docProducts and Pricing on the Alberta Blue Cross Drug Price List
download 
Report Transcription
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, 2014 DIN/ PIN/ NPN 00002192691 00002192683 00002247825 00002162113 00002166607 00000437999 00002351463 00080013172 00002412942 00002414619 00002414627 00002414600 00001919385 00001919393 00001919407 00002281066 00002245677 00002364174 00002364182 00002364190 00002364204 00002364212 00002364220 00001922246 00000095494 00002341107 00002341093 00002164396 00002164418 00002164426 00002230435 00001999648 00000374148 00000605751 00000789798 00001905864 00002272482 00000706221 00002028174 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-AMINOSALICYLIC ACID 400 MG ENTERIC COATED TABLET 5-HTP 100 MG CAPSULE ABBOTT-CLOPIDOGREL 75 MG TABLET ABBOTT-TOPIRAMATE 100 MG TABLET ABBOTT-TOPIRAMATE 200 MG TABLET ABBOTT-TOPIRAMATE 25 MG TABLET ABENOL 120 MG RECTAL SUPPOSITORY ABENOL 325 MG RECTAL SUPPOSITORY ABENOL 650 MG RECTAL SUPPOSITORY 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-AMLODIPINE 10 MG TABLET ACCEL-AMLODIPINE 5 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 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 Route ORL ORL ORL TOP TOP INJ ORL ORL ORL ORL ORL ORL RT RT RT INJ TOP SLG SLG SLG SLG SLG SLG ORL ORL ORL ORL ORL ORL ORL RT ORL ORL ORL ORL ORL ORL ORL ORL Form LIQ TAB TAB ALCGEL LOT DEFAUL ECT CAP TAB TAB TAB TAB SUP SUP SUP DEFAUL CRM SLT SLT SLT SLT SLT SLT TAB TAB TAB TAB TAB TAB TAB SUP TAB TAB TAB TAB DPS ERT 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 GSK ML GSK TAB GSK TAB CLC G NVC ML BAX ML SNS TAB VTH CAP ABB TAB ABB TAB ABB TAB ABB TAB PPH SUP PPH SUP PPH SUP CLG VIAL GKC G PAL TAB PAL TAB PAL TAB PAL TAB PAL TAB PAL TAB PPH TAB DTC TAB ACP TAB ACP TAB PDL TAB PDL TAB PDL TAB PPH SUP PMS TAB WAM TAB WTR TAB TLI TAB TLI ML PRI TAB WTR TAB PPH TAB Base Price 0.3411 5.2548 10.5097 0.2327 0.1984 0.0055 0.3972 0.2000 0.6576 0.3128 0.8853 0.3128 0.5417 0.7258 0.8258 971.0000 7.2100 11.8410 13.4050 16.0750 18.2640 24.3640 30.4510 0.0510 0.0592 0.3587 0.2417 0.0787 0.1177 0.2466 0.8325 0.1413 0.0184 0.0326 0.0444 0.1300 0.0755 0.0258 0.0458 Pg 1 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00001905856 00002255251 00000605778 00002252813 00001904132 00001958836 00002143933 00002025337 00002251914 00000834319 00000834300 00001999656 00002300435 00002247551 00080011789 00002404095 00002297310 00002238302 00002249405 00002309009 00002316838 00002370417 00002248722 00002369362 00002236926 00002281074 00002240255 00002352044 00002313766 00002313774 00002313782 00000266507 00002290081 00002401347 00002338327 00002248809 00002248810 00002248811 00002248812 Product Description 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 ORAL SOLUTION FOR CHILDREN USP ACETAMINOPHEN WITH CODEINE CAPLET ACETAMINOPHEN WITH CODEINE TABLET ACETAMINOPHEN, CAFFEINE & 8 MG CODEINE PHOS. TAB ACETAZONE FORTE C-8 TABLET ACETAZONE FORTE TABLET ACET-CODEINE 60 MG TABLET ACETYLCYSTEINE 20% INHALATION SOLUTION ACID REDUCER 75 MG TABLET ACIDOPHILUS WITH BIFIDUS CAPSULE ACT OLAPATADINE 0.2% OPHTHALMIC SOLUTION ACT PRAMIPEXOLE 0.5 MG TABLET 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 ACUVAIL 0.45% OPHTHALMIC SOLUTION 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 Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL OPH ORL ORL ORL ORL ORL ORL OPH OPH INJ TOP INJ INJ ORL ORL ORL TOP TOP INJ ORL ORL ORL ORL ORL Form TAB TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB TAB SOL TAB CAP SOL TAB TAB TAB TAB TAB DRT SOL SOL DEFAUL GEL DEFAUL DEFAUL ERT ERT ERT LIQ GEL DEFAUL TAB ERC ERC ERC ERC This document is for pricing use only and should 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 TLI PMT WTR PMT TAN TLI ROG PMS PMT RPH RPH PMS ALV PMS WNP APH APH PFI NNA NNA ASC ASC ALL ALL PPC VCL SFP SFP BAI BAI BAI ODN ODN STG LIL SHB SHB SHB SHB Unit of Issue TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB TAB ML TAB CAP ML TAB TAB TAB TAB TAB TAB ML ML ML G ML ML TAB TAB TAB ML ML VIAL TAB CAP CAP CAP CAP Base Price 0.1000 0.0660 0.0390 0.0621 0.0179 0.0296 0.0460 0.0458 0.0396 0.4740 0.3586 0.1504 1.6500 0.1313 0.1133 10.4520 1.3860 0.3246 2.1657 2.1657 60.6400 13.7875 3.5820 1.6754 12.5840 1.1350 60.4600 40.4640 0.7123 0.6704 1.0186 0.0302 0.1738 96.8000 14.6664 2.6537 2.9723 3.2910 3.6096 Pg 2 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002248813 00002248808 00002412764 00002412772 00002412799 00002412802 00002412810 00002071002 00002296462 00002296470 00002296489 00080025646 00002270447 00002270439 00001933558 00002036312 00002248645 00002244577 00002248231 00001933531 00002246403 00002241769 00002242522 00002243919 00002339528 00002369257 00002339501 00002243542 00002346850 00002236859 00000888230 00002408848 00002387468 00002407922 00002407930 00002407914 00000001147 00000433519 00002254506 Product Description 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 2MG/ML INJECTION ADVAGRAF 0.5 MG EXTENDED-RELEASE CAPSULE ADVAGRAF 1 MG EXTENDED-RELEASE CAPSULE ADVAGRAF 5 MG EXTENDED-RELEASE CAPSULE 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 AGENERASE 150 MG CAPSULE AGRIFLU INJECTION SYRINGE AGRYLIN 0.5 MG CAPSULE A-HYDROCORT 100 MG/VIAL INJECTION AJ-CISATRACURIUM 2MG/ML WITH PRESERVATIVE INJ AJ-LABETALOL 5 MG/ML INJECTION AJ-VANCOMYCIN 1 G/VIAL INJECTION AJ-VANCOMYCIN 5 G/VIAL INJECTION AJ-VANCOMYCIN 500 MG/VIAL INJECTION ALBALON 0.1% OPH SOLUTION ALBALON-A OPH SOLUTION ALDURAZYME 0.58 MG/ML INJECTION Route 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 INJ ORL INJ INJ INJ INJ INJ INJ OPH OPH INJ Form ERC ERC TAB TAB TAB TAB TAB DEFAUL ERC ERC ERC CAP TAB TAB TAB TAB TAB TAB CAP TAB CTB CAP DPS TAB TAB TAB TAB CAP DEFAUL CAP DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL SOL 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 SHB SHB BAI BAI BAI BAI BAI PFI ASP ASP ASP AOR SUN SUN PDH PDH PDH PDH PDH PDH PDH PDH PDH SCH NOV NOV NOV GSK NVD SHB HSP AJP AJP AJP AJP AJP ALL ALL GZM Unit of Issue CAP CAP TAB TAB TAB TAB TAB ML CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB CAP TAB TAB CAP ML TAB TAB TAB TAB CAP SYR CAP VIAL ML ML VIAL VIAL VIAL ML ML ML Base Price 3.9285 2.3351 42.7500 42.7500 42.7500 42.7500 42.7500 12.1800 1.9700 2.7090 13.5664 0.2941 1.3900 1.2400 0.1970 0.3820 0.4300 0.2806 0.3742 0.1471 0.3235 0.2708 0.3327 1.0320 188.7900 202.9493 202.9493 1.9200 9.3000 6.2100 3.4500 2.1652 1.5105 95.7130 509.7900 50.3750 0.6220 0.5760 1045.0000 Pg 3 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002381478 00002301733 00080014418 00002253437 00000004715 00002231462 00002242819 00002239853 00002146142 00002176483 00000271411 00001949454 00000764647 00002141728 00002240266 00000804193 00002097583 00002097575 00002369656 00002240265 00002364689 00000555681 00002130157 00000555703 00000569801 00002241407 00000893560 00002381710 00002381729 00080005881 00002248151 00001908189 00001908170 00002248706 00002241680 00002320924 00002281112 00002245272 00002245273 Product Description ALENDRONATE SODIUM 5 MG TABLET ALEVE 220 MG 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 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 FORMULA 25 MG CAPLET ALLERGY RELIEF 10 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 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 Route ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL OPH 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 Form TAB TAB CAP DEFAUL TAB TAB TAB SRT ELX TAB CAP TAB SOL TAB TAB ELX TAB TAB TAB TAB TAB TAB TAB TAB LIQ SOL SOL DEFAUL CAP CAP SOL TAB TAB TAB DEFAUL SUS CAP/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 AHI BAI PGI LIL GSK SAV SAV SAV ROG ROG VCL TAN BSH PRI APX ROG ROG ROG ROG APX PMS PDL PDL PDL ATL ALL ALC EIS EIS WNP ALL PDL PDL PDL TEV BSH SAV SAV SAV Unit of Issue TAB TAB CAP VIAL TAB TAB TAB TAB ML TAB CAP TAB ML TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB ML ML ML ML CAP CAP ML TAB TAB TAB ML ML CAP TAB TAB Base Price 1.0371 0.2240 0.9179 2988.2900 1.7894 0.4092 0.8017 0.5490 0.0342 0.2198 0.1303 0.1125 0.1887 0.1200 0.4083 0.0457 0.3033 0.4750 0.5120 0.4083 0.4080 0.0780 0.1300 0.2125 0.0179 6.8460 1.2140 18.0000 71.7200 0.1107 3.7640 0.0609 0.0728 0.2092 185.0000 6.0440 1.2725 1.0017 1.0900 Pg 4 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002245274 00002241630 00002230575 00002259052 00000870943 00002242971 00000370991 00000371009 00000456349 00002326795 00000638064 00002326523 00002125862 00002124971 00000606987 00000613495 00001933477 00002221861 00002245345 00002245346 00002249499 00000874019 00002268825 00002280361 00000566756 00000566748 00000695351 00002222132 00001945939 00001945920 00001945912 00001945904 00000621447 00000621439 00002248424 00002231379 00080017904 00080005832 00002229873 Product Description AMARYL 4 MG TABLET AMBISOME 50 MG/VIAL INJECTION AMETOP 4% TOPICAL GEL AMEVIVE 15 MG/VIAL INJECTION 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 AMOSAN 68.6% MOUTHWASH AMOXI-CLAV 875 MG/125 MG TABLET AMPHOJEL 320 MG/5ML ORAL LIQUID AMPHOJEL 600 MG TABLET ANACIN CAPLET ANACIN EXTRA STRENGTH CAPLET ANACIN TABLET 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 ANTHELIOS XL SPF 60 TOPICAL CREAM ANTHRAFORTE 1 1% TOPICAL OINTMENT ANTHRAFORTE 2 2% TOPICAL OINTMENT ANTHRASCALP 0.4% TOPICAL LOTION 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 AOR CHROMIUM PICOLINATE 600 MCG CAPSULE AOR N.A.C. 500 MG CAPSULE APO-ACETAMINOPHEN 325 MG CAPLET Route ORL INJ TOP INJ ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP INJ ORL TOP TOP TOP TOP TOP RT RT RT RT TOP RT RT ORL ORL ORL ORL Form TAB DEFAUL GEL DEFAUL TAB DEFAUL TAB TAB TAB TAB MWH TAB LIQ TAB TAB TAB TAB TAB GEL GEL GEL DEFAUL TAB CRM ONT ONT LOT ONT ONT SUP ONT SUP ONT SUP ONT TAB CAP CAP 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 SAV TAB ASP VIAL SNE G BIO VIAL PDL TAB SDZ ML PDL TAB PDL TAB PDL TAB PDL TAB OLB ML PDL TAB AXC ML AUP TAB WHH TAB WHH TAB WCH TAB SAV TAB ABB G ABB G ABB G HLR ML BAI TAB LRP G MPQ G MPQ G STI ML CHD G WLA G WLA SUP WLA G WLA SUP SDZ G SDZ SUP SDZ G SAV TAB AOR CAP AOR CAP APX TAB Base Price 1.1667 121.0000 3.1467 890.0000 0.0838 23.3440 0.0435 0.0829 0.1540 0.1380 0.3340 1.0008 0.0191 0.1338 0.0661 0.0996 0.0814 2.4062 0.9693 0.8570 0.9793 5.6956 0.8500 0.1772 0.3696 0.8066 0.7000 0.0616 0.1557 0.4483 0.1863 0.5625 0.1250 0.4433 0.1173 29.5953 0.1333 0.1375 0.0354 Pg 5 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000544981 00002248727 00002243611 00002243612 00002411318 00002411326 00002411334 00002411342 00002411253 00002411261 00002411288 00002411296 00002288559 00002374420 00000510696 00000472476 00002318024 00002318083 00002318032 00002318040 00002318059 00002318067 00002318075 00002239044 00002296063 00002301334 00002242504 00000682047 00000682039 00002365340 00001999559 00000402699 00002231603 00000399302 00000312711 00002298953 00002263130 00002274744 00002274752 Product Description APO-ACETAMINOPHEN 325 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-BENZYDAMINE 0.15% ORAL RINSE APO-BICALUTAMIDE 50 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 6.25 MG TABLET APO-CARBAMAZEPINE 200 MG TABLET APO-CETIRIZINE 10 MG TABLET APO-CHLORPROPAMIDE 100 MG TABLET APO-CHLORPROPAMIDE 250 MG TABLET APO-CICLOPIROX 8% TOPICAL SOLUTION APO-CIPROFLOX 0.3% OPHTHALMIC SOL. APO-CLARITHROMYCIN 250 MG TABLET APO-CLARITHROMYCIN 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 OPH NAS ORL ORL ORL ORL ORL ORL ORL ORL TOP OPH ORL ORL Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SUS TAB ECT ECT CAP CAP CAP CAP CAP CAP CAP RNS TAB SOL SPR TAB TAB TAB TAB TAB TAB TAB TAB SOL SOL 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 APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB CAP CAP CAP CAP CAP CAP CAP ML TAB ML ML TAB TAB TAB TAB TAB TAB TAB TAB G ML TAB TAB Base Price 0.0354 1.0370 0.3368 0.5985 0.9194 1.0234 1.0624 1.0624 0.7551 0.8591 0.8981 0.8981 0.1969 2.7667 0.1537 0.2500 2.5147 4.7290 2.8820 3.1818 3.6270 4.0232 4.3423 0.0464 4.0573 1.8830 24.5720 0.0282 0.0700 0.3693 0.1344 0.0795 0.4083 0.0810 0.0826 8.4150 1.9120 0.4479 1.7705 Pg 6 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000868957 00002243433 00002354403 00002296055 00002386054 00002386062 00002339099 00002339102 00002292025 00002292041 00002292068 00000545031 00001912518 00002294745 00002293358 00002293366 00000885754 00002295377 00002295385 00002295393 00000396796 00000396818 00000463698 00000396826 00000396834 00002327856 00000441643 00002355337 00002355345 00000611158 00000611166 00002246084 00002369052 00002369060 00002375540 00002358514 00002261995 00002243880 00002248974 Product Description APO-CLONIDINE 0.2 MG TABLET APO-DICLO RAPIDE 50 MG TABLET APO-DICLOFENAC 1.5% TOPICAL SOLUTION APO-DORZOLAMIDE 2% OPHTHALMIC SOLUTION APO-ELETRIPTAN 20 MG TABLET APO-ELETRIPTAN 40 MG TABLET APO-ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET APO-ESOMEPRAZOLE 40 MG DELAYED-RELEASE 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-GABAPENTIN 600 MG TABLET APO-GABAPENTIN 800 MG TABLET APO-GAIN 2% TOPICAL SOLUTION 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-HALOPERIDOL 2 MG TABLET APO-HALOPERIDOL 5 MG TABLET APO-HYDRO 12.5 MG TABLET APO-IBUPROFEN 200 MG TABLET APO-IMATINIB 100 MG TABLET APO-IMATINIB 400 MG TABLET APO-INDOMETHACIN 25 MG CAPSULE APO-INDOMETHACIN 50 MG CAPSULE APO-IPRAVENT 0.06% NASAL SPRAY 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-LISINOPRIL/HCTZ 20 MG/25 MG TABLET APO-LORATADINE 10 MG TABLET APO-MELOXICAM 15 MG TABLET Route ORL ORL TOP OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL ORL ORL ORL ORL ORL Form TAB TAB SOL SOL TAB TAB DRT DRT TAB TAB TAB TAB TAB SPM TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP SPR TAB 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 APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX Unit of Issue TAB TAB ML ML TAB TAB TAB TAB TAB TAB TAB TAB TAB DOSE TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP ML TAB TAB TAB TAB TAB TAB TAB Base Price 0.3149 0.4278 0.5165 1.6880 10.9583 10.9583 2.0310 2.0309 2.1993 2.9557 4.5943 0.0439 0.0353 0.1989 1.4175 1.8900 0.4956 0.5325 0.5325 0.5325 0.1224 0.1839 0.6378 0.2748 0.4385 0.0367 0.0700 20.4557 81.8228 0.0871 0.1511 1.6193 3.6269 7.2538 8.5094 2.9947 0.3506 0.6810 0.6161 Pg 7 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002248973 00002366487 00002305062 00002258935 00002273950 00000842834 00000842826 00002286610 00002286637 00002352559 00002352567 00002365499 00002365502 00002333015 00002360632 00002360640 00002305054 00002243661 00002284294 00002284308 00002284316 00002366754 00002394766 00002366762 00002394774 00002306530 00002366746 00002394782 00002366789 00002248844 00002292912 00002240907 00000755885 00000755893 00000755877 00002302942 00002302950 00002302977 00002292386 Product Description 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-METOCLOP 10 MG TABLET APO-METOCLOP 5 MG TABLET APO-MIRTAZAPINE 15 MG TABLET APO-MIRTAZAPINE 45 MG TABLET APO-MYCOPHENOLATE 250 MG CAPSULE APO-MYCOPHENOLATE 500 MG TABLET APO-NARATRIPTAN 1 MG TABLET APO-NARATRIPTAN 2.5 MG TABLET 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-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-PRAMIPEXOLE 0.5 MG TABLET Route ORL ORL ORL 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 INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL Form TAB TAB ERT TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB DISNTAB DISNTAB SOL TAB TAB TAB TAB CRT CRT CRT CRT CRT CRT CRT CRT DEFAUL ECT TAB TAB 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 APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.5340 1.7774 0.4273 0.1735 0.1081 0.0583 0.0556 0.4073 1.2223 1.1203 2.2407 8.4338 6.1437 11.2026 5.3553 7.5977 5.6780 0.6892 0.6747 0.9891 1.9781 0.4770 0.5759 0.7156 0.8700 1.2402 0.3423 1.5750 2.2907 37.0808 1.3855 1.1334 0.2524 0.3662 0.1479 0.5000 0.7000 1.0500 1.5061 Pg 8 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000598194 00002394278 00002394286 00002394235 00002394294 00002394243 00002394251 00000402788 00000663719 00000402753 00000402761 00002325381 00002377721 00002248203 00002248201 00002248202 00002418118 00000812404 00000812390 00002136112 00002136120 00000755850 00000755869 00000755842 00002290812 00002336790 00002371510 00002409682 00002409674 00001946323 00002375885 00000723754 00002273322 00002162075 00002391791 00002392356 00002269465 00002269457 00002224135 Product Description APO-PREDNISONE 1 MG TABLET 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 10 MG TABLET APO-PROPRANOLOL 20 MG TABLET APO-PROPRANOLOL 40 MG TABLET APO-PROPRANOLOL 80 MG TABLET APO-RAMIPRIL 15 MG CAPSULE APO-RISEDRONATE 150 MG TABLET APO-SILDENAFIL 100 MG TABLET APO-SILDENAFIL 25 MG TABLET APO-SILDENAFIL 50 MG TABLET APO-SILDENAFIL R 20 MG TABLET APO-TAMOX 10 MG TABLET APO-TAMOX 20 MG TABLET APO-TIAPROFENIC 200 MG TABLET APO-TIAPROFENIC 300 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-TRAMADOL/ACET 37.5 MG/325 MG TABLET APO-VALSARTAN 40 MG TABLET APO-VORICONAZOLE 200 MG TABLET APO-VORICONAZOLE 50 MG TABLET APO-ZIDOVUDINE 100 MG CAPSULE APPRILON 40 MG MODIFIED RELEASE CAPSULE APRESOLINE 20 MG/VIAL INJECTION APTIVUS 250 MG CAPSULE AQUASOL E 50 UNIT/ML ORAL DROPS ARANESP 150 MCG/0.3 ML INJECTION SYRINGE ARANESP 60 MCG/ 0.3 ML INJECTION SYRINGE ARICEPT RDT 10 MG ORALLY DISINTEGRATING TABLET ARICEPT RDT 5 MG ORALLY DISINTEGRATING TABLET ARIMIDEX 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 ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL INJ ORL ORL INJ INJ ORL ORL ORL Form TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP/TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB LAS TAB TAB TAB TAB CAP MRC DEFAUL CAP DPS NDL NDL DISNTAB DISNTAB 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 APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX APX GAL STM BOE NOV AMG AMG PFI PFI AZC Unit of Issue TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB TAB CAP CAP VIAL CAP ML SYR SYR TAB TAB TAB Base Price 0.1035 1.7270 1.7270 0.6173 1.7270 0.9683 1.2529 0.0192 0.0277 0.0348 0.0585 0.9291 44.5000 9.9975 9.0075 9.6150 7.2940 0.1750 0.3500 0.3437 0.3257 0.2835 0.5439 0.1817 2.7300 0.6807 0.5823 12.9808 3.2465 1.3977 2.7168 12.6590 8.2500 0.9336 422.1000 168.8400 5.2889 5.2889 5.5637 Pg 9 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002194155 00080008677 00080015109 00002242705 00002286653 00002229632 00002229570 00000180041 00000036145 00000530336 00002244993 00002046253 00002009013 00002243974 00002238545 00002242281 00002280167 00002352427 00000266086 00002074710 00002150328 00002229967 00002239090 00000293482 00000013668 00000293504 00000293512 00000293490 00000828793 00000828807 00002396904 00002396912 00002396920 00002396939 00002396947 00002346486 00002387891 00002396424 00002346494 Product Description ARISTOSPAN 20 MG/ML INJECTION ARNICA 7% GEL ARNICA GEL-CREAM RUB A535 TOPICAL GEL AROMASIN 25 MG TABLET ARTHRITIS PAIN 650 MG EXTENDED RELIEF TABLET ARTIFICIAL TEARS EXTRA OPH SOLUTION ARTIFICIAL TEARS OPH SOLUTION ASA & CODEINE 8 MG TABLET ASA 325 MG TABLET ASA 325 MG TABLET ASA 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 ASPERCREME CREME RUB 10% TOPICAL CREAM ASPIRIN 325 MG TABLET 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-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 Route INJ TOP TOP ORL ORL OPH OPH ORL ORL 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 ORL ORL ORL ORL Form DEFAUL GEL GEL TAB ERT SOL SOL TAB TAB TAB ECT ECT TAB CTB ECT ECT CTB ECT TAB CRM TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP 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 VLP ML BCI G CHD G PFI TAB VTH TAB PMS ML PPH ML SDR TAB WAM TAB VTH TAB PMS TAB PPH TAB PMS TAB PMS TAB PMS TAB PMS TAB ODN TAB ODN TAB PMT TAB SLL G BAI TAB BAI TAB AZC TAB CHD TAB CHD TAB CHD TAB CHD TAB CHD TAB PDL TAB PDL TAB PDL CAP PDL CAP PDL CAP PDL CAP PDL CAP PDL TAB SIV TAB APX TAB PDL TAB Base Price 6.7000 0.1314 0.0971 5.7363 0.1225 0.3033 0.2927 0.0426 0.0136 0.0273 0.1330 0.0125 0.0605 0.0784 0.0560 0.0977 0.0630 0.0295 0.0300 0.0581 0.1138 0.1037 0.7860 0.0630 0.0586 0.1150 0.1338 0.0756 0.2362 0.1437 1.4040 1.6093 1.7767 2.0250 2.2463 0.3138 0.4160 0.3138 0.3922 Pg 10 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002387905 00002396432 00002346508 00002387913 00002396440 00002387921 00002396459 00002351765 00002299925 00002300699 00002094703 00002148358 00002163713 00002416328 00002332477 00002407256 00002407264 00002407272 00002407280 00002418517 00002418525 00002418495 00002418509 00002418428 00002385627 00002414414 00002411695 00002299801 00002299828 00002299836 00002422867 00002422875 00002318601 00002422212 00002422220 00002384906 00002384914 00002384922 00002405156 Product Description 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-20 20 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 AUBAGIO 14 MG TABLET AURALGAN OTIC SOLUTION AURO-ATORVASTATIN 10 MG TABLET AURO-ATORVASTATIN 20 MG TABLET AURO-ATORVASTATIN 40 MG TABLET AURO-ATORVASTATIN 80 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-EFAVIRENZ 600 MG TABLET AURO-FLUOXETINE 10 MG CAPSULE AURO-LAMIVUDINE/ZIDOVUDINE 150 MG/300 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-MONTELUKAST 4 MG CHEWABLE TABLET AURO-MONTELUKAST 5 MG CHEWABLE TABLET AURO-NEVIRAPINE 200 MG TABLET AURO-OMEPRAZOLE 10 MG DELAYED-RELEASE CAPSULE AURO-OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE AURO-PIOGLITAZONE 15 MG TABLET AURO-PIOGLITAZONE 30 MG TABLET AURO-PIOGLITAZONE 45 MG TABLET AURO-SIMVASTATIN 10 MG TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL INJ OPH NAS ORL 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 Form TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB DEFAUL SOL SPR TAB SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB DISNTAB DISNTAB DISNTAB CTB CTB TAB CAP/SRT CAP/SRT 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 SIV APX PDL SIV APX SIV APX PDL GSK BMG ALV BSH BOE GZS PAL AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR AUR Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB ML TAB ML ML ML TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB Base Price 0.5200 0.3922 0.4216 0.5590 0.4216 0.5590 0.4216 1.0400 9.6892 45.4443 2.7170 6.6667 2.1580 53.4247 0.5657 0.3138 0.3922 0.4216 0.4216 0.3377 0.3377 0.3377 0.3377 8.4984 0.4595 7.8308 0.3750 0.2967 0.5933 0.8900 0.3647 0.5567 2.4690 0.8166 0.4117 0.5809 0.8139 1.2237 0.5057 Pg 11 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002405164 00002405172 00002405148 00002405180 00002363798 00002363801 00002363828 00002360969 00002363372 00002363364 00002363380 00002371413 00002371421 00002360993 00002363895 00002363887 00002363399 00002363402 00002370751 00002370786 00002370735 00002370743 00002362864 00002362848 00002362872 00002362856 00002364255 00002366371 00002366398 00002364719 00002364727 00002360861 00002360888 00002366665 00002366673 00002366703 00002366681 00002364271 00002363488 Product Description AURO-SIMVASTATIN 20 MG TABLET AURO-SIMVASTATIN 40 MG TABLET AURO-SIMVASTATIN 5 MG TABLET AURO-SIMVASTATIN 80 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 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 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 ORL ORL Form 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 TAB TAB CAP CAP TAB TAB ECT ECT SRT SRT 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 AUR AUR AUR AUR AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB ML TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB ML TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.6250 0.6250 0.2556 0.6250 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 1.1001 1.8249 0.4890 0.9780 0.1523 0.1765 0.1902 0.3804 0.7608 0.5706 0.1418 0.5932 Pg 12 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 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 00002371693 00002361027 00002361035 00002362880 00002362899 00002362902 00002364239 00002364247 00002364506 00002364514 00002364859 