List 6f covered drugs as of July 1, 2015 [ CfdJ!IDfl, ~ POSTES

UpJd tecl l i!;t can be found at canadapost.ca/drugplan . You may also obtam a list from Great-West Lrfe at POS/ \:_ ./C ANADA

l-866-71Jc313 .

111e l: mploy'~r reserves the nght to change th e con tent of the drug plan list w ithout notice . te: n~l strengths and formulations of the drugs listed below are covered. )

Acne al!!ooloVchlorthalidone, avalide, avapro, Cystic Flbnlsis -kalydoco, pulmozyme benzaclin. benzamycil'\ benzoyl benazepril Ootensin), bisoprolol peroxide >596, dindamycin (dalacin t), (monoco~. a.ptopri( carvedilol (coregL Dental clindasol, dindets, clindoxy( differin chlorthalidone. cilazapril (inhibace), triamcinolone paste (oracort) eryso~ retin-a, stieva, stievamycin, cilazapriVhctz (lnhibace plus), clonidine, vitamin a acid coversy~ cozaar, diovarv'diDYan het Depression

amitriptyline, bupropion (wellbutrin),doxazosin (cardura}, fosinopril (monopriQ,Acromegaly - somcrvert cipralex, citalopram (celexa),hcll/-spiroooladane (aldactazide),

hct7/lriamterene, hydralazine, domipramine. desipramine, doxepin,ADHD/Norcolepsy fluoxetine (prozac), flwoxamine,hydrochlorothiazide,dexedrlne, methylphenidate (ritalin), imipramine, maproti&ne, mirtazapinehydrochlorothiazid</amilolide, hyzaar,modafln/1 (alertet:}, xymn (remeron1 moclobemide, nortrWtn.,labetalol,lisnopril (prinivil/zestril),

paroxetine (paxi0 10mg/20mg/30mg.Allergy conditions l~nopriVhct7, movi~methyldopa,

ailerject, alomide, avamys. methyldopa/ i"((drochlorothiazide, sertraline (zoloft~ trazodane, trimipramine, venlafaxine (effexor)beclomethasone nasal spray, metcprolol, micardis,lmicartf~ plus,

budesonide aq nasal spray, nadolo~ olmetec/olmetec plus, pindolo\ Dlabebs epipenltwlnject, flonase, flunisolide prazosin propranolo~ ramipril (a~ce), apidra, chlorpropamide, diabetic test (rhinalar) Spr.l)', hydroxyzine, rasilez, rasilez het, reserpine, sotalo~ strips, glucagon, glucagon glucobay,ipratropium (atrovent) nasal spray, spironoladane, lilrb, lerazosin (hytrin), glyburide, humalog, humulin, hypurin,livostin, nasacort. nasonex, omnaris, teveten/leveten plus, timolo~ trasicor, insulin needles/syringes, lancets, lantus, patanol, pollinex r lwynsta, vaseretic, vasotec, viskazicle, levemir, metformin. novolin ge,

zaroxolyn novomix, novorapld, tolbutamide Alzheimer's Disease aricept. exelon, reminyl lload thlnners Disease prevention vaccines

arixtra, brilinta. fragmin, fraxiparine, act hib, adace~ avaxin, beg, boastrix, dlAngina innohep, lovenox, plavix, sintrom, ipv- polio absorbed, dukoral ora~ qerixdi~iazem (cardizern,l1iazac), felodipine warfarin (coumadin) b ped. engerix- b, gardasi( havrix~imovax(plendil/renedm, isosorbide, nifedipine polio, irn<>lax rabies, irfilenza, ixiaro,(adalat) pa/x( nitroglycerin Bane metabolism menaclra, rnl!ll<Z\Ial( ac, meningitec;patches(nitrodur1 nitroglyce<in spnry, aclasta. aclone!/actonel plus calcium,

nitroglycerin tablets, nitrol ointmen~ alendronate (fosamax), aredia, banefos, men~ rnenomut"W:, m-m-r i\ moru­viral!!n bema, mutBa>l berna, nelsvac-~ pedvaxhib, penlilce~ pneumoc:ocaol23­

norvasc. Vel'illpamil c.ak:rtonin. c.alcium/c.akium with vitamin d, dasteon form, fosavan<:e, astac

