLOVASTATINMYLAN-LOVASTATINNOVO-LOVASTATINPMS-LOVASTATINRATIO-LOVASTATINSANDOZ LOVASTATINMEVACOR

APO-LOVASTATINAVA-LOVASTATINCO LOVASTATINLOVASTATINMYLAN-LOVASTATINNOVO-LOVASTATINPMS-LOVASTATINRATIO-LOVASTATINSANDOZ LOVASTATINMEVACOR

NOV

NOV

NOV

APXAVACOBSNSMYPTEVPMSRPHSDZMFC

APXAVACOBSNSMYPTEVPMSRPHSDZMFC


ANTILIPEMIC AGENTS

24:00

24:06.08

1.4756

0.8732

1.2261

0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 0.7213 2.0609

1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 1.3176 3.7647


$

$

$

$$$$$$$$$$

$$$$$$$$$$





PRAVASTATIN SODIUM10 MG ORAL TABLET

20 MG ORAL TABLET

40 MG ORAL TABLET

000022435060000224818200002330954000023174510000225709200002247008000022476550000233219100002356546000022844210000224785600000893749

000022435070000224818300002330962000023174780000225710600002247009000022476560000233220500002356554000022844480000224785700000893757

000022435080000224818400002330970000023174860000225711400002247010000022476570000233221300002356562000022844560000224785800002222051

APO-PRAVASTATINCO PRAVASTATINJAMP-PRAVASTATINMINT-PRAVASTATINMYLAN-PRAVASTATINNOVO-PRAVASTATINPMS-PRAVASTATINPRAVASTATINPRAVASTATINRAN-PRAVASTATINSANDOZ PRAVASTATINPRAVACHOL



APXCOBJPCMPIMYPTEVPMSRANSNSRANSDZBMS




ANTILIPEMIC AGENTS

24:00

24:06.08

0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.5956 0.9530

0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 0.7027 1.1243

0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 0.8464 1.3543


$$$$$$$$$$$$

$$$$$$$$$$$$

$$$$$$$$$$$$




ROSUVASTATIN CALCIUM5 MG (BASE) ORAL TABLET




0000233797500002339765000023812650000237852300002382644000023387260000235460800002265540

0000233798300002339773000023812730000237853100002382652000023387340000235461600002247162

0000233799100002339781000023812810000237855800002382660000023387420000235462400002247163

0000233800900002339803000023813030000237856600002382679000023387500000235463200002247164

APO-ROSUVASTATINCO ROSUVASTATINMYLAN-ROSUVASTATINPMS-ROSUVASTATINRAN-ROSUVASTATINSANDOZ ROSUVASTATINTEVA-ROSUVASTATINCRESTOR




APXCOBMYPPMSRANSDZTEVAZC





ANTILIPEMIC AGENTS

24:00

24:06.08

0.4854 0.4854 0.4854 0.4854 0.4854 0.4854 0.4854 1.2900

0.5117 0.5117 0.5117 0.5117 0.5117 0.5117 0.5117 1.3600

0.6396 0.6396 0.6396 0.6396 0.6396 0.6396 0.6396 1.7000

0.7487 0.7487 0.7487 0.7487 0.7487 0.7487 0.7487 1.9900


$$$$$$$$

$$$$$$$$

$$$$$$$$

$$$$$$$$





SIMVASTATIN5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

0000224701100002248103000023310200000237503600002372932000022465820000228154600002269252000023291310000228472300002331969000023788840000225014400000884324

000022470120000224810400002331039000023750440000237294000002246583000022815540000226926000002329158000022478280000228473100002331985000023788920000225015200000884332

000022470130000224810500002331047000023750520000237295900002246737000022815620000226927900002329166000022478300000228475800002331993000023789060000225016000000884340

APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR

APO-SIMVASTATINCO SIMVASTATINJAMP-SIMVASTATINMAR-SIMVASTATINMINT-SIMVASTATINMYLAN-SIMVASTATINPHL-SIMVASTATINPMS-SIMVASTATINRAN-SIMVASTATINSANDOZ SIMVASTATINSIMVASTATINSIMVASTATINSIMVASTATIN-ODANTEVA-SIMVASTATINZOCOR


APXCOBJPCMARMPIMYPPHHPMSRANSNSRANODNTEVMFC

APXCOBJPCMARMPIMYPPHHPMSRANSDZSNSRANODNTEVMFC



ANTILIPEMIC AGENTS

24:00

24:06.08

0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 0.3704 1.0584

0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 0.7287 2.0819

0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729


$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$




SIMVASTATIN

CLONIDINE HCL

METHYLDOPA

40 MG ORAL TABLET

80 MG ORAL TABLET

0.1 MG ORAL TABLET

0.2 MG ORAL TABLET

125 MG ORAL TABLET

250 MG ORAL TABLET

000022470140000224810600002331055000023750600000237296700002246584000022815700000226928700002329174000022478310000228476600002332000000023789140000225017900000884359

000022470150000224810700002331063000023750790000237297500002246585000022815890000226929500002329182000022478330000228477400002332019000023789220000225018700002240332

0000204612100000259527

0000204614800000291889

00000360252

00000360260



NOVO-CLONIDINECATAPRES

NOVO-CLONIDINECATAPRES

METHYLDOPA

METHYLDOPA



TEVBOE

TEVBOE

AAP

AAP



ANTILIPEMIC AGENTS

HYPOTENSIVE AGENTS

24

24

:00

:00

24:06.08

24:08.16

0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729

0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 0.9005 2.5729

0.1765 0.1853

0.3149 0.3306

0.0989

0.1433


$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$

$$

$$

$

$


(CENTRAL ALPHA-AGONISTS)




METHYLDOPA

DIAZOXIDE

HYDRALAZINE HCL

MINOXIDIL

ETHACRYNIC ACID

FUROSEMIDE

500 MG ORAL TABLET

100 MG ORAL CAPSULE

10 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

2.5 MG ORAL TABLET

10 MG ORAL TABLET

25 MG ORAL TABLET

20 MG ORAL TABLET

40 MG ORAL TABLET

00000426830

00000503347

00000441619

00000441627

00000441635

00000514497

00000514500

00002258528

0000039678800002364573000023514200000033773000002224690

0000036216600002364581000023514390000033774900002224704

METHYLDOPA

PROGLYCEM

APO-HYDRALAZINE

APO-HYDRALAZINE

APO-HYDRALAZINE

LONITEN

LONITEN

EDECRIN

APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDELASIX

APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDELASIX

AAP

MFC

APX

APX

APX

PFI

PFI

VCL

APXAVASNSTEVSAV

APXAVASNSTEVSAV

(LOOP DIURETICS)




HYPOTENSIVE AGENTS

HYPOTENSIVE AGENTS

HYPOTENSIVE AGENTS

24

24

24

:00

:00

:00

24:08.16

24:08.20

24:08.24.08

0.2537

1.6179

0.1347

0.2314

0.3633

0.3432

0.7565

3.3000

0.0373 0.0373 0.0373 0.0373 0.0873

0.0558 0.0558 0.0558 0.0558 0.1307


$

$

$

$

$

$

$

$

$$$$$

$$$$$

(CENTRAL ALPHA-AGONISTS)

(DIRECT VASODILATORS)

DIURETICS



FUROSEMIDE

OLMESARTAN MEDOXOMIL

OLMESARTAN MEDOXOMIL/ HYDROCHLOROTHIAZIDE

ISOSORBIDE DINITRATE

80 MG ORAL TABLET

500 MG ORAL TABLET



20 MG ORAL TABLET

40 MG ORAL TABLET

20 MG * 12.5 MG ORAL TABLET



10 MG ORAL TABLET

30 MG ORAL TABLET

5 MG ORAL SUBLINGUAL TABLET


00000707570000023646030000235144700000765953

00002224755

00002224720

00000527033

00002318660

00002318679

00002319616

00002319624

00002319632

00000441686

00000441694

00000670944

00000740721

APO-FUROSEMIDEAVA-FUROSEMIDEFUROSEMIDENOVO-SEMIDE

LASIX SPECIAL

LASIX

FUROSEMIDE

OLMETEC

OLMETEC

OLMETEC PLUS

OLMETEC PLUS

OLMETEC PLUS

ISDN

ISDN

ISDN

CEDOCARD-SR

APXAVASNSTEV

SAV

SAV

SDZ

MFC

MFC

MFC

MFC

MFC

AAP

AAP

AAP

PAL

(LOOP DIURETICS)

(ANGIOTENSIN II RECEPTOR ANTAGONISTS)




HYPOTENSIVE AGENTS

HYPOTENSIVE AGENTS

VASODILATING AGENTS

24

24

24

:00

:00

:00

24:08.24.08

24:08.44.08

24:12.08

0.1220 0.1220 0.1220 0.1220

3.0150

0.2756

0.8047

1.0187

1.0187

1.0187

1.0187

1.0187

0.0365

0.0857

0.0621

0.4195


$$$$

$

$

$

$

$

$

$

$

$

$

$

$

DIURETICS

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

(NITRATES AND NITRITES)




ISOSORBIDE-5-MONONITRATE

NITROGLYCERIN

ALPROSTADIL

DIPYRIDAMOLE


0.3 MG ORAL SUBLINGUAL TABLET


0.4 MG / DOSE SUBLINGUAL METERED DOSE SPRAY

2 % TOPICAL OINTMENT

0.2 MG/HR TRANSDERMAL PATCH




500 MCG / ML INJECTION

25 MG ORAL TABLET

50 MG ORAL TABLET

75 MG ORAL TABLET

000022728300000230128800002126559

00000037613

00000037621

000022435880000223899800002231441

00001926454

00001911910000022307320000216280600000584223

00001911902000022307330000216352700000852384

00001911929000022307340000216353500002046156

00002011271

00000559253

00000895644

00000895652

00000895660

APO-ISMNPMS-ISMNIMDUR

NITROSTAT

NITROSTAT

MYLAN-NITRORHO-NITRO PUMPSPRAYNITROLINGUAL PUMPSPRAY

NITROL

NITRO-DUR 0.2TRINIPATCH 0.2MINITRAN 0.2TRANSDERM-NITRO 0.2



NITRO-DUR 0.8

PROSTIN VR

APO-DIPYRIDAMOLE (FC)



APXPMSAZC

PFI

PFI

MYPSDZSAV

PAL

MFCPALMEPNOV

MFCPALMEPNOV

MFCPALMEPNOV

MFC

PFI

APX

APX

APX



VASODILATING AGENTS

VASODILATING AGENTS

24

24

:00

:00

24:12.08

24:12.92

0.3523 0.3523 0.6850

0.1169

0.1169

0.0421 0.0421 0.0730

0.6390

0.5667 0.5780 0.5941 0.6616

0.6400 0.6528 0.6712 0.7474

0.6400 0.6528 0.6714 0.7474

1.1100

241.1150

0.2633

0.2932

0.4397


$$$

$

$

$$$

$

$$$$

$$$$

$$$$

$

$

$

$

$

(NITRATES AND NITRITES)

(MISCELLANEOUS VASODILATING AGENTS)



NYLIDRIN HCL

SODIUM TETRADECYL SULFATE

DOXAZOSIN MESYLATE

PRAZOSIN HCL

6 MG ORAL TABLET

1 % INJECTION







00001926713

00000511234

0000224058800002240498000022427280000224452700001958100

0000224058900002240499000022427290000224452800001958097

0000224059000002240500000022427300000224452900001958119

0000088280100001934198

0000088282800001934201

0000088283600001934228

ARLIDIN

TROMBOJECT

APO-DOXAZOSINMYLAN-DOXAZOSINNOVO-DOXAZOSINPMS-DOXAZOSINCARDURA



APO-PRAZONOVO-PRAZIN



ERF

OMG

APXMYPTEVPMSPFI

APXMYPTEVPMSPFI

APXMYPTEVPMSPFI

APXTEV

APXTEV

APXTEV




VASODILATING AGENTS

SCLEROSING AGENTS

ALPHA-ADRENERGIC BLOCKING AGENTS

24

24

24

:00

:00

:00

24:12.92

24:16

24:20

0.4756

3.7500

0.2176 0.2176 0.2176 0.2176 0.5784

0.2610 0.2610 0.2610 0.2610 0.6938

0.3395 0.3395 0.3395 0.3395 0.9022

0.1371 0.1371

0.1862 0.1862

0.2560 0.2560


$

$

$$$$$

$$$$$

$$$$$

$$

$$

$$

(MISCELLANEOUS VASODILATING AGENTS)




TAMSULOSIN HCL

TERAZOSIN HCL

0.4 MG ORAL EXTENDED-RELEASE TABLET

0.4 MG ORAL SUSTAINED-RELEASE CAPSULE





00002362406000023662310000234020800002368242

00002298570000022813920000229426500002295121

000022345020000224351800002218941000023504750000223080500000818658

000022345030000224351900002218968000023504830000223080600000818682

000022345040000224352000002218976000023504910000223080700000818666

000022345050000224352100002218984000023505050000223080800000818674

APO-TAMSULOSIN CRAVA-TAMSULOSIN CRSANDOZ TAMSULOSIN CRTEVA-TAMSULOSIN CR

MYLAN-TAMSULOSINNOVO-TAMSULOSINRATIO-TAMSULOSINSANDOZ TAMSULOSIN

APO-TERAZOSINPMS-TERAZOSINRATIO-TERAZOSINTERAZOSINTEVA-TERAZOSINHYTRIN




APXAVASDZTEV

MYPTEVRPHSDZ

APXPMSRPHSNSTEVABB

APXPMSRPHSNSTEVABB

APXPMSRPHSNSTEVABB

APXPMSRPHSNSTEVABB


ALPHA-ADRENERGIC BLOCKING AGENTS

24:00

24:20

0.2100 0.2100 0.2100 0.2100

0.3415 0.3415 0.3415 0.3415

0.2563 0.2563 0.2563 0.2563 0.2563 0.7323

0.3258 0.3258 0.3258 0.3258 0.3258 0.9309

0.4425 0.4425 0.4425 0.4425 0.4425 1.2642

0.6477 0.6477 0.6477 0.6477 0.6477 1.8506


$$$$

$$$$

$$$$$$

$$$$$$

$$$$$$

$$$$$$



ACEBUTOLOL HCL

ATENOLOL




25 MG ORAL TABLET

50 MG ORAL TABLET

0000228624600002147602000023637980000223772100002237885000022045170000191014000001926543

0000228625400002147610000023638010000223772200002237886000022045250000191015900001926551

0000228626200002147629000023638280000223772300002237887000022045330000191016700001926578

00002368013000023036470000224658100002266660

0000077368900002255545000023675640000237198700002368021000021468940000223831600002237600000022679850000217179100002231731000023686410000191206200002039532

ACEBUTOLOLAPO-ACEBUTOLOLAVA-ACEBUTOLOLMYLAN-ACEBUTOLOLMYLAN-ACEBUTOLOL (TYPE S)NOVO-ACEBUTOLOLRHOTRALSECTRAL



MINT-ATENOLMYLAN-ATENOLOLPMS-ATENOLOLTEVA-ATENOLOL

APO-ATENOLCO ATENOLOLJAMP-ATENOLOLMAR-ATENOLOLMINT-ATENOLMYLAN-ATENOLOLPHL-ATENOLOLPMS-ATENOLOLRAN-ATENOLOLRATIO-ATENOLOLSANDOZ ATENOLOLSEPTA-ATENOLOLTEVA-ATENOLTENORMIN

SNSAPXAVAMYPMYPTEVSDZSAV



MPIMYPPMSTEV

APXCOBJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVAZC


BETA-ADRENERGIC BLOCKING AGENTS

24:00

24:24

0.1298 0.1298 0.1298 0.1298 0.1298 0.1298 0.1298 0.3450

0.1947 0.1947 0.1947 0.1947 0.1947 0.1947 0.1947 0.5176

0.3875 0.3875 0.3875 0.3875 0.3875 0.3875 0.3875 1.0300

0.1081 0.1081 0.1081 0.1081

0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.2246 0.5970


$$$$$$$$

$$$$$$$$

$$$$$$$$

$$$$

$$$$$$$$$$$$$$




ATENOLOL

ATENOLOL/ CHLORTHALIDONE

BISOPROLOL FUMARATE

100 MG ORAL TABLET



5 MG ORAL TABLET

10 MG ORAL TABLET

0000077369700002255553000023675720000237199500002368048000021474320000223831800002237601000022679930000217180500002231733000023686680000191205400002039540

000022487630000230291800002049961

000022487640000230292600002049988

00002256134000022674700000230263200002247439

0000225617700002363895000022674890000230264000002247440

APO-ATENOLCO ATENOLOLJAMP-ATENOLOLMAR-ATENOLOLMINT-ATENOLMYLAN-ATENOLOLPHL-ATENOLOLPMS-ATENOLOLRAN-ATENOLOLRATIO-ATENOLOLSANDOZ ATENOLOLSEPTA-ATENOLOLTEVA-ATENOLTENORMIN

APO-ATENIDONETEVA-ATENOLTHALIDONETENORETIC 50/25

APO-ATENIDONETEVA-ATENOLTHALIDONETENORETIC 100/25

APO-BISOPROLOLNOVO-BISOPROLOLPMS-BISOPROLOLSANDOZ BISOPROLOL

APO-BISOPROLOLAVA-BISOPROLOLNOVO-BISOPROLOLPMS-BISOPROLOLSANDOZ BISOPROLOL

APXCOBJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVAZC

APXTEVAZC

APXTEVAZC

APXTEVPMSSDZ

APXAVATEVPMSSDZ



24:00

24:24

0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.3692 0.9813

0.3195 0.3195 0.6640

0.5236 0.5236 1.0880

0.1378 0.1378 0.1378 0.1378

0.2284 0.2284 0.2284 0.2284 0.2284


$$$$$$$$$$$$$$

$$$

$$$

$$$$

$$$$$



CARVEDILOL

LABETALOL HCL


6.25 MG ORAL TABLET

12.5 MG ORAL TABLET

25 MG ORAL TABLET

100 MG ORAL TABLET

200 MG ORAL TABLET

5 MG / ML INJECTION

0000224793300002370735000023649130000234751200002248752000022459140000226802700002252309

0000224793400002370743000023649210000234752000002248753000022459150000226803500002252317

0000224793500002370751000023649480000234755500002248754000022459160000226804300002252325

00002247936000023707860000236495600002347571000022459170000226805100002252333

00002106272

00002106280

00002231689

APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPHL-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL



APO-CARVEDILOLAVA-CARVEDILOLCARVEDILOLMYLAN-CARVEDILOLPMS-CARVEDILOLRAN-CARVEDILOLRATIO-CARVEDILOL

TRANDATE

TRANDATE

LABETALOL HYDROCHLORIDE

APXAVASNSMYPPHHPMSRANRPH



APXAVASNSMYPPMSRANRPH

PAL

PAL

SDZ



24:00

24:24

0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728

0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728

0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728

0.4728 0.4728 0.4728 0.4728 0.4728 0.4728 0.4728

0.2677

0.4733

1.2930


$$$$$$$$

$$$$$$$$

$$$$$$$$

$$$$$$$

$

$

$




METOPROLOL TARTRATE

NADOLOL

25 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET


200 MG (BASE) ORAL SUSTAINED-RELEASE TABLET


40 MG ORAL TABLET

80 MG ORAL TABLET

160 MG ORAL TABLET

00002246010000023568130000230205500002248855

000006186320000074935400002364824000023648400000235682100002350394000021745450000223080300002354187000008426480000064803500000397423

00000618640000007511700000236483200002364859000023568480000235040800002174553000022308040000224787600002354195000008426560000064804300000397431

000022851690000230339600000658855

000022851770000230341800000534560

00000590819

0000078250500002126753

0000078246700002126761

00000782475

APO-METOPROLOLJAMP-METOPROLOL-LMYLAN-METOPROLOLPMS-METOPROLOL-L

APO-METOPROLOLAPO-METOPROLOL (TYPE L)AVA-METOPROLOLAVA-METOPROLOL (TYPE L)JAMP-METOPROLOL-LMETOPROLOLMYLAN-METOPROLOL (TYPE L)PMS-METOPROLOL-LSANDOZ METOPROLOL (TYPE L)TEVA-METOPROLTEVA-METOPROL (FC)LOPRESOR

APO-METOPROLOLAPO-METOPROLOL (TYPE L)AVA-METOPROLOLAVA-METOPROLOL (TYPE L)JAMP-METOPROLOL-LMETOPROLOLMYLAN-METOPROLOL (TYPE L)PMS-METOPROLOL-LSANDOZ METOPROLOL (TYPE L)SANDOZ METOPROLOL (TYPE L)TEVA-METOPROLTEVA-METOPROL (FC)LOPRESOR

APO-METOPROLOL SRSANDOZ METOPROLOL SRLOPRESOR SR

APO-METOPROLOL SRSANDOZ METOPROLOL SRLOPRESOR SR

LOPRESOR

APO-NADOLNOVO-NADOLOL

APO-NADOLNOVO-NADOLOL

APO-NADOL

APXJPCMYPPMS

APXAPXAVAAVAJPCSNSMYPPMSSDZTEVTEVNOV

APXAPXAVAAVAJPCSNSMYPPMSSDZSDZTEVTEVNOV

APXSDZNOV

APXSDZNOV

NOV

APXTEV

APXTEV

APX



24:00

24:24

0.0643 0.0643 0.0643 0.0643

0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.1047 0.2781

0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.2147 0.5706

0.1312 0.1312 0.3116

0.2499 0.2499 0.5655

1.1953

0.2465 0.2465

0.3515 0.3515

1.2046


$$$$

$$$$$$$$$$$$

$$$$$$$$$$$$$

$$$

$$$

$

$$

$$

$



PINDOLOL

PINDOLOL/ HYDROCHLOROTHIAZIDE

PROPRANOLOL HCL

5 MG ORAL TABLET

10 MG ORAL TABLET

15 MG ORAL TABLET



10 MG ORAL TABLET

20 MG ORAL TABLET

40 MG ORAL TABLET

80 MG ORAL TABLET

120 MG ORAL TABLET

60 MG ORAL SUSTAINED-RELEASE CAPSULE




0000075587700000869007000022315360000226178200000417270

0000075588500000869015000022315370000226179000000443174

0000075589300000869023000022315390000226180400000417289

00000568627

00000568635

0000040278800000496480

0000066371900000740675

0000040275300000496499

0000040276100000496502

00000504335

00002042231

00002042258

00002042266

00002042274

APO-PINDOLNOVO-PINDOLPMS-PINDOLOLSANDOZ PINDOLOLVISKEN



VISKAZIDE 10/25

VISKAZIDE 10/50

APO-PROPRANOLOLNOVO-PRANOL




APO-PROPRANOLOL

INDERAL-LA

INDERAL-LA

INDERAL-LA

INDERAL-LA

APXTEVPMSSDZNOV

APXTEVPMSSDZNOV

APXTEVPMSSDZNOV

NOV

NOV

APXTEV

APXTEV

APXTEV

APXTEV

APX

WAY

WAY

WAY

WAY



24:00

24:24

0.2147 0.2147 0.2147 0.2147 0.5706

0.3666 0.3666 0.3666 0.3666 0.9744

0.5318 0.5318 0.5318 0.5318 1.4135

0.8746

0.8746

0.0192 0.0192

0.0346 0.0346

0.0348 0.0348

0.0585 0.0585

0.3091

0.5562

0.6272

0.9656

1.1420


$$$$$

$$$$$

$$$$$

$

$

$$

$$

$$

$$

$

$

$

$

$




SOTALOL HCL

TIMOLOL MALEATE

80 MG ORAL TABLET

160 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

0000221042800002363674000022706250000222977800002231181000022383260000208422800002257831

0000216779400002363682000022706330000222977900002231182000022383270000208423600002257858

0000075584200001947796

0000075585000001947818

0000075586900001947826

APO-SOTALOLAVA-SOTALOLCO SOTALOLMYLAN-SOTALOLNOVO-SOTALOLPMS-SOTALOLRATIO-SOTALOLSANDOZ SOTALOL

APO-SOTALOLAVA-SOTALOLCO SOTALOLMYLAN-SOTALOLNOVO-SOTALOLPMS-SOTALOLRATIO-SOTALOLSANDOZ SOTALOL

APO-TIMOLNOVO-TIMOL

APO-TIMOLNOVO-TIMOL

APO-TIMOLNOVO-TIMOL

APXAVACOBMYPTEVPMSRPHSDZ

APXAVACOBMYPTEVPMSRPHSDZ

APXTEV

APXTEV

APXTEV



24:00

24:24

0.3708 0.3708 0.3708 0.3708 0.3708 0.3708 0.3708 0.3708

0.4058 0.4058 0.4058 0.4058 0.4058 0.4058 0.4058 0.4058

0.1649 0.1649

0.2572 0.2572

0.5005 0.5005


$$$$$$$$

$$$$$$$$

$$

$$

$$



AMLODIPINE BESYLATE

FELODIPINE

2.5 MG ORAL TABLET



2.5 MG ORAL EXTENDED-RELEASE TABLET


0000232676000002295148

000023312840000233193400002273373000022974850000228013200002331071000023571940000237171500002362651000022721130000232677900002284065000023218580000225960500002284383000023577120000225049700000878928

000023312920000233194200002273381000022974930000228014000002331098000023572080000237172300002362678000022721210000232678700002284073000023218660000225961300002284391000023577200000225050000000878936

0000222198500002057778

000022802640000222199300000851779

PHL-AMLODIPINEPMS-AMLODIPINE

AMLODIPINEAMLODIPINEAPO-AMLODIPINECO AMLODIPINEGD-AMLODIPINEJAMP-AMLODIPINEJAMP-AMLODIPINEMAR-AMLODIPINEMINT-AMLODIPINEMYLAN-AMLODIPINEPHL-AMLODIPINEPMS-AMLODIPINERAN-AMLODIPINERATIO-AMLODIPINESANDOZ AMLODIPINESEPTA-AMLODIPINETEVA-AMLODIPINENORVASC

AMLODIPINEAMLODIPINEAPO-AMLODIPINECO AMLODIPINEGD-AMLODIPINEJAMP-AMLODIPINEJAMP-AMLODIPINEMAR-AMLODIPINEMINT-AMLODIPINEMYLAN-AMLODIPINEPHL-AMLODIPINEPMS-AMLODIPINERAN-AMLODIPINERATIO-AMLODIPINESANDOZ AMLODIPINESEPTA-AMLODIPINETEVA-AMLODIPINENORVASC

RENEDILPLENDIL

SANDOZ FELODIPINERENEDILPLENDIL

PHHPMS

SNSRANAPXCOBGMDJPCJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVPFI

SNSRANAPXCOBGMDJPCJPCMARMPIMYPPHHPMSRANRPHSDZSEPTEVPFI

SAVAZC

SDZSAVAZC


CALCIUM-CHANNEL BLOCKING AGENTS

24:00

24:28.08

0.2684 0.2684

0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 0.5052 1.3426

0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 0.7499 1.9930

0.3170 0.5090

0.4620 0.4633 0.6800


$$

$$$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$$$

$$

$$$

(DIHYDROPYRIDINES)




FELODIPINE

NIFEDIPINE

DILTIAZEM HCL





5 MG ORAL CAPSULE

10 MG ORAL CAPSULE

30 MG ORAL TABLET

60 MG ORAL TABLET






120 MG ORAL CONTROLLED-DELIVERY CAPSULE

000022220000000228027200000851787

00002237618

0000234916700002155907

0000232114900002155990

00000725110

00000755907

0000077137600000862924

0000077138400000862932

00002256738

00002256746

00002256754

00002256762

00002256770

00002230997000023706110000224253800002355752000022297810000224333800002097249

RENEDILSANDOZ FELODIPINEPLENDIL

ADALAT XL

MYLAN-NIFEDIPINE EXTENDED RELEASEADALAT XL

MYLAN-NIFEDIPINE EXTENDED RELEASEADALAT XL

NIFEDIPINE

NIFEDIPINE

APO-DILTIAZNOVO-DILTAZEM

APO-DILTIAZNOVO-DILTAZEM

TIAZAC XC

TIAZAC XC

TIAZAC XC

TIAZAC XC

TIAZAC XC

APO-DILTIAZ CDCO DILTIAZEM CDNOVO-DILTAZEM CDPMS-DILTIAZEM CDRATIO-DILTIAZEM CDSANDOZ DILTIAZEM CDCARDIZEM CD

SAVSDZAZC

BAI

MYPBAI

MYPBAI

AAP

AAP

APXTEV

APXTEV

VCL

VCL

VCL

VCL

VCL

APXCOBTEVPMSRPHSDZVCL





24

24

:00

:00

24:28.08

24:28.92

0.6733 0.6733 1.0207

1.2487

0.6171 0.7177

0.9374 1.1285

0.3679

0.4877

0.1866 0.1866

0.3273 0.3273

0.8194

1.0887

1.4470

1.4441

1.4447

0.5157 0.5157 0.5157 0.5157 0.5157 0.5157 1.4734


$$$

$

$$

$$

$

$

$$

$$

$

$

$

$

$

$$$$$$$

(DIHYDROPYRIDINES)

(MISCELLANEOUS CALCIUM-CHANNEL BLOCKING AGENTS)



DILTIAZEM HCL180 MG ORAL CONTROLLED-DELIVERY CAPSULE







00002230998000023706380000224253900002355760000022297820000224333900002097257

00002230999000023706460000224254000002355779000022297830000224334000002097265

00002229526000023706540000224254100002355787000022297840000224334100002097273

0000229103700002370441000022716050000224591800002231150

0000229104500002370492000022716130000224591900002231151

0000229105300002370506000022716210000224592000002231152

0000229106100002370514000022716480000224592100002231154




APO-DILTIAZ TZCO DILTIAZEM TNOVO-DILTIAZEM HCL ERSANDOZ DILTIAZEM TTIAZAC







APXCOBTEVSDZVCL

APXCOBTEVSDZVCL

APXCOBTEVSDZVCL

APXCOBTEVSDZVCL



24:00

24:28.92

0.6846 0.6846 0.6846 0.6846 0.6846 0.6846 1.9559

0.9080 0.9080 0.9080 0.9080 0.9080 0.9080 2.5944

1.1351 1.1351 1.1351 1.1351 1.1351 1.1351 3.2431

0.2987 0.2987 0.2987 0.2987 0.8533

0.4045 0.4045 0.4045 0.4045 1.1556

0.5365 0.5365 0.5365 0.5365 1.5328

0.6607 0.6607 0.6607 0.6607 1.8878


$$$$$$$

$$$$$$$

$$$$$$$

$$$$$

$$$$$

$$$$$

$$$$$





DILTIAZEM HCL

VERAPAMIL HCL

BENAZEPRIL HCL


80 MG ORAL TABLET

120 MG ORAL TABLET




5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

0000229108800002370522000022716560000224592200002231155

0000078248300002237921

0000078249100002237922

000022468930000221034700001907123

000022468940000221035500001934317

0000224689500002210363000022119200000223779100000742554

0000229033200000885835

00002290340

0000227391800000885851


APO-VERAPMYLAN-VERAPAMIL

APO-VERAPMYLAN-VERAPAMIL

APO-VERAP SRMYLAN-VERAPAMIL SRISOPTIN SR

APO-VERAP SRMYLAN-VERAPAMIL SRISOPTIN SR

APO-VERAP SRMYLAN-VERAPAMIL SRNOVO-VERAMIL SRPMS-VERAPAMIL SRISOPTIN SR

BENAZEPRILLOTENSIN

BENAZEPRIL

BENAZEPRILLOTENSIN

APXCOBTEVSDZVCL

APXMYP

APXMYP

APXMYPABB

APXMYPABB

APXMYPTEVPMSABB

AAPNOV

AAP

AAPNOV





24

24

:00

:00

24:28.92

24:32.04

0.8089 0.8089 0.8089 0.8089 2.3112

0.2735 0.2735

0.4250 0.4250

0.5078 0.5078 1.3448

0.5315 0.5315 1.5186

0.7088 0.7088 0.7088 0.7088 2.0252

0.5995 0.7795

0.6595

0.8135 1.0577


$$$$$

$$

$$

$$$

$$$

$$$$$

$$

$

$$


(ANGIOTENSIN-CONVERTING ENZYME INHIBITORS)



CAPTOPRIL

CILAZAPRIL

CILAZAPRIL/ HYDROCHLOROTHIAZIDE

12.5 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET

1 MG ORAL TABLET

2.5 MG ORAL TABLET

5 MG ORAL TABLET


000008935950000216355100001942964

000008936090000216357800001942972

000008936170000216358600001942980

000008936250000216359400001942999

0000229113400002283778000022804420000235096300002266350

00002291142000023509710000228521500002283786000022663690000228045000001911473

00002291150000023509980000228522300002283794000022663770000228046900001911481

000022849870000231373100002181479

APO-CAPTOMYLAN-CAPTOPRILNOVO-CAPTORIL




APO-CILAZAPRILMYLAN-CILAZAPRILPMS-CILAZAPRILCILAZAPRILNOVO-CILAZAPRIL

APO-CILAZAPRILCILAZAPRILCO CILAZAPRILMYLAN-CILAZAPRILNOVO-CILAZAPRILPMS-CILAZAPRILINHIBACE

APO-CILAZAPRILCILAZAPRILCO CILAZAPRILMYLAN-CILAZAPRILNOVO-CILAZAPRILPMS-CILAZAPRILINHIBACE

APO-CILAZAPRIL/HCTZNOVO-CILAZAPRIL/HCTZINHIBACE PLUS

APXMYPTEV

APXMYPTEV

APXMYPTEV

APXMYPTEV

APXMYPPMSSNSTEV

APXSNSCOBMYPTEVPMSHLR

APXSNSCOBMYPTEVPMSHLR

APXTEVHLR



24:00

24:32.04

0.1325 0.1325 0.1325

0.1875 0.1875 0.1875

0.3494 0.3494 0.3494

0.6497 0.6497 0.6497

0.2492 0.2492 0.2492 0.2804 0.2804

0.2755 0.2755 0.2755 0.2755 0.2755 0.2755 0.7323

0.3201 0.3201 0.3201 0.3201 0.3201 0.3201 0.8508

0.4170 0.4170 0.8507


$$$

$$$

$$$

$$$

$$$$$

$$$$$$$

$$$$$$$

$$$





ENALAPRIL MALEATE

ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE

2.5 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET



000020200250000236345300002291878000023000360000230068000002300079000023522300000229993300000851795

000020198840000236346100002291886000023000440000223300500002300087000023522490000229994100000708879

000020198920000236348800002291894000023000520000223300600002300095000023522570000229996800000670901

000020199060000236349600002291908000023000600000223300700002300109000023522650000229997600000670928

0000230022200002352923

000023529310000230023000000657298

APO-ENALAPRILAVA-ENALAPRILCO ENALAPRILMYLAN-ENALAPRILNOVO-ENALAPRILPMS-ENALAPRILRAN-ENALAPRILSANDOZ ENALAPRILVASOTEC




NOVO-ENALAPRIL/HCTZAPO-ENALAPRIL MALEATE/HCTZ

APO-ENALAPRIL MALEATE/HCTZNOVO-ENALAPRIL/HCTZVASERETIC

APXAVACOBMYPTEVPMSRANSDZMFC




TEVAPX

APXTEVMFC



24:00

24:32.04

0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.2731 0.7803

0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.3231 0.9231

0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 0.3882 1.1092

0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 1.3385

0.4927 0.4941

0.6108 0.6108 1.1425


$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

$$

$$$




FOSINOPRIL SODIUM

LISINOPRIL

10 MG ORAL TABLET

20 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

00002266008000023325660000233100400002262401000022945240000224780200001907107

00002266016000023325740000233101200002262428000022945320000224780300001907115

0000221748100002271443000023615310000233216700002274833000022851180000229220300002294230000022567970000229987900002289199000022850610000204933300000839388

0000221750300002271451000023615580000233217500002274841000022851260000229221100002294249000022568000000229988700002289202000022850880000204937600000839396

APO-FOSINOPRILFOSINOPRILJAMP-FOSINOPRILMYLAN-FOSINOPRILRAN-FOSINOPRILTEVA-FOSINOPRILMONOPRIL

APO-FOSINOPRILFOSINOPRILJAMP-FOSINOPRILMYLAN-FOSINOPRILRAN-FOSINOPRILTEVA-FOSINOPRILMONOPRIL

APO-LISINOPRILCO LISINOPRILJAMP-LISINOPRILLISINOPRILMYLAN-LISINOPRILNOVO-LISINOPRIL (TYPE Z)PMS-LISINOPRILRAN-LISINOPRILRATIO-LISINOPRIL PRATIO-LISINOPRIL ZSANDOZ LISINOPRILTEVA-LISINOPRIL (TYPE P)ZESTRILPRINIVIL


APXRANJPCMYPRANTEVBMS

APXRANJPCMYPRANTEVBMS

APXCOBJPCRANMYPTEVPMSRANRPHRPHSDZTEVAZCMFC




24:00

24:32.04

0.3194 0.3194 0.3194 0.3194 0.3194 0.3194 0.9125

0.3841 0.3841 0.3841 0.3841 0.3841 0.3841 1.0973

0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.2094 0.5594 0.5983

0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.2516 0.6723 0.7189


$$$$$$$

$$$$$$$

$$$$$$$$$$$$$$

$$$$$$$$$$$$$$





LISINOPRIL

LISINOPRIL/ HYDROCHLOROTHIAZIDE

PERINDOPRIL ERBUMINE

20 MG ORAL TABLET







2 MG ORAL TABLET

4 MG ORAL TABLET

0000221751100002271478000023615660000233218300002274868000022851340000229223800002294257000022568190000229989500002289229000022850960000204938400000839418

00002261979000023628800000236294500002297736000023023650000230176800002103729

00002261987000023628990000236295300002297744000023023730000230177600002045737

000023629020000236296100002297752000023023810000230178400002045729

00002302136

0000230214400000884413

00002302152

00002123274

00002123282


APO-LISINOPRIL/HCTZAVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC

APO-LISINOPRIL/HCTZAVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC

AVA-LISINOPRIL HCTLISINOPRIL/HCTZ (TYPE Z)MYLAN-LISINOPRIL HCTZSANDOZ LISINOPRIL HCTTEVA-LISINOPRIL/HCTZ (TYPE Z)ZESTORETIC

NOVO-LISINOPRIL/HCTZ (TYPE P)

NOVO-LISINOPRIL/HCTZ (TYPE P)PRINZIDE

NOVO-LISINOPRIL/HCTZ (TYPE P)

COVERSYL

COVERSYL


APXAVASNSMYPSDZTEVAZC

APXAVASNSMYPSDZTEVAZC

AVASNSMYPSDZTEVAZC

TEV

TEVMFC

TEV

SEV

SEV



24:00

24:32.04

0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.3026 0.8078 0.8645

0.3256 0.3256 0.3256 0.3256 0.3256 0.3256 0.8654

0.3913 0.3913 0.3913 0.3913 0.3913 0.3913 1.0400

0.3913 0.3913 0.3913 0.3913 0.3913 1.0400

0.4076

0.3506 0.8904

0.6068

0.6526

0.8170


$$$$$$$$$$$$$$

$$$$$$$

$$$$$$$

$$$$$$

$

$$

$

$

$




PERINDOPRIL ERBUMINE

PERINDOPRIL ERBUMINE/ INDAPAMIDE HEMIHYDRATE

QUINAPRIL HCL

QUINAPRIL HCL/ HYDROCHLOROTHIAZIDE

RAMIPRIL

8 MG ORAL TABLET







10 MG (BASE) * 12.5 MG ORAL TABLET

20 MG (BASE) * 12.5 MG ORAL TABLET


1.25 MG ORAL CAPSULE/TABLET

2.5 MG ORAL CAPSULE/TABLET

00002246624

00002246569

00002321653

00001947664

00001947672

00001947680

00001947699

00002237367

00002237368

00002237369

00002251515000023632670000229548200002331101000023011480000229536900002332299000023105030000229139800002221829

000022515310000236327500002295490000023311280000230115600002247917000023323020000237484600002310511000022914010000224794500002221837

COVERSYL

COVERSYL PLUS

COVERSYL PLUS HD

ACCUPRIL

ACCUPRIL

ACCUPRIL

ACCUPRIL

ACCURETIC 10/12.5

ACCURETIC 20/12.5

ACCURETIC 20/25

APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)ALTACE (CAPSULE)

APO-RAMIPRIL (CAPSULE)AVA-RAMIPRIL (TABLET)CO RAMIPRIL (CAPSULE)JAMP-RAMIPRIL (CAPSULE)MYLAN-RAMIPRIL (CAPSULE)PMS-RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAMIPRIL (CAPSULE)RAN-RAMIPRIL (CAPSULE)SANDOZ RAMIPRIL (TABLET)TEVA-RAMIPRIL (CAPSULE)ALTACE (CAPSULE)

SEV

SEV

SEV

PFI

PFI

PFI

PFI

PFI

PFI

PFI

APXAVACOBJPCMYPPMSRANRANSDZSAV

APXAVACOBJPCMYPPMSRANSNSRANSDZTEVSAV



24:00

24:32.04

1.1436

0.9843

1.1436

0.8976

0.8976

0.8976

0.8976

0.8974

0.8974

0.8682

0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.2663 0.7077

0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.8167


$

$

$

$

$

$

$

$

$

$

$$$$$$$$$$

$$$$$$$$$$$$





RAMIPRIL

RAMIPRIL/ HYDROCHLOROTHIAZIDE

TRANDOLAPRIL



2.5 MG * 12.5 MG ORAL TABLET





0.5 MG ORAL CAPSULE

1 MG ORAL CAPSULE

2 MG ORAL CAPSULE

000022515740000236328300002295504000023311360000230116400002247918000023323100000237485400002310538000022914280000224794600002221845

000022515820000236329100002295512000023311440000230117200002247919000023323290000237486200002310546000022914360000224794700002221853

0000234213800002283131

0000234214600002283158

0000234216200002283174

0000234215400002283166

0000234217000002283182

00002231457

00002231459

00002231460



PMS-RAMIPRIL-HCTZALTACE HCT





MAVIK

MAVIK

MAVIK



PMSSAV

PMSSAV

PMSSAV

PMSSAV

PMSSAV

ABB

ABB

ABB



24:00

24:32.04

0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.3073 0.8167

0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 0.3892 1.0343

0.2250 0.2989

0.2263 0.3829

0.2263 0.3829

0.2865 0.4875

0.2865 0.4875

0.4030

0.6901

0.7931


$$$$$$$$$$$$

$$$$$$$$$$$$

$$

$$

$$

$$

$$

$

$

$




TRANDOLAPRIL

CANDESARTAN CILEXETIL

CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE

EPROSARTAN MESYLATE

EPROSARTAN MESYLATE/ HYDROCHLOROTHIAZIDE

4 MG ORAL CAPSULE

8 MG ORAL TABLET

16 MG ORAL TABLET

32 MG ORAL TABLET







00002239267

00002365359000023792790000237653900002379139000023269650000236631200002239091

00002365367000023792870000237654700002379147000023269730000236632000002239092

0000237929500002376555000023791550000236633900002311658

00002244021

00002332922

00002332957

00002240432

00002243942

00002253631

MAVIK

APO-CANDESARTANCANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANSANDOZ CANDESARTANTEVA-CANDESARTANATACAND

APO-CANDESARTANCANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANSANDOZ CANDESARTANTEVA-CANDESARTANATACAND

CANDESARTAN CILEXETILCO CANDESARTANMYLAN-CANDESARTANTEVA-CANDESARTANATACAND

ATACAND PLUS

ATACAND PLUS

ATACAND PLUS

TEVETEN

TEVETEN

TEVETEN PLUS

ABB

APXAHICOBMYPSDZTEVAZC

APXAHICOBMYPSDZTEVAZC

AHICOBMYPTEVAZC

AZC

AZC

AZC

ABB

ABB

ABB





24

24

:00

:00

24:32.04

24:32.08

0.9785

0.4455 0.4455 0.4455 0.4455 0.4455 0.4455 1.1840

0.4455 0.4455 0.4455 0.4455 0.4455 0.4455 1.1840

0.4455 0.4455 0.4455 0.4455 1.1840

1.1700

1.1700

1.1700

0.7075

1.0836

1.0836


$

$$$$$$$

$$$$$$$

$$$$$

$

$

$

$

$

$






IRBESARTAN

IRBESARTAN/ HYDROCHLOROTHIAZIDE

75 MG ORAL TABLET

150 MG ORAL TABLET

300 MG ORAL TABLET



000023733190000232807000002372347000023472960000231706000002316390000023284610000231597100002237923

000023733270000232808900002372371000023473180000231707900002316404000023284880000231599800002237924

000023733350000232810000002372398000023473260000231708700002316412000023284960000231600500002237925

000023733430000235739900002372886000023285180000236320800002330512000023374280000231601300002241818

000023733510000235740200002372894000023285260000236321600002330520000023374360000231602100002241819

AVA-IRBESARTANCO IRBESARTANIRBESARTANMYLAN-IRBESARTANPMS-IRBESARTANRATIO-IRBESARTANSANDOZ IRBESARTANTEVA-IRBESARTANAVAPRO



AVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZPMS-IRBESARTAN-HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZAVALIDE 150/12.5

AVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZPMS-IRBESARTAN-HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZAVALIDE 300/12.5

AVACOBSNSMYPPMSRPHSDZTEVSAV



AVACOBSNSPMSRANRPHSDZTEVSAV

AVACOBSNSPMSRANRPHSDZTEVSAV



24:00

24:32.08

0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633

0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633

0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633

0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633

0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 0.4422 1.2633


$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

$$$$$$$$$




IRBESARTAN/ HYDROCHLOROTHIAZIDE

LOSARTAN POTASSIUM

LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE


25 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET



0000232853400002373378000023574100000237290800002363224000023305390000233744400002316048

00002379058000023548290000236827700002309750000023133320000238083800002182815

00002353504000023548370000236828500002309769000023133400000235796800002182874

00002353512000023548450000236829300002309777000023133590000235797600002182882

0000237123500002378078000023133750000235826300002230047

0000237124300002378086000023624490000237714400002297841

PMS-IRBESARTAN-HCTZAVA-IRBESARTAN/HCTZCO IRBESARTAN/HCTIRBESARTAN/HCTZRAN-IRBESARTAN HCTZRATIO-IRBESARTAN HCTZSANDOZ IRBESARTAN HCTTEVA-IRBESARTAN/HCTZ

APO-LOSARTANCO LOSARTANMYLAN-LOSARTANPMS-LOSARTANSANDOZ LOSARTANTEVA-LOSARTANCOZAAR



APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCTTEVA-LOSARTAN/HCTZHYZAAR

APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCTTEVA-LOSARTAN/HCTZHYZAAR

PMSAVACOBSNSRANRPHSDZTEV

APXCOBMYPPMSSDZTEVMFC



APXMYPSDZTEVMFC

APXMYPSDZTEVMFC



24:00

24:32.08

0.4205 0.4206 0.4206 0.4206 0.4206 0.4206 0.4206 0.4206

0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590

0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590

0.4407 0.4407 0.4407 0.4407 0.4407 0.4407 1.2590

0.4407 0.4407 0.4407 0.4407 1.2590

0.4314 0.4314 0.4314 0.4314 1.2327


$$$$$$$$

$$$$$$$

$$$$$$$

$$$$$$$

$$$$$

$$$$$





LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

TELMISARTAN

TELMISARTAN/ AMLODIPINE BESYLATE

TELMISARTAN/ HYDROCHLOROTHIAZIDE


40 MG ORAL TABLET

80 MG ORAL TABLET







0000237125100002378094000023133830000237715200002241007

00002376717000023759580000232017700002240769

00002376725000023759660000232018500002240770

00002371022

00002371030

00002371049

00002371057

000023735640000233028800002244344

000023735720000237925200002318709

APO-LOSARTAN/HCTZMYLAN-LOSARTAN HCTZSANDOZ LOSARTAN HCT DSTEVA-LOSARTAN/HCTZHYZAAR DS

MYLAN-TELMISARTANSANDOZ TELMISARTANTEVA-TELMISARTANMICARDIS

MYLAN-TELMISARTANSANDOZ TELMISARTANTEVA-TELMISARTANMICARDIS

TWYNSTA

TWYNSTA

TWYNSTA

TWYNSTA

MYLAN-TELMISARTAN HCTZTEVA-TELMISARTAN HCTZMICARDIS PLUS

MYLAN-TELMISARTAN HCTZTEVA-TELMISARTAN HCTZMICARDIS PLUS

APXMYPSDZTEVMFC

MYPSDZTEVBOE

MYPSDZTEVBOE

BOE

BOE

BOE

BOE

MYPTEVBOE

MYPTEVBOE



24:00

24:32.08

0.4407 0.4407 0.4407 0.4407 1.2590

0.4080 0.4080 0.4080 1.1657

0.4080 0.4080 0.4080 1.1657

0.6818

0.6818

0.6818

0.6818

0.4080 0.4080 1.1657

0.4080 0.4080 1.1657


$$$$$

$$$$

$$$$

$

$

$

$

$$$

$$$




VALSARTAN

VALSARTAN/ HYDROCHLOROTHIAZIDE

80 MG ORAL TABLET

160 MG ORAL TABLET

320 MG ORAL TABLET





00002371529000023671220000233749500002363100000023567590000235665100002244781

00002371537000023671300000233750900002363119000023567670000235667800002244782

000023715450000236714900002337517000023567750000235668600002289504

000023825470000236706800002373734000023566940000235699600002241900

000023825550000236707600002373742000023567080000235700300002241901

000023825630000236708400002373750000023567160000235701100002246955

000023825710000236709200002373769000023567240000235703800002308908

APO-VALSARTANAVA-VALSARTANCO VALSARTANRAN-VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN

APO-VALSARTANAVA-VALSARTANCO VALSARTANRAN-VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN

APO-VALSARTANAVA-VALSARTANCO VALSARTANSANDOZ VALSARTANTEVA-VALSARTANDIOVAN

APO-VALSARTAN/HCTZAVA-VALSARTAN HCTMYLAN-VALSARTAN HCTZSANDOZ VALSARTAN HCTTEVA-VALSARTAN/HCTZDIOVAN-HCT




APXAVACOBRANSDZTEVNOV

APXAVACOBRANSDZTEVNOV

APXAVACOBSDZTEVNOV

APXAVAMYPSDZTEVNOV

APXAVAMYPSDZTEVNOV

APXAVAMYPSDZTEVNOV

APXAVAMYPSDZTEVNOV



24:00

24:32.08

0.4514 0.4514 0.4514 0.4514 0.4514 0.4514 1.1996

0.4512 0.4512 0.4512 0.4512 0.4512 0.4512 1.1993

0.4347 0.4347 0.4347 0.4347 0.4347 1.1554

0.4492 0.4492 0.4492 0.4492 0.4492 1.1939

0.4504 0.4504 0.4504 0.4504 0.4504 1.1971

0.4519 0.4519 0.4519 0.4519 0.4519 1.2011

0.4452 0.4452 0.4452 0.4452 0.4452 1.1832


$$$$$$$

$$$$$$$

$$$$$$

$$$$$$

$$$$$$

$$$$$$

$$$$$$





VALSARTAN/ HYDROCHLOROTHIAZIDE

HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE

SPIRONOLACTONE




25 MG ORAL TABLET

100 MG ORAL TABLET

000023825980000236710600002373777000023567320000235704600002308916

0000061323100000180408

0000065718200000594377

0000061321500000028606

0000061322300000285455


NOVO-SPIROZINEALDACTAZIDE 25

NOVO-SPIROZINEALDACTAZIDE 50

NOVO-SPIROTONALDACTONE

NOVO-SPIROTONALDACTONE

APXAVAMYPSDZTEVNOV

TEVPFI

TEVPFI

TEVPFI

TEVPFI





24

24

:00

:00

24:32.08

24:32.20

0.4452 0.4452 0.4452 0.4452 0.4452 1.1832

0.1216 0.1307

0.2571 0.2771

0.1194 0.1307

0.2780 0.3080


$$$$$$

$$

$$

$$

$$


(MINERALOCORTICOID (ALDOSTERONE) RECEPTOR ANTAGONISTS)


28:00 Central N

ervous System A

gents

28:00

Central Nervous System Agents


COMPOUND PRESCRIPTION


ASA

BUTALBITAL/ CAFFEINE/ ASA

TOPICAL

TOPICAL

TOPICAL

TOPICAL


50 MG * 40 MG * 330 MG ORAL TABLET

50 MG * 40 MG * 330 MG ORAL CAPSULE

00000999105

00000999205

00000999102

00000999202

00000010340

00000608211

0000060823800000226327

COMPD- NSAID/ ANALG/MUSCLE RELAX (NOT DICLOFENAC)-TOPICAL

COMPD-NSAID/ ANALG/MUSCLE RELAX (NOT DICLOFENAC)-TOPICAL

COMPOUND-DICLOFENAC (TOPICAL)

COMPOUND- DICLOFENAC (TOPICAL)

ENTROPHEN 10

RATIO-TECNAL

RATIO-TECNALFIORINAL

XXX

XXX

XXX

XXX

PPH

RPH

RPHNOV

(SALICYLATES)

CENTRAL NERVOUS SYSTEM AGENTS



ANALGESICS AND ANTIPYRETICS



28

28

28

:00

:00

:00

28:08

28:08.04

28:08.04.24

0.0000

0.0000

0.0000

0.0000

0.0818

0.6265

1.0304 1.5175


$

$

$

$

$

$

$$

To be used when the compound has been prepared and dispensed by a licensed community pharmacy.

To be used when the compound has been procured from a licensed compounding and repackaging pharmacy and dispensed by a licensed community pharmacy.



(NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS




DICLOFENAC SODIUM

DICLOFENAC SODIUM/ MISOPROSTOL





50 MG RECTAL SUPPOSITORY


50 MG * 200 MCG ORAL TABLET


00002162814000023666810000235240000002158582000022315040000226190100000782459

000020911940000236670300002048698000022315050000226194400000590827

0000083917500002366665000008085390000230261600002261952

00000839183000023666730000235239700000808547000023026240000226196000000514012

00002231506000022412240000226192800000632724

000022315080000226193600000632732

00001917056

00002229837

APO-DICLO SRAVA-DICLOFENAC SRDICLOFENAC SODIUM SRNOVO-DIFENAC SRPMS-DICLOFENAC-SRSANDOZ DICLOFENAC SRVOLTAREN SR

APO-DICLO SRAVA-DICLOFENAC SRNOVO-DIFENAC SRPMS-DICLOFENAC-SRSANDOZ DICLOFENAC SRVOLTAREN SR

APO-DICLOAVA-DICLOFENACNOVO-DIFENACPMS-DICLOFENACSANDOZ DICLOFENAC

APO-DICLOAVA-DICLOFENACDICLOFENAC SODIUMNOVO-DIFENACPMS-DICLOFENACSANDOZ DICLOFENACVOLTAREN

PMS-DICLOFENACSANDOZ DICLOFENACSANDOZ DICLOFENACVOLTAREN

PMS-DICLOFENACSANDOZ DICLOFENACVOLTAREN

ARTHROTEC-50

ARTHROTEC-75

APXAVASNSTEVPMSSDZNOV

APXAVATEVPMSSDZNOV

APXAVATEVPMSSDZ

APXAVASNSTEVPMSSDZNOV

PMSSDZSDZNOV

PMSSDZNOV

PFI

PFI

(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)



28:00

28:08.04.92

0.4491 0.4491 0.4491 0.4491 0.4491 0.4491 1.1937

0.6402 0.6402 0.6402 0.6402 0.6402 1.7016

0.1189 0.1189 0.1189 0.1189 0.1189

0.3257 0.3257 0.3257 0.3257 0.3257 0.3257 0.8656

0.4891 0.4891 0.4891 1.2999

0.6583 0.6583 1.7496

0.6053

0.8239


$ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567 $ 0.3567

$ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756 $ 0.4756

$ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378 $ 0.2378

MAC pricing has been applied based on the LCA Price for 3 x 25 mg oral enteric-coated tablets.

MAC pricing has been applied based on the LCA Price for 4 X 25 mg oral enteric-coated tablets.

MAC pricing has been applied based on the LCA Price for 2 x 25 mg oral enteric-coated tablets.

$$$$$$$

$$$$$$

$$$$$

$$$$$$$

$$$$

$$$

$

$




DIFLUNISAL

ETODOLAC

FLOCTAFENINE

FLURBIPROFEN

IBUPROFEN

INDOMETHACIN

250 MG ORAL TABLET

500 MG ORAL TABLET

200 MG ORAL CAPSULE

300 MG ORAL CAPSULE

200 MG ORAL TABLET

400 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET

300 MG ORAL TABLET

400 MG ORAL TABLET

600 MG ORAL TABLET

25 MG ORAL CAPSULE

50 MG ORAL CAPSULE



0000204849300002039486

00002039494

00002232317

00002232318

00002244680

00002244681

0000191204600002100509

0000191203800002100517

00000441651

0000050605200000629340

0000058511400000629359

00000337420

00000337439

00002231799

0000193413900002231800

NOVO-DIFLUNISAL FCAPO-DIFLUNISAL

APO-DIFLUNISAL

ETODOLAC

ETODOLAC

FLOCTAFENINE

FLOCTAFENINE

APO-FLURBIPROFENNOVO-FLURPROFEN

APO-FLURBIPROFENNOVO-FLURPROFEN

APO-IBUPROFEN

APO-IBUPROFENNOVO-PROFEN

APO-IBUPROFENNOVO-PROFEN

NOVO-METHACIN

NOVO-METHACIN

SANDOZ INDOMETHACIN

RATIO-INDOMETHACINSANDOZ INDOMETHACIN

TEVAPX

APX

AAP

AAP

AAP

AAP

APXTEV

APXTEV

APX

APXTEV

APXTEV

TEV

TEV

SDZ

RPHSDZ




28:00

28:08.04.92

0.5366 0.5646

0.7150

0.7600

0.7600

0.4175

0.8123

0.2221 0.2221

0.3039 0.3039

0.1087

0.0474 0.0474

0.1313 0.1313

0.0871

0.1511

0.8225

0.8910 0.8910


$$

$

$

$

$

$

$$

$$

$

$$

$$

$

$

$

$$





KETOPROFEN

KETOROLAC TROMETHAMINE

MEFENAMIC ACID

NABUMETONE

NAPROXEN




50 MG ORAL CAPSULE


10 MG ORAL TABLET



250 MG ORAL CAPSULE

500 MG ORAL TABLET

125 MG ORAL TABLET

250 MG ORAL TABLET

375 MG ORAL TABLET

500 MG ORAL TABLET

00002172577

00000790435

00000842664

00000790427

00002015951

000022290800000223020100002162660

00002162644

00002239944

00002229452

00002238639000022445630000234328200002240867

00000522678

000005226510000235075000000565350

00000600806000023658200000235076900000627097

00000592277000023658390000235077700000589861

KETOPROFEN SR

KETOPROFEN-E

KETOPROFEN-E

KETOPROFEN

PMS-KETOPROFEN

APO-KETOROLACNOVO-KETOROLACTORADOL

TORADOL


MEFENAMIC

APO-NABUMETONEMYLAN-NABUMETONENABUMETONENOVO-NABUMETONE

APO-NAPROXEN

APO-NAPROXENNAPROXENTEVA-NAPROX

APO-NAPROXENAVA-NAPROXENNAPROXENTEVA-NAPROX

APO-NAPROXENAVA-NAPROXENNAPROXENTEVA-NAPROX

AAP

AAP

AAP

AAP

PMS

APXTEVHLR

HLR

SDZ

AAP

APXMYPSNSTEV

APX

APXSNSTEV

APXAVASNSTEV

APXAVASNSTEV




28:00

28:08.04.92

1.3890

0.3373

0.6823

0.3373

1.1453

0.4085 0.4085 0.6922

2.2380

4.0000

0.4988

0.3625 0.3625 0.3625 0.3625

0.0781

0.1068 0.1068 0.1068

0.1458 0.1458 0.1458 0.1458

0.2110 0.2110 0.2110 0.2110


$ 1.4670

MAC pricing has been applied based on the price for 2 x 100 mg oral enteric-coated tablets.

$

$

$

$

$

$$$

$

$

$

$$$$

$

$$$

$$$$

$$$$




NAPROXEN

NAPROXEN SODIUM







275 MG ORAL TABLET

550 MG ORAL TABLET

00002162466

0000224669900002365847000023507850000224331200002162792

00002246700000023658550000224343200002350793000022947020000224331300002162415

00002246701000023658630000224102400002350807000022947100000224331400002162423

00002162431

00002017237

00000784354000023510130000077838900002162725

00001940309000023510210000202660000002162717

NAPROSYN SR

APO-NAPROXEN ECAVA-NAPROXEN ECNAPROXEN ECTEVA-NAPROX ECNAPROSYN E

APO-NAPROXEN ECAVA-NAPROXEN ECMYLAN-NAPROXEN ECNAPROXEN ECPMS-NAPROXEN ECTEVA-NAPROX ECNAPROSYN E

APO-NAPROXEN ECAVA-NAPROXEN ECMYLAN-NAPROXEN ECNAPROXEN ECPMS-NAPROXEN ECTEVA-NAPROX ECNAPROSYN E

NAPROSYN

PMS-NAPROXEN

APO-NAPRO-NANAPROXEN SODIUMTEVA-NAPROX SODIUMANAPROX

APO-NAPRO-NA DSNAPROXEN SODIUM DSTEVA-NAPROX SODIUM DSANAPROX DS

HLR

APXAVASNSTEVHLR

APXAVAMYPSNSPMSTEVHLR

APXAVAMYPSNSPMSTEVHLR

HLR

PMS

APXSNSTEVHLR

APXSNSTEVHLR




28:00

28:08.04.92

1.3211

0.1570 0.1570 0.1570 0.1570 0.4174

0.2062 0.2062 0.2062 0.2062 0.2062 0.2062 0.5479

0.3718 0.3718 0.3718 0.3718 0.3718 0.3718 0.9882

0.0626

0.8883

0.3422 0.3422 0.3422 0.6239

0.6667 0.6667 0.6667 1.2012


$ 0.2916

$ 0.1068 $ 0.1068 $ 0.1068 $ 0.1068 $ 0.1068

$ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458 $ 0.1458

$ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110 $ 0.2110


MAC pricing has been applied based on the LCA price for 2 x 375 mg oral tablets.




