99
Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective June 16, 2014 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 1 of 99 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.3411 00002192683 3TC 150 MG TABLET ORL TAB GSK TAB 5.2548 00002247825 3TC 300 MG TABLET ORL TAB GSK TAB 10.5097 00002162113 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL CLC G 0.2327 00002166607 5 BENZAGEL 5% TOPICAL LOTION TOP LOT NVC ML 0.1984 00000437999 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ INJ DEFAUL BAX ML 0.0027 00002351463 5-AMINOSALICYLIC ACID 400 MG ENTERIC COATED TABLET ORL ECT SNS TAB 0.3972 00080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.2000 00000888230 A-HYDROCORT 100 MG/VIAL INJECTION INJ DEFAUL HSP VIAL 3.4500 00002414570 ABBOTT-CITALOPRAM 10 MG TABLET ORL TAB ABB TAB 0.1432 00002414589 ABBOTT-CITALOPRAM 20 MG TABLET ORL TAB ABB TAB 0.2397 00002414597 ABBOTT-CITALOPRAM 40 MG TABLET ORL TAB ABB TAB 0.2397 00002414619 ABBOTT-TOPIRAMATE 100 MG TABLET ORL TAB ABB TAB 0.5928 00002414627 ABBOTT-TOPIRAMATE 200 MG TABLET ORL TAB ABB TAB 0.8853 00002414600 ABBOTT-TOPIRAMATE 25 MG TABLET ORL TAB ABB TAB 0.3128 00001919385 ABENOL 120 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.5417 00001919393 ABENOL 325 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.7258 00001919407 ABENOL 650 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.8258 00002420864 ABILIFY MAINTENA 300 MG/VIAL INJECTION INJ DEFAUL OTS VIAL 478.9890 00002420872 ABILIFY MAINTENA 400 MG/VIAL INJECTION INJ DEFAUL OTS VIAL 478.9890 00002281066 ABRAXANE 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 971.0000 00002245677 ABREVA 10% TOPICAL CREAM TOP CRM GKC G 7.2100 00002364174 ABSTRAL 100 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 11.8410 00002364182 ABSTRAL 200 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 13.4050 00002364190 ABSTRAL 300 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 16.0750 00002364204 ABSTRAL 400 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 18.2640 00002364212 ABSTRAL 600 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 24.3640 00002364220 ABSTRAL 800 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 30.4510 00001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.0510 00000095494 AC WITH CODEINE 8 MG TABLET ORL TAB DTC TAB 0.0592 00002341107 ACCEL-AMLODIPINE 10 MG TABLET ORL TAB ACP TAB 0.3587 00002341093 ACCEL-AMLODIPINE 5 MG TABLET ORL TAB ACP TAB 0.2417 00002419874 ACCEL-DONEPEZIL 10 MG TABLET ORL TAB ACP TAB 1.1806 00002419866 ACCEL-DONEPEZIL 5 MG TABLET ORL TAB ACP TAB 1.1806 00002164396 ACEBUTOLOL-100 100 MG TABLET ORL TAB PDL TAB 0.0787 00002164418 ACEBUTOLOL-200 200 MG TABLET ORL TAB PDL TAB 0.1177 00002164426 ACEBUTOLOL-400 400 MG TABLET ORL TAB PDL TAB 0.2466 00002230435 ACET 160 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.8325 00001999648 ACET CODEINE 30 TABLET ORL TAB PMS TAB 0.1413

Products and Pricing on the Alberta Blue Cross Drug Price

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Page 1: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 1 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.341100002192683 3TC 150 MG TABLET ORL TAB GSK TAB 5.254800002247825 3TC 300 MG TABLET ORL TAB GSK TAB 10.509700002162113 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL CLC G 0.232700002166607 5 BENZAGEL 5% TOPICAL LOTION TOP LOT NVC ML 0.198400000437999 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ INJ DEFAUL BAX ML 0.002700002351463 5-AMINOSALICYLIC ACID 400 MG ENTERIC COATED TABLET ORL ECT SNS TAB 0.397200080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.200000000888230 A-HYDROCORT 100 MG/VIAL INJECTION INJ DEFAUL HSP VIAL 3.450000002414570 ABBOTT-CITALOPRAM 10 MG TABLET ORL TAB ABB TAB 0.143200002414589 ABBOTT-CITALOPRAM 20 MG TABLET ORL TAB ABB TAB 0.239700002414597 ABBOTT-CITALOPRAM 40 MG TABLET ORL TAB ABB TAB 0.239700002414619 ABBOTT-TOPIRAMATE 100 MG TABLET ORL TAB ABB TAB 0.592800002414627 ABBOTT-TOPIRAMATE 200 MG TABLET ORL TAB ABB TAB 0.885300002414600 ABBOTT-TOPIRAMATE 25 MG TABLET ORL TAB ABB TAB 0.312800001919385 ABENOL 120 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.541700001919393 ABENOL 325 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.725800001919407 ABENOL 650 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.825800002420864 ABILIFY MAINTENA 300 MG/VIAL INJECTION INJ DEFAUL OTS VIAL 478.989000002420872 ABILIFY MAINTENA 400 MG/VIAL INJECTION INJ DEFAUL OTS VIAL 478.989000002281066 ABRAXANE 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 971.000000002245677 ABREVA 10% TOPICAL CREAM TOP CRM GKC G 7.210000002364174 ABSTRAL 100 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 11.841000002364182 ABSTRAL 200 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 13.405000002364190 ABSTRAL 300 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 16.075000002364204 ABSTRAL 400 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 18.264000002364212 ABSTRAL 600 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 24.364000002364220 ABSTRAL 800 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 30.451000001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.051000000095494 AC WITH CODEINE 8 MG TABLET ORL TAB DTC TAB 0.059200002341107 ACCEL-AMLODIPINE 10 MG TABLET ORL TAB ACP TAB 0.358700002341093 ACCEL-AMLODIPINE 5 MG TABLET ORL TAB ACP TAB 0.241700002419874 ACCEL-DONEPEZIL 10 MG TABLET ORL TAB ACP TAB 1.180600002419866 ACCEL-DONEPEZIL 5 MG TABLET ORL TAB ACP TAB 1.180600002164396 ACEBUTOLOL-100 100 MG TABLET ORL TAB PDL TAB 0.078700002164418 ACEBUTOLOL-200 200 MG TABLET ORL TAB PDL TAB 0.117700002164426 ACEBUTOLOL-400 400 MG TABLET ORL TAB PDL TAB 0.246600002230435 ACET 160 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.832500001999648 ACET CODEINE 30 TABLET ORL TAB PMS TAB 0.1413

Page 2: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 2 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001999656 ACET-CODEINE 60 MG TABLET ORL TAB PMS TAB 0.150400000374148 ACETAMINOPHEN 325 MG TABLET ORL TAB WAM TAB 0.018400000605751 ACETAMINOPHEN 325 MG TABLET ORL TAB WTR TAB 0.032600000789798 ACETAMINOPHEN 500 MG TABLET ORL TAB TLI TAB 0.044400001905864 ACETAMINOPHEN 80 MG/ML ORAL DROPS ORL DPS TLI ML 0.130000002272482 ACETAMINOPHEN ARTHRITIS PAIN 650 MG EXT.REL TABLET ORL ERT PRI TAB 0.075500000706221 ACETAMINOPHEN CAFFEINE & CODEINE 8 MG TABLET ORL TAB WTR TAB 0.025800002028174 ACETAMINOPHEN COMPOUND WITH CODEINE CAPLET ORL TAB PPH TAB 0.045800001905856 ACETAMINOPHEN COMPRIME A CROQUER 80 MG ORL TAB TLI TAB 0.100000002255251 ACETAMINOPHEN EXT STR EASY TO SWALLOW 500 MG TAB ORL TAB PMT TAB 0.066000000605778 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB WTR TAB 0.039000002252813 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB PMT TAB 0.062100001904132 ACETAMINOPHEN EXTRA-STRENGTH 500 MG TABLET ORL TAB TAN TAB 0.017900001958836 ACETAMINOPHEN ORAL SOLUTION FOR CHILDREN USP ORL SOL TLI ML 0.029600002143933 ACETAMINOPHEN WITH CODEINE CAPLET ORL TAB ROG TAB 0.046000002025337 ACETAMINOPHEN WITH CODEINE TABLET ORL TAB PMS TAB 0.045800002251914 ACETAMINOPHEN, CAFFEINE & 8 MG CODEINE PHOS. TAB ORL TAB PMT TAB 0.039600000834319 ACETAZONE FORTE C-8 TABLET ORL TAB RPH TAB 0.474000000834300 ACETAZONE FORTE TABLET ORL TAB RPH TAB 0.358600002300435 ACETYLCYSTEINE 20% INHALATION SOLUTION INH SOL ALV ML 1.650000002247551 ACID REDUCER 75 MG TABLET ORL TAB PMS TAB 0.131300080011789 ACIDOPHILUS WITH BIFIDUS CAPSULE ORL CAP WNP CAP 0.113300002404095 ACT OLAPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL APH ML 10.452000002297310 ACT PRAMIPEXOLE 0.5 MG TABLET ORL TAB APH TAB 1.386000002337487 ACT VALSARTAN 40 MG TABLET ORL TAB APH TAB 0.582300002238302 ACTIFED 60 MG/2.5 MG TABLET ORL TAB PFI TAB 0.324600002249405 ACTIVELLE 1 MG/0.5 MG TABLET ORL TAB NNA TAB 2.165700002309009 ACTIVELLE LD 0.5 MG/0.1 MG TABLET ORL TAB NNA TAB 2.165700002316838 ACTONEL 150 MG TABLET ORL TAB ASC TAB 60.640000002370417 ACTONEL DR 35 MG DELAYED-RELEASE TABLET ORL DRT ASC TAB 13.787500002248722 ACULAR LS 0.4% OPH SOLUTION OPH SOL ALL ML 3.582000002369362 ACUVAIL 0.45% OPHTHALMIC SOLUTION OPH SOL ALL ML 1.675400002236926 ACYCLOVIR SODIUM 50 MG/ML INJECTION INJ DEFAUL PPC ML 12.584000002281074 ACZONE 5% TOPICAL GEL TOP GEL VCL G 1.135000002240255 ADACEL INJECTION INJ DEFAUL SFP ML 60.460000002352044 ADACEL-POLIO INJECTION INJ DEFAUL SFP ML 40.464000002313766 ADALAT XL PLUS 20 MG/81 MG TABLET ORL ERT BAI TAB 0.712300002313774 ADALAT XL PLUS 30 MG/81 MG TABLET ORL ERT BAI TAB 0.670400002313782 ADALAT XL PLUS 60 MG/81 MG TABLET ORL ERT BAI TAB 1.0186

Page 3: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 3 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000266507 ADASEPT 0.5% TOPICAL LIQUID TOP LIQ ODN ML 0.030200002290081 ADASEPT BP5 ACNE GEL 5% TOPICAL GEL TOP GEL ODN ML 0.173800002401347 ADCETRIS 50MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL STG VIAL 96.800000002338327 ADCIRCA 20 MG TABLET ORL TAB LIL TAB 14.666400002248809 ADDERALL XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.653700002248810 ADDERALL XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.972300002248811 ADDERALL XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.291000002248812 ADDERALL XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.609600002248813 ADDERALL XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.928500002248808 ADDERALL XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.335100002412764 ADEMPAS 0.5 MG TABLET ORL TAB BAI TAB 42.750000002412772 ADEMPAS 1 MG TABLET ORL TAB BAI TAB 42.750000002412799 ADEMPAS 1.5 MG TABLET ORL TAB BAI TAB 42.750000002412802 ADEMPAS 2 MG TABLET ORL TAB BAI TAB 42.750000002412810 ADEMPAS 2.5 MG TABLET ORL TAB BAI TAB 42.750000002071002 ADRIAMYCIN PFS 2MG/ML INJECTION INJ DEFAUL PFI ML 12.180000002296462 ADVAGRAF 0.5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 1.970000002296470 ADVAGRAF 1 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 2.709000002296489 ADVAGRAF 5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 13.566400080025646 ADVANCED B COMPLEX ORL CAP AOR CAP 0.294100002270447 ADVICOR 1000 MG/20 MG TABLET ORL TAB SUN TAB 1.390000002270439 ADVICOR 500 MG/20 MG TABLET ORL TAB SUN TAB 1.240000001933558 ADVIL 200 MG TABLET ORL TAB PDH TAB 0.197000002036312 ADVIL COLD AND SINUS CAPLET ORL TAB PDH TAB 0.382000002248645 ADVIL COLD AND SINUS PLUS CAPLET ORL TAB PDH TAB 0.430000002244577 ADVIL EXTRA STRENGTH 400 MG CAPLET ORL TAB PDH TAB 0.280600002248231 ADVIL EXTRA STRENGTH LIQUI-GEL 400 MG CAPSULE ORL CAP PDH CAP 0.374200001933531 ADVIL IBUPROFEN 200 MG CAPLET ORL TAB PDH TAB 0.147100002246403 ADVIL JUNIOR STRENGTH CHEWABLE TABLET ORL CTB PDH TAB 0.323500002241769 ADVIL LIQUI-GELS 200 MG CAPSULE ORL CAP PDH CAP 0.270800002242522 ADVIL PEDIATRIC 40 MG/ML SUSPENSION DROPS ORL DPS PDH ML 0.332700002243919 AERIUS 5 MG TABLET ORL TAB SCH TAB 1.032000002339528 AFINITOR 10 MG TABLET ORL TAB NOV TAB 188.790000002369257 AFINITOR 2.5 MG TABLET ORL TAB NOV TAB 202.949300002339501 AFINITOR 5 MG TABLET ORL TAB NOV TAB 202.949300002243542 AGENERASE 150 MG CAPSULE ORL CAP GSK CAP 1.920000002346850 AGRIFLU INJECTION SYRINGE INJ DEFAUL NVD SYR 9.300000002236859 AGRYLIN 0.5 MG CAPSULE ORL CAP SHB CAP 6.210000002408848 AJ-CISATRACURIUM 2MG/ML WITH PRESERVATIVE INJ INJ DEFAUL AJP ML 2.1652

Page 4: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 4 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002387468 AJ-LABETALOL 5 MG/ML INJECTION INJ DEFAUL AJP ML 1.510500002407922 AJ-VANCOMYCIN 1 G/VIAL INJECTION INJ DEFAUL AJP VIAL 95.713000002407930 AJ-VANCOMYCIN 5 G/VIAL INJECTION INJ DEFAUL AJP VIAL 509.790000002407914 AJ-VANCOMYCIN 500 MG/VIAL INJECTION INJ DEFAUL AJP VIAL 50.375000000001147 ALBALON 0.1% OPH SOLUTION OPH SOL ALL ML 0.622000000433519 ALBALON-A OPH SOLUTION OPH SOL ALL ML 0.576000002254506 ALDURAZYME 0.58 MG/ML INJECTION INJ DEFAUL GZM ML 1045.000000002381478 ALENDRONATE SODIUM 5 MG TABLET ORL TAB AHI TAB 1.037100002301733 ALEVE 220 MG TABLET ORL TAB BAI TAB 0.224000002414759 ALFUZOSIN 10 MG PROLONGED-RELEASE TABLET ORL SRT PDL TAB 0.496600080014418 ALIGN PROBIOTIC CAPSULE ORL CAP PGI CAP 0.917900002253437 ALIMTA 500 MG/VIAL INJECTION INJ DEFAUL LIL VIAL 2988.290000000004715 ALKERAN 2 MG TABLET ORL TAB GSK TAB 1.789400002231462 ALLEGRA 12 HOUR 60 MG TABLET ORL TAB SAV TAB 0.409200002242819 ALLEGRA 24 HOUR 120 MG TABLET ORL TAB SAV TAB 0.801700002239853 ALLEGRA-D SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.549000002146142 ALLER-AIDE 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.034200002176483 ALLER-AIDE 25 MG CAPLET ORL TAB ROG TAB 0.219800002240265 ALLER-RELIEF 10 MG TABLET ORL TAB APX TAB 0.408300002364689 ALLER-RELIEF 10 MG TABLET ORL TAB PMS TAB 0.408000000271411 ALLERDRYL 50 MG CAPSULE ORL CAP VCL CAP 0.130300001949454 ALLERGY 25 MG TABLET ORL TAB TAN TAB 0.112500000764647 ALLERGY DROPS 0.012% OPH SOLUTION OPH SOL BSH ML 0.188700002141728 ALLERGY FORMULA 25 MG CAPLET ORL TAB PRI TAB 0.120000002240266 ALLERGY RELIEF 10 MG TABLET ORL TAB APX TAB 0.408300000804193 ALLERNIX 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.045700002097583 ALLERNIX 25 MG CAPLET ORL TAB ROG TAB 0.303300002097575 ALLERNIX EXTRA STRENGTH 50 MG CAPLET ORL TAB ROG TAB 0.475000002369656 ALLERNIX MULTI SYMPTOM 5 MG TABLET ORL TAB ROG TAB 0.512000000555681 ALLOPURINOL 100 MG TABLET ORL TAB PDL TAB 0.078000002130157 ALLOPURINOL 200 MG TABLET ORL TAB PDL TAB 0.130000000555703 ALLOPURINOL 300 MG TABLET ORL TAB PDL TAB 0.212500000569801 ALMAGEL 200 ORAL LIQUID ORL LIQ ATL ML 0.017900002241407 ALOCRIL 2% OPH SOLUTION OPH SOL ALL ML 6.846000000893560 ALOMIDE 0.1% (BASE) OPH SOLUTION OPH SOL ALC ML 1.214000002381710 ALOXI 0.05 MG/ML INJECTION INJ DEFAUL EIS ML 18.000000002381729 ALOXI 0.5 MG CAPSULE ORL CAP EIS CAP 71.720000080005881 ALPHA LIPOIC ACID 100MG CAPSULE ORL CAP WNP CAP 0.110700002248151 ALPHAGAN P 0.15% OPHTHALMIC SOLUTION OPH SOL ALL ML 3.7640

Page 5: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 5 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001908189 ALPRAZOLAM-0.25 MG TABLET ORL TAB PDL TAB 0.060900001908170 ALPRAZOLAM-0.5 MG TABLET ORL TAB PDL TAB 0.072800002248706 ALPRAZOLAM-1 1 MG TABLET ORL TAB PDL TAB 0.209200002241680 ALPROSTADIL 0.5 MG/ML INJECTION INJ DEFAUL TEV ML 185.000000002320924 ALREX 0.2% OPHTHALMIC SUSPENSION OPH SUS BSH ML 6.044000002281112 ALTACE 15 MG CAPSULE ORL CAP/TAB SAV CAP 1.272500002245272 AMARYL 1 MG TABLET ORL TAB SAV TAB 1.001700002245273 AMARYL 2 MG TABLET ORL TAB SAV TAB 1.090000002245274 AMARYL 4 MG TABLET ORL TAB SAV TAB 1.166700002241630 AMBISOME 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 121.000000002230575 AMETOP 4% TOPICAL GEL TOP GEL SNE G 3.146700002259052 AMEVIVE 15 MG/VIAL INJECTION INJ DEFAUL BIO VIAL 890.000000000870943 AMI-HYDRO TABLET ORL TAB PDL TAB 0.083800002242971 AMIKACIN SULFATE 250 MG/ML INJECTION INJ DEFAUL SDZ ML 23.344000000370991 AMITRIPTYLINE 10 MG TABLET ORL TAB PDL TAB 0.043500000371009 AMITRIPTYLINE 25 MG TABLET ORL TAB PDL TAB 0.082900000456349 AMITRIPTYLINE 50 MG TABLET ORL TAB PDL TAB 0.154000002326795 AMLODIPINE 2.5 MG TABLET ORL TAB PDL TAB 0.138000000638064 AMOSAN 68.6% MOUTHWASH ORL MWH OLB ML 0.334000002326523 AMOXI-CLAV 875 MG/125 MG TABLET ORL TAB PDL TAB 1.000800002125862 AMPHOJEL 320 MG/5ML ORAL LIQUID ORL LIQ AXC ML 0.019100002124971 AMPHOJEL 600 MG TABLET ORL TAB AUP TAB 0.133800000606987 ANACIN CAPLET ORL TAB WHH TAB 0.066100000613495 ANACIN EXTRA STRENGTH CAPLET ORL TAB WHH TAB 0.099600001933477 ANACIN TABLET ORL TAB WCH TAB 0.081400002221861 ANANDRON 50 MG TABLET ORL TAB SAV TAB 2.406200002245345 ANDROGEL (2.5 G/ PACKET) 1% TOPICAL GEL TOP GEL ABB G 0.969300002245346 ANDROGEL (5 G/ PACKET) 1% TOPICAL GEL TOP GEL ABB G 0.857000002249499 ANDROGEL (75 G/PUMP) 1% TOPICAL GEL TOP GEL ABB G 0.979300000874019 ANEXATE 0.1 MG/ ML INJECTION INJ DEFAUL HLR ML 5.695600002268825 ANGELIQ 1 MG / 1 MG TABLET ORL TAB BAI TAB 0.850000002418401 ANORO ELLIPTA 62.5 MCG/25MCG INHALATION POWDER INH MIP GSK DOSE 2.700000002280361 ANTHELIOS XL SPF 60 TOPICAL CREAM TOP CRM LRP G 0.177200000566756 ANTHRAFORTE 1 1% TOPICAL OINTMENT TOP ONT MPQ G 0.369600000566748 ANTHRAFORTE 2 2% TOPICAL OINTMENT TOP ONT MPQ G 0.806600000695351 ANTHRASCALP 0.4% TOPICAL LOTION TOP LOT STI ML 0.700000002222132 ANTIPHLOGISTINE RUB A-535 NO ODOUR 13.3% TOP OINT TOP ONT CHD G 0.061600001945939 ANUSOL 0.5% RECTAL OINTMENT RT ONT WLA G 0.155700001945920 ANUSOL 10 MG RECTAL SUPPOSITORY RT SUP WLA SUP 0.4483

Page 6: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 6 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001945912 ANUSOL PLUS RECTAL OINTMENT RT ONT WLA G 0.186300001945904 ANUSOL PLUS RECTAL SUPPOSITORY RT SUP WLA SUP 0.562500000621447 ANUZINC 0.5% W/W TOPICAL OINTMENT TOP ONT SDZ G 0.125000000621439 ANUZINC 10 MG RECTAL SUPPOSITORY RT SUP SDZ SUP 0.443300002248424 ANUZINC PLUS RECTAL OINTMENT RT ONT SDZ G 0.117300002231379 ANZEMET 100 MG TABLET ORL TAB SAV TAB 29.595300080017904 AOR CHROMIUM PICOLINATE 600 MCG CAPSULE ORL CAP AOR CAP 0.133300080005832 AOR N.A.C. 500 MG CAPSULE ORL CAP AOR CAP 0.137500002229873 APO-ACETAMINOPHEN 325 MG CAPLET ORL TAB APX TAB 0.035400000544981 APO-ACETAMINOPHEN 325 MG TABLET ORL TAB APX TAB 0.035400002248727 APO-ALENDRONATE 5 MG TABLET ORL TAB APX TAB 1.037000002243611 APO-ALPRAZ 1 MG TABLET ORL TAB APX TAB 0.336800002243612 APO-ALPRAZ TS 2 MG TABLET ORL TAB APX TAB 0.598500002411318 APO-AMLODIPINE-ATORVASTATIN 10 MG/10 MG TABLET ORL TAB APX TAB 0.919400002411326 APO-AMLODIPINE-ATORVASTATIN 10 MG/20 MG TABLET ORL TAB APX TAB 1.023400002411334 APO-AMLODIPINE-ATORVASTATIN 10 MG/40 MG TABLET ORL TAB APX TAB 1.062400002411342 APO-AMLODIPINE-ATORVASTATIN 10 MG/80 MG TABLET ORL TAB APX TAB 1.062400002411253 APO-AMLODIPINE-ATORVASTATIN 5 MG/10 MG TABLET ORL TAB APX TAB 0.755100002411261 APO-AMLODIPINE-ATORVASTATIN 5 MG/20 MG TABLET ORL TAB APX TAB 0.859100002411288 APO-AMLODIPINE-ATORVASTATIN 5 MG/40 MG TABLET ORL TAB APX TAB 0.898100002411296 APO-AMLODIPINE-ATORVASTATIN 5 MG/80 MG TABLET ORL TAB APX TAB 0.898100002288559 APO-AMOXI CLAV 80 MG/11.4 MG/ML ORAL SUSPENSION ORL SUS APX ML 0.196900002374420 APO-ANASTROZOLE 1 MG TABLET ORL TAB APX TAB 2.766700000510696 APO-ASEN ECT 325 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.153700000472476 APO-ASEN ECT 650 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.250000002318024 APO-ATOMOXETINE 10 MG CAPSULE ORL CAP APX CAP 2.514700002318083 APO-ATOMOXETINE 100 MG CAPSULE ORL CAP APX CAP 4.729000002318032 APO-ATOMOXETINE 18 MG CAPSULE ORL CAP APX CAP 2.882000002318040 APO-ATOMOXETINE 25 MG CAPSULE ORL CAP APX CAP 3.181800002318059 APO-ATOMOXETINE 40 MG CAPSULE ORL CAP APX CAP 3.627000002318067 APO-ATOMOXETINE 60 MG CAPSULE ORL CAP APX CAP 4.023200002318075 APO-ATOMOXETINE 80 MG CAPSULE ORL CAP APX CAP 4.342300002239044 APO-BENZYDAMINE 0.15% ORAL RINSE ORL RNS APX ML 0.046400002296063 APO-BICALUTAMIDE 50 MG TABLET ORL TAB APX TAB 4.057300002301334 APO-BRIMONIDINE P 0.15% OPHTHALMIC SOLUTION OPH SOL APX ML 1.883000002242504 APO-BUTORPHANOL 10 MG/ML NASAL SPRAY NAS SPR APX ML 24.572000000682047 APO-CAL 250 625 MG TABLET ORL TAB APX TAB 0.028200000682039 APO-CAL 500 MG TABLET ORL TAB APX TAB 0.070000002365340 APO-CANDESARTAN 4 MG TABLET ORL TAB APX TAB 0.3693

Page 7: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 7 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001999559 APO-CAPTO 6.25 MG TABLET ORL TAB APX TAB 0.134400000402699 APO-CARBAMAZEPINE 200 MG TABLET ORL TAB APX TAB 0.079500002231603 APO-CETIRIZINE 10 MG TABLET ORL TAB APX TAB 0.408300000399302 APO-CHLORPROPAMIDE 100 MG TABLET ORL TAB APX TAB 0.081000000312711 APO-CHLORPROPAMIDE 250 MG TABLET ORL TAB APX TAB 0.082600002298953 APO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL APX G 8.415000000749494 APO-CIMETIDINE 800 MG TABLET ORL TAB APX TAB 0.243000002263130 APO-CIPROFLOX 0.3% OPHTHALMIC SOL. OPH SOL APX ML 1.912000002274744 APO-CLARITHROMYCIN 250 MG TABLET ORL TAB APX TAB 0.447900002274752 APO-CLARITHROMYCIN 500 MG TABLET ORL TAB APX TAB 1.770500000868957 APO-CLONIDINE 0.2 MG TABLET ORL TAB APX TAB 0.314900002243433 APO-DICLO RAPIDE 50 MG TABLET ORL TAB APX TAB 0.427800002354403 APO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL APX ML 0.516500002296055 APO-DORZOLAMIDE 2% OPHTHALMIC SOLUTION OPH SOL APX ML 1.688000002386054 APO-ELETRIPTAN 20 MG TABLET ORL TAB APX TAB 10.958300002386062 APO-ELETRIPTAN 40 MG TABLET ORL TAB APX TAB 10.958300002339099 APO-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT APX TAB 2.031000002339102 APO-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT APX TAB 2.030900002419726 APO-EXEMESTANE 25 MG TABLET ORL TAB APX TAB 3.900800002292025 APO-FAMCICLOVIR 125 MG TABLET ORL TAB APX TAB 2.199300002292041 APO-FAMCICLOVIR 250 MG TABLET ORL TAB APX TAB 2.955700002292068 APO-FAMCICLOVIR 500 MG TABLET ORL TAB APX TAB 4.594300000545031 APO-FERROUS GLUCONATE 300 MG TABLET ORL TAB APX TAB 0.043900001912518 APO-FERROUS SULFATE-FC 300 MG TABLET ORL TAB APX TAB 0.035300002294745 APO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM APX DOSE 0.198900002293358 APO-GABAPENTIN 600 MG TABLET ORL TAB APX TAB 1.417500002293366 APO-GABAPENTIN 800 MG TABLET ORL TAB APX TAB 1.890000000885754 APO-GAIN 2% TOPICAL SOLUTION TOP SOL APX ML 0.495600002295377 APO-GLIMEPIRIDE 1 MG TABLET ORL TAB APX TAB 0.532500002295385 APO-GLIMEPIRIDE 2 MG TABLET ORL TAB APX TAB 0.532500002295393 APO-GLIMEPIRIDE 4 MG TABLET ORL TAB APX TAB 0.532500000396796 APO-HALOPERIDOL 0.5 MG TABLET ORL TAB APX TAB 0.122400000396818 APO-HALOPERIDOL 1 MG TABLET ORL TAB APX TAB 0.183900000463698 APO-HALOPERIDOL 10 MG TABLET ORL TAB APX TAB 0.637800000396826 APO-HALOPERIDOL 2 MG TABLET ORL TAB APX TAB 0.274800000396834 APO-HALOPERIDOL 5 MG TABLET ORL TAB APX TAB 0.438500002327856 APO-HYDRO 12.5 MG TABLET ORL TAB APX TAB 0.036700000441643 APO-IBUPROFEN 200 MG TABLET ORL TAB APX TAB 0.070000002355337 APO-IMATINIB 100 MG TABLET ORL TAB APX TAB 20.4557

Page 8: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 8 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002355345 APO-IMATINIB 400 MG TABLET ORL TAB APX TAB 81.822800000611158 APO-INDOMETHACIN 25 MG CAPSULE ORL CAP APX CAP 0.087100000611166 APO-INDOMETHACIN 50 MG CAPSULE ORL CAP APX CAP 0.151100002369052 APO-LAMIVUDINE 150 MG TABLET ORL TAB APX TAB 3.626900002369060 APO-LAMIVUDINE 300 MG TABLET ORL TAB APX TAB 7.253800002375540 APO-LAMIVUDINE-ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB APX TAB 8.509400002358514 APO-LETROZOLE 2.5 MG TABLET ORL TAB APX TAB 2.994700002261995 APO-LISINOPRIL/HCTZ 20 MG/25 MG TABLET ORL TAB APX TAB 0.350600002243880 APO-LORATADINE 10 MG TABLET ORL TAB APX TAB 0.681000002248974 APO-MELOXICAM 15 MG TABLET ORL TAB APX TAB 0.616100002248973 APO-MELOXICAM 7.5 MG TABLET ORL TAB APX TAB 0.534000002366487 APO-MEMANTINE 10 MG TABLET ORL TAB APX TAB 1.777400002305062 APO-METFORMIN ER 500 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 0.427300002258935 APO-METHIMAZOLE 5 MG TABLET ORL TAB APX TAB 0.173500002273950 APO-METHYLPHENIDATE 5 MG TABLET ORL TAB APX TAB 0.108100000842834 APO-METOCLOP 10 MG TABLET ORL TAB APX TAB 0.058300000842826 APO-METOCLOP 5 MG TABLET ORL TAB APX TAB 0.055600002286610 APO-MIRTAZAPINE 15 MG TABLET ORL TAB APX TAB 0.407300002286637 APO-MIRTAZAPINE 45 MG TABLET ORL TAB APX TAB 1.222300002352559 APO-MYCOPHENOLATE 250 MG CAPSULE ORL CAP APX CAP 1.120300002352567 APO-MYCOPHENOLATE 500 MG TABLET ORL TAB APX TAB 2.240700002365499 APO-NARATRIPTAN 1 MG TABLET ORL TAB APX TAB 8.433800002365502 APO-NARATRIPTAN 2.5 MG TABLET ORL TAB APX TAB 6.143700002333015 APO-OLANZAPINE 20 MG TABLET ORL TAB APX TAB 11.202600002360632 APO-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB ORL DISNTAB APX TAB 5.355300002360640 APO-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB ORL DISNTAB APX TAB 7.597700002305054 APO-OLOPATADINE 0.1% OPH SOLUTION OPH SOL APX ML 5.678000002402823 APO-OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL APX ML 10.452200002243661 APO-OXAPROZIN 600 MG TABLET ORL TAB APX TAB 0.689200002284294 APO-OXCARBAZEPINE 150 MG TABLET ORL TAB APX TAB 0.674700002284308 APO-OXCARBAZEPINE 300 MG TABLET ORL TAB APX TAB 0.989100002284316 APO-OXCARBAZEPINE 600 MG TABLET ORL TAB APX TAB 1.978100002366754 APO-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.477000002394766 APO-OXYCODONE CR 15 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.575900002366762 APO-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.715600002394774 APO-OXYCODONE CR 30 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.870000002306530 APO-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.240200002366746 APO-OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.342300002394782 APO-OXYCODONE CR 60 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.5750

Page 9: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 9 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002366789 APO-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 2.290700002248844 APO-PACLITAXEL 6 MG/ML INJECTION INJ DEFAUL APX ML 37.080800002292912 APO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT APX TAB 1.385500002240907 APO-PAROXETINE 10 MG TABLET ORL TAB APX TAB 1.133400000755885 APO-PINDOL 10 MG TABLET ORL TAB APX TAB 0.252400000755893 APO-PINDOL 15 MG TABLET ORL TAB APX TAB 0.366200000755877 APO-PINDOL 5 MG TABLET ORL TAB APX TAB 0.147900002302942 APO-PIOGLITAZONE 15 MG TABLET ORL TAB APX TAB 0.500000002302950 APO-PIOGLITAZONE 30 MG TABLET ORL TAB APX TAB 0.700000002302977 APO-PIOGLITAZONE 45 MG TABLET ORL TAB APX TAB 1.050000002292386 APO-PRAMIPEXOLE 0.5 MG TABLET ORL TAB APX TAB 1.506100000598194 APO-PREDNISONE 1 MG TABLET ORL TAB APX TAB 0.103500002394278 APO-PREGABALIN 150 MG CAPSULE ORL CAP APX CAP 1.727000002394286 APO-PREGABALIN 225 MG CAPSULE ORL CAP APX CAP 1.727000002394235 APO-PREGABALIN 25 MG CAPSULE ORL CAP APX CAP 0.617300002394294 APO-PREGABALIN 300 MG CAPSULE ORL CAP APX CAP 1.727000002394243 APO-PREGABALIN 50 MG CAPSULE ORL CAP APX CAP 0.968300002394251 APO-PREGABALIN 75 MG CAPSULE ORL CAP APX CAP 1.252900000402788 APO-PROPRANOLOL 10 MG TABLET ORL TAB APX TAB 0.019200000663719 APO-PROPRANOLOL 20 MG TABLET ORL TAB APX TAB 0.027700000402753 APO-PROPRANOLOL 40 MG TABLET ORL TAB APX TAB 0.034800000402761 APO-PROPRANOLOL 80 MG TABLET ORL TAB APX TAB 0.058500002325381 APO-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB APX CAP 0.929100002377721 APO-RISEDRONATE 150 MG TABLET ORL TAB APX TAB 44.500000002248203 APO-SILDENAFIL 100 MG TABLET ORL TAB APX TAB 9.997500002248201 APO-SILDENAFIL 25 MG TABLET ORL TAB APX TAB 9.007500002248202 APO-SILDENAFIL 50 MG TABLET ORL TAB APX TAB 9.615000002418118 APO-SILDENAFIL R 20 MG TABLET ORL TAB APX TAB 7.294000000812404 APO-TAMOX 10 MG TABLET ORL TAB APX TAB 0.175000000812390 APO-TAMOX 20 MG TABLET ORL TAB APX TAB 0.350000002413094 APO-TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APX CAP 113.596000002413116 APO-TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APX CAP 159.036000002413124 APO-TEMOZOLOMIDE 180 MG CAPSULE ORL CAP APX CAP 253.672600002413043 APO-TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APX CAP 22.720000002413132 APO-TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APX CAP 283.984000002413035 APO-TEMOZOLOMIDE 5 MG CAPSULE ORL CAP APX CAP 5.850000002136112 APO-TIAPROFENIC 200 MG TABLET ORL TAB APX TAB 0.343700002136120 APO-TIAPROFENIC 300 MG TABLET ORL TAB APX TAB 0.325700000755850 APO-TIMOL 10 MG TABLET ORL TAB APX TAB 0.2835

Page 10: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 10 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000755869 APO-TIMOL 20 MG TABLET ORL TAB APX TAB 0.543900000755842 APO-TIMOL 5 MG TABLET ORL TAB APX TAB 0.181700002290812 APO-TIMOP GEL 0.5% OPHTHALMIC SOLUTION OPH LAS APX ML 2.730000002336790 APO-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB APX TAB 0.680700002371510 APO-VALSARTAN 40 MG TABLET ORL TAB APX TAB 0.582300002409682 APO-VORICONAZOLE 200 MG TABLET ORL TAB APX TAB 38.942300002409674 APO-VORICONAZOLE 50 MG TABLET ORL TAB APX TAB 9.739700001946323 APO-ZIDOVUDINE 100 MG CAPSULE ORL CAP APX CAP 1.397700002375885 APPRILON 40 MG MODIFIED RELEASE CAPSULE ORL MRC GAL CAP 2.716800000723754 APRESOLINE 20 MG/VIAL INJECTION INJ DEFAUL STM VIAL 12.659000002273322 APTIVUS 250 MG CAPSULE ORL CAP BOE CAP 8.250000002162075 AQUASOL E 50 UNIT/ML ORAL DROPS ORL DPS NOV ML 0.933600002391805 ARANESP 200 MCG /0.4 ML INJECTION SYRINGE INJ NDL AMG SYR 603.193500002391759 ARANESP 50 MCG /0.5 ML INJECTION SYRINGE INJ NDL AMG SYR 140.700000002269465 ARICEPT RDT 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PFI TAB 5.288900002269457 ARICEPT RDT 5 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PFI TAB 5.288900002224135 ARIMIDEX 1 MG TABLET ORL TAB AZC TAB 5.563700002194155 ARISTOSPAN 20 MG/ML INJECTION INJ DEFAUL VLP ML 6.700000080008677 ARNICA 7% GEL TOP GEL BCI G 0.131400080015109 ARNICA GEL-CREAM RUB A535 TOPICAL GEL TOP GEL CHD G 0.097100002242705 AROMASIN 25 MG TABLET ORL TAB PFI TAB 5.736300002286653 ARTHRITIS PAIN 650 MG EXTENDED RELIEF TABLET ORL ERT VTH TAB 0.122500002229632 ARTIFICIAL TEARS EXTRA OPH SOLUTION OPH SOL PMS ML 0.303300002229570 ARTIFICIAL TEARS OPH SOLUTION OPH SOL PPH ML 0.292700000180041 ASA & CODEINE 8 MG TABLET ORL TAB SDR TAB 0.042600000036145 ASA 325 MG TABLET ORL TAB WAM TAB 0.013600000530336 ASA 325 MG TABLET ORL TAB VTH TAB 0.027300002244993 ASA 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.133000002046253 ASADOL 325 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.012500002009013 ASAPHEN 80 MG TABLET ORL TAB PMS TAB 0.060500002243974 ASAPHEN 81 MG CHEWABLE TABLET ORL CTB PMS TAB 0.078400002238545 ASAPHEN E.C. 80 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.056000002242281 ASAPHEN E.C. 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.097700002280167 ASATAB 80 MG CHEWABLE TABLET ORL CTB ODN TAB 0.063000002352427 ASATAB EC 325 MG ENTERIC-COATED TABLET ORL ECT ODN TAB 0.029500000266086 ASCORBIC ACID 500 MG TABLET ORL TAB PMT TAB 0.030000002074710 ASPERCREME CREME RUB 10% TOPICAL CREAM TOP CRM SLL G 0.058100002150328 ASPIRIN 325 MG TABLET ORL TAB BAI TAB 0.113800002316897 ASPIRIN STOMACH GUARD EXTRA STRENGTH 500 MG CAPLET ORL TAB BIC TAB 0.0960

Page 11: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 11 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002229967 ASPIRIN WITH STOMACH GUARD EXTRA STRENGTH CAPLET ORL TAB BAI TAB 0.103700002239090 ATACAND 4 MG TABLET ORL TAB AZC TAB 0.786000000293482 ATASOL 325 MG TABLET ORL TAB CHD TAB 0.063000000013668 ATASOL FORTE 500 MG TABLET ORL TAB CHD TAB 0.058600000293504 ATASOL-15 TABLET ORL TAB CHD TAB 0.115000000293512 ATASOL-30 TABLET ORL TAB CHD TAB 0.133800000293490 ATASOL-8 TABLET ORL TAB CHD TAB 0.075600000828793 ATENOLOL-100 MG TABLET ORL TAB PDL TAB 0.236200000828807 ATENOLOL-50 MG TABLET ORL TAB PDL TAB 0.143700002396904 ATOMOXETINE 10 MG CAPSULE ORL CAP PDL CAP 1.404000002396912 ATOMOXETINE 18 MG CAPSULE ORL CAP PDL CAP 1.609300002396920 ATOMOXETINE 25 MG CAPSULE ORL CAP PDL CAP 1.776700002396939 ATOMOXETINE 40 MG CAPSULE ORL CAP PDL CAP 2.025000002396947 ATOMOXETINE 60 MG CAPSULE ORL CAP PDL CAP 2.246300002346486 ATORVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.313800002387891 ATORVASTATIN 10 MG TABLET ORL TAB SIV TAB 0.416000002396424 ATORVASTATIN 10 MG TABLET ORL TAB APX TAB 0.313800002346494 ATORVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.392200002387905 ATORVASTATIN 20 MG TABLET ORL TAB SIV TAB 0.520000002396432 ATORVASTATIN 20 MG TABLET ORL TAB APX TAB 0.392200002346508 ATORVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.421600002387913 ATORVASTATIN 40 MG TABLET ORL TAB SIV TAB 0.559000002396440 ATORVASTATIN 40 MG TABLET ORL TAB APX TAB 0.421600002387921 ATORVASTATIN 80 MG TABLET ORL TAB SIV TAB 0.559000002396459 ATORVASTATIN 80 MG TABLET ORL TAB APX TAB 0.421600002351765 ATORVASTATIN-20 20 MG TABLET ORL TAB PDL TAB 1.040000002299925 ATRIANCE 5 MG/ML INJECTION INJ DEFAUL GSK ML 9.689200002300699 ATRIPLA TABLET ORL TAB BMG TAB 45.444300002094703 ATROPINE 0.6 MG/ML INJECTION INJ DEFAUL ALV ML 2.717000002148358 ATROPINE SULFATE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002163713 ATROVENT 0.06% NASAL SPRAY NAS SPR BOE ML 2.158000002416328 AUBAGIO 14 MG TABLET ORL TAB GZS TAB 53.424700002332477 AURALGAN OTIC SOLUTION OT SOL PAL ML 0.565700002407256 AURO-ATORVASTATIN 10 MG TABLET ORL TAB AUR TAB 0.313800002407264 AURO-ATORVASTATIN 20 MG TABLET ORL TAB AUR TAB 0.392200002407272 AURO-ATORVASTATIN 40 MG TABLET ORL TAB AUR TAB 0.421600002407280 AURO-ATORVASTATIN 80 MG TABLET ORL TAB AUR TAB 0.421600002418517 AURO-CARVEDILOL 12.5 MG TABLET ORL TAB AUR TAB 0.337700002418525 AURO-CARVEDILOL 25 MG TABLET ORL TAB AUR TAB 0.3377

Page 12: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 12 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002418495 AURO-CARVEDILOL 3.125 MG TABLET ORL TAB AUR TAB 0.337700002418509 AURO-CARVEDILOL 6.25 MG TABLET ORL TAB AUR TAB 0.337700002418428 AURO-EFAVIRENZ 600 MG TABLET ORL TAB AUR TAB 8.498400002385627 AURO-FLUOXETINE 10 MG CAPSULE ORL CAP AUR CAP 0.459500002414414 AURO-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB AUR TAB 7.830800002411695 AURO-MIRTAZAPINE 15 MG TABLET ORL TAB AUR TAB 0.375000002299801 AURO-MIRTAZAPINE OD 15 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.296700002299828 AURO-MIRTAZAPINE OD 30 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.593300002299836 AURO-MIRTAZAPINE OD 45 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.890000002318601 AURO-NEVIRAPINE 200 MG TABLET ORL TAB AUR TAB 2.469000002384906 AURO-PIOGLITAZONE 15 MG TABLET ORL TAB AUR TAB 0.580900002384914 AURO-PIOGLITAZONE 30 MG TABLET ORL TAB AUR TAB 0.813900002384922 AURO-PIOGLITAZONE 45 MG TABLET ORL TAB AUR TAB 1.223700002424061 AURO-PRAMIPEXOLE 0.25 MG TABLET ORL TAB AUR TAB 0.262800002424096 AURO-PRAMIPEXOLE 1 MG TABLET ORL TAB AUR TAB 0.525700002424118 AURO-PRAMIPEXOLE 1.5 MG TABLET ORL TAB AUR TAB 0.525700002424258 AURO-REPAGLINIDE 0.5 MG TABLET ORL TAB AUR TAB 0.099600002424266 AURO-REPAGLINIDE 1 MG TABLET ORL TAB AUR TAB 0.103600002424274 AURO-REPAGLINIDE 2 MG TABLET ORL TAB AUR TAB 0.107500002405156 AURO-SIMVASTATIN 10 MG TABLET ORL TAB AUR TAB 0.505700002405164 AURO-SIMVASTATIN 20 MG TABLET ORL TAB AUR TAB 0.625000002405172 AURO-SIMVASTATIN 40 MG TABLET ORL TAB AUR TAB 0.625000002405148 AURO-SIMVASTATIN 5 MG TABLET ORL TAB AUR TAB 0.255600002405180 AURO-SIMVASTATIN 80 MG TABLET ORL TAB AUR TAB 0.625000002414201 AURO-VALSARTAN 40 MG TABLET ORL TAB AUR TAB 0.524000002363798 AVA-ACEBUTOLOL 100 MG TABLET ORL TAB AVA TAB 0.163000002363801 AVA-ACEBUTOLOL 200 MG TABLET ORL TAB AVA TAB 0.244000002363828 AVA-ACEBUTOLOL 400 MG TABLET ORL TAB AVA TAB 0.484800002360969 AVA-ATENOLOL 25 MG TABLET ORL TAB AVA TAB 0.173000002363372 AVA-AZITHROMYCIN 20 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.640700002363364 AVA-AZITHROMYCIN 250 MG TABLET ORL TAB AVA TAB 2.965000002363380 AVA-AZITHROMYCIN 40 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.908000002371413 AVA-BACLOFEN 10 MG TABLET ORL TAB AVA TAB 0.291100002371421 AVA-BACLOFEN 20 MG TABLET ORL TAB AVA TAB 0.566700002360993 AVA-BICALUTAMIDE 50 MG TABLET ORL TAB AVA TAB 4.057300002363895 AVA-BISOPROLOL 10 MG TABLET ORL TAB AVA TAB 0.365400002363887 AVA-BISOPROLOL 5 MG TABLET ORL TAB AVA TAB 0.220500002363399 AVA-BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.336500002363402 AVA-BUPROPION SR 150 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.5040

