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Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002192691 3TC 10 MG/ML ORAL LIQUID ORL LIQ GSK ML 0.3183 00002192683 3TC 150 MG TABLET ORL TAB GSK TAB 4.9035 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 00080013172 5-HTP 100 MG CAPSULE ORL CAP VTH CAP 0.2000 00002412942 ABBOTT-CLOPIDOGREL 75 MG TABLET ORL TAB ABB TAB 0.4735 00002414619 ABBOTT-TOPIRAMATE 100 MG TABLET ORL TAB ABB TAB 0.5928 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 8.6795 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 7.0000 00002364174 ABSTRAL 100 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 10.8970 00002364182 ABSTRAL 200 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 12.3360 00002364190 ABSTRAL 300 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 14.7930 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 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002364204 ABSTRAL 400 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 16.8080 00002364212 ABSTRAL 600 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 22.4210 00002364220 ABSTRAL 800 MCG SUBLINGUAL TABLET SLG SLT PAL TAB 28.0230 00001922246 AC & C 8 MG TABLET ORL TAB PPH TAB 0.0510 00000095494 AC WITH CODEINE 8 MG TABLET ORL TAB DTC TAB 0.0592 00002401126 ACCEL-ALENDRONATE 10 MG TABLET ORL TAB ACP TAB 0.3989 00002401134 ACCEL-ALENDRONATE 70 MG TABLET ORL TAB ACP TAB 2.0125 00002341107 ACCEL-AMLODIPINE 10 MG TABLET ORL TAB ACP TAB 0.3587 00002341093 ACCEL-AMLODIPINE 5 MG TABLET ORL TAB ACP TAB 0.2417 00002435632 ACCEL-CELECOXIB 100 MG CAPSULE ORL CAP ACP CAP 0.1407 00002435640 ACCEL-CELECOXIB 200 MG CAPSULE ORL CAP ACP CAP 0.2814 00002419874 ACCEL-DONEPEZIL 10 MG TABLET ORL TAB ACP TAB 0.9637 00002419866 ACCEL-DONEPEZIL 5 MG TABLET ORL TAB ACP TAB 0.9637 00002400391 ACCEL-FLUOXETINE 10 MG CAPSULE ORL CAP ACP CAP 0.3676 00002400405 ACCEL-FLUOXETINE 20 MG CAPSULE ORL CAP ACP CAP 0.3679 00002400359 ACCEL-QUETIAPINE 100 MG TABLET ORL TAB ACP TAB 0.2636 00002400375 ACCEL-QUETIAPINE 200 MG TABLET ORL TAB ACP TAB 0.5294 00002400340 ACCEL-QUETIAPINE 25 MG TABLET ORL TAB ACP TAB 0.0988 00002400383 ACCEL-QUETIAPINE 300 MG TABLET ORL TAB ACP TAB 0.7725 00002435349 ACCEL-TOPIRAMATE 100 MG TABLET ORL TAB ACP TAB 0.4743 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 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002435357 ACCEL-TOPIRAMATE 200 MG TABLET ORL TAB ACP TAB 0.7083 00002435330 ACCEL-TOPIRAMATE 25 MG TABLET ORL TAB ACP TAB 0.2502 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 0.6217 00001999648 ACET CODEINE 30 TABLET ORL TAB PMS TAB 0.1320 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 00000374148 ACETAMINOPHEN 325 MG TABLET ORL TAB WAM TAB 0.0184 00000789801 ACETAMINOPHEN 325 MG TABLET ORL TAB TLI TAB 0.0592 00000605751 ACETAMINOPHEN 325 MG TABLET ORL TAB VTH TAB 0.0272 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 00002252813 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB PMT TAB 0.0621 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 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002285797 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB VTH TAB 0.0600 00000605778 ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ORL TAB WTR TAB 0.0306 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 00002362228 ACETAMINOPHENE 500 MG CAPLET ORL TAB RIV 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 0.1405 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 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 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002439255 ACT AMPHETAMINE XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC APH CAP 2.3250 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 2.5460 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 00002397625 ACT DONEPEZIL ODT 10 MG ORALLY DISINT. TABLET ORL DISNTAB APH TAB 3.6176 00002397617 ACT DONEPEZIL ODT 5 MG ORALLY DISINT. TABLET ORL DISNTAB APH TAB 3.6176 00002423855 ACT ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT APH TAB 1.8690 00002423863 ACT ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT APH TAB 1.8690 00002305682 ACT FAMCICLOVIR 125 MG TABLET ORL TAB APH TAB 2.0240 00002305690 ACT FAMCICLOVIR 250 MG TABLET ORL TAB APH TAB 2.7200 00002305704 ACT FAMCICLOVIR 500 MG TABLET ORL TAB APH TAB 4.2281 00002397285 ACT IMATINIB 100 MG TABLET ORL TAB COB TAB 20.4557 00002397293 ACT IMATINIB 400 MG TABLET ORL TAB COB TAB 81.8228 00002250020 ACT MELOXICAM 15 MG TABLET ORL TAB APH TAB 0.5670 00002250012 ACT MELOXICAM 7.5 MG TABLET ORL TAB APH TAB 0.4914 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 5 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002404656 ACT MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL ACV ML 3.9767 00002325713 ACT OLANZAPINE 20 MG TABLET ORL TAB APH TAB 10.3093 00002327589 ACT OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB APH TAB 5.3553 00002327597 ACT OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB APH TAB 7.5977 00002404095 ACT OLAPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL APH ML 10.4520 00002403986 ACT OLOPATADINE 0.1% OPH SOLUTION OPH SOL APH ML 5.2260 00002394189 ACT OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.4390 00002394197 ACT OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.6585 00002394200 ACT OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 1.1413 00002394170 ACT OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 0.3150 00002394219 ACT OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT APH TAB 2.1080 00002262746 ACT PAROXETINE 10 MG TABLET ORL TAB APH TAB 1.0430 00002297310 ACT PRAMIPEXOLE 0.5 MG TABLET ORL TAB APH TAB 1.3860 00002402955 ACT PREGABALIN 150 MG CAPSULE ORL CAP APH CAP 1.7270 00002402971 ACT PREGABALIN 225 MG CAPSULE ORL CAP APH CAP 1.7270 00002402912 ACT PREGABALIN 25 MG CAPSULE ORL CAP APH CAP 0.6173 00002402998 ACT PREGABALIN 300 MG CAPSULE ORL CAP APH CAP 1.7270 00002402920 ACT PREGABALIN 50 MG CAPSULE ORL CAP APH CAP 0.9683 00002402939 ACT PREGABALIN 75 MG CAPSULE ORL CAP APH CAP 1.2528 00002372088 ACT SILDENAFIL 100 MG TABLET ORL TAB APH TAB 9.2000 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 6 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002372053 ACT SILDENAFIL 25 MG TABLET ORL TAB APH TAB 8.2900 00002372061 ACT SILDENAFIL 50 MG TABLET ORL TAB APH TAB 8.8475 00002257882 ACT SUMATRIPTAN 25 MG TABLET ORL TAB APH TAB 8.9900 00002395282 ACT TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APH CAP 113.5966 00002395290 ACT TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APH CAP 159.0360 00002395274 ACT TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APH CAP 22.7200 00002395312 ACT TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APH CAP 283.9840 00002441160 ACT TEMOZOLOMIDE 5 MG CAPSULE ORL CAP APH CAP 6.6300 00002337487 ACT VALSARTAN 40 MG TABLET ORL TAB APH TAB 0.5823 00002424770 ACTEMRA 162 MG /0.9 ML INJECTION SYRINGE INJ DEFAUL HLR SYR 355.0000 00002238302 ACTIFED 60 MG/2.5 MG TABLET ORL TAB MCL TAB 0.3246 00002249405 ACTIVELLE 1 MG/0.5 MG TABLET ORL TAB NNA TAB 2.1921 00002309009 ACTIVELLE LD 0.5 MG/0.1 MG TABLET ORL TAB NNA TAB 2.1921 00002316838 ACTONEL 150 MG TABLET ORL TAB ASC TAB 55.8000 00002370417 ACTONEL DR 35 MG DELAYED-RELEASE TABLET ORL DRT ASC TAB 13.1875 00002248722 ACULAR LS 0.4% OPH SOLUTION OPH SOL ALL ML 3.2960 00002286556 ACYCLOVIR 200 MG TABLET ORL TAB SNS TAB 0.6397 00002286572 ACYCLOVIR 800 MG TABLET ORL TAB SNS TAB 1.2673 00002236916 ACYCLOVIR SODIUM 25 MG/ML INJECTION INJ DEFAUL HSP ML 4.8620 00002236926 ACYCLOVIR SODIUM 50 MG/ML INJECTION INJ DEFAUL PPC ML 12.5840 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 7 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002281074 ACZONE 5% TOPICAL GEL TOP GEL VCL G 1.0445 00002240255 ADACEL INJECTION INJ DEFAUL SFP ML 56.7600 00002352044 ADACEL-POLIO INJECTION INJ DEFAUL SFP ML 38.4040 00002313766 ADALAT XL PLUS 20 MG/81 MG TABLET ORL ERT BAI TAB 0.6555 00002313774 ADALAT XL PLUS 30 MG/81 MG TABLET ORL ERT BAI TAB 0.6170 00002313782 ADALAT XL PLUS 60 MG/81 MG TABLET ORL ERT BAI TAB 0.9373 00000266507 ADASEPT 0.5% TOPICAL LIQUID TOP LIQ ODN ML 0.0284 00002290081 ADASEPT BP5 ACNE GEL 5% TOPICAL GEL TOP GEL ODN ML 0.1650 00002401347 ADCETRIS 50MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL STG VIAL 4840.0000 00002338327 ADCIRCA 20 MG TABLET ORL TAB LIL TAB 13.4970 00002248809 ADDERALL XR 10 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.4421 00002248810 ADDERALL XR 15 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.7353 00002248811 ADDERALL XR 20 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.0286 00002248812 ADDERALL XR 25 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.3218 00002248813 ADDERALL XR 30 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 3.6152 00002248808 ADDERALL XR 5 MG EXTENDED-RELEASE CAPSULE ORL ERC SHB CAP 2.1489 00002412764 ADEMPAS 0.5 MG TABLET ORL TAB BAI TAB 42.7500 00002412772 ADEMPAS 1 MG TABLET ORL TAB BAI TAB 42.7500 00002412799 ADEMPAS 1.5 MG TABLET ORL TAB BAI TAB 42.7500 00002412802 ADEMPAS 2 MG TABLET ORL TAB BAI TAB 42.7500 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 8 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002412810 ADEMPAS 2.5 MG TABLET ORL TAB BAI TAB 42.7500 00002071002 ADRIAMYCIN PFS 2 MG/ML INJECTION INJ DEFAUL PFI ML 11.2080 00002296462 ADVAGRAF 0.5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 1.9700 00002296470 ADVAGRAF 1 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 2.5200 00002331667 ADVAGRAF 3 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 7.5600 00002296489 ADVAGRAF 5 MG EXTENDED-RELEASE CAPSULE ORL ERC ASP CAP 12.6200 00080025646 ADVANCED B COMPLEX ORL CAP AOR CAP 0.2941 00002270447 ADVICOR 1000 MG/20 MG TABLET ORL TAB SUN TAB 1.3900 00002270439 ADVICOR 500 MG/20 MG TABLET ORL TAB SUN TAB 1.2400 00001933558 ADVIL 200 MG TABLET ORL TAB PDH TAB 0.1870 00002036312 ADVIL COLD AND SINUS CAPLET ORL TAB PDH TAB 0.3750 00002248645 ADVIL COLD AND SINUS PLUS CAPLET ORL TAB PDH TAB 0.4120 00002244577 ADVIL EXTRA STRENGTH 400 MG CAPLET ORL TAB PDH TAB 0.2706 00002248231 ADVIL EXTRA STRENGTH LIQUI-GEL 400 MG CAPSULE ORL CAP PDH CAP 0.3608 00001933531 ADVIL IBUPROFEN 200 MG CAPLET ORL TAB PDH TAB 0.1433 00002246403 ADVIL JUNIOR STRENGTH CHEWABLE TABLET ORL CTB PDH TAB 0.3070 00002241769 ADVIL LIQUI-GELS 200 MG CAPSULE ORL CAP PDH CAP 0.2469 00002242522 ADVIL PEDIATRIC 40 MG/ML SUSPENSION DROPS ORL DPS PDH ML 0.3160 00002243919 AERIUS 5 MG TABLET ORL TAB SCH TAB 0.9560 00002339528 AFINITOR 10 MG TABLET ORL TAB NOV TAB 188.7900 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 9 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002369257 AFINITOR 2.5 MG TABLET ORL TAB NOV TAB 188.7900 00002339501 AFINITOR 5 MG TABLET ORL TAB NOV TAB 188.7900 00002425645 AFINITOR DISPERZ 2 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 186.0000 00002425653 AFINITOR DISPERZ 3 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 186.0000 00002425661 AFINITOR DISPERZ 5 MG TABLET FOR SUSPENSION ORL DTS NOV TAB 186.0000 00002432692 AG-DONEPEZIL 10 MG TABLET ORL TAB AGP TAB 0.8752 00002432684 AG-DONEPEZIL 5 MG TABLET ORL TAB AGP TAB 0.8752 00002243542 AGENERASE 150 MG CAPSULE ORL CAP GSK CAP 1.9200 00002346850 AGRIFLU INJECTION SYRINGE INJ DEFAUL NVD SYR 9.3000 00002428881 AGRIFLU MULTI-DOSE VIAL INJECTION INJ DEFAUL NOV ML 17.7000 00002236859 AGRYLIN 0.5 MG CAPSULE ORL CAP SHB CAP 5.8576 00002410265 AHI-MONTELUKAST 4 MG CHEWABLE TABLET ORL CTB AHI TAB 0.3646 00002410273 AHI-MONTELUKAST 5 MG CHEWABLE TABLET ORL CTB AHI TAB 0.5565 00000888230 A-HYDROCORT 100 MG/VIAL INJECTION INJ DEFAUL HSP VIAL 3.4500 00002408848 AJ-CISATRACURIUM 2MG/ML WITH PRESERVATIVE INJ INJ DEFAUL AJP ML 2.1652 00000001147 ALBALON 0.1% OPH SOLUTION OPH SOL ALL ML 0.5933 00000433519 ALBALON-A OPH SOLUTION OPH SOL ALL ML 0.5760 00002254506 ALDURAZYME 0.58 MG/ML INJECTION INJ DEFAUL GZM ML 209.0000 00002381478 ALENDRONATE SODIUM 5 MG TABLET ORL TAB AHI TAB 1.0371 00002301733 ALEVE 220 MG TABLET ORL TAB BAI TAB 0.2240 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 10 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002414759 ALFUZOSIN 10 MG PROLONGED-RELEASE TABLET ORL SRT PDL TAB 0.4966 00080014418 ALIGN PROBIOTIC CAPSULE ORL CAP PGI CAP 0.9007 00002253437 ALIMTA 500 MG/VIAL INJECTION INJ DEFAUL LIL VIAL 2750.0000 00000004715 ALKERAN 2 MG TABLET ORL TAB ASN TAB 1.6846 00002231462 ALLEGRA 12 HOUR 60 MG TABLET ORL TAB SAV TAB 0.3792 00002242819 ALLEGRA 24 HOUR 120 MG TABLET ORL TAB SAV TAB 0.7417 00002239853 ALLEGRA-D SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.5080 00002146142 ALLER-AIDE 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.0342 00002176483 ALLER-AIDE 25 MG CAPLET ORL TAB ROG TAB 0.2198 00000271411 ALLERDRYL 50 MG CAPSULE ORL CAP VCL CAP 0.1303 00001949454 ALLERGY 25 MG TABLET ORL TAB TAN TAB 0.0938 00000764647 ALLERGY DROPS 0.012% OPH SOLUTION OPH SOL BSH ML 0.1773 00000833266 ALLERGY ELIXIR 2.5 MG/ML ORAL ELIXIR ORL ELX TAN ML 0.0180 00002141728 ALLERGY FORMULA 25 MG CAPLET ORL TAB PRI TAB 0.1200 00002240266 ALLERGY RELIEF 10 MG TABLET ORL TAB APX TAB 0.4083 00002230398 ALLERGY TABLETS EXTRA STRENGTH 50 MG TABLET ORL TAB TAN TAB 0.1625 00000804193 ALLERNIX 2.5 MG/ML ORAL ELIXIR ORL ELX ROG ML 0.0425 00002097583 ALLERNIX 25 MG CAPLET ORL TAB ROG TAB 0.2200 00002097575 ALLERNIX EXTRA STRENGTH 50 MG CAPLET ORL TAB ROG TAB 0.4400 00002369656 ALLERNIX MULTI SYMPTOM 5 MG TABLET ORL TAB ROG TAB 0.5120 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 11 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002364689 ALLER-RELIEF 10 MG TABLET ORL TAB PMS TAB 0.4080 00002240265 ALLER-RELIEF 10 MG TABLET ORL TAB APX TAB 0.4083 00000555681 ALLOPURINOL 100 MG TABLET ORL TAB PDL TAB 0.0780 00002130157 ALLOPURINOL 200 MG TABLET ORL TAB PDL TAB 0.1300 00000555703 ALLOPURINOL 300 MG TABLET ORL TAB PDL TAB 0.2125 00000569801 ALMAGEL 200 ORAL LIQUID ORL LIQ ATL ML 0.0179 00002424029 ALMOTRIPTAN 12.5 MG TABLET ORL TAB PDL TAB 7.0433 00002241407 ALOCRIL 2% OPH SOLUTION OPH SOL ALL ML 6.3000 00000893560 ALOMIDE 0.1% (BASE) OPH SOLUTION OPH SOL ALC ML 1.1620 00002381710 ALOXI 0.05 MG/ML INJECTION INJ DEFAUL EIS ML 18.0000 00002381729 ALOXI 0.5 MG CAPSULE ORL CAP EIS CAP 66.0000 00080005881 ALPHA LIPOIC ACID 100MG CAPSULE ORL CAP WNP CAP 0.1055 00002248151 ALPHAGAN P 0.15% OPHTHALMIC SOLUTION OPH SOL ALL ML 3.4640 00001908189 ALPRAZOLAM-0.25 MG TABLET ORL TAB PDL TAB 0.0609 00001908170 ALPRAZOLAM-0.5 MG TABLET ORL TAB PDL TAB 0.0728 00002248706 ALPRAZOLAM-1 1 MG TABLET ORL TAB PDL TAB 0.2092 00002241680 ALPROSTADIL 0.5 MG/ML INJECTION INJ DEFAUL TEV ML 185.0000 00002320924 ALREX 0.2% OPHTHALMIC SUSPENSION OPH SUS BSH ML 5.5620 00002281112 ALTACE 15 MG CAPSULE ORL CAP/TAB VCL CAP 1.1710 00002245272 AMARYL 1 MG TABLET ORL TAB SAV TAB 0.9217 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 12 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002245273 AMARYL 2 MG TABLET ORL TAB SAV TAB 1.0030 00002245274 AMARYL 4 MG TABLET ORL TAB SAV TAB 1.0737 00002241630 AMBISOME 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 121.0000 00002230575 AMETOP 4% TOPICAL GEL TOP GEL SNE G 2.6511 00000870943 AMI-HYDRO TABLET ORL TAB PDL TAB 0.0838 00002242971 AMIKACIN SULFATE 250 MG/ML INJECTION INJ DEFAUL SDZ ML 29.1800 00002374684 AMIODARONE SYRINGE 50 MG/ML INJECTION INJ NDL SDZ SYR 66.4500 00000370991 AMITRIPTYLINE 10 MG TABLET ORL TAB PDL TAB 0.0435 00000371009 AMITRIPTYLINE 25 MG TABLET ORL TAB PDL TAB 0.0829 00000456349 AMITRIPTYLINE 50 MG TABLET ORL TAB PDL TAB 0.1540 00002326795 AMLODIPINE 2.5 MG TABLET ORL TAB PDL TAB 0.1380 00002378779 AMLODIPINE-ODAN 10 MG TABLET ORL TAB ODN TAB 0.3587 00002378760 AMLODIPINE-ODAN 5 MG TABLET ORL TAB ODN TAB 0.2417 00000638064 AMOSAN 68.6% MOUTHWASH ORL MWH OLB ML 0.3340 00002401576 AMOXICILLIN SUGAR-REDUCED 50 MG/ML ORAL SUSPENSION ORL SUS SIV ML 0.0540 00002326515 AMOXI-CLAV 500 MG/125 MG TABLET ORL TAB PDL TAB 0.6673 00002326523 AMOXI-CLAV 875 MG/125 MG TABLET ORL TAB PDL TAB 1.0008 00002125862 AMPHOJEL 320 MG/5ML ORAL LIQUID ORL LIQ AXC ML 0.0179 00002124971 AMPHOJEL 600 MG TABLET ORL TAB AUP TAB 0.1250 00080006771 A-MULSION ORAL LIQUID ORL LIQ SRL ML 0.4000 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 13 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002221861 ANANDRON 50 MG TABLET ORL TAB SAV TAB 2.2719 00002245345 ANDROGEL (2.5 G/PACKET) 1% TOPICAL GEL TOP GEL BGP G 0.8920 00002245346 ANDROGEL (5 G/PACKET) 1% TOPICAL GEL TOP GEL BGP G 0.7887 00002249499 ANDROGEL (75 G/PUMP) 1% TOPICAL GEL TOP GEL BGP G 0.9013 00000874019 ANEXATE 0.1 MG/ ML INJECTION INJ DEFAUL HLR ML 5.6956 00002268825 ANGELIQ 1 MG/1 MG TABLET ORL TAB BAI TAB 0.7821 00002280361 ANTHELIOS XL SPF 60 TOPICAL CREAM TOP CRM LRP G 0.1688 00000566756 ANTHRAFORTE 1 1% TOPICAL OINTMENT TOP ONT MPQ G 0.3696 00000566748 ANTHRAFORTE 2 2% TOPICAL OINTMENT TOP ONT MPQ G 0.8066 00000695351 ANTHRASCALP 0.4% TOPICAL LOTION TOP LOT STI ML 0.7000 00002230251 ANTIBIOTIC TOPICAL OINTMENT USP TOP ONT TAR G 0.1500 00002241532 ANTI-NAUSEANT 50 MG TABLET ORL TAB VTH TAB 0.0790 00002222132 ANTIPHLOGISTINE RUB A-535 NO ODOUR 13.3% TOP OINT TOP ONT CHD G 0.0570 00001945939 ANUSOL 0.5% RECTAL OINTMENT RT ONT MCL G 0.1530 00001945920 ANUSOL 10 MG RECTAL SUPPOSITORY RT SUP MCL SUP 0.4183 00001945912 ANUSOL PLUS RECTAL OINTMENT RT ONT MCL G 0.1807 00001945904 ANUSOL PLUS RECTAL SUPPOSITORY RT SUP MCL SUP 0.5592 00000621447 ANUZINC 0.5% W/W TOPICAL OINTMENT TOP ONT SDZ G 0.1250 00000621439 ANUZINC 10 MG RECTAL SUPPOSITORY RT SUP SDZ SUP 0.4083 00002248424 ANUZINC PLUS RECTAL OINTMENT RT ONT SDZ G 0.1173 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 14 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002231379 ANZEMET 100 MG TABLET ORL TAB SAV TAB 29.5953 00080017904 AOR CHROMIUM PICOLINATE 600 MCG CAPSULE ORL CAP AOR CAP 0.1333 00080005832 AOR N.A.C. 500 MG CAPSULE ORL CAP AOR CAP 0.1375 00002416255 APO-ABACAVIR-LAMIVUDINE-ZIDOVUDINE TABLET ORL TAB APX TAB 15.4613 00002229873 APO-ACETAMINOPHEN 325 MG CAPLET ORL TAB APX TAB 0.0326 00000544981 APO-ACETAMINOPHEN 325 MG TABLET ORL TAB APX TAB 0.0326 00002248727 APO-ALENDRONATE 5 MG TABLET ORL TAB APX TAB 1.0370 00002243611 APO-ALPRAZ 1 MG TABLET ORL TAB APX TAB 0.3099 00002243612 APO-ALPRAZ TS 2 MG TABLET ORL TAB APX TAB 0.5508 00002411318 APO-AMLODIPINE-ATORVASTATIN 10 MG/10 MG TABLET ORL TAB APX TAB 0.9194 00002411326 APO-AMLODIPINE-ATORVASTATIN 10 MG/20 MG TABLET ORL TAB APX TAB 1.0234 00002411334 APO-AMLODIPINE-ATORVASTATIN 10 MG/40 MG TABLET ORL TAB APX TAB 1.0624 00002411342 APO-AMLODIPINE-ATORVASTATIN 10 MG/80 MG TABLET ORL TAB APX TAB 1.0624 00002411253 APO-AMLODIPINE-ATORVASTATIN 5 MG/10 MG TABLET ORL TAB APX TAB 0.7551 00002411261 APO-AMLODIPINE-ATORVASTATIN 5 MG/20 MG TABLET ORL TAB APX TAB 0.8591 00002411288 APO-AMLODIPINE-ATORVASTATIN 5 MG/40 MG TABLET ORL TAB APX TAB 0.8981 00002411296 APO-AMLODIPINE-ATORVASTATIN 5 MG/80 MG TABLET ORL TAB APX TAB 0.8981 00002288559 APO-AMOXI CLAV 80 MG/11.4 MG/ML ORAL SUSPENSION ORL SUS APX ML 0.1969 00002374420 APO-ANASTROZOLE 1 MG TABLET ORL TAB APX TAB 2.5460 00000510696 APO-ASEN ECT 325 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.0304 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 15 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000472476 APO-ASEN ECT 650 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.2500 00002318024 APO-ATOMOXETINE 10 MG CAPSULE ORL CAP APX CAP 2.3140 00002318083 APO-ATOMOXETINE 100 MG CAPSULE ORL CAP APX CAP 4.3520 00002318032 APO-ATOMOXETINE 18 MG CAPSULE ORL CAP APX CAP 2.6523 00002318040 APO-ATOMOXETINE 25 MG CAPSULE ORL CAP APX CAP 2.9281 00002318059 APO-ATOMOXETINE 40 MG CAPSULE ORL CAP APX CAP 3.3377 00002318067 APO-ATOMOXETINE 60 MG CAPSULE ORL CAP APX CAP 3.7024 00002318075 APO-ATOMOXETINE 80 MG CAPSULE ORL CAP APX CAP 3.9960 00002247423 APO-AZITHROMYCIN 250 MG TABLET ORL TAB APX TAB 1.2317 00002296063 APO-BICALUTAMIDE 50 MG TABLET ORL TAB APX TAB 4.0573 00002399210 APO-BOSENTAN 125 MG TABLET ORL TAB APX TAB 22.4625 00002399202 APO-BOSENTAN 62.5 MG TABLET ORL TAB APX TAB 22.4625 00002301334 APO-BRIMONIDINE P 0.15% OPHTHALMIC SOLUTION OPH SOL AAP ML 1.7330 00002242504 APO-BUTORPHANOL 10 MG/ML NASAL SPRAY NAS SPR AAP ML 22.6120 00000682047 APO-CAL 250 625 MG TABLET ORL TAB APX TAB 0.0266 00000682039 APO-CAL 500 MG TABLET ORL TAB APX TAB 0.0645 00002365340 APO-CANDESARTAN 4 MG TABLET ORL TAB APX TAB 0.3400 00000893625 APO-CAPTO 100 MG TABLET ORL TAB APX TAB 1.0395 00000893595 APO-CAPTO 12.5 MG TABLET ORL TAB APX TAB 0.2120 00000893609 APO-CAPTO 25 MG TABLET ORL TAB APX TAB 0.3000 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 16 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000893617 APO-CAPTO 50 MG TABLET ORL TAB APX TAB 0.5590 00001999559 APO-CAPTO 6.25 MG TABLET ORL TAB APX TAB 0.1237 00002293943 APO-CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS APX ML 0.1187 00002293951 APO-CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS APX ML 0.2367 00002231603 APO-CETIRIZINE 10 MG TABLET ORL TAB APX TAB 0.4083 00000399302 APO-CHLORPROPAMIDE 100 MG TABLET ORL TAB APX TAB 0.0803 00000312711 APO-CHLORPROPAMIDE 250 MG TABLET ORL TAB APX TAB 0.1624 00002298953 APO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL APX G 7.7433 00000749494 APO-CIMETIDINE 800 MG TABLET ORL TAB APX TAB 0.2430 00002263130 APO-CIPROFLOX 0.3% OPHTHALMIC SOL. OPH SOL APX ML 1.7600 00002274744 APO-CLARITHROMYCIN 250 MG TABLET ORL TAB APX TAB 0.4209 00002274752 APO-CLARITHROMYCIN 500 MG TABLET ORL TAB APX TAB 1.6293 00002243433 APO-DICLO RAPIDE 50 MG TABLET ORL TAB APX TAB 0.3937 00002354403 APO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL APX ML 0.5165 00002291037 APO-DILTIAZ TZ 120 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 0.2133 00002291045 APO-DILTIAZ TZ 180 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 0.2889 00002291053 APO-DILTIAZ TZ 240 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 0.3832 00002291061 APO-DILTIAZ TZ 300 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 0.4720 00002291088 APO-DILTIAZ TZ 360 MG EXTENDED-RELEASE CAPSULE ORL ERC APX CAP 0.5778 00002296055 APO-DORZOLAMIDE 2% OPHTHALMIC SOLUTION OPH SOL APX ML 1.6880 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 17 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002386054 APO-ELETRIPTAN 20 MG TABLET ORL TAB APX TAB 10.0850 00002386062 APO-ELETRIPTAN 40 MG TABLET ORL TAB APX TAB 10.0850 00002352931 APO-ENALAPRIL MALEATE/HCTZ 10 MG/25 MG TABLET ORL TAB APX TAB 1.0741 00002352923 APO-ENALAPRIL MALEATE/HCTZ 5 MG/12.5 MG TABLET ORL TAB APX TAB 0.7493 00002339099 APO-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT APX TAB 1.8690 00002339102 APO-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT APX TAB 1.8690 00002419726 APO-EXEMESTANE 25 MG TABLET ORL TAB APX TAB 3.9008 00002292025 APO-FAMCICLOVIR 125 MG TABLET ORL TAB APX TAB 2.0240 00002292041 APO-FAMCICLOVIR 250 MG TABLET ORL TAB APX TAB 2.7200 00002292068 APO-FAMCICLOVIR 500 MG TABLET ORL TAB APX TAB 4.2280 00000545031 APO-FERROUS GLUCONATE 300 MG TABLET ORL TAB APX TAB 0.0404 00001912518 APO-FERROUS SULFATE-FC 300 MG TABLET ORL TAB APX TAB 0.0353 00002294745 APO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM APX DOSE 0.1831 00002426471 APO-FROVATRIPTAN 2.5 MG TABLET ORL TAB APX TAB 12.5033 00002293358 APO-GABAPENTIN 600 MG TABLET ORL TAB APX TAB 1.3045 00002293366 APO-GABAPENTIN 800 MG TABLET ORL TAB APX TAB 1.7393 00000885754 APO-GAIN 2% TOPICAL SOLUTION TOP SOL APX ML 0.4956 00002295377 APO-GLIMEPIRIDE 1 MG TABLET ORL TAB APX TAB 0.4900 00002295385 APO-GLIMEPIRIDE 2 MG TABLET ORL TAB APX TAB 0.4900 00002295393 APO-GLIMEPIRIDE 4 MG TABLET ORL TAB APX TAB 0.4900 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 18 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000396796 APO-HALOPERIDOL 0.5 MG TABLET ORL TAB APX TAB 0.1224 00000396818 APO-HALOPERIDOL 1 MG TABLET ORL TAB APX TAB 0.1839 00000463698 APO-HALOPERIDOL 10 MG TABLET ORL TAB APX TAB 0.6378 00002327856 APO-HYDRO 12.5 MG TABLET ORL TAB APX TAB 0.0338 00000441643 APO-IBUPROFEN 200 MG TABLET ORL TAB APX TAB 0.0590 00002355337 APO-IMATINIB 100 MG TABLET ORL TAB APX TAB 20.4557 00002355345 APO-IMATINIB 400 MG TABLET ORL TAB APX TAB 81.8228 00002369052 APO-LAMIVUDINE 150 MG TABLET ORL TAB APX TAB 3.6269 00002369060 APO-LAMIVUDINE 300 MG TABLET ORL TAB APX TAB 7.2538 00002375540 APO-LAMIVUDINE-ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB APX TAB 7.8309 00002358514 APO-LETROZOLE 2.5 MG TABLET ORL TAB APX TAB 2.7560 00002261979 APO-LISINOPRIL/HCTZ 10 MG/12.5 MG TABLET ORL TAB APX TAB 0.2083 00002261987 APO-LISINOPRIL/HCTZ 20 MG/12.5 MG TABLET ORL TAB APX TAB 0.2503 00002261995 APO-LISINOPRIL/HCTZ 20 MG/25 MG TABLET ORL TAB APX TAB 0.3506 00002243880 APO-LORATADINE 10 MG TABLET ORL TAB APX TAB 0.6267 00002248974 APO-MELOXICAM 15 MG TABLET ORL TAB APX TAB 0.5670 00002248973 APO-MELOXICAM 7.5 MG TABLET ORL TAB APX TAB 0.4914 00002366487 APO-MEMANTINE 10 MG TABLET ORL TAB APX TAB 1.6357 00002305062 APO-METFORMIN ER 500 MG EXTENDED-RELEASE TABLET ORL ERT APX TAB 0.4273 00002258935 APO-METHIMAZOLE 5 MG TABLET ORL TAB APX TAB 0.1735 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 19 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002273950 APO-METHYLPHENIDATE 5 MG TABLET ORL TAB APX TAB 0.0995 00002286610 APO-MIRTAZAPINE 15 MG TABLET ORL TAB APX TAB 0.3750 00002286637 APO-MIRTAZAPINE 45 MG TABLET ORL TAB APX TAB 1.1250 00002406373 APO-MOXIFLOXACIN 0.5 % OPHTHALMIC SOLUTION OPH SOL APX ML 3.7570 00002352559 APO-MYCOPHENOLATE 250 MG CAPSULE ORL CAP APX CAP 1.0310 00002352567 APO-MYCOPHENOLATE 500 MG TABLET ORL TAB APX TAB 2.0620 00002372738 APO-MYCOPHENOLIC ACID 180 MG ENTERIC-COATED TAB ORL ECT APX TAB 1.6980 00002372746 APO-MYCOPHENOLIC ACID 360 MG ENTERIC-COATED TAB ORL ECT APX TAB 3.3960 00002444275 APO-NALTREXONE 50 MG TABLET ORL TAB APX TAB 7.3025 00002246699 APO-NAPROXEN EC 250 MG ENTERIC-COATED TABLET ORL ECT APX TAB 0.2087 00002365499 APO-NARATRIPTAN 1 MG TABLET ORL TAB APX TAB 8.4338 00002365502 APO-NARATRIPTAN 2.5 MG TABLET ORL TAB APX TAB 6.1437 00002245231 APO-NITRAZEPAM 10 MG TABLET ORL TAB APX TAB 0.0534 00002245230 APO-NITRAZEPAM 5 MG TABLET ORL TAB APX TAB 0.0357 00002220156 APO-NIZATIDINE 150 MG CAPSULE ORL CAP APX CAP 0.2098 00002220164 APO-NIZATIDINE 300 MG CAPSULE ORL CAP APX CAP 0.3802 00002223511 APO-NORTRIPTYLINE 10 MG CAPSULE ORL CAP APX CAP 0.0500 00002223538 APO-NORTRIPTYLINE 25 MG CAPSULE ORL CAP APX CAP 0.1011 00002333015 APO-OLANZAPINE 20 MG TABLET ORL TAB APX TAB 10.3093 00002360632 APO-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB APX TAB 5.3553 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 20 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002360640 APO-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB APX TAB 7.5977 00002305054 APO-OLOPATADINE 0.1% OPH SOLUTION OPH SOL APX ML 5.2261 00002402823 APO-OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL APX ML 10.4522 00002243661 APO-OXAPROZIN 600 MG TABLET ORL TAB APX TAB 0.6892 00002284294 APO-OXCARBAZEPINE 150 MG TABLET ORL TAB APX TAB 0.6209 00002284308 APO-OXCARBAZEPINE 300 MG TABLET ORL TAB APX TAB 0.9102 00002284316 APO-OXCARBAZEPINE 600 MG TABLET ORL TAB APX TAB 1.8204 00002366754 APO-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.4390 00002394766 APO-OXYCODONE CR 15 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.5300 00002366762 APO-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.6585 00002394774 APO-OXYCODONE CR 30 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.8700 00002306530 APO-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.1413 00002366746 APO-OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 0.3150 00002394782 APO-OXYCODONE CR 60 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 1.5750 00002366789 APO-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT APX TAB 2.1080 00002248844 APO-PACLITAXEL 6 MG/ML INJECTION INJ DEFAUL APX ML 37.0808 00002292912 APO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT APX TAB 1.2750 00002240907 APO-PAROXETINE 10 MG TABLET ORL TAB APX TAB 1.0430 00000755885 APO-PINDOL 10 MG TABLET ORL TAB APX TAB 0.2323 00000755893 APO-PINDOL 15 MG TABLET ORL TAB APX TAB 0.3370 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 21 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000755877 APO-PINDOL 5 MG TABLET ORL TAB APX TAB 0.1361 00002292386 APO-PRAMIPEXOLE 0.5 MG TABLET ORL TAB APX TAB 1.3860 00000598194 APO-PREDNISONE 1 MG TABLET ORL TAB APX TAB 0.1035 00002394278 APO-PREGABALIN 150 MG CAPSULE ORL CAP APX CAP 1.7270 00002394286 APO-PREGABALIN 225 MG CAPSULE ORL CAP APX CAP 1.7270 00002394235 APO-PREGABALIN 25 MG CAPSULE ORL CAP APX CAP 0.6173 00002394294 APO-PREGABALIN 300 MG CAPSULE ORL CAP APX CAP 1.7270 00002394243 APO-PREGABALIN 50 MG CAPSULE ORL CAP APX CAP 0.9683 00002394251 APO-PREGABALIN 75 MG CAPSULE ORL CAP APX CAP 1.2529 00000504335 APO-PROPRANOLOL 120 MG TABLET ORL TAB APX TAB 0.3091 00000663719 APO-PROPRANOLOL 20 MG TABLET ORL TAB APX TAB 0.0277 00002325381 APO-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB APX CAP 0.8550 00002377721 APO-RISEDRONATE 150 MG TABLET ORL TAB APX TAB 40.9500 00002248203 APO-SILDENAFIL 100 MG TABLET ORL TAB APX TAB 9.2007 00002248201 APO-SILDENAFIL 25 MG TABLET ORL TAB APX TAB 8.2900 00002248202 APO-SILDENAFIL 50 MG TABLET ORL TAB APX TAB 8.8481 00002418118 APO-SILDENAFIL R 20 MG TABLET ORL TAB APX TAB 7.2940 00000778354 APO-SULIN 150 MG TABLET ORL TAB APX TAB 0.3824 00000778362 APO-SULIN 200 MG TABLET ORL TAB APX TAB 0.3920 00002421933 APO-TADALAFIL PAH 20 MG TABLET ORL TAB APX TAB 11.4725 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 22 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000812404 APO-TAMOX 10 MG TABLET ORL TAB APX TAB 0.1750 00000812390 APO-TAMOX 20 MG TABLET ORL TAB APX TAB 0.3500 00002413094 APO-TEMOZOLOMIDE 100 MG CAPSULE ORL CAP APX CAP 113.5960 00002413116 APO-TEMOZOLOMIDE 140 MG CAPSULE ORL CAP APX CAP 159.0360 00002413124 APO-TEMOZOLOMIDE 180 MG CAPSULE ORL CAP APX CAP 253.6726 00002413043 APO-TEMOZOLOMIDE 20 MG CAPSULE ORL CAP APX CAP 22.7200 00002413132 APO-TEMOZOLOMIDE 250 MG CAPSULE ORL CAP APX CAP 283.9840 00002413035 APO-TEMOZOLOMIDE 5 MG CAPSULE ORL CAP APX CAP 5.8500 00002237701 APO-TICLOPIDINE 250 MG TABLET ORL TAB APX TAB 1.0679 00000755850 APO-TIMOL 10 MG TABLET ORL TAB APX TAB 0.3239 00000755869 APO-TIMOL 20 MG TABLET ORL TAB APX TAB 0.6304 00000755842 APO-TIMOL 5 MG TABLET ORL TAB APX TAB 0.2077 00002290812 APO-TIMOP GEL 0.5% OPHTHALMIC SOLUTION OPH LAS APX ML 2.7300 00002259893 APO-TIZANIDINE 4 MG TABLET ORL TAB AAP TAB 0.6884 00002426153 APO-TRAMADOL 50 MG TABLET ORL TAB APX TAB 0.6386 00002336790 APO-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB APX TAB 0.6264 00002147653 APO-TRAZODONE 150 MG TABLET ORL TAB APX TAB 0.4613 00002371510 APO-VALSARTAN 40 MG TABLET ORL TAB APX TAB 0.5823 00001946323 APO-ZIDOVUDINE 100 MG CAPSULE ORL CAP APX CAP 1.3977 00002434946 APO-ZOLPIDEM ODT 10 MG SUBLINGUAL DISINT TABLET SLG DISNTAB APX TAB 1.1884 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 23 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002436159 APO-ZOLPIDEM ODT 5 MG SUBLINGUAL DISINT. TABLET SLG DISNTAB APX TAB 1.1827 00002375885 APPRILON 40 MG MODIFIED RELEASE CAPSULE ORL MRC GAL CAP 2.6071 00000723754 APRESOLINE 20 MG/VIAL INJECTION INJ DEFAUL STM VIAL 11.6500 00002273322 APTIVUS 250 MG CAPSULE ORL CAP BOE CAP 8.2500 00002162075 AQUASOL E 50 UNIT/ML ORAL DROPS ORL DPS NOV ML 0.8488 00002269465 ARICEPT RDT 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PFI TAB 4.8671 00002269457 ARICEPT RDT 5 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PFI TAB 4.8671 00002224135 ARIMIDEX 1 MG TABLET ORL TAB AZC TAB 5.1863 00080008677 ARNICA 7% GEL TOP GEL BCI G 0.1314 00080015109 ARNICA GEL-CREAM RUB A535 TOPICAL GEL TOP GEL CHD G 0.0971 00002242705 AROMASIN 25 MG TABLET ORL TAB PFI TAB 5.2790 00002286653 ARTHRITIS PAIN 650 MG EXTENDED RELIEF TABLET ORL ERT VTH TAB 0.0792 00002371146 ARTHRITIS PAIN RELIEF 650 MG EXTENDED-RELEASE TAB ORL ERT VTH TAB 0.0498 00002229632 ARTIFICIAL TEARS EXTRA OPH SOLUTION OPH SOL PMS ML 0.3033 00002229570 ARTIFICIAL TEARS OPH SOLUTION OPH SOL PPH ML 0.2927 00002381559 ARZERRA 100 MG/5 ML VIAL INJECTION INJ DEFAUL NOV VIAL 336.0000 00002381567 ARZERRA 1000 MG/50 ML VIAL INJECTION INJ DEFAUL NOV VIAL 3360.0000 00000180041 ASA & CODEINE 8 MG TABLET ORL TAB SDR TAB 0.0247 00000230324 ASA 325 MG TABLET ORL TAB TEV TAB 0.0621 00000530336 ASA 325 MG TABLET ORL TAB VTH TAB 0.0215 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 24 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000036145 ASA 325 MG TABLET ORL TAB WAM TAB 0.0136 00002372177 ASA 81 MG ENTERIC-COATED TABLET ORL ECT VTH TAB 0.0530 00002244993 ASA 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0361 00002433044 ASA 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0560 00002426811 ASA EC 81 MG ENTERIC-COATED TABLET ORL ECT SNS TAB 0.0530 00002046253 ASADOL 325 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.0125 00002009013 ASAPHEN 80 MG TABLET ORL TAB PMS TAB 0.0560 00002243974 ASAPHEN 81 MG CHEWABLE TABLET ORL CTB PMS TAB 0.0713 00002238545 ASAPHEN E.C. 80 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0560 00002242281 ASAPHEN E.C. 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0713 00002280167 ASATAB 80 MG CHEWABLE TABLET ORL CTB ODN TAB 0.0580 00002352427 ASATAB EC 325 MG ENTERIC-COATED TABLET ORL ECT ODN TAB 0.0295 00000266086 ASCORBIC ACID 500 MG TABLET ORL TAB PMT TAB 0.0300 00002074710 ASPERCREME CREME RUB 10% TOPICAL CREAM TOP CRM SAH G 0.0581 00002150328 ASPIRIN 325 MG TABLET ORL TAB BAI TAB 0.0929 00002316897 ASPIRIN STOMACH GUARD EXTRA STRENGTH 500 MG CAPLET ORL TAB BIC TAB 0.0960 00002229967 ASPIRIN WITH STOMACH GUARD EXTRA STRENGTH CAPLET ORL TAB BAI TAB 0.0960 00002239090 ATACAND 4 MG TABLET ORL TAB AZC TAB 0.7233 00000013668 ATASOL FORTE 500 MG TABLET ORL TAB CHD TAB 0.0543 00000293504 ATASOL-15 TABLET ORL TAB CHD TAB 0.0910 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 25 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000293512 ATASOL-30 TABLET ORL TAB CHD TAB 0.1325 00000293490 ATASOL-8 TABLET ORL TAB CHD TAB 0.0703 00002326701 ATENOLOL 25 MG TABLET ORL TAB PDL TAB 0.0676 00000828793 ATENOLOL-100 MG TABLET ORL TAB PDL TAB 0.2362 00000828807 ATENOLOL-50 MG TABLET ORL TAB PDL TAB 0.1437 00002396904 ATOMOXETINE 10 MG CAPSULE ORL CAP PDL CAP 1.4040 00002396912 ATOMOXETINE 18 MG CAPSULE ORL CAP PDL CAP 1.6093 00002396920 ATOMOXETINE 25 MG CAPSULE ORL CAP PDL CAP 1.7767 00002396939 ATOMOXETINE 40 MG CAPSULE ORL CAP PDL CAP 2.0250 00002396947 ATOMOXETINE 60 MG CAPSULE ORL CAP PDL CAP 2.2463 00002387891 ATORVASTATIN 10 MG TABLET ORL TAB SIV TAB 0.4160 00002346486 ATORVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.3138 00002396424 ATORVASTATIN 10 MG TABLET ORL TAB APX TAB 0.3138 00002346494 ATORVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.3922 00002387905 ATORVASTATIN 20 MG TABLET ORL TAB SIV TAB 0.5200 00002396432 ATORVASTATIN 20 MG TABLET ORL TAB APX TAB 0.3922 00002346508 ATORVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.4216 00002387913 ATORVASTATIN 40 MG TABLET ORL TAB SIV TAB 0.5590 00002396440 ATORVASTATIN 40 MG TABLET ORL TAB APX TAB 0.4216 00002387921 ATORVASTATIN 80 MG TABLET ORL TAB SIV TAB 0.5590 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 26 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002346516 ATORVASTATIN 80 MG TABLET ORL TAB PDL TAB 0.4216 00002396459 ATORVASTATIN 80 MG TABLET ORL TAB APX TAB 0.4216 00002351765 ATORVASTATIN-20 20 MG TABLET ORL TAB PDL TAB 0.1569 00002421429 ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ORL TAB SNS TAB 4.1308 00002299925 ATRIANCE 5 MG/ML INJECTION INJ DEFAUL NOV ML 9.6892 00002300699 ATRIPLA TABLET ORL TAB BMG TAB 42.3340 00002094703 ATROPINE 0.6 MG/ML INJECTION INJ DEFAUL ALV ML 2.5000 00002148358 ATROPINE SULFATE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00002163713 ATROVENT 0.06% NASAL SPRAY NAS SPR BOE ML 1.9860 00002332477 AURALGAN OTIC SOLUTION OT SOL PAL ML 0.5236 00002407256 AURO-ATORVASTATIN 10 MG TABLET ORL TAB AUR TAB 0.3138 00002407264 AURO-ATORVASTATIN 20 MG TABLET ORL TAB AUR TAB 0.3922 00002407272 AURO-ATORVASTATIN 40 MG TABLET ORL TAB AUR TAB 0.4216 00002407280 AURO-ATORVASTATIN 80 MG TABLET ORL TAB AUR TAB 0.4216 00002347261 AURO-CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS AUR ML 0.0593 00002347245 AURO-CEFPROZIL 250 MG TABLET ORL TAB AUR TAB 0.4332 00002347288 AURO-CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS AUR ML 0.1185 00002347253 AURO-CEFPROZIL 500 MG TABLET ORL TAB AUR TAB 0.8494 00002418428 AURO-EFAVIRENZ 600 MG TABLET ORL TAB AUR TAB 11.2103 00002385627 AURO-FLUOXETINE 10 MG CAPSULE ORL CAP AUR CAP 0.4595 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 27 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002414414 AURO-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB AUR TAB 7.8308 00002423650 AURO-LOSARTAN HCT 100 MG/12.5 MG TABLET ORL TAB AUR TAB 0.3082 00002423669 AURO-LOSARTAN HCT 100 MG/25 MG TABLET ORL TAB AUR TAB 0.3146 00002423642 AURO-LOSARTAN HCT 50 MG/12.5 MG TABLET ORL TAB AUR TAB 0.3146 00002390892 AURO-MELOXICAM 15 MG TABLET ORL TAB AUR TAB 0.4623 00002390884 AURO-MELOXICAM 7.5 MG TABLET ORL TAB AUR TAB 0.4007 00002411695 AURO-MIRTAZAPINE 15 MG TABLET ORL TAB AUR TAB 0.3750 00002299801 AURO-MIRTAZAPINE OD 15 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.2730 00002299828 AURO-MIRTAZAPINE OD 30 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.5460 00002299836 AURO-MIRTAZAPINE OD 45 MG ORALLY DISINT. TABLET ORL DISNTAB AUR TAB 0.8190 00002430487 AURO-MODAFINIL 100 MG TABLET ORL TAB AUR TAB 0.9293 00002432242 AURO-MOXIFLOXACIN 400 MG TABLET ORL TAB AUR TAB 1.5230 00002318601 AURO-NEVIRAPINE 200 MG TABLET ORL TAB AUR TAB 2.4690 00002422212 AURO-OMEPRAZOLE 10 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT AUR CAP 0.8166 00002384906 AURO-PIOGLITAZONE 15 MG TABLET ORL TAB AUR TAB 0.5809 00002384914 AURO-PIOGLITAZONE 30 MG TABLET ORL TAB AUR TAB 0.8139 00002384922 AURO-PIOGLITAZONE 45 MG TABLET ORL TAB AUR TAB 1.2237 00002424061 AURO-PRAMIPEXOLE 0.25 MG TABLET ORL TAB AUR TAB 0.2628 00002424096 AURO-PRAMIPEXOLE 1 MG TABLET ORL TAB AUR TAB 0.5257 00002424118 AURO-PRAMIPEXOLE 1.5 MG TABLET ORL TAB AUR TAB 0.5257 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 28 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002433907 AURO-PREGABALIN 150 MG CAPSULE ORL CAP AUR CAP 1.7270 00002433869 AURO-PREGABALIN 25 MG CAPSULE ORL CAP AUR CAP 0.6172 00002433877 AURO-PREGABALIN 50 MG CAPSULE ORL CAP AUR CAP 0.9682 00002433885 AURO-PREGABALIN 75 MG CAPSULE ORL CAP AUR CAP 1.2528 00002405156 AURO-SIMVASTATIN 10 MG TABLET ORL TAB AUR TAB 0.5057 00002405164 AURO-SIMVASTATIN 20 MG TABLET ORL TAB AUR TAB 0.6250 00002405172 AURO-SIMVASTATIN 40 MG TABLET ORL TAB AUR TAB 0.6250 00002405148 AURO-SIMVASTATIN 5 MG TABLET ORL TAB AUR TAB 0.2556 00002405180 AURO-SIMVASTATIN 80 MG TABLET ORL TAB AUR TAB 0.4501 00002439050 AURO-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB AUR TAB 0.6096 00002405040 AURO-VALACYCLOVIR 500 MG TABLET ORL TAB AUR TAB 0.8475 00002414201 AURO-VALSARTAN 40 MG TABLET ORL TAB AUR TAB 0.5240 00002363798 AVA-ACEBUTOLOL 100 MG TABLET ORL TAB AVA TAB 0.1630 00002363801 AVA-ACEBUTOLOL 200 MG TABLET ORL TAB AVA TAB 0.2440 00002363828 AVA-ACEBUTOLOL 400 MG TABLET ORL TAB AVA TAB 0.4848 00002360969 AVA-ATENOLOL 25 MG TABLET ORL TAB AVA TAB 0.1730 00002363372 AVA-AZITHROMYCIN 20 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.6407 00002363364 AVA-AZITHROMYCIN 250 MG TABLET ORL TAB AVA TAB 2.9650 00002363380 AVA-AZITHROMYCIN 40 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.9080 00002371413 AVA-BACLOFEN 10 MG TABLET ORL TAB AVA TAB 0.2911 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 29 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002371421 AVA-BACLOFEN 20 MG TABLET ORL TAB AVA TAB 0.5667 00002360993 AVA-BICALUTAMIDE 50 MG TABLET ORL TAB AVA TAB 4.0573 00002363895 AVA-BISOPROLOL 10 MG TABLET ORL TAB AVA TAB 0.3654 00002363887 AVA-BISOPROLOL 5 MG TABLET ORL TAB AVA TAB 0.2205 00002363399 AVA-BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.3365 00002363402 AVA-BUPROPION SR 150 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.5040 00002370751 AVA-CARVEDILOL 12.5 MG TABLET ORL TAB AVA TAB 0.7564 00002370786 AVA-CARVEDILOL 25 MG TABLET ORL TAB AVA TAB 0.7564 00002370735 AVA-CARVEDILOL 3.125 MG TABLET ORL TAB AVA TAB 0.7564 00002370743 AVA-CARVEDILOL 6.25 MG TABLET ORL TAB AVA TAB 0.7564 00002362864 AVA-CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.0948 00002362848 AVA-CEFPROZIL 250 MG TABLET ORL TAB AVA TAB 0.9703 00002362872 AVA-CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS AVA ML 0.1896 00002362856 AVA-CEFPROZIL 500 MG TABLET ORL TAB AVA TAB 1.9025 00002364255 AVA-CITALOPRAM 10 MG TABLET ORL TAB AVA TAB 0.4464 00002366371 AVA-CLARITHROMYCIN 250 MG TABLET ORL TAB AVA TAB 1.1001 00002366398 AVA-CLARITHROMYCIN 500 MG TABLET ORL TAB AVA TAB 1.8249 00002364719 AVA-CLINDAMYCIN 150 MG CAPSULE ORL CAP AVA CAP 0.4890 00002364727 AVA-CLINDAMYCIN 