Clickable Table
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. |
N 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. |
N Opioid Dependency | Opioid Dependency | |||
Methadone | Methadose | BC / NIHB - Covered |
Daily Dose: 60-120 mg Dispensing Frequency: Every 2 weeks Cost of 2 Week Supply: $20 Doses individualized, cost of 2 week supply based on highest daily dose. |
N Opioid Dependency | Opioid Dependency | |||
Methadone | Methadose | BC / NIHB - Covered |
Daily Dose: 60-120 mg Dispensing Frequency: Daily Cost of 2 Week Supply: $75 Doses individualized, cost of 2 week supply based on highest daily dose. |
N 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 |
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 | |||
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 |
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 | |||
Ferrous Sulphate | Generic adult susp | BC - Restricted / 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 |
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 |
Price is for a 30 g tube of cream; since majority of price is from dispensing fee, large quantities cause small price increases. |
L 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. |
L 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. |
L 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. |
L Topicals | Topical Corticosteroids |
Clobetasol 17-propionate | 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. |
L 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. |
L 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. |
L 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. |
L Topicals | Topical Corticosteroids |
Tacrolimus | Protopic (30g tube) | 0.03% | As dir | $95 | BC / NIHB - SA | 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 | $300 | 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 | |
Tretinoin Cream | Stieva-A (25g tube) | 0.03% | As dir | $25 | BC - SA / NIHB - Covered | L Topicals | Acne Treatments | |
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 | $215 | 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 | Prolia | 60 mg SQ every 6 months | $245 | BC / NIHB - SA | O Miscellaneous | Osteoporosis | ||
Alendronate | Fosamax | 70 mg once weekly | $40 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
Teriparatide | Forteo | 20 mcg SQ | QD | $1935 | BC / NIHB - NC | O Miscellaneous | Osteoporosis | |
Risedronate | Actonel | 35 mg once weekly | $35 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
Zoledronic Acid | Aclasta | 5 mg yearly | $110 | 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 x 12 weeks | $795 | BC / NIHB - Covered |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
Cicloporox | Penlac | Nail lacquer; price for 6 g | $70 | BC / NIHB - NC |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
Terbinafine | Lamisil | 250 mg QD x 12 weeks | $85 | BC / NIHB - Covered |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
Efinaconazole | Jublia | Nail lacquer; price for 8ml | $125 | BC / NIHB - NC |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
Fluconazole | Diflucan | 150 mg once weekly x 12 weeks | $65 | BC / NIHB - Covered |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
Azithromycin | Zithromax | 250 mg x 4 days | $20 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Fosfomycin | Monurol | 3 g as a single dose (uncomplicated UTI) | $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 - SA / NIHB Covered | O Miscellaneous | Antibiotics | ||
Clarithromycin | Biaxin | 2x250 mg BID x 5 days | $25 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Moxifloxacin | Avelox | 400 mg QD x 7 days | $25 | BC - SA / 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 | $105 | 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 | $55 | BC / NIHB - Covered | K Analgesics | Non-Steroidal Antiinflammatory Drugs (NSAIDs) | |
Celecoxib | Celebrex | 200 mg | QD | $40 | BC - SA / 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) | |
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 | 25 mg | HS | $25 | BC / NIHB - Covered | K Analgesics | Neuropathic or Chronic Pain | |
Amitriptyline | Elavil | 10 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 - Restricted / NIHB - Covered |
6 tablets |
K Analgesics | Anti-Migraine |
Topiramate | Topamax | 100 mg | QD | $60 | BC / NIHB - Covered | K Analgesics | Anti-Migraine | |
