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Products and Pricing on the Alberta Blue Cross Drug Price List
Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002192691 00002192683 00002247825 00002162113 00002166607 00000437999 00080013172 00002414619 00002414627 00002414600 00002231590 00001919385 00001919393 00001919407 00002420864 00002420872 00002281066 00002245677 00002364174 00002364182 00002364190 00002364204 00002364212 00002364220 00001922246 00000095494 00002401126 00002401134 00002341107 00002341093 00002435632 00002435640 00002419874 00002419866 00002400391 00002400405 00002400359 Product Description 3TC 10 MG/ML ORAL LIQUID 3TC 150 MG TABLET 3TC 300 MG TABLET 5 BENZAGEL 5% TOPICAL (ALCOHOL) GEL 5 BENZAGEL 5% TOPICAL LOTION 5% DEXTROSE & 0.45% NACL W 0.15% KCL 20 MEQ INJ 5-HTP 100 MG CAPSULE ABBOTT-TOPIRAMATE 100 MG TABLET ABBOTT-TOPIRAMATE 200 MG TABLET ABBOTT-TOPIRAMATE 25 MG TABLET ABELCET 5MG/ML LIPID COMPLEX INJECTION ABENOL 120 MG RECTAL SUPPOSITORY ABENOL 325 MG RECTAL SUPPOSITORY ABENOL 650 MG RECTAL SUPPOSITORY ABILIFY MAINTENA 300 MG/VIAL INJECTION ABILIFY MAINTENA 400 MG/VIAL INJECTION ABRAXANE 100 MG/VIAL INJECTION ABREVA 10% TOPICAL CREAM ABSTRAL 100 MCG SUBLINGUAL TABLET ABSTRAL 200 MCG SUBLINGUAL TABLET ABSTRAL 300 MCG SUBLINGUAL TABLET ABSTRAL 400 MCG SUBLINGUAL TABLET ABSTRAL 600 MCG SUBLINGUAL TABLET ABSTRAL 800 MCG SUBLINGUAL TABLET AC & C 8 MG TABLET AC WITH CODEINE 8 MG TABLET ACCEL-ALENDRONATE 10 MG TABLET ACCEL-ALENDRONATE 70 MG TABLET ACCEL-AMLODIPINE 10 MG TABLET ACCEL-AMLODIPINE 5 MG TABLET ACCEL-CELECOXIB 100 MG CAPSULE ACCEL-CELECOXIB 200 MG CAPSULE ACCEL-DONEPEZIL 10 MG TABLET ACCEL-DONEPEZIL 5 MG TABLET ACCEL-FLUOXETINE 10 MG CAPSULE ACCEL-FLUOXETINE 20 MG CAPSULE ACCEL-QUETIAPINE 100 MG TABLET Route ORL ORL ORL TOP TOP INJ ORL ORL ORL ORL INJ RT RT RT INJ INJ INJ TOP SLG SLG SLG SLG SLG SLG ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form LIQ TAB TAB ALCGEL LOT DEFAUL CAP TAB TAB TAB DEFAUL SUP SUP SUP DEFAUL DEFAUL DEFAUL CRM SLT SLT SLT SLT SLT SLT TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB CAP CAP TAB MFR Unit of Issue GSK ML GSK TAB GSK TAB CLC G NVC ML BAX ML VTH CAP ABB TAB ABB TAB ABB TAB SGM ML PPH SUP PPH SUP PPH SUP OTS VIAL OTS VIAL CLG VIAL GKC G PAL TAB PAL TAB PAL TAB PAL TAB PAL TAB PAL TAB PPH TAB DTC TAB ACP TAB ACP TAB ACP TAB ACP TAB ACP CAP ACP CAP ACP TAB ACP TAB ACP CAP ACP CAP ACP TAB Base Price 0.3375 5.3543 10.3970 0.2207 0.1984 0.0027 0.2000 0.5928 0.8853 0.3128 8.6795 0.5417 0.7092 0.7683 490.3900 490.3900 971.0000 7.3850 11.8990 13.4700 16.1530 18.3530 24.4820 30.5990 0.0510 0.0592 0.4357 2.1975 0.3587 0.2417 0.1536 0.3073 1.0523 1.0523 0.4014 0.4017 0.2878 Pg 1 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002400375 00002400340 00002400383 00002435349 00002435357 00002435330 00002164396 00002164418 00002164426 00002230435 00001999648 00002154234 00000374148 00000605751 00000789798 00001905864 00002272482 00000706221 00002028174 00001905856 00002255251 00002252813 00002285797 00000605778 00001904132 00001958836 00002143933 00002025337 00002251914 00002017458 00000834319 00000834300 00001999656 00002300435 00000718831 00002247551 00080042609 Product Description ACCEL-QUETIAPINE 200 MG TABLET ACCEL-QUETIAPINE 25 MG TABLET ACCEL-QUETIAPINE 300 MG TABLET ACCEL-TOPIRAMATE 100 MG TABLET ACCEL-TOPIRAMATE 200 MG TABLET ACCEL-TOPIRAMATE 25 MG TABLET ACEBUTOLOL-100 100 MG TABLET ACEBUTOLOL-200 200 MG TABLET ACEBUTOLOL-400 400 MG TABLET ACET 160 MG RECTAL SUPPOSITORY ACET CODEINE 30 TABLET ACETAMINOPHEN 300MG/15MG CAFFEINE/8MG COD. CAPLET ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 500 MG TABLET ACETAMINOPHEN 80 MG/ML ORAL DROPS ACETAMINOPHEN ARTHRITIS PAIN 650 MG EXT.REL TABLET ACETAMINOPHEN CAFFEINE & CODEINE 8 MG TABLET ACETAMINOPHEN COMPOUND WITH CODEINE CAPLET ACETAMINOPHEN COMPRIME A CROQUER 80 MG ACETAMINOPHEN EXT STR EASY TO SWALLOW 500 MG TAB ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ACETAMINOPHEN EXTRA STRENGTH 500 MG TABLET ACETAMINOPHEN EXTRA-STRENGTH 500 MG TABLET ACETAMINOPHEN ORAL SOLUTION FOR CHILDREN USP ACETAMINOPHEN WITH CODEINE CAPLET ACETAMINOPHEN WITH CODEINE TABLET ACETAMINOPHEN, CAFFEINE & 8 MG CODEINE PHOS. TAB ACETAMINOPHENE 80MGCO.CROQUABLE POUR ENFANT ACETAZONE FORTE C-8 TABLET ACETAZONE FORTE TABLET ACET-CODEINE 60 MG TABLET ACETYLCYSTEINE 20% INHALATION SOLUTION ACETYLSALICYLIC ACID 325 MG TABLET ACID REDUCER 75 MG TABLET ACIDOPHILUS PROBIOTIC COMPLETE CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL RT ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL 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. Form TAB TAB TAB TAB TAB TAB TAB TAB TAB SUP TAB TAB TAB TAB TAB DPS ERT TAB TAB TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB CTB TAB TAB TAB SOL TAB TAB CAP MFR Unit of Issue ACP TAB ACP TAB ACP TAB ACP TAB ACP TAB ACP TAB PDL TAB PDL TAB PDL TAB PPH SUP PMS TAB VTH TAB WAM TAB VTH TAB TLI TAB TLI ML PRI TAB WTR TAB PPH TAB TLI TAB PMT TAB PMT TAB VTH TAB WTR TAB TAN TAB TLI ML ROG TAB PMS TAB PMT TAB RIV TAB RPH TAB RPH TAB PMS TAB ALV ML PHH TAB PMS TAB WNP CAP Base Price 0.5781 0.1079 0.8435 0.5179 0.7734 0.2732 0.0787 0.1177 0.2466 0.8325 0.1441 0.0348 0.0184 0.0326 0.0444 0.1300 0.0755 0.0258 0.0428 0.1000 0.0660 0.0621 0.1125 0.0390 0.0179 0.0296 0.0460 0.0434 0.0396 0.1000 0.4740 0.3586 0.1534 1.6500 0.0621 0.1067 0.2892 Pg 2 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080011789 00002394898 00002374765 00002376520 00002397625 00002397617 00002305682 00002305690 00002305704 00002429764 00002397285 00002397293 00002250020 00002250012 00002325713 00002404095 00002403986 00002394189 00002394197 00002394200 00002394170 00002394219 00002262746 00002297310 00002402955 00002402971 00002402912 00002402998 00002402920 00002402939 00002372088 00002372053 00002372061 00002257882 00002395282 00002395290 00002395274 Product Description ACIDOPHILUS WITH BIFIDUS CAPSULE ACT ANASTROZOLE 1 MG TABLET ACT BETAHISTINE 24 MG TABLET ACT CANDESARTAN 4 MG TABLET ACT DONEPEZIL ODT 10 MG ORALLY DISINTEGRATING TAB ACT DONEPEZIL ODT 5 MG ORALLY DISINTEGRATING TAB ACT FAMCICLOVIR 125 MG TABLET ACT FAMCICLOVIR 250 MG TABLET ACT FAMCICLOVIR 500 MG TABLET ACT GLICLAZIDE MR 30 MG SUSTAINED-RELEASE TABLET ACT IMATINIB 100 MG TABLET ACT IMATINIB 400 MG TABLET ACT MELOXICAM 15 MG TABLET ACT MELOXICAM 7.5 MG TABLET ACT OLANZAPINE 20 MG TABLET ACT OLAPATADINE 0.2% OPHTHALMIC SOLUTION ACT OLOPATADINE 0.1% OPH SOLUTION ACT OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET ACT OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET ACT OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET ACT OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET ACT OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET ACT PAROXETINE 10 MG TABLET ACT PRAMIPEXOLE 0.5 MG TABLET ACT PREGABALIN 150 MG CAPSULE ACT PREGABALIN 225 MG CAPSULE ACT PREGABALIN 25 MG CAPSULE ACT PREGABALIN 300 MG CAPSULE ACT PREGABALIN 50 MG CAPSULE ACT PREGABALIN 75 MG CAPSULE ACT SILDENAFIL 100 MG TABLET ACT SILDENAFIL 25 MG TABLET ACT SILDENAFIL 50 MG TABLET ACT SUMATRIPTAN 25 MG TABLET ACT TEMOZOLOMIDE 100 MG CAPSULE ACT TEMOZOLOMIDE 140 MG CAPSULE ACT TEMOZOLOMIDE 20 MG CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form CAP TAB TAB TAB DISNTAB DISNTAB TAB TAB TAB SRT TAB TAB TAB TAB TAB SOL SOL CRT CRT CRT CRT CRT TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP CAP CAP MFR Unit of Issue WNP CAP APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB COB TAB COB TAB APH TAB APH TAB APH TAB APH ML APH ML APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH CAP APH CAP APH CAP APH CAP APH CAP APH CAP APH TAB APH TAB APH TAB APH TAB APH CAP APH CAP APH CAP Base Price 0.1147 2.6223 0.5132 0.3502 3.7261 3.7261 2.0850 2.8017 4.3548 0.1405 21.0693 84.2773 0.5840 0.5061 10.6186 10.7640 5.3820 0.4522 0.6783 1.2462 0.3244 2.1712 1.0743 1.4276 1.7788 1.7788 0.6358 1.7788 0.9973 1.2904 9.4760 8.5375 9.1125 9.2600 117.0045 163.8080 23.4020 Pg 3 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002395312 00002337487 00002424770 00002238302 00002249405 00002309009 00002316838 00002370417 00002248722 00002236916 00002236926 00002281074 00002240255 00002352044 00002313766 00002313774 00002313782 00000266507 00002290081 00002401347 00002338327 00002248809 00002248810 00002248811 00002248812 00002248813 00002248808 00002412764 00002412772 00002412799 00002412802 00002412810 00002071002 00002296462 00002296470 00002331667 00002296489 Product Description ACT TEMOZOLOMIDE 250 MG CAPSULE ACT VALSARTAN 40 MG TABLET ACTEMRA 162 MG /0.9 ML INJECTION SYRINGE ACTIFED 60 MG/2.5 MG TABLET ACTIVELLE 1 MG/0.5 MG TABLET ACTIVELLE LD 0.5 MG/0.1 MG TABLET ACTONEL 150 MG TABLET ACTONEL DR 35 MG DELAYED-RELEASE TABLET ACULAR LS 0.4% OPH SOLUTION ACYCLOVIR SODIUM 25 MG/ML INJECTION ACYCLOVIR SODIUM 50 MG/ML INJECTION ACZONE 5% TOPICAL GEL ADACEL INJECTION ADACEL-POLIO INJECTION ADALAT XL PLUS 20 MG/81 MG TABLET ADALAT XL PLUS 30 MG/81 MG TABLET ADALAT XL PLUS 60 MG/81 MG TABLET ADASEPT 0.5% TOPICAL LIQUID ADASEPT BP5 ACNE GEL 5% TOPICAL GEL ADCETRIS 50MG/VIAL INJECTION POWDER FOR SOLUTION ADCIRCA 20 MG TABLET ADDERALL XR 10 MG EXTENDED-RELEASE CAPSULE ADDERALL XR 15 MG EXTENDED-RELEASE CAPSULE ADDERALL XR 20 MG EXTENDED-RELEASE CAPSULE ADDERALL XR 25 MG EXTENDED-RELEASE CAPSULE ADDERALL XR 30 MG EXTENDED-RELEASE CAPSULE ADDERALL XR 5 MG EXTENDED-RELEASE CAPSULE ADEMPAS 0.5 MG TABLET ADEMPAS 1 MG TABLET ADEMPAS 1.5 MG TABLET ADEMPAS 2 MG TABLET ADEMPAS 2.5 MG TABLET ADRIAMYCIN PFS 2 MG/ML INJECTION ADVAGRAF 0.5 MG EXTENDED-RELEASE CAPSULE ADVAGRAF 1 MG EXTENDED-RELEASE CAPSULE ADVAGRAF 3 MG EXTENDED-RELEASE CAPSULE ADVAGRAF 5 MG EXTENDED-RELEASE CAPSULE Route ORL ORL INJ ORL ORL ORL ORL ORL OPH INJ INJ TOP INJ INJ ORL ORL ORL TOP TOP INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL 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. Form CAP TAB DEFAUL TAB TAB TAB TAB DRT SOL DEFAUL DEFAUL GEL DEFAUL DEFAUL ERT ERT ERT LIQ GEL DEFAUL TAB ERC ERC ERC ERC ERC ERC TAB TAB TAB TAB TAB DEFAUL ERC ERC ERC ERC MFR Unit of Issue APH CAP APH TAB HLR SYR PFI TAB NNA TAB NNA TAB ASC TAB ASC TAB ALL ML HSP ML PPC ML VCL G SFP ML SFP ML BAI TAB BAI TAB BAI TAB ODN ML ODN ML STG VIAL LIL TAB SHB CAP SHB CAP SHB CAP SHB CAP SHB CAP SHB CAP BAI TAB BAI TAB BAI TAB BAI TAB BAI TAB PFI ML ASP CAP ASP CAP ASP CAP ASP CAP Base Price 292.5040 0.5998 355.0000 0.3246 2.3936 2.3936 60.9300 14.4000 3.6000 4.8620 12.5840 1.1405 61.9800 41.2840 0.6555 0.6170 0.9373 0.0301 0.1802 4840.0000 14.7377 2.6253 2.9868 3.3070 3.6272 3.9475 2.3464 42.7500 42.7500 42.7500 42.7500 42.7500 11.2080 1.9700 2.7090 8.1270 13.5664 Pg 4 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080025646 00002270447 00002270439 00001933558 00002036312 00002248645 00002244577 00002248231 00001933531 00002246403 00002241769 00002242522 00002243919 00002339528 00002369257 00002339501 00002425645 00002425653 00002425661 00002243542 00002346850 00002236859 00002410265 00002410273 00000888230 00002408848 00000001147 00000433519 00002254506 00002381478 00002301733 00002414759 00080014418 00002253437 00000004715 00002231462 00002242819 Product Description ADVANCED B COMPLEX ADVICOR 1000 MG/20 MG TABLET ADVICOR 500 MG/20 MG TABLET ADVIL 200 MG TABLET ADVIL COLD AND SINUS CAPLET ADVIL COLD AND SINUS PLUS CAPLET ADVIL EXTRA STRENGTH 400 MG CAPLET ADVIL EXTRA STRENGTH LIQUI-GEL 400 MG CAPSULE ADVIL IBUPROFEN 200 MG CAPLET ADVIL JUNIOR STRENGTH CHEWABLE TABLET ADVIL LIQUI-GELS 200 MG CAPSULE ADVIL PEDIATRIC 40 MG/ML SUSPENSION DROPS AERIUS 5 MG TABLET AFINITOR 10 MG TABLET AFINITOR 2.5 MG TABLET AFINITOR 5 MG TABLET AFINITOR DISPERZ 2 MG TABLET FOR SUSPENSION AFINITOR DISPERZ 3 MG TABLET FOR SUSPENSION AFINITOR DISPERZ 5 MG TABLET FOR SUSPENSION AGENERASE 150 MG CAPSULE AGRIFLU INJECTION SYRINGE AGRYLIN 0.5 MG CAPSULE AHI-MONTELUKAST 4 MG CHEWABLE TABLET AHI-MONTELUKAST 5 MG CHEWABLE TABLET A-HYDROCORT 100 MG/VIAL INJECTION AJ-CISATRACURIUM 2MG/ML WITH PRESERVATIVE INJ ALBALON 0.1% OPH SOLUTION ALBALON-A OPH SOLUTION ALDURAZYME 0.58 MG/ML INJECTION ALENDRONATE SODIUM 5 MG TABLET ALEVE 220 MG TABLET ALFUZOSIN 10 MG PROLONGED-RELEASE TABLET ALIGN PROBIOTIC CAPSULE ALIMTA 500 MG/VIAL INJECTION ALKERAN 2 MG TABLET ALLEGRA 12 HOUR 60 MG TABLET ALLEGRA 24 HOUR 120 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL INJ INJ OPH OPH INJ ORL ORL ORL ORL INJ ORL ORL ORL 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. Form CAP TAB TAB TAB TAB TAB TAB CAP TAB CTB CAP DPS TAB TAB TAB TAB DTS DTS DTS CAP DEFAUL CAP CTB CTB DEFAUL DEFAUL SOL SOL DEFAUL TAB TAB SRT CAP DEFAUL TAB TAB TAB MFR Unit of Issue AOR CAP SUN TAB SUN TAB PDH TAB PDH TAB PDH TAB PDH TAB PDH CAP PDH TAB PDH TAB PDH CAP PDH ML SCH TAB NOV TAB NOV TAB NOV TAB NOV TAB NOV TAB NOV TAB GSK CAP NVD SYR SHB CAP AHI TAB AHI TAB HSP VIAL AJP ML ALL ML ALL ML GZM ML AHI TAB BAI TAB PDL TAB PGI CAP LIL VIAL ASN TAB SAV TAB SAV TAB Base Price 0.2941 1.3900 1.2400 0.1980 0.3980 0.4370 0.2869 0.3850 0.1521 0.3255 0.2775 0.3347 1.0500 202.9493 202.9493 202.9493 186.0000 186.0000 186.0000 1.9200 9.3000 6.2969 0.3646 0.5565 3.4500 2.1652 0.6287 0.5760 209.0000 1.0371 0.2240 0.4966 0.9489 2750.0000 1.8394 0.4017 0.7867 Pg 5 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002239853 00002146142 00002176483 00000271411 00001949454 00000764647 00000833266 00002141728 00002240266 00002230398 00000804193 00002097583 00002097575 00002369656 00002240265 00002364689 00000555681 00002130157 00000555703 00000569801 00002424029 00002241407 00000893560 00002381710 00002381729 00080005881 00002248151 00001908189 00001908170 00002248706 00002241680 00002320924 00002281112 00002245272 00002245273 00002245274 00002241630 Product Description ALLEGRA-D SUSTAINED-RELEASE TABLET ALLER-AIDE 2.5 MG/ML ORAL ELIXIR ALLER-AIDE 25 MG CAPLET ALLERDRYL 50 MG CAPSULE ALLERGY 25 MG TABLET ALLERGY DROPS 0.012% OPH SOLUTION ALLERGY ELIXIR 2.5 MG/ML ORAL ELIXIR ALLERGY FORMULA 25 MG CAPLET ALLERGY RELIEF 10 MG TABLET ALLERGY TABLETS EXTRA STRENGTH 50 MG TABLET ALLERNIX 2.5 MG/ML ORAL ELIXIR ALLERNIX 25 MG CAPLET ALLERNIX EXTRA STRENGTH 50 MG CAPLET ALLERNIX MULTI SYMPTOM 5 MG TABLET ALLER-RELIEF 10 MG TABLET ALLER-RELIEF 10 MG TABLET ALLOPURINOL 100 MG TABLET ALLOPURINOL 200 MG TABLET ALLOPURINOL 300 MG TABLET ALMAGEL 200 ORAL LIQUID ALMOTRIPTAN 12.5 MG TABLET ALOCRIL 2% OPH SOLUTION ALOMIDE 0.1% (BASE) OPH SOLUTION ALOXI 0.05 MG/ML INJECTION ALOXI 0.5 MG CAPSULE ALPHA LIPOIC ACID 100MG CAPSULE ALPHAGAN P 0.15% OPHTHALMIC SOLUTION ALPRAZOLAM-0.25 MG TABLET ALPRAZOLAM-0.5 MG TABLET ALPRAZOLAM-1 1 MG TABLET ALPROSTADIL 0.5 MG/ML INJECTION ALREX 0.2% OPHTHALMIC SUSPENSION ALTACE 15 MG CAPSULE AMARYL 1 MG TABLET AMARYL 2 MG TABLET AMARYL 4 MG TABLET AMBISOME 50 MG/VIAL INJECTION Route ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OPH INJ ORL ORL OPH ORL ORL ORL INJ OPH ORL ORL ORL ORL INJ 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. Form SRT ELX TAB CAP TAB SOL ELX TAB TAB TAB ELX TAB TAB TAB TAB TAB TAB TAB TAB LIQ TAB SOL SOL DEFAUL CAP CAP SOL TAB TAB TAB DEFAUL SUS CAP/TAB TAB TAB TAB DEFAUL MFR Unit of Issue SAV TAB ROG ML ROG TAB VCL CAP TAN TAB BSH ML TAN ML PRI TAB APX TAB TAN TAB ROG ML ROG TAB ROG TAB ROG TAB APX TAB PMS TAB PDL TAB PDL TAB PDL TAB ATL ML PDL TAB ALL ML ALC ML EIS ML EIS CAP WNP CAP ALL ML PDL TAB PDL TAB PDL TAB TEV ML BSH ML VCL CAP SAV TAB SAV TAB SAV TAB ASP VIAL Base Price 0.5380 0.0342 0.2198 0.1303 0.0938 0.1880 0.0180 0.1200 0.4083 0.1625 0.0457 0.2333 0.4667 0.5120 0.4083 0.4080 0.0780 0.1300 0.2125 0.0179 7.0433 6.8800 1.2690 18.0000 72.0700 0.1118 3.7820 0.0609 0.0728 0.2092 185.0000 6.0740 1.2787 1.0063 1.0953 1.1723 121.0000 Pg 6 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002230575 00000870943 00002242971 00000370991 00000371009 00000456349 00002326795 00002378779 00002378760 00000638064 00002326515 00002326523 00002125862 00002124971 00080006771 00002221861 00002245345 00002245346 00002249499 00000874019 00002268825 00002418401 00002280361 00000566756 00000566748 00000695351 00002230251 00002241532 00002222132 00001945939 00001945920 00001945912 00001945904 00000621447 00000621439 00002248424 00002231379 Product Description AMETOP 4% TOPICAL GEL AMI-HYDRO TABLET AMIKACIN SULFATE 250 MG/ML INJECTION AMITRIPTYLINE 10 MG TABLET AMITRIPTYLINE 25 MG TABLET AMITRIPTYLINE 50 MG TABLET AMLODIPINE 2.5 MG TABLET AMLODIPINE-ODAN 10 MG TABLET AMLODIPINE-ODAN 5 MG TABLET AMOSAN 68.6% MOUTHWASH AMOXI-CLAV 500 MG/125 MG TABLET AMOXI-CLAV 875 MG/125 MG TABLET AMPHOJEL 320 MG/5ML ORAL LIQUID AMPHOJEL 600 MG TABLET A-MULSION ORAL LIQUID ANANDRON 50 MG TABLET ANDROGEL (2.5 G/ PACKET) 1% TOPICAL GEL ANDROGEL (5 G/ PACKET) 1% TOPICAL GEL ANDROGEL (75 G/PUMP) 1% TOPICAL GEL ANEXATE 0.1 MG/ ML INJECTION ANGELIQ 1 MG/1 MG TABLET ANORO ELLIPTA 62.5 MCG/25MCG INHALATION POWDER ANTHELIOS XL SPF 60 TOPICAL CREAM ANTHRAFORTE 1 1% TOPICAL OINTMENT ANTHRAFORTE 2 2% TOPICAL OINTMENT ANTHRASCALP 0.4% TOPICAL LOTION ANTIBIOTIC TOPICAL OINTMENT USP ANTI-NAUSEANT 50 MG TABLET ANTIPHLOGISTINE RUB A-535 NO ODOUR 13.3% TOP OINT ANUSOL 0.5% RECTAL OINTMENT ANUSOL 10 MG RECTAL SUPPOSITORY ANUSOL PLUS RECTAL OINTMENT ANUSOL PLUS RECTAL SUPPOSITORY ANUZINC 0.5% W/W TOPICAL OINTMENT ANUZINC 10 MG RECTAL SUPPOSITORY ANUZINC PLUS RECTAL OINTMENT ANZEMET 100 MG TABLET Route TOP ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP INJ ORL INH TOP TOP TOP TOP TOP ORL TOP RT RT RT RT TOP RT RT ORL 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. Form GEL TAB DEFAUL TAB TAB TAB TAB TAB TAB MWH TAB TAB LIQ TAB LIQ TAB GEL GEL GEL DEFAUL TAB MIP CRM ONT ONT LOT ONT TAB ONT ONT SUP ONT SUP ONT SUP ONT TAB MFR Unit of Issue SNE G PDL TAB SDZ ML PDL TAB PDL TAB PDL TAB PDL TAB ODN TAB ODN TAB OLB ML PDL TAB PDL TAB AXC ML AUP TAB SRL ML SAV TAB ABB G ABB G ABB G HLR ML BAI TAB GSK DOSE LRP G MPQ G MPQ G STI ML TAR G VTH TAB CHD G WLA G WLA SUP WLA G WLA SUP SDZ G SDZ SUP SDZ G SAV TAB Base Price 3.1467 0.0838 29.1800 0.0435 0.0829 0.1540 0.1380 0.3587 0.2417 0.3340 0.6673 1.0008 0.0189 0.1324 0.4000 2.4423 0.9589 0.8478 0.9689 5.6956 0.8539 2.9483 0.1836 0.3696 0.8066 0.7000 0.2467 0.1060 0.0601 0.1623 0.4433 0.1917 0.5925 0.1250 0.4208 0.1173 29.5953 Pg 7 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080017904 00080005832 00002229873 00000544981 00002420333 00002248727 00002243611 00002243612 00002411318 00002411326 00002411334 00002411342 00002411253 00002411261 00002411288 00002411296 00002288559 00002374420 00000510696 00000472476 00002318024 00002318083 00002318032 00002318040 00002318059 00002318067 00002318075 00002247423 00002296063 00002399210 00002399202 00002301334 00002242504 00000682047 00000682039 00002365340 00000893625 Product Description AOR CHROMIUM PICOLINATE 600 MCG CAPSULE AOR N.A.C. 500 MG CAPSULE APO-ACETAMINOPHEN 325 MG CAPLET APO-ACETAMINOPHEN 325 MG TABLET APO-ADEFOVIR 10 MG TABLET APO-ALENDRONATE 5 MG TABLET APO-ALPRAZ 1 MG TABLET APO-ALPRAZ TS 2 MG TABLET APO-AMLODIPINE-ATORVASTATIN 10 MG/10 MG TABLET APO-AMLODIPINE-ATORVASTATIN 10 MG/20 MG TABLET APO-AMLODIPINE-ATORVASTATIN 10 MG/40 MG TABLET APO-AMLODIPINE-ATORVASTATIN 10 MG/80 MG TABLET APO-AMLODIPINE-ATORVASTATIN 5 MG/10 MG TABLET APO-AMLODIPINE-ATORVASTATIN 5 MG/20 MG TABLET APO-AMLODIPINE-ATORVASTATIN 5 MG/40 MG TABLET APO-AMLODIPINE-ATORVASTATIN 5 MG/80 MG TABLET APO-AMOXI CLAV 80 MG/11.4 MG/ML ORAL SUSPENSION APO-ANASTROZOLE 1 MG TABLET APO-ASEN ECT 325 MG ENTERIC-COATED TABLET APO-ASEN ECT 650 MG ENTERIC-COATED TABLET APO-ATOMOXETINE 10 MG CAPSULE APO-ATOMOXETINE 100 MG CAPSULE APO-ATOMOXETINE 18 MG CAPSULE APO-ATOMOXETINE 25 MG CAPSULE APO-ATOMOXETINE 40 MG CAPSULE APO-ATOMOXETINE 60 MG CAPSULE APO-ATOMOXETINE 80 MG CAPSULE APO-AZITHROMYCIN 250 MG TABLET APO-BICALUTAMIDE 50 MG TABLET APO-BOSENTAN 125 MG TABLET APO-BOSENTAN 62.5 MG TABLET APO-BRIMONIDINE P 0.15% OPHTHALMIC SOLUTION APO-BUTORPHANOL 10 MG/ML NASAL SPRAY APO-CAL 250 625 MG TABLET APO-CAL 500 MG TABLET APO-CANDESARTAN 4 MG TABLET APO-CAPTO 100 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH NAS ORL ORL ORL ORL 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. Form CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SUS TAB ECT ECT CAP CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB SOL SPR TAB TAB TAB TAB MFR Unit of Issue AOR CAP AOR CAP APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX ML APX TAB APX TAB APX TAB APX CAP APX CAP APX CAP APX CAP APX CAP APX CAP APX CAP APX TAB APX TAB APX TAB APX TAB APX ML APX ML APX TAB APX TAB APX TAB APX TAB Base Price 0.1333 0.1375 0.0356 0.0356 22.3190 1.0681 0.3192 0.6014 0.9470 1.0541 1.0943 1.0943 0.7778 0.8849 0.9250 0.9250 0.2027 2.7800 0.1537 0.2500 2.5267 4.7520 2.8960 3.1973 3.6443 4.0428 4.3633 1.2317 4.1790 22.4625 22.4625 1.8920 24.6920 0.0282 0.0703 0.3713 1.0395 Pg 8 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000893595 00000893609 00000893617 00001999559 00002293951 00002231603 00000399302 00000312711 00002298953 00000749494 00002263130 00002274744 00002274752 00002243433 00002354403 00002291037 00002291045 00002291053 00002291061 00002291088 00002296055 00002386054 00002386062 00002352931 00002352923 00002339099 00002339102 00002419726 00002292025 00002292041 00002292068 00000545031 00001912518 00002294745 00002426471 00002293358 00002293366 Product Description APO-CAPTO 12.5 MG TABLET APO-CAPTO 25 MG TABLET APO-CAPTO 50 MG TABLET APO-CAPTO 6.25 MG TABLET APO-CEFPROZIL 50 MG/ML ORAL SUSPENSION APO-CETIRIZINE 10 MG TABLET APO-CHLORPROPAMIDE 100 MG TABLET APO-CHLORPROPAMIDE 250 MG TABLET APO-CICLOPIROX 8% TOPICAL SOLUTION APO-CIMETIDINE 800 MG TABLET APO-CIPROFLOX 0.3% OPHTHALMIC SOL. APO-CLARITHROMYCIN 250 MG TABLET APO-CLARITHROMYCIN 500 MG TABLET APO-DICLO RAPIDE 50 MG TABLET APO-DICLOFENAC 1.5% TOPICAL SOLUTION APO-DILTIAZ TZ 120 MG EXTENDED-RELEASE CAPSULE APO-DILTIAZ TZ 180 MG EXTENDED-RELEASE CAPSULE APO-DILTIAZ TZ 240 MG EXTENDED-RELEASE CAPSULE APO-DILTIAZ TZ 300 MG EXTENDED-RELEASE CAPSULE APO-DILTIAZ TZ 360 MG EXTENDED-RELEASE CAPSULE APO-DORZOLAMIDE 2% OPHTHALMIC SOLUTION APO-ELETRIPTAN 20 MG TABLET APO-ELETRIPTAN 40 MG TABLET APO-ENALAPRIL MALEATE/HCTZ 10 MG/25 MG TABLET APO-ENALAPRIL MALEATE/HCTZ 5 MG/12.5 MG TABLET APO-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET APO-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET APO-EXEMESTANE 25 MG TABLET APO-FAMCICLOVIR 125 MG TABLET APO-FAMCICLOVIR 250 MG TABLET APO-FAMCICLOVIR 500 MG TABLET APO-FERROUS GLUCONATE 300 MG TABLET APO-FERROUS SULFATE-FC 300 MG TABLET APO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY APO-FROVATRIPTAN 2.5 MG TABLET APO-GABAPENTIN 600 MG TABLET APO-GABAPENTIN 800 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL OPH ORL ORL ORL TOP ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL 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. Form TAB TAB TAB TAB SUS TAB TAB TAB SOL TAB SOL TAB TAB TAB SOL ERC ERC ERC ERC ERC SOL TAB TAB TAB TAB DRT DRT TAB TAB TAB TAB TAB TAB SPM TAB TAB TAB MFR Unit of Issue APX TAB APX TAB APX TAB APX TAB APX ML APX TAB APX TAB APX TAB APX G APX TAB APX ML APX TAB APX TAB APX TAB APX ML APX CAP APX CAP APX CAP APX CAP APX CAP APX ML APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX DOSE APX TAB APX TAB APX TAB Base Price 0.2120 0.3000 0.5590 0.1351 0.2437 0.4458 0.0813 0.0830 8.4550 0.2430 1.8120 0.4501 1.7791 0.4299 0.5165 0.2133 0.2889 0.3832 0.4720 0.5778 1.6880 11.0117 11.0117 1.0741 0.7493 2.0408 2.0408 4.2593 2.0847 2.8017 4.3550 0.0428 0.0353 0.1999 13.6533 1.4244 1.8992 Pg 9 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000885754 00002407124 00002295377 00002295385 00002295393 00000396796 00000396818 00000463698 00002327856 00000441643 00002355337 00002355345 00002369052 00002369060 00002375540 00002358514 00002426552 00002261979 00002261987 00002261995 00002243880 00002248974 00002248973 00002366487 00002305062 00002258935 00002273950 00002285169 00002285177 00002286610 00002286637 00002352559 00002352567 00002372738 00002372746 00002246699 00002365499 Product Description APO-GAIN 2% TOPICAL SOLUTION APO-GLICLAZIDE MR 60 MG SUSTAINED-RELEASE TABLET APO-GLIMEPIRIDE 1 MG TABLET APO-GLIMEPIRIDE 2 MG TABLET APO-GLIMEPIRIDE 4 MG TABLET APO-HALOPERIDOL 0.5 MG TABLET APO-HALOPERIDOL 1 MG TABLET APO-HALOPERIDOL 10 MG TABLET APO-HYDRO 12.5 MG TABLET APO-IBUPROFEN 200 MG TABLET APO-IMATINIB 100 MG TABLET APO-IMATINIB 400 MG TABLET APO-LAMIVUDINE 150 MG TABLET APO-LAMIVUDINE 300 MG TABLET APO-LAMIVUDINE-ZIDOVUDINE 150 MG/300 MG TABLET APO-LETROZOLE 2.5 MG TABLET APO-LINEZOLID 600 MG TABLET APO-LISINOPRIL/HCTZ 10 MG/12.5 MG TABLET APO-LISINOPRIL/HCTZ 20 MG/12.5 MG TABLET APO-LISINOPRIL/HCTZ 20 MG/25 MG TABLET APO-LORATADINE 10 MG TABLET APO-MELOXICAM 15 MG TABLET APO-MELOXICAM 7.5 MG TABLET APO-MEMANTINE 10 MG TABLET APO-METFORMIN ER 500 MG EXTENDED-RELEASE TABLET APO-METHIMAZOLE 5 MG TABLET APO-METHYLPHENIDATE 5 MG TABLET APO-METOPROLOL SR 100 MG SUSTAINED-RELEASE TABLET APO-METOPROLOL SR 200 MG SUSTAINED-RELEASE TABLET APO-MIRTAZAPINE 15 MG TABLET APO-MIRTAZAPINE 45 MG TABLET APO-MYCOPHENOLATE 250 MG CAPSULE APO-MYCOPHENOLATE 500 MG TABLET APO-MYCOPHENOLIC ACID 180 MG ENTERIC-COATED TAB APO-MYCOPHENOLIC ACID 360 MG ENTERIC-COATED TAB APO-NAPROXEN EC 250 MG ENTERIC-COATED TABLET APO-NARATRIPTAN 1 MG TABLET Route TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SOL SRT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ERT TAB TAB SRT SRT TAB TAB CAP TAB ECT ECT ECT TAB MFR Unit of Issue APX ML APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX CAP APX TAB APX TAB APX TAB APX TAB APX TAB Base Price 0.5253 0.2150 0.5047 0.5047 0.5350 0.1261 0.1894 0.6378 0.0369 0.0700 21.0693 84.2773 3.7357 7.4714 8.5508 2.8387 40.4560 0.2083 0.2503 0.3506 0.6843 0.6191 0.5061 1.7861 0.4273 0.1735 0.1086 0.1782 0.3234 0.4093 1.2283 1.1258 2.1239 1.8541 3.7082 0.2087 8.4338 Pg 10 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002365502 00002245231 00002245230 00002220156 00002220164 00002223511 00002223538 00002333015 00002360632 00002360640 00002305054 00002402823 00002243661 00002284294 00002284308 00002284316 00002366754 00002394766 00002366762 00002394774 00002306530 00002366746 00002394782 00002366789 00002248844 00002292912 00002240907 00000755885 00000755893 00000755877 00002302942 00002302950 00002302977 00000642886 00000642894 00002292386 00000598194 Product Description APO-NARATRIPTAN 2.5 MG TABLET APO-NITRAZEPAM 10 MG TABLET APO-NITRAZEPAM 5 MG TABLET APO-NIZATIDINE 150 MG CAPSULE APO-NIZATIDINE 300 MG CAPSULE APO-NORTRIPTYLINE 10 MG CAPSULE APO-NORTRIPTYLINE 25 MG CAPSULE APO-OLANZAPINE 20 MG TABLET APO-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB APO-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB APO-OLOPATADINE 0.1% OPH SOLUTION APO-OLOPATADINE 0.2% OPHTHALMIC SOLUTION APO-OXAPROZIN 600 MG TABLET APO-OXCARBAZEPINE 150 MG TABLET APO-OXCARBAZEPINE 300 MG TABLET APO-OXCARBAZEPINE 600 MG TABLET APO-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 15 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 30 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 60 MG CONTROLLED-RELEASE TABLET APO-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET APO-PACLITAXEL 6 MG/ML INJECTION APO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET APO-PAROXETINE 10 MG TABLET APO-PINDOL 10 MG TABLET APO-PINDOL 15 MG TABLET APO-PINDOL 5 MG TABLET APO-PIOGLITAZONE 15 MG TABLET APO-PIOGLITAZONE 30 MG TABLET APO-PIOGLITAZONE 45 MG TABLET APO-PIROXICAM 10 MG CAPSULE APO-PIROXICAM 20 MG CAPSULE APO-PRAMIPEXOLE 0.5 MG TABLET APO-PREDNISONE 1 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB CAP CAP CAP CAP TAB DISNTAB DISNTAB SOL SOL TAB TAB TAB TAB CRT CRT CRT CRT CRT CRT CRT CRT DEFAUL ECT TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB MFR Unit of Issue APX TAB APX TAB APX TAB APX CAP APX CAP APX CAP APX CAP APX TAB APX TAB APX TAB APX ML APX ML APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX ML APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX CAP APX CAP APX TAB APX TAB Base Price 6.1437 0.0534 0.0357 0.2098 0.3802 0.0500 0.1011 11.2570 5.5160 7.8257 5.7060 11.4120 0.7099 0.6780 0.9939 1.9877 0.4522 0.5787 0.6783 0.8961 1.1755 0.3440 1.6222 2.3018 37.0808 1.3132 1.1389 0.2537 0.3680 0.1486 0.5150 0.7210 1.0815 0.4426 0.7422 1.4276 0.1035 Pg 11 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002394278 00002394286 00002394235 00002394294 00002394243 00002394251 00000663719 00002325381 00002377721 00002280396 00002248203 00002248201 00002248202 00002418118 00002125250 00000778354 00000778362 00000812404 00000812390 00002413094 00002413116 00002413124 00002413043 00002413132 00002413035 00002237701 00000755850 00000755869 00000755842 00002290812 00002259893 00002426153 00002336790 00002147653 00002238048 00002371510 00001946323 Product Description APO-PREGABALIN 150 MG CAPSULE APO-PREGABALIN 225 MG CAPSULE APO-PREGABALIN 25 MG CAPSULE APO-PREGABALIN 300 MG CAPSULE APO-PREGABALIN 50 MG CAPSULE APO-PREGABALIN 75 MG CAPSULE APO-PROPRANOLOL 20 MG TABLET APO-RAMIPRIL 15 MG CAPSULE APO-RISEDRONATE 150 MG TABLET APO-RISPERIDONE 1 MG/ML ORAL SOLUTION APO-SILDENAFIL 100 MG TABLET APO-SILDENAFIL 25 MG TABLET APO-SILDENAFIL 50 MG TABLET APO-SILDENAFIL R 20 MG TABLET APO-SUCRALFATE 1 G TABLET APO-SULIN 150 MG TABLET APO-SULIN 200 MG TABLET APO-TAMOX 10 MG TABLET APO-TAMOX 20 MG TABLET APO-TEMOZOLOMIDE 100 MG CAPSULE APO-TEMOZOLOMIDE 140 MG CAPSULE APO-TEMOZOLOMIDE 180 MG CAPSULE APO-TEMOZOLOMIDE 20 MG CAPSULE APO-TEMOZOLOMIDE 250 MG CAPSULE APO-TEMOZOLOMIDE 5 MG CAPSULE APO-TICLOPIDINE 250 MG TABLET APO-TIMOL 10 MG TABLET APO-TIMOL 20 MG TABLET APO-TIMOL 5 MG TABLET APO-TIMOP GEL 0.5% OPHTHALMIC SOLUTION APO-TIZANIDINE 4 MG TABLET APO-TRAMADOL 50 MG TABLET APO-TRAMADOL/ACET 37.5 MG/325 MG TABLET APO-TRAZODONE 150 MG TABLET APO-VALPROIC 250 MG CAPSULE APO-VALSARTAN 40 MG TABLET APO-ZIDOVUDINE 100 MG CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL 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. Form CAP CAP CAP CAP CAP CAP TAB CAP/TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB LAS TAB TAB TAB TAB CAP TAB CAP MFR Unit of Issue APX CAP APX CAP APX CAP APX CAP APX CAP APX CAP APX TAB APX CAP APX TAB APX ML APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX TAB APX CAP APX CAP APX CAP APX CAP APX CAP APX CAP APX TAB APX TAB APX TAB APX TAB APX ML APX TAB APX TAB APX TAB APX TAB APX CAP APX TAB APX CAP Base Price 1.7788 1.7788 0.6358 1.7788 0.9973 1.2905 0.0277 0.9337 44.7100 0.7080 10.0450 9.0525 9.6600 7.5128 0.3029 0.3824 0.3920 0.1802 0.3605 113.5960 159.0360 253.6726 22.7200 283.9840 5.8500 1.0679 0.2835 0.5465 0.1817 2.8120 0.7517 0.6973 0.6840 0.4613 0.2905 0.5997 1.4396 Pg 12 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002434946 00002436159 00002375885 00000723754 00002426862 00002426870 00002426889 00002426897 00002273322 00002162075 00002269465 00002269457 00002224135 00080008677 00080015109 00002242705 00002286653 00002371146 00002229632 00002229570 00002381559 00002381567 00000180041 00000530336 00000036145 00000230324 00002372177 00002244993 00002426811 00002046253 00002009013 00002243974 00002238545 00002242281 00002280167 00002352427 00000266086 Product Description APO-ZOLPIDEM ODT 10 MG SUBLINGUAL DISINT TABLET APO-ZOLPIDEM ODT 5 MG SUBLINGUAL DISINT TABLET APPRILON 40 MG MODIFIED RELEASE CAPSULE APRESOLINE 20 MG/VIAL INJECTION APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET APTIVUS 250 MG CAPSULE AQUASOL E 50 UNIT/ML ORAL DROPS ARICEPT RDT 10 MG ORALLY DISINTEGRATING TABLET ARICEPT RDT 5 MG ORALLY DISINTEGRATING TABLET ARIMIDEX 1 MG TABLET ARNICA 7% GEL ARNICA GEL-CREAM RUB A535 TOPICAL GEL AROMASIN 25 MG TABLET ARTHRITIS PAIN 650 MG EXTENDED RELIEF TABLET ARTHRITIS PAIN RELIEF 650 MG EXTENDED-RELEASE TAB ARTIFICIAL TEARS EXTRA OPH SOLUTION ARTIFICIAL TEARS OPH SOLUTION ARZERRA 100 MG/5 ML VIAL INJECTION ARZERRA 1000 MG/50 ML VIAL INJECTION ASA & CODEINE 8 MG TABLET ASA 325 MG TABLET ASA 325 MG TABLET ASA 325 MG TABLET ASA 81 MG ENTERIC-COATED TABLET ASA 81 MG ENTERIC-COATED TABLET ASA EC 81 MG ENTERIC-COATED TABLET ASADOL 325 MG ENTERIC-COATED TABLET ASAPHEN 80 MG TABLET ASAPHEN 81 MG CHEWABLE TABLET ASAPHEN E.C. 80 MG ENTERIC-COATED TABLET ASAPHEN E.C. 81 MG ENTERIC-COATED TABLET ASATAB 80 MG CHEWABLE TABLET ASATAB EC 325 MG ENTERIC-COATED TABLET ASCORBIC ACID 500 MG TABLET Route SLG SLG ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP ORL ORL ORL OPH OPH INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form DISNTAB DISNTAB MRC DEFAUL TAB TAB TAB TAB CAP DPS DISNTAB DISNTAB TAB GEL GEL TAB ERT ERT SOL SOL DEFAUL DEFAUL TAB TAB TAB TAB ECT ECT ECT ECT TAB CTB ECT ECT CTB ECT TAB MFR Unit of Issue APX TAB APX TAB GAL CAP STM VIAL SUN TAB SUN TAB SUN TAB SUN TAB BOE CAP NOV ML PFI TAB PFI TAB AZC TAB BCI G CHD G PFI TAB VTH TAB VTH TAB PMS ML PPH ML GSK VIAL GSK VIAL SDR TAB VTH TAB WAM TAB TEV TAB VTH TAB PMS TAB SNS TAB PPH TAB PMS TAB PMS TAB PMS TAB PMS TAB ODN TAB ODN TAB PMT TAB Base Price 1.2977 1.2913 2.8468 12.7210 10.3187 10.3187 10.3187 10.3187 8.2500 0.9336 5.3146 5.3146 5.6630 0.1314 0.0971 5.7643 0.0872 0.0498 0.3033 0.2927 336.0000 3360.0000 0.0396 0.0273 0.0136 0.0621 0.0546 0.0394 0.0530 0.0125 0.0594 0.0755 0.0560 0.0887 0.0612 0.0295 0.0300 Pg 13 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002074710 00002150328 00002316897 00002229967 00002239090 00000293482 00000013668 00000293504 00000293512 00000293490 00002326701 00000828793 00000828807 00002396904 00002396912 00002396920 00002396939 00002396947 00002387891 00002396424 00002346486 00002396432 00002387905 00002346494 00002346508 00002396440 00002387913 00002387921 00002396459 00002346516 00002351765 00002421429 00002299925 00002300699 00002094703 00002148358 00002163713 Product Description ASPERCREME CREME RUB 10% TOPICAL CREAM ASPIRIN 325 MG TABLET ASPIRIN STOMACH GUARD EXTRA STRENGTH 500 MG CAPLET ASPIRIN WITH STOMACH GUARD EXTRA STRENGTH CAPLET ATACAND 4 MG TABLET ATASOL 325 MG TABLET ATASOL FORTE 500 MG TABLET ATASOL-15 TABLET ATASOL-30 TABLET ATASOL-8 TABLET ATENOLOL 25 MG TABLET ATENOLOL-100 MG TABLET ATENOLOL-50 MG TABLET ATOMOXETINE 10 MG CAPSULE ATOMOXETINE 18 MG CAPSULE ATOMOXETINE 25 MG CAPSULE ATOMOXETINE 40 MG CAPSULE ATOMOXETINE 60 MG CAPSULE ATORVASTATIN 10 MG TABLET ATORVASTATIN 10 MG TABLET ATORVASTATIN 10 MG TABLET ATORVASTATIN 20 MG TABLET ATORVASTATIN 20 MG TABLET ATORVASTATIN 20 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 80 MG TABLET ATORVASTATIN 80 MG TABLET ATORVASTATIN 80 MG TABLET ATORVASTATIN-20 20 MG TABLET ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET ATRIANCE 5 MG/ML INJECTION ATRIPLA TABLET ATROPINE 0.6 MG/ML INJECTION ATROPINE SULFATE 1% OPH SOLUTION (MINIMS) ATROVENT 0.06% NASAL SPRAY Route TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL INJ OPH NAS 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. Form CRM TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB DEFAUL SOL SPR MFR Unit of Issue SLL G BAI TAB BIC TAB BAI TAB AZC TAB CHD TAB CHD TAB CHD TAB CHD TAB CHD TAB PDL TAB PDL TAB PDL TAB PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP SIV TAB APX TAB PDL TAB APX TAB SIV TAB PDL TAB PDL TAB APX TAB SIV TAB SIV TAB APX TAB PDL TAB PDL TAB SNS TAB GSK ML BMG TAB ALV ML BSH ML BOE ML Base Price 0.0581 0.1138 0.1013 0.1018 0.7897 0.0630 0.0576 0.1150 0.0666 0.0756 0.0676 0.2362 0.1437 1.4040 1.6093 1.7767 2.0250 2.2463 0.4160 0.3138 0.3138 0.3922 0.5200 0.3922 0.4216 0.4216 0.5590 0.5590 0.4216 0.4216 0.1569 4.1308 9.6892 46.2257 2.7300 6.6667 2.1687 Pg 14 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002332477 00002407256 00002407264 00002407272 00002407280 00002421038 00002421046 00002421054 00002418517 00002418525 00002418495 00002418509 00002347261 00002347245 00002347288 00002347253 00002418428 00002385627 00002414414 00002423650 00002423669 00002423642 00002390892 00002390884 00002438275 00002438283 00002411695 00002299801 00002299828 00002299836 00002430487 00002318601 00002422212 00002384906 00002384914 00002384922 00002424061 Product Description AURALGAN OTIC SOLUTION AURO-ATORVASTATIN 10 MG TABLET AURO-ATORVASTATIN 20 MG TABLET AURO-ATORVASTATIN 40 MG TABLET AURO-ATORVASTATIN 80 MG TABLET AURO-CANDESARTAN HCT 16 MG/12.5 MG TABLET AURO-CANDESARTAN HCT 32 MG/12.5 MG TABLET AURO-CANDESARTAN HCT 32 MG/25 MG TABLET AURO-CARVEDILOL 12.5 MG TABLET AURO-CARVEDILOL 25 MG TABLET AURO-CARVEDILOL 3.125 MG TABLET AURO-CARVEDILOL 6.25 MG TABLET AURO-CEFPROZIL 25 MG/ML ORAL SUSPENSION AURO-CEFPROZIL 250 MG TABLET AURO-CEFPROZIL 50 MG/ML ORAL SUSPENSION AURO-CEFPROZIL 500 MG TABLET AURO-EFAVIRENZ 600 MG TABLET AURO-FLUOXETINE 10 MG CAPSULE AURO-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET AURO-LOSARTAN HCT 100 MG/12.5 MG TABLET AURO-LOSARTAN HCT 100 MG/25 MG TABLET AURO-LOSARTAN HCT 50 MG/12.5 MG TABLET AURO-MELOXICAM 15 MG TABLET AURO-MELOXICAM 7.5 MG TABLET AURO-METFORMIN 500 MG TABLET AURO-METFORMIN 850 MG TABLET AURO-MIRTAZAPINE 15 MG TABLET AURO-MIRTAZAPINE OD 15 MG ORALLY DISINT. TABLET AURO-MIRTAZAPINE OD 30 MG ORALLY DISINT. TABLET AURO-MIRTAZAPINE OD 45 MG ORALLY DISINT. TABLET AURO-MODAFINIL 100 MG TABLET AURO-NEVIRAPINE 200 MG TABLET AURO-OMEPRAZOLE 10 MG DELAYED-RELEASE CAPSULE AURO-PIOGLITAZONE 15 MG TABLET AURO-PIOGLITAZONE 30 MG TABLET AURO-PIOGLITAZONE 45 MG TABLET AURO-PRAMIPEXOLE 0.25 MG TABLET Route OT ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SUS TAB SUS TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB DISNTAB DISNTAB DISNTAB TAB TAB CAP/SRT TAB TAB TAB TAB MFR Unit of Issue PAL ML AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR ML AUR TAB AUR ML AUR TAB AUR TAB AUR CAP AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR CAP AUR TAB AUR TAB AUR TAB AUR TAB Base Price 0.5550 0.3138 0.3922 0.4216 0.4216 0.3047 0.3047 0.3047 0.3377 0.3377 0.3377 0.3377 0.0593 