$

$$$$$

$$$$$$$

$$$$$$$

$

$

$$$$

$$$$





PIROXICAM

SULINDAC

TENOXICAM

TIAPROFENIC ACID

ASA/ CODEINE PHOSPHATE/ CAFFEINE CITRATE

BUTALBITAL/ CODEINE PHOSPHATE/ ASA/ CAFFEINE

10 MG ORAL CAPSULE

20 MG ORAL CAPSULE


150 MG ORAL TABLET

200 MG ORAL TABLET

20 MG ORAL TABLET

200 MG ORAL TABLET

300 MG ORAL TABLET


50 MG * 15 MG * 330 MG * 40 MG ORAL CAPSULE

50 MG * 30 MG * 330 MG * 40 MG ORAL CAPSULE

0000064288600000695718

0000064289400000695696

00002154463

0000077835400000745588

0000077836200000745596

00002230661

0000213611200002179679

0000213612000002179687

00002234510

0000060820300000176192

0000060818100000176206

APO-PIROXICAMNOVO-PIROCAM

APO-PIROXICAMNOVO-PIROCAM

PMS-PIROXICAM

APO-SULINNOVO-SUNDAC

APO-SULINNOVO-SUNDAC

TENOXICAM

APO-TIAPROFENICNOVO-TIAPROFENIC

APO-TIAPROFENICNOVO-TIAPROFENIC

282

RATIO-TECNAL-C 1/4FIORINAL-C 1/4

RATIO-TECNAL-C 1/2FIORINAL-C 1/2

APXTEV

APXTEV

PMS

APXTEV

APXTEV

AAP

APXTEV

APXTEV

PPH

RPHNOV

RPHNOV






28

28

:00

:00

28:08.04.92

28:08.08

0.3210 0.3210

0.5195 0.5195

2.0580

0.3824 0.3824

0.3920 0.3920

1.1552

0.3437 0.3437

0.3257 0.3257

0.0683

1.1051 1.6274

1.3532 1.9928


$$

$$

$

$$

$$

$

$$

$$

$

$$

$$


(OPIATE AGONISTS)



CODEINE PHOSPHATE

CODEINE PHOSPHATE/ ACETAMINOPHEN

CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE

CODEINE PHOSPHATE/ ASA/ CAFFEINE CITRATE

CODEINE PHOSPHATE/ ASA/ MEPROBAMATE/ CAFFEINE CITRATE


15 MG ORAL TABLET

30 MG ORAL TABLET




1.6 MG / ML * 32 MG / ML ORAL ELIXIR




15 MG * 350 MG * 200 MG * 30 MG ORAL TABLET

00000593435

00000593451

00000544884

00000608882

0000062146300002163918

00002163942

0000065324100002163934

0000065327600002163926

00002238645

00002238646

00000999108

00000999208

RATIO-CODEINE

RATIO-CODEINE

CODEINE PHOSPHATE

RATIO-EMTEC-30

RATIO-LENOLTEC NO.4TYLENOL NO. 4

TYLENOL WITH CODEINE



292

282 MEP

COMPOUND NARCOTIC MIXTURES - ORAL AND INJECTION

COMPOUND NARCOTIC MIXTURES - ORAL AND INJECTION

RPH

RPH

SDZ

RPH

RPHJAI

JAI

RPHJAI

RPHJAI

PPH

PPH

XXX

XXX



28:00

28:08.08

0.0765

0.1284

1.3116

0.1616

0.1685 0.1877

0.1043

0.0807 0.0807

0.0798 0.0888

0.1766

0.2205

0.0000

0.0000


$

$

$

$

$$

$

$$

$$

$

$

$

$



(OPIATE AGONISTS)




HYDROMORPHONE HCL1 MG ORAL TABLET

2 MG ORAL TABLET

4 MG ORAL TABLET

8 MG ORAL TABLET


4.5 MG ORAL CONTROLLED-RELEASE CAPSULE








2 MG / ML INJECTION




00002364115000007054380000088544400002319403

00002319411000023641230000012508300000885436

00002364131000001251210000088540100002319438

00002364158000007865430000088542800002319446

00002125323

00002359502

00002125331

00002359510

00002125366

00002243562

00002125382

00002125390

0000191638600000786535

0000214590100000627100

0000214592800000622133

00002145936

00002146126

APO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONETEVA-HYDROMORPHONE

TEVA-HYDROMORPHONEAPO-HYDROMORPHONEDILAUDIDPMS-HYDROMORPHONE



HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

HYDROMORPH CONTIN

PMS-HYDROMORPHONEDILAUDID

HYDROMORPHONEDILAUDID

HYDROMORPHONE HPDILAUDID-HP

HYDROMORPHONE HP 20

HYDROMORPHONE HP 50

APXPURPMSTEV

TEVAPXPURPMS

APXPURPMSTEV

APXPURPMSTEV

PUR

PUR

PUR

PUR

PUR

PUR

PUR

PUR

PMSPUR

SDZPUR

SDZPUR

SDZ

SDZ



28:00

28:08.08

0.0959 0.0959 0.0959 0.0959

0.1416 0.1417 0.1417 0.1417

0.2240 0.2240 0.2240 0.2240

0.3528 0.3528 0.3528 0.3528

0.6745

0.8140

1.0115

1.3340

1.7530

2.5290

3.2365

3.8775

0.0665 0.0792

0.9450 1.1400

2.3380 2.7900

4.5100

13.1500


$$$$

$$$$

$$$$

$$$$

$

$

$

$

$

$

$

$

$$

$$

$$

$

$

(OPIATE AGONISTS)



HYDROMORPHONE HCL

MEPERIDINE HCL

METHADONE COMPOUND

METHADONE HCL

MORPHINE HCL



50 MG ORAL TABLET




ORAL LIQUID

1 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

25 MG ORAL TABLET









00002085895

00001916394

00002138018

00000725765

00000725757

00000725749

00000999995

00002247698

00002247699

00002247700

00002247701

00002247694

00002241377

00000776181

00000776203

00000607762

00000607770

00000690783

00000690791

DILAUDID STERILE POWDER

PMS-HYDROMORPHONE

DEMEROL

MEPERIDINE HYDROCHLORIDE



METHADONE

METADOL

METADOL

METADOL

METADOL

METADOL

METADOL CONCENTRATE

M.O.S.-SR

M.O.S.-SR

RATIO-MORPHINE

RATIO-MORPHINE

RATIO-MORPHINE

RATIO-MORPHINE

PUR

PMS

SAV

SDZ

SDZ

SDZ

XXX

PAL

PAL

PAL

PAL

PAL

PAL

VCL

VCL

RPH

RPH

RPH

RPH



28:00

28:08.08

70.1425

2.9640

0.1503

0.8930

0.9395

0.9953

0.0000

0.1689

0.5627

0.9003

1.6879

0.1017

0.3676

0.4614

0.8134

0.0151

0.0602

0.1931

0.5489


$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

(OPIATE AGONISTS)




MORPHINE SULFATE5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

25 MG ORAL TABLET

30 MG ORAL TABLET

50 MG ORAL TABLET











000005946520000200977300002014203

000005946440000200976500002014211

00002014238

0000059463600002009749

00002014254

0000067596200002009706

00002350815000023027640000224479000002015439

00002350890000023027720000224479100002014297

00002350912000023027800000224479200002014300

000023509200000230279900002014319

000023509470000230280200002014327

00002019930

00002177749

00002019949

00002019957

00002019965

STATEXM.O.S. SULFATEMS.IR

STATEXM.O.S. SULFATEMS.IR

MS.IR

STATEXM.O.S. SULFATE

MS.IR

STATEXM.O.S. SULFATE

MORPHINE SRNOVO-MORPHINE SRSANDOZ MORPHINE SRMS CONTIN



MORPHINE SRNOVO-MORPHINE SRMS CONTIN

MORPHINE SRNOVO-MORPHINE SRMS CONTIN

M-ESLON

M-ESLON

M-ESLON

M-ESLON

M-ESLON

PALVCLPUR

PALVCLPUR

PUR

PALVCL

PUR

PALVCL

SNSTEVSDZPUR

SNSTEVSDZPUR

SNSTEVSDZPUR

SNSTEVPUR

SNSTEVPUR

ETP

ETP

ETP

ETP

ETP



28:00

28:08.08

0.1100 0.1129 0.1240

0.1700 0.1745 0.1930

0.3440

0.2250 0.2309

0.4410

0.3450 0.3541

0.2559 0.2559 0.2559 0.6800

0.3872 0.3872 0.3872 1.0290

0.6822 0.6822 0.6822 1.8130

1.0400 1.0400 2.7640

1.9335 1.9335 5.1390

0.2984

0.3447

0.5145

0.9132

1.9654


$$$

$$$

$

$$

$

$$

$$$$

$$$$

$$$$

$$$

$$$

$

$

$

$

$

(OPIATE AGONISTS)



MORPHINE SULFATE

OPIUM/ BELLADONNA








20 MG / ML ORAL DROPS



1 MG / ML INJECTION









65 MG * 15 MG RECTAL SUPPOSITORY

00002177757

00002242163

00002184435

00002184443

00002184451

00000591467

00000591475

00000621935

00000705799

00002021056

00002021048

00000392588

00000392561

00000676411

00000617288

00000632228

00000632201

00000596965

00000639389

00001901869

M-ESLON

KADIAN

KADIAN

KADIAN

KADIAN

STATEX

STATEX

STATEX

STATEX

MORPHINE LP EPIDURAL

MORPHINE LP EPIDURAL

MORPHINE SULFATE

MORPHINE SULFATE

MORPHINE HP 25

MORPHINE HP 50

STATEX

STATEX

STATEX

STATEX

SANDOZ OPIUM & BELLADONNA

ETP

ABB

ABB

ABB

ABB

PAL

PAL

PAL

PAL

SDZ

SDZ

SDZ

SDZ

SDZ

SDZ

PAL

PAL

PAL

PAL

SDZ



28:00

28:08.08

3.9306

0.3680

0.7151

1.3145

2.2926

0.0200

0.0803

0.4980

0.9464

1.0623

2.1247

0.9209

0.9349

2.6884

3.7116

1.6690

1.8640

2.2190

2.4340

2.6791


$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

(OPIATE AGONISTS)




OXYCODONE HCL

OXYCODONE HCL/ ACETAMINOPHEN

5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

5 MG ORAL CONTROLLED-RELEASE TABLET












0000231997700000789739

000023199850000044394800002240131

000023199930000226298300002240132

00002258129

0000220244100002372525

0000232319200002372533

0000237279700002202468

0000232320600002372541

0000237256800002202476

0000232321400002372576

0000237258400002202484

00000392480

00000392472

00001916491

000023246280000191654800002361361000006081650000230789800001916475

PMS-OXYCODONESUPEUDOL

PMS-OXYCODONESUPEUDOLOXY-IR

PMS-OXYCODONESUPEUDOLOXY-IR

OXYCONTIN

OXYCONTINOXYNEO

OXYCONTINOXYNEO

OXYNEOOXYCONTIN

OXYCONTINOXYNEO

OXYNEOOXYCONTIN

OXYCONTINOXYNEO

OXYNEOOXYCONTIN

SUPEUDOL

SUPEUDOL

PERCOCET DEMI

APO-OXYCODONEENDOCETOXYCODONE/ACETRATIO-OXYCOCETSANDOZ-OXYCODONE ACETPERCOCET

PMSSDZ

PMSSDZPUR

PMSSDZPUR

PUR

PURPUR

PURPUR

PURPUR

PURPUR

PURPUR

PURPUR

PURPUR

SDZ

SDZ

BMS

APXBMSSNSRPHSDZBMS



28:00

28:08.08

0.1287 0.1332

0.1896 0.2283 0.3860

0.2964 0.3965 0.6710

0.6300

0.8780 0.8780

1.0600 1.0600

1.3170 1.3190

1.7400 1.7400

2.2825 2.2900

3.1500 3.1500

4.2160 4.2300

2.1034

2.6698

0.6299

0.1285 0.1285 0.1285 0.1285 0.1285 0.7706


$$

$$$

$$$

$

$$

$$

$$

$$

$$

$$

$$

$

$

$

$$$$$$

(OPIATE AGONISTS)



OXYCODONE HCL/ ASA

BUPRENORPHINE HCL/ NALOXONE HYDROCHLORIDE DIHYDRATE

PENTAZOCINE HCL

PENTAZOCINE LACTATE

PRIMIDONE

CLOBAZAM


2 MG (BASE) * 0.5 MG (BASE) ORAL SUBLINGUAL TABLET

8 MG (BASE) * 2 MG (BASE) ORAL SUBLINGUAL TABLET



125 MG ORAL TABLET

250 MG ORAL TABLET

10 MG ORAL TABLET

00000608157

00002295695

00002295709

00002137984

00002241976

00000399310

00000396761

000022446380000223833400002244474

RATIO-OXYCODAN

SUBOXONE

SUBOXONE

TALWIN

TALWIN

PRIMIDONE

PRIMIDONE

APO-CLOBAZAMNOVO-CLOBAZAMPMS-CLOBAZAM

RPH

RBC

RBC

SAV

HSP

AAP

AAP

APXTEVPMS







ANTICONVULSANTS

ANTICONVULSANTS

28

28

28

28

:00

:00

:00

:00

28:08.08

28:08.12

28:12.04

28:12.08

0.3879

2.6700

4.7300

0.4337

11.9700

0.0553

0.0870

0.1537 0.1537 0.1537


$

$

$

$

$

$

$

$$$

(OPIATE AGONISTS)

(OPIATE PARTIAL AGONISTS)

(BARBITURATES)

(BENZODIAZEPINES)




CLONAZEPAM

PHENYTOIN

PHENYTOIN SODIUM

0.25 MG ORAL TABLET

0.5 MG ORAL TABLET

1 MG ORAL TABLET

2 MG ORAL TABLET




30 MG ORAL CAPSULE

100 MG ORAL CAPSULE


00002179660

0000217788900002270641000022309500000223902400002145227000022369480000204870100002207818000021036560000223396000000382825

00002270668000021452350000204872800002233982

000021778970000227067600002230951000022390250000214524300002048736000021037370000223398500000382841

00000023698

00000023442

0000225089600000023450

00000022772

00000022780

00000780626

PMS-CLONAZEPAM

APO-CLONAZEPAMCO CLONAZEPAMMYLAN-CLONAZEPAMNOVO-CLONAZEPAMPHL-CLONAZEPAMPHL-CLONAZEPAM-RPMS-CLONAZEPAMPMS-CLONAZEPAM-RRATIO-CLONAZEPAMSANDOZ CLONAZEPAMRIVOTRIL

CO CLONAZEPAMPHL-CLONAZEPAMPMS-CLONAZEPAMSANDOZ CLONAZEPAM

APO-CLONAZEPAMCO CLONAZEPAMMYLAN-CLONAZEPAMNOVO-CLONAZEPAMPHL-CLONAZEPAMPMS-CLONAZEPAMRATIO-CLONAZEPAMSANDOZ CLONAZEPAMRIVOTRIL

DILANTIN INFATABS

DILANTIN-30

TARO-PHENYTOINDILANTIN-125

DILANTIN

DILANTIN

PHENYTOIN SODIUM

PMS

APXCOBMYPTEVPHHPHHPMSPMSRPHSDZHLR

COBPHHPMSSDZ

APXCOBMYPTEVPHHPMSRPHSDZHLR

PFI

PFI

TARPFI

PFI

PFI

SDZ



ANTICONVULSANTS

ANTICONVULSANTS

28

28

:00

:00

28:12.08

28:12.12

0.0719

0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.0746 0.1982

0.1487 0.1487 0.1487 0.1487

0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.1286 0.3417

0.0724

0.0399

0.0311 0.0470

0.0528

0.0734

2.4465


$

$$$$$$$$$$$

$$$$

$$$$$$$$$

$

$

$$

$

$

$

(BENZODIAZEPINES)

(HYDANTOINS)



ETHOSUXIMIDE

METHSUXIMIDE

CARBAMAZEPINE

DIVALPROEX SODIUM (VALPROIC ACID EQUIV.)

250 MG ORAL CAPSULE


300 MG ORAL CAPSULE

200 MG ORAL TABLET






125 MG (BASE) ORAL ENTERIC-COATED TABLET


00000022799

00000023485

00000022802

0000078271800000010405

00002231542000022618550000224440300000369810

00002231540000022618630000224440400000665088

00002241882000022315430000226183900000773611

00002241883000022315440000226184700000755583

0000236739400002194333

000022396980000223970100000596418

000022396990000223970200000596426

ZARONTIN

ZARONTIN

CELONTIN

TEVA-CARBAMAZTEGRETOL

PMS-CARBAMAZEPINESANDOZ CARBAMAZEPINETARO-CARBAMAZEPINETEGRETOL

PMS-CARBAMAZEPINESANDOZ CARBAMAZEPINETARO-CARBAMAZEPINETEGRETOL

MYLAN-CARBAMAZEPINE CRPMS-CARBAMAZEPINE-CRSANDOZ CARBAMAZEPINE CRTEGRETOL CR

MYLAN-CARBAMAZEPINE CRPMS-CARBAMAZEPINE-CRSANDOZ CARBAMAZEPINE CRTEGRETOL CR

TARO-CARBAMAZEPINETEGRETOL

APO-DIVALPROEXNOVO-DIVALPROEXEPIVAL


ERF

ERF

ERF

TEVNOV

PMSSDZTARNOV

PMSSDZTARNOV

MYPPMSSDZNOV

MYPPMSSDZNOV

TARNOV

APXTEVABB

APXTEVABB



ANTICONVULSANTS

ANTICONVULSANTS

28

28

:00

:00

28:12.20

28:12.92

0.3203

0.0640

0.5933

0.0795 0.3867

0.0599 0.0599 0.0599 0.1591

0.1181 0.1181 0.1181 0.3139

0.1467 0.1467 0.1467 0.3899

0.2933 0.2933 0.2933 0.7796

0.0541 0.0751

0.1011 0.1011 0.2889

0.1817 0.1817 0.5192


$

$

$

$$

$$$$

$$$$

$$$$

$$$$

$$

$$$

$$$

(SUCCINIMIDES)

(MISCELLANEOUS ANTICONVULSANTS)




DIVALPROEX SODIUM (VALPROIC ACID EQUIV.)

GABAPENTIN


100 MG ORAL CAPSULE

300 MG ORAL CAPSULE

400 MG ORAL CAPSULE

000022397000000223970300000596434

0000224430400002321203000022561420000224631400002332582000023532450000228581900002361469000022482590000224344600002319055000022608830000224451300002084260

00002244305000023212110000225615000002246315000023325900000235325300002285827000023614850000224826000002243447000023190630000224451400002084279

0000224430600002321238000022561690000224631600002332604000023532610000228583500002361493000022482610000224344800002319071000022609050000224451500002084287


APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINRATIO-GABAPENTINTEVA-GABAPENTINNEURONTIN

APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINTEVA-GABAPENTINNEURONTIN

APO-GABAPENTINAURO-GABAPENTINCO GABAPENTINGABAPENTINGABAPENTINGABAPENTINGD-GABAPENTINJAMP-GABAPENTINMYLAN-GABAPENTINPMS-GABAPENTINRAN-GABAPENTINRATIO-GABAPENTINTEVA-GABAPENTINNEURONTIN

APXTEVABB

APXAURCOBMELRANSNSGMDJPCMYPPMSRANRPHTEVPFI

APXAURCOBMELRANSNSGMDJPCMYPPMSRANTEVPFI

APXAURCOBMELRANSNSGMDJPCMYPPMSRANRPHTEVPFI


ANTICONVULSANTS

28:00

28:12.92

0.3637 0.3637 1.0392

0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.1598 0.4247

0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 0.3887 1.0332

0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 0.4633 1.2313


$$$

$$$$$$$$$$$$$$

$$$$$$$$$$$$$

$$$$$$$$$$$$$$




LAMOTRIGINE

LEVETIRACETAM

25 MG ORAL TABLET

100 MG ORAL TABLET

150 MG ORAL TABLET


250 MG ORAL TABLET

500 MG ORAL TABLET

750 MG ORAL TABLET

00002245208000023430100000226549400002248232000022468970000224335200002142082

00002245209000023430290000226550800002248233000022468980000224335300002142104

00002245210000023430370000226551600002248234000022468990000224696300002142112

00002240115

00002285924000023752490000237167700002274183000023533420000229610100002247027

00002285932000023752570000237168500002274191000023533500000229612800002247028

00002285940000023752650000237169300002274205000023533690000229613600002247029

APO-LAMOTRIGINELAMOTRIGINEMYLAN-LAMOTRIGINENOVO-LAMOTRIGINEPMS-LAMOTRIGINERATIO-LAMOTRIGINELAMICTAL



LAMICTAL

APO-LEVETIRACETAMAURO-LEVETIRACETAMAVA-LEVETIRACETAMCO LEVETIRACETAMLEVETIRACETAMPMS-LEVETIRACETAMKEPPRA



APXSNSMYPTEVPMSRPHGSK



GSK

APXAURAVACOBSNSPMSUCB




ANTICONVULSANTS

28:00

28:12.92

0.1438 0.1438 0.1438 0.1438 0.1438 0.1438 0.3821

0.5739 0.5739 0.5739 0.5739 0.5739 0.5739 1.5254

0.8458 0.8458 0.8458 0.8458 0.8458 0.8458 2.2481

0.1630

0.8000 0.8000 0.8000 0.8000 0.8000 0.8000 1.6613

0.9750 0.9750 0.9750 0.9750 0.9750 0.9750 2.0427

1.3500 1.3500 1.3500 1.3500 1.3500 1.3500 2.8283


$$$$$$$

$$$$$$$

$$$$$$$

$

$$$$$$$

$$$$$$$

$$$$$$$





TOPIRAMATE25 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET

200 MG ORAL TABLET

15 MG ORAL CAPSULE

25 MG ORAL CAPSULE

000022796140000234580300002370972000022877650000231564500002263351000022488600000227118400002262991000022600500000235685600002230893

00002312085

000022796300000234583800002370980000022877730000231565300002263378000022488610000227119200002263009000022600690000235686400002230894

000022796490000234584600002370999000022877810000231566100002263386000022488620000227120600002263017000022678370000235687200002230896

00002239907

00002239908

APO-TOPIRAMATEAURO-TOPIRAMATEAVA-TOPIRAMATECO TOPIRAMATEMINT-TOPIRAMATEMYLAN-TOPIRAMATENOVO-TOPIRAMATEPHL-TOPIRAMATEPMS-TOPIRAMATESANDOZ TOPIRAMATETOPIRAMATETOPAMAX

PMS-TOPIRAMATE



TOPAMAX SPRINKLE

TOPAMAX SPRINKLE

APXAURAVACOBMPIMYPTEVPHHPMSSDZSNSJAI

PMS



JAI

JAI


ANTICONVULSANTS

28:00

28:12.92

0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 0.4811 1.2787

1.0674

0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 0.9119 2.4235

1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 1.3616 3.6190

1.1675

1.2255


$$$$$$$$$$$$

$

$$$$$$$$$$$$

$$$$$$$$$$$$

$

$




VALPROIC ACID

VIGABATRIN

MOCLOBEMIDE

PHENELZINE SULFATE

TRANYLCYPROMINE SULFATE

250 MG ORAL CAPSULE

500 MG ORAL ENTERIC-COATED CAPSULE


500 MG ORAL TABLET

500 MG ORAL POWDER PACKET

100 MG ORAL TABLET

150 MG ORAL TABLET

300 MG ORAL TABLET



000022380480000218464800002100630000022307680000223971400000443840

0000221832100002229628

00002238370000022368070000214006300000443832

00002065819

00002068036

0000223214800002239746

0000223215000002239747

0000224045600002239748

00000476552

00001919598

APO-VALPROICMYLAN-VALPROICNOVO-VALPROICPMS-VALPROIC ACIDSANDOZ VALPROICDEPAKENE

NOVO-VALPROICPMS-VALPROIC ACID E.C.

APO-VALPROICPMS-VALPROIC ACIDRATIO-VALPROICDEPAKENE

SABRIL

SABRIL

APO-MOCLOBEMIDENOVO-MOCLOBEMIDE



NARDIL

PARNATE

APXMYPTEVPMSSDZABB

TEVPMS

APXPMSRPHABB

LUI

LUI

APXTEV

APXTEV

APXTEV

ERF

GSK

(MONOAMINE OXIDASE INHIBITORS)



ANTICONVULSANTS

PSYCHOTHERAPEUTIC AGENTS

28

28

:00

:00

28:12.92

28:16.04.12

0.1908 0.1908 0.1908 0.1908 0.1908 0.5452

0.5197 0.5197

0.0398 0.0398 0.0398 0.1136

0.9110

0.9110

0.2520 0.2520

0.2279 0.2279

0.4476 0.4476

0.3561

0.3759


$$$$$$

$$

$$$$

$

$

$$

$$

$$

$

$


ANTIDEPRESSANTS




DULOXETINE HYDROCHLORIDE

VENLAFAXINE HCL

30 MG (BASE) ORAL DELAYED RELEASE CAPSULE

60 MG (BASE) ORAL DELAYED RELEASE CAPSULE

37.5 MG (BASE) ORAL EXTENDED-RELEASE CAPSULE



00002301482

00002301490

0000233168300002304317000023600200000231027900002278545000023800720000227396900002310317000022750230000235471300002237279

0000233169100002304325000023600390000231028700002278553000023800800000227397700002310325000022750310000235472100002237280

0000233170500002304333000023600470000231029500002278561000023800990000227398500002310333000022750580000235474800002237282

CYMBALTA

CYMBALTA

APO-VENLAFAXINE XRCO VENLAFAXINE XRGD-VENLAFAXINE XRMYLAN-VENLAFAXINE XRPMS-VENLAFAXINE XRRAN-VENLAFAXINE XRRATIO-VENLAFAXINE XRSANDOZ VENLAFAXINE XRTEVA-VENLAFAXINE XRVENLAFAXINE XREFFEXOR XR



LIL

LIL

APXCOBGMDMYPPMSRANRPHSDZTEVSNSWAY



(SELECTIVE SEROTONIN- AND NOREPINEPHRINE-REUPTAKE INHIBITORS)



28:00

28:16.04.16

1.8766

3.7536

0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.3477 0.9242

0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 0.6956 1.8488

0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 0.7343 1.9517


$

$

$$$$$$$$$$$

$$$$$$$$$$$

$$$$$$$$$$$

ANTIDEPRESSANTS



CITALOPRAM HYDROBROMIDE

ESCITALOPRAM OXALATE







00002370077

0000224605600002331950000023536600000230623900002248050000023134050000237189800002304686000022465940000229321800002248944000022480100000228562200002252112000022481700000235527200002239607

00002296152

0000224605700002331977000023536790000230624700002248051000023134130000237190100002304694000022465950000229322600002248945000022480110000228563000002252120000022481710000235528000002239608

00002263238

00002263254

MINT-CITALOPRAM

APO-CITALOPRAMCITALOPRAMCITALOPRAMCITALOPRAM-ODANCO CITALOPRAMJAMP-CITALOPRAMMAR-CITALOPRAMMINT-CITALOPRAMMYLAN-CITALOPRAMNOVO-CITALOPRAMPHL-CITALOPRAMPMS-CITALOPRAMRAN-CITALORATIO-CITALOPRAMSANDOZ CITALOPRAMSEPTA-CITALOPRAMCELEXA

CTP 30

APO-CITALOPRAMCITALOPRAMCITALOPRAMCITALOPRAM-ODANCO CITALOPRAMJAMP-CITALOPRAMMAR-CITALOPRAMMINT-CITALOPRAMMYLAN-CITALOPRAMNOVO-CITALOPRAMPHL-CITALOPRAMPMS-CITALOPRAMRAN-CITALORATIO-CITALOPRAMSANDOZ CITALOPRAMSEPTA-CITALOPRAMCELEXA

CIPRALEX

CIPRALEX

MPI

APXRANSNSODNCOBJPCMARMPIMYPTEVPHHPMSRANRPHSDZSEPLBC

SUN

APXRANSNSODNCOBJPCMARMPIMYPTEVPHHPMSRANRPHSDZSEPLBC

LBC

LBC

(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)



28:00

28:16.04.20

0.2790

0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 1.3317

0.8750

0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 0.5011 1.3317

1.6933

1.8027


$

$$$$$$$$$$$$$$$$$

$

$$$$$$$$$$$$$$$$$

$

$

ANTIDEPRESSANTS




FLUOXETINE HCL

FLUVOXAMINE MALEATE




50 MG ORAL TABLET

100 MG ORAL TABLET

0000221635300002242177000022860680000238056000002237813000022234810000217757900002241371000022434860000221658200002018985

000022163610000236453000002242178000022860760000238057900002237814000022235030000217758700002241374000022434870000221659000000636622

00002231328

0000223132900002363763000022555290000223995300002240682000022184530000224705400001919342

0000223133000002363771000022555370000223995400002240683000022184610000224705500001919369

APO-FLUOXETINECO FLUOXETINEFLUOXETINEMINT-FLUOXETINEMYLAN-FLUOXETINEPHL-FLUOXETINEPMS-FLUOXETINERATIO-FLUOXETINE HYDROCHLORIDESANDOZ FLUOXETINETEVA-FLUOXETINEPROZAC

APO-FLUOXETINEAVA-FLUOXETINECO FLUOXETINEFLUOXETINEMINT-FLUOXETINEMYLAN-FLUOXETINEPHL-FLUOXETINEPMS-FLUOXETINERATIO-FLUOXETINE HYDROCHLORIDESANDOZ FLUOXETINETEVA-FLUOXETINEPROZAC

APO-FLUOXETINE

APO-FLUVOXAMINEAVA-FLUVOXAMINECO FLUVOXAMINENOVO-FLUVOXAMINEPMS-FLUVOXAMINERATIO-FLUVOXAMINESANDOZ FLUVOXAMINELUVOX

APO-FLUVOXAMINEAVA-FLUVOXAMINECO FLUVOXAMINENOVO-FLUVOXAMINEPMS-FLUVOXAMINERATIO-FLUVOXAMINESANDOZ FLUVOXAMINELUVOX

APXCOBSNSMPIMYPPHHPMSRPHSDZTEVLIL

APXAVACOBSNSMPIMYPPHHPMSRPHSDZTEVLIL

APX

APXAVACOBTEVPMSRPHSDZABB

APXAVACOBTEVPMSRPHSDZABB




28:00

28:16.04.20

0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 0.8650 1.8379

0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 0.6920 1.8393

0.5859

0.3063 0.3063 0.3063 0.3063 0.3063 0.3063 0.3063 0.8750

0.5506 0.5506 0.5506 0.5506 0.5506 0.5506 0.5506 1.5730


$$$$$$$$$$$

$$$$$$$$$$$$

$

$$$$$$$$

$$$$$$$$

ANTIDEPRESSANTS



PAROXETINE HCL

SERTRALINE HCL






00002240908000022627540000224801300002248451000022828520000224775100002247811000022694300000224855700001940481

0000224090900002262762000022480140000224845200002282860000022477520000224781200002254778000022694490000224855800001940473

00002293749

0000223828000002287390000022736830000224251900002245824000022448380000237455200002245159000023535200000224048500002132702

0000223828100002287404000022736910000224252000002245825000022448390000237456000002245160000023535390000224048400001962817

APO-PAROXETINECO PAROXETINEMYLAN-PAROXETINEPAROXETINEPAROXETINEPMS-PAROXETINERATIO-PAROXETINESANDOZ PAROXETINETEVA-PAROXETINEPAXIL

APO-PAROXETINECO PAROXETINEMYLAN-PAROXETINEPAROXETINEPAROXETINEPMS-PAROXETINERATIO-PAROXETINESANDOZ PAROXETINESANDOZ PAROXETINETEVA-PAROXETINEPAXIL

PMS-PAROXETINE

APO-SERTRALINECO SERTRALINEGD-SERTRALINEMYLAN-SERTRALINEPHL-SERTRALINEPMS-SERTRALINERAN-SERTRALINESANDOZ SERTRALINESERTRALINETEVA-SERTRALINEZOLOFT


APXCOBMYPMELSNSPMSRPHSDZTEVGSK

APXCOBMYPMELSNSPMSRPHSDZSDZTEVGSK

PMS

APXCOBGMDMYPPHHPMSRANSDZSNSTEVPFI





28:00

28:16.04.20

0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 0.6794 1.8056

0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 0.7218 1.9183

2.2454

0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.3169 0.8422

0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 0.6337 1.6844


$$$$$$$$$$

$$$$$$$$$$$

$

$$$$$$$$$$$

$$$$$$$$$$$

ANTIDEPRESSANTS




SERTRALINE HCL

TRAZODONE HCL


50 MG ORAL TABLET

75 MG ORAL TABLET

100 MG ORAL TABLET

150 MG ORAL TABLET

0000223828200002287412000022737050000224252100002245826000022448400000237457900002245161000023535470000224048100001962779

0000214763700002231683000019372270000214426300002348772

00002237339

0000214764500002231684000019372350000214427100002348780

000021476530000214429800002348799


APO-TRAZODONEMYLAN-TRAZODONEPMS-TRAZODONETEVA-TRAZODONETRAZODONE

PMS-TRAZODONE

APO-TRAZODONEMYLAN-TRAZODONEPMS-TRAZODONETEVA-TRAZODONETRAZODONE

APO-TRAZODONE DTEVA-TRAZODONETRAZODONE


APXMYPPMSTEVSNS

PMS

APXMYPPMSTEVSNS

APXTEVSNS


(SEROTONIN MODULATORS)





28

28

:00

:00

28:16.04.20

28:16.04.24

0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 0.6641 1.7650

0.1384 0.1384 0.1384 0.1384 0.1384

0.3506

0.2473 0.2473 0.2473 0.2473 0.2473

0.3633 0.3633 0.3633


$$$$$$$$$$$

$$$$$

$

$$$$$

$$$

ANTIDEPRESSANTS

ANTIDEPRESSANTS



AMITRIPTYLINE HCL

CLOMIPRAMINE HCL

DESIPRAMINE HCL

DOXEPIN HCL

10 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

75 MG ORAL TABLET

10 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

10 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

75 MG ORAL TABLET





00000335053

00000335061

00000335088

00000754129

000020407860000224481600000330566

000020407780000224481700000324019

000020407510000224481800000402591

00002216248

00002216256

00002216264

00002216272

0000204999600000024325

000019134250000205000500000024333

000019134330000205001300000024341

000019134410000205002100000400750

ELAVIL

ELAVIL

ELAVIL

ELAVIL

APO-CLOMIPRAMINECO CLOMIPRAMINEANAFRANIL



APO-DESIPRAMINE

APO-DESIPRAMINE

APO-DESIPRAMINE

APO-DESIPRAMINE

APO-DOXEPINSINEQUAN

NOVO-DOXEPINAPO-DOXEPINSINEQUAN



AAP

AAP

AAP

AAP

APXCOBSUN

APXCOBSUN

APXCOBSUN

APX

APX

APX

APX

APXERF

TEVAPXERF

TEVAPXERF

TEVAPXERF

(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE INHIBITORS)



28:00

28:16.04.28

0.0664

0.1211

0.2347

0.3634

0.1290 0.1290 0.2766

0.1758 0.1758 0.3769

0.3237 0.3237 0.6940

0.3804

0.3804

0.6704

0.8915

0.1889 0.2575

0.1576 0.1860 0.3141

0.2923 0.3450 0.5814

0.3916 0.4953 0.8416


$

$

$

$

$$$

$$$

$$$

$

$

$

$

$$

$$$

$$$

$$$

ANTIDEPRESSANTS




DOXEPIN HCL

IMIPRAMINE HCL

MAPROTILINE HCL

NORTRIPTYLINE HCL

TRIMIPRAMINE MALEATE



10 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

75 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

75 MG ORAL TABLET







000019134680000205004800000326925

00001913476

00000360201

00000312797

00000326852

00000644579

00002158612

00002158620

00002158639

0000222351100002364301000022317810000217769200000015229

0000222353800002364328000022317820000217770600000015237

00000740799

00000740802

00000740810

00000740829


NOVO-DOXEPIN

IMIPRAMINE

IMIPRAMINE

IMIPRAMINE

IMIPRAMINE

NOVO-MAPROTILINE

NOVO-MAPROTILINE

NOVO-MAPROTILINE

APO-NORTRIPTYLINEAVA-NORTRIPTYLINENOVO-NORTRIPTYLINEPMS-NORTRIPTYLINEAVENTYL

APO-NORTRIPTYLINEAVA-NORTRIPTYLINENOVO-NORTRIPTYLINEPMS-NORTRIPTYLINEAVENTYL

TRIMIPRAMINE

TRIMIPRAMINE

TRIMIPRAMINE

TRIMIPRAMINE

TEVAPXERF

TEV

AAP

AAP

AAP

AAP

TEV

TEV

TEV

APXAVATEVPMSPPH

APXAVATEVPMSPPH

AAP

AAP

AAP

AAP




28:00

28:16.04.28

0.5160 0.6526 1.1089

1.1841

0.1370

0.2471

0.4822

0.6308

0.5957

1.1281

1.5406

0.0893 0.0893 0.0893 0.0893 0.2373

0.1804 0.1804 0.1804 0.1804 0.4794

0.2156

0.2776

0.5434

0.9273


$$$

$

$

$

$

$

$

$

$

$$$$$

$$$$$

$

$

$

$

ANTIDEPRESSANTS



TRIMIPRAMINE MALEATE

BUPROPION HCL

L-TRYPTOPHAN






250 MG ORAL TABLET

500 MG ORAL TABLET

750 MG ORAL TABLET

1 G ORAL TABLET

500 MG ORAL CAPSULE

00002070987

0000228565700002275074

0000236340200002313421000022856650000227508200002237825

00002275090

00002275104

00002239326

000022485380000224033300002029456

00002239327

000022485390000223725000000654531

000022485400000224033400000718149

TRIMIPRAMINE

RATIO-BUPROPION SRSANDOZ BUPROPION SR

AVA-BUPROPION SRPMS-BUPROPION SRRATIO-BUPROPION SRSANDOZ BUPROPION SRWELLBUTRIN SR

WELLBUTRIN XL

WELLBUTRIN XL

TRYPTAN

APO-TRYPTOPHANRATIO-TRYPTOPHANTRYPTAN

TRYPTAN



AAP

RPHSDZ

AVAPMSRPHSDZVCL

VCL

VCL

VCL

APXRPHVCL

VCL

APXRPHVCL

APXRPHVCL


(MISCELLANEOUS ANTIDEPRESSANTS)





28

28

:00

:00

28:16.04.28

28:16.04.92

0.7314

0.2103 0.2103

0.3275 0.3275 0.3275 0.3275 0.9356

0.5573

1.1150

0.3719

0.3563 0.3563 0.7438

1.1159

0.7126 0.7126 1.4878

0.3563 0.3563 0.7438


$

$$

$$$$$

$

$

$

$$$

$

$$$

$$$

ANTIDEPRESSANTS

ANTIDEPRESSANTS




MIRTAZAPINE

ARIPIPRAZOLE

CLOZAPINE

15 MG ORAL TABLET

30 MG ORAL TABLET

45 MG ORAL TABLET

2 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

15 MG ORAL TABLET

20 MG ORAL TABLET

30 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

0000225609600002273942

000022866290000236293700002252279000023706890000225611800002259354000022487620000225060800002243910

00002256126

00002322374

00002322382

00002322390

00002322404

00002322412

00002322455

000022480340000224724300000894737

00002305003

MYLAN-MIRTAZAPINEPMS-MIRTAZAPINE

APO-MIRTAZAPINEAVA-MIRTAZAPINEMIRTAZAPINEMIRTAZAPINEMYLAN-MIRTAZAPINENOVO-MIRTAZAPINEPMS-MIRTAZAPINESANDOZ MIRTAZAPINEREMERON

MYLAN-MIRTAZAPINE

ABILIFY

ABILIFY

ABILIFY

ABILIFY

ABILIFY

ABILIFY

APO-CLOZAPINEGEN-CLOZAPINECLOZARIL

GEN-CLOZAPINE

MYPPMS

APXAVAMELSNSMYPTEVPMSSDZMFC

MYP

BMS

BMS

BMS

BMS

BMS

BMS

APXMYPNOV

MYP

(MISCELLANEOUS ANTIDEPRESSANTS)

(ATYPICAL ANTIPSYCHOTICS)





28

28

:00

:00

28:16.04.92

28:16.08.04

0.2344 0.2344

0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 0.4546 1.2989

1.1576

2.9140

3.2800

3.7800

3.7800

3.7800

3.7800

0.6594 0.6594 0.9420

1.3188


$$

$$$$$$$$$

$

$

$

$

$

$

$

$$$

$

RESTRICTED BENEFIT - This Drug Product is a benefit for patients 15 to 17 years of age inclusive for the treatment of schizophrenia.

RESTRICTED BENEFIT - This Drug Product is a benefit for patients 15 to 17 years of age inclusive for the treatment of schizophrenia.

ANTIDEPRESSANTS

ANTIPSYCHOTICS



CLOZAPINE

OLANZAPINE

100 MG ORAL TABLET

200 MG ORAL TABLET

2.5 MG ORAL TABLET

5 MG ORAL TABLET

7.5 MG ORAL TABLET

10 MG ORAL TABLET

000022480350000224724400000894745

00002305011

000022817910000237343200002325659000023378780000237281900002303116000023103410000227671200002229250

000022818050000237344000002325667000023378860000237282700002303159000023103680000227672000002229269

000022818130000237345900002325675000023378940000237283500002303167000023103760000227673900002229277

000022818210000237346700002325683000023379080000237284300002303175000023103840000227674700002229285

APO-CLOZAPINEGEN-CLOZAPINECLOZARIL

GEN-CLOZAPINE

APO-OLANZAPINEAVA-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA




APXMYPNOV

MYP

APXAVACOBMYPSNSPMSSDZTEVLIL







28:00

28:16.08.04

2.6446 2.6446 3.7780

5.2892

0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 0.6762 1.7972

1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 1.3524 3.5944

2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 2.0286 5.3916

2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 2.7048 7.1888


$$$

$

$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

$$$$$$$$$

ANTIPSYCHOTICS




OLANZAPINE

QUETIAPINE FUMARATE

15 MG ORAL TABLET

5 MG ORAL DISINTEGRATING TABLET



50 MG ORAL TABLET


0000228184800002325691000023379160000237285100002303183000023103920000227675500002238850

0000236061600002327562000023827090000235297400002303191000023277750000232134300002243086

0000236062400002327570000023827170000235298200002303205000023277830000232135100002243087

000023139010000231608000002330415000023078040000228423500002296551000023531640000231399500002236951

00002361892

000023139280000231609900002330423000023078120000228424300002296578000023531720000231400200002236952

APO-OLANZAPINECO OLANZAPINEMYLAN-OLANZAPINEOLANZAPINEPMS-OLANZAPINESANDOZ OLANZAPINETEVA-OLANZAPINEZYPREXA

APO-OLANZAPINE ODTCO OLANZAPINE ODTMYLAN-OLANZAPINE ODTOLANZAPINE ODTPMS-OLANZAPINE ODTSANDOZ OLANZAPINE ODTTEVA-OLANZAPINE ODZYPREXA ZYDIS

APO-OLANZAPINE ODTCO OLANZAPINE ODTMYLAN-OLANZAPINE ODTOLANZAPINE ODTPMS-OLANZAPINE ODTSANDOZ OLANZAPINE ODTTEVA-OLANZAPINE ODZYPREXA ZYDIS

APO-QUETIAPINECO QUETIAPINEJAMP-QUETIAPINEMYLAN-QUETIAPINENOVO-QUETIAPINEPMS-QUETIAPINEQUETIAPINESANDOZ QUETIAPINESEROQUEL

PMS-QUETIAPINE


APXCOBMYPSNSPMSSDZTEVLIL



APXCOBJPCMYPTEVPMSSNSSDZAZC

PMS





28:00

28:16.08.04

4.0571 4.0571 4.0571 4.0571 4.0571 4.0571 4.0571

10.7831

1.3449 1.3449 1.3449 1.3449 1.3449 1.3449 1.3449 3.5746

2.6875 2.6875 2.6875 2.6875 2.6875 2.6875 2.6875 7.1429

0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.1932 0.5135

0.5614

0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 0.5155 1.3700


$$$$$$$$

$$$$$$$$

$$$$$$$$

$$$$$$$$$

$

$$$$$$$$$

ANTIPSYCHOTICS



QUETIAPINE FUMARATE150 MG (BASE) ORAL TABLET



00002284251

000023139360000231611000002330458000023078390000228427800002296594000023531990000231401000002236953

000023139440000231612900002330466000023078470000228428600002296608000023532020000231402900002244107

NOVO-QUETIAPINE



TEV






28:00

28:16.08.04

1.6222

1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 1.0354 2.7520

1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 1.5105 4.0145


$

$$$$$$$$$

$$$$$$$$$

ANTIPSYCHOTICS




RISPERIDONE0.25 MG ORAL TABLET

0.5 MG ORAL TABLET

1 MG ORAL TABLET

00002282119000023671730000228258500002359529000023717660000235979000002282240000022826900000225843900002252007000022809060000232830500002332051000023568800000230365500002240551

00002282127000023671810000228259300002359537000023717740000235980400002282259000022641880000225844700002252015000022809140000232831300002332078000023568990000230366300002240552

00002282135000023672030000228260700002359545000023717820000235981200002282267000022641960000225845500002252023000022809220000232832100002332086000023569020000227980000002025280

APO-RISPERIDONEAVA-RISPERIDONECO RISPERIDONEJAMP-RISPERIDONEMAR-RISPERIDONEMINT-RISPERIDONMYLAN-RISPERIDONENOVO-RISPERIDONEPHL-RISPERIDONEPMS-RISPERIDONERAN-RISPERIDONERAN-RISPERIDONERISPERIDONERISPERIDONESANDOZ RISPERIDONERISPERDAL



APXAVACOBJPCMARMPIMYPTEVPHHPMSRANRANRANSNSSDZJAI






28:00

28:16.08.04

0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.2035 0.5409

0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.3409 0.9061

0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 0.4710 1.2518


$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$

ANTIPSYCHOTICS



RISPERIDONE2 MG ORAL TABLET

3 MG ORAL TABLET

4 MG ORAL TABLET

00002282143000023672110000228261500002359553000023717900000235982000002282275000022642180000225846300002252031000022809300000232834800002332094000023569100000227981900002025299

00002282151000023672380000228262300002359561000023718040000235983900002282283000022642260000225847100002252058000022809490000232836400002332108000023569290000227982700002025302

00002282178000023672460000228263100002359588000023718120000235984700002282291000022642340000225849800002252066000022809570000232837200002332116000023569370000227983500002025310










28:00

28:16.08.04

0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 0.9402 2.4989

1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 1.4104 3.7486

1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 1.8807 4.9984


$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$$

ANTIPSYCHOTICS




RISPERIDONE

RISPERIDONE TARTRATE

ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE

HALOPERIDOL

0.5 MG ORAL DISINTEGRATING TABLET










0.5 MG ORAL TABLET

1 MG ORAL TABLET

00002247704

0000229178900002247705

0000229179700002247706

0000237069700002268086

0000237070000002268094

00002280396000023643440000227926600002236950

00002298597

00002298600

00002298619

00002298627

0000039679600000363685

0000039681800000363677

RISPERDAL M-TAB

PMS-RISPERIDONE ODTRISPERDAL M-TAB




APO-RISPERIDONEAVA-RISPERIDONEPMS-RISPERIDONERISPERDAL

ZELDOX

ZELDOX

ZELDOX

ZELDOX

APO-HALOPERIDOLNOVO-PERIDOL


JAI

PMSJAI

PMSJAI

PMSJAI

PMSJAI

APXAVAPMSJAI

PFI

PFI

PFI

PFI

APXTEV

APXTEV


(BUTYROPHENONES)





28

28

:00

:00

28:16.08.04

28:16.08.08

0.7450

0.7725 1.0300

1.5281 2.0375

2.1913 3.0550

3.0638 4.0850

0.5312 0.5312 0.5312 1.4118

1.6978

1.9448

1.9448

1.9448

0.0360 0.0360

0.0614 0.0614


$

$$

$$

$$

$$

$$$$

$

$

$

$

$$

$$

RESTRICTED BENEFIT - This product is a benefit for patients 18 years of age and older for the management of the manifestations of schizophrenia and related psychotic disorders, as well as in severe dementia for the short-term symptomatic management of inappropriate behavior due to aggression and/or psychosis.

ANTIPSYCHOTICS

ANTIPSYCHOTICS



HALOPERIDOL

HALOPERIDOL DECANOATE

CHLORPROMAZINE HCL

FLUPHENAZINE DECANOATE

FLUPHENAZINE HCL

2 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET

5 MG / ML INJECTION









1 MG ORAL TABLET

2 MG ORAL TABLET

0000039682600000363669

0000039683400000363650

0000046369800000713449

00000768820

00000808652

00002130297

00002130300

00000232823

00000232807

00000232831

00000743518

00002239636

0000224257000000755575

00000405345

00000410632




NOVO-PERIDOL

HALOPERIDOL

HALOPERIDOL LA

HALOPERIDOL LA

TEVA-CHLORPROMAZINE

TEVA-CHLORPROMAZINE

TEVA-CHLORPROMAZINE

CHLORPROMAZINE HCL

FLUPHENAZINE OMEGA

FLUPHENAZINE OMEGAMODECATE CONCENTRATE

APO-FLUPHENAZINE

APO-FLUPHENAZINE

APXTEV

APXTEV

APXTEV

TEV

SDZ

SDZ

SDZ

TEV

TEV

TEV

SDZ

OMG

OMGBMS

APX

APX

(BUTYROPHENONES)

(PHENOTHIAZINES)





28

28

:00

:00

28:16.08.08

28:16.08.24

0.1050 0.1050

0.1487 0.1487

0.1330 0.1330

0.6816

4.4930

6.8465

13.6909

0.1816

0.2078

0.4000

1.0326

4.6320

29.7800 29.7800

0.1739

0.2252



$$

$$

$$

$

$

$

$

$

$

$

$

$

$$

$

$

ANTIPSYCHOTICS

ANTIPSYCHOTICS




FLUPHENAZINE HCL

METHOTRIMEPRAZINE HCL

METHOTRIMEPRAZINE MALEATE

PERICYAZINE

PERPHENAZINE

PIPOTIAZINE PALMITATE

THIOPROPERAZINE MESYLATE

5 MG ORAL TABLET






5 MG ORAL CAPSULE

10 MG ORAL CAPSULE

20 MG ORAL CAPSULE


2 MG ORAL TABLET

4 MG ORAL TABLET

8 MG ORAL TABLET

16 MG ORAL TABLET




00000405361

00001927698

00002238403

00002238404

00002238405

00002238406

00001926780

00001926772

00001926764

00001926756

00000335134

00000335126

00000335118

00000335096

00001926667

00001926675

00001927639

APO-FLUPHENAZINE

NOZINAN

APO-METHOPRAZINE

APO-METHOPRAZINE

APO-METHOPRAZINE

APO-METHOPRAZINE

NEULEPTIL

NEULEPTIL

NEULEPTIL

NEULEPTIL

PERPHENAZINE

PERPHENAZINE

PERPHENAZINE

PERPHENAZINE

PIPORTIL L4

PIPORTIL L4

MAJEPTIL

APX

SAV

APX

APX

APX

APX

ERF

ERF

ERF

ERF

AAP

AAP

AAP

AAP

SAV

SAV

ERF

(PHENOTHIAZINES)



28:00

28:16.08.24

0.1720

3.3370

0.0685

0.0991

0.2547

0.3857

0.1884

0.3069

0.4721

0.3718

0.0626

0.0758

0.0832

0.1274

16.0600

51.7800

0.5442


$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

ANTIPSYCHOTICS



TRIFLUOPERAZINE HCL

FLUPENTIXOL DECANOATE

FLUPENTIXOL DIHYDROCHLORIDE

THIOTHIXENE

ZUCLOPENTHIXOL ACETATE

ZUCLOPENTHIXOL DECANOATE








0.5 MG ORAL TABLET

3 MG ORAL TABLET

2 MG ORAL CAPSULE

5 MG ORAL CAPSULE

10 MG ORAL CAPSULE



00000345539

00000312754

00000312746

00000326836

00000595942

00002156032

00002156040

00002156008

00002156016

00000024430

00000024449

00000024457

00002230405

00002230406

TRIFLUOPERAZINE

TRIFLUOPERAZINE

TRIFLUOPERAZINE

TRIFLUOPERAZINE

TRIFLUOPERAZINE

FLUANXOL DEPOT

FLUANXOL DEPOT

FLUANXOL

FLUANXOL

NAVANE

NAVANE

NAVANE

CLOPIXOL ACUPHASE

CLOPIXOL DEPOT

AAP

AAP

AAP

AAP

AAP

LBC

LBC

LBC

LBC

ERF

ERF

ERF

LBC

LBC

(PHENOTHIAZINES)

(THIOXANTHENES)





28

28

:00

:00

28:16.08.24

28:16.08.32

0.1340

0.1758

0.2328

0.2790

0.5580

7.1860

35.9300

0.2483

0.5362

0.3171

0.3529

0.4416

14.9140

14.9140


$

$

$

$

$

$

$

$

$

$

$

$

$

$

ANTIPSYCHOTICS

ANTIPSYCHOTICS




ZUCLOPENTHIXOL DIHYDROCHLORIDE

LOXAPINE HCL

LOXAPINE SUCCINATE

PIMOZIDE

DEXTROAMPHETAMINE SULFATE









2 MG ORAL TABLET

4 MG ORAL TABLET

5 MG ORAL TABLET



00002230402

00002230403

00002169991

00002242868

00002230837

00002230838

00002230839

00002230840

0000224543200000313815

0000224543300000313823

00001924516

00001924559

00001924567

CLOPIXOL

CLOPIXOL

LOXAPAC

XYLAC

XYLAC

XYLAC

XYLAC

XYLAC

APO-PIMOZIDEORAP

APO-PIMOZIDEORAP

DEXEDRINE

DEXEDRINE

DEXEDRINE

LBC

LBC

SDZ

MMT

MMT

MMT

MMT

MMT

APXPHH

APXPHH

PAL

PAL

PAL

(THIOXANTHENES)

(MISCELLANEOUS ANTIPSYCHOTICS)






ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL STIMULANTS

28

28

28

:00

:00

:00

28:16.08.32

28:16.08.92

28:20.04

0.3835

0.9588

7.0419

0.1759

0.1649

0.2745

0.4255

0.5672

0.3093 0.3093

0.4136 0.4671

0.5748

0.8246

1.0081


$

$

$

$

$

$

$

$

$$

$$

$

$

$

ANTIPSYCHOTICS

ANTIPSYCHOTICS

(AMPHETAMINES)



METHYLPHENIDATE HCL

PHENOBARBITAL

5 MG ORAL TABLET

10 MG ORAL TABLET

20 MG ORAL TABLET


15 MG ORAL TABLET

30 MG ORAL TABLET

60 MG ORAL TABLET

100 MG ORAL TABLET

5 MG / ML ORAL ELIXIR

00002234749

000022493240000058499100000005606

0000058500900000005614

000022666870000232031200000632775

00000178799

00000178802

00000178810

00000178829

00000645575

PMS-METHYLPHENIDATE

APO-METHYLPHENIDATEPMS-METHYLPHENIDATERITALIN

PMS-METHYLPHENIDATERITALIN

APO-METHYLPHENIDATE SRSANDOZ METHYLPHENIDATERITALIN SR

PHENOBARB

PHENOBARB

PHENOBARB

PHENOBARB

PHENOBARB

PMS

APXPMSNOV

PMSNOV

APXSDZNOV

PPH

PPH

PPH

PPH

PPH



ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL STIMULANTS

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

28

28

:00

:00

28:20.92

28:24.04

0.0995

0.1331 0.1331 0.3539

0.2326 0.6183

0.2820 0.2820 0.6208

0.0874

0.1040

0.1410

0.1930

0.1167


$

$$$

$$

$$$

$

$

$

$

$

(MISCELLANEOUS ANOREXIGENIC AGENTS & RESPIRATORYAND CEREBRAL STIMULANTS)

(BARBITURATES)




ALPRAZOLAM

BROMAZEPAM

CHLORDIAZEPOXIDE HCL

CHLORDIAZEPOXIDE HCL/ CLIDINIUM BROMIDE

CLORAZEPATE DIPOTASSIUM

DIAZEPAM

0.25 MG ORAL TABLET

0.5 MG ORAL TABLET

1.5 MG ORAL TABLET

3 MG ORAL TABLET

6 MG ORAL TABLET

5 MG ORAL CAPSULE

10 MG ORAL CAPSULE

25 MG ORAL CAPSULE

5 MG * 2.5 MG ORAL CAPSULE

3.75 MG ORAL CAPSULE

7.5 MG ORAL CAPSULE

15 MG ORAL CAPSULE

2 MG ORAL TABLET

5 MG ORAL TABLET

0000234919100000865397000021375340000191348400000548359

0000234920500000865400000021375420000191349200000548367

00002177153

000021771610000223058400000518123

000021771880000223058500000518131

00000522724

00000522988

00000522996

0000061845400000115630

00000860689

00000860700

00000860697

00000405329

00000362158

ALPRAZOLAMAPO-ALPRAZMYLAN-ALPRAZOLAMTEVA-ALPRAZOLXANAX

ALPRAZOLAMAPO-ALPRAZMYLAN-ALPRAZOLAMTEVA-ALPRAZOLXANAX

APO-BROMAZEPAM

APO-BROMAZEPAMNOVO-BROMAZEPAMLECTOPAM

APO-BROMAZEPAMNOVO-BROMAZEPAMLECTOPAM

APO-CHLORDIAZEPOXIDE



APO-CHLORAXLIBRAX

APO-CLORAZEPATE

APO-CLORAZEPATE

APO-CLORAZEPATE

APO-DIAZEPAM

APO-DIAZEPAM

SNSAPXMYPTEVPFI

SNSAPXMYPTEVPFI

APX

APXTEVHLR

APXTEVHLR

APX

APX

APX

APXVCL

APX

APX

APX

APX

APX



28:00

28:24.08

0.0760 0.0760 0.0760 0.0760 0.2486

0.0920 0.0920 0.0920 0.0920 0.2973

0.0693

0.0575 0.0575 0.1529

0.0841 0.0841 0.2234

0.0679

0.1070

0.1658

0.2330 0.3074

0.1476

0.1926

0.3856

0.0508

0.0650


$$$$$

$$$$$

$

$$$

$$$

$

$

$

$$

$

$

$

$

$

(BENZODIAZEPINES)



DIAZEPAM

FLURAZEPAM HCL

LORAZEPAM

MIDAZOLAM HCL

10 MG ORAL TABLET

5 MG / ML INJECTION

5 MG / ML INJECTION EMULSION

15 MG ORAL CAPSULE

30 MG ORAL CAPSULE

0.5 MG ORAL TABLET

1 MG ORAL TABLET

2 MG ORAL TABLET





00000405337

00000399728

00002065614

00000521698

00000521701

0000065574000002041413000023510720000071110100000728187

0000065575900002041421000023510800000063774200000728195

0000065576700002041448000023510990000063775000000728209

00002041456

00002041464

00002041472

00002240286

APO-DIAZEPAM

DIAZEPAM

DIAZEMULS

APO-FLURAZEPAM

APO-FLURAZEPAM

APO-LORAZEPAMATIVANLORAZEPAMNOVO-LORAZEMPMS-LORAZEPAM



ATIVAN

ATIVAN

ATIVAN

MIDAZOLAM

APX

SDZ

PFI

APX

APX

APXWAYSNSTEVPMS

APXWAYSNSTEVPMS

APXWAYSNSTEVPMS

WAY

WAY

WAY

SDZ



28:00

28:24.08

0.0867

0.7302

1.1429

0.1166

0.1364

0.0359 0.0359 0.0359 0.0359 0.0359

0.0447 0.0447 0.0447 0.0447 0.0447

0.0699 0.0699 0.0699 0.0699 0.0699

0.1073

0.1348

0.2097

3.8140



$

$

$

$

$

$$$$$

$$$$$

$$$$$

$

$

$

$

(BENZODIAZEPINES)




NITRAZEPAM

OXAZEPAM

TEMAZEPAM

TRIAZOLAM

BUSPIRONE HCL

CHLORAL HYDRATE

5 MG ORAL TABLET

10 MG ORAL TABLET

10 MG ORAL TABLET

15 MG ORAL TABLET

30 MG ORAL TABLET

15 MG ORAL CAPSULE

30 MG ORAL CAPSULE


0.25 MG ORAL TABLET

10 MG ORAL TABLET


00002245230000022340030000222965400000511528

00002245231000022340070000222965500000511536

00000402680

00000402745

00000402737

00002225964000022448140000223009500000604453

00002225972000022448150000223010200000604461

00000808563

00000808571

000022110760000223149200002230942

00000792659

APO-NITRAZEPAMSANDOZ NITRAZEPAMNITRAZADONMOGADON

APO-NITRAZEPAMSANDOZ NITRAZEPAMNITRAZADONMOGADON

APO-OXAZEPAM

APO-OXAZEPAM

APO-OXAZEPAM

APO-TEMAZEPAMCO TEMAZEPAMNOVO-TEMAZEPAMRESTORIL

APO-TEMAZEPAMCO TEMAZEPAMNOVO-TEMAZEPAMRESTORIL

APO-TRIAZO

APO-TRIAZO

APO-BUSPIRONENOVO-BUSPIRONEPMS-BUSPIRONE

PMS-CHLORAL HYDRATE

APXSDZVCLVCL

APXSDZVCLVCL

APX

APX

APX

APXCOBTEVSUN

APXCOBTEVSUN

APX

APX

APXTEVPMS

PMS





28

28

:00

:00

28:24.08

28:24.92

0.0500 0.0500 0.0698 0.1490

0.0748 0.0748 0.1044 0.2230

0.0420

0.0660

0.0900

0.0730 0.0730 0.0730 0.1940

0.0883 0.0883 0.0883 0.2348

0.1496

0.2502

0.3723 0.3723 0.3723

0.0455


$$$$

$$$$

$

$

$

$$$$

$$$$

$

$

$$$

$

(BENZODIAZEPINES)

(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS)



HYDROXYZINE HCL

ZOPICLONE

10 MG ORAL CAPSULE

25 MG ORAL CAPSULE

50 MG ORAL CAPSULE



5 MG ORAL TABLET

7.5 MG ORAL TABLET

0000064605900000738824

0000064602400000738832

0000064601600000738840

0000074181700000024694

00000742813

0000224507700002363534000022719310000229661600002251450000022434260000226791800002246534000022575720000234412200002216167

000022183130000236354200002271958000022385960000225146900002240606000022679260000224248100002008203000022575800000228244500001926799

APO-HYDROXYZINENOVO-HYDROXYZIN



PMS-HYDROXYZINEATARAX

HYDROXYZINE HCL

APO-ZOPICLONEAVA-ZOPICLONECO ZOPICLONEMYLAN-ZOPICLONENOVO-ZOPICLONEPMS-ZOPICLONERAN-ZOPICLONERATIO-ZOPICLONESANDOZ ZOPICLONEZOPICLONEIMOVANE

APO-ZOPICLONEAVA-ZOPICLONECO ZOPICLONEMYLAN-ZOPICLONENOVO-ZOPICLONEPMS-ZOPICLONERAN-ZOPICLONERATIO-ZOPICLONERHOVANESANDOZ ZOPICLONEZOPICLONEIMOVANE

APXTEV

APXTEV

APXTEV

PMSERF

SDZ

APXAVACOBMYPTEVPMSRANRPHSDZSNSSAV

APXAVACOBMYPTEVPMSRANRPHSDZSDZSNSSAV



28:00

28:24.92

0.1116 0.1116

0.1425 0.1425

0.2068 0.2068

0.0436 0.0519

4.4186

0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 0.2231 1.0340

0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 0.4685 1.3056


$$

$$

$$

$$

$

$$$$$$$$$$$

$$$$$$$$$$$$

(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS)




LITHIUM CARBONATE

NARATRIPTAN HCL


150 MG ORAL CAPSULE

150 MG ORAL CAPSULE

300 MG ORAL CAPSULE

300 MG ORAL CAPSULE

600 MG ORAL CAPSULE





000022428370000221613200000461733

0000224283700002013231

000022428380000221614000000236683

0000224283800000406775

00002216159

0000231429000002237820

000023223230000231430400002237821

00002240521

00002374730000023791980000235187000002240518

APO-LITHIUM CARBONATEPMS-LITHIUM CARBONATECARBOLITH

APO-LITHIUM CARBONATELITHANE

APO-LITHIUM CARBONATEPMS-LITHIUM CARBONATECARBOLITH

APO-LITHIUM CARBONATELITHANE

PMS-LITHIUM CARBONATE

NOVO-NARATRIPTANAMERGE

SANDOZ NARATRIPTANNOVO-NARATRIPTANAMERGE

MAXALT


APXPMSVCL

APXERF

APXPMSVCL

APXERF

PMS

TEVGSK

SDZTEVGSK

MFC

COBMYPSDZMFC



ANTIMANIC AGENTS

ANTIMIGRAINE AGENTS

28

28

:00

:00

28:28

28:32.28

0.0449 0.0449 0.1190

0.0449 0.1019

0.0443 0.0443 0.0924

0.0443 0.1015

0.1429

8.4338 14.1715

6.1437 6.1438

14.9372

15.2201

5.3270 5.3270 5.3270

15.2201


$$$

$$

$$$

$$

$

$$

$$$

$

$$$$

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 other 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 in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)

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 and Alberta Seniors (AISH) clients.)

(SELECTIVE SEROTONIN AGONISTS)




SUMATRIPTAN HEMISULFATE

SUMATRIPTAN SUCCINATE







00002374749000023792010000235188900002240519

00002230418

00002230420

000022683880000236625800002257890000022689140000228682300002256436000022630250000228652100002212153

00002268396000023662660000225790400002268922000022393670000228683100002256444000022630330000228654800002212161

0000236169800002212188


IMITREX

IMITREX

APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF

APO-SUMATRIPTANAVA-SUMATRIPTANCO SUMATRIPTANMYLAN-SUMATRIPTANNOVO-SUMATRIPTANNOVO-SUMATRIPTAN DFPMS-SUMATRIPTANSANDOZ SUMATRIPTANSUMATRIPTANIMITREX DF

SUMATRIPTAN SUN (0.5 ML)IMITREX (0.5 ML)

COBMYPSDZMFC

GSK

GSK

APXAVACOBMYPTEVPMSSDZSNSGSK

APXAVACOBMYPTEVTEVPMSSDZSNSGSK

SPGGSK


ANTIMIGRAINE AGENTS

28:00

28:32.28

5.3270 5.3270 5.3270

15.2201

14.3859

14.8045

7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350 7.1350

15.1567

7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600 7.8600

16.6968

16.5889 44.0900


$$$$

$

$

$$$$$$$$$

$$$$$$$$$$

$$

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 other 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 and Alberta Seniors (AISH) clients.)

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 other 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 in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)





ZOLMITRIPTAN

PIZOTIFEN MALATE

AMANTADINE HCL

2.5 MG ORAL TABLET

2.5 MG ORAL DISPERSIBLE TABLET

5 MG / DOSE NASAL UNIT DOSE SPRAY


100 MG ORAL CAPSULE


0000236903600002324229000023629880000231396000002238660

00002324768000023629960000234254500002243045

00002248993

00000329320

0000213920000001990403

00002022826

MYLAN-ZOLMITRIPTANPMS-ZOLMITRIPTANSANDOZ ZOLMITRIPTANTEVA-ZOLMITRIPTANZOMIG

PMS-ZOLMITRIPTAN ODTSANDOZ ZOLMITRIPTAN ODTTEVA-ZOLMITRIPTAN ODZOMIG RAPIMELT

ZOMIG

SANDOMIGRAN

MYLAN-AMANTADINEPMS-AMANTADINE HYDROCHLORIDE

PMS-AMANTADINE HYDROCHLORIDE

MYPPMSSDZTEVAZC

PMSSDZTEVAZC

AZC

PAL

MYPPMS

PMS




ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS

ANTIPARKINSONIAN AGENTS

28

28

28

:00

:00

:00

28:32.28

28:32.92

28:36.04

5.2110 5.2110 5.2110 5.2110

13.8500

5.2110 5.2110 5.2110

13.8500

13.8500

0.3875

0.5179 0.5179

0.1005


$$$$$

$$$$

$

$

$$

$

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 other 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 and Alberta Seniors (AISH) clients.)


