Docstoc

AEIDBS - July 1_ 2011 - Alberta Blue Cross

Document Sample
AEIDBS - July 1_ 2011 - Alberta Blue Cross Powered By Docstoc
					                                                    Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                        (Regular Benefits)
                                                                                                                                                                        LCA /
                                                                                                                                                                        MAC
   PTC      PTC DESCRIPTION     DIN / PIN       PRODUCT NAME                 IC          GENERIC NAME           STRENGTH     ROUTE           FORM        MFR   PRICE    PRICE COVERAGE STATUS
000002   DIABETES SUPPLIES /   00999955 BLOOD GLUCOSE TEST STRIPS        N        DIABETES SUPPLIES                                                      XXX     0.0000       REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00999941 BLOOD LETTING LANCET             N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00990058 GLUCOSE CALIBRATION SOLUTION     N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00990045 INFUSION SETS (TUBING & NEEDLE) N         DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
                                        INSULIN CARTRIDGES /
000002   DIABETES SUPPLIES /   00990057 RESERVOIRS                      N         DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00999985 INSULIN PEN NEEDLES              N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00999952 INSULIN SYRINGES                 N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00999942 LANCING DEVICE                   N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
000002   DIABETES SUPPLIES /   00999957 URINE TEST STRIPS                N        DIABETES SUPPLIES                                                      XXX     0.0000      REGULAR BENEFIT
                                      9
081408   AZOLES /              02241895 APO-FLUCONAZOLE-150              Y        FLUCONAZOLE                  150 MG       ORAL     CAPSULE             APX     8.7632 8.7632 REGULAR BENEFIT
081408   AZOLES /              02282348 PMS-FLUCONAZOLE                  Y        FLUCONAZOLE                  150 MG       ORAL     CAPSULE             PMS     8.7632 8.7632 REGULAR BENEFIT
                                      2
         MISCELLANEOUS                                                                                                               SUSTAINED-RELEASE
129200   AUTONOMIC DRUGS /     02238441 ZYBAN                            N        BUPROPION HCL                150 MG       ORAL     TABLET              BOV     0.9228      REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        02238295 CHILDRENS TYLENOL                N        ACETAMINOPHEN                80 MG        ORAL     CHEWABLE TABLET     MCL     0.1836      REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        00876038 CHILDRENS TEMPRA D.S.            N        ACETAMINOPHEN                160 MG       ORAL     CHEWABLE TABLET     BMS     0.1560      REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        02027801 PEDIATRIX                        Y        ACETAMINOPHEN                80 MG / ML   ORAL     DROPS               ROG     0.1196 0.1196 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        00875988 TEMPRA                           Y        ACETAMINOPHEN                80 MG / ML   ORAL     DROPS               BMS     0.2207 0.1196 REGULAR BENEFIT
                                      2
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        00792713 PMS-ACETAMINOPHEN                N        ACETAMINOPHEN                16 MG / ML   ORAL     SOLUTION            PMS     0.0398      REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /        02027798 PEDIATRIX                        N        ACETAMINOPHEN                32 MG / ML   ORAL     SOLUTION            ROG     0.0375      REGULAR BENEFIT
                                      1




                                                                                        Updated July 1, 2011                                                                         Page 1 of 15
                                                   Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                       (Regular Benefits)
                                                                                                                                                                     LCA /
                                                                                                                                                                     MAC
  PTC       PTC DESCRIPTION   DIN / PIN           PRODUCT NAME              IC         GENERIC NAME            STRENGTH     ROUTE            FORM   MFR   PRICE      PRICE COVERAGE STATUS
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00884553 CHILDRENS TEMPRA                 N        ACETAMINOPHEN                16 MG / ML   ORAL     SYRUP           BMS     0.0393        REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00875996 TEMPRA D.S.                      N        ACETAMINOPHEN                32 MG / ML   ORAL     SYRUP           BMS     0.0393        REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00545007 APO-ACETAMINOPHEN                Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          APX     0.0285 0.0285 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       02229977 APO-ACETAMINOPHEN (CAPLET)       Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          APX     0.0285 0.0285 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00482323 NOVO GESIC FORTE                 Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          TEV     0.0285 0.0285 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00013668 ATASOL FORTE                     Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          CHD     0.0584 0.0285 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00723908 TYLENOL EXT STR (CAPLET)         Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          MCL     0.1120 0.0285 REGULAR BENEFIT
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       00559407 TYLENOL EXTRA STRENGTH           Y        ACETAMINOPHEN                500 MG       ORAL     TABLET          MCL     0.1120 0.0285 REGULAR BENEFIT
                                      6
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       02230434 ACET 120                         N        ACETAMINOPHEN                120 MG       RECTAL   SUPPOSITORY     PMS     0.8325        REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       02230436 ACET 325                         N        ACETAMINOPHEN                325 MG       RECTAL   SUPPOSITORY     PMS     0.8325        REGULAR BENEFIT
                                      1
         MISCELLANEOUS
         ANALGESICS AND
280892   ANTIPYRETICS /       02230437 ACET 650                         N        ACETAMINOPHEN                650 MG       RECTAL   SUPPOSITORY     PMS     0.8325        REGULAR BENEFIT
                                      1




