Drug Benefit List

Table of Contents

Section 1-Policies and Guidelines PDF
(click here for entire Section 1 or click on subheadings highlighted below)

Introduction PDF
Eligibility
Additional Notes Regarding Application of the List
Legend
Example of Drug Product Listings
Acknowledgments
Drug Review Procedure
Alberta Health Expert Committee on Drug Evaluation and Therapeutics

Submission and Drug Review Process PDF
Submission Requirements and Criteria
Interpretation Notices
Submission Requirements
Criteria for Listing Drug Products
Interchangeable Drug Products
Review of Benefit Status (ROBS) Criteria
Supply Shortage Policy for Drug Products
Policy for Administering Interchangeability Challenges
Your Comments are Important to Us

Units of Issue for Pricing PDF

Price Policy PDF- Effective February 20, 2014

Restricted Benefits PDF
Restricted Benefits
Products Designated as Restricted Benefits
Limited Restricted Benefits
Products Designated as Limited Restricted Benefits

Special Authorization Guidelines PDF
Special Authorization Policy
Special Authorization Procedures
Special Authorization Forms
Prescriber Registration Forms

Drug Special Authorization Request Form PDF (ABC 20061)

Donepezil/Galantamine/Rivastigmine Special Authorization Request Form PDF (ABC 30776)

Clopidogrel Special Authorization Request Form PDF (ABC 30786)

Darbepoetin/Epoetin Special Authorization Request Form PDF (ABC 30888)

Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form PDF (ABC 30902)

Ezetimibe Special Authorization Request Form PDF (ABC 30925)

Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form PDF (ABC 30932)

Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form PDF (ABC 30944)

Etanercept for Juvenile Rheumatoid Arthritis Special Authorization Request Form PDF (ABC 30948)

Adalimumab/Etanercept/Infliximab for Psoriatic Arthritis Special Authorization Request Form PDF (ABC 30964)

Select Quinolones Special Authorization Request Form PDF (ABC 30966)

Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form PDF (ABC 31086)

Celecoxib Special Authorization Request Form PDF(ABC 31140)

Filgrastim/Pegfilgrastim Special Authorization Request Form PDF(ABC 31150)

Fentanyl Special Authorization Request Form PDF(ABC 31169)

Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form PDF (ABC 31192)

Adalimumab/Etanercept/Infliximab for Ankylosing Spondylitis Special Authorization Request Form PDF(ABC 31195)

Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form PDF(ABC 31200)

Rituximab for Rheumatoid Arthritis Special Authorization Request Form PDF (ABC 31205)

Imiquimod Special Authorization Request Form PDF (ABC 31222)

Dutasteride/Finasteride Special Authorization Request Form PDF (ABC 31257)

Risperidone Prolonged Release Injection Special Authorization Request Form PDF (ABC 31258)

Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 31291)

Montelukast/Zafirlukast Special Authorization Request Form PDF (ABC 31313)

Febuxostat Special Authorization Request Form PDF (ABC 31376)

Denosumab/Zoledronic Acid for Special Authorization Request Form PDF (ABC 31377)

Omalizumab Special Authorization Request Form PDF (ABC 31406)

Telaprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form PDF (ABC 31418)

Tocilizumab for Systemic Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 31419)

Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request Form PDF (ABC 31420)

Boceprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form PDF(ABC 31424)

Saxagliptin/Sitagliptin/Sitagliptin+Metformin/ Linagliptin Special Authorization Request Form PDF(ABC 31461)

Apixaban/Dabigatran/Rivaroxaban Special Authorization Request FormPDF (ABC 31482)

Valganciclovir Special Authorization Request FormPDF (ABC 31483)

Tacrolimus Topical Ointment Special Authorization Request FormPDF (ABC 31488)

Fingolimod Hydrochloride Special Authorization Request Form PDF(ABC 60000)

Glatiramer Acetate/Interferon Beta-1A/Interferon Beta-1B Special Authorization Request Form PDF(ABC 60001)

Natalizumab Special Authorization Request Form PDF (ABC 60003)

Section 2-Rare Diseases Drug Coverage Program PDF

Section 3-Criteria for Special Authorization of Select Drug Products PDF

Section 3A- Criteria for Optional Special Authorization of Select Drug Products PDF

Back to top


Listing of benefits by Pharmacologic-Therapeutic Classification (PTC) of Drugs PDF
(excluding Special Authorization products PDF)

Listing by separate PTC:
00:00 Non-Classified Drugs PDF
04:00 Antihistamine Drugs PDF
08:00 Anti-Infective Agents PDF
10:00 Antineoplastic Agents PDF
12:00 Autonomic Drugs PDF
20:00 Blood Formulation, Coagulation and Thrombosis PDF
24:00 Cardiovascular Drugs PDF
28:00 Central Nervous System Agents PDF
34:00 Dental Agents PDF
36:00 Diagnostic Agents PDF
40:00 Electrolytic, Caloric and Water Balance PDF
48:00 Respiratory Tract Agents PDF
52:00 Eye, Ear, Nose and Throat (EENT) Preparations PDF
56:00 Gastrointestinal Drugs PDF
60:00 Gold Compounds PDF
64:00 Heavy Metal Antagonists PDF
68:00 Hormones and Synthetic Substitutes PDF
80:00 Serums, Toxoids, and Vaccines PDF
84:00 Skin and Mucous Membrane Agents PDF
86:00 Smooth Muscle Relaxants PDF
88:00 Vitamins PDF
92:00 Miscellaneous Therapeutic Agents PDF
94:00 Devices PDF

Back to top

Appendices
Appendix 1 Abbreviations PDF
Appendix 2 Manufacturers PDF

Indices
TIP: For a quick search use the following lists. They contain the names and DIN numbers of all products included, either regular benefits, special authorization or restricted benefits, in the latest edition of the DBL.
Index 1 Alphabetical List of Products PDF (use this to confirm spelling of product and location of the listing, if an eligible benefit)
Index 2 Numerical List of Products PDF (by Drug Identification Number (DIN))

 


NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.

Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.

Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL (iDBL), and any such changes to the Interactive DBL (iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper/CD version or updates.