Anti inliommotory/Anlligoslcs valent, prelll'oar, priorilr, quadrace~ arthrotec, didofenac, diclofenac sr, Botulinum Toxin TYP• A rabaver1; recombivax. rotrteq Id polio floctafenine, flurbiprofen. ibuprofen botcur. xeomln adsorbed adult let and diph toxoid adult (adviVmotrin), indomethacin tetanus toxoid adsorbed, tripace~ twil1'ix. ketoprofen ketorolac (toradol), typhelix, typhim vL vaqlil. varilrix, varivaxBotulinum Taxln Type B

myablacnaproxen (naprosyn)/naproxen sodium ii~ vivaxim, vivotif bema, yellow ~r

(anaprox), piroxicam, sulindac, Bunltls Electrolyte t-eplocement tiaprofenic add, tolmetin celestone soluspan apo-k, k-dur, k-lyle/k-lyte c~ k-med, Antlblotlco/Antl-infactivao miao-k,1amsccr,. slow-kCancer acyclovlr (zovirax), amitacin, amoxicillin, lli>r1lxrlno. oflnl,.,, allmllo_ alkellll\ EpilepsyamoxicillirV'potassium clavulanate androcur-<lepo\ arimidex, carbama<epine (tegretoQ, celontin(davulin), ampicillin azithromycin CMISffll. bleomycin ba<ulif. cam,.,_ donazepam (rivotril), dilantin(zilhromax), cefaclor (cedo~. cefadroxil ..,.ma. casodeJ<, ceenu. divalproex (epivaQ, gabapentin(duricef), cefazolin,cefzil, cephalexin cyclophosphamide, cyproterone. (neurontin), lamotriglne QamictaQ,(keflex), clarithromycin (biaxin1 cytarabine, eludex, eligard, _,.., levetiracetam (keppra), prlmidone,clindamycin (dalacin c), claxaciDin aiJIIID(. eriwdge. etoposide, 1­ sabri~ topiramate (topamax), valproicdoxycycline (\'ibramycin), erythromycin (fenHJra}, frrmagon fluda~ fluorouraci~ acid (depakene), zarontin (erybid/eryc), etlbi, famcidovir (famvir), flutarnide..glalrif.glftwc; """'-'. fucldln Isoniazid, metronidazole (flagyQ, ~ hydroxyu,..,lmlllulli<v. Eye-ear-nose meciiC8tlano nitrofurantoin (macrobicl), pediazole, ,.,_ intron a.lmov. llfn*arn,}Dittlri. dexamethasone <yWear,atropinepenicillin g, penicillin v, pondocillin, }otifano. /aJdqta, kidrolase, lanvis, lederle eye.chloramphenicol, ciprodex oti~ pyrazinamide, relenza, rifampin, rifater, leuCO'.Orin leukeran Jeustatin, lupron cortimyxin cortispo~ cyclopentolate,sulfamethoxazole, dep~ lysodren mabaJmp<llh. matulane, cliopheny~~ dipivefrin epifrlnsulfamethoxazole/trimethoprim meges1ro~ meldnlst. mesna, erythromycin~ fluoromelholone,(septra), sulfasalazine (salazopyrin), methotrexate, myler.-. ,_.,..,, peljelo, hamatropine,}olrN. ketDrola~ locacorten tamiflu,tetracycline, lobi tobramycin ~.purlnetho~ ....timid, rifw<an, vioform,lucenlls. mawgen maxitro~ vartrex sp~.sfl- suprefact,sulmt, ocufen. opti<Drt, .....,.,., phenylephrine,

ttJflnlar. tamoxifenru~mp predrisolone, m!sod. sofracort,Antlfungals sulfa-mide, sulfaa>lamlde/ketoconazole, nystatin sporanox, -... temodo' IDmudex. _,.