                                                                                       Updated July 1, 2011                                                                      Page 2 of 15
                                                   Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                       (Regular Benefits)
                                                                                                                                                                        LCA /
                                                                                                                                                                        MAC
  PTC       PTC DESCRIPTION   DIN / PIN         PRODUCT NAME                IC          GENERIC NAME            STRENGTH       ROUTE            FORM   MFR   PRICE      PRICE COVERAGE STATUS
                                                                                 SODIUM CHLORIDE/              470 MG / G *
                                                                                 POTASSIUM CHLORIDE (K+)(CL-   300 MG / G *
         REPLACEMENT                                                             )/ SODIUM CITRATE,ACID/       530 MG / G *
401200   PREPARATIONS /       01931563 GASTROLYTE                       N        DEXTROSE                      3.56 G / G     ORAL     POWDER          SAV     0.1744        REGULAR BENEFIT
                                      1
                                                                                                             0.045 MEQ /
                                                                                                             ML * 0.02
                                                                                                             MEQ / ML *
                                                                                                             0.035 MEQ /
                                                                                                             ML * 0.03
         REPLACEMENT                                                             SODIUM/ POTASSIUM/          MEQ / ML *
401200   PREPARATIONS /       00630365 PEDIALYTE                        Y        CHLORIDE/ CITRATE/ DEXTROSE 0.025 G / ML     ORAL     LIQUID          ABN     0.0074 0.0074 REGULAR BENEFIT
                                                                                                             0.045 MEQ /
                                                                                                             ML * 0.02
                                                                                                             MEQ / ML *
                                                                                                             0.035 MEQ /
                                                                                                             ML * 0.03
         REPLACEMENT                                                             SODIUM/ POTASSIUM/          MEQ / ML *
401200   PREPARATIONS /       02219883 PEDIATRIC ELECTROLYTE            Y        CHLORIDE/ CITRATE/ DEXTROSE 0.025 G / ML     ORAL     LIQUID          PPH     0.0140 0.0074 REGULAR BENEFIT
                                      2
402000   CALORIC AGENTS /     00999449 SIMILAC ALIMENTUM WITH IRON      N        INFANT FORMULA                               ORAL     LIQUID          ABN     0.0064        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999521 NUTRAMIGEN A+                    N        INFANT FORMULA                               ORAL     LIQUID          MJO     0.0123        REGULAR BENEFIT
                                      2
402000   CALORIC AGENTS /     00999465 SIMILAC ADVANCE NEOSURE          N        INFANT FORMULA                               ORAL     POWDER          ABN     0.0397        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999520 NUTRAMIGEN A+                    N        INFANT FORMULA                               ORAL     POWDER          MJO     0.0491        REGULAR BENEFIT
                                      2
402000   CALORIC AGENTS /     00999469 RESOURCE DAIRY THICK             N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0049        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999960 BOOST 1.0 STANDARD               N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0053        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999410 ISOSOURCE HN                     N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0054        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999429 RESOURCE THICKENED JUICE         N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0058        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999932 BOOST 1.5 PLUS CALORIES          N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0066        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999940 GLUCERNA                         N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          ABN     0.0067        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999418 NUTREN JUNIOR                    N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0067        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999419 NUTREN JUNIOR FIBRE W PREBIO 1 N          NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0067        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999413 RESOURCE DIABETIC                N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0070        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999901 ENSURE                           N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          ABN     0.0071        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999902 ENSURE PLUS                      N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          ABN     0.0071        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999525 ENSURE PREBIOTICS                N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          ABN     0.0071        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999918 ENSURE WITH FIBRE                N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          ABN     0.0071        REGULAR BENEFIT
402000   CALORIC AGENTS /     00999920 BOOST                            N        NUTRITIONAL PRODUCTS                         ORAL     LIQUID          NHN     0.0072        REGULAR BENEFIT



                                                                                        Updated July 1, 2011                                                                        Page 3 of 15
                                                      Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                          (Regular Benefits)
                                                                                                                                                                         LCA /
                                                                                                                                                                         MAC
   PTC      PTC DESCRIPTION       DIN / PIN       PRODUCT NAME                 IC          GENERIC NAME           STRENGTH        ROUTE            FORM   MFR   PRICE    PRICE COVERAGE STATUS
402000   CALORIC AGENTS /        00999921 BOOST PLUS CALORIES              N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0072       REGULAR BENEFIT
402000   CALORIC AGENTS /        00999424 ISOSOURCE HN WITH FIBRE          N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0074      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999425 ISOSOURCE 1.5 CAL                N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0075      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999936 NUTREN 1.5                       N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0081      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999966 COMPLEAT                         N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0082      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999409 RESOURCE 2.0                     N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0087      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999414 SUPLENA                          N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0087      REGULAR BENEFIT
402000   CALORIC AGENTS /        00990056 NOVASOURCE RENAL                 N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0088      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999922 NEPRO                            N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0089      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999545 NEPRO CARB STEADY                N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0089      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999551 RESOURCE KID ESSENTIALS          N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0089      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999933 PEDIASURE                        N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0098      REGULAR BENEFIT
402000   CALORIC AGENTS /        00990029 PEDIASURE WITH FIBRE             N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0098      REGULAR BENEFIT
                                          RESOURCE KID ESSENTIALS 1.5
402000   CALORIC AGENTS /        00999458 CAL                              N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0099      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999938 JEVITY 1 CAL                     N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0103      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999964 NUTREN 2.0                       N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0109      REGULAR BENEFIT
402000   CALORIC AGENTS /        00999412 PULMOCARE                        N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          ABN     0.0137      REGULAR BENEFIT
                                       31
402000   CALORIC AGENTS /        00999483 BOOST DIABETIC                   N        NUTRITIONAL PRODUCTS                        ORAL      LIQUID          NHN     0.0072      REGULAR BENEFIT
                                        1
                                                                                                                                OPHTHALM
520200   ANTIALLERGIC AGENTS /   02009277 CROMOLYN                         Y        SODIUM CROMOGLYCATE          2%             IC       SOLUTION         PMS     0.9500 0.9500 REGULAR BENEFIT
                                                                                                                                OPHTHALM
520200   ANTIALLERGIC AGENTS /   02230621 OPTICROM                         Y        SODIUM CROMOGLYCATE          2%             IC       SOLUTION         ALL     1.0730 0.9500 REGULAR BENEFIT
                                        2
                                                                                                                 54 MG / ML *
521600   LOCAL ANESTHETICS /     02332477 AURALGAN                         N        ANTIPYRINE/ BENZOCAINE       14 MG / ML     OTIC      SOLUTION        PAL     0.5141      REGULAR BENEFIT
                                        1
         MISCELLANEOUS EENT
529200   DRUGS /                 00857777 OTRIVIN-SALINE                   N        SODIUM CHLORIDE              0.7 %          NASAL     SOLUTION        NVC     0.1415      REGULAR BENEFIT
                                        1
         MISCELLANEOUS EENT
529200   DRUGS /                 00489530 SALINEX                          N        SODIUM CHLORIDE              0.9 %          NASAL     SOLUTION        SDZ     0.1370      REGULAR BENEFIT
                                        1
         MISCELLANEOUS EENT
529200   DRUGS /                 00810436 OTRIVIN-SALINE                   N        SODIUM CHLORIDE              0.7 %          NASAL     SPRAY           NVC     0.1267      REGULAR BENEFIT
                                        1
                                        PMS-LOPERAMIDE
560800   ANTIDIARRHEA AGENTS / 02016095 HYDROCHLORIDE                      N        LOPERAMIDE HCL               0.2 MG / ML    ORAL      LIQUID          PMS     0.0918      REGULAR BENEFIT



