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
02460203 ABOBOTULINUMTOXINA DYSPORT THERAPEUTIC 300 IU / VIAL INJECTION 385.5600
VIAL
ISP N/A N/A NO REGULAR BENEFIT Details
02456117 ABOBOTULINUMTOXINA DYSPORT THERAPEUTIC 500 IU / VIAL INJECTION 642.6000
VIAL
ISP N/A N/A NO REGULAR BENEFIT Details
02324032 BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN XEOMIN 100 UNIT / VIAL INJECTION 330.0000
VIAL
MPC N/A N/A NO REGULAR BENEFIT Details
02371081 BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN XEOMIN 50 UNIT / VIAL INJECTION 165.0000
VIAL
MPC N/A N/A NO REGULAR BENEFIT Details
02464705 CYSTEAMINE BITARTRATE PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE 10.3500
CAP
RAP N/A N/A NO SPECIAL AUTHORIZATION Details
02464713 CYSTEAMINE BITARTRATE PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE 31.0500
CAP
RAP N/A N/A NO SPECIAL AUTHORIZATION Details
02379910 FAMPRIDINE FAMPYRA 10 MG ORAL SUSTAINED-RELEASE TABLET N/A
TAB
BIO N/A N/A NO NOT A BENEFIT Details
02468042 MIGALASTAT HYDROCHLORIDE GALAFOLD 123 MG ORAL CAPSULE 1,700.0000
CAP
AMI N/A N/A NO SPECIAL AUTHORIZATION Details
02457733 NITISINONE MDK-NITISINONE 10 MG ORAL CAPSULE 47.4000
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458632 NITISINONE NITISINONE 10 MG ORAL TABLET 47.4000
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459728 NITISINONE ORFADIN 10 MG ORAL CAPSULE 47.4000
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02457717 NITISINONE MDK-NITISINONE 2 MG ORAL CAPSULE 12.9500
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458616 NITISINONE NITISINONE 2 MG ORAL TABLET 12.9500
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459698 NITISINONE ORFADIN 2 MG ORAL CAPSULE 12.9500
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02470055 NITISINONE MDK-NITISINONE 20 MG ORAL CAPSULE 128.1000
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02459736 NITISINONE ORFADIN 20 MG ORAL CAPSULE 128.1000
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02457725 NITISINONE MDK-NITISINONE 5 MG ORAL CAPSULE 25.0600
CAP
MEN N/A N/A NO SPECIAL AUTHORIZATION Details
02458624 NITISINONE NITISINONE 5 MG ORAL TABLET 25.0600
TAB
CYC N/A N/A NO SPECIAL AUTHORIZATION Details
02459701 NITISINONE ORFADIN 5 MG ORAL CAPSULE 25.0600
CAP
BVM N/A N/A NO SPECIAL AUTHORIZATION Details
02465663 NUSINERSEN SODIUM SPINRAZA 2.4 MG / ML INJECTION 23,600.0000
ML
BIO N/A N/A NO SPECIAL AUTHORIZATION Details
01981501 ONABOTULINUMTOXINA BOTOX (50/100/200 UNITS/VIAL) INJECTION 3.5700
UNIT
ALL N/A N/A NO REGULAR BENEFIT Details
02350580 SAPROPTERIN DIHYDROCHLORIDE KUVAN 100 MG ORAL TABLET N/A
TAB
BMI N/A N/A NO NOT A BENEFIT Details
DIN/NPN/ PIN 02460203
Generic Name ABOBOTULINUMTOXINA
Product Name, Strength & Dosage Form DYSPORT THERAPEUTIC 300 IU / VIAL INJECTION
Unit Price, Unit of Issue 385.5600
Manufacturer ISP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02456117
Generic Name ABOBOTULINUMTOXINA
Product Name, Strength & Dosage Form DYSPORT THERAPEUTIC 500 IU / VIAL INJECTION
Unit Price, Unit of Issue 642.6000
Manufacturer ISP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02324032
Generic Name BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN
Product Name, Strength & Dosage Form XEOMIN 100 UNIT / VIAL INJECTION
Unit Price, Unit of Issue 330.0000
Manufacturer MPC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02371081
Generic Name BOTULINUMTOXINA(150KD), FREE FROM COMPLEXING PROTEIN
Product Name, Strength & Dosage Form XEOMIN 50 UNIT / VIAL INJECTION
Unit Price, Unit of Issue 165.0000
Manufacturer MPC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02464705
Generic Name CYSTEAMINE BITARTRATE
Product Name, Strength & Dosage Form PROCYSBI 25 MG ORAL DELAYED-RELEASE CAPSULE
Unit Price, Unit of Issue 10.3500