Page 13: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 13 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002370751 AVA-CARVEDILOL 12.5 MG TABLET ORL TAB AVA TAB 0.756400002370786 AVA-CARVEDILOL 25 MG TABLET ORL TAB AVA TAB 0.756400002370735 AVA-CARVEDILOL 3.125 MG TABLET ORL TAB AVA TAB 0.756400002370743 AVA-CARVEDILOL 6.25 MG TABLET ORL TAB AVA TAB 0.756400002362864 AVA-CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.094800002362848 AVA-CEFPROZIL 250 MG TABLET ORL TAB AVA TAB 0.970300002362872 AVA-CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.189600002362856 AVA-CEFPROZIL 500 MG TABLET ORL TAB AVA TAB 1.902500002364255 AVA-CITALOPRAM 10 MG TABLET ORL TAB AVA TAB 0.446400002366371 AVA-CLARITHROMYCIN 250 MG TABLET ORL TAB AVA TAB 1.100100002366398 AVA-CLARITHROMYCIN 500 MG TABLET ORL TAB AVA TAB 1.824900002364719 AVA-CLINDAMYCIN 150 MG CAPSULE ORL CAP AVA CAP 0.489000002364727 AVA-CLINDAMYCIN 300 MG CAPSULE ORL CAP AVA CAP 0.978000002360861 AVA-CLONIDINE 0.025 MG TABLET ORL TAB AVA TAB 0.152300002360888 AVA-CLONIDINE 0.1 MG TABLET ORL TAB AVA TAB 0.176500002366665 AVA-DICLOFENAC 25 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.190200002366673 AVA-DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.380400002366703 AVA-DICLOFENAC SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.760800002366681 AVA-DICLOFENAC SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.570600002364271 AVA-DOMPERIDONE 10 MG TABLET ORL TAB AVA TAB 0.141800002363488 AVA-ENALAPRIL 10 MG TABLET ORL TAB AVA TAB 0.593200002363453 AVA-ENALAPRIL 2.5 MG TABLET ORL TAB AVA TAB 0.417200002363496 AVA-ENALAPRIL 20 MG TABLET ORL TAB AVA TAB 0.715600002363461 AVA-ENALAPRIL 5 MG TABLET ORL TAB AVA TAB 0.493500002373920 AVA-FAMOTIDINE 20 MG TABLET ORL TAB AVA TAB 0.589600002373939 AVA-FAMOTIDINE 40 MG TABLET ORL TAB AVA TAB 1.061200002364409 AVA-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP AVA CAP 1.089000002364530 AVA-FLUOXETINE 20 MG CAPSULE ORL CAP AVA CAP 1.011200002363771 AVA-FLUVOXAMINE 100 MG TABLET ORL TAB AVA TAB 0.890200002363763 AVA-FLUVOXAMINE 50 MG TABLET ORL TAB AVA TAB 0.495200002364573 AVA-FUROSEMIDE 20 MG TABLET ORL TAB AVA TAB 0.044500002364581 AVA-FUROSEMIDE 40 MG TABLET ORL TAB AVA TAB 0.067000002364603 AVA-FUROSEMIDE 80 MG TABLET ORL TAB AVA TAB 0.122000002363518 AVA-GLICLAZIDE 80 MG TABLET ORL TAB AVA TAB 0.224200002363704 AVA-GLYBURIDE 2.5 MG TABLET ORL TAB AVA TAB 0.039300002363712 AVA-GLYBURIDE 5 MG TABLET ORL TAB AVA TAB 0.068300002363968 AVA-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB AVA TAB 0.039500002363976 AVA-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB AVA TAB 0.055100002373327 AVA-IRBESARTAN 150 MG TABLET ORL TAB AVA TAB 0.5444

Page 14: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 14 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002373335 AVA-IRBESARTAN 300 MG TABLET ORL TAB AVA TAB 0.544400002373319 AVA-IRBESARTAN 75 MG TABLET ORL TAB AVA TAB 0.544400002373343 AVA-IRBESARTAN/HCTZ 150/12.5 MG TABLET ORL TAB AVA TAB 0.544400002373351 AVA-IRBESARTAN/HCTZ 300/12.5 MG TABLET ORL TAB AVA TAB 0.544400002373378 AVA-IRBESARTAN/HCTZ 300/25 MG TABLET ORL TAB AVA TAB 0.540700002371677 AVA-LEVETIRACETAM 250 MG TABLET ORL TAB AVA TAB 0.963200002371685 AVA-LEVETIRACETAM 500 MG TABLET ORL TAB AVA TAB 1.173900002371693 AVA-LEVETIRACETAM 750 MG TABLET ORL TAB AVA TAB 1.625400002361027 AVA-LEVOFLOXACIN 250 MG TABLET ORL TAB AVA TAB 2.849400002361035 AVA-LEVOFLOXACIN 500 MG TABLET ORL TAB AVA TAB 3.215300002362880 AVA-LISINOPRIL HCT 10 MG/12.5 MG TABLET ORL TAB AVA TAB 0.501900002362899 AVA-LISINOPRIL HCT 20 MG/12.5 MG TABLET ORL TAB AVA TAB 0.603000002362902 AVA-LISINOPRIL HCT 20 MG/25 MG TABLET ORL TAB AVA TAB 0.603000002364239 AVA-LOVASTATIN 20 MG TABLET ORL TAB AVA TAB 1.090700002364247 AVA-LOVASTATIN 40 MG TABLET ORL TAB AVA TAB 2.011700002364506 AVA-METFORMIN 500 MG TABLET ORL TAB AVA TAB 0.121600002364514 AVA-METFORMIN 850 MG TABLET ORL TAB AVA TAB 0.204000002364859 AVA-METOPROLOL (TYPE L) 100 MG TABLET ORL TAB AVA TAB 0.222300002364840 AVA-METOPROLOL (TYPE L) 50 MG TABLET ORL TAB AVA TAB 0.122500002364832 AVA-METOPROLOL 100 MG TABLET ORL TAB AVA TAB 0.222300002364824 AVA-METOPROLOL 50 MG TABLET ORL TAB AVA TAB 0.122500002362937 AVA-MIRTAZAPINE 30 MG TABLET ORL TAB AVA TAB 0.694400002365820 AVA-NAPROXEN 375 MG TABLET ORL TAB AVA TAB 0.145800002365839 AVA-NAPROXEN 500 MG TABLET ORL TAB AVA TAB 0.211000002365847 AVA-NAPROXEN EC 250 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.246700002365855 AVA-NAPROXEN EC 375 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.323400002365863 AVA-NAPROXEN EC 500 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.584200002366304 AVA-NORFLOXACIN 400 MG TABLET ORL TAB AVA TAB 1.220400002364301 AVA-NORTRIPTYLINE 10 MG CAPSULE ORL CAP AVA CAP 0.126000002364328 AVA-NORTRIPTYLINE 25 MG CAPSULE ORL CAP AVA CAP 0.254600002373467 AVA-OLANZAPINE 10 MG TABLET ORL TAB AVA TAB 4.227000002373432 AVA-OLANZAPINE 2.5 MG TABLET ORL TAB AVA TAB 1.056800002373440 AVA-OLANZAPINE 5 MG TABLET ORL TAB AVA TAB 2.113500002373459 AVA-OLANZAPINE 7.5 MG TABLET ORL TAB AVA TAB 3.170300002363429 AVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 1.213500002363305 AVA-PRAMIPEXOLE 0.25 MG TABLET ORL TAB AVA TAB 0.588700002363321 AVA-PRAMIPEXOLE 1 MG TABLET ORL TAB AVA TAB 1.177600002363348 AVA-PRAMIPEXOLE 1.5 MG TABLET ORL TAB AVA TAB 1.177600002363267 AVA-RAMIPRIL 1.25 MG TABLET ORL CAP/TAB AVA TAB 0.4174

Page 15: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 15 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002363291 AVA-RAMIPRIL 10 MG TABLET ORL CAP/TAB AVA TAB 0.610000002363275 AVA-RAMIPRIL 2.5 MG TABLET ORL CAP/TAB AVA TAB 0.481500002363283 AVA-RAMIPRIL 5 MG TABLET ORL CAP/TAB AVA TAB 0.481500002364816 AVA-RISEDRONATE 35 MG TABLET ORL TAB AVA TAB 4.816900002367173 AVA-RISPERIDONE 0.25 MG TABLET ORL TAB AVA TAB 0.261500002367181 AVA-RISPERIDONE 0.5 MG TABLET ORL TAB AVA TAB 0.437900002367203 AVA-RISPERIDONE 1 MG TABLET ORL TAB AVA TAB 0.604800002364344 AVA-RISPERIDONE 1 MG/ML ORAL SOLUTION ORL SOL AVA ML 0.772700002367211 AVA-RISPERIDONE 2 MG TABLET ORL TAB AVA TAB 1.207500002367238 AVA-RISPERIDONE 3 MG TABLET ORL TAB AVA TAB 1.811300002367246 AVA-RISPERIDONE 4 MG TABLET ORL TAB AVA TAB 2.415000002363682 AVA-SOTALOL 160 MG TABLET ORL TAB AVA TAB 0.577100002363674 AVA-SOTALOL 80 MG TABLET ORL TAB AVA TAB 0.492200002366266 AVA-SUMATRIPTAN 100 MG TABLET ORL TAB AVA TAB 9.843300002366258 AVA-SUMATRIPTAN 50 MG TABLET ORL TAB AVA TAB 8.935000002366231 AVA-TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET ORL ERT AVA TAB 0.270000002370980 AVA-TOPIRAMATE 100 MG TABLET ORL TAB AVA TAB 1.253700002370999 AVA-TOPIRAMATE 200 MG TABLET ORL TAB AVA TAB 1.984500002370972 AVA-TOPIRAMATE 25 MG TABLET ORL TAB AVA TAB 0.661500002367130 AVA-VALSARTAN 160 MG TABLET ORL TAB AVA TAB 0.572400002367149 AVA-VALSARTAN 320 MG TABLET ORL TAB AVA TAB 0.550000002367114 AVA-VALSARTAN 40 MG TABLET ORL TAB AVA TAB 0.524000002367122 AVA-VALSARTAN 80 MG TABLET ORL TAB AVA TAB 0.572400002367084 AVA-VALSARTAN HCT 160 MG/ 25 MG TABLET ORL TAB AVA TAB 0.572400002367076 AVA-VALSARTAN HCT 160 MG/12.5 MG TABLET ORL TAB AVA TAB 0.572400002367092 AVA-VALSARTAN HCT 320 MG/12.5 MG TABLET ORL TAB AVA TAB 0.563300002367106 AVA-VALSARTAN HCT 320 MG/25 MG TABLET ORL TAB AVA TAB 0.563300002367068 AVA-VALSARTAN HCT 80 MG/12.5 MG TABLET ORL TAB AVA TAB 0.572400002363534 AVA-ZOPICLONE 5 MG TABLET ORL TAB AVA TAB 0.223100002363542 AVA-ZOPICLONE 7.5 MG TABLET ORL TAB AVA TAB 0.468500002298589 AVAMYS 27.5 MCG/DOSE NASAL SPRAY NAS SPM GSK DOSE 0.227600002247085 AVANDAMET 1 MG/500 MG TABLET ORL TAB GSK TAB 0.690300002270994 AVASTIN 25 MG/ML INJECTION INJ DEFAUL HLR ML 135.832500002237792 AVAXIM 160 U/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 46.130000002243741 AVAXIM-PEDIATRIC 80 UNIT/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 23.070000002317508 AVEENO CREAM TOP CRM JJI G 0.021900002241416 AVEENO MOISTURIZING BATH TOP PWR JJI G 0.049900002237770 AVONEX (30 MCG) 6 MILLION IU/VIAL INJECTION INJ DEFAUL BIO VIAL 364.762500002382369 AXIRON 2% TOPICAL SOLUTION TOP SOL LIL ML 1.4887

Page 16: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 16 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002284642 AZILECT 0.5 MG TABLET ORL TAB TMP TAB 7.834700002284650 AZILECT 1.0 MG TABLET ORL TAB TMP TAB 7.834700000598577 B COMPLEX 50 TABLET ORL TAB JAM TAB 0.112700000598569 B COMPLEX 75 TABLET ORL TAB JAM TAB 0.168600000123803 B COMPLEX PLUS C TABLET ORL TAB JAM TAB 0.084500080007498 B&C VITAMINS TABLET ORL TAB WBP TAB 0.069400000498815 B-COMPLEX 100 SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.225200080002409 B12 1000 MCG TABLET ORL TAB WNP TAB 0.085000002245512 B50 COMPLEX CAPSULE ORL CAP WNP CAP 0.125200001927906 BACID 1 B CAPSULE ORL CAP ERF CAP 0.991800000876488 BACIMYXIN TOPICAL OINTMENT TOP ONT PMS G 0.243300000584908 BACITIN 500 UNIT/G TOPICAL OINTMENT TOP ONT PPH G 0.208700000030708 BACITRACIN 50,000 U/VIAL INJECTION INJ DEFAUL PFI VIAL 12.514000002152584 BACLOFEN 10 MG TABLET ORL TAB PDL TAB 0.159500002152592 BACLOFEN 20 MG TABLET ORL TAB PDL TAB 0.310400000037818 BACTERIOSTATIC SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL HSP ML 0.213000002243425 BALANCED B COMPLEX 100 MG SUSTAINED-RELEASE TABLET ORL SRT PMT TAB 0.085000002244010 BALMINIL CODEINE NIGHT TIME + EXPECTORANT ORL SYR ROG ML 0.029500000436895 BALMINIL DM 3 MG/ML ORAL SYRUP ORL SYR ROG ML 0.045000001908855 BALNETAR 2.5% TOPICAL SOLUTION TOP SOL WSD ML 0.049600002369613 BANZEL 100 MG TABLET ORL TAB EIS TAB 0.780700002369621 BANZEL 200 MG TABLET ORL TAB EIS TAB 1.560900002369648 BANZEL 400 MG TABLET ORL TAB EIS TAB 3.364600002060841 BARRIERE 20% TOPICAL CREAM TOP CRM WSP G 0.071000002135620 BASALJEL 500 MG CAPSULE ORL CAP AUP CAP 0.163000002243966 BAZA CLEANSE & PROTECT 2% TOPICAL LOTION TOP LOT COC ML 0.048500000075124 BCG VACCINE (FREEZE-DRIED) 1 MG INJECTION INJ DEFAUL NNA VIAL 189.510000002237567 BEANO 150 UNIT TABLET ORL TAB BLO TAB 0.194300002019736 BENADRYL 12.5 MG/5 ML ORAL ELIXIR ORL ELX PDH ML 0.058500002019701 BENADRYL 2% TOPICAL CREAM TOP CRM WLA G 0.292700002017849 BENADRYL 25 MG CAPLET ORL TAB PDH TAB 0.420000002019671 BENADRYL 50 MG CAPSULE ORL CAP PDH CAP 0.251400002061287 BENADRYL ALLERGY JUNIOR STRENGTH CHEWABLE TABLET ORL CTB PDH TAB 0.448300002229367 BENADRYL ALLERGY SINUS HEADACHE CAPLET ORL TAB PDH TAB 0.317500002019698 BENADRYL CHILDREN'S 1.25 MG/ML ORAL LIQUID ORL LIQ PDH ML 0.058500002239138 BENADRYL EXTRA STRENGTH 50 MG CAPLET ORL TAB PDH TAB 0.558300002370050 BENLYSTA 120 MG / VIAL INJECTION INJ DEFAUL GSK VIAL 281.360000002370069 BENLYSTA 400 MG / VIAL INJECTION INJ DEFAUL GSK VIAL 937.860000000294926 BENURYL 500 MG TABLET ORL TAB VCL TAB 0.5280

Page 17: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 17 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002245709 BENYLIN 2 COLD AND FLU WITH CODEINE ORAL SYRUP ORL SYR PDH ML 0.057000001944738 BENYLIN DM 3 MG/ML ORAL SYRUP ORL SYR WLA ML 0.053500002215268 BENYLIN DM FOR CHILDREN 1.5 MG/ML ORAL SYRUP ORL SYR WLA ML 0.053500002245383 BENYLIN DM FREEZER POPS 7.5 MG/ PACKET ORAL LIQUID ORL LIQ PDH PCKT 0.592500001944746 BENYLIN DM-D FOR CHILDREN ORAL SYRUP ORL SYR WWA ML 0.053500001944711 BENYLIN DM-D ORAL SYRUP ORL SYR PDH ML 0.047400002003317 BENYLIN DM-D-E EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.039600001944673 BENYLIN DM-D-E ORAL SYRUP ORL SYR PDH ML 0.053500001944762 BENYLIN DM-E ORAL SYRUP ORL SYR WLA ML 0.053500002265427 BENYLIN E EXTRA STR W/ MENTHACTIN 40/3MG/ML SYR ORL SYR PDH ML 0.051800001912437 BENZAC AC 10% TOPICAL COPOLYMER GEL TOP COPGEL GAL G 0.333300000899453 BENZAC AC 5% TOPICAL COPLYMER GEL TOP COPGEL GAL G 0.150000001925199 BENZAC W10 10% TOPICAL WASH TOP WAS GAL G 0.169000000896276 BENZAC W5 5% TOPICAL WASH TOP WAS GAL G 0.060000001925180 BENZAC W5 5% TOPICAL WATER GEL TOP WTRGEL GAL G 0.150000002162121 BENZAGEL 5 5% WASH TOP WAS NVC ML 0.065400002225271 BENZAMYCIN TOPICAL GEL TOP GEL VCL G 1.192300002336847 BESIVANCE 0.6% OPHTHALMIC SOLUTION OPH SOL BSH ML 2.910000000716634 BETADERM 0.1% SCALP LOTION SCP LOT TAR ML 0.092500000158348 BETADINE 10% TOPICAL SOLUTION TOP SOL PUR ML 0.031600000158313 BETADINE SURGICAL SCRUB 7.5% TOPICAL SOLUTION TOP SOL PUR ML 0.016400002237835 BETAJECT INJECTION INJ DEFAUL SDZ ML 10.483000002326302 BI-PEGLYTE KIT ORL ECT/PWR PPH KIT 21.590000002359685 BIACNA 1.2%/0.025% TOPICAL GEL TOP GEL VCL G 1.149800002382423 BICALUTAMIDE 50 MG TABLET ORL TAB SIV TAB 1.610000002291924 BICILLIN L-A 1,200,000 IU/2 ML INJ SYR INJ NDL KNG SYR 44.804000000297763 BICNU 100 MG/VIAL INJECTION INJ DEFAUL BMS VIAL 120.040000002230897 BILTRICIDE 600 MG TABLET ORL TAB BAI TAB 6.835000002247371 BIO-FUROSEMIDE 20 MG TABLET ORL TAB BMD TAB 0.037300002247372 BIO-FUROSEMIDE 40 MG TABLET ORL TAB BMD TAB 0.055800002247170 BIO-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.015700002247171 BIO-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.021700000621366 BIODERM TOPICAL OINTMENT TOP ONT ODN G 0.360000080012473 BIOGAIA DROPS ORL DPS FEI ML 4.320000080006533 BIOMEDIC MULTIVITAMIN ORL CAP VTH CAP 0.130000002216051 BION TEARS OPH SOLUTION OPH SOL ALC ML 1.002100000116785 BIONET TABLET ORL TAB CHD TAB 0.209400080003128 BIONUTRITION FORMULA 3 CAPSULE ORL CAP BNI CAP 1.166600000999776 BIOTENE ORAL BALANCE GEL ORL GEL GSK G 0.1715

Page 18: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 18 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999782 BIOTENE ORAL RINSE ORL MWH GSK ML 0.015300000999777 BIOTENE SPRAY ORL SPR GSK ML 0.163700000437522 BIOTIN 250 MCG TABLET ORL TAB JAM TAB 0.059200002277166 BIPHENTIN 10 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 0.755200002277131 BIPHENTIN 15 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 1.080100002277158 BIPHENTIN 20 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 1.396300002277174 BIPHENTIN 30 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 1.915800002277182 BIPHENTIN 40 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 2.440600002277190 BIPHENTIN 50 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 2.960000002277204 BIPHENTIN 60 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 3.444600002277212 BIPHENTIN 80 MG CONTROLLED-RELEASE CAPSULE ORL CRC PUR CAP 4.546600002273411 BISACODYL-ODAN 5 MGENTERIC-COATED TABLET ORL ECT ODN TAB 0.055000002131692 BLEOMYCIN SULFATE 15 UNIT/VIAL INJECTION INJ DEFAUL MNP VIAL 457.890000000220442 BONAMINE 25 MG CHEWABLE TABLET ORL CTB JJM TAB 0.442000002247600 BOOSTRIX INJECTION SYRINGE INJ DEFAUL GSK SYR 29.790000002268140 BRAVELLE 75 UNIT/VIAL POWDER FOR INJECTION INJ DEFAUL FEI VIAL 71.502000002408872 BREO ELLIPTA 100 MCG/25 MCG POWDER FOR INHALATION INH MIP GSK DOSE 4.346700002220520 BROMAZEPAM 3 MG TABLET ORL TAB PDL TAB 0.037500002220539 BROMAZEPAM 6 MG TABLET ORL TAB PDL TAB 0.054800000522791 BRONCHOPHAN FORTE DM ORAL SYRUP ORL SYR ATL ML 0.026000000512990 BSS BALANCED SALT OPH SOLUTION OPH SOL ALC ML 0.418000000729655 BUCKLEY'S DM ORAL LIQUID ORL LIQ BUA ML 0.050600002247970 BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB ORL CTB BIC TAB 0.087300080022907 BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB ORL CTB BIC TAB 0.086900002331616 BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.266700000728284 BURINEX 1 MG TABLET ORL TAB LEO TAB 0.810300000728276 BURINEX 5 MG TABLET ORL TAB LEO TAB 3.126000000674222 BURO-SOL OTIC SOLUTION OT SOL TCD ML 0.276000000579947 BURO-SOL TOPICAL POWDER TOP PWR TCD G 0.751000002223163 BUSPIRONE 10 MG TABLET ORL TAB PDL TAB 0.352100002341212 BUTRANS 10 (10 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 24.450000002341220 BUTRANS 20 (20 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 44.445000002341174 BUTRANS 5 (5 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 13.312500002361817 BYETTA 10 MCG/DOSE (2.4 ML) INJECTION SYRINGE INJ NDL LIL SYR 149.630000002361809 BYETTA 5 MCG/DOSE (1.2 ML) INJECTION SYRINGE INJ NDL LIL SYR 149.630000002399016 BYSTOLIC 10 MG TABLET ORL TAB FLC TAB 1.290000002398990 BYSTOLIC 2.5 MG TABLET ORL TAB FLC TAB 1.304000002399024 BYSTOLIC 20 MG TABLET ORL TAB FLC TAB 1.290000002399008 BYSTOLIC 5 MG TABLET ORL TAB FLC TAB 1.3040

Page 19: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 19 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000265470 C.E.S. 0.625 MG TABLET ORL TAB VCL TAB 0.101500002273284 CADUET 10 MG/10 MG TABLET ORL TAB PFI TAB 2.662300002273292 CADUET 10 MG/20 MG TABLET ORL TAB PFI TAB 3.319100002273306 CADUET 10 MG/40 MG TABLET ORL TAB PFI TAB 3.477300002273314 CADUET 10 MG/80 MG TABLET ORL TAB PFI TAB 3.477300002273233 CADUET 5 MG/10 MG TABLET ORL TAB PFI TAB 2.521700002273241 CADUET 5 MG/20 MG TABLET ORL TAB PFI TAB 2.973700002273268 CADUET 5 MG/40 MG TABLET ORL TAB PFI TAB 3.143200002273276 CADUET 5 MG/80 MG TABLET ORL TAB PFI TAB 3.109400002238389 CAELYX 2 MG/ML PEGYLATED LIPOSOME INJECTION INJ DEFAUL SCH ML 68.300000000176095 CAFERGOT TABLET ORL TAB NOV TAB 0.890700002241460 CAL MAG 2:1 WITH D TABLET ORL TAB WNP TAB 0.039100001906828 CAL-MAG WITH ZINC & VITAMIN D CAPLET ORL TAB SWS TAB 0.090200000730602 CALCIUM & MAGNESIUM WITH VITAMIN D CAPSULE ORL CAP SIS CAP 0.244200002240973 CALCIUM (CARBONATE) W/ VITAMIN D 500 MG/125 U TAB ORL TAB WNP TAB 0.075000000621722 CALCIUM 500 MG TABLET ORL TAB HAL TAB 0.027400002240240 CALCIUM 500 MG TABLET ORL TAB PMT TAB 0.085000002240977 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.044900080003658 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.025500080000248 CALCIUM 650 MG TABLET ORL TAB JAM TAB 0.074500080009369 CALCIUM 650 MG TABLET ORL TAB PMT TAB 0.034200080007105 CALCIUM 650 MG WITH VITAMIN D 400 IU CAPLET ORL TAB HHC TAB 0.074500002040875 CALCIUM AND MAGNESIUM CAPLET ORL TAB JAM TAB 0.070300080006568 CALCIUM AND MAGNESIUM TABLET ORL TAB GFR TAB 0.114000002244861 CALCIUM AND MAGNESIUM WITH VITAMIN D TAB ORL TAB PMT TAB 0.034500002048965 CALCIUM AND MAGNESIUM WITH ZINC CAPLET ORL TAB JAM TAB 0.033500002243418 CALCIUM BONE SOLUTION ORL LIQ ULT ML 0.034300000730599 CALCIUM CARBONATE & VITAMIN D3 500 MG/125 U TABLET ORL TAB PMT TAB 0.034500000644684 CALCIUM CARBONATE 500 MG (BASE) TABLET ORL TAB WBP TAB 0.024500001922238 CALCIUM CARBONATE 500 MG CHEWABLE TABLET ORL CTB WAM TAB 0.098800080003855 CALCIUM CITRATE 300 MG TABLET ORL TAB WNP TAB 0.067200002243766 CALCIUM CITRATE 300 MG TABLET ORL TAB PMT TAB 0.079100002158728 CALCIUM CITRATE 350 MG TABLET ORL TAB SWS TAB 0.094500002237590 CALCIUM CITRATE WITH VITAMIN D TABLET ORL TAB JAM TAB 0.069000002243669 CALCIUM CITRATE WITH VITAMIN D TABLET ORL TAB WNP TAB 0.083300002141019 CALCIUM GLUCONATE 94 MG/ML INJECTION INJ DEFAUL PPC ML 0.951000080007103 CALCIUM MAGNESIUM WITH VITAMIN D CAPLET ORL TAB JAM TAB 0.070300002040905 CALCIUM MAGNESIUM WITH VITAMIN D TABLET ORL TAB JAM TAB 0.068500080007265 CALCIUM SOFT CHEWS WITH VITAMIN D ORL CAP JAM CAP 0.1820

Page 20: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 20 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002198630 CALMYLIN ACE 2 MG/ML SYRUP ORL SYR RPH ML 0.102100000535230 CALMYLIN WITH CODEINE COUGH ORAL LIQUID ORL LIQ RPH ML 0.054300002172917 CALMYLIN WITH CODEINE ORAL SYRUP ORL SYR ROG ML 0.057900002007134 CALTINE 100 UNIT/ML INJECTION INJ DEFAUL FEI ML 8.055000002242997 CALTRATE 600 MG WITH VITAMIN D SOFT CHEWS TABLET ORL CTB WCH TAB 0.192200002231948 CALTRATE 600 MG WITH VITAMIN D TABLET ORL TAB WCH TAB 0.183200080003751 CALTRATE 600 TABLET ORL TAB WCH TAB 0.183200002240959 CALTRATE PLUS CHEWABLE TABLET ORL CTB WCH TAB 0.230600080009423 CALTRATE PLUS CHEWABLES 400 IU ORL TAB PDH TAB 0.222100002231422 CALTRATE PLUS TABLET ORL TAB WCH TAB 0.166400080009761 CALTRATE PLUS TABLET ORL TAB PDH TAB 0.192200002247976 CALTRATE SELECT 600 MG/ 400 IU TABLET ORL TAB WCH TAB 0.219800080012593 CALTRATE WITH VITAMIN D SOFT CHEWS ORL CTB WAY TAB 0.192200002381680 CAMBIA 50 MG ORAL POWDER PACKET ORL PWDPKT TRI PCKT 10.757800002293269 CAMPRAL 333 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 0.869300002231622 CAMPTOSAR 20 MG/ML INJECTION INJ DEFAUL PFI ML 119.538000002377942 CANDESARTAN 16 MG TABLET ORL TAB PDL TAB 0.342000002388693 CANDESARTAN 4 MG TABLET ORL TAB SIV TAB 0.340000002388901 CANDESARTAN 4 MG TABLET ORL TAB SNS TAB 0.340000002377934 CANDESARTAN 8 MG TABLET ORL TAB PDL TAB 0.342000002379260 CANDESARTAN CILEXETIL 4 MG TABLET ORL TAB AHI TAB 0.340000002311690 CANESORAL 150 MG CAPSULE ORL CAP BIC CAP 16.650000002311739 CANESORAL COMBI-PAK KIT ORL/VAG CAP/CRM BIC KIT 17.630000002311720 CANESTEN 1% EXTERNAL CREAM TOP CRM BIC G 13.310000002150867 CANESTEN 1% TOPICAL CREAM TOP CRM BAI G 0.389300080028872 CANTHACUR 0.7% TOPICAL SOLUTION TOP SOL PMS ML 7.254700000589500 CANTHACUR-PS TOPICAL SOLUTION TOP SOL PMS ML 8.790700000619035 CANTHARONE 0.7% TOPICAL SOLUTION TOP SOL BAK ML 7.237300000619027 CANTHARONE PLUS TOPICAL SOLUTION TOP SOL BAK ML 7.993000000772011 CANTHARONE PLUS TOPICAL SOLUTION TOP SOL DLX ML 8.685300002242738 CAPEX 0.01% TOPICAL SHAMPOO TOP SHP GAL ML 0.720300002157101 CAPSAICIN 0.025% TOPICAL CREAM TOP CRM VLP G 0.201300002157128 CAPSAICIN 0.075% TOPICAL CREAM TOP CRM VLP G 0.243000002060043 CARBACHOL 2 MG TABLET ORL TAB BNQ TAB 0.590000002413590 CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.093000002413604 CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.185900002241999 CARBOCAINE 10 MG/ML INJECTION INJ DEFAUL HSP ML 0.631300002242001 CARBOCAINE 20 MG/ ML INJECTION INJ DEFAUL HSP ML 1.262500002245511 CARBOCAL D 400 TABLET ORL TAB EUP TAB 0.1260

Page 21: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 21 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002011239 CARBOLITH 600 MG CAPSULE ORL CAP VCL CAP 0.199100002126680 CARBOPLATIN 10 MG/ML INJECTION INJ DEFAUL HSP ML 19.250000002397447 CARIPUL 0.5 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 17.176000002397455 CARIPUL 1.5 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 34.447000002324520 CARVEDILOL 12.5 MG TABLET ORL TAB PDL TAB 0.635000002324539 CARVEDILOL 25 MG TABLET ORL TAB PDL TAB 0.635000002324504 CARVEDILOL 3.125 MG TABLET ORL TAB PDL TAB 0.635000002324512 CARVEDILOL 6.25 MG TABLET ORL TAB PDL TAB 0.635000002184478 CASODEX 50 MG TABLET ORL TAB AZC TAB 7.465300000291889 CATAPRES 0.2 MG TABLET ORL TAB BOE TAB 0.330600002215756 CAVERJECT 20 MCG INJECTION INJ DEFAUL PFI VIAL 25.736000000465208 CECLOR 25 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.128600000465186 CECLOR 250 MG CAPSULE ORL CAP PPH CAP 1.109200000832804 CECLOR 375 MG/5ML ORAL SUSPENSION ORL SUS PHH ML 0.287200000465216 CECLOR 50 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.235400000465194 CECLOR 500 MG CAPSULE ORL CAP PPH CAP 2.366400000360430 CEENU 10 MG CAPSULE ORL CAP BMS CAP 7.613500000360414 CEENU 100 MG CAPSULE ORL CAP BMS CAP 21.669500000360422 CEENU 40 MG CAPSULE ORL CAP BMS CAP 13.268000002237138 CEFAZOLIN 1 G/VIAL USP INJECTION INJ DEFAUL PPC VIAL 6.000000002319039 CEFEPIME 2G/VIAL INJECTION INJ DEFAUL APX VIAL 25.115000002036274 CEFOTAN 1 G/VIAL INJECTION INJ DEFAUL WAY VIAL 15.000000002240773 CEFOXITIN 10 G/VIAL USP INJECTION INJ DEFAUL TEV VIAL 105.950000000886971 CEFTAZIDIME 1 G/VIAL INJECTION INJ DEFAUL PPC VIAL 31.970000002212307 CEFTIN 125 MG/5ML ORAL SUSPENSION ORL SUS GSK ML 0.189900002287668 CEFTRIAXONE SODIUM FOR INJECTION 10 G/VIAL INJ INJ DEFAUL TEV VIAL 214.200000002250292 CEFTRIAXONE SODIUM FOR INJECTION BP 1 G/VIAL INJ INJ DEFAUL HSP VIAL 35.250000002241639 CEFUROXIME 1.5 G/VIAL USP INJECTION INJ DEFAUL PPC VIAL 39.790000002241640 CEFUROXIME 7.5 G/VIAL USP INJECTION INJ DEFAUL PPC VIAL 149.200000002241638 CEFUROXIME 750 MG/VIAL USP INJECTION INJ DEFAUL PPC VIAL 19.890000002357844 CELESTODERM-V 0.1% TOPICAL CREAM TOP CRM VLP G 0.099000002357852 CELESTODERM-V 0.1% TOPICAL OINTMENT TOP ONT VLP G 0.099000002357860 CELESTODERM-V/2 0.05% TOPICAL CREAM TOP CRM VLP G 0.066400002357879 CELESTODERM-V/2 0.05% TOPICAL OINTMENT TOP ONT VLP G 0.066400002242145 CELLCEPT 200 MG/ ML ORAL SUSPENSION ORL SUS HLR ML 1.880800002192748 CELLCEPT 250 MG ORAL CAPSULE ORL CAP HLR CAP 2.240700002237484 CELLCEPT 500 MG TABLET ORL TAB HLR TAB 4.481400002240347 CELLCEPT I.V. 500 MG/VIAL INJECTION POWDER FOR SOL INJ DEFAUL HLR VIAL 32.000000000870153 CELLUVISC 1% OPH SOLUTION OPH SOL ALL ML 0.8625

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 22 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000022802 CELONTIN 300 MG CAPSULE ORL CAP ERF CAP 0.637800002299844 CELSENTRI 150 MG TABLET ORL TAB PFI TAB 17.737500002299852 CELSENTRI 300 MG TABLET ORL TAB PFI TAB 16.500000080013657 CENTRUM ADVANTAGE TABLET ORL TAB PDH TAB 0.196300080022930 CENTRUM CARDIO TABLET ORL TAB PDH TAB 0.225800080024482 CENTRUM FOR WOMEN ORL TAB PDH TAB 0.151700002246361 CENTRUM FORTE TABLET ORL TAB WCH TAB 0.161500080005174 CENTRUM FORTE TABLET ORL TAB PDH TAB 0.170000080020794 CENTRUM JUNIOR COMPLETE CHEWABLE TABLET ORL CTB PDH TAB 0.130500002246440 CENTRUM SELECT CHEWABLE TABLET ORL CTB WCH TAB 0.222300002246346 CENTRUM SELECT TABLET ORL TAB WCH TAB 0.157700080005153 CENTRUM SELECT TABLET ORL TAB PFI TAB 0.157700002246362 CENTRUM TABLET ORL TAB WCH TAB 0.096900080021452 CENTRUM TABLET ORL TAB PDH TAB 0.132800002099365 CEPACOL MINT WITH FLUORIDE MOUTHWASH ORL MWH SKB ML 0.004000000828866 CEPHALEXIN 500 MG TABLET ORL TAB PDL TAB 0.450000002230988 CEREBYX 75 MG/ML INJECTION INJ DEFAUL PFI ML 11.058000002230694 CEREZYME 200 U/VIAL INJECTION INJ DEFAUL GZM VIAL 1230.000000002241751 CEREZYME 400 U/VIAL INJECTION INJ DEFAUL GZM VIAL 2460.000000001926683 CERUBIDINE 20 MG/VIAL INJECTION INJ DEFAUL ERF VIAL 90.200000000158356 CERUMENEX 10% OTIC DROPS OT DPS PUR ML 0.574000000221570 CERUMOL OTIC DROPS OT DPS PAL ML 0.539100002342227 CERVARIX 0.5 ML INJECTION INJ DEFAUL GSK ML 195.600000002312263 CESAMET 0.25 MG ORAL CAPSULE ORL CAP VCL CAP 1.835600002247766 CETROTIDE 0.25 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 96.750000002247767 CETROTIDE 3 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 340.000000000496685 CHELATED CHROMIUM 200 MCG TABLET ORL TAB JAM TAB 0.074200080009742 CHEWABLE PEPPERMINT VITAMIN D 1000 IU ORL TAB SWS TAB 0.047900002248435 CHILDREN'S ADVIL COLD ORAL SUSPENSION ORL SUS PDH ML 0.062200002238626 CHILDREN'S MOTRIN 40 MG/ML SUSPENSION DROPS ORL DPS MCL ML 0.273300002039990 CHILDREN'S TYLENOL COLD DM ORAL SUSPENSION ORL SUS MCL ML 0.056100002046040 CHILDREN'S TYLENOL GRAPE 32 MG/ML ORAL SUSPENSION ORL SUS MCL ML 0.058500000870455 CHILDRENS TYLENOL COLD DM CHEWABLE TABLET ORL CTB MCL TAB 0.176300002229538 CHILDRENS TYLENOL DECONGESTANT LIQUID ORL LIQ MCL ML 0.056100000738972 CHLOR-TRIPOLON 4 MG TABLET ORL TAB SCH TAB 0.228800001970399 CHLOR-TRIPOLON N.D. SUSTAINED-RELEASE TABLET ORL TAB SCH TAB 0.434200000738964 CHLOR-TRIPOLON REPETABS 12 MG SUST RELEASE TABLET ORL SRT SCH TAB 0.347100002247621 CHLORAL HYDRATE-ODAN 100 MG/ML ORAL SYRUP ORL SYR ODN ML 0.043300080015373 CHONDROCARE TABLET ORL TAB MTG TAB 0.4500

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 23 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002247459 CHORIONIC GONADOTROPIN 10,000 UNIT/VIAL INJECTION INJ DEFAUL PPC VIAL 130.390000002238274 CI-CAL + D TABLET ORL TAB EUP TAB 0.151300002238273 CI-CAL 250 MG TABLET ORL TAB EUP TAB 0.143700002248088 CIALIS 10 MG TABLET ORL TAB LIL TAB 15.245000002296888 CIALIS 2.5 MG TABLET ORL TAB LIL TAB 4.662500002248089 CIALIS 20 MG TABLET ORL TAB LIL TAB 15.797500002296896 CIALIS 5 MG TABLET ORL TAB LIL TAB 4.662500002350971 CILAZAPRIL 2.5 MG TABLET ORL TAB SNS TAB 0.428400002200864 CILOXAN 0.3% OPH OINTMENT OPH ONT ALC G 3.282900002331675 CIMZIA 200 MG/ML INJECTION SYRINGE INJ NDL UCB SYR 722.090000002391449 CIPRALEX MELTZ 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LBC TAB 1.840000002391457 CIPRALEX MELTZ 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LBC TAB 1.959000002251787 CIPRO XL 1000 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.381600002247916 CIPRO XL 500 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.381600002304546 CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ INJ DEFAUL APX ML 0.144500002304759 CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ INJ DEFAUL SDZ ML 0.154000002126613 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL MNP ML 6.460000002403188 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL TEV ML 6.152400002301822 CITALOPRAM 10 MG TABLET ORL TAB MEL TAB 0.446400002387948 CITALOPRAM 10 MG TABLET ORL TAB SIV TAB 0.249300002301830 CITALOPRAM 20 MG TABLET ORL TAB MEL TAB 0.875000002301849 CITALOPRAM 40 MG TABLET ORL TAB MEL TAB 0.875000002257521 CITALOPROM-40 40 MG TABLET ORL TAB PDL TAB 0.332900000519235 CITANEST PLAIN 4% INJECTION INJ DEFAUL DSC ML 0.865800002150220 CITRACAL MG TABLET ORL TAB SFD TAB 0.153500002150158 CITRACAL PLUS D CAPLET ORL TAB SFD TAB 0.154800000262609 CITRO MAG 50 MG ORAL LIQUID ORL LIQ ROG ML 0.016100002225085 CLAFORAN 0.5 G/VIAL INJECTION INJ DEFAUL SAV VIAL 10.535000002324490 CLARITHROMYCIN 500 MG TABLET ORL TAB PDL TAB 1.629700002237734 CLARITIN 10 MG RAPID DISSOLVE TONGUE TABLET ORL DISPTAB SCH TAB 0.724000000782696 CLARITIN 10 MG TABLET ORL TAB SCH TAB 0.898300001945157 CLARITIN EXTRA SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.724000000442968 CLEARASIL BP PLUS 5% TOPICAL LOTION TOP LOT RBC ML 0.189300002324989 CLEARLAX ORAL POWDER ORL PWR PRI G 0.027500002250616 CLIMARA PRO 4.40 MG/1.39 MG TRANSDERMAL PATCH TRD PTH BAI PTH 6.930000002408511 CLINDAMYCIN IV INFUSION 12 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.391000002408538 CLINDAMYCIN IV INFUSION 18 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.544500002248525 CLINDAMYCINE-150 150 MG TABLET ORL TAB PDL TAB 0.221700002248526 CLINDAMYCINE-300 300 MG CAPSULE ORL CAP PDL CAP 0.4434

Page 24: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 24 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002242970 CLINDASOL 1% TOPICAL CREAM TOP CRM GSK G 0.811200002243050 CLINDETS PLEDGET 1% TOPICAL PAD TOP PAD GSK PAD 0.727800080007070 CLINIDERM GENTLE SPF 45 LOTION TOP LOT SAH ML 0.241500002248454 CLOBAZAM-10 10 MG TABLET ORL TAB PDL TAB 0.109700002256398 CLOBEX 0.05% TOPICAL LOTION TOP LOT GAL ML 0.814100002256371 CLOBEX 0.05% TOPICAL SHAMPOO TOP SHP GAL ML 0.814100002299739 CLOBEX 0.05% TOPICAL SPRAY TOP SPR GAL ML 1.630000001910396 CLONIDINE 0.1 MG TABLET ORL TAB PDL TAB 0.135800002394820 CLOPIDOGREL 75 MG TABLET ORL TAB PDL TAB 0.657700000812382 CLOTRIMADERM 1% TOPICAL CREAM TOP CRM TAR G 0.323500002229380 CLOTRIMAZOLE 1% TOPICAL CREAM USP TOP CRM TAR G 0.210000002394898 CO ANASTROZOLE 1 MG TABLET ORL TAB APH TAB 2.546000002274337 CO BICALUTAMIDE 50 MG TABLET ORL TAB APH TAB 4.057300002376520 CO CANDESARTAN 4 MG TABLET ORL TAB APH TAB 0.340000002285215 CO CILAZAPRIL 2.5 MG TABLET ORL TAB APH TAB 0.179500002285223 CO CILAZAPRIL 5 MG TABLET ORL TAB APH TAB 0.208500002270641 CO CLONAZEPAM 0.5 MG TABLET ORL TAB APH TAB 0.049500002270668 CO CLONAZEPAM 1.0 MG TABLET ORL TAB APH TAB 0.148700002270676 CO CLONAZEPAM 2.0 MG TABLET ORL TAB APH TAB 0.128600002397625 CO DONEPEZIL ODT 10 MG ORALLY DISINTEGRATING TAB ORL DISNTAB APH TAB 3.617600002397617 CO DONEPEZIL ODT 5 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB APH TAB 3.617600002390183 CO EXEMESTANE 25 MG TABLET ORL TAB APH TAB 3.900800002305682 CO FAMCICLOVIR 125 MG TABLET ORL TAB APH TAB 2.024000002305690 CO FAMCICLOVIR 250 MG TABLET ORL TAB APH TAB 2.720000002305704 CO FAMCICLOVIR 500 MG TABLET ORL TAB APH TAB 4.228100002274248 CO GLIMEPIRIDE 1 MG TABLET ORL TAB APH TAB 0.490000002274256 CO GLIMEPIRIDE 2 MG TABLET ORL TAB APH TAB 0.490000002274272 CO GLIMEPIRIDE 4 MG TABLET ORL TAB APH TAB 0.490000002397285 CO IMATINIB 100 MG TABLET ORL TAB COB TAB 20.455700002397293 CO IMATINIB 400 MG TABLET ORL TAB COB TAB 81.822800002250020 CO MELOXICAM 15 MG TABLET ORL TAB APH TAB 0.567000002250012 CO MELOXICAM 7.5 MG TABLET ORL TAB APH TAB 0.491400002379996 CO MYCOPHENOLATE 500 MG TABLET ORL TAB APH TAB 2.062000002269627 CO NORFLOXACIN 400 MG TABLET ORL TAB APH TAB 0.544900002325713 CO OLANZAPINE 20 MG TABLET ORL TAB APH TAB 10.309300002327589 CO OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB ORL DISNTAB APH TAB 5.355300002327597 CO OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB ORL DISNTAB APH TAB 7.597700002394189 CO OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.439000002394197 CO OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.6585

Page 25: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 25 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002394200 CO OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 1.141300002394170 CO OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.315000002394219 CO OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 2.108000002262746 CO PAROXETINE 10 MG TABLET ORL TAB APH TAB 1.043000002302861 CO PIOGLITAZONE 15 MG TABLET ORL TAB APH TAB 0.580900002302888 CO PIOGLITAZONE 30 MG TABLET ORL TAB APH TAB 0.813900002302896 CO PIOGLITAZONE 45 MG TABLET ORL TAB APH TAB 1.223700002402955 CO PREGABALIN 150 MG CAPSULE ORL CAP APH CAP 1.727000002402971 CO PREGABALIN 225 MG CAPSULE ORL CAP APH CAP 1.727000002402912 CO PREGABALIN 25 MG CAPSULE ORL CAP APH CAP 0.617300002402998 CO PREGABALIN 300 MG CAPSULE ORL CAP APH CAP 1.727000002402920 CO PREGABALIN 50 MG CAPSULE ORL CAP APH CAP 0.968300002402939 CO PREGABALIN 75 MG CAPSULE ORL CAP APH CAP 1.252800080006266 CO Q10 100 MG CAPSULE ORL CAP SIS CAP 0.166600080007078 CO Q10 LIQUID ORL LIQ INN ML 0.794100002372088 CO SILDENAFIL 100 MG TABLET ORL TAB APH TAB 9.202500002372053 CO SILDENAFIL 25 MG TABLET ORL TAB APH TAB 8.290000002372061 CO SILDENAFIL 50 MG TABLET ORL TAB APH TAB 8.847500002270633 CO SOTALOL 160 MG TABLET ORL TAB APH TAB 0.405800002270625 CO SOTALOL 80 MG TABLET ORL TAB APH TAB 0.370800002257882 CO SUMATRIPTAN 25 MG TABLET ORL TAB APH TAB 8.990000002395282 CO TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APH CAP 113.596600002395290 CO TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APH CAP 159.036000002395274 CO TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APH CAP 22.720000002395312 CO TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APH CAP 283.984000002383209 CO TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB APH TAB 0.626400002403986 CO-OLOPATADINE 0.1% OPH SOLUTION OPH SOL APH ML 5.226000000068756 COACTIFED EXPECTORANT ORAL LIQUID ORL LIQ GSK ML 0.190600000068594 COACTIFED ORAL SYRUP ORL SYR GSK ML 0.178500000068608 COACTIFED TABLET ORL TAB GSK TAB 1.088000002150417 COATED ASPIRIN 325 MG CAPLET ORL ECT BAI TAB 0.084600002237726 COATED ASPIRIN DAILY LOW DOSE 81 MG ECT ORL ECT BIC TAB 0.117300002150425 COATED ASPIRIN EXTRA STRENGTH 500 MG CAPLET ORL ECT BAI TAB 0.081500002243897 COATED DAILY LOW-DOSE ASA 81 MG TABLET ORL ECT PMS TAB 0.043300002163748 CODEINE CONTIN 100 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.712800002163780 CODEINE CONTIN 150 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 1.069300002163799 CODEINE CONTIN 200 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 1.425700002230302 CODEINE CONTIN 50 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.356500000050024 CODEINE PHOSPHATE 5 MG/ML ORAL SYRUP ORL SYR ATL ML 0.0542

