Pharmaceutic Pricing

Generic Name Brand Name Strength Dosing 90 Day Cost Coverage Comments Category 1 Category 2
Lisinopril/HCTZ Zestoretic 20 mg / 25mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors -Diuretic Combinations
Buprenorphine/Naloxone Suboxone BC - Covered / IA - SA

Daily Dose: 2/0.5 mg - 8/2 mg

Dispensing Frequency: Every 2 weeks

Cost of 2 Week Supply: $20

Doses individualized, cost of 2 week supply based on highest daily dose.

Opioid Dependency Opioid Dependency
Buprenorphine/Naloxone Suboxone BC - Covered / IA - SA

Daily Dose: 2/0.5 mg - 8/2 mg

Dispensing Frequency: Daily

Cost of 2 Week Supply: $250

Doses individualized, cost of 2 week supply based on highest daily dose.

Opioid Dependency Opioid Dependency
Methadone Methadose BC / IA - Covered

Daily Dose: 60-120 mg

Dispensing Frequency: Every 2 weeks

Cost of 2 Week Supply: $25

Doses individualized, cost of 2 week supply based on highest daily dose.

Opioid Dependency Opioid Dependency
Methadone Methadose BC / IA - Covered

Daily Dose: 60-120 mg

Dispensing Frequency: Daily

Cost of 2 Week Supply: $150

Doses individualized, cost of 2 week supply based on highest daily dose.

Opioid Dependency Opioid Dependency
Ferrous fumarate Wampole BC - NC/ IA - Covered

Total Dose (mg/tab or 5mL): 300

Elemental Iron (mg/tab or 5mL): 100

90 Day Cost (100 mg elemental iron/day): $20

Iron Preparations Iron Preparations
Ferrous fumarate Palafer BC - NC/ IA - Covered

Total Dose (mg/tab or 5mL): 300

Elemental Iron (mg/tab or 5mL): 100

90 Day Cost (100 mg elemental iron/day): $30

Iron Preparations Iron Preparations
Ferrous sulphate Generic infant susp BC / IA - Covered

Total Dose (mg/tab or 5mL): 375

Elemental Iron (mg/tab or 5mL): 75

90 Day Cost (100 mg elemental iron/day): $90

Iron Preparations Iron Preparations
Ferrous sulphate Generic brands BC - NC/ IA - Covered

Total Dose (mg/tab or 5mL): 300

Elemental Iron (mg/tab or 5mL): 60

90 Day Cost (100 mg elemental iron/day): $15

Iron Preparations Iron Preparations
Ferrous gluconate Generic brands BC - NC/ IA - Covered

Total Dose (mg/tab or 5mL): 300

Elemental Iron (mg/tab or 5mL): 35

90 Day Cost (100 mg elemental iron/day): $15

Iron Preparations Iron Preparations
Ferrous sulphate Generic adult susp BC / IA - Covered

Total Dose (mg/tab or 5mL): 150

Elemental Iron (mg/tab or 5mL): 30

90 Day Cost (100 mg elemental iron/day): $30

Iron Preparations Iron Preparations
Polysaccharide Iron Feramax BC / IA - NC

Total Dose (mg/tab or 5mL): 150

Elemental Iron (mg/tab or 5mL): 150

90 Day Cost (100 mg elemental iron/day): $55

Iron Preparations Iron Preparations
Mometasone Furoate Elocom 0.10% As dir $35 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Betamethasone Dipropionate Diprosone 0.05% As dir $20 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Betamethasone Dipropionate Glycol Diprolene 0.05% As dir $30 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Desonide Desonate 0.05% As dir $25 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Clobetasol 17-propionate Dermovate 0.05% As dir $20 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Amcinonide Cyclocort 0.10% As dir $20 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Hydrocortisone Cortate 1.00% As dir $20 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Betamethasone Valerate Betaderm/Betnovate 0.10% As dir $15 BC / IA - Covered

Price is for a 30g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.

