Pharmaceutic Pricing
Generic Name  Brand Name  Strength  Dosing  90 Day Cost  Coverage  Comments  Category 1  Category 2 

Buprenorphine/Naloxone  Suboxone  BC / NIHB  Covered 
Daily Dose: 2/0.5 mg  8/2 mg Dispensing Frequency: Every 2 weeks Cost of 2 Week Supply: $30 Doses individualized, cost of 2 week supply based on highest daily dose. 
P Opioid Dependency  Opioid Dependency  
Buprenorphine/Naloxone  Suboxone  BC / NIHB  Covered 
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. 
P Opioid Dependency  Opioid Dependency  
Methadone  Methadose  BC / NIHB  Covered 
Daily Dose: 60120 mg Dispensing Frequency: Every 2 weeks Cost of 2 Week Supply: $20 Doses individualized, cost of 2 week supply based on highest daily dose. 
P Opioid Dependency  Opioid Dependency  
Methadone  Methadose  BC / NIHB  Covered 
Daily Dose: 60120 mg Dispensing Frequency: Daily Cost of 2 Week Supply: $75 Doses individualized, cost of 2 week supply based on highest daily dose. 
P Opioid Dependency  Opioid Dependency  
Ferrous Fumarate  Wampole  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 300 Elemental Iron (mg/tab or 5mL): 100 90 Day Cost (100 mg elemental iron/day): $25 
P Iron Preparations  Iron Preparations  
Ferrous Fumarate  Palafer  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 300 Elemental Iron (mg/tab or 5mL): 100 90 Day Cost (100 mg elemental iron/day): $30 
P Iron Preparations  Iron Preparations  
Ferrous Sulphate  Generic infant susp  BC  Restricted / NIHB  Covered 
Total Dose (mg/tab or 5mL): 375 Elemental Iron (mg/tab or 5mL): 75 90 Day Cost (100 mg elemental iron/day): $90 
P Iron Preparations  Iron Preparations  
Ferrous Sulphate  Generic brands  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 300 Elemental Iron (mg/tab or 5mL): 60 90 Day Cost (100 mg elemental iron/day): $15 
P Iron Preparations  Iron Preparations  
Ferrous Gluconate  Generic brands  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 300 Elemental Iron (mg/tab or 5mL): 35 90 Day Cost (100 mg elemental iron/day): $20 
P Iron Preparations  Iron Preparations  
Ferrous Sulphate  Generic adult susp  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 150 Elemental Iron (mg/tab or 5mL): 30 90 Day Cost (100 mg elemental iron/day): $30 
P Iron Preparations  Iron Preparations  
Polysaccharide Iron  Feramax  BC  NC / NIHB  Covered 
Total Dose (mg/tab or 5mL): 150 Elemental Iron (mg/tab or 5mL): 150 90 Day Cost (100 mg elemental iron/day): $55 
P Iron Preparations  Iron Preparations  
Mometasone Furoate  Elocom  0.10%  As dir  $35  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Betamethasone Dipropionate  Diprosone  0.05%  As dir  $20  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Betamethasone Dipropionate Glycol  Diprolene  0.05%  As dir  $30  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Desonide  Desonate  0.05%  As dir  $30  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Clobetasol 17propionate  Dermovate  0.05%  As dir  $20  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Amcinonide  Cyclocort  0.10%  As dir  $30  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Hydrocortisone  Cortate  1.00%  As dir  $20  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Betamethasone Valerate  Betaderm/Betnovate  0.10%  As dir  $15  BC / NIHB  Covered 
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. 
