Palliative Coverage Drug Benefit Supplement

Palliative Coverage Drug Benefit Supplement Effective April 1, 2015

Inquiries 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) 109BWebsite: http://www.health.alberta.ca/services/drugs-palliative-care.html 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. 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. Copies of the Alberta Drug Benefit List Publication are available from Pharmacy Services, Alberta Blue Cross at the address shown above. Binder and contents: 42.00 (40.00 + 2.00 G.S.T.) Contents only: 36.75 (35.00 + 1.75 G.S.T.) A cheque or money order must accompany the request for copies. Changes may be made, without notice, to the List/Supplement through the on-line interactive List/Supplement, and any such changes to the on-line interactive List/Supplement are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates. Please visit http://www.health.alberta.ca/services/drugs-palliative-care.html for the most current Palliative Coverage Drug Benefit Supplement information. ABC 40211/81160 (R2015/04)

Table of Contents PALLIATIVE COVERAGE DRUG BENEFIT SUPPLEMENT SECTION 1 - INTRODUCTION AND THERAPEUTIC CLASSIFICATION OF DRUGS Introduction Eligibility... i Notes... i Price Policy... i Interchangeable Drug Products... i Excluded Special Authorization Drug Products... ii Pharmacologic-Therapeutic Classification of Drugs 10:00 Antineoplastic Agents... 1 28:00 Central Nervous System Drugs... 1 40:00 Electrolytic, Caloric, and Water Balance... 2 56:00 Gastrointestinal Drugs... 2 72:00 Local Anesthetics... 4 APPENDICES Appendix 1 - Pharmaceutical Manufacturers... 5 Appendix 2 - Alphabetical List of Pharmaceutical Products... 6 Appendix 3 - Numerical List by Drug Identification Number... 8 EFFECTIVE APRIL 1, 2015 i

SECTION 1 Introduction and Therapeutic Classification of Drugs Section 1 Introduction and Therapeutic Classification of Drugs

INTRODUCTION Eligibility Benefits for Palliative Coverage are defined by the Alberta Drug Benefit List and the Palliative Coverage Drug Benefit Supplement (which defines select hydrating agents, laxatives and other products as additional benefits). In order for patients to be eligible for Palliative Coverage, an application for the Palliative Coverage Program must be completed and signed by both the patient (or guardian) and the physician. This Palliative Coverage Program application form must be forwarded to Alberta Health for their consideration and approval. Notes Palliative Coverage will pay the prescription charge for hydrating agents using the guidelines for injectable drugs as referenced in the Schedule of Prices in Appendix A of the ABC Benefits Corporation Pharmacy Agreement. Price Policy The Price Policy is stated in the Alberta Drug Benefit List. Interchangeable Drug Products A box containing an X ( ) to the left of the DIN or Product Identification Number (PIN) indicates that the product is not interchangeable with other products or interchangeability has not been assessed within the category. Refer to Policies and Guidelines Section 1 of the current Alberta Drug Benefit List for further information regarding interchangeable drug products. EFFECTIVE APRIL 1, 2015 i

Excluded Special Authorization Drug Products The following drug product(s) are listed in the special authorization section (Section 3) of the Alberta Drug Benefit List. However, special authorization coverage for these drug product(s) cannot be considered for those patients with Palliative Coverage: Trade Name / Strength / Form Generic Description DIN MFG NEULASTA 6 MG/0.6ML INJECTION SYRINGE PEGFILGRASTIM 00002249790 AMG NEUPOGEN 0.3 MG/ML INJECTION FILGRASTIM 00001968017 AMG Excluded Criteria: To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppresive anti-neoplastic drugs with curative intent. This drug product must be prescribed by the Directors of Alberta Health Services Cancer Care Cancer Centres (or their designates). EFFECTIVE APRIL 1, 2015 ii.

Pharmacologic Therapeutic Classification of Drugs Pharmacologic -Therapeutic Classification of Drugs

