Updates to the

Alberta Drug Benefit List

Effective June 1, 2017

Inquiries should be directed to:
Pharmacy Services
Alberta Blue Cross
10009 108 Street NW
Edmonton AB T5J 3C5
Telephone Number: (780) 498-8370 (Edmonton)
(403) 294-4041 (Calgary)
1-800-361-9632 (Toll Free)
FAX Number: (780) 498-8406
1-877-305-9911 (Toll Free)
Website: http://www.health.alberta.ca/services/drug-benefit-list.html
Administered by Alberta Blue Cross
on behalf of Alberta Health.

The Drug Benefit List (DBL) is a list of drugs for which

coverage June be provided to program participants. The DBL
is not intended to be, and must not be used as a diagnostic
or prescribing tool. Inclusion of a drug on the DBL does not
mean or imply that the drug is fit or effective for any specific
purpose. Prescribing professionals must always use their
professional judgment and should refer to product
monographs and any applicable practice guidelines when
prescribing drugs. The product monograph contains
information that June be required for the safe and effective
use of the product.

Copies of the Alberta Drug Benefit List are available from

Pharmacy Services, Alberta Blue Cross at the address
shown above.

Binder and contents: $42.00 ($40.00 + $2.00 G.S.T.)

Contents only: $36.75 ($35.00 + $1.75 G.S.T.)
A cheque or money order must accompany the request
for copies.

ABC 40211/81160 (R2017/06)

 UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Table of Contents
Added Product(s) ....................................................................................................................................... 1
Discontinued Listing(s) ............................................................................................................................... 1
Part 2 Drug Additions .............................................................................................................................. 2-1

EFFECTIVE JUNE 1, 2017

 UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Added Product(s)
Trade Name / Strength / Form Generic Description DIN MFR
MAR-ATORVASTATIN 10 MG TABLET ATORVASTATIN CALCIUM 00002454017 MAR

MAR-ATORVASTATIN 20 MG TABLET ATORVASTATIN CALCIUM 00002454025 MAR

MAR-ATORVASTATIN 40 MG TABLET ATORVASTATIN CALCIUM 00002454033 MAR

MAR-ATORVASTATIN 80 MG TABLET ATORVASTATIN CALCIUM 00002454041 MAR

Discontinued Listing(s)
Notification of discontinuation has been received from the manufacturer(s). The Alberta government-sponsored drug
programs previously covered the following drug product(s). Effective June 1, 2017, the listed product(s) will no
longer be a benefit and will not be considered for coverage by Special Authorization. A transition period will be
applied and, as of July 1, 2017 claims will no longer pay for these product(s).
Trade Name / Strength / Form Generic Description DIN MFR
LORAZEPAM 0.5 MG TABLET LORAZEPAM 00002351072 SNS

MYLAN-EZETIMIBE 10 MG TABLET EZETIMIBE 00002378035 MYP

MYLAN-LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 00002313979 MYP

MYLAN-LEVOFLOXACIN 500 MG TABLET LEVOFLOXACIN 00002313987 MYP

MYLAN-METOPROLOL (TYPE L) 100 MG METOPROLOL TARTRATE 00002174553 MYP

TABLET

MYLAN-METOPROLOL (TYPE L) 25 MG METOPROLOL TARTRATE 00002302055 MYP

TABLET

MYLAN-METOPROLOL (TYPE L) 50 MG METOPROLOL TARTRATE 00002174545 MYP

TABLET

MYLAN-QUETIAPINE 25 MG TABLET QUETIAPINE FUMARATE 00002307804 MYP

MYLAN-QUETIAPINE 100 MG TABLET QUETIAPINE FUMARATE 00002307812 MYP

MYLAN-QUETIAPINE 200 MG TABLET QUETIAPINE FUMARATE 00002307839 MYP

MYLAN-QUETIAPINE 300 MG TABLET QUETIAPINE FUMARATE 00002307847 MYP

MYLAN-RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 00002301148 MYP

MYLAN-RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 00002301156 MYP

MYLAN-RAMIPRIL 5 MG CAPSULE RAMIPRIL 00002301164 MYP

MYLAN-RAMIPRIL 10 MG CAPSULE RAMIPRIL 00002301172 MYP

MYLAN-RANITIDINE 150 MG TABLET RANITIDINE HCL 00002207761 MYP

MYLAN-RANITIDINE 300 MG TABLET RANITIDINE HCL 00002207788 MYP

MYLAN-TELMISARTAN HCTZ 80 MG / 12.5 MG TELMISARTAN/ 00002373564 MYP

TABLET HYDROCHLOROTHIAZIDE

MYLAN-TELMISARTAN HCTZ 80 MG / 25 MG TELMISARTAN/ 00002373572 MYP

TABLET HYDROCHLOROTHIAZIDE

EFFECTIVE JUNE 1, 2017 1

 UPDATES TO THE ALBERTA DRUG BENEFIT LIST

Discontinued Listing(s), continued

Trade Name / Strength / Form Generic Description DIN MFR
MYLAN-VALSARTAN HCTZ 80 MG / 12.5 MG VALSARTAN/ 00002373734 MYP
TABLET HYDROCHLOROTHIAZIDE

