Clickable Table - Pharmaceutic Pricing

Generic Name	Brand Name	Strength	Dosing	90 Day Cost	Coverage	Comments	Category 1	Category 2
Buprenorphine Extended Release	Sublocade	100 mg, 300 mg	Monthly	$1810	BC / NIHB - Covered		P Opioid Agonist Therapy Learn more about the OAT Gap Coverage Program, visit https://bit.ly/oatgapcoverage.	Opioid Dependency
Buprenorphine/Naloxone	Suboxone	2/0.5 mg - 8/2 mg		$720	BC / NIHB - Covered	Cost estimate based on 24 mg of suboxone daily	P Opioid Agonist Therapy Learn more about the OAT Gap Coverage Program, visit https://bit.ly/oatgapcoverage.	Opioid Dependency
Methadone	Methadose	60 mg, 120 mg	Daily	$45	BC / NIHB - Covered	Cost estimate based on 60 mg dose of methadone daily	P Opioid Agonist Therapy Learn more about the OAT Gap Coverage Program, visit https://bit.ly/oatgapcoverage.	Opioid Dependency
Iron Sucrose	Venofer				BC - NC / NIHB - Covered	Total Dose (mg/tab or 5mL): 20 mg/ml Elemental Iron (mg/tab or 5mL): As dir 90 Day Cost (100 mg elemental iron/day): $140	M 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	M Iron Preparations	Iron Preparations
Ferric Derisomaltose	Monoferric				BC - SA / NIHB - Covered	Total Dose (mg/tab or 5mL): 100 mg/ml Elemental Iron (mg/tab or 5mL): As dir 90 Day Cost (100 mg elemental iron/day): $225	M 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	M 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	M 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	M Iron Preparations	Iron Preparations
Mometasone Furoate	Elocom	0.10%	As dir	$35	BC / NIHB - Covered		L Topicals	Topical Corticosteroids Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.
Betamethasone Dipropionate	Diprosone	0.05%	As dir	$20	BC / NIHB - Covered		L Topicals	Topical Corticosteroids Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.
Clobetasol 17-propionate	Dermovate	0.05%	As dir	$20	BC / NIHB - Covered		L Topicals	Topical Corticosteroids Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.
Hydrocortisone	Cortate	1.00%	As dir	$20	BC / NIHB - Covered		L Topicals	Topical Corticosteroids Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.
Betamethasone Valerate	Betaderm/Betnovate	0.10%	As dir	$15	BC / NIHB - Covered		L Topicals	Topical Corticosteroids Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases.
Tacrolimus	Protopic (30g tube)	0.03%	As dir	$100	BC - SA / NIHB - Covered		L Topicals	Miscellaneous Topicals
Betamethasone/Calcipotriol	Dovobet (60g tube)	0.05/0.005%	As dir	$100	BC / NIHB - Covered		L Topicals	Miscellaneous Topicals
Imiquimod	Aldara (24x250mg)	5%	As dir	$310	BC - SA / NIHB - Covered		L Topicals	Miscellaneous Topicals
Isopropyl Myristate	Resultz	50%	As dir	$35	BC / NIHB - Covered		L Topicals	Lice
Pyrethrins/Piperonyl Butoxide	R&C	0.33%/3%	As dir	$25	BC / NIHB - Covered		L Topicals	Lice
Dimethicone	Nyda	50%	As dir	$40	BC / NIHB - Covered		L Topicals	Lice
Permethrin	Nix	1%	As dir	$25	BC / NIHB - Covered		L Topicals	Lice
Adapalene/Benzoyl Peroxide	TactuPump Forte (70g tube)	0.3%/2.5%	As dir	$165	BC - NC / NIHB - Covered		L Topicals	Acne Treatments
Adapalene	Differin (60g tube)	0.10%	As dir	$235	BC - NC / NIHB - Covered		L Topicals	Acne Treatments
Benzoyl Peroxide/Clindamycin	Clindoxyl (45g tube)	5%/1%	As dir	$50	BC - SA / NIHB - Covered		L Topicals	Acne Treatments
Isotretinoin	Accutane	40 mg	QD x 90 days	$205	BC / NIHB - Covered		L Topicals	Acne Treatments
Denosumab	Stoboclo	60 mg SQ every 6 months		$120	BC / NIHB - SA		O Miscellaneous	Osteoporosis
Denosumab	Jubbonti	60 mg SQ every 6 months		$120	BC / NIHB - SA		O Miscellaneous	Osteoporosis
Denosumab	Prolia	60 mg SQ every 6 months		$255	BC / NIHB - NC		O Miscellaneous	Osteoporosis
