Download 28:00 Central Nervous System Agents

Central Nervous System Agents
28:00 Central Nervous System Agents
28:00
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08
COMPOUND PRESCRIPTION
TOPICAL
00000999105
COMPD- NSAID/ ANALG/MUSCLE RELAX
(NOT DICLOFENAC)-TOPICAL
XXX
$
0.0000
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been prepared and dispensed by a licensed
community pharmacy.
TOPICAL
00000999205
COMPD-NSAID/ ANALG/MUSCLE RELAX
(NOT DICLOFENAC)-TOPICAL
XXX
$
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been procured from a licensed compound
and repackaging pharmacy and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
73
EFFECTIVE APRIL 1, 2016
0.0000
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04
(NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
COMPOUND PRESCRIPTION
TOPICAL
00000999102
COMPOUND-DICLOFENAC (TOPICAL)
XXX
$
0.0000
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been prepared and dispensed by a licensed
community pharmacy.
TOPICAL
00000999202
COMPOUND-DICLOFENAC (TOPICAL)
XXX
$
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been procured from a licensed compound
and repackaging pharmacy and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
74
EFFECTIVE APRIL 1, 2016
0.0000
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.24
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(SALICYLATES)
BUTALBITAL/ CAFFEINE/ ASA
50 MG * 40 MG * 330 MG
00000608211
RATIO-TECNAL
50 MG * 40 MG * 330 MG
00000608238
00000226327
28:00
ORAL TABLET
RPH
$
1.1568
RPH
TRI
$
$
1.4687
1.6172
ORAL CAPSULE
RATIO-TECNAL
FIORINAL
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.92
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
DICLOFENAC SODIUM
75 MG
ORAL SUSTAINED-RELEASE TABLET
00002162814
00002231504
00002261901
00002158582
00000782459
100 MG
APO-DICLO SR
PMS-DICLOFENAC-SR
SANDOZ DICLOFENAC SR
TEVA-DICLOFENAC SR
VOLTAREN SR
$
$
$
$
$
0.2320
0.2320
0.2320
0.2343
1.1937
$
$
$
$
0.4048
0.4048
0.4048
1.7016
$
$
$
$
0.0781
0.0781
0.0781
0.0781
$
$
$
$
$
$
0.2024
0.2024
0.2024
0.2024
0.2024
0.9170
PMS
SDZ
NOV
$
$
$
0.4339
0.4339
1.3773
PMS
SDZ
NOV
$
$
$
0.5840
0.5840
1.8536
APX
PMS
SDZ
TEV
NOV
ORAL SUSTAINED-RELEASE TABLET
00002091194
00002231505
00002261944
00000590827
APO-DICLO SR
PMS-DICLOFENAC-SR
SANDOZ DICLOFENAC SR
VOLTAREN SR
APX
PMS
SDZ
NOV
$
$
$
$
0.3124
0.3124
0.3124
0.3124
MAC pricing has been applied based on the LCA Price for 4 X 25 mg oral entericcoated tablets.
25 MG
ORAL ENTERIC-COATED TABLET
00000839175
00002302616
00002261952
00000808539
50 MG
APO-DICLO
PMS-DICLOFENAC
SANDOZ DICLOFENAC
TEVA-DICLOFENAC EC
APX
PMS
SDZ
TEV
ORAL ENTERIC-COATED TABLET
00000839183
00002352397
00002302624
00002261960
00000808547
00000514012
APO-DICLO
DICLOFENAC SODIUM
PMS-DICLOFENAC
SANDOZ DICLOFENAC
TEVA-DICLOFENAC EC
VOLTAREN
APX
SNS
PMS
SDZ
TEV
NOV
$
$
$
$
$
$
0.1562
0.1562
0.1562
0.1562
0.1562
0.1562
MAC pricing has been applied based on the LCA Price for 2 x 25 mg oral entericcoated tablets.
50 MG
RECTAL SUPPOSITORY
00002231506
00002261928
00000632724
100 MG
PMS-DICLOFENAC
SANDOZ DICLOFENAC
VOLTAREN
RECTAL SUPPOSITORY
00002231508
00002261936
00000632732
PMS-DICLOFENAC
SANDOZ DICLOFENAC
VOLTAREN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
75
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.92
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
DICLOFENAC SODIUM/ MISOPROSTOL
50 MG * 200 MCG
00002341689
00001917056
75 MG * 200 MCG
00002341697
00002229837
ORAL ENTERIC-COATED TABLET
GD-DICLOFENAC/MISOPROSTOL 50
ARTHROTEC-50
GMD
PFI
$
$
0.3149
0.6417
GMD
PFI
$
$
0.4286
0.8734
AAP
$
0.7600
AAP
$
0.7600
AAP
$
0.4259
AAP
$
0.8285
APX
TEV
$
$
0.2221
0.2332
APX
TEV
$
$
0.3039
0.3191
APX
$
0.1377
APX
TEV
$
$
0.0936
0.1113
APX
TEV
$
$
0.1313
0.1379
TEV
$
0.2508
TEV
$
0.5015
SDZ
$
0.8842
SDZ
RPH
$
$
0.8910
0.9356
ORAL ENTERIC-COATED TABLET
GD-DICLOFENAC/MISOPROSTOL 75
ARTHROTEC-75
ETODOLAC
200 MG
ORAL CAPSULE
00002232317
300 MG
ETODOLAC
ORAL CAPSULE
00002232318
ETODOLAC
FLOCTAFENINE
200 MG
ORAL TABLET
00002244680
400 MG
FLOCTAFENINE
ORAL TABLET
00002244681
FLOCTAFENINE
FLURBIPROFEN
50 MG
ORAL TABLET
00001912046
00002100509
100 MG
APO-FLURBIPROFEN
NOVO-FLURPROFEN
ORAL TABLET
00001912038
00002100517
APO-FLURBIPROFEN
NOVO-FLURPROFEN
IBUPROFEN
300 MG
ORAL TABLET
00000441651
400 MG
00000506052
00000629340
600 MG
APO-IBUPROFEN
ORAL TABLET
APO-IBUPROFEN
NOVO-PROFEN
ORAL TABLET
00000585114
00000629359
APO-IBUPROFEN
NOVO-PROFEN
INDOMETHACIN
25 MG
ORAL CAPSULE
00000337420
50 MG
00000337439
50 MG
NOVO-METHACIN
RECTAL SUPPOSITORY
00002231799
100 MG
NOVO-METHACIN
ORAL CAPSULE
SANDOZ INDOMETHACIN
RECTAL SUPPOSITORY
00002231800
00001934139
SANDOZ INDOMETHACIN
RATIO-INDOMETHACIN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
76
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.92
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
KETOPROFEN
200 MG
ORAL SUSTAINED-RELEASE TABLET
00002172577
AAP
KETOPROFEN SR
$ 1.3918
$
1.4168
MAC pricing has been applied based on the price for 2 x 100 mg oral enteric-coated
tablets.
50 MG
ORAL ENTERIC-COATED TABLET
00000790435
100 MG
00000842664
50 MG
AAP
$
0.3440
KETOPROFEN-E
AAP
$
0.6959
AAP
$
0.3440
PMS
$
1.2516
AAP
AMP
$
$
0.5192
0.7092
AMP
$
1.2451
SDZ
$
4.4100
AAP
ERF
$
$
0.3990
0.4109
APX
TEV
$
$
0.3625
0.3625
APX
$
0.0781
APX
SNS
TEV
$
$
$
0.1068
0.1068
0.1068
APX
SNS
TEV
$
$
$
0.1458
0.1458
0.1458
APX
SNS
TEV
$
$
$
0.2110
0.2110
0.2110
$
1.4086
ORAL CAPSULE
00000790427
100 MG
KETOPROFEN-E
ORAL ENTERIC-COATED TABLET
KETOPROFEN
RECTAL SUPPOSITORY
00002015951
PMS-KETOPROFEN
KETOROLAC TROMETHAMINE
10 MG
ORAL TABLET
00002229080
00002162660
10 MG / ML
INJECTION
00002162644
30 MG / ML
KETOROLAC
TORADOL
TORADOL
INJECTION
00002239944
KETOROLAC TROMETHAMINE
MEFENAMIC ACID
250 MG
ORAL CAPSULE
00002229452
00000155225
MEFENAMIC
PONSTAN
NABUMETONE
500 MG
ORAL TABLET
00002238639
00002240867
APO-NABUMETONE
NOVO-NABUMETONE
NAPROXEN
125 MG
ORAL TABLET
00000522678
250 MG
00000522651
00002350750
00000565350
375 MG
APO-NAPROXEN
NAPROXEN
TEVA-NAPROX
ORAL TABLET
00000592277
00002350777
00000589861
750 MG
APO-NAPROXEN
NAPROXEN
TEVA-NAPROX
ORAL TABLET
00000600806
00002350769
00000627097
500 MG
APO-NAPROXEN
ORAL TABLET
APO-NAPROXEN
NAPROXEN
TEVA-NAPROX
ORAL SUSTAINED-RELEASE TABLET
00002162466
AMP
NAPROSYN SR
$ 0.2916
MAC pricing has been applied based on the LCA price for 2 x 375 mg oral tablets.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
77
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.92
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
NAPROXEN
250 MG
ORAL ENTERIC-COATED TABLET
00002350785
00002243312
$
$
0.1068
0.1177
$
$
$
$
$
$
0.1458
0.1458
0.1458
0.1458
0.1458
0.5841
$
$
$
$
$
$
0.2110
0.2110
0.2110
0.2110
0.2110
1.0537
PMS
$
1.0045
APX
SNS
TEV
AMP
$
$
$
$
0.3422
0.3422
0.3422
0.6652
APX
SNS
TEV
AMP
$
$
$
$
0.6667
0.6667
0.6667
1.2808
APX
TEV
$
$
0.4426
0.4426
APX
TEV
$
$
0.7422
0.7422
TEV
$
0.4216
TEV
$
0.4322
SNS
TEV
NAPROXEN EC
TEVA-NAPROX EC
$ 0.1068
$ 0.1068
MAC pricing has been applied based on the LCA price for 1 x 250 mg oral tablet.
375 MG
ORAL ENTERIC-COATED TABLET
00002246700
00002243432
00002350793
00002294702
00002243313
00002162415
APO-NAPROXEN EC
MYLAN-NAPROXEN EC
NAPROXEN EC
PMS-NAPROXEN EC
TEVA-NAPROX EC
NAPROSYN E
APX
MYP
SNS
PMS
TEV
AMP
$
$
$
$
$
$
0.1458
0.1458
0.1458
0.1458
0.1458
0.1458
MAC pricing has been applied based on the LCA price for 1 x 375 mg oral tablet.
500 MG
ORAL ENTERIC-COATED TABLET
00002246701
00002241024
00002350807
00002294710
00002243314
00002162423
APO-NAPROXEN EC
MYLAN-NAPROXEN EC
NAPROXEN EC
PMS-NAPROXEN EC
TEVA-NAPROX EC
NAPROSYN E
APX
MYP
SNS
PMS
TEV
AMP
$
$
$
$
$
$
0.2110
0.2110
0.2110
0.2110
0.2110
0.2110
MAC pricing has been applied based on the LCA price for 1 x 500 mg oral tablet.
500 MG
RECTAL SUPPOSITORY
00002017237
PMS-NAPROXEN
NAPROXEN SODIUM
275 MG
ORAL TABLET
00000784354
00002351013
00000778389
00002162725
550 MG
APO-NAPRO-NA
NAPROXEN SODIUM
TEVA-NAPROX SODIUM
ANAPROX
ORAL TABLET
00001940309
00002351021
00002026600
00002162717
APO-NAPRO-NA DS
NAPROXEN SODIUM DS
TEVA-NAPROX SODIUM DS
ANAPROX DS
PIROXICAM
10 MG
ORAL CAPSULE
00000642886
00000695718
20 MG
APO-PIROXICAM
TEVA-PIROXICAM
ORAL CAPSULE
00000642894
00000695696
APO-PIROXICAM
TEVA-PIROXICAM
SULINDAC
150 MG
ORAL TABLET
00000745588
200 MG
TEVA-SULINDAC
ORAL TABLET
00000745596
TEVA-SULINDAC
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
78
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.04.92
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
(OTHER NONSTEROIDAL ANTI-INFLAMMATORY AGENTS)
TENOXICAM
20 MG
ORAL TABLET
00002230661
TENOXICAM
AAP
$
1.1783
TEV
$
0.5401
TEV
$
0.7467
RPH
TRI
$
$
1.5749
1.7344
RPH
TRI
$
$
1.9285
2.1237
RPH
$
0.0863
RPH
$
0.1450
SDZ
$
3.2991
RPH
$
0.1738
RPH
JAI
$
$
0.1526
0.2119
PMS
$
0.0960
RPH
JAI
$
$
0.0847
0.0910
RPH
JAI
$
$
0.0887
0.1002
TIAPROFENIC ACID
200 MG
ORAL TABLET
00002179679
300 MG
00002179687
28:00
TEVA-TIAPROFENIC ACID
ORAL TABLET
TEVA-TIAPROFENIC ACID
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
BUTALBITAL/ CODEINE PHOSPHATE/ ASA/ CAFFEINE
50 MG * 15 MG * 330 MG * 40 MG
00000608203
00000176192
50 MG * 30 MG * 330 MG * 40 MG
00000608181
00000176206
ORAL CAPSULE
RATIO-TECNAL-C 1/4
FIORINAL-C 1/4
ORAL CAPSULE
RATIO-TECNAL-C 1/2
FIORINAL-C 1/2
CODEINE PHOSPHATE
15 MG
ORAL TABLET
00000593435
30 MG
RATIO-CODEINE
ORAL TABLET
00000593451
30 MG / ML
RATIO-CODEINE
INJECTION
00000544884
CODEINE PHOSPHATE
CODEINE PHOSPHATE/ ACETAMINOPHEN
30 MG * 300 MG
ORAL TABLET
00000608882
60 MG * 300 MG
RATIO-EMTEC-30
ORAL TABLET
00000621463
00002163918
RATIO-LENOLTEC NO.4
TYLENOL NO. 4
1.6 MG / ML * 32 MG / ML
00000816027
ORAL ELIXIR
PMS-ACETAMINOPHEN WITH CODEINE
RESTRICTED BENEFIT
This Drug Product is a benefit for patients 12 years of age and older
CODEINE PHOSPHATE/ ACETAMINOPHEN/ CAFFEINE
15 MG * 300 MG * 15 MG
00000653241
00002163934
30 MG * 300 MG * 15 MG
00000653276
00002163926
ORAL TABLET
RATIO-LENOLTEC NO.2
TYLENOL NO. 2
ORAL TABLET
RATIO-LENOLTEC NO.3
TYLENOL NO. 3
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
79
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
CODEINE PHOSPHATE/ ASA/ CAFFEINE CITRATE
15 MG * 375 MG * 30 MG
00002234510
30 MG * 375 MG * 30 MG
00002238645
ORAL TABLET
282
PPH
$
0.0683
PPH
$
0.1871
ORAL TABLET
292
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
80
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
COMPOUND PRESCRIPTION
00000999108
COMPOUND NARCOTIC MIXTURES - ORAL
AND INJECTION
XXX
$
0.0000
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been prepared and dispensed by a licensed
community pharmacy.
00000999208
COMPOUND NARCOTIC MIXTURES - ORAL
AND INJECTION
XXX
$
To determine eligibility of a compound, pharmacies can contact Alberta Blue Cross
for verification.
In order for a compound to be eligible:
- the compounded prescription must contain in therapeutic dosage; one or more
drug(s) identified as allowable Drug Benefits; or one or more chemical entities; and
- the compounded prescription must not duplicate a manufactured drug product,
whether the drug product is or is not identified as an allowable Drug Benefit; and
- the compounded prescription must not include a chemical entitiy or drug product,
with the exception of diluents or bases, specifically identified as not an allowable
Drug Benefit.