(MISCELLANEOUS ANTIMIGRAINE AGENTS)

(ADAMANTANES)



BENZTROPINE MESYLATE

ETHOPROPAZINE HCL

PROCYCLIDINE HCL

TRIHEXYPHENIDYL HCL

ENTACAPONE

LEVODOPA/ BENSERAZIDE HCL

1 MG ORAL TABLET

2 MG ORAL TABLET

1 MG / ML INJECTION


2.5 MG ORAL TABLET

5 MG ORAL TABLET

0.5 MG / ML ORAL ELIXIR

2 MG ORAL TABLET

5 MG ORAL TABLET

200 MG ORAL TABLET

50 MG * 12.5 MG (BASE) ORAL CAPSULE

100 MG * 25 MG (BASE) ORAL CAPSULE

200 MG * 50 MG (BASE) ORAL CAPSULE

00000706531

0000042685700000587265

00002238903

00001927744

00000649392

00000587354

00000587362

00000545058

00000545074

000023214590000237555900002243763

00000522597

00000386464

00000386472

PMS-BENZTROPINE

BENZTROPINEPMS-BENZTROPINE

BENZTROPINE OMEGA

PARSITAN

PMS-PROCYCLIDINE

PMS-PROCYCLIDINE

PMS-PROCYCLIDINE

TRIHEXYPHENIDYL

TRIHEXYPHENIDYL

APO-ENTACAPONETEVA-ENTACAPONECOMTAN

PROLOPA 50-12.5

PROLOPA 100-25

PROLOPA 200-50

PMS

PMSPMS

OMG

ERF

PMS

PMS

PMS

AAP

AAP

APXTEVNOV

HLR

HLR

HLR







28

28

28

:00

:00

:00

28:36.08

28:36.12

28:36.16

0.0450

0.0450 0.0450

7.5000

0.2081

0.0624

0.1248

0.2516

0.0369

0.0668

0.6095 0.6095 1.6199

0.2787

0.4588

0.7702


$

$$

$

$

$

$

$

$

$

$$$

$

$

$

(ANTICHOLINERGIC AGENTS)

(CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS)

(DOPAMINE PRECURSORS)




LEVODOPA/ CARBIDOPA

LEVODOPA/ CARBIDOPA/ ENTACAPONE

BROMOCRIPTINE MESYLATE




100 MG * 25 MG ORAL SUSTAINED-RELEASE TABLET


50 MG * 12.5 MG * 200 MG ORAL TABLET







000021959330000224449400000355658

000021959410000224449500000513997

000021959680000224449600000328219

0000227287300002028786

00000870935

00002305933

00002337827

00002305941

00002337835

00002305968

00002087324

00002230454

APO-LEVOCARBNOVO-LEVOCARBIDOPASINEMET 100/10



LEVOCARB CRSINEMET CR 100/25

SINEMET CR 200/50

STALEVO

STALEVO

STALEVO

STALEVO

STALEVO

APO-BROMOCRIPTINE

APO-BROMOCRIPTINE

APXTEVMFC

APXTEVMFC

APXTEVMFC

AAPMFC

MFC

NOV

NOV

NOV

NOV

NOV

APX

APX

(ERGOT-DERIVATIVE-DOPAMINE RECEPTOR AGONISTS)





28

28

:00

:00

28:36.16

28:36.20.04

0.1877 0.1877 0.4554

0.2803 0.2803 0.6800

0.3129 0.3129 0.7591

0.5510 0.7374

1.3603

1.6018

1.6018

1.6018

1.6018

1.6018

0.9782

1.4644


$$$

$$$

$$$

$$

$

$

$

$

$

$

$

$

(DOPAMINE PRECURSORS)

DOPAMINE RECEPTOR AGONISTS



PRAMIPEXOLE DIHYDROCHLORIDE

ROPINIROLE HCL

0.25 MG ORAL TABLET

1 MG ORAL TABLET

1.5 MG ORAL TABLET



0000229237800002363305000022973020000237635000002269309000022901110000236760200002315262

00002292394000023633210000229732900002376377000022693250000229014600002315289

00002292408000023633480000229733700002376385000022693330000229015400002315297

0000233774600002316846000023523380000232659000002314037000023323610000235304000002232565

0000233776200002316854000023523460000232661200002314053000023324260000235305900002232567

APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLEPRAMIPEXOLESANDOZ PRAMIPEXOLE

APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLESANDOZ PRAMIPEXOLE

APO-PRAMIPEXOLEAVA-PRAMIPEXOLECO PRAMIPEXOLEMYLAN-PRAMIPEXOLENOVO-PRAMIPEXOLEPMS-PRAMIPEXOLESANDOZ PRAMIPEXOLE

APO-ROPINIROLECO ROPINIROLEJAMP-ROPINIROLEPMS-ROPINIROLERAN-ROPINIROLEROPINIROLEROPINIROLEREQUIP


APXAVACOBMYPTEVPMSSNSSDZ

APXAVACOBMYPTEVPMSSDZ

APXAVACOBMYPTEVPMSSDZ

APXCOBJPCPMSRANRANSNSGSK


(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)



28:00

28:36.20.08

0.3679 0.3679 0.3679 0.3679 0.3679 0.3679 0.3679 0.3679

0.7360 0.7360 0.7360 0.7360 0.7360 0.7360 0.7360

0.7360 0.7360 0.7360 0.7360 0.7360 0.7360 0.7360

0.1068 0.1068 0.1068 0.1068 0.1068 0.1068 0.1068 0.2838

0.4271 0.4271 0.4271 0.4271 0.4271 0.4271 0.4271 1.1353


$$$$$$$$

$$$$$$$

$$$$$$$

$$$$$$$$

$$$$$$$$





ROPINIROLE HCL

SELEGILINE HCL

PIZOTIFEN MALATE



5 MG ORAL TABLET


0000233777000002316862000023523540000232662000002314061000023324340000235306700002232568

0000233780000002316870000023523620000232663900002314088000023324420000235307500002232569

000022306410000223103600002068087

00000511552



APO-SELEGILINEMYLAN-SELEGILINENOVO-SELEGILINE

SANDOMIGRAN DS



APXMYPTEV

PAL

(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)






MISCELLANEOUS CENTRAL NERVOUS SYSTEM AGENTS

28

28

28

:00

:00

:00

28:36.20.08

28:36.32

28:92

0.4699 0.4699 0.4699 0.4699 0.4699 0.4699 0.4699 1.2489

1.2937 1.2937 1.2937 1.2937 1.2937 1.2937 1.2937 3.4384

0.7906 0.7906 0.7906

0.6434


$$$$$$$$

$$$$$$$$

$$$

$


(MONOAMINE OXIDASE B INHIBITORS)


34:00 Dental A

gents

34:00

Dental Agents


SODIUM FLUORIDE2.21 MG ORAL CHEWABLE TABLET

5.56 MG / ML ORAL DROPS00000575569

00000610100

FLUOR-A-DAY

FLUOR-A-DAY

PMS

PMS

DENTAL AGENTS34:00

34:00

0.0867

0.1734


$

$


36:00 Diagnostic A

gents

36:00

Diagnostic Agents


THYROTROPIN ALFA0.9 MG / VIAL INJECTION

00002246016 THYROGEN GZM

DIAGNOSTIC AGENTS

THYROID FUNCTION

36:00

36:60

1363.7200


$


40:00 Electrolytic, Caloric, and W

ater Balance

40:00

Electrolytic, Caloric, and Water Balance


LACTULOSE

MAGNESIUM GLUCOHEPTONATE

MAGNESIUM GLUCONATE

POTASSIUM CHLORIDE (K+)

POTASSIUM CHLORIDE (K+)(CL-)

POTASSIUM CITRATE (K+)

SODIUM ACID PHOSPHATE/ SODIUM BICARBONATE/ POTASSIUM BICARBONATE

CALCIUM POLYSTYRENE SULPHONATE



500 MG ORAL TABLET

8 MEQ ORAL SUSTAINED-RELEASE TABLET

20 MEQ ORAL SUSTAINED-RELEASE TABLET

8 MEQ ORAL SUSTAINED-RELEASE CAPSULE

1.33 MEQ / ML ORAL LIQUID

25 MEQ ORAL EFFERVESCENT TABLET

500 MG (BASE) * 469 MG (BASE) * 123 MG (BASE) ORAL EFFERVESCENT TABLET

ORAL POWDER

0000224281400002295881000007034860000085440900002331551

00000026697

00000555126

0000060288400000074225

00000713376

00002042304

0000223860400080024360

00002085992

00080027202

00002017741

APO-LACTULOSEJAMP-LACTULOSEPMS-LACTULOSERATIO-LACTULOSETEVA-LACTULOSE

ROUGIER MAGNESIUM

MAGLUCATE

APO-KSLOW K

K-DUR

MICRO-K EXTENCAPS

PMS - POTASSIUM CHLORIDEK-10 ORAL LIQUID

K-LYTE

PHOSPHATE-NOVARTIS

RESONIUM CALCIUM

APXJPCPMSRPHTEV

ROG

PMS

APXNOV

MFC

PAL

PMSGSK

WSP

NOV

SAV

ELECTROLYTIC, CALORIC, AND WATER BALANCE



AMMONIA DETOXICANTS

REPLACEMENT PREPARATIONS

ION-REMOVING AGENTS

40

40

40

:00

:00

:00

40:10

40:12

40:18.18

0.0145 0.0145 0.0145 0.0145 0.0145

0.0200

0.1166

0.0899 0.1475

0.2052

0.0930

0.0146 0.0157

0.5550

0.6858

0.3545


$ 0.0899


MAC pricing has been applied based on the lowest unit cost for an 8 mEq (K+) oral sustained-release tablet: APO-K.

$$$$$

$

$

$$

$

$

$$

$

$

$

(POTASSIUM-REMOVING AGENTS)




SODIUM POLYSTYRENE SULFONATE

AMILORIDE HCL

HYDROCHLOROTHIAZIDE

HYDROCHLOROTHIAZIDE/ AMILORIDE HCL

HYDROCHLOROTHIAZIDE/ TRIAMTERENE

CHLORTHALIDONE


ORAL POWDER

30 G / ENM RECTAL RETENTION ENEMA

5 MG ORAL TABLET

12.5 MG ORAL TABLET

25 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET



50 MG ORAL TABLET

00000769541

0000075533800002026961

00000769533

00002249510

00002274086

00000326844

00000312800

00000644552

0000078440000001937219

0000044177500000532657

00000360279

SOLYSTAT

PMS-SODIUM POLYSTYRENE SULF.KAYEXALATE

SOLYSTAT

MIDAMOR

PMS-HYDROCHLOROTHIAZIDE

APO-HYDRO

APO-HYDRO

APO-HYDRO

APO-AMILZIDENOVAMILOR

APO-TRIAZIDENOVO-TRIAMZIDE

CHLORTHALIDONE

PPH

PMSSAV

PPH

AAP

PMS

APX

APX

APX

APXTEV

APXTEV

AAP





ION-REMOVING AGENTS

DIURETICS

DIURETICS

DIURETICS

40

40

40

40

:00

:00

:00

:00

40:18.18

40:28.16

40:28.20

40:28.24

0.1306

0.1696 0.1835

15.3608

0.2717

0.0338

0.0247

0.0344

0.1232

0.1293 0.1293

0.0608 0.0608

0.1242


$

$$

$

$

$

$

$

$

$$

$$

$

(POTASSIUM-REMOVING AGENTS)

(POTASSIUM-SPARING DIURETICS)

(THIAZIDE DIURETICS)

(THIAZIDE-LIKE DIURETICS)



INDAPAMIDE HEMIHYDRATE

METOLAZONE

PROBENECID

SULFINPYRAZONE



2.5 MG ORAL TABLET

500 MG ORAL TABLET

200 MG ORAL TABLET

000022452460000224006700002239619

0000222367800002153483000022311840000223962000000564966

00000888400

00000294926

00000441767

APO-INDAPAMIDEMYLAN-INDAPAMIDEPMS-INDAPAMIDE

APO-INDAPAMIDEMYLAN-INDAPAMIDENOVO-INDAPAMIDEPMS-INDAPAMIDELOZIDE

ZAROXOLYN

BENURYL

SULFINPYRAZONE

APXMYPPMS

APXMYPTEVPMSSEV

SAV

VCL

AAP



DIURETICS

URICOSURIC AGENTS

40

40

:00

:00

40:28.24

40:40

0.1173 0.1173 0.1173

0.1833 0.1833 0.1833 0.1833 0.4873

0.1937

0.5280

0.2997


$$$

$$$$$

$

$

$

(THIAZIDE-LIKE DIURETICS)


48:00 Respiratory Tract A

gents

48:00

Respiratory Tract Agents


MONTELUKAST SODIUM

ZAFIRLUKAST




4 MG (BASE) ORAL GRANULE

20 MG ORAL TABLET

00002374609000023793330000236822600002373947000023285930000235552300002238217

00002377608000023793170000238074900002354977000023303850000235550700002243602

00002377616000023793250000238075700002354985000023303930000235551500002238216

0000235861100002247997

00002236606

APO-MONTELUKASTMONTELUKASTMYLAN-MONTELUKASTPMS-MONTELUKAST FCSANDOZ MONTELUKASTTEVA-MONTELUKASTSINGULAIR



SANDOZ MONTELUKASTSINGULAIR

ACCOLATE




SDZMFC

AZC

RESPIRATORY TRACT AGENTS

ANTI-INFLAMMATORY AGENTS

48:00

48:10.24

0.8483 0.8483 0.8483 0.8483 0.8483 0.8483 2.4238

0.5216 0.5216 0.5216 0.5216 0.5216 0.5216 1.4904

0.5776 0.5776 0.5776 0.5776 0.5776 0.5776 1.6503

0.5216 1.4904

0.7492


$$$$$$$

$$$$$$$

$$$$$$$

$$

$

RESTRICTED BENEFIT - This product is a benefit for patients 6 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)

RESTRICTED BENEFIT - This product is a benefit for patients 2 to 18 years of age inclusive for the prophylaxis and treatment of asthma.

RESTRICTED BENEFIT - This product is a benefit for patients 6 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to Criteria for Special Authorization of Select Drug Products of the List, and Criteria for Special Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)

RESTRICTED BENEFIT - This product is a benefit for patients 2 to 18 years of age inclusive for the prophylaxis and treatment of asthma.

RESTRICTED BENEFIT - This product is a benefit for patients 12 to 18 years of age inclusive for the prophylaxis and treatment of asthma. (For eligibility in patients over 18 years of age refer to the Criteria for Special Authorization of Select Drug Products of the List, and Criteria forSpecial Authorization of Select Drug Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta Human Services and Alberta Seniors (AISH) clients.)

(LEUKOTRIENE MODIFIERS)




SODIUM CROMOGLYCATE

ACETYLCYSTEINE

100 MG ORAL CAPSULE

1 % INHALATION SOLUTION

20 % INHALATION SOLUTION

00000500895

00002046113

0000224309800002091526

NALCROM

PMS-SODIUM CROMOGLYCATE

ACETYLCYSTEINEMUCOMYST

SAV

PMS

SDZWSP




MUCOLYTIC AGENTS

48

48

:00

:00

48:10.32

48:24

1.4276

0.7696

0.6800 0.7200


$

$

$$

(MAST-CELL STABILIZERS)


52:00 Eye, Ear, Nose and Throat (EEN

T) Preparations

52:00

Eye, Ear, Nose and Throat (EENT) Preparations


CIPROFLOXACIN HCL

ERYTHROMYCIN

GENTAMICIN SULFATE

NEOMYCIN SULFATE/ POLYMYXIN B SULFATE/ GRAMICIDIN

OFLOXACIN

TOBRAMYCIN

TRIFLURIDINE

0.3 % (BASE) OPHTHALMIC SOLUTION

0.5 % OPHTHALMIC OINTMENT


0.3 % (BASE) OPHTHALMIC OINTMENT

0.3 % (BASE) OTIC SOLUTION

0.25 % * 10,000 UNIT / ML * 0.03 MG / ML OTIC/OPHTHALMIC SOLUTION

0.3 % OPHTHALMIC SOLUTION



1 % OPHTHALMIC SOLUTION

0000225393300001945270

00001912755

0000051219200002229440

00002230888

0000051218400002229441

00000807435

000022483980000225257000002143291

000022395770000224175500000513962

00000614254

0000224852900000687456

PMS-CIPROFLOXACINCILOXAN

PMS-ERYTHROMYCIN

GARAMYCINSANDOZ GENTAMICIN SULFATE

SANDOZ GENTAMICIN SULFATE

GARAMYCINSANDOZ GENTAMICIN SULFATE

OPTIMYXIN PLUS

APO-OFLOXACINPMS-OFLOXACINOCUFLOX

PMS-TOBRAMYCINSANDOZ TOBRAMYCINTOBREX

TOBREX

SANDOZ TRIFLURIDINEVIROPTIC

PMSALC

PMS

MFCSDZ

SDZ

MFCSDZ

SDZ

APXPMSALL

PMSSDZALC

ALC

SDZVCL

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS


ANTI-INFECTIVES

ANTI-INFECTIVES

52

52

:00

:00

52:04.04

52:04.20

0.7639 2.0302

1.2959

0.4060 0.4060

1.4286

1.0320 1.0320

0.7656

0.9203 0.9203 2.4460

0.6560 0.6560 1.7435

2.4728

3.0387 3.0387


$$

$

$$

$

$$

$

$$$

$$$

$

$$

(ANTIBACTERIALS)

(ANTIVIRALS)




BECLOMETHASONE DIPROPIONATE

BUDESONIDE

CIPROFLOXACIN HCL/ DEXAMETHASONE

DEXAMETHASONE

DEXAMETHASONE SODIUM PHOSPHATE

FLUNISOLIDE

FLUOROMETHOLONE

FLUOROMETHOLONE ACETATE

HYDROCORTISONE ACETATE

MOMETASONE FUROATE

50 MCG / DOSE NASAL METERED DOSE SPRAY

100 MCG / DOSE NASAL METERED DOSE AEROSOL


0.3 % * 0.1 % OTIC SUSPENSION

0.1 % OPHTHALMIC SUSPENSION


0.1 % OTIC/OPHTHALMIC SOLUTION

0.025 % NASAL SPRAY






0000223879600002172712

00002035324

00002230648

00002252716

00000042560

00000042579

00000739839

00002239288

00002238568

00000707511

00000756784

00001980661

00002238465

APO-BECLOMETHASONEMYLAN-BECLO AQ.

RHINOCORT TURBUHALER

MYLAN-BUDESONIDE AQ

CIPRODEX

MAXIDEX

MAXIDEX

SANDOZ DEXAMETHASONE SOD. PHOSPHATE

APO-FLUNISOLIDE

PMS-FLUOROMETHOLONE

FML FORTE

FLAREX

CORTAMED

NASONEX

APXMYP

AZC

MYP

ALC

ALC

ALC

SDZ

APX

PMS

ALL

ALC

SDZ

MFC



52:00

52:08.08

0.0613 0.0613

0.1178

0.1006

3.5533

1.6116

2.4967

1.3079

0.5940

1.7880

2.6260

1.8209

5.7674

0.2065


$$

$

$

$

$

$

$

$

$

$

$

$

$RESTRICTED BENEFIT - This product is a benefit for patients 3 to 12 years of age inclusive for the treatment of seasonal allergic rhinitis or perennial allergic rhinitis.

(CORTICOSTEROIDS)



PREDNISOLONE ACETATE

BETAMETHASONE SODIUM PHOSPHATE/ GENTAMICIN SULFATE

DEXAMETHASONE/ FRAMYCETIN SULFATE/ GRAMICIDIN

DEXAMETHASONE/ NEOMYCIN SULFATE/ POLYMYXIN B SULFATE

DEXAMETHASONE/ TOBRAMYCIN

FLUMETHASONE PIVALATE/ CLIOQUINOL

PREDNISOLONE ACETATE/ SULFACETAMIDE SODIUM


1 % OPHTHALMIC SUSPENSION

0.1 % (BASE) * 0.3 % (BASE) OTIC/OPHTHALMIC SOLUTION

0.5 MG / ML * 5 MG / ML * 0.05 MG / ML OTIC/OPHTHALMIC SOLUTION

1 MG / ML * 3.5 MG / ML (BASE) * 6,000 UNIT / ML OPHTHALMIC SUSPENSION

1 MG / G * 3.5 MG / G (BASE) * 6,000 UNIT / G OPHTHALMIC OINTMENT

0.1 % * 0.3 % OPHTHALMIC SUSPENSION

0.1 % * 0.3 % OPHTHALMIC OINTMENT

0.02 % * 1 % OTIC SOLUTION

0.2 % * 10 % OPHTHALMIC SUSPENSION

0.2 % * 10 % OPHTHALMIC OINTMENT

0000191618100000299405

000007004010000191620300000301175

0000068221700002244999

0000224792000002224623

00000042676

00000358177

00000778907

00000778915

00000074454

00000807788

00000307246

SANDOZ PREDNISOLONE ACETATEPRED MILD

RATIO-PREDNISOLONESANDOZ PREDNISOLONE ACETATEPRED FORTE

GARASONESANDOZ PENTASONE

SANDOZ OPTICORTSOFRACORT

MAXITROL

MAXITROL

TOBRADEX

TOBRADEX

LOCACORTEN VIOFORM

BLEPHAMIDE

BLEPHAMIDE S.O.P.

SDZALL

RPHSDZALL

MFCSDZ

SDZSAV

ALC

ALC

ALC

ALC

PAL

ALL

ALL

(COMBINATION ANTI-INFECTIVE/CORTICOSTEROID AGENTS)





52

52

:00

:00

52:08.08

52:08.08.00

1.3450 1.7960

1.9400 1.9400 5.2880

1.2813 1.2813

1.3000 1.8663

1.9926

2.7778

2.0400

3.0057

1.4790

2.6623

3.4057


$$

$$$

$$

$$

$

$

$

$

$

$

$

(CORTICOSTEROIDS)

CORTICOSTEROIDS




DICLOFENAC SODIUM


LIDOCAINE HCL

PROPARACAINE HCL

ATROPINE SULFATE

CYCLOPENTOLATE HCL

HOMATROPINE HYDROBROMIDE

TROPICAMIDE



2 % ORAL LIQUID








00001940414

000022474610000224582100001968300

0000196882300000001686

00000035076

00000035017

00000252506

00000000779

00000000787

00000000981

00000001007

VOLTAREN OPHTHA

RATIO-KETOROLACAPO-KETOROLACACULAR

LIDODAN VISCOUSXYLOCAINE VISCOUS

ALCAINE

ISOPTO ATROPINE

CYCLOGYL

ISOPTO HOMATROPINE

ISOPTO HOMATROPINE

MYDRIACYL

MYDRIACYL

ALC

RPHAPXALL

ODNAZC

ALC

ALC

ALC

ALC

ALC

ALC

ALC





LOCAL ANESTHETICS

MYDRIATICS

52

52

52

:00

:00

:00

52:08.20

52:16

52:24

2.5200

1.6000 2.0160 3.3600

0.0525 0.0950

0.6280

0.6279

0.8442

0.6384

0.7605

0.8756

1.1268


$

$$$

$$

$

$

$

$

$

$

$

(NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)



BENZYDAMINE HCL


EPINEPHRINE HCL

PHENYLEPHRINE HCL

BRIMONIDINE TARTRATE

BETAXOLOL HCL

0.15 % ORAL RINSE

ORAL

ORAL

1 MG / ML TOPICAL SOLUTION



0.25 % (BASE) OPHTHALMIC SUSPENSION

0000231042200002229777

00000999209

00000999109

00000155365

00000465763

0000226007700002246284000022430260000230542900002236876

00001908448

NOVO-BENZYDAMINEPMS-BENZYDAMINE

COMPD-CHLORHEX. MOUTH RINSE (ANY CONCENTRATION, NOT 0.12%)

COMPD-CHLORHEX. MOUTH RINSE (ANY CONCENTRATION, NOT 12%)

ADRENALIN

MYDFRIN

APO-BRIMONIDINEPMS-BRIMONIDINERATIO-BRIMONIDINESANDOZ BRIMONIDINEALPHAGAN

BETOPTIC S

TEVPMS

XXX

XXX

ERF

ALC

APXPMSRPHSDZALL

ALC





MOUTHWASHES AND GARGLES

VASOCONSTRICTORS

ANTIGLAUCOMA AGENTS

ANTIGLAUCOMA AGENTS

52

52

52

52

:00

:00

:00

:00

52:28

52:32

52:40.04

52:40.08

0.0290 0.2900

0.0000

0.0000

0.5545

1.0151

1.2418 1.2418 1.2418 1.2418 3.3005

2.3000


$$

$

$

$

$

$$$$$

$



(ALPHA-ADRENERGIC AGONISTS)

(BETA-ADRENERGIC AGENTS)




LEVOBUNOLOL HCL

TIMOLOL MALEATE

ACETAZOLAMIDE

BRINZOLAMIDE

DORZOLAMIDE HCL

METHAZOLAMIDE





0.25 % (BASE) OPHTHALMIC LONG ACTING GELLAN SOLUTION

0.5 % (BASE) OPHTHALMIC LONG ACTING GELLAN SOLUTION

250 MG ORAL TABLET

1 % OPHTHALMIC SUSPENSION

2 % (BASE) OPHTHALMIC SOLUTION

50 MG ORAL TABLET

0000224171500002031159

00002237991000020311670000224171600000637661

000007558260000208335300002166712

00000755834000020833450000216672000000451207

00002171880

00002171899

00000545015

00002238873

000023163070000221620500002269090

00002245882

SANDOZ LEVOBUNOLOLRATIO-LEVOBUNOLOL

PMS-LEVOBUNOLOLRATIO-LEVOBUNOLOLSANDOZ LEVOBUNOLOLBETAGAN

APO-TIMOPPMS-TIMOLOLSANDOZ TIMOLOL MALEATE

APO-TIMOPPMS-TIMOLOLSANDOZ TIMOLOL MALEATETIMOPTIC

TIMOPTIC-XE

TIMOPTIC-XE

ACETAZOLAMIDE

AZOPT

SANDOZ DORZOLAMIDETRUSOPTTRUSOPT (PRESERVATIVE-FREE)

METHAZOLAMIDE

SDZRPH

PMSRPHSDZALL

APXPMSSDZ

APXPMSSDZMFC

MFC

MFC

AAP

ALC

SDZMFCMFC

AAP



ANTIGLAUCOMA AGENTS

ANTIGLAUCOMA AGENTS

52

52

:00

:00

52:40.08

52:40.12

0.9320 1.9143

1.2379 1.2379 1.2379 3.2900

0.9688 0.9688 0.9688

1.2722 1.2722 1.2722 3.6348

3.8799

4.6408

0.1237

3.2844

1.3505 3.8585 3.8639

0.4817


$$

$$$$

$$$

$$$$

$

$

$

$

$$$

$

(BETA-ADRENERGIC AGENTS)

(CARBONIC ANHYDRASE INHIBITORS)



CARBACHOL

PILOCARPINE HCL

BIMATOPROST

LATANOPROST

TRAVOPROST

BRIMONIDINE TARTRATE/ TIMOLOL MALEATE

BRINZOLAMIDE/ TIMOLOL MALEATE






4 % OPHTHALMIC GEL

OPHTHALMIC SOLUTION



0.2 % * 0.5 % (BASE) OPHTHALMIC SOLUTION

1 % * 0.5 % (BASE) OPHTHALMIC SUSPENSION

00000000655

00000000663

00000000841

00000000868

00000000884

00000575240

00002324997

0000229652700002254786000023730410000236733500002231493

00002318008

00002248347

00002331624

ISOPTO CARBACHOL

ISOPTO CARBACHOL

ISOPTO CARPINE

ISOPTO CARPINE

ISOPTO CARPINE

PILOPINE HS

LUMIGAN RC 0.01%

APO-LATANOPROSTCO LATANOPROSTGD-LATANOPROSTSANDOZ LATANOPROSTXALATAN

TRAVATAN Z

COMBIGAN

AZARGA

ALC

ALC

ALC

ALC

ALC

ALC

ALL

APXCOBGMDSDZPFI

ALC

ALL

ALC




ANTIGLAUCOMA AGENTS

ANTIGLAUCOMA AGENTS

ANTIGLAUCOMA AGENTS

52

52

52

:00

:00

:00

52:40.20

52:40.28

52:40.92

0.7047

0.8477

0.2142

0.2470

0.2791

2.6142

10.8160

4.1427 4.1427 4.1427 4.1427

11.0106

11.0800

4.0120

4.2840


$

$

$

$

$

$

$

$$$$$

$

$

$

(MIOTICS)

(PROSTAGLANDIN ANALOGS)

(MISCELLANEOUS ANTIGLAUCOMA AGENTS)




DORZOLAMIDE HCL/ TIMOLOL MALEATE

LATANOPROST/ TIMOLOL MALEATE

TRAVOPROST/ TIMOLOL MALEATE

APRACLONIDINE HCL

2 % (BASE) * 0.5 % (BASE) OPHTHALMIC SOLUTION




0000229961500002344351000023205250000225869200002240113

00002246619

00002278251

00002076306

APO-DORZO-TIMOPSANDOZ DORZOLAMIDE/ TIMOLOLTEVA-DORZOTIMOLCOSOPT PRESERVATIVE-FREECOSOPT

XALACOM

DUO TRAV

IOPIDINE

APXSDZTEVMFCMFC

PFI

ALC

ALC



ANTIGLAUCOMA AGENTS

MISCELLANEOUS EENT DRUGS

52

52

:00

:00

52:40.92

52:92

2.0459 2.0459 2.0459 2.3675 5.8454

12.4603

12.4848

4.4519


$$$$$

$

$

$

(MISCELLANEOUS ANTIGLAUCOMA AGENTS)



RANIBIZUMAB

2.3 MG / VIAL INJECTION00002296810 LUCENTIS NOV


MISCELLANEOUS EENT DRUGS

52:00

52:92

1575.0000


For this product - pricing has been established on a per vial basis.$

RESTRICTED BENEFIT - This product is a benefit when prescribed by a registered prescriber conditional to the following criteria.

"For the treatment of neovascular (wet) age-related macular degeneration (AMD) if all of the following circumstances apply to the eye to be treated:- The best corrected visual acuity (BCVA) is between 6/12 (20/40) and 6/96 (20/320)- There is active disease activity (choroidal neovascularization) and no permanent structural damage to the central fovea- The lesion size is less than or equal to 12 disc areas in greatest linear dimension- There is evidence of recent (< 3 months) presumed disease progression (blood vessel growth, as indicated by fluoroscein angiography, optical coherence tomography (OCT) or recent visual acuity changes)- No concurrent verteporfin PDT treatment- Injection will be by a qualified ophthalmologist with experience in intravitreal injections.

The interval between the doses should be no shorter than one month.

Treatment with ranibizumab should be continued only in people who maintain adequate response to therapy.

Ranibizumab should be discontinued if any one of the following occur:- Reduction in BCVA in the treated eye to less than 15 letters (absolute) on 2 consecutive visitsin the treated eye, attributed to AMD in the absence of other pathology,- Reduction in BCVA of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect or adverse event or both.- There is evidence of deterioration of the lesion morphology despite optimum treatment over three consecutive visits."


56:00 Gastrointestinal D

rugs

56:00

Gastrointestinal Drugs


DIPHENOXYLATE HCL/ ATROPINE SULFATE

URSODIOL

LIPASE/ AMYLASE/ PROTEASE


250 MG ORAL TABLET

500 MG ORAL TABLET

8,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL TABLET

16,000 UNIT * 60,000 UNIT * 60,000 UNIT ORAL TABLET

8,000 UNIT * 30,000 UNIT * 30,000 UNIT ORAL CAPSULE

4,000 UNIT * 12,000 UNIT * 12,000 UNIT ORAL CAPSULE (ENTERIC-COATED PELLET)










00000036323

0000227349700002238984

0000227350000002245894

00002230019

00002241933

00000263818

00000789445

00002203324

00000502790

00000789437

00002200104

00002045834

00000789429

00000821373

00002045869

00001985205

LOMOTIL

PMS-URSODIOL CURSO

PMS-URSODIOL CURSO DS

VIOKASE

VIOKASE 16

COTAZYM

PANCREASE MT 4

ULTRASE MS4 MICROSPHERES

COTAZYM ECS 8

PANCREASE MT 10

CREON 10 MINIMICROSPHERES

ULTRASE MT12 MINITABLETS

PANCREASE MT 16

COTAZYM ECS 20

ULTRASE MT20 MINITABLETS

CREON 25 MINIMICROSPHERES

PFI

PMSAXC

PMSAXC

AXC

AXC

ORG

JAI

AXC

ORG

JAI

ABB

AXC

JAI

ORG

AXC

ABB

GASTROINTESTINAL DRUGS



ANTIDIARRHEA AGENTS

CHOLELITHOLYTIC AGENTS

DIGESTANTS

56

56

56

:00

:00

:00

56:08

56:14

56:16

0.4450

0.8808 1.3701

1.6708 2.5988

0.2314

0.3551

0.1866

0.4555

0.2266

0.3368

1.1385

0.2723

0.4432

1.8214

0.8830

0.7679

0.8507


$

$$

$$

$

$

$

$

$

$

$

$

$

$

$

$

$




DIMENHYDRINATE

PROCHLORPERAZINE

DOLASETRON MESYLATE

GRANISETRON HCL

ONDANSETRON



5 MG ORAL TABLET

10 MG ORAL TABLET

5 MG / ML INJECTION


100 MG ORAL TABLET




00000392731

00000392537

00000886440

00000886432

00000789747

00000789720

00002231379

0000230889400002185881

00002239372

00002239373

DIMENHYDRINATE I.V.

DIMENHYDRINATE I.M.

APO-PROCHLORAZINE

APO-PROCHLORAZINE

PROCHLORPERAZINE

SANDOZ PROCHLORPERAZINE

ANZEMET

GRANISETRONKYTRIL

ZOFRAN ODT

ZOFRAN ODT

SDZ

SDZ

APX

APX

SDZ

SDZ

SAV

AAPHLR

GSK

GSK



ANTIEMETICS

ANTIEMETICS

56

56

:00

:00

56:22.08

56:22.20

0.3274

1.0698

0.1659

0.2025

0.9721

1.1628

29.1580

14.5125 18.0000

13.0890

19.9720


$

$

$

$

$

$

$

$$

$

$

(ANTIHISTAMINES)

(5-HT3 RECEPTOR ANTAGONISTS)



ONDANSETRON HCL DIHYDRATE4 MG (BASE) ORAL TABLET


0.8 MG / ML (BASE) ORAL SOLUTION



000022881840000229634900002313685000023717310000230525900002297868000023062120000227861800002258188000023122470000227852900002274310000023760910000226405600002213567

000022881920000229635700002313693000023717580000230526700002297876000023062200000227862600002258196000023122550000227853700002274329000023761050000226406400002213575

0000229196700002229639

00002271761

000002213745

00002271788

00002213745

APO-ONDANSETRONCO ONDANSETRONJAMP-ONDANSETRONMAR-ONDANSETRONMINT-ONDANSETRONMYLAN-ONDANSETRONONDANSETRON-ODANPHL-ONDANSETRONPMS-ONDANSETRONRAN-ONDANSETRONRATIO-ONDANSETRONSANDOZ ONDANSETRONSEPTA-ONDANSETRONTEVA-ONDANSETRONZOFRAN

APO-ONDANSETRONCO ONDANSETRONJAMP-ONDANSETRONMAR-ONDANSETRONMINT-ONDANSETRONMYLAN-ONDANSETRONONDANSETRON-ODANPHL-ONDANSETRONPMS-ONDANSETRONRAN-ONDANSETRONRATIO-ONDANSETRONSANDOZ ONDANSETRONSEPTA-ONDANSETRONTEVA-ONDANSETRONZOFRAN

ONDANSETRONZOFRAN

ONDANSETRON OMEGA (PRESERVATIVE FREE)ZOFRAN

ONDANSETRON OMEGA (WITH PRESERVATIVE)ZOFRAN

APXCOBJPCMARMPIMYPODNPHHPMSRANRPHSDZSEPTEVGSK

APXCOBJPCMARMPIMYPODNPHHPMSRANRPHSDZSEPTEVGSK

AAPGSK

OMG

GSK

OMG

GSK


ANTIEMETICS

56:00

56:22.20

5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410 5.0410

13.3980

7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921 7.6921

20.4440

1.5710 2.0442

3.7143

9.8720

3.7143

9.8720


$$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$

$$

$

$

$

$

(5-HT3 RECEPTOR ANTAGONISTS)




APREPITANT

APREPITANT/ APREPITANT

DOXYLAMINE SUCCINATE/ PYRIDOXINE HCL

NABILONE

CIMETIDINE

80 MG ORAL CAPSULE

80 MG * 125 MG ORAL CAPSULE


0.5 MG ORAL CAPSULE

1 MG ORAL CAPSULE

200 MG ORAL TABLET

300 MG ORAL TABLET

400 MG ORAL TABLET

600 MG ORAL TABLET

800 MG ORAL TABLET

00002298791

00002298813

00000609129

000023809000000235808500002256193

000023809190000235809300000548375

00000584215

000004878720000222744400000582417

000006000590000222745200000603678

000006000670000222746000000603686

0000222747900000749494

EMEND

EMEND TRI-PACK

DICLECTIN

PMS-NABILONERAN-NABILONECESAMET

PMS-NABILONERAN-NABILONECESAMET

APO-CIMETIDINE

APO-CIMETIDINEMYLAN-CIMETIDINENOVO-CIMETINE



MYLAN-CIMETIDINEAPO-CIMETIDINE

MFC

MFC

DUI

PMSRANVCL

PMSRANVCL

APX

APXMYPTEV

APXMYPTEV

APXMYPTEV

MYPAPX



ANTIEMETICS

ANTIULCER AGENTS AND ACID SUPPRESSANTS

56

56

:00

:00

56:22.92

56:28.12

30.1800

30.1800

1.2471

1.1674 1.1674 3.1026

2.3346 2.3346 6.2050

0.0860

0.0860 0.0860 0.0860

0.1350 0.1350 0.1350

0.1702 0.1702 0.1702

0.2430 0.2530


$

$

$

$$$

$$$

$

$$$

$$$

$$$

$$

RESTRICTED BENEFIT - This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates).

RESTRICTED BENEFIT - This drug product must be prescribed by the Directors of Alberta Health Services - Cancer Care "Cancer Centres" (or their designates).

(MISCELLANEOUS ANTIEMETICS)

(HISTAMINE H2-ANTAGONISTS)



FAMOTIDINE

NIZATIDINE

RANITIDINE HCL

20 MG ORAL TABLET

40 MG ORAL TABLET

150 MG ORAL CAPSULE

300 MG ORAL CAPSULE



000019538420000237392000002351102000021960180000202213300000710121

000019538340000237393900002351110000021960260000202214100000710113

00002220156000022404570000217771400000778338

00002220164000022404580000217772200000778346

000007330590000224857000002367378000022077610000082856400002245782000022424530000233648000002353016000008288230000224322900002212331

0000073306700002248571000023673860000220778800000828556000022457830000224245400002336502000023530240000224323000002212358

APO-FAMOTIDINEAVA-FAMOTIDINEFAMOTIDINEMYLAN-FAMOTIDINENOVO-FAMOTIDINEPEPCID

APO-FAMOTIDINEAVA-FAMOTIDINEFAMOTIDINEMYLAN-FAMOTIDINENOVO-FAMOTIDINEPEPCID

APO-NIZATIDINENOVO-NIZATIDINEPMS-NIZATIDINEAXID

APO-NIZATIDINENOVO-NIZATIDINEPMS-NIZATIDINEAXID

APO-RANITIDINECO RANITIDINEMYL-RANITIDINEMYLAN-RANITIDINENOVO-RANIDINEPHL-RANITIDINEPMS-RANITIDINERAN-RANITIDINERANITIDINERATIO-RANITIDINESANDOZ RANITIDINEZANTAC

APO-RANITIDINECO RANITIDINEMYL-RANITIDINEMYLAN-RANITIDINENOVO-RANIDINEPHL-RANITIDINEPMS-RANITIDINERAN-RANITIDINERANITIDINESANDOZ RANITIDINEZANTAC

APXAVASNSMYPTEVMFC

APXAVASNSMYPTEVMFC

APXTEVPMSMMT

APXTEVPMSMMT

APXCOBMYPMYPTEVPHHPMSRANSNSRPHSDZGSK

APXCOBMYPMYPTEVPHHPMSRANSNSSDZGSK



56:00

56:28.12

0.3882 0.3882 0.3882 0.3882 0.3882 1.1092

0.7089 0.7089 0.7089 0.7089 0.7089 2.0254

0.3566 0.3566 0.3566 0.9478

0.6347 0.6347 0.6347 1.6870

0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800 0.1800

0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600 0.3600


$$$$$$

$$$$$$

$$$$

$$$$

$$$$$$$$$$$$

$$$$$$$$$$$





RANITIDINE HCL

MISOPROSTOL

SUCRALFATE



100 MCG ORAL TABLET

200 MCG ORAL TABLET

1 G ORAL TABLET


0000228083300002242940

0000225671100002212366

00002244022

00002244023

000021252500000204570200002100622

00002103567

APO-RANITIDINENOVO-RANIDINE

RANITIDINEZANTAC

MISOPROSTOL

MISOPROSTOL

APO-SUCRALFATENOVO-SUCRALATESULCRATE

SULCRATE SUSPENSION PLUS

APXTEV

SDZGSK

AAP

AAP

APXTEVAXC

AXC







56

56

56

:00

:00

:00

56:28.12

56:28.28

56:28.32

0.0932 0.0932

1.3310 1.4000

0.2584

0.4303

0.2148 0.2148 0.5710

0.1037


$$

$$

$

$

$$$

$


(PROSTAGLANDINS)

(PROTECTANTS)



LANSOPRAZOLE

LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/ CLARITHROMYCIN

OMEPRAZOLE

15 MG ORAL DELAYED RELEASE CAPSULE

30 MG ORAL DELAYED RELEASE CAPSULE

30 MG * 500 MG (BASE) * 500 MG ORAL TABLET/CAPSULE

10 MG ORAL CAPSULE/SUSTAINED RELEASE TABLET

20 MG ORAL CAPSULE/SUSTAINED RELEASE TABLET

0000229381100002357682000023538300000228051500002165503

0000229383800002357690000023538490000228052300002165511

00002238525

0000232942500002296438

00002230737

000022450580000232943300002295415

0000234869100002320851

00002310260

00002374870

00002260867

00002296446

0000084650300002190915

APO-LANSOPRAZOLELANSOPRAZOLEMYLAN-LANSOPRAZOLENOVO-LANSOPRAZOLEPREVACID

APO-LANSOPRAZOLELANSOPRAZOLEMYLAN-LANSOPRAZOLENOVO-LANSOPRAZOLEPREVACID

HP-PAC ( KIT )

MYLAN-OMEPRAZOLE (CAPSULE)SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE TABLET)

APO-OMEPRAZOLE (CAPSULE)MYLAN-OMEPRAZOLE (CAPSULE)NOVO-OMEPRAZOLE (DELAYED RELEASE TABLET)OMEPRAZOLE (CAPSULE)PMS-OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)PMS-OMEPRAZOLE DR (DELAYED RELEASETABLET)RAN-OMEPRAZOLE (DELAYED RELEASE TABLET)RATIO-OMEPRAZOLE (SUSTAINED-RELEASE TABLET)SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE CAPSULE)LOSEC (SUSTAINED-RELEASE TABLET)

APXSNSMYPTEVABB

APXSNSMYPTEVABB

ABB

MYPSDZ

AZC

APXMYPTEV

SNSPMS

PMS

RAN

RPH

SDZ

AZCAZC



56:00

56:28.36

0.7000 0.7000 0.7000 0.7000 2.0000

0.7000 0.7000 0.7000 0.7000 2.0000

84.2700

0.8167 0.8167

1.8200

0.7700 0.7700 0.7700

0.7700 0.7700

0.7700

0.7700

0.7700

0.7700

1.1000 2.2870


$$$$$

$$$$$

$

$$

$

$$$

$$

$

$

$

$

$$

Please note: For individuals who require alternative administration (capsules to be opened and intact delayed release granules to be sprinkled on applesauce and swallowed immediately or mixed in water or apple juice and administered through a nasogastric tube) application for coverage for the Prevacid brand may be made using the Drug Special Authorization Request Form (ABC 20061), indicating a requirement for alternative administration.

(PROTON-PUMP INHIBITORS)




PANTOPRAZOLE

RABEPRAZOLE SODIUM

DOMPERIDONE MALEATE

METOCLOPRAMIDE HCL





5 MG ORAL TABLET

10 MG ORAL TABLET

000022672330000229292000002363429000023004860000229958500002285487000023098660000237080800002307871000023050460000230108300002229453

00002345579000023108050000235651100002298074000023141770000229663200002243796

00002345587000023108130000235653800002298082000023141850000229664000002243797

0000210361300002364271000023504400000227866900002236466000022680780000191207000002157195

00002230431

00002230432

TECTAAPO-PANTOPRAZOLEAVA-PANTOPRAZOLECO PANTOPRAZOLEMYLAN-PANTOPRAZOLENOVO-PANTOPRAZOLEPANTOPRAZOLEPANTOPRAZOLEPMS-PANTOPRAZOLERAN-PANTOPRAZOLESANDOZ PANTOPRAZOLEPANTOLOC

APO-RABEPRAZOLEPMS-RABEPRAZOLE ECRABEPRAZOLE ECRAN-RABEPRAZOLESANDOZ RABEPRAZOLETEVA-RABEPRAZOLEPARIET

APO-RABEPRAZOLEPMS-RABEPRAZOLE ECRABEPRAZOLE ECRAN-RABEPRAZOLESANDOZ RABEPRAZOLETEVA-RABEPRAZOLEPARIET

APO-DOMPERIDONEAVA-DOMPERIDONEDOMPERIDONEMYLAN-DOMPERIDONEPMS-DOMPERIDONERAN-DOMPERIDONERATIO-DOMPERIDONE MALEATETEVA-DOMPERIDONE

PMS-METOCLOPRAMIDE

PMS-METOCLOPRAMIDE

NYCAPXAVACOBMYPTEVMELSNSPMSRANSDZNYC

APXPMSSNSRANSDZTEVJAI

APXPMSSNSRANSDZTEVJAI

APXAVASNSMYPPMSRANRPHTEV

PMS

PMS




PROKINETIC AGENTS

56

56

:00

:00

56:28.36

56:32

0.7500 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 0.7827 2.0803

0.2517 0.2517 0.2517 0.2517 0.2517 0.2517 0.6688

0.5033 0.5033 0.5033 0.5033 0.5033 0.5033 1.3377

0.0886 0.0886 0.0886 0.0886 0.0886 0.0886 0.0886 0.0886

0.0556

0.0583


$$$$$$$$$$$$

$$$$$$$

$$$$$$$

$$$$$$$$

$

$

(PROTON-PUMP INHIBITORS)



METOCLOPRAMIDE HCL

MESALAZINE

OLSALAZINE SODIUM

PINAVERIUM BROMIDE


5 MG / ML INJECTION






1 G RECTAL SUPPOSITORY

1,000 MG RECTAL SUPPOSITORY

1 G / ENM RECTAL ENEMA



250 MG ORAL CAPSULE

50 MG ORAL TABLET

100 MG ORAL TABLET

00002230433

00002185431

00002099683

0000217192900001997580

0000211278700001914030

00002267217

00002112760

00002153564

00002242146

00002153521

00002112795

0000215355600002112809

00002063808

00001950592

00002230684

PMS-METOCLOPRAMIDE

METOCLOPRAMIDE HYDROCHLORIDE

PENTASA

NOVO-5 ASAASACOL

SALOFALKMESASAL

ASACOL 800

SALOFALK

PENTASA

SALOFALK

PENTASA (1G/100ML)

SALOFALK (2G/60G)

PENTASA (4G/100 ML)SALOFALK (4G/60G)

DIPENTUM

DICETEL

DICETEL

PMS

SDZ

FEI

TEVWCC

AXCGSK

WCC

AXC

FEI

AXC

FEI

AXC

FEIAXC

UCB

ABB

ABB




PROKINETIC AGENTS


MISCELLANEOUS GI DRUGS

56

56

56

:00

:00

:00

56:32

56:36

56:92

0.0448

1.3163

0.5569

0.4039 0.5440

0.5375 0.6274

1.0575

1.1882

1.6000

1.7452

3.7000

3.8279

4.4600 6.5003

0.5300

0.3533

0.6160



$

$

$

$$

$$

$

$

$

$

$

$

$$

$

$

$




TRIMEBUTINE MALEATE100 MG ORAL TABLET

200 MG ORAL TABLET00002245663

0000224566400000803499

TRIMEBUTINE

TRIMEBUTINEMODULON

AAP

AAPAXC


MISCELLANEOUS GI DRUGS

56:00

56:92

0.2690

0.5628 0.6622


$

$$


60:00 Gold C

ompounds

60:00

Gold Compounds


AURANOFIN

GOLD SODIUM THIOMALATE

3 MG ORAL CAPSULE




00001916823

0000224545600001927620

00002245457

0000224545800001927604

RIDAURA

SODIUM AUROTHIOMALATEMYOCHRYSINE

SODIUM AUROTHIOMALATE

SODIUM AUROTHIOMALATEMYOCHRYSINE

XPI

SDZSAV

SDZ

SDZSAV

GOLD COMPOUNDS60:00

60:00

6.0141

9.6600 11.9000

10.9457

18.2100 22.4800


$

$$

$

$$


64:00 Heavy M

etal Antagonists

64:00

Heavy Metal Antagonists


DEFEROXAMINE MESYLATE

PENICILLAMINE



250 MG ORAL CAPSULE

000022420550000224160000001981242

000022434500000224702200001981250

00000016055

PMS-DEFEROXAMINEDESFERRIOXAMINE MESILATEDESFERAL

PMS-DEFEROXAMINEDESFERRIOXAMINE MESILATEDESFERAL

CUPRIMINE

PMSHSPNOV

PMSHSPNOV

VCL

HEAVY METAL ANTAGONISTS64:00

64:00

7.0600 7.5400

13.9862

28.3500 30.2900 56.1800

3.5767


$$$

$$$

$


68:00 Horm

ones and Synthetic Substitutes

68:00

Hormones and Synthetic Substitutes




BETAMETHASONE SODIUM PHOSPHATE/ BETAMETHASONE ACETATE

BUDESONIDE

CICLESONIDE

CORTISONE ACETATE



3 MG / ML (BASE) * 3 MG / ML INJECTION




0.125 MG / ML INHALATION SUSPENSION





25 MG ORAL TABLET

00000999111

00000999212

00002242029

00002242030

00000028096

00000852074

00000851752

00000851760

00002229099

00001978918

00001978926

00002285606

00002285614

00000280437

COMPOUND HORMONES (ESTROGEN PROGEST TESTOSTERONE)

COMPOUND HORMONES (ESTROGEN PROGEST TESTOSTERONE)

QVAR CFC-FREE

QVAR CFC-FREE

CELESTONE SOLUSPAN

PULMICORT TURBUHALER



PULMICORT NEBUAMP

PULMICORT NEBUAMP

PULMICORT NEBUAMP

ALVESCO

ALVESCO

CORTISONE ACETATE

XXX

XXX

MEP

MEP

MFC

AZC

AZC

AZC

AZC

AZC

AZC

NYC

NYC

VCL

HORMONES AND SYNTHETIC SUBSTITUTES


ADRENALS

68

68

:00

:00

68:00

68:04

0.0000

0.0000

0.1464

0.2928

10.3140

0.1545

0.3158

0.5568

0.2143

0.4285

0.8570

0.3713

0.6138

0.3200


$

$

$

$

$

$

$

$

$

$

$

$

$

$






DEXAMETHASONE

DEXAMETHASONE SODIUM PHOSPHATE

FLUDROCORTISONE ACETATE

FLUTICASONE PROPIONATE

HYDROCORTISONE

HYDROCORTISONE SODIUM SUCCINATE

0.5 MG ORAL TABLET

0.75 MG ORAL TABLET

2 MG ORAL TABLET

4 MG ORAL TABLET



0.1 MG ORAL TABLET






10 MG ORAL TABLET

20 MG ORAL TABLET




000022610810000196497600002240684

00001964968

00002279363

00001964070000022500550000224068700000489158

0000066422700001977547

0000078390000000874582

00002086026

00002244291

00002244292

00002244293

00002237246

00002237247

00000030910

00000030929

0000087252000000030600

0000087253900000030619

0000087861800000030627

APO-DEXAMETHASONEPMS-DEXAMETHASONERATIO-DEXAMETHASONE

PMS-DEXAMETHASONE

PMS-DEXAMETHASONE

PMS-DEXAMETHASONEAPO-DEXAMETHASONERATIO-DEXAMETHASONEDEXASONE

DEXAMETHASONE SODIUM PHOSPHATEDEXAMETHASONE SODIUM PHOSPHATE

PMS-DEXAMETHASONE SODIUM PHOSPDEXAMETHASONE SODIUM PHOSPHATE

FLORINEF

FLOVENT HFA

FLOVENT HFA

FLOVENT HFA

FLOVENT DISKUS

FLOVENT DISKUS

CORTEF

CORTEF

HYDROCORTISONE SOD. SUCCINATESOLU-CORTEF



APXPMSRPH

PMS

PMS

PMSAPXRPHVCL

SDZCYT

PMSSDZ

PAL

GSK

GSK

GSK

GSK

GSK

PFI

PFI

TEVPFI

TEVPFI

TEVPFI


ADRENALS

68:00

68:04

0.1094 0.1094 0.1094

0.4728

0.4389

0.4263 0.4264 0.4264 0.7877

1.6060 1.6900

1.2830 4.5600

0.2468

0.1994

0.3440

0.6880

0.6880

1.3757

0.1527

0.2756

2.3000 3.6102

3.9100 6.2642

5.8650 9.4679


$$$

$

$

$$$$

$$

$$

$

$

$

$

$

$

$

$

$$

$$

$$



HYDROCORTISONE SODIUM SUCCINATE

METHYLPREDNISOLONE

METHYLPREDNISOLONE ACETATE

METHYLPREDNISOLONE ACETATE/ LIDOCAINE HCL

METHYLPREDNISOLONE SODIUM SUCCINATE


4 MG ORAL TABLET

16 MG ORAL TABLET






40 MG / ML * 10 MG / ML INJECTION





0000087862600000030635

00000030988

00000036129

00001934325

0000224540000000030759

0000224540600000030767

0000224540700001934333

0000224540800001934341

00000260428

0000223189300002367947

0000223189400002367955

000022318950000003067800002367963

000022412290000003613700002063697

00002367971


MEDROL

MEDROL

DEPO-MEDROL

METHYLPREDNISOLONE ACETATEDEPO-MEDROL

METHYLPREDNISOLONE ACETATEDEPO-MEDROL

METHYLPREDNISOLONE ACETATE (P)DEPO-MEDROL (PRESERVED)

METHYLPREDNISOLONE ACETATE (P)DEPO-MEDROL (PRESERVED)

DEPO-MEDROL WITH LIDOCAINE

METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)

METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)

METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROLSOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)

METHYLPREDNISOLONE SOD SUCCIN.SOLU-MEDROLSOLU-MEDROL ACT-O-VIAL (WITH PRESERVATIVE)SOLU-MEDROL ACT-O-VIAL (PRESERVATIVEFREE)

TEVPFI

PFI

PFI

PFI

SDZPFI

SDZPFI

SDZPFI

SDZPFI

PFI

TEVPFI

TEVPFI

TEVPFIPFI

TEVPFIPFI

PFI


ADRENALS

68:00

68:04

9.8900 15.8656

0.3454

0.9954

2.3800

4.1000 5.3400

8.2000 10.3222

4.1000 5.1611

6.9900 7.8960

6.0398

3.9600 6.0710

9.3500 14.4130

22.2002 35.4112 36.1220

34.1000 54.2800 55.3697

55.3700


$$

$

$

$

$$

$$

$$

$$

$

$$

$$

$$$

$$$

$




PREDNISOLONE SODIUM PHOSPHATE

PREDNISONE

TRIAMCINOLONE ACETONIDE

DANAZOL

TESTOSTERONE CYPIONATE

TESTOSTERONE ENANTHATE


1 MG ORAL TABLET

5 MG ORAL TABLET

50 MG ORAL TABLET



50 MG ORAL CAPSULE

100 MG ORAL CAPSULE

200 MG ORAL CAPSULE



0000224553200002230619

0000027137300000598194

00000312770

00000550957

0000222954000001999761

000022295500000197756300001999869

00002018144

00002018152

00002018160

0000224606300000030783

00000029246

PMS-PREDNISOLONEPEDIAPRED

WINPREDAPO-PREDNISONE

APO-PREDNISONE

APO-PREDNISONE

TRIAMCINOLONE ACETONIDEKENALOG-10

TRIAMCINOLONE ACETONIDETRIAMCINOLONE ACETONIDE USPKENALOG-40

CYCLOMEN

CYCLOMEN

CYCLOMEN

TESTOSTERONE CYPIONATEDEPO-TESTOSTERONE CYPIONATE

DELATESTRYL

PMSSAV

VCLAPX

APX

APX

SDZWSD

SDZCYTWSD

SAV

SAV

SAV

SDZPFI

VCL



ADRENALS

ANDROGENS

68

68

:00

:00

68:04

68:08

0.0478 0.1270

0.1035 0.1072

0.0401

0.1735

2.4500 3.2423

4.7700 4.7700 7.5320

0.9047

1.3425

2.1453

2.3580 2.6977

9.5500


$$

$$

$

$

$$

$$$

$

$

$

$$

$



DESOGESTREL/ ETHINYL ESTRADIOL

DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL

DROSPIRENONE/ ETHINYL ESTRADIOL

ETHYNODIOL DIACETATE/ ETHINYL ESTRADIOL

LEVONORGESTREL

LEVONORGESTREL/ ETHINYL ESTRADIOL

LEVONORGESTREL/ ETHINYL ESTRADIOL/ LEVONORGESTREL/ETHINYL ESTRADIOL/ LEVONORGESTREL/ ETHINYL ESTRADIOL

NORETHINDRONE



0.1 MG * 0.025 MG * 0.125 MG * 0.025 MG * 0.15 MG * 0.025 MG ORAL TABLET



0.75 MG ORAL TABLET

52 MG INTRAUTERINE INSERT

100 MCG * 20 MCG ORAL TABLET




50 MCG * 30 MCG * 75 MCG * 40 MCG * 125 MCG * 30 MCG ORAL TABLET

0.35 MG ORAL TABLET

0000231719200002042487

000023172060000204247900002042533

0000225723800002272903

0000226173100002261723

0000047152600000469327

00002241674

00002243005

0000229853800002236974

0000229594600002042320

0000229854600002236975

0000229595400002042339

0000070750300000707600

00000037605

APRI 21MARVELON (21 DAY)

APRI 28MARVELON (28 DAY)ORTHO-CEPT (28 DAY)

LINESSA 28LINESSA 21

YASMIN 28YASMIN 21

DEMULEN 30 (28 DAY)DEMULEN 30 (21 DAY)

PLAN B

MIRENA SYSTEM

AVIANE 21ALESSE (21 DAY)

PORTIA 21MIN-OVRAL (21 DAY)

AVIANE 28ALESSE (28 DAY)

PORTIA 28MIN-OVRAL (28 DAY)

TRIQUILAR (28 DAY)TRIQUILAR (21 DAY)

MICRONOR (28 DAY)

BARMFC

BARMFCJAI

MFCMFC

BAIBAI

PFIPFI

DUR

BHP

BARWAY

BARWAY

BARWAY

BARWAY

BHPBHP

JAI


CONTRACEPTIVES

68:00

68:12

0.5436 0.6586

0.4077 0.4939 0.6098

0.4678 0.6238

0.4229 0.5640

0.4732 0.5898

8.6000

329.6100

0.4636 0.7029

0.4636 0.7029

0.3477 0.5271

0.3477 0.5271

0.5236 0.6981

0.6098



$$

$$$

$$

$$

$$

$

$

$$

$$

$$

$$

$$

$




NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL

NORETHINDRONE/ ETHINYL ESTRADIOL

NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL

NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL

NORGESTIMATE/ ETHINYL ESTRADIOL

NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL





0.5 MG * 0.035 MG * 1 MG * 0.035 MG ORAL TABLET

0.5 MG * 0.035 MG * 0.75 MG * 0.035 MG * 1 MG * 0.035 MG ORAL TABLET




0000034383800000315966

0000035302700000297143

00002187094000021870860000034073100000317047

000021992970000219750200002189062000021890540000037283800000372846

0000218711600002187108

0000060296500000602957

0000199287200001968440

0000225858700002258560

0000202942100002028700

MINESTRIN 1/20 (28 DAY)MINESTRIN 1/20 (21 DAY)

LOESTRIN 1.5/30 (28 DAY)LOESTRIN 1.5/30 (21 DAY)

BREVICON 0.5/35 (28 DAY)BREVICON 0.5/35 (21 DAY)ORTHO 0.5/35 (28 DAY)ORTHO 0.5/35 (21 DAY)

SELECT 1/35 (28 DAY)SELECT 1/35 (21 DAY)BREVICON 1/35 (28 DAY)BREVICON 1/35 (21 DAY)ORTHO 1/35 (28 DAY)ORTHO 1/35 (21 DAY)

SYNPHASIC (28 DAY)SYNPHASIC (21 DAY)

ORTHO 7/7/7 (28 DAY)ORTHO 7/7/7 (21 DAY)

CYCLEN (28 DAY)CYCLEN (21 DAY)

TRI-CYCLEN LO 28TRI-CYCLEN LO 21

TRI-CYCLEN (28 DAY)TRI-CYCLEN (21 DAY)

PALPAL

PALPAL

PFIPFIJAIJAI

PFIPFIPFIPFIJAIJAI

PFIPFI

JAIJAI

JAIJAI

JAIJAI

JAIJAI


CONTRACEPTIVES

68:00

68:12

0.4653 0.6205

0.4653 0.6205

0.4054 0.5405 0.6098 0.8131

0.2737 0.3651 0.4054 0.5405 0.6098 0.8131

0.3725 0.4967

0.6098 0.8131

0.6098 0.8131

0.4383 0.5843

0.6098 0.8131


$$

$$

$$$$

$$$$$$

$$

$$

$$

$$

$$



CONJUGATED ESTROGENS

ESTRADIOL-17B

0.3 MG ORAL TABLET


1.25 MG ORAL TABLET

0.625 MG / G VAGINAL CREAM

0.5 MG ORAL TABLET

1 MG ORAL TABLET

2 MG ORAL TABLET

0.06 % TRANSDERMAL GEL

25 MCG/DAY TRANSDERMAL PATCH

37.5 MCG/DAY TRANSDERMAL PATCH




10 MCG VAGINAL TABLET

25 MCG VAGINAL TABLET

2 MG VAGINAL SLOW-RELEASE RING

00002043394

0000026547000002043408

00002043424

00002043440

00002225190

00002148587

00002148595

00002238704

00002245676000022437220000075684900002247499

00002243999

00002246967000022437240000224400000002231509

000022469680000224400100002247500

00002246969000022440020000075679200002231510

00002325462

00002241332

00002168898

PREMARIN

C.E.S.PREMARIN

PREMARIN

PREMARIN

ESTRACE

ESTRACE

ESTRACE

ESTROGEL

ESTRADOT 25 (0.39 MG/PTH)OESCLIM 25 (5 MG/PTH)ESTRADERM-25 (2 MG/PTH)CLIMARA 25 (2 MG/PTH)

ESTRADOT 37.5 (0.585 MG/PTH)

SANDOZ ESTRADIOL DERM 50 (4 MG/PTH)OESCLIM 50 (10 MG/PTH)ESTRADOT 50 (0.78 MG/PTH)CLIMARA 50 (3.9 MG/PTH)

SANDOZ ESTRADIOL DERM 75 (6 MG/PTH)ESTRADOT 75 (1.17 MG/PTH)CLIMARA 75 (5.7 MG/PTH)

SANDOZ ESTRADIOL DERM 100 (8 MG/PTH)ESTRADOT 100 (1.56 MG/PTH)ESTRADERM-100 (8.0 MG/PTH)CLIMARA 100 (7.8 MG/PTH)

VAGIFEM

VAGIFEM

ESTRING

WAY

VCLWAY

WAY

WAY

SHB

SHB

SHB

MFC

NOVTPINOVBHP

NOV

SDZTPINOVBHP

SDZNOVBHP

SDZNOVNOVBHP

NNA

NNA

PAL


ESTROGENS AND ANTIESTROGENS

68:00

68:16.04

0.2900

0.1014 0.2900

0.2900

0.6270

0.1287

0.2486

0.4390

0.3134

2.6098 2.6312 3.3238 4.9175

2.6278

2.1000 2.6397 2.7994 5.2525

2.2375 3.0026 5.6000

2.3375 3.1724 4.0113 5.9225

3.2133

3.2133

65.3934



$

$$

$

$

$

$

$

$

$$$$

$

$$$$

$$$

$$$$

$

$

$

(ESTROGENS)




NORETHINDRONE ACETATE/ ESTRADIOL-17B

CLOMIPHENE CITRATE

ACARBOSE

140 MCG/DAY * 50 MCG/DAY TRANSDERMAL PATCH

250 MCG/DAY * 50 MCG/DAY TRANSDERMAL PATCH

50 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET

00002241835

00002241837

0000089372200002091879

00002190885

00002190893

ESTALIS (2.7*.62 MG/PTH)

ESTALIS (4.8*.51 MG/PTH)

SEROPHENECLOMID

GLUCOBAY

GLUCOBAY

NOV

NOV

SROSAV

BAI

BAI






ANTIDIABETIC AGENTS

68

68

68

:00

:00

:00

68:16.04

68:16.12

68:20.02

3.0856

3.0856

4.9882 5.5608

0.2642

0.3659


$

$

$$

$

$

(ESTROGENS)

(ESTROGEN AGONISTS-ANTAGONISTS)

(ALPHA-GLUCOSIDASE INHIBITORS)



METFORMIN HCL

INSULIN ASPART

INSULIN DETEMIR

INSULIN GLARGINE

500 MG ORAL TABLET

850 MG ORAL TABLET

100 UNIT / ML INJECTION



0000216778600002364506000022577260000237862000002242794000023533770000237884100002148765000020457100000222356200002269031000022429740000224682000002099233

000023645140000225773400002378639000023533850000237886800002229656000022304750000224258900002269058000022429310000224682100002162849

0000224539700002244353

00002271842

000022456890000225193000002294338

APO-METFORMINAVA-METFORMINCO METFORMINMAR-METFORMINMETFORMINMETFORMINMETFORMINMYLAN-METFORMINNOVO-METFORMINPMS-METFORMINRAN-METFORMINRATIO-METFORMIN HYDROCHLORIDESANDOZ METFORMIN FCGLUCOPHAGE

AVA-METFORMINCO METFORMINMAR-METFORMINMETFORMINMETFORMINMYLAN-METFORMINNOVO-METFORMINPMS-METFORMINRAN-METFORMINRATIO-METFORMIN HYDROCHLORIDESANDOZ METFORMIN FCGLUCOPHAGE

NOVORAPIDNOVORAPID CARTRIDGE

LEVEMIR CARTRIDGE

LANTUSLANTUS CARTRIDGELANTUS PEN

APXAVACOBMARMELSNSMARMYPTEVPMSRANRPHSDZSAV

AVACOBMARSNSMARMYPTEVPMSRANRPHSDZSAV

NNANNA

NNA

SAVSAVSAV



ANTIDIABETIC AGENTS

ANTIDIABETIC AGENTS

68

68

:00

:00

68:20.04

68:20.08

0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.1022 0.2716

0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.1331 0.3538

2.7920 3.7733

6.6787

5.9820 6.0027 6.0027



$$$$$$$$$$$$$$

$$$$$$$$$$$$

$$

$

$$$

(BIGUANIDES)

(INSULINS)




INSULIN GLULISINE (RDNA ORIGIN)

INSULIN HUMAN BIOSYNTHETIC (ISOPHANE)

INSULIN HUMAN BIOSYNTHETIC (REGULAR)

INSULIN HUMAN BIOSYNTHETIC (REGULAR)/ INSULIN HUMAN BIOSYNTHETIC (ISOPHANE)

INSULIN LISPRO

INSULIN LISPRO/ INSULIN LISPRO PROTAMINE




30 UNIT / ML * 70 UNIT / ML INJECTION




25 % * 75 % INJECTION

50 % * 50 % INJECTION

000022794600000227947900002294346

00000587737000020242250000195923900002024268

00000586714000020242330000195922000002024284

00000795879000020242170000195921200002025248

00002024314

00002024322

0000222970400002229705

00002240294

00002240297

APIDRAAPIDRA CARTRIDGEAPIDRA PEN

HUMULIN NNOVOLIN GE NPHHUMULIN N CARTRIDGE/KWIKPENNOVOLIN GE NPH CARTRIDGE

HUMULIN RNOVOLIN GE TORONTOHUMULIN R CARTRIDGENOVOLIN GE TORONTO CARTRIDGE

HUMULIN 30/70NOVOLIN GE 30/70HUMULIN 30/70 CARTRIDGENOVOLIN GE 30/70 CARTRIDGE

NOVOLIN GE 40/60 CARTRIDGE

NOVOLIN GE 50/50 CARTRIDGE

HUMALOGHUMALOG CARTRIDGE/KWIKPEN

HUMALOG MIX 25 CARTRIDGE/KWIKPEN

HUMALOG MIX 50 CARTRIDGE/KWIKPEN

SAVSAVSAV

LILNNALILNNA

LILNNALILNNA

LILNNALILNNA

NNA

NNA

LILLIL

LIL

LIL


ANTIDIABETIC AGENTS

68:00

68:20.08

2.4500 3.2300 3.2667

2.1666 2.1930 2.8350 2.8580

2.1666 2.1930 2.8350 2.8687

2.1666 2.1930 2.8350 2.8553

2.9240

2.9240

2.7110 3.6300

3.6300

3.6299


$$$

$$$$

$$$$

$$$$

$

$

$$

$

$

(INSULINS)