Manufacturer RAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02464713
Generic Name CYSTEAMINE BITARTRATE
Product Name, Strength & Dosage Form PROCYSBI 75 MG ORAL DELAYED-RELEASE CAPSULE
Unit Price, Unit of Issue 31.0500
Manufacturer RAP
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02379910
Generic Name FAMPRIDINE
Product Name, Strength & Dosage Form FAMPYRA 10 MG ORAL SUSTAINED-RELEASE TABLET
Unit Price, Unit of Issue N/A
Manufacturer BIO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
DIN/NPN/ PIN 02468042
Generic Name MIGALASTAT HYDROCHLORIDE
Product Name, Strength & Dosage Form GALAFOLD 123 MG ORAL CAPSULE
Unit Price, Unit of Issue 1,700.0000
Manufacturer AMI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02457733
Generic Name NITISINONE
Product Name, Strength & Dosage Form MDK-NITISINONE 10 MG ORAL CAPSULE
Unit Price, Unit of Issue 47.4000
Manufacturer MEN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458632
Generic Name NITISINONE
Product Name, Strength & Dosage Form NITISINONE 10 MG ORAL TABLET
Unit Price, Unit of Issue 47.4000
Manufacturer CYC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02459728
Generic Name NITISINONE
Product Name, Strength & Dosage Form ORFADIN 10 MG ORAL CAPSULE
Unit Price, Unit of Issue 47.4000
Manufacturer BVM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02457717
Generic Name NITISINONE
Product Name, Strength & Dosage Form MDK-NITISINONE 2 MG ORAL CAPSULE
Unit Price, Unit of Issue 12.9500
Manufacturer MEN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458616
Generic Name NITISINONE
Product Name, Strength & Dosage Form NITISINONE 2 MG ORAL TABLET
Unit Price, Unit of Issue 12.9500
Manufacturer CYC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02459698
Generic Name NITISINONE
Product Name, Strength & Dosage Form ORFADIN 2 MG ORAL CAPSULE
Unit Price, Unit of Issue 12.9500
Manufacturer BVM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02470055
Generic Name NITISINONE
Product Name, Strength & Dosage Form MDK-NITISINONE 20 MG ORAL CAPSULE
Unit Price, Unit of Issue 128.1000
Manufacturer MEN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02459736
Generic Name NITISINONE
Product Name, Strength & Dosage Form ORFADIN 20 MG ORAL CAPSULE
Unit Price, Unit of Issue 128.1000
Manufacturer BVM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02457725
Generic Name NITISINONE
Product Name, Strength & Dosage Form MDK-NITISINONE 5 MG ORAL CAPSULE
Unit Price, Unit of Issue 25.0600
Manufacturer MEN
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02458624
Generic Name NITISINONE
Product Name, Strength & Dosage Form NITISINONE 5 MG ORAL TABLET
Unit Price, Unit of Issue 25.0600
Manufacturer CYC
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02459701
Generic Name NITISINONE
Product Name, Strength & Dosage Form ORFADIN 5 MG ORAL CAPSULE
Unit Price, Unit of Issue 25.0600
Manufacturer BVM
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 02465663
Generic Name NUSINERSEN SODIUM
Product Name, Strength & Dosage Form SPINRAZA 2.4 MG / ML INJECTION
Unit Price, Unit of Issue 23,600.0000
Manufacturer BIO
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status SPECIAL AUTHORIZATION
Details
DIN/NPN/ PIN 01981501
Generic Name ONABOTULINUMTOXINA
Product Name, Strength & Dosage Form BOTOX (50/100/200 UNITS/VIAL) INJECTION
Unit Price, Unit of Issue 3.5700
Manufacturer ALL
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status REGULAR BENEFIT
Details
DIN/NPN/ PIN 02350580
Generic Name SAPROPTERIN DIHYDROCHLORIDE
Product Name, Strength & Dosage Form KUVAN 100 MG ORAL TABLET
Unit Price, Unit of Issue N/A
Manufacturer BMI
LCA Price N/A
MAC Price N/A
Interchangeable Products NO
Coverage Status NOT A BENEFIT
Details
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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.