Topicals Topical Corticosteroids
Tacrolimus Protopic (30g tube) 0.03% As dir $90 BC / IA - SA Topicals Miscellaneous Topicals
Betamethasone/Calcipotriol Dovobet (60g tube) 0.05/0.005% As dir $115 BC / IA - Covered Topicals Miscellaneous Topicals
Imiquimod Aldara (24x250mg) 5% As dir $300 BC / IA - SA Topicals Miscellaneous Topicals
Isopropyl Myristate Resultz 50% As dir $30 BC / IA - Covered Topicals Lice
Pyrethrins/Piperonyl Butoxide R&C 0.33%/3% As dir $25 BC / IA - Covered Topicals Lice
Dimethicone Nyda 50% As dir $40 BC / IA - Covered Topicals Lice
Permethrin Nix 1% As dir $25 BC / IA - Covered Topicals Lice
Tretinoin Cream Stieva-A (25g tube) 0.025% As dir $25 BC - SA / IA Covered Topicals Acne Treatments
Minocycline Minocin 100 mg QD x 90 days $35 BC - Covered / IA - SA Topicals Acne Treatments
Adapalene Differin (60g tube) 0.10% As dir $150 BC - NC; IA - Covered Topicals Acne Treatments
Benzoyl Peroxide/Clindamycin Clindoxyl (45g tube) 5%/1% As dir $50 BC - SA / IA Covered Topicals Acne Treatments
Isotretinoin Accutane 40 mg QD x 90 days $205 BC / IA - Covered Topicals Acne Treatments
Denosumab Prolia 60 mg sub-Q every 6 months 60 mg sub-Q every 6 months $220 BC / IA - SA Miscellaneous Osteoporosis
Alendronate Fosamax 70 mg once weekly 70 mg once weekly $40 BC / IA - Covered Miscellaneous Osteoporosis
Teriparatide Forteo 20 mcg sub-Q QD $3010 BC / IA - NC Miscellaneous Osteoporosis
Etidronate/Calcium Didrocal As directed As directed $50 Discontinued Miscellaneous Osteoporosis
Risedronate Actonel 35 mg once weekly 35 mg once weekly $40 BC / IA - Covered Miscellaneous Osteoporosis
Zoledronic Acid Aclasta 5 mg yearly 5 mg yearly $105 BC / IA - SA Miscellaneous Osteoporosis
Galantamine ER Reminyl ER 16 mg QD $140 BC / IA - SA Miscellaneous Dementia
Rivastigmine Exelon 3 mg BID $145 BC / IA - SA Miscellaneous Dementia
Donepezil Aricept 5 mg QD $60 BC / IA - SA Miscellaneous Dementia
Itraconazole Sporanox 2x100 mg QD x 12 weeks 2x100 mg QD x 12 weeks $795 BC / IA - Covered

Onychomycosis dosing

Miscellaneous Antifungals
Cicloporox Penlac Nail lacquer; price for 6 g Nail lacquer; price for 6 g $70 BC / IA - NC

Onychomycosis dosing

Miscellaneous Antifungals
Terbinafine Lamisil 250 mg QD x 12 weeks 250 mg QD x 12 weeks $85 BC / IA - Covered

Onychomycosis dosing

Miscellaneous Antifungals
Efinaconazole Jublia Nail lacquer; price for 8 ml Nail lacquer; price for 8 ml $115 BC / IA - NC

Onychomycosis dosing

Miscellaneous Antifungals
Fluconazole Diflucan 150 mg once weekly x 12 weeks 150 mg once weekly x 12 weeks $65 BC / IA - Covered