P Topicals  Topical Corticosteroids 
Tacrolimus  Protopic (30g tube)  0.03%  As dir  $90  BC / NIHB  SA  P Topicals  Miscellaneous Topicals  
Betamethasone/Calcipotriol  Dovobet (60g tube)  0.05/0.005%  As dir  $100  BC / NIHB  Covered  P Topicals  Miscellaneous Topicals  
Imiquimod  Aldara (24x250mg)  5%  As dir  $300  BC  SA / NIHB  Covered  P Topicals  Miscellaneous Topicals  
Isopropyl Myristate  Resultz  50%  As dir  $30  BC / NIHB  Covered  P Topicals  Lice  
Pyrethrins/Piperonyl Butoxide  R&C  0.33%/3%  As dir  $25  BC / NIHB  Covered  P Topicals  Lice  
Dimethicone  Nyda  50%  As dir  $40  BC / NIHB  Covered  P Topicals  Lice  
Permethrin  Nix  1%  As dir  $25  BC / NIHB  Covered  P Topicals  Lice  
Tretinoin Cream  StievaA (25g tube)  0.03%  As dir  $25  BC  SA / NIHB  Covered  P Topicals  Acne Treatments  
Adapalene/Benzoyl Peroxide  TactuPump Forte (70g tube)  0.3%/2.5%  As dir  $165  BC / NIHB  NC  P Topicals  Acne Treatments  
Adapalene  Differin (60g tube)  0.10%  As dir  $185  BC  NC / NIHB  Covered  P Topicals  Acne Treatments  
Benzoyl Peroxide/Clindamycin  Clindoxyl (45g tube)  5%/1%  As dir  $50  BC  SA / NIHB Covered  P Topicals  Acne Treatments  
Isotretinoin  Accutane  40 mg  QD x 90 days  $205  BC / NIHB  Covered  P Topicals  Acne Treatments  
Denosumab  Prolia  60 mg SQ every 6 months  $230  BC / NIHB  SA  P Miscellaneous  Osteoporosis  
Alendronate  Fosamax  70 mg once weekly  $40  BC / NIHB  Covered  P Miscellaneous  Osteoporosis  
Teriparatide  Forteo  20 mcg SQ  QD  $1935  BC  NC / NIHB  Covered  P Miscellaneous  Osteoporosis  
Risedronate  Actonel  35 mg once weekly  $35  BC / NIHB  Covered  P Miscellaneous  Osteoporosis  
Zoledronic Acid  Aclasta  5 mg yearly  $110  BC / NIHB  SA  P Miscellaneous  Osteoporosis  
Galantamine ER  Reminyl ER  16 mg  QD  $140  BC / NIHB  SA  P Miscellaneous  Dementia  
Rivastigmine  Exelon  3 mg  BID  $145  BC / NIHB  SA  P Miscellaneous  Dementia  
Memantine  Ebixa  10 mg  QD  $185  BC  NC / NIHB  SA  P Miscellaneous  Dementia  
Donepezil  Aricept  5 mg  QD  $60  BC / NIHB  SA  P Miscellaneous  Dementia  
Itraconazole  Sporanox  2x100 mg QD x 12 weeks  $795  BC / NIHB  Covered 
Onychomycosis dosing 
P Miscellaneous  Antifungals  
Cicloporox  Penlac  Nail lacquer; price for 6 g  $70  BC / NIHB  NC 
Onychomycosis dosing 
P Miscellaneous  Antifungals  
Terbinafine  Lamisil  250 mg QD x 12 weeks  $85  BC / NIHB  Covered 
Onychomycosis dosing 
P Miscellaneous  Antifungals  
Efinaconazole  Jublia  Nail lacquer; price for 8ml  $120  BC / NIHB  NC 
Onychomycosis dosing 
P Miscellaneous  Antifungals  
Fluconazole  Diflucan  150 mg once weekly x 12 weeks  $65  BC / NIHB  Covered 
Onychomycosis dosing 
P Miscellaneous  Antifungals  
Azithromycin  Zithromax  250 mg x 4 days  $20  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Fosfomycin  Monurol  3 g as a single dose (uncomplicated UTI)  $30  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Nitrofurantoin  Macrobid  100 mg BID x 3 days  $20  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Cephalexin  Keflex  500 mg QID x 7 days  $20  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Doxycycline  Doxycycline  100 mg QD x 7 days  $20  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Amoxicillin/Clavulanate  Clavulin  500 mg TID x 7 days  $25  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Ciprofloxacin  Cipro  500 mg BID x 5 days  $20  BC  SA / NIHB Covered  P Miscellaneous  Antibiotics  
Clarithromycin  Biaxin  2x250 mg BID x 5 days  $25  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Moxifloxacin  Avelox  400 mg QD x 7 days  $25  BC  SA / NIHB  Covered  P Miscellaneous  Antibiotics  
Amoxicillin  Amoxil  500 mg TID x 7 days  $15  BC / NIHB  Covered  P Miscellaneous  Antibiotics  
Diclofenac  Voltaren SR  75 mg  BID  $60  BC / NIHB  Covered  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Naproxen/Esomeprazole  Vimovo  500 mg/20 mg  BID  $205  BC / NIHB  NC  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Ketorolac  Toradol  10 mg  BID  $50  BC  Covered / NIHB  SA  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Naproxen  Naproxen  500 mg  BID  $55  BC / NIHB  Covered  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Celecoxib  Celebrex  200 mg  QD  $40  BC  SA / NIHB Covered  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Diclofenac/Misoprostol  Arthrotec  75 mg/200 mcg  BID  $100  BC / NIHB  Covered  P Analgesics  NonSteroidal Antiinflammatory Drugs (NSAIDs)  
