Clickable Table

Generic Name Brand Name Strength Dosing 90 Day Cost Coverage Comments Category 1 Category 2
Methadone Methadose 60 mg, 120 mg Daily $45 BC / NIHB - Covered

Cost estimate based on 60 mg dose of methadone daily

 Opioid Agonist Therapy 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

 Opioid Agonist Therapy Opioid Dependency
Buprenorphine Extended Release Sublocade 100 mg, 300 mg Monthly $1810 BC / NIHB - Covered Opioid Agonist Therapy Opioid Dependency
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

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

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

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

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

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

Iron Preparations Iron Preparations
Betamethasone/Calcipotriol Dovobet (60g tube) 0.05/0.005% As dir $100 BC / NIHB - Covered Topicals Miscellaneous Topicals
Tacrolimus Protopic (30g tube) 0.03% As dir $95 BC / NIHB - SA Topicals Miscellaneous Topicals
Betamethasone Valerate Betaderm/Betnovate 0.10% As dir $15 BC / NIHB - Covered 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 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.
Amcinonide Cyclocort 0.10% As dir $30 BC / NIHB - Covered 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 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 Glycol Diprolene 0.05% As dir $30 BC / NIHB - Covered 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 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.
Dimethicone Nyda 50% As dir $40 BC / NIHB - Covered Topicals Lice
Pyrethrins/Piperonyl Butoxide R&C 0.33%/3% As dir $25 BC / NIHB - Covered Topicals Lice
Isopropyl Myristate Resultz 50% As dir $35 BC / NIHB - Covered Topicals Lice
Imiquimod Aldara (24x250mg) 5% As dir $300 BC - SA / NIHB - Covered Topicals Miscellaneous Topicals
Benzoyl Peroxide/Clindamycin Clindoxyl (45g tube) 5%/1% As dir $50 BC - SA / NIHB Covered Topicals Acne Treatments
Adapalene Differin (60g tube) 0.10% As dir $215 BC - NC / NIHB - Covered Topicals Acne Treatments
Adapalene/Benzoyl Peroxide TactuPump Forte (70g tube) 0.3%/2.5% As dir $165 BC - NC / NIHB - Covered Topicals Acne Treatments
Tretinoin Cream Stieva-A (25g tube) 0.03% As dir $25 BC - NC / NIHB - Covered Topicals Acne Treatments
Permethrin Nix 1% As dir $25 BC / NIHB - Covered Topicals Lice
Galantamine ER Reminyl ER 16 mg QD $140 BC / NIHB - SA Miscellaneous Dementia
Zoledronic Acid Aclasta 5 mg yearly $110 BC / NIHB - SA Miscellaneous Osteoporosis
Risedronate Actonel 35 mg once weekly $35 BC / NIHB - Covered Miscellaneous Osteoporosis
Teriparatide Forteo 20 mcg SQ QD $1935 BC - NC / NIHB - SA Miscellaneous Osteoporosis
Alendronate Fosamax 70 mg once weekly $40 BC / NIHB - Covered Miscellaneous Osteoporosis
Denosumab Prolia 60 mg SQ every 6 months $245 BC / NIHB - SA Miscellaneous Osteoporosis
Isotretinoin Accutane 40 mg QD x 90 days $205 BC / NIHB - Covered Topicals Acne Treatments
Efinaconazole Jublia Nail lacquer; price for 8ml $130 BC / NIHB - NC Miscellaneous Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Terbinafine Lamisil 250 mg QD $85 BC / NIHB - Covered 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 Miscellaneous Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Itraconazole Sporanox 2x100 mg QD $795 BC / NIHB - Covered Miscellaneous Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Donepezil Aricept 5 mg QD $60 BC / NIHB - SA Miscellaneous Dementia
Memantine Ebixa 10 mg QD $185 BC - NC / NIHB - SA Miscellaneous Dementia
Rivastigmine Exelon 3 mg BID $145 BC / NIHB - SA Miscellaneous Dementia
Fosfomycin Monurol 3 g as a single dose $30 BC / NIHB - Covered Miscellaneous Antibiotics
Azithromycin Zithromax 250 mg x 4 days $20 BC / NIHB - Covered Miscellaneous Antibiotics
Fluconazole Diflucan 150 mg once weekly $65 BC / NIHB - Covered Miscellaneous Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
Allopurinol Zyloprim 200 mg QD $25 BC / NIHB - Covered Analgesics Gout
Tramadol/Acetaminophen Tramacet 37.5 mg/325 mg PRN $80 BC - NC / NIHB - SA

