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, 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), , 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, delstrigo tarka, terazosin (hytrin), teveten/teveten plus, complera, crixivan, , descovy, dovato, trihexyphenidylkal nasal spray, livostin, nasacort, nasonex, imipramine, maprotiline, mirtazapine (remeron), 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/ Disease prevention vaccines forteo, osnuvo Hunter Syndrome: elaprase arthrotec, , diclofenac sr, clasteon, fosavance, , ostac, act hib, adacel, avaxim, bcg, boostrix, dt ipv – Rheumatoid Arthritis xospata floctafenine, , polio absorbed, dukoral oral, engerix b ped, Immunosuppressive actemra, adalimumab, amgevita, avsola, (advil/motrin), indomethacin, , brenzys, cimzia, enbrel, erelzi, gold sodium Botulinum Toxin Type A engerix- b, gardasil, havrix-a,imovax polio, imovax azathioprine (imuran), cellcept, cyclosporine (toradol), 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, , , , 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 , 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, , 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, majeptil, Antifungals: ketoconazole, nystatin, lynparza, mabcampath, tactuo, taltz, tremfya, triamcinolone, zovirax lupron depot, lysodren, methotrimeprazine, olanzapine (zyprexa), sporanox, terbinafine (Lamisil) matulane, megestrol, mekinist, mektovi, mesna, Eye-ear-nose medications pericyazine (neuleptil), perphenazine, pimozide, Smoking cessation: champix nerlynx, ninlaro, beovu, dexamethasone eye/ear,atropine Asthma methotrexate, myleran, piportil l4, revia, risperidone (risperdal), seroquel, nubeqa onureg opdivo, perjeta piqray eye,chloramphenicol, ciprodex otic, cortimyxin, atectura breezhaler, advair, aermony respiclick, , , , , thiothixene, trifluoperazine Stress/Sedation pomalyst qinlock retevmo cortisporin, cyclopentolate, cystadrops, alvesco, aminophylline, arbesda, arnuity ellipta, , purinethol, , , alprazolam (xanax), bromazepam, buspirone revlimid, riabni rituxan, riximyo, rozlytrek diophenyl-t, dipivefrin, epifrin, erythromycin, asmanex, atrovent, baca respiclick, berotec, , , Migraines (buspar), chlordiazepoxide, clobazam, ruxience rydapt, sarclisa , eylea, fluorometholone, homatropine, iluvien, aimovig ajovy emgality breo ellipta, bricanyl, cinqair, combivent, , , sprycel stivarga, , , dihydroergotamine, , diazepam (valium), lorazepam (ativan), , tafinlar, tagrisso, jetrea, ketorolac, locacorten vioform, lucentis, vyepti duovent, enerzair breezhaler, fasenra, flovent, suprefact, sutent tamoxifen, sandomigran, nitrazepam (mogadon), oxazepam (serax) tarceva, , taxotere, tecentriq, tepmetko macugen, maxitrol, ocufen, opticort, otixal, foradil, incruse ellipta, nucala, orciprenaline, tasigna , treanda, tukysa oxervate, phenylephrine, prednisolone, sofracort, Multiple sclerosis oxeze, oxtriphylline, pulmicort, qvar, tomudex, trelstar, , vectibix, Systemic Juvenile Idiopathic Arthritis: velcade, venclexta, verzenio, vitrakvi, sulfacetamide, sulfacetamide/ prednisolone, aubagio, avonex, betaseron, copaxone, extavia, salbutamol (ventolin), serevent, symbicort, vizimpro, Ilaris yervoy, zejula, zelboraf tobramycin, tobramycin/dexamethasone, gilenya, glatect, kesimpta, mavenclad, theophylline, trelegy ellipta, xolair, zenhale xeloda, , zeulide depot, zirabev, zoladex depot, zydelig, zykadia, tropicamide, viroptic , voltaren ophtha, vosol-hc mayzent, ocrevus, plegridy, lemtrada, Thyroid and Glandular otic ponvory sativex, tysabri Birth control , rebif, tecfidera, andriol, androgel, bromocriptine, ddavp melt, alesse, brevicon 0.5/35, brevicon 1/35, cyclen, Cardiac disease depo-testosterone, desmopressin, egrifta, Fertility disorders Muscle relaxants amiodarone (cordarone), burinex, digoxin florinef, levothyroxine (synthroid/eltroxin), demulen 30, depo-provera, jaydess, kyleena, clomid,menopur,ovidrel,repronex, serophene baclofen (lioresal), cyclobenzaprine (lanoxin), edecrin, furosemide (lasix), liothyronine (cytomel), norprolac, linessa, loestrin 1.5/30, loette, marvelon, Plus for CUPW & RSMC only: , procainamide, propafenone, bravelle, micronor, minestrin 1/20, min-ovral, Myasthenia gravis: mestinon, prostigmin propylthiouracil, tapazole, testim quinidine, rythmodan, vyndaqel, vyndamax cetrotide, chorionic gonadtropin, crinone, nexplanon, norlevo, ortho 0.5/35, ortho 1/35, decapeptyl, endometrin, gonal-f, inprosub, Narcotic analgesics Ulcers ortho 7/7/7, ortho-cept, ovral, plan b, select Cholesterol disorders lutrepulse, luveris, orgalutran, pergoveris, codeine contin, codeine phosphate, codeine cimetidine (tagamet), famotidine (pepcid), 1/35, synphasic, tri-cyclen/tri-cyclen lo, advicor, bezafibrate (bezalip), cholestyramine pregnyl, puregon, rekovelle, utrogestan phosphate/acetaminphen/ caffeine (tylenol (cytotec), nizatidine (axid), pariet, triquilar, yasmin, yaz, mirena 52mg (questran), colestid, crestor, fenofibrate (lipidil), #1,#2,#3,#4), codeine phosphate/asa/caffeine, ranitidine (zantac), sucralfate (sulcrate), tecta gemfibrozil, juxtapid, leqvio, lescol, lipitor, Gastrointestinal Blood formation: dexiron, folic acid, infufer, dilaudid, demerol, mersyndol, , lorelco, lovastatin (mevacor), praluent, 5-asa (asacol), bentylol, betnesol retention Vertigo: betahistine (serc) lapelga, monoferric, neulasta, nivestym, carbaglu, , /acetaminophen pravastatin (pravachol), repatha,simvastatin enema, colestid, cortifoam, reblozyl, revolade, tavalisse, venofer, vitamin Vitamins and Minerals (zocor) dicetel,dicyclomine, dipentum, domperidone, b12 injection entocort, entyvio, hydrocortisone enema, Nausea: diclectin, prochlorperazine, zofran, ergocalciferol (d forte), neo-bex, one-alpha, caduet metoclopramide, mezera suppository, mezavant, ndissolve ODF pregvit & pregvit folic 5, pyridoxine injection, Blood pressure Cholesterol/Cardiac: pheburane ravicti, revestive, thiamine injection, vitamin a accupril, accuretic, acebutolol, altace hct, altace modulon, olestyr, , Chronic Obstructive Pulmonary Disease: xermelo Neuropathic Pain: lyrica plus felodipine, amiloride (midamor), ursodiol, combivent, duaklir genuair, inspiolto respimat, Weight control: contrave, saxenda, xenical atacand/atacand plus, atenolol (tenormin), seebri, spiriva, tudorza Glaucoma Osteoarthritis: synovial fluid supplements atenolol/chlorthalidone, avalide, avapro, acetazolamide, azarga, betaxolol, carbachol, (e.g. synvisc/neovisc/suplasyn/monovisc)