Gabapentin  Neurontin  300 mg  TID  $45  BC / NIHB  Covered  P Analgesics  Neuropathic or Chronic Pain  
Pregabalin  Lyrica  50 mg  HS  $35  BC  Covered / NIHB  SA  P Analgesics  Neuropathic or Chronic Pain  
Amitriptyline  Elavil  25 mg  HS  $25  BC / NIHB  Covered  P Analgesics  Neuropathic or Chronic Pain  
Amitriptyline  Elavil  10 mg  HS  $20  BC / NIHB  Covered  P Analgesics  Neuropathic or Chronic Pain  
Tramadol/Acetaminophen  Tramacet  37.5 mg/325 mg  PRN  $80  BC  NC / NIHB  SA 
90 tablets 
P Analgesics  Miscellaneous Analgesics 
Allopurinol  Zyloprim  200 mg  QD  $25  BC / NIHB  Covered  P Analgesics  Gout  
Colchicine  Colchicine  0.6 mg  QD  $40  BC / NIHB  Covered  P Analgesics  Gout  
Zolmitriptan  Zomig  2.5 mg  PRN  $40  BC  Restricted / NIHB  Covered 
6 tablets 
P Analgesics  AntiMigraine 
Topiramate  Topamax  100 mg  QD  $60  BC / NIHB  Covered  P Analgesics  AntiMigraine  
Sumatriptan  Imitrex  100 mg  PRN  $35  BC  Restricted / NIHB  Covered 
6 tablets 
P Analgesics  AntiMigraine 
Testosterone Cypionate  DepoTestosterone  100 mg/mL  200 mg Q2W  $60  BC / NIHB  Covered  P Urology  Testosterone Replacement  
Testosterone Enanthate  Delatestryl  200 mg/mL  400 mg Q30D  $85  BC / NIHB  Covered  P Urology  Testosterone Replacement  
Testosterone Gel  Androgel  5 g  QD  $455  BC  NC / NIHB  SA  P Urology  Testosterone Replacement  
Testosterone Patch  Androderm  5 mg/day  QD  $455  BC / NIHB  SA  P Urology  Testosterone Replacement  
Testosterone Undecanoate  Andriol  40 mg  BID  $105  BC  SA / NIHB  Covered  P Urology  Testosterone Replacement  
Sildenafil  Viagra  50 mg, 100 mg  As dir  $55  BC / NIHB  NC 
4 tablets; may split tablet for lower dose to save costs 
P Urology  Erectile Dysfunction 
Vardenafil  Levitra  20 mg  As dir  $70  BC / NIHB  NC 
4 tablets; may split tablet for lower dose to save costs 
P Urology  Erectile Dysfunction 
Tadalafil  Cialis  20 mg  As dir  $70  BC / NIHB  NC 
4 tablets; may split tablet for lower dose to save costs 
P Urology  Erectile Dysfunction 
Finasteride  Proscar  5 mg  QD  $50  BC / NIHB  Covered  P Urology  Benign Prostatic Hyperplasia (BPH)  
Terazosin  Hytrin  2 mg  QD  $35  BC / NIHB  Covered  P Urology  Benign Prostatic Hyperplasia (BPH)  
Tamsulosin CR  Flomax CR  0.4 mg  QD  $30  BC / NIHB  Covered  P Urology  Benign Prostatic Hyperplasia (BPH)  
Dutasteride  Avodart  0.5 mg  QD  $40  BC / NIHB  Covered  P Urology  Benign Prostatic Hyperplasia (BPH)  
Estradiol17Î² Vaginal Tablet  Vagifem10  10 mcg  Twice weekly  $130  BC / NIHB  Covered  P Hormone Replacement Therapy  Vaginal  
Conjugated Estrogens  Premarin Vaginal Cr  0.625 mg  QD  $90  BC / NIHB  Covered  P Hormone Replacement Therapy  Vaginal  
Estradiol17Î² Gel  Estrogel  2.5 g gel = 1.5 mg estradiol  QD  $100  BC / NIHB  Covered  P Hormone Replacement Therapy  Transdermal  
Estradiol17Î² Patch  Estradot/Oesclim  50 mcg  Twice weekly  $85  BC / NIHB  Covered  P Hormone Replacement Therapy  Transdermal  
Medroxyprogesterone  Provera  5 mg  QD  $40  BC / NIHB  Covered  P Hormone Replacement Therapy  Oral  
Micronized Progesterone  Prometrium  100 mg  HS  $50  BC / NIHB  Covered  P Hormone Replacement Therapy  Oral  
Conjugated Estrogens  Premarin  0.625 mg  QD  $50  BC / NIHB  Covered  P Hormone Replacement Therapy  Oral  
Estradiol17Î²  Estrace  1 mg  QD  $35  BC / NIHB  Covered  P Hormone Replacement Therapy  Oral  
Etonogestrel  Nuvaring  Vaginal ring  As dir  $65  BC  NC / NIHB  Covered 
P
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  $95  BC  NC / NIHB  Covered 
P
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  
Levonorgestrel  Mirena  IUD  As dir  $20  BC / NIHB  Covered 
Upfront cost is $396 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days 
P
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.