10:00 ANTINEOPLASTIC AGENTS 10:00 MEGESTROL ACETATE 40 MG ORAL TABLET 00002195917 MEGESTROL 160 MG ORAL TABLET 00002195925 MEGESTROL 40 MG / ML ORAL SUSPENSION 00002168979 MEGACE OS AAP AAP BMS 1.0577 4.4762 1.7126 28:00 CENTRAL NERVOUS SYSTEM AGENTS 28:08.08 ANALGESICS AND ANTIPYRETICS (OPIATE AGONISTS) FENTANYL 12 MCG/HR TRANSDERMAL PATCH 00002341379 -FENTANYL MTX 00002327112 SANDOZ FENTANYL PATCH 00002311925 A-FENTANYL 00002386844 CO FENTANYL 00002396696 MYLAN-FENTANYL MATRIX 00002330105 RAN-FENTANYL MATRIX 25 MCG/HR TRANSDERMAL PATCH 00002341387 -FENTANYL MTX 00002327120 SANDOZ FENTANYL PATCH 00002282941 A-FENTANYL 00002314630 APO-FENTANYL 25 00002386852 CO FENTANYL 00002396718 MYLAN-FENTANYL MATRIX 00002330113 RAN-FENTANYL MATRIX 50 MCG/HR TRANSDERMAL PATCH 00002341395 -FENTANYL MTX 00002327147 SANDOZ FENTANYL PATCH 00002282968 A-FENTANYL 00002314649 APO-FENTANYL 50 00002386879 CO FENTANYL 00002396726 MYLAN-FENTANYL MATRIX 00002330121 RAN-FENTANYL MATRIX 75 MCG/HR TRANSDERMAL PATCH 00002341409 -FENTANYL MTX 00002327155 SANDOZ FENTANYL PATCH 00002282976 A-FENTANYL 00002314657 APO-FENTANYL 75 00002386887 CO FENTANYL 00002396734 MYLAN-FENTANYL MATRIX 00002330148 RAN-FENTANYL MATRIX 100 MCG/HR TRANSDERMAL PATCH 00002341417 00002327163 00002282984 00002314665 00002386895 00002396742 00002330156 -FENTANYL MTX SANDOZ FENTANYL PATCH A-FENTANYL APO-FENTANYL 100 CO FENTANYL MYLAN-FENTANYL MATRIX RAN-FENTANYL MATRIX SDZ APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN SDZ APX APH MYP RAN 2.2280 2.2280 2.2280 2.2300 2.2300 2.2300 3.6560 3.6560 3.6560 3.6580 3.6580 3.6580 3.6580 6.8820 6.8820 6.8820 6.8838 6.8838 6.8838 6.8838 9.6800 9.6800 9.6800 9.6817 9.6817 9.6817 9.6817 12.0500 12.0500 12.0500 12.0512 12.0512 12.0512 12.0512 UNIT OF ISSUE - REFER TO PRICE POLICY 1 EFFECTIVE APRIL 1, 2015

28:00 40:00 56:00 CENTRAL NERVOUS SYSTEM AGENTS 28:08.08 FENTANYL CITRATE 0.05 MG / ML (BASE) INJECTION 00002240434 FENTANYL CITRATE PARENTERAL SOLUTIONS (LARGE & SMALL VOL) INJECTION 00000990040 00000990034 00000990037 00000990038 00000990033 00000990035 00000990036 00000990039 POTASSIUM CHLORIDE (K+) 149 MG / ML INJECTION 00000037869 POTASSIUM CHLORIDE SODIUM CHLORIDE 0.9 % INJECTION 00000037796 BISACODYL 5 MG ORAL ENTERIC-COATED TABLET 00000545023 APO-BISACODYL APX 00000254142 DULCOLAX BOE Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Care Drug Coverage program. 10 MG RECTAL SUPPOSITORY 00000582883 -BISACODYL 00000003875 DULCOLAX BOE Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Care Drug Coverage program. DOCUSATE CALCIUM (OPIATE AGONISTS) ELECTROLYTIC, CALORIC, AND WATER BALANCE 40:12 GASTROINTESTINAL DRUGS 56:12 ANALGESICS AND ANTIPYRETICS REPLACEMENT PREPARATIONS 0.9% SODIUM CHLORIDE 3.3% DEXT/ 0.3% NACL (2/3-1/3) 3.3% DEXT/0.3% NACL/20 MEQ KCL 3.3% DEXT/0.3% NACL/40 MEQ KCL 5% DEXTROSE (D5W) 5% DEXTROSE/ 0.15% KCL 20 MEQ 5% DEXTROSE/ 0.3% KCL 40 MEQ LACTATED RINGER'S SODIUM CHLORIDE CATHARTICS AND LAXATIVES 240 MG ORAL CAPSULE 00000806226 CALAX 00002283255 JAMP-DOCUSATE CALCIUM 00000842044 NOVO-DOCUSATE CALCIUM 00000809055 A-DOCUSATE CALCIUM 00000664553 -DOCUSATE CALCIUM SDZ HSP HSP ODN JPC 2.0633 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.9686 0.1174 0.0450 0.1890 0.4681 1.1266 0.0816 0.0816 0.0886 0.0892 0.1408 PRODUCT IS NOT INTERCHANGEABLE 2 EFFECTIVE APRIL 1, 2015