REPAGLINIDE

GLICLAZIDE

0.5 MG ORAL TABLET

1 MG ORAL TABLET

2 MG ORAL TABLET

80 MG ORAL TABLET



0000235566300002321475000023549260000235745300002239924

0000235567100002321483000023549340000235746100002239925

0000235569800002321491000023549420000235748800002239926

000022452470000236351800002287072000022295190000223810300000765996

0000224298700002297795

00002356422

APO-REPAGLINIDECO REPAGLINIDEPMS-REPAGLINIDESANDOZ REPAGLINIDEGLUCONORM



APO-GLICLAZIDEAVA-GLICLAZIDEGLICLAZIDEMYLAN-GLICLAZIDENOVO-GLICLAZIDEDIAMICRON

DIAMICRON MRGLICLAZIDE MR

DIAMICRON MR

APXCOBPMSSDZNNA

APXCOBPMSSDZNNA

APXCOBPMSSDZNNA

APXAVASNSMYPTEVSEV

SEVAAP

SEV



ANTIDIABETIC AGENTS

ANTIDIABETIC AGENTS

68

68

:00

:00

68:20.16

68:20.20

0.1094 0.1094 0.1094 0.1094 0.3126

0.1138 0.1138 0.1138 0.1138 0.3250

0.1182 0.1182 0.1182 0.1182 0.3376

0.1401 0.1401 0.1401 0.1401 0.1401 0.3725

0.1405 0.1510

0.2529


$$$$$

$$$$$

$$$$$

$$$$$$

$$

$

(MEGLITINIDES)

(SULFONYLUREAS)




GLYBURIDE

GLUCAGON, RDNA ORIGIN

SYNTHETIC CALCITONIN SALMON (SALCATONIN)

COSYNTROPIN ZINC HYDROXIDE COMPLEX

2.5 MG ORAL TABLET

5 MG ORAL TABLET


100 IU / ML INJECTION

200 IU / ML INJECTION


0000191365400002363704000023504590000080873300001900927000022480080000191367000002224550

000019136620000236371200002350467000008087410000223673400001900935000022480090000191368900002224569

000023336190000233362700002243297

00002007134

00001926691

00000253952

APO-GLYBURIDEAVA-GLYBURIDEGLYBURIDEMYLAN-GLYBERATIO-GLYBURIDESANDOZ GLYBURIDETEVA-GLYBURIDEDIABETA

APO-GLYBURIDEAVA-GLYBURIDEGLYBURIDEMYLAN-GLYBEPMS-GLYBURIDERATIO-GLYBURIDESANDOZ GLYBURIDETEVA-GLYBURIDEDIABETA

GLUCAGENGLUCAGEN HYPOKITGLUCAGON

CALTINE 100 (100 IU/ML)

CALCIMAR

SYNACTHEN DEPOT

APXAVASNSMYPRPHSDZTEVSAV

APXAVASNSMYPPMSRPHSDZTEVSAV

NPANPALIL

FEI

SAV

NOV





ANTIDIABETIC AGENTS

ANTIHYPOGLYCEMIC AGENTS

PARATHYROID

PITUITARY

68

68

68

68

:00

:00

:00

:00

68:20.20

68:22.12

68:24

68:28

0.0393 0.0393 0.0393 0.0393 0.0393 0.0393 0.0393 0.1337

0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.0683 0.2393

77.7150 77.7150 86.3500

7.8200

27.6250

32.2797


$$$$$$$$

$$$$$$$$$

$$$

$

$

$

(SULFONYLUREAS)

(GLYCOGENOLYTIC AGENTS)



DESMOPRESSIN ACETATE

MEDROXYPROGESTERONE ACETATE

PROGESTERONE

0.1 MG ORAL TABLET

0.2 MG ORAL TABLET



0.1 MG / ML NASAL SOLUTION


2.5 MG ORAL TABLET

5 MG ORAL TABLET

10 MG ORAL TABLET

100 MG ORAL TABLET



100 MG ORAL CAPSULE


00002284030000022877300000230436800000824305

00002284049000022877490000230437600000824143

0000224246500000836362

00002237860

00000402516

00000873993

0000222128400000708917

0000222129200000030937

0000222130600000729973

00002267640

00000030848

0000232225000000585092

00002166704

00001977652

APO-DESMOPRESSINNOVO-DESMOPRESSINPMS-DESMOPRESSINDDAVP

APO-DESMOPRESSINNOVO-DESMOPRESSINPMS-DESMOPRESSINDDAVP

DESMOPRESSINDDAVP

OCTOSTIM

DDAVP

DDAVP

NOVO-MEDRONEPROVERA

NOVO-MEDRONEPROVERA

NOVO-MEDRONEPROVERA

APO-MEDROXY

DEPO-PROVERA

MEDROXYPROGESTERONE ACETATEDEPO-PROVERA

PROMETRIUM

PROGESTERONE

APXTEVPMSFEI

APXTEVPMSFEI

AAPFEI

FEI

FEI

FEI

TEVPFI

TEVPFI

TEVPFI

APX

PFI

SDZPFI

MFC

CYT



PITUITARY

PROGESTINS

68

68

:00

:00

68:28

68:32

0.4973 0.4973 0.4973 1.3217

0.9945 0.9945 0.9945 2.6433

1.5222 1.8880

15.4400

18.8800

10.0600

0.0615 0.1635

0.1216 0.3232

0.2468 0.6559

1.2057

5.3388

22.0000 27.5429

1.0910

5.8605


$$$$

$$$$

$$

$

$

$

$$

$$

$$

$

$

$$

$

$




DESSICATED THYROID

LEVOTHYROXINE SODIUM

LIOTHYRONINE SODIUM

30 MG ORAL TABLET

60 MG ORAL TABLET

125 MG ORAL TABLET


0.05 MG ORAL TABLET



0.1 MG ORAL TABLET




0.15 MG ORAL TABLET


0.2 MG ORAL TABLET

0.3 MG ORAL TABLET

5 MCG (BASE) ORAL TABLET

25 MCG (BASE) ORAL TABLET

00000023949

00000023957

00000023965

00002172062

0000221319200002172070

00002172089

00002172097

0000221320600002172100

00002171228

00002172119

00002233852

0000221321400002172127

00002172135

0000221322200002172143

00002172151

00001919458

00001919466

THYROID

THYROID

THYROID

SYNTHROID

ELTROXINSYNTHROID

SYNTHROID

SYNTHROID

ELTROXINSYNTHROID

SYNTHROID

SYNTHROID

SYNTHROID

ELTROXINSYNTHROID

SYNTHROID

ELTROXINSYNTHROID

SYNTHROID

CYTOMEL

CYTOMEL

ERF

ERF

ERF

ABB

TPIABB

ABB

ABB

TPIABB

ABB

ABB

ABB

TPIABB

ABB

TPIABB

ABB

KNG

KNG


THYROID AND ANTITHYROID AGENTS

68:00

68:36.04

0.0535

0.0656

0.0941

0.0865

0.0288 0.0594

0.0935

0.0935

0.0354 0.0732

0.0987

0.0999

0.1687

0.0392 0.0784

0.1071

0.0415 0.0837

0.1154

0.9819

1.0673


$

$

$

$

$$

$

$

$$

$

$

$

$$

$

$$

$

$

$

(THYROID AGENTS)



METHIMAZOLE

PROPYLTHIOURACIL

5 MG ORAL TABLET

50 MG ORAL TABLET

100 MG ORAL TABLET

00000015741

00000010200

00000010219

TAPAZOLE

PROPYL-THYRACIL

PROPYL-THYRACIL

PAL

PAL

PAL


THYROID AND ANTITHYROID AGENTS

68:00

68:36.08

0.2503

0.2160

0.3380


$

$

$

(ANTITHYROID AGENTS)


80:00 Serums, Toxoids and Vaccines

80:00

Serums, Toxoids and Vaccines


ALLERGY SERUM

HEPATITIS B VACCINE (RECOMBINANT)

INJECTION



00000999981

00000749486

00001919431

ALLERGY SERUM

RECOMBIVAX-HB

ENGERIX-B

XXX

MFC

GSK

SERUMS, TOXOIDS, AND VACCINES

SERUMS, TOXOIDS, AND VACCINES

SERUMS

VACCINES

80

80

:00

:00

80:04

80:12

0.0000

21.3500

21.1900


$

$

$


84:00 Skin and Mucous M

embrane A

gents

84:00

Skin and Mucous Membrane Agents




FUSIDIC ACID

GENTAMICIN SULFATE

METRONIDAZOLE

TOPICAL

TOPICAL

TOPICAL

TOPICAL

2 % TOPICAL CREAM

0.1 % (BASE) TOPICAL CREAM

0.1 % (BASE) TOPICAL OINTMENT


1 % TOPICAL CREAM

0.75 % TOPICAL LOTION

1 % TOPICAL GEL

00000999119

00000999112

00000999219

00000999213

00000999103

00000999203

00000586668

00000805386

00000805025

00002226839

0000224291900002156091

00002248206

00002297809

COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL)MISCELLANEOUS TOPICAL COMPOUND

COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL)MISCELLANEOUS TOPICAL COMPOUND

COMPOUND-ANTI-INFECTIVE (TOPICAL)

COMPOUND-ANTI-INFECTIVE (TOPICAL)

FUCIDIN

RATIO-GENTAMICIN SULFATE

RATIO-GENTAMICIN SULFATE

METROCREAM

ROSASOLNORITATE

METROLOTION

METROGEL

XXX

XXX

XXX

XXX

XXX

XXX

LEO

RPH

RPH

GAL

GSKVCL

GAL

GAL

SKIN AND MUCOUS MEMBRANE AGENTS



ANTI-INFECTIVES

ANTI-INFECTIVES

84

84

84

:00

:00

:00

84:00

84:04

84:04.04

0.0000

0.0000

0.0000

0.0000

0.0000

0.0000

0.6122

0.4425

0.4273

0.5183

0.5203 0.5409

0.5183

0.6285



$

$

$

$

$

$

$

$

$

$

$$

$

$





(ANTIBACTERIALS)




METRONIDAZOLE

METRONIDAZOLE/ NYSTATIN

MUPIROCIN

NEOMYCIN SULFATE/ POLYMYXIN B SULFATE

SODIUM FUSIDATE

TERBINAFINE HCL

KETOCONAZOLE

10 % VAGINAL CREAM

100 MG / G * 20,000 UNIT / G VAGINAL CREAM

500 MG * 100,000 UNIT VAGINAL OVULE

2 % TOPICAL CREAM


40 MG / ML (BASE) * 200,000 UNIT / ML IRRIGATION SOLUTION


1 % TOPICAL CREAM

1 % TOPICAL SOLUTION

2 % TOPICAL CREAM

00001926861

00001926845

00001926829

00002239757

0000227998300001916947

00000666157

00000586676

00002031094

00002238703

00002245662

FLAGYL

FLAGYSTATIN

FLAGYSTATIN

BACTROBAN

TARO-MUPIROCINBACTROBAN

NEOSPORIN

FUCIDIN

LAMISIL

LAMISIL

KETODERM

SAV

SAV

SAV

GKC

TARGKC

GSK

LEO

NOV

NOV

TPT

(ALLYLAMINES)

(AZOLES)




ANTI-INFECTIVES

ANTI-INFECTIVES

ANTI-INFECTIVES

84

84

84

:00

:00

:00

84:04.04

84:04.08.04

84:04.08.08

0.2322

0.5678

3.1230

0.5481

0.3453 0.5481

1.6862

0.6122

0.5184

0.5262

0.3268


$

$

$

$

$$

$

$

$

$

$

(ANTIBACTERIALS)

ANTIFUNGALS

ANTIFUNGALS



CICLOPIROX OLAMINE

AMCINONIDE


BETAMETHASONE DIPROPIONATE

BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID

1 % TOPICAL CREAM

0.1 % TOPICAL CREAM



250 MCG / G TOPICAL CREAM


0.05 % (BASE) TOPICAL GLYCOL CREAM


0.05 % (BASE) TOPICAL GLYCOL OINTMENT

0.05 % (BASE) TOPICAL LOTION

0.05 % (BASE) TOPICAL GLYCOL LOTION

0.5 MG / G (BASE) * 30 MG / G TOPICAL OINTMENT

0.5 MG / ML (BASE) * 20 MG / ML TOPICAL LOTION

00002221802

000022470980000224671400002192284

0000224709600002192268

0000224709700002192276

00002089602

0000080499100000323071

0000068862200000849650

0000034492300000805009

0000062936700000849669

0000041724600000809187

0000086297500001927914

00000578436

0000224568800000578428

LOPROX

RATIO-AMCINONIDETARO-AMCINONIDECYCLOCORT

RATIO-AMCINONIDECYCLOCORT

RATIO-AMCINONIDECYCLOCORT

PROPADERM

RATIO-TOPISONEDIPROSONE

DIPROLENE GLYCOLRATIO-TOPILENE

DIPROSONERATIO-TOPISONE


DIPROSONERATIO-TOPISONE


DIPROSALIC

RATIO-TOPISALICDIPROSALIC

VCL

RPHTARGSK

RPHGSK

RPHGSK

PAL

RPHMFC

MFCRPH

MFCRPH

MFCRPH

MFCRPH

MFCRPH

MFC

RPHMFC

(HYDROXYPYRIDONES)



ANTI-INFECTIVES


84

84

:00

:00

84:04.08.20

84:06

0.4731

0.2099 0.2099 0.5580

0.4199 0.5580

0.3533 0.4695

0.4371

0.2046 0.2048

0.5186 0.5186

0.2152 0.2153

0.5186 0.5186

0.1980 0.1980

0.2697 0.2697

0.8371

0.3698 0.4158


$

$$$

$$

$$

$

$$

$$

$$

$$

$$

$$

$

$$

ANTIFUNGALS




BETAMETHASONE SODIUM PHOSPHATE

BETAMETHASONE VALERATE

BUDESONIDE

CLOBETASOL 17-PROPIONATE


5 MG / ENM (BASE) RECTAL ENEMA



0.1 % (BASE) TOPICAL OCCLUSIVE CREAM





0.1 % (BASE) SCALP LOTION

2.3 MG / ENM RECTAL ENEMA



0.05 % SCALP LOTION

TOPICAL

TOPICAL

00002060884

0000071661800000535427

0000071662600000535435

00000804541

00000716642

00000716650

00000653209

00000750050

0000065321700000027944

00002052431

00002093162000019102720000224552300002213265

00002126192000019102800000224552400002213273

0000224552200002213281

00000999107

00000999207

BETNESOL (5MG/100ML)

BETADERM MILDRATIO-ECTOSONE MILD

BETADERM REGULARRATIO-ECTOSONE REGULAR

PREVEX B

BETADERM MILD

BETADERM REGULAR

RATIO-ECTOSONE MILD

RATIO-ECTOSONE REGULAR

RATIO-ECTOSONE SCALPVALISONE SCALP

ENTOCORT (115 ML)

NOVO-CLOBETASOLRATIO-CLOBETASOLTARO-CLOBETASOLDERMOVATE

NOVO-CLOBETASOLRATIO-CLOBETASOLTARO-CLOBETASOLDERMOVATE

TARO-CLOBETASOLDERMOVATE

COMPOUND-CORTICOSTEROIDS - TOPICAL

COMPOUND-CORTICOSTEROIDS - TOPICAL

PAL

TARRPH

TARRPH

GSK

TAR

TAR

RPH

RPH

RPHVLP

AZC

TEVRPHTARTPT

TEVRPHTARTPT

TARTPT

XXX

XXX



84:00

84:06

9.5145

0.0606 0.0606

0.0903 0.0903

0.3600

0.0625

0.0932

0.2530

0.3125

0.0853 0.0853

8.2400

0.2470 0.2470 0.2470 0.6721

0.2470 0.2470 0.2470 0.6721

0.2156 0.5867

0.0000

0.0000


$

$$

$$

$

$

$

$

$

$$

$

$$$$

$$$$

$$

$

$





DESONIDE

DESOXIMETASONE

DIFLUCORTOLONE VALERATE

FLUOCINONIDE

HALOBETASOL PROPIONATE

HYDROCORTISONE





0.1 % TOPICAL CREAM



0.05 % TOPICAL EMOLLIENT CREAM


0.05 % TOPICAL GEL


1 % TOPICAL CREAM

2.5 % TOPICAL CREAM

1 % TOPICAL OCCLUSIVE CREAM



1 % TOPICAL LOTION


100 MG / ENM RECTAL ENEMA

00002229315

00002229323

00002221918

00002221896

0000058782600000587818

00000587834

00000716863

00000598933

00002236996

00002236997

00001962701

00000192597

00000595799

00000804533

00000716685

00000716693

0000057854100000192600

0000085671100000595802

0000023031600002112736

PMS-DESONIDE

PMS-DESONIDE

TOPICORT MILD

TOPICORT

NERISONENERISONE OILY

NERISONE

LYDERM

TIAMOL

LYDERM

LYDERM

ULTRAVATE

EMO-CORT

EMO-CORT

PREVEX HC

CORTODERM MILD

CORTODERM REGULAR

SARNA HCEMO-CORT

SARNA HCEMO-CORT

HYCORT (100MG/60ML)CORTENEMA (100MG/60ML)

PMS

PMS

VCL

VCL

GSKGSK

GSK

TPT

TPT

TPT

TPT

VCL

GSK

GSK

GSK

TAR

TAR

GSKGSK

GSKGSK

VCLAXC



84:00

84:06

0.3085

0.2992

0.4670

0.6730

0.3943 0.3947

0.3943

0.2700

0.2511

0.3478

0.3527

0.8590

0.1718

0.2347

0.2677

0.1404

0.0402

0.0938 0.1587

0.1813 0.2100

5.2786 6.7194



$

$

$

$

$$

$

$

$

$

$

$

$

$

$

$

$

$$

$$

$$




HYDROCORTISONE 17-VALERATE

HYDROCORTISONE ACETATE

HYDROCORTISONE ACETATE/ PRAMOXINE HCL

HYDROCORTISONE ACETATE/ PRAMOXINE HCL/ ZINC SULFATE

HYDROCORTISONE ACETATE/ UREA

HYDROCORTISONE ACETATE/ ZINC SULFATE

MOMETASONE FUROATE

0.2 % TOPICAL CREAM


0.5 % TOPICAL CREAM

1 % TOPICAL CREAM

10 % RECTAL FOAM

1 % * 1 % RECTAL FOAM

10 MG * 20 MG * 10 MG RECTAL SUPPOSITORY

0.5 % * 1 % * 0.5 % RECTAL OINTMENT

1 % * 10 % TOPICAL CREAM

1 % * 10 % TOPICAL LOTION

10 MG * 10 MG RECTAL SUPPOSITORY

0.5 % * 0.5 % RECTAL OINTMENT

0.1 % TOPICAL CREAM



00002242984

00002242985

00000716820

00000716839

00000579335

00000363014

0000224085100002242797

0000223446600002247692

00000503134

00000560022

000006077970000224279800002236399

000006077890000224769100002128446

0000236715700000851744

000022481300000226474900000851736

0000226638500000871095

HYDROVAL

HYDROVAL

HYDERM

HYDERM

CORTIFOAM

PROCTOFOAM-HC

PROCTODAN-HCSANDOZ ANUZINC HC PLUS

PROCTODAN-HCSANDOZ ANUZINC HC PLUS

UREMOL-HC

UREMOL-HC

RATIO-HEMCORT H.C.SANDOZ ANUZINC HCANODAN-HC

RATIO-HEMCORT H.C.SANDOZ ANUZINC HCANODAN-HC

TARO-MOMETASONEELOCOM

RATIO-MOMETASONETARO-MOMETASONEELOCOM

TARO-MOMETASONEELOCOM

TPT

TPT

TAR

TAR

PAL

DUI

ODNSDZ

ODNSDZ

GSK

GSK

RPHSDZODN

RPHSDZODN

TARMFC

RPHTARMFC

TARMFC



84:00

84:06

0.1250

0.1250

0.1720

0.0376

6.1365

1.6572

0.7826 1.0875

0.5218 0.7320

0.1746

0.0971

0.5833 0.5833 0.6075

0.3850 0.3850 0.4130

0.2379 0.6796

0.2253 0.2720 0.6112

0.3124 0.4556


$

$

$

$

$

$

$$

$$

$

$

$$$

$$$

$$

$$$

$$



TRIAMCINOLONE ACETONIDE

BETAMETHASONE DIPROPIONATE/ CLOTRIMAZOLE


HYDROCORTISONE/ CINCHOCAINE HCL/ FRAMYCETIN SULFATE/ ESCULIN

LIDOCAINE

0.1 % TOPICAL CREAM

0.5 % TOPICAL CREAM


0.1 % DENTAL PASTE

0.05 % (BASE) * 1 % TOPICAL CREAM

5 MG * 5 MG * 10 MG * 10 MG RECTAL SUPPOSITORY

5 MG / G * 5 MG / G * 10 MG / G * 10 MG / G RECTAL OINTMENT


0000071696000002194058

00002194066

00002194031

00001964054

00000611174

00000999110

00000999211

000022263910000224788200002242528

00002226383000022473220000224252700002223252

0000208379500000001961

TRIADERM REGULARARISTOCORT R

ARISTOCORT C

ARISTOCORT R

ORACORT

LOTRIDERM

COMBINATION ANTI-INFECTIVE /CORTICOSTEROID

COMBINATION ANTI-INFECTIVE /CORTICOSTEROID

RATIO-PROCTOSONEPROCTOLSANDOZ PROCTOMYXIN HC

RATIO-PROCTOSONEPROCTOLSANDOZ PROCTOMYXIN HCPROCTOSEDYL

LIDODANXYLOCAINE

TARVLP

VLP

VLP

TAR

MFC

XXX

XXX

RPHODNSDZ

RPHODNSDZAXC

ODNAZC






ANTIPRURITICS AND LOCAL ANESTHETICS

84

84

84

:00

:00

:00

84:06

84:06.00

84:08

0.0650 0.1300

1.1523

0.1335

1.1146

0.7295

0.0000

0.0000

0.6000 0.6487 0.6487

0.4000 0.4577 0.4577 0.7823

0.1548 0.2714


$$

$

$

$

$

$

$

$$$

$$$$

$$



(COMBINATION ANTI-INFECTIVE/ANTI-INFLAMMATORY AGENTS)




LIDOCAINE HCL


METHOXSALEN

5-FLUOROURACIL

ACITRETIN

AMINOBENZOATE POTASSIUM

AZELAIC ACID

2 % TOPICAL JELLY

TOPICAL

TOPICAL

10 MG ORAL CAPSULE

10 MG / ML TOPICAL LOTION

50 MG / G TOPICAL CREAM

10 MG ORAL CAPSULE

25 MG ORAL CAPSULE

500 MG ORAL TABLET

500 MG ORAL CAPSULE

15 % TOPICAL GEL

00000001694

00000999104

00000999204

0000025265400001946374

00001907476

00000330582

00002070847

00002070863

00000550175

00000611271

00002270811

XYLOCAINE JELLY

COMPOUND- SALICYLIC ACID (TOPICAL)

COMPOUND- SALICYLIC ACID (TOPICAL)

OXSORALEN ULTRAOXSORALEN

OXSORALEN

EFUDEX

SORIATANE

SORIATANE

POTABA

POTABA

FINACEA

AZC

XXX

XXX

VCLVCL

VCL

VCL

ACV

ACV

GLE

GLE

BAI





ANTIPRURITICS AND LOCAL ANESTHETICS

KERATOLYTIC AGENTS

DEPIGMENTING AND PIGMENTING AGENTS

MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

84

84

84

84

:00

:00

:00

:00

84:08

84:28

84:50.06

84:92

0.4200

0.0000

0.0000

0.4414 0.5926

1.5080

0.8350

1.8544

3.2572

0.3641

0.2768

0.6000


$

$

$

$$

$

$

$

$

$

$

$



(PIGMENTING AGENTS)



CALCIPOTRIOL

CALCIPOTRIOL MONOHYDRATE/ BETAMETHASONE DIPROPIONATE

CALCIPOTRIOL/ BETAMETHASONE DIPROPIONATE

COLLAGENASE

ISOTRETINOIN

PODOFILOX

TAZAROTENE

50 MCG / G TOPICAL CREAM

50 MCG / G TOPICAL OINTMENT

50 MCG / ML SCALP SOLUTION

50 MCG / G (BASE) * 0.5 MG / G (BASE) TOPICAL GEL

50 MCG / G * 0.5 MG / G TOPICAL OINTMENT

250 UNIT / G TOPICAL OINTMENT

10 MG ORAL CAPSULE

40 MG ORAL CAPSULE

0.5 % TOPICAL SOLUTION

0.05 % TOPICAL GEL

0.1 % TOPICAL GEL

00002150956

00001976133

00002194341

00002319012

00002244126

00002063670

0000058234400002257955

0000058235200002257963

00002074788

00002230784

00002230785

DOVONEX

DOVONEX

DOVONEX

XAMIOL

DOVOBET

SANTYL

ACCUTANECLARUS

ACCUTANECLARUS

WARTEC

TAZORAC

TAZORAC

LEO

LEO

LEO

LEO

LEO

HPC

HLRMYP

HLRMYP

PAL

ALL

ALL


MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

84:00

84:92

0.7559

0.7336

0.7593

1.4402

1.4359

2.9167

0.9313 0.9313

1.9003 1.9003

14.2610

1.3212

1.3212


$

$

$

$

$

$

$$

$$

$

$

$


86:00 Smooth M

uscle Relaxants

86:00

Smooth Muscle Relaxants


OXYBUTYNIN CHLORIDE

AMINOPHYLLINE

OXTRIPHYLLINE

OXTRIPHYLLINE/ GUAIFENESIN

THEOPHYLLINE

2.5 MG ORAL TABLET

5 MG ORAL TABLET



20 MG / ML ORAL ELIXIR

20 MG / ML * 10 MG / ML ORAL ELIXIR






5.3 MG / ML ORAL LIQUID

00002240549

0000216354300002230800000022303940000235023800002240550

00002223376

00000497193

0000079294200000476366

00000476374

00000692689

00000692697

00000692700

00002014165

00002014181

00001966219

PMS-OXYBUTYNIN

APO-OXYBUTYNINMYLAN-OXYBUTYNINNOVO-OXYBUTYNINOXYBUTYNINPMS-OXYBUTYNIN

PMS-OXYBUTYNIN

AMINOPHYLLINE

PMS-OXTRIPHYLLINECHOLEDYL

CHOLEDYL EXPECTORANT

APO-THEO LA

APO-THEO LA

APO-THEO LA

UNIPHYL

UNIPHYL

THEOLAIR

PMS

APXMYPTEVSNSPMS

PMS

HSP

PMSERF

ERF

APX

APX

APX

PUR

PUR

MEP

SMOOTH MUSCLE RELAXANTS

SMOOTH MUSCLE RELAXANTS

GENITOURINARY SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

86

86

:00

:00

86:12

86:16

0.1428

0.1553 0.1553 0.1553 0.1553 0.1553

0.1183

0.4103

0.0325 0.0367

0.0736

0.1300

0.1350

0.1400

0.4980

0.6032

0.0252



$

$$$$$

$

$

$$

$

$

$

$

$

$

$


88:00 Vitamins

88:00

Vitamins


CYANOCOBALAMIN

FOLIC ACID

THIAMINE HCL

ALFACALCIDOL

CALCITRIOL

PHYTONADIONE

1,000 MCG / ML INJECTION

5 MG ORAL TABLET

5 MG / ML INJECTION


0.25 MCG ORAL CAPSULE

1 MCG ORAL CAPSULE

2 MCG / ML ORAL DROPS






2 MG / ML INJECTION


0000198700300000521515

00000426849

00000816086

0000219322100002243525

00000474517

00000474525

00002240329

00002242502

00000481823

00000481815

00000891738

00000891746

00000781878

00000804312

CYANOCOBALAMINVITAMIN B12

APO-FOLIC

FOLIC ACID

THIAMIJECTTHIAMINE HCL

ONE-ALPHA

ONE-ALPHA

ONE-ALPHA

ONE-ALPHA

ROCALTROL

ROCALTROL

CALCIJEX

CALCIJEX

VITAMIN K1 PEDIATRIC

VITAMIN K1

CYTSDZ

APX

SDZ

OMGCYT

LEO

LEO

LEO

LEO

HLR

HLR

ABB

ABB

SDZ

SDZ

VITAMINS

VITAMINS

VITAMINS

VITAMIN B COMPLEX

VITAMIN D

VITAMIN K ACTIVITY

88

88

88

:00

:00

:00

88:08

88:16

88:24

0.3060 0.3060

0.0404

1.8125

1.1880 1.1880

0.4384

1.3120

5.0127

16.0751

0.9280

1.4758

10.4140

18.8890

4.6381

3.2986


$$

$

$

$$

$

$

$

$

$

$

$

$

$

$




PIPRADROL HCL/ THIAMINE HCL/ RIBOFLAVIN/ PYRIDOXINE HCL/ NIACINAMIDE/ CHOLINE/ INOSITOL

0.04 MG / ML * 0.22 MG / ML * 0.11 MG / ML * 0.04 MG / ML * 1.11 MG / ML * 2.22 MG / ML * 2.22 MG / ML ORAL LIQUID

00002103052 ALERTONIC ODN

VITAMINS

MULTIVITAMIN PREPARATIONS

88:00

88:28

0.0643


$


92:00 Miscellaneous Therapeutic A

gents

92:00

Miscellaneous Therapeutic Agents


ALLOPURINOL

AZATHIOPRINE

BETAHISTINE DIHYDROCHLORIDE

BOTULINUM NEUROTOXIN TYPE A (150KD), FREE FROM COMPLEXI

CLODRONATE DISODIUM

CLODRONATE DISODIUM TETRAHYDRATE

CLONIDINE HCL

COLCHICINE

100 MG ORAL TABLET

200 MG ORAL TABLET

300 MG ORAL TABLET

50 MG ORAL TABLET

16 MG ORAL TABLET

100 UNIT / VIAL INJECTION

400 MG ORAL CAPSULE

400 MG ORAL CAPSULE



0.6 MG ORAL TABLET

1 MG ORAL TABLET

00000402818

00000479799

00000402796

0000224290700002343002000022314910000223681900000004596

000023747570000228019100002243878

00002324032

00002245828

00001984845

00001984837

0000230416300000519251

00000572349

00000621374

ZYLOPRIM

ZYLOPRIM

ZYLOPRIM

APO-AZATHIOPRINEAZATHIOPRINEMYLAN-AZATHIOPRINETEVA-AZATHIOPRINEIMURAN

CO BETAHISTINENOVO-BETAHISTINESERC

XEOMIN

CLASTEON

BONEFOS

BONEFOS

NOVO-CLONIDINEDIXARIT

COLCHICINE

COLCHICINE

AAP

AAP

AAP

APXSNSMYPTEVTPI

COBTEVABB

MPC

SUN

BHP

BHP

TEVBOE

ODN

ODN

MISCELLANEOUS THERAPEUTIC AGENTS92:00

92:00

0.0780

0.1300

0.2125

0.3724 0.3724 0.3724 0.3724 0.9897

0.1770 0.1770 0.4599

330.0000

1.2083

1.8937

12.3906

0.2584 0.2720

0.2665

0.5285


$

$

$

$$$$$

$$$

$

$

$

$

$$

$

$

Please note: Xeomin is indicated in adults for the symptomatic management of blepharospasm,cervical dystonia of a predominantly rotational form (spasmodic torticollis), and post-stroke spasticity of the upper limb.





DIMETHYL SULFOXIDE

ETIDRONATE DISODIUM

ETIDRONATE DISODIUM/ CALCIUM CARBONATE

FLUNARIZINE HCL

LEUCOVORIN CALCIUM

INJECTION

INJECTION

ORAL

ORAL

50 % BLADDER IRRIGATION SOLUTION

200 MG ORAL TABLET





00000999114

00000999215

00000999999

00000999216

00000999214

00000999113

0000224323100000493392

0000224868600002245330

0000226386600002353210000022473230000232419900002176017

00002246082

00002170493

00002087316

MISCELLANEOUS INJECTABLE COMPOUND

MISCELLANEOUS INJECTABLE COMPOUND

MISCELLANEOUS COMPOUND

MISCELLANEOUS COMPOUND

MISCELLANEOUS ORAL COMPOUND

MISCELLANEOUS ORAL COMPOUND

DIMETHYL SULFOXIDE IRRIGATIONRIMSO-50

CO ETIDRONATEMYLAN-ETIDRONATE

CO ETIDROCALETIDROCALMYLAN-ETI-CAL-CAREPACNOVO-ETIDRONATECALDIDROCAL

FLUNARIZINE

LEDERLE LEUCOVORIN CALCIUM

LEUCOVORIN CALCIUM

XXX

XXX

XXX

XXX

XXX

XXX

SDZALV

COBMYP

COBSNSMYPTEVWCC

AAP

WAY

TEV

MISCELLANEOUS THERAPEUTIC AGENTS92:00

92:00

0.0000

0.0000

0.0000

0.0000

0.0000

0.0000

1.1840 1.1900

0.5161 0.5161

0.2221 0.2221 0.2221 0.2221 0.4870

0.7204

6.1958

12.2119


$

$

$

$

$

$

$$

$$

$$$$$

$

$

$









NAFARELIN ACETATE

ONABOTULINUMTOXINA

PAMIDRONATE DISODIUM

PENTOSAN POLYSULFATE SODIUM

LEFLUNOMIDE

2 MG / ML (BASE) NASAL SOLUTION

INJECTION




100 MG ORAL CAPSULE

10 MG ORAL TABLET

20 MG ORAL TABLET

00002188783

00001981501

00002249669000022649510000224455000002059762

0000226497800002244551

00002249685000022649860000224455200002059789

00002029448

0000225649500002351668000022612510000228396400002241888

0000225650900002351676000022612780000228397200002241889

SYNAREL

BOTOX (50/100/200 UNITS/VIAL)

PAMIDRONATE DISODIUM OMEGAPAMIDRONATE DISODIUMPAMIDRONATE DISODIUMAREDIA

PAMIDRONATE DISODIUMPAMIDRONATE DISODIUM

PAMIDRONATE DISODIUM OMEGAPAMIDRONATE DISODIUMPAMIDRONATE DISODIUMAREDIA

ELMIRON

APO-LEFLUNOMIDELEFLUNOMIDENOVO-LEFLUNOMIDESANDOZ LEFLUNOMIDEARAVA

APO-LEFLUNOMIDELEFLUNOMIDENOVO-LEFLUNOMIDESANDOZ LEFLUNOMIDEARAVA

PFI

ALL

OMGSDZHSPNOV

SDZHSP

OMGSDZHSPNOV

JAI

APXSNSTEVSDZSAV

APXSNSTEVSDZSAV

MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTS

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

92

92

:00

:00

92:00

92:36

35.7369

3.5700

82.1860 86.6800 93.2900

166.9300

176.7000 188.7400

246.5581 260.3700 278.0600 500.7900

1.6545

4.1027 4.1027 4.1027 4.1027

10.9043

4.1046 4.1046 4.1046 4.1046

10.9093


$

$

$$$$

$$

$$$$

$

$$$$$

$$$$$

For the products within the following three groupings, pricing has been established on a per vialbasis.

RESTRICTED BENEFIT - This product is a benefit for the treatment of rheumatoid arthritis when prescribed by a Specialist in Rheumatology or Internal Medicine.


94:00 Devices

94:00

Devices


AEROSOL HOLDING CHAMBER

AEROSOL HOLDING CHAMBER/MASK

DEVICE

DEVICE

INFANT DEVICE

PEDIATRIC DEVICE

ADULT DEVICE

DEVICE

0000099001400000990095

000009900800000099008900000990088000009901000000099009900000990091

000009900810000099001500000990096

00000990092

000009900820000099001600000990097

00000990093

0000099001700000990098

00000990094

00000999949

SPACE CHAMBEROPTICHAMBER ADVANTAGE II (CHAMBER ONLY)VORTEXAEROCHAMBER AC BOYZ CHAMBERAEROCHAMBER AC GIRLZ CHAMBERAEROCHAMBER AC BOYZ CHAMBERAEROCHAMBER AC GIRLZ CHAMBERAEROCHAMBER PLUS FLOW-VU W/ MOUTHPIECE

VORTEX BABY WHIRL INFANT MASKSPACE CHAMBER INFANT MASKOPTICHAMBER ADVANTAGE II (WITH SMALL MASK)AEROCHAMBER PLUS FLOW-VU W/ SMALL MASK

VORTEX SPINNER PEDIATRIC MASKSPACE CHAMBER PEDIATRIC MASKOPTICHAMBER ADVANTAGE II (WITH MEDIUM MASK)AEROCHAMBER PLUS FLOW-VU W/ MEDIUMMASK

SPACE CHAMBER ADULT MASKOPTICHAMBER ADVANTAGE II (WITH LARGEMASK)AEROCHAMBER PLUS FLOW-VU W/ LARGE MASK

SEREVENT DISKHALER

KGHACM

KGHTMITMITMITMITMI

KGHKGHACM

TMI

KGHKGHACM

TMI

KGHACM

TMI

GSK

DEVICES94:00

94:00

12.0000 15.6000

19.4977 21.5400 21.5400 23.5500 23.5500 23.5500

8.5023 13.0047 26.8000

37.6700

8.5023 13.0047 26.8000

37.6700

13.0047 29.6000

39.8600

5.4600


$$

$$$$$$

$$$

$

$$$

$

$$

$

$

RESTRICTED BENEFIT - Coverage is limited to one aerosol holding chamber per plan participant per year.

RESTRICTED BENEFIT - Coverage is limited to one of each size (infant, pediatric, adult) aerosol holding chamber mask or chamber w/ mask per plan participant per year.


Appendices

Appendices

Abbreviations Pharmaceutical Manufacturers

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST APPENDIX 1 - ABBREVIATIONS

Appendix 1 Abbreviations



ASA ........................................... acetylsalicylic acid ENM ........................................... enema FC .............................................. film coated G ................................................ gram(s) HCL............................................ hydrochloride

HR .............................................. hour IU ............................................... international unit(s) MCG........................................... microgram MEQ ........................................... milliequivalent

MG ............................................. milligram ML .............................................. millilitre PTH ............................................ patch SYR............................................ syringe

W................................................ with % ................................................ percent

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST APPENDIX 2 - PHARMACEUTICAL MANUFACTURERS

Appendix 2 Pharmaceutical Manufacturers

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. 191 EFFECTIVE JULY 1, 2012

0BA

AAP AA Pharma Inc. ABB Abbott Laboratories Limited ACV Actavis ACM Auto Control Medical Inc. ACP Accel Pharma Inc. AHI Accord Healthcare Inc. ALC Alcon Canada Inc. ALL Allergan Inc. ALV Alveda Pharmaceuticals Inc. AMG Amgen Inc. API Alexion Pharmaceuticals, Inc. APX Apotex Inc. ASP Astellas Pharma Canada, Inc. AUR Auro Pharma Inc. AVA Avanstra Inc. AXC Axcan Pharma Inc. AZC AstraZeneca Canada Inc.

1BB BAI Bayer Inc. BAR Barr laboratories, Inc. BHP Bayer Healthcare Pharmaceuticals BIO Biogen Idec Canada Inc BMS Bristol-Myers Squibb BOE Boehringer Ingelheim (Canada) Ltd. BVM Biovitrum AB

2BC COB Cobalt Pharmaceuticals Inc. COR Corepharma LLC CYT Cytex Pharmaceuticals Inc.

3BD DUI Duchesnay Inc. DUR Duramed Pharmaceuticals Inc.

4BE ERF ERFA Canada Inc. ETP Ethypharm Inc.

5BF FAB Fournier/Abbott Laboratories Limited FEI Ferring Inc.

6BG GAL Galderma Canada Inc. GIL Gilead Sciences Inc. GKC GlaxoSmithKline Consumer Healthcare GLE Glenwood Laboratories Canada Ltd. GMD Genmed, a Division of Pfizer Canada Inc.

GSK GlaxoSmithKline GZM Genzyme Canada Inc.

7BH HLR Hoffman-La Roche Limited HPC Healthpoint Canada ULC HSP Hospira Healthcare Corporation 8BJ JAI Janssen Inc. JHP JHP Pharmaceuticals, LLC JPC Jamp Pharma Corporation

9BK KGH Kego Healthcare KNG King Pharmaceuticals Canada Inc.

10BL LBC Lundbeck Canada Inc. LEO Leo Pharma Inc. LIL Eli Lilly Canada Inc. LPI Luitpold Pharmaceuticals, Inc. LUI Lundbeck Inc.

11BM MAR Marcan Pharmaceuticals Inc MEL Meliapharm Inc. MEP Medicis Pharmaceutical Corporation MFC Merck Canada Inc. MLI Merus Labs Inc. MMT MM Therapeutics Inc. MPC Merz Pharma Canada Ltd. MPI Mint Pharmaceuticals Inc. MYP Mylan Pharmaceuticals ULC

12BN NNA Novo Nordisk Canada Inc. NOV Novartis Pharmaceuticals Canada Inc. NPA Novo Nordisk Canada/Paladin Labs NTI Nucro-Technics Incorporated NYC Nycomed Canada Inc.

13BO ODN Odan Laboratories Ltd. OMG Omega Laboratories Ltd. ORG Organon Canada Ltd.

14BP PAL Paladin Labs Inc. PAT Patriot, a Division of Janssen Inc. PFI Pfizer Canada Inc. PHH Pharmel Inc. PMS Pharmascience Inc.

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST REFRESHED APPENDIX 2 - PHARMACEUTICAL MANUFACTURERS

Appendix 2 Pharmaceutical Manufacturers


PPC Pharmaceutical Partners of Canada, a Division of Abraxis Bioscience Inc.

PPH Pendopharm Inc. PUR Purdue Pharma

15BR

RAN Ranbaxy Pharmaceuticals Canada Inc RBC Reckitt Benckiser (Canada) Inc. ROG Rougier Pharma Inc. (Div. of ratiopharm) RPH ratiopharm

16BS SAV Sanofi-Aventis SDZ Sandoz Canada Inc. SEP Septa Pharmaceuticals Inc. SEV Servier Canada Inc. SHB Shire Canada Inc. SNS Sanis Health Inc. SPG Sun Pharma Global Fze SRO EMD Serono Canada Inc. STM Sterimax Inc. SUN Sunovion Pharmaceutical Inc.

T TAK Takeda Canada, Inc. TAR Taro Pharmaceuticals Inc. TCI Tercica, Inc. TEV Teva Canada Limited TMI Trudell Medical International TMP Teva Canada Innovation TPI Triton Pharma Inc. TPT Taropharma, a Div. of Taro

Pharmaceuticals Inc.

17BU

UCB UCB Pharma Canada Inc.

18BV VCL Valeant Canada Limittee/Limited VLP Valeo Pharma Inc.

19BW WAY Wyeth Pharmaceuticals WCC Warner Chilcott Canada Co. WSD Westwood Squibb (Div. Bristol-Myers Squibb

Canada) WSP Wellspring Pharmaceutical Canada Corp.

20BX XPI Xediton Pharmaceuticals Inc. XXX Miscellaneous Manufacturers

21B

Indices

Indices

Alphabetical List of Pharmaceutical Products

Numerical List by Drug Identification Number

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 1 – ALPHABETICAL LIST OF PRODUCTS

ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS

Product Name Page Product Name Page


NUMERIC

282 ................................................................................ 76 282 MEP ....................................................................... 77 292 ................................................................................ 77 5-FLUOROURACIL ..................................................... 180

A

ABATACEPT ........................................................ SEC 3.6 ABILIFY ......................................................................... 98 ACARBOSE ................................................................ 162 ACCEL PIOGLITAZONE .................................... SEC 3.72 ACCOLATE ................................................................. 129 ACCOLATE ........................................................ SEC 3.94 ACCUPRIL .................................................................... 63 ACCURETIC 10/12.5 .................................................... 63 ACCURETIC 20/12.5 .................................................... 63 ACCURETIC 20/25 ....................................................... 63 ACCUTANE ................................................................ 181 ACEBUTOLOL .............................................................. 49 ACEBUTOLOL HCL ...................................................... 49 ACENOCOUMAROL ..................................................... 29 ACETAZOLAMIDE ...................................................... 136 ACETYLCYSTEINE .................................................... 130 ACITRETIN ................................................................. 180 ACLASTA ........................................................... SEC 3.94 ACTEMRA (10 ML) ............................................ SEC 3.89 ACTEMRA (20 ML) ............................................ SEC 3.89 ACTEMRA (4 ML) .............................................. SEC 3.89 ACTONEL .......................................................... SEC 3.75 ACTOS ............................................................... SEC 3.72 ACULAR ...................................................................... 134 ACYCLOVIR ................................................................. 17 ADALAT XL ................................................................... 56 ADALIMUMAB ................................................... SEC 3.13 ADEFOVIR DIPIVOXIL ................................................. 17 ADRENALIN ................................................................ 135 ADRENALIN .................................................................. 26 ADVAIR 100 DISKUS .................................................... 26 ADVAIR 125 .................................................................. 25 ADVAIR 250 .................................................................. 25 ADVAIR 250 DISKUS .................................................... 26 ADVAIR 500 DISKUS .................................................... 26 AEROCHAMBER AC BOYZ CHAMBER ..................... 191 AEROCHAMBER AC GIRLZ CHAMBER .................... 191 AEROCHAMBER PLUS FLOW-VU W/ LARGE MASK 191 AEROCHAMBER PLUS FLOW-VU W/ MEDIUM MASK

................................................................................ 191 AEROCHAMBER PLUS FLOW-VU W/ MOUTHPIECE191

AEROCHAMBER PLUS FLOW-VU W/ SMALL MASK 191 AEROSOL HOLDING CHAMBER ................................ 191 AEROSOL HOLDING CHAMBER/MASK .................... 191 AGGRENOX .................................................................. 33 AIROMIR CFC-FREE ..................................................... 25 ALCAINE ...................................................................... 134 ALDACTAZIDE 25 ......................................................... 70 ALDACTAZIDE 50 ......................................................... 70 ALDACTONE ................................................................. 70 ALDARA ............................................................. SEC 3.47 ALENDRONATE ................................................ SEC 3.14 ALENDRONATE SODIUM ................................. SEC 3.14 ALENDRONATE SODIUM/ VITAMIN D3 ........... SEC 3.15 ALENDRONATE-FC .......................................... SEC 3.14 ALERTEC .......................................................... SEC 3.59 ALERTONIC................................................................. 186 ALESSE (21 DAY) ....................................................... 159 ALESSE (28 DAY) ....................................................... 159 ALFACALCIDOL .......................................................... 185 ALFUZOSIN HCL ............................................... SEC 3.15 ALLERGY SERUM ....................................................... 171 ALLOPURINOL ............................................................ 187 ALPHAGAN ................................................................. 135 ALPRAZOLAM ............................................................. 110 ALPROSTADIL .............................................................. 46 ALTACE (CAPSULE) ..................................................... 63 ALTACE (CAPSULE) ..................................................... 64 ALTACE HCT ................................................................. 64 ALVESCO .................................................................... 155 AMANTADINE HCL ..................................................... 116 AMCINONIDE .............................................................. 175 AMERGE ..................................................................... 114 AMERGE ........................................................... SEC 3.61 AMILORIDE HCL ......................................................... 126 AMINOBENZOATE POTASSIUM ................................ 180 AMINOPHYLLINE ........................................................ 183 AMIODARONE............................................................... 36 AMIODARONE HCL ...................................................... 36 AMITRIPTYLINE HCL .................................................... 95 AMLODIPINE ................................................................. 55 AMLODIPINE BESYLATE ............................................. 55 AMOXICILLIN ................................................................ 10 AMOXICILLIN ................................................................ 11 AMOXICILLIN SUGAR-REDUCED ................................ 10 AMOXICILLIN SUGAR-REDUCED ................................ 11 AMOXICILLIN TRIHYDRATE......................................... 10 AMOXICILLIN TRIHYDRATE......................................... 11 AMOXICILLIN TRIHYDRATE/ CLAVULANATE

POTASSIUM .............................................................. 11 AMPHOTERICIN B ........................................................ 16 AMPICILLIN ....................................................... SEC 3.15 AMPICILLIN SODIUM .................................................... 11





EFFECTIVE JULY 1, 2012 194

ANAFRANIL .................................................................. 95 ANAKINRA ......................................................... SEC 3.17 ANAPROX ..................................................................... 75 ANAPROX DS ............................................................... 75 ANDRIOL ........................................................... SEC 3.86 ANDROCUR ...................................................... SEC 3.21 ANDROCUR DEPOT ......................................... SEC 3.21 ANDRODERM (2.5 MG/DAY) ............................ SEC 3.86 ANDRODERM (5 MG/DAY) ............................... SEC 3.86 ANODAN-HC .............................................................. 178 ANZEMET ................................................................... 142 APIDRA ....................................................................... 164 APIDRA CARTRIDGE ................................................. 164 APIDRA PEN .............................................................. 164 APO-ACEBUTOLOL ..................................................... 49 APO-ACYCLOVIR ......................................................... 17 APO-ALENDRONATE ........................................ SEC 3.14 APO-ALFUZOSIN .............................................. SEC 3.15 APO-ALPRAZ ............................................................. 110 APO-AMILZIDE ........................................................... 126 APO-AMIODARONE ..................................................... 36 APO-AMLODIPINE ....................................................... 55 APO-AMOXI .................................................................. 10 APO-AMOXI .................................................................. 11 APO-AMOXI CLAV........................................................ 11 APO-ATENIDONE......................................................... 50 APO-ATENOL ............................................................... 49 APO-ATENOL ............................................................... 50 APO-ATORVASTATIN .................................................. 38 APO-AZATHIOPRINE ................................................. 187 APO-AZITHROMYCIN .................................................... 9 APO-BACLOFEN .......................................................... 27 APO-BECLOMETHASONE ......................................... 132 APO-BISOPROLOL ...................................................... 50 APO-BRIMONIDINE .................................................... 135 APO-BROMAZEPAM .................................................. 110 APO-BROMOCRIPTINE ............................................. 118 APO-BUSPIRONE ...................................................... 112 APO-CALCITONIN ............................................. SEC 3.85 APO-CANDESARTAN .................................................. 65 APO-CAPTO ................................................................. 59 APO-CARVEDILOL ....................................................... 51 APO-CEFADROXIL............................................ SEC 3.19 APO-CEFPROZIL ........................................................... 6 APO-CEFUROXIME ........................................................ 7 APO-CEPHALEX ............................................................ 5 APO-CHLORAX .......................................................... 110 APO-CHLORDIAZEPOXIDE ....................................... 110 APO-CILAZAPRIL ......................................................... 59 APO-CILAZAPRIL/HCTZ .............................................. 59 APO-CIMETIDINE ....................................................... 144 APO-CIPROFLOX .............................................. SEC 3A.2

APO-CIPROFLOX .............................................. SEC 3A.3 APO-CITALOPRAM ....................................................... 91 APO-CLINDAMYCIN ...................................................... 14 APO-CLOBAZAM ........................................................... 83 APO-CLOMIPRAMINE ................................................... 95 APO-CLONAZEPAM ...................................................... 84 APO-CLOPIDOGREL .................................................... 32 APO-CLOPIDOGREL ........................................ SEC 3.20 APO-CLORAZEPATE .................................................. 110 APO-CLOZAPINE .......................................................... 98 APO-CLOZAPINE .......................................................... 99 APO-CYCLOBENZAPRINE ........................................... 27 APO-CYCLOSPORINE ...................................... SEC 3.21 APO-DESIPRAMINE ...................................................... 95 APO-DESMOPRESSIN ............................................... 167 APO-DEXAMETHASONE ............................................ 156 APO-DIAZEPAM .......................................................... 110 APO-DIAZEPAM .......................................................... 111 APO-DICLO ................................................................... 72 APO-DICLO SR ............................................................. 72 APO-DIFLUNISAL .......................................................... 73 APO-DILTIAZ ................................................................. 56 APO-DILTIAZ CD ........................................................... 56 APO-DILTIAZ CD ........................................................... 57 APO-DILTIAZ TZ ............................................................ 57 APO-DILTIAZ TZ ............................................................ 58 APO-DIPYRIDAMOLE (FC) ........................................... 46 APO-DIVALPROEX ....................................................... 85 APO-DIVALPROEX ....................................................... 86 APO-DOMPERIDONE ................................................. 148 APO-DORZO-TIMOP ................................................... 138 APO-DOXAZOSIN ......................................................... 47 APO-DOXEPIN .............................................................. 95 APO-DOXEPIN .............................................................. 96 APO-DOXY .................................................................... 13 APO-ENALAPRIL ........................................................... 60 APO-ENALAPRIL MALEATE/HCTZ .............................. 60 APO-ENTACAPONE .................................................... 117 APO-FAMOTIDINE ...................................................... 145 APO-FENO-MICRO ....................................................... 37 APO-FENO-SUPER ....................................................... 37 APO-FENO-SUPER (TABLET) ...................................... 37 APO-FENOFIBRATE ..................................................... 37 APO-FINASTERIDE ........................................... SEC 3.41 APO-FLUCONAZOLE .................................................... 15 APO-FLUNISOLIDE ..................................................... 132 APO-FLUOXETINE ........................................................ 92 APO-FLUPHENAZINE ................................................. 105 APO-FLUPHENAZINE ................................................. 106 APO-FLURAZEPAM .................................................... 111 APO-FLURBIPROFEN ................................................... 73 APO-FLUTAMIDE .............................................. SEC 3.42





APO-FLUVOXAMINE .................................................... 92 APO-FOLIC ................................................................. 185 APO-FOSINOPRIL ........................................................ 61 APO-FUROSEMIDE ...................................................... 44 APO-FUROSEMIDE ...................................................... 45 APO-GABAPENTIN ...................................................... 86 APO-GEMFIBROZIL ..................................................... 37 APO-GLICLAZIDE....................................................... 165 APO-GLYBURIDE ....................................................... 166 APO-HALOPERIDOL .................................................. 104 APO-HALOPERIDOL .................................................. 105 APO-HYDRALAZINE .................................................... 44 APO-HYDRO .............................................................. 126 APO-HYDROMORPHONE ........................................... 78 APO-HYDROXYQUINE ................................................ 18 APO-HYDROXYZINE .................................................. 113 APO-IBUPROFEN......................................................... 73 APO-INDAPAMIDE ..................................................... 127 APO-IPRAVENT............................................................ 24 APO-ISMN .................................................................... 46 APO-K ......................................................................... 125 APO-KETOCONAZOLE ................................................ 15 APO-KETOROLAC ..................................................... 134 APO-KETOROLAC ....................................................... 74 APO-LACTULOSE ...................................................... 125 APO-LAMOTRIGINE ..................................................... 87 APO-LANSOPRAZOLE ............................................... 147 APO-LATANOPROST ................................................. 137 APO-LEFLUNOMIDE .................................................. 189 APO-LEVETIRACETAM ................................................ 87 APO-LEVOCARB ........................................................ 118 APO-LEVOFLOXACIN ....................................... SEC 3A.4 APO-LISINOPRIL .......................................................... 61 APO-LISINOPRIL .......................................................... 62 APO-LISINOPRIL/HCTZ ............................................... 62 APO-LITHIUM CARBONATE ...................................... 114 APO-LORAZEPAM ..................................................... 111 APO-LOSARTAN .......................................................... 67 APO-LOSARTAN/HCTZ ................................................ 67 APO-LOSARTAN/HCTZ ................................................ 68 APO-LOVASTATIN ....................................................... 39 APO-MEDROXY ......................................................... 167 APO-METFORMIN ...................................................... 163 APO-METHOPRAZINE ............................................... 106 APO-METHOTREXATE ................................................ 21 APO-METHYLPHENIDATE ........................................ 109 APO-METHYLPHENIDATE SR .................................. 109 APO-METOPROLOL ..................................................... 52 APO-METOPROLOL (TYPE L) ..................................... 52 APO-METOPROLOL SR ............................................... 52 APO-MINOCYCLINE ..................................................... 13 APO-MIRTAZAPINE ..................................................... 98

APO-MOCLOBEMIDE ................................................... 89 APO-MONTELUKAST ................................................. 129 APO-MONTELUKAST ....................................... SEC 3.60 APO-NABUMETONE ..................................................... 74 APO-NADOL .................................................................. 52 APO-NAPRO-NA ........................................................... 75 APO-NAPRO-NA DS ..................................................... 75 APO-NAPROXEN .......................................................... 74 APO-NAPROXEN EC .................................................... 75 APO-NITRAZEPAM ..................................................... 112 APO-NIZATIDINE ........................................................ 145 APO-NORFLOX ............................................................. 12 APO-NORTRIPTYLINE .................................................. 96 APO-OFLOXACIN ........................................................ 131 APO-OLANZAPINE ...................................................... 100 APO-OLANZAPINE ........................................................ 99 APO-OLANZAPINE ODT ............................................. 100 APO-OMEPRAZOLE (CAPSULE) ............................... 147 APO-ONDANSETRON ................................................ 143 APO-ORCIPRENALINE ................................................. 25 APO-OXAZEPAM ........................................................ 112 APO-OXYBUTYNIN ..................................................... 183 APO-OXYCODONE ....................................................... 82 APO-PANTOPRAZOLE ............................................... 148 APO-PAROXETINE ....................................................... 93 APO-PEN-VK ................................................................. 10 APO-PENTOXIFYLLINE SR .......................................... 33 APO-PIMOZIDE ........................................................... 108 APO-PINDOL ................................................................. 53 APO-PIOGLITAZONE ........................................ SEC 3.72 APO-PIROXICAM .......................................................... 76 APO-PRAMIPEXOLE ................................................... 119 APO-PRAVASTATIN ..................................................... 40 APO-PRAZO .................................................................. 47 APO-PREDNISONE ..................................................... 158 APO-PROCHLORAZINE ............................................. 142 APO-PROPAFENONE ................................................... 35 APO-PROPRANOLOL ................................................... 53 APO-QUETIAPINE ....................................................... 100 APO-QUETIAPINE ....................................................... 101 APO-QUININE ............................................................... 19 APO-RABEPRAZOLE .................................................. 148 APO-RALOXIFENE ............................................ SEC 3.74 APO-RAMIPRIL (CAPSULE) ......................................... 63 APO-RAMIPRIL (CAPSULE) ......................................... 64 APO-RANITIDINE ........................................................ 145 APO-RANITIDINE ........................................................ 146 APO-REPAGLINIDE .................................................... 165 APO-RISEDRONATE ........................................ SEC 3.75 APO-RISPERIDONE .................................................... 102 APO-RISPERIDONE .................................................... 103 APO-RISPERIDONE .................................................... 104






APO-RIVASTIGMINE ......................................... SEC 3.78 APO-ROPINIROLE ..................................................... 119 APO-ROPINIROLE ..................................................... 120 APO-ROSUVASTATIN .................................................. 41 APO-SALVENT ............................................................. 25 APO-SALVENT CFC FREE .......................................... 25 APO-SELEGILINE....................................................... 120 APO-SERTRALINE ....................................................... 93 APO-SERTRALINE ....................................................... 94 APO-SIMVASTATIN ...................................................... 42 APO-SIMVASTATIN ...................................................... 43 APO-SOTALOL ............................................................. 54 APO-SUCRALFATE .................................................... 146 APO-SULFATRIM ......................................................... 12 APO-SULFATRIM DS ................................................... 12 APO-SULIN ................................................................... 76 APO-SUMATRIPTAN .................................................. 115 APO-SUMATRIPTAN ......................................... SEC 3.84 APO-TAMSULOSIN CR ................................................ 48 APO-TEMAZEPAM ..................................................... 112 APO-TERAZOSIN ......................................................... 48 APO-TERBINAFINE ...................................................... 15 APO-THEO LA ............................................................ 183 APO-TIAPROFENIC ..................................................... 76 APO-TICLOPIDINE ....................................................... 33 APO-TIMOL .................................................................. 54 APO-TIMOP ................................................................ 136 APO-TIZANIDINE............................................... SEC 3.87 APO-TOPIRAMATE ...................................................... 88 APO-TRAZODONE ....................................................... 94 APO-TRAZODONE D ................................................... 94 APO-TRIAZIDE ........................................................... 126 APO-TRIAZO .............................................................. 112 APO-TRYPTOPHAN ..................................................... 97 APO-VALACYCLOVIR (CAPLET) ................................. 18 APO-VALPROIC ........................................................... 89 APO-VALSARTAN ........................................................ 69 APO-VALSARTAN/HCTZ .............................................. 69 APO-VALSARTAN/HCTZ .............................................. 70 APO-VENLAFAXINE XR ............................................... 90 APO-VERAP ................................................................. 58 APO-VERAP SR ........................................................... 58 APO-WARFARIN .......................................................... 29 APO-WARFARIN .......................................................... 30 APO-ZOPICLONE ....................................................... 113 APRACLONIDINE HCL ............................................... 138 APREPITANT .............................................................. 144 APREPITANT/ APREPITANT ..................................... 144 APRI 21 ....................................................................... 159 APRI 28 ....................................................................... 159 ARANESP (0.3/ 0.4/ 0.5 ML SYR)...................... SEC 3.23 ARANESP (0.3/ 0.4/ 0.5/ 0.65 ML SYR) ............. SEC 3.23

ARANESP (0.3/0.4/0.6/1.0 ML SYR) ................. SEC 3.23 ARANESP (0.4 ML SYRINGE)........................... SEC 3.23 ARANESP (0.5 ML SYRINGE)........................... SEC 3.23 ARAVA ......................................................................... 189 AREDIA ........................................................................ 189 ARICEPT ........................................................... SEC 3.25 ARIPIPRAZOLE ............................................................. 98 ARISTOCORT C .......................................................... 179 ARISTOCORT R .......................................................... 179 ARIXTRA (0.5 ML SYRINGE) ........................................ 32 ARIXTRA (0.6 ML SYRINGE) ........................................ 32 ARLIDIN ......................................................................... 47 ARTHROTEC-50 ............................................................ 72 ARTHROTEC-75 ............................................................ 72 ASA ................................................................................ 71 ASA/ CODEINE PHOSPHATE/ CAFFEINE CITRATE ... 76 ASACOL ...................................................................... 149 ASACOL 800................................................................ 149 ATACAND ...................................................................... 65 ATACAND PLUS ............................................................ 65 ATARAX ....................................................................... 113 ATENOLOL .................................................................... 49 ATENOLOL .................................................................... 50 ATENOLOL/ CHLORTHALIDONE ................................. 50 ATIVAN ........................................................................ 111 ATORVASTATIN ............................................................ 38 ATORVASTATIN CALCIUM .......................................... 38 ATOVAQUONE .............................................................. 19 ATROPINE SULFATE .................................................. 134 ATROPINE SULFATE .................................................... 23 ATROVENT.................................................................... 24 ATROVENT HFA ........................................................... 24 AURANOFIN ................................................................ 151 AURO-CEFPROZIL .........................................................6 AURO-CEFUROXIME ......................................................7 AURO-GABAPENTIN .................................................... 86 AURO-LEVETIRACETAM .............................................. 87 AURO-TERBINAFINE .................................................... 15 AURO-TOPIRAMATE .................................................... 88 AVA-ACEBUTOLOL ....................................................... 49 AVA-AMIODARONE ...................................................... 36 AVA-AZITHROMYCIN .....................................................9 AVA-BACLOFEN ........................................................... 27 AVA-BISOPROLOL ........................................................ 50 AVA-BUPROPION SR ................................................... 97 AVA-CARVEDILOL ........................................................ 51 AVA-CEFPROZIL .............................................................6 AVA-CLARITHROMYCIN ................................................9 AVA-CLINDAMYCIN ...................................................... 14 AVA-DICLOFENAC ........................................................ 72 AVA-DICLOFENAC SR .................................................. 72 AVA-DOMPERIDONE .................................................. 148





AVA-ENALAPRIL .......................................................... 60 AVA-FAMOTIDINE ...................................................... 145 AVA-FENOFIBRATE MICRO ........................................ 37 AVA-FLUOXETINE ....................................................... 92 AVA-FLUVOXAMINE .................................................... 92 AVA-FUROSEMIDE ...................................................... 44 AVA-FUROSEMIDE ...................................................... 45 AVA-GLICLAZIDE ....................................................... 165 AVA-GLYBURIDE ....................................................... 166 AVA-IRBESARTAN ....................................................... 66 AVA-IRBESARTAN/HCTZ ............................................ 66 AVA-IRBESARTAN/HCTZ ............................................ 67 AVA-LEVETIRACETAM ................................................ 87 AVA-LEVOFLOXACIN ....................................... SEC 3A.4 AVA-LISINOPRIL HCT .................................................. 62 AVA-LOVASTATIN........................................................ 39 AVA-METFORMIN ...................................................... 163 AVA-METOPROLOL ..................................................... 52 AVA-METOPROLOL (TYPE L) ..................................... 52 AVA-MIRTAZAPINE ...................................................... 98 AVA-NAPROXEN .......................................................... 74 AVA-NAPROXEN EC .................................................... 75 AVA-NORTRIPTYLINE ................................................. 96 AVA-OLANZAPINE ....................................................... 99 AVA-PANTOPRAZOLE ............................................... 148 AVA-PIOGLITAZONE ........................................ SEC 3.72 AVA-PRAMIPEXOLE .................................................. 119 AVA-RAMIPRIL (TABLET) ............................................ 63 AVA-RAMIPRIL (TABLET) ............................................ 64 AVA-RISEDRONATE ......................................... SEC 3.75 AVA-RISPERIDONE ................................................... 102 AVA-RISPERIDONE ................................................... 103 AVA-RISPERIDONE ................................................... 104 AVA-SOTALOL ............................................................. 54 AVA-SUMATRIPTAN .................................................. 115 AVA-SUMATRIPTAN ......................................... SEC 3.84 AVA-TAMSULOSIN CR ................................................ 48 AVA-TOPIRAMATE....................................................... 88 AVA-VALSARTAN......................................................... 69 AVA-VALSARTAN HCT ................................................ 69 AVA-VALSARTAN HCT ................................................ 70 AVA-ZOPICLONE ....................................................... 113 AVALIDE 150/12.5 ........................................................ 66 AVALIDE 300/12.5 ........................................................ 66 AVANDAMET ..................................................... SEC 3.80 AVANDIA ........................................................... SEC 3.79 AVAPRO ....................................................................... 66 AVELOX ............................................................. SEC 3A.5 AVENTYL ...................................................................... 96 AVIANE 21 .................................................................. 159 AVIANE 28 .................................................................. 159 AVODART .......................................................... SEC 3.25

AVONEX (30 MCG) ............................................. SEC 2.4 AVONEX PS/PEN (30 MCG/0.5 ML) ................... SEC 2.4 AXID ............................................................................. 145 AZARGA ...................................................................... 137 AZATHIOPRINE ........................................................... 187 AZELAIC ACID............................................................. 180 AZITHROMYCIN ..............................................................9 AZITHROMYCIN ................................................ SEC 3.17 AZOPT ......................................................................... 136 AZTREONAM..................................................... SEC 3.17

B

BACLOFEN .................................................................... 27 BACTROBAN ............................................................... 174 BARACLUDE ................................................................. 17 BECLOMETHASONE DIPROPIONATE ...................... 132 BECLOMETHASONE DIPROPIONATE ...................... 155 BECLOMETHASONE DIPROPIONATE ...................... 175 BELLADONNA/ ERGOTAMINE TARTRATE/

PHENOBARBITAL ..................................................... 23 BELLERGAL SPACETABS ............................................ 23 BENAZEPRIL ................................................................. 58 BENAZEPRIL HCL ......................................................... 58 BENTYLOL .................................................................... 23 BENURYL .................................................................... 127 BENZACLIN ....................................................... SEC 3.19 BENZOYL PEROXIDE ....................................... SEC 3.18 BENZTROPINE ............................................................ 117 BENZTROPINE MESYLATE........................................ 117 BENZTROPINE OMEGA ............................................. 117 BENZYDAMINE HCL ................................................... 135 BETADERM MILD ........................................................ 176 BETADERM REGULAR ............................................... 176 BETAGAN .................................................................... 136 BETAHISTINE DIHYDROCHLORIDE .......................... 187 BETAMETHASONE DIPROPIONATE ......................... 175 BETAMETHASONE DIPROPIONATE/ CLOTRIMAZOLE