Intrauterine Devices (IUDs) 
Levonorgestrel  Kyleena  IUD  As dir  $20  BC / NIHB  Covered 
Upfront cost is $371 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $18 every 90 days 
P
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.

Intrauterine Devices (IUDs) 
Drospirenone  YAZ  QD  $75  BC  NC / NIHB  Covered 
Same chemical constituents. Yasmin is 21 active pills & 7 pillfree days; Yaz is 24 active pills & 4 pillfree days. 
P
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.

AntiAndrogenic  
Drospirenone  Yasmin  QD  $60  BC / NIHB  Covered 
Same chemical constituents. Yasmin is 21 active pills & 7 pillfree days; Yaz is 24 active pills & 4 pillfree days. 
P
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.

AntiAndrogenic  
Norgestimate  TriCyclen  QD  $65  BC / NIHB  Covered 
P
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 / NIHB  Covered 
P
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 / NIHB  Covered 
P
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  Seasonique  QD  $85  BC  NC / NIHB  Covered 
P
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  MinOvral  QD  $40  BC / NIHB  Covered 
P
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 / NIHB  Covered 
P
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 / NIHB  Covered 
P
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  
Norethindrone AcetateLolo  Lolo  QD  $80  BC  NC / NIHB  Covered 
P
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  Restricted / NIHB  Covered  P Psychiatry  Stimulants (ADHD)  
Methylphenidate  Ritalin  10 mg  BID  $60  BC / NIHB  Covered  P Psychiatry  Stimulants (ADHD)  
Methylphenidate  Concerta  36 mg  QD  $400  BC  NC / NIHB  Covered  P Psychiatry  Stimulants (ADHD)  
Amphetamines, Mixed Salts  Adderall XR  10 mg  QD  $265  BC / NIHB  NC  P Psychiatry  Stimulants (ADHD)  
Temazepam  Restoril  30 mg  PRN  $40  BC / NIHB  Covered 
90 tablets 
P Psychiatry  Anxiolytic Sedative 
Zopiclone  Imovane  7.5 mg  PRN  $25  BC  Covered / NIHB  NC 
90 tablets 
P Psychiatry  Anxiolytic Sedative 
Trazodone  Desyrel  50 mg  PRN  $20  BC / NIHB  Covered 
90 tablets 
P Psychiatry  Anxiolytic Sedative 
Lorazepam  Ativan  1 mg  PRN  $20  BC / NIHB  Covered 
90 tablets 
P Psychiatry  Anxiolytic Sedative 
Olanzapine  Zyprexa  5 mg, 10 mg  QD  $85  BC / NIHB  Covered  P Psychiatry  Antipsychotics  
Quetiapine  Seroquel XR  300 mg  QD  $110  BC / NIHB  Covered  P Psychiatry  Antipsychotics  
Quetiapine  Seroquel  25 mg  HS  $20  BC / NIHB  Covered  P Psychiatry  Antipsychotics  
Risperidone  Risperdal  1 mg  QD  $35  BC / NIHB  Covered  P Psychiatry  Antipsychotics  
Aripiprazole  Abilify  15 mg  QD  $140  BC  Restricted / NIHB  Covered  P Psychiatry  Antipsychotics  
Sertraline  Zoloft  50 mg  QD  $45  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Bupropion  Wellbutrin XL  150 mg  QD  $30  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Vortioxetine  Trintellix  20 mg  QD  $340  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Mirtazapine  Remeron  30 mg  HS  $35  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Fluoxetine  Prozac  20 mg  QD  $45  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Desvenlafaxine  Pristiq  50 mg  QD  $255  BC  NC / NIHB  SA  P Psychiatry  Antidepressants  
Paroxetine  Paxil  20 mg  QD  $45  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Venlafaxine  Effexor XR  75 mg  QD  $30  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Duloxetine  Cymbalta  30 mg  QD  $50  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Escitalopram  Cipralex  10 mg  QD  $45  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Citalopram  Celexa  20 mg  QD  $25  BC / NIHB  Covered  P Psychiatry  Antidepressants  
Pantoprazole Magnesium  Tecta  40 mg  QD  $35  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
Lansoprazole  Prevacid  30 mg  QD  $65  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
Rabeprazole  Pariet  10 mg  QD  $20  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