00002364840 00002364832 00002364824 Product Description 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 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 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 ORL ORL Form 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 TAB TAB TAB TAB TAB TAB TAB TAB 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 AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA Unit of Issue 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 TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 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 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 Pg 13 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002362937 00002298589 00002365820 00002365839 00002365847 00002365855 00002365863 00002247085 00002366304 00002364301 00002364328 00002373467 00002373432 00002373440 00002373459 00002363429 00002363305 00002363321 00002363348 00002363267 00002363291 00002363275 00002363283 00002364816 00002367173 00002367181 00002367203 00002364344 00002367211 00002367238 00002367246 00002363682 00002363674 00002270994 00002366266 00002366258 00002366231 00002370980 00002370999 Product Description 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 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 Route ORL NAS 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 ORL ORL ORL ORL Form 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 TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB DEFAUL TAB TAB ERT 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 AVA GSK AVA AVA AVA AVA AVA GSK AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA HLR AVA AVA AVA AVA AVA Unit of Issue TAB DOSE 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 ML TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB Base Price 0.6944 0.2276 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 4.8169 0.2615 0.4379 0.6048 0.7727 1.2075 1.8113 2.4150 0.5771 0.4922 135.8325 9.8433 8.9350 0.2700 1.2537 1.9845 Pg 14 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002370972 00002367130 00002367149 00002367114 00002367122 00002367084 00002367076 00002367092 00002367106 00002367068 00002237792 00002243741 00002363534 00002363542 00002317508 00002241416 00002237770 00002382369 00002284642 00002284650 00000598577 00000598569 00000123803 00080007498 00080002409 00002245512 00001927906 00000876488 00000584908 00000030708 00002152584 00002152592 00000037818 00002243425 00002244010 00000436895 00001908855 00002369613 00002369621 Product Description 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 AVONEX (30 MCG) 6 MILLION IU/VIAL INJECTION AXIRON 2% TOPICAL SOLUTION AZILECT 0.5 MG TABLET AZILECT 1.0 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 Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL TOP TOP INJ TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP INJ ORL ORL INJ ORL ORL ORL TOP ORL ORL Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB NDL NDL TAB TAB CRM PWR DEFAUL SOL TAB TAB TAB TAB TAB TAB TAB CAP CAP ONT ONT DEFAUL TAB TAB DEFAUL SRT SYR SYR SOL 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 AVA AVA AVA AVA AVA AVA AVA AVA AVA AVA SFP SFP AVA AVA JJI JJI BIO LIL TMP TMP JAM JAM JAM WBP WNP WNP ERF PMS PPH PFI PDL PDL HSP PMT ROG ROG WSD EIS EIS Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SYR SYR TAB TAB G G VIAL ML TAB TAB TAB TAB TAB TAB TAB CAP CAP G G VIAL TAB TAB ML TAB ML ML ML TAB TAB Base Price 0.6615 0.5724 0.5500 0.5240 0.5724 0.5724 0.5724 0.5633 0.5633 0.5724 46.1300 23.0700 0.2231 0.4685 0.0219 0.0499 364.7625 1.4887 7.8347 7.8347 0.1127 0.1686 0.0845 0.0694 0.0850 0.1252 0.9918 0.2433 0.2087 12.5140 0.1595 0.3104 0.2130 0.0850 0.0295 0.0450 0.0496 0.7807 1.5609 Pg 15 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002369648 00002060841 00002135620 00002243966 00000075124 00000498815 00002237567 00002019736 00002019701 00002017849 00002019671 00002061287 00002229367 00002019698 00002239138 00002370050 00002370069 00000294926 00002245709 00001944738 00002215268 00002245383 00001944746 00001944711 00002003317 00001944673 00001944762 00002265427 00001912437 00000899453 00001925199 00000896276 00001925180 00002162121 00002225271 00002336847 00000716634 00000158348 00000158313 Product Description 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 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 BENLYSTA 120 MG / VIAL INJECTION BENLYSTA 400 MG / VIAL INJECTION BENURYL 500 MG TABLET 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 AC 5% TOPICAL COPLYMER GEL BENZAC W10 10% TOPICAL WASH BENZAC W5 5% TOPICAL WASH BENZAC W5 5% TOPICAL WATER GEL BENZAGEL 5 5% WASH BENZAMYCIN TOPICAL GEL BESIVANCE 0.6% OPHTHALMIC SOLUTION BETADERM 0.1% SCALP LOTION BETADINE 10% TOPICAL SOLUTION BETADINE SURGICAL SCRUB 7.5% TOPICAL SOLUTION Route ORL TOP ORL TOP INJ ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP TOP TOP TOP TOP OPH SCP TOP TOP Form TAB CRM CAP LOT DEFAUL SRT TAB ELX CRM TAB CAP CTB TAB LIQ TAB DEFAUL DEFAUL TAB SYR SYR SYR LIQ SYR SYR SYR SYR SYR SYR COPGEL COPGEL WAS WAS WTRGEL WAS GEL SOL LOT SOL SOL This document is for pricing use only and should 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 EIS TAB WSP G AUP CAP COC ML NNA VIAL JAM TAB BLO TAB PDH ML WLA G PDH TAB PDH CAP PDH TAB PDH TAB PDH ML PDH TAB GSK VIAL GSK VIAL VCL TAB PDH ML WLA ML WLA ML PDH PCKT WWA ML PDH ML PDH ML PDH ML WLA ML PDH ML GAL G GAL G GAL G GAL G GAL G NVC ML VCL G BSH ML TAR ML PUR ML PUR ML Base Price 3.3646 0.0710 0.1630 0.0485 189.5100 0.2252 0.1943 0.0585 0.2927 0.4200 0.2514 0.4483 0.3175 0.0585 0.5583 281.3600 937.8600 0.5280 0.0570 0.0535 0.0535 0.5925 0.0535 0.0474 0.0396 0.0535 0.0535 0.0518 0.3333 0.1500 0.1690 0.0600 0.1500 0.0654 1.1923 2.9100 0.0925 0.0316 0.0164 Pg 16 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002237835 00002359685 00002382423 00002291924 00000297763 00002230897 00000621366 00002247371 00002247372 00080012473 00002247170 00002247171 00080006533 00002216051 00000116785 00080003128 00000999776 00000999782 00000999777 00000437522 00002326302 00002277166 00002277131 00002277158 00002277174 00002277182 00002277190 00002277204 00002277212 00002273411 00002131692 00000220442 00002247600 00002268140 00002408872 00002220520 00002220539 00000522791 00000512990 Product Description BETAJECT INJECTION BIACNA 1.2%/0.025% TOPICAL GEL BICALUTAMIDE 50 MG TABLET BICILLIN L-A 1,200,000 IU/2 ML INJ SYR BICNU 100 MG/VIAL INJECTION BILTRICIDE 600 MG TABLET BIODERM TOPICAL OINTMENT BIO-FUROSEMIDE 20 MG TABLET BIO-FUROSEMIDE 40 MG TABLET BIOGAIA DROPS BIO-HYDROCHLOROTHIAZIDE 25 MG TABLET BIO-HYDROCHLOROTHIAZIDE 50 MG TABLET 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 BIPHENTIN 10 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 15 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 20 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 30 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 40 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 50 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 60 MG CONTROLLED-RELEASE CAPSULE BIPHENTIN 80 MG CONTROLLED-RELEASE CAPSULE BISACODYL-ODAN 5 MGENTERIC-COATED TABLET BLEOMYCIN SULFATE 15 UNIT/VIAL INJECTION BONAMINE 25 MG CHEWABLE TABLET BOOSTRIX INJECTION SYRINGE 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 Route INJ TOP ORL INJ INJ ORL TOP ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL INJ INJ INH ORL ORL ORL OPH Form DEFAUL GEL TAB NDL DEFAUL TAB ONT TAB TAB DPS TAB TAB CAP SOL TAB CAP GEL MWH SPR TAB ECT/PWR CRC CRC CRC CRC CRC CRC CRC CRC ECT DEFAUL CTB DEFAUL DEFAUL MIP TAB TAB SYR SOL This document is for pricing use only and should 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 SDZ VCL SIV KNG BMS BAI ODN BMD BMD FEI PMS PMS VTH ALC CHD BNI GSK GSK GSK JAM PPH PUR PUR PUR PUR PUR PUR PUR PUR ODN MNP JJM GSK FEI GSK PDL PDL ATL ALC Unit of Issue ML G TAB SYR VIAL TAB G TAB TAB ML TAB TAB CAP ML TAB CAP G ML ML TAB KIT CAP CAP CAP CAP CAP CAP CAP CAP TAB VIAL TAB SYR VIAL DOSE TAB TAB ML ML Base Price 10.4830 1.1498 1.6100 44.8040 120.0400 6.8350 0.3600 0.0373 0.0558 4.3200 0.0157 0.0217 0.1300 1.0021 0.2094 1.1666 0.1715 0.0153 0.1637 0.0592 21.5900 0.7552 1.0801 1.3963 1.9158 2.4406 2.9600 3.4446 4.5466 0.0550 457.8900 0.4420 29.7900 71.5020 4.3467 0.0375 0.0548 0.0260 0.4180 Pg 17 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000729655 00002247970 00002331616 00000728284 00000728276 00000674222 00000579947 00002223163 00002341212 00002341220 00002341174 00002361817 00002361809 00002399016 00002398990 00002399024 00002399008 00000265470 00002273284 00002273292 00002273306 00002273314 00002273233 00002273241 00002273268 00002273276 00002238389 00000176095 00002241460 00000730602 00002240973 00000621722 00002240240 00002240977 00080003658 00080000248 00080009369 00080007105 00002040875 Product Description BUCKLEY'S DM ORAL LIQUID 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 OTIC SOLUTION 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 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 C.E.S. 0.625 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 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 Route ORL ORL ORL ORL ORL OT TOP ORL TRD TRD TRD INJ INJ ORL 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 Form LIQ CTB SRT TAB TAB SOL PWR TAB PTH PTH PTH NDL NDL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB TAB CAP TAB TAB TAB 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 BUA BIC PDL LEO LEO TCD TCD PDL PUR PUR PUR LIL LIL FLC FLC FLC FLC VCL PFI PFI PFI PFI PFI PFI PFI PFI SCH NOV WNP SIS WNP HAL PMT WNP WNP JAM PMT HHC JAM Unit of Issue ML TAB TAB TAB TAB ML G TAB PTH PTH PTH SYR SYR TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.0506 0.0873 0.2667 0.8103 3.1260 0.2760 0.7510 0.3521 24.4500 44.4450 13.3125 149.6300 149.6300 1.2900 1.3040 1.2900 1.3040 0.1015 2.6623 3.3191 3.4773 3.4773 2.5217 2.9737 3.1432 3.1094 68.3000 0.8907 0.0391 0.2442 0.0750 0.0274 0.0850 0.0449 0.0255 0.0745 0.0342 0.0745 0.0703 Pg 18 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080006568 00002244861 00002048965 00002243418 00000730599 00000644684 00001922238 00080003855 00002243766 00002158728 00002237590 00002243669 00002141019 00080007103 00002040905 00080007265 00001906828 00002198630 00000535230 00002172917 00002007134 00002242997 00002231948 00080003751 00002240959 00080009423 00002231422 00080009761 00002247976 00080012593 00002381680 00002293269 00002231622 00002377942 00002388693 00002388901 00002377934 00002379260 00002311690 Product Description 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 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 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 PLUS TABLET CALTRATE SELECT 600 MG/ 400 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 4 MG TABLET CANDESARTAN 4 MG TABLET CANDESARTAN 8 MG TABLET CANDESARTAN CILEXETIL 4 MG TABLET CANESORAL 150 MG CAPSULE Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL Form TAB TAB TAB LIQ TAB TAB CTB TAB TAB TAB TAB TAB DEFAUL TAB TAB CAP TAB SYR LIQ SYR DEFAUL CTB TAB TAB CTB TAB TAB TAB TAB CTB PWDPKT DRT DEFAUL TAB TAB TAB TAB TAB 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 GFR TAB PMT TAB JAM TAB ULT ML PMT TAB WBP TAB WAM TAB WNP TAB PMT TAB SWS TAB JAM TAB WNP TAB PPC ML JAM TAB JAM TAB JAM CAP SWS TAB RPH ML RPH ML ROG ML FEI ML WCH TAB WCH TAB WCH TAB WCH TAB PDH TAB WCH TAB PDH TAB WCH TAB WAY TAB TRI PCKT MYP TAB PFI ML PDL TAB SIV TAB SNS TAB PDL TAB AHI TAB BIC CAP Base Price 0.1140 0.0345 0.0335 0.0343 0.0345 0.0245 0.0988 0.0672 0.0791 0.0945 0.0690 0.0833 0.9510 0.0703 0.0685 0.1820 0.0902 0.1021 0.0543 0.0579 8.0550 0.1922 0.1832 0.1832 0.2306 0.2221 0.1664 0.1922 0.2198 0.1922 10.7578 0.8693 119.5380 0.3420 0.3400 0.3400 0.3420 0.3400 16.6500 Pg 19 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002311739 00002311720 00002150867 00080028872 00000589500 00000619035 00000619027 00000772011 00002242738 00002157101 00002157128 00002060043 00002413590 00002413604 00002241999 00002242001 00002245511 00002011239 00002126680 00002397447 00002397455 00002324520 00002324539 00002324504 00002324512 00002184478 00002215756 00000465208 00000465186 00000832804 00000465216 00000465194 00000360430 00000360414 00000360422 00002237138 00002319039 00002036274 00002240773 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 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 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 CEENU 40 MG CAPSULE CEFAZOLIN 1 G/VIAL USP INJECTION CEFEPIME 2G/VIAL INJECTION CEFOTAN 1 G/VIAL INJECTION CEFOXITIN 10 G/VIAL USP INJECTION Route ORL/VAG 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 INJ ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ Form CAP/CRM CRM CRM SOL SOL SOL SOL SOL SHP CRM CRM TAB SRT SRT DEFAUL DEFAUL TAB CAP DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB TAB DEFAUL SUS CAP SUS SUS CAP CAP CAP CAP 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. MFR BIC BIC BAI PMS PMS BAK BAK DLX GAL VLP VLP BNQ PDL PDL HSP HSP EUP VCL HSP ACT ACT PDL PDL PDL PDL AZC PFI PPH PPH PHH PPH PPH BMS BMS BMS PPC APX WAY TEV Unit of Issue KIT G G ML ML ML ML ML ML G G TAB TAB TAB ML ML TAB CAP ML VIAL VIAL TAB TAB TAB TAB TAB VIAL ML CAP ML ML CAP CAP CAP CAP VIAL VIAL VIAL VIAL Base Price 17.6300 13.3100 0.3893 7.2547 8.7907 7.2373 7.9930 8.6853 0.7203 0.1935 0.2430 0.5900 0.0930 0.1859 0.6313 1.2625 0.1260 0.1991 19.2500 17.1760 34.4470 0.6350 0.6350 0.6350 0.6350 7.4653 25.7360 0.1286 1.1092 0.2872 0.2354 2.3664 7.6135 21.6695 13.2680 6.0000 25.1150 15.0000 105.9500 Pg 20 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000886971 00002212307 00002287668 00002250292 00002241639 00002241640 00002241638 00002357844 00002357852 00002357860 00002357879 00002242145 00002192748 00002237484 00002240347 00000870153 00000022802 00002299844 00002299852 00080013657 00080022930 00080024482 00002246361 00080005174 00080020794 00002246440 00002246346 00080005153 00002246362 00080021452 00002099373 00002099365 00000828866 00002230988 00002230694 00002241751 00001926683 00000158356 00000221570 Product Description CEFTAZIDIME 1 G/VIAL INJECTION CEFTIN 125 MG/5ML ORAL SUSPENSION 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 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 CENTRUM FORTE TABLET CENTRUM JUNIOR COMPLETE CHEWABLE TABLET CENTRUM SELECT CHEWABLE TABLET CENTRUM SELECT TABLET CENTRUM SELECT TABLET CENTRUM TABLET CENTRUM TABLET CEPACOL 0.05% MOUTHWASH CEPACOL MINT WITH FLUORIDE MOUTHWASH CEPHALEXIN 500 MG TABLET 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 Route INJ ORL INJ INJ INJ INJ INJ TOP TOP TOP TOP ORL ORL ORL INJ OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ OT OT Form DEFAUL SUS DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CRM ONT CRM ONT SUS CAP TAB DEFAUL SOL CAP TAB TAB TAB TAB TAB TAB TAB CTB CTB TAB TAB TAB TAB MWH MWH TAB DEFAUL DEFAUL DEFAUL DEFAUL DPS DPS This document is for pricing use only and should 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 PPC VIAL GSK ML TEV VIAL HSP VIAL PPC VIAL PPC VIAL PPC VIAL VLP G VLP G VLP G VLP G HLR ML HLR CAP HLR TAB HLR VIAL ALL ML ERF CAP PFI TAB PFI TAB PDH TAB PDH TAB PDH TAB WCH TAB PDH TAB PDH TAB WCH TAB WCH TAB PFI TAB WCH TAB PDH TAB SKB ML SKB ML PDL TAB PFI ML GZM VIAL GZM VIAL ERF VIAL PUR ML PAL ML Base Price 31.9700 0.1899 214.2000 35.2500 39.7900 149.2000 19.8900 0.0990 0.0990 0.0664 0.0664 1.8808 2.2407 4.4814 32.0000 0.8625 0.6378 17.7375 16.5000 0.1963 0.2258 0.1517 0.1615 0.1700 0.1305 0.2223 0.1577 0.1577 0.0969 0.1328 0.0063 0.0040 0.4500 11.0580 1230.0000 2460.0000 90.2000 0.5740 0.5391 Pg 21 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002342227 00002312263 00002247766 00002247767 00000496685 00080009742 00002248435 00002238626 00000870455 00002039990 00002229538 00002046040 00002247621 00000738972 00001970399 00000738964 00080015373 00002247459 00002248088 00002296888 00002248089 00002296896 00002238274 00002238273 00002350971 00002200864 00002331675 00002391449 00002391457 00002251787 00002247916 00002304546 00002304759 00002126613 00002403188 00002301822 00002387948 00002301830 00002301849 Product Description 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 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 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 CIALIS 5 MG TABLET CI-CAL + D TABLET CI-CAL 250 MG TABLET 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 20 MG TABLET CITALOPRAM 40 MG TABLET Route INJ ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL OPH INJ ORL ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL Form DEFAUL CAP DEFAUL DEFAUL TAB TAB SUS DPS CTB SUS LIQ SUS SYR TAB TAB SRT TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB ONT NDL DISNTAB DISNTAB ERT ERT DEFAUL DEFAUL DEFAUL DEFAUL 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 GSK VCL SRO SRO JAM SWS PDH MCL MCL MCL MCL MCL ODN SCH SCH SCH MTG PPC LIL LIL LIL LIL EUP EUP SNS ALC UCB LBC LBC BAI BAI APX SDZ MNP TEV MEL SIV MEL MEL Unit of Issue ML CAP VIAL VIAL TAB TAB ML ML TAB ML ML ML ML TAB TAB TAB TAB VIAL TAB TAB TAB TAB TAB TAB TAB G SYR TAB TAB TAB TAB ML ML ML ML TAB TAB TAB TAB Base Price 195.6000 1.8356 96.7500 340.0000 0.0742 0.0479 0.0622 0.2733 0.1763 0.0561 0.0561 0.0585 0.0433 0.2288 0.4342 0.3471 0.4500 130.3900 15.2450 4.6625 15.7975 4.6625 0.1513 0.1437 0.4284 3.2829 722.0900 1.8400 1.9590 3.3816 3.3816 0.1445 0.1540 6.4600 6.1524 0.4464 0.2493 0.8750 0.8750 Pg 22 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002257521 00000519235 00002150220 00002150158 00000262609 00002225085 00002324490 00002237734 00000782696 00001945157 00000442968 00002324989 00002250616 00002408511 00002408538 00002248525 00002248526 00002242970 00002243050 00080007070 00002248454 00002256398 00002256371 00002299739 00001910396 00002394820 00000812382 00002229380 00002394898 00002274337 00002376520 00002285215 00002285223 00002270641 00002270668 00002270676 00002397625 00002397617 00002390183 Product Description CITALOPROM-40 40 MG TABLET CITANEST PLAIN 4% INJECTION CITRACAL MG TABLET CITRACAL PLUS D CAPLET CITRO MAG 50 MG ORAL LIQUID CLAFORAN 0.5 G/VIAL INJECTION 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 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 ANASTROZOLE 1 MG TABLET CO BICALUTAMIDE 50 MG TABLET CO CANDESARTAN 4 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 DONEPEZIL ODT 10 MG ORALLY DISINTEGRATING TAB CO DONEPEZIL ODT 5 MG ORALLY DISINTEGRATING TABLET CO EXEMESTANE 25 MG TABLET Route ORL INJ ORL ORL ORL INJ ORL ORL ORL ORL TOP ORL TRD INJ INJ ORL ORL TOP TOP TOP ORL TOP TOP TOP ORL ORL TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form TAB DEFAUL TAB TAB LIQ DEFAUL TAB DISPTAB TAB SRT LOT PWR PTH DEFAUL DEFAUL TAB CAP CRM PAD LOT TAB LOT SHP SPR TAB TAB CRM CRM TAB TAB TAB TAB TAB TAB TAB TAB DISNTAB DISNTAB 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 PDL DSC SFD SFD ROG SAV PDL SCH SCH SCH RBC PRI BAI SDZ SDZ PDL PDL GSK GSK SAH PDL GAL GAL GAL PDL PDL TAR TAR APH APH APH APH APH APH APH APH APH APH APH Unit of Issue TAB ML TAB TAB ML VIAL TAB TAB TAB TAB ML G PTH ML ML TAB CAP G PAD ML TAB ML ML ML TAB TAB G G TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.3329 0.8658 0.1535 0.1548 0.0161 10.5350 1.6297 0.7240 0.8983 0.7240 0.1893 0.0275 6.9300 0.3910 0.5445 0.2217 0.4434 0.8112 0.7278 0.2415 0.1097 0.8141 0.8141 1.6300 0.1358 0.6577 0.3235 0.2100 2.5460 4.0573 0.3400 0.1795 0.2085 0.0495 0.1487 0.1286 3.6176 3.6176 3.9008 Pg 23 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002305682 00002305690 00002305704 00002274248 00002274256 00002274272 00002250020 00002250012 00002379996 00002269627 00002325713 00002327589 00002327597 00002394189 00002394197 00002394200 00002394170 00002394219 00002262746 00002302861 00002302888 00002302896 00002402955 00002402971 00002402912 00002402998 00002402920 00002402939 00080006266 00080007078 00002372088 00002372053 00002372061 00002270633 00002270625 00002257882 00002395282 00002395290 00002395274 Product Description CO FAMCICLOVIR 125 MG TABLET CO FAMCICLOVIR 250 MG TABLET CO FAMCICLOVIR 500 MG TABLET CO GLIMEPIRIDE 1 MG TABLET CO GLIMEPIRIDE 2 MG TABLET CO GLIMEPIRIDE 4 MG TABLET CO MELOXICAM 15 MG TABLET CO MELOXICAM 7.5 MG TABLET CO MYCOPHENOLATE 500 MG TABLET CO NORFLOXACIN 400 MG TABLET CO OLANZAPINE 20 MG TABLET CO OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB CO OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB CO OXYCODONE CR 10 MG CONTROLLED-RELEASE TABLET CO OXYCODONE CR 20 MG CONTROLLED-RELEASE TABLET CO OXYCODONE CR 40 MG CONTROLLED-RELEASE TABLET CO OXYCODONE CR 5 MG CONTROLLED-RELEASE TABLET CO OXYCODONE CR 80 MG CONTROLLED-RELEASE TABLET CO PAROXETINE 10 MG TABLET CO PIOGLITAZONE 15 MG TABLET CO PIOGLITAZONE 30 MG TABLET CO PIOGLITAZONE 45 MG TABLET CO PREGABALIN 150 MG CAPSULE CO PREGABALIN 225 MG CAPSULE CO PREGABALIN 25 MG CAPSULE CO PREGABALIN 300 MG CAPSULE CO PREGABALIN 50 MG CAPSULE CO PREGABALIN 75 MG CAPSULE CO Q10 100 MG CAPSULE CO Q10 LIQUID CO SILDENAFIL 100 MG TABLET CO SILDENAFIL 25 MG TABLET CO SILDENAFIL 50 MG TABLET CO SOTALOL 160 MG TABLET CO SOTALOL 80 MG TABLET CO SUMATRIPTAN 25 MG TABLET CO TEMOZOLOMIDE 100 MG CAPSULE CO TEMOZOLOMIDE 140 MG CAPSULE CO TEMOZOLOMIDE 20 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 ORL ORL ORL ORL ORL ORL ORL Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DISNTAB DISNTAB CRT CRT CRT CRT CRT TAB TAB TAB TAB CAP CAP CAP CAP CAP CAP CAP LIQ TAB TAB TAB TAB TAB TAB 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 APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH APH SIS INN APH APH APH APH APH APH APH APH APH Unit of Issue 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 CAP CAP CAP CAP ML TAB TAB TAB TAB TAB TAB CAP CAP CAP Base Price 2.0240 2.7200 4.2281 0.4900 0.4900 0.4900 0.5670 0.4914 2.0620 0.5449 10.3093 5.3553 7.5977 0.4390 0.6585 1.1413 0.3150 2.1080 1.0430 0.5809 0.8139 1.2237 1.7270 1.7270 0.6173 1.7270 0.9683 1.2528 0.1666 0.7941 9.2025 8.2900 8.8475 0.4058 0.3708 8.9900 113.5966 159.0360 22.7200 Pg 24 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002395312 00002383209 00002337487 00000068756 00000068594 00000068608 00002150417 00002237726 00002150425 00002243897 00002163748 00002163780 00002163799 00002230302 00000050024 00002246219 00002248644 00080010367 00080006827 00002231735 00002245926 00080006674 00080006505 00000287873 00000621374 00000476420 00001944363 00001944355 00002239213 00002374129 00002229633 00002247732 00002250241 00002247733 00002247734 00001945149 00002403986 00002224577 00002176955 Product Description CO TEMOZOLOMIDE 250 MG CAPSULE CO TRAMADOL/ACET 37.5 MG/325 MG TABLET CO VALSARTAN 40 MG TABLET COACTIFED EXPECTORANT ORAL LIQUID 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 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 COLCHICINE 1 MG TABLET COLY-MYCIN M 150 MG/VIAL INJECTION COMBANTRIN 125 MG TABLET COMBANTRIN 50 MG/ML (BASE) ORAL SUSPENSION 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 CO-OLOPATADINE 0.1% OPH SOLUTION COPHYLAC ORAL SOLUTION COQ10 30 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 INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP OPH ORL ORL Form CAP TAB TAB LIQ SYR TAB ECT ECT ECT ECT SRT SRT SRT SRT SYR CAP CAP CAP CAP CAP CAP CAP TAB TAB TAB DEFAUL TAB SUS TAB TAB TAB ERT ERT ERT ERT SOL SOL SOL 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 APH CAP APH TAB APH TAB GSK ML GSK ML GSK TAB BAI TAB BIC TAB BAI TAB PMS TAB PUR TAB PUR TAB PUR TAB PUR TAB ATL ML WNP CAP VTH CAP WBP CAP WNP CAP WNP CAP HHC CAP WNP CAP WNP TAB EUP TAB ODN TAB PFI VIAL PDH TAB PDH ML GSK TAB GIL TAB WAM TAB JAI TAB JAI TAB JAI TAB JAI TAB CDX ML APH ML VLP ML JAM CAP Base Price 283.9840 0.6264 0.5823 0.1906 0.1785 1.0880 0.0846 0.1173 0.0815 0.0433 0.7128 1.0693 1.4257 0.3565 0.0542 0.1403 0.3266 0.3887 0.1297 0.3000 0.2540 0.2593 0.2917 0.2787 0.5285 42.9200 1.1325 0.2789 11.3458 44.3300 