Interactive Drug Benefit List
DIN/NPN/PIN 00020877 NOVO-AMPICILLIN 250 MG ORAL CAPSULE AMPICILLIN
080000 ANTI-INFECTIVE AGENTS
081200 ANTIBACTERIALS
081216 PENICILLINS
08121608 AMINOPENICILLINS
Date Listed/Coverage Update: 01-Feb-2017
Unit Price: 0.4434
LCA Price: N/A
MAC Price:

N/A

Unit of Issue: Capsule
Manufacturer: TEVA CANADA LIMITED (TEV)
ATC: J01CA01
1
Interchangeable Products: No

Coverage Status: RESTRICTED BENEFIT/ SPECIAL AUTHORIZATION
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)

Special Authorization Request Form:

Drug Special Authorization Request Form (ABC 60015)

RESTRICTED BENEFIT

This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber.

(Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or a designated prescriber.)


SPECIAL AUTHORIZATION

(Refer to Section 1 - Restricted Benefits of the Alberta Drug Benefit List for coverage of the product when prescribed by a Specialist in Infectious Diseases or a designated prescriber.)

"For the treatment of infections caused by susceptible Shigella and Salmonella."*

*Special Authorization is only required when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or a designated prescriber.

Review Status / Past Decisions

Indication Reviewing
Body
Submission
Completion
Date
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
Review
Status
N/A Expert Committee 2016/11/24 2017/02/01 Change to Restricted Benefit/Special Authorization
N/A Expert Committee 2016/11/24 2017/02/01 Change to Restricted Benefit/Special Authorization
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2016/11/24
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2017/02/01
CDR
Recommendation
Review
Status
Change to Restricted Benefit/Special Authorization
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2016/11/24
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2017/02/01
CDR
Recommendation
Review
Status
Change to Restricted Benefit/Special Authorization
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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.