Esomeprazole  Nexium  40 mg  QD  $210  BC  NC / NIHB  SA 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
Omeprazole  Losec  20 mg  QD  $35  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
Dexlansoprazole  Dexilant  30 mg  QD  $250  BC / NIHB  NC 
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Gastrointestinal  Proton Pump Inhibitors (PPIs) 
PEG3350  Restoralax/LaxADay  17 g  QD  $55  BC  NC/ NIHB  Covered  P Gastrointestinal  Laxatives  
Lactulose  Lactulose  1 tbsp  QD  $35  BC / NIHB  Covered  P Gastrointestinal  Laxatives  
Ranitidine  Zantac  150 mg  BID  $40  BC / NIHB  Covered  P Gastrointestinal  Histamine2 Receptor Antagonists (H2RAs)  
Pantoprazole Magnesium  Tecta  40 mg  BID x 14d  BC / NIHB  Covered 
As 4 separate generic 
P Gastrointestinal  Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)  
Metronidazole  Flagyl  500 mg  BID x 14d  BC / NIHB  Covered 
As 4 separate generic 
P Gastrointestinal  Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)  
Clarithromycin  Biaxin  2x250 mg  BID x 14d  BC / NIHB  Covered 
As 4 separate generic 
P Gastrointestinal  Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)  
Amoxicillin  Amoxil  1 g  BID x 14d  $95  BC / NIHB  Covered 
As 4 separate generic 
P Gastrointestinal  Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) 
Pyridoxine  Pyridoxine  25 mg  PRN  $5  BC  NC/ NIHB  Covered 
30 tablets 
P Gastrointestinal  Antiemetics 
Ondansetron  Zofran  8mg  PRN  $145  BC / NIHB  Covered  P Gastrointestinal  Antiemetics  
Metoclopramide  Maxeran  2x5 mg  PRN  $20  BC / NIHB  Covered  P Gastrointestinal  Antiemetics  
Dimenhydrinate  Gravol  50 mg  PRN  $15  BC / NIHB  Covered  P Gastrointestinal  Antiemetics  
Doxylamine/Pyridoxine  Diclectin  10 mg/10 mg  PRN  $35  BC / NIHB  Covered  P Gastrointestinal  Antiemetics  
Budesonide/Formoterol  Symbicort (120)  200/6 mcg  1 pf qd  $160  BC / NIHB  SA 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Longacting betaagonist/Corticosteroid Combos 
Fluticasone/Vilanterol  Breo Ellipta (30)  100/25 mcg  1 pf qd  $310  BC / NIHB  SA 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Longacting betaagonist/Corticosteroid Combos 
Fluticasone/Salmeterol  Advair MDI (120)  250/25 mcg  1 pf bid  $265  BC / NIHB  SA 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Longacting betaagonist/Corticosteroid Combos 
Fluticasone/Salmeterol  Advair Diskus (60)  250/50 mcg  1 pf bid  $180  BC / NIHB  SA 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Longacting betaagonist/Corticosteroid Combos 
Glycopyrronium/Indacaterol  Ultibro (30)  50/110 mcg  1 pf qd  $270  BC  SA / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Longacting Anticholinergic/Longacting Betaagonist Combos 
Montelukast  Singulair  10 mg  QD  $55  BC / NIHB  SA 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Leukotriene Receptor Antagonist 
Beclomethasone  Qvar (200)  100 mcg  1 pf bid  $80  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Corticosteroids 
Budesonide  Pulmicort (200)  200 mcg  1 pf bid  $80  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Corticosteroids 
Fluticasone  Flovent (120)  250 mcg  1 pf bid  $90  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Corticosteroids 
Fluticasone  Flovent (120)  125 mcg  1 pf bid  $70  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Corticosteroids 
Salbutamol  Ventolin (200)  100 mcg  4 pfs/d  $25  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Bronchodilators / Anticholingergics 
Tiotropium  Spiriva (30)  18 mcg  1 pf qd  $195  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Bronchodilators / Anticholingergics 
Glycopyrronium  Seebri (30)  50 mcg  1 pf qd  $190  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Bronchodilators / Anticholingergics 
Ipratropium  Atrovent (200)  200 mcg  1 pf qid  $55  BC / NIHB  Covered 
Puffers differ in their â€˜dosesâ€™ (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. 