Sumatriptan | Imitrex | 100 mg | PRN | $35 | BC - Restricted / NIHB - Covered |
6 tablets |
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 | $80 | BC / NIHB - Covered | J Urology | Testosterone Replacement | |
Testosterone Gel | Androgel | 5 g | QD | $470 | BC - NC / NIHB - SA | J Urology | Testosterone Replacement | |
Testosterone Undecanoate | Andriol | 40 mg | BID | $105 | BC - SA / NIHB - Covered | J 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 |
J Urology | Erectile Dysfunction |
Vardenafil | Levitra | 20 mg | As dir | $70 | BC / NIHB - NC |
4 tablets; may split tablet for lower dose to save costs |
J Urology | Erectile Dysfunction |
Tadalafil | Cialis | 20 mg | As dir | $70 | BC / NIHB - NC |
4 tablets; may split tablet for lower dose to save costs |
J Urology | Erectile Dysfunction |
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) | |
Estradiol-17β Vaginal Tablet | Vagifem-10 | 10 mcg | Twice weekly | $140 | BC / NIHB - Covered | I Hormone Replacement Therapy | Vaginal | |
Conjugated Estrogens | Premarin Vaginal Cr | 0.625 mg | QD | $95 | BC / NIHB - Covered | I Hormone Replacement Therapy | Vaginal | |
Estradiol-17β Gel | Estrogel | 2.5 g gel = 1.5 mg estradiol | QD | $105 | BC / NIHB - Covered | I Hormone Replacement Therapy | Transdermal | |
Estradiol-17β Patch | Estradot/Oesclim | 50 mcg | Twice weekly | $85 | BC / NIHB - Covered | I Hormone Replacement Therapy | Transdermal | |
Medroxyprogesterone | Provera | 5 mg | QD | $40 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Micronized Progesterone | Prometrium | 100 mg | HS | $50 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Conjugated Estrogens | Premarin | 0.625 mg | QD | $55 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Estradiol-17β | Estrace | 1 mg | QD | $35 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
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 | $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.
|
Transdermal / Vaginal | |
Levonorgestrel | Mirena | IUD | As dir | $25 | BC / NIHB - Covered |
Upfront cost is $422 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $21 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 $396 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 |
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free 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.
|
Anti-Androgenic | |
Drospirenone | Yasmin | QD | $60 | BC / NIHB - Covered |
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free 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.
|
Anti-Androgenic | |
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 | $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.
|
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 | $95 | 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 AcetateLolo | 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 | $295 | BC - Restricted / NIHB - Covered | G Psychiatry | Stimulants (ADHD) | |
Methylphenidate | Ritalin | 10 mg | BID | $60 | BC / NIHB - Covered | G Psychiatry | Stimulants (ADHD) | |
Methylphenidate | Concerta | 36 mg | QD | $445 | BC - Restricted / NIHB - Covered | G Psychiatry | Stimulants (ADHD) | |
Amphetamines, Mixed Salts | Adderall XR | 10 mg | QD | $295 | BC - Restricted / NIHB - Covered | G Psychiatry | Stimulants (ADHD) | |
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 | $340 | 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 |
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf. |
F 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/MAC-pricing-categories.pdf. |
F 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/MAC-pricing-categories.pdf. |
F 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/MAC-pricing-categories.pdf. |
F 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/MAC-pricing-categories.pdf. |
F Gastrointestinal | Proton Pump Inhibitors (PPIs) |
Dexlansoprazole | Dexilant | 30 mg | QD | $225 | BC / NIHB - NC |
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf. |
F Gastrointestinal | Proton Pump Inhibitors (PPIs) |
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 |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
Metronidazole | Flagyl | 500 mg | BID x 14d | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
Clarithromycin | Biaxin | 2x250 mg | BID x 14d | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
Amoxicillin | Amoxil | 1 g | BID x 14d | $95 | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) |
