Products and Pricing on the Alberta Blue Cross Drug Price ...

1 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price000009990413M CAVILON NO STING BARRIER FILM (WIPES) 10 MG/ML ORAL 150 MG 300 MG BENZAGEL 5% TOPICAL (ALCOHOL) BENZAGEL 5% TOPICAL DEXTROSE & NACL W KCL 20 MEQ DEXTROSE 500 MG/ML injection 100 MG 20 MGML ORAL 100 MG/ML ORAL 5MG/ML LIPID COMPLEX 120 MG RECTAL 325 MG RECTAL 650 MG RECTAL 100 MG/VIAL 10% TOPICAL & C 8 MG 12 UNIT SQ-HDM 800 MG 100 MG 25 MG 50 MG 100 MG 200 MG 400 MG 160 MG RECTAL CODEINE 30 10 MG/ML 325 MG 325 MG 325 MG 325 MG 325 MG 500 MG 80 MG/ML ORAL ARTHRITIS PAIN 650 MG COMPOUND WITH CODEINE COMPRIME A CROQUER 80 EXT STR EASY TO SWALLOW 500 MG EXTRA STRENGTH 500 MG EXTRA STRENGTH 500 MG ORAL SOLUTION FOR CHILDREN WITH CODEINE document is for Pricing use only and should not be used to determine benefit status is

2 Applicable to a Drug Product regardless of the package size for each Drug Product. Page 1 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002025337 ACETAMINOPHEN WITH CODEINE , CAFFEINE & 8 MG CODEINE PHOS. 160 POUR 325 MG 500 MG 500 MG POUR FORTE C-8 60 MG 20% INHALATION 20% INHALATION SOLUTION ACID 80 MG CHEWABLE 1 MG 150 MG 500 MG 100 MG 400 MG MG 250 MG 225 MG REDUCER 75 MG PROBIOTIC COMPLETE WITH BIFIDUS AMPHETAMINE XR 10 MG EXTENDED-RELEASE AMPHETAMINE XR 15 MG EXTENDED-RELEASE AMPHETAMINE XR 20 MG EXTENDED-RELEASE AMPHETAMINE XR 25 MG EXTENDED-RELEASE AMPHETAMINE XR 30 MG EXTENDED-RELEASE AMPHETAMINE XR 5 MG EXTENDED-RELEASE ANASTROZOLE 1 MG CABERGOLINE MG DICLO-MISO 50 MG/200 MCG ENTERIC-COATED DICLO-MISO 75 MG/200 MCG ENTERIC-COATED FAMCICLOVIR 125 MG FAMCICLOVIR 250 MG FAMCICLOVIR 500 MG MEMANTINE 10 MG METHYLPHENIDATE ER 18 MG

3 EXTENDED-RELEASE METHYLPHENIDATE ER 27 MG EXTENDED-RELEASE METHYLPHENIDATE ER 36 MG EXTENDED-RELEASE METHYLPHENIDATE ER 54 MG EXTENDED-RELEASE OLANZAPINE ODT 20 MG ORAL DISINT. PRAMIPEXOLE MG PROGESTERONE injection 50 MG/ML document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 2 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002437961 ACT PROPOFOL 10 MG/ML TEMOZOLOMIDE 100 MG TEMOZOLOMIDE 140 MG TEMOZOLOMIDE 20 MG TEMOZOLOMIDE 250 MG TEMOZOLOMIDE 5 MG ODT 10 MG ORAL DISINTEGRATING ODT 20 MG ORAL DISINTEGRATING 1 MG LD MG 150 MG DR 35 MG DELAYED-RELEASE LS OPH SODIUM 25 MG/ML SODIUM 50 MG/ML SODIUM 50 MG/ML 5% TOPICAL XL 20 MG EXTENDED-RELEASE XL 60 MG EXTENDED-RELEASE XL PLUS 20 MG/81 MG XL PLUS 30 MG/81 MG XL PLUS 60 MG/81 MG TOPICAL BP5 ACNE GEL 5% TOPICAL 50MG/VIAL injection POWDER FOR 20 MG XR 10 MG EXTENDED-RELEASE XR 15 MG EXTENDED-RELEASE XR 20 MG EXTENDED-RELEASE XR 25 MG