Alendronate	Fosamax	70 mg once weekly		$40	BC / NIHB - Covered		O Miscellaneous	Osteoporosis
Teriparatide	Forteo	20 mcg SQ	QD	$1935	BC - NC / NIHB - SA		O Miscellaneous	Osteoporosis
Risedronate	Actonel	35 mg once weekly		$35	BC / NIHB - Covered		O Miscellaneous	Osteoporosis
Zoledronic Acid	Aclasta	5 mg yearly		$120	BC / NIHB - SA		O Miscellaneous	Osteoporosis
Galantamine ER	Reminyl ER	16 mg	QD	$140	BC / NIHB - SA		O Miscellaneous	Dementia
Rivastigmine	Exelon	3 mg	BID	$145	BC / NIHB - SA		O Miscellaneous	Dementia
Memantine	Ebixa	10 mg	QD	$185	BC - NC / NIHB - SA		O Miscellaneous	Dementia
Donepezil	Aricept	5 mg	QD	$60	BC / NIHB - SA		O Miscellaneous	Dementia
Itraconazole	Sporanox	2x100 mg QD		$795	BC / NIHB - Covered		O Miscellaneous	Antifungals Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Cicloporox	Penlac	Nail lacquer; price for 6 g		$70	BC / NIHB - NC		O Miscellaneous	Antifungals Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Terbinafine	Lamisil	250 mg QD		$85	BC / NIHB - Covered		O Miscellaneous	Antifungals Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Efinaconazole	Jublia	Nail lacquer; price for 8ml		$135	BC / NIHB - NC		O Miscellaneous	Antifungals Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Fluconazole	Diflucan	150 mg once weekly		$65	BC / NIHB - Covered		O Miscellaneous	Antifungals Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Azithromycin	Zithromax	250 mg x 4 days		$20	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Fosfomycin	Monurol	3 g as a single dose		$30	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Nitrofurantoin	Macrobid	100 mg BID x 3 days		$15	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Cephalexin	Keflex	500 mg QID x 7 days		$20	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Doxycycline	Doxycycline	100 mg QD x 7 days		$20	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Amoxicillin/Clavulanate	Clavulin	500 mg TID x 7 days		$25	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Ciprofloxacin	Cipro	500 mg BID x 5 days		$20	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Clarithromycin	Biaxin	2x250 mg BID x 5 days		$25	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Amoxicillin	Amoxil	500 mg TID x 7 days		$15	BC / NIHB - Covered		O Miscellaneous	Antibiotics
Diclofenac	Voltaren SR	75 mg	BID	$165	BC / NIHB - Covered		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Naproxen/Esomeprazole	Vimovo	500 mg/20 mg	BID	$205	BC / NIHB - NC		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Ketorolac	Toradol	10 mg	BID	$50	BC / NIHB - Covered		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Naproxen	Naproxen	500 mg	BID	$105	BC / NIHB - Covered		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Celecoxib	Celebrex	200 mg	QD	$40	BC / NIHB - Covered		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Diclofenac/Misoprostol	Arthrotec	75 mg/200 mcg	BID	$100	BC / NIHB - Covered		K Analgesics	Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Duloxetine	Cymbalta	30 mg, 60 mg	QD	$85	BC / NIHB - Covered		K Analgesics	Neuropathic or Chronic Pain
Gabapentin	Neurontin	300 mg	TID	$45	BC / NIHB - Covered		K Analgesics	Neuropathic or Chronic Pain
Pregabalin	Lyrica	50 mg	HS	$35	BC / NIHB - Covered		K Analgesics	Neuropathic or Chronic Pain
Amitriptyline	Elavil	10 mg, 25 mg	HS	$20	BC / NIHB - Covered		K Analgesics	Neuropathic or Chronic Pain
Tramadol/Acetaminophen	Tramacet	37.5 mg/325 mg	PRN	$80	BC - NC / NIHB - SA	90 tablets	K Analgesics	Miscellaneous Analgesics
Allopurinol	Zyloprim	200 mg	QD	$25	BC / NIHB - Covered		K Analgesics	Gout