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 26 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246219 COENZYME Q10 100 MG CAPSULE ORL CAP WNP CAP 0.140300002248644 COENZYME Q10 100 MG CAPSULE ORL CAP VTH CAP 0.326600080010367 COENZYME Q10 150 MG SOFTGEL ORL CAP WBP CAP 0.388700080006827 COENZYME Q10 30 MG CAPSULE ORL CAP WNP CAP 0.129700002231735 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.300000002245926 COENZYME Q10 60 MG CAPSULE ORL CAP HHC CAP 0.254000080006674 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.259300080006505 COENZYME Q10 SOFTGEL ORL TAB WNP TAB 0.291700000287873 COLCHICINE 0.6 MG TABLET ORL TAB EUP TAB 0.278700000621374 COLCHICINE 1 MG TABLET ORL TAB ODN TAB 0.528500000476420 COLY-MYCIN M 150 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 42.920000001944363 COMBANTRIN 125 MG TABLET ORL TAB PDH TAB 1.132500001944355 COMBANTRIN 50 MG/ML (BASE) ORAL SUSPENSION ORL SUS PDH ML 0.278900002239213 COMBIVIR TABLET ORL TAB GSK TAB 11.345800002374129 COMPLERA 200 MG/25 MG/300 MG TABLET ORL TAB GIL TAB 44.330000002229633 COMPLETE MULTI-ADULT TABLET ORL TAB WAM TAB 0.060700002247732 CONCERTA 18 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.280300002250241 CONCERTA 27 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.631600002247733 CONCERTA 36 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.983000002247734 CONCERTA 54 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.685400001945149 CONDYLINE 0.5% TOPICAL SOLUTION TOP SOL CDX ML 12.408600002224577 COPHYLAC ORAL SOLUTION ORL SOL VLP ML 2.372700002176955 COQ10 30 MG CAPSULE ORL CAP JAM CAP 0.224800080012965 COQ10 MRB 60 MG SOFTGEL CAPSULE ORL CAP INN CAP 0.795000001980661 CORTAMED 25 MG/G OPH OINTMENT OPH ONT SDZ G 6.085700000513288 CORTATE 0.5% TOPICAL CREAM TOP CRM PMS G 0.146700001912828 CORTISPORIN OTIC SOLUTION OT SOL GSK ML 1.406000000666246 CORTISPORIN TOPICAL OINTMENT TOP ONT GSK G 0.847300000022381 CORTROSYN 0.25 MG/VIAL INJECTION INJ DEFAUL LYN VIAL 98.760000002181215 COTAZYM ECS 4 CAPSULE (ENTERIC-COATED PELLET) ORL CAP/ENCP ORG CAP 0.179500002099748 COUGH SYRUP WITH CODEINE ORL SYR ROG ML 0.016200002240206 COUMADIN 6 MG TABLET ORL TAB DPM TAB 0.512900002243063 COVAN ORAL SYRUP ORL SYR PMS ML 0.061300002246568 COVERSYL PLUS LD 2 MG/0.625 MG TABLET ORL TAB SEV TAB 0.921000080027158 CRANBERRY COMPLEX 500 MG CAPSULE ORL CAP JAM CAP 0.200200000299561 CREO-RECTAL ADULT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.750000000299588 CREO-RECTAL INFANT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.602000000299596 CREO-RECTAL INFANT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.750000002239007 CREON 5 MINIMICROSPHERES CAPSULE ORL CAP/ENCP ABB CAP 0.1703

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 27 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002415194 CREON MINIMICROSPHERES 6 CAPSULE ORL CAP/ENCP ABB CAP 0.183100002241013 CRINONE 8% VAGINAL GEL VAG GEL SRO G 8.993100002229161 CRIXIVAN 200 MG CAPSULE ORL CAP MFC CAP 1.447700002229196 CRIXIVAN 400 MG CAPSULE ORL CAP MFC CAP 2.926700001950541 CROMOLYN 2% NASAL SOLUTION NAS SOL PPH ML 0.829200002299909 CUBICIN 500 MG/VIAL INJECTION INJ DEFAUL CUB VIAL 174.000000002089912 CUTIVATE 0.05% TOPICAL CREAM TOP CRM GKC G 0.725000002220644 CYCLOBENZAPRINE 10 MG TABLET ORL TAB PDL TAB 0.372700002148331 CYCLOPENTOLATE HCL 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002148382 CYCLOPENTOLATE HCL 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002290308 CYESTRA-35 TABLET ORL TAB PMS TAB 1.207600080038525 CYSTA-Q CAPSULE ORL CAP TPI CAP 0.541500002238526 CYSTADANE 1 G/SCOOP ORAL POWDER ORL PWR ORP G 4.552400002126656 CYTARABINE 100MG/ ML INJECTION INJ DEFAUL MNP ML 16.702000000386715 CYTOSAR 100 MG/5ML INJECTION INJ DEFAUL PFI VIAL 10.724000002237450 D-FORTE 50000 IU CAPSULE ORL CAP EUP CAP 0.198600000821772 D-TAB 10,000 UNIT TABLET ORL TAB RIV TAB 0.221500002060604 DALACIN 2% VAGINAL CREAM VAG CRM PAL G 0.821000000582301 DALACIN T 1% (BASE) TOPICAL SOLUTION TOP SOL PFI ML 0.362000000507415 DAN-GARD 2% TOPICAL SHAMPOO TOP SHP VLP ML 0.056000001997653 DANTRIUM 100 MG CAPSULE ORL CAP JHP CAP 0.768400000004774 DARAPRIM 25 MG TABLET ORL TAB COR TAB 1.519000002359456 DAXAS 500 MCG TABLET ORL TAB TAK TAB 2.282000002027860 DAYPRO 600 MG TABLET ORL TAB PFI TAB 0.725500002285002 DDAVP MELT 120 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 2.154000002285010 DDAVP MELT 240 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 3.877700002284995 DDAVP MELT 60 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 1.077000080001791 DDROPS 1,000 IU/DROP ORAL LIQUID ORL LIQ DDR ML 1.490000002389282 DECAPEPTYL 0.1 MG/ML INJECTION SYRINGE INJ DEFAUL FEI SYR 12.000000000791172 DECONGEST 0.1 MG NASAL SOLUTION NAS SOL RPH ML 0.151000002018403 DELSYM 6 MG/ML CONTROLLED-RELEASE SUSPENSION ORL CRSUS NVC ML 0.063400002238848 DENAVIR 1% TOPICAL CREAM TOP CRM BRR G 14.320000000873292 DERMA-SMOOTHE/FS 0.01% TOPICAL OIL TOP OIL HDI ML 0.305300000681989 DERMAFLEX HC 1% CREAM TOP CRM NEO G 0.189800000681997 DERMAFLEX HC 1% TOPICAL LOTION TOP LOT NEO ML 0.112700002247093 DERMAL THERAPY- HEEL CARE CREAM TOP CRM DTR ML 0.085600002239903 DERMALAC 12% CREAM TOP CRM TAR G 0.062800002060345 DERMAREST DRICORT 0.5% TOPICAL CREAM TOP CRM DEL G 0.165700002230642 DERMATOP 0.1% EMOLLIENT CREAM TOP EMCRM VCL G 1.8070

Page 28: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 28 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002227517 DERMATOP 0.1% TOPICAL OINTMENT TOP ONT VCL G 1.663000002238407 DERMAZINC 0.25% TOPICAL SPRAY TOP SPR DPI ML 0.231800002300559 DERMOTIC OIL EAR DROPS 0.01% OTIC SOLUTION OT SOL HDI ML 1.738500002216280 DESIPRAMINE 100 MG TABLET ORL TAB AAP TAB 0.968700001942417 DESITIN DIAPER RASH OINTMENT TOP ONT PDH G 0.058800002298155 DESLORATADINE ALLERGY CONTROL 5 MG TABLET ORL TAB PMS TAB 0.576900002239064 DETROL 1 MG TABLET ORL TAB PFI TAB 1.054700002239065 DETROL 2 MG TABLET ORL TAB PFI TAB 1.054700002204274 DEXAMETHASONE OMEGA 10 MG/ML INJECTION INJ DEFAUL OMG ML 1.394000002204266 DEXAMETHASONE OMEGA 4 MG/ML INJECTION INJ DEFAUL OMG ML 1.606000000832030 DEXIDIN 20 MG TOPICAL SOLUTION TOP LIQ ATL ML 0.036500002354950 DEXILANT 30 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.390700002354969 DEXILANT 60 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.390700000833231 DEXTROMETHORPHAN 15 MG/5 ML COUGH SYRUP ORL SYR TAN ML 0.019900002058235 DEY-PAK SODIUM CHLORIDE 0.9% INHALATION SOLUTION INH SOL MYP ML 0.061600002398958 DIACOMIT 250 MG CAPSULE ORL CAP BCF CAP 6.366700002398974 DIACOMIT 250 MG ORAL POWDER PACKET ORL PWDPKT BCF PCKT 6.366700002398966 DIACOMIT 500 MG CAPSULE ORL CAP BCF CAP 12.733300002398982 DIACOMIT 500 MG ORAL POWDER PACKET ORL PWDPKT BCF PCKT 12.733300002245391 DIAMINE TABLET ORL TAB EUP TAB 0.066300002233542 DIANE-35 2 MG/0.035 MG TABLET ORL TAB BHP TAB 1.745200002192667 DIARR-EZE 0.2 MG/ML ORAL LIQUID ORL LIQ PMS ML 0.087800002229552 DIARR-EZE 2 MG CAPLET ORL TAB PMS TAB 0.300000002248994 DIARRHEA RELIEF 2 MG TABLET ORL TAB PMS TAB 0.261700002238162 DIASTAT RECTAL DELIVERY SYS 5 MG/ML RECTAL GEL RT GEL DAX SYS 82.775000000434388 DIAZEPAM 10 MG TABLET ORL TAB PDL TAB 0.086700000313580 DIAZEPAM 5 TABLET ORL TAB PDL TAB 0.065000000870978 DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.202400002351684 DICLOFENAC POTASSIUM 50 MG TABLET ORL TAB SNS TAB 0.393700002224127 DICLOFENAC-SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.404800002224119 DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.234300000392820 DICYCLOMINE HCL 10 MG CAPSULE ORL CAP SDZ CAP 0.075800000392812 DICYCLOMINE HYDROCHLORIDE 10 MG/ML INJECTION INJ DEFAUL SDZ ML 4.308000002176017 DIDROCAL 400 MG/500 MG TABLET ORL TAB ASC TAB 0.494200002231592 DIFFERIN 0.1% TOPICAL CREAM TOP CRM GAL G 1.691800002148749 DIFFERIN 0.1% TOPICAL GEL TOP GEL GAL G 1.691800002274000 DIFFERIN XP 0.3% TOPICAL GEL TOP GEL GAL G 1.095700002387174 DIFICID 200 MG FILM-COATED TABLET ORL TAB OPL TAB 110.000000000627100 DILAUDID 2 MG/ML INJECTION INJ DEFAUL PUR ML 1.0832

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 29 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002085895 DILAUDID STERILE POWDER 250 MG/VIAL INJECTION INJ DEFAUL PUR VIAL 66.635000000622133 DILAUDID-HP 10 MG/ML INJECTION INJ DEFAUL PUR ML 2.651000002325306 DILTIAZEM TZ 120 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.404300002325314 DILTIAZEM TZ 180 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.536600002325322 DILTIAZEM TZ 240 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.711800002325330 DILTIAZEM TZ 300 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.889700002325349 DILTIAZEM TZ 360 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.073200002231472 DILTIAZEM-CD 120 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.352900002231474 DILTIAZEM-CD 180 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.468400002231475 DILTIAZEM-CD 240 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.621300002231057 DILTIAZEM-CD 300 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.776600002300648 DIMENHYDRINATE 50 MG/ML INJECTION INJ DEFAUL ALV ML 2.717000002244079 DIMETANE EXPECTORANT C ORAL SYRUP ORL SYR PDH ML 0.091900002244080 DIMETANE EXPECTORANT DC ORAL SYRUP ORL SYR PDH ML 0.124200002243083 DIMETAPP DAYTIME COLD EXTRA STRENGTH CAPLET ORL TAB WCH TAB 0.291300002243969 DIMETAPP DM COUGH & COLD ORAL LIQUID ORL LIQ PDH ML 0.054000002243091 DIMETAPP NIGHTTIME COLD EXTRA STRENGTH CAPLET ORL TAB WCH TAB 0.312500002244078 DIMETAPP-C ORAL SYRUP ORL SYR PDH ML 0.117800002243231 DIMETHYL SULFOXIDE IRRIGAT. 500 MG/G BLADDER SOL. BLDIR SOL SDZ ML 1.184000002027100 DIONEPHRINE 2.5% OPH SOLUTION OPH SOL DIO ML 0.718000002023717 DIOPHENYL-T OPH SOLUTION OPH SOL DIO ML 1.946700002023768 DIOPRED 1% OPH SUSPENSION OPH SUS SDZ ML 1.940000002270528 DIOVAN 40 MG TABLET ORL TAB NOV TAB 1.268200002157624 DIOVOL PLUS AF CHEWABLE TABLET ORL CTB CHD TAB 0.128400002157616 DIOVOL PLUS AF-SUSPENSION ORL SUS CHD ML 0.018300000116815 DIOVOL PLUS ORAL SUSPENSION ORL SUS CHD ML 0.018300000116882 DIOVOL PLUS TABLET ORL TAB CHD TAB 0.128400002369567 DIPHENHYDRAMINE HYDROCHLORIDE 50 MG/ML INJECTION INJ DEFAUL PPC ML 4.390000002219336 DIPHENIST 50 MG/ML INJECTION INJ DEFAUL OMG ML 4.100000000417262 DIPROGEN TOPICAL CREAM TOP CRM SCH G 0.855600002243961 DITROPAN XL 10 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.475400002243960 DITROPAN XL 5 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.475400002240341 DIVALPROEX-125 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.072400002240342 DIVALPROEX-250 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.130100002240343 DIVALPROEX-500 MG ENTERIC-COATED TABLET ORL TAB PDL TAB 0.260400000579955 DOAK OIL 2% TOPICAL SOLUTION TOP SOL TCD ML 0.029600002228335 DOBUTAMINE HYDROCHLORIDE 12.5 MG/ML INJECTION INJ DEFAUL TEV VIAL 23.250000002412225 DOCETAXEL 28 MG/ML (20 MG/0.72 ML) INJECTION INJ DEFAUL TEV ML 317.319400002412233 DOCETAXEL 28 MG/ML (80 MG/2.88 ML) INJECTION INJ DEFAUL TEV ML 317.3194

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 30 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246741 DOCUSATE CALCIUM 240 MG CAPSULE ORL CAP ROG CAP 0.160300000870218 DOCUSATE SODIUM 10 MG/ML ORAL DROPS ORL DPS ROG ML 0.200800000794406 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP VTH CAP 0.033400000830267 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP TLI CAP 0.033800002245946 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP JPC CAP 0.039000002246036 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP ROG CAP 0.040500002246854 DOCUSATE SODIUM 4 MG/ML ORAL SYRUP ORL SYR ROG ML 0.026400000614491 DOLORAL 1 MG ORAL SYRUP ORL SYR ATL ML 0.031900000614505 DOLORAL 5 MG ORAL SYRUP ORL SYR ATL ML 0.054500002130963 DOM-AMANTADINE 100 MG CAPSULE ORL CAP DPC CAP 0.517900002246331 DOM-AMIODARONE 200 MG TABLET ORL TAB DPC TAB 0.617700002229468 DOM-ATENOLOL 100 MG TABLET ORL TAB DPC TAB 0.330600002229467 DOM-ATENOLOL 50 MG TABLET ORL TAB DPC TAB 0.201100002399482 DOM-ATORVASTATIN 10 MG TABLET ORL TAB DPC TAB 0.313700002399490 DOM-ATORVASTATIN 20 MG TABLET ORL TAB DPC TAB 0.392200002399504 DOM-ATORVASTATIN 40 MG TABLET ORL TAB DPC TAB 0.421600002138271 DOM-BACLOFEN 10 MG TABLET ORL TAB DPC TAB 0.159500002138298 DOM-BACLOFEN 20 MG TABLET ORL TAB DPC TAB 0.460700002232564 DOM-BUSPIRONE 10 MG TABLET ORL TAB DPC TAB 0.352100002238222 DOM-CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TAB ORL SRT DPC TAB 0.130100002238223 DOM-CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TAB ORL SRT DPC TAB 0.260200002247230 DOM-CLOBAZAM 10 MG TABLET ORL TAB DPC TAB 0.153800002130998 DOM-CLONAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.069400002131013 DOM-CLONAZEPAM 2 MG TABLET ORL TAB DPC TAB 0.119600002224100 DOM-CLONAZEPAM-R 0.5 MG TABLET ORL TAB DPC TAB 0.069400002238633 DOM-CYCLOBENZAPRINE 10 MG TABLET ORL TAB DPC TAB 0.372700002130092 DOM-DESIPRAMINE 25 MG TABLET ORL TAB DPC TAB 0.272300002231662 DOM-DICLOFENAC 25 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.109400002231664 DOM-DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.406000002238315 DOM-DOMPERIDONE 10 MG TABLET ORL TAB DPC TAB 0.083100002376709 DOM-FINASTERIDE 5 MG TABLET ORL TAB DPC TAB 0.463300002246109 DOM-FLUCONAZOLE 100 MG TABLET ORL TAB DPC TAB 3.204700002246108 DOM-FLUCONAZOLE 50 MG TABLET ORL TAB DPC TAB 1.806500002177617 DOM-FLUOXETINE 10 MG CAPSULE ORL CAP DPC CAP 0.865000002177625 DOM-FLUOXETINE 20 MG CAPSULE ORL CAP DPC CAP 0.643800002241348 DOM-FLUVOXAMINE 100 MG TABLET ORL TAB DPC TAB 0.529700002241347 DOM-FLUVOXAMINE 50 MG TABLET ORL TAB DPC TAB 0.294700002243743 DOM-GABAPENTIN 100 MG CAPSULE ORL CAP DPC CAP 0.145600002243744 DOM-GABAPENTIN 300 MG CAPSULE ORL CAP DPC CAP 0.3542

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 31 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002243745 DOM-GABAPENTIN 400 MG CAPSULE ORL CAP DPC CAP 0.422100002241608 DOM-GEMFIBROZIL 300 MG CAPSULE ORL CAP DPC CAP 0.180300002234514 DOM-GLYBURIDE 5 MG TABLET ORL TAB DPC TAB 0.068300002239913 DOM-INDAPAMIDE 1.25 MG TABLET ORL TAB DPC TAB 0.104300002239917 DOM-INDAPAMIDE 2.5 MG TABLET ORL TAB DPC TAB 0.170600002372193 DOM-IRBESARTAN 150 MG TABLET ORL TAB DPC TAB 0.302500002245784 DOM-LORAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.035900002245785 DOM-LORAZEPAM 1 MG TABLET ORL TAB DPC TAB 0.038000002247232 DOM-LOVASTATIN 40 MG TABLET ORL TAB DPC TAB 1.257900002242726 DOM-METFORMIN 850 MG TABLET ORL TAB DPC TAB 0.118600002231122 DOM-METOPROLOL-L 100 MG TABLET ORL TAB DPC TAB 0.194100002231121 DOM-METOPROLOL-L 50 MG TABLET ORL TAB DPC TAB 0.087400002178729 DOM-NORTRIPTYLINE 10 MG CAPSULE ORL CAP DPC CAP 0.077200002178737 DOM-NORTRIPTYLINE 25 MG CAPSULE ORL CAP DPC CAP 0.156000002125145 DOM-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION ORL SUS DPC ML 0.052100002241285 DOM-OXYBUTYNIN 5 MG TABLET ORL TAB DPC TAB 0.150800002248447 DOM-PAROXETINE 10 MG TABLET ORL TAB DPC TAB 0.821000002248448 DOM-PAROXETINE 20 MG TABLET ORL TAB DPC TAB 0.632000002248449 DOM-PAROXETINE 30 MG TABLET ORL TAB DPC TAB 0.671400002238046 DOM-PINDOLOL 10 MG TABLET ORL TAB DPC TAB 0.325300002238047 DOM-PINDOLOL 15 MG TABLET ORL TAB DPC TAB 0.471800002231650 DOM-PINDOLOL 5 MG TABLET ORL TAB DPC TAB 0.190500002249758 DOM-PRAVASTATIN 40 MG TABLET ORL TAB DPC TAB 0.805700002243038 DOM-RANITIDINE 150 MG TABLET ORL TAB DPC TAB 0.180000002216949 DOM-SALBUTAMOL 1 MG/ML INHALATION SOLUTION INH SOL DPC ML 0.361800002245750 DOM-SERTRALINE 100 MG CAPSULE ORL CAP DPC CAP 0.420000002245748 DOM-SERTRALINE 25 MG CAPSULE ORL CAP DPC CAP 0.200400002245749 DOM-SERTRALINE 50 MG CAPSULE ORL CAP DPC CAP 0.400000002238635 DOM-SOTALOL 160 MG TABLET ORL TAB DPC TAB 0.162300002238634 DOM-SOTALOL 80 MG TABLET ORL TAB DPC TAB 0.296600002243749 DOM-TERAZOSIN 10 MG TABLET ORL TAB DPC TAB 0.618300002128969 DOM-TRAZODONE 100 MG TABLET ORL TAB DPC TAB 0.098900002128950 DOM-TRAZODONE 50 MG TABLET ORL TAB DPC TAB 0.055400002240321 DOM-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.676700002240823 DOM-ZOPICLONE 7.5 MG TABLET ORL TAB DPC TAB 0.468500002236857 DOMPERIDONE-10 10 MG TABLET ORL TAB PDL TAB 0.059400002416425 DONEPEZIL 10 MG TABLET ORL TAB PDL TAB 1.234000002416417 DONEPEZIL 5 MG TABLET ORL TAB PDL TAB 1.234000002230108 DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION INJ DEFAUL TEV ML 11.4000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 32 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000887064 DOXYTAB 100 MG TABLET ORL TAB PDL TAB 0.586000001929313 DRISTAN DECONGESTANT NASAL MIST SOLUTION NAS SOL PDH ML 0.326700001929372 DRISTAN LONG LASTING 0.05% NASAL MIST SOLUTION NAS SOL PDH ML 0.326700001929380 DRISTAN LONG LASTING MENTHOLATED 0.05% NASAL SPRAY NAS SPR PDH ML 0.326700000740861 DRIXORAL DESCONGESTANT 0.05% NASAL SOLUTION NAS SOL SCH ML 0.159300000298433 DRIXORAL SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.434000000342742 DRYSOL 20% TOPICAL SOLUTION TOP SOL SFD ML 0.462400002247208 DUKORAL ORAL SUSPENSION ORL SUS AVE DOSE 39.110000000003867 DULCOLAX 5 MG RECTAL SUPPOSITORY RT SUP BOE SUP 1.093300002292165 DUODOPA 20 MG/ML / 5MG/ML (100 ML) INTESTINAL GEL INTRA GEL ABV CAS 166.000000002239299 DUOFILM 40% TOPICAL PATCH TOP PTH MMH PTH 0.463300000370576 DUOFILM TOPICAL SOLUTION TOP SOL STI ML 0.541300002125706 DUOLUBE OPH OINTMENT OPH ONT BSH G 1.574300000656747 DUONALC E (MILD) 20% TOPICAL SOLUTION TOP SOL VCL ML 0.219600000490156 DUONALC E 47.5% TOPICAL SOLUTION TOP SOL VCL ML 0.219600002148633 DUOVENT UDV INHALATION SOLUTION INH SOL BOE ML 0.898000002275848 DURAGESIC MAT 75 (75 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 38.664000002275856 DURAGESIC MAT 100 (100 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 48.124000002334186 DURAGESIC MAT 12 (12 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 5.214000002275813 DURAGESIC MAT 25 (25 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 14.606000002275821 DURAGESIC MAT 50 (50 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 27.492000002373017 DURELA 100 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 1.238700002373025 DURELA 200 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 2.260300002373033 DURELA 300 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 3.281700002415534 DUREZOL 0.05% OPHTHALMIC EMULSION OPH EML ALC ML 5.400000000999010 DUROLANE DEFAUL DEV QMD ML 116.666700001947958 DUVOID 10 MG TABLET ORL TAB PAL TAB 0.323200001947931 DUVOID 25 MG TABLET ORL TAB PAL TAB 0.523500001947923 DUVOID 50 MG TABLET ORL TAB PAL TAB 0.689600002260638 EBIXA 10 MG TABLET ORL TAB LBC TAB 2.615300002381389 EDARBI 40 MG TABLET ORL TAB TAK TAB 1.295700002381397 EDARBI 80 MG TABLET ORL TAB TAK TAB 1.295700002397749 EDARBYCLOR 40 MG/12.5 MG TABLET ORL TAB TAK TAB 1.295700002397765 EDARBYCLOR 40 MG/25 MG TABLET ORL TAB TAK TAB 1.295700002397757 EDARBYCLOR 80 MG/12.5 MG TABLET ORL TAB TAK TAB 1.295700002370603 EDURANT 25 MG TABLET ORL TAB JAI TAB 15.582000080009719 EFAMOL 1000 MG CAPSULE ORL CAP FMD CAP 0.166700002349124 EFFIENT 10 MG TABLET ORL TAB LIL TAB 2.948300002209764 EGOZINC-HC RECTAL OINTMENT RT ONT PMS G 0.4487

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 33 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002210517 EGOZINC-HC RECTAL SUPPOSITORY RT SUP PMS SUP 0.607500002247238 ELIDEL 1 % TOPICAL CREAM TOP CRM VCL G 2.474200002248239 ELIGARD 10.2 MG/SYR INJECTION INJ NDL SAV SYR 343.580000002248240 ELIGARD 28.2 MG/SYR INJECTION INJ NDL SAV SYR 957.820000002248999 ELIGARD 35.8 MG/SYR INJECTION INJ NDL SAV SYR 1381.590000002268892 ELIGARD 56.3 MG/SYR INJECTION INJ NDL SAV SYR 1575.640000000627410 ELIXIR DE THEOPHYLLINE ORL ELX ATL ML 0.004900002296284 ELOXATIN 5 MG/ML INJECTION INJ DEFAUL SAV ML 51.816000002103109 ELTOR-120 120 MG SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.295800002237355 EMADINE 0.05% OPH SOLUTION OPH SOL ALC ML 3.666000002298805 EMEND 125 MG CAPSULE ORL CAP MFC CAP 33.223300002324679 EMEND IV 115MG/VIAL INJ DEFAUL MFC VIAL 30.180000000886858 EMLA TOPICAL CREAM TOP CRM AZC G 1.978000002057794 EMLA TOPICAL PATCH TOP PTH AZC PTH 2.905000080008611 EMPOWER 18 PLUS CAPSULE ORL CAP TRU CAP 0.302500002248209 ENCA 100 MG CAPSULE ORL CAP PRP CAP 1.033200002248208 ENCA 50 MG CAPSULE ORL CAP PRP CAP 0.535000002334992 ENDOMETRIN 100 MG VAGINAL EFFERVESCENT TABLET VAG EVT FEI TAB 4.346700002296454 ENGERIX-B 10 MCG/0.5 ML SUSPENSION INJ DEFAUL GSK ML 22.520000002010526 ENTERIC COATED ASA 325 MG TABLET ORL ECT WTR TAB 0.028000000794244 ENTERIC COATED ASA 650 MG TABLET ORL ECT VTH TAB 0.055000002246971 ENTEX LA SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.423800001905392 ENTROPHEN 10 SUPER EXTRA STRENGTH 650 MG ECCPT ORL ECT PPH TAB 0.070500000852015 ENTROPHEN 500 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.068600002050161 ENTROPHEN REGULAR STRENGTH (CAPLET) 325 MG ECCPT ORL ECT PPH TAB 0.053100000010332 ENTROPHEN REGULAR STRENGTH 325 MG ECT ORL ECT PPH TAB 0.053100000880183 EPI-LYT TOP LOT VLP ML 0.106900000721891 EPINEPHRINE 1 MG/ML INJECTION USP INJ NDL HSP SYR 4.184000002264927 EPIRUBICIN HYDROCHLORIDE 2 MG/ML INJECTION INJ DEFAUL HSP ML 13.319600002396971 EPURIS 10 MG CAPSULE ORL CAP CIP CAP 1.163700002396998 EPURIS 20 MG CAPSULE ORL CAP CIP CAP 1.567300002397005 EPURIS 30 MG CAPSULE ORL CAP CIP CAP 1.971300002397013 EPURIS 40 MG CAPSULE ORL CAP CIP CAP 2.374700002243801 EQUATE DAILY LOW-DOSE 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.109600002271249 ERBITUX 2 MG/ML INJECTION INJ DEFAUL BMS ML 6.700000080003615 ERDOL 8288 IU/ML ORAL SOLUTION ORL SOL ODN ML 0.425700002409267 ERIVEDGE 150 MG CAPSULE ORL CAP HLR CAP 294.223800002034506 ERYSOL TOPICAL (ALCOHOL) GEL TOP ALCGEL GSK G 0.700400002393751 ESBRIET 267 MG CAPSULE ORL CAP INC CAP 12.7679

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 34 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002394839 ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT PDL TAB 1.588700002394847 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT PDL TAB 1.588700002244990 ESSENTIAL VITAMINS AND MINERALS TABLET ORL TAB WNP TAB 0.021400002237515 ESTER C 1000 MG TABLET ORL TAB SIS TAB 0.172700002247480 ESTER-C 250 MG CHEWABLE TABLET ORL CTB WNP TAB 0.086300080003499 ESTER-C CAPSULE ORL CAP BMD CAP 0.149600000756792 ESTRADERM-100 (8.0 MG/PTH) TOPICAL PATCH TRD PTH NOV PTH 4.011300000756849 ESTRADERM-25 (2 MG/PTH) TOPICAL PATCH TRD PTH NOV PTH 3.323800000727369 ESTRAGYN 1MG/G VAGINAL CREAM VAG CRM TPI G 0.641600000247960 ETIBI 100 MG TABLET ORL TAB VCL TAB 0.217300000247979 ETIBI 400 MG TABLET ORL TAB VCL TAB 0.652000002080036 ETOPOSIDE 20 MG/ML INJECTION INJ DEFAUL TEV ML 15.000000000637726 EUFLEX 250 MG TABLET ORL TAB MFC TAB 1.413100000720941 EUGLUCON 5 MG TABLET ORL TAB PMS TAB 0.115000080013021 EUPHORBIUM COMPOSITUM SN ORAL DROPS ORL DPS HEE ML 0.765000000623377 EURAX 10% TOPICAL CREAM TOP CRM CLC G 0.394200002242291 EURO - K8 600 MG SUSTAINED-RELEASE CAPSULE ORL SRC EUP CAP 0.061400002303825 EURO DOCUSATE C 100 MG CAPSULE ORL CAP EUP CAP 0.034400002245668 EURO-CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP ORL SYR EUP ML 0.067800002242651 EURO-D VITAMIN D3 400 IU CAPSULE ORL CAP EUP CAP 0.031700002247385 EURO-DOCUSATE 100 MG CAPSULE ORL CAP EUP CAP 0.032800002237556 EURO-FER 300 MG CAPSULE ORL CAP EUP CAP 0.153700002241802 EURO-FER CF CAPSULE ORL CAP EUP CAP 0.245700002412926 EURO-HYDROCORTISONE 1% CREAM TOP CRM EUP G 0.098900002247383 EURO-LAC 667 MG/ML SOLUTION ORL SOL EUP ML 0.015200002247389 EURO-SENNA 8.6 MG TABLET ORL TAB EUP TAB 0.046400002247390 EURO-SENNA S 8.6 MG/50 MG TABLET ORL TAB EUP TAB 0.119200002264374 EUTHYROX 100 MCG TABLET ORL TAB SRO TAB 0.030600002264390 EUTHYROX 112 MCG TABLET ORL TAB SRO TAB 0.064400002264404 EUTHYROX 125 MCG TABLET ORL TAB SRO TAB 0.065400002264412 EUTHYROX 137 MCG TABLET ORL TAB SRO TAB 0.114800002264420 EUTHYROX 150 MCG TABLET ORL TAB SRO TAB 0.033900002264439 EUTHYROX 175 MCG TABLET ORL TAB SRO TAB 0.069900002264447 EUTHYROX 200 MCG TABLET ORL TAB SRO TAB 0.035900002264323 EUTHYROX 25 MCG TABLET ORL TAB SRO TAB 0.056400002264455 EUTHYROX 300 MCG TABLET ORL TAB SRO TAB 0.078500002264331 EUTHYROX 50 MCG TABLET ORL TAB SRO TAB 0.024900002264358 EUTHYROX 75 MCG TABLET ORL TAB SRO TAB 0.061000002264366 EUTHYROX 88 MCG TABLET ORL TAB SRO TAB 0.0610

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 35 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080005494 EVENING PRIMROSE OIL SOFTGEL CAPSULE ORL CAP WNP CAP 0.082200002248297 EVRA 6 MG/0.6 MG TRANSDERMAL PATCH TRD PTH JAI PTH 5.976700002237524 EX-LAX EXTRA STRENGHT 25 MG TABLET ORL TAB NVC TAB 0.254200002377179 EXACT ANTI-NAUSEANT 50 MG TABLET ORL TAB APX TAB 0.062700002243896 EXACT DAILY LOW-DOSE ASA 81 MG ENTERIC-COATED TAB ORL ECT PMS TAB 0.133000001990675 EXCEDRIN EXTRA-STRENGTH CAPLET ORL TAB NVC TAB 0.076700002302853 EXELON PATCH 10 (9.5 MG/24 H) TRD PTH NOV PTH 4.893300002302845 EXELON PATCH 5 (4.6 MG/24 H) TRD PTH NOV PTH 4.888000002184672 EXOREX 1% TOPICAL GEL TOP GEL YNG ML 0.225000002184680 EXOREX 2% TOPICAL GEL TOP GEL YNG ML 0.225000000813095 EXPECTORANT COUGH FORMULA 100 MG/5 ML ORAL SYRUP ORL SYR TAN ML 0.019900002315955 EXTRA STRENGTH ALLERGY RELIEF 10 MG TABLET ORL TAB PMS TAB 0.189000002242632 EXTRA STRENGTH MOTRIN IB 300 MG TABLET ORL TAB MCL TAB 0.141500002244142 EXTRA STRENGTH NIGHTTIME COLD RELIEF TABLET ORL TAB PPH TAB 0.128300000707937 EYE-STREAM EYE LIQUID OPH LIQ ALC ML 0.097000000889806 EYELUBE .5% OPH DROPS OPH DPS SDZ ML 0.309300000874965 EYELUBE 1% OPH DROPS OPH DPS SDZ ML 0.384000002415992 EYLEA 2 MG/VIAL INJECTION INJ DEFAUL BHP VIAL 1540.870000002248968 FACTIVE 320 MG TABLET ORL TAB ABB TAB 7.524000002247745 FAMOTIDINE OMEGA-(W PRES,BENZYL ALC) 10 MG/ML INJ INJ DEFAUL OMG ML 1.400000002247735 FAMOTIDINE OMEGA-(W/O PRESERVATIVE) 10 MG/ML INJ INJ DEFAUL OMG ML 2.350000002379910 FAMPYRA 10 MG SUSTAINED-RELEASE TABLET ORL SRT BIO TAB 9.967300002229110 FAMVIR 125 MG TABLET ORL TAB NOV TAB 3.146000002229129 FAMVIR 250 MG TABLET ORL TAB NOV TAB 4.220700002177102 FAMVIR 500 MG TABLET ORL TAB NOV TAB 7.615200002248624 FASLODEX 250 MG/5 ML INJECTION INJ NDL AZC SYR 606.350000002231384 FEMARA 2.5 MG TABLET ORL TAB NOV TAB 6.733000002242531 FEMHRT 1/5 TABLET ORL TAB PFI TAB 0.840000002240360 FENO-MICRO-200 MG CAPSULE ORL CAP PDL CAP 0.272300002395703 FENTANYL 100 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 12.052000002395657 FENTANYL 12 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 2.348000002395665 FENTANYL 25 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 3.660000002395673 FENTANYL 50 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 6.884000002395681 FENTANYL 75 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 9.682000000888346 FENTANYL CITRATE 50 MCG/ML INJECTION INJ DEFAUL HSP ML 1.755000002126648 FENTANYL CITRATE 50 MCG/ML INJECTION INJ DEFAUL MNP ML 1.500000002240434 FENTANYL CITRATE 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 2.135600002384124 FENTANYL CITRATE SDZ 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 1.965000002377217 FERAHEME 30 MG/ML INJECTION INJ DEFAUL TAK ML 11.8566

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 36 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080033717 FERAMAX 15 MG POWDER ORL PWR BIS G 0.216900080013210 FERAMAX 150 150 MG CAPSULE ORL CAP BIS CAP 0.486000000232599 FERMALAC VAGINAL CAPSULE VAG CAP ROG CAP 1.931000002246590 FERRATE 20 MG/ML ORAL SUSPENSION ORL SUS EUP ML 0.085800002243333 FERRLECIT 12.5 MG/ ML INJECTION INJ DEFAUL SAV ML 5.535600002138751 FERROUS FUMARATE 200 MG TABLET ORL TAB VTH TAB 0.020900000031089 FERROUS FUMARATE 300 MG TABLET ORL TAB WAM TAB 0.128900000031097 FERROUS GLUCONATE 300 MG TABLET ORL TAB WAM TAB 0.022400002244532 FERROUS GLUCONATE 300 MG TABLET ORL TAB PMT TAB 0.040000000582727 FERROUS GLUCONATE 324 MG TABLET ORL TAB VTH TAB 0.027700002245389 FERROUS GLUCONATE 35 MG TABLET ORL TAB WNP TAB 0.078500000346918 FERROUS SULFATE 300 MG TABLET ORL TAB PMT TAB 0.038500000782114 FERROUS SULFATE 300 MG TABLET ORL TAB WTR TAB 0.034600080005803 FIBER PLUS CAPSULE ORL CAP PLT CAP 0.200000002207230 FIBRE LAXATIVE 3.4 G/12 G ORAL POWDER ORL PWR PRI G 0.006000002408163 FIBRISTAL 5 MG TABLET ORL TAB ASC TAB 12.453000002337037 FIRMAGON 120 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 405.500000002337029 FIRMAGON 80 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 300.000000001926853 FLAGYL 500 MG CAPSULE ORL CAP SAV CAP 1.154800000323098 FLAMAZINE 1% TOPICAL CREAM TOP CRM SNE G 0.301400080000193 FLAX SEED OIL ORL LIQ HHC CAP 0.041000002149133 FLAX SEED OIL 500 MG CAPSULE ORL CAP JAM CAP 0.066200080000580 FLAXSEED OIL 1000 MG SOFTGEL ORL CAP PMT CAP 0.093700080000840 FLAXSEED OIL LIQUID ORL LIQ VML ML 0.042200002206218 FLEET PHOSPO-SODA ORAL LIQUID ORL LIQ JJM ML 0.083800080021934 FLINTSTONES MULTI VITAMINS COMPLETE CHEWABLE TAB ORL CTB BAI TAB 0.137000002230845 FLOLAN 0.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 18.640000002230848 FLOLAN 1.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 37.270000002213672 FLONASE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM GSK DOSE 0.281300080011335 FLORASMART TABLET ORL TAB RLC TAB 0.542100080013321 FLORASTOR 250 MG CAPSULE ORL CAP BCX CAP 1.101000002244405 FLORAZOLE ER 750 MG EXTENDED-RELEASE TABLET ORL ERT FEI TAB 2.070000002237245 FLOVENT DISKUS 100 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.433300002237244 FLOVENT DISKUS 50 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.274000002248443 FLUCONAZOLE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 0.469500002247749 FLUCONAZOLE OMEGA 2 MG/ML INJECTION INJ DEFAUL OMG ML 0.366000002246226 FLUDARA 10 MG TABLET ORL TAB GZM TAB 43.548500002249561 FLUMAZENIL 0.1 MG/ML INJECTION INJ DEFAUL SDZ ML 5.476800002352621 FLUMIST INFLUENZA VACCINE NASAL SPRAY NAS SPR AZC ML 77.4000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 37 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001977857 FLUOR A DAY 1.1 MG CHEWABLE TABLET ORL CTB PMS TAB 0.092200002090139 FLUOR-A-DAY 0.56 MG CHEWABLE TABLET ORL CTB PMS TAB 0.089600000012882 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL VCL ML 1.463000002182742 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL MNP ML 2.037600002331721 FLUPENTIXOL DECANOATE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 26.750000002242570 FLUPHENAZINE OMEGA 100 MG/ML INJECTION INJ DEFAUL OMG ML 29.780000002239636 FLUPHENAZINE OMEGA 25 MG/ML INJECTION INJ DEFAUL OMG ML 4.980000000578479 FLURAZEPAM 15 MG CAPSULE ORL CAP PDL CAP 0.067500000578487 FLURAZEPAM 30 MG CAPSULE ORL CAP PDL CAP 0.077500002015986 FLUVIRAL S/F SPLIT-VIRION INFLUENZA VACCINE INJ INJ DEFAUL IAF ML 16.000000002236754 FLUVOXAMINE 100 MG TABLET ORL TAB PDL TAB 0.378300002236753 FLUVOXAMINE 50 MG TABLET ORL TAB PDL TAB 0.210500000247855 FML LIQUIFILM 0.1% OPH SUSPENSION OPH SUS ALL ML 3.212000080000549 FOLAPRO 0.8 MG TABLET ORL TAB MTG TAB 0.191600000318973 FOLIC ACID 1 MG TABLET ORL TAB JAM TAB 0.042200000647039 FOLIC ACID 1 MG TABLET ORL TAB VTH TAB 0.007900002048841 FOLIC ACID USP 1 MG TABLET ORL TAB PMT TAB 0.017100002254689 FORTEO 250 MCG/ML INJECTION INJ DEFAUL LIL ML 411.637500002241568 FORZA-10 TABLET ORL TAB EUP TAB 0.171000002201038 FOSAMAX 40 MG TABLET ORL TAB MFC TAB 4.074300002276429 FOSAVANCE 70 MG/2800 UNIT TABLET ORL TAB MFC TAB 5.022500002303000 FOSINOPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.217800002303019 FOSINOPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.261900002287188 FOSRENOL 1000 MG CHEWABLE TABLET ORL CTB SHB TAB 4.849000002287145 FOSRENOL 250 MG CHEWABLE TABLET ORL CTB SHB TAB 1.215000002287153 FOSRENOL 500 MG CHEWABLE TABLET ORL CTB SHB TAB 2.430200002287161 FOSRENOL 750 MG CHEWABLE TABLET ORL CTB SHB TAB 3.657100002377454 FRAGMIN 2,500 IU/ML INJECTION INJ DEFAUL PFI ML 4.078500002221799 FRISIUM 10 MG TABLET ORL TAB LUI TAB 0.477300002257084 FROVA 2.5 MG TABLET ORL TAB TMP TAB 15.265700002264625 FSME-IMMUN 2.4 MCG/0.5 ML INJECTION SYRINGE INJ NDL BAX SYR 51.000000002238578 FUCIDIN H TOPICAL CREAM TOP CRM LEO G 1.364300002243862 FUCITHALMIC 1% VISCOUS OPH DROPS (PRESERVED) OPH GEL LEO G 2.236000002243861 FUCITHALMIC 1% VISCOUS OPH DROPS (UNPRESERVED) OPH GEL LEO G 5.191700002360365 FUROSEMIDE 10MG/ML INJECTION INJ DEFAUL OMG ML 1.050000000496723 FUROSEMIDE 20 TABLET ORL TAB PDL TAB 0.037300000397792 FUROSEMIDE 40 MG TABLET ORL TAB PDL TAB 0.055800000667080 FUROSEMIDE-80 MG TABLET ORL TAB PDL TAB 0.122000002247725 FUZEON 108 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 42.7420