4 EXTENDED-RELEASE XR 30 MG EXTENDED-RELEASE XR 5 MG EXTENDED-RELEASE 100 MG MG 1 MG MG 2 MG MG STARTER CHLORIDE 1 MG/ML ESSENTIALS OMEGA-3 MG EXTENDED-RELEASE document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 3 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002296470 ADVAGRAF 1 MG EXTENDED-RELEASE 3 MG EXTENDED-RELEASE 5 MG EXTENDED-RELEASE B 12 HOUR 600 MG EXTENDED-RELEASE 200 MG COLD AND SINUS COLD AND SINUS PLUS EXTRA STRENGTH 400 MG EXTRA STRENGTH LIQUI-GEL 400 MG IBUPROFEN 200 MG JUNIOR STRENGTH CHEWABLE LIQUI-GELS 200 MG PEDIATRIC 40 MG/ML SUSPENSION 5 MG OSC POSITIVE EXPIRATORY PRESS THERAPY 2 GO AVHC WITH 2 GO AVHC WITH 10 MG MG 5 MG DISPERZ 2 MG TABLET FOR DISPERZ 3 MG TABLET FOR DISPERZ 5 MG TABLET FOR TETRA ML SINGLE-DOSE SYR TETRA MULTI-DOSE VIAL 100 MG 200 MG 300 MG 10 MG 5 MG 25 MG 500 MG CIT.

5 D 400 CROQ 500 MG/400 IU CHEW D 400 CROQ. 500 MG/400 IU CHEW D 500 MG/1000 IU D 500 MG/400 IU 10 MG 20 MG 40 MG SODIUM 100 MG 20 MG 40 MG 150 MG document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 4 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002474417AG-IRBESARTAN 300 MG 75 MG 100 MG 25 MG 50 MG 25 MG 10 MG OPHTHALMIC 20 MG 40 MG 40 MG ENTERIC-COATED 10 MG 100 MG 200 MG 300 MG injection MULTI-DOSE VIAL ODT 5 MG ORAL DISINT.

6 MG 100 MG 100 MG B12 ER 1200 MCG EXTENDED-RELEASE ODT MG ORAL DISP. 4 MG CHEWABLE 5 MG CHEWABLE 140 MG/ML PREFILLED 70 MG/ML PREFILLED 50 MCG/G TOPICAL MG/300 MG OPH PREP TOPICAL SWABS BD 100 MG 25 MG MG/ML 150 MG SODIUM 5 MG 70 MG 220 MG LIQUID GEL 220 MG PROBIOTIC 500 MG/VIAL 2 MG 12 HOUR 60 MG document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 5 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002242819 ALLEGRA 24 HOUR 120 MG SUSTAINED-RELEASE MG/ML ORAL 25 MG 50 MG EXTRACT POLLENS 100000 UNIT/ML 25 MG DROPS OPH FORMULA 25 MG RELIEF 10 MG REMEDY 10 MG TABLETS EXTRA STRENGTH 50 MG 1:1000 ( MG) AUTO INJECTOR 1.

7 1000 ( MG) AUTO INJECTOR MG/ML ORAL 25 MG EXTRA STRENGTH 50 MG MULTI SYMPTOM 5 MG 10 MG 100 MG 200 MG 300 MG 200 ORAL PLUS ORAL MG (BASE) OPH MG/ML MG LIPOIC ACID 100MG P OPHTHALMIC MG MG MG MG 1 MG 3000 UNIT/VIAL OPHTHALMIC INFANT FORMULA ORAL 15 MG 180 MG 30 MG 90 MG 90 MG/180 MG TABLET INITIATION 50 MG/VIAL document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 6 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002230575 AMETOP 4% TOPICAL SULFATE 250 MG/ML SULFATE 500 MG/2 ML injection 25 MG/ML 10 MG 25 MG 50 MG 10 MG 10 MG MG MG 5 MG 5 MG CLAV 1000/200 MG CLAV 2000/200 MG CLAV 500/100 MG 320 MG/5ML ORAL 600 MG 1 G/VIAL 2 G/VIAL 250 MG/VIAL 500 MG/VIAL SODIUM FOR injection BP 1 G/VIAL SODIUM FOR injection BP 2 G/VIAL SODIUM FOR injection BP 250 MG/VIAL SODIUM FOR injection BP 500 MG/VIAL ORAL 50 MG 1 MG 1 MG ( G/PUMP) 1% TOPICAL ( G/PACKET) 1% TOPICAL (5 G/PACKET)