90 tablets

 Analgesics Miscellaneous Analgesics
Amitriptyline Elavil 10 mg, 25 mg HS $20 BC / NIHB - Covered Analgesics Neuropathic or Chronic Pain
Pregabalin Lyrica 50 mg HS $35 BC / NIHB - Covered Analgesics Neuropathic or Chronic Pain
Gabapentin Neurontin 300 mg TID $45 BC / NIHB - Covered Analgesics Neuropathic or Chronic Pain
Duloxetine Cymbalta 30 mg, 60 mg QD $85 BC / NIHB - Covered Analgesics Neuropathic or Chronic Pain
Diclofenac/Misoprostol Arthrotec 75 mg/200 mcg BID $100 BC / NIHB - Covered Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Celecoxib Celebrex 200 mg QD $40 BC / NIHB - Covered Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Naproxen Naproxen 500 mg BID $55 BC / NIHB - Covered Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Ketorolac Toradol 10 mg BID $50 BC / NIHB - Covered Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Naproxen/Esomeprazole Vimovo 500 mg/20 mg BID $205 BC / NIHB - NC Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Diclofenac Voltaren SR 75 mg BID $105 BC / NIHB - Covered Analgesics Non-Steroidal Antiinflammatory Drugs (NSAIDs)
Amoxicillin Amoxil 500 mg TID x 7 days $15 BC / NIHB - Covered Miscellaneous Antibiotics
Clarithromycin Biaxin 2x250 mg BID x 5 days $25 BC / NIHB - Covered Miscellaneous Antibiotics
Ciprofloxacin Cipro 500 mg BID x 5 days $20 BC - SA / NIHB - Covered Miscellaneous Antibiotics
Amoxicillin/Clavulanate Clavulin 500 mg TID x 7 days $25 BC / NIHB - Covered Miscellaneous Antibiotics
Doxycycline Doxycycline 100 mg QD x 7 days $20 BC / NIHB - Covered Miscellaneous Antibiotics
Cephalexin Keflex 500 mg QID x 7 days $20 BC / NIHB - Covered Miscellaneous Antibiotics
Nitrofurantoin Macrobid 100 mg BID x 3 days $15 BC / NIHB - Covered Miscellaneous Antibiotics
Medroxyprogesterone Provera 5 mg QD $40 BC / NIHB - Covered Hormone Replacement Therapy Oral
Estradiol-17β Patch Estradot/Oesclim 50 mcg Twice weekly $85 BC / NIHB - Covered Hormone Replacement Therapy Transdermal
Estradiol-17β Gel Estrogel 2.5 g gel = 1.5 mg estradiol QD $105 BC / NIHB - Covered Hormone Replacement Therapy Transdermal
Conjugated Estrogens Premarin Vaginal Cr 0.625 mg QD $95 BC / NIHB - Covered Hormone Replacement Therapy Vaginal
Estradiol-17β Vaginal Tablet Vagifem-10 10 mcg Twice weekly $140 BC / NIHB - Covered Hormone Replacement Therapy Vaginal
Dutasteride Avodart 0.5 mg QD $40 BC / NIHB - Covered Urology Benign Prostatic Hyperplasia (BPH)
Tamsulosin CR Flomax CR 0.4 mg QD $30 BC / NIHB - Covered Urology Benign Prostatic Hyperplasia (BPH)
Terazosin Hytrin 2 mg QD $65 BC / NIHB - Covered Urology Benign Prostatic Hyperplasia (BPH)
Finasteride Proscar 5 mg QD $50 BC / NIHB - Covered Urology Benign Prostatic Hyperplasia (BPH)
Tadalafil Cialis 20 mg As dir $70 BC / NIHB - NC Urology Erectile Dysfunction
4 tablets; may split tablet for lower dose to save costs
Vardenafil Levitra 20 mg As dir $70 BC / NIHB - NC Urology Erectile Dysfunction
4 tablets; may split tablet for lower dose to save costs
Sildenafil Viagra 50 mg, 100 mg As dir $55 BC / NIHB - NC Urology Erectile Dysfunction
4 tablets; may split tablet for lower dose to save costs
Testosterone Undecanoate Andriol 40 mg BID $105 BC - SA / NIHB - Covered Urology Testosterone Replacement
Testosterone Gel Androgel 5 g QD $470 BC - NC / NIHB - SA Urology Testosterone Replacement
Testosterone Enanthate Delatestryl 200 mg/mL 400 mg Q30D $60 BC / NIHB - Covered Urology Testosterone Replacement
Testosterone Cypionate Depo-Testosterone 100 mg/mL 200 mg Q2W $60 BC / NIHB - Covered Urology Testosterone Replacement
Sumatriptan Imitrex 100 mg PRN $35 BC - Restricted / NIHB - Covered