Page 38: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 38 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002388200 GABAPENTIN 600 MG TABLET ORL TAB SIV TAB 0.958000002388219 GABAPENTIN 800 MG TABLET ORL TAB SIV TAB 1.277300002416441 GALEXOS 150 MG CAPSULE ORL CAP JAI CAP 472.203900000512192 GARAMYCIN 3 MG/ML OPH SOLUTION OPH SOL MFC ML 0.406000000512184 GARAMYCIN 3 MG/ML OTIC SOLUTION OT SOL MFC ML 1.032000000682217 GARASONE 3 MG/ML / 1 MG/ML OTIC OPH SOLUTION OT/OPH SOL MFC ML 1.281300002283190 GARDASIL 0.5 ML INJECTION INJ DEFAUL MFC ML 308.060000000896675 GAS X EXTRA STRENGTH TABLET ORL TAB NVC TAB 0.255000002300761 GAS X ULTRA STRENGTH 180 MG CAPSULE ORL CAP NVC CAP 0.209300002159791 GAVISCON HEARTBURN RELIEF CHEWABLE TABLET ORL CTB SKB TAB 0.149500002231538 GAVISCON HEARTBURN RELIEF EXTRA STRENGTH TABLET ORL TAB SKB TAB 0.286100002159775 GAVISCON HEARTBURN RELIEF ORAL LIQUID - FRUIT ORL LIQ SKB ML 0.022000002280124 GD-AMLODIPINE 2.5 MG TABLET ORL TAB GMD TAB 0.138000002342235 GD-ELETRIPTAN 20 MG TABLET ORL TAB GMD TAB 10.958300002342243 GD-ELETRIPTAN 40 MG TABLET ORL TAB GMD TAB 10.958300002352818 GD-TERBINAFINE 250 MG TABLET ORL TAB GMD TAB 2.524300002352877 GD-TOPIRAMATE 100 MG TABLET ORL TAB GMD TAB 0.592800002352885 GD-TOPIRAMATE 200 MG TABLET ORL TAB GMD TAB 1.984500002352850 GD-TOPIRAMATE 25 MG TABLET ORL TAB GMD TAB 0.661500002028107 GEL-KAM 0.4% DENTAL GEL DEN GEL COL G 0.070500002366150 GELNIQUE 100 MG/G TOPICAL GEL TOP GEL ASC G 3.042700001945831 GELUSIL EXTRA STRENGTH CHEWABLE TABLET ORL CTB WLA TAB 0.148400001933906 GELUSIL TABLET ORL TAB WSP TAB 0.137000002324210 GEMCITABINE 1 G/VIAL INJECTION INJ DEFAUL AHI VIAL 265.000000002412292 GEMCITABINE 40 MG/ML INJECTION INJ DEFAUL SDZ ML 10.812000002136058 GEMFIBROZIL-600 MG TABLET ORL TAB PDL TAB 0.515700002230309 GEMZAR 1 G/ VIAL INJECTION INJ DEFAUL LIL VIAL 308.350000002230308 GEMZAR 200 MG/ VIAL INJECTION INJ DEFAUL LIL VIAL 65.670000002246047 GEN-NIZATIDINE 300 MG CAPSULE ORL CAP MYP CAP 0.958000080020663 GENESTRA BRAND HMF INTENSIVE PROBIOTIC ORL CAP SRL CAP 1.716600080008885 GENESTRA BRANDS D-MULSION ORL LIQ SRL ML 0.566300080034399 GENESTRA BRANDS DIGEST GLUTEN PLUS CAPSULE ORL CAP SRL CAP 0.314300002082144 GENTAMICIN (E) 1.2 MG/ML INJECTION INJ DEFAUL BAX ML 0.079400002082152 GENTAMICIN (E) 1.6 MG/ML INJECTION INJ DEFAUL BAX ML 0.089000002268531 GENTAMICIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 2.707000002148404 GENTAMICIN SULFATE 0.3% (BASE) OPH SOL (MINIMS) OPH SOL NVO ML 6.348300002082136 GENTAMICINE (E) 1 MG/ML INJECTION INJ DEFAUL BAX ML 0.046700002231289 GENTEAL 0.3% OPHTHALMIC DROPS OPH DPS ALC ML 0.449300002242977 GENTEAL 0.3% OPHTHALMIC GEL OPH GEL ALC ML 0.8420

Page 39: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 39 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002415666 GIOTRIF 20 MG TABLET ORL TAB BOE TAB 80.000000002415674 GIOTRIF 30 MG TABLET ORL TAB BOE TAB 80.000000002415682 GIOTRIF 40 MG TABLET ORL TAB BOE TAB 80.000000080003490 GLA 130 PRIMROSE OIL CAPSULE ORL CAP SRL CAP 0.443800002244725 GLEEVEC 100 MG CAPSULE ORL CAP NOV CAP 25.324000002253275 GLEEVEC 100 MG TABLET ORL TAB NOV TAB 29.759600002253283 GLEEVEC 400 MG TABLET ORL TAB NOV TAB 119.038300002248453 GLICLAZIDE-80 MG TABLET ORL TAB PDL TAB 0.093100002300451 GLUMETZA 1000 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.277000002268493 GLUMETZA 500 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 0.633500001959352 GLYBURIDE-2.5 MG TABLET ORL TAB PDL TAB 0.032100001926039 GLYCERIN RECTAL SUPPOSITORY RT SUP WSP SUP 0.160000000873462 GLYCERINE 90% RECTAL SUPPOSITORY USP RT SUP MCO SUP 0.085000080006852 GLYCINE ORAL POWDER ORL PWR AOR G 0.063900002229516 GLYCON 500 MG TABLET ORL TAB VCL TAB 0.128900002239214 GLYCON 850 MG TABLET ORL TAB VCL TAB 0.209000002382857 GLYCOPYRROLATE 0.2 MG/ML INJECTION INJ DEFAUL OMG ML 3.700000002382849 GLYCOPYRROLATE 0.2 MG/ML MULTIDOSE INJECTION INJ DEFAUL OMG ML 2.687500002247884 GLYQUIN XM TOPICAL CREAM TOP CRM VCL G 1.250000000652512 GOLYTELY POWDER FOR ORAL LAVAGE SOLUTION ORL PWR BAX G 0.004400002248156 GONAL-F 33 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 457.140000002248154 GONAL-F 5.5 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 77.020000002248157 GONAL-F 77 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 992.250000002270404 GONAL-F PEN 300 IU/0.5 ML INJECTION SYRINGE INJ NDL SRO SYR 304.760000002270390 GONAL-F PEN 450 IU/0.75 ML INJECTION SYRINGE INJ NDL SRO SYR 457.140000002270382 GONAL-F PEN 900 IU/1.5 ML INJECTION SYRINGE INJ NDL SRO SYR 914.290000002232483 GRAMCAL 1000 MG EFFERVESCENT TABLET ORL EVT NVC TAB 0.791500080006061 GRAPE SEED CAPLET ORL TAB JAM TAB 0.332200000116858 GRAVERGOL CAPSULE ORL CAP AXS CAP 1.010800002254409 GRAVOL 100 MG LONG ACTING SUSTAINED-RELEASE CAPLET ORL SRT CHD TAB 0.476200000511196 GRAVOL 15 MG CHEWABLE TABLET ORL CTB CHD TAB 0.262500000230197 GRAVOL 3 MG/ML ORAL LIQUID ORL SYR CHD ML 0.076400000013803 GRAVOL 50 MG TABLET ORL TAB CHD TAB 0.393800000013609 GRAVOL ADULT 100 MG RECTAL SUPPOSITORY RT SUP CHD SUP 0.581000000783595 GRAVOL CHILDREN 25 MG RECTAL SUPPOSITORIES RT SUP CHD SUP 0.536000002248180 GRAVOL GINGER LOZENGE ORL LOZ CHD LOZ 0.232500000013579 GRAVOL I.M. 50 MG/ML INJECTION INJ DEFAUL CHD ML 1.237000002245718 GRAVOL NATURAL SOURCE 500 MG TABLET ORL TAB CHD TAB 0.232500080014526 GREEN TEA PHYTOSOME COMPLEX CAPSULE ORL CAP JAM CAP 0.2280

Page 40: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 40 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080012417 GREENS+ BONE BUILDER ORAL POWDER ORL PWR GNH G 0.094800002384272 GUM PAROEX 0.12% ORAL RINSE ORL MWH SUA ML 0.015300002248417 GYNAZOLE 1 2% VAGINAL CREAM VAG CRM FEI G 3.450000002377438 HALAVEN 0.5 MG/ML INJECTION INJ DEFAUL EIS ML 270.000000000271691 HALIBUT LIVER OIL SUPER CAPSULE ORL CAP SWS CAP 0.032900000202061 HALIBUT LIVER OIL WITH VITAMIN D CAPSULE ORL CAP WAM CAP 0.026800002366010 HALOPERIDOL (PRESERVATIVE FREE) 5 MG/ML INJECTION INJ DEFAUL OMG ML 5.325000000587796 HALOPERIDOL 0.5 MG TABLET ORL TAB PDL TAB 0.036000002239640 HALOPERIDOL-LA 100 MG/ML INJECTION INJ DEFAUL OMG ML 13.690000002239639 HALOPERIDOL-LA OMEGA 50 MG/ML INJECTION INJ DEFAUL OMG ML 6.846000002187078 HAVRIX 1,440 U/ML INJECTION INJ DEFAUL GSK ML 47.800000002231056 HAVRIX JUNIOR 720 U/0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 23.910000000740578 HEPALEAN-LOK 100 IU/ML LOCK FLUSH INJECTION USP INJ LOCFLUSH ORG ML 0.327500000453781 HEPARIN LEO 25,000 IU/ML INJECTION INJ DEFAUL LEO ML 8.339000000725323 HEPARIN LOCK FLUSH 10 IU/ML INJECTION USP INJ LOCFLUSH HSP ML 0.228000000725315 HEPARIN LOCK FLUSH 100 IU/ML INJECTION USP INJ LOCFLUSH HSP ML 0.290000000640468 HEPARIN LOCK FLUSH SOLUTION 10 UNIT/ML INJECTION INJ LOCFLUSH ABB ML 1.205600002264315 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL PPC ML 2.600000002303086 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL SDZ ML 0.565000002382296 HEPARIN SODIUM 1,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 0.501000002382326 HEPARIN SODIUM 10,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 5.010000002382334 HEPARIN SODIUM 5,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 1.247000002303094 HEPARIN SODIUM(PRESERVAT FREE)10,000 IU/ML INJ USP INJ DEFAUL SDZ ML 5.727000002303108 HEPARIN SODIUM(WITH PRESERVAT)10,000 IU/ML INJ USP INJ DEFAUL SDZ ML 3.716000002239194 HEPTOVIR 5 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.230000002240692 HERCEPTIN 440 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2902.500000002245872 HEXIT 1% TOPICAL LOTION TOP LOT ODN ML 0.138000000430617 HEXIT 1.0% TOPICAL SHAMPOO TOP SHP ODN ML 0.138000002244784 HILL-VITE TABLET ORL TAB HIL TAB 0.132000000575178 HISTANTIL 25 MG TABLET ORL TAB PMS TAB 0.115800000575186 HISTANTIL 50 MG TABLET ORL TAB PMS TAB 0.195300001948903 HONEY BEE VENOM 1.1 MG INJ DEFAUL ALG VIAL 30.866700001948911 HONEY BEE VENOM 120 MCG INJ DEFAUL ALG VIAL 30.866700002241793 HONVOL 50 MG/ML INJECTION INJ DEFAUL ASM ML 2.998600002078759 HUMATIN 250 MG CAPSULE ORL CAP PFI CAP 2.895900000745626 HUMATROPE 1 MG/ML INJECTION INJ DEFAUL LIL VIAL 250.850000002243079 HUMATROPE 24 MG INJECTION INJ DEFAUL LIL VIAL 1217.130000000999015 HYALGAN DEFAUL DEV MDX ML 25.000000001916580 HYCODAN 1 MG/ML ORAL SYRUP ORL SYR BMS ML 0.1314

Page 41: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 41 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001916599 HYCODAN 5 MG TABLET ORL TAB DPM TAB 1.138800001916564 HYCOMINE ORAL SYRUP ORL SYR DPM ML 0.216500001916521 HYCOMINE-S PEDIATRIC ORAL SYRUP ORL SYR DPM ML 0.189500002231476 HYDRASENSE NASAL SOLUTION NAS SOL SCH ML 0.076600000465283 HYDREA 500 MG CAPSULE ORL CAP BMS CAP 1.108700000341975 HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PDL TAB 0.015700002242930 HYDROCORTISONE ACETATE 0.5% TOPICAL CREAM TOP CRM TAR G 0.084600002244797 HYDROMORPHONE HP FORTE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 53.246000000564281 HYDROSONE 0.5% CREAM TOP CRM RPH G 0.134700002343096 HYDROXYUREA 500 MG CAPSULE ORL CAP SNS CAP 1.020300002229868 HYOSCINE BUTYLBROMIDE 20 MG/ML INJECTION INJ DEFAUL SDZ ML 4.906000002230697 HYPERTET S/D 250 IU/SYR INJECTION INJ DEFAUL GRL SYR 78.000000002133253 HYPOTEARS 1% OPH SOLUTION OPH SOL ALC ML 0.414700002133288 HYPOTEARS 85%/15% EYE OINTMENT OPH ONT ALC G 1.588600002275864 HYPURIN NPH INSULIN ISOPHANE PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.240000002275872 HYPURIN REGULAR INSULIN PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.240000080022866 IBEROGAST ORAL SOLUTION ORL SOL STA ML 0.195100002257912 IBUPROFEN 200 MG TABLET ORL TAB PMT TAB 0.049800002317338 IBUPROFEN 400 MG CAPLET ORL TAB PMT TAB 0.039200000636533 IBUPROFEN 400 MG TABLET ORL TAB PDL TAB 0.037200002183862 IMODIUM 2 MG CAPLET ORL TAB MCL TAB 0.773300002376016 IMODIUM 2 MG CAPSULE ORL CAP MCL CAP 0.773300002245185 IMODIUM ADVANCED CAPLET ORL TAB MCL TAB 0.928000002237297 IMODIUM ADVANCED CHEWABLE TABLET ORL CTB MCL TAB 0.928000002230542 IMODIUM QUICK DISSOLVE 2 MG TABLET ORL TAB MCL TAB 0.838000001959042 IMOVAX POLIO INJECTION SYRINGE INJ NDL SFP SYR 46.200000001908286 IMOVAX RABIES VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL SFP VIAL 211.670000002240713 IMUNOVIR 500 MG TABLET ORL TAB RIP TAB 1.950900002244895 IMURAN 50 MG/VIAL INJECTION INJ DEFAUL TPI VIAL 96.060000002042266 INDERAL-LA 120 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 1.058700002042274 INDERAL-LA 160 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 1.252100002042231 INDERAL-LA 60 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.609800002042258 INDERAL-LA 80 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.687600002046059 INFANTS' TYLENOL 80 MG/ML ORAL SUSPENSION DROPS ORL DPS MCL ML 0.296000002269562 INFLUVAC VACCINE INJECTION SYRINGE INJ DEFAUL ABB SYR 9.300000002389630 INLYTA 1 MG TABLET ORL TAB PFI TAB 19.995000002389649 INLYTA 5 MG TABLET ORL TAB PFI TAB 99.975000080013031 INNO-Q-NOL 100 MG SOFT GEL CAPSULE ORL CAP INN CAP 1.132500002323052 INSPRA 25 MG TABLET ORL TAB PFI TAB 2.8400

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 42 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002323060 INSPRA 50 MG TABLET ORL TAB PFI TAB 2.840000000762040 INSTA-GLUCOSE (1 DOSE PER TUBE) ORAL LIQUID ORL LIQ VCL DOSE 4.036700080026628 INSTAFLEX JOINT SUPPORT CAPSULE ORL CAP DDI CAP 0.333200002348756 INTANZA INJECTION SYRINGE INJ DEFAUL SFP SYR 12.900000002306778 INTELENCE 100 MG TABLET ORL TAB JAI TAB 6.308600002375931 INTELENCE 200 MG TABLET ORL TAB JAI TAB 12.226000002238675 INTRON A 10 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 131.420000002223406 INTRON A 10,000,000 UNIT/VIAL INJECTION INJ DEFAUL MFC ML 125.200000002238674 INTRON A 6 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 72.563300002240693 INTRON A MULTI-DOSE PEN 15 MIU/ML INJECTION SYR INJ NDL MFC SYR 236.550000002240694 INTRON A MULTI-DOSE PEN 25 MIU/ML INJECTION SYR INJ NDL MFC SYR 394.210000002240695 INTRON A MULTI-DOSE PEN 50 MIU/ML INJECTION SYR INJ NDL MFC SYR 780.030000002409100 INTUNIV XR 1 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.260000002409119 INTUNIV XR 2 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.966300002409127 INTUNIV XR 3 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 4.672600002409135 INTUNIV XR 4 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 5.378900002216965 INVIRASE 200 MG CAPSULE ORL CAP HLR CAP 2.026500002279320 INVIRASE 500 MG TABLET ORL TAB HLR TAB 4.676600000888354 IOPIDINE 1% OPH SOLUTION (UNIT DOSE) OPH SOL ALC ML 62.375000002246084 IPRAVENT 0.06% NASAL SPRAY NAS SPR AAP ML 1.619300002365200 IRBESARTAN 150 MG TABLET ORL TAB PDL TAB 0.342500002365219 IRBESARTAN 300 MG TABLET ORL TAB PDL TAB 0.342500002365197 IRBESARTAN 75 MG TABLET ORL TAB PDL TAB 0.342500002365162 IRBESARTAN-HCTZ 150 MG/12.5 MG TABLET ORL TAB PDL TAB 0.342500002365170 IRBESARTAN-HCTZ 300 MG/12.5 MG TABLET ORL TAB PDL TAB 0.342500002365189 IRBESARTAN-HCTZ 300 MG/25 MG TABLET ORL TAB PDL TAB 0.338400002248676 IRESSA 250 MG TABLET ORL TAB AZC TAB 73.300000002301881 ISENTRESS 400 MG TABLET ORL TAB MFC TAB 14.669800000897639 ISOPROTERENOL HYDROCHLORIDE 0.2 MG/ML INJECTION INJ DEFAUL SDZ ML 5.444000000000655 ISOPTO CARBACHOL 1.5% OPH SOLUTION OPH SOL ALC ML 0.704700000000663 ISOPTO CARBACHOL 3% OPH SOLUTION OPH SOL ALC ML 0.848000000000809 ISOPTO TEARS 0.5% OPH DROPS OPH DPS ALC ML 0.536700000000817 ISOPTO TEARS 1.0% OPH DROPS OPH DPS ALC ML 0.536700000272655 ISOTAMINE 300 MG TABLET ORL TAB VCL TAB 0.089900002333279 IXIARO 6 MCG/0.5ML INJECTION SYRINGE INJ NDL NOV SYR 210.000000002388014 JAKAVI 15 MG TABLET ORL TAB NOV TAB 88.356200002388022 JAKAVI 20 MG TABLET ORL TAB NOV TAB 88.356200002388006 JAKAVI 5 MG TABLET ORL TAB NOV TAB 88.356200002372010 JALYN 0.5 MG/0.4 MG MODIFIED RELEASE CAPSULE ORL MRC GSK CAP 1.8007

Page 43: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 43 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002388308 JAMP-ACET-TRAMADOL 37.5 MG/325 MG TABLET ORL TAB JPC TAB 0.626400002246039 JAMP-BISACODYL 5 MG TABLET ORL TAB JPC TAB 0.045000002415550 JAMP-CLOPIDOGREL 75 MG TABLET ORL TAB JPC TAB 0.657600002373823 JAMP-COLCHICINE 0.6 MG TABLET ORL TAB JPC TAB 0.256500002391619 JAMP-DICYCLOMINE HCL 10 MG TABLET ORL TAB JPC TAB 0.122600002366088 JAMP-DICYCLOMINE HCL 20 MG TABLET ORL TAB JPC TAB 0.220700002283220 JAMP-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP ORL SYR JPC ML 0.920300000031100 JAMP-FERROUS SULFATE 300 MG TABLET ORL TAB JPC TAB 0.067500002366061 JAMP-FOLIC ACID 5 MG TABLET ORL TAB JPC TAB 0.041700002402289 JAMP-GABAPENTIN 600 MG TABLET ORL TAB JPC TAB 1.304500002402297 JAMP-GABAPENTIN 800 MG TABLET ORL TAB JPC TAB 1.739300002401290 JAMP-IBUPROFEN 400 MG TABLET ORL TAB JPC TAB 0.047400080023817 JAMP-K-CITRATE 10 MEQ TABLET ORL SRT JPC TAB 0.162600080041590 JAMP-MAGNESIUM 100 MG TABLET ORL TAB JPC TAB 0.263200002420414 JAMP-ONDANSETRON 2 MG/ ML PRESERVATIVE FREE INJ INJ DEFAUL JPC ML 3.455200002420422 JAMP-ONDANSETRON 2 MG/ ML PRESERVATIVE INJECTION INJ DEFAUL JPC ML 3.455200002408414 JAMP-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT JPC TAB 1.275000002397307 JAMP-PIOGLITAZONE 15 MG TABLET ORL TAB JPC TAB 0.580900002365529 JAMP-PIOGLITAZONE 30 MG TABLET ORL TAB JPC TAB 0.813900002365537 JAMP-PIOGLITAZONE 45 MG TABLET ORL TAB JPC TAB 1.223700002420430 JAMP-PIP/TAZ 4 G/500 MG/VIAL INJECTION INJ DEFAUL JPC VIAL 12.110000002380617 JAMP-PYRANTEL PAMOATE 125 MG TABLET ORL TAB JPC TAB 0.940500080040279 JAMP-QUININE 200 MG CAPSULE ORL CAP JPC CAP 0.239000080040277 JAMP-QUININE 300 MG CAPSULE ORL CAP JPC CAP 0.375000002405687 JAMP-SILDENAFIL 100 MG TABLET ORL TAB JPC TAB 9.200000002405660 JAMP-SILDENAFIL 25 MG TABLET ORL TAB JPC TAB 9.007500002405679 JAMP-SILDENAFIL 50 MG TABLET ORL TAB JPC TAB 8.847500002331039 JAMP-SIMVASTATIN 10 MG TABLET ORL TAB JPC TAB 0.728700002331047 JAMP-SIMVASTATIN 20 MG TABLET ORL TAB JPC TAB 0.900500002331055 JAMP-SIMVASTATIN 40 MG TABLET ORL TAB JPC TAB 0.900500002331020 JAMP-SIMVASTATIN 5 MG TABLET ORL TAB JPC TAB 0.370400002331063 JAMP-SIMVASTATIN 80 MG TABLET ORL TAB JPC TAB 0.900500080034416 JAMP-SODIUM PHOSPHATE 0.891 G -2.4 G/5 ML SOLUTION ORL SOL JPC ML 0.094700002368625 JAMP-SOTALOL 160 MG TABLET ORL TAB JPC TAB 0.208700002352419 JAMP-TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE ORL SRC JPC CAP 0.546400002420287 JAMP-TOBRAMYCIN 40 MG/ ML INJECTION INJ DEFAUL JPC ML 2.725000002379007 JAMP-VITAMIN D 10000 UNIT TABLET ORL TAB JPC TAB 0.210000002421623 JAMP-ZOLMITRIPTAN 2.5 MG TABLET ORL TAB JPC TAB 4.605000002416794 JANUMET XR 50 MG/1000 MG EXTENDED-RELEASE TABLET ORL ERT MFC TAB 1.7252

Page 44: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 44 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002388839 JANUVIA 25 MG TABLET ORL TAB MFC TAB 3.183700002388847 JANUVIA 50 MG TABLET ORL TAB MFC TAB 3.183700002408295 JAYDESS 13.5 MG INTRAUTERINE INSERT IU INS BAI SYS 294.130000002048744 JE-VAX INJECTION INJ DEFAUL CNG VIAL 131.663300002403277 JENTADUETO 2.5 MG/1000 MG TABLET ORL TAB BOE TAB 1.449200002403250 JENTADUETO 2.5 MG/500 MG TABLET ORL TAB BOE TAB 1.449200002403269 JENTADUETO 2.5 MG/850 MG TABLET ORL TAB BOE TAB 1.449200002410818 JETREA 0.5 MG/VIAL INJECTION INJ DEFAUL ALC VIAL 3950.000000002369524 JEVTANA 40 MG/ML INJECTION INJ DEFAUL SAV VIAL 5800.000000002247344 JUNIOR STRENGTH MOTRIN 100 MG CHEWABLE TABLET ORL CTB MCL TAB 0.225000002337282 JURNISTA 16 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 5.004000002337290 JURNISTA 32 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 10.007000002337266 JURNISTA 4 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.250700002337274 JURNISTA 8 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.501300080011529 K-CITRA 2 MEQ/ML SOLUTION ORL LIQ SFD ML 0.034900002243768 K-CITRA POTASSIUM CITRATE 10 MEQ SRT ORL SRT SFD TAB 0.290100000713376 K-DUR 1500 MG SUSTAINED RELEASE TABLET ORL SRT MFC TAB 0.205200002412365 KADCYLA 20 MG/ML INJECTION POWDER FOR SOLUTION INJ DEFAUL HLR ML 430.000000002312301 KALETRA 100 MG/25 MG TABLET ORL TAB ABV TAB 2.999000002285533 KALETRA 200 MG/50 MG TABLET ORL TAB ABV TAB 5.997900002243644 KALETRA 80MG/20MG ORAL SOLUTION ORL SOL ABV ML 2.374000002397412 KALYDECO 150 MG TABLET ORL TAB VER TAB 420.000000000376167 KEMSOL 70% TOPICAL SOLUTION TOP SOL AXS ML 0.278600000224391 KETALAR 10 MG/ML INJECTION INJ DEFAUL ERF ML 1.738500000224405 KETALAR 50 MG/ML INJECTION INJ DEFAUL ERF ML 5.759000002246796 KETAMINE 50 MG/ML INJECTION USP INJ DEFAUL SDZ ML 5.435000002246795 KETAMINE HYDROCHLORIDE 10 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.787500002244947 KETOROLAC TROMETHAMINE 30 MG/ML INJECTION INJ DEFAUL PPC ML 5.335200002400871 KETOTIFEN 0.25 MG/ML OPH SOLUTION OPH SOL STM ML 4.600000080020666 KID'S LIQUID VITAMIN D 400 IU ORL LIQ WBP ML 0.141000001926438 KIDROLASE 10,000 UNIT/VIAL INJECTION INJ DEFAUL AVE VIAL 134.790000002269341 KIVEXA 600 MG/300 MG TABLET ORL TAB GSK TAB 25.665700001928783 KOFFEX SIROP 3 MG/ML ORAL SYRUP ORL SYR ROG ML 0.020900002389185 KOMBOGLYZE 2.5 MG/1000 MG TABLET ORL TAB BMS TAB 1.380000002389169 KOMBOGLYZE 2.5 MG/500 MG TABLET ORL TAB BMS TAB 1.380000002389177 KOMBOGLYZE 2.5 MG/850 MG TABLET ORL TAB BMS TAB 1.380000080022006 KRILL OIL SOFTGEL CAPSULE ORL CAP WBP CAP 0.229700002350580 KUVAN 100 MG TABLET ORL TAB BMI TAB 33.000000080004073 KYOLIC AGED GARLIC EXTRACT ORAL CAPLET ORL TAB WKG TAB 0.5991

Page 45: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 45 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002185881 KYTRIL 1 MG TABLET ORL TAB HLR TAB 10.946000002231689 LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION INJ DEFAUL SDZ ML 1.510500000210889 LACRI-LUBE OPH OINTMENT OPH ONT ALL G 2.154300002250624 LACRISERT 5 MG OPHTHALMIC INSERT OPH INS ATP DEV 3.362300080012831 LACTOBACILLUS ACIDOPHILUS & BIFIDUS ORL CAP SWS CAP 0.112300000468401 LAIT DE MAGNESIE ORL SUSP (MILK OF MAGNESIA) ORL SUS ATL ML 0.006900002243803 LAMICTAL 2 MG CHEWABLE TABLET ORL CTB GSK TAB 0.184700002366282 LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PDL CAP 0.600000000608734 LANSOYL JELLY 78% ORL GEL JOU G 0.049900002186926 LANSOYL SUGAR FREE JELLY 78% ORL GEL JOU G 0.046700000282081 LANVIS 40 MG TABLET ORL TAB GSK TAB 4.820400002018055 LARIAM 250 MG TABLET ORL TAB HLR TAB 4.920000002224690 LASIX 20 MG TABLET ORL TAB SAV TAB 0.087300002224704 LASIX 40 MG TABLET ORL TAB SAV TAB 0.130700002387786 LATUDA 120 MG TABLET ORL TAB SUN TAB 4.401000002422050 LATUDA 20 MG TABLET ORL TAB SUN TAB 4.080000002387751 LATUDA 40 MG TABLET ORL TAB SUN TAB 4.401000002413361 LATUDA 60 MG TABLET ORL TAB SUN TAB 4.252500002387778 LATUDA 80 MG TABLET ORL TAB SUN TAB 4.401000002415828 LEFLUNOMIDE 10 MG TABLET ORL TAB PDL TAB 2.643300002415836 LEFLUNOMIDE 20 MG TABLET ORL TAB PDL TAB 2.643300002418320 LEMTRADA 12 MG/1.2 ML INJECTION INJ DEFAUL GZS VIAL 9970.000000002338459 LETROZOLE 2.5 MG TABLET ORL TAB AHI TAB 3.061700002347997 LETROZOLE 2.5 MG TABLET ORL TAB TEV TAB 2.756000002402025 LETROZOLE 2.5 MG TABLET ORL TAB PDL TAB 1.378000002183005 LEUCOVORIN CALCIUM 10 MG/ML INJECTION INJ DEFAUL MNP ML 12.704000000004626 LEUKERAN 2 MG TABLET ORL TAB GSK TAB 1.559200002236840 LEVAQUIN 25 MG/ML INJECTION INJ DEFAUL JAI ML 2.289500002236839 LEVAQUIN 5 MG/ML INJECTION INJ DEFAUL JAI ML 0.457800002412829 LEVEMIR FLEXTOUCH 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 7.734000002250470 LEVITRA 10 MG TABLET ORL TAB BAI TAB 13.292500002250489 LEVITRA 20 MG TABLET ORL TAB BAI TAB 14.395000002250462 LEVITRA 5 MG TABLET ORL TAB BAI TAB 11.915000002245948 LEVOTHYROXINE SODIUM 0.5 MG/VIAL INJECTION INJ DEFAUL PPC VIAL 220.840000002243933 LEVULAN KERASTICK 20% TOPICAL SOLUTION TOP SOL DSP ML 149.444400002296187 LIDOCAINE HCL 2% INJECTION (BLOCK OR INFILTRATION) INJ LIQ ALV ML 1.050000000436208 LIDOCAINE HYDROCHLORIDE 2% INJECTION INJ DEFAUL HSP ML 5.934000002231147 LIDODAN ENDOTRACHEAL 10 MG/DOSE NON-AEROSOL SPRAY TOP SPR ODN DOSE 0.212600000874949 LIDOMYXIN OTIC LIQUID OT LIQ SDZ ML 0.5960

Page 46: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 46 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002243101 LIFE BRAND DAILY LOW DOSE ASA 81 MG ECT ORL ECT PMS TAB 0.159700080003212 LIFE BRAND ORAL LAXATIVE ORL LIQ HJS ML 0.092000000030732 LINCOCIN 300 MG/ML INJECTION INJ DEFAUL PFI ML 2.942000002269082 LIPIDIL EZ 145 MG TABLET ORL TAB FOU TAB 1.192700002269074 LIPIDIL EZ 48 MG TABLET ORL TAB FOU TAB 0.465700080006893 LIQUID CALCIUM WITH VITAMIN D ORL LIQ WBP ML 0.017600080001853 LIQUID GLUCOSAMINE ORL LIQ JAM ML 0.032300080007222 LIQUID OMEGA-3 PLUS VITAMIN A & D ORL LIQ WNP ML 0.098400002266695 LITHMAX 300 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.271100002131625 LIVOSTIN 0.5 MG/ML (BASE) OPH SUSPENSION OPH SUS NOV ML 5.136000002020017 LIVOSTIN 50 MCG PER DOSE NASAL SPRAY NAS SPR JAI ML 1.942700000074462 LOCACORTEN VIOFORM TOPICAL CREAM TOP CRM PAL G 0.993300002373955 LODALIS 625 MG TABLET ORL TAB VCL TAB 1.195300002417456 LOLO (28 DAY) TABLET ORL TAB WCC TAB 0.623600000590819 LOPRESOR 1.0 MG/ML INJECTION INJ DEFAUL NOV ML 1.316000002221810 LOPROX 1% TOPICAL LOTION TOP LOT VCL ML 0.542300002244692 LORATADINE 10 MG TABLET ORL TAB VTH TAB 0.444200002243278 LORAZEPAM 4 MG INJECTION USP INJ DEFAUL SDZ ML 4.672000002394383 LOSARTAN 100 MG TABLET ORL TAB PDL TAB 0.314700002394367 LOSARTAN 25 MG TABLET ORL TAB PDL TAB 0.314700002394375 LOSARTAN 50 MG TABLET ORL TAB PDL TAB 0.314700002394413 LOSARTAN-HCTZ 100 MG/25 MG TABLET ORL TAB PDL TAB 0.314700002119579 LOSEC 10 MG SUSTAINED-RELEASE CAPSULE ORL SRC AZC CAP 1.007900002321114 LOTEMAX 0.5% OPHTHALMIC SUSPENSION OPH SUS BSH ML 4.782000002179709 LOZIDE 1.25 MG TABLET ORL TAB SEV TAB 0.323700002239833 LUPRON DEPOT 30 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 1535.100000002242933 LUSTRA 4% TOPICAL CREAM TOP CRM MEI G 1.162000002242934 LUSTRA-AF TOPICAL CREAM TOP CRM MEI G 1.293000002046210 LUTREPULSE 0.8 MG/VIAL INJECTION INJ DEFAUL FEI VIAL 115.000000002269066 LUVERIS 75 IU/VIAL INJECTION INJ DEFAUL SRO VIAL 28.480000002366924 LUXIQ 0.12% TOPICAL FOAM TOP FOA GSK G 0.818400002268450 LYRICA 150 MG CAPSULE ORL CAP PFI CAP 2.502200002268477 LYRICA 225 MG CAPSULE ORL CAP PFI CAP 2.502200002268418 LYRICA 25 MG CAPSULE ORL CAP PFI CAP 0.894300002268485 LYRICA 300 MG CAPSULE ORL CAP PFI CAP 2.502200002268426 LYRICA 50 MG CAPSULE ORL CAP PFI CAP 1.402800002268434 LYRICA 75 MG CAPSULE ORL CAP PFI CAP 1.815200000463221 LYSODREN 500 MG TABLET ORL TAB BMS TAB 4.890500000466085 M-M-R II VIRUS VACCINE LIVE ATTENUATED INJECTION INJ DEFAUL MSD VIAL 32.1760

Page 47: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 47 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002244690 MAALOX ANTACID WITH ANTI-GAS EXTRA STRENGTH SUSP ORL SUS NVC ML 0.022800002244689 MAALOX ANTACID WITH ANTI-GAS ORAL SUSPENSION ORL SUS NVC ML 0.019600002238291 MAALOX QUICK DISSOVE EXTRA STR. CHEWABLE TABLET ORL TAB NVC TAB 0.111400002267225 MACUGEN 0.3 MG/SYR INJECTION SYRINGE INJ NDL PFI SYR 995.000000002068400 MAGNESIUM 100 MG TABLET ORL TAB JAM TAB 0.074200080025339 MAGNESIUM 250 MG TABLET ORL TAB WNP TAB 0.049100002040921 MAGNESIUM 50 MG TABLET ORL TAB JAM TAB 0.057700080005581 MAGNESIUM CITRATE 150 MG CAPSULE ORL CAP WBP CAP 0.079000080005079 MAGNESIUM COMPLEX 250 MG CAPLET ORL TAB JAM TAB 0.094900002247017 MAGNESIUM COMPLEX 250 MG TABLET ORL TAB JAM TAB 0.045000080013414 MAGNESIUM EXTRA STRENGTH 500 MG TABLET ORL TAB WNP TAB 0.079000080014800 MAGNESIUM PLUS CALCIUM POWDER FOR SUSPENSION ORL PWRSUS NCC G 0.097300000392618 MAGNESIUM SULFATE 20% INJECTION INJ DEFAUL SDZ ML 0.511700000602264 MAGNESIUM SULFATE 50% INJECTION USP INJ DEFAUL SDZ ML 1.645000002139499 MAGNESIUM SULFATE 500 MG/ML INJECTION USP INJ DEFAUL PPC ML 0.431000000202045 MAGNOLAX ORAL EMULSION ORL EML PPH ML 0.014500001927639 MAJEPTIL 10 MG (BASE) TABLET ORL TAB ERF TAB 0.544200002264935 MALARONE PEDIATRIC TABLET ORL TAB GSK TAB 1.686700002238151 MALARONE TABLET ORL TAB GSK TAB 5.062500002243459 MALTLEVOL-12 ORAL LIQUID ORL LIQ CHD ML 0.022200000499013 MANDELAMINE 500 MG TABLET ORL TAB PFI TAB 0.396600000899356 MANERIX 150 MG TABLET ORL TAB MED TAB 0.690800002166747 MANERIX 300 MG TABLET ORL TAB MED TAB 1.371200002371707 MAR-AMLODIPINE 2.5 MG TABLET ORL TAB MAR TAB 0.172600002379562 MAR-ANASTROZOLE 1 MG TABLET ORL TAB MAR TAB 3.328000002371871 MAR-CITALOPRAM 10 MG TABLET ORL TAB MAR TAB 0.143200002403870 MAR-DOMPERIDONE 10 MG TABLET ORL TAB MAR TAB 0.164600002373424 MAR-LETROZOLE 2.5 MG TABLET ORL TAB MAR TAB 3.061700002389118 MAR-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB ORL DISNTAB MAR TAB 6.962300002389126 MAR-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB ORL DISNTAB MAR TAB 7.590000002416557 MAR-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT MAR TAB 1.275000002411946 MAR-PAROXETINE 10 MG TABLET ORL TAB MAR TAB 1.043000002420457 MAR-RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB MAR CAP 0.127400002420481 MAR-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB MAR CAP 0.186200002420503 MAR-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB MAR CAP 0.855000002420465 MAR-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB MAR CAP 0.147000002420473 MAR-RAMIPRIL 5 MG CAPSULE ORL CAP/TAB MAR CAP 0.147000002388324 MAR-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MAR TAB 0.626400002399458 MAR-ZOLMITRIPTAN 2.5 MG TABLET ORL TAB MAR TAB 4.6050

Page 48: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 48 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002241918 MARCAINE 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 0.815600002241919 MARCAINE 5 MG/ML INJECTION INJ DEFAUL HSP ML 0.970400002305909 MARCAINE 5 MG/ML INJECTION INJ DEFAUL HSP ML 0.969600002241917 MARCAINE 7.5 MG/ML INJECTION INJ DEFAUL HSP ML 1.971800002241915 MARCAINE E 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 0.845400002241914 MARCAINE SPINAL 7.5 MG/ML INJECTION INJ DEFAUL HSP ML 12.722500000611190 MARINOL 2.5 MG CAPSULE ORL CAP ABB CAP 2.229200000611204 MARINOL 5 MG CAPSULE ORL CAP ABB CAP 4.458200000012750 MATULANE 50 MG CAPSULE ORL CAP SGM CAP 63.106400002244533 MAXILENE 4% TOPICAL CREAM TOP CRM RGR G 1.738000002245939 MAXILENE 5 % TOPICAL CREAM TOP CRM RGR G 1.590000002163632 MAXIPIME 1 G/VIAL INJECTION INJ DEFAUL TMD VIAL 17.765000002163640 MAXIPIME 2 G/VIAL INJECTION INJ DEFAUL TMD VIAL 35.525000002253550 MEDROXY-2.5 2.5 MG TABLET ORL TAB PDL TAB 0.041600002253577 MEDROXY-5 5MG TABLET ORL TAB PDL TAB 0.082300002322250 MEDROXYPROGESTERONE ACETATE 150 MG/ML INJECTION INJ DEFAUL SDZ ML 22.000000002244366 MEFLOQUINE 250 MG TABLET ORL TAB AAP TAB 4.015000002040891 MEGA-CAL CALCIUM W/ VITAMIN D 650 MG/200 UNIT CPT ORL TAB JAM TAB 0.102800002409623 MEKINIST 0.5 MG TABLET ORL TAB GSK TAB 77.937300002409658 MEKINIST 2 MG TABLET ORL TAB GSK TAB 311.750000080006449 MELATONIN TIMED RELEASED ORL TAB PLH TAB 0.055600002353156 MELOXICAM 15 MG TABLET ORL TAB SNS TAB 0.567000002353148 MELOXICAM 7.5 MG TABLET ORL TAB SNS TAB 0.491300002279924 MENACTRA A/C/Y/W-135 (0.5ML SINGLE-DOSE) INJECTION INJ DEFAUL SFP ML 239.060000002248649 MENINGITECTM (10 MCG/15 MCG) 0.5 ML INJECTION INJ DEFAUL AYE ML 139.800000002243820 MENJUGATE VACCINE (10 MCG/25 MCG) .5 ML INJECTION INJ DEFAUL NOV VIAL 96.710000000588490 MENOMUNE A/C/Y/W-135 (MULTI-DOSE) INJECTION INJ DEFAUL SFP VIAL 157.290000001959018 MENOMUNE A/C/Y/W-135 (SINGLE-DOSE) INJECTION INJ DEFAUL SFP VIAL 178.100000002283093 MENOPUR 75 IU/VIAL INJECTION INJ DEFAUL FEI VIAL 65.800000002347393 MENVEO 0.5 ML INJECTION INJ DEFAUL NOV ML 217.160000000725749 MEPERIDINE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 1.338000000725757 MEPERIDINE HYDROCHLORIDE 75 MG/ML INJECTION INJ DEFAUL SDZ ML 1.263000002415275 MERCAPTOPURINE 50 MG TABLET ORL TAB STM TAB 3.109200002378795 MEROPENEM 1G/VIAL INJECTION INJ DEFAUL SDZ VIAL 47.990000002378787 MEROPENEM 500 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 23.995000002047667 MERSYNDOL WITH CODEINE TABLET ORL TAB SAV TAB 0.227100002241615 METAMUCIL FIBRE APPLE CRISP 3.4 G/2 WAFERS ORL WAF PGI WAF 0.254500002174812 METAMUCIL FIBRE THERAPY 3.4 G/TSP ORAL POWDER ORL PWR PGI G 0.027400002247034 METAMUCIL FIBRE THERAPY CAPSULE ORL CAP PGI CAP 0.1235

Page 49: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 49 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002174782 METAMUCIL FIBRE THERAPY-SMOOTH TEXTURE-ORANGE S.F. ORL PWR PGI G 0.068200002174790 METAMUCIL SMOOTH TEXTURE-ORANGE 3 G/TBSP ORAL PWDR ORL PWR PGI G 0.016000002174804 METAMUCIL SMOOTH UNFLAVORED SUGAR FREE POWDER ORL PWR PGI G 0.032500002398427 METHOTREXATE (PRESERVED) 25 MG/ML INJECTION USP INJ DEFALT SDZ ML 8.370000002182971 METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION INJ DEFAUL MNP ML 7.875500002182947 METHOTREXATE SODIUM (UNPRESERVED) 10 MG/ML INJ INJ DEFAUL MNP ML 8.981000002230521 METHOXACET CAPLET ORL TAB RPH TAB 0.341700002236872 METHOXACET-C 1/8 CAPLET ORL TAB RPH TAB 0.615000000868868 METHOXISAL CAPLET ORL TAB RPH TAB 0.277200001966375 METHOXISAL-C 1/2 TABLET ORL TAB RPH TAB 1.035000001966367 METHOXISAL-C 1/4 TABLET ORL TAB RPH TAB 0.833500001941895 METHOXISAL-C 1/8 CAPLET ORL TAB RPH TAB 0.556100002326248 METHYLPHENIDATE 10 MG TABLET ORL TAB PDL TAB 0.126200002326256 METHYLPHENIDATE 20 MG TABLET ORL TAB PDL TAB 0.243500002326221 METHYLPHENIDATE 5 MG TABLET ORL TAB PDL TAB 0.094700002243563 METOCLOPRAMIDE OMEGA 5MG/ML INJECTION INJ DEFAUL OMG ML 1.025000002320037 METOJECT 10 MG/1 ML INJECTION SYRINGE INJ NDL MDX SYR 53.100000002320045 METOJECT 15 MG/1.5 ML INJECTION SYRINGE INJ NDL MDX SYR 58.700000002304767 METOJECT 20 MG/2 ML INJECTION SYRINGE INJ NDL MDX SYR 64.280000002320053 METOJECT 25 MG/2.5 ML INJECTION SYRINGE INJ NDL MDX SYR 69.880000002320029 METOJECT 7.5 MG/0.75 ML INJECTION SYRINGE INJ NDL MDX SYR 50.310000000648027 METOPROLOL-100 MG TABLET ORL TAB PDL TAB 0.125000000648019 METOPROLOL-50 MG TABLET ORL TAB PDL TAB 0.062400002351404 METOPROLOL SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.141500002351412 METOPROLOL SR 200 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.249900002092832 METROGEL 0.75% TOPICAL GEL TOP GEL GAL G 1.448800002248562 METRONIDAZOLE 500 MG CAPSULE ORL CAP AAP CAP 0.763700002323273 METVIX 16.8% TOPICAL CREAM TOP CRM GAL G 162.820000000795860 MEVACOR 20 MG TABLET ORL TAB MFC TAB 2.061000000795852 MEVACOR 40 MG TABLET ORL TAB MFC TAB 3.764700002085852 MICATIN 2% TOPICAL CREAM TOP CRM WSP G 0.384000002171775 MICONAZOLE 3 DAY OVULE TREATMENT VAG OVL VTH OVL 1.696600002091143 MICRO PLUS 4 CONCETRATE INJECTION INJ DEFAUL SDZ ML 2.527600002091135 MICRO PLUS 4 REGULAR STRENGTH INJECTION INJ DEFAUL SDZ ML 0.909000000787000 MICRO-ZN 5 MG/ML INJECTION INJ DEFAUL SDZ ML 2.404200002063905 MICROLAX MICRO RECTAL ENEMA RT ENM JJM ENM 1.295000000487805 MIDAMOR 5 MG TABLET ORL TAB OPI TAB 0.286000002240285 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.847600002242904 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL PPC ML 1.2440

Page 50: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 50 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002242905 MIDAZOLAM 5 MG/ML INJECTION INJ DEFAUL PPC ML 4.455500002382873 MIDAZOLAM INJECTION SDZ 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.847500002244622 MILRINONE LACTATE 1 MG/ML INJECTION INJ DEFAUL PPC ML 5.061000001935348 MINERAL OIL (HEAVY) ORL LIQ RBW ML 0.008800000485802 MINERAL OIL 100% ORAL LIQUID ORL LIQ RPH ML 0.012200002246500 MINIRIN 0.1 MG TABLET ORL TAB FEI TAB 1.436100002326477 MINT-PIOGLITAZONE 15 MG TABLET ORL TAB MPI TAB 0.580900002326485 MINT-PIOGLITAZONE 30 MG TABLET ORL TAB MPI TAB 0.813900002326493 MINT-PIOGLITAZONE 45 MG TABLET ORL TAB MPI TAB 1.223700002421321 MINT-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB MPI CAP 0.186200002421305 MINT-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB MPI CAP 0.147000002421313 MINT-RAMIPRIL 5 MG CAPSULE ORL CAP/TAB MPI CAP 0.147000002393085 MINT-SILDENAFIL 100 MG TABLET ORL TAB MPI TAB 9.200000002393069 MINT-SILDENAFIL 25 MG TABLET ORL TAB MPI TAB 8.290000002393077 MINT-SILDENAFIL 50 MG TABLET ORL TAB MPI TAB 8.847500002389800 MINT-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MPI TAB 0.626400002419521 MINT-ZOLMITRIPTAN 2.5MG TABLET ORL TAB MPI TAB 4.665000002419513 MINT-ZOLMITRIPTAN ODT 2.5MG ORALLY DISPERSIBLE TAB ORL DISPTAB MPI TAB 4.605000000042544 MIOSTAT 0.01% OPH SOLUTION OPH SOL ALC ML 13.511700002241594 MIRAPEX 0.5 MG TABLET ORL TAB BOE TAB 2.355000002248846 MISOPROSTOL-200 200 MCG TABLET ORL TAB PDL TAB 0.285000002230451 MITOMYCIN 20 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 377.200000002230450 MITOMYCIN 5 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 94.300000001948873 MIXED VESPID VENOM PROTEIN 1.1 MG VIAL INJ INJ DEFAUL ALK ML 71.383300001948881 MIXED VESPID VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 71.383300002242786 MOBICOX 15 MG TABLET ORL TAB BOE TAB 1.004400002242785 MOBICOX 7.5 MG TABLET ORL TAB BOE TAB 0.870500002238696 MOI-STIR SPRAY ORAL LIQUID ORL LIQ PMS ML 0.068800001909142 MOISTUREL TOPICAL CREAM TOP CRM WSD G 0.062300001909169 MOISTUREL TOPICAL LOTION TOP LOT WSD ML 0.022900002239601 MONISTAT 1 1200 MG VAGINAL OVULE VAG OVL MCL OVL 12.980000002244005 MONISTAT 3 4% VAGINAL CREAM VAG CRM MCL G 0.865300002126605 MONISTAT 3 400 MG VAGINAL OVULE VAG OVL MCL OVL 4.326700002126249 MONISTAT 3 DUAL-PAK KIT VAG/TOP OVL/CRM MCL KIT 14.860000002084309 MONISTAT 7 2% VAGINAL CREAM VAG CRM MCL G 0.370900002126257 MONISTAT 7 DUAL-PAK VAGINAL OVULE/TOPICAL CREAM VAG/TOP OVL/CRM MCL KIT 14.860000002126567 MONISTAT DERM 2% TOPICAL CREAM TOP CRM MCL G 0.424700002239600 MONISTAT-1 COMBINATION PACK VAG OVULE/TOP CREAM VAG/TOP OVL/CRM MCL KIT 14.860000001907107 MONOPRIL 10 MG TABLET ORL TAB BMS TAB 0.9262