300 MG CAPSULE ORL CAP AVA CAP 0.9780 00002360861 AVA-CLONIDINE 0.025 MG TABLET ORL TAB AVA TAB 0.1523 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 30 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002366665 AVA-DICLOFENAC 25 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.1902 00002366673 AVA-DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.3804 00002366703 AVA-DICLOFENAC SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.7608 00002366681 AVA-DICLOFENAC SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT AVA TAB 0.5706 00002364271 AVA-DOMPERIDONE 10 MG TABLET ORL TAB AVA TAB 0.1418 00002363488 AVA-ENALAPRIL 10 MG TABLET ORL TAB AVA TAB 0.5932 00002363453 AVA-ENALAPRIL 2.5 MG TABLET ORL TAB AVA TAB 0.4172 00002363496 AVA-ENALAPRIL 20 MG TABLET ORL TAB AVA TAB 0.7156 00002363461 AVA-ENALAPRIL 5 MG TABLET ORL TAB AVA TAB 0.4935 00002373920 AVA-FAMOTIDINE 20 MG TABLET ORL TAB AVA TAB 0.5896 00002373939 AVA-FAMOTIDINE 40 MG TABLET ORL TAB AVA TAB 1.0612 00002364409 AVA-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP AVA CAP 1.0890 00002364530 AVA-FLUOXETINE 20 MG CAPSULE ORL CAP AVA CAP 1.0112 00002363771 AVA-FLUVOXAMINE 100 MG TABLET ORL TAB AVA TAB 0.8902 00002363763 AVA-FLUVOXAMINE 50 MG TABLET ORL TAB AVA TAB 0.4952 00002364573 AVA-FUROSEMIDE 20 MG TABLET ORL TAB AVA TAB 0.0445 00002364581 AVA-FUROSEMIDE 40 MG TABLET ORL TAB AVA TAB 0.0670 00002364603 AVA-FUROSEMIDE 80 MG TABLET ORL TAB AVA TAB 0.1220 00002363518 AVA-GLICLAZIDE 80 MG TABLET ORL TAB AVA TAB 0.2242 00002363704 AVA-GLYBURIDE 2.5 MG TABLET ORL TAB AVA TAB 0.0393 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 31 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002363712 AVA-GLYBURIDE 5 MG TABLET ORL TAB AVA TAB 0.0683 00002363968 AVA-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB AVA TAB 0.0395 00002363976 AVA-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB AVA TAB 0.0551 00002373327 AVA-IRBESARTAN 150 MG TABLET ORL TAB AVA TAB 0.5444 00002373335 AVA-IRBESARTAN 300 MG TABLET ORL TAB AVA TAB 0.5444 00002373319 AVA-IRBESARTAN 75 MG TABLET ORL TAB AVA TAB 0.5444 00002373343 AVA-IRBESARTAN/HCTZ 150/12.5 MG TABLET ORL TAB AVA TAB 0.5444 00002373351 AVA-IRBESARTAN/HCTZ 300/12.5 MG TABLET ORL TAB AVA TAB 0.5444 00002373378 AVA-IRBESARTAN/HCTZ 300/25 MG TABLET ORL TAB AVA TAB 0.5407 00002371677 AVA-LEVETIRACETAM 250 MG TABLET ORL TAB AVA TAB 0.9632 00002371685 AVA-LEVETIRACETAM 500 MG TABLET ORL TAB AVA TAB 1.1739 00002371693 AVA-LEVETIRACETAM 750 MG TABLET ORL TAB AVA TAB 1.6254 00002361027 AVA-LEVOFLOXACIN 250 MG TABLET ORL TAB AVA TAB 2.8494 00002361035 AVA-LEVOFLOXACIN 500 MG TABLET ORL TAB AVA TAB 3.2153 00002362880 AVA-LISINOPRIL HCT 10 MG/12.5 MG TABLET ORL TAB AVA TAB 0.5019 00002362899 AVA-LISINOPRIL HCT 20 MG/12.5 MG TABLET ORL TAB AVA TAB 0.6030 00002362902 AVA-LISINOPRIL HCT 20 MG/25 MG TABLET ORL TAB AVA TAB 0.6030 00002364239 AVA-LOVASTATIN 20 MG TABLET ORL TAB AVA TAB 1.0907 00002364247 AVA-LOVASTATIN 40 MG TABLET ORL TAB AVA TAB 2.0117 00002364506 AVA-METFORMIN 500 MG TABLET ORL TAB AVA TAB 0.1216 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 32 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002364514 AVA-METFORMIN 850 MG TABLET ORL TAB AVA TAB 0.2040 00002364859 AVA-METOPROLOL (TYPE L) 100 MG TABLET ORL TAB AVA TAB 0.2223 00002364840 AVA-METOPROLOL (TYPE L) 50 MG TABLET ORL TAB AVA TAB 0.1225 00002364832 AVA-METOPROLOL 100 MG TABLET ORL TAB AVA TAB 0.2223 00002364824 AVA-METOPROLOL 50 MG TABLET ORL TAB AVA TAB 0.1225 00002362937 AVA-MIRTAZAPINE 30 MG TABLET ORL TAB AVA TAB 0.6944 00002298589 AVAMYS 27.5 MCG/DOSE NASAL SPRAY NAS SPM GSK DOSE 0.2094 00002365820 AVA-NAPROXEN 375 MG TABLET ORL TAB AVA TAB 0.1458 00002365839 AVA-NAPROXEN 500 MG TABLET ORL TAB AVA TAB 0.2110 00002365847 AVA-NAPROXEN EC 250 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.2467 00002365855 AVA-NAPROXEN EC 375 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.3234 00002365863 AVA-NAPROXEN EC 500 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 0.5842 00002366304 AVA-NORFLOXACIN 400 MG TABLET ORL TAB AVA TAB 1.2204 00002364301 AVA-NORTRIPTYLINE 10 MG CAPSULE ORL CAP AVA CAP 0.1260 00002364328 AVA-NORTRIPTYLINE 25 MG CAPSULE ORL CAP AVA CAP 0.2546 00002373467 AVA-OLANZAPINE 10 MG TABLET ORL TAB AVA TAB 4.2270 00002373432 AVA-OLANZAPINE 2.5 MG TABLET ORL TAB AVA TAB 1.0568 00002373440 AVA-OLANZAPINE 5 MG TABLET ORL TAB AVA TAB 2.1135 00002373459 AVA-OLANZAPINE 7.5 MG TABLET ORL TAB AVA TAB 3.1703 00002363429 AVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT AVA TAB 1.2135 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 33 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002363305 AVA-PRAMIPEXOLE 0.25 MG TABLET ORL TAB AVA TAB 0.5887 00002363321 AVA-PRAMIPEXOLE 1 MG TABLET ORL TAB AVA TAB 1.1776 00002363348 AVA-PRAMIPEXOLE 1.5 MG TABLET ORL TAB AVA TAB 1.1776 00002363267 AVA-RAMIPRIL 1.25 MG TABLET ORL CAP/TAB AVA TAB 0.4174 00002363291 AVA-RAMIPRIL 10 MG TABLET ORL CAP/TAB AVA TAB 0.6100 00002363275 AVA-RAMIPRIL 2.5 MG TABLET ORL CAP/TAB AVA TAB 0.4815 00002363283 AVA-RAMIPRIL 5 MG TABLET ORL CAP/TAB AVA TAB 0.4815 00002364816 AVA-RISEDRONATE 35 MG TABLET ORL TAB AVA TAB 4.8169 00002367173 AVA-RISPERIDONE 0.25 MG TABLET ORL TAB AVA TAB 0.2615 00002367181 AVA-RISPERIDONE 0.5 MG TABLET ORL TAB AVA TAB 0.4379 00002367203 AVA-RISPERIDONE 1 MG TABLET ORL TAB AVA TAB 0.6048 00002364344 AVA-RISPERIDONE 1 MG/ML ORAL SOLUTION ORL SOL AVA ML 0.7727 00002367211 AVA-RISPERIDONE 2 MG TABLET ORL TAB AVA TAB 1.2075 00002367238 AVA-RISPERIDONE 3 MG TABLET ORL TAB AVA TAB 1.8113 00002367246 AVA-RISPERIDONE 4 MG TABLET ORL TAB AVA TAB 2.4150 00002363682 AVA-SOTALOL 160 MG TABLET ORL TAB AVA TAB 0.5771 00002363674 AVA-SOTALOL 80 MG TABLET ORL TAB AVA TAB 0.4922 00002270994 AVASTIN 25 MG/ML INJECTION INJ DEFAUL HLR ML 125.0000 00002366266 AVA-SUMATRIPTAN 100 MG TABLET ORL TAB AVA TAB 9.8433 00002366258 AVA-SUMATRIPTAN 50 MG TABLET ORL TAB AVA TAB 8.9350 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 34 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002366231 AVA-TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET ORL ERT AVA TAB 0.2700 00002370980 AVA-TOPIRAMATE 100 MG TABLET ORL TAB AVA TAB 1.2537 00002370999 AVA-TOPIRAMATE 200 MG TABLET ORL TAB AVA TAB 1.9845 00002370972 AVA-TOPIRAMATE 25 MG TABLET ORL TAB AVA TAB 0.6615 00002367130 AVA-VALSARTAN 160 MG TABLET ORL TAB AVA TAB 0.5724 00002367149 AVA-VALSARTAN 320 MG TABLET ORL TAB AVA TAB 0.5500 00002367114 AVA-VALSARTAN 40 MG TABLET ORL TAB AVA TAB 0.5240 00002367122 AVA-VALSARTAN 80 MG TABLET ORL TAB AVA TAB 0.5724 00002367084 AVA-VALSARTAN HCT 160 MG/ 25 MG TABLET ORL TAB AVA TAB 0.5724 00002367076 AVA-VALSARTAN HCT 160 MG/12.5 MG TABLET ORL TAB AVA TAB 0.5724 00002367092 AVA-VALSARTAN HCT 320 MG/12.5 MG TABLET ORL TAB AVA TAB 0.5633 00002367106 AVA-VALSARTAN HCT 320 MG/25 MG TABLET ORL TAB AVA TAB 0.5633 00002367068 AVA-VALSARTAN HCT 80 MG/12.5 MG TABLET ORL TAB AVA TAB 0.5724 00002237792 AVAXIM 160 U/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 42.4500 00002243741 AVAXIM-PEDIATRIC 80 UNIT/0.5 ML INJECTION SYRINGE INJ NDL SFP SYR 21.2300 00002363534 AVA-ZOPICLONE 5 MG TABLET ORL TAB AVA TAB 0.2231 00002363542 AVA-ZOPICLONE 7.5 MG TABLET ORL TAB AVA TAB 0.4685 00002317508 AVEENO CREAM TOP CRM JJI G 0.0219 00002241416 AVEENO MOISTURIZING BATH TOP PWR JJI G 0.0461 00002382369 AXIRON 2% TOPICAL SOLUTION TOP SOL LIL ML 1.5259 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 35 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002343002 AZATHIOPRINE 50 MG TABLET ORL TAB SNS TAB 0.2405 00002284642 AZILECT 0.5 MG TABLET ORL TAB TMP TAB 7.2100 00002284650 AZILECT 1.0 MG TABLET ORL TAB TMP TAB 7.2100 00002274388 AZITHROMYCIN 20 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.3727 00002274396 AZITHROMYCIN 40 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.5280 00002330911 AZITHROMYCIN 600 MG TABLET ORL TAB SNS TAB 6.0000 00000598577 B COMPLEX 50 TABLET ORL TAB JAM TAB 0.0810 00000598569 B COMPLEX 75 TABLET ORL TAB JAM TAB 0.1616 00000123803 B COMPLEX PLUS C TABLET ORL TAB JAM TAB 0.0810 00080007498 B&C VITAMINS TABLET ORL TAB WBP TAB 0.0631 00080002409 B12 1000 MCG TABLET ORL TAB WNP TAB 0.0850 00002245512 B50 COMPLEX CAPSULE ORL CAP WNP CAP 0.0895 00001927906 BACID 1 B CAPSULE ORL CAP ERF CAP 0.6598 00000876488 BACIMYXIN TOPICAL OINTMENT TOP ONT PMS G 0.2433 00000584908 BACITIN 500 UNIT/G TOPICAL OINTMENT TOP ONT PPH G 0.1933 00000030708 BACITRACIN 50,000 U/VIAL INJECTION INJ DEFAUL PFI VIAL 11.5200 00002152584 BACLOFEN 10 MG TABLET ORL TAB PDL TAB 0.1595 00002152592 BACLOFEN 20 MG TABLET ORL TAB PDL TAB 0.3104 00000037818 BACTERIOSTATIC SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL HSP ML 0.1960 00002243425 BALANCED B COMPLEX 100 MG SUSTAINED-RELEASE TABLET ORL SRT PMT TAB 0.0850 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 36 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002244010 BALMINIL CODEINE NIGHT TIME + EXPECTORANT ORL SYR ROG ML 0.0295 00000436895 BALMINIL DM 3 MG/ML ORAL SYRUP ORL SYR ROG ML 0.0332 00001908855 BALNETAR 2.5% TOPICAL SOLUTION TOP SOL WSD ML 0.0496 00002060841 BARRIERE 20% TOPICAL CREAM TOP CRM WSP G 0.0660 00002135620 BASALJEL 500 MG CAPSULE ORL CAP AUP CAP 0.1500 00000658413 BAXEDIN 20% SOLUTION TOP SOL OMG ML 0.0520 00002243966 BAZA CLEANSE & PROTECT 2% TOPICAL LOTION TOP LOT COC ML 0.0485 00000075124 BCG VACCINE (FREEZE-DRIED) 1 MG INJECTION INJ DEFAUL SFP VIAL 193.3000 00000498815 B-COMPLEX 100 SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.2158 00002237567 BEANO 150 UNIT TABLET ORL TAB GSK TAB 0.1800 00080043158 BEDUZIL 1500 1500 MCG TABLET ORL ERT ORI TAB 0.1158 00002019736 BENADRYL 12.5 MG/5 ML ORAL ELIXIR ORL ELX MCL ML 0.0540 00002019701 BENADRYL 2% TOPICAL CREAM TOP CRM MCL G 0.2703 00002017849 BENADRYL 25 MG CAPLET ORL TAB MCL TAB 0.3883 00002019671 BENADRYL 50 MG CAPSULE ORL CAP MCL CAP 0.2514 00002061287 BENADRYL ALLERGY JUNIOR STRENGTH CHEWABLE TABLET ORL CTB MCL TAB 0.4483 00002229367 BENADRYL ALLERGY SINUS HEADACHE CAPLET ORL TAB MCL TAB 0.3175 00002019698 BENADRYL CHILDREN'S 1.25 MG/ML ORAL LIQUID ORL LIQ MCL ML 0.0540 00002239138 BENADRYL EXTRA STRENGTH 50 MG CAPLET ORL TAB MCL TAB 0.4096 00002370050 BENLYSTA 120 MG /VIAL INJECTION INJ DEFAUL GSK VIAL 285.3000 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 37 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002370069 BENLYSTA 400 MG /VIAL INJECTION INJ DEFAUL GSK VIAL 950.9900 00002245709 BENYLIN 2 COLD AND FLU WITH CODEINE ORAL SYRUP ORL SYR MCL ML 0.0570 00002003317 BENYLIN COUGH AND CHEST CONGESTION WARMING SYRUP ORL SYR MCL ML 0.0366 00001944738 BENYLIN DM 3 MG/ML ORAL SYRUP ORL SYR MCL ML 0.0494 00002215268 BENYLIN DM FOR CHILDREN 1.5 MG/ML ORAL SYRUP ORL SYR MCL ML 0.0494 00002245383 BENYLIN DM FREEZER POPS 7.5 MG/ PACKET ORAL LIQUID ORL LIQ MCL PCKT 0.5925 00001944746 BENYLIN DM-D FOR CHILDREN ORAL SYRUP ORL SYR MCL ML 0.0494 00001944711 BENYLIN DM-D ORAL SYRUP ORL SYR MCL ML 0.0474 00001944673 BENYLIN DM-D-E ORAL SYRUP ORL SYR MCL ML 0.0494 00001944762 BENYLIN DM-E ORAL SYRUP ORL SYR MCL ML 0.0494 00002265427 BENYLIN E EXTRA STR W/ MENTHACTIN 40/3MG/ML SYR ORL SYR MCL ML 0.0366 00001912437 BENZAC AC 10% TOPICAL COPOLYMER GEL TOP COPGEL GAL G 0.3333 00001925199 BENZAC W10 10% TOPICAL WASH TOP WAS GAL G 0.3351 00002162121 BENZAGEL 5 5% WASH TOP WAS NVC ML 0.0584 00002225271 BENZAMYCIN TOPICAL GEL TOP GEL VCL G 1.1071 00002336847 BESIVANCE 0.6% OPHTHALMIC SOLUTION OPH SOL BSH ML 2.6780 00000716634 BETADERM 0.1% SCALP LOTION SCP LOT TAR ML 0.0852 00000158348 BETADINE 10% TOPICAL SOLUTION TOP SOL PUR ML 0.0293 00002237835 BETAJECT INJECTION INJ DEFAUL SDZ ML 10.4830 00002417030 BEXSERO 0.5 ML INJECTION SYRINGE INJ NDL NOV SYR 101.0000 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 38 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002359685 BIACNA 1.2%/0.025% TOPICAL GEL TOP GEL VCL G 1.0582 00002382423 BICALUTAMIDE 50 MG TABLET ORL TAB SIV TAB 4.0573 00002325985 BICALUTAMIDE 50 MG TABLET ORL TAB AHI TAB 4.0572 00002291924 BICILLIN L-A 1,200,000 IU/2 ML INJ SYR INJ NDL PFI SYR 42.5130 00000297763 BICNU 100 MG/VIAL INJECTION INJ DEFAUL BMS VIAL 120.0400 00002230897 BILTRICIDE 600 MG TABLET ORL TAB BAI TAB 6.2900 00080026265 BIO K 20 POTASSIUM 20 MEQ TABLET ORL TAB BMD TAB 0.1995 00002392143 BIO-AMLODIPINE 10 MG TABLET ORL TAB BMD TAB 0.3587 00002392127 BIO-AMLODIPINE 2.5 MG TABLET ORL TAB BMD TAB 0.1380 00002392135 BIO-AMLODIPINE 5 MG TABLET ORL TAB BMD TAB 0.2417 00002392186 BIO-ATENOLOL 100 MG TABLET ORL TAB BMD TAB 0.2362 00002392194 BIO-ATENOLOL 25 MG TABLET ORL TAB BMD TAB 0.0676 00002392178 BIO-ATENOLOL 50 MG TABLET ORL TAB BMD TAB 0.1437 00000621366 BIODERM TOPICAL OINTMENT TOP ONT ODN G 0.3600 00002412861 BIO-DONEPEZIL 10 MG TABLET ORL TAB BMD TAB 0.8753 00002412853 BIO-DONEPEZIL 5 MG TABLET ORL TAB BMD TAB 0.8753 00002425211 BIO-EZETIMIBE 10 MG TABLET ORL TAB BMD TAB 0.4549 00002247371 BIO-FUROSEMIDE 20 MG TABLET ORL TAB BMD TAB 0.0373 00002247372 BIO-FUROSEMIDE 40 MG TABLET ORL TAB BMD TAB 0.0558 00080012473 BIOGAIA DROPS ORL DPS FEI ML 4.2800 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 39 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002247170 BIO-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.0157 00002247171 BIO-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.0217 00080015104 BIO-K EXTRA STRENGTH PROBIOTIC CAPSULE ORL CAP BKP CAP 1.5627 00000989995 BIO-K PLUS RICE PROBIOTIC DRINK ORL LIQ BKP G 0.0536 00080006533 BIOMEDIC MULTIVITAMIN ORL CAP VTH CAP 0.0607 00002216051 BION TEARS OPH SOLUTION OPH SOL ALC ML 0.9604 00000116785 BIONET TABLET ORL TAB CHD TAB 0.1938 00080003128 BIONUTRITION FORMULA 3 CAPSULE ORL CAP BNI CAP 1.1666 00000999776 BIOTENE ORAL BALANCE GEL ORL GEL GSK G 0.1715 00000999782 BIOTENE ORAL RINSE ORL MWH GSK ML 0.0153 00000999777 BIOTENE SPRAY ORL SPR GSK ML 0.1637 00000437522 BIOTIN 250 MCG TABLET ORL TAB JAM TAB 0.0567 00002326302 BI-PEGLYTE KIT ORL ECT/PWR PPH KIT 19.9900 00002361450 BISACODYL 10 MG RECTAL SUPPOSITORY RT SUP JPC SUP 0.5014 00002273411 BISACODYL-ODAN 5 MGENTERIC-COATED TABLET ORL ECT ODN TAB 0.0550 00002131692 BLEOMYCIN SULFATE 15 UNIT/VIAL INJECTION INJ DEFAUL MNP VIAL 421.3800 00080053068 BLOOD PRESSURE FORMULATION COMBO CAPSULE ORL CAP BEL CAP 0.3483 00002247600 BOOSTRIX INJECTION SYRINGE INJ DEFAUL GSK SYR 27.7900 00002423405 BORTEZOMIB FOR INJECTION 3.5 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 1402.4200 00002419149 BOSULIF 100 MG TABLET ORL TAB PFI TAB 36.5900 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 40 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002419157 BOSULIF 500 MG TABLET ORL TAB PFI TAB 146.3400 00002268140 BRAVELLE 75 UNIT/VIAL POWDER FOR INJECTION INJ DEFAUL FEI VIAL 74.0000 00002220520 BROMAZEPAM 3 MG TABLET ORL TAB PDL TAB 0.0375 00002220539 BROMAZEPAM 6 MG TABLET ORL TAB PDL TAB 0.0548 00000522791 BRONCHOPHAN FORTE DM ORAL SYRUP ORL SYR ATL ML 0.0268 00000512990 BSS BALANCED SALT OPH SOLUTION OPH SOL ALC ML 0.4387 00000729655 BUCKLEY'S DM ORAL LIQUID ORL LIQ BUA ML 0.0489 00080022907 BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB ORL CTB BIC TAB 0.0869 00002247970 BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB ORL CTB BIC TAB 0.0873 00002331616 BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.2667 00000728284 BURINEX 1 MG TABLET ORL TAB LEO TAB 0.7907 00000728276 BURINEX 5 MG TABLET ORL TAB LEO TAB 3.0183 00000579947 BURO-SOL TOPICAL POWDER TOP PWR GSK G 0.7510 00002223163 BUSPIRONE 10 MG TABLET ORL TAB PDL TAB 0.3521 00002341212 BUTRANS 10 (10 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 22.7000 00002341220 BUTRANS 20 (20 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 41.2600 00002341174 BUTRANS 5 (5 MCG/HR) TRANSDERMAL PATCH TRD PTH PUR PTH 12.3600 00002361817 BYETTA 10 MCG/DOSE (2.4 ML) INJECTION SYRINGE INJ NDL AZC SYR 139.4900 00002361809 BYETTA 5 MCG/DOSE (1.2 ML) INJECTION SYRINGE INJ NDL AZC SYR 139.4900 00002399016 BYSTOLIC 10 MG TABLET ORL TAB FLC TAB 1.2240 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 41 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002398990 BYSTOLIC 2.5 MG TABLET ORL TAB FLC TAB 1.2240 00002399024 BYSTOLIC 20 MG TABLET ORL TAB FLC TAB 1.2240 00002399008 BYSTOLIC 5 MG TABLET ORL TAB FLC TAB 1.2240 00002273284 CADUET 10 MG/10 MG TABLET ORL TAB PFI TAB 2.4500 00002273292 CADUET 10 MG/20 MG TABLET ORL TAB PFI TAB 3.0544 00002273306 CADUET 10 MG/40 MG TABLET ORL TAB PFI TAB 3.2000 00002273314 CADUET 10 MG/80 MG TABLET ORL TAB PFI TAB 3.2000 00002273233 CADUET 5 MG/10 MG TABLET ORL TAB PFI TAB 2.3206 00002273241 CADUET 5 MG/20 MG TABLET ORL TAB PFI TAB 2.7366 00002273268 CADUET 5 MG/40 MG TABLET ORL TAB PFI TAB 2.8926 00002273276 CADUET 5 MG/80 MG TABLET ORL TAB PFI TAB 2.8926 00002238389 CAELYX 2 MG/ML PEGYLATED LIPOSOME INJECTION INJ DEFAUL SCH ML 69.2560 00000176095 CAFERGOT TABLET ORL TAB NOV TAB 0.8286 00002241460 CAL MAG 2:1 WITH D TABLET ORL TAB WNP TAB 0.0536 00000730602 CALCIUM & MAGNESIUM WITH VITAMIN D CAPSULE ORL CAP SIS CAP 0.2442 00002240973 CALCIUM (CARBONATE) W/ VITAMIN D 500 MG/125 U TAB ORL TAB WNP TAB 0.0750 00000621722 CALCIUM 500 MG TABLET ORL TAB HAL TAB 0.0274 00002240977 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.0449 00002240240 CALCIUM 500 MG TABLET ORL TAB PMT TAB 0.0850 00080003658 CALCIUM 500 MG TABLET ORL TAB WNP TAB 0.0243 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 42 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080000248 CALCIUM 650 MG TABLET ORL TAB JAM TAB 0.0609 00080009369 CALCIUM 650 MG TABLET ORL TAB PMT TAB 0.0342 00080007105 CALCIUM 650 MG WITH VITAMIN D 400 IU CAPLET ORL TAB JMS TAB 0.0609 00002040875 CALCIUM AND MAGNESIUM CAPLET ORL TAB JAM TAB 0.0345 00002245170 CALCIUM AND MAGNESIUM CITRATE WITH VITAMIN D TAB ORL TAB WNP TAB 0.0467 00080006568 CALCIUM AND MAGNESIUM TABLET ORL TAB GFR TAB 0.1140 00002244861 CALCIUM AND MAGNESIUM WITH VITAMIN D TAB ORL TAB PMT TAB 0.0345 00002048965 CALCIUM AND MAGNESIUM WITH ZINC CAPLET ORL TAB JAM TAB 0.0335 00002243418 CALCIUM BONE SOLUTION ORL LIQ ULT ML 0.0343 00000730599 CALCIUM CARBONATE & VITAMIN D3 500 MG/125 U TABLET ORL TAB PMT TAB 0.0345 00000644684 CALCIUM CARBONATE 500 MG (BASE) TABLET ORL TAB WBP TAB 0.0245 00001922238 CALCIUM CARBONATE 500 MG CHEWABLE TABLET ORL CTB WAM TAB 0.0988 00080003855 CALCIUM CITRATE 300 MG TABLET ORL TAB WNP TAB 0.0642 00002243766 CALCIUM CITRATE 300 MG TABLET ORL TAB PMT TAB 0.0791 00002158728 CALCIUM CITRATE 350 MG TABLET ORL TAB SWS TAB 0.0945 00080003662 CALCIUM CITRATE W/ VITAMIN D 300 MG/200 IU TABLET ORL TAB WNP TAB 0.0669 00002237590 CALCIUM CITRATE WITH VITAMIN D TABLET ORL TAB JAM TAB 0.0677 00002243669 CALCIUM CITRATE WITH VITAMIN D TABLET ORL TAB WNP TAB 0.0833 00002141019 CALCIUM GLUCONATE 94 MG/ML INJECTION INJ DEFAUL PPC ML 1.0364 00080007103 CALCIUM MAGNESIUM WITH VITAMIN D CAPLET ORL TAB JMS TAB 0.0345 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 43 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002040905 CALCIUM MAGNESIUM WITH VITAMIN D TABLET ORL TAB JAM TAB 0.0685 00080007265 CALCIUM SOFT CHEWS WITH VITAMIN D ORL CAP JAM CAP 0.1787 00001906828 CAL-MAG WITH ZINC & VITAMIN D CAPLET ORL TAB SWS TAB 0.0902 00080027151 CALMOSEPTINE OINTMENT TOP ONT CAL G 0.0619 00002198630 CALMYLIN ACE 2 MG/ML SYRUP ORL SYR RPH ML 0.0960 00000535230 CALMYLIN WITH CODEINE COUGH ORAL LIQUID ORL LIQ RPH ML 0.0515 00002172917 CALMYLIN WITH CODEINE ORAL SYRUP ORL SYR ROG ML 0.0549 00002007134 CALTINE 100 UNIT/ML INJECTION INJ DEFAUL FEI ML 8.0550 00002242997 CALTRATE 600 MG WITH VITAMIN D SOFT CHEWS TABLET ORL CTB WCH TAB 0.1825 00002231948 CALTRATE 600 MG WITH VITAMIN D TABLET ORL TAB WCH TAB 0.1738 00080003751 CALTRATE 600 TABLET ORL TAB PDH TAB 0.1738 00002240959 CALTRATE PLUS CHEWABLE TABLET ORL CTB WCH TAB 0.2190 00080009423 CALTRATE PLUS CHEWABLES 400 IU ORL TAB PDH TAB 0.2221 00080009761 CALTRATE PLUS TABLET ORL TAB PDH TAB 0.1922 00080023065 CALTRATE SELECT 600 MG/400 IU TABLET ORL TAB PDH TAB 0.2198 00002247976 CALTRATE SELECT 600 MG/400 IU TABLET ORL TAB WCH TAB 0.2086 00080033741 CALTRATE WITH VITAMIN D 600 MG/800 IU TABLET ORL TAB PDH TAB 0.1738 00080012593 CALTRATE WITH VITAMIN D SOFT CHEWS ORL CTB WAY TAB 0.1922 00002381680 CAMBIA 50 MG ORAL POWDER PACKET ORL PWDPKT TRI PCKT 9.9000 00002293269 CAMPRAL 333 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 0.8000 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 44 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002231622 CAMPTOSAR 20 MG/ML INJECTION INJ DEFAUL PFI ML 111.1980 00002377942 CANDESARTAN 16 MG TABLET ORL TAB PDL TAB 0.3420 00002422069 CANDESARTAN 32 MG TABLET ORL TAB PDL TAB 0.2850 00002388693 CANDESARTAN 4 MG TABLET ORL TAB SIV TAB 0.3400 00002388901 CANDESARTAN 4 MG TABLET ORL TAB SNS TAB 0.3400 00002377934 CANDESARTAN 8 MG TABLET ORL TAB PDL TAB 0.3420 00002379260 CANDESARTAN CILEXETIL 4 MG TABLET ORL TAB AHI TAB 0.3400 00002392275 CANDESARTAN-HCTZ 16 MG/12.5 MG TABLET ORL TAB PDL TAB 0.2993 00080038188 CANDIBACTIN BR TABLET ORL TAB MTG TAB 0.3033 00080050373 CANDIBACTIN-AR CAPSULE ORL CAP MTG CAP 0.4550 00002311690 CANESORAL 150 MG CAPSULE ORL CAP BIC CAP 15.4200 00002311739 CANESORAL COMBI-PAK KIT ORL/VAG CAP/CRM BIC KIT 17.6300 00002311720 CANESTEN 1% EXTERNAL CREAM TOP CRM BIC G 13.3100 00002150867 CANESTEN 1% TOPICAL CREAM TOP CRM BAI G 0.3693 00080028872 CANTHACUR 0.7% TOPICAL SOLUTION TOP SOL PMS ML 6.7920 00000589500 CANTHACUR-PS TOPICAL SOLUTION TOP SOL PMS ML 8.1520 00000619035 CANTHARONE 0.7% TOPICAL SOLUTION TOP SOL BAK ML 6.6600 00080023975 CANTHARONE 0.7% TOPICAL SOLUTION TOP SOL DLX ML 6.6600 00000772011 CANTHARONE PLUS TOPICAL SOLUTION TOP SOL DLX ML 7.9933 00000619027 CANTHARONE PLUS TOPICAL SOLUTION TOP SOL BAK ML 7.9930 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 45 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002242738 CAPEX 0.01% TOPICAL SHAMPOO TOP SHP GAL ML 0.7203 00002157101 CAPSAICIN 0.025% TOPICAL CREAM TOP CRM VCL G 0.1917 00002157128 CAPSAICIN 0.075% TOPICAL CREAM TOP CRM VCL G 0.2325 00002060043 CARBACHOL 2 MG TABLET ORL TAB BNQ TAB 0.5900 00002413590 CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.0930 00002413604 CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.1859 00002241999 CARBOCAINE 10 MG/ML INJECTION INJ DEFAUL HSP ML 0.6313 00002242001 CARBOCAINE 20 MG/ ML INJECTION INJ DEFAUL HSP ML 1.2625 00002245511 CARBOCAL D 400 TABLET ORL TAB EUP TAB 0.1200 00002011239 CARBOLITH 600 MG CAPSULE ORL CAP VCL CAP 0.1848 00002126680 CARBOPLATIN 10 MG/ML INJECTION INJ DEFAUL HSP ML 19.2500 00002397447 CARIPUL 0.5 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 17.1760 00002397455 CARIPUL 1.5 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 34.4470 00002324520 CARVEDILOL 12.5 MG TABLET ORL TAB PDL TAB 0.6350 00002324539 CARVEDILOL 25 MG TABLET ORL TAB PDL TAB 0.6350 00002324504 CARVEDILOL 3.125 MG TABLET ORL TAB PDL TAB 0.6350 00002324512 CARVEDILOL 6.25 MG TABLET ORL TAB PDL TAB 0.6350 00002184478 CASODEX 50 MG TABLET ORL TAB AZC TAB 6.9733 00000291889 CATAPRES 0.2 MG TABLET ORL TAB BOE TAB 0.3306 00002245859 CATHFLO 1 MG/ML POWDER FOR SOLUTION INJ DEFAUL HLR ML 32.2880 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 46 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002215756 CAVERJECT 20 MCG INJECTION INJ DEFAUL PFI VIAL 24.3000 00000465208 CECLOR 25 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.1183 00000465186 CECLOR 250 MG CAPSULE ORL CAP PPH CAP 1.1092 00000832804 CECLOR 375 MG/5ML ORAL SUSPENSION ORL SUS PHH ML 0.2872 00000465216 CECLOR 50 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.2166 00000465194 CECLOR 500 MG CAPSULE ORL CAP PPH CAP 2.1777 00000360430 CEENU 10 MG CAPSULE ORL CAP BMS CAP 7.2950 00000360414 CEENU 100 MG CAPSULE ORL CAP BMS CAP 20.7625 00000360422 CEENU 40 MG CAPSULE ORL CAP BMS CAP 12.5775 00002237138 CEFAZOLIN 1 G/VIAL USP INJECTION INJ DEFAUL PPC VIAL 6.0000 00002437120 CEFAZOLIN 10 G/VIAL INJECTION INJ DEFAUL STM VIAL 30.1500 00002319039 CEFEPIME 2G/VIAL INJECTION INJ DEFAUL APX VIAL 30.1960 00002036274 CEFOTAN 1 G/VIAL INJECTION INJ DEFAUL WAY VIAL 15.0000 00002240773 CEFOXITIN 10 G/VIAL USP INJECTION INJ DEFAUL TEV VIAL 105.9500 00002332027 CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS RAN ML 0.2366 00000886971 CEFTAZIDIME 1 G/VIAL INJECTION INJ DEFAUL PPC VIAL 31.9700 00002437848 CEFTAZIDIME 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 22.9270 00002437856 CEFTAZIDIME 2 G/VIAL INJECTION INJ DEFAUL STM VIAL 45.0770 00000886955 CEFTAZIDIME 2 G/VIAL INJECTION INJ DEFAUL PPC VIAL 60.8100 00002439522 CEFTAZIDIME 3 G/VIAL INJECTION INJ DEFAUL STM VIAL 67.5000 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 47 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002437864 CEFTAZIDIME 6 G/VIAL INJECTION INJ DEFAUL STM VIAL 135.3000 00000886963 CEFTAZIDIME 6 G/VIAL INJECTION INJ DEFAUL PPC VIAL 190.9900 00002212307 CEFTIN 125 MG/5ML ORAL SUSPENSION ORL SUS GSK ML 0.1700 00002409968 CEFTRIAXONE 100 G/SMARTPAK BULK PACKAGE INJECTION INJ DEFAUL PPC G 21.4200 00002292262 CEFTRIAXONE FOR INJECTION BP 0.25G/VIAL INJECTION INJ DEFAUL SDZ VIAL 7.5250 00002287668 CEFTRIAXONE SODIUM FOR INJECTION 10 G/VIAL INJ INJ DEFAUL TEV VIAL 214.2000 00002250292 CEFTRIAXONE SODIUM FOR INJECTION BP 1 G/VIAL INJ INJ DEFAUL HSP VIAL 35.2500 00002422301 CEFUROXIME 1.5 G/VIAL INJECTION USP INJ DEFAUL STM VIAL 39.7900 00002241639 CEFUROXIME 1.5 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 39.7900 00002241640 CEFUROXIME 7.5 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 149.2000 00002422328 CEFUROXIME 7.5 G/VIAL INJECTION USP INJ DEFAUL STM VIAL 149.2000 00002422298 CEFUROXIME 750 MG/VIAL INJECTION USP INJ DEFAUL STM VIAL 19.8900 00002241638 CEFUROXIME 750 MG/VIAL INJECTION USP INJ DEFAUL PPC VIAL 19.8900 00002424371 CELECOXIB 100 MG CAPSULE ORL CAP PDL CAP 0.1776 00002424398 CELECOXIB 200 MG CAPSULE ORL CAP PDL CAP 0.3553 00002357844 CELESTODERM-V 0.1% TOPICAL CREAM TOP CRM VCL G 0.0911 00002357852 CELESTODERM-V 0.1% TOPICAL OINTMENT TOP ONT VCL G 0.0911 00002357860 CELESTODERM-V/2 0.05% TOPICAL CREAM TOP CRM VCL G 0.0611 00002357879 CELESTODERM-V/2 0.05% TOPICAL OINTMENT TOP ONT VCL G 0.0611 00002242145 CELLCEPT 200 MG/ ML ORAL SUSPENSION ORL SUS HLR ML 1.7653 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 48 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002192748 CELLCEPT 250 MG ORAL CAPSULE ORL CAP HLR CAP 2.0806 00002237484 CELLCEPT 500 MG TABLET ORL TAB HLR TAB 4.1612 00002240347 CELLCEPT I.V. 500 MG/VIAL INJECTION POWDER FOR SOL INJ DEFAUL HLR VIAL 32.0000 00000870153 CELLUVISC 1% OPH SOLUTION OPH SOL ALL ML 0.8217 00002299844 CELSENTRI 150 MG TABLET ORL TAB PFI TAB 16.6485 00002299852 CELSENTRI 300 MG TABLET ORL TAB PFI TAB 16.6485 00080013657 CENTRUM ADVANTAGE TABLET ORL TAB PDH TAB 0.1863 00080022930 CENTRUM CARDIO TABLET ORL TAB PDH TAB 0.2226 00080024482 CENTRUM FOR WOMEN ORL TAB PDH TAB 0.1440 00080005174 CENTRUM FORTE TABLET ORL TAB PDH TAB 0.1700 00080020794 CENTRUM JUNIOR COMPLETE CHEWABLE TABLET ORL CTB PDH TAB 0.1238 00002246440 CENTRUM SELECT CHEWABLE TABLET ORL CTB WCH TAB 0.2223 00080005153 CENTRUM SELECT TABLET ORL TAB WCH TAB 0.1563 00080021452 CENTRUM TABLET ORL TAB PDH TAB 0.1328 00002246362 CENTRUM TABLET ORL TAB PDH TAB 0.0919 00002099365 CEPACOL MINT WITH FLUORIDE MOUTHWASH ORL MWH RBC ML 0.0040 00000828866 CEPHALEXIN 500 MG TABLET ORL TAB PDL TAB 0.4500 00002410923 CERAVE TOPICAL LOTION TOP LOT VCL ML 0.1010 00002230988 CEREBYX 75 MG/ML INJECTION INJ DEFAUL PFI ML 7.6000 00002230694 CEREZYME 200 U/VIAL INJECTION INJ DEFAUL GZM VIAL 1230.0000 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 49 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002241751 CEREZYME 400 U/VIAL INJECTION INJ DEFAUL GZM VIAL 2460.0000 00001926683 CERUBIDINE 20 MG/VIAL INJECTION INJ DEFAUL ERF VIAL 92.0000 00000158356 CERUMENEX 10% OTIC DROPS OT DPS PUR ML 0.5740 00000221570 CERUMOL OTIC DROPS OT DPS PAL ML 0.4900 00002342227 CERVARIX 0.5 ML INJECTION INJ DEFAUL GSK ML 181.6200 00002312263 CESAMET 0.25 MG ORAL CAPSULE ORL CAP VCL CAP 1.7044 00002247766 CETROTIDE 0.25 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 90.0000 00002247767 CETROTIDE 3 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 340.0000 00000496685 CHELATED CHROMIUM 200 MCG TABLET ORL TAB JAM TAB 0.0721 00080009742 CHEWABLE PEPPERMINT VITAMIN D 1000 IU ORL TAB SWS TAB 0.0479 00002248435 CHILDREN'S ADVIL COLD ORAL SUSPENSION ORL SUS PDH ML 0.0590 00002354799 CHILDREN'S EUROPROFEN 20 MG/ML ORAL SUSPENSION ORL SUS PPH ML 0.0528 00002238626 CHILDREN'S MOTRIN 40 MG/ML SUSPENSION DROPS ORL DPS MCL ML 0.1907 00002238295 CHILDRENS TYLENOL 80 MG CHEWABLE TABLET ORL CTB MCL TAB 0.1708 00000870455 CHILDRENS TYLENOL COLD DM CHEWABLE TABLET ORL CTB MCL TAB 0.1763 00002039990 CHILDREN'S TYLENOL COLD DM ORAL SUSPENSION ORL SUS MCL ML 0.0540 00002229538 CHILDRENS TYLENOL DECONGESTANT LIQUID ORL LIQ MCL ML 0.0540 00002046040 CHILDREN'S TYLENOL GRAPE 32 MG/ML ORAL SUSPENSION ORL SUS MCL ML 0.0540 00002247621 CHLORAL HYDRATE-ODAN 100 MG/ML ORAL SYRUP ORL SYR ODN ML 0.0433 00000743518 CHLORPROMAZINE HCL 25 MG/ML (BASE) INJECTION INJ DEFAUL SDZ ML 1.8350 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 50 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000738972 CHLOR-TRIPOLON 4 MG TABLET ORL TAB SCH TAB 0.2117 00001970399 CHLOR-TRIPOLON N.D. SUSTAINED-RELEASE TABLET ORL TAB SCH TAB 0.4342 00000738964 CHLOR-TRIPOLON REPETABS 12 MG SUST RELEASE TABLET ORL SRT SCH TAB 0.3213 00080015373 CHONDROCARE TABLET ORL TAB MTG TAB 0.4500 00002247459 CHORIONIC GONADOTROPIN 10,000 UNIT/VIAL INJECTION INJ DEFAUL PPC VIAL 126.0000 00080005091 CHROMIUM GTF TABLET ORL TAB WNP TAB 0.0412 00002248088 CIALIS 10 MG TABLET ORL TAB LIL TAB 14.0300 00002296888 CIALIS 2.5 MG TABLET ORL TAB LIL TAB 4.2907 00002248089 CIALIS 20 MG TABLET ORL TAB LIL TAB 14.5375 00002296896 CIALIS 5 MG TABLET ORL TAB LIL TAB 4.2907 00002238274 CI-CAL + D TABLET ORL TAB EUP TAB 0.1442 00002238273 CI-CAL 250 MG TABLET ORL TAB EUP TAB 0.1368 00002410346 CICLOPIROX 8% TOPICAL SOLUTION TOP SOL STM G 7.7433 00002350971 CILAZAPRIL 2.5 MG TABLET ORL TAB SNS TAB 0.4284 00002350998 CILAZAPRIL 5 MG TABLET ORL TAB SNS TAB 0.2085 00002200864 CILOXAN 0.3% OPH OINTMENT OPH ONT ALC G 3.0943 00002331675 CIMZIA 200 MG/ML INJECTION SYRINGE INJ NDL UCB SYR 664.5100 00080005972 CINNAMON 500 MG CAPSULE ORL CAP VTH CAP 0.0600 00002391449 CIPRALEX MELTZ 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LBC TAB 1.7170 00002391457 CIPRALEX MELTZ 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LBC TAB 1.8280 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 51 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002251787 CIPRO XL 1000 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.1120 00002247916 CIPRO XL 500 MG EXTENDED-RELEASE TABLET ORL ERT BAI TAB 3.1120 00002304546 CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ INJ DEFAUL APX ML 0.1445 00002304759 CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ INJ DEFAUL SDZ ML 0.1540 00002403188 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL TEV ML 6.1524 00002126613 CISPLATIN 1 MG/ML INJECTION INJ DEFAUL MNP ML 6.4600 00002301822 CITALOPRAM 10 MG TABLET ORL TAB MEL TAB 0.4464 00002445719 CITALOPRAM 10 MG TABLET ORL TAB SNS TAB 0.1432 00002301830 CITALOPRAM 20 MG TABLET ORL TAB MEL TAB 0.8750 00002301849 CITALOPRAM 40 MG TABLET ORL TAB MEL TAB 0.8750 00002325047 CITALOPRAM-10 10 MG TABLET ORL TAB PDL TAB 0.1432 00002257521 CITALOPROM-40 40 MG TABLET ORL TAB PDL TAB 0.3329 00000519235 CITANEST PLAIN 4% INJECTION INJ DEFAUL DSC ML 0.8658 00002150220 CITRACAL MG TABLET ORL TAB SFD TAB 0.1535 00002150158 CITRACAL PLUS D CAPLET ORL TAB SFD TAB 0.1548 00000262609 CITRO MAG 50 MG ORAL LIQUID ORL LIQ ROG ML 0.0146 00002324482 CLARITHROMYCIN 250 MG TABLET ORL TAB PDL TAB 0.4122 00002442485 CLARITHROMYCIN 500 MG TABLET ORL TAB SIV TAB 1.6292 00002324490 CLARITHROMYCIN 500 MG TABLET ORL TAB PDL TAB 1.6297 00002237734 CLARITIN 10 MG RAPID DISSOLVE TONGUE TABLET ORL DISPTAB SCH TAB 0.6700 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 52 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000782696 CLARITIN 10 MG TABLET ORL TAB SCH TAB 0.8356 00001945157 CLARITIN EXTRA SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.6700 00000442968 CLEARASIL BP PLUS 5% TOPICAL LOTION TOP LOT RBC ML 0.1707 00002324989 CLEARLAX ORAL POWDER ORL PWR PRI G 0.0275 00002250616 CLIMARA PRO 4.40 MG/1.39 MG TRANSDERMAL PATCH TRD PTH BAI PTH 6.6950 00002408511 CLINDAMYCIN IV INFUSION 12 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.3724 00002408538 CLINDAMYCIN IV INFUSION 18 MG/ML MINIBAG INJECTION INJ DEFAUL SDZ ML 0.5186 00002248525 CLINDAMYCINE-150 150 MG TABLET ORL TAB PDL TAB 0.2217 00002248526 CLINDAMYCINE-300 300 MG CAPSULE ORL CAP PDL CAP 0.4434 00002242970 CLINDASOL 1% TOPICAL CREAM TOP CRM GSK G 0.8112 00002243050 CLINDETS PLEDGET 1% TOPICAL PAD TOP PAD GSK PAD 0.6698 00080007070 CLINIDERM GENTLE SPF 45 LOTION TOP LOT SAH ML 0.2415 00002248454 CLOBAZAM-10 10 MG TABLET ORL TAB PDL TAB 0.1097 00002256398 CLOBEX 0.05% TOPICAL LOTION TOP LOT GAL ML 0.8763 00002256371 CLOBEX 0.05% TOPICAL SHAMPOO TOP SHP GAL ML 0.8763 00002299739 CLOBEX 0.05% TOPICAL SPRAY TOP SPR GAL ML 1.7822 00002442027 CLONAZEPAM 0.25 MG TABLET ORL TAB SIV TAB 0.0774 00002442043 CLONAZEPAM 1 MG TABLET ORL TAB SIV TAB 0.1487 00001910396 CLONIDINE 0.1 MG TABLET ORL TAB PDL TAB 0.1358 00002394820 CLOPIDOGREL 75 MG TABLET ORL TAB PDL TAB 0.6577 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 53 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000812382 CLOTRIMADERM 1% TOPICAL CREAM TOP CRM TAR G 0.3065 00002229380 CLOTRIMAZOLE 1% TOPICAL CREAM USP TOP CRM TAR G 0.2100 00002274337 CO BICALUTAMIDE 50 MG TABLET ORL TAB APH TAB 4.0573 00002285215 CO CILAZAPRIL 2.5 MG TABLET ORL TAB APH TAB 0.1795 00002285223 CO CILAZAPRIL 5 MG TABLET ORL TAB APH TAB 0.2085 00002390183 CO EXEMESTANE 25 MG TABLET ORL TAB APH TAB 3.9008 00002379996 CO MYCOPHENOLATE 500 MG TABLET ORL TAB APH TAB 2.0620 00080006266 CO Q10 100 MG CAPSULE ORL CAP SIS CAP 0.1666 00080007078 CO Q10 LIQUID ORL LIQ INN ML 0.7941 00002244814 CO TEMAZEPAM 15 MG CAPSULE ORL CAP APH CAP 0.0438 00002244815 CO TEMAZEPAM 30 MG CAPSULE ORL CAP APH CAP 0.0526 00002383209 CO TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB APH TAB 0.6264 00002331748 CO VALACYCLOVIR 500 MG TABLET (CAPLET) ORL TAB APH TAB 0.8475 00000068594 COACTIFED ORAL SYRUP ORL SYR GSK ML 0.1643 00000068608 COACTIFED TABLET ORL TAB GSK TAB 1.0012 00002150417 COATED ASPIRIN 325 MG CAPLET ORL ECT BAI TAB 0.0802 00002237726 COATED ASPIRIN DAILY LOW DOSE 81 MG ECT ORL ECT BIC TAB 0.1087 00002150425 COATED ASPIRIN EXTRA STRENGTH 500 MG CAPLET ORL ECT BAI TAB 0.0755 00002243897 COATED DAILY LOW-DOSE ASA 81 MG TABLET ORL ECT PMS TAB 0.0433 00002009757 CODEINE 30 MG TABLET ORL TAB RIV TAB 0.0773 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 54 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002163748 CODEINE CONTIN 100 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.6660 00002163780 CODEINE CONTIN 150 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.9990 00002163799 CODEINE CONTIN 200 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 1.3320 00002230302 CODEINE CONTIN 50 MG SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.3330 00000050024 CODEINE PHOSPHATE 5 MG/ML ORAL SYRUP ORL SYR ATL ML 0.0555 00002246219 COENZYME Q10 100 MG CAPSULE ORL CAP WNP CAP 0.1403 00002248644 COENZYME Q10 100 MG CAPSULE ORL CAP VTH CAP 0.3266 00080010367 COENZYME Q10 150 MG SOFTGEL ORL CAP WBP CAP 0.3887 00080006827 COENZYME Q10 30 MG CAPSULE ORL CAP WNP CAP 0.1237 00002231735 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.3000 00080006674 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.2473 00002245926 COENZYME Q10 60 MG CAPSULE ORL CAP WNP CAP 0.2540 00080006505 COENZYME Q10 SOFTGEL ORL TAB WNP TAB 0.1390 00000287873 COLCHICINE 0.6 MG TABLET ORL TAB EUP TAB 0.2565 00000476420 COLY-MYCIN M 150 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 39.5000 00001944363 COMBANTRIN 125 MG TABLET ORL TAB MCL TAB 1.1083 00001944355 COMBANTRIN 50 MG/ML ORAL SUSPENSION ORL SUS MCL ML 0.2789 00002419106 COMBIVENT RESPIMAT 20 MCG/100 MCG INH SOLUTION INH CTG BOE CTG 28.7000 00002239213 COMBIVIR TABLET ORL TAB GSK TAB 10.5873 00002374129 COMPLERA 200 MG/25 MG/300 MG TABLET ORL TAB GIL TAB 41.5741 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 55 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002229633 COMPLETE MULTI-ADULT TABLET ORL TAB WAM TAB 0.0607 00000999760 COMPLEX 15 DAILY FACE CREAM TOP CRM MFC ML 0.0632 00002247732 CONCERTA 18 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.0985 00002250241 CONCERTA 27 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.4218 00002247733 CONCERTA 36 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.7451 00002247734 CONCERTA 54 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.3915 00001945149 CONDYLINE 0.5% TOPICAL SOLUTION TOP SOL SAV ML 11.5771 00002417162 CONSTELLA 145 MCG CAPSULE ORL CAP FLC CAP 3.3000 00002417170 CONSTELLA 290 MCG CAPSULE ORL CAP FLC CAP 5.3000 00002224577 COPHYLAC ORAL SOLUTION ORL SOL VCL ML 2.2027 00002176955 COQ10 30 MG CAPSULE ORL CAP JAM CAP 0.2248 00080012965 COQ10 MRB 60 MG SOFTGEL CAPSULE ORL CAP INN CAP 0.7950 00002036282 CORDARONE 200 MG TABLET ORL TAB PFI TAB 2.0589 00000513288 CORTATE 0.5% TOPICAL CREAM TOP CRM MFC G 0.1333 00000022381 CORTROSYN 0.25 MG/VIAL INJECTION INJ DEFAUL LYN VIAL 98.7600 00002438070 COSENTYX 150 MG/ML INJECTION SYRINGE INJ NDL NOV SYR 822.5000 00002181215 COTAZYM ECS 4 CAPSULE (ENTERIC-COATED PELLET) ORL CAP/ENCP ORG CAP 0.1795 00002099748 COUGH SYRUP WITH CODEINE ORL SYR ROG ML 0.0162 00002240206 COUMADIN 6 MG TABLET ORL TAB DPM TAB 0.4865 00002243063 COVAN ORAL SYRUP ORL SYR PMS ML 0.0573 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 56 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002246568 COVERSYL PLUS LD 2 MG/0.625 MG TABLET ORL TAB SEV TAB 0.8477 00080018683 CRANBERRY 500 MG CAPSULE ORL CAP VCL CAP 0.0516 00080027158 CRANBERRY COMPLEX 500 MG CAPSULE ORL CAP JAM CAP 0.1965 00002239007 CREON 5 MINIMICROSPHERES CAPSULE ORL CAP/ENCP ABB CAP 0.1703 00002415194 CREON MINIMICROSPHERES 6 CAPSULE ORL CAP/ENCP BGP CAP 0.1703 00000299561 CREO-RECTAL ADULT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.7500 00000299588 CREO-RECTAL INFANT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.6020 00000299596 CREO-RECTAL INFANT RECTAL SUPPOSITORY RT SUP SDZ SUP 0.7500 00002241013 CRINONE 8% VAGINAL GEL VAG GEL SRO G 8.2759 00002277778 CRITIC-AID CLEAR OINTMENT TOP ONT COC G 0.1070 00002229161 CRIXIVAN 200 MG CAPSULE ORL CAP MFC CAP 1.3467 00002229196 CRIXIVAN 400 MG CAPSULE ORL CAP MFC CAP 2.6933 00002089912 CUTIVATE 0.05% TOPICAL CREAM TOP CRM GKC G 0.7250 00002220644 CYCLOBENZAPRINE 10 MG TABLET ORL TAB PDL TAB 0.3727 00002424584 CYCLOBENZAPRINE 10 MG TABLET ORL TAB SIV TAB 0.3727 00002148331 CYCLOPENTOLATE HCL 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00002148382 CYCLOPENTOLATE HCL 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00002290308 CYESTRA-35 TABLET ORL TAB PMS TAB 1.1114 00002443805 CYRAMZA 10 MG/ ML INJECTION INJ DEFAUL LIL ML 8.4858 00002238526 CYSTADANE 1 G/SCOOP ORAL POWDER ORL PWR ORP G 4.5524 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 57 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080038525 CYSTA-Q CAPSULE ORL CAP TPI CAP 0.4900 00002126656 CYTARABINE 100MG/ ML INJECTION INJ DEFAUL MNP ML 12.6700 00000386715 CYTOSAR 100 MG/5 ML INJECTION INJ DEFAUL PFI VIAL 10.7240 00002444747 DAKLINZA 30 MG TABLET ORL TAB BMS TAB 428.5700 00002444755 DAKLINZA 60 MG TABLET ORL TAB BMS TAB 428.5700 00002060604 DALACIN 2% VAGINAL CREAM VAG CRM PAL G 0.7705 00000582301 DALACIN T 1% (BASE) TOPICAL SOLUTION TOP SOL PFI ML 0.3397 00000507415 DAN-GARD 2% TOPICAL SHAMPOO TOP SHP VLP ML 0.0400 00001997653 DANTRIUM 100 MG CAPSULE ORL CAP PAR CAP 0.7684 00002359456 DAXAS 500 MCG TABLET ORL TAB TAK TAB 2.1000 00002027860 DAYPRO 600 MG TABLET ORL TAB PFI TAB 0.7255 00002285002 DDAVP MELT 120 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 1.9823 00002285010 DDAVP MELT 240 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 3.5683 00002284995 DDAVP MELT 60 MCG ORALLY DISINTEGRATING TABLET ORL DISNTAB FEI TAB 0.9910 00080001791 DDROPS 1,000 IU/DROP ORAL LIQUID ORL LIQ DDR ML 1.3800 00002389282 DECAPEPTYL 0.1 MG/ML INJECTION SYRINGE INJ DEFAUL FEI SYR 12.0000 00000791172 DECONGEST 0.1 MG NASAL SOLUTION NAS SOL RPH ML 0.1510 00002018403 DELSYM 6 MG/ML CONTROLLED-RELEASE SUSPENSION ORL CRSUS NVC ML 0.0634 00002238848 DENAVIR 1% TOPICAL CREAM TOP CRM BRR G 14.3200 00000681989 DERMAFLEX HC 1% CREAM TOP CRM PAL G 0.1746 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 58 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000681997 DERMAFLEX HC 1% TOPICAL LOTION TOP LOT PAL ML 0.1037 00002247093 DERMAL THERAPY- HEEL CARE CREAM TOP CRM DTR ML 0.0792 00002239903 DERMALAC 12% CREAM TOP CRM TAR G 0.0571 00002060345 DERMAREST DRICORT 0.5% TOPICAL CREAM TOP CRM DEL G 0.1657 00000873292 DERMA-SMOOTHE/FS 0.01% TOPICAL OIL TOP OIL HDI ML 0.2809 00002230642 DERMATOP 0.1% EMOLLIENT CREAM TOP EMCRM VCL G 1.7125 00002227517 DERMATOP 0.1% TOPICAL OINTMENT TOP ONT VCL G 1.5095 00002238407 DERMAZINC 0.25% TOPICAL SPRAY TOP SPR DPI ML 0.2333 00002300559 DERMOTIC OIL EAR DROPS 0.01% OTIC SOLUTION OT SOL HDI ML 1.6000 00002216280 DESIPRAMINE 100 MG TABLET ORL TAB AAP TAB 0.9093 00001942417 DESITIN DIAPER RASH OINTMENT TOP ONT JJI G 0.0588 00002298155 DESLORATADINE ALLERGY CONTROL 5 MG TABLET ORL TAB PMS TAB 0.5193 00002239064 DETROL 1 MG TABLET ORL TAB PFI TAB 0.9928 00002239065 DETROL 2 MG TABLET ORL TAB PFI TAB 0.9928 00002204274 DEXAMETHASONE OMEGA 10 MG/ML INJECTION INJ DEFAUL OMG ML 1.2830 00002204266 DEXAMETHASONE OMEGA 4 MG/ML INJECTION INJ DEFAUL OMG ML 1.6060 00000489158 DEXASONE 4 MG TABLET ORL TAB VCL TAB 0.8140 00000832030 DEXIDIN 20 MG TOPICAL SOLUTION TOP LIQ ATL ML 0.0374 00000832111 DEXIDIN 4 % TOPICAL LIQUID TOP LIQ ATL ML 0.0119 00002354950 DEXILANT 30 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.2000 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 59 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002354969 DEXILANT 60 MG DELAYED-RELEASE CAPSULE ORL DRC TAK CAP 2.2000 00000833231 DEXTROMETHORPHAN 15 MG/5 ML COUGH SYRUP ORL SYR TAN ML 0.0199 00002058235 DEY-PAK SODIUM CHLORIDE 0.9% INHALATION SOLUTION INH SOL MYP ML 0.0567 00002237450 D-FORTE 50000 IU CAPSULE ORL CAP EUP CAP 0.1986 00002245391 DIAMINE TABLET ORL TAB EUP TAB 0.0631 00080028781 DIAMINE TABLET ORL TAB EUP TAB 0.0631 00002233542 DIANE-35 2 MG/0.035 MG TABLET ORL TAB BHP TAB 1.6381 00002337452 DIAPER RASH 15% TOPICAL CREAM TOP CRM HJS G 0.0093 00002229552 DIARR-EZE 2 MG CAPLET ORL TAB PMS TAB 0.3000 00002248994 DIARRHEA RELIEF 2 MG TABLET ORL TAB PMS TAB 0.1778 00002238162 DIASTAT RECTAL DELIVERY SYS 5 MG/ML RECTAL GEL RT GEL VCL SYS 76.7900 00000434388 DIAZEPAM 10 MG TABLET ORL TAB PDL TAB 0.0867 00000313580 DIAZEPAM 5 TABLET ORL TAB PDL TAB 0.0650 00000870978 DICLOFENAC 50 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.2024 00002351684 DICLOFENAC POTASSIUM 50 MG TABLET ORL TAB SNS TAB 0.3937 00002224127 DICLOFENAC-SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.4048 00002224119 DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.2343 00000392812 DICYCLOMINE HYDROCHLORIDE 10 MG/ML INJECTION INJ DEFAUL SDZ ML 4.3080 00002176017 DIDROCAL 400 MG/500 MG TABLET ORL TAB ASC TAB 0.4942 00002231592 DIFFERIN 0.1% TOPICAL CREAM TOP CRM GAL G 1.8635 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 60 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002148749 DIFFERIN 0.1% TOPICAL GEL TOP GEL GAL G 1.8635 00002274000 DIFFERIN XP 0.3% TOPICAL GEL TOP GEL GAL G 2.2287 00002387174 DIFICID 200 MG FILM-COATED TABLET ORL TAB MFC TAB 110.0000 00002039486 DIFLUNISAL 250 MG TABLET ORL TAB AAP TAB 0.5646 00002039494 DIFLUNISAL 500 MG TABLET ORL TAB AAP TAB 0.7150 00002048264 DIGOXIN 0.25 MG/ML INJECTION INJ DEFAUL SDZ ML 6.0745 00002048272 DIGOXIN PEDIATRIC 0.05 MG/ML INJECTION INJ DEFAUL SDZ ML 11.1700 00002241163 DIHYDROERGOTAMINE MESYLATE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 3.7933 00000627100 DILAUDID 2 MG/ML INJECTION INJ DEFAUL PUR ML 1.0832 00000622133 DILAUDID-HP 10 MG/ML INJECTION INJ DEFAUL PUR ML 2.6510 00002325306 DILTIAZEM TZ 120 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.4043 00002325314 DILTIAZEM TZ 180 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.5366 00002325322 DILTIAZEM TZ 240 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.7118 00002325330 DILTIAZEM TZ 300 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.8897 00002325349 DILTIAZEM TZ 360 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.0732 00002231472 DILTIAZEM-CD 120 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.3529 00002231474 DILTIAZEM-CD 180 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.4684 00002231475 DILTIAZEM-CD 240 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.6213 00002231057 DILTIAZEM-CD 300 MG CONTROLLED-DELIVERY CAPSULE ORL CDC PDL CAP 0.7766 00002300648 DIMENHYDRINATE 50 MG/ML INJECTION INJ DEFAUL ALV ML 2.5000 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 61 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002244079 DIMETANE EXPECTORANT C ORAL SYRUP ORL SYR PDH ML 0.0919 00002244080 DIMETANE EXPECTORANT DC ORAL SYRUP ORL SYR PDH ML 0.1242 00002243969 DIMETAPP DM COUGH & COLD ORAL LIQUID ORL LIQ PDH ML 0.0513 00002243091 DIMETAPP NIGHTTIME COLD EXTRA STRENGTH CAPLET ORL TAB WCH TAB 0.3125 00002244078 DIMETAPP-C ORAL SYRUP ORL SYR PDH ML 0.1111 00002243231 DIMETHYL SULFOXIDE IRRIGAT. 