12 Tablets / 30 Days

 Analgesics Anti-Migraine
Topiramate Topamax 100 mg QD $60 BC / NIHB - Covered Analgesics Anti-Migraine
Zolmitriptan Zomig 2.5 mg PRN $40 BC - Restricted / NIHB - Covered

12 Tablets / 30 Days

 Analgesics Anti-Migraine
Colchicine Colchicine 0.6 mg QD $40 BC / NIHB - Covered Analgesics Gout
Desogestrel Marvelon QD $40 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Norgestimate Tri-Cyclen QD $65 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
3rd Generation Progestins
Drospirenone Yasmin QD $60 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.
Drospirenone YAZ QD $75 BC - NC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Anti-Androgenic
Same chemical constituents. Yasmin is 21 active pills & 7 pill-free days; Yaz is 24 active pills & 4 pill-free days.
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

 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 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

 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)
Norelgestromin Evra Patch As dir $100 BC - NC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal / Vaginal
Etonogestrel Nuvaring Vaginal ring As dir $65 BC - NC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Transdermal / Vaginal
Etonogestrel implant Nexplanon Hormonal implant One time insertion $20 BC / NIHB - Covered

Upfront cost is $338 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $17 every 90 days

 Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Hormonal implant
Medroxyprogesterone Depo-Provera Intramuscular Q 3 months $50 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
Injectable
Estradiol-17β Estrace 1 mg QD $35 BC / NIHB - Covered Hormone Replacement Therapy Oral
Conjugated Estrogens Premarin 0.3 mg, 0.625 mg QD $55 BC / NIHB - Covered Hormone Replacement Therapy Oral
Micronized Progesterone Prometrium 100 mg HS $50 BC / NIHB - Covered Hormone Replacement Therapy Oral
Lemborexant Dayvigo 5 mg, 10 mg HS $190 BC / NIHB - NC Psychiatry Anxiolytic Sedative
Amphetamines, Mixed Salts Adderall XR 10 mg QD $295 BC - Restricted / NIHB - Covered Psychiatry Stimulants (ADHD)
Methylphenidate Concerta 36 mg QD $445 BC - Restricted / NIHB - Covered Psychiatry Stimulants (ADHD)
Methylphenidate Ritalin 10 mg BID $60 BC / NIHB - Covered Psychiatry Stimulants (ADHD)
Methylphenidate Biphentin 10 mg QD $65 BC - Restricted / NIHB - NC Psychiatry Stimulants (ADHD)
Lisdexamfetamine Vyvanse 20 mg QD $295 BC - Restricted / NIHB - Covered Psychiatry Stimulants (ADHD)
Norethindrone AcetateLolo Lolo QD $85 BC - NC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
1st Generation Progestins
Norethindrone Synphasic QD $60 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
1st Generation Progestins
Levonorgestrel Alesse QD $30 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Min-Ovral QD $40 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Seasonique QD $95 BC - NC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Levonorgestrel Triquilar QD $70 BC / NIHB - Covered Contraceptives
Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.
2nd Generation Progestins
Lansoprazole Prevacid 30 mg QD $65 BC / NIHB - Covered 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.
Pantoprazole Magnesium Tecta 40 mg QD $35 BC / NIHB - Covered 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.
Citalopram Celexa 20 mg QD $25 BC / NIHB - Covered Psychiatry Antidepressants
Escitalopram Cipralex 10 mg QD $45 BC / NIHB - Covered Psychiatry Antidepressants
Duloxetine Cymbalta 30 mg QD $50 BC / NIHB - Covered Psychiatry Antidepressants
Venlafaxine Effexor XR 75 mg QD $30 BC / NIHB - Covered Psychiatry Antidepressants
Paroxetine Paxil 20 mg QD $45 BC / NIHB - Covered Psychiatry Antidepressants