Onychomycosis dosing

Miscellaneous Antifungals
Azithromycin Zithromax 250 mg x 4 days 250 mg x 4 days $20 BC / IA - Covered Miscellaneous Antibiotics
Fosfomycin Monurol 3 g as a single dose (uncomplicated UTI) 3 g as a single dose (uncomplicated UTI) $30 BC - Covered / IA - SA Miscellaneous Antibiotics
Nitrofurantoin Macrobid 100 mg BID x 3 days 100 mg BID x 3 days $20 BC / IA - Covered Miscellaneous Antibiotics
Cephalexin Keflex 500 mg QID x 7 days 500 mg QID x 7 days $20 BC / IA - Covered Miscellaneous Antibiotics
Doxycycline Doxycycline 100 mg QD x 7 days 100 mg QD x 7 days $20 BC / IA - Covered Miscellaneous Antibiotics
Amoxicillin/Clavulanate Clavulin 500 mg TID x 7 days 500 mg TID x 7 days $30 BC / IA - Covered Miscellaneous Antibiotics
Ciprofloxacin Cipro 500 mg BID x 5 days 500 mg BID x 5 days $20 BC - SA / IA Covered Miscellaneous Antibiotics
Clarithromycin Biaxin 2x250 mg BID x 5 days 2x250 mg BID x 5 days $25 BC / IA - Covered Miscellaneous Antibiotics
Moxifloxacin Avelox 400 mg QD x 7 days 400 mg QD x 7 days $25 BC - SA / IA Covered Miscellaneous Antibiotics
Amoxicillin Amoxil 500 mg TID x 7 days 500 mg TID x 7 days $15 BC / IA - Covered Miscellaneous Antibiotics
Diclofenac Voltaren SR 75 mg BID $60 BC / IA - Covered Analgesics Non-Steroidal Antiinflammatory Drugs
Naproxen/Esomeprazole Vimovo 500 mg/20 mg BID $205 BC / IA - NC Analgesics Non-Steroidal Antiinflammatory Drugs
Ketorolac Toradol 10 mg BID $85 BC - Covered / IA - SA Analgesics Non-Steroidal Antiinflammatory Drugs
Naproxen Naproxen 500 mg BID $55 BC / IA - Covered Analgesics Non-Steroidal Antiinflammatory Drugs
Diclofenac/Misoprostol Arthrotec 75 mg/200 mcg BID $100 BC / IA - Covered Analgesics Non-Steroidal Antiinflammatory Drugs
Gabapentin Neurontin 300 mg TID $45 BC / IA - Covered Analgesics Neuropathic or Chronic Pain
Pregabalin Lyrica 50 mg HS $35 BC - Covered / IA - SA Analgesics Neuropathic or Chronic Pain
Amitriptyline Elavil 25 mg HS $25 BC / IA - Covered Analgesics Neuropathic or Chronic Pain
Amitriptyline Elavil 10 mg HS $20 BC / IA - Covered Analgesics Neuropathic or Chronic Pain
Tramadol/Acetaminophen Tramacet 37.5 mg/325 mg PRN $80 BC / IA - NC

90 tablets

Analgesics Miscellaneous Analgesics
Allopurinol Zyloprim 200 mg QD $25 BC / IA - Covered Analgesics Gout
Colchicine Colchicine 0.6 mg QD $40 BC / IA - Covered Analgesics Gout
Celecoxib Celebrex 200 mg QD $40 BC - SA / IA Covered Analgesics COX2 Inhibitor
Zolmitriptan Zomig 2.5 mg PRN $40 BC - SA / IA Covered

6 tablets

Analgesics Anti-Migraine
Sumatriptan Imitrex 100 mg PRN $35 BC - SA / IA Covered

6 tablets

Analgesics Anti-Migraine
Testosterone Cypionate Depo-Testosterone 100 mg/ml 200mg Q2W $75 BC / IA - Covered Urology Testosterone Replacement
Testosterone Enanthate Delatestryl 200 mg/ml 400mg Q30D $85 BC / IA - Covered Urology Testosterone Replacement
Testosterone Gel Androgel 5 g QD $440 BC - NC / IA - SA Urology Testosterone Replacement
Testosterone Patch Androderm 5 mg/day QD $445 BC / IA - SA Urology Testosterone Replacement
Testosterone Undecanoate Andriol 40 mg BID $105 BC - SA / IA Covered Urology Testosterone Replacement
Sildenafil Viagra 50 mg, 100 mg As dir $55 BC / IA - NC