To be used when the compound has been procured from a licensed compound
and repackaging pharmacy and dispensed by a licensed community pharmacy.
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
81
EFFECTIVE APRIL 1, 2016
0.0000
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
HYDROMORPHONE HCL
1 MG
ORAL TABLET
00002364115
00000705438
00000885444
00002319403
2 MG
0.2240
0.2240
0.2240
0.2240
APO-HYDROMORPHONE
DILAUDID
PMS-HYDROMORPHONE
TEVA-HYDROMORPHONE
APX
PUR
PMS
TEV
$
$
$
$
0.3528
0.3528
0.3528
0.3528
HYDROMORPH CONTIN
PUR
$
0.7145
HYDROMORPH CONTIN
PUR
$
0.8620
HYDROMORPH CONTIN
PUR
$
1.0715
HYDROMORPH CONTIN
PUR
$
1.4135
HYDROMORPH CONTIN
PUR
$
1.8570
HYDROMORPH CONTIN
PUR
$
2.6785
HYDROMORPH CONTIN
PUR
$
3.4295
PUR
$
4.1085
PMS
PUR
$
$
0.0739
0.0752
SDZ
$
1.9613
SDZ
$
4.3460
SDZ
$
8.0989
SDZ
$
20.1212
PMS
$
3.3516
ORAL CONTROLLED-RELEASE CAPSULE
00002125390
1 MG / ML
2 MG / ML
HYDROMORPHONE HP
INJECTION
00002145936
50 MG / ML
HYDROMORPHONE
INJECTION
00002145928
20 MG / ML
PMS-HYDROMORPHONE
DILAUDID
INJECTION
00002145901
10 MG / ML
HYDROMORPH CONTIN
ORAL LIQUID
00001916386
00000786535
HYDROMORPHONE HP 20
INJECTION
00002146126
3 MG
$
$
$
$
ORAL CONTROLLED-RELEASE CAPSULE
00002125382
30 MG
APX
PUR
PMS
TEV
ORAL CONTROLLED-RELEASE CAPSULE
00002243562
24 MG
APO-HYDROMORPHONE
DILAUDID
PMS-HYDROMORPHONE
TEVA-HYDROMORPHONE
ORAL CONTROLLED-RELEASE CAPSULE
00002125366
18 MG
0.1416
0.1416
0.1416
0.1416
ORAL CONTROLLED-RELEASE CAPSULE
00002359510
12 MG
$
$
$
$
ORAL CONTROLLED-RELEASE CAPSULE
00002125331
9 MG
APX
PUR
PMS
TEV
ORAL CONTROLLED-RELEASE CAPSULE
00002359502
6 MG
APO-HYDROMORPHONE
DILAUDID
PMS-HYDROMORPHONE
TEVA-HYDROMORPHONE
ORAL CONTROLLED-RELEASE CAPSULE
00002125323
4.5 MG
0.0950
0.0950
0.0950
0.0950
ORAL TABLET
00002364158
00000786543
00000885428
00002319446
3 MG
$
$
$
$
ORAL TABLET
00002364131
00000125121
00000885401
00002319438
8 MG
APX
PUR
PMS
TEV
ORAL TABLET
00002364123
00000125083
00000885436
00002319411
4 MG
APO-HYDROMORPHONE
DILAUDID
PMS-HYDROMORPHONE
TEVA-HYDROMORPHONE
HYDROMORPHONE HP 50
RECTAL SUPPOSITORY
00001916394
PMS-HYDROMORPHONE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
82
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
MEPERIDINE HCL
50 MG
ORAL TABLET
00002138018
50 MG / ML
DEMEROL
SAV
$
0.1590
SDZ
$
2.0493
PAL
$
0.1704
PAL
$
0.5678
PAL
$
0.9084
PAL
$
1.6879
PAL
PAL
$
$
0.0540
0.1078
PAL
MAL
MAL
PAL
$
$
$
$
0.1500
0.1500
0.1500
0.3895
RPH
$
0.0170
RPH
$
0.0679
RPH
$
0.2213
RPH
$
0.6106
PAL
PUR
$
$
0.1100
0.1240
PAL
PUR
$
$
0.1700
0.1930
PUR
$
0.3440
PAL
$
0.2250
PUR
$
0.4410
PAL
$
0.3450
INJECTION
00000725765
MEPERIDINE HYDROCHLORIDE
METHADONE HCL
1 MG
ORAL TABLET
00002247698
5 MG
00002247699
10 MG
METADOL
ORAL TABLET
00002247700
25 MG
METADOL
ORAL TABLET
METADOL
ORAL TABLET
00002247701
1 MG / ML
00002247374
00002247694
10 MG / ML
METADOL
ORAL SOLUTION
METADOL-D
METADOL
ORAL LIQUID
00002244290
00002394596
00002394618
00002241377
METADOL-D
METHADOSE
METHADOSE SUGAR FREE
METADOL CONCENTRATE
MORPHINE HCL
1 MG / ML
ORAL SYRUP
00000607762
5 MG / ML
00000607770
10 MG / ML
RATIO-MORPHINE
ORAL SYRUP
00000690783
20 MG / ML
RATIO-MORPHINE
ORAL SYRUP
RATIO-MORPHINE
ORAL SYRUP
00000690791
RATIO-MORPHINE
MORPHINE SULFATE
5 MG
ORAL TABLET
00000594652
00002014203
10 MG
ORAL TABLET
00000594644
00002014211
20 MG
STATEX
ORAL TABLET
00002014254
50 MG
MS.IR
ORAL TABLET
00000594636
30 MG
STATEX
MS.IR
ORAL TABLET
00002014238
25 MG
STATEX
MS.IR
MS.IR
ORAL TABLET
00000675962
STATEX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
83
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
MORPHINE SULFATE
15 MG
ORAL SUSTAINED-RELEASE TABLET
00002350815
00002244790
00002302764
00002015439
30 MG
TEV
PUR
$
$
2.6844
2.9100
TEVA-MORPHINE SR
MS CONTIN
TEV
PUR
$
$
4.9912
5.4110
M-ESLON
ETP
$
0.3130
M-ESLON
ETP
$
0.3610
M-ESLON
ETP
$
0.5390
M-ESLON
ETP
$
0.9570
M-ESLON
ETP
$
2.0620
M-ESLON
ETP
$
4.1250
KADIAN
BGP
$
0.3956
KADIAN
BGP
$
0.7686
BGP
$
1.4130
BGP
$
2.4644
PAL
$
0.0200
PAL
$
0.0803
PAL
$
0.5176
PAL
$
0.9836
ORAL SUSTAINED-RELEASE CAPSULE
00002184443
100 MG
TEVA-MORPHINE SR
MS CONTIN
ORAL SUSTAINED-RELEASE CAPSULE
00002184435
50 MG
0.6167
0.6167
0.6167
1.9080
ORAL SUSTAINED-RELEASE CAPSULE
00002242163
20 MG
$
$
$
$
ORAL EXTENDED-RELEASE CAPSULE
00002177757
10 MG
SNS
SDZ
TEV
PUR
ORAL EXTENDED-RELEASE CAPSULE
00002019965
200 MG
MORPHINE SR
SANDOZ MORPHINE SR
TEVA-MORPHINE SR
MS CONTIN
ORAL EXTENDED-RELEASE CAPSULE
00002019957
100 MG
0.3500
0.3500
0.3500
1.0830
ORAL EXTENDED-RELEASE CAPSULE
00002019949
60 MG
$
$
$
$
ORAL EXTENDED-RELEASE CAPSULE
00002177749
30 MG
SNS
SDZ
TEV
PUR
ORAL EXTENDED-RELEASE CAPSULE
00002019930
15 MG
MORPHINE SR
SANDOZ MORPHINE SR
TEVA-MORPHINE SR
MS CONTIN
ORAL SUSTAINED-RELEASE TABLET
00002302802
00002014327
10 MG
0.2317
0.2317
0.2317
0.7160
ORAL SUSTAINED-RELEASE TABLET
00002302799
00002014319
200 MG
$
$
$
$
ORAL SUSTAINED-RELEASE TABLET
00002350912
00002244792
00002302780
00002014300
100 MG
SNS
SDZ
TEV
PUR
ORAL SUSTAINED-RELEASE TABLET
00002350890
00002244791
00002302772
00002014297
60 MG
MORPHINE SR
SANDOZ MORPHINE SR
TEVA-MORPHINE SR
MS CONTIN
KADIAN
ORAL SUSTAINED-RELEASE CAPSULE
00002184451
1 MG / ML
00000591467
5 MG / ML
STATEX
ORAL DROPS
00000621935
50 MG / ML
STATEX
ORAL SYRUP
00000591475
20 MG / ML
KADIAN
ORAL SYRUP
STATEX
ORAL DROPS
00000705799
STATEX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
84
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
MORPHINE SULFATE
1 MG / ML
INJECTION
00002021048
10 MG / ML
00000392588
15 MG / ML
SDZ
$
2.2715
MORPHINE SULFATE
SDZ
$
2.4081
MORPHINE HP 50
SDZ
$
6.8195
STATEX
PAL
$
1.7420
STATEX
PAL
$
1.9460
PAL
$
2.3170
PAL
$
2.5410
SDZ
$
4.7813
PMS
SDZ
$
$
0.1287
0.1332
PMS
SDZ
PUR
$
$
$
0.1896
0.2283
0.4010
PMS
SDZ
PUR
$
$
$
0.2964
0.3965
0.6970
PUR
$
0.9115
PUR
$
1.1010
PUR
$
1.3675
PUR
$
1.8070
PUR
$
2.3710
PUR
$
3.2710
PUR
$
4.3780
SDZ
$
3.4586
SDZ
$
4.9922
RECTAL SUPPOSITORY
00000596965
30 MG
MORPHINE SULFATE
RECTAL SUPPOSITORY
00000632201
20 MG
4.7612
RECTAL SUPPOSITORY
00000632228
10 MG
$
INJECTION
00000617288
5 MG
SDZ
INJECTION
00000392561
50 MG / ML
MORPHINE LP EPIDURAL
INJECTION
STATEX
RECTAL SUPPOSITORY
00000639389
STATEX
OPIUM/ BELLADONNA
65 MG * 15 MG
RECTAL SUPPOSITORY
00001901869
SANDOZ OPIUM & BELLADONNA
OXYCODONE HCL
5 MG
ORAL TABLET
00002319977
00000789739
10 MG
ORAL TABLET
00002319985
00000443948
00002240131
20 MG
OXYNEO
RECTAL SUPPOSITORY
00000392480
20 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372584
10 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372576
80 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372568
60 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372541
40 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372797
30 MG
OXYNEO
ORAL CONTROLLED-RELEASE TABLET
00002372533
20 MG
PMS-OXYCODONE
SUPEUDOL
OXY-IR
ORAL CONTROLLED-RELEASE TABLET
00002372525
15 MG
PMS-OXYCODONE
SUPEUDOL
OXY-IR
ORAL TABLET
00002319993
00002262983
00002240132
10 MG
PMS-OXYCODONE
SUPEUDOL
SUPEUDOL
RECTAL SUPPOSITORY
00000392472
SUPEUDOL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
85
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.08
(OPIATE AGONISTS)
OXYCODONE HCL/ ACETAMINOPHEN
2.5 MG * 325 MG
ORAL TABLET
00001916491
5 MG * 325 MG
PERCOCET DEMI
BMS
$
0.6674
APX
BMS
SNS
RPH
SDZ
BMS
$
$
$
$
$
$
0.1285
0.1285
0.1285
0.1285
0.1285
0.8166
RPH
$
0.4380
MYP
TEV
IUK
$
$
$
1.3350
1.3350
2.6700
MYP
TEV
IUK
$
$
$
2.3650
2.3650
4.7300
SAV
$
0.4597
HSP
$
12.0777
AAP
$
0.0564
AAP
$
0.0887
ORAL TABLET
00002324628
00001916548
00002361361
00000608165
00002307898
00001916475
APO-OXYCODONE
ENDOCET
OXYCODONE/ACET
RATIO-OXYCOCET
SANDOZ-OXYCODONE ACET
PERCOCET
OXYCODONE HCL/ ASA
5 MG * 325 MG
ORAL TABLET
00000608157
28:00
RATIO-OXYCODAN
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
28:08.12
(OPIATE PARTIAL AGONISTS)
BUPRENORPHINE HCL/ NALOXONE HYDROCHLORIDE
DIHYDRATE
2 MG (BASE) * 0.5 MG (BASE)
00002408090
00002424851
00002295695
8 MG (BASE) * 2 MG (BASE)
00002408104
00002424878
00002295709
ORAL SUBLINGUAL TABLET
MYLAN-BUPRENORPHINE NALOXONE
TEVA-BUPRENORPHINE/NALOXONE
SUBOXONE
ORAL SUBLINGUAL TABLET
MYLAN-BUPRENORPHINE NALOXONE
TEVA-BUPRENORPHINE/NALOXONE
SUBOXONE
PENTAZOCINE HCL
50 MG (BASE)
ORAL TABLET
00002137984
TALWIN
PENTAZOCINE LACTATE
30 MG / ML
INJECTION
00002241976
28:00
TALWIN
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.04
(BARBITURATES)
PRIMIDONE
125 MG
ORAL TABLET
00000399310
250 MG
PRIMIDONE
ORAL TABLET
00000396761
PRIMIDONE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
86
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.08
(BENZODIAZEPINES)
CLOBAZAM
10 MG
ORAL TABLET
00002238334
00002244638
NOVO-CLOBAZAM
APO-CLOBAZAM
TEV
APX
$
$
0.1152
0.2197
PMS
$
0.0801
APX
SIV
MYP
PMS
PMS
TEV
HLR
$
$
$
$
$
$
$
0.0554
0.0554
0.0554
0.0554
0.0554
0.0554
0.2218
PMS
$
0.1487
APX
SIV
MYP
PMS
TEV
HLR
$
$
$
$
$
$
0.0954
0.0954
0.0954
0.0954
0.0954
0.3825
PFI
$
0.0827
PFI
$
0.0455
TAR
PFI
$
$
0.0372
0.0537
PFI
$
0.1306
PFI
$
0.0839
CLONAZEPAM
0.25 MG
ORAL TABLET
00002179660
0.5 MG
00002177889
00002442035
00002230950
00002048701
00002207818
00002239024
00000382825
1 MG
PMS-CLONAZEPAM
ORAL TABLET
00002177897
00002442051
00002230951
00002048736
00002239025
00000382841
28:00
APO-CLONAZEPAM
CLONAZEPAM
MYLAN-CLONAZEPAM
PMS-CLONAZEPAM
PMS-CLONAZEPAM-R
TEVA-CLONAZEPAM
RIVOTRIL
ORAL TABLET
00002048728
2 MG
PMS-CLONAZEPAM
ORAL TABLET
APO-CLONAZEPAM
CLONAZEPAM
MYLAN-CLONAZEPAM
PMS-CLONAZEPAM
TEVA-CLONAZEPAM
RIVOTRIL
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.12
(HYDANTOINS)
PHENYTOIN
50 MG
ORAL CHEWABLE TABLET
00000023698
6 MG / ML
00000023442
25 MG / ML
DILANTIN INFATABS
ORAL SUSPENSION
DILANTIN-30
ORAL SUSPENSION
00002250896
00000023450
TARO-PHENYTOIN
DILANTIN-125
PHENYTOIN SODIUM
30 MG
ORAL CAPSULE
00000022772
100 MG
DILANTIN
ORAL CAPSULE
00000022780
DILANTIN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
87
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.20
(SUCCINIMIDES)
ETHOSUXIMIDE
250 MG
ORAL CAPSULE
00000022799
50 MG / ML
00000023485
28:00
ZARONTIN
ERF
$
0.3299
ERF
$
0.0659
TAR
TEV
NOV
$
$
$
0.2432
0.2432
0.4096
PMS
NOV
$
$
0.0380
0.1684
PMS
NOV
$
$
0.0749
0.3325
PMS
SDZ
NOV
$
$
$
0.0930
0.0930
0.4130
PMS
SDZ
NOV
$
$
$
0.1859
0.1859
0.8259
TAR
NOV
$
$
0.0616
0.0794
APX
SNS
TEV
BGP
$
$
$
$
0.0724
0.0724
0.0760
0.2932
APX
SNS
TEV
BGP
$
$
$
$
0.1301
0.1301
0.1366
0.5270
APX
SNS
TEV
BGP
$
$
$
$
0.2604
0.2604
0.2734
1.0547
ORAL SYRUP
ZARONTIN
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.92
(MISCELLANEOUS ANTICONVULSANTS)
CARBAMAZEPINE
200 MG
ORAL TABLET
00002407515
00000782718
00000010405
100 MG
ORAL CHEWABLE TABLET
00002231542
00000369810
200 MG
PMS-CARBAMAZEPINE
TEGRETOL
ORAL SUSTAINED-RELEASE TABLET
00002231543
00002261839
00000773611
400 MG
PMS-CARBAMAZEPINE
TEGRETOL
ORAL CHEWABLE TABLET
00002231540
00000665088
200 MG
TARO-CARBAMAZEPINE
TEVA-CARBAMAZ
TEGRETOL
PMS-CARBAMAZEPINE-CR
SANDOZ CARBAMAZEPINE CR
TEGRETOL CR
ORAL SUSTAINED-RELEASE TABLET
00002231544
00002261847
00000755583
20 MG / ML
PMS-CARBAMAZEPINE-CR
SANDOZ CARBAMAZEPINE CR
TEGRETOL CR
ORAL SUSPENSION
00002367394
00002194333
TARO-CARBAMAZEPINE
TEGRETOL
DIVALPROEX SODIUM (VALPROIC ACID EQUIV.)