1

Request for Drug Exception Form (For list of drugs covered – Refer to page 1) In order for your exception to be considered you must have previously tried a covered drug for your medical condition and either the drug was not effective, or you have a contraindication to the drug.

Use this form to request coverage of a drug that is not automatically covered under your drug plan. Provide the requested information to ensure timely assessment of your claim. Do not use this form for drugs that require PRIOR AUTHORIZATION. Please refer to page one (1) for the list of Prior Authorization drugs which are indicated in bold italics. The Prior Authorization forms can be found at canadalife.com or call Canada Life at 1-866-716-1313.

PLAN MEMBER INFORMATION

Please select your plan number: Employee/Retiree ID #: □ 51391 or □ 162954 (MGT/XMT who retired on or after January 2, 2011)

Name: Address:

PATIENT INFORMATION

Name: Relationship: Date of Birth:

Drug Name:

Would you like Canada Life to contact you by telephone upon completion of the exception review? Yes □ No □

If yes, please indicate the phone number where they can reach you and leave a message should you be unable to answer: (____)______

At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect is used for the purpose of assessing eligibility for this drug and for administering the group benefits plan. I authorize Canada Life, my physician or healthcare provider, and TELUS Health Solutions to exchange information when necessary for these purposes.

Patient/Guardian’s signature: ______Date: ______

TO BE COMPLETED BY ATTENDING PHYSICIAN

Attending Physician Name: Registration Number:

Address:

Telephone Number: Fax Number:

Required Information

To obtain coverage for the drug, one other covered pharmacotherapy must have been tried in the past, unless contraindication exists.

What is the health condition being treated with this drug?

Is the drug prescribed to treat a health condition for which the specific drug use is approved by Health Canada? Yes □ No □

Did the patient previously try a medication (pharmacotherapy) to treat this health condition? Yes □ No □

If yes, list the specific names of other medications (pharmacotherapies) used to treat the health condition?

If no other medication (pharmacotherapy) was tried, please explain why this drug must be prescribed (for example a contraindication resulting from an allergy reaction):

Information on requested drug

Drug Name: Dose Prescribed:

Physician’s signature: ______Date: ______

Once completed, the Request for Drug Exception Form can be returned to Canada Life by mail, fax or email as noted below. Note: As email is not a secure medium, any person with concerns about their form/medical information being intercepted by an unauthorized party is encouraged to submit their form by other means. Mail to: The Canada Life Assurance Company Fax to: The Canada Life Assurance Company Email: [email protected] Drug Services P.O. Box 6000 Fax 1 866 239 7140 Attention: Drug Claims Management Winnipeg MB R3C 0E6 Attention: Drug Claims Management 2