Desvenlafaxine Pristiq 50 mg QD $255 BC - NC / NIHB - SA Psychiatry Antidepressants
Fluoxetine Prozac 20 mg QD $45 BC / NIHB - Covered Psychiatry Antidepressants
Mirtazapine Remeron 30 mg HS $35 BC / NIHB - Covered Psychiatry Antidepressants
Vortioxetine Trintellix 20 mg QD $340 BC / NIHB - Covered Psychiatry Antidepressants
Bupropion Wellbutrin XL 150 mg QD $45 BC / NIHB - Covered Psychiatry Antidepressants
Sertraline Zoloft 50 mg QD $45 BC / NIHB - Covered Psychiatry Antidepressants
Aripiprazole Abilify 15 mg QD $140 BC - Restricted / NIHB - Covered Psychiatry Antipsychotics
Risperidone Risperdal 1 mg QD $35 BC / NIHB - Covered Psychiatry Antipsychotics
Quetiapine Seroquel 25 mg HS $20 BC / NIHB - Covered Psychiatry Antipsychotics
Quetiapine Seroquel XR 300 mg QD $110 BC / NIHB - Covered Psychiatry Antipsychotics
Olanzapine Zyprexa 5 mg, 10 mg QD $85 BC / NIHB - Covered Psychiatry Antipsychotics
Lorazepam Ativan 1 mg PRN $20 BC / NIHB - Covered Psychiatry Anxiolytic Sedative (90)
90 tablets
Trazodone Desyrel 50 mg PRN $20 BC / NIHB - Covered Psychiatry Anxiolytic Sedative (90)
90 tablets
Zopiclone Imovane 7.5 mg PRN $25 BC - Covered / NIHB - NC Psychiatry Anxiolytic Sedative (90)
90 tablets
Temazepam Restoril 30 mg PRN $45 BC / NIHB - Covered Psychiatry Anxiolytic Sedative (90)
90 tablets
Fluticasone/Vilanterol Breo Ellipta (30) 100/25 mcg 1 pf qd $325 BC / NIHB - SA Respiratory Long-acting beta-agonist/Corticosteroid Combos
Budesonide/Formoterol Symbicort (120) 200/6 mcg 1 pf qd $175 BC / NIHB - SA Respiratory Long-acting beta-agonist/Corticosteroid Combos
Montelukast Singulair 10 mg QD $55 BC - SA / NIHB - Covered Respiratory Leukotriene Receptor Antagonist
Fluticasone furoate/Umeclidinium/Vilanterol Trelegy Ellipta (30) 100/62.5/25 mcg 1 pf qd $470 BC / NIHB - SA Respiratory Long-acting beta-agonist/long acting muscarinic antagonist/Corticosteroid Combos
Doxylamine/Pyridoxine Diclectin 10 mg/10 mg PRN $35 BC / NIHB - Covered Gastrointestinal Antiemetics
30 tablets
Dimenhydrinate Gravol 50 mg PRN $15 BC / NIHB - Covered Gastrointestinal Antiemetics
30 tablets
Metoclopramide Maxeran 2x5 mg PRN $15 BC / NIHB - Covered Gastrointestinal Antiemetics
30 tablets
Ondansetron Zofran 8mg PRN $145 BC / NIHB - Covered Gastrointestinal Antiemetics
30 tablets
Pyridoxine (Vitamin B6) Pyridoxine 25 mg PRN $5 BC - NC/ NIHB - Covered Gastrointestinal Antiemetics
30 tablets
Amoxicillin Amoxil 1 g BID x 14d $95 BC / NIHB - Covered Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
Clarithromycin Biaxin 2x250 mg BID x 14d BC / NIHB - Covered Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
Metronidazole Flagyl 500 mg BID x 14d BC / NIHB - Covered Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
Pantoprazole Magnesium Tecta 40 mg BID x 14d BC / NIHB - Covered Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
Ranitidine Zantac 150 mg BID $40 BC / NIHB - Covered Gastrointestinal Histamine-2 Receptor Antagonists (H2RAs)
Lactulose Lactulose 1 tbsp QD $35 BC / NIHB - Covered Gastrointestinal Laxatives
PEG3350 Restoralax/Lax-A-Day 17 g QD $55 BC - NC/ NIHB - Covered Gastrointestinal Laxatives
Dexlansoprazole Dexilant 30 mg QD $225 BC / NIHB - NC 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 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 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 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.
Gliclazide MR Diamicron MR 30 mg MR 2 QD $35 BC / NIHB - Covered Hypoglycemic Agents Sulfonylureas
Glyburide Diabeta 5 mg BID $25 BC / NIHB - Covered Hypoglycemic Agents Sulfonylureas
Liraglutide Saxenda 3 mg SQ QD $1450 BC / NIHB - NC Obesity Obesity
Orlistat Xenical 120 mg TID $595 BC / NIHB - NC Obesity Obesity
Semaglutide Ozempic 2.4 mg SQ Once weekly $1245 NC for weight management

