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Covered Drug List / Request for Exception List of covered drugs as of September 1, 2021* * This list is for all Non-Retired members and all Retired members. o This list is for reference purposes only. To find out if a specific drug is covered under the CPC drug plan, please consult the drug search lookup tool on My Canada Life At Work (www.mycanadalifeatwork.com). If you need assistance with this, please contact Canada Life at 1-866-716-1313. The Employer reserves the right to change the content of the drug plan list without notice. (Note: not all strengths and formulations of the drugs listed below are covered.) Bold and italics = requires Prior Authorization form Acne benazepril (lotensin), bisoprolol (monocor), cosopt, duo trav, iopidine, izba, levobunolol aklief, benzaclin, benzamycin, benzoyl peroxide captopril, carvedilol (coreg), chlorthalidone, Circulatory disease: pentoxifylline (betagan), lumigan RC, lumigan Pain >5%, clindamycin (dalacin t), clindasol, cilazapril (inhibace), cilazapril/hctz (inhibace methazolamide, pilocarpine, probeta, timolol, codeine phosphate/acetaminophen/ caffeine Corticosteroid clindets, clindoxyl, differin, erysol, retin-a, plus), clonidine, coversyl, coversyl plus, cozaar, travatan, trusopt, vyzulta, xalacom, xalatan (tylenol #1,#2,#3,#4), acetaminophen (tylenol), cortef, cortisone, dexamethasone, depo- acetylsalicylic acid stieva, stievamycin, vitamin a acid diovan/diovan hct, doxazosin (cardura), medrol, depo-medrol with lidocaine, fosinopril (monopril), hct/spironolactone Gynecological (80mg/81mg/325mg/650mg), diflunisal, ADHD/Narcolepsy hydrocortisone, medrol, methylprednisolone, disalcid, m-ediat (aldactazide), hct/triamterene, hydralazine, prednisolone (pediapred), prednisone, dalacin vaginal, fibristal, gynazole vaginal, amphetamine (adderall xr), dexedrine, hydrochlorothiazide, metronidazole, nystatin,terconazole modafinil triamcinolone hexacetonide Parasitic treatment methylphenidate (ritalin, concerta), hydrochlorothiazide/amiloride, hyzaar, labetalol, Hepatitis (alertec), sunosi, wakix xyrem chloroquine, daraprim, diodoquin, , lisinopril (prinivil/zestril), lisinopril/hct, mavik, baraclude, epclusa, heptovir, harvoni holkira Dental: triamcinolone paste (oracort) , hydroxychloroquine (plaquenil), mefloquine, methyldopa, methyldopa/ hydrochlorothiazide, maviret Allergy conditions pak, ibavyr, incivek, , pegasys rbv, mepron, primaquine, stromectol metoprolol, micardis/micardis plus, nadolol, pegetron, sebivo, sovaldi, vosevi, zepatier allerject, alomide, avamys, beclomethasone Depression olmetec/olmetec plus, pindolol, prazosin, Parkinson disease nasal spray, budesonide aq nasal spray, amitriptyline, bupropion (wellbutrin), cipralex, HIV epipen/twinject, flonase, flunisolide (rhinalar) propranolol, ramipril (altace), ramipril/hct, rasilez, citalopram (celexa), clomipramine, desipramine, amantadine, benztropine, carbidopa/levodopa rasilez hct, reserpine, sotalol, spironolactone, 3tc, agenerase, atripla, biktarvy, combivir, (sinemet), procyclidine, prolopa, selegiline, spray, hydroxyzine, ipratropium (atrovent) doxepin, fluoxetine (prozac), fluvoxamine, complera, crixivan, delstrigo, descovy, dovato, nasal