125 MG (BASE)
ORAL ENTERIC-COATED TABLET
00002239698
00002400499
00002239701
00000596418
250 MG (BASE)
ORAL ENTERIC-COATED TABLET
00002239699
00002400502
00002239702
00000596426
500 MG (BASE)
APO-DIVALPROEX
DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
APO-DIVALPROEX
DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
ORAL ENTERIC-COATED TABLET
00002239700
00002400510
00002239703
00000596434
APO-DIVALPROEX
DIVALPROEX
NOVO-DIVALPROEX
EPIVAL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
88
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.92
(MISCELLANEOUS ANTICONVULSANTS)
GABAPENTIN
100 MG
ORAL CAPSULE
00002244304
00002321203
00002256142
00002246314
00002332582
00002353245
00002416840
00002285819
00002361469
00002391473
00002248259
00002243446
00002319055
00002244513
00002431408
00002084260
300 MG
APX
AUR
APH
SIV
RAN
SNS
AHI
GMD
JPC
MAR
MYP
PMS
RAN
TEV
VAN
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.0749
0.4467
APX
AUR
APH
SIV
RAN
SNS
AHI
GMD
JPC
MAR
MYP
PMS
RAN
TEV
VAN
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
0.1821
1.0867
APX
AUR
APH
SIV
RAN
SNS
AHI
GMD
JPC
MAR
MYP
PMS
RAN
TEV
VAN
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
0.2171
1.2951
ORAL CAPSULE
00002244305
00002321211
00002256150
00002246315
00002332590
00002353253
00002416859
00002285827
00002361485
00002391481
00002248260
00002243447
00002319063
00002244514
00002431416
00002084279
400 MG
APO-GABAPENTIN
AURO-GABAPENTIN
CO GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GD-GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
MYLAN-GABAPENTIN
PMS-GABAPENTIN
RAN-GABAPENTIN
TEVA-GABAPENTIN
VAN-GABAPENTIN
NEURONTIN
APO-GABAPENTIN
AURO-GABAPENTIN
CO GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GD-GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
MYLAN-GABAPENTIN
PMS-GABAPENTIN
RAN-GABAPENTIN
TEVA-GABAPENTIN
VAN-GABAPENTIN
NEURONTIN
ORAL CAPSULE
00002244306
00002321238
00002256169
00002246316
00002332604
00002353261
00002416867
00002285835
00002361493
00002391503
00002248261
00002243448
00002319071
00002244515
00002431424
00002084287
APO-GABAPENTIN
AURO-GABAPENTIN
CO GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GABAPENTIN
GD-GABAPENTIN
JAMP-GABAPENTIN
MAR-GABAPENTIN
MYLAN-GABAPENTIN
PMS-GABAPENTIN
RAN-GABAPENTIN
TEVA-GABAPENTIN
VAN-GABAPENTIN
NEURONTIN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
89
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.92
(MISCELLANEOUS ANTICONVULSANTS)
LAMOTRIGINE
25 MG
ORAL TABLET
00002245208
00002246897
00002381354
00002343010
00002428202
00002265494
00002248232
00002142082
100 MG
$
$
$
$
$
$
$
$
0.0936
0.0936
0.0970
0.0970
0.0970
0.0970
0.0970
0.3878
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
AURO-LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
MYLAN-LAMOTRIGINE
TEVA-LAMOTRIGINE
LAMICTAL
APX
PMS
AUR
SNS
SIV
MYP
TEV
GSK
$
$
$
$
$
$
$
$
0.3735
0.3735
0.3871
0.3871
0.3871
0.3871
0.3871
1.5483
APX
PMS
AUR
SNS
SIV
MYP
RPH
TEV
GSK
$
$
$
$
$
$
$
$
$
0.5505
0.5505
0.5705
0.5705
0.5705
0.5705
0.5705
0.5705
2.2817
GSK
$
0.1654
APH
APX
AUR
JPC
SNS
AHI
PMS
RAN
UCB
$
$
$
$
$
$
$
$
$
0.8000
0.8000
0.8000
0.8000
0.8000
0.8000
0.8000
0.8000
1.7252
APH
APX
AUR
JPC
SNS
AHI
PMS
RAN
UCB
$
$
$
$
$
$
$
$
$
0.9750
0.9750
0.9750
0.9750
0.9750
0.9750
0.9750
0.9750
2.1213
ORAL TABLET
00002245210
00002246899
00002381370
00002343037
00002428229
00002265516
00002246963
00002248234
00002142112
5 MG
APX
PMS
AUR
SNS
SIV
MYP
TEV
GSK
ORAL TABLET
00002245209
00002246898
00002381362
00002343029
00002428210
00002265508
00002248233
00002142104
150 MG
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
AURO-LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
MYLAN-LAMOTRIGINE
TEVA-LAMOTRIGINE
LAMICTAL
APO-LAMOTRIGINE
PMS-LAMOTRIGINE
AURO-LAMOTRIGINE
LAMOTRIGINE
LAMOTRIGINE
MYLAN-LAMOTRIGINE
RATIO-LAMOTRIGINE
TEVA-LAMOTRIGINE
LAMICTAL
ORAL CHEWABLE TABLET
00002240115
LAMICTAL
LEVETIRACETAM
250 MG
ORAL TABLET
00002274183
00002285924
00002375249
00002403005
00002353342
00002399776
00002296101
00002396106
00002247027
500 MG
ACT LEVETIRACETAM
APO-LEVETIRACETAM
AURO-LEVETIRACETAM
JAMP-LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
PMS-LEVETIRACETAM
RAN-LEVETIRACETAM
KEPPRA
ORAL TABLET
00002274191
00002285932
00002375257
00002403021
00002353350
00002399784
00002296128
00002396114
00002247028
ACT LEVETIRACETAM
APO-LEVETIRACETAM
AURO-LEVETIRACETAM
JAMP-LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
PMS-LEVETIRACETAM
RAN-LEVETIRACETAM
KEPPRA
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
90
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.92
(MISCELLANEOUS ANTICONVULSANTS)
LEVETIRACETAM
750 MG
ORAL TABLET
00002274205
00002285940
00002375265
00002403048
00002353369
00002399792
00002296136
00002396122
00002247029
ACT LEVETIRACETAM
APO-LEVETIRACETAM
AURO-LEVETIRACETAM
JAMP-LEVETIRACETAM
LEVETIRACETAM
LEVETIRACETAM
PMS-LEVETIRACETAM
RAN-LEVETIRACETAM
KEPPRA
APH
APX
AUR
JPC
SNS
AHI
PMS
RAN
UCB
$
$
$
$
$
$
$
$
$
1.3500
1.3500
1.3500
1.3500
1.3500
1.3500
1.3500
1.3500
2.9371
AHI
APH
APX
AUR
MPI
MYP
PMS
SDZ
TEV
SNS
SIV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
0.3128
0.3290
0.3290
0.3290
0.3290
0.3290
0.3290
0.3290
0.3290
0.3290
0.3290
1.3337
PMS
$
1.1494
AHI
APH
APX
AUR
MPI
MYP
PMS
SDZ
TEV
SNS
SIV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
0.5928
0.6235
0.6235
0.6235
0.6235
0.6235
0.6235
0.6235
0.6235
0.6235
0.6235
2.5157
AHI
APH
APX
AUR
MPI
MYP
PMS
SDZ
TEV
SNS
JAI
$
$
$
$
$
$
$
$
$
$
$
0.8853
0.9310
0.9310
0.9310
0.9310
0.9310
0.9310
0.9310
0.9310
0.9310
3.7275
TOPIRAMATE
25 MG
ORAL TABLET
00002395738
00002287765
00002279614
00002345803
00002315645
00002263351
00002262991
00002431807
00002248860
00002356856
00002389460
00002230893
50 MG
ORAL TABLET
00002312085
100 MG
PMS-TOPIRAMATE
ORAL TABLET
00002395746
00002287773
00002279630
00002345838
00002315653
00002263378
00002263009
00002431815
00002248861
00002356864
00002389487
00002230894
200 MG
TOPIRAMATE
ACT TOPIRAMATE
APO-TOPIRAMATE
AURO-TOPIRAMATE
MINT-TOPIRAMATE
MYLAN-TOPIRAMATE
PMS-TOPIRAMATE
SANDOZ TOPIRAMATE
TEVA-TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPAMAX
TOPIRAMATE
ACT TOPIRAMATE
APO-TOPIRAMATE
AURO-TOPIRAMATE
MINT-TOPIRAMATE
MYLAN-TOPIRAMATE
PMS-TOPIRAMATE
SANDOZ TOPIRAMATE
TEVA-TOPIRAMATE
TOPIRAMATE
TOPIRAMATE
TOPAMAX
ORAL TABLET
00002395754
00002287781
00002279649
00002345846
00002315661
00002263386
00002263017
00002431823
00002248862
00002356872
00002230896
TOPIRAMATE
ACT TOPIRAMATE
APO-TOPIRAMATE
AURO-TOPIRAMATE
MINT-TOPIRAMATE
MYLAN-TOPIRAMATE
PMS-TOPIRAMATE
SANDOZ TOPIRAMATE
TEVA-TOPIRAMATE
TOPIRAMATE
TOPAMAX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
91
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
28:12.92
(MISCELLANEOUS ANTICONVULSANTS)
TOPIRAMATE
15 MG
ORAL CAPSULE
00002239907
25 MG
TOPAMAX SPRINKLE
JAI
$
1.2153
JAI
$
1.2759
APX
PMS
BGP
$
$
$
0.2905
0.2905
0.5534
PMS
$
0.5765
PMS
APX
BGP
$
$
$
0.0379
0.0605
0.1153
LUI
$
0.9110
LUI
$
0.9110
APX
TEV
$
$
0.2520
0.2646
APX
TEV
$
$
0.3120
0.3276
APX
TEV
$
$
0.6126
0.6432
ERF
$
0.3667
GSK
$
0.3816
ORAL CAPSULE
00002239908
TOPAMAX SPRINKLE
VALPROIC ACID
250 MG
ORAL CAPSULE
00002238048
00002230768
00000443840
500 MG
APO-VALPROIC
PMS-VALPROIC ACID
DEPAKENE
ORAL ENTERIC-COATED CAPSULE
00002229628
50 MG / ML
PMS-VALPROIC ACID E.C.