0.4332 0.1185 0.8494 11.3300 0.4595 7.8308 0.3082 0.3146 0.3146 0.4623 0.4007 0.0444 0.0610 0.3750 0.2980 0.5963 0.8943 0.9293 2.4690 0.8166 0.5809 0.8139 1.2237 0.2628 Pg 15 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002424096 00002424118 00002433907 00002433869 00002433877 00002433885 00002405156 00002405164 00002405172 00002405148 00002405180 00002439050 00002435179 00002414201 00002363798 00002363801 00002363828 00002360969 00002363372 00002363364 00002363380 00002371413 00002371421 00002360993 00002363895 00002363887 00002363399 00002363402 00002370751 00002370786 00002370735 00002370743 00002362864 00002362848 00002362872 00002362856 00002364255 Product Description AURO-PRAMIPEXOLE 1 MG TABLET AURO-PRAMIPEXOLE 1.5 MG TABLET AURO-PREGABALIN 150 MG CAPSULE AURO-PREGABALIN 25 MG CAPSULE AURO-PREGABALIN 50 MG CAPSULE AURO-PREGABALIN 75 MG CAPSULE AURO-SIMVASTATIN 10 MG TABLET AURO-SIMVASTATIN 20 MG TABLET AURO-SIMVASTATIN 40 MG TABLET AURO-SIMVASTATIN 5 MG TABLET AURO-SIMVASTATIN 80 MG TABLET AURO-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET AURO-VALGANCICLOVIR 450 MG TABLET AURO-VALSARTAN 40 MG TABLET AVA-ACEBUTOLOL 100 MG TABLET AVA-ACEBUTOLOL 200 MG TABLET AVA-ACEBUTOLOL 400 MG TABLET AVA-ATENOLOL 25 MG TABLET AVA-AZITHROMYCIN 20 MG/ML ORAL SUSPENSION AVA-AZITHROMYCIN 250 MG TABLET AVA-AZITHROMYCIN 40 MG/ML ORAL SUSPENSION AVA-BACLOFEN 10 MG TABLET AVA-BACLOFEN 20 MG TABLET AVA-BICALUTAMIDE 50 MG TABLET AVA-BISOPROLOL 10 MG TABLET AVA-BISOPROLOL 5 MG TABLET AVA-BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET AVA-BUPROPION SR 150 MG SUSTAINED-RELEASE TABLET AVA-CARVEDILOL 12.5 MG TABLET AVA-CARVEDILOL 25 MG TABLET AVA-CARVEDILOL 3.125 MG TABLET AVA-CARVEDILOL 6.25 MG TABLET AVA-CEFPROZIL 25 MG/ML ORAL SUSPENSION AVA-CEFPROZIL 250 MG TABLET AVA-CEFPROZIL 50 MG/ML ORAL SUSPENSION AVA-CEFPROZIL 500 MG TABLET AVA-CITALOPRAM 10 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SUS TAB SUS TAB TAB TAB TAB TAB SRT SRT TAB TAB TAB TAB SUS TAB SUS TAB TAB MFR Unit of Issue AUR TAB AUR TAB AUR CAP AUR CAP AUR CAP AUR CAP AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AUR TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA ML AVA TAB AVA ML AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA ML AVA TAB AVA ML AVA TAB AVA TAB Base Price 0.5257 0.5257 0.5757 0.2058 0.3228 0.4176 0.5057 0.6250 0.6250 0.2556 0.4501 0.6096 5.8031 0.5240 0.1630 0.2440 0.4848 0.1730 0.6407 2.9650 0.9080 0.2911 0.5667 4.0573 0.3654 0.2205 0.3365 0.5040 0.7564 0.7564 0.7564 0.7564 0.0948 0.9703 0.1896 1.9025 0.4464 Pg 16 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002366371 00002366398 00002364719 00002364727 00002360861 00002360888 00002366665 00002366673 00002366703 00002366681 00002364271 00002363488 00002363453 00002363496 00002363461 00002373920 00002373939 00002364409 00002364530 00002363771 00002363763 00002364573 00002364581 00002364603 00002363518 00002363704 00002363712 00002363968 00002363976 00002373327 00002373335 00002373319 00002373343 00002373351 00002373378 00002371677 00002371685 Product Description AVA-CLARITHROMYCIN 250 MG TABLET AVA-CLARITHROMYCIN 500 MG TABLET AVA-CLINDAMYCIN 150 MG CAPSULE AVA-CLINDAMYCIN 300 MG CAPSULE AVA-CLONIDINE 0.025 MG TABLET AVA-CLONIDINE 0.1 MG TABLET AVA-DICLOFENAC 25 MG ENTERIC-COATED TABLET AVA-DICLOFENAC 50 MG ENTERIC-COATED TABLET AVA-DICLOFENAC SR 100 MG SUSTAINED-RELEASE TABLET AVA-DICLOFENAC SR 75 MG SUSTAINED-RELEASE TABLET AVA-DOMPERIDONE 10 MG TABLET AVA-ENALAPRIL 10 MG TABLET AVA-ENALAPRIL 2.5 MG TABLET AVA-ENALAPRIL 20 MG TABLET AVA-ENALAPRIL 5 MG TABLET AVA-FAMOTIDINE 20 MG TABLET AVA-FAMOTIDINE 40 MG TABLET AVA-FENOFIBRATE MICRO 200 MG CAPSULE AVA-FLUOXETINE 20 MG CAPSULE AVA-FLUVOXAMINE 100 MG TABLET AVA-FLUVOXAMINE 50 MG TABLET AVA-FUROSEMIDE 20 MG TABLET AVA-FUROSEMIDE 40 MG TABLET AVA-FUROSEMIDE 80 MG TABLET AVA-GLICLAZIDE 80 MG TABLET AVA-GLYBURIDE 2.5 MG TABLET AVA-GLYBURIDE 5 MG TABLET AVA-HYDROCHLOROTHIAZIDE 25 MG TABLET AVA-HYDROCHLOROTHIAZIDE 50 MG TABLET AVA-IRBESARTAN 150 MG TABLET AVA-IRBESARTAN 300 MG TABLET AVA-IRBESARTAN 75 MG TABLET AVA-IRBESARTAN/HCTZ 150/12.5 MG TABLET AVA-IRBESARTAN/HCTZ 300/12.5 MG TABLET AVA-IRBESARTAN/HCTZ 300/25 MG TABLET AVA-LEVETIRACETAM 250 MG TABLET AVA-LEVETIRACETAM 500 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB CAP CAP TAB TAB ECT ECT SRT SRT TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue AVA TAB AVA TAB AVA CAP AVA CAP AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA CAP AVA CAP AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB Base Price 1.1001 1.8249 0.4890 0.9780 0.1523 0.1765 0.1902 0.3804 0.7608 0.5706 0.1418 0.5932 0.4172 0.7156 0.4935 0.5896 1.0612 1.0890 1.0112 0.8902 0.4952 0.0445 0.0670 0.1220 0.2242 0.0393 0.0683 0.0395 0.0551 0.5444 0.5444 0.5444 0.5444 0.5444 0.5407 0.9632 1.1739 Pg 17 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002371693 00002361027 00002361035 00002362880 00002362899 00002362902 00002364239 00002364247 00002364506 00002364514 00002364859 00002364840 00002364832 00002364824 00002362937 00002298589 00002365820 00002365839 00002365847 00002365855 00002365863 00002247085 00002366304 00002364301 00002364328 00002373467 00002373432 00002373440 00002373459 00002363429 00002363305 00002363321 00002363348 00002363267 00002363291 00002363275 00002363283 Product Description AVA-LEVETIRACETAM 750 MG TABLET AVA-LEVOFLOXACIN 250 MG TABLET AVA-LEVOFLOXACIN 500 MG TABLET AVA-LISINOPRIL HCT 10 MG/12.5 MG TABLET AVA-LISINOPRIL HCT 20 MG/12.5 MG TABLET AVA-LISINOPRIL HCT 20 MG/25 MG TABLET AVA-LOVASTATIN 20 MG TABLET AVA-LOVASTATIN 40 MG TABLET AVA-METFORMIN 500 MG TABLET AVA-METFORMIN 850 MG TABLET AVA-METOPROLOL (TYPE L) 100 MG TABLET AVA-METOPROLOL (TYPE L) 50 MG TABLET AVA-METOPROLOL 100 MG TABLET AVA-METOPROLOL 50 MG TABLET AVA-MIRTAZAPINE 30 MG TABLET AVAMYS 27.5 MCG/DOSE NASAL SPRAY AVA-NAPROXEN 375 MG TABLET AVA-NAPROXEN 500 MG TABLET AVA-NAPROXEN EC 250 MG ENTERIC-COATED TABLET AVA-NAPROXEN EC 375 MG ENTERIC-COATED TABLET AVA-NAPROXEN EC 500 MG ENTERIC-COATED TABLET AVANDAMET 1 MG/500 MG TABLET AVA-NORFLOXACIN 400 MG TABLET AVA-NORTRIPTYLINE 10 MG CAPSULE AVA-NORTRIPTYLINE 25 MG CAPSULE AVA-OLANZAPINE 10 MG TABLET AVA-OLANZAPINE 2.5 MG TABLET AVA-OLANZAPINE 5 MG TABLET AVA-OLANZAPINE 7.5 MG TABLET AVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET AVA-PRAMIPEXOLE 0.25 MG TABLET AVA-PRAMIPEXOLE 1 MG TABLET AVA-PRAMIPEXOLE 1.5 MG TABLET AVA-RAMIPRIL 1.25 MG TABLET AVA-RAMIPRIL 10 MG TABLET AVA-RAMIPRIL 2.5 MG TABLET AVA-RAMIPRIL 5 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SPM TAB TAB ECT ECT ECT TAB TAB CAP CAP TAB TAB TAB TAB ECT TAB TAB TAB CAP/TAB CAP/TAB CAP/TAB CAP/TAB MFR Unit of Issue AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB GSK DOSE AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB GSK TAB AVA TAB AVA CAP AVA CAP AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB Base Price 1.6254 2.8494 3.2153 0.5019 0.6030 0.6030 1.0907 2.0117 0.1216 0.2040 0.2223 0.1225 0.2223 0.1225 0.6944 0.2287 0.1458 0.2110 0.2467 0.3234 0.5842 0.6903 1.2204 0.1260 0.2546 4.2270 1.0568 2.1135 3.1703 1.2135 0.5887 1.1776 1.1776 0.4174 0.6100 0.4815 0.4815 Pg 18 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002364816 00002367173 00002367181 00002367203 00002364344 00002367211 00002367238 00002367246 00002363682 00002363674 00002270994 00002366266 00002366258 00002366231 00002370980 00002370999 00002370972 00002367130 00002367149 00002367114 00002367122 00002367084 00002367076 00002367092 00002367106 00002367068 00002237792 00002243741 00002363534 00002363542 00002317508 00002241416 00002382369 00002343002 00002284642 00002284650 00002274388 Product Description AVA-RISEDRONATE 35 MG TABLET AVA-RISPERIDONE 0.25 MG TABLET AVA-RISPERIDONE 0.5 MG TABLET AVA-RISPERIDONE 1 MG TABLET AVA-RISPERIDONE 1 MG/ML ORAL SOLUTION AVA-RISPERIDONE 2 MG TABLET AVA-RISPERIDONE 3 MG TABLET AVA-RISPERIDONE 4 MG TABLET AVA-SOTALOL 160 MG TABLET AVA-SOTALOL 80 MG TABLET AVASTIN 25 MG/ML INJECTION AVA-SUMATRIPTAN 100 MG TABLET AVA-SUMATRIPTAN 50 MG TABLET AVA-TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET AVA-TOPIRAMATE 100 MG TABLET AVA-TOPIRAMATE 200 MG TABLET AVA-TOPIRAMATE 25 MG TABLET AVA-VALSARTAN 160 MG TABLET AVA-VALSARTAN 320 MG TABLET AVA-VALSARTAN 40 MG TABLET AVA-VALSARTAN 80 MG TABLET AVA-VALSARTAN HCT 160 MG/ 25 MG TABLET AVA-VALSARTAN HCT 160 MG/12.5 MG TABLET AVA-VALSARTAN HCT 320 MG/12.5 MG TABLET AVA-VALSARTAN HCT 320 MG/25 MG TABLET AVA-VALSARTAN HCT 80 MG/12.5 MG TABLET AVAXIM 160 U/0.5 ML INJECTION SYRINGE AVAXIM-PEDIATRIC 80 UNIT/0.5 ML INJECTION SYRINGE AVA-ZOPICLONE 5 MG TABLET AVA-ZOPICLONE 7.5 MG TABLET AVEENO CREAM AVEENO MOISTURIZING BATH AXIRON 2% TOPICAL SOLUTION AZATHIOPRINE 50 MG TABLET AZILECT 0.5 MG TABLET AZILECT 1.0 MG TABLET AZITHROMYCIN 20 MG/ML ORAL SUSPENSION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL TOP TOP TOP ORL ORL ORL ORL 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. Form TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB DEFAUL TAB TAB ERT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB NDL NDL TAB TAB CRM PWR SOL TAB TAB TAB SUS MFR Unit of Issue AVA TAB AVA TAB AVA TAB AVA TAB AVA ML AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB HLR ML AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB AVA TAB SFP SYR SFP SYR AVA TAB AVA TAB JJI G JJI G LIL ML SNS TAB TMP TAB TMP TAB PMS ML Base Price 4.8169 0.2615 0.4379 0.6048 0.7727 1.2075 1.8113 2.4150 0.5771 0.4922 136.4925 9.8433 8.9350 0.2700 1.2537 1.9845 0.6615 0.5724 0.5500 0.5240 0.5724 0.5724 0.5724 0.5633 0.5633 0.5724 46.3500 23.1800 0.2231 0.4685 0.0219 0.0494 1.5259 0.2405 7.8727 7.8727 0.3727 Pg 19 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002274396 00002330911 00000598577 00000598569 00000123803 00080007498 00080002409 00002245512 00001927906 00000876488 00000584908 00000030708 00002152584 00002152592 00000037818 00002243425 00002244010 00000436895 00001908855 00002369613 00002369621 00002369648 00002060841 00002135620 00002243966 00000075124 00000498815 00002237567 00080043158 00002019736 00002019701 00002017849 00002019671 00002061287 00002229367 00002019698 00002239138 Product Description AZITHROMYCIN 40 MG/ML ORAL SUSPENSION AZITHROMYCIN 600 MG TABLET B COMPLEX 50 TABLET B COMPLEX 75 TABLET B COMPLEX PLUS C TABLET B&C VITAMINS TABLET B12 1000 MCG TABLET B50 COMPLEX CAPSULE BACID 1 B CAPSULE BACIMYXIN TOPICAL OINTMENT BACITIN 500 UNIT/G TOPICAL OINTMENT BACITRACIN 50,000 U/VIAL INJECTION BACLOFEN 10 MG TABLET BACLOFEN 20 MG TABLET BACTERIOSTATIC SODIUM CHLORIDE 0.9% INJECTION BALANCED B COMPLEX 100 MG SUSTAINED-RELEASE TABLET BALMINIL CODEINE NIGHT TIME + EXPECTORANT BALMINIL DM 3 MG/ML ORAL SYRUP BALNETAR 2.5% TOPICAL SOLUTION BANZEL 100 MG TABLET BANZEL 200 MG TABLET BANZEL 400 MG TABLET BARRIERE 20% TOPICAL CREAM BASALJEL 500 MG CAPSULE BAZA CLEANSE & PROTECT 2% TOPICAL LOTION BCG VACCINE (FREEZE-DRIED) 1 MG INJECTION B-COMPLEX 100 SUSTAINED-RELEASE TABLET BEANO 150 UNIT TABLET BEDUZIL 1500 1500 MCG TABLET BENADRYL 12.5 MG/5 ML ORAL ELIXIR BENADRYL 2% TOPICAL CREAM BENADRYL 25 MG CAPLET BENADRYL 50 MG CAPSULE BENADRYL ALLERGY JUNIOR STRENGTH CHEWABLE TABLET BENADRYL ALLERGY SINUS HEADACHE CAPLET BENADRYL CHILDREN'S 1.25 MG/ML ORAL LIQUID BENADRYL EXTRA STRENGTH 50 MG CAPLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP INJ ORL ORL INJ ORL ORL ORL TOP ORL ORL ORL TOP ORL TOP INJ ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL 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. Form SUS TAB TAB TAB TAB TAB TAB CAP CAP ONT ONT DEFAUL TAB TAB DEFAUL SRT SYR SYR SOL TAB TAB TAB CRM CAP LOT DEFAUL SRT TAB ERT ELX CRM TAB CAP CTB TAB LIQ TAB MFR Unit of Issue PMS ML SNS TAB JAM TAB JAM TAB JAM TAB WBP TAB WNP TAB WNP CAP ERF CAP PMS G PPH G PFI VIAL PDL TAB PDL TAB HSP ML PMT TAB ROG ML ROG ML WSD ML EIS TAB EIS TAB EIS TAB WSP G AUP CAP COC ML SFP VIAL JAM TAB GSK TAB ORI TAB PDH ML WLA G PDH TAB PDH CAP PDH TAB PDH TAB PDH ML PDH TAB Base Price 0.5280 6.0000 0.1144 0.1712 0.0859 0.0669 0.0850 0.1193 0.6598 0.2433 0.2067 12.5800 0.1595 0.3104 0.2140 0.0850 0.0295 0.0450 0.0496 0.7843 1.5685 3.3646 0.0710 0.1638 0.0485 207.8000 0.2288 0.1907 0.1158 0.0570 0.2867 0.4117 0.2514 0.4483 0.3175 0.0570 0.5583 Pg 20 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002370050 00002370069 00002245709 00001944738 00002215268 00002245383 00001944746 00001944711 00002003317 00001944673 00001944762 00002265427 00001912437 00001925199 00002162121 00002225271 00002336847 00000716634 00000158348 00002237835 00002417030 00002359685 00002382423 00002325985 00002291924 00000297763 00002230897 00002392143 00002392127 00002392135 00002392186 00002392194 00002392178 00000621366 00002247371 00002247372 00080012473 Product Description BENLYSTA 120 MG /VIAL INJECTION BENLYSTA 400 MG /VIAL INJECTION BENYLIN 2 COLD AND FLU WITH CODEINE ORAL SYRUP BENYLIN DM 3 MG/ML ORAL SYRUP BENYLIN DM FOR CHILDREN 1.5 MG/ML ORAL SYRUP BENYLIN DM FREEZER POPS 7.5 MG/ PACKET ORAL LIQUID BENYLIN DM-D FOR CHILDREN ORAL SYRUP BENYLIN DM-D ORAL SYRUP BENYLIN DM-D-E EXTRA STRENGTH ORAL SYRUP BENYLIN DM-D-E ORAL SYRUP BENYLIN DM-E ORAL SYRUP BENYLIN E EXTRA STR W/ MENTHACTIN 40/3MG/ML SYR BENZAC AC 10% TOPICAL COPOLYMER GEL BENZAC W10 10% TOPICAL WASH BENZAGEL 5 5% WASH BENZAMYCIN TOPICAL GEL BESIVANCE 0.6% OPHTHALMIC SOLUTION BETADERM 0.1% SCALP LOTION BETADINE 10% TOPICAL SOLUTION BETAJECT INJECTION BEXSERO SUSPENSION 0.5 ML SYRINGE INJECTION BIACNA 1.2%/0.025% TOPICAL GEL BICALUTAMIDE 50 MG TABLET BICALUTAMIDE 50 MG TABLET BICILLIN L-A 1,200,000 IU/2 ML INJ SYR BICNU 100 MG/VIAL INJECTION BILTRICIDE 600 MG TABLET BIO-AMLODIPINE 10 MG TABLET BIO-AMLODIPINE 2.5 MG TABLET BIO-AMLODIPINE 5 MG TABLET BIO-ATENOLOL 100 MG TABLET BIO-ATENOLOL 25 MG TABLET BIO-ATENOLOL 50 MG TABLET BIODERM TOPICAL OINTMENT BIO-FUROSEMIDE 20 MG TABLET BIO-FUROSEMIDE 40 MG TABLET BIOGAIA DROPS Route INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP TOP OPH SCP TOP INJ INJ TOP ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL TOP ORL ORL ORL 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. Form DEFAUL DEFAUL SYR SYR SYR LIQ SYR SYR SYR SYR SYR SYR COPGEL WAS WAS GEL SOL LOT SOL DEFAUL NDL GEL TAB TAB NDL DEFAUL TAB TAB TAB TAB TAB TAB TAB ONT TAB TAB DPS MFR Unit of Issue GSK VIAL GSK VIAL PDH ML WLA ML WLA ML PDH PCKT WWA ML PDH ML PDH ML PDH ML WLA ML PDH ML GAL G GAL G NVC ML VCL G BSH ML TAR ML PUR ML SDZ ML NOV SYR VCL G SIV TAB AHI TAB PFI SYR BMS VIAL BAI TAB BMD TAB BMD TAB BMD TAB BMD TAB BMD TAB BMD TAB ODN G BMD TAB BMD TAB FEI ML Base Price 285.3000 950.9900 0.0570 0.0524 0.0524 0.5925 0.0524 0.0474 0.0388 0.0524 0.0524 0.0518 0.3333 0.3397 0.0619 1.2088 2.9240 0.0931 0.0311 10.7970 110.2800 1.1555 4.0573 4.0572 45.7010 120.0400 6.8683 0.3587 0.1380 0.2417 0.2362 0.0676 0.1437 0.3600 0.0373 0.0558 4.3200 Pg 21 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002247170 00002247171 00080015104 00080006533 00002216051 00000116785 00080003128 00000999776 00000999782 00000999777 00000437522 00002326302 00002361450 00002273411 00002131692 00000220442 00002247600 00002419149 00002419157 00002268140 00002408872 00002220520 00002220539 00000522791 00000512990 00000729655 00080022907 00002247970 00002331616 00000728284 00000728276 00000579947 00002223163 00002341212 00002341220 00002341174 00002361817 Product Description BIO-HYDROCHLOROTHIAZIDE 25 MG TABLET BIO-HYDROCHLOROTHIAZIDE 50 MG TABLET BIO-K EXTRA STRENGTH PROBIOTIC CAPSULE BIOMEDIC MULTIVITAMIN BION TEARS OPH SOLUTION BIONET TABLET BIONUTRITION FORMULA 3 CAPSULE BIOTENE ORAL BALANCE GEL BIOTENE ORAL RINSE BIOTENE SPRAY BIOTIN 250 MCG TABLET BI-PEGLYTE KIT BISACODYL 10 MG RECTAL SUPPOSITORY BISACODYL-ODAN 5 MGENTERIC-COATED TABLET BLEOMYCIN SULFATE 15 UNIT/VIAL INJECTION BONAMINE 25 MG CHEWABLE TABLET BOOSTRIX INJECTION SYRINGE BOSULIF 100 MG TABLET BOSULIF 500 MG TABLET BRAVELLE 75 UNIT/VIAL POWDER FOR INJECTION BREO ELLIPTA 100 MCG/25 MCG POWDER FOR INHALATION BROMAZEPAM 3 MG TABLET BROMAZEPAM 6 MG TABLET BRONCHOPHAN FORTE DM ORAL SYRUP BSS BALANCED SALT OPH SOLUTION BUCKLEY'S DM ORAL LIQUID BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB BUGS BUNNY AND FRIENDS COMPLETE MULTI VIT CHEW TAB BUPROPION SR 100 MG SUSTAINED-RELEASE TABLET BURINEX 1 MG TABLET BURINEX 5 MG TABLET BURO-SOL TOPICAL POWDER BUSPIRONE 10 MG TABLET BUTRANS 10 (10 MCG/HR) TRANSDERMAL PATCH BUTRANS 20 (20 MCG/HR) TRANSDERMAL PATCH BUTRANS 5 (5 MCG/HR) TRANSDERMAL PATCH BYETTA 10 MCG/DOSE (2.4 ML) INJECTION SYRINGE Route ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL RT ORL INJ ORL INJ ORL ORL INJ INH ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL TOP ORL TRD TRD TRD INJ Form TAB TAB CAP CAP SOL TAB CAP GEL MWH SPR TAB ECT/PWR SUP ECT DEFAUL CTB DEFAUL TAB TAB DEFAUL MIP TAB TAB SYR SOL LIQ CTB CTB SRT TAB TAB PWR TAB PTH PTH PTH NDL 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. MFR Unit of Issue PMS TAB PMS TAB BKP CAP VTH CAP ALC ML CHD TAB BNI CAP GSK G GSK ML GSK ML JAM TAB PPH KIT JPC SUP ODN TAB MNP VIAL JJM TAB GSK SYR PFI TAB PFI TAB FEI VIAL GSK DOSE PDL TAB PDL TAB ATL ML ALC ML BUA ML BIC TAB BIC TAB PDL TAB LEO TAB LEO TAB GSK G PDL TAB PUR PTH PUR PTH PUR PTH AZC SYR Base Price 0.0157 0.0217 1.5627 0.0607 0.9792 0.1938 1.1666 0.1715 0.0153 0.1637 0.0601 21.1900 0.5164 0.0550 460.1200 0.4420 29.8700 39.3343 157.3154 75.3440 4.3677 0.0375 0.0548 0.0268 0.4387 0.0513 0.0873 0.0873 0.2667 0.8633 3.2957 0.7510 0.3521 24.7875 45.0525 13.4975 152.3100 Pg 22 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002361809 00002399016 00002398990 00002399024 00002399008 00002273284 00002273292 00002273306 00002273314 00002273233 00002273241 00002273268 00002273276 00002238389 00000176095 00002241460 00002399334 00002399342 00000730602 00002240973 00000621722 00002240240 00002240977 00080003658 00080009369 00080000248 00080007105 00002040875 00002245170 00080006568 00002244861 00002048965 00002243418 00000730599 00000644684 00001922238 00080003855 Product Description BYETTA 5 MCG/DOSE (1.2 ML) INJECTION SYRINGE BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET CADUET 10 MG/10 MG TABLET CADUET 10 MG/20 MG TABLET CADUET 10 MG/40 MG TABLET CADUET 10 MG/80 MG TABLET CADUET 5 MG/10 MG TABLET CADUET 5 MG/20 MG TABLET CADUET 5 MG/40 MG TABLET CADUET 5 MG/80 MG TABLET CAELYX 2 MG/ML PEGYLATED LIPOSOME INJECTION CAFERGOT TABLET CAL MAG 2:1 WITH D TABLET CALCITRIOL 1 MCG/ML INJECTION USP CALCITRIOL 2 MCG/ML INJECTION USP CALCIUM & MAGNESIUM WITH VITAMIN D CAPSULE CALCIUM (CARBONATE) W/ VITAMIN D 500 MG/125 U TAB CALCIUM 500 MG TABLET CALCIUM 500 MG TABLET CALCIUM 500 MG TABLET CALCIUM 500 MG TABLET CALCIUM 650 MG TABLET CALCIUM 650 MG TABLET CALCIUM 650 MG WITH VITAMIN D 400 IU CAPLET CALCIUM AND MAGNESIUM CAPLET CALCIUM AND MAGNESIUM CITRATE WITH VITAMIN D TAB CALCIUM AND MAGNESIUM TABLET CALCIUM AND MAGNESIUM WITH VITAMIN D TAB CALCIUM AND MAGNESIUM WITH ZINC CAPLET CALCIUM BONE SOLUTION CALCIUM CARBONATE & VITAMIN D3 500 MG/125 U TABLET CALCIUM CARBONATE 500 MG (BASE) TABLET CALCIUM CARBONATE 500 MG CHEWABLE TABLET CALCIUM CITRATE 300 MG TABLET Route INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form NDL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB TAB DEFAUL DEFAUL CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB LIQ TAB TAB CTB TAB MFR Unit of Issue AZC SYR FLC TAB FLC TAB FLC TAB FLC TAB PFI TAB PFI TAB PFI TAB PFI TAB PFI TAB PFI TAB PFI TAB PFI TAB SCH ML NOV TAB WNP TAB STM ML STM ML SIS CAP WNP TAB HAL TAB PMT TAB WNP TAB WNP TAB PMT TAB JAM TAB JAM TAB JAM TAB WNP TAB GFR TAB PMT TAB JAM TAB ULT ML PMT TAB WBP TAB WAM TAB WNP TAB Base Price 152.3100 1.3157 1.3367 1.3157 1.3367 2.6752 3.3352 3.4400 3.4400 2.5339 2.9881 3.1094 3.1094 69.2560 0.8907 0.0568 9.5130 17.2550 0.2442 0.0750 0.0274 0.0850 0.0449 0.0258 0.0342 0.0775 0.0775 0.0731 0.0660 0.1140 0.0345 0.0335 0.0343 0.0345 0.0245 0.0988 0.0680 Pg 23 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002243766 00002158728 00002243669 00002237590 00002141019 00080007103 00002040905 00080007265 00001906828 00080027151 00002198630 00000535230 00002172917 00002007134 00002242997 00002231948 00080003751 00002240959 00080009423 00080009761 00080023065 00002247976 00080033741 00080012593 00002381680 00002293269 00002231622 00002377942 00002422069 00002388901 00002388693 00002377934 00002379260 00002392275 00080038188 00080050373 00002311690 Product Description CALCIUM CITRATE 300 MG TABLET CALCIUM CITRATE 350 MG TABLET CALCIUM CITRATE WITH VITAMIN D TABLET CALCIUM CITRATE WITH VITAMIN D TABLET CALCIUM GLUCONATE 94 MG/ML INJECTION CALCIUM MAGNESIUM WITH VITAMIN D CAPLET CALCIUM MAGNESIUM WITH VITAMIN D TABLET CALCIUM SOFT CHEWS WITH VITAMIN D CAL-MAG WITH ZINC & VITAMIN D CAPLET CALMOSEPTINE OINTMENT CALMYLIN ACE 2 MG/ML SYRUP CALMYLIN WITH CODEINE COUGH ORAL LIQUID CALMYLIN WITH CODEINE ORAL SYRUP CALTINE 100 UNIT/ML INJECTION CALTRATE 600 MG WITH VITAMIN D SOFT CHEWS TABLET CALTRATE 600 MG WITH VITAMIN D TABLET CALTRATE 600 TABLET CALTRATE PLUS CHEWABLE TABLET CALTRATE PLUS CHEWABLES 400 IU CALTRATE PLUS TABLET CALTRATE SELECT 600 MG/400 IU TABLET CALTRATE SELECT 600 MG/400 IU TABLET CALTRATE WITH VITAMIN D 600 MG/800 IU TABLET CALTRATE WITH VITAMIN D SOFT CHEWS CAMBIA 50 MG ORAL POWDER PACKET CAMPRAL 333 MG DELAYED-RELEASE TABLET CAMPTOSAR 20 MG/ML INJECTION CANDESARTAN 16 MG TABLET CANDESARTAN 32 MG TABLET CANDESARTAN 4 MG TABLET CANDESARTAN 4 MG TABLET CANDESARTAN 8 MG TABLET CANDESARTAN CILEXETIL 4 MG TABLET CANDESARTAN-HCTZ 16 MG/12.5 MG TABLET CANDIBACTIN BR TABLET CANDIBACTIN-AR CAPSULE CANESORAL 150 MG CAPSULE Route ORL ORL ORL ORL INJ ORL ORL ORL ORL TOP ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB TAB DEFAUL TAB TAB CAP TAB ONT SYR LIQ SYR DEFAUL CTB TAB TAB CTB TAB TAB TAB TAB TAB CTB PWDPKT DRT DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP MFR Unit of Issue PMT TAB SWS TAB WNP TAB JAM TAB PPC ML JAM TAB JAM TAB JAM CAP SWS TAB CAL G RPH ML RPH ML ROG ML FEI ML WCH TAB WCH TAB PDH TAB WCH TAB PDH TAB PDH TAB PDH TAB WCH TAB PDH TAB WAY TAB TRI PCKT MYP TAB PFI ML PDL TAB PDL TAB SNS TAB SIV TAB PDL TAB AHI TAB PDL TAB MTG TAB MTG CAP BIC CAP Base Price 0.0791 0.0945 0.0833 0.0718 1.0364 0.0731 0.0685 0.1893 0.0902 0.0669 0.1048 0.0554 0.0590 8.0550 0.1935 0.1843 0.1843 0.2322 0.2221 0.1922 0.2200 0.2212 0.1738 0.1935 10.8100 0.8736 119.5380 0.3420 0.2850 0.3400 0.3400 0.3420 0.3400 0.2993 0.3033 0.4550 18.6900 Pg 24 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002311739 00002311720 00002150867 00080028872 00000589500 00000619035 00080023975 00000619027 00000772011 00002242738 00002157101 00002157128 00002060043 00002413590 00002413604 00002241999 00002242001 00002245511 00002011239 00002126680 00002397447 00002397455 00002324520 00002324539 00002324504 00002324512 00002184478 00000291889 00002245859 00002215756 00000465208 00000465186 00000832804 00000465216 00000465194 00000360430 00000360414 Product Description CANESORAL COMBI-PAK KIT CANESTEN 1% EXTERNAL CREAM CANESTEN 1% TOPICAL CREAM CANTHACUR 0.7% TOPICAL SOLUTION CANTHACUR-PS TOPICAL SOLUTION CANTHARONE 0.7% TOPICAL SOLUTION CANTHARONE 0.7% TOPICAL SOLUTION CANTHARONE PLUS TOPICAL SOLUTION CANTHARONE PLUS TOPICAL SOLUTION CAPEX 0.01% TOPICAL SHAMPOO CAPSAICIN 0.025% TOPICAL CREAM CAPSAICIN 0.075% TOPICAL CREAM CARBACHOL 2 MG TABLET CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TABLET CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TABLET CARBOCAINE 10 MG/ML INJECTION CARBOCAINE 20 MG/ ML INJECTION CARBOCAL D 400 TABLET CARBOLITH 600 MG CAPSULE CARBOPLATIN 10 MG/ML INJECTION CARIPUL 0.5 MG/VIAL INJECTION CARIPUL 1.5 MG/VIAL INJECTION CARVEDILOL 12.5 MG TABLET CARVEDILOL 25 MG TABLET CARVEDILOL 3.125 MG TABLET CARVEDILOL 6.25 MG TABLET CASODEX 50 MG TABLET CATAPRES 0.2 MG TABLET CATHFLO 1 MG/ML POWDER FOR SOLUTION CAVERJECT 20 MCG INJECTION CECLOR 25 MG/ML ORAL SUSPENSION CECLOR 250 MG CAPSULE CECLOR 375 MG/5ML ORAL SUSPENSION CECLOR 50 MG/ML ORAL SUSPENSION CECLOR 500 MG CAPSULE CEENU 10 MG CAPSULE CEENU 100 MG CAPSULE Route ORL/VAG TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP ORL ORL ORL INJ INJ ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL Form CAP/CRM CRM CRM SOL SOL SOL SOL SOL SOL SHP CRM CRM TAB SRT SRT DEFAUL DEFAUL TAB CAP DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL SUS CAP SUS SUS CAP CAP CAP 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. MFR Unit of Issue BIC KIT BIC G BAI G PMS ML PMS ML BAK ML DLX ML BAK ML DLX ML GAL ML VCL G VCL G BNQ TAB PDL TAB PDL TAB HSP ML HSP ML EUP TAB VCL CAP HSP ML ACT VIAL ACT VIAL PDL TAB PDL TAB PDL TAB PDL TAB AZC TAB BOE TAB HLR ML PFI VIAL PPH ML PPH CAP PHH ML PPH ML PPH CAP BMS CAP BMS CAP Base Price 17.6300 13.3100 0.3913 7.4160 8.9013 7.1600 7.2720 7.9930 8.7280 0.7203 0.2032 0.2465 0.5900 0.0930 0.1859 0.6313 1.3572 0.1310 0.2018 19.2500 17.1760 34.4470 0.6350 0.6350 0.6350 0.6350 7.6143 0.3306 35.2560 26.5340 0.1292 1.1092 0.2872 0.2365 2.1777 7.8420 22.3195 Pg 25 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000360422 00002237138 00002319039 00002036274 00002434091 00002434105 00002240773 00002332027 00000886971 00000886955 00000886963 00002212307 00002409968 00002292262 00002287668 00002250292 00002241639 00002241640 00002241638 00002424371 00002424398 00002357844 00002357852 00002357860 00002357879 00002242145 00002192748 00002237484 00002240347 00000870153 00000022802 00002299844 00002299852 00080013657 00080022930 00080024482 00080005174 Product Description CEENU 40 MG CAPSULE CEFAZOLIN 1 G/VIAL USP INJECTION CEFEPIME 2G/VIAL INJECTION CEFOTAN 1 G/VIAL INJECTION CEFOTAXIME SODIUM 1 G/VIAL INJECTION BP CEFOTAXIME SODIUM 2 G/VIAL INJECTION BP CEFOXITIN 10 G/VIAL USP INJECTION CEFPROZIL 50 MG/ML ORAL SUSPENSION CEFTAZIDIME 1 G/VIAL INJECTION CEFTAZIDIME 2 G/VIAL INJECTION CEFTAZIDIME 6 G/VIAL INJECTION CEFTIN 125 MG/5ML ORAL SUSPENSION CEFTRIAXONE 100 G/SMARTPAK BULK PACKAGE INJECTION CEFTRIAXONE FOR INJECTION BP 0.25G/VIAL INJECTION CEFTRIAXONE SODIUM FOR INJECTION 10 G/VIAL INJ CEFTRIAXONE SODIUM FOR INJECTION BP 1 G/VIAL INJ CEFUROXIME 1.5 G/VIAL USP INJECTION CEFUROXIME 7.5 G/VIAL USP INJECTION CEFUROXIME 750 MG/VIAL USP INJECTION CELECOXIB 100 MG CAPSULE CELECOXIB 200 MG CAPSULE CELESTODERM-V 0.1% TOPICAL CREAM CELESTODERM-V 0.1% TOPICAL OINTMENT CELESTODERM-V/2 0.05% TOPICAL CREAM CELESTODERM-V/2 0.05% TOPICAL OINTMENT CELLCEPT 200 MG/ ML ORAL SUSPENSION CELLCEPT 250 MG ORAL CAPSULE CELLCEPT 500 MG TABLET CELLCEPT I.V. 500 MG/VIAL INJECTION POWDER FOR SOL CELLUVISC 1% OPH SOLUTION CELONTIN 300 MG CAPSULE CELSENTRI 150 MG TABLET CELSENTRI 300 MG TABLET CENTRUM ADVANTAGE TABLET CENTRUM CARDIO TABLET CENTRUM FOR WOMEN CENTRUM FORTE TABLET Route ORL INJ INJ INJ INJ INJ INJ ORL INJ INJ INJ ORL INJ INJ INJ INJ INJ INJ INJ ORL ORL TOP TOP TOP TOP ORL ORL ORL INJ OPH ORL ORL ORL ORL ORL ORL ORL 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. Form CAP DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SUS DEFAUL DEFAUL DEFAUL SUS DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CAP CAP CRM ONT CRM ONT SUS CAP TAB DEFAUL SOL CAP TAB TAB TAB TAB TAB TAB MFR Unit of Issue BMS CAP PPC VIAL APX VIAL WAY VIAL STM VIAL STM VIAL TEV VIAL RAN ML PPC VIAL PPC VIAL PPC VIAL GSK ML PPC G SDZ VIAL TEV VIAL HSP VIAL PPC VIAL PPC VIAL PPC VIAL PDL CAP PDL CAP VCL G VCL G VCL G VCL G HLR ML HLR CAP HLR TAB HLR VIAL ALL ML ERF CAP PFI TAB PFI TAB PDH TAB PDH TAB PDH TAB PDH TAB Base Price 13.7335 6.0000 30.1960 15.0000 9.8000 19.6300 105.9500 0.2366 31.9700 60.8100 190.9900 0.1909 21.4200 7.7510 214.2000 35.2500 39.7900 149.2000 19.8900 0.1776 0.3553 0.0995 0.0995 0.0667 0.0629 1.8175 2.2719 4.5438 32.0000 0.8708 0.6378 17.7375 16.6485 0.1963 0.2258 0.1517 0.1700 Pg 26 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080020794 00002246440 00080005153 00002246362 00080021452 00002099365 00000828866 00002410923 00002230988 00002230694 00002241751 00001926683 00000158356 00000221570 00002342227 00002312263 00002247766 00002247767 00000496685 00080009742 00002248435 00002238626 00002238295 00000870455 00002039990 00002229538 00002046040 00002247621 00000743518 00000738972 00001970399 00000738964 00080015373 00002247459 00002248088 00002296888 00002248089 Product Description CENTRUM JUNIOR COMPLETE CHEWABLE TABLET CENTRUM SELECT CHEWABLE TABLET CENTRUM SELECT TABLET CENTRUM TABLET CENTRUM TABLET CEPACOL MINT WITH FLUORIDE MOUTHWASH CEPHALEXIN 500 MG TABLET CERAVE TOPICAL LOTION CEREBYX 75 MG/ML INJECTION CEREZYME 200 U/VIAL INJECTION CEREZYME 400 U/VIAL INJECTION CERUBIDINE 20 MG/VIAL INJECTION CERUMENEX 10% OTIC DROPS CERUMOL OTIC DROPS CERVARIX 0.5 ML INJECTION CESAMET 0.25 MG ORAL CAPSULE CETROTIDE 0.25 MG/VIAL INJECTION CETROTIDE 3 MG/VIAL INJECTION CHELATED CHROMIUM 200 MCG TABLET CHEWABLE PEPPERMINT VITAMIN D 1000 IU CHILDREN'S ADVIL COLD ORAL SUSPENSION CHILDREN'S MOTRIN 40 MG/ML SUSPENSION DROPS CHILDRENS TYLENOL 80 MG CHEWABLE TABLET CHILDRENS TYLENOL COLD DM CHEWABLE TABLET CHILDREN'S TYLENOL COLD DM ORAL SUSPENSION CHILDRENS TYLENOL DECONGESTANT LIQUID CHILDREN'S TYLENOL GRAPE 32 MG/ML ORAL SUSPENSION CHLORAL HYDRATE-ODAN 100 MG/ML ORAL SYRUP CHLORPROMAZINE HCL 25 MG/ML (BASE) INJECTION CHLOR-TRIPOLON 4 MG TABLET CHLOR-TRIPOLON N.D. SUSTAINED-RELEASE TABLET CHLOR-TRIPOLON REPETABS 12 MG SUST RELEASE TABLET CHONDROCARE TABLET CHORIONIC GONADOTROPIN 10,000 UNIT/VIAL INJECTION CIALIS 10 MG TABLET CIALIS 2.5 MG TABLET CIALIS 20 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL TOP INJ INJ INJ INJ OT OT INJ ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL INJ ORL ORL ORL 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. Form CTB CTB TAB TAB TAB MWH TAB LOT DEFAUL DEFAUL DEFAUL DEFAUL DPS DPS DEFAUL CAP DEFAUL DEFAUL TAB TAB SUS DPS CTB CTB SUS LIQ SUS SYR DEFAUL TAB TAB SRT TAB DEFAUL TAB TAB TAB MFR Unit of Issue PDH TAB WCH TAB WCH TAB PDH TAB PDH TAB SKB ML PDL TAB VCL ML PFI ML GZM VIAL GZM VIAL ERF VIAL PUR ML PAL ML GSK ML VCL CAP SRO VIAL SRO VIAL JAM TAB SWS TAB PDH ML MCL ML MCL TAB MCL TAB MCL ML MCL ML MCL ML ODN ML SDZ ML SCH TAB SCH TAB SCH TAB MTG TAB PPC VIAL LIL TAB LIL TAB LIL TAB Base Price 0.1305 0.2223 0.1577 0.0969 0.1328 0.0040 0.4500 0.1071 10.1000 1230.0000 2460.0000 92.0000 0.5740 0.5191 198.3200 1.8322 96.7500 340.0000 0.0764 0.0479 0.0625 0.2733 0.1836 0.1763 0.0572 0.0572 0.0570 0.0433 1.8350 0.2242 0.4342 0.3404 0.4500 131.0200 15.3200 4.6850 15.8750 Pg 27 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002296896 00002238274 00002238273 00002410346 00002350971 00002200864 00002331675 00002391449 00002391457 00002251787 00002247916 00002304759 00002304546 00002403188 00002126613 00002430517 00002301822 00002387948 00002301830 00002301849 00002325047 00002257521 00000519235 00002150220 00002150158 00000262609 00002324490 00002237734 00000782696 00001945157 00000442968 00002324989 00002250616 00002408511 00002408538 00002248525 00002248526 Product Description CIALIS 5 MG TABLET CI-CAL + D TABLET CI-CAL 250 MG TABLET CICLOPIROX 8% TOPICAL SOLUTION CILAZAPRIL 2.5 MG TABLET CILOXAN 0.3% OPH OINTMENT CIMZIA 200 MG/ML INJECTION SYRINGE CIPRALEX MELTZ 10 MG ORALLY DISINTEGRATING TABLET CIPRALEX MELTZ 20 MG ORALLY DISINTEGRATING TABLET CIPRO XL 1000 MG EXTENDED-RELEASE TABLET CIPRO XL 500 MG EXTENDED-RELEASE TABLET CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ CIPROFLOXACIN INTRAVENOUS INFUSION BP 2 MG/ML INJ CISPLATIN 1 MG/ML INJECTION CISPLATIN 1 MG/ML INJECTION CITALOPRAM 10 MG TABLET CITALOPRAM 10 MG TABLET CITALOPRAM 10 MG TABLET CITALOPRAM 20 MG TABLET CITALOPRAM 40 MG TABLET CITALOPRAM-10 10 MG TABLET CITALOPROM-40 40 MG TABLET CITANEST PLAIN 4% INJECTION CITRACAL MG TABLET CITRACAL PLUS D CAPLET CITRO MAG 50 MG ORAL LIQUID CLARITHROMYCIN 500 MG TABLET CLARITIN 10 MG RAPID DISSOLVE TONGUE TABLET CLARITIN 10 MG TABLET CLARITIN EXTRA SUSTAINED-RELEASE TABLET CLEARASIL BP PLUS 5% TOPICAL LOTION CLEARLAX ORAL POWDER CLIMARA PRO 4.40 MG/1.39 MG TRANSDERMAL PATCH CLINDAMYCIN IV INFUSION 12 MG/ML MINIBAG INJECTION CLINDAMYCIN IV INFUSION 18 MG/ML MINIBAG INJECTION CLINDAMYCINE-150 150 MG TABLET CLINDAMYCINE-300 300 MG CAPSULE Route ORL ORL ORL TOP ORL OPH INJ ORL ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL TOP ORL TRD INJ INJ ORL ORL 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. Form TAB TAB TAB SOL TAB ONT NDL DISNTAB DISNTAB ERT ERT DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB TAB LIQ TAB DISPTAB TAB SRT LOT PWR PTH DEFAUL DEFAUL TAB CAP MFR Unit of Issue LIL TAB EUP TAB EUP TAB STM G SNS TAB ALC G UCB SYR LBC TAB LBC TAB BAI TAB BAI TAB SDZ ML APX ML TEV ML MNP ML JPC TAB MEL TAB SIV TAB MEL TAB MEL TAB PDL TAB PDL TAB DSC ML SFD TAB SFD TAB ROG ML PDL TAB SCH TAB SCH TAB SCH TAB RBC ML PRI G BAI PTH SDZ ML SDZ ML PDL TAB PDL CAP Base Price 4.6850 0.1513 0.1437 7.7433 0.4284 3.3800 725.6000 1.8750 1.9960 3.3980 3.3980 0.1540 0.1445 6.3370 6.4600 0.1432 0.4464 0.1432 0.8750 0.8750 0.1432 0.3329 0.8658 0.1535 0.1640 0.0155 1.6297 0.7100 0.8983 0.7100 0.1707 0.0275 7.3100 0.3724 0.5186 0.2217 0.4434 Pg 28 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002242970 00002243050 00080007070 00002248454 00002256398 00002256371 00002299739 00001910396 00002394820 00000812382 00002229380 00002274337 00002285215 00002285223 00002270641 00002270668 00002270676 00002390183 00002274248 00002274256 00002274272 00002379996 00002269627 00002327589 00002327597 00002302861 00002302888 00002302896 00080006266 00080007078 00002383209 00000068594 00000068608 00002150417 00002237726 00002150425 00002243897 Product Description CLINDASOL 1% TOPICAL CREAM CLINDETS PLEDGET 1% TOPICAL PAD CLINIDERM GENTLE SPF 45 LOTION CLOBAZAM-10 10 MG TABLET CLOBEX 0.05% TOPICAL LOTION CLOBEX 0.05% TOPICAL SHAMPOO CLOBEX 0.05% TOPICAL SPRAY CLONIDINE 0.1 MG TABLET CLOPIDOGREL 75 MG TABLET CLOTRIMADERM 1% TOPICAL CREAM CLOTRIMAZOLE 1% TOPICAL CREAM USP CO BICALUTAMIDE 50 MG TABLET CO CILAZAPRIL 2.5 MG TABLET CO CILAZAPRIL 5 MG TABLET CO CLONAZEPAM 0.5 MG TABLET CO CLONAZEPAM 1.0 MG TABLET CO CLONAZEPAM 2.0 MG TABLET CO EXEMESTANE 25 MG TABLET CO GLIMEPIRIDE 1 MG TABLET CO GLIMEPIRIDE 2 MG TABLET CO GLIMEPIRIDE 4 MG TABLET CO MYCOPHENOLATE 500 MG TABLET CO NORFLOXACIN 400 MG TABLET CO OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB CO OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB CO PIOGLITAZONE 15 MG TABLET CO PIOGLITAZONE 30 MG TABLET CO PIOGLITAZONE 45 MG TABLET CO Q10 100 MG CAPSULE CO Q10 LIQUID CO TRAMADOL/ACET 37.5 MG/325 MG TABLET COACTIFED ORAL SYRUP COACTIFED TABLET COATED ASPIRIN 325 MG CAPLET COATED ASPIRIN DAILY LOW DOSE 81 MG ECT COATED ASPIRIN EXTRA STRENGTH 500 MG CAPLET COATED DAILY LOW-DOSE ASA 81 MG TABLET Route TOP TOP TOP ORL TOP TOP TOP ORL ORL TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form CRM PAD LOT TAB LOT SHP SPR TAB TAB CRM CRM TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DISNTAB DISNTAB TAB TAB TAB CAP LIQ TAB SYR TAB ECT ECT ECT ECT MFR Unit of Issue GSK G GSK PAD SAH ML PDL TAB GAL ML GAL ML GAL ML PDL TAB PDL TAB TAR G TAR G APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB APH TAB SIS CAP INN ML APH TAB GSK ML GSK TAB BAI TAB BIC TAB BAI TAB PMS TAB Base Price 0.8112 0.7313 0.2415 0.1097 0.8180 0.8180 1.7854 0.1358 0.6577 0.3235 0.2100 4.1790 0.1849 0.2085 0.0495 0.1487 0.1286 4.0177 0.4900 0.4900 0.4900 2.1238 0.5449 5.5160 7.8257 0.5983 0.8383 1.2604 0.1666 0.7941 0.6452 0.1794 1.0012 0.0850 0.1153 0.0800 0.0433 Pg 29 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002009757 00002163748 00002163780 00002163799 00002230302 00000050024 00002248644 00002246219 00080010367 00080006827 00080006674 00002245926 00002231735 00080006505 00000287873 00000476420 00001944363 00001944355 00002419106 00002239213 00002374129 00002229633 00002247732 00002250241 00002247733 00002247734 00001945149 00002417162 00002417170 00002224577 00002176955 00080012965 00001980661 00000513288 00000022381 00002181215 00002099748 Product Description CODEINE 30 MG TABLET CODEINE CONTIN 100 MG SUSTAINED-RELEASE TABLET CODEINE CONTIN 150 MG SUSTAINED-RELEASE TABLET CODEINE CONTIN 200 MG SUSTAINED-RELEASE TABLET CODEINE CONTIN 50 MG SUSTAINED-RELEASE TABLET CODEINE PHOSPHATE 5 MG/ML ORAL SYRUP COENZYME Q10 100 MG CAPSULE COENZYME Q10 100 MG CAPSULE COENZYME Q10 150 MG SOFTGEL COENZYME Q10 30 MG CAPSULE COENZYME Q10 60 MG CAPSULE COENZYME Q10 60 MG CAPSULE COENZYME Q10 60 MG CAPSULE COENZYME Q10 SOFTGEL COLCHICINE 0.6 MG TABLET COLY-MYCIN M 150 MG/VIAL INJECTION COMBANTRIN 125 MG TABLET COMBANTRIN 50 MG/ML (BASE) ORAL SUSPENSION COMBIVENT RESPIMAT 20 MCG/100 MCG INH SOLUTION COMBIVIR TABLET COMPLERA 200 MG/25 MG/300 MG TABLET COMPLETE MULTI-ADULT TABLET CONCERTA 18 MG EXTENDED-RELEASE TABLET CONCERTA 27 MG EXTENDED-RELEASE TABLET CONCERTA 36 MG EXTENDED-RELEASE TABLET CONCERTA 54 MG EXTENDED-RELEASE TABLET CONDYLINE 0.5% TOPICAL SOLUTION CONSTELLA 145 MCG CAPSULE CONSTELLA 290 MCG CAPSULE COPHYLAC ORAL SOLUTION COQ10 30 MG CAPSULE COQ10 MRB 60 MG SOFTGEL CAPSULE CORTAMED 25 MG/G OPH OINTMENT CORTATE 0.5% TOPICAL CREAM CORTROSYN 0.25 MG/VIAL INJECTION COTAZYM ECS 4 CAPSULE (ENTERIC-COATED PELLET) COUGH SYRUP WITH CODEINE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL INH ORL ORL ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL OPH TOP INJ ORL ORL Form TAB SRT SRT SRT SRT SYR CAP CAP CAP CAP CAP CAP CAP TAB TAB DEFAUL TAB SUS CTG TAB TAB TAB ERT ERT ERT ERT SOL CAP CAP SOL CAP CAP ONT CRM DEFAUL CAP/ENCP SYR 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. MFR Unit of Issue RIV TAB PUR TAB PUR TAB PUR TAB PUR TAB ATL ML VTH CAP WNP CAP WBP CAP WNP CAP WNP CAP WNP CAP WNP CAP WNP TAB EUP TAB PFI VIAL PDH TAB PDH ML BOE CTG GSK TAB GIL TAB WAM TAB JAI TAB JAI TAB JAI TAB JAI TAB SAV ML FLC CAP FLC CAP VCL ML JAM CAP INN CAP SDZ G MFC G LYN VIAL ORG CAP ROG ML Base Price 0.0773 0.7272 