Colchicine	Colchicine	0.6 mg	QD	$40	BC / NIHB - Covered		K Analgesics	Gout
Zolmitriptan	Zomig	2.5 mg	PRN	$40	BC / NIHB - Covered	12 Tablets / 30 Days	K Analgesics	Anti-Migraine
Topiramate	Topamax	100 mg	QD	$60	BC / NIHB - Covered		K Analgesics	Anti-Migraine
Sumatriptan	Imitrex	100 mg	PRN	$35	BC / NIHB - Covered	12 Tablets / 30 Days	K Analgesics	Anti-Migraine
Testosterone Cypionate	Depo-Testosterone	100 mg/mL	200 mg Q2W	$60	BC / NIHB - Covered		J Urology	Testosterone Replacement
Testosterone Enanthate	Delatestryl	200 mg/mL	400 mg Q30D	$60	BC / NIHB - Covered		J Urology	Testosterone Replacement
Testosterone Gel	Androgel	5 g	QD	$480	BC - NC / NIHB - SA		J Urology	Testosterone Replacement
Testosterone Undecanoate	Andriol	40 mg	BID	$125	BC - SA / NIHB - Covered		J Urology	Testosterone Replacement
Sildenafil	Viagra	50 mg, 100 mg	As dir	$55	BC / NIHB - NC		J Urology	Erectile Dysfunction 4 tablets; may split tablet for lower dose to save costs
Vardenafil	Levitra	20 mg	As dir	$70	BC / NIHB - NC		J Urology	Erectile Dysfunction 4 tablets; may split tablet for lower dose to save costs
Tadalafil	Cialis	20 mg	As dir	$70	BC / NIHB - NC		J Urology	Erectile Dysfunction 4 tablets; may split tablet for lower dose to save costs
Finasteride	Proscar	5 mg	QD	$50	BC / NIHB - Covered		J Urology	Benign Prostatic Hyperplasia (BPH)
Terazosin	Hytrin	2 mg	QD	$65	BC / NIHB - Covered		J Urology	Benign Prostatic Hyperplasia (BPH)
Tamsulosin CR	Flomax CR	0.4 mg	QD	$30	BC / NIHB - Covered		J Urology	Benign Prostatic Hyperplasia (BPH)
Dutasteride	Avodart	0.5 mg	QD	$40	BC / NIHB - Covered		J Urology	Benign Prostatic Hyperplasia (BPH)
Micronized Progesterone	Prometrium	100 mg	HS	$50	BC / NIHB - Covered		P Menopause Hormone Therapy	Oral
Medroxyprogesterone	Provera	5 mg	QD	$40	BC / NIHB - Covered		P Menopause Hormone Therapy	Oral
Estradiol-17β Vaginal Tablet	Vagifem-10	10 mcg	Twice weekly	$145	BC / NIHB - Covered		P Menopause Hormone Therapy	Vaginal
Estradiol-17β Vaginal Tablet	Imvexxy	4 mcg, 10 mcg	Twice weekly	$110	BC / NIHB - Covered		P Menopause Hormone Therapy	Vaginal
Estradiol-17β Patch	Estradot/Oesclim	50 mcg	Twice weekly	$85	BC / NIHB - Covered		P Menopause Hormone Therapy	Transdermal
Estradiol-17β Gel	Estrogel	2.5 g gel = 1.5 mg estradiol	QD	$110	BC / NIHB - Covered		P Menopause Hormone Therapy	Transdermal
Estradiol-17β	Estrace	1 mg	QD	$35	BC / NIHB - Covered		P Menopause Hormone Therapy	Oral
Conjugated Estrogens	Premarin Vaginal Cr	0.625 mg	QD	$100	BC / NIHB - Covered		P Menopause Hormone Therapy	Vaginal
Conjugated Estrogens	Premarin	0.3 mg, 0.625 mg	QD	$55	BC / NIHB - Covered		P Menopause Hormone Therapy	Oral
Medroxyprogesterone	Depo-Provera	Intramuscular	Q 3 months	$50	BC / NIHB - Covered		H 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.	Injectable
Etonogestrel implant	Nexplanon	Hormonal implant	One time insertion	$20	BC / NIHB - Covered	Upfront cost is $353 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $18 every 90 days	H 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.	Hormonal implant
Etonogestrel	Nuvaring	Vaginal ring	As dir	$65	BC - NC / NIHB - Covered		H 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	$105	BC - NC / NIHB - Covered		H 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	$25	BC / NIHB - Covered	Upfront cost is $431 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $22 every 90 days	H 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 $404 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days	H 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		H 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 Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.