ORAL SYRUP
00002236807
00002238370
00000443832
PMS-VALPROIC ACID
APO-VALPROIC
DEPAKENE
VIGABATRIN
500 MG
ORAL TABLET
00002065819
500 MG
00002068036
28:00
SABRIL
ORAL POWDER PACKET
SABRIL
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.12
ANTIDEPRESSANTS
(MONOAMINE OXIDASE INHIBITORS)
MOCLOBEMIDE
100 MG
ORAL TABLET
00002232148
00002239746
150 MG
ORAL TABLET
00002232150
00002239747
300 MG
APO-MOCLOBEMIDE
TEVA-MOCLOBEMIDE
APO-MOCLOBEMIDE
TEVA-MOCLOBEMIDE
ORAL TABLET
00002240456
00002239748
APO-MOCLOBEMIDE
TEVA-MOCLOBEMIDE
PHENELZINE SULFATE
15 MG (BASE)
ORAL TABLET
00000476552
NARDIL
TRANYLCYPROMINE SULFATE
10 MG (BASE)
ORAL TABLET
00001919598
PARNATE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
92
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.04.16
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
(SELECTIVE SEROTONIN- AND NOREPINEPHRINEREUPTAKE INHIBITORS)
DULOXETINE HYDROCHLORIDE
30 MG (BASE)
ORAL DELAYED-RELEASE CAPSULE
00002301482
60 MG (BASE)
CYMBALTA
LIL
$
1.9254
LIL
$
3.9075
APH
APX
GMD
MYP
PMS
RAN
SDZ
TEV
SNS
SIV
PFI
$
$
$
$
$
$
$
$
$
$
$
0.1643
0.1643
0.1643
0.1643
0.1643
0.1643
0.1643
0.1643
0.1643
0.1643
0.9661
APH
APX
GMD
MYP
PMS
RAN
SDZ
TEV
SNS
SIV
PFI
$
$
$
$
$
$
$
$
$
$
$
0.3285
0.3285
0.3285
0.3285
0.3285
0.3285
0.3285
0.3285
0.3285
0.3285
1.9599
APH
APX
GMD
MYP
PMS
RAN
SDZ
TEV
SNS
SIV
PFI
$
$
$
$
$
$
$
$
$
$
$
0.3469
0.3469
0.3469
0.3469
0.3469
0.3469
0.3469
0.3469
0.3469
0.3469
2.0690
ORAL DELAYED-RELEASE CAPSULE
00002301490
CYMBALTA
VENLAFAXINE HCL
37.5 MG (BASE)
ORAL EXTENDED-RELEASE CAPSULE
00002304317
00002331683
00002360020
00002310279
00002278545
00002380072
00002310317
00002275023
00002354713
00002385929
00002237279
75 MG (BASE)
ORAL EXTENDED-RELEASE CAPSULE
00002304325
00002331691
00002360039
00002310287
00002278553
00002380080
00002310325
00002275031
00002354721
00002385937
00002237280
150 MG (BASE)
ACT VENLAFAXINE XR
APO-VENLAFAXINE XR
GD-VENLAFAXINE XR
MYLAN-VENLAFAXINE XR
PMS-VENLAFAXINE XR
RAN-VENLAFAXINE XR
SANDOZ VENLAFAXINE XR
TEVA-VENLAFAXINE XR
VENLAFAXINE XR
VENLAFAXINE XR
EFFEXOR XR
ACT VENLAFAXINE XR
APO-VENLAFAXINE XR
GD-VENLAFAXINE XR
MYLAN-VENLAFAXINE XR
PMS-VENLAFAXINE XR
RAN-VENLAFAXINE XR
SANDOZ VENLAFAXINE XR
TEVA-VENLAFAXINE XR
VENLAFAXINE XR
VENLAFAXINE XR
EFFEXOR XR
ORAL EXTENDED-RELEASE CAPSULE
00002304333
00002331705
00002360047
00002310295
00002278561
00002380099
00002310333
00002275058
00002354748
00002385945
00002237282
ACT VENLAFAXINE XR
APO-VENLAFAXINE XR
GD-VENLAFAXINE XR
MYLAN-VENLAFAXINE XR
PMS-VENLAFAXINE XR
RAN-VENLAFAXINE XR
SANDOZ VENLAFAXINE XR
TEVA-VENLAFAXINE XR
VENLAFAXINE XR
VENLAFAXINE XR
EFFEXOR XR
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
93
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.04.20
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
CITALOPRAM HYDROBROMIDE
10 MG (BASE)
ORAL TABLET
00002355248
00002387948
00002430517
00002445719
00002421739
00002370085
00002371871
00002370077
00002409003
00002270609
00002431629
00002312336
20 MG (BASE)
ACP
SIV
JPC
SNS
ECL
JPC
MAR
MPI
NTP
PMS
SEP
TEV
$
$
$
$
$
$
$
$
$
$
$
$
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
0.1432
ACP
APH
APX
AUR
RAN
SNS
SIV
JPC
ODN
ECL
JPC
MAR
MPI
MPI
MYP
NTP
PMS
RAN
RPH
SDZ
SEP
TEV
LBC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
1.3625
SUN
$
0.8961
ORAL TABLET
00002355256
00002248050
00002246056
00002275562
00002331950
00002353660
00002387956
00002430541
00002306239
00002421747
00002313405
00002371898
00002304686
00002429705
00002246594
00002409011
00002248010
00002285622
00002252112
00002248170
00002355272
00002293218
00002239607
30 MG (BASE)
ACCEL-CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM
ECL-CITALOPRAM
JAMP-CITALOPRAM
MAR-CITALOPRAM
MINT-CITALOPRAM
NAT-CITALOPRAM
PMS-CITALOPRAM
SEPTA-CITALOPRAM
TEVA-CITALOPRAM
ACCEL-CITALOPRAM
ACT CITALOPRAM
APO-CITALOPRAM
AURO-CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM-ODAN
ECL-CITALOPRAM
JAMP-CITALOPRAM
MAR-CITALOPRAM
MINT-CITALOPRAM
MINT-CITALOPRAM
MYLAN-CITALOPRAM
NAT-CITALOPRAM
PMS-CITALOPRAM
RAN-CITALO
RATIO-CITALOPRAM
SANDOZ CITALOPRAM
SEPTA-CITALOPRAM
TEVA-CITALOPRAM
CELEXA
ORAL TABLET
00002296152
CTP 30
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
94
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.04.20
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
CITALOPRAM HYDROBROMIDE
40 MG (BASE)
ORAL TABLET
00002355264
00002248051
00002246057
00002275570
00002331977
00002353679
00002387964
00002430568
00002421755
00002313413
00002371901
00002304694
00002429713
00002246595
00002409038
00002248011
00002285630
00002248171
00002355280
00002293226
00002239608
ACCEL-CITALOPRAM
ACT CITALOPRAM
APO-CITALOPRAM
AURO-CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM
CITALOPRAM
ECL-CITALOPRAM
JAMP-CITALOPRAM
MAR-CITALOPRAM
MINT-CITALOPRAM
MINT-CITALOPRAM
MYLAN-CITALOPRAM
NAT-CITALOPRAM
PMS-CITALOPRAM
RAN-CITALO
SANDOZ CITALOPRAM
SEPTA-CITALOPRAM
TEVA-CITALOPRAM
CELEXA
ACP
APH
APX
AUR
RAN
SNS
SIV
JPC
ECL
JPC
MAR
MPI
MPI
MYP
NTP
PMS
RAN
SDZ
SEP
TEV
LBC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
95
EFFECTIVE APRIL 1, 2016
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
0.2397
1.3625
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.20
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
ESCITALOPRAM
10 MG
ORAL TABLET
00002313561
00002295016
00002397358
00002429039
00002430118
00002429780
00002423480
00002407418
00002309467
00002440296
00002303949
00002385481
00002364077
00002318180
00002263238
20 MG
ACT ESCITALOPRAM
APO-ESCITALOPRAM
AURO-ESCITALOPRAM
ESCITALOPRAM
ESCITALOPRAM
JAMP-ESCITALOPRAM
MAR-ESCITALOPRAM
MINT-ESCITALOPRAM
MYLAN-ESCITALOPRAM
NAT-ESCITALOPRAM
PMS-ESCITALOPRAM
RAN-ESCITALOPRAM
SANDOZ ESCITALOPRAM
TEVA-ESCITALOPRAM
CIPRALEX
APH
APX
AUR
SIV
SNS
JPC
MAR
MPI
MYP
NTP
PMS
RAN
SDZ
TEV
LBC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
0.4318
1.7950
APH
APX
AUR
SIV
SNS
JPC
MAR
MPI
MYP
NTP
PMS
RAN
SDZ
TEV
LBC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
0.4597
1.9111
ORAL TABLET
00002313588
00002295024
00002397374
00002429047
00002430126
00002429799
00002423502
00002407434
00002309475
00002440318
00002303965
00002385503
00002364085
00002318202
00002263254
ACT ESCITALOPRAM
APO-ESCITALOPRAM
AURO-ESCITALOPRAM
ESCITALOPRAM
ESCITALOPRAM
JAMP-ESCITALOPRAM
MAR-ESCITALOPRAM
MINT-ESCITALOPRAM
MYLAN-ESCITALOPRAM
NAT-ESCITALOPRAM
PMS-ESCITALOPRAM
RAN-ESCITALOPRAM
SANDOZ ESCITALOPRAM
TEVA-ESCITALOPRAM
CIPRALEX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
96
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.20
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
FLUOXETINE HCL
10 MG (BASE)
ORAL CAPSULE
00002393441
00002401894
00002432412
00002216353
00002242177
00002286068
00002374447
00002392909
00002380560
00002237813
00002177579
00002216582
00002018985
20 MG (BASE)
FLUOXETINE BP
JAMP-FLUOXETINE
VAN-FLUOXETINE
APO-FLUOXETINE
CO FLUOXETINE
FLUOXETINE
FLUOXETINE
MAR-FLUOXETINE
MINT-FLUOXETINE
MYLAN-FLUOXETINE
PMS-FLUOXETINE
TEVA-FLUOXETINE
PROZAC
AHI
JPC
VAN
APX
APH
SNS
SIV
MAR
MPI
MYP
PMS
TEV
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4595
0.4595
0.4595
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
1.8735
AHI
JPC
VAN
APX
AUR
APH
SNS
SIV
MAR
MPI
MYP
PMS
TEV
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4598
0.4598
0.4598
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
0.4728
1.8735
AAP
$
0.5859
APH
APX
TEV
BGP
$
$
$
$
0.2105
0.2105
0.2105
0.9403
APH
APX
BGP
$
$
$
0.3783
0.3783
1.6910
ORAL CAPSULE
00002383241
00002386402
00002432420
00002216361
00002385635
00002242178
00002286076
00002374455
00002392917
00002380579
00002237814
00002177587
00002216590
00000636622
4 MG / ML (BASE)
00002231328
FLUOXETINE BP
JAMP-FLUOXETINE
VAN-FLUOXETINE
APO-FLUOXETINE
AURO-FLUOXETINE
CO FLUOXETINE
FLUOXETINE
FLUOXETINE
MAR-FLUOXETINE
MINT-FLUOXETINE
MYLAN-FLUOXETINE
PMS-FLUOXETINE
TEVA-FLUOXETINE
PROZAC
ORAL LIQUID
FLUOXETINE
FLUVOXAMINE MALEATE
50 MG
ORAL TABLET
00002255529
00002231329
00002239953
00001919342
100 MG
ACT FLUVOXAMINE
APO-FLUVOXAMINE
NOVO-FLUVOXAMINE
LUVOX
ORAL TABLET
00002255537
00002231330
00001919369
ACT FLUVOXAMINE
APO-FLUVOXAMINE
LUVOX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
97
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.04.20
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
PAROXETINE HCL
20 MG (BASE)
ORAL TABLET
00002262754
00002240908
00002383284
00002368870
00002411954
00002421380
00002248013
00002282852
00002388235
00002247751
00002247811
00002269430
00002431785
00002248557
00001940481
30 MG (BASE)
APH
APX
AUR
JPC
MAR
MPI
MYP
SNS
SIV
PMS
RPH
SDZ
SDZ
TEV
GSK
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
0.4513
1.8056
APH
APX
AUR
JPC
MAR
MPI
MYP
SNS
SIV
PMS
SDZ
TEV
GSK
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
0.4796
1.9183
PMS
$
2.4542
ORAL TABLET
00002262762
00002240909
00002383292
00002368889
00002411962
00002421399
00002248014
00002282860
00002388243
00002247752
00002431793
00002248558
00001940473
40 MG (BASE)
ACT PAROXETINE
APO-PAROXETINE
AURO-PAROXETINE
JAMP-PAROXETINE
MAR-PAROXETINE
MINT-PAROXETINE
MYLAN-PAROXETINE
PAROXETINE
PAROXETINE
PMS-PAROXETINE
RATIO-PAROXETINE
SANDOZ PAROXETINE
SANDOZ PAROXETINE
TEVA-PAROXETINE
PAXIL
ACT PAROXETINE
APO-PAROXETINE
AURO-PAROXETINE
JAMP-PAROXETINE
MAR-PAROXETINE
MINT-PAROXETINE
MYLAN-PAROXETINE
PAROXETINE
PAROXETINE
PMS-PAROXETINE
SANDOZ PAROXETINE
TEVA-PAROXETINE
PAXIL
ORAL TABLET
00002293749
PMS-PAROXETINE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
98
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.04.20
PSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
(SELECTIVE-SEROTONIN REUPTAKE INHIBITORS)
SERTRALINE HCL
25 MG (BASE)
ORAL CAPSULE
00002357143
00002427761
00002402378
00002287390
00002238280
00002390906
00002399415
00002242519
00002244838
00002374552
00002245159
00002353520
00002386070
00002240485
00002132702
50 MG (BASE)
JPC
VAN
MPI
APH
APX
AUR
MAR
MYP
PMS
RAN
SDZ
SNS
SIV
TEV
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2004
0.2004
0.2104
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.2106
0.8675
JPC
VAN
MPI
APH
APX
AUR
MAR
MYP
PMS
RAN
SDZ
SNS
SIV
TEV
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4000
0.4000
0.4200
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
0.4211
1.7349
VAN
MPI
APH
APX
AUR
JPC
MAR
MYP
PMS
RAN
SDZ
SNS
SIV
TEV
PFI
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4200
0.4410
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
0.4588
1.8452
ORAL CAPSULE
00002357151
00002427788
00002402394
00002287404
00002238281
00002390914
00002399423
00002242520
00002244839
00002374560
00002245160
00002353539
00002386089
00002240484
00001962817
100 MG (BASE)
JAMP-SERTRALINE
VAN-SERTRALINE
MINT-SERTRALINE
ACT SERTRALINE
APO-SERTRALINE
AURO-SERTRALINE
MAR-SERTRALINE
MYLAN-SERTRALINE
PMS-SERTRALINE
RAN-SERTRALINE
SANDOZ SERTRALINE
SERTRALINE
SERTRALINE
TEVA-SERTRALINE
ZOLOFT
JAMP-SERTRALINE
VAN-SERTRALINE
MINT-SERTRALINE
ACT SERTRALINE
APO-SERTRALINE
AURO-SERTRALINE
MAR-SERTRALINE
MYLAN-SERTRALINE
PMS-SERTRALINE
RAN-SERTRALINE
SANDOZ SERTRALINE
SERTRALINE
SERTRALINE
TEVA-SERTRALINE
ZOLOFT
ORAL CAPSULE
00002427796
00002402408
00002287412
00002238282
00002390922
00002357178
00002399431
00002242521
00002244840
00002374579
00002245161
00002353547
00002386097
00002240481
00001962779
VAN-SERTRALINE
MINT-SERTRALINE
ACT SERTRALINE
APO-SERTRALINE
AURO-SERTRALINE
JAMP-SERTRALINE
MAR-SERTRALINE
MYLAN-SERTRALINE
PMS-SERTRALINE
RAN-SERTRALINE
SANDOZ SERTRALINE
SERTRALINE
SERTRALINE
TEVA-SERTRALINE
ZOLOFT
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
99
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.24
ANTIDEPRESSANTS
(SEROTONIN MODULATORS)
TRAZODONE HCL
50 MG
ORAL TABLET
00002147637
00001937227
00002144263
00002348772
75 MG
0.0554
0.0554
0.0554
0.0554
PMS-TRAZODONE
PMS
$
0.3775
APO-TRAZODONE
PMS-TRAZODONE
TEVA-TRAZODONE
TRAZODONE
APX
PMS
TEV
SNS
$
$
$
$
0.0989
0.0989
0.0989
0.0989
SNS
TEV
$
$
0.1453
0.1526
ORAL TABLET
00002348799
00002144298
28:00
$
$
$
$
ORAL TABLET
00002147645
00001937235
00002144271
00002348780
150 MG
APX
PMS
TEV
SNS
ORAL TABLET
00002237339
100 MG
APO-TRAZODONE
PMS-TRAZODONE
TEVA-TRAZODONE
TRAZODONE
TRAZODONE
TEVA-TRAZODONE
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.28
ANTIDEPRESSANTS
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE
INHIBITORS)
AMITRIPTYLINE HCL
10 MG
ORAL TABLET
00002403137
00000335053
25 MG
$
$
0.0664
0.0664
APO-AMITRIPTYLINE
ELAVIL
APX
AAP
$
$
0.1211
0.1211
APX
AAP
$
$
0.2347
0.2347
APX
AAP
$
$
0.3634
0.3634
APR
$
0.2917
APR
$
0.3976
APR
$
0.7320
ORAL TABLET
00002403153
00000335088
75 MG
APX
AAP
ORAL TABLET
00002403145
00000335061
50 MG
APO-AMITRIPTYLINE
ELAVIL
APO-AMITRIPTYLINE
ELAVIL
ORAL TABLET
00002403161
00000754129
APO-AMITRIPTYLINE
ELAVIL
CLOMIPRAMINE HCL
10 MG
ORAL TABLET
00000330566
25 MG
00000324019
50 MG
ANAFRANIL
ORAL TABLET
ANAFRANIL
ORAL TABLET
00000402591
ANAFRANIL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
100
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.28
ANTIDEPRESSANTS
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE
INHIBITORS)
DESIPRAMINE HCL
10 MG
ORAL TABLET
00002216248
25 MG
DESIPRAMINE
00002216256
50 MG
$
0.3880
DESIPRAMINE
AAP
$
0.3880
AAP
$
0.6838
AAP
$
0.9093
APX
ERF
$
$
0.2397
0.2651
APX
ERF
$
$
0.2940
0.3234
APX
ERF
$
$
0.5455
0.5987
APX
$
0.8066
APX
$
1.3438
AAP
$
0.1397
AAP
$
0.2520
AAP
$
0.4918
AAP
$
0.6434
AAP
$
0.2517
AAP
$
0.5086
AAP
$
0.2199
AAP
$
0.2832
AAP
$
0.5543
AAP
$
0.9458
ORAL TABLET
00002216264
75 MG
AAP
ORAL TABLET
DESIPRAMINE
ORAL TABLET
00002216272
DESIPRAMINE
DOXEPIN HCL
10 MG (BASE)
ORAL CAPSULE
00002049996
00000024325
25 MG (BASE)
APO-DOXEPIN
SINEQUAN
ORAL CAPSULE
00002050005
00000024333
50 MG (BASE)
APO-DOXEPIN
SINEQUAN
ORAL CAPSULE
00002050013
00000024341
75 MG (BASE)
APO-DOXEPIN
SINEQUAN
ORAL CAPSULE
00002050021
100 MG (BASE)
APO-DOXEPIN
ORAL CAPSULE
00002050048
APO-DOXEPIN
IMIPRAMINE HCL
10 MG
ORAL TABLET
00000360201
25 MG
00000312797
50 MG
IMIPRAMINE
ORAL TABLET
00000326852
75 MG
IMIPRAMINE
ORAL TABLET
IMIPRAMINE
ORAL TABLET
00000644579
IMIPRAMINE
NORTRIPTYLINE HCL
10 MG (BASE)
ORAL CAPSULE
00000015229
25 MG (BASE)
AVENTYL
ORAL CAPSULE
00000015237
AVENTYL
TRIMIPRAMINE MALEATE
12.5 MG (BASE)
ORAL TABLET
00000740799
25 MG (BASE)
00000740802
50 MG (BASE)
TRIMIPRAMINE
ORAL TABLET
00000740810
100 MG (BASE)
TRIMIPRAMINE
ORAL TABLET
TRIMIPRAMINE
ORAL TABLET
00000740829
TRIMIPRAMINE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
101
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.28
ANTIDEPRESSANTS
(TRICYCLICS AND OTHER NOREPINEPHRINE-REUPTAKE
INHIBITORS)
TRIMIPRAMINE MALEATE
75 MG (BASE)
ORAL CAPSULE
00002070987
28:00
$
0.7460
SNS
PMS
RPH
SDZ
$
$
$
$
0.1547
0.1547
0.1547
0.1547
SNS
PMS
RPH
SDZ
VCL
$
$
$
$
$
0.2297
0.2297
0.2297
0.2297
0.9768
MYP
VCL
$
$
0.4181
0.5862
MYP
VCL
$
$
0.8361
1.1706
VCL
$
0.3876
APX
TEV
VCL
$
$
$
0.3563
0.3741
0.7755
TRYPTAN
VCL
$
1.1428
APO-TRYPTOPHAN
TEVA-TRYPTOPHAN
TRYPTAN
APX
TEV
VCL
$
$
$
0.7126
0.7482
1.5584
APX
TEV
VCL
$
$
$
0.3563
0.3741
0.7755
AAP
TRIMIPRAMINE
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.92
ANTIDEPRESSANTS
(MISCELLANEOUS ANTIDEPRESSANTS)
BUPROPION HCL
100 MG
ORAL SUSTAINED-RELEASE TABLET
00002391562
00002325373
00002285657
00002275074
150 MG
ORAL SUSTAINED-RELEASE TABLET
00002391570
00002313421
00002285665
00002275082
00002237825
150 MG
BUPROPION SR
PMS-BUPROPION SR
RATIO-BUPROPION SR
SANDOZ BUPROPION SR
WELLBUTRIN SR
ORAL EXTENDED-RELEASE TABLET
00002382075
00002275090
300 MG
BUPROPION SR
PMS-BUPROPION SR
RATIO-BUPROPION SR
SANDOZ BUPROPION SR
MYLAN-BUPROPION XL
WELLBUTRIN XL
ORAL EXTENDED-RELEASE TABLET
00002382083
00002275104
MYLAN-BUPROPION XL
WELLBUTRIN XL
L-TRYPTOPHAN
250 MG
ORAL TABLET
00002239326
500 MG
00002248538
00002240333
00002029456
750 MG
APO-TRYPTOPHAN
TEVA-TRYPTOPHAN
TRYPTAN
ORAL TABLET
00002239327
1G
TRYPTAN
ORAL TABLET
ORAL TABLET
00002248539
00002237250
00000654531
500 MG
ORAL CAPSULE
00002248540
00002240334
00000718149
APO-TRYPTOPHAN
TEVA-TRYPTOPHAN
TRYPTAN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
102
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.04.92
ANTIDEPRESSANTS
(MISCELLANEOUS ANTIDEPRESSANTS)
MIRTAZAPINE
15 MG
ORAL TABLET
00002256096
00002273942
30 MG
$
$
0.0975
0.0975
APO-MIRTAZAPINE
MYLAN-MIRTAZAPINE
PMS-MIRTAZAPINE
SANDOZ MIRTAZAPINE
AURO-MIRTAZAPINE
MIRTAZAPINE
TEVA-MIRTAZAPINE
REMERON
APX
MYP
PMS
SDZ
AUR
SNS
TEV
MFC
$
$
$
$
$
$
$
$
0.1950
0.1950
0.1950
0.1950
0.2338
0.2338
0.2338
1.3894
MYP
$
1.1576
BMS
$
3.0878
ORAL TABLET
00002256126
28:00
MYP
PMS
ORAL TABLET
00002286629
00002256118
00002248762
00002250608
00002411709
00002370689
00002259354
00002243910
45 MG
MYLAN-MIRTAZAPINE
PMS-MIRTAZAPINE
MYLAN-MIRTAZAPINE
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
ARIPIPRAZOLE
2 MG
ORAL TABLET
00002322374
ABILIFY
ALBERTA HEALTH RESTRICTED BENEFIT
This Drug Product is a benefit for patients 13 to 17 years of age inclusive.