1.0908 1.4545 0.3637 0.0558 0.3266 0.1403 0.3887 0.1312 0.2623 0.2540 0.3000 0.2947 0.2801 43.1300 1.1750 0.2789 28.7000 11.2243 45.3960 0.0607 2.2914 2.6444 2.9975 3.7033 12.4686 3.6033 5.7873 2.3680 0.2248 0.7950 6.0857 0.1467 98.7600 0.1795 0.0162 Pg 30 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002240206 00002243063 00002246568 00080027158 00002239007 00002415194 00000299561 00000299596 00000299588 00002241013 00002277778 00002229161 00002229196 00001950541 00002299909 00002089912 00002413795 00002220644 00002424584 00002148331 00002148382 00002290308 00002238526 00080038525 00002126656 00000386715 00002060604 00000582301 00000507415 00001997653 00000004774 00002359456 00002027860 00002285002 00002285010 00002284995 00080001791 Product Description COUMADIN 6 MG TABLET COVAN ORAL SYRUP COVERSYL PLUS LD 2 MG/0.625 MG TABLET CRANBERRY COMPLEX 500 MG CAPSULE CREON 5 MINIMICROSPHERES CAPSULE CREON MINIMICROSPHERES 6 CAPSULE CREO-RECTAL ADULT RECTAL SUPPOSITORY CREO-RECTAL INFANT RECTAL SUPPOSITORY CREO-RECTAL INFANT RECTAL SUPPOSITORY CRINONE 8% VAGINAL GEL CRITIC-AID CLEAR OINTMENT CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE CROMOLYN 2% NASAL SOLUTION CUBICIN 500 MG/VIAL INJECTION CUTIVATE 0.05% TOPICAL CREAM CYANOCOBALAMIN 1000 MCG/ML INJECTION CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE 10 MG TABLET CYCLOPENTOLATE HCL 0.5% OPH SOLUTION (MINIMS) CYCLOPENTOLATE HCL 1% OPH SOLUTION (MINIMS) CYESTRA-35 TABLET CYSTADANE 1 G/SCOOP ORAL POWDER CYSTA-Q CAPSULE CYTARABINE 100MG/ ML INJECTION CYTOSAR 100 MG/5 ML INJECTION DALACIN 2% VAGINAL CREAM DALACIN T 1% (BASE) TOPICAL SOLUTION DAN-GARD 2% TOPICAL SHAMPOO DANTRIUM 100 MG CAPSULE DARAPRIM 25 MG TABLET DAXAS 500 MCG TABLET DAYPRO 600 MG TABLET DDAVP MELT 120 MCG ORALLY DISINTEGRATING TABLET DDAVP MELT 240 MCG ORALLY DISINTEGRATING TABLET DDAVP MELT 60 MCG ORALLY DISINTEGRATING TABLET DDROPS 1,000 IU/DROP ORAL LIQUID Route ORL ORL ORL ORL ORL ORL RT RT RT VAG TOP ORL ORL NAS INJ TOP INJ ORL ORL OPH OPH ORL ORL ORL INJ INJ VAG TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL Form TAB SYR TAB CAP CAP/ENCP CAP/ENCP SUP SUP SUP GEL ONT CAP CAP SOL DEFAUL CRM DEFAUL TAB TAB SOL SOL TAB PWR CAP DEFAUL DEFAUL CRM SOL SHP CAP TAB TAB TAB DISNTAB DISNTAB DISNTAB LIQ 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. MFR Unit of Issue DPM TAB PMS ML SEV TAB JAM CAP ABB CAP ABB CAP SDZ SUP SDZ SUP SDZ SUP SRO G COC G MFC CAP MFC CAP PPH ML CUB VIAL GKC G MYP ML PDL TAB SIV TAB BSH ML BSH ML PMS TAB ORP G TPI CAP MNP ML PFI VIAL PAL G PFI ML VLP ML PAR CAP COR TAB TAK TAB PFI TAB FEI TAB FEI TAB FEI TAB DDR ML Base Price 0.5312 0.0625 0.9257 0.2083 0.1703 0.1831 0.7720 0.7500 0.6020 9.0368 0.1690 1.3467 2.8953 0.8138 174.0000 0.7250 0.4500 0.3727 0.3727 6.6667 6.6667 1.2138 4.5524 0.6155 16.7820 10.7240 0.8412 0.3710 0.0560 0.7684 1.3978 2.2930 0.7255 2.1647 3.8963 1.0820 1.4900 Pg 31 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002389282 00000791172 00002018403 00002238848 00000681989 00000681997 00002247093 00002239903 00002060345 00000873292 00002230642 00002227517 00002238407 00002300559 00002216280 00001942417 00002298155 00002239064 00002239065 00002204274 00002204266 00000489158 00000832030 00002354950 00002354969 00000833231 00002058235 00002237450 00002398958 00002398974 00002398966 00002398982 00002245391 00080028781 00002233542 00002337452 00002229552 Product Description DECAPEPTYL 0.1 MG/ML INJECTION SYRINGE DECONGEST 0.1 MG NASAL SOLUTION DELSYM 6 MG/ML CONTROLLED-RELEASE SUSPENSION DENAVIR 1% TOPICAL CREAM DERMAFLEX HC 1% CREAM DERMAFLEX HC 1% TOPICAL LOTION DERMAL THERAPY- HEEL CARE CREAM DERMALAC 12% CREAM DERMAREST DRICORT 0.5% TOPICAL CREAM DERMA-SMOOTHE/FS 0.01% TOPICAL OIL DERMATOP 0.1% EMOLLIENT CREAM DERMATOP 0.1% TOPICAL OINTMENT DERMAZINC 0.25% TOPICAL SPRAY DERMOTIC OIL EAR DROPS 0.01% OTIC SOLUTION DESIPRAMINE 100 MG TABLET DESITIN DIAPER RASH OINTMENT DESLORATADINE ALLERGY CONTROL 5 MG TABLET DETROL 1 MG TABLET DETROL 2 MG TABLET DEXAMETHASONE OMEGA 10 MG/ML INJECTION DEXAMETHASONE OMEGA 4 MG/ML INJECTION DEXASONE 4 MG TABLET DEXIDIN 20 MG TOPICAL SOLUTION DEXILANT 30 MG DELAYED-RELEASE CAPSULE DEXILANT 60 MG DELAYED-RELEASE CAPSULE DEXTROMETHORPHAN 15 MG/5 ML COUGH SYRUP DEY-PAK SODIUM CHLORIDE 0.9% INHALATION SOLUTION D-FORTE 50000 IU CAPSULE DIACOMIT 250 MG CAPSULE DIACOMIT 250 MG ORAL POWDER PACKET DIACOMIT 500 MG CAPSULE DIACOMIT 500 MG ORAL POWDER PACKET DIAMINE TABLET DIAMINE TABLET DIANE-35 2 MG/0.035 MG TABLET DIAPER RASH 15% TOPICAL CREAM DIARR-EZE 2 MG CAPLET Route INJ NAS ORL TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP OT ORL TOP ORL ORL ORL INJ INJ ORL TOP ORL ORL ORL INH ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL 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. Form DEFAUL SOL CRSUS CRM CRM LOT CRM CRM CRM OIL EMCRM ONT SPR SOL TAB ONT TAB TAB TAB DEFAUL DEFAUL TAB LIQ DRC DRC SYR SOL CAP CAP PWDPKT CAP PWDPKT TAB TAB TAB CRM TAB MFR Unit of Issue FEI SYR RPH ML NVC ML BRR G PAL G PAL ML DTR ML TAR G DEL G HDI ML VCL G VCL G DPI ML HDI ML AAP TAB PDH G PMS TAB PFI TAB PFI TAB OMG ML OMG ML VCL TAB ATL ML TAK CAP TAK CAP TAN ML MYP ML EUP CAP BCF CAP BCF PCKT BCF CAP BCF PCKT EUP TAB EUP TAB BHP TAB HJS G PMS TAB Base Price 13.1029 0.1510 0.0634 14.3200 0.1907 0.1132 0.0840 0.0628 0.1657 0.3068 1.8700 1.6630 0.2473 1.7470 0.9735 0.0588 0.5505 1.0842 1.0842 1.4010 1.6060 0.8140 0.0374 2.4022 2.4022 0.0199 0.0619 0.1986 6.3667 6.3667 12.7333 12.7333 0.0663 0.0631 1.7886 0.0093 0.3000 Pg 32 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002248994 00002238162 00000434388 00000313580 00000870978 00002351684 00002224127 00002224119 00000392820 00000392812 00002176017 00002231592 00002148749 00002274000 00002387174 00002048264 00002048272 00002241163 00000627100 00000622133 00002325306 00002325314 00002325322 00002325330 00002325349 00002231472 00002231474 00002231475 00002231057 00002300648 00002244079 00002244080 00002243083 00002243969 00002243091 00002244078 00002243231 Product Description DIARRHEA RELIEF 2 MG TABLET DIASTAT RECTAL DELIVERY SYS 5 MG/ML RECTAL GEL DIAZEPAM 10 MG TABLET DIAZEPAM 5 TABLET DICLOFENAC 50 MG ENTERIC-COATED TABLET DICLOFENAC POTASSIUM 50 MG TABLET DICLOFENAC-SR 100 MG SUSTAINED-RELEASE TABLET DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET DICYCLOMINE HCL 10 MG CAPSULE DICYCLOMINE HYDROCHLORIDE 10 MG/ML INJECTION DIDROCAL 400 MG/500 MG TABLET DIFFERIN 0.1% TOPICAL CREAM DIFFERIN 0.1% TOPICAL GEL DIFFERIN XP 0.3% TOPICAL GEL DIFICID 200 MG FILM-COATED TABLET DIGOXIN 0.25 MG/ML INJECTION DIGOXIN PEDIATRIC 0.05 MG/ML INJECTION DIHYDROERGOTAMINE MESYLATE 1 MG/ML INJECTION DILAUDID 2 MG/ML INJECTION DILAUDID-HP 10 MG/ML INJECTION DILTIAZEM TZ 120 MG EXTENDED-RELEASE CAPSULE DILTIAZEM TZ 180 MG EXTENDED-RELEASE CAPSULE DILTIAZEM TZ 240 MG EXTENDED-RELEASE CAPSULE DILTIAZEM TZ 300 MG EXTENDED-RELEASE CAPSULE DILTIAZEM TZ 360 MG EXTENDED-RELEASE CAPSULE DILTIAZEM-CD 120 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM-CD 180 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM-CD 240 MG CONTROLLED-DELIVERY CAPSULE DILTIAZEM-CD 300 MG CONTROLLED-DELIVERY CAPSULE DIMENHYDRINATE 50 MG/ML INJECTION DIMETANE EXPECTORANT C ORAL SYRUP DIMETANE EXPECTORANT DC ORAL SYRUP DIMETAPP DAYTIME COLD EXTRA STRENGTH CAPLET DIMETAPP DM COUGH & COLD ORAL LIQUID DIMETAPP NIGHTTIME COLD EXTRA STRENGTH CAPLET DIMETAPP-C ORAL SYRUP DIMETHYL SULFOXIDE IRRIGAT. 500 MG/G BLADDER SOL. Route ORL RT ORL ORL ORL ORL ORL ORL ORL INJ ORL TOP TOP TOP ORL INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL BLDIR 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. Form TAB GEL TAB TAB ECT TAB SRT SRT CAP DEFAUL TAB CRM GEL GEL TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL ERC ERC ERC ERC ERC CDC CDC CDC CDC DEFAUL SYR SYR TAB LIQ TAB SYR SOL MFR Unit of Issue PMS TAB VCL SYS PDL TAB PDL TAB PDL TAB SNS TAB PDL TAB PDL TAB SDZ CAP SDZ ML ASC TAB GAL G GAL G GAL G OPL TAB SDZ ML SDZ ML SDZ ML PUR ML PUR ML PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP ALV ML PDH ML PDH ML WCH TAB PDH ML WCH TAB PDH ML SDZ ML Base Price 0.2617 83.8500 0.0867 0.0650 0.2024 0.3937 0.4048 0.2343 0.0758 4.3080 0.4942 1.8668 1.8668 1.7002 118.2500 6.0745 11.1700 3.9067 1.0832 2.6510 0.4043 0.5366 0.7118 0.8897 1.0732 0.3529 0.4684 0.6213 0.7766 2.7300 0.0919 0.1242 0.2913 0.0544 0.3125 0.1213 1.2196 Pg 33 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001997769 00001997750 00002027100 00002023717 00002023768 00002270528 00002157624 00002157616 00000116815 00000116882 00002257548 00002257556 00002369567 00002219336 00000417262 00002243961 00002243960 00002240341 00002240342 00002240343 00002228335 00002412225 00002412233 00002246741 00000870218 00002246036 00002245946 00000794406 00000830267 00002246854 00000614491 00000614505 00002130963 00002246331 00002326841 00002326825 00002326833 Product Description DIODOQUIN 210 MG TABLET DIODOQUIN 650 MG TABLET DIONEPHRINE 2.5% OPH SOLUTION DIOPHENYL-T OPH SOLUTION DIOPRED 1% OPH SUSPENSION DIOVAN 40 MG TABLET DIOVOL PLUS AF CHEWABLE TABLET DIOVOL PLUS AF-SUSPENSION DIOVOL PLUS ORAL SUSPENSION DIOVOL PLUS TABLET DIPHENHYDRAMINE HYDROCHLORIDE 25 MG CAPLET DIPHENHYDRAMINE HYDROCHLORIDE 50 MG CAPLET DIPHENHYDRAMINE HYDROCHLORIDE 50 MG/ML INJECTION DIPHENIST 50 MG/ML INJECTION DIPROGEN TOPICAL CREAM DITROPAN XL 10 MG EXTENDED-RELEASE TABLET DITROPAN XL 5 MG EXTENDED-RELEASE TABLET DIVALPROEX-125 MG ENTERIC-COATED TABLET DIVALPROEX-250 MG ENTERIC-COATED TABLET DIVALPROEX-500 MG ENTERIC-COATED TABLET DOBUTAMINE HYDROCHLORIDE 12.5 MG/ML INJECTION DOCETAXEL 28 MG/ML (20 MG/0.72 ML) INJECTION DOCETAXEL 28 MG/ML (80 MG/2.88 ML) INJECTION DOCUSATE CALCIUM 240 MG CAPSULE DOCUSATE SODIUM 10 MG/ML ORAL DROPS DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 4 MG/ML ORAL SYRUP DOLORAL 1 MG ORAL SYRUP DOLORAL 5 MG ORAL SYRUP DOM-AMANTADINE 100 MG CAPSULE DOM-AMIODARONE 200 MG TABLET DOM-AMLODIPINE 10 MG TABLET DOM-AMLODIPINE 2.5 MG TABLET DOM-AMLODIPINE 5 MG TABLET Route ORL ORL OPH OPH OPH ORL ORL ORL ORL ORL ORL ORL INJ INJ TOP ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB SOL SOL SUS TAB CTB SUS SUS TAB TAB TAB DEFAUL DEFAUL CRM ERT ERT ECT ECT TAB DEFAUL DEFAUL DEFAUL CAP DPS CAP CAP CAP CAP SYR SYR SYR CAP TAB TAB TAB TAB MFR Unit of Issue GLE TAB GLE TAB DIO ML DIO ML SDZ ML NOV TAB CHD TAB CHD ML CHD ML CHD TAB JPC TAB JPC TAB PPC ML OMG ML SCH G JAI TAB JAI TAB PDL TAB PDL TAB PDL TAB TEV VIAL TEV ML TEV ML ROG CAP ROG ML ROG CAP JPC CAP VTH CAP TLI CAP ROG ML ATL ML ATL ML DPC CAP DPC TAB DPC TAB DPC TAB DPC TAB Base Price 0.8098 1.0048 0.7180 1.9467 1.9400 1.2743 0.1260 0.0180 0.0180 0.1260 0.1379 0.1709 4.3900 4.1000 0.8556 2.4874 2.4874 0.0724 0.1301 0.2604 23.2500 317.3194 317.3194 0.1360 0.1972 0.0446 0.0258 0.0334 0.0338 0.0260 0.0327 0.0559 0.5179 0.6177 0.3587 0.1380 0.2417 Pg 34 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002229468 00002229467 00002399482 00002399490 00002399504 00002278499 00002138271 00002138298 00002232564 00002238222 00002238223 00002251280 00002273055 00002351005 00002247230 00002130998 00002131013 00002224100 00002238633 00002130092 00002231662 00002231664 00002238315 00002376709 00002246109 00002246108 00002177617 00002177625 00002241348 00002241347 00002243743 00002243744 00002243745 00002241608 00002234514 00002239913 00002239917 Product Description DOM-ATENOLOL 100 MG TABLET DOM-ATENOLOL 50 MG TABLET DOM-ATORVASTATIN 10 MG TABLET DOM-ATORVASTATIN 20 MG TABLET DOM-ATORVASTATIN 40 MG TABLET DOM-AZITHROMYCIN 250 MG TABLET DOM-BACLOFEN 10 MG TABLET DOM-BACLOFEN 20 MG TABLET DOM-BUSPIRONE 10 MG TABLET DOM-CARBAMAZEPINE CR 200 MG SUSTAINED-RELEASE TAB DOM-CARBAMAZEPINE CR 400 MG SUSTAINED-RELEASE TAB DOM-CIPROFLOXACIN 500 MG TABLET DOM-CITALOPRAM 10 MG TABLET DOM-CLARITHROMYCIN 500 MG TABLET DOM-CLOBAZAM 10 MG TABLET DOM-CLONAZEPAM 0.5 MG TABLET DOM-CLONAZEPAM 2 MG TABLET DOM-CLONAZEPAM-R 0.5 MG TABLET DOM-CYCLOBENZAPRINE 10 MG TABLET DOM-DESIPRAMINE 25 MG TABLET DOM-DICLOFENAC 25 MG ENTERIC-COATED TABLET DOM-DICLOFENAC-SR 75 MG SUSTAINED-RELEASE TABLET DOM-DOMPERIDONE 10 MG TABLET DOM-FINASTERIDE 5 MG TABLET DOM-FLUCONAZOLE 100 MG TABLET DOM-FLUCONAZOLE 50 MG TABLET DOM-FLUOXETINE 10 MG CAPSULE DOM-FLUOXETINE 20 MG CAPSULE DOM-FLUVOXAMINE 100 MG TABLET DOM-FLUVOXAMINE 50 MG TABLET DOM-GABAPENTIN 100 MG CAPSULE DOM-GABAPENTIN 300 MG CAPSULE DOM-GABAPENTIN 400 MG CAPSULE DOM-GEMFIBROZIL 300 MG CAPSULE DOM-GLYBURIDE 5 MG TABLET DOM-INDAPAMIDE 1.25 MG TABLET DOM-INDAPAMIDE 2.5 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB TAB TAB TAB TAB TAB TAB SRT SRT TAB TAB TAB TAB TAB TAB TAB TAB TAB ECT SRT TAB TAB TAB TAB CAP CAP TAB TAB CAP CAP CAP CAP TAB TAB TAB MFR Unit of Issue DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC CAP DPC CAP DPC TAB DPC TAB DPC CAP DPC CAP DPC CAP DPC CAP DPC TAB DPC TAB DPC TAB Base Price 0.3306 0.2011 0.3137 0.3922 0.4216 1.2317 0.1595 0.4607 0.3521 0.1301 0.2602 0.6979 0.1432 1.6293 0.1538 0.0694 0.1196 0.0694 0.3727 0.2723 0.1094 0.4060 0.0831 0.4633 3.2047 1.8065 0.8650 0.6438 0.5297 0.2947 0.1456 0.3542 0.4221 0.1803 0.0683 0.1043 0.1706 Pg 35 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002372193 00002414775 00002245784 00002245785 00002247232 00002242726 00002231122 00002231121 00002376695 00002178729 00002178737 00002125145 00002333430 00002241285 00002248447 00002248448 00002248449 00002236857 00002238046 00002238047 00002231650 00002249723 00002249731 00002249758 00002320460 00002287986 00002287951 00002287978 00002243038 00002309831 00002396203 00002216949 00002245750 00002245748 00002245749 00002238635 00002238634 Product Description DOM-IRBESARTAN 150 MG TABLET DOM-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE DOM-LORAZEPAM 0.5 MG TABLET DOM-LORAZEPAM 1 MG TABLET DOM-LOVASTATIN 40 MG TABLET DOM-METFORMIN 850 MG TABLET DOM-METOPROLOL-L 100 MG TABLET DOM-METOPROLOL-L 50 MG TABLET DOM-MONTELUKAST FC 10 MG TABLET DOM-NORTRIPTYLINE 10 MG CAPSULE DOM-NORTRIPTYLINE 25 MG CAPSULE DOM-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION DOM-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET DOM-OXYBUTYNIN 5 MG TABLET DOM-PAROXETINE 10 MG TABLET DOM-PAROXETINE 20 MG TABLET DOM-PAROXETINE 30 MG TABLET DOMPERIDONE-10 10 MG TABLET DOM-PINDOLOL 10 MG TABLET DOM-PINDOLOL 15 MG TABLET DOM-PINDOLOL 5 MG TABLET DOM-PRAVASTATIN 10 MG TABLET DOM-PRAVASTATIN 20 MG TABLET DOM-PRAVASTATIN 40 MG TABLET DOM-RABEPRAZOLE EC 20 MG ENTERIC-COATED TABLET DOM-RAMIPRIL 10 MG CAPSULE DOM-RAMIPRIL 2.5 MG CAPSULE DOM-RAMIPRIL 5 MG CAPSULE DOM-RANITIDINE 150 MG TABLET DOM-RISEDRONATE 35 MG TABLET DOM-RIZATRIPTAN RDT 10 MG ORALLY DISINTEG TAB DOM-SALBUTAMOL 1 MG/ML INHALATION SOLUTION DOM-SERTRALINE 100 MG CAPSULE DOM-SERTRALINE 25 MG CAPSULE DOM-SERTRALINE 50 MG CAPSULE DOM-SOTALOL 160 MG TABLET DOM-SOTALOL 80 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL ORL ORL 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. Form TAB DRC TAB TAB TAB TAB TAB TAB TAB CAP CAP SUS CAP/SRT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ECT CAP/TAB CAP/TAB CAP/TAB TAB TAB DISNTAB SOL CAP CAP CAP TAB TAB MFR Unit of Issue DPC TAB DPC CAP DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC CAP DPC CAP DPC ML DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB PDL TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC CAP DPC CAP DPC CAP DPC TAB DPC TAB DPC TAB DPC ML DPC CAP DPC CAP DPC CAP DPC TAB DPC TAB Base Price 0.3025 0.5000 0.0359 0.0380 1.2579 0.1186 0.1941 0.0874 0.8195 0.0772 0.1560 0.0521 0.4117 0.1508 0.8210 0.6320 0.6714 0.0594 0.3253 0.4718 0.1905 0.4050 0.4778 0.8057 0.2407 0.1862 0.1470 0.1470 0.1800 2.4275 3.7050 0.3618 0.4200 0.2004 0.4000 0.1623 0.2966 Pg 36 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002270765 00002243749 00002128969 00002128950 00002414147 00002299313 00002299291 00002299305 00002240321 00002389525 00002246317 00002240823 00002416425 00002416417 00002240978 00002240979 00002240980 00002230108 00002375710 00002413973 00000817120 00000860751 00000887064 00001929313 00001929372 00001929380 00000740861 00000298433 00000342742 00000821772 00002247208 00002292165 00002239299 00000370576 00002125706 00000656747 00000490156 Product Description DOM-SUMATRIPTAN 100 MG TABLET DOM-TERAZOSIN 10 MG TABLET DOM-TRAZODONE 100 MG TABLET DOM-TRAZODONE 50 MG TABLET DOM-VALSARTAN 80 MG TABLET DOM-VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE DOM-VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAP DOM-VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAP DOM-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET DOM-ZOLMITRIPTAN 2.5 MG TABLET DOM-ZOPICLONE 5 MG TABLET DOM-ZOPICLONE 7.5 MG TABLET DONEPEZIL 10 MG TABLET DONEPEZIL 5 MG TABLET DOXAZOSIN-1 1MG TABLET DOXAZOSIN-2 2 MG TABLET DOXAZOSIN-4 4 MG TABLET DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION DOXORUBICIN HYDROCHLORIDE 2MG/ML INJECTION USP DOXYCIN 100 MG CAPSULE DOXYCIN 100 MG TABLET DOXYTAB 100 MG TABLET DRISTAN DECONGESTANT NASAL MIST SOLUTION DRISTAN LONG LASTING 0.05% NASAL MIST SOLUTION DRISTAN LONG LASTING MENTHOLATED 0.05% NASAL SPRAY DRIXORAL DESCONGESTANT 0.05% NASAL SOLUTION DRIXORAL SUSTAINED-RELEASE TABLET DRYSOL 20% TOPICAL SOLUTION D-TAB 10,000 UNIT TABLET DUKORAL ORAL SUSPENSION DUODOPA 20 MG/ML / 5MG/ML (100 ML) INTESTINAL GEL DUOFILM 40% TOPICAL PATCH DUOFILM TOPICAL SOLUTION DUOLUBE OPH OINTMENT DUONALC E (MILD) 20% TOPICAL SOLUTION DUONALC E 47.5% TOPICAL SOLUTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL NAS NAS NAS NAS ORL TOP ORL ORL INTRA TOP TOP OPH TOP TOP 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. Form TAB TAB TAB TAB TAB ERC ERC ERC SRT TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL CAP TAB TAB SOL SOL SPR SOL SRT SOL TAB SUS GEL PTH SOL ONT SOL SOL MFR Unit of Issue DPC TAB DPC TAB DPC TAB DPC TAB DPC TAB DPC CAP DPC CAP DPC CAP DPC TAB DPC TAB DPC TAB DPC TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB TEV ML SDZ ML MYP ML RIV CAP RIV TAB PDL TAB PDH ML PDH ML PDH ML SCH ML SCH TAB SFD ML RIV TAB AVE DOSE ABV CAS MMH PTH GSK ML BSH G VCL ML VCL ML Base Price 7.8600 0.6183 0.0989 0.0554 0.2957 0.3469 0.1643 0.3285 0.6767 4.6050 0.2231 0.4685 1.2340 1.2340 0.1416 0.1699 0.2209 11.4000 13.0420 11.4000 0.5860 0.5860 0.5860 0.3367 0.3367 0.3367 0.1593 0.4020 0.4539 0.2215 39.3000 166.0000 0.4633 0.5413 1.5657 0.2196 0.2196 Pg 37 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002148633 00002275848 00002275856 00002334186 00002275813 00002275821 00002373017 00002373025 00002373033 00002415534 00000999010 00002421712 00001947958 00001947931 00001947923 00002432889 00002260638 00002381389 00002381397 00002397749 00002397765 00002397757 00002370603 00080009719 00002349124 00002209764 00002210517 00002425637 00002247238 00002248239 00002248240 00002248999 00002268892 00000627410 00002296284 00002103109 00002298805 Product Description DUOVENT UDV INHALATION SOLUTION DURAGESIC MAT 75 (75 MCG/HR) TRANSDERMAL PATCH DURAGESIC MAT 100 (100 MCG/HR) TRANSDERMAL PATCH DURAGESIC MAT 12 (12 MCG/HR) TRANSDERMAL PATCH DURAGESIC MAT 25 (25 MCG/HR) TRANSDERMAL PATCH DURAGESIC MAT 50 (50 MCG/HR) TRANSDERMAL PATCH DURELA 100 MG EXTENDED-RELEASE CAPSULE DURELA 200 MG EXTENDED-RELEASE CAPSULE DURELA 300 MG EXTENDED-RELEASE CAPSULE DUREZOL 0.05% OPHTHALMIC EMULSION DUROLANE DUTASTERIDE 0.5 MG CAPSULE DUVOID 10 MG TABLET DUVOID 25 MG TABLET DUVOID 50 MG TABLET DYMISTA 50 MCG/137 MCG METERED DOSE NASAL SPRAY EBIXA 10 MG TABLET EDARBI 40 MG TABLET EDARBI 80 MG TABLET EDARBYCLOR 40 MG/12.5 MG TABLET EDARBYCLOR 40 MG/25 MG TABLET EDARBYCLOR 80 MG/12.5 MG TABLET EDURANT 25 MG TABLET EFAMOL 1000 MG CAPSULE EFFIENT 10 MG TABLET EGOZINC-HC RECTAL OINTMENT EGOZINC-HC RECTAL SUPPOSITORY ELELYSO 200 UNIT/VIAL INJECTION ELIDEL 1 % TOPICAL CREAM ELIGARD 10.2 MG/SYR INJECTION ELIGARD 28.2 MG/SYR INJECTION ELIGARD 35.8 MG/SYR INJECTION ELIGARD 58.2 MG/SYR INJECTION ELIXIR DE THEOPHYLLINE ELOXATIN 5 MG/ML INJECTION ELTOR-120 120 MG SUSTAINED-RELEASE TABLET EMEND 125 MG CAPSULE Route INH TRD TRD TRD TRD TRD ORL ORL ORL OPH DEFAUL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL ORL ORL ORL ORL RT RT INJ TOP INJ INJ INJ INJ ORL INJ ORL ORL 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. Form SOL PTH PTH PTH PTH PTH ERC ERC ERC EML DEV CAP TAB TAB TAB SPM TAB TAB TAB TAB TAB TAB TAB CAP TAB ONT SUP DEFAUL CRM NDL NDL NDL NDL ELX DEFAUL SRT CAP MFR Unit of Issue BOE ML JAI PTH JAI PTH JAI PTH JAI PTH JAI PTH CIP CAP CIP CAP CIP CAP ALC ML QMD ML PDL CAP PAL TAB PAL TAB PAL TAB MDP DOSE LBC TAB VCL TAB VCL TAB TAK TAB TAK TAB TAK TAB JAI TAB FMD CAP LIL TAB PMS G PMS SUP PFI VIAL VCL G SAV SYR SAV SYR SAV SYR SAV SYR ATL ML SAV ML SAV TAB MFC CAP Base Price 0.9024 42.0740 52.3680 5.7360 15.8940 29.9180 1.2447 2.2713 3.2977 5.8960 116.6667 0.9624 0.3312 0.5366 0.7068 0.7875 2.6647 1.2997 1.3200 1.3200 1.3200 1.3200 15.8003 0.1667 2.9893 0.4510 0.6075 648.3600 2.4862 310.7200 957.8200 1381.5900 1583.3000 0.0050 51.8160 0.2908 33.5550 Pg 38 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002324679 00000886858 00002057794 00080008611 00002248209 00002248208 00002334992 00002296454 00002010526 00000794244 00002246971 00000010340 00001905392 00000852015 00002050161 00000010332 00000880183 00000721891 00002264927 00002396971 00002396998 00002397005 00002397013 00002243801 00002271249 00080003615 00002409267 00000726672 00001925938 00002393751 00002424401 00002424428 00002394839 00002431173 00002394847 00002244990 00002237515 Product Description EMEND IV 115 MG/VIAL EMLA TOPICAL CREAM EMLA TOPICAL PATCH EMPOWER 18 PLUS CAPSULE ENCA 100 MG CAPSULE ENCA 50 MG CAPSULE ENDOMETRIN 100 MG VAGINAL EFFERVESCENT TABLET ENGERIX-B 10 MCG/0.5 ML SUSPENSION ENTERIC COATED ASA 325 MG TABLET ENTERIC COATED ASA 650 MG TABLET ENTEX LA SUSTAINED-RELEASE TABLET ENTROPHEN 10 650 MG ENTERIC-COATED TABLET ENTROPHEN 10 SUPER EXTRA STRENGTH 650 MG ECCPT ENTROPHEN 500 MG ENTERIC-COATED TABLET ENTROPHEN REGULAR STRENGTH (CAPLET) 325 MG ECCPT ENTROPHEN REGULAR STRENGTH 325 MG ECT EPI-LYT EPINEPHRINE 1 MG/ML INJECTION USP EPIRUBICIN HYDROCHLORIDE 2 MG/ML INJECTION EPURIS 10 MG CAPSULE EPURIS 20 MG CAPSULE EPURIS 30 MG CAPSULE EPURIS 40 MG CAPSULE EQUATE DAILY LOW-DOSE 81 MG ENTERIC-COATED TABLET ERBITUX 2 MG/ML INJECTION ERDOL 8288 IU/ML ORAL SOLUTION ERIVEDGE 150 MG CAPSULE ERYTHRO-EC 250 MG ENTERIC-COATED CAPSULE ERYTHRO-EC 333 MG ENTERIC-COATED CAPSULE ESBRIET 267 MG CAPSULE ESCITALOPRAM 10 MG TABLET ESCITALOPRAM 20 MG TABLET ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ESSENTIAL VITAMINS AND MINERALS TABLET ESTER C 1000 MG TABLET Route INJ TOP TOP ORL ORL ORL VAG INJ ORL ORL ORL ORL ORL ORL ORL ORL TOP INJ INJ ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form MFR Unit of Issue DEFAUL MFC VIAL CRM AZC G PTH AZC PTH CAP TRU CAP CAP PRP CAP CAP PRP CAP EVT FEI TAB DEFAUL GSK ML ECT WTR TAB ECT VTH TAB SRT PUR TAB ECT PPH TAB ECT PPH TAB ECT PPH TAB ECT PPH TAB ECT PPH TAB LOT VCL ML NDL HSP SYR DEFAUL HSP ML CAP CIP CAP CAP CIP CAP CAP CIP CAP CAP CIP CAP ECT PMS TAB DEFAUL BMS ML SOL ODN ML CAP HLR CAP CAP/ENCP AAP CAP CAP/ENCP AAP CAP CAP HLR CAP TAB PDL TAB TAB PDL TAB DRT PDL TAB DRT SNS TAB DRT PDL TAB TAB WNP TAB TAB SIS TAB 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. Base Price 30.1800 2.0520 2.9050 0.3025 1.0332 0.5350 4.3676 22.8400 0.0288 0.0566 0.4081 0.0843 0.0705 0.0686 0.0533 0.0533 0.1195 4.2040 13.3196 1.1693 1.5750 1.9807 2.3863 0.1096 6.7000 0.4152 294.2238 0.4193 0.4657 13.0302 1.4680 1.5630 1.5887 1.8690 1.5887 0.0214 0.1727 Pg 39 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002247480 00080003499 00000727369 00002403404 00000247960 00000247979 00002353210 00002080036 00000637726 00080013021 00000623377 00002242291 00080003010 00002303825 00002245668 00002242651 00002247385 00002246590 00002237556 00002241802 00002246733 00002412926 00002247383 00002247389 00002247390 00002264374 00002264390 00002264404 00002264412 00002264420 00002264439 00002264447 00002264323 00002264455 00002264331 00002264358 00002264366 Product Description ESTER-C 250 MG CHEWABLE TABLET ESTER-C CAPSULE ESTRAGYN 1MG/G VAGINAL CREAM ESTROGEL PROPAK 0.06% TRANSDERM. GEL/100MG CAPSULE ETIBI 100 MG TABLET ETIBI 400 MG TABLET ETIDROCAL 400 MG/500 MG TABLET ETOPOSIDE 20 MG/ML INJECTION EUFLEX 250 MG TABLET EUPHORBIUM COMPOSITUM SN ORAL DROPS EURAX 10% TOPICAL CREAM EURO - K8 600 MG SUSTAINED-RELEASE CAPSULE EURO D 800 IU CAPSULE EURO DOCUSATE C 100 MG CAPSULE EURO-CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP EURO-D VITAMIN D3 400 IU CAPSULE EURO-DOCUSATE 100 MG CAPSULE EURO-FER 20 MG/ML ORAL SUSPENSION EURO-FER 300 MG CAPSULE EURO-FER CF CAPSULE EURO-FERROUS SULFATE 300 MG TABLET EURO-HYDROCORTISONE 1% CREAM EURO-LAC 667 MG/ML SOLUTION EURO-SENNA 8.6 MG TABLET EURO-SENNA S 8.6 MG/50 MG TABLET EUTHYROX 100 MCG TABLET EUTHYROX 112 MCG TABLET EUTHYROX 125 MCG TABLET EUTHYROX 137 MCG TABLET EUTHYROX 150 MCG TABLET EUTHYROX 175 MCG TABLET EUTHYROX 200 MCG TABLET EUTHYROX 25 MCG TABLET EUTHYROX 300 MCG TABLET EUTHYROX 50 MCG TABLET EUTHYROX 75 MCG TABLET EUTHYROX 88 MCG TABLET Route ORL ORL VAG TRD/ORL ORL ORL ORL INJ ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form CTB CAP CRM GEL/CAP TAB TAB TAB DEFAUL TAB DPS CRM SRC CAP CAP SYR CAP CAP SUS CAP CAP TAB CRM SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue WNP TAB BMD CAP PAL G MFC KIT VCL TAB VCL TAB SNS TAB TEV ML MFC TAB HEE ML CLC G EUP CAP EUP CAP EUP CAP EUP ML EUP CAP EUP CAP EUP ML EUP CAP EUP CAP EUP TAB EUP G PMS ML EUP TAB EUP TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB SRO TAB Base Price 0.0863 0.1496 0.7280 51.0000 0.2204 0.6611 0.2221 15.0000 1.4131 0.7650 0.3914 0.0614 0.0600 0.0344 0.0658 0.0317 0.0328 0.0858 0.1537 0.2457 0.1571 0.1251 0.0154 0.0464 0.1192 0.0306 0.0644 0.0654 0.1148 0.0339 0.0699 0.0359 0.0564 0.0785 0.0249 0.0610 0.0610 Pg 40 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080005494 00002248297 00002377179 00002243896 00001990675 00002302853 00002432803 00002302845 00002226030 00002237524 00002184672 00002184680 00000813095 00002315955 00002242632 00002244142 00000889806 00000874965 00000707937 00002415992 00002422549 00002248968 00002324865 00002247745 00002247735 00002379910 00002229110 00002229129 00002177102 00002248624 00002231384 00002242531 00002286092 00002240360 00002395703 00002395657 00002395665 Product Description EVENING PRIMROSE OIL SOFTGEL CAPSULE EVRA 6 MG/0.6 MG TRANSDERMAL PATCH EXACT ANTI-NAUSEANT 50 MG TABLET EXACT DAILY LOW-DOSE ASA 81 MG ENTERIC-COATED TAB EXCEDRIN EXTRA-STRENGTH CAPLET EXELON PATCH 10 (9.5 MG/24 H) EXELON PATCH 15 (13.3 MG/24 H)EXELON PATCH 15 EXELON PATCH 5 (4.6 MG/24 H) EX-LAX CHOCOLATED TABLET EX-LAX EXTRA STRENGHT 25 MG TABLET EXOREX 1% TOPICAL GEL EXOREX 2% TOPICAL GEL EXPECTORANT COUGH FORMULA 100 MG/5 ML ORAL SYRUP EXTRA STRENGTH ALLERGY RELIEF 10 MG TABLET EXTRA STRENGTH MOTRIN IB 300 MG TABLET EXTRA STRENGTH NIGHTTIME COLD RELIEF TABLET EYELUBE .5% OPH DROPS EYELUBE 1% OPH DROPS EYE-STREAM EYE LIQUID EYLEA 2 MG/VIAL INJECTION EZETIMIBE 10 MG TABLET FACTIVE 320 MG TABLET FAMCICLOVIR 125 MG TABLET FAMOTIDINE OMEGA-(W PRES,BENZYL ALC) 10 MG/ML INJ FAMOTIDINE OMEGA-(W/O PRESERVATIVE) 10 MG/ML INJ FAMPYRA 10 MG SUSTAINED-RELEASE TABLET FAMVIR 125 MG TABLET FAMVIR 250 MG TABLET FAMVIR 500 MG TABLET FASLODEX 250 MG/5 ML INJECTION FEMARA 2.5 MG TABLET FEMHRT 1/5 TABLET FENOFIBRATE MICRO 200 MG CAPSULE FENO-MICRO-200 MG CAPSULE FENTANYL 100 MCG/HR TRANSDERMAL PATCH FENTANYL 12 MCG/HR TRANSDERMAL PATCH FENTANYL 25 MCG/HR TRANSDERMAL PATCH Route ORL TRD ORL ORL ORL TRD TRD TRD ORL ORL TOP TOP ORL ORL ORL ORL OPH OPH OPH INJ ORL ORL ORL INJ INJ ORL ORL ORL ORL INJ ORL ORL ORL ORL TRD TRD TRD 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. Form CAP PTH TAB ECT TAB PTH PTH PTH TAB TAB GEL GEL SYR TAB TAB TAB DPS DPS LIQ DEFAUL TAB TAB TAB DEFAUL DEFAUL SRT TAB TAB TAB NDL TAB TAB CAP CAP PTH PTH PTH MFR Unit of Issue WNP CAP JAI PTH APX TAB PMS TAB NVC TAB NOV PTH NOV PTH NOV PTH NVC TAB NVC TAB YNG ML YNG ML TAN ML PMS TAB MCL TAB PPH TAB SDZ ML SDZ ML ALC ML BHP VIAL PDL TAB ABB TAB PDL TAB OMG ML OMG ML BIO TAB NOV TAB NOV TAB NOV TAB AZC SYR NOV TAB PFI TAB SNS CAP PDL CAP PDL PTH PDL PTH PDL PTH Base Price 0.0822 6.0067 0.0627 0.1330 0.0767 4.9560 4.3877 4.9560 0.2128 0.2496 0.2250 0.2250 0.0199 0.1730 0.1385 0.1283 0.3093 0.3840 0.0947 1548.3600 0.4612 7.5240 0.1394 1.4000 2.3500 10.1159 3.2150 4.2923 7.7667 617.2150 6.8870 0.8400 0.2723 0.2723 12.0520 2.3480 3.6600 Pg 41 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002395673 00002395681 00002126648 00000888346 00002384124 00002408007 00002408015 00002408023 00002408031 00002408058 00002377217 00080033717 00080013210 00000232599 00002248699 00002243333 00002138751 00000031089 00000031097 00080009681 00002244532 00000041157 00000582727 00002245389 00000346918 00000782114 00080005803 00002207230 00080009650 00080009651 00002408163 00002350270 00002425696 00002337037 00002337029 00001926853 00080000193 Product Description FENTANYL 50 MCG/HR TRANSDERMAL PATCH FENTANYL 75 MCG/HR TRANSDERMAL PATCH FENTANYL CITRATE 50 MCG/ML INJECTION FENTANYL CITRATE 50 MCG/ML INJECTION FENTANYL CITRATE SDZ 50 MCG/ML INJECTION FENTORA 100 MCG EFFERVESCENT TABLET FENTORA 200 MCG EFFERVESCENT TABLET FENTORA 400 MCG EFFERVESCENT TABLET FENTORA 600 MCG EFFERVESCENT TABLET FENTORA 800 MCG EFFERVESCENT TABLET FERAHEME 30 MG/ML INJECTION FERAMAX 15/1/4 TSP POWDER FERAMAX 150 150 MG CAPSULE FERMALAC VAGINAL CAPSULE FERODAN 300 MG TABLET FERRLECIT 12.5 MG/ ML INJECTION FERROUS FUMARATE 200 MG TABLET FERROUS FUMARATE 300 MG TABLET FERROUS GLUCONATE 300 MG TABLET FERROUS GLUCONATE 300 MG TABLET FERROUS GLUCONATE 300 MG TABLET FERROUS GLUCONATE 300 MG TABLET FERROUS GLUCONATE 324 MG TABLET FERROUS GLUCONATE 35 MG TABLET FERROUS SULFATE 300 MG TABLET FERROUS SULFATE 300 MG TABLET FIBER PLUS CAPSULE FIBRE LAXATIVE 3.4 G/12 G ORAL POWDER FIBRE LAXATIVE SMOOTH TEXTURE ORANGE FLAVOUR FIBRE LAXATIVE UNFLAVOURED ORAL POWDER FIBRISTAL 5 MG TABLET FINASTERIDE 5 MG TABLET FIRAZYR 10 MG/ML (3 ML) INJECTION SYRINGE FIRMAGON 120 MG/VIAL INJECTION POWDER FOR SOLUTION FIRMAGON 80 MG/VIAL INJECTION POWDER FOR SOLUTION FLAGYL 500 MG CAPSULE FLAX SEED OIL Route TRD TRD INJ INJ INJ BUC/SLG BUC/SLG BUC/SLG BUC/SLG BUC/SLG INJ ORL ORL VAG ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL 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. Form PTH PTH DEFAUL DEFAUL DEFAUL EVT EVT EVT EVT EVT DEFAUL PWR CAP CAP TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP PWR PWR PWR TAB TAB DEFAUL DEFAUL DEFAUL CAP LIQ MFR Unit of Issue PDL PTH PDL PTH MNP ML HSP ML SDZ ML TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TAK ML BIS G BIS CAP ROG CAP ODN TAB SAV ML VTH TAB WAM TAB WAM TAB WAM TAB PMT TAB ADA TAB VTH TAB WNP TAB PMT TAB WTR TAB PLT CAP PRI G ACV G APH G ASC TAB PDL TAB SOT SYR FEI VIAL FEI VIAL SAV CAP WNP CAP Base Price 6.8840 9.6820 1.5000 1.7550 2.0240 11.8986 11.8986 11.8986 11.8986 11.8986 11.8566 0.2342 0.5003 1.9310 0.0199 5.5356 0.0209 0.1289 0.0224 0.0662 0.0400 0.0371 0.0277 0.0785 0.0385 0.0346 0.2000 0.0060 0.0103 0.0109 12.5137 0.4633 2700.0000 405.5000 300.0000 1.1548 0.0410 Pg 42 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002149133 00080000580 00080000840 00002206218 00080021934 00002230845 00002230848 00002213672 00080011335 00080013321 00002244405 00002237245 00002237244 00002261472 00002248443 00002388448 00002247749 00002246226 00002249561 00002352621 00001977857 00002090139 00002182742 00000012882 00002331721 00000578479 00000578487 00002015986 00002236754 00002236753 00000247855 00080000549 00000318973 00000647039 00002048841 00002254689 00002435470 Product Description FLAX SEED OIL 500 MG CAPSULE FLAXSEED OIL 1000 MG SOFTGEL FLAXSEED OIL LIQUID FLEET PHOSPO-SODA ORAL LIQUID FLINTSTONES MULTI VITAMINS COMPLETE CHEWABLE TAB FLOLAN 0.5 MG/VIAL INJECTION FLOLAN 1.5 MG/VIAL INJECTION FLONASE 50 MCG/DOSE AQUEOUS NASAL SPRAY FLORASMART TABLET FLORASTOR 250 MG CAPSULE FLORAZOLE ER 750 MG EXTENDED-RELEASE TABLET FLOVENT DISKUS 100 MCG/DOSE PWDR FOR INHAL FLOVENT DISKUS 50 MCG/DOSE PWDR FOR INHAL FLUCONAZOLE 2 MG/ML INJECTION FLUCONAZOLE 2 MG/ML INJECTION FLUCONAZOLE INJECTION SDZ 2 MG/ML INJECTION FLUCONAZOLE OMEGA 2 MG/ML INJECTION FLUDARA 10 MG TABLET FLUMAZENIL 0.1 MG/ML INJECTION FLUMIST INFLUENZA VACCINE NASAL SPRAY FLUOR A DAY 1.1 MG CHEWABLE TABLET FLUOR-A-DAY 0.56 MG CHEWABLE TABLET FLUOROURACIL 50 MG/ML INJECTION FLUOROURACIL 50 MG/ML INJECTION FLUPENTIXOL DECANOATE 100 MG/ML INJECTION FLURAZEPAM 15 MG CAPSULE FLURAZEPAM 30 MG CAPSULE FLUVIRAL S/F SPLIT-VIRION INFLUENZA VACCINE INJ FLUVOXAMINE 100 MG TABLET FLUVOXAMINE 50 MG TABLET FML LIQUIFILM 0.1% OPH SUSPENSION FOLAPRO 0.8 MG TABLET FOLIC ACID 1 MG TABLET FOLIC ACID 1 MG TABLET FOLIC ACID USP 1 MG TABLET FORTEO 250 MCG/ML INJECTION FORXIGA 10 MG TABLET Route ORL ORL ORL ORL ORL INJ INJ NAS ORL ORL ORL INH INH INJ INJ INJ INJ ORL INJ NAS ORL ORL INJ INJ INJ ORL ORL INJ ORL ORL OPH ORL ORL ORL ORL INJ ORL 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. Form CAP CAP LIQ LIQ CTB DEFAUL DEFAUL SPM TAB CAP ERT MIP MIP DEFAUL DEFAUL DEFAUL DEFAUL TAB DEFAUL SPR CTB CTB DEFAUL DEFAUL DEFAUL CAP CAP DEFAUL TAB TAB SUS TAB TAB TAB TAB DEFAUL TAB MFR Unit of Issue JAM CAP PMT CAP VML ML JJM ML BAI TAB GLA VIAL GLA VIAL GSK DOSE RLC TAB BCX CAP FEI TAB GSK DOSE GSK DOSE BAX ML SDZ ML SDZ ML OMG ML SAV TAB SDZ ML AZC ML PMS TAB PMS TAB MNP ML VCL ML SDZ ML PDL CAP PDL CAP IAF ML PDL TAB PDL TAB ALL ML MTG TAB JAM TAB VTH TAB PMT TAB LIL ML AZC TAB Base Price 0.0659 0.0937 0.0422 0.0838 0.1377 18.6400 37.2700 0.2828 0.5421 1.1010 2.0700 0.4355 0.2753 0.1635 0.4836 0.4836 0.3660 42.0800 5.5034 72.0000 0.0922 0.0896 2.2249 1.4630 27.5500 0.0675 0.0775 16.0000 0.3783 0.2105 3.5080 0.1916 0.0428 0.0079 0.0171 413.6375 2.8610 Pg 43 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002435462 00002241568 00002276429 00002332566 00002332574 00002303000 00002303019 00002287188 00002287145 00002287153 00002287161 00002377454 00002430789 00002221799 00002257084 00002264625 00002238578 00002243862 00002243861 00002360365 00000496723 00000397792 00000667080 00002247725 00002431289 00002388200 00002392526 00002431297 00002388219 00002392534 00002416581 00002416603 00002416573 00002404761 00000512192 00000512184 00002283190 Product Description FORXIGA 5 MG TABLET FORZA-10 TABLET FOSAVANCE 70 MG/2800 UNIT TABLET FOSINOPRIL 10 MG TABLET FOSINOPRIL 20 MG TABLET FOSINOPRIL-10 10 MG TABLET FOSINOPRIL-20 20 MG TABLET FOSRENOL 1000 MG CHEWABLE TABLET FOSRENOL 250 MG CHEWABLE TABLET FOSRENOL 500 MG CHEWABLE TABLET FOSRENOL 750 MG CHEWABLE TABLET FRAGMIN 2,500 IU/ML INJECTION FRAGMIN 3,500 IU/0.28 ML INJECTION FRISIUM 10 MG TABLET FROVA 2.5 MG TABLET FSME-IMMUN 2.4 MCG/0.5 ML INJECTION SYRINGE FUCIDIN H TOPICAL CREAM FUCITHALMIC 1% VISCOUS OPH DROPS (PRESERVED) FUCITHALMIC 1% VISCOUS OPH DROPS (UNPRESERVED) FUROSEMIDE 10MG/ML INJECTION FUROSEMIDE 20 TABLET FUROSEMIDE 40 MG TABLET FUROSEMIDE-80 MG TABLET FUZEON 108 MG/VIAL INJECTION GABAPENTIN 600 MG TABLET GABAPENTIN 600 MG TABLET GABAPENTIN 600 MG TABLET USP GABAPENTIN 800 MG TABLET GABAPENTIN 800 MG TABLET GABAPENTIN 800 MG TABLET USP GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE GANCICLOVIR 500 MG/VIAL INJECTION USP GARAMYCIN 3 MG/ML OPH SOLUTION GARAMYCIN 3 MG/ML OTIC SOLUTION GARDASIL 0.5 ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL INJ TOP OPH OPH INJ ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ OPH OT INJ 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. Form TAB TAB TAB TAB TAB TAB TAB CTB CTB CTB CTB DEFAUL NDL TAB TAB NDL CRM GEL GEL DEFAUL TAB TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB ERC ERC ERC DEFAUL SOL SOL DEFAUL MFR Unit of Issue AZC TAB EUP TAB MFC TAB RAN TAB RAN TAB PDL TAB PDL TAB SHB TAB SHB TAB SHB TAB SHB TAB PFI ML PFI SYR LUI TAB TMP TAB BAX SYR LEO G AMD G AMD G OMG ML PDL TAB PDL TAB PDL TAB HLR VIAL SNS TAB SIV TAB AHI TAB SNS TAB SIV TAB AHI TAB PDL CAP PDL CAP PDL CAP PPC VIAL MFC ML MFC ML MFC ML Base Price 2.8610 0.1710 5.1175 0.4977 0.5985 0.2178 0.2619 4.9400 1.2380 2.4762 3.7262 4.0785 7.2310 0.4797 15.3400 51.0000 1.5083 2.2800 5.2167 1.0500 0.0373 0.0558 0.1220 43.1267 1.3045 1.3045 0.3256 1.7393 1.7393 0.4341 1.2467 1.2467 1.2467 42.0300 0.4060 1.0320 313.8800 Pg 44 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002437058 00000896675 00002300761 00002159791 00002231538 00002159775 00002434806 00002280124 00002342235 00002342243 00002285843 00002285851 00002360179 00002360195 00002360136 00002360209 00002360144 00002360152 00002290995 00002291002 00002291010 00002290987 00002273705 00002273683 00002273691 00002352818 00002352877 00002352885 00002352850 00002028107 00002366150 00001945831 00001933906 00002324210 00002412292 00002136058 00002230309 Product Description GARDASIL 9 0.5 ML INJECTION GAS X EXTRA STRENGTH TABLET GAS X ULTRA STRENGTH 180 MG CAPSULE GAVISCON HEARTBURN RELIEF CHEWABLE TABLET GAVISCON HEARTBURN RELIEF EXTRA STRENGTH TABLET GAVISCON HEARTBURN RELIEF ORAL LIQUID - FRUIT GAZYVA 1000 MG/VIAL INJECTION GD-AMLODIPINE 2.5 MG TABLET GD-ELETRIPTAN 20 MG TABLET GD-ELETRIPTAN 40 MG TABLET GD-GABAPENTIN 600 MG TABLET GD-GABAPENTIN 800 MG TABLET GD-PREGABALIN 150 MG CAPSULE GD-PREGABALIN 225 MG CAPSULE GD-PREGABALIN 25 MG CAPSULE GD-PREGABALIN 300 MG CAPSULE GD-PREGABALIN 50 MG CAPSULE GD-PREGABALIN 75 MG CAPSULE GD-QUINAPRIL 10 MG TABLET GD-QUINAPRIL 20 MG TABLET GD-QUINAPRIL 40 MG TABLET GD-QUINAPRIL 5 MG TABLET GD-SERTRALINE 100 MG CAPSULE GD-SERTRALINE 25 MG CAPSULE GD-SERTRALINE 50 MG CAPSULE GD-TERBINAFINE 250 MG TABLET GD-TOPIRAMATE 100 MG TABLET GD-TOPIRAMATE 200 MG TABLET GD-TOPIRAMATE 25 MG TABLET GEL-KAM 0.4% DENTAL GEL GELNIQUE 100 MG/G TOPICAL GEL GELUSIL EXTRA STRENGTH CHEWABLE TABLET GELUSIL TABLET GEMCITABINE 1 G/VIAL