Drospirenone	Yasmin		QD	$60	BC / NIHB - Covered		H 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 Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.
Norgestimate	Tri-Cyclen		QD	$65	BC / NIHB - Covered		H 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	$35	BC / NIHB - Covered		H 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		H 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	$100	BC - NC / NIHB - Covered		H 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 / NIHB - Covered		H 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	$30	BC / NIHB - Covered		H 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		H 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 Acetate	Lolo		QD	$85	BC - NC / NIHB - Covered		H 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	$85	BC - Restricted / NIHB - Covered		G Psychiatry	Stimulants (ADHD)
Methylphenidate	Biphentin	10 mg	QD	$65	BC - Restricted / NIHB - SA		G Psychiatry	Stimulants (ADHD)
Methylphenidate	Ritalin	10 mg	BID	$60	BC / NIHB - Covered		G Psychiatry	Stimulants (ADHD)
Methylphenidate	Concerta	36 mg	QD	$150	BC - Restricted / NIHB - Covered		G Psychiatry	Stimulants (ADHD)
Amphetamines, Mixed Salts	Adderall XR	10 mg	QD	$75	BC - Restricted / NIHB - Covered		G Psychiatry	Stimulants (ADHD)
Zolpidem Tartrate	Sublinox	5 mg, 10 mg	PRN	$135	BC / NIHB - NC	90 tablets	G Psychiatry	Anxiolytic Sedative
Lemborexant	Dayvigo	5 mg, 10 mg	HS	$200	BC / NIHB - NC		G Psychiatry	Anxiolytic Sedative
Temazepam	Restoril	30 mg	PRN	$45	BC / NIHB - Covered	90 tablets	G Psychiatry	Anxiolytic Sedative
Zopiclone	Imovane	7.5 mg	PRN	$25	BC - Covered / NIHB - NC	90 tablets	G Psychiatry	Anxiolytic Sedative
Trazodone	Desyrel	50 mg	PRN	$20	BC / NIHB - Covered	90 tablets	G Psychiatry	Anxiolytic Sedative
Lorazepam	Ativan	1 mg	PRN	$20	BC / NIHB - Covered	90 tablets	G Psychiatry	Anxiolytic Sedative
Olanzapine	Zyprexa	5 mg, 10 mg	QD	$85	BC / NIHB - Covered		G Psychiatry	Antipsychotics
Quetiapine	Seroquel XR	300 mg	QD	$110	BC / NIHB - Covered		G Psychiatry	Antipsychotics
Quetiapine	Seroquel	25 mg	HS	$20	BC / NIHB - Covered		G Psychiatry	Antipsychotics
Risperidone	Risperdal	1 mg	QD	$35	BC / NIHB - Covered		G Psychiatry	Antipsychotics
Aripiprazole	Abilify	15 mg	QD	$140	BC - Restricted / NIHB - Covered		G Psychiatry	Antipsychotics
Sertraline	Zoloft	50 mg	QD	$45	BC / NIHB - Covered		G Psychiatry	Antidepressants
Bupropion	Wellbutrin XL	150 mg	QD	$45	BC / NIHB - Covered		G Psychiatry	Antidepressants
Vortioxetine	Trintellix	20 mg	QD	$195	BC / NIHB - Covered		G Psychiatry	Antidepressants
Mirtazapine	Remeron	30 mg	HS	$35	BC / NIHB - Covered		G Psychiatry	Antidepressants
Fluoxetine	Prozac	20 mg	QD	$45	BC / NIHB - Covered		G Psychiatry	Antidepressants
Desvenlafaxine	Pristiq	50 mg	QD	$255	BC - NC / NIHB - SA		G Psychiatry	Antidepressants
Paroxetine	Paxil	20 mg	QD	$45	BC / NIHB - Covered		G Psychiatry	Antidepressants
Venlafaxine	Effexor XR	75 mg	QD	$30	BC / NIHB - Covered		G Psychiatry	Antidepressants
Duloxetine	Cymbalta	30 mg	QD	$50	BC / NIHB - Covered		G Psychiatry	Antidepressants
Escitalopram	Cipralex	10 mg	QD	$45	BC / NIHB - Covered		G Psychiatry	Antidepressants
Citalopram	Celexa	20 mg	QD	$25	BC / NIHB - Covered		G Psychiatry	Antidepressants