0.0607 2.2803 2.6316 2.9830 3.6854 12.4086 5.2260 2.3727 0.2248 Pg 25 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080012965 00001980661 00000513288 00001912828 00000666246 00000022381 00002181215 00002099748 00002240206 00002243063 00002246568 00080027158 00002239007 00002415194 00000299561 00000299588 00000299596 00002241013 00002229161 00002229196 00001950541 00002299909 00002089912 00002220644 00002148331 00002148382 00002290308 00002238526 00080038525 00002126656 00000386715 00002060604 00000582301 00000507415 00001997653 00000004774 00002359456 00002027860 00002285002 Product Description COQ10 MRB 60 MG SOFTGEL CAPSULE CORTAMED 25 MG/G OPH OINTMENT CORTATE 0.5% TOPICAL CREAM CORTISPORIN OTIC SOLUTION CORTISPORIN TOPICAL OINTMENT CORTROSYN 0.25 MG/VIAL INJECTION COTAZYM ECS 4 CAPSULE (ENTERIC-COATED PELLET) COUGH SYRUP WITH CODEINE 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 CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE CROMOLYN 2% NASAL SOLUTION CUBICIN 500 MG/VIAL INJECTION CUTIVATE 0.05% TOPICAL CREAM 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/5ML 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 Route ORL OPH TOP OT TOP INJ ORL ORL ORL ORL ORL ORL ORL ORL RT RT RT VAG ORL ORL NAS INJ TOP ORL OPH OPH ORL ORL ORL INJ INJ VAG TOP TOP ORL ORL ORL ORL ORL Form CAP ONT CRM SOL ONT DEFAUL CAP/ENCP SYR TAB SYR TAB CAP CAP/ENCP CAP/ENCP SUP SUP SUP GEL CAP CAP SOL DEFAUL CRM TAB SOL SOL TAB PWR CAP DEFAUL DEFAUL CRM SOL SHP CAP TAB TAB TAB DISNTAB This document is for pricing use only and should 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 INN SDZ PMS GSK GSK LYN ORG ROG DPM PMS SEV JAM ABB ABB SDZ SDZ SDZ SRO MFC MFC PPH CUB GKC PDL BSH BSH PMS ORP TPI MNP PFI PAL PFI VLP JHP COR TAK PFI FEI Unit of Issue CAP G G ML G VIAL CAP ML TAB ML TAB CAP CAP CAP SUP SUP SUP G CAP CAP ML VIAL G TAB ML ML TAB G CAP ML VIAL G ML ML CAP TAB TAB TAB TAB Base Price 0.7950 6.0857 0.1467 1.4060 0.8473 98.7600 0.1795 0.0162 0.5129 0.0613 0.9210 0.2002 0.1703 0.1831 0.6340 0.6020 0.6220 8.9931 1.4477 2.9267 0.8292 174.0000 0.7250 0.3727 6.6667 6.6667 1.2076 4.5524 0.5415 16.7020 10.7240 0.8210 0.3620 0.0560 0.7684 1.5190 2.2820 0.7255 2.1540 Pg 26 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002285010 00002284995 00080001791 00002389282 00000791172 00002018403 00002238848 00000681989 00000681997 00002247093 00002239903 00002060345 00000873292 00002230642 00002227517 00002238407 00002300559 00002216280 00001942417 00002298155 00002239064 00002239065 00002204274 00002204266 00000832030 00002354950 00002354969 00000833231 00002058235 00002237450 00002398958 00002398974 00002398966 00002398982 00002245391 00002233542 00002192667 00002229552 00002248994 Product Description DDAVP MELT 240 MCG ORALLY DISINTEGRATING TABLET DDAVP MELT 60 MCG ORALLY DISINTEGRATING TABLET DDROPS 1,000 IU/DROP ORAL LIQUID 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 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 DIANE-35 2 MG/0.035 MG TABLET DIARR-EZE 0.2 MG/ML ORAL LIQUID DIARR-EZE 2 MG CAPLET DIARRHEA RELIEF 2 MG TABLET Route ORL ORL ORL INJ NAS ORL TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP OT ORL TOP ORL ORL ORL INJ INJ TOP ORL ORL ORL INH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form DISNTAB DISNTAB LIQ DEFAUL SOL CRSUS CRM CRM LOT CRM CRM CRM OIL EMCRM ONT SPR SOL TAB ONT TAB TAB TAB DEFAUL DEFAUL LIQ DRC DRC SYR SOL CAP CAP PWDPKT CAP PWDPKT TAB TAB LIQ 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 FEI FEI DDR FEI RPH NVC BRR NEO NEO DTR TAR DEL HDI VCL VCL DPI HDI AAP PDH PMS PFI PFI OMG OMG ATL TAK TAK TAN MYP EUP BCF BCF BCF BCF EUP BHP PMS PMS PMS Unit of Issue TAB TAB ML SYR ML ML G G ML ML G G ML G G ML ML TAB G TAB TAB TAB ML ML ML CAP CAP ML ML CAP CAP PCKT CAP PCKT TAB TAB ML TAB TAB Base Price 3.8777 1.0770 1.4900 12.0000 0.1510 0.0634 14.3200 0.1898 0.1127 0.0856 0.0628 0.1657 0.3053 1.8070 1.6630 0.2318 1.7385 0.9687 0.0588 0.5769 1.0547 1.0547 1.3940 1.6060 0.0365 2.3907 2.3907 0.0199 0.0616 0.1986 6.3667 6.3667 12.7333 12.7333 0.0663 1.7452 0.0878 0.3000 0.2617 Pg 27 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002238162 00000434388 00000313580 00000870978 00002351684 00002224127 00002224119 00000392820 00000392812 00002176017 00002231592 00002148749 00002274000 00002387174 00000627100 00002085895 00000622133 00002325306 00002325314 00002325322 00002325330 00002325349 00002231472 00002231474 00002231475 00002231057 00002300648 00002244079 00002244080 00002243083 00002243969 00002243091 00002244078 00002243231 00002027100 00002023717 00002023768 00002270528 00002157624 Product Description 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 DILAUDID 2 MG/ML INJECTION DILAUDID STERILE POWDER 250 MG/VIAL 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. DIONEPHRINE 2.5% OPH SOLUTION DIOPHENYL-T OPH SOLUTION DIOPRED 1% OPH SUSPENSION DIOVAN 40 MG TABLET DIOVOL PLUS AF CHEWABLE TABLET Route RT ORL ORL ORL ORL ORL ORL ORL INJ ORL TOP TOP TOP ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL BLDIR OPH OPH OPH ORL ORL Form GEL TAB TAB ECT TAB SRT SRT CAP DEFAUL TAB CRM GEL GEL TAB DEFAUL DEFAUL DEFAUL ERC ERC ERC ERC ERC CDC CDC CDC CDC DEFAUL SYR SYR TAB LIQ TAB SYR SOL SOL SOL SUS TAB CTB This document is for pricing use only and should 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 DAX 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 PUR ML PUR VIAL 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 DIO ML DIO ML SDZ ML NOV TAB CHD TAB Base Price 82.7750 0.0867 0.0650 0.2024 0.3937 0.4048 0.2343 0.0758 4.3080 0.4942 1.6918 1.6918 1.0957 110.0000 1.0832 66.6350 2.6510 0.4043 0.5366 0.7118 0.8897 1.0732 0.3529 0.4684 0.6213 0.7766 2.7170 0.0919 0.1242 0.2913 0.0540 0.3125 0.1178 1.1840 0.7180 1.9467 1.9400 1.2682 0.1284 Pg 28 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002157616 00000116815 00000116882 00002369567 00002219336 00000417262 00002243961 00002243960 00002240341 00002240342 00002240343 00000579955 00002228335 00002246741 00000870218 00000794406 00000830267 00002245946 00002246036 00002246854 00000614491 00000614505 00002130963 00002246331 00002229468 00002229467 00002399482 00002399490 00002399504 00002138271 00002138298 00002232564 00002238222 00002238223 00002247230 00002130998 00002131013 00002224100 00002238633 Product Description DIOVOL PLUS AF-SUSPENSION DIOVOL PLUS ORAL SUSPENSION DIOVOL PLUS TABLET 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 DOAK OIL 2% TOPICAL SOLUTION DOBUTAMINE HYDROCHLORIDE 12.5 MG/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-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-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-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 Route ORL ORL ORL INJ INJ TOP ORL ORL ORL ORL ORL TOP 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 Form SUS SUS TAB DEFAUL DEFAUL CRM ERT ERT ECT ECT TAB SOL DEFAUL CAP DPS CAP CAP CAP CAP SYR SYR SYR CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB SRT SRT 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 CHD CHD CHD PPC OMG SCH JAI JAI PDL PDL PDL TCD TEV ROG ROG VTH TLI JPC ROG ROG ATL ATL DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC Unit of Issue ML ML TAB ML ML G TAB TAB TAB TAB TAB ML VIAL CAP ML CAP CAP CAP CAP ML ML ML CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.0183 0.0183 0.1284 4.3900 4.1000 0.8556 2.4754 2.4754 0.0724 0.1301 0.2604 0.0296 23.2500 0.1603 0.2008 0.0334 0.0338 0.0390 0.0405 0.0264 0.0319 0.0545 0.5179 0.6177 0.3306 0.2011 0.3137 0.3922 0.4216 0.1595 0.4607 0.3521 0.1301 0.2602 0.1538 0.0694 0.1196 0.0694 0.3727 Pg 29 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002130092 00002231662 00002231664 00002238315 00002376709 00002246109 00002246108 00002177617 00002177625 00002241348 00002241347 00002243743 00002243744 00002243745 00002241608 00002234514 00002239913 00002239917 00002372193 00002245784 00002245785 00002247232 00002242726 00002231122 00002231121 00002178729 00002178737 00002125145 00002241285 00002248447 00002248448 00002248449 00002236857 00002238046 00002238047 00002231650 00002249758 00002243038 00002216949 Product Description 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 DOM-IRBESARTAN 150 MG TABLET 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-NORTRIPTYLINE 10 MG CAPSULE DOM-NORTRIPTYLINE 25 MG CAPSULE DOM-NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION 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 40 MG TABLET DOM-RANITIDINE 150 MG TABLET DOM-SALBUTAMOL 1 MG/ML INHALATION SOLUTION 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 ORL INH Form TAB ECT SRT TAB TAB TAB TAB CAP CAP TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP SUS TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SOL This document is for pricing use only and should 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 DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC PDL DPC DPC DPC DPC DPC DPC Unit of Issue TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML Base Price 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 0.3025 0.0359 0.0380 1.2579 0.1186 0.1941 0.0874 0.0772 0.1560 0.0521 0.1508 0.8210 0.6320 0.6714 0.0594 0.3253 0.4718 0.1905 0.8057 0.1800 0.3618 Pg 30 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002245750 00002245748 00002245749 00002238635 00002238634 00002243749 00002128969 00002128950 00002240321 00002240823 00002416425 00002420600 00002416417 00002420597 00002230108 00000887064 00001929313 00001929372 00001929380 00000740861 00000298433 00000342742 00000821772 00002247208 00000003867 00002292165 00002239299 00000370576 00002125706 00000656747 00000490156 00002148633 00002275848 00002275856 00002334186 00002275813 00002275821 00002373017 00002373025 Product Description 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 DOM-TERAZOSIN 10 MG TABLET DOM-TRAZODONE 100 MG TABLET DOM-TRAZODONE 50 MG TABLET DOM-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET DOM-ZOPICLONE 7.5 MG TABLET DONEPEZIL 10 MG TABLET DONEPEZIL 10 MG TABLET DONEPEZIL 5 MG TABLET DONEPEZIL 5 MG TABLET DOXORUBICIN HYDROCHLORIDE 2 MG/ML INJECTION 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 DULCOLAX 5 MG RECTAL SUPPOSITORY 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 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 Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL NAS NAS NAS NAS ORL TOP ORL ORL RT INTRA TOP TOP OPH TOP TOP INH TRD TRD TRD TRD TRD ORL ORL Form CAP CAP CAP TAB TAB TAB TAB TAB SRT TAB TAB TAB TAB TAB DEFAUL TAB SOL SOL SPR SOL SRT SOL TAB SUS SUP GEL PTH SOL ONT SOL SOL SOL PTH PTH PTH PTH PTH ERC ERC This document is for pricing use only and should 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 DPC DPC DPC DPC DPC DPC DPC DPC DPC DPC PDL SIV PDL SIV TEV PDL PDH PDH PDH SCH SCH SFD RIV AVE BOE ABV MMH STI BSH VCL VCL BOE JAI JAI JAI JAI JAI CIP CIP Unit of Issue CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB ML ML ML ML TAB ML TAB DOSE SUP CAS PTH ML G ML ML ML PTH PTH PTH PTH PTH CAP CAP Base Price 0.4200 0.2004 0.4000 0.1623 0.2966 0.6183 0.0989 0.0554 0.6767 0.4685 1.2340 1.1806 1.2340 1.1806 11.4000 0.5860 0.3267 0.3267 0.3267 0.1593 0.4340 0.4624 0.2215 39.1100 1.0933 166.0000 0.4633 0.5413 1.5743 0.2196 0.2196 0.8980 38.6640 48.1240 5.2140 14.6060 27.4920 1.2387 2.2603 Pg 31 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002373033 00000999010 00001947958 00001947931 00001947923 00002260638 00002381389 00002381397 00002397749 00002397765 00002397757 00002370603 00080009719 00002349124 00002209764 00002210517 00002247238 00002248239 00002248240 00002248999 00002268892 00000627410 00002296284 00002103109 00002237355 00002298805 00002324679 00000886858 00002057794 00080008611 00002248209 00002248208 00002334992 00002296454 00002010526 00000794244 00002246971 00001905392 00000852015 Product Description DURELA 300 MG EXTENDED-RELEASE CAPSULE DUROLANE DUVOID 10 MG TABLET DUVOID 25 MG TABLET DUVOID 50 MG TABLET 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 ELIDEL 1 % TOPICAL CREAM ELIGARD 10.2 MG/SYR INJECTION ELIGARD 28.2 MG/SYR INJECTION ELIGARD 35.8 MG/SYR INJECTION ELIGARD 56.3 MG/SYR INJECTION ELIXIR DE THEOPHYLLINE ELOXATIN 5 MG/ML INJECTION ELTOR-120 120 MG SUSTAINED-RELEASE TABLET EMADINE 0.05% OPH SOLUTION EMEND 125 MG CAPSULE EMEND IV 115MG/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 SUPER EXTRA STRENGTH 650 MG ECCPT ENTROPHEN 500 MG ENTERIC-COATED TABLET Route ORL DEFAUL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT RT TOP INJ INJ INJ INJ ORL INJ ORL OPH ORL INJ TOP TOP ORL ORL ORL VAG INJ ORL ORL ORL ORL ORL Form ERC DEV TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB ONT SUP CRM NDL NDL NDL NDL ELX DEFAUL SRT SOL CAP DEFAUL CRM PTH CAP CAP CAP EVT DEFAUL ECT ECT SRT ECT ECT This document is for pricing use only and should 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 CIP QMD PAL PAL PAL LBC TAK TAK TAK TAK TAK JAI FMD LIL PMS PMS VCL SAV SAV SAV SAV ATL SAV SAV ALC MFC MFC AZC AZC TRU PRP PRP FEI GSK WTR VTH PUR PPH PPH Unit of Issue CAP ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB G SUP G SYR SYR SYR SYR ML ML TAB ML CAP VIAL G PTH CAP CAP CAP TAB ML TAB TAB TAB TAB TAB Base Price 3.2817 116.6667 0.3232 0.5235 0.6896 2.6153 1.2957 1.2957 1.2957 1.2957 1.2957 15.5820 0.1667 2.9483 0.4487 0.6075 2.4742 343.5800 957.8200 1381.5900 1575.6400 0.0049 51.8160 0.2958 3.6660 33.2233 30.1800 1.9780 2.9050 0.3025 1.0332 0.5350 4.3467 22.5200 0.0280 0.0550 0.4238 0.0705 0.0686 Pg 32 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002050161 00000010332 00000880183 00000721891 00002264927 00002396971 00002396998 00002397005 00002397013 00002243801 00002271249 00080003615 00002409267 00002034506 00002393751 00002394839 00002394847 00002244990 00002237515 00002247480 00080003499 00000756792 00000756849 00000727369 00000247960 00000247979 00002080036 00000637726 00000720941 00080013021 00000623377 00002242291 00002303825 00002245668 00002242651 00002247385 00002237556 00002241802 00002412926 Product Description 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 ERYSOL TOPICAL (ALCOHOL) GEL ESBRIET 267 MG CAPSULE ESOMEPRAZOLE 20 MG DELAYED-RELEASE TABLET ESOMEPRAZOLE 40 MG DELAYED-RELEASE TABLET ESSENTIAL VITAMINS AND MINERALS TABLET ESTER C 1000 MG TABLET ESTER-C 250 MG CHEWABLE TABLET ESTER-C CAPSULE ESTRADERM-100 (8.0 MG/PTH) TOPICAL PATCH ESTRADERM-25 (2 MG/PTH) TOPICAL PATCH ESTRAGYN 1MG/G VAGINAL CREAM ETIBI 100 MG TABLET ETIBI 400 MG TABLET ETOPOSIDE 20 MG/ML INJECTION EUFLEX 250 MG TABLET EUGLUCON 5 MG TABLET EUPHORBIUM COMPOSITUM SN ORAL DROPS EURAX 10% TOPICAL CREAM EURO - K8 600 MG SUSTAINED-RELEASE 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 300 MG CAPSULE EURO-FER CF CAPSULE EURO-HYDROCORTISONE 1% CREAM Route ORL ORL TOP INJ INJ ORL ORL ORL ORL ORL INJ ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL TRD TRD VAG ORL ORL INJ ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL TOP Form ECT ECT LOT NDL DEFAUL CAP CAP CAP CAP ECT DEFAUL SOL CAP ALCGEL CAP DRT DRT TAB TAB CTB CAP PTH PTH CRM TAB TAB DEFAUL TAB TAB DPS CRM SRC CAP SYR CAP CAP CAP CAP 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 PPH PPH VLP HSP HSP CIP CIP CIP CIP PMS BMS ODN HLR GSK INC PDL PDL WNP SIS WNP BMD NOV NOV TPI VCL VCL TEV MFC PMS HEE CLC EUP EUP EUP EUP EUP EUP EUP EUP Unit of Issue TAB TAB ML SYR ML CAP CAP CAP CAP TAB ML ML CAP G CAP TAB TAB TAB TAB TAB CAP PTH PTH G TAB TAB ML TAB TAB ML G CAP CAP ML CAP CAP CAP CAP G Base Price 0.0531 0.0531 0.1069 4.1840 13.3196 1.1637 1.5673 1.9713 2.3747 0.1096 6.7000 0.4257 294.2238 0.7004 12.7679 1.5887 1.5887 0.0214 0.1727 0.0863 0.1496 4.0113 3.3238 0.6416 0.2173 0.6520 15.0000 1.4131 0.1150 0.7650 0.3942 0.0614 0.0344 0.0678 0.0317 0.0328 0.1537 0.2457 0.0989 Pg 33 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002247383 00002247389 00002247390 00002264374 00002264390 00002264404 00002264412 00002264420 00002264439 00002264447 00002264323 00002264455 00002264331 00002264358 00002264366 00080005494 00002248297 00002377179 00002243896 00001990675 00002302853 00002302845 00002237524 00002184672 00002184680 00000813095 00002315955 00002242632 00002244142 00000889806 00000874965 00000707937 00002415992 00002248968 00002247745 00002247735 00002379910 00002229110 00002229129 Product Description 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 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 5 (4.6 MG/24 H) 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 FACTIVE 320 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 Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TRD ORL ORL ORL TRD TRD ORL TOP TOP ORL ORL ORL ORL OPH OPH OPH INJ ORL INJ INJ ORL ORL ORL Form SOL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP PTH TAB ECT TAB PTH PTH TAB GEL GEL SYR TAB TAB TAB DPS DPS LIQ DEFAUL TAB DEFAUL DEFAUL SRT 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 EUP EUP EUP SRO SRO SRO SRO SRO SRO SRO SRO SRO SRO SRO SRO WNP JAI APX PMS NVC NOV NOV NVC YNG YNG TAN PMS MCL PPH SDZ SDZ ALC BHP ABB OMG OMG BIO NOV NOV Unit of Issue ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP PTH TAB TAB TAB PTH PTH TAB ML ML ML TAB TAB TAB ML ML ML VIAL TAB ML ML TAB TAB TAB Base Price 0.0152 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 0.0822 5.9767 0.0662 0.1330 0.0767 4.8933 4.8880 0.2542 0.2250 0.2250 0.0199 0.1890 0.1415 0.1283 0.3093 0.3840 0.0970 1540.8700 7.5240 1.4000 2.3500 9.9673 3.1460 4.2207 Pg 34 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002177102 00002248624 00002231384 00002242531 00002240360 00002395703 00002395657 00002395665 00002395673 00002395681 00000888346 00002126648 00002240434 00002377217 00080013210 00000232599 00002246590 00002243333 00002138751 00000031089 00000031097 00002244532 00000582727 00002245389 00000346918 00000782114 00080005803 00002207230 00002408163 00002337037 00002337029 00001926853 00000323098 00080000193 00002149133 00080000580 00080000840 00002206218 00002230845 Product Description FAMVIR 500 MG TABLET FASLODEX 250 MG/5 ML INJECTION FEMARA 2.5 MG TABLET FEMHRT 1/5 TABLET FENO-MICRO-200 MG CAPSULE FENTANYL 100 MCG/HR TRANSDERMAL PATCH FENTANYL 12 MCG/HR TRANSDERMAL PATCH FENTANYL 25 MCG/HR TRANSDERMAL PATCH 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 50 MCG/ML INJECTION FERAHEME 30 MG/ML INJECTION FERAMAX 150 150 MG CAPSULE FERMALAC VAGINAL CAPSULE FERRATE 20 MG/ML ORAL SUSPENSION 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 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 FIBRISTAL 5 MG TABLET FIRMAGON 120 MG/VIAL INJECTION POWDER FOR SOLUTION FIRMAGON 80 MG/VIAL INJECTION POWDER FOR SOLUTION FLAGYL 500 MG CAPSULE FLAMAZINE 1% TOPICAL CREAM FLAX SEED OIL FLAX SEED OIL 500 MG CAPSULE FLAXSEED OIL 1000 MG SOFTGEL FLAXSEED OIL LIQUID FLEET PHOSPO-SODA ORAL LIQUID FLOLAN 0.5 MG/VIAL INJECTION Route ORL INJ ORL ORL ORL TRD TRD TRD TRD TRD INJ INJ INJ INJ ORL VAG ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL TOP ORL ORL ORL ORL ORL INJ Form TAB NDL TAB TAB CAP PTH PTH PTH PTH PTH DEFAUL DEFAUL DEFAUL DEFAUL CAP CAP SUS DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB CAP PWR TAB DEFAUL DEFAUL CAP CRM LIQ CAP CAP LIQ LIQ 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 NOV TAB AZC SYR NOV TAB PFI TAB PDL CAP PDL PTH PDL PTH PDL PTH PDL PTH PDL PTH HSP ML MNP ML SDZ ML TAK ML BIS CAP ROG CAP EUP ML SAV ML VTH TAB WAM TAB WAM TAB PMT TAB VTH TAB WNP TAB PMT TAB WTR TAB PLT CAP PRI G ASC TAB FEI VIAL FEI VIAL SAV CAP SNE G HHC CAP JAM CAP PMT CAP VML ML JJM ML GLA VIAL Base Price 7.6152 606.3500 6.7330 0.8400 0.2723 12.0520 2.3480 3.6600 6.8840 9.6820 1.7550 1.5000 2.1356 11.8566 0.4860 1.9310 0.0858 5.2720 0.0209 0.1289 0.0224 0.0400 0.0277 0.0785 0.0385 0.0346 0.2000 0.0060 12.4530 405.5000 300.0000 1.1548 0.3014 0.0410 0.0662 0.0937 0.0422 0.0838 18.6400 Pg 35 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002230848 00002213672 00080011335 00080013321 00002244405 00002237245 00002237244 00002248443 00002247749 00002246226 00002249561 00002352621 00001977857 00002090139 00000012882 00002182742 00002331721 00002242570 00002239636 00000578479 00000578487 00002015986 00002236754 00002236753 00000247855 00080000549 00000318973 00000647039 00002048841 00002254689 00002241568 00002201038 00002276429 00002303000 00002303019 00002287188 00002287145 00002287153 00002287161 Product Description 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 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 FLUPHENAZINE OMEGA 100 MG/ML INJECTION FLUPHENAZINE OMEGA 25 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 FORZA-10 TABLET FOSAMAX 40 MG TABLET FOSAVANCE 70 MG/2800 UNIT 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 Route INJ NAS ORL ORL ORL INH INH INJ INJ ORL INJ NAS ORL ORL INJ INJ INJ INJ INJ ORL ORL INJ ORL ORL OPH ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL Form DEFAUL SPM TAB CAP ERT MIP MIP DEFAUL DEFAUL TAB DEFAUL SPR CTB CTB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CAP CAP DEFAUL TAB TAB SUS TAB TAB TAB TAB DEFAUL TAB TAB TAB TAB TAB CTB CTB CTB CTB This document is for pricing use only and should 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 GLA GSK RLC BCX FEI GSK GSK SDZ OMG GZM SDZ AZC PMS PMS VCL MNP SDZ OMG OMG PDL PDL IAF PDL PDL ALL MTG JAM VTH PMT LIL EUP MFC MFC PDL PDL SHB SHB SHB SHB Unit of Issue VIAL DOSE TAB CAP TAB DOSE DOSE ML ML TAB ML ML TAB TAB ML ML ML ML ML CAP CAP ML TAB TAB ML TAB TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB Base Price 37.2700 0.2813 0.5421 1.1010 2.0700 0.4333 0.2740 0.4695 0.3660 43.5485 5.4768 77.4000 0.0922 0.0896 1.4630 2.0376 26.7500 29.7800 4.9800 0.0675 0.0775 16.0000 0.3783 0.2105 3.4900 0.1916 0.0422 0.0079 0.0171 411.6375 0.1710 4.0743 5.0225 0.2178 0.2619 4.8490 1.2150 2.4302 3.6571 Pg 36 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002377454 00002221799 00002257084 00002264625 00002238578 00002243862 00002243861 00002360365 00000496723 00000397792 00000667080 00002247725 00002388200 00002388219 00002416441 00000512192 00000512184 00000682217 00002283190 00000896675 00002300761 00002159791 00002231538 00002159775 00002280124 00002342235 00002342243 00002352818 00002352877 00002352885 00002352850 00002028107 00002366150 00001945831 00001933906 00002324210 00002412292 00002136058 00002230309 Product Description FRAGMIN 2,500 IU/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 800 MG TABLET GALEXOS 150 MG CAPSULE GARAMYCIN 3 MG/ML OPH SOLUTION GARAMYCIN 3 MG/ML OTIC SOLUTION GARASONE 3 MG/ML / 1 MG/ML OTIC OPH SOLUTION GARDASIL 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 GD-AMLODIPINE 2.5 MG TABLET GD-ELETRIPTAN 20 MG TABLET GD-ELETRIPTAN 40 MG TABLET 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 INJ TOP OPH OPH INJ ORL ORL ORL INJ ORL ORL ORL OPH OT OT/OPH INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL DEN TOP ORL ORL INJ INJ ORL INJ Form DEFAUL TAB TAB NDL CRM GEL GEL DEFAUL TAB TAB TAB DEFAUL TAB TAB CAP SOL SOL SOL DEFAUL TAB CAP CTB TAB LIQ TAB TAB TAB TAB TAB TAB TAB GEL GEL CTB TAB DEFAUL DEFAUL 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 PFI LUI TMP BAX LEO LEO LEO OMG PDL PDL PDL HLR SIV SIV JAI MFC MFC MFC MFC NVC NVC SKB SKB SKB GMD GMD GMD GMD GMD GMD GMD COL ASC WLA WSP AHI SDZ PDL LIL Unit of Issue ML TAB TAB SYR G G G ML TAB TAB TAB VIAL TAB TAB CAP ML ML ML ML TAB CAP TAB TAB ML TAB TAB TAB TAB TAB TAB TAB G G TAB TAB VIAL ML TAB VIAL Base Price 4.0785 0.4773 15.2657 51.0000 1.3643 2.2360 5.1917 1.0500 0.0373 0.0558 0.1220 42.7420 0.9580 1.2773 472.2039 0.4060 1.0320 1.2813 308.0600 0.2550 0.2093 0.1495 0.2861 0.0220 0.1380 10.9583 10.9583 2.5243 0.5928 1.9845 0.6615 0.0705 3.0427 0.1484 0.1370 265.0000 10.8120 0.5157 308.3500 Pg 37 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002230308 00080020663 00080034399 00080008885 00002246047 00002082144 00002082152 00002268531 00002148404 00002082136 00002231289 00002242977 00002415666 00002415674 00002415682 00080003490 