INJECTION GEMCITABINE 40 MG/ML INJECTION GEMFIBROZIL-600 MG TABLET GEMZAR 1 G/VIAL INJECTION Route INJ ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL DEN TOP ORL ORL INJ INJ ORL INJ 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. Form DEFAUL TAB CAP CTB TAB LIQ DEFAUL TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP CAP CAP TAB TAB TAB TAB GEL GEL CTB TAB DEFAUL DEFAUL TAB DEFAUL MFR Unit of Issue MFC ML NVC TAB NVC CAP SKB TAB SKB TAB SKB ML HLR VIAL GMD TAB GMD TAB GMD TAB GMD TAB GMD TAB GMD CAP GMD CAP GMD CAP GMD CAP GMD CAP GMD CAP GMD TAB GMD TAB GMD TAB GMD TAB GMD CAP GMD CAP GMD CAP GMD TAB GMD TAB GMD TAB GMD TAB COL G ASC G WLA TAB WSP TAB AHI VIAL SDZ ML PDL TAB LIL VIAL Base Price 310.5000 0.2500 0.2093 0.1468 0.2875 0.0216 141.7790 0.1380 11.0117 11.0117 1.4244 1.8992 1.7270 1.7270 0.6173 1.7270 0.9683 1.2528 0.6867 0.6867 0.6867 0.6867 0.4200 0.2004 0.4008 2.5243 0.5928 1.9845 0.6615 0.0705 2.0953 0.1484 0.1270 265.0000 10.8120 0.5157 308.3500 Pg 45 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002230308 00080020663 00080034399 00080008885 00080012475 00002246047 00002082144 00002082152 00002268531 00002148404 00002082136 00002231289 00002242977 00080044443 00002415666 00002415674 00002415682 00080003490 00002244725 00002253275 00002253283 00002248453 00080000015 00080000082 00080000083 00002300451 00002268493 00080009026 00001959352 00001926039 00000873462 00080006852 00002229516 00002239214 00002382857 00002382849 00002247884 Product Description GEMZAR 200 MG/VIAL INJECTION GENESTRA BRAND HMF INTENSIVE PROBIOTIC GENESTRA BRANDS DIGEST GLUTEN PLUS CAPSULE GENESTRA BRANDS D-MULSION GENESTRA BRANDS D-MULSION 400 GEN-NIZATIDINE 300 MG CAPSULE GENTAMICIN (E) 1.2 MG/ML INJECTION GENTAMICIN (E) 1.6 MG/ML INJECTION GENTAMICIN 10 MG/ML INJECTION GENTAMICIN SULFATE 0.3% (BASE) OPH SOL (MINIMS) GENTAMICINE (E) 1 MG/ML INJECTION GENTEAL 0.3% OPHTHALMIC DROPS GENTEAL 0.3% OPHTHALMIC GEL GI SUSTAIN ORAL POWDER GIOTRIF 20 MG TABLET GIOTRIF 30 MG TABLET GIOTRIF 40 MG TABLET GLA 130 PRIMROSE OIL CAPSULE GLEEVEC 100 MG CAPSULE GLEEVEC 100 MG TABLET GLEEVEC 400 MG TABLET GLICLAZIDE-80 MG TABLET GLUCOSAMINE SULFATE 500 MG CAPLET GLUCOSAMINE SULFATE 500 MG CAPSULE GLUCOSAMINE SULFATE 500 MG TABLET GLUMETZA 1000 MG EXTENDED-RELEASE TABLET GLUMETZA 500 MG EXTENDED-RELEASE TABLET GLUTAMINE MAXX ORAL POWDER GLYBURIDE-2.5 MG TABLET GLYCERIN RECTAL SUPPOSITORY GLYCERINE 90% RECTAL SUPPOSITORY USP GLYCINE ORAL POWDER GLYCON 500 MG TABLET GLYCON 850 MG TABLET GLYCOPYRROLATE 0.2 MG/ML INJECTION GLYCOPYRROLATE 0.2 MG/ML MULTIDOSE INJECTION GLYQUIN XM TOPICAL CREAM Route INJ ORL ORL ORL ORL ORL INJ INJ INJ OPH INJ OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT RT ORL ORL ORL INJ INJ TOP 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. Form DEFAUL CAP CAP LIQ LIQ CAP DEFAUL DEFAUL DEFAUL SOL DEFAUL DPS GEL PWR TAB TAB TAB CAP CAP TAB TAB TAB TAB CAP TAB ERT ERT PWR TAB SUP SUP PWR TAB TAB DEFAUL DEFAUL CRM MFR Unit of Issue LIL VIAL SRL CAP SRL CAP SRL ML SRL ML MYP CAP BAX ML BAX ML SDZ ML NVO ML BAX ML ALC ML ALC ML MTG G BOE TAB BOE TAB BOE TAB SRL CAP NOV CAP NOV TAB NOV TAB PDL TAB JAM TAB WBP CAP WBP TAB VCL TAB VCL TAB IHS G PDL TAB WSP SUP MCO SUP AOR G VCL TAB VCL TAB OMG ML OMG ML VCL G Base Price 65.6700 1.7166 0.3143 0.5663 0.2367 0.9580 0.0794 0.0890 5.2785 6.3483 0.0467 0.4407 0.8270 0.0676 80.0000 80.0000 80.0000 0.4438 25.3240 29.7596 119.0383 0.0931 0.0570 0.0458 0.0388 1.2851 0.6400 0.0600 0.0321 0.1600 0.0850 0.0639 0.0485 0.0898 3.9750 3.0000 1.2500 Pg 46 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000652512 00002248156 00002248154 00002248157 00002270404 00002270390 00002270382 00000999578 00002232483 00080006061 00002418304 00000116858 00002254409 00000511196 00000230197 00000013803 00000013609 00000783595 00002248180 00000013579 00002245718 00080014526 00080012417 00002384272 00002248417 00002377438 00000271691 00000202061 00002366010 00000587796 00002130297 00002239640 00002187078 00002231056 00000740578 00000640468 00002264315 Product Description GOLYTELY POWDER FOR ORAL LAVAGE SOLUTION GONAL-F 33 MCG/VIAL INJECTION GONAL-F 5.5 MCG/VIAL INJECTION GONAL-F 77 MCG/VIAL INJECTION GONAL-F PEN 300 IU/0.5 ML INJECTION SYRINGE GONAL-F PEN 450 IU/0.75 ML INJECTION SYRINGE GONAL-F PEN 900 IU/1.5 ML INJECTION SYRINGE GOOD START STAGE 2 INFANT FORMULA GRAMCAL 1000 MG EFFERVESCENT TABLET GRAPE SEED CAPLET GRASTEK 2800 UNIT SUBLINGUAL TABLET GRAVERGOL CAPSULE GRAVOL 100 MG LONG ACTING SUSTAINED-RELEASE CAPLET GRAVOL 15 MG CHEWABLE TABLET GRAVOL 3 MG/ML ORAL LIQUID GRAVOL 50 MG TABLET GRAVOL ADULT 100 MG RECTAL SUPPOSITORY GRAVOL CHILDREN 25 MG RECTAL SUPPOSITORIES GRAVOL GINGER LOZENGE GRAVOL I.M. 50 MG/ML INJECTION GRAVOL NATURAL SOURCE 500 MG TABLET GREEN TEA PHYTOSOME COMPLEX CAPSULE GREENS+ BONE BUILDER ORAL POWDER GUM PAROEX 0.12% ORAL RINSE GYNAZOLE 1 2% VAGINAL CREAM HALAVEN 0.5 MG/ML INJECTION HALIBUT LIVER OIL SUPER CAPSULE HALIBUT LIVER OIL WITH VITAMIN D CAPSULE HALOPERIDOL (PRESERVATIVE FREE) 5 MG/ML INJECTION HALOPERIDOL 0.5 MG TABLET HALOPERIDOL LA 50 MG/ML INJECTION HALOPERIDOL-LA 100 MG/ML INJECTION HAVRIX 1,440 U/ML INJECTION HAVRIX JUNIOR 720 U/0.5 ML INJECTION SYRINGE HEPALEAN-LOK 100 IU/ML LOCK FLUSH INJECTION USP HEPARIN LOCK FLUSH SOLUTION 10 UNIT/ML INJECTION HEPARIN SODIUM 1,000 IU/ML INJECTION USP Route ORL INJ INJ INJ INJ INJ INJ ORL ORL ORL SLG ORL ORL ORL ORL ORL RT RT ORL INJ ORL ORL ORL ORL VAG INJ ORL ORL INJ ORL INJ INJ INJ INJ INJ INJ INJ Form PWR DEFAUL DEFAUL DEFAUL NDL NDL NDL PWR EVT TAB DISNTAB CAP SRT CTB SYR TAB SUP SUP LOZ DEFAUL TAB CAP PWR MWH CRM DEFAUL CAP CAP DEFAUL TAB DEFAUL DEFAUL DEFAUL NDL LOCFLUSH LOCFLUSH DEFAUL 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. MFR Unit of Issue BAX G SRO VIAL SRO VIAL SRO VIAL SRO SYR SRO SYR SRO SYR NHN G NVC TAB JAM TAB MFC TAB AXS CAP CHD TAB CHD TAB CHD ML CHD TAB CHD SUP CHD SUP CHD LOZ CHD ML CHD TAB JAM CAP GNH G SUA ML FEI G EIS ML SWS CAP WAM CAP OMG ML PDL TAB SDZ ML OMG ML GSK ML GSK SYR ORG ML HSP ML PPC ML Base Price 0.0044 457.1400 76.2000 992.2500 304.7600 457.1400 914.2900 0.0404 0.7915 0.3322 4.1493 1.0108 0.4762 0.2558 0.0747 0.3850 0.5700 0.5260 0.2325 1.2370 0.2285 0.2280 0.0948 0.0166 3.4500 270.0000 0.0329 0.0268 5.3500 0.0360 8.7180 13.6900 48.7100 24.3600 0.3275 1.2056 2.6736 Pg 47 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002303086 00002382296 00002382326 00002382334 00002303094 00002303108 00002239194 00002240692 00002244784 00000575178 00000575186 00002436027 00001948903 00001948911 00002078759 00000745626 00002243079 00000999015 00001916580 00001916599 00001916564 00001916521 00000230316 00002231476 00000465283 00000341975 00002242930 00002244797 00000564281 00002343096 00000742813 00002229868 00002230697 00002133253 00002133288 00002275864 00002275872 Product Description HEPARIN SODIUM 1,000 IU/ML INJECTION USP HEPARIN SODIUM 1,000 UNIT/ML INJECTION HEPARIN SODIUM 10,000 UNIT/ML INJECTION HEPARIN SODIUM 5,000 UNIT/ML INJECTION HEPARIN SODIUM(PRESERVAT FREE)10,000 IU/ML INJ USP HEPARIN SODIUM(WITH PRESERVAT)10,000 IU/ML INJ USP HEPTOVIR 5 MG/ML ORAL SOLUTION HERCEPTIN 440 MG/VIAL INJECTION HILL-VITE TABLET HISTANTIL 25 MG TABLET HISTANTIL 50 MG TABLET HOLKIRA PAK TABLET HONEY BEE VENOM 1.1 MG HONEY BEE VENOM 120 MCG HUMATIN 250 MG CAPSULE HUMATROPE 1 MG/ML INJECTION HUMATROPE 24 MG INJECTION HYALGAN HYCODAN 1 MG/ML ORAL SYRUP HYCODAN 5 MG TABLET HYCOMINE ORAL SYRUP HYCOMINE-S PEDIATRIC ORAL SYRUP HYCORT 1.67 MG/ML RECTAL ENEMA HYDRASENSE NASAL SOLUTION HYDREA 500 MG CAPSULE HYDROCHLOROTHIAZIDE 25 MG TABLET HYDROCORTISONE ACETATE 0.5% TOPICAL CREAM HYDROMORPHONE HP FORTE 100 MG/ML INJECTION HYDROSONE 0.5% CREAM HYDROXYUREA 500 MG CAPSULE HYDROXYZINE HCL 50 MG/ML INJECTION USP HYOSCINE BUTYLBROMIDE 20 MG/ML INJECTION HYPERTET S/D 250 IU/SYR INJECTION HYPOTEARS 1% OPH SOLUTION HYPOTEARS 85%/15% EYE OINTMENT HYPURIN NPH INSULIN ISOPHANE PORK 100 UNIT/ML INJ HYPURIN REGULAR INSULIN PORK 100 UNIT/ML INJ Route INJ INJ INJ INJ INJ INJ ORL INJ ORL ORL ORL ORL INJ INJ ORL INJ INJ DEFAUL ORL ORL ORL ORL RT NAS ORL ORL TOP INJ TOP ORL INJ INJ INJ OPH OPH INJ INJ 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. Form DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL TAB TAB TAB TAB DEFAUL DEFAUL CAP DEFAUL DEFAUL DEV SYR TAB SYR SYR ENM SOL CAP TAB CRM DEFAUL CRM CAP DEFAUL DEFAUL DEFAUL SOL ONT DEFAUL DEFAUL MFR Unit of Issue SDZ ML PFI ML PFI ML PFI ML SDZ ML SDZ ML GSK ML HLR VIAL HIL TAB PMS TAB PMS TAB ABV TAB ALG VIAL ALG VIAL PFI CAP LIL VIAL LIL VIAL MDX ML BMS ML BMS TAB DPM ML DPM ML VCL ENM SCH ML BMS CAP PDL TAB TAR G SDZ ML RPH G SNS CAP SDZ ML SDZ ML GRL SYR ALC ML ALC G NTI ML NTI ML Base Price 0.5650 0.5010 5.0100 1.2470 5.7540 3.7160 0.2300 2947.9700 0.1320 0.1158 0.1908 166.2500 30.8667 30.8667 2.9482 250.8500 1223.0500 25.0000 0.1386 1.1787 0.2165 0.1895 5.2971 0.0709 1.1141 0.0157 0.0846 64.2050 0.1347 1.0203 8.5360 4.9360 78.0000 0.4147 1.5886 9.9000 9.9000 Pg 48 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080022866 00002357275 00002257912 00002317338 00000636533 00002344939 00002411393 00002434407 00002183862 00002376016 00002245185 00002237297 00002230542 00001959042 00001908286 00002240713 00002244895 00002371553 00002042266 00002042274 00002042231 00002042258 00002046059 00002419475 00002269562 00002221780 00002389630 00002389649 00080013031 00002323052 00002323060 00080026628 00000762040 00002294990 00002348756 00002306778 00002375931 Product Description IBEROGAST ORAL SOLUTION IBUPROFEN 200 MG LIQUID CAPSULE IBUPROFEN 200 MG TABLET IBUPROFEN 400 MG CAPLET IBUPROFEN 400 MG TABLET ILARIS 150 MG/VIAL INJECTION ILEVRO 0.3% OPHTHALMIC SUSPENSION IMBRUVICA 140 MG CAPSULE IMODIUM 2 MG CAPLET IMODIUM 2 MG CAPSULE IMODIUM ADVANCED CAPLET IMODIUM ADVANCED CHEWABLE TABLET IMODIUM QUICK DISSOLVE 2 MG TABLET IMOVAX POLIO INJECTION SYRINGE IMOVAX RABIES VACCINE 2.5 UNIT/VIAL INJECTION IMUNOVIR 500 MG TABLET IMURAN 50 MG/VIAL INJECTION INCIVEK 375 MG TABLET INDERAL-LA 120 MG SUSTAINED-RELEASE CAPSULE INDERAL-LA 160 MG SUSTAINED-RELEASE CAPSULE INDERAL-LA 60 MG SUSTAINED-RELEASE CAPSULE INDERAL-LA 80 MG SUSTAINED-RELEASE CAPSULE INFANTS' TYLENOL 80 MG/ML ORAL SUSPENSION DROPS INFLECTRA 100 MG/VIAL INJECTION INFLUVAC VACCINE INJECTION SYRINGE INFUFER 50 MG/ML INJECTION INLYTA 1 MG TABLET INLYTA 5 MG TABLET INNO-Q-NOL 100 MG SOFT GEL CAPSULE INSPRA 25 MG TABLET INSPRA 50 MG TABLET INSTAFLEX JOINT SUPPORT CAPSULE INSTA-GLUCOSE (1 DOSE PER TUBE) ORAL LIQUID INSTILLAGEL 2% /0.05% TOPICAL GEL INTANZA INJECTION SYRINGE INTELENCE 100 MG TABLET INTELENCE 200 MG TABLET Route ORL ORL ORL ORL ORL INJ OPH ORL ORL ORL ORL ORL ORL INJ INJ ORL INJ ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL TOP INJ ORL ORL 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. Form SOL CAP TAB TAB TAB DEFAUL SUS CAP TAB CAP TAB CTB TAB NDL DEFAUL TAB DEFAUL TAB SRC SRC SRC SRC DPS DEFAUL DEFAUL DEFAUL TAB TAB CAP TAB TAB CAP LIQ GEL DEFAUL TAB TAB MFR Unit of Issue STA ML VTH CAP PMT TAB PMT TAB PDL TAB NOV VIAL ALC ML JAI CAP MCL TAB MCL CAP MCL TAB MCL TAB MCL TAB SFP SYR SFP VIAL RIP TAB ASN VIAL VER TAB PFI CAP PFI CAP PFI CAP PFI CAP MCL ML CHH VIAL ABB SYR SDZ ML PFI TAB PFI TAB INN CAP PFI TAB PFI TAB DDI CAP VCL DOSE PPH ML SFP SYR JAI TAB JAI TAB Base Price 0.2048 0.1128 0.0498 0.0392 0.0372 16000.0000 7.9833 90.6500 0.7733 0.8700 0.9280 0.9280 0.8690 47.3600 196.5400 1.9509 98.2700 76.8600 1.0683 1.2634 0.6153 0.6939 0.3067 650.0000 9.3000 14.7500 19.9950 99.9750 1.1325 2.8797 2.8797 0.3332 4.0600 1.0555 12.9000 6.3392 12.3968 Pg 49 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002238675 00002223406 00002238674 00002240693 00002240694 00002240695 00002409100 00002409119 00002409127 00002409135 00002216965 00002279320 00002425483 00002425491 00000888354 00002246084 00002365200 00002365219 00002365197 00002365162 00002365170 00002365189 00002248676 00002392437 00002392429 00002301881 00000897639 00000000809 00000000817 00000272655 00002414295 00002333279 00002388014 00002388022 00002388006 00002372010 00002246040 Product Description INTRON A 10 MIU/ML INJECTION - HUMAN ALBUMIN FREE INTRON A 10,000,000 UNIT/VIAL INJECTION INTRON A 6 MIU/ML INJECTION - HUMAN ALBUMIN FREE INTRON A MULTI-DOSE PEN 15 MIU/ML INJECTION SYR INTRON A MULTI-DOSE PEN 25 MIU/ML INJECTION SYR INTRON A MULTI-DOSE PEN 50 MIU/ML INJECTION SYR INTUNIV XR 1 MG EXTENDED-RELEASE TABLET INTUNIV XR 2 MG EXTENDED-RELEASE TABLET INTUNIV XR 3 MG EXTENDED-RELEASE TABLET INTUNIV XR 4 MG EXTENDED-RELEASE TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET IOPIDINE 1% OPH SOLUTION (UNIT DOSE) IPRAVENT 0.06% NASAL SPRAY IRBESARTAN 150 MG TABLET IRBESARTAN 300 MG TABLET IRBESARTAN 75 MG TABLET IRBESARTAN-HCTZ 150 MG/12.5 MG TABLET IRBESARTAN-HCTZ 300 MG/12.5 MG TABLET IRBESARTAN-HCTZ 300 MG/25 MG TABLET IRESSA 250 MG TABLET ISENTRESS 100 MG CHEWABLE TABLET ISENTRESS 25 MG CHEWABLE TABLET ISENTRESS 400 MG TABLET ISOPROTERENOL HYDROCHLORIDE 0.2 MG/ML INJECTION ISOPTO TEARS 0.5% OPH DROPS ISOPTO TEARS 1.0% OPH DROPS ISOTAMINE 300 MG TABLET ISTODAX 10 MG/VIAL INJECTION IXIARO 6 MCG/0.5ML INJECTION SYRINGE JAKAVI 15 MG TABLET JAKAVI 20 MG TABLET JAKAVI 5 MG TABLET JALYN 0.5 MG/0.4 MG MODIFIED RELEASE CAPSULE JAMP CALCIUM 500 MG TABLET Route INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL OPH NAS ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ OPH OPH ORL INJ INJ ORL ORL ORL ORL ORL 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. Form DEFAUL DEFAUL DEFAUL NDL NDL NDL ERT ERT ERT ERT CAP TAB TAB TAB SOL SPR TAB TAB TAB TAB TAB TAB TAB CTB CTB TAB DEFAUL DPS DPS TAB DEFAUL NDL TAB TAB TAB MRC TAB MFR Unit of Issue MFC ML MFC ML MFC ML MFC SYR MFC SYR MFC SYR SHB TAB SHB TAB SHB TAB SHB TAB HLR CAP HLR TAB JAI TAB JAI TAB ALC ML AAP ML PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB AZC TAB MFC TAB MFC TAB MFC TAB SDZ ML ALC ML ALC ML VCL TAB CLG VIAL NOV SYR NOV TAB NOV TAB NOV TAB GSK CAP JPC TAB Base Price 132.0600 125.2000 72.5633 234.0200 391.9400 780.0300 3.2758 3.9855 4.6953 5.4051 2.0448 4.7188 2.8583 2.8583 66.4375 1.6267 0.3425 0.3425 0.3425 0.3425 0.3425 0.3384 78.7973 4.1208 1.0302 14.7410 8.7530 0.5247 0.5247 0.0899 2582.0000 211.0200 88.3562 88.3562 88.3562 1.8093 0.0222 Pg 50 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002388308 00080037789 00002421593 00002421607 00002421615 00002331098 00002331071 00002339080 00002283905 00002357216 00002410893 00002246039 00080028892 00002373823 00002420147 00002391619 00002366088 00002283220 00080036242 00002423235 00080024232 00080025200 00080047569 00000031100 00080053274 00002366061 00002402289 00002402297 00002401290 00080047136 00080023817 00002280078 00002373009 00080041590 00080009357 00080043440 00002419173 Product Description JAMP-ACET-TRAMADOL 37.5 MG/325 MG TABLET JAMP-AD 5000 IU/ 400 IU CHEWABLE TABLET JAMP-ALLOPURINOL 100 MG TABLET JAMP-ALLOPURINOL 200 MG TABLET JAMP-ALLOPURINOL 300 MG TABLET JAMP-AMLODIPINE 10 MG TABLET JAMP-AMLODIPINE 5 MG TABLET JAMP-ANASTROZOLE 1 MG TABLET JAMP-ASA 80 MG TABLET JAMP-BICALUTAMIDE 50 MG TABLET JAMP-BISACODYL 5 MG SUPPOSITORY JAMP-BISACODYL 5 MG TABLET JAMP-CALCIUM CITRATE 250 MG + VIT D 1000 IU TABLET JAMP-COLCHICINE 0.6 MG TABLET JAMP-CYANOCOBALAMIN 1000 MCG/ML INJECTION JAMP-DICYCLOMINE HCL 10 MG TABLET JAMP-DICYCLOMINE HCL 20 MG TABLET JAMP-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP JAMP-E 200 IU CHEWABLE TABLET JAMP-EZETIMIBE 10 MG TABLET JAMP-FER 300 MG CAPSULE JAMP-FER FC 100 MG/ 0.5 MG/ 200 MG CAPSULE JAMP-FERROUS POLYSACCHARIDE 150 MG CAPSULE JAMP-FERROUS SULFATE 300 MG TABLET JAMP-FOLIC ACID 1 MG TABLET JAMP-FOLIC ACID 5 MG TABLET JAMP-GABAPENTIN 600 MG TABLET JAMP-GABAPENTIN 800 MG TABLET JAMP-IBUPROFEN 400 MG TABLET JAMP-IRON POLYPEPTIDE 11 MG TABLET JAMP-K-CITRATE 10 MEQ TABLET JAMP-LACTULOSE 667 MG/ML ORAL SYRUP JAMP-LETROZOLE 2.5 MG TABLET JAMP-MAGNESIUM 100 MG TABLET JAMP-MAGNESIUM 25 MG ORAL LIQUID JAMP-MAGNESIUM 250 MG TABLET JAMP-METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ 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. Form TAB CTB TAB TAB TAB TAB TAB TAB DRT TAB SUP TAB TAB TAB DEFAUL TAB TAB SYR CTB TAB CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB SRT SYR TAB TAB LIQ TAB DEFAUL MFR Unit of Issue JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC SUP JPC TAB JPC TAB JPC TAB JPC ML JPC TAB JPC TAB JPC ML JPC TAB JPC TAB JPC CAP JPC CAP JPC CAP JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC ML JPC TAB JPC TAB JPC ML JPC TAB JPC ML Base Price 0.6452 0.1053 0.0780 0.1300 0.2125 0.3695 0.2490 2.5458 0.0560 4.0573 0.7267 0.0450 0.1224 0.2642 0.5100 0.1128 0.2207 0.9203 0.1474 0.4753 0.1299 0.2281 0.4687 0.0180 0.0171 0.0441 1.3436 1.7915 0.0474 0.6773 0.1626 0.0145 2.7560 0.2632 0.0210 0.1026 5.7940 Pg 51 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002433443 00002427745 00002406640 00002406659 00002408414 00002397307 00002365529 00002365537 00002380617 00080040279 00080040277 00002405687 00002405660 00002405679 00002331039 00002331047 00002331055 00002331020 00002331063 00080034416 00002435616 00002435624 00002435608 00002420309 00002420325 00002420317 00002420295 00080054130 00080028902 00002379007 00002416794 00002048744 00002369524 00002413388 00002247344 00002337282 00002337290 Product Description JAMP-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION JAMPOCAINE 2% VISCOUS TOPICAL SOLUTION JAMP-OLANZAPINE 15 MG ORALLY DISINTEGRATING TAB JAMP-OLANZAPINE 20 MG ORALLY DISINTEGRATING TAB JAMP-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET JAMP-PIOGLITAZONE 15 MG TABLET JAMP-PIOGLITAZONE 30 MG TABLET JAMP-PIOGLITAZONE 45 MG TABLET JAMP-PYRANTEL PAMOATE 125 MG TABLET JAMP-QUININE 200 MG CAPSULE JAMP-QUININE 300 MG CAPSULE JAMP-SILDENAFIL 100 MG TABLET JAMP-SILDENAFIL 25 MG TABLET JAMP-SILDENAFIL 50 MG TABLET JAMP-SIMVASTATIN 10 MG TABLET JAMP-SIMVASTATIN 20 MG TABLET JAMP-SIMVASTATIN 40 MG TABLET JAMP-SIMVASTATIN 5 MG TABLET JAMP-SIMVASTATIN 80 MG TABLET JAMP-SODIUM PHOSPHATE 0.891 G -2.4 G/5 ML SOLUTION JAMP-TOPIRAMATE 100 MG TABLET JAMP-TOPIRAMATE 200 MG TABLET JAMP-TOPIRAMATE 25 MG TABLET JAMP-VANCOMYCIN 1 G/VIAL INJECTION JAMP-VANCOMYCIN 10 G/VIAL INJECTION JAMP-VANCOMYCIN 5 G/VIAL INJECTION JAMP-VANCOMYCIN 500 MG/VIAL INJECTION JAMP-VITAMIN A 10, 000 IU CAPSULE JAMP-VITAMIN B12 1000 MCG RAPID DISSOLVE TABLET JAMP-VITAMIN D 10000 UNIT TABLET JANUMET XR 50 MG/1000 MG EXTENDED-RELEASE TABLET JE-VAX INJECTION JEVTANA 40 MG/ML INJECTION JUBLIA 10% TOPICAL SOLUTION JUNIOR STRENGTH MOTRIN 100 MG CHEWABLE TABLET JURNISTA 16 MG EXTENDED-RELEASE TABLET JURNISTA 32 MG EXTENDED-RELEASE TABLET Route ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL INJ INJ TOP ORL ORL ORL 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. Form SUS SOL DISNTAB DISNTAB ECT TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL CAP TAB TAB ERT DEFAUL DEFAUL SOL CTB ERT ERT MFR Unit of Issue JPC ML JPC ML JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC CAP JPC CAP JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC TAB JPC ML JPC TAB JPC TAB JPC TAB JPC VIAL JPC VIAL JPC VIAL JPC VIAL JPC CAP JPC TAB JPC TAB MFC TAB CNG VIAL SAV VIAL VCL ML MCL TAB JAI TAB JAI TAB Base Price 0.0520 0.0525 5.3553 7.5977 1.2750 0.5809 0.8139 1.2237 0.9930 0.2390 0.3750 10.0450 9.0525 9.6600 0.7287 0.9005 0.9005 0.3704 0.9005 0.0947 0.5929 0.8854 0.3128 58.9900 589.9000 509.7900 31.0500 0.0431 0.0884 0.2163 1.7493 131.6633 5800.0000 11.7517 0.2250 5.4450 10.8897 Pg 52 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002337266 00002337274 00002420376 00002420384 00002420341 00002412365 00002312301 00002285533 00002243644 00002417235 00002417219 00002417227 00080011529 00002243768 00000376167 00000224391 00000224405 00002246796 00002246795 00002244947 00002400871 00001926438 00080020666 00002269341 00001928783 00002389185 00002389169 00002389177 00080022006 00002350580 00080004073 00002185881 00002231689 00002387468 00000210889 00002250624 00080012831 Product Description JURNISTA 4 MG EXTENDED-RELEASE TABLET JURNISTA 8 MG EXTENDED-RELEASE TABLET JUXTAPID 10 MG CAPSULE JUXTAPID 20 MG CAPSULE JUXTAPID 5 MG CAPSULE KADCYLA 20 MG/ML INJECTION POWDER FOR SOLUTION KALETRA 100 MG/25 MG TABLET KALETRA 200 MG/50 MG TABLET KALETRA 80MG/20MG ORAL SOLUTION KAZANO 12.5 MG/1000 MG TABLET KAZANO 12.5 MG/500 MG TABLET KAZANO 12.5 MG/850 MG TABLET K-CITRA 2 MEQ/ML SOLUTION K-CITRA POTASSIUM CITRATE 10 MEQ SRT KEMSOL 70% TOPICAL SOLUTION KETALAR 10 MG/ML INJECTION KETALAR 50 MG/ML INJECTION KETAMINE 50 MG/ML INJECTION USP KETAMINE HYDROCHLORIDE 10 MG/ML INJECTION USP KETOROLAC TROMETHAMINE 30 MG/ML INJECTION KETOTIFEN 0.25 MG/ML OPH SOLUTION KIDROLASE 10,000 UNIT/VIAL INJECTION KID'S LIQUID VITAMIN D 400 IU KIVEXA 600 MG/300 MG TABLET KOFFEX SIROP 3 MG/ML ORAL SYRUP KOMBOGLYZE 2.5 MG/1000 MG TABLET KOMBOGLYZE 2.5 MG/500 MG TABLET KOMBOGLYZE 2.5 MG/850 MG TABLET KRILL OIL SOFTGEL CAPSULE KUVAN 100 MG TABLET KYOLIC AGED GARLIC EXTRACT ORAL CAPLET KYTRIL 1 MG TABLET LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION LACRI-LUBE OPH OINTMENT LACRISERT 5 MG OPHTHALMIC INSERT LACTOBACILLUS ACIDOPHILUS & BIFIDUS Route ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL TOP INJ INJ INJ INJ INJ OPH INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ OPH OPH ORL 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. Form ERT ERT CAP CAP CAP DEFAUL TAB TAB SOL TAB TAB TAB LIQ SRT SOL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL LIQ TAB SYR TAB TAB TAB CAP TAB TAB TAB DEFAUL DEFAUL ONT INS CAP MFR Unit of Issue JAI TAB JAI TAB AEP CAP AEP CAP AEP CAP HLR ML ABV TAB ABV TAB ABV ML TAK TAB TAK TAB TAK TAB SFD ML SFD TAB AXS ML ERF ML ERF ML SDZ ML SDZ ML PPC ML STM ML AVE VIAL WBP ML GSK TAB ROG ML AZC TAB AZC TAB AZC TAB WBP CAP BMI TAB WKG TAB HLR TAB SDZ ML MYP ML ALL G ATP DEV SWS CAP Base Price 1.3610 2.7220 1040.0000 1040.0000 1040.0000 433.8700 3.0135 6.0271 2.3740 1.4727 1.4727 1.4727 0.0349 0.2901 0.2786 1.7470 5.7870 5.4050 1.7960 5.1452 4.6240 134.7900 0.1410 25.7647 0.0202 1.3868 1.3868 1.3868 0.2323 33.0000 0.5991 10.0730 1.5180 1.2930 2.1771 3.4798 0.1123 Pg 53 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000468401 00002243803 00002385767 00002366282 00002385775 00000608734 00002186926 00000282081 00002224690 00002375508 00002415828 00002415836 00002418320 00002402025 00002347997 00002338459 00002348969 00002183005 00000004626 00002236840 00002236841 00002236839 00002250470 00002250489 00002250462 00002415879 00002245948 00002243933 00002296187 00000436208 00002231147 00000874949 00002243101 00080003212 00000030732 00002402637 00002269082 Product Description LAIT DE MAGNESIE ORL SUSP (MILK OF MAGNESIA) LAMICTAL 2 MG CHEWABLE TABLET LANSOPRAZOLE 15 MG DELAYED-RELEASE CAPSULE LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE LANSOYL JELLY 78% LANSOYL SUGAR FREE JELLY 78% LANVIS 40 MG TABLET LASIX 20 MG TABLET LATANOPROST 0.005% OPHTHALMIC SOLUTION LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 MG TABLET LEMTRADA 12 MG/1.2 ML INJECTION LETROZOLE 2.5 MG TABLET LETROZOLE 2.5 MG TABLET LETROZOLE 2.5 MG TABLET LETROZOLE 2.5 MG TABLET LEUCOVORIN CALCIUM 10 MG/ML INJECTION LEUKERAN 2 MG TABLET LEVAQUIN 25 MG/ML INJECTION LEVAQUIN 250 MG TABLET LEVAQUIN 5 MG/ML INJECTION LEVITRA 10 MG TABLET LEVITRA 20 MG TABLET LEVITRA 5 MG TABLET LEVOFLOXACIN 500 MG TABLET LEVOTHYROXINE SODIUM 0.5 MG/VIAL INJECTION LEVULAN KERASTICK 20% TOPICAL SOLUTION LIDOCAINE HCL 2% INJECTION (BLOCK OR INFILTRATION) LIDOCAINE HYDROCHLORIDE 2% INJECTION LIDODAN ENDOTRACHEAL 10 MG/DOSE NON-AEROSOL SPRAY LIDOMYXIN OTIC LIQUID LIFE BRAND DAILY LOW DOSE ASA 81 MG ECT LIFE BRAND ORAL LAXATIVE LINCOCIN 300 MG/ML INJECTION LINEZOLID 2 MG/ML INJECTION LIPIDIL EZ 145 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL INJ ORL ORL ORL ORL INJ ORL INJ ORL INJ ORL ORL ORL ORL INJ TOP INJ INJ TOP OT ORL ORL INJ INJ ORL 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. Form SUS CTB DRC DRC DRC GEL GEL TAB TAB SOL TAB TAB DEFAUL TAB TAB TAB TAB DEFAUL TAB DEFAUL TAB DEFAUL TAB TAB TAB TAB DEFAUL SOL LIQ DEFAUL SPR LIQ ECT LIQ DEFAUL DEFAUL TAB MFR Unit of Issue ATL ML GSK TAB SIV CAP PDL CAP SIV CAP AUP G AUP G ASN TAB SAV TAB RIV ML PDL TAB PDL TAB GZM VIAL PDL TAB TEV TAB AHI TAB APH TAB MNP ML ASN TAB JAI ML JAI TAB JAI ML BAI TAB BAI TAB BAI TAB PDL TAB PPC VIAL DSP ML ALV ML HSP ML ODN DOSE SDZ ML PMS TAB HJS ML PFI ML TEV ML FOU TAB Base Price 0.0071 0.1827 0.5000 0.6000 0.5000 0.0495 0.0467 4.8440 0.0873 3.6320 2.6433 2.6433 11964.0000 1.3780 2.7560 3.0617 2.8387 12.7040 1.6028 2.2895 5.0324 0.4578 13.3575 14.5375 11.9725 1.3718 253.9700 166.0000 1.0500 5.9620 0.2160 0.6140 0.1597 0.0920 3.0190 0.2958 1.1800 Pg 54 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002269074 00080006893 00080001853 00080007222 00002266695 00002131625 00002020017 00000074462 00002417456 00000590819 00002221810 00002280159 00002244692 00002243278 00002394383 00002394367 00002394375 00002394405 00002394413 00002394391 00002119579 00002421941 00002321114 00002169991 00002179709 00002425629 00002239833 00002242933 00002242934 00002046210 00002269066 00002366924 00002268450 00002268477 00002268418 00002268485 00002268426 Product Description LIPIDIL EZ 48 MG TABLET LIQUID CALCIUM WITH VITAMIN D LIQUID GLUCOSAMINE LIQUID OMEGA-3 PLUS VITAMIN A & D LITHMAX 300 MG SUSTAINED-RELEASE TABLET LIVOSTIN 0.5 MG/ML (BASE) OPH SUSPENSION LIVOSTIN 50 MCG PER DOSE NASAL SPRAY LOCACORTEN VIOFORM TOPICAL CREAM LOLO (28 DAY) TABLET LOPRESOR 1.0 MG/ML INJECTION LOPROX 1% TOPICAL LOTION LORATADINE 10 MG TABLET LORATADINE 10 MG TABLET LORAZEPAM 4 MG INJECTION USP LOSARTAN 100 MG TABLET LOSARTAN 25 MG TABLET LOSARTAN 50 MG TABLET LOSARTAN-HCTZ 100 MG/12.5 MG TABLET LOSARTAN-HCTZ 100 MG/25 MG TABLET LOSARTAN-HCTZ 50 MG/12.5 MG TABLET LOSEC 10 MG SUSTAINED-RELEASE CAPSULE LOTEMAX 0.5% OPHTHALMIC OINTMENT LOTEMAX 0.5% OPHTHALMIC SUSPENSION LOXAPAC 50 MG/ML INJECTION LOZIDE 1.25 MG TABLET LUCENTIS 10 MG/ML INJECTION SYRINGE LUPRON DEPOT 30 MG/VIAL INJECTION LUSTRA 4% TOPICAL CREAM LUSTRA-AF TOPICAL CREAM LUTREPULSE 0.8 MG/VIAL INJECTION LUVERIS 75 IU/VIAL INJECTION LUXIQ 0.12% TOPICAL FOAM LYRICA 150 MG CAPSULE LYRICA 225 MG CAPSULE LYRICA 25 MG CAPSULE LYRICA 300 MG CAPSULE LYRICA 50 MG CAPSULE Route ORL ORL ORL ORL ORL OPH NAS TOP ORL INJ TOP ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL OPH OPH INJ ORL INJ INJ TOP TOP INJ INJ TOP ORL ORL ORL ORL ORL 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. Form TAB LIQ LIQ LIQ SRT SUS SPR CRM TB DEFAUL LOT TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB SRC ONT SUS DEFAUL TAB DEFAUL DEFAUL CRM CRM DEFAUL DEFAUL FOA CAP CAP CAP CAP CAP MFR Unit of Issue FOU TAB WBP ML JAM ML WNP ML AAP TAB NOV ML JAI ML PAL G ASC TAB NOV ML VCL ML VTH TAB VTH TAB SDZ ML PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB AZC CAP BSH G BSH ML SDZ ML SEV TAB NOV SYR ABV VIAL MEI G MEI G FEI VIAL SRO VIAL GSK G PFI CAP PFI CAP PFI CAP PFI CAP PFI CAP Base Price 0.4607 0.0179 0.0329 0.0996 0.2724 5.1360 2.1140 0.9980 0.6486 1.3604 0.3520 0.1540 0.4442 23.1490 0.3147 0.3147 0.3147 0.3083 0.3147 0.3146 1.0079 6.8629 4.8040 15.2350 0.3253 1575.0000 1535.1000 1.1620 1.2930 115.0000 28.4800 0.8223 2.5143 2.5143 0.8987 2.5143 1.4097 Pg 55 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002268434 00000463221 00002009765 00002009749 00002009773 00002009706 00002244690 00002244689 00002238291 00002267225 00002068400 00080025339 00002040921 00080005581 00080005079 00002247017 00080013414 00000299448 00080014800 00000392618 00000602264 00002139499 00000202045 00001927639 00002264935 00002238151 00002243459 00000499013 00000899356 00002166747 00002429861 00002429888 00002429896 00002429918 00002371707 00002379562 00002241918 Product Description LYRICA 75 MG CAPSULE LYSODREN 500 MG TABLET M.O.S. SULPHATE 10 MG TABLET M.O.S. SULPHATE 25 MG TABLET M.O.S. SULPHATE 5 MG TABLET M.O.S. SULPHATE 50 MG TABLET MAALOX ANTACID WITH ANTI-GAS EXTRA STRENGTH SUSP MAALOX ANTACID WITH ANTI-GAS ORAL SUSPENSION MAALOX QUICK DISSOVE EXTRA STR. CHEWABLE TABLET MACUGEN 0.3 MG/SYR INJECTION SYRINGE MAGNESIUM 100 MG TABLET MAGNESIUM 250 MG TABLET MAGNESIUM 50 MG TABLET MAGNESIUM CITRATE 150 MG CAPSULE MAGNESIUM COMPLEX 250 MG CAPLET MAGNESIUM COMPLEX 250 MG TABLET MAGNESIUM EXTRA STRENGTH 500 MG TABLET MAGNESIUM OXIDE 420 MG TABLET MAGNESIUM PLUS CALCIUM POWDER FOR SUSPENSION MAGNESIUM SULFATE 20% INJECTION MAGNESIUM SULFATE 50% INJECTION USP MAGNESIUM SULFATE 500 MG/ML INJECTION USP MAGNOLAX ORAL EMULSION MAJEPTIL 10 MG (BASE) TABLET MALARONE PEDIATRIC TABLET MALARONE TABLET MALTLEVOL-12 ORAL LIQUID MANDELAMINE 500 MG TABLET MANERIX 150 MG TABLET MANERIX 300 MG TABLET MAR-AMITRIPTYLINE 10 MG TABLET MAR-AMITRIPTYLINE 25 MG TABLET MAR-AMITRIPTYLINE 50 MG TABLET MAR-AMITRIPTYLINE 75 MG TABLET MAR-AMLODIPINE 2.5 MG TABLET MAR-ANASTROZOLE 1 MG TABLET MARCAINE 2.5 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ Form CAP TAB TAB TAB TAB TAB SUS SUS TAB NDL TAB TAB TAB CAP TAB TAB TAB TAB PWRSUS DEFAUL DEFAUL DEFAUL EML TAB TAB TAB LIQ TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL 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. MFR Unit of Issue PFI CAP BMS TAB VCL TAB VCL TAB VCL TAB VCL TAB NVC ML NVC ML NVC TAB PFI SYR JAM TAB WNP TAB JAM TAB WBP CAP JAM TAB JAM TAB WNP TAB VCL TAB NCC G SDZ ML SDZ ML PPC ML PPH ML ERF TAB GSK TAB GSK TAB CHD ML ERF TAB MED TAB MED TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB HSP ML Base Price 1.8240 5.0616 0.1751 0.2317 0.1133 0.3553 0.0224 0.0192 0.1094 995.0000 0.0739 0.0491 0.0577 0.0800 0.0949 0.0450 0.0800 0.0348 0.0973 0.5117 1.4890 0.4633 0.0142 0.5442 1.6950 5.0875 0.0222 0.4149 0.6970 1.3902 0.0664 0.1211 0.2347 0.3634 0.1726 3.3280 0.8195 Pg 56 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002241919 00002305909 00002241917 00002241915 00002241914 00002403870 00000611190 00000611204 00002373424 00002422484 00002422468 00002422476 00002432560 00002389118 00002389126 00002416557 00002411946 00002417561 00002417537 00002417545 00002420503 00002432102 00002432110 00002432099 00002388324 00000012750 00002244533 00002245939 00002163632 00002163640 00002379104 00002426935 00002253550 00002253577 00002322250 00002244366 00002040891 Product Description MARCAINE 5 MG/ML INJECTION MARCAINE 5 MG/ML INJECTION MARCAINE 7.5 MG/ML INJECTION MARCAINE E 2.5 MG/ML INJECTION MARCAINE SPINAL 7.5 MG/ML INJECTION MAR-DOMPERIDONE 10 MG TABLET MARINOL 2.5 MG CAPSULE MARINOL 5 MG CAPSULE MAR-LETROZOLE 2.5 MG TABLET MAR-LOSARTAN 100 MG TABLET MAR-LOSARTAN 25 MG TABLET MAR-LOSARTAN 50 MG TABLET MAR-MODAFINIL 100 MG TABLET MAR-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB MAR-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB MAR-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET MAR-PAROXETINE 10 MG TABLET MAR-PREGABALIN 150 MG CAPSULE MAR-PREGABALIN 50 MG CAPSULE MAR-PREGABALIN 75 MG CAPSULE MAR-RAMIPRIL 15 MG CAPSULE MAR-TOPIRAMATE 100 MG TABLET MAR-TOPIRAMATE 200 MG TABLET MAR-TOPIRAMATE 25 MG TABLET MAR-TRAMADOL/ACET 37.5 MG/325 MG TABLET MATULANE 50 MG CAPSULE MAXILENE 4% TOPICAL CREAM MAXILENE 5 % TOPICAL CREAM MAXIPIME 1 G/VIAL INJECTION MAXIPIME 2 G/VIAL INJECTION MED-ANASTROZOLE 1 MG TABLET MED-LATANOPROST 0.005% OPHTHALMIC SOLUTION MEDROXY-2.5 2.5 MG TABLET MEDROXY-5 5MG TABLET MEDROXYPROGESTERONE ACETATE 150 MG/ML INJECTION MEFLOQUINE 250 MG TABLET MEGA-CAL CALCIUM W/ VITAMIN D 650 MG/200 UNIT CPT Route INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP INJ INJ ORL OPH ORL ORL INJ ORL ORL 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. Form DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB CAP CAP TAB TAB TAB TAB TAB DISNTAB DISNTAB ECT TAB CAP CAP CAP CAP/TAB TAB TAB TAB TAB CAP CRM CRM DEFAUL DEFAUL TAB SOL TAB TAB DEFAUL TAB TAB MFR Unit of Issue HSP ML HSP ML HSP ML HSP ML HSP ML MAR TAB ABB CAP ABB CAP MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR TAB MAR CAP MAR CAP MAR CAP MAR CAP MAR TAB MAR TAB MAR TAB MAR TAB SGM CAP RGR G RGR G TMD VIAL TMD VIAL GMP TAB GMP ML PDL TAB PDL TAB SDZ ML AAP TAB JAM TAB Base Price 0.9751 0.9742 1.9813 0.8495 12.7225 0.1646 2.2292 4.4582 3.0617 0.3147 0.3147 0.3147 0.9293 6.9623 7.5900 1.2750 1.0430 1.8652 1.0458 1.3532 0.8550 0.5928 0.8853 0.3128 0.6264 63.1064 1.7480 1.5980 17.7650 35.5250 1.7820 3.6320 0.0416 0.0823 22.6600 4.0350 0.1028 Pg 57 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002242594 00002409623 00002409658 00080006449 00002353156 00002353148 00002279924 00002248649 00002243820 00000588490 00001959018 00002283093 00002347393 00000725749 00000725757 00002415275 00002378795 00002378787 00002047667 00002247374 00002244290 00002241615 00002241614 00002174812 00002247034 00002174782 00002174790 00002174804 00002398427 00002182971 00002417626 00002327236 00002182947 00002230521 00002236872 00000868868 00001966375 Product Description MEGA-VIM CAPLET MEKINIST 0.5 MG TABLET MEKINIST 2 MG TABLET MELATONIN TIMED RELEASED MELOXICAM 15 MG TABLET MELOXICAM 7.5 MG TABLET MENACTRA A/C/Y/W-135 (0.5ML SINGLE-DOSE) INJECTION MENINGITEC (10 MCG/15 MCG) 0.5 ML INJECTION MENJUGATE VACCINE (10 MCG/25 MCG) .5 ML INJECTION MENOMUNE A/C/Y/W-135 (MULTI-DOSE) INJECTION MENOMUNE A/C/Y/W-135 (SINGLE-DOSE) INJECTION MENOPUR 75 IU/VIAL INJECTION MENVEO 0.5 ML INJECTION MEPERIDINE HYDROCHLORIDE 100 MG/ML INJECTION MEPERIDINE HYDROCHLORIDE 75 MG/ML INJECTION MERCAPTOPURINE 50 MG TABLET MEROPENEM 1G/VIAL INJECTION MEROPENEM 500 MG/VIAL INJECTION MERSYNDOL WITH CODEINE TABLET METADOL-D 1 MG/ML ORAL SOLUTION METADOL-D CONCENTRATE 10 MG/ML ORAL LIQUID METAMUCIL FIBRE APPLE CRISP 3.4 G/2 WAFERS METAMUCIL FIBRE CINNAMON SPICE 3.4 G/2 WAFERS METAMUCIL FIBRE THERAPY 3.4 G/TSP ORAL POWDER METAMUCIL FIBRE THERAPY CAPSULE METAMUCIL FIBRE THERAPY-SMOOTH TEXTURE-ORANGE S.F. METAMUCIL SMOOTH TEXTURE-ORANGE 3 G/TBSP ORAL PWDR METAMUCIL SMOOTH UNFLAVORED SUGAR FREE POWDER METHOTREXATE (PRESERVED) 25 MG/ML INJECTION USP METHOTREXATE (UNPRESERVED) 25 MG/ML INJECTION METHOTREXATE 25 MG/ML INJECTION (UNPRESERVED) METHOTREXATE 25 MG/ML INJECTION BP (UNPRESERVED) METHOTREXATE SODIUM (UNPRESERVED) 10 MG/ML INJ METHOXACET CAPLET METHOXACET-C 1/8 CAPLET METHOXISAL CAPLET METHOXISAL-C 1/2 TABLET Route ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ INJ INJ INJ ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ ORL ORL ORL ORL 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. Form TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB DEFAUL DEFAUL TAB SOL LIQ WAF WAF PWR CAP PWR PWR PWR DEFALT DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB MFR Unit of Issue JAM TAB GSK TAB GSK TAB PLH TAB SNS TAB SNS TAB SFP ML NBV ML NOV VIAL SFP VIAL SFP VIAL FEI VIAL NOV ML SDZ ML SDZ ML STM TAB SDZ VIAL SDZ VIAL SAV TAB PAL ML PAL ML PGI WAF PGI WAF PGI G PGI CAP PGI G PGI G PGI G SDZ ML MNP ML MYP ML AHI ML MNP ML RPH TAB RPH TAB RPH TAB RPH TAB Base Price 0.1893 77.9373 311.7500 0.0556 0.5670 0.4913 240.2200 139.8000 97.1800 157.2900 172.4700 69.0000 217.1600 1.3380 1.2630 3.1244 47.9900 23.9950 0.2308 0.0540 0.1500 0.1717 0.2120 0.0298 0.1351 0.0727 0.0174 0.0354 6.1420 7.8755 6.2500 7.5000 9.0250 0.1678 0.6267 0.2772 1.0401 Pg 58 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001966367 00001941895 00002326248 00002326256 00002326221 00002245407 00002245408 00002245400 00002245406 00002243563 00002320037 00002320045 00002304767 00002320053 00002320029 00002351404 00002351412 00002267853 00000648027 00000648019 00002092832 00002248562 00002323273 00000795860 00000795852 00002085852 00002171775 00002091143 00002091135 00002063905 00000787000 00000487805 00002242904 00002240285 00002242905 00002382873 00002244622 Product Description METHOXISAL-C 1/4 TABLET METHOXISAL-C 1/8 CAPLET METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE 20 MG TABLET METHYLPHENIDATE 5 MG TABLET METHYLPREDNISOLONE ACETATE (PRES.) 40 MG/ML INJ METHYLPREDNISOLONE ACETATE (PRES.) 80 MG/ML INJ. METHYLPREDNISOLONE ACETATE 40 MG/ML INJECTION USP METHYLPREDNISOLONE ACETATE 80 MG/ML INJECTION USP METOCLOPRAMIDE OMEGA 5MG/ML INJECTION METOJECT 10 MG/1 ML INJECTION SYRINGE METOJECT 15 MG/1.5 ML INJECTION SYRINGE METOJECT 20 MG/2 ML INJECTION SYRINGE METOJECT 25 MG/2.5 ML INJECTION SYRINGE METOJECT 7.5 MG/0.75 ML INJECTION SYRINGE METOPROLOL SR 100 MG SUSTAINED-RELEASE TABLET METOPROLOL SR 200 MG SUSTAINED-RELEASE TABLET METOPROLOL TARTRATE 1 MG/ML INJECTION USP METOPROLOL-100 MG TABLET METOPROLOL-50 MG TABLET METROGEL 0.75% TOPICAL GEL METRONIDAZOLE 500 MG CAPSULE METVIX 16.8% TOPICAL CREAM MEVACOR 20 MG TABLET MEVACOR 40 MG TABLET MICATIN 2% TOPICAL CREAM MICONAZOLE 3 DAY OVULE TREATMENT MICRO PLUS 4 CONCETRATE INJECTION MICRO PLUS 4 REGULAR STRENGTH INJECTION MICROLAX MICRO RECTAL ENEMA MICRO-ZN 5 MG/ML INJECTION MIDAMOR 5 MG TABLET MIDAZOLAM 1 MG/ML INJECTION MIDAZOLAM 1 MG/ML INJECTION MIDAZOLAM 5 MG/ML INJECTION MIDAZOLAM INJECTION SDZ 1 MG/ML INJECTION MILRINONE LACTATE 1 MG/ML INJECTION Route ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ ORL ORL INJ ORL ORL TOP ORL TOP ORL ORL TOP VAG INJ INJ RT INJ ORL INJ INJ INJ INJ INJ 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. Form TAB TAB TAB TAB TAB DEFALT DEFALT DEFAUL DEFAUL DEFAUL NDL NDL NDL NDL NDL SRT SRT DEFAUL TAB TAB GEL CAP CRM TAB TAB CRM OVL DEFAUL DEFAUL ENM DEFAUL TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL MFR Unit of Issue RPH TAB RPH TAB PDL TAB PDL TAB PDL TAB SDZ ML SDZ ML SDZ ML SDZ ML OMG ML MDX SYR MDX SYR MDX SYR MDX SYR MDX SYR PDL TAB PDL TAB SDZ ML PDL TAB PDL TAB GAL G AAP CAP GAL G MFC TAB MFC TAB WSP G VTH OVL SDZ ML SDZ ML JJM ENM SDZ ML OPI TAB PPC ML SDZ ML PPC ML SDZ ML PPC ML Base Price 0.8825 0.5667 0.1262 0.2435 0.0947 4.1000 6.9900 4.1000 8.2000 1.0250 53.1000 58.7000 64.2800 69.8800 50.3100 0.1415 0.2499 1.4162 0.1250 0.0624 1.4558 0.7674 162.8200 