Pantoprazole Magnesium	Tecta	40 mg	QD	$35	BC / NIHB - Covered		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Lansoprazole	Prevacid	30 mg	QD	$65	BC / NIHB - Covered		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Rabeprazole	Pariet	10 mg, 20 mg	QD	$20	BC / NIHB - Covered		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Esomeprazole	Nexium	40 mg	QD	$210	BC - NC / NIHB - SA		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Omeprazole	Losec	20 mg	QD	$35	BC / NIHB - Covered		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Dexlansoprazole	Dexilant	30 mg	QD	$245	BC / NIHB - NC		F Gastrointestinal	Proton Pump Inhibitors (PPIs) Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
PEG3350	Restoralax/Lax-A-Day	17 g	QD	$55	BC - NC/ NIHB - Covered		F Gastrointestinal	Laxatives
Lactulose	Lactulose	1 tbsp	QD	$35	BC / NIHB - Covered		F Gastrointestinal	Laxatives
Ranitidine	Zantac	150 mg	BID	$40	BC / NIHB - Covered		F Gastrointestinal	Histamine-2 Receptor Antagonists (H2RAs)
Pantoprazole Magnesium	Tecta	40 mg	BID x 14d		BC / NIHB - Covered		F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) All HP regimens covered
Metronidazole	Flagyl	500 mg	BID x 14d		BC / NIHB - Covered		F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) All HP regimens covered
Clarithromycin	Biaxin	2x250 mg	BID x 14d		BC / NIHB - Covered		F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) All HP regimens covered
Amoxicillin	Amoxil	1 g	BID x 14d	$95	BC / NIHB - Covered		F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) All HP regimens covered
Pyridoxine (Vitamin B6)	Pyridoxine	25 mg	PRN	$5	BC - NC/ NIHB - Covered		F Gastrointestinal	Antiemetics 30 tablets
Ondansetron	Zofran	8mg	PRN	$145	BC / NIHB - Covered		F Gastrointestinal	Antiemetics 30 tablets
Metoclopramide	Maxeran	2x5 mg	PRN	$15	BC / NIHB - Covered		F Gastrointestinal	Antiemetics 30 tablets
Dimenhydrinate	Gravol	50 mg	PRN	$15	BC / NIHB - Covered		F Gastrointestinal	Antiemetics 30 tablets
Doxylamine/Pyridoxine	Diclectin	10 mg/10 mg	PRN	$25	BC / NIHB - Covered		F Gastrointestinal	Antiemetics 30 tablets
Fluticasone furoate/Umeclidinium/Vilanterol	Trelegy Ellipta (30)	100/62.5/25 mcg	1 pf qd	$470	BC - SA / NIHB - Covered		E Respiratory	Long-acting beta-agonist/long acting muscarinic antagonist/Corticosteroid Combos
Montelukast	Singulair	10 mg	QD	$55	BC - Restricted / NIHB - Covered		E Respiratory	Leukotriene Receptor Antagonist
Budesonide/Formoterol	Symbicort (120)	200/6 mcg	1 pf qd	$180	BC / NIHB - SA		E Respiratory	Long-acting beta-agonist/Corticosteroid Combos
Fluticasone/Vilanterol	Breo Ellipta (30)	100/25 mcg	1 pf qd	$340	BC / NIHB - SA		E Respiratory	Long-acting beta-agonist/Corticosteroid Combos
Fluticasone/Salmeterol	Advair MDI (120)	250/25 mcg	1 pf bid	$290	BC / NIHB - SA		E Respiratory	Long-acting beta-agonist/Corticosteroid Combos
Fluticasone/Salmeterol	Advair Diskus (60)	250/50 mcg	1 pf bid	$180	BC / NIHB - SA		E Respiratory	Long-acting beta-agonist/Corticosteroid Combos
Glycopyrronium/Indacaterol	Ultibro (30)	50/110 mcg	1 pf qd	$270	BC / NIHB - Covered		E Respiratory	Long-acting Anti-cholinergic/Long-acting Beta-agonist Combos 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.