                                                                                          Updated July 1, 2011                                                                        Page 4 of 15
                                                   Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                       (Regular Benefits)
                                                                                                                                                                         LCA /
                                                                                                                                                                         MAC
   PTC      PTC DESCRIPTION     DIN / PIN       PRODUCT NAME                IC         GENERIC NAME             STRENGTH        ROUTE            FORM     MFR   PRICE    PRICE COVERAGE STATUS
560800   ANTIDIARRHEA AGENTS / 02192667 DIARR-EZE                       N        LOPERAMIDE HCL               0.2 MG / ML     ORAL      LIQUID            PMS     0.1103       REGULAR BENEFIT
                                      2
560800   ANTIDIARRHEA AGENTS / 02291800 IMODIUM                         N        LOPERAMIDE HCL               0.13 MG / ML    ORAL      SOLUTION          MCL     0.0347       REGULAR BENEFIT
                                      1
560800   ANTIDIARRHEA AGENTS / 02212005 APO-LOPERAMIDE                  Y        LOPERAMIDE HCL               2 MG            ORAL      TABLET            APX     0.2466 0.2466 REGULAR BENEFIT
560800   ANTIDIARRHEA AGENTS / 02132591 NOVO-LOPERAMIDE (CAPLET)        Y        LOPERAMIDE HCL               2 MG            ORAL      TABLET            TEV     0.2466 0.2466 REGULAR BENEFIT
560800   ANTIDIARRHEA AGENTS / 02228351 PMS-LOPERAMIDE (CAPLET)         Y        LOPERAMIDE HCL               2 MG            ORAL      TABLET            PMS     0.2466 0.2466 REGULAR BENEFIT
560800   ANTIDIARRHEA AGENTS / 02257564 SANDOZ LOPERAMIDE               N        LOPERAMIDE HCL               2 MG            ORAL      TABLET            SDZ     0.2658       REGULAR BENEFIT
560800   ANTIDIARRHEA AGENTS / 02183862 IMODIUM (CAPLET)                Y        LOPERAMIDE HCL               2 MG            ORAL      TABLET            MCL     0.8313 0.2466 REGULAR BENEFIT
                                      5
561000   ANTIFLATULENTS /      00013617 OVOL                            N        SIMETHICONE                  40 MG / ML      ORAL      DROPS             CHD     0.3462       REGULAR BENEFIT
                                      1
         CATHARTICS AND                                                                                                                 ENTERIC-COATED                          PALLIATIVE CARE
561200   LAXATIVES /           00545023 APO-BISACODYL                   Y        BISACODYL                    5 MG            ORAL      TABLET            APX     0.0522 0.0522 DBS
         CATHARTICS AND                                                                                                                 ENTERIC-COATED                          PALLIATIVE CARE
561200   LAXATIVES /           00587273 PMS-BISACODYL                   Y        BISACODYL                    5 MG            ORAL      TABLET            PMS     0.0522 0.0522 DBS
         CATHARTICS AND                                                                                                                 ENTERIC-COATED                          PALLIATIVE CARE
561200   LAXATIVES /           00254142 DULCOLAX                        Y        BISACODYL                    5 MG            ORAL      TABLET            BOE     0.1860 0.0522 DBS
                                      3
         CATHARTICS AND                                                                                                                                                         PALLIATIVE CARE
561200   LAXATIVES /           00582883 PMS-BISACODYL                   Y        BISACODYL                    10 MG           RECTAL    SUPPOSITORY       PMS     0.5014 0.5014 DBS
         CATHARTICS AND
561200   LAXATIVES /           00404802 RATIO-BISACODYL                 N        BISACODYL                    10 MG           RECTAL    SUPPOSITORY       RPH     0.5014       REGULAR BENEFIT
         CATHARTICS AND
561200   LAXATIVES /           02241091 THE MAGIC BULLET                N        BISACODYL                    10 MG           RECTAL    SUPPOSITORY       DCM     0.8300        REGULAR BENEFIT
         CATHARTICS AND                                                                                                                                                         PALLIATIVE CARE
561200   LAXATIVES /           00003875 DULCOLAX                        Y        BISACODYL                    10 MG           RECTAL    SUPPOSITORY       BOE     1.1100 0.5014 DBS
                                      4
         CATHARTICS AND                                                          SODIUM PHOSPHATE/ SODIUM     10.4 G / ENM                                                      PALLIATIVE CARE
561200   LAXATIVES /           02096900 ENEMOL                          Y        ACID PHOSPHATE               * 3.9 G / ENM   RECTAL    ENEMA             PMS     2.9600 2.9600 DBS
         CATHARTICS AND                                                          SODIUM PHOSPHATE/ SODIUM     10.4 G / ENM                                                      PALLIATIVE CARE
561200   LAXATIVES /           00009911 FLEET ENEMA                     Y        ACID PHOSPHATE               * 3.9 G / ENM   RECTAL    ENEMA             JJM     4.1710 2.9600 DBS
                                      2
561600   DIGESTANTS /          02230653 LACTAID                         N        LACTASE                      3,000 UNIT      ORAL      TABLET            MCL     0.1423       REGULAR BENEFIT
                                      1
561600   DIGESTANTS /          02230654 EXTRA STRENGTH LACTAID          N        LACTASE                      4,500 UNIT      ORAL      TABLET            MCL     0.2128       REGULAR BENEFIT
                                      1
561600   DIGESTANTS /          02231507 LACTAID ULTRA (CAPLET)          N        LACTASE                      9,000 UNIT      ORAL      TABLET            MCL     0.4257       REGULAR BENEFIT
                                      1
562208   ANTIHISTAMINES /      00511196 GRAVOL                          N        DIMENHYDRINATE               15 MG           ORAL      CHEWABLE TABLET   CHD     0.2491       REGULAR BENEFIT