................................................................................. 179 BETAMETHASONE DIPROPIONATE/ SALICYLIC ACID

................................................................................. 175 BETAMETHASONE SODIUM PHOSPHATE ............... 176 BETAMETHASONE SODIUM PHOSPHATE/

BETAMETHASONE ACETATE................................ 155 BETAMETHASONE SODIUM PHOSPHATE/

GENTAMICIN SULFATE ......................................... 133 BETAMETHASONE VALERATE ................................. 176 BETASERON (0.3 MG) ........................................ SEC 2.4 BETAXOLOL HCL ........................................................ 135 BETNESOL (5MG/100ML) ........................................... 176






BETOPTIC S ............................................................... 135 BEZAFIBRATE .............................................................. 37 BEZALIP ....................................................................... 37 BIAXIN ............................................................................ 9 BIAXIN BID ..................................................................... 9 BIAXIN XL ....................................................................... 9 BIMATOPROST .......................................................... 137 BISOPROLOL FUMARATE .......................................... 50 BLEPHAMIDE ............................................................. 133 BLEPHAMIDE S.O.P. .................................................. 133 BLOOD GLUCOSE TEST STRIPS ................................. 1 BLOOD LETTING LANCET ............................................ 1 BONEFOS ................................................................... 187 BOTOX (50/100/200 UNITS/VIAL) .............................. 189 BOTULINUM NEUROTOXIN TYPE A (150KD), FREE

FROM COMPLEXI .................................................. 187 BREVICON 0.5/35 (21 DAY) ....................................... 160 BREVICON 0.5/35 (28 DAY) ....................................... 160 BREVICON 1/35 (21 DAY) .......................................... 160 BREVICON 1/35 (28 DAY) .......................................... 160 BRICANYL TURBUHALER ........................................... 26 BRIMONIDINE TARTRATE ........................................ 135 BRIMONIDINE TARTRATE/ TIMOLOL MALEATE ..... 137 BRINZOLAMIDE ......................................................... 136 BRINZOLAMIDE/ TIMOLOL MALEATE ...................... 137 BROMAZEPAM ........................................................... 110 BROMOCRIPTINE MESYLATE .................................. 118 BUDESONIDE ............................................................ 132 BUDESONIDE ............................................................ 155 BUDESONIDE ............................................................ 176 BUDESONIDE ................................................... SEC 3.18 BUDESONIDE/ FORMOTEROL FUMARATE

DIHYDRATE ............................................................. 24 BUPRENORPHINE HCL/ NALOXONE

HYDROCHLORIDE DIHYDRATE ............................. 83 BUPROPION HCL......................................................... 97 BUSCOPAN .................................................................. 23 BUSERELIN ACETATE ..................................... SEC 3.18 BUSPIRONE HCL ....................................................... 112 BUTALBITAL/ CAFFEINE/ ASA .................................... 71 BUTALBITAL/ CODEINE PHOSPHATE/ ASA/ CAFFEINE

.................................................................................. 76

C

C.E.S. .......................................................................... 161 CABERGOLINE ................................................. SEC 3.18 CAFERGOT .................................................................. 26 CALCIJEX ................................................................... 185 CALCIMAR .................................................................. 166 CALCIPOTRIOL .......................................................... 181

CALCIPOTRIOL MONOHYDRATE/ BETAMETHASONE DIPROPIONATE ...................................................... 181

CALCIPOTRIOL/ BETAMETHASONE DIPROPIONATE ................................................................................. 181

CALCITRIOL ................................................................ 185 CALCIUM POLYSTYRENE SULPHONATE ................ 125 CALTINE 100 (100 IU/ML) ........................................... 166 CANCIDAS ........................................................ SEC 3.19 CANDESARTAN CILEXETIL ......................................... 65 CANDESARTAN CILEXETIL/ HYDROCHLOROTHIAZIDE

................................................................................... 65 CAPTOPRIL ................................................................... 59 CARBACHOL ............................................................... 137 CARBAMAZEPINE ........................................................ 85 CARBOLITH................................................................. 114 CARDIZEM CD .............................................................. 56 CARDIZEM CD .............................................................. 57 CARDURA ..................................................................... 47 CARNITOR ........................................................ SEC 3.57 CARVEDILOL ................................................................ 51 CASPOFUNGIN ................................................. SEC 3.19 CATAPRES .................................................................... 43 CAYSTON .......................................................... SEC 3.17 CEDOCARD-SR ............................................................ 45 CEFADROXIL .................................................... SEC 3.19 CEFAZOLIN .....................................................................5 CEFAZOLIN SODIUM ......................................................5 CEFIXIME ........................................................................7 CEFOTAXIME SODIUM ..................................................7 CEFPROZIL .....................................................................6 CEFTAZIDIME .................................................................7 CEFTIN ............................................................................7 CEFTRIAXONE FOR INJECTION USP ...........................7 CEFTRIAXONE SODIUM ................................................7 CEFUROXIME AXETIL ....................................................7 CEFZIL .............................................................................6 CELEBREX ........................................................ SEC 3.19 CELECOXIB....................................................... SEC 3.19 CELESTONE SOLUSPAN ........................................... 155 CELEXA ......................................................................... 91 CELONTIN ..................................................................... 85 CEPHALEXIN ..................................................................5 CEPHALEXIN ..................................................................6 CESAMET .................................................................... 144 CHAMPIX ....................................................................... 28 CHAMPIX ........................................................... SEC 3.92 CHAMPIX (STARTER PACK) ........................................ 28 CHAMPIX (STARTER PACK) ............................ SEC 3.93 CHLORAL HYDRATE .................................................. 112 CHLORAMPHENICOL SODIUM SUCCINATE ................8 CHLORDIAZEPOXIDE HCL ........................................ 110 CHLORDIAZEPOXIDE HCL/ CLIDINIUM BROMIDE .. 110





CHLOROMYCETIN ......................................................... 8 CHLOROQUINE PHOSPHATE .................................... 18 CHLORPROMAZINE HCL .......................................... 105 CHLORTHALIDONE ................................................... 126 CHOLEDYL ................................................................. 183 CHOLEDYL EXPECTORANT ..................................... 183 CHOLESTYRAMINE RESIN ......................................... 36 CICLESONIDE ............................................................ 155 CICLOPIROX OLAMINE ............................................. 175 CILAZAPRIL .................................................................. 59 CILAZAPRIL/ HYDROCHLOROTHIAZIDE ................... 59 CILOXAN .................................................................... 131 CIMETIDINE ............................................................... 144 CIPRALEX .................................................................... 91 CIPRO ................................................................ SEC 3A.1 CIPRO ................................................................ SEC 3A.2 CIPRO ................................................................ SEC 3A.3 CIPRODEX ................................................................. 132 CIPROFLOXACIN .............................................. SEC 3A.1 CIPROFLOXACIN .............................................. SEC 3A.2 CIPROFLOXACIN .............................................. SEC 3A.3 CIPROFLOXACIN HCL ............................................... 131 CIPROFLOXACIN HCL ...................................... SEC 3A.2 CIPROFLOXACIN HCL ...................................... SEC 3A.3 CIPROFLOXACIN HCL/ DEXAMETHASONE ............ 132 CITALOPRAM ............................................................... 91 CITALOPRAM HYDROBROMIDE ................................ 91 CITALOPRAM-ODAN ................................................... 91 CLAFORAN ..................................................................... 7 CLARITHROMYCIN ........................................................ 9 CLARUS ...................................................................... 181 CLASTEON ................................................................. 187 CLAVULIN-125F ........................................................... 11 CLAVULIN-200 ............................................................. 11 CLAVULIN-250F ........................................................... 11 CLAVULIN-400 ............................................................. 11 CLAVULIN-500F ........................................................... 11 CLAVULIN-875 ............................................................. 11 CLIMARA 100 (7.8 MG/PTH) ...................................... 161 CLIMARA 25 (2 MG/PTH) ........................................... 161 CLIMARA 50 (3.9 MG/PTH) ........................................ 161 CLIMARA 75 (5.7 MG/PTH) ........................................ 161 CLINDAMYCIN ............................................................. 14 CLINDAMYCIN (60 & 120 ML) ...................................... 14 CLINDAMYCIN HCL ..................................................... 14 CLINDAMYCIN PALMITATE HCL................................. 14 CLINDAMYCIN PHOSPHATE ...................................... 14 CLINDAMYCIN PHOSPHATE/ BENZOYL PEROXIDE

....................................................................... SEC 3.19 CLINDOXYL ....................................................... SEC 3.19 CLOBAZAM .................................................................. 83 CLOBETASOL 17-PROPIONATE .............................. 176

CLODRONATE DISODIUM ......................................... 187 CLODRONATE DISODIUM TETRAHYDRATE ............ 187 CLOMID ....................................................................... 162 CLOMIPHENE CITRATE ............................................. 162 CLOMIPRAMINE HCL ................................................... 95 CLONAZEPAM .............................................................. 84 CLONIDINE HCL ......................................................... 187 CLONIDINE HCL ........................................................... 43 CLOPIDOGREL BISULFATE ......................................... 32 CLOPIDOGREL BISULFATE ............................. SEC 3.20 CLOPIXOL ................................................................... 108 CLOPIXOL ACUPHASE .............................................. 107 CLOPIXOL DEPOT ...................................................... 107 CLORAZEPATE DIPOTASSIUM ................................. 110 CLOXACILLIN SODIUM ................................................ 12 CLOZAPINE ................................................................... 98 CLOZAPINE ................................................................... 99 CLOZARIL ..................................................................... 98 CLOZARIL ..................................................................... 99 CO ALENDRONATE .......................................... SEC 3.14 CO AMLODIPINE ........................................................... 55 CO ATENOLOL.............................................................. 49 CO ATENOLOL.............................................................. 50 CO ATORVASTATIN ..................................................... 38 CO AZITHROMYCIN .......................................................9 CO AZITHROMYCIN ......................................... SEC 3.17 CO BETAHISTINE ....................................................... 187 CO CABERGOLINE ........................................... SEC 3.18 CO CANDESARTAN ...................................................... 65 CO CILAZAPRIL ............................................................ 59 CO CIPROFLOXACIN ....................................... SEC 3A.2 CO CIPROFLOXACIN ....................................... SEC 3A.3 CO CITALOPRAM ......................................................... 91 CO CLOMIPRAMINE ..................................................... 95 CO CLONAZEPAM ........................................................ 84 CO CLOPIDOGREL ....................................................... 32 CO CLOPIDOGREL ........................................... SEC 3.20 CO DILTIAZEM CD ........................................................ 56 CO DILTIAZEM CD ........................................................ 57 CO DILTIAZEM T ........................................................... 57 CO DILTIAZEM T ........................................................... 58 CO ENALAPRIL ............................................................. 60 CO ETIDROCAL .......................................................... 188 CO ETIDRONATE ........................................................ 188 CO FINASTERIDE ............................................. SEC 3.41 CO FLUCONAZOLE ...................................................... 15 CO FLUOXETINE .......................................................... 92 CO FLUVOXAMINE ....................................................... 92 CO GABAPENTIN .......................................................... 86 CO IRBESARTAN .......................................................... 66 CO IRBESARTAN/HCT ................................................. 66 CO IRBESARTAN/HCT ................................................. 67






CO LATANOPROST ................................................... 137 CO LEVETIRACETAM .................................................. 87 CO LEVOFLOXACIN ......................................... SEC 3A.4 CO LISINOPRIL ............................................................ 61 CO LISINOPRIL ............................................................ 62 CO LOSARTAN ............................................................ 67 CO LOVASTATIN.......................................................... 39 CO METFORMIN ........................................................ 163 CO OLANZAPINE ....................................................... 100 CO OLANZAPINE ......................................................... 99 CO OLANZAPINE ODT ............................................... 100 CO ONDANSETRON .................................................. 143 CO PANTOPRAZOLE ................................................. 148 CO PAROXETINE ......................................................... 93 CO PIOGLITAZONE .......................................... SEC 3.72 CO PRAMIPEXOLE .................................................... 119 CO PRAVASTATIN ....................................................... 40 CO QUETIAPINE ........................................................ 100 CO QUETIAPINE ........................................................ 101 CO RAMIPRIL (CAPSULE) ........................................... 63 CO RAMIPRIL (CAPSULE) ........................................... 64 CO RANITIDINE.......................................................... 145 CO REPAGLINIDE ...................................................... 165 CO RISPERIDONE ..................................................... 102 CO RISPERIDONE ..................................................... 103 CO RIZATRIPTAN ODT .............................................. 114 CO RIZATRIPTAN ODT .............................................. 115 CO RIZATRIPTAN ODT ..................................... SEC 3.79 CO ROPINIROLE ........................................................ 119 CO ROPINIROLE ........................................................ 120 CO ROSUVASTATIN .................................................... 41 CO SERTRALINE ......................................................... 93 CO SERTRALINE ......................................................... 94 CO SIMVASTATIN ........................................................ 42 CO SIMVASTATIN ........................................................ 43 CO SOTALOL ............................................................... 54 CO SUMATRIPTAN .................................................... 115 CO SUMATRIPTAN ........................................... SEC 3.84 CO TEMAZEPAM........................................................ 112 CO TERBINAFINE ........................................................ 15 CO TOPIRAMATE......................................................... 88 CO VALACYCLOVIR .................................................... 18 CO VALSARTAN........................................................... 69 CO VENLAFAXINE XR ................................................. 90 CO ZOPICLONE ......................................................... 113 CODEINE PHOSPHATE ............................................... 77 CODEINE PHOSPHATE/ ACETAMINOPHEN .............. 77 CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE ................................................................................ 77 CODEINE PHOSPHATE/ ASA/ CAFFEINE CITRATE .. 77 CODEINE PHOSPHATE/ ASA/ MEPROBAMATE/

CAFFEINE CITRATE ................................................ 77 COLCHICINE .............................................................. 187

COLESTID ..................................................................... 36 COLESTID ORANGE ..................................................... 36 COLESTIPOL HCL ........................................................ 36 COLISTIMETHATE FOR INJECTION ............................ 14 COLISTIMETHATE SODIUM ......................................... 14 COLLAGENASE .......................................................... 181 COMBIGAN.................................................................. 137 COMBINATION ANTI-INFECTIVE /CORTICOSTEROID

................................................................................. 179 COMBIVENT UDV ......................................................... 24 COMPD- NSAID/ ANALG/MUSCLE RELAX (NOT

DICLOFENAC)-TOPICAL .......................................... 71 COMPD-CHLORHEX. MOUTH RINSE (ANY

CONCENTRATION, NOT 0.12%) ............................ 135 COMPD-CHLORHEX. MOUTH RINSE (ANY

CONCENTRATION, NOT 12%) ............................... 135 COMPD-NSAID/ ANALG/MUSCLE RELAX (NOT

DICLOFENAC)-TOPICAL .......................................... 71 COMPOUND - RETINOIC ACID (TRETINOIN) (TOPICAL) ...................... COMPOUND HORMONES (ESTROGEN PROGEST

TESTOSTERONE) ................................................... 155 COMPOUND NARCOTIC MIXTURES - ORAL AND

INJECTION ................................................................ 77 COMPOUND PRESCRIPTION .................................... 135 COMPOUND PRESCRIPTION .................................... 155 COMPOUND PRESCRIPTION .................................... 173 COMPOUND PRESCRIPTION .................................... 176 COMPOUND PRESCRIPTION .................................... 179 COMPOUND PRESCRIPTION .................................... 180 COMPOUND PRESCRIPTION .................................... 188 COMPOUND PRESCRIPTION ...................................... 71 COMPOUND PRESCRIPTION ...................................... 77 COMPOUND- DICLOFENAC (TOPICAL) ...................... 71 COMPOUND- SALICYLIC ACID (TOPICAL) ............... 180 COMPOUND-ANTI-INFECTIVE (TOPICAL) ................ 173 COMPOUND-CORTICOSTEROIDS - TOPICAL ......... 176 COMPOUND-DICLOFENAC (TOPICAL) ....................... 71 COMTAN ..................................................................... 117 CONJUGATED ESTROGENS ..................................... 161 COPAXONE ......................................................... SEC 2.4 CORDARONE ................................................................ 36 CORTAMED................................................................. 132 CORTEF ...................................................................... 156 CORTENEMA (100MG/60ML) ..................................... 177 CORTIFOAM................................................................ 178 CORTISONE ACETATE .............................................. 155 CORTODERM MILD .................................................... 177 CORTODERM REGULAR ........................................... 177 COSOPT ...................................................................... 138 COSOPT PRESERVATIVE-FREE ............................... 138 COSYNTROPIN ZINC HYDROXIDE COMPLEX ......... 166 COTAZYM ................................................................... 141





COTAZYM ECS 20 ..................................................... 141 COTAZYM ECS 8 ....................................................... 141 COUMADIN ................................................................... 29 COUMADIN ................................................................... 30 COVERSYL ................................................................... 62 COVERSYL ................................................................... 63 COVERSYL PLUS ........................................................ 63 COVERSYL PLUS HD .................................................. 63 COZAAR ....................................................................... 67 CREON 10 MINIMICROSPHERES ............................. 141 CREON 25 MINIMICROSPHERES ............................. 141 CRESTOR ..................................................................... 41 CTP 30 .......................................................................... 91 CUPRIMINE ................................................................ 153 CYANOCOBALAMIN .................................................. 185 CYCLEN (21 DAY) ...................................................... 160 CYCLEN (28 DAY) ...................................................... 160 CYCLOBENZAPRINE ................................................... 27 CYCLOBENZAPRINE HCL ........................................... 27 CYCLOCORT .............................................................. 175 CYCLOGYL ................................................................. 134 CYCLOMEN ................................................................ 158 CYCLOPENTOLATE HCL .......................................... 134 CYCLOSPORINE ............................................... SEC 3.21 CYKLOKAPRON ........................................................... 33 CYMBALTA ................................................................... 90 CYPROTERONE................................................ SEC 3.21 CYPROTERONE ACETATE .............................. SEC 3.21 CYTOMEL ................................................................... 168 CYTOVENE .................................................................. 18

D

DABIGATRAN ETEXILATE ................................ SEC 3.22 DALACIN C ................................................................... 14 DALACIN C PALMITATE .............................................. 14 DALACIN C PHOSPHATE ............................................ 14 DALTEPARIN SODIUM ................................................ 30 DALTEPARIN SODIUM ................................................ 31 DANAPAROID SODIUM .................................... SEC 3.22 DANAZOL ................................................................... 158 DANTRIUM ................................................................... 27 DANTROLENE SODIUM .............................................. 27 DAPSONE ..................................................................... 16 DARAPRIM ................................................................... 18 DARBEPOETIN ................................................. SEC 3.23 DARIFENACIN HYDROBROMIDE .................... SEC 3.23 DDAVP ........................................................................ 167 DEFERASIROX ................................................. SEC 3.24 DEFEROXAMINE MESYLATE ................................... 153

DELATESTRYL............................................................ 158 DEMEROL ..................................................................... 79 DEMULEN 30 (21 DAY) ............................................... 159 DEMULEN 30 (28 DAY) ............................................... 159 DENOSUMAB .................................................... SEC 3.24 DEPAKENE ................................................................... 89 DEPO-MEDROL .......................................................... 157 DEPO-MEDROL (PRESERVED) ................................. 157 DEPO-MEDROL WITH LIDOCAINE ............................ 157 DEPO-PROVERA ........................................................ 167 DEPO-TESTOSTERONE CYPIONATE ....................... 158 DERMOVATE .............................................................. 176 DESFERAL .................................................................. 153 DESFERRIOXAMINE MESILATE ................................ 153 DESIPRAMINE HCL ...................................................... 95 DESMOPRESSIN ........................................................ 167 DESMOPRESSIN ACETATE ....................................... 167 DESOGESTREL/ ETHINYL ESTRADIOL .................... 159 DESOGESTREL/ ETHINYL ESTRADIOL/

DESOGESTREL/ ETHINYL ESTRADIOL/ DESOGESTREL/ ETHINYL ESTRADIOL ................ 159

DESONIDE .................................................................. 177 DESOXIMETASONE ................................................... 177 DESSICATED THYROID ............................................. 168 DETROL LA ....................................................... SEC 3.89 DEVICE ........................................................................ 191 DEXAMETHASONE ..................................................... 132 DEXAMETHASONE ..................................................... 156 DEXAMETHASONE SODIUM PHOSPHATE .............. 132 DEXAMETHASONE SODIUM PHOSPHATE .............. 156 DEXAMETHASONE/ FRAMYCETIN SULFATE/

GRAMICIDIN............................................................ 133 DEXAMETHASONE/ NEOMYCIN SULFATE/

POLYMYXIN B SULFATE ........................................ 133 DEXAMETHASONE/ TOBRAMYCIN ........................... 133 DEXASONE ................................................................. 156 DEXEDRINE ................................................................ 108 DEXIRON ....................................................................... 29 DEXTROAMPHETAMINE SULFATE ........................... 108 DIABETA ...................................................................... 166 DIABETES SUPPLIES .....................................................1 DIAMICRON................................................................. 165 DIAMICRON MR .......................................................... 165 DIAZEMULS................................................................. 111 DIAZEPAM ................................................................... 110 DIAZEPAM ................................................................... 111 DIAZOXIDE .................................................................... 44 DICETEL ...................................................................... 149 DICLECTIN .................................................................. 144 DICLOFENAC SODIUM ............................................... 134 DICLOFENAC SODIUM ................................................. 72 DICLOFENAC SODIUM SR ........................................... 72






DICLOFENAC SODIUM/ MISOPROSTOL .................... 72 DICYCLOMINE HCL ..................................................... 23 DICYCLOMINE HYDROCHLORIDE ............................. 23 DIDROCAL .................................................................. 188 DIFLUCAN .................................................................... 15 DIFLUCAN ......................................................... SEC 3.42 DIFLUCORTOLONE VALERATE ............................... 177 DIFLUNISAL ................................................................. 73 DIGOXIN ....................................................................... 36 DIGOXIN PEDIATRIC ................................................... 36 DIHYDROERGOTAMINE (DHE) ................................... 26 DIHYDROERGOTAMINE MESYLATE .......................... 26 DILANTIN ...................................................................... 84 DILANTIN INFATABS ................................................... 84 DILANTIN-125 ............................................................... 84 DILANTIN-30 ................................................................. 84 DILAUDID ..................................................................... 78 DILAUDID STERILE POWDER .................................... 79 DILAUDID-HP ............................................................... 78 DILTIAZEM HCL ........................................................... 56 DILTIAZEM HCL ........................................................... 57 DILTIAZEM HCL ........................................................... 58 DIMENHYDRINATE .................................................... 142 DIMENHYDRINATE I.M. ............................................. 142 DIMENHYDRINATE I.V. .............................................. 142 DIMETHYL SULFOXIDE ............................................. 188 DIMETHYL SULFOXIDE IRRIGATION ....................... 188 DIODOQUIN ................................................................. 18 DIOVAN ........................................................................ 69 DIOVAN-HCT ................................................................ 69 DIOVAN-HCT ................................................................ 70 DIPENTUM ................................................................. 149 DIPHENHYDRAMINE ..................................................... 3 DIPHENHYDRAMINE HCL ............................................. 3 DIPHENOXYLATE HCL/ ATROPINE SULFATE ......... 141 DIPROLENE GLYCOL ................................................ 175 DIPROSALIC .............................................................. 175 DIPROSONE ............................................................... 175 DIPYRIDAMOLE ........................................................... 46 DIPYRIDAMOLE/ ASA .................................................. 33 DISOPYRAMIDE ........................................................... 35 DIVALPROEX SODIUM (VALPROIC ACID EQUIV.) .... 85 DIVALPROEX SODIUM (VALPROIC ACID EQUIV.) .... 86 DIXARIT ...................................................................... 187 DOLASETRON MESYLATE ....................................... 142 DOMPERIDONE ......................................................... 148 DOMPERIDONE MALEATE ....................................... 148 DONEPEZIL HCL ............................................... SEC 3.25 DORZOLAMIDE HCL .................................................. 136 DORZOLAMIDE HCL/ TIMOLOL MALEATE .............. 138 DOSTINEX ......................................................... SEC 3.18 DOVOBET ................................................................... 181

DOVONEX ................................................................... 181 DOXAZOSIN MESYLATE .............................................. 47 DOXEPIN HCL ............................................................... 95 DOXEPIN HCL ............................................................... 96 DOXYCYCLINE ............................................................. 13 DOXYCYCLINE HYCLATE ............................................ 13 DOXYLAMINE SUCCINATE/ PYRIDOXINE HCL ........ 144 DROSPIRENONE/ ETHINYL ESTRADIOL .................. 159 DULOXETINE HYDROCHLORIDE ................................ 90 DUO TRAV .................................................................. 138 DUTASTERIDE .................................................. SEC 3.25

E

ECULIZUMAB .................................................... SEC 3.30 EDECRIN ....................................................................... 44 EFFEXOR XR ................................................................ 90 EFUDEX ...................................................................... 180 ELAVIL ........................................................................... 95 ELMIRON ..................................................................... 189 ELOCOM ..................................................................... 178 ELTROXIN ................................................................... 168 EMEND ........................................................................ 144 EMEND TRI-PACK ...................................................... 144 EMO-CORT.................................................................. 177 ENABLEX .......................................................... SEC 3.23 ENALAPRIL MALEATE .................................................. 60 ENALAPRIL MALEATE/ HYDROCHLOROTHIAZIDE ... 60 ENBREL ............................................................. SEC 3.38 ENDOCET ..................................................................... 82 ENGERIX-B ................................................................. 171 ENOXAPARIN SODIUM ................................................ 31 ENTACAPONE ............................................................ 117 ENTECAVIR................................................................... 17 ENTOCORT ....................................................... SEC 3.18 ENTOCORT (115 ML) .................................................. 176 ENTROPHEN 10 ............................................................ 71 EPINEPHRINE ............................................................... 26 EPINEPHRINE HCL ..................................................... 135 EPINEPHRINE HCL ....................................................... 26 EPIPEN .......................................................................... 26 EPIPEN JR .................................................................... 26 EPIVAL .......................................................................... 85 EPIVAL .......................................................................... 86 EPOETIN ALFA ................................................. SEC 3.30 EPOETIN ALFA ................................................. SEC 3.31 EPREX ............................................................... SEC 3.30 EPREX (0.3 ML SYRINGE) ............................... SEC 3.31 EPREX (0.4 ML SYRINGE) ............................... SEC 3.31 EPREX (0.5 ML SYRINGE) ............................... SEC 3.31





EPREX (0.6 ML SYRINGE) ................................ SEC 3.31 EPREX (0.8 ML SYRINGE) ................................ SEC 3.31 EPREX (1 ML SYRINGE) ................................... SEC 3.31 EPROSARTAN MESYLATE ......................................... 65 EPROSARTAN MESYLATE/ HYDROCHLOROTHIAZIDE

.................................................................................. 65 ERGOLOID MESYLATES ............................................. 26 ERGOTAMINE TARTRATE/ CAFFEINE ....................... 26 ERTAPENEM ..................................................... SEC 3.32 ERYC .............................................................................. 8 ERYTHRO-BASE ............................................................ 8 ERYTHRO-EC ................................................................ 8 ERYTHRO-ES ................................................................. 8 ERYTHRO-S ................................................................... 8 ERYTHROMYCIN ....................................................... 131 ERYTHROMYCIN ........................................................... 8 ERYTHROMYCIN ESTOLATE ....................................... 8 ERYTHROMYCIN ETHYLSUCCINATE .......................... 8 ERYTHROMYCIN STEARATE ....................................... 8 ERYTHROMYCIN/ TRETINOIN ......................... SEC 3.32 ESCITALOPRAM OXALATE ......................................... 91 ESTALIS (2.7*.62 MG/PTH) ........................................ 162 ESTALIS (4.8*.51 MG/PTH) ........................................ 162 ESTRACE ................................................................... 161 ESTRADERM-100 (8.0 MG/PTH) ............................... 161 ESTRADERM-25 (2 MG/PTH) .................................... 161 ESTRADIOL-17B ........................................................ 161 ESTRADOT 100 (1.56 MG/PTH) ................................ 161 ESTRADOT 25 (0.39 MG/PTH) .................................. 161 ESTRADOT 37.5 (0.585 MG/PTH).............................. 161 ESTRADOT 50 (0.78 MG/PTH) .................................. 161 ESTRADOT 75 (1.17 MG/PTH) .................................. 161 ESTRING .................................................................... 161 ESTROGEL ................................................................. 161 ETANERCEPT ................................................... SEC 3.38 ETHACRYNIC ACID ..................................................... 44 ETHOPROPAZINE HCL ............................................. 117 ETHOSUXIMIDE ........................................................... 85 ETHYNODIOL DIACETATE/ ETHINYL ESTRADIOL.. 159 ETIDROCAL ................................................................ 188 ETIDRONATE DISODIUM .......................................... 188 ETIDRONATE DISODIUM/ CALCIUM CARBONATE . 188 ETODOLAC .................................................................. 73 EUFLEX ............................................................. SEC 3.42 EVISTA .............................................................. SEC 3.74 EXELON ............................................................. SEC 3.78 EXJADE ............................................................. SEC 3.24 EXTAVIA (0.3 MG) ............................................... SEC 2.4 EZETIMIBE ........................................................ SEC 3.38 EZETROL ........................................................... SEC 3.38

F

FAMOTIDINE ............................................................... 145 FEBUXOSTAT ................................................... SEC 3.39 FELODIPINE .................................................................. 55 FELODIPINE .................................................................. 56 FENOFIBRATE .............................................................. 37 FENOFIBRATE MICRO ................................................. 37 FENOFIBRATE-S .......................................................... 37 FENOFIBRATE-S (TABLET).......................................... 37 FENTANYL ........................................................ SEC 3.39 FENTANYL ........................................................ SEC 3.40 FENTANYL CITRATE ........................................ SEC 3.40 FILGRASTIM...................................................... SEC 3.41 FINACEA ..................................................................... 180 FINASTERIDE ................................................... SEC 3.41 FIORINAL ...................................................................... 71 FIORINAL-C 1/2 ............................................................. 76 FIORINAL-C 1/4 ............................................................. 76 FLAGYL ....................................................................... 174 FLAGYSTATIN............................................................. 174 FLAREX ....................................................................... 132 FLECAINIDE .................................................................. 35 FLECAINIDE ACETATE ................................................ 35 FLOCTAFENINE ............................................................ 73 FLORINEF ................................................................... 156 FLOVENT DISKUS ...................................................... 156 FLOVENT HFA ............................................................ 156 FLUANXOL .................................................................. 107 FLUANXOL DEPOT ..................................................... 107 FLUCONAZOLE ............................................................. 15 FLUCONAZOLE ................................................. SEC 3.42 FLUCONAZOLE OMEGA .............................................. 15 FLUDROCORTISONE ACETATE ................................ 156 FLUMETHASONE PIVALATE/ CLIOQUINOL.............. 133 FLUNARIZINE.............................................................. 188 FLUNARIZINE HCL ..................................................... 188 FLUNISOLIDE.............................................................. 132 FLUOCINONIDE .......................................................... 177 FLUOR-A-DAY ............................................................. 121 FLUOROMETHOLONE ............................................... 132 FLUOROMETHOLONE ACETATE .............................. 132 FLUOXETINE................................................................. 92 FLUOXETINE HCL ........................................................ 92 FLUPENTIXOL DECANOATE ..................................... 107 FLUPENTIXOL DIHYDROCHLORIDE ......................... 107 FLUPHENAZINE DECANOATE................................... 105 FLUPHENAZINE HCL .................................................. 105 FLUPHENAZINE HCL .................................................. 106 FLUPHENAZINE OMEGA ........................................... 105 FLURAZEPAM HCL ..................................................... 111






FLURBIPROFEN........................................................... 73 FLUTAMIDE ....................................................... SEC 3.42 FLUTICASONE PROPIONATE ................................... 156 FLUVASTATIN SODIUM ............................................... 39 FLUVOXAMINE MALEATE ........................................... 92 FML FORTE ................................................................ 132 FOLIC ACID ................................................................ 185 FONDAPARINUX SODIUM .......................................... 32 FORADIL ....................................................................... 24 FORMOTEROL FUMARATE ........................................ 24 FORMOTEROL FUMARATE DIHYDRATE ................... 25 FORTAZ .......................................................................... 7 FOSAMAX .......................................................... SEC 3.14 FOSAVANCE ..................................................... SEC 3.15 FOSINOPRIL ................................................................ 61 FOSINOPRIL SODIUM ................................................. 61 FRAGMIN ...................................................................... 30 FRAGMIN (0.2 ML SYRINGE) ...................................... 30 FRAGMIN (0.3 ML SYRINGE) ...................................... 30 FRAGMIN (0.4 ML SYRINGE) ...................................... 30 FRAGMIN (0.5 ML SYRINGE) ...................................... 30 FRAGMIN (0.6 ML SYRINGE) ...................................... 30 FRAGMIN (0.72 ML SYRINGE) .................................... 31 FRAXIPARINE (.3-1ML SYR) ....................................... 31 FRAXIPARINE FORTE (.6-1ML SYR) .......................... 31 FUCIDIN ...................................................................... 173 FUCIDIN ...................................................................... 174 FUNGIZONE IV ............................................................. 16 FUROSEMIDE .............................................................. 44 FUROSEMIDE .............................................................. 45 FUSIDIC ACID ............................................................ 173

G

GABAPENTIN ............................................................... 86 GALANTAMINE HYDROBROMIDE ................... SEC 3.42 GANCICLOVIR SODIUM .............................................. 18 GARAMYCIN .............................................................. 131 GARASONE ................................................................ 133 GD-AMLODIPINE.......................................................... 55 GD-ATORVASTATIN .................................................... 38 GD-AZITHROMYCIN ...................................................... 9 GD-GABAPENTIN......................................................... 86 GD-LATANOPROST ................................................... 137 GD-SERTRALINE ......................................................... 93 GD-SERTRALINE ......................................................... 94 GD-VENLAFAXINE XR ................................................. 90 GEMFIBROZIL .............................................................. 37 GEN-CLOZAPINE ......................................................... 98 GEN-CLOZAPINE ......................................................... 99

GENTAMICIN...................................................................5 GENTAMICIN SULFATE ............................................. 131 GENTAMICIN SULFATE ............................................. 173 GENTAMICIN SULFATE .................................................5 GLATIRAMER ACETATE .................................... SEC 2.4 GLICLAZIDE ................................................................ 165 GLICLAZIDE MR .......................................................... 165 GLUCAGEN ................................................................. 166 GLUCAGEN HYPOKIT ................................................ 166 GLUCAGON................................................................. 166 GLUCAGON, RDNA ORIGIN ....................................... 166 GLUCOBAY ................................................................. 162 GLUCONORM ............................................................. 165 GLUCOPHAGE ............................................................ 163 GLYBURIDE ................................................................ 166 GLYCOPYRROLATE ..................................................... 23 GOLD SODIUM THIOMALATE .................................... 151 GOLIMUMAB ..................................................... SEC 3.46 GOSERELIN ACETATE ..................................... SEC 3.46 GRANISETRON ........................................................... 142 GRANISETRON HCL ................................................... 142

H

HALOBETASOL PROPIONATE .................................. 177 HALOPERIDOL............................................................ 104 HALOPERIDOL............................................................ 105 HALOPERIDOL DECANOATE .................................... 105 HALOPERIDOL LA ...................................................... 105 HEPARIN LEO ............................................................... 31 HEPARIN SODIUM ........................................................ 31 HEPATITIS B VACCINE (RECOMBINANT) ................ 171 HEPSERA ...................................................................... 17 HEPTOVIR ..................................................................... 16 HOMATROPINE HYDROBROMIDE ............................ 134 HP-PAC ( KIT )............................................................. 147 HUMALOG ................................................................... 164 HUMALOG CARTRIDGE/KWIKPEN ........................... 164 HUMALOG MIX 25 CARTRIDGE/KWIKPEN ............... 164 HUMALOG MIX 50 CARTRIDGE/KWIKPEN ............... 164 HUMATROPE .................................................... SEC 3.82 HUMIRA ............................................................. SEC 3.13 HUMULIN 30/70 ........................................................... 164 HUMULIN 30/70 CARTRIDGE ..................................... 164 HUMULIN N ................................................................. 164 HUMULIN N CARTRIDGE/KWIKPEN .......................... 164 HUMULIN R ................................................................. 164 HUMULIN R CARTRIDGE ........................................... 164 HYCORT (100MG/60ML) ............................................. 177 HYDERGINE .................................................................. 26





HYDERM ..................................................................... 178 HYDRALAZINE HCL ..................................................... 44 HYDROCHLOROTHIAZIDE ........................................ 126 HYDROCHLOROTHIAZIDE/ AMILORIDE HCL .......... 126 HYDROCHLOROTHIAZIDE/ SPIRONOLACTONE ...... 70 HYDROCHLOROTHIAZIDE/ TRIAMTERENE ............ 126 HYDROCORTISONE .................................................. 156 HYDROCORTISONE .................................................. 177 HYDROCORTISONE 17-VALERATE ......................... 178 HYDROCORTISONE ACETATE ................................ 132 HYDROCORTISONE ACETATE ................................ 178 HYDROCORTISONE ACETATE/ PRAMOXINE HCL . 178 HYDROCORTISONE ACETATE/ PRAMOXINE HCL/

ZINC SULFATE ....................................................... 178 HYDROCORTISONE ACETATE/ UREA ..................... 178 HYDROCORTISONE ACETATE/ ZINC SULFATE ..... 178 HYDROCORTISONE SOD. SUCCINATE ................... 156 HYDROCORTISONE SOD. SUCCINATE ................... 157 HYDROCORTISONE SODIUM SUCCINATE ............. 156 HYDROCORTISONE SODIUM SUCCINATE ............. 157 HYDROCORTISONE/ CINCHOCAINE HCL/

FRAMYCETIN SULFATE/ ESCULIN ...................... 179 HYDROMORPH CONTIN ............................................. 78 HYDROMORPHONE .................................................... 78 HYDROMORPHONE HCL ............................................ 78 HYDROMORPHONE HCL ............................................ 79 HYDROMORPHONE HP .............................................. 78 HYDROMORPHONE HP 20 ......................................... 78 HYDROMORPHONE HP 50 ......................................... 78 HYDROVAL ................................................................ 178 HYDROXYCHLOROQUINE SULFATE ......................... 18 HYDROXYZINE HCL .................................................. 113 HYOSCINE BUTYLBROMIDE ...................................... 23 HYTRIN ......................................................................... 48 HYZAAR ........................................................................ 67 HYZAAR DS .................................................................. 68

I

IBUPROFEN ................................................................. 73 IMDUR .......................................................................... 46 IMIPENEM/ CILASTATIN SODIUM.................... SEC 3.47 IMIPRAMINE ................................................................. 96 IMIPRAMINE HCL ......................................................... 96 IMIQUIMOD ....................................................... SEC 3.47 IMITREX ...................................................................... 115 IMITREX ............................................................. SEC 3.83 IMITREX (0.5 ML) ....................................................... 115 IMITREX (0.5 ML) .............................................. SEC 3.84 IMITREX DF ................................................................ 115

IMITREX DF ....................................................... SEC 3.84 IMOVANE .................................................................... 113 IMURAN ....................................................................... 187 INDAPAMIDE HEMIHYDRATE .................................... 127 INDERAL-LA .................................................................. 53 INDOMETHACIN ........................................................... 73 INFLIXIMAB ....................................................... SEC 3.55 INFUFER ....................................................................... 29 INHIBACE ...................................................................... 59 INHIBACE PLUS ............................................................ 59 INNOHEP ....................................................................... 31 INNOHEP (0.25 ML SYRINGE) ..................................... 31 INNOHEP (0.35 ML SYRINGE) ..................................... 31 INNOHEP (0.45 ML SYRINGE) ..................................... 31 INNOHEP (0.5 ML SYRINGE) ....................................... 31 INNOHEP (0.7 ML SYRINGE) ....................................... 31 INNOHEP (0.9 ML SYRINGE) ....................................... 32 INSULIN ASPART ........................................................ 163 INSULIN DETEMIR ...................................................... 163 INSULIN GLARGINE ................................................... 163 INSULIN GLULISINE (RDNA ORIGIN) ........................ 164 INSULIN HUMAN BIOSYNTHETIC (ISOPHANE) ........ 164 INSULIN HUMAN BIOSYNTHETIC (REGULAR) ......... 164 INSULIN HUMAN BIOSYNTHETIC (REGULAR)/ INSULIN

HUMAN BIOSYNTHETIC (ISOPHANE) ................... 164 INSULIN LISPRO ......................................................... 164 INSULIN LISPRO/ INSULIN LISPRO PROTAMINE .... 164 INSULIN PEN NEEDLES .................................................1 INSULIN SYRINGES .......................................................1 INTERFERON BETA-1A ...................................... SEC 2.4 INTERFERON BETA-1B ...................................... SEC 2.4 INVANZ .............................................................. SEC 3.32 INVEGA SUSTENNA (0.5 ML SYR) .................. SEC 3.65 INVEGA SUSTENNA (0.75 ML SYR) ................ SEC 3.65 INVEGA SUSTENNA (1 ML SYR) ..................... SEC 3.65 INVEGA SUSTENNA (1.5 ML SYR) .................. SEC 3.65 IODOQUINOL ................................................................ 18 IOPIDINE ..................................................................... 138 IPRATROPIUM BROMIDE ............................................ 24 IPRATROPIUM BROMIDE ................................ SEC 3.55 IPRATROPIUM BROMIDE/ SALBUTAMOL SULFATE . 24 IRBESARTAN ................................................................ 66 IRBESARTAN/ HYDROCHLOROTHIAZIDE .................. 66 IRBESARTAN/ HYDROCHLOROTHIAZIDE .................. 67 IRBESARTAN/HCTZ ...................................................... 66 IRBESARTAN/HCTZ ...................................................... 67 IRON DEXTRAN COMPLEX.......................................... 29 ISDN .............................................................................. 45 ISOPTIN SR ................................................................... 58 ISOPTO ATROPINE .................................................... 134 ISOPTO CARBACHOL ................................................ 137 ISOPTO CARPINE ....................................................... 137






ISOPTO HOMATROPINE ........................................... 134 ISOSORBIDE DINITRATE ............................................ 45 ISOSORBIDE-5-MONONITRATE ................................. 46 ISOTRETINOIN ........................................................... 181 ITRACONAZOLE .......................................................... 15 ITRACONAZOLE ............................................... SEC 3.55

J

JAMP-AMLODIPINE ..................................................... 55 JAMP-ATENOLOL ........................................................ 49 JAMP-ATENOLOL ........................................................ 50 JAMP-CITALOPRAM .................................................... 91 JAMP-FINASTERIDE ......................................... SEC 3.41 JAMP-FOSINOPRIL ...................................................... 61 JAMP-GABAPENTIN .................................................... 86 JAMP-LACTULOSE .................................................... 125 JAMP-LISINOPRIL ........................................................ 61 JAMP-LISINOPRIL ........................................................ 62 JAMP-METOPROLOL-L ............................................... 52 JAMP-ONDANSETRON .............................................. 143 JAMP-PRAVASTATIN ................................................... 40 JAMP-QUETIAPINE .................................................... 100 JAMP-QUETIAPINE .................................................... 101 JAMP-RAMIPRIL (CAPSULE) ...................................... 63 JAMP-RAMIPRIL (CAPSULE) ...................................... 64 JAMP-RISPERIDONE ................................................. 102 JAMP-RISPERIDONE ................................................. 103 JAMP-ROPINIROLE ................................................... 119 JAMP-ROPINIROLE ................................................... 120 JAMP-SIMVASTATIN .................................................... 42 JAMP-SIMVASTATIN .................................................... 43 JANUMET .......................................................... SEC 3.81

K

K-10 ORAL LIQUID ..................................................... 125 K-DUR ......................................................................... 125 K-LYTE ........................................................................ 125 KADIAN ......................................................................... 81 KAYEXALATE ............................................................. 126 KENALOG-10 .............................................................. 158 KENALOG-40 .............................................................. 158 KEPPRA ........................................................................ 87 KETOCONAZOLE ......................................................... 15 KETOCONAZOLE ....................................................... 174 KETODERM ................................................................ 174 KETOPROFEN ............................................................. 74 KETOPROFEN SR........................................................ 74

KETOPROFEN-E ........................................................... 74 KETOROLAC TROMETHAMINE ................................. 134 KETOROLAC TROMETHAMINE ................................... 74 KETOTIFEN FUMARATE ................................................3 KINERET ........................................................... SEC 3.17 KYTRIL ........................................................................ 142

L

L-TRYPTOPHAN ........................................................... 97 LABETALOL HCL .......................................................... 51 LABETALOL HYDROCHLORIDE .................................. 51 LACOSAMIDE.................................................... SEC 3.55 LACOSAMIDE.................................................... SEC 3.56 LACTULOSE ................................................................ 125 LAMICTAL ..................................................................... 87 LAMISIL ......................................................................... 15 LAMISIL ....................................................................... 174 LAMIVUDINE ................................................................. 16 LAMOTRIGINE .............................................................. 87 LANREOTIDE ACETATE ................................... SEC 3.56 LANSOPRAZOLE ........................................................ 147 LANSOPRAZOLE/ AMOXICILLIN TRIHYDRATE/

CLARITHROMYCIN ................................................. 147 LANTUS ....................................................................... 163 LANTUS CARTRIDGE ................................................. 163 LANTUS PEN............................................................... 163 LASIX ............................................................................. 44 LASIX ............................................................................. 45 LASIX SPECIAL ............................................................. 45 LATANOPROST .......................................................... 137 LATANOPROST/ TIMOLOL MALEATE ....................... 138 LECTOPAM ................................................................. 110 LEDERLE LEUCOVORIN CALCIUM ........................... 188 LEFLUNOMIDE ............................................................ 189 LESCOL ......................................................................... 39 LESCOL XL ................................................................... 39 LEUCOVORIN CALCIUM ............................................ 188 LEUPROLIDE ACETATE ................................... SEC 3.56 LEVAQUIN ......................................................... SEC 3A.4 LEVEMIR CARTRIDGE ............................................... 163 LEVETIRACETAM ......................................................... 87 LEVOBUNOLOL HCL .................................................. 136 LEVOCARB CR ........................................................... 118 LEVOCARNITINE .............................................. SEC 3.57 LEVODOPA/ BENSERAZIDE HCL .............................. 117 LEVODOPA/ CARBIDOPA .......................................... 118 LEVODOPA/ CARBIDOPA/ ENTACAPONE ................ 118 LEVOFLOXACIN ................................................ SEC 3A.4 LEVONORGESTREL ................................................... 159





LEVONORGESTREL/ ETHINYL ESTRADIOL ............ 159 LEVONORGESTREL/ ETHINYL ESTRADIOL/

LEVONORGESTREL/ ETHINYL ESTRADIOL/ LEVONORGESTREL/ ETHINYL ESTRADIOL ........ 159

LEVOTHYROXINE SODIUM ...................................... 168 LIBRAX ....................................................................... 110 LIDOCAINE ................................................................. 179 LIDOCAINE HCL ......................................................... 134 LIDOCAINE HCL ......................................................... 180 LIDODAN .................................................................... 179 LIDODAN VISCOUS ................................................... 134 LINAGLIPTIN ..................................................... SEC 3.57 LINESSA 21 ................................................................ 159 LINESSA 28 ................................................................ 159 LINEZOLID ......................................................... SEC 3.58 LIORESAL ..................................................................... 27 LIORESAL D.S. ............................................................. 27 LIORESAL INTRATHECAL ........................................... 27 LIOTHYRONINE SODIUM .......................................... 168 LIPASE/ AMYLASE/ PROTEASE ............................... 141 LIPIDIL MICRO ............................................................. 37 LIPIDIL SUPRA ............................................................. 37 LIPIDIL SUPRA (TABLET) ............................................ 37 LIPITOR ........................................................................ 38 LISINOPRIL .................................................................. 61 LISINOPRIL .................................................................. 62 LISINOPRIL/ HYDROCHLOROTHIAZIDE .................... 62 LISINOPRIL/HCTZ (TYPE Z) ....................................... 62 LITHANE ..................................................................... 114 LITHIUM CARBONATE ............................................... 114 LOCACORTEN VIOFORM .......................................... 133 LOESTRIN 1.5/30 (21 DAY) ........................................ 160 LOESTRIN 1.5/30 (28 DAY) ........................................ 160 LOMOTIL .................................................................... 141 LONITEN ....................................................................... 44 LOPRESOR .................................................................. 52 LOPRESOR SR ............................................................ 52 LOPROX ..................................................................... 175 LORAZEPAM .............................................................. 111 LOSARTAN POTASSIUM ............................................. 67 LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

.................................................................................. 67 LOSARTAN POTASSIUM/ HYDROCHLOROTHIAZIDE

.................................................................................. 68 LOSEC (SUSTAINED-RELEASE CAPSULE) ............. 147 LOSEC (SUSTAINED-RELEASE TABLET) ................ 147 LOTENSIN .................................................................... 58 LOTRIDERM ............................................................... 179 LOVASTATIN ................................................................ 39 LOVENOX ..................................................................... 31 LOVENOX (0.3 ML SYRINGE) ..................................... 31 LOVENOX (0.4 - 1 ML SYRINGE) ................................ 31

LOVENOX HP (0.8ML/1ML SYRINGE) ......................... 31 LOXAPAC .................................................................... 108 LOXAPINE HCL ........................................................... 108 LOXAPINE SUCCINATE ............................................. 108 LOZIDE ........................................................................ 127 LUCENTIS ................................................................... 139 LUMIGAN RC 0.01% ................................................... 137 LUPRON ............................................................ SEC 3.56 LUPRON DEPOT ............................................... SEC 3.56 LUVOX ........................................................................... 92 LYDERM ...................................................................... 177

M

M-ESLON ....................................................................... 80 M-ESLON ....................................................................... 81 M.O.S. SULFATE ........................................................... 80 M.O.S.-SR ...................................................................... 79 MACROBID .................................................................... 19 MAGLUCATE ............................................................... 125 MAGNESIUM GLUCOHEPTONATE ........................... 125 MAGNESIUM GLUCONATE ........................................ 125 MAJEPTIL .................................................................... 106 MAPROTILINE HCL ....................................................... 96 MAR-AMLODIPINE ........................................................ 55 MAR-ATENOLOL ........................................................... 49 MAR-ATENOLOL ........................................................... 50 MAR-CIPROFLOXACIN ..................................... SEC 3A.2 MAR-CIPROFLOXACIN ..................................... SEC 3A.3 MAR-CITALOPRAM ....................................................... 91 MAR-METFORMIN ...................................................... 163 MAR-ONDANSETRON ................................................ 143 MAR-RISPERIDONE ................................................... 102 MAR-RISPERIDONE ................................................... 103 MAR-SIMVASTATIN ...................................................... 42 MAR-SIMVASTATIN ...................................................... 43 MARVELON (21 DAY) ................................................. 159 MARVELON (28 DAY) ................................................. 159 MAVIK ............................................................................ 64 MAVIK ............................................................................ 65 MAXALT ....................................................................... 114 MAXALT ............................................................. SEC 3.79 MAXALT RPD .............................................................. 114 MAXALT RPD .............................................................. 115 MAXALT RPD .................................................... SEC 3.79 MAXIDEX ..................................................................... 132 MAXITROL ................................................................... 133 MEBENDAZOLE ..............................................................5 MEDROL ...................................................................... 157 MEDROXYPROGESTERONE ACETATE ................... 167






MEFENAMIC ................................................................. 74 MEFENAMIC ACID ....................................................... 74 MEGACE OS ..................................................... SEC 3.58 MEGESTROL ..................................................... SEC 3.58 MEGESTROL ACETATE ................................... SEC 3.58 MEPERIDINE HCL ........................................................ 79 MEPERIDINE HYDROCHLORIDE................................ 79 MEPRON ...................................................................... 19 MEROPENEM .................................................... SEC 3.59 MERREM ........................................................... SEC 3.59 MESALAZINE ............................................................. 149 MESASAL ................................................................... 149 MESTINON ................................................................... 23 MESTINON-SR ............................................................. 23 METADOL ..................................................................... 79 METADOL CONCENTRATE ......................................... 79 METFORMIN .............................................................. 163 METFORMIN HCL ...................................................... 163 METHADONE ............................................................... 79 METHADONE COMPOUND ......................................... 79 METHADONE HCL ....................................................... 79 METHAZOLAMIDE ..................................................... 136 METHIMAZOLE .......................................................... 169 METHOTREXATE ......................................................... 21 METHOTREXATE SOD. (PRESERVED) ...................... 21 METHOTREXATE SOD.(UNPRESERVED) ................. 21 METHOTREXATE SODIUM ......................................... 21 METHOTRIMEPRAZINE HCL .................................... 106 METHOTRIMEPRAZINE MALEATE ........................... 106 METHOXSALEN ......................................................... 180 METHSUXIMIDE ........................................................... 85 METHYLDOPA ............................................................. 43 METHYLDOPA ............................................................. 44 METHYLPHENIDATE HCL ......................................... 109 METHYLPREDNISOLONE ......................................... 157 METHYLPREDNISOLONE ACETATE ........................ 157 METHYLPREDNISOLONE ACETATE (P) .................. 157 METHYLPREDNISOLONE ACETATE/ LIDOCAINE HCL

................................................................................ 157 METHYLPREDNISOLONE ACETATE/ NEOMYCIN

SULFATE/ ALUMINUM CHLORHYDROXIDE COMPLEX/ SULFUR ..................................... SEC 3.59

METHYLPREDNISOLONE SOD SUCCIN. ................. 157 METHYLPREDNISOLONE SODIUM SUCCINATE .... 157 METOCLOPRAMIDE HCL .......................................... 148 METOCLOPRAMIDE HCL .......................................... 149 METOCLOPRAMIDE HYDROCHLORIDE .................. 149 METOLAZONE ........................................................... 127 METOPROLOL ............................................................. 52 METOPROLOL TARTRATE ......................................... 52 METROCREAM .......................................................... 173 METROGEL ................................................................ 173

METROLOTION ........................................................... 173 METRONIDAZOLE ...................................................... 173 METRONIDAZOLE ...................................................... 174 METRONIDAZOLE ........................................................ 19 METRONIDAZOLE/ NYSTATIN ................................... 174 MEVACOR ..................................................................... 39 MEXILETINE HCL .......................................................... 35 MIACALCIN........................................................ SEC 3.85 MICARDIS ..................................................................... 68 MICARDIS PLUS ........................................................... 68 MICRO-K EXTENCAPS ............................................... 125 MICRONOR (28 DAY) ................................................. 159 MIDAMOR .................................................................... 126 MIDAZOLAM ................................................................ 111 MIDAZOLAM HCL ........................................................ 111 MIDODRINE................................................................... 24 MIDODRINE HCL .......................................................... 24 MIGRANAL .................................................................... 26 MIN-OVRAL (21 DAY) ................................................. 159 MIN-OVRAL (28 DAY) ................................................. 159 MINESTRIN 1/20 (21 DAY) .......................................... 160 MINESTRIN 1/20 (28 DAY) .......................................... 160 MINITRAN 0.2 ................................................................ 46 MINITRAN 0.4 ................................................................ 46 MINITRAN 0.6 ................................................................ 46 MINOCYCLINE .............................................................. 13 MINOCYCLINE HCL ...................................................... 13 MINOXIDIL ..................................................................... 44 MINT-AMLODIPINE ....................................................... 55 MINT-ATENOL ............................................................... 49 MINT-ATENOL ............................................................... 50 MINT-CIPROFLOXACIN .................................... SEC 3A.2 MINT-CIPROFLOXACIN .................................... SEC 3A.3 MINT-CITALOPRAM ...................................................... 91 MINT-FLUOXETINE ....................................................... 92 MINT-ONDANSETRON ............................................... 143 MINT-PIOGLITAZONE ....................................... SEC 3.72 MINT-PRAVASTATIN .................................................... 40 MINT-RISPERIDON ..................................................... 102 MINT-RISPERIDON ..................................................... 103 MINT-SIMVASTATIN ..................................................... 42 MINT-SIMVASTATIN ..................................................... 43 MINT-TOPIRAMATE ...................................................... 88 MIRENA SYSTEM ....................................................... 159 MIRTAZAPINE ............................................................... 98 MISCELLANEOUS COMPOUND ................................ 188 MISCELLANEOUS INJECTABLE COMPOUND .......... 188 MISCELLANEOUS ORAL COMPOUND ...................... 188 MISCELLANEOUS TOPICAL COMPOUND ................ 173 MISOPROSTOL ........................................................... 146 MOCLOBEMIDE ............................................................ 89 MODAFINIL........................................................ SEC 3.59





MODECATE CONCENTRATE .................................... 105 MODULON .................................................................. 150 MOGADON ................................................................. 112 MOMETASONE FUROATE ........................................ 132 MOMETASONE FUROATE ........................................ 178 MONOPRIL ................................................................... 61 MONTELUKAST ......................................................... 129 MONTELUKAST ................................................ SEC 3.60 MONTELUKAST SODIUM .......................................... 129 MONTELUKAST SODIUM ................................. SEC 3.60 MORPHINE HCL ........................................................... 79 MORPHINE HP 25 ........................................................ 81 MORPHINE HP 50 ........................................................ 81 MORPHINE LP EPIDURAL ........................................... 81 MORPHINE SR ............................................................. 80 MORPHINE SULFATE .................................................. 80 MORPHINE SULFATE .................................................. 81 MOXIFLOXACIN HCL ........................................ SEC 3A.5 MS CONTIN .................................................................. 80 MS.IR ............................................................................ 80 MUCOMYST ............................................................... 130 MUPIROCIN ................................................................ 174 MYCOBUTIN ...................................................... SEC 3.74 MYDFRIN .................................................................... 135 MYDRIACYL ............................................................... 134 MYL-RANITIDINE ....................................................... 145 MYLAN-ACEBUTOLOL ................................................. 49 MYLAN-ACEBUTOLOL (TYPE S)................................. 49 MYLAN-ACYCLOVIR .................................................... 17 MYLAN-ALENDRONATE ................................... SEC 3.14 MYLAN-ALPRAZOLAM ............................................... 110 MYLAN-AMANTADINE ............................................... 116 MYLAN-AMIODARONE ................................................ 36 MYLAN-AMLODIPINE ................................................... 55 MYLAN-AMOXICILLIN .................................................. 10 MYLAN-ATENOLOL...................................................... 49 MYLAN-ATENOLOL...................................................... 50 MYLAN-ATORVASTATIN ............................................. 38 MYLAN-AZATHIOPRINE ............................................ 187 MYLAN-AZITHROMYCIN ............................................... 9 MYLAN-BACLOFEN ..................................................... 27 MYLAN-BECLO AQ. ................................................... 132 MYLAN-BUDESONIDE AQ ......................................... 132 MYLAN-CANDESARTAN .............................................. 65 MYLAN-CAPTOPRIL .................................................... 59 MYLAN-CARBAMAZEPINE CR .................................... 85 MYLAN-CARVEDILOL .................................................. 51 MYLAN-CILAZAPRIL .................................................... 59 MYLAN-CIMETIDINE .................................................. 144 MYLAN-CIPROFLOXACIN ................................ SEC 3A.2 MYLAN-CIPROFLOXACIN ................................ SEC 3A.3 MYLAN-CITALOPRAM ................................................. 91

MYLAN-CLARITHROMYCIN ...........................................9 MYLAN-CLINDAMYCIN ................................................. 14 MYLAN-CLONAZEPAM ................................................. 84 MYLAN-CLOPIDOGREL ................................................ 32 MYLAN-CLOPIDOGREL .................................... SEC 3.20 MYLAN-COMBO STERINEBS ....................................... 24 MYLAN-CYCLOBENZAPRINE ...................................... 27 MYLAN-DOMPERIDONE ............................................ 148 MYLAN-DOXAZOSIN .................................................... 47 MYLAN-ENALAPRIL ...................................................... 60 MYLAN-ETI-CAL-CAREPAC ....................................... 188 MYLAN-ETIDRONATE ................................................ 188 MYLAN-FAMOTIDINE ................................................. 145 MYLAN-FENOFIBRATE MICRO .................................... 37 MYLAN-FINASTERIDE ...................................... SEC 3.41 MYLAN-FLUCONAZOLE ............................................... 15 MYLAN-FLUOXETINE ................................................... 92 MYLAN-FOSINOPRIL .................................................... 61 MYLAN-GABAPENTIN .................................................. 86 MYLAN-GALANTAMINE ER .............................. SEC 3.42 MYLAN-GEMFIBROZIL ................................................. 37 MYLAN-GLICLAZIDE ................................................... 165 MYLAN-GLYBE............................................................ 166 MYLAN-HYDROXYCHLOROQUINE ............................. 18 MYLAN-INDAPAMIDE ................................................. 127 MYLAN-IPRATROPIUM ................................................. 24 MYLAN-IPRATROPIUM STERINEBS ............... SEC 3.55 MYLAN-IRBESARTAN ................................................... 66 MYLAN-LAMOTRIGINE ................................................. 87 MYLAN-LANSOPRAZOLE ........................................... 147 MYLAN-LEVOFLOXACIN .................................. SEC 3A.4 MYLAN-LISINOPRIL ...................................................... 61 MYLAN-LISINOPRIL ...................................................... 62 MYLAN-LISINOPRIL HCTZ ........................................... 62 MYLAN-LOSARTAN ...................................................... 67 MYLAN-LOSARTAN HCTZ ............................................ 67 MYLAN-LOSARTAN HCTZ ............................................ 68 MYLAN-LOVASTATIN ................................................... 39 MYLAN-METFORMIN .................................................. 163 MYLAN-METOPROLOL ................................................. 52 MYLAN-METOPROLOL (TYPE L) ................................. 52 MYLAN-MINOCYCLINE ................................................. 13 MYLAN-MIRTAZAPINE ................................................. 98 MYLAN-MONTELUKAST ............................................. 129 MYLAN-MONTELUKAST ................................... SEC 3.60 MYLAN-NABUMETONE ................................................ 74 MYLAN-NAPROXEN EC ............................................... 75 MYLAN-NIFEDIPINE EXTENDED RELEASE................ 56 MYLAN-NITRO .............................................................. 46 MYLAN-OLANZAPINE ................................................. 100 MYLAN-OLANZAPINE ................................................... 99 MYLAN-OLANZAPINE ODT ........................................ 100






MYLAN-OMEPRAZOLE (CAPSULE) .......................... 147 MYLAN-ONDANSETRON ........................................... 143 MYLAN-OXYBUTYNIN ............................................... 183 MYLAN-PANTOPRAZOLE .......................................... 148 MYLAN-PAROXETINE .................................................. 93 MYLAN-PIOGLITAZONE ................................... SEC 3.72 MYLAN-PRAMIPEXOLE ............................................. 119 MYLAN-PRAVASTATIN ................................................ 40 MYLAN-QUETIAPINE ................................................. 100 MYLAN-QUETIAPINE ................................................. 101 MYLAN-RAMIPRIL (CAPSULE) .................................... 63 MYLAN-RAMIPRIL (CAPSULE) .................................... 64 MYLAN-RANITIDINE .................................................. 145 MYLAN-RISEDRONATE .................................... SEC 3.75 MYLAN-RISPERIDONE .............................................. 102 MYLAN-RISPERIDONE .............................................. 103 MYLAN-RIVASTIGMINE .................................... SEC 3.78 MYLAN-RIZATRIPTAN ODT ....................................... 114 MYLAN-RIZATRIPTAN ODT ....................................... 115 MYLAN-RIZATRIPTAN ODT .............................. SEC 3.79 MYLAN-ROSUVASTATIN ............................................. 41 MYLAN-SALBUTAMOL STERINEBS P.F. .................... 25 MYLAN-SELEGILINE .................................................. 120 MYLAN-SERTRALINE .................................................. 93 MYLAN-SERTRALINE .................................................. 94 MYLAN-SIMVASTATIN ................................................. 42 MYLAN-SIMVASTATIN ................................................. 43 MYLAN-SOTALOL ........................................................ 54 MYLAN-SUMATRIPTAN ............................................. 115 MYLAN-SUMATRIPTAN .................................... SEC 3.84 MYLAN-TAMSULOSIN ................................................. 48 MYLAN-TELMISARTAN ................................................ 68 MYLAN-TELMISARTAN HCTZ ..................................... 68 MYLAN-TERBINAFINE ................................................. 15 MYLAN-TIZANIDINE .......................................... SEC 3.87 MYLAN-TOPIRAMATE ................................................. 88 MYLAN-TRAZODONE .................................................. 94 MYLAN-VALACYCLOVIR (CAPLET) ............................ 18 MYLAN-VALPROIC....................................................... 89 MYLAN-VALSARTAN HCTZ ......................................... 69 MYLAN-VALSARTAN HCTZ ......................................... 70 MYLAN-VENLAFAXINE XR .......................................... 90 MYLAN-VERAPAMIL .................................................... 58 MYLAN-VERAPAMIL SR .............................................. 58 MYLAN-WARFARIN ...................................................... 29 MYLAN-WARFARIN ...................................................... 30 MYLAN-ZOLMITRIPTAN ............................................ 116 MYLAN-ZOLMITRIPTAN ................................... SEC 3.95 MYLAN-ZOPICLONE .................................................. 113 MYOCHRYSINE.......................................................... 151

N

NABILONE ................................................................... 144 NABUMETONE .............................................................. 74 NADOLOL ...................................................................... 52 NADROPARIN CALCIUM .............................................. 31 NAFARELIN ACETATE ............................................... 189 NALCROM ................................................................... 130 NAPROSYN ................................................................... 75 NAPROSYN E................................................................ 75 NAPROSYN SR ............................................................. 75 NAPROXEN ................................................................... 74 NAPROXEN ................................................................... 75 NAPROXEN EC ............................................................. 75 NAPROXEN SODIUM .................................................... 75 NAPROXEN SODIUM DS .............................................. 75 NARATRIPTAN HCL .................................................... 114 NARATRIPTAN HCL .......................................... SEC 3.61 NARDIL .......................................................................... 89 NASONEX ................................................................... 132 NATALIZUMAB .................................................... SEC 2.7 NAVANE ...................................................................... 107 NEO-MEDROL ACNE ........................................ SEC 3.59 NEOMYCIN SULFATE/ POLYMYXIN B SULFATE ..... 174 NEOMYCIN SULFATE/ POLYMYXIN B SULFATE/

