Interactive Drug Benefit List
DIN/NPN/PIN 02239505 ALDARA P 50 MG/G / G TOPICAL CREAM IMIQUIMOD
840000 SKIN AND MUCOUS MEMBRANE AGENTS
849200 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS
Date Listed/Coverage Update: 01-Oct-2008
Unit Price: 55.5780
LCA Price: 0.0000
MAC Price:

0.0000

Unit of Issue: Gram
Manufacturer: BAUSCH HEALTH (VCL)
ATC: D06BB10
1
Interchangeable Products: Yes

Coverage Status: 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:

Imiquimod Special Authorization Request Form (ABC 60038)

SPECIAL AUTHORIZATION

"For the treatment of Actinic Keratosis located on the head and neck in patients who have failed treatment with cryotherapy (where appropriate) and 5-fluorouracil (5-FU).

Special authorization may be granted for 6 months."

All requests for imiquimod must be completed using the Imiquimod Special Authorization Request Form (ABC 60038).

The following product(s) are eligible for auto-renewal.

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 2008/05/13 2009/04/01 Special Authorization Criteria Change
N/A Expert Committee 2008/05/13 2008/10/01 Special Authorization
N/A Expert Committee 2008/05/13 2009/07/01 Special Authorization Criteria Change
N/A Expert Committee 2006/05/18 2006/10/01 Not a Benefit
N/A Expert Committee 2005/08/18 2006/01/01 Not a Benefit
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2008/05/13
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2009/04/01
CDR
Recommendation
Review
Status
Special Authorization Criteria Change
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2008/05/13
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2008/10/01
CDR
Recommendation
Review
Status
Special Authorization
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2008/05/13
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2009/07/01
CDR
Recommendation
Review
Status
Special Authorization Criteria Change
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2006/05/18
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2006/10/01
CDR
Recommendation
Review
Status
Not a Benefit
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2005/08/18
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2006/01/01
CDR
Recommendation
Review
Status
Not a Benefit
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.