                                                                                       Updated July 1, 2011                                                                            Page 5 of 15
                                                    Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                        (Regular Benefits)
                                                                                                                                                                       LCA /
                                                                                                                                                                       MAC
  PTC       PTC DESCRIPTION     DIN / PIN         PRODUCT NAME               IC          GENERIC NAME            STRENGTH    ROUTE             FORM   MFR   PRICE      PRICE COVERAGE STATUS
                                         1
562208   ANTIHISTAMINES /       00230197 GRAVOL                          N        DIMENHYDRINATE                3 MG / ML   ORAL      SYRUP           CHD     0.0722        REGULAR BENEFIT
                                        1
562208   ANTIHISTAMINES /       00363766 APO-DIMENHYDRINATE              Y        DIMENHYDRINATE                50 MG       ORAL      TABLET          APX     0.0624 0.0624 REGULAR BENEFIT
562208   ANTIHISTAMINES /       00021423 NOVODIMENATE                    Y        DIMENHYDRINATE                50 MG       ORAL      TABLET          TEV     0.0624 0.0624 REGULAR BENEFIT
562208   ANTIHISTAMINES /       00013803 GRAVOL                          Y        DIMENHYDRINATE                50 MG       ORAL      TABLET          CHD     0.2172 0.0624 REGULAR BENEFIT
                                        3
562208   ANTIHISTAMINES /       00783595 GRAVOL                          N        DIMENHYDRINATE                25 MG       RECTAL    SUPPOSITORY     CHD     0.5074        REGULAR BENEFIT
                                        1
562208   ANTIHISTAMINES /       00392553 SANDOZ DIMENHYDRINATE           N        DIMENHYDRINATE                50 MG       RECTAL    SUPPOSITORY     SDZ     0.4356        REGULAR BENEFIT
                                        1
562208   ANTIHISTAMINES /       00392545 SANDOZ DIMENHYDRINATE           Y        DIMENHYDRINATE                100 MG      RECTAL    SUPPOSITORY     SDZ     0.4250 0.4250 REGULAR BENEFIT
562208   ANTIHISTAMINES /       00013609 GRAVOL                          Y        DIMENHYDRINATE                100 MG      RECTAL    SUPPOSITORY     CHD     0.5482 0.4250 REGULAR BENEFIT
                                        2
                                         CANESTEN EXTERNAL CREAM
84040808 ANTIFUNGALS / AZOLES   02239432 REFILL                          N        CLOTRIMAZOLE                  1%          TOPICAL   CREAM           BIC     0.3593        REGULAR BENEFIT
                                        1
84040808 ANTIFUNGALS / AZOLES   00812366 CLOTRIMADERM                    N        CLOTRIMAZOLE                  1%          VAGINAL   CREAM           TAR     0.1843        REGULAR BENEFIT
84040808 ANTIFUNGALS / AZOLES   02150891 CANESTEN 6                      N        CLOTRIMAZOLE                  1%          VAGINAL   CREAM           BIC     0.2322        REGULAR BENEFIT
                                        2
84040808 ANTIFUNGALS / AZOLES   00812374 CLOTRIMADERM                    N        CLOTRIMAZOLE                  2%          VAGINAL   CREAM           TAR     0.3686        REGULAR BENEFIT
84040808 ANTIFUNGALS / AZOLES   02150905 CANESTEN 3                      N        CLOTRIMAZOLE                  2%          VAGINAL   CREAM           BIC     0.4644        REGULAR BENEFIT
                                        2
84040808 ANTIFUNGALS / AZOLES   02150883 CANESTEN 1                      N        CLOTRIMAZOLE                  10 %        VAGINAL   CREAM           BIC     2.3220        REGULAR BENEFIT
                                        1
                                                                                                                            TOPICAL/V
84040808 ANTIFUNGALS / AZOLES   02230509 CANESTEN 1 CREAM COMBI-PAK      N        CLOTRIMAZOLE/ CLOTRIMAZOLE 1 % * 10 %     AGINAL    CREAM/CREAM     BIC    12.6800        REGULAR BENEFIT
                                        1
                                         CANESTEN 3 COMFORTAB COMBI-                                                        VAGINAL/T
84040808 ANTIFUNGALS / AZOLES   02264099 PAK                             N        CLOTRIMAZOLE/ CLOTRIMAZOLE 200 MG * 1 %   OPICAL    TABLET/CREAM    BIC    12.6800        REGULAR BENEFIT
                                        1
                                         CANESTEN 1 COMFORTAB COMBI-                                                        VAGINAL/T
84040808 ANTIFUNGALS / AZOLES   02264102 PAK                             N        CLOTRIMAZOLE/ CLOTRIMAZOLE 500 MG * 1 %   OPICAL    TABLET/CREAM    BIC    12.6800        REGULAR BENEFIT
                                        1
84040808 ANTIFUNGALS / AZOLES   02231106 MICOZOLE                        N        MICONAZOLE NITRATE            2%          VAGINAL   CREAM           TAR     0.1592        REGULAR BENEFIT
84040808 ANTIFUNGALS / AZOLES   02084309 MONISTAT 7                      N        MICONAZOLE NITRATE            2%          VAGINAL   CREAM           MCL     0.3692        REGULAR BENEFIT
                                        2
84040808 ANTIFUNGALS / AZOLES   02244005 MONISTAT 3                      N        MICONAZOLE NITRATE            4%          VAGINAL   CREAM           MCL     0.8614        REGULAR BENEFIT
                                        1



                                                                                         Updated July 1, 2011                                                                      Page 6 of 15
                                                     Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                         (Regular Benefits)
                                                                                                                                                                        LCA /
                                                                                                                                                                        MAC
   PTC      PTC DESCRIPTION      DIN / PIN       PRODUCT NAME                 IC         GENERIC NAME             STRENGTH       ROUTE            FORM   MFR   PRICE    PRICE COVERAGE STATUS
84040808 ANTIFUNGALS / AZOLES   02239601 MONISTAT 1                       N        MICONAZOLE NITRATE           1,200 MG       VAGINAL   OVULE           MCL    12.9215       REGULAR BENEFIT
                                       1
84040808 ANTIFUNGALS / AZOLES   02126605 MONISTAT 3                       N        MICONAZOLE NITRATE           400 MG         VAGINAL   OVULE           MCL     4.3071      REGULAR BENEFIT
                                       1
                                                                                   MICONAZOLE NITRATE/                         VAGINAL/T
84040808 ANTIFUNGALS / AZOLES   02126257 MONISTAT 7 DUAL-PAK              N        MICONAZOLE NITRATE           100 MG * 2 %   OPICAL    OVULE/CREAM     MCL    14.7920      REGULAR BENEFIT
                                       1
                                                                                   MICONAZOLE NITRATE/                         VAGINAL/T
84040808 ANTIFUNGALS / AZOLES   02126249 MONISTAT 3 DUAL-PAK              N        MICONAZOLE NITRATE           400 MG * 2 %   OPICAL    OVULE/CREAM     MCL    14.7920      REGULAR BENEFIT
                                       1
                                                                                   MICONAZOLE NITRATE/          1,200 MG * 2   VAGINAL/T
84040808 ANTIFUNGALS / AZOLES   02239600 MONISTAT-1 COMBINATION PACK      N        MICONAZOLE NITRATE           %              OPICAL    OVULE/CREAM     MCL    14.7920      REGULAR BENEFIT
                                       1
         SCABICIDES AND
840412   PEDICULICIDES /        02279592 RESULTZ                          N        ISOPROPYL MYRISTATE          50 %           TOPICAL   SOLUTION        NYC     0.1098      REGULAR BENEFIT
                                       1
         SCABICIDES AND
840412   PEDICULICIDES /        00703591 PMS-LINDANE                      N        LINDANE                      1%             TOPICAL   LOTION          PPH     0.1261      REGULAR BENEFIT
                                       1
         SCABICIDES AND
840412   PEDICULICIDES /        00430617 HEXIT                            Y        LINDANE                      1%             TOPICAL   SHAMPOO         ODN     0.1123 0.1123 REGULAR BENEFIT
         SCABICIDES AND
840412   PEDICULICIDES /        00703605 PMS-LINDANE                      Y        LINDANE                      1%             TOPICAL   SHAMPOO         PPH     0.1258 0.1123 REGULAR BENEFIT
                                       2
         SCABICIDES AND
840412   PEDICULICIDES /        02219905 NIX DERMAL                       N        PERMETHRIN                   5%             TOPICAL   CREAM           GKC     0.4822      REGULAR BENEFIT
                                       1
         SCABICIDES AND
840412   PEDICULICIDES /        02231348 KWELLADA-P                       N        PERMETHRIN                   5%             TOPICAL   LOTION          GKC     0.2606      REGULAR BENEFIT
                                       1
         SCABICIDES AND
840412   PEDICULICIDES /        02231480 KWELLADA-P CREME                 Y        PERMETHRIN                   10 MG / ML     TOPICAL   RINSE           GKC     0.1199 0.1199 REGULAR BENEFIT
         SCABICIDES AND
840412   PEDICULICIDES /        00771368 NIX CREME                        Y        PERMETHRIN                   10 MG / ML     TOPICAL   RINSE           ANB     0.1350 0.1199 REGULAR BENEFIT
                                       2
         SCABICIDES AND                  R & C SHAMPOO WITH                        PYRETHRINS/ PIPERONYL
840412   PEDICULICIDES /        02125447 CONDITIONER                      N        BUTOXIDE                     0.33 % * 3 %   TOPICAL   SHAMPOO         GKC     0.1171      REGULAR BENEFIT
                                       1