P Respiratory  Bronchodilators / Anticholingergics 
Bupropion  Zyban  150 mg  BID  $225  BC / NIHB  Covered 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Smoking Cessation  
Bupropion  Wellbutrin SR  150 mg  BID  $120  BC / NIHB  Covered 
P
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  $190  BC  Restricted / NIHB  Covered 
Quantity limits 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Smoking Cessation  
Nortriptyline  Aventyl  25 mg  3 HS  $185  BC / NIHB  Covered 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Smoking Cessation  
Nicotine Inhaler  Nicorette  Cartridges  6 ctgs/d  $470  BC  Restricted / NIHB  Covered 
Lifetime $ limit 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Nicotine Replacement Therapy 
Nicotine Gum  Nicorette  4 mg  12 pcs/d  $380  BC  Restricted / NIHB  Covered 
Lifetime $ limit 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Nicotine Replacement Therapy 
Nicotine Gum  Nicorette  2 mg  12 pcs/d  $380  BC  Restricted / NIHB  Covered 
Lifetime $ limit 
P
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)  $280  BC  Restricted/ NIHB  Covered 
Lifetime $ limit 
P
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency

Nicotine Replacement Therapy  
Semaglutide  Ozempic  2.4 mg SQ  Once Weekly  $3340  NC for weight management 
Must titrate to 2.4 mg dose 
P Obesity  Obesity 
Orlistat  Xenical  120 mg  TID  $535  BC / NIHB  NC  P Obesity  Obesity  
Liraglutide  Saxenda  3 mg SQ  QD  $1360  BC / NIHB  NC  P Obesity  Obesity  
Glyburide  Diabeta  5 mg  BID  $25  BC / NIHB  Covered  P Hypoglycemic Agents  Sulfonylureas  
Gliclazide MR  Diamicron MR  30 mg MR  2 QD  $35  BC / NIHB  Covered  P Hypoglycemic Agents  Sulfonylureas  
Gliclazide  Diamicron  80 mg  BID  $35  BC / NIHB  Covered  P Hypoglycemic Agents  Sulfonylureas  
Empagliflozin  Jardiance  10 mg  QD  $290  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors  
Dapagliflozin Propanediol Monohydrate  Forxiga  10 mg  QD  $285  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors  
Canagliflozin  Invokana  100 mg  QD  $295  BC / NIHB  SA  P Hypoglycemic Agents  Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors  
Repaglinide  Gluconorm  1 mg  TID  $40  BC / NIHB  Covered  P Hypoglycemic Agents  Meglitinides  
Regular insulin  Novolin Toronto/Humulin R  100 U/ml  As dir  $65  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Rapidacting insulin biosimilars  Trurapi  100 U/ml  As dir  $65  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Rapidacting insulin biosimilars  Admelog  100 U/ml  As dir  $65  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Rapidacting insulin  Novorapid  100 U/ml  As dir  $85  BC  NC / NIHB  SA 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Rapidacting insulin  Humalog  100 U/ml  As dir  $90  BC  NC / NIHB  SA 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Longacting insulin  Novolin NPH/Humulin N  100 U/ml  As dir  $65  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Basal insulin biosimilar (Glargine)  Basaglar  100 U/ml  As dir  $90  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Basal insulin (Glargine)  Toujeo  300 U/ml  As dir  $115  BC  NC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Basal insulin (Glargine)  Lantus  100 U/ml  As dir  $120  BC  NC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Basal insulin (Detemir)  Levemir  100 U/ml  As dir  $135  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Basal insulin (Degludec)  Tresiba  100 U/ml  As dir  $135  BC / NIHB  Covered 
Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively). 
