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Pg 1 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017

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Pg 1 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.3307 00002192683 3TC 150 MG TABLET ORL TAB GSK TAB 5.0507 00002247825 3TC 300 MG TABLET ORL TAB GSK TAB 9.8070 00002162113 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL TOP ALCGEL CLC G 0.2080 00002166607 5 BENZAGEL 5% TOPICAL LOTION TOP LOT NVC ML 0.1984 00000437999 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ INJ DEFAUL BAX ML 0.0030 00000037974 50% DEXTROSE 500 MG/ML INJECTION USP INJ DEFAUL HSP ML 0.5842 00080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.2000 00002414570 ABBOTT-CITALOPRAM 10 MG TABLET ORL TAB ABB TAB 0.1432 00002414589 ABBOTT-CITALOPRAM 20 MG TABLET ORL TAB ABB TAB 0.2397 00002414597 ABBOTT-CITALOPRAM 40 MG TABLET ORL TAB ABB TAB 0.2397 00002412942 ABBOTT-CLOPIDOGREL 75 MG TABLET ORL TAB ABB TAB 0.4735 00002414805 ABBOTT-LEVETIRACETAM 250 MG TABLET ORL TAB ABB TAB 0.8000 00002414791 ABBOTT-LEVETIRACETAM 500 MG TABLET ORL TAB ABB TAB 0.9750 00002414783 ABBOTT-LEVETIRACETAM 750 MG TABLET ORL TAB ABB TAB 1.3500 00002414546 ABBOTT-OLANZAPINE ODT 10 MG TABLET ORL DISNTAB ABB TAB 1.2857 00002414538 ABBOTT-OLANZAPINE ODT 5 MG TABLET ORL DISNTAB ABB TAB 0.6434 00002412969 ABBOTT-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT ABB TAB 0.3628 00002412985 ABBOTT-QUETIAPINE 100 MG TABLET ORL TAB ABB TAB 0.3295 00002412993 ABBOTT-QUETIAPINE 200 MG TABLET ORL TAB ABB TAB 0.6617 00002412977 ABBOTT-QUETIAPINE 25 MG TABLET ORL TAB ABB TAB 0.1235 00002413000 ABBOTT-QUETIAPINE 300 MG TABLET ORL TAB ABB TAB 0.9656 00002422638 ABBOTT-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT ABB TAB 0.1204 00002422646 ABBOTT-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT ABB TAB 0.2408 00002414619 ABBOTT-TOPIRAMATE 100 MG TABLET ORL TAB ABB TAB 0.5928 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 1 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002414627 ABBOTT-TOPIRAMATE 200 MG TABLET ORL TAB ABB TAB 0.8853 00002414600 ABBOTT-TOPIRAMATE 25 MG TABLET ORL TAB ABB TAB 0.3128 00002231590 ABELCET 5MG/ML LIPID COMPLEX INJECTION INJ DEFAUL SGM ML 9.4395 00001919385 ABENOL 120 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.5417 00001919393 ABENOL 325 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.6692 00001919407 ABENOL 650 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.7683 00002281066 ABRAXANE 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 971.0000 00002245677 ABREVA 10% TOPICAL CREAM TOP CRM GKC G 7.2800 00002364174 ABSTRAL 100 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 11.1930 00002364182 ABSTRAL 200 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 12.6710 00002364190 ABSTRAL 300 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 15.1950 00002364204 ABSTRAL 400 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 