Pyridoxine | Pyridoxine | 25 mg | PRN | $5 | BC - NC/ NIHB - Covered |
30 tablets |
F Gastrointestinal | Antiemetics |
Ondansetron | Zofran | 8mg | PRN | $145 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
Metoclopramide | Maxeran | 2x5 mg | PRN | $20 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
Dimenhydrinate | Gravol | 50 mg | PRN | $15 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
Doxylamine/Pyridoxine | Diclectin | 10 mg/10 mg | PRN | $35 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
Budesonide/Formoterol | Symbicort (120) | 200/6 mcg | 1 pf qd | $175 | BC / NIHB - 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. |
E Respiratory | Long-acting beta-agonist/Corticosteroid Combos |
Fluticasone/Vilanterol | Breo Ellipta (30) | 100/25 mcg | 1 pf qd | $325 | BC / NIHB - 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. |
E Respiratory | Long-acting beta-agonist/Corticosteroid Combos |
Fluticasone/Salmeterol | Advair MDI (120) | 250/25 mcg | 1 pf bid | $280 | BC / NIHB - 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. |
E Respiratory | Long-acting beta-agonist/Corticosteroid Combos |
Fluticasone/Salmeterol | Advair Diskus (60) | 250/50 mcg | 1 pf bid | $180 | BC / NIHB - 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. |
E Respiratory | Long-acting beta-agonist/Corticosteroid Combos |
Glycopyrronium/Indacaterol | Ultibro (30) | 50/110 mcg | 1 pf qd | $270 | BC - SA / NIHB - 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. |
E Respiratory | Long-acting Anti-cholinergic/Long-acting Beta-agonist Combos |
Montelukast | Singulair | 10 mg | QD | $55 | BC - SA / NIHB - 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. |
E Respiratory | Leukotriene Receptor Antagonist |
Beclomethasone | Qvar (200) | 100 mcg | 1 pf bid | $85 | BC / NIHB - 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. |
E Respiratory | Corticosteroids |
Budesonide | Pulmicort (200) | 200 mcg | 1 pf bid | $85 | BC / NIHB - 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. |
E Respiratory | Corticosteroids |
Fluticasone | Flovent (120) | 250 mcg | 1 pf bid | $90 | BC / NIHB - 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. |
E Respiratory | Corticosteroids |
Fluticasone | Flovent (120) | 125 mcg | 1 pf bid | $55 | BC / NIHB - 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. |
E Respiratory | Corticosteroids |
Salbutamol | Ventolin (200) | 100 mcg | 4 pfs/d | $25 | BC / NIHB - 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. |
E Respiratory | Bronchodilators / Anti-cholingergics |
Tiotropium | Spiriva (30) | 18 mcg | 1 pf qd | $115 | BC / NIHB - 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. |
E Respiratory | Bronchodilators / Anti-cholingergics |
Glycopyrronium | Seebri (30) | 50 mcg | 1 pf qd | $195 | BC / NIHB - 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. |
E Respiratory | Bronchodilators / Anti-cholingergics |
Ipratropium | Atrovent (200) | 200 mcg | 1 pf qid | $45 | BC / NIHB - 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. |
E Respiratory | Bronchodilators / Anti-cholingergics |
Bupropion | Zyban | 150 mg | BID | $240 | 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 | $205 | BC / NIHB - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Nicotine Inhaler | Nicorette | Cartridges | 6 ctgs/d | $485 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nicotine Gum | Nicorette | 4 mg | 12 pcs/d | $390 | 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 | 12 pcs/d | $390 | 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 | |
Semaglutide | Ozempic | 2.4 mg SQ | Once Weekly | $3540 | NC for weight management |
Must titrate to 2.4 mg dose |
C Obesity | Obesity |
Orlistat | Xenical | 120 mg | TID | $595 | BC / NIHB - NC | C Obesity | Obesity | |
Liraglutide | Saxenda | 3 mg SQ | QD | $1450 | 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 | QD | $290 | 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 / NIHB - SA | B Hypoglycemic Agents | Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors | |
Repaglinide | Gluconorm | 1 mg | TID | $40 | BC / NIHB - Covered | B Hypoglycemic Agents | Meglitinides | |
Regular insulin | Novolin Toronto/Humulin R | 100 U/ml | As dir | $70 | 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). |
B Hypoglycemic Agents | Insulin |
Rapid-acting 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). |
B Hypoglycemic Agents | Insulin |