Page 51: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 51 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001907115 MONOPRIL 20 MG TABLET ORL TAB BMS TAB 1.113800000999332 MONOVISC DEFAUL DEV PMS ML 93.750000002379856 MONTELUKAST 10 MG TABLET ORL TAB PDL TAB 0.946000002379821 MONTELUKAST 4 MG TABLET ORL TAB PDL TAB 0.946000002379848 MONTELUKAST 5 MG TABLET ORL TAB PDL TAB 0.946000000676411 MORPHINE HP 25 25 MG/ML INJECTION INJ DEFAUL SDZ ML 2.832500002350920 MORPHINE SR 100 MG SUSTAINED RELEASE TABLET ORL SRT SNS TAB 1.040000002350947 MORPHINE SR 200 MG SUSTAINED RELEASE TABLET ORL SRT SNS TAB 1.933600001964437 MORPHINE SULFATE 2 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.252800001964429 MORPHINE SULFATE 5 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.415300001980696 MORPHINE SULFATE 1 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.372600002242484 MORPHINE SULFATE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 1.460000080028360 MOTION MEDICINE TOPICAL CREAM TOP CRM NDP G 0.121200002186934 MOTRIN IB 200 MG TABLET ORL TAB MCL TAB 0.132900002377225 MOZOBIL 24 MG/1.2 ML INJECTION INJ DEFAUL SAV ML 6295.833300080001844 MSM 1000 MG ORL TAB WNP TAB 0.068600002125013 MUCAINE ORAL SUSPENSION ORL SUS AXC ML 0.024300000599875 MUCILLIUM 500 MG/G ORAL POWDER ORL PWR PMS G 0.018900002330989 MULTAQ 400 MG TABLET ORL TAB SAV TAB 2.338000000782203 MULTI VITAMIN PLUS IRON TABLET ORL TAB VTH TAB 0.060000000782211 MULTI VITAMIN TABLET ORL TAB VTH TAB 0.027000000586315 MULTI-1000 INJECTION INJ DEFAUL SDZ ML 0.819700002100606 MULTI-12 INJECTION INJ DEFAUL SDZ ML 0.915000002240942 MULTI-TAR PLUS REGULAR TOPICAL SHAMPOO TOP SHP VCL ML 0.038100080005483 MULTI-VITAMIN TABLET ORL TAB WNP TAB 0.035700002244898 MULTIPLE VITAMIN TABLET ORL TAB PMT TAB 0.070000000374083 MULTIPLE VITAMIN WITH MINERAL TABLET ORL TAB ADA TAB 0.110000002248775 MULTISURE FOR WOMEN ORL CAP WNP CAP 0.170200002248778 MULTISURE FOR WOMEN OVER 50 GELATIN CAPSULE ORL CAP WBP CAP 0.127600000233498 MULTIVITAMIN TABLET ORL TAB WAM TAB 0.222600002242779 MULTIVITAMINS & MULTIMINERALS FORMULA FORTE SR.TAB ORL TAB PMT TAB 0.080000002242939 MULTIVITAMINS + MULTIMINERALS 50+ FORMULA TAB. ORL TAB PMT TAB 0.066500002242780 MULTIVITAMINS AND MULTIMINERALS FORMULA FORTE TAB ORL TAB PMT TAB 0.067800002244864 MULTIVITAMINS FOR ADULTS TABLET ORL TAB PMT TAB 0.030000000750816 MURO-128 5% OPH OINTMENT OPH ONT BSH G 3.140000000750824 MURO-128 5% OPH SOLUTION OPH SOL BSH ML 0.732700002238595 MUSE 1000 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 33.760000002238593 MUSE 250 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 33.760000002238594 MUSE 500 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 33.7600

Page 52: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 52 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000016063 MUSTARGEN HCL TRITURATION 10 MG/VIAL INJECTION INJ DEFAUL LUI VIAL 8.550000002415380 MYA 28 TABLET ORL TAB APX TAB 0.422900002294222 MYCAMINE 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 98.000000002264560 MYFORTIC 180 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 2.170800002264579 MYFORTIC 360 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 4.341500002372169 MYL-LETROZOLE 2.5 MG TABLET ORL TAB MYP TAB 2.756000002408694 MYL-PREGABALIN 150 MG CAPSULE ORL CAP MYP CAP 1.727000002408651 MYL-PREGABALIN 25 MG CAPSULE ORL CAP MYP CAP 0.617300002408708 MYL-PREGABALIN 300 MG CAPSULE ORL CAP MYP CAP 1.727000002408678 MYL-PREGABALIN 50 MG CAPSULE ORL CAP MYP CAP 0.968300002408686 MYL-PREGABALIN 75 MG CAPSULE ORL CAP MYP CAP 1.252900002392593 MYL-SILDENAFIL 100 MG TABLET ORL TAB MYP TAB 9.200700002392577 MYL-SILDENAFIL 25 MG TABLET ORL TAB MYP TAB 8.290000002392585 MYL-SILDENAFIL 50 MG TABLET ORL TAB MYP TAB 8.847700002270110 MYLAN-ALENDRONATE 5 MG TABLET ORL TAB MYP TAB 1.037000002229813 MYLAN-ALPRAZOLAM 1 MG TABLET ORL TAB MYP TAB 0.309900002229814 MYLAN-ALPRAZOLAM 2 MG TABLET ORL TAB MYP TAB 0.550800002139200 MYLAN-AMANTADINE 100 MG CAPSULE ORL CAP MYP CAP 0.517900002253054 MYLAN-ANAGRELIDE 0.5 MG CAPSULE ORL CAP MYP CAP 3.639300002361418 MYLAN-ANASTROZOLE 1 MG TABLET ORL TAB MYP TAB 2.749700002378981 MYLAN-ATOMOXETINE 100 MG CAPSULE ORL CAP MYP CAP 4.352000002378930 MYLAN-ATOMOXETINE 18 MG CAPSULE ORL CAP MYP CAP 2.650000002378949 MYLAN-ATOMOXETINE 25 MG CAPSULE ORL CAP MYP CAP 2.928100002378957 MYLAN-ATOMOXETINE 40 MG CAPSULE ORL CAP MYP CAP 3.337500002378965 MYLAN-ATOMOXETINE 60 MG CAPSULE ORL CAP MYP CAP 3.702400002378973 MYLAN-ATOMOXETINE 80 MG CAPSULE ORL CAP MYP CAP 3.996000002402165 MYLAN-ATOVAQUONE/PROGUANIL 250 MG/ 100 MG TABLET ORL TAB MYP TAB 4.130800002302403 MYLAN-BICALUTAMIDE 50 MG TABLET ORL TAB MYP TAB 4.057300002384426 MYLAN-BISOPROLOL 10 MG TABLET ORL TAB MYP TAB 0.145000002384418 MYLAN-BISOPROLOL 5 MG TABLET ORL TAB MYP TAB 0.108000002383500 MYLAN-BOSENTAN 125 MG TABLET ORL TAB MYP TAB 22.462500002383497 MYLAN-BOSENTAN 62.5 MG TABLET ORL TAB MYP TAB 22.462500002241003 MYLAN-BUDESONIDE AQ 64 MCG/DOSE MET DOSE NAS SPRAY NAS SPM MYP DOSE 0.091700002379120 MYLAN-CANDESARTAN 4 MG TABLET ORL TAB MYP TAB 0.340000002227479 MYLAN-CIMETIDINE 800 MG TABLET ORL TAB MYP TAB 0.243000002381524 MYLAN-EFAVIRENZ 600 MG TABLET ORL TAB MYP TAB 12.181700002383039 MYLAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 2.030900002383047 MYLAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 2.030900002397471 MYLAN-GABAPENTIN 600 MG TABLET ORL TAB MYP TAB 1.3045

Page 53: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002397498 MYLAN-GABAPENTIN 800 MG TABLET ORL TAB MYP TAB 1.739300002185407 MYLAN-GEMFIBROZIL 300 MG CAPSULE ORL CAP MYP CAP 0.128800002230476 MYLAN-GEMFIBROZIL 600 MG TABLET ORL TAB MYP TAB 0.515700002242920 MYLAN-HYDROXYUREA 500 MG CAPSULE ORL CAP MYP CAP 1.108700002319225 MYLAN-LEFLUNOMIDE 10 MG TABLET ORL TAB MYP TAB 6.041700002319233 MYLAN-LEFLUNOMIDE 20 MG TABLET ORL TAB MYP TAB 6.041700002255995 MYLAN-MELOXICAM 15 MG TABLET ORL TAB MYP TAB 0.616100002255987 MYLAN-MELOXICAM 7.5 MG TABLET ORL TAB MYP TAB 0.491400002371154 MYLAN-MYCOPHENOLATE 250 MG CAPSULE ORL CAP MYP CAP 1.120400002370549 MYLAN-MYCOPHENOLATE 500 MG TABLET ORL TAB MYP TAB 2.240600002244563 MYLAN-NABUMETONE 500 MG TABLET ORL TAB MYP TAB 0.362500002387727 MYLAN-NEVIRAPINE 200 MG TABLET ORL TAB MYP TAB 1.728500002382725 MYLAN-OLANZAPINE ODT 15 MG ORALLY DISINTEG. TABLET ORL DISNTAB MYP TAB 4.124000002382733 MYLAN-OLANZAPINE ODT 20 MG ORALLY DISINTEG.TABLET ORL DISNTAB MYP TAB 7.597700002248012 MYLAN-PAROXETINE 10 MG TABLET ORL TAB MYP TAB 1.043000002298279 MYLAN-PIOGLITAZONE 15 MG TABLET ORL TAB MYP TAB 0.631200002298287 MYLAN-PIOGLITAZONE 30 MG TABLET ORL TAB MYP TAB 0.884400002298295 MYLAN-PIOGLITAZONE 45 MG TABLET ORL TAB MYP TAB 1.329700002376369 MYLAN-PRAMIPEXOLE 0.5 MG TABLET ORL TAB MYP TAB 1.051400002245372 MYLAN-PROPAFENONE 150 MG TABLET ORL TAB MYP TAB 0.322200002245373 MYLAN-PROPAFENONE 300 MG TABLET ORL TAB MYP TAB 0.568000002397773 MYLAN-RISEDRONATE 150 MG TABLET ORL TAB MYP TAB 40.950000002332809 MYLAN-RIVASTIGMINE 1.5 MG CAPSULE ORL CAP MYP CAP 1.302900002332817 MYLAN-RIVASTIGMINE 3 MG CAPSULE ORL CAP MYP CAP 1.302900002332825 MYLAN-RIVASTIGMINE 4.5 MG CAPSULE ORL CAP MYP CAP 1.302900002332833 MYLAN-RIVASTIGMINE 6 MG CAPSULE ORL CAP MYP CAP 1.302900002268906 MYLAN-SUMATRIPTAN 25 MG TABLET ORL TAB MYP TAB 8.990000002088428 MYLAN-TAMOXIFEN 10 MG TABLET ORL TAB MYP TAB 0.175000002089858 MYLAN-TAMOXIFEN 20 MG TABLET ORL TAB MYP TAB 0.350000002298570 MYLAN-TAMSULOSIN 0.4 MG EXTENDED-RELEASE CAPSULE ORL SRC MYP CAP 0.258100000893773 MYLAN-TIMOLOL 0.25% OPH SOLUTION OPH SOL MYP ML 1.550000002351560 MYLAN-VALACYCLOVIR 1000 MG CAPLET ORL TAB MYP TAB 3.392400002184648 MYLAN-VALPROIC 250 MG CAPSULE ORL CAP MYP CAP 0.136600002383527 MYLAN-VALSARTAN 40 MG TABLET ORL TAB MYP TAB 0.523900002287501 MYLAN-WARFARIN 6 MG TABLET ORL TAB MYP TAB 0.280500002287528 MYLAN-WARFARIN 7.5 MG TABLET ORL TAB MYP TAB 0.301400002019795 MYLANTA REGULAR STRENGTH CHEWABLE TABLET ORL CTB WLA TAB 0.106200000004618 MYLERAN 2 MG TABLET ORL TAB GSK TAB 1.636400001927612 MYOCHRYSINE 25 MG/ML INJECTION INJ DEFAUL AVE ML 16.0820

Page 54: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 54 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002226022 MYOFLEX EXTRA STRENGTH 15% CREAM TOP CRM BIC G 0.103400002402874 MYRBETRIQ 25 MG EXTENDED-RELEASE TABLET ORL ERT ASP TAB 1.890800002402882 MYRBETRIQ 50 MG EXTENDED-RELEASE TABLET ORL ERT ASP TAB 1.890800002343282 NABUMETONE 500 MG TABLET ORL TAB SNS TAB 0.376900000828815 NADOLOL-40 MG TABLET ORL TAB PDL TAB 0.246500000818704 NADOLOL-80 MG TABLET ORL TAB PDL TAB 0.351500002382601 NALOXONE HYDROCHLORIDE (PRES. FREE) 0.4 MG/ML INJ INJ DEFAUL SDZ ML 14.936000002148706 NALOXONE HYDROCHLORIDE 0.4 MG/ML INJECTION INJ DEFAUL SDZ ML 14.936000002148714 NALOXONE HYDROCHLORIDE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 20.147500000390283 NAPHCON FORTE 0.1% OPH SOLUTION OPH SOL ALC ML 0.525300000481408 NAPHCON-A OPH SOLUTION OPH SOL ALC ML 0.495300002242505 NAPRELAN 375 MG CONTROLLED-RELEASE TABLET ORL CRT SUN TAB 1.043600002242506 NAPRELAN 500 MG CONTROLLED-RELEASE TABLET ORL CRT SUN TAB 1.372700002162431 NAPROSYN 25 MG/ML ORAL SUSPENSION ORL SUS HLR ML 0.063100002162792 NAPROSYN E 250 MG ENTERIC-COATED TABLET ORL ECT HLR TAB 0.417400000618721 NAPROXEN 500 MG TABLET ORL TAB PDL TAB 0.211000000590762 NAPROXEN 250 MG TABLET ORL TAB PDL TAB 0.106800000655686 NAPROXEN-375 375 MG TABLET ORL TAB PDL TAB 0.145800002153386 NAPROXEN-NA DF 550 MG TABLET ORL TAB PDL TAB 0.666700002229415 NAROPIN 5 MG/ML INJECTION INJ DEFAUL AZC ML 0.375000002213834 NASACORT AQ 55 MCG NASAL METERED DOSE SPRAY NAS SPM SAV DOSE 0.217300002192799 NASAL + SINUS DECONGESTANT RELIEF 60 MG TABLET ORL TAB VTH TAB 0.131700000788503 NASAL DECONGESTANT SPRAY 0.1% NAS LIQ CNF ML 0.092000002409003 NAT-CITALOPRAM 10 MG TABLET ORL TAB NTP TAB 0.143200002409011 NAT-CITALOPRAM 20 MG TABLET ORL TAB NTP TAB 0.239700000024457 NAVANE 10 MG CAPSULE ORL CAP ERF CAP 0.479900080029758 NEBUSAL 7% INHALATION SOLUTION MIS DEFAUL STM ML 0.264200002245057 NEISVAC-C 10 MCG/20 MCG INJECTION SYRINGE INJ NDL SHB SYR 80.185000000147680 NEO-BEX (LIDOCAINE HCL) INJECTION VIAL INJ DEFAUL BRO ML 6.144000000749834 NEO-HC 2% TOPICAL CREAM TOP CRM NEO G 0.360300000666157 NEOSPORIN IRRIGATING SOLUTION IR SOL GSK ML 1.686000000666122 NEOSPORIN TOPICAL OINTMENT TOP ONT GSK G 0.468000000874957 NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INJECTION INJ DEFAUL SDZ ML 0.884400000885282 NEOSTIGMINE METHYLSULFATE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.993000001915436 NEOSTIGMINE METHYLSULFATE 2.5 MG/ML INJECTION INJ DEFAUL SDZ ML 3.434200002230593 NEOSTIGMINE OMEGA 0.5 MG/ML INJECTION INJ DEFAUL OMG ML 0.885000002230592 NEOSTIGMINE OMEGA 1 MG/ML INJECTION INJ DEFAUL OMG ML 0.995000001958690 NEOSTRATA HQ 2% GEL TOP GEL CDX G 0.828000000999459 NEOVISC DEFAUL DEV STL ML 41.3333

Page 55: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 55 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000999922 NEPRO ORAL LIQUID ORL LIQ ABN ML 0.009000002028719 NERISALIC OILY TOPICAL CREAM TOP CRM GSK G 0.530300000587834 NERISONE 0.1% TOPICAL OINTMENT TOP ONT GSK G 0.386300080007796 NERVOHEEL N TABLET ORL TAB HEE TAB 0.285800002403897 NEUPRO 1 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 3.846700002403900 NEUPRO 2 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 3.846700002403919 NEUPRO 3 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.063300002403927 NEUPRO 4 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.063300002403935 NEUPRO 6 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.900000002403943 NEUPRO 8 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.811700002239717 NEURONTIN 600 MG TABLET ORL TAB PFI TAB 2.025100002239718 NEURONTIN 800 MG TABLET ORL TAB PFI TAB 2.673700002308983 NEVANAC 0.1% OPHTHALMIC SUSPENSION OPH SUS ALC ML 4.334000002284227 NEXAVAR 200 MG TABLET ORL TAB BAI TAB 49.919600002300524 NEXIUM 10 MG/DOSE DEL REL GRANULES FOR ORAL SUSP ORL DRGRNUL AZC PCKT 2.366700002244521 NEXIUM 20 MG DELAYED-RELEASE TABLET ORL DRT AZC TAB 2.366700002244522 NEXIUM 40 MG DELAYED-RELEASE TABLET ORL DRT AZC TAB 2.366700000232459 NIACIN 100 MG TABLET ORL TAB ADA TAB 0.083000000268585 NIACIN 100 MG TABLET ORL TAB VCL TAB 0.034000000779806 NIACIN 500 MG SUSTAINED-RELEASE CAPSULE ORL SRC VTH CAP 0.923700000294950 NIACIN 500 MG TABLET ORL TAB VCL TAB 0.054700000309737 NIACIN 500 MG TABLET ORL TAB JAM TAB 0.059200002242138 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB QVS TAB 0.139500002244702 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB JAM TAB 0.204700002262339 NIASPAN 1000 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.327000002262347 NIASPAN 500 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.360300002262355 NIASPAN 750 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.418000002309289 NIASPAN FCT 1000 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.421600002309254 NIASPAN FCT 500 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.421600002309262 NIASPAN FCT 750 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.406300002247347 NICORETTE MINI LOZENGE 2 MG ORL LOZ MCL LOZ 0.471400002247348 NICORETTE MINI LOZENGE 4 MG ORL LOZ MCL LOZ 0.542300002065762 NICORETTE PATCH 15MG; NICORETTE COMBOQUIT TOP PTH MCL PTH 3.477100080007461 NICOTINE LOZENGES; THRIVE LOZENGES 1 MG ORL LOZ NOV LOZ 0.274400080007464 NICOTINE LOZENGES; THRIVE LOZENGES 2 MG ORL LOZ NOV LOZ 0.311900080000402 NICOTINELL/THRIVE 4 MG ORAL GUM ORL GUM NVC PIECE 0.311900080000396 NICOTINELL; THRIVE 2 MG ORAL GUM ORL GUM NOV PIECE 0.278100002125226 NIDAGEL 0.75% VAGINAL GEL VAG GEL VCL G 0.323300002325926 NIMOTOP 30 MG TABLET ORL TAB BAI TAB 10.8334

Page 56: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 56 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002229655 NITRAZADON 10 MG TABLET ORL TAB AAP TAB 0.128200002229654 NITRAZADON 5 MG TABLET ORL TAB AAP TAB 0.070800002182920 NIZORAL 2% TOPICAL SHAMPOO TOP SHP MCL ML 0.097200002397927 NOCDURNA 25 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 1.320000002048485 NOLVADEX-D 20 MG (BASE) TABLET ORL TAB AZC TAB 0.400300080016396 NON-FLUSH/FLUSH FREE NIACIN CAPSULE ORL CAP PLH CAP 0.156000001966154 NORFLEX 100 MG TABLET ORL TAB MMH TAB 0.841400001966162 NORFLEX 30 MG/ML INJECTION INJ DEFAUL GRC ML 5.664200002285576 NORLEVO 0.75 MG TABLET ORL TAB BAI TAB 9.345000000023760 NORLUTATE 5 MG TABLET ORL TAB PFI TAB 1.469300002357593 NORVIR 100 MG FILM-COATED TABLET ORL TAB ABV TAB 1.594000002229145 NORVIR 80 MG SOLUTION ORL SOL ABV ML 1.285400002241480 NORVIR SEC 100 MG CAPSULE ORL CAP ABB CAP 1.561200002049481 NOVAHISTEX DH ADULT ORAL LIQUID ORL LIQ SAV ML 0.186300002049473 NOVAHISTINE DH CHILDREN ORAL LIQUID ORL LIQ SAV ML 0.151700000216666 NOVASEN 325 MG ENTERIC-COATED TABLET ORL ECT TEV TAB 0.032100002314282 NOVO-ALFUZOSIN PR 10 MG PROLONGED-RELEASE TABLET ORL SRT TEV TAB 0.598000002314541 NOVO-ATOMOXETINE 10 MG CAPSULE ORL CAP TEV CAP 2.514700002314568 NOVO-ATOMOXETINE 18 MG CAPSULE ORL CAP TEV CAP 2.882000002314576 NOVO-ATOMOXETINE 25 MG CAPSULE ORL CAP TEV CAP 3.181700002314584 NOVO-ATOMOXETINE 40 MG CAPSULE ORL CAP TEV CAP 3.337700002314592 NOVO-ATOMOXETINE 60 MG CAPSULE ORL CAP TEV CAP 3.702300002310422 NOVO-BENZYDAMINE 0.15% ORAL RINSE ORL RNS TEV ML 0.029000002280205 NOVO-BETAHISTINE 24 MG TABLET ORL TAB TEV TAB 0.541500002280183 NOVO-BETAHISTINE 8 MG TABLET ORL TAB TEV TAB 0.207000002270226 NOVO-BICALUTAMIDE 50 MG TABLET ORL TAB TEV TAB 4.057300002312336 NOVO-CITALOPRAM 10 MG TABLET ORL TAB TEV TAB 0.279000002248138 NOVO-CLAVAMOXIN 875 MG/125 MG TABLET ORL TAB TEV TAB 0.555000002309556 NOVO-CYPROTERONE/ETHINYL ESTRADIOL 2MG/0.035MG TAB ORL TAB TEV TAB 1.207600001913468 NOVO-DOXEPIN 100 MG CAPSULE ORL CAP TEV CAP 0.345000001913476 NOVO-DOXEPIN 150 MG CAPSULE ORL CAP TEV CAP 1.212700001913425 NOVO-DOXEPIN 25 MG CAPSULE ORL CAP TEV CAP 0.098500001913433 NOVO-DOXEPIN 50 MG CAPSULE ORL CAP TEV CAP 0.182700001913441 NOVO-DOXEPIN 75 MG CAPSULE ORL CAP TEV CAP 0.367300002330601 NOVO-ENALAPRIL 40 MG TABLET ORL TAB TEV TAB 1.256000002324199 NOVO-ETIDRONATECAL 400 MG/500 MG TABLET ORL TAB TEV TAB 0.280800000595829 NOVO-FIBER 469 MG TABLET ORL TAB TEV TAB 0.070600002239954 NOVO-FLUVOXAMINE 100 MG TABLET ORL TAB TEV TAB 0.550600000389218 NOVO-GESIC 325 MG TABLET ORL TAB TEV TAB 0.0354

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 57 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002273756 NOVO-GLIMEPIRIDE 1 MG TABLET ORL TAB TEV TAB 0.490000002273764 NOVO-GLIMEPIRIDE 2 MG TABLET ORL TAB TEV TAB 0.490000002273772 NOVO-GLIMEPIRIDE 4 MG TABLET ORL TAB TEV TAB 0.490000002210479 NOVO-IPRAMIDE 0.25% INHALATION SOLUTION INH SOL TEV ML 0.315500002230201 NOVO-KETOROLAC 10 MG TABLET ORL TAB TEV TAB 0.408500002176084 NOVO-KETOTIFEN 0.2 MG/ML (BASE) ORAL SYRUP ORL SYR TEV ML 0.454500002230730 NOVO-KETOTIFEN 1 MG TABLET ORL TAB TEV TAB 0.633500002315068 NOVO-METHYLPHENIDATE ER-C 18 MG EXTEND RELEASE TAB ORL ERT TEV TAB 1.551300002315076 NOVO-METHYLPHENIDATE ER-C 27 MG EXTEND RELEASE TAB ORL ERT TEV TAB 1.790300002315084 NOVO-METHYLPHENIDATE ER-C 36 MG EXTEND RELEASE TAB ORL ERT TEV TAB 2.029200002315092 NOVO-METHYLPHENIDATE ER-C 54 MG EXTEND RELEASE TAB ORL ERT TEV TAB 2.507100002279894 NOVO-MIRTAZAPINE OD 15 MG ORALLY DISINTEGRATING TA ORL DISNTAB TEV TAB 0.296700002279908 NOVO-MIRTAZAPINE OD 30MG ORALLY DISINTEGRATING TAB ORL DISNTAB TEV TAB 0.593300002279916 NOVO-MIRTAZAPINE OD 45MG ORALLY DISINTEGRATING TAB ORL DISNTAB TEV TAB 0.819000002364883 NOVO-MYCOPHENOLATE 250 MG CAPSULE ORL CAP TEV CAP 1.031000002348675 NOVO-MYCOPHENOLATE 500 MG TABLET ORL TAB TEV TAB 2.062000002240868 NOVO-NABUMETONE 750 MG TABLET ORL TAB TEV TAB 0.919200002126753 NOVO-NADOLOL 40 MG TABLET ORL TAB TEV TAB 0.246500002126761 NOVO-NADOLOL 80 MG TABLET ORL TAB TEV TAB 0.351500002240457 NOVO-NIZATIDINE 150 MG CAPSULE ORL CAP TEV CAP 0.209800002240458 NOVO-NIZATIDINE 300 MG CAPSULE ORL CAP TEV CAP 0.413100002285479 NOVO-PANTOPRAZOLE 20MG ENTERIC-COATED ORAL TAB ORL ECT TEV TAB 1.275000000021202 NOVO-PEN-VK 300 MG TABLET ORL TAB TEV TAB 0.071000000391603 NOVO-PEN-VK 60 MG/ML ORAL LIQUID SUSPENSION ORL LIQ TEV ML 0.047200000021288 NOVO-PHENIRAM 4 MG TABLET ORL TAB TEV TAB 0.069000000869015 NOVO-PINDOL 10 MG TABLET ORL TAB TEV TAB 0.232300000869023 NOVO-PINDOL 15 MG TABLET ORL TAB TEV TAB 0.337000000869007 NOVO-PINDOL 5 MG TABLET ORL TAB TEV TAB 0.136100000021695 NOVO-PREDNISONE 5 MG TABLET ORL TAB TEV TAB 0.043600000232378 NOVO-PREDNISONE 50 MG TABLET ORL TAB TEV TAB 0.188500002283891 NOVO-RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB TEV CAP 0.420000000605859 NOVO-RYTHRO EES 40 MG/ML (BASE) ORAL SUSPENSION ORL SUS TEV ML 0.096700000652318 NOVO-RYTHRO EES 80 MG/ML (BASE) ORAL SUSPENSION ORL SUS TEV ML 0.146400002326450 NOVO-SALBUTAMOL HFA 100 MCG/DOSE METERED DOSE AERO INH AEM TEV DOSE 0.032500002308754 NOVO-SILDENAFIL 100 MG TABLET ORL TAB TEV TAB 9.997800002308738 NOVO-SILDENAFIL 25 MG TABLET ORL TAB TEV TAB 8.290000002308746 NOVO-SILDENAFIL 50 MG TABLET ORL TAB TEV TAB 9.615000002231182 NOVO-SOTALOL 160 MG TABLET ORL TAB TEV TAB 0.208700002286815 NOVO-SUMATRIPTAN DF 25 MG TABLET ORL TAB TEV TAB 8.9900

Page 58: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 58 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000851965 NOVO-TAMOXIFEN 10 MG TABLET ORL TAB TEV TAB 0.190200000851973 NOVO-TAMOXIFEN 20 MG TABLET ORL TAB TEV TAB 0.380300002230085 NOVO-THEOPHYL SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT TEV TAB 0.141300002230086 NOVO-THEOPHYL SR 200 MG SUSTAINED-RELEASE TABLET ORL SRT TEV TAB 0.146700002230087 NOVO-THEOPHYL SR 300 MG SUSTAINED-RELEASE TABLET ORL SRT TEV TAB 0.140000001947818 NOVO-TIMOL 10 MG TABLET ORL TAB TEV TAB 0.271700001947826 NOVO-TIMOL 20 MG TABLET ORL TAB TEV TAB 0.500500001947796 NOVO-TIMOL 5 MG TABLET ORL TAB TEV TAB 0.164900002218321 NOVO-VALPROIC 500 MG ENTERIC COATED CAPSULE ORL ECC TEV CAP 0.519700000021458 NOVOFERROGLUC 300 MG TABLET ORL TAB TEV TAB 0.025400002265435 NOVOMIX 30 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 3.841300002265443 NOVOMIX 30 FLEXPEN 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 3.183300002322854 NPLATE 250 MCG/0.5 ML VIAL INJECTION INJ DEFAUL AMG VIAL 942.425000002322862 NPLATE 500 MCG/1 ML VIAL INJECTION INJ DEFAUL AMG VIAL 1884.870100002197405 NU-ACYCLOVIR 200MG TABLET ORL TAB NXP TAB 0.878300000886106 NU-AMILZIDE TABLET ORL TAB NXP TAB 0.191700000865567 NU-AMOXI 250 MG CAPSULE ORL CAP NXP CAP 0.103200000865575 NU-AMOXI 500 MG CAPSULE ORL CAP NXP CAP 0.201000001913824 NU-CAPTO 12.5 MG TABLET ORL TAB NXP TAB 0.212000001913840 NU-CAPTO 50 MG TABLET ORL TAB NXP TAB 0.559000000886017 NU-DICLO 25 MG ENTERIC COATED TABLET ORL ECT NXP TAB 0.190200002020742 NU-GLYBURIDE 5 MG TABLET ORL TAB NXP TAB 0.068300001913980 NUBAIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 7.330000001913972 NUBAIN 20 MG/ML INJECTION INJ DEFAUL SDZ ML 6.085000002415585 NUCYNTA 100 MG EXTENDED RELEASE TABLET ORL ERT JAI TAB 1.543500002415593 NUCYNTA 150 MG EXTENDED RELEASE TABLET ORL ERT JAI TAB 2.068500002415607 NUCYNTA 200 MG EXTENDED RELEASE TABLET ORL ERT JAI TAB 2.688000002415615 NUCYNTA 250 MG EXTENDED RELEASE TABLET ORL ERT JAI TAB 3.717000002415577 NUCYNTA 50 MG EXTENDED RELEASE TABLET ORL ERT JAI TAB 1.029000002360381 NUCYNTA CR 100 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.600700002360403 NUCYNTA CR 150 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.142800002360411 NUCYNTA CR 200 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.778000002360438 NUCYNTA CR 250 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.846700002360373 NUCYNTA CR 50 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.068200002378299 NUCYNTA IR 100 MG TABLET ORL TAB JAI TAB 1.600600002378272 NUCYNTA IR 50 MG TABLET ORL TAB JAI TAB 1.068200002378280 NUCYNTA IR 75 MG TABLET ORL TAB JAI TAB 1.319900000623385 NUPERCAINAL ANESTHETIC 1% RECTAL OINTMENT RT ONT NVC G 0.152000002216191 NUTROPIN 10 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 389.4400

Page 59: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 59 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002229722 NUTROPIN AQ 5 MG/ML INJECTION INJ DEFAUL HLR ML 194.718300002249002 NUTROPIN AQ 5 MG/ML PEN CARTRIDGE INJ CTG HLR ML 214.870000002376393 NUTROPIN AQ NUSPIN 10 10 MG/2ML PEN CARTRIDGE INJ CTG HLR ML 197.735000002399083 NUTROPIN AQ NUSPIN 20 20 MG/2 ML SOLUTION INJ DEFAUL HLR ML 778.880000002399091 NUTROPIN AQ NUSPIN 5 5 MG/2 ML SOLUTION INJ DEFAUL HLR ML 194.720000002253186 NUVARING 11.4 MG/2.6 MG SLOW-RELEASE VAGINAL RING VAG SDE MFC RNG 16.233300000716901 NYADERM 25,000 U/G VAGINAL CREAM VAG CRM TAR G 0.135800000687766 O-CALCIUM 250 MG AND VITAMIN D TABLET ORL TAB WTR TAB 0.062000000622443 O-CALCIUM 500 MG (BASE) TABLET ORL TAB VTH TAB 0.025700002239742 OBUSFORME EXTRA STRENGTH (W ACETAMINOPHEN) CAPLET ORL TAB WAM TAB 0.361100002237577 OBUSFORME METHOCARBAMOL & ACETAMINOPHEN CAPLET ORL TAB WAM TAB 0.330600002024179 OCTOSTIM 15 MCG INJECTION INJ DEFAUL FEI ML 36.288000002299437 OCTREOTIDE 100 MCG/ML INJECTION INJ DEFAUL TEV ML 5.670000002299445 OCTREOTIDE 200 MCG/ML INJECTION INJ DEFAUL TEV ML 15.584000002299453 OCTREOTIDE 500 MCG/ML INJECTION INJ DEFAUL TEV ML 38.072000002248640 OCTREOTIDE ACETATE OMEGA 100 MCG/ML INJECTION INJ DEFAUL OMG ML 11.200000002248642 OCTREOTIDE ACETATE OMEGA 200 MCG/ML INJECTION INJ DEFAUL OMG ML 23.400000002248639 OCTREOTIDE ACETATE OMEGA 50 MCG/ML INJECTION INJ DEFAUL OMG ML 5.950000002248641 OCTREOTIDE ACETATE OMEGA 500 MCG/ML INJECTION INJ DEFAUL OMG ML 52.300000000358495 ODANS LIQUOR CARBONIS DETERGENS TOP LIQ ODN ML 0.066000002343681 OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB SIV TAB 2.678000002343703 OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB SIV TAB 7.422700002344408 OLUX-E 0.05% TOPICAL FOAM TOP FOA GSK G 1.570100002239144 OMBRELLE ECRAN SPF 60 TOPICAL CREAM TOP CRM COS G 0.099100002241277 OMBRELLE EXTREME SPF 30 TOPICAL LOTION TOP LOT COS ML 0.087500002303639 OMBRELLE SPF 60 TOPICAL LOTION TOP LOT OMB ML 0.115400002239016 OMBRELLE VAPO SPORT SPF 15 TOPICAL LOTION TOP LOT COS ML 0.086800080003480 OMEGA 3 CAPSULE ORL CAP PMT CAP 0.099000080008273 OMEGA 3 CAPSULE ORL CAP WNP CAP 0.258700080015284 OMEGA 3 LIQUID ORL LIQ WNP ML 0.027400080002596 OMEGA 3 SELECT CAPSULE ORL CAP JAM CAP 0.113100002240743 OMEGA 3-6-9 CAPSULE ORL CAP JAM CAP 0.164700080003356 OMEGA 3-6-9 ORAL CAPSULE ORL CAP JAM CAP 0.098300080003127 OMEGA-3 ELITE SOFTGEL ORL CAP WBP CAP 0.061300080003179 OMEGA-3 TABLET ORL TAB JAM TAB 0.164100002385384 OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT SIV CAP 0.550000002303671 OMNARIS 50 MCG/DOSE METERED DOSE NASAL SPRAY NAS SPM TAK DOSE 0.233400002153513 ONCOTICE 800 M UNIT/VIAL FOR BLADDER INSTILLATION BLDIR PWS MFC VIAL 273.140000002271761 ONDANSETRON OMEGA (PRESERVATIVE FREE) 2 MG/ML INJ INJ DEFAUL OMG ML 8.1750

Page 60: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 60 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002271788 ONDANSETRON OMEGA (WITH PRESERVATIVE) 2 MG/ML INJ INJ DEFALT OMG ML 8.125000002306212 ONDANSETRON-ODAN 4 MG TABLET ORL TAB ODN TAB 3.350000080020211 ONE A DAY FRUITI-SSENTIAL GUMMIES ORL CTB BAI TAB 0.156300002248292 ONE A DAY MEN 50 PLUS TABLET ORL TAB BIC TAB 0.106700002248319 ONE A DAY WEIGHTSMART TABLET ORL TAB BAI TAB 0.124800080003089 ONGLES & CHEVEUX CAPSULE ORL CAP VTH CAP 0.106300002375842 ONGLYZA 2.5 MG TABLET ORL TAB BMS TAB 2.537000002421208 ONRELTEA 0.33 % TOPICAL GEL TOP GEL GAL G 3.518000002350726 ONSOLIS 1200 MCG BUCCAL SOLUBLE FILM BUC FILM MED FILM 30.000000002350661 ONSOLIS 200 MCG BUCCAL SOLUBLE FILM BUC FILM MED FILM 12.000000002350688 ONSOLIS 400 MCG BUCCAL SOLUBLE FILM BUC FILM MED FILM 16.350000002350696 ONSOLIS 600 MCG BUCCAL SOLUBLE FILM BUC FILM MED FILM 21.810000002350718 ONSOLIS 800 MCG BUCCAL SOLUBLE FILM BUC FILM MED FILM 27.260000000750794 OPCON-A OPH SOLUTION OPH SOL BSH ML 0.298000002280078 OPI-LACTULOSE 667 MG/ML ORAL SYRUP ORL SYR OPI ML 0.014500002415690 OPSUMIT 10 MG FILM COATED TABLET ORL TAB ACT TAB 128.333300000990059 OPTICHAMBER DEVICE DEFAUL DEV ACM DEV 30.720000000990061 OPTICHAMBER LARGE FACE MASK DEVICE DEFAUL ADUDEV ACM DEV 35.340000000990062 OPTICHAMBER MEDIUM FACE MASK DEVICE DEFAUL PEDDEV ACM DEV 28.530000000990063 OPTICHAMBER SMALL FACE MASK DEVICE DEFAUL INFDEV ACM DEV 29.430000000355666 OPTIMINE 1 MG TABLET ORL TAB SCH TAB 0.421600002160889 OPTIMYXIN OPHTHALMIC OINTMENT OPH ONT SDZ G 1.454300000701785 OPTIMYXIN OTIC OPH DROPS OT/OPH DPS SDZ ML 0.649000000807435 OPTIMYXIN PLUS OTIC OPH SOLUTION OT/OPH SOL SDZ ML 0.823000002371189 OPTION 2 0.75 MG TABLET ORL TAB PRI TAB 8.225000001985396 ORAJEL MAXIMUM STRENGTH GEL ORL GEL CHD G 0.438900002381885 ORALAIR 100 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 1.370000002381893 ORALAIR 300 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 4.129200002047535 ORFENACE 100 MG TABLET ORL TAB KPC TAB 0.470000002245641 ORGALUTRAN 250 MCG/ 0.5 ML INJECTION SYRINGE INJ NDL MFC SYR 94.710000002209055 ORO-CLENSE 0.12% ORAL RINSE ORL MWH GER ML 0.016800080023808 ORTHO BONE CAPSULE ORL CAP AOR CAP 0.156500000999460 ORTHOVISC DEFAUL DEV PMS ML 57.500000000999490 OSTENIL DEFAUL DEV TRB ML 50.260000002247548 OSTEOCIT D PLUS TABLET ORL TAB SFD TAB 0.182700002301911 OSTO-D2 50000 IU CAPSULE ORL CAP TPI CAP 0.220200002238867 OTRIVIN 0.05% DECONGESTANT NASAL SPRAY NAS SPR NVC ML 0.247000000653330 OTRIVIN 0.1% DECONGESTANT NASAL SPRAY NAS SPR CGS ML 0.247000000741043 OTRIVIN 0.1% METERED DOSE SPRAY DEFAUL SPM CGS ML 0.2470

Page 61: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 61 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002331403 OTRIVIN MOIST 0.1% NASAL SPRAY NAS SPR NVC ML 0.332000002262088 OVIDREL 250 MCG INJECTION SYRINGE INJ NDL SRO SYR 77.400000002371588 OVIDREL 250 MCG/0.5 ML PEN CARTRIDGE INJECTION INJ DEFAUL SRO ML 72.000000000013617 OVOL 40 MG/ML ORAL DROPS ORL DPS CHD ML 0.366700002239298 OVOL-180 ULTRA STRENGTH 180 MG CAPSULE ORL CAP CHD CAP 0.187500000292990 OVOL-80 80 MG TABLET ORL TAB CHD TAB 0.140400000497770 OXAZEPAM 30 MG TABLET ORL TAB PDL TAB 0.075000000497754 OXAZEPAM 10 MG TABLET ORL TAB PDL TAB 0.035000000497762 OXAZEPAM 15 MG TABLET ORL TAB PDL TAB 0.055000001907476 OXSORALEN 1% TOPICAL LOTION TOP LOT VCL ML 1.579300001946374 OXSORALEN 10 MG CAPSULE ORL CAP VCL CAP 0.620600000252654 OXSORALEN ULTRA 10 MG CAPSULE ORL CAP VCL CAP 0.486300002231934 OXY-IR 5 MG TABLET ORL TAB PUR TAB 0.284700002202441 OXYCONTIN 10 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 0.868000002323192 OXYCONTIN 15 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 1.060000002202468 OXYCONTIN 20 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 1.300000002323206 OXYCONTIN 30 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 1.740000002202476 OXYCONTIN 40 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 2.256000002258129 OXYCONTIN 5 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 0.624000002323214 OXYCONTIN 60 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 3.150000002202484 OXYCONTIN 80 MG CONTROLLED RELEASE TABLET ORL CRT PUR TAB 4.164000002139561 OXYTOCIN 10 UNIT/ML INJECTION INJ DEFAUL PPC ML 7.030800002254735 OXYTROL 36 MG TRANSDERMAL PATCH TRD PTH ASC PTH 7.330000080001408 OYSTER SHELL CALCIUM 500 MG CAPLET ORL TAB NCI TAB 0.029000002248374 OYSTER SHELL CALCIUM WITH VIT D 500 MG TABLET ORL TAB VTH TAB 0.026600002363445 OZURDEX 0.7 MG INTRAVITREAL IMPLANT OPH IMP ALL SYS 1333.850000002130947 PACIS 120 MG INJECTION INJ DEFAUL IAF VIAL 113.600000001923420 PALAFER 300 MG CAPSULE ORL CAP GKC CAP 0.248700001923455 PALAFER-CF CAPSULE ORL CAP GKC CAP 0.340000002264951 PAMIDRONATE DISODIUM 30 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 88.350000002246597 PAMIDRONATE DISODIUM 30MG/10ML VIAL INJECTION INJ DEFAUL PPC ML 15.750000002246598 PAMIDRONATE DISODIUM 60 MG/10ML INJECTION INJ DEFAUL PPC ML 29.900000002264978 PAMIDRONATE DISODIUM 60 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 12.328000002264986 PAMIDRONATE DISODIUM 90 MG/VIAL INJECTION INJ DEFAUL SDZ ML 24.655000002246599 PAMIDRONATE DISODIUM 90MG/10ML VIAL INJECTION INJ DEFAUL PPC ML 44.800000002249677 PAMIDRONATE DISODIUM OMEGA 60 MG/10 ML VIAL INJ INJ DEFAUL OMG ML 17.670000000718130 PAMPRIN EXTRA STRENGTH CAPLET ORL TAB CTE TAB 0.206300000263699 PANOXYL 10 TOPICAL (ALCOHOL) GEL TOP ALCGEL GSK G 0.146200002214830 PANOXYL 2.5% AQUAGEL TOP WTRGEL STI G 0.1208

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 62 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000373036 PANOXYL 20 TOPICAL (ALCOHOL) GEL TOP ALCGEL GSK G 0.190500002188708 PANOXYL 4% CREAMY WASH TOP WAS STI G 0.067100000263702 PANOXYL 5 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL STI G 0.124300000483184 PANOXYL 5 5% TOPICAL BAR TOP BAR STI G 0.085300002214857 PANOXYL 5 5% WASH TOP WAS STI ML 0.060900002214849 PANOXYL 5% AQUAGEL TOP WTRGEL STI G 0.124300002239616 PANTO IV 40 MG/VIAL INJECTION INJ DEFAUL TAK VIAL 13.700000002241804 PANTOLOC 20 MG ENTERIC-COATED TABLET ORL ECT TAK TAB 1.965600002385740 PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT SIV TAB 1.275000002318695 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.978500002306727 PANTOPRAZOLE SODIUM FOR INJECTION 40 MG/VIAL INJ INJ DEFAUL SDZ VIAL 11.910000002282844 PAROXETINE 10 MG TABLET ORL TAB SNS TAB 1.043000002388227 PAROXETINE 10 MG TABLET ORL TAB SIV TAB 1.043000002248913 PAROXETINE-10 MG TABLET ORL TAB PDL TAB 0.821000002248914 PAROXETINE-20 MG TABLET ORL TAB PDL TAB 0.451300002248915 PAROXETINE-30 MG TABLET ORL TAB PDL TAB 0.479600002389274 PAT-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB PAT TAB 0.626300002362171 PATADAY 0.2% OPHTHALMIC SOLUTION OPH SOL ALC ML 12.940000002233143 PATANOL 0.1% OPH SOLUTION OPH SOL ALC ML 6.470000002027887 PAXIL 10 MG TABLET ORL TAB GSK TAB 1.838700002248503 PAXIL CR 12.5 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 1.872300002248504 PAXIL CR 25 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 2.045700002242863 PEDIAFER 30 MG/ML ORAL SOLUTION USP ORL SYR EUP ML 0.028600002232202 PEDIAFER 75 MG/ML ORAL SOLUTION USP ORL SYR EUP ML 0.194600002245747 PEDIAFLOUR 5.56 MG/ML ORAL SOLUTION ORL DPS EUP ML 0.069700002358034 PEG 3350 ORAL POWDER ORL PWR MES G 0.054400002328232 PEGALAX ORAL POWDER ORL PWR MFI G 0.038100000468029 PENICILLINE V 300 TABLET ORL TAB PDL TAB 0.071000002250535 PENLAC NAIL LACQUER 8% TOPICAL SOLUTION TOP SOL VCL G 13.691700002247265 PENNSAID 1.5% TOPICAL SOLUTION TOP SOL PAL ML 0.845800001980602 PENTA-3B PLUS VITAMIN C TABLET ORL TAB SDZ TAB 0.582000001980599 PENTA-3B TABLET ORL TAB SDZ TAB 0.478000002183080 PENTAMIDINE ISETHIONATE 300 MG/VIAL INJECTION BP INJ DEFAUL HSP VIAL 127.120000001980556 PENTAMYCETIN 0.25% OPH SOLUTION OPH SOL SDZ ML 0.618000002164051 PENTAMYCETIN 0.5% OPH SOLUTION OPH SOL SDZ ML 0.630000001980564 PENTAMYCETIN 1% OPH OINTMENT OPH ONT SDZ G 2.160000001980580 PENTAMYCETIN-HC OTIC OPH OINTMENT OT/OPH ONT SDZ G 2.971400001980572 PENTAMYCETIN-HC OTIC OPH SUSPENSION OT/OPH SUS SDZ ML 2.458000000710121 PEPCID 20 MG TABLET ORL TAB MFC TAB 1.1093