ALBERTA HUMAN SERVICES RESTRICTED BENEFIT
This Drug Product is a benefit for Alberta Human Services clients 13 years of age
and older
5 MG
ORAL TABLET
00002322382
BMS
ABILIFY
$
3.4757
ALBERTA HEALTH RESTRICTED BENEFIT
This Drug Product is a benefit for patients 13 to 17 years of age inclusive.
ALBERTA HUMAN SERVICES RESTRICTED BENEFIT
This Drug Product is a benefit for Alberta Human Services clients 13 years of age
and older
10 MG
ORAL TABLET
00002322390
15 MG
ABILIFY
BMS
$
4.0055
BMS
$
4.0055
ORAL TABLET
00002322404
ABILIFY
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
103
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
ARIPIPRAZOLE
20 MG
ORAL TABLET
00002322412
30 MG
ABILIFY
BMS
$
4.0055
BMS
$
4.0055
APX
MYP
NOV
$
$
$
0.6594
0.6594
0.9420
MYP
$
1.3188
APX
MYP
NOV
$
$
$
2.6446
2.6446
3.7780
MYP
$
5.2892
SUN
$
4.0800
SUN
$
4.0800
SUN
$
4.0800
SUN
$
4.0800
SUN
$
4.0800
ORAL TABLET
00002322455
ABILIFY
CLOZAPINE
25 MG
ORAL TABLET
00002248034
00002247243
00000894737
50 MG
ORAL TABLET
00002305003
100 MG
GEN-CLOZAPINE
ORAL TABLET
00002248035
00002247244
00000894745
200 MG
APO-CLOZAPINE
GEN-CLOZAPINE
CLOZARIL
APO-CLOZAPINE
GEN-CLOZAPINE
CLOZARIL
ORAL TABLET
00002305011
GEN-CLOZAPINE
LURASIDONE HCL
20 MG
ORAL TABLET
00002422050
40 MG
00002387751
60 MG
LATUDA
ORAL TABLET
00002387778
120 MG
LATUDA
ORAL TABLET
00002413361
80 MG
LATUDA
ORAL TABLET
LATUDA
ORAL TABLET
00002387786
LATUDA
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
104
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
OLANZAPINE
2.5 MG
ORAL TABLET
00002325659
00002281791
00002417243
00002421232
00002337878
00002372819
00002385864
00002303116
00002403064
00002310341
00002276712
00002428008
00002229250
5 MG
APH
APX
JPC
MAR
MYP
SNS
SIV
PMS
RAN
SDZ
TEV
VAN
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
0.3189
1.8132
APH
APX
JPC
MAR
MYP
SNS
SIV
PMS
RAN
SDZ
TEV
VAN
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
0.6379
3.6268
APH
APX
JPC
MAR
MYP
SNS
SIV
PMS
RAN
SDZ
TEV
VAN
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
0.9568
5.4400
ORAL TABLET
00002325667
00002281805
00002417251
00002421240
00002337886
00002372827
00002385872
00002303159
00002403072
00002310368
00002276720
00002428016
00002229269
7.5 MG
ACT OLANZAPINE
APO-OLANZAPINE
JAMP OLANZAPINE FC
MAR-OLANZAPINE
MYLAN-OLANZAPINE
OLANZAPINE
OLANZAPINE
PMS-OLANZAPINE
RAN-OLANZAPINE
SANDOZ OLANZAPINE
TEVA-OLANZAPINE
VAN-OLANZAPINE
ZYPREXA
ACT OLANZAPINE
APO-OLANZAPINE
JAMP OLANZAPINE FC
MAR-OLANZAPINE
MYLAN-OLANZAPINE
OLANZAPINE
OLANZAPINE
PMS-OLANZAPINE
RAN-OLANZAPINE
SANDOZ OLANZAPINE
TEVA-OLANZAPINE
VAN-OLANZAPINE
ZYPREXA
ORAL TABLET
00002325675
00002281813
00002417278
00002421259
00002337894
00002372835
00002385880
00002303167
00002403080
00002310376
00002276739
00002428024
00002229277
ACT OLANZAPINE
APO-OLANZAPINE
JAMP OLANZAPINE FC
MAR-OLANZAPINE
MYLAN-OLANZAPINE
OLANZAPINE
OLANZAPINE
PMS-OLANZAPINE
RAN-OLANZAPINE
SANDOZ OLANZAPINE
TEVA-OLANZAPINE
VAN-OLANZAPINE
ZYPREXA
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
105
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
OLANZAPINE
10 MG (BASE)
ORAL TABLET
00002325683
00002281821
00002417286
00002421267
00002337908
00002372843
00002385899
00002303175
00002403099
00002310384
00002276747
00002428032
00002229285
15 MG
APH
APX
JPC
MAR
MYP
SNS
SIV
PMS
RAN
SDZ
TEV
VAN
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
1.2758
7.2536
APH
APX
JPC
MAR
MYP
SNS
SIV
PMS
SDZ
TEV
VAN
LIL
$
$
$
$
$
$
$
$
$
$
$
$
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
1.9136
10.8804
APH
APX
JPC
MAR
MPI
MYP
SIV
SNS
PMS
RAN
SDZ
TEV
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
0.6434
3.6068
ORAL TABLET
00002325691
00002281848
00002417294
00002421275
00002337916
00002372851
00002385902
00002303183
00002310392
00002276755
00002428040
00002238850
5 MG
ACT OLANZAPINE
APO-OLANZAPINE
JAMP OLANZAPINE FC
MAR-OLANZAPINE
MYLAN-OLANZAPINE
OLANZAPINE
OLANZAPINE
PMS-OLANZAPINE
RAN-OLANZAPINE
SANDOZ OLANZAPINE
TEVA-OLANZAPINE
VAN-OLANZAPINE
ZYPREXA
ACT OLANZAPINE
APO-OLANZAPINE
JAMP OLANZAPINE FC
MAR-OLANZAPINE
MYLAN-OLANZAPINE
OLANZAPINE
OLANZAPINE
PMS-OLANZAPINE
SANDOZ OLANZAPINE
TEVA-OLANZAPINE
VAN-OLANZAPINE
ZYPREXA
ORAL DISINTEGRATING TABLET
00002327562
00002360616
00002406624
00002389088
00002436965
00002382709
00002343665
00002352974
00002303191
00002414090
00002327775
00002321343
00002243086
ACT OLANZAPINE ODT
APO-OLANZAPINE ODT
JAMP-OLANZAPINE ODT
MAR-OLANZAPINE ODT
MINT-OLANZAPINE ODT
MYLAN-OLANZAPINE ODT
OLANZAPINE ODT
OLANZAPINE ODT
PMS-OLANZAPINE ODT
RAN-OLANZAPINE ODT
SANDOZ OLANZAPINE ODT
TEVA-OLANZAPINE OD
ZYPREXA ZYDIS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
106
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
OLANZAPINE
10 MG (BASE)
ORAL DISINTEGRATING TABLET
00002327570
00002360624
00002406632
00002389096
00002436973
00002382717
00002343673
00002352982
00002303205
00002414104
00002327783
00002321351
00002243087
ACT OLANZAPINE ODT
APO-OLANZAPINE ODT
JAMP-OLANZAPINE ODT
MAR-OLANZAPINE ODT
MINT-OLANZAPINE ODT
MYLAN-OLANZAPINE ODT
OLANZAPINE ODT
OLANZAPINE ODT
PMS-OLANZAPINE ODT
RAN-OLANZAPINE ODT
SANDOZ OLANZAPINE ODT
TEVA-OLANZAPINE OD
ZYPREXA ZYDIS
APH
APX
JPC
MAR
MPI
MYP
SIV
SNS
PMS
RAN
SDZ
TEV
LIL
$
$
$
$
$
$
$
$
$
$
$
$
$
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
1.2857
7.2071
JAI
$
3.7240
JAI
$
5.5700
JAI
$
7.4240
APH
APX
AUR
JPC
MAR
MPI
MYP
NTP
PMS
SIV
SNS
AHI
RAN
SDZ
TEV
VAN
AZC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.0889
0.5195
PMS
$
0.5665
PALIPERIDONE
3 MG
ORAL EXTENDED-RELEASE TABLET
00002300273
6 MG
00002300281
9 MG
INVEGA
ORAL EXTENDED-RELEASE TABLET
INVEGA
ORAL EXTENDED-RELEASE TABLET
00002300303
INVEGA
QUETIAPINE FUMARATE
25 MG (BASE)
ORAL TABLET
00002316080
00002313901
00002390205
00002330415
00002399822
00002438003
00002307804
00002439158
00002296551
00002317893
00002353164
00002387794
00002397099
00002313995
00002284235
00002434024
00002236951
50 MG (BASE)
ACT QUETIAPINE
APO-QUETIAPINE
AURO-QUETIAPINE
JAMP-QUETIAPINE
MAR-QUETIAPINE
MINT-QUETIAPINE
MYLAN-QUETIAPINE
NAT-QUETIAPINE
PMS-QUETIAPINE
QUETIAPINE
QUETIAPINE
QUETIAPINE
RAN-QUETIAPINE
SANDOZ QUETIAPINE
TEVA-QUETIAPINE
VAN-QUETIAPINE
SEROQUEL
ORAL TABLET
00002361892
PMS-QUETIAPINE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
107
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.08.04
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
QUETIAPINE FUMARATE
100 MG (BASE)
ORAL TABLET
00002316099
00002313928
00002390213
00002330423
00002399830
00002438011
00002307812
00002439166
00002296578
00002317907
00002353172
00002387808
00002397102
00002314002
00002284243
00002434032
00002236952
150 MG (BASE)
APH
APX
AUR
JPC
MAR
MPI
MYP
NTP
PMS
SIV
SNS
AHI
RAN
SDZ
TEV
VAN
AZC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
0.2372
1.3860
TEV
$
1.7288
APH
APX
AUR
JPC
MAR
MPI
MYP
NTP
PMS
SIV
SNS
AHI
RAN
SDZ
TEV
VAN
AZC
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
0.4764
2.7830
ORAL TABLET
00002284251
200 MG (BASE)
ACT QUETIAPINE
APO-QUETIAPINE
AURO-QUETIAPINE
JAMP-QUETIAPINE
MAR-QUETIAPINE
MINT-QUETIAPINE
MYLAN-QUETIAPINE
NAT-QUETIAPINE
PMS-QUETIAPINE
QUETIAPINE
QUETIAPINE
QUETIAPINE
RAN-QUETIAPINE
SANDOZ QUETIAPINE
TEVA-QUETIAPINE
VAN-QUETIAPINE
SEROQUEL
TEVA-QUETIAPINE
ORAL TABLET
00002316110
00002313936
00002390248
00002330458
00002399849
00002438046
00002307839
00002439182
00002296594
00002317923
00002353199
00002387824
00002397110
00002314010
00002284278
00002434040
00002236953
ACT QUETIAPINE
APO-QUETIAPINE
AURO-QUETIAPINE
JAMP-QUETIAPINE
MAR-QUETIAPINE
MINT-QUETIAPINE
MYLAN-QUETIAPINE
NAT-QUETIAPINE
PMS-QUETIAPINE
QUETIAPINE
QUETIAPINE
QUETIAPINE
RAN-QUETIAPINE
SANDOZ QUETIAPINE
TEVA-QUETIAPINE
VAN-QUETIAPINE
SEROQUEL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
108
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
28:16.08.04
PSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
QUETIAPINE FUMARATE
300 MG (BASE)
ORAL TABLET
00002316129
00002313944
00002390256
00002330466
00002399857
00002438054
00002307847
00002439190
00002296608
00002317931
00002353202
00002387832
00002397129
00002314029
00002284286
00002434059
00002244107
50 MG (BASE)
SANDOZ QUETIAPINE XRT
TEVA-QUETIAPINE XR
SEROQUEL XR
SDZ
TEV
AZC
$
$
$
0.3950
0.3950
1.0003
SANDOZ QUETIAPINE XRT
TEVA-QUETIAPINE XR
SEROQUEL XR
SDZ
TEV
AZC
$
$
$
0.7780
0.7780
1.9701
SANDOZ QUETIAPINE XRT
TEVA-QUETIAPINE XR
SEROQUEL XR
SDZ
TEV
AZC
$
$
$
1.0520
1.0520
2.6641
SDZ
TEV
AZC
$
$
$
1.5440
1.5440
3.9101
SDZ
TEV
AZC
$
$
$
2.0960
2.0960
5.3080
ORAL EXTENDED-RELEASE TABLET
00002407728
00002395479
00002300206
400 MG (BASE)
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
0.6953
4.0610
ORAL EXTENDED-RELEASE TABLET
00002407701
00002395460
00002300192
300 MG (BASE)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
ORAL EXTENDED-RELEASE TABLET
00002407698
00002395452
00002321513
200 MG (BASE)
APH
APX
AUR
JPC
MAR
MPI
MYP
NTP
PMS
SIV
SNS
AHI
RAN
SDZ
TEV
VAN
AZC
ORAL EXTENDED-RELEASE TABLET
00002407671
00002395444
00002300184
150 MG (BASE)
ACT QUETIAPINE
APO-QUETIAPINE
AURO-QUETIAPINE
JAMP-QUETIAPINE
MAR-QUETIAPINE