500 MG/G BLADDER SOL. BLDIR SOL SDZ ML 1.1840 00001997769 DIODOQUIN 210 MG TABLET ORL TAB GLE TAB 0.7533 00001997750 DIODOQUIN 650 MG TABLET ORL TAB GLE TAB 0.9347 00002027100 DIONEPHRINE 2.5% OPH SOLUTION OPH SOL DIO ML 0.7180 00002023717 DIOPHENYL-T OPH SOLUTION OPH SOL DIO ML 1.9467 00002023768 DIOPRED 1% OPH SUSPENSION OPH SUS SDZ ML 1.9400 00002270528 DIOVAN 40 MG TABLET ORL TAB NOV TAB 1.1671 00002157624 DIOVOL PLUS AF CHEWABLE TABLET ORL CTB CHD TAB 0.1188 00002157616 DIOVOL PLUS AF-SUSPENSION ORL SUS CHD ML 0.0170 00000116815 DIOVOL PLUS ORAL SUSPENSION ORL SUS CHD ML 0.0170 00000116882 DIOVOL PLUS TABLET ORL TAB CHD TAB 0.1188 00002257548 DIPHENHYDRAMINE HYDROCHLORIDE 25 MG CAPLET ORL TAB JPC TAB 0.1379 00002257556 DIPHENHYDRAMINE HYDROCHLORIDE 50 MG CAPLET ORL TAB JPC TAB 0.1659 00002369567 DIPHENHYDRAMINE HYDROCHLORIDE 50 MG/ML INJECTION INJ DEFAUL PPC ML 4.3900 00002219336 DIPHENIST 50 MG/ML INJECTION INJ DEFAUL OMG ML 4.1000 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 62 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000417262 DIPROGEN TOPICAL CREAM TOP CRM SCH G 0.8556 00002243961 DITROPAN XL 10 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.3000 00002243960 DITROPAN XL 5 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.3000 00002240341 DIVALPROEX-125 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.0724 00002240342 DIVALPROEX-250 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.1301 00002240343 DIVALPROEX-500 MG ENTERIC-COATED TABLET ORL TAB PDL TAB 0.2604 00002228335 DOBUTAMINE HYDROCHLORIDE 12.5 MG/ML INJECTION INJ DEFAUL TEV VIAL 23.2500 00002412225 DOCETAXEL 28 MG/ML (20 MG/0.72 ML) INJECTION INJ DEFAUL TEV ML 317.3194 00002412233 DOCETAXEL 28 MG/ML (80 MG/2.88 ML) INJECTION INJ DEFAUL TEV ML 317.3194 00002246741 DOCUSATE CALCIUM 240 MG CAPSULE ORL CAP ROG CAP 0.1283 00000870218 DOCUSATE SODIUM 10 MG/ML ORAL DROPS ORL DPS ROG ML 0.1860 00000794406 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP VTH CAP 0.0334 00000830267 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP TLI CAP 0.0338 00002245946 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP JPC CAP 0.0250 00002246036 DOCUSATE SODIUM 100 MG CAPSULE ORL CAP ROG CAP 0.0405 00002246854 DOCUSATE SODIUM 4 MG/ML ORAL SYRUP ORL SYR ROG ML 0.0245 00000614491 DOLORAL 1 MG ORAL SYRUP ORL SYR ATL ML 0.0327 00000614505 DOLORAL 5 MG ORAL SYRUP ORL SYR ATL ML 0.0559 00002130963 DOM-AMANTADINE 100 MG CAPSULE ORL CAP DPC CAP 0.5179 00002246331 DOM-AMIODARONE 200 MG TABLET ORL TAB DPC TAB 0.6177 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 63 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002326841 DOM-AMLODIPINE 10 MG TABLET ORL TAB DPC TAB 0.3587 00002326825 DOM-AMLODIPINE 2.5 MG TABLET ORL TAB DPC TAB 0.1380 00002326833 DOM-AMLODIPINE 5 MG TABLET ORL TAB DPC TAB 0.2417 00002229468 DOM-ATENOLOL 100 MG TABLET ORL TAB DPC TAB 0.3306 00002229467 DOM-ATENOLOL 50 MG TABLET ORL TAB DPC TAB 0.2011 00002399482 DOM-ATORVASTATIN 10 MG TABLET ORL TAB DPC TAB 0.3137 00002399490 DOM-ATORVASTATIN 20 MG TABLET ORL TAB DPC TAB 0.3922 00002399504 DOM-ATORVASTATIN 40 MG TABLET ORL TAB DPC TAB 0.4216 00002278499 DOM-AZITHROMYCIN 250 MG TABLET ORL TAB DPC TAB 1.2317 00002138271 DOM-BACLOFEN 10 MG TABLET ORL TAB DPC TAB 0.1595 00002138298 DOM-BACLOFEN 20 MG TABLET ORL TAB DPC TAB 0.4607 00002232564 DOM-BUSPIRONE 10 MG TABLET ORL TAB DPC TAB 0.3521 00002238222 DOM-CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TAB ORL SRT DPC TAB 0.1301 00002238223 DOM-CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TAB ORL SRT DPC TAB 0.2602 00002251280 DOM-CIPROFLOXACIN 500 MG TABLET ORL TAB DPC TAB 0.6979 00002273055 DOM-CITALOPRAM 10 MG TABLET ORL TAB DPC TAB 0.1432 00002351005 DOM-CLARITHROMYCIN 500 MG TABLET ORL TAB DPC TAB 1.6293 00002247230 DOM-CLOBAZAM 10 MG TABLET ORL TAB DPC TAB 0.1538 00002130998 DOM-CLONAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.0694 00002131013 DOM-CLONAZEPAM 2 MG TABLET ORL TAB DPC TAB 0.1196 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 64 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002224100 DOM-CLONAZEPAM-R 0.5 MG TABLET ORL TAB DPC TAB 0.0694 00002238633 DOM-CYCLOBENZAPRINE 10 MG TABLET ORL TAB DPC TAB 0.3727 00002130092 DOM-DESIPRAMINE 25 MG TABLET ORL TAB DPC TAB 0.2723 00002231662 DOM-DICLOFENAC 25 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.1094 00002231664 DOM-DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.4060 00002238315 DOM-DOMPERIDONE 10 MG TABLET ORL TAB DPC TAB 0.0831 00002376709 DOM-FINASTERIDE 5 MG TABLET ORL TAB DPC TAB 0.4633 00002246109 DOM-FLUCONAZOLE 100 MG TABLET ORL TAB DPC TAB 3.2047 00002246108 DOM-FLUCONAZOLE 50 MG TABLET ORL TAB DPC TAB 1.8065 00002177617 DOM-FLUOXETINE 10 MG CAPSULE ORL CAP DPC CAP 0.8650 00002177625 DOM-FLUOXETINE 20 MG CAPSULE ORL CAP DPC CAP 0.6438 00002241348 DOM-FLUVOXAMINE 100 MG TABLET ORL TAB DPC TAB 0.5297 00002241347 DOM-FLUVOXAMINE 50 MG TABLET ORL TAB DPC TAB 0.2947 00002243743 DOM-GABAPENTIN 100 MG CAPSULE ORL CAP DPC CAP 0.1456 00002243744 DOM-GABAPENTIN 300 MG CAPSULE ORL CAP DPC CAP 0.3542 00002243745 DOM-GABAPENTIN 400 MG CAPSULE ORL CAP DPC CAP 0.4221 00002241608 DOM-GEMFIBROZIL 300 MG CAPSULE ORL CAP DPC CAP 0.1803 00002234514 DOM-GLYBURIDE 5 MG TABLET ORL TAB DPC TAB 0.0683 00002239913 DOM-INDAPAMIDE 1.25 MG TABLET ORL TAB DPC TAB 0.1043 00002239917 DOM-INDAPAMIDE 2.5 MG TABLET ORL TAB DPC TAB 0.1706 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 65 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002372193 DOM-IRBESARTAN 150 MG TABLET ORL TAB DPC TAB 0.3025 00002414775 DOM-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC DPC CAP 0.5000 00002245784 DOM-LORAZEPAM 0.5 MG TABLET ORL TAB DPC TAB 0.0359 00002245785 DOM-LORAZEPAM 1 MG TABLET ORL TAB DPC TAB 0.0380 00002247232 DOM-LOVASTATIN 40 MG TABLET ORL TAB DPC TAB 1.2579 00002242726 DOM-METFORMIN 850 MG TABLET ORL TAB DPC TAB 0.1186 00002231122 DOM-METOPROLOL-L 100 MG TABLET ORL TAB DPC TAB 0.1941 00002231121 DOM-METOPROLOL-L 50 MG TABLET ORL TAB DPC TAB 0.0874 00002376695 DOM-MONTELUKAST FC 10 MG TABLET ORL TAB DPC TAB 0.8195 00002178729 DOM-NORTRIPTYLINE 10 MG CAPSULE ORL CAP DPC CAP 0.0772 00002178737 DOM-NORTRIPTYLINE 25 MG CAPSULE ORL CAP DPC CAP 0.1560 00002125145 DOM-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION ORL SUS DPC ML 0.0521 00002333430 DOM-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT DPC TAB 0.4117 00002241285 DOM-OXYBUTYNIN 5 MG TABLET ORL TAB DPC TAB 0.1508 00002248447 DOM-PAROXETINE 10 MG TABLET ORL TAB DPC TAB 0.8210 00002248448 DOM-PAROXETINE 20 MG TABLET ORL TAB DPC TAB 0.6320 00002248449 DOM-PAROXETINE 30 MG TABLET ORL TAB DPC TAB 0.6714 00002236857 DOMPERIDONE-10 10 MG TABLET ORL TAB PDL TAB 0.0594 00002238046 DOM-PINDOLOL 10 MG TABLET ORL TAB DPC TAB 0.3253 00002238047 DOM-PINDOLOL 15 MG TABLET ORL TAB DPC TAB 0.4718 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 66 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002231650 DOM-PINDOLOL 5 MG TABLET ORL TAB DPC TAB 0.1905 00002249723 DOM-PRAVASTATIN 10 MG TABLET ORL TAB DPC TAB 0.4050 00002249731 DOM-PRAVASTATIN 20 MG TABLET ORL TAB DPC TAB 0.4778 00002249758 DOM-PRAVASTATIN 40 MG TABLET ORL TAB DPC TAB 0.8057 00002299003 DOM-QUETIAPINE 100 MG TABLET ORL TAB DPC TAB 0.3295 00002299038 DOM-QUETIAPINE 200 MG TABLET ORL TAB DPC TAB 0.6617 00002298996 DOM-QUETIAPINE 25 MG TABLET ORL TAB DPC TAB 0.1235 00002299046 DOM-QUETIAPINE 300 MG TABLET ORL TAB DPC TAB 0.9656 00002320460 DOM-RABEPRAZOLE EC 20 MG ENTERIC-COATED TABLET ORL ECT DPC TAB 0.2407 00002287986 DOM-RAMIPRIL 10 MG CAPSULE ORL CAP/TAB DPC CAP 0.1862 00002287951 DOM-RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB DPC CAP 0.1470 00002287978 DOM-RAMIPRIL 5 MG CAPSULE ORL CAP/TAB DPC CAP 0.1470 00002243038 DOM-RANITIDINE 150 MG TABLET ORL TAB DPC TAB 0.1800 00002309831 DOM-RISEDRONATE 35 MG TABLET ORL TAB DPC TAB 2.4275 00002396203 DOM-RIZATRIPTAN RDT 10 MG ORALLY DISINT. TABLET ORL DISNTAB DPC TAB 3.7050 00002216949 DOM-SALBUTAMOL 1 MG/ML INHALATION SOLUTION INH SOL DPC ML 0.3618 00002245750 DOM-SERTRALINE 100 MG CAPSULE ORL CAP DPC CAP 0.4200 00002245748 DOM-SERTRALINE 25 MG CAPSULE ORL CAP DPC CAP 0.2004 00002245749 DOM-SERTRALINE 50 MG CAPSULE ORL CAP DPC CAP 0.4000 00002238635 DOM-SOTALOL 160 MG TABLET ORL TAB DPC TAB 0.1623 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 67 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002238634 DOM-SOTALOL 80 MG TABLET ORL TAB DPC TAB 0.2966 00002270765 DOM-SUMATRIPTAN 100 MG TABLET ORL TAB DPC TAB 7.8600 00002243749 DOM-TERAZOSIN 10 MG TABLET ORL TAB DPC TAB 0.6183 00002128969 DOM-TRAZODONE 100 MG TABLET ORL TAB DPC TAB 0.0989 00002128950 DOM-TRAZODONE 50 MG TABLET ORL TAB DPC TAB 0.0554 00002414147 DOM-VALSARTAN 80 MG TABLET ORL TAB DPC TAB 0.2957 00002299313 DOM-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE ORL ERC DPC CAP 0.3469 00002299291 DOM-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAP ORL ERC DPC CAP 0.1643 00002299305 DOM-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAP ORL ERC DPC CAP 0.3285 00002240321 DOM-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT DPC TAB 0.6767 00002389525 DOM-ZOLMITRIPTAN 2.5 MG TABLET ORL TAB DPC TAB 4.6050 00002246317 DOM-ZOPICLONE 5 MG TABLET ORL TAB DPC TAB 0.2231 00002240823 DOM-ZOPICLONE 7.5 MG TABLET ORL TAB DPC TAB 0.4685 00002416425 DONEPEZIL 10 MG TABLET ORL TAB PDL TAB 1.2340 00002416417 DONEPEZIL 5 MG TABLET ORL TAB PDL TAB 1.2340 00002240978 DOXAZOSIN-1 1MG TABLET ORL TAB PDL TAB 0.1416 00002240979 DOXAZOSIN-2 2 MG TABLET ORL TAB PDL TAB 0.1699 00002240980 DOXAZOSIN-4 4 MG TABLET ORL TAB PDL TAB 0.2209 00002375710 DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 13.0420 00002230108 DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION INJ DEFAUL TEV ML 11.4000 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 68 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002413973 DOXORUBICIN HYDROCHLORIDE 2MG/ML INJECTION USP INJ DEFAUL MYP ML 11.4000 00000817120 DOXYCIN 100 MG CAPSULE ORL CAP RIV CAP 0.5860 00000860751 DOXYCIN 100 MG TABLET ORL TAB RIV TAB 0.5860 00000887064 DOXYTAB 100 MG TABLET ORL TAB PDL TAB 0.5860 00001929313 DRISTAN DECONGESTANT NASAL MIST SOLUTION NAS SOL PDH ML 0.3173 00001929372 DRISTAN LONG LASTING 0.05% NASAL MIST SOLUTION NAS SOL PDH ML 0.3173 00001929380 DRISTAN LONG LASTING MENTHOLATED 0.05% NASAL SPRAY NAS SPR PDH ML 0.3173 00000740861 DRIXORAL DESCONGESTANT 0.05% NASAL SOLUTION NAS SOL SCH ML 0.1593 00000298433 DRIXORAL SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.4020 00000342742 DRYSOL 20% TOPICAL SOLUTION TOP SOL SFD ML 0.4203 00000821772 D-TAB 10,000 UNIT TABLET ORL TAB RIV TAB 0.2100 00002439530 DUAKLIR GENUAIR 400MCG/12MCG INHALATION POWDER INH MIP AZC DOSE 1.2350 00002247208 DUKORAL ORAL SUSPENSION ORL SUS AVE DOSE 35.9900 00002292165 DUODOPA 20 MG/ML / 5MG/ML (100 ML) INTESTINAL GEL INTRA GEL ABV CAS 166.0000 00002239299 DUOFILM 40% TOPICAL PATCH TOP PTH MMH PTH 0.4633 00000370576 DUOFILM TOPICAL SOLUTION TOP SOL GSK ML 0.5413 00002125706 DUOLUBE OPH OINTMENT OPH ONT BSH G 1.4771 00000656747 DUONALC E (MILD) 20% TOPICAL SOLUTION TOP SOL VCL ML 0.2196 00000490156 DUONALC E 47.5% TOPICAL SOLUTION TOP SOL VCL ML 0.2196 00002148633 DUOVENT UDV INHALATION SOLUTION INH SOL BOE ML 0.8264 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 69 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002275848 DURAGESIC MAT 75 (75 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 39.1380 00002275856 DURAGESIC MAT 100 (100 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 48.7140 00002334186 DURAGESIC MAT 12 (12 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 5.7360 00002275813 DURAGESIC MAT 25 (25 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 14.7860 00002275821 DURAGESIC MAT 50 (50 MCG/HR) TRANSDERMAL PATCH TRD PTH JAI PTH 27.8300 00002373017 DURELA 100 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 1.1400 00002373025 DURELA 200 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 2.0800 00002373033 DURELA 300 MG EXTENDED-RELEASE CAPSULE ORL ERC CIP CAP 2.8800 00002415534 DUREZOL 0.05% OPHTHALMIC EMULSION OPH EML ALC ML 5.4000 00000999010 DUROLANE DEFAUL DEV QMD ML 143.3300 00002421712 DUTASTERIDE 0.5 MG CAPSULE ORL CAP PDL CAP 0.9624 00001947958 DUVOID 10 MG TABLET ORL TAB PAL TAB 0.3033 00001947931 DUVOID 25 MG TABLET ORL TAB PAL TAB 0.4914 00001947923 DUVOID 50 MG TABLET ORL TAB PAL TAB 0.6473 00002432889 DYMISTA 50 MCG/137 MCG METERED DOSE NASAL SPRAY NAS SPM MDP DOSE 0.7875 00002260638 EBIXA 10 MG TABLET ORL TAB LBC TAB 2.4403 00002381389 EDARBI 40 MG TABLET ORL TAB VCL TAB 1.2090 00002381397 EDARBI 80 MG TABLET ORL TAB VCL TAB 1.2090 00002397749 EDARBYCLOR 40 MG/12.5 MG TABLET ORL TAB TAK TAB 1.2090 00002397765 EDARBYCLOR 40 MG/25 MG TABLET ORL TAB TAK TAB 1.2090 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 70 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002397757 EDARBYCLOR 80 MG/12.5 MG TABLET ORL TAB TAK TAB 1.2090 00002370603 EDURANT 25 MG TABLET ORL TAB JAI TAB 14.6980 00080009719 EFAMOL 1000 MG CAPSULE ORL CAP FMD CAP 0.1667 00002349124 EFFIENT 10 MG TABLET ORL TAB LIL TAB 2.7377 00002209764 EGOZINC-HC RECTAL OINTMENT RT ONT PMS G 0.4160 00002210517 EGOZINC-HC RECTAL SUPPOSITORY RT SUP PMS SUP 0.6075 00002438712 EGRIFTA 1 MG/VIAL INJECTION INJ DEFAUL THE VIAL 51.4170 00002425637 ELELYSO 200 UNIT/VIAL INJECTION INJ DEFAUL PFI VIAL 648.3600 00002247238 ELIDEL 1 % TOPICAL CREAM TOP CRM VCL G 2.2768 00002248239 ELIGARD 10.2 MG/SYR INJECTION INJ NDL SAV SYR 310.7200 00002248240 ELIGARD 28.2 MG/SYR INJECTION INJ NDL SAV SYR 891.0000 00002248999 ELIGARD 35.8 MG/SYR INJECTION INJ NDL SAV SYR 1285.2000 00002268892 ELIGARD 58.2 MG/SYR INJECTION INJ NDL SAV SYR 1450.0000 00000627410 ELIXIR DE THEOPHYLLINE ORL ELX ATL ML 0.0050 00002436329 ELLA 30 MG TABLET ORL TAB ASC TAB 25.0000 00002296284 ELOXATIN 5 MG/ML INJECTION INJ DEFAUL SAV ML 51.8160 00002103109 ELTOR-120 120 MG SUSTAINED-RELEASE TABLET ORL SRT SAV TAB 0.2742 00002298805 EMEND 125 MG CAPSULE ORL CAP MFC CAP 31.2133 00002324679 EMEND IV 115 MG/VIAL INJ DEFAUL MFC VIAL 30.1800 00000886858 EMLA TOPICAL CREAM TOP CRM AZC G 1.8800 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 71 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002057794 EMLA TOPICAL PATCH TOP PTH AZC PTH 2.7000 00080008611 EMPOWER 18 PLUS CAPSULE ORL CAP TRU CAP 0.3025 00002248209 ENCA 100 MG CAPSULE ORL CAP PRP CAP 1.0332 00002248208 ENCA 50 MG CAPSULE ORL CAP PRP CAP 0.5350 00002334992 ENDOMETRIN 100 MG VAGINAL EFFERVESCENT TABLET VAG EVT FEI TAB 4.0000 00002296454 ENGERIX-B 10 MCG/0.5 ML SUSPENSION INJ DEFAUL GSK ML 20.9200 00002010526 ENTERIC COATED ASA 325 MG TABLET ORL ECT WTR TAB 0.0280 00000794244 ENTERIC COATED ASA 650 MG TABLET ORL ECT VTH TAB 0.0550 00002246971 ENTEX LA SUSTAINED-RELEASE TABLET ORL SRT PUR TAB 0.4425 00000010340 ENTROPHEN 10 650 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.0843 00001905392 ENTROPHEN 10 SUPER EXTRA STRENGTH 650 MG ECCPT ORL ECT PPH TAB 0.0705 00000852015 ENTROPHEN 500 MG ENTERIC-COATED TABLET ORL ECT PPH TAB 0.0686 00002050161 ENTROPHEN REGULAR STRENGTH (CAPLET) 325 MG ECCPT ORL ECT PPH TAB 0.0503 00000010332 ENTROPHEN REGULAR STRENGTH 325 MG ECT ORL ECT PPH TAB 0.0503 00002436841 ENTYVIO 300 MG/VIAL INJECTION INJ DEFAUL TAK VIAL 3290.0000 00000880183 EPI-LYT TOP LOT VCL ML 0.1127 00000721891 EPINEPHRINE 1 MG/ML INJECTION USP INJ NDL HSP SYR 3.8500 00002264927 EPIRUBICIN HYDROCHLORIDE 2 MG/ML INJECTION INJ DEFAUL HSP ML 13.3196 00002396971 EPURIS 10 MG CAPSULE ORL CAP CIP CAP 1.0710 00002396998 EPURIS 20 MG CAPSULE ORL CAP CIP CAP 1.4423 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 72 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002397005 EPURIS 30 MG CAPSULE ORL CAP CIP CAP 1.8140 00002397013 EPURIS 40 MG CAPSULE ORL CAP CIP CAP 2.1853 00002243801 EQUATE DAILY LOW-DOSE 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.1096 00002271249 ERBITUX 2 MG/ML INJECTION INJ DEFAUL BMS ML 7.2924 00002409267 ERIVEDGE 150 MG CAPSULE ORL CAP HLR CAP 294.2238 00000726672 ERYTHRO-EC 250 MG ENTERIC-COATED CAPSULE ORL CAP/ENCP AAP CAP 0.3900 00001925938 ERYTHRO-EC 333 MG ENTERIC-COATED CAPSULE ORL CAP/ENCP AAP CAP 0.4332 00002393751 ESBRIET 267 MG CAPSULE ORL CAP HLR CAP 13.0302 00002424401 ESCITALOPRAM 10 MG TABLET ORL TAB PDL TAB 1.4680 00002424428 ESCITALOPRAM 20 MG TABLET ORL TAB PDL TAB 1.5630 00002442493 ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT SIV TAB 1.8690 00002394839 ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT PDL TAB 1.5887 00002442507 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT SIV TAB 1.8690 00002431173 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT SNS TAB 1.8690 00002394847 ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT PDL TAB 1.4298 00002244990 ESSENTIAL VITAMINS AND MINERALS TABLET ORL TAB WNP TAB 0.0214 00002237515 ESTER C 1000 MG TABLET ORL TAB SIS TAB 0.1598 00002247480 ESTER-C 250 MG CHEWABLE TABLET ORL CTB WNP TAB 0.0799 00080003499 ESTER-C CAPSULE ORL CAP BMD CAP 0.1496 00000727369 ESTRAGYN 1MG/G VAGINAL CREAM VAG CRM SLP G 0.6667 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 73 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price TRD/ORL GEL/CAP MFC KIT 51.0000 00002403404 ESTROGEL PROPAK 0.06% TRANSDERM. GEL/100MG CAPSULE 00000247960 ETIBI 100 MG TABLET ORL TAB VCL TAB 0.2018 00000247979 ETIBI 400 MG TABLET ORL TAB VCL TAB 0.6054 00002353210 ETIDROCAL 400 MG/500 MG TABLET ORL TAB SNS TAB 0.2221 00002080036 ETOPOSIDE 20 MG/ML INJECTION INJ DEFAUL TEV ML 15.0000 00000637726 EUFLEX 250 MG TABLET ORL TAB MFC TAB 1.4131 00000999330 EUFLEXXA DEFAUL DEV FEI ML 56.8333 00080013021 EUPHORBIUM COMPOSITUM SN ORAL DROPS ORL DPS HEE ML 0.7650 00000623377 EURAX 10% TOPICAL CREAM TOP CRM CLC G 0.3584 00002242291 EURO - K8 600 MG SUSTAINED-RELEASE CAPSULE ORL SRC EUP CAP 0.0614 00080003010 EURO D 800 IU CAPSULE ORL CAP EUP CAP 0.0600 00002303825 EURO DOCUSATE C 100 MG CAPSULE ORL CAP EUP CAP 0.0328 00080011428 EURO K 975 975 MG (25 MEQ) EFFERVESCENT TABLET ORL EVT EUP TAB 0.5550 00002245668 EURO-CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP ORL SYR EUP ML 0.0624 00002242651 EURO-D VITAMIN D3 400 IU CAPSULE ORL CAP EUP CAP 0.0300 00002247385 EURO-DOCUSATE 100 MG CAPSULE ORL CAP EUP CAP 0.0328 00002246590 EURO-FER 20 MG/ML ORAL SUSPENSION ORL SUS EUP ML 0.0780 00002237556 EURO-FER 300 MG CAPSULE ORL CAP EUP CAP 0.1397 00002241802 EURO-FER CF CAPSULE ORL CAP EUP CAP 0.2330 00002246733 EURO-FERROUS SULFATE 300 MG TABLET ORL TAB EUP TAB 0.0157 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 74 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002412926 EURO-HYDROCORTISONE 1% CREAM TOP CRM EUP G 0.2000 00002247383 EURO-LAC 667 MG/ML SOLUTION ORL SOL PMS ML 0.0145 00002247389 EURO-SENNA 8.6 MG TABLET ORL TAB EUP TAB 0.0464 00002247390 EURO-SENNA S 8.6 MG/50 MG TABLET ORL TAB EUP TAB 0.1135 00002264374 EUTHYROX 100 MCG TABLET ORL TAB SRO TAB 0.0306 00002264390 EUTHYROX 112 MCG TABLET ORL TAB SRO TAB 0.0644 00002264404 EUTHYROX 125 MCG TABLET ORL TAB SRO TAB 0.0654 00002264412 EUTHYROX 137 MCG TABLET ORL TAB SRO TAB 0.1148 00002264420 EUTHYROX 150 MCG TABLET ORL TAB SRO TAB 0.0339 00002264439 EUTHYROX 175 MCG TABLET ORL TAB SRO TAB 0.0699 00002264447 EUTHYROX 200 MCG TABLET ORL TAB SRO TAB 0.0359 00002264323 EUTHYROX 25 MCG TABLET ORL TAB SRO TAB 0.0564 00002264455 EUTHYROX 300 MCG TABLET ORL TAB SRO TAB 0.0785 00002264331 EUTHYROX 50 MCG TABLET ORL TAB SRO TAB 0.0249 00002264358 EUTHYROX 75 MCG TABLET ORL TAB SRO TAB 0.0610 00002264366 EUTHYROX 88 MCG TABLET ORL TAB SRO TAB 0.0610 00080005494 EVENING PRIMROSE OIL SOFTGEL CAPSULE ORL CAP WNP CAP 0.0644 00002248297 EVRA 6 MG/0.6 MG TRANSDERMAL PATCH TRD PTH JAI PTH 5.5767 00002377179 EXACT ANTI-NAUSEANT 50 MG TABLET ORL TAB APX TAB 0.0627 00002243896 EXACT DAILY LOW-DOSE ASA 81 MG ENTERIC-COATED TAB ORL ECT PMS TAB 0.1330 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 75 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001990675 EXCEDRIN EXTRA-STRENGTH CAPLET ORL TAB NVC TAB 0.0588 00002302853 EXELON PATCH 10 (9.5 MG/24 H) TRD PTH NOV PTH 4.5387 00002432803 EXELON PATCH 15 (13.3 MG/24 H) TRD PTH NOV PTH 4.3877 00002302845 EXELON PATCH 5 (4.6 MG/24 H) TRD PTH NOV PTH 4.5387 00002226030 EX-LAX CHOCOLATED TABLET ORL TAB NVC TAB 0.2006 00002237524 EX-LAX EXTRA STRENGHT 25 MG TABLET ORL TAB NVC TAB 0.2354 00002184672 EXOREX 1% TOPICAL GEL TOP GEL YNG ML 0.2250 00002184680 EXOREX 2% TOPICAL GEL TOP GEL YNG ML 0.2250 00000813095 EXPECTORANT COUGH FORMULA 100 MG/5 ML ORAL SYRUP ORL SYR TAN ML 0.0199 00002315955 EXTRA STRENGTH ALLERGY RELIEF 10 MG TABLET ORL TAB PMS TAB 0.1730 00002242632 EXTRA STRENGTH MOTRIN IB 300 MG TABLET ORL TAB MCL TAB 0.1307 00002244142 EXTRA STRENGTH NIGHTTIME COLD RELIEF TABLET ORL TAB PPH TAB 0.1283 00000889806 EYELUBE .5% OPH DROPS OPH DPS SDZ ML 0.3093 00000874965 EYELUBE 1% OPH DROPS OPH DPS SDZ ML 0.3840 00000707937 EYE-STREAM EYE LIQUID OPH LIQ ALC ML 0.0930 00002415992 EYLEA 2 MG/VIAL INJECTION INJ DEFAUL BHP VIAL 1418.0000 00002422549 EZETIMIBE 10 MG TABLET ORL TAB PDL TAB 0.4612 00002248968 FACTIVE 320 MG TABLET ORL TAB ABB TAB 7.0000 00002324865 FAMCICLOVIR 125 MG TABLET ORL TAB PDL TAB 0.1394 00002247745 FAMOTIDINE OMEGA-(W PRES,BENZYL ALC) 10 MG/ML INJ INJ DEFAUL OMG ML 1.4000 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 76 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002247735 FAMOTIDINE OMEGA-(W/O PRESERVATIVE) 10 MG/ML INJ INJ DEFAUL OMG ML 2.3500 00002379910 FAMPYRA 10 MG SUSTAINED-RELEASE TABLET ORL SRT BIO TAB 9.2643 00002229110 FAMVIR 125 MG TABLET ORL TAB NOV TAB 2.9440 00002229129 FAMVIR 250 MG TABLET ORL TAB NOV TAB 3.9930 00002177102 FAMVIR 500 MG TABLET ORL TAB NOV TAB 7.1129 00002248624 FASLODEX 250 MG/5 ML INJECTION INJ NDL AZC SYR 565.2500 00002231384 FEMARA 2.5 MG TABLET ORL TAB NOV TAB 6.3073 00002242531 FEMHRT 1/5 TABLET ORL TAB PFI TAB 0.8400 00002286092 FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP SNS CAP 0.2723 00002240360 FENO-MICRO-200 MG CAPSULE ORL CAP PDL CAP 0.2723 00002395703 FENTANYL 100 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 12.0520 00002395657 FENTANYL 12 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 2.3480 00002395665 FENTANYL 25 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 3.6600 00002395673 FENTANYL 50 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 6.8840 00002395681 FENTANYL 75 MCG/HR TRANSDERMAL PATCH TRD PTH PDL PTH 9.6820 00002126648 FENTANYL CITRATE 50 MCG/ML INJECTION INJ DEFAUL MNP ML 1.5000 00002384124 FENTANYL CITRATE SDZ 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 2.2598 00002408007 FENTORA 100 MCG EFFERVESCENT TABLET BUC/SLG EVT TEV TAB 10.8968 00002408015 FENTORA 200 MCG EFFERVESCENT TABLET BUC/SLG EVT TEV TAB 10.8968 00002408023 FENTORA 400 MCG EFFERVESCENT TABLET BUC/SLG EVT TEV TAB 10.8968 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 77 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002408031 FENTORA 600 MCG EFFERVESCENT TABLET BUC/SLG EVT TEV TAB 10.8968 00002408058 FENTORA 800 MCG EFFERVESCENT TABLET BUC/SLG EVT TEV TAB 10.8968 00002377217 FERAHEME 30 MG/ML INJECTION INJ DEFAUL TAK ML 11.0294 00080033717 FERAMAX 15/1/4 TSP POWDER ORL PWR BIS G 0.2169 00080013210 FERAMAX 150 150 MG CAPSULE ORL CAP BIS CAP 0.4633 00000232599 FERMALAC VAGINAL CAPSULE VAG CAP ROG CAP 1.9310 00002248699 FERODAN 300 MG TABLET ORL TAB ODN TAB 0.0199 00002436558 FERRIPROX 1000 MG TABLET ORL TAB APP TAB 30.3600 00002243333 FERRLECIT 12.5 MG/ ML INJECTION INJ DEFAUL SAV ML 5.2720 00002138751 FERROUS FUMARATE 200 MG TABLET ORL TAB VTH TAB 0.0209 00000031089 FERROUS FUMARATE 300 MG TABLET ORL TAB WAM TAB 0.0625 00080009681 FERROUS GLUCONATE 300 MG TABLET ORL TAB WAM TAB 0.0625 00002244532 FERROUS GLUCONATE 300 MG TABLET ORL TAB PMT TAB 0.0400 00000041157 FERROUS GLUCONATE 300 MG TABLET ORL TAB ADA TAB 0.0371 00000031097 FERROUS GLUCONATE 300 MG TABLET ORL TAB WAM TAB 0.0212 00000582727 FERROUS GLUCONATE 324 MG TABLET ORL TAB VTH TAB 0.0231 00002245389 FERROUS GLUCONATE 35 MG TABLET ORL TAB WNP TAB 0.0785 00000782114 FERROUS SULFATE 300 MG TABLET ORL TAB WTR TAB 0.0346 00000346918 FERROUS SULFATE 300 MG TABLET ORL TAB PMT TAB 0.0385 00080005803 FIBER PLUS CAPSULE ORL CAP PLT CAP 0.2000 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 78 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002207230 FIBRE LAXATIVE 3.4 G/12 G ORAL POWDER ORL PWR PRI G 0.0060 00080009650 FIBRE LAXATIVE SMOOTH TEXTURE ORANGE FLAVOUR ORL PWR ACV G 0.0103 00080009651 FIBRE LAXATIVE UNFLAVOURED ORAL POWDER ORL PWR APH G 0.0109 00002408163 FIBRISTAL 5 MG TABLET ORL TAB ASC TAB 11.4600 00002445077 FINASTERIDE 5 MG TABLET ORL TAB SNS TAB 0.4633 00002350270 FINASTERIDE 5 MG TABLET ORL TAB PDL TAB 0.4633 00002425696 FIRAZYR 10 MG/ML (3 ML) INJECTION SYRINGE INJ DEFAUL SOT SYR 2700.0000 00002337037 FIRMAGON 120 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 405.5000 00002337029 FIRMAGON 80 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL FEI VIAL 300.0000 00001926853 FLAGYL 500 MG CAPSULE ORL CAP SAV CAP 1.0742 00080000193 FLAX SEED OIL ORL LIQ WNP CAP 0.0410 00002149133 FLAX SEED OIL 500 MG CAPSULE ORL CAP JAM CAP 0.0622 00080000580 FLAXSEED OIL 1000 MG SOFTGEL ORL CAP PMT CAP 0.0937 00080000840 FLAXSEED OIL LIQUID ORL LIQ VML ML 0.0422 00002206218 FLEET PHOSPO-SODA ORAL LIQUID ORL LIQ JJM ML 0.0838 00000999052 FLEXI-T +300 IUD 1 DEFAUL DEFAUL TSN DEV 76.1300 00000999053 FLEXI-T +380 IUD 1 DEFAUL DEFAUL TSN DEV 76.1300 00000999051 FLEXI-T 300 IUD 1 DEFAUL DEFAUL TSN DEV 67.6000 00080021934 FLINTSTONES MULTI VITAMINS COMPLETE CHEWABLE TAB ORL CTB BAI TAB 0.1370 00002230845 FLOLAN 0.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 18.6400 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 79 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002230848 FLOLAN 1.5 MG/VIAL INJECTION INJ DEFAUL GLA VIAL 37.2700 00002213672 FLONASE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM GSK DOSE 0.2589 00080011335 FLORASMART TABLET ORL TAB RLC TAB 0.5421 00080013321 FLORASTOR 250 MG CAPSULE ORL CAP BCX CAP 1.0150 00002237245 FLOVENT DISKUS 100 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.3988 00002237244 FLOVENT DISKUS 50 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.2522 00002261472 FLUCONAZOLE 2 MG/ML INJECTION INJ DEFAUL BAX ML 0.1635 00002248443 FLUCONAZOLE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 0.4695 00002388448 FLUCONAZOLE INJECTION SDZ 2 MG/ML INJECTION INJ DEFAUL SDZ ML 0.4695 00002247749 FLUCONAZOLE OMEGA 2 MG/ML INJECTION INJ DEFAUL OMG ML 0.3660 00002246226 FLUDARA 10 MG TABLET ORL TAB SAV TAB 40.0760 00002249561 FLUMAZENIL 0.1 MG/ML INJECTION INJ DEFAUL SDZ ML 5.0400 00002352621 FLUMIST INFLUENZA VACCINE NASAL SPRAY NAS SPR AZC ML 72.0000 00002426544 FLUMIST QUADRIVALENT NASAL SPRAY NAS SPR AZC ML 90.0000 00001977857 FLUOR A DAY 1.1 MG CHEWABLE TABLET ORL CTB PMS TAB 0.0849 00002090139 FLUOR-A-DAY 0.56 MG CHEWABLE TABLET ORL CTB PMS TAB 0.0849 00002182742 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL MNP ML 2.0376 00000012882 FLUOROURACIL 50 MG/ML INJECTION INJ DEFAUL VCL ML 1.4630 00002331721 FLUPENTIXOL DECANOATE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 26.7500 00000578479 FLURAZEPAM 15 MG CAPSULE ORL CAP PDL CAP 0.0675 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 80 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000578487 FLURAZEPAM 30 MG CAPSULE ORL CAP PDL CAP 0.0775 00002015986 FLUVIRAL S/F SPLIT-VIRION INFLUENZA VACCINE INJ INJ DEFAUL IAF ML 16.0000 00002236754 FLUVOXAMINE 100 MG TABLET ORL TAB PDL TAB 0.3783 00002236753 FLUVOXAMINE 50 MG TABLET ORL TAB PDL TAB 0.2105 00000247855 FML LIQUIFILM 0.1% OPH SUSPENSION OPH SUS ALL ML 3.2120 00080000549 FOLAPRO 0.8 MG TABLET ORL TAB MTG TAB 0.1916 00000318973 FOLIC ACID 1 MG TABLET ORL TAB JAM TAB 0.0404 00000647039 FOLIC ACID 1 MG TABLET ORL TAB VTH TAB 0.0079 00002048841 FOLIC ACID USP 1 MG TABLET ORL TAB PMT TAB 0.0171 00002254689 FORTEO 250 MCG/ML INJECTION INJ DEFAUL LIL ML 373.8542 00002435470 FORXIGA 10 MG TABLET ORL TAB AZC TAB 2.6200 00002435462 FORXIGA 5 MG TABLET ORL TAB AZC TAB 2.6200 00002241568 FORZA-10 TABLET ORL TAB EUP TAB 0.1628 00002276429 FOSAVANCE 70 MG/2800 UNIT TABLET ORL TAB MFC TAB 4.6875 00002332566 FOSINOPRIL 10 MG TABLET ORL TAB RAN TAB 0.4977 00002332574 FOSINOPRIL 20 MG TABLET ORL TAB RAN TAB 0.5985 00002303000 FOSINOPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.2178 00002303019 FOSINOPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.2619 00002287188 FOSRENOL 1000 MG CHEWABLE TABLET ORL CTB SHB TAB 4.5243 00002287145 FOSRENOL 250 MG CHEWABLE TABLET ORL CTB SHB TAB 1.1338 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 81 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002287153 FOSRENOL 500 MG CHEWABLE TABLET ORL CTB SHB TAB 2.2678 00002287161 FOSRENOL 750 MG CHEWABLE TABLET ORL CTB SHB TAB 3.4126 00002377454 FRAGMIN 2,500 IU/ML INJECTION INJ DEFAUL PFI ML 4.0785 00002221799 FRISIUM 10 MG TABLET ORL TAB LUI TAB 0.4393 00002257084 FROVA 2.5 MG TABLET ORL TAB TMP TAB 14.0486 00002264625 FSME-IMMUN 2.4 MCG/0.5 ML INJECTION SYRINGE INJ NDL BAX SYR 51.0000 00002238578 FUCIDIN H TOPICAL CREAM TOP CRM LEO G 1.3813 00002243862 FUCITHALMIC 1% VISCOUS OPH DROPS (PRESERVED) OPH GEL AMD G 2.1200 00002243861 FUCITHALMIC 1% VISCOUS OPH DROPS (UNPRESERVED) OPH GEL AMD G 4.7790 00002360365 FUROSEMIDE 10MG/ML INJECTION INJ DEFAUL OMG ML 1.0500 00000496723 FUROSEMIDE 20 TABLET ORL TAB PDL TAB 0.0373 00000397792 FUROSEMIDE 40 MG TABLET ORL TAB PDL TAB 0.0558 00000667080 FUROSEMIDE-80 MG TABLET ORL TAB PDL TAB 0.1220 00002247725 FUZEON 108 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 40.1178 00002431289 GABAPENTIN 600 MG TABLET ORL TAB SNS TAB 1.3045 00002388200 GABAPENTIN 600 MG TABLET ORL TAB SIV TAB 1.3045 00002392526 GABAPENTIN 600 MG TABLET USP ORL TAB AHI TAB 0.3256 00002431297 GABAPENTIN 800 MG TABLET ORL TAB SNS TAB 1.7393 00002388219 GABAPENTIN 800 MG TABLET ORL TAB SIV TAB 1.7393 00002392534 GABAPENTIN 800 MG TABLET USP ORL TAB AHI TAB 0.4341 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 82 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002416581 GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.2467 00002416603 GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.2467 00002416573 GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 1.2467 00002404761 GANCICLOVIR 500 MG/VIAL INJECTION USP INJ DEFAUL PPC VIAL 42.0300 00000512192 GARAMYCIN 3 MG/ML OPH SOLUTION OPH SOL MFC ML 0.4060 00000512184 GARAMYCIN 3 MG/ML OTIC SOLUTION OT SOL MFC ML 1.0320 00002283190 GARDASIL 0.5 ML INJECTION INJ DEFAUL MFC ML 287.4600 00002437058 GARDASIL 9 0.5 ML INJECTION INJ DEFAUL MFC ML 310.5000 00000896675 GAS X EXTRA STRENGTH TABLET ORL TAB NVC TAB 0.2361 00002300761 GAS X ULTRA STRENGTH 180 MG CAPSULE ORL CAP NVC CAP 0.2093 00002159791 GAVISCON HEARTBURN RELIEF CHEWABLE TABLET ORL CTB SKB TAB 0.1455 00002231538 GAVISCON HEARTBURN RELIEF EXTRA STRENGTH TABLET ORL TAB SKB TAB 0.2850 00002159775 GAVISCON HEARTBURN RELIEF ORAL LIQUID - FRUIT ORL LIQ SKB ML 0.0214 00002434806 GAZYVA 25 MG/ML INJECTION INJ DEFAUL HLR ML 5275.5000 00002280124 GD-AMLODIPINE 2.5 MG TABLET ORL TAB GMD TAB 0.1380 00002362791 GD-AMLODIPINE/ATORVASTATIN 10 MG/10 MG TABLET ORL TAB GMD TAB 0.9194 00002362805 GD-AMLODIPINE/ATORVASTATIN 10 MG/20 MG TABLET ORL TAB GMD TAB 1.0234 00002362813 GD-AMLODIPINE/ATORVASTATIN 10 MG/40 MG TABLET ORL TAB GMD TAB 1.0624 00002362821 GD-AMLODIPINE/ATORVASTATIN 10 MG/80 MG TABLET ORL TAB GMD TAB 1.0624 00002362759 GD-AMLODIPINE/ATORVASTATIN 5 MG/10 MG TABLET ORL TAB GMD TAB 0.7551 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 83 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002362767 GD-AMLODIPINE/ATORVASTATIN 5 MG/20 MG TABLET ORL TAB GMD TAB 0.8591 00002362775 GD-AMLODIPINE/ATORVASTATIN 5 MG/40 MG TABLET ORL TAB GMD TAB 0.8981 00002362783 GD-AMLODIPINE/ATORVASTATIN 5 MG/80 MG TABLET ORL TAB GMD TAB 0.8981 00002342235 GD-ELETRIPTAN 20 MG TABLET ORL TAB GMD TAB 10.0850 00002342243 GD-ELETRIPTAN 40 MG TABLET ORL TAB GMD TAB 10.0850 00002285843 GD-GABAPENTIN 600 MG TABLET ORL TAB GMD TAB 1.3045 00002285851 GD-GABAPENTIN 800 MG TABLET ORL TAB GMD TAB 1.7393 00002360179 GD-PREGABALIN 150 MG CAPSULE ORL CAP GMD CAP 1.7270 00002360195 GD-PREGABALIN 225 MG CAPSULE ORL CAP GMD CAP 1.7270 00002360136 GD-PREGABALIN 25 MG CAPSULE ORL CAP GMD CAP 0.6173 00002360209 GD-PREGABALIN 300 MG CAPSULE ORL CAP GMD CAP 1.7270 00002360144 GD-PREGABALIN 50 MG CAPSULE ORL CAP GMD CAP 0.9683 00002360152 GD-PREGABALIN 75 MG CAPSULE ORL CAP GMD CAP 1.2528 00002290995 GD-QUINAPRIL 10 MG TABLET ORL TAB GMD TAB 0.6867 00002291002 GD-QUINAPRIL 20 MG TABLET ORL TAB GMD TAB 0.6867 00002291010 GD-QUINAPRIL 40 MG TABLET ORL TAB GMD TAB 0.6867 00002290987 GD-QUINAPRIL 5 MG TABLET ORL TAB GMD TAB 0.6867 00002273705 GD-SERTRALINE 100 MG CAPSULE ORL CAP GMD CAP 0.4200 00002273683 GD-SERTRALINE 25 MG CAPSULE ORL CAP GMD CAP 0.2004 00002273691 GD-SERTRALINE 50 MG CAPSULE ORL CAP GMD CAP 0.4008 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 84 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002028107 GEL-KAM 0.4% DENTAL GEL DEN GEL COL G 0.0705 00002366150 GELNIQUE 100 MG/G TOPICAL GEL TOP GEL ASC G 1.9190 00001945831 GELUSIL EXTRA STRENGTH CHEWABLE TABLET ORL CTB WLA TAB 0.1484 00001933906 GELUSIL TABLET ORL TAB WSP TAB 0.0598 00002324210 GEMCITABINE 1 G/VIAL INJECTION INJ DEFAUL AHI VIAL 265.0000 00002412292 GEMCITABINE 40 MG/ML INJECTION INJ DEFAUL SDZ ML 10.8120 00002136058 GEMFIBROZIL-600 MG TABLET ORL TAB PDL TAB 0.5157 00002230309 GEMZAR 1 G/VIAL INJECTION INJ DEFAUL LIL VIAL 308.3500 00002230308 GEMZAR 200 MG/VIAL INJECTION INJ DEFAUL LIL VIAL 61.0900 00080020663 GENESTRA BRAND HMF INTENSIVE PROBIOTIC ORL CAP SRL CAP 1.7166 00080034399 GENESTRA BRANDS DIGEST GLUTEN PLUS CAPSULE ORL CAP SRL CAP 0.3143 00080008885 GENESTRA BRANDS D-MULSION ORL LIQ SRL ML 0.5663 00080012475 GENESTRA BRANDS D-MULSION 400 ORL LIQ SRL ML 0.2367 00002246047 GEN-NIZATIDINE 300 MG CAPSULE ORL CAP MYP CAP 0.9580 00002082144 GENTAMICIN (E) 1.2 MG/ML INJECTION INJ DEFAUL BAX ML 0.0794 00002082152 GENTAMICIN (E) 1.6 MG/ML INJECTION INJ DEFAUL BAX ML 0.0890 00002268531 GENTAMICIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 5.2785 00002148404 GENTAMICIN SULFATE 0.3% (BASE) OPH SOL (MINIMS) OPH SOL NVO ML 6.3483 00002082136 GENTAMICINE (E) 1 MG/ML INJECTION INJ DEFAUL BAX ML 0.0467 00002231289 GENTEAL 0.3% OPHTHALMIC DROPS OPH DPS ALC ML 0.4327 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 85 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002242977 GENTEAL 0.3% OPHTHALMIC GEL OPH GEL ALC ML 0.8110 00080044443 GI SUSTAIN ORAL POWDER ORL PWR MTG G 0.0676 00002415666 GIOTRIF 20 MG TABLET ORL TAB BOE TAB 80.0000 00002415674 GIOTRIF 30 MG TABLET ORL TAB BOE TAB 80.0000 00002415682 GIOTRIF 40 MG TABLET ORL TAB BOE TAB 80.0000 00080003490 GLA 130 PRIMROSE OIL CAPSULE ORL CAP SRL CAP 0.4438 00002244725 GLEEVEC 100 MG CAPSULE ORL CAP NOV CAP 25.3240 00002253275 GLEEVEC 100 MG TABLET ORL TAB NOV TAB 27.6833 00002253283 GLEEVEC 400 MG TABLET ORL TAB NOV TAB 110.7333 00002248453 GLICLAZIDE-80 MG TABLET ORL TAB PDL TAB 0.0931 00080000015 GLUCOSAMINE SULFATE 500 MG CAPLET ORL TAB JAM TAB 0.0448 00080000082 GLUCOSAMINE SULFATE 500 MG CAPSULE ORL CAP WBP CAP 0.0432 00080000083 GLUCOSAMINE SULFATE 500 MG TABLET ORL TAB WBP TAB 0.0360 00002300451 GLUMETZA 1000 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.1769 00002268493 GLUMETZA 500 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 0.5861 00080009026 GLUTAMINE MAXX ORAL POWDER ORL PWR IHS G 0.0600 00001959352 GLYBURIDE-2.5 MG TABLET ORL TAB PDL TAB 0.0321 00001926039 GLYCERIN RECTAL SUPPOSITORY RT SUP WSP SUP 0.1517 00000873462 GLYCERINE 90% RECTAL SUPPOSITORY USP RT SUP MCO SUP 0.0850 00080006852 GLYCINE ORAL POWDER ORL PWR AOR G 0.0639 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 86 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002229516 GLYCON 500 MG TABLET ORL TAB VCL TAB 0.0444 00002239214 GLYCON 850 MG TABLET ORL TAB VCL TAB 0.0610 00002382857 GLYCOPYRROLATE 0.2 MG/ML INJECTION INJ DEFAUL OMG ML 3.9750 00002382849 GLYCOPYRROLATE 0.2 MG/ML MULTIDOSE INJECTION INJ DEFAUL OMG ML 3.0000 00002247884 GLYQUIN XM TOPICAL CREAM TOP CRM VCL G 1.2500 00000652512 GOLYTELY POWDER FOR ORAL LAVAGE SOLUTION ORL PWR BAX G 0.0041 00002248156 GONAL-F 33 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 425.2500 00002248154 GONAL-F 5.5 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 70.8800 00002248157 GONAL-F 77 MCG/VIAL INJECTION INJ DEFAUL SRO VIAL 992.2500 00002270404 GONAL-F PEN 300 IU/0.5 ML