56:00 GASTROINTESTINAL DRUGS 56:12 DOCUSATE SODIUM 100 MG ORAL CAPSULE 00000514888 SELAX 00000716731 DOCUSATE SODIUM 00002426838 DOCUSATE SODIUM 00000703494 -DOCUSATE SODIUM 00001994344 SOFLAX 00000870196 A-DOCUSATE SODIUM 00002245079 APO-DOCUSATE SODIUM 00002020084 NOVO-DOCUSATE SODIUM 00002106256 COLACE 200 MG ORAL CAPSULE 00002029529 SOFLAX 250 MG ORAL CAPSULE 00002006596 SELAX 250 4 MG / ML ORAL SYRUP 00000870226 RATIO-DOCUSATE SODIUM RPH 00000695033 SELAX ODN 00002086018 COLACE WSP 00000703508 -DOCUSATE SODIUM Please note: The LCA price indicated for this product is not applicable to clients who are enrolled in the Palliative Care Drug Coverage program. 50 MG / ML ORAL SYRUP 00000848417 -DOCUSATE SODIUM 10 MG / ML ORAL DROPS 00002090163 COLACE WSP POLYETHYLENE GLYCOL 3350 1 G / G ORAL POWDER 00002317680 LAX-A-DAY SENNOSIDES CATHARTICS AND LAXATIVES 8.6 MG ORAL TABLET 00080009595 JAMP-SENNA 00080009182 SENNOSIDES 00002068109 SENNATAB 00000896411 -SENNOSIDES 00000026158 SENOKOT 12 MG ORAL TABLET 00080009183 SENNOSIDES 00000896403 -SENNOSIDES 1.7 MG / ML ORAL LIQUID 00080024394 JAMP SENNAQUIL 1.7 MG / ML ORAL SYRUP 00000367729 SENOKOT SENNOSIDES/ DOCUSATE SODIUM 8.6 MG * 50 MG ORAL TABLET 00000026123 SENOKOT S SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE 10.4 G / ENM * 3.9 G / ENM RECTAL ENEMA 00002096900 ENEMOL ODN TAR SNS APX WSP ODN PPH JPC JPC PUR JPC JPC PUR PUR PPH 0.0383 0.0394 0.0412 0.0412 0.0412 0.0416 0.0470 0.0481 0.1310 0.0920 0.0950 0.0220 0.0220 0.0232 0.0254 0.9844 0.1770 0.0503 0.0555 0.0555 0.0619 0.0633 0.0856 0.0555 0.0746 0.0318 0.0462 0.1754 2.9600 UNIT OF ISSUE - REFER TO PRICE POLICY 3 EFFECTIVE APRIL 1, 2015

72:00 LOCAL ANESTHETICS 72:00 BUPIVACAINE HCL 2.5 MG / ML INJECTION 00001976141 SENSORCAINE 5 MG / ML INJECTION 00001976168 SENSORCAINE AZC AZC 0.5030 0.5980 BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE 2.5 MG / ML * 5 MCG / ML INJECTION 00001976184 SENSORCAINE WITH EPINEPHRINE 5 MG / ML * 5 MCG / ML INJECTION 00001976206 SENSORCAINE WITH EPINEPHRINE AZC AZC 0.5180 0.6164 PRODUCT IS NOT INTERCHANGEABLE 4 EFFECTIVE APRIL 1, 2015

Appendices APPENDICES Pharmaceutical Manufacturers Alphabetical List of Pharmaceutical Products Numerical List by Drug Identification Number

Appendix 1: Pharmaceutical Manufacturers AAP APH APX AZC BMS BOE HSP JPC MYP ODN PPH PUR RAN RPH SDZ SNS TAR WSP A AA Pharma Inc. Actavis Pharma Company Apotex Inc. AstraZeneca Canada Inc. B Bristol-Myers Squibb Boehringer Ingelheim (Canada) Ltd. H Hospira Healthcare Corporation J Jamp Pharma Corporation M Mylan Pharmaceuticals ULC O Odan Laboratories Ltd. P Pharmascience Inc. Pendopharm Inc. Purdue Pharma R Ranbaxy Pharmaceuticals Canada Inc. Ratiopharm S Sandoz Canada Inc. Sanis Health Inc. T Taro Pharmaceuticals Inc. Teva Canada Limited W Wellspring Pharmaceutical Canada Corp. X Miscellaneous Manufacturers EFFECTIVE APRIL 1, 2015 5