spray, livostin, nasacort, nasonex, tarka, terazosin (hytrin), teveten/teveten plus, imipramine, maprotiline, mirtazapine (remeron), trihexyphenidylkal edurant, fuzeon, hivid, intelence, juluca, kaletra, omnaris, patanol, pollinex r timolol, trasicor, twynsta, vaseretic, vasotec, moclobemide, nortriptyline, paroxetine (paxil) viskazide, zaroxolyn kivexa, norvir, odefsey, pifeltro, prezcobix , Rare Diseases 10mg/20mg/30mg, sertraline (zoloft), spravato, adcirca, aldurazyme, bosentan, cerdelga, Alzheimer’s disease: aricept, exelon, reminyl prezista, rescriptor, reyataz, saquinavir, sebivo, Blood thinners: arixtra, brilinta, cablivi, trazodone, trimipramine, venlafaxine (effexor) stribild, sustiva, symtuza, telzir, tivicay, trizivir, cerezyme, dojolvi, elelyso, enspryng, esbriet, fabrazyme/replagal, firazyr, firdapse, Angina fragmin, fraxiparine, inclunox, innohep, Diabetes truvada, videx, viracept, viramune, viread, zerit, galafold, givlaari, kalydeco, kanuma, diltiazem (cardizem/tiazac), felodipine lovenox, noromby, plavix, redesca, sintrom, admelog, apidra, basaglar, chlorpropamide, ziagen, zidovudine (azt) kuvan, myozyme, nitisinone, ocaliva, ofev, (plendil/renedil), isosorbide, nifedipine (adalat) warfarin (coumadin) entuzity, fiasp, glucagen, glucagon, glucobay, pa/xl, nitroglycerin patches(nitrodur), Hormonotherapy opsumit, orfadin, orkambi, prolastin, glyburide, humalog, humulin, hypurin, lantus, increlex nutropin, somatropin (humatrope, nitroglycerin spray, nitroglycerin tablets, nitrol Bone metabolism , pulmozyme, radicava, revatio, ruzurgi, levemir, metformin, novolin ge, novomix, norditropin nordiflex, omnitrope, protropin, ointment, norvasc, verapamil aclasta, actonel/actonel plus calcium, soliris, spinraza, strensiq, symdeko, tegsedi, alendronate (fosamax), aredia, bonefos, novorapid, tolbutamide, tresiba saizen, serostim) trikafta, vimizim, vpriv, zavesca calcitonin, calcium/calcium with vitamin d, Anti Inflammatory/Analgesics Disease prevention vaccines forteo, osnuvo Hunter Syndrome: elaprase arthrotec, diclofenac, diclofenac sr, clasteon, fosavance, , ostac, act hib, adacel, avaxim, bcg, boostrix, dt ipv – Rheumatoid Arthritis xospata floctafenine, flurbiprofen, ibuprofen polio absorbed, dukoral oral, engerix b ped, Immunosuppressive actemra, adalimumab, amgevita, avsola, (advil/motrin), indomethacin, ketoprofen, brenzys, cimzia, enbrel, erelzi, gold sodium Botulinum Toxin Type A engerix- b, gardasil, havrix-a,imovax polio, imovax azathioprine (imuran), cellcept, cyclosporine ketorolac (toradol), naproxen thiomalate (myochrysine), hadlima, hulio, botox, dysport, xeomin rabies, influenza, ixiaro, menactra, mencevax ac, (neoral), myfortic, penicillamine, prograf (naprosyn)/naproxen sodium (anaprox), meningitec, menjugate, menomune, m-m-r ii, humira, hyrimoz, idacio, inflectra, kevzara, piroxicam, sulindac, tiaprofenic acid, tolmetin Botulinum Toxin Type B: myobloc moru-viraten berna, mutacol berna, neisvac-c, Insomnia kineret, olumiant, omvyence, orencia, pedvaxhib, pentacel, pneumococcal 23-valent, phenobarbital, temazepam (restoril), triazolam remicade, remsima sc, renflexis, rinvoq, Antibiotics/Anti-infectives Bursitis: celestone soluspan