17.2650 00002364212 ABSTRAL 600 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 23.0300 00002364220 ABSTRAL 800 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 28.7840 00001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.0510 00002401126 ACCEL-ALENDRONATE 10 MG TABLET ORL TAB ACP TAB 0.3989 00002401134 ACCEL-ALENDRONATE 70 MG TABLET ORL TAB ACP TAB 1.9000 00002341107 ACCEL-AMLODIPINE 10 MG TABLET ORL TAB ACP TAB 0.3587 00002341093 ACCEL-AMLODIPINE 5 MG TABLET ORL TAB ACP TAB 0.2417 00002419874 ACCEL-DONEPEZIL 10 MG TABLET ORL TAB ACP TAB 0.8145 00002419866 ACCEL-DONEPEZIL 5 MG TABLET ORL TAB ACP TAB 0.8145 00002400391 ACCEL-FLUOXETINE 10 MG CAPSULE ORL CAP ACP CAP 0.3300 00002400405 ACCEL-FLUOXETINE 20 MG CAPSULE ORL CAP ACP CAP 0.3300 00002400359 ACCEL-QUETIAPINE 100 MG TABLET ORL TAB ACP TAB 0.2100 00002400375 ACCEL-QUETIAPINE 200 MG TABLET ORL TAB ACP TAB 0.4300 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 2 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002400340 ACCEL-QUETIAPINE 25 MG TABLET ORL TAB ACP TAB 0.0800 00002400383 ACCEL-QUETIAPINE 300 MG TABLET ORL TAB ACP TAB 0.6300 00002435349 ACCEL-TOPIRAMATE 100 MG TABLET ORL TAB ACP TAB 0.4400 00002435357 ACCEL-TOPIRAMATE 200 MG TABLET ORL TAB ACP TAB 0.6600 00002435330 ACCEL-TOPIRAMATE 25 MG TABLET ORL TAB ACP TAB 0.2300 00002164396 ACEBUTOLOL-100 100 MG TABLET ORL TAB PDL TAB 0.0787 00002164418 ACEBUTOLOL-200 200 MG TABLET ORL TAB PDL TAB 0.1177 00002164426 ACEBUTOLOL-400 400 MG TABLET ORL TAB PDL TAB 0.2466 00002230435 ACET 160 MG RECTAL SUPPOSITORY RT SUP PPH SUP 0.6242 00001999648 ACET CODEINE 30 TABLET ORL TAB PMS TAB 0.1655 00002154234 ACETAMINOPHEN 300MG/15MG CAFFEINE/8MG COD. CAPLET ORL TAB VTH TAB 0.0348 00001977415 ACETAMINOPHEN 325 MG CAPLET ORL TAB TLI TAB 0.0592 00000789801 ACETAMINOPHEN 325 MG TABLET ORL TAB TLI TAB 0.0592 00001938088 ACETAMINOPHEN 325 MG TABLET ORL TAB JPC TAB 0.0120 00000605751 ACETAMINOPHEN 325 MG TABLET ORL TAB VTH TAB 0.0272 00000374148 ACETAMINOPHEN 325 MG TABLET ORL TAB WAM TAB 0.0184 00000789798 ACETAMINOPHEN 500 MG TABLET ORL TAB TLI TAB 0.0243 00001905864 ACETAMINOPHEN 80 MG/ML ORAL DROPS ORL DPS TLI ML 0.1300 00002272482 ACETAMINOPHEN ARTHRITIS PAIN 650 MG EXT.REL TABLET ORL ERT PRI TAB 0.0755 00000706221 ACETAMINOPHEN CAFFEINE & CODEINE 8 MG TABLET ORL TAB WTR TAB 0.0258 00002028174 ACETAMINOPHEN COMPOUND WITH CODEINE CAPLET ORL TAB PPH TAB 0.0398 00001905856 ACETAMINOPHEN COMPRIME A CROQUER 80 MG ORL TAB TLI TAB 0.1000 00002255251 ACETAMINOPHEN EXT STR EASY TO SWALLOW 500 MG TAB ORL TAB PMT TAB 0.0660 00000605778 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB WTR TAB 0.0306 00002285797 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB VTH TAB 0.0600 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 3 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002252813 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB PMT TAB 0.0621 00001904132 ACETAMINOPHEN EXTRA-STRENGTH 500 MG TABLET