MINT-QUETIAPINE
MYLAN-QUETIAPINE
NAT-QUETIAPINE
PMS-QUETIAPINE
QUETIAPINE
QUETIAPINE
QUETIAPINE
RAN-QUETIAPINE
SANDOZ QUETIAPINE
TEVA-QUETIAPINE
VAN-QUETIAPINE
SEROQUEL
SANDOZ QUETIAPINE XRT
TEVA-QUETIAPINE XR
SEROQUEL XR
ORAL EXTENDED-RELEASE TABLET
00002407736
00002395487
00002300214
SANDOZ QUETIAPINE XRT
TEVA-QUETIAPINE XR
SEROQUEL XR
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
109
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
RISPERIDONE
0.25 MG
ORAL TABLET
00002282585
00002282119
00002359529
00002371766
00002359790
00002282240
00002252007
00002328305
00002332051
00002356880
00002303655
00002282690
00002240551
0.5 MG
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
$
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.1252
0.5539
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.2097
0.9280
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
0.2896
1.2815
ORAL TABLET
00002282593
00002282127
00002359537
00002371774
00002359804
00002282259
00002252015
00002328313
00002332078
00002356899
00002303663
00002264188
00002240552
1 MG
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
ORAL TABLET
00002282607
00002282135
00002359545
00002371782
00002359812
00002282267
00002252023
00002328321
00002332086
00002356902
00002279800
00002264196
00002025280
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
110
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
RISPERIDONE
2 MG
ORAL TABLET
00002282615
00002282143
00002359553
00002371790
00002359820
00002282275
00002252031
00002328348
00002332094
00002356910
00002279819
00002264218
00002025299
3 MG
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
0.5782
2.5588
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
$
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
0.8673
3.8380
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
$
$
$
$
$
$
$
$
$
$
$
$
$
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
1.1565
5.1185
MYP
JAI
$
$
0.5588
0.7823
MYP
PMS
JAI
$
$
$
0.5150
0.5150
1.0815
ORAL DISINTEGRATING TABLET
00002413485
00002247704
1 MG
$
$
$
$
$
$
$
$
$
$
$
$
$
ORAL TABLET
00002282631
00002282178
00002359588
00002371812
00002359847
00002282291
00002252066
00002328372
00002332116
00002356937
00002279835
00002264234
00002025310
0.5 MG
APH
APX
JPC
MAR
MPI
MYP
PMS
RAN
RAN
SNS
SDZ
TEV
JAI
ORAL TABLET
00002282623
00002282151
00002359561
00002371804
00002359839
00002282283
00002252058
00002328364
00002332108
00002356929
00002279827
00002264226
00002025302
4 MG
ACT RISPERIDONE
APO-RISPERIDONE
JAMP-RISPERIDONE
MAR-RISPERIDONE
MINT-RISPERIDON
MYLAN-RISPERIDONE
PMS-RISPERIDONE
RAN-RISPERIDONE
RISPERIDONE
RISPERIDONE
SANDOZ RISPERIDONE
TEVA-RISPERIDONE
RISPERDAL
MYLAN-RISPERIDONE ODT
RISPERDAL M-TAB
ORAL DISINTEGRATING TABLET
00002413493
00002291789
00002247705
MYLAN-RISPERIDONE ODT
PMS-RISPERIDONE ODT
RISPERDAL M-TAB
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
111
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.04
ANTIPSYCHOTICS
(ATYPICAL ANTIPSYCHOTICS)
RISPERIDONE
2 MG
ORAL DISINTEGRATING TABLET
00002291797
00002413507
00002247706
3 MG
PMS
MYP
JAI
$
$
$
1.0187
1.0188
2.1394
MYP
PMS
JAI
$
$
$
1.5275
1.5275
3.2078
MYP
PMS
JAI
$
$
$
2.0425
2.0425
4.2893
ORAL DISINTEGRATING TABLET
00002413515
00002370697
00002268086
4 MG
PMS-RISPERIDONE ODT
MYLAN-RISPERIDONE ODT
RISPERDAL M-TAB
MYLAN-RISPERIDONE ODT
PMS-RISPERIDONE ODT
RISPERDAL M-TAB
ORAL DISINTEGRATING TABLET
00002413523
00002370700
00002268094
MYLAN-RISPERIDONE ODT
PMS-RISPERIDONE ODT
RISPERDAL M-TAB
RISPERIDONE TARTRATE
RESTRICTED BENEFIT - This product is a benefit for patients 18 years of age and older for
the management of the manifestations of schizophrenia and related psychotic disorders, as
well as in severe dementia for the short-term symptomatic management of inappropriate
behavior due to aggression and/or psychosis.
1 MG / ML (BASE)
00002280396
00002279266
00002236950
ORAL SOLUTION
APO-RISPERIDONE
PMS-RISPERIDONE
RISPERDAL
APX
PMS
JAI
$
$
$
0.7080
0.7080
1.4118
PFI
$
1.7998
PFI
$
2.0618
PFI
$
2.0618
PFI
$
2.0618
TEV
$
0.1362
TEV
$
0.2046
TEV
$
0.3058
TEV
$
0.4877
ZIPRASIDONE HYDROCHLORIDE MONOHYDRATE
20 MG (BASE)
ORAL CAPSULE
00002298597
40 MG (BASE)
00002298600
60 MG (BASE)
ZELDOX
ORAL CAPSULE
00002298619
80 MG (BASE)
ZELDOX
ORAL CAPSULE
00002298627
28:00
ZELDOX
ORAL CAPSULE
ZELDOX
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.08
ANTIPSYCHOTICS
(BUTYROPHENONES)
HALOPERIDOL
0.5 MG
ORAL TABLET
00000363685
1 MG
00000363677
2 MG
NOVO-PERIDOL
ORAL TABLET
00000363669
5 MG
NOVO-PERIDOL
ORAL TABLET
NOVO-PERIDOL
ORAL TABLET
00000363650
NOVO-PERIDOL
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
112
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.08
ANTIPSYCHOTICS
(BUTYROPHENONES)
HALOPERIDOL
10 MG
ORAL TABLET
00000713449
20 MG
NOVO-PERIDOL
TEV
$
0.7095
TEV
$
1.3047
SDZ
$
4.8300
SDZ
$
17.7696
TEV
$
0.2454
TEV
$
0.2808
TEV
$
0.7475
BMS
$
29.7800
AAP
$
0.1786
AAP
$
0.2297
AAP
$
0.1720
SAV
$
3.5330
AAP
$
0.0699
AAP
$
0.1011
AAP
$
0.2599
AAP
$
0.3934
ORAL TABLET
00000768820
5 MG / ML
NOVO-PERIDOL
INJECTION
00000808652
HALOPERIDOL
HALOPERIDOL DECANOATE
100 MG / ML (BASE)
00002130300
28:00
INJECTION
HALOPERIDOL LA
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.24
ANTIPSYCHOTICS
(PHENOTHIAZINES)
CHLORPROMAZINE HCL
25 MG (BASE)
ORAL TABLET
00000232823
50 MG (BASE)
TEVA-CHLORPROMAZINE
ORAL TABLET
00000232807
100 MG (BASE)
TEVA-CHLORPROMAZINE
ORAL TABLET
00000232831
TEVA-CHLORPROMAZINE
FLUPHENAZINE DECANOATE
100 MG / ML
INJECTION
00000755575
MODECATE CONCENTRATE
FLUPHENAZINE HCL
1 MG
ORAL TABLET
00000405345
2 MG
00000410632
5 MG
FLUPHENAZINE
ORAL TABLET
FLUPHENAZINE
ORAL TABLET
00000405361
FLUPHENAZINE
METHOTRIMEPRAZINE HCL
25 MG / ML (BASE)
INJECTION
00001927698
NOZINAN
METHOTRIMEPRAZINE MALEATE
2 MG (BASE)
ORAL TABLET
00002238403
5 MG (BASE)
00002238404
25 MG (BASE)
METHOPRAZINE
ORAL TABLET
00002238405
50 MG (BASE)
METHOPRAZINE
ORAL TABLET
METHOPRAZINE
ORAL TABLET
00002238406
METHOPRAZINE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
113
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.24
ANTIPSYCHOTICS
(PHENOTHIAZINES)
PERICYAZINE
5 MG
ORAL CAPSULE
00001926780
10 MG
00001926772
20 MG
NEULEPTIL
ERF
$
0.1940
ERF
$
0.3161
ERF
$
0.4862
ERF
$
0.3829
AAP
$
0.0639
AAP
$
0.0773
AAP
$
0.0849
AAP
$
0.1299
SAV
$
53.0200
AAP
$
0.1367
AAP
$
0.1793
AAP
$
0.2375
AAP
$
0.2846
AAP
$
0.5692
LBC
$
7.3522
LBC
$
36.7609
ORAL CAPSULE
NEULEPTIL
ORAL CAPSULE
00001926764
10 MG / ML
NEULEPTIL
ORAL DROPS
00001926756
NEULEPTIL
PERPHENAZINE
2 MG
ORAL TABLET
00000335134
4 MG
00000335126
8 MG
PERPHENAZINE
ORAL TABLET
00000335118
16 MG
PERPHENAZINE
ORAL TABLET
PERPHENAZINE
ORAL TABLET
00000335096
PERPHENAZINE
PIPOTIAZINE PALMITATE
50 MG / ML
INJECTION
00001926675
PIPORTIL L4
TRIFLUOPERAZINE HCL
1 MG (BASE)
ORAL TABLET
00000345539
2 MG (BASE)
00000312754
5 MG (BASE)
TRIFLUOPERAZINE
ORAL TABLET
00000312746
10 MG (BASE)
TRIFLUOPERAZINE
ORAL TABLET
00000326836
20 MG (BASE)
TRIFLUOPERAZINE
ORAL TABLET
00000595942
28:00
TRIFLUOPERAZINE
ORAL TABLET
TRIFLUOPERAZINE
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.32
ANTIPSYCHOTICS
(THIOXANTHENES)
FLUPENTIXOL DECANOATE
20 MG / ML
INJECTION
00002156032
100 MG / ML
FLUANXOL DEPOT
INJECTION
00002156040
FLUANXOL DEPOT
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
114
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.32
ANTIPSYCHOTICS
(THIOXANTHENES)
FLUPENTIXOL DIHYDROCHLORIDE
0.5 MG
ORAL TABLET
00002156008
3 MG
FLUANXOL
LBC
$
0.2540
LBC
$
0.5486
ERF
$
0.3634
LBC
$
15.2589
LBC
$
15.2589
LBC
$
0.3924
LBC
$
0.9809
PPH
$
0.1951
PPH
$
0.1829
PPH
$
0.3045
PPH
$
0.4719
PPH
$
0.6291
AAP
$
0.3093
AAP
PPH
$
$
0.4136
0.4811
ORAL TABLET
00002156016
FLUANXOL
THIOTHIXENE
5 MG
ORAL CAPSULE
00000024449
NAVANE
ZUCLOPENTHIXOL ACETATE
50 MG / ML
INJECTION
00002230405
CLOPIXOL ACUPHASE
ZUCLOPENTHIXOL DECANOATE
200 MG / ML
INJECTION
00002230406
CLOPIXOL DEPOT
ZUCLOPENTHIXOL DIHYDROCHLORIDE
10 MG (BASE)
ORAL TABLET
00002230402
25 MG (BASE)
00002230403
28:00
CLOPIXOL
ORAL TABLET
CLOPIXOL
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
28:16.08.92
ANTIPSYCHOTICS
(MISCELLANEOUS ANTIPSYCHOTICS)
LOXAPINE SUCCINATE
2.5 MG (BASE)
ORAL TABLET
00002242868
5 MG (BASE)
00002230837
10 MG (BASE)
XYLAC
ORAL TABLET
00002230839
50 MG (BASE)
XYLAC
ORAL TABLET
00002230838
25 MG (BASE)
XYLAC
ORAL TABLET
XYLAC
ORAL TABLET
00002230840
XYLAC
PIMOZIDE
2 MG
ORAL TABLET
00002245432
4 MG
PIMOZIDE
ORAL TABLET
00002245433
00000313823
PIMOZIDE
ORAP
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
115
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL
STIMULANTS
(AMPHETAMINES)
28:20.04
DEXTROAMPHETAMINE SULFATE
5 MG
ORAL TABLET
00002443236
00001924516
10 MG
APX
PAL
$
$
0.5081
0.6091
PAL
$
0.8738
PAL
$
1.0682
ORAL SUSTAINED-RELEASE CAPSULE
00001924559
15 MG
APO-DEXTROAMPHETAMINE
DEXEDRINE
DEXEDRINE
ORAL SUSTAINED-RELEASE CAPSULE
00001924567
DEXEDRINE
LISDEXAMFETAMINE DIMESYLATE
RESTRICTED BENEFIT - For the treatment of Attention Deficit Hyperactivity Disorder (ADHD)
as a restricted benefit for patients 6 years of age and older.