P Hypoglycemic Agents  Insulin 
Liraglutide  Victoza  1.8 mg SQ  QD  $1020  BC / NIHB  NC  P Hypoglycemic Agents  Glucagonlike Peptide 1 Agonist (GLP1)  
Liraglutide  Victoza  1.2 mg SQ  QD  $685  BC / NIHB  NC  P Hypoglycemic Agents  Glucagonlike Peptide 1 Agonist (GLP1)  
Semaglutide  Ozempic  0.5 mg SQ  Once weekly  $680  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Glucagonlike Peptide 1 Agonist (GLP1)  
Lixisenatide  Adlyxine  0.02 mg SQ  QD  $390  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Glucagonlike Peptide 1 Agonist (GLP1)  
Sitagliptin  Januvia  100 mg  QD  $335  BC / NIHB  SA  P Hypoglycemic Agents  Dipeptidylpeptidase4 Inhibitors (DPP4)  
Saxagliptin  Onglyza  5 mg  QD  $310  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Dipeptidylpeptidase4 Inhibitors (DPP4)  
Linagliptin  Trajenta  5 mg  QD  $280  BC  SA / NIHB  Covered  P Hypoglycemic Agents  Dipeptidylpeptidase4 Inhibitors (DPP4)  
Metformin SR  Glumetza SR  1000 mg  2 QD  $225  BC  NC / NIHB  SA  P Hypoglycemic Agents  Biguanides  
Metformin  Glucophage  500 mg  2 BID  $25  BC / NIHB  Covered  P Hypoglycemic Agents  Biguanides  
Sacubitril/Valsartan  Entresto  97 mg/103 mg  BID  $750  BC / NIHB  SA  P Cardiovascular  Neprilysin Inhibitor / ARB Combos  
Evolocumab  Repatha  140 mg SQ  Q2W  $1735  BC / NIHB  SA  P Cardiovascular  Lipid Lowering Agents  
Alirocumab  Praluent  75 mg x Q2W SQ  Q2W  $1830  BC / NIHB  SA  P Cardiovascular  Lipid Lowering Agents  
Ezetimibe  Ezetrol  10 mg  QD  $30  BC / NIHB  Covered  P Cardiovascular  Lipid Lowering Agents  
Simvastatin  Zocor  10 mg  QD  $35  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Lipid Lowering Agents 
Pravastatin  Pravachol  20 mg  QD  $50  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Lipid Lowering Agents 
Atorvastatin  Lipitor  10 mg  QD  $30  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Lipid Lowering Agents 
Rosuvastatin  Crestor  10 mg, 20 mg  QD  $30  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Lipid Lowering Agents 
Indapamide  Lozide  2.5 mg  QD  $40  BC / NIHB  Covered  P Cardiovascular  Diuretics  
Furosemide  Lasix  20 mg, 40 mg  QD  $15  BC / NIHB  Covered  P Cardiovascular  Diuretics  
Chlorthalidone  Hygroton  50 mg  1/41/2 QD  $20  BC / NIHB  Covered  P Cardiovascular  Diuretics  
Hydrochlorothiazide  Hydrodiuril  12.5 mg, 25 mg  QD  $15  BC / NIHB  Covered  P Cardiovascular  Diuretics  
Spironolactone  Aldactone  25 mg, 100 mg  QD  $25  BC / NIHB  Covered  P Cardiovascular  Diuretics  
Diltiazem  Tiazac  240 mg  QD  $50  BC / NIHB  Covered 
Generic equivalents of TiazacT and Tiazac XC 
P Cardiovascular  Calcium Channel Blockers 
Amlodipine  Norvasc  5 mg, 10 mg  QD  $35  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Calcium Channel Blockers 
Nifedipine  Adalat XL  30 mg  QD  $75  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  Calcium Channel Blockers 
Atenolol  Tenormin  50 mg  QD  $25  BC / NIHB  Covered  P Cardiovascular  Beta Blockers  
Bisoprolol  Monocor  10 mg  QD  $25  BC / NIHB  Covered  P Cardiovascular  Beta Blockers  
MetoprololSR  Lopresor SR  100 mg, 200 mg  QD  $50  BC / NIHB  Covered  P Cardiovascular  Beta Blockers  
Metoprolol  Lopresor  25 mg, 50 mg  BID  $25  BC / NIHB  Covered  P Cardiovascular  Beta Blockers  
Telmisartan/Amlodipine  Twynsta  80 mg/5 mg  QD  $70  BC / NIHB  Covered  P Cardiovascular  ARB / CCB Combos  