2.0610 3.7647 0.3840 1.6966 2.5276 0.9090 1.2950 2.4042 0.2860 1.1450 0.8518 4.1000 0.8515 5.0610 Pg 59 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001935348 00000485802 00002246500 00002393573 00002423243 00002425947 00002426196 00002426218 00002422727 00002326477 00002326485 00002326493 00002393085 00002393069 00002393077 00002389800 00000042544 00002241594 00002312786 00002248846 00002230451 00002230450 00001948873 00001948881 00000466085 00002242786 00002242785 00002238696 00001909142 00001909169 00002239601 00002244005 00002126605 00002126249 00002084309 00002126257 00002126567 Product Description MINERAL OIL (HEAVY) MINERAL OIL 100% ORAL LIQUID MINIRIN 0.1 MG TABLET MINT-ANASTROZOLE 1 MG TABLET MINT-EZETIMIBE 10 MG TABLET MINT-HYDROCHLOROTHIAZIDE 12.5 MG TABLET MINT-HYDROCHLOROTHIAZIDE 25 MG TABLET MINT-HYDROCHLOROTHIAZIDE 50 MG TABLET MINT-OLOPATADINE 0.1% OPHTHALMIC SOLUTION MINT-PIOGLITAZONE 15 MG TABLET MINT-PIOGLITAZONE 30 MG TABLET MINT-PIOGLITAZONE 45 MG TABLET MINT-SILDENAFIL 100 MG TABLET MINT-SILDENAFIL 25 MG TABLET MINT-SILDENAFIL 50 MG TABLET MINT-TRAMADOL/ACET 37.5 MG/325 MG TABLET MIOSTAT 0.01% OPH SOLUTION MIRAPEX 0.5 MG TABLET MIRTAZAPINE-30 30 MG TABLET MISOPROSTOL-200 200 MCG TABLET MITOMYCIN 20 MG/VIAL INJECTION MITOMYCIN 5 MG/VIAL INJECTION MIXED VESPID VENOM PROTEIN 1.1 MG VIAL INJ MIXED VESPID VENOM PROTEIN 120 MCG M-M-R II VIRUS VACCINE LIVE ATTENUATED INJECTION MOBICOX 15 MG TABLET MOBICOX 7.5 MG TABLET MOI-STIR SPRAY ORAL LIQUID MOISTUREL TOPICAL CREAM MOISTUREL TOPICAL LOTION MONISTAT 1 1200 MG VAGINAL OVULE MONISTAT 3 4% VAGINAL CREAM MONISTAT 3 400 MG VAGINAL OVULE MONISTAT 3 DUAL-PAK KIT MONISTAT 7 2% VAGINAL CREAM MONISTAT 7 DUAL-PAK VAGINAL OVULE/TOPICAL CREAM MONISTAT DERM 2% TOPICAL CREAM Route ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL INJ INJ INJ INJ INJ ORL ORL ORL TOP TOP VAG VAG VAG VAG/TOP VAG VAG/TOP TOP Form LIQ LIQ TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB LIQ CRM LOT OVL CRM OVL OVL/CRM CRM OVL/CRM CRM 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. MFR Unit of Issue RBW ML RPH ML FEI TAB MPI TAB MPI TAB MPI TAB MPI TAB MPI TAB MPI ML MPI TAB MPI TAB MPI TAB MPI TAB MPI TAB MPI TAB MPI TAB ALC ML BOE TAB PDL TAB PDL TAB TEV VIAL TEV VIAL ALK ML ALG VIAL MSD VIAL BOE TAB BOE TAB PMS ML WSD G WSD ML MCL OVL MCL G MCL OVL MCL KIT MCL G MCL KIT MCL G Base Price 0.0097 0.0122 1.4207 1.7821 0.4750 0.0351 0.0162 0.0224 5.2260 0.5809 0.8139 1.2237 9.2000 8.2900 8.8475 0.6264 14.2561 2.3664 0.1950 0.2850 377.2000 94.3000 71.3833 71.3833 33.3020 1.0093 0.8747 0.0675 0.0601 0.0220 12.7400 0.8493 4.2467 14.5900 0.3640 14.5900 0.4167 Pg 60 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002239600 00001907107 00001907115 00000999332 00002379856 00002379821 00002379848 00000676411 00002021056 00001964437 00001964429 00001980696 00002242484 00080028360 00002186934 00080001844 00002125013 00000599875 00002330989 00000782203 00000782211 00000586315 00002100606 00002244898 00000374083 00002248775 00002248778 00002240942 00000233498 00080005483 00002242779 00002242939 00002242780 00002244864 00000750816 00000750824 00002238595 Product Description MONISTAT-1 COMBINATION PACK VAG OVULE/TOP CREAM MONOPRIL 10 MG TABLET MONOPRIL 20 MG TABLET MONOVISC MONTELUKAST 10 MG TABLET MONTELUKAST 4 MG TABLET MONTELUKAST 5 MG TABLET MORPHINE HP 25 25 MG/ML INJECTION MORPHINE LP EPIDURAL 0.5 MG/ML INJECTION MORPHINE SULFATE 2 MG/ML INJECTION USP MORPHINE SULFATE 5 MG/ML INJECTION USP MORPHINE SULFATE 1 MG/ML INJECTION USP MORPHINE SULFATE 2 MG/ML INJECTION MOTION MEDICINE TOPICAL CREAM MOTRIN IB 200 MG TABLET MSM 1000 MG MUCAINE ORAL SUSPENSION MUCILLIUM 500 MG/G ORAL POWDER MULTAQ 400 MG TABLET MULTI VITAMIN PLUS IRON TABLET MULTI VITAMIN TABLET MULTI-1000 INJECTION MULTI-12 INJECTION MULTIPLE VITAMIN TABLET MULTIPLE VITAMIN WITH MINERAL TABLET MULTISURE FOR WOMEN MULTISURE FOR WOMEN OVER 50 GELATIN CAPSULE MULTI-TAR PLUS REGULAR TOPICAL SHAMPOO MULTIVITAMIN TABLET MULTI-VITAMIN TABLET MULTIVITAMINS & MULTIMINERALS FORMULA FORTE SR.TAB MULTIVITAMINS + MULTIMINERALS 50+ FORMULA TAB. MULTIVITAMINS AND MULTIMINERALS FORMULA FORTE TAB MULTIVITAMINS FOR ADULTS TABLET MURO-128 5% OPH OINTMENT MURO-128 5% OPH SOLUTION MUSE 1000 MCG URETHRAL SUPPOSITORY Route VAG/TOP ORL ORL DEFAUL ORL ORL ORL INJ INJ INJ INJ INJ INJ TOP ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL OPH OPH URH Form OVL/CRM TAB TAB DEV TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CRM TAB TAB SUS PWR TAB TAB TAB DEFAUL DEFAUL TAB TAB CAP CAP SHP TAB TAB TAB TAB TAB TAB ONT SOL SUP 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. MFR Unit of Issue MCL KIT BMS TAB BMS TAB PMS ML PDL TAB PDL TAB PDL TAB SDZ ML SDZ ML SDZ ML SDZ ML SDZ ML SDZ ML NDP G MCL TAB WNP TAB AXC ML PMS G SAV TAB VTH TAB VTH TAB SDZ ML SDZ ML PMT TAB ADA TAB WNP CAP WBP CAP VCL ML WAM TAB WNP TAB PMT TAB PMT TAB PMT TAB PMT TAB BSH G BSH ML PAL SUP Base Price 14.5900 0.9262 1.1138 93.7500 0.9460 0.9460 0.9460 3.7210 2.3806 0.2604 0.4153 0.3726 2.1280 0.1212 0.1304 0.0694 0.0243 0.0185 2.3658 0.0600 0.0270 0.8197 0.9150 0.0700 0.1100 0.1702 0.1276 0.0381 0.2226 0.0357 0.0800 0.0665 0.0678 0.0300 3.1257 0.7293 37.2500 Pg 61 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002238593 00002238594 00000016063 00002415380 00002311054 00002294222 00002264560 00002264579 00002270110 00002229813 00002229814 00002139200 00002253054 00002361418 00002378981 00002378930 00002378949 00002378957 00002378965 00002378973 00002402165 00002302403 00002384426 00002384418 00002383500 00002383497 00002241003 00002408090 00002408104 00002379120 00002241883 00002227479 00002381524 00002383039 00002383047 00002247323 00002392631 Product Description MUSE 250 MCG URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOSITORY MUSTARGEN HCL TRITURATION 10 MG/VIAL INJECTION MYA 28 TABLET MYCAMINE 100 MG/VIAL INJECTION MYCAMINE 50 MG/VIAL INJECTION MYFORTIC 180 MG ENTERIC-COATED TABLET MYFORTIC 360 MG ENTERIC-COATED TABLET MYLAN-ALENDRONATE 5 MG TABLET MYLAN-ALPRAZOLAM 1 MG TABLET MYLAN-ALPRAZOLAM 2 MG TABLET MYLAN-AMANTADINE 100 MG CAPSULE MYLAN-ANAGRELIDE 0.5 MG CAPSULE MYLAN-ANASTROZOLE 1 MG TABLET MYLAN-ATOMOXETINE 100 MG CAPSULE MYLAN-ATOMOXETINE 18 MG CAPSULE MYLAN-ATOMOXETINE 25 MG CAPSULE MYLAN-ATOMOXETINE 40 MG CAPSULE MYLAN-ATOMOXETINE 60 MG CAPSULE MYLAN-ATOMOXETINE 80 MG CAPSULE MYLAN-ATOVAQUONE/PROGUANIL 250 MG/ 100 MG TABLET MYLAN-BICALUTAMIDE 50 MG TABLET MYLAN-BISOPROLOL 10 MG TABLET MYLAN-BISOPROLOL 5 MG TABLET MYLAN-BOSENTAN 125 MG TABLET MYLAN-BOSENTAN 62.5 MG TABLET MYLAN-BUDESONIDE AQ 64 MCG/DOSE MET DOSE NAS SPRAY MYLAN-BUPRENORPHINE NALOXONE 2 MG/0.5 MG SUBL TAB MYLAN-BUPRENORPHINE NALOXONE 8 MG/2 MG SUBL TAB MYLAN-CANDESARTAN 4 MG TABLET MYLAN-CARBAMAZEPINE CR 400 MG SUSTAIN RELEASE TAB MYLAN-CIMETIDINE 800 MG TABLET MYLAN-EFAVIRENZ 600 MG TABLET MYLAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET MYLAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET MYLAN-ETI-CAL CAREPAC 400 MG/500 MG TABLET MYLAN-FINASTERIDE HG 1 MG TABLET Route URH URH INJ ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SUP SUP DEFAUL TB DEFAUL DEFAUL ECT ECT TAB TAB TAB CAP CAP TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB SPM SLT SLT TAB SRT TAB TAB DRT DRT TAB TAB MFR Unit of Issue PAL SUP PAL SUP LUI VIAL APX TAB ASP VIAL ASP VIAL NOV TAB NOV TAB MYP TAB MYP TAB MYP TAB MYP CAP MYP CAP MYP TAB MYP CAP MYP CAP MYP CAP MYP CAP MYP CAP MYP CAP MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP DOSE MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB Base Price 37.2500 37.2500 8.5500 0.4618 196.0000 98.0000 2.1813 4.3626 1.0370 0.3384 0.5508 0.5179 3.3491 2.7497 4.3520 2.6500 2.9281 3.3375 3.7024 3.9960 4.5105 4.0573 0.1450 0.1085 22.4625 22.4625 0.0921 2.4781 4.3901 0.3400 0.1859 0.2430 12.2410 1.8690 1.8690 0.2221 1.1454 Pg 62 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002397471 00002397498 00002185407 00002230476 00000808733 00002242920 00002319225 00002319233 00002255995 00002255987 00002430371 00002371154 00002370549 00002244563 00002387727 00002382725 00002382733 00002230800 00002248012 00002298279 00002298287 00002298295 00002376369 00002245372 00002245373 00002397773 00002229778 00002268906 00002019795 00002088428 00002089858 00002298570 00002272059 00002425599 00002231684 00002351560 00002351579 Product Description MYLAN-GABAPENTIN 600 MG TABLET MYLAN-GABAPENTIN 800 MG TABLET MYLAN-GEMFIBROZIL 300 MG CAPSULE MYLAN-GEMFIBROZIL 600 MG TABLET MYLAN-GLYBE 2.5 MG TABLET MYLAN-HYDROXYUREA 500 MG CAPSULE MYLAN-LEFLUNOMIDE 10 MG TABLET MYLAN-LEFLUNOMIDE 20 MG TABLET MYLAN-MELOXICAM 15 MG TABLET MYLAN-MELOXICAM 7.5 MG TABLET MYLAN-MEMANTINE 10 MG TABLET MYLAN-MYCOPHENOLATE 250 MG CAPSULE MYLAN-MYCOPHENOLATE 500 MG TABLET MYLAN-NABUMETONE 500 MG TABLET MYLAN-NEVIRAPINE 200 MG TABLET MYLAN-OLANZAPINE ODT 15 MG ORALLY DISINTEG. TABLET MYLAN-OLANZAPINE ODT 20 MG ORALLY DISINTEG.TABLET MYLAN-OXYBUTYNIN 5 MG TABLET MYLAN-PAROXETINE 10 MG TABLET MYLAN-PIOGLITAZONE 15 MG TABLET MYLAN-PIOGLITAZONE 30 MG TABLET MYLAN-PIOGLITAZONE 45 MG TABLET MYLAN-PRAMIPEXOLE 0.5 MG TABLET MYLAN-PROPAFENONE 150 MG TABLET MYLAN-PROPAFENONE 300 MG TABLET MYLAN-RISEDRONATE 150 MG TABLET MYLAN-SOTALOL 80 MG TABLET MYLAN-SUMATRIPTAN 25 MG TABLET MYLANTA REGULAR STRENGTH CHEWABLE TABLET MYLAN-TAMOXIFEN 10 MG TABLET MYLAN-TAMOXIFEN 20 MG TABLET MYLAN-TAMSULOSIN 0.4 MG EXTENDED-RELEASE CAPSULE MYLAN-TIZANIDINE 4 MG TABLET MYLAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET MYLAN-TRAZODONE 100 MG TABLET MYLAN-VALACYCLOVIR 1000 MG CAPLET MYLAN-VALACYCLOVIR 500 MG CAPLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB CAP TAB TAB CAP TAB TAB TAB TAB TAB CAP TAB TAB TAB DISNTAB DISNTAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CTB TAB TAB SRC TAB TAB TAB TAB TAB MFR Unit of Issue MYP TAB MYP TAB MYP CAP MYP TAB MYP TAB MYP CAP MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP CAP MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB WLA TAB MYP TAB MYP TAB MYP CAP MYP TAB MYP TAB MYP TAB MYP TAB MYP TAB Base Price 1.3045 1.7393 0.1288 0.5157 0.0321 1.1141 6.0417 6.0417 0.6191 0.4914 1.6357 1.0310 2.0620 0.3625 1.7285 4.1240 7.5977 0.0986 1.0430 0.6343 0.8887 1.3361 1.0514 0.3238 0.5708 40.9500 0.2966 8.9900 0.1062 0.1750 0.3500 0.2375 0.3686 0.6264 0.0989 3.3924 0.8475 Pg 63 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002184648 00002383527 00002287501 00002287528 00000004618 00002372169 00002408694 00002408651 00002408708 00002408678 00002408686 00002392593 00002392577 00002392585 00001927612 00002226022 00002402874 00002402882 00000828815 00000818704 00002382601 00002148706 00002148714 00000390283 00000481408 00002242505 00002242506 00002162792 00000618721 00002362430 00000590762 00000655686 00002153386 00002229415 00002213834 00002192799 00000788503 Product Description MYLAN-VALPROIC 250 MG CAPSULE MYLAN-VALSARTAN 40 MG TABLET MYLAN-WARFARIN 6 MG TABLET MYLAN-WARFARIN 7.5 MG TABLET MYLERAN 2 MG TABLET MYL-LETROZOLE 2.5 MG TABLET MYL-PREGABALIN 150 MG CAPSULE MYL-PREGABALIN 25 MG CAPSULE MYL-PREGABALIN 300 MG CAPSULE MYL-PREGABALIN 50 MG CAPSULE MYL-PREGABALIN 75 MG CAPSULE MYL-SILDENAFIL 100 MG TABLET MYL-SILDENAFIL 25 MG TABLET MYL-SILDENAFIL 50 MG TABLET MYOCHRYSINE 25 MG/ML INJECTION MYOFLEX EXTRA STRENGTH 15% CREAM MYRBETRIQ 25 MG EXTENDED-RELEASE TABLET MYRBETRIQ 50 MG EXTENDED-RELEASE TABLET NADOLOL-40 MG TABLET NADOLOL-80 MG TABLET NALOXONE HYDROCHLORIDE (PRES. FREE) 0.4 MG/ML INJ NALOXONE HYDROCHLORIDE 0.4 MG/ML INJECTION NALOXONE HYDROCHLORIDE 1 MG/ML INJECTION NAPHCON FORTE 0.1% OPH SOLUTION NAPHCON-A OPH SOLUTION NAPRELAN 375 MG CONTROLLED-RELEASE TABLET NAPRELAN 500 MG CONTROLLED-RELEASE TABLET NAPROSYN E 250 MG ENTERIC-COATED TABLET NAPROXEN 500 MG TABLET NAPROXEN 220 MG TABLET NAPROXEN 250 MG TABLET NAPROXEN-375 375 MG TABLET NAPROXEN-NA DF 550 MG TABLET NAROPIN 5 MG/ML INJECTION NASACORT AQ 55 MCG NASAL METERED DOSE SPRAY NASAL + SINUS DECONGESTANT RELIEF 60 MG TABLET NASAL DECONGESTANT SPRAY 0.1% Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ TOP ORL ORL ORL ORL INJ INJ INJ OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL INJ NAS ORL NAS 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. Form CAP TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB TAB DEFAUL CRM ERT ERT TAB TAB DEFAUL DEFAUL DEFAUL SOL SOL CRT CRT ECT TAB TAB TAB TAB TAB DEFAUL SPM TAB LIQ MFR Unit of Issue MYP CAP MYP TAB MYP TAB MYP TAB ASN TAB MYP TAB MYP CAP MYP CAP MYP CAP MYP CAP MYP CAP MYP TAB MYP TAB MYP TAB AVE ML BIC G ASP TAB ASP TAB PDL TAB PDL TAB SDZ ML SDZ ML SDZ ML ALC ML ALC ML SUN TAB SUN TAB HLR TAB PDL TAB PMS TAB PDL TAB PDL TAB PDL TAB AZC ML SAV DOSE VTH TAB CNF ML Base Price 0.1366 0.5239 0.2805 0.3014 1.6364 2.7560 1.7270 0.6173 1.7270 0.9683 1.2529 9.2007 8.2900 8.8475 16.3780 0.0988 1.9000 1.9000 0.2465 0.3515 15.0090 15.0090 20.7520 0.5133 0.4840 1.0487 1.5790 0.4174 0.2110 0.0954 0.1068 0.1458 0.6667 0.3798 0.2184 0.1317 0.0920 Pg 64 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002417855 00002409003 00002421585 00002417839 00002417847 00002436612 00002436604 00000024457 00080029758 00080027142 00002245057 00000147680 00000666157 00000666122 00000874957 00000885282 00001915436 00002230593 00002230592 00001958690 00000999459 00000999922 00000587826 00000587834 00080007796 00002417197 00002417200 00002417189 00002403897 00002403900 00002403919 00002403927 00002403935 00002403943 00002239717 00002239718 00080006269 Product Description NAT-ANASTROZOLE 1 MG TABLET NAT-CITALOPRAM 10 MG TABLET NAT-LETROZOLE 2.5 MG TABLET NAT-ONDANSETRON 4 MG TABLET NAT-ONDANSETRON 8 MG TABLET NAT-RIZATRIPTAN ODT 10 MG ORALLY DISINTEG TAB NAT-RIZATRIPTAN ODT 5 MG ORALLY DISINTEG TAB NAVANE 10 MG CAPSULE NEBUSAL 7% INHALATION SOLUTION NEILMED NASAL SINUS RINSE NEISVAC-C 10 MCG/20 MCG INJECTION SYRINGE NEO-BEX (LIDOCAINE HCL) INJECTION VIAL NEOSPORIN IRRIGATING SOLUTION NEOSPORIN TOPICAL OINTMENT NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INJECTION NEOSTIGMINE METHYLSULFATE 1 MG/ML INJECTION NEOSTIGMINE METHYLSULFATE 2.5 MG/ML INJECTION NEOSTIGMINE OMEGA 0.5 MG/ML INJECTION NEOSTIGMINE OMEGA 1 MG/ML INJECTION NEOSTRATA HQ 2% GEL NEOVISC NEPRO ORAL LIQUID NERISONE 0.1% TOPICAL CREAM NERISONE 0.1% TOPICAL OINTMENT NERVOHEEL N TABLET NESINA 12.5 MG TABLET NESINA 25 MG TABLET NESINA 6.25 MG TABLET NEUPRO 1 MG/24 HOUR TRANSDERMAL PATCH NEUPRO 2 MG/24 HOUR TRANSDERMAL PATCH NEUPRO 3 MG/24 HOUR TRANSDERMAL PATCH NEUPRO 4 MG/24 HOUR TRANSDERMAL PATCH NEUPRO 6 MG/24 HOUR TRANSDERMAL PATCH NEUPRO 8 MG/24 HOUR TRANSDERMAL PATCH NEURONTIN 600 MG TABLET NEURONTIN 800 MG TABLET NEUTROGENA BODY CLEAR BODY WASH PINK GRAPEFRUIT Route ORL ORL ORL ORL ORL ORL ORL ORL MIS NAS INJ INJ IR TOP INJ INJ INJ INJ INJ TOP DEFAUL ORL TOP TOP ORL ORL ORL ORL TRD TRD TRD TRD TRD TRD ORL ORL TOP 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. Form TAB TAB TAB TAB TAB DISNTAB DISNTAB CAP DEFAUL PWS NDL DEFAUL SOL ONT DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL GEL DEV LIQ CRM ONT TAB TAB TAB TAB PTH PTH PTH PTH PTH PTH TAB TAB GEL MFR Unit of Issue NTP TAB NTP TAB NTP TAB NTP TAB NTP TAB NTP TAB NTP TAB ERF CAP STM ML NPI PCKT SHB SYR BRO ML GSK ML GSK G SDZ ML SDZ ML SDZ ML OMG ML OMG ML CDX G STL ML ABN ML GSK G GSK G HEE TAB TAK TAB TAK TAB TAK TAB UCB PTH UCB PTH UCB PTH UCB PTH UCB PTH UCB PTH PFI TAB PFI TAB JJI ML Base Price 2.9000 0.1432 3.1300 3.2720 4.9930 3.7050 3.7050 0.4416 0.2654 0.2384 80.1850 6.1440 1.8125 0.4680 0.8844 0.9981 3.4342 0.9400 1.0500 0.8127 41.3333 0.0090 0.3943 0.3863 0.2858 2.8140 2.8140 2.8140 3.8653 3.8653 7.0977 7.0977 7.9383 7.8117 2.0314 2.7112 0.0270 Pg 65 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002308983 00080039670 00002284227 00002300524 00002244521 00002244522 00000232459 00000779806 00000309737 00002244702 00002242138 00002262339 00002262347 00002262355 00002309289 00002309254 00002309262 00002247347 00002247348 00002065762 00080007461 00080007464 00080000402 00080000396 00002125226 00002325926 00002229655 00002229654 00002182920 00002397927 00002048485 00080016396 00080008766 00080007895 00080002913 00001966154 00001966162 Product Description NEVANAC 0.1% OPHTHALMIC SUSPENSION NEW NORDIC HAIR VOLUME TABLET NEXAVAR 200 MG TABLET NEXIUM 10 MG/DOSE DEL REL GRANULES FOR ORAL SUSP NEXIUM 20 MG DELAYED-RELEASE TABLET NEXIUM 40 MG DELAYED-RELEASE TABLET NIACIN 100 MG TABLET NIACIN 500 MG SUSTAINED-RELEASE CAPSULE NIACIN 500 MG TABLET NIACIN AND INOSITOL 500 MG/150 MG TABLET NIACIN AND INOSITOL 500 MG/150 MG TABLET NIASPAN 1000 MG EXTENDED-RELEASE TABLET NIASPAN 500 MG EXTENDED-RELEASE TABLET NIASPAN 750 MG EXTENDED-RELEASE TABLET NIASPAN FCT 1000 MG EXTENDED-RELEASE TABLET NIASPAN FCT 500 MG EXTENDED-RELEASE TABLET NIASPAN FCT 750 MG EXTENDED-RELEASE TABLET NICORETTE MINI LOZENGE 2 MG NICORETTE MINI LOZENGE 4 MG NICORETTE PATCH 15MG; NICORETTE COMBOQUIT NICOTINE LOZENGES; THRIVE LOZENGES 1 MG NICOTINE LOZENGES; THRIVE LOZENGES 2 MG NICOTINELL/THRIVE 4 MG ORAL GUM NICOTINELL; THRIVE 2 MG ORAL GUM NIDAGEL 0.75% VAGINAL GEL NIMOTOP 30 MG TABLET NITRAZADON 10 MG TABLET NITRAZADON 5 MG TABLET NIZORAL 2% TOPICAL SHAMPOO NOCDURNA 25 MCG ORALLY DISINTEGRATING TABLET NOLVADEX-D 20 MG (BASE) TABLET NON-FLUSH/FLUSH FREE NIACIN CAPSULE NORDIC NATURALS ARCTIC COD LIVER OIL NORDIC NATURALS ARCTIC COD LIVER OIL LIQUID NORDIC NATURALS OMEGA-3 LIQUID NORFLEX 100 MG TABLET NORFLEX 30 MG/ML INJECTION Route OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL VAG ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL INJ Form SUS TAB TAB DRGRNUL DRT DRT TAB SRC TAB TAB TAB ERT ERT ERT ERT ERT ERT LOZ LOZ PTH LOZ LOZ GUM GUM GEL TAB TAB TAB SHP DISNTAB TAB CAP LIQ LIQ LIQ TAB DEFAUL 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. MFR Unit of Issue ALC ML NNO TAB BAI TAB AZC PCKT AZC TAB AZC TAB ADA TAB VTH CAP JAM TAB JAM TAB QVS TAB SUN TAB SUN TAB SUN TAB SUN TAB SUN TAB SUN TAB MCL LOZ MCL LOZ MCL PTH NOV LOZ NOV LOZ NVC PIECE NOV PIECE VCL G BAI TAB AAP TAB AAP TAB MCL ML FEI TAB AZC TAB PLH CAP NRD ML NRD ML NRD ML MMH TAB GRC ML Base Price 4.4080 0.9313 49.9196 2.4023 2.4023 2.4023 0.0830 0.9281 0.0601 0.2080 0.1395 1.3337 1.3810 1.4180 1.4522 1.4522 1.4298 0.4714 0.5423 3.4771 0.2744 0.3119 0.3119 0.2781 0.3249 10.8334 0.1282 0.0708 0.1028 1.4413 0.4223 0.1560 0.1105 0.0827 0.0827 0.8414 5.6642 Pg 66 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002285576 00000023760 00002357593 00002229145 00002241480 00002049481 00002049473 00000216666 00002314282 00002315157 00002315165 00002270226 00000603678 00002248138 00002309556 00002048698 00002048493 00001913468 00001913476 00001913425 00001913433 00001913441 00002300230 00002300222 00002324199 00002243551 00000021458 00000595829 00000389218 00002273756 00002273764 00002273772 00002210479 00002176084 00002230730 00002158612 00002158620 Product Description NORLEVO 0.75 MG TABLET NORLUTATE 5 MG TABLET NORVIR 100 MG FILM-COATED TABLET NORVIR 80 MG SOLUTION NORVIR SEC 100 MG CAPSULE NOVAHISTEX DH ADULT ORAL LIQUID NOVAHISTINE DH CHILDREN ORAL LIQUID NOVASEN 325 MG ENTERIC-COATED TABLET NOVO-ALFUZOSIN PR 10 MG PROLONGED-RELEASE TABLET NOVO-AZITHROMYCIN 20 MG/ML PEDIATRIC SUSPENSION NOVO-AZITHROMYCIN 40 MG/ML PEDIATRIC SUSPENSION NOVO-BICALUTAMIDE 50 MG TABLET NOVO-CIMETINE 400 MG TABLET NOVO-CLAVAMOXIN 875 MG/125 MG TABLET NOVO-CYPROTERONE/ETHINYL ESTRADIOL 2MG/0.035MG TAB NOVO-DIFENAC SR 100 MG SUSTAINED-RELEASE TABLET NOVO-DIFLUNISAL FC 250 MG TABLET NOVO-DOXEPIN 100 MG CAPSULE NOVO-DOXEPIN 150 MG CAPSULE NOVO-DOXEPIN 25 MG CAPSULE NOVO-DOXEPIN 50 MG CAPSULE NOVO-DOXEPIN 75 MG CAPSULE NOVO-ENALAPRIL/HCTZ 10 MG/25 MG TABLET NOVO-ENALAPRIL/HCTZ 5 MG/12.5 MG TABLET NOVO-ETIDRONATECAL 400 MG/500 MG TABLET NOVO-FENOFIBRATE MICRONIZED 67 MG CAPSULE NOVOFERROGLUC 300 MG TABLET NOVO-FIBER 469 MG TABLET NOVO-GESIC 325 MG TABLET NOVO-GLIMEPIRIDE 1 MG TABLET NOVO-GLIMEPIRIDE 2 MG TABLET NOVO-GLIMEPIRIDE 4 MG TABLET NOVO-IPRAMIDE 0.25% INHALATION SOLUTION NOVO-KETOTIFEN 0.2 MG/ML (BASE) ORAL SYRUP NOVO-KETOTIFEN 1 MG TABLET NOVO-MAPROTILINE 25 MG TABLET NOVO-MAPROTILINE 50 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL ORL 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. Form TAB TAB TAB SOL CAP LIQ LIQ ECT SRT SUS SUS TAB TAB TAB TAB SRT TAB CAP CAP CAP CAP CAP TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB SOL SYR TAB TAB TAB MFR Unit of Issue BAI TAB PFI TAB ABV TAB ABV ML ABB CAP SAV ML SAV ML TEV TAB TEV TAB TEV ML TEV ML TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV TAB TEV TAB TEV TAB TEV CAP TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV ML TEV ML TEV TAB TEV TAB TEV TAB Base Price 9.3900 1.5470 1.6020 1.2854 1.4671 0.1899 0.1539 0.0322 0.5980 0.3840 0.5440 4.1790 0.1350 0.5715 1.2138 0.4169 0.5647 0.3450 1.2127 0.0985 0.1827 0.3673 0.5480 0.4927 0.2221 0.4325 0.0254 0.0748 0.0356 0.5047 0.5047 0.5047 0.3250 0.4682 0.6525 0.5957 1.1281 Pg 67 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002158639 00002265435 00002265443 00002364883 00002348675 00002240868 00002240457 00002240458 00002231781 00002231782 00000021288 00000021695 00000232378 00002283891 00002326450 00002231181 00002100630 00002211920 00002322854 00002322862 00001913980 00001913972 00002415585 00002415593 00002415607 00002415615 00002415577 00002360381 00002360403 00002360411 00002360438 00002360373 00002378299 00002378272 00002378280 00000623385 00002216191 Product Description NOVO-MAPROTILINE 75 MG TABLET NOVOMIX 30 100 UNIT/ML INJECTION NOVOMIX 30 FLEXPEN 100 UNIT/ML INJECTION NOVO-MYCOPHENOLATE 250 MG CAPSULE NOVO-MYCOPHENOLATE 500 MG TABLET NOVO-NABUMETONE 750 MG TABLET NOVO-NIZATIDINE 150 MG CAPSULE NOVO-NIZATIDINE 300 MG CAPSULE NOVO-NORTRIPTYLINE 10 MG CAPSULE NOVO-NORTRIPTYLINE 25 MG CAPSULE NOVO-PHENIRAM 4 MG TABLET NOVO-PREDNISONE 5 MG TABLET NOVO-PREDNISONE 50 MG TABLET NOVO-RAMIPRIL 1.25 MG CAPSULE NOVO-SALBUTAMOL HFA 100 MCG/DOSE METERED DOSE AERO NOVO-SOTALOL 80 MG TABLET NOVO-VALPROIC 250 MG CAPSULE NOVO-VERAMIL SR 240MG SUSTAINED-RELEASE TABLET NPLATE 250 MCG/0.5 ML VIAL INJECTION NPLATE 500 MCG/1 ML VIAL INJECTION NUBAIN 10 MG/ML INJECTION NUBAIN 20 MG/ML INJECTION NUCYNTA 100 MG EXTENDED-RELEASE TABLET NUCYNTA 150 MG EXTENDED-RELEASE TABLET NUCYNTA 200 MG EXTENDED-RELEASE TABLET NUCYNTA 250 MG EXTENDED-RELEASE TABLET NUCYNTA 50 MG EXTENDED-RELEASE TABLET NUCYNTA CR 100 MG EXTENDED-RELEASE TABLET NUCYNTA CR 150 MG EXTENDED-RELEASE TABLET NUCYNTA CR 200 MG EXTENDED-RELEASE TABLET NUCYNTA CR 250 MG EXTENDED-RELEASE TABLET NUCYNTA CR 50 MG EXTENDED-RELEASE TABLET NUCYNTA IR 100 MG TABLET NUCYNTA IR 50 MG TABLET NUCYNTA IR 75 MG TABLET NUPERCAINAL ANESTHETIC 1% RECTAL OINTMENT NUTROPIN 10 MG/VIAL INJECTION Route ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT INJ 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. Form TAB DEFAUL DEFAUL CAP TAB TAB CAP CAP CAP CAP TAB TAB TAB CAP/TAB AEM TAB CAP SRT DEFAUL DEFAUL DEFAUL DEFAUL ERT ERT ERT ERT ERT ERT ERT ERT ERT ERT TAB TAB TAB ONT DEFAUL MFR Unit of Issue TEV TAB NNA ML NNA ML TEV CAP TEV TAB TEV TAB TEV CAP TEV CAP TEV CAP TEV CAP TEV TAB TEV TAB TEV TAB TEV CAP TEV DOSE TEV TAB TEV CAP TEV TAB AMG VIAL AMG VIAL SDZ ML SDZ ML JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB NVC G HLR VIAL Base Price 1.5406 3.9680 3.1833 1.0619 2.1238 0.9468 0.2098 0.3802 0.0500 0.1011 0.0701 0.0438 0.1787 0.4327 0.0335 0.3055 0.1407 0.5075 1017.4700 2034.9400 10.6290 6.0850 1.6083 2.1533 2.7915 3.8655 1.0733 1.4730 1.9720 2.5565 3.8655 0.9830 1.6084 1.0734 1.3384 0.1407 389.4400 Pg 68 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002229722 00002249002 00002376393 00002399083 00002399091 00002253186 00000716901 00002239742 00002237577 00000687766 00000622443 00002024179 00002299437 00002299445 00002299453 00002248640 00002248642 00002248639 00002248641 00080038562 00000358495 00080046696 00080046737 00002311992 00002312018 00002311968 00002421704 00002311976 00002311984 00002416522 00002338653 00002343681 00002352990 00002338661 00002425114 00002343703 00002338645 Product Description NUTROPIN AQ 5 MG/ML INJECTION NUTROPIN AQ 5 MG/ML PEN CARTRIDGE NUTROPIN AQ NUSPIN 10 10 MG/2ML PEN CARTRIDGE NUTROPIN AQ NUSPIN 20 20 MG/2 ML SOLUTION NUTROPIN AQ NUSPIN 5 5 MG/2 ML SOLUTION NUVARING 11.4 MG/2.6 MG SLOW-RELEASE VAGINAL RING NYADERM 25,000 U/G VAGINAL CREAM OBUSFORME EXTRA STRENGTH (W ACETAMINOPHEN) CAPLET OBUSFORME METHOCARBAMOL & ACETAMINOPHEN CAPLET O-CALCIUM 250 MG AND VITAMIN D TABLET O-CALCIUM 500 MG (BASE) TABLET OCTOSTIM 15 MCG INJECTION OCTREOTIDE 100 MCG/ML INJECTION OCTREOTIDE 200 MCG/ML INJECTION OCTREOTIDE 500 MCG/ML INJECTION OCTREOTIDE ACETATE OMEGA 100 MCG/ML INJECTION OCTREOTIDE ACETATE OMEGA 200 MCG/ML INJECTION OCTREOTIDE ACETATE OMEGA 50 MCG/ML INJECTION OCTREOTIDE ACETATE OMEGA 500 MCG/ML INJECTION OCUVITE ADULT 50+ ODANS LIQUOR CARBONIS DETERGENS ODAN-SODIUM CHLORIDE 5% OPHTHALMIC OINTMENT ODAN-SODIUM CHLORIDE 5% OPHTHALMIC SOLUTION OLANZAPINE 10 MG TABLET OLANZAPINE 15 MG TABLET OLANZAPINE 2.5 MG TABLET OLANZAPINE 20 MG TABLET OLANZAPINE 5 MG TABLET OLANZAPINE 7.5 MG TABLET OLANZAPINE FOR INJECTION 10MG/VIAL INJ OLANZAPINE ODT 10 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 5 MG ORALLY DISINTEGRATING TABLET Route INJ INJ INJ INJ INJ VAG VAG ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ INJ INJ ORL TOP OPH OPH ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL 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. Form DEFAUL CTG CTG DEFAUL DEFAUL SDE CRM TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CAP LIQ ONT SOL TAB TAB TAB TAB TAB TAB DEFAUL DISNTAB DISNTAB DISNTAB DISNTAB DISNTAB DISNTAB DISNTAB MFR Unit of Issue HLR ML HLR ML HLR ML HLR ML HLR ML MFC RNG TAR G WAM TAB WAM TAB WTR TAB VTH TAB FEI ML TEV ML TEV ML TEV ML OMG ML OMG ML OMG ML OMG ML BSH CAP ODN ML ODN G ODN ML PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB SDZ VIAL PDL TAB SIV TAB SNS TAB PDL TAB PDL TAB SIV TAB PDL TAB Base Price 194.7183 215.9150 197.7350 389.4400 105.6050 16.5433 0.1365 0.3611 0.3306 0.0620 0.0257 36.2880 5.6700 15.5840 38.0720 11.2000 23.4000 5.9500 52.3000 0.2656 0.0750 2.9771 0.6947 1.7857 2.6775 0.4493 5.9377 0.8936 1.3479 24.0800 1.7857 5.3553 5.3553 2.6777 5.9377 7.5977 0.8937 Pg 69 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002365677 00002344408 00002239144 00002241277 00002303639 00002239016 00080003480 00080008273 00080044844 00080015284 00080002435 00080002596 00080019234 00002240743 00080003356 00080003127 00080003179 00002385384 00002339927 00002303671 00002153513 00002271761 00002271788 00002306212 00080020211 00002248292 00002248319 00080003089 00002375842 00002421208 00002350661 00000750794 00002415690 00000990059 00000990061 00000990062 00000990063 Product Description OLEX 20 MG DELAYED-RELEASE TABLET OLUX-E 0.05% TOPICAL FOAM OMBRELLE ECRAN SPF 60 TOPICAL CREAM OMBRELLE EXTREME SPF 30 TOPICAL LOTION OMBRELLE SPF 60 TOPICAL LOTION OMBRELLE VAPO SPORT SPF 15 TOPICAL LOTION OMEGA 3 CAPSULE OMEGA 3 CAPSULE OMEGA 3 KRILL OIL 500 MG CAPSULE OMEGA 3 LIQUID OMEGA 3 PREMIUM FISH OIL 1000 MG CAPSULE OMEGA 3 SELECT CAPSULE OMEGA 3 TRIPLE STRENGTH 900 MG SOFTGEL OMEGA 3-6-9 CAPSULE OMEGA 3-6-9 ORAL CAPSULE OMEGA-3 ELITE SOFTGEL OMEGA-3 TABLET OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE OMNARIS 50 MCG/DOSE METERED DOSE NASAL SPRAY ONCOTICE 800 M UNIT/VIAL FOR BLADDER INSTILLATION ONDANSETRON OMEGA (PRESERVATIVE FREE) 2 MG/ML INJ ONDANSETRON OMEGA (WITH PRESERVATIVE) 2 MG/ML INJ ONDANSETRON-ODAN 4 MG TABLET ONE A DAY FRUITI-SSENTIAL GUMMIES ONE A DAY MEN 50 PLUS TABLET ONE A DAY WEIGHTSMART TABLET ONGLES & CHEVEUX CAPSULE ONGLYZA 2.5 MG TABLET ONRELTEA 0.33 % TOPICAL GEL ONSOLIS 200 MCG BUCCAL SOLUBLE FILM OPCON-A OPH SOLUTION OPSUMIT 10 MG FILM COATED TABLET OPTICHAMBER DEVICE OPTICHAMBER LARGE FACE MASK DEVICE OPTICHAMBER MEDIUM FACE MASK DEVICE OPTICHAMBER SMALL FACE MASK DEVICE Route ORL TOP TOP TOP TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS BLDIR INJ INJ ORL ORL ORL ORL ORL ORL TOP BUC OPH ORL DEFAUL DEFAUL DEFAUL DEFAUL 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. Form DRT FOA CRM LOT LOT LOT CAP CAP CAP LIQ CAP CAP CAP CAP CAP CAP TAB CAP/SRT CAP/SRT SPM PWS DEFAUL DEFALT TAB CTB TAB TAB CAP TAB GEL FILM SOL TAB DEV ADUDEV PEDDEV INFDEV MFR Unit of Issue PPH TAB GSK G COS G COS ML OMB ML COS ML PMT CAP WNP CAP JMS CAP WNP ML WNP CAP JAM CAP WBP CAP JAM CAP JAM CAP WBP CAP JAM TAB SIV CAP PDL CAP TAK DOSE MFC VIAL OMG ML OMG ML ODN TAB BAI TAB BIC TAB BAI TAB VTH CAP AZC TAB GAL G MED FILM BSH ML ACT TAB ACM DEV ACM DEV ACM DEV ACM DEV Base Price 0.6929 1.5777 0.0991 0.0875 0.1068 0.0868 0.0990 0.2587 0.4250 0.0277 0.0602 0.1149 0.2552 0.1647 0.0983 0.0613 0.1641 0.5500 0.4117 0.2346 273.1400 8.1750 8.1250 3.3500 0.1640 0.1099 0.1287 0.0933 2.5823 3.8413 12.0000 0.2967 128.3333 30.7200 35.3400 28.5300 29.4300 Pg 70 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000999420 00000355666 00002160889 00000701785 00000807435 00002371189 00080027592 00002035286 00001985396 00002381885 00002381893 00000313815 00002047535 00002245641 00002209055 00080023808 00000999460 00000999490 00002247548 00002301911 00002434318 00002434334 00002238867 00000653330 00000741043 00002331403 00000857777 00000810436 00002262088 00002371588 00000013617 00002239298 00000292990 00000497754 00000497762 00000497770 00001907476 Product Description OPTIMENTAL ORAL LIQUID OPTIMINE 1 MG TABLET OPTIMYXIN OPHTHALMIC OINTMENT OPTIMYXIN OTIC OPH DROPS OPTIMYXIN PLUS OTIC OPH SOLUTION OPTION 2 0.75 MG TABLET OPUS D-1000 SOFTGEL ORABASE PASTE ORAJEL MAXIMUM STRENGTH GEL ORALAIR 100 UNIT SUBLINGUAL TABLET ORALAIR 300 UNIT SUBLINGUAL TABLET ORAP 2 MG TABLET ORFENACE 100 MG TABLET ORGALUTRAN 250 MCG/ 0.5 ML INJECTION SYRINGE ORO-CLENSE 0.12% ORAL RINSE ORTHO BONE CAPSULE ORTHOVISC OSTENIL OSTEOCIT D PLUS TABLET OSTO-D2 50000 IU CAPSULE OTEZLA 10 MG/20 MG/30 MG TABLET STARTER PACK OTEZLA 30 MG TABLET OTRIVIN 0.05% DECONGESTANT NASAL SPRAY OTRIVIN 0.1% DECONGESTANT NASAL SPRAY OTRIVIN 0.1% METERED DOSE SPRAY OTRIVIN MOIST 0.1% NASAL SPRAY OTRIVIN-SALINE 0.7% NASAL DROPS OTRIVIN-SALINE 0.7% NASAL SPRAY OVIDREL 250 MCG INJECTION SYRINGE OVIDREL 250 MCG/0.5 ML PEN CARTRIDGE INJECTION OVOL 40 MG/ML ORAL DROPS OVOL-180 ULTRA STRENGTH 180 MG CAPSULE OVOL-80 80 MG TABLET OXAZEPAM 10 MG TABLET OXAZEPAM 15 MG TABLET OXAZEPAM 30 MG TABLET OXSORALEN 1% TOPICAL LOTION Route ORL ORL OPH OT/OPH OT/OPH ORL ORL ORL ORL SLG SLG ORL ORL INJ ORL ORL DEFAUL DEFAUL ORL ORL ORL ORL NAS NAS DEFAUL NAS NAS NAS INJ INJ ORL ORL ORL ORL ORL ORL TOP 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. Form LIQ TAB ONT DPS SOL TAB CAP PST GEL TAB TAB TAB TAB NDL MWH CAP DEV DEV TAB CAP TAB TAB SPR SPR SPM SPR SOL SPR NDL DEFAUL DPS CAP TAB TAB TAB TAB LOT MFR Unit of Issue ABN ML SCH TAB SDZ G SDZ ML SDZ ML PRI TAB OPU CAP CVO G CHD G PAL TAB PAL TAB PPH TAB STM TAB MFC SYR GER ML AOR CAP PMS ML TRB ML SFD TAB TPI CAP CLG TAB CLG TAB NVC ML NVC ML CGS ML NVC ML NVC ML NVC ML SRO SYR SRO ML CHD ML CHD CAP CHD TAB PDL TAB PDL TAB PDL TAB VCL ML Base Price 0.0278 0.4216 1.4971 0.6680 0.8230 7.7950 0.0700 1.0867 0.4389 1.3533 4.0850 0.3282 0.4700 94.7100 0.0169 0.1565 57.5000 50.2600 0.1827 0.2257 18.9041 20.3220 0.2480 0.2480 0.2480 0.3260 0.1424 0.1187 77.4000 72.0000 0.3600 0.1875 0.1378 0.0350 0.0550 0.0750 1.5080 Pg 71 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001946374 00000252654 00002220636 00002231934 00002139561 00002254735 00080001408 00002248374 00002363445 00002130947 00001923420 00001923455 00002246597 00002246598 00002264986 00002246599 00002249677 00000718130 00002188708 00000483184 00002239616 00002241804 00002385740 00002431327 00002318695 00002306727 00002428172 00002428180 00000009881 00002388227 00002282844 00002248913 00002248914 00002248915 00002362171 00002233143 00000886327 Product Description OXSORALEN 10 MG CAPSULE OXSORALEN ULTRA 10 MG CAPSULE OXYBUTYNINE-5 5 MG TABLET OXY-IR 5 MG TABLET OXYTOCIN 10 UNIT/ML INJECTION OXYTROL 36 MG TRANSDERMAL PATCH OYSTER SHELL CALCIUM 500 MG CAPLET OYSTER SHELL CALCIUM WITH VIT D 500 MG TABLET OZURDEX 0.7 MG INTRAVITREAL IMPLANT PACIS 120 MG INJECTION PALAFER 300 MG CAPSULE PALAFER-CF CAPSULE PAMIDRONATE DISODIUM 30MG/10ML VIAL INJECTION PAMIDRONATE DISODIUM 60 MG/10ML INJECTION PAMIDRONATE DISODIUM 90 MG/VIAL INJECTION PAMIDRONATE DISODIUM 90MG/10ML VIAL INJECTION PAMIDRONATE DISODIUM OMEGA 60 MG/10 ML VIAL INJ PAMPRIN EXTRA STRENGTH CAPLET PANOXYL 4% CREAMY WASH PANOXYL 5 5% TOPICAL BAR PANTO IV 40 MG/VIAL INJECTION PANTOLOC 20 MG ENTERIC-COATED TABLET PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET PANTOPRAZOLE SODIUM FOR INJECTION 40 MG/VIAL INJ PANTOPRAZOLE-20 20 MG ENTERIC-COATED TABLET PANTOPRAZOLE-40 40 MG ENTERIC-COATED TABLET PAPAVERINE HCL 32.5 MG/ML INJECTION PAROXETINE 10 MG TABLET PAROXETINE 10 MG TABLET PAROXETINE-10 MG TABLET PAROXETINE-20 MG TABLET PAROXETINE-30 MG TABLET PATADAY 0.2% OPHTHALMIC SOLUTION PATANOL 0.1% OPH SOLUTION PATE D'IHLE ZINC OXIDE 25% PASTE Route ORL ORL ORL ORL INJ TRD ORL ORL OPH INJ ORL ORL INJ INJ INJ INJ INJ ORL TOP TOP INJ ORL ORL ORL ORL INJ ORL ORL INJ ORL ORL ORL ORL ORL OPH OPH TOP 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. Form CAP CAP TAB TAB DEFAUL PTH TAB TAB IMP DEFAUL CAP CAP DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB WAS BAR DEFAUL ECT ECT ECT ECT DEFAUL ECT ECT DEFAUL TAB TAB TAB TAB TAB SOL SOL PST MFR Unit of Issue VCL CAP VCL CAP PDL TAB PUR TAB PPC ML ASC PTH NCI TAB VTH TAB ALL SYS IAF VIAL GKC CAP GKC CAP PPC ML PPC ML SDZ ML PPC ML OMG ML CTE TAB GSK G GSK G TAK VIAL TAK TAB SIV TAB RIV TAB PDL TAB SDZ VIAL SIV TAB SIV TAB SDZ ML SIV TAB SNS TAB PDL TAB PDL TAB PDL TAB ALC ML ALC ML ATL G Base Price 0.5926 0.4414 0.0986 0.2883 6.6600 7.3650 0.0290 0.0282 1352.5000 113.6000 0.2487 0.3400 15.7500 29.9000 25.3950 44.8000 17.6700 0.2063 0.0671 0.0853 13.7000 1.9752 1.2750 0.3628 0.9785 11.9680 1.2750 0.3628 4.1995 1.0430 1.0430 0.8210 0.4513 0.4796 13.2160 6.6080 0.0234 Pg 72 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002381737 00002381745 00002389274 00002027887 00002248503 00002248504 00000577790 00000577804 00000577812 00002242863 00002232202 00002245747 00002162431 00080004595 00002358034 00002328232 00002246030 00002246026 00000468029 00002250535 00002247265 00001980602 00001980599 00002183080 00001980556 00002164051 00001980564 00001980580 00001980572 00002185938 00000728128 00002097079 00002177994 00002237315 00000999423 00000254916 00002240433 Product Description PAT-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET PAT-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET PAT-TRAMADOL/ACET 37.5 MG/325 MG TABLET PAXIL 10 MG TABLET PAXIL CR 12.5 MG SUSTAINED-RELEASE TABLET PAXIL CR 25 MG SUSTAINED-RELEASE TABLET PDP-ISONIAZID 100 MG TABLET PDP-ISONIAZID 300 MG TABLET PDP-ISONIAZID 50 MG/5ML ORAL LIQUID PEDIAFER 30 MG/ML ORAL SOLUTION USP PEDIAFER 75 MG/ML ORAL SOLUTION USP PEDIAFLOUR 5.56 MG/ML ORAL SOLUTION PEDIAPHARM NAPROXEN 25 MG/ML ORAL SUSPENSION PEDIAVIT D DROPS 400 IU PEG 3350 ORAL POWDER PEGALAX ORAL POWDER PEGETRON 200 MG CAP/150 MCG/0.5 ML INJ KIT PEGETRON 200 MG CAP/50 MCG/0.5ML INJ KIT PENICILLINE V 300 TABLET PENLAC NAIL LACQUER 8% TOPICAL SOLUTION PENNSAID 1.5% TOPICAL SOLUTION PENTA-3B PLUS VITAMIN C TABLET PENTA-3B TABLET PENTAMIDINE ISETHIONATE 300 MG/VIAL INJECTION BP PENTAMYCETIN 0.25% OPH SOLUTION PENTAMYCETIN 0.5% OPH SOLUTION PENTAMYCETIN 1% OPH OINTMENT PENTAMYCETIN-HC OTIC OPH OINTMENT PENTAMYCETIN-HC OTIC OPH SUSPENSION PEPCID AC 10 MG TABLET PEPCID IV 10 MG/ML INJECTION PEPTO-BISMOL 17.6 MG/ML ORAL LIQUID PEPTO-BISMOL CAPLET PEPTO-BISMOL CHEWABLES CHEWABLE TABLET PERATIVE ORAL LIQUID PERGONAL 75 UNIT/75 UNIT INJECTION PERICHLOR 0.12% ORAL RINSE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL TOP TOP ORL ORL INJ OPH OPH OPH OT/OPH OT/OPH ORL INJ ORL ORL ORL ORL INJ ORL Form ECT ECT TAB TAB SRT SRT TAB TAB LIQ SYR SYR DPS SUS LIQ PWR PWR VIAL/CAP VIAL/CAP TAB SOL SOL TAB TAB DEFAUL SOL SOL ONT ONT SUS TAB DEFAUL LIQ TAB CTB LIQ DEFAUL MWH 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. MFR Unit of Issue PAT TAB PAT TAB PAT TAB GSK TAB GSK TAB GSK TAB PPH TAB PPH TAB PPH ML EUP ML EUP ML EUP ML PPI ML EUP ML MES G MFI G MFC KIT MFC KIT PDL TAB VCL G PAL ML SDZ TAB SDZ TAB HSP VIAL SDZ ML SDZ ML SDZ G SDZ G SDZ ML MFC TAB MFC ML PGI ML PGI TAB PGI TAB ABN ML SRO VIAL PMS ML Base Price 0.1204 0.2408 0.6263 1.8477 1.8813 2.0557 0.7986 0.7986 0.2472 0.0286 0.1946 0.0697 0.0678 0.1156 0.0544 0.0410 915.0700 770.3500 0.0710 14.1708 0.9083 0.5820 0.4780 127.1200 0.6180 0.6300 2.1600 2.9714 2.4580 0.3410 1.9955 0.0247 0.1683 0.3367 0.0113 46.0000 0.0198 Pg 73 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002237452 00002207796 00002247104 00002229501 00080017389 00080001122 00080004281 00002371499 00080001145 00002371502 00080040416 00080038071 00002436663 00002162180 00002304090 00002304082 00002148455 00002148447 00000780626 00002150638 00002150646 00002017733 00002245781 00002326787 00002326760 00002326779 00002278588 00002236964 00002273543 00002248944 00002248945 00002145227 00002145235 00002236948 00002249359 00002223481 00002223503 Product Description PERIDEX 0.12% ORAL RINSE PERIOGARD 0.12% ORAL RINSE PERIOSTAT 20 MG CAPSULE PERI-WASH II ANTISEPTIC 0.1% CLEANSER PGX 750 DAILY CAPSULE PHARMA-CAL 500 MG PHARMA-CAL D 500 MG/125 IU TABLET PHARMA-D 10,000 UNIT CAPSULE PHARMA-D 400 IU GELCAP PHARMA-D 50,000 UNIT CAPSULE PHARMA-K20 20 MEQ SUSTAINED-RELEASE TABLET PHARMANAC TM ACETYLCYSTEINE 900 MG TABLET PHEBURANE 483 MG/G ORAL GRANULES PHENERGAN EXPECTORANT WITH CODEINE ORAL SYRUP PHENOBARBITAL SODIUM 120 MG/ML INJECTION USP PHENOBARBITAL SODIUM 30 MG/ML INJECTION USP PHENYLEPHRINE HCL 10% OPH SOLUTION (MINIMS) PHENYLEPHRINE HYDROCHLORIDE OPH SOLUTION (MINIMS) PHENYTOIN 50 MG/ML INJECTION PHILLIPS MAGNESIA 300 MG