20 MG
ORAL CAPSULE
00002347156
30 MG
00002322951
40 MG
2.7166
VYVANSE
SHB
$
3.2492
VYVANSE
SHB
$
3.7819
VYVANSE
SHB
$
4.3145
SHB
$
4.8471
ORAL CAPSULE
00002347172
28:00
$
ORAL CAPSULE
00002322978
60 MG
SHB
ORAL CAPSULE
00002347164
50 MG
VYVANSE
ORAL CAPSULE
VYVANSE
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL
STIMULANTS
(MISCELLANEOUS ANOREXIGENIC AGENTS & RESPIRATORY
AND CEREBRAL STIMULANTS)
28:20.92
METHYLPHENIDATE HCL
5 MG
ORAL TABLET
00002234749
10 MG
00002249324
00000584991
00000005606
20 MG
$
0.1004
APO-METHYLPHENIDATE
PMS-METHYLPHENIDATE
RITALIN
APX
PMS
NOV
$
$
$
0.0816
0.0816
0.3732
APO-METHYLPHENIDATE
PMS-METHYLPHENIDATE
RITALIN
APX
PMS
NOV
$
$
$
0.2326
0.2326
0.6520
APX
SDZ
NOV
$
$
$
0.2820
0.2820
0.6547
PUR
$
0.7170
ORAL EXTENDED-RELEASE TABLET
00002266687
00002320312
00000632775
10 MG
PMS
ORAL TABLET
00002249332
00000585009
00000005614
20 MG
PMS-METHYLPHENIDATE
ORAL TABLET
APO-METHYLPHENIDATE SR
SANDOZ METHYLPHENIDATE
RITALIN SR
ORAL CONTROLLED-RELEASE CAPSULE
00002277166
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
116
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS & RESPIRATORY AND CEREBRAL
STIMULANTS
(MISCELLANEOUS ANOREXIGENIC AGENTS & RESPIRATORY
AND CEREBRAL STIMULANTS)
28:20.92
METHYLPHENIDATE HCL
15 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277131
$
1.0260
$
1.3250
$
1.8190
$
2.3170
$
2.8100
$
3.2700
$
4.3150
PPH
$
0.0984
PPH
$
0.1170
PPH
$
0.1587
PPH
$
0.2172
PPH
$
0.1313
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
20 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277158
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
30 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277174
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
40 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277182
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
50 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277190
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
60 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277204
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
80 MG
ORAL CONTROLLED-RELEASE CAPSULE
00002277212
PUR
BIPHENTIN
"For the treatment of Attention Deficit Hyperactivity Disorder (ADHD) as a
restricted benefit for patients 6 years of age and older."
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.04
(BARBITURATES)
PHENOBARBITAL
15 MG
ORAL TABLET
00000178799
30 MG
00000178802
60 MG
PHENOBARB
ORAL TABLET
00000178810
100 MG
PHENOBARB
ORAL TABLET
PHENOBARB
ORAL TABLET
00000178829
5 MG / ML
PHENOBARB
ORAL ELIXIR
00000645575
PHENOBARB
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
117
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.08
(BENZODIAZEPINES)
ALPRAZOLAM
0.25 MG
ORAL TABLET
00002400111
00002137534
00002417634
00002349191
00000865397
00001913484
0.5 MG
JAMP-ALPRAZOLAM
MYLAN-ALPRAZOLAM
NAT-ALPRAZOLAM
ALPRAZOLAM
APO-ALPRAZ
TEVA-ALPRAZOL
JPC
MYP
NTP
SNS
APX
TEV
$
$
$
$
$
$
0.0609
0.0609
0.0609
0.0659
0.0659
0.0659
JPC
MYP
NTP
SNS
APX
TEV
$
$
$
$
$
$
0.0728
0.0728
0.0728
0.0788
0.0788
0.0788
APX
$
0.1028
APX
TEV
HLR
$
$
$
0.0776
0.0815
0.1711
APX
TEV
HLR
$
$
$
0.1134
0.1191
0.2500
AAP
$
0.0693
AAP
$
0.1091
AAP
$
0.1692
AAP
VCL
$
$
0.2330
0.3268
AAP
$
0.1506
AAP
$
0.1965
AAP
$
0.3933
APX
$
0.0508
APX
$
0.0650
ORAL TABLET
00002400138
00002137542
00002417642
00002349205
00000865400
00001913492
JAMP-ALPRAZOLAM
MYLAN-ALPRAZOLAM
NAT-ALPRAZOLAM
ALPRAZOLAM
APO-ALPRAZ
TEVA-ALPRAZOL
BROMAZEPAM
1.5 MG
ORAL TABLET
00002177153
3 MG
00002177161
00002230584
00000518123
6 MG
APO-BROMAZEPAM
ORAL TABLET
APO-BROMAZEPAM
NOVO-BROMAZEPAM
LECTOPAM
ORAL TABLET
00002177188
00002230585
00000518131
APO-BROMAZEPAM
NOVO-BROMAZEPAM
LECTOPAM
CHLORDIAZEPOXIDE HCL
5 MG
ORAL CAPSULE
00000522724
10 MG
CHLORDIAZEPOXIDE
ORAL CAPSULE
00000522988
25 MG
CHLORDIAZEPOXIDE
ORAL CAPSULE
00000522996
CHLORDIAZEPOXIDE
CHLORDIAZEPOXIDE HCL/ CLIDINIUM BROMIDE
5 MG * 2.5 MG
ORAL CAPSULE
00000618454
00000115630
CHLORAX
LIBRAX
CLORAZEPATE DIPOTASSIUM
3.75 MG
ORAL CAPSULE
00000860689
7.5 MG
00000860700
15 MG
CLORAZEPATE
ORAL CAPSULE
CLORAZEPATE
ORAL CAPSULE
00000860697
CLORAZEPATE
DIAZEPAM
2 MG
ORAL TABLET
00000405329
5 MG
APO-DIAZEPAM
ORAL TABLET
00000362158
APO-DIAZEPAM
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
118
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.08
(BENZODIAZEPINES)
DIAZEPAM
10 MG
ORAL TABLET
00000405337
5 MG / ML
APO-DIAZEPAM
APX
$
0.0867
SDZ
$
1.4275
AAP
$
0.1166
AAP
$
0.1364
APX
SNS
PMS
TEV
PFI
$
$
$
$
$
0.0359
0.0359
0.0359
0.0359
0.0378
APX
SNS
PMS
TEV
PFI
$
$
$
$
$
0.0447
0.0447
0.0447
0.0447
0.0471
APX
SNS
PMS
TEV
PFI
$
$
$
$
$
0.0699
0.0699
0.0699
0.0699
0.0737
APX
PFI
$
$
0.0875
0.1147
APX
PFI
$
$
0.1100
0.1442
APX
PFI
$
$
0.1711
0.2242
SDZ
SDZ
$
$
4.1000
4.1000
AAP
$
0.1534
AAP
$
0.2296
INJECTION
00000399728
DIAZEPAM
FLURAZEPAM HCL
15 MG
ORAL CAPSULE
00000521698
30 MG
FLURAZEPAM
ORAL CAPSULE
00000521701
FLURAZEPAM
LORAZEPAM
0.5 MG
ORAL TABLET
00000655740
00002351072
00000728187
00000711101
00002041413
1 MG
ORAL TABLET
00000655759
00002351080
00000728195
00000637742
00002041421
2 MG
APO-LORAZEPAM
ATIVAN
ORAL SUBLINGUAL TABLET
00002410753
00002041464
2 MG
APO-LORAZEPAM
LORAZEPAM
PMS-LORAZEPAM
TEVA-LORAZEPAM
ATIVAN
ORAL SUBLINGUAL TABLET
00002410745
00002041456
1 MG
APO-LORAZEPAM
LORAZEPAM
PMS-LORAZEPAM
TEVA-LORAZEPAM
ATIVAN
ORAL TABLET
00000655767
00002351099
00000728209
00000637750
00002041448
0.5 MG
APO-LORAZEPAM
LORAZEPAM
PMS-LORAZEPAM
TEVA-LORAZEPAM
ATIVAN
APO-LORAZEPAM
ATIVAN
ORAL SUBLINGUAL TABLET
00002410761
00002041472
APO-LORAZEPAM
ATIVAN
MIDAZOLAM HCL
5 MG / ML (BASE)
00002240286
00002382903
INJECTION
MIDAZOLAM
MIDAZOLAM INJECTION SDZ
NITRAZEPAM
5 MG
ORAL TABLET
00000511528
10 MG
MOGADON
ORAL TABLET
00000511536
MOGADON
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
119
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.08
(BENZODIAZEPINES)
OXAZEPAM
10 MG
ORAL TABLET
00000402680
15 MG
00000402745
30 MG
APO-OXAZEPAM
APX
$
0.0420
APX
$
0.0660
APX
$
0.0900
APX
APR
$
$
0.1313
0.2047
APX
APR
$
$
0.1579
0.2476
AAP
$
0.2551
$
$
$
0.3517
0.3517
0.3517
ORAL TABLET
APO-OXAZEPAM
ORAL TABLET
00000402737
APO-OXAZEPAM
TEMAZEPAM
15 MG
ORAL CAPSULE
00002225964
00000604453
30 MG
APO-TEMAZEPAM
RESTORIL
ORAL CAPSULE
00002225972
00000604461
APO-TEMAZEPAM
RESTORIL
TRIAZOLAM
0.25 MG
ORAL TABLET
00000808571
28:00
TRIAZO
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.92
(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND
HYPNOTICS)
BUSPIRONE HCL
10 MG
ORAL TABLET
00002211076
00002231492
00002230942
APO-BUSPIRONE
NOVO-BUSPIRONE
PMS-BUSPIRONE
APX
TEV
PMS
CHLORAL HYDRATE
RESTRICTED BENEFIT - This Drug Product is restricted for use as a premedicant prior to
surgery or procedure for patients less than 18 years of age. A limit of 2 doses per procedure
will be allowed and coverage will be granted for a total of 4 procedures per year. Chloral
Hydrate will continue to be a regular benefit for patients greater than or equal to 18 years of
age.
Coverage will be provided for dosing based on the Canadian Pharmacists Association (CPhA)
product monograph.
100 MG / ML
ORAL SYRUP
00000792659
PMS-CHLORAL HYDRATE
PMS
$
0.0466
APX
TEV
$
$
0.1116
0.1172
APX
TEV
$
$
0.1425
0.1496
APX
TEV
$
$
0.2068
0.2171
HYDROXYZINE HCL
10 MG
ORAL CAPSULE
00000646059
00000738824
25 MG
ORAL CAPSULE
00000646024
00000738832
50 MG
APO-HYDROXYZINE
NOVO-HYDROXYZIN
APO-HYDROXYZINE
NOVO-HYDROXYZIN
ORAL CAPSULE
00000646016
00000738840
APO-HYDROXYZINE
NOVO-HYDROXYZIN
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
120
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
28:24.92
(MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND
HYPNOTICS)
HYDROXYZINE HCL
2 MG / ML
ORAL SYRUP
00000741817
00000024694
PMS-HYDROXYZINE
ATARAX
PMS
ERF
$
$
0.0490
0.0533
APH
APX
JPC
MAR
MPI
MYP
TEV
PMS
RAN
RPH
SDZ
SEP
SNS
SIV
SAV
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
0.1782
1.0589
APH
APX
JPC
JPC
MAR
MPI
MYP
PMS
RAN
RPH
SDZ
SEP
SNS
SIV
SAV
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
0.2250
1.3370
PMS
APX
VCL
$
$
$
0.0422
0.0667
0.1240
APX
ERF
$
$
0.0667
0.1048
ZOPICLONE
5 MG
ORAL TABLET
00002271931
00002245077
00002406969
00002386771
00002391716
00002296616
00002251450
00002243426
00002267918
00002246534
00002257572
00002386909
00002344122
00002385821
00002216167
7.5 MG
ORAL TABLET
00002271958
00002218313
00002356805
00002406977
00002386798
00002391724
00002238596
00002240606
00002267926
00002242481
00002008203
00002386917
00002282445
00002385848
00001926799
28:00
ACT ZOPICLONE
APO-ZOPICLONE
JAMP-ZOPICLONE
MAR-ZOPICLONE
MINT-ZOPICLONE
MYLAN-ZOPICLONE
NOVO-ZOPICLONE
PMS-ZOPICLONE
RAN-ZOPICLONE
RATIO-ZOPICLONE
SANDOZ ZOPICLONE
SEPTA-ZOPICLONE
ZOPICLONE
ZOPICLONE
IMOVANE
ACT ZOPICLONE
APO-ZOPICLONE
JAMP-ZOPICLONE
JAMP-ZOPICLONE
MAR-ZOPICLONE
MINT-ZOPICLONE
MYLAN-ZOPICLONE
PMS-ZOPICLONE
RAN-ZOPICLONE
RATIO-ZOPICLONE
RHOVANE
SEPTA-ZOPICLONE
ZOPICLONE
ZOPICLONE
IMOVANE
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
28:28
LITHIUM CARBONATE
150 MG
ORAL CAPSULE
00002216132
00002242837
00000461733
150 MG
PMS-LITHIUM CARBONATE
APO-LITHIUM CARBONATE
CARBOLITH
ORAL CAPSULE
00002242837
00002013231
APO-LITHIUM CARBONATE
LITHANE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
121
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
28:28
LITHIUM CARBONATE
300 MG
ORAL CAPSULE
00002216140
00002242838
00000236683
300 MG
$
$
$
0.0443
0.0657
0.0964
APO-LITHIUM CARBONATE
LITHANE
APX
ERF
$
$
0.0657
0.1044
PMS
$
0.1623
ORAL CAPSULE
00002216159
28:00
PMS
APX
VCL
ORAL CAPSULE
00002242838
00000406775
600 MG
PMS-LITHIUM CARBONATE
APO-LITHIUM CARBONATE
CARBOLITH
PMS-LITHIUM CARBONATE
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:32.28
(SELECTIVE SEROTONIN AGONISTS)
ALMOTRIPTAN MALATE
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where other standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older, and Criteria for Special Authorization of Select Drug
Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
6.25 MG (BASE)
ORAL TABLET
00002405792
00002398435
00002248128
12.5 MG (BASE)
APO-ALMOTRIPTAN
MYLAN-ALMOTRIPTAN
AXERT
APX
MYP
MCL
$
$
$
7.0433
7.0433
13.9217
APX
MYP
SDZ
MCL
$
$
$
$
7.0433
7.0433
7.0433
13.9217
ORAL TABLET
00002405806
00002398443
00002405334
00002248129
APO-ALMOTRIPTAN
MYLAN-ALMOTRIPTAN
SANDOZ ALMOTRIPTAN
AXERT
NARATRIPTAN HCL
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where other standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older; and Criteria for Special Authorization of Select Drug
Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
1 MG (BASE)
ORAL TABLET
00002314290
00002237820
2.5 MG (BASE)
TEVA-NARATRIPTAN
AMERGE
TEV
GSK
$
$
11.9041
14.1715
SDZ
TEV
GSK
$
$
$
6.1436
6.4508
14.9372
ORAL TABLET
00002322323
00002314304
00002237821
SANDOZ NARATRIPTAN
TEVA-NARATRIPTAN
AMERGE
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
122
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:32.28
(SELECTIVE SEROTONIN AGONISTS)
RIZATRIPTAN BENZOATE
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older; and Criteria for Special Authorization of Select Drug
Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
5 MG (BASE)
ORAL TABLET
00002393468
00002380455
00002429233
00002428512
10 MG (BASE)
$
$
$
$
3.7050
3.7050
3.7050
3.7050
JAMP-RIZATRIPTAN
JAMP-RIZATRIPTAN IR
VAN-RIZATRIPTAN
ACT RIZATRIPTAN
APO-RIZATRIPTAN
MAR-RIZATRIPTAN
MAXALT
JPC
JPC
VAN
APH
APX
MAR
MFC
$
$
$
$
$
$
$
3.7050
3.7050
3.7050
4.1300
4.1300
4.1300
16.2798
APH
APX
MPI
MYP
NTP
PMS
SNS
SIV
SDZ
TEV
MFC
$
$
$
$
$
$
$
$
$
$
$
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
16.2798
APH
APX
MPI
MYP
NTP
PMS
SNS
SIV
SDZ
TEV
MFC
$
$
$
$
$
$
$
$
$
$
$
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
4.1300
16.2798
ORAL DISINTEGRATING TABLET
00002374730
00002393484
00002439573
00002379198
00002436604
00002393360
00002442906
00002446111
00002351870
00002396661
00002240518
10 MG (BASE)
APX
JPC
JPC
VAN
ORAL TABLET
00002380463
00002429241
00002428520
00002381702
00002393476
00002379678
00002240521
5 MG (BASE)
APO-RIZATRIPTAN
JAMP-RIZATRIPTAN
JAMP-RIZATRIPTAN IR
VAN-RIZATRIPTAN
ACT RIZATRIPTAN ODT
APO-RIZATRIPTAN RPD
MINT-RIZATRIPTAN ODT
MYLAN-RIZATRIPTAN ODT
NAT-RIZATRIPTAN ODT
PMS-RIZATRIPTAN RDT
RIZATRIPTAN ODT
RIZATRIPTAN ODT
SANDOZ RIZATRIPTAN ODT
TEVA-RIZATRIPTAN ODT
MAXALT RPD
ORAL DISINTEGRATING TABLET
00002374749
00002393492
00002439581
00002379201
00002436612
00002393379
00002442914
00002446138
00002351889
00002396688
00002240519
ACT RIZATRIPTAN ODT
APO-RIZATRIPTAN RPD
MINT-RIZATRIPTAN ODT
MYLAN-RIZATRIPTAN ODT
NAT-RIZATRIPTAN ODT
PMS-RIZATRIPTAN RDT
RIZATRIPTAN ODT
RIZATRIPTAN ODT
SANDOZ RIZATRIPTAN ODT
TEVA-RIZATRIPTAN ODT
MAXALT RPD
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
123
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:32.28
(SELECTIVE SEROTONIN AGONISTS)
SUMATRIPTAN HEMISULFATE
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where other standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older; and Criteria for Special Authorization of Select Drug
Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
5 MG / DOSE (BASE)
00002230418
20 MG / DOSE (BASE)
00002230420
NASAL UNIT DOSE SPRAY
IMITREX
GSK
$
15.0350
GSK
$
15.4750
NASAL UNIT DOSE SPRAY
IMITREX
SUMATRIPTAN SUCCINATE
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where other standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older, and Criteria for Special Authorization of Select Drug
Products in the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
50 MG (BASE)
ORAL TABLET
00002257890
00002268388
00002268914
00002256436
00002263025
00002286521
00002385570
00002286823
00002212153
100 MG (BASE)
ACT SUMATRIPTAN
APO-SUMATRIPTAN
MYLAN-SUMATRIPTAN
PMS-SUMATRIPTAN
SANDOZ SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN DF
TEVA-SUMATRIPTAN DF
IMITREX DF
APH
APX
MYP
PMS
SDZ
SNS
SIV
TEV
GSK
$
$
$
$
$
$
$
$
$
7.1350
7.1350
7.1350
7.1350
7.1350
7.1350
7.1350
7.1350
15.1567
APH
APX
MYP
PMS
SDZ
SNS
SIV
TEV
TEV
GSK
$
$
$
$
$
$
$
$
$
$
7.8596
7.8596
7.8596
7.8596
7.8596
7.8596
7.8596
7.8596
7.8596
16.6967
SPG
GSK
$
$
33.1745
45.4100
ORAL TABLET
00002257904
00002268396
00002268922
00002256444
00002263033
00002286548
00002385589
00002239367
00002286831
00002212161
6 MG / SYR (BASE)
00002361698
00002212188
ACT SUMATRIPTAN
APO-SUMATRIPTAN
MYLAN-SUMATRIPTAN
PMS-SUMATRIPTAN
SANDOZ SUMATRIPTAN
SUMATRIPTAN
SUMATRIPTAN DF
TEVA-SUMATRIPTAN
TEVA-SUMATRIPTAN DF
IMITREX DF
INJECTION SYRINGE
SUMATRIPTAN SUN (0.5 ML)
IMITREX (0.5 ML)
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
124
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:32.28
(SELECTIVE SEROTONIN AGONISTS)
ZOLMITRIPTAN
RESTRICTED BENEFIT - This product is a benefit for patients 18 to 64 years of age inclusive
for the treatment of acute migraine attacks in patients where other standard therapy has failed.