Beclomethasone	Qvar (200)	100 mcg	1 pf bid	$85	BC / NIHB - Covered		E Respiratory	Corticosteroids 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.
Budesonide	Pulmicort (200)	200 mcg	1 pf bid	$90	BC / NIHB - Covered		E Respiratory	Corticosteroids 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.
Fluticasone	Flovent (120)	250 mcg	1 pf bid	$90	BC / NIHB - Covered		E Respiratory	Corticosteroids 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.
Fluticasone	Flovent (120)	125 mcg	1 pf bid	$55	BC / NIHB - Covered		E Respiratory	Corticosteroids 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.
Salbutamol	Ventolin (200)	100 mcg	4 pfs/d	$25	BC / NIHB - Covered		E Respiratory	Bronchodilators / Anti-cholingergics 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.
Tiotropium	Spiriva (30)	18 mcg	1 pf qd	$105	BC / NIHB - Covered		E Respiratory	Bronchodilators / Anti-cholingergics 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.
Glycopyrronium	Seebri (30)	50 mcg	1 pf qd	$195	BC / NIHB - Covered		E Respiratory	Bronchodilators / Anti-cholingergics 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.
Ipratropium	Atrovent (200)	200 mcg	1 pf qid	$35	BC / NIHB - Covered		E Respiratory	Bronchodilators / Anti-cholingergics 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.
Ciclesonide	Alvesco (120)	100 mcg, 200 mcg	2 pf qd	$160	BC / NIHB - Covered		E Respiratory	Adrenals
Bupropion	Zyban	150 mg	BID	$250	BC / NIHB - Covered		D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Smoking Cessation
Bupropion	Wellbutrin SR	150 mg	BID	$195	BC / NIHB - Covered		D 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		$100	BC - Restricted / NIHB - Covered	Quantity limits	D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Smoking Cessation
Nortriptyline	Aventyl	25 mg	3 HS	$210	BC / NIHB - Covered		D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Smoking Cessation
Nicotine Inhaler	Nicorette	Cartridges	6 ctgs/d	$505	BC - Restricted / NIHB - Covered	Lifetime $ limit	D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Nicotine Replacement Therapy
Nicotine Gum	Nicorette	2 mg, 4 mg	12 pcs/d	$405	BC - Restricted / NIHB - Covered	Lifetime $ limit	D 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	D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Nicotine Replacement Therapy
Tirzepatide	Zepbound	10 mg SQ	Once weekly	$1125	BC / NIHB - NC		C Obesity	Obesity
Naltrexone	Contrave	16 mg/180 mg	BID	$1010	BC / NIHB - NC		C Obesity	Obesity
Semaglutide	Wegovy	2.4 mg SQ	Once weekly	$1515	BC / NIHB - NC		C Obesity	Obesity
Semaglutide	Ozempic	2.4 mg SQ	Once weekly	$455	NC for weight management	Must titrate to 2.4 mg dose	C Obesity	Obesity
Orlistat	Xenical	120 mg	TID	$620	BC / NIHB - NC		C Obesity	Obesity
Liraglutide	Saxenda	3 mg SQ	QD	$1515	BC / NIHB - NC		C Obesity	Obesity
Glyburide	Diabeta	5 mg	BID	$25	BC / NIHB - Covered		B Hypoglycemic Agents	Sulfonylureas
Gliclazide MR	Diamicron MR	30 mg MR	2 QD	$35	BC / NIHB - Covered		B Hypoglycemic Agents	Sulfonylureas
Gliclazide	Diamicron	80 mg	BID	$35	BC / NIHB - Covered		B Hypoglycemic Agents	Sulfonylureas