4 tablets; may split tablet for lower dose to save costs

Urology Erectile Dysfunction
Vardenafil Levitra 20 mg As dir $70 BC / IA - NC

4 tablets; may split tablet for lower dose to save costs

Urology Erectile Dysfunction
Tadalafil Cialis 20 mg As dir $70 BC / IA - NC

4 tablets; may split tablet for lower dose to save costs

Urology Erectile Dysfunction
Finasteride Proscar 5 mg QD $55 BC - Covered / IA - SA Urology Benign Prostatic Hyperplasia (BPH)
Terazosin Hytrin 2 mg QD $35 BC / IA - Covered Urology Benign Prostatic Hyperplasia (BPH)
Tamsulosin CR Flomax CR 0.4 mg QD $30 BC / IA - Covered Urology Benign Prostatic Hyperplasia (BPH)
Dutasteride Avodart 0.5 mg QD $45 BC - Covered / IA - SA Urology Benign Prostatic Hyperplasia (BPH)
Estradiol-17β Vaginal Tablet Vagifem-10 10 mcg Twice weekly $125 BC / IA - Covered Hormone Replacement Therapy Vaginal
Conjugated Estrogens Premarin Vaginal Cr 0.625 mg QD $85 BC / IA - Covered Hormone Replacement Therapy Vaginal
Estradiol-17β Gel Estrogel 2.5 g gel = 1.5 mg estradiol QD $100 BC / IA - Covered Hormone Replacement Therapy Transdermal
Estradiol-17β Patch Estradot/Oesclim 50 mcg Twice weekly $80 BC / IA - Covered Hormone Replacement Therapy Transdermal
Medroxyprogesterone Provera 5 mg QD $20 BC / IA - Covered Hormone Replacement Therapy Oral
Micronized progesterone Prometrium 100 mg HS $125 BC - Covered / IA - SA Hormone Replacement Therapy Oral
Conjugated Estrogens Premarin 0.625 mg QD $50 BC / IA - Covered Hormone Replacement Therapy Oral
Estradiol-17β Estrace 1 mg QD $35 BC / IA - Covered Hormone Replacement Therapy Oral
Etonogestrel Nuvaring Vaginal ring As dir $70 BC - NC; IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal Vaginal
Norelgestromin Evra Patch As dir $80 BC - NC; IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal Vaginal
Copper IUD Mona Lisa IUD As dir $5 BC / IA - Covered

Upfront cost is $89 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $4 every 90 days

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
IUD
Levonorgestrel Mirena IUD As dir $20 BC / IA - Covered

Upfront cost is $396 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
IUD
Drospirenone YAZ QD $75 BC - NC; IA - Covered

Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Drospirenone Yasmin QD $60 BC / IA - Covered

Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.

Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Norgestimate Tri-Cyclen Lo QD $70 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Norgestimate Tri-Cyclen QD $110 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Desogestrel Marvelon QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Levonorgestrel Triquilar QD $70 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Min-Ovral QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Alesse QD $40 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Norethindrone Synphasic QD $60 BC / IA - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
1st Generation Progestins
Lisdexamfetamine Vyvanse 20 mg QD $290 BC - RST / IA - Covered Psychiatry Stimulants (ADHD)
Methylphenidate Ritalin 10 mg BID $30 BC / IA - Covered Psychiatry Stimulants (ADHD)
Methylphenidate Concerta 36 mg QD $345 BC - NC / IA - Covered Psychiatry Stimulants (ADHD)
Amphetamines, Mixed Salts Adderall XR 10 mg QD $265 BC - NC / IA - Covered Psychiatry Stimulants (ADHD)
Temazepam Restoril 30 mg PRN $40 BC / IA - Covered

90 tablets

Psychiatry Anxiolytic Sedative
Zopiclone Imovane 7.5 mg PRN $25 BC - Covered / IA - NC