Rapid-acting 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). |
B Hypoglycemic Agents | Insulin |
Rapid-acting 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). |
B Hypoglycemic Agents | Insulin |
Rapid-acting insulin | Humalog | 100 U/ml | As dir | $95 | 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). |
B Hypoglycemic Agents | Insulin |
Long-acting insulin | Novolin NPH/Humulin N | 100 U/ml | As dir | $70 | 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). |
B Hypoglycemic Agents | Insulin |
Basal insulin biosimilar (Glargine) | Basaglar | 100 U/ml | As dir | $100 | 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). |
B 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). |
B Hypoglycemic Agents | Insulin |
Basal insulin (Glargine) | Lantus | 100 U/ml | As dir | $120 | 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). |
B Hypoglycemic Agents | Insulin |
Basal insulin (Detemir) | Levemir | 100 U/ml | As dir | $140 | 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). |
B 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). |
B Hypoglycemic Agents | Insulin |
Liraglutide | Victoza | 1.8 mg SQ | QD | $1090 | BC / NIHB - NC | B Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Liraglutide | Victoza | 1.2 mg SQ | QD | $730 | BC / NIHB - NC | B Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Semaglutide | Ozempic | 0.5 mg SQ | Once weekly | $720 | BC / NIHB - SA | B Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Lixisenatide | Adlyxine | 0.02 mg SQ | QD | $405 | BC - NC / NIHB - Covered | B Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Sitagliptin | Januvia | 100 mg | QD | $95 | BC / NIHB - SA | B Hypoglycemic Agents | Dipeptidylpeptidase-4 Inhibitors (DPP-4) | |
Saxagliptin | Onglyza | 5 mg | QD | $165 | BC - SA / NIHB - Covered | B Hypoglycemic Agents | Dipeptidylpeptidase-4 Inhibitors (DPP-4) | |
Linagliptin | Trajenta | 5 mg | QD | $280 | BC - SA / NIHB - Covered | B Hypoglycemic Agents | Dipeptidylpeptidase-4 Inhibitors (DPP-4) | |
Metformin SR | Glumetza SR | 1000 mg | 2 QD | $260 | 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 | $750 | BC / NIHB - SA | A Cardiovascular | Neprilysin Inhibitor / ARB Combos | |
Evolocumab | Repatha | 140 mg SQ | Q2W | $1875 | BC / NIHB - SA | A Cardiovascular | Lipid Lowering Agents | |
Alirocumab | Praluent | 75 mg x Q2W SQ | Q2W | $1885 | BC / NIHB - SA | A Cardiovascular | Lipid Lowering Agents | |
Ezetimibe | Ezetrol | 10 mg | QD | $30 | BC / NIHB - Covered | A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A Cardiovascular | Lipid Lowering Agents |
Indapamide | Lozide | 2.5 mg | QD | $40 | BC / NIHB - Covered | A Cardiovascular | Diuretics | |
Furosemide | Lasix | 20 mg, 40 mg | QD | $15 | BC / NIHB - Covered | A Cardiovascular | Diuretics | |
Chlorthalidone | Hygroton | 50 mg | 1/4-1/2 QD | $20 | BC / NIHB - Covered | A Cardiovascular | Diuretics | |
Hydrochlorothiazide | Hydrodiuril | 12.5 mg, 25 mg | QD | $15 | BC / NIHB - Covered | A Cardiovascular | Diuretics | |
Spironolactone | Aldactone | 25 mg, 100 mg | QD | $25 | BC / NIHB - Covered | A Cardiovascular | Diuretics | |
Diltiazem | Tiazac | 240 mg | QD | $50 | BC / NIHB - Covered |
Generic equivalents of Tiazac-T and Tiazac XC |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A Cardiovascular | Calcium Channel Blockers |
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 | |
Telmisartan/Amlodipine | Twynsta | 80 mg/5 mg | QD | $70 | BC / NIHB - Covered | A Cardiovascular | ARB / CCB Combos | |
Clopidogrel | Plavix | 75 mg | QD | $40 | BC / NIHB - Covered | A Cardiovascular | Anti-Platelet | |
Ticagrelor | Brilinta | 90 mg | BID | $95 | BC - SA / NIHB - Covered | A Cardiovascular | Anti-Platelet | |
Rivaroxaban | Xarelto | 2.5 mg | BID | $85 | BC - Covered / NIHB - SA | 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 | $305 | 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 |
All have HCTZ combo products that are similar in price to the single entity product |
A 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 |
A 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 |
A 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 |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A 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/MAC-pricing-categories.pdf. |
A 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 |
A Cardiovascular | ACE Inhibitors |