Alberta Drug Benefit List - Home | Alberta Blue Cross

1 Alberta drug Benefit List Effective April 1, 2021 ABC 40211/81160 (R2021/04) 78 BInquiries should be directed to: Pharmacy Services Alberta Blue Cross 10009 108 Street NW Edmonton AB T5J 3C5 Telephone Number: (780) 498-8370 (Edmonton) (403) 294-4041 (Calgary) 1-800-361-9632 (Toll Free) Fax Number: (780) 498-8384 1-877-828-4106 (Toll Free) 109 BWebsite: Administered by Alberta Blue Cross on behalf of Alberta health . The drug Benefit List (DBL) is a list of drugs for which coverage may be provided to program participants. The DBL is not intended to be, and must not be used as a diagnostic or prescribing tool.

2 Inclusion of a drug on the DBL does not mean or imply that the drug is fit or effective for any specific purpose. Prescribing professionals must always use their professional judgment and should refer to product monographs and any applicable practice guidelines when prescribing drugs. The product monograph contains information that may be required for the safe and effective use of the product. Alberta drug Benefit LIST The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment. EFFECTIVE APRIL 1, 2021 i 1 BTable of Contents 79 BPART 1 80 BSECTION 1 POLICIES AND GUIDELINES Introduction Acknowledgments.

3 Eligibility .. Additional Notes Regarding Application of the List .. Legend .. Example of drug Product Listings .. drug Reviews .. Alberta health Expert Committee on drug Evaluation and Therapeutics .. Submissions for drug Reviews Submissions for drug Reviews .. Criteria for Listing drug Products .. Interchangeable drug Products Additional Criteria .. Interchangeable drug Products Additional Criteria Appendices .. Review of Benefit Status (ROBS) Criteria .. Submission Requirements .. Non-Innovator Policy .. Supply Shortages .. Units of Issue for Pricing .. Policy for Administering Interchangeability Challenges.

4 Your Comments Disclosure for Potential Conflicts of Interest .. Restricted benefits Restricted benefits .. Products Designated as Restricted benefits .. Limited Restricted benefits .. Special Authorization Guidelines Special Authorization Policy .. Special Authorization Procedures .. Special Authorization Forms .. Prescriber Registration Forms .. drug Special Authorization Request Donepezil/Galantamine/Rivastigmine Special Authorization Request Form .. Darbepoetin/Epoetin Special Authorization Request Form .. Abatacept/Adalimumab/Anakinra/Certolizum ab/Etanercept/Golimumab/Infliximab/Saril umab/Tocilizumab/Tofacitinib for Rheumatoid Arthritis Special Authorization Request Form.

5 Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form .. Adalimumab/Etanercept/Tocilizumab for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form .. Adalimumab/Certolizumab/Etanercept/Golim umab/Infliximab/Ixekizumab/Secukinumab for Psoriatic Arthritis Special Authorization Request Form .. Select Quinolones Special Authorization Request Form .. Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form .. Alberta drug Benefit LIST The DBL is not a prescribing or a diagnostic tool. Prescribers should refer to drug monographs and utilize professional judgment.

6 EFFECTIVE APRIL 1, 2021 i Table of Contents, continued Celecoxib Special Authorization Request Form .. Filgrastim/Pegfilgrastim/Plerixafor Special Authorization Request Form .. Fentanyl Special Authorization Request Form .. Adalimumab/Etanercept/Infliximab/Ixekizu mab/Risankizumab/Secukinumab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form .. Adalimumab/Certolizumab/Etanercept/Golim umab/Infliximab/Secukinumab for Ankylosing Spondylitis Special Authorization Request Form .. Adalimumab/Vedolizumab for Crohn s/Infliximab for Crohn s/Fistulizing Crohn s Disease Special Authorization Request Form.

7 Rituximab for Rheumatoid Arthritis Special Authorization Request Form .. Imiquimod Special Authorization Request Form .. Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form .. Abatacept for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form .. Montelukast/Zafirlukast Special Authorization Request Form .. Febuxostat Special Authorization Request Form .. Denosumab/Zoledronic Acid for Osteoperosis Special Authorization Request Form .. Omalizumab for Asthma Special Authorization Request Form .. Eculizumab Special Authorization Request Form.

8 Eculizumab Consent Form .. Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request Form .. Tocilizumab for Systemic Juvenile Idiopathic Arthritis Special Authorization Request Form .. DPP-4/SGLT2 Inhibitors Special Authorization Request Form .. Apixaban/Dabigatran/Edoxaban/Rivaroxaban Special Authorization Request Form .. Tacrolimus Topical Ointment Special Authorization Request Form .. Dimethyl Fumarate/Glatiramer Acetate/Interferon Beta-1a/Ocrelizumab/Peginterferon Beta-1a/Teriflunomide for RRMS/Interferon Beta-1b for SPMS or RRMS Special Authorization Request Form.

9 Cladribine/Fingolimod/Natalizumab for Multiple Sclerosis Special Authorization Request Form .. Ivacaftor Special Authorization Request Adalimumab/Golimumab/Infliximab/Vedolizu mab for Ulcerative Colitis Special Authorization Request Form .. Antivirals for Chronic Hepatitis C Special Authorization Request Form .. Proton-Pump Inhibitors Pricing Authorization Request Form .. Nintedanib/Pirfenidone Special Authorization Request Form .. Deferiprone Special Authorization Request Form .. Long-Acting Fixed-Dose Combination Products for Asthma/COPD Special Authorization Request Form .. Eplernone/Ivabradine/Sacubitril+Valsarta n Special Authorization Request Form.

10 Adalimumab for Hidradenitis Suppurativa Special Authorization Request Omalizumab for Chronic Idiopathic Urticaria Special Authorization Request Form .. Benralizumab/Mepolizumab Special Authorization Request Form .. Alirocumab/Evolocumab for HeFH Special Authorization Request Form .. Fidaxomicin Special Authorization Request Form .. Asfotase Alfa Special Authorization Request Form .. Asfotase Alfa Consent Form .. Tocilizumab for Giant Cell Arteritis Special Authorization Request Form .. Nusinersen Special Authorization Request Form .. Obeticholic Acid Special Authorization Request Form.