ORL TAB TAN TAB 0.0179 00001958836 ACETAMINOPHEN ORAL SOLUTION FOR CHILDREN USP ORL SOL TLI ML 0.0296 00002143933 ACETAMINOPHEN WITH CODEINE CAPLET ORL TAB ROG TAB 0.0460 00002025337 ACETAMINOPHEN WITH CODEINE TABLET ORL TAB PMS TAB 0.0398 00002251914 ACETAMINOPHEN, CAFFEINE & 8 MG CODEINE PHOS. TAB ORL TAB PMT TAB 0.0396 00002017431 ACETAMINOPHENE 160 MGCO.CROQUABLE POUR ENFANT ORL CTB RIV TAB 0.1475 00002022214 ACETAMINOPHENE 325 MG COMPRIME ORL TAB RIV TAB 0.0114 00000382752 ACETAMINOPHENE 325 MG TABLET ORL TAB PDL TAB 0.0114 00002362228 ACETAMINOPHENE 500 MG CAPLET ORL TAB RIV TAB 0.0149 00002022222 ACETAMINOPHENE 500 MG COMPRIME ORL TAB RIV TAB 0.0149 00000386626 ACETAMINOPHENE 500 MG TABLET ORL TAB PDL TAB 0.0149 00002017458 ACETAMINOPHENE 80MGCO.CROQUABLE POUR ENFANT ORL CTB RIV TAB 0.1000 00000834319 ACETAZONE FORTE C-8 TABLET ORL TAB RPH TAB 0.4495 00000834300 ACETAZONE FORTE TABLET ORL TAB RPH TAB 0.3399 00001999656 ACET-CODEINE 60 MG TABLET ORL TAB PMS TAB 0.2640 00002300435 ACETYLCYSTEINE 20% INHALATION SOLUTION INH SOL ALV ML 1.9500 00000718831 ACETYLSALICYLIC ACID 325 MG TABLET ORL TAB PHH TAB 0.0621 00002426757 ACH-CAPECITABINE 150 MG TABLET ORL TAB AHI TAB 1.4640 00002426765 ACH-CAPECITABINE 500 MG TABLET ORL TAB AHI TAB 4.8800 00002247551 ACID REDUCER 75 MG TABLET ORL TAB PMS TAB 0.1067 00080042609 ACIDOPHILUS PROBIOTIC COMPLETE CAPSULE ORL CAP WNP CAP 0.2892 00080011789 ACIDOPHILUS WITH BIFIDUS CAPSULE ORL CAP WNP CAP 0.1082 00002439247 ACT AMPHETAMINE XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.0758 00002439255 ACT AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.3250 This document is for pricing use only and should not be used to determine benefit status information. Pricing is applicable to a Drug Product regardless of the package size for each Drug Product. Pg 4 of 189 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective April 13, 2017 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002439263 ACT AMPHETAMINE XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.5743 00002439271 ACT AMPHETAMINE XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.8235 00002439298 ACT AMPHETAMINE XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 3.0729 00002439239 ACT AMPHETAMINE XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 1.8266 00002394898 ACT ANASTROZOLE 1 MG TABLET ORL TAB APH TAB 2.5459 00002374765 ACT BETAHISTINE 24 MG TABLET ORL TAB APH TAB 0.4983 00002376520 ACT CANDESARTAN 4 MG TABLET ORL TAB APH TAB 0.3400 00002244816 ACT CLOMIPRAMINE 10 MG TABLET ORL TAB APH TAB 0.1290 00002244817 ACT CLOMIPRAMINE 25 MG TABLET ORL TAB APH TAB 0.1758 00002244818 ACT CLOMIPRAMINE 50 MG TABLET ORL TAB APH TAB 0.3237 00002397145 ACT DICLO-MISO 50 MG/200 MCG ENTERIC-COATED TABLET ORL ECT APH TAB 0.4541 00002397153 ACT DICLO-MISO 75 MG/200 MCG ENTERIC-COATED TABLET ORL ECT APH TAB 0.6179 00002397625 ACT DONEPEZIL ODT 10 MG ORALLY DISINT.
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