00002244725 00002253275 00002253283 00002248453 00002300451 00002268493 00001959352 00001926039 00000873462 00080006852 00002229516 00002239214 00002382857 00002382849 00002247884 00000652512 00002248156 00002248154 00002248157 00002270404 00002270390 00002270382 00002232483 Product Description GEMZAR 200 MG/ VIAL INJECTION GENESTRA BRAND HMF INTENSIVE PROBIOTIC GENESTRA BRANDS DIGEST GLUTEN PLUS CAPSULE GENESTRA BRANDS D-MULSION 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 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 GLUMETZA 1000 MG EXTENDED-RELEASE TABLET GLUMETZA 500 MG EXTENDED-RELEASE TABLET 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 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 GRAMCAL 1000 MG EFFERVESCENT TABLET Route INJ ORL ORL ORL ORL INJ INJ INJ OPH INJ OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL RT RT ORL ORL ORL INJ INJ TOP ORL INJ INJ INJ INJ INJ INJ ORL Form DEFAUL CAP CAP LIQ CAP DEFAUL DEFAUL DEFAUL SOL DEFAUL DPS GEL TAB TAB TAB CAP CAP TAB TAB TAB ERT ERT TAB SUP SUP PWR TAB TAB DEFAUL DEFAUL CRM PWR DEFAUL DEFAUL DEFAUL NDL NDL NDL EVT This document is for pricing use only and should 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 LIL SRL SRL SRL MYP BAX BAX SDZ NVO BAX ALC ALC BOE BOE BOE SRL NOV NOV NOV PDL VCL VCL PDL WSP MCO AOR VCL VCL OMG OMG VCL BAX SRO SRO SRO SRO SRO SRO NVC Unit of Issue VIAL CAP CAP ML CAP ML ML ML ML ML ML ML TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB SUP SUP G TAB TAB ML ML G G VIAL VIAL VIAL SYR SYR SYR TAB Base Price 65.6700 1.7166 0.3143 0.5663 0.9580 0.0794 0.0890 2.7070 6.3483 0.0467 0.4493 0.8420 80.0000 80.0000 80.0000 0.4438 25.3240 29.7596 119.0383 0.0931 1.2770 0.6335 0.0321 0.1600 0.0850 0.0639 0.1289 0.2090 3.7000 2.6875 1.2500 0.0044 457.1400 77.0200 992.2500 304.7600 457.1400 914.2900 0.7915 Pg 38 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080006061 00000116858 00002254409 00000511196 00000230197 00000013803 00000013609 00000783595 00002248180 00000013579 00002245718 00080014526 00080012417 00002248417 00002377438 00000271691 00000202061 00002366010 00000587796 00002239640 00002239639 00002187078 00002231056 00000740578 00000453781 00000725323 00000725315 00000640468 00002264315 00002303086 00002382296 00002382326 00002382334 00002303094 00002303108 00002239194 00002240692 00002245872 00000430617 Product Description GRAPE SEED CAPLET 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 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 100 MG/ML INJECTION HALOPERIDOL-LA OMEGA 50 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 LEO 25,000 IU/ML INJECTION HEPARIN LOCK FLUSH 10 IU/ML INJECTION USP HEPARIN LOCK FLUSH 100 IU/ML INJECTION USP HEPARIN LOCK FLUSH SOLUTION 10 UNIT/ML INJECTION HEPARIN SODIUM 1,000 IU/ML INJECTION USP 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 HEXIT 1% TOPICAL LOTION HEXIT 1.0% TOPICAL SHAMPOO Route ORL ORL ORL ORL ORL ORL RT RT ORL INJ ORL ORL ORL VAG INJ ORL ORL INJ ORL INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ INJ ORL INJ TOP TOP Form TAB CAP SRT CTB SYR TAB SUP SUP LOZ DEFAUL TAB CAP PWR CRM DEFAUL CAP CAP DEFAUL TAB DEFAUL DEFAUL DEFAUL NDL LOCFLUSH DEFAUL LOCFLUSH LOCFLUSH LOCFLUSH DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL LOT SHP This document is for pricing use only and should 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 JAM 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 FEI G EIS ML SWS CAP WAM CAP OMG ML PDL TAB OMG ML OMG ML GSK ML GSK SYR ORG ML LEO ML HSP ML HSP ML ABB ML PPC ML SDZ ML PFI ML PFI ML PFI ML SDZ ML SDZ ML GSK ML HLR VIAL ODN ML ODN ML Base Price 0.3322 1.0108 0.4762 0.2625 0.0764 0.3938 0.5810 0.5360 0.2325 1.2370 0.2325 0.2280 0.0948 3.4500 270.0000 0.0329 0.0268 5.3250 0.0360 13.6900 6.8460 47.8000 23.9100 0.3275 8.3390 0.2280 0.2900 1.2056 2.5200 0.5650 0.5010 5.0100 1.2470 5.7270 3.7160 0.2300 2902.5000 0.1380 0.1380 Pg 39 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002244784 00000575178 00000575186 00001948903 00001948911 00002241793 00002078759 00000745626 00002243079 00000999015 00001916599 00001916564 00001916521 00002231476 00000465283 00000341975 00002242930 00002244797 00000564281 00002343096 00002229868 00002230697 00002133253 00002133288 00002275864 00002275872 00080022866 00002257912 00002317338 00000636533 00002183862 00002245185 00002237297 00002230542 00001959042 00001908286 00002240713 00002244895 00002042266 Product Description HILL-VITE TABLET HISTANTIL 25 MG TABLET HISTANTIL 50 MG TABLET HONEY BEE VENOM 1.1 MG HONEY BEE VENOM 120 MCG HONVOL 50 MG/ML INJECTION HUMATIN 250 MG CAPSULE HUMATROPE 1 MG/ML INJECTION HUMATROPE 24 MG INJECTION HYALGAN HYCODAN 5 MG TABLET HYCOMINE ORAL SYRUP HYCOMINE-S PEDIATRIC ORAL SYRUP 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 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 IBEROGAST ORAL SOLUTION IBUPROFEN 200 MG TABLET IBUPROFEN 400 MG CAPLET IBUPROFEN 400 MG TABLET IMODIUM 2 MG CAPLET 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 INDERAL-LA 120 MG SUSTAINED-RELEASE CAPSULE Route ORL ORL ORL INJ INJ INJ ORL INJ INJ DEFAUL ORL ORL ORL NAS ORL ORL TOP INJ TOP ORL INJ INJ OPH OPH INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL INJ ORL Form TAB TAB TAB DEFAUL DEFAUL DEFAUL CAP DEFAUL DEFAUL DEV TAB SYR SYR SOL CAP TAB CRM DEFAUL CRM CAP DEFAUL DEFAUL SOL ONT DEFAUL DEFAUL SOL TAB TAB TAB TAB TAB CTB TAB NDL DEFAUL TAB DEFAUL SRC This document is for pricing use only and should 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 HIL PMS PMS ALG ALG ASM PFI LIL LIL MDX DPM DPM DPM SCH BMS PDL TAR SDZ RPH SNS SDZ GRL ALC ALC NTI NTI STA PMT PMT PDL MCL MCL MCL MCL SFP SFP RIP TPI PFI Unit of Issue TAB TAB TAB VIAL VIAL ML CAP VIAL VIAL ML TAB ML ML ML CAP TAB G ML G CAP ML SYR ML G ML ML ML TAB TAB TAB TAB TAB TAB TAB SYR VIAL TAB VIAL CAP Base Price 0.1320 0.1158 0.1953 30.8667 30.8667 2.9986 2.8959 250.8500 1217.1300 25.0000 1.1388 0.2165 0.1895 0.0766 1.1087 0.0157 0.0846 53.2460 0.1347 1.0203 4.9060 78.0000 0.4147 1.5886 9.2400 9.2400 0.1951 0.0498 0.0392 0.0372 0.7733 0.9280 0.9280 0.8380 46.2000 211.6700 1.9509 96.0600 1.0587 Pg 40 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002042274 00002042231 00002042258 00002046059 00002269562 00002389630 00002389649 00080013031 00002323052 00002323060 00080026628 00000762040 00002348756 00002306778 00002375931 00002238675 00002223406 00002238674 00002240693 00002240694 00002240695 00002409100 00002409119 00002409127 00002409135 00002216965 00002279320 00000888354 00002365200 00002365219 00002365197 00002365162 00002365170 00002365189 00002248676 00002301881 00000897639 00000000655 00000000663 Product Description 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 INFLUVAC VACCINE INJECTION SYRINGE 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 INTANZA INJECTION SYRINGE INTELENCE 100 MG TABLET INTELENCE 200 MG TABLET 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 IOPIDINE 1% OPH SOLUTION (UNIT DOSE) 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 400 MG TABLET ISOPROTERENOL HYDROCHLORIDE 0.2 MG/ML INJECTION ISOPTO CARBACHOL 1.5% OPH SOLUTION ISOPTO CARBACHOL 3% OPH SOLUTION Route ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL INJ OPH OPH Form SRC SRC SRC DPS DEFAUL TAB TAB CAP TAB TAB CAP LIQ DEFAUL TAB TAB DEFAUL DEFAUL DEFAUL NDL NDL NDL ERT ERT ERT ERT CAP TAB SOL TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL SOL SOL This document is for pricing use only and should 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 PFI PFI PFI MCL ABB PFI PFI INN PFI PFI DDI VCL SFP JAI JAI MFC MFC MFC MFC MFC MFC SHB SHB SHB SHB HLR HLR ALC PDL PDL PDL PDL PDL PDL AZC MFC SDZ ALC ALC Unit of Issue CAP CAP CAP ML SYR TAB TAB CAP TAB TAB CAP DOSE SYR TAB TAB ML ML ML SYR SYR SYR TAB TAB TAB TAB CAP TAB ML TAB TAB TAB TAB TAB TAB TAB TAB ML ML ML Base Price 1.2521 0.6098 0.6876 0.2960 9.3000 19.9950 99.9750 1.1325 2.8400 2.8400 0.3332 4.0367 12.9000 6.3086 12.2260 131.4200 125.2000 71.4900 236.5500 394.2100 780.0300 3.2600 3.9663 4.6726 5.3789 2.0265 4.6766 62.3750 0.3425 0.3425 0.3425 0.3425 0.3425 0.3384 73.3000 14.6698 5.4440 0.7047 0.8480 Pg 41 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000000809 00000000817 00000272655 00002333279 00002388014 00002388022 00002388006 00002372010 00002388308 00002246039 00002373823 00002391619 00002366088 00002283255 00002283220 00000031100 00002366061 00002402289 00002402297 00002401290 00002420198 00002397307 00002365529 00002365537 00080040279 00080040277 00002405687 00002405660 00002405679 00002331039 00002331047 00002331055 00002331020 00002331063 00002368625 00002352419 00002379007 00002416794 00002388839 Product Description ISOPTO TEARS 0.5% OPH DROPS ISOPTO TEARS 1.0% OPH DROPS ISOTAMINE 300 MG TABLET 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-ACET-TRAMADOL 37.5 MG/325 MG TABLET JAMP-BISACODYL 5 MG TABLET JAMP-COLCHICINE 0.6 MG TABLET JAMP-DICYCLOMINE HCL 10 MG TABLET JAMP-DICYCLOMINE HCL 20 MG TABLET JAMP-DOCUSATE CALCIUM 240 MG CAPSULE JAMP-DOCUSATE SODIUM 50 MG/ML ORAL SYRUP JAMP-FERROUS SULFATE 300 MG TABLET JAMP-FOLIC ACID 5 MG TABLET JAMP-GABAPENTIN 600 MG TABLET JAMP-GABAPENTIN 800 MG TABLET JAMP-IBUPROFEN 400 MG TABLET JAMP-OMEPRAZOLE DR 20 MG DELAYED-RELEASE TABLET JAMP-PIOGLITAZONE 15 MG TABLET JAMP-PIOGLITAZONE 30 MG TABLET JAMP-PIOGLITAZONE 45 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-SOTALOL 160 MG TABLET JAMP-TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE JAMP-VITAMIN D 10000 UNIT TABLET JANUMET XR 50 MG/1000 MG EXTENDED-RELEASE TABLET JANUVIA 25 MG TABLET Route OPH OPH 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 ORL ORL ORL ORL ORL ORL ORL Form DPS DPS TAB NDL TAB TAB TAB MRC TAB TAB TAB TAB TAB CAP SYR TAB TAB TAB TAB TAB CAP/SRT TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB SRC TAB ERT 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 ALC ALC VCL NOV NOV NOV NOV GSK JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC JPC MFC MFC Unit of Issue ML ML TAB SYR TAB TAB TAB CAP TAB TAB TAB TAB TAB CAP ML TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB Base Price 0.5367 0.5367 0.0899 210.0000 88.3562 88.3562 88.3562 1.8007 0.6264 0.0450 0.2565 0.1226 0.2207 0.0816 0.9203 0.0675 0.0417 1.3045 1.7393 0.0474 0.4117 0.5809 0.8139 1.2237 0.2390 0.3750 9.2000 9.0075 8.8475 0.7287 0.9005 0.9005 0.3704 0.9005 0.2087 54.6400 0.2100 1.7252 3.1837 Pg 42 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002388847 00002408295 00002403277 00002403250 00002403269 00002410818 00002048744 00002369524 00002247344 00002337282 00002337290 00002337266 00002337274 00002412365 00002312301 00002285533 00002243644 00002397412 00080011529 00002243768 00000713376 00000376167 00000224391 00000224405 00002246796 00002246795 00002244947 00002400871 00001926438 00080020666 00002269341 00001928783 00002389185 00002389169 00002389177 00080022006 00002350580 00080004073 00002185881 Product Description JANUVIA 50 MG TABLET JAYDESS 13.5 MG INTRAUTERINE INSERT JENTADUETO 2.5 MG/1000 MG TABLET JENTADUETO 2.5 MG/500 MG TABLET JENTADUETO 2.5 MG/850 MG TABLET JETREA 0.5 MG/VIAL INJECTION JE-VAX INJECTION JEVTANA 40 MG/ML INJECTION JUNIOR STRENGTH MOTRIN 100 MG CHEWABLE TABLET JURNISTA 16 MG EXTENDED-RELEASE TABLET JURNISTA 32 MG EXTENDED-RELEASE TABLET JURNISTA 4 MG EXTENDED-RELEASE TABLET JURNISTA 8 MG EXTENDED-RELEASE TABLET 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 KALYDECO 150 MG TABLET K-CITRA 2 MEQ/ML SOLUTION K-CITRA POTASSIUM CITRATE 10 MEQ SRT K-DUR 1500 MG SUSTAINED RELEASE TABLET 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 Route ORL IU ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL INJ 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 Form TAB INS TAB TAB TAB DEFAUL DEFAUL DEFAUL CTB ERT ERT ERT ERT DEFAUL TAB TAB SOL TAB LIQ SRT SRT SOL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL LIQ TAB SYR TAB TAB TAB CAP 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 MFC TAB BAI SYS BOE TAB BOE TAB BOE TAB ALC VIAL CNG VIAL SAV VIAL MCL TAB JAI TAB JAI TAB JAI TAB JAI TAB HLR ML ABV TAB ABV TAB ABV ML VER TAB SFD ML SFD TAB MFC TAB AXS ML ERF ML ERF ML SDZ ML SDZ ML PPC ML STM ML AVE VIAL WBP ML GSK TAB ROG ML BMS TAB BMS TAB BMS TAB WBP CAP BMI TAB WKG TAB HLR TAB Base Price 3.1837 294.1300 1.4492 1.4492 1.4492 3950.0000 131.6633 5800.0000 0.2250 5.0040 10.0070 1.2507 2.5013 430.0000 2.9990 5.9979 2.3740 420.0000 0.0349 0.2901 0.2052 0.2786 1.7385 5.7590 5.4350 1.7875 5.3352 4.6000 134.7900 0.1410 25.6657 0.0209 1.3800 1.3800 1.3800 0.2297 33.0000 0.5991 10.9460 Pg 43 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002231689 00000210889 00002250624 00080012831 00000468401 00002243803 00002366282 00000608734 00002186926 00000282081 00002018055 00002224690 00002224704 00002387786 00002387751 00002387778 00002415828 00002415836 00002338459 00002347997 00002402025 00002183005 00000004626 00002236840 00002236839 00002412829 00002250470 00002250489 00002250462 00002245948 00002243933 00002296187 00000436208 00002231147 00000874949 00002243101 00080003212 00000030732 00002269082 Product Description LABETALOL HYDROCHLORIDE 5 MG/ML INJECTION LACRI-LUBE OPH OINTMENT LACRISERT 5 MG OPHTHALMIC INSERT LACTOBACILLUS ACIDOPHILUS & BIFIDUS LAIT DE MAGNESIE ORL SUSP (MILK OF MAGNESIA) LAMICTAL 2 MG CHEWABLE TABLET LANSOPRAZOLE 30 MG DELAYED-RELEASE CAPSULE LANSOYL JELLY 78% LANSOYL SUGAR FREE JELLY 78% LANVIS 40 MG TABLET LARIAM 250 MG TABLET LASIX 20 MG TABLET LASIX 40 MG TABLET LATUDA 120 MG TABLET LATUDA 40 MG TABLET LATUDA 80 MG TABLET LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 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 5 MG/ML INJECTION LEVEMIR FLEXTOUCH 100 UNIT/ML INJECTION LEVITRA 10 MG TABLET LEVITRA 20 MG TABLET LEVITRA 5 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 LIPIDIL EZ 145 MG TABLET Route INJ OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL INJ INJ INJ ORL ORL ORL INJ TOP INJ INJ TOP OT ORL ORL INJ ORL Form DEFAUL ONT INS CAP SUS CTB DRC GEL GEL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB DEFAUL DEFAUL DEFAUL TAB TAB TAB DEFAUL SOL LIQ DEFAUL SPR LIQ ECT LIQ DEFAUL 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 SDZ ALL ATP SWS ATL GSK PDL JOU JOU GSK HLR SAV SAV SUN SUN SUN PDL PDL AHI TEV PDL MNP GSK JAI JAI NNA BAI BAI BAI PPC DSP ALV HSP ODN SDZ PMS HJS PFI FOU Unit of Issue ML G DEV CAP ML TAB CAP G G TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB ML ML ML TAB TAB TAB VIAL ML ML ML DOSE ML TAB ML ML TAB Base Price 1.5105 2.1543 3.3623 0.1123 0.0069 0.1847 0.6000 0.0499 0.0467 4.8204 4.9200 0.0873 0.1307 4.4010 4.4010 4.4010 2.6433 2.6433 3.0617 2.7560 1.3780 12.7040 1.5592 2.2895 0.4578 7.7340 13.2925 14.3950 11.9150 208.3400 149.4444 1.0500 5.9340 0.1812 0.5960 0.1597 0.0920 2.9420 1.1927 Pg 44 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002269074 00080006893 00080001853 00080007222 00002266695 00002131625 00002020017 00000074462 00002373955 00000590819 00002221810 00002244692 00002243278 00002394413 00002119579 00002321114 00002179709 00002239833 00002242933 00002242934 00002046210 00002269066 00002366924 00002268450 00002268477 00002268418 00002268485 00002268426 00002268434 00000463221 00002244690 00002244689 00002238291 00002267225 00002068400 00080025339 00002040921 00080005581 00080005079 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 LODALIS 625 MG TABLET LOPRESOR 1.0 MG/ML INJECTION LOPROX 1% TOPICAL LOTION LORATADINE 10 MG TABLET LORAZEPAM 4 MG INJECTION USP LOSARTAN-HCTZ 100 MG/25 MG TABLET LOSEC 10 MG SUSTAINED-RELEASE CAPSULE LOTEMAX 0.5% OPHTHALMIC SUSPENSION LOZIDE 1.25 MG TABLET 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 LYRICA 75 MG CAPSULE LYSODREN 500 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 Route ORL ORL ORL ORL ORL OPH NAS TOP ORL INJ TOP ORL INJ ORL ORL OPH ORL INJ TOP TOP INJ INJ TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL Form TAB LIQ LIQ LIQ SRT SUS SPR CRM TAB DEFAUL LOT TAB DEFAUL TAB SRC SUS TAB DEFAUL CRM CRM DEFAUL DEFAUL FOA CAP CAP CAP CAP CAP CAP TAB SUS SUS TAB NDL TAB TAB TAB CAP 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 FOU WBP JAM WNP AAP NOV JAI PAL VCL NOV VCL VTH SDZ PDL AZC BSH SEV ABV MEI MEI FEI SRO GSK PFI PFI PFI PFI PFI PFI BMS NVC NVC NVC PFI JAM WNP JAM WBP JAM Unit of Issue TAB ML ML ML TAB ML ML G TAB ML ML TAB ML TAB CAP ML TAB VIAL G G VIAL VIAL G CAP CAP CAP CAP CAP CAP TAB ML ML TAB SYR TAB TAB TAB CAP TAB Base Price 0.4657 0.0176 0.0323 0.0984 0.2711 5.1360 1.9427 0.9933 1.1953 1.3160 0.5423 0.4442 4.6720 0.3147 1.0079 4.7820 0.3237 1535.1000 1.1620 1.2930 115.0000 28.4800 0.8184 2.5022 2.5022 0.8943 2.5022 1.4028 1.8152 4.8905 0.0228 0.0196 0.1114 995.0000 0.0742 0.0491 0.0577 0.0790 0.0949 Pg 45 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002247017 00080013414 00080014800 00000392618 00000602264 00002139499 00000202045 00001927639 00002264935 00002238151 00002243459 00000499013 00000899356 00002166747 00002371707 00002379562 00002241918 00002241919 00002305909 00002241917 00002241915 00002241914 00002371871 00002422255 00002403870 00000611190 00000611204 00002373424 00002389118 00002389126 00002416557 00002411946 00002420457 00002420481 00002420503 00002420465 00002420473 00002388324 00000012750 Product Description MAGNESIUM COMPLEX 250 MG TABLET MAGNESIUM EXTRA STRENGTH 500 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-AMLODIPINE 2.5 MG TABLET MAR-ANASTROZOLE 1 MG TABLET MARCAINE 2.5 MG/ML INJECTION 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-CITALOPRAM 10 MG TABLET MAR-CLOPIDOGREL 75 MG TABLET MAR-DOMPERIDONE 10 MG TABLET MARINOL 2.5 MG CAPSULE MARINOL 5 MG CAPSULE MAR-LETROZOLE 2.5 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-RAMIPRIL 1.25 MG CAPSULE MAR-RAMIPRIL 10 MG CAPSULE MAR-RAMIPRIL 15 MG CAPSULE MAR-RAMIPRIL 2.5 MG CAPSULE MAR-RAMIPRIL 5 MG CAPSULE MAR-TRAMADOL/ACET 37.5 MG/325 MG TABLET MATULANE 50 MG CAPSULE Route ORL ORL ORL INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form TAB TAB PWRSUS DEFAUL DEFAUL DEFAUL EML TAB TAB TAB LIQ TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB TAB CAP CAP TAB DISNTAB DISNTAB ECT TAB CAP/TAB CAP/TAB CAP/TAB CAP/TAB CAP/TAB TAB 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 JAM WNP NCC SDZ SDZ PPC PPH ERF GSK GSK CHD PFI MED MED MAR MAR HSP HSP HSP HSP HSP HSP MAR MAR MAR ABB ABB MAR MAR MAR MAR MAR MAR MAR MAR MAR MAR MAR SGM Unit of Issue TAB TAB G ML ML ML ML TAB TAB TAB ML TAB TAB TAB TAB TAB ML ML ML ML ML ML TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP TAB CAP Base Price 0.0450 0.0790 0.0973 0.5117 1.6450 0.4310 0.0145 0.5442 1.6867 5.0625 0.0222 0.3966 0.6908 1.3712 0.1726 3.3280 0.8156 0.9704 0.9696 1.9718 0.8454 12.7225 0.1432 0.6576 0.1646 2.2292 4.4582 3.0617 6.9623 7.5900 1.2750 1.0430 0.1274 0.1862 0.8550 0.1470 0.1470 0.6264 63.1064 Pg 46 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002244533 00002245939 00002163632 00002163640 00002253550 00002253577 00002322250 00002244366 00002040891 00002409623 00002409658 00080006449 00002353156 00002353148 00002279924 00002248649 00002243820 00000588490 00001959018 00002283093 00002347393 00000725749 00000725757 00002415275 00002378795 00002378787 00002047667 00002241615 00002174812 00002247034 00002174782 00002174790 00002174804 00002398427 00002182971 00002182947 00002230521 00002236872 00000868868 Product Description MAXILENE 4% TOPICAL CREAM MAXILENE 5 % TOPICAL CREAM MAXIPIME 1 G/VIAL INJECTION MAXIPIME 2 G/VIAL INJECTION 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 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 MENINGITECTM (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 METAMUCIL FIBRE APPLE CRISP 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 SODIUM (UNPRESERVED) 10 MG/ML INJ METHOXACET CAPLET METHOXACET-C 1/8 CAPLET METHOXISAL CAPLET Route TOP TOP INJ INJ ORL ORL INJ ORL 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 INJ INJ INJ ORL ORL ORL Form CRM CRM DEFAUL DEFAUL TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB DEFAUL DEFAUL TAB WAF PWR CAP PWR PWR PWR DEFALT DEFAUL DEFAUL 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 RGR RGR TMD TMD PDL PDL SDZ AAP JAM GSK GSK PLH SNS SNS SFP AYE NOV SFP SFP FEI NOV SDZ SDZ STM SDZ SDZ SAV PGI PGI PGI PGI PGI PGI SDZ MNP MNP RPH RPH RPH Unit of Issue G G VIAL VIAL TAB TAB ML TAB TAB TAB TAB TAB TAB TAB ML ML VIAL VIAL VIAL VIAL ML ML ML TAB VIAL VIAL TAB WAF G CAP G G G ML ML ML TAB TAB TAB Base Price 1.7380 1.5900 17.7650 35.5250 0.0416 0.0823 22.0000 4.0150 0.1028 77.9373 311.7500 0.0556 0.5670 0.4913 239.0600 139.8000 96.7100 157.2900 178.1000 65.8000 217.1600 1.3380 1.2630 3.1092 47.9900 23.9950 0.2271 0.2545 0.0274 0.1235 0.0682 0.0160 0.0325 8.3700 7.8755 8.9810 0.3417 0.6150 0.2772 Pg 47 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00001966375 00001966367 00001941895 00002326248 00002326256 00002326221 00002243563 00002320037 00002320045 00002304767 00002320053 00002320029 00000648027 00000648019 00002092832 00002248562 00002323273 00000795860 00000795852 00002085852 00002171775 00002091143 00002091135 00002063905 00000787000 00000487805 00002240285 00002242904 00002242905 00002382873 00002244622 00001935348 00000485802 00002246500 00002421380 00002421399 00002326477 00002326485 00002326493 Product Description METHOXISAL-C 1/2 TABLET METHOXISAL-C 1/4 TABLET METHOXISAL-C 1/8 CAPLET METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE 20 MG TABLET METHYLPHENIDATE 5 MG TABLET 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-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 MINERAL OIL (HEAVY) MINERAL OIL 100% ORAL LIQUID MINIRIN 0.1 MG TABLET MINT-PAROXETINE 20 MG TABLET MINT-PAROXETINE 30 MG TABLET MINT-PIOGLITAZONE 15 MG TABLET MINT-PIOGLITAZONE 30 MG TABLET MINT-PIOGLITAZONE 45 MG TABLET Route ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ ORL ORL TOP ORL TOP ORL ORL TOP VAG INJ INJ RT INJ ORL INJ INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL Form TAB TAB TAB TAB TAB TAB DEFAUL NDL NDL NDL NDL NDL TAB TAB GEL CAP CRM TAB TAB CRM OVL DEFAUL DEFAUL ENM DEFAUL TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL LIQ LIQ 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 RPH RPH RPH PDL PDL PDL OMG MDX MDX MDX MDX MDX PDL PDL GAL AAP GAL MFC MFC WSP VTH SDZ SDZ JJM SDZ OPI SDZ PPC PPC SDZ PPC RBW RPH FEI MPI MPI MPI MPI MPI Unit of Issue TAB TAB TAB TAB TAB TAB ML SYR SYR SYR SYR SYR TAB TAB G CAP G TAB TAB G OVL ML ML ENM ML TAB ML ML ML ML ML ML ML TAB TAB TAB TAB TAB TAB Base Price 1.0350 0.8335 0.5561 0.1262 0.2435 0.0947 1.0250 53.1000 58.7000 64.2800 69.8800 50.3100 0.1250 0.0624 1.4488 0.7637 162.8200 2.0610 3.7647 0.3840 1.6966 2.5276 0.9090 1.2950 2.4042 0.2860 0.8476 1.2440 4.4555 0.8475 5.0610 0.0088 0.0122 1.4361 0.4513 0.4796 0.5809 0.8139 1.2237 Pg 48 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002393085 00002393069 00002393077 00002389800 00000042544 00002241594 00002248846 00002230451 00002230450 00001948873 00001948881 00000466085 00002242786 00002242785 00002238696 00001909142 00001909169 00002239601 00002244005 00002126605 00002126249 00002084309 00002126257 00002126567 00002239600 00001907107 00001907115 00000999332 00002379856 00002379821 00002379848 00000676411 00002350920 00002350947 00001964437 00001964429 00001980696 00002242484 00080028360 Product Description 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 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 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 SR 100 MG SUSTAINED RELEASE TABLET MORPHINE SR 200 MG SUSTAINED RELEASE TABLET 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 Route ORL ORL ORL ORL OPH ORL ORL INJ INJ INJ INJ INJ ORL ORL ORL TOP TOP VAG VAG VAG VAG/TOP VAG VAG/TOP TOP VAG/TOP ORL ORL DEFAUL ORL ORL ORL INJ ORL ORL INJ INJ INJ INJ TOP Form TAB TAB TAB TAB SOL TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB TAB LIQ CRM LOT OVL CRM OVL OVL/CRM CRM OVL/CRM CRM OVL/CRM TAB TAB DEV TAB TAB TAB