CHEWABLE TABLET PHILLIPS MILK OF MAGNESIA 80 MG/ML ORAL LIQUID PHISOHEX 3% TOPICAL CLEANSER PHL-AMIODARONE 200 MG TABLET PHL-AMLODIPINE 10 MG TABLET PHL-AMLODIPINE 2.5 MG TABLET PHL-AMLODIPINE 5 MG TABLET PHL-AZITHROMYCIN 250 MG TABLET PHL-BACLOFEN 20 MG TABLET PHL-CITALOPRAM 10 MG TABLET PHL-CITALOPRAM 20 MG TABLET PHL-CITALOPRAM 40 MG TABLET PHL-CLONAZEPAM 0.5 MG TABLET PHL-CLONAZEPAM 1 MG TABLET PHL-CLONAZEPAM-R 0.5 MG TABLET PHL-CYCLOBENZAPRINE 10 MG TABLET PHL-FLUOXETINE 10 MG CAPSULE PHL-FLUOXETINE 20 MG CAPSULE Route ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ OPH OPH INJ ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form MWH MWH CAP WAS CAP CAP TAB CAP CAP CAP TAB/SRT TAB GRNUL SYR DEFAUL DEFAUL SOL SOL DEFAUL CTB LIQ CLR TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP MFR Unit of Issue ZIL ML COL ML PPH CAP COC ML NFN CAP PPH CAP PMS TAB PMS CAP PPH CAP PMS CAP PMS TAB BAP TAB MDK G CLC ML SDZ ML SDZ ML BSH ML OPT ML SDZ ML BAI TAB BAI ML SAV ML PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH CAP PHH CAP Base Price 0.0245 0.0176 1.3648 0.0147 0.1759 0.0222 0.0700 0.2163 0.0322 0.9785 0.2055 0.7056 9.2690 0.0794 13.5520 12.1700 6.6667 6.6667 5.2855 0.0516 0.0147 0.0714 1.2971 0.3587 0.1380 0.2417 1.2313 0.3104 0.1432 0.2397 0.2397 0.0495 0.1487 0.0495 0.3765 0.4595 0.4598 Pg 74 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002248608 00002248607 00002281732 00002278618 00002278626 00002307669 00002307677 00002307723 00002249766 00002249774 00002249782 00002299062 00002299089 00002299054 00002299097 00002245782 00002245783 00002258439 00002258447 00002258455 00002258463 00002258471 00002258498 00002245826 00002245824 00002245825 00002281554 00002281562 00002281570 00002281546 00002281589 00002271192 00002271206 00002271184 00002236942 00002236941 00002294052 Product Description PHL-MELOXICAM 15 MG TABLET PHL-MELOXICAM 7.5 MG TABLET PHL-MIRTAZAPINE 15 MG TABLET PHL-ONDANSETRON 4 MG TABLET PHL-ONDANSETRON 8 MG TABLET PHL-PIOGLITAZONE 15 MG TABLET PHL-PIOGLITAZONE 30 MG TABLET PHL-PIOGLITAZONE 45 MG TABLET PHL-PRAVASTATIN 10 MG TABLET PHL-PRAVASTATIN 20 MG TABLET PHL-PRAVASTATIN 40 MG TABLET PHL-QUETIAPINE 100 MG TABLET PHL-QUETIAPINE 200 MG TABLET PHL-QUETIAPINE 25 MG TABLET PHL-QUETIAPINE 300 MG TABLET PHL-RANITIDINE 150 MG TABLET PHL-RANITIDINE 300 MG TABLET PHL-RISPERIDONE 0.25 MG TABLET PHL-RISPERIDONE 0.5 MG TABLET PHL-RISPERIDONE 1 MG TABLET PHL-RISPERIDONE 2 MG TABLET PHL-RISPERIDONE 3 MG TABLET PHL-RISPERIDONE 4 MG TABLET PHL-SERTRALINE 100 MG CAPSULE PHL-SERTRALINE 25 MG CAPSULE PHL-SERTRALINE 50 MG CAPSULE PHL-SIMVASTATIN 10 MG TABLET PHL-SIMVASTATIN 20 MG TABLET PHL-SIMVASTATIN 40 MG TABLET PHL-SIMVASTATIN 5 MG TABLET PHL-SIMVASTATIN 80 MG TABLET PHL-TOPIRAMATE 100 MG TABLET PHL-TOPIRAMATE 200 MG TABLET PHL-TOPIRAMATE 25 MG TABLET PHL-TRAZODONE 100 MG TABLET PHL-TRAZODONE 50 MG TABLET PHL-ZOPICLONE 5 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH CAP PHH CAP PHH CAP PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB PHH TAB Base Price 0.5670 0.4914 0.3750 3.2720 4.9930 1.5716 0.2017 3.3105 0.5670 0.6689 0.8057 0.9226 1.8527 0.3458 2.7038 0.1800 0.3600 0.1252 0.2097 0.2896 0.5782 0.8673 1.1565 0.4200 0.2004 0.4000 0.3642 0.4501 0.4501 0.1841 0.4501 0.5928 0.8853 0.3128 0.3956 0.2214 0.2231 Pg 75 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002294060 00002229437 00002230399 00002019876 00002400987 00002400995 00002254794 00002300583 00002148463 00002148471 00000828424 00000828416 00002374013 00002374021 00002374048 00002391600 00002339587 00002339595 00002246640 00002248939 00002246641 00002248940 00002246642 00002248941 00002401312 00002401320 00002401339 00002330547 00002391511 00002370158 00000501190 00002237405 00001946897 00000792691 00002243435 00000654523 00000654515 Product Description PHL-ZOPICLONE 7.5 MG TABLET PHOSLO 667 MG ORAL TABLET PHOSPHATES SOLUTION ORAL LIQUID PHOTOFRIN 75MG/ VIAL INJECTION PICATO 0.015% TOPICAL GEL PICATO 0.05% TOPICAL GEL PICO SALAX ORAL POWDER PICODAN PILOCARPINE NITRATE 2% OPH SOLUTION (MINIMS) PILOCARPINE NITRATE 4% OPH SOLUTION (MINIMS) PINDOLOL-10 MG TABLET PINDOLOL-5 MG TABLET PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE HYDROCHLORIDE 15 MG TABLET PIOGLITAZONE HYDROCHLORIDE 30 MG TABLET PIOGLITAZONE HYDROCHLORIDE 45 MG TABLET PIPERACILLIN 2 G/VIAL INJECTION PIPERACILLIN 2 G/VIAL INJECTION USP PIPERACILLIN 3 G/VIAL INJECTION PIPERACILLIN 3 G/VIAL INJECTION USP PIPERACILLIN 4 G/VIAL INJECTION PIPERACILLIN 4 G/VIAL INJECTION USP PIPERACILLIN AND TAZOBACTAM 2 G/250 MG VIAL INJ PIPERACILLIN AND TAZOBACTAM 3 G/375 MG VIAL INJ PIPERACILLIN AND TAZOBACTAM 4 G/500 MG VIAL INJ PIPERACILLIN SOD/TAZOBACTAM SOD 12G/1500 MG VL INJ PIPERACILLIN/TAZOBACTAM 2 G/250 MG/VIAL INJECTION PIPERACILLIN/TAZOBACTAM 2G/250 MG/VIAL INJECTION PLACEBO 100 MG TABLET PLANTE GUMMI BEAR MULTIPLE VITAMINS ORAL GUM PMS DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR PMS-ACETAMINOPHEN 32 MG/ML ORAL SOLUTION PMS-ADENOSINE 3 MG/ML INJECTION PMS-AMITRIPTYLINE 10 MG TABLET PMS-AMITRIPTYLINE 25 MG TABLET Route ORL ORL ORL INJ TOP TOP ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL INJ ORL ORL 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. Form TAB TAB LIQ DEFAUL GEL GEL PWR PWDPKT SOL SOL TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB GUM ELX SOL DEFAUL TAB TAB MFR Unit of Issue PHH TAB PRP TAB PPH ML AXC VIAL LEO DOSE LEO DOSE FEI PCKT ODN PCKT BSH ML BSH ML PDL TAB PDL TAB SIV TAB SIV TAB SIV TAB AHI TAB AHI TAB AHI TAB MNP VIAL PPC VIAL MNP VIAL PPC VIAL MNP VIAL PPC VIAL ALV VIAL ALV VIAL ALV VIAL SDZ VIAL MYP VIAL TEV VIAL ODN TAB PLI PIECE PMS ML PPH ML PMS ML PMS TAB PMS TAB Base Price 0.4685 0.4500 0.0920 19255.1000 139.4033 209.1050 6.5500 3.6000 6.6667 6.3483 0.2323 0.1361 0.9295 1.3022 1.9580 0.8718 0.8139 1.2237 9.5000 15.2800 22.8200 22.9300 19.0000 30.5500 6.0600 9.0800 12.1100 67.5000 9.6120 9.6120 0.0750 0.1660 0.4133 0.0282 21.2950 0.0725 0.1322 Pg 76 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000654507 00002247304 00002274949 00002320738 00002284529 00002283700 00002381028 00002381036 00002381044 00002381052 00002381060 00002313448 00002313456 00002313464 00002313472 00002330237 00002275589 00002383020 00002383012 00002244508 00002391171 00002185830 00002185857 00002185865 00002185849 00002185873 00002315963 00002413574 00002416433 00002244474 00002232195 00002232191 00002309548 00002232193 00002243450 00002242055 00001946277 Product Description PMS-AMITRIPTYLINE 50 MG TABLET PMS-AMITRIPTYLINE 50 MG TABLET PMS-ANAGRELIDE 0.5 MG CAPSULE PMS-ANASTROZOLE 1 MG TABLET PMS-ASA EC 325 MG ENTERIC-COATED TABLET PMS-ASA EC 81 MG ENTERIC-COATED TABLET PMS-ATOMOXETINE 10 MG CAPSULE PMS-ATOMOXETINE 18 MG CAPSULE PMS-ATOMOXETINE 25 MG CAPSULE PMS-ATOMOXETINE 40 MG CAPSULE PMS-ATOMOXETINE 60 MG CAPSULE PMS-ATORVASTATIN 10 MG TABLET PMS-ATORVASTATIN 20 MG TABLET PMS-ATORVASTATIN 40 MG TABLET PMS-ATORVASTATIN 80 MG TABLET PMS-BETAHISTINE 24 MG TABLET PMS-BICALUTAMIDE 50 MG TABLET PMS-BOSENTAN 125 MG TABLET PMS-BOSENTAN 62.5 MG TABLET PMS-BUTORPHANOL 10MG/ML NASAL SPRAY PMS-CANDESARTAN 4 MG TABLET PMS-CEFACLOR 250 MG CAPSULE PMS-CEFACLOR 25MG/ML ORAL SUSPENSION PMS-CEFACLOR 50 MG/ML ORAL SUSPENSION PMS-CEFACLOR 500 MG CAPSULE PMS-CEFACLOR 75 MG/ML ORAL SUSPENSION PMS-CETIRIZINE 20 MG TABLET PMS-CICLOPIROX NAIL LACQUER 8% TOPICAL SOLUTION PMS-CIPROFLOXACIN XL 500 MG EXTENDED-RELEASE TAB PMS-CLOBAZAM 10 MG TABLET PMS-CLOBETASOL 0.05% SCALP LOTION PMS-CLOBETASOL 0.05% TOPICAL CREAM PMS-CLOBETASOL 0.05% TOPICAL OINTMENT PMS-CLOBETASOL 0.05% TOPICAL OINTMENT PMS-DEFEROXAMINE 2G/VIAL INJECTION PMS-DEFEROXAMINE 500 MG/VIAL INJ PMS-DESIPRAMINE 50 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL ORL ORL TOP ORL ORL SCP TOP TOP TOP INJ INJ ORL 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. Form TAB TAB CAP TAB ECT ECT CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB SPR TAB CAP SUS SUS CAP SUS TAB SOL ERT TAB LOT CRM ONT ONT DEFAUL DEFAUL TAB MFR Unit of Issue PMS TAB PMS TAB PMS CAP PMS TAB PMS TAB PMS TAB PMS CAP PMS CAP PMS CAP PMS CAP PMS CAP PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS ML PMS TAB PMS CAP PMS ML PMS ML PMS CAP PMS ML PMS TAB PMS G PMS TAB PMS TAB PMS ML PMS G PMS G PMS G PMS VIAL PMS VIAL PMS TAB Base Price 0.2563 0.2346 3.4496 2.6223 0.0337 0.0588 2.3833 2.7320 3.0160 3.4377 3.8133 0.3232 0.4040 0.4342 0.4342 0.5441 4.1790 49.5780 52.5590 16.6600 0.3503 0.6430 0.0762 0.1395 1.2625 0.2010 0.8228 7.9758 2.5235 0.1097 0.2342 0.4068 0.2684 0.4068 22.0800 8.1750 0.4110 Pg 77 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000891797 00002247492 00002247490 00002247491 00000721344 00002356783 00002239753 00000757683 00000757691 00002434342 00002434350 00002379171 00002278081 00002278103 00002278111 00002273551 00000586323 00002222574 00002320169 00002238568 00000726354 00002230104 00002247493 00002247494 00002255898 00002255901 00002239951 00002230183 00002247386 00002247387 00002324253 00000836133 00002395258 00002395266 00002288265 00002288273 00002309114 Product Description PMS-DIAZEPAM 1 MG/ML ORAL SOLUTION PMS-DIAZEPAM 10 MG TABLET PMS-DIAZEPAM 2 MG TABLET PMS-DIAZEPAM 5 MG TABLET PMS-DICITRATE ORAL SOLUTION PMS-DICLOFENAC 1.5% TOPICAL SOLUTION PMS-DICLOFENAC-K 50 MG TABLET PMS-DIPHENHYDRAMINE 25 MG CAPSULE PMS-DIPHENHYDRAMINE 50 MG CAPSULE PMS-ELETRIPTAN 20 MG TABLET PMS-ELETRIPTAN 40 MG TABLET PMS-ESOMEPRAZOLE 40 MG DELAYED-RELEASE CAPSULE PMS-FAMCICLOVIR 125 MG TABLET PMS-FAMCICLOVIR 250 MG TABLET PMS-FAMCICLOVIR 500 MG TABLET PMS-FENOFIBRATE MICRO 200 MG CAPSULE PMS-FERROUS SULFATE 300 MG TABLET PMS-FERROUS SULFATE INFANT DROPS 75 MG/ML PMS-FINASTERIDE 1 MG TABLET PMS-FLUOROMETHOLONE 0.1% OPH SUSPENSION PMS-FLUPHENAZINE 5 MG TABLET PMS-FLUTAMIDE 250 MG TABLET PMS-FUROSEMIDE 20 MG TABLET PMS-FUROSEMIDE 40 MG TABLET PMS-GABAPENTIN 600 MG TABLET PMS-GABAPENTIN 800 MG TABLET PMS-GEMFIBROZIL 300 MG CAPSULE PMS-GEMFIBROZIL 600 MG TABLET PMS-HYDROCHLOROTHIAZIDE 25 MG TABLET PMS-HYDROCHLOROTHIAZIDE 50 MG TABLET PMS-HYDROCODONE 1 MG/ML ORAL SYRUP PMS-IBUPROFEN 400 MG TABLET PMS-LANSOPRAZOLE 15 MG DELAYED-RELEASE CAPSULE PMS-LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE PMS-LEFLUNOMIDE 10 MG TABLET PMS-LEFLUNOMIDE 20 MG TABLET PMS-LETROZOLE 2.5 MG TABLET Route ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SOL TAB TAB TAB SOL SOL TAB CAP CAP TAB TAB DRC TAB TAB TAB CAP TAB DPS TAB SUS TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB SYR TAB DRC DRC TAB TAB TAB MFR Unit of Issue PMS ML PMS TAB PMS TAB PMS TAB PMS ML PMS ML PMS TAB PPH CAP PPH CAP PMS TAB PMS TAB PMS CAP PMS TAB PMS TAB PMS TAB PMS CAP PPH TAB PMS ML PMS TAB PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS CAP PMS TAB PMS TAB PMS TAB PMS ML PMS TAB PMS CAP PMS CAP PMS TAB PMS TAB PMS TAB Base Price 0.1150 0.0947 0.0555 0.0670 0.0518 0.6413 0.4299 0.0931 0.1175 10.3883 11.0117 1.9251 2.2100 2.9700 4.6167 0.2723 0.0305 0.3593 1.2508 1.7880 0.1878 1.3530 0.0384 0.0815 1.4244 1.8992 0.2964 0.7520 0.0474 0.0568 0.1249 0.1010 0.5000 0.5000 6.5970 6.5970 3.0093 Pg 78 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000811874 00002074834 00002248268 00002248267 00002321130 00002382830 00002413728 00002413736 00002413744 00002413752 00000783137 00002405776 00002177714 00002177722 00002246596 00002177692 00002177706 00002367483 00002303213 00002423944 00000792942 00002309882 00002309890 00002309904 00002309912 00002247750 00002231537 00002231539 00002231536 00002303124 00002303132 00002303140 00002154463 00002240363 00002290138 00002359634 00002398079 Product Description PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID PMS-LITHIUM CITRATE 8 MMO/5ML ORAL SYRUP PMS-MELOXICAM 15 MG TABLET PMS-MELOXICAM 7.5 MG TABLET PMS-MEMANTINE 10 MG TABLET PMS-MEMANTINE 5 MG TABLET PMS-METHYLPHENIDATE 18 MG EXTENDED RELEASE TABLET PMS-METHYLPHENIDATE 27 MG EXTENDED RELEASE TABLET PMS-METHYLPHENIDATE 36 MG EXTENDED RELEASE TABLET PMS-METHYLPHENIDATE 54 MG EXTENDED RELEASE TABLET PMS-METRONIDAZOLE 500 MG CAPSULE PMS-NEVIRAPINE 200 MG TABLET PMS-NIZATIDINE 150 MG CAPSULE PMS-NIZATIDINE 300 MG CAPSULE PMS-NORFLOXACIN 400 MG TABLET PMS-NORTRIPTYLINE 10 MG CAPSULE PMS-NORTRIPTYLINE 25 MG CAPSULE PMS-OLANZAPINE 20 MG TABLET PMS-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB PMS-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB PMS-OXTRIPHYLLINE ORAL ELIXIR PMS-OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET PMS-OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET PMS-OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET PMS-OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET PMS-PAROXETINE 10 MG TABLET PMS-PINDOLOL 10 MG TABLET PMS-PINDOLOL 15 MG TABLET PMS-PINDOLOL 5 MG TABLET PMS-PIOGLITAZONE 15 MG TABLET PMS-PIOGLITAZONE 30 MG TABLET PMS-PIOGLITAZONE 45 MG TABLET PMS-PIROXICAM 20 MG RECTAL SUPPOSITORY PMS-POLYTRIMETHOPRIM OPHTHALMIC SOLUTION PMS-PRAMIPEXOLE 0.5 MG TABLET PMS-PREGABALIN 150 MG CAPSULE PMS-PREGABALIN 225 MG CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT OPH ORL ORL ORL 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. Form LIQ SYR TAB TAB TAB TAB ERT ERT ERT ERT CAP TAB CAP CAP TAB CAP CAP TAB DISNTAB DISNTAB ELX CRT CRT CRT CRT TAB TAB TAB TAB TAB TAB TAB SUP SOL TAB CAP CAP MFR Unit of Issue PMS ML PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS CAP PMS TAB PMS CAP PMS CAP PMS TAB PMS CAP PMS CAP PMS TAB PMS TAB PMS TAB PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS SUP PMS ML PMS TAB PMS CAP PMS CAP Base Price 0.1038 0.0773 0.6191 0.5367 1.7861 1.6848 1.4704 1.6969 1.9234 2.3764 0.7674 2.6962 0.2255 0.4087 0.5449 0.0500 0.1011 10.6186 5.5160 7.8257 0.0335 0.4794 0.7190 1.2462 2.3018 1.0743 0.2323 0.3370 0.1361 0.5983 0.8383 1.2604 2.2118 2.3880 1.5134 1.8858 1.8858 Pg 79 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002359596 00002359642 00002359618 00002359626 00000753688 00000753661 00002294559 00002294575 00000815993 00000618810 00002340569 00002340577 00002340585 00002340550 00002343932 00002424177 00002069571 00002371642 00002371626 00002371634 00002412179 00002252635 00002252651 00002256428 00002237460 00002391236 00002391244 00002240807 00002239577 00002401657 00002381230 00002312999 00001954504 00001954342 00001985604 00002231259 00000431648 Product Description PMS-PREGABALIN 25 MG CAPSULE PMS-PREGABALIN 300 MG CAPSULE PMS-PREGABALIN 50 MG CAPSULE PMS-PREGABALIN 75 MG CAPSULE PMS-PROCHLORPERAZINE 10 MG RECTAL SUPPOSITORY PMS-PROCHLORPERAZINE 5 MG TABLET PMS-PROPAFENONE 150 MG TABLET PMS-PROPAFENONE 300 MG TABLET PMS-PSEUDOEPHEDRINE HCL 6 MG/ML ORAL SYRUP PMS-PYRAZINAMIDE 500 MG TABLET PMS-QUINAPRIL 10 MG TABLET PMS-QUINAPRIL 20 MG TABLET PMS-QUINAPRIL 40 MG TABLET PMS-QUINAPRIL 5 MG TABLET PMS-RAMIPRIL 15 MG CAPSULE PMS-RISEDRONATE 150 MG TABLET PMS-SALBUTAMOL 5 MG/ML INHALATION SOLUTION PMS-SILDENAFIL 100 MG TABLET PMS-SILDENAFIL 25 MG TABLET PMS-SILDENAFIL 50 MG TABLET PMS-SILDENAFIL R 20 MG TABLET PMS-SIMVASTATIN 10 MG TABLET PMS-SIMVASTATIN 40 MG TABLET PMS-SUMATRIPTAN 25 MG TABLET PMS-TAMOXIFEN 20 MG TABLET PMS-TELMISARTAN 40 MG TABLET PMS-TELMISARTAN 80 MG TABLET PMS-TERBINAFINE 250 MG TABLET PMS-TOBRAMYCIN 0.3% OPH SOLUTION PMS-TRAMADOL-ACET 37.5 MG/325 MG TABLET PMS-VALACYCLOVIR 1000 MG CAPLET PMS-VALSARTAN 40 MG TABLET PMS-YOHIMBINE 2 MG TABLET PMS-YOHIMBINE 5.4 MG TABLET PMS-YOHIMBINE 6 MG TABLET PNEUMO 23 25 MCG/0.5ML INJECTION SYRINGE PNEUMOVAX 23 25 MCG/VIAL INJECTION Route ORL ORL ORL ORL RT ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL INJ INJ 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. Form CAP CAP CAP CAP SUP TAB TAB TAB SYR TAB TAB TAB TAB TAB CAP/TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL MFR Unit of Issue PMS CAP PMS CAP PMS CAP PMS CAP PMS SUP PMS TAB PMS TAB PMS TAB PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS CAP PMS TAB PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS ML PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB PMS TAB CNG SYR MSD VIAL Base Price 0.6740 1.8858 1.0573 1.3681 0.8550 0.1659 0.4668 0.8230 0.0443 1.2951 0.7498 0.7498 0.7498 0.7498 0.8133 42.1800 0.3510 9.2006 9.0525 8.8481 7.5128 0.5057 0.6250 9.8167 0.3500 0.2821 0.2821 2.5245 0.6560 0.6452 3.1447 0.5397 0.2063 0.4395 0.7364 19.2400 20.0500 Pg 80 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000990067 00000990069 00000598208 00000464988 00000999389 00000999928 00002230844 00002237227 00002239155 00002239201 00002239157 00002239156 00002237226 00001981021 00000249866 00001942921 00002011956 00002419580 00002419599 00002419602 00002419610 00002424622 00002293404 00000611271 00000550175 00000316121 00000804789 00002139545 00002312433 00002367602 00002309130 00002367610 00002367629 00000770957 00001954210 00002243824 00002243825 Product Description POCKET CHAMBER DEVICE POCKET CHAMBER PEDIATRIC MEDIUM MASK DEVICE PODOFILM 250 MG/ML TOPICAL LIQUID POLLINEX R INJECTION POLYCAL ORAL POWDER POLYCOSE ORAL POWDER POLYSPORIN 10,000 U/0.25 MG ANTIBIOTIC TOPICAL CRM POLYSPORIN ANTIBIOTIC TOPICAL OINTMENT POLYSPORIN PLUS PAIN RELIEF EAR DROPS POLYSPORIN PLUS PAIN RELIEF TOPICAL CREAM POLYSPORIN STERILE OPHTHALMIC OINTMENT POLYSPORIN STERILE OTIC OPH DROPS POLYSPORIN TRIPLE ANTIBIOTIC TOPICAL OINTMENT POLYTAR AF TOPICAL SHAMPOO POLYTAR REGULAR 1% TOPICAL SHAMPOO POLYTOPIC TOPICAL OINTMENT POLYTRIM OPH SOLUTION POMALYST 1 MG CAPSULE POMALYST 2 MG CAPSULE POMALYST 3 MG CAPSULE POMALYST 4 MG CAPSULE POSANOL 100 MG DELAYED-RELEASE TABLET POSANOL 40 MG/ML ORAL SUSPENSION POTABA 0.5 G CAPSULE POTABA 0.5 G TABLET POTASSIUM 50 MG TABLET POTASSIUM PHOSPHATE 224 MG/ML/ 236 MG/ML INJECTION POTASSIUM PHOSPHATES 224 MG/ML/236 MG/ML INJECTION PRADAXA 75 MG CAPSULE PRAMIPEXOLE 0.25 MG TABLET PRAMIPEXOLE 0.5 MG TABLET PRAMIPEXOLE 0.5 MG TABLET PRAMIPEXOLE 1 MG TABLET PRAMOX H.C. TOPICAL CREAM PRAMOX H.C. TOPICAL LOTION PRAVASTATIN-10 10 MG TABLET PRAVASTATIN-20 20 MG TABLET Route DEFAUL DEFAUL TOP INJ ORL ORL TOP TOP OT TOP OPH OT/OPH TOP TOP TOP TOP OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL ORL TOP TOP ORL ORL 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. Form DEV PEDDEV LIQ DEFAUL PWR PWR CRM ONT SOL CRM ONT DPS ONT SHP SHP ONT SOL CAP CAP CAP CAP DRT SUS CAP TAB TAB DEFAUL DEFAUL CAP TAB TAB TAB TAB CRM LOT TAB TAB MFR Unit of Issue MMS DEV MMS DEV PMS ML BEE ML XXX G ABN G PFI G WLA G JJI ML WLA G PFI G WLA ML PDH G GSK ML GSK ML SDZ G ALL ML CLG CAP CLG CAP CLG CAP CLG CAP MFC TAB MFC ML GLE CAP GLE TAB JAM TAB SDZ ML PPC ML BOE CAP SNS TAB SIV TAB SNS TAB SNS TAB DPT G DPT ML PDL TAB PDL TAB Base Price 15.9900 49.9900 1.5072 189.8750 0.0224 0.0253 0.3833 0.3833 0.9100 0.4160 1.6886 0.7387 0.4160 0.0623 0.0403 0.3801 3.5920 500.0000 500.0000 500.0000 500.0000 50.2272 10.0454 0.3560 0.4643 0.0563 0.4463 0.4940 1.7470 0.2628 1.3860 1.3860 0.5257 0.4853 0.2002 0.4050 0.4777 Pg 81 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002243826 00002148498 00000156876 00000607517 00002396521 00002405563 00002403722 00002403749 00002405539 00002403692 00002396483 00002405598 00002396548 00002403730 00002403706 00002405547 00002396505 00002405555 00002403714 00002396513 00002411768 00002411725 00002411733 00002411741 00002182904 00002276194 00002246067 00002043386 00002244574 00000886750 00001926217 00000693820 00002246133 00002249464 00002249472 00000635189 00002210754 Product Description PRAVASTATIN-40 40 MG TABLET PREDNISOLONE SOD PHOS 0.5% OPH SOLUTION (MINIMS) PREDNISONE 5 MG TABLET PREDNISONE-50 50 MG TABLET PREGABALIN 150 MG CAPSULE PREGABALIN 150 MG CAPSULE PREGABALIN 150 MG CAPSULE PREGABALIN 225 MG CAPSULE PREGABALIN 25 MG CAPSULE PREGABALIN 25 MG CAPSULE PREGABALIN 25 MG CAPSULE PREGABALIN 300 MG CAPSULE PREGABALIN 300 MG CAPSULE PREGABALIN 300 MG CAPSULE PREGABALIN 50 MG CAPSULE PREGABALIN 50 MG CAPSULE PREGABALIN 50 MG CAPSULE PREGABALIN 75 MG CAPSULE PREGABALIN 75 MG CAPSULE PREGABALIN 75 MG CAPSULE PREGABALIN-150 150 MG CAPSULE PREGABALIN-25 25 MG CAPSULE PREGABALIN-50 50 MG CAPSULE PREGABALIN-75 75 MG CAPSULE PREGNYL 10,000 UNIT INJECTION PREGVIT FOLIC 5 TABLET PREGVIT TABLET PREMARIN 25 MG/VIAL INJECTION PRENATAL VITAMIN AND MINERAL SUPPLEMENT CAPLET PREPARATION H TOPICAL CREAM PREPARATION H TOPICAL OINTMENT PRESSYN 20 U/ML INJECTION PRESSYN AR 20U/ML INJECTION PREVACID FASTAB 15 MG ORALLY DISINTEGRATING TABLET PREVACID FASTAB 30 MG ORALLY DISINTEGRATING TABLET PREVEX 67% TOPICAL CREAM PREVIDENT 5000 PLUS DENTAL CREAM Route ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL INJ ORL TOP TOP INJ INJ ORL ORL TOP DEN 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. Form TAB SOL TAB TAB CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP DEFAUL TAB TAB DEFAUL TAB CRM ONT DEFAUL DEFAUL DISNTAB DISNTAB CRM CRM MFR Unit of Issue PDL TAB BSH ML PDL TAB PDL TAB PDL CAP SNS CAP SIV CAP SIV CAP SNS CAP SIV CAP PDL CAP SNS CAP PDL CAP SIV CAP SIV CAP SNS CAP PDL CAP SNS CAP SIV CAP PDL CAP SIV CAP SIV CAP SIV CAP SIV CAP MFC VIAL DUI TAB DUI TAB PFI VIAL WNP TAB PDH G PDH G FEI ML FEI ML ABB TAB ABB TAB GSK G COL G Base Price 0.5755 7.2800 0.0220 0.0913 1.1698 1.7270 1.7270 1.1698 0.6173 0.6173 0.4181 1.7270 1.1698 1.7270 0.9683 0.9683 0.6558 1.2528 1.2529 0.8486 1.7270 0.6173 0.9683 1.2529 78.6200 0.5800 0.4143 45.3100 0.0775 0.2696 0.2340 7.9000 10.0000 2.1500 2.1500 0.1658 0.2133 Pg 82 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002335204 00002244081 00002426501 00002369753 00002324016 00002324024 00002338432 00002393050 00080033655 00000884413 00002239208 00002321106 00002321092 00000644315 00002311518 00002311496 00002309661 00000644331 00080026419 00002310600 00002209071 00002311038 00080014464 00002184486 00080008566 00000638676 00000638684 00002311062 00002311453 00002232658 00000789747 00002317796 00002317818 00002311607 00002311615 00002223260 00002241799 Product Description PREVNAR 13 SUSPENSION 0.5 ML SYRINGE INJECTION PREVNAR VACCINE 0.5 ML INJECTION PREZCOBIX 800 MG/150 MG TABLET PREZISTA 150 MG TABLET PREZISTA 400 MG TABLET PREZISTA 600 MG TABLET PREZISTA 75 MG TABLET PREZISTA 800 MG TABLET PRIMADOPHILUS OPTIMA MAX BIFIDO 90 BILLION CAPSULE PRINZIDE 20 MG/12.5 MG TABLET PRIORIX VIAL INJECTION PRISTIQ 100 MG EXTENDED-RELEASE TABLET PRISTIQ 50 MG EXTENDED-RELEASE TABLET PRO AMOX-500 MG CAPSULE PRO-AAS (CROQUABLE) 80 MG CHEWABLE TABLET PRO-AAS EC 80 MG TABLET PRO-AMIODARONE-200 200 MG TABLET PRO-AMOX 250 MG/5 ML POWDER FOR ORAL SUSPENSION PROARGI-9 PLUS ORAL POWDER PRO-AZITHROMYCINE 250 MG TABLET PROBETA 0.5% OPHTHALMIC SOLUTION PRO-BICALUTAMIDE-50 50 MG TABLET PROBIOTIC 10 BILLION PROCAINAMIDE HYDROCHLORIDE 100 MG/ML INJECTION PRO-CAL-D 400 IU ORAL CAPLET PROCAN 500 MG SUSTAINED-RELEASE TABLET PROCAN 750 MG SUSTAINED-RELEASE TABLET PRO-CEFADROXIL-500 500 MG CAPSULE PRO-CEFUROXIME-500 500 MG TABLET PROCET-30 TABLET PROCHLORPERAZINE 5 MG/ML INJECTION USP PRO-CIPROFLOXACIN 250 MG TABLET PRO-CIPROFLOXACIN 500 MG TABLET PRO-CLONAZEPAM 1 MG TABLET PRO-CLONAZEPAM 2 MG TABLET PROCTOSEDYL RECTAL SUPPOSITORY PROCYTOX 1,000 MG/VIAL INJECTION Route INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL INJ ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL RT INJ 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. Form NDL DEFAUL TAB TAB TAB TAB TAB TAB CAP TB DEFAUL ERT ERT CAP CTB ECT TAB SUS PWR TAB SOL TAB CAP DEFAUL DEFAUL SRT SRT CAP TAB TAB DEFAUL TAB TAB TAB TAB SUP DEFAUL MFR Unit of Issue PFI SYR PFI ML JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB ENT CAP MFC TAB GSK VIAL PFI TAB PFI TAB PDL CAP PDL TAB PDL TAB PDL TAB PDL ML NHP G PDL TAB ALL ML PDL TAB JAM CAP SDZ ML PDL TAB ERF TAB ERF TAB PDL CAP PDL TAB PDL TAB SDZ ML PDL TAB PDL TAB PDL TAB PDL TAB AXC SUP ASM VIAL Base Price 98.3700 193.6940 24.9100 3.7860 10.8580 16.5970 1.8930 23.7123 1.4283 0.9038 27.7760 2.9747 2.9750 0.3417 0.0560 0.5600 0.5147 0.0540 0.1252 2.4667 2.9500 1.6100 0.2398 3.0748 0.1200 0.5445 0.9425 0.8421 1.4337 0.1300 1.5470 0.6186 0.6979 0.1860 0.1595 1.2642 77.8100 Pg 83 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002241797 00002241795 00002241796 00002241800 00002311267 00002246645 00002246576 00002311429 00002311402 00002311437 00002311410 00002310228 00002310236 00002247909 00002310686 00002314991 00002315009 00002310449 00002310457 00002310465 00002310473 00002310481 00000503347 00002243144 00002175991 00002175983 00002311011 00000646261 00000646288 00002204606 00002310988 00002310996 00002310961 00000655643 00000655651 00000655678 00002314908 Product Description PROCYTOX 200 MG/VIAL INJECTION PROCYTOX 25 MG TABLET PROCYTOX 50 MG TABLET PROCYTOX INJECTION PRO-DEXAMETHASONE-4 4 MG TABLET PRODIEM BULK FIBRE THERAPY 625 MG TABLET PRODIEM OVERNIGHT RELIEF THERAPY 15 MG TABLET PRO-ENALAPRIL-10 10 MG TABLET PRO-ENALAPRIL-2.5 2.5 MG TABLET PRO-ENALAPRIL-20 20 MG TABLET PRO-ENALAPRIL-5 5 MG TABLET PRO-FENO-SUPER-100 100 MG TABLET PRO-FENO-SUPER-160 160 MG TABLET PROFERRIN 11 MG TABLET PRO-FLUCONAZOLE 100 MG TABLET PRO-FLUOXETINE 10 MG CAPSULE PRO-FLUOXETINE 20 MG CAPSULE PRO-GABAPENTIN 100 MG CAPSULE PRO-GABAPENTIN 300 MG CAPSULE PRO-GABAPENTIN 400 MG CAPSULE PRO-GABAPENTIN 600 MG TABLET PRO-GABAPENTIN 800 MG TABLET PROGLYCEM 100 MG CAPSULE PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE PRO-HYDROXYQUINE-200 200 MG TABLET PRO-INDO 25 MG CAPSULE PRO-INDO 50 MG CAPSULE PROLASTIN-C 1 G/VIAL INJECTION PRO-LISINOPRIL-10 10 MG TABLET PRO-LISINOPRIL-20 20 MG TABLET PRO-LISINOPRIL-5 5 MG TABLET PRO-LORAZEPAM 0.5 MG TABLET PRO-LORAZEPAM 1.0 MG TABLET PRO-LORAZEPAM 2 MG TABLET PRO-METFORMIN 500 MG TABLET Route INJ ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL 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. Form DEFAUL TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB CAP/TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB CAP CAP CAP CAP TAB CAP CAP DEFAUL TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue ASM VIAL ASM TAB ASM TAB ASM VIAL PDL TAB NVC TAB NVC TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB CBI TAB PDL TAB PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL TAB PDL TAB MFC CAP ASP CAP ASP CAP ASP CAP PDL TAB PDL CAP PDL CAP GRL VIAL PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB PDL TAB Base Price 51.8700 0.6410 0.9262 152.3500 0.3046 0.1711 0.2153 0.2647 0.1863 0.3195 0.2203 0.5406 0.2723 0.7410 2.2890 0.4595 0.4598 0.1040 0.2530 0.3015 0.9580 1.2773 1.8062 2.1511 2.7517 13.7802 0.2620 0.0871 0.1511 429.0600 0.1619 0.1945 0.1347 0.0359 0.0447 0.0699 0.0587 Pg 84 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002314894 00002343053 00002343061 00002243783 00002243784 00002238213 00002311224 00002315181 00002315203 00002310023 00002310104 00002310066 00002310074 00002316536 00002316528 00000519367 00000512524 00000287709 00000513059 00002239656 00002243834 00002246492 00002246493 00002313065 00002313073 00080002201 00000999412 00000466409 00002046733 00002242439 00002242441 00002243948 00002317966 00000004723 00080009682 00000497517 00002245215 Product Description PRO-METFORMIN 850 MG TABLET PROPAFENONE 150 MG TABLET PROPAFENONE 300 MG TABLET PROPAFENONE-150 150 MG TABLET PROPAFENONE-300 300 MG TABLET PROPECIA 1 MG TABLET PRO-QUININE-300 300 MG CAPSULE PRO-RABEPRAZOLE 10 MG ENTERIC-COATED TABLET PRO-RABEPRAZOLE 20 MG ENTERIC-COATED TABLET PRO-RAMIPRIL-1.25 1.25 MG CAPSULE PRO-RAMIPRIL-10 10 MG CAPSULE PRO-RAMIPRIL-2.5 2.5 MG CAPSULE PRO-RAMIPRIL-5 5 MG CAPSULE PRO-SOTALOL 160 MG TABLET PRO-SOTALOL 80 MG TABLET PRO-TRIAZIDE TABLET PROTRIN DF 800 MG/160 MG TABLET PROTYLOL 10 MG CAPSULE PROTYLOL 20 MG TABLET PROVOCHOLINE 100 MG/VIAL INHALATION PWD FOR SOL PROVOCHOLINE 1280 MG/VIAL INHALATION PWD FOR SOL PROVOCHOLINE 160 MG/VIAL INHALATION PWD FOR SOL PROVOCHOLINE 320 MG/VIAL INHALATION PWD FOR SOL PRO-ZOPICLONE 5 MG TABLET PRO-ZOPICLONE 7.5 MG TABLET PSN 056 CAPSULE PULMOCARE ORAL LIQUID PULMOPHYLLINE 5.3 MG/ML ORAL ELIXIR PULMOZYME 1 ML AMPOULE INHALATION SOLUTION PUREGON 100 IU/ML INJECTION PUREGON 200 IU/ML INJECTION PUREGON 833 IU/ML INJECTION CARTRIDGE PURG-ODAN ORL POWDER PURINETHOL 50 MG TABLET PYCNOGENOL 25 MG ORAL CASPULE PYRIDOXINE HCL 100 MG/ML INJECTION PYRIDOXINE HYDROCHLORIDE 100 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH INH INH INH ORL ORL ORL ORL ORL INH INJ INJ INJ ORL ORL ORL INJ INJ 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. Form TAB TAB TAB TAB TAB TAB CAP ECT ECT CAP/TAB CAP/TAB CAP/TAB CAP/TAB TAB TAB TAB TAB CAP TAB PWS PWS PWS PWS TAB TAB CAP LIQ ELX SOL DEFAUL DEFAUL CTG PWDPKT TAB CAP DEFAUL DEFAUL MFR Unit of Issue PDL TAB SNS TAB SNS TAB PDL TAB PDL TAB MFC TAB PDL CAP PDL TAB PDL TAB PDL CAP PDL CAP PDL CAP PDL CAP PDL TAB PDL TAB PDL TAB PDL TAB PDL CAP PDL TAB MTP VIAL MTP VIAL MTP VIAL MTP VIAL PDL TAB PDL TAB PSN CAP ABN ML RIV ML HLR ML MFC ML MFC ML MFC ML ODN PCKT TEV TAB NFN CAP HSP ML BNQ ML Base Price 0.0847 0.4303 0.7537 0.3395 0.5227 1.9643 0.3750 0.1204 0.2408 0.2057 0.3003 0.2370 0.2370 0.6492 0.5932 0.0608 0.1221 0.0655 0.1817 40.0000 487.0000 64.0000 128.0000 0.2231 0.4685 0.0750 0.0137 0.0086 16.8668 97.0000 208.5600 808.3333 5.6400 3.0755 0.5665 1.9500 1.2737 Pg 85 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080015945 00002417790 00002417367 00002417375 00002417804 00002417383 00002417812 00002417820 00002417391 00002417782 00002417359 00002415925 00002415933 00002415941 00002415917 00000695440 00000695459 00000695432 00080039114 00002267667 00002423723 00002299194 00002299208 00002299216 00002415852 00002308363 00002287943 00002287927 00002287935 00002415895 00002415909 00002415887 00002384698 00002398877 00002328690 00002371324 00002380684 Product Description QUEST TABLET QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 150 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 200 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 300 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 400 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET QUETIAPINE XR 50 MG EXTENDED-RELEASE TABLET QUINAPRIL 10 MG TABLET QUINAPRIL 20 MG TABLET QUINAPRIL 40 MG TABLET QUINAPRIL 5 MG TABLET QUININE-ODAN 200 MG CAPSULE QUININE-ODAN 300 MG CAPSULE QUININE-ODAN 300 MG TABLET Q-UROL TABLET RABAVERT VACCINE 2.5 UNIT/VIAL INJECTION RAGWITEK 12 UNIT SUBLINGUAL TABLET RALIVIA 100 MG EXTENDED-RELEASE TABLET RALIVIA 200 MG EXTENDED-RELEASE TABLET RALIVIA 300 MG EXTENDED-RELEASE TABLET RALOXIFENE 60 MG TABLET RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 10 MG CAPSULE RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 5 MG CAPSULE RAMIPRIL-HCTZ 10 MG/ 12.5 MG TABLET RAMIPRIL-HCTZ 10 MG/25 MG TABLET RAMIPRIL-HCTZ 5 MG/12.5 MG TABLET RAN-ALENDRONATE 5 MG TABLET RAN-AMLODIPINE 2.5 MG TABLET RAN-ANASTROZOLE 1 MG TABLET RAN-BICALUTAMIDE 50 MG TABLET RAN-CANDESARTAN 4 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ SLG ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB ERT ERT ERT ERT ERT ERT ERT ERT ERT ERT TAB TAB TAB TAB CAP CAP TAB TAB DEFAUL TAB ERT ERT ERT TAB CAP/TAB CAP/TAB CAP/TAB CAP/TAB TAB TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue PLH TAB PDL TAB SIV TAB SIV TAB PDL TAB SIV TAB PDL TAB PDL TAB SIV TAB PDL TAB SIV TAB PDL TAB PDL TAB PDL TAB PDL TAB ODN CAP ODN CAP ODN TAB TPI TAB MFC VIAL MFC TAB VCL TAB VCL TAB VCL TAB PDL TAB SIV CAP SIV CAP SIV CAP SIV CAP PDL TAB PDL TAB PDL TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB Base Price 0.3943 0.8753 0.7780 1.0520 1.1882 1.5440 1.7505 2.3763 2.0960 0.4445 0.3950 0.5329 0.5329 0.5329 0.5329 0.2610 0.4095 0.4095 0.7415 187.6800 4.0850 1.3699 2.4992 3.6209 0.4814 0.1274 0.1862 0.1470 0.1470 0.2633 0.2633 0.2067 1.0682 0.1421 2.6221 4.4303 0.3713 Pg 86 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002329204 00002293579 00002361426 00002361434 00002423979 00002423987 00002294524 00002294532 00002351706 00000740748 00000740756 00002372282 00002421364 00002358077 00002414112 00002414120 00002305038 00002375850 00002375869 00002375877 00002392844 00002392852 00002392801 00002392860 00002392828 00002392836 00002425548 00002383136 00002383101 00002383128 00002396084 00002396092 00002396076 00002388197 00002363062 00002361663 00002361671 Product Description RAN-CEFPROZIL 25 MG/ML ORAL SUSPENSION RAN-CEFPROZIL 50 MG/ML ORAL SUSPENSION RAN-CLARITHROMYCIN 250 MG TABLET RAN-CLARITHROMYCIN 500 MG TABLET RAN-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET RAN-ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET RAN-FOSINOPRIL 10 MG TABLET RAN-FOSINOPRIL 20 MG TABLET RAN-IMIPENEM-CILASTATIN 500 MG/500 MG/VIAL INJ RANITIDINE 150 MG TABLET RANITIDINE 300 MG TABLET RAN-LETROZOLE 2.5 MG TABLET RAN-MEMANTINE 10 MG TABLET RAN-NABILONE 0.25 MG CAPSULE RAN-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB RAN-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB RAN-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET RAN-PIOGLITAZONE 15 MG TABLET RAN-PIOGLITAZONE 30 MG TABLET RAN-PIOGLITAZONE 45 MG TABLET RAN-PREGABALIN 150 MG CAPSULE RAN-PREGABALIN 225 MG CAPSULE RAN-PREGABALIN 25 MG CAPSULE RAN-PREGABALIN 300 MG CAPSULE RAN-PREGABALIN 50 MG CAPSULE RAN-PREGABALIN 75 MG CAPSULE RAN-RAMIPRIL 15 MG CAPSULE RAN-SILDENAFIL 100 MG TABLET RAN-SILDENAFIL 25 MG TABLET RAN-SILDENAFIL 50 MG TABLET RAN-TOPIRAMATE 100 MG TABLET RAN-TOPIRAMATE 200 MG TABLET RAN-TOPIRAMATE 25 MG TABLET RAN-TRAMADOL/ACET 37.5 MG/325 MG TABLET RAN-VALSARTAN 40 MG TABLET RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SUS SUS TAB TAB DRT DRT TAB TAB DEFAUL TAB TAB TAB TAB CAP DISNTAB DISNTAB ECT TAB TAB TAB CAP CAP CAP CAP CAP CAP CAP/TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP MFR Unit of Issue RAN ML RAN ML RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN VIAL PDL TAB PDL TAB RAN TAB RAN TAB RAN CAP RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN CAP RAN CAP RAN CAP RAN CAP RAN CAP RAN CAP RAN CAP RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB RAN TAB ASC CAP ASC CAP Base Price 0.1186 0.2367 0.4501 1.6782 1.9251 1.9251 0.2177 0.2619 21.9400 0.1800 0.3600 2.8387 1.6357 1.5246 5.5161 7.8257 1.3922 0.5983 0.8887 1.3362 1.7788 1.7788 0.6358 1.7788 0.9973 1.2904 0.8550 9.2000 8.2900 8.8477 0.6106 0.9667 0.3222 0.6452 0.5396 2.0710 2.0711 Pg 87 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002247111 00002243237 00002302063 00002302071 00002332728 00002332736 00002332744 00002332752 00002275279 00002277700 00000550477 00002247818 00002247819 00002103737 00000694827 00002053403 00002169126 00002229781 00002229782 00002229783 00002229784 00002296071 00002218461 00002275252 00002275260 00000805386 00000805025 00002273101 00002273128 00002273136 00002243789 00002097168 00002243353 00002243352 00000653233 00002031159 00002248031 Product Description RAPAMUNE 1 MG TABLET RAPAMUNE 1 MG/ML ORAL LIQUID RASILEZ 150 MG TABLET RASILEZ 300 MG TABLET RASILEZ HCT 150 MG/12.5 MG TABLET RASILEZ HCT 150 MG/25 MG TABLET RASILEZ HCT 300 MG/12.5 MG TABLET RASILEZ HCT 300 MG/25 MG TABLET RATIO-ALENDRONATE 70 MG TABLET RATIO-BICALUTAMIDE 50 MG TABLET RATIO-CALMYDONE ORAL SYRUP RATIO-CLARITHROMYCIN 250 MG TABLET RATIO-CLARITHROMYCIN 500 MG TABLET RATIO-CLONAZEPAM 2 MG TABLET RATIO-CORISTEX-DH ORAL LIQUID RATIO-COTRIDIN EXPECTORANT ORAL SYRUP RATIO-COTRIDIN ORAL SYRUP RATIO-DILTIAZEM CD 120 MG CONTROLLED-DELIVERY CAP RATIO-DILTIAZEM CD 180 MG CONTROLLED-DELIVERY CAP RATIO-DILTIAZEM CD 240 MG CONTROLLED-DELIVERY CAP RATIO-DILTIAZEM CD 300 MG CONTROLLED-DELIVERY CAP RATIO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY RATIO-FLUVOXAMINE 100 MG TABLET RATIO-FOSINOPRIL 10 MG TABLET RATIO-FOSINOPRIL 20 MG TABLET RATIO-GENTAMICIN SULFATE 0.1% TOPICAL CREAM RATIO-GENTAMYCIN SULFATE 0.1% TOPICAL OINTMENT RATIO-GLIMEPIRIDE 1 MG TABLET RATIO-GLIMEPIRIDE 2 MG TABLET RATIO-GLIMEPIRIDE 4 MG TABLET RATIO-IPRA SAL UDV INHALATION SOLUTION RATIO-IPRATROPIUM UDV 250 MCG/ML INHALATION SOL'N RATIO-LAMOTRIGINE 100 MG TABLET RATIO-LAMOTRIGINE 25 MG TABLET RATIO-LENOLTEC NO.1 TABLET RATIO-LEVOBUNOLOL 0.25% OPH SOLUTION RATIO-MELOXICAM 15 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL TOP TOP ORL ORL ORL INH INH ORL ORL ORL OPH ORL 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. Form TAB LIQ TAB TAB TAB TAB TAB TAB TAB TAB SYR TAB TAB TAB LIQ SYR SYR CDC CDC CDC CDC SPM TAB TAB TAB CRM ONT TAB TAB TAB SOL UDSOL TAB TAB TAB SOL TAB MFR Unit of Issue PFI TAB PFI ML NOV TAB NOV TAB NOV TAB NOV TAB NOV TAB NOV TAB RPH TAB RPH TAB RPH ML RPH TAB RPH TAB RPH TAB RPH ML RPH ML RPH ML RPH CAP RPH CAP RPH CAP RPH CAP RPH DOSE RPH TAB RPH TAB RPH TAB RPH G RPH G RPH TAB RPH TAB RPH TAB RPH ML RPH ML RPH TAB RPH TAB RPH TAB RPH ML RPH TAB Base Price 8.6415 8.5075 1.3746 1.3746 1.3804 1.3593 1.3593 1.3804 2.5430 4.1790 0.0596 0.4122 1.6293 0.2010 0.0826 0.0634 0.0570 0.3635 0.6846 0.6399 1.1351 0.1999 0.3896 0.4977 0.5985 0.4427 0.4273 0.5047 0.5047 0.5350 0.4524 0.6590 0.5739 0.0936 0.0547 3.9000 0.5670 Pg 88 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002247889 00002320908 00002194163 00002260867 00002308681 00002247810 00002301423 00002301431 00002301458 00002311194 00001986864 00002319500 00002247068 00002247070 00002247071 00000317225 00000550507 00002140063 00002223554 00001900978 00002223546 00002246162 00002368064 00002358352 00002243676 00000013447 00000897221 00000897256 00002138670 00002244650 00002399148 00002049260 00002231008 00002239405 00002242592 00002192640 00002346672 Product Description RATIO-MELOXICAM 7.5 MG TABLET RATIO-MEMANTINE 10 MG TABLET RATIO-NYSTATIN 100,000 UNIT/G VAGINAL CREAM RATIO-OMEPRAZOLE 20 MG SUSTAINED-RELEASE TABLET RATIO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET RATIO-PAROXETINE 10 MG TABLET RATIO-PIOGLITAZONE 15 MG TABLET RATIO-PIOGLITAZONE 30 MG TABLET RATIO-PIOGLITAZONE 45 MG TABLET RATIO-RAMIPRIL 15 MG CAPSULE RATIO-SALBUTAMOL SULFATE U.D. P.F. 1 MG/ML INH SOL RATIO-SILDENAFIL R 20 MG TABLET RATIO-SIMVASTATIN 10 MG TABLET RATIO-SIMVASTATIN 40 MG TABLET RATIO-SIMVASTATIN 