INJECTION SYRINGE INJ NDL SRO SYR 283.5000 00002270390 GONAL-F PEN 450 IU/0.75 ML INJECTION SYRINGE INJ NDL SRO SYR 425.2500 00002270382 GONAL-F PEN 900 IU/1.5 ML INJECTION SYRINGE INJ NDL SRO SYR 850.5000 00000999578 GOOD START STAGE 2 INFANT FORMULA ORL PWR NHN G 0.0404 00002232483 GRAMCAL 1000 MG EFFERVESCENT TABLET ORL EVT NVC TAB 0.7295 00080006061 GRAPE SEED CAPLET ORL TAB JAM TAB 0.3122 00002418304 GRASTEK 2800 UNIT SUBLINGUAL TABLET SLG DISNTAB MFC TAB 3.8000 00000116858 GRAVERGOL CAPSULE ORL CAP AXS CAP 1.0108 00002254409 GRAVOL 100 MG LONG ACTING SUSTAINED-RELEASE CAPLET ORL SRT CHD TAB 0.4688 00000511196 GRAVOL 15 MG CHEWABLE TABLET ORL CTB CHD TAB 0.2433 00000230197 GRAVOL 3 MG/ML ORAL LIQUID ORL SYR CHD ML 0.0708 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 87 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price ORL TAB CHD TAB 0.2220 00000013803 GRAVOL 50 MG TABLET 00000013609 GRAVOL ADULT 100 MG RECTAL SUPPOSITORY RT SUP CHD SUP 0.5630 00000783595 GRAVOL CHILDREN 25 MG RECTAL SUPPOSITORIES RT SUP CHD SUP 0.4960 00002248180 GRAVOL GINGER LOZENGE ORL LOZ CHD LOZ 0.2275 00000013579 GRAVOL I.M. 50 MG/ML INJECTION INJ DEFAUL CHD ML 1.2080 00002245718 GRAVOL NATURAL SOURCE 500 MG TABLET ORL TAB CHD TAB 0.2275 00080014526 GREEN TEA PHYTOSOME COMPLEX CAPSULE ORL CAP JAM CAP 0.2143 00080012417 GREENS+ BONE BUILDER ORAL POWDER ORL PWR GNH G 0.0948 00002384272 GUM PAROEX 0.12% ORAL RINSE ORL MWH SUA ML 0.0153 00080003089 HAIR & NAILS CAPSULE ORL CAP VTH CAP 0.0933 00002377438 HALAVEN 0.5 MG/ML INJECTION INJ DEFAUL EIS ML 270.0000 00000271691 HALIBUT LIVER OIL SUPER CAPSULE ORL CAP SWS CAP 0.0329 00000202061 HALIBUT LIVER OIL WITH VITAMIN D CAPSULE ORL CAP WAM CAP 0.0268 00002366010 HALOPERIDOL (PRESERVATIVE FREE) 5 MG/ML INJECTION INJ DEFAUL OMG ML 4.9000 00000587796 HALOPERIDOL 0.5 MG TABLET ORL TAB PDL TAB 0.0360 00002130297 HALOPERIDOL LA 50 MG/ML INJECTION INJ DEFAUL SDZ ML 8.4640 00002239640 HALOPERIDOL-LA 100 MG/ML INJECTION INJ DEFAUL OMG ML 13.6900 00002187078 HAVRIX 1,440 U/ML INJECTION INJ DEFAUL GSK ML 44.6100 00002231056 HAVRIX JUNIOR 720 U/0.5 ML INJECTION SYRINGE INJ GSK SYR 22.3100 00000740578 HEPALEAN-LOK 100 IU/ML LOCK FLUSH INJECTION USP INJ NDL LOCFLUS H ORG ML 0.3275 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 88 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price LEO ML 1.1000 HSP ML 1.2056 00000579718 HEPARIN LEO 10,000 IU/ML INJECTION INJ 00000640468 HEPARIN LOCK FLUSH SOLUTION 10 UNIT/ML INJECTION INJ DEFAUL LOCFLUS H 00002264315 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL PPC ML 2.6736 00002303086 HEPARIN SODIUM 1,000 IU/ML INJECTION USP INJ DEFAUL SDZ ML 0.5650 00002382296 HEPARIN SODIUM 1,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 0.5010 00002264307 HEPARIN SODIUM 10,000 IU/ML INJECTION USP INJ DEFAUL PPC ML 5.6444 00002382326 HEPARIN SODIUM 10,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 5.0100 00002382334 HEPARIN SODIUM 5,000 UNIT/ML INJECTION INJ DEFAUL PFI ML 1.2470 00002303094 HEPARIN SODIUM(PRESERVAT FREE)10,000 IU/ML INJ USP INJ DEFAUL SDZ ML 5.2700 00002303108 HEPARIN SODIUM(WITH PRESERVAT)10,000 IU/ML INJ USP INJ DEFAUL SDZ ML 3.7160 00002239194 HEPTOVIR 5 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.2300 00002175622 HERBAL WATER TABLET ORL TAB VCL TAB 0.0621 00002240692 HERCEPTIN 440 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2724.3000 00002244784 HILL-VITE TABLET ORL TAB HIL TAB 0.1320 00000575178 HISTANTIL 25 MG TABLET ORL TAB PMS TAB 0.1158 00000575186 HISTANTIL 50 MG TABLET ORL TAB PMS TAB 0.1800 00001948903 HONEY BEE VENOM 1.1 MG INJ DEFAUL ALG VIAL 30.8667 00001948911 HONEY BEE VENOM 120 MCG INJ DEFAUL ALG VIAL 30.8667 00002439611 HUMALOG 200 UNIT/ML INJECTION KWIKPEN INJ DEFAUL LIL ML 6.8587 00002078759 HUMATIN 250 MG CAPSULE ORL CAP PFI CAP 2.7000 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 89 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000745626 HUMATROPE 1 MG/ML INJECTION INJ DEFAUL LIL VIAL 233.3500 00002243079 HUMATROPE 24 MG INJECTION INJ DEFAUL LIL VIAL 1120.0800 00000999015 HYALGAN DEFAUL DEV MDX ML 25.0000 00001916580 HYCODAN 1 MG/ML ORAL SYRUP ORL SYR BMS ML 0.1289 00001916599 HYCODAN 5 MG TABLET ORL TAB BMS TAB 1.0795 00001916564 HYCOMINE ORAL SYRUP ORL SYR DPM ML 0.2165 00001916521 HYCOMINE-S PEDIATRIC ORAL SYRUP ORL SYR DPM ML 0.1895 00000230316 HYCORT 1.67 MG/ML RECTAL ENEMA RT ENM VCL ENM 5.2971 00002231476 HYDRASENSE NASAL SOLUTION NAS SOL SCH ML 0.0598 00000465283 HYDREA 500 MG CAPSULE ORL CAP BMS CAP 1.0203 00000341975 HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PDL TAB 0.0157 00002242930 HYDROCORTISONE ACETATE 0.5% TOPICAL CREAM TOP CRM TAR G 0.0846 00002244797 HYDROMORPHONE HP FORTE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 58.8000 00000564281 HYDROSONE 0.5% CREAM TOP CRM RPH G 0.1267 00002343096 HYDROXYUREA 500 MG CAPSULE ORL CAP SNS CAP 1.0203 00000742813 HYDROXYZINE HCL 50 MG/ML INJECTION USP INJ DEFAUL SDZ ML 8.5360 00002229868 HYOSCINE BUTYLBROMIDE 20 MG/ML INJECTION INJ DEFAUL SDZ ML 4.5200 00002230697 HYPERTET S/D 250 IU/SYR INJECTION INJ DEFAUL GRL SYR 78.0000 00002133253 HYPOTEARS 1% OPH SOLUTION OPH SOL ALC ML 0.4147 00002133288 HYPOTEARS 85%/15% EYE OINTMENT OPH ONT ALC G 1.5886 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 90 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002275864 HYPURIN NPH INSULIN ISOPHANE PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.9000 00002275872 HYPURIN REGULAR INSULIN PORK 100 UNIT/ML INJ INJ DEFAUL NTI ML 9.9000 00080022866 IBEROGAST ORAL SOLUTION ORL SOL STA ML 0.1951 00002357275 IBUPROFEN 200 MG LIQUID CAPSULE ORL CAP VTH CAP 0.0681 00002257912 IBUPROFEN 200 MG TABLET ORL TAB PMT TAB 0.0498 00002317338 IBUPROFEN 400 MG CAPLET ORL TAB PMT TAB 0.0392 00000636533 IBUPROFEN 400 MG TABLET ORL TAB PDL TAB 0.0372 00002437333 ICLUSIG 15 MG TABLET ORL TAB ARI TAB 142.8446 00002344939 ILARIS 150 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 16000.0000 00002411393 ILEVRO 0.3% OPHTHALMIC SUSPENSION OPH SUS ALC ML 7.3100 00002434407 IMBRUVICA 140 MG CAPSULE ORL CAP JAI CAP 90.6500 00002183862 IMODIUM 2 MG CAPLET ORL TAB MCL TAB 0.7733 00002376016 IMODIUM 2 MG CAPSULE ORL CAP MCL CAP 0.8200 00002245185 IMODIUM ADVANCED CAPLET ORL TAB MCL TAB 0.6345 00002237297 IMODIUM ADVANCED CHEWABLE TABLET ORL CTB MCL TAB 0.9280 00002230542 IMODIUM QUICK DISSOLVE 2 MG TABLET ORL TAB MCL TAB 0.8200 00001959042 IMOVAX POLIO INJECTION SYRINGE INJ NDL SFP SYR 43.3700 00001908286 IMOVAX RABIES VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL SFP VIAL 179.9900 00002240713 IMUNOVIR 500 MG TABLET ORL TAB RIP TAB 1.9507 00002244895 IMURAN 50 MG/VIAL INJECTION INJ DEFAUL ASN VIAL 98.2700 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 91 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002371553 INCIVEK 375 MG TABLET ORL TAB VER TAB 69.3810 00002423596 INCRUSE ELLIPTA 62.5 MCG INHALATION POWDER INH MIP GSK DOSE 2.0000 00002445824 INDAPAMIDE 1.25 MG TABLET ORL TAB SNS TAB 0.0745 00002445832 INDAPAMIDE 2.5 MG TABLET ORL TAB SNS TAB 0.1182 00002042266 INDERAL-LA 120 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.9938 00002042274 INDERAL-LA 160 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 1.1753 00002042231 INDERAL-LA 60 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.5724 00002042258 INDERAL-LA 80 MG SUSTAINED-RELEASE CAPSULE ORL SRC PFI CAP 0.6455 00000558079 INFANTOL ORAL LIQUID ORL LIQ CHD ML 0.0191 00002046059 INFANTS' TYLENOL 80 MG/ML ORAL SUSPENSION DROPS ORL DPS MCL ML 0.2893 00002419475 INFLECTRA 100 MG/VIAL INJECTION INJ DEFAUL CHH VIAL 650.0000 00002269562 INFLUVAC VACCINE INJECTION SYRINGE INJ DEFAUL ABB SYR 7.4400 00002221780 INFUFER 50 MG/ML INJECTION INJ DEFAUL SDZ ML 14.7500 00002389630 INLYTA 1 MG TABLET ORL TAB PFI TAB 18.6000 00002389649 INLYTA 5 MG TABLET ORL TAB PFI TAB 93.0000 00080013031 INNO-Q-NOL 100 MG SOFT GEL CAPSULE ORL CAP INN CAP 1.1325 00002441888 INSPIOLTO RESPIMAT 2.5MCG/ACTUATION INH SOLUTION INH CTG BOE CTG 1.0500 00000990102 INSPIRA CHAMBER W/ MED INSIRAMASK/SOOTHERMASK DEV DEFAUL PEDDEV LUP DEV 37.6700 00000990103 INSPIRA CHAMBER W/ SM INSPIRAMASK/SOOTHERMASK DEV DEFAUL INFDEV LUP DEV 37.6700 00000990101 INSPIRA CHAMBER WITH MOUTHPIECE DEFAUL DEV LUP DEV 23.5500 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 92 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080026628 INSTAFLEX JOINT SUPPORT CAPSULE ORL CAP DDI CAP 0.3332 00000762040 INSTA-GLUCOSE (1 DOSE PER TUBE) ORAL LIQUID ORL LIQ VCL DOSE 3.8300 00002294990 INSTILLAGEL 2% /0.05% TOPICAL GEL TOP GEL PPH ML 0.9667 00002348756 INTANZA INJECTION SYRINGE INJ DEFAUL SFP SYR 12.0000 00002306778 INTELENCE 100 MG TABLET ORL TAB JAI TAB 5.8860 00002375931 INTELENCE 200 MG TABLET ORL TAB JAI TAB 11.5320 00002238675 INTRON A 10 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 120.9400 00002223406 INTRON A 10,000,000 UNIT/VIAL INJECTION INJ DEFAUL MFC ML 125.2000 00002238674 INTRON A 6 MIU/ML INJECTION - HUMAN ALBUMIN FREE INJ DEFAUL MFC ML 72.5633 00002240693 INTRON A MULTI-DOSE PEN 15 MIU/ML INJECTION SYR INJ NDL MFC SYR 217.6900 00002240694 INTRON A MULTI-DOSE PEN 25 MIU/ML INJECTION SYR INJ NDL MFC SYR 362.7800 00002240695 INTRON A MULTI-DOSE PEN 50 MIU/ML INJECTION SYR INJ NDL MFC SYR 725.6100 00002409100 INTUNIV XR 1 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.0000 00002409119 INTUNIV XR 2 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 3.6500 00002409127 INTUNIV XR 3 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 4.3000 00002409135 INTUNIV XR 4 MG EXTENDED-RELEASE TABLET ORL ERT SHB TAB 4.9500 00002216965 INVIRASE 200 MG CAPSULE ORL CAP HLR CAP 1.9021 00002279320 INVIRASE 500 MG TABLET ORL TAB HLR TAB 4.3895 00000888354 IOPIDINE 1% OPH SOLUTION (UNIT DOSE) OPH SOL ALC ML 60.8458 00002246084 IPRAVENT 0.06% NASAL SPRAY NAS SPR AAP ML 1.4900 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 93 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002365200 IRBESARTAN 150 MG TABLET ORL TAB PDL TAB 0.3425 00002365219 IRBESARTAN 300 MG TABLET ORL TAB PDL TAB 0.3425 00002365197 IRBESARTAN 75 MG TABLET ORL TAB PDL TAB 0.3425 00002365162 IRBESARTAN-HCTZ 150 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3425 00002365170 IRBESARTAN-HCTZ 300 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3425 00002365189 IRBESARTAN-HCTZ 300 MG/25 MG TABLET ORL TAB PDL TAB 0.3384 00002248676 IRESSA 250 MG TABLET ORL TAB AZC TAB 73.3000 00002392437 ISENTRESS 100 MG CHEWABLE TABLET ORL CTB MFC TAB 3.8333 00002392429 ISENTRESS 25 MG CHEWABLE TABLET ORL CTB MFC TAB 0.9583 00002301881 ISENTRESS 400 MG TABLET ORL TAB MFC TAB 13.5000 00000897639 ISOPROTERENOL HYDROCHLORIDE 0.2 MG/ML INJECTION INJ DEFAUL SDZ ML 8.0160 00000000809 ISOPTO TEARS 0.5% OPH DROPS OPH DPS ALC ML 0.5147 00000000817 ISOPTO TEARS 1.0% OPH DROPS OPH DPS ALC ML 0.5147 00000272655 ISOTAMINE 300 MG TABLET ORL TAB VCL TAB 0.0899 00002414295 ISTODAX 10 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 2582.0000 00002333279 IXIARO 6 MCG/0.5ML INJECTION SYRINGE INJ NDL NOV SYR 193.2500 00002434814 JAKAVI 10 MG TABLET ORL TAB NOV TAB 82.1918 00002388014 JAKAVI 15 MG TABLET ORL TAB NOV TAB 82.1918 00002388022 JAKAVI 20 MG TABLET ORL TAB NOV TAB 82.1918 00002388006 JAKAVI 5 MG TABLET ORL TAB NOV TAB 82.1918 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 94 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002372010 JALYN 0.5 MG/0.4 MG MODIFIED RELEASE CAPSULE ORL MRC GSK CAP 1.6570 00002246040 JAMP CALCIUM 500 MG TABLET ORL TAB JPC TAB 0.0216 00002417308 JAMP OLANZAPINE FC 20 MG TABLET ORL TAB JPC TAB 2.5880 00002388308 JAMP-ACET-TRAMADOL 37.5 MG/325 MG TABLET ORL TAB JPC TAB 0.6264 00080037789 JAMP-AD 5000 IU/ 400 IU CHEWABLE TABLET ORL CTB JPC TAB 0.1053 00002421593 JAMP-ALLOPURINOL 100 MG TABLET ORL TAB JPC TAB 0.0780 00002421607 JAMP-ALLOPURINOL 200 MG TABLET ORL TAB JPC TAB 0.1300 00002421615 JAMP-ALLOPURINOL 300 MG TABLET ORL TAB JPC TAB 0.2125 00002400154 JAMP-ALPRAZOLAM 2 MG TABLET ORL TAB JPC TAB 0.5508 00002435527 JAMP-AMITRIPTYLINE 10 MG TABLET ORL TAB JPC TAB 0.0435 00002435535 JAMP-AMITRIPTYLINE 25 MG TABLET ORL TAB JPC TAB 0.0829 00002435543 JAMP-AMITRIPTYLINE 50 MG TABLET ORL TAB JPC TAB 0.1540 00002435551 JAMP-AMITRIPTYLINE 75 MG TABLET ORL TAB JPC TAB 0.3634 00002331098 JAMP-AMLODIPINE 10 MG TABLET ORL TAB JPC TAB 0.3587 00002331071 JAMP-AMLODIPINE 5 MG TABLET ORL TAB JPC TAB 0.2417 00002433060 JAMP-AMOXICILLIN 250 MG CAPSULE ORL CAP JPC CAP 0.1750 00002433079 JAMP-AMOXICILLIN 500 MG CAPSULE ORL CAP JPC CAP 0.3417 00002339080 JAMP-ANASTROZOLE 1 MG TABLET ORL TAB JPC TAB 2.5458 00002283905 JAMP-ASA 80 MG TABLET ORL DRT JPC TAB 0.0560 00002357216 JAMP-BICALUTAMIDE 50 MG TABLET ORL TAB JPC TAB 4.0573 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 95 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price RT SUP JPC SUP 0.4367 00002410893 JAMP-BISACODYL 5 MG SUPPOSITORY 00002246039 JAMP-BISACODYL 5 MG TABLET ORL TAB JPC TAB 0.0426 00080028892 JAMP-CALCIUM CITRATE 250 MG + VIT D 1000 IU TABLET ORL TAB JPC TAB 0.1224 00002373823 JAMP-COLCHICINE 0.6 MG TABLET ORL TAB JPC TAB 0.2565 00002391619 JAMP-DICYCLOMINE HCL 10 MG TABLET ORL TAB JPC TAB 0.1128 00002366088 JAMP-DICYCLOMINE HCL 20 MG TABLET ORL TAB JPC TAB 0.2207 00002283220 JAMP-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP ORL SYR JPC ML 0.9203 00080036242 JAMP-E 200 IU CHEWABLE TABLET ORL CTB JPC TAB 0.1474 00080024232 JAMP-FER 300 MG CAPSULE ORL CAP JPC CAP 0.1300 00080025200 JAMP-FER FC 100 MG/ 0.5 MG/ 200 MG CAPSULE ORL CAP JPC CAP 0.2281 00080047569 JAMP-FERROUS POLYSACCHARIDE 150 MG CAPSULE ORL CAP JPC CAP 0.3997 00000031100 JAMP-FERROUS SULFATE 300 MG TABLET ORL TAB JPC TAB 0.0165 00080053274 JAMP-FOLIC ACID 1 MG TABLET ORL TAB JPC TAB 0.0152 00002366061 JAMP-FOLIC ACID 5 MG TABLET ORL TAB JPC TAB 0.0404 00002402289 JAMP-GABAPENTIN 600 MG TABLET ORL TAB JPC TAB 1.3045 00002402297 JAMP-GABAPENTIN 800 MG TABLET ORL TAB JPC TAB 1.7393 00080057189 JAMP-HYDROCORTISONE CREAM 1% TOPICAL CREAM TOP CRM JPC G 0.1251 00080057191 JAMP-HYDROCORTISONE LOTION 1% TOPICAL LOTION TOP LOT JPC ML 0.1192 00002401290 JAMP-IBUPROFEN 400 MG TABLET ORL TAB JPC TAB 0.0372 00080047136 JAMP-IRON POLYPEPTIDE 11 MG TABLET ORL TAB JPC TAB 0.6420 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 96 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080023817 JAMP-K-CITRATE 10 MEQ TABLET ORL SRT JPC TAB 0.1626 00002280078 JAMP-LACTULOSE 667 MG/ML ORAL SYRUP ORL SYR JPC ML 0.0145 00002373009 JAMP-LETROZOLE 2.5 MG TABLET ORL TAB JPC TAB 2.7560 00002386836 JAMP-LIDOCAINE 5% TOPICAL OINTMENT TOP ONT JPC G 0.2800 00080041590 JAMP-MAGNESIUM 100 MG TABLET ORL TAB JPC TAB 0.2632 00080009357 JAMP-MAGNESIUM 25 MG ORAL LIQUID ORL LIQ JPC ML 0.0210 00080043440 JAMP-MAGNESIUM 250 MG TABLET ORL TAB JPC TAB 0.1026 00002419173 JAMP-METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION INJ DEFAUL JPC ML 5.6250 00002443929 JAMP-MOXIFLOXACIN 400 MG TABLET ORL TAB JPC TAB 5.1783 00002427745 JAMPOCAINE 2% VISCOUS TOPICAL SOLUTION TOP SOL JPC ML 0.0525 00002406640 JAMP-OLANZAPINE 15 MG ORALLY DISINT. TABLET ORL DISNTAB JPC TAB 5.3553 00002406659 JAMP-OLANZAPINE 20 MG ORALLY DISINT. TABLET ORL DISNTAB JPC TAB 7.5977 00002440717 JAMP-OXCARBAZEPINE 150 MG TABLET ORL TAB JPC TAB 0.6209 00002440725 JAMP-OXCARBAZEPINE 300 MG TABLET ORL TAB JPC TAB 0.7242 00002440733 JAMP-OXCARBAZEPINE 600 MG TABLET ORL TAB JPC TAB 1.4484 00002408414 JAMP-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT JPC TAB 1.2750 00002420430 JAMP-PIP/TAZ 4 G/500 MG/VIAL INJECTION INJ DEFAUL JPC VIAL 12.1100 00002380617 JAMP-PYRANTEL PAMOATE 125 MG TABLET ORL TAB JPC TAB 0.9410 00002445190 JAMP-QUININE 200 MG CAPSULE ORL CAP JPC CAP 0.2390 00080040279 JAMP-QUININE 200 MG CAPSULE ORL CAP JPC CAP 0.2390 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 97 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080040277 JAMP-QUININE 300 MG CAPSULE ORL CAP JPC CAP 0.3750 00002445204 JAMP-QUININE 300 MG CAPSULE ORL CAP JPC CAP 0.3750 00002405687 JAMP-SILDENAFIL 100 MG TABLET ORL TAB JPC TAB 9.2000 00002405660 JAMP-SILDENAFIL 25 MG TABLET ORL TAB JPC TAB 8.2900 00002405679 JAMP-SILDENAFIL 50 MG TABLET ORL TAB JPC TAB 8.8475 00080034416 JAMP-SODIUM PHOSPHATE 0.891 G -2.4 G/5 ML SOLUTION ORL SOL JPC ML 0.0947 00002435616 JAMP-TOPIRAMATE 100 MG TABLET ORL TAB JPC TAB 0.5929 00002435624 JAMP-TOPIRAMATE 200 MG TABLET ORL TAB JPC TAB 0.8854 00002435608 JAMP-TOPIRAMATE 25 MG TABLET ORL TAB JPC TAB 0.3128 00002420309 JAMP-VANCOMYCIN 1 G/VIAL INJECTION INJ DEFAUL JPC VIAL 58.9900 00002420325 JAMP-VANCOMYCIN 10 G/VIAL INJECTION INJ DEFAUL JPC VIAL 589.9000 00002420317 JAMP-VANCOMYCIN 5 G/VIAL INJECTION INJ DEFAUL JPC VIAL 509.7900 00002420295 JAMP-VANCOMYCIN 500 MG/VIAL INJECTION INJ DEFAUL JPC VIAL 31.0500 00080054130 JAMP-VITAMIN A 10, 000 IU CAPSULE ORL CAP JPC CAP 0.0431 00080028902 JAMP-VITAMIN B12 1000 MCG RAPID DISSOLVE TABLET ORL TAB JPC TAB 0.0884 00002379007 JAMP-VITAMIN D 10000 UNIT TABLET ORL TAB JPC TAB 0.2100 00002416794 JANUMET XR 50 MG/1000 MG EXTENDED-RELEASE TABLET ORL ERT MFC TAB 1.6020 00002443937 JARDIANCE 10 MG TABLET ORL TAB BOE TAB 2.6177 00002443945 JARDIANCE 25 MG TABLET ORL TAB BOE TAB 2.6177 00002048744 JE-VAX INJECTION INJ DEFAUL CNG VIAL 131.6633 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 98 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002369524 JEVTANA 40 MG/ML INJECTION INJ DEFAUL SAV VIAL 5800.0000 00002437503 JINARC 45 MG/15 MG COMBINATION PACK ORL TAB OTS TAB 45.2057 00002437511 JINARC 60 MG/30 MG COMBINATION PACK ORL TAB OTS TAB 45.2057 00002437538 JINARC 90 MG/30 MG COMBINATION PACK ORL TAB OTS TAB 45.2057 00002413388 JUBLIA 10% TOPICAL SOLUTION TOP SOL VCL ML 10.7617 00002247344 JUNIOR STRENGTH MOTRIN 100 MG CHEWABLE TABLET ORL CTB MCL TAB 0.2250 00002337282 JURNISTA 16 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 5.0650 00002337290 JURNISTA 32 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 10.1300 00002337266 JURNISTA 4 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.2660 00002337274 JURNISTA 8 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.5320 00002420376 JUXTAPID 10 MG CAPSULE ORL CAP AEP CAP 1040.0000 00002420384 JUXTAPID 20 MG CAPSULE ORL CAP AEP CAP 1040.0000 00002420341 JUXTAPID 5 MG CAPSULE ORL CAP AEP CAP 1040.0000 00002412365 KADCYLA 20 MG/ML INJECTION POWDER FOR SOLUTION INJ DEFAUL HLR ML 403.6000 00002312301 KALETRA 100 MG/25 MG TABLET ORL TAB ABV TAB 2.7598 00002285533 KALETRA 200 MG/50 MG TABLET ORL TAB ABV TAB 5.5197 00002243644 KALETRA 80MG/20MG ORAL SOLUTION ORL SOL ABV ML 2.2084 00002442612 KALYDECO 50 MG GRANULES ORL GRNUL VER PCKT 420.0000 00002442620 KALYDECO 75 MG GRANULES ORL GRNUL VER PCKT 420.0000 00002417235 KAZANO 12.5 MG/1000 MG TABLET ORL TAB TAK TAB 1.3700 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 99 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002417219 KAZANO 12.5 MG/500 MG TABLET ORL TAB TAK TAB 1.3700 00002417227 KAZANO 12.5 MG/850 MG TABLET ORL TAB TAK TAB 1.3700 00080011529 K-CITRA 2 MEQ/ML SOLUTION ORL LIQ SFD ML 0.0349 00002243768 K-CITRA POTASSIUM CITRATE 10 MEQ SRT ORL SRT SFD TAB 0.2699 00000376167 KEMSOL 70% TOPICAL SOLUTION TOP SOL AXS ML 0.2786 00000224391 KETALAR 10 MG/ML INJECTION INJ DEFAUL ERF ML 1.6000 00000224405 KETALAR 50 MG/ML INJECTION INJ DEFAUL ERF ML 5.3000 00002246796 KETAMINE 50 MG/ML INJECTION USP INJ DEFAUL SDZ ML 4.9500 00002246795 KETAMINE HYDROCHLORIDE 10 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.6450 00002244947 KETOROLAC TROMETHAMINE 30 MG/ML INJECTION INJ DEFAUL PPC ML 5.1452 00002400871 KETOTIFEN 0.25 MG/ML OPH SOLUTION OPH SOL STM ML 4.2340 00002441152 KEYTRUDA 50 MG/VIAL INJECTION INJ DEFAUL MFC VIAL 2200.0000 00001926438 KIDROLASE 10,000 UNIT/VIAL INJECTION INJ DEFAUL AVE VIAL 134.7900 00080020666 KID'S LIQUID VITAMIN D 400 IU ORL LIQ WBP ML 0.1306 00002269341 KIVEXA 600 MG/300 MG TABLET ORL TAB GSK TAB 23.5957 00001928783 KOFFEX SIROP 3 MG/ML ORAL SYRUP ORL SYR ROG ML 0.0190 00002389185 KOMBOGLYZE 2.5 MG/1000 MG TABLET ORL TAB AZC TAB 1.2700 00002389169 KOMBOGLYZE 2.5 MG/500 MG TABLET ORL TAB AZC TAB 1.2700 00002389177 KOMBOGLYZE 2.5 MG/850 MG TABLET ORL TAB AZC TAB 1.2700 00080052499 KRILL OIL CAPSULE ORL CAP WNP CAP 0.4383 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 100 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080022006 KRILL OIL SOFTGEL CAPSULE ORL CAP WBP CAP 0.2192 00002350580 KUVAN 100 MG TABLET ORL TAB BMI TAB 33.0000 00080004073 KYOLIC AGED GARLIC EXTRACT ORAL CAPLET ORL TAB WKG TAB 0.5991 00002185881 KYTRIL 1 MG TABLET ORL TAB HLR TAB 10.0730 00002387468 LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION INJ DEFAUL MYP ML 1.2930 00002231689 LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION INJ DEFAUL SDZ ML 1.3900 00000210889 LACRI-LUBE OPH OINTMENT OPH ONT ALL G 2.0543 00002250624 LACRISERT 5 MG OPHTHALMIC INSERT OPH INS ATP DEV 3.1869 00080012831 LACTOBACILLUS ACIDOPHILUS & BIFIDUS ORL CAP SWS CAP 0.1123 00000468401 LAIT DE MAGNESIE ORL SUSP (MILK OF MAGNESIA) ORL SUS ATL ML 0.0068 00002243803 LAMICTAL 2 MG CHEWABLE TABLET ORL CTB GSK TAB 0.1700 00002385775 LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC SIV CAP 0.5000 00002366282 LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PDL CAP 0.6000 00000608734 LANSOYL JELLY 78% ORL GEL AUP G 0.0467 00002186926 LANSOYL SUGAR FREE JELLY 78% ORL GEL AUP G 0.0467 00000282081 LANVIS 40 MG TABLET ORL TAB ASN TAB 4.5380 00002375508 LATANOPROST 0.005% OPHTHALMIC SOLUTION OPH SOL RIV ML 3.6320 00002415828 LEFLUNOMIDE 10 MG TABLET ORL TAB PDL TAB 2.6433 00002415836 LEFLUNOMIDE 20 MG TABLET ORL TAB PDL TAB 2.6433 00002418320 LEMTRADA 12 MG/1.2 ML INJECTION INJ DEFAUL GZM VIAL 11964.0000 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 101 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002061562 LESCOL 20 MG CAPSULE ORL CAP NOV CAP 0.9003 00002061570 LESCOL 40 MG CAPSULE ORL CAP NOV CAP 1.2642 00002338459 LETROZOLE 2.5 MG TABLET ORL TAB AHI TAB 3.0617 00002347997 LETROZOLE 2.5 MG TABLET ORL TAB TEV TAB 2.7560 00002348969 LETROZOLE 2.5 MG TABLET ORL TAB APH TAB 2.7560 00002402025 LETROZOLE 2.5 MG TABLET ORL TAB PDL TAB 1.3780 00002183005 LEUCOVORIN CALCIUM 10 MG/ML INJECTION INJ DEFAUL MNP ML 14.0080 00000004626 LEUKERAN 2 MG TABLET ORL TAB ASN TAB 1.4680 00002236840 LEVAQUIN 25 MG/ML INJECTION INJ DEFAUL JAI ML 2.2895 00002236841 LEVAQUIN 250 MG TABLET ORL TAB JAI TAB 5.0324 00002236839 LEVAQUIN 5 MG/ML INJECTION INJ DEFAUL JAI ML 0.4578 00002236842 LEVAQUIN 500 MG TABLET ORL TAB JAI TAB 5.6784 00002246804 LEVAQUIN 750 MG TABLET ORL TAB JAI TAB 10.0474 00002442531 LEVETIRACETAM 250 MG TABLET ORL TAB SIV TAB 0.8000 00002442558 LEVETIRACETAM 500 MG TABLET ORL TAB SIV TAB 0.9750 00002442566 LEVETIRACETAM 750 MG TABLET ORL TAB SIV TAB 1.3500 00002250470 LEVITRA 10 MG TABLET ORL TAB BAI TAB 12.2325 00002250489 LEVITRA 20 MG TABLET ORL TAB BAI TAB 13.3125 00002250462 LEVITRA 5 MG TABLET ORL TAB BAI TAB 10.9650 00002415879 LEVOFLOXACIN 500 MG TABLET ORL TAB PDL TAB 1.3718 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 102 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002245948 LEVOTHYROXINE SODIUM 0.5 MG/VIAL INJECTION INJ DEFAUL PPC VIAL 253.9700 00002243933 LEVULAN KERASTICK 20% TOPICAL SOLUTION TOP SOL DSP ML 166.0000 00000999056 LIBERTE COPPER IUD TT380 STANDARD 10 YEARS DEFAUL DEFAUL MDI DEV 59.0000 00000999054 LIBERTE UT380 COPPER IUD 380MG SHORT DEFAUL DEFAUL MDI DEV 51.0000 00000999055 LIBERTE UT380 COPPER IUD 380MG STANDARD DEFAUL DEFAUL MDI DEV 51.0000 00002296187 LIDOCAINE HCL 2% INJECTION (BLOCK OR INFILTRATION) INJ LIQ ALV ML 1.0500 00000436208 LIDOCAINE HYDROCHLORIDE 2% INJECTION INJ DEFAUL HSP ML 5.4600 00002143879 LIDODAN 2% TOPICAL JELLY TOP JEL ODN ML 0.3983 00002231147 LIDODAN ENDOTRACHEAL 10 MG/DOSE NON-AEROSOL SPRAY TOP SPR ODN DOSE 0.1828 00000874949 LIDOMYXIN OTIC LIQUID OT LIQ SDZ ML 0.5960 00002243101 LIFE BRAND DAILY LOW DOSE ASA 81 MG ECT ORL ECT PMS TAB 0.1597 00080003212 LIFE BRAND ORAL LAXATIVE ORL LIQ HJS ML 0.0920 00000030732 LINCOCIN 300 MG/ML INJECTION INJ DEFAUL PFI ML 3.0190 00002402637 LINEZOLID 2 MG/ML INJECTION INJ DEFAUL TEV ML 0.2958 00002269082 LIPIDIL EZ 145 MG TABLET ORL TAB BGP TAB 1.0977 00002269074 LIPIDIL EZ 48 MG TABLET ORL TAB BGP TAB 0.4287 00002146959 LIPIDIL MICRO 200 MG CAPSULE ORL CAP FAB CAP 1.0890 00080006893 LIQUID CALCIUM WITH VITAMIN D ORL LIQ WBP ML 0.0168 00080001853 LIQUID GLUCOSAMINE ORL LIQ JAM ML 0.0310 00080001800 LIQUID GLUCOSAMINE/CHONDROITIN & MSM LIQUID ORL LIQ WBP ML 0.0334 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 103 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080007222 LIQUID OMEGA-3 PLUS VITAMIN A & D ORL LIQ WNP ML 0.0939 00002266695 LITHMAX 300 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.2545 00002020017 LIVOSTIN 50 MCG PER DOSE NASAL SPRAY NAS SPR JAI ML 1.9667 00000074462 LOCACORTEN VIOFORM TOPICAL CREAM TOP CRM PAL G 0.9140 00002417456 LOLO (28 DAY) TABLET ORL TB ASC TAB 0.5939 00000590819 LOPRESOR 1.0 MG/ML INJECTION INJ DEFAUL NOV ML 1.2460 00002221810 LOPROX 1% TOPICAL LOTION TOP LOT VCL ML 0.3223 00002280159 LORATADINE 10 MG TABLET ORL TAB VTH TAB 0.1540 00002244692 LORATADINE 10 MG TABLET ORL TAB VTH TAB 0.4442 00002429810 LORAZEPAM 1 MG TABLET ORL TAB SIV TAB 0.0447 00002429829 LORAZEPAM 2 MG TABLET ORL TAB SIV TAB 0.0699 00002243278 LORAZEPAM 4 MG INJECTION USP INJ DEFAUL SDZ ML 21.2000 00002394383 LOSARTAN 100 MG TABLET ORL TAB PDL TAB 0.3147 00002394367 LOSARTAN 25 MG TABLET ORL TAB PDL TAB 0.3147 00002394375 LOSARTAN 50 MG TABLET ORL TAB PDL TAB 0.3147 00002394405 LOSARTAN-HCTZ 100 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3083 00002394413 LOSARTAN-HCTZ 100 MG/25 MG TABLET ORL TAB PDL TAB 0.3147 00002394391 LOSARTAN-HCTZ 50 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3146 00002435853 LOTEMAX 0.5% OPHTHALMIC GEL OPH GEL BSH G 4.4000 00002421941 LOTEMAX 0.5% OPHTHALMIC OINTMENT OPH ONT BSH G 6.2857 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 104 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price OPH SUS BSH ML 4.4000 00002321114 LOTEMAX 0.5% OPHTHALMIC SUSPENSION 00002169991 LOXAPAC 50 MG/ML INJECTION INJ DEFAUL SDZ ML 15.2350 00002179709 LOZIDE 1.25 MG TABLET ORL TAB SEV TAB 0.2980 00002425629 LUCENTIS 1.65 MG/SYRINGE INJECTION INJ DEFAUL NOV SYR 1575.0000 00002239833 LUPRON DEPOT 30 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 1428.0000 00002242934 LUSTRA-AF TOPICAL CREAM TOP CRM MEI G 1.1972 00002046210 LUTREPULSE 0.8 MG/VIAL INJECTION INJ DEFAUL FEI VIAL 115.0000 00002269066 LUVERIS 75 IU/VIAL INJECTION INJ DEFAUL SRO VIAL 26.4900 00002366924 LUXIQ 0.12% TOPICAL FOAM TOP FOA GSK G 0.7531 00002268450 LYRICA 150 MG CAPSULE ORL CAP PFI CAP 2.3027 00002268477 LYRICA 225 MG CAPSULE ORL CAP PFI CAP 2.3027 00002268418 LYRICA 25 MG CAPSULE ORL CAP PFI CAP 0.8230 00002268485 LYRICA 300 MG CAPSULE ORL CAP PFI CAP 2.3027 00002268426 LYRICA 50 MG CAPSULE ORL CAP PFI CAP 1.2910 00002268434 LYRICA 75 MG CAPSULE ORL CAP PFI CAP 1.6705 00000463221 LYSODREN 500 MG TABLET ORL TAB BMS TAB 4.6355 00002009765 M.O.S. SULPHATE 10 MG TABLET ORL TAB VCL TAB 0.1751 00002009749 M.O.S. SULPHATE 25 MG TABLET ORL TAB VCL TAB 0.2317 00002009773 M.O.S. SULPHATE 5 MG TABLET ORL TAB VCL TAB 0.1133 00002009706 M.O.S. SULPHATE 50 MG TABLET ORL TAB VCL TAB 0.3553 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 105 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000776203 M.O.S.-SR 60 MG SUSTAINED-RELEASE TABLET ORL SRT VCL TAB 0.8232 00002244690 MAALOX ANTACID WITH ANTI-GAS EXTRA STRENGTH SUSP ORL SUS NVC ML 0.0211 00002244689 MAALOX ANTACID WITH ANTI-GAS ORAL SUSPENSION ORL SUS NVC ML 0.0181 00002238291 MAALOX QUICK DISSOVE EXTRA STR. CHEWABLE TABLET ORL TAB NVC TAB 0.1031 00002267225 MACUGEN 0.3 MG/SYR INJECTION SYRINGE INJ NDL PFI SYR 995.0000 00002068400 MAGNESIUM 100 MG TABLET ORL TAB JAM TAB 0.0697 00080025339 MAGNESIUM 250 MG TABLET ORL TAB WNP TAB 0.0306 00002040921 MAGNESIUM 50 MG TABLET ORL TAB JAM TAB 0.0542 00080005581 MAGNESIUM CITRATE 150 MG CAPSULE ORL CAP WBP CAP 0.0755 00080005079 MAGNESIUM COMPLEX 250 MG CAPLET ORL TAB JAM TAB 0.0892 00002247017 MAGNESIUM COMPLEX 250 MG TABLET ORL TAB JAM TAB 0.0450 00080013414 MAGNESIUM EXTRA STRENGTH 500 MG TABLET ORL TAB WNP TAB 0.0755 00000299448 MAGNESIUM OXIDE 420 MG TABLET ORL TAB VCL TAB 0.0328 00080014800 MAGNESIUM PLUS CALCIUM POWDER FOR SUSPENSION ORL PWRSUS NCC G 0.0973 00000392618 MAGNESIUM SULFATE 20% INJECTION INJ DEFAUL SDZ ML 0.7048 00000602264 MAGNESIUM SULFATE 50% INJECTION USP INJ DEFAUL BAX ML 1.4890 00002139499 MAGNESIUM SULFATE 500 MG/ML INJECTION USP INJ DEFAUL PPC ML 0.4310 00000202045 MAGNOLAX ORAL EMULSION ORL EML PPH ML 0.0134 00002264935 MALARONE PEDIATRIC TABLET ORL TAB GSK TAB 1.5525 00002238151 MALARONE TABLET ORL TAB GSK TAB 4.6592 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 106 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002243459 MALTLEVOL-12 ORAL LIQUID ORL LIQ CHD ML 0.0206 00000499013 MANDELAMINE 500 MG TABLET ORL TAB ERF TAB 0.3800 00000899356 MANERIX 150 MG TABLET ORL TAB MED TAB 0.6483 00002166747 MANERIX 300 MG TABLET ORL TAB MED TAB 1.2732 00002429861 MAR-AMITRIPTYLINE 10 MG TABLET ORL TAB MAR TAB 0.0664 00002429888 MAR-AMITRIPTYLINE 25 MG TABLET ORL TAB MAR TAB 0.1211 00002429896 MAR-AMITRIPTYLINE 50 MG TABLET ORL TAB MAR TAB 0.2347 00002429918 MAR-AMITRIPTYLINE 75 MG TABLET ORL TAB MAR TAB 0.3634 00002371707 MAR-AMLODIPINE 2.5 MG TABLET ORL TAB MAR TAB 0.1726 00002379562 MAR-ANASTROZOLE 1 MG TABLET ORL TAB MAR TAB 3.3280 00002241918 MARCAINE 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 0.7505 00002305909 MARCAINE 5 MG/ML INJECTION INJ DEFAUL HSP ML 0.8922 00002241919 MARCAINE 5 MG/ML INJECTION INJ DEFAUL HSP ML 0.8930 00002241917 MARCAINE 7.5 MG/ML INJECTION INJ DEFAUL HSP ML 1.8145 00002241915 MARCAINE E 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 0.7780 00002241914 MARCAINE SPINAL 7.5 MG/ML INJECTION INJ DEFAUL HSP ML 11.8350 00000611190 MARINOL 2.5 MG CAPSULE ORL CAP ABB CAP 2.0310 00000611204 MARINOL 5 MG CAPSULE ORL CAP ABB CAP 4.0618 00002373424 MAR-LETROZOLE 2.5 MG TABLET ORL TAB MAR TAB 3.0617 00002432560 MAR-MODAFINIL 100 MG TABLET ORL TAB MAR TAB 0.9293 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 107 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002447053 MAR-MOXIFLOXACIN 400 MG TABLET ORL TAB MAR TAB 1.5300 00002389118 MAR-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB MAR TAB 6.9623 00002389126 MAR-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB MAR TAB 7.5900 00002416557 MAR-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT MAR TAB 1.2750 00002411946 MAR-PAROXETINE 10 MG TABLET ORL TAB MAR TAB 1.0430 00002417561 MAR-PREGABALIN 150 MG CAPSULE ORL CAP MAR CAP 1.8652 00002417529 MAR-PREGABALIN 25 MG CAPSULE ORL CAP MAR CAP 0.6667 00002417537 MAR-PREGABALIN 50 MG CAPSULE ORL CAP MAR CAP 1.0458 00002417545 MAR-PREGABALIN 75 MG CAPSULE ORL CAP MAR CAP 1.3532 00002420503 MAR-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB MAR CAP 0.8550 00002432102 MAR-TOPIRAMATE 100 MG TABLET ORL TAB MAR TAB 0.5928 00002432110 MAR-TOPIRAMATE 200 MG TABLET ORL TAB MAR TAB 0.8853 00002432099 MAR-TOPIRAMATE 25 MG TABLET ORL TAB MAR TAB 0.3128 00002388324 MAR-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MAR TAB 0.6264 00000012750 MATULANE 50 MG CAPSULE ORL CAP SGM CAP 56.7958 00002244533 MAXILENE 4% TOPICAL CREAM TOP CRM RGR G 1.6800 00002245939 MAXILENE 5 % TOPICAL CREAM TOP CRM RGR G 1.5367 00002163632 MAXIPIME 1 G/VIAL INJECTION INJ DEFAUL BMS VIAL 17.7650 00002163640 MAXIPIME 2 G/VIAL INJECTION INJ DEFAUL BMS VIAL 35.5250 00002379104 MED-ANASTROZOLE 1 MG TABLET ORL TAB GMP TAB 3.3280 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 108 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002426935 MED-LATANOPROST 0.005% OPHTHALMIC SOLUTION OPH SOL GMP ML 3.6320 00002253550 MEDROXY-2.5 2.5 MG TABLET ORL TAB PDL TAB 0.0416 00002253577 MEDROXY-5 5MG TABLET ORL TAB PDL TAB 0.0823 00002244366 MEFLOQUINE 250 MG TABLET ORL TAB AAP TAB 3.6950 00002040891 MEGA-CAL CALCIUM W/ VITAMIN D 650 MG/200 UNIT CPT ORL TAB JAM TAB 0.1028 00002242594 MEGA-VIM CAPLET ORL TAB JAM TAB 0.1893 00002409623 MEKINIST 0.5 MG TABLET ORL TAB NOV TAB 72.5000 00002409658 MEKINIST 2 MG TABLET ORL TAB NOV TAB 290.0000 00080006449 MELATONIN TIMED RELEASED ORL TAB PLH TAB 0.0556 00002353156 MELOXICAM 15 MG TABLET ORL TAB SNS TAB 0.5670 00002353148 MELOXICAM 7.5 MG TABLET ORL TAB SNS TAB 0.4913 00002443082 MEMANTINE 10 MG TABLET ORL TAB SNS TAB 1.6357 00002279924 MENACTRA A/C/Y/W-135 (0.5ML SINGLE-DOSE) INJECTION INJ DEFAUL SFP ML 220.0000 00002248649 MENINGITEC (10 MCG/15 MCG) 0.5 ML INJECTION INJ DEFAUL NBV ML 130.0400 00002243820 MENJUGATE VACCINE (10 MCG/25 MCG) .5 ML INJECTION INJ DEFAUL NOV VIAL 89.0000 00000588490 MENOMUNE A/C/Y/W-135 (MULTI-DOSE) INJECTION INJ DEFAUL SFP VIAL 157.2900 00001959018 MENOMUNE A/C/Y/W-135 (SINGLE-DOSE) INJECTION INJ DEFAUL SFP VIAL 160.4400 00002283093 MENOPUR 75 IU/VIAL INJECTION INJ DEFAUL FEI VIAL 74.0000 00002347393 MENVEO 0.5 ML INJECTION INJ DEFAUL NOV ML 202.0000 00002415275 MERCAPTOPURINE 50 MG TABLET ORL TAB STM TAB 2.8612 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 109 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002378795 MEROPENEM 1G/VIAL INJECTION INJ DEFAUL SDZ VIAL 47.9900 00002378787 MEROPENEM 500 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 23.9950 00002047667 MERSYNDOL WITH CODEINE TABLET ORL TAB SAV TAB 0.2113 00002244931 MESNA 100 MG/ML INJECTION INJ DEFAUL PPC ML 10.1855 00002241615 METAMUCIL FIBRE APPLE CRISP 3.4 G/2 WAFERS ORL WAF PGI WAF 0.1717 00002241614 METAMUCIL FIBRE CINNAMON SPICE 3.4 G/2 WAFERS ORL WAF PGI WAF 0.2120 00002174812 METAMUCIL FIBRE THERAPY 3.4 G/TSP ORAL POWDER ORL PWR PGI G 0.0269 00002247034 METAMUCIL FIBRE THERAPY CAPSULE ORL CAP PGI CAP 0.1220 00002174782 METAMUCIL FIBRE THERAPY-SMOOTH TEXTURE-ORANGE S.F. ORL PWR PGI G 0.0686 00002174790 METAMUCIL SMOOTH TEXTURE-ORANGE 3 G/TBSP ORAL PWDR ORL PWR PGI G 0.0157 00002174804 METAMUCIL SMOOTH UNFLAVORED SUGAR FREE POWDER ORL PWR PGI G 0.0320 00002182971 METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION INJ DEFAUL MNP ML 7.8755 00002422174 METHOTREXATE 10 MG/0.4ML INJECTION SYRINGE BP INJ NDL PMS SYR 7.0000 00002422182 METHOTREXATE 15 MG/0.6 ML INJECTION SYRINGE BP INJ NDL PMS SYR 8.4000 00002422190 METHOTREXATE 20 MG/0.8 ML INJECTION SYRINGE BP INJ NDL PMS SYR 11.2000 00002417626 METHOTREXATE 25 MG/ML INJECTION (UNPRESERVED) INJ DEFAUL MYP ML 6.2500 00002327236 METHOTREXATE 25 MG/ML INJECTION BP (UNPRESERVED) INJ DEFAUL AHI ML 8.0000 00002422204 METHOTREXATE 25 MG/ML INJECTION SYRINGE BP INJ NDL PMS SYR 14.0000 00002422166 METHOTREXATE 7.5 ML/0.3 ML INJECTION SYRINGE BP INJ NDL PMS SYR 5.6000 00002182947 METHOTREXATE SODIUM (UNPRESERVED) 10 MG/ML INJ INJ DEFAUL MNP ML 8.2650 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 110 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002230521 METHOXACET CAPLET ORL TAB RPH TAB 0.1583 00002236872 METHOXACET-C 1/8 CAPLET ORL TAB RPH TAB 0.5828 00000868868 METHOXISAL CAPLET ORL TAB RPH TAB 0.2772 00001966375 METHOXISAL-C 1/2 TABLET ORL TAB RPH TAB 0.9525 00001966367 METHOXISAL-C 1/4 TABLET ORL TAB RPH TAB 0.8208 00001941895 METHOXISAL-C 1/8 CAPLET ORL TAB RPH TAB 0.5272 00002326248 METHYLPHENIDATE 10 MG TABLET ORL TAB PDL TAB 0.1262 00002326256 METHYLPHENIDATE 20 MG TABLET ORL TAB PDL TAB 0.2435 00002326221 METHYLPHENIDATE 5 MG TABLET ORL TAB PDL TAB 0.0947 00002245407 METHYLPREDNISOLONE ACETATE (PRES.) 40 MG/ML INJ INJ DEFALT SDZ ML 4.1000 00002245408 METHYLPREDNISOLONE ACETATE (PRES.) 80 MG/ML INJ. INJ DEFALT SDZ ML 6.9900 00002245400 METHYLPREDNISOLONE ACETATE 40 MG/ML INJECTION USP INJ DEFAUL SDZ ML 4.1000 00002245406 METHYLPREDNISOLONE ACETATE 80 MG/ML INJECTION USP INJ DEFAUL SDZ ML 8.2000 00002243563 METOCLOPRAMIDE OMEGA 5MG/ML INJECTION INJ DEFAUL OMG ML 10.2500 00002320037 METOJECT 10 MG/1 ML INJECTION SYRINGE INJ NDL MDX SYR 49.4000 00002320045 METOJECT 15 MG/1.5 ML INJECTION SYRINGE INJ NDL MDX SYR 54.6000 00002304767 METOJECT 20 MG/2 ML INJECTION SYRINGE INJ NDL MDX SYR 59.8000 00002320053 METOJECT 25 MG/2.5 ML INJECTION SYRINGE INJ NDL MDX SYR 65.0000 00002320029 METOJECT 7.5 MG/0.75 ML INJECTION SYRINGE INJ NDL MDX SYR 46.8000 00002351404 METOPROLOL SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.1415 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 111 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002351412 METOPROLOL SR 200 MG SUSTAINED-RELEASE TABLET ORL SRT PDL TAB 0.2499 00002267853 METOPROLOL TARTRATE 1 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.4162 00000648027 METOPROLOL-100 MG TABLET ORL TAB PDL TAB 0.1250 00000648019 METOPROLOL-50 MG TABLET ORL TAB PDL TAB 0.0624 00002442116 METOPROLOL-L 25 MG TABLET ORL TAB SIV TAB 0.0643 00002092832 METROGEL 0.75% TOPICAL GEL TOP GEL GAL G 1.3333 00002248562 METRONIDAZOLE 500 MG CAPSULE ORL CAP AAP CAP 0.7028 00002323273 METVIX 16.8% TOPICAL CREAM TOP CRM GAL G 162.8200 00000795860 MEVACOR 20 MG TABLET ORL TAB MFC TAB 2.0610 00000795852 MEVACOR 40 MG TABLET ORL TAB MFC TAB 3.7647 00002085852 MICATIN 2% TOPICAL CREAM TOP CRM WSP G 0.3840 00002171775 MICONAZOLE 3 DAY OVULE TREATMENT VAG OVL VTH OVL 1.6966 00002091143 MICRO PLUS 4 CONCENTRATE INJECTION INJ DEFAUL SDZ ML 2.5276 00002091135 MICRO PLUS 4 REGULAR STRENGTH INJECTION INJ DEFAUL SDZ ML 0.9090 00002063905 MICROLAX MICRO RECTAL ENEMA RT ENM JJM ENM 1.2050 00000787000 MICRO-ZN 5 MG/ML INJECTION INJ DEFAUL SDZ ML 2.4042 00000487805 MIDAMOR 5 MG TABLET ORL TAB OPI TAB 0.2860 00002240285 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.7800 00002242904 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL PPC ML 1.1450 00002423758 MIDAZOLAM 1 MG/ML INJECTION INJ DEFAUL PFI ML 0.8200 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 112 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002242905 MIDAZOLAM 5 MG/ML INJECTION INJ DEFAUL PPC ML 4.1000 00002423766 MIDAZOLAM 5 MG/ML INJECTION INJ DEFAUL PFI ML 4.1000 00002382873 MIDAZOLAM INJECTION SDZ 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.7800 00002244622 MILRINONE LACTATE 1 MG/ML INJECTION INJ DEFAUL PPC ML 5.3692 00001935348 MINERAL OIL (HEAVY) ORL LIQ RBW ML 0.0092 00000485802 MINERAL OIL 100% ORAL LIQUID ORL LIQ RPH ML 0.0122 00002246500 MINIRIN 0.1 MG TABLET ORL TAB FEI TAB 1.3216 00002394863 MINT-ALENDRONATE 10 MG TABLET ORL TAB MPI TAB 0.4986 00002393573 MINT-ANASTROZOLE 1 MG TABLET ORL TAB MPI TAB 1.7821 00002317427 MINT-CIPROFLOXACIN 250 MG TABLET ORL TAB MPI TAB 0.6186 00002317435 MINT-CIPROFLOXACIN 500 MG TABLET ORL TAB MPI TAB 0.6979 00002429691 MINT-CITALOPRAM 10 MG TABLET ORL TAB MPI TAB 0.1432 00002429705 MINT-CITALOPRAM 20 MG TABLET ORL TAB MPI TAB 0.2397 00002429713 MINT-CITALOPRAM 40 MG TABLET ORL TAB MPI TAB 0.2397 00002443090 MINT-DORZOLAMIDE/TIMOLOL 2 %/0.5 % OPH SOLUTION OPH SOL MPI ML 1.9887 00002407418 MINT-ESCITALOPRAM 10 MG TABLET ORL TAB MPI TAB 0.4318 00002407434 MINT-ESCITALOPRAM 20 MG TABLET ORL TAB MPI TAB 0.4597 00002425947 MINT-HYDROCHLOROTHIAZIDE 12.5 MG TABLET ORL TAB MPI TAB 0.0341 00002426196 MINT-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB MPI TAB 0.0157 00002426218 MINT-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB MPI TAB 0.0217 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 113 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002388766 MINT-METFORMIN 500 MG TABLET ORL TAB MPI TAB 0.0444 00002388774 MINT-METFORMIN 850 MG TABLET ORL TAB MPI TAB 0.0610 00002436981 MINT-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB MPI TAB 1.9280 00002437007 MINT-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB MPI TAB 7.5977 00002422727 MINT-OLOPATADINE 0.1% OPHTHALMIC SOLUTION OPH SOL MPI ML 5.2260 00002424185 MINT-PREGABALIN 75 MG CAPSULE ORL CAP MPI CAP 1.2529 00002438011 MINT-QUETIAPINE 100 MG TABLET ORL TAB MPI TAB 0.3465 00002438046 MINT-QUETIAPINE 200 MG TABLET ORL TAB MPI TAB 0.6958 00002438003 MINT-QUETIAPINE 25 MG TABLET ORL TAB MPI TAB 0.1299 00002438054 MINT-QUETIAPINE 300 MG TABLET ORL TAB MPI TAB 1.0153 00002421348 MINT-RAMIPRIL 15 MG CAPSULE ORL CAP MPI CAP 0.8551 00002393085 MINT-SILDENAFIL 100 MG TABLET ORL TAB MPI TAB 9.2000 00002393069 MINT-SILDENAFIL 25 MG TABLET ORL TAB MPI TAB 8.2900 00002393077 MINT-SILDENAFIL 50 MG TABLET ORL TAB MPI TAB 8.8475 00002389800 MINT-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MPI TAB 0.6264 00000042544 MIOSTAT 0.01% OPH SOLUTION OPH SOL ALC ML 13.0561 00002297256 MIRAPEX 0.125 MG TABLET ORL TAB BOE TAB 1.0833 00002241594 MIRAPEX 0.5 MG TABLET ORL TAB BOE TAB 2.1672 00002312786 MIRTAZAPINE-30 30 MG TABLET ORL TAB PDL TAB 0.1950 00002248846 MISOPROSTOL-200 200 MCG TABLET ORL TAB PDL TAB 0.2850 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 114 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002230451 MITOMYCIN 20 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 377.2000 00002230450 MITOMYCIN 5 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 94.3000 00001948873 MIXED VESPID VENOM PROTEIN 1.1 MG VIAL INJ INJ DEFAUL ALK ML 71.3833 00001948881 MIXED VESPID VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 71.3833 00080025624 MK 20 A LIBERATION PROLONGEE 20 MEQ TABLET ORL TAB MTR TAB 