DEFAUL SRT SRT 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 MPI MPI MPI MPI ALC BOE PDL TEV TEV ALK ALG MSD BOE BOE PMS WSD WSD MCL MCL MCL MCL MCL MCL MCL MCL BMS BMS PMS PDL PDL PDL SDZ SNS SNS SDZ SDZ SDZ SDZ NDP Unit of Issue TAB TAB TAB TAB ML TAB TAB VIAL VIAL ML VIAL VIAL TAB TAB ML G ML OVL G OVL KIT G KIT G KIT TAB TAB ML TAB TAB TAB ML TAB TAB ML ML ML ML G Base Price 9.2000 8.2900 8.8475 0.6264 13.5117 2.3550 0.2850 377.2000 94.3000 71.3833 71.3833 32.1760 1.0044 0.8705 0.0688 0.0623 0.0229 12.9800 0.8653 4.3267 14.8600 0.3709 14.8600 0.4247 14.8600 0.9262 1.1138 93.7500 0.9460 0.9460 0.9460 2.8325 1.0400 1.9336 0.2528 0.4153 0.3726 1.4600 0.1212 Pg 49 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002186934 00002377225 00080001844 00002125013 00000599875 00002330989 00000782203 00000782211 00000586315 00002100606 00002244898 00000374083 00002248775 00002248778 00002240942 00000233498 00080005483 00002242779 00002242939 00002242780 00002244864 00000750816 00000750824 00002238595 00002238593 00002238594 00000016063 00002294222 00002264560 00002264579 00002270110 00002229813 00002229814 00002139200 00002253054 00002361418 00002378981 00002378930 00002378949 Product Description MOTRIN IB 200 MG TABLET MOZOBIL 24 MG/1.2 ML INJECTION 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 MUSE 250 MCG URETHRAL SUPPOSITORY MUSE 500 MCG URETHRAL SUPPOSITORY MUSTARGEN HCL TRITURATION 10 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 Route ORL INJ ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL OPH OPH URH URH URH INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form TAB DEFAUL TAB SUS PWR TAB TAB TAB DEFAUL DEFAUL TAB TAB CAP CAP SHP TAB TAB TAB TAB TAB TAB ONT SOL SUP SUP SUP DEFAUL DEFAUL ECT ECT TAB TAB TAB CAP CAP TAB 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 MCL TAB SAV ML 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 PAL SUP PAL SUP LUI 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 Base Price 0.1329 6295.8333 0.0686 0.0243 0.0189 2.3380 0.0600 0.0270 0.8197 0.8380 0.0700 0.1100 0.1702 0.1276 0.0381 0.2226 0.0357 0.0800 0.0665 0.0678 0.0300 3.1400 0.7327 33.7600 33.7600 33.7600 8.5500 98.0000 2.1708 4.3415 1.0370 0.3099 0.5508 0.5179 3.6393 2.7497 4.3520 2.6500 2.9281 Pg 50 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002378957 00002378965 00002378973 00002302403 00002384426 00002384418 00002383500 00002383497 00002241003 00002379120 00002227479 00002381524 00002383039 00002383047 00002397471 00002397498 00002185407 00002230476 00002242920 00002319225 00002319233 00002255995 00002255987 00002371154 00002370549 00002244563 00002387727 00002382725 00002382733 00002248012 00002298279 00002298287 00002298295 00002376369 00002245372 00002245373 00002397773 00002332809 00002332817 Product Description MYLAN-ATOMOXETINE 40 MG CAPSULE MYLAN-ATOMOXETINE 60 MG CAPSULE MYLAN-ATOMOXETINE 80 MG CAPSULE 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-CANDESARTAN 4 MG TABLET 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-GABAPENTIN 600 MG TABLET MYLAN-GABAPENTIN 800 MG TABLET MYLAN-GEMFIBROZIL 300 MG CAPSULE MYLAN-GEMFIBROZIL 600 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-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-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-RIVASTIGMINE 1.5 MG CAPSULE MYLAN-RIVASTIGMINE 3 MG CAPSULE Route 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 ORL ORL ORL ORL ORL ORL ORL ORL ORL Form CAP CAP CAP TAB TAB TAB TAB TAB SPM TAB TAB TAB DRT DRT TAB TAB CAP TAB CAP TAB TAB TAB TAB CAP TAB TAB TAB DISNTAB DISNTAB TAB TAB TAB TAB TAB TAB TAB TAB 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 MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP MYP Unit of Issue CAP CAP CAP TAB TAB TAB TAB TAB DOSE TAB TAB TAB TAB TAB TAB TAB CAP TAB CAP TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP Base Price 3.3375 3.7024 3.9960 4.0573 0.1450 0.1080 22.4625 22.4625 0.0917 0.3400 0.2430 12.1817 2.0309 2.0309 1.3045 1.7393 0.1288 0.5157 1.1087 6.0417 6.0417 0.6161 0.4914 1.1204 2.2406 0.3625 1.7285 4.1240 7.5977 1.0430 0.6312 0.8844 1.3297 1.0514 0.3222 0.5680 40.9500 1.3029 1.3029 Pg 51 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002332825 00002332833 00002268906 00002019795 00002088428 00002089858 00002298570 00000893773 00002351560 00002184648 00002383527 00002287501 00002287528 00000004618 00002372169 00002408694 00002408651 00002408708 00002408678 00002408686 00002392593 00002392577 00002392585 00001927612 00002226022 00002402874 00002402882 00002343282 00000828815 00000818704 00002382601 00002148706 00002148714 00000390283 00000481408 00002242505 00002242506 00002162431 00002162792 Product Description MYLAN-RIVASTIGMINE 4.5 MG CAPSULE MYLAN-RIVASTIGMINE 6 MG CAPSULE 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-TIMOLOL 0.25% OPH SOLUTION MYLAN-VALACYCLOVIR 1000 MG CAPLET 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 NABUMETONE 500 MG 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 25 MG/ML ORAL SUSPENSION NAPROSYN E 250 MG ENTERIC-COATED TABLET Route ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ TOP ORL ORL ORL ORL ORL INJ INJ INJ OPH OPH ORL ORL ORL ORL Form CAP CAP TAB CTB TAB TAB SRC SOL TAB CAP TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB TAB DEFAUL CRM ERT ERT TAB TAB TAB DEFAUL DEFAUL DEFAUL SOL SOL CRT CRT SUS ECT This document is for pricing use only and should 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 MYP MYP MYP WLA MYP MYP MYP MYP MYP MYP MYP MYP MYP GSK MYP MYP MYP MYP MYP MYP MYP MYP MYP AVE BIC ASP ASP SNS PDL PDL SDZ SDZ SDZ ALC ALC SUN SUN HLR HLR Unit of Issue CAP CAP TAB TAB TAB TAB CAP ML TAB CAP TAB TAB TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB TAB ML G TAB TAB TAB TAB TAB ML ML ML ML ML TAB TAB ML TAB Base Price 1.3029 1.3029 8.9900 0.1062 0.1750 0.3500 0.2581 1.5500 3.3924 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 8.8477 16.0820 0.1034 1.8908 1.8908 0.3769 0.2465 0.3515 14.9360 14.9360 20.1475 0.5253 0.4953 1.0436 1.3727 0.0631 0.4174 Pg 52 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000618721 00000590762 00000655686 00002153386 00002229415 00002213834 00002192799 00000788503 00002409003 00002409011 00000024457 00080029758 00002245057 00000147680 00000749834 00000666157 00000666122 00000874957 00000885282 00001915436 00002230593 00002230592 00001958690 00000999459 00002028719 00000587834 00080007796 00002403897 00002403900 00002403919 00002403927 00002403935 00002403943 00002239717 00002239718 00002308983 00002284227 00002300524 00002244521 Product Description NAPROXEN 500 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% NAT-CITALOPRAM 10 MG TABLET NAT-CITALOPRAM 20 MG TABLET NAVANE 10 MG CAPSULE NEBUSAL 7% INHALATION SOLUTION NEISVAC-C 10 MCG/20 MCG INJECTION SYRINGE NEO-BEX (LIDOCAINE HCL) INJECTION VIAL NEO-HC 2% TOPICAL CREAM 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 NERISALIC OILY TOPICAL CREAM NERISONE 0.1% TOPICAL OINTMENT NERVOHEEL N 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 NEVANAC 0.1% OPHTHALMIC SUSPENSION NEXAVAR 200 MG TABLET NEXIUM 10 MG/DOSE DEL REL GRANULES FOR ORAL SUSP NEXIUM 20 MG DELAYED-RELEASE TABLET Route ORL ORL ORL ORL INJ NAS ORL NAS ORL ORL ORL MIS INJ INJ TOP IR TOP INJ INJ INJ INJ INJ TOP DEFAUL TOP TOP ORL TRD TRD TRD TRD TRD TRD ORL ORL OPH ORL ORL ORL Form TAB TAB TAB TAB DEFAUL SPM TAB LIQ TAB TAB CAP DEFAUL NDL DEFAUL CRM SOL ONT DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL GEL DEV CRM ONT TAB PTH PTH PTH PTH PTH PTH TAB TAB SUS TAB DRGRNUL DRT This document is for pricing use only and should 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 PDL PDL PDL PDL AZC SAV VTH CNF NTP NTP ERF STM SHB BRO NEO GSK GSK SDZ SDZ SDZ OMG OMG CDX STL GSK GSK HEE UCB UCB UCB UCB UCB UCB PFI PFI ALC BAI AZC AZC Unit of Issue TAB TAB TAB TAB ML DOSE TAB ML TAB TAB CAP ML SYR ML G ML G ML ML ML ML ML G ML G G TAB PTH PTH PTH PTH PTH PTH TAB TAB ML TAB PCKT TAB Base Price 0.2110 0.1068 0.1458 0.6667 0.3750 0.2173 0.1317 0.0920 0.1432 0.2397 0.4799 0.2642 80.1850 6.1440 0.3603 1.6860 0.4680 0.8844 0.9930 3.4342 0.8850 0.9950 0.8280 41.3333 0.5303 0.3863 0.2858 3.8467 3.8467 7.0633 7.0633 7.9000 7.8117 2.0251 2.6737 4.3340 49.9196 2.3667 2.3667 Pg 53 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002244522 00000232459 00000779806 00000309737 00002242138 00002244702 00002262339 00002262347 00002262355 00002309289 00002309254 00002309262 00002247347 00002247348 00002065762 00080007461 00080007464 00080000402 00080000396 00002125226 00002325926 00002229655 00002229654 00002182920 00002397927 00002048485 00080016396 00001966154 00001966162 00002285576 00000023760 00002357593 00002229145 00002241480 00002049481 00002049473 00000216666 00002314282 00002314541 Product Description 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 NORFLEX 100 MG TABLET NORFLEX 30 MG/ML INJECTION 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-ATOMOXETINE 10 MG CAPSULE Route 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 INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form 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 TAB DEFAUL TAB TAB TAB SOL CAP LIQ LIQ ECT SRT 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 AZC ADA VTH JAM QVS JAM SUN SUN SUN SUN SUN SUN MCL MCL MCL NOV NOV NVC NOV VCL BAI AAP AAP MCL FEI AZC PLH MMH GRC BAI PFI ABV ABV ABB SAV SAV TEV TEV TEV Unit of Issue TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB LOZ LOZ PTH LOZ LOZ PIECE PIECE G TAB TAB TAB ML TAB TAB CAP TAB ML TAB TAB TAB ML CAP ML ML TAB TAB CAP Base Price 2.3667 0.0830 0.9237 0.0592 0.1395 0.2047 1.3270 1.3603 1.4180 1.4216 1.4216 1.4063 0.4714 0.5423 3.4771 0.2744 0.3119 0.3119 0.2781 0.3233 10.8334 0.1282 0.0708 0.0972 1.3200 0.4003 0.1560 0.8414 5.6642 9.3450 1.4693 1.5940 1.2854 1.5612 0.1863 0.1517 0.0321 0.5980 2.5147 Pg 54 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002314568 00002314576 00002314584 00002314592 00002310422 00002280205 00002280183 00002270226 00002312336 00002309556 00002330601 00002324199 00000021458 00000595829 00002239954 00000389218 00002273756 00002273764 00002273772 00002230201 00002176084 00002230730 00002315068 00002315076 00002315084 00002315092 00002279894 00002279908 00002279916 00002265435 00002265443 00002364883 00002348675 00002240868 00002126753 00002126761 00002240457 00002240458 00002285479 Product Description NOVO-ATOMOXETINE 18 MG CAPSULE NOVO-ATOMOXETINE 25 MG CAPSULE NOVO-ATOMOXETINE 40 MG CAPSULE NOVO-ATOMOXETINE 60 MG CAPSULE NOVO-BENZYDAMINE 0.15% ORAL RINSE NOVO-BETAHISTINE 24 MG TABLET NOVO-BETAHISTINE 8 MG TABLET NOVO-BICALUTAMIDE 50 MG TABLET NOVO-CITALOPRAM 10 MG TABLET NOVO-CYPROTERONE/ETHINYL ESTRADIOL 2MG/0.035MG TAB NOVO-ENALAPRIL 40 MG TABLET NOVO-ETIDRONATECAL 400 MG/500 MG TABLET NOVOFERROGLUC 300 MG TABLET NOVO-FIBER 469 MG TABLET NOVO-FLUVOXAMINE 100 MG TABLET NOVO-GESIC 325 MG TABLET NOVO-GLIMEPIRIDE 1 MG TABLET NOVO-GLIMEPIRIDE 2 MG TABLET NOVO-GLIMEPIRIDE 4 MG TABLET NOVO-KETOROLAC 10 MG TABLET NOVO-KETOTIFEN 0.2 MG/ML (BASE) ORAL SYRUP NOVO-KETOTIFEN 1 MG TABLET NOVO-METHYLPHENIDATE ER-C 18 MG EXTEND RELEASE TAB NOVO-METHYLPHENIDATE ER-C 27 MG EXTEND RELEASE TAB NOVO-METHYLPHENIDATE ER-C 36 MG EXTEND RELEASE TAB NOVO-METHYLPHENIDATE ER-C 54 MG EXTEND RELEASE TAB NOVO-MIRTAZAPINE OD 15 MG ORALLY DISINTEGRATING TA NOVO-MIRTAZAPINE OD 30MG ORALLY DISINTEGRATING TAB NOVO-MIRTAZAPINE OD 45MG ORALLY DISINTEGRATING TAB 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-NADOLOL 40 MG TABLET NOVO-NADOLOL 80 MG TABLET NOVO-NIZATIDINE 150 MG CAPSULE NOVO-NIZATIDINE 300 MG CAPSULE NOVO-PANTOPRAZOLE 20MG ENTERIC-COATED ORAL TAB 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 INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL Form CAP CAP CAP CAP RNS TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SYR TAB ERT ERT ERT ERT DISNTAB DISNTAB DISNTAB DEFAUL DEFAUL CAP TAB TAB TAB TAB CAP CAP ECT This document is for pricing use only and should 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 TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV NNA NNA TEV TEV TEV TEV TEV TEV TEV TEV Unit of Issue CAP CAP CAP CAP ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB ML ML CAP TAB TAB TAB TAB CAP CAP TAB Base Price 2.8820 3.1817 3.3377 3.7023 0.0290 0.5415 0.2070 4.0573 0.2790 1.2076 1.2560 0.2808 0.0254 0.0706 0.5506 0.0354 0.4900 0.4900 0.4900 0.4085 0.4545 0.6335 1.5513 1.7903 2.0292 2.5071 0.2967 0.5933 0.8190 3.8413 3.1833 1.0310 2.0620 0.9192 0.2465 0.3515 0.2098 0.4131 1.2750 Pg 55 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000021202 00000391603 00000021288 00000869015 00000869023 00000869007 00000021695 00000232378 00002283891 00000605859 00000652318 00002326450 00002308754 00002308738 00002308746 00002231182 00002286815 00000851965 00000851973 00002230085 00002230086 00002230087 00001947818 00001947826 00001947796 00002218321 00002322854 00002322862 00002197405 00000886106 00000865567 00000865575 00001913980 00001913972 00001913824 00001913840 00002360381 00002360403 00002360411 Product Description NOVO-PEN-VK 300 MG TABLET NOVO-PEN-VK 60 MG/ML ORAL LIQUID SUSPENSION NOVO-PHENIRAM 4 MG TABLET NOVO-PINDOL 10 MG TABLET NOVO-PINDOL 15 MG TABLET NOVO-PINDOL 5 MG TABLET NOVO-PREDNISONE 5 MG TABLET NOVO-PREDNISONE 50 MG TABLET NOVO-RAMIPRIL 1.25 MG CAPSULE NOVO-RYTHRO EES 40 MG/ML (BASE) ORAL SUSPENSION NOVO-RYTHRO EES 80 MG/ML (BASE) ORAL SUSPENSION NOVO-SALBUTAMOL HFA 100 MCG/DOSE METERED DOSE AERO NOVO-SILDENAFIL 100 MG TABLET NOVO-SILDENAFIL 25 MG TABLET NOVO-SILDENAFIL 50 MG TABLET NOVO-SOTALOL 160 MG TABLET NOVO-SUMATRIPTAN DF 25 MG TABLET NOVO-TAMOXIFEN 10 MG TABLET NOVO-TAMOXIFEN 20 MG TABLET NOVO-THEOPHYL SR 100 MG SUSTAINED-RELEASE TABLET NOVO-THEOPHYL SR 200 MG SUSTAINED-RELEASE TABLET NOVO-THEOPHYL SR 300 MG SUSTAINED-RELEASE TABLET NOVO-TIMOL 10 MG TABLET NOVO-TIMOL 20 MG TABLET NOVO-TIMOL 5 MG TABLET NOVO-VALPROIC 500 MG ENTERIC COATED CAPSULE NPLATE 250 MCG/0.5 ML VIAL INJECTION NPLATE 500 MCG/1 ML VIAL INJECTION NU-ACYCLOVIR 200MG TABLET NU-AMILZIDE TABLET NU-AMOXI 250 MG CAPSULE NU-AMOXI 500 MG CAPSULE NUBAIN 10 MG/ML INJECTION NUBAIN 20 MG/ML INJECTION NU-CAPTO 12.5 MG TABLET NU-CAPTO 50 MG TABLET NUCYNTA CR 100 MG EXTENDED-RELEASE TABLET NUCYNTA CR 150 MG EXTENDED-RELEASE TABLET NUCYNTA CR 200 MG EXTENDED-RELEASE TABLET Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL ORL Form TAB LIQ TAB TAB TAB TAB TAB TAB CAP/TAB SUS SUS AEM TAB TAB TAB TAB TAB TAB TAB SRT SRT SRT TAB TAB TAB ECC DEFAUL DEFAUL TAB TAB CAP CAP DEFAUL DEFAUL TAB TAB ERT ERT ERT This document is for pricing use only and should 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 TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV AMG AMG NXP NXP NXP NXP SDZ SDZ NXP NXP JAI JAI JAI Unit of Issue TAB ML TAB TAB TAB TAB TAB TAB CAP ML ML DOSE TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP VIAL VIAL TAB TAB CAP CAP ML ML TAB TAB TAB TAB TAB Base Price 0.0710 0.0472 0.0690 0.2323 0.3370 0.1361 0.0436 0.1885 0.4200 0.0967 0.1464 0.0325 9.9978 8.2900 9.6150 0.2087 8.9900 0.1902 0.3803 0.1413 0.1467 0.1400 0.2717 0.5005 0.1649 0.5197 942.4250 1884.8701 0.8783 0.1917 0.1032 0.2010 7.3300 6.0850 0.2120 0.5590 1.6007 2.1428 2.7780 Pg 56 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002360438 00002360373 00002378299 00002378272 00002378280 00000886017 00002020742 00000623385 00002216191 00002229722 00002249002 00002376393 00002399083 00002399091 00002253186 00000716901 00002239742 00002237577 00000687766 00000622443 00002024179 00002299437 00002299445 00002299453 00002248640 00002248642 00002248639 00002248641 00000358495 00002343681 00002343703 00002344408 00002239144 00002241277 00002303639 00002239016 00080003480 00080008273 00080015284 Product Description 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 NU-DICLO 25 MG ENTERIC COATED TABLET NU-GLYBURIDE 5 MG TABLET NUPERCAINAL ANESTHETIC 1% RECTAL OINTMENT NUTROPIN 10 MG/VIAL INJECTION 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 ODANS LIQUOR CARBONIS DETERGENS OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TABLET OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING 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 LIQUID Route ORL ORL ORL ORL ORL ORL ORL RT INJ INJ INJ INJ INJ INJ VAG VAG ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ INJ INJ TOP ORL ORL TOP TOP TOP TOP TOP ORL ORL ORL Form ERT ERT TAB TAB TAB ECT TAB ONT DEFAUL DEFAUL CTG CTG DEFAUL DEFAUL SDE CRM TAB TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL LIQ DISNTAB DISNTAB FOA CRM LOT LOT LOT CAP CAP 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 JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB NXP TAB NXP TAB NVC G HLR VIAL 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 ODN ML SIV TAB SIV TAB GSK G COS G COS ML OMB ML COS ML PMT CAP WNP CAP WNP ML Base Price 3.8467 1.0682 1.6006 1.0682 1.3199 0.1902 0.0683 0.1520 389.4400 194.7183 214.8700 197.7350 778.8800 194.7200 16.2333 0.1358 0.3611 0.3306 0.0620 0.0257 36.2880 5.6700 15.5840 38.0720 11.2000 23.4000 5.9500 52.3000 0.0660 2.6780 7.4227 1.5701 0.0991 0.0875 0.1154 0.0868 0.0990 0.2587 0.0274 Pg 57 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080002596 00002240743 00080003356 00080003127 00080003179 00002385384 00002303671 00002153513 00002421402 00002421410 00002271761 00002271788 00002306212 00080020211 00002248292 00002248319 00080003089 00002375842 00002350726 00002350661 00002350688 00002350696 00002350718 00000750794 00002280078 00000990059 00000990061 00000990062 00000990063 00000355666 00002160889 00000701785 00000807435 00002371189 00001985396 00002381885 00002381893 00002047535 00002245641 Product Description OMEGA 3 SELECT CAPSULE OMEGA 3-6-9 CAPSULE OMEGA 3-6-9 ORAL CAPSULE OMEGA-3 ELITE SOFTGEL OMEGA-3 TABLET OMEPRAZOLE 20 MG DELAYED-RELEASE CAPSULE OMNARIS 50 MCG/DOSE METERED DOSE NASAL SPRAY ONCOTICE 800 M UNIT/VIAL FOR BLADDER INSTILLATION ONDANSETRON 4 MG TABLET ONDANSETRON 8 MG TABLET 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 ONSOLIS 1200 MCG BUCCAL SOLUBLE FILM ONSOLIS 200 MCG BUCCAL SOLUBLE FILM ONSOLIS 400 MCG BUCCAL SOLUBLE FILM ONSOLIS 600 MCG BUCCAL SOLUBLE FILM ONSOLIS 800 MCG BUCCAL SOLUBLE FILM OPCON-A OPH SOLUTION OPI-LACTULOSE 667 MG/ML ORAL SYRUP OPTICHAMBER DEVICE OPTICHAMBER LARGE FACE MASK DEVICE OPTICHAMBER MEDIUM FACE MASK DEVICE OPTICHAMBER SMALL FACE MASK DEVICE OPTIMINE 1 MG TABLET OPTIMYXIN OPHTHALMIC OINTMENT OPTIMYXIN OTIC OPH DROPS OPTIMYXIN PLUS OTIC OPH SOLUTION OPTION 2 0.75 MG TABLET ORAJEL MAXIMUM STRENGTH GEL ORALAIR 100 UNIT SUBLINGUAL TABLET ORALAIR 300 UNIT SUBLINGUAL TABLET ORFENACE 100 MG TABLET ORGALUTRAN 250 MCG/ 0.5 ML INJECTION SYRINGE Route ORL ORL ORL ORL ORL ORL NAS BLDIR ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL BUC BUC BUC BUC BUC OPH ORL DEFAUL DEFAUL DEFAUL DEFAUL ORL OPH OT/OPH OT/OPH ORL ORL SLG SLG ORL INJ Form CAP CAP CAP CAP TAB CAP/SRT SPM PWS TAB TAB DEFAUL DEFALT TAB CTB TAB TAB CAP TAB FILM FILM FILM FILM FILM SOL SYR DEV ADUDEV PEDDEV INFDEV TAB ONT DPS SOL TAB GEL TAB TAB TAB 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 JAM JAM JAM WBP JAM SIV TAK MFC SNS SNS OMG OMG ODN BAI BIC BAI VTH BMS MED MED MED MED MED BSH OPI ACM ACM ACM ACM SCH SDZ SDZ SDZ PRI CHD PAL PAL KPC MFC Unit of Issue CAP CAP CAP CAP TAB CAP DOSE VIAL TAB TAB ML ML TAB TAB TAB TAB CAP TAB FILM FILM FILM FILM FILM ML ML DEV DEV DEV DEV TAB G ML ML TAB G TAB TAB TAB SYR Base Price 0.1131 0.1647 0.0983 0.0613 0.1641 0.5500 0.2334 273.1400 3.2720 4.9930 8.1750 8.1250 3.3500 0.1563 0.1067 0.1248 0.1063 2.5370 30.0000 12.0000 16.3500 21.8100 27.2600 0.2980 0.0145 30.7200 35.3400 28.5300 29.4300 0.4216 1.4543 0.6490 0.8230 8.2250 0.4389 1.3700 4.1292 0.4700 94.7100 Pg 58 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002209055 00080023808 00000999460 00000999490 00002247548 00002301911 00002238867 00000653330 00000741043 00002331403 00002262088 00002371588 00000013617 00002239298 00000292990 00000497770 00000497754 00000497762 00001907476 00001946374 00000252654 00002202441 00002323192 00002202468 00002323206 00002202476 00002258129 00002323214 00002202484 00002231934 00002139561 00002254735 00080001408 00002248374 00002363445 00002130947 00001923420 00001923455 00002264951 Product Description ORO-CLENSE 0.12% ORAL RINSE ORTHO BONE CAPSULE ORTHOVISC OSTENIL OSTEOCIT D PLUS TABLET OSTO-D2 50000 IU CAPSULE OTRIVIN 0.05% DECONGESTANT NASAL SPRAY OTRIVIN 0.1% DECONGESTANT NASAL SPRAY OTRIVIN 0.1% METERED DOSE SPRAY OTRIVIN MOIST 0.1% 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 30 MG TABLET OXAZEPAM 10 MG TABLET OXAZEPAM 15 MG TABLET OXSORALEN 1% TOPICAL LOTION OXSORALEN 10 MG CAPSULE OXSORALEN ULTRA 10 MG CAPSULE OXYCONTIN 10 MG CONTROLLED RELEASE TABLET OXYCONTIN 15 MG CONTROLLED RELEASE TABLET OXYCONTIN 20 MG CONTROLLED RELEASE TABLET OXYCONTIN 30 MG CONTROLLED RELEASE TABLET OXYCONTIN 40 MG CONTROLLED RELEASE TABLET OXYCONTIN 5 MG CONTROLLED RELEASE TABLET OXYCONTIN 60 MG CONTROLLED RELEASE TABLET OXYCONTIN 80 MG CONTROLLED RELEASE 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 30 MG/VIAL INJECTION Route ORL ORL DEFAUL DEFAUL ORL ORL NAS NAS DEFAUL NAS INJ INJ ORL ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ TRD ORL ORL OPH INJ ORL ORL INJ Form MWH CAP DEV DEV TAB CAP SPR SPR SPM SPR NDL DEFAUL DPS CAP TAB TAB TAB TAB LOT CAP CAP CRT CRT CRT CRT CRT CRT CRT CRT TAB DEFAUL PTH TAB TAB IMP DEFAUL CAP CAP 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 GER AOR PMS TRB SFD TPI NVC CGS CGS NVC SRO SRO CHD CHD CHD PDL PDL PDL VCL VCL VCL PUR PUR PUR PUR PUR PUR PUR PUR PUR PPC ASC NCI VTH ALL IAF GKC GKC SDZ Unit of Issue ML CAP ML ML TAB CAP ML ML ML ML SYR ML ML CAP TAB TAB TAB TAB ML CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB ML PTH TAB TAB SYS VIAL CAP CAP VIAL Base Price 0.0168 0.1565 57.5000 50.2600 0.1827 0.2202 0.2470 0.2470 0.2470 0.3320 77.4000 72.0000 0.3667 0.1875 0.1404 0.0750 0.0350 0.0550 1.5793 0.6206 0.4863 0.8680 1.0600 1.3000 1.7400 2.2560 0.6240 3.1500 4.1640 0.2847 7.0308 7.3300 0.0290 0.0266 1333.8500 113.6000 0.2487 0.3400 88.3500 Pg 59 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002246597 00002246598 00002264978 00002264986 00002246599 00002249677 00000718130 00000263699 00002214830 00000373036 00002188708 00000263702 00000483184 00002214857 00002214849 00002239616 00002241804 00002385740 00002318695 00002306727 00002282844 00002388227 00002248913 00002248914 00002248915 00002362171 00002233143 00002389274 00002027887 00002248503 00002248504 00002242863 00002232202 00002245747 00002358034 00002328232 00000468029 00002250535 00002247265 Product Description PAMIDRONATE DISODIUM 30MG/10ML VIAL INJECTION PAMIDRONATE DISODIUM 60 MG/10ML INJECTION PAMIDRONATE DISODIUM 60 MG/VIAL 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 10 TOPICAL (ALCOHOL) GEL PANOXYL 2.5% AQUAGEL PANOXYL 20 TOPICAL (ALCOHOL) GEL PANOXYL 4% CREAMY WASH PANOXYL 5 5% TOPICAL (ALCOHOL) GEL PANOXYL 5 5% TOPICAL BAR PANOXYL 5 5% WASH PANOXYL 5% AQUAGEL 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 SODIUM FOR INJECTION 40 MG/VIAL INJ 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 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 PEDIAFER 30 MG/ML ORAL SOLUTION USP PEDIAFER 75 MG/ML ORAL SOLUTION USP PEDIAFLOUR 5.56 MG/ML ORAL SOLUTION PEG 3350 ORAL POWDER PEGALAX ORAL POWDER PENICILLINE V 300 TABLET PENLAC NAIL LACQUER 8% TOPICAL SOLUTION PENNSAID 1.5% TOPICAL SOLUTION Route INJ INJ INJ INJ INJ INJ ORL TOP TOP TOP TOP TOP TOP TOP TOP INJ ORL ORL ORL INJ ORL ORL ORL ORL ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP Form DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL TAB ALCGEL WTRGEL ALCGEL WAS ALCGEL BAR WAS WTRGEL DEFAUL ECT ECT ECT DEFAUL TAB TAB TAB TAB TAB SOL SOL TAB TAB SRT SRT SYR SYR DPS PWR PWR TAB SOL SOL This document is for pricing use only and should 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 PPC PPC SDZ SDZ PPC OMG CTE GSK STI GSK STI STI STI STI STI TAK TAK SIV PDL SDZ SNS SIV