Interactive Drug Benefit List
DIN/NPN/ PIN Generic Name Product Name, Strength & Dosage Form Unit Price, Unit of Issue Manufacturer LCA Price MAC Price Interchangeable Products Coverage Status
02377233 APIXABAN ELIQUIS 2.5 MG ORAL TABLET 1.6336
TAB
BMS N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02397714 APIXABAN ELIQUIS 5 MG ORAL TABLET 1.6336
TAB
BMS N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02458640 EDOXABAN TOSYLATE MONOHYDRATE LIXIANA 15 MG ORAL TABLET 2.8400
TAB
SEV N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02458659 EDOXABAN TOSYLATE MONOHYDRATE LIXIANA 30 MG ORAL TABLET 2.8400
TAB
SEV N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02458667 EDOXABAN TOSYLATE MONOHYDRATE LIXIANA 60 MG ORAL TABLET 2.8400
TAB
SEV N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02245531 FONDAPARINUX SODIUM ARIXTRA (0.5 ML SYRINGE) 2.5 MG / SYR INJECTION SYRINGE 9.8620
SYR
APC 9.8620 N/A YES REGULAR BENEFIT Details
02406853 FONDAPARINUX SODIUM FONDAPARINUX SODIUM (0.5 ML SYRINGE) 2.5 MG / SYR INJECTION SYRINGE 9.8620
SYR
DRL 9.8620 N/A YES REGULAR BENEFIT Details
02258056 FONDAPARINUX SODIUM ARIXTRA (0.6 ML SYRINGE) 7.5 MG / SYR INJECTION SYRINGE 17.5000
SYR
APC 17.5000 N/A YES REGULAR BENEFIT Details
02406896 FONDAPARINUX SODIUM FONDAPARINUX SODIUM (0.6 ML SYRINGE) 7.5 MG / SYR INJECTION SYRINGE 18.1356
SYR
DRL 17.5000 N/A YES REGULAR BENEFIT Details
02316986 RIVAROXABAN XARELTO 10 MG ORAL TABLET 2.8700
TAB
BAI N/A N/A NO RESTRICTED BENEFIT Details
02378604 RIVAROXABAN XARELTO 15 MG ORAL TABLET 2.8700
TAB
BAI N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
02378612 RIVAROXABAN XARELTO 20 MG ORAL TABLET 2.8700
TAB
BAI N/A N/A NO STEP THERAPY/ SPECIAL AUTHORIZATION Details
DIN/NPN/ PIN 02377233
Generic Name APIXABAN
Product Name, Strength & Dosage Form ELIQUIS 2.5 MG ORAL TABLET
Unit Price, Unit of Issue 1.6336
Manufacturer BMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02397714
Generic Name APIXABAN
Product Name, Strength & Dosage Form ELIQUIS 5 MG ORAL TABLET
Unit Price, Unit of Issue 1.6336
Manufacturer BMS
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458640
Generic Name EDOXABAN TOSYLATE MONOHYDRATE
Product Name, Strength & Dosage Form LIXIANA 15 MG ORAL TABLET
Unit Price, Unit of Issue 2.8400
Manufacturer SEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458659
Generic Name EDOXABAN TOSYLATE MONOHYDRATE
Product Name, Strength & Dosage Form LIXIANA 30 MG ORAL TABLET
Unit Price, Unit of Issue 2.8400
Manufacturer SEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458667
Generic Name EDOXABAN TOSYLATE MONOHYDRATE
Product Name, Strength & Dosage Form LIXIANA 60 MG ORAL TABLET
Unit Price, Unit of Issue 2.8400
Manufacturer SEV
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02245531
Generic Name FONDAPARINUX SODIUM
Product Name, Strength & Dosage Form ARIXTRA (0.5 ML SYRINGE) 2.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 9.8620
Manufacturer APC
LCA Price 9.8620
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02406853
Generic Name FONDAPARINUX SODIUM
Product Name, Strength & Dosage Form FONDAPARINUX SODIUM (0.5 ML SYRINGE) 2.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 9.8620
Manufacturer DRL
LCA Price 9.8620
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02258056
Generic Name FONDAPARINUX SODIUM
Product Name, Strength & Dosage Form ARIXTRA (0.6 ML SYRINGE) 7.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 17.5000
Manufacturer APC
LCA Price 17.5000
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02406896
Generic Name FONDAPARINUX SODIUM
Product Name, Strength & Dosage Form FONDAPARINUX SODIUM (0.6 ML SYRINGE) 7.5 MG / SYR INJECTION SYRINGE
Unit Price, Unit of Issue 18.1356
Manufacturer DRL
LCA Price 17.5000
MAC Price N/A
Interchangeable Products YES
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02316986
Generic Name RIVAROXABAN
Product Name, Strength & Dosage Form XARELTO 10 MG ORAL TABLET
Unit Price, Unit of Issue 2.8700
Manufacturer BAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status RESTRICTED BENEFIT
Details
DIN/NPN/ PIN 02378604
Generic Name RIVAROXABAN
Product Name, Strength & Dosage Form XARELTO 15 MG ORAL TABLET
Unit Price, Unit of Issue 2.8700
Manufacturer BAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02378612
Generic Name RIVAROXABAN
Product Name, Strength & Dosage Form XARELTO 20 MG ORAL TABLET
Unit Price, Unit of Issue 2.8700
Manufacturer BAI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status STEP THERAPY/ SPECIAL AUTHORIZATION
Details
To return to the printable Drug Benefit List and related publications, click here
Last Updated:
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 version or updates.