90 tablets

Psychiatry Anxiolytic Sedative
Trazodone Desyrel 50 mg PRN $20 BC / IA - Covered

90 tablets

Psychiatry Anxiolytic Sedative
Lorazepam Ativan 1 mg PRN $20 BC / IA - Covered

90 tablets

Psychiatry Anxiolytic Sedative
Olanzapine Zyprexa 5 mg, 10 mg QD $85 BC / IA - Covered Psychiatry Antipsychotics
Quetiapine Seroquel XR 300 mg QD $110 BC / IA - Covered Psychiatry Antipsychotics
Quetiapine Seroquel 25 mg HS $20 BC / IA - Covered Psychiatry Antipsychotics
Risperidone Risperdal 1 mg QD $40 BC / IA - Covered Psychiatry Antipsychotics
Aripiprazole Abilify 15 mg QD $140 BC - RST / IA - SA Psychiatry Antipsychotics
Sertraline Zoloft 50 mg QD $45 BC / IA - Covered Psychiatry Antidepressants
Vortioxetine Trintellix 20 mg QD $345 BC / IA - NC Psychiatry Antidepressants
Mirtazapine Remeron 30 mg HS $35 BC / IA - Covered Psychiatry Antidepressants
Fluoxetine Prozac 20 mg QD $45 BC / IA - Covered Psychiatry Antidepressants
Desvenlafaxine Pristiq 50 mg QD $255 BC / IA - NC Psychiatry Antidepressants
Paroxetine Paxil 20 mg QD $45 BC / IA - Covered Psychiatry Antidepressants
Venlafaxine Effexor XR 75 mg QD $30 BC / IA - Covered Psychiatry Antidepressants
Duloxetine Cymbalta 30 mg QD $60 BC / IA - Covered Psychiatry Antidepressants
Escitalopram Cipralex 10 mg QD $45 BC / IA - Covered Psychiatry Antidepressants
Citalopram Celexa 20 mg QD $25 BC / IA - Covered Psychiatry Antidepressants
Pantoprazole Magnesium Tecta 40 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Lansoprazole Prevacid 30 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Rabeprazole Pariet 10 mg QD $20 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Esomeprazole Nexium 40 mg QD $210 BC / IA - NC

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Omeprazole Losec 20 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Dexlansoprazole Dexilant 30 mg QD $245 BC / IA - NC

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
PEG3350 Restoralax/Lax-A-Day 17 g QD $55 BC - NC; IA - Covered Gastrointestinal Laxatives
Lactulose Lactulose 1 tbsp QD $35 BC / IA - Covered Gastrointestinal Laxatives
Ranitidine Zantac 150 mg BID $40 BC / IA - Covered Gastrointestinal Histamine-2 Receptor Antagonists (H2RAs)
Pantoprazole Magnesium Tecta 40 mg BID x 14d BC / IA - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Metronidazole Flagyl 500 mg BID x 14d BC / IA - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Clarithromycin Biaxin 2x250 mg BID x 14d BC / IA - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Amoxicillin Amoxil 1 g BID x 14d $95 BC / IA - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Pyridoxine Pyridoxine 25 mg PRN $5 BC - NC; IA - Covered

30 tablets

Gastrointestinal Antiemetics
Ondansetron Zofran 8 mg PRN $180 BC / IA - Covered Gastrointestinal Antiemetics
Metoclopramide Maxeran 2x5 mg PRN $20 BC / IA - Covered Gastrointestinal Antiemetics
Dimenhydrinate Gravol 50 mg PRN $15 BC / IA - Covered Gastrointestinal Antiemetics
Doxylamine/Pyridoxine Diclectin 10 mg/10 mg PRN $35 BC / IA - Covered Gastrointestinal Antiemetics
Budesonide/Formoterol Symbicort (120) 200/6 mcg 1 pf bid $160 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Long-acting beta agonist/Corticosteroid Combos
Fluticasone/Vilanterol Breo Ellipta (30) 100/25 mcg 1 pf qd $295 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Long-acting beta agonist/Corticosteroid Combos
Fluticasone/Salmeterol Advair MDI (120) 250/25 mcg 1 pf bid $250 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Long-acting beta agonist/Corticosteroid Combos
Fluticasone/Salmeterol Advair Diskus (60) 250/50 mcg 1 pf bid $350 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Long-acting beta agonist/Corticosteroid Combos
Glycopyrronium/Indacaterol Ultibro (30) 50/110 mcg 1 pf qd $275 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Long-acting Anti-cholinergic/Long-acting Beta-agonist Combos
Montelukast Singulair 10 mg QD $55 BC / IA - SA