trelstar,lykerb, -lblx. ,..,.,.,., predrisolone, 1xlbrarnycinterbinafine (LamisiQ Wlllrien(.J«Jikori,xeloda,~-. tobramycirVdexametlmone, tropamide,

Aithma albonJf, zoladex ~ .zro11nzu. qtlga viroptic, vo~ren ophtha, wsol·hc otic advair, aN'esco, aminophylline, asmanex.

cardiac disease Fabry's Dls..saatroven~ berotec, bric.anyl, combive~

amiodarone (cordarone), burinex, fobmzym</npltltJDIduove~ llove~ foradi~ ordprenaline, digoxin (lanoxln), edecrin, furosemide oxeze, o>rtriphylline. pulmicort, qvar, Fertility dlsard•N (lasix), mexiletine, proc.ainamide,salbutamol (ventolin), serevent, clomid,menopur,ovidre~repronex,propafenone, quinidine, rythmodansymbicort, theophylline, xololr serophene Cholasterol disorders Birth control Gastrointestinoladvicor, bezafibrate (bezalip),alesse, brevicon 0.5/35, brevicon 1/35, 5-asa (asacoO,betnesol retention enema,cholestyramine (questran}, colestid,cyclen demulen 30, depo-provera, cortifoam,dicetel,dicyclomine, dipentum,crestor, fenoflbrate (lipidJO, gemfibrolil,j&ydt::ts, l!ne:;sc, ~oestrin 1.5/30, loette, ciomperidone, entocort, enlyrio,juxtopld, lesco~ llp~r. lorelco,marvelon, micronor, minestrin 1/20, hydromrtisone enem~ metoclopramide,lovastatin (mevaco~. pravastatinmln-ovra~ norlevo, ortho 0.5/35, ortho mezava~ modulon :rlgnl(w, u"odiol

l/35, ortho 7{7{7, ortho-cep~ ovral, plan b, select l/35, synphasic, tri­

(pravachol), simvastatin (zocor)

Cholesteroi/Cordloc- caduet Genl!tlc Enzyme Replacementcyclerv'tri-<yden lo, triquilar, yasmin cerezymo:. prolartill. llpriv, zanscv yaz. mlrena 52mg Ch,..nlc Obstructive Pulmonary

Disease Glaucoma Blood formltion seebri, spiriva, tudorza acetazolamide, betaxolo~ carbacho~ dexirof\ folic acid.. infufer, mozobU, coso~ duo trav, iopidine, lovobunolol nplo~ nvalod., vitamin bl2 injection arculatory disease: pentoxifylline (betagan), lumigan RC, lumigan

methazolamide, pilocarpine, probeta, Blaad PI1!Soure Cor1lc:ofterold timolol,b'avatan,trusopt.xalacom,xalatanacaJpril, acaJretlc, acebutolo~ a~ het. cortef, cortisone, dexamethasone,

a~ce plus felodipine, amiloride hydrocortisone, medrol, Gynecologlcal(midamor1atacand/atacand plus, methylprednisolone, prednisolone dalacin vaginal, fibristJ~ gynazoleal!!nolol (tenormin), (pediapred), prednisone

vaginal, metronidazole, nystatin,terconazole

Hepatitis baraclude, heptovir, golaoo, """""''· halkira pail._ibavyr, incivek, pegasys rbv, pegetron sebiYo, 101/Gidl

Hereclbry Angioedemo: F#lru:p

HlV 3tc. agenerase, atr~, combMr, complera, crixiYan eduran~ fuzeon, hivid, intelence, kaletra, lciYexa, norvir, prezcobix , prezista, rescrlptor, reyataz, saquinavir, sebivo, stribild, sustiva, telzir, tivicay, trizivir, trwada. videx. viracept. viramune, viread, zerit. ziagen, zidovudine (azl)