Must titrate to 2.4 mg dose

 Obesity Obesity
Semaglutide Rybelsus 14 mg Once daily $760 BC - NC / NIHB - SA Obesity Obesity
Semaglutide Wegovy 2.4 mg SQ Once weekly $1265 BC / NIHB - NC Obesity Obesity
Naltrexone Contrave 16 mg/180 mg BID $850 BC / NIHB - NC Obesity Obesity
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 Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Lifetime $ limit
Nicotine Gum Nicorette 2 mg, 4 mg 12 pcs/d $390 BC - Restricted / NIHB - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Lifetime $ limit
Nicotine Inhaler Nicorette Cartridges 6 ctgs/d $485 BC - Restricted / NIHB - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Lifetime $ limit
Nortriptyline Aventyl 25 mg 3 HS $205 BC / NIHB - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Varenicline Champix 0.5 mg QD x 3 days, 0.5 mg BID x 4 days, 1 mg BID thereafter $100 BC - Restricted / NIHB - Covered

Quantity limits

 Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Bupropion Wellbutrin SR 150 mg BID $195 BC / NIHB - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Bupropion Zyban 150 mg BID $240 BC / NIHB - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Ipratropium Atrovent (200) 200 mcg 1 pf qid $35 BC / NIHB - Covered 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 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 $110 BC / NIHB - Covered 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.
Salbutamol Ventolin (200) 100 mcg 4 pfs/d $25 BC / NIHB - Covered 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.
Fluticasone Flovent (120) 125 mcg 1 pf bid $55 BC / NIHB - Covered Respiratory Corticosteroids
Fluticasone Flovent (120) 250 mcg 1 pf bid $90 BC / NIHB - Covered Respiratory Corticosteroids
Budesonide Pulmicort (200) 200 mcg 1 pf bid $85 BC / NIHB - Covered Respiratory Corticosteroids
Beclomethasone Qvar (200) 100 mcg 1 pf bid $85 BC / NIHB - Covered Respiratory Corticosteroids
Glycopyrronium/Indacaterol Ultibro (30) 50/110 mcg 1 pf qd $270 BC / NIHB - Covered Respiratory Long-acting Anti-cholinergic/Long-acting Beta-agonist Combos
Fluticasone/Salmeterol Advair Diskus (60) 250/50 mcg 1 pf bid $180 BC / NIHB - SA Respiratory Long-acting beta-agonist/Corticosteroid Combos
Fluticasone/Salmeterol Advair MDI (120) 250/25 mcg 1 pf bid $280 BC / NIHB - SA Respiratory Long-acting beta-agonist/Corticosteroid Combos
Sacubitril/Valsartan Entresto 97 mg/103 mg BID $750 BC / NIHB - SA Cardiovascular Neprilysin Inhibitor / ARB Combos
Metformin Glucophage 500 mg 2 BID $25 BC / NIHB - Covered Hypoglycemic Agents Biguanides
Metformin SR Glumetza SR 1000 mg 2 QD $290 BC - NC / NIHB - SA Hypoglycemic Agents Biguanides