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Leukotriene Receptor Antagonist
Beclomethasone Qvar (200) 100 mcg 1 pf bid $75 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Corticosteroids
Budesonide Pulmicort (200) 200 mcg 1 pf bid $80 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Corticosteroids
Fluticasone Flovent (120) 250 mcg 1 pf bid $155 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Corticosteroids
Fluticasone Flovent (120) 125 mcg 1 pf bid $85 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Corticosteroids
Salbutamol Ventolin (200) 100 mcg 4 pfs/d $25 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Bronchodilators / Anti-cholingergics
Tiotropium Spiriva (30) 18 mcg 1 pf qd $195 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Bronchodilators / Anti-cholingergics
Glycopyrronium Seebri (30) 50 mcg 1 pf qd $190 BC - Covered / IA - NC

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Bronchodilators / Anti-cholingergics
Ipratropium Atrovent (200) 200 mcg 1 pf qid $55 BC / IA - Covered

Puffers differ in their ‘doses’ (puffs) per device, so comparing costs is difficult. The 90 day cost was calculated by: 1. Determining the total number of doses over 90 days (using the stated dosing frequency). 2. Multiplying by the calculated cost per dose 3.Adding the dispensing fee and markup. This will not be exactly what patients pay for these products but allows for a more fair comparison between therapies. Brackets next to brand name indicate number of doses per device.

Respiratory Bronchodilators / Anti-cholingergics
Bupropion Zyban 150 mg BID $215 BC / IA - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Bupropion Wellbutrin SR 150 mg BID $60 BC / IA - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Varenicline Champix 0.5 mg QD x 3 days, 0.5 mg BID x 4 days, 1 mg BID thereafter 0.5 mg QD x 3 days, 0.5 mg BID x 4 days, 1 mg BID thereafter $190 BC - SA / IA Covered

Quantity limits

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Nortriptyline Aventyl 25 mg 3 HS $170 BC / IA - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Nicotine Inhaler Nicorette Cartridges 6 ctgs/d $465 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Gum Nicorette 4 mg 12 pcs/d $375 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Gum Nicorette 2 mg 12 pcs/d $375 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Patch Nicoderm 21 mg x 8 wks, 14 mg x 2 wks, 7 mg x 2 wks (patch daily) 21 mg x 8 wks, 14 mg x 2 wks, 7 mg x 2 wks (patch daily) $280 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Orlistat Xenical 120 mg TID $535 BC / IA - NC Obesity Obesity
Liraglutide Saxenda 3 mg sub-Q QD $1285 BC / IA - NC Obesity Obesity
Gliclazide MR Diamicron MR 30 mg MR 2 QD $35 BC / IA - Covered Hypoglycemic Agents Sulfonylureas
Gliclazide Diamicron 80 mg BID $35 BC / IA - Covered Hypoglycemic Agents Sulfonylureas
Glyburide Diabeta 5 mg BID $25 BC / IA - Covered Hypoglycemic Agents Sulfonylureas
Empagliflozin Jardiance 10 mg QD $285 BC / IA - SA Hypoglycemic Agents Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Canagliflozin Invokana 100 mg QD $295 BC / IA - SA Hypoglycemic Agents Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Repaglinide Gluconorm 1 mg TID $40 BC / IA - Covered Hypoglycemic Agents Meglitinides
Basal insulin (Degludec) Tresiba 100 U/ml As dir $135 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Basal insulin (Glargine) Toujeo 300 U/ml As dir $115 BC - NC; IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Rapid-acting insulin Novorapid/Humalog 100 U/ml As dir $85 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Regular insulin Novolin Toronto/ Humulin R 100 U/ml As dir $65 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Long-acting insulin Novolin NPH/ Humulin N 100 U/ml As dir $65 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Basal insulin (Detemir) Levemir 100 U/ml As dir $135 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Basal insulin (Glargine) Lantus 100 U/ml As dir $115 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Basal insulin (Glargine) Basaglar 100 U/ml As dir $90 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Rapid-acting insulin Apidra 100 U/ml As dir $75 BC / IA - Covered

Prices may vary between pharmacies, relative differences likely consistent.
Max allowable price for 1500 Units of penfill insulin.