MYLAN-VALSARTAN HCTZ 320 MG / 12.5 MG VALSARTAN/ 00002373769 MYP

TABLET HYDROCHLOROTHIAZIDE

MYLAN-VALSARTAN HCTZ 320 MG / 25 MG VALSARTAN/ 00002373777 MYP

TABLET HYDROCHLOROTHIAZIDE

2 EFFECTIVE JUNE 1, 2017

 Drug Additions
PART 2

Drug Additions
 ALBERTA DRUG BENEFIT LIST UPDATE

ATORVASTATIN CALCIUM
10 MG (BASE) ORAL TABLET
00002310899 ACT ATORVASTATIN APH $ 0.2615
00002295261 APO-ATORVASTATIN APX $ 0.2615
00002348705 ATORVASTATIN SNS $ 0.2615
00002411350 ATORVASTATIN-10 SIV $ 0.2615
00002407256 AURO-ATORVASTATIN AUR $ 0.2615
00002391058 JAMP-ATORVASTATIN JPC $ 0.2615
00002454017 MAR-ATORVASTATIN MAR $ 0.2615
00002392933 MYLAN-ATORVASTATIN MYP $ 0.2615
00002399377 PMS-ATORVASTATIN PMS $ 0.2615
00002313707 RAN-ATORVASTATIN RAN $ 0.2615
00002350297 RATIO-ATORVASTATIN TEV $ 0.2615
00002417936 REDDY-ATORVASTATIN DRL $ 0.2615
00002324946 SANDOZ ATORVASTATIN SDZ $ 0.2615
00002230711 LIPITOR PFI $ 1.8223
20 MG (BASE) ORAL TABLET
00002310902 ACT ATORVASTATIN APH $ 0.3268
00002295288 APO-ATORVASTATIN APX $ 0.3268
00002348713 ATORVASTATIN SNS $ 0.3268
00002411369 ATORVASTATIN-20 SIV $ 0.3268
00002407264 AURO-ATORVASTATIN AUR $ 0.3268
00002391066 JAMP-ATORVASTATIN JPC $ 0.3268
00002454025 MAR-ATORVASTATIN MAR $ 0.3268
00002392941 MYLAN-ATORVASTATIN MYP $ 0.3268
00002399385 PMS-ATORVASTATIN PMS $ 0.3268
00002313715 RAN-ATORVASTATIN RAN $ 0.3268
00002350319 RATIO-ATORVASTATIN TEV $ 0.3268
00002417944 REDDY-ATORVASTATIN DRL $ 0.3268
00002324954 SANDOZ ATORVASTATIN SDZ $ 0.3268
00002230713 LIPITOR PFI $ 2.2779
40 MG (BASE) ORAL TABLET
00002310910 ACT ATORVASTATIN APH $ 0.3513
00002295296 APO-ATORVASTATIN APX $ 0.3513
00002348721 ATORVASTATIN SNS $ 0.3513
00002411377 ATORVASTATIN-40 SIV $ 0.3513
00002407272 AURO-ATORVASTATIN AUR $ 0.3513
00002391074 JAMP-ATORVASTATIN JPC $ 0.3513
00002454033 MAR-ATORVASTATIN MAR $ 0.3513
00002392968 MYLAN-ATORVASTATIN MYP $ 0.3513
00002399393 PMS-ATORVASTATIN PMS $ 0.3513
00002313723 RAN-ATORVASTATIN RAN $ 0.3513
00002350327 RATIO-ATORVASTATIN TEV $ 0.3513
00002417952 REDDY-ATORVASTATIN DRL $ 0.3513
00002324962 SANDOZ ATORVASTATIN SDZ $ 0.3513
00002230714 LIPITOR PFI $ 2.4483
80 MG (BASE) ORAL TABLET
00002310929 ACT ATORVASTATIN APH $ 0.3513
00002295318 APO-ATORVASTATIN APX $ 0.3513
00002348748 ATORVASTATIN SNS $ 0.3513
00002411385 ATORVASTATIN-80 SIV $ 0.3513
00002407280 AURO-ATORVASTATIN AUR $ 0.3513
00002391082 JAMP-ATORVASTATIN JPC $ 0.3513
00002454041 MAR-ATORVASTATIN MAR $ 0.3513
00002392976 MYLAN-ATORVASTATIN MYP $ 0.3513
00002399407 PMS-ATORVASTATIN PMS $ 0.3513
00002313758 RAN-ATORVASTATIN RAN $ 0.3513
00002350335 RATIO-ATORVASTATIN TEV $ 0.3513
00002417960 REDDY-ATORVASTATIN DRL $ 0.3513
00002324970 SANDOZ ATORVASTATIN SDZ $ 0.3513
00002243097 LIPITOR PFI $ 2.4483

The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.
UNIT OF ISSUE - REFER TO PRICE POLICY 2 . 1 EFFECTIVE JUNE 1, 2017