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 63 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000710113 PEPCID 40 MG TABLET ORL TAB MFC TAB 2.025400002185938 PEPCID AC 10 MG TABLET ORL TAB MFC TAB 0.313700000728128 PEPCID IV 10 MG/ML INJECTION INJ DEFAUL MFC ML 1.995500002097079 PEPTO-BISMOL 17.6 MG/ML ORAL LIQUID ORL LIQ PGI ML 0.026800002177994 PEPTO-BISMOL CAPLET ORL TAB PGI TAB 0.168300002237315 PEPTO-BISMOL CHEWABLES CHEWABLE TABLET ORL CTB PGI TAB 0.336700000254916 PERGONAL 75 UNIT/75 UNIT INJECTION INJ DEFAUL SRO VIAL 46.000000002229501 PERI-WASH II ANTISEPTIC 0.1% CLEANSER TOP WAS COC ML 0.014700002240433 PERICHLOR 0.12% ORAL RINSE ORL MWH PMS ML 0.019700002237452 PERIDEX 0.12% ORAL RINSE ORL MWH ZIL ML 0.024400002207796 PERIOGARD 0.12% ORAL RINSE ORL MWH COL ML 0.017600002247104 PERIOSTAT 20 MG CAPSULE ORL CAP PPH CAP 1.250000080017389 PGX 750 DAILY CAPSULE ORL CAP NFN CAP 0.195200080001122 PHARMA-CAL 500 MG ORL CAP PPH CAP 0.021600002371499 PHARMA-D 10,000 UNIT CAPSULE ORL CAP PMS CAP 0.210000080001145 PHARMA-D 400 IU GELCAP ORL CAP PPH CAP 0.032200002371502 PHARMA-D 50,000 UNIT CAPSULE ORL CAP PMS CAP 0.950000002162180 PHENERGAN EXPECTORANT WITH CODEINE ORAL SYRUP ORL SYR CLC ML 0.079400002304090 PHENOBARBITAL SODIUM 120 MG/ML INJECTION USP INJ DEFAUL SDZ ML 9.301000002304082 PHENOBARBITAL SODIUM 30 MG/ML INJECTION USP INJ DEFAUL SDZ ML 8.352000002148455 PHENYLEPHRINE HCL 10% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002148447 PHENYLEPHRINE HYDROCHLORIDE OPH SOLUTION (MINIMS) OPH SOL OPT ML 6.666700002150638 PHILLIPS MAGNESIA 300 MG CHEWABLE TABLET ORL CTB BAI TAB 0.052600002150646 PHILLIPS MILK OF MAGNESIA 80 MG/ML ORAL LIQUID ORL LIQ BAI ML 0.015000002017733 PHISOHEX 3% TOPICAL CLEANSER TOP CLR SAV ML 0.077600002245781 PHL-AMIODARONE 200 MG TABLET ORL TAB PHH TAB 1.297100002273543 PHL-CITALOPRAM 10 MG TABLET ORL TAB PHH TAB 0.143200002249359 PHL-CYCLOBENZAPRINE 10 MG TABLET ORL TAB PHH TAB 0.376500002248608 PHL-MELOXICAM 15 MG TABLET ORL TAB PHH TAB 0.567000002248607 PHL-MELOXICAM 7.5 MG TABLET ORL TAB PHH TAB 0.491400002281732 PHL-MIRTAZAPINE 15 MG TABLET ORL TAB PHH TAB 0.375000002307669 PHL-PIOGLITAZONE 15 MG TABLET ORL TAB PHH TAB 1.571600002307677 PHL-PIOGLITAZONE 30 MG TABLET ORL TAB PHH TAB 0.201700002307723 PHL-PIOGLITAZONE 45 MG TABLET ORL TAB PHH TAB 3.310500002249766 PHL-PRAVASTATIN 10 MG TABLET ORL TAB PHH TAB 0.567000002249774 PHL-PRAVASTATIN 20 MG TABLET ORL TAB PHH TAB 0.668900002249782 PHL-PRAVASTATIN 40 MG TABLET ORL TAB PHH TAB 0.805700002299062 PHL-QUETIAPINE 100 MG TABLET ORL TAB PHH TAB 0.922600002299089 PHL-QUETIAPINE 200 MG TABLET ORL TAB PHH TAB 1.8527

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 64 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002299054 PHL-QUETIAPINE 25 MG TABLET ORL TAB PHH TAB 0.345800002299097 PHL-QUETIAPINE 300 MG TABLET ORL TAB PHH TAB 2.703800002236942 PHL-TRAZODONE 100 MG TABLET ORL TAB PHH TAB 0.395600002236941 PHL-TRAZODONE 50 MG TABLET ORL TAB PHH TAB 0.221400002294052 PHL-ZOPICLONE 5 MG TABLET ORL TAB PHH TAB 0.223100002294060 PHL-ZOPICLONE 7.5 MG TABLET ORL TAB PHH TAB 0.468500002229437 PHOSLO 667 MG ORAL TABLET ORL TAB PRP TAB 0.450000002230399 PHOSPHATES SOLUTION ORAL LIQUID ORL LIQ PPH ML 0.092400002019876 PHOTOFRIN 75MG/ VIAL INJECTION INJ DEFAUL AXC VIAL 19255.100000002400987 PICATO 0.015% TOPICAL GEL TOP GEL LEO DOSE 138.730000002400995 PICATO 0.05% TOPICAL GEL TOP GEL LEO DOSE 208.095000002254794 PICO SALAX ORAL POWDER ORL PWR FEI PCKT 8.695000002300583 PICODAN ORL PWDPKT ODN PCKT 3.600000002148463 PILOCARPINE NITRATE 2% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700002148471 PILOCARPINE NITRATE 4% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.348300000575240 PILOPINE HS 4% OPH GEL OPH GEL ALC G 2.614000000828424 PINDOLOL-10 MG TABLET ORL TAB PDL TAB 0.232300000828416 PINDOLOL-5 MG TABLET ORL TAB PDL TAB 0.136100002374013 PIOGLITAZONE HCL 15 MG TABLET ORL TAB SIV TAB 0.929500002374021 PIOGLITAZONE HCL 30 MG TABLET ORL TAB SIV TAB 1.302200002374048 PIOGLITAZONE HCL 45 MG TABLET ORL TAB SIV TAB 1.958000002391600 PIOGLITAZONE HYDROCHLORIDE 15 MG TABLET ORL TAB AHI TAB 0.871800002339587 PIOGLITAZONE HYDROCHLORIDE 30 MG TABLET ORL TAB AHI TAB 0.813900002339595 PIOGLITAZONE HYDROCHLORIDE 45 MG TABLET ORL TAB AHI TAB 1.223700002246640 PIPERACILLIN 2 G/VIAL INJECTION INJ DEFAUL MNP VIAL 9.500000002248939 PIPERACILLIN 2 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 15.280000002246641 PIPERACILLIN 3 G/VIAL INJECTION INJ DEFAUL MNP VIAL 22.820000002248940 PIPERACILLIN 3 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 22.930000002246642 PIPERACILLIN 4 G/VIAL INJECTION INJ DEFAUL MNP VIAL 19.000000002248941 PIPERACILLIN 4 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 30.550000002370158 PIPERACILLIN/TAZOBACTAM 2G/250 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 9.612000000501190 PLACEBO 100 MG TABLET ORL TAB ODN TAB 0.075000002237405 PLANTE GUMMI BEAR MULTIPLE VITAMINS ORAL GUM ORL GUM PLI PIECE 0.161200001946897 PMS DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR ORL ELX PMS ML 0.405200000792691 PMS-ACETAMINOPHEN 32 MG/ML ORAL SOLUTION ORL SOL PPH ML 0.027600002243435 PMS-ADENOSINE 3 MG/ML INJECTION INJ DEFAUL PMS ML 21.190000000654523 PMS-AMITRIPTYLINE 10 MG TABLET ORL TAB PMS TAB 0.072200000654515 PMS-AMITRIPTYLINE 25 MG TABLET ORL TAB PMS TAB 0.131600000654507 PMS-AMITRIPTYLINE 50 MG TABLET ORL TAB PMS TAB 0.2550

Page 65: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 65 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002247304 PMS-AMITRIPTYLINE 50 MG TABLET ORL TAB PMS TAB 0.234600002274949 PMS-ANAGRELIDE 0.5 MG CAPSULE ORL CAP PMS CAP 3.349100002320738 PMS-ANASTROZOLE 1 MG TABLET ORL TAB PMS TAB 2.546000002284529 PMS-ASA EC 325 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.030400002283700 PMS-ASA EC 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.057600002381028 PMS-ATOMOXETINE 10 MG CAPSULE ORL CAP PMS CAP 2.314000002381036 PMS-ATOMOXETINE 18 MG CAPSULE ORL CAP PMS CAP 2.652300002381044 PMS-ATOMOXETINE 25 MG CAPSULE ORL CAP PMS CAP 2.928100002381052 PMS-ATOMOXETINE 40 MG CAPSULE ORL CAP PMS CAP 3.337700002381060 PMS-ATOMOXETINE 60 MG CAPSULE ORL CAP PMS CAP 3.702400002313448 PMS-ATORVASTATIN 10 MG TABLET ORL TAB PMS TAB 0.341000002313456 PMS-ATORVASTATIN 20 MG TABLET ORL TAB PMS TAB 0.392200002313464 PMS-ATORVASTATIN 40 MG TABLET ORL TAB PMS TAB 0.458100002313472 PMS-ATORVASTATIN 80 MG TABLET ORL TAB PMS TAB 0.421600000587265 PMS-BENZTROPINE 2 MG TABLET ORL TAB PMS TAB 0.045000002330237 PMS-BETAHISTINE 24 MG TABLET ORL TAB PMS TAB 0.541500000759171 PMS-BETHANECHOL CHLORIDE 10 MG TABLET ORL TAB PMS TAB 0.230000000739162 PMS-BETHANECHOL CHLORIDE 25 MG TABLET ORL TAB PMS TAB 0.358000000759198 PMS-BETHANECHOL CHLORIDE 50 MG TABLET ORL TAB PMS TAB 0.492500002275589 PMS-BICALUTAMIDE 50 MG TABLET ORL TAB PMS TAB 4.057300000587273 PMS-BISACODYL 5 MG ENTERIC COATED TABLET ORL ECT PMS TAB 0.052200002383020 PMS-BOSENTAN 125 MG TABLET ORL TAB PMS TAB 48.134000002383012 PMS-BOSENTAN 62.5 MG TABLET ORL TAB PMS TAB 52.304800002244508 PMS-BUTORPHANOL 10MG/ML NASAL SPRAY NAS SPR PMS ML 16.660000002391171 PMS-CANDESARTAN 4 MG TABLET ORL TAB PMS TAB 0.340000002185830 PMS-CEFACLOR 250 MG CAPSULE ORL CAP PMS CAP 0.643000002185857 PMS-CEFACLOR 25MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.076200002185865 PMS-CEFACLOR 50 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.139500002185849 PMS-CEFACLOR 500 MG CAPSULE ORL CAP PMS CAP 1.262500002185873 PMS-CEFACLOR 75 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.201000002315963 PMS-CETIRIZINE 20 MG TABLET ORL TAB PMS TAB 0.818800002413574 PMS-CICLOPIROX NAIL LACQUER 8% TOPICAL SOLUTION TOP SOL PMS G 7.743300002253933 PMS-CIPROFLOXACIN 0.3% OPHTHALMIC SOL. OPH SOL PMS ML 0.830000002416433 PMS-CIPROFLOXACIN XL 500 MG EXTENDED-RELEASE TAB ORL ERT PMS TAB 2.311000002232195 PMS-CLOBETASOL 0.05% SCALP LOTION SCP LOT PMS ML 0.227300002232191 PMS-CLOBETASOL 0.05% TOPICAL CREAM TOP CRM PMS G 0.406800002232193 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.406800002309548 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.260600002243450 PMS-DEFEROXAMINE 2G/VIAL INJECTION INJ DEFAUL PMS VIAL 20.2200

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 66 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002242055 PMS-DEFEROXAMINE 500 MG/VIAL INJ INJ DEFAUL PMS VIAL 8.175000001946277 PMS-DESIPRAMINE 50 MG TABLET ORL TAB PMS TAB 0.411000000891797 PMS-DIAZEPAM 1 MG/ML ORAL SOLUTION ORL SOL PMS ML 0.112700002247492 PMS-DIAZEPAM 10 MG TABLET ORL TAB PMS TAB 0.094200002247490 PMS-DIAZEPAM 2 MG TABLET ORL TAB PMS TAB 0.055200002247491 PMS-DIAZEPAM 5 MG TABLET ORL TAB PMS TAB 0.065000000721344 PMS-DICITRATE ORAL SOLUTION ORL SOL PMS ML 0.051500002239753 PMS-DICLOFENAC-K 50 MG TABLET ORL TAB PMS TAB 0.427800000757683 PMS-DIPHENHYDRAMINE 25 MG CAPSULE ORL CAP PPH CAP 0.093100000757691 PMS-DIPHENHYDRAMINE 50 MG CAPSULE ORL CAP PPH CAP 0.116900002278081 PMS-FAMCICLOVIR 125 MG TABLET ORL TAB PMS TAB 2.199000002278103 PMS-FAMCICLOVIR 250 MG TABLET ORL TAB PMS TAB 2.955700002278111 PMS-FAMCICLOVIR 500 MG TABLET ORL TAB PMS TAB 4.594400002273551 PMS-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP PMS CAP 0.272300000586323 PMS-FERROUS SULFATE 300 MG TABLET ORL TAB PPH TAB 0.021000002222574 PMS-FERROUS SULFATE INFANT DROPS 75 MG/ML ORL DPS PMS ML 0.359300002320169 PMS-FINASTERIDE 1 MG TABLET ORL TAB PMS TAB 1.244800002238568 PMS-FLUOROMETHOLONE 0.1% OPH SUSPENSION OPH SUS PMS ML 1.788000000726354 PMS-FLUPHENAZINE 5 MG TABLET ORL TAB PMS TAB 0.186900002230104 PMS-FLUTAMIDE 250 MG TABLET ORL TAB PMS TAB 1.353000002240683 PMS-FLUVOXAMINE 100 MG TABLET ORL TAB PMS TAB 0.550600002240682 PMS-FLUVOXAMINE 50 MG TABLET ORL TAB PMS TAB 0.306300002247493 PMS-FUROSEMIDE 20 MG TABLET ORL TAB PMS TAB 0.037300002247494 PMS-FUROSEMIDE 40 MG TABLET ORL TAB PMS TAB 0.081100002255898 PMS-GABAPENTIN 600 MG TABLET ORL TAB PMS TAB 1.417500002255901 PMS-GABAPENTIN 800 MG TABLET ORL TAB PMS TAB 1.890000002239951 PMS-GEMFIBROZIL 300 MG CAPSULE ORL CAP PMS CAP 0.296400002230183 PMS-GEMFIBROZIL 600 MG TABLET ORL TAB PMS TAB 0.752000002247386 PMS-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.039500002247387 PMS-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.055100002324253 PMS-HYDROCODONE 1 MG/ML ORAL SYRUP ORL SYR PMS ML 0.124900000836133 PMS-IBUPROFEN 400 MG TABLET ORL TAB PMS TAB 0.101000000577790 PMS-ISONIAZID 100 MG TABLET ORL TAB PMS TAB 0.794800000577804 PMS-ISONIAZID 300 MG TABLET ORL TAB PMS TAB 0.794800000577812 PMS-ISONIAZID 50 MG/5ML ORAL LIQUID ORL LIQ PMS ML 0.230000002288265 PMS-LEFLUNOMIDE 10 MG TABLET ORL TAB PMS TAB 6.565300002288273 PMS-LEFLUNOMIDE 20 MG TABLET ORL TAB PMS TAB 6.565300002309114 PMS-LETROZOLE 2.5 MG TABLET ORL TAB PMS TAB 2.994700002237991 PMS-LEVOBUNOLOL 0.5% OPH SOLUTION OPH SOL PMS ML 1.2380

Page 67: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 67 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000811874 PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID ORL LIQ PMS ML 0.103200000703605 PMS-LINDANE 1% TOPICAL SHAMPOO TOP SHP PPH ML 0.105400002074834 PMS-LITHIUM CITRATE 8 MMO/5ML ORAL SYRUP ORL SYR PMS ML 0.076900002248268 PMS-MELOXICAM 15 MG TABLET ORL TAB PMS TAB 0.616100002248267 PMS-MELOXICAM 7.5 MG TABLET ORL TAB PMS TAB 0.534000002321130 PMS-MEMANTINE 10 MG TABLET ORL TAB PMS TAB 1.777400002413728 PMS-METHYLPHENIDATE 18 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.427600002413736 PMS-METHYLPHENIDATE 27 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.647500002413744 PMS-METHYLPHENIDATE 36 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.867400002413752 PMS-METHYLPHENIDATE 54 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 2.307200000783137 PMS-METRONIDAZOLE 500 MG CAPSULE ORL CAP PMS CAP 0.763700002405776 PMS-NEVIRAPINE 200 MG TABLET ORL TAB PMS TAB 2.683200002246596 PMS-NORFLOXACIN 400 MG TABLET ORL TAB PMS TAB 0.544900002252570 PMS-OFLOXACIN 0.3% OPH SOLUTION OPH SOL PMS ML 0.920000002303213 PMS-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB ORL DISNTAB PMS TAB 5.355300000792942 PMS-OXTRIPHYLLINE ORAL ELIXIR ORL ELX PMS ML 0.033500002309882 PMS-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.515200002309890 PMS-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.772800002309904 PMS-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 1.339400002309912 PMS-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 2.473900002307863 PMS-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 1.275000002247750 PMS-PAROXETINE 10 MG TABLET ORL TAB PMS TAB 1.043000002231537 PMS-PINDOLOL 10 MG TABLET ORL TAB PMS TAB 0.252400002231539 PMS-PINDOLOL 15 MG TABLET ORL TAB PMS TAB 0.337000002231536 PMS-PINDOLOL 5 MG TABLET ORL TAB PMS TAB 0.136100002303124 PMS-PIOGLITAZONE 15 MG TABLET ORL TAB PMS TAB 0.580900002303132 PMS-PIOGLITAZONE 30 MG TABLET ORL TAB PMS TAB 0.813900002303140 PMS-PIOGLITAZONE 45 MG TABLET ORL TAB PMS TAB 1.223700002240363 PMS-POLYTRIMETHOPRIM OPHTHALMIC SOLUTION OPH SOL PMS ML 2.388000002290138 PMS-PRAMIPEXOLE 0.5 MG TABLET ORL TAB PMS TAB 1.506100002359634 PMS-PREGABALIN 150 MG CAPSULE ORL CAP PMS CAP 1.876600002398079 PMS-PREGABALIN 225 MG CAPSULE ORL CAP PMS CAP 1.876600002359596 PMS-PREGABALIN 25 MG CAPSULE ORL CAP PMS CAP 0.670800002359642 PMS-PREGABALIN 300 MG CAPSULE ORL CAP PMS CAP 1.876600002359618 PMS-PREGABALIN 50 MG CAPSULE ORL CAP PMS CAP 1.052200002359626 PMS-PREGABALIN 75 MG CAPSULE ORL CAP PMS CAP 1.361500000753688 PMS-PROCHLORPERAZINE 10 MG RECTAL SUPPOSITORY RT SUP PMS SUP 0.902000000753637 PMS-PROCHLORPERAZINE 10 MG TABLET ORL TAB PMS TAB 0.202500000753661 PMS-PROCHLORPERAZINE 5 MG TABLET ORL TAB PMS TAB 0.1659

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 68 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002294559 PMS-PROPAFENONE 150 MG TABLET ORL TAB PMS TAB 0.464500002294575 PMS-PROPAFENONE 300 MG TABLET ORL TAB PMS TAB 0.819000000815993 PMS-PSEUDOEPHEDRINE HCL 6 MG/ML ORAL SYRUP ORL SYR PMS ML 0.044300000618810 PMS-PYRAZINAMIDE 500 MG TABLET ORL TAB PMS TAB 1.204700002340569 PMS-QUINAPRIL 10 MG TABLET ORL TAB PMS TAB 0.686700002340577 PMS-QUINAPRIL 20 MG TABLET ORL TAB PMS TAB 0.686700002340585 PMS-QUINAPRIL 40 MG TABLET ORL TAB PMS TAB 0.686700002340550 PMS-QUINAPRIL 5 MG TABLET ORL TAB PMS TAB 0.686700002343932 PMS-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB PMS CAP 0.813300002424177 PMS-RISEDRONATE 150 MG TABLET ORL TAB PMS TAB 40.950000002306069 PMS-RIVASTIGMINE 6 MG CAPSULE ORL CAP PMS CAP 1.260500002371642 PMS-SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.200600002371626 PMS-SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 9.007500002371634 PMS-SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 9.615000002252635 PMS-SIMVASTATIN 10 MG TABLET ORL TAB PMS TAB 0.505700002252651 PMS-SIMVASTATIN 40 MG TABLET ORL TAB PMS TAB 0.625000002256428 PMS-SUMATRIPTAN 25 MG TABLET ORL TAB PMS TAB 9.769000002237460 PMS-TAMOXIFEN 20 MG TABLET ORL TAB PMS TAB 0.350000002240807 PMS-TERBINAFINE 250 MG TABLET ORL TAB PMS TAB 2.524500002239577 PMS-TOBRAMYCIN 0.3% OPH SOLUTION OPH SOL PMS ML 0.656000002401657 PMS-TRAMADOL-ACET 37.5 MG/325 MG TABLET ORL TAB PMS TAB 0.626400002312999 PMS-VALSARTAN 40 MG TABLET ORL TAB PMS TAB 0.569300001954504 PMS-YOHIMBINE 2 MG TABLET ORL TAB PMS TAB 0.206300001954342 PMS-YOHIMBINE 5.4 MG TABLET ORL TAB PMS TAB 0.439500001985604 PMS-YOHIMBINE 6 MG TABLET ORL TAB PMS TAB 0.620800002231259 PNEUMO 23 25 MCG/0.5ML INJECTION SYRINGE INJ DEFAUL CNG SYR 19.240000000431648 PNEUMOVAX 23 25 MCG/VIAL INJECTION INJ DEFAUL MSD VIAL 19.010000000990067 POCKET CHAMBER DEVICE DEFAUL DEV MMS DEV 15.990000000990069 POCKET CHAMBER PEDIATRIC MEDIUM MASK DEVICE DEFAUL PEDDEV MMS DEV 49.990000000598208 PODOFILM 250 MG/ML TOPICAL LIQUID TOP LIQ PMS ML 1.365200000464988 POLLINEX R INJECTION INJ DEFAUL BEE ML 189.875000002230844 POLYSPORIN 10,000 U/0.25 MG ANTIBIOTIC TOPICAL CRM TOP CRM PFI G 0.393300002237227 POLYSPORIN ANTIBIOTIC TOPICAL OINTMENT TOP ONT WLA G 0.393300002239155 POLYSPORIN PLUS PAIN RELIEF EAR DROPS OT SOL JJI ML 0.985000002239201 POLYSPORIN PLUS PAIN RELIEF TOPICAL CREAM TOP CRM WLA G 0.426700002239157 POLYSPORIN STERILE OPHTHALMIC OINTMENT OPH ONT PFI G 1.688600002239156 POLYSPORIN STERILE OTIC OPH DROPS OT/OPH DPS WLA ML 0.985000002237226 POLYSPORIN TRIPLE ANTIBIOTIC TOPICAL OINTMENT TOP ONT PDH G 0.426700001981021 POLYTAR AF TOPICAL SHAMPOO TOP SHP STI ML 0.0623

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 69 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000249866 POLYTAR REGULAR 1% TOPICAL SHAMPOO TOP SHP STI ML 0.040300001942921 POLYTOPIC TOPICAL OINTMENT TOP ONT SDZ G 0.380100002011956 POLYTRIM OPH SOLUTION OPH SOL ALL ML 3.575000002419580 POMALYST 1 MG CAPSULE ORL CAP CLG CAP 500.000000002419599 POMALYST 2 MG CAPSULE ORL CAP CLG CAP 500.000000002419602 POMALYST 3 MG CAPSULE ORL CAP CLG CAP 500.000000002419610 POMALYST 4 MG CAPSULE ORL CAP CLG CAP 500.000000002293404 POSANOL 40 MG/ML ORAL SUSPENSION ORL SUS MFC ML 10.115200000316121 POTASSIUM 50 MG TABLET ORL TAB JAM TAB 0.056300000804789 POTASSIUM PHOSPHATE 224 MG/ML/ 236 MG/ML INJECTION INJ DEFAUL SDZ ML 0.437600002312433 PRADAXA 75 MG CAPSULE ORL CAP BOE CAP 1.738700002367602 PRAMIPEXOLE 0.25 MG TABLET ORL TAB SNS TAB 0.588700002309130 PRAMIPEXOLE 0.5 MG TABLET ORL TAB SIV TAB 1.386000002367610 PRAMIPEXOLE 0.5 MG TABLET ORL TAB SNS TAB 1.386000002367629 PRAMIPEXOLE 1 MG TABLET ORL TAB SNS TAB 1.177600002367645 PRAMIPEXOLE 1.5 MG TABLET ORL TAB SNS TAB 1.177600000770957 PRAMOX H.C. TOPICAL CREAM TOP CRM DPT G 0.434700001954210 PRAMOX H.C. TOPICAL LOTION TOP LOT DPT ML 0.190200000893749 PRAVACHOL 10 MG TABLET ORL TAB BMS TAB 1.558700002148498 PREDNISOLONE SOD PHOS 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 7.245000000156876 PREDNISONE 5 MG TABLET ORL TAB PDL TAB 0.022000000607517 PREDNISONE-50 50 MG TABLET ORL TAB PDL TAB 0.091300002396521 PREGABALIN 150 MG CAPSULE ORL CAP PDL CAP 1.169800002403722 PREGABALIN 150 MG CAPSULE ORL CAP SIV CAP 1.169800002405563 PREGABALIN 150 MG CAPSULE ORL CAP SNS CAP 1.727000002403749 PREGABALIN 225 MG CAPSULE ORL CAP SIV CAP 1.169800002396483 PREGABALIN 25 MG CAPSULE ORL CAP PDL CAP 0.418100002403692 PREGABALIN 25 MG CAPSULE ORL CAP SIV CAP 0.418100002405539 PREGABALIN 25 MG CAPSULE ORL CAP SNS CAP 0.617300002396548 PREGABALIN 300 MG CAPSULE ORL CAP PDL CAP 1.169800002403730 PREGABALIN 300 MG CAPSULE ORL CAP SIV CAP 1.169800002405598 PREGABALIN 300 MG CAPSULE ORL CAP SNS CAP 1.727000002396505 PREGABALIN 50 MG CAPSULE ORL CAP PDL CAP 0.655800002403706 PREGABALIN 50 MG CAPSULE ORL CAP SIV CAP 0.655800002405547 PREGABALIN 50 MG CAPSULE ORL CAP SNS CAP 0.968300002396513 PREGABALIN 75 MG CAPSULE ORL CAP PDL CAP 0.848600002403714 PREGABALIN 75 MG CAPSULE ORL CAP SIV CAP 0.848600002405555 PREGABALIN 75 MG CAPSULE ORL CAP SNS CAP 1.252800002411768 PREGABALIN-150 150 MG CAPSULE ORL CAP SIV CAP 1.7270

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 70 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002411725 PREGABALIN-25 25 MG CAPSULE ORL CAP SIV CAP 0.617300002411733 PREGABALIN-50 50 MG CAPSULE ORL CAP SIV CAP 0.968300002411741 PREGABALIN-75 75 MG CAPSULE ORL CAP SIV CAP 1.252900002182904 PREGNYL 10,000 UNIT INJECTION INJ DEFAUL MFC VIAL 78.240000002276194 PREGVIT FOLIC 5 TABLET ORL TAB DUI TAB 0.577200002246067 PREGVIT TABLET ORL TAB DUI TAB 0.398500002043386 PREMARIN 25 MG/VIAL INJECTION INJ DEFAUL WAY VIAL 44.640000002244574 PRENATAL VITAMIN AND MINERAL SUPPLEMENT CAPLET ORL TAB WNP TAB 0.076600000886750 PREPARATION H TOPICAL CREAM TOP CRM WCH G 0.268000001926217 PREPARATION H TOPICAL OINTMENT TOP ONT WCH G 0.232400000693820 PRESSYN 20 U/ML INJECTION INJ DEFAUL FEI ML 7.900000002246133 PRESSYN AR 20U/ML INJECTION INJ DEFAUL FEI ML 10.000000002249464 PREVACID FASTAB 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB ABB TAB 2.173300002249472 PREVACID FASTAB 30 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB ABB TAB 2.173300000635189 PREVEX 67% TOPICAL CREAM TOP CRM STI G 0.159000002210754 PREVIDENT 5000 PLUS DENTAL CREAM DEN CRM COL G 0.210800002244081 PREVNAR VACCINE 0.5 ML INJECTION INJ DEFAUL WAY ML 191.030000002369753 PREZISTA 150 MG TABLET ORL TAB JAI TAB 3.786000002324016 PREZISTA 400 MG TABLET ORL TAB JAI TAB 11.672300002324024 PREZISTA 600 MG TABLET ORL TAB JAI TAB 16.597000002338432 PREZISTA 75 MG TABLET ORL TAB JAI TAB 1.893000002393050 PREZISTA 800 MG TABLET ORL TAB JAI TAB 23.344700080033655 PRIMADOPHILUS OPTIMA MAX BIFIDO 90 BILLION CAPSULE ORL CAP ENT CAP 1.428300000717274 PRIMAXIN 250 MG/250 MG INJECTION INJ DEFAUL MFC VIAL 326.000000000884413 PRINZIDE 20 MG/12.5 MG TABLET ORL TB MFC TAB 0.903800002239208 PRIORIX VIAL INJECTION INJ DEFAUL GSK VIAL 27.776000002321106 PRISTIQ 100 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.960300002321092 PRISTIQ 50 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.960700000644315 PRO AMOX-500 MG CAPSULE ORL CAP PDL CAP 0.341700002311518 PRO-AAS (CROQUABLE) 80 MG CHEWABLE TABLET ORL CTB PDL TAB 0.056000002311496 PRO-AAS EC 80 MG TABLET ORL ECT PDL TAB 0.560000000644331 PRO-AMOX 250 MG/5 ML POWDER FOR ORAL SUSPENSION ORL SUS PDL ML 0.054000002310600 PRO-AZITHROMYCINE 250 MG TABLET ORL TAB PDL TAB 2.466700002311453 PRO-CEFUROXIME-500 500 MG TABLET ORL TAB PDL TAB 1.433700002311607 PRO-CLONAZEPAM 1 MG TABLET ORL TAB PDL TAB 0.186000002311615 PRO-CLONAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.159500002310473 PRO-GABAPENTIN 600 MG TABLET ORL TAB PDL TAB 0.958000002310481 PRO-GABAPENTIN 800 MG TABLET ORL TAB PDL TAB 1.277300000646261 PRO-INDO 25 MG CAPSULE ORL CAP PDL CAP 0.0871

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 71 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000646288 PRO-INDO 50 MG CAPSULE ORL CAP PDL CAP 0.151100000655643 PRO-LORAZEPAM 0.5 MG TABLET ORL TAB PDL TAB 0.035900000655651 PRO-LORAZEPAM 1.0 MG TABLET ORL TAB PDL TAB 0.044700000655678 PRO-LORAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.069900002314908 PRO-METFORMIN 500 MG TABLET ORL TAB PDL TAB 0.058700002314894 PRO-METFORMIN 850 MG TABLET ORL TAB PDL TAB 0.084700002310023 PRO-RAMIPRIL-1.25 1.25 MG CAPSULE ORL CAP/TAB PDL CAP 0.205700002310104 PRO-RAMIPRIL-10 10 MG CAPSULE ORL CAP/TAB PDL CAP 0.300300002310066 PRO-RAMIPRIL-2.5 2.5 MG CAPSULE ORL CAP/TAB PDL CAP 0.237000002310074 PRO-RAMIPRIL-5 5 MG CAPSULE ORL CAP/TAB PDL CAP 0.237000002316536 PRO-SOTALOL 160 MG TABLET ORL TAB PDL TAB 0.649200002316528 PRO-SOTALOL 80 MG TABLET ORL TAB PDL TAB 0.593200000519367 PRO-TRIAZIDE TABLET ORL TAB PDL TAB 0.060800080026419 PROARGI-9 PLUS ORAL POWDER ORL PWR NHP G 0.125200002209071 PROBETA 0.5% OPHTHALMIC SOLUTION OPH SOL ALL ML 2.950000080014464 PROBIOTIC 10 BILLION ORL CAP JAM CAP 0.239800002184486 PROCAINAMIDE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 1.974200000638676 PROCAN 500 MG SUSTAINED-RELEASE TABLET ORL SRT ERF TAB 0.550400000638684 PROCAN 750 MG SUSTAINED-RELEASE TABLET ORL SRT ERF TAB 0.942500002223260 PROCTOSEDYL RECTAL SUPPOSITORY RT SUP AXC SUP 1.240800002241799 PROCYTOX 1,000 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 77.810000002241797 PROCYTOX 200 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 51.870000002241795 PROCYTOX 25 MG TABLET ORL TAB ASM TAB 0.619400002241796 PROCYTOX 50 MG TABLET ORL TAB ASM TAB 0.836300002241800 PROCYTOX INJECTION INJ DEFAUL ASM VIAL 152.350000002246645 PRODIEM BULK FIBRE THERAPY 625 MG TABLET ORL TAB NVC TAB 0.174300002246576 PRODIEM OVERNIGHT RELIEF THERAPY 15 MG TABLET ORL TAB NVC TAB 0.219300002247909 PROFERRIN 11 MG TABLET ORL TAB CBI TAB 0.538000002243144 PROGRAF 0.5 MG CAPSULE ORL CAP ASP CAP 2.140700002175991 PROGRAF 1 MG CAPSULE ORL CAP ASP CAP 2.738400002175983 PROGRAF 5 MG CAPSULE ORL CAP ASP CAP 13.713500002204606 PROLASTIN-C 1 G/VIAL INJECTION INJ DEFAUL GRL VIAL 425.170000002343053 PROPAFENONE 150 MG TABLET ORL TAB SNS TAB 0.430300002343061 PROPAFENONE 300 MG TABLET ORL TAB SNS TAB 0.753700002243783 PROPAFENONE-150 150 MG TABLET ORL TAB PDL TAB 0.339500002238213 PROPECIA 1 MG TABLET ORL TAB MFC TAB 1.927500000512524 PROTRIN DF 800 MG/160 MG TABLET ORL TAB PDL TAB 0.122100000287709 PROTYLOL 10 MG CAPSULE ORL CAP PDL CAP 0.065500000513059 PROTYLOL 20 MG TABLET ORL TAB PDL TAB 0.1817

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 72 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002239656 PROVOCHOLINE 100 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 40.000000002243834 PROVOCHOLINE 1280 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 487.000000002246492 PROVOCHOLINE 160 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 64.000000002246493 PROVOCHOLINE 320 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 128.000000080002201 PSN 056 CAPSULE ORL CAP PSN CAP 0.075000000466409 PULMOPHYLLINE 5.3 MG/ML ORAL ELIXIR ORL ELX RIV ML 0.008600002046733 PULMOZYME 1 ML AMPOULE INHALATION SOLUTION INH SOL HLR ML 16.635600002242439 PUREGON 100 IU/ML INJECTION INJ DEFAUL MFC ML 97.000000002242441 PUREGON 200 IU/ML INJECTION INJ DEFAUL MFC ML 208.560000002243948 PUREGON 833 IU/ML INJECTION CARTRIDGE INJ CTG MFC ML 808.333300002317966 PURG-ODAN ORL POWDER ORL PWDPKT ODN PCKT 5.640000000004723 PURINETHOL 50 MG TABLET ORL TAB TEV TAB 5.181600080009682 PYCNOGENOL 25 MG ORAL CASPULE ORL CAP NFN CAP 0.566500000497517 PYRIDOXINE HCL 100 MG/ML INJECTION INJ DEFAUL HSP ML 1.950000002245215 PYRIDOXINE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL BNQ ML 1.267300080039114 Q-UROL TABLET ORL TAB TPI TAB 0.741500080015945 QUEST TABLET ORL TAB PLH TAB 0.394300002417367 QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 0.778000002417790 QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.875300002417375 QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 1.052000002417804 QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 1.188200002417383 QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 1.544000002417812 QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 1.750500002417391 QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 2.096000002417820 QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 2.376300002417359 QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 0.395000002417782 QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.444500002415925 QUINAPRIL 10 MG TABLET ORL TAB PDL TAB 0.532900002415933 QUINAPRIL 20 MG TABLET ORL TAB PDL TAB 0.532900002415941 QUINAPRIL 40 MG TABLET ORL TAB PDL TAB 0.532900002415917 QUINAPRIL 5 MG TABLET ORL TAB PDL TAB 0.532900000695440 QUININE-ODAN 200 MG CAPSULE ORL CAP ODN CAP 0.259700000695459 QUININE-ODAN 300 MG CAPSULE ORL CAP ODN CAP 0.407500000695432 QUININE-ODAN 300 MG TABLET ORL TAB ODN TAB 0.407500002267667 RABAVERT VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL MFC VIAL 186.770000002299194 RALIVIA 100 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.359800002299208 RALIVIA 200 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 2.484200002299216 RALIVIA 300 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 3.603300002415852 RALOXIFENE 60 MG TABLET ORL TAB PDL TAB 0.4814

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002308363 RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB SIV CAP 0.127400002287943 RAMIPRIL 10 MG CAPSULE ORL CAP/TAB SIV CAP 0.186200002287927 RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB SIV CAP 0.147000002287935 RAMIPRIL 5 MG CAPSULE ORL CAP/TAB SIV CAP 0.147000002415895 RAMIPRIL-HCTZ 10 MG/ 12.5 MG TABLET ORL TAB PDL TAB 0.263300002415909 RAMIPRIL-HCTZ 10 MG/25 MG TABLET ORL TAB PDL TAB 0.263300002415887 RAMIPRIL-HCTZ 5 MG/12.5 MG TABLET ORL TAB PDL TAB 0.206700002384698 RAN-ALENDRONATE 5 MG TABLET ORL TAB RAN TAB 1.037100002398877 RAN-AMLODIPINE 2.5 MG TABLET ORL TAB RAN TAB 0.138000002328690 RAN-ANASTROZOLE 1 MG TABLET ORL TAB RAN TAB 2.545700002371324 RAN-BICALUTAMIDE 50 MG TABLET ORL TAB RAN TAB 4.409000002380684 RAN-CANDESARTAN 4 MG TABLET ORL TAB RAN TAB 0.340000002361426 RAN-CLARITHROMYCIN 250 MG TABLET ORL TAB RAN TAB 0.640300002361434 RAN-CLARITHROMYCIN 500 MG TABLET ORL TAB RAN TAB 1.629300002351706 RAN-IMIPENEM-CILASTATIN 500 MG/500 MG/VIAL INJ INJ DEFAUL RAN VIAL 21.940000002372282 RAN-LETROZOLE 2.5 MG TABLET ORL TAB RAN TAB 2.756000002358077 RAN-NABILONE 0.25 MG CAPSULE ORL CAP RAN CAP 1.517200002414112 RAN-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB ORL DISNTAB RAN TAB 5.355400002414120 RAN-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB ORL DISNTAB RAN TAB 7.597900002305038 RAN-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT RAN TAB 1.275000002375850 RAN-PIOGLITAZONE 15 MG TABLET ORL TAB RAN TAB 0.631200002375869 RAN-PIOGLITAZONE 30 MG TABLET ORL TAB RAN TAB 0.884400002375877 RAN-PIOGLITAZONE 45 MG TABLET ORL TAB RAN TAB 1.329700002392844 RAN-PREGABALIN 150 MG CAPSULE ORL CAP RAN CAP 1.727000002392852 RAN-PREGABALIN 225 MG CAPSULE ORL CAP RAN CAP 1.727000002392801 RAN-PREGABALIN 25 MG CAPSULE ORL CAP RAN CAP 0.617300002392860 RAN-PREGABALIN 300 MG CAPSULE ORL CAP RAN CAP 1.727000002392828 RAN-PREGABALIN 50 MG CAPSULE ORL CAP RAN CAP 0.968300002392836 RAN-PREGABALIN 75 MG CAPSULE ORL CAP RAN CAP 1.252800002280906 RAN-RISPERIDONE 0.25 MG TABLET ORL TAB RAN TAB 0.261500002280914 RAN-RISPERIDONE 0.5 MG TABLET ORL TAB RAN TAB 0.437900002280922 RAN-RISPERIDONE 1 MG TABLET ORL TAB RAN TAB 0.604800002280930 RAN-RISPERIDONE 2 MG TABLET ORL TAB RAN TAB 1.207500002280949 RAN-RISPERIDONE 3 MG TABLET ORL TAB RAN TAB 1.811200002280957 RAN-RISPERIDONE 4 MG TABLET ORL TAB RAN TAB 2.415000002383136 RAN-SILDENAFIL 100 MG TABLET ORL TAB RAN TAB 9.200000002383101 RAN-SILDENAFIL 25 MG TABLET ORL TAB RAN TAB 8.290000002383128 RAN-SILDENAFIL 50 MG TABLET ORL TAB RAN TAB 8.847700002294885 RAN-TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE ORL SRC RAN CAP 0.5464

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 74 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002396084 RAN-TOPIRAMATE 100 MG TABLET ORL TAB RAN TAB 0.592800002396092 RAN-TOPIRAMATE 200 MG TABLET ORL TAB RAN TAB 0.962000002396076 RAN-TOPIRAMATE 25 MG TABLET ORL TAB RAN TAB 0.312800002388197 RAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB RAN TAB 0.626400002363062 RAN-VALSARTAN 40 MG TABLET ORL TAB RAN TAB 0.523900000740748 RANITIDINE 150 MG TABLET ORL TAB PDL TAB 0.180000000740756 RANITIDINE 300 MG TABLET ORL TAB PDL TAB 0.360000002361663 RAPAFLO 4 MG CAPSULE ORL CAP ASC CAP 1.981000002361671 RAPAFLO 8 MG CAPSULE ORL CAP ASC CAP 1.981100002247111 RAPAMUNE 1 MG TABLET ORL TAB WAY TAB 8.599700002243237 RAPAMUNE 1 MG/ ML ORAL LIQUID ORL LIQ WAY ML 8.507500002302063 RASILEZ 150 MG TABLET ORL TAB NOV TAB 1.361400002302071 RASILEZ 300 MG TABLET ORL TAB NOV TAB 1.361400002332728 RASILEZ HCT 150 MG/12.5 MG TABLET ORL TAB NOV TAB 1.367100002332736 RASILEZ HCT 150 MG/25 MG TABLET ORL TAB NOV TAB 1.352500002332744 RASILEZ HCT 300 MG/12.5 MG TABLET ORL TAB NOV TAB 1.367100002332752 RASILEZ HCT 300 MG/25 MG TABLET ORL TAB NOV TAB 1.367100002275279 RATIO-ALENDRONATE 70 MG TABLET ORL TAB RPH TAB 2.543000002277700 RATIO-BICALUTAMIDE 50 MG TABLET ORL TAB RPH TAB 4.057300000550477 RATIO-CALMYDONE ORAL SYRUP ORL SYR RPH ML 0.059600002247818 RATIO-CLARITHROMYCIN 250 MG TABLET ORL TAB RPH TAB 0.412200002247819 RATIO-CLARITHROMYCIN 500 MG TABLET ORL TAB RPH TAB 1.629300002103656 RATIO-CLONAZEPAM 0.5 MG TABLET ORL TAB RPH TAB 0.116600002103737 RATIO-CLONAZEPAM 2 MG TABLET ORL TAB RPH TAB 0.201000000779474 RATIO-CODEINE 5 MG/ML ORAL SYRUP ORL SYR RPH ML 0.030400000694827 RATIO-CORISTEX-DH ORAL LIQUID ORL LIQ RPH ML 0.082600002053403 RATIO-COTRIDIN EXPECTORANT ORAL SYRUP ORL SYR RPH ML 0.063100002169126 RATIO-COTRIDIN ORAL SYRUP ORL SYR RPH ML 0.056700002296071 RATIO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM RPH DOSE 0.198900002275252 RATIO-FOSINOPRIL 10 MG TABLET ORL TAB RPH TAB 0.497700002275260 RATIO-FOSINOPRIL 20 MG TABLET ORL TAB RPH TAB 0.598500000805386 RATIO-GENTAMICIN SULFATE 0.1% TOPICAL CREAM TOP CRM RPH G 0.442700002273101 RATIO-GLIMEPIRIDE 1 MG TABLET ORL TAB RPH TAB 0.490000002273128 RATIO-GLIMEPIRIDE 2 MG TABLET ORL TAB RPH TAB 0.490000002273136 RATIO-GLIMEPIRIDE 4 MG TABLET ORL TAB RPH TAB 0.532300002243789 RATIO-IPRA SAL UDV INHALATION SOLUTION INH SOL RPH ML 0.452400002097168 RATIO-IPRATROPIUM UDV 250 MCG/ML INHALATION SOL'N INH UDSOL RPH ML 0.659000002247461 RATIO-KETOROLAC 0.5% OPH SOLUTION OPH SOL RPH ML 1.600000002243353 RATIO-LAMOTRIGINE 100 MG TABLET ORL TAB RPH TAB 0.5739