0.1995 00080035346 MK 8 8 MEQ TABLET ORL TAB MTR TAB 0.2250 00000466085 M-M-R II VIRUS VACCINE LIVE ATTENUATED INJECTION INJ DEFAUL MSD VIAL 30.4980 00002242786 MOBICOX 15 MG TABLET ORL TAB BOE TAB 0.9243 00002242785 MOBICOX 7.5 MG TABLET ORL TAB BOE TAB 0.8011 00002238696 MOI-STIR SPRAY ORAL LIQUID ORL LIQ PMS ML 0.0637 00001909142 MOISTUREL TOPICAL CREAM TOP CRM WSD G 0.0567 00001909169 MOISTUREL TOPICAL LOTION TOP LOT WSD ML 0.0208 00000999058 MONA LISA 10 IUD COPPER STERILE DEFAUL DEFAUL BSN DEV 61.5000 00000999057 MONA LISA 5 IUD COPPER STERILE DEFAUL DEFAUL BSN DEV 48.0000 00002239601 MONISTAT 1 1200 MG VAGINAL OVULE VAG OVL MCL OVL 12.0200 00002244005 MONISTAT 3 4% VAGINAL CREAM VAG CRM MCL G 0.8013 00002126605 MONISTAT 3 400 MG VAGINAL OVULE VAG OVL MCL OVL 4.0067 00002126249 MONISTAT 3 DUAL-PAK KIT VAG/TOP OVL/CRM MCL KIT 13.7600 00002084309 MONISTAT 7 2% VAGINAL CREAM VAG CRM MCL G 0.3434 00002126257 MONISTAT 7 DUAL-PAK VAGINAL OVULE/TOPICAL CREAM VAG/TOP OVL/CRM MCL KIT 13.7600 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 115 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price TOP CRM MCL G 0.3933 00002126567 MONISTAT DERM 2% TOPICAL CREAM 00002239600 MONISTAT-1 COMBINATION PACK VAG OVULE/TOP CREAM VAG/TOP OVL/CRM MCL KIT 13.7600 00000999332 MONOVISC DEFAUL DEV PMS ML 75.0000 00002379856 MONTELUKAST 10 MG TABLET ORL TAB PDL TAB 0.9460 00002379821 MONTELUKAST 4 MG TABLET ORL TAB PDL TAB 0.9460 00002379848 MONTELUKAST 5 MG TABLET ORL TAB PDL TAB 0.9460 00000676411 MORPHINE HP 25 25 MG/ML INJECTION INJ DEFAUL SDZ ML 3.6130 00002021056 MORPHINE LP EPIDURAL 0.5 MG/ML INJECTION INJ DEFAUL SDZ ML 2.3806 00001964437 MORPHINE SULFATE 2 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.2528 00001964429 MORPHINE SULFATE 5 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.4153 00001980696 MORPHINE SULFATE 1 MG/ML INJECTION USP INJ DEFAUL SDZ ML 0.3726 00002242484 MORPHINE SULFATE 2 MG/ML INJECTION INJ DEFAUL SDZ ML 1.9490 00080028360 MOTION MEDICINE TOPICAL CREAM TOP CRM NDP G 0.1212 00002186934 MOTRIN IB 200 MG TABLET ORL TAB MCL TAB 0.1229 00002442167 MOVANTIK 12.5 MG TABLET ORL TAB AZC TAB 5.9500 00002442175 MOVANTIK 25 MG TABLET ORL TAB AZC TAB 5.9500 00002359499 MOVIPREP POWDER FOR ORAL LAVAGE SOLUTION ORL PWDPKT MFI PCKT 5.5800 00080001844 MSM 1000 MG ORL TAB WNP TAB 0.0654 00002125013 MUCAINE ORAL SUSPENSION ORL SUS AXC ML 0.0243 00000599875 MUCILLIUM 500 MG/G ORAL POWDER ORL PWR PMS G 0.0175 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 116 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002330989 MULTAQ 400 MG TABLET ORL TAB SAV TAB 2.1667 00000782203 MULTI VITAMIN PLUS IRON TABLET ORL TAB VTH TAB 0.0600 00000782211 MULTI VITAMIN TABLET ORL TAB VTH TAB 0.0270 00000586315 MULTI-1000 INJECTION INJ DEFAUL SDZ ML 0.8197 00002100606 MULTI-12 INJECTION INJ DEFAUL SDZ ML 1.0462 00002244898 MULTIPLE VITAMIN TABLET ORL TAB PMT TAB 0.0700 00000374083 MULTIPLE VITAMIN WITH MINERAL TABLET ORL TAB ADA TAB 0.1100 00002248775 MULTISURE FOR WOMEN ORL CAP WNP CAP 0.0850 00002248778 MULTISURE FOR WOMEN OVER 50 GELATIN CAPSULE ORL CAP WBP CAP 0.0850 00002240942 MULTI-TAR PLUS REGULAR TOPICAL SHAMPOO TOP SHP VCL ML 0.0381 00000233498 MULTIVITAMIN TABLET ORL TAB WAM TAB 0.2226 00080005483 MULTI-VITAMIN TABLET ORL TAB WNP TAB 0.0351 00002242779 MULTIVITAMINS & MULTIMINERALS FORMULA FORTE SR.TAB ORL TAB PMT TAB 0.0800 00002242939 MULTIVITAMINS + MULTIMINERALS 50+ FORMULA TAB. ORL TAB PMT TAB 0.0665 00002242780 MULTIVITAMINS AND MULTIMINERALS FORMULA FORTE TAB ORL TAB PMT TAB 0.0678 00002244864 MULTIVITAMINS FOR ADULTS TABLET ORL TAB PMT TAB 0.0300 00000750816 MURO-128 5% OPH OINTMENT OPH ONT BSH G 2.9486 00000750824 MURO-128 5% OPH SOLUTION OPH SOL BSH ML 0.6880 00002238595 MUSE 1000 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 34.1100 00002238593 MUSE 250 MCG URETHRAL SUPPOSITORY URH SUP PAL SUP 34.1100 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 117 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price URH SUP PAL SUP 34.1100 00002238594 MUSE 500 MCG URETHRAL SUPPOSITORY 00000016063 MUSTARGEN HCL TRITURATION 10 MG/VIAL INJECTION INJ DEFAUL LUI VIAL 7.9500 00002415380 MYA 28 TABLET ORL TB APX TAB 0.4229 00002311054 MYCAMINE 100 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 196.0000 00002294222 MYCAMINE 50 MG/VIAL INJECTION INJ DEFAUL ASP VIAL 98.0000 00002264560 MYFORTIC 180 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 1.9977 00002264579 MYFORTIC 360 MG ENTERIC-COATED TABLET ORL ECT NOV TAB 3.9953 00002270129 MYLAN-ALENDRONATE 10 MG TABLET ORL TAB MYP TAB 0.5134 00002270110 MYLAN-ALENDRONATE 5 MG TABLET ORL TAB MYP TAB 1.0370 00002229813 MYLAN-ALPRAZOLAM 1 MG TABLET ORL TAB MYP TAB 0.3099 00002229814 MYLAN-ALPRAZOLAM 2 MG TABLET ORL TAB MYP TAB 0.5508 00002253054 MYLAN-ANAGRELIDE 0.5 MG CAPSULE ORL CAP MYP CAP 3.3491 00002361418 MYLAN-ANASTROZOLE 1 MG TABLET ORL TAB MYP TAB 2.7497 00002378981 MYLAN-ATOMOXETINE 100 MG CAPSULE ORL CAP MYP CAP 4.3520 00002378930 MYLAN-ATOMOXETINE 18 MG CAPSULE ORL CAP MYP CAP 2.6500 00002378949 MYLAN-ATOMOXETINE 25 MG CAPSULE ORL CAP MYP CAP 2.9281 00002378957 MYLAN-ATOMOXETINE 40 MG CAPSULE ORL CAP MYP CAP 3.3375 00002378965 MYLAN-ATOMOXETINE 60 MG CAPSULE ORL CAP MYP CAP 3.7024 00002378973 MYLAN-ATOMOXETINE 80 MG CAPSULE ORL CAP MYP CAP 3.9960 00002373203 MYLAN-ATORVASTATIN 10 MG TABLET ORL TAB MYP TAB 0.3138 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 118 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002373211 MYLAN-ATORVASTATIN 20 MG TABLET ORL TAB MYP TAB 0.3922 00002402165 MYLAN-ATOVAQUONE/PROGUANIL 250 MG/ 100 MG TABLET ORL TAB MYP TAB 4.1308 00002302403 MYLAN-BICALUTAMIDE 50 MG TABLET ORL TAB MYP TAB 4.0573 00002383500 MYLAN-BOSENTAN 125 MG TABLET ORL TAB MYP TAB 22.4625 00002383497 MYLAN-BOSENTAN 62.5 MG TABLET ORL TAB MYP TAB 22.4625 00002241003 MYLAN-BUDESONIDE AQ 64 MCG/DOSE MET DOSE NAS SPRAY NAS SPM MYP DOSE 0.0843 00002379120 MYLAN-CANDESARTAN 4 MG TABLET ORL TAB MYP TAB 0.3400 00002163594 MYLAN-CAPTOPRIL 100 MG TABLET ORL TAB MYP TAB 0.5198 00002163551 MYLAN-CAPTOPRIL 12.5 MG TABLET ORL TAB MYP TAB 0.1060 00002163578 MYLAN-CAPTOPRIL 25 MG TABLET ORL TAB MYP TAB 0.1500 00002163586 MYLAN-CAPTOPRIL 50 MG TABLET ORL TAB MYP TAB 0.2795 00002241883 MYLAN-CARBAMAZEPINE CR 400 MG SUSTAIN RELEASE TAB ORL SRT MYP TAB 0.1859 00002278669 MYLAN-DOMPERIDONE 10 MG TABLET ORL TAB MYP TAB 0.0594 00002240498 MYLAN-DOXAZOSIN 1 MG TABLET ORL TAB MYP TAB 0.1416 00002240499 MYLAN-DOXAZOSIN 2 MG TABLET ORL TAB MYP TAB 0.1699 00002240500 MYLAN-DOXAZOSIN 4 MG TABLET ORL TAB MYP TAB 0.2209 00002381524 MYLAN-EFAVIRENZ 600 MG TABLET ORL TAB MYP TAB 11.2103 00002383039 MYLAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 1.8690 00002383047 MYLAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT MYP TAB 1.8690 00002247323 MYLAN-ETI-CAL CAREPAC 400 MG/500 MG TABLET ORL TAB MYP TAB 0.2221 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 119 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002392631 MYLAN-FINASTERIDE HG 1 MG TABLET ORL TAB MYP TAB 1.1454 00002397471 MYLAN-GABAPENTIN 600 MG TABLET ORL TAB MYP TAB 1.3045 00002397498 MYLAN-GABAPENTIN 800 MG TABLET ORL TAB MYP TAB 1.7393 00000808733 MYLAN-GLYBE 2.5 MG TABLET ORL TAB MYP TAB 0.0321 00000808741 MYLAN-GLYBE 5 MG TABLET ORL TAB MYP TAB 0.0573 00002242920 MYLAN-HYDROXYUREA 500 MG CAPSULE ORL CAP MYP CAP 1.0203 00002319225 MYLAN-LEFLUNOMIDE 10 MG TABLET ORL TAB MYP TAB 6.0417 00002319233 MYLAN-LEFLUNOMIDE 20 MG TABLET ORL TAB MYP TAB 6.0417 00002297736 MYLAN-LISINOPRIL HCTZ 10 MG/12.5 MG TABLET ORL TAB MYP TAB 0.2083 00002297744 MYLAN-LISINOPRIL HCTZ 20 MG/12.5 MG TABLET ORL TAB MYP TAB 0.2503 00002297752 MYLAN-LISINOPRIL HCTZ 20 MG/25 MG TABLET ORL TAB MYP TAB 0.2503 00002255995 MYLAN-MELOXICAM 15 MG TABLET ORL TAB MYP TAB 0.5670 00002255987 MYLAN-MELOXICAM 7.5 MG TABLET ORL TAB MYP TAB 0.4914 00002430371 MYLAN-MEMANTINE 10 MG TABLET ORL TAB MYP TAB 1.6357 00002371154 MYLAN-MYCOPHENOLATE 250 MG CAPSULE ORL CAP MYP CAP 1.0310 00002370549 MYLAN-MYCOPHENOLATE 500 MG TABLET ORL TAB MYP TAB 2.0620 00002244563 MYLAN-NABUMETONE 500 MG TABLET ORL TAB MYP TAB 0.3625 00002387727 MYLAN-NEVIRAPINE 200 MG TABLET ORL TAB MYP TAB 1.7285 00002382725 MYLAN-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB MYP TAB 4.1240 00002382733 MYLAN-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB MYP TAB 7.5977 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 120 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002230800 MYLAN-OXYBUTYNIN 5 MG TABLET ORL TAB MYP TAB 0.0986 00002248012 MYLAN-PAROXETINE 10 MG TABLET ORL TAB MYP TAB 1.0430 00002298279 MYLAN-PIOGLITAZONE 15 MG TABLET ORL TAB MYP TAB 0.5809 00002298287 MYLAN-PIOGLITAZONE 30 MG TABLET ORL TAB MYP TAB 0.8139 00002298295 MYLAN-PIOGLITAZONE 45 MG TABLET ORL TAB MYP TAB 1.2237 00002376369 MYLAN-PRAMIPEXOLE 0.5 MG TABLET ORL TAB MYP TAB 1.0514 00002245372 MYLAN-PROPAFENONE 150 MG TABLET ORL TAB MYP TAB 0.2965 00002245373 MYLAN-PROPAFENONE 300 MG TABLET ORL TAB MYP TAB 0.5227 00002397773 MYLAN-RISEDRONATE 150 MG TABLET ORL TAB MYP TAB 40.9500 00002229779 MYLAN-SOTALOL 160 MG TABLET ORL TAB MYP TAB 0.1672 00002229778 MYLAN-SOTALOL 80 MG TABLET ORL TAB MYP TAB 0.2966 00002268906 MYLAN-SUMATRIPTAN 25 MG TABLET ORL TAB MYP TAB 8.9900 00002019795 MYLANTA REGULAR STRENGTH CHEWABLE TABLET ORL CTB WLA TAB 0.1062 00002088428 MYLAN-TAMOXIFEN 10 MG TABLET ORL TAB MYP TAB 0.1750 00002089858 MYLAN-TAMOXIFEN 20 MG TABLET ORL TAB MYP TAB 0.3500 00002298570 MYLAN-TAMSULOSIN 0.4 MG EXTENDED-RELEASE CAPSULE ORL SRC MYP CAP 0.2375 00002396289 MYLAN-TERAZOSIN 1 MG TABLET ORL TAB MYP TAB 0.1835 00002396319 MYLAN-TERAZOSIN 10 MG TABLET ORL TAB MYP TAB 0.4637 00002396297 MYLAN-TERAZOSIN 2 MG TABLET ORL TAB MYP TAB 0.2333 00002396300 MYLAN-TERAZOSIN 5 MG TABLET ORL TAB MYP TAB 0.3168 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 121 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002242503 MYLAN-TERBINAFINE 250 MG TABLET ORL TAB MYP TAB 1.8525 00002239744 MYLAN-TICLOPIDINE 250 MG TABLET ORL TAB MYP TAB 0.3139 00002272059 MYLAN-TIZANIDINE 4 MG TABLET ORL TAB MYP TAB 0.3686 00002404184 MYLAN-TOLTERODINE ER 2 MG EXTENDED-RELEASE CAPSULE ORL ERC MYP CAP 1.6697 00002404192 MYLAN-TOLTERODINE ER 4 MG EXTENDED-RELEASE CAPSULE ORL ERC MYP CAP 1.6697 00002425599 MYLAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB MYP TAB 0.6264 00002231684 MYLAN-TRAZODONE 100 MG TABLET ORL TAB MYP TAB 0.0989 00002231683 MYLAN-TRAZODONE 50 MG TABLET ORL TAB MYP TAB 0.0554 00002351560 MYLAN-VALACYCLOVIR 1000 MG CAPLET ORL TAB MYP TAB 5.8537 00002383527 MYLAN-VALSARTAN 40 MG TABLET ORL TAB MYP TAB 0.5239 00002287501 MYLAN-WARFARIN 6 MG TABLET ORL TAB MYP TAB 0.2805 00002287528 MYLAN-WARFARIN 7.5 MG TABLET ORL TAB MYP TAB 0.3014 00000004618 MYLERAN 2 MG TABLET ORL TAB ASN TAB 1.5576 00002372169 MYL-LETROZOLE 2.5 MG TABLET ORL TAB MYP TAB 2.7560 00002408694 MYL-PREGABALIN 150 MG CAPSULE ORL CAP MYP CAP 1.7270 00002408651 MYL-PREGABALIN 25 MG CAPSULE ORL CAP MYP CAP 0.6173 00002408708 MYL-PREGABALIN 300 MG CAPSULE ORL CAP MYP CAP 1.7270 00002408678 MYL-PREGABALIN 50 MG CAPSULE ORL CAP MYP CAP 0.9683 00002408686 MYL-PREGABALIN 75 MG CAPSULE ORL CAP MYP CAP 1.2529 00002367378 MYL-RANITIDINE 150 MG TABLET ORL TAB MYP TAB 0.1800 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 122 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002367386 MYL-RANITIDINE 300 MG TABLET ORL TAB MYP TAB 0.3600 00002392593 MYL-SILDENAFIL 100 MG TABLET ORL TAB MYP TAB 9.2007 00002392577 MYL-SILDENAFIL 25 MG TABLET ORL TAB MYP TAB 8.2900 00002392585 MYL-SILDENAFIL 50 MG TABLET ORL TAB MYP TAB 8.8475 00001927612 MYOCHRYSINE 25 MG/ML INJECTION INJ DEFAUL AVE ML 15.0000 00002226022 MYOFLEX EXTRA STRENGTH 15% CREAM TOP CRM BIC G 0.0598 00000828815 NADOLOL-40 MG TABLET ORL TAB PDL TAB 0.2465 00000818704 NADOLOL-80 MG TABLET ORL TAB PDL TAB 0.3515 00002382601 NALOXONE HYDROCHLORIDE (PRES. FREE) 0.4 MG/ML INJ INJ DEFAUL SDZ ML 13.7450 00002148706 NALOXONE HYDROCHLORIDE 0.4 MG/ML INJECTION INJ DEFAUL SDZ ML 13.7450 00002148714 NALOXONE HYDROCHLORIDE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 20.1475 00000390283 NAPHCON FORTE 0.1% OPH SOLUTION OPH SOL ALC ML 0.5060 00000481408 NAPHCON-A OPH SOLUTION OPH SOL ALC ML 0.4747 00002242505 NAPRELAN 375 MG CONTROLLED-RELEASE TABLET ORL CRT SUN TAB 0.9604 00002242506 NAPRELAN 500 MG CONTROLLED-RELEASE TABLET ORL CRT SUN TAB 1.5792 00000618721 NAPROXEN 500 MG TABLET ORL TAB PDL TAB 0.2110 00002362430 NAPROXEN 220 MG TABLET ORL TAB PMS TAB 0.0696 00000590762 NAPROXEN 250 MG TABLET ORL TAB PDL TAB 0.1068 00000655686 NAPROXEN-375 375 MG TABLET ORL TAB PDL TAB 0.1458 00000887056 NAPROXEN-NA 275 MG TABLET ORL TAB PDL TAB 0.3440 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 123 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002153386 NAPROXEN-NA DF 550 MG TABLET ORL TAB PDL TAB 0.6667 00002229415 NAROPIN 5 MG/ML INJECTION INJ DEFAUL AZC ML 0.3798 00002213834 NASACORT AQ 55 MCG NASAL METERED DOSE SPRAY NAS SPM SAV DOSE 0.2000 00002192799 NASAL + SINUS DECONGESTANT RELIEF 60 MG TABLET ORL TAB VTH TAB 0.1242 00000788503 NASAL DECONGESTANT SPRAY 0.1% NAS LIQ CNF ML 0.0920 00002417855 NAT-ANASTROZOLE 1 MG TABLET ORL TAB NTP TAB 2.9000 00002421585 NAT-LETROZOLE 2.5 MG TABLET ORL TAB NTP TAB 3.1300 00080029758 NEBUSAL 7% INHALATION SOLUTION MIS DEFAUL STM ML 0.2431 00080027142 NEILMED NASAL SINUS RINSE NAS PWS NPI PCKT 0.2350 00002245057 NEISVAC-C 10 MCG/20 MCG INJECTION SYRINGE INJ NDL PFI SYR 80.1850 00000147680 NEO-BEX (LIDOCAINE HCL) INJECTION VIAL INJ DEFAUL BRO ML 5.5850 00000666157 NEOSPORIN IRRIGATING SOLUTION IR SOL GSK ML 1.6860 00000666122 NEOSPORIN TOPICAL OINTMENT TOP ONT GSK G 0.4680 00000874957 NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INJECTION INJ DEFAUL SDZ ML 0.8844 00000885282 NEOSTIGMINE METHYLSULFATE 1 MG/ML INJECTION INJ DEFAUL SDZ ML 0.9690 00001915436 NEOSTIGMINE METHYLSULFATE 2.5 MG/ML INJECTION INJ DEFAUL SDZ ML 3.4342 00002230593 NEOSTIGMINE OMEGA 0.5 MG/ML INJECTION INJ DEFAUL OMG ML 0.9400 00002230592 NEOSTIGMINE OMEGA 1 MG/ML INJECTION INJ DEFAUL OMG ML 1.0500 00001958690 NEOSTRATA HQ 2% GEL TOP GEL CDX G 0.7667 00000999459 NEOVISC DEFAUL DEV STL ML 47.7400 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 124 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000999922 NEPRO ORAL LIQUID ORL LIQ ABN ML 0.0090 00000587826 NERISONE 0.1% TOPICAL CREAM TOP CRM GSK G 0.3943 00000587834 NERISONE 0.1% TOPICAL OINTMENT TOP ONT GSK G 0.3863 00080007796 NERVOHEEL N TABLET ORL TAB HEE TAB 0.2858 00002417197 NESINA 12.5 MG TABLET ORL TAB TAK TAB 2.6177 00002417200 NESINA 25 MG TABLET ORL TAB TAK TAB 2.6177 00002417189 NESINA 6.25 MG TABLET ORL TAB TAK TAB 2.6177 00002403897 NEUPRO 1 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 3.5400 00002403900 NEUPRO 2 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 3.5400 00002403919 NEUPRO 3 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 6.5000 00002403927 NEUPRO 4 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 6.5000 00002403935 NEUPRO 6 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.2700 00002403943 NEUPRO 8 MG/24 HOUR TRANSDERMAL PATCH TRD PTH UCB PTH 7.2700 00002239717 NEURONTIN 600 MG TABLET ORL TAB PFI TAB 1.8897 00002239718 NEURONTIN 800 MG TABLET ORL TAB PFI TAB 2.5220 00080006269 NEUTROGENA BODY CLEAR BODY WASH PINK GRAPEFRUIT TOP GEL JJI ML 0.0270 00002308983 NEVANAC 0.1% OPHTHALMIC SUSPENSION OPH SUS ALC ML 4.0360 00080039670 NEW NORDIC HAIR VOLUME TABLET ORL TAB NNO TAB 0.9313 00002284227 NEXAVAR 200 MG TABLET ORL TAB BAI TAB 46.0088 00002300524 NEXIUM 10 MG/DOSE DEL REL GRANULES FOR ORAL SUSP ORL DRGRNUL AZC PCKT 2.2000 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 125 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002244521 NEXIUM 20 MG DELAYED-RELEASE TABLET ORL DRT AZC TAB 2.2000 00002244522 NEXIUM 40 MG DELAYED-RELEASE TABLET ORL DRT AZC TAB 2.2000 00000232459 NIACIN 100 MG TABLET ORL TAB ADA TAB 0.0830 00000779806 NIACIN 500 MG SUSTAINED-RELEASE CAPSULE ORL SRC VTH CAP 0.8500 00000309737 NIACIN 500 MG TABLET ORL TAB JAM TAB 0.0567 00002244702 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB JAM TAB 0.1962 00002242138 NIACIN AND INOSITOL 500 MG/150 MG TABLET ORL TAB QVS TAB 0.1277 00002262339 NIASPAN 1000 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.2213 00002262347 NIASPAN 500 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.2647 00002262355 NIASPAN 750 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.4180 00002309289 NIASPAN FCT 1000 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.3300 00002309254 NIASPAN FCT 500 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.3300 00002309262 NIASPAN FCT 750 MG EXTENDED-RELEASE TABLET ORL ERT SUN TAB 1.3300 00002247347 NICORETTE MINI LOZENGE 2 MG ORL LOZ MCL LOZ 0.4714 00002247348 NICORETTE MINI LOZENGE 4 MG ORL LOZ MCL LOZ 0.4714 00002065762 NICORETTE PATCH 15MG; NICORETTE COMBOQUIT TOP PTH MCL PTH 3.4771 00080007461 NICOTINE LOZENGES; THRIVE LOZENGES 1 MG ORL LOZ NOV LOZ 0.2542 00080007464 NICOTINE LOZENGES; THRIVE LOZENGES 2 MG ORL LOZ NOV LOZ 0.2889 00080000117 NICOTINE POLACRILEX; NIC-ASSIST 2 MG GUM ORL GUM PRI PIECE 0.2104 00080000118 NICOTINE POLACRILEX; NIC-ASSIST 4 MG GUM ORL GUM PER PIECE 0.2539 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 126 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080000402 NICOTINELL/THRIVE 4 MG ORAL GUM ORL GUM NVC PIECE 0.2889 00080000396 NICOTINELL; THRIVE 2 MG ORAL GUM ORL GUM NOV PIECE 0.2542 00002125226 NIDAGEL 0.75% VAGINAL GEL VAG GEL VCL G 0.2976 00002421631 NIFEDIPINE 30 MG EXTENDED RELEASE TABLET ORL ERT PDL TAB 0.6171 00002421658 NIFEDIPINE 60 MG EXTENDED RELEASE TABLET ORL ERT PDL TAB 0.9374 00002325926 NIMOTOP 30 MG TABLET ORL TAB BAI TAB 10.0776 00002229655 NITRAZADON 10 MG TABLET ORL TAB AAP TAB 0.1282 00002229654 NITRAZADON 5 MG TABLET ORL TAB AAP TAB 0.0708 00002182920 NIZORAL 2% TOPICAL SHAMPOO TOP SHP MCL ML 0.0970 00002397927 NOCDURNA 25 MCG SL ORALLY DISINTEGRATING TABLET SLG DISNTAB FEI TAB 1.3200 00002431076 NOCDURNA 50 MCG SL ORALLY DISINTEGRATING TABLET SLG DISNTAB FEI TAB 1.3200 00002048485 NOLVADEX-D 20 MG (BASE) TABLET ORL TAB AZC TAB 0.3867 00080016396 NON-FLUSH/FLUSH FREE NIACIN CAPSULE ORL CAP PLH CAP 0.1560 00080008766 NORDIC NATURALS ARCTIC COD LIVER OIL ORL LIQ NRD ML 0.1105 00080007895 NORDIC NATURALS ARCTIC COD LIVER OIL LIQUID ORL LIQ NRD ML 0.0827 00080002913 NORDIC NATURALS OMEGA-3 LIQUID ORL LIQ NRD ML 0.0827 00002334860 NORDITROPIN NORDIFLEX 10 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 389.4000 00002334879 NORDITROPIN NORDIFLEX 15 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 584.1000 00002334852 NORDITROPIN NORDIFLEX 5 MG PEN INJECTION SYRINGE INJ DEFAUL NNA SYR 194.7000 00001966154 NORFLEX 100 MG TABLET ORL TAB MMH TAB 0.8414 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 127 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001966162 NORFLEX 30 MG/ML INJECTION INJ DEFAUL GRC ML 5.6642 00002285576 NORLEVO 0.75 MG TABLET ORL TAB BAI TAB 8.6000 00000023760 NORLUTATE 5 MG TABLET ORL TAB PFI TAB 1.4167 00002357593 NORVIR 100 MG FILM-COATED TABLET ORL TAB ABV TAB 1.4673 00002229145 NORVIR 80 MG SOLUTION ORL SOL ABV ML 1.1958 00002241480 NORVIR SEC 100 MG CAPSULE ORL CAP ABB CAP 1.4671 00002049481 NOVAHISTEX DH ADULT ORAL LIQUID ORL LIQ SAV ML 0.1740 00002049473 NOVAHISTINE DH CHILDREN ORAL LIQUID ORL LIQ SAV ML 0.1432 00000216666 NOVASEN 325 MG ENTERIC-COATED TABLET ORL ECT TEV TAB 0.0304 00000229296 NOVASEN 650 MG ENTERIC COATED TABLET ORL ECT NOP TAB 0.0650 00002314282 NOVO-ALFUZOSIN PR 10 MG PROLONGED-RELEASE TABLET ORL SRT TEV TAB 0.5980 00002315157 NOVO-AZITHROMYCIN 20 MG/ML PEDIATRIC SUSPENSION ORL SUS TEV ML 0.3727 00002315165 NOVO-AZITHROMYCIN 40 MG/ML PEDIATRIC SUSPENSION ORL SUS TEV ML 0.5280 00002270226 NOVO-BICALUTAMIDE 50 MG TABLET ORL TAB TEV TAB 4.0573 00000582417 NOVO-CIMETINE 300 MG TABLET ORL TAB TEV TAB 0.0860 00000603678 NOVO-CIMETINE 400 MG TABLET ORL TAB TEV TAB 0.1350 00000603686 NOVO-CIMETINE 600 MG TABLET ORL TAB TEV TAB 0.1720 00002248138 NOVO-CLAVAMOXIN 875 MG/125 MG TABLET ORL TAB TEV TAB 0.5550 00002309556 NOVO-CYPROTERONE/ETHINYL ESTRADIOL 2MG/0.035MG TAB ORL TAB TEV TAB 1.1114 00002048698 NOVO-DIFENAC SR 100 MG SUSTAINED-RELEASE TABLET ORL SRT TEV TAB 0.4048 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 128 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002048493 NOVO-DIFLUNISAL FC 250 MG TABLET ORL TAB TEV TAB 0.5647 00000842044 NOVO-DOCUSATE CALCIUM 240 MG CAPSULE ORL CAP TEV CAP 0.0886 00002020084 NOVO-DOCUSATE SODIUM 100 MG CAPSULE ORL CAP TEV CAP 0.0481 00001913468 NOVO-DOXEPIN 100 MG CAPSULE ORL CAP TEV CAP 0.3450 00001913476 NOVO-DOXEPIN 150 MG CAPSULE ORL CAP TEV CAP 1.2127 00001913425 NOVO-DOXEPIN 25 MG CAPSULE ORL CAP TEV CAP 0.0985 00001913433 NOVO-DOXEPIN 50 MG CAPSULE ORL CAP TEV CAP 0.1827 00001913441 NOVO-DOXEPIN 75 MG CAPSULE ORL CAP TEV CAP 0.3673 00002300230 NOVO-ENALAPRIL/HCTZ 10 MG/25 MG TABLET ORL TAB TEV TAB 0.5480 00002300222 NOVO-ENALAPRIL/HCTZ 5 MG/12.5 MG TABLET ORL TAB TEV TAB 0.4927 00002324199 NOVO-ETIDRONATECAL 400 MG/500 MG TABLET ORL TAB TEV TAB 0.2221 00002243551 NOVO-FENOFIBRATE MICRONIZED 67 MG CAPSULE ORL CAP TEV CAP 0.4325 00000021458 NOVOFERROGLUC 300 MG TABLET ORL TAB TEV TAB 0.0254 00000595829 NOVO-FIBER 469 MG TABLET ORL TAB TEV TAB 0.0979 00080042720 NOVO-FIBRE 469 MG TABLET ORL TAB TEV TAB 0.0979 00000389218 NOVO-GESIC 325 MG TABLET ORL TAB TEV TAB 0.0326 00002273756 NOVO-GLIMEPIRIDE 1 MG TABLET ORL TAB TEV TAB 0.4900 00002273764 NOVO-GLIMEPIRIDE 2 MG TABLET ORL TAB TEV TAB 0.4900 00002273772 NOVO-GLIMEPIRIDE 4 MG TABLET ORL TAB TEV TAB 0.4900 00002210479 NOVO-IPRAMIDE 0.25% INHALATION SOLUTION INH SOL TEV ML 0.3155 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 129 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002176084 NOVO-KETOTIFEN 0.2 MG/ML (BASE) ORAL SYRUP ORL SYR TEV ML 0.4545 00002230730 NOVO-KETOTIFEN 1 MG TABLET ORL TAB TEV TAB 0.6335 00002158612 NOVO-MAPROTILINE 25 MG TABLET ORL TAB TEV TAB 0.5687 00002158620 NOVO-MAPROTILINE 50 MG TABLET ORL TAB TEV TAB 1.0769 00002158639 NOVO-MAPROTILINE 75 MG TABLET ORL TAB TEV TAB 1.4707 00002265435 NOVOMIX 30 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 3.6913 00002265443 NOVOMIX 30 FLEXPEN 100 UNIT/ML INJECTION INJ DEFAUL NNA ML 3.1833 00002364883 NOVO-MYCOPHENOLATE 250 MG CAPSULE ORL CAP TEV CAP 1.0310 00002348675 NOVO-MYCOPHENOLATE 500 MG TABLET ORL TAB TEV TAB 2.0620 00002240868 NOVO-NABUMETONE 750 MG TABLET ORL TAB TEV TAB 0.9192 00002240457 NOVO-NIZATIDINE 150 MG CAPSULE ORL CAP TEV CAP 0.2098 00002240458 NOVO-NIZATIDINE 300 MG CAPSULE ORL CAP TEV CAP 0.3802 00002231781 NOVO-NORTRIPTYLINE 10 MG CAPSULE ORL CAP TEV CAP 0.0500 00002231782 NOVO-NORTRIPTYLINE 25 MG CAPSULE ORL CAP TEV CAP 0.1011 00000021288 NOVO-PHENIRAM 4 MG TABLET ORL TAB TEV TAB 0.0645 00000021695 NOVO-PREDNISONE 5 MG TABLET ORL TAB TEV TAB 0.0401 00000232378 NOVO-PREDNISONE 50 MG TABLET ORL TAB TEV TAB 0.1735 00002283891 NOVO-RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB TEV CAP 0.4200 00002326450 NOVO-SALBUTAMOL HFA 100 MCG/DOSE METERED DOSE AERO INH AEM TEV DOSE 0.0325 00002231181 NOVO-SOTALOL 80 MG TABLET ORL TAB TEV TAB 0.2966 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 130 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002100630 NOVO-VALPROIC 250 MG CAPSULE ORL CAP TEV CAP 0.1366 00002211920 NOVO-VERAMIL SR 240MG SUSTAINED-RELEASE TABLET ORL SRT TEV TAB 0.5075 00002251469 NOVO-ZOPICLONE 7.5 MG TABLET ORL TAB TEV TAB 0.3125 00002322854 NPLATE 250 MCG/0.5 ML VIAL INJECTION INJ DEFAUL AMG VIAL 946.4800 00002322862 NPLATE 500 MCG/1 ML VIAL INJECTION INJ DEFAUL AMG VIAL 1892.9700 00001913980 NUBAIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 10.6290 00001913972 NUBAIN 20 MG/ML INJECTION INJ DEFAUL SDZ ML 6.0850 00002415585 NUCYNTA 100 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.4940 00002415593 NUCYNTA 150 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.9995 00002415607 NUCYNTA 200 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.5920 00002415615 NUCYNTA 250 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.5895 00002415577 NUCYNTA 50 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 0.9965 00002360381 NUCYNTA CR 100 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.4730 00002360403 NUCYNTA CR 150 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 1.9720 00002360411 NUCYNTA CR 200 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 2.5565 00002360438 NUCYNTA CR 250 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 3.5895 00002360373 NUCYNTA CR 50 MG EXTENDED-RELEASE TABLET ORL ERT JAI TAB 0.9830 00002378299 NUCYNTA IR 100 MG TABLET ORL TAB JAI TAB 1.4936 00002378272 NUCYNTA IR 50 MG TABLET ORL TAB JAI TAB 0.9968 00002378280 NUCYNTA IR 75 MG TABLET ORL TAB JAI TAB 1.2450 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 131 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000623385 NUPERCAINAL ANESTHETIC 1% RECTAL OINTMENT RT ONT NVC G 0.1407 00002249002 NUTROPIN AQ 5 MG/ML PEN CARTRIDGE INJ CTG HLR ML 197.7350 00002376393 NUTROPIN AQ NUSPIN 10 10 MG/2ML PEN CARTRIDGE INJ CTG HLR ML 197.7350 00002399083 NUTROPIN AQ NUSPIN 20 20 MG/2 ML SOLUTION INJ DEFAUL HLR ML 392.9450 00002399091 NUTROPIN AQ NUSPIN 5 5 MG/2 ML SOLUTION INJ DEFAUL HLR ML 98.2350 00002253186 NUVARING 11.4 MG/2.6 MG SLOW-RELEASE VAGINAL RING VAG SDE MFC RNG 15.1500 00000716901 NYADERM 25,000 U/G VAGINAL CREAM VAG CRM TAR G 0.1250 00002239742 OBUSFORME EXTRA STRENGTH (W ACETAMINOPHEN) CAPLET ORL TAB WAM TAB 0.3611 00002237577 OBUSFORME METHOCARBAMOL & ACETAMINOPHEN CAPLET ORL TAB WAM TAB 0.3306 00000687766 O-CALCIUM 250 MG AND VITAMIN D TABLET ORL TAB WTR TAB 0.0620 00000622443 O-CALCIUM 500 MG (BASE) TABLET ORL TAB VTH TAB 0.0257 00002024179 OCTOSTIM 15 MCG INJECTION INJ DEFAUL FEI ML 36.2880 00002299437 OCTREOTIDE 100 MCG/ML INJECTION INJ DEFAUL TEV ML 5.6700 00002299445 OCTREOTIDE 200 MCG/ML INJECTION INJ DEFAUL TEV ML 15.5840 00002299453 OCTREOTIDE 500 MCG/ML INJECTION INJ DEFAUL TEV ML 38.0720 00002248640 OCTREOTIDE ACETATE OMEGA 100 MCG/ML INJECTION INJ DEFAUL OMG ML 11.2000 00002248642 OCTREOTIDE ACETATE OMEGA 200 MCG/ML INJECTION INJ DEFAUL OMG ML 23.4000 00002248639 OCTREOTIDE ACETATE OMEGA 50 MCG/ML INJECTION INJ DEFAUL OMG ML 5.9500 00002248641 OCTREOTIDE ACETATE OMEGA 500 MCG/ML INJECTION INJ DEFAUL OMG ML 52.3000 00080038562 OCUVITE ADULT 50+ ORL CAP BSH CAP 0.2644 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 132 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000358495 ODANS LIQUOR CARBONIS DETERGENS TOP LIQ ODN ML 0.0750 00080046696 ODAN-SODIUM CHLORIDE 5% OPHTHALMIC OINTMENT OPH ONT ODN G 2.5686 00080046737 ODAN-SODIUM CHLORIDE 5% OPHTHALMIC SOLUTION OPH SOL ODN ML 0.5993 00002443066 OFEV 100 MG CAPSULE ORL CAP BOE CAP 27.1800 00002443074 OFEV 150 MG CAPSULE ORL CAP BOE CAP 54.3600 00002231529 OFLOXACIN 200 MG TABLET ORL TAB AAP TAB 1.3693 00002231531 OFLOXACIN 300 MG TABLET ORL TAB AAP TAB 1.6089 00002231532 OFLOXACIN 400 MG TABLET ORL TAB AAP TAB 1.6089 00002311992 OLANZAPINE 10 MG TABLET ORL TAB PDL TAB 1.7857 00002312018 OLANZAPINE 15 MG TABLET ORL TAB PDL TAB 2.6775 00002311968 OLANZAPINE 2.5 MG TABLET ORL TAB PDL TAB 0.4493 00002421704 OLANZAPINE 20 MG TABLET ORL TAB PDL TAB 5.9377 00002311976 OLANZAPINE 5 MG TABLET ORL TAB PDL TAB 0.8936 00002311984 OLANZAPINE 7.5 MG TABLET ORL TAB PDL TAB 1.3479 00002416522 OLANZAPINE FOR INJECTION 10MG/VIAL INJ INJ DEFAUL SDZ VIAL 24.0800 00002338653 OLANZAPINE ODT 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PDL TAB 1.7857 00002352990 OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB SNS TAB 5.3553 00002338661 OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PDL TAB 2.6777 00002343681 OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB SIV TAB 5.3553 00002425114 OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PDL TAB 5.9377 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 133 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002343703 OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB SIV TAB 7.5977 00002338645 OLANZAPINE ODT 5 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB PDL TAB 0.8937 00002365677 OLEX 20 MG DELAYED-RELEASE TABLET ORL DRT PPH TAB 0.6536 00002344408 OLUX-E 0.05% TOPICAL FOAM TOP FOA GSK G 1.4449 00002239144 OMBRELLE ECRAN SPF 60 TOPICAL CREAM TOP CRM COS G 0.0991 00002241277 OMBRELLE EXTREME SPF 30 TOPICAL LOTION TOP LOT COS ML 0.0875 00002303639 OMBRELLE SPF 60 TOPICAL LOTION TOP LOT OMB ML 0.1008 00002239016 OMBRELLE VAPO SPORT SPF 15 TOPICAL LOTION TOP LOT COS ML 0.0868 00080003480 OMEGA 3 CAPSULE ORL CAP PMT CAP 0.0990 00080008273 OMEGA 3 CAPSULE ORL CAP WNP CAP 0.2587 00080044844 OMEGA 3 KRILL OIL 500 MG CAPSULE ORL CAP JMS CAP 0.3078 00080015284 OMEGA 3 LIQUID ORL LIQ WNP ML 0.0261 00080002435 OMEGA 3 PREMIUM FISH OIL 1000 MG CAPSULE ORL CAP WNP CAP 0.0593 00080002596 OMEGA 3 SELECT CAPSULE ORL CAP JAM CAP 0.1131 00080019234 OMEGA 3 TRIPLE STRENGTH 900 MG SOFTGEL ORL CAP WBP CAP 0.2552 00002240743 OMEGA 3-6-9 CAPSULE ORL CAP JAM CAP 0.1647 00080003127 OMEGA-3 ELITE SOFTGEL ORL CAP WBP CAP 0.0511 00080003179 OMEGA-3 TABLET ORL TAB JAM TAB 0.1542 00002385384 OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT SIV CAP 0.5500 00002339927 OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE ORL CAP/SRT PDL CAP 0.4117 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 134 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002303671 OMNARIS 50 MCG/DOSE METERED DOSE NASAL SPRAY NAS SPM TAK DOSE 0.2148 00002153513 ONCOTICE 800 M UNIT/VIAL FOR BLADDER INSTILLATION BLDIR PWS MFC VIAL 273.1400 00002271761 ONDANSETRON OMEGA (PRESERVATIVE FREE) 2 MG/ML INJ INJ DEFAUL OMG ML 8.1750 00002271788 ONDANSETRON OMEGA (WITH PRESERVATIVE) 2 MG/ML INJ INJ DEFALT OMG ML 8.1250 00002306212 ONDANSETRON-ODAN 4 MG TABLET ORL TAB ODN TAB 3.3500 00080020211 ONE A DAY FRUITI-SSENTIAL GUMMIES ORL CTB BAI TAB 0.1563 00002248292 ONE A DAY MEN 50 PLUS TABLET ORL TAB BIC TAB 0.1037 00002248319 ONE A DAY WEIGHTSMART TABLET ORL TAB BAI TAB 0.1213 00002375842 ONGLYZA 2.5 MG TABLET ORL TAB AZC TAB 2.3650 00002421208 ONRELTEA 0.33 % TOPICAL GEL TOP GEL GAL G 3.5180 00000750794 OPCON-A OPH SOLUTION OPH SOL BSH ML 0.2800 00002415690 OPSUMIT 10 MG FILM COATED TABLET ORL TAB ACT TAB 128.3333 00000990059 OPTICHAMBER DEVICE DEFAUL DEV ACM DEV 30.7200 00000990061 OPTICHAMBER LARGE FACE MASK DEVICE DEFAUL ADUDEV ACM DEV 35.3400 00000990062 OPTICHAMBER MEDIUM FACE MASK DEVICE DEFAUL PEDDEV ACM DEV 28.5300 00000990063 OPTICHAMBER SMALL FACE MASK DEVICE DEFAUL INFDEV ACM DEV 29.4300 00000999420 OPTIMENTAL ORAL LIQUID ORL LIQ ABN ML 0.0278 00000355666 OPTIMINE 1 MG TABLET ORL TAB SCH TAB 0.4216 00002160889 OPTIMYXIN OPHTHALMIC OINTMENT OPH ONT SDZ G 1.4543 00000701785 OPTIMYXIN OTIC OPH DROPS OT/OPH DPS SDZ ML 0.6490 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 135 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002371189 OPTION 2 0.75 MG TABLET ORL TAB PRI TAB 7.7950 00080027592 OPUS D-1000 SOFTGEL ORL CAP OPU CAP 0.0700 00002035286 ORABASE PASTE ORL PST CVO G 1.1200 00001985396 ORAJEL MAXIMUM STRENGTH GEL ORL GEL CHD G 0.4063 00002381885 ORALAIR 100 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 1.2600 00002381893 ORALAIR 300 UNIT SUBLINGUAL TABLET SLG TAB PAL TAB 3.8000 00000313815 ORAP 2 MG TABLET ORL TAB PPH TAB 0.3186 00002047535 ORFENACE 100 MG TABLET ORL TAB STM TAB 0.4700 00002245641 ORGALUTRAN 250 MCG/ 0.5 ML INJECTION SYRINGE INJ NDL MFC SYR 94.7100 00002209055 ORO-CLENSE 0.12% ORAL RINSE ORL MWH GER ML 0.0165 00080023808 ORTHO BONE CAPSULE ORL CAP AOR CAP 0.1565 00002042533 ORTHO-CEPT (28 DAY) TABLET ORL TB JAI TAB 0.7850 00000999460 ORTHOVISC DEFAUL DEV PMS ML 50.0000 00000999490 OSTENIL DEFAUL DEV TRB ML 50.2600 00002247548 OSTEOCIT D PLUS TABLET ORL TAB SFD TAB 0.1683 00002301911 OSTO-D2 50000 IU CAPSULE ORL CAP TPI CAP 0.2067 00002434318 OTEZLA 10 MG/20 MG/30 MG TABLET STARTER PACK ORL TAB CLG TAB 18.9041 00002434334 OTEZLA 30 MG TABLET ORL TAB CLG TAB 18.9041 00002238867 OTRIVIN 0.05% DECONGESTANT NASAL SPRAY NAS SPR NVC ML 0.2340 00000653330 OTRIVIN 0.1% DECONGESTANT NASAL SPRAY NAS SPR NVC ML 0.2340 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 136 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price DEFAUL SPM CGS ML 0.2340 00000741043 OTRIVIN 0.1% METERED DOSE SPRAY 00002331403 OTRIVIN MOIST 0.1% NASAL SPRAY NAS SPR NVC ML 0.3075 00000857777 OTRIVIN-SALINE 0.7% NASAL DROPS NAS SOL NVC ML 0.1348 00000810436 OTRIVIN-SALINE 0.7% NASAL SPRAY NAS SPR NVC ML 0.1187 00002262088 OVIDREL 250 MCG INJECTION SYRINGE INJ NDL SRO SYR 72.0000 00002371588 OVIDREL 250 MCG/0.5 ML PEN CARTRIDGE INJECTION INJ DEFAUL SRO ML 72.0000 00000013617 OVOL 40 MG/ML ORAL DROPS ORL DPS CHD ML 0.3393 00002239298 OVOL-180 ULTRA STRENGTH 180 MG CAPSULE ORL CAP CHD CAP 0.1850 00000292990 OVOL-80 80 MG TABLET ORL TAB CHD TAB 0.1300 00000497754 OXAZEPAM 10 MG TABLET ORL TAB PDL TAB 0.0350 00000497762 OXAZEPAM 15 MG TABLET ORL TAB PDL TAB 0.0550 00000497770 OXAZEPAM 30 MG TABLET ORL TAB PDL TAB 0.0750 00002220636 OXYBUTYNINE-5 5 MG TABLET ORL TAB PDL TAB 0.0986 00002231934 OXY-IR 5 MG TABLET ORL TAB PUR TAB 0.2640 00002139561 OXYTOCIN 10 UNIT/ML INJECTION INJ DEFAUL PPC ML 6.8640 00002254735 OXYTROL 36 MG TRANSDERMAL PATCH TRD PTH ASC PTH 6.7450 00080001408 OYSTER SHELL CALCIUM 500 MG CAPLET ORL TAB NCI TAB 0.0290 00002248374 OYSTER SHELL CALCIUM WITH VIT D 500 MG TABLET ORL TAB VTH TAB 0.0266 00002363445 OZURDEX 0.7 MG INTRAVITREAL IMPLANT OPH IMP ALL SYS 1352.5000 00002130947 PACIS 120 MG INJECTION INJ DEFAUL IAF VIAL 113.6000 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 137 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002320150 PACLITAXEL 6 MG/ML INJECTION USP INJ DEFAUL SDZ ML 74.8000 00001923420 PALAFER 300 MG CAPSULE ORL CAP GKC CAP 0.2293 00001923455 PALAFER-CF CAPSULE ORL CAP GKC CAP 0.3133 00002246597 PAMIDRONATE DISODIUM 30MG/10ML VIAL INJECTION INJ DEFAUL PPC ML 15.7500 00002246598 PAMIDRONATE DISODIUM 60 MG/10ML INJECTION INJ DEFAUL PPC ML 29.9000 00002264986 PAMIDRONATE DISODIUM 90 MG/VIAL INJECTION INJ DEFAUL SDZ ML 24.6550 00002246599 PAMIDRONATE DISODIUM 90MG/10ML VIAL INJECTION INJ DEFAUL PPC ML 44.8000 00002249677 PAMIDRONATE DISODIUM OMEGA 60 MG/10 ML VIAL INJ INJ DEFAUL OMG ML 17.6700 00000718130 PAMPRIN EXTRA STRENGTH CAPLET ORL TAB CTE TAB 0.2063 00002188708 PANOXYL 4% CREAMY WASH TOP WAS GSK G 0.0671 00000483184 PANOXYL 5 5% TOPICAL BAR TOP BAR GSK G 0.0853 00002239616 PANTO IV 40 MG/VIAL INJECTION INJ DEFAUL TAK VIAL 13.7000 00002241804 PANTOLOC 20 MG ENTERIC-COATED TABLET ORL ECT TAK TAB 1.8089 00002385740 PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT SIV TAB 1.2750 00002431327 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.3628 00002318695 PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.9785 00002306727 PANTOPRAZOLE SODIUM FOR INJECTION 40 MG/VIAL INJ INJ DEFAUL SDZ VIAL 10.9600 00002428172 PANTOPRAZOLE-20 20 MG ENTERIC-COATED TABLET ORL ECT SIV TAB 1.2750 00002428180 PANTOPRAZOLE-40 40 MG ENTERIC-COATED TABLET ORL ECT SIV TAB 0.3628 00000009881 PAPAVERINE HCL 32.5 MG/ML INJECTION INJ DEFAUL SDZ ML 3.8460 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 138 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002388227 PAROXETINE 10 MG TABLET ORL TAB SIV TAB 1.0430 00002282844 PAROXETINE 10 MG TABLET ORL TAB SNS TAB 1.0430 00002248913 PAROXETINE-10 MG TABLET ORL TAB PDL TAB 0.8210 00002248914 PAROXETINE-20 MG TABLET ORL TAB PDL TAB 0.4513 00002248915 PAROXETINE-30 MG TABLET ORL TAB PDL TAB 0.4796 00002362171 PATADAY 0.2% OPHTHALMIC SOLUTION OPH SOL ALC ML 12.1040 00002233143 PATANOL 0.1% OPH SOLUTION OPH SOL ALC ML 6.0520 00000886327 PATE D'IHLE ZINC OXIDE 25% PASTE TOP PST ATL G 0.0234 00000532576 PATE D'IHLE ZINC OXIDE PASTE TOP PST ROG G 0.0306 00002381737 PAT-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT PAT TAB 0.1204 00002381745 PAT-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT PAT TAB 0.2408 00002389274 PAT-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB PAT TAB 0.6263 00002027887 PAXIL 10 MG TABLET ORL TAB GSK TAB 1.6920 00002248503 PAXIL CR 12.5 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 1.7230 00002248504 PAXIL CR 25 MG SUSTAINED-RELEASE TABLET ORL SRT GSK TAB 1.8827 00000577790 PDP-ISONIAZID 100 MG TABLET ORL TAB PPH TAB 0.7533 00000577804 PDP-ISONIAZID 300 MG TABLET ORL TAB PPH TAB 0.7533 00000577812 PDP-ISONIAZID 50 MG/5ML ORAL LIQUID ORL LIQ PPH ML 0.2369 00002242863 PEDIAFER 30 MG/ML ORAL SOLUTION USP ORL SYR EUP ML 0.0272 00002232202 PEDIAFER 75 MG/ML ORAL SOLUTION USP ORL SYR EUP ML 0.1432 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 139 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002245747 PEDIAFLOUR 5.56 MG/ML ORAL SOLUTION ORL DPS EUP ML 0.0697 00002162431 PEDIAPHARM NAPROXEN 25 MG/ML ORAL SUSPENSION ORL SUS PPI ML 0.0631 00080004595 PEDIAVIT D DROPS 400 IU ORL LIQ EUP ML 0.1100 00002358034 PEG 3350 ORAL POWDER ORL PWR MES G 0.0668 00002328232 PEGALAX ORAL POWDER ORL PWR MFI G 0.0387 00002246030 PEGETRON 200 MG CAP/150 MCG/0.5 ML INJ KIT INJ VIAL/CAP MFC KIT 851.2300 00002246026 PEGETRON 200 MG CAP/50 MCG/0.5ML INJ KIT INJ VIAL/CAP MFC KIT 770.3500 00000468029 PENICILLINE V 300 TABLET ORL TAB PDL TAB 0.0710 00002250535 PENLAC NAIL LACQUER 8% TOPICAL SOLUTION TOP SOL VCL G 12.9775 00002247265 PENNSAID 1.5% TOPICAL SOLUTION TOP SOL PAL ML 0.8318 00001980602 PENTA-3B PLUS VITAMIN C TABLET ORL TAB SDZ TAB 0.5820 00001980599 PENTA-3B TABLET ORL TAB SDZ TAB 0.4780 00002183080 PENTAMIDINE ISETHIONATE 300 MG/VIAL INJECTION BP INJ DEFAUL HSP VIAL 127.1200 00001980556 PENTAMYCETIN 0.25% OPH SOLUTION OPH SOL SDZ ML 0.6180 00002164051 PENTAMYCETIN 0.5% OPH SOLUTION OPH SOL SDZ ML 0.6300 00001980564 PENTAMYCETIN 1% OPH OINTMENT OPH ONT SDZ G 2.1600 00001980580 PENTAMYCETIN-HC OTIC OPH OINTMENT OT/OPH ONT SDZ G 2.9714 00001980572 PENTAMYCETIN-HC OTIC OPH SUSPENSION OT/OPH SUS SDZ ML 2.4580 00002185938 PEPCID AC 10 MG TABLET ORL TAB MCL TAB 0.3217 00000728128 PEPCID IV 10 MG/ML INJECTION INJ DEFAUL MFC ML 1.9955 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 140 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002097079 PEPTO-BISMOL 17.6 MG/ML ORAL LIQUID ORL LIQ PGI ML 0.0223 00002177994 PEPTO-BISMOL CAPLET ORL TAB PGI TAB 0.1521 00002237315 PEPTO-BISMOL CHEWABLES CHEWABLE TABLET ORL CTB PGI TAB 0.1521 00000999423 PERATIVE ORAL LIQUID ORL LIQ ABN ML 0.0113 00000254916 PERGONAL 75 UNIT/75 UNIT INJECTION INJ DEFAUL SRO VIAL 46.0000 00002240433 PERICHLOR 0.12% ORAL RINSE ORL MWH PMS ML 0.0181 00002237452 PERIDEX 0.12% ORAL RINSE ORL MWH ZIL ML 0.0224 00002207796 PERIOGARD 0.12% ORAL RINSE ORL MWH COL ML 0.0164 00002247104 PERIOSTAT 20 MG CAPSULE ORL CAP PPH CAP 1.2500 00002229501 PERI-WASH II ANTISEPTIC 0.1% CLEANSER TOP WAS COC ML 0.0147 00080017389 PGX 750 DAILY CAPSULE ORL CAP NFN CAP 0.0805 00080001122 PHARMA-CAL 500 MG ORL CAP PPH CAP 0.0216 00080004281 PHARMA-CAL D 500 MG/125 IU TABLET ORL TAB PMS TAB 0.0680 00002371499 PHARMA-D 10,000 UNIT CAPSULE ORL CAP PMS CAP 0.2100 00080001145 PHARMA-D 400 IU GELCAP ORL CAP PPH CAP 0.0300 00002371502 PHARMA-D 50,000 UNIT CAPSULE ORL CAP PMS CAP 0.9500 00080040416 PHARMA-K20 20 MEQ SUSTAINED-RELEASE TABLET ORL TAB/SRT PMS TAB 0.1995 00080038071 PHARMANAC TM ACETYLCYSTEINE 900 MG TABLET ORL TAB BAP TAB 0.7653 00002436663 PHEBURANE 483 MG/G ORAL GRANULES ORL GRNUL MDK G 9.2690 00002304090 PHENOBARBITAL SODIUM 120 MG/ML INJECTION USP INJ DEFAUL SDZ ML 12.4110 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 141 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002304082 PHENOBARBITAL SODIUM 30 MG/ML INJECTION USP INJ DEFAUL SDZ ML 11.1450 00002148455 PHENYLEPHRINE HCL 10% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00002148447 PHENYLEPHRINE HYDROCHLORIDE OPH SOLUTION (MINIMS) OPH SOL OPT ML 6.6667 00000780626 PHENYTOIN 50 MG/ML INJECTION INJ DEFAUL SDZ ML 5.2855 00002431378 PHENYTOIN SODIUM 50 MG/ML INJECTION USP INJ DEFAUL STM ML 5.2856 00002150638 PHILLIPS MAGNESIA 300 MG CHEWABLE TABLET ORL CTB BAI TAB 0.0487 00002150646 PHILLIPS MILK OF MAGNESIA 80 MG/ML ORAL LIQUID ORL LIQ BAI ML 0.0139 00002243578 PHISODERM FACIAL CLEANSER TOP WAS MNT G 0.0225 00002017733 PHISOHEX 3% TOPICAL CLEANSER TOP CLR SAV ML 0.0714 00002245781 PHL-AMIODARONE 200 MG TABLET ORL TAB PHH TAB 1.2971 00002326787 PHL-AMLODIPINE 10 MG TABLET ORL TAB PHH TAB 0.3587 00002326760 PHL-AMLODIPINE 2.5 MG TABLET ORL TAB PHH TAB 0.1380 00002326779 PHL-AMLODIPINE 5 MG TABLET ORL TAB PHH TAB 0.2417 00002278588 PHL-AZITHROMYCIN 250 MG TABLET ORL TAB PHH TAB 1.2313 00002236964 PHL-BACLOFEN 20 MG TABLET ORL TAB PHH TAB 0.3104 00002273543 PHL-CITALOPRAM 10 MG TABLET ORL TAB PHH TAB 0.1432 00002248944 PHL-CITALOPRAM 20 MG TABLET ORL TAB PHH TAB 0.2397 00002248945 PHL-CITALOPRAM 40 MG TABLET ORL TAB PHH TAB 0.2397 00002145227 PHL-CLONAZEPAM 0.5 MG TABLET ORL TAB PHH TAB 0.0495 00002145235 PHL-CLONAZEPAM 1 MG TABLET ORL TAB PHH TAB 0.1487 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 142 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002236948 PHL-CLONAZEPAM-R 0.5 MG TABLET ORL TAB PHH TAB 0.0495 00002249359 PHL-CYCLOBENZAPRINE 10 MG TABLET ORL TAB PHH TAB 0.3765 00002223481 