PDL PDL PDL ALC ALC PAT GSK GSK GSK EUP EUP EUP MES MFI PDL VCL PAL Unit of Issue ML ML VIAL ML ML ML TAB G G G G G G ML G VIAL TAB TAB TAB VIAL TAB TAB TAB TAB TAB ML ML TAB TAB TAB TAB ML ML ML G G TAB G ML Base Price 15.7500 29.9000 12.3280 24.6550 44.8000 17.6700 0.2063 0.1462 0.1208 0.1905 0.0671 0.1243 0.0853 0.0609 0.1243 13.7000 1.9656 1.2750 0.9785 11.9100 1.0430 0.8210 0.8210 0.4513 0.4796 12.9400 6.4700 0.6263 1.8387 1.8723 2.0457 0.0286 0.1946 0.0697 0.0544 0.0381 0.0710 13.6917 0.8458 Pg 60 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00001980602 00001980599 00002183080 00001980556 00002164051 00001980564 00001980580 00001980572 00000710121 00000710113 00002185938 00000728128 00002097079 00002177994 00002237315 00000254916 00002240433 00002237452 00002207796 00002247104 00002229501 00080017389 00080001122 00002371499 00080001145 00002371502 00002162180 00002304090 00002304082 00002148455 00002148447 00002150638 00002150646 00002017733 00002245781 00002273543 00002249359 00002248608 00002248607 Product Description 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 20 MG TABLET PEPCID 40 MG TABLET 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 PERGONAL 75 UNIT/75 UNIT INJECTION PERICHLOR 0.12% ORAL RINSE 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-D 10,000 UNIT CAPSULE PHARMA-D 400 IU GELCAP PHARMA-D 50,000 UNIT CAPSULE 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) 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-CITALOPRAM 10 MG TABLET PHL-CYCLOBENZAPRINE 10 MG TABLET PHL-MELOXICAM 15 MG TABLET PHL-MELOXICAM 7.5 MG TABLET Route ORL ORL INJ OPH OPH OPH OT/OPH OT/OPH ORL ORL ORL INJ ORL ORL ORL INJ ORL ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL INJ INJ OPH OPH ORL ORL TOP ORL ORL ORL ORL ORL Form TAB TAB DEFAUL SOL SOL ONT ONT SUS TAB TAB TAB DEFAUL LIQ TAB CTB DEFAUL MWH MWH MWH CAP WAS CAP CAP CAP CAP CAP SYR DEFAUL DEFAUL SOL SOL CTB LIQ CLR 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 SDZ SDZ HSP SDZ SDZ SDZ SDZ SDZ MFC MFC MFC MFC PGI PGI PGI SRO PMS ZIL COL PPH COC NFN PPH PMS PPH PMS CLC SDZ SDZ BSH OPT BAI BAI SAV PHH PHH PHH PHH PHH Unit of Issue TAB TAB VIAL ML ML G G ML TAB TAB TAB ML ML TAB TAB VIAL ML ML ML CAP ML CAP CAP CAP CAP CAP ML ML ML ML ML TAB ML ML TAB TAB TAB TAB TAB Base Price 0.5820 0.4780 127.1200 0.6180 0.6300 2.1600 2.9714 2.4580 1.1093 2.0254 0.3137 1.9955 0.0268 0.1683 0.3367 46.0000 0.0197 0.0244 0.0176 1.2497 0.0147 0.1952 0.0216 0.2100 0.0322 0.9500 0.0794 9.3010 8.3520 6.6667 6.6667 0.0526 0.0150 0.0776 1.2971 0.1432 0.3765 0.5670 0.4914 Pg 61 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002281732 00002307669 00002307677 00002307723 00002249766 00002249774 00002249782 00002299062 00002299089 00002299054 00002299097 00002236942 00002236941 00002294052 00002294060 00002229437 00002230399 00002019876 00002400987 00002400995 00002254794 00002300583 00002148463 00002148471 00000575240 00000828424 00000828416 00002374013 00002374021 00002374048 00002391600 00002339587 00002339595 00002246640 00002248939 00002246641 00002248940 00002246642 00002248941 Product Description PHL-MIRTAZAPINE 15 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-TRAZODONE 100 MG TABLET PHL-TRAZODONE 50 MG TABLET PHL-ZOPICLONE 5 MG TABLET 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) PILOPINE HS 4% OPH GEL 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 Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ TOP TOP ORL ORL OPH OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ INJ INJ INJ INJ Form TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB LIQ DEFAUL GEL GEL PWR PWDPKT SOL SOL GEL TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL 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. MFR PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PHH PRP PPH AXC LEO LEO FEI ODN BSH BSH ALC PDL PDL SIV SIV SIV AHI AHI AHI MNP PPC MNP PPC MNP PPC Unit of Issue TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML VIAL DOSE DOSE PCKT PCKT ML ML G TAB TAB TAB TAB TAB TAB TAB TAB VIAL VIAL VIAL VIAL VIAL VIAL Base Price 0.3750 1.5716 0.2017 3.3105 0.5670 0.6689 0.8057 0.9226 1.8527 0.3458 2.7038 0.3956 0.2214 0.2231 0.4685 0.4500 0.0924 19255.1000 138.7300 208.0950 8.6950 3.6000 6.6667 6.3483 2.6140 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 Pg 62 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002370158 00000501190 00002237405 00001946897 00000792691 00002243435 00000654523 00000654515 00000654507 00002247304 00002274949 00002320738 00002284529 00002283700 00002381028 00002381036 00002381044 00002381052 00002381060 00002313448 00002313456 00002313464 00002313472 00000587265 00002330237 00000759171 00000739162 00000759198 00002275589 00000587273 00002383020 00002383012 00002244508 00002391171 00002185830 00002185857 00002185865 00002185849 00002185873 Product Description 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 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-BENZTROPINE 2 MG TABLET PMS-BETAHISTINE 24 MG TABLET PMS-BETHANECHOL CHLORIDE 10 MG TABLET PMS-BETHANECHOL CHLORIDE 25 MG TABLET PMS-BETHANECHOL CHLORIDE 50 MG TABLET PMS-BICALUTAMIDE 50 MG TABLET PMS-BISACODYL 5 MG ENTERIC COATED 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 Route INJ 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 NAS ORL ORL ORL ORL ORL ORL Form DEFAUL TAB GUM ELX SOL DEFAUL TAB TAB TAB TAB CAP TAB ECT ECT CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ECT TAB TAB SPR TAB CAP SUS SUS CAP SUS This document is for pricing use only and should 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 TEV ODN PLI PMS PPH PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS Unit of Issue VIAL TAB PIECE ML ML ML TAB TAB TAB TAB CAP TAB TAB TAB CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB CAP ML ML CAP ML Base Price 9.6120 0.0750 0.1612 0.4052 0.0276 21.1900 0.0722 0.1316 0.2550 0.2346 3.3491 2.5460 0.0304 0.0576 2.3140 2.6523 2.9281 3.3377 3.7024 0.3410 0.3922 0.4581 0.4216 0.0450 0.5415 0.2300 0.3580 0.4925 4.0573 0.0522 48.1340 52.3048 16.6600 0.3400 0.6430 0.0762 0.1395 1.2625 0.2010 Pg 63 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002315963 00002413574 00002253933 00002232195 00002232191 00002232193 00002309548 00002243450 00002242055 00001946277 00000891797 00002247492 00002247490 00002247491 00000721344 00002239753 00000757683 00000757691 00002278081 00002278103 00002278111 00002273551 00000586323 00002222574 00002320169 00002238568 00000726354 00002230104 00002240683 00002240682 00002247493 00002247494 00002255898 00002255901 00002230183 00002247386 00002247387 00002324253 00000836133 Product Description PMS-CETIRIZINE 20 MG TABLET PMS-CICLOPIROX NAIL LACQUER 8% TOPICAL SOLUTION PMS-CIPROFLOXACIN 0.3% OPHTHALMIC SOL. 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 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-K 50 MG TABLET PMS-DIPHENHYDRAMINE 25 MG CAPSULE PMS-DIPHENHYDRAMINE 50 MG 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-FLUVOXAMINE 100 MG TABLET PMS-FLUVOXAMINE 50 MG TABLET PMS-FUROSEMIDE 20 MG TABLET PMS-FUROSEMIDE 40 MG TABLET PMS-GABAPENTIN 600 MG TABLET PMS-GABAPENTIN 800 MG TABLET 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 Route ORL TOP OPH SCP TOP TOP TOP INJ INJ ORL ORL ORL 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 Form TAB SOL SOL LOT CRM ONT ONT DEFAUL DEFAUL TAB SOL TAB TAB TAB SOL TAB CAP CAP TAB TAB TAB CAP TAB DPS TAB SUS TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SYR 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 PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PPH PPH PMS PMS PMS PMS PPH PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS Unit of Issue TAB G ML ML G G G VIAL VIAL TAB ML TAB TAB TAB ML TAB CAP CAP TAB TAB TAB CAP TAB ML TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB Base Price 0.8188 7.7433 0.8300 0.2273 0.4068 0.4068 0.2606 20.2200 8.1750 0.4110 0.1127 0.0942 0.0552 0.0650 0.0515 0.4278 0.0931 0.1169 2.1990 2.9557 4.5944 0.2723 0.0210 0.3593 1.2448 1.7880 0.1869 1.3530 0.5506 0.3063 0.0373 0.0811 1.4175 1.8900 0.7520 0.0395 0.0551 0.1249 0.1010 Pg 64 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000577790 00000577804 00000577812 00002288265 00002288273 00002309114 00002237991 00002421488 00002421496 00000811874 00000703605 00002074834 00002248268 00002248267 00002321130 00000783137 00002405776 00002246596 00002252570 00002303213 00000792942 00002309882 00002309890 00002309904 00002309912 00002247750 00002231537 00002231539 00002231536 00002303124 00002303132 00002303140 00002240363 00002290138 00002359634 00002398079 00002359596 00002359642 00002359618 Product Description PMS-ISONIAZID 100 MG TABLET PMS-ISONIAZID 300 MG TABLET PMS-ISONIAZID 50 MG/5ML ORAL LIQUID PMS-LEFLUNOMIDE 10 MG TABLET PMS-LEFLUNOMIDE 20 MG TABLET PMS-LETROZOLE 2.5 MG TABLET PMS-LEVOBUNOLOL 0.5% OPH SOLUTION PMS-LEVOCARB CR 100 MG/25 MG SUSTAINED-RELEASE TAB PMS-LEVOCARB CR 200 MG/50 MG SUSTAINED-RELEASE TAB PMS-LIDOCAINE VISCOUS 2% ORAL LIQUID PMS-LINDANE 1% TOPICAL SHAMPOO 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-METRONIDAZOLE 500 MG CAPSULE PMS-NEVIRAPINE 200 MG TABLET PMS-NORFLOXACIN 400 MG TABLET PMS-OFLOXACIN 0.3% OPH SOLUTION PMS-OLANZAPINE ODT 15 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-POLYTRIMETHOPRIM OPHTHALMIC SOLUTION PMS-PRAMIPEXOLE 0.5 MG TABLET PMS-PREGABALIN 150 MG CAPSULE PMS-PREGABALIN 225 MG CAPSULE PMS-PREGABALIN 25 MG CAPSULE PMS-PREGABALIN 300 MG CAPSULE PMS-PREGABALIN 50 MG CAPSULE Route ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL ORL Form TAB TAB LIQ TAB TAB TAB SOL SRT SRT LIQ SHP SYR TAB TAB TAB CAP TAB TAB SOL DISNTAB ELX CRT CRT CRT CRT TAB TAB TAB TAB TAB TAB TAB SOL TAB CAP CAP 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 PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PPH PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS Unit of Issue TAB TAB ML TAB TAB TAB ML TAB TAB ML ML ML TAB TAB TAB CAP TAB TAB ML TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB CAP CAP CAP CAP CAP Base Price 0.7948 0.7948 0.2300 6.5653 6.5653 2.9947 1.2380 0.5229 1.0200 0.1032 0.1054 0.0769 0.6161 0.5340 1.7774 0.7637 2.6832 0.5449 0.9200 5.3553 0.0335 0.5152 0.7728 1.3394 2.4739 1.0430 0.2524 0.3370 0.1361 0.5809 0.8139 1.2237 2.3880 1.5061 1.8766 1.8766 0.6708 1.8766 1.0522 Pg 65 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002359626 00000753688 00000753637 00000753661 00002294559 00002294575 00000815993 00000618810 00002340569 00002340577 00002340585 00002340550 00002343932 00002306069 00002371642 00002371626 00002371634 00002252635 00002252651 00002256428 00002237460 00002240807 00002239577 00002401657 00002312999 00001954504 00001954342 00001985604 00002231259 00000431648 00000990067 00000990069 00000598208 00000464988 00002230844 00002237227 00002239155 00002239201 00002239157 Product Description PMS-PREGABALIN 75 MG CAPSULE PMS-PROCHLORPERAZINE 10 MG RECTAL SUPPOSITORY PMS-PROCHLORPERAZINE 10 MG TABLET 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-RIVASTIGMINE 6 MG CAPSULE PMS-SILDENAFIL 100 MG TABLET PMS-SILDENAFIL 25 MG TABLET PMS-SILDENAFIL 50 MG TABLET PMS-SIMVASTATIN 10 MG TABLET PMS-SIMVASTATIN 40 MG TABLET PMS-SUMATRIPTAN 25 MG TABLET PMS-TAMOXIFEN 20 MG TABLET PMS-TERBINAFINE 250 MG TABLET PMS-TOBRAMYCIN 0.3% OPH SOLUTION PMS-TRAMADOL-ACET 37.5 MG/325 MG TABLET 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 POCKET CHAMBER DEVICE POCKET CHAMBER PEDIATRIC MEDIUM MASK DEVICE PODOFILM 250 MG/ML TOPICAL LIQUID POLLINEX R INJECTION 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 Route ORL RT 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 INJ INJ DEFAUL DEFAUL TOP INJ TOP TOP OT TOP OPH Form CAP SUP TAB TAB TAB TAB SYR TAB TAB TAB TAB TAB CAP/TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB SOL TAB TAB TAB TAB TAB DEFAUL DEFAUL DEV PEDDEV LIQ DEFAUL CRM ONT SOL CRM ONT This document is for pricing use only and should 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 PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS PMS CNG MSD MMS MMS PMS BEE PFI WLA JJI WLA PFI Unit of Issue CAP SUP TAB TAB TAB TAB ML TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB TAB TAB TAB SYR VIAL DEV DEV ML ML G G ML G G Base Price 1.3615 0.9020 0.2025 0.1659 0.4645 0.8190 0.0443 1.2047 0.6867 0.6867 0.6867 0.6867 0.8133 1.2605 9.2006 9.0075 9.6150 0.5057 0.6250 9.7690 0.3500 2.5245 0.6560 0.6264 0.5693 0.2063 0.4395 0.6208 19.2400 19.0100 15.9900 49.9900 1.3652 189.8750 0.3933 0.3933 0.9850 0.4267 1.6886 Pg 66 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002239156 00002237226 00001981021 00000249866 00001942921 00002011956 00002293404 00000316121 00000804789 00002312433 00002367602 00002309130 00002367610 00002367629 00002367645 00000770957 00001954210 00000893749 00002148498 00000156876 00000607517 00002396521 00002403722 00002405563 00002403749 00002396483 00002403692 00002405539 00002396548 00002403730 00002405598 00002396505 00002403706 00002405547 00002396513 00002403714 00002405555 00002411768 00002411725 Product Description 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 POSANOL 40 MG/ML ORAL SUSPENSION POTASSIUM 50 MG TABLET POTASSIUM PHOSPHATE 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 PRAMIPEXOLE 1.5 MG TABLET PRAMOX H.C. TOPICAL CREAM PRAMOX H.C. TOPICAL LOTION PRAVACHOL 10 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 Route OT/OPH TOP TOP TOP TOP OPH ORL ORL INJ ORL ORL ORL ORL ORL ORL TOP TOP ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form DPS ONT SHP SHP ONT SOL SUS TAB DEFAUL CAP TAB TAB TAB TAB TAB CRM LOT TAB SOL TAB TAB CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP 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 WLA PDH STI STI SDZ ALL MFC JAM SDZ BOE SNS SIV SNS SNS SNS DPT DPT BMS BSH PDL PDL PDL SIV SNS SIV PDL SIV SNS PDL SIV SNS PDL SIV SNS PDL SIV SNS SIV SIV Unit of Issue ML G ML ML G ML ML TAB ML CAP TAB TAB TAB TAB TAB G ML TAB ML TAB TAB CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP CAP Base Price 0.9850 0.4267 0.0623 0.0403 0.3801 3.5750 10.1152 0.0563 0.4376 1.7387 0.5887 1.3860 1.3860 1.1776 1.1776 0.4347 0.1902 1.5587 7.2450 0.0220 0.0913 1.1698 1.1698 1.7270 1.1698 0.4181 0.4181 0.6173 1.1698 1.1698 1.7270 0.6558 0.6558 0.9683 0.8486 0.8486 1.2528 1.7270 0.6173 Pg 67 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002411733 00002411741 00002182904 00002276194 00002246067 00002043386 00002244574 00000886750 00001926217 00000693820 00002246133 00002249464 00002249472 00000635189 00002210754 00002244081 00002369753 00002324016 00002324024 00002338432 00002393050 00080033655 00000717274 00000884413 00002239208 00002321106 00002321092 00000644315 00002311518 00002311496 00000644331 00080026419 00002310600 00002209071 00080014464 00002184486 00000638676 00000638684 00002311453 Product Description 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 PREVNAR VACCINE 0.5 ML INJECTION 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 PRIMAXIN 250 MG/250 MG INJECTION 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-AMOX 250 MG/5 ML POWDER FOR ORAL SUSPENSION PROARGI-9 PLUS ORAL POWDER PRO-AZITHROMYCINE 250 MG TABLET PROBETA 0.5% OPHTHALMIC SOLUTION PROBIOTIC 10 BILLION PROCAINAMIDE HYDROCHLORIDE 100 MG/ML INJECTION PROCAN 500 MG SUSTAINED-RELEASE TABLET PROCAN 750 MG SUSTAINED-RELEASE TABLET PRO-CEFUROXIME-500 500 MG TABLET Route ORL ORL INJ ORL ORL INJ ORL TOP TOP INJ INJ ORL ORL TOP DEN INJ ORL ORL ORL ORL ORL ORL INJ ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL INJ ORL ORL ORL Form CAP CAP DEFAUL TAB TAB DEFAUL TAB CRM ONT DEFAUL DEFAUL DISNTAB DISNTAB CRM CRM DEFAUL TAB TAB TAB TAB TAB CAP DEFAUL TB DEFAUL ERT ERT CAP CTB ECT SUS PWR TAB SOL CAP DEFAUL SRT SRT 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 SIV CAP SIV CAP MFC VIAL DUI TAB DUI TAB WAY VIAL WNP TAB WCH G WCH G FEI ML FEI ML ABB TAB ABB TAB STI G COL G WAY ML JAI TAB JAI TAB JAI TAB JAI TAB JAI TAB ENT CAP MFC VIAL MFC TAB GSK VIAL PFI TAB PFI TAB PDL CAP PDL TAB PDL TAB PDL ML NHP G PDL TAB ALL ML JAM CAP SDZ ML ERF TAB ERF TAB PDL TAB Base Price 0.9683 1.2529 78.2400 0.5772 0.3985 44.6400 0.0766 0.2680 0.2324 7.9000 10.0000 2.1733 2.1733 0.1590 0.2108 191.0300 3.7860 11.6723 16.5970 1.8930 23.3447 1.4283 326.0000 0.9038 27.7760 2.9603 2.9607 0.3417 0.0560 0.5600 0.0540 0.1252 2.4667 2.9500 0.2398 1.9742 0.5504 0.9425 1.4337 Pg 68 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002311607 00002311615 00002223260 00002241799 00002241797 00002241795 00002241796 00002241800 00002246645 00002246576 00002247909 00002243144 00002175991 00002175983 00000646261 00000646288 00002204606 00000655643 00000655651 00000655678 00002314908 00002314894 00002343053 00002343061 00002243783 00002238213 00002310023 00002310104 00002310066 00002310074 00002316536 00002316528 00000519367 00000512524 00000287709 00000513059 00002239656 00002243834 00002246492 Product Description PRO-CLONAZEPAM 1 MG TABLET PRO-CLONAZEPAM 2 MG TABLET PROCTOSEDYL RECTAL SUPPOSITORY PROCYTOX 1,000 MG/VIAL INJECTION PROCYTOX 200 MG/VIAL INJECTION PROCYTOX 25 MG TABLET PROCYTOX 50 MG TABLET PROCYTOX INJECTION PRODIEM BULK FIBRE THERAPY 625 MG TABLET PRODIEM OVERNIGHT RELIEF THERAPY 15 MG TABLET PROFERRIN 11 MG TABLET PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE PRO-INDO 25 MG CAPSULE PRO-INDO 50 MG CAPSULE PROLASTIN-C 1 G/VIAL INJECTION PRO-LORAZEPAM 0.5 MG TABLET PRO-LORAZEPAM 1.0 MG TABLET PRO-LORAZEPAM 2 MG TABLET PRO-METFORMIN 500 MG TABLET PRO-METFORMIN 850 MG TABLET PROPAFENONE 150 MG TABLET PROPAFENONE 300 MG TABLET PROPAFENONE-150 150 MG TABLET PROPECIA 1 MG 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 Route ORL ORL RT INJ INJ ORL ORL INJ 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 INH INH INH Form TAB TAB SUP DEFAUL DEFAUL TAB TAB DEFAUL TAB TAB TAB CAP CAP CAP CAP CAP DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP/TAB CAP/TAB CAP/TAB CAP/TAB TAB TAB TAB TAB CAP TAB PWS PWS PWS This document is for pricing use only and should 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 PDL PDL AXC ASM ASM ASM ASM ASM NVC NVC CBI ASP ASP ASP PDL PDL GRL PDL PDL PDL PDL PDL SNS SNS PDL MFC PDL PDL PDL PDL PDL PDL PDL PDL PDL PDL MTP MTP MTP Unit of Issue TAB TAB SUP VIAL VIAL TAB TAB VIAL TAB TAB TAB CAP CAP CAP CAP CAP VIAL TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB CAP TAB VIAL VIAL VIAL Base Price 0.1860 0.1595 1.2408 77.8100 51.8700 0.6194 0.8363 134.0200 0.1743 0.2193 0.5380 2.1407 2.7384 13.7135 0.0871 0.1511 425.1700 0.0359 0.0447 0.0699 0.0587 0.0847 0.4303 0.7537 0.3395 1.9275 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 Pg 69 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002246493 00080002201 00000466409 00002046733 00002242439 00002242441 00002243948 00002317966 00000004723 00080009682 00000497517 00002245215 00080015945 00000695440 00000695459 00000695432 00080039114 00002267667 00002299194 00002299208 00002299216 00002308363 00002287943 00002287927 00002287935 00002384698 00002398877 00002328690 00002371324 00002380684 00002361426 00002361434 00002351706 00000740748 00000740756 00002372282 00002358077 00002414112 00002414120 Product Description PROVOCHOLINE 320 MG/VIAL INHALATION PWD FOR SOL PSN 056 CAPSULE 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 QUEST 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 RALIVIA 100 MG EXTENDED-RELEASE TABLET RALIVIA 200 MG EXTENDED-RELEASE TABLET RALIVIA 300 MG EXTENDED-RELEASE TABLET RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 10 MG CAPSULE RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 5 MG CAPSULE 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 RAN-CLARITHROMYCIN 250 MG TABLET RAN-CLARITHROMYCIN 500 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-NABILONE 0.25 MG CAPSULE RAN-OLANZAPINE ODT 15 MG ORALLY DISINTEGRATING TAB RAN-OLANZAPINE ODT 20 MG ORALLY DISINTEGRATING TAB Route INH ORL ORL INH INJ INJ INJ ORL ORL ORL INJ INJ 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 ORL Form PWS CAP ELX SOL DEFAUL DEFAUL CTG PWDPKT TAB CAP DEFAUL DEFAUL TAB CAP CAP TAB TAB DEFAUL ERT ERT ERT CAP/TAB CAP/TAB CAP/TAB CAP/TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL TAB TAB TAB CAP DISNTAB DISNTAB This document is for pricing use only and should 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 MTP PSN RIV HLR MFC MFC MFC ODN TEV NFN HSP BNQ PLH ODN ODN ODN TPI MFC VCL VCL VCL SIV SIV SIV SIV RAN RAN RAN RAN RAN RAN RAN RAN PDL PDL RAN RAN RAN RAN Unit of Issue VIAL CAP ML ML ML ML ML PCKT TAB CAP ML ML TAB CAP CAP TAB TAB VIAL TAB TAB TAB CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB VIAL TAB TAB TAB CAP TAB TAB Base Price 128.0000 0.0750 0.0086 16.6356 97.0000 208.5600 808.3333 5.6400 5.1816 0.5665 1.9500 1.2673 0.3943 0.2597 0.4075 0.4075 0.7415 186.7700 1.3598 2.4842 3.6033 0.1274 0.1862 0.1470 0.1470 1.0371 0.1380 2.5457 4.4090 0.3400 0.6403 1.6293 21.9400 0.1800 0.3600 2.7560 1.5172 5.3554 7.5979 Pg 70 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002305038 00002375850 00002375869 00002375877 00002392844 00002392852 00002392801 00002392860 00002392828 00002392836 00002280906 00002280914 00002280922 00002280930 00002280949 00002280957 00002383136 00002383101 00002383128 00002294885 00002396084 00002396092 00002396076 00002388197 00002363062 00002361663 00002361671 00002247111 00002243237 00002302063 00002302071 00002332728 00002332736 00002332744 00002332752 00002275279 00002277700 00000550477 00002247818 Product Description 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-RISPERIDONE 0.25 MG TABLET RAN-RISPERIDONE 0.5 MG TABLET RAN-RISPERIDONE 1 MG TABLET RAN-RISPERIDONE 2 MG TABLET RAN-RISPERIDONE 3 MG TABLET RAN-RISPERIDONE 4 MG TABLET RAN-SILDENAFIL 100 MG TABLET RAN-SILDENAFIL 25 MG TABLET RAN-SILDENAFIL 50 MG TABLET RAN-TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE 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 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 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 ORL ORL Form ECT TAB TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB SRC TAB TAB TAB TAB TAB CAP CAP TAB LIQ TAB TAB TAB TAB TAB TAB TAB TAB SYR 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 RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN RAN ASC ASC WAY WAY NOV NOV NOV NOV NOV NOV RPH RPH RPH RPH Unit of Issue TAB TAB TAB TAB CAP CAP CAP CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB CAP CAP TAB ML TAB TAB TAB TAB TAB TAB TAB TAB ML TAB Base Price 1.2750 0.6312 0.8844 1.3297 1.7270 1.7270 0.6173 1.7270 0.9683 1.2528 0.2615 0.4379 0.6048 1.2075 1.8112 2.4150 9.2000 8.2900 8.8477 0.5464 0.5928 0.9620 0.3128 0.6264 0.5239 1.9810 1.9811 8.5997 8.5075 1.3614 1.3614 1.3671 1.3525 1.3671 1.3671 2.5430 4.0573 0.0596 0.4122 Pg 71 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002247819 00002103656 00002103737 00000779474 00000694827 00002053403 00002169126 00002296071 00002275252 00002275260 00000805386 00002273101 00002273128 00002273136 00002243789 00002097168 00002247461 00000653233 00002248031 00002247889 00002320908 00002194163 00002194198 00002260867 00002308681 00002247810 00002247812 00002301423 00002301431 00002301458 00002311194 00002319500 00002247068 00002247070 00002247071 00002084236 00000317225 00000550507 00002140063 Product Description RATIO-CLARITHROMYCIN 500 MG TABLET RATIO-CLONAZEPAM 0.5 MG TABLET RATIO-CLONAZEPAM 2 MG TABLET RATIO-CODEINE 5 MG/ML ORAL SYRUP RATIO-CORISTEX-DH ORAL LIQUID RATIO-COTRIDIN EXPECTORANT ORAL SYRUP RATIO-COTRIDIN ORAL SYRUP RATIO-FLUTICASONE 50 MCG/DOSE AQUEOUS NASAL SPRAY RATIO-FOSINOPRIL 10 MG TABLET RATIO-FOSINOPRIL 20 MG TABLET RATIO-GENTAMICIN SULFATE 0.1% TOPICAL CREAM 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-KETOROLAC 0.5% OPH SOLUTION RATIO-LENOLTEC NO.1 TABLET RATIO-MELOXICAM 15 MG TABLET RATIO-MELOXICAM 7.5 MG TABLET RATIO-MEMANTINE 10 MG TABLET RATIO-NYSTATIN 100,000 UNIT/G VAGINAL CREAM RATIO-NYSTATIN 500,000 UNIT TABLET RATIO-OMEPRAZOLE 20 MG