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 75 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002243352 RATIO-LAMOTRIGINE 25 MG TABLET ORL TAB RPH TAB 0.093600000653233 RATIO-LENOLTEC NO.1 TABLET ORL TAB RPH TAB 0.054700002248031 RATIO-MELOXICAM 15 MG TABLET ORL TAB RPH TAB 0.567000002247889 RATIO-MELOXICAM 7.5 MG TABLET ORL TAB RPH TAB 0.491400002320908 RATIO-MEMANTINE 10 MG TABLET ORL TAB RPH TAB 1.777400002194163 RATIO-NYSTATIN 100,000 UNIT/G VAGINAL CREAM VAG CRM RPH G 0.346700002194198 RATIO-NYSTATIN 500,000 UNIT TABLET ORL TAB RPH TAB 0.259400002260867 RATIO-OMEPRAZOLE 20 MG SUSTAINED-RELEASE TABLET ORL CAP/SRT RPH TAB 0.411700002308681 RATIO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT RPH TAB 1.275000002247810 RATIO-PAROXETINE 10 MG TABLET ORL TAB RPH TAB 1.043000002247812 RATIO-PAROXETINE 30 MG TABLET ORL TAB RPH TAB 0.721700002301423 RATIO-PIOGLITAZONE 15 MG TABLET ORL TAB RPH TAB 0.580900002301431 RATIO-PIOGLITAZONE 30 MG TABLET ORL TAB RPH TAB 0.813900002301458 RATIO-PIOGLITAZONE 45 MG TABLET ORL TAB RPH TAB 1.223700002311194 RATIO-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB RPH CAP 0.813300002319500 RATIO-SILDENAFIL R 20 MG TABLET ORL TAB RPH TAB 7.294000002247068 RATIO-SIMVASTATIN 10 MG TABLET ORL TAB RPH TAB 0.364300002247070 RATIO-SIMVASTATIN 40 MG TABLET ORL TAB RPH TAB 0.450100002247071 RATIO-SIMVASTATIN 80 MG TABLET ORL TAB RPH TAB 0.450000002084236 RATIO-SOTALOL 160 MG TABLET ORL TAB RPH TAB 0.208700000317225 RATIO-THEO-BRONC ORAL SOLUTION ORL SOL RPH ML 0.034000000550507 RATIO-TRIACOMB REGULAR TOPICAL CREAM TOP CRM RPH G 0.416700002140063 RATIO-VALPROIC 50 MG/ML ORAL SYRUP ORL SYR RPH ML 0.039800002238337 REACTINE 1 MG/ML ORAL SYRUP ORL SYR JJM ML 0.066300002223554 REACTINE 10 MG TABLET ORL TAB PDH TAB 0.766700001900978 REACTINE 20 MG TABLET ORL TAB PDH TAB 0.924000002223546 REACTINE 5 MG TABLET ORL TAB PDH TAB 0.584600002246162 REACTINE ALLERGY & SINUS EXTENDED-RELEASE TABLET ORL ERT PDH TAB 0.762000002368064 REACTINE ALLERGY LIQUID GELS 10 MG CAPSULE ORL CAP MCL CAP 0.776400002281708 REBIF INIT PACK 8.8MCG/0.2ML/22MCG/0.5ML INJ SYR INJ NDL SRO SYR 117.070000002420813 RECLIPSEN (21 DAY) TABLET ORL TAB APH TAB 0.370000002417464 RECLIPSEN (28 DAY) TABLET ORL TAB APH TAB 0.277500002243676 RECOMBIVAX HB (PRESERVATIVE FREE) 5MCG/0.5ML INJ INJ DEFAUL MFC ML 24.160000000749486 RECOMBIVAX-HB 10 MCG/ML(RECOMBINANT) INJECTION INJ DEFAUL MFC ML 21.350000000013447 REDOXON (BL CHERRY) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.270000000897221 REDOXON (LEMON) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.264000000897256 REDOXON (ORANGE) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.270000002138670 REFRESH 1.4% OPH SOLUTION OPH SOL ALL ML 0.895800002244650 REFRESH LIQUIGEL 1% OPH SOLUTION OPH SOL ALL ML 0.5393

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 76 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002399148 REFRESH OPTIVE ADVANCED NAS SOL ALL ML 0.967000002049260 REFRESH PLUS 0.5% OPH SOLUTION OPH SOL ALL ML 0.796700002231008 REFRESH TEARS 0.5% OPH SOLUTION OPH SOL ALL ML 0.450000002239405 REGRANEX TOPICAL GEL TOP GEL JAI G 35.333300002242592 REGULAR VITA-VIM CAPLET ORL TAB JAM TAB 0.101200002192640 REJUVA-A 0.025% TOPICAL CREAM TOP CRM GSK G 1.841000002346672 RELAXA PEG 3350 ORAL POWDER ORL PWR RED G 0.027700002240863 RELENZA 5 MG/DOSE INHALATION DISK INH DSK GSK DISC 7.942000002308215 RELISTOR 20 MG/ML INJECTION INJ DEFAUL SLX ML 68.816700002256290 RELPAX 20 MG TABLET ORL TAB PFI TAB 14.875000002256304 RELPAX 40 MG TABLET ORL TAB PFI TAB 14.875000002248542 REMERON RD 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.454700002248543 REMERON RD 30 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.909000002248544 REMERON RD 45 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 1.363700002246552 REMODULIN 1 MG/ML INJECTION INJ DEFAUL NTH ML 45.000000002246555 REMODULIN 10 MG/ML INJECTION INJ DEFAUL NTH ML 450.000000002246553 REMODULIN 2.5 MG/ML INJECTION INJ DEFAUL NTH ML 112.500000002246554 REMODULIN 5 MG/ML INJECTION INJ DEFAUL NTH ML 225.000000002244310 RENAGEL 800 MG TABLET ORL TAB GZM TAB 1.784900002222000 RENEDIL 10 MG EXTENDED-RELEASE TABLET ORL ERT SAV TAB 0.725700002221985 RENEDIL 2.5 MG EXTENDED-RELEASE TABLET ORL ERT SAV TAB 0.317000002221993 RENEDIL 5 MG EXTENDED-RELEASE TABLET ORL ERT SAV TAB 0.463300002052407 RENOVA 0.05% TOPICAL CREAM TOP CRM MCN G 1.350000002354586 RENVELA 800 MG TABLET ORL TAB GZM TAB 1.684600002249057 REPLAGAL 1 MG/ML INJECTION INJ DEFAUL PAL ML 657.142900002247790 REPRONEX 75 UNIT/VIAL INJECTION INJ DEFAUL FEI VIAL 71.066000002377012 RESOTRAN 1 MG FILM-COATED TABLET ORL TAB JAI TAB 2.442100002377020 RESOTRAN 2 MG FILM-COATED TABLET ORL TAB JAI TAB 3.748900002355655 RESTASIS 0.05% OPH EMULSION OPH EML ALL ML 9.005800002318164 RESTORALAX ORAL POWDER ORL PWR SPL G 0.065100000870013 RETIN-A 0.01% TOPICAL GEL TOP GEL JJI G 0.373700000443816 RETIN-A 0.025% TOPICAL GEL TOP GEL JJI G 0.425700000443794 RETIN-A 0.05% TOPICAL CREAM TOP CRM JJI G 0.430300000870021 RETIN-A 0.1% TOPICAL CREAM TOP CRM JJI G 0.373700002264633 RETIN-A MICRO 0.04% TOPICAL GEL TOP GEL JJI G 1.170000002243914 RETIN-A MICRO 0.I % GEL TOP GEL JJI G 1.170000002306980 RETISERT 0.59 MG INTRAVITREAL IMPLANT OPH IMP BSH SYS 16000.000000002008726 RETISOL-A 0.01% TOPICAL CREAM TOP CRM GSK G 0.799100002008696 RETISOL-A 0.025% TOPICAL CREAM TOP CRM GSK G 0.7731

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 77 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002008718 RETISOL-A 0.05% TOPICAL CREAM TOP CRM GSK G 0.773100002008688 RETISOL-A O.1% TOPICAL CREAM TOP CRM GSK G 0.773100001902660 RETROVIR 100 MG CAPSULE ORL CAP GSK CAP 2.025100001902652 RETROVIR 50 MG/5ML ORAL SYRUP ORL SYR GSK ML 0.212300002279401 REVATIO 20 MG TABLET ORL TAB PFI TAB 11.956000002213826 REVIA 50 MG TABLET ORL TAB BAR TAB 6.223600002035871 REVITONUS C-1000 ORAL LIQUID ORL LIQ SDZ AMP 0.855500002304902 REVLIMID 10 MG CAPSULE ORL CAP CLG CAP 361.000000002317699 REVLIMID 15 MG CAPSULE ORL CAP CLG CAP 382.000000002317710 REVLIMID 25 MG CAPSULE ORL CAP CLG CAP 424.000000002304899 REVLIMID 5 MG CAPSULE ORL CAP CLG CAP 340.000000002361825 REVOLADE 25 MG TABLET ORL TAB GSK TAB 62.500000002361833 REVOLADE 50 MG TABLET ORL TAB GSK TAB 125.000000002248610 REYATAZ 150 MG CAPSULE ORL CAP BMS CAP 12.016800002248611 REYATAZ 200 MG CAPSULE ORL CAP BMS CAP 11.058700002294176 REYATAZ 300 MG CAPSULE ORL CAP BMS CAP 24.033700002220806 RHINARIS LUBRICATING NASAL GEL NAS GEL PMS G 0.290400000732230 RHINARIS NASAL AEROSOL NAS AER PMS DOSE 0.193300002231923 RHINOCORT AQUA 64 MCG/DOSE METERED DOSE NAS. SPRAY NAS SPM AZC DOSE 0.098700080026370 RHODIOLA ROSEA CAPSULE ORL CAP AOR CAP 0.254600001910140 RHOTRAL 100 MG TABLET ORL TAB SDZ TAB 0.163000001910159 RHOTRAL 200 MG TABLET ORL TAB SDZ TAB 0.244000001910167 RHOTRAL 400 MG TABLET ORL TAB SDZ TAB 0.484800002260107 RHOXAL-ANAGRELIDE 0.5 MG CAPSULE ORL CAP SDZ CAP 3.349100002269589 RHOXAL-GLIMEPIRIDE 1 MG TABLET ORL TAB SDZ TAB 0.532300002269597 RHOXAL-GLIMEPIRIDE 2 MG TABLET ORL TAB SDZ TAB 0.532300002269619 RHOXAL-GLIMEPIRIDE 4 MG TABLET ORL TAB SDZ TAB 0.532300002243559 RHOXAL-ORPHENADRINE 100 MG EXTENDED-RELEASE TABLET ORL ERT SDZ TAB 0.809800000309702 RIBOFLAVINE 100 MG TABLET ORL TAB JAM TAB 0.067500002091887 RIFADIN 150 MG CAPSULE ORL CAP SAV CAP 0.912200002092808 RIFADIN 300 MG CAPSULE ORL CAP SAV CAP 1.435600002347474 RISEDRONATE 35 MG TABLET ORL TAB PDL TAB 2.427500002352141 RISEDRONATE 35 MG TABLET ORL TAB SIV TAB 2.489300002298465 RISPERDAL CONSTA 12.5 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 85.400000002242093 RIVA-ATENOLOL 100 MG TABLET ORL TAB RIV TAB 0.236200002242094 RIVA-ATENOLOL 50 MG TABLET ORL TAB RIV TAB 0.143700002242077 RIVA-CLONAZEPAM 0.5 MG TABLET ORL TAB RIV TAB 0.049500002239081 RIVA-METFORMIN 500 MG TABLET ORL TAB RIV TAB 0.058600002242783 RIVA-METFORMIN 850 MG TABLET ORL TAB RIV TAB 0.0847

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 78 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002265265 RIVA-MIRTAZAPINE 30 MG TABLET ORL TAB RIV TAB 0.233800002240788 RIVA-NAPROXEN 500 MG TABLET ORL TAB RIV TAB 0.211000002316463 RIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.505400002242157 RIVA-SOTALOL 160 MG TABLET ORL TAB RIV TAB 0.162300002248082 RIVA-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT RIV TAB 0.507500002228300 RIVANASE AQ 50 MCG/DOSE METER DOSE NASAL SPRAY NAS SPM RIV DOSE 0.049000002202352 RIVASA CROQUABLE 80 MG TABLET ORL CTB RIV TAB 0.056000002240112 RIVASOL-HC RECTAL SUPPOSITORY RT SUP RIV SUP 0.583300001940112 RIVASONE SCALP 0.1% TOPICAL LOTION TOP LOT RIV ML 0.085300002416999 RIVASTIGMINE 1.5 MG CAPSULE ORL CAP PDL CAP 0.651400002417006 RIVASTIGMINE 3 MG CAPSULE ORL CAP PDL CAP 0.651400002417014 RIVASTIGMINE 4.5 MG CAPSULE ORL CAP PDL CAP 0.651400002417022 RIVASTIGMINE 6 MG CAPSULE ORL CAP PDL CAP 0.651400002415801 RIZATRIPTAN ODT 10 MG ORALLY DISINTEG TAB ORL DISNTAB PDL TAB 3.705000002415798 RIZATRIPTAN ODT 5 MG ORALLY DISINTEG TAB ORL DISNTAB PDL TAB 3.705000002247147 ROBAX PLATINUM TABLET ORL TAB PDH TAB 0.670000002026805 ROBAXACET CAPLET ORL TAB PDH TAB 0.482200002231176 ROBAXACET EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.530000001934767 ROBAXACET-8 TABLET ORL TAB PDH TAB 0.742600001930990 ROBAXIN 500 MG TABLET ORL TAB PDH TAB 0.511600001932187 ROBAXIN-750 750 MG TABLET ORL TAB PDH TAB 0.844600002026783 ROBAXISAL CAPLET ORL TAB WCH TAB 0.402200002230949 ROBAXISAL EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.530000001934791 ROBAXISAL-C 1/2 TABLET ORL TAB PDH TAB 1.249600001934783 ROBAXISAL-C 1/4 TABLET ORL TAB PDH TAB 1.045800001931032 ROBITUSSIN 20 MG ORAL SYRUP ORL SYR PDH ML 0.052200002142783 ROBITUSSIN 200 MG/5 ML EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.052200001934740 ROBITUSSIN A-C ORAL SYRUP ORL SYR PDH ML 0.108100002068419 ROBITUSSIN COUGH AND COLD ORAL SYRUP ORL SYR PDH ML 0.052200002142775 ROBITUSSIN DM EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.052200001931024 ROBITUSSIN DM ORAL SYRUP ORL SYR PDH ML 0.052200000824291 ROCALTROL 1 MCG/ML ORAL SOLUTION ORL SOL HLR ML 2.956000002318415 ROCURONIUM BROMIDE 10MG/ML INJECTION INJ DEFAUL SDZ ML 1.026000000393444 ROFACT 150 MG CAPSULE ORL CAP VCL CAP 0.706700000343617 ROFACT 300 MG CAPSULE ORL CAP VCL CAP 1.124500000708925 ROGAINE 20 MG/ML TOPICAL SOLUTION TOP SOL UPJ ML 0.660500002368684 ROGAINE FOAM 50 MG/G AEROSOL FOAM TOP FOA JJI G 0.751700002242979 ROGITINE 10 MG/ML INJECTION INJ DEFAUL PAL ML 39.442000002381184 ROSUVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.3400

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 79 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002389045 ROSUVASTATIN 10 MG TABLET ORL TAB SIV TAB 0.340000002381192 ROSUVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.425000002389053 ROSUVASTATIN 20 MG TABLET ORL TAB SIV TAB 0.425000002381206 ROSUVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.497700002389061 ROSUVASTATIN 40 MG TABLET ORL TAB SIV TAB 0.497700002381176 ROSUVASTATIN 5 MG TABLET ORL TAB PDL TAB 0.322700002389037 ROSUVASTATIN 5 MG TABLET ORL TAB SIV TAB 0.322700002284413 ROTATEQ (2 ML/DOSE) ORAL SOLUTION ORL SOL MFC ML 30.770000000466425 ROUGIER CALCIUM ORAL LIQUID ORL LIQ ROG ML 0.021000002222116 RUB A-535 EXTRA STRENGTH TOP CRM CHD G 0.061600002248563 RUB A535 DUAL ACTION TOP CRM CHD G 0.061600002224828 RYTHMODAN 150 MG CAPSULE ORL CAP SAV CAP 0.392400002245735 SAB-SODIUM CHLORIDE 5% OPTHALMIC SOLUTION USP OPH SOL SDZ ML 0.563300000623571 SALIJECT 570 MG/ML INJECTION INJ DEFAUL OMG ML 1.430000080024381 SALINEX 9 MG/ML NASAL SPRAY NAS SPR SDZ ML 0.138000000779296 SALINEX NASAL LUBRICANT GEL NAS GEL SDZ G 0.148300001910701 SALINEX NASAL LUBRICANT SPRAY NAS SPR SDZ ML 0.169700080004542 SALMON & FISH OILS 1000 MG SOFTGEL ORL TAB WNP TAB 0.071500002370468 SAMSCA 15 MG TABLET ORL TAB OTS TAB 250.000000002370476 SAMSCA 30 MG TABLET ORL TAB OTS TAB 250.000000000593257 SANDIMMUNE I.V. 50 MG/ML INJECTION INJ DEFAUL NOV ML 4.800000002288079 SANDOZ ALENDRONATE 5 MG TABLET ORL TAB SDZ TAB 1.037000002338467 SANDOZ ANASTROZOLE 1 MG TABLET ORL TAB SDZ TAB 2.766700002247692 SANDOZ ANUZINC HC PLUS OINTMENT RT ONT SDZ G 0.883300002231733 SANDOZ ATENOLOL 100 MG TABLET ORL TAB SDZ TAB 0.568700002231731 SANDOZ ATENOLOL 50 MG TABLET ORL TAB SDZ TAB 0.346000002386410 SANDOZ ATOMOXETINE 10 MG CAPSULE ORL CAP SDZ CAP 2.314000002386429 SANDOZ ATOMOXETINE 18 MG CAPSULE ORL CAP SDZ CAP 2.652300002386437 SANDOZ ATOMOXETINE 25 MG CAPSULE ORL CAP SDZ CAP 2.928000002386445 SANDOZ ATOMOXETINE 40 MG CAPSULE ORL CAP SDZ CAP 3.337300002386453 SANDOZ ATOMOXETINE 60 MG CAPSULE ORL CAP SDZ CAP 3.702300002386283 SANDOZ BOSENTAN 125 MG TABLET ORL TAB SDZ TAB 52.304800002386275 SANDOZ BOSENTAN 62.5 MG TABLET ORL TAB SDZ TAB 52.304800002417340 SANDOZ CANDESARTAN 32 MG TABLET ORL TAB SDZ TAB 0.285000002326957 SANDOZ CANDESARTAN 4 MG TABLET ORL TAB SDZ TAB 0.340000002303426 SANDOZ CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS SDZ ML 0.059200002303434 SANDOZ CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS SDZ ML 0.118500002242485 SANDOZ CORTIMYXIN OPH OINTMENT OPH ONT SDZ G 3.614300002230386 SANDOZ CORTIMYXIN OTIC SOLUTION OT SOL SDZ ML 1.1400

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000739839 SANDOZ DEXAMETHASONE SOD PHOSPHATE 0.1% OT/OPH SOL OT/OPH SOL SDZ ML 1.378000002241224 SANDOZ DICLOFENAC 50 MG RECTAL SUPPOSITORY RT SUP SDZ SUP 0.623600002400596 SANDOZ DICLOFENAC MISOPROSTOL 50 MG/200 MCG ECT ORL ECT SDZ TAB 0.454100002400618 SANDOZ DICLOFENAC MISOPROSTOL 75 MG/200 MCG ECT ORL ECT SDZ TAB 0.617900002261774 SANDOZ DICLOFENAC RAPIDE 50 MG TABLET ORL TAB SDZ TAB 0.393700002367696 SANDOZ DONEPEZIL ODT 10 MG TABLET ORL DISNTAB SDZ TAB 3.617700002367688 SANDOZ DONEPEZIL ODT 5 MG TABLET ORL DISNTAB SDZ TAB 3.617700002278634 SANDOZ FAMCICLOVIR 125 MG TABLET ORL TAB SDZ TAB 2.024000002278642 SANDOZ FAMCICLOVIR 250 MG TABLET ORL TAB SDZ TAB 2.720000002278650 SANDOZ FAMCICLOVIR 500 MG TABLET ORL TAB SDZ TAB 4.594400002390701 SANDOZ FENOFIBRATE E 145 MG TABLET ORL TAB SDZ TAB 0.990300002390698 SANDOZ FENOFIBRATE E 48 MG TABLET ORL TAB SDZ TAB 0.387000002327139 SANDOZ FENTANYL PATCH 37 MCG/HR TRANSDERMAL PATCH TRD PTH SDZ PTH 9.236000002339471 SANDOZ FINASTERIDE A 1 MG TABLET ORL TAB SDZ TAB 1.244700002247055 SANDOZ FLUVOXAMINE 100 MG TABLET ORL TAB SDZ TAB 0.411100002247054 SANDOZ FLUVOXAMINE 50 MG TABLET ORL TAB SDZ TAB 0.210500002230888 SANDOZ GENTAMICIN SULFATE 0.3% OPH OINTMENT OPH ONT SDZ G 1.500000002229440 SANDOZ GENTAMICIN SULFATE 0.3% OPH SOLUTION OPH SOL SDZ ML 0.406000002229441 SANDOZ GENTAMICIN SULFATE 0.3% OTIC SOLUTION OT SOL SDZ ML 1.032000002237187 SANDOZ IDOXURIDINE 0.1% TOPICAL SOLUTION TOP SOL SDZ ML 4.990000002344815 SANDOZ LETROZOLE 2.5 MG TABLET ORL TAB SDZ TAB 2.756000002241715 SANDOZ LEVOBUNOLOL 0.25% OPH SOLUTION OPH SOL SDZ ML 1.176000002257564 SANDOZ LOPERAMIDE 2 MG TABLET ORL TAB SDZ TAB 0.288900002247057 SANDOZ LOVASTATIN 40 MG TABLET ORL TAB SDZ TAB 0.898500002344807 SANDOZ MEMANTINE 10 MG TABLET ORL TAB SDZ TAB 1.635700002247876 SANDOZ METOPROLOL (TYPE L) 100 MG TABLET ORL TAB SDZ TAB 0.222300002250594 SANDOZ MIRTAZAPINE 15 MG TABLET ORL TAB SDZ TAB 0.407400002320630 SANDOZ MYCOPHENOLATE MOFETIL 250 MG CAPSULE ORL CAP SDZ CAP 1.120300002313855 SANDOZ MYCOPHENOLATE MOFETIL 500 MG TABLET ORL TAB SDZ TAB 2.886800002327791 SANDOZ OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 5.819300002327805 SANDOZ OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 8.256000002358913 SANDOZ OLOPATADINE 0.1% OPH SOLUTION OPH SOL SDZ ML 5.226000002420171 SANDOZ OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL SDZ ML 10.452000002247920 SANDOZ OPTICORT OTIC OPH SOLUTION OT/OPH SOL SDZ ML 1.467500002301075 SANDOZ PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT SDZ TAB 1.275000002269422 SANDOZ PAROXETINE 10 MG TABLET ORL TAB SDZ TAB 1.043000002254778 SANDOZ PAROXETINE 30 MG TABLET ORL TAB SDZ TAB 1.064700002244999 SANDOZ PENTASONE 0.1%/0.3% OTIC OPH SOL OT/OPH SOL SDZ ML 1.281300002261790 SANDOZ PINDOLOL 10 MG TABLET ORL TAB SDZ TAB 0.2323

Page 81: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 81 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002261804 SANDOZ PINDOLOL 15 MG TABLET ORL TAB SDZ TAB 0.337000002261782 SANDOZ PINDOLOL 5 MG TABLET ORL TAB SDZ TAB 0.136100002297906 SANDOZ PIOGLITAZONE 15 MG TABLET ORL TAB SDZ TAB 0.580900002297914 SANDOZ PIOGLITAZONE 30 MG TABLET ORL TAB SDZ TAB 0.813900002297922 SANDOZ PIOGLITAZONE 45 MG TABLET ORL TAB SDZ TAB 1.223700002239234 SANDOZ POLYTRIMETHOPRIM OPH SOLUTION OPH SOL SDZ ML 2.727000002315270 SANDOZ PRAMIPEXOLE 0.5 MG TABLET ORL TAB SDZ TAB 1.386000001916181 SANDOZ PREDNISOLONE ACETATE 0.12% OPH SUSPENSION OPH SUS SDZ ML 1.345000001916203 SANDOZ PREDNISOLONE ACETATE 1% OPH SUSPENSION OPH SUS SDZ ML 1.940000002390841 SANDOZ PREGABALIN 150 MG CAPSULE ORL CAP SDZ CAP 1.727000002390817 SANDOZ PREGABALIN 25 MG CAPSULE ORL CAP SDZ CAP 0.617200002390868 SANDOZ PREGABALIN 300 MG CAPSULE ORL CAP SDZ CAP 1.727000002390825 SANDOZ PREGABALIN 50 MG CAPSULE ORL CAP SDZ CAP 0.968200002390833 SANDOZ PREGABALIN 75 MG CAPSULE ORL CAP SDZ CAP 1.252800002318822 SANDOZ SILDENAFIL 100 MG TABLET ORL TAB SDZ TAB 9.997500002318806 SANDOZ SILDENAFIL 25 MG TABLET ORL TAB SDZ TAB 8.290000002318814 SANDOZ SILDENAFIL 50 MG TABLET ORL TAB SDZ TAB 8.848100002234013 SANDOZ SOTALOL 160 MG TABLET ORL TAB SDZ TAB 0.208700002416824 SANDOZ TACROLIMUS 1 MG CAPSULE ORL CAP SDZ CAP 2.053800002416832 SANDOZ TACROLIMUS 5 MG CAPSULE ORL CAP SDZ CAP 10.285100002243587 SANDOZ TICLOPIDINE 250 MG TABLET ORL TAB SDZ TAB 0.688500002248529 SANDOZ TRIFLURIDINE 1% OPH SOLUTION OPH SOL SDZ ML 3.266700002239714 SANDOZ VALPROIC 250 MG CAPSULE ORL CAP SDZ CAP 0.136600002356740 SANDOZ VALSARTAN 40 MG TABLET ORL TAB SDZ TAB 0.569400002399253 SANDOZ VORICONAZOLE 200MG TABLET ORL TAB SDZ TAB 38.561000002399245 SANDOZ VORICONAZOLE 50MG TABLET ORL TAB SDZ TAB 9.644300002257580 SANDOZ ZOPICLONE 7.5 MG TABLET ORL TAB SDZ TAB 0.468500000874825 SARNA-P TOPICAL LOTION TOP LOT STI ML 0.054700002266121 SATIVEX BUCCAL SPRAY BUC SPR BHP ML 22.809000080041540 SCHINOUSSA PROBIOTIC WHEY ISOLATE ORAL POWDER ORL PWR QUA G 0.035700001919245 SCHOLL ATHLETE'S FOOT SPRAY 1% TOPICAL POWDER TOP PWR SCH G 0.049900002020939 SCLERODEX INJECTION INJ DEFAUL OMG ML 1.304000002020793 SCLERODINE 6 INJECTION INJ DEFAUL OMG ML 2.710000000541869 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML INJECTION INJ DEFAUL HSP ML 5.314000000541877 SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION INJ DEFAUL HSP ML 5.824000002296659 SEASONALE (91 DAY) TABLET ORL TAB ASC TAB 0.668700002346176 SEASONIQUE (91 DAY) TABLET ORL TAB ASC TAB 0.668700000666106 SEBCUR 4% TOPICAL SHAMPOO TOP SHP DPT ML 0.062100000666114 SEBCUR-T TOPICAL SHAMPOO TOP SHP DPT ML 0.0659

Page 82: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 82 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002288389 SEBIVO 600 MG TABLET ORL TAB NOV TAB 17.688900000551805 SECARIS NASAL GEL NAS GEL PMS G 0.341400000633380 SELENIUM 100 MCG TABLET ORL TAB JAM TAB 0.074200000554987 SELENIUM 50 MCG TABLET ORL TAB JAM TAB 0.065900000243000 SELSUN 2.5% TOPICAL SOLUTION TOP SOL ABB ML 0.048400000483796 SELSUN BLUE 1% TOPICAL LOTION TOP LOT ABB ML 0.025500000709069 SELSUN BLUE EXTRA CONDITIONING 1% TOPICAL SHAMPOO TOP SHP ABB ML 0.025500002247134 SENNA LAXATIVE & DOCUSATE SODIUM 8.6MG/50MG TABLET ORL TAB VTH TAB 0.053200002237105 SENNA LAXATIVE 8.6 MG TABLET ORL TAB SDR TAB 0.024900002257130 SENSIPAR 30 MG TABLET ORL TAB AMG TAB 12.613700002257149 SENSIPAR 60 MG TABLET ORL TAB AMG TAB 23.000300002257157 SENSIPAR 90 MG TABLET ORL TAB AMG TAB 33.469700002357704 SEPTA-AMLODIPINE 2.5 MG TABLET ORL TAB SEP TAB 0.138000002368633 SEPTA-ATENOLOL 25 MG TABLET ORL TAB SEP TAB 0.173000002247998 SERC 24 MG TABLET ORL TAB ABB TAB 0.760700002239046 SEROSTIM 5 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 1633.000000002241304 SERTRALINE 100 MG CAPSULE ORL CAP PDL CAP 0.420000002241302 SERTRALINE 25 MG CAPSULE ORL CAP PDL CAP 0.200400002241303 SERTRALINE 50 MG CAPSULE ORL CAP PDL CAP 0.400000002240344 SIALOR 25 MG TABLET ORL TAB PMS TAB 0.963000080039305 SIERRASIL JOINT FORMULA 14 CAPSULE ORL CAP SMM CAP 0.227300002413299 SIGNIFOR 0.3 MG/ML INJECTION INJ DEFAUL NOV ML 80.513000002317583 SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.200700002406160 SILDENAFIL 100 MG TABLET ORL TAB SNS TAB 9.200000002317559 SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 8.290000002317575 SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 8.848000002406152 SILDENAFIL 50 MG TABLET ORL TAB SNS TAB 8.847500002398257 SILENOR 3 MG TABLET ORL TAB PAL TAB 0.630300002398265 SILENOR 6 MG TABLET ORL TAB PAL TAB 1.260700080012979 SILICA WITH ZINC CAPLET ORL TAB JAM TAB 0.206200002338572 SILKIS 3 MCG/G TOPICAL OINTMENT TOP ONT GAL G 1.358300002239548 SIMPLY SLEEP 25 MG CAPLET ORL TAB MCL TAB 0.201500002413183 SIMPONI 100 MG/1 ML INJECTION AUTO INJECTOR INJ NDL JAI SYR 1610.320000002413175 SIMPONI 100 MG/1 ML INJECTION SYRINGE INJ NDL JAI SYR 1610.320000002417472 SIMPONI I.V. 50 MG/4.0 ML VIAL INJECTION INJ DEFAUL JAI ML 224.627500002247224 SIMVASTATIN-80 80 MG TABLET ORL TAB PDL TAB 0.625000000326925 SINEQUAN 100 MG CAPSULE ORL CAP ERF CAP 1.192100000400750 SINEQUAN 75 MG CAPSULE ORL CAP ERF CAP 0.914500001926055 SINUTAB N.D. REGULAR STRENGTH TABLET ORL TAB WLA TAB 0.1808

Page 83: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 83 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001938371 SINUTAB NO DROWSINESS EXTRA STRENGTH TABLET ORL TAB WLA TAB 0.287500001926004 SINUTAB REGULAR STRENGTH TABLET ORL TAB WLA TAB 0.239200001938363 SINUTAB WITH CODEINE TABLET ORL TAB PDH TAB 0.406300001994247 SLEEP AID (REGULAR STRENGTH) 25 MGTABLET ORL TAB TAN TAB 0.095000000623520 SLOW-FE 160 MG TABLET ORL SRT CGS TAB 0.289000002245456 SODIUM AUROTHIOMALATE INJECTION B.P. 10 MG/ ML INJ DEFAUL SDZ ML 9.660000002245457 SODIUM AUROTHIOMALATE INJECTION B.P. 25 MG/ML INJ DEFAUL SDZ ML 14.050000000481912 SODIUM BICARBONATE 325 MG TABLET ORL TAB SLW TAB 0.032400080022194 SODIUM BICARBONATE 500 MG TABLET ORL TAB SDZ TAB 0.075400000261998 SODIUM BICARBONATE 8.4 % INJECTION INJ DEFAUL HSP ML 0.593400000037842 SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL HSP ML 0.022000000060208 SODIUM CHLORIDE 0.9% INJECTION USP INJ DEFAUL BAX ML 0.006200000392499 SODIUM CHLORIDE 234 MG/ML INJECTION INJ DEFAUL SDZ ML 3.890000002139510 SODIUM CHLORIDE 234 MG/ML INJECTION INJ DEFAUL PPC ML 0.316300000402230 SODIUM CHLORIDE 234 MG/ML INJECTION USP INJ DEFAUL OMG ML 0.216700002150204 SODIUM CHLORIDE 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.325000000037834 SODIUM CHLORIDE 9 MG/ML IRRIGATION SOLUTION IR SOL HSP ML 0.022400000402249 SODIUM CHLORIDE BACTERIOSTATIC 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.161700000268313 SODIUM EDECRIN 50 MG/VIAL INJECTION INJ DEFAUL VCL VIAL 466.260000000896187 SODIUM PHOSPHATE INJECTION INJ DEFAUL SDZ ML 0.984700000028053 SODIUM SULAMYD 10% OPH SOLUTION OPH SOL SDZ ML 0.493300002006758 SOFLAX 4 MG/ML ORAL SYRUP ORL SYR PMS ML 0.023200001988840 SOFRA-TULLE (10 X 10 CM) TOPICAL GAUZE TOP GAU ERF DRE 1.684000001987682 SOFRA-TULLE STRIP (10 X 30 CM) TOPICAL GAUZE TOP GAU AVE DRE 3.870000002224895 SOFRAMYCIN 0.5% OPH OINTMENT OPH ONT ERF G 4.216000002224887 SOFRAMYCIN 0.5% OPH SOLUTION OPH SOL ERF ML 1.468800002224879 SOFRAMYCIN 15 MG/50 MCG TOPICAL OINTMENT TOP ONT ERF G 1.184000002224860 SOFRAMYCIN NASAL SPRAY NAS SPR ERF ML 2.934000002243257 SOLAGE 0.01%/ 2% TOPICAL SOLUTION TOP SOL GAL ML 1.693300001923986 SOLARCAINE FIRST AID LIDOCAINE 0.5% TOPICAL AEROSO TOP AER SCH G 0.038500002230211 SOLU-MEDROL 40MG/VIAL INJECTION INJ DEFAUL PFI VIAL 5.267200002063697 SOLU-MEDROL ACT-O-VIAL (PRES) 1 G/VIAL (BASE) INJ INJ DEFAUL PFI VIAL 55.370000002063727 SOLU-MEDROL ACT-O-VIAL (PRES) 125MG/VIAL (BASE)INJ INJ DEFAUL PFI VIAL 15.662000002063719 SOLU-MEDROL ACT-O-VIAL (PRES) 40MG/VIAL (BASE) INJ INJ DEFAUL PFI VIAL 6.071000002063700 SOLU-MEDROL ACT-O-VIAL (PRES) 500MG/VIAL (BASE)INJ INJ DEFAUL PFI VIAL 36.122000001975382 SOLUGEL 4% TOPICAL GEL TOP GEL STI G 0.226900002019825 SOLUGEL 8% TOPICAL GEL TOP GEL GSK G 0.348000000690333 SOLUVER 20% TOPICAL SOLUTION TOP SOL DPT ML 0.771400000837733 SOLUVER PLUS LIQ 27% TOP SOL DPT ML 1.2420

Page 84: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 84 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000769533 SOLYSTAT 250 MG/ML RECTAL SUSPENSION RT RTNENM PPH ENM 13.640000002272199 SOMAVERT 10 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 128.660000002272202 SOMAVERT 15 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 177.420000002272210 SOMAVERT 20 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 236.440000000483818 SOMNOL 30 MG TABLET ORL TAB AXS TAB 0.114500002385996 SOTALOL 160 MG TABLET ORL TAB SIV TAB 0.162300002418355 SOVALDI 400 MG TABLET ORL TAB GIL TAB 711.496800002237578 SPASMHALT-8 CAPLET ORL TAB PPH TAB 0.369300002237580 SPASMHALT-ASA-8 CAPLET ORL TAB WAM TAB 0.330000002214415 SPECTRO ECZEMACARE MEDICATED CREAM TOP CRM GKC G 0.440000002320193 SPRYCEL 100 MG TABLET ORL TAB BMS TAB 161.298300002293129 SPRYCEL 20 MG TABLET ORL TAB BMS TAB 37.338700002293137 SPRYCEL 50 MG TABLET ORL TAB BMS TAB 75.147300002293145 SPRYCEL 70 MG TABLET ORL TAB BMS TAB 89.383700001938991 STANHEXIDINE 2% SOL WITH 4% ISOPROPYL ALCOHOL TOP SOL OMG ML 0.010500001938983 STANHEXIDINE 4% WITH 4% ISOPROPYL ALCOHOL SOLUTION TOP SOL OMG ML 0.016300002245439 STARLIX 120 MG TABLET ORL TAB NOV TAB 0.606500002245438 STARLIX 60 MG TABLET ORL TAB NOV TAB 0.600100002372436 STAXYN 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB BAI TAB 7.172500002139383 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL PPC VIAL 102.303000002230192 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL HSP VIAL 78.890000002241807 STERILE VANCOMYCIN HCL 10 G/VIAL INJECTION INJ DEFAUL PPC VIAL 971.050000002139243 STERILE VANCOMYCIN HCL 5 G/VIAL INJECTION INJ DEFAUL PPC VIAL 509.790000002139375 STERILE VANCOMYCIN HCL 500 MG/VIAL INJ USP INJ DEFAUL PPC VIAL 47.704000002230191 STERILE VANCOMYCIN HCL 500 MG/VIAL INJECTION INJ DEFAUL HSP VIAL 45.118000000038245 STERILE WATER FOR INJECTION DEFAUL INJ HSP ML 0.095000000402257 STERILE WATER FOR INJECTION DEFAUL INJ OMG ML 0.350000002142546 STERILE WATER FOR INJECTION DEFAUL INJ HSP ML 0.201000002247228 STIEPROX 1.5 % TOPICAL SHAMPOO TOP SHP GSK ML 0.146400000587966 STIEVA-A 0.025% TOPICAL GEL TOP GEL GSK G 0.299600000578568 STIEVA-A 0.025% TOPICAL SOLUTION TOP SOL GSK ML 0.183600000641863 STIEVA-A 0.05% TOPICAL GEL TOP GEL GSK G 0.299600002125277 STILAMIN 3 MG/AMPOULE INJECTION INJ DEFAUL SRO VIAL 210.000000002403390 STIVARGA 40 MG TABLET ORL TAB BAI TAB 80.683800002262800 STRATTERA 10 MG CAPSULE ORL CAP LIL CAP 2.924300002279355 STRATTERA 100 MG CAPSULE ORL CAP LIL CAP 5.555400002262819 STRATTERA 18 MG CAPSULE ORL CAP LIL CAP 3.330700002262827 STRATTERA 25 MG CAPSULE ORL CAP LIL CAP 3.737100002262835 STRATTERA 40 MG CAPSULE ORL CAP LIL CAP 4.2050

Page 85: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002262843 STRATTERA 60 MG CAPSULE ORL CAP LIL CAP 4.710700002279347 STRATTERA 80 MG CAPSULE ORL CAP LIL CAP 5.057100002243660 STREPTOMYCIN 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 43.600000002174383 STRESSEASE MULTIVITAMIN AND MINERAL CAPLET ORL TAB JAM TAB 0.112700002166615 STRESSTABS + ZINC-COPPER TABLET ORL TAB WCH TAB 0.107100080009625 STRESSTABS FOR WOMEN TABLET ORL TAB PDH TAB 0.104200002167948 STRESSTABS PLUS IRON TABLET ORL TAB WCH TAB 0.107100002397137 STRIBILD TABLET ORL TAB GIL TAB 48.934000002370433 SUBLINOX 10 MG SUBLINGUAL DISINTEGRATING TABLET SLG DISNTAB MED TAB 1.451000002391678 SUBLINOX 5 MG SUBLINGUAL DISINTEGRATING TAB SLG DISNTAB MED TAB 1.437000002238099 SUDAFED DECONGESTANT 12-HOUR 120 MG CAPLET ORL TAB WLA TAB 0.495000002237793 SUDAFED DECONGESTANT EXTRA STRENGTH 60 MG TABLET ORL TAB WLA TAB 0.290800002250217 SUDAFED PE DECONGESTANT 10 MG TABLET ORL TAB MCL TAB 0.300000001951319 SUFENTA 50 MCG/ML INJECTION INJ DEFAUL JAI ML 6.932000002244147 SUFENTANIL CITRATE USP 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 10.670000000187534 SULFUR TOPICAL SOAP TOP SOP STI G 0.068400000678996 SUPER B COMPLEX CAPSULE ORL CAP SIS CAP 0.258100080002944 SUPER CALCIUM 600 MG WITH VITAMIN D 400 IU ORL TAB JAM TAB 0.155700080011269 SUPER MULTI IRON FREE TABLET ORL TAB NFN TAB 0.214300080023127 SUPER STRAIN ACIDOPHILUS PROBIOTIC 2 BILLION ORL CAP JAM CAP 0.129300002242658 SUPER STRENGTH MOTRIN IB 400 MG TABLET ORL TAB MCL TAB 0.199400080017929 SUPER VITA VIM CAPLET ORL TAB JAM TAB 0.136600002242595 SUPER VITA-VIM CAPLET ORL TAB JAM TAB 0.133400002240749 SUPREFACT DEPOT 9.45 MG IMPLANT INJECTION INJ IMP SAV SYS 1222.550000002239888 SUSTIVA 200 MG CAPSULE ORL CAP DPM CAP 5.414000002239886 SUSTIVA 50 MG CAPSULE ORL CAP DPM CAP 1.245700002246045 SUSTIVA 600 MG TABLET ORL TAB DPM TAB 16.242000002280795 SUTENT 12.5 MG CAPSULE ORL CAP PFI CAP 66.906800002280809 SUTENT 25 MG CAPSULE ORL CAP PFI CAP 133.813200002280817 SUTENT 50 MG CAPSULE ORL CAP PFI CAP 267.626800002245890 SYNAGIS 100 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 1504.510000002245889 SYNAGIS 50 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 752.260000002162504 SYNALAR 0.01% TOPICAL SOLUTION TOP SOL VLP ML 0.444700002162512 SYNALAR 0.025% TOPICAL OINTMENT TOP ONT VLP G 0.468200000990010 SYNVISC DEFAUL DEV GZB ML 65.275000000999331 SYNVISC ONE DEFAUL DEV GZB ML 66.333300002248967 SYSTANE OPHTHALMIC SOLUTION OPH SOL ALC ML 0.835000080032792 SYSTANE VITAMIN- OMEGA 3 CAPSULE ORL CAP ALC CAP 0.228700002239122 T.R. SWISS ONE 50 MULTIVITAMIN & MINERAL TABLET ORL TAB SWS TAB 0.2212

Page 86: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002365871 TACTUO 0.1%/2.5% TOPICAL GEL TOP GEL GAL G 1.691800002409607 TAFINLAR 50 MG CAPSULE ORL CAP GSK CAP 45.388900002409615 TAFINLAR 75 MG CAPSULE ORL CAP GSK CAP 68.083300001966200 TAMBOCOR 100 MG TABLET ORL TAB VCL TAB 1.077000001966197 TAMBOCOR 50 MG TABLET ORL TAB VCL TAB 0.538400002245549 TAMIFLU 12 MG/ML ORAL SUSPENSION ORL SUS HLR ML 0.530400002304848 TAMIFLU 30 MG CAPSULE ORL CAP HLR CAP 2.194000002304856 TAMIFLU 45 MG CAPSULE ORL CAP HLR CAP 3.376000002381842 TAMIFLU 6 MG/ML ORAL SUSPENSION ORL SUS HLR ML 0.337500002241472 TAMIFLU 75 MG CAPSULE ORL CAP HLR CAP 4.389000001926624 TAMOFEN 10 MG TABLET ORL TAB SAV TAB 0.175000002331780 TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE ORL SRC RAN CAP 0.566400002413612 TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.150000001962353 TANTAPHEN EXTRA STRENGTH 500 MG CAPLET ORL TAB TAN TAB 0.021400002296039 TAPAZOLE 10 MG TABLET ORL TAB PAL TAB 0.580200002269015 TARCEVA 100 MG TABLET ORL TAB HLR TAB 57.333300002269023 TARCEVA 150 MG TABLET ORL TAB HLR TAB 86.932000002269007 TARCEVA 25 MG TABLET ORL TAB HLR TAB 13.333300000510335 TARGEL SA TOPICAL LIQUID TOP LIQ ODN G 0.187900000344508 TARGEL TOPICAL GEL TOP GEL ODN G 0.173600002339609 TARGIN 10 MG/ 5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.049700002339617 TARGIN 20 MG/ 10 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.574500002339625 TARGIN 40 MG/ 20 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 2.727500002387425 TARGIN 5 MG/ 2.5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.753000002240945 TARKA 1 MG/ 240 MG TABLET ORL TAB ABB TAB 1.540000002238096 TARKA 2 MG/ 180 MG TABLET ORL TAB ABB TAB 1.550000002240946 TARKA 2 MG/ 240 MG TABLET ORL TAB ABB TAB 1.902500002238097 TARKA 4 MG/ 240 MG TABLET ORL TAB ABB TAB 2.111300002365650 TARO-ANASTROZOLE 1 MG TABLET ORL TAB TAR TAB 1.273000002244403 TARO-CARBAMAZEPINE 100 MG CHEWABLE TABLET ORL CTB TAR TAB 0.118800002244404 TARO-CARBAMAZEPINE 200 MG CHEWABLE TABLET ORL CTB TAR TAB 0.255800002407515 TARO-CARBAMAZEPINE 200 MG TABLET ORL TAB TAR TAB 0.231600002353288 TARO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL TAR G 8.415000002266938 TARO-CLINDAMYCIN 1% (BASE) TOPICAL SOLUTION TOP SOL TAR ML 0.284000002420988 TARO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL TAR ML 0.622700002264749 TARO-MOMETASONE 0.1% OINTMENT TOP ONT TAR G 0.272000001925350 TARO-SONE 0.05% TOPICAL CREAM TOP CRM TAR G 0.204800002247651 TARO-TERCONAZOLE 0.4% VAGINAL CREAM VAG CRM TAR G 0.495300002368250 TASIGNA 150 MG CAPSULE ORL CAP NOV CAP 30.0273