Clopidogrel  Plavix  75 mg  QD  $40  BC / NIHB  Covered  P Cardiovascular  AntiPlatelet  
Ticagrelor  Brilinta  90 mg  BID  $250  BC  SA / NIHB  Covered  P Cardiovascular  AntiPlatelet  
Rivaroxaban  Xarelto  2.5 mg  BID  $295  BC / NIHB  SA  P Cardiovascular  AntiCoagulant  
Rivaroxaban  Xarelto  15 mg, 20 mg  QD  $300  BC  SA / NIHB  Covered  P Cardiovascular  AntiCoagulant  
Dabigatran  Pradaxa  110 mg, 150 mg  BID  $265  BC  SA / NIHB  Covered  P Cardiovascular  AntiCoagulant  
Edoxaban  Lixiana  60 mg  QD  $305  BC  SA / NIHB  Covered  P Cardiovascular  AntiCoagulant  
Apixaban  Eliquis  5 mg  BID  $95  BC  SA / NIHB  Covered  P Cardiovascular  AntiCoagulant  
Warfarin  Coumadin  5 mg  QD  $20  BC / NIHB  Covered  P Cardiovascular  AntiCoagulant  
Telmisartan  Micardis  80 mg  QD  $35  BC / NIHB  Covered 
All have HCTZ combo products that are similar in price to the single entity product 
P Cardiovascular  Angiotensin Receptor Blockers 
Valsartan  Diovan  80 mg, 160 mg  QD  $35  BC / NIHB  Covered 
All have HCTZ combo products that are similar in price to the single entity product 
P Cardiovascular  Angiotensin Receptor Blockers 
Losartan  Cozaar  50 mg  QD  $30  BC / NIHB  Covered 
All have HCTZ combo products that are similar in price to the single entity product 
P Cardiovascular  Angiotensin Receptor Blockers 
Candesartan  Atacand  8 mg  QD  $35  BC / NIHB  Covered 
All have HCTZ combo products that are similar in price to the single entity product 
P Cardiovascular  Angiotensin Receptor Blockers 
Lisinopril  Zestril  20 mg  QD  $35  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  ACE Inhibitors 
Enalapril  Vasotec  10 mg  QD  $40  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  ACE Inhibitors 
Perindopril/Indapamide  Coversyl Plus  4 mg/1.25 mg  QD  $40  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  ACE Inhibitors 
Perindopril  Coversyl  4 mg, 8 mg  QD  $40  BC / NIHB  Covered 
Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MACpricingcategories.pdf. 
P Cardiovascular  ACE Inhibitors 
Ramipril  Altace  5 mg, 10 mg  QD  $25  BC / NIHB  Covered 
All have HCTZ combo products that are similar in price to the single entity product 
P 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  $53  BC  NC / NIHB  Covered  
Ferrous Sulphate  Generic adult susp  150  30  $26  BC  NC / NIHB  Covered  
Ferrous Gluconate  Generic brands  300  35  $16  BC  NC / NIHB  Covered  
Ferrous Sulphate  Generic brands  300  60  $14  BC  NC / NIHB  Covered  
Ferrous Sulphate  Generic infant susp  375  75  $86  BC  Restricted / NIHB  Covered  
Ferrous Fumarate  Palafer  300  100  $26  BC  NC / NIHB  Covered  
Ferrous Fumarate  Wampole  300  100  $23  BC  NC / NIHB  Covered 
Opioid Dependency
Generic Name  Brand Name  Daily Dose  Dispensing Frequency  Cost of 2 Week Supply  Coverage  Comments 

Methadone  Methadose  60120 mg  Daily  $75  BC / NIHB  Covered  Doses individualized, cost of 2 week supply based on highest daily dose. 
Methadone  Methadose  60120 mg  Every 2 weeks  $16  BC / NIHB  Covered  Doses individualized, cost of 2 week supply based on highest daily dose. 
Buprenorphine/Naloxone  Suboxone  2/0.5 mg  8/2 mg  Daily  $247  BC / NIHB  Covered  Doses individualized, cost of 2 week supply based on highest daily dose. 
Buprenorphine/Naloxone  Suboxone  2/0.5 mg  8/2 mg  Every 2 weeks  $28  BC / NIHB  Covered  Doses individualized, cost of 2 week supply based on highest daily dose. 