SUSTAINED-RELEASE TABLET RATIO-PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET RATIO-PAROXETINE 10 MG TABLET RATIO-PAROXETINE 30 MG TABLET RATIO-PIOGLITAZONE 15 MG TABLET RATIO-PIOGLITAZONE 30 MG TABLET RATIO-PIOGLITAZONE 45 MG TABLET RATIO-RAMIPRIL 15 MG CAPSULE RATIO-SILDENAFIL R 20 MG TABLET RATIO-SIMVASTATIN 10 MG TABLET RATIO-SIMVASTATIN 40 MG TABLET RATIO-SIMVASTATIN 80 MG TABLET RATIO-SOTALOL 160 MG TABLET RATIO-THEO-BRONC ORAL SOLUTION RATIO-TRIACOMB REGULAR TOPICAL CREAM RATIO-VALPROIC 50 MG/ML ORAL SYRUP Route ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL TOP ORL ORL ORL INH INH OPH ORL ORL ORL ORL VAG ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL Form TAB TAB TAB SYR LIQ SYR SYR SPM TAB TAB CRM TAB TAB TAB SOL UDSOL SOL TAB TAB TAB TAB CRM TAB CAP/SRT ECT TAB TAB TAB TAB TAB CAP/TAB TAB TAB TAB TAB TAB SOL CRM 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 RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH RPH Unit of Issue TAB TAB TAB ML ML ML ML DOSE TAB TAB G TAB TAB TAB ML ML ML TAB TAB TAB TAB G TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB ML G ML Base Price 1.6293 0.1166 0.2010 0.0304 0.0826 0.0631 0.0567 0.1989 0.4977 0.5985 0.4427 0.4900 0.4900 0.5323 0.4524 0.6590 1.6000 0.0547 0.5670 0.4914 1.7774 0.3467 0.2594 0.4117 1.2750 1.0430 0.7217 0.5809 0.8139 1.2237 0.8133 7.2940 0.3643 0.4501 0.4500 0.2087 0.0340 0.4167 0.0398 Pg 72 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002238337 00002223554 00001900978 00002223546 00002246162 00002368064 00002281708 00002243676 00000749486 00000013447 00000897221 00000897256 00002138670 00002244650 00002399148 00002049260 00002231008 00002239405 00002242592 00002192640 00002346672 00002240863 00002308215 00002256290 00002256304 00002248542 00002248543 00002248544 00002246552 00002246555 00002246553 00002246554 00002244310 00002222000 00002221985 00002221993 00002052407 00002354586 00002249057 Product Description REACTINE 1 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 REBIF INIT PACK 8.8MCG/0.2ML/22MCG/0.5ML INJ SYR RECOMBIVAX HB (PRESERVATIVE FREE) 5MCG/0.5ML INJ RECOMBIVAX-HB 10 MCG/ML(RECOMBINANT) INJECTION 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 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 REPLAGAL 1 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL INJ INJ INJ ORL ORL ORL OPH OPH NAS OPH OPH TOP ORL TOP ORL INH INJ ORL ORL ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL TOP ORL INJ Form SYR TAB TAB TAB ERT CAP NDL DEFAUL DEFAUL EVT EVT EVT SOL SOL SOL SOL SOL GEL TAB CRM PWR DSK DEFAUL TAB TAB DISNTAB DISNTAB DISNTAB DEFAUL DEFAUL DEFAUL DEFAUL TAB ERT ERT ERT CRM 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 JJM PDH PDH PDH PDH MCL SRO MFC MFC HLR HLR HLR ALL ALL ALL ALL ALL JAI JAM GSK RED GSK SLX PFI PFI MFC MFC MFC NTH NTH NTH NTH GZM SAV SAV SAV MCN GZM PAL Unit of Issue ML TAB TAB TAB TAB CAP SYR ML ML TAB TAB TAB ML ML ML ML ML G TAB G G DISC ML TAB TAB TAB TAB TAB ML ML ML ML TAB TAB TAB TAB G TAB ML Base Price 0.0663 0.7667 0.9240 0.5846 0.7620 0.7764 117.0700 24.1600 21.3500 0.2700 0.2640 0.2700 0.8958 0.5393 0.9670 0.7967 0.4500 35.3333 0.1012 1.8410 0.0277 7.9420 68.8167 14.8750 14.8750 0.4547 0.9090 1.3637 45.0000 450.0000 112.5000 225.0000 1.7849 0.7257 0.3170 0.4633 1.3500 1.6846 657.1429 Pg 73 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002247790 00002377012 00002377020 00002355655 00002318164 00000870013 00000443816 00000443794 00000870021 00002264633 00002243914 00002306980 00002008726 00002008696 00002008718 00002008688 00001902660 00001902652 00002279401 00002213826 00002035871 00002304902 00002317699 00002317710 00002304899 00002361825 00002361833 00002248610 00002248611 00002294176 00002220806 00000732230 00002231923 00080026370 00001910140 00001910159 00001910167 00002260107 00002269589 Product Description REPRONEX 75 UNIT/VIAL INJECTION RESOTRAN 1 MG FILM-COATED TABLET RESOTRAN 2 MG FILM-COATED TABLET RESTASIS 0.05% OPH EMULSION RESTORALAX ORAL POWDER RETIN-A 0.01% TOPICAL GEL RETIN-A 0.025% TOPICAL GEL RETIN-A 0.05% TOPICAL CREAM RETIN-A 0.1% TOPICAL CREAM RETIN-A MICRO 0.04% TOPICAL GEL RETIN-A MICRO 0.I % 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 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 RHINOCORT AQUA 64 MCG/DOSE METERED DOSE NAS. SPRAY RHODIOLA ROSEA CAPSULE RHOTRAL 100 MG TABLET RHOTRAL 200 MG TABLET RHOTRAL 400 MG TABLET RHOXAL-ANAGRELIDE 0.5 MG CAPSULE RHOXAL-GLIMEPIRIDE 1 MG TABLET Route INJ ORL ORL OPH ORL TOP TOP TOP TOP TOP TOP OPH TOP TOP TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL NAS NAS NAS ORL ORL ORL ORL ORL ORL Form DEFAUL TAB TAB EML PWR GEL GEL CRM CRM GEL GEL IMP CRM CRM CRM CRM CAP SYR TAB TAB LIQ CAP CAP CAP CAP TAB TAB CAP CAP CAP GEL AER SPM CAP TAB TAB TAB CAP 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 FEI JAI JAI ALL SPL JJI JJI JJI JJI JJI JJI BSH GSK GSK GSK GSK GSK GSK PFI BAR SDZ CLG CLG CLG CLG GSK GSK BMS BMS BMS PMS PMS AZC AOR SDZ SDZ SDZ SDZ SDZ Unit of Issue VIAL TAB TAB ML G G G G G G G SYS G G G G CAP ML TAB TAB AMP CAP CAP CAP CAP TAB TAB CAP CAP CAP G DOSE DOSE CAP TAB TAB TAB CAP TAB Base Price 71.0660 2.4421 3.7489 9.0058 0.0651 0.3737 0.4257 0.4303 0.3737 1.1700 1.1700 16000.0000 0.7991 0.7731 0.7731 0.7731 2.0251 0.2123 11.9560 6.2236 0.8555 361.0000 382.0000 424.0000 340.0000 62.5000 125.0000 12.0168 11.0587 24.0337 0.2904 0.1933 0.0987 0.2546 0.1630 0.2440 0.4848 3.3491 0.5323 Pg 74 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002269597 00002269619 00002243559 00000309702 00002091887 00002092808 00002347474 00002352141 00002298465 00002242093 00002242094 00002242077 00002239081 00002242783 00002265265 00002240788 00002228300 00002316463 00002202352 00002240112 00001940112 00002242157 00002248082 00002247147 00002026805 00002231176 00001934767 00001930990 00001932187 00002026783 00002230949 00001934791 00001934783 00001931032 00002142783 00001934740 00002068419 00002142775 00001931024 Product Description 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-ATENOLOL 100 MG TABLET RIVA-ATENOLOL 50 MG TABLET RIVA-CLONAZEPAM 0.5 MG TABLET 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-PANTOPRAZOLE 40 MG ENTERIC-COATED TABLET RIVASA CROQUABLE 80 MG TABLET RIVASOL-HC RECTAL SUPPOSITORY RIVASONE SCALP 0.1% TOPICAL LOTION RIVA-SOTALOL 160 MG TABLET RIVA-VERAPAMIL SR 240 MG SUSTAINED-RELEASE TABLET 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 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 Route ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL NAS ORL ORL RT TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form TAB TAB ERT TAB CAP CAP TAB TAB DEFAUL TAB TAB TAB TAB TAB TAB TAB SPM ECT CTB SUP LOT TAB SRT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB SYR SYR SYR SYR SYR 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 SDZ TAB SDZ TAB SDZ TAB JAM TAB SAV CAP SAV CAP PDL TAB SIV TAB JAI VIAL RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV TAB RIV DOSE RIV TAB RIV TAB RIV SUP RIV ML RIV TAB RIV TAB PDH TAB PDH TAB PDH TAB PDH TAB PDH TAB PDH TAB WCH TAB PDH TAB PDH TAB PDH TAB PDH ML PDH ML PDH ML PDH ML PDH ML PDH ML Base Price 0.5323 0.5323 0.8098 0.0675 0.9122 1.4356 2.4275 2.4893 85.4000 0.2362 0.1437 0.0495 0.0586 0.0847 0.2338 0.2110 0.0490 0.5054 0.0560 0.5833 0.0853 0.1623 0.5075 0.6700 0.4822 0.5300 0.7426 0.5116 0.8446 0.4022 0.5300 1.2496 1.0458 0.0522 0.0522 0.1081 0.0522 0.0522 0.0522 Pg 75 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000824291 00002318415 00000393444 00000343617 00000708925 00002368684 00002242979 00002381184 00002389045 00002381192 00002389053 00002381206 00002389061 00002381176 00002389037 00002284413 00000466425 00002248563 00002222116 00002224828 00002245735 00002419858 00000623571 00080024381 00000779296 00001910701 00080004542 00002370468 00002370476 00000593257 00002288079 00002338467 00002247692 00002231733 00002231731 00002386410 00002386429 00002386437 00002386445 Product Description 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 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 ROTATEQ (2 ML/DOSE) ORAL SOLUTION ROUGIER CALCIUM ORAL LIQUID RUB A535 DUAL ACTION RUB A-535 EXTRA STRENGTH RYTHMODAN 150 MG CAPSULE SAB-SODIUM CHLORIDE 5% OPTHALMIC SOLUTION USP SALBUTAMOL HFA 100 MCG/DOSE METERED DOSE AEROSOL 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 SANDOZ ALENDRONATE 5 MG TABLET SANDOZ ANASTROZOLE 1 MG TABLET SANDOZ ANUZINC HC PLUS OINTMENT SANDOZ ATENOLOL 100 MG TABLET SANDOZ ATENOLOL 50 MG TABLET SANDOZ ATOMOXETINE 10 MG CAPSULE SANDOZ ATOMOXETINE 18 MG CAPSULE SANDOZ ATOMOXETINE 25 MG CAPSULE SANDOZ ATOMOXETINE 40 MG CAPSULE Route ORL INJ ORL ORL TOP TOP INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP ORL OPH INH INJ NAS NAS NAS ORL ORL ORL INJ ORL ORL RT ORL ORL ORL ORL ORL ORL Form SOL DEFAUL CAP CAP SOL FOA DEFAUL TAB TAB TAB TAB TAB TAB TAB TAB SOL LIQ CRM CRM CAP SOL AEM DEFAUL SPR GEL SPR TAB TAB TAB DEFAUL TAB TAB ONT TAB TAB CAP 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 HLR SDZ VCL VCL UPJ JJI PAL PDL SIV PDL SIV PDL SIV PDL SIV MFC ROG CHD CHD SAV SDZ SNS OMG SDZ SDZ SDZ WNP OTS OTS NOV SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ Unit of Issue ML ML CAP CAP ML G ML TAB TAB TAB TAB TAB TAB TAB TAB ML ML G G CAP ML DOSE ML ML G ML TAB TAB TAB ML TAB TAB G TAB TAB CAP CAP CAP CAP Base Price 2.9560 10.2600 0.7067 1.1245 0.6605 0.7517 39.4420 0.3400 0.3400 0.4250 0.4250 0.4977 0.4977 0.3227 0.3227 30.7700 0.0210 0.0616 0.0616 0.3924 0.5633 0.0300 1.4300 0.1380 0.1483 0.1697 0.0715 250.0000 250.0000 4.8000 1.0370 2.7667 0.8833 0.5687 0.3460 2.3140 2.6523 2.9280 3.3373 Pg 76 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002386453 00002386283 00002386275 00002326957 00002242485 00002230386 00000739839 00002241224 00002400596 00002400618 00002261774 00002278634 00002278642 00002278650 00002390701 00002390698 00002327139 00002339471 00002247055 00002247054 00002230888 00002229440 00002229441 00002237187 00002344815 00002241715 00002257564 00002247057 00002344807 00002247876 00002250594 00002320630 00002313855 00002327791 00002327805 00002358913 00002247920 00002301075 00002269422 Product Description SANDOZ ATOMOXETINE 60 MG CAPSULE SANDOZ BOSENTAN 125 MG TABLET SANDOZ BOSENTAN 62.5 MG TABLET SANDOZ CANDESARTAN 4 MG TABLET SANDOZ CORTIMYXIN OPH OINTMENT SANDOZ CORTIMYXIN OTIC SOLUTION SANDOZ DEXAMETHASONE SOD PHOSPHATE 0.1% OT/OPH SOL SANDOZ DICLOFENAC 50 MG RECTAL SUPPOSITORY SANDOZ DICLOFENAC MISOPROSTOL 50 MG/200 MCG ECT SANDOZ DICLOFENAC MISOPROSTOL 75 MG/200 MCG ECT SANDOZ DICLOFENAC RAPIDE 50 MG TABLET 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 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 0.25% OPH SOLUTION SANDOZ LOPERAMIDE 2 MG TABLET SANDOZ LOVASTATIN 40 MG TABLET SANDOZ MEMANTINE 10 MG TABLET SANDOZ METOPROLOL (TYPE L) 100 MG TABLET SANDOZ MIRTAZAPINE 15 MG TABLET SANDOZ MYCOPHENOLATE MOFETIL 250 MG CAPSULE SANDOZ MYCOPHENOLATE MOFETIL 500 MG TABLET SANDOZ OLANZAPINE ODT 15 MG ORALLY DISINT. TABLET SANDOZ OLANZAPINE ODT 20 MG ORALLY DISINT. TABLET SANDOZ OLOPATADINE 0.1% OPH SOLUTION SANDOZ OPTICORT OTIC OPH SOLUTION SANDOZ PANTOPRAZOLE 20 MG ENTERIC-COATED TABLET SANDOZ PAROXETINE 10 MG TABLET Route ORL ORL ORL ORL OPH OT OT/OPH RT ORL ORL ORL ORL ORL ORL ORL ORL TRD ORL ORL ORL OPH OPH OT TOP ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OT/OPH ORL ORL Form CAP TAB TAB TAB ONT SOL SOL SUP ECT ECT TAB TAB TAB TAB TAB TAB PTH TAB TAB TAB ONT SOL SOL SOL TAB SOL TAB TAB TAB TAB TAB CAP TAB DISNTAB DISNTAB SOL SOL ECT 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 SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ Unit of Issue CAP TAB TAB TAB G ML ML SUP TAB TAB TAB TAB TAB TAB TAB TAB PTH TAB TAB TAB G ML ML ML TAB ML TAB TAB TAB TAB TAB CAP TAB TAB TAB ML ML TAB TAB Base Price 3.7023 52.3048 52.3048 0.3400 3.6143 1.1400 1.3780 0.6236 0.4541 0.6179 0.3937 2.0240 2.7200 4.5944 0.9903 0.3870 9.2360 1.2447 0.4111 0.2105 1.5000 0.4060 1.0320 4.9900 2.7560 1.1760 0.2889 0.8985 1.6357 0.2223 0.4074 1.1203 2.8868 5.8193 8.2560 5.2260 1.4675 1.2750 1.0430 Pg 77 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002254778 00002244999 00002261790 00002261804 00002261782 00002297906 00002297914 00002297922 00002239234 00002315270 00001916181 00001916203 00002390841 00002390817 00002390868 00002390825 00002390833 00002318822 00002318806 00002318814 00002234013 00002416824 00002416832 00002319217 00002243587 00002248529 00002239714 00002356740 00002399253 00002399245 00002257580 00000874825 00002266121 00080041540 00001919245 00002020939 00002020793 00000541869 00000541877 Product Description 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 SANDOZ POLYTRIMETHOPRIM OPH SOLUTION SANDOZ PRAMIPEXOLE 0.5 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 SILDENAFIL 100 MG TABLET SANDOZ SILDENAFIL 25 MG TABLET SANDOZ SILDENAFIL 50 MG TABLET SANDOZ SOTALOL 160 MG TABLET SANDOZ TACROLIMUS 1 MG CAPSULE SANDOZ TACROLIMUS 5 MG CAPSULE SANDOZ TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE SANDOZ TICLOPIDINE 250 MG TABLET SANDOZ TRIFLURIDINE 1% OPH SOLUTION SANDOZ VALPROIC 250 MG CAPSULE SANDOZ VALSARTAN 40 MG TABLET SANDOZ VORICONAZOLE 200MG TABLET SANDOZ VORICONAZOLE 50MG TABLET SANDOZ ZOPICLONE 7.5 MG TABLET SARNA-P TOPICAL LOTION SATIVEX BUCCAL SPRAY SCHINOUSSA PROBIOTIC WHEY ISOLATE ORAL POWDER 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 Route ORL OT/OPH ORL ORL ORL ORL ORL ORL OPH ORL OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH ORL ORL ORL ORL ORL TOP BUC ORL TOP INJ INJ INJ INJ Form TAB SOL TAB TAB TAB TAB TAB TAB SOL TAB SUS SUS CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP CAP SRC TAB SOL CAP TAB TAB TAB TAB LOT SPR PWR PWR 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. MFR SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ SDZ STI BHP QUA SCH OMG OMG HSP HSP Unit of Issue TAB ML TAB TAB TAB TAB TAB TAB ML TAB ML ML CAP CAP CAP CAP CAP TAB TAB TAB TAB CAP CAP CAP TAB ML CAP TAB TAB TAB TAB ML ML G G ML ML ML ML Base Price 1.0647 1.2813 0.2323 0.3370 0.1361 0.5809 0.8139 1.2237 2.7270 1.3860 1.3450 1.9400 1.7270 0.6172 1.7270 0.9682 1.2528 9.9975 8.2900 8.8481 0.2087 2.0538 10.2851 0.1500 0.6885 3.2667 0.1366 0.5694 38.5610 9.6443 0.4685 0.0547 22.8090 0.0357 0.0499 1.3040 2.7100 5.3140 5.8240 Pg 78 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002296659 00002346176 00000666106 00000666114 00002288389 00000551805 00000633380 00000554987 00000243000 00000483796 00000709069 00002247134 00002237105 00002257130 00002257149 00002257157 00002357704 00002368633 00002247998 00002239046 00002241304 00002241302 00002241303 00002240344 00080039305 00002317583 00002406160 00002317559 00002317575 00002406152 00002398257 00002398265 00080012979 00002338572 00002239548 00002413183 00002413175 00002417472 00002247224 Product Description 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 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 SILDENAFIL 100 MG TABLET SILDENAFIL 100 MG TABLET SILDENAFIL 25 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 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 Route ORL ORL TOP TOP ORL NAS ORL ORL TOP TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP ORL INJ INJ INJ ORL Form TAB TAB SHP SHP TAB GEL TAB TAB SOL LOT SHP TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL CAP CAP CAP TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB ONT TAB NDL NDL DEFAUL 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 DUR PAL DPT DPT NOV PMS JAM JAM ABB ABB ABB VTH SDR AMG AMG AMG SEP SEP ABB SRO PDL PDL PDL PMS SMM PMS SNS PMS PMS SNS PAL PAL JAM GAL MCL JAI JAI JAI PDL Unit of Issue TAB TAB ML ML TAB G TAB TAB ML ML ML TAB TAB TAB TAB TAB TAB TAB TAB VIAL CAP CAP CAP TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB G TAB SYR SYR ML TAB Base Price 0.6687 0.6687 0.0621 0.0659 17.6889 0.3414 0.0742 0.0659 0.0484 0.0255 0.0255 0.0532 0.0249 12.6137 23.0003 33.4697 0.1380 0.1730 0.7607 1633.0000 0.4200 0.2004 0.4000 0.9630 0.2273 9.2007 9.2000 8.2900 8.8480 8.8475 0.6303 1.2607 0.2062 1.3583 0.2015 1610.3200 1610.3200 224.6275 0.6250 Pg 79 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000326925 00000400750 00001926055 00001938371 00001926004 00001938363 00001994247 00000623520 00002245456 00002245457 00000481912 00080022194 00000261998 00000037842 00000060208 00000392499 00002139510 00000402230 00002150204 00000037834 00000402249 00000268313 00000896187 00000028053 00002006758 00002224895 00002224887 00002224879 00002224860 00001988840 00001987682 00002243257 00001923986 00001975382 00002019825 00002230211 00002063697 00002063727 00002063719 Product Description 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-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 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 40MG/VIAL INJECTION SOLU-MEDROL ACT-O-VIAL (PRES) 1 G/VIAL (BASE) INJ SOLU-MEDROL ACT-O-VIAL (PRES) 125MG/VIAL (BASE)INJ SOLU-MEDROL ACT-O-VIAL (PRES) 40MG/VIAL (BASE) INJ Route ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL INJ INJ INJ INJ INJ INJ INJ IR INJ INJ INJ OPH ORL OPH OPH TOP NAS TOP TOP TOP TOP TOP TOP INJ INJ INJ INJ Form CAP CAP TAB TAB TAB TAB TAB SRT DEFAUL DEFAUL TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL SOL DEFAUL DEFAUL DEFAUL SOL SYR ONT SOL ONT SPR GAU GAU SOL AER GEL GEL 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. MFR ERF ERF WLA WLA WLA PDH TAN CGS SDZ SDZ SLW SDZ HSP HSP BAX SDZ PPC OMG OMG HSP OMG VCL SDZ SDZ PMS ERF ERF ERF ERF ERF AVE GAL SCH STI GSK PFI PFI PFI PFI Unit of Issue CAP CAP TAB TAB TAB TAB TAB TAB ML ML TAB TAB ML ML ML ML ML ML ML ML ML VIAL ML ML ML G ML G ML DRE DRE ML G G G VIAL VIAL VIAL VIAL Base Price 1.1921 0.9145 0.1808 0.2875 0.2392 0.4063 0.0950 0.2890 9.6600 14.0500 0.0324 0.0754 0.5934 0.0220 0.0062 3.8900 0.3163 0.2167 0.3250 0.0224 0.1617 466.2600 0.8876 0.4933 0.0232 4.2160 1.4688 1.1840 2.9340 1.6840 3.8700 1.6933 0.0385 0.2269 0.3480 5.2672 55.3700 15.6620 6.0710 Pg 80 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002063700 00000690333 00000837733 00000769533 00002272199 00002272202 00002272210 00000483818 00002385996 00002418355 00002237578 00002237580 00002214415 00002320193 00002293129 00002293137 00002293145 00001938991 00001938983 00002245439 00002245438 00002372436 00002139383 00002230192 00002241807 00002139243 00002139375 00002230191 00000038245 00000402257 00002142546 00002247228 00000587966 00000641863 00002125277 00002403390 00002262800 00002279355 00002262819 Product Description SOLU-MEDROL ACT-O-VIAL (PRES) 500MG/VIAL (BASE)INJ 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 SOTALOL 160 MG TABLET SOVALDI 400 MG TABLET SPASMHALT-8 CAPLET SPASMHALT-ASA-8 CAPLET SPECTRO ECZEMACARE MEDICATED CREAM SPRYCEL 100 MG TABLET 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 10 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 GEL STIEVA-A 0.05% TOPICAL GEL STILAMIN 3 MG/AMPOULE INJECTION STIVARGA 40 MG TABLET STRATTERA 10 MG CAPSULE STRATTERA 100 MG CAPSULE STRATTERA 18 MG CAPSULE Route INJ TOP TOP RT INJ INJ INJ ORL ORL ORL ORL ORL TOP ORL ORL ORL ORL TOP TOP ORL ORL ORL INJ INJ INJ INJ INJ INJ DEFAUL DEFAUL DEFAUL TOP TOP TOP INJ ORL ORL ORL ORL Form DEFAUL SOL SOL RTNENM DEFAUL DEFAUL DEFAUL TAB TAB TAB TAB TAB CRM TAB TAB TAB TAB SOL SOL TAB TAB DISNTAB DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL INJ INJ INJ SHP GEL GEL DEFAUL TAB 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 PFI VIAL DPT ML DPT ML PPH ENM PFI VIAL PFI VIAL PFI VIAL AXS TAB SIV TAB GIL TAB PPH TAB WAM TAB GKC G BMS TAB BMS TAB BMS TAB BMS TAB OMG ML OMG ML NOV TAB NOV TAB BAI TAB PPC VIAL HSP VIAL PPC VIAL PPC VIAL PPC VIAL HSP VIAL HSP ML OMG ML HSP ML GSK ML GSK G GSK G SRO VIAL BAI TAB LIL CAP LIL CAP LIL CAP Base Price 36.1220 0.7714 1.2420 13.6400 128.6600 177.4200 236.4400 0.1145 0.2087 711.4968 0.3693 0.3300 0.4400 161.2983 37.3387 75.1473 89.3837 0.0105 0.0163 0.6065 0.6001 7.1725 102.3030 78.8900 971.0500 509.7900 47.7040 45.1180 0.0950 0.3500 0.2010 0.1464 0.2996 0.2996 210.0000 80.6838 2.9243 5.5554 3.3307 Pg 81 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002262827 00002262835 00002262843 00002279347 00002243660 00002174383 00002166615 00080009625 00002167948 00002397137 00002370433 00002391678 00002238099 00002237793 00002250217 00001951319 00002244147 00000187534 00000678996 00080002944 00080011269 00080023127 00002242658 00080017929 00002242595 00002240749 00002239888 00002239886 00002246045 00002280795 00002280809 00002280817 00002245890 00002245889 00002162504 00002162512 00000990010 00000999331 00002248967 Product Description STRATTERA 25 MG CAPSULE STRATTERA 40 MG CAPSULE STRATTERA 60 MG CAPSULE STRATTERA 80 MG CAPSULE STREPTOMYCIN 1 G/VIAL INJECTION 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 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 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 Route ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL SLG SLG ORL ORL ORL INJ INJ TOP ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL INJ INJ TOP TOP DEFAUL DEFAUL OPH Form CAP CAP CAP CAP DEFAUL TAB TAB TAB TAB TAB DISNTAB DISNTAB TAB TAB TAB DEFAUL DEFAUL SOP CAP TAB TAB CAP TAB TAB TAB IMP CAP CAP TAB CAP CAP CAP DEFAUL DEFAUL SOL ONT DEV DEV SOL This document is for pricing use only and should 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 LIL CAP LIL CAP LIL CAP LIL CAP STM VIAL JAM TAB WCH TAB PDH TAB WCH TAB GIL TAB MED TAB MED TAB WLA TAB WLA TAB MCL TAB JAI ML SDZ ML STI G SIS CAP JAM TAB NFN TAB JAM CAP MCL TAB JAM TAB JAM TAB SAV SYS DPM CAP DPM CAP DPM TAB PFI CAP PFI CAP PFI CAP ABV VIAL ABV VIAL VLP ML VLP G GZB ML GZB ML ALC ML Base Price 3.7371 4.2050 4.7107 5.0571 43.6000 0.1127 0.1071 0.1042 0.1071 48.9340 1.4510 1.4370 0.4950 0.2908 0.3000 6.9320 10.6700 0.0684 0.2581 0.1557 0.2143 0.1293 0.1994 0.1366 0.1334 1222.5500 5.4140 1.2457 16.2420 66.9068 133.8132 267.6268 1504.5100 752.2600 0.4447 0.4682 65.2750 66.3333 0.8350 Pg 82 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080032792 00002239122 00002365871 00002409607 00002409615 00001966200 00001966197 00002245549 00002304848 00002304856 00002381842 00002241472 00001926624 00002331780 00001962353 00002296039 00002269015 00002269023 00002269007 00000510335 00000344508 00002339609 00002339617 00002339625 00002387425 00002240945 00002238096 00002240946 00002238097 00002365650 00002244403 00002244404 00002353288 00002266938 00002264749 00001925350 00002247651 00002368250 00002315874 Product Description SYSTANE VITAMIN- OMEGA 3 CAPSULE T.R. SWISS ONE 50 MULTIVITAMIN & MINERAL TABLET TACTUO 0.1%/2.5% TOPICAL GEL TAFINLAR 50 MG CAPSULE TAFINLAR 75 MG CAPSULE TAMBOCOR 100 MG TABLET TAMBOCOR 50 MG TABLET TAMIFLU 12 MG/ML ORAL SUSPENSION TAMIFLU 30 MG CAPSULE TAMIFLU 45 MG CAPSULE TAMIFLU 6 MG/ML ORAL SUSPENSION TAMIFLU 75 MG CAPSULE TAMOFEN 10 MG TABLET TAMSULOSIN 0.4 MG SUSTAINED-RELEASE CAPSULE 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-MOMETASONE 0.1% OINTMENT TARO-SONE 0.05% TOPICAL CREAM TARO-TERCONAZOLE 0.4% VAGINAL CREAM TASIGNA 150 MG CAPSULE TASIGNA 200 MG CAPSULE Route ORL ORL TOP ORL ORL ORL ORL ORL ORL ORL ORL 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 VAG ORL ORL Form CAP TAB GEL CAP CAP TAB TAB SUS CAP CAP SUS CAP TAB SRC TAB TAB TAB TAB TAB LIQ GEL ERT ERT ERT ERT TAB TAB TAB TAB TAB CTB CTB SOL SOL ONT CRM CRM 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 ALC SWS GAL GSK GSK VCL VCL HLR HLR HLR HLR HLR SAV RAN TAN PAL HLR HLR HLR ODN ODN PUR PUR PUR PUR ABB ABB ABB ABB TAR TAR TAR TAR TAR TAR TAR TAR NOV NOV Unit of Issue CAP TAB G CAP CAP TAB TAB ML CAP CAP ML CAP TAB CAP TAB TAB TAB TAB TAB G G TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB G ML G G G CAP CAP Base Price 0.2287 0.2212 1.6918 45.3889 68.0833 1.0770 0.5384 0.5304 2.1940 3.3760 0.3375 4.3890 0.1750 0.5664 0.0214 0.5802 57.3333 86.9320 13.3333 0.1879 0.1736 1.2000 1.8000 3.2000 0.7530 1.5400 1.5500 1.9025 2.1113 1.2730 0.1188 0.2558 8.4150 0.2840 0.2720 0.2048 