Honnonatherapy nutropln. somatropln (humotrope/lalzeii/IOtDrtlm/ protropln}

Hunter syndrome ~lapmse

Hyperphenylalanlnemlo Sopropterin d'lhydrrxhiDride (lamm}

Idiopathic Pulmanory FlbnJIIs abrid

lmmuh05uppnsslve azathioprine Omuran), cellcep~ cydosporine (neoraQ, myfortlc, penicillamine, prograf

Insomnia phenobarbital, tema<epam (restoril), triazolam

Kidney and Bladder disorders allopurinol, benuryl, bethanechol (duvoid), carbacho~ colchicine, ajode, flavoxate, oxybutynin (ditropan), phenazo, srnslpar, sulfinpyrazone, IBmSlJiosin (flomax~ trimethoprlm, IH!Osporin bladder, uroc~-K

Menopause angeliq. donidine (dlxarit), estrace, estradiol valerate, estrogens­conjugated, fern hrt, medroxyprogesterone (provera), neo­estrone, ogen, premplus, prometrium, vagifem, visanne

Mental dlsorden abilify, chlorpromazine, fluaroco~

fluphenazine, haloperidol (haldol), invega, l~hium (carbolit!VIithane), loxapine, majeptil, methotrimeprazlne, pericyazine (neulepti~ p<rphenazine, pimozide, piporti 14, revia, risperidone (risperdal), seroque\ thiothixene, trifluoperazine

Migraines cafergot, dihydroergotamine, sandomigran

Mucopalysaccharfdoslsl aldunuyme

Multiplosclerasls Aubagio. avonex, betaseron, copaxone, extavia, fornpyru, gllenya, lomtnniG, rebif, sotlvu, t.cfldetu, tysolwf

Muscle relaxants baclofen (lioresal),cyclobenzaprine

Myasthenia Gravis mestir'IOf\ prostigmin

Nanotlc analgesics codeine conlil\ codeine phosphate, codeine phosphate!acetaminpherV caffeine (\yleool #1,#2.103,#4), codeine phosphate/asa/caffeine, hydromorphone (dilaudid), meperidine (demeroO, mersyndol, methadone, morphine, oxycodonejacetaminophen (endoc:et/oxycocet)

From anywhere... to anyone

Nausea prochlorperazine, zofran, ondissolve

Neuropathic Pain- lyrica Osteaar1hrltls synovial fluid supplements (synvisc/neovisc/suplasyn/ monovisc)

Pain acetamioophen (tylenoO, acety~allcylic

acid (80mg/8lmg/32Smg/650rng), difunisal, disalcid

Parasitic treatment chloroquine, daraprim, diodoquln hydroxychloroquine (plaquenil), mefloquine, mepron, primaquine

Parkinson Disease amantadine, benztropine, carbidopa!levodopa (sinemet), duodopo, procyclidine, prolopa, selegiline, lrihexyphenidyl

Paroxysmal NodlB'nal Hemogloblnurla : sollrls

Pompe's DiseMe : myozyme

Pulmonary Alterlal Hypertension adcimr, flalan, OIJIUinft, nmodulln, IWVGffD, trlldftr, vollbris

Rheumatoid Arthritis octomra,clmzlo. onb~ gold sodium lhiomalate (myochrysine),llumlro, lnflectnl, klneret, arendo, mnlcodo, slmpan~ xeljDnz

Sexual Dysfunction : vlagra

Sldndlsorden amcinonide (cydocort), azelaic acid (finacia), belamelhasone (betnovale), dobetasol (dermovate), _,ly>r, cutivate, denna1op, desonide, desoximetasone (lopicort), diprosali~ ecostatin fluocinolone (synala~• fluocinonicle, fucidiJV lJcidin 1\ ha log. hydrocortisone (cortate), ketoconazale (nizoraO, lamisi cream/-spr.l)', loprox, melhoxsalen (oxsoralen), metronidazole, mometasone (elocom), mupirocin (bactroban1 neomyciN gramicidin/ nystatin/ triamcinolone (Viadenn Ice~ nerisone, otcz1a, propaderm, silver sulfadiazine (flamazine), ftelont IBctuo, triamcinolone, zovirax