GRAMICIDIN............................................................ 131 NEORAL ............................................................ SEC 3.21 NEOSPORIN................................................................ 174 NEOSTIGMINE BROMIDE ............................................ 23 NERISONE .................................................................. 177 NERISONE OILY ......................................................... 177 NEULASTA (0.6 ML SYRINGE) ......................... SEC 3.65 NEULEPTIL ................................................................. 106 NEUPOGEN....................................................... SEC 3.41 NEURONTIN .................................................................. 86 NIFEDIPINE ................................................................... 56 NITOMAN .......................................................... SEC 3.87 NITRAZADON .............................................................. 112 NITRAZEPAM .............................................................. 112 NITRO-DUR 0.2 ............................................................. 46 NITRO-DUR 0.4 ............................................................. 46 NITRO-DUR 0.6 ............................................................. 46 NITRO-DUR 0.8 ............................................................. 46 NITROFURANTOIN ....................................................... 19 NITROGLYCERIN .......................................................... 46 NITROL .......................................................................... 46 NITROLINGUAL PUMPSPRAY ..................................... 46 NITROSTAT ................................................................... 46 NIZATIDINE ................................................................. 145 NORETHINDRONE ..................................................... 159 NORETHINDRONE ACETATE/ ESTRADIOL-17B ...... 162





NORETHINDRONE ACETATE/ ETHINYL ESTRADIOL ................................................................................ 160

NORETHINDRONE/ ETHINYL ESTRADIOL .............. 160 NORETHINDRONE/ ETHINYL ESTRADIOL/

NORETHINDRONE/ ETHINYL ESTRADIOL .......... 160 NORETHINDRONE/ ETHINYL ESTRADIOL/

NORETHINDRONE/ ETHINYL ESTRADIOL/ NORETHINDRONE/ ETHINYL ESTRADIOL .......... 160

NORFLOXACIN ............................................................ 12 NORGESTIMATE/ ETHINYL ESTRADIOL ................. 160 NORGESTIMATE/ ETHINYL ESTRADIOL/

NORGESTIMATE/ ETHINYL ESTRADIOL/ NORGESTIMATE/ ETHINYL ESTRADIOL ............. 160

NORITATE .................................................................. 173 NORPROLAC .................................................... SEC 3.73 NORTRIPTYLINE HCL ................................................. 96 NORVASC .................................................................... 55 NOVAMILOR ............................................................... 126 NOVAMOXIN ................................................................ 10 NOVAMOXIN ................................................................ 11 NOVAMOXIN SUGAR-REDUCED ................................ 10 NOVAMOXIN SUGAR-REDUCED ................................ 11 NOVO-5 ASA .............................................................. 149 NOVO-ACEBUTOLOL .................................................. 49 NOVO-ACYCLOVIR ...................................................... 17 NOVO-ALFUZOSIN PR ..................................... SEC 3.15 NOVO-AMPICILLIN............................................ SEC 3.15 NOVO-ATORVASTATIN ............................................... 38 NOVO-AZITHROMYCIN ................................................. 9 NOVO-BENZYDAMINE ............................................... 135 NOVO-BETAHISTINE ................................................. 187 NOVO-BISOPROLOL ................................................... 50 NOVO-BROMAZEPAM ............................................... 110 NOVO-BUSPIRONE ................................................... 112 NOVO-CAPTORIL......................................................... 59 NOVO-CEFADROXIL ......................................... SEC 3.19 NOVO-CHLOROQUINE ................................................ 18 NOVO-CILAZAPRIL ...................................................... 59 NOVO-CILAZAPRIL/HCTZ ........................................... 59 NOVO-CIMETINE ....................................................... 144 NOVO-CIPROFLOXACIN .................................. SEC 3A.2 NOVO-CIPROFLOXACIN .................................. SEC 3A.3 NOVO-CITALOPRAM ................................................... 91 NOVO-CLAVAMOXIN ................................................... 11 NOVO-CLOBAZAM ....................................................... 83 NOVO-CLOBETASOL ................................................. 176 NOVO-CLONAZEPAM .................................................. 84 NOVO-CLONIDINE ..................................................... 187 NOVO-CLONIDINE ....................................................... 43 NOVO-CLOXIN ............................................................. 12 NOVO-CYCLOPRINE ................................................... 27 NOVO-DESMOPRESSIN ............................................ 167

NOVO-DIFENAC ............................................................ 72 NOVO-DIFENAC SR ...................................................... 72 NOVO-DIFLUNISAL FC ................................................. 73 NOVO-DILTAZEM .......................................................... 56 NOVO-DILTAZEM CD ................................................... 56 NOVO-DILTAZEM CD ................................................... 57 NOVO-DILTIAZEM HCL ER .......................................... 57 NOVO-DILTIAZEM HCL ER .......................................... 58 NOVO-DIVALPROEX .................................................... 85 NOVO-DIVALPROEX .................................................... 86 NOVO-DOXAZOSIN ...................................................... 47 NOVO-DOXEPIN ........................................................... 95 NOVO-DOXEPIN ........................................................... 96 NOVO-DOXYLIN ............................................................ 13 NOVO-ENALAPRIL ........................................................ 60 NOVO-ENALAPRIL/HCTZ ............................................. 60 NOVO-ETIDRONATECAL ........................................... 188 NOVO-FAMOTIDINE ................................................... 145 NOVO-FENOFIBRATE MICRONIZED ........................... 37 NOVO-FENOFIBRATE-S ............................................... 37 NOVO-FENOFIBRATE-S (TABLET) .............................. 37 NOVO-FENTANYL 100 ...................................... SEC 3.40 NOVO-FENTANYL 25 ........................................ SEC 3.39 NOVO-FENTANYL 50 ........................................ SEC 3.40 NOVO-FENTANYL 75 ........................................ SEC 3.40 NOVO-FINASTERIDE ........................................ SEC 3.41 NOVO-FLUCONAZOLE ................................................. 15 NOVO-FLURPROFEN ................................................... 73 NOVO-FLUTAMIDE ........................................... SEC 3.42 NOVO-FLUVOXAMINE .................................................. 92 NOVO-FURANTOIN ...................................................... 19 NOVO-GEMFIBROZIL ................................................... 37 NOVO-GLICLAZIDE .................................................... 165 NOVO-HYDROXYZIN .................................................. 113 NOVO-INDAPAMIDE ................................................... 127 NOVO-IPRAMIDE .......................................................... 24 NOVO-KETOCONAZOLE .............................................. 15 NOVO-KETOROLAC ..................................................... 74 NOVO-KETOTIFEN .........................................................3 NOVO-LAMOTRIGINE ................................................... 87 NOVO-LANSOPRAZOLE ............................................ 147 NOVO-LEFLUNOMIDE ................................................ 189 NOVO-LEVOCARBIDOPA ........................................... 118 NOVO-LEVOFLOXACIN .................................... SEC 3A.4 NOVO-LEXIN ...................................................................5 NOVO-LEXIN ...................................................................6 NOVO-LISINOPRIL (TYPE Z) ........................................ 61 NOVO-LISINOPRIL (TYPE Z) ........................................ 62 NOVO-LISINOPRIL/HCTZ (TYPE P) ............................. 62 NOVO-LORAZEM ........................................................ 111 NOVO-LOVASTATIN ..................................................... 39 NOVO-MAPROTILINE ................................................... 96






NOVO-MEDRONE ...................................................... 167 NOVO-METFORMIN ................................................... 163 NOVO-METHACIN ........................................................ 73 NOVO-MEXILETINE ..................................................... 35 NOVO-MINOCYCLINE .................................................. 13 NOVO-MIRTAZAPINE .................................................. 98 NOVO-MOCLOBEMIDE ................................................ 89 NOVO-MORPHINE SR ................................................. 80 NOVO-NABUMETONE ................................................. 74 NOVO-NADOLOL ......................................................... 52 NOVO-NARATRIPTAN ............................................... 114 NOVO-NARATRIPTAN ...................................... SEC 3.61 NOVO-NIZATIDINE..................................................... 145 NOVO-NORFLOXACIN ................................................. 12 NOVO-NORTRIPTYLINE .............................................. 96 NOVO-OMEPRAZOLE (DELAYED RELEASE TABLET)

................................................................................ 147 NOVO-OXYBUTYNIN ................................................. 183 NOVO-PANTOPRAZOLE ........................................... 148 NOVO-PEN-VK ............................................................. 10 NOVO-PERIDOL ......................................................... 104 NOVO-PERIDOL ......................................................... 105 NOVO-PINDOL ............................................................. 53 NOVO-PIOGLITAZONE ..................................... SEC 3.72 NOVO-PIROCAM .......................................................... 76 NOVO-PRAMIPEXOLE ............................................... 119 NOVO-PRANOL ............................................................ 53 NOVO-PRAVASTATIN .................................................. 40 NOVO-PRAZIN ............................................................. 47 NOVO-PROFEN............................................................ 73 NOVO-QUETIAPINE ................................................... 100 NOVO-QUETIAPINE ................................................... 101 NOVO-QUININE............................................................ 19 NOVO-RALOXIFENE ......................................... SEC 3.74 NOVO-RANIDINE ....................................................... 145 NOVO-RANIDINE ....................................................... 146 NOVO-RISEDRONATE ...................................... SEC 3.75 NOVO-RISPERIDONE ................................................ 102 NOVO-RISPERIDONE ................................................ 103 NOVO-RIVASTIGMINE ...................................... SEC 3.78 NOVO-RYTHRO EES ..................................................... 8 NOVO-RYTHRO ESTOLATE .......................................... 8 NOVO-SELEGILINE.................................................... 120 NOVO-SEMIDE ............................................................. 44 NOVO-SEMIDE ............................................................. 45 NOVO-SOTALOL .......................................................... 54 NOVO-SPIROTON ........................................................ 70 NOVO-SPIROZINE ....................................................... 70 NOVO-SUCRALATE ................................................... 146 NOVO-SUMATRIPTAN ............................................... 115 NOVO-SUMATRIPTAN ...................................... SEC 3.84 NOVO-SUMATRIPTAN DF ......................................... 115

NOVO-SUMATRIPTAN DF ................................ SEC 3.84 NOVO-SUNDAC ............................................................ 76 NOVO-TAMSULOSIN .................................................... 48 NOVO-TEMAZEPAM ................................................... 112 NOVO-TERBINAFINE .................................................... 15 NOVO-TIAPROFENIC ................................................... 76 NOVO-TICLOPIDINE ..................................................... 33 NOVO-TIMOL ................................................................ 54 NOVO-TOPIRAMATE .................................................... 88 NOVO-TRIAMZIDE ...................................................... 126 NOVO-TRIMEL .............................................................. 12 NOVO-TRIMEL DS ........................................................ 12 NOVO-VALPROIC ......................................................... 89 NOVO-VERAMIL SR ...................................................... 58 NOVO-WARFARIN ........................................................ 29 NOVO-WARFARIN ........................................................ 30 NOVO-ZOPICLONE ..................................................... 113 NOVOLIN GE 30/70 ..................................................... 164 NOVOLIN GE 30/70 CARTRIDGE ............................... 164 NOVOLIN GE 40/60 CARTRIDGE ............................... 164 NOVOLIN GE 50/50 CARTRIDGE ............................... 164 NOVOLIN GE NPH ...................................................... 164 NOVOLIN GE NPH CARTRIDGE ................................ 164 NOVOLIN GE TORONTO ............................................ 164 NOVOLIN GE TORONTO CARTRIDGE ...................... 164 NOVORAPID................................................................ 163 NOVORAPID CARTRIDGE ......................................... 163 NOZINAN ..................................................................... 106 NYLIDRIN HCL .............................................................. 47 NYSTATIN ..................................................................... 16

O

OCTOSTIM .................................................................. 167 OCTREOTIDE ACETATE .................................. SEC 3.61 OCTREOTIDE ACETATE .................................. SEC 3.62 OCTREOTIDE ACETATE OMEGA .................... SEC 3.61 OCUFLOX .................................................................... 131 OESCLIM 25 (5 MG/PTH) ............................................ 161 OESCLIM 50 (10 MG/PTH) .......................................... 161 OFLOXACIN ................................................................ 131 OFLOXACIN ...................................................... SEC 3A.5 OLANZAPINE .............................................................. 100 OLANZAPINE ................................................................ 99 OLANZAPINE ODT ...................................................... 100 OLESTYR LIGHT ........................................................... 36 OLESTYR REGULAR .................................................... 36 OLMESARTAN MEDOXOMIL........................................ 45 OLMESARTAN MEDOXOMIL/

HYDROCHLOROTHIAZIDE....................................... 45





OLMETEC ..................................................................... 45 OLMETEC PLUS........................................................... 45 OLSALAZINE SODIUM ............................................... 149 OMALIZUMAB ................................................... SEC 3.64 OMEPRAZOLE ........................................................... 147 OMEPRAZOLE (CAPSULE) ....................................... 147 OMNITROPE ..................................................... SEC 3.82 ONABOTULINUMTOXINA .......................................... 189 ONDANSETRON ........................................................ 142 ONDANSETRON ........................................................ 143 ONDANSETRON HCL DIHYDRATE........................... 143 ONDANSETRON OMEGA (PRESERVATIVE FREE) . 143 ONDANSETRON OMEGA (WITH PRESERVATIVE) . 143 ONDANSETRON-ODAN ............................................. 143 ONE-ALPHA ............................................................... 185 ONGLYZA .......................................................... SEC 3.80 OPIUM/ BELLADONNA ................................................ 81 OPTICHAMBER ADVANTAGE II (CHAMBER ONLY) 191 OPTICHAMBER ADVANTAGE II (WITH LARGE MASK)

................................................................................ 191 OPTICHAMBER ADVANTAGE II (WITH MEDIUM MASK)

................................................................................ 191 OPTICHAMBER ADVANTAGE II (WITH SMALL MASK)

................................................................................ 191 OPTIMYXIN PLUS ...................................................... 131 ORACORT .................................................................. 179 ORAP .......................................................................... 108 ORCIPRENALINE SULFATE ........................................ 25 ORENCIA ............................................................. SEC 3.6 ORGARAN ......................................................... SEC 3.22 ORTHO 0.5/35 (21 DAY) ............................................. 160 ORTHO 0.5/35 (28 DAY) ............................................. 160 ORTHO 1/35 (21 DAY) ................................................ 160 ORTHO 1/35 (28 DAY) ................................................ 160 ORTHO 7/7/7 (21 DAY) ............................................... 160 ORTHO 7/7/7 (28 DAY) ............................................... 160 ORTHO-CEPT (28 DAY) ............................................. 159 OXAZEPAM ................................................................ 112 OXEZE TURBUHALER ................................................. 25 OXSORALEN .............................................................. 180 OXSORALEN ULTRA ................................................. 180 OXTRIPHYLLINE ........................................................ 183 OXTRIPHYLLINE/ GUAIFENESIN .............................. 183 OXY-IR .......................................................................... 82 OXYBUTYNIN ............................................................. 183 OXYBUTYNIN CHLORIDE ......................................... 183 OXYBUTYNIN CHLORIDE ................................ SEC 3.64 OXYCODONE HCL ....................................................... 82 OXYCODONE HCL/ ACETAMINOPHEN ...................... 82 OXYCODONE HCL/ ASA .............................................. 83 OXYCODONE/ACET .................................................... 82 OXYCONTIN ................................................................. 82

OXYNEO ........................................................................ 82

P

PALIPERIDONE PALMITATE ............................ SEC 3.65 PAMIDRONATE DISODIUM ........................................ 189 PAMIDRONATE DISODIUM OMEGA .......................... 189 PANCREASE MT 10 .................................................... 141 PANCREASE MT 16 .................................................... 141 PANCREASE MT 4 ...................................................... 141 PANECTYL ......................................................................3 PANOXYL 10 ..................................................... SEC 3.18 PANOXYL 20 ..................................................... SEC 3.18 PANTOLOC ................................................................. 148 PANTOPRAZOLE ........................................................ 148 PAPAVERINE HCL ............................................ SEC 3.65 PARIET ........................................................................ 148 PARNATE ...................................................................... 89 PAROXETINE ................................................................ 93 PAROXETINE HCL ........................................................ 93 PARSITAN ................................................................... 117 PAT-GALANTAMINE ER ................................... SEC 3.42 PAXIL ............................................................................. 93 PEDIAPRED ................................................................ 158 PEGASYS (0.5 ML SYRINGE)....................................... 17 PEGASYS (0.5 ML SYRINGE)........................... SEC 3.67 PEGASYS RBV (KIT) ......................................... SEC 3.69 PEGETRON (KIT) .............................................. SEC 3.71 PEGETRON REDIPEN (KIT) ............................. SEC 3.71 PEGFILGRASTIM .............................................. SEC 3.65 PEGINTERFERON ALFA-2A ......................................... 17 PEGINTERFERON ALFA-2A ............................. SEC 3.67 PEGINTERFERON ALFA-2A/ RIBAVIRIN ......... SEC 3.69 PEGINTERFERON ALFA-2B/ RIBAVIRIN ......... SEC 3.71 PENICILLAMINE .......................................................... 153 PENICILLIN G SODIUM ................................................ 10 PENICILLIN V POTASSIUM .......................................... 10 PENTASA .................................................................... 149 PENTASA (1G/100ML) ................................................ 149 PENTASA (4G/100 ML) ............................................... 149 PENTAZOCINE HCL ..................................................... 83 PENTAZOCINE LACTATE ............................................ 83 PENTOSAN POLYSULFATE SODIUM ....................... 189 PENTOXIFYLLINE ......................................................... 33 PEPCID ........................................................................ 145 PERCOCET ................................................................... 82 PERCOCET DEMI ......................................................... 82 PERICYAZINE ............................................................. 106 PERINDOPRIL ERBUMINE ........................................... 62 PERINDOPRIL ERBUMINE ........................................... 63






PERINDOPRIL ERBUMINE/ INDAPAMIDE HEMIHYDRATE ........................................................ 63

PERPHENAZINE ........................................................ 106 PHENELZINE SULFATE ............................................... 89 PHENOBARB .............................................................. 109 PHENOBARBITAL ...................................................... 109 PHENYLEPHRINE HCL .............................................. 135 PHENYTOIN ................................................................. 84 PHENYTOIN SODIUM .................................................. 84 PHL-AMLODIPINE ........................................................ 55 PHL-ATENOLOL ........................................................... 49 PHL-ATENOLOL ........................................................... 50 PHL-AZITHROMYCIN ..................................................... 9 PHL-BACLOFEN ........................................................... 27 PHL-CARVEDILOL ....................................................... 51 PHL-CITALOPRAM ....................................................... 91 PHL-CLONAZEPAM ..................................................... 84 PHL-CLONAZEPAM-R .................................................. 84 PHL-FLUOXETINE........................................................ 92 PHL-ONDANSETRON ................................................ 143 PHL-PIOGLITAZONE ......................................... SEC 3.72 PHL-RANITIDINE ........................................................ 145 PHL-RISPERIDONE ................................................... 102 PHL-RISPERIDONE ................................................... 103 PHL-SERTRALINE........................................................ 93 PHL-SERTRALINE........................................................ 94 PHL-SIMVASTATIN ...................................................... 42 PHL-SIMVASTATIN ...................................................... 43 PHL-TOPIRAMATE ....................................................... 88 PHOSPHATE-NOVARTIS ........................................... 125 PHYTONADIONE........................................................ 185 PILOCARPINE HCL .................................................... 137 PILOCARPINE HCL ...................................................... 23 PILOPINE HS .............................................................. 137 PIMOZIDE ................................................................... 108 PINAVERIUM BROMIDE ............................................ 149 PINDOLOL .................................................................... 53 PINDOLOL/ HYDROCHLOROTHIAZIDE ...................... 53 PIOGLITAZONE HCL ......................................... SEC 3.72 PIOGLITAZONE HYDROCHLORIDE ................ SEC 3.72 PIPERACILLIN AND TAZOBACTAM ................. SEC 3.73 PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM

....................................................................... SEC 3.73 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM

....................................................................... SEC 3.73 PIPORTIL L4 ............................................................... 106 PIPOTIAZINE PALMITATE ......................................... 106 PIPRADROL HCL/ THIAMINE HCL/ RIBOFLAVIN/

PYRIDOXINE HCL/ NIACINAMIDE/ CHOLINE/ INOSITOL ............................................................... 186

PIROXICAM .................................................................. 76 PIZOTIFEN MALATE .................................................. 116

PIZOTIFEN MALATE ................................................... 120 PLAN B ........................................................................ 159 PLAQUENIL SULFATE .................................................. 18 PLAVIX .......................................................................... 32 PLAVIX .............................................................. SEC 3.20 PLENDIL ........................................................................ 55 PLENDIL ........................................................................ 56 PMS - POTASSIUM CHLORIDE .................................. 125 PMS-ALENDRONATE-FC ................................. SEC 3.14 PMS-AMANTADINE HYDROCHLORIDE .................... 116 PMS-AMIODARONE ...................................................... 36 PMS-AMLODIPINE ........................................................ 55 PMS-AMOXICILLIN ....................................................... 10 PMS-AMOXICILLIN ....................................................... 11 PMS-ATENOLOL ........................................................... 49 PMS-ATENOLOL ........................................................... 50 PMS-ATORVASTATIN ................................................... 38 PMS-AZITHROMYCIN .....................................................9 PMS-AZITHROMYCIN ....................................... SEC 3.17 PMS-BACLOFEN ........................................................... 27 PMS-BENZTROPINE ................................................... 117 PMS-BENZYDAMINE .................................................. 135 PMS-BISOPROLOL ....................................................... 50 PMS-BRIMONIDINE .................................................... 135 PMS-BUPROPION SR ................................................... 97 PMS-BUSPIRONE ....................................................... 112 PMS-CARBAMAZEPINE ............................................... 85 PMS-CARBAMAZEPINE-CR ......................................... 85 PMS-CARVEDILOL ....................................................... 51 PMS-CHLORAL HYDRATE ......................................... 112 PMS-CILAZAPRIL .......................................................... 59 PMS-CIPROFLOXACIN ............................................... 131 PMS-CIPROFLOXACIN ..................................... SEC 3A.2 PMS-CIPROFLOXACIN ..................................... SEC 3A.3 PMS-CITALOPRAM ....................................................... 91 PMS-CLARITHROMYCIN ................................................9 PMS-CLOBAZAM .......................................................... 83 PMS-CLONAZEPAM ..................................................... 84 PMS-CLONAZEPAM-R .................................................. 84 PMS-CLOPIDOGREL .................................................... 32 PMS-CLOPIDOGREL ........................................ SEC 3.20 PMS-CYCLOBENZAPRINE ........................................... 27 PMS-DEFEROXAMINE ............................................... 153 PMS-DESMOPRESSIN ............................................... 167 PMS-DESONIDE ......................................................... 177 PMS-DEXAMETHASONE ............................................ 156 PMS-DEXAMETHASONE SODIUM PHOSP ............... 156 PMS-DICLOFENAC ....................................................... 72 PMS-DICLOFENAC-SR ................................................. 72 PMS-DILTIAZEM CD ..................................................... 56 PMS-DILTIAZEM CD ..................................................... 57 PMS-DOMPERIDONE ................................................. 148





PMS-DOXAZOSIN ........................................................ 47 PMS-ENALAPRIL.......................................................... 60 PMS-ERYTHROMYCIN .............................................. 131 PMS-FENOFIBRATE MICRO ....................................... 37 PMS-FENTANYL MTX ....................................... SEC 3.39 PMS-FENTANYL MTX ....................................... SEC 3.40 PMS-FINASTERIDE ........................................... SEC 3.41 PMS-FLUCONAZOLE ................................................... 15 PMS-FLUOROMETHOLONE ...................................... 132 PMS-FLUOXETINE ....................................................... 92 PMS-FLUTAMIDE .............................................. SEC 3.42 PMS-FLUVOXAMINE .................................................... 92 PMS-GABAPENTIN ...................................................... 86 PMS-GEMFIBROZIL ..................................................... 37 PMS-GLYBURIDE....................................................... 166 PMS-HYDROCHLOROTHIAZIDE ............................... 126 PMS-HYDROMORPHONE ........................................... 78 PMS-HYDROMORPHONE ........................................... 79 PMS-HYDROXYZINE ................................................. 113 PMS-INDAPAMIDE ..................................................... 127 PMS-IPRATROPIUM .................................................... 24 PMS-IPRATROPIUM ......................................... SEC 3.55 PMS-IPRATROPIUM (1ML) ............................... SEC 3.55 PMS-IPRATROPIUM (2ML) ............................... SEC 3.55 PMS-IRBESARTAN ...................................................... 66 PMS-IRBESARTAN-HCTZ ............................................ 66 PMS-IRBESARTAN-HCTZ ............................................ 67 PMS-ISMN .................................................................... 46 PMS-KETOPROFEN ..................................................... 74 PMS-LACTULOSE ...................................................... 125 PMS-LAMOTRIGINE ..................................................... 87 PMS-LEVETIRACETAM ............................................... 87 PMS-LEVOBUNOLOL ................................................. 136 PMS-LEVOFLOXACIN ....................................... SEC 3A.4 PMS-LISINOPRIL.......................................................... 61 PMS-LISINOPRIL.......................................................... 62 PMS-LITHIUM CARBONATE ...................................... 114 PMS-LORAZEPAM ..................................................... 111 PMS-LOSARTAN .......................................................... 67 PMS-LOVASTATIN ....................................................... 39 PMS-METFORMIN...................................................... 163 PMS-METHYLPHENIDATE ........................................ 109 PMS-METOCLOPRAMIDE ......................................... 148 PMS-METOCLOPRAMIDE ......................................... 149 PMS-METOPROLOL-L ................................................. 52 PMS-MINOCYCLINE .................................................... 13 PMS-MIRTAZAPINE ..................................................... 98 PMS-MONTELUKAST ................................................ 129 PMS-MONTELUKAST ....................................... SEC 3.60 PMS-MONTELUKAST FC ........................................... 129 PMS-MONTELUKAST FC .................................. SEC 3.60 PMS-NABILONE ......................................................... 144

PMS-NAPROXEN .......................................................... 75 PMS-NAPROXEN EC .................................................... 75 PMS-NIZATIDINE ........................................................ 145 PMS-NORFLOXACIN .................................................... 12 PMS-NORTRIPTYLINE ................................................. 96 PMS-NYSTATIN ............................................................ 16 PMS-OFLOXACIN ....................................................... 131 PMS-OLANZAPINE ..................................................... 100 PMS-OLANZAPINE ....................................................... 99 PMS-OLANZAPINE ODT ............................................. 100 PMS-OMEPRAZOLE (SUSTAINED-RELEASE

CAPSULE) ............................................................... 147 PMS-OMEPRAZOLE DR (DELAYED RELEASE TABLET)

................................................................................. 147 PMS-ONDANSETRON ................................................ 143 PMS-OXTRIPHYLLINE ................................................ 183 PMS-OXYBUTYNIN ..................................................... 183 PMS-OXYCODONE ....................................................... 82 PMS-PANTOPRAZOLE ............................................... 148 PMS-PAROXETINE ....................................................... 93 PMS-PINDOLOL ............................................................ 53 PMS-PIOGLITAZONE ........................................ SEC 3.72 PMS-PIROXICAM .......................................................... 76 PMS-PRAMIPEXOLE .................................................. 119 PMS-PRAVASTATIN ..................................................... 40 PMS-PREDNISOLONE ................................................ 158 PMS-PROCYCLIDINE ................................................. 117 PMS-QUETIAPINE ...................................................... 100 PMS-QUETIAPINE ...................................................... 101 PMS-RABEPRAZOLE EC ............................................ 148 PMS-RALOXIFENE ........................................... SEC 3.74 PMS-RAMIPRIL (CAPSULE) ......................................... 63 PMS-RAMIPRIL (CAPSULE) ......................................... 64 PMS-RAMIPRIL-HCTZ .................................................. 64 PMS-RANITIDINE ........................................................ 145 PMS-REPAGLINIDE .................................................... 165 PMS-RISEDRONATE ........................................ SEC 3.75 PMS-RISPERIDONE ................................................... 102 PMS-RISPERIDONE ................................................... 103 PMS-RISPERIDONE ................................................... 104 PMS-RISPERIDONE ODT ........................................... 104 PMS-RIVASTIGMINE ........................................ SEC 3.78 PMS-ROPINIROLE ...................................................... 119 PMS-ROPINIROLE ...................................................... 120 PMS-ROSUVASTATIN .................................................. 41 PMS-SALBUTAMOL ...................................................... 25 PMS-SALBUTAMOL POLYNEB .................................... 25 PMS-SERTRALINE ........................................................ 93 PMS-SERTRALINE ........................................................ 94 PMS-SIMVASTATIN ...................................................... 42 PMS-SIMVASTATIN ...................................................... 43 PMS-SODIUM CROMOGLYCATE .............................. 130






PMS-SODIUM POLYSTYRENE SULF. ...................... 126 PMS-SOTALOL ............................................................. 54 PMS-SULFASALAZINE ................................................ 13 PMS-SUMATRIPTAN .................................................. 115 PMS-SUMATRIPTAN ......................................... SEC 3.84 PMS-TERAZOSIN ......................................................... 48 PMS-TERBINAFINE ...................................................... 15 PMS-TIMOLOL ........................................................... 136 PMS-TOBRAMYCIN ................................................... 131 PMS-TOPIRAMATE ...................................................... 88 PMS-TRAZODONE ....................................................... 94 PMS-URSODIOL C ..................................................... 141 PMS-VALACYCLOVIR (CAPLET) ................................ 18 PMS-VALPROIC ACID .................................................. 89 PMS-VALPROIC ACID E.C. .......................................... 89 PMS-VANCOMYCIN ..................................................... 14 PMS-VENLAFAXINE XR ............................................... 90 PMS-VERAPAMIL SR ................................................... 58 PMS-ZOLMITRIPTAN ................................................. 116 PMS-ZOLMITRIPTAN ........................................ SEC 3.95 PMS-ZOLMITRIPTAN ODT ........................................ 116 PMS-ZOLMITRIPTAN ODT ............................... SEC 3.95 PMS-ZOPICLONE....................................................... 113 PODOFILOX ............................................................... 181 PORTIA 21 .................................................................. 159 PORTIA 28 .................................................................. 159 POTABA ...................................................................... 180 POTASSIUM CHLORIDE (K+) .................................... 125 POTASSIUM CHLORIDE (K+)(CL-) ............................ 125 POTASSIUM CITRATE (K+) ....................................... 125 PRADAX ............................................................ SEC 3.22 PRAMIPEXOLE .......................................................... 119 PRAMIPEXOLE DIHYDROCHLORIDE ....................... 119 PRAVACHOL ................................................................ 40 PRAVASTATIN ............................................................. 40 PRAVASTATIN SODIUM .............................................. 40 PRAZOSIN HCL ............................................................ 47 PRED FORTE ............................................................. 133 PRED MILD ................................................................. 133 PREDNISOLONE ACETATE ...................................... 133 PREDNISOLONE ACETATE/ SULFACETAMIDE

SODIUM .................................................................. 133 PREDNISOLONE SODIUM PHOSPHATE ................. 158 PREDNISONE ............................................................ 158 PREMARIN ................................................................. 161 PREVACID .................................................................. 147 PREVEX B .................................................................. 176 PREVEX HC ............................................................... 177 PRIMAQUINE PHOSPHATE ........................................ 18 PRIMAXIN .......................................................... SEC 3.47 PRIMIDONE .................................................................. 83 PRINIVIL ....................................................................... 61

PRINIVIL ........................................................................ 62 PRINZIDE ...................................................................... 62 PROBENECID ............................................................. 127 PROCAINAMIDE HCL ................................................... 35 PROCAN SR .................................................................. 35 PROCHLORPERAZINE ............................................... 142 PROCTODAN-HC ........................................................ 178 PROCTOFOAM-HC ..................................................... 178 PROCTOL .................................................................... 179 PROCTOSEDYL .......................................................... 179 PROCYCLIDINE HCL .................................................. 117 PROGESTERONE ....................................................... 167 PROGLYCEM ................................................................ 44 PROLIA .............................................................. SEC 3.24 PROLOPA 100-25 ........................................................ 117 PROLOPA 200-50 ........................................................ 117 PROLOPA 50-12.5 ....................................................... 117 PROMETHAZINE .............................................................3 PROMETHAZINE HCL ....................................................3 PROMETRIUM............................................................. 167 PROPADERM .............................................................. 175 PROPAFENONE HCL ................................................... 35 PROPARACAINE HCL ................................................ 134 PROPRANOLOL HCL .................................................... 53 PROPYL-THYRACIL .................................................... 169 PROPYLTHIOURACIL ................................................. 169 PROSCAR ......................................................... SEC 3.41 PROSTIGMIN ................................................................ 23 PROSTIN VR ................................................................. 46 PROTOPIC ........................................................ SEC 3.85 PROTOPIC ........................................................ SEC 3.86 PROVERA ................................................................... 167 PROZAC ........................................................................ 92 PULMICORT NEBUAMP ............................................. 155 PULMICORT TURBUHALER ....................................... 155 PYRIDOSTIGMINE BROMIDE ...................................... 23 PYRIMETHAMINE ......................................................... 18

Q

QUETIAPINE ............................................................... 100 QUETIAPINE ............................................................... 101 QUETIAPINE FUMARATE ........................................... 100 QUETIAPINE FUMARATE ........................................... 101 QUINAGOLIDE .................................................. SEC 3.73 QUINAPRIL HCL ............................................................ 63 QUINAPRIL HCL/ HYDROCHLOROTHIAZIDE ............. 63 QUININE SULFATE ....................................................... 19 QVAR CFC-FREE ........................................................ 155





R

RABEPRAZOLE EC .................................................... 148 RABEPRAZOLE SODIUM .......................................... 148 RALOXIFENE HCL ............................................ SEC 3.74 RAMIPRIL ..................................................................... 63 RAMIPRIL ..................................................................... 64 RAMIPRIL (CAPSULE) ................................................. 63 RAMIPRIL (CAPSULE) ................................................. 64 RAMIPRIL/ HYDROCHLOROTHIAZIDE ....................... 64 RAN-AMLODIPINE ....................................................... 55 RAN-ATENOLOL .......................................................... 49 RAN-ATENOLOL .......................................................... 50 RAN-ATORVASTATIN .................................................. 38 RAN-CARVEDILOL ....................................................... 51 RAN-CEFPROZIL ........................................................... 6 RAN-CIPROFLOX .............................................. SEC 3A.2 RAN-CIPROFLOX .............................................. SEC 3A.3 RAN-CITALO ................................................................ 91 RAN-DOMPERIDONE ................................................ 148 RAN-ENALAPRIL .......................................................... 60 RAN-FENTANYL MATRIX ................................. SEC 3.39 RAN-FENTANYL MATRIX ................................. SEC 3.40 RAN-FINASTERIDE ........................................... SEC 3.41 RAN-FOSINOPRIL ........................................................ 61 RAN-GABAPENTIN ...................................................... 86 RAN-IRBESARTAN HCTZ ............................................ 66 RAN-IRBESARTAN HCTZ ............................................ 67 RAN-LISINOPRIL .......................................................... 61 RAN-LISINOPRIL .......................................................... 62 RAN-METFORMIN ...................................................... 163 RAN-NABILONE ......................................................... 144 RAN-OMEPRAZOLE (DELAYED RELEASE TABLET)147 RAN-ONDANSETRON ................................................ 143 RAN-PANTOPRAZOLE .............................................. 148 RAN-PRAVASTATIN ..................................................... 40 RAN-RABEPRAZOLE ................................................. 148 RAN-RAMIPRIL (CAPSULE) ........................................ 63 RAN-RAMIPRIL (CAPSULE) ........................................ 64 RAN-RANITIDINE ....................................................... 145 RAN-RISPERIDONE ................................................... 102 RAN-RISPERIDONE ................................................... 103 RAN-ROPINIROLE ..................................................... 119 RAN-ROPINIROLE ..................................................... 120 RAN-ROSUVASTATIN .................................................. 41 RAN-SERTRALINE ....................................................... 93 RAN-SERTRALINE ....................................................... 94 RAN-SIMVASTATIN ...................................................... 42 RAN-SIMVASTATIN ...................................................... 43 RAN-VALSARTAN ........................................................ 69 RAN-VENLAFAXINE XR ............................................... 90

RAN-ZOPICLONE ........................................................ 113 RANIBIZUMAB............................................................. 139 RANITIDINE ................................................................. 145 RANITIDINE ................................................................. 146 RANITIDINE HCL ......................................................... 145 RANITIDINE HCL ......................................................... 146 RATIO-ACLAVULANATE ............................................... 11 RATIO-ACLAVULANATE 125F...................................... 11 RATIO-ACLAVULANATE 250F...................................... 11 RATIO-ACYCLOVIR ...................................................... 17 RATIO-ALENDRONATE .................................... SEC 3.14 RATIO-AMCINONIDE .................................................. 175 RATIO-AMIODARONE .................................................. 36 RATIO-AMLODIPINE ..................................................... 55 RATIO-ATENOLOL ........................................................ 49 RATIO-ATENOLOL ........................................................ 50 RATIO-ATORVASTATIN ............................................... 38 RATIO-AZITHROMYCIN ..................................................9 RATIO-BACLOFEN ........................................................ 27 RATIO-BRIMONIDINE ................................................. 135 RATIO-BUPROPION SR ............................................... 97 RATIO-CARVEDILOL .................................................... 51 RATIO-CEFUROXIME .....................................................7 RATIO-CIPROFLOXACIN .................................. SEC 3A.2 RATIO-CIPROFLOXACIN .................................. SEC 3A.3 RATIO-CITALOPRAM .................................................... 91 RATIO-CLARITHROMYCIN .............................................9 RATIO-CLOBETASOL ................................................. 176 RATIO-CLONAZEPAM .................................................. 84 RATIO-CODEINE ........................................................... 77 RATIO-DEXAMETHASONE ........................................ 156 RATIO-DILTIAZEM CD .................................................. 56 RATIO-DILTIAZEM CD .................................................. 57 RATIO-DOMPERIDONE MALEATE ............................ 148 RATIO-ECTOSONE MILD ........................................... 176 RATIO-ECTOSONE REGULAR ................................... 176 RATIO-ECTOSONE SCALP ........................................ 176 RATIO-EMTEC-30 ......................................................... 77 RATIO-FENOFIBRATE MC ........................................... 37 RATIO-FENTANYL ............................................ SEC 3.39 RATIO-FENTANYL ............................................ SEC 3.40 RATIO-FINASTERIDE ....................................... SEC 3.41 RATIO-FLUOXETINE HYDROCHLORIDE .................... 92 RATIO-FLUVOXAMINE ................................................. 92 RATIO-GABAPENTIN .................................................... 86 RATIO-GENTAMICIN SULFATE ................................. 173 RATIO-GLYBURIDE .................................................... 166 RATIO-HEMCORT H.C. ............................................... 178 RATIO-INDOMETHACIN ............................................... 73 RATIO-IPRA SAL UDV .................................................. 24 RATIO-IPRATROPIUM UDV.............................. SEC 3.55 RATIO-IRBESARTAN .................................................... 66






RATIO-IRBESARTAN HCTZ ......................................... 66 RATIO-IRBESARTAN HCTZ ......................................... 67 RATIO-KETOROLAC .................................................. 134 RATIO-LACTULOSE ................................................... 125 RATIO-LAMOTRIGINE ................................................. 87 RATIO-LENOLTEC NO.2 .............................................. 77 RATIO-LENOLTEC NO.3 .............................................. 77 RATIO-LENOLTEC NO.4 .............................................. 77 RATIO-LEVOBUNOLOL ............................................. 136 RATIO-LISINOPRIL P ................................................... 61 RATIO-LISINOPRIL P ................................................... 62 RATIO-LISINOPRIL Z ................................................... 61 RATIO-LISINOPRIL Z ................................................... 62 RATIO-LOVASTATIN .................................................... 39 RATIO-METFORMIN HYDROCHLORIDE .................. 163 RATIO-METHOTREXATE SODIUM ............................. 21 RATIO-MOMETASONE .............................................. 178 RATIO-MORPHINE ....................................................... 79 RATIO-NYSTATIN ........................................................ 16 RATIO-OMEPRAZOLE (SUSTAINED-RELEASE

TABLET) ................................................................. 147 RATIO-ONDANSETRON ............................................ 143 RATIO-OXYCOCET ...................................................... 82 RATIO-OXYCODAN ...................................................... 83 RATIO-PAROXETINE ................................................... 93 RATIO-PIOGLITAZONE ..................................... SEC 3.72 RATIO-PREDNISOLONE ............................................ 133 RATIO-PROCTOSONE ............................................... 179 RATIO-RANITIDINE .................................................... 145 RATIO-RISEDRONATE ..................................... SEC 3.75 RATIO-RIVASTIGMINE ..................................... SEC 3.78 RATIO-SALBUTAMOL .................................................. 25 RATIO-SALBUTAMOL SULF U.D.P.F. ......................... 25 RATIO-SALBUTAMOL UNI DOSE P.F. ........................ 25 RATIO-SALBUTAMOL UNIT DOSE P.F ....................... 25 RATIO-SOTALOL.......................................................... 54 RATIO-TAMSULOSIN ................................................... 48 RATIO-TECNAL ............................................................ 71 RATIO-TECNAL-C 1/2 .................................................. 76 RATIO-TECNAL-C 1/4 .................................................. 76 RATIO-TERAZOSIN ...................................................... 48 RATIO-TOPILENE ...................................................... 175 RATIO-TOPISALIC ..................................................... 175 RATIO-TOPISONE...................................................... 175 RATIO-TRYPTOPHAN .................................................. 97 RATIO-VALPROIC ........................................................ 89 RATIO-VENLAFAXINE XR ........................................... 90 RATIO-ZOPICLONE ................................................... 113 REBIF (0.5 ML SYRINGE) ................................... SEC 2.4 REBIF (1.5 ML CARTRIDGE) .............................. SEC 2.4 RECOMBIVAX-HB ...................................................... 171 REMERON .................................................................... 98

REMICADE ........................................................ SEC 3.55 REMINYL ER ..................................................... SEC 3.42 RENEDIL ....................................................................... 55 RENEDIL ....................................................................... 56 REPAGLINIDE ............................................................. 165 REQUIP ....................................................................... 119 REQUIP ....................................................................... 120 RESONIUM CALCIUM ................................................. 125 RESTORIL ................................................................... 112 RHINOCORT TURBUHALER ...................................... 132 RHO-NITRO PUMPSPRAY ........................................... 46 RHOTRAL ...................................................................... 49 RHOVANE ................................................................... 113 RIDAURA ..................................................................... 151 RIFABUTIN ........................................................ SEC 3.74 RILUTEK ............................................................ SEC 3.74 RILUZOLE ......................................................... SEC 3.74 RIMSO-50 .................................................................... 188 RISEDRONATE ................................................. SEC 3.75 RISEDRONATE SODIUM .................................. SEC 3.75 RISPERDAL ................................................................. 102 RISPERDAL ................................................................. 103 RISPERDAL ................................................................. 104 RISPERDAL CONSTA ....................................... SEC 3.76 RISPERDAL M-TAB ..................................................... 104 RISPERIDONE ............................................................ 102 RISPERIDONE ............................................................ 103 RISPERIDONE ............................................................ 104 RISPERIDONE .................................................. SEC 3.76 RISPERIDONE TARTRATE ........................................ 104 RITALIN ....................................................................... 109 RITALIN SR ................................................................. 109 RITUXAN ........................................................... SEC 3.77 RITUXIMAB........................................................ SEC 3.77 RIVAROXABAN ............................................................. 32 RIVASTIGMINE HYDROGEN TARTRATE ........ SEC 3.78 RIVOTRIL ...................................................................... 84 RIZATRIPTAN BENZOATE ......................................... 114 RIZATRIPTAN BENZOATE ......................................... 115 RIZATRIPTAN BENZOATE ............................... SEC 3.79 ROCALTROL ............................................................... 185 ROPINIROLE ............................................................... 119 ROPINIROLE ............................................................... 120 ROPINIROLE HCL ....................................................... 119 ROPINIROLE HCL ....................................................... 120 ROSASOL .................................................................... 173 ROSIGLITAZONE MALEATE ............................ SEC 3.79 ROSIGLITAZONE MALEATE/ METFORMIN HCL

....................................................................... SEC 3.80 ROSUVASTATIN CALCIUM .......................................... 41 ROUGIER MAGNESIUM ............................................. 125 RYTHMODAN ................................................................ 35





RYTHMOL ..................................................................... 35

S

SABRIL ......................................................................... 89 SAIZEN .............................................................. SEC 3.82 SAIZEN (1.5 ML) ................................................ SEC 3.82 SAIZEN (2.5 ML) ................................................ SEC 3.82 SALAGEN ..................................................................... 23 SALAZOPYRIN ............................................................. 13 SALAZOPYRIN EN-TABS ............................................. 13 SALBUTAMOL .............................................................. 25 SALBUTAMOL SULFATE ............................................. 25 SALMETEROL XINAFOATE ......................................... 25 SALMETEROL XINAFOATE/ FLUTICASONE

PROPIONATE ........................................................... 25 SALMETEROL XINAFOATE/ FLUTICASONE

PROPIONATE ........................................................... 26 SALOFALK .................................................................. 149 SALOFALK (2G/60G) .................................................. 149 SALOFALK (4G/60G) .................................................. 149 SANDOMIGRAN ......................................................... 116 SANDOMIGRAN DS ................................................... 120 SANDOSTATIN .................................................. SEC 3.61 SANDOSTATIN LAR .......................................... SEC 3.61 SANDOSTATIN LAR .......................................... SEC 3.62 SANDOZ FLUOXETINE ............................................... 92 SANDOZ GLYBURIDE ............................................... 166 SANDOZ ALENDRONATE ................................ SEC 3.14 SANDOZ ALFUZOSIN ....................................... SEC 3.15 SANDOZ AMIODARONE .............................................. 36 SANDOZ AMLODIPINE ................................................ 55 SANDOZ ANUZINC HC .............................................. 178 SANDOZ ANUZINC HC PLUS .................................... 178 SANDOZ ATENOLOL ................................................... 49 SANDOZ ATENOLOL ................................................... 50 SANDOZ ATORVASTATIN ........................................... 38 SANDOZ AZITHROMYCIN ............................................. 9 SANDOZ BISOPROLOL ............................................... 50 SANDOZ BRIMONIDINE ............................................ 135 SANDOZ BUPROPION SR ........................................... 97 SANDOZ CALCITONIN NS ................................ SEC 3.85 SANDOZ CANDESARTAN ........................................... 65 SANDOZ CARBAMAZEPINE ........................................ 85 SANDOZ CARBAMAZEPINE CR.................................. 85 SANDOZ CEFPROZIL .................................................... 6 SANDOZ CIPROFLOXACIN .............................. SEC 3A.2 SANDOZ CIPROFLOXACIN .............................. SEC 3A.3 SANDOZ CITALOPRAM ............................................... 91 SANDOZ CLARITHROMYCIN ........................................ 9

SANDOZ CLONAZEPAM .............................................. 84 SANDOZ CLOPIDOGREL ............................................. 32 SANDOZ CLOPIDOGREL ................................. SEC 3.20 SANDOZ CYCLOSPORINE ............................... SEC 3.21 SANDOZ DEXAMETHASONE SOD. PHOSPHATE .... 132 SANDOZ DICLOFENAC ................................................ 72 SANDOZ DICLOFENAC SR .......................................... 72 SANDOZ DILTIAZEM CD .............................................. 56 SANDOZ DILTIAZEM CD .............................................. 57 SANDOZ DILTIAZEM T ................................................. 57 SANDOZ DILTIAZEM T ................................................. 58 SANDOZ DORZOLAMIDE ........................................... 136 SANDOZ DORZOLAMIDE/ TIMOLOL ......................... 138 SANDOZ ENALAPRIL ................................................... 60 SANDOZ ESTRADIOL DERM 100 (8 MG/PTH) .......... 161 SANDOZ ESTRADIOL DERM 50 (4 MG/PTH) ............ 161 SANDOZ ESTRADIOL DERM 75 (6 MG/PTH) ............ 161 SANDOZ FELODIPINE .................................................. 55 SANDOZ FELODIPINE .................................................. 56 SANDOZ FENOFIBRATE S ........................................... 37 SANDOZ FENOFIBRATE S (TABLET) .......................... 37 SANDOZ FENTANYL PATCH ........................... SEC 3.39 SANDOZ FENTANYL PATCH ........................... SEC 3.40 SANDOZ FINASTERIDE ................................... SEC 3.41 SANDOZ FLUOXETINE ................................................. 92 SANDOZ FLUVOXAMINE ............................................. 92 SANDOZ GENTAMICIN SULFATE .............................. 131 SANDOZ GLYBURIDE ................................................ 166 SANDOZ INDOMETHACIN ........................................... 73 SANDOZ IRBESARTAN ................................................ 66 SANDOZ IRBESARTAN HCT ........................................ 66 SANDOZ IRBESARTAN HCT ........................................ 67 SANDOZ LATANOPROST .......................................... 137 SANDOZ LEFLUNOMIDE ............................................ 189 SANDOZ LEVOBUNOLOL .......................................... 136 SANDOZ LEVOFLOXACIN ................................ SEC 3A.4 SANDOZ LISINOPRIL ................................................... 61 SANDOZ LISINOPRIL ................................................... 62 SANDOZ LISINOPRIL HCT ........................................... 62 SANDOZ LOSARTAN .................................................... 67 SANDOZ LOSARTAN HCT ........................................... 67 SANDOZ LOSARTAN HCT DS...................................... 68 SANDOZ LOVASTATIN ................................................. 39 SANDOZ METFORMIN FC .......................................... 163 SANDOZ METHYLPHENIDATE .................................. 109 SANDOZ METOPROLOL (TYPE L) ............................... 52 SANDOZ METOPROLOL SR ........................................ 52 SANDOZ MINOCYCLINE .............................................. 13 SANDOZ MIRTAZAPINE ............................................... 98 SANDOZ MONTELUKAST .......................................... 129 SANDOZ MONTELUKAST ................................ SEC 3.60 SANDOZ MORPHINE SR .............................................. 80






SANDOZ NARATRIPTAN ........................................... 114 SANDOZ NARATRIPTAN .................................. SEC 3.61 SANDOZ NITRAZEPAM ............................................. 112 SANDOZ OLANZAPINE .............................................. 100 SANDOZ OLANZAPINE ................................................ 99 SANDOZ OLANZAPINE ODT ..................................... 100 SANDOZ OMEPRAZOLE (SUSTAINED-RELEASE

CAPSULE) .............................................................. 147 SANDOZ ONDANSETRON ........................................ 143 SANDOZ OPIUM & BELLADONNA .............................. 81 SANDOZ OPTICORT .................................................. 133 SANDOZ PANTOPRAZOLE ....................................... 148 SANDOZ PAROXETINE ............................................... 93 SANDOZ PENTASONE .............................................. 133 SANDOZ PINDOLOL .................................................... 53 SANDOZ PIOGLITAZONE ................................. SEC 3.72 SANDOZ PRAMIPEXOLE ........................................... 119 SANDOZ PRAVASTATIN ............................................. 40 SANDOZ PREDNISOLONE ACETATE ...................... 133 SANDOZ PROCHLORPERAZINE .............................. 142 SANDOZ PROCTOMYXIN HC ................................... 179 SANDOZ QUETIAPINE ............................................... 100 SANDOZ QUETIAPINE ............................................... 101 SANDOZ RABEPRAZOLE .......................................... 148 SANDOZ RAMIPRIL (TABLET) .................................... 63 SANDOZ RAMIPRIL (TABLET) .................................... 64 SANDOZ RANITIDINE ................................................ 145 SANDOZ REPAGLINIDE ............................................ 165 SANDOZ RISEDRONATE ................................. SEC 3.75 SANDOZ RISPERIDONE ............................................ 102 SANDOZ RISPERIDONE ............................................ 103 SANDOZ RIVASTIGMINE .................................. SEC 3.78 SANDOZ RIZATRIPTAN ODT .................................... 114 SANDOZ RIZATRIPTAN ODT .................................... 115 SANDOZ RIZATRIPTAN ODT ........................... SEC 3.79 SANDOZ ROSUVASTATIN .......................................... 41 SANDOZ SALBUTAMOL .............................................. 25 SANDOZ SERTRALINE ................................................ 93 SANDOZ SERTRALINE ................................................ 94 SANDOZ SIMVASTATIN .............................................. 42 SANDOZ SIMVASTATIN .............................................. 43 SANDOZ SOTALOL ...................................................... 54 SANDOZ SUMATRIPTAN ........................................... 115 SANDOZ SUMATRIPTAN .................................. SEC 3.84 SANDOZ TAMSULOSIN ............................................... 48 SANDOZ TAMSULOSIN CR ......................................... 48 SANDOZ TELMISARTAN ............................................. 68 SANDOZ TERBINAFINE ............................................... 15 SANDOZ TICLOPIDINE ................................................ 33 SANDOZ TIMOLOL MALEATE ................................... 136 SANDOZ TOBRAMYCIN ............................................ 131 SANDOZ TOPIRAMATE ............................................... 88

SANDOZ TRIFLURIDINE ............................................ 131 SANDOZ VALPROIC ..................................................... 89 SANDOZ VALSARTAN .................................................. 69 SANDOZ VALSARTAN HCT.......................................... 69 SANDOZ VALSARTAN HCT.......................................... 70 SANDOZ VENLAFAXINE XR......................................... 90 SANDOZ ZOLMITRIPTAN ........................................... 116 SANDOZ ZOLMITRIPTAN ................................. SEC 3.95 SANDOZ ZOLMITRIPTAN ODT .................................. 116 SANDOZ ZOLMITRIPTAN ODT ........................ SEC 3.95 SANDOZ ZOPICLONE ................................................ 113 SANDOZ-OXYCODONE ACET ..................................... 82 SANTYL ....................................................................... 181 SARNA HC .................................................................. 177 SAXAGLIPTIN HCL ........................................... SEC 3.80 SECTRAL ...................................................................... 49 SELECT 1/35 (21 DAY) ............................................... 160 SELECT 1/35 (28 DAY) ............................................... 160 SELEGILINE HCL ........................................................ 120 SEPTA-AMLODIPINE .................................................... 55 SEPTA-ATENOLOL ....................................................... 49 SEPTA-ATENOLOL ....................................................... 50 SEPTA-CITALOPRAM ................................................... 91 SEPTA-ONDANSETRON ............................................ 143 SEPTRA ......................................................................... 12 SERC ........................................................................... 187 SEREVENT .................................................................... 25 SEREVENT DISKHALER ............................................ 191 SEREVENT DISKUS ..................................................... 25 SEROPHENE............................................................... 162 SEROQUEL ................................................................. 100 SEROQUEL ................................................................. 101 SERTRALINE................................................................. 93 SERTRALINE................................................................. 94 SERTRALINE HCL ........................................................ 93 SERTRALINE HCL ........................................................ 94 SIMPONI ............................................................ SEC 3.46 SIMVASTATIN ............................................................... 42 SIMVASTATIN ............................................................... 43 SIMVASTATIN-ODAN .................................................... 42 SIMVASTATIN-ODAN .................................................... 43 SINEMET 100/10 ......................................................... 118 SINEMET 100/25 ......................................................... 118 SINEMET 250/25 ......................................................... 118 SINEMET CR 100/25 ................................................... 118 SINEMET CR 200/50 ................................................... 118 SINEQUAN .................................................................... 95 SINEQUAN .................................................................... 96 SINGULAIR .................................................................. 129 SINGULAIR ........................................................ SEC 3.60 SINTROM ...................................................................... 29 SITAGLIPTIN PHOSPHATE MONOHYDRATE . SEC 3.81





SITAGLIPTIN PHOSPHATE MONOHYDRATE/ METFORMIN HCL ......................................... SEC 3.81

SLOW K ...................................................................... 125 SODIUM ACID PHOSPHATE/ SODIUM BICARBONATE/

POTASSIUM BICARBONATE ................................ 125 SODIUM AUROTHIOMALATE .................................... 151 SODIUM CROMOGLYCATE ...................................... 130 SODIUM FLUORIDE ................................................... 121 SODIUM FUSIDATE ................................................... 174 SODIUM POLYSTYRENE SULFONATE .................... 126 SODIUM TETRADECYL SULFATE .............................. 47 SOFRACORT .............................................................. 133 SOLIFENACIN SUCCINATE .............................. SEC 3.82 SOLIRIS ............................................................. SEC 3.30 SOLU-CORTEF .......................................................... 156 SOLU-CORTEF .......................................................... 157 SOLU-MEDROL .......................................................... 157 SOLU-MEDROL ACT-O-VIAL (PRESERVATIVE FREE)

................................................................................ 157 SOLU-MEDROL ACT-O-VIAL (WITH PRESERVATIVE)

................................................................................ 157 SOLYSTAT ................................................................. 126 SOMATROPIN ................................................... SEC 3.82 SOMATROPIN R-DNA ORIGIN ......................... SEC 3.82 SOMATULINE AUTOGEL (0.3 ML SYRINGE) .. SEC 3.56 SOMATULINE AUTOGEL (0.5 ML SYRINGE) .. SEC 3.56 SORIATANE ............................................................... 180 SOTALOL HCL ............................................................. 54 SPACE CHAMBER ..................................................... 191 SPACE CHAMBER ADULT MASK ............................. 191 SPACE CHAMBER INFANT MASK ............................ 191 SPACE CHAMBER PEDIATRIC MASK ...................... 191 SPIRIVA ........................................................................ 24 SPIRONOLACTONE ..................................................... 70 SPORANOX .................................................................. 15 SPORANOX ....................................................... SEC 3.55 STALEVO .................................................................... 118 STATEX ........................................................................ 80 STATEX ........................................................................ 81 STELARA (0.5 ML VIAL OR SYRINGE) ............ SEC 3.91 STIEVA-A ........................................................... SEC 3.89 STIEVA-A ........................................................... SEC 3.90 STIEVA-A FORTE .............................................. SEC 3.89 STIEVAMYCIN FORTE ...................................... SEC 3.32 STIEVAMYCIN MILD ......................................... SEC 3.32 STIEVAMYCIN REGULAR ................................. SEC 3.32 SUBOXONE .................................................................. 83 SUCRALFATE ............................................................ 146 SULCRATE ................................................................. 146 SULCRATE SUSPENSION PLUS .............................. 146 SULFACET-R ..................................................... SEC 3.83 SULFAMETHOXAZOLE/ TRIMETHOPRIM .................. 12

SULFASALAZINE .......................................................... 13 SULFINPYRAZONE ..................................................... 127 SULFUR/ SULFACETAMIDE SODIUM ............. SEC 3.83 SULINDAC ..................................................................... 76 SUMATRIPTAN ........................................................... 115 SUMATRIPTAN ................................................. SEC 3.84 SUMATRIPTAN HEMISULFATE ................................. 115 SUMATRIPTAN HEMISULFATE ....................... SEC 3.83 SUMATRIPTAN SUCCINATE ...................................... 115 SUMATRIPTAN SUCCINATE ............................ SEC 3.84 SUMATRIPTAN SUN (0.5 ML)..................................... 115 SUMATRIPTAN SUN (0.5 ML)........................... SEC 3.84 SUPEUDOL ................................................................... 82 SUPRAX ..........................................................................7 SUPREFACT ..................................................... SEC 3.18 SUPREFACT DEPOT ........................................ SEC 3.18 SUPREFACT INTRANASAL .............................. SEC 3.18 SYMBICORT 100 TURBUHALER .................................. 24 SYMBICORT 200 TURBUHALER .................................. 24 SYNACTHEN DEPOT .................................................. 166 SYNAREL .................................................................... 189 SYNPHASIC (21 DAY) ................................................. 160 SYNPHASIC (28 DAY) ................................................. 160 SYNTHETIC CALCITONIN SALMON (SALCATONIN)

................................................................................. 166 SYNTHETIC CALCITONIN SALMON (SALCATONIN)

....................................................................... SEC 3.85 SYNTHROID ................................................................ 168

T

TACROLIMUS.................................................... SEC 3.85 TACROLIMUS.................................................... SEC 3.86 TALWIN ......................................................................... 83 TAMBOCOR .................................................................. 35 TAMSULOSIN HCL ........................................................ 48 TAPAZOLE .................................................................. 169 TARO-AMCINONIDE ................................................... 175 TARO-CARBAMAZEPINE ............................................. 85 TARO-CLOBETASOL .................................................. 176 TARO-MOMETASONE ................................................ 178 TARO-MUPIROCIN ..................................................... 174 TARO-PHENYTOIN ....................................................... 84 TARO-WARFARIN ......................................................... 29 TARO-WARFARIN ......................................................... 30 TAZAROTENE ............................................................. 181 TAZOCIN ........................................................... SEC 3.73 TAZORAC .................................................................... 181 TECTA ......................................................................... 148 TEGRETOL .................................................................... 85 TEGRETOL CR .............................................................. 85






TELMISARTAN ............................................................. 68 TELMISARTAN/ AMLODIPINE BESYLATE .................. 68 TELMISARTAN/ HYDROCHLOROTHIAZIDE ............... 68 TEMAZEPAM .............................................................. 112 TENOFOVIR DISOPROXIL FUMARATE ...................... 16 TENORETIC 50/25....................................................... 50 TENORETIC 100/25...................................................... 50 TENORMIN ................................................................... 49 TENORMIN ................................................................... 50 TENOXICAM ................................................................. 76 TERAZOSIN .................................................................. 48 TERAZOSIN HCL.......................................................... 48 TERBINAFINE .............................................................. 15 TERBINAFINE HCL ...................................................... 15 TERBINAFINE HCL .................................................... 174 TERBUTALINE SULFATE ............................................ 26 TESTOSTERONE .............................................. SEC 3.86 TESTOSTERONE CYPIONATE ................................. 158 TESTOSTERONE ENANTHATE ................................ 158 TESTOSTERONE UNDECANOATE .................. SEC 3.86 TETRABENAZINE.............................................. SEC 3.87 TETRACYCLINE ........................................................... 13 TETRACYCLINE HCL ................................................... 13 TEVA-ALENDRONATE ...................................... SEC 3.14 TEVA-ALPRAZOL ....................................................... 110 TEVA-AMIODARONE ................................................... 36 TEVA-AMLODIPINE...................................................... 55 TEVA-ATENOL ............................................................. 49 TEVA-ATENOL ............................................................. 50 TEVA-ATENOLOL......................................................... 49 TEVA-ATENOLTHALIDONE ......................................... 50 TEVA-AZATHIOPRINE ............................................... 187 TEVA-CANDESARTAN ................................................. 65 TEVA-CARBAMAZ ........................................................ 85 TEVA-CHLORPROMAZINE ........................................ 105 TEVA-CLINDAMYCIN ................................................... 14 TEVA-CLOPIDOGREL .................................................. 32 TEVA-CLOPIDOGREL ....................................... SEC 3.20 TEVA-DOMPERIDONE ............................................... 148 TEVA-DORZOTIMOL .................................................. 138 TEVA-ENTACAPONE ................................................. 117 TEVA-FLUOXETINE ..................................................... 92 TEVA-FOSINOPRIL ...................................................... 61 TEVA-GABAPENTIN ..................................................... 86 TEVA-GALANTAMINE ER ................................. SEC 3.42 TEVA-GLYBURIDE ..................................................... 166 TEVA-HYDROMORPHONE .......................................... 78 TEVA-IRBESARTAN ..................................................... 66 TEVA-IRBESARTAN/HCTZ .......................................... 66 TEVA-IRBESARTAN/HCTZ .......................................... 67 TEVA-LACTULOSE .................................................... 125 TEVA-LISINOPRIL (TYPE P) ........................................ 61

TEVA-LISINOPRIL (TYPE P) ......................................... 62 TEVA-LISINOPRIL/HCTZ (TYPE Z) .............................. 62 TEVA-LOSARTAN ......................................................... 67 TEVA-LOSARTAN/HCTZ ............................................... 67 TEVA-LOSARTAN/HCTZ ............................................... 68 TEVA-METOPROL ........................................................ 52 TEVA-METOPROL (FC) ................................................ 52 TEVA-MONTELUKAST ................................................ 129 TEVA-MONTELUKAST ...................................... SEC 3.60 TEVA-NAPROX ............................................................. 74 TEVA-NAPROX EC ....................................................... 75 TEVA-NAPROX SODIUM .............................................. 75 TEVA-NAPROX SODIUM DS ........................................ 75 TEVA-OLANZAPINE .................................................... 100 TEVA-OLANZAPINE ...................................................... 99 TEVA-OLANZAPINE OD ............................................. 100 TEVA-ONDANSETRON ............................................... 143 TEVA-PAROXETINE ..................................................... 93 TEVA-RABEPRAZOLE ................................................ 148 TEVA-RAMIPRIL (CAPSULE)........................................ 63 TEVA-RAMIPRIL (CAPSULE)........................................ 64 TEVA-ROSUVASTATIN ................................................. 41 TEVA-SERTRALINE ...................................................... 93 TEVA-SERTRALINE ...................................................... 94 TEVA-SIMVASTATIN ..................................................... 42 TEVA-SIMVASTATIN ..................................................... 43 TEVA-TAMSULOSIN CR ............................................... 48 TEVA-TELMISARTAN ................................................... 68 TEVA-TELMISARTAN HCTZ ......................................... 68 TEVA-TERAZOSIN ........................................................ 48 TEVA-TRAZODONE ...................................................... 94 TEVA-VALSARTAN ....................................................... 69 TEVA-VALSARTAN/HCTZ ............................................. 69 TEVA-VALSARTAN/HCTZ ............................................. 70 TEVA-VENLAFAXINE XR .............................................. 90 TEVA-ZOLMITRIPTAN ................................................ 116 TEVA-ZOLMITRIPTAN ...................................... SEC 3.95 TEVA-ZOLMITRIPTAN OD .......................................... 116 TEVA-ZOLMITRIPTAN OD ................................ SEC 3.95 TEVETEN ...................................................................... 65 TEVETEN PLUS ............................................................ 65 THEOLAIR ................................................................... 183 THEOPHYLLINE .......................................................... 183 THIAMIJECT ................................................................ 185 THIAMINE HCL ............................................................ 185 THIOPROPERAZINE MESYLATE ............................... 106 THIOTHIXENE ............................................................. 107 THYROGEN ................................................................. 123 THYROID ..................................................................... 168 THYROTROPIN ALFA ................................................. 123 TIAMOL ........................................................................ 177 TIAPROFENIC ACID ..................................................... 76