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002315874 TASIGNA 200 MG CAPSULE ORL CAP NOV CAP 42.242500002016796 TAXOL 6 MG/ML INJECTION INJ DEFAUL BMS ML 1.980200002177099 TAXOTERE 40 MG/ML (20 MG/0.5 ML) INJECTION INJ DEFAUL SAV ML 456.940000002177080 TAXOTERE 40 MG/ML (80 MG/2 ML) INJECTION INJ DEFAUL SAV ML 456.940000000886955 TAZIDIME 2 G/VIAL INJECTION INJ DEFAUL LIL VIAL 60.810000000886963 TAZIDIME 6 G/VIAL INJECTION INJ DEFAUL LIL VIAL 190.990000002243894 TAZORAC 0.05% TOPICAL CREAM TOP CRM ALL G 1.478000002243895 TAZORAC 0.1% TOPICAL CREAM TOP CRM ALL G 1.462000000615358 TD POLIO ADSORBED FOR ADULT INJECTION INJ DEFAUL AVE VIAL 59.044000001950010 TEARS ENCORE 1.4% OPH SOLUTION OPH SOL AKN ML 0.971000002246397 TEARS NATURAL FORTE OPH SOLUTION OPH SOL ALC ML 0.414000001943308 TEARS NATURALE FREE OPH SOLUTION OPH SOL ALC ML 0.516000000743445 TEARS NATURALE II OPH SOLUTION OPH SOL ALC ML 0.440700000390291 TEARS NATURALE OPH DROPS OPH DPS ALC ML 0.428700002082519 TEARS NATURALE P.M. OPH OINTMENT OPH ONT ALC G 1.611400000579408 TEARS PLUS 1.4% OPH SOLUTION OPH SOL ALL ML 0.503300000283991 TEBRAZID 500 MG TABLET ORL TAB VCL TAB 0.498000002404508 TECFIDERA 120 MG DELAYED-RELEASE CAPSULE ORL DRC BIO CAP 17.595500002420201 TECFIDERA 240 MG DELAYED-RELEASE CAPSULE ORL DRC BIO CAP 32.385000002395223 TELMISARTAN 40 MG TABLET ORL TAB PDL TAB 0.282400002395231 TELMISARTAN 80 MG TABLET ORL TAB PDL TAB 0.282400002395525 TELMISARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.282400002395533 TELMISARTAN-HCTZ 80 MG/25 MG TABLET ORL TAB PDL TAB 0.282400002261553 TELZIR 50 MG/ML ORAL SUSPENSION ORL SUS GSK ML 0.591200002261545 TELZIR 700 MG TABLET ORL TAB GSK TAB 8.918800002241095 TEMODAL 100 MG CAPSULE ORL CAP MFC CAP 164.910000002321262 TEMODAL 100 MG/VIAL INJECTION INJ DEFAUL MFC VIAL 411.260000002312794 TEMODAL 140 MG CAPSULE ORL CAP MFC CAP 230.876000002312816 TEMODAL 180 MG CAPSULE ORL CAP MFC CAP 264.380500002241094 TEMODAL 20 MG CAPSULE ORL CAP MFC CAP 32.984000002241096 TEMODAL 250 MG CAPSULE ORL CAP MFC CAP 412.262000002241093 TEMODAL 5 MG CAPSULE ORL CAP MFC CAP 8.384000000876038 TEMPRA DOUBLE STRENGTH 160 MG CHEWABLE TABLET ORL CTB PAL TAB 0.156000000875988 TEMPRA INFANT 80 MG/ML ORAL DROPS ORL DPS PAL ML 0.272700000894710 TERAZOL 3 80 MG VAGINAL OVULE VAG OVL JAI OVL 6.376700002130874 TERAZOL 3 DUAL PAK KIT VAG/TOP OVL/CRM JAI KIT 33.030000000894729 TERAZOL 7 0.4% VAGINAL CREAM VAG CRM JAI G 0.697600000632309 TERSA-TAR 3% TOPICAL SHAMPOO TOP SHP TCD ML 0.039300000632295 TERSA-TAR MILD 1% TOPICAL SHAMPOO TOP SHP TCD ML 0.0367

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 88 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000632317 TERSASEPTIC 0.5% TOPICAL SHAMPOO TOP SHP TCD ML 0.027300002280248 TESTIM 1% TOPICAL GEL TOP GEL PAL G 0.783100000514462 TETANUS & DIPHTHERIA TOXOIDS ADULT INJECTION INJ LIQ CNG ML 45.224000002148528 TETRACAINE 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 7.245000002248251 TEVA-ALENDRONATE 5 MG TABLET ORL TAB TEV TAB 1.037000002403633 TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG/2800 U TAB ORL TAB TEV TAB 4.052500002313049 TEVA-ANASTROZOLE 1 MG TABLET ORL TAB TEV TAB 2.546000002362538 TEVA-ATOMOXETINE 100 MG CAPSULE ORL CAP TEV CAP 4.352000002362511 TEVA-ATOMOXETINE 80 MG CAPSULE ORL CAP TEV CAP 3.996000002380927 TEVA-ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ORL TAB TEV TAB 4.489200002398419 TEVA-BOSENTAN 125 MG TABLET ORL TAB TEV TAB 48.134000002398400 TEVA-BOSENTAN 62.5 MG TABLET ORL TAB TEV TAB 48.134000002400022 TEVA-CAPECITABINE 150 MG TABLET ORL TAB TEV TAB 1.590800002400030 TEVA-CAPECITABINE 500 MG TABLET ORL TAB TEV TAB 5.302800002239355 TEVA-DIFENAC-K 50 MG TABLET ORL TAB TEV TAB 0.393700002389762 TEVA-EFAVIRENZ 600 MG TABLET ORL TAB TEV TAB 11.210300002382091 TEVA-ELETRIPTAN 20 MG TABLET ORL TAB TEV TAB 10.085000002382105 TEVA-ELETRIPTAN 40 MG TABLET ORL TAB TEV TAB 10.085000002408473 TEVA-EXEMESTANE 25 MG TABLET ORL TAB TEV TAB 3.900700002248457 TEVA-GABAPENTIN 600 MG TABLET ORL TAB TEV TAB 1.304500002247346 TEVA-GABAPENTIN 800 MG TABLET ORL TAB TEV TAB 1.739300002399806 TEVA-IMATINIB 100 MG TABLET ORL TAB TEV TAB 20.455700002399814 TEVA-IMATINIB 400 MG TABLET ORL TAB TEV TAB 81.822800002387247 TEVA-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB TEV TAB 7.830900002343657 TEVA-LETROZOLE 2.5 MG TABLET ORL TAB TEV TAB 2.756000002258323 TEVA-MELOXICAM 15 MG TABLET ORL TAB TEV TAB 0.567000002258315 TEVA-MELOXICAM 7.5 MG TABLET ORL TAB TEV TAB 0.491400002261898 TEVA-METOPROL 25 MG TABLET ORL TAB TEV TAB 0.064300002392925 TEVA-NABILONE 0.25 MG CAPSULE ORL CAP TEV CAP 1.396200002352893 TEVA-NEVIRAPINE 200 MG TABLET ORL TAB TEV TAB 2.469200002359707 TEVA-OLANZAPINE 20 MG TABLET ORL TAB TEV TAB 10.309300002321378 TEVA-OLANZAPINE OD 15 MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 5.355300002321386 TEVA-OLANZAPINE OD 20 MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 7.597700002248556 TEVA-PAROXETINE 10 MG TABLET ORL TAB TEV TAB 1.043000002274914 TEVA-PIOGLITAZONE 15 MG TABLET ORL TAB TEV TAB 0.580900002274922 TEVA-PIOGLITAZONE 30 MG TABLET ORL TAB TEV TAB 0.813900002274930 TEVA-PIOGLITAZONE 45 MG TABLET ORL TAB TEV TAB 1.329700002269317 TEVA-PRAMIPEXOLE 0.5 MG TABLET ORL TAB TEV TAB 1.386000002361205 TEVA-PREGABALIN 150 MG CAPSULE ORL CAP TEV CAP 1.7270

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 89 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002361221 TEVA-PREGABALIN 225 MG CAPSULE ORL CAP TEV CAP 1.727000002361159 TEVA-PREGABALIN 25 MG CAPSULE ORL CAP TEV CAP 0.617300002361248 TEVA-PREGABALIN 300 MG CAPSULE ORL CAP TEV CAP 1.727000002361175 TEVA-PREGABALIN 50 MG CAPSULE ORL CAP TEV CAP 0.968300002361183 TEVA-PREGABALIN 75 MG CAPSULE ORL CAP TEV CAP 1.252900002413809 TEVA-RISEDRONATE 150 MG TABLET ORL TAB TEV TAB 40.950000002347180 TEVA-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB TEV TAB 0.680700002144271 TEVA-TRAZODONE 100 MG TABLET ORL TAB TEV TAB 0.127200002144298 TEVA-TRAZODONE 150 MG TABLET ORL TAB TEV TAB 0.186900002144263 TEVA-TRAZODONE 50 MG TABLET ORL TAB TEV TAB 0.071200002357542 TEVA-VALACYCLOVIR 1000 MG TABLET (CAPLET) ORL TAB TEV TAB 3.053100002356643 TEVA-VALSARTAN 40 MG TABLET ORL TAB TEV TAB 0.569300002396874 TEVA-VORICONAZOLE 200 MG TABLET ORL TAB TEV TAB 38.942300002396866 TEVA-VORICONAZOLE 50 MG TABLET ORL TAB TEV TAB 9.739700002355205 THALOMID 100 MG CAPSULE ORL CAP CLG CAP 58.940000002355221 THALOMID 200 MG CAPSULE ORL CAP CLG CAP 117.880000002355191 THALOMID 50 MG CAPSULE ORL CAP CLG CAP 29.470000002360101 THEO ER 400 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.405900002360128 THEO ER 600 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.491600080015438 THERA TEARS NUTRITION CAPSULE ORL CAP AVR CAP 0.114000002242082 THERATEARS (PRESERVATIVE-FREE) 0.25% OPH SOLUTION OPH SOL AVR ML 0.659700002248854 THERATEARS 0.25% OPH SOLUTION OPH SOL AVR ML 0.492700001916939 TIMENTIN 3.1G INJECTION INJ DEFAUL GSK VIAL 10.752000002242275 TIMOLOL MALEATE-EX 0.25% OPHTHALMIC SOLUTION OPH LAS ALC ML 3.216000002242276 TIMOLOL MALEATE-EX 0.5% OPHTHALMIC SOLUTION OPH LAS ALC ML 3.848000000576050 TINACTIN 1% TOPICAL AEROSOL TOP AER SCH G 0.056500000576034 TINACTIN 1% TOPICAL CREAM TOP CRM SCH G 0.376700000576042 TINACTIN 1% TOPICAL POWDER TOP PWR SCH G 0.070100002414945 TIVICAY 50 MG TABLET ORL TAB VIV TAB 19.887300002244826 TNKASE 50 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2700.000000000533688 TOBRAMYCIN 1.2 G/VIAL INJECTION INJ DEFAUL PPC VIAL 199.000000002230640 TOBRAMYCIN 40 MG/ML INJECTION INJ DEFAUL PPC ML 3.531000002337630 TOCTINO 10 MG CAPSULE ORL CAP GST CAP 23.639300002337649 TOCTINO 30 MG CAPSULE ORL CAP GST CAP 23.895300000312762 TOLBUTAMIDE 500 MG TABLET ORL TAB AAP TAB 0.118300002229566 TOMUDEX 2 MG/VIAL INJECTION INJ DEFAUL AZC VIAL 324.620000002221926 TOPICORT 0.05% TOPICAL GEL TOP GEL VCL G 0.531800002221934 TOPICORT 0.25% TOPICAL OINTMENT TOP ONT VCL G 0.685700002390981 TOPOTECAN 4 MG / VIAL INJECTION INJ DEFAUL SDZ VIAL 141.7500

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 90 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002304104 TORISEL 25 MG/ML INJECTION INJ DEFAUL WAY VIAL 1261.250000002244982 TRACLEER 125 MG TABLET ORL TAB ACT TAB 69.739600002244981 TRACLEER 62.5 MG TABLET ORL TAB ACT TAB 68.992000002264846 TRAMACET 37.5 MG/325 MG TABLET ORL TAB JAI TAB 0.830200002417502 TRAMADOL-ACET 37.5 MG/325 MG TABLET ORL TAB PDL TAB 0.626400002388294 TRAMAPHEN-ODAN 37.5 MG/325 MG TABLET ORL TAB ODN TAB 0.626400002246365 TRANEXAMIC ACID 100 MG/ML INJECTION INJ DEFAUL SDZ ML 3.886000080024336 TRANSDERM-V 1.5 MG TOPICAL PATCH TOP PTH NOV PTH 3.925000000605786 TRAVEL AID 50 MG TABLET ORL TAB WTR TAB 0.072000002230285 TRAZOREL 100 MG TABLET ORL TAB ICN TAB 0.395600002230284 TRAZOREL 50 MG TABLET ORL TAB ICN TAB 0.221400002392569 TREANDA 100 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL LUI VIAL 1250.000000002392550 TREANDA 25 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL LUI VIAL 312.500000002240000 TRELSTAR 3.75 MG/VIAL INJECTION INJ DEFAUL PAL VIAL 366.060000002243856 TRELSTAR LA 11.25 MG/VIAL INJECTION INJ DEFAUL PAL VIAL 1021.600000002221977 TRENTAL 400 MG SUSTAINED RELEASE TABLET ORL SRT SAV TAB 0.809700000896179 TRIAMINIC DM NIGHTIME ORAL SYRUP ORL SYR NVC ML 0.051200000789828 TRIATEC-30 TABLET ORL TAB TLI TAB 0.130000000852163 TRIATEC-8 TABLET ORL TAB TLI TAB 0.047300002296381 TRIDURAL 100 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 1.326300002296403 TRIDURAL 200 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 2.418100002296411 TRIDURAL 300 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 3.513700002242067 TRILEPTAL 150 MG TABLET ORL TAB NOV TAB 0.899600002242068 TRILEPTAL 300 MG TABLET ORL TAB NOV TAB 0.989000002244673 TRILEPTAL 60 MG/ML ORAL SUSPENSION ORL SUS NOV ML 0.359700002242069 TRILEPTAL 600 MG TABLET ORL TAB NOV TAB 1.978200000517895 TRINALIN REPETABS SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.653500080002067 TRIPLE STRENGTH ODOURLESS GARLIC SOFTGEL CAPSULE ORL CAP VCL CAP 0.046000002244757 TRIZIVIR TABLET ORL TAB GSK TAB 19.493200000511226 TROMBOJECT 30 MG/ML INJECTION INJ DEFAUL OMG ML 4.971500080015078 TROPHIC KRILL OIL CAPSULE ORL CAP MTA CAP 0.423700002148536 TROPICAMIDE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.666700080000383 TRUEHOPE EMP CAPSULE ORL CAP TRU CAP 0.208700002274906 TRUVADA 200 MG/300 MG TABLET ORL TAB GIL TAB 29.202300000317268 TUBERSOL TUBERCULIN PPD 5 TUB INJECTION INJ DEFAUL AVE ML 155.400000002409720 TUDORZA GENUAIR 400MCG METERED INHALATION POWDER INH MIP ALM DOSE 1.177200001967932 TUMS EXTRA STRENGTH 750 MG CHEWABLE TABLET ORL CTB SKB TAB 0.045300001970240 TUMS REGULAR 500 MG CHEWABLE TABLET ORL CTB SKB TAB 0.047200002151138 TUMS ULTRA STRENGTH 1G CHEWABLE TABLET ORL CTB SKB TAB 0.0510

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 91 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00001916971 TUSSIONEX ORAL SUSTAINED-RELEASE SUSPENSION ORL SRSUS SAV ML 0.353600001916963 TUSSIONEX TABLET ORL SRT SAV TAB 1.767900080019103 TUZEN CAPSULE ORL CAP FEI CAP 0.820700002230578 TWINRIX INJECTION SYRINGE INJ NDL GSK SYR 50.860000002237548 TWINRIX JUNIOR 0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 25.430000002285401 TYGACIL 50MG/VIAL INJECTION INJ DEFAUL WAY VIAL 86.269000002326442 TYKERB 250 MG TABLET ORL TAB GSK TAB 25.262600002246060 TYLENOL 8 HOUR 650 MG EXTENDED-RELIEF CAPLET ORL ERT MCL TAB 0.180000001933728 TYLENOL ALLERGY SINUS EXTRA STRENGTH CAPLET ORL TAB MCL TAB 0.285000002238885 TYLENOL ARTHRITIS PAIN 650 MG EXT-RELIEF CAPLET ORL ERT MCL TAB 0.169600000743224 TYLENOL CHILDRENS COLD CHEWABLE TABLET ORL CTB MCL TAB 0.176300000890677 TYLENOL COLD DM JUNIOR STRENGTH CHEWABLE TABLET ORL CTB MCL TAB 0.280500000743275 TYLENOL COLD EXTRA STRENGTH CAPLET ORL TAB MCL TAB 0.285000000743267 TYLENOL COLD EXTRA STRENGTH N.D. CAPLET ORL TAB MCL TAB 0.285000002276259 TYLENOL COLD EXTRA STRENGTH NIGHTTIME TABLET ORL TAB MCL TAB 0.304000000574007 TYLENOL COLD REGULAR STRENGTH CAPLET ORL TAB MCL TAB 0.200400000743283 TYLENOL COLD REGULAR STRENGTH N.D. CAPLET ORL TAB MCL TAB 0.201200002290510 TYLENOL EXTRA STR. BACK PAIN 400 MG/500 MG TABLET ORL TAB MCL TAB 0.520600000863270 TYLENOL EXTRA-STRENGTH GELCAPS 500 MG CAPSULE ORL CAP MCL CAP 0.138300000663980 TYLENOL EXTRA-STRENGTH SINUS MEDICATION CAPLET ORL TAB MCL TAB 0.478300002347792 TYLENOL FASTMELTS JUNIOR STRENGTH 160 MG CHEW TAB ORL CTB MCL TAB 0.292500002241361 TYLENOL JUNIOR STRENGTH 160 MG SOFT CHEW TABLET ORL CTB MCL TAB 0.270000002181061 TYLENOL NO.1 WITH CODEINE TABLET ORL TAB MCL TAB 0.173000000559393 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.153300000723894 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.130800000778400 TYLENOL SINUS CAPLET ORL TAB MCL TAB 0.200400002163942 TYLENOL WITH CODEINE ELIXIR ORL ELX JAI ML 0.105900002242727 TYPHERIX 25 MCG/0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 24.060000002130955 TYPHIM VI 50 MCG/ML INJECTION INJ DEFAUL CNG ML 52.700000080022377 UDO'S CHOICE SUPER 8 PLUS PROBIOTIC ORL CAP FMD CAP 0.990000001966294 ULONE 5 MG ORAL SYRUP ORL SYR MMH ML 0.140600002418282 ULTIBRO BREEZHALER 110 MCG/ 50 MCG INH CAPSULE INH CAP NOV CAP 2.680000080015173 ULTIMATE FLORA CRITICAL CARE 50 BILLION ORL CAP RLC CAP 1.166500080006259 ULTIMATE OMEGA FACTORS 3-6-9 SOFT GEL CAPSULE ORL CAP NFN CAP 0.238700080033880 ULTRA C 1000 TABLET ORL TAB MTG TAB 0.313500080011779 ULTRA FLORA PLUS CAPSULE ORL CAP MTG CAP 0.411600080011780 ULTRA FLORA PLUS; ULTRA FLORA BALANCE ORL CAP MTG CAP 0.416700002237698 ULTRA STRENGTH PHAZYME 180 MG CAPSULE ORL CAP BLO CAP 0.222100080004965 ULTRA-FIBER SUPPLEMENT CHEWABLE TABLET ORL TAB AAM TAB 0.0917

Page 92: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 92 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00080044443 ULTRACLEAR SUSTAIN ORAL POWDER ORL PWR MTG G 0.067600002349469 ULTRAM 50 MG TABLET ORL TAB JAI TAB 0.779700000626724 ULTRAQUIN 4% TOPICAL GEL TOP GEL CDX G 1.080000000632783 ULTRAQUIN PLAIN 4% CREAM TOP CRM CDX G 0.866700001962728 ULTRAVATE 0.05% TOPICAL OINTMENT TOP ONT VCL G 0.961200001946994 UNISOM-2 NIGHTTIME SLEEP AID TAB 25 MG ORL TAB PDH TAB 0.204000000116866 URASAL GRANULES ORAL EFFERVESCENT POWDER ORL EVP AXS G 0.113800001946099 UREMOL 10 10% TOPICAL CREAM TOP CRM TCD G 0.077500000398179 UREMOL 20% TOPICAL CREAM TOP CRM TCD G 0.081500001946102 UREMOL-10 10% TOPICAL LOTION TOP LOT TCD ML 0.043800080005531 URISEC 40 40% TOPICAL CREAM TOP CRM ODN G 1.400000002353997 UROCIT-K 10 MEQ EXTENDED-RELEASE TABLET ORL ERT PAL TAB 0.559300001914022 UROCIT-K 5 MEQ TABLET ORL SRT SFD TAB 0.344900002273578 UROMAX 10 MG CONTROLLED RELEASE TABLET ORL ERT PUR TAB 1.365500002273586 UROMAX 15 MG CONTROLLED RELEASE TABLET ORL ERT PUR TAB 1.471000002241411 UROMITEXAN 100 MG/ML INJECTION INJ DEFAUL AST ML 6.489000080030062 UTI CLEANSE TABLET ORL TAB AOR TAB 0.441600002241332 VAGIFEM 25 MCG VAGINAL TABLET VAG TAB NNA TAB 3.213300002306085 VALCYTE 50 MG/ML ORAL SUSPENSION ORL SUS HLR ML 2.752100000177016 VALISONE-G TOPICAL CREAM TOP CRM VLP G 1.083000000232351 VALISONE-G TOPICAL OINTMENT TOP ONT VLP G 1.083000000013285 VALIUM 5 MG TABLET ORL TAB HLR TAB 0.172500002367742 VALSARTAN 160 MG TABLET ORL TAB PDL TAB 0.333000002367750 VALSARTAN 320 MG TABLET ORL TAB PDL TAB 0.333000002366940 VALSARTAN 40 MG TABLET ORL TAB SNS TAB 0.523900002367726 VALSARTAN 40 MG TABLET ORL TAB PDL TAB 0.408000002384523 VALSARTAN 40 MG TABLET ORL TAB SIV TAB 0.408000002367734 VALSARTAN 80 MG TABLET ORL TAB PDL TAB 0.333000002384760 VALSARTAN HCT 320 MG/12.5 MG TABLET ORL TAB SIV TAB 0.325300002384779 VALSARTAN HCT 320 MG/25 MG TABLET ORL TAB SIV TAB 0.325300002367777 VALSARTAN-HCTZ 160 MG/12.5 MG TABLET ORL TAB PDL TAB 0.333000002367785 VALSARTAN-HCTZ 160 MG/25 MG TABLET ORL TAB PDL TAB 0.333000002367769 VALSARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.333000002246559 VALTREX 1000 MG CAPLET ORL TAB GSK TAB 7.483300002394634 VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJ USP INJ DEFAUL SDZ VIAL 58.990000002394626 VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJ USP INJ DEFAUL SDZ VIAL 31.050000002243837 VANIQA 13.9% TOPICAL CREAM TOP CRM TPI G 2.599000002229702 VAQTA 50 U/ML INJECTION INJ DEFAUL MSD ML 47.540000002241047 VARILRIX 2000 UNITS/(0.5 ML) VIAL INJECTION INJ DEFAUL GSK VIAL 62.7900

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 93 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002246081 VARIVAX III VACCINE 1350 U/VIAL INJECTION INJ DEFAUL MFC VIAL 76.720000002139502 VASOPRESSIN 20 UNIT/ML INJECTION INJ DEFAUL PPC ML 19.830000002223929 VAXIGRIP INFLUENZA VACCINE INJECTION INJ DEFAUL CNG ML 8.350000002308487 VECTIBIX 20 MG/ML (5 ML VIAL) INJECTION INJ DEFAUL AMG ML 123.192000002273985 VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 0.346900002339269 VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.886800002273969 VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 0.347700002339242 VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.420000002273977 VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 0.695600002339250 VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.839900002243716 VENOFER 20 MG/ML INJECTION INJ DEFAUL LPI ML 8.149800002226286 VENOMIL YELLOW JACKET VENOM PROTEIN 120 MCG INJ INJ DEFAUL BAI VIAL 195.000000002243115 VENTOLIN DISKUS 200 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.209500000616192 VEPESID 50 MG CAPSULE ORL CAP BMS CAP 40.567500000839299 VERAPAMIL HYDROCHLORIDE 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 19.150000002166739 VERAPAMIL HYDROCHLORIDE USP 2.5 MG/ML INJECTION INJ DEFAUL SDZ ML 20.755000002348489 VERDESO 0.05% TOPICAL FOAM TOP FOA GSK G 0.319900000594601 VERSEL 2.5% TOPICAL LOTION TOP LOT VLP ML 0.067000002145839 VESANOID 10 MG CAPSULE ORL CAP HLR CAP 14.223300002163691 VEXOL 1% OPH SOLUTION OPH SUS ALC ML 4.088000000717002 VIADERM K.C. TOPICAL CREAM TOP CRM TAR G 0.460000000717029 VIADERM K.C. TOPICAL OINTMENT TOP ONT TAR G 0.677300002239768 VIAGRA 100 MG TABLET ORL TAB PFI TAB 9.997500002239766 VIAGRA 25 MG TABLET ORL TAB PFI TAB 9.007500002239767 VIAGRA 50 MG TABLET ORL TAB PFI TAB 9.615000002273330 VICKS CHILDREN'S NYQUIL COLD & COUGH ORAL LIQUID ORL LIQ PGI ML 0.026700001938959 VICKS FORMULA 44 ORAL LIQUID ORL LIQ PGI ML 0.034100002050684 VICKS NYQUIL ADULT NIGHTTIME COLD MEDICINE ORL LIQ ORL LIQ PGI ML 0.027600001935747 VICKS VAPORUB TOPICAL OINTMENT TOP ONT PGI G 0.076000002351064 VICTOZA 6 MG/ML PEN INJECTION SYRINGE INJ DEFAUL NNA ML 26.936700002336707 VIDAZA 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 628.000000002244596 VIDEX EC 125 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 3.989300002244597 VIDEX EC 200 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 6.383700002244598 VIDEX EC 250 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 7.907300002244599 VIDEX EC 400 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 12.930700002252260 VIGAMOX 0.5% OPHTHALMIC SOLUTION OPH SOL ALC ML 4.723300002361701 VIMOVO 375 MG/20 MG TABLET ORL TAB AZC TAB 1.151800002361728 VIMOVO 500 MG/20 MG TABLET ORL TAB AZC TAB 1.151800002183056 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL MNP ML 11.5000

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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

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DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002401460 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 17.679000002143305 VINCRISTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 31.000000000074500 VIOFORM HC TOPICAL CREAM TOP CRM PAL G 0.937700002238617 VIRACEPT 250 MG TABLET ORL TAB AGR TAB 2.027600002248761 VIRACEPT 625 MG TABLET ORL TAB PFI TAB 5.068900002238748 VIRAMUNE 200 MG TABLET ORL TAB BOE TAB 5.366200002367289 VIRAMUNE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT BOE TAB 2.469000080030855 VISION CARE CAPSULE ORL CAP PLT CAP 0.899100000568627 VISKAZIDE 10/25 MG TABLET ORL TAB NOV TAB 0.973400000568635 VISKAZIDE 10/50 MG TABLET ORL TAB NOV TAB 0.973400000443174 VISKEN 10 MG TABLET ORL TAB NOV TAB 0.997900000417289 VISKEN 15 MG TABLET ORL TAB NOV TAB 1.447600000417270 VISKEN 5 MG TABLET ORL TAB NOV TAB 0.628100002242367 VISUDYNE 15 MG/VIAL INJECTION INJ DEFAUL NVO VIAL 1850.670000080016590 VITALUX CAPLET ORL TAB ALC TAB 0.237400080016683 VITALUX PLUS OMEGA 3 CAPSULE ORL CAP ALC CAP 0.226800002245911 VITALUX TABLET ORL TAB NOV TAB 0.243000002240199 VITALUX TR MULTIVITAMIN/MULTIMINERAL TABLET ORL TAB NCI TAB 0.243000080028004 VITALUX-S PLUS OMEGA-3 CAPSULE ORL CAP ALC CAP 0.305900080016576 VITALUX-S TABLET ORL TAB ALC TAB 0.237400000123137 VITAMIN A & D FORTIFIED CAPSULE ORL CAP JAM CAP 0.048200000297720 VITAMIN A 10,000 IU CAPSULE ORL CAP JAM CAP 0.045300002245311 VITAMIN A 10,000 IU CAPSULE ORL CAP WNP CAP 0.026000080035590 VITAMIN B 100 MG TIME RELEASE TABLET ORL TAB WNP TAB 0.157500000487082 VITAMIN B CMPD 100 SUSTAINED-RELEASE TABLET ORL SRT SWS TAB 0.173200000294853 VITAMIN B1 100 MG TABLET ORL TAB VCL TAB 0.090000000407011 VITAMIN B1 100 MG TABLET ORL TAB JAM TAB 0.091000002239350 VITAMIN B1 100 MG TABLET ORL TAB PMT TAB 0.021400000816078 VITAMIN B1 100 MG/ML INJECTION USP INJ DEFAUL SDZ ML 2.771000000610267 VITAMIN B1 50 MG TABLET ORL TAB LEA TAB 0.074000000331015 VITAMIN B12 100 MCG TABLET ORL TAB JAM TAB 0.059200000450642 VITAMIN B12 100 MCG TABLET ORL TAB VTH TAB 0.070000002023598 VITAMIN B12 100 MCG TABLET ORL TAB PMT TAB 0.056800002241500 VITAMIN B12 100 MCG/ML INJECTION INJ DEFAUL SDZ ML 1.565000002230932 VITAMIN B12 1000 MCG TABLET ORL TAB WES TAB 0.077100002237736 VITAMIN B12 1000 MCG TABLET ORL TAB SWS TAB 0.090700080006939 VITAMIN B12 1000 MCG TABLET ORL TAB WNP TAB 0.136000080012952 VITAMIN B12 1000 MCG TABLET ORL TAB JAM TAB 0.143900000626112 VITAMIN B12 1000 MCG/ML INJ DEFAUL OMG ML 0.3100

Page 95: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 95 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000335940 VITAMIN B12 250 MCG TABLET ORL TAB JAM TAB 0.067500000305243 VITAMIN B12 50 MCG TABLET ORL TAB JAM TAB 0.054800000689726 VITAMIN B12 500 MCG TABLET ORL TAB SNS TAB 0.074100002243767 VITAMIN B12 500 MCG TABLET ORL TAB VTH TAB 0.046500000329185 VITAMIN B6 100 MG TABLET ORL TAB JAM TAB 0.067500000528846 VITAMIN B6 100 MG TABLET ORL TAB HAL TAB 0.030000002239348 VITAMIN B6 100 MG TABLET ORL TAB PMT TAB 0.022800000122645 VITAMIN B6 25 MG TABLET ORL TAB JAM TAB 0.033600000331031 VITAMIN B6 250 MG TABLET ORL TAB JAM TAB 0.109600000305227 VITAMIN B6 50 MG TABLET ORL TAB JAM TAB 0.050500000341207 VITAMIN C 1000 MG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.110800000305235 VITAMIN C 1000 MG TABLET ORL TAB JAM TAB 0.085400001994336 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB JAM TAB 0.063100002243893 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB PMT TAB 0.033300000237116 VITAMIN C 500 MG ORANGE FLAVORED CHEWABLE TABLET ORL CTB TEV TAB 0.025700000373699 VITAMIN C 500 MG SUSTAINED-RELEASE CAPSULE ORL SRC JAM CAP 0.101000000036188 VITAMIN C 500 MG TABLET ORL TAB WAM TAB 0.040000002163268 VITAMIN C 500 MG TABLET ORL TAB JAM TAB 0.050300002240883 VITAMIN C 500 MG TABLET ORL TAB WNP TAB 0.035900000463108 VITAMIN C CHEWABLE TABLET ORL TAB GAH TAB 0.097000080001870 VITAMIN D 1,000 IU TAB ORL TAB SIS TAB 0.044000080017530 VITAMIN D 1000 IU CAPSULE ORL CAP JAM CAP 0.042900080000436 VITAMIN D 1000 IU TABLET ORL TAB JAM TAB 0.045300080006264 VITAMIN D 1000 IU TABLET ORL TAB GFR TAB 0.050000000323179 VITAMIN D 1000 UNIT TABLET ORL TAB SWS TAB 0.030500000765384 VITAMIN D 400 IU TABLET ORL TAB LCO TAB 0.040000002229879 VITAMIN D 400 IU TABLET ORL TAB SWS TAB 0.039800002240624 VITAMIN D 400 IU TABLET ORL TAB WAM TAB 0.016100002240858 VITAMIN D 400 IU TABLET ORL TAB PMT TAB 0.011700002242175 VITAMIN D 400 IU TABLET ORL TAB JAM TAB 0.046500080002452 VITAMIN D 400 IU TABLET ORL TAB WNP TAB 0.028400080009578 VITAMIN D 400 IU TABLET ORL TAB VCL TAB 0.026100080018025 VITAMIN D DROPS 400 IU ORL LIQ JAM ML 0.931600080015280 VITAMIN D3 1000 IU CAPSULE ORL GEL VTH CAP 0.082200080012124 VITAMIN D3 1000 IU ORAL LIQUID ORL LIQ WBP ML 0.164800002245842 VITAMIN D3 1000 IU TABLET ORL TAB PMT TAB 0.017800080003663 VITAMIN D3 1000 IU TABLET ORL TAB WNP TAB 0.034200000122823 VITAMIN E 100 IU OBLONG AMBER CAPSULE ORL CAP JAM CAP 0.067200000332348 VITAMIN E 200 IU CAPSULE (NATURAL) ORL CAP LDL CAP 0.0629

Page 96: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 96 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00000122831 VITAMIN E 200 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.086500000266108 VITAMIN E 400 IU CAPSULE ORL CAP PMT CAP 0.054200000480940 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.074100000782181 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.081600002240967 VITAMIN E 400 IU CAPSULE ORL CAP WNP CAP 0.110000000332356 VITAMIN E 400 IU CAPSULE (NATURAL) ORL CAP LDL CAP 0.053900000122858 VITAMIN E 400 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.131200000330191 VITAMIN E 800 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.296600002015293 VITAMIN E NATURAL SOURCE 400 UNIT CAPSULE ORL CAP QVS CAP 0.059200000201995 VITAMIN E NF NATURAL SOURCE 400 IU CAPSULE ORL CAP WAM CAP 0.116500000480878 VITAMINE B12 1200 MCG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.140800000816175 VITAMINE C 600 MG CAPSULE ORL CAP SIS CAP 0.211200002248361 VIVAXIM INJECTION INJ DEFAUL SFP SYR 87.690000000013765 VIVOL 5 MG TABLET ORL TAB AXS TAB 0.085800000885975 VIVOTIF BERNA 6 B CAPSULE ORL CAP SSV CAP 6.367500002307073 VOLIBRIS 10 MG TABLET ORL TAB GSK TAB 122.520000002307065 VOLIBRIS 5 MG TABLET ORL TAB GSK TAB 122.520000002290375 VOLTAREN EMULGEL 1.16% TOPICAL GEL TOP GEL NVC G 0.129700002338580 VOLTAREN EMULGEL JOINT PAIN 1.16% TOPICAL GEL TOP GEL NVC G 0.121300000881635 VOLTAREN RAPIDE 50 MG TABLET ORL TAB NOV TAB 0.975400002381966 VORICONAZOLE 200 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 130.080000002352303 VOTRIENT 200 MG TABLET ORL TAB GSK TAB 36.990800002357119 VPRIV 400 UNIT/VIAL INJECTION INJ DEFAUL SHG VIAL 1955.000000080037590 VSL #3 ORAL POWDER ORL PWR FEI G 3.699600002365561 VYLOMA 3.75% TOPICAL CREAM TOP CRM VCL G 45.918600080006877 WAMPOLE MINERAL CALCIUM ORAL LIQUID ORL LIQ JPC ML 0.037800080008041 WAMPOLE MULTIVITAMIN LIQUID ORL LIQ WAM ML 0.037800001948970 WASP VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 41.483300001949004 WHITE FACED HORNET VENOM 120 MCG INJ DEFAUL ALG VIAL 35.683300002136740 WOBENZYM N TABLET ORL TAB MUC TAB 0.349700000866598 X-SEB PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.063900000866601 X-SEB T PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.063900000509906 X-SEB T TOPICAL SHAMPOO TOP SHP PMS ML 0.063900000800694 X-TAR TOPICAL SHAMPOO TOP SHP DLX ML 0.067600002384256 XALKORI 200 MG CAPSULE ORL CAP PFI CAP 157.666700002384264 XALKORI 250 MG CAPSULE ORL CAP PFI CAP 157.666700000723770 XANAX 1 MG TABLET ORL TAB PFI TAB 0.592400000813958 XANAX TS 2 MG TABLET ORL TAB PFI TAB 1.041600002238453 XELODA 150 MG TABLET ORL TAB HLR TAB 1.9885

Page 97: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 97 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002238454 XELODA 500 MG TABLET ORL TAB HLR TAB 6.628600002240325 XENICAL 120 MG CAPSULE ORL CAP HLR CAP 1.749900002404044 XERESE 5%/1% TOPICAL CREAM TOP CRM VCL G 7.594000002368153 XGEVA 120 MG/VIAL INJECTION INJ DEFAUL AMG VIAL 600.670000002388316 XIAFLEX 0.9 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 1120.000000002407329 XTANDI 40 MG CAPSULE ORL CAP ASP CAP 30.470800000001791 XYLOCAINE 1% W EPINEPHRINE 1:100,000 INJ INJ DEFAUL AZC ML 0.371500000385484 XYLOCAINE 2% TOPICAL JELLY URH JEL AZC ML 0.953500000001821 XYLOCAINE 2% W EPINEPHRINE 1:100,000 INJ INJ DEFAUL AZC ML 0.267000002373130 XYLOCAINE 2% W EPINEPHRINE 1:200,000 INJECTION ORL DEFAUL AZC VIAL 0.390300000001732 XYLOCAINE HCL 1% LIQUID (BLOCK OR INFILTRATION) INJ LIQ AZC ML 0.957300000036641 XYLOCAINE HCL 2% PLAIN LIQ (BLOCK OR INFILTRATION) INJ LIQ AZC ML 1.146400000049816 XYLOCAINE HYDROCHLORIDE 4% TOPICAL SOLUTION TOP SOL AZC ML 0.184800002268272 XYREM 500 MG/ML ORAL SOLUTION ORL SOL VCL ML 2.610900002321157 YAZ 28 TABLET ORL TAB BAI TAB 0.611800002387433 YAZ PLUS 28 TABLET ORL TAB BAI TAB 0.459600001948954 YELLOW JACKET VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 35.683300001948962 YELLOW JACKET VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 35.683300000428833 YF-VAX 109648 U/0.5 ML INJECTION INJ DEFAUL SFP VIAL 128.208000000795283 YOCON 5.4 MG TABLET ORL TAB GLE TAB 0.556800000885533 YOHIMBINE-ODAN 2 MG TABLET ORL TAB ODN TAB 0.428100001901885 YOHIMBINE-ODAN 5.4 MG TABLET ORL TAB ODN TAB 0.615000002246740 Z-BEC STRESSTABS TABLET ORL TAB WCH TAB 0.165300000800686 Z-PLUS TOPICAL SHAMPOO TOP SHP DLX ML 0.100900000600784 ZADITEN 0.2 MG/ML ORAL SYRUP ORL SYR TEV ML 0.488600002279223 ZADITOR (PRESERVATIVE FREE) 0.25 MG/ML OPH SOL OPH SOL NOV ML 3.528300002242324 ZADITOR 0.25 MG/ML OPH SOLUTION OPH SOL NOV ML 5.750000002230287 ZANTAC 75 MG TABLET ORL TAB GSK TAB 0.427000000568392 ZAPEX 10 MG TABLET ORL TAB RIV TAB 0.035000000568406 ZAPEX 15 MG TABLET ORL TAB RIV TAB 0.055000000568414 ZAPEX 30 MG TABLET ORL TAB RIV TAB 0.075000002250519 ZAVESCA 100 MG CAPSULE ORL CAP ACT CAP 108.550000002410702 ZAXINE 550 MG TABLET ORL TAB SLX TAB 17.160000000237213 ZEASORB MEDICATED TOPICAL POWDER TOP PWR STI G 0.145000002380242 ZELBORAF 240 MG FILM-COATED TABLET ORL TAB HLR TAB 50.032700002361752 ZENHALE 100 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.787300002361760 ZENHALE 200 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.954200002361744 ZENHALE 50 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.613800002216086 ZERIT 15 MG CAPSULE ORL CAP BMS CAP 4.8640

Page 98: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 98 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002216094 ZERIT 20 MG CAPSULE ORL CAP BMS CAP 5.057500002216108 ZERIT 30 MG CAPSULE ORL CAP BMS CAP 5.275500002216116 ZERIT 40 MG CAPSULE ORL CAP BMS CAP 5.528200002240358 ZIAGEN 20 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.456800002240357 ZIAGEN 300 MG TABLET ORL TAB GSK TAB 7.384500000297666 ZINC 10 MG TABLET ORL TAB JAM TAB 0.049400000441589 ZINC 25 MG TABLET ORL TAB JAM TAB 0.065900000505463 ZINC 50 MG TABLET ORL TAB JAM TAB 0.074200001922351 ZINC 50 MG TABLET ORL TAB SWS TAB 0.046600000480886 ZINC 50 MG TIMED RELEASE TABLET ORL TAB JAM TAB 0.091400002239162 ZINCOFAX 15% TOPICAL OINTMENT TOP ONT PDH G 0.081800002239160 ZINCOFAX EXTRA STRENGTH 40% TOPICAL OINTMENT TOP ONT PDH G 0.065000002153432 ZINECARD 250 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 137.060000002153440 ZINECARD 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 274.140000002239952 ZITHROMAX 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 22.831000002231143 ZITHROMAX 600 MG TABLET ORL TAB PFI TAB 12.069300002354802 ZMAX SR 27 MG/ML ORAL SUPENSION ORL SUS PFI ML 0.578300002240332 ZOCOR 80 MG TABLET ORL TAB MFC TAB 2.611400002327619 ZOLINZA 100 MG CAPSULE ORL CAP MFC CAP 76.179500002379929 ZOLMITRIPTAN 2.5 MG TABLET ORL TAB PDL TAB 5.333300002379988 ZOLMITRIPTAN ODT 2.5 MG ORALLY DISPERSIBLE TABLET ORL DISPTAB PDL TAB 5.333300002248992 ZOMIG 2.5 MG NASAL SPRAY NAS SPU AZC DOSE 15.375000002315939 ZOSTAVAX 19,400 UNITS/(0.65 ML) VIAL INJECTION INJ DEFAUL MFC VIAL 157.500000000740306 ZOSTRIX 0.025% TOPICAL CREAM TOP CRM GEU G 0.231200002004240 ZOSTRIX H.P. 0.075% TOPICAL CREAM TOP CRM GEU G 0.295300001911627 ZOVIRAX 400 MG TABLET ORL TAB GSK TAB 2.671500002039524 ZOVIRAX 5% TOPICAL CREAM TOP CRM VCL G 14.276000000569771 ZOVIRAX 5% TOPICAL OINTMENT TOP ONT VCL G 14.322500002354772 ZUACTA 0.075% TOPICAL CREAM TOP CRM SAV G 1.893000002340445 ZYCLARA 3.75% TOPICAL CREAM TOP CRM VCL G 46.368600002342804 ZYM-AMLODIPINE 10 MG TABLET ORL TAB ZMC TAB 0.358700002342790 ZYM-AMLODIPINE 5 MG TABLET ORL TAB ZMC TAB 0.241700002338106 ZYM-CARVEDILOL 12.5 MG TABLET ORL TAB ZMC TAB 0.800100002338114 ZYM-CARVEDILOL 25 MG TABLET ORL TAB ZMC TAB 0.800100002338068 ZYM-CARVEDILOL 3.125 MG TABLET ORL TAB ZMC TAB 0.800100002338092 ZYM-CARVEDILOL 6.25 MG TABLET ORL TAB ZMC TAB 0.800100002345676 ZYM-CLONAZEPAM 0.5 MG TABLET ORL TAB ZMC TAB 0.116600002303329 ZYM-CLONAZEPAM 1 MG TABLET ORL TAB ZMC TAB 0.186000002303337 ZYM-CLONAZEPAM 2 MG TABLET ORL TAB ZMC TAB 0.2010

Page 99: Products and Pricing on the Alberta Blue Cross Drug Price

Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective June 16, 2014

This document is for pricing use only and should not be used to determine benefit status information.Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 99 of 99

DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price00002302659 ZYM-FLUOXETINE 10 MG CAPSULE ORL CAP ZMC CAP 1.177300002302667 ZYM-FLUOXETINE 20 MG CAPSULE ORL CAP ZMC CAP 1.011200002325179 ZYM-MIRTAZAPINE 15 MG TABLET ORL TAB ZMC TAB 0.375000002325187 ZYM-MIRTAZAPINE 30 MG TABLET ORL TAB ZMC TAB 0.780000002344440 ZYM-ONDANSETRON 4 MG TABLET ORL TAB ZMC TAB 7.545300002344459 ZYM-ONDANSETRON 8 MG TABLET ORL TAB ZMC TAB 11.517000002320754 ZYM-PIOGLITAZONE 15 MG TABLET ORL TAB ZMC TAB 1.571600002320762 ZYM-PIOGLITAZONE 30 MG TABLET ORL TAB ZMC TAB 2.201700002320770 ZYM-PIOGLITAZONE 45 MG TABLET ORL TAB ZMC TAB 3.310500002303817 ZYM-SERTRALINE 100 MG (BASE) CAPSULE ORL CAP ZMC CAP 1.102500002303779 ZYM-SERTRALINE 25 MG (BASE) CAPSULE ORL CAP ZMC CAP 0.504000002303809 ZYM-SERTRALINE 50 MG (BASE) CAPSULE ORL CAP ZMC CAP 1.008000002325144 ZYM-TOPIRAMATE 100 MG TABLET ORL TAB ZMC TAB 1.253700002325152 ZYM-TOPIRAMATE 200 MG TABLET ORL TAB ZMC TAB 1.984500002325136 ZYM-TOPIRAMATE 25 MG TABLET ORL TAB ZMC TAB 0.661500002257270 ZYMAR 0.3% OPHTHALMIC SOLUTION OPH SOL ALL ML 2.820000002238851 ZYPREXA 20 MG TABLET ORL TAB LIL TAB 15.623200002243088 ZYPREXA ZYDIS 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LIL TAB 11.639300002243089 ZYPREXA ZYDIS 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LIL TAB 15.362100002371065 ZYTIGA 250 MG TABLET ORL TAB JAI TAB 31.372100002360349 ZYTRAM XL 100 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.171700002286424 ZYTRAM XL 150 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 1.738700002286432 ZYTRAM XL 200 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 2.282000002286440 ZYTRAM XL 300 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 3.314300002286459 ZYTRAM XL 400 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 4.346700002360322 ZYTRAM XL 75 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.912800002243685 ZYVOXAM 2 MG/ML INJECTION INJ DEFAUL PFI ML 0.342600002243686 ZYVOXAM 20 MG/ML ORAL SUSPENSION ORL SUS PFI ML 2.7023