80 MG TABLET RATIO-THEO-BRONC ORAL SOLUTION RATIO-TRIACOMB REGULAR TOPICAL CREAM RATIO-VALPROIC 50 MG/ML ORAL SYRUP REACTINE 10 MG TABLET REACTINE 20 MG TABLET REACTINE 5 MG TABLET REACTINE ALLERGY & SINUS EXTENDED-RELEASE TABLET REACTINE ALLERGY LIQUID GELS 10 MG CAPSULE REACTINE FAST MELT 10 MG ODT RECOMBIVAX HB (PRESERVATIVE FREE) 5MCG/0.5ML INJ REDOXON (BL CHERRY) 1,000 MG EFFERVESCENT TABLET REDOXON (LEMON) 1,000 MG EFFERVESCENT TABLET REDOXON (ORANGE) 1,000 MG EFFERVESCENT TABLET REFRESH 1.4% OPH SOLUTION REFRESH LIQUIGEL 1% OPH SOLUTION REFRESH OPTIVE ADVANCED REFRESH PLUS 0.5% OPH SOLUTION REFRESH TEARS 0.5% OPH SOLUTION REGRANEX TOPICAL GEL REGULAR VITA-VIM CAPLET REJUVA-A 0.025% TOPICAL CREAM RELAXA PEG 3350 ORAL POWDER Route ORL ORL VAG ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL OPH OPH NAS OPH OPH TOP ORL TOP ORL 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. Form TAB TAB CRM CAP/SRT ECT TAB TAB TAB TAB CAP/TAB SOL TAB TAB TAB TAB SOL CRM SYR TAB TAB TAB ERT CAP ODT DEFAUL EVT EVT EVT SOL SOL SOL SOL SOL GEL TAB CRM PWR MFR Unit of Issue RPH TAB RPH TAB RPH G RPH TAB RPH TAB RPH TAB RPH TAB RPH TAB RPH TAB RPH CAP RPH ML RPH TAB RPH TAB RPH TAB RPH TAB RPH ML RPH G RPH ML PDH TAB PDH TAB PDH TAB PDH TAB MCL CAP MCL TAB MFC ML HLR TAB HLR TAB HLR TAB ALL ML ALL ML ALL ML ALL ML ALL ML JAI G JAM TAB GSK G RED G Base Price 0.4914 1.7861 0.3484 0.4117 1.2750 1.0430 0.5809 0.8139 1.2237 0.8133 0.1578 7.5128 0.3753 0.4636 0.4633 0.0350 0.3947 0.0398 0.9967 0.9240 0.5696 0.7430 0.7604 0.6717 24.5200 0.2700 0.2640 0.2700 0.9042 0.5447 0.9490 0.8050 0.4413 35.3333 0.1012 1.8410 0.0277 Pg 89 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002240863 00002308215 00002256290 00002256304 00002248542 00002248543 00002248544 00002246552 00002246555 00002246553 00002246554 00002244310 00002222000 00002221985 00002221993 00002052407 00002354586 00002415968 00002415976 00002415984 00002249057 00002247790 00002377012 00002377020 00000999551 00002355655 00002318164 00000443816 00000443794 00002264633 00002243914 00002306980 00002008726 00002008696 00002008718 00002008688 00001902660 Product Description RELENZA 5 MG/DOSE INHALATION DISK RELISTOR 20 MG/ML INJECTION RELPAX 20 MG TABLET RELPAX 40 MG TABLET REMERON RD 15 MG ORALLY DISINTEGRATING TABLET REMERON RD 30 MG ORALLY DISINTEGRATING TABLET REMERON RD 45 MG ORALLY DISINTEGRATING TABLET REMODULIN 1 MG/ML INJECTION REMODULIN 10 MG/ML INJECTION REMODULIN 2.5 MG/ML INJECTION REMODULIN 5 MG/ML INJECTION RENAGEL 800 MG TABLET RENEDIL 10 MG EXTENDED-RELEASE TABLET RENEDIL 2.5 MG EXTENDED-RELEASE TABLET RENEDIL 5 MG EXTENDED-RELEASE TABLET RENOVA 0.05% TOPICAL CREAM RENVELA 800 MG TABLET REPAGLINIDE 0.5 MG TABLET REPAGLINIDE 1 MG TABLET REPAGLINIDE 2 MG TABLET REPLAGAL 1 MG/ML INJECTION REPRONEX 75 UNIT/VIAL INJECTION RESOTRAN 1 MG FILM-COATED TABLET RESOTRAN 2 MG FILM-COATED TABLET RESOURCE KID ESSENTIALS ORAL LIQUID RESTASIS 0.05% OPH EMULSION RESTORALAX ORAL POWDER RETIN-A 0.025% TOPICAL GEL RETIN-A 0.05% TOPICAL CREAM RETIN-A MICRO 0.04% TOPICAL GEL RETIN-A MICRO 0.1% GEL RETISERT 0.59 MG INTRAVITREAL IMPLANT RETISOL-A 0.01% TOPICAL CREAM RETISOL-A 0.025% TOPICAL CREAM RETISOL-A 0.05% TOPICAL CREAM RETISOL-A O.1% TOPICAL CREAM RETROVIR 100 MG CAPSULE Route INH INJ ORL ORL ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL TOP ORL ORL ORL ORL INJ INJ ORL ORL ORL OPH ORL TOP TOP TOP TOP OPH TOP TOP TOP TOP ORL 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. Form DSK DEFAUL TAB TAB DISNTAB DISNTAB DISNTAB DEFAUL DEFAUL DEFAUL DEFAUL TAB ERT ERT ERT CRM TAB TAB TAB TAB DEFAUL DEFAUL TAB TAB LIQ EML PWR GEL CRM GEL GEL IMP CRM CRM CRM CRM CAP MFR Unit of Issue GSK DISC SLX ML PFI TAB PFI TAB MFC TAB MFC TAB MFC TAB NTH ML NTH ML NTH ML NTH ML SAV TAB SAV TAB SAV TAB SAV TAB MCN G SAV TAB PDL TAB PDL TAB PDL TAB PAL ML FEI VIAL JAI TAB JAI TAB NHN ML ALL ML SPL G JJI G JJI G JJI G JJI G BSH SYS GSK G GSK G GSK G GSK G GSK CAP Base Price 7.9800 69.1500 15.1567 15.1567 0.4633 0.9263 1.3897 45.0000 450.0000 112.5000 225.0000 1.7936 0.7257 0.3170 0.4633 1.3500 1.6928 0.0996 0.1036 0.1075 657.1429 74.9060 2.4543 3.7671 0.0087 9.1725 0.0633 0.4293 0.4360 1.2105 1.2105 16000.0000 0.7904 0.7649 0.7649 0.7649 2.0034 Pg 90 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001902652 00002279401 00002213826 00002035871 00002304902 00002317699 00002317710 00002304899 00002361825 00002361833 00002248610 00002248611 00002294176 00002220806 00000732230 00080058002 00002231923 00080026370 00002260107 00002269589 00002269597 00002269619 00002243559 00000309702 00002091887 00002092808 00002352141 00002347474 00002298465 00002247217 00002331500 00002331489 00002242093 00002242094 00002422751 00002422778 00002422786 Product Description RETROVIR 50 MG/5ML ORAL SYRUP REVATIO 20 MG TABLET REVIA 50 MG TABLET REVITONUS C-1000 ORAL LIQUID REVLIMID 10 MG CAPSULE REVLIMID 15 MG CAPSULE REVLIMID 25 MG CAPSULE REVLIMID 5 MG CAPSULE REVOLADE 25 MG TABLET REVOLADE 50 MG TABLET REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE RHINARIS LUBRICATING NASAL GEL RHINARIS NASAL AEROSOL RHINARIS NOZOIL NASAL SPRAY RHINOCORT AQUA 64 MCG/DOSE METERED DOSE NAS. SPRAY RHODIOLA ROSEA CAPSULE RHOXAL-ANAGRELIDE 0.5 MG CAPSULE RHOXAL-GLIMEPIRIDE 1 MG TABLET RHOXAL-GLIMEPIRIDE 2 MG TABLET RHOXAL-GLIMEPIRIDE 4 MG TABLET RHOXAL-ORPHENADRINE 100 MG EXTENDED-RELEASE TABLET RIBOFLAVINE 100 MG TABLET RIFADIN 150 MG CAPSULE RIFADIN 300 MG CAPSULE RISEDRONATE 35 MG TABLET RISEDRONATE 35 MG TABLET RISPERDAL CONSTA 12.5 MG/VIAL INJECTION RIVA-AMIODARONE 200 MG TABLET RIVA-AMLODIPINE 10 MG TABLET RIVA-AMLODIPINE 2.5 MG TABLET RIVA-ATENOLOL 100 MG TABLET RIVA-ATENOLOL 50 MG TABLET RIVA-ATORVASTATIN 10 MG TABLET RIVA-ATORVASTATIN 20 MG TABLET RIVA-ATORVASTATIN 40 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS NAS NAS NAS ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL 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. Form SYR TAB TAB LIQ CAP CAP CAP CAP TAB TAB CAP CAP CAP GEL AER SPR SPM CAP CAP TAB TAB TAB ERT TAB CAP CAP TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB MFR Unit of Issue GSK ML PFI TAB BAR TAB SDZ AMP CLG CAP CLG CAP CLG CAP CLG CAP GSK TAB GSK TAB BMS CAP BMS CAP BMS CAP PMS G PMS DOSE PPH ML AZC DOSE AOR CAP SDZ CAP SDZ TAB SDZ TAB SDZ TAB SDZ TAB JAM TAB SAV CAP SAV CAP SIV TAB PDL TAB JAI VIAL RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB Base Price 0.2123 11.9561 9.3810 0.8110 361.0000 382.0000 424.0000 340.0000 62.5000 125.0000 12.0753 11.0587 24.1507 0.2851 0.1933 1.7990 0.1004 0.2546 3.4496 0.5047 0.5350 0.5047 0.9358 0.0686 0.9167 1.4425 2.4893 2.4275 85.8100 0.5147 0.3587 0.1380 0.2362 0.1437 0.3138 0.3922 0.4216 Pg 91 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002422794 00002242077 00002247306 00002251167 00002251175 00002251183 00002239081 00002242783 00002265265 00002240788 00002228300 00002402416 00002316463 00002330083 00002330091 00002202352 00002240112 00001940112 00002242157 00002416999 00002417006 00002417014 00002417022 00002248082 00002415801 00002415798 00002247147 00002026805 00002231176 00001934767 00001930990 00001932187 00002026783 00002230949 00001934791 00001934783 00001931032 Product Description RIVA-ATORVASTATIN 80 MG TABLET RIVA-CLONAZEPAM 0.5 MG TABLET RIVA-FENOFIBRATE MICRO 200 MG CAPSULE RIVA-GABAPENTIN 100 MG CAPSULE RIVA-GABAPENTIN 300 MG CAPSULE RIVA-GABAPENTIN 400 MG CAPSULE RIVA-METFORMIN 500 MG TABLET RIVA-METFORMIN 850 MG TABLET RIVA-MIRTAZAPINE 30 MG TABLET RIVA-NAPROXEN 500 MG TABLET RIVANASE AQ 50 MCG/DOSE METER DOSE NASAL SPRAY RIVA-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET RIVA-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET RIVA-RABEPRAZOLE EC 10 MG ENTERIC-COATED TABLET RIVA-RABEPRAZOLE EC 20 MG ENTERIC-COATED TABLET RIVASA CROQUABLE 80 MG TABLET RIVASOL-HC RECTAL SUPPOSITORY RIVASONE SCALP 0.1% TOPICAL LOTION RIVA-SOTALOL 160 MG TABLET RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE 6 MG CAPSULE RIVA-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET RIZATRIPTAN ODT 10 MG ORALLY DISINTEG TAB RIZATRIPTAN ODT 5 MG ORALLY DISINTEG TAB ROBAX PLATINUM TABLET ROBAXACET CAPLET ROBAXACET EXTRA STRENGTH CAPLET ROBAXACET-8 TABLET ROBAXIN 500 MG TABLET ROBAXIN-750 750 MG TABLET ROBAXISAL CAPLET ROBAXISAL EXTRA STRENGTH CAPLET ROBAXISAL-C 1/2 TABLET ROBAXISAL-C 1/4 TABLET ROBITUSSIN 20 MG ORAL SYRUP Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL RT TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB SPM CAP/SRT ECT ECT ECT CTB SUP LOT TAB CAP CAP CAP CAP SRT DISNTAB DISNTAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SYR MFR Unit of Issue RIV TAB RIV TAB RIV CAP RIV CAP RIV CAP RIV CAP RIV TAB RIV TAB RIV TAB RIV TAB RIV DOSE RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV SUP RIV ML RIV TAB PDL CAP PDL CAP PDL CAP PDL CAP RIV TAB PDL TAB PDL TAB PDH TAB PDH TAB PDH TAB PDH TAB PDH TAB PDH TAB WCH TAB PDH TAB PDH TAB PDH TAB PDH ML Base Price 0.4216 0.0495 0.2723 0.1040 0.2530 0.3015 0.0586 0.0847 0.2338 0.2110 0.0490 0.4117 0.5054 0.1203 0.2407 0.0560 0.5833 0.0853 0.1623 0.6514 0.6514 0.6514 0.6514 0.5075 3.7050 3.7050 0.6744 0.4972 0.5461 0.7612 0.5270 0.8698 0.4022 0.5461 1.2871 1.0775 0.0538 Pg 92 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002142783 00001934740 00002068419 00002142775 00001931024 00000824291 00002318415 00000393444 00000343617 00000708925 00002368684 00002242979 00002242919 00002389045 00002381184 00002381192 00002389053 00002381206 00002389061 00002389037 00002381176 00002300591 00002284413 00000466425 00002248563 00002222116 00080015240 00002224828 00002245735 00000623571 00080024381 00000779296 00001910701 00080004542 00002370468 00002370476 00000593257 Product Description ROBITUSSIN 200 MG/5 ML EXTRA STRENGTH ORAL SYRUP ROBITUSSIN A-C ORAL SYRUP ROBITUSSIN COUGH AND COLD ORAL SYRUP ROBITUSSIN DM EXTRA STRENGTH ORAL SYRUP ROBITUSSIN DM ORAL SYRUP ROCALTROL 1 MCG/ML ORAL SOLUTION ROCURONIUM BROMIDE 10MG/ML INJECTION ROFACT 150 MG CAPSULE ROFACT 300 MG CAPSULE ROGAINE 20 MG/ML TOPICAL SOLUTION ROGAINE FOAM 50 MG/G AEROSOL FOAM ROGITINE 10 MG/ML INJECTION ROSASOL 1% TOPICAL CREAM ROSUVASTATIN 10 MG TABLET ROSUVASTATIN 10 MG TABLET ROSUVASTATIN 20 MG TABLET ROSUVASTATIN 20 MG TABLET ROSUVASTATIN 40 MG TABLET ROSUVASTATIN 40 MG TABLET ROSUVASTATIN 5 MG TABLET ROSUVASTATIN 5 MG TABLET ROTARIX 1 000 000 CCID50 DOSE (1.5ML) ORAL SUSP ROTATEQ (2 ML/DOSE) ORAL SOLUTION ROUGIER CALCIUM ORAL LIQUID RUB A535 DUAL ACTION RUB A-535 EXTRA STRENGTH RUGBY NICOTINE POLACRILEX; NIC-ASSIST 2 MG GUM RYTHMODAN 150 MG CAPSULE SAB-SODIUM CHLORIDE 5% OPTHALMIC SOLUTION USP SALIJECT 570 MG/ML INJECTION SALINEX 9 MG/ML NASAL SPRAY SALINEX NASAL LUBRICANT GEL SALINEX NASAL LUBRICANT SPRAY SALMON & FISH OILS 1000 MG SOFTGEL SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET SANDIMMUNE I.V. 50 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL INJ ORL ORL TOP TOP INJ TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP ORL ORL OPH INJ NAS NAS NAS ORL ORL ORL INJ 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. Form SYR SYR SYR SYR SYR SOL DEFAUL CAP CAP SOL FOA DEFAUL CRM TAB TAB TAB TAB TAB TAB TAB TAB SUS SOL LIQ CRM CRM GUM CAP SOL DEFAUL SPR GEL SPR TAB TAB TAB DEFAUL MFR Unit of Issue PDH ML PDH ML PDH ML PDH ML PDH ML HLR ML SDZ ML VCL CAP VCL CAP UPJ ML JJI G PAL ML GSK G SIV TAB PDL TAB PDL TAB SIV TAB PDL TAB SIV TAB SIV TAB PDL TAB GSK DOSE MFC ML ROG ML CHD G CHD G APH PIECE SAV CAP SDZ ML OMG ML SDZ ML SDZ G SDZ ML WNP TAB OTS TAB OTS TAB NOV ML Base Price 0.0538 0.1113 0.0538 0.0538 0.0538 2.9560 1.0260 0.7130 1.1224 0.6468 0.5221 43.4360 0.5257 0.3400 0.3400 0.4250 0.4250 0.4977 0.4977 0.3227 0.3227 79.6700 31.2000 0.0222 0.0616 0.0616 0.1650 0.3924 0.5633 1.4300 0.1380 0.1407 0.1697 0.0715 90.4110 90.4110 4.8230 Pg 93 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002288079 00002338467 00002386410 00002386429 00002386437 00002386445 00002386453 00002386461 00002276089 00002386283 00002386275 00002326957 00002421917 00002421925 00002261855 00002261863 00002303426 00002303434 00002387131 00002233960 00002233985 00002242485 00002230386 00000739839 00002400596 00002400618 00002261774 00002367696 00002367688 00002316307 00002278634 00002278642 00002278650 00002390701 00002390698 00002327139 00002339471 Product Description SANDOZ ALENDRONATE 5 MG TABLET SANDOZ ANASTROZOLE 1 MG TABLET SANDOZ ATOMOXETINE 10 MG CAPSULE SANDOZ ATOMOXETINE 18 MG CAPSULE SANDOZ ATOMOXETINE 25 MG CAPSULE SANDOZ ATOMOXETINE 40 MG CAPSULE SANDOZ ATOMOXETINE 60 MG CAPSULE SANDOZ ATOMOXETINE 80 MG CAPSULE SANDOZ BICALUTAMIDE 50 MG TABLET SANDOZ BOSENTAN 125 MG TABLET SANDOZ BOSENTAN 62.5 MG TABLET SANDOZ CANDESARTAN 4 MG TABLET SANDOZ CAPECITABINE 150 MG TABLET SANDOZ CAPECITABINE 500 MG TABLET SANDOZ CARBAMAZEPINE 100 MG CHEWABLE TABLET SANDOZ CARBAMAZEPINE 200 MG CHEWABLE TABLET SANDOZ CEFPROZIL 25 MG/ML ORAL SUSPENSION SANDOZ CEFPROZIL 50 MG/ML ORAL SUSPENSION SANDOZ CIPROFLOXACIN 0.3% OPHTHALMIC SOLUTION SANDOZ CLONAZEPAM 0.5 MG TABLET SANDOZ CLONAZEPAM 2 MG TABLET SANDOZ CORTIMYXIN OPH OINTMENT SANDOZ CORTIMYXIN OTIC SOLUTION SANDOZ DEXAMETHASONE SOD PHOSPHATE 0.1% OT/OPH SOL SANDOZ DICLOFENAC MISOPROSTOL 50 MG/200 MCG ECT SANDOZ DICLOFENAC MISOPROSTOL 75 MG/200 MCG ECT SANDOZ DICLOFENAC RAPIDE 50 MG TABLET SANDOZ DONEPEZIL ODT 10 MG TABLET SANDOZ DONEPEZIL ODT 5 MG TABLET SANDOZ DORZOLAMIDE 2% OPHTHALMIC SOLUTION SANDOZ FAMCICLOVIR 125 MG TABLET SANDOZ FAMCICLOVIR 250 MG TABLET SANDOZ FAMCICLOVIR 500 MG TABLET SANDOZ FENOFIBRATE E 145 MG TABLET SANDOZ FENOFIBRATE E 48 MG TABLET SANDOZ FENTANYL PATCH 37 MCG/HR TRANSDERMAL PATCH SANDOZ FINASTERIDE A 1 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL OPH OT OT/OPH ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL TRD ORL 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. Form TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB CTB CTB SUS SUS SOL TAB TAB ONT SOL SOL ECT ECT TAB DISNTAB DISNTAB SOL TAB TAB TAB TAB TAB PTH TAB MFR Unit of Issue SDZ TAB SDZ TAB SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ ML SDZ ML SDZ ML SDZ TAB SDZ TAB SDZ G SDZ ML SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ PTH SDZ TAB Base Price 1.0680 2.6223 2.3833 2.7320 3.0160 3.4373 3.8133 4.1160 4.4303 52.5590 52.5590 0.3502 1.5987 5.3286 0.0380 0.0749 0.0592 0.1221 1.8600 0.0495 0.0932 3.6143 1.1400 1.3780 0.4541 0.6179 0.3937 3.7263 3.7263 3.0700 2.0850 2.8017 4.3548 0.9951 0.3887 9.2820 1.2507 Pg 94 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002243486 00002247055 00002247054 00002230888 00002229440 00002229441 00002237187 00002344815 00002241716 00002257564 00002247056 00002247057 00002344807 00002375532 00002250594 00002358611 00002320630 00002313855 00002234007 00002234003 00002247189 00002327791 00002327805 00002358913 00002420171 00002247920 00002301075 00002269422 00002254778 00002269449 00002244999 00002261790 00002261804 00002261782 00002297906 00002297914 00002297922 Product Description SANDOZ FLUOXETINE 10 MG CAPSULE SANDOZ FLUVOXAMINE 100 MG TABLET SANDOZ FLUVOXAMINE 50 MG TABLET SANDOZ GENTAMICIN SULFATE 0.3% OPH OINTMENT SANDOZ GENTAMICIN SULFATE 0.3% OPH SOLUTION SANDOZ GENTAMICIN SULFATE 0.3% OTIC SOLUTION SANDOZ IDOXURIDINE 0.1% TOPICAL SOLUTION SANDOZ LETROZOLE 2.5 MG TABLET SANDOZ LEVOBUNOLOL 0.5% OPH SOLUTION SANDOZ LOPERAMIDE 2 MG TABLET SANDOZ LOVASTATIN 20 MG TABLET SANDOZ LOVASTATIN 40 MG TABLET SANDOZ MEMANTINE 10 MG TABLET SANDOZ MEMANTINE FCT 10 MG TABLET SANDOZ MIRTAZAPINE 15 MG TABLET SANDOZ MONTELUKAST 4 MG GRANULES SANDOZ MYCOPHENOLATE MOFETIL 250 MG CAPSULE SANDOZ MYCOPHENOLATE MOFETIL 500 MG TABLET SANDOZ NITRAZEPAM 10 MG TABLET SANDOZ NITRAZEPAM 5 MG TABLET SANDOZ OFLOXACIN 0.3% OPHTHALMIC SOLUTION SANDOZ OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET SANDOZ OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET SANDOZ OLOPATADINE 0.1% OPH SOLUTION SANDOZ OLOPATADINE 0.2% OPHTHALMIC SOLUTION SANDOZ OPTICORT OTIC OPH SOLUTION SANDOZ PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET SANDOZ PAROXETINE 10 MG TABLET SANDOZ PAROXETINE 30 MG TABLET SANDOZ PAROXETINE 30 MG TABLET SANDOZ PENTASONE 0.1%/0.3% OTIC OPH SOL SANDOZ PINDOLOL 10 MG TABLET SANDOZ PINDOLOL 15 MG TABLET SANDOZ PINDOLOL 5 MG TABLET SANDOZ PIOGLITAZONE 15 MG TABLET SANDOZ PIOGLITAZONE 30 MG TABLET SANDOZ PIOGLITAZONE 45 MG TABLET Route ORL ORL ORL OPH OPH OT TOP ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL OPH OPH OT/OPH ORL ORL ORL ORL OT/OPH ORL ORL ORL ORL ORL ORL 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. Form CAP TAB TAB ONT SOL SOL SOL TAB SOL TAB TAB TAB TAB TAB TAB GRNUL CAP TAB TAB TAB SOL DISNTAB DISNTAB SOL SOL SOL ECT TAB TAB TAB SOL TAB TAB TAB TAB TAB TAB MFR Unit of Issue SDZ CAP SDZ TAB SDZ TAB SDZ G SDZ ML SDZ ML SDZ ML SDZ TAB SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ PCKT SDZ CAP SDZ TAB SDZ TAB SDZ TAB SDZ ML SDZ TAB SDZ TAB SDZ ML SDZ ML SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB Base Price 0.4595 0.3783 0.2168 1.5000 0.4060 1.0320 4.9900 2.8387 1.1520 0.2659 0.4919 0.8985 1.6847 1.6848 0.4094 1.0937 1.1258 2.9734 0.0534 0.0357 1.4680 5.8477 8.2960 5.7060 11.4120 1.4675 1.3132 1.0743 1.0647 0.4796 1.2813 0.2323 0.3370 0.1361 0.5983 0.8383 1.2604 Pg 95 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002239234 00002315270 00002247856 00002247857 00002247858 00001916181 00001916203 00002390841 00002390817 00002390868 00002390825 00002390833 00002089645 00080024148 00002318822 00002318806 00002318814 00002247828 00002247830 00002247831 00002247833 00002234013 00002416816 00002416824 00002416832 00002295121 00002262177 00002241755 00002267837 00002248529 00002239714 00002356740 00002257580 00000578541 00000856711 00002266121 00080041540 Product Description SANDOZ POLYTRIMETHOPRIM OPH SOLUTION SANDOZ PRAMIPEXOLE 0.5 MG TABLET SANDOZ PRAVASTATIN 10 MG TABLET SANDOZ PRAVASTATIN 20 MG TABLET SANDOZ PRAVASTATIN 40 MG TABLET SANDOZ PREDNISOLONE ACETATE 0.12% OPH SUSPENSION SANDOZ PREDNISOLONE ACETATE 1% OPH SUSPENSION SANDOZ PREGABALIN 150 MG CAPSULE SANDOZ PREGABALIN 25 MG CAPSULE SANDOZ PREGABALIN 300 MG CAPSULE SANDOZ PREGABALIN 50 MG CAPSULE SANDOZ PREGABALIN 75 MG CAPSULE SANDOZ SENNOSIDES 12 MG TABLET SANDOZ SENNOSIDES 8.6 MG TABLET SANDOZ SILDENAFIL 100 MG TABLET SANDOZ SILDENAFIL 25 MG TABLET SANDOZ SILDENAFIL 50 MG TABLET SANDOZ SIMVASTATIN 10 MG TABLET SANDOZ SIMVASTATIN 20 MG TABLET SANDOZ SIMVASTATIN 40 MG TABLET SANDOZ SIMVASTATIN 80 MG TABLET SANDOZ SOTALOL 160 MG TABLET SANDOZ TACROLIMUS 0.5 MG CAPSULE SANDOZ TACROLIMUS 1 MG CAPSULE SANDOZ TACROLIMUS 5 MG CAPSULE SANDOZ TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE SANDOZ TERBINAFINE 250 MG TABLET SANDOZ TOBRAMYCIN 0.3% OPH SOLUTION SANDOZ TOPIRAMATE 200 MG TABLET SANDOZ TRIFLURIDINE 1% OPH SOLUTION SANDOZ VALPROIC 250 MG CAPSULE SANDOZ VALSARTAN 40 MG TABLET SANDOZ ZOPICLONE 7.5 MG TABLET SARNA HC 1% TOPICAL LOTION SARNA HC 2.5% TOPICAL LOTION SATIVEX BUCCAL SPRAY SCHINOUSSA PROBIOTIC WHEY ISOLATE ORAL POWDER Route OPH ORL ORL ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL OPH ORL ORL ORL TOP TOP BUC ORL 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. Form SOL TAB TAB TAB TAB SUS SUS CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP SRC TAB SOL TAB SOL CAP TAB TAB LOT LOT SPR PWR MFR Unit of Issue SDZ ML SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ ML SDZ ML SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ TAB SDZ CAP SDZ CAP SDZ CAP SDZ CAP SDZ TAB SDZ ML SDZ TAB SDZ ML SDZ CAP SDZ TAB SDZ TAB GSK ML GSK ML BHP ML QUA G Base Price 3.0540 1.4276 0.4050 0.4777 0.5755 1.3450 1.9980 1.7788 0.6357 1.7788 0.9972 1.2904 0.0604 0.0505 10.0450 8.5375 9.1125 0.5057 0.6251 0.4501 0.6251 0.2087 1.5218 2.0637 9.7490 0.1500 1.8525 1.2580 0.8853 3.2667 0.1407 0.5722 0.4685 0.0938 0.1813 22.9200 0.0357 Pg 96 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001919245 00002020939 00002020793 00000541869 00002242811 00000541877 00002296659 00002346176 00000666106 00000666114 00002288389 00000551805 00000633380 00000554987 00000243000 00000483796 00000709069 00002247134 00002237105 00002257130 00002257149 00002257157 00002357704 00002368633 00002431629 00002247998 00002239046 00002241304 00002241302 00002241303 00002240344 00080039305 00002413299 00002413302 00002413310 00002424320 00002317583 Product Description SCHOLL ATHLETE'S FOOT SPRAY 1% TOPICAL POWDER SCLERODEX INJECTION SCLERODINE 6 INJECTION SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML INJECTION SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION SCOPOLAMINE HYDROBROMIDE 0.6 MG/ML INJECTION SEASONALE (91 DAY) TABLET SEASONIQUE (91 DAY) TABLET SEBCUR 4% TOPICAL SHAMPOO SEBCUR-T TOPICAL SHAMPOO SEBIVO 600 MG TABLET SECARIS NASAL GEL SELENIUM 100 MCG TABLET SELENIUM 50 MCG TABLET SELSUN 2.5% TOPICAL SOLUTION SELSUN BLUE 1% TOPICAL LOTION SELSUN BLUE EXTRA CONDITIONING 1% TOPICAL SHAMPOO SENNA LAXATIVE & DOCUSATE SODIUM 8.6MG/50MG TABLET SENNA LAXATIVE 8.6 MG TABLET SENSIPAR 30 MG TABLET SENSIPAR 60 MG TABLET SENSIPAR 90 MG TABLET SEPTA-AMLODIPINE 2.5 MG TABLET SEPTA-ATENOLOL 25 MG TABLET SEPTA-CITALOPRAM 10 MG TABLET SERC 24 MG TABLET SEROSTIM 5 MG/VIAL INJECTION SERTRALINE 100 MG CAPSULE SERTRALINE 25 MG CAPSULE SERTRALINE 50 MG CAPSULE SIALOR 25 MG TABLET SIERRASIL JOINT FORMULA 14 CAPSULE SIGNIFOR 0.3 MG/ML INJECTION SIGNIFOR 0.6 MG /ML INJECTION SIGNIFOR 0.9 MG /ML INJECTION SILDENAFIL 100 MG TABLET SILDENAFIL 100 MG TABLET Route TOP INJ INJ INJ INJ INJ ORL ORL TOP TOP ORL NAS ORL ORL TOP TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL 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. Form PWR DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB SHP SHP TAB GEL TAB TAB SOL LOT SHP TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL CAP CAP CAP TAB CAP DEFAUL DEFAUL DEFAUL TAB TAB MFR Unit of Issue SCH G OMG ML OMG ML HSP ML OMG ML HSP ML ASC TAB ASC TAB DPT ML DPT ML NOV TAB PMS G JAM TAB JAM TAB ABB ML ABB ML ABB ML VTH TAB SDR TAB AMG TAB AMG TAB AMG TAB SEP TAB SEP TAB SEP TAB ABB TAB SRO VIAL PDL CAP PDL CAP PDL CAP PMS TAB SMM CAP NOV ML NOV ML NOV ML PDL TAB PMS TAB Base Price 0.0490 1.3760 2.7100 5.3400 5.0000 5.8530 0.6813 0.6813 0.0621 0.0682 17.7311 0.3414 0.0764 0.0679 0.0484 0.0251 0.0251 0.0532 0.0249 12.8370 24.4370 34.0623 0.1380 0.1730 0.1432 0.7525 1633.0000 0.4200 0.2004 0.4000 0.9827 0.2349 80.5130 85.5160 85.5160 9.2000 9.4767 Pg 97 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002406160 00002317559 00002317575 00002424312 00002406152 00002398257 00002398265 00080012979 00002338572 00002435411 00002239548 00002413183 00002413175 00002417472 00002247224 00002378892 00002378906 00002378914 00002378884 00002378922 00000326925 00000400750 00001926055 00001938371 00001926004 00001938363 00001994247 00000074225 00000623520 00002245456 00002245457 00000481912 00080022194 00000261998 00000037842 00000060208 00000851388 Product Description SILDENAFIL 100 MG TABLET SILDENAFIL 25 MG TABLET SILDENAFIL 50 MG TABLET SILDENAFIL 50 MG TABLET SILDENAFIL 50 MG TABLET SILENOR 3 MG TABLET SILENOR 6 MG TABLET SILICA WITH ZINC CAPLET SILKIS 3 MCG/G TOPICAL OINTMENT SIMBRINZA 1%/0.2% OPHTHALMIC SUSPENSION SIMPLY SLEEP 25 MG CAPLET SIMPONI 100 MG/1 ML INJECTION AUTO INJECTOR SIMPONI 100 MG/1 ML INJECTION SYRINGE SIMPONI I.V. 50 MG/4.0 ML VIAL INJECTION SIMVASTATIN-80 80 MG TABLET SIMVASTATIN-ODAN 10 MG TABLET SIMVASTATIN-ODAN 20 MG TABLET SIMVASTATIN-ODAN 40 MG TABLET SIMVASTATIN-ODAN 5 MG TABLET SIMVASTATIN-ODAN 80 MG TABLET SINEQUAN 100 MG CAPSULE SINEQUAN 75 MG CAPSULE SINUTAB N.D. REGULAR STRENGTH TABLET SINUTAB NO DROWSINESS EXTRA STRENGTH TABLET SINUTAB REGULAR STRENGTH TABLET SINUTAB WITH CODEINE TABLET SLEEP AID (REGULAR STRENGTH) 25 MGTABLET SLOW K 8 MEQ SUSTAINED-RELEASE TABLET SLOW-FE 160 MG TABLET SODIUM AUROTHIOMALATE INJECTION B.P. 10 MG/ ML SODIUM AUROTHIOMALATE INJECTION B.P. 25 MG/ML SODIUM BICARBONATE 325 MG TABLET SODIUM BICARBONATE 500 MG TABLET SODIUM BICARBONATE 8.4 % INJECTION SODIUM CHLORIDE 0.9% INJECTION SODIUM CHLORIDE 0.9% INJECTION USP SODIUM CHLORIDE 0.9% NASAL SPRAY Route ORL ORL ORL ORL ORL ORL ORL ORL TOP OPH ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL INJ INJ INJ NAS 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. Form TAB TAB TAB TAB TAB TAB TAB TAB ONT SUS TAB NDL NDL DEFAUL TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB SRT SRT DEFAUL DEFAUL TAB TAB DEFAUL DEFAUL DEFAUL SPR MFR Unit of Issue SNS TAB PMS TAB PMS TAB PDL TAB SNS TAB PAL TAB PAL TAB JAM TAB GAL G ALC ML MCL TAB JAI SYR JAI SYR JAI ML PDL TAB ODN TAB ODN TAB ODN TAB ODN TAB ODN TAB ERF CAP ERF CAP WLA TAB WLA TAB WLA TAB PDH TAB TAN TAB NOV TAB CGS TAB SDZ ML SDZ ML SLW TAB SDZ TAB HSP ML HSP ML BAX ML SFY ML Base Price 9.2000 8.5375 9.1133 8.8475 8.8475 0.6417 1.2837 0.2062 1.3648 4.9870 0.2015 1618.1400 1618.1400 225.7175 0.6250 0.3642 0.4501 0.4501 0.1841 0.4501 1.1921 0.9047 0.1808 0.2875 0.2392 0.4063 0.0950 0.1510 0.2890 9.9500 14.0500 0.0329 0.0823 0.5962 0.0994 0.0067 0.0530 Pg 98 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002139510 00000392499 00000402230 00002150204 00000037834 00000402249 00000268313 00000896187 00000028053 00002006758 00002224895 00002224887 00002224879 00002224860 00001988840 00001987682 00002243257 00001923986 00001975382 00002019825 00002230211 00000690333 00000837733 00000769533 00002272199 00002272202 00002272210 00000483818 00002237578 00002237580 00000999031 00000999034 00000999033 00000999035 00002214415 00002435381 00002320193 Product Description SODIUM CHLORIDE 234 MG/ML INJECTION SODIUM CHLORIDE 234 MG/ML INJECTION SODIUM CHLORIDE 234 MG/ML INJECTION USP SODIUM CHLORIDE 9 MG/ML INJECTION SODIUM CHLORIDE 9 MG/ML IRRIGATION SOLUTION SODIUM CHLORIDE BACTERIOSTATIC 9 MG/ML INJECTION SODIUM EDECRIN 50 MG/VIAL INJECTION SODIUM PHOSPHATE INJECTION SODIUM SULAMYD 10% OPH SOLUTION SOFLAX 4 MG/ML ORAL SYRUP SOFRAMYCIN 0.5% OPH OINTMENT SOFRAMYCIN 0.5% OPH SOLUTION SOFRAMYCIN 15 MG/50 MCG TOPICAL OINTMENT SOFRAMYCIN NASAL SPRAY SOFRA-TULLE (10 X 10 CM) TOPICAL GAUZE SOFRA-TULLE STRIP (10 X 30 CM) TOPICAL GAUZE SOLAGE 0.01%/ 2% TOPICAL SOLUTION SOLARCAINE FIRST AID LIDOCAINE 0.5% TOPICAL AEROSO SOLUGEL 4% TOPICAL GEL SOLUGEL 8% TOPICAL GEL SOLU-MEDROL 40 MG/VIAL INJECTION SOLUVER 20% TOPICAL SOLUTION SOLUVER PLUS LIQ 27% SOLYSTAT 250 MG/ML RECTAL SUSPENSION SOMAVERT 10 MG/VIAL INJECTION SOMAVERT 15 MG/VIAL INJECTION SOMAVERT 20 MG/VIAL INJECTION SOMNOL 30 MG TABLET SPASMHALT-8 CAPLET SPASMHALT-ASA-8 CAPLET SPECIAL ACCESS DRUG - DEFLAZACORT SPECIAL ACCESS DRUG - MVW COMPLETE D3000 CHEW TAB SPECIAL ACCESS DRUG - MVW COMPLETE D3000 SOFTGEL SPECIAL ACCESS DRUG - MVW COMPLETE FORMULATION DRP SPECTRO ECZEMACARE MEDICATED CREAM SPIRIVA RESPIMAT 2.5 MCG/ACTUATION INH SOLUTION SPRYCEL 100 MG TABLET Route INJ INJ INJ INJ IR INJ INJ INJ OPH ORL OPH OPH TOP NAS TOP TOP TOP TOP TOP TOP INJ TOP TOP RT INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL TOP INH ORL 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. Form DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL DEFAUL DEFAUL SOL SYR ONT SOL ONT SPR GAU GAU SOL AER GEL GEL DEFAUL SOL SOL RTNENM DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB CTB CAP DPS CRM CTG TAB MFR Unit of Issue PPC ML SDZ ML OMG ML OMG ML HSP ML OMG ML VCL VIAL SDZ ML SDZ ML PMS ML ERF G ERF ML ERF G ERF ML ERF DRE AVE DRE GAL ML SCH G GSK G GSK G PFI VIAL DPT ML DPT ML PPH ENM PFI VIAL PFI VIAL PFI VIAL AXS TAB PPH TAB WAM TAB XXX TAB MVW TAB MVW CAP MVW ML GKC G BOE CTG BMS TAB Base Price 0.3260 4.4075 0.3250 0.3250 0.0224 0.1738 480.2400 0.9847 0.4933 0.0232 4.2160 1.4688 1.0893 3.0940 1.6660 3.8700 1.6933 0.0385 0.2269 0.3480 5.2672 0.8100 1.2960 13.6400 118.4000 177.4200 236.4400 0.1145 0.3693 0.3300 0.3158 0.5168 0.4705 0.8757 0.4400 65.0000 164.4270 Pg 99 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002293129 00002293137 00002293145 00001938991 00001938983 00002245439 00002245438 00002372436 00002139383 00002230192 00002139243 00002139375 00002230191 00002142546 00000402257 00000038245 00002247228 00000578568 00002125277 00002403390 00002262800 00002279355 00002262819 00002262827 00002262835 00002262843 00002279347 00002243660 00000613959 00002174383 00002166615 00080009625 00002167948 00002397137 00002370433 00002391678 00002130939 Product Description SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET SPRYCEL 70 MG TABLET STANHEXIDINE 2% SOL WITH 4% ISOPROPYL ALCOHOL STANHEXIDINE 4% WITH 4% ISOPROPYL ALCOHOL SOLUTION STARLIX 120 MG TABLET STARLIX 60 MG TABLET STAXYN 10 MG ORALLY DISINTEGRATING TABLET STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION STERILE VANCOMYCIN HCL 1 G/VIAL INJECTION STERILE VANCOMYCIN HCL 5 G/VIAL INJECTION STERILE VANCOMYCIN HCL 500 MG/VIAL INJ USP STERILE VANCOMYCIN HCL 500 MG/VIAL INJECTION STERILE WATER FOR INJECTION STERILE WATER FOR INJECTION STERILE WATER FOR INJECTION STIEPROX 1.5 % TOPICAL SHAMPOO STIEVA-A 0.025% TOPICAL SOLUTION STILAMIN 3 MG/AMPOULE INJECTION STIVARGA 40 MG TABLET STRATTERA 10 MG CAPSULE STRATTERA 100 MG CAPSULE STRATTERA 18 MG CAPSULE STRATTERA 25 MG CAPSULE STRATTERA 40 MG CAPSULE STRATTERA 60 MG CAPSULE STRATTERA 80 MG CAPSULE STREPTOMYCIN 1 G/VIAL INJECTION STRESS FORMULA VITAMIN WITH ZINC CAPSULE STRESSEASE MULTIVITAMIN AND MINERAL CAPLET STRESSTABS + ZINC-COPPER TABLET STRESSTABS FOR WOMEN TABLET STRESSTABS PLUS IRON TABLET STRIBILD TABLET SUBLINOX 10 MG SUBLINGUAL DISINTEGRATING TABLET SUBLINOX 5 MG SUBLINGUAL DISINTEGRATING TAB SUCRALFATE-1 1 G TABLET Route ORL ORL ORL TOP TOP ORL ORL ORL INJ INJ INJ INJ INJ DEFAUL DEFAUL DEFAUL TOP TOP INJ ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL SLG SLG ORL 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. Form TAB TAB TAB SOL SOL TAB TAB DISNTAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL INJ INJ INJ SHP SOL DEFAUL TAB CAP CAP CAP CAP CAP CAP CAP DEFAUL CAP TAB TAB TAB TAB TAB DISNTAB DISNTAB TAB MFR Unit of Issue BMS TAB BMS TAB BMS TAB OMG ML OMG ML NOV TAB NOV TAB BAI TAB PPC VIAL HSP VIAL PPC VIAL PPC VIAL HSP VIAL HSP ML OMG ML HSP ML GSK ML GSK ML SRO VIAL BAI TAB LIL CAP LIL CAP LIL CAP LIL CAP LIL CAP LIL CAP LIL CAP STM VIAL WAM CAP JAM TAB WCH TAB PDH TAB WCH TAB GIL TAB MED TAB MED TAB PDL TAB Base Price 38.4053 77.2943 91.1175 0.0104 0.0159 0.6095 0.6001 7.2425 102.3030 78.8900 509.7900 47.7040 45.3370 0.2020 0.3500 0.0950 0.1471 0.1836 210.0000 79.2960 3.0971 5.8450 3.4871 3.8943 4.4704 4.9086 5.3254 89.0000 0.0617 0.1144 0.1078 0.1042 0.1078 50.6540 1.4580 1.4507 0.1309 Pg 100 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002238099 00002237793 00002250217 00001951319 00002244147 00000187534 00002324660 00002324652 00000678996 00080002944 00080011269 00080023127 00002242658 00080017929 00002242595 00002240749 00002239888 00002239886 00002246045 00002280795 00002280809 00002280817 00002245890 00002245889 00002162504 00002162512 00000990010 00000999331 00002248967 00080032792 00002239122 00002365871 00002409607 00002409615 00002304848 00002304856 00002381842 Product Description SUDAFED DECONGESTANT 12-HOUR 120 MG CAPLET SUDAFED DECONGESTANT EXTRA STRENGTH 60 MG TABLET SUDAFED PE DECONGESTANT 10 MG TABLET SUFENTA 50 MCG/ML INJECTION SUFENTANIL CITRATE USP 50 MCG/ML INJECTION SULFUR TOPICAL SOAP SUMATRIPTAN 100 MG TABLET SUMATRIPTAN 50 MG TABLET SUPER B COMPLEX CAPSULE SUPER CALCIUM 600 MG WITH VITAMIN D 400 IU SUPER MULTI IRON FREE TABLET SUPER STRAIN ACIDOPHILUS PROBIOTIC 2 BILLION SUPER STRENGTH MOTRIN IB 400 MG TABLET SUPER VITA VIM CAPLET SUPER VITA-VIM CAPLET SUPREFACT DEPOT 9.45 MG IMPLANT INJECTION SUSTIVA 200 MG CAPSULE SUSTIVA 50 MG CAPSULE SUSTIVA 600 MG TABLET SUTENT 12.5 MG CAPSULE SUTENT 25 MG CAPSULE SUTENT 50 MG CAPSULE SYNAGIS 100 MG/VIAL INJECTION SYNAGIS 50 MG/VIAL INJECTION SYNALAR 0.01% TOPICAL SOLUTION SYNALAR 0.025% TOPICAL OINTMENT SYNVISC SYNVISC ONE SYSTANE OPHTHALMIC SOLUTION SYSTANE VITAMIN- OMEGA 3 CAPSULE T.R. SWISS ONE 50 MULTIVITAMIN & MINERAL TABLET TACTUPUMP 0.1%/2.5% TOPICAL GEL TAFINLAR 50 MG CAPSULE TAFINLAR 75 MG CAPSULE TAMIFLU 30 MG CAPSULE TAMIFLU 45 MG CAPSULE TAMIFLU 6 MG/ML ORAL SUSPENSION Route ORL ORL ORL INJ INJ TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL INJ INJ TOP TOP DEFAUL DEFAUL OPH ORL ORL TOP ORL ORL ORL ORL ORL 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. Form TAB TAB TAB DEFAUL DEFAUL SOP TAB TAB CAP TAB TAB CAP TAB TAB TAB IMP CAP CAP TAB CAP CAP CAP DEFAUL DEFAUL SOL ONT DEV DEV SOL CAP TAB GEL CAP CAP CAP CAP SUS MFR Unit of Issue WLA TAB WLA TAB MCL TAB JAI ML SDZ ML VCL G PDL TAB PDL TAB SIS CAP JAM TAB NFN TAB JAM CAP MCL TAB JAM TAB JAM TAB SAV SYS BMS CAP BMS CAP BMS TAB PFI CAP PFI CAP PFI CAP ABV VIAL ABV VIAL VCL ML VCL G GZB ML GZB ML ALC ML ALC CAP SWS TAB GAL G GSK CAP GSK CAP HLR CAP HLR CAP HLR ML Base Price 0.5140 0.2908 0.3000 6.9320 12.8660 0.0777 7.8600 7.1350 0.2581 0.1650 0.2143 0.1333 0.1956 0.1366 0.1334 1240.8800 5.4403 1.2457 16.3210 66.9068 133.8132 267.6268 1504.5100 752.2600 0.4128 0.4747 65.2750 66.3333 0.8350 0.2287 0.2160 1.5427 45.3889 68.0833 2.2050 3.4230 0.3422 Pg 101 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002241472 00001926624 00002413612 00001962353 00002296039 00002269015 00002269023 00002269007 00000510335 00000344508 00002339609 00002339617 00002339625 00002387425 00002240945 00002238096 00002240946 00002238097 00002365650 00002244403 00002244404 00002353288 00002266938 00002420988 00002264749 00001925350 00002247651 00002368250 00002315874 00002016796 00002177099 00002177080 00002243894 00002243895 00000615358 00001950010 00002246397 Product Description TAMIFLU 75 MG CAPSULE TAMOFEN 10 MG TABLET TAMSULOSIN CR 0.4 MG EXTENDED-RELEASE TABLET TANTAPHEN EXTRA STRENGTH 500 MG CAPLET TAPAZOLE 10 MG TABLET TARCEVA 100 MG TABLET TARCEVA 150 MG TABLET TARCEVA 25 MG TABLET TARGEL SA TOPICAL LIQUID TARGEL TOPICAL GEL TARGIN 10 MG/ 5 MG EXTENDED-RELEASE TABLET TARGIN 20 MG/ 10 MG EXTENDED-RELEASE TABLET TARGIN 40 MG/ 20 MG EXTENDED-RELEASE TABLET TARGIN 5 MG/ 2.5 MG EXTENDED-RELEASE TABLET TARKA 1 MG/ 240 MG TABLET TARKA 2 MG/ 180 MG TABLET TARKA 2 MG/ 240 MG TABLET TARKA 4 MG/ 240 MG TABLET TARO-ANASTROZOLE 1 MG TABLET TARO-CARBAMAZEPINE 100 MG CHEWABLE TABLET TARO-CARBAMAZEPINE 200 MG CHEWABLE TABLET TARO-CICLOPIROX 8% TOPICAL SOLUTION TARO-CLINDAMYCIN 1% (BASE) TOPICAL SOLUTION TARO-DICLOFENAC 1.5% TOPICAL SOLUTION TARO-MOMETASONE 0.1% OINTMENT TARO-SONE 0.05% TOPICAL CREAM TARO-TERCONAZOLE 0.4% VAGINAL CREAM TASIGNA 150 MG CAPSULE TASIGNA 200 MG CAPSULE TAXOL 6 MG/ML INJECTION TAXOTERE 40 MG/ML (20 MG/0.5 ML) INJECTION TAXOTERE 40 MG/ML (80 MG/2 ML) INJECTION TAZORAC 0.05% TOPICAL CREAM TAZORAC 0.1% TOPICAL CREAM TD POLIO ADSORBED FOR ADULT INJECTION TEARS ENCORE 1.4% OPH SOLUTION TEARS NATURAL FORTE OPH SOLUTION Route ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP TOP TOP VAG ORL ORL INJ INJ INJ TOP TOP INJ OPH OPH 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. Form CAP TAB ERT TAB TAB TAB TAB TAB LIQ GEL ERT ERT ERT ERT TAB TAB TAB TAB TAB CTB CTB SOL SOL SOL ONT CRM CRM CAP CAP DEFAUL DEFAUL DEFAUL CRM CRM DEFAUL SOL SOL MFR Unit of Issue HLR CAP SAV TAB PDL TAB TAN TAB PAL TAB HLR TAB HLR TAB HLR TAB ODN G ODN G PUR TAB PUR TAB PUR TAB PUR TAB ABB TAB ABB TAB ABB TAB ABB TAB TAR TAB TAR TAB TAR TAB TAR G TAR ML TAR ML TAR G TAR G TAR G NOV CAP NOV CAP BMS ML SAV ML SAV ML ALL G ALL G AVE VIAL AKN ML ALC ML Base Price 4.4500 0.1750 0.1500 0.0214 0.5947 57.8493 86.7740 13.3333 0.1844 0.1696 1.0548 1.5822 2.7407 0.7567 1.5400 1.5500 1.9025 2.1113 1.2730 0.1224 0.2425 8.4550 0.2853 0.6799 0.2802 0.2110 0.4978 30.0273 42.2425 1.9802 456.9400 456.9400 1.4850 1.4850 64.7400 0.9710 0.4140 Pg 102 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001943308 00000743445 00000390291 00002082519 00000579408 00000283991 00002420201 00002395223 00002395231 00002395525 00002395533 00002261553 00002261545 00002241095 00002321262 00002312794 00002312816 00002241094 00002241096 00002241093 00000875988 00000894710 00002130874 00000894729 00002242735 00000632317 00000632295 00002280248 00002246063 00000514462 00002148528 00002248251 00002403633 00002326043 00002326051 00002326078 00002313049 Product Description TEARS NATURALE FREE OPH SOLUTION TEARS NATURALE II OPH SOLUTION TEARS NATURALE OPH DROPS TEARS NATURALE P.M. OPH OINTMENT TEARS PLUS 1.4% OPH SOLUTION TEBRAZID 500 MG TABLET TECFIDERA 240 MG DELAYED-RELEASE CAPSULE TELMISARTAN 40 MG TABLET TELMISARTAN 80 MG TABLET TELMISARTAN-HCTZ 80 MG/12.5 MG TABLET TELMISARTAN-HCTZ 80 MG/25 MG TABLET TELZIR 50 MG/ML ORAL SUSPENSION TELZIR 700 MG TABLET TEMODAL 100 MG CAPSULE TEMODAL 100 MG/VIAL INJECTION TEMODAL 140 MG CAPSULE TEMODAL 180 MG CAPSULE TEMODAL 20 MG CAPSULE TEMODAL 250 MG CAPSULE TEMODAL 5 MG CAPSULE TEMPRA INFANT 80 MG/ML ORAL DROPS TERAZOL 3 80 MG VAGINAL OVULE TERAZOL 3 DUAL PAK KIT TERAZOL 7 0.4% VAGINAL CREAM TERBINAFINE-250 MG TABLET TERSASEPTIC 0.5% TOPICAL SHAMPOO TERSA-TAR MILD 1% TOPICAL SHAMPOO TESTIM 1% TOPICAL GEL TESTOSTERONE CYPIONATE 100 MG/ML INJECTION USP TETANUS & DIPHTHERIA TOXOIDS ADULT INJECTION TETRACAINE 0.5% OPH SOLUTION (MINIMS) TEVA-ALENDRONATE 5 MG TABLET TEVA-ALENDRONATE/CHOLECALCIFEROL 70 MG/2800 U TAB TEVA-AMITRIPTYLINE 10 MG TABLET TEVA-AMITRIPTYLINE 25 MG TABLET TEVA-AMITRIPTYLINE 50 MG TABLET TEVA-ANASTROZOLE 1 MG TABLET Route OPH OPH OPH OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL VAG VAG/TOP VAG ORL TOP TOP TOP INJ INJ OPH ORL ORL ORL ORL ORL ORL Form SOL SOL DPS ONT SOL TAB DRC TAB TAB TAB TAB SUS TAB CAP DEFAUL CAP CAP CAP CAP CAP DPS OVL OVL/CRM CRM TAB SHP SHP GEL DEFAUL LIQ SOL TAB TAB TAB TAB TAB TAB 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. MFR Unit of Issue ALC ML ALC ML ALC ML ALC G ALL ML VCL TAB BIO CAP PDL TAB PDL TAB PDL TAB PDL TAB GSK ML GSK TAB MFC CAP MFC VIAL MFC CAP MFC CAP MFC CAP MFC CAP MFC CAP PAL ML