TIAZAC ......................................................................... 57 TIAZAC ......................................................................... 58 TIAZAC XC ................................................................... 56 TICLOPIDINE HCL........................................................ 33 TIMOLOL MALEATE ................................................... 136 TIMOLOL MALEATE ..................................................... 54 TIMOPTIC ................................................................... 136 TIMOPTIC-XE ............................................................. 136 TINZAPARIN SODIUM .................................................. 31 TINZAPARIN SODIUM .................................................. 32 TIOTROPIUM BROMIDE MONOHYDRATE ................. 24 TIZANIDINE HCL ............................................... SEC 3.87 TOBI ................................................................................ 5 TOBI PODHALER ........................................................... 5 TOBRADEX ................................................................ 133 TOBRAMYCIN ............................................................ 131 TOBRAMYCIN ................................................................ 5 TOBRAMYCIN SULFATE ............................................... 5 TOBREX ..................................................................... 131 TOCILIZUMAB ................................................... SEC 3.89 TOLOXIN ...................................................................... 36 TOLOXIN PEDIATRIC .................................................. 36 TOLTERODINE L-TARTRATE ........................... SEC 3.89 TOPAMAX ..................................................................... 88 TOPAMAX SPRINKLE .................................................. 88 TOPICORT .................................................................. 177 TOPICORT MILD ........................................................ 177 TOPIRAMATE ............................................................... 88 TORADOL ..................................................................... 74 TRAJENTA ......................................................... SEC 3.57 TRANDATE ................................................................... 51 TRANDOLAPRIL ........................................................... 64 TRANDOLAPRIL ........................................................... 65 TRANEXAMIC ACID ..................................................... 33 TRANSDERM-NITRO 0.2 ............................................. 46 TRANSDERM-NITRO 0.4 ............................................. 46 TRANSDERM-NITRO 0.6 ............................................. 46 TRANYLCYPROMINE SULFATE ................................. 89 TRAVATAN Z .............................................................. 137 TRAVOPROST ........................................................... 137 TRAVOPROST/ TIMOLOL MALEATE ........................ 138 TRAZODONE ................................................................ 94 TRAZODONE HCL........................................................ 94 TRENTAL ...................................................................... 33 TRETINOIN ........................................................ SEC 3.89 TRETINOIN ........................................................ SEC 3.90 TRI-CYCLEN (21 DAY) ............................................... 160 TRI-CYCLEN (28 DAY) ............................................... 160 TRI-CYCLEN LO 21 .................................................... 160 TRI-CYCLEN LO 28 .................................................... 160 TRIADERM REGULAR ............................................... 179 TRIAMCINOLONE ACETONIDE................................. 158

TRIAMCINOLONE ACETONIDE ................................. 179 TRIAMCINOLONE ACETONIDE USP ......................... 158 TRIAZOLAM................................................................. 112 TRIFLUOPERAZINE .................................................... 107 TRIFLUOPERAZINE HCL ............................................ 107 TRIFLURIDINE ............................................................ 131 TRIHEXYPHENIDYL .................................................... 117 TRIHEXYPHENIDYL HCL ........................................... 117 TRIMEBUTINE ............................................................. 150 TRIMEBUTINE MALEATE ........................................... 150 TRIMEPRAZINE TARTRATE...........................................3 TRIMETHOPRIM ........................................................... 19 TRIMIPRAMINE ............................................................. 96 TRIMIPRAMINE ............................................................. 97 TRIMIPRAMINE MALEATE ........................................... 96 TRIMIPRAMINE MALEATE ........................................... 97 TRINIPATCH 0.2 ............................................................ 46 TRINIPATCH 0.4 ............................................................ 46 TRINIPATCH 0.6 ............................................................ 46 TRIQUILAR (21 DAY) .................................................. 159 TRIQUILAR (28 DAY) .................................................. 159 TROMBOJECT .............................................................. 47 TROPICAMIDE ............................................................ 134 TROSEC ............................................................ SEC 3.90 TROSPIUM CHLORIDE ..................................... SEC 3.90 TRUSOPT .................................................................... 136 TRUSOPT (PRESERVATIVE-FREE) .......................... 136 TRYPTAN ...................................................................... 97 TWINJECT AUTO INJECTOR ....................................... 26 TWYNSTA ..................................................................... 68 TYLENOL NO. 2 ............................................................ 77 TYLENOL NO. 3 ............................................................ 77 TYLENOL NO. 4 ............................................................ 77 TYLENOL WITH CODEINE ........................................... 77 TYSABRI .............................................................. SEC 2.7

U

ULORIC ............................................................. SEC 3.39 ULTRASE MS4 MICROSPHERES .............................. 141 ULTRASE MT12 MINITABLETS .................................. 141 ULTRASE MT20 MINITABLETS .................................. 141 ULTRAVATE ................................................................ 177 UNIPHYL ..................................................................... 183 UREMOL-HC ............................................................... 178 URINE TEST STRIPS ......................................................1 UROMAX ........................................................... SEC 3.64 URSO ........................................................................... 141 URSO DS ..................................................................... 141 URSODIOL .................................................................. 141






USTEKINUMAB ................................................. SEC 3.91

V

VAGIFEM .................................................................... 161 VAL-VANCO ................................................................. 14 VALACYCLOVIR ........................................................... 18 VALCYTE ........................................................... SEC 3.92 VALGANCICLOVIR HCL .................................... SEC 3.92 VALISONE SCALP...................................................... 176 VALPROIC ACID........................................................... 89 VALSARTAN ................................................................. 69 VALSARTAN/ HYDROCHLOROTHIAZIDE .................. 69 VALSARTAN/ HYDROCHLOROTHIAZIDE .................. 70 VALTREX (CAPLET) ..................................................... 18 VANCOCIN ........................................................ SEC 3.92 VANCOMYCIN HCL ...................................................... 14 VANCOMYCIN HCL ........................................... SEC 3.92 VARENICLINE TARTRATE .......................................... 28 VARENICLINE TARTRATE ............................... SEC 3.92 VARENICLINE TARTRATE/ VARENICLINE TARTRATE

.................................................................................. 28 VARENICLINE TARTRATE/ VARENICLINE TARTRATE

....................................................................... SEC 3.93 VASERETIC .................................................................. 60 VASOTEC ..................................................................... 60 VENLAFAXINE HCL ..................................................... 90 VENLAFAXINE XR........................................................ 90 VENTOLIN .................................................................... 25 VENTOLIN HFA ............................................................ 25 VENTOLIN NEBULES P.F. ........................................... 25 VERAPAMIL HCL.......................................................... 58 VERMOX ......................................................................... 5 VESICARE ......................................................... SEC 3.82 VFEND ............................................................... SEC 3.93 VIBRAMYCIN ................................................................ 13 VIGABATRIN ................................................................ 89 VIMPAT .............................................................. SEC 3.55 VIMPAT .............................................................. SEC 3.56 VIOKASE .................................................................... 141 VIOKASE 16 ............................................................... 141 VIREAD ......................................................................... 16 VIROPTIC ................................................................... 131 VISKAZIDE 10/25.......................................................... 53 VISKAZIDE 10/50.......................................................... 53 VISKEN ......................................................................... 53 VITAMIN A ACID ................................................ SEC 3.89 VITAMIN A ACID ................................................ SEC 3.90 VITAMIN B12 .............................................................. 185 VITAMIN K1 ................................................................ 185

VITAMIN K1 PEDIATRIC ............................................. 185 VOLTAREN .................................................................... 72 VOLTAREN OPHTHA .................................................. 134 VOLTAREN SR .............................................................. 72 VORICONAZOLE ............................................... SEC 3.93 VORTEX ...................................................................... 191 VORTEX BABY WHIRL INFANT MASK ...................... 191 VORTEX SPINNER PEDIATRIC MASK ...................... 191

W

WARFARIN .................................................................... 29 WARFARIN .................................................................... 30 WARFARIN SODIUM ..................................................... 29 WARFARIN SODIUM ..................................................... 30 WARTEC ..................................................................... 181 WELLBUTRIN SR .......................................................... 97 WELLBUTRIN XL ........................................................... 97 WINPRED .................................................................... 158

X

XALACOM ................................................................... 138 XALATAN ..................................................................... 137 XAMIOL ....................................................................... 181 XANAX ......................................................................... 110 XARELTO ...................................................................... 32 XATRAL ............................................................. SEC 3.15 XEOMIN ....................................................................... 187 XOLAIR .............................................................. SEC 3.64 XYLAC ......................................................................... 108 XYLOCAINE................................................................. 179 XYLOCAINE JELLY ..................................................... 180 XYLOCAINE VISCOUS ............................................... 134

Y

YASMIN 21 .................................................................. 159 YASMIN 28 .................................................................. 159

Z

ZADITEN ..........................................................................3 ZAFIRLUKAST ............................................................. 129 ZAFIRLUKAST ................................................... SEC 3.94 ZANAFLEX ........................................................ SEC 3.87 ZANTAC ....................................................................... 145





ZANTAC ...................................................................... 146 ZARONTIN .................................................................... 85 ZAROXOLYN .............................................................. 127 ZELDOX ...................................................................... 104 ZESTORETIC ............................................................... 62 ZESTRIL ....................................................................... 61 ZESTRIL ....................................................................... 62 ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE104 ZITHROMAX ................................................................... 9 ZITHROMAX ...................................................... SEC 3.17 ZOCOR ......................................................................... 42 ZOCOR ......................................................................... 43 ZOFRAN ..................................................................... 143 ZOFRAN ODT ............................................................. 142 ZOLADEX .......................................................... SEC 3.46 ZOLADEX LA ..................................................... SEC 3.46 ZOLEDRONIC ACID .......................................... SEC 3.94 ZOLMITRIPTAN .......................................................... 116 ZOLMITRIPTAN ................................................. SEC 3.95 ZOLOFT ........................................................................ 93 ZOLOFT ........................................................................ 94 ZOMETA CONCENTRATE ................................ SEC 3.94 ZOMIG ........................................................................ 116 ZOMIG ............................................................... SEC 3.95 ZOMIG RAPIMELT...................................................... 116 ZOMIG RAPIMELT............................................. SEC 3.95 ZOPICLONE ............................................................... 113 ZOVIRAX ...................................................................... 17 ZUCLOPENTHIXOL ACETATE .................................. 107 ZUCLOPENTHIXOL DECANOATE............................. 107 ZUCLOPENTHIXOL DIHYDROCHLORIDE ................ 108 ZYLOPRIM .................................................................. 187 ZYPREXA ................................................................... 100 ZYPREXA ..................................................................... 99 ZYPREXA ZYDIS ........................................................ 100 ZYVOXAM .......................................................... SEC 3.58

ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST INDEX 2 - NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER

DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS

DIN Page DIN Page DIN Page DIN Page



00000000655 .......... 137 00000000663 .......... 137 00000000779 .......... 134 00000000787 .......... 134 00000000841 .......... 137 00000000868 .......... 137 00000000884 .......... 137 00000000981 .......... 134 00000001007 .......... 134 00000001686 .......... 134 00000001694 .......... 180 00000001961 .......... 179 00000004596 .......... 187 00000004774 ............ 18 00000005606 .......... 109 00000005614 .......... 109 00000009881 . SEC 3.65 00000010200 .......... 169 00000010219 .......... 169 00000010340 ............ 71 00000010383 ............ 29 00000010391 ............ 29 00000010405 ............ 85 00000015229 ............ 96 00000015237 ............ 96 00000015741 .......... 169 00000016055 .......... 153 00000020877 . SEC 3.15 00000020885 . SEC 3.15 00000021008 ............ 19 00000021016 ............ 19 00000021202 ............ 10 00000021261 ............ 18 00000022772 ............ 84 00000022780 ............ 84 00000022799 ............ 85 00000022802 ............ 85 00000023442 ............ 84 00000023450 ............ 84 00000023485 ............ 85 00000023698 ............ 84 00000023949 .......... 168 00000023957 .......... 168 00000023965 .......... 168 00000024325 ............ 95 00000024333 ............ 95 00000024341 ............ 95 00000024368 ............ 13 00000024430 .......... 107 00000024449 .......... 107

00000024457 .......... 107 00000024694 .......... 113 00000026697 .......... 125 00000027243 ............ 26 00000027944 .......... 176 00000028096 .......... 155 00000028606 ............ 70 00000029149 ............ 16 00000029246 .......... 158 00000030570 ............ 14 00000030600 .......... 156 00000030619 .......... 156 00000030627 .......... 156 00000030635 .......... 157 00000030678 .......... 157 00000030759 .......... 157 00000030767 .......... 157 00000030783 .......... 158 00000030848 .......... 167 00000030910 .......... 156 00000030929 .......... 156 00000030937 .......... 167 00000030988 .......... 157 00000035017 .......... 134 00000035076 .......... 134 00000036129 .......... 157 00000036137 .......... 157 00000036323 .......... 141 00000037605 .......... 159 00000037613 ............ 46 00000037621 ............ 46 00000042560 .......... 132 00000042579 .......... 132 00000042676 .......... 133 00000074225 .......... 125 00000074454 .......... 133 00000115630 .......... 110 00000125083 ............ 78 00000125121 ............ 78 00000155357 ............ 26 00000155365 .......... 135 00000176095 ............ 26 00000176141 ............ 23 00000176176 ............ 26 00000176192 ............ 76 00000176206 ............ 76 00000178799 .......... 109 00000178802 .......... 109 00000178810 .......... 109 00000178829 .......... 109

00000180408 ............ 70 00000192597 .......... 177 00000192600 .......... 177 00000195057 .SEC 3.59 00000225851 ............ 14 00000226327 ............ 71 00000230316 .......... 177 00000232807 .......... 105 00000232823 .......... 105 00000232831 .......... 105 00000236683 .......... 114 00000252506 .......... 134 00000252654 .......... 180 00000253952 .......... 166 00000259527 ............ 43 00000260428 .......... 157 00000260436 ............ 14 00000262595 .............. 8 00000263699 .SEC 3.18 00000263818 .......... 141 00000265470 .......... 161 00000271373 .......... 158 00000280437 .......... 155 00000285455 ............ 70 00000291889 ............ 43 00000294926 .......... 127 00000297143 .......... 160 00000299405 .......... 133 00000301175 .......... 133 00000307246 .......... 133 00000312363 .............. 8 00000312738 ............ 19 00000312746 .......... 107 00000312754 .......... 107 00000312770 .......... 158 00000312797 ............ 96 00000312800 .......... 126 00000313815 .......... 108 00000313823 .......... 108 00000315966 .......... 160 00000317047 .......... 160 00000319511 ............ 19 00000323071 .......... 175 00000324019 ............ 95 00000326836 .......... 107 00000326844 .......... 126 00000326852 ............ 96 00000326925 ............ 96 00000328219 .......... 118 00000329320 .......... 116

00000330566 ............ 95 00000330582 .......... 180 00000335053 ............ 95 00000335061 ............ 95 00000335088 ............ 95 00000335096 .......... 106 00000335118 .......... 106 00000335126 .......... 106 00000335134 .......... 106 00000337420 ............ 73 00000337439 ............ 73 00000337730 ............ 44 00000337749 ............ 44 00000337757 ............ 12 00000337765 ............ 12 00000337773 ............ 12 00000340731 .......... 160 00000342084 .............. 5 00000342092 .............. 6 00000342106 .............. 5 00000342114 .............. 5 00000343838 .......... 160 00000344923 .......... 175 00000345539 .......... 107 00000353027 .......... 160 00000355658 .......... 118 00000358177 .......... 133 00000360201 ............ 96 00000360252 ............ 43 00000360260 ............ 43 00000360279 .......... 126 00000362158 .......... 110 00000362166 ............ 44 00000363014 .......... 178 00000363650 .......... 105 00000363669 .......... 105 00000363677 .......... 104 00000363685 .......... 104 00000363812 ............ 23 00000363839 ............ 23 00000369810 ............ 85 00000372838 .......... 160 00000372846 .......... 160 00000373036 SEC 3.18 00000382825 ............ 84 00000382841 ............ 84 00000386464 .......... 117 00000386472 .......... 117 00000391603 ............ 10 00000392472 ............ 82


DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page DIN Page DIN Page



00000392480 ............ 82 00000392537 .......... 142 00000392561 ............ 81 00000392588 ............ 81 00000392693 ............ 23 00000392731 .......... 142 00000392782 ............ 23 00000392812 ............ 23 00000396761 ............ 83 00000396788 ............ 44 00000396796 .......... 104 00000396818 .......... 104 00000396826 .......... 105 00000396834 .......... 105 00000397423 ............ 52 00000397431 ............ 52 00000399310 ............ 83 00000399728 .......... 111 00000400750 ............ 95 00000402516 .......... 167 00000402591 ............ 95 00000402680 .......... 112 00000402737 .......... 112 00000402745 .......... 112 00000402753 ............ 53 00000402761 ............ 53 00000402788 ............ 53 00000402796 .......... 187 00000402818 .......... 187 00000405329 .......... 110 00000405337 .......... 111 00000405345 .......... 105 00000405361 .......... 106 00000406716 ............ 10 00000406724 ............ 10 00000406775 .......... 114 00000410632 .......... 105 00000417246 .......... 175 00000417270 ............ 53 00000417289 ............ 53 00000426830 ............ 44 00000426849 .......... 185 00000426857 .......... 117 00000441619 ............ 44 00000441627 ............ 44 00000441635 ............ 44 00000441651 ............ 73 00000441686 ............ 45 00000441694 ............ 45 00000441767 .......... 127

00000441775 .......... 126 00000443174 ............ 53 00000443832 ............ 89 00000443840 ............ 89 00000443948 ............ 82 00000445266 ............ 12 00000445274 ............ 12 00000445282 ............ 12 00000451207 .......... 136 00000452130 ............ 11 00000452149 ............ 10 00000453781 ............ 31 00000453811 ............ 31 00000455881 ............ 27 00000461733 .......... 114 00000463698 .......... 105 00000465763 .......... 135 00000469327 .......... 159 00000471526 .......... 159 00000474517 .......... 185 00000474525 .......... 185 00000476366 .......... 183 00000476374 .......... 183 00000476552 ............ 89 00000479799 .......... 187 00000481815 .......... 185 00000481823 .......... 185 00000487872 .......... 144 00000489158 .......... 156 00000493392 .......... 188 00000496480 ............ 53 00000496499 ............ 53 00000496502 ............ 53 00000497193 .......... 183 00000500895 .......... 130 00000502790 .......... 141 00000503134 .......... 178 00000503347 ............ 44 00000504335 ............ 53 00000506052 ............ 73 00000509558 ............ 26 00000510637 ............ 12 00000510645 ............ 12 00000511234 ............ 47 00000511528 .......... 112 00000511536 .......... 112 00000511552 .......... 120 00000512184 .......... 131 00000512192 .......... 131 00000513962 .......... 131

00000513997 .......... 118 00000514012 ............ 72 00000514497 ............ 44 00000514500 ............ 44 00000518123 .......... 110 00000518131 .......... 110 00000518182 .SEC 3.89 00000519251 .......... 187 00000521515 .......... 185 00000521698 .......... 111 00000521701 .......... 111 00000522597 .......... 117 00000522651 ............ 74 00000522678 ............ 74 00000522724 .......... 110 00000522988 .......... 110 00000522996 .......... 110 00000527033 ............ 45 00000532657 .......... 126 00000534560 ............ 52 00000535427 .......... 176 00000535435 .......... 176 00000544884 ............ 77 00000545015 .......... 136 00000545058 .......... 117 00000545066 ............ 19 00000545074 .......... 117 00000545678 .............. 8 00000548359 .......... 110 00000548367 .......... 110 00000548375 .......... 144 00000550086 ............ 12 00000550175 .......... 180 00000550957 .......... 158 00000555126 .......... 125 00000556734 .............. 5 00000559253 ............ 46 00000560022 .......... 178 00000564966 .......... 127 00000565350 ............ 74 00000567434 .............. 3 00000568627 ............ 53 00000568635 ............ 53 00000572349 .......... 187 00000575240 .......... 137 00000575569 .......... 121 00000577308 .............. 3 00000578428 .......... 175 00000578436 .......... 175 00000578541 .......... 177

00000578576 SEC 3.89 00000578657 ............ 26 00000579335 .......... 178 00000579718 ............ 31 00000580929 ............ 13 00000582344 .......... 181 00000582352 .......... 181 00000582417 .......... 144 00000583413 .............. 5 00000583421 .............. 5 00000584215 .......... 144 00000584223 ............ 46 00000584991 .......... 109 00000585009 .......... 109 00000585092 .......... 167 00000585114 ............ 73 00000586668 .......... 173 00000586676 .......... 174 00000586714 .......... 164 00000587265 .......... 117 00000587354 .......... 117 00000587362 .......... 117 00000587737 .......... 164 00000587818 .......... 177 00000587826 .......... 177 00000587834 .......... 177 00000587966 SEC 3.89 00000589861 ............ 74 00000590819 ............ 52 00000590827 ............ 72 00000591467 ............ 81 00000591475 ............ 81 00000592277 ............ 74 00000593435 ............ 77 00000593451 ............ 77 00000594377 ............ 70 00000594636 ............ 80 00000594644 ............ 80 00000594652 ............ 80 00000595799 .......... 177 00000595802 .......... 177 00000595942 .......... 107 00000596418 ............ 85 00000596426 ............ 85 00000596434 ............ 86 00000596612 .............. 3 00000596965 ............ 81 00000598194 .......... 158 00000598461 ............ 13 00000598488 ............ 13




00000598933 .......... 177 00000600059 .......... 144 00000600067 .......... 144 00000600806 ............ 74 00000602884 .......... 125 00000602957 .......... 160 00000602965 .......... 160 00000603678 .......... 144 00000603686 .......... 144 00000603708 ............ 35 00000603716 ............ 35 00000604453 .......... 112 00000604461 .......... 112 00000605859 .............. 8 00000607142 .............. 8 00000607762 ............ 79 00000607770 ............ 79 00000607789 .......... 178 00000607797 .......... 178 00000608157 ............ 83 00000608165 ............ 82 00000608181 ............ 76 00000608203 ............ 76 00000608211 ............ 71 00000608238 ............ 71 00000608882 ............ 77 00000609129 .......... 144 00000610100 .......... 121 00000611174 .......... 179 00000611271 .......... 180 00000613215 ............ 70 00000613223 ............ 70 00000613231 ............ 70 00000614254 .......... 131 00000617288 ............ 81 00000618454 .......... 110 00000618632 ............ 52 00000618640 ............ 52 00000621374 .......... 187 00000621463 ............ 77 00000621935 ............ 81 00000622133 ............ 78 00000627097 ............ 74 00000627100 ............ 78 00000628115 ............ 10 00000628123 ............ 10 00000628131 ............ 10 00000628158 ............ 11 00000629340 ............ 73 00000629359 ............ 73

00000629367 .......... 175 00000632201 ............ 81 00000632228 ............ 81 00000632724 ............ 72 00000632732 ............ 72 00000632775 .......... 109 00000634506 ............ 17 00000636576 ............ 27 00000636622 ............ 92 00000637416 .............. 8 00000637661 .......... 136 00000637726 . SEC 3.42 00000637742 .......... 111 00000637750 .......... 111 00000638676 ............ 35 00000638684 ............ 35 00000638692 ............ 35 00000639389 ............ 81 00000641863 . SEC 3.90 00000642215 ............ 10 00000642223 ............ 10 00000642231 ............ 10 00000642886 ............ 76 00000642894 ............ 76 00000642975 ............ 36 00000644552 .......... 126 00000644579 ............ 96 00000645575 .......... 109 00000646016 .......... 113 00000646024 .......... 113 00000646059 .......... 113 00000648035 ............ 52 00000648043 ............ 52 00000649074 ............ 19 00000649392 .......... 117 00000652318 .............. 8 00000653209 .......... 176 00000653217 .......... 176 00000653241 ............ 77 00000653276 ............ 77 00000654531 ............ 97 00000655740 .......... 111 00000655759 .......... 111 00000655767 .......... 111 00000657182 ............ 70 00000657204 . SEC 3.89 00000657298 ............ 60 00000658855 ............ 52 00000662348 . SEC 3.89 00000663719 ............ 53

00000664227 .......... 156 00000665088 ............ 85 00000666157 .......... 174 00000670901 ............ 60 00000670928 ............ 60 00000670944 ............ 45 00000675962 ............ 80 00000676411 ............ 81 00000682020 .............. 8 00000682217 .......... 133 00000687456 .......... 131 00000688568 .............. 8 00000688622 .......... 175 00000690783 ............ 79 00000690791 ............ 79 00000692689 .......... 183 00000692697 .......... 183 00000692700 .......... 183 00000695696 ............ 76 00000695718 ............ 76 00000700401 .......... 133 00000703486 .......... 125 00000704423 .SEC 3.21 00000704431 .SEC 3.21 00000705438 ............ 78 00000705799 ............ 81 00000706531 .......... 117 00000707503 .......... 159 00000707511 .......... 132 00000707570 ............ 45 00000707600 .......... 159 00000708879 ............ 60 00000708917 .......... 167 00000710113 .......... 145 00000710121 .......... 145 00000711101 .......... 111 00000713376 .......... 125 00000713449 .......... 105 00000716618 .......... 176 00000716626 .......... 176 00000716642 .......... 176 00000716650 .......... 176 00000716685 .......... 177 00000716693 .......... 177 00000716820 .......... 178 00000716839 .......... 178 00000716863 .......... 177 00000716960 .......... 179 00000717274 .SEC 3.47 00000717282 .SEC 3.47

00000718149 ............ 97 00000725110 ............ 56 00000725250 ............ 13 00000725749 ............ 79 00000725757 ............ 79 00000725765 ............ 79 00000726540 ............ 12 00000726672 .............. 8 00000727520 ............ 31 00000727695 SEC 3.56 00000728187 .......... 111 00000728195 .......... 111 00000728209 .......... 111 00000729973 .......... 167 00000733059 .......... 145 00000733067 .......... 145 00000738824 .......... 113 00000738832 .......... 113 00000738840 .......... 113 00000739839 .......... 132 00000740675 ............ 53 00000740713 ............ 13 00000740721 ............ 45 00000740799 ............ 96 00000740802 ............ 96 00000740810 ............ 96 00000740829 ............ 96 00000741817 .......... 113 00000742554 ............ 58 00000742813 .......... 113 00000743518 .......... 105 00000745588 ............ 76 00000745596 ............ 76 00000749354 ............ 52 00000749486 .......... 171 00000749494 .......... 144 00000750050 .......... 176 00000751170 ............ 52 00000754129 ............ 95 00000755338 .......... 126 00000755575 .......... 105 00000755583 ............ 85 00000755826 .......... 136 00000755834 .......... 136 00000755842 ............ 54 00000755850 ............ 54 00000755869 ............ 54 00000755877 ............ 53 00000755885 ............ 53 00000755893 ............ 53





00000755907 ............ 56 00000756784 .......... 132 00000756792 .......... 161 00000756849 .......... 161 00000765953 ............ 45 00000765996 .......... 165 00000768715 .............. 5 00000768723 .............. 5 00000768820 .......... 105 00000769533 .......... 126 00000769541 .......... 126 00000771376 ............ 56 00000771384 ............ 56 00000773611 ............ 85 00000773689 ............ 49 00000773697 ............ 50 00000776181 ............ 79 00000776203 ............ 79 00000778338 .......... 145 00000778346 .......... 145 00000778354 ............ 76 00000778362 ............ 76 00000778389 ............ 75 00000778907 .......... 133 00000778915 .......... 133 00000780626 ............ 84 00000781878 .......... 185 00000782327 . SEC 3.86 00000782459 ............ 72 00000782467 ............ 52 00000782475 ............ 52 00000782483 ............ 58 00000782491 ............ 58 00000782505 ............ 52 00000782718 ............ 85 00000783900 .......... 156 00000784354 ............ 75 00000784400 .......... 126 00000786535 ............ 78 00000786543 ............ 78 00000786616 ............ 26 00000788716 . SEC 3.92 00000789429 .......... 141 00000789437 .......... 141 00000789445 .......... 141 00000789720 .......... 142 00000789739 ............ 82 00000789747 .......... 142 00000790427 ............ 74 00000790435 ............ 74

00000792659 .......... 112 00000792667 ............ 16 00000792942 .......... 183 00000795852 ............ 39 00000795860 ............ 39 00000795879 .......... 164 00000800430 . SEC 3.92 00000803499 .......... 150 00000804312 .......... 185 00000804533 .......... 177 00000804541 .......... 176 00000804991 .......... 175 00000805009 .......... 175 00000805025 .......... 173 00000805386 .......... 173 00000807435 .......... 131 00000807788 .......... 133 00000808539 ............ 72 00000808547 ............ 72 00000808563 .......... 112 00000808571 .......... 112 00000808652 .......... 105 00000808733 .......... 166 00000808741 .......... 166 00000809187 .......... 175 00000816086 .......... 185 00000818658 ............ 48 00000818666 ............ 48 00000818674 ............ 48 00000818682 ............ 48 00000821373 .......... 141 00000824143 .......... 167 00000824305 .......... 167 00000828556 .......... 145 00000828564 .......... 145 00000828823 .......... 145 00000836273 . SEC 3.56 00000836362 .......... 167 00000839175 ............ 72 00000839183 ............ 72 00000839191 . SEC 3.61 00000839205 . SEC 3.61 00000839213 . SEC 3.61 00000839388 ............ 61 00000839396 ............ 61 00000839418 ............ 62 00000842648 ............ 52 00000842656 ............ 52 00000842664 ............ 74 00000846503 .......... 147

00000849650 .......... 175 00000849669 .......... 175 00000851736 .......... 178 00000851744 .......... 178 00000851752 .......... 155 00000851760 .......... 155 00000851779 ............ 55 00000851787 ............ 56 00000851795 ............ 60 00000852074 .......... 155 00000852384 ............ 46 00000854409 .......... 125 00000856711 .......... 177 00000860689 .......... 110 00000860697 .......... 110 00000860700 .......... 110 00000860808 ............ 25 00000862924 ............ 56 00000862932 ............ 56 00000862975 .......... 175 00000865397 .......... 110 00000865400 .......... 110 00000868965 .............. 7 00000868981 .............. 7 00000869007 ............ 53 00000869015 ............ 53 00000869023 ............ 53 00000869945 ............ 23 00000869953 ............ 23 00000869961 ............ 23 00000870935 .......... 118 00000871095 .......... 178 00000872520 .......... 156 00000872539 .......... 156 00000872644 ............ 11 00000872652 ............ 11 00000873454 .............. 8 00000873993 .......... 167 00000874256 ............ 13 00000874582 .......... 156 00000878618 .......... 156 00000878626 .......... 157 00000878928 ............ 55 00000878936 ............ 55 00000882801 ............ 47 00000882828 ............ 47 00000882836 ............ 47 00000883751 ............ 10 00000884324 ............ 42 00000884332 ............ 42

00000884340 ............ 42 00000884359 ............ 43 00000884413 ............ 62 00000884502 SEC 3.56 00000885401 ............ 78 00000885428 ............ 78 00000885436 ............ 78 00000885444 ............ 78 00000885835 ............ 58 00000885851 ............ 58 00000886157 ............ 17 00000886432 .......... 142 00000886440 .......... 142 00000888346 SEC 3.40 00000888400 .......... 127 00000890960 ............ 36 00000891738 .......... 185 00000891746 .......... 185 00000891835 ............ 15 00000893595 ............ 59 00000893609 ............ 59 00000893617 ............ 59 00000893625 ............ 59 00000893722 .......... 162 00000893749 ............ 40 00000893757 ............ 40 00000894737 ............ 98 00000894745 ............ 99 00000895644 ............ 46 00000895652 ............ 46 00000895660 ............ 46 00000990014 .......... 191 00000990015 .......... 191 00000990016 .......... 191 00000990017 .......... 191 00000990080 .......... 191 00000990081 .......... 191 00000990082 .......... 191 00000990088 .......... 191 00000990089 .......... 191 00000990091 .......... 191 00000990092 .......... 191 00000990093 .......... 191 00000990094 .......... 191 00000990095 .......... 191 00000990096 .......... 191 00000990097 .......... 191 00000990098 .......... 191 00000990099 .......... 191 00000990100 .......... 191




00000999102 ............ 71 00000999103 .......... 173 00000999104 .......... 180 00000999105 ............ 71 00000999107 .......... 176 00000999108 ............ 77 00000999109 .......... 135 00000999110 .......... 179 00000999111 .......... 155 00000999112 .......... 173 00000999113 .......... 188 00000999114 .......... 188 00000999119 .......... 173 00000999202 ............ 71 00000999203 .......... 173 00000999204 .......... 180 00000999205 ............ 71 00000999207 .......... 176 00000999208 ............ 77 00000999209 .......... 135 00000999211 .......... 179 00000999212 .......... 155 00000999213 .......... 173 00000999214 .......... 188 00000999215 .......... 188 00000999216 .......... 188 00000999219 .......... 173 00000999941 .............. 1 00000999949 .......... 191 00000999952 .............. 1 00000999955 .............. 1 00000999957 .............. 1 00000999981 .......... 171 00000999985 .............. 1 00000999995 ............ 79 00000999999 .......... 188 00001900927 .......... 166 00001900935 .......... 166 00001901869 ............ 81 00001905112 . SEC 3.32 00001907107 ............ 61 00001907115 ............ 61 00001907123 ............ 58 00001907476 .......... 180 00001908448 .......... 135 00001910140 ............ 49 00001910159 ............ 49 00001910167 ............ 49 00001910272 .......... 176 00001910280 .......... 176

00001911473 ............ 59 00001911481 ............ 59 00001911627 ............ 17 00001911902 ............ 46 00001911910 ............ 46 00001911929 ............ 46 00001912038 ............ 73 00001912046 ............ 73 00001912054 ............ 50 00001912062 ............ 49 00001912070 .......... 148 00001912410 ............ 12 00001912429 ............ 12 00001912755 .......... 131 00001913425 ............ 95 00001913433 ............ 95 00001913441 ............ 95 00001913468 ............ 96 00001913476 ............ 96 00001913484 .......... 110 00001913492 .......... 110 00001913654 .......... 166 00001913662 .......... 166 00001913670 .......... 166 00001913689 .......... 166 00001914030 .......... 149 00001916181 .......... 133 00001916203 .......... 133 00001916386 ............ 78 00001916394 ............ 79 00001916475 ............ 82 00001916491 ............ 82 00001916548 ............ 82 00001916823 .......... 151 00001916858 ............ 11 00001916874 ............ 11 00001916882 ............ 11 00001916947 .......... 174 00001917056 ............ 72 00001918311 ............ 29 00001918338 ............ 29 00001918346 ............ 29 00001918354 ............ 30 00001918362 ............ 30 00001919342 ............ 92 00001919369 ............ 92 00001919431 .......... 171 00001919458 .......... 168 00001919466 .......... 168 00001919598 ............ 89

00001924516 .......... 108 00001924559 .......... 108 00001924567 .......... 108 00001925938 .............. 8 00001926292 .............. 3 00001926306 .............. 3 00001926454 ............ 46 00001926462 .SEC 3.89 00001926470 .SEC 3.89 00001926489 .SEC 3.90 00001926543 ............ 49 00001926551 ............ 49 00001926578 ............ 49 00001926667 .......... 106 00001926675 .......... 106 00001926691 .......... 166 00001926713 ............ 47 00001926756 .......... 106 00001926764 .......... 106 00001926772 .......... 106 00001926780 .......... 106 00001926799 .......... 113 00001926829 .......... 174 00001926845 .......... 174 00001926861 .......... 174 00001926934 ............ 25 00001927604 .......... 151 00001927620 .......... 151 00001927639 .......... 106 00001927698 .......... 106 00001927744 .......... 117 00001927914 .......... 175 00001930672 ............ 10 00001930680 ............ 10 00001933345 ............ 11 00001933353 ............ 11 00001934139 ............ 73 00001934163 ............ 11 00001934171 ............ 10 00001934198 ............ 47 00001934201 ............ 47 00001934228 ............ 47 00001934317 ............ 58 00001934325 .......... 157 00001934333 .......... 157 00001934341 .......... 157 00001937219 .......... 126 00001937227 ............ 94 00001937235 ............ 94 00001940309 ............ 75

00001940414 .......... 134 00001940473 ............ 93 00001940481 ............ 93 00001942964 ............ 59 00001942972 ............ 59 00001942980 ............ 59 00001942999 ............ 59 00001945262 SEC 3.32 00001945270 .......... 131 00001946374 .......... 180 00001947664 ............ 63 00001947672 ............ 63 00001947680 ............ 63 00001947699 ............ 63 00001947796 ............ 54 00001947818 ............ 54 00001947826 ............ 54 00001950592 .......... 149 00001953834 .......... 145 00001953842 .......... 145 00001958097 ............ 47 00001958100 ............ 47 00001958119 ............ 47 00001959212 .......... 164 00001959220 .......... 164 00001959239 .......... 164 00001962701 .......... 177 00001962779 ............ 94 00001962817 ............ 93 00001964054 .......... 179 00001964070 .......... 156 00001964968 .......... 156 00001964976 .......... 156 00001966197 ............ 35 00001966200 ............ 35 00001966219 .......... 183 00001968017 SEC 3.41 00001968300 .......... 134 00001968440 .......... 160 00001968823 .......... 134 00001975447 ............ 12 00001976133 .......... 181 00001977547 .......... 156 00001977563 .......... 158 00001977652 .......... 167 00001978918 .......... 155 00001978926 .......... 155 00001979574 ............ 37 00001979582 ............ 37 00001980661 .......... 132





00001981242 .......... 153 00001981250 .......... 153 00001981501 .......... 189 00001984837 .......... 187 00001984845 .......... 187 00001984853 .............. 9 00001985205 .......... 141 00001986864 ............ 25 00001987003 .......... 185 00001990403 .......... 116 00001992872 .......... 160 00001997580 .......... 149 00001997602 ............ 27 00001997653 ............ 27 00001997750 ............ 18 00001997769 ............ 18 00001999761 .......... 158 00001999869 .......... 158 00002007134 .......... 166 00002007959 ............ 30 00002008203 .......... 113 00002009706 ............ 80 00002009749 ............ 80 00002009765 ............ 80 00002009773 ............ 80 00002010909 . SEC 3.41 00002011271 ............ 46 00002012472 ............ 31 00002013231 .......... 114 00002014165 .......... 183 00002014181 .......... 183 00002014203 ............ 80 00002014211 ............ 80 00002014238 ............ 80 00002014254 ............ 80 00002014297 ............ 80 00002014300 ............ 80 00002014319 ............ 80 00002014327 ............ 80 00002015439 ............ 80 00002015951 ............ 74 00002015994 . SEC 3.32 00002017237 ............ 75 00002017709 ............ 18 00002017741 .......... 125 00002017776 ............ 18 00002018144 .......... 158 00002018152 .......... 158 00002018160 .......... 158 00002018985 ............ 92

00002019884 ............ 60 00002019892 ............ 60 00002019906 ............ 60 00002019930 ............ 80 00002019949 ............ 80 00002019957 ............ 80 00002019965 ............ 80 00002020025 ............ 60 00002021048 ............ 81 00002021056 ............ 81 00002022133 .......... 145 00002022141 .......... 145 00002022826 .......... 116 00002024152 . SEC 3.42 00002024217 .......... 164 00002024225 .......... 164 00002024233 .......... 164 00002024268 .......... 164 00002024284 .......... 164 00002024314 .......... 164 00002024322 .......... 164 00002025248 .......... 164 00002025280 .......... 102 00002025299 .......... 103 00002025302 .......... 103 00002025310 .......... 103 00002026600 ............ 75 00002026961 .......... 126 00002028700 .......... 160 00002028786 .......... 118 00002029421 .......... 160 00002029448 .......... 189 00002029456 ............ 97 00002031094 .......... 174 00002031116 ............ 15 00002031159 .......... 136 00002031167 .......... 136 00002035324 .......... 132 00002036282 ............ 36 00002036347 ............ 10 00002036355 ............ 10 00002039486 ............ 73 00002039494 ............ 73 00002039508 ............ 23 00002039532 ............ 49 00002039540 ............ 50 00002040751 ............ 95 00002040778 ............ 95 00002040786 ............ 95 00002041413 .......... 111

00002041421 .......... 111 00002041448 .......... 111 00002041456 .......... 111 00002041464 .......... 111 00002041472 .......... 111 00002041510 ............ 16 00002042231 ............ 53 00002042258 ............ 53 00002042266 ............ 53 00002042274 ............ 53 00002042304 .......... 125 00002042320 .......... 159 00002042339 .......... 159 00002042479 .......... 159 00002042487 .......... 159 00002042533 .......... 159 00002043394 .......... 161 00002043408 .......... 161 00002043424 .......... 161 00002043440 .......... 161 00002045702 .......... 146 00002045710 .......... 163 00002045729 ............ 62 00002045737 ............ 62 00002045834 .......... 141 00002045869 .......... 141 00002046113 .......... 130 00002046121 ............ 43 00002046148 ............ 43 00002046156 ............ 46 00002047454 ............ 15 00002048264 ............ 36 00002048272 ............ 36 00002048493 ............ 73 00002048698 ............ 72 00002048701 ............ 84 00002048728 ............ 84 00002048736 ............ 84 00002049325 .SEC 3.46 00002049333 ............ 61 00002049376 ............ 61 00002049384 ............ 62 00002049392 .SEC 3.61 00002049961 ............ 50 00002049988 ............ 50 00002049996 ............ 95 00002050005 ............ 95 00002050013 ............ 95 00002050021 ............ 95 00002050048 ............ 96

00002052431 .......... 176 00002057778 ............ 55 00002059762 .......... 189 00002059789 .......... 189 00002060884 .......... 176 00002061562 ............ 39 00002061570 ............ 39 00002063662 ............ 19 00002063670 .......... 181 00002063697 .......... 157 00002063735 ............ 27 00002063743 ............ 27 00002063786 SEC 3.74 00002063808 .......... 149 00002064405 ............ 33 00002064472 ............ 13 00002064480 ............ 13 00002065614 .......... 111 00002065819 ............ 89 00002068036 ............ 89 00002068087 .......... 120 00002069571 ............ 25 00002070847 .......... 180 00002070863 .......... 180 00002070987 ............ 97 00002074788 .......... 181 00002076306 .......... 138 00002078627 ............ 17 00002078635 ............ 17 00002078651 ............ 17 00002080052 ............ 27 00002083345 .......... 136 00002083353 .......... 136 00002083523 ............ 37 00002083795 .......... 179 00002084090 ............ 13 00002084104 ............ 13 00002084228 ............ 54 00002084236 ............ 54 00002084260 ............ 86 00002084279 ............ 86 00002084287 ............ 86 00002085895 ............ 79 00002085992 .......... 125 00002086026 .......... 156 00002087316 .......... 188 00002087324 .......... 118 00002088398 ............ 27 00002088401 ............ 27 00002089602 .......... 175




00002091194 ............ 72 00002091526 .......... 130 00002091879 .......... 162 00002093162 .......... 176 00002097168 . SEC 3.55 00002097176 . SEC 3.55 00002097249 ............ 56 00002097257 ............ 57 00002097265 ............ 57 00002097273 ............ 57 00002099233 .......... 163 00002099683 .......... 149 00002099705 ............ 21 00002100509 ............ 73 00002100517 ............ 73 00002100622 .......... 146 00002100630 ............ 89 00002102978 ............ 23 00002103052 .......... 186 00002103087 ............ 23 00002103095 ............ 23 00002103567 .......... 146 00002103613 .......... 148 00002103656 ............ 84 00002103729 ............ 62 00002103737 ............ 84 00002106272 ............ 51 00002106280 ............ 51 00002108143 ............ 13 00002108151 ............ 13 00002112736 .......... 177 00002112760 .......... 149 00002112787 .......... 149 00002112795 .......... 149 00002112809 .......... 149 00002123274 ............ 62 00002123282 ............ 62 00002125250 .......... 146 00002125323 ............ 78 00002125331 ............ 78 00002125366 ............ 78 00002125382 ............ 78 00002125390 ............ 78 00002126192 .......... 176 00002126222 ............ 24 00002126559 ............ 46 00002126710 .............. 9 00002126753 ............ 52 00002126761 ............ 52 00002128446 .......... 178

00002129043 . SEC 3.22 00002130297 .......... 105 00002130300 .......... 105 00002131048 ............ 27 00002131056 ............ 27 00002131064 ............ 27 00002132621 ............ 30 00002132648 ............ 30 00002132664 ............ 30 00002132680 ............ 36 00002132699 ............ 36 00002132702 ............ 93 00002136112 ............ 76 00002136120 ............ 76 00002137534 .......... 110 00002137542 .......... 110 00002137984 ............ 83 00002138018 ............ 79 00002139200 .......... 116 00002139332 ............ 27 00002139391 ............ 27 00002140063 ............ 89 00002142074 ............ 37 00002142082 ............ 87 00002142104 ............ 87 00002142112 ............ 87 00002143291 .......... 131 00002144263 ............ 94 00002144271 ............ 94 00002144298 ............ 94 00002144328 . SEC 3.57 00002144336 . SEC 3.57 00002144344 . SEC 3.57 00002145227 ............ 84 00002145235 ............ 84 00002145243 ............ 84 00002145901 ............ 78 00002145928 ............ 78 00002145936 ............ 78 00002146126 ............ 78 00002146843 ............ 25 00002146851 ............ 25 00002146894 ............ 49 00002146908 .............. 9 00002146959 ............ 37 00002147432 ............ 50 00002147602 ............ 49 00002147610 ............ 49 00002147629 ............ 49 00002147637 ............ 94

00002147645 ............ 94 00002147653 ............ 94 00002148587 .......... 161 00002148595 .......... 161 00002148765 .......... 163 00002150662 .SEC 3.21 00002150670 .SEC 3.21 00002150689 .SEC 3.21 00002150697 .SEC 3.21 00002150956 .......... 181 00002153483 .......... 127 00002153521 .......... 149 00002153556 .......... 149 00002153564 .......... 149 00002154412 ............ 25 00002154463 ............ 76 00002155907 ............ 56 00002155958 SEC 3A.2 00002155966 SEC 3A.3 00002155974 SEC 3A.3 00002155990 ............ 56 00002156008 .......... 107 00002156016 .......... 107 00002156032 .......... 107 00002156040 .......... 107 00002156091 .......... 173 00002157195 .......... 148 00002158574 ............ 13 00002158582 ............ 72 00002158612 ............ 96 00002158620 ............ 96 00002158639 ............ 96 00002161737 SEC 3A.2 00002161745 SEC 3A.3 00002161753 SEC 3A.3 00002162415 ............ 75 00002162423 ............ 75 00002162431 ............ 75 00002162466 ............ 75 00002162644 ............ 74 00002162660 ............ 74 00002162695 ............ 18 00002162717 ............ 75 00002162725 ............ 75 00002162792 ............ 75 00002162806 ............ 46 00002162814 ............ 72 00002162849 .......... 163 00002163527 ............ 46 00002163535 ............ 46

00002163543 .......... 183 00002163551 ............ 59 00002163578 ............ 59 00002163586 ............ 59 00002163594 ............ 59 00002163659 .............. 6 00002163667 .............. 6 00002163675 .............. 6 00002163683 .............. 6 00002163705 ............ 24 00002163918 ............ 77 00002163926 ............ 77 00002163934 ............ 77 00002163942 ............ 77 00002165503 .......... 147 00002165511 .......... 147 00002166704 .......... 167 00002166712 .......... 136 00002166720 .......... 136 00002167786 .......... 163 00002167794 ............ 54 00002167840 ............ 31 00002168898 .......... 161 00002168979 SEC 3.58 00002169649 .. SEC 2.4 00002169991 .......... 108 00002170493 .......... 188 00002170698 ............ 21 00002170795 SEC 3.73 00002170809 SEC 3.73 00002170817 SEC 3.73 00002171228 .......... 168 00002171791 ............ 49 00002171805 ............ 50 00002171880 .......... 136 00002171899 .......... 136 00002171929 .......... 149 00002172062 .......... 168 00002172070 .......... 168 00002172089 .......... 168 00002172097 .......... 168 00002172100 .......... 168 00002172119 .......... 168 00002172127 .......... 168 00002172135 .......... 168 00002172143 .......... 168 00002172151 .......... 168 00002172577 ............ 74 00002172712 .......... 132 00002173360 ............ 25





00002174545 ............ 52 00002174553 ............ 52 00002176017 .......... 188 00002176084 .............. 3 00002177145 ............ 27 00002177153 .......... 110 00002177161 .......... 110 00002177188 .......... 110 00002177579 ............ 92 00002177587 ............ 92 00002177692 ............ 96 00002177706 ............ 96 00002177714 .......... 145 00002177722 .......... 145 00002177749 ............ 80 00002177757 ............ 81 00002177889 ............ 84 00002177897 ............ 84 00002179660 ............ 84 00002179679 ............ 76 00002179687 ............ 76 00002181479 ............ 59 00002182750 ............ 21 00002182777 ............ 21 00002182815 ............ 67 00002182866 ............ 14 00002182874 ............ 67 00002182882 ............ 67 00002182955 ............ 21 00002182963 ............ 21 00002184435 ............ 81 00002184443 ............ 81 00002184451 ............ 81 00002184648 ............ 89 00002185407 ............ 37 00002185431 .......... 149 00002185881 .......... 142 00002187086 .......... 160 00002187094 .......... 160 00002187108 .......... 160 00002187116 .......... 160 00002188783 .......... 189 00002189054 .......... 160 00002189062 .......... 160 00002190885 .......... 162 00002190893 .......... 162 00002190915 .......... 147 00002192268 .......... 175 00002192276 .......... 175 00002192284 .......... 175

00002193221 .......... 185 00002194031 .......... 179 00002194058 .......... 179 00002194066 .......... 179 00002194198 ............ 16 00002194201 ............ 16 00002194333 ............ 85 00002194341 .......... 181 00002195917 . SEC 3.58 00002195925 . SEC 3.58 00002195933 .......... 118 00002195941 .......... 118 00002195968 .......... 118 00002196018 .......... 145 00002196026 .......... 145 00002197502 .......... 160 00002199270 . SEC 3.87 00002199297 .......... 160 00002200104 .......... 141 00002201038 . SEC 3.14 00002202441 ............ 82 00002202468 ............ 82 00002202476 ............ 82 00002202484 ............ 82 00002203324 .......... 141 00002204517 ............ 49 00002204525 ............ 49 00002204533 ............ 49 00002205963 ............ 29 00002207621 ............ 17 00002207648 ............ 17 00002207656 ............ 17 00002207761 .......... 145 00002207788 .......... 145 00002207818 ............ 84 00002208229 ............ 25 00002208237 ............ 25 00002208245 ............ 25 00002210320 ............ 36 00002210347 ............ 58 00002210355 ............ 58 00002210363 ............ 58 00002210428 ............ 54 00002210479 ............ 24 00002211076 .......... 112 00002211920 ............ 58 00002212021 .............. 9 00002212048 ............ 27 00002212153 .......... 115 00002212153 . SEC 3.84

00002212161 .......... 115 00002212161 .SEC 3.84 00002212188 .......... 115 00002212188 .SEC 3.84 00002212218 .............. 7 00002212226 .............. 7 00002212234 .............. 7 00002212277 .............. 7 00002212285 .............. 7 00002212331 .......... 145 00002212358 .......... 145 00002212366 .......... 146 00002213192 .......... 168 00002213206 .......... 168 00002213214 .......... 168 00002213222 .......... 168 00002213265 .......... 176 00002213273 .......... 176 00002213281 .......... 176 00002213419 ............ 25 00002213427 ............ 25 00002213486 ............ 25 00002213567 .......... 143 00002213575 .......... 143 00002213745 .......... 143 00002214261 ............ 25 00002215136 .SEC 3.82 00002216132 .......... 114 00002216140 .......... 114 00002216159 .......... 114 00002216167 .......... 113 00002216205 .......... 136 00002216221 .SEC 3.55 00002216248 ............ 95 00002216256 ............ 95 00002216264 ............ 95 00002216272 ............ 95 00002216345 ............ 23 00002216353 ............ 92 00002216361 ............ 92 00002216582 ............ 92 00002216590 ............ 92 00002217422 ............ 19 00002217481 ............ 61 00002217503 ............ 61 00002217511 ............ 62 00002218313 .......... 113 00002218321 ............ 89 00002218453 ............ 92 00002218461 ............ 92

00002218488 SEC 3.59 00002218496 SEC 3.59 00002218941 ............ 48 00002218968 ............ 48 00002218976 ............ 48 00002218984 ............ 48 00002219492 ............ 18 00002220156 .......... 145 00002220164 .......... 145 00002220172 ............ 39 00002220180 ............ 39 00002220407 SEC 3.83 00002221284 .......... 167 00002221292 .......... 167 00002221306 .......... 167 00002221780 ............ 29 00002221802 .......... 175 00002221829 ............ 63 00002221837 ............ 63 00002221845 ............ 64 00002221853 ............ 64 00002221896 .......... 177 00002221918 .......... 177 00002221977 ............ 33 00002221985 ............ 55 00002221993 ............ 55 00002222000 ............ 56 00002222051 ............ 40 00002223252 .......... 179 00002223376 .......... 183 00002223481 ............ 92 00002223503 ............ 92 00002223511 ............ 96 00002223538 ............ 96 00002223562 .......... 163 00002223678 .......... 127 00002223716 .............. 9 00002223724 .............. 9 00002223767 SEC 3.73 00002223775 SEC 3.73 00002224550 .......... 166 00002224569 .......... 166 00002224623 .......... 133 00002224690 ............ 44 00002224704 ............ 44 00002224720 ............ 45 00002224755 ............ 45 00002224801 ............ 35 00002224828 ............ 35 00002225085 .............. 7




00002225093 .............. 7 00002225107 .............. 7 00002225158 . SEC 3.18 00002225166 . SEC 3.18 00002225190 .......... 161 00002225905 . SEC 3.46 00002225964 .......... 112 00002225972 .......... 112 00002225980 ............ 37 00002226383 .......... 179 00002226391 .......... 179 00002226839 .......... 173 00002227444 .......... 144 00002227452 .......... 144 00002227460 .......... 144 00002227479 .......... 144 00002228947 ............ 26 00002228955 . SEC 3.18 00002229080 ............ 74 00002229099 .......... 155 00002229250 ............ 99 00002229269 ............ 99 00002229277 ............ 99 00002229285 ............ 99 00002229293 . SEC 3.18 00002229315 .......... 177 00002229323 .......... 177 00002229440 .......... 131 00002229441 .......... 131 00002229452 ............ 74 00002229453 .......... 148 00002229515 ............ 31 00002229519 .......... 165 00002229521 SEC 3A.2 00002229522 SEC 3A.3 00002229523 SEC 3A.3 00002229524 ............ 12 00002229526 ............ 57 00002229540 .......... 158 00002229550 .......... 158 00002229628 ............ 89 00002229639 .......... 143 00002229654 .......... 112 00002229655 .......... 112 00002229656 .......... 163 00002229704 .......... 164 00002229705 .......... 164 00002229755 ............ 31 00002229777 .......... 135 00002229778 ............ 54

00002229779 ............ 54 00002229781 ............ 56 00002229782 ............ 57 00002229783 ............ 57 00002229784 ............ 57 00002229837 ............ 72 00002230019 .......... 141 00002230047 ............ 67 00002230089 . SEC 3.42 00002230090 ............ 33 00002230095 .......... 112 00002230102 .......... 112 00002230104 . SEC 3.42 00002230183 ............ 37 00002230201 ............ 74 00002230243 ............ 10 00002230244 ............ 10 00002230245 ............ 10 00002230246 ............ 11 00002230248 . SEC 3.56 00002230359 ............ 35 00002230360 ............ 35 00002230394 .......... 183 00002230402 .......... 108 00002230403 .......... 108 00002230405 .......... 107 00002230406 .......... 107 00002230418 .......... 115 00002230418 . SEC 3.83 00002230420 .......... 115 00002230420 . SEC 3.83 00002230431 .......... 148 00002230432 .......... 148 00002230433 .......... 149 00002230454 .......... 118 00002230475 .......... 163 00002230476 ............ 37 00002230535 ............ 14 00002230540 ............ 14 00002230584 .......... 110 00002230585 .......... 110 00002230619 .......... 158 00002230641 .......... 120 00002230648 .......... 132 00002230661 ............ 76 00002230684 .......... 149 00002230711 ............ 38 00002230713 ............ 38 00002230714 ............ 38 00002230732 ............ 46

00002230733 ............ 46 00002230734 ............ 46 00002230735 ............ 13 00002230736 ............ 13 00002230737 .......... 147 00002230768 ............ 89 00002230784 .......... 181 00002230785 .......... 181 00002230800 .......... 183 00002230803 ............ 52 00002230804 ............ 52 00002230805 ............ 48 00002230806 ............ 48 00002230807 ............ 48 00002230808 ............ 48 00002230837 .......... 108 00002230838 .......... 108 00002230839 .......... 108 00002230840 .......... 108 00002230888 .......... 131 00002230893 ............ 88 00002230894 ............ 88 00002230896 ............ 88 00002230898 ............ 24 00002230942 .......... 112 00002230950 ............ 84 00002230951 ............ 84 00002230997 ............ 56 00002230998 ............ 57 00002230999 ............ 57 00002231015 ............ 19 00002231016 ............ 19 00002231036 .......... 120 00002231061 ............ 15 00002231129 ............ 25 00002231135 .SEC 3.55 00002231136 ............ 24 00002231143 .SEC 3.17 00002231150 ............ 57 00002231151 ............ 57 00002231152 ............ 57 00002231154 ............ 57 00002231155 ............ 58 00002231171 ............ 30 00002231181 ............ 54 00002231182 ............ 54 00002231184 .......... 127 00002231244 .SEC 3.55 00002231245 .SEC 3.55 00002231328 ............ 92

00002231329 ............ 92 00002231330 ............ 92 00002231347 SEC 3.55 00002231353 ............ 27 00002231379 .......... 142 00002231441 ............ 46 00002231457 ............ 64 00002231459 ............ 64 00002231460 ............ 64 00002231478 ............ 31 00002231491 .......... 187 00002231492 .......... 112 00002231493 .......... 137 00002231504 ............ 72 00002231505 ............ 72 00002231506 ............ 72 00002231508 ............ 72 00002231509 .......... 161 00002231510 .......... 161 00002231529 SEC 3A.5 00002231531 SEC 3A.5 00002231532 SEC 3A.5 00002231536 ............ 53 00002231537 ............ 53 00002231539 ............ 53 00002231540 ............ 85 00002231542 ............ 85 00002231543 ............ 85 00002231544 ............ 85 00002231583 SEC 3.31 00002231584 SEC 3.31 00002231585 SEC 3.31 00002231586 SEC 3.31 00002231587 SEC 3.31 00002231675 ............ 24 00002231683 ............ 94 00002231684 ............ 94 00002231689 ............ 51 00002231731 ............ 49 00002231733 ............ 50 00002231781 ............ 96 00002231782 ............ 96 00002231799 ............ 73 00002231800 ............ 73 00002231893 .......... 157 00002231894 .......... 157 00002231895 .......... 157 00002232043 SEC 3.25 00002232044 SEC 3.25 00002232148 ............ 89





00002232150 ............ 89 00002232317 ............ 73 00002232318 ............ 73 00002232565 .......... 119 00002232567 .......... 119 00002232568 .......... 120 00002232569 .......... 120 00002232570 ............ 25 00002233005 ............ 60 00002233006 ............ 60 00002233007 ............ 60 00002233852 .......... 168 00002233960 ............ 84 00002233982 ............ 84 00002233985 ............ 84 00002234003 .......... 112 00002234007 .......... 112 00002234466 .......... 178 00002234502 ............ 48 00002234503 ............ 48 00002234504 ............ 48 00002234505 ............ 48 00002234510 ............ 76 00002234749 .......... 109 00002235134 . SEC 3.19 00002236399 .......... 178 00002236466 .......... 148 00002236507 ............ 27 00002236508 ............ 27 00002236564 ............ 31 00002236606 .......... 129 00002236606 . SEC 3.94 00002236734 .......... 166 00002236783 ............ 25 00002236807 ............ 89 00002236819 .......... 187 00002236841 SEC 3A.4 00002236842 SEC 3A.4 00002236848 ............ 33 00002236876 .......... 135 00002236883 ............ 31 00002236913 ............ 31 00002236948 ............ 84 00002236950 .......... 104 00002236951 .......... 100 00002236952 .......... 100 00002236953 .......... 101 00002236963 ............ 27 00002236964 ............ 27 00002236974 .......... 159

00002236975 .......... 159 00002236978 ............ 15 00002236979 ............ 15 00002236996 .......... 177 00002236997 .......... 177 00002237137 .............. 5 00002237138 .............. 5 00002237140 .............. 5 00002237224 ............ 25 00002237225 ............ 25 00002237235 ............ 15 00002237246 .......... 156 00002237247 .......... 156 00002237250 ............ 97 00002237279 ............ 90 00002237280 ............ 90 00002237282 ............ 90 00002237313 ............ 13 00002237314 ............ 13 00002237319 ... SEC 2.4 00002237320 ... SEC 2.4 00002237339 ............ 94 00002237367 ............ 63 00002237368 ............ 63 00002237369 ............ 63 00002237370 ............ 15 00002237371 ............ 15 00002237514 SEC 3A.1 00002237600 ............ 49 00002237601 ............ 50 00002237618 ............ 56 00002237671 . SEC 3.21 00002237682 ............ 12 00002237701 ............ 33 00002237721 ............ 49 00002237722 ............ 49 00002237723 ............ 49 00002237770 ... SEC 2.4 00002237791 ............ 58 00002237813 ............ 92 00002237814 ............ 92 00002237820 .......... 114 00002237820 . SEC 3.61 00002237821 .......... 114 00002237821 . SEC 3.61 00002237825 ............ 97 00002237860 .......... 167 00002237885 ............ 49 00002237886 ............ 49 00002237887 ............ 49

00002237921 ............ 58 00002237922 ............ 58 00002237923 ............ 66 00002237924 ............ 66 00002237925 ............ 66 00002237971 .SEC 3.82 00002237991 .......... 136 00002238048 ............ 89 00002238103 .......... 165 00002238171 ............ 10 00002238172 ............ 10 00002238216 .......... 129 00002238216 .SEC 3.60 00002238217 .......... 129 00002238217 .SEC 3.60 00002238280 ............ 93 00002238281 ............ 93 00002238282 ............ 94 00002238316 ............ 49 00002238318 ............ 50 00002238326 ............ 54 00002238327 ............ 54 00002238334 ............ 83 00002238370 ............ 89 00002238403 .......... 106 00002238404 .......... 106 00002238405 .......... 106 00002238406 .......... 106 00002238465 .......... 132 00002238525 .......... 147 00002238560 .SEC 3.42 00002238568 .......... 132 00002238596 .......... 113 00002238604 .......... 125 00002238639 ............ 74 00002238645 ............ 77 00002238646 ............ 77 00002238660 .......... 116 00002238660 .SEC 3.95 00002238682 .SEC 3.20 00002238703 .......... 174 00002238704 .......... 161 00002238796 .......... 132 00002238829 ............ 11 00002238830 ............ 11 00002238831 ............ 11 00002238850 .......... 100 00002238873 .......... 136 00002238903 .......... 117 00002238984 .......... 141

00002238998 ............ 46 00002239024 ............ 84 00002239025 ............ 84 00002239028 SEC 3.74 00002239091 ............ 65 00002239092 ............ 65 00002239131 ............ 24 00002239146 SEC 3.75 00002239170 SEC 3.87 00002239193 ............ 16 00002239267 ............ 65 00002239288 .......... 132 00002239323 SEC 3.61 00002239324 SEC 3.62 00002239325 SEC 3.62 00002239326 ............ 97 00002239327 ............ 97 00002239365 ............ 25 00002239366 ............ 25 00002239367 .......... 115 00002239367 SEC 3.84 00002239372 .......... 142 00002239373 .......... 142 00002239505 SEC 3.47 00002239577 .......... 131 00002239607 ............ 91 00002239608 ............ 91 00002239619 .......... 127 00002239620 .......... 127 00002239627 ............ 24 00002239630 .............. 5 00002239636 .......... 105 00002239653 SEC 3.86 00002239665 SEC 3.59 00002239698 ............ 85 00002239699 ............ 85 00002239700 ............ 86 00002239701 ............ 85 00002239702 ............ 85 00002239703 ............ 86 00002239714 ............ 89 00002239746 ............ 89 00002239747 ............ 89 00002239748 ............ 89 00002239757 .......... 174 00002239834 SEC 3.56 00002239835 ............ 36 00002239864 ............ 37 00002239893 ............ 15 00002239907 ............ 88




00002239908 ............ 88 00002239924 .......... 165 00002239925 .......... 165 00002239926 .......... 165 00002239941 . SEC 3.19 00002239942 . SEC 3.19 00002239944 ............ 74 00002239951 ............ 37 00002239953 ............ 92 00002239954 ............ 92 00002240067 .......... 127 00002240071 ............ 36 00002240113 .......... 138 00002240114 ............ 31 00002240115 ............ 87 00002240131 ............ 82 00002240132 ............ 82 00002240205 ............ 29 00002240210 ............ 37 00002240286 .......... 111 00002240294 .......... 164 00002240297 .......... 164 00002240329 .......... 185 00002240332 ............ 43 00002240333 ............ 97 00002240334 ............ 97 00002240346 ............ 15 00002240432 ............ 65 00002240456 ............ 89 00002240457 .......... 145 00002240458 .......... 145 00002240481 ............ 94 00002240484 ............ 93 00002240485 ............ 93 00002240498 ............ 47 00002240499 ............ 47 00002240500 ............ 47 00002240518 .......... 114 00002240518 . SEC 3.79 00002240519 .......... 115 00002240519 . SEC 3.79 00002240521 .......... 114 00002240521 . SEC 3.79 00002240549 .......... 183 00002240550 .......... 183 00002240551 .......... 102 00002240552 .......... 102 00002240588 ............ 47 00002240589 ............ 47 00002240590 ............ 47

00002240604 ............ 36 00002240606 .......... 113 00002240682 ............ 92 00002240683 ............ 92 00002240684 .......... 156 00002240687 .......... 156 00002240722 . SEC 3.30 00002240769 ............ 68 00002240770 ............ 68 00002240774 . SEC 3.19 00002240775 . SEC 3.85 00002240807 ............ 15 00002240835 ............ 26 00002240836 ............ 26 00002240837 ............ 26 00002240851 .......... 178 00002240867 ............ 74 00002240908 ............ 93 00002240909 ............ 93 00002241007 ............ 68 00002241024 ............ 75 00002241112 . SEC 3.79 00002241113 . SEC 3.79 00002241114 . SEC 3.79 00002241163 ............ 26 00002241209 .............. 5 00002241210 .............. 5 00002241224 ............ 72 00002241229 .......... 157 00002241332 .......... 161 00002241371 ............ 92 00002241374 ............ 92 00002241377 ............ 79 00002241497 ............ 25 00002241600 .......... 153 00002241601 ............ 37 00002241602 ............ 37 00002241674 .......... 159 00002241704 ............ 37 00002241709 ............ 14 00002241710 ............ 14 00002241715 .......... 136 00002241716 .......... 136 00002241755 .......... 131 00002241818 ............ 66 00002241819 ............ 66 00002241820 ............ 14 00002241821 ............ 14 00002241835 .......... 162 00002241837 .......... 162

00002241882 ............ 85 00002241883 ............ 85 00002241888 .......... 189 00002241889 .......... 189 00002241900 ............ 69 00002241901 ............ 69 00002241927 .SEC 3.77 00002241933 .......... 141 00002241976 ............ 83 00002242029 .......... 155 00002242030 .......... 155 00002242055 .......... 153 00002242115 .SEC 3.78 00002242116 .SEC 3.78 00002242117 .SEC 3.78 00002242118 .SEC 3.78 00002242119 ............ 33 00002242146 .......... 149 00002242163 ............ 81 00002242177 ............ 92 00002242178 ............ 92 00002242320 ............ 36 00002242453 .......... 145 00002242454 .......... 145 00002242463 ............ 17 00002242464 ............ 17 00002242465 .......... 167 00002242471 .SEC 3.18 00002242472 ............ 36 00002242481 .......... 113 00002242502 .......... 185 00002242503 ............ 15 00002242518 .SEC 3.75 00002242519 ............ 93 00002242520 ............ 93 00002242521 ............ 94 00002242527 .......... 179 00002242528 .......... 179 00002242538 ............ 56 00002242539 ............ 57 00002242540 ............ 57 00002242541 ............ 57 00002242570 .......... 105 00002242572 .SEC 3.72 00002242573 .SEC 3.72 00002242574 .SEC 3.72 00002242589 .......... 163 00002242652 .............. 5 00002242656 .............. 7 00002242657 .............. 7