Hypoglycemic Agents Insulin
Liraglutide Victoza 1.8 mg sub-Q QD $955 BC / IA - NC Hypoglycemic Agents Glucagon-like Peptide 1 Agonist (GLP-1)
Liraglutide Victoza 1.2 mg sub-Q QD $640 BC / IA - NC Hypoglycemic Agents Glucagon-like Peptide 1 Agonist (GLP-1)
Linagliptin Trajenta 5 mg QD $280 BC / IA - SA Hypoglycemic Agents Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Saxagliptin Onglyza 5 mg QD $305 BC / IA - SA Hypoglycemic Agents Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Sitagliptin Januvia 100 mg QD $320 BC / IA - SA Hypoglycemic Agents Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Metformin SR Glumetza SR 1000 mg 2 QD $225 BC / IA - NC Hypoglycemic Agents Biguanides
Metformin Glucophage 500 mg 2 BID $25 BC / IA - Covered Hypoglycemic Agents Biguanides
Simvastatin Zocor 10 mg QD $25 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular Lipid Lowering Agents
Evolocumab Repatha 140 mg sub-Q Q2W $1670 BC / IA - SA Cardiovascular Lipid Lowering Agents
Pravastatin Pravachol 20 mg QD $25 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular Lipid Lowering Agents
Atorvastatin Lipitor 10 mg QD $25 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular Lipid Lowering Agents
Ezetimibe Ezetrol 10 mg QD $25 BC - SA / IA Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular Lipid Lowering Agents
Rosuvastatin Crestor 10 mg, 20 mg QD $25 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular Lipid Lowering Agents
Indapamide Lozide 2.5 mg QD $25 BC / IA - Covered Cardiovascular Diuretics
Furosemide Lasix 20 mg, 40 mg QD $15 BC / IA - Covered Cardiovascular Diuretics
Chlorthalidone Hygroton 50 mg 1/4-1/2 QD $20 BC / IA - Covered Cardiovascular Diuretics
Spironolactone Aldactone 25 mg, 100 mg QD $45 BC / IA - Covered Cardiovascular Diuretics
Diltiazem-T Tiazac 240 mg QD $50 BC / IA - Covered Cardiovascular Calcium Channel Blockers
Amlodipine Norvasc 5 mg, 10 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for dihydropyridine calcium channel blockers (DHP-CCBs) paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than amlodipine 10mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Please see: the MAC Policy – Expanded Drug Categories.

Cardiovascular Calcium Channel Blockers
Nifedipine Adalat XL 30 mg QD $30 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for dihydropyridine calcium channel blockers (DHP-CCBs) paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than amlodipine 10mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Please see: the MAC Policy – Expanded Drug Categories.