                                                                                         Updated July 1, 2011                                                                        Page 7 of 15
                                                   Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                       (Regular Benefits)
                                                                                                                                                                         LCA /
                                                                                                                                                                         MAC
  PTC       PTC DESCRIPTION      DIN / PIN        PRODUCT NAME              IC          GENERIC NAME             STRENGTH       ROUTE            FORM   MFR   PRICE      PRICE COVERAGE STATUS



                                                                                                                2,500 IU *
                                                                                                                1,000 IU * 30
                                                                                                                IU * 85 MG * 1
                                                                                                                MG * 1.4 MG *
                                                                                                                1.4 MG * 18
                                                                                 BETA CAROTENE/ VITAMIN A       MG * 1.9 MG *
                                                                                 ACETATE/ VITAMIN E (DL-ALPHA 2.6 MCG * 400
                                                                                 TOCOPHERYL ACETATE)/           IU * 30 MCG *
                                                                                 ASCORBIC ACID/ FOLIC ACID/     6 MG * 250
                                                                                 THIAMINE MONONITRATE/          MG * 50 MG *
                                                                                 RIBOFLAVIN (VITAMIN B2)/       220 MCG * 27
                                                                                 NIACINAMIDE/ PYRIDOXINE        MG * 1 MG *
                                                                                 HCL/ CYANOCOBALAMIN/           7.5 MG * 30
                                                                                 VITAMIN D3/ BIOTIN/ CALCIUM D- MCG * 2 MG *
                                                                                 PANTOTHENATE/ CALCIUM          50 MCG * 30
882801   VITAMINS & MINERALS /   80001842 CENTRUM MATERNA               N        CARBONATE                      MCG            ORAL     TABLET          WCH     0.1488        REGULAR BENEFIT
                                         1
         MISCELLANEOUS
920000   THERAPEUTIC AGENTS /    00999455 CONSIST-RITE                  N        INSTANT FOOD THICKENER                      ORAL       POWDER          DFI     0.0156        REGULAR BENEFIT
         MISCELLANEOUS
920000   THERAPEUTIC AGENTS /    00999453 RESOURCE THICKENUP            N        INSTANT FOOD THICKENER                      ORAL       POWDER          NHN     0.0571        REGULAR BENEFIT
                                         2
                                       133




                                                                                        Updated July 1, 2011                                                                         Page 8 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                            (Restricted Benefits)
                                                                                                                                                                                    LCA /
                                                                                                                                                                                    MAC
   PTC    DIABETES SUPPLIES DIN / PIN
            PTC DESCRIPTION                  PRODUCT NAME                        IC        GENERIC NAME                   STRENGTH             ROUTE       FORM    MFR   PRICE      PRICE     COVERAGE STATUS
000002    /                 00990024 BLOOD GLUCOSE METER                     N        BLOOD GLUCOSE METER                                                          XXX     0.0000           RESTRICTED BENEFIT
                                        1
          PEDIATRIC COUGH                                                             BROMPHENIRAMINE
          AND COLD                                                                    MALEATE/ PHENYLEPHRINE
020000    PREPARATIONS /        02243980 DIMETAPP COLD                       N        HCL                        0.4 MG / ML * 1 MG / ML    ORAL         LIQUID    WCH     0.0515           RESTRICTED BENEFIT
                                        1
          PEDIATRIC COUGH                                                             CHLORPHENIRAMINE
          AND COLD                       VICKS CHILDREN'S NYQUIL COLD                 MALEATE/
020000    PREPARATIONS /        02273330 AND COUGH                           N        DEXTROMETHORPHAN HBR       0.13 MG / ML * 1 MG / ML   ORAL         LIQUID    PGI     0.0514           RESTRICTED BENEFIT
                                        1
          PEDIATRIC COUGH
          AND COLD                       ROBITUSSIN CHILDRENS COUGH                   DEXTROMETHORPHAN HBR/
020000    PREPARATIONS /        02044013 AND COLD                            N        PSEUDOEPHEDRINE HCL        1.5 MG / ML * 3 MG / ML    ORAL         LIQUID    WCH     0.0518           RESTRICTED BENEFIT
                                        1
          PEDIATRIC
040200    ANTIHISTAMINES /      02238337 REACTINE                            N        CETIRIZINE HCL             1 MG / ML                  ORAL         SYRUP     JJM     0.0747           RESTRICTED BENEFIT
                                        1
          PEDIATRIC
040200    ANTIHISTAMINES /      00757713 PMS-CYPROHEPTADINE HCL              N        CYPROHEPTADINE HCL         4 MG                       ORAL         TABLET    PPH     0.2483           RESTRICTED BENEFIT
                                        1
          PEDIATRIC
040200    ANTIHISTAMINES /      02247193 AERIUS KIDS                         N        DESLORATADINE              0.5 MG / ML                ORAL         SYRUP     SCH     0.0700           RESTRICTED BENEFIT
                                        1
          PEDIATRIC
040200    ANTIHISTAMINES /      00792705 PMS-DIPHENHYDRAMINE                 Y        DIPHENHYDRAMINE HCL        2.5 MG / ML                ORAL         ELIXIR    PPH     0.0299 0.0299 RESTRICTED BENEFIT
          PEDIATRIC
040200    ANTIHISTAMINES /      00804193 ALLERNIX                            Y        DIPHENHYDRAMINE HCL        2.5 MG / ML                ORAL         ELIXIR    ROG     0.0379 0.0299 RESTRICTED BENEFIT
                                        2
          PEDIATRIC
040200    ANTIHISTAMINES /      02241523 CLARITIN                            N        LORATADINE                 1 MG / ML                  ORAL         SYRUP     SCH     0.0517           RESTRICTED BENEFIT
                                        1

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02241742 NICORETTE INHALER                       N        NICOTINE                   10 MG / DOSE               INHALATION   CARTRIDGE JJI     0.7500           RESTRICTED BENEFIT
                                        1

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02091933 NICORETTE                               N        NICOTINE                   2 MG                       ORAL         GUM       JJI     0.3130           RESTRICTED BENEFIT
                                        1




Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html for restricted criteria                  Updated July 1, 2011                                                                              Page 9 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                            (Restricted Benefits)
                                                                                                                                                                           LCA /
                                                                                                                                                                           MAC
   PTC      PTC DESCRIPTION     DIN / PIN          PRODUCT NAME                  IC         GENERIC NAME                STRENGTH      ROUTE       FORM    MFR   PRICE      PRICE    COVERAGE STATUS

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02091941 NICORETTE                               N        NICOTINE                 4 MG                ORAL         GUM      JJI      0.3793           RESTRICTED BENEFIT
                                        1

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 01943057 HABITROL 7 MG/DAY                       N        NICOTINE                 7 MG/DAY            TRANSDERMAL PATCH     NVC      2.8795           RESTRICTED BENEFIT

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02241227 TRANSDERMAL NICOTINE 7 MG/DAY N                  NICOTINE                 7 MG/DAY            TRANSDERMAL PATCH     NVC      2.9301           RESTRICTED BENEFIT

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02093111 NICODERM 7 MG/DAY                       N        NICOTINE                 7 MG/DAY            TRANSDERMAL PATCH     JJI      3.4771           RESTRICTED BENEFIT
                                        3

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 01943065 HABITROL 14 MG/DAY                      N        NICOTINE                 14 MG/DAY           TRANSDERMAL PATCH     NVC      2.8795           RESTRICTED BENEFIT

          MISCELLANEOUS              TRANSDERMAL NICOTINE 14
129200    AUTONOMIC DRUGS / 02241226 MG/DAY                                  N        NICOTINE                 14 MG/DAY           TRANSDERMAL PATCH     NVC      2.9301           RESTRICTED BENEFIT

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02093138 NICODERM 14 MG/DAY                      N        NICOTINE                 14 MG/DAY           TRANSDERMAL PATCH     JJI      3.4771           RESTRICTED BENEFIT
                                        3

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 01943073 HABITROL 21 MG/DAY                      N        NICOTINE                 21 MG/DAY           TRANSDERMAL PATCH     NVC      2.8795           RESTRICTED BENEFIT

          MISCELLANEOUS              TRANSDERMAL NICOTINE 21
129200    AUTONOMIC DRUGS / 02241228 MG/DAY                                  N        NICOTINE                 21 MG/DAY           TRANSDERMAL PATCH     NVC      2.9301           RESTRICTED BENEFIT

          MISCELLANEOUS
129200    AUTONOMIC DRUGS / 02093146 NICODERM 21 MG/DAY                      N        NICOTINE                 21 MG/DAY           TRANSDERMAL PATCH     JJI      3.4771           RESTRICTED BENEFIT
                                        3
          IRON                                                                                                                                  SUSPENSIO
200404    PREPARATIONS /        01923439 PALAFER                             N        FERROUS FUMARATE         60 MG / ML          ORAL         N         GKC     0.0872           RESTRICTED BENEFIT
                                        1
          IRON
200404    PREPARATIONS /        02237385 FERODAN INFANT                      Y        FERROUS SULFATE          75 MG / ML          ORAL         DROPS    ODN      0.1432 0.1432 RESTRICTED BENEFIT
          IRON
200404    PREPARATIONS /        00762954 FER-IN-SOL                          Y        FERROUS SULFATE          75 MG / ML          ORAL         DROPS    MJO      0.2558 0.1432 RESTRICTED BENEFIT
                                        2


Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html for restricted criteria                Updated July 1, 2011                                                                      Page 10 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                            (Restricted Benefits)
                                                                                                                                                                            LCA /
                                                                                                                                                                            MAC
   PTC      PTC DESCRIPTION     DIN / PIN          PRODUCT NAME                  IC        GENERIC NAME                  STRENGTH      ROUTE      FORM     MFR   PRICE      PRICE    COVERAGE STATUS
          IRON
200404    PREPARATIONS /        00792675 PMS-FERROUS SULFATE                 N        FERROUS SULFATE           30 MG / ML          ORAL        SOLUTION   PMS     0.0403           RESTRICTED BENEFIT
                                        1
          IRON
200404    PREPARATIONS /        00758469 FERODAN                             Y        FERROUS SULFATE           30 MG / ML          ORAL        SYRUP      ODN     0.0291 0.0291 RESTRICTED BENEFIT
          IRON
200404    PREPARATIONS /        00017884 FER-IN-SOL                          Y        FERROUS SULFATE           30 MG / ML          ORAL        SYRUP      MJO     0.0519 0.0291 RESTRICTED BENEFIT
                                        2
         NONSTEROIDAL
         ANTI-
         INFLAMMATORY
         AGENTS / OTHER
         NONSTEROIDAL
         ANTI-
         INFLAMMATORY                                                                                                                           SUSPENSIO
28080492 AGENTS                 02242365 CHILDREN'S MOTRIN                   N        IBUPROFEN                 20 MG / ML          ORAL        N         MCL      0.0484           RESTRICTED BENEFIT
         NONSTEROIDAL
         ANTI-
         INFLAMMATORY
         AGENTS / OTHER
         NONSTEROIDAL
         ANTI-
         INFLAMMATORY                                                                                                                           SUSPENSIO
28080492 AGENTS                 02232297 CHILDREN'S ADVIL                    N        IBUPROFEN                 20 MG / ML          ORAL        N         WCH      0.0613           RESTRICTED BENEFIT
                                        2
          CATHARTICS AND                                                                                                                        SUPPOSITO                           RESTRICTED BENEFIT/
561200    LAXATIVES /           00003867 DULCOLAX                            N        BISACODYL                 5 MG                RECTAL      RY        BOE      1.0933           PALLIATIVE CARE DBS
                                        1
          CATHARTICS AND                                                                                                                                                         RESTRICTED BENEFIT/
561200    LAXATIVES /           02090163 COLACE                              N        DOCUSATE SODIUM           10 MG / ML          ORAL        DROPS      WSP     0.1770 0.0000 PALLIATIVE CARE DBS
                                        1
          CATHARTICS AND                                                                                                                                                         RESTRICTED BENEFIT/
561200    LAXATIVES /           00870226 RATIO-DOCUSATE SODIUM               Y        DOCUSATE SODIUM           4 MG / ML           ORAL        SYRUP      RPH     0.0190 0.0190 PALLIATIVE CARE DBS
          CATHARTICS AND                                                                                                                                                         RESTRICTED BENEFIT/
561200    LAXATIVES /           00695033 SELAX                               Y        DOCUSATE SODIUM           4 MG / ML           ORAL        SYRUP      ODN     0.0220 0.0190 PALLIATIVE CARE DBS
          CATHARTICS AND                                                                                                                                                         RESTRICTED BENEFIT/
561200    LAXATIVES /           02086018 COLACE                              Y        DOCUSATE SODIUM           4 MG / ML           ORAL        SYRUP      WSP     0.0232 0.0190 PALLIATIVE CARE DBS
                                        3
                                                                                                                                                PEDIATRIC
          CATHARTICS AND                                                                                                                        SUPPOSITO
561200    LAXATIVES /           02020815 GLYCERIN INFANT                     N        GLYCERIN                                      RECTAL      RY        ROG      0.1625           RESTRICTED BENEFIT
                                        1

Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html for restricted criteria                 Updated July 1, 2011                                                                      Page 11 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                            (Restricted Benefits)
                                                                                                                                                                                     LCA /
                                                                                                                                                                                     MAC
   PTC     PTC DESCRIPTION      DIN / PIN          PRODUCT NAME                  IC         GENERIC NAME                  STRENGTH               ROUTE     FORM    MFR    PRICE      PRICE     COVERAGE STATUS
          CATHARTICS AND                                                              SODIUM PHOSPHATE/                                                  PEDIATRIC                           RESTRICTED BENEFIT/
561200    LAXATIVES /           00108065 FLEET ENEMA PEDIATRIC (65 ML)       N        SODIUM ACID PHOSPHATE      10.4 G / ENM * 3.9 G / ENM   RECTAL     ENEMA     MCL      4.1925           PALLIATIVE CARE DBS
                                        1
         ANTIFUNGALS /
84040828 POLYENES               00716871 NYADERM                             Y        NYSTATIN                   100,000 UNIT / G             TOPICAL    CREAM      TAR     0.0700 0.0700 RESTRICTED BENEFIT
         ANTIFUNGALS /
84040828 POLYENES               02194236 RATIO-NYSTATIN                      Y        NYSTATIN                   100,000 UNIT / G             TOPICAL    CREAM      RPH     0.0700 0.0700 RESTRICTED BENEFIT
                                        2
         ANTIFUNGALS /
84040828 POLYENES               02194228 RATIO-NYSTATIN                      N        NYSTATIN                   100,000 UNIT / G             TOPICAL    OINTMENT   RPH     0.0922           RESTRICTED BENEFIT
                                        1
881600    VITAMIN D /           00762881 D-VI-SOL INFANT                     N        VITAMIN D3                 400 UNIT / ML                ORAL       DROPS      MJO     0.1996           RESTRICTED BENEFIT
                                        1


                                                                                      VITAMIN A ACETATE/
                                                                                      THIAMINE MONONITRATE/
                                                                                      RIBOFLAVIN (VITAMIN B2)/
                                                                                      PYRIDOXINE HCL/            1,600 UNIT * 1.5 MG * 1.5
                                                                                      CYANOCOBALAMIN/ SODIUM     MG * 1 MG * 3 MCG * 50
          MULTIVITAMIN                   FLINTSTONES MULTI VITAMINS W                 ASCORBATE/ VITAMIN D/      MG * 400 UNIT * 0.1 MG * 8              CHEWABLE
882800    PREPARATIONS /        02247975 EXTRA C                             N        FOLIC ACID/ NIACINAMIDE    MG                         ORAL         TABLET   BIC       0.1243           RESTRICTED BENEFIT


                                                                                      VITAMIN A ACETATE/
                                                                                      THIAMINE MONONITRATE/
                                                                                      RIBOFLAVIN (VITAMIN B2)/
                                                                                      PYRIDOXINE HCL/            1,600 UNIT * 1.5 MG * 1.5
                                                                                      CYANOCOBALAMIN/ SODIUM     MG * 1 MG * 3 MCG * 50
          MULTIVITAMIN                                                                ASCORBATE/ VITAMIN D/      MG * 400 UNIT * 0.1 MG * 8              CHEWABLE
882800    PREPARATIONS /        02247971 FLINTSTONES MULTIPLE VITAMINS       N        FOLIC ACID/ NIACINAMIDE    MG                         ORAL         TABLET   BIC       0.1243           RESTRICTED BENEFIT
                                        2
          MULTIVITAMIN                                                                VITAMIN A PALMITATE/       2,500 UNIT / ML * 667 UNIT
882800    PREPARATIONS /        00762903 TRI-VI-SOL                          N        VITAMIN D/ ASCORBIC ACID   / ML * 50 MG / ML          ORAL         DROPS      MJO     0.2346           RESTRICTED BENEFIT
                                        1
                                                                                      VITAMIN A PALMITATE/
                                                                                      VITAMIN D/ SODIUM          1,500 UNIT / ML * 400 UNIT
                                                                                      ASCORBATE/ THIAMINE HCL/   / ML * 30 MG / ML * 0.5 MG
          MULTIVITAMIN                                                                RIBOFLAVIN (VITAMIN B2)/   / ML * 0.6 MG / ML * 4 MG /
882800    PREPARATIONS /        00762946 POLY-VI-SOL                         N        NIACINAMIDE                ML                          ORAL        DROPS      MJO     0.2346           RESTRICTED BENEFIT
                                        1




Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html for restricted criteria                  Updated July 1, 2011                                                                              Page 12 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                            (Restricted Benefits)
                                                                                                                                                                                    LCA /
                                                                                                                                                                                    MAC
   PTC      PTC DESCRIPTION     DIN / PIN          PRODUCT NAME                  IC         GENERIC NAME                 STRENGTH                 ROUTE     FORM   MFR   PRICE      PRICE    COVERAGE STATUS
                                                                                      VITAMIN A/ VITAMIN D/      320 UNIT / ML * 80 UNIT /
                                                                                      ASCORBIC ACID/ THIAMINE/   ML * 16 MG / ML * 0.25 MG
          MULTIVITAMIN                                                                RIBOFLAVIN (VITAMIN B2)/   / ML * 0.4 MG / ML * 2 MG /
882800    PREPARATIONS /        00558079 INFANTOL                            N        NIACINAMIDE/ PYRIDOXINE    ML * 0.24 MG / ML             ORAL       LIQUID   CHD     0.0196           RESTRICTED BENEFIT
                                        1


                                                                                      VITAMIN A ACETATE/
                                                                                      THIAMINE MONONITRATE/
                                                                                      RIBOFLAVIN (VITAMIN B2)/
                                                                                      PYRIDOXINE HCL/
                                                                                      CYANOCOBALAMIN/ SODIUM     1,600 UNIT * 1.5 MG * 1.5
                                                                                      ASCORBATE/ VITAMIN D/      MG * 1 MG * 3 MCG * 50
          VITAMINS &                     FLINTSTONES MULTI VITAMINS                   FOLIC ACID/ NIACINAMIDE/   MG * 400 UNIT * 0.1 MG * 8               CHEWABLE
882801    MINERALS /            02247995 PLUS IRON                           N        FERROUS FUMARATE           MG * 4 MG                  ORAL          TABLET   BIC     0.1243           RESTRICTED BENEFIT
                                        1