JAI OVL JAI KIT JAI G PDL TAB GSK ML GSK ML PAL G SDZ ML CNG ML BSH ML TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB Base Price 0.5042 0.4307 0.4193 1.5743 0.5087 0.4980 36.0696 0.2824 0.2824 0.2824 0.2824 0.5912 8.6928 164.9100 411.2600 230.8760 264.3805 32.9840 412.2620 8.3840 0.2653 6.3767 30.4000 0.7589 1.8527 0.0273 0.0367 0.7979 2.3580 46.3520 7.2800 1.0681 4.0725 0.0684 0.1247 0.2417 2.5460 Pg 103 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001912054 00001912062 00002314541 00002362538 00002314568 00002314576 00002314584 00002314592 00002362511 00002380927 00002280205 00002280183 00002398419 00002398400 00002424851 00002424878 00002395576 00002400022 00002400030 00002239355 00002389762 00002382091 00002382105 00002330601 00002377705 00002377713 00002377691 00002408473 00002230089 00002248457 00002247346 00002377969 00002377977 00002377950 00002399806 00002399814 00002316005 Product Description TEVA-ATENOLOL 100 MG TABLET TEVA-ATENOLOL 50 MG TABLET TEVA-ATOMOXETINE 10 MG CAPSULE TEVA-ATOMOXETINE 100 MG CAPSULE TEVA-ATOMOXETINE 18 MG CAPSULE TEVA-ATOMOXETINE 25 MG CAPSULE TEVA-ATOMOXETINE 40 MG CAPSULE TEVA-ATOMOXETINE 60 MG CAPSULE TEVA-ATOMOXETINE 80 MG CAPSULE TEVA-ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET TEVA-BETAHISTINE 24 MG TABLET TEVA-BETAHISTINE 8 MG TABLET TEVA-BOSENTAN 125 MG TABLET TEVA-BOSENTAN 62.5 MG TABLET TEVA-BUPRENORPHINE/NALOXONE 2 MG/0.5 MG SUB TAB TEVA-BUPRENORPHINE/NALOXONE 8 MG/2 MG SUB TAB TEVA-CANDESARTAN/HCTZ 32 MG/25 MG TABLET TEVA-CAPECITABINE 150 MG TABLET TEVA-CAPECITABINE 500 MG TABLET TEVA-DIFENAC-K 50 MG TABLET TEVA-EFAVIRENZ 600 MG TABLET TEVA-ELETRIPTAN 20 MG TABLET TEVA-ELETRIPTAN 40 MG TABLET TEVA-ENALAPRIL 40 MG TABLET TEVA-ERLOTINIB 100 MG TABLET TEVA-ERLOTINIB 150 MG TABLET TEVA-ERLOTINIB 25 MG TABLET TEVA-EXEMESTANE 25 MG TABLET TEVA-FLUTAMIDE 250 MG TABLET TEVA-GABAPENTIN 600 MG TABLET TEVA-GABAPENTIN 800 MG TABLET TEVA-GALANTAMINE ER 16 MG EXTENDED-RELEASE CAPSULE TEVA-GALANTAMINE ER 24 MG EXTENDED-RELEASE CAPSULE TEVA-GALANTAMINE ER 8 MG EXTENDED-RELEASE CAPSULE TEVA-IMATINIB 100 MG TABLET TEVA-IMATINIB 400 MG TABLET TEVA-IRBESARTAN 300 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB CAP CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB SLT SLT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ERC ERC ERC TAB TAB TAB MFR Unit of Issue TEV TAB TEV TAB TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV CAP TEV CAP TEV CAP TEV TAB TEV TAB TEV TAB Base Price 0.2433 0.1480 2.3833 4.4826 2.7320 3.0160 3.4377 3.8133 4.1159 4.5108 0.5441 0.2132 49.5780 49.5780 2.3377 4.1413 0.8985 1.5987 5.3286 0.4055 11.5467 10.3883 10.3883 1.2560 48.8907 73.3360 12.2227 4.0177 1.3530 1.3436 1.7915 1.2467 1.2467 1.2467 21.0693 84.2773 0.3116 Pg 104 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002387247 00002343657 00002258323 00002258315 00002315068 00002315076 00002315084 00002315092 00002261898 00002279894 00002279908 00002279916 00002420260 00002392925 00002352893 00002359707 00002321378 00002321386 00002285479 00002248556 00000869015 00000869023 00000869007 00002274914 00002274922 00002274930 00002269317 00002361205 00002361221 00002361159 00002361248 00002361175 00002361183 00002388359 00002388340 00002413809 00002396688 Product Description TEVA-LAMIVUDINE/ZIDOVUDINE 150 MG/300 MG TABLET TEVA-LETROZOLE 2.5 MG TABLET TEVA-MELOXICAM 15 MG TABLET TEVA-MELOXICAM 7.5 MG TABLET TEVA-METHYLPHENIDATE ER-C 18 MG EXTEND RELEASE TAB TEVA-METHYLPHENIDATE ER-C 27 MG EXTEND RELEASE TAB TEVA-METHYLPHENIDATE ER-C 36 MG EXTEND RELEASE TAB TEVA-METHYLPHENIDATE ER-C 54 MG EXTEND RELEASE TAB TEVA-METOPROL 25 MG TABLET TEVA-MIRTAZAPINE OD 15 MG ORALLY DISINTEGRATING TA TEVA-MIRTAZAPINE OD 30MG ORALLY DISINTEGRATING TAB TEVA-MIRTAZAPINE OD 45MG ORALLY DISINTEGRATING TAB TEVA-MODAFINIL 100 MG TABLET TEVA-NABILONE 0.25 MG CAPSULE TEVA-NEVIRAPINE 200 MG TABLET TEVA-OLANZAPINE 20 MG TABLET TEVA-OLANZAPINE OD 15 MG ORALLY DISINT. TABLET TEVA-OLANZAPINE OD 20 MG ORALLY DISINT. TABLET TEVA-PANTOPRAZOLE 20MG ENTERIC-COATED ORAL TAB TEVA-PAROXETINE 10 MG TABLET TEVA-PINDOLOL 10 MG TABLET TEVA-PINDOLOL 15 MG TABLET TEVA-PINDOLOL 5 MG TABLET TEVA-PIOGLITAZONE 15 MG TABLET TEVA-PIOGLITAZONE 30 MG TABLET TEVA-PIOGLITAZONE 45 MG TABLET TEVA-PRAMIPEXOLE 0.5 MG TABLET TEVA-PREGABALIN 150 MG CAPSULE TEVA-PREGABALIN 225 MG CAPSULE TEVA-PREGABALIN 25 MG CAPSULE TEVA-PREGABALIN 300 MG CAPSULE TEVA-PREGABALIN 50 MG CAPSULE TEVA-PREGABALIN 75 MG CAPSULE TEVA-RAMIPRIL/HCTZ 10 MG/12.5 MG TABLET TEVA-RAMIPRIL/HCTZ 5 MG/12.5 MG TABLET TEVA-RISEDRONATE 150 MG TABLET TEVA-RIZATRIPTAN ODT 10 MG ORALLY DISINT TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB TAB TAB TAB ERT ERT ERT ERT TAB DISNTAB DISNTAB DISNTAB TAB CAP TAB TAB DISNTAB DISNTAB ECT TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB DISNTAB MFR Unit of Issue TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV CAP TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV CAP TEV TAB TEV TAB TEV TAB TEV TAB Base Price 8.0658 2.8387 0.5840 0.5061 1.5588 1.7990 2.0391 2.5193 0.0662 0.2980 0.5963 0.8437 0.9573 1.4380 2.5432 10.3093 5.5160 7.8257 1.3132 1.0743 0.2393 0.3370 0.1402 0.5983 0.8383 1.2604 1.4276 1.7788 1.7788 0.6358 1.7788 0.9973 1.2905 0.2633 0.2070 42.1800 3.8167 Pg 105 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002396661 00002308754 00002308738 00002308746 00002286815 00000851965 00000851973 00002230085 00002230086 00002230087 00001947818 00001947826 00001947796 00002347180 00002357542 00002356643 00002355205 00002355221 00002355191 00002360101 00002360128 00080015438 00002242082 00002248854 00002343045 00002409356 00001916939 00002242275 00002242276 00000576050 00000576034 00000576042 00002414945 00002244826 00000533688 00002241209 00002230640 Product Description TEVA-RIZATRIPTAN ODT 5 MG ORALLY DISINT TABLET TEVA-SILDENAFIL 100 MG TABLET TEVA-SILDENAFIL 25 MG TABLET TEVA-SILDENAFIL 50 MG TABLET TEVA-SUMATRIPTAN DF 25 MG TABLET TEVA-TAMOXIFEN 10 MG TABLET TEVA-TAMOXIFEN 20 MG TABLET TEVA-THEOPHYLLINE SR 100 MG EXTENDED RELEASE TAB TEVA-THEOPHYLLINE SR 200 MG EXTENDED RELEASE TAB TEVA-THEOPHYLLINE SR 300 MG EXTENDED RELEASE TAB TEVA-TIMOLOL 10 MG TABLET TEVA-TIMOLOL 20 MG TABLET TEVA-TIMOLOL 5 MG TABLET TEVA-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET TEVA-VALACYCLOVIR 1000 MG TABLET (CAPLET) TEVA-VALSARTAN 40 MG TABLET THALOMID 100 MG CAPSULE THALOMID 200 MG CAPSULE THALOMID 50 MG CAPSULE THEO ER 400 MG SUSTAINED-RELEASE TABLET THEO ER 600 MG SUSTAINED-RELEASE TABLET THERA TEARS NUTRITION CAPSULE THERATEARS (PRESERVATIVE-FREE) 0.25% OPH SOLUTION THERATEARS 0.25% OPH SOLUTION TICLOPIDINE 250 MG TABLET TIGECYCLINE 50 MG/VIAL INJECTION TIMENTIN 3.1G INJECTION TIMOLOL MALEATE-EX 0.25% OPHTHALMIC SOLUTION TIMOLOL MALEATE-EX 0.5% OPHTHALMIC SOLUTION TINACTIN 1% TOPICAL AEROSOL TINACTIN 1% TOPICAL CREAM TINACTIN 1% TOPICAL POWDER TIVICAY 50 MG TABLET TNKASE 50 MG/VIAL INJECTION TOBRAMYCIN 1.2 G/VIAL INJECTION TOBRAMYCIN 10 MG/ML INJECTION TOBRAMYCIN 40 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OPH ORL INJ INJ OPH OPH TOP TOP TOP ORL INJ INJ INJ INJ 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. Form DISNTAB TAB TAB TAB TAB TAB TAB SRT SRT SRT TAB TAB TAB TAB TAB TAB CAP CAP CAP SRT SRT CAP SOL SOL TAB DEFAUL DEFAUL LAS LAS AER CRM PWR TAB DEFAUL DEFAUL DEFAUL DEFAUL MFR Unit of Issue TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB TEV TAB CLG CAP CLG CAP CLG CAP AAP TAB AAP TAB AVR CAP AVR ML AVR ML SNS TAB APX VIAL GSK VIAL ALC ML ALC ML SCH G SCH G SCH G VIV TAB HLR VIAL PPC VIAL SDZ ML PPC ML Base Price 3.8167 9.4766 8.5375 9.1125 9.2600 0.1803 0.3823 0.1420 0.1390 0.1442 0.2572 0.5005 0.1649 0.6452 3.0531 0.5397 58.9400 117.8800 29.4700 0.3671 0.4446 0.1140 0.6479 0.4927 0.3139 73.5660 10.7520 3.3120 4.2020 0.0554 0.3693 0.0688 19.8873 2724.3000 199.0000 5.1585 3.5310 Pg 106 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002337630 00002337649 00000312762 00002229566 00002221926 00002221934 00000749834 00002390981 00002304104 00002244982 00002244981 00002264846 00002426803 00002429969 00002417502 00002388294 00002246365 00080044392 00080044389 00080044393 00080024336 00000605786 00002164361 00002164388 00002164353 00002230285 00002230284 00002392569 00002392550 00002240000 00002243856 00002229540 00002229550 00000896179 00000789828 00000852163 00000808563 Product Description TOCTINO 10 MG CAPSULE TOCTINO 30 MG CAPSULE TOLBUTAMIDE 500 MG TABLET TOMUDEX 2 MG/VIAL INJECTION TOPICORT 0.05% TOPICAL GEL TOPICORT 0.25% TOPICAL OINTMENT TOPIDERM HC 2% TOPICAL CREAM TOPOTECAN 4 MG / VIAL INJECTION TORISEL 25 MG/ML INJECTION TRACLEER 125 MG TABLET TRACLEER 62.5 MG TABLET TRAMACET 37.5 MG/325 MG TABLET TRAMADOL/ACET 37.5 MG/325 MG TABLET TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET TRAMADOL-ACET 37.5 MG/325 MG TABLET TRAMAPHEN-ODAN 37.5 MG/325 MG TABLET TRANEXAMIC ACID 100 MG/ML INJECTION TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 14 MG TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 21 MG TRANSDERMAL NICOTINE PATCH; NICOTINE PATCH 7 MG TRANSDERM-V 1.5 MG TOPICAL PATCH TRAVEL AID 50 MG TABLET TRAZODONE-100 100 MG TABLET TRAZODONE-150 D 150 MG TABLET TRAZODONE-50 50 MG TABLET TRAZOREL 100 MG TABLET TRAZOREL 50 MG TABLET TREANDA 100 MG/VIAL INJECTION POWDER FOR SOLUTION TREANDA 25 MG/VIAL INJECTION POWDER FOR SOLUTION TRELSTAR 3.75 MG/VIAL INJECTION TRELSTAR LA 11.25 MG/VIAL INJECTION TRIAMCINOLONE ACETONIDE 10 MG/ML INJ. TRIAMCINOLONE ACETONIDE 40MG/ML INJ. TRIAMINIC DM NIGHTIME ORAL SYRUP TRIATEC-30 TABLET TRIATEC-8 TABLET TRIAZO 0.125 MG TABLET Route ORL ORL ORL INJ TOP TOP TOP INJ INJ ORL ORL ORL ORL ORL ORL ORL INJ TRD TRD TRD TOP ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL 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. Form CAP CAP TAB DEFAUL GEL ONT CRM DEFAUL DEFAUL TAB TAB TAB TAB TAB TAB TAB DEFAUL PTH PTH PTH PTH TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SYR TAB TAB TAB MFR Unit of Issue GST CAP GST CAP AAP TAB AZC VIAL VCL G VCL G PAL G SDZ VIAL PFI VIAL ACT TAB ACT TAB JAI TAB SNS TAB SIV TAB PDL TAB ODN TAB SDZ ML APH PTH APH PTH APH PTH NOV PTH WTR TAB PDL TAB PDL TAB PDL TAB ICN TAB ICN TAB LUI VIAL LUI VIAL ASC VIAL ASC VIAL SDZ ML SDZ ML NVC ML TLI TAB TLI TAB AAP TAB Base Price 23.6393 24.0117 0.1189 324.6200 0.5392 0.6952 0.3620 567.0000 1278.9100 70.0786 68.9920 0.8342 0.6264 0.6264 0.6264 0.6264 3.8860 2.1500 2.1500 2.1500 4.1400 0.0720 0.0989 0.1453 0.0554 0.3956 0.2214 1250.0000 312.5000 373.3800 1120.1800 2.8600 5.5000 0.0502 0.1300 0.0473 0.1496 Pg 107 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002296381 00002296403 00002296411 00002242067 00002242068 00002244673 00002242069 00000517895 00002432927 00002432943 00002432919 00080002067 00002407833 00002430932 00002244757 00000511226 00080015078 00002148536 00080000383 00002274906 00000317268 00001967932 00001970240 00002151138 00001916971 00001916963 00080019103 00002230578 00002237548 00002285401 00002326442 00002246060 00001933728 00002238885 00000743224 00000890677 00000743275 Product Description TRIDURAL 100 MG EXTENDED-RELEASE TABLET TRIDURAL 200 MG EXTENDED-RELEASE TABLET TRIDURAL 300 MG EXTENDED-RELEASE TABLET TRILEPTAL 150 MG TABLET TRILEPTAL 300 MG TABLET TRILEPTAL 60 MG/ML ORAL SUSPENSION TRILEPTAL 600 MG TABLET TRINALIN REPETABS SUSTAINED-RELEASE TABLET TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET TRIPLE STRENGTH ODOURLESS GARLIC SOFTGEL CAPSULE TRISENOX 1 MG/ML AMPOULE INJECTION TRIUMEQ TABLET TRIZIVIR TABLET TROMBOJECT 30 MG/ML INJECTION TROPHIC KRILL OIL CAPSULE TROPICAMIDE 1% OPH SOLUTION (MINIMS) TRUEHOPE EMP CAPSULE TRUVADA 200 MG/300 MG TABLET TUBERSOL TUBERCULIN PPD 5 TUB INJECTION TUMS EXTRA STRENGTH 750 MG CHEWABLE TABLET TUMS REGULAR 500 MG CHEWABLE TABLET TUMS ULTRA STRENGTH 1G CHEWABLE TABLET TUSSIONEX ORAL SUSTAINED-RELEASE SUSPENSION TUSSIONEX TABLET TUZEN CAPSULE TWINRIX INJECTION SYRINGE TWINRIX JUNIOR 0.5 ML INJECTION SYRINGE TYGACIL 50 MG/VIAL INJECTION TYKERB 250 MG TABLET TYLENOL 8 HOUR 650 MG EXTENDED-RELIEF CAPLET TYLENOL ALLERGY SINUS EXTRA STRENGTH CAPLET TYLENOL ARTHRITIS PAIN 650 MG EXT-RELIEF CAPLET TYLENOL CHILDRENS COLD CHEWABLE TABLET TYLENOL COLD DM JUNIOR STRENGTH CHEWABLE TABLET TYLENOL COLD EXTRA STRENGTH CAPLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL INJ ORL OPH ORL ORL INJ ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL 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. Form ERT ERT ERT TAB TAB SUS TAB SRT TAB TAB TAB CAP DEFAUL TAB TAB DEFAUL CAP SOL CAP TAB DEFAUL CTB CTB CTB SRSUS SRT CAP NDL NDL DEFAUL TAB ERT TAB ERT CTB CTB TAB MFR Unit of Issue PAL TAB PAL TAB PAL TAB NOV TAB NOV TAB NOV ML NOV TAB SCH TAB LBC TAB LBC TAB LBC TAB VCL CAP LBC ML VIV TAB GSK TAB OMG ML MTA CAP BSH ML TRU CAP GIL TAB AVE ML SKB TAB SKB TAB SKB TAB SAV ML SAV TAB FEI CAP GSK SYR GSK SYR PFI VIAL GSK TAB MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB Base Price 1.3327 2.4299 3.5308 0.9038 0.9938 0.3614 1.9878 0.6535 3.0071 3.2650 2.8261 0.0460 53.0000 41.3833 19.5687 5.2415 0.4237 6.6667 0.2087 29.9047 168.7300 0.0469 0.0469 0.0525 0.3606 1.8031 0.8300 51.8200 25.9100 86.2690 25.2626 0.1762 0.2850 0.1662 0.1763 0.2590 0.2850 Pg 108 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000743267 00002276259 00000574007 00000743283 00002290510 00000863270 00000663980 00002347792 00002241361 00002181061 00000559393 00000723894 00000778400 00002163942 00002242727 00002130955 00080022377 00001966294 00002418282 00080015173 00080006259 00080033880 00080011779 00080011780 00002237698 00080004965 00002349469 00002324113 00000626724 00000632783 00001962728 00001946994 00000116866 00001946099 00000398179 00001946102 00000503134 Product Description TYLENOL COLD EXTRA STRENGTH N.D. CAPLET TYLENOL COLD EXTRA STRENGTH NIGHTTIME TABLET TYLENOL COLD REGULAR STRENGTH CAPLET TYLENOL COLD REGULAR STRENGTH N.D. CAPLET TYLENOL EXTRA STR. BACK PAIN 400 MG/500 MG TABLET TYLENOL EXTRA-STRENGTH GELCAPS 500 MG CAPSULE TYLENOL EXTRA-STRENGTH SINUS MEDICATION CAPLET TYLENOL FASTMELTS JUNIOR STRENGTH 160 MG CHEW TAB TYLENOL JUNIOR STRENGTH 160 MG SOFT CHEW TABLET TYLENOL NO.1 WITH CODEINE TABLET TYLENOL REGULAR STRENGTH 325 MG TABLET TYLENOL REGULAR STRENGTH 325 MG TABLET TYLENOL SINUS CAPLET TYLENOL WITH CODEINE ELIXIR TYPHERIX 25 MCG/0.5 ML INJECTION SYRINGE TYPHIM VI 50 MCG/ML INJECTION UDO'S CHOICE SUPER 8 PLUS PROBIOTIC ULONE 5 MG ORAL SYRUP ULTIBRO BREEZHALER 110 MCG/50 MCG INH CAPSULE ULTIMATE FLORA CRITICAL CARE 50 BILLION ULTIMATE OMEGA FACTORS 3-6-9 SOFT GEL CAPSULE ULTRA C 1000 TABLET ULTRA FLORA PLUS CAPSULE ULTRA FLORA PLUS; ULTRA FLORA BALANCE ULTRA STRENGTH PHAZYME 180 MG CAPSULE ULTRA-FIBER SUPPLEMENT CHEWABLE TABLET ULTRAM 50 MG TABLET ULTRAQUIN 4% HYDROQUINONE CREAM WITH SUNSCREENS ULTRAQUIN 4% TOPICAL GEL ULTRAQUIN PLAIN 4% CREAM ULTRAVATE 0.05% TOPICAL OINTMENT UNISOM-2 NIGHTTIME SLEEP AID TAB 25 MG URASAL GRANULES ORAL EFFERVESCENT POWDER UREMOL 10 10% TOPICAL CREAM UREMOL 20% TOPICAL CREAM UREMOL-10 10% TOPICAL LOTION UREMOL-HC TOPICAL CREAM Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL INH ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP TOP ORL ORL TOP TOP TOP TOP 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. Form TAB TAB TAB TAB TAB CAP TAB CTB CTB TAB TAB TAB TAB ELX NDL DEFAUL CAP SYR CAP CAP CAP TAB CAP CAP CAP TAB TAB CRM GEL CRM ONT TAB EVP CRM CRM LOT CRM MFR Unit of Issue MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB MCL CAP MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB MCL TAB JAI ML GSK SYR CNG ML FMD CAP MMH ML NOV CAP RLC CAP NFN CAP MTG TAB MTG CAP MTG CAP CBF CAP AAM TAB JAI TAB SAH G SAH G SAH G VCL G PDH TAB AXS G GKC G GKC G GKC ML GSK G Base Price 0.2850 0.3180 0.2004 0.2012 0.5100 0.1383 0.4783 0.2850 0.2700 0.1730 0.1500 0.1279 0.2004 0.1059 23.8000 52.9600 0.9900 0.1406 2.9263 1.1665 0.2387 0.3135 0.4116 0.4167 0.2221 0.0917 0.7835 1.7333 1.0600 0.8667 0.9744 0.2040 0.1138 0.0815 0.0860 0.0456 0.1746 Pg 109 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000560022 00080005531 00002353997 00001914022 00002241411 00080030062 00000177016 00000232351 00000013285 00002367742 00002367750 00002384523 00002366940 00002367726 00002367734 00002384760 00002384779 00002367777 00002367785 00002367769 00002246559 00002394634 00002407922 00002407930 00002394626 00002407914 00002243837 00002229702 00002241047 00002246081 00002139502 00002223929 00002308487 00002273985 00002339269 00002339242 00002339250 Product Description UREMOL-HC TOPICAL LOTION URISEC 40 40% TOPICAL CREAM UROCIT-K 10 MEQ EXTENDED-RELEASE TABLET UROCIT-K 5 MEQ TABLET UROMITEXAN 100 MG/ML INJECTION UTI CLEANSE TABLET VALISONE-G TOPICAL CREAM VALISONE-G TOPICAL OINTMENT VALIUM 5 MG TABLET VALSARTAN 160 MG TABLET VALSARTAN 320 MG TABLET VALSARTAN 40 MG TABLET VALSARTAN 40 MG TABLET VALSARTAN 40 MG TABLET VALSARTAN 80 MG TABLET VALSARTAN HCT 320 MG/12.5 MG TABLET VALSARTAN HCT 320 MG/25 MG TABLET VALSARTAN-HCTZ 160 MG/12.5 MG TABLET VALSARTAN-HCTZ 160 MG/25 MG TABLET VALSARTAN-HCTZ 80 MG/12.5 MG TABLET VALTREX 1000 MG CAPLET VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJ USP VANCOMYCIN HYDROCHLORIDE 1 G/VIAL INJECTION VANCOMYCIN HYDROCHLORIDE 5 G/VIAL INJECTION VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJ USP VANCOMYCIN HYDROCHLORIDE 500 MG/VIAL INJECTION VANIQA 13.9% TOPICAL CREAM VAQTA 50 U/ML INJECTION VARILRIX 2000 UNITS/(0.5 ML) VIAL INJECTION VARIVAX III VACCINE 1350 U/VIAL INJECTION VASOPRESSIN 20 UNIT/ML INJECTION VAXIGRIP INFLUENZA VACCINE INJECTION VECTIBIX 20 MG/ML (5 ML VIAL) INJECTION VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAP VENLAFAXINE XR 150 MG EXTENDED-RELEASE CAPSULE VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE Route TOP TOP ORL ORL INJ ORL TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ TOP INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL 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. Form LOT CRM ERT SRT DEFAUL TAB CRM ONT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CRM DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL ERC ERC ERC ERC MFR Unit of Issue GSK ML ODN G PAL TAB SFD TAB AST ML AOR TAB VCL G VCL G HLR TAB PDL TAB PDL TAB SIV TAB SNS TAB PDL TAB PDL TAB SIV TAB SIV TAB PDL TAB PDL TAB PDL TAB GSK TAB SDZ VIAL MYP VIAL MYP VIAL SDZ VIAL MYP VIAL ALM G MSD ML GSK VIAL MFC VIAL PPC ML CNG ML AMG ML PMS CAP PDL CAP PDL CAP PDL CAP Base Price 0.0982 1.4000 0.5733 0.3729 6.4890 0.4416 1.0977 1.0977 0.1819 0.3330 0.3330 0.5240 0.5239 0.4080 0.3330 0.3253 0.3253 0.3330 0.3330 0.3330 7.5195 60.7600 58.9900 509.7900 31.9820 31.0500 2.6117 48.9600 62.7900 79.4100 19.8300 8.3500 124.9900 0.3573 0.8868 0.4200 0.8399 Pg 110 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002243716 00002226286 00002243115 00000616192 00080033844 00000839299 00002166739 00002348489 00002411849 00000594601 00002145839 00002163691 00000717002 00000717029 00002239768 00002239766 00002239767 00002273330 00001938959 00002050684 00001935747 00002351064 00002336707 00002244596 00002244597 00002244598 00002244599 00002417685 00002252260 00002427184 00002361701 00002361728 00002401460 00002183056 00002183013 00002143305 00000074500 Product Description VENOFER 20 MG/ML INJECTION VENOMIL YELLOW JACKET VENOM PROTEIN 120 MCG INJ VENTOLIN DISKUS 200 MCG/DOSE PWDR FOR INHAL VEPESID 50 MG CAPSULE VERALAC HYDROSOLUBLE NAIL LACQUER VERAPAMIL HYDROCHLORIDE 2.5 MG/ML INJECTION VERAPAMIL HYDROCHLORIDE USP 2.5 MG/ML INJECTION VERDESO 0.05% TOPICAL FOAM VEREGEN 10% TOPICAL OINTMENT VERSEL 2.5% TOPICAL LOTION VESANOID 10 MG CAPSULE VEXOL 1% OPH SOLUTION VIADERM K.C. TOPICAL CREAM VIADERM K.C. TOPICAL OINTMENT VIAGRA 100 MG TABLET VIAGRA 25 MG TABLET VIAGRA 50 MG TABLET VICKS CHILDREN'S NYQUIL COLD & COUGH ORAL LIQUID VICKS FORMULA 44 ORAL LIQUID VICKS NYQUIL ADULT NIGHTTIME COLD MEDICINE ORL LIQ VICKS VAPORUB TOPICAL OINTMENT VICTOZA 6 MG/ML PEN INJECTION SYRINGE VIDAZA 100 MG/VIAL INJECTION VIDEX EC 125 MG CAPSULE (ENTERIC-COATED BEADLETS) VIDEX EC 200 MG CAPSULE (ENTERIC-COATED BEADLETS) VIDEX EC 250 MG CAPSULE (ENTERIC-COATED BEADLETS) VIDEX EC 400 MG CAPSULE (ENTERIC-COATED BEADLETS) VIDEXTRA 10,000 UNIT TABLET VIGAMOX 0.5% OPHTHALMIC SOLUTION VIMIZIM 5MG/5ML (SINGLE-USE) VIAL INJECTION VIMOVO 375 MG/20 MG TABLET VIMOVO 500 MG/20 MG TABLET VINBLASTINE SULPHATE 1 MG/ML INJECTION VINBLASTINE SULPHATE 1 MG/ML INJECTION VINCRISTINE SULFATE 1 MG/ML INJECTION VINCRISTINE SULPHATE 1 MG/ML INJECTION VIOFORM HC TOPICAL CREAM Route INJ INJ INH ORL TOP INJ INJ TOP TOP TOP ORL OPH TOP TOP ORL ORL ORL ORL ORL ORL TOP INJ INJ ORL ORL ORL ORL ORL OPH INJ ORL ORL INJ INJ INJ INJ TOP Form DEFAUL DEFAUL MIP CAP SOL DEFAUL DEFAUL FOA ONT LOT CAP SUS CRM ONT TAB TAB TAB LIQ LIQ LIQ ONT DEFAUL DEFAUL CAP/ENCP CAP/ENCP CAP/ENCP CAP/ENCP TAB SOL DEFAUL TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL CRM 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. MFR Unit of Issue LPI ML BAI VIAL GSK DOSE BMS CAP VCL ML HSP ML SDZ ML GSK G PAL G VCL ML CAG CAP ALC ML TAR G TAR G PFI TAB PFI TAB PFI TAB PGI ML PGI ML PGI ML PGI G NNA ML CLG VIAL BMS CAP BMS CAP BMS CAP BMS CAP ORI TAB ALC ML BMI VIAL AZC TAB AZC TAB TEV ML MNP ML HSP ML TEV ML PAL G Base Price 8.1894 195.0000 0.2105 41.9875 3.8939 19.1500 20.8560 0.3215 4.3847 0.0759 17.6153 3.8900 0.4623 0.6807 10.0462 9.0525 9.6612 0.0277 0.0341 0.0276 0.0779 29.5633 628.0000 4.0667 6.5073 8.0607 13.0403 0.2500 4.8133 1199.0000 1.1723 1.1678 17.6790 18.5630 63.3650 31.0000 0.9613 Pg 111 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002238617 00002248761 00002238748 00002367289 00080030855 00000568627 00000568635 00000443174 00000417289 00000417270 00002242367 00080016590 00080016683 00002245911 00002240199 00080028004 00080016576 00000123137 00002245311 00000297720 00080035590 00000487082 00000294853 00002239350 00000407011 00000816078 00080009633 00000610267 00002023598 00000331015 00000450642 00002241500 00080012952 00002237736 00002230932 00080006939 00080003575 Product Description VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VIRAMUNE 200 MG TABLET VIRAMUNE XR 400 MG EXTENDED-RELEASE TABLET VISION CARE CAPSULE VISKAZIDE 10/25 MG TABLET VISKAZIDE 10/50 MG TABLET VISKEN 10 MG TABLET VISKEN 15 MG TABLET VISKEN 5 MG TABLET VISUDYNE 15 MG/VIAL INJECTION VITALUX CAPLET VITALUX PLUS OMEGA 3 CAPSULE VITALUX TABLET VITALUX TR MULTIVITAMIN/MULTIMINERAL TABLET VITALUX-S PLUS OMEGA-3 CAPSULE VITALUX-S TABLET VITAMIN A & D FORTIFIED CAPSULE VITAMIN A 10,000 IU CAPSULE VITAMIN A 10,000 IU CAPSULE VITAMIN B 100 MG TIME RELEASE TABLET VITAMIN B CMPD 100 SUSTAINED-RELEASE TABLET VITAMIN B1 100 MG TABLET VITAMIN B1 100 MG TABLET VITAMIN B1 100 MG TABLET VITAMIN B1 100 MG/ML INJECTION USP VITAMIN B1 50 MG TABLET VITAMIN B1 50 MG TABLET VITAMIN B12 100 MCG TABLET VITAMIN B12 100 MCG TABLET VITAMIN B12 100 MCG TABLET VITAMIN B12 100 MCG/ML INJECTION VITAMIN B12 1000 MCG TABLET VITAMIN B12 1000 MCG TABLET VITAMIN B12 1000 MCG TABLET VITAMIN B12 1000 MCG TABLET VITAMIN B12 1000 MCG TIME RELEASE TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL 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. Form TAB TAB TAB ERT CAP TAB TAB TAB TAB TAB DEFAUL TAB CAP TAB TAB CAP TAB CAP CAP CAP TAB SRT TAB TAB TAB DEFAUL TAB TAB TAB TAB TAB DEFAUL TAB TAB TAB TAB ERT MFR Unit of Issue AGR TAB PFI TAB BOE TAB BOE TAB PLT CAP NOV TAB NOV TAB NOV TAB NOV TAB NOV TAB VCL VIAL ALC TAB ALC CAP NOV TAB NCI TAB ALC CAP ALC TAB JAM CAP WNP CAP JAM CAP WNP TAB SWS TAB VCL TAB PMT TAB JAM TAB SDZ ML JPC TAB LEA TAB PMT TAB JAM TAB VTH TAB SDZ ML JAM TAB SWS TAB WES TAB WNP TAB PMT TAB Base Price 2.0276 5.0689 5.3923 2.4690 0.8991 0.9780 0.9780 0.9979 1.4476 0.6281 1859.6700 0.2374 0.2268 0.2430 0.2430 0.3059 0.2374 0.0482 0.0260 0.0471 0.1575 0.1732 0.0900 0.0214 0.0910 2.8690 0.0781 0.0740 0.0568 0.0601 0.0700 2.1760 0.1439 0.0840 0.0771 0.1370 0.0512 Pg 112 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00000626112 00000502758 00000335940 00000305243 00002243767 00000689726 00000528846 00000329185 00002239348 00000122645 00000331031 00000305227 00000341207 00000305235 00080040321 00001922378 00002243893 00001994336 00000237116 00000373699 00002163268 00000036188 00002240883 00000463108 00080001870 00080017530 00080000436 00080006264 00000323179 00000765384 00002240858 00080002452 00002229879 00002242175 00080009578 00002240624 00080018025 Product Description VITAMIN B12 1000 MCG/ML VITAMIN B12 250 MCG TABLET VITAMIN B12 250 MCG TABLET VITAMIN B12 50 MCG TABLET VITAMIN B12 500 MCG TABLET VITAMIN B12 500 MCG TABLET VITAMIN B6 100 MG TABLET VITAMIN B6 100 MG TABLET VITAMIN B6 100 MG TABLET VITAMIN B6 25 MG TABLET VITAMIN B6 250 MG TABLET VITAMIN B6 50 MG TABLET VITAMIN C 1000 MG SUSTAINED-RELEASE TABLET VITAMIN C 1000 MG TABLET VITAMIN C 125 MG GUMMY VITAMIN C 500 MG TABLET VITAMIN C 500 MG CHEWABLE TABLET VITAMIN C 500 MG CHEWABLE TABLET VITAMIN C 500 MG ORANGE FLAVORED CHEWABLE TABLET VITAMIN C 500 MG SUSTAINED-RELEASE CAPSULE VITAMIN C 500 MG TABLET VITAMIN C 500 MG TABLET VITAMIN C 500 MG TABLET VITAMIN C CHEWABLE TABLET VITAMIN D 1,000 IU TAB VITAMIN D 1000 IU CAPSULE VITAMIN D 1000 IU TABLET VITAMIN D 1000 IU TABLET VITAMIN D 1000 UNIT TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D 400 IU TABLET VITAMIN D DROPS 400 IU Route INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SRT TAB DEFAUL TAB CTB CTB CTB SRC TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB LIQ MFR Unit of Issue OMG ML SWS TAB JAM TAB JAM TAB VTH TAB SNS TAB HAL TAB JAM TAB PMT TAB JAM TAB JAM TAB JAM TAB JAM TAB JAM TAB JAM PIECE SWS TAB PMT TAB JAM TAB TEV TAB JAM CAP JAM TAB WAM TAB WNP TAB GAH TAB SIS TAB JAM CAP JAM TAB GFR TAB SWS TAB LCO TAB PMT TAB WNP TAB SWS TAB JAM TAB VCL TAB WAM TAB JAM ML Base Price 0.3100 0.1397 0.0686 0.0556 0.0465 0.0741 0.0300 0.0686 0.0228 0.0336 0.1114 0.0514 0.1152 0.0867 0.1325 0.0479 0.0333 0.0640 0.0257 0.1025 0.0512 0.0400 0.0359 0.0970 0.0440 0.0446 0.0471 0.0500 0.0305 0.0400 0.0117 0.0284 0.0398 0.0465 0.0249 0.0161 0.9316 Pg 113 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00080015280 00080012124 00002245842 00080003663 00000480924 00000122823 00000332348 00000122831 00000266108 00000480940 00002240967 00000782181 00000332356 00000122858 00000330191 00002015293 00000201995 00080030153 00000480878 00000816175 00002417995 00002248361 00000013765 00000885975 00002307073 00002307065 00002290375 00002338580 00000881635 00002381966 00002352303 00002357119 00080037590 00002365561 00080006877 00080008041 00002344025 Product Description VITAMIN D3 1000 IU CAPSULE VITAMIN D3 1000 IU ORAL LIQUID VITAMIN D3 1000 IU TABLET VITAMIN D3 1000 IU TABLET VITAMIN E 100 IU NATURAL SOURCE CAPSULE VITAMIN E 100 IU OBLONG AMBER CAPSULE VITAMIN E 200 IU CAPSULE (NATURAL) VITAMIN E 200 IU NATURAL SOURCE CAPSULE VITAMIN E 400 IU CAPSULE VITAMIN E 400 IU CAPSULE VITAMIN E 400 IU CAPSULE VITAMIN E 400 IU CAPSULE VITAMIN E 400 IU CAPSULE (NATURAL) VITAMIN E 400 IU NATURAL SOURCE CAPSULE VITAMIN E 800 IU NATURAL SOURCE CAPSULE VITAMIN E NATURAL SOURCE 400 UNIT CAPSULE VITAMIN E NF NATURAL SOURCE 400 IU CAPSULE VITAMIN K2 100 MCG CAPSULE VITAMINE B12 1200 MCG SUSTAINED-RELEASE TABLET VITAMINE C 600 MG CAPSULE VITAMINE D 10 000 10000 UNIT TABLET VIVAXIM INJECTION VIVOL 5 MG TABLET VIVOTIF BERNA 6 B CAPSULE VOLIBRIS 10 MG TABLET VOLIBRIS 5 MG TABLET VOLTAREN EMULGEL 1.16% TOPICAL GEL VOLTAREN EMULGEL JOINT PAIN 1.16% TOPICAL GEL VOLTAREN RAPIDE 50 MG TABLET VORICONAZOLE 200 MG/VIAL INJECTION VOTRIENT 200 MG TABLET VPRIV 400 UNIT/VIAL INJECTION VSL #3 ORAL POWDER VYLOMA 3.75% TOPICAL CREAM WAMPOLE MINERAL CALCIUM ORAL LIQUID WAMPOLE MULTIVITAMIN LIQUID WARFARIN 1 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL TOP TOP ORL INJ ORL INJ ORL TOP ORL ORL ORL 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. Form GEL LIQ TAB TAB CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP SRT CAP TAB DEFAUL TAB CAP TAB TAB GEL GEL TAB DEFAUL TAB DEFAUL PWR CRM LIQ LIQ TAB MFR Unit of Issue VTH CAP WBP ML PMT TAB WNP TAB VTH CAP JAM CAP LDL CAP JAM CAP PMT CAP VTH CAP WNP CAP VTH CAP LDL CAP JAM CAP JAM CAP QVS CAP WAM CAP NFN CAP JAM TAB SIS CAP PDL TAB SFP SYR AXS TAB SSV CAP GSK TAB GSK TAB NVC G NVC G NOV TAB SDZ VIAL GSK TAB SHG VIAL FEI PCKT VCL G JPC ML WAM ML SNS TAB Base Price 0.0400 0.2064 0.0178 0.0347 0.0468 0.0676 0.0629 0.0870 0.0542 0.0741 0.1100 0.0816 0.0539 0.1346 0.2982 0.0592 0.1165 0.1248 0.1432 0.2112 0.2100 88.1200 0.0858 6.3000 122.5200 122.5200 0.1297 0.1185 0.9977 142.0400 36.9908 1955.0000 3.3480 42.2213 0.0378 0.0378 0.0780 Pg 114 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002344114 00002344033 00002344041 00002344068 00002344076 00002344084 00001948970 00080002343 00001949004 00002136740 00002384256 00002384264 00000723770 00000813958 00002423898 00002238453 00002238454 00002240325 00002404044 00002368153 00002388316 00000866598 00000866601 00000509906 00002407329 00000800694 00000001791 00000385484 00000001821 00002373130 00000001732 00000036641 00000049816 00002268272 00002321157 00002387433 00001948954 Product Description WARFARIN 10 MG TABLET WARFARIN 2 MG TABLET WARFARIN 2.5 MG TABLET WARFARIN 3 MG TABLET WARFARIN 4 MG TABLET WARFARIN 5 MG TABLET WASP VENOM PROTEIN 1.1 MG WELLESSE JOINT MOVEMENT GLUCOSAMINE LIQUID WHITE FACED HORNET VENOM 120 MCG WOBENZYM N TABLET XALKORI 200 MG CAPSULE XALKORI 250 MG CAPSULE XANAX 1 MG TABLET XANAX TS 2 MG TABLET XELJANZ 5 MG TABLET XELODA 150 MG TABLET XELODA 500 MG TABLET XENICAL 120 MG CAPSULE XERESE 5%/1% TOPICAL CREAM XGEVA 120 MG/VIAL INJECTION XIAFLEX 0.9 MG/VIAL INJECTION X-SEB PLUS CONDITIONING TOPICAL SHAMPOO X-SEB T PLUS CONDITIONING TOPICAL SHAMPOO X-SEB T TOPICAL SHAMPOO XTANDI 40 MG CAPSULE X-TAR TOPICAL SHAMPOO XYLOCAINE 1% W EPINEPHRINE 1:100,000 INJ XYLOCAINE 2% TOPICAL JELLY XYLOCAINE 2% W EPINEPHRINE 1:100,000 INJ XYLOCAINE 2% W EPINEPHRINE 1:200,000 INJECTION XYLOCAINE HCL 1% LIQUID (BLOCK OR INFILTRATION) XYLOCAINE HCL 2% PLAIN LIQ (BLOCK OR INFILTRATION) XYLOCAINE HYDROCHLORIDE 4% TOPICAL SOLUTION XYREM 500 MG/ML ORAL SOLUTION YAZ 28 TABLET YAZ PLUS 28 TABLET YELLOW JACKET VENOM PROTEIN 1.1 MG Route ORL ORL ORL ORL ORL ORL INJ ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP INJ INJ TOP TOP TOP ORL TOP INJ URH INJ ORL INJ INJ TOP ORL ORL ORL INJ 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. Form TAB TAB TAB TAB TAB TAB DEFAUL LIQ DEFAUL TAB CAP CAP TAB TAB TAB TAB TAB CAP CRM DEFAUL DEFAUL SHP SHP SHP CAP SHP DEFAUL JEL DEFAUL DEFAUL LIQ LIQ SOL SOL TB TB DEFAUL MFR Unit of Issue SNS TAB SNS TAB SNS TAB SNS TAB SNS TAB SNS TAB ALG VIAL BOT ML ALG VIAL MUC TAB PFI CAP PFI CAP PFI TAB PFI TAB PFI TAB HLR TAB HLR TAB HLR CAP VCL G AMG VIAL ACT VIAL BAK ML BAK ML PMS ML ASP CAP DLX ML AZC ML AZC ML AZC ML AZC VIAL AZC ML AZC ML AZC ML VCL ML BAI TAB BAI TAB ALG VIAL Base Price 0.1187 0.0825 0.0660 0.1023 0.1023 0.0662 41.4833 0.0284 35.6833 0.3497 157.6667 157.6667 0.6072 1.0624 25.2198 2.0162 6.7208 1.7743 7.6680 610.1600 1120.0000 0.0639 0.0639 0.0639 30.4708 0.0676 0.3930 0.9858 0.2670 0.4171 1.0100 1.2099 0.1700 2.6370 0.6179 0.4618 35.6833 Pg 115 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00001948962 00002379384 00000428833 00000795283 00000885533 00001901885 00000600784 00002279223 00002242324 00002230287 00000568392 00000568406 00000568414 00002250519 00002410702 00002246740 00000237213 00002380242 00002361752 00002361760 00002361744 00002216086 00002216094 00002216108 00002216116 00002240358 00002240357 00000297666 00000441589 00000505463 00001922351 00000480886 00002239162 00002239160 00002153432 00002153440 00002239952 Product Description YELLOW JACKET VENOM PROTEIN 120 MCG YERVOY INTRAVENOUS INFUSION 5 MG/ML INJECTION YF-VAX 109648 U/0.5 ML INJECTION YOCON 5.4 MG TABLET YOHIMBINE-ODAN 2 MG TABLET YOHIMBINE-ODAN 5.4 MG TABLET ZADITEN 0.2 MG/ML ORAL SYRUP ZADITOR (PRESERVATIVE FREE) 0.25 MG/ML OPH SOL ZADITOR 0.25 MG/ML OPH SOLUTION ZANTAC 75 MG TABLET ZAPEX 10 MG TABLET ZAPEX 15 MG TABLET ZAPEX 30 MG TABLET ZAVESCA 100 MG CAPSULE ZAXINE 550 MG TABLET Z-BEC STRESSTABS TABLET ZEASORB MEDICATED TOPICAL POWDER ZELBORAF 240 MG FILM-COATED TABLET ZENHALE 100 MCG/5 MCG/DOSE METERED DOSE AEROSOL ZENHALE 200 MCG/5 MCG/DOSE METERED DOSE AEROSOL ZENHALE 50 MCG/5 MCG/DOSE METERED DOSE AEROSOL ZERIT 15 MG CAPSULE ZERIT 20 MG CAPSULE ZERIT 30 MG CAPSULE ZERIT 40 MG CAPSULE ZIAGEN 20 MG/ML ORAL SOLUTION ZIAGEN 300 MG TABLET ZINC 10 MG TABLET ZINC 25 MG TABLET ZINC 50 MG TABLET ZINC 50 MG TABLET ZINC 50 MG TIMED RELEASE TABLET ZINCOFAX 15% TOPICAL OINTMENT ZINCOFAX EXTRA STRENGTH 40% TOPICAL OINTMENT ZINECARD 250 MG/VIAL INJECTION ZINECARD 500 MG/VIAL INJECTION ZITHROMAX 500 MG/VIAL INJECTION Route INJ INJ INJ ORL ORL ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL TOP ORL INH INH INH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP INJ INJ INJ 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. Form DEFAUL DEFAUL DEFAUL TAB TAB TAB SYR SOL SOL TAB TAB TAB TAB CAP TAB TAB PWR TAB AEM AEM AEM CAP CAP CAP CAP SOL TAB TAB TAB TAB TAB TAB ONT ONT DEFAUL DEFAUL DEFAUL MFR Unit of Issue ALG VIAL BMS ML SFP VIAL GLE TAB ODN TAB ODN TAB TEV ML NOV ML NOV ML GSK TAB RIV TAB RIV TAB RIV TAB ACT CAP SLX TAB WCH TAB GSK G HLR TAB MFC DOSE MFC DOSE MFC DOSE BMS CAP BMS CAP BMS CAP BMS CAP GSK ML GSK TAB JAM TAB JAM TAB JAM TAB SWS TAB JAM TAB PDH G PDH G PFI VIAL PFI VIAL PFI VIAL Base Price 35.6833 5800.0000 128.2080 0.5568 0.4957 0.7338 0.4886 3.5283 5.7780 0.4300 0.0350 0.0550 0.0750 108.5500 7.6775 0.1653 0.1450 50.0327 0.7983 0.9675 0.6194 4.9580 5.1555 5.3777 5.6630 0.4568 7.3845 0.0501 0.0669 0.0754 0.0466 0.0929 0.0795 0.0631 137.0600 274.1400 23.5150 Pg 116 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002231143 00002354802 00000884324 00002240332 00002421550 00002327619 00002379929 00002379988 00002248992 00002315939 00002375516 00000740306 00002004240 00000634506 00001911627 00002039524 00000569771 00000800686 00002354772 00002340445 00002342804 00002342790 00002257270 00002338106 00002338114 00002338068 00002338092 00002345676 00002303329 00002303337 00002302659 00002302667 00002325179 00002325187 00002344440 00002344459 00002320754 Product Description ZITHROMAX 600 MG TABLET ZMAX SR 27 MG/ML ORAL SUPENSION ZOCOR 5 MG TABLET ZOCOR 80 MG TABLET ZOLEDRONIC ACID 4 MG/5 ML INJECTION ZOLINZA 100 MG CAPSULE ZOLMITRIPTAN 2.5 MG TABLET ZOLMITRIPTAN ODT 2.5 MG ORALLY DISPERSIBLE TABLET ZOMIG 2.5 MG NASAL SPRAY ZOSTAVAX 19,400 UNITS/(0.65 ML) VIAL INJECTION ZOSTAVAX II 19,400 UNITS/(0.65 ML) VIAL INJECTION ZOSTRIX 0.025% TOPICAL CREAM ZOSTRIX H.P. 0.075% TOPICAL CREAM ZOVIRAX 200 MG TABLET ZOVIRAX 400 MG TABLET ZOVIRAX 5% TOPICAL CREAM ZOVIRAX 5% TOPICAL OINTMENT Z-PLUS TOPICAL SHAMPOO ZUACTA 0.075% TOPICAL CREAM ZYCLARA 3.75% TOPICAL CREAM ZYM-AMLODIPINE 10 MG TABLET ZYM-AMLODIPINE 5 MG TABLET ZYMAR 0.3% OPHTHALMIC SOLUTION ZYM-CARVEDILOL 12.5 MG TABLET ZYM-CARVEDILOL 25 MG TABLET ZYM-CARVEDILOL 3.125 MG TABLET ZYM-CARVEDILOL 6.25 MG TABLET ZYM-CLONAZEPAM 0.5 MG TABLET ZYM-CLONAZEPAM 1 MG TABLET ZYM-CLONAZEPAM 2 MG TABLET ZYM-FLUOXETINE 10 MG CAPSULE ZYM-FLUOXETINE 20 MG CAPSULE ZYM-MIRTAZAPINE 15 MG TABLET ZYM-MIRTAZAPINE 30 MG TABLET ZYM-ONDANSETRON 4 MG TABLET ZYM-ONDANSETRON 8 MG TABLET ZYM-PIOGLITAZONE 15 MG TABLET Route ORL ORL ORL ORL INJ ORL ORL ORL NAS INJ INJ TOP TOP ORL ORL TOP TOP TOP TOP TOP ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL 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. Form TAB SUS TAB TAB DEFAUL CAP TAB DISPTAB SPU DEFAUL DEFAUL CRM CRM TAB TAB CRM ONT SHP CRM CRM TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB MFR Unit of Issue PFI TAB PFI ML MFC TAB MFC TAB HSP ML MFC CAP PDL TAB PDL TAB AZC DOSE MFC VIAL MFC VIAL GEU G GEU G GSK TAB GSK TAB VCL G VCL G DLX ML SAV G VCL G ZMC TAB ZMC TAB ALL ML ZMC TAB ZMC TAB ZMC TAB ZMC TAB ZMC TAB ZMC TAB ZMC TAB ZMC CAP ZMC CAP ZMC TAB ZMC TAB ZMC TAB ZMC TAB ZMC TAB Base Price 12.0693 0.5812 1.0840 2.6114 415.5600 76.1795 5.3333 5.3333 15.6450 157.5000 185.5200 0.2312 0.2953 1.4253 2.6715 14.5200 14.5210 0.1009 1.9592 43.4880 0.3587 0.2417 2.8740 0.8001 0.8001 0.8001 0.8001 0.1166 0.1860 0.2010 1.1773 1.0112 0.3750 0.7800 7.5453 11.5170 1.5716 Pg 117 of 118 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2015 DIN/ PIN/ NPN 00002320762 00002320770 00002303817 00002303779 00002303809 00002325144 00002325152 00002325136 00002238851 00002243088 00002243089 00002371065 00002360349 00002286424 00002286432 00002286440 00002286459 00002360322 00002243685 00002243686 Product Description ZYM-PIOGLITAZONE 30 MG TABLET ZYM-PIOGLITAZONE 45 MG TABLET ZYM-SERTRALINE 100 MG (BASE) CAPSULE ZYM-SERTRALINE 25 MG (BASE) CAPSULE ZYM-SERTRALINE 50 MG (BASE) CAPSULE ZYM-TOPIRAMATE 100 MG TABLET ZYM-TOPIRAMATE 200 MG TABLET ZYM-TOPIRAMATE 25 MG TABLET ZYPREXA 20 MG TABLET ZYPREXA ZYDIS 15 MG ORALLY DISINTEGRATING TABLET ZYPREXA ZYDIS 20 MG ORALLY DISINTEGRATING TABLET ZYTIGA 250 MG TABLET ZYTRAM XL 100 MG EXTENDED-RELEASE TABLET ZYTRAM XL 150 MG CONTROLLED-RELEASE TABLET ZYTRAM XL 200 MG CONTROLLED-RELEASE TABLET ZYTRAM XL 300 MG CONTROLLED-RELEASE TABLET ZYTRAM XL 400 MG CONTROLLED-RELEASE TABLET ZYTRAM XL 75 MG EXTENDED-RELEASE TABLET ZYVOXAM 2 MG/ML INJECTION ZYVOXAM 20 MG/ML ORAL SUSPENSION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL 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. Form TAB TAB CAP CAP CAP TAB TAB TAB TAB DISNTAB DISNTAB TAB ERT CRT CRT CRT CRT ERT DEFAUL SUS MFR Unit of Issue ZMC TAB ZMC TAB ZMC CAP ZMC CAP ZMC CAP ZMC TAB ZMC TAB ZMC TAB LIL TAB LIL TAB LIL TAB JAI TAB PUR TAB PUR TAB PUR TAB PUR TAB PUR TAB PUR TAB PFI ML PFI ML Base Price 2.2017 3.3105 1.1025 0.5040 1.0080 1.2537 1.9845 0.6615 15.4557 11.6957 15.3343 31.8103 1.1717 1.7472 2.2930 3.3303 4.3677 0.9172 0.3446 2.7184 Pg 118 of 118
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