Cardiovascular Calcium Channel Blockers
Atenolol Tenormin 50 mg QD $25 BC / IA - Covered Cardiovascular Beta Blockers
Atenolol Tenormin 100 mg QD $30 BC / IA - Covered Cardiovascular Beta Blockers
Bisoprolol Monocor 10 mg QD $25 BC / IA - Covered Cardiovascular Beta Blockers
Metoprolol-SR Lopresor SR 100 mg, 200 mg QD $50 BC / IA - Covered Cardiovascular Beta Blockers
Metoprolol Lopresor 25 mg, 50 mg BID $25 BC / IA - Covered Cardiovascular Beta Blockers
Telmisartan/Amlodipine Twynsta 80 mg/5 mg QD $85 BC / IA - Covered Cardiovascular ARB / CCB Combos
Clopidogrel Plavix 75 mg QD $40 BC / IA - Covered Cardiovascular Anti-Platelet
Ticagrelor Brilinta 90 mg BID $325 BC - RST / IA - Covered Cardiovascular Anti-Platelet
Rivaroxaban Xarelto 20 mg QD $300 BC / IA - SA Cardiovascular Anti-Coagulant
Rivaroxaban Xarelto 15 mg QD $300 BC / IA - SA Cardiovascular Anti-Coagulant
Rivaroxaban Xarelto 10 mg QD $300 BC - RST / IA - Covered Cardiovascular Anti-Coagulant
Dabigatran Pradaxa 150 mg BID $265 BC / IA - SA Cardiovascular Anti-Coagulant
Dabigatran Pradaxa 110 mg BID $265 BC / IA - SA Cardiovascular Anti-Coagulant
Edoxaban Lixiana 60 mg QD $295 BC / IA - SA Cardiovascular Anti-Coagulant
Apixaban Eliquis 5 mg BID $340 BC / IA - SA Cardiovascular Anti-Coagulant
Warfarin Coumadin 5 mg QD $20 BC / IA - Covered Cardiovascular Anti-Coagulant
Telmisartan Micardis 80 mg QD $35 BC / IA - Covered

All have HCTZ combo products that are similar in price to the single entity product

Cardiovascular Angiotensin Receptor Blockers
Valsartan Diovan 80 mg QD $35 BC / IA - Covered

All have HCTZ combo products that are similar in price to the single entity product

Cardiovascular Angiotensin Receptor Blockers
Valsartan Diovan 160 mg QD $35 BC / IA - Covered

All have HCTZ combo products that are similar in price to the single entity product

Cardiovascular Angiotensin Receptor Blockers
Losartan Cozaar 50 mg QD $30 BC / IA - Covered

All have HCTZ combo products that are similar in price to the single entity product

Cardiovascular Angiotensin Receptor Blockers
Candesartan Atacand 8 mg QD $35 BC / IA - Covered

All have HCTZ combo products that are similar in price to the single entity product

Cardiovascular Angiotensin Receptor Blockers
Lisinopril Zestril 20 mg QD $30 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors
Enalapril Vasotec 10 mg QD $30 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors
Perindopril/Indapamide Coversyl Plus 4 mg/1.25 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors -Diuretic Combinations
Perindopril Coversyl 4 mg, 8 mg QD $30 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors
Ramipril Altace 5 mg, 10 mg QD $30 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for ACE inhibitors paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost equal to or less than lisinopril 20mg. Patients who wish to continue on non-MAC priced medications will have to pay the difference in cost. Exceptions include: pediatric patients, BID heart failure dosing and pregnant patients. Please see: MAC Policy – Expanded Drug Categories.

Cardiovascular ACE Inhibitors

Iron Preparations

Generic Name Brand Name Total Dose
(mg/tab or 5mL)
Elemental Iron
(mg/tab or 5mL)
90 Day Cost
(100 mg elemental iron/day)
Coverage Comments
Polysaccharide Iron Feramax 150 150 $55 BC / IA - NC
Ferrous sulphate Generic adult susp 150 30 $25 BC / IA - Covered
Ferrous gluconate Generic brands 300 35 $15 BC - NC/ IA - Covered

Opioid Dependency

Generic Name Brand Name Daily Dose Dispensing Frequency Cost of 2 Week Supply Coverage Comments
Methadone Methadose 60-120 mg Daily $190 BC / IA - Covered Doses individualized, cost of 2 week supply based on highest daily dose.
Methadone Methadose 60-120 mg Every 2 weeks $25 BC / IA - Covered Doses individualized, cost of 2 week supply based on highest daily dose.
Legend:
BC = Alberta Blue Cross, IA = Indian Affairs, NC = Not covered, SA = special authorization, SR = sustained release, OTC = over the counter, SQ = subcutaneous injection, SS=Social Services