Smoking ce55ation: ch&lmpix

Strea/Seclatlan alprazolam (xanax), bromazepam, buspirone (buspar), chlordiazi!poxide, clobazam, diazepam (va6um), lontzepam (atiYan), nitrazepam (mogadon), oxazepam (seraX)

Systemic Lupus Erythematos111 (SLE)

ben!Ymr

Systemic Juvenile Idlopothlc Althrltls llaris

Thyroid and Glandulor andriol, bromocrlptine, ddavp melt, desmopressin, florinef, levothyroxine (synthroid/eltmxin), :iothyronine (cytomel), norprolac, propy~hiouraci!,

tapazole

UlcMS cimetidine (tagamet), famotidine (pepcid), misoprostol (cytotec), nizatidine (axid), pariet, ranltidine (zantac), sucralfate (sukr.lte)

Ver1igo: betahistine (serc)

Vbmlns and Mlnenols ergocaldferol (d forte), neo-be)C, one­alpha, pregvit & pregvit folic 5, pyridoxine, thiamine injection, vitamin a

Weight control: xenlml

bold Italic = requires Prior Authorization form

( ,\ ', f1. [J 11 .,.._ ' P \ l ~ T f- 'lRequest for Drug Exception Form r-r.·- .3 t :, ·,r,..J!t(For list of drugs covered - Refer to page 1 )

In order fo r your except1on to be considered you must have prev•ously tned a cove re d drug fo r your med1cal cond 1t1on and e1ther the drug was not effective or you have a contra1nd1cat 1on to t he drug .

Use this form to request coverage of a drug that is not automatically covered under your drug plan. Provide the requested information to ensure timely assessment of your claim.

Do not use this form for drugs that require PRIOR AUTHORIZATION . Please refer to page one (1) for the list of Prior Authorization drugs which are indicated in bold italics. The Prior Authorization forms can be found at canadapost.ca/drugplan or call Great-West Life at 1-866-716-1313.

PLAN MEMBER INFORMATION

Please select your plan number: Employee/Retiree ID #: o 51391 or o 162954 (MGT/XMT who retired on or after January 2, 2011)

Name: Address:

PATIENT INFORMATION

Name: Relationship: IDate of Birth:

Drug Name:

Was the drug prescribed by a doctor in the Hospital Emergency Room? Yes o No o If yes, please include a copy of the prescription from the doctor with this form, and original receipt.

Would you like Great-West Life to contact you by telephone upon completion of the exception review? Yes o No o

If yes, please indicate the phone number where they can reach you and leave a message should you be unable to answer: (_)

-·------At Great-West Life, we recognize and respect the importance of privacy. Personal information that we collect is used for the purpose of assessing eligibility for this drug and for administering the group benefits plan. I authorize Great-West Ufe, my physldan or healthcare provider, and TELUS Health Solutions to exchange Information when necessary for these purposes.

Patient/Guardian's signature: Date:-

TO BE COMPLETED BY ATTENDING PHYSICIAN

Attending Physician Name: Registration Number:

Address: ·---- ..-

Telephone Number: Fax Number:

Required Information

To obtain coverage for the drug, one other covered pharmacotherapy must have been tried in the past, unless contraindication exists.

What is the health condition being treated with this drug?

Is the drug prescribed to treat a health condition for which the specific drug use is approved by Health Canada? Yes o NoD

Did the patient previously try a medication (pharmacotherapy) to treat this health condition? Yes o NoD

If yes, list the specific names of other medications (pharmacotherapies) used to treat the health condition?

If no other medication (pharmacotherapy) was tried, please explain why this drug must be prescribed (for example a contraindication resulting from an allergy reaction):

I Information on requested drug

Drug Name: Dose Prescribed:

Physician's signature: Date:

Once completed, the Request for Drug Exception Form can be returned to Great-West Ufe at the address or fax number below.

Fax to: The Great-West Life Assurance Company Mail to: The Great-West Life Assurance Company Fax Number: 1 866 239-7140 Drug Services P.O. Box 6000 Attention: Drug Services Winnipeg MB R3C OE6

2