prevnar, priorix, quadracel, rabavert, recombivax, simponi, xeljanz acyclovir (zovirax), amikacin, amoxicillin, Kidney and Bladder disorders rotateq, td polio adsorbed adult, tet and diph amoxicillin/potassium clavulanate (clavulin), Cancer allopurinol, benuryl, bethanechol (duvoid), Sexual Dysfunction: viagra ampicillin, azithromycin (zithromax), cefaclor abraxane, adcetris, afinitor, alecensaro, toxoid adult, tetanus toxoid adsorbed, tripacel, carbachol, colchicine, envarsus pa, exjade, (ceclor), cefadroxil (duricef), cefazolin, cefzil, alkeran, alunbrig, androcur-depot, arimidex, twinrix, typherix, typhim vi, vaqta, varilrix, varivax ferriprox, flavoxate, jadenu, jinarc, Skin disorders cephalexin (keflex), ciprofloxacin (cipro), avastin, balversa, bavencio, besponsa, iii, vivaxim, vivotif berna, yellow fever, oxybutynin, phenazo, procysbi, sensipar, actikerall, amcinonide (cyclocort), azelaic acid clarithromycin (biaxin), clindamycin (dalacin c), bleomycin, bosulif, braftovi, brukinsa, zostavax/zostavax II sulfinpyrazone, tamsulosin, trimethoprim, (finacia), betamethasone (betnovate), clobetasol cabometyx, calquence, camptosar, (dermovate), cosentyx, cutivate, dermatop, cloxacillin, doxycycline (vibramycin), casodex, Electrolyte replacement neosporin bladder, urocit-K cotellic, desonide, desoximetasone (topicort), diprosalic, erythromycin (erybid/eryc), etibi, famciclovir ceenu, cyclophosphamide, cyproterone, apo-k, k-dur, k-lyte/k-lyte cl, k-med, micro-k, darzalex, daurismo Menopause dupixent, ecostatin, fluocinolone (synalar), (famvir), fucidin, isoniazid, metronidazole cytarabine, , efudex, eligard, samsca, slow-k (flagyl), nitrofurantoin (macrobid), pediazole, eloxatin, erbitux, erleada, etoposide, femara, angeliq, clonidine (dixarit), estrace, estradiol fluocinonide, fucidin/ fucidin h, halog, penicillin g, penicillin v, pondocillin, prevymis, firmagon, fludara, fluorouracil, flutamide, gavreto, Epilepsy valerate, estrogens-conjugated, fem hrt, hydrocortisone (cortate), ilumya, ketoconazole pyrazinamide, relenza, rifampin, rifater, giotrif, gleevec, halaven, herceptin, carbamazepine (tegretol), celontin, medroxyprogesterone (provera), neo-estrone, (nizoral), lamisil cream/-spray, loprox, sulfamethoxazole, sulfamethoxazole/ hydroxyurea, ibrance, iclusig, idhifa, imbruvica, clonazepam (rivotril), dilantin, divalproex ogen, premplus, prometrium, vagifem, visanne methoxsalen (oxsoralen), metronidazole, trimethoprim (septra), sulfasalazine imfinzi, intron a, inqovi, inrebic, iressa, (epival), gabapentin (neurontin), lamotrigine mometasone (elocom), mupirocin (bactroban), Mental disorders irinotecan, jakavi jevtana, keytruda, neomycin/ gramicidin/ nystatin/ triamcinolone (salazopyrin), tamiflu, tetracycline, tobi, , kidrolase, (lamictal), levetiracetam (keppra), primidone, abilify, chlorpromazine, fluanxol, fluphenazine, kisqali, kyprolis, lartruvo (viaderm kc), nerisone, otezla, propaderm, siliq, tobramycin, valtrex lanvis, , lederle sabril, topiramate (topamax), valproic acid haloperidol (haldol), invega, lithium lonsurf lorbrena silver sulfadiazine (flamazine), skyrizi, stelara, leucovorin, leukeran, leustatin, , , (depakene), zarontin (carbolith/lithane), loxapine,
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