PHL-FLUOXETINE 10 MG CAPSULE ORL CAP PHH CAP 0.4595 00002223503 PHL-FLUOXETINE 20 MG CAPSULE ORL CAP PHH CAP 0.4598 00002248608 PHL-MELOXICAM 15 MG TABLET ORL TAB PHH TAB 0.5670 00002248607 PHL-MELOXICAM 7.5 MG TABLET ORL TAB PHH TAB 0.4914 00002281732 PHL-MIRTAZAPINE 15 MG TABLET ORL TAB PHH TAB 0.3750 00002278618 PHL-ONDANSETRON 4 MG TABLET ORL TAB PHH TAB 3.2720 00002278626 PHL-ONDANSETRON 8 MG TABLET ORL TAB PHH TAB 4.9930 00002307669 PHL-PIOGLITAZONE 15 MG TABLET ORL TAB PHH TAB 1.5716 00002307677 PHL-PIOGLITAZONE 30 MG TABLET ORL TAB PHH TAB 0.2017 00002307723 PHL-PIOGLITAZONE 45 MG TABLET ORL TAB PHH TAB 3.3105 00002249766 PHL-PRAVASTATIN 10 MG TABLET ORL TAB PHH TAB 0.5670 00002249774 PHL-PRAVASTATIN 20 MG TABLET ORL TAB PHH TAB 0.6689 00002249782 PHL-PRAVASTATIN 40 MG TABLET ORL TAB PHH TAB 0.8057 00002299062 PHL-QUETIAPINE 100 MG TABLET ORL TAB PHH TAB 0.9226 00002299089 PHL-QUETIAPINE 200 MG TABLET ORL TAB PHH TAB 1.8527 00002299054 PHL-QUETIAPINE 25 MG TABLET ORL TAB PHH TAB 0.3458 00002299097 PHL-QUETIAPINE 300 MG TABLET ORL TAB PHH TAB 2.7038 00002245782 PHL-RANITIDINE 150 MG TABLET ORL TAB PHH TAB 0.1800 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 143 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002245783 PHL-RANITIDINE 300 MG TABLET ORL TAB PHH TAB 0.3600 00002258439 PHL-RISPERIDONE 0.25 MG TABLET ORL TAB PHH TAB 0.1252 00002258447 PHL-RISPERIDONE 0.5 MG TABLET ORL TAB PHH TAB 0.2097 00002258455 PHL-RISPERIDONE 1 MG TABLET ORL TAB PHH TAB 0.2896 00002258463 PHL-RISPERIDONE 2 MG TABLET ORL TAB PHH TAB 0.5782 00002258471 PHL-RISPERIDONE 3 MG TABLET ORL TAB PHH TAB 0.8673 00002258498 PHL-RISPERIDONE 4 MG TABLET ORL TAB PHH TAB 1.1565 00002245826 PHL-SERTRALINE 100 MG CAPSULE ORL CAP PHH CAP 0.4200 00002245824 PHL-SERTRALINE 25 MG CAPSULE ORL CAP PHH CAP 0.2004 00002245825 PHL-SERTRALINE 50 MG CAPSULE ORL CAP PHH CAP 0.4000 00002281554 PHL-SIMVASTATIN 10 MG TABLET ORL TAB PHH TAB 0.3642 00002281562 PHL-SIMVASTATIN 20 MG TABLET ORL TAB PHH TAB 0.4501 00002281570 PHL-SIMVASTATIN 40 MG TABLET ORL TAB PHH TAB 0.4501 00002281546 PHL-SIMVASTATIN 5 MG TABLET ORL TAB PHH TAB 0.1841 00002281589 PHL-SIMVASTATIN 80 MG TABLET ORL TAB PHH TAB 0.4501 00002271192 PHL-TOPIRAMATE 100 MG TABLET ORL TAB PHH TAB 0.5928 00002271206 PHL-TOPIRAMATE 200 MG TABLET ORL TAB PHH TAB 0.8853 00002271184 PHL-TOPIRAMATE 25 MG TABLET ORL TAB PHH TAB 0.3128 00002236942 PHL-TRAZODONE 100 MG TABLET ORL TAB PHH TAB 0.3956 00002236941 PHL-TRAZODONE 50 MG TABLET ORL TAB PHH TAB 0.2214 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 144 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002294052 PHL-ZOPICLONE 5 MG TABLET ORL TAB PHH TAB 0.2231 00002294060 PHL-ZOPICLONE 7.5 MG TABLET ORL TAB PHH TAB 0.4685 00002229437 PHOSLO 667 MG ORAL TABLET ORL TAB PRP TAB 0.4500 00002230399 PHOSPHATES SOLUTION ORAL LIQUID ORL LIQ PPH ML 0.0856 00002019876 PHOTOFRIN 75MG/ VIAL INJECTION INJ DEFAUL AXC VIAL 19255.1000 00002400987 PICATO 0.015% TOPICAL GEL TOP GEL LEO DOSE 127.6667 00002400995 PICATO 0.05% TOPICAL GEL TOP GEL LEO DOSE 191.5000 00002254794 PICO SALAX ORAL POWDER ORL PWR FEI PCKT 7.0000 00002300583 PICODAN ORL PWDPKT ODN PCKT 3.6000 00002402483 PILOCARPINE HYDROCHLORIDE 5 MG TABLET ORL TAB STM TAB 0.7805 00002148463 PILOCARPINE NITRATE 2% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00000828424 PINDOLOL-10 MG TABLET ORL TAB PDL TAB 0.2323 00000828416 PINDOLOL-5 MG TABLET ORL TAB PDL TAB 0.1361 00002374013 PIOGLITAZONE HCL 15 MG TABLET ORL TAB SIV TAB 0.9295 00002374021 PIOGLITAZONE HCL 30 MG TABLET ORL TAB SIV TAB 1.3022 00002374048 PIOGLITAZONE HCL 45 MG TABLET ORL TAB SIV TAB 1.9580 00002391600 PIOGLITAZONE HYDROCHLORIDE 15 MG TABLET ORL TAB AHI TAB 0.8718 00002339587 PIOGLITAZONE HYDROCHLORIDE 30 MG TABLET ORL TAB AHI TAB 0.8139 00002339595 PIOGLITAZONE HYDROCHLORIDE 45 MG TABLET ORL TAB AHI TAB 1.2237 00002246640 PIPERACILLIN 2 G/VIAL INJECTION INJ DEFAUL HSP VIAL 9.5000 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 145 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002248939 PIPERACILLIN 2 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 15.2800 00002246641 PIPERACILLIN 3 G/VIAL INJECTION INJ DEFAUL HSP VIAL 22.8200 00002248940 PIPERACILLIN 3 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 22.9300 00002246642 PIPERACILLIN 4 G/VIAL INJECTION INJ DEFAUL HSP VIAL 19.0000 00002248941 PIPERACILLIN 4 G/VIAL INJECTION USP INJ DEFAUL PPC VIAL 30.5500 00002330547 PIPERACILLIN SOD/TAZOBACTAM SOD 12G/1500 MG VL INJ INJ DEFAUL SDZ VIAL 67.5000 00002391511 PIPERACILLIN/TAZOBACTAM 2 G/250 MG/VIAL INJECTION INJ DEFAUL MYP VIAL 9.6120 00002370158 PIPERACILLIN/TAZOBACTAM 2G/250 MG/VIAL INJECTION INJ DEFAUL TEV VIAL 9.6120 00002391538 PIPERACILLIN/TAZOBACTAM 3 G/375 MG/VIAL INJECTION INJ DEFAUL MYP VIAL 9.0800 00002391546 PIPERACILLIN/TAZOBACTAM 4 G/500 MG/VIAL INJECTION INJ DEFAUL MYP VIAL 12.1100 00001926667 PIPORTIL L4 25 MG/ML INJECTION INJ DEFAUL SAV ML 16.4400 00000501190 PLACEBO 100 MG TABLET ORL TAB ODN TAB 0.0750 00002293854 PLAN B 1.5 MG TABLET ORL TAB TEP TAB 17.2000 00002237405 PLANTE GUMMI BEAR MULTIPLE VITAMINS ORAL GUM ORL GUM PLI PIECE 0.1566 00002444399 PLEGRIDY 125 MCG/ 0.5 ML PS/PEN INJECTION INJ NDL BIO SYR 830.1538 00002444402 PLEGRIDY 63 MCG/94 MCG PS/PEN INJ STARTER PACK INJ NDL BIO SYR 1660.3100 00001946897 PMS DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR ORL ELX PMS ML 0.3785 00000792691 PMS-ACETAMINOPHEN 32 MG/ML ORAL SOLUTION ORL SOL PPH ML 0.0258 00002243435 PMS-ADENOSINE 3 MG/ML INJECTION INJ DEFAUL PMS ML 19.5000 00000654523 PMS-AMITRIPTYLINE 10 MG TABLET ORL TAB PMS TAB 0.0664 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 146 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000654515 PMS-AMITRIPTYLINE 25 MG TABLET ORL TAB PMS TAB 0.1211 00000654507 PMS-AMITRIPTYLINE 50 MG TABLET ORL TAB PMS TAB 0.2347 00002247304 PMS-AMITRIPTYLINE 50 MG TABLET ORL TAB PMS TAB 0.2346 00002274949 PMS-ANAGRELIDE 0.5 MG CAPSULE ORL CAP PMS CAP 3.3491 00002320738 PMS-ANASTROZOLE 1 MG TABLET ORL TAB PMS TAB 2.5460 00002284529 PMS-ASA EC 325 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0309 00002283700 PMS-ASA EC 81 MG ENTERIC-COATED TABLET ORL ECT PMS TAB 0.0538 00002381028 PMS-ATOMOXETINE 10 MG CAPSULE ORL CAP PMS CAP 2.3140 00002381036 PMS-ATOMOXETINE 18 MG CAPSULE ORL CAP PMS CAP 2.6523 00002381044 PMS-ATOMOXETINE 25 MG CAPSULE ORL CAP PMS CAP 2.9281 00002381052 PMS-ATOMOXETINE 40 MG CAPSULE ORL CAP PMS CAP 3.3377 00002381060 PMS-ATOMOXETINE 60 MG CAPSULE ORL CAP PMS CAP 3.7024 00002313448 PMS-ATORVASTATIN 10 MG TABLET ORL TAB PMS TAB 0.3138 00002313456 PMS-ATORVASTATIN 20 MG TABLET ORL TAB PMS TAB 0.3922 00002313464 PMS-ATORVASTATIN 40 MG TABLET ORL TAB PMS TAB 0.4216 00002313472 PMS-ATORVASTATIN 80 MG TABLET ORL TAB PMS TAB 0.4216 00002330237 PMS-BETAHISTINE 24 MG TABLET ORL TAB PMS TAB 0.4983 00002275589 PMS-BICALUTAMIDE 50 MG TABLET ORL TAB PMS TAB 4.0573 00002383020 PMS-BOSENTAN 125 MG TABLET ORL TAB PMS TAB 48.1340 00002383012 PMS-BOSENTAN 62.5 MG TABLET ORL TAB PMS TAB 48.1340 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 147 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002391171 PMS-CANDESARTAN 4 MG TABLET ORL TAB PMS TAB 0.3400 00002185830 PMS-CEFACLOR 250 MG CAPSULE ORL CAP PMS CAP 0.6430 00002185857 PMS-CEFACLOR 25MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.0762 00002185865 PMS-CEFACLOR 50 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.1395 00002185849 PMS-CEFACLOR 500 MG CAPSULE ORL CAP PMS CAP 1.2625 00002185873 PMS-CEFACLOR 75 MG/ML ORAL SUSPENSION ORL SUS PMS ML 0.2010 00002315963 PMS-CETIRIZINE 20 MG TABLET ORL TAB PMS TAB 0.7535 00002413574 PMS-CICLOPIROX NAIL LACQUER 8% TOPICAL SOLUTION TOP SOL PMS G 7.7433 00002416433 PMS-CIPROFLOXACIN XL 500 MG EXTENDED-RELEASE TAB ORL ERT PMS TAB 2.3110 00002244474 PMS-CLOBAZAM 10 MG TABLET ORL TAB PMS TAB 0.1097 00002232195 PMS-CLOBETASOL 0.05% SCALP LOTION SCP LOT PMS ML 0.2273 00002232191 PMS-CLOBETASOL 0.05% TOPICAL CREAM TOP CRM PMS G 0.3648 00002232193 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.4068 00002309548 PMS-CLOBETASOL 0.05% TOPICAL OINTMENT TOP ONT PMS G 0.2606 00002243450 PMS-DEFEROXAMINE 2G/VIAL INJECTION INJ DEFAUL PMS VIAL 20.2200 00002242055 PMS-DEFEROXAMINE 500 MG/VIAL INJ INJ DEFAUL PMS VIAL 8.1750 00000891797 PMS-DIAZEPAM 1 MG/ML ORAL SOLUTION ORL SOL PMS ML 0.1053 00002247492 PMS-DIAZEPAM 10 MG TABLET ORL TAB PMS TAB 0.0867 00002247490 PMS-DIAZEPAM 2 MG TABLET ORL TAB PMS TAB 0.0508 00002247491 PMS-DIAZEPAM 5 MG TABLET ORL TAB PMS TAB 0.0650 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 148 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000721344 PMS-DICITRATE ORAL SOLUTION ORL SOL PMS ML 0.0474 00002356783 PMS-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL PMS ML 0.6227 00002239753 PMS-DICLOFENAC-K 50 MG TABLET ORL TAB PMS TAB 0.3937 00000757683 PMS-DIPHENHYDRAMINE 25 MG CAPSULE ORL CAP PPH CAP 0.0866 00000757691 PMS-DIPHENHYDRAMINE 50 MG CAPSULE ORL CAP PPH CAP 0.1076 00002434342 PMS-ELETRIPTAN 20 MG TABLET ORL TAB PMS TAB 10.0850 00002434350 PMS-ELETRIPTAN 40 MG TABLET ORL TAB PMS TAB 10.0850 00002379171 PMS-ESOMEPRAZOLE 40 MG DELAYED-RELEASE CAPSULE ORL DRC PMS CAP 1.8690 00002278081 PMS-FAMCICLOVIR 125 MG TABLET ORL TAB PMS TAB 2.0240 00002278103 PMS-FAMCICLOVIR 250 MG TABLET ORL TAB PMS TAB 2.7200 00002278111 PMS-FAMCICLOVIR 500 MG TABLET ORL TAB PMS TAB 4.2281 00002273551 PMS-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP PMS CAP 0.2723 00000586323 PMS-FERROUS SULFATE 300 MG TABLET ORL TAB PPH TAB 0.0296 00002222574 PMS-FERROUS SULFATE INFANT DROPS 75 MG/ML ORL DPS PMS ML 0.1900 00002320169 PMS-FINASTERIDE 1 MG TABLET ORL TAB PMS TAB 1.1455 00002238568 PMS-FLUOROMETHOLONE 0.1% OPH SUSPENSION OPH SUS PMS ML 1.7880 00000726354 PMS-FLUPHENAZINE 5 MG TABLET ORL TAB PMS TAB 0.1720 00002247493 PMS-FUROSEMIDE 20 MG TABLET ORL TAB PMS TAB 0.0373 00002247494 PMS-FUROSEMIDE 40 MG TABLET ORL TAB PMS TAB 0.0746 00002255898 PMS-GABAPENTIN 600 MG TABLET ORL TAB PMS TAB 1.3045 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 149 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002255901 PMS-GABAPENTIN 800 MG TABLET ORL TAB PMS TAB 1.7393 00002239951 PMS-GEMFIBROZIL 300 MG CAPSULE ORL CAP PMS CAP 0.2964 00002230183 PMS-GEMFIBROZIL 600 MG TABLET ORL TAB PMS TAB 0.7520 00002247386 PMS-HYDROCHLOROTHIAZIDE 25 MG TABLET ORL TAB PMS TAB 0.0474 00002247387 PMS-HYDROCHLOROTHIAZIDE 50 MG TABLET ORL TAB PMS TAB 0.0551 00002324253 PMS-HYDROCODONE 1 MG/ML ORAL SYRUP ORL SYR PMS ML 0.1224 00000836133 PMS-IBUPROFEN 400 MG TABLET ORL TAB PMS TAB 0.1010 00002431114 PMS-IMATINIB 100 MG TABLET ORL TAB PMS TAB 20.4557 00002431122 PMS-IMATINIB 400 MG TABLET ORL TAB PMS TAB 81.8227 00002395258 PMS-LANSOPRAZOLE 15 MG DELAYED-RELEASE CAPSULE ORL DRC PMS CAP 0.5000 00002395266 PMS-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE ORL DRC PMS CAP 0.5000 00002288265 PMS-LEFLUNOMIDE 10 MG TABLET ORL TAB PMS TAB 6.0417 00002288273 PMS-LEFLUNOMIDE 20 MG TABLET ORL TAB PMS TAB 6.0417 00002309114 PMS-LETROZOLE 2.5 MG TABLET ORL TAB PMS TAB 2.7560 00000811874 PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID ORL LIQ PMS ML 0.0950 00002074834 PMS-LITHIUM CITRATE 8 MMO/5ML ORAL SYRUP ORL SYR PMS ML 0.0708 00002248268 PMS-MELOXICAM 15 MG TABLET ORL TAB PMS TAB 0.5670 00002248267 PMS-MELOXICAM 7.5 MG TABLET ORL TAB PMS TAB 0.4914 00002321130 PMS-MEMANTINE 10 MG TABLET ORL TAB PMS TAB 1.6357 00002382830 PMS-MEMANTINE 5 MG TABLET ORL TAB PMS TAB 1.6357 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 150 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002413728 PMS-METHYLPHENIDATE 18 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.4276 00002413736 PMS-METHYLPHENIDATE 27 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.6475 00002413744 PMS-METHYLPHENIDATE 36 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 1.8674 00002413752 PMS-METHYLPHENIDATE 54 MG EXTENDED RELEASE TABLET ORL ERT PMS TAB 2.3072 00000783137 PMS-METRONIDAZOLE 500 MG CAPSULE ORL CAP PMS CAP 0.7028 00002405776 PMS-NEVIRAPINE 200 MG TABLET ORL TAB PMS TAB 2.4692 00002418630 PMS-NIFEDIPINE ER 30 MG EXTENDED-RELEASE TABLET ORL ERT PMS TAB 0.6171 00002416301 PMS-NIFEDIPINE ER 60 MG EXTENDED-RELEASE TABLET ORL ERT PMS TAB 0.9374 00002177714 PMS-NIZATIDINE 150 MG CAPSULE ORL CAP PMS CAP 0.2098 00002177722 PMS-NIZATIDINE 300 MG CAPSULE ORL CAP PMS CAP 0.3802 00002246596 PMS-NORFLOXACIN 400 MG TABLET ORL TAB PMS TAB 0.5449 00002177692 PMS-NORTRIPTYLINE 10 MG CAPSULE ORL CAP PMS CAP 0.0500 00002177706 PMS-NORTRIPTYLINE 25 MG CAPSULE ORL CAP PMS CAP 0.1011 00002367483 PMS-OLANZAPINE 20 MG TABLET ORL TAB PMS TAB 10.3093 00002303213 PMS-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB PMS TAB 5.3553 00002423944 PMS-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB PMS TAB 7.5977 00000792942 PMS-OXTRIPHYLLINE ORAL ELIXIR ORL ELX PMS ML 0.0335 00002309882 PMS-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.4390 00002309890 PMS-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 0.6585 00002309904 PMS-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 1.1413 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 151 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002309912 PMS-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ORL CRT PMS TAB 2.1080 00002247750 PMS-PAROXETINE 10 MG TABLET ORL TAB PMS TAB 1.0430 00002231537 PMS-PINDOLOL 10 MG TABLET ORL TAB PMS TAB 0.2323 00002231539 PMS-PINDOLOL 15 MG TABLET ORL TAB PMS TAB 0.3370 00002231536 PMS-PINDOLOL 5 MG TABLET ORL TAB PMS TAB 0.1361 00002303124 PMS-PIOGLITAZONE 15 MG TABLET ORL TAB PMS TAB 0.5809 00002303132 PMS-PIOGLITAZONE 30 MG TABLET ORL TAB PMS TAB 0.8139 00002303140 PMS-PIOGLITAZONE 45 MG TABLET ORL TAB PMS TAB 1.2237 00002154463 PMS-PIROXICAM 20 MG RECTAL SUPPOSITORY RT SUP PMS SUP 2.2117 00002240363 PMS-POLYTRIMETHOPRIM OPHTHALMIC SOLUTION OPH SOL PMS ML 2.3880 00002290138 PMS-PRAMIPEXOLE 0.5 MG TABLET ORL TAB PMS TAB 1.3860 00002359634 PMS-PREGABALIN 150 MG CAPSULE ORL CAP PMS CAP 1.7270 00002398079 PMS-PREGABALIN 225 MG CAPSULE ORL CAP PMS CAP 1.7270 00002359596 PMS-PREGABALIN 25 MG CAPSULE ORL CAP PMS CAP 0.6173 00002359642 PMS-PREGABALIN 300 MG CAPSULE ORL CAP PMS CAP 1.7270 00002359618 PMS-PREGABALIN 50 MG CAPSULE ORL CAP PMS CAP 0.9683 00002359626 PMS-PREGABALIN 75 MG CAPSULE ORL CAP PMS CAP 1.2529 00000753688 PMS-PROCHLORPERAZINE 10 MG RECTAL SUPPOSITORY RT SUP PMS SUP 0.8300 00000753661 PMS-PROCHLORPERAZINE 5 MG TABLET ORL TAB PMS TAB 0.1659 00002294559 PMS-PROPAFENONE 150 MG TABLET ORL TAB PMS TAB 0.4275 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 152 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002294575 PMS-PROPAFENONE 300 MG TABLET ORL TAB PMS TAB 0.7537 00000815993 PMS-PSEUDOEPHEDRINE HCL 6 MG/ML ORAL SYRUP ORL SYR PMS ML 0.0443 00000618810 PMS-PYRAZINAMIDE 500 MG TABLET ORL TAB PMS TAB 1.2408 00002340569 PMS-QUINAPRIL 10 MG TABLET ORL TAB PMS TAB 0.6867 00002340577 PMS-QUINAPRIL 20 MG TABLET ORL TAB PMS TAB 0.6867 00002340585 PMS-QUINAPRIL 40 MG TABLET ORL TAB PMS TAB 0.6867 00002340550 PMS-QUINAPRIL 5 MG TABLET ORL TAB PMS TAB 0.6867 00002343932 PMS-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB PMS CAP 0.8133 00002424177 PMS-RISEDRONATE 150 MG TABLET ORL TAB PMS TAB 40.9500 00002069571 PMS-SALBUTAMOL 5 MG/ML INHALATION SOLUTION INH SOL PMS ML 0.3510 00002371642 PMS-SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.2006 00002371626 PMS-SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 8.2894 00002371634 PMS-SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 8.8481 00002412179 PMS-SILDENAFIL R 20 MG TABLET ORL TAB PMS TAB 7.2940 00002252635 PMS-SIMVASTATIN 10 MG TABLET ORL TAB PMS TAB 0.5057 00002252651 PMS-SIMVASTATIN 40 MG TABLET ORL TAB PMS TAB 0.4500 00002417731 PMS-SOLIFENACIN 10 MG TABLET ORL TAB PMS TAB 1.2670 00002417723 PMS-SOLIFENACIN 5 MG TABLET ORL TAB PMS TAB 1.2670 00002256428 PMS-SUMATRIPTAN 25 MG TABLET ORL TAB PMS TAB 8.9900 00002237460 PMS-TAMOXIFEN 20 MG TABLET ORL TAB PMS TAB 0.3500 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 153 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002391236 PMS-TELMISARTAN 40 MG TABLET ORL TAB PMS TAB 0.2821 00002391244 PMS-TELMISARTAN 80 MG TABLET ORL TAB PMS TAB 0.2821 00002239577 PMS-TOBRAMYCIN 0.3% OPH SOLUTION OPH SOL PMS ML 0.6560 00002401657 PMS-TRAMADOL-ACET 37.5 MG/325 MG TABLET ORL TAB PMS TAB 0.6264 00002381230 PMS-VALACYCLOVIR 1000 MG CAPLET ORL TAB PMS TAB 5.8537 00002312999 PMS-VALSARTAN 40 MG TABLET ORL TAB PMS TAB 0.5240 00002241821 PMS-VANCOMYCIN 1 G/VIAL INJECTION INJ DEFAUL PMS VIAL 58.9900 00002241820 PMS-VANCOMYCIN 500 MG/VIAL INJECTION INJ DEFAUL PMS VIAL 31.0500 00001954504 PMS-YOHIMBINE 2 MG TABLET ORL TAB PMS TAB 0.2063 00001954342 PMS-YOHIMBINE 5.4 MG TABLET ORL TAB PMS TAB 0.4395 00001985604 PMS-YOHIMBINE 6 MG TABLET ORL TAB PMS TAB 0.6850 00002231259 PNEUMO 23 25 MCG/0.5ML INJECTION SYRINGE INJ DEFAUL CNG SYR 19.2400 00000431648 PNEUMOVAX 23 25 MCG/VIAL INJECTION INJ DEFAUL MSD VIAL 18.3600 00000990067 POCKET CHAMBER DEVICE DEFAUL DEV MMS DEV 15.9900 00000990069 POCKET CHAMBER PEDIATRIC MEDIUM MASK DEVICE DEFAUL PEDDEV MMS DEV 49.9900 00000598208 PODOFILM 250 MG/ML TOPICAL LIQUID TOP LIQ PMS ML 1.3804 00000464988 POLLINEX R INJECTION INJ VIAL/SYR BEE VL/SYR 87.5000 00000999389 POLYCAL ORAL POWDER ORL PWR XXX G 0.0224 00000999928 POLYCOSE ORAL POWDER ORL PWR ABN G 0.0253 00002230844 POLYSPORIN 10,000 U/0.25 MG ANTIBIOTIC TOPICAL CRM TOP CRM JJI G 0.3633 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 154 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002237227 POLYSPORIN ANTIBIOTIC TOPICAL OINTMENT TOP ONT JJI G 0.3633 00002239155 POLYSPORIN PLUS PAIN RELIEF EAR DROPS OT SOL JJI ML 0.6967 00002239201 POLYSPORIN PLUS PAIN RELIEF TOPICAL CREAM TOP CRM JJI G 0.3940 00002239157 POLYSPORIN STERILE OPHTHALMIC OINTMENT OPH ONT JJI G 1.6886 00002239156 POLYSPORIN STERILE OTIC OPH DROPS OT/OPH DPS JJI ML 0.6967 00002237226 POLYSPORIN TRIPLE ANTIBIOTIC TOPICAL OINTMENT TOP ONT JJI G 0.3940 00001981021 POLYTAR AF TOPICAL SHAMPOO TOP SHP GSK ML 0.0623 00000249866 POLYTAR REGULAR 1% TOPICAL SHAMPOO TOP SHP GSK ML 0.0403 00001942921 POLYTOPIC TOPICAL OINTMENT TOP ONT SDZ G 0.3333 00002011956 POLYTRIM OPH SOLUTION OPH SOL ALL ML 3.2900 00002419580 POMALYST 1 MG CAPSULE ORL CAP CLG CAP 500.0000 00002419599 POMALYST 2 MG CAPSULE ORL CAP CLG CAP 500.0000 00002419602 POMALYST 3 MG CAPSULE ORL CAP CLG CAP 500.0000 00002419610 POMALYST 4 MG CAPSULE ORL CAP CLG CAP 500.0000 00002424622 POSANOL 100 MG DELAYED-RELEASE TABLET ORL DRT MFC TAB 46.7230 00002293404 POSANOL 40 MG/ML ORAL SUSPENSION ORL SUS MFC ML 9.3446 00000611271 POTABA 0.5 G CAPSULE ORL CAP GLE CAP 0.3311 00000550175 POTABA 0.5 G TABLET ORL TAB GLE TAB 0.4319 00000316121 POTASSIUM 50 MG TABLET ORL TAB JAM TAB 0.0563 00080028233 POTASSIUM CHLORIDE 20 MEQ TABLET ORL TAB/SRT OPU TAB 0.1995 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 155 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080026332 POTASSIUM CITRATE 10 MMOL 10 MEQ TABLET ORL TAB MTR TAB 0.1545 00000804789 POTASSIUM PHOSPHATE 224 MG/ML/ 236 MG/ML INJECTION INJ DEFAUL SDZ ML 0.5248 00002139545 POTASSIUM PHOSPHATES 224 MG/ML/236 MG/ML INJECTION INJ DEFAUL PPC ML 0.5085 00002312433 PRADAXA 75 MG CAPSULE ORL CAP BOE CAP 1.6000 00002309130 PRAMIPEXOLE 0.5 MG TABLET ORL TAB SIV TAB 1.3860 00002367610 PRAMIPEXOLE 0.5 MG TABLET ORL TAB SNS TAB 1.3860 00000770957 PRAMOX H.C. TOPICAL CREAM TOP CRM DPT G 0.4444 00001954210 PRAMOX H.C. TOPICAL LOTION TOP LOT DPT ML 0.1833 00002243824 PRAVASTATIN-10 10 MG TABLET ORL TAB PDL TAB 0.4050 00002243825 PRAVASTATIN-20 20 MG TABLET ORL TAB PDL TAB 0.4777 00002243826 PRAVASTATIN-40 40 MG TABLET ORL TAB PDL TAB 0.5755 00002148498 PREDNISOLONE SOD PHOS 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00000156876 PREDNISONE 5 MG TABLET ORL TAB PDL TAB 0.0220 00000607517 PREDNISONE-50 50 MG TABLET ORL TAB PDL TAB 0.0913 00002405563 PREGABALIN 150 MG CAPSULE ORL CAP SNS CAP 1.7270 00002403722 PREGABALIN 150 MG CAPSULE ORL CAP SIV CAP 1.7270 00002396521 PREGABALIN 150 MG CAPSULE ORL CAP PDL CAP 1.1698 00002403749 PREGABALIN 225 MG CAPSULE ORL CAP SIV CAP 1.1698 00002405539 PREGABALIN 25 MG CAPSULE ORL CAP SNS CAP 0.6173 00002403692 PREGABALIN 25 MG CAPSULE ORL CAP SIV CAP 0.6173 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 156 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002396483 PREGABALIN 25 MG CAPSULE ORL CAP PDL CAP 0.4181 00002396548 PREGABALIN 300 MG CAPSULE ORL CAP PDL CAP 1.1698 00002403730 PREGABALIN 300 MG CAPSULE ORL CAP SIV CAP 1.7270 00002405598 PREGABALIN 300 MG CAPSULE ORL CAP SNS CAP 1.7270 00002405547 PREGABALIN 50 MG CAPSULE ORL CAP SNS CAP 0.9683 00002396505 PREGABALIN 50 MG CAPSULE ORL CAP PDL CAP 0.6558 00002403706 PREGABALIN 50 MG CAPSULE ORL CAP SIV CAP 0.9683 00002405555 PREGABALIN 75 MG CAPSULE ORL CAP SNS CAP 1.2528 00002396513 PREGABALIN 75 MG CAPSULE ORL CAP PDL CAP 0.8486 00002403714 PREGABALIN 75 MG CAPSULE ORL CAP SIV CAP 1.2529 00002411768 PREGABALIN-150 150 MG CAPSULE ORL CAP SIV CAP 1.7270 00002411725 PREGABALIN-25 25 MG CAPSULE ORL CAP SIV CAP 0.6173 00002411733 PREGABALIN-50 50 MG CAPSULE ORL CAP SIV CAP 0.9683 00002411741 PREGABALIN-75 75 MG CAPSULE ORL CAP SIV CAP 1.2529 00002182904 PREGNYL 10,000 UNIT INJECTION INJ DEFAUL MFC VIAL 72.0000 00002276194 PREGVIT FOLIC 5 TABLET ORL TAB DUI TAB 0.5312 00002246067 PREGVIT TABLET ORL TAB DUI TAB 0.3795 00002043394 PREMARIN 0.3 MG TABLET ORL TAB PFI TAB 0.3027 00002043408 PREMARIN 0.625 MG TABLET ORL TAB PFI TAB 0.3027 00002043424 PREMARIN 1.25 MG TABLET ORL TAB PFI TAB 0.3027 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 157 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002043386 PREMARIN 25 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 42.1500 00002244574 PRENATAL VITAMIN AND MINERAL SUPPLEMENT CAPLET ORL TAB WNP TAB 0.0766 00000886750 PREPARATION H TOPICAL CREAM TOP CRM PDH G 0.2544 00001926217 PREPARATION H TOPICAL OINTMENT TOP ONT PDH G 0.2208 00000999899 PRESIDENT'S CHOICE ORAL LIQUID ORL LIQ XXX ML 0.0071 00000693820 PRESSYN 20 U/ML INJECTION INJ DEFAUL FEI ML 7.9000 00002246133 PRESSYN AR 20U/ML INJECTION INJ DEFAUL FEI ML 10.0000 00002249464 PREVACID FASTAB 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB ABB TAB 2.0000 00002249472 PREVACID FASTAB 30 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB ABB TAB 2.0000 00000635189 PREVEX 67% TOPICAL CREAM TOP CRM GSK G 0.1565 00002210754 PREVIDENT 5000 PLUS DENTAL CREAM DEN CRM COL G 0.2013 00002335204 PREVNAR 13 SUSPENSION 0.5 ML SYRINGE INJECTION INJ NDL PFI SYR 90.0900 00002244081 PREVNAR VACCINE 0.5 ML INJECTION INJ DEFAUL PFI ML 180.1800 00002426501 PREZCOBIX 800 MG/150 MG TABLET ORL TAB JAI TAB 23.1720 00002369753 PREZISTA 150 MG TABLET ORL TAB JAI TAB 3.7860 00002324016 PREZISTA 400 MG TABLET ORL TAB JAI TAB 10.8580 00002324024 PREZISTA 600 MG TABLET ORL TAB JAI TAB 15.4390 00002338432 PREZISTA 75 MG TABLET ORL TAB JAI TAB 1.8930 00002393050 PREZISTA 800 MG TABLET ORL TAB JAI TAB 21.7160 00080033655 PRIMADOPHILUS OPTIMA MAX BIFIDO 90 BILLION CAPSULE ORL CAP ENT CAP 1.4283 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 158 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000839388 PRINIVIL 5 MG TABLET ORL TAB MFC TAB 0.6073 00000884413 PRINZIDE 20 MG/12.5 MG TABLET ORL TB MFC TAB 0.9038 00002239208 PRIORIX VIAL INJECTION INJ DEFAUL GSK VIAL 27.7760 00002321106 PRISTIQ 100 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.7250 00002321092 PRISTIQ 50 MG EXTENDED-RELEASE TABLET ORL ERT PFI TAB 2.7250 00002426366 PRIVA-CELECOXIB 100 MG CAPSULE ORL CAP PMI CAP 0.1730 00002426374 PRIVA-CELECOXIB 200 MG CAPSULE ORL CAP PMI CAP 0.3497 00002425238 PRIVA-EZETIMIBE 10 MG TABLET ORL TAB PMI TAB 0.4612 00002425378 PRIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT PMI TAB 0.3628 00002425874 PRIVA-ZOPICLONE 5 MG TABLET ORL TAB PMI TAB 0.2231 00002425882 PRIVA-ZOPICLONE 7.5 MG TABLET ORL TAB PMI TAB 0.4685 00000644315 PRO AMOX-500 MG CAPSULE ORL CAP PDL CAP 0.3417 00002311518 PRO-AAS (CROQUABLE) 80 MG CHEWABLE TABLET ORL CTB PDL TAB 0.0560 00002311496 PRO-AAS EC 80 MG TABLET ORL ECT PDL TAB 0.5600 00002309661 PRO-AMIODARONE-200 200 MG TABLET ORL TAB PDL TAB 0.5147 00000644331 PRO-AMOX 250 MG/5 ML POWDER FOR ORAL SUSPENSION ORL SUS PDL ML 0.0540 00080026419 PROARGI-9 PLUS ORAL POWDER ORL PWR NHP G 0.1252 00002310600 PRO-AZITHROMYCINE 250 MG TABLET ORL TAB PDL TAB 2.4667 00002209071 PROBETA 0.5% OPHTHALMIC SOLUTION OPH SOL ALL ML 2.9500 00002311038 PRO-BICALUTAMIDE-50 50 MG TABLET ORL TAB PDL TAB 1.6100 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 159 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080014464 PROBIOTIC 10 BILLION ORL CAP JAM CAP 0.2398 00002184486 PROCAINAMIDE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL SDZ ML 2.8160 00080008566 PRO-CAL-D 400 IU ORAL CAPLET ORL DEFAUL PDL TAB 0.1200 00002311062 PRO-CEFADROXIL-500 500 MG CAPSULE ORL CAP PDL CAP 0.8421 00002311453 PRO-CEFUROXIME-500 500 MG TABLET ORL TAB PDL TAB 1.4337 00002232658 PROCET-30 TABLET ORL TAB PDL TAB 0.1300 00000789747 PROCHLORPERAZINE 5 MG/ML INJECTION USP INJ DEFAUL SDZ ML 1.5020 00002317796 PRO-CIPROFLOXACIN 250 MG TABLET ORL TAB PDL TAB 0.6186 00002317818 PRO-CIPROFLOXACIN 500 MG TABLET ORL TAB PDL TAB 0.6979 00002311607 PRO-CLONAZEPAM 1 MG TABLET ORL TAB PDL TAB 0.1860 00002311615 PRO-CLONAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.1595 00002223260 PROCTOSEDYL RECTAL SUPPOSITORY RT SUP AXC SUP 1.1758 00002241799 PROCYTOX 1,000 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 77.8100 00002241797 PROCYTOX 200 MG/VIAL INJECTION INJ DEFAUL ASM VIAL 51.8700 00002241795 PROCYTOX 25 MG TABLET ORL TAB ASM TAB 0.4986 00002241796 PROCYTOX 50 MG TABLET ORL TAB ASM TAB 0.6690 00002241800 PROCYTOX INJECTION INJ DEFAUL ASM VIAL 152.3500 00002311267 PRO-DEXAMETHASONE-4 4 MG TABLET ORL TAB PDL TAB 0.3046 00002246645 PRODIEM BULK FIBRE THERAPY 625 MG TABLET ORL TAB NVC TAB 0.1614 00002246576 PRODIEM OVERNIGHT RELIEF THERAPY 15 MG TABLET ORL TAB NVC TAB 0.2030 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 160 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002311429 PRO-ENALAPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.2647 00002311402 PRO-ENALAPRIL-2.5 2.5 MG TABLET ORL TAB PDL TAB 0.1863 00002311437 PRO-ENALAPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.3195 00002311410 PRO-ENALAPRIL-5 5 MG TABLET ORL TAB PDL TAB 0.2203 00002310228 PRO-FENO-SUPER-100 100 MG TABLET ORL TAB PDL TAB 0.5406 00002310236 PRO-FENO-SUPER-160 160 MG TABLET ORL CAP/TAB PDL TAB 0.2723 00002247909 PROFERRIN 11 MG TABLET ORL TAB CBI TAB 0.6990 00002310686 PRO-FLUCONAZOLE 100 MG TABLET ORL TAB PDL TAB 2.2890 00002310694 PRO-FLUCONAZOLE 150 MG CAPSULE ORL CAP PDL CAP 3.9400 00002314991 PRO-FLUOXETINE 10 MG CAPSULE ORL CAP PDL CAP 0.4595 00002315009 PRO-FLUOXETINE 20 MG CAPSULE ORL CAP PDL CAP 0.4598 00002310449 PRO-GABAPENTIN 100 MG CAPSULE ORL CAP PDL CAP 0.1040 00002310457 PRO-GABAPENTIN 300 MG CAPSULE ORL CAP PDL CAP 0.2530 00002310465 PRO-GABAPENTIN 400 MG CAPSULE ORL CAP PDL CAP 0.3015 00002310473 PRO-GABAPENTIN 600 MG TABLET ORL TAB PDL TAB 0.9580 00002310481 PRO-GABAPENTIN 800 MG TABLET ORL TAB PDL TAB 1.2773 00000503347 PROGLYCEM 100 MG CAPSULE ORL CAP MFC CAP 1.6802 00002243144 PROGRAF 0.5 MG CAPSULE ORL CAP ASP CAP 1.9700 00002175991 PROGRAF 1 MG CAPSULE ORL CAP ASP CAP 2.5200 00002175983 PROGRAF 5 MG CAPSULE ORL CAP ASP CAP 12.6200 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 161 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002311011 PRO-HYDROXYQUINE-200 200 MG TABLET ORL TAB PDL TAB 0.2620 00000646261 PRO-INDO 25 MG CAPSULE ORL CAP PDL CAP 0.0871 00000646288 PRO-INDO 50 MG CAPSULE ORL CAP PDL CAP 0.1511 00080053887 PRO-K 20 20 MEQ SUSTAINED-RELEASE TABLET ORL TAB PDL TAB 0.1995 00002204606 PROLASTIN-C 1 G/VIAL INJECTION INJ DEFAUL GRL VIAL 429.0600 00002439123 PROLENSA 0.07 % OPHTHALMIC SOLUTION OPH SOL BSH ML 7.6700 00002310988 PRO-LISINOPRIL-10 10 MG TABLET ORL TAB PDL TAB 0.1619 00002310996 PRO-LISINOPRIL-20 20 MG TABLET ORL TAB PDL TAB 0.1945 00002310961 PRO-LISINOPRIL-5 5 MG TABLET ORL TAB PDL TAB 0.1347 00000655643 PRO-LORAZEPAM 0.5 MG TABLET ORL TAB PDL TAB 0.0359 00000655651 PRO-LORAZEPAM 1.0 MG TABLET ORL TAB PDL TAB 0.0447 00000655678 PRO-LORAZEPAM 2 MG TABLET ORL TAB PDL TAB 0.0699 00002314908 PRO-METFORMIN 500 MG TABLET ORL TAB PDL TAB 0.0587 00002314894 PRO-METFORMIN 850 MG TABLET ORL TAB PDL TAB 0.0847 00002310953 PRO-NAPROXEN EC - 500 500 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 2.1100 00002343053 PROPAFENONE 150 MG TABLET ORL TAB SNS TAB 0.4303 00002343061 PROPAFENONE 300 MG TABLET ORL TAB SNS TAB 0.7537 00002243783 PROPAFENONE-150 150 MG TABLET ORL TAB PDL TAB 0.3395 00002243784 PROPAFENONE-300 300 MG TABLET ORL TAB PDL TAB 0.5227 00002238213 PROPECIA 1 MG TABLET ORL TAB MFC TAB 1.7989 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 162 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002317354 PRO-QUETIAPINE 100 MG TABLET ORL TAB PDL TAB 0.3295 00002317362 PRO-QUETIAPINE 200 MG TABLET ORL TAB PDL TAB 0.6617 00002317346 PRO-QUETIAPINE 25 MG TABLET ORL TAB PDL TAB 0.1235 00002317370 PRO-QUETIAPINE 300 MG TABLET ORL TAB PDL TAB 0.9656 00002311224 PRO-QUININE-300 300 MG CAPSULE ORL CAP PDL CAP 0.3750 00002315181 PRO-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.1204 00002315203 PRO-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT PDL TAB 0.2408 00002310023 PRO-RAMIPRIL-1.25 1.25 MG CAPSULE ORL CAP/TAB PDL CAP 0.2057 00002310104 PRO-RAMIPRIL-10 10 MG CAPSULE ORL CAP/TAB PDL CAP 0.3003 00002310066 PRO-RAMIPRIL-2.5 2.5 MG CAPSULE ORL CAP/TAB PDL CAP 0.2370 00002310074 PRO-RAMIPRIL-5 5 MG CAPSULE ORL CAP/TAB PDL CAP 0.2370 00002316536 PRO-SOTALOL 160 MG TABLET ORL TAB PDL TAB 0.6492 00002316528 PRO-SOTALOL 80 MG TABLET ORL TAB PDL TAB 0.5932 00000519367 PRO-TRIAZIDE TABLET ORL TAB PDL TAB 0.0608 00000512524 PROTRIN DF 800 MG/160 MG TABLET ORL TAB PDL TAB 0.1221 00000287709 PROTYLOL 10 MG CAPSULE ORL CAP PDL CAP 0.0609 00000513059 PROTYLOL 20 MG TABLET ORL TAB PDL TAB 0.1690 00002239656 PROVOCHOLINE 100 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 40.0000 00002243834 PROVOCHOLINE 1280 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 487.0000 00002246492 PROVOCHOLINE 160 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 64.0000 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 163 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002246493 PROVOCHOLINE 320 MG/VIAL INHALATION PWD FOR SOL INH PWS MTP VIAL 128.0000 00002313065 PRO-ZOPICLONE 5 MG TABLET ORL TAB PDL TAB 0.2231 00002313073 PRO-ZOPICLONE 7.5 MG TABLET ORL TAB PDL TAB 0.4685 00080002201 PSN 056 CAPSULE ORL CAP PSN CAP 0.0750 00000999412 PULMOCARE ORAL LIQUID ORL LIQ ABN ML 0.0137 00000466409 PULMOPHYLLINE 5.3 MG/ML ORAL ELIXIR ORL ELX RIV ML 0.0086 00002046733 PULMOZYME 1 ML AMPOULE INHALATION SOLUTION INH SOL HLR ML 15.4468 00002242439 PUREGON 100 IU/ML INJECTION INJ DEFAUL MFC ML 97.0000 00002242441 PUREGON 200 IU/ML INJECTION INJ DEFAUL MFC ML 194.0000 00002243948 PUREGON 833 IU/ML INJECTION CARTRIDGE INJ CTG MFC ML 808.3333 00002317966 PURG-ODAN ORL POWDER ORL PWDPKT ODN PCKT 5.2500 00000004723 PURINETHOL 50 MG TABLET ORL TAB TEV TAB 2.8610 00080009682 PYCNOGENOL 25 MG ORAL CASPULE ORL CAP NFN CAP 0.5665 00000497517 PYRIDOXINE HCL 100 MG/ML INJECTION INJ DEFAUL HSP ML 1.9500 00002245215 PYRIDOXINE HYDROCHLORIDE 100 MG/ML INJECTION INJ DEFAUL BNQ ML 1.1663 00080015945 QUEST TABLET ORL TAB PLH TAB 0.3943 00002417790 QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.8753 00002417367 QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 0.7780 00002417375 QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 1.0520 00002417804 QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 1.1882 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 164 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002417383 QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 1.5440 00002417812 QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 1.7505 00002417820 QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 2.3763 00002417391 QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 2.0960 00002417782 QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.4445 00002417359 QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET ORL ERT SIV TAB 0.3950 00002415925 QUINAPRIL 10 MG TABLET ORL TAB PDL TAB 0.5329 00002415933 QUINAPRIL 20 MG TABLET ORL TAB PDL TAB 0.5329 00002415941 QUINAPRIL 40 MG TABLET ORL TAB PDL TAB 0.5329 00002415917 QUINAPRIL 5 MG TABLET ORL TAB PDL TAB 0.5329 00000695440 QUININE-ODAN 200 MG CAPSULE ORL CAP ODN CAP 0.2390 00000695459 QUININE-ODAN 300 MG CAPSULE ORL CAP ODN CAP 0.3750 00000695432 QUININE-ODAN 300 MG TABLET ORL TAB ODN TAB 0.3750 00080039114 Q-UROL TABLET ORL TAB TPI TAB 0.7415 00002267667 RABAVERT VACCINE 2.5 UNIT/VIAL INJECTION INJ DEFAUL MFC VIAL 171.8800 00002423723 RAGWITEK 12 UNIT SUBLINGUAL TABLET SLG TAB MFC TAB 3.8000 00002299194 RALIVIA 100 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 1.2546 00002299208 RALIVIA 200 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 2.2888 00002299216 RALIVIA 300 MG EXTENDED-RELEASE TABLET ORL ERT VCL TAB 3.3160 00002415852 RALOXIFENE 60 MG TABLET ORL TAB PDL TAB 0.4585 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 165 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002308363 RAMIPRIL 1.25 MG CAPSULE ORL CAP/TAB SIV CAP 0.1274 00002287943 RAMIPRIL 10 MG CAPSULE ORL CAP/TAB SIV CAP 0.1862 00002287927 RAMIPRIL 2.5 MG CAPSULE ORL CAP/TAB SIV CAP 0.1470 00002287935 RAMIPRIL 5 MG CAPSULE ORL CAP/TAB SIV CAP 0.1470 00002415895 RAMIPRIL-HCTZ 10 MG/ 12.5 MG TABLET ORL TAB PDL TAB 0.2633 00002415909 RAMIPRIL-HCTZ 10 MG/25 MG TABLET ORL TAB PDL TAB 0.2633 00002415887 RAMIPRIL-HCTZ 5 MG/12.5 MG TABLET ORL TAB PDL TAB 0.2067 00002384698 RAN-ALENDRONATE 5 MG TABLET ORL TAB RAN TAB 1.0371 00002398877 RAN-AMLODIPINE 2.5 MG TABLET ORL TAB RAN TAB 0.1380 00002328690 RAN-ANASTROZOLE 1 MG TABLET ORL TAB RAN TAB 2.5457 00002371324 RAN-BICALUTAMIDE 50 MG TABLET ORL TAB RAN TAB 4.0573 00002380684 RAN-CANDESARTAN 4 MG TABLET ORL TAB RAN TAB 0.3400 00002361434 RAN-CLARITHROMYCIN 500 MG TABLET ORL TAB RAN TAB 1.6293 00002423979 RAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ORL DRT RAN TAB 1.8690 00002423987 RAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ORL DRT RAN TAB 1.8690 00002294524 RAN-FOSINOPRIL 10 MG TABLET ORL TAB RAN TAB 0.2177 00002294532 RAN-FOSINOPRIL 20 MG TABLET ORL TAB RAN TAB 0.2619 00002351706 RAN-IMIPENEM-CILASTATIN 500 MG/500 MG/VIAL INJ INJ DEFAUL RAN VIAL 21.9400 00000740748 RANITIDINE 150 MG TABLET ORL TAB PDL TAB 0.1800 00000740756 RANITIDINE 300 MG TABLET ORL TAB PDL TAB 0.3600 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 166 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002372282 RAN-LETROZOLE 2.5 MG TABLET ORL TAB RAN TAB 2.7560 00002421364 RAN-MEMANTINE 10 MG TABLET ORL TAB RAN TAB 1.6357 00002358077 RAN-NABILONE 0.25 MG CAPSULE ORL CAP RAN CAP 1.3962 00002414112 RAN-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB RAN TAB 5.3554 00002414120 RAN-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB RAN TAB 7.5979 00002305038 RAN-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT RAN TAB 1.2750 00002375850 RAN-PIOGLITAZONE 15 MG TABLET ORL TAB RAN TAB 0.5809 00002375869 RAN-PIOGLITAZONE 30 MG TABLET ORL TAB RAN TAB 0.8139 00002375877 RAN-PIOGLITAZONE 45 MG TABLET ORL TAB RAN TAB 1.2237 00002392844 RAN-PREGABALIN 150 MG CAPSULE ORL CAP RAN CAP 1.7270 00002392852 RAN-PREGABALIN 225 MG CAPSULE ORL CAP RAN CAP 1.7270 00002392801 RAN-PREGABALIN 25 MG CAPSULE ORL CAP RAN CAP 0.6173 00002392860 RAN-PREGABALIN 300 MG CAPSULE ORL CAP RAN CAP 1.7270 00002392828 RAN-PREGABALIN 50 MG CAPSULE ORL CAP RAN CAP 0.9683 00002392836 RAN-PREGABALIN 75 MG CAPSULE ORL CAP RAN CAP 1.2528 00002425548 RAN-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB RAN CAP 0.8550 00002383136 RAN-SILDENAFIL 100 MG TABLET ORL TAB RAN TAB 9.2000 00002383101 RAN-SILDENAFIL 25 MG TABLET ORL TAB RAN TAB 8.2900 00002383128 RAN-SILDENAFIL 50 MG TABLET ORL TAB RAN TAB 8.8477 00002396084 RAN-TOPIRAMATE 100 MG TABLET ORL TAB RAN 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 167 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002396092 RAN-TOPIRAMATE 200 MG TABLET ORL TAB RAN TAB 0.8853 00002396076 RAN-TOPIRAMATE 25 MG TABLET ORL TAB RAN TAB 0.3128 00002388197 RAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB RAN TAB 0.6264 00002363062 RAN-VALSARTAN 40 MG TABLET ORL TAB RAN TAB 0.5239 00002361663 RAPAFLO 4 MG CAPSULE ORL CAP ASC CAP 1.8967 00002361671 RAPAFLO 8 MG CAPSULE ORL CAP ASC CAP 1.8968 00002247111 RAPAMUNE 1 MG TABLET ORL TAB PFI TAB 7.9140 00002243237 RAPAMUNE 1 MG/ML ORAL LIQUID ORL LIQ PFI ML 7.9140 00002302063 RASILEZ 150 MG TABLET ORL TAB NOV TAB 1.2589 00002302071 RASILEZ 300 MG TABLET ORL TAB NOV TAB 1.2589 00002332728 RASILEZ HCT 150 MG/12.5 MG TABLET ORL TAB NOV TAB 1.2643 00002332736 RASILEZ HCT 150 MG/25 MG TABLET ORL TAB NOV TAB 1.2643 00002332744 RASILEZ HCT 300 MG/12.5 MG TABLET ORL TAB NOV TAB 1.2643 00002332752 RASILEZ HCT 300 MG/25 MG TABLET ORL TAB NOV TAB 1.2643 00002244646 RATIO-ACLAVULANATE 125F 25 MG/6.25 MG ORAL SUSP ORL SUS RPH ML 0.0543 00002244647 RATIO-ACLAVULANATE 250F 50 MG/12.5 MG ORAL SUSP ORL SUS RPH ML 0.1830 00002275287 RATIO-AZITHROMYCIN 250 MG TABLET ORL TAB RPH TAB 1.2317 00002277700 RATIO-BICALUTAMIDE 50 MG TABLET ORL TAB RPH TAB 4.0573 00002243026 RATIO-BRIMONIDINE 0.2% OPHTHALMIC SOLUTION OPH SOL RPH ML 1.1560 00000550477 RATIO-CALMYDONE ORAL SYRUP ORL SYR RPH ML 0.0596 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 168 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002247818 RATIO-CLARITHROMYCIN 250 MG TABLET ORL TAB RPH TAB 0.4122 00002247819 RATIO-CLARITHROMYCIN 500 MG TABLET ORL TAB RPH TAB 1.6293 00002053403 RATIO-COTRIDIN EXPECTORANT ORAL SYRUP ORL SYR RPH ML 0.0610 00002169126 RATIO-COTRIDIN ORAL SYRUP ORL SYR RPH ML 0.0550 00002229781 RATIO-DILTIAZEM CD 120 MG CONTROLLED-DELIVERY CAP ORL CDC RPH CAP 0.3529 00002229782 RATIO-DILTIAZEM CD 180 MG CONTROLLED-DELIVERY CAP ORL CDC RPH CAP 0.4684 00002229783 RATIO-DILTIAZEM CD 240 MG CONTROLLED-DELIVERY CAP ORL CDC RPH CAP 0.6213 00002229784 RATIO-DILTIAZEM CD 300 MG CONTROLLED-DELIVERY CAP ORL CDC RPH CAP 0.7766 00002306905 RATIO-FINASTERIDE 5 MG TABLET ORL TAB RPH TAB 0.4633 00002241371 RATIO-FLUOXETINE HYDROCHLORIDE 10 MG CAPSULE ORL CAP RPH CAP 0.4595 00002241374 RATIO-FLUOXETINE HYDROCHLORIDE 20 MG CAPSULE ORL CAP RPH CAP 0.4598 00002296071 RATIO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY NAS SPM RPH DOSE 0.1831 00002218461 RATIO-FLUVOXAMINE 100 MG TABLET ORL TAB RPH TAB 0.3783 00002218453 RATIO-FLUVOXAMINE 50 MG TABLET ORL TAB RPH TAB 0.2105 00002275252 RATIO-FOSINOPRIL 10 MG TABLET ORL TAB RPH TAB 0.4977 00002275260 RATIO-FOSINOPRIL 20 MG TABLET ORL TAB RPH TAB 0.5985 00000805025 RATIO-GENTAMYCIN SULFATE 0.1% TOPICAL OINTMENT TOP ONT RPH G 0.4273 00002273101 RATIO-GLIMEPIRIDE 1 MG TABLET ORL TAB RPH TAB 0.4900 00002273128 RATIO-GLIMEPIRIDE 2 MG TABLET ORL TAB RPH TAB 0.4900 00002273136 RATIO-GLIMEPIRIDE 4 MG TABLET ORL TAB RPH TAB 0.4900 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 169 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002243789 RATIO-IPRA SAL UDV INHALATION SOLUTION INH SOL RPH ML 0.4524 00002097168 RATIO-IPRATROPIUM UDV 250 MCG/ML INHALATION SOL'N INH UDSOL RPH ML 0.6590 00002243353 RATIO-LAMOTRIGINE 100 MG TABLET ORL TAB RPH TAB 0.5739 00002243352 RATIO-LAMOTRIGINE 25 MG TABLET ORL TAB RPH TAB 0.0936 00000653233 RATIO-LENOLTEC NO.1 TABLET ORL TAB RPH TAB 0.0517 00002031159 RATIO-LEVOBUNOLOL 0.25% OPH SOLUTION OPH SOL RPH ML 3.9000 00002031167 RATIO-LEVOBUNOLOL 0.5% OPH SOLUTION OPH SOL RPH ML 1.1520 00002248031 RATIO-MELOXICAM 15 MG TABLET ORL TAB RPH TAB 0.5670 00002247889 RATIO-MELOXICAM 7.5 MG TABLET ORL TAB RPH TAB 0.4914 00002320908 RATIO-MEMANTINE 10 MG TABLET ORL TAB RPH TAB 1.6357 00002194163 RATIO-NYSTATIN 100,000 UNIT/G VAGINAL CREAM VAG CRM RPH G 0.3191 00002260867 RATIO-OMEPRAZOLE 20 MG SUSTAINED-RELEASE TABLET ORL CAP/SRT RPH TAB 0.4117 00002278529 RATIO-ONDANSETRON 4 MG TABLET ORL TAB RPH TAB 3.3500 00002278537 RATIO-ONDANSETRON 8 MG TABLET ORL TAB RPH TAB 5.1877 00002308681 RATIO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT RPH TAB 1.2750 00002247810 RATIO-PAROXETINE 10 MG TABLET ORL TAB RPH TAB 1.0430 00002301423 RATIO-PIOGLITAZONE 15 MG TABLET ORL TAB RPH TAB 0.5809 00002301431 RATIO-PIOGLITAZONE 30 MG TABLET ORL TAB RPH TAB 0.8139 00002301458 RATIO-PIOGLITAZONE 45 MG TABLET ORL TAB RPH TAB 1.2237 00002311194 RATIO-RAMIPRIL 15 MG CAPSULE ORL CAP/TAB RPH CAP 0.8133 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 170 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001986864 RATIO-SALBUTAMOL SULFATE U.D. P.F. 1 MG/ML INH SOL INH SOL RPH ML 0.1446 00002239366 RATIO-SALBUTAMOL SULFATE U.D. P.F. 2MG/ML INH SOL INH UDSOL RPH ML 0.2748 00002319500 RATIO-SILDENAFIL R 20 MG TABLET ORL TAB RPH TAB 7.2940 00002247068 RATIO-SIMVASTATIN 10 MG TABLET ORL TAB RPH TAB 0.3643 00002247070 RATIO-SIMVASTATIN 40 MG TABLET ORL TAB RPH TAB 0.4501 00002247071 RATIO-SIMVASTATIN 80 MG TABLET