APPENDIX 2 ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS Appendix 2: Alphabetical List of Pharmaceutical Products Product Name Page Product Name Page NUMERIC 0.9% SODIUM CHLORIDE... 2 3.3% DEXT/ 0.3% NACL (2/3-1/3)... 2 3.3% DEXT/0.3% NACL/20 MEQ KCL... 2 3.3% DEXT/0.3% NACL/40 MEQ KCL... 2 5% DEXTROSE (D5W)... 2 5% DEXTROSE/ 0.15% KCL 20 MEQ... 2 5% DEXTROSE/ 0.3% KCL 40 MEQ... 2 A APO-BISACODYL... 2 APO-DOCUSATE SODIUM... 3 APO-FENTANYL 100... 1 APO-FENTANYL 25... 1 APO-FENTANYL 50... 1 APO-FENTANYL 75... 1 B BISACODYL... 2 BUPIVACAINE HCL... 4 BUPIVACAINE HCL/ EPINEPHRINE BITARTRATE... 4 C CALAX... 2 CO FENTANYL... 1 COLACE... 3 D DOCUSATE CALCIUM... 2 DOCUSATE SODIUM... 3 DULCOLAX... 2 E ENEMOL... 3 F FENTANYL... 1 FENTANYL CITRATE... 2 J JAMP SENNAQUIL... 3 JAMP-DOCUSATE CALCIUM... 2 JAMP-SENNA... 3 L LACTATED RINGER'S... 2 LAX-A-DAY... 3 M MEGACE OS... 1 MEGESTROL... 1 MEGESTROL ACETATE... 1 MYLAN-FENTANYL MATRIX... 1 N NOVO-DOCUSATE CALCIUM... 2 NOVO-DOCUSATE SODIUM... 3 P PARENTERAL SOLUTIONS (LARGE & SMALL VOL). 2 -BISACODYL... 2 -DOCUSATE CALCIUM... 2 -DOCUSATE SODIUM... 3 -FENTANYL MTX... 1 -SENNOSIDES... 3 POLYETHYLENE GLYCOL 3350... 3 POTASSIUM CHLORIDE... 2 POTASSIUM CHLORIDE (K+)... 2 R RAN-FENTANYL MATRIX... 1 RATIO-DOCUSATE SODIUM... 3 S SANDOZ FENTANYL PATCH... 1 SELAX... 3 SELAX 250... 3 SENNATAB... 3 SENNOSIDES... 3 SENNOSIDES/ DOCUSATE SODIUM... 3 SENOKOT... 3 SENOKOT S... 3 SENSORCAINE... 4 SENSORCAINE WITH EPINEPHRINE... 4 SODIUM CHLORIDE... 2 SODIUM PHOSPHATE/ SODIUM ACID PHOSPHATE 3 SOFLAX... 3 EFFECTIVE APRIL 1, 2015 6

APPENDIX 2 ALPHABETICAL LIST OF PHARMACEUTICAL PRODUCTS Product Name Page Product Name Page T A-DOCUSATE CALCIUM... 2 A-DOCUSATE SODIUM... 3 A-FENTANYL... 1 EFFECTIVE APRIL 1, 2015 7

APPENDIX 3 NUMERICAL LIST BY DRUG IDENTIFICATION NUMBER DRUG IDENTIFICATION NUMBERS OF PHARMACEUTICAL PRODUCTS DIN Page DIN Page 00000003875... 2 00000026123... 3 00000026158... 3 00000037796... 2 00000037869... 2 00000254142... 2 00000367729... 3 00000514888... 3 00000545023... 2 00000582883... 2 00000664553... 2 00000695033... 3 00000703494... 3 00000703508... 3 00000716731... 3 00000806226... 2 00000809055... 2 00000842044... 2 00000848417... 3 00000870196... 3 00000870226... 3 00000896403... 3 00000896411... 3 00000990033... 2 00000990034... 2 00000990035... 2 00000990036... 2 00000990037... 2 00000990038... 2 00000990039... 2 00000990040... 2 00001976141... 4 00001976168... 4 00001976184... 4 00001976206... 4 00001994344... 3 00002006596... 3 00002020084... 3 00002029529... 3 00002068109... 3 00002282968... 1 00002282976... 1 00002282984... 1 00002283255... 2 00002311925... 1 00002314630... 1 00002314649... 1 00002314657... 1 00002314665... 1 00002317680... 3 00002327112... 1 00002327120... 1 00002327147... 1 00002327155... 1 00002327163... 1 00002330105... 1 00002330113... 1 00002330121... 1 00002330148... 1 00002330156... 1 00002341379... 1 00002341387... 1 00002341395... 1 00002341409... 1 00002341417... 1 00002386844... 1 00002386852... 1 00002386879... 1 00002386887... 1 00002386895... 1 00002396696... 1 00002396718... 1 00002396726... 1 00002396734... 1 00002396742... 1 00002426838... 3 00080009182... 3 00080009183... 3 00080009595... 3 00080024394... 3 00002086018... 3 00002090163... 3 00002096900... 3 00002106256... 3 00002168979... 1 00002195917... 1 00002195925... 1 00002240434... 2 00002245079... 3 00002282941... 1 EFFECTIVE APRIL 1, 2015 8