00002242680 ............ 29 00002242681 ............ 29 00002242682 ............ 29 00002242683 ............ 29 00002242684 ............ 30 00002242685 ............ 30 00002242686 ............ 30 00002242687 ............ 30 00002242692 ............ 31 00002242697 ............ 30 00002242728 ............ 47 00002242729 ............ 47 00002242730 ............ 47 00002242763 SEC 3.74 00002242784 ............ 17 00002242794 .......... 163 00002242797 .......... 178 00002242798 .......... 178 00002242814 .......... 125 00002242821 SEC 3.21 00002242837 .......... 114 00002242838 .......... 114 00002242868 .......... 108 00002242903 SEC 3.38 00002242907 .......... 187 00002242919 .......... 173 00002242924 ............ 29 00002242925 ............ 29 00002242926 ............ 29 00002242927 ............ 30 00002242928 ............ 30 00002242929 ............ 30 00002242931 .......... 163 00002242940 .......... 146 00002242965 SEC 3A.5 00002242974 .......... 163 00002242984 .......... 178 00002242985 .......... 178 00002242987 .......... 165 00002243005 .......... 159 00002243026 .......... 135 00002243045 .......... 116 00002243045 SEC 3.95 00002243077 SEC 3.82 00002243078 SEC 3.82 00002243086 .......... 100 00002243087 .......... 100 00002243097 ............ 38 00002243098 .......... 130 00002243116 ............ 19





00002243117 ............ 19 00002243127 ............ 39 00002243129 ............ 39 00002243158 . SEC 3.19 00002243180 ............ 37 00002243229 .......... 145 00002243230 .......... 145 00002243231 .......... 188 00002243239 . SEC 3.31 00002243297 .......... 166 00002243312 ............ 75 00002243313 ............ 75 00002243314 ............ 75 00002243324 ............ 35 00002243325 ............ 35 00002243338 ............ 56 00002243339 ............ 57 00002243340 ............ 57 00002243341 ............ 57 00002243350 ............ 11 00002243351 ............ 11 00002243352 ............ 87 00002243353 ............ 87 00002243400 . SEC 3.31 00002243401 . SEC 3.31 00002243403 . SEC 3.31 00002243426 .......... 113 00002243432 ............ 75 00002243446 ............ 86 00002243447 ............ 86 00002243448 ............ 86 00002243450 .......... 153 00002243486 ............ 92 00002243487 ............ 92 00002243506 ............ 40 00002243507 ............ 40 00002243508 ............ 40 00002243518 ............ 48 00002243519 ............ 48 00002243520 ............ 48 00002243521 ............ 48 00002243525 .......... 185 00002243551 ............ 37 00002243552 ............ 37 00002243562 ............ 78 00002243587 ............ 33 00002243588 ............ 46 00002243602 .......... 129 00002243684 . SEC 3.58 00002243722 .......... 161

00002243724 .......... 161 00002243763 .......... 117 00002243771 ............ 11 00002243789 ............ 24 00002243796 .......... 148 00002243797 .......... 148 00002243836 ............ 36 00002243878 .......... 187 00002243910 ............ 98 00002243942 ............ 65 00002243986 ............ 11 00002243987 ............ 11 00002243999 .......... 161 00002244000 .......... 161 00002244001 .......... 161 00002244002 .......... 161 00002244016 . SEC 3.55 00002244021 ............ 65 00002244022 .......... 146 00002244023 .......... 146 00002244107 .......... 101 00002244126 .......... 181 00002244148 . SEC 3.85 00002244149 . SEC 3.86 00002244265 . SEC 3.19 00002244266 . SEC 3.19 00002244291 .......... 156 00002244292 .......... 156 00002244293 .......... 156 00002244304 ............ 86 00002244305 ............ 86 00002244306 ............ 86 00002244324 . SEC 3.21 00002244344 ............ 68 00002244353 .......... 163 00002244393 .............. 7 00002244394 .............. 7 00002244403 ............ 85 00002244404 ............ 85 00002244462 ............ 29 00002244463 ............ 29 00002244464 ............ 29 00002244465 ............ 30 00002244466 ............ 30 00002244467 ............ 30 00002244474 ............ 83 00002244494 .......... 118 00002244495 .......... 118 00002244496 .......... 118 00002244513 ............ 86

00002244514 ............ 86 00002244515 ............ 86 00002244527 ............ 47 00002244528 ............ 47 00002244529 ............ 47 00002244550 .......... 189 00002244551 .......... 189 00002244552 .......... 189 00002244563 ............ 74 00002244612 .SEC 3.89 00002244613 .SEC 3.89 00002244638 ............ 83 00002244641 .............. 9 00002244646 ............ 11 00002244647 ............ 11 00002244680 ............ 73 00002244681 ............ 73 00002244756 .............. 9 00002244781 ............ 69 00002244782 ............ 69 00002244790 ............ 80 00002244791 ............ 80 00002244792 ............ 80 00002244798 ............ 21 00002244814 .......... 112 00002244815 .......... 112 00002244816 ............ 95 00002244817 ............ 95 00002244818 ............ 95 00002244838 ............ 93 00002244839 ............ 93 00002244840 ............ 94 00002244849 ............ 14 00002244999 .......... 133 00002245058 .......... 147 00002245077 .......... 113 00002245126 ............ 25 00002245127 ............ 25 00002245159 ............ 93 00002245160 ............ 93 00002245161 ............ 94 00002245208 ............ 87 00002245209 ............ 87 00002245210 ............ 87 00002245230 .......... 112 00002245231 .......... 112 00002245232 ............ 14 00002245233 ............ 14 00002245240 .SEC 3.78 00002245246 .......... 127

00002245247 .......... 165 00002245292 ............ 15 00002245293 ............ 15 00002245329 SEC 3.14 00002245330 .......... 188 00002245385 ............ 24 00002245386 ............ 24 00002245397 .......... 163 00002245400 .......... 157 00002245406 .......... 157 00002245407 .......... 157 00002245408 .......... 157 00002245432 .......... 108 00002245433 .......... 108 00002245456 .......... 151 00002245457 .......... 151 00002245458 .......... 151 00002245522 .......... 176 00002245523 .......... 176 00002245524 .......... 176 00002245531 ............ 32 00002245532 .......... 158 00002245565 SEC 3.15 00002245618 ............ 29 00002245619 .. SEC 2.4 00002245623 ............ 11 00002245643 ............ 15 00002245644 ............ 15 00002245647 SEC 3A.2 00002245648 SEC 3A.3 00002245649 SEC 3A.3 00002245662 .......... 174 00002245663 .......... 150 00002245664 .......... 150 00002245669 ............ 25 00002245676 .......... 161 00002245688 .......... 175 00002245689 .......... 163 00002245777 SEC 3.92 00002245782 .......... 145 00002245783 .......... 145 00002245821 .......... 134 00002245822 ............ 39 00002245823 ............ 39 00002245824 ............ 93 00002245825 ............ 93 00002245826 ............ 94 00002245828 .......... 187 00002245882 .......... 136 00002245894 .......... 141




00002245898 . SEC 3.21 00002245913 . SEC 3.17 00002245914 ............ 51 00002245915 ............ 51 00002245916 ............ 51 00002245917 ............ 51 00002245918 ............ 57 00002245919 ............ 57 00002245920 ............ 57 00002245921 ............ 57 00002245922 ............ 58 00002245972 . SEC 3.86 00002246010 ............ 52 00002246013 ............ 39 00002246014 ............ 39 00002246016 .......... 123 00002246026 . SEC 3.71 00002246030 . SEC 3.71 00002246056 ............ 91 00002246057 ............ 91 00002246063 .......... 158 00002246082 .......... 188 00002246194 ............ 36 00002246284 .......... 135 00002246314 ............ 86 00002246315 ............ 86 00002246316 ............ 86 00002246354 . SEC 3.23 00002246355 . SEC 3.23 00002246357 . SEC 3.23 00002246358 . SEC 3.23 00002246360 . SEC 3.23 00002246534 .......... 113 00002246542 ............ 39 00002246543 ............ 39 00002246569 ............ 63 00002246581 ............ 49 00002246582 ............ 42 00002246583 ............ 42 00002246584 ............ 43 00002246585 ............ 43 00002246594 ............ 91 00002246595 ............ 91 00002246596 ............ 12 00002246619 .......... 138 00002246624 ............ 63 00002246691 ............ 18 00002246699 ............ 75 00002246700 ............ 75 00002246701 ............ 75

00002246714 .......... 175 00002246737 ............ 42 00002246793 ............ 24 00002246804 SEC 3A.4 00002246820 .......... 163 00002246821 .......... 163 00002246825 SEC 3A.2 00002246826 SEC 3A.3 00002246827 SEC 3A.3 00002246859 ............ 37 00002246860 ............ 37 00002246893 ............ 58 00002246894 ............ 58 00002246895 ............ 58 00002246896 . SEC 3.75 00002246897 ............ 87 00002246898 ............ 87 00002246899 ............ 87 00002246955 ............ 69 00002246963 ............ 87 00002246967 .......... 161 00002246968 .......... 161 00002246969 .......... 161 00002247008 ............ 40 00002247009 ............ 40 00002247010 ............ 40 00002247011 ............ 42 00002247012 ............ 42 00002247013 ............ 42 00002247014 ............ 43 00002247015 ............ 43 00002247021 ............ 11 00002247022 .......... 153 00002247027 ............ 87 00002247028 ............ 87 00002247029 ............ 87 00002247054 ............ 92 00002247055 ............ 92 00002247056 ............ 39 00002247057 ............ 39 00002247073 . SEC 3.21 00002247074 . SEC 3.21 00002247085 . SEC 3.80 00002247086 . SEC 3.80 00002247087 . SEC 3.80 00002247096 .......... 175 00002247097 .......... 175 00002247098 .......... 175 00002247128 ............ 16 00002247162 ............ 41

00002247163 ............ 41 00002247164 ............ 41 00002247243 ............ 98 00002247244 ............ 99 00002247310 ............ 26 00002247322 .......... 179 00002247323 .......... 188 00002247339 SEC 3A.2 00002247340 SEC 3A.3 00002247341 SEC 3A.3 00002247373 .SEC 3.14 00002247423 .............. 9 00002247437 .SEC 3.32 00002247439 ............ 50 00002247440 ............ 50 00002247461 .......... 134 00002247499 .......... 161 00002247500 .......... 161 00002247521 .SEC 3.38 00002247573 .............. 9 00002247574 .............. 9 00002247585 .SEC 3.85 00002247655 ............ 40 00002247656 ............ 40 00002247657 ............ 40 00002247686 ............ 24 00002247691 .......... 178 00002247692 .......... 178 00002247694 ............ 79 00002247698 ............ 79 00002247699 ............ 79 00002247700 ............ 79 00002247701 ............ 79 00002247704 .......... 104 00002247705 .......... 104 00002247706 .......... 104 00002247749 ............ 15 00002247751 ............ 93 00002247752 ............ 93 00002247802 ............ 61 00002247803 ............ 61 00002247811 ............ 93 00002247812 ............ 93 00002247813 .SEC 3.25 00002247818 .............. 9 00002247819 .............. 9 00002247823 ............ 17 00002247828 ............ 42 00002247830 ............ 42 00002247831 ............ 43

00002247833 ............ 43 00002247856 ............ 40 00002247857 ............ 40 00002247858 ............ 40 00002247876 ............ 52 00002247882 .......... 179 00002247917 ............ 63 00002247918 ............ 64 00002247919 ............ 64 00002247920 .......... 133 00002247922 ............ 15 00002247933 ............ 51 00002247934 ............ 51 00002247935 ............ 51 00002247936 ............ 51 00002247945 ............ 63 00002247946 ............ 64 00002247947 ............ 64 00002247997 .......... 129 00002248008 .......... 166 00002248009 .......... 166 00002248010 ............ 91 00002248011 ............ 91 00002248013 ............ 93 00002248014 ............ 93 00002248034 ............ 98 00002248035 ............ 99 00002248050 ............ 91 00002248051 ............ 91 00002248077 ............ 17 00002248077 SEC 3.67 00002248103 ............ 42 00002248104 ............ 42 00002248105 ............ 42 00002248106 ............ 43 00002248107 ............ 43 00002248130 .......... 178 00002248138 ............ 11 00002248170 ............ 91 00002248171 ............ 91 00002248182 ............ 40 00002248183 ............ 40 00002248184 ............ 40 00002248206 .......... 173 00002248232 ............ 87 00002248233 ............ 87 00002248234 ............ 87 00002248259 ............ 86 00002248260 ............ 86 00002248261 ............ 86





00002248262 SEC 3A.4 00002248263 SEC 3A.4 00002248296 . SEC 3.94 00002248347 .......... 137 00002248398 .......... 131 00002248437 SEC 3A.2 00002248438 SEC 3A.3 00002248439 SEC 3A.3 00002248440 . SEC 3.80 00002248441 . SEC 3.80 00002248451 ............ 93 00002248452 ............ 93 00002248472 . SEC 3.19 00002248529 .......... 131 00002248538 ............ 97 00002248539 ............ 97 00002248540 ............ 97 00002248557 ............ 93 00002248558 ............ 93 00002248570 .......... 145 00002248571 .......... 145 00002248572 ............ 39 00002248573 ............ 39 00002248639 . SEC 3.61 00002248640 . SEC 3.61 00002248641 . SEC 3.61 00002248642 . SEC 3.61 00002248686 .......... 188 00002248728 . SEC 3.14 00002248730 . SEC 3.14 00002248752 ............ 51 00002248753 ............ 51 00002248754 ............ 51 00002248756 SEC 3A.2 00002248757 SEC 3A.3 00002248758 SEC 3A.3 00002248762 ............ 98 00002248763 ............ 50 00002248764 ............ 50 00002248855 ............ 52 00002248856 .............. 9 00002248857 .............. 9 00002248860 ............ 88 00002248861 ............ 88 00002248862 ............ 88 00002248944 ............ 91 00002248945 ............ 91 00002248993 .......... 116 00002248993 . SEC 3.95 00002249324 .......... 109

00002249510 .......... 126 00002249669 .......... 189 00002249685 .......... 189 00002249790 . SEC 3.65 00002250039 ............ 37 00002250055 .......... 156 00002250144 ............ 42 00002250152 ............ 42 00002250160 ............ 42 00002250179 ............ 43 00002250187 ............ 43 00002250497 ............ 55 00002250500 ............ 55 00002250527 ............ 39 00002250608 ............ 98 00002250896 ............ 84 00002251450 .......... 113 00002251469 .......... 113 00002251515 ............ 63 00002251531 ............ 63 00002251574 ............ 64 00002251582 ............ 64 00002251930 .......... 163 00002252007 .......... 102 00002252015 .......... 102 00002252023 .......... 102 00002252031 .......... 103 00002252058 .......... 103 00002252066 .......... 103 00002252112 ............ 91 00002252120 ............ 91 00002252279 ............ 98 00002252309 ............ 51 00002252317 ............ 51 00002252325 ............ 51 00002252333 ............ 51 00002252570 .......... 131 00002252600 ............ 18 00002252716 .......... 132 00002252767 . SEC 3.20 00002253429 . SEC 3.69 00002253631 ............ 65 00002253933 .......... 131 00002254514 ............ 19 00002254522 ............ 19 00002254581 . SEC 3.71 00002254603 . SEC 3.71 00002254638 . SEC 3.71 00002254646 . SEC 3.71 00002254727 ............ 15

00002254778 ............ 93 00002254786 .......... 137 00002255340 .............. 9 00002255529 ............ 92 00002255537 ............ 92 00002255545 ............ 49 00002255553 ............ 50 00002255707 .SEC 3.76 00002255723 .SEC 3.76 00002255758 .SEC 3.76 00002256088 .SEC 3.17 00002256096 ............ 98 00002256118 ............ 98 00002256126 ............ 98 00002256134 ............ 50 00002256142 ............ 86 00002256150 ............ 86 00002256169 ............ 86 00002256177 ............ 50 00002256193 .......... 144 00002256436 .......... 115 00002256436 .SEC 3.84 00002256444 .......... 115 00002256444 .SEC 3.84 00002256460 .SEC 3.93 00002256479 .SEC 3.93 00002256487 .SEC 3.93 00002256495 .......... 189 00002256509 .......... 189 00002256711 .......... 146 00002256738 ............ 56 00002256746 ............ 56 00002256754 ............ 56 00002256762 ............ 56 00002256770 ............ 56 00002256797 ............ 61 00002256800 ............ 61 00002256819 ............ 62 00002257092 ............ 40 00002257106 ............ 40 00002257114 ............ 40 00002257238 .......... 159 00002257572 .......... 113 00002257580 .......... 113 00002257726 .......... 163 00002257734 .......... 163 00002257831 ............ 54 00002257858 ............ 54 00002257890 .......... 115 00002257890 .SEC 3.84

00002257904 .......... 115 00002257904 SEC 3.84 00002257955 .......... 181 00002257963 .......... 181 00002258056 ............ 32 00002258102 SEC 3.14 00002258110 SEC 3.14 00002258129 ............ 82 00002258188 .......... 143 00002258196 .......... 143 00002258331 ............ 14 00002258358 ............ 14 00002258439 .......... 102 00002258447 .......... 102 00002258455 .......... 102 00002258463 .......... 103 00002258471 .......... 103 00002258498 .......... 103 00002258528 ............ 44 00002258560 .......... 160 00002258587 .......... 160 00002258595 SEC 3.13 00002258692 .......... 138 00002259354 ............ 98 00002259605 ............ 55 00002259613 ............ 55 00002259893 SEC 3.87 00002260050 ............ 88 00002260069 ............ 88 00002260077 .......... 135 00002260565 SEC 3.64 00002260867 .......... 147 00002260883 ............ 86 00002260905 ............ 86 00002261081 .......... 156 00002261251 .......... 189 00002261278 .......... 189 00002261634 .............. 9 00002261642 SEC 3.17 00002261715 SEC 3.14 00002261723 .......... 159 00002261731 .......... 159 00002261766 SEC 3.85 00002261782 ............ 53 00002261790 ............ 53 00002261804 ............ 53 00002261839 ............ 85 00002261847 ............ 85 00002261855 ............ 85 00002261863 ............ 85




00002261901 ............ 72 00002261928 ............ 72 00002261936 ............ 72 00002261944 ............ 72 00002261952 ............ 72 00002261960 ............ 72 00002261979 ............ 62 00002261987 ............ 62 00002262177 ............ 15 00002262401 ............ 61 00002262428 ............ 61 00002262754 ............ 93 00002262762 ............ 93 00002262983 ............ 82 00002262991 ............ 88 00002263009 ............ 88 00002263017 ............ 88 00002263025 .......... 115 00002263025 . SEC 3.84 00002263033 .......... 115 00002263033 . SEC 3.84 00002263238 ............ 91 00002263254 ............ 91 00002263351 ............ 88 00002263378 ............ 88 00002263386 ............ 88 00002263866 .......... 188 00002264056 .......... 143 00002264064 .......... 143 00002264188 .......... 102 00002264196 .......... 102 00002264218 .......... 103 00002264226 .......... 103 00002264234 .......... 103 00002264749 .......... 178 00002264951 .......... 189 00002264978 .......... 189 00002264986 .......... 189 00002265273 ............ 29 00002265281 ............ 29 00002265303 ............ 29 00002265311 ............ 29 00002265338 ............ 30 00002265346 ............ 30 00002265494 ............ 87 00002265508 ............ 87 00002265516 ............ 87 00002265540 ............ 41 00002265826 .............. 9 00002266008 ............ 61

00002266016 ............ 61 00002266350 ............ 59 00002266369 ............ 59 00002266377 ............ 59 00002266385 .......... 178 00002266539 .............. 9 00002266547 .............. 9 00002266660 ............ 49 00002266687 .......... 109 00002266717 . SEC 3.42 00002266725 . SEC 3.42 00002266733 . SEC 3.42 00002267217 .......... 149 00002267233 .......... 148 00002267470 ............ 50 00002267489 ............ 50 00002267640 .......... 167 00002267837 ............ 88 00002267845 .............. 9 00002267918 .......... 113 00002267926 .......... 113 00002267985 ............ 49 00002267993 ............ 50 00002268027 ............ 51 00002268035 ............ 51 00002268043 ............ 51 00002268051 ............ 51 00002268078 .......... 148 00002268086 .......... 104 00002268094 .......... 104 00002268205 ............ 26 00002268388 .......... 115 00002268388 . SEC 3.84 00002268396 .......... 115 00002268396 . SEC 3.84 00002268914 .......... 115 00002268914 . SEC 3.84 00002268922 .......... 115 00002268922 . SEC 3.84 00002269031 .......... 163 00002269058 .......... 163 00002269090 .......... 136 00002269198 . SEC 3.94 00002269201 ... SEC 2.4 00002269252 ............ 42 00002269260 ............ 42 00002269279 ............ 42 00002269287 ............ 43 00002269295 ............ 43 00002269309 .......... 119

00002269325 .......... 119 00002269333 .......... 119 00002269430 ............ 93 00002269449 ............ 93 00002270625 ............ 54 00002270633 ............ 54 00002270641 ............ 84 00002270668 ............ 84 00002270676 ............ 84 00002270811 .......... 180 00002271184 ............ 88 00002271192 ............ 88 00002271206 ............ 88 00002271443 ............ 61 00002271451 ............ 61 00002271478 ............ 62 00002271605 ............ 57 00002271613 ............ 57 00002271621 ............ 57 00002271648 ............ 57 00002271656 ............ 58 00002271761 .......... 143 00002271788 .......... 143 00002271842 .......... 163 00002271931 .......... 113 00002271958 .......... 113 00002272059 .SEC 3.87 00002272083 .SEC 3.82 00002272113 ............ 55 00002272121 ............ 55 00002272695 ............ 24 00002272830 ............ 46 00002272873 .......... 118 00002272903 .......... 159 00002273217 .SEC 3.23 00002273225 .SEC 3.23 00002273373 ............ 55 00002273381 ............ 55 00002273497 .......... 141 00002273500 .......... 141 00002273551 ............ 37 00002273578 .SEC 3.64 00002273586 .SEC 3.64 00002273683 ............ 93 00002273691 ............ 93 00002273705 ............ 94 00002273918 ............ 58 00002273942 ............ 98 00002273969 ............ 90 00002273977 ............ 90

00002273985 ............ 90 00002274086 .......... 126 00002274183 ............ 87 00002274191 ............ 87 00002274205 ............ 87 00002274310 .......... 143 00002274329 .......... 143 00002274388 .............. 9 00002274396 .............. 9 00002274531 .............. 9 00002274728 SEC 3.38 00002274833 ............ 61 00002274841 ............ 61 00002274868 ............ 62 00002274914 SEC 3.72 00002274922 SEC 3.72 00002274930 SEC 3.72 00002275023 ............ 90 00002275031 ............ 90 00002275058 ............ 90 00002275066 SEC 3.90 00002275074 ............ 97 00002275082 ............ 97 00002275090 ............ 97 00002275104 ............ 97 00002275279 SEC 3.14 00002275287 .............. 9 00002275538 ............ 35 00002275546 ............ 35 00002276712 ............ 99 00002276720 ............ 99 00002276739 ............ 99 00002276747 ............ 99 00002276755 .......... 100 00002277263 SEC 3.82 00002277271 SEC 3.82 00002278251 .......... 138 00002278359 .............. 9 00002278529 .......... 143 00002278537 .......... 143 00002278545 ............ 90 00002278553 ............ 90 00002278561 ............ 90 00002278588 .............. 9 00002278618 .......... 143 00002278626 .......... 143 00002278669 .......... 148 00002278677 ............ 24 00002278685 ............ 24 00002279215 SEC 3.74





00002279266 .......... 104 00002279363 .......... 156 00002279460 .......... 164 00002279479 .......... 164 00002279614 ............ 88 00002279630 ............ 88 00002279649 ............ 88 00002279800 .......... 102 00002279819 .......... 103 00002279827 .......... 103 00002279835 .......... 103 00002279983 .......... 174 00002280132 ............ 55 00002280140 ............ 55 00002280191 .......... 187 00002280264 ............ 55 00002280272 ............ 56 00002280396 .......... 104 00002280442 ............ 59 00002280450 ............ 59 00002280469 ............ 59 00002280515 .......... 147 00002280523 .......... 147 00002280833 .......... 146 00002280906 .......... 102 00002280914 .......... 102 00002280922 .......... 102 00002280930 .......... 103 00002280949 .......... 103 00002280957 .......... 103 00002281260 ............ 15 00002281279 ............ 15 00002281392 ............ 48 00002281546 ............ 42 00002281554 ............ 42 00002281562 ............ 42 00002281570 ............ 43 00002281589 ............ 43 00002281791 ............ 99 00002281805 ............ 99 00002281813 ............ 99 00002281821 ............ 99 00002281848 .......... 100 00002282097 ... SEC 3.6 00002282119 .......... 102 00002282127 .......... 102 00002282135 .......... 102 00002282143 .......... 103 00002282151 .......... 103 00002282178 .......... 103

00002282224 ............ 17 00002282240 .......... 102 00002282259 .......... 102 00002282267 .......... 102 00002282275 .......... 103 00002282283 .......... 103 00002282291 .......... 103 00002282445 .......... 113 00002282585 .......... 102 00002282593 .......... 102 00002282607 .......... 102 00002282615 .......... 103 00002282623 .......... 103 00002282631 .......... 103 00002282690 .......... 102 00002282852 ............ 93 00002282860 ............ 93 00002282941 . SEC 3.39 00002282968 . SEC 3.40 00002282976 . SEC 3.40 00002282984 . SEC 3.40 00002283131 ............ 64 00002283158 ............ 64 00002283166 ............ 64 00002283174 ............ 64 00002283182 ............ 64 00002283395 . SEC 3.56 00002283409 . SEC 3.56 00002283417 . SEC 3.56 00002283778 ............ 59 00002283786 ............ 59 00002283794 ............ 59 00002283964 .......... 189 00002283972 .......... 189 00002284006 . SEC 3.14 00002284030 .......... 167 00002284049 .......... 167 00002284065 ............ 55 00002284073 ............ 55 00002284235 .......... 100 00002284243 .......... 100 00002284251 .......... 101 00002284278 .......... 101 00002284286 .......... 101 00002284383 ............ 55 00002284391 ............ 55 00002284421 ............ 40 00002284448 ............ 40 00002284456 ............ 40 00002284677 SEC 3A.4

00002284685 SEC 3A.4 00002284707 SEC 3A.4 00002284715 SEC 3A.4 00002284723 ............ 42 00002284731 ............ 42 00002284758 ............ 42 00002284766 ............ 43 00002284774 ............ 43 00002284987 ............ 59 00002285061 ............ 61 00002285088 ............ 61 00002285096 ............ 62 00002285118 ............ 61 00002285126 ............ 61 00002285134 ............ 62 00002285169 ............ 52 00002285177 ............ 52 00002285215 ............ 59 00002285223 ............ 59 00002285398 .SEC 3.59 00002285487 .......... 148 00002285606 .......... 155 00002285614 .......... 155 00002285622 ............ 91 00002285630 ............ 91 00002285649 SEC 3A.4 00002285657 ............ 97 00002285665 ............ 97 00002285819 ............ 86 00002285827 ............ 86 00002285835 ............ 86 00002285924 ............ 87 00002285932 ............ 87 00002285940 ............ 87 00002285959 ............ 17 00002285967 ............ 17 00002285975 ............ 17 00002286068 ............ 92 00002286076 ............ 92 00002286092 ............ 37 00002286246 ............ 49 00002286254 ............ 49 00002286262 ............ 49 00002286335 .SEC 3.14 00002286386 ... SEC 2.7 00002286521 .......... 115 00002286521 .SEC 3.84 00002286548 .......... 115 00002286548 .SEC 3.84 00002286556 ............ 17

00002286564 ............ 17 00002286572 ............ 17 00002286629 ............ 98 00002286823 .......... 115 00002286823 SEC 3.84 00002286831 .......... 115 00002286831 SEC 3.84 00002287021 ............ 27 00002287048 ............ 27 00002287064 ............ 27 00002287072 .......... 165 00002287226 ............ 13 00002287234 ............ 13 00002287390 ............ 93 00002287404 ............ 93 00002287412 ............ 94 00002287420 SEC 3.24 00002287439 SEC 3.24 00002287447 SEC 3.24 00002287498 ............ 29 00002287730 .......... 167 00002287749 .......... 167 00002287765 ............ 88 00002287773 ............ 88 00002287781 ............ 88 00002288044 ............ 37 00002288052 ............ 37 00002288087 SEC 3.14 00002288109 SEC 3.14 00002288184 .......... 143 00002288192 .......... 143 00002288346 ............ 38 00002288354 ............ 38 00002288362 ............ 38 00002288370 ............ 38 00002288680 SEC 3.30 00002289083 ............ 37 00002289091 ............ 37 00002289199 ............ 61 00002289202 ............ 61 00002289229 ............ 62 00002289504 ............ 69 00002290111 .......... 119 00002290146 .......... 119 00002290154 .......... 119 00002290332 ............ 58 00002290340 ............ 58 00002291037 ............ 57 00002291045 ............ 57 00002291053 ............ 57




00002291061 ............ 57 00002291088 ............ 58 00002291134 ............ 59 00002291142 ............ 59 00002291150 ............ 59 00002291177 . SEC 3.92 00002291185 . SEC 3.92 00002291398 ............ 63 00002291401 ............ 63 00002291428 ............ 64 00002291436 ............ 64 00002291789 .......... 104 00002291797 .......... 104 00002291878 ............ 60 00002291886 ............ 60 00002291894 ............ 60 00002291908 ............ 60 00002291967 .......... 143 00002292173 ............ 36 00002292203 ............ 61 00002292211 ............ 61 00002292238 ............ 62 00002292270 .............. 7 00002292289 .............. 7 00002292378 .......... 119 00002292394 .......... 119 00002292408 .......... 119 00002292866 .............. 7 00002292874 .............. 7 00002292882 .............. 7 00002292920 .......... 148 00002292998 .............. 6 00002293005 .............. 6 00002293161 . SEC 3.20 00002293218 ............ 91 00002293226 ............ 91 00002293528 .............. 6 00002293536 .............. 6 00002293579 .............. 6 00002293749 ............ 93 00002293811 .......... 147 00002293838 .......... 147 00002293943 .............. 6 00002293951 .............. 6 00002294230 ............ 61 00002294249 ............ 61 00002294257 ............ 62 00002294265 ............ 48 00002294273 ............ 15 00002294338 .......... 163

00002294346 .......... 164 00002294419 ............ 13 00002294427 ............ 13 00002294524 ............ 61 00002294532 ............ 61 00002294702 ............ 75 00002294710 ............ 75 00002295121 ............ 48 00002295148 ............ 55 00002295261 ............ 38 00002295288 ............ 38 00002295296 ............ 38 00002295318 ............ 38 00002295369 ............ 63 00002295415 .......... 147 00002295482 ............ 63 00002295490 ............ 63 00002295504 ............ 64 00002295512 ............ 64 00002295695 ............ 83 00002295709 ............ 83 00002295822 ............ 18 00002295881 .......... 125 00002295946 .......... 159 00002295954 .......... 159 00002296101 ............ 87 00002296128 ............ 87 00002296136 ............ 87 00002296152 ............ 91 00002296349 .......... 143 00002296357 .......... 143 00002296438 .......... 147 00002296446 .......... 147 00002296527 .......... 137 00002296551 .......... 100 00002296578 .......... 100 00002296594 .......... 101 00002296608 .......... 101 00002296616 .......... 113 00002296632 .......... 148 00002296640 .......... 148 00002296810 .......... 139 00002297302 .......... 119 00002297329 .......... 119 00002297337 .......... 119 00002297485 ............ 55 00002297493 ............ 55 00002297736 ............ 62 00002297744 ............ 62 00002297752 ............ 62

00002297795 .......... 165 00002297809 .......... 173 00002297841 ............ 67 00002297868 .......... 143 00002297876 .......... 143 00002297906 .SEC 3.72 00002297914 .SEC 3.72 00002297922 .SEC 3.72 00002298074 .......... 148 00002298082 .......... 148 00002298279 .SEC 3.72 00002298287 .SEC 3.72 00002298295 .SEC 3.72 00002298309 .SEC 3.93 00002298376 .SEC 3.75 00002298384 .SEC 3.75 00002298392 .SEC 3.75 00002298457 ............ 18 00002298538 .......... 159 00002298546 .......... 159 00002298570 ............ 48 00002298597 .......... 104 00002298600 .......... 104 00002298619 .......... 104 00002298627 .......... 104 00002298635 SEC 3A.4 00002298643 SEC 3A.4 00002298651 SEC 3A.4 00002298791 .......... 144 00002298813 .......... 144 00002299585 .......... 148 00002299615 .......... 138 00002299623 .SEC 3.73 00002299631 .SEC 3.73 00002299658 .SEC 3.73 00002299712 .SEC 3.14 00002299879 ............ 61 00002299887 ............ 61 00002299895 ............ 62 00002299933 ............ 60 00002299941 ............ 60 00002299968 ............ 60 00002299976 ............ 60 00002300036 ............ 60 00002300044 ............ 60 00002300052 ............ 60 00002300060 ............ 60 00002300079 ............ 60 00002300087 ............ 60 00002300095 ............ 60

00002300109 ............ 60 00002300222 ............ 60 00002300230 ............ 60 00002300486 .......... 148 00002300680 ............ 60 00002301083 .......... 148 00002301148 ............ 63 00002301156 ............ 63 00002301164 ............ 64 00002301172 ............ 64 00002301288 ............ 46 00002301407 SEC 3.18 00002301423 SEC 3.72 00002301431 SEC 3.72 00002301458 SEC 3.72 00002301482 ............ 90 00002301490 ............ 90 00002301768 ............ 62 00002301776 ............ 62 00002301784 ............ 62 00002302055 ............ 52 00002302136 ............ 62 00002302144 ............ 62 00002302152 ............ 62 00002302179 .............. 6 00002302187 .............. 6 00002302209 SEC 3.75 00002302365 ............ 62 00002302373 ............ 62 00002302381 ............ 62 00002302616 ............ 72 00002302624 ............ 72 00002302632 ............ 50 00002302640 ............ 50 00002302675 ............ 38 00002302683 ............ 38 00002302691 ............ 38 00002302713 ............ 38 00002302764 ............ 80 00002302772 ............ 80 00002302780 ............ 80 00002302799 ............ 80 00002302802 ............ 80 00002302861 SEC 3.72 00002302888 SEC 3.72 00002302896 SEC 3.72 00002302918 ............ 50 00002302926 ............ 50 00002302942 SEC 3.72 00002302950 SEC 3.72





00002302977 . SEC 3.72 00002303027 . SEC 3.20 00002303116 ............ 99 00002303124 . SEC 3.72 00002303132 . SEC 3.72 00002303140 . SEC 3.72 00002303159 ............ 99 00002303167 ............ 99 00002303175 ............ 99 00002303183 .......... 100 00002303191 .......... 100 00002303205 .......... 100 00002303396 ............ 52 00002303418 ............ 52 00002303426 .............. 6 00002303434 .............. 6 00002303442 . SEC 3.72 00002303450 . SEC 3.72 00002303469 . SEC 3.72 00002303647 ............ 49 00002303655 .......... 102 00002303663 .......... 102 00002303728 SEC 3A.2 00002303736 SEC 3A.3 00002303744 SEC 3A.3 00002303922 . SEC 3.81 00002304163 .......... 187 00002304317 ............ 90 00002304325 ............ 90 00002304333 ............ 90 00002304368 .......... 167 00002304376 .......... 167 00002304678 . SEC 3.15 00002304686 ............ 91 00002304694 ............ 91 00002305003 ............ 98 00002305011 ............ 99 00002305046 .......... 148 00002305259 .......... 143 00002305267 .......... 143 00002305429 .......... 135 00002305585 SEC 3A.4 00002305933 .......... 118 00002305941 .......... 118 00002305968 .......... 118 00002305984 . SEC 3.78 00002305992 . SEC 3.78 00002306018 . SEC 3.78 00002306026 . SEC 3.78 00002306034 . SEC 3.78

00002306042 . SEC 3.78 00002306050 . SEC 3.78 00002306069 . SEC 3.78 00002306212 .......... 143 00002306220 .......... 143 00002306239 ............ 91 00002306247 ............ 91 00002306905 . SEC 3.41 00002307669 . SEC 3.72 00002307677 . SEC 3.72 00002307723 . SEC 3.72 00002307804 .......... 100 00002307812 .......... 100 00002307839 .......... 101 00002307847 .......... 101 00002307871 .......... 148 00002307898 ............ 82 00002308444 . SEC 3.73 00002308452 . SEC 3.73 00002308460 . SEC 3.73 00002308894 .......... 142 00002308908 ............ 69 00002308916 ............ 70 00002309750 ............ 67 00002309769 ............ 67 00002309777 ............ 67 00002309866 .......... 148 00002310112 . SEC 3.41 00002310260 .......... 147 00002310279 ............ 90 00002310287 ............ 90 00002310295 ............ 90 00002310317 ............ 90 00002310325 ............ 90 00002310333 ............ 90 00002310341 ............ 99 00002310368 ............ 99 00002310376 ............ 99 00002310384 ............ 99 00002310392 .......... 100 00002310422 .......... 135 00002310503 ............ 63 00002310511 ............ 63 00002310538 ............ 64 00002310546 ............ 64 00002310805 .......... 148 00002310813 .......... 148 00002310899 ............ 38 00002310902 ............ 38 00002310910 ............ 38

00002310929 ............ 38 00002311283 .SEC 3.78 00002311291 .SEC 3.78 00002311305 .SEC 3.78 00002311313 .SEC 3.78 00002311658 ............ 65 00002311925 .SEC 3.39 00002312085 ............ 88 00002312247 .......... 143 00002312255 .......... 143 00002312298 .SEC 3.74 00002312441 .SEC 3.22 00002313332 ............ 67 00002313340 ............ 67 00002313359 ............ 67 00002313375 ............ 67 00002313383 ............ 68 00002313405 ............ 91 00002313413 ............ 91 00002313421 ............ 97 00002313448 ............ 38 00002313456 ............ 38 00002313464 ............ 38 00002313472 ............ 38 00002313685 .......... 143 00002313693 .......... 143 00002313707 ............ 38 00002313715 ............ 38 00002313723 ............ 38 00002313731 ............ 59 00002313758 ............ 38 00002313901 .......... 100 00002313928 .......... 100 00002313936 .......... 101 00002313944 .......... 101 00002313960 .......... 116 00002313960 .SEC 3.95 00002313979 SEC 3A.4 00002313987 SEC 3A.4 00002313995 .......... 100 00002314002 .......... 100 00002314010 .......... 101 00002314029 .......... 101 00002314037 .......... 119 00002314053 .......... 119 00002314061 .......... 120 00002314088 .......... 120 00002314177 .......... 148 00002314185 .......... 148 00002314282 .SEC 3.15

00002314290 .......... 114 00002314290 SEC 3.61 00002314304 .......... 114 00002314304 SEC 3.61 00002314630 SEC 3.39 00002314649 SEC 3.40 00002314657 SEC 3.40 00002314665 SEC 3.40 00002314940 SEC 3.15 00002315157 .............. 9 00002315165 .............. 9 00002315262 .......... 119 00002315289 .......... 119 00002315297 .......... 119 00002315424 SEC 3A.4 00002315432 SEC 3A.4 00002315440 SEC 3A.4 00002315645 ............ 88 00002315653 ............ 88 00002315661 ............ 88 00002315866 SEC 3.15 00002315971 ............ 66 00002315998 ............ 66 00002316005 ............ 66 00002316013 ............ 66 00002316021 ............ 66 00002316048 ............ 67 00002316080 .......... 100 00002316099 .......... 100 00002316110 .......... 101 00002316129 .......... 101 00002316307 .......... 136 00002316390 ............ 66 00002316404 ............ 66 00002316412 ............ 66 00002316846 .......... 119 00002316854 .......... 119 00002316862 .......... 120 00002316870 .......... 120 00002316943 SEC 3.42 00002316951 SEC 3.42 00002316978 SEC 3.42 00002316986 ............ 32 00002317060 ............ 66 00002317079 ............ 66 00002317087 ............ 66 00002317192 .......... 159 00002317206 .......... 159 00002317427 SEC 3A.2 00002317435 SEC 3A.3




00002317443 SEC 3A.3 00002317451 ............ 40 00002317478 ............ 40 00002317486 ............ 40 00002318008 .......... 137 00002318253 ... SEC 2.4 00002318261 ... SEC 2.4 00002318660 ............ 45 00002318679 ............ 45 00002318709 ............ 68 00002319012 .......... 181 00002319055 ............ 86 00002319063 ............ 86 00002319071 ............ 86 00002319403 ............ 78 00002319411 ............ 78 00002319438 ............ 78 00002319446 ............ 78 00002319616 ............ 45 00002319624 ............ 45 00002319632 ............ 45 00002319861 . SEC 3.75 00002319977 ............ 82 00002319985 ............ 82 00002319993 ............ 82 00002320134 ............ 15 00002320177 ............ 68 00002320185 ............ 68 00002320312 .......... 109 00002320525 .......... 138 00002320673 . SEC 3.91 00002320851 .......... 147 00002321149 ............ 56 00002321203 ............ 86 00002321211 ............ 86 00002321238 ............ 86 00002321343 .......... 100 00002321351 .......... 100 00002321459 .......... 117 00002321475 .......... 165 00002321483 .......... 165 00002321491 .......... 165 00002321653 ............ 63 00002321858 ............ 55 00002321866 ............ 55 00002322250 .......... 167 00002322285 . SEC 3.30 00002322323 .......... 114 00002322323 . SEC 3.61 00002322374 ............ 98

00002322382 ............ 98 00002322390 ............ 98 00002322404 ............ 98 00002322412 ............ 98 00002322455 ............ 98 00002322579 . SEC 3.41 00002323192 ............ 82 00002323206 ............ 82 00002323214 ............ 82 00002324032 .......... 187 00002324199 .......... 188 00002324229 .......... 116 00002324229 . SEC 3.95 00002324563 . SEC 3.78 00002324571 . SEC 3.78 00002324598 . SEC 3.78 00002324601 . SEC 3.78 00002324628 ............ 82 00002324768 .......... 116 00002324768 . SEC 3.95 00002324776 . SEC 3.46 00002324784 . SEC 3.46 00002324946 ............ 38 00002324954 ............ 38 00002324962 ............ 38 00002324970 ............ 38 00002324997 .......... 137 00002325063 . SEC 3.82 00002325071 . SEC 3.82 00002325462 .......... 161 00002325659 ............ 99 00002325667 ............ 99 00002325675 ............ 99 00002325683 ............ 99 00002325691 .......... 100 00002325942 SEC 3A.4 00002326477 . SEC 3.72 00002326485 . SEC 3.72 00002326493 . SEC 3.72 00002326590 .......... 119 00002326612 .......... 119 00002326620 .......... 120 00002326639 .......... 120 00002326760 ............ 55 00002326779 ............ 55 00002326787 ............ 55 00002326965 ............ 65 00002326973 ............ 65 00002327112 . SEC 3.39 00002327120 . SEC 3.39

00002327147 .SEC 3.40 00002327155 .SEC 3.40 00002327163 .SEC 3.40 00002327295 .SEC 3.75 00002327562 .......... 100 00002327570 .......... 100 00002327775 .......... 100 00002327783 .......... 100 00002328070 ............ 66 00002328089 ............ 66 00002328100 ............ 66 00002328305 .......... 102 00002328313 .......... 102 00002328321 .......... 102 00002328348 .......... 103 00002328364 .......... 103 00002328372 .......... 103 00002328461 ............ 66 00002328488 ............ 66 00002328496 ............ 66 00002328518 ............ 66 00002328526 ............ 66 00002328534 ............ 67 00002328593 .......... 129 00002328593 .SEC 3.60 00002329131 ............ 42 00002329158 ............ 42 00002329166 ............ 42 00002329174 ............ 43 00002329182 ............ 43 00002329204 .............. 6 00002329425 .......... 147 00002329433 .......... 147 00002329840 .SEC 3.17 00002330105 .SEC 3.39 00002330113 .SEC 3.39 00002330121 .SEC 3.40 00002330148 .SEC 3.40 00002330156 .SEC 3.40 00002330288 ............ 68 00002330385 .......... 129 00002330393 .......... 129 00002330393 .SEC 3.60 00002330415 .......... 100 00002330423 .......... 100 00002330458 .......... 101 00002330466 .......... 101 00002330512 ............ 66 00002330520 ............ 66 00002330539 ............ 67

00002330881 .............. 9 00002330911 SEC 3.17 00002330954 ............ 40 00002330962 ............ 40 00002330970 ............ 40 00002331004 ............ 61 00002331012 ............ 61 00002331020 ............ 42 00002331039 ............ 42 00002331047 ............ 42 00002331055 ............ 43 00002331063 ............ 43 00002331071 ............ 55 00002331098 ............ 55 00002331101 ............ 63 00002331128 ............ 63 00002331136 ............ 64 00002331144 ............ 64 00002331284 ............ 55 00002331292 ............ 55 00002331551 .......... 125 00002331624 .......... 137 00002331683 ............ 90 00002331691 ............ 90 00002331705 ............ 90 00002331748 ............ 18 00002331934 ............ 55 00002331942 ............ 55 00002331950 ............ 91 00002331969 ............ 42 00002331977 ............ 91 00002331985 ............ 42 00002331993 ............ 42 00002332000 ............ 43 00002332019 ............ 43 00002332027 .............. 6 00002332035 .............. 6 00002332043 .............. 6 00002332051 .......... 102 00002332078 .......... 102 00002332086 .......... 102 00002332094 .......... 103 00002332108 .......... 103 00002332116 .......... 103 00002332132 SEC 3A.2 00002332140 SEC 3A.3 00002332159 SEC 3A.3 00002332167 ............ 61 00002332175 ............ 61 00002332183 ............ 62





00002332191 ............ 40 00002332205 ............ 40 00002332213 ............ 40 00002332299 ............ 63 00002332302 ............ 63 00002332310 ............ 64 00002332329 ............ 64 00002332361 .......... 119 00002332388 .............. 9 00002332396 .............. 9 00002332426 .......... 119 00002332434 .......... 120 00002332442 .......... 120 00002332566 ............ 61 00002332574 ............ 61 00002332582 ............ 86 00002332590 ............ 86 00002332604 ............ 86 00002332809 . SEC 3.78 00002332817 . SEC 3.78 00002332825 . SEC 3.78 00002332833 . SEC 3.78 00002332922 ............ 65 00002332957 ............ 65 00002333554 . SEC 3.80 00002333619 .......... 166 00002333627 .......... 166 00002333856 . SEC 3.81 00002333864 . SEC 3.81 00002333872 . SEC 3.81 00002335700 ............ 36 00002335719 ............ 36 00002335727 ............ 36 00002336480 .......... 145 00002336502 .......... 145 00002336715 . SEC 3.78 00002336723 . SEC 3.78 00002336731 . SEC 3.78 00002336758 . SEC 3.78 00002337428 ............ 66 00002337436 ............ 66 00002337444 ............ 67 00002337495 ............ 69 00002337509 ............ 69 00002337517 ............ 69 00002337746 .......... 119 00002337762 .......... 119 00002337770 .......... 120 00002337800 .......... 120 00002337819 ... SEC 2.4

00002337827 .......... 118 00002337835 .......... 118 00002337878 ............ 99 00002337886 ............ 99 00002337894 ............ 99 00002337908 ............ 99 00002337916 .......... 100 00002337975 ............ 41 00002337983 ............ 41 00002337991 ............ 41 00002338009 ............ 41 00002338726 ............ 41 00002338734 ............ 41 00002338742 ............ 41 00002338750 ............ 41 00002339439 . SEC 3.42 00002339447 . SEC 3.42 00002339455 . SEC 3.42 00002339587 . SEC 3.72 00002339595 . SEC 3.72 00002339765 ............ 41 00002339773 ............ 41 00002339781 ............ 41 00002339803 ............ 41 00002340208 ............ 48 00002341379 . SEC 3.39 00002341387 . SEC 3.39 00002341395 . SEC 3.40 00002341409 . SEC 3.40 00002341417 . SEC 3.40 00002342138 ............ 64 00002342146 ............ 64 00002342154 ............ 64 00002342162 ............ 64 00002342170 ............ 64 00002342545 .......... 116 00002342545 . SEC 3.95 00002342855 ............ 14 00002342863 ............ 14 00002343002 .......... 187 00002343010 ............ 87 00002343029 ............ 87 00002343037 ............ 87 00002343282 ............ 74 00002343541 . SEC 3.24 00002344025 ............ 29 00002344033 ............ 29 00002344041 ............ 29 00002344068 ............ 29 00002344076 ............ 30

00002344084 ............ 30 00002344114 ............ 30 00002344122 .......... 113 00002344351 .......... 138 00002344823 .............. 7 00002344831 .............. 7 00002345579 .......... 148 00002345587 .......... 148 00002345803 ............ 88 00002345838 ............ 88 00002345846 ............ 88 00002347245 .............. 6 00002347253 .............. 6 00002347261 .............. 6 00002347288 .............. 6 00002347296 ............ 66 00002347318 ............ 66 00002347326 ............ 66 00002347512 ............ 51 00002347520 ............ 51 00002347555 ............ 51 00002347571 ............ 51 00002348004 .SEC 3.20 00002348500 .SEC 3.41 00002348691 .......... 147 00002348705 ............ 38 00002348713 ............ 38 00002348721 ............ 38 00002348748 ............ 38 00002348772 ............ 94 00002348780 ............ 94 00002348799 ............ 94 00002349167 ............ 56 00002349191 .......... 110 00002349205 .......... 110 00002350092 .SEC 3.89 00002350106 .SEC 3.89 00002350114 .SEC 3.89 00002350122 .SEC 3.82 00002350130 .SEC 3.82 00002350149 .SEC 3.82 00002350238 .......... 183 00002350297 ............ 38 00002350319 ............ 38 00002350327 ............ 38 00002350335 ............ 38 00002350394 ............ 52 00002350408 ............ 52 00002350440 .......... 148 00002350459 .......... 166

00002350467 .......... 166 00002350475 ............ 48 00002350483 ............ 48 00002350491 ............ 48 00002350505 ............ 48 00002350750 ............ 74 00002350769 ............ 74 00002350777 ............ 74 00002350785 ............ 75 00002350793 ............ 75 00002350807 ............ 75 00002350815 ............ 80 00002350890 ............ 80 00002350912 ............ 80 00002350920 ............ 80 00002350947 ............ 80 00002350963 ............ 59 00002350971 ............ 59 00002350998 ............ 59 00002351013 ............ 75 00002351021 ............ 75 00002351072 .......... 111 00002351080 .......... 111 00002351099 .......... 111 00002351102 .......... 145 00002351110 .......... 145 00002351234 ............ 13 00002351242 ............ 13 00002351420 ............ 44 00002351439 ............ 44 00002351447 ............ 45 00002351536 SEC 3.20 00002351579 ............ 18 00002351668 .......... 189 00002351676 .......... 189 00002351870 .......... 114 00002351870 SEC 3.79 00002351889 .......... 115 00002351889 SEC 3.79 00002352230 ............ 60 00002352249 ............ 60 00002352257 ............ 60 00002352265 ............ 60 00002352338 .......... 119 00002352346 .......... 119 00002352354 .......... 120 00002352362 .......... 120 00002352397 ............ 72 00002352400 ............ 72 00002352648 ............ 30




00002352656 ............ 30 00002352664 ............ 30 00002352672 ............ 30 00002352680 ............ 31 00002352710 ............ 10 00002352729 ............ 10 00002352745 ............ 10 00002352753 ............ 11 00002352761 ............ 10 00002352788 ............ 11 00002352923 ............ 60 00002352931 ............ 60 00002352966 . SEC 3.14 00002352974 .......... 100 00002352982 .......... 100 00002353016 .......... 145 00002353024 .......... 145 00002353040 .......... 119 00002353059 .......... 119 00002353067 .......... 120 00002353075 .......... 120 00002353121 ............ 15 00002353164 .......... 100 00002353172 .......... 100 00002353199 .......... 101 00002353202 .......... 101 00002353210 .......... 188 00002353229 ............ 39 00002353237 ............ 39 00002353245 ............ 86 00002353253 ............ 86 00002353261 ............ 86 00002353318 SEC 3A.2 00002353326 SEC 3A.3 00002353334 SEC 3A.3 00002353342 ............ 87 00002353350 ............ 87 00002353369 ............ 87 00002353377 .......... 163 00002353385 .......... 163 00002353504 ............ 67 00002353512 ............ 67 00002353520 ............ 93 00002353539 ............ 93 00002353547 ............ 94 00002353660 ............ 91 00002353679 ............ 91 00002353687 . SEC 3.75 00002353830 .......... 147 00002353849 .......... 147

00002354187 ............ 52 00002354195 ............ 52 00002354217 . SEC 3.65 00002354225 . SEC 3.65 00002354233 . SEC 3.65 00002354241 . SEC 3.65 00002354462 . SEC 3.41 00002354608 ............ 41 00002354616 ............ 41 00002354624 ............ 41 00002354632 ............ 41 00002354705 ............ 18 00002354713 ............ 90 00002354721 ............ 90 00002354748 ............ 90 00002354829 ............ 67 00002354837 ............ 67 00002354845 ............ 67 00002354926 .......... 165 00002354934 .......... 165 00002354942 .......... 165 00002354977 .......... 129 00002354985 .......... 129 00002354985 . SEC 3.60 00002355043 . SEC 3.41 00002355272 ............ 91 00002355280 ............ 91 00002355507 .......... 129 00002355515 .......... 129 00002355515 . SEC 3.60 00002355523 .......... 129 00002355523 . SEC 3.60 00002355663 .......... 165 00002355671 .......... 165 00002355698 .......... 165 00002355752 ............ 56 00002355760 ............ 57 00002355779 ............ 57 00002355787 ............ 57 00002356058 . SEC 3.41 00002356422 .......... 165 00002356511 .......... 148 00002356538 .......... 148 00002356546 ............ 40 00002356554 ............ 40 00002356562 ............ 40 00002356570 ............ 37 00002356589 ............ 37 00002356651 ............ 69 00002356678 ............ 69

00002356686 ............ 69 00002356694 ............ 69 00002356708 ............ 69 00002356716 ............ 69 00002356724 ............ 69 00002356732 ............ 70 00002356759 ............ 69 00002356767 ............ 69 00002356775 ............ 69 00002356813 ............ 52 00002356821 ............ 52 00002356848 ............ 52 00002356856 ............ 88 00002356864 ............ 88 00002356872 ............ 88 00002356880 .......... 102 00002356899 .......... 102 00002356902 .......... 102 00002356910 .......... 103 00002356929 .......... 103 00002356937 .......... 103 00002356996 ............ 69 00002357003 ............ 69 00002357011 ............ 69 00002357038 ............ 69 00002357046 ............ 70 00002357194 ............ 55 00002357208 ............ 55 00002357224 .SEC 3.41 00002357380 .SEC 3.39 00002357399 ............ 66 00002357402 ............ 66 00002357410 ............ 67 00002357453 .......... 165 00002357461 .......... 165 00002357488 .......... 165 00002357615 .SEC 3.55 00002357623 .SEC 3.55 00002357631 .SEC 3.56 00002357658 .SEC 3.56 00002357682 .......... 147 00002357690 .......... 147 00002357712 ............ 55 00002357720 ............ 55 00002357968 ............ 67 00002357976 ............ 67 00002357984 .SEC 3.75 00002358085 .......... 144 00002358093 .......... 144 00002358158 ............ 31

00002358166 ............ 31 00002358174 ............ 31 00002358182 ............ 32 00002358263 ............ 67 00002358611 .......... 129 00002358808 SEC 3.22 00002358921 SEC 3.74 00002359316 SEC 3.20 00002359502 ............ 78 00002359510 ............ 78 00002359529 .......... 102 00002359537 .......... 102 00002359545 .......... 102 00002359553 .......... 103 00002359561 .......... 103 00002359588 .......... 103 00002359790 .......... 102 00002359804 .......... 102 00002359812 .......... 102 00002359820 .......... 103 00002359839 .......... 103 00002359847 .......... 103 00002360020 ............ 90 00002360039 ............ 90 00002360047 ............ 90 00002360616 .......... 100 00002360624 .......... 100 00002361027 SEC 3A.4 00002361035 SEC 3A.4 00002361361 ............ 82 00002361469 ............ 86 00002361485 ............ 86 00002361493 ............ 86 00002361531 ............ 61 00002361558 ............ 61 00002361566 ............ 62 00002361698 .......... 115 00002361698 SEC 3.84 00002361892 .......... 100 00002362406 ............ 48 00002362449 ............ 67 00002362651 ............ 55 00002362678 ............ 55 00002362848 .............. 6 00002362856 .............. 6 00002362864 .............. 6 00002362872 .............. 6 00002362880 ............ 62 00002362899 ............ 62 00002362902 ............ 62





00002362937 ............ 98 00002362945 ............ 62 00002362953 ............ 62 00002362961 ............ 62 00002362988 .......... 116 00002362988 . SEC 3.95 00002362996 .......... 116 00002362996 . SEC 3.95 00002363100 ............ 69 00002363119 ............ 69 00002363208 ............ 66 00002363216 ............ 66 00002363224 ............ 67 00002363232 . SEC 3.72 00002363240 . SEC 3.72 00002363259 . SEC 3.72 00002363267 ............ 63 00002363275 ............ 63 00002363283 ............ 64 00002363291 ............ 64 00002363305 .......... 119 00002363321 .......... 119 00002363348 .......... 119 00002363364 .............. 9 00002363372 .............. 9 00002363380 .............. 9 00002363402 ............ 97 00002363429 .......... 148 00002363453 ............ 60 00002363461 ............ 60 00002363488 ............ 60 00002363496 ............ 60 00002363518 .......... 165 00002363534 .......... 113 00002363542 .......... 113 00002363674 ............ 54 00002363682 ............ 54 00002363704 .......... 166 00002363712 .......... 166 00002363763 ............ 92 00002363771 ............ 92 00002363798 ............ 49 00002363801 ............ 49 00002363828 ............ 49 00002363895 ............ 50 00002364115 ............ 78 00002364123 ............ 78 00002364131 ............ 78 00002364158 ............ 78 00002364239 ............ 39

00002364247 ............ 39 00002364263 ............ 36 00002364271 .......... 148 00002364301 ............ 96 00002364328 ............ 96 00002364336 ............ 36 00002364344 .......... 104 00002364409 ............ 37 00002364506 .......... 163 00002364514 .......... 163 00002364530 ............ 92 00002364573 ............ 44 00002364581 ............ 44 00002364603 ............ 45 00002364719 ............ 14 00002364727 ............ 14 00002364816 . SEC 3.75 00002364824 ............ 52 00002364832 ............ 52 00002364840 ............ 52 00002364859 ............ 52 00002364913 ............ 51 00002364921 ............ 51 00002364948 ............ 51 00002364956 ............ 51 00002365154 .............. 5 00002365359 ............ 65 00002365367 ............ 65 00002365383 . SEC 3.41 00002365820 ............ 74 00002365839 ............ 74 00002365847 ............ 75 00002365855 ............ 75 00002365863 ............ 75 00002366231 ............ 48 00002366258 .......... 115 00002366258 . SEC 3.84 00002366266 .......... 115 00002366266 . SEC 3.84 00002366312 ............ 65 00002366320 ............ 65 00002366339 ............ 65 00002366398 .............. 9 00002366665 ............ 72 00002366673 ............ 72 00002366681 ............ 72 00002366703 ............ 72 00002367068 ............ 69 00002367076 ............ 69 00002367084 ............ 69

00002367092 ............ 69 00002367106 ............ 70 00002367122 ............ 69 00002367130 ............ 69 00002367149 ............ 69 00002367157 .......... 178 00002367173 .......... 102 00002367181 .......... 102 00002367203 .......... 102 00002367211 .......... 103 00002367238 .......... 103 00002367246 .......... 103 00002367335 .......... 137 00002367378 .......... 145 00002367386 .......... 145 00002367394 ............ 85 00002367564 ............ 49 00002367572 ............ 50 00002367602 .......... 119 00002367947 .......... 157 00002367955 .......... 157 00002367963 .......... 157 00002367971 .......... 157 00002368013 ............ 49 00002368021 ............ 49 00002368048 ............ 50 00002368226 .......... 129 00002368226 .SEC 3.60 00002368242 ............ 48 00002368277 ............ 67 00002368285 ............ 67 00002368293 ............ 67 00002368641 ............ 49 00002368668 ............ 50 00002369036 .......... 116 00002369036 .SEC 3.95 00002370077 ............ 91 00002370255 .SEC 3.75 00002370441 ............ 57 00002370492 ............ 57 00002370506 ............ 57 00002370514 ............ 57 00002370522 ............ 58 00002370611 ............ 56 00002370638 ............ 57 00002370646 ............ 57 00002370654 ............ 57 00002370689 ............ 98 00002370697 .......... 104 00002370700 .......... 104

00002370735 ............ 51 00002370743 ............ 51 00002370751 ............ 51 00002370786 ............ 51 00002370808 .......... 148 00002370921 SEC 3.57 00002370972 ............ 88 00002370980 ............ 88 00002370999 ............ 88 00002371022 ............ 68 00002371030 ............ 68 00002371049 ............ 68 00002371057 ............ 68 00002371235 ............ 67 00002371243 ............ 67 00002371251 ............ 68 00002371413 ............ 27 00002371421 ............ 27 00002371529 ............ 69 00002371537 ............ 69 00002371545 ............ 69 00002371677 ............ 87 00002371685 ............ 87 00002371693 ............ 87 00002371715 ............ 55 00002371723 ............ 55 00002371731 .......... 143 00002371758 .......... 143 00002371766 .......... 102 00002371774 .......... 102 00002371782 .......... 102 00002371790 .......... 103 00002371804 .......... 103 00002371812 .......... 103 00002371820 SEC 3.41 00002371898 ............ 91 00002371901 ............ 91 00002371987 ............ 49 00002371995 ............ 50 00002372347 ............ 66 00002372371 ............ 66 00002372398 ............ 66 00002372525 ............ 82 00002372533 ............ 82 00002372541 ............ 82 00002372568 ............ 82 00002372576 ............ 82 00002372584 ............ 82 00002372797 ............ 82 00002372819 ............ 99




00002372827 ............ 99 00002372835 ............ 99 00002372843 ............ 99 00002372851 .......... 100 00002372886 ............ 66 00002372894 ............ 66 00002372908 ............ 67 00002372932 ............ 42 00002372940 ............ 42 00002372959 ............ 42 00002372967 ............ 43 00002372975 ............ 43 00002373041 .......... 137 00002373203 ............ 38 00002373211 ............ 38 00002373238 ............ 38 00002373246 ............ 38 00002373319 ............ 66 00002373327 ............ 66 00002373335 ............ 66 00002373343 ............ 66 00002373351 ............ 66 00002373378 ............ 67 00002373432 ............ 99 00002373440 ............ 99 00002373459 ............ 99 00002373467 ............ 99 00002373564 ............ 68 00002373572 ............ 68 00002373734 ............ 69 00002373742 ............ 69 00002373750 ............ 69 00002373769 ............ 69 00002373777 ............ 70 00002373920 .......... 145 00002373939 .......... 145 00002373947 .......... 129 00002373947 . SEC 3.60 00002374552 ............ 93 00002374560 ............ 93 00002374579 ............ 94 00002374609 .......... 129 00002374609 . SEC 3.60 00002374730 .......... 114 00002374730 . SEC 3.79 00002374749 .......... 115 00002374749 . SEC 3.79 00002374757 .......... 187 00002374846 ............ 63 00002374854 ............ 64

00002374862 ............ 64 00002374870 .......... 147 00002375036 ............ 42 00002375044 ............ 42 00002375052 ............ 42 00002375060 ............ 43 00002375079 ............ 43 00002375249 ............ 87 00002375257 ............ 87 00002375265 ............ 87 00002375559 .......... 117 00002375958 ............ 68 00002375966 ............ 68 00002376091 .......... 143 00002376105 .......... 143 00002376350 .......... 119 00002376377 .......... 119 00002376385 .......... 119 00002376539 ............ 65 00002376547 ............ 65 00002376555 ............ 65 00002376717 ............ 68 00002376725 ............ 68 00002377144 ............ 67 00002377152 ............ 68 00002377608 .......... 129 00002377616 .......... 129 00002377616 . SEC 3.60 00002377950 . SEC 3.42 00002377969 . SEC 3.42 00002377977 . SEC 3.42 00002378078 ............ 67 00002378086 ............ 67 00002378094 ............ 68 00002378523 ............ 41 00002378531 ............ 41 00002378558 ............ 41 00002378566 ............ 41 00002378620 .......... 163 00002378639 .......... 163 00002378841 .......... 163 00002378868 .......... 163 00002378884 ............ 42 00002378892 ............ 42 00002378906 ............ 42 00002378914 ............ 43 00002378922 ............ 43 00002379058 ............ 67 00002379139 ............ 65 00002379147 ............ 65

00002379155 ............ 65 00002379198 .......... 114 00002379198 .SEC 3.79 00002379201 .......... 115 00002379201 .SEC 3.79 00002379252 ............ 68 00002379279 ............ 65 00002379287 ............ 65 00002379295 ............ 65 00002379317 .......... 129 00002379325 .......... 129 00002379325 .SEC 3.60 00002379333 .......... 129 00002379333 .SEC 3.60 00002379686 SEC 3A.2 00002379694 SEC 3A.3 00002379708 SEC 3A.3 00002380072 ............ 90 00002380080 ............ 90 00002380099 ............ 90 00002380560 ............ 92 00002380579 ............ 92 00002380749 .......... 129 00002380757 .......... 129 00002380757 .SEC 3.60 00002380838 ............ 67 00002380900 .......... 144 00002380919 .......... 144 00002381265 ............ 41 00002381273 ............ 41 00002381281 ............ 41 00002381303 ............ 41 00002382547 ............ 69 00002382555 ............ 69 00002382563 ............ 69 00002382571 ............ 69 00002382598 ............ 70 00002382644 ............ 41 00002382652 ............ 41 00002382660 ............ 41 00002382679 ............ 41 00002382709 .......... 100 00002382717 .......... 100 00080024360 .......... 125 00080027202 .......... 125 00002298309 ............ 28 00002291185 ............ 28 00002291177 ............ 28 00002293161 ............ 32 00002359316 ............ 32

00002348004 ............ 32 00002351536 ............ 32 00002303027 ............ 32 00002252767 ............ 32 00002238682 ............ 32

Documents

Alberta Health and Wellness Drug Benefit List - Group … · Febuxostat Special Authorization Request Form ... Product Monograph . ALBERTA HEALTH AND WELLNESS DRUG BENEFIT LIST