ORL TAB RPH TAB 0.4500 00000550507 RATIO-TRIACOMB REGULAR TOPICAL CREAM TOP CRM RPH G 0.4027 00002140063 RATIO-VALPROIC 50 MG/ML ORAL SYRUP ORL SYR RPH ML 0.0379 00002223554 REACTINE 10 MG TABLET ORL TAB MCL TAB 0.7040 00001900978 REACTINE 20 MG TABLET ORL TAB MCL TAB 0.8595 00002223546 REACTINE 5 MG TABLET ORL TAB MCL TAB 0.4981 00002246162 REACTINE ALLERGY & SINUS EXTENDED-RELEASE TABLET ORL ERT MCL TAB 0.7040 00002368064 REACTINE ALLERGY LIQUID GELS 10 MG CAPSULE ORL CAP MCL CAP 0.7172 00002358352 REACTINE FAST MELT 10 MG ODT ORL ODT MCL TAB 0.6367 00002243676 RECOMBIVAX HB (PRESERVATIVE FREE) 5MCG/0.5ML INJ INJ DEFAUL MFC ML 22.8000 00000013447 REDOXON (BL CHERRY) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.2700 00000897221 REDOXON (LEMON) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.2640 00000897256 REDOXON (ORANGE) 1,000 MG EFFERVESCENT TABLET ORL EVT HLR TAB 0.2367 00002138670 REFRESH 1.4% OPH SOLUTION OPH SOL ALL ML 0.8533 00002244650 REFRESH LIQUIGEL 1% OPH SOLUTION OPH SOL ALL ML 0.5140 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 171 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002399148 REFRESH OPTIVE ADVANCED NAS SOL ALL ML 0.8950 00002049260 REFRESH PLUS 0.5% OPH SOLUTION OPH SOL ALL ML 0.7592 00002231008 REFRESH TEARS 0.5% OPH SOLUTION OPH SOL ALL ML 0.4167 00002239405 REGRANEX TOPICAL GEL TOP GEL JAI G 35.3333 00002242592 REGULAR VITA-VIM CAPLET ORL TAB JAM TAB 0.1012 00002192640 REJUVA-A 0.025% TOPICAL CREAM TOP CRM GSK G 1.8410 00002240863 RELENZA 5 MG/DOSE INHALATION DISK INH DSK GSK DISC 7.3080 00002308215 RELISTOR 20 MG/ML INJECTION INJ DEFAUL SLX ML 63.3333 00002256290 RELPAX 20 MG TABLET ORL TAB PFI TAB 13.8800 00002256304 RELPAX 40 MG TABLET ORL TAB PFI TAB 13.8800 00002248542 REMERON RD 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.4243 00002248543 REMERON RD 30 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 0.8483 00002248544 REMERON RD 45 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB MFC TAB 1.2727 00002246552 REMODULIN 1 MG/ML INJECTION INJ DEFAUL NTH ML 45.0000 00002246555 REMODULIN 10 MG/ML INJECTION INJ DEFAUL NTH ML 450.0000 00002246553 REMODULIN 2.5 MG/ML INJECTION INJ DEFAUL NTH ML 112.5000 00002246554 REMODULIN 5 MG/ML INJECTION INJ DEFAUL NTH ML 225.0000 00002244310 RENAGEL 800 MG TABLET ORL TAB SAV TAB 1.6426 00002354586 RENVELA 800 MG TABLET ORL TAB SAV TAB 1.5503 00002415968 REPAGLINIDE 0.5 MG TABLET ORL TAB PDL TAB 0.0996 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 172 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002415976 REPAGLINIDE 1 MG TABLET ORL TAB PDL TAB 0.1036 00002415984 REPAGLINIDE 2 MG TABLET ORL TAB PDL TAB 0.1075 00002249057 REPLAGAL 1 MG/ML INJECTION INJ DEFAUL PAL ML 657.1429 00002247790 REPRONEX 75 UNIT/VIAL INJECTION INJ DEFAUL FEI VIAL 74.0000 00002377012 RESOTRAN 1 MG FILM-COATED TABLET ORL TAB JAI TAB 2.2700 00002377020 RESOTRAN 2 MG FILM-COATED TABLET ORL TAB JAI TAB 3.4850 00000999551 RESOURCE KID ESSENTIALS ORAL LIQUID ORL LIQ NHN ML 0.0087 00002355655 RESTASIS 0.05% OPH EMULSION OPH EML ALL ML 8.4000 00002318164 RESTORALAX ORAL POWDER ORL PWR SPL G 0.0603 00000443816 RETIN-A 0.025% TOPICAL GEL TOP GEL JJI G 0.3993 00000443794 RETIN-A 0.05% TOPICAL CREAM TOP CRM JJI G 0.3993 00002264633 RETIN-A MICRO 0.04% TOPICAL GEL TOP GEL JJI G 1.1085 00002243914 RETIN-A MICRO 0.1% GEL TOP GEL JJI G 1.1085 00002306980 RETISERT 0.59 MG INTRAVITREAL IMPLANT OPH IMP BSH SYS 16000.0000 00002008726 RETISOL-A 0.01% TOPICAL CREAM TOP CRM GSK G 0.7353 00002008696 RETISOL-A 0.025% TOPICAL CREAM TOP CRM GSK G 0.7116 00002008718 RETISOL-A 0.05% TOPICAL CREAM TOP CRM GSK G 0.7116 00002008688 RETISOL-A O.1% TOPICAL CREAM TOP CRM GSK G 0.7116 00001902660 RETROVIR 100 MG CAPSULE ORL CAP GSK CAP 1.8897 00001902652 RETROVIR 50 MG/5ML ORAL SYRUP ORL SYR GSK ML 0.1975 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 173 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002279401 REVATIO 20 MG TABLET ORL TAB PFI TAB 11.1220 00002213826 REVIA 50 MG TABLET ORL TAB BAR TAB 8.5912 00002035871 REVITONUS C-1000 ORAL LIQUID ORL LIQ SDZ AMP 0.7875 00002304902 REVLIMID 10 MG CAPSULE ORL CAP CLG CAP 361.0000 00002317699 REVLIMID 15 MG CAPSULE ORL CAP CLG CAP 382.0000 00002440601 REVLIMID 20 MG CAPSULE ORL CAP CLG CAP 403.0000 00002317710 REVLIMID 25 MG CAPSULE ORL CAP CLG CAP 424.0000 00002304899 REVLIMID 5 MG CAPSULE ORL CAP CLG CAP 340.0000 00002361825 REVOLADE 25 MG TABLET ORL TAB NOV TAB 62.5000 00002361833 REVOLADE 50 MG TABLET ORL TAB NOV TAB 125.0000 00002248610 REYATAZ 150 MG CAPSULE ORL CAP BMS CAP 11.0587 00002248611 REYATAZ 200 MG CAPSULE ORL CAP BMS CAP 11.0587 00002294176 REYATAZ 300 MG CAPSULE ORL CAP BMS CAP 22.1173 00002220806 RHINARIS LUBRICATING NASAL GEL NAS GEL PMS G 0.2689 00000732230 RHINARIS NASAL AEROSOL NAS AER PMS DOSE 0.1933 00080058002 RHINARIS NOZOIL NASAL SPRAY NAS SPR PPH ML 1.7990 00001950541 RHINARIS-CS 2% NASAL SOLUTION NAS SOL PPH ML 0.7677 00002231923 RHINOCORT AQUA 64 MCG/DOSE METERED DOSE NAS. SPRAY NAS SPM AZC DOSE 0.0920 00080026370 RHODIOLA ROSEA CAPSULE ORL CAP AOR CAP 0.2546 00002260107 RHOXAL-ANAGRELIDE 0.5 MG CAPSULE ORL CAP SDZ CAP 3.3491 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 174 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002269589 RHOXAL-GLIMEPIRIDE 1 MG TABLET ORL TAB SDZ TAB 0.4900 00002269597 RHOXAL-GLIMEPIRIDE 2 MG TABLET ORL TAB SDZ TAB 0.4900 00002269619 RHOXAL-GLIMEPIRIDE 4 MG TABLET ORL TAB SDZ TAB 0.4900 00002243559 RHOXAL-ORPHENADRINE 100 MG EXTENDED-RELEASE TABLET ORL ERT SDZ TAB 0.8570 00000309702 RIBOFLAVINE 100 MG TABLET ORL TAB JAM TAB 0.0647 00002091887 RIFADIN 150 MG CAPSULE ORL CAP SAV CAP 0.8395 00002092808 RIFADIN 300 MG CAPSULE ORL CAP SAV CAP 1.3211 00002352141 RISEDRONATE 35 MG TABLET ORL TAB SIV TAB 2.4893 00002347474 RISEDRONATE 35 MG TABLET ORL TAB PDL TAB 2.4275 00002298465 RISPERDAL CONSTA 12.5 MG/VIAL INJECTION INJ DEFAUL JAI VIAL 78.5900 00002247217 RIVA-AMIODARONE 200 MG TABLET ORL TAB RIV TAB 0.5147 00002331500 RIVA-AMLODIPINE 10 MG TABLET ORL TAB RIV TAB 0.3587 00002331489 RIVA-AMLODIPINE 2.5 MG TABLET ORL TAB RIV TAB 0.1380 00002242093 RIVA-ATENOLOL 100 MG TABLET ORL TAB RIV TAB 0.2362 00002242094 RIVA-ATENOLOL 50 MG TABLET ORL TAB RIV TAB 0.1437 00002422751 RIVA-ATORVASTATIN 10 MG TABLET ORL TAB RIV TAB 0.3138 00002422778 RIVA-ATORVASTATIN 20 MG TABLET ORL TAB RIV TAB 0.3922 00002422786 RIVA-ATORVASTATIN 40 MG TABLET ORL TAB RIV TAB 0.4216 00002422794 RIVA-ATORVASTATIN 80 MG TABLET ORL TAB RIV TAB 0.4216 00002242077 RIVA-CLONAZEPAM 0.5 MG TABLET ORL TAB RIV TAB 0.0495 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 175 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002388529 RIVA-CLOPIDOGREL 75 MG TABLET ORL TAB RIV TAB 0.4735 00002242468 RIVACOCET 5 MG/325 MG TABLET ORL TAB RIV TAB 0.1285 00002424436 RIVA-EZETIMIBE 10 MG TABLET ORL TAB RIV TAB 0.4549 00002247306 RIVA-FENOFIBRATE MICRO 200 MG CAPSULE ORL CAP RIV CAP 0.2723 00002251167 RIVA-GABAPENTIN 100 MG CAPSULE ORL CAP RIV CAP 0.1040 00002251175 RIVA-GABAPENTIN 300 MG CAPSULE ORL CAP RIV CAP 0.2530 00002251183 RIVA-GABAPENTIN 400 MG CAPSULE ORL CAP RIV CAP 0.3015 00002239081 RIVA-METFORMIN 500 MG TABLET ORL TAB RIV TAB 0.0586 00002242783 RIVA-METFORMIN 850 MG TABLET ORL TAB RIV TAB 0.0847 00002265265 RIVA-MIRTAZAPINE 30 MG TABLET ORL TAB RIV TAB 0.2338 00002240788 RIVA-NAPROXEN 500 MG TABLET ORL TAB RIV TAB 0.2110 00002228300 RIVANASE AQ 50 MCG/DOSE METER DOSE NASAL SPRAY NAS SPM RIV DOSE 0.0490 00002337150 RIVA-OLANZAPINE 10 MG TABLET ORL TAB RIV TAB 1.2757 00002337169 RIVA-OLANZAPINE 15 MG TABLET ORL TAB RIV TAB 1.9136 00002337126 RIVA-OLANZAPINE 2.5 MG TABLET ORL TAB RIV TAB 0.3189 00002337134 RIVA-OLANZAPINE 5 MG TABLET ORL TAB RIV TAB 0.6379 00002337142 RIVA-OLANZAPINE 7.5 MG TABLET ORL TAB RIV TAB 0.9568 00002339838 RIVA-OLANZAPINE ODT 10 MG ORALLY DISINT. TABLET ORL DISNTAB RIV TAB 1.2757 00002339846 RIVA-OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB RIV TAB 1.9137 00002392399 RIVA-OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB RIV TAB 2.5447 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 176 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002339811 RIVA-OLANZAPINE ODT 5 MG ORALLY DISINT. TABLET ORL DISNTAB RIV TAB 0.6380 00002402416 RIVA-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET ORL CAP/SRT RIV TAB 0.4117 00002316463 RIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.5054 00002330083 RIVA-RABEPRAZOLE EC 10 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.1203 00002330091 RIVA-RABEPRAZOLE EC 20 MG ENTERIC-COATED TABLET ORL ECT RIV TAB 0.2407 00002380056 RIVA-ROSUVASTATIN 10 MG TABLET ORL TAB RIV TAB 0.2437 00002380064 RIVA-ROSUVASTATIN 20 MG TABLET ORL TAB RIV TAB 0.3046 00002380102 RIVA-ROSUVASTATIN 40 MG TABLET ORL TAB RIV TAB 0.3582 00002202352 RIVASA CROQUABLE 80 MG TABLET ORL CTB RIV TAB 0.0560 00002240112 RIVASOL-HC RECTAL SUPPOSITORY RT SUP RIV SUP 0.5833 00001940112 RIVASONE SCALP 0.1% TOPICAL LOTION TOP LOT RIV ML 0.0853 00002242157 RIVA-SOTALOL 160 MG TABLET ORL TAB RIV TAB 0.1623 00002416999 RIVASTIGMINE 1.5 MG CAPSULE ORL CAP PDL CAP 0.6514 00002417006 RIVASTIGMINE 3 MG CAPSULE ORL CAP PDL CAP 0.6514 00002417014 RIVASTIGMINE 4.5 MG CAPSULE ORL CAP PDL CAP 0.6514 00002417022 RIVASTIGMINE 6 MG CAPSULE ORL CAP PDL CAP 0.6514 00002307790 RIVA-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAP ORL ERC RIV CAP 0.3469 00002307774 RIVA-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAP ORL ERC RIV CAP 0.1643 00002307782 RIVA-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC RIV CAP 0.3285 00002248082 RIVA-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET ORL SRT RIV TAB 0.5075 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 177 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002278030 RIVA-ZOPICLONE 5 MG TABLET ORL TAB RIV TAB 0.2231 00002278049 RIVA-ZOPICLONE 7.5 MG TABLET ORL TAB RIV TAB 0.4685 00002415801 RIZATRIPTAN ODT 10 MG ORALLY DISINT. TABLET ORL DISNTAB PDL TAB 3.7050 00002415798 RIZATRIPTAN ODT 5 MG ORALLY DISINT. TABLET ORL DISNTAB PDL TAB 3.7050 00002247147 ROBAX PLATINUM TABLET ORL TAB PDH TAB 0.6361 00002026805 ROBAXACET CAPLET ORL TAB PDH TAB 0.4689 00002231176 ROBAXACET EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.5150 00001934767 ROBAXACET-8 TABLET ORL TAB PDH TAB 0.7081 00001930990 ROBAXIN 500 MG TABLET ORL TAB PDH TAB 0.4826 00001932187 ROBAXIN-750 750 MG TABLET ORL TAB PDH TAB 0.7966 00002026783 ROBAXISAL CAPLET ORL TAB WCH TAB 0.4022 00002230949 ROBAXISAL EXTRA STRENGTH CAPLET ORL TAB PDH TAB 0.5150 00001934791 ROBAXISAL-C 1/2 TABLET ORL TAB PDH TAB 1.1788 00001934783 ROBAXISAL-C 1/4 TABLET ORL TAB PDH TAB 0.9867 00001931032 ROBITUSSIN 20 MG ORAL SYRUP ORL SYR PDH ML 0.0508 00002142783 ROBITUSSIN 200 MG/5 ML EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.0508 00001934740 ROBITUSSIN A-C ORAL SYRUP ORL SYR PDH ML 0.1019 00002068419 ROBITUSSIN COUGH AND COLD ORAL SYRUP ORL SYR PDH ML 0.0508 00002142775 ROBITUSSIN DM EXTRA STRENGTH ORAL SYRUP ORL SYR PDH ML 0.0508 00001931024 ROBITUSSIN DM ORAL SYRUP ORL SYR PDH ML 0.0508 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 178 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002318415 ROCURONIUM BROMIDE 10MG/ML INJECTION INJ DEFAUL SDZ ML 1.0260 00000393444 ROFACT 150 MG CAPSULE ORL CAP VCL CAP 0.6633 00000343617 ROFACT 300 MG CAPSULE ORL CAP VCL CAP 1.0441 00000708925 ROGAINE 20 MG/ML TOPICAL SOLUTION TOP SOL JJI ML 0.6102 00002368684 ROGAINE FOAM 50 MG/G AEROSOL FOAM TOP FOA JJI G 0.4926 00002242979 ROGITINE 10 MG/ML INJECTION INJ DEFAUL PAL ML 39.7800 00002353067 ROPINIROLE 2 MG TABLET ORL TAB SNS TAB 0.3122 00002242919 ROSASOL 1% TOPICAL CREAM TOP CRM GSK G 0.5257 00002440342 ROSIVER 1% TOPICAL CREAM TOP CRM GAL G 2.6665 00002389045 ROSUVASTATIN 10 MG TABLET ORL TAB SIV TAB 0.3400 00002381184 ROSUVASTATIN 10 MG TABLET ORL TAB PDL TAB 0.3400 00002389053 ROSUVASTATIN 20 MG TABLET ORL TAB SIV TAB 0.4250 00002381192 ROSUVASTATIN 20 MG TABLET ORL TAB PDL TAB 0.4250 00002381206 ROSUVASTATIN 40 MG TABLET ORL TAB PDL TAB 0.4977 00002389061 ROSUVASTATIN 40 MG TABLET ORL TAB SIV TAB 0.4977 00002381176 ROSUVASTATIN 5 MG TABLET ORL TAB PDL TAB 0.3227 00002389037 ROSUVASTATIN 5 MG TABLET ORL TAB SIV TAB 0.3227 00002300591 ROTARIX 1 000 000 CCID50/DOSE (1.5ML) ORAL SUSP ORL SUS GSK DOSE 79.6700 00002284413 ROTATEQ (2 ML/DOSE) ORAL SOLUTION ORL SOL MFC ML 29.0250 00000466425 ROUGIER CALCIUM ORAL LIQUID ORL LIQ ROG ML 0.0210 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 179 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002248563 RUB A535 DUAL ACTION TOP CRM CHD G 0.0570 00002222116 RUB A-535 EXTRA STRENGTH TOP CRM CHD G 0.0570 00080015240 RUGBY NICOTINE POLACRILEX; NIC-ASSIST 2 MG GUM ORL GUM APH PIECE 0.1650 00002245735 SAB-SODIUM CHLORIDE 5% OPTHALMIC SOLUTION USP OPH SOL SDZ ML 0.5633 00000623571 SALIJECT 570 MG/ML INJECTION INJ DEFAUL OMG ML 1.4300 00080024381 SALINEX 9 MG/ML NASAL SPRAY NAS SPR SDZ ML 0.1307 00000779296 SALINEX NASAL LUBRICANT GEL NAS GEL SDZ G 0.1407 00001910701 SALINEX NASAL LUBRICANT SPRAY NAS SPR SDZ ML 0.1697 00080004542 SALMON & FISH OILS 1000 MG SOFTGEL ORL TAB WNP TAB 0.0568 00080003356 SALMON AND FISH OILS ORAL CAPSULE ORL CAP JAM CAP 0.0923 00002370468 SAMSCA 15 MG TABLET ORL TAB OTS TAB 90.4110 00002370476 SAMSCA 30 MG TABLET ORL TAB OTS TAB 90.4110 00000593257 SANDIMMUNE I.V. 50 MG/ML INJECTION INJ DEFAUL NOV ML 4.4170 00002288079 SANDOZ ALENDRONATE 5 MG TABLET ORL TAB SDZ TAB 1.0370 00002338467 SANDOZ ANASTROZOLE 1 MG TABLET ORL TAB SDZ TAB 2.5460 00002386410 SANDOZ ATOMOXETINE 10 MG CAPSULE ORL CAP SDZ CAP 2.3140 00002386429 SANDOZ ATOMOXETINE 18 MG CAPSULE ORL CAP SDZ CAP 2.6523 00002386437 SANDOZ ATOMOXETINE 25 MG CAPSULE ORL CAP SDZ CAP 2.9280 00002386445 SANDOZ ATOMOXETINE 40 MG CAPSULE ORL CAP SDZ CAP 3.3373 00002386453 SANDOZ ATOMOXETINE 60 MG CAPSULE ORL CAP SDZ CAP 3.7023 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 180 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002386461 SANDOZ ATOMOXETINE 80 MG CAPSULE ORL CAP SDZ CAP 3.9963 00002276089 SANDOZ BICALUTAMIDE 50 MG TABLET ORL TAB SDZ TAB 4.0573 00002386283 SANDOZ BOSENTAN 125 MG TABLET ORL TAB SDZ TAB 48.1340 00002386275 SANDOZ BOSENTAN 62.5 MG TABLET ORL TAB SDZ TAB 48.1340 00002392267 SANDOZ CANDESARTAN 32 MG TABLET ORL TAB SDZ TAB 0.3009 00002326957 SANDOZ CANDESARTAN 4 MG TABLET ORL TAB SDZ TAB 0.3400 00002421917 SANDOZ CAPECITABINE 150 MG TABLET ORL TAB SDZ TAB 1.4640 00002421925 SANDOZ CAPECITABINE 500 MG TABLET ORL TAB SDZ TAB 4.8800 00002261855 SANDOZ CARBAMAZEPINE 100 MG CHEWABLE TABLET ORL CTB SDZ TAB 0.0380 00002261863 SANDOZ CARBAMAZEPINE 200 MG CHEWABLE TABLET ORL CTB SDZ TAB 0.0749 00002303426 SANDOZ CEFPROZIL 25 MG/ML ORAL SUSPENSION ORL SUS SDZ ML 0.0592 00002303434 SANDOZ CEFPROZIL 50 MG/ML ORAL SUSPENSION ORL SUS SDZ ML 0.1185 00002387131 SANDOZ CIPROFLOXACIN 0.3% OPHTHALMIC SOLUTION OPH SOL SDZ ML 1.8600 00002233960 SANDOZ CLONAZEPAM 0.5 MG TABLET ORL TAB SDZ TAB 0.0495 00002233985 SANDOZ CLONAZEPAM 2 MG TABLET ORL TAB SDZ TAB 0.0854 00002242485 SANDOZ CORTIMYXIN OPH OINTMENT OPH ONT SDZ G 3.6143 00002230386 SANDOZ CORTIMYXIN OTIC SOLUTION OT SOL SDZ ML 1.1400 00002400596 SANDOZ DICLOFENAC MISOPROSTOL 50 MG/200 MCG ECT ORL ECT SDZ TAB 0.4541 00002400618 SANDOZ DICLOFENAC MISOPROSTOL 75 MG/200 MCG ECT ORL ECT SDZ TAB 0.6179 00002261774 SANDOZ DICLOFENAC RAPIDE 50 MG TABLET ORL TAB SDZ TAB 0.3937 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 181 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002367696 SANDOZ DONEPEZIL ODT 10 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 3.6177 00002367688 SANDOZ DONEPEZIL ODT 5 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 3.6177 00002278634 SANDOZ FAMCICLOVIR 125 MG TABLET ORL TAB SDZ TAB 2.0240 00002278642 SANDOZ FAMCICLOVIR 250 MG TABLET ORL TAB SDZ TAB 2.7200 00002278650 SANDOZ FAMCICLOVIR 500 MG TABLET ORL TAB SDZ TAB 4.2281 00002390701 SANDOZ FENOFIBRATE E 145 MG TABLET ORL TAB SDZ TAB 0.9113 00002390698 SANDOZ FENOFIBRATE E 48 MG TABLET ORL TAB SDZ TAB 0.3560 00002327139 SANDOZ FENTANYL PATCH 37 MCG/HR TRANSDERMAL PATCH TRD PTH SDZ PTH 8.5000 00002339471 SANDOZ FINASTERIDE A 1 MG TABLET ORL TAB SDZ TAB 1.1455 00002243486 SANDOZ FLUOXETINE 10 MG CAPSULE ORL CAP SDZ CAP 0.4595 00002243487 SANDOZ FLUOXETINE 20 MG CAPSULE ORL CAP SDZ CAP 0.4598 00002247055 SANDOZ FLUVOXAMINE 100 MG TABLET ORL TAB SDZ TAB 0.3783 00002247054 SANDOZ FLUVOXAMINE 50 MG TABLET ORL TAB SDZ TAB 0.2105 00002248009 SANDOZ GLYBURIDE 5 MG TABLET ORL TAB SDZ TAB 0.0573 00002237187 SANDOZ IDOXURIDINE 0.1% TOPICAL SOLUTION TOP SOL SDZ ML 4.9900 00002344815 SANDOZ LETROZOLE 2.5 MG TABLET ORL TAB SDZ TAB 2.7560 00002241716 SANDOZ LEVOBUNOLOL 0.5% OPH SOLUTION OPH SOL SDZ ML 1.1520 00002247056 SANDOZ LOVASTATIN 20 MG TABLET ORL TAB SDZ TAB 0.4919 00002247057 SANDOZ LOVASTATIN 40 MG TABLET ORL TAB SDZ TAB 0.8985 00002344807 SANDOZ MEMANTINE 10 MG TABLET ORL TAB SDZ TAB 1.6357 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 182 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002375532 SANDOZ MEMANTINE FCT 10 MG TABLET ORL TAB SDZ TAB 1.6357 00002250594 SANDOZ MIRTAZAPINE 15 MG TABLET ORL TAB SDZ TAB 0.3750 00002411520 SANDOZ MOXIFLOXACIN 0.5% OPHTHALMIC SOLUTION OPH SOL SDZ ML 3.7567 00002320630 SANDOZ MYCOPHENOLATE MOFETIL 250 MG CAPSULE ORL CAP SDZ CAP 1.0310 00002313855 SANDOZ MYCOPHENOLATE MOFETIL 500 MG TABLET ORL TAB SDZ TAB 2.0620 00002234007 SANDOZ NITRAZEPAM 10 MG TABLET ORL TAB SDZ TAB 0.0534 00002234003 SANDOZ NITRAZEPAM 5 MG TABLET ORL TAB SDZ TAB 0.0357 00002247189 SANDOZ OFLOXACIN 0.3% OPHTHALMIC SOLUTION OPH SOL SDZ ML 1.4680 00002327791 SANDOZ OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 5.3553 00002327805 SANDOZ OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET ORL DISNTAB SDZ TAB 7.5977 00002358913 SANDOZ OLOPATADINE 0.1% OPH SOLUTION OPH SOL SDZ ML 5.2260 00002420171 SANDOZ OLOPATADINE 0.2% OPHTHALMIC SOLUTION OPH SOL SDZ ML 10.4520 00002444674 SANDOZ ONDANSETRON ODT 4 MG ORALLY DISINT. TABLET ORL DSNTB/FM SDZ TAB 3.2720 00002444682 SANDOZ ONDANSETRON ODT 8 MG ORALLY DISINT. TABLET ORL DSNTB/FM SDZ TAB 4.9930 00002301075 SANDOZ PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET ORL ECT SDZ TAB 1.2750 00002269422 SANDOZ PAROXETINE 10 MG TABLET ORL TAB SDZ TAB 1.0430 00002269449 SANDOZ PAROXETINE 30 MG TABLET ORL TAB SDZ TAB 0.4796 00002261790 SANDOZ PINDOLOL 10 MG TABLET ORL TAB SDZ TAB 0.2323 00002261804 SANDOZ PINDOLOL 15 MG TABLET ORL TAB SDZ TAB 0.3370 00002261782 SANDOZ PINDOLOL 5 MG TABLET ORL TAB SDZ TAB 0.1361 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 183 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002297906 SANDOZ PIOGLITAZONE 15 MG TABLET ORL TAB SDZ TAB 0.5809 00002297914 SANDOZ PIOGLITAZONE 30 MG TABLET ORL TAB SDZ TAB 0.8139 00002297922 SANDOZ PIOGLITAZONE 45 MG TABLET ORL TAB SDZ TAB 1.2237 00002239234 SANDOZ POLYTRIMETHOPRIM OPH SOLUTION OPH SOL SDZ ML 2.7970 00002315270 SANDOZ PRAMIPEXOLE 0.5 MG TABLET ORL TAB SDZ TAB 1.3860 00002247856 SANDOZ PRAVASTATIN 10 MG TABLET ORL TAB SDZ TAB 0.4050 00002247857 SANDOZ PRAVASTATIN 20 MG TABLET ORL TAB SDZ TAB 0.4777 00002247858 SANDOZ PRAVASTATIN 40 MG TABLET ORL TAB SDZ TAB 0.5755 00002390841 SANDOZ PREGABALIN 150 MG CAPSULE ORL CAP SDZ CAP 1.7270 00002390817 SANDOZ PREGABALIN 25 MG CAPSULE ORL CAP SDZ CAP 0.6172 00002390868 SANDOZ PREGABALIN 300 MG CAPSULE ORL CAP SDZ CAP 1.7270 00002390825 SANDOZ PREGABALIN 50 MG CAPSULE ORL CAP SDZ CAP 0.9682 00002390833 SANDOZ PREGABALIN 75 MG CAPSULE ORL CAP SDZ CAP 1.2528 00002154412 SANDOZ SALBUTAMOL 5 MG/ML INHALATION SOLUTION INH SOL SDZ ML 0.3510 00002089645 SANDOZ SENNOSIDES 12 MG TABLET ORL TAB SDZ TAB 0.0604 00080024148 SANDOZ SENNOSIDES 8.6 MG TABLET ORL TAB SDZ TAB 0.0505 00002318822 SANDOZ SILDENAFIL 100 MG TABLET ORL TAB SDZ TAB 9.2006 00002318806 SANDOZ SILDENAFIL 25 MG TABLET ORL TAB SDZ TAB 8.2900 00002318814 SANDOZ SILDENAFIL 50 MG TABLET ORL TAB SDZ TAB 8.8481 00002247828 SANDOZ SIMVASTATIN 10 MG TABLET ORL TAB SDZ TAB 0.5057 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 184 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002247830 SANDOZ SIMVASTATIN 20 MG TABLET ORL TAB SDZ TAB 0.6251 00002247831 SANDOZ SIMVASTATIN 40 MG TABLET ORL TAB SDZ TAB 0.4501 00002247833 SANDOZ SIMVASTATIN 80 MG TABLET ORL TAB SDZ TAB 0.6251 00002399040 SANDOZ SOLIFENACIN 10 MG TABLET ORL TAB SDZ TAB 1.2670 00002399032 SANDOZ SOLIFENACIN 5 MG TABLET ORL TAB SDZ TAB 1.2670 00002234013 SANDOZ SOTALOL 160 MG TABLET ORL TAB SDZ TAB 0.1623 00002416816 SANDOZ TACROLIMUS 0.5 MG CAPSULE ORL CAP SDZ CAP 1.4775 00002416824 SANDOZ TACROLIMUS 1 MG CAPSULE ORL CAP SDZ CAP 1.8900 00002416832 SANDOZ TACROLIMUS 5 MG CAPSULE ORL CAP SDZ CAP 9.4650 00002295121 SANDOZ TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE ORL SRC SDZ CAP 0.1500 00002262177 SANDOZ TERBINAFINE 250 MG TABLET ORL TAB SDZ TAB 1.8525 00002260069 SANDOZ TOPIRAMATE 100 MG TABLET ORL TAB SDZ TAB 0.6235 00002267837 SANDOZ TOPIRAMATE 200 MG TABLET ORL TAB SDZ TAB 0.8853 00002260050 SANDOZ TOPIRAMATE 25 MG TABLET ORL TAB SDZ TAB 0.3128 00002239714 SANDOZ VALPROIC 250 MG CAPSULE ORL CAP SDZ CAP 0.1366 00002356740 SANDOZ VALSARTAN 40 MG TABLET ORL TAB SDZ TAB 0.5240 00000578541 SARNA HC 1% TOPICAL LOTION TOP LOT GSK ML 0.0938 00000856711 SARNA HC 2.5% TOPICAL LOTION TOP LOT GSK ML 0.1813 00002266121 SATIVEX BUCCAL SPRAY BUC SPR BHP ML 20.9900 00002437899 SAXENDA 6 MG/ML PEN INJECTION SYRINGE INJ DEFAUL NNA ML 22.8300 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 185 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080041540 SCHINOUSSA PROBIOTIC WHEY ISOLATE ORAL POWDER ORL PWR QUA G 0.0357 00001919245 SCHOLL ATHLETE'S FOOT SPRAY 1% TOPICAL POWDER TOP PWR SCH G 0.0462 00002020939 SCLERODEX INJECTION INJ DEFAUL OMG ML 1.2600 00002020793 SCLERODINE 6 INJECTION INJ DEFAUL OMG ML 2.7100 00000541869 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML INJECTION INJ DEFAUL HSP ML 4.8900 00002242811 SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION INJ DEFAUL OMG ML 5.0000 00000541877 SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION INJ DEFAUL HSP ML 5.3600 00002296659 SEASONALE (91 DAY) TABLET ORL TAB ASC TAB 0.6240 00002346176 SEASONIQUE (91 DAY) TABLET ORL TAB ASC TAB 0.6240 00000666106 SEBCUR 4% TOPICAL SHAMPOO TOP SHP DPT ML 0.0575 00000666114 SEBCUR-T TOPICAL SHAMPOO TOP SHP DPT ML 0.0646 00002288389 SEBIVO 600 MG TABLET ORL TAB NOV TAB 17.7311 00000551805 SECARIS NASAL GEL NAS GEL PMS G 0.3240 00000633380 SELENIUM 100 MCG TABLET ORL TAB JAM TAB 0.0721 00000554987 SELENIUM 50 MCG TABLET ORL TAB JAM TAB 0.0641 00000243000 SELSUN 2.5% TOPICAL SOLUTION TOP SOL ABB ML 0.0448 00000483796 SELSUN BLUE 1% TOPICAL LOTION TOP LOT ABB ML 0.0236 00000709069 SELSUN BLUE EXTRA CONDITIONING 1% TOPICAL SHAMPOO TOP SHP ABB ML 0.0236 00002247134 SENNA LAXATIVE & DOCUSATE SODIUM 8.6MG/50MG TABLET ORL TAB VTH TAB 0.1152 00002237105 SENNA LAXATIVE 8.6 MG TABLET ORL TAB SDR TAB 0.0249 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 186 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002257130 SENSIPAR 30 MG TABLET ORL TAB AMG TAB 11.7563 00002257149 SENSIPAR 60 MG TABLET ORL TAB AMG TAB 21.4370 00002257157 SENSIPAR 90 MG TABLET ORL TAB AMG TAB 31.1947 00002357704 SEPTA-AMLODIPINE 2.5 MG TABLET ORL TAB SEP TAB 0.1380 00002368633 SEPTA-ATENOLOL 25 MG TABLET ORL TAB SEP TAB 0.1730 00002247998 SERC 24 MG TABLET ORL TAB BGP TAB 0.7000 00002239046 SEROSTIM 5 MG/VIAL INJECTION INJ DEFAUL SRO VIAL 1633.0000 00002241304 SERTRALINE 100 MG CAPSULE ORL CAP PDL CAP 0.4200 00002241302 SERTRALINE 25 MG CAPSULE ORL CAP PDL CAP 0.2004 00002241303 SERTRALINE 50 MG CAPSULE ORL CAP PDL CAP 0.4000 00002240344 SIALOR 25 MG TABLET ORL TAB PMS TAB 0.9000 00080039305 SIERRASIL JOINT FORMULA 14 CAPSULE ORL CAP SMM CAP 0.2127 00002413299 SIGNIFOR 0.3 MG/ML INJECTION INJ DEFAUL NOV ML 76.6790 00002413302 SIGNIFOR 0.6 MG /ML INJECTION INJ DEFAUL NOV ML 85.5160 00002413310 SIGNIFOR 0.9 MG /ML INJECTION INJ DEFAUL NOV ML 85.5160 00002437260 SIGNIFOR LAR 40 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 4840.0000 00002437279 SIGNIFOR LAR 60 MG/VIAL INJECTION INJ DEFAUL NOV VIAL 4840.0000 00002406160 SILDENAFIL 100 MG TABLET ORL TAB SNS TAB 9.2000 00002317583 SILDENAFIL 100 MG TABLET ORL TAB PMS TAB 9.2007 00002424320 SILDENAFIL 100 MG TABLET ORL TAB PDL TAB 9.2000 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 187 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002317559 SILDENAFIL 25 MG TABLET ORL TAB PMS TAB 8.2900 00002424312 SILDENAFIL 50 MG TABLET ORL TAB PDL TAB 8.8475 00002406152 SILDENAFIL 50 MG TABLET ORL TAB SNS TAB 8.8475 00002317575 SILDENAFIL 50 MG TABLET ORL TAB PMS TAB 8.8480 00002398257 SILENOR 3 MG TABLET ORL TAB PAL TAB 0.5877 00002398265 SILENOR 6 MG TABLET ORL TAB PAL TAB 1.1757 00080012979 SILICA WITH ZINC CAPLET ORL TAB JAM TAB 0.1937 00002338572 SILKIS 3 MCG/G TOPICAL OINTMENT TOP ONT GAL G 1.2500 00002239548 SIMPLY SLEEP 25 MG CAPLET ORL TAB MCL TAB 0.2015 00002413183 SIMPONI 100 MG/1 ML INJECTION AUTO INJECTOR INJ NDL JAI SYR 1481.9100 00002413175 SIMPONI 100 MG/1 ML INJECTION SYRINGE INJ NDL JAI SYR 1481.9100 00002417472 SIMPONI I.V. 50 MG/4.0 ML VIAL INJECTION INJ DEFAUL JAI ML 206.7150 00002247224 SIMVASTATIN-80 80 MG TABLET ORL TAB PDL TAB 0.6250 00002378892 SIMVASTATIN-ODAN 10 MG TABLET ORL TAB ODN TAB 0.3642 00002378906 SIMVASTATIN-ODAN 20 MG TABLET ORL TAB ODN TAB 0.4501 00002378914 SIMVASTATIN-ODAN 40 MG TABLET ORL TAB ODN TAB 0.4501 00002378884 SIMVASTATIN-ODAN 5 MG TABLET ORL TAB ODN TAB 0.1841 00002378922 SIMVASTATIN-ODAN 80 MG TABLET ORL TAB ODN TAB 0.4501 00001926055 SINUTAB N.D. REGULAR STRENGTH TABLET ORL TAB MCL TAB 0.1808 00001938371 SINUTAB NO DROWSINESS EXTRA STRENGTH TABLET ORL TAB MCL TAB 0.2629 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 188 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001926004 SINUTAB REGULAR STRENGTH TABLET ORL TAB MCL TAB 0.1988 00001938363 SINUTAB WITH CODEINE TABLET ORL TAB MCL TAB 0.4063 00001994247 SLEEP AID (REGULAR STRENGTH) 25 MGTABLET ORL TAB TAN TAB 0.0950 00000074225 SLOW K 8 MEQ SUSTAINED-RELEASE TABLET ORL SRT NOV TAB 0.1475 00000623520 SLOW-FE 160 MG TABLET ORL SRT CGS TAB 0.2677 00000481912 SODIUM BICARBONATE 325 MG TABLET ORL TAB SLW TAB 0.0302 00080022194 SODIUM BICARBONATE 500 MG TABLET ORL TAB SDZ TAB 0.0754 00000261998 SODIUM BICARBONATE 8.4 % INJECTION INJ DEFAUL HSP ML 0.5460 00000037842 SODIUM CHLORIDE 0.9% INJECTION INJ DEFAUL HSP ML 0.0994 00000060208 SODIUM CHLORIDE 0.9% INJECTION USP INJ DEFAUL BAX ML 0.1212 00000851388 SODIUM CHLORIDE 0.9% NASAL SPRAY NAS SPR SFY ML 0.0357 00002139510 SODIUM CHLORIDE 234 MG/ML INJECTION INJ DEFAUL PPC ML 0.3356 00000392499 SODIUM CHLORIDE 234 MG/ML INJECTION INJ DEFAUL SDZ ML 4.2790 00000402230 SODIUM CHLORIDE 234 MG/ML INJECTION USP INJ DEFAUL OMG ML 0.3250 00002150204 SODIUM CHLORIDE 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.3250 00000037834 SODIUM CHLORIDE 9 MG/ML IRRIGATION SOLUTION IR SOL HSP ML 0.0224 00000402249 SODIUM CHLORIDE BACTERIOSTATIC 9 MG/ML INJECTION INJ DEFAUL OMG ML 0.1617 00000268313 SODIUM EDECRIN 50 MG/VIAL INJECTION INJ DEFAUL VCL VIAL 480.2400 00000896187 SODIUM PHOSPHATE INJECTION INJ DEFAUL SDZ ML 1.1259 00000028053 SODIUM SULAMYD 10% OPH SOLUTION OPH SOL SDZ ML 0.4933 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 189 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002006758 SOFLAX 4 MG/ML ORAL SYRUP ORL SYR PMS ML 0.0232 00002224887 SOFRAMYCIN 0.5% OPH SOLUTION OPH SOL ERF ML 1.3663 00002224879 SOFRAMYCIN 15 MG/50 MCG TOPICAL OINTMENT TOP ONT ERF G 1.0893 00002224860 SOFRAMYCIN NASAL SPRAY NAS SPR ERF ML 2.8667 00001988840 SOFRA-TULLE (10 X 10 CM) TOPICAL GAUZE TOP GAU ERF DRE 1.5500 00001987682 SOFRA-TULLE STRIP (10 X 30 CM) TOPICAL GAUZE TOP GAU AVE DRE 3.6000 00002243257 SOLAGE 0.01%/ 2% TOPICAL SOLUTION TOP SOL GAL ML 1.6933 00001923986 SOLARCAINE FIRST AID LIDOCAINE 0.5% TOPICAL AEROSO TOP AER SCH G 0.0385 00001975382 SOLUGEL 4% TOPICAL GEL TOP GEL GSK G 0.2269 00002019825 SOLUGEL 8% TOPICAL GEL TOP GEL GSK G 0.3480 00002230211 SOLU-MEDROL 40 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 5.2672 00000690333 SOLUVER 20% TOPICAL SOLUTION TOP SOL DPT ML 0.7500 00000837733 SOLUVER PLUS LIQ 27% TOP SOL DPT ML 1.2000 00002272199 SOMAVERT 10 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 118.4000 00002272202 SOMAVERT 15 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 177.4200 00002272210 SOMAVERT 20 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 236.4400 00000483818 SOMNOL 30 MG TABLET ORL TAB AXS TAB 0.1145 00002237578 SPASMHALT-8 CAPLET ORL TAB PPH TAB 0.3433 00002237580 SPASMHALT-ASA-8 CAPLET ORL TAB WAM TAB 0.3300 00000999031 SPECIAL ACCESS DRUG - DEFLAZACORT ORL TAB XXX TAB 0.3158 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 190 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000999034 SPECIAL ACCESS DRUG - MVW COMPLETE D3000 CHEW TAB ORL CTB MVW TAB 0.5168 00000999033 SPECIAL ACCESS DRUG - MVW COMPLETE D3000 SOFTGEL ORL CAP MVW CAP 0.4705 00000999035 SPECIAL ACCESS DRUG - MVW COMPLETE FORMULATION DRP ORL DPS MVW ML 0.8757 00002214415 SPECTRO ECZEMACARE MEDICATED CREAM TOP CRM GKC G 0.4400 00002435381 SPIRIVA RESPIMAT 2.5 MCG/ACTUATION INH SOLUTION INH CTG BOE CTG 65.0000 00002320193 SPRYCEL 100 MG TABLET ORL TAB BMS TAB 152.9553 00002293129 SPRYCEL 20 MG TABLET ORL TAB BMS TAB 38.4053 00002293137 SPRYCEL 50 MG TABLET ORL TAB BMS TAB 77.2943 00002293145 SPRYCEL 70 MG TABLET ORL TAB BMS TAB 84.7605 00001938991 STANHEXIDINE 2% SOL WITH 4% ISOPROPYL ALCOHOL TOP SOL OMG ML 0.0094 00001938983 STANHEXIDINE 4% WITH 4% ISOPROPYL ALCOHOL SOLUTION TOP SOL OMG ML 0.0150 00002245439 STARLIX 120 MG TABLET ORL TAB NOV TAB 0.5582 00002245438 STARLIX 60 MG TABLET ORL TAB NOV TAB 0.5582 00002372436 STAXYN 10 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB BAI TAB 6.6325 00002139383 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL PPC VIAL 95.1660 00002230192 STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION INJ DEFAUL HSP VIAL 78.8900 00002139243 STERILE VANCOMYCIN HCL 5 G/VIAL INJECTION INJ DEFAUL PPC VIAL 509.7900 00002139375 STERILE VANCOMYCIN HCL 500 MG/VIAL INJ USP INJ DEFAUL PPC VIAL 47.7040 00002230191 STERILE VANCOMYCIN HCL 500 MG/VIAL INJECTION INJ DEFAUL HSP VIAL 41.5200 00000038245 STERILE WATER FOR INJECTION DEFAUL INJ HSP ML 0.0950 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 191 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002142546 STERILE WATER FOR INJECTION DEFAUL INJ HSP ML 0.1850 00000402257 STERILE WATER FOR INJECTION DEFAUL INJ OMG ML 0.3500 00002247228 STIEPROX 1.5 % TOPICAL SHAMPOO TOP SHP GSK ML 0.1347 00000578568 STIEVA-A 0.025% TOPICAL SOLUTION TOP SOL GSK ML 0.1836 00001945262 STIEVAMYCIN FORTE TOPICAL GEL TOP GEL GSK G 0.8427 00002015994 STIEVAMYCIN MILD TOPICAL GEL TOP GEL GSK G 0.8427 00001905112 STIEVAMYCIN REGULAR TOPICAL GEL TOP GEL GSK G 0.8427 00002125277 STILAMIN 3 MG/AMPOULE INJECTION INJ DEFAUL SRO VIAL 210.0000 00002403390 STIVARGA 40 MG TABLET ORL TAB BAI TAB 72.6200 00002262800 STRATTERA 10 MG CAPSULE ORL CAP LIL CAP 2.8364 00002279355 STRATTERA 100 MG CAPSULE ORL CAP LIL CAP 5.3529 00002262819 STRATTERA 18 MG CAPSULE ORL CAP LIL CAP 3.1936 00002262827 STRATTERA 25 MG CAPSULE ORL CAP LIL CAP 3.5664 00002262835 STRATTERA 40 MG CAPSULE ORL CAP LIL CAP 4.0939 00002262843 STRATTERA 60 MG CAPSULE ORL CAP LIL CAP 4.4954 00002279347 STRATTERA 80 MG CAPSULE ORL CAP LIL CAP 4.8771 00002444615 STRENSIQ 18 MG/VIAL INJECTION INJ DEFAUL APG VIAL 1836.0000 00002444623 STRENSIQ 28 MG/VIAL INJECTION INJ DEFAUL APG VIAL 2856.0000 00002444631 STRENSIQ 40 MG/VIAL INJECTION INJ DEFAUL APG VIAL 4080.0000 00002444658 STRENSIQ 80 MG/VIAL INJECTION INJ DEFAUL APG VIAL 8160.0000 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 192 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002243660 STREPTOMYCIN 1 G/VIAL INJECTION INJ DEFAUL STM VIAL 89.0000 00000613959 STRESS FORMULA VITAMIN WITH ZINC CAPSULE ORL CAP WAM CAP 0.0617 00002174383 STRESSEASE MULTIVITAMIN AND MINERAL CAPLET ORL TAB JAM TAB 0.1080 00002166615 STRESSTABS + ZINC-COPPER TABLET ORL TAB WCH TAB 0.1017 00080009625 STRESSTABS FOR WOMEN TABLET ORL TAB PDH TAB 0.1042 00002167948 STRESSTABS PLUS IRON TABLET ORL TAB WCH TAB 0.1017 00002397137 STRIBILD TABLET ORL TAB GIL TAB 46.3894 00002370433 SUBLINOX 10 MG SUBLINGUAL DISINTEGRATING TABLET SLG DISNTAB MED TAB 1.3353 00002391678 SUBLINOX 5 MG SUBLINGUAL DISINTEGRATING TAB SLG DISNTAB MED TAB 1.3287 00002130939 SUCRALFATE-1 1 G TABLET ORL TAB PDL TAB 0.1309 00002238099 SUDAFED DECONGESTANT 12-HOUR 120 MG CAPLET ORL TAB MCL TAB 0.4850 00002237793 SUDAFED DECONGESTANT EXTRA STRENGTH 60 MG TABLET ORL TAB MCL TAB 0.2908 00002250217 SUDAFED PE DECONGESTANT 10 MG TABLET ORL TAB MCL TAB 0.3000 00001951319 SUFENTA 50 MCG/ML INJECTION INJ DEFAUL JAI ML 6.4480 00002244147 SUFENTANIL CITRATE USP 50 MCG/ML INJECTION INJ DEFAUL SDZ ML 11.7830 00002220407 SULFACET-R TOPICAL LOTION TOP LOT VCL G 1.0300 00000187534 SULFUR TOPICAL SOAP TOP SOP VCL G 0.0733 00002324660 SUMATRIPTAN 100 MG TABLET ORL TAB PDL TAB 7.8600 00002324652 SUMATRIPTAN 50 MG TABLET ORL TAB PDL TAB 7.1350 00000678996 SUPER B COMPLEX CAPSULE ORL CAP SIS CAP 0.2581 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 193 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080002944 SUPER CALCIUM 600 MG WITH VITAMIN D 400 IU ORL TAB JAM TAB 0.1251 00080011269 SUPER MULTI IRON FREE TABLET ORL TAB NFN TAB 0.2143 00080023127 SUPER STRAIN ACIDOPHILUS PROBIOTIC 2 BILLION ORL CAP JAM CAP 0.1258 00002242658 SUPER STRENGTH MOTRIN IB 400 MG TABLET ORL TAB MCL TAB 0.1844 00080017929 SUPER VITA VIM CAPLET ORL TAB JMS TAB 0.1283 00002242595 SUPER VITA-VIM CAPLET ORL TAB JAM TAB 0.1334 00002240749 SUPREFACT DEPOT 9.45 MG IMPLANT INJECTION INJ IMP SAV SYS 1154.3100 00002239888 SUSTIVA 200 MG CAPSULE ORL CAP BMS CAP 4.9823 00002239886 SUSTIVA 50 MG CAPSULE ORL CAP BMS CAP 1.2457 00002246045 SUSTIVA 600 MG TABLET ORL TAB BMS TAB 14.9470 00002280795 SUTENT 12.5 MG CAPSULE ORL CAP PFI CAP 63.7207 00002280809 SUTENT 25 MG CAPSULE ORL CAP PFI CAP 127.4411 00002280817 SUTENT 50 MG CAPSULE ORL CAP PFI CAP 254.8825 00000253952 SYNACTHEN DEPOT 1 MG/ML INJECTION INJ DEFAUL QST VIAL 680.0000 00002245890 SYNAGIS 100 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 1504.5100 00002245889 SYNAGIS 50 MG/VIAL INJECTION INJ DEFAUL ABV VIAL 752.2600 00002162504 SYNALAR 0.01% TOPICAL SOLUTION TOP SOL VCL ML 0.4128 00002162512 SYNALAR 0.025% TOPICAL OINTMENT TOP ONT VCL G 0.4347 00000990010 SYNVISC DEFAUL DEV GZB ML 67.9100 00000999331 SYNVISC ONE DEFAUL DEV GZB ML 69.0117 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 194 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002248967 SYSTANE OPHTHALMIC SOLUTION OPH SOL ALC ML 0.5267 00080032792 SYSTANE VITAMIN- OMEGA 3 CAPSULE ORL CAP ALC CAP 0.2197 00002239122 T.R. SWISS ONE 50 MULTIVITAMIN & MINERAL TABLET ORL TAB SWS TAB 0.2048 00002365871 TACTUPUMP 0.1%/2.5% TOPICAL GEL TOP GEL GAL G 1.4129 00002409607 TAFINLAR 50 MG CAPSULE ORL CAP NOV CAP 42.2223 00002409615 TAFINLAR 75 MG CAPSULE ORL CAP NOV CAP 63.3333 00002304848 TAMIFLU 30 MG CAPSULE ORL CAP HLR CAP 2.0370 00002304856 TAMIFLU 45 MG CAPSULE ORL CAP HLR CAP 3.1350 00002381842 TAMIFLU 6 MG/ML ORAL SUSPENSION ORL SUS HLR ML 0.3134 00002241472 TAMIFLU 75 MG CAPSULE ORL CAP HLR CAP 4.0750 00001926624 TAMOFEN 10 MG TABLET ORL TAB SAV TAB 0.1750 00002413612 TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET ORL ERT PDL TAB 0.1500 00001962353 TANTAPHEN EXTRA STRENGTH 500 MG CAPLET ORL TAB TAN TAB 0.0214 00002296039 TAPAZOLE 10 MG TABLET ORL TAB PAL TAB 0.5446 00002269015 TARCEVA 100 MG TABLET ORL TAB HLR TAB 53.8133 00002269023 TARCEVA 150 MG TABLET ORL TAB HLR TAB 80.7200 00002269007 TARCEVA 25 MG TABLET ORL TAB HLR TAB 13.3333 00000510335 TARGEL SA TOPICAL LIQUID TOP LIQ ODN G 0.1740 00000344508 TARGEL TOPICAL GEL TOP GEL ODN G 0.1600 00002339609 TARGIN 10 MG/ 5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.9660 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 195 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002339617 TARGIN 20 MG/ 10 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.4490 00002339625 TARGIN 40 MG/ 20 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 2.5100 00002387425 TARGIN 5 MG/ 2.5 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.6930 00002240945 TARKA 1 MG/ 240 MG TABLET ORL TAB ABB TAB 1.5400 00002238096 TARKA 2 MG/ 180 MG TABLET ORL TAB ABB TAB 1.5500 00002240946 TARKA 2 MG/ 240 MG TABLET ORL TAB BGP TAB 1.7698 00002238097 TARKA 4 MG/ 240 MG TABLET ORL TAB BGP TAB 1.9640 00002365650 TARO-ANASTROZOLE 1 MG TABLET ORL TAB TAR TAB 1.2730 00002244403 TARO-CARBAMAZEPINE 100 MG CHEWABLE TABLET ORL CTB TAR TAB 0.1188 00002244404 TARO-CARBAMAZEPINE 200 MG CHEWABLE TABLET ORL CTB TAR TAB 0.2354 00002353288 TARO-CICLOPIROX 8% TOPICAL SOLUTION TOP SOL TAR G 7.7433 00002266938 TARO-CLINDAMYCIN 1% (BASE) TOPICAL SOLUTION TOP SOL TAR ML 0.2613 00002440180 TARO-CLINDAMYCIN/BENZOYL PEROXIDE 1%/5% TOP GEL TOP GEL TAR G 0.7771 00002420988 TARO-DICLOFENAC 1.5% TOPICAL SOLUTION TOP SOL TAR ML 0.6227 00002264749 TARO-MOMETASONE 0.1% OINTMENT TOP ONT TAR G 0.2720 00001925350 TARO-SONE 0.05% TOPICAL CREAM TOP CRM TAR G 0.2048 00002443511 TARO-TEMOZOLOMIDE 100 MG CAPSULE ORL CAP TAR CAP 113.5965 00002443538 TARO-TEMOZOLOMIDE 140 MG CAPSULE ORL CAP TAR CAP 159.0360 00002443481 TARO-TEMOZOLOMIDE 20 MG CAPSULE ORL CAP TAR CAP 22.7200 00002443554 TARO-TEMOZOLOMIDE 250 MG CAPSULE ORL CAP TAR CAP 283.9840 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 196 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002443473 TARO-TEMOZOLOMIDE 5 MG CAPSULE ORL CAP TAR CAP 6.6300 00002247651 TARO-TERCONAZOLE 0.4% VAGINAL CREAM VAG CRM TAR G 0.5296 00002368250 TASIGNA 150 MG CAPSULE ORL CAP NOV CAP 27.9324 00002315874 TASIGNA 200 MG CAPSULE ORL CAP NOV CAP 39.2954 00002177099 TAXOTERE 40 MG/ML (20 MG/0.5 ML) INJECTION INJ DEFAUL SAV ML 456.9400 00002177080 TAXOTERE 40 MG/ML (80 MG/2 ML) INJECTION INJ DEFAUL SAV ML 456.9400 00002170817 TAZOCIN 2 G/250 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 11.9220 00002170795 TAZOCIN 3 G/375 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 17.8830 00002170809 TAZOCIN 4 G/500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 23.8450 00002243894 TAZORAC 0.05% TOPICAL CREAM TOP CRM ALL G 1.3600 00002243895 TAZORAC 0.1% TOPICAL CREAM TOP CRM ALL G 1.3600 00000615358 TD POLIO ADSORBED FOR ADULT INJECTION INJ DEFAUL SFP VIAL 60.2240 00001950010 TEARS ENCORE 1.4% OPH SOLUTION OPH SOL AKN ML 0.9710 00002246397 TEARS NATURAL FORTE OPH SOLUTION OPH SOL ALC ML 0.4087 00001943308 TEARS NATURALE FREE OPH SOLUTION OPH SOL ALC ML 0.4944 00000743445 TEARS NATURALE II OPH SOLUTION OPH SOL ALC ML 0.4220 00000390291 TEARS NATURALE OPH DROPS OPH DPS ALC ML 0.4220 00002082519 TEARS NATURALE P.M. OPH OINTMENT OPH ONT ALC G 1.5457 00000579408 TEARS PLUS 1.4% OPH SOLUTION OPH SOL ALL ML 0.4800 00000283991 TEBRAZID 500 MG TABLET ORL TAB VCL TAB 0.4980 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 197 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002420201 TECFIDERA 240 MG DELAYED-RELEASE CAPSULE ORL DRC BIO CAP 33.0329 00002395223 TELMISARTAN 40 MG TABLET ORL TAB PDL TAB 0.2824 00002395231 TELMISARTAN 80 MG TABLET ORL TAB PDL TAB 0.2824 00002395525 TELMISARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.2824 00002395533 TELMISARTAN-HCTZ 80 MG/25 MG TABLET ORL TAB PDL TAB 0.2824 00002261553 TELZIR 50 MG/ML ORAL SUSPENSION ORL SUS GSK ML 0.5912 00002261545 TELZIR 700 MG TABLET ORL TAB GSK TAB 8.0863 00002241095 TEMODAL 100 MG CAPSULE ORL CAP MFC CAP 153.4045 00002321262 TEMODAL 100 MG/VIAL INJECTION INJ DEFAUL MFC VIAL 411.2600 00002312794 TEMODAL 140 MG CAPSULE ORL CAP MFC CAP 214.7680 00002312816 TEMODAL 180 MG CAPSULE ORL CAP MFC CAP 264.3805 00002241094 TEMODAL 20 MG CAPSULE ORL CAP MFC CAP 30.6820 00002241096 TEMODAL 250 MG CAPSULE ORL CAP MFC CAP 383.5000 00002241093 TEMODAL 5 MG CAPSULE ORL CAP MFC CAP 7.6705 00000875988 TEMPRA INFANT 80 MG/ML ORAL DROPS ORL DPS PAL ML 0.2500 00000894710 TERAZOL 3 80 MG VAGINAL OVULE VAG OVL JAI OVL 6.3767 00002130874 TERAZOL 3 DUAL PAK KIT VAG/TOP OVL/CRM JAI KIT 30.4000 00000894729 TERAZOL 7 0.4% VAGINAL CREAM VAG CRM JAI G 0.7060 00002242735 TERBINAFINE-250 MG TABLET ORL TAB PDL TAB 1.8527 00000632317 TERSASEPTIC 0.5% TOPICAL SHAMPOO TOP SHP GSK ML 0.0273 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 198 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000632295 TERSA-TAR MILD 1% TOPICAL SHAMPOO TOP SHP GSK ML 0.0367 00002280248 TESTIM 1% TOPICAL GEL TOP GEL PAL G 0.7307 00002246063 TESTOSTERONE CYPIONATE 100 MG/ML INJECTION USP INJ DEFAUL SDZ ML 2.3580 00000514462 TETANUS & DIPHTHERIA TOXOIDS ADULT INJECTION INJ LIQ CNG ML 42.4480 00002148528 TETRACAINE 0.5% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00002248251 TEVA-ALENDRONATE 5 MG TABLET ORL TAB TEV TAB 1.0370 00002403633 TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG/2800 U TAB ORL TAB TEV TAB 3.7300 00002326043 TEVA-AMITRIPTYLINE 10 MG TABLET ORL TAB TEV TAB 0.0664 00002326051 TEVA-AMITRIPTYLINE 25 MG TABLET ORL TAB TEV TAB 0.1211 00002326078 TEVA-AMITRIPTYLINE 50 MG TABLET ORL TAB TEV TAB 0.2347 