Empagliflozin	Jardiance	10 mg, 25 mg	QD	$295	BC - SA / NIHB - Covered		B Hypoglycemic Agents	Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Dapagliflozin Propanediol Monohydrate	Forxiga	10 mg	QD	$80	BC / NIHB - Covered		B Hypoglycemic Agents	Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Canagliflozin	Invokana	100 mg	QD	$295	BC - SA / NIHB - Covered		B Hypoglycemic Agents	Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Rapid-acting insulin biosimilars	Trurapi	100 U/ml	As dir	$65	BC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Rapid-acting insulin biosimilars	Admelog	100 U/ml	As dir	$65	BC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Rapid-acting insulin	Novorapid	100 U/ml	As dir	$90	BC - NC / NIHB - SA		B Hypoglycemic Agents	Insulin 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).
Rapid-acting insulin	Humalog	100 U/ml	As dir	$105	BC - NC / NIHB - SA		B Hypoglycemic Agents	Insulin 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).
Rapid-acting insulin	Apidra	100 U/ml	As dir	$80	BC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Basal insulin biosimilar (Glargine)	Basaglar	100 U/ml	As dir	$100	BC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Basal insulin (Glargine)	Toujeo	300 U/ml	As dir	$115	BC - NC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Basal insulin (Glargine)	Lantus	100 U/ml	As dir	$120	BC - NC / NIHB - SA		B Hypoglycemic Agents	Insulin 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).
Basal insulin (Degludec)	Tresiba	100 U/ml	As dir	$145	BC / NIHB - Covered		B Hypoglycemic Agents	Insulin 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).
Liraglutide	Victoza	1.8 mg SQ	QD	$1135	BC / NIHB - NC		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Liraglutide	Victoza	1.2 mg SQ	QD	$765	BC / NIHB - NC		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Semaglutide	Ozempic	1 mg SQ	Once weekly	$200	BC / NIHB - SA		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Tirzepatide	Mounjaro	5 mg SQ	Once weekly	$290	BC / NIHB - NC		B Hypoglycemic Agents	Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Sitagliptin	Januvia	100 mg	QD	$95	BC - SA / NIHB - Covered		B Hypoglycemic Agents	Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Linagliptin	Trajenta	5 mg	QD	$285	BC / NIHB - SA		B Hypoglycemic Agents	Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Metformin SR	Glumetza SR	1000 mg	2 QD	$290	BC - NC / NIHB - SA		B Hypoglycemic Agents	Biguanides
Metformin	Glucophage	500 mg	2 BID	$25	BC / NIHB - Covered		B Hypoglycemic Agents	Biguanides
Sacubitril/Valsartan	Entresto	97 mg/103 mg	BID	$380	BC / NIHB - SA		A Cardiovascular	Neprilysin Inhibitor / ARB Combos
Evolocumab	Repatha	140 mg SQ	Q2W	$1920	BC / NIHB - SA		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Alirocumab	Praluent	75 mg x Q2W SQ	Q2W	$1925	BC / NIHB - SA		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Ezetimibe	Ezetrol	10 mg	QD	$30	BC / NIHB - Covered		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Simvastatin	Zocor	10 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Pravastatin	Pravachol	20 mg	QD	$50	BC / NIHB - Covered		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Atorvastatin	Lipitor	10 mg	QD	$30	BC / NIHB - Covered		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Rosuvastatin	Crestor	10 mg, 20 mg	QD	$30	BC / NIHB - Covered		A Cardiovascular	Lipid Lowering Agents Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Indapamide	Lozide	2.5 mg	QD	$40	BC / NIHB - Covered		A Cardiovascular	Diuretics Same qualifier for MAC pricing as ACE: All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf
Furosemide	Lasix	20 mg, 40 mg	QD	$15	BC / NIHB - Covered		A Cardiovascular	Diuretics Same qualifier for MAC pricing as ACE: All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf
Chlorthalidone	Hygroton	12.5 mg, 25 mg, 50 mg	QD	$25	BC / NIHB - Covered		A Cardiovascular	Diuretics Same qualifier for MAC pricing as ACE: All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf
Hydrochlorothiazide	Hydrodiuril	12.5 mg, 25 mg	QD	$15	BC / NIHB - Covered		A Cardiovascular	Diuretics Same qualifier for MAC pricing as ACE: All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf
Spironolactone	Aldactone	25 mg, 100 mg	QD	$25	BC / NIHB - Covered		A Cardiovascular	Diuretics Same qualifier for MAC pricing as ACE: All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf
Diltiazem	Tiazac	240 mg	QD	$50	BC / NIHB - Covered		A Cardiovascular	Calcium Channel Blockers Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Amlodipine	Norvasc	5 mg, 10 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	Calcium Channel Blockers Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Nifedipine	Adalat XL	30 mg	QD	$75	BC / NIHB - Covered		A Cardiovascular	Calcium Channel Blockers Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Atenolol	Tenormin	50 mg	QD	$25	BC / NIHB - Covered		A Cardiovascular	Beta Blockers
Bisoprolol	Monocor	10 mg	QD	$25	BC / NIHB - Covered		A Cardiovascular	Beta Blockers
Metoprolol-SR	Lopresor SR	100 mg, 200 mg	QD	$50	BC / NIHB - Covered		A Cardiovascular	Beta Blockers
Metoprolol	Lopresor	25 mg, 50 mg	BID	$25	BC / NIHB - Covered		A Cardiovascular	Beta Blockers
Clopidogrel	Plavix	75 mg	QD	$40	BC / NIHB - Covered		A Cardiovascular	Anti-Platelet
Ticagrelor	Brilinta	90 mg	BID	$95	BC - Restricted / NIHB - Covered		A Cardiovascular	Anti-Platelet
Rivaroxaban	Xarelto	2.5 mg	BID	$85	BC / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Rivaroxaban	Xarelto	15 mg, 20 mg	QD	$85	BC / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Dabigatran	Pradaxa	110 mg, 150 mg	BID	$265	BC - SA / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Edoxaban	Lixiana	60 mg	QD	$85	BC - SA / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Apixaban	Eliquis	5 mg	BID	$95	BC / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Warfarin	Coumadin	5 mg	QD	$20	BC / NIHB - Covered		A Cardiovascular	Anti-Coagulant
Telmisartan	Micardis	80 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	Angiotensin Receptor Blockers
Valsartan	Diovan	80 mg, 160 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	Angiotensin Receptor Blockers
Losartan	Cozaar	50 mg	QD	$30	BC / NIHB - Covered		A Cardiovascular	Angiotensin Receptor Blockers
Candesartan	Atacand	8 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	Angiotensin Receptor Blockers
Lisinopril	Zestril	20 mg	QD	$35	BC / NIHB - Covered		A Cardiovascular	ACE Inhibitors All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Enalapril	Vasotec	10 mg	QD	$40	BC / NIHB - Covered		A Cardiovascular	ACE Inhibitors All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Perindopril/Indapamide	Coversyl Plus	4 mg/1.25 mg	QD	$40	BC / NIHB - Covered		A Cardiovascular	ACE Inhibitors All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Perindopril	Coversyl	4 mg, 8 mg	QD	$40	BC / NIHB - Covered		A Cardiovascular	ACE Inhibitors All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Ramipril	Altace	5 mg, 10 mg	QD	$25	BC / NIHB - Covered		A Cardiovascular	ACE Inhibitors All have HCTZ combo products that are similar in price to the single entity product. Maximum Allowable Cost (MAC) pricing exists for ACE Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.

Legend:

BC = Alberta Blue Cross, NIHB = Non-Insured Health Benefits for First Nations and Inuit, NC = Not covered, SA = special authorization