Linagliptin Trajenta 5 mg QD $280 BC - SA / NIHB - Covered Hypoglycemic Agents Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Sitagliptin Januvia 100 mg QD $95 BC / NIHB - SA Hypoglycemic Agents Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Semaglutide Ozempic 1 mg SQ Once weekly $525 BC / NIHB - SA Hypoglycemic Agents Glucagon-like Peptide 1 Agonist (GLP-1)
Liraglutide Victoza 1.2 mg SQ QD $730 BC / NIHB - NC Hypoglycemic Agents Glucagon-like Peptide 1 Agonist (GLP-1)
Liraglutide Victoza 1.8 mg SQ QD $1090 BC / NIHB - NC Hypoglycemic Agents Glucagon-like Peptide 1 Agonist (GLP-1)
Basal insulin (Degludec) Tresiba 100 U/ml As dir $135 BC / NIHB - Covered 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 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 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 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 $75 BC / NIHB - Covered 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 $100 BC - NC / NIHB - SA 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 $85 BC - NC / NIHB - SA 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 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 Trurapi 100 U/ml As dir $65 BC / NIHB - Covered 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).
Repaglinide Gluconorm 1 mg TID $40 BC / NIHB - Covered Hypoglycemic Agents Meglitinides
Canagliflozin Invokana 100 mg QD $295 BC / NIHB - SA Hypoglycemic Agents Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Dapagliflozin Propanediol Monohydrate Forxiga 10 mg QD $80 BC / NIHB - Covered Hypoglycemic Agents Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Empagliflozin Jardiance 10 mg, 25 mg QD $290 BC - SA / NIHB - Covered Hypoglycemic Agents Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors
Gliclazide Diamicron 80 mg BID $35 BC / NIHB - Covered Hypoglycemic Agents Sulfonylureas
Perindopril Coversyl 4 mg, 8 mg QD $40 BC / NIHB - Covered 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 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 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.
Lisinopril Zestril 20 mg QD $35 BC / NIHB - Covered 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.
Candesartan Atacand 8 mg QD $35 BC / NIHB - Covered Cardiovascular Angiotensin Receptor Blockers
All have HCTZ combo products that are similar in price to the single entity product
Losartan Cozaar 50 mg QD $30 BC / NIHB - Covered Cardiovascular Angiotensin Receptor Blockers
All have HCTZ combo products that are similar in price to the single entity product
Valsartan Diovan 80 mg, 160 mg QD $35 BC / NIHB - Covered Cardiovascular Angiotensin Receptor Blockers
All have HCTZ combo products that are similar in price to the single entity product
Telmisartan Micardis 80 mg QD $35 BC / NIHB - Covered Cardiovascular Angiotensin Receptor Blockers