                                                                                      VITAMIN A ACETATE/
                                                                                      VITAMIN E (DL-ALPHA
                                                                                      TOCOPHERYL ACETATE)/
                                                                                      VITAMIN C/ FOLIC ACID/
                                                                                      THIAMINE MONONITRATE/
                                                                                      RIBOFLAVIN (VITAMIN B2)/
                                                                                      NIACINAMIDE/ PYRIDOXINE    1,600 UNIT * 10 UNIT * 75
                                                                                      HCL/ CYANOCOBALAMIN/       MG * 0.1 MG * 1.6 MG * 1.8
                                                                                      VITAMIN D3/ BIOTIN/        MG * 10 MG * 2 MG * 4
                                                                                      CALCIUM D-PANTOTHENATE/    MCG * 400 UNIT * 30 MCG *
          VITAMINS &                                                                  CALCIUM/ PHOSPHORUS (AS    10 MG * 162 MG * 125 MG *                CHEWABLE
882801    MINERALS /            02246236 CENTRUM JUNIOR COMPLETE             N        CA PHOSPHATE               0.15 MG * 5 MG * 1 MG      ORAL          TABLET   WCH     0.1260           RESTRICTED BENEFIT
                                        1
                                       48




Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html for restricted criteria                Updated July 1, 2011                                                                               Page 13 of 15
                                                           Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                       (Additional Special Authorization)


                                                                                                                                                                    LCA / MAC
  PTC     PTC DESCRIPTION         DIN / PIN           IC          PRODUCT NAME               GENERIC NAME        STRENGTH ROUTE  FORM           MFR      PRICE        PRICE        COVERAGE STATUS
402000 CALORIC AGENTS /         00999456          N         NEOCATE                     INFANT FORMULA                    ORAL POWDER        NUN           0.1088               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999543          N         NUTRAMIGEN AA               INFANT FORMULA                     ORAL   POWDER     MJO           0.1318               SPECIAL AUTHORIZATION
                                              2
402000 CALORIC AGENTS /         00999934          N         ENSURE HIGH-PROTEIN         NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0071               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999937          N         OSMOLITE HN                 NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0071               SPECIAL AUTHORIZATION
                                                            BOOST FRUIT FLAVOURED
402000 CALORIC AGENTS /         00999402          N         BEVERAGE                    NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0072               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999427          N         BOOST HIGH PROTEIN          NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0072               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999428          N         ISOSOURCE VHN               NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0085               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999550          N         ISOSOURCE VHP FIBRE-FREE    NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0085               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999426          N         COMPLEAT PEDIATRIC          NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0104               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999434          N         PEDIASURE PLUS WITH FIBRE   NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0108               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999423          N         PERATIVE                    NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0113               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999416          N         JEVITY 1.2 CAL              NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0122               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999475          N         JEVITY 1.5 CAL              NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0141               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999430          N         TWOCAL HN                   NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0144               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999524          N         E028 SPLASH                 NUTRITIONAL PRODUCTS               ORAL   LIQUID     NUN           0.0269               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999420          N         OPTIMENTAL                  NUTRITIONAL PRODUCTS               ORAL   LIQUID     ABN           0.0278               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999944          N         PEPTAMEN                    NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0286               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999408          N         PEPTAMEN JUNIOR             NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0286               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999435          N         PEPTAMEN WITH PREBIO 1      NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0286               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999927          N         MCT OIL                     NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0392               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999421          N         PEPTAMEN 1.5                NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0413               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999553          N         PEPTAMEN JUNIOR 1.5         NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0429               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999467          N         PEPTAMEN AF 1.2             NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0455               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999347          N         NUTRIHEP                    NUTRITIONAL PRODUCTS               ORAL   LIQUID     NHN           0.0645               SPECIAL AUTHORIZATION
                                           22
402000 CALORIC AGENTS /         00999404          N         ENSURE                      NUTRITIONAL PRODUCTS               ORAL   PUDDING    ABN           0.0111               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999440          N         BOOST                       NUTRITIONAL PRODUCTS               ORAL   PUDDING    NHN           0.0119               SPECIAL AUTHORIZATION
                                              2
402000 CALORIC AGENTS /         00999928          N         POLYCOSE                    NUTRITIONAL PRODUCTS               ORAL   POWDER     ABN           0.0249               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999935          N         SCANDISHAKE                 NUTRITIONAL PRODUCTS               ORAL   POWDER     AXC           0.0363               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999929          N         TOLEREX                     NUTRITIONAL PRODUCTS               ORAL   POWDER     NHN           0.0525               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999444          N         DUOCAL                      NUTRITIONAL PRODUCTS               ORAL   POWDER     NUN           0.0625               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999559          N         MODULEN IBD                 NUTRITIONAL PRODUCTS               ORAL   POWDER     NNU           0.0728               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999415          N         BENEPROTEIN                 NUTRITIONAL PRODUCTS               ORAL   POWDER     NHN           0.0777               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999983          N         VIVONEX T.E.N.              NUTRITIONAL PRODUCTS               ORAL   POWDER     NHN           0.0878               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999405          N         VIVONEX PLUS                NUTRITIONAL PRODUCTS               ORAL   POWDER     NHN           0.0888               SPECIAL AUTHORIZATION


Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html
 for special authorization criteria.                                                         Updated July 1, 2011                                                                             Page 14 of 15
                                                         Alberta Employment and Immigration Drug Benefit Supplement (AEIDBS) Effective April 1, 2011
                                                                                     (Additional Special Authorization)


                                                                                                                                                                  LCA / MAC
  PTC     PTC DESCRIPTION         DIN / PIN         IC          PRODUCT NAME               GENERIC NAME        STRENGTH ROUTE  FORM           MFR      PRICE        PRICE        COVERAGE STATUS
402000 CALORIC AGENTS /         00999445        N         KETOCAL                     NUTRITIONAL PRODUCTS              ORAL POWDER        NUN           0.1000               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999965        N         VITAL HN                    NUTRITIONAL PRODUCTS               ORAL   POWDER     ABN           0.1002               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999447        N         NEOCATE JUNIOR              NUTRITIONAL PRODUCTS               ORAL   POWDER     NUN           0.1150               SPECIAL AUTHORIZATION
                                                          NEOCATE JUNIOR WITH
402000 CALORIC AGENTS /         00999560        N         PREBIOTIC FIBRE             NUTRITIONAL PRODUCTS               ORAL   POWDER     NUN           0.1150               SPECIAL AUTHORIZATION
402000 CALORIC AGENTS /         00999422        N         VIVONEX PEDIATRIC           NUTRITIONAL PRODUCTS               ORAL   POWDER     NHN           0.1450               SPECIAL AUTHORIZATION
                                           13
                                           39




Please refer to the iDBL or PDF version of the AHWDBL available online at
http://www.health.alberta.ca/AHCIP/drug-benefit-list.html
 for special authorization criteria.                                                       Updated July 1, 2011                                                                             Page 15 of 15

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:47
posted:7/31/2011
language:English
pages:15