0.4953 30.0273 42.2425 Pg 83 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002016796 00002177099 00002177080 00000886955 00000886963 00002243894 00002243895 00000615358 00001950010 00002246397 00001943308 00000743445 00000390291 00002082519 00000579408 00000283991 00002404508 00002395223 00002395231 00002395525 00002395533 00002261553 00002261545 00002241095 00002321262 00002312794 00002312816 00002241094 00002241096 00002241093 00000876038 00000875988 00000894710 00002130874 00000894729 00000632317 00000632309 00000632295 00002280248 Product Description TAXOL 6 MG/ML INJECTION TAXOTERE 40 MG/ML (20 MG/0.5 ML) INJECTION TAXOTERE 40 MG/ML (80 MG/2 ML) INJECTION TAZIDIME 2 G/VIAL INJECTION TAZIDIME 6 G/VIAL 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 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 120 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 DOUBLE STRENGTH 160 MG CHEWABLE TABLET TEMPRA INFANT 80 MG/ML ORAL DROPS TERAZOL 3 80 MG VAGINAL OVULE TERAZOL 3 DUAL PAK KIT TERAZOL 7 0.4% VAGINAL CREAM TERSASEPTIC 0.5% TOPICAL SHAMPOO TERSA-TAR 3% TOPICAL SHAMPOO TERSA-TAR MILD 1% TOPICAL SHAMPOO TESTIM 1% TOPICAL GEL Route INJ INJ INJ INJ INJ TOP TOP INJ OPH OPH OPH OPH OPH OPH OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL VAG VAG/TOP VAG TOP TOP TOP TOP Form DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL CRM CRM DEFAUL SOL SOL SOL SOL DPS ONT SOL TAB DRC TAB TAB TAB TAB SUS TAB CAP DEFAUL CAP CAP CAP CAP CAP CTB DPS OVL OVL/CRM CRM SHP SHP SHP GEL This document is for pricing use only and should 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 BMS SAV SAV LIL LIL ALL ALL AVE AKN ALC ALC ALC ALC ALC ALL VCL BIO PDL PDL PDL PDL GSK GSK MFC MFC MFC MFC MFC MFC MFC PAL PAL JAI JAI JAI TCD TCD TCD PAL Unit of Issue ML ML ML VIAL VIAL G G VIAL ML ML ML ML ML G ML TAB CAP TAB TAB TAB TAB ML TAB CAP VIAL CAP CAP CAP CAP CAP TAB ML OVL KIT G ML ML ML G Base Price 1.9802 456.9400 456.9400 60.8100 190.9900 1.4780 1.4620 59.0440 0.9710 0.4140 0.5160 0.4407 0.4287 1.6114 0.5033 0.4980 17.5955 0.2824 0.2824 0.2824 0.2824 0.5912 8.9188 164.9100 411.2600 230.8760 264.3805 32.9840 412.2620 8.3840 0.1560 0.2727 6.3767 33.0300 0.6976 0.0273 0.0393 0.0367 0.7831 Pg 84 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000514462 00002148528 00002248251 00002403633 00002313049 00002362538 00002362511 00002380927 00002398419 00002398400 00002400022 00002400030 00002239355 00002389762 00002382091 00002382105 00002248457 00002247346 00002399806 00002399814 00002387247 00002343657 00002258323 00002258315 00002261898 00002392925 00002352893 00002359707 00002321378 00002321386 00002248556 00002274914 00002274922 00002274930 00002269317 00002361205 00002361221 00002361159 00002361248 Product Description 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-ANASTROZOLE 1 MG TABLET TEVA-ATOMOXETINE 100 MG CAPSULE TEVA-ATOMOXETINE 80 MG CAPSULE TEVA-ATOVAQUONE PROGUANIL 250 MG/100 MG TABLET TEVA-BOSENTAN 125 MG TABLET TEVA-BOSENTAN 62.5 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-GABAPENTIN 600 MG TABLET TEVA-GABAPENTIN 800 MG TABLET TEVA-IMATINIB 100 MG TABLET TEVA-IMATINIB 400 MG TABLET 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-METOPROL 25 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-PAROXETINE 10 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 Route INJ OPH 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 Form LIQ SOL TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB DISNTAB DISNTAB TAB TAB TAB TAB TAB CAP 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 CNG BSH TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV TEV Unit of Issue ML ML TAB TAB TAB CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP CAP Base Price 45.2240 7.2450 1.0370 4.0525 2.5460 4.3520 3.9960 4.4892 48.1340 48.1340 1.5908 5.3028 0.3937 11.2103 10.0850 10.0850 1.3045 1.7393 20.4557 81.8228 7.8309 2.7560 0.5670 0.4914 0.0643 1.3962 2.4692 10.3093 5.3553 7.5977 1.0430 0.5809 0.8139 1.3297 1.3860 1.7270 1.7270 0.6173 1.7270 Pg 85 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002361175 00002361183 00002413809 00002347180 00002144271 00002144298 00002144263 00002357542 00002356643 00002355205 00002355221 00002355191 00002360101 00002360128 00080015438 00002242082 00002248854 00001916939 00002242275 00002242276 00000576050 00000576034 00000576042 00002414945 00002244826 00000533688 00002230640 00002337630 00002337649 00000312762 00002229566 00002221926 00002221934 00002304104 00002244982 00002244981 00002264846 00002388294 00002246365 Product Description TEVA-PREGABALIN 50 MG CAPSULE TEVA-PREGABALIN 75 MG CAPSULE TEVA-RISEDRONATE 150 MG TABLET TEVA-TRAMADOL/ACETAMINOPHEN 37.5 MG/325 MG TABLET TEVA-TRAZODONE 100 MG TABLET TEVA-TRAZODONE 150 MG TABLET TEVA-TRAZODONE 50 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 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 40 MG/ML INJECTION 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 TORISEL 25 MG/ML INJECTION TRACLEER 125 MG TABLET TRACLEER 62.5 MG TABLET TRAMACET 37.5 MG/325 MG TABLET TRAMAPHEN-ODAN 37.5 MG/325 MG TABLET TRANEXAMIC ACID 100 MG/ML INJECTION Route ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL OPH OPH INJ OPH OPH TOP TOP TOP ORL INJ INJ INJ ORL ORL ORL INJ TOP TOP INJ ORL ORL ORL ORL INJ Form CAP CAP TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP SRT SRT CAP SOL SOL DEFAUL LAS LAS AER CRM PWR TAB DEFAUL DEFAUL DEFAUL CAP CAP TAB DEFAUL GEL ONT DEFAUL 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 TEV TEV TEV TEV TEV TEV TEV TEV TEV CLG CLG CLG AAP AAP AVR AVR AVR GSK ALC ALC SCH SCH SCH VIV HLR PPC PPC GST GST AAP AZC VCL VCL WAY ACT ACT JAI ODN SDZ Unit of Issue CAP CAP TAB TAB TAB TAB TAB TAB TAB CAP CAP CAP TAB TAB CAP ML ML VIAL ML ML G G G TAB VIAL VIAL ML CAP CAP TAB VIAL G G VIAL TAB TAB TAB TAB ML Base Price 0.9683 1.2529 40.9500 0.6807 0.1272 0.1869 0.0712 3.0531 0.5693 58.9400 117.8800 29.4700 0.4059 0.4916 0.1140 0.6597 0.4927 10.7520 2.9540 3.8380 0.0565 0.3767 0.0701 19.8873 2700.0000 199.0000 3.5310 23.6393 23.8953 0.1183 324.6200 0.5318 0.6857 1261.2500 69.7396 68.9920 0.8302 0.6264 3.8860 Pg 86 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080024336 00000605786 00002230285 00002230284 00002392569 00002392550 00002240000 00002243856 00002221977 00000896179 00000789828 00000852163 00002401967 00002401975 00002296381 00002296403 00002296411 00002242067 00002242068 00002244673 00002242069 00000517895 00080002067 00002244757 00000511226 00080015078 00002148536 00080000383 00002274906 00000317268 00002409720 00001967932 00001970240 00002151138 00001916971 00001916963 00080019103 00002230578 00002237548 Product Description TRANSDERM-V 1.5 MG TOPICAL PATCH TRAVEL AID 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 TRENTAL 400 MG SUSTAINED RELEASE TABLET TRIAMINIC DM NIGHTIME ORAL SYRUP TRIATEC-30 TABLET TRIATEC-8 TABLET TRICIRA LO 21 TABLET TRICIRA LO 28 TABLET 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 TRIPLE STRENGTH ODOURLESS GARLIC SOFTGEL CAPSULE 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 TUDORZA GENUAIR 400MCG METERED INHALATION POWDER 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 Route TOP ORL ORL ORL INJ INJ INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ ORL OPH ORL ORL INJ INH ORL ORL ORL ORL ORL ORL INJ INJ Form PTH TAB TAB TAB DEFAUL DEFAUL DEFAUL DEFAUL SRT SYR TAB TAB TAB TAB ERT ERT ERT TAB TAB SUS TAB SRT CAP TAB DEFAUL CAP SOL CAP TAB DEFAUL MIP CTB CTB CTB SRSUS SRT CAP NDL 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 NOV WTR ICN ICN LUI LUI PAL PAL SAV NVC TLI TLI APX APX PAL PAL PAL NOV NOV NOV NOV SCH VCL GSK OMG MTA BSH TRU GIL AVE ALM SKB SKB SKB SAV SAV FEI GSK GSK Unit of Issue PTH TAB TAB TAB VIAL VIAL VIAL VIAL TAB ML TAB TAB TAB TAB TAB TAB TAB TAB TAB ML TAB TAB CAP TAB ML CAP ML CAP TAB ML DOSE TAB TAB TAB ML TAB CAP SYR SYR Base Price 3.9250 0.0720 0.3956 0.2214 1250.0000 312.5000 366.0600 1021.6000 0.8097 0.0512 0.1300 0.0473 0.5112 0.3834 1.3263 2.4181 3.5137 0.8996 0.9890 0.3597 1.9782 0.6535 0.0460 19.4932 4.9715 0.4237 6.6667 0.2087 29.2023 155.4000 1.1772 0.0453 0.0472 0.0510 0.3536 1.7679 0.8207 50.8600 25.4300 Pg 87 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002285401 00002326442 00002246060 00001933728 00002238885 00000743224 00000890677 00000743275 00000743267 00002276259 00000574007 00000743283 00002290510 00000863270 00000663980 00002347792 00002241361 00002181061 00000559393 00000723894 00000778400 00002163942 00002242727 00002130955 00080022377 00001966294 00080015173 00080006259 00080033880 00080011779 00080011780 00002237698 00080044443 00002349469 00000626724 00000632783 00001962728 00001946994 00000116866 Product Description TYGACIL 50MG/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 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 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 ULTRACLEAR SUSTAIN ORAL POWDER ULTRAM 50 MG TABLET 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 Route INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL TOP TOP TOP ORL ORL Form DEFAUL TAB ERT TAB ERT CTB CTB TAB TAB TAB TAB TAB TAB CAP TAB CTB CTB TAB TAB TAB TAB ELX NDL DEFAUL CAP SYR CAP CAP TAB CAP CAP CAP PWR TAB GEL CRM ONT TAB EVP This document is for pricing use only and should 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 WAY GSK MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL MCL JAI GSK CNG FMD MMH RLC NFN MTG MTG MTG BLO MTG JAI CDX CDX VCL PDH AXS Unit of Issue VIAL TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB ML SYR ML CAP ML CAP CAP TAB CAP CAP CAP G TAB G G G TAB G Base Price 86.2690 25.2626 0.1800 0.2850 0.1696 0.1763 0.2805 0.2850 0.2850 0.3040 0.2004 0.2012 0.5206 0.1383 0.4783 0.2925 0.2700 0.1730 0.1533 0.1308 0.2004 0.1059 24.0600 52.7000 0.9900 0.1406 1.1665 0.2387 0.3135 0.4116 0.4167 0.2221 0.0676 0.7797 1.0800 0.8667 0.9612 0.2040 0.1138 Pg 88 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00001946099 00000398179 00001946102 00080005531 00002353997 00001914022 00002273578 00002273586 00002241411 00080030062 00002241332 00002306085 00000177016 00000232351 00000013285 00002367742 00002367750 00002366940 00002367726 00002384523 00002367734 00002384760 00002384779 00002367777 00002367785 00002367769 00002246559 00002394634 00002394626 00002243837 00002229702 00002241047 00002246081 00002139502 00002223929 00002308487 00002273985 00002339269 00002273969 Product Description UREMOL 10 10% TOPICAL CREAM UREMOL 20% TOPICAL CREAM UREMOL-10 10% TOPICAL LOTION URISEC 40 40% TOPICAL CREAM UROCIT-K 10 MEQ EXTENDED-RELEASE TABLET UROCIT-K 5 MEQ TABLET UROMAX 10 MG CONTROLLED RELEASE TABLET UROMAX 15 MG CONTROLLED RELEASE TABLET UROMITEXAN 100 MG/ML INJECTION UTI CLEANSE TABLET VAGIFEM 25 MCG VAGINAL TABLET VALCYTE 50 MG/ML ORAL SUSPENSION 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 500 MG/VIAL INJ USP 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 CAP Route TOP TOP TOP TOP ORL ORL ORL ORL INJ ORL VAG ORL TOP TOP ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL INJ INJ TOP INJ INJ INJ INJ INJ INJ ORL ORL ORL Form CRM CRM LOT CRM ERT SRT ERT ERT DEFAUL TAB TAB SUS CRM ONT TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB DEFAUL DEFAUL CRM DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL DEFAUL ERC ERC ERC This document is for pricing use only and should 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 TCD TCD TCD ODN PAL SFD PUR PUR AST AOR NNA HLR VLP VLP HLR PDL PDL SNS PDL SIV PDL SIV SIV PDL PDL PDL GSK SDZ SDZ TPI MSD GSK MFC PPC CNG AMG PMS PDL PMS Unit of Issue G G ML G TAB TAB TAB TAB ML TAB TAB ML G G TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB VIAL VIAL G ML VIAL VIAL ML ML ML CAP CAP CAP Base Price 0.0775 0.0815 0.0438 1.4000 0.5593 0.3449 1.3655 1.4710 6.4890 0.4416 3.2133 2.7521 1.0830 1.0830 0.1725 0.3330 0.3330 0.5239 0.4080 0.4080 0.3330 0.3253 0.3253 0.3330 0.3330 0.3330 7.4833 58.9900 31.0500 2.5990 47.5400 62.7900 76.7200 19.8300 8.3500 123.1920 0.3469 0.8868 0.3477 Pg 89 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002339242 00002273977 00002339250 00002243716 00002226286 00002243115 00000616192 00000839299 00002166739 00002348489 00000594601 00002145839 00002163691 00000717002 00000717029 00002239768 00002239766 00002239767 00002273330 00001938959 00002050684 00001935747 00002351064 00002336707 00002244596 00002244597 00002244598 00002244599 00002252260 00002361701 00002361728 00002183056 00002401460 00002143305 00000074500 00002238617 00002248761 00002238748 00002367289 Product Description VENLAFAXINE XR 37.5 MG EXTENDED-RELEASE CAPSULE VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAP VENLAFAXINE XR 75 MG EXTENDED-RELEASE CAPSULE 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 VERAPAMIL HYDROCHLORIDE 2.5 MG/ML INJECTION VERAPAMIL HYDROCHLORIDE USP 2.5 MG/ML INJECTION VERDESO 0.05% TOPICAL FOAM 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) VIGAMOX 0.5% OPHTHALMIC SOLUTION 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 SULPHATE 1 MG/ML INJECTION VIOFORM HC TOPICAL CREAM VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VIRAMUNE 200 MG TABLET VIRAMUNE XR 400 MG EXTENDED-RELEASE TABLET Route ORL ORL ORL INJ INJ INH ORL INJ INJ TOP TOP ORL OPH TOP TOP ORL ORL ORL ORL ORL ORL TOP INJ INJ ORL ORL ORL ORL OPH ORL ORL INJ INJ INJ TOP ORL ORL ORL ORL Form ERC ERC ERC DEFAUL DEFAUL MIP CAP DEFAUL DEFAUL FOA LOT CAP SUS CRM ONT TAB TAB TAB LIQ LIQ LIQ ONT DEFAUL DEFAUL CAP/ENCP CAP/ENCP CAP/ENCP CAP/ENCP SOL TAB TAB DEFAUL DEFAUL DEFAUL CRM TAB TAB TAB ERT This document is for pricing use only and should 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 PDL PMS PDL LPI BAI GSK BMS HSP SDZ GSK VLP HLR ALC TAR TAR PFI PFI PFI PGI PGI PGI PGI NNA CLG BMS BMS BMS BMS ALC AZC AZC MNP TEV TEV PAL AGR PFI BOE BOE Unit of Issue CAP CAP CAP ML VIAL DOSE CAP ML ML G ML CAP ML G G TAB TAB TAB ML ML ML G ML VIAL CAP CAP CAP CAP ML TAB TAB ML ML ML G TAB TAB TAB TAB Base Price 0.4200 0.6956 0.8399 8.1498 195.0000 0.2095 40.5675 19.1500 20.7550 0.3199 0.0670 14.2233 4.0880 0.4600 0.6773 9.9975 9.0075 9.6150 0.0267 0.0341 0.0276 0.0760 26.9367 628.0000 3.9893 6.3837 7.9073 12.9307 4.7233 1.1518 1.1518 11.5000 17.6790 31.0000 0.9377 2.0276 5.0689 5.3662 2.4690 Pg 90 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00080030855 00000568627 00000568635 00000443174 00000417289 00000417270 00002242367 00080016590 00080016683 00002245911 00002240199 00080028004 00080016576 00000123137 00000297720 00002245311 00080035590 00000487082 00000294853 00000407011 00002239350 00000816078 00000610267 00000331015 00000450642 00002023598 00002241500 00002230932 00002237736 00080006939 00000626112 00000335940 00000305243 00000689726 00002243767 00000329185 00000528846 00002239348 00000122645 Product Description 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 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/ML 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 Route 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 INJ ORL ORL ORL INJ ORL ORL ORL ORL ORL ORL ORL ORL Form 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 DEFAUL TAB TAB TAB DEFAUL TAB TAB 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 PLT NOV NOV NOV NOV NOV NVO ALC ALC NOV NCI ALC ALC JAM JAM WNP WNP SWS VCL JAM PMT SDZ LEA JAM VTH PMT SDZ WES SWS WNP OMG JAM JAM SNS VTH JAM HAL PMT JAM Unit of Issue CAP TAB TAB TAB TAB TAB VIAL TAB CAP TAB TAB CAP TAB CAP CAP CAP TAB TAB TAB TAB TAB ML TAB TAB TAB TAB ML TAB TAB TAB ML TAB TAB TAB TAB TAB TAB TAB TAB Base Price 0.8991 0.9734 0.9734 0.9979 1.4476 0.6281 1850.6700 0.2374 0.2268 0.2430 0.2430 0.3059 0.2374 0.0482 0.0453 0.0260 0.1575 0.1732 0.0900 0.0910 0.0214 2.7710 0.0740 0.0592 0.0700 0.0568 1.5650 0.0771 0.0907 0.1360 0.3100 0.0675 0.0548 0.0741 0.0465 0.0675 0.0300 0.0228 0.0336 Pg 91 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00000331031 00000305227 00000341207 00000305235 00001994336 00002243893 00000237116 00000373699 00000036188 00002163268 00002240883 00000463108 00080001870 00080017530 00080000436 00080006264 00000323179 00000765384 00002229879 00002240624 00002240858 00002242175 00080002452 00080009578 00080018025 00080015280 00080012124 00002245842 00080003663 00000122823 00000332348 00000122831 00000266108 00000480940 00000782181 00002240967 00000332356 00000122858 00000330191 Product Description VITAMIN B6 250 MG TABLET VITAMIN B6 50 MG TABLET VITAMIN C 1000 MG SUSTAINED-RELEASE TABLET VITAMIN C 1000 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 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 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 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 ORL ORL Form TAB TAB SRT TAB CTB CTB CTB SRC TAB TAB TAB TAB TAB CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB LIQ GEL LIQ TAB TAB CAP CAP CAP CAP CAP CAP CAP 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 JAM TAB JAM TAB JAM TAB JAM TAB JAM TAB PMT TAB TEV TAB JAM CAP WAM TAB JAM TAB WNP TAB GAH TAB SIS TAB JAM CAP JAM TAB GFR TAB SWS TAB LCO TAB SWS TAB WAM TAB PMT TAB JAM TAB WNP TAB VCL TAB JAM ML VTH CAP WBP ML PMT TAB WNP TAB JAM CAP LDL CAP JAM CAP PMT CAP VTH CAP VTH CAP WNP CAP LDL CAP JAM CAP JAM CAP Base Price 0.1096 0.0505 0.1108 0.0854 0.0631 0.0333 0.0257 0.1010 0.0400 0.0503 0.0359 0.0970 0.0440 0.0429 0.0453 0.0500 0.0305 0.0400 0.0398 0.0161 0.0117 0.0465 0.0284 0.0261 0.9316 0.0822 0.1648 0.0178 0.0342 0.0672 0.0629 0.0865 0.0542 0.0741 0.0816 0.1100 0.0539 0.1312 0.2966 Pg 92 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002015293 00000201995 00000480878 00000816175 00002248361 00000013765 00000885975 00002307073 00002307065 00002290375 00002338580 00000881635 00002352303 00002357119 00080037590 00002365561 00080006877 00080008041 00001948970 00001949004 00002136740 00002384256 00002384264 00000723770 00000813958 00002238453 00002238454 00002240325 00002404044 00002368153 00002388316 00000866598 00000866601 00000509906 00002407329 00000800694 00000001791 00000385484 00000001821 Product Description VITAMIN E NATURAL SOURCE 400 UNIT CAPSULE VITAMIN E NF NATURAL SOURCE 400 IU CAPSULE VITAMINE B12 1200 MCG SUSTAINED-RELEASE TABLET VITAMINE C 600 MG CAPSULE 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 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 WASP VENOM PROTEIN 1.1 MG 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 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 Route ORL ORL ORL ORL INJ ORL ORL ORL ORL TOP TOP ORL ORL INJ ORL TOP ORL ORL INJ INJ ORL ORL ORL ORL ORL ORL ORL ORL TOP INJ INJ TOP TOP TOP ORL TOP INJ URH INJ Form CAP CAP SRT CAP DEFAUL TAB CAP TAB TAB GEL GEL TAB TAB DEFAUL PWR CRM LIQ LIQ DEFAUL DEFAUL TAB CAP CAP TAB TAB TAB TAB CAP CRM DEFAUL DEFAUL SHP SHP SHP CAP SHP DEFAUL JEL 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 QVS CAP WAM CAP JAM TAB SIS CAP SFP SYR AXS TAB SSV CAP GSK TAB GSK TAB NVC G NVC G NOV TAB GSK TAB SHG VIAL FEI G VCL G JPC ML WAM ML ALG VIAL ALG VIAL MUC TAB PFI CAP PFI CAP 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 Base Price 0.0592 0.1165 0.1408 0.2112 87.6900 0.0858 6.3675 122.5200 122.5200 0.1297 0.1213 0.9754 36.9908 1955.0000 3.6996 45.9186 0.0378 0.0378 41.4833 35.6833 0.3497 157.6667 157.6667 0.5924 1.0416 1.9885 6.6286 1.7499 7.5940 600.6700 1120.0000 0.0639 0.0639 0.0639 30.4708 0.0676 0.3715 0.9535 0.2670 Pg 93 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002373130 00000001732 00000036641 00000049816 00002268272 00002321157 00002387433 00001948954 00001948962 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 Product Description 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 YELLOW JACKET VENOM PROTEIN 120 MCG 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 Route ORL INJ INJ TOP ORL ORL ORL 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 Form DEFAUL LIQ LIQ SOL SOL TAB TAB 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 This document is for pricing use only and should 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 AZC VIAL AZC ML AZC ML AZC ML VCL ML BAI TAB BAI TAB ALG VIAL ALG VIAL 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 STI 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 Base Price 0.3903 0.9573 1.1464 0.1848 2.6109 0.6118 0.4596 35.6833 35.6833 128.2080 0.5568 0.4281 0.6150 0.4886 3.5283 5.7500 0.4270 0.0350 0.0550 0.0750 108.5500 17.1600 0.1653 0.1450 50.0327 0.7873 0.9542 0.6138 4.8640 5.0575 5.2755 5.5282 0.4568 7.3845 0.0494 0.0659 0.0742 0.0466 0.0914 Pg 94 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002239162 00002239160 00002153432 00002153440 00002239952 00002231143 00002354802 00002240332 00002407639 00002408082 00002327619 00002379929 00002379988 00002248992 00002315939 00000740306 00002004240 00001911627 00002039524 00000569771 00000800686 00002354772 00002340445 00002342804 00002342790 00002257270 00002338106 00002338114 00002338068 00002338092 00002345676 00002303329 00002303337 00002302659 00002302667 00002325179 00002325187 00002344440 00002344459 Product Description 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 ZITHROMAX 600 MG TABLET ZMAX SR 27 MG/ML ORAL SUPENSION ZOCOR 80 MG TABLET ZOLEDRONIC ACID 4 MG/5 ML INJECTION ZOLEDRONIC ACID 5 MG/100 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 ZOSTRIX 0.025% TOPICAL CREAM ZOSTRIX H.P. 0.075% TOPICAL CREAM 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 Route TOP TOP INJ INJ INJ ORL ORL ORL INJ INJ ORL ORL ORL NAS INJ TOP TOP ORL TOP TOP TOP TOP TOP ORL ORL OPH ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL ORL Form ONT ONT DEFAUL DEFAUL DEFAUL TAB SUS TAB DEFAUL DEFAUL CAP TAB DISPTAB SPU DEFAUL CRM CRM TAB CRM ONT SHP CRM CRM TAB TAB SOL TAB TAB TAB TAB TAB TAB TAB CAP CAP 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 PDH PDH PFI PFI PFI PFI PFI MFC TEV TEV MFC PDL PDL AZC MFC GEU GEU GSK VCL VCL DLX SAV VCL ZMC ZMC ALL ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC Unit of Issue G G VIAL VIAL VIAL TAB ML TAB ML ML CAP TAB TAB DOSE VIAL G G TAB G G ML G G TAB TAB ML TAB TAB TAB TAB TAB TAB TAB CAP CAP TAB TAB TAB TAB Base Price 0.0818 0.0650 137.0600 274.1400 22.8310 12.0693 0.5783 2.6114 83.1120 5.0310 76.1795 5.3333 5.3333 15.3750 157.5000 0.2312 0.2953 2.6715 14.2760 14.3225 0.1009 1.8930 46.3686 0.3587 0.2417 2.8200 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 Pg 95 of 96 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL) Effective May 15, 2014 DIN/ PIN/ NPN 00002320754 00002320762 00002320770 00002303817 00002303779 00002303809 00002325144 00002325152 00002325136 00002238851 00002243088 00002243089 00002371065 00002360349 00002286424 00002286432 00002286440 00002286459 00002360322 00002243685 00002243686 Product Description ZYM-PIOGLITAZONE 15 MG TABLET 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 ORL INJ ORL Form TAB TAB TAB CAP CAP CAP TAB TAB TAB TAB DISNTAB DISNTAB TAB ERT CRT CRT CRT CRT ERT DEFAUL SUS This document is for pricing use only and should 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 ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC ZMC LIL LIL LIL JAI PUR PUR PUR PUR PUR PUR PFI PFI Unit of Issue TAB TAB TAB CAP CAP CAP TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB TAB ML ML Base Price 1.5716 2.2017 3.3105 1.1025 0.5040 1.0080 1.2537 1.9845 0.6615 15.6232 11.6393 15.3621 31.3721 1.1717 1.7387 2.2820 3.3143 4.3467 0.9128 0.3426 2.7023 Pg 96 of 96
Similar documents
Products and Pricing on the Alberta Blue Cross Drug Price List
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
...
Pg 1 of 230 - Alberta Blue Cross
This document is for pricing use only and should not be used to determine benefit status information.
Pricing is applicable to a Drug Product regardless of the package size for each Drug Product.
Pg 1 of 227
Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)
Effective December 14, 2015
DIN/ PIN/ NPN
Alberta Blue Cross Drug Price List
Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)
Effective September 14, 2016