All have HCTZ combo products that are similar in price to the single entity product
Warfarin Coumadin 5 mg QD $20 BC / NIHB - Covered Cardiovascular Anti-Coagulant
Apixaban Eliquis 5 mg BID $95 BC / NIHB - Covered Cardiovascular Anti-Coagulant
Edoxaban Lixiana 60 mg QD $305 BC - SA / NIHB - Covered Cardiovascular Anti-Coagulant
Dabigatran Pradaxa 110 mg, 150 mg BID $265 BC - SA / NIHB - Covered Cardiovascular Anti-Coagulant
Rivaroxaban Xarelto 15 mg, 20 mg QD $85 BC / NIHB - Covered Cardiovascular Anti-Coagulant
Rivaroxaban Xarelto 2.5 mg BID $85 BC - Covered / NIHB - SA Cardiovascular Anti-Coagulant
Ticagrelor Brilinta 90 mg BID $95 BC - SA / NIHB - Covered Cardiovascular Anti-Platelet
Clopidogrel Plavix 75 mg QD $40 BC / NIHB - Covered Cardiovascular Anti-Platelet
Metoprolol Lopresor 25 mg, 50 mg BID $25 BC / NIHB - Covered Cardiovascular Beta Blockers
Metoprolol-SR Lopresor SR 100 mg, 200 mg QD $50 BC / NIHB - Covered Cardiovascular Beta Blockers
Bisoprolol Monocor 10 mg QD $25 BC / NIHB - Covered Cardiovascular Beta Blockers
Atenolol Tenormin 50 mg QD $25 BC / NIHB - Covered Cardiovascular Beta Blockers
Nifedipine Adalat XL 30 mg QD $75 BC / NIHB - Covered Cardiovascular Calcium Channel Blockers (MAC)
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 Cardiovascular Calcium Channel Blockers (MAC)
Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
Diltiazem Tiazac 240 mg QD $50 BC / NIHB - Covered Cardiovascular Calcium Channel Blockers
Spironolactone Aldactone 25 mg, 100 mg QD $25 BC / NIHB - Covered Cardiovascular Diuretics
Hydrochlorothiazide Hydrodiuril 12.5 mg, 25 mg QD $15 BC / NIHB - Covered Cardiovascular Diuretics
Chlorthalidone Hygroton 12.5 mg, 25 mg, 50 mg QD $25 BC / NIHB - Covered Cardiovascular Diuretics
Furosemide Lasix 20 mg, 40 mg QD $15 BC / NIHB - Covered Cardiovascular Diuretics
Indapamide Lozide 2.5 mg QD $40 BC / NIHB - Covered Cardiovascular Diuretics
Rosuvastatin Crestor 10 mg, 20 mg QD $30 BC / NIHB - Covered Cardiovascular Lipid Lowering Agents (MAC)
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 Cardiovascular Lipid Lowering Agents
Pravastatin Pravachol 20 mg QD $50 BC / NIHB - Covered Cardiovascular Lipid Lowering Agents (MAC)
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 Cardiovascular Lipid Lowering Agents (MAC)
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 Cardiovascular Lipid Lowering Agents
Alirocumab Praluent 75 mg x Q2W SQ Q2W $1885 BC / NIHB - SA Cardiovascular Lipid Lowering Agents
Evolocumab Repatha 140 mg SQ Q2W $1875 BC / NIHB - SA Cardiovascular Lipid Lowering Agents
Ramipril Altace 5 mg, 10 mg QD $25 BC / NIHB - Covered 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