8 1% TOPICAL 1 MG/1 MG ULTRA-FLUID TOPICAL TOPICAL OINTMENT 50 MG RUB A-535 NO ODOUR TOP COMPACT SPACE CHAMBER PLUS COMPACT SPACE CHAMBER PLUS W/ LG COMPACT SPACE CHAMBER PLUS W/ MED COMPACT SPACE CHAMBER PLUS W/ SM RECTAL document is for Pricing use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 7 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00001945939 ANUSOL RECTAL 10 MG RECTAL PLUS RECTAL PLUS RECTAL CHROMIUM PICOLINATE 600 MCG 500 MG 300 MG 600 MG/300 MG 250 MG FILM COATED 500 MG FILM COATED 325 MG 325 MG 500 MG 5% TOPICAL D3 70 MG/2800 UNIT 1 MG TS 2 MG 10 MG 5 MG 10 MG/10 MG 10 MG/20 MG 10 MG/40 MG 10 MG/80 MG 5 MG/10 MG 5 MG/20 MG 5 MG/40 MG 5 MG/80 MG XR 10 MG EXTENDED-RELEASE XR 15 MG EXTENDED-RELEASE XR 20 MG EXTENDED-RELEASE XR 25 MG EXTENDED-RELEASE XR 30 MG EXTENDED-RELEASE XR 5 MG EXTENDED-RELEASE 1 MG 10 MG 100 MG 18 MG 25 MG 40 MG 60 MG 80 MG 50 MG 4 MG document is for Pricing

9 Use only and should not be used to determine benefit status is applicable to a Drug Product regardless of the package size for each Drug Product. Page 8 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00000893625 APO-CAPTO 100 MG MG 25 MG 50 MG 1 G/VIAL 2 G/VIAL 10 MG 20 MG 8% TOPICAL 30 MG 60 MG 90 MG 250 MG 500 MG TOPICAL 625 MG 75 MG 600 MG 800 MG 100 MG 20 MG 50 MG 70 MG 80 MG 100 MG EXTENDED-RELEASE 50 MG EXTENDED-RELEASE TOPICAL FUMARATE 240 MG DELAYED-RELEASE 2% OPHTHALMIC MR 40 MG MODIFIED RELEASE 20 MG 40 MG 200 MG 100 MG 150 MG 25 MG 20 MG DELAYED-RELEASE 40 MG DELAYED-RELEASE 125 MG 250 MG 500 MG GLUCONATE 300 MG 50 MCG/DOSE AQUEOUS NASAL document is for Pricing use only and should not be used to determine benefit status is applicable to a

10 Drug Product regardless of the package size for each Drug Product. Page 9 of 113 Products and Pricing on the Alberta Blue Cross Drug Price List (ABCDPL)Effective Febuary 14, 2022 DIN/PIN/NPNP roduct DescriptionRouteFormMFRUnit of IssueBase Price00002426471 APO-FROVATRIPTAN MG 600 MG 800 MG OPHTHALMIC 250 MG 500 MG 200 MG 100 MG 400 MG 150 MG 300 MG 150 MG/300 MG 10 MG 15 MG MG 20 MG 25 MG 5 MG MG 10 MG 15 MG MG 10 MG ER 1000 MG EXTENDED-RELEASE ER 500 MG EXTENDED-RELEASE ER 18 MG EXTENDED REL. ER 27 MG EXTENDED REL. ER 36 MG EXTENDED REL. ER 54 MG EXTENDED REL. 500 MG 15 MG 45 MG % OPHTHALMIC 250 MG 500 MG ACID 180 MG ENTERIC-COATED ACID 360 MG ENTERIC-COATED EC 250 MG ENTERIC-COATED 1 MG MG 20 MG ODT 15 MG ORAL DISINT.