00002313049 TEVA-ANASTROZOLE 1 MG TABLET ORL TAB TEV TAB 2.5460 00001912054 TEVA-ATENOLOL 100 MG TABLET ORL TAB TEV TAB 0.2363 00001912062 TEVA-ATENOLOL 50 MG TABLET ORL TAB TEV TAB 0.1437 00002314541 TEVA-ATOMOXETINE 10 MG CAPSULE ORL CAP TEV CAP 2.3140 00002362538 TEVA-ATOMOXETINE 100 MG CAPSULE ORL CAP TEV CAP 4.3520 00002314568 TEVA-ATOMOXETINE 18 MG CAPSULE ORL CAP TEV CAP 2.6523 00002314576 TEVA-ATOMOXETINE 25 MG CAPSULE ORL CAP TEV CAP 2.9280 00002314584 TEVA-ATOMOXETINE 40 MG CAPSULE ORL CAP TEV CAP 3.3377 00002314592 TEVA-ATOMOXETINE 60 MG CAPSULE ORL CAP TEV CAP 3.7023 00002362511 TEVA-ATOMOXETINE 80 MG CAPSULE ORL CAP TEV CAP 3.9960 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 199 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002380927 TEVA-ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ORL TAB TEV TAB 4.1310 00002280205 TEVA-BETAHISTINE 24 MG TABLET ORL TAB TEV TAB 0.4983 00002280183 TEVA-BETAHISTINE 8 MG TABLET ORL TAB TEV TAB 0.2111 00002398419 TEVA-BOSENTAN 125 MG TABLET ORL TAB TEV TAB 48.1340 00002398400 TEVA-BOSENTAN 62.5 MG TABLET ORL TAB TEV TAB 48.1340 00002395576 TEVA-CANDESARTAN/HCTZ 32 MG/25 MG TABLET ORL TAB TEV TAB 0.8985 00002400022 TEVA-CAPECITABINE 150 MG TABLET ORL TAB TEV TAB 1.4640 00002400030 TEVA-CAPECITABINE 500 MG TABLET ORL TAB TEV TAB 4.8800 00002239355 TEVA-DIFENAC-K 50 MG TABLET ORL TAB TEV TAB 0.3937 00002389762 TEVA-EFAVIRENZ 600 MG TABLET ORL TAB TEV TAB 11.2103 00002382091 TEVA-ELETRIPTAN 20 MG TABLET ORL TAB TEV TAB 10.0850 00002382105 TEVA-ELETRIPTAN 40 MG TABLET ORL TAB TEV TAB 10.0850 00002300680 TEVA-ENALAPRIL 2.5 MG TABLET ORL TAB TEV TAB 0.1863 00002330601 TEVA-ENALAPRIL 40 MG TABLET ORL TAB TEV TAB 1.2560 00002377705 TEVA-ERLOTINIB 100 MG TABLET ORL TAB TEV TAB 47.4667 00002377713 TEVA-ERLOTINIB 150 MG TABLET ORL TAB TEV TAB 71.2000 00002377691 TEVA-ERLOTINIB 25 MG TABLET ORL TAB TEV TAB 11.8667 00002408473 TEVA-EXEMESTANE 25 MG TABLET ORL TAB TEV TAB 3.9007 00002230089 TEVA-FLUTAMIDE 250 MG TABLET ORL TAB TEV TAB 1.3530 00002415844 TEVA-FROVATRIPTAN 2.5 MG TABLET ORL TAB TEV TAB 12.5029 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 200 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002248457 TEVA-GABAPENTIN 600 MG TABLET ORL TAB TEV TAB 1.3045 00002247346 TEVA-GABAPENTIN 800 MG TABLET ORL TAB TEV TAB 1.7393 00002377969 TEVA-GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE ORL ERC TEV CAP 1.2467 00002377977 TEVA-GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE ORL ERC TEV CAP 1.2467 00002377950 TEVA-GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE ORL ERC TEV CAP 1.2467 00002399806 TEVA-IMATINIB 100 MG TABLET ORL TAB TEV TAB 20.4557 00002399814 TEVA-IMATINIB 400 MG TABLET ORL TAB TEV TAB 81.8228 00002316005 TEVA-IRBESARTAN 300 MG TABLET ORL TAB TEV TAB 0.3025 00002316013 TEVA-IRBESARTAN/HCTZ 150/12.5 MG TABLET ORL TAB TEV TAB 0.3024 00002316021 TEVA-IRBESARTAN/HCTZ 300/12.5 MG TABLET ORL TAB TEV TAB 0.3024 00002316048 TEVA-IRBESARTAN/HCTZ 300/25 MG TABLET ORL TAB TEV TAB 0.3004 00002387247 TEVA-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET ORL TAB TEV TAB 7.8309 00002343657 TEVA-LETROZOLE 2.5 MG TABLET ORL TAB TEV TAB 2.7560 00002258323 TEVA-MELOXICAM 15 MG TABLET ORL TAB TEV TAB 0.5670 00002258315 TEVA-MELOXICAM 7.5 MG TABLET ORL TAB TEV TAB 0.4914 00002315068 TEVA-METHYLPHENIDATE ER-C 18 MG EXTEND RELEASE TAB ORL ERT TEV TAB 1.4276 00002315076 TEVA-METHYLPHENIDATE ER-C 27 MG EXTEND RELEASE TAB ORL ERT TEV TAB 1.6475 00002315084 TEVA-METHYLPHENIDATE ER-C 36 MG EXTEND RELEASE TAB ORL ERT TEV TAB 1.8674 00002315092 TEVA-METHYLPHENIDATE ER-C 54 MG EXTEND RELEASE TAB ORL ERT TEV TAB 2.3072 00002261898 TEVA-METOPROL 25 MG TABLET ORL TAB TEV TAB 0.0643 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 201 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002279894 TEVA-MIRTAZAPINE OD 15 MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 0.2730 00002279908 TEVA-MIRTAZAPINE OD 30MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 0.5460 00002279916 TEVA-MIRTAZAPINE OD 45MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 0.8190 00002420260 TEVA-MODAFINIL 100 MG TABLET ORL TAB TEV TAB 0.9293 00002375702 TEVA-MOXIFLOXACIN 400 MG TABLET ORL TAB TEV TAB 1.5230 00002392925 TEVA-NABILONE 0.25 MG CAPSULE ORL CAP TEV CAP 1.3962 00002352893 TEVA-NEVIRAPINE 200 MG TABLET ORL TAB TEV TAB 2.4692 00002359707 TEVA-OLANZAPINE 20 MG TABLET ORL TAB TEV TAB 10.3093 00002321378 TEVA-OLANZAPINE OD 15 MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 5.3553 00002321386 TEVA-OLANZAPINE OD 20 MG ORALLY DISINT. TABLET ORL DISNTAB TEV TAB 7.5977 00002285479 TEVA-PANTOPRAZOLE 20MG ENTERIC-COATED ORAL TAB ORL ECT TEV TAB 1.2750 00002440628 TEVA-PANTOPRAZOLE MAGNESIUM 40 MG EC TABLET ORL ET TEV TAB 0.6375 00002248556 TEVA-PAROXETINE 10 MG TABLET ORL TAB TEV TAB 1.0430 00000869015 TEVA-PINDOLOL 10 MG TABLET ORL TAB TEV TAB 0.2323 00000869023 TEVA-PINDOLOL 15 MG TABLET ORL TAB TEV TAB 0.3370 00000869007 TEVA-PINDOLOL 5 MG TABLET ORL TAB TEV TAB 0.1361 00002274914 TEVA-PIOGLITAZONE 15 MG TABLET ORL TAB TEV TAB 0.5809 00002274922 TEVA-PIOGLITAZONE 30 MG TABLET ORL TAB TEV TAB 0.8139 00002274930 TEVA-PIOGLITAZONE 45 MG TABLET ORL TAB TEV TAB 1.2237 00002269317 TEVA-PRAMIPEXOLE 0.5 MG TABLET ORL TAB TEV TAB 1.3860 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 202 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002361205 TEVA-PREGABALIN 150 MG CAPSULE ORL CAP TEV CAP 1.7270 00002361221 TEVA-PREGABALIN 225 MG CAPSULE ORL CAP TEV CAP 1.7270 00002361159 TEVA-PREGABALIN 25 MG CAPSULE ORL CAP TEV CAP 0.6173 00002361248 TEVA-PREGABALIN 300 MG CAPSULE ORL CAP TEV CAP 1.7270 00002361175 TEVA-PREGABALIN 50 MG CAPSULE ORL CAP TEV CAP 0.9683 00002361183 TEVA-PREGABALIN 75 MG CAPSULE ORL CAP TEV CAP 1.2529 00002388359 TEVA-RAMIPRIL/HCTZ 10 MG/12.5 MG TABLET ORL TAB TEV TAB 0.2633 00002388375 TEVA-RAMIPRIL/HCTZ 10 MG/25 MG TABLET ORL TAB TEV TAB 0.2633 00002388332 TEVA-RAMIPRIL/HCTZ 2.5 MG/12.5 MG TABLET ORL TAB TEV TAB 0.1694 00002388340 TEVA-RAMIPRIL/HCTZ 5 MG/12.5 MG TABLET ORL TAB TEV TAB 0.2070 00002388367 TEVA-RAMIPRIL/HCTZ 5 MG/25 MG TABLET ORL TAB TEV TAB 0.2070 00002413809 TEVA-RISEDRONATE 150 MG TABLET ORL TAB TEV TAB 40.9500 00002308754 TEVA-SILDENAFIL 100 MG TABLET ORL TAB TEV TAB 9.2006 00002308738 TEVA-SILDENAFIL 25 MG TABLET ORL TAB TEV TAB 8.2900 00002308746 TEVA-SILDENAFIL 50 MG TABLET ORL TAB TEV TAB 8.8475 00002286815 TEVA-SUMATRIPTAN DF 25 MG TABLET ORL TAB TEV TAB 8.9900 00000851965 TEVA-TAMOXIFEN 10 MG TABLET ORL TAB TEV TAB 0.1750 00000851973 TEVA-TAMOXIFEN 20 MG TABLET ORL TAB TEV TAB 0.3500 00002230085 TEVA-THEOPHYLLINE SR 100 MG EXTENDED RELEASE TAB ORL SRT TEV TAB 0.1300 00002230086 TEVA-THEOPHYLLINE SR 200 MG EXTENDED RELEASE TAB ORL SRT TEV TAB 0.1350 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 203 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002230087 TEVA-THEOPHYLLINE SR 300 MG EXTENDED RELEASE TAB ORL SRT TEV TAB 0.1400 00002236848 TEVA-TICLOPIDINE 250 MG TABLET ORL TAB TEV TAB 0.3139 00001947818 TEVA-TIMOLOL 10 MG TABLET ORL TAB TEV TAB 0.2572 00001947826 TEVA-TIMOLOL 20 MG TABLET ORL TAB TEV TAB 0.5005 00001947796 TEVA-TIMOLOL 5 MG TABLET ORL TAB TEV TAB 0.1649 00002347180 TEVA-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB TEV TAB 0.6264 00002357542 TEVA-VALACYCLOVIR 1000 MG TABLET (CAPLET) ORL TAB TEV TAB 3.0531 00002356643 TEVA-VALSARTAN 40 MG TABLET ORL TAB TEV TAB 0.5240 00002355205 THALOMID 100 MG CAPSULE ORL CAP CLG CAP 58.9400 00002355221 THALOMID 200 MG CAPSULE ORL CAP CLG CAP 117.8800 00002355191 THALOMID 50 MG CAPSULE ORL CAP CLG CAP 29.4700 00002360101 THEO ER 400 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.3362 00002360128 THEO ER 600 MG SUSTAINED-RELEASE TABLET ORL SRT AAP TAB 0.4072 00080015438 THERA TEARS NUTRITION CAPSULE ORL CAP AVR CAP 0.1056 00002242082 THERATEARS (PRESERVATIVE-FREE) 0.25% OPH SOLUTION OPH SOL AVR ML 0.6111 00002248854 THERATEARS 0.25% OPH SOLUTION OPH SOL AVR ML 0.4667 00002343045 TICLOPIDINE 250 MG TABLET ORL TAB SNS TAB 0.3139 00002409356 TIGECYCLINE 50 MG/VIAL INJECTION INJ DEFAUL APX VIAL 71.4230 00001916939 TIMENTIN 3.1G INJECTION INJ DEFAUL GSK VIAL 10.7520 00002242275 TIMOLOL MALEATE-EX 0.25% OPHTHALMIC SOLUTION OPH LAS ALC ML 3.2160 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 204 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002242276 TIMOLOL MALEATE-EX 0.5% OPHTHALMIC SOLUTION OPH LAS ALC ML 3.8480 00000576050 TINACTIN 1% TOPICAL AEROSOL TOP AER SCH G 0.0523 00000576034 TINACTIN 1% TOPICAL CREAM TOP CRM SCH G 0.3487 00000576042 TINACTIN 1% TOPICAL POWDER TOP PWR SCH G 0.0649 00002414945 TIVICAY 50 MG TABLET ORL TAB VIV TAB 18.6667 00002244826 TNKASE 50 MG/VIAL INJECTION INJ DEFAUL HLR VIAL 2724.3000 00000533688 TOBRAMYCIN 1.2 G/VIAL INJECTION INJ DEFAUL PPC VIAL 199.0000 00002241209 TOBRAMYCIN 10 MG/ML INJECTION INJ DEFAUL SDZ ML 5.1585 00002230640 TOBRAMYCIN 40 MG/ML INJECTION INJ DEFAUL PPC ML 3.5310 00002337630 TOCTINO 10 MG CAPSULE ORL CAP GST CAP 21.9900 00002337649 TOCTINO 30 MG CAPSULE ORL CAP GST CAP 21.9907 00000312762 TOLBUTAMIDE 500 MG TABLET ORL TAB AAP TAB 0.1111 00002229566 TOMUDEX 2 MG/VIAL INJECTION INJ DEFAUL AZC VIAL 324.6200 00002221926 TOPICORT 0.05% TOPICAL GEL TOP GEL VCL G 0.4938 00002221934 TOPICORT 0.25% TOPICAL OINTMENT TOP ONT VCL G 0.6367 00000749834 TOPIDERM HC 2% TOPICAL CREAM TOP CRM PAL G 0.3317 00002390981 TOPOTECAN 4 MG / VIAL INJECTION INJ DEFAUL SDZ VIAL 567.0000 00002304104 TORISEL 25 MG/ML INJECTION INJ DEFAUL PFI VIAL 1278.9100 00002441829 TOUJEO SOLOSTAR 300 UNIT/ML INJECTION INJ DEFAUL SAV ML 17.6227 00002244982 TRACLEER 125 MG TABLET ORL TAB ACT TAB 64.1786 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 205 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002244981 TRACLEER 62.5 MG TABLET ORL TAB ACT TAB 64.1786 00002264846 TRAMACET 37.5 MG/325 MG TABLET ORL TAB JAI TAB 0.7640 00002426803 TRAMADOL/ACET 37.5 MG/325 MG TABLET ORL TAB SNS TAB 0.6264 00002429969 TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET ORL TAB SIV TAB 0.6264 00002417502 TRAMADOL-ACET 37.5 MG/325 MG TABLET ORL TAB PDL TAB 0.6264 00002388294 TRAMAPHEN-ODAN 37.5 MG/325 MG TABLET ORL TAB ODN TAB 0.6264 00002246365 TRANEXAMIC ACID 100 MG/ML INJECTION INJ DEFAUL SDZ ML 3.8860 00080044392 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 14 MG TRD PTH APH PTH 2.1500 00080044389 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 21 MG TRD PTH APH PTH 2.1500 00080044393 TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 7 MG TRD PTH APH PTH 2.1500 00080024336 TRANSDERM-V 1.5 MG TOPICAL PATCH TOP PTH NOV PTH 3.9250 00000605786 TRAVEL AID 50 MG TABLET ORL TAB WTR TAB 0.0488 00002164361 TRAZODONE-100 100 MG TABLET ORL TAB PDL TAB 0.0989 00002164388 TRAZODONE-150 D 150 MG TABLET ORL TAB PDL TAB 0.1453 00002164353 TRAZODONE-50 50 MG TABLET ORL TAB PDL TAB 0.0554 00002230285 TRAZOREL 100 MG TABLET ORL TAB ICN TAB 0.3956 00002230284 TRAZOREL 50 MG TABLET ORL TAB ICN TAB 0.2214 00002392569 TREANDA 100 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL LUI VIAL 1250.0000 00002392550 TREANDA 25 MG/VIAL INJECTION POWDER FOR SOLUTION INJ DEFAUL LUI VIAL 312.5000 00002240000 TRELSTAR 3.75 MG/VIAL INJECTION INJ DEFAUL ASC VIAL 347.3300 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 206 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002243856 TRELSTAR LA 11.25 MG/VIAL INJECTION INJ DEFAUL ASC VIAL 1042.0300 00002229540 TRIAMCINOLONE ACETONIDE 10 MG/ML INJ. INJ DEFAUL SDZ ML 2.8600 00002229550 TRIAMCINOLONE ACETONIDE 40MG/ML INJ. INJ DEFAUL SDZ ML 5.5000 00000896179 TRIAMINIC DM NIGHTIME ORAL SYRUP ORL SYR NVC ML 0.0474 00000789828 TRIATEC-30 TABLET ORL TAB TLI TAB 0.1300 00000852163 TRIATEC-8 TABLET ORL TAB TLI TAB 0.0473 00000808563 TRIAZO 0.125 MG TABLET ORL TAB AAP TAB 0.1496 00002296381 TRIDURAL 100 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 1.2205 00002296403 TRIDURAL 200 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 2.2253 00002296411 TRIDURAL 300 MG EXTENDED-RELEASE TABLET ORL ERT PAL TAB 3.2335 00002242067 TRILEPTAL 150 MG TABLET ORL TAB NOV TAB 0.8278 00002242068 TRILEPTAL 300 MG TABLET ORL TAB NOV TAB 0.9102 00002244673 TRILEPTAL 60 MG/ML ORAL SUSPENSION ORL SUS NOV ML 0.3310 00002242069 TRILEPTAL 600 MG TABLET ORL TAB NOV TAB 1.8204 00000517895 TRINALIN REPETABS SUSTAINED-RELEASE TABLET ORL SRT SCH TAB 0.6535 00002432927 TRINTELLIX 10 MG TABLET ORL TAB LBC TAB 2.7540 00002432943 TRINTELLIX 20 MG TABLET ORL TAB LBC TAB 2.9900 00002432919 TRINTELLIX 5 MG TABLET ORL TAB LBC TAB 2.6290 00080002067 TRIPLE STRENGTH ODOURLESS GARLIC SOFTGEL CAPSULE ORL CAP VCL CAP 0.0460 00002407833 TRISENOX 1 MG/ML AMPOULE INJECTION INJ DEFAUL LBC ML 53.0000 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 207 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002430932 TRIUMEQ TABLET ORL TAB VIV TAB 41.3833 00002244757 TRIZIVIR TABLET ORL TAB GSK TAB 17.9212 00000511226 TROMBOJECT 30 MG/ML INJECTION INJ DEFAUL OMG ML 4.8000 00080015078 TROPHIC KRILL OIL CAPSULE ORL CAP MTA CAP 0.4237 00002148536 TROPICAMIDE 1% OPH SOLUTION (MINIMS) OPH SOL BSH ML 6.6667 00080000383 TRUEHOPE EMP CAPSULE ORL CAP TRU CAP 0.2087 00002274906 TRUVADA 200 MG/300 MG TABLET ORL TAB GIL TAB 27.3870 00000317268 TUBERSOL TUBERCULIN PPD 5 TUB INJECTION INJ DEFAUL AVE ML 154.5300 00001967932 TUMS EXTRA STRENGTH 750 MG CHEWABLE TABLET ORL CTB SKB TAB 0.0442 00001970240 TUMS REGULAR 500 MG CHEWABLE TABLET ORL CTB SKB TAB 0.0311 00002151138 TUMS ULTRA STRENGTH 1G CHEWABLE TABLET ORL CTB SKB TAB 0.0496 00001916971 TUSSIONEX ORAL SUSTAINED-RELEASE SUSPENSION ORL SRSUS SAV ML 0.3303 00001916963 TUSSIONEX TABLET ORL SRT SAV TAB 1.6513 00080019103 TUZEN CAPSULE ORL CAP FEI CAP 0.7600 00002230578 TWINRIX INJECTION SYRINGE INJ NDL GSK SYR 47.4600 00002237548 TWINRIX JUNIOR 0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 23.7300 00002285401 TYGACIL 50 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 81.3740 00002326442 TYKERB 250 MG TABLET ORL TAB NOV TAB 23.5000 00002246060 TYLENOL 8 HOUR 650 MG EXTENDED-RELIEF CAPLET ORL ERT MCL TAB 0.1663 00001933728 TYLENOL ALLERGY SINUS EXTRA STRENGTH CAPLET ORL TAB MCL TAB 0.2850 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 208 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002238885 TYLENOL ARTHRITIS PAIN 650 MG EXT-RELIEF CAPLET ORL ERT MCL TAB 0.1567 00000743224 TYLENOL CHILDRENS COLD CHEWABLE TABLET ORL CTB MCL TAB 0.1763 00000890677 TYLENOL COLD DM JUNIOR STRENGTH CHEWABLE TABLET ORL CTB MCL TAB 0.2590 00000743275 TYLENOL COLD EXTRA STRENGTH CAPLET ORL TAB MCL TAB 0.2850 00000743267 TYLENOL COLD EXTRA STRENGTH N.D. CAPLET ORL TAB MCL TAB 0.2850 00002276259 TYLENOL COLD EXTRA STRENGTH NIGHTTIME TABLET ORL TAB MCL TAB 0.3000 00000574007 TYLENOL COLD REGULAR STRENGTH CAPLET ORL TAB MCL TAB 0.2004 00000743283 TYLENOL COLD REGULAR STRENGTH N.D. CAPLET ORL TAB MCL TAB 0.2012 00002290510 TYLENOL EXTRA STR. BACK PAIN 400 MG/500 MG TABLET ORL TAB MCL TAB 0.4811 00000863270 TYLENOL EXTRA-STRENGTH GELCAPS 500 MG CAPSULE ORL CAP MCL CAP 0.1383 00000663980 TYLENOL EXTRA-STRENGTH SINUS MEDICATION CAPLET ORL TAB MCL TAB 0.4783 00002347792 TYLENOL FASTMELTS JUNIOR STRENGTH 160 MG CHEW TAB ORL CTB MCL TAB 0.2700 00002241361 TYLENOL JUNIOR STRENGTH 160 MG SOFT CHEW TABLET ORL CTB MCL TAB 0.2700 00002181061 TYLENOL NO.1 WITH CODEINE TABLET ORL TAB MCL TAB 0.1396 00000559393 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.1417 00000723894 TYLENOL REGULAR STRENGTH 325 MG TABLET ORL TAB MCL TAB 0.1208 00000778400 TYLENOL SINUS CAPLET ORL TAB MCL TAB 0.2004 00002242727 TYPHERIX 25 MCG/0.5 ML INJECTION SYRINGE INJ NDL GSK SYR 22.1400 00002130955 TYPHIM VI 50 MCG/ML INJECTION INJ DEFAUL CNG ML 48.5000 00080022377 UDO'S CHOICE SUPER 8 PLUS PROBIOTIC ORL CAP FMD CAP 0.9900 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 209 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001966294 ULONE 5 MG ORAL SYRUP ORL SYR MMH ML 0.1406 00080015173 ULTIMATE FLORA CRITICAL CARE 50 BILLION ORL CAP RLC CAP 1.1665 00080006259 ULTIMATE OMEGA FACTORS 3-6-9 SOFT GEL CAPSULE ORL CAP NFN CAP 0.2387 00080033880 ULTRA C 1000 TABLET ORL TAB MTG TAB 0.3135 00080032885 ULTRA C TM 500 500 MG TABLET ORL TAB MTG TAB 0.2817 00080011779 ULTRA FLORA PLUS CAPSULE ORL CAP MTG CAP 0.4116 00080011780 ULTRA FLORA PLUS; ULTRA FLORA BALANCE ORL CAP MTG CAP 0.4167 00002237698 ULTRA STRENGTH PHAZYME 180 MG CAPSULE ORL CAP CBF CAP 0.2221 00080025550 ULTRA-FIBER BALANCED CAPLET ORL TAB AAM TAB 0.0802 00080004965 ULTRA-FIBER SUPPLEMENT CHEWABLE TABLET ORL TAB AAM TAB 0.0917 00002349469 ULTRAM 50 MG TABLET ORL TAB JAI TAB 0.7275 00002324113 ULTRAQUIN 4% HYDROQUINONE CREAM WITH SUNSCREENS TOP CRM SAH G 1.0000 00000626724 ULTRAQUIN 4% TOPICAL GEL TOP GEL SAH G 1.0000 00000632783 ULTRAQUIN PLAIN 4% CREAM TOP CRM SAH G 0.8667 00001962728 ULTRAVATE 0.05% TOPICAL OINTMENT TOP ONT VCL G 0.8924 00001946994 UNISOM-2 NIGHTTIME SLEEP AID TAB 25 MG ORL TAB PDH TAB 0.2040 00000116866 URASAL GRANULES ORAL EFFERVESCENT POWDER ORL EVP AXS G 0.1138 00001946099 UREMOL 10 10% TOPICAL CREAM TOP CRM GKC G 0.0769 00000398179 UREMOL 20% TOPICAL CREAM TOP CRM GKC G 0.0811 00001946102 UREMOL-10 10% TOPICAL LOTION TOP LOT GKC ML 0.0430 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 210 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000503134 UREMOL-HC TOPICAL CREAM TOP CRM GSK G 0.1746 00000560022 UREMOL-HC TOPICAL LOTION TOP LOT GSK ML 0.0982 00080005531 URISEC 40 40% TOPICAL CREAM TOP CRM ODN G 1.2500 00002353997 UROCIT-K 10 MEQ EXTENDED-RELEASE TABLET ORL ERT PAL TAB 0.5250 00001914022 UROCIT-K 5 MEQ TABLET ORL SRT SFD TAB 0.3518 00002241411 UROMITEXAN 100 MG/ML INJECTION INJ DEFAUL AST ML 6.4890 00080030062 UTI CLEANSE TABLET ORL TAB AOR TAB 0.4416 00080046888 UXOR 7.5% GEL TOP GEL JPC G 0.1787 00002442019 VALACYCLOVIR 1000 MG CAPLET ORL TAB SIV TAB 5.8538 00000177016 VALISONE-G TOPICAL CREAM TOP CRM VCL G 1.0053 00000232351 VALISONE-G TOPICAL OINTMENT TOP ONT VCL G 1.0053 00000013285 VALIUM 5 MG TABLET ORL TAB HLR TAB 0.1666 00002367742 VALSARTAN 160 MG TABLET ORL TAB PDL TAB 0.3330 00002367750 VALSARTAN 320 MG TABLET ORL TAB PDL TAB 0.3330 00002367726 VALSARTAN 40 MG TABLET ORL TAB PDL TAB 0.4080 00002384523 VALSARTAN 40 MG TABLET ORL TAB SIV TAB 0.5240 00002366940 VALSARTAN 40 MG TABLET ORL TAB SNS TAB 0.5239 00002367734 VALSARTAN 80 MG TABLET ORL TAB PDL TAB 0.3330 00002384760 VALSARTAN HCT 320 MG/12.5 MG TABLET ORL TAB SIV TAB 0.3253 00002384779 VALSARTAN HCT 320 MG/25 MG TABLET ORL TAB SIV TAB 0.3253 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 211 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002367777 VALSARTAN-HCTZ 160 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3330 00002367785 VALSARTAN-HCTZ 160 MG/25 MG TABLET ORL TAB PDL TAB 0.3330 00002367769 VALSARTAN-HCTZ 80 MG/12.5 MG TABLET ORL TAB PDL TAB 0.3330 00002246559 VALTREX 1000 MG CAPLET ORL TAB GSK TAB 6.8867 00002394634 VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJ USP INJ DEFAUL SDZ VIAL 58.9900 00002407922 VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJECTION INJ DEFAUL MYP VIAL 58.9900 00002407930 VANCOMYCIN HYDROCHLORIDE 5 G/VIAL INJECTION INJ DEFAUL MYP VIAL 509.7900 00002394626 VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJ USP INJ DEFAUL SDZ VIAL 31.0500 00002407914 VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJECTION INJ DEFAUL MYP VIAL 31.0500 00002432544 VAN-GABAPENTIN 600 MG TABLET ORL TAB VAN TAB 1.3045 00002432552 VAN-GABAPENTIN 800 MG TABLET ORL TAB VAN TAB 1.7393 00002243837 VANIQA 13.9% TOPICAL CREAM TOP CRM ALM G 2.3917 00002229702 VAQTA 50 U/ML INJECTION INJ DEFAUL MSD ML 45.5400 00002241047 VARILRIX 2000 UNITS/(0.5 ML) VIAL INJECTION INJ DEFAUL GSK VIAL 62.7900 00002246081 VARIVAX III VACCINE 1350 U/VIAL INJECTION INJ DEFAUL MFC VIAL 72.7200 00002139502 VASOPRESSIN 20 UNIT/ML INJECTION INJ DEFAUL PPC ML 19.8300 00002223929 VAXIGRIP INFLUENZA VACCINE INJECTION INJ DEFAUL CNG ML 8.3500 00002308487 VECTIBIX 20 MG/ML (5 ML VIAL) INJECTION INJ DEFAUL AMG ML 124.9900 00002273985 VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAP ORL ERC PMS CAP 0.3469 00002339269 VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.8868 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 212 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002339242 VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.4200 00002339250 VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE ORL ERC PDL CAP 0.8399 00002243716 VENOFER 20 MG/ML INJECTION INJ DEFAUL LPI ML 7.5000 00002226286 VENOMIL YELLOW JACKET VENOM PROTEIN 120 MCG INJ INJ DEFAUL BAI VIAL 195.0000 00002243115 VENTOLIN DISKUS 200 MCG/DOSE PWDR FOR INHAL INH MIP GSK DOSE 0.1928 00000616192 VEPESID 50 MG CAPSULE ORL CAP BMS CAP 38.4525 00080033844 VERALAC HYDROSOLUBLE NAIL LACQUER TOP SOL VCL ML 3.5894 00000839299 VERAPAMIL HYDROCHLORIDE 2.5 MG/ML INJECTION INJ DEFAUL HSP ML 19.1500 00002166739 VERAPAMIL HYDROCHLORIDE USP 2.5 MG/ML INJECTION INJ DEFAUL SDZ ML 19.1000 00002348489 VERDESO 0.05% TOPICAL FOAM TOP FOA GSK G 0.2944 00002411849 VEREGEN 10% TOPICAL OINTMENT TOP ONT PAL G 4.0153 00000594601 VERSEL 2.5% TOPICAL LOTION TOP LOT VCL ML 0.0716 00002145839 VESANOID 10 MG CAPSULE ORL CAP CAG CAP 16.3863 00002163691 VEXOL 1% OPH SOLUTION OPH SUS ALC ML 3.5620 00000717002 VIADERM K.C. TOPICAL CREAM TOP CRM TAR G 0.4233 00000717029 VIADERM K.C. TOPICAL OINTMENT TOP ONT TAR G 0.6233 00002239768 VIAGRA 100 MG TABLET ORL TAB PFI TAB 9.2000 00002239766 VIAGRA 25 MG TABLET ORL TAB PFI TAB 8.2900 00002239767 VIAGRA 50 MG TABLET ORL TAB PFI TAB 8.8475 00002273330 VICKS CHILDREN'S NYQUIL COLD & COUGH ORAL LIQUID ORL LIQ PGI ML 0.0250 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 213 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00001938959 VICKS FORMULA 44 ORAL LIQUID ORL LIQ PGI ML 0.0341 00002050684 VICKS NYQUIL ADULT NIGHTTIME COLD MEDICINE ORL LIQ ORL LIQ PGI ML 0.0276 00001935747 VICKS VAPORUB TOPICAL OINTMENT TOP ONT PGI G 0.0704 00002351064 VICTOZA 6 MG/ML PEN INJECTION SYRINGE INJ DEFAUL NNA ML 27.5000 00002336707 VIDAZA 100 MG/VIAL INJECTION INJ DEFAUL CLG VIAL 628.0000 00002244596 VIDEX EC 125 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 3.7830 00002244597 VIDEX EC 200 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 6.0533 00002244598 VIDEX EC 250 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 7.4983 00002244599 VIDEX EC 400 MG CAPSULE (ENTERIC-COATED BEADLETS) ORL CAP/ENCP BMS CAP 12.1307 00002417685 VIDEXTRA 10,000 UNIT TABLET ORL TAB ORI TAB 0.2500 00002252260 VIGAMOX 0.5% OPHTHALMIC SOLUTION OPH SOL ALC ML 4.4067 00002427184 VIMIZIM 5MG/5ML (SINGLE-USE) VIAL INJECTION INJ DEFAUL BMI VIAL 1199.0000 00002361701 VIMOVO 375 MG/20 MG TABLET ORL TAB AZC TAB 1.0737 00002361728 VIMOVO 500 MG/20 MG TABLET ORL TAB AZC TAB 1.0695 00002401460 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 17.6790 00002183056 VINBLASTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL MNP ML 18.5630 00002183013 VINCRISTINE SULFATE 1 MG/ML INJECTION INJ DEFAUL HSP ML 63.3650 00002143305 VINCRISTINE SULPHATE 1 MG/ML INJECTION INJ DEFAUL TEV ML 31.0000 00000074500 VIOFORM HC TOPICAL CREAM TOP CRM PAL G 0.8803 00002238617 VIRACEPT 250 MG TABLET ORL TAB AGR TAB 1.8842 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 214 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002248761 VIRACEPT 625 MG TABLET ORL TAB PFI TAB 4.7152 00002238748 VIRAMUNE 200 MG TABLET ORL TAB BOE TAB 4.9383 00002367289 VIRAMUNE XR 400 MG EXTENDED-RELEASE TABLET ORL ERT BOE TAB 2.4690 00080030855 VISION CARE CAPSULE ORL CAP PLT CAP 0.8991 00000568627 VISKAZIDE 10/25 MG TABLET ORL TAB TRI TAB 0.8957 00000568635 VISKAZIDE 10/50 MG TABLET ORL TAB TRI TAB 0.8957 00000443174 VISKEN 10 MG TABLET ORL TAB TRI TAB 0.9979 00000417289 VISKEN 15 MG TABLET ORL TAB TRI TAB 1.4476 00000417270 VISKEN 5 MG TABLET ORL TAB TRI TAB 0.5843 00002242367 VISUDYNE 15 MG/VIAL INJECTION INJ DEFAUL VCL VIAL 1703.1000 00080044606 VITALUX ADVANCED CAPLET ORL TAB ALC TAB 0.2083 00080016590 VITALUX CAPLET ORL TAB ALC TAB 0.2353 00080016683 VITALUX PLUS OMEGA 3 CAPSULE ORL CAP ALC CAP 0.2100 00002245911 VITALUX TABLET ORL TAB NOV TAB 0.2398 00002240199 VITALUX TR MULTIVITAMIN/MULTIMINERAL TABLET ORL TAB NCI TAB 0.2398 00080028004 VITALUX-S PLUS OMEGA-3 CAPSULE ORL CAP ALC CAP 0.2100 00080016576 VITALUX-S TABLET ORL TAB ALC TAB 0.2374 00000123137 VITAMIN A & D FORTIFIED CAPSULE ORL CAP JAM CAP 0.0482 00000297720 VITAMIN A 10,000 IU CAPSULE ORL CAP JAM CAP 0.0444 00002245311 VITAMIN A 10,000 IU CAPSULE ORL CAP WNP CAP 0.0260 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 215 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00080035590 VITAMIN B 100 MG TIME RELEASE TABLET ORL TAB WNP TAB 0.1575 00000487082 VITAMIN B CMPD 100 SUSTAINED-RELEASE TABLET ORL SRT SWS TAB 0.1732 00000294853 VITAMIN B1 100 MG TABLET ORL TAB VCL TAB 0.0900 00002239350 VITAMIN B1 100 MG TABLET ORL TAB PMT TAB 0.0214 00000407011 VITAMIN B1 100 MG TABLET ORL TAB JAM TAB 0.0567 00000816078 VITAMIN B1 100 MG/ML INJECTION USP INJ DEFAUL SDZ ML 2.4250 00080009633 VITAMIN B1 50 MG TABLET ORL TAB JPC TAB 0.0737 00000610267 VITAMIN B1 50 MG TABLET ORL TAB LEA TAB 0.0740 00002247479 VITAMIN B100 COMPLEX TABLET ORL TAB WBP TAB 0.1082 00000450642 VITAMIN B12 100 MCG TABLET ORL TAB VTH TAB 0.0700 00002023598 VITAMIN B12 100 MCG TABLET ORL TAB PMT TAB 0.0568 00000331015 VITAMIN B12 100 MCG TABLET ORL TAB JAM TAB 0.0567 00002241500 VITAMIN B12 100 MCG/ML INJECTION INJ DEFAUL SDZ ML 2.1130 00080012952 VITAMIN B12 1000 MCG TABLET ORL TAB JAM TAB 0.0893 00080006939 VITAMIN B12 1000 MCG TABLET ORL TAB WNP TAB 0.0974 00002230932 VITAMIN B12 1000 MCG TABLET ORL TAB WES TAB 0.0771 00002237736 VITAMIN B12 1000 MCG TABLET ORL TAB SWS TAB 0.0420 00080003575 VITAMIN B12 1000 MCG TIME RELEASE TABLET ORL ERT PMT TAB 0.0470 00000626112 VITAMIN B12 1000 MCG/ML INJ DEFAUL OMG ML 0.3100 00000335940 VITAMIN B12 250 MCG TABLET ORL TAB JAM TAB 0.0647 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 216 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000502758 VITAMIN B12 250 MCG TABLET ORL TAB SWS TAB 0.1397 00000305243 VITAMIN B12 50 MCG TABLET ORL TAB JAM TAB 0.0525 00002243767 VITAMIN B12 500 MCG TABLET ORL TAB VTH TAB 0.0465 00000689726 VITAMIN B12 500 MCG TABLET ORL TAB SNS TAB 0.0741 00000528846 VITAMIN B6 100 MG TABLET ORL TAB HAL TAB 0.0300 00002239348 VITAMIN B6 100 MG TABLET ORL TAB PMT TAB 0.0228 00000329185 VITAMIN B6 100 MG TABLET ORL TAB JAM TAB 0.0647 00000122645 VITAMIN B6 25 MG TABLET ORL TAB JAM TAB 0.0336 00000331031 VITAMIN B6 250 MG TABLET ORL TAB JAM TAB 0.1051 00000305227 VITAMIN B6 50 MG TABLET ORL TAB JAM TAB 0.0485 00000341207 VITAMIN C 1000 MG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.1087 00000305235 VITAMIN C 1000 MG TABLET ORL TAB JAM TAB 0.0818 00080040321 VITAMIN C 125 MG GUMMY ORL DEFAUL JAM PIECE 0.1250 00001922378 VITAMIN C 500 MG TABLET ORL TAB SWS TAB 0.0479 00001994336 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB JAM TAB 0.0604 00002243893 VITAMIN C 500 MG CHEWABLE TABLET ORL CTB PMT TAB 0.0333 00000237116 VITAMIN C 500 MG ORANGE FLAVORED CHEWABLE TABLET ORL CTB TEV TAB 0.0257 00000373699 VITAMIN C 500 MG SUSTAINED-RELEASE CAPSULE ORL SRC JAM CAP 0.0967 00000036188 VITAMIN C 500 MG TABLET ORL TAB WAM TAB 0.0400 00002240883 VITAMIN C 500 MG TABLET ORL TAB WNP TAB 0.0359 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 217 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002163268 VITAMIN C 500 MG TABLET ORL TAB JAM TAB 0.0403 00080020803 VITAMIN C 500 MG TIMED RELEASE CAPLET ORL SRT JAM TAB 0.0804 00000463108 VITAMIN C CHEWABLE TABLET ORL TAB GAH TAB 0.0970 00080001870 VITAMIN D 1,000 IU TAB ORL TAB SIS TAB 0.0440 00080017530 VITAMIN D 1000 IU CAPSULE ORL CAP JAM CAP 0.0351 00080006264 VITAMIN D 1000 IU TABLET ORL TAB GFR TAB 0.0500 00080000436 VITAMIN D 1000 IU TABLET ORL TAB JAM TAB 0.0444 00000323179 VITAMIN D 1000 UNIT TABLET ORL TAB SWS TAB 0.0305 00000765384 VITAMIN D 400 IU TABLET ORL TAB LCO TAB 0.0400 00002242175 VITAMIN D 400 IU TABLET ORL TAB JAM TAB 0.0433 00080009578 VITAMIN D 400 IU TABLET ORL TAB VCL TAB 0.0236 00080002452 VITAMIN D 400 IU TABLET ORL TAB WNP TAB 0.0180 00002240624 VITAMIN D 400 IU TABLET ORL TAB WAM TAB 0.0161 00002240858 VITAMIN D 400 IU TABLET ORL TAB PMT TAB 0.0117 00002229879 VITAMIN D 400 IU TABLET ORL TAB SWS TAB 0.0398 00080018025 VITAMIN D DROPS 400 IU ORL LIQ JAM ML 0.9316 00080015280 VITAMIN D3 1000 IU CAPSULE ORL GEL VTH CAP 0.0415 00080012124 VITAMIN D3 1000 IU ORAL LIQUID ORL LIQ WBP ML 0.1948 00080003663 VITAMIN D3 1000 IU TABLET ORL TAB WNP TAB 0.0327 00002245842 VITAMIN D3 1000 IU TABLET ORL TAB PMT TAB 0.0178 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 218 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000480924 VITAMIN E 100 IU NATURAL SOURCE CAPSULE ORL CAP VTH CAP 0.0468 00000122823 VITAMIN E 100 IU OBLONG AMBER CAPSULE ORL CAP JAM CAP 0.0638 00000332348 VITAMIN E 200 IU CAPSULE (NATURAL) ORL CAP LDL CAP 0.0629 00000122831 VITAMIN E 200 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.0821 00000782181 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.0816 00002240967 VITAMIN E 400 IU CAPSULE ORL CAP WNP CAP 0.0541 00000266108 VITAMIN E 400 IU CAPSULE ORL CAP PMT CAP 0.0542 00000480940 VITAMIN E 400 IU CAPSULE ORL CAP VTH CAP 0.0741 00000332356 VITAMIN E 400 IU CAPSULE (NATURAL) ORL CAP LDL CAP 0.0539 00000122858 VITAMIN E 400 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.1058 00000330191 VITAMIN E 800 IU NATURAL SOURCE CAPSULE ORL CAP JAM CAP 0.2814 00002015293 VITAMIN E NATURAL SOURCE 400 UNIT CAPSULE ORL CAP QVS CAP 0.0592 00000201995 VITAMIN E NF NATURAL SOURCE 400 IU CAPSULE ORL CAP WAM CAP 0.1165 00080030153 VITAMIN K2 100 MCG CAPSULE ORL CAP NFN CAP 0.1248 00000480878 VITAMINE B12 1200 MCG SUSTAINED-RELEASE TABLET ORL SRT JAM TAB 0.1013 00000816175 VITAMINE C 600 MG CAPSULE ORL CAP SIS CAP 0.2112 00002417995 VITAMINE D 10 000 10000 UNIT TABLET ORL TAB PDL TAB 0.2100 00002248361 VIVAXIM INJECTION INJ DEFAUL SFP SYR 80.7000 00080028217 VIVISCAL MAXIMUM STRENGTH TABLET ORL TAB IRI TAB 0.9998 00000013765 VIVOL 5 MG TABLET ORL TAB AXS TAB 0.0858 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 219 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000885975 VIVOTIF BERNA 6 B CAPSULE ORL CAP SSV CAP 5.8600 00002307073 VOLIBRIS 10 MG TABLET ORL TAB GSK TAB 122.5200 00002307065 VOLIBRIS 5 MG TABLET ORL TAB GSK TAB 122.5200 00002290375 VOLTAREN EMULGEL 1.16% TOPICAL GEL TOP GEL NVC G 0.1297 00002338580 VOLTAREN EMULGEL JOINT PAIN 1.16% TOPICAL GEL TOP GEL NVC G 0.1124 00000881635 VOLTAREN RAPIDE 50 MG TABLET ORL TAB NOV TAB 0.9137 00002381966 VORICONAZOLE 200 MG/VIAL INJECTION INJ DEFAUL SDZ VIAL 130.0800 00002352303 VOTRIENT 200 MG TABLET ORL TAB NOV TAB 34.4100 00002357119 VPRIV 400 UNIT/VIAL INJECTION INJ DEFAUL SHG VIAL 1955.0000 00080037590 VSL #3 ORAL POWDER ORL PWR FEI PCKT 3.1000 00002365561 VYLOMA 3.75% TOPICAL CREAM TOP CRM VCL G 38.6667 00002439603 VYVANSE 10 MG CAPSULE ORL CAP SHB CAP 2.1411 00080006877 WAMPOLE MINERAL CALCIUM ORAL LIQUID ORL LIQ JPC ML 0.0350 00080008041 WAMPOLE MULTIVITAMIN LIQUID ORL LIQ WAM ML 0.0350 00002344025 WARFARIN 1 MG TABLET ORL TAB SNS TAB 0.0780 00002344114 WARFARIN 10 MG TABLET ORL TAB SNS TAB 0.1187 00002344033 WARFARIN 2 MG TABLET ORL TAB SNS TAB 0.0825 00002344041 WARFARIN 2.5 MG TABLET ORL TAB SNS TAB 0.0660 00002344068 WARFARIN 3 MG TABLET ORL TAB SNS TAB 0.1023 00002344076 WARFARIN 4 MG TABLET ORL TAB SNS TAB 0.1023 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 220 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002344084 WARFARIN 5 MG TABLET ORL TAB SNS TAB 0.0662 00001948970 WASP VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 41.4833 00001910787 WEBBER OINTMENT VITAMIN E 30 IU/G TOPICAL OINTMENT TOP ONT JLF G 0.1116 00080002343 WELLESSE JOINT MOVEMENT GLUCOSAMINE LIQUID ORL LIQ BOT ML 0.0284 00001949004 WHITE FACED HORNET VENOM 120 MCG INJ DEFAUL ALG VIAL 35.6833 00002136740 WOBENZYM N TABLET ORL TAB MUC TAB 0.3497 00002424703 WOMEN'S ROGAINE FOAM 5% AEROSOL FOAM TOP FOA JJI G 0.7697 00002384256 XALKORI 200 MG CAPSULE ORL CAP PFI CAP 146.6667 00002384264 XALKORI 250 MG CAPSULE ORL CAP PFI CAP 146.6667 00000723770 XANAX 1 MG TABLET ORL TAB PFI TAB 0.5561 00000813958 XANAX TS 2 MG TABLET ORL TAB PFI TAB 0.9883 00002441535 XARELTO 15 MG / 20 MG TABLET STARTER PACK ORL TAB BAI TAB 2.8400 00002423898 XELJANZ 5 MG TABLET ORL TAB PFI TAB 23.0965 00002238453 XELODA 150 MG TABLET ORL TAB HLR TAB 1.8465 00002238454 XELODA 500 MG TABLET ORL TAB HLR TAB 6.1549 00002240325 XENICAL 120 MG CAPSULE ORL CAP HLR CAP 1.6249 00002404044 XERESE 5%/1% TOPICAL CREAM TOP CRM VCL G 7.0220 00002368153 XGEVA 120 MG/VIAL INJECTION INJ DEFAUL AMG VIAL 558.7900 00002388316 XIAFLEX 0.9 MG/VIAL INJECTION INJ DEFAUL ACT VIAL 1120.0000 00000866598 X-SEB PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.0639 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 221 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000866601 X-SEB T PLUS CONDITIONING TOPICAL SHAMPOO TOP SHP BAK ML 0.0639 00000509906 X-SEB T TOPICAL SHAMPOO TOP SHP PMS ML 0.0639 00002407329 XTANDI 40 MG CAPSULE ORL CAP ASP CAP 28.3450 00000800694 X-TAR TOPICAL SHAMPOO TOP SHP DLX ML 0.0676 00000001791 XYLOCAINE 1% W EPINEPHRINE 1:100,000 INJ INJ DEFAUL AZC ML 0.3600 00000385484 XYLOCAINE 2% TOPICAL JELLY URH JEL AZC ML 0.9170 00002373130 XYLOCAINE 2% W EPINEPHRINE 1:200,000 INJECTION ORL DEFAUL AZC VIAL 0.3820 00000001732 XYLOCAINE HCL 1% LIQUID (BLOCK OR INFILTRATION) INJ LIQ AZC ML 0.9250 00000036641 XYLOCAINE HCL 2% PLAIN LIQ (BLOCK OR INFILTRATION) INJ LIQ AZC ML 1.1080 00002268272 XYREM 500 MG/ML ORAL SOLUTION ORL SOL VCL ML 2.6370 00002321157 YAZ 28 TABLET ORL TB BAI TAB 0.5657 00002387433 YAZ PLUS 28 TABLET ORL TB BAI TAB 0.4229 00001948954 YELLOW JACKET VENOM PROTEIN 1.1 MG INJ DEFAUL ALG VIAL 35.6833 00001948962 YELLOW JACKET VENOM PROTEIN 120 MCG INJ DEFAUL ALG VIAL 35.6833 00002379384 YERVOY INTRAVENOUS INFUSION 5 MG/ML INJECTION INJ DEFAUL BMS ML 5800.0000 00000428833 YF-VAX 109648 U/0.5 ML INJECTION INJ DEFAUL SFP VIAL 128.2080 00000795283 YOCON 5.4 MG TABLET ORL TAB GLE TAB 0.5568 00000885533 YOHIMBINE-ODAN 2 MG TABLET ORL TAB ODN TAB 0.4540 00001901885 YOHIMBINE-ODAN 5.4 MG TABLET ORL TAB ODN TAB 0.6720 00000600784 ZADITEN 0.2 MG/ML ORAL SYRUP ORL SYR TEV ML 0.4636 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 222 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002279223 ZADITOR (PRESERVATIVE FREE) 0.25 MG/ML OPH SOL OPH SOL NOV ML 3.5283 00002242324 ZADITOR 0.25 MG/ML OPH SOLUTION OPH SOL NOV ML 5.2920 00002230287 ZANTAC 75 MG TABLET ORL TAB GSK TAB 0.4060 00000568392 ZAPEX 10 MG TABLET ORL TAB RIV TAB 0.0350 00000568406 ZAPEX 15 MG TABLET ORL TAB RIV TAB 0.0550 00000568414 ZAPEX 30 MG TABLET ORL TAB RIV TAB 0.0750 00002250519 ZAVESCA 100 MG CAPSULE ORL CAP ACT CAP 108.5500 00002410702 ZAXINE 550 MG TABLET ORL TAB SLX TAB 7.6775 00002246740 Z-BEC STRESSTABS TABLET ORL TAB WCH TAB 0.1653 00000237213 ZEASORB MEDICATED TOPICAL POWDER TOP PWR GSK G 0.1450 00002380242 ZELBORAF 240 MG FILM-COATED TABLET ORL TAB HLR TAB 46.5420 00002361752 ZENHALE 100 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.7311 00002361760 ZENHALE 200 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.8861 00002361744 ZENHALE 50 MCG/5 MCG/DOSE METERED DOSE AEROSOL INH AEM MFC DOSE 0.5762 00002216086 ZERIT 15 MG CAPSULE ORL CAP BMS CAP 4.6122 00002216094 ZERIT 20 MG CAPSULE ORL CAP BMS CAP 4.7958 00002216108 ZERIT 30 MG CAPSULE ORL CAP BMS CAP 5.0025 00002216116 ZERIT 40 MG CAPSULE ORL CAP BMS CAP 5.1862 00002240358 ZIAGEN 20 MG/ML ORAL SOLUTION ORL SOL GSK ML 0.4568 00002240357 ZIAGEN 300 MG TABLET ORL TAB GSK TAB 6.9655 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 223 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00000297666 ZINC 10 MG TABLET ORL TAB JAM TAB 0.0473 00000441589 ZINC 25 MG TABLET ORL TAB JAM TAB 0.0631 00001922351 ZINC 50 MG TABLET ORL TAB SWS TAB 0.0466 00000505463 ZINC 50 MG TABLET ORL TAB JAM TAB 0.0711 00000480886 ZINC 50 MG TIMED RELEASE TABLET ORL TAB JAM TAB 0.0877 00080012983 ZINC COPPER BALANCE 15 MG/2 MG CAPSULE ORL CAP AOR CAP 0.1550 00002239162 ZINCOFAX 15% TOPICAL OINTMENT TOP ONT PAL G 0.0748 00002239160 ZINCOFAX EXTRA STRENGTH 40% TOPICAL OINTMENT TOP ONT PDH G 0.0595 00002153432 ZINECARD 250 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 137.0600 00002153440 ZINECARD 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 274.1400 00002239952 ZITHROMAX 500 MG/VIAL INJECTION INJ DEFAUL PFI VIAL 21.5350 00002231143 ZITHROMAX 600 MG TABLET ORL TAB PFI TAB 12.0693 00002354802 ZMAX SR 27 MG/ML ORAL SUPENSION ORL SUS PFI ML 0.5322 00000884324 ZOCOR 5 MG TABLET ORL TAB MFC TAB 1.0839 00002240332 ZOCOR 80 MG TABLET ORL TAB MFC TAB 2.6114 00002421550 ZOLEDRONIC ACID 4 MG/5 ML INJECTION INJ DEFAUL HSP ML 415.5600 00002327619 ZOLINZA 100 MG CAPSULE ORL CAP MFC CAP 76.1795 00002379929 ZOLMITRIPTAN 2.5 MG TABLET ORL TAB PDL TAB 5.3333 00002379988 ZOLMITRIPTAN ODT 2.5 MG ORALLY DISPERSIBLE TABLET ORL DISPTAB PDL TAB 5.3333 00002248992 ZOMIG 2.5 MG NASAL SPRAY NAS SPU AZC DOSE 14.3300 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 224 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002315939 ZOSTAVAX 19,400 UNITS/(0.65 ML) VIAL INJECTION INJ DEFAUL MFC VIAL 157.5000 00002375516 ZOSTAVAX II 19,400 UNITS/(0.65 ML) VIAL INJECTION INJ DEFAUL MFC VIAL 169.9000 00000740306 ZOSTRIX 0.025% TOPICAL CREAM TOP CRM GEU G 0.2192 00002004240 ZOSTRIX H.P. 0.075% TOPICAL CREAM TOP CRM GEU G 0.2800 00000634506 ZOVIRAX 200 MG TABLET ORL TAB GSK TAB 1.3259 00001911627 ZOVIRAX 400 MG TABLET ORL TAB GSK TAB 2.6715 00002039524 ZOVIRAX 5% TOPICAL CREAM TOP CRM VCL G 13.2980 00000569771 ZOVIRAX 5% TOPICAL OINTMENT TOP ONT VCL G 13.2983 00000800686 Z-PLUS TOPICAL SHAMPOO TOP SHP DLX ML 0.0956 00002354772 ZUACTA 0.075% TOPICAL CREAM TOP CRM SAV G 1.7942 00002340445 ZYCLARA 3.75% TOPICAL CREAM TOP CRM VCL G 39.8267 00002438798 ZYDELIG 100 MG TABLET ORL TAB GIL TAB 85.3500 00002438801 ZYDELIG 150 MG TABLET ORL TAB GIL TAB 85.3500 00002436779 ZYKADIA 150 MG CAPSULE ORL CAP NOV CAP 67.4666 00002342804 ZYM-AMLODIPINE 10 MG TABLET ORL TAB ZMC TAB 0.3587 00002342790 ZYM-AMLODIPINE 5 MG TABLET ORL TAB ZMC TAB 0.2417 00002257270 ZYMAR 0.3% OPHTHALMIC SOLUTION OPH SOL ALL ML 2.6320 00002338106 ZYM-CARVEDILOL 12.5 MG TABLET ORL TAB ZMC TAB 0.8001 00002338114 ZYM-CARVEDILOL 25 MG TABLET ORL TAB ZMC TAB 0.8001 00002338068 ZYM-CARVEDILOL 3.125 MG TABLET ORL TAB ZMC TAB 0.8001 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 225 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002338092 ZYM-CARVEDILOL 6.25 MG TABLET ORL TAB ZMC TAB 0.8001 00002345676 ZYM-CLONAZEPAM 0.5 MG TABLET ORL TAB ZMC TAB 0.1166 00002303329 ZYM-CLONAZEPAM 1 MG TABLET ORL TAB ZMC TAB 0.1860 00002303337 ZYM-CLONAZEPAM 2 MG TABLET ORL TAB ZMC TAB 0.2010 00002302659 ZYM-FLUOXETINE 10 MG CAPSULE ORL CAP ZMC CAP 1.1773 00002302667 ZYM-FLUOXETINE 20 MG CAPSULE ORL CAP ZMC CAP 1.0112 00002325179 ZYM-MIRTAZAPINE 15 MG TABLET ORL TAB ZMC TAB 0.3750 00002325187 ZYM-MIRTAZAPINE 30 MG TABLET ORL TAB ZMC TAB 0.7800 00002344440 ZYM-ONDANSETRON 4 MG TABLET ORL TAB ZMC TAB 7.5453 00002344459 ZYM-ONDANSETRON 8 MG TABLET ORL TAB ZMC TAB 11.5170 00002320754 ZYM-PIOGLITAZONE 15 MG TABLET ORL TAB ZMC TAB 1.5716 00002320762 ZYM-PIOGLITAZONE 30 MG TABLET ORL TAB ZMC TAB 2.2017 00002320770 ZYM-PIOGLITAZONE 45 MG TABLET ORL TAB ZMC TAB 3.3105 00002303817 ZYM-SERTRALINE 100 MG (BASE) CAPSULE ORL CAP ZMC CAP 1.1025 00002303779 ZYM-SERTRALINE 25 MG (BASE) CAPSULE ORL CAP ZMC CAP 0.5040 00002303809 ZYM-SERTRALINE 50 MG (BASE) CAPSULE ORL CAP ZMC CAP 1.0080 00002325144 ZYM-TOPIRAMATE 100 MG TABLET ORL TAB ZMC TAB 1.2537 00002325152 ZYM-TOPIRAMATE 200 MG TABLET ORL TAB ZMC TAB 1.9845 00002325136 ZYM-TOPIRAMATE 25 MG TABLET ORL TAB ZMC TAB 0.6615 00002238851 ZYPREXA 20 MG TABLET ORL TAB LIL TAB 14.3775 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 226 of 227 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective December 14, 2015 DIN/ PIN/ NPN Product Description Route Form MFR Unit of Issue Base Price 00002243088 ZYPREXA ZYDIS 15 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LIL TAB 10.7111 00002243089 ZYPREXA ZYDIS 20 MG ORALLY DISINTEGRATING TABLET ORL DISNTAB LIL TAB 14.2643 00002371065 ZYTIGA 250 MG TABLET ORL TAB JAI TAB 29.5910 00002360349 ZYTRAM XL 100 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 1.1440 00002286424 ZYTRAM XL 150 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 1.6800 00002286432 ZYTRAM XL 200 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 2.2050 00002286440 ZYTRAM XL 300 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 3.2000 00002286459 ZYTRAM XL 400 MG CONTROLLED-RELEASE TABLET ORL CRT PUR TAB 4.2000 00002360322 ZYTRAM XL 75 MG EXTENDED-RELEASE TABLET ORL ERT PUR TAB 0.8820 00002243685 ZYVOXAM 2 MG/ML INJECTION INJ DEFAUL PFI ML 0.3446 00002243686 ZYVOXAM 20 MG/ML ORAL SUSPENSION ORL SUS PFI ML 2.5287 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 227 of 227
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Products and Pricing on the Alberta Blue Cross Drug Price List
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