(Refer to Criteria for Special Authorization of Select Drug Products of the List for eligibility in
patients 65 years of age and older; and Criteria for Special Authorization of Select Drug
Products of the Alberta Human Services Drug Benefit Supplement for eligibility in Alberta
Human Services clients.)
2.5 MG
ORAL TABLET
00002380951
00002421623
00002399458
00002419521
00002369036
00002421534
00002324229
00002362988
00002313960
00002238660
2.5 MG
APX
JPC
MAR
MPI
MYP
NTP
PMS
SDZ
TEV
AZC
$
$
$
$
$
$
$
$
$
$
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
14.6100
SEP
AGP
JPC
MPI
MYP
PMS
SDZ
TEV
AZC
$
$
$
$
$
$
$
$
$
2.1477
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
3.5375
14.6100
AZC
$
14.6100
PAL
$
0.3990
PAL
$
0.6817
ORAL DISPERSIBLE TABLET
00002428474
00002438453
00002428237
00002419513
00002387158
00002324768
00002362996
00002342545
00002243045
5 MG / DOSE
SEPTA-ZOLMITRIPTAN-ODT
AG-ZOLMITRIPTAN ODT
JAMP-ZOLMITRIPTAN ODT
MINT-ZOLMITRIPTAN ODT
MYLAN-ZOLMITRIPTAN ODT
PMS-ZOLMITRIPTAN ODT
SANDOZ ZOLMITRIPTAN ODT
TEVA-ZOLMITRIPTAN OD
ZOMIG RAPIMELT
NASAL UNIT DOSE SPRAY
00002248993
28:00
APO-ZOLMITRIPTAN
JAMP-ZOLMITRIPTAN
MAR-ZOLMITRIPTAN
MINT-ZOLMITRIPTAN
MYLAN-ZOLMITRIPTAN
NAT-ZOLMITRIPTAN
PMS-ZOLMITRIPTAN
SANDOZ ZOLMITRIPTAN
TEVA-ZOLMITRIPTAN
ZOMIG
ZOMIG
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
28:32.92
(MISCELLANEOUS ANTIMIGRAINE AGENTS)
PIZOTIFEN MALATE
0.5 MG (BASE)
ORAL TABLET
00000329320
1 MG (BASE)
SANDOMIGRAN
ORAL TABLET
00000511552
SANDOMIGRAN DS
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
125
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.04
(ADAMANTANES)
AMANTADINE HCL
100 MG
ORAL CAPSULE
00001990403
10 MG / ML
00002022826
28:00
PMS-AMANTADINE HYDROCHLORIDE
PMS
$
0.5659
PMS
$
0.1131
PMS
$
0.0507
PMS
$
0.0608
OMG
$
10.5000
ERF
$
0.2143
PPH
$
0.0702
PPH
$
0.1449
PPH
$
0.2831
AAP
$
0.0376
AAP
$
0.0681
ORAL SYRUP
PMS-AMANTADINE HYDROCHLORIDE
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.08
(ANTICHOLINERGIC AGENTS)
BENZTROPINE MESYLATE
1 MG
ORAL TABLET
00000706531
2 MG
PMS-BENZTROPINE
ORAL TABLET
00000426857
1 MG / ML
BENZTROPINE
INJECTION
00002238903
BENZTROPINE OMEGA
ETHOPROPAZINE HCL
50 MG (BASE)
ORAL TABLET
00001927744
PARSITAN
PROCYCLIDINE HCL
2.5 MG
ORAL TABLET
00000649392
5 MG
PDP-PROCYCLIDINE
ORAL TABLET
00000587354
0.5 MG / ML
PDP-PROCYCLIDINE
ORAL ELIXIR
00000587362
PDP-PROCYCLIDINE
TRIHEXYPHENIDYL HCL
2 MG
ORAL TABLET
00000545058
5 MG
00000545074
28:00
TRIHEXYPHENIDYL
ORAL TABLET
TRIHEXYPHENIDYL
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.12
(CATECHOL-O-METHYLTRANSFERASE (COMT) INHIBITORS)
ENTACAPONE
200 MG
ORAL TABLET
00002321459
00002390337
00002380005
00002375559
00002243763
APO-ENTACAPONE
MYLAN-ENTACAPONE
SANDOZ ENTACAPONE
TEVA-ENTACAPONE
COMTAN
APX
MYP
SDZ
TEV
NOV
$
$
$
$
$
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
126
EFFECTIVE APRIL 1, 2016
0.4010
0.4010
0.4010
0.4010
1.6344
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.16
(DOPAMINE PRECURSORS)
LEVODOPA/ BENSERAZIDE HCL
50 MG * 12.5 MG (BASE)
00000522597
100 MG * 25 MG (BASE)
00000386464
HLR
$
0.2998
HLR
$
0.4936
HLR
$
0.8286
APX
TEV
MFC
$
$
$
0.1877
0.1971
0.4871
APX
TEV
MFC
$
$
$
0.2803
0.2943
0.7273
APX
TEV
MFC
$
$
$
0.3129
0.3285
0.8119
APX
PMS
MFC
$
$
$
0.3857
0.3857
0.7888
APX
PMS
MFC
$
$
$
0.7115
0.7115
1.4550
NOV
$
1.6963
NOV
$
1.6963
NOV
$
1.6963
NOV
$
1.6963
NOV
$
1.6963
ORAL CAPSULE
PROLOPA 100-25
200 MG * 50 MG (BASE)
00000386472
ORAL CAPSULE
PROLOPA 50-12.5
ORAL CAPSULE
PROLOPA 200-50
LEVODOPA/ CARBIDOPA
100 MG * 10 MG
ORAL TABLET
00002195933
00002244494
00000355658
100 MG * 25 MG
ORAL TABLET
00002195941
00002244495
00000513997
250 MG * 25 MG
APO-LEVOCARB
TEVA-LEVOCARBIDOPA
SINEMET 250/25
ORAL SUSTAINED-RELEASE TABLET
00002272873
00002421488
00002028786
200 MG * 50 MG
APO-LEVOCARB
TEVA-LEVOCARBIDOPA
SINEMET 100/25
ORAL TABLET
00002195968
00002244496
00000328219
100 MG * 25 MG
APO-LEVOCARB
TEVA-LEVOCARBIDOPA
SINEMET 100/10
APO-LEVOCARB CR
PMS-LEVOCARB CR
SINEMET CR 100/25
ORAL SUSTAINED-RELEASE TABLET
00002245211
00002421496
00000870935
APO-LEVOCARB CR
PMS-LEVOCARB CR
SINEMET CR 200/50
LEVODOPA/ CARBIDOPA/ ENTACAPONE
50 MG * 12.5 MG * 200 MG
00002305933
ORAL TABLET
STALEVO
75 MG * 18.75 MG * 200 MG
00002337827
STALEVO
100 MG * 25 MG * 200 MG
00002305941
ORAL TABLET
ORAL TABLET
STALEVO
125 MG * 31.25 MG * 200 MG
00002337835
STALEVO
150 MG * 37.5 MG * 200 MG
00002305968
ORAL TABLET
ORAL TABLET
STALEVO
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
127
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.20.04
DOPAMINE RECEPTOR AGONISTS
(ERGOT-DERIVATIVE-DOPAMINE RECEPTOR AGONISTS)
BROMOCRIPTINE MESYLATE
2.5 MG (BASE)
ORAL TABLET
00002087324
5 MG (BASE)
00002230454
28:00
BROMOCRIPTINE
AAP
$
0.9978
AAP
$
1.4937
ORAL CAPSULE
BROMOCRIPTINE
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.20.08
DOPAMINE RECEPTOR AGONISTS
(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)
PRAMIPEXOLE DIHYDROCHLORIDE
0.25 MG
ORAL TABLET
00002376350
00002309122
00002297302
00002292378
00002290111
00002367602
00002315262
00002269309
00002237145
1 MG
MYP
SIV
APH
APX
PMS
SNS
SDZ
TEV
BOE
$
$
$
$
$
$
$
$
$
0.2628
0.2628
0.2709
0.2709
0.2709
0.2709
0.2709
0.2709
1.1161
MYP
SIV
APH
APX
PMS
SNS
SDZ
TEV
BOE
$
$
$
$
$
$
$
$
$
0.5257
0.5257
0.5418
0.5418
0.5418
0.5418
0.5418
0.5418
2.2322
APH
APX
MYP
PMS
SIV
SDZ
TEV
BOE
$
$
$
$
$
$
$
$
0.5257
0.5257
0.5257
0.5257
0.5257
0.5257
0.5257
2.2322
ORAL TABLET
00002376377
00002309149
00002297329
00002292394
00002290146
00002367629
00002315289
00002269325
00002237146
1.5 MG
MYLAN-PRAMIPEXOLE
PRAMIPEXOLE
ACT PRAMIPEXOLE
APO-PRAMIPEXOLE
PMS-PRAMIPEXOLE
PRAMIPEXOLE
SANDOZ PRAMIPEXOLE
TEVA-PRAMIPEXOLE
MIRAPEX
MYLAN-PRAMIPEXOLE
PRAMIPEXOLE
ACT PRAMIPEXOLE
APO-PRAMIPEXOLE
PMS-PRAMIPEXOLE
PRAMIPEXOLE
SANDOZ PRAMIPEXOLE
TEVA-PRAMIPEXOLE
MIRAPEX
ORAL TABLET
00002297337
00002292408
00002376385
00002290154
00002309157
00002315297
00002269333
00002237147
ACT PRAMIPEXOLE
APO-PRAMIPEXOLE
MYLAN-PRAMIPEXOLE
PMS-PRAMIPEXOLE
PRAMIPEXOLE
SANDOZ PRAMIPEXOLE
TEVA-PRAMIPEXOLE
MIRAPEX
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
PRODUCT IS NOT INTERCHANGEABLE
128
EFFECTIVE APRIL 1, 2016
ALBERTA DRUG BENEFIT LIST
28:00
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.20.08
DOPAMINE RECEPTOR AGONISTS
(NONERGOT-DERIVATIVE DOPAMINE RECEPTOR AGONISTS)
ROPINIROLE HCL
0.25 MG (BASE)
ORAL TABLET
00002316846
00002337746
00002352338
00002326590
00002314037
00002332361
00002353040
00002232565
1 MG (BASE)
0.0709
0.0709
0.0709
0.0709
0.0709
0.0709
0.0709
0.2881
ACT ROPINIROLE
APO-ROPINIROLE
JAMP-ROPINIROLE
PMS-ROPINIROLE
RAN-ROPINIROLE
ROPINIROLE
ROPINIROLE
REQUIP
APH
APX
JPC
PMS
RAN
RAN
SNS
GSK
$
$
$
$
$
$
$
$
0.2838
0.2838
0.2838
0.2838
0.2838
0.2838
0.2838
1.1523
ACT ROPINIROLE
APO-ROPINIROLE
JAMP-ROPINIROLE
PMS-ROPINIROLE
RAN-ROPINIROLE
ROPINIROLE
REQUIP
APH
APX
JPC
PMS
RAN
RAN
GSK
$
$
$
$
$
$
$
0.3122
0.3122
0.3122
0.3122
0.3122
0.3122
1.2676
APH
APX
JPC
PMS
RAN
RAN
GSK
$
$
$
$
$
$
$
0.8596
0.8596
0.8596
0.8596
0.8596
0.8596
3.4900
$
$
$
0.5021
0.5021
0.5021
ORAL TABLET
00002316870
00002337800
00002352362
00002326639
00002314088
00002332442
00002232569
28:00
$
$
$
$
$
$
$
$
ORAL TABLET
00002316862
00002337770
00002352354
00002326620
00002314061
00002332434
00002232568
5 MG (BASE)
APH
APX
JPC
PMS
RAN
RAN
SNS
GSK
ORAL TABLET
00002316854
00002337762
00002352346
00002326612
00002314053
00002332426
00002353059
00002232567
2 MG (BASE)
ACT ROPINIROLE
APO-ROPINIROLE
JAMP-ROPINIROLE
PMS-ROPINIROLE
RAN-ROPINIROLE
ROPINIROLE
ROPINIROLE
REQUIP
ACT ROPINIROLE
APO-ROPINIROLE
JAMP-ROPINIROLE
PMS-ROPINIROLE
RAN-ROPINIROLE
ROPINIROLE
REQUIP
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
28:36.32
(MONOAMINE OXIDASE B INHIBITORS)
SELEGILINE HCL
5 MG
ORAL TABLET
00002230641
00002231036
00002068087
APO-SELEGILINE
MYLAN-SELEGILINE
NOVO